Laparoscopic Cholecystectomy In Cirrhotic Patients Research Articles

Management of Cholelithiasis in Cirrhotic Patients.

Gallstone disease (GD) is a common disease worldwide and has a higher incidence in cirrhotic patients than in the general population. The main indications for cholecystectomy surgery in cirrhotic patients remain symptomatic cholelithiasis and its complications. Over the past two decades, numerous published reports have attested to the feasibility and safety of laparoscopic cholecystectomy in cirrhotic patients. Surgery in patients with liver cirrhosis represents an additional source of stress for an already impaired liver function and perioperative complications are remarkably high compared to non-cirrhotic patients, despite significant advances in surgical management. Therefore, preoperative risk stratification and adequate patient selection are mandatory to minimize postoperative complications. We have conducted a systematic review of the literature over the last 22 years for specific information on indications for surgery in cirrhotic patients and individual percentages of Child-Pugh grades undergoing treatment. There are very few reported cases of cholecystectomy and minimally invasive treatment, such as percutaneous transhepatic cholecystostomy (PTC), in patients with Child-Pugh grade C cirrhosis. With this work, we would like to pay attention to the treatment of cholelithiasis in cirrhotic patients who are still able to undergo cholecystectomy, thus also encouraging this type of intervention in cases of asymptomatic cholelithiasis in patients with Child-Pugh grades A and B.

Short-term out comes of laparoscopic cholecystectomy in cirrhotic patients with portal hypertension

Advantages of laparoscopic cholecystectomy (LC) for most of patients have been extensively recognized, and (LC) has become the golden standard in treating benign gallbladder diseases. When LC began in early 90's pregnancy, previous abdominal surgery, obesity, cirrhosis, and acute cholecystitis were considered absolute contraindications for the laparoscopic skills and instrumentation, a range of increasingly complex procedures has been performed, making all of these traditional contraindications at best relative. Several studies reported good results and suggested liberal use of LC in patients with early-stage cirrhosis and symptomatic gallstone disease. However, its benefits and successful use in patients with cirrhotic portal hypertension (CPH) are not well-documented. Based on our previous studies on the influence of LC on hepatic function and our experience with LC for cirrhotic patients, LC has been successfully performed for patients with Cirrhotic Portal Hypertension. New studies reports safety of LC in cirrhotic patients class Child’s A-B patients.Aim of the workStudy aims to evaluate Laparoscopic cholecystectomy in patients with cirrhotic portal hypertension regarding the intra-operative difficulties and short-term post-operative outcomes including: bleeding, bile leakage, wound infection and hepatic insufficiency

Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary centre and the rule of harmonic device

Objectives: With improved laparoscopic techniques and experience, availability of newer tools and instruments like ultrasonic shears; laparoscopic cholecystectomy(LC) became feasible option in cirrhotic patients, the aim of this work was to analyze the outcome of LC in cirrhotic patients and the rule of harmonic device. Patients and Methods: We retrospectively analyzed 213 cirrhotic patients underwent LC in the period from 2011 to 2019, the overall male /female ratio was 114/99. Results: The most frequent CTP score was A, The most frequent cause of cirrhosis was HCV, while biliary colic was the most frequent presentation. Harmonic device was used in around 40% of patients, and on comparing patients with and without harmonic use, there were significant lower operative bleeding, less amount of blood and plasma transfusion, shorter operative time and hospital stay, and lower conversion and morbidity rates in the Harmonic group. The morbidity and mortality rates were arround around 22% and 2% respectively, and the morbidity significant predictors were CTP score B, C, non Harmonic group, operative bleeding, increased MELD score, incresed blood and plasma transfusion units, lower platelet count and longer operative time. Conclusion: LC can be safely performed in cirrhotic patients with appropriate patient selection. However, operative bleeding, increased blood and plasma transfusion units, higher CTP, and MELD scores, and lower platelet count are predictors of poor outcome that can be improved by using Harmonic scalpel shears.

Laparoscopic versus Open Cholecystectomy in Cirrhotic Patients: A Prospective Comparative Study

Abstract Background: Prevalence of gallstones in cirrhotics is estimated at 29-46% and thus is three times as high as those without liver cirrhosis. Cirrhosis increase incidence of gall-stones formation (black stones) with an overall prevalence of 25% to 30%. Aim Study: To compare between the rationale, risk and morbidity of open cholecystetomy versus and laparoscopic cholecystectomy in cirrhotic patients. As regard to operative time, intra operative and post-operative blood loss, time to resume diet, complications, mortality incidence, and post-operative subjective pain score. Patients and Method: This study was a prospective com-parative study on laparoscopic versus open cholecystectomy in cirrhotic patients. The cases were performed in the period from April 2016 till October 2018. 100 patients with sympto-matic gallstone disease and liver cirrhosis including Child class A or Child class B, were randomly divided into two groups, Group (A): Laparoscopic Cholecystectomy (LC) and Group (B): Open Cholecystectomy (OC). Results: In LC group two cases (4%) were converted to open cholecystectomy. Mean surgical times were significantly shorter in LC (Group A) group. The mean +SD (in minutes) of OC (Group B) and LC (Group A) was 97.69±15.79 versus 63.58±9.93, respectively, (p<0.001), associated with significantly higher intraoperative bleeding in OC group (p<0.001). The mean time to resume diet (hours) was 10.69± 5.41 in (Group A) it was significantly earlier than in (Group B) 24.15±6.74 (p<0.001). The length of hospital stay (days) was significantly longer in (Group B) with a mean hospital stay 5.08±1.56, compared with a mean hospital stay 2.60±0.61 for (Group A) (p<0.001) with low post-operative morbidity and no operative mortality. Conclusion: Laparoscopic Cholecystectomy (LC) offers safe and effective surgical treatment for cirrhotic patients of (Child class A and early B) suffering from gallstone disease, as it has lower morbidity, shorter operative time; early re-sumption diet with less need for blood transfusion and reducing hospital stay than OC.

Comparison Between Outcomes of Laparoscopic Cholecystectomy in Patients With Liver Cirrhosis or With Normal Liver Function

Objective and Background:The safety of laparoscopic cholecystectomy in patients with Child–Pugh A and B cirrhosis is well-established, but perioperative complications are frequently observed in patients with cirrhosis. Technical challenges of this operation in cirrhotic patients remain in need of resolution.Methods:Twenty-one patients preoperatively diagnosed as having cirrhosis underwent laparoscopic cholecystectomy mainly using the French approach and were retrospectively reviewed. Their clinicopathologic characteristics were compared with 74 continuous patients with gallstone but no cirrhosis who underwent laparoscopic cholecystectomy using the American approach.Results:Most cirrhotic patients (19/21, 90.5%) had a chronic liver disease such as hepatitis B/C, alcoholic hepatitis, or primary biliary cholangitis. On imaging, the Chilaiditi sign and gallbladder bed pocket score, previously proposed to be informative in these patients, were significantly higher in the cirrhosis group than in the no cirrhosis group. Although the Child–Pugh score was higher in patients with cirrhosis, the model for end-stage liver disease (MELD) score was similar for the 2 groups. There were no differences in the operation time or the amount of intraoperative blood transfused. Postoperative hospital stay and postoperative morbidity rates were significantly greater in the cirrhosis group, although severe complications with a Clavien–Dindo score ≥ IIIa occurred in only 1 patient in each group.Conclusions:The safety of laparoscopic cholecystectomy in cirrhotic patients was confirmed. Because the gallbladder is completely covered in patients with cirrhosis, the French style approach, which enables surgeons to more easily access the gallbladder pocket, is assumed to be one of the operative options.

Is Cirrhosis a Contraindication to Laparoscopic Cholecystectomy?

Laparoscopic cholecystectomy is the gold standard treatment for the vast majority of patients with symptomatic cholelithiasis. Although cirrhotic patients are twice as likely to develop gallstones as compared with noncirrhotic patients, cirrhosis has historically been considered a relative, if not absolute, contraindication to laparoscopic cholecystectomy. More recently a number of authors have reported on the safety of laparoscopic cholecystectomy in cirrhotic patients. We reviewed our patients retrospectively and assessed the safety of laparoscopic cholecystectomy in cirrhotic patients as compared with noncirrhotics at a large liver transplant center. A retrospective longitudinal cohort study was conducted of all laparoscopic cholecystectomies performed by our surgical group between August 2002 and April 2011. Of 63 patients undergoing laparoscopic cholecystectomy, 32 (51%) were cirrhotic. Of the 30 for whom a Child score could be calculated, 11 (34%) were Child A, 14 (44%) were Child B, and five (16%) were Child C. The morbidity rate was 33 per cent and mortality rate was 2 per cent. Length of stay, conversion rates, 30-day readmission rates, and morbidity and mortality rates were not significantly different between the cirrhotic and noncirrhotic groups. There was a trend toward higher complication rates in Child C cirrhotics. Our results indicate that laparoscopic cholecystectomy can be performed with acceptable morbidity and mortality in carefully selected cirrhotic patients.

Laparoscopic cholecystectomy in liver cirrhosis patients: An Egyptian experience

Aim: Cirrhosis represents a common histological pathway for a wide variety of chronic liver diseases. Hepatitis C virus (HCV) is the most important cause of liver cirrhosis in Egypt. Although cirrhosis has been regarded as a relative contraindication for laparoscopic cholecystectomy (LC) as a result of bleeding complications and subsequent liver failure, several reports support the safety of LC in selected patients. This was a prospective study to evaluate the efficacy and safety of LC in cirrhotic patients. Methods: A total of 177 hepatitis C positive patients with chronic calculus cholecystitis who here scheduled for LC between January 2010 and March 2011 were included in the present study. LC was carried out on patients who fulfilled the inclusion criteria. Two risk stratification-schemes were used to estimate the perioperative risk of patients with cirrhosis; the Child–Turcotte–Pugh (CTP) score and the Model for End-stage Liver Disease (MELD) score. Results: All patients were HCV-positive patients with Child class A cirrhosis and MELD score ≤ 9. Mean surgical time was 55 min. Surgical difficulty varied between average in 64%, moderate in 28% and extensive in 8%, where 3.4% required conversion to open cholecystectomy. Postoperative follow up of all patients was a multidisciplinary approach by both surgeons and hepatologists. All patients showed sound recovery confirmed by abdominal sonar to exclude intra-abdominal collections, and application of both CTP and MELD scores, where all patients kept a Child class A score and MELD score ≤ 9. Conclusion: LC is a safe procedure for hepatitis C-positive cirrhotic patients when established risk stratifications systems, such as CTP and MELD scores, are used for evaluation.

Laparoscopic Cholecystectomy in Cirrhotics

Due to the concern of risk of intra- and postoperative complications and associated morbidity, cirrhosis of the liver is often considered a contraindication for laparoscopic cholecystectomy (LC). This article intends to review the literature and underline the various approaches to dealing with this technically challenging procedure. A Medline search of major articles in the English literature on LC in cirrhotic patients over a 16-y period from 1994 to 2011 was reviewed and the findings analyzed. A total of 1310 cases were identified. Most the patients who underwent LC were in Child-Pugh class A, followed by Child-Pugh classes B and C, respectively. The overall conversion rate was 4.58%, and morbidity was 17% and mortality 0.45%. Among the patients who died, most were in Child-Pugh class C, with a small number in classes B and A. The cause of death included, postoperative bleeding, liver failure, sepsis, duodenal perforation, and myocardial infarction. A meta-analysis of 400 patients in the literature, comparing outcomes of patients undergoing LC with and without cirrhosis, revealed higher conversion rate, longer operative time, higher bleeding complications, and overall increased morbidity in patients with cirrhosis. Safe LC was facilitated by measures that included the use of ultrasonic shears and other hemostatic measures and using subtotal cholecystectomy in patients with difficult hilum and gallbladder bed. Laparoscopic cholecystectomy can be safely performed in cirrhotic patients, within Child-Pugh classes A and B, with acceptable morbidity and conversion rate.

Laparoscopic cholecystectomy in cirrhotic patients: the value of MELD score and Child–Pugh classification in predicting outcome

Laparoscopic cholecystectomy is a challenging procedure in patients with cirrhosis. This study aims to evaluate the safety and outcome of laparoscopic cholecystectomy in patients with cirrhosis and examines the value of model for end-stage liver disease (MELD) score and Child-Pugh classification in predicting morbidity. From January 1995 to July 2008, 220 laparoscopic cholecystectomies were performed in cirrhotic, Child-Pugh class A and B patients. Indications included symptomatic gallbladder disease and cholecystitis. MELD score ranged between 8 and 27. Child-Pugh class and MELD score were preoperatively calculated and associated with postoperative results. Data regarding patients and surgical outcome were retrospectively analyzed. No deaths occurred. Postoperative morbidity occurred in 19% of the patients and included hemorrhage, wound complications, and intra-abdominal collections controlled conservatively. Intraoperative difficulty due to liver bed bleeding was experienced in 19 patients. Conversion to open cholecystectomy was necessary in 12 cases. Median operative time was 95 min. Median hospital stay was 4 days. Patients with preoperative MELD score above 13 showed a tendency for higher complication rate postoperatively. Child-Pugh classification did not seem to predict morbidity effectively. Laparoscopic cholecystectomy can be performed safely in selected patients with cirrhosis Child-Pugh A and B and symptomatic cholelithiasis with acceptable morbidity. Some of its advantages are shorter operative time and reduced hospital stay. MELD score seems to predict morbidity more accurately than Child-Pugh classification system.

Laparoscopic Cholecystectomy in Cirrhotic Patients

Gallstones are twice as common in cirrhotic patients as in the general population. Although laparoscopic cholecystectomy (LC) has become the gold standard for symptomatic gallstones, cirrhosis has been considered an absolute or relative contraindication. Many authors have reported on the safety of LC in cirrhotic patients. We reviewed our patients retrospectively and assessed the safety of LC in cirrhotic patients at a tertiary care hospital in Pakistan. From January 2003 to December 2005, a retrospective study was conducted at SU IV, Liaquat University of Medical & Health Sciences Jamshoro. All the cirrhotic patients with Child-Pugh class A and B cirrhosis undergoing LC were included in the study. Cirrhosis was diagnosed based on clinical, biochemical, ultrasonography, and intraoperative findings of the nodular liver and histopathological study. Of 250 patients undergoing laparoscopic cholecystectomy, 20 (12.5%) were cirrhotic. Of these 20, 12 (60%) were Childs group A and 8 (40%) were group B. Thirty percent were hepatitis B positive, and 70% were hepatitis C positive. Preoperative diagnosis of cirrhosis was possible in 80% of cases, and 20% were diagnosed during surgery. Morbidity rate was 15% and mortality rate was 0%. Two patients developed postoperative ascites, and mean hospital stay was 2.8+/-0.1 days. Of the 20 cases, 2 (10%) were converted to open cholecystectomy. The mean operation time was 70.2+/-32.54 minutes. Laparoscopic cholecystectomy is an effective and safe treatment for symptomatic gallstone disease in select patients with Child-Pugh A and B cirrhosis. The advantages over open cholecystectomy are the lower morbidity rate and reduced hospital stay.

Laparoscopic cholecystectomy in cirrhotic patients: Feasibility in a developing country

Background/Aims:Although laparoscopic cholecystectomy (LC) has become the procedure of choice for cholelithiasis in the general population, many consider cirrhosis as a relative or absolute contraindication for laparoscopic surgery. The aim of this study was to confirm the safety of LC in cirrhotic patients in our set-up.Materials and Methods:This is a retrospective case series including all the patients with cirrhosis who underwent LC for gallstones from January 2000 to December 2006 at our institution. Data were analyzed for Child class, indication for surgery, hospital stay, and procedure-related morbidity and mortality. Results are given as mean ± standard deviation.Results:Thirty patients, including 21 females (median age: 42 years) underwent LC during the study period. There was no operative mortality. Twenty-four patients belonged to Child class A and 6 belonged to Child class B. Mean operative time was 80 ± 26 min. There was no incidence of bile duct injury, but two patients (6.7%) required conversion to open procedure. Mean hospital stay was 3 ± 2.7 days. Postoperative morbidity was observed in seven patients, including postoperative deterioration of liver function in 2, worsening of ascites in 2 and pneumonia, and port-site infection in 1. Two patients had significant drop in hemoglobin requiring blood transfusion.Conclusions:Cirrhosis is not a contraindication for LC and it can be performed safely in compensated cirrhotic patients with acceptable morbidity and mortality.

Risk Factors for Conversion to Open Surgery in Patients Undergoing Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is the gold standard treatment for most gallbladder diseases. Conversion to open cholecystectomy is necessary in some patients for any of a number of factors. Identifying these factors will help the patient, the surgeon, and the hospital. One thousand laparoscopic cholecystectomies were performed from May 1998 to May 2004 in Changi General Hospital, Singapore; 103 patients (10.3%) required conversion to open cholecystectomy. All data were kept prospectively and analyzed retrospectively. The patients who had conversion were mostly men (P < 0.0001), were heavier (P < 0.05), had acute cholecystitis (P < 0.0001), and had a history of upper abdominal surgery (P < 0.001). There were no differences in terms of race (P = 0.315) and presence of diabetes mellitus (P = 0.126). Diabetic patients who had conversion had a significantly higher glycosylated hemoglobin (Hba1c) (8.9% +/- 0.6%; P < 0.038). Patients who had conversion had a higher total white count (P < 0.05), but liver function tests were similar between the two groups. There was a higher conversion rate among the junior surgeons than the more experience surgeons (P < 0.032). The significant risk factors for conversion were male gender, advanced age (> 60 years), higher body weight > 65 kg, acute cholecystitis, previous upper abdominal surgery, junior surgeons, and diabetes associated with Hba1c > 6. Chronic liver disease was not found to be a risk factor (P = 0.345), and performing laparoscopic cholecystectomy in cirrhotic patients is safe. Identifying risk factors will help the surgeon to plan and counsel the patient and introduce new policies to the unit. Some of the risk factors are similar to those reported from international centers, but others may be unique to our department.

Laparoscopic Cholecystectomy in Cirrhotic Patients: The Role of Subtotal Cholecystectomy and Its Variants

Open cholecystectomy is associated with considerable morbidity and mortality in cirrhotic patients. Laparoscopic cholecystectomy may offer a better option because of the magnification available and the availability of newer instruments like the ultrasonic shears. We present our experience of 265 laparoscopic cholecystectomies and attempt to identify the difficulties encountered in this group of patients. Between 1991 and 2005, 265 cirrhotic patients of Child-Pugh Classification A and B, with symptomatic gallstones, were subjected to laparoscopic cholecystectomy. We describe here our tailored approach and our techniques of subtotal cholecystectomy. Features of acute cholecystitis were present in 35.1% of the patients, and 64.9% presented with chronic cholecystitis. In 81.5% of the patients, the diagnosis of cirrhosis was established preoperatively. In 8.3% of the patients, a fundus first method was adopted when the hilum could not be approached despite additional ports. Modified subtotal cholecystectomy was performed in a total of 206 patients. Mean operative time in the subtotal cholecystectomy group was 72 minutes; in the standard group, it was 41 minutes. There was no mortality. In 15% of patients, postoperative deterioration in liver function occurred. Worsening of ascites, port site infection, port site bleeding, intraoperative hemorrhage, bilious drainage, and stone formation in the remnant were the other complications encountered. Laparoscopic cholecystectomy is a safe and effective treatment for calculous cholecystitis in cirrhotic patients. Appropriate modification of subtotal cholecystectomy should be practiced, depending on the risk factors present, to avoid complications.

Laparoscopic cholecystectomy in cirrhotic patients.

Since 1992, laparoscopic cholecystectomy has been the treatment of choice for symptomatic gallstones. The advantages of laparoscopic cholecystectomy for most patients have been extensively published. However, its benefits and successful use in patients with cirrhosis are less well documented. The aim of this study was to determine the efficacy and safety of laparoscopic cholecystectomy in cirrhotic patients. We did a retrospective review of the records of 26 consecutive laparoscopic cholecystectomy procedures performed on cirrhotic patients between January 1992 and September 2000. Twenty-two patients were classified as having Child's class A cirrhosis, and 4 patients were classified as having Child's class B. No patients were classified as having Child's class C cirrhosis. There were 20 men and 6 women, with a mean age of 57 years (range, 37-76). All procedures were completed laparoscopically. There was histologic confirmation of cirrhosis in all patients. The mean operative time was 126 minutes (range, 60-184). The mean estimated blood loss was 110 mL (range, 40-380). Complications occurred in 7 patients (27%). No operative mortality occurred in this study. The mean length of hospital stay was 5 days (range, 3-14). Our results and the results of others show that laparoscopic cholecystectomy in cirrhotic patients seems to be safe in selected Child-Pugh class A and B patients with compensated cirrhosis. Cholecystectomy remains a high-risk procedure in cirrhotic patients, and indications for cholecystectomy should be evaluated carefully. Controlled trials are required to confirm the safety of this procedure, and further studies are also required to evaluate the management of gallbladder disease in patients with Child-Pugh class C cirrhosis.

Laparoscopic Cholecystectomy in Cirrhotic Patients

Background/Aims: Laparoscopic cholecystectomy has become the procedure of choice for symptomatic cholelithiasis. A study to evaluate the benefits and risks of laparoscopic cholecystectomy in cirrhotic patients was performed. Methods: Between January 1994 and December 2000, 1,100 laparoscopic cholecystectomies for symptomatic gallbladder diseases were performed. There were 24 cirrhotic patients (group A) and 72 age- and sex-matched controls (group B). All patients had well-compensated cirrhosis (Child’s class A or B). Results: There was no operative mortality in either group and the postoperative complication rates were 20.8 and 9.72% in groups A and B, respectively (p < 0.000001). Operative time in group A was 89.16 vs. 68.41 min in group B (p < 0.000001). The estimated intraoperative blood loss in group A was 106.25 vs. 37.08 ml in group B (p < 0.000001). The average transfusion requirement was 0.155 and 0.0 units in groups A and B, respectively (p < 0.025). The hospital stay in groups A and B was 4.7 and 3.61 days, respectively (p < 0.0500). Conclusion: Laparoscopic cholecystectomy in patients with compensated cirrhosis is safe and should be the treatment of choice for these patients. Laparotomy should be applied only if the surgeon considers the operation inadequate to be continued laparoscopically.