Or Open Cholecystectomy Research Articles

Comparative Study between Laparoscopic and Open Cholecystectomy: Complications and Management

Introduction: Laparoscopic cholecystectomy (LC) is currently the most widely used surgical procedure for the treatment of gallstones. The aim of the study was to analyze and compare the postoperative results of patients undergoing laparoscopic cholecystectomy or open cholecystectomy (OC) with regard to complications, recovery time and hospital stays.
 Materials and Methods: This is a retrospective study which was conducted at the General Hospital Khulna and some of the private Hospital in Khulna City from January 2015 to December 2019. This study which analyzed among 950 patients, 20-65 years old, diagnosed with gallstones undergoing LC or OC. We evaluated postoperative respiratory complications, surgical site infection, deep vein thrombosis, time to oral feeding and ambulation, use of antibiotics and duration of the postoperative period.
 Results: We analyzed 570(60%) patients undergoing LC and 380 (40%) OC. Most patients were female (55%). Patients' comorbidities were hypertension (12.8%), diabetes mellitus (4.5%) and asthma (1.00%). LC resulted in lower prevalence of postoperative complications (2.8%) than OC (3.4%). Postoperative hospitalization for 2-3 days was found in LC patients and 5-7 days in OC.
 Conclusion: Laparoscopic cholecystectomy showed higher benefits for patients with lower prevalence of postoperative complications, feeding earlier and shorter mean hospital stay compared with open cholecystectomy.
 Medicine Today 2021 Vol.33(1): 19-21

Percutaneous cholecystostomy for grade III acute cholecystitis is associated with worse outcomes

BackgroundThe aim of the present study was to evaluate the mortality, morbidity, and readmissions associated with management of grade 3 cholecystitis in the elderly, vulnerable population. MethodsThis was a retrospective cohort study of non-elective admissions for acute cholecystitis from 2010 to 2015 using the nationwide readmissions database for adults ≥ 65 years with evidence of end-organ dysfunction (grade 3) who underwent percutaneous cholecystostomy (PC), laparoscopic (LC) or open cholecystectomy (OC). Index and readmission outcomes were analyzed using logistic regression and inverse probability treatment weight analysis. ResultsOf the estimated 358,624 patients, 14.9% underwent PC, 15.7% OC, and 69.4% LC. PC had significantly higher odds of mortality (AOR 5.8, 95%CI 5.1–6.6), composite morbidity (AOR 3.8, 95%CI 3.5–4.1), early (AOR 1.9, 95%CI 1.7–2.0) and intermediate (AOR 2.2, 95%CI 2.0–2.5) readmission compared to LC and OC. ConclusionsPatients undergoing cholecystostomy had higher mortality, complications, and readmission rates warranting revaluation of criteria for cholecystostomy at initial presentation.

Cholecystectomy following percutaneous cholecystostomy tube placement leads to higher rate of CBD injuries.

Percutaneous cholecystostomy tube (PCT) placement is often the management of severe acute cholecystitis in the unstable patient. PCT can be later reversed and cholecystectomy performed. The purpose of this study is to investigate the incidence of subsequent cholecystectomy and clinical factors associated with subsequent procedure. The SPARCS, an administrative database, was used to search all patients undergoing PCT placement between 2000 and 2012 in the state of New York. Using a unique identifier, all patients were followed for subsequent cholecystectomy procedures for at least 2years. Patients were also followed up to 2014 for potential CBD injury during subsequent laparoscopic (LC) or open cholecystectomy (OC). Univariate and multivariable regression analysis were performed when appropriate. There were 9738 patients identified who underwent PCT placements. The incidence of patients who had a PCT in 2000-2012, which subsequently underwent cholecystectomy increased from 25.0% in 2000 to 31.7% in 2012. In addition, patients undergoing subsequent LC increased from 11.8% in 2000 to 22.2% in 2012, while the incidence of OC decreased from 13.2% in 2000 to 9.5% in 2012. After accounting for other confounding factors, younger male patients, race as white compared to black, who didn't have any complications during PCT placement were more likely to undergo subsequent cholecystectomy (p < 0.05). Average time to LC was 122.0 days versus 159.6 days for OC (p < 0.0001). From the patients who underwent cholecystectomy following PCT, 47 patients experienced CBD injury (1.6%). Incidence of cholecystectomy following PCT increased during the study period. Surgeons seem to be more comfortable performing LC as rate of LC increased from 11.8 to 22.2%. However, rate of CBD injury is higher during subsequent cholecystectomy compared to that of the general population. Caution should be used when performing subsequent cholecystectomy following PCT, as these procedures may be more technically challenging.

Cholecystectomy vs. percutaneous cholecystostomy for the management of critically ill patients with acute cholecystitis: a protocol for a systematic review.

BackgroundAcute cholecystitis is a common diagnosis. However, the heterogeneity of presentation makes it difficult to standardize management. Although surgery is the mainstay of treatment, critically ill patients have been managed via percutaneous cholecystostomy. However, the role of percutaneous cholecystostomy in the management of such patients has not been clearly established. This systematic review will compare the outcomes of critically ill patients with acute cholecystitis managed with percutaneous cholecystostomy to those of similar patients managed with cholecystectomy.Methods/designSystematic searches will be conducted across relevant health databases including the Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, Embase, and Scopus using the following keywords: (acute cholecystitis OR severe cholecystitis OR cholecystitis) AND (cholecystectomy OR laparoscopic cholecystectomy OR open cholecystectomy) AND (Cholecystostomy OR percutaneous cholecystectomy OR gallbladder drain OR gallbladder tube OR transhepatic gallbladder drain OR transhepatic gallbladder tube OR cholecystostomy tube). The reference lists of eligible articles will be hand searched. Articles from 2000–2014 will be identified using the key terms “acute cholecystitis, cholecystectomy, and percutaneous cholecystostomy”. Studies including both interventions will be included. Relevant data will be extracted from eligible studies using a specially designed data extraction sheet. The Newcastle-Ottawa scale will be used to assess the quality of non-randomized studies. Central tendencies will be reported in terms of means and standard deviations where necessary, and risk ratios will be calculated where possible. All calculations will be performed with a 95 % confidence interval. Furthermore, the Fisher’s exact test will be used for the calculation of significance, which will be set at p < 0.05. Pooled estimates will be presented after consideration of both clinical and methodological heterogeneity of included studies. Both interventions would be compared with regard to in-hospital mortality, 30-day mortality, procedure-dependent complications, re-intervention, length of intensive care unit (ICU) stay, length of hospital stay, re-admission, and cost of treatment.The review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.DiscussionThis systematic review aims at identifying and evaluating the clinical value of percutaneous cholecystostomy in the management of critically ill patients with acute cholecystitis.Systematic review registrationPROSPERO CRD42015016205

Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study

BackgroundMorbidity and mortality are very high for critically ill patients who develop acute acalculous cholecystitis (AAC). The aim of this study was to compare outcomes in extremely ill patients with AAC treated with percutaneous cholecystostomy (PC), laparoscopic cholecystectomy (LC), or open cholecystectomy (OC), which were also analyzed together in the LC-plus-OC (LO) group. MethodsDischarge data from the University HealthSystem Consortium database were accessed using International Classification of Diseases codes. The University HealthSystem Consortium's Clinical Data Base/Resource Manager allows member hospitals to compare patient-level, risk-adjusted outcomes. Multivariate regression models for extremely ill patients undergoing PC or LO for the diagnosis of AAC were created and analyzed. ResultsA total of 1,725 extremely ill patients were diagnosed with AAC between October 2007 and June 2011. Patients undergoing PC (n = 704) compared with the LO group (n = 1,021) showed decreased morbidity (5.0% with PC vs 8.0% with LO, P < .05), fewer intensive care unit admissions (28.1% with PC vs 34.6% with LO, P < .05), decreased length of stay (7 days with PC vs 8 days with LO, P < .05), and lower costs ($40,516 with PC vs $53,011 with LO, P < .05). Although perioperative outcomes of PC compared with LC were statistically similar, PC had lower costs compared with LC ($40,516 vs 51,596, P < .005). Multivariate regression analysis showed that LC (n = 822), compared with OC (n = 199), had lower mortality (odds ratio [OR], .3; 95% confidence interval [CI], .1 to .6), lower morbidity (OR, .4; 95% CI, .2 to .7), reduced intensive care unit admission (OR, .3; 95% CI, .2 to .5), and similar 30-day readmission rates (OR, 1.0; 95% CI, .6 to 1.5). Also, decreased length of stay (7 days with LC vs 8 days with OC) and costs ($51,596 with LC vs $61,407 with OC) were observed, with a 26% conversion rate to an open procedure. ConclusionsOn the basis of this experience, extremely ill patients with AAC have superior outcomes with PC. LC should be performed in patients in whom the risk for conversion is low and in whom medical conditions allow. These results show PC to be a safe and cost-effective bridge treatment strategy with perioperative outcomes superior to those of OC.

Laparoscopic versus open cholecystectomy: complications and cost

Purpose: Laparoscopic cholecystectomy (LC) is currently the most widely used surgical procedure for the treatment of gallstones. The aim of the study was to analyze and compare the postoperative results of patients undergoing laparoscopic cholecystectomy or open cholecystectomy (OC) with regard to complications, recovery time, hospital stay and cost. Method: This is a prospective study, which analyzed 1015 patients, 20-65 years old, diagnosed with gallstones undergoing LC or OC. We evaluated postoperative respiratory complications, surgical site infection, deep vein thrombosis, time to oral feeding and ambulation, use of antibiotics, duration of the postoperative period and the cost of surgery. Results: We analyzed 470 (46%) patients undergoing LC and 545 (54%) OC. Most patients were female (68,4%). Patients' comorbidities were hypertension (15.8%), diabetes mellitus (4.0%) and asthma (1.18%). LC resulted in lower prevalence of postoperative complications (2.9%) than OC (5.13%). Postoperative hospitalization for 18-24 hours was found in 71.68% of LC patients and in 13.4% in OC. The financial cost per surgery was US$ 495.00 in LC and US$ 435.00 in OC. Conclusion: Laparoscopic cholecystectomy showed higher benefits for patients with lower prevalence of postoperative complications, feeding earlier, shorter mean hospital stay and equivalent cost compared with open cholecystectomy.

Thirty-day complications after laparoscopic or open cholecystectomy: a population-based cohort study in Italy

ObjectiveThe objective of the study is to evaluate short-term complications after laparoscopic (LC) or open cholecystectomy (OC) in patients with gallstones by using linked hospital discharge data.DesignPopulation-based cohort study.SettingData were...

Efficacy and feasibility of laparoscopic subtotal cholecystectomy for acute cholecystitis.

Backgrounds/AimsFor patients with acute cholecystitis, conversion from laparoscopic cholecystectomy to open surgery is not uncommon due to possibilities of serious hemorrhage at the liver bed and bile duct injury. Recent studies reported successful laparoscopic subtotal cholecystectomy for acute cholecystitis. The purpose of this study was to determine the efficacy and feasibility of such an operation based on the experience of surgeons at our facility.MethodsIn this study, we enrolled 144 patients who had received either laparoscopic subtotal cholecystectomy (LSC), laparoscopic cholecystectomy (LC), or open cholecystectomy (OC) for acute cholecystitis from January 2004 to December 2009 at the Department of Surgery of our hospital. Their symptoms, signs, operative findings, pathologic results and postoperative results were compared and analyzed.ResultsThere were 26 patients in the LSC group 80 in the LC group and 38 in the OC group. There were no differences in mean age, sex, and symptoms of acute cholecystitis. The LSC group showed higher CRP levels (p<0.001) and a higher grade according to the Tokyo criteria (p=0.001). The mean operative time was 115.6 minutes and mean blood loss was 158.9 ml without intra-operative or postoperative transfusion. There weren't any bile duct injuries during the operation. No group suffered bile leakage. Drains were removed 3.3 days after the operation in the LC group, the shortest time compared to the other groups (p<0.001). LC and LSC groups demonstrated shorter postoperative hospital days and time to diet resumption than the OC group (p<0.001).ConclusionsLSC appears to be a safe and effective treatment in cases of severe acute cholecystitis that require consideration of conversion to open surgery.

Immunological Effects of Laparoscopic and Open Cholecystectomy

This prospective, randomized, controlled study evaluated plasma levels of interleukin-18 (IL-18) and monocyte chemotactic protein-1 (MCP-l) in patients undergoing cholecystectomy. Forty patients were randomized to undergo laparoscopic cholecystectomy (LC) or open cholecystectomy (OC). Plasma concentrations of IL-18 and MCP-1 were measured before anaesthesia (T(0)), before operation (T(1)), 30 min after the start of the operation (T(2)) and at the end of the operation (T(3)). Compared with T(0), the IL-18 concentration was significantly increased at T(2) and T(3) in both groups. In addition, the MCP-1 concentration was significantly increased at T(3) compared with T(0) in the LC group. Both the IL-18 and MCP-1 concentrations were significantly lower in the OC group than in the LC group at T(3). It is suggested that carbon dioxide pneumoperitoneum may cause immunodepression, that epidural anaesthesia can attenuate the stress response, and that IL-18 and MCP-1 are sensitive markers for evaluating the patient's immune function.

Conversion rate in laparoscopic cholecystectomy: evolution from 1993 and current state.

The definition of difficult laparoscopic cholecystectomy (LC) is inconsistent. The aim of this study was to analyze the factors that make LC difficult to perform and determine ways to avoid conversion, based on our series. All patients who underwent LC or open cholecystectomy (OC) between January 1993 and December 2001 in our division of general surgery were the subject matter of this study. Preliminary decisions regarding LC or OC were avoided. Our experience (1993-2001) was based on 1360 consecutive elective LC procedures in 381 male and 979 female patients. The mean age of the patients at operation was 53 years (range, 17-84). The median operating time was 55 minutes (range, 35-180). The overall conversion rate was 1.8%. Indications for conversion included surgical difficulty during the laparoscopic procedure and anesthesia issues. The conversion rate has decreased to less than 1% in recent years. There were no mortalities, and the postoperative complication rates were low. The mean hospital stay of the patients was 2.6 days. In conclusion, based on our experience, we suggest limiting OC to patients with proven contraindications to LC (i.e., Mirizzi syndrome or systemic illness incompatible with pneumoperitoneum), attempting LC in all other cases, and considering cholecystostomy and delayed LC as an alternative to conversion during difficult LC.

The learning curve of laparoscopic cholecystectomy and changes in indications: one institutions's experience with 2,650 cholecystectomies.

In a prospective series of 2,650 consecutive patients undergoing cholecystectomy, we analyzed the learning curve since the introduction of laparoscopic cholecystectomy (LC) in terms of operating time, conversion rate, morbidity, mortality, and consequent changes in indications for either laparoscopic or open cholecystectomy (OC). Between July 1990 and June 1997, LC was performed in 1,929 patients (73%), 203 of whom (7.5%) had to be converted to OC, while 518 patients (19.5%) had primary OC. Patients having LC were predominantly female, younger, with less comorbidity and less complicated gallstone disease than patients having OC. Barring a learning curve during the first 6 months of LC, operating time remained constant at an average of 71 minutes while operating on ever more complex pathologies. The conversion rate decreased from 9.4% to 6.7% during the 7-year period. A relatively constant team of surgeons with growing experience as well as constantly improving technical equipment allowed the complication rate to remain low. The total morbidity of LC was 2.5% (0.1% bile duct injury), that of conversions 5%, and that of OC 12.5%. The mortality was 0 for LC, 0.5% for conversions, and 1% for OC. The indications for primary OC decreased from 50% to 8.5% and the indications for LC could be broadened over the years.

Effect of open and laparoscopic surgery on cellular immunity in a swine model.

Immune suppression associated with trauma has been demonstrated to be proportional to the magnitude of injury. Laparoscopic surgery has been shown to produce a diminished stress response compared to open surgery. Postoperative immune function, specifically cellular immunity, may be better preserved after laparoscopic surgery compared to open surgery. The aim of this study was to examine the effect of open versus laparoscopic surgery on cellular immunity in a swine model. Twenty domestic female pigs were randomly selected for laparoscopic cholecystectomy (LC) or open cholecystectomy (OC). Cellular immune functions were evaluated with delayed-type hypersensitivity (DTH) skin test and serial phytohemoagglutinin (PHA)-induced T-cell proliferation of the peripheral blood. There was a significant reduction in PHA-induced T-cell proliferation in both LC and OC groups on days 1 and 3 compared to preoperative values (p < 0.05). The reduction of mitogen-induced T-cell proliferation after LC was significantly less than after OC on day 1 (p = 0.03). The mean DTH reaction was 29.7 +/- 3.7 mm2 in the LC group compared to 13.9 +/- 1.2 mm2 in the OC group (p < 0.001). There was no difference in postoperative white blood count values between the two groups. Suppression of cellular immunity occurred after both LC and OC. The magnitude and duration of impaired cellular immunity after laparoscopic surgery was less than after open surgery as measured by T-cell proliferation and DTH response.

Effect of Open and Laparoscopic Surgery on Cellular Immunity in a Swine Model

Immune suppression associated with trauma has been demonstrated to be proportional to the magnitude of injury. Laparoscopic surgery has been shown to produce a diminished stress response compared to open surgery. Postoperative immune function, specifically cellular immunity, may be better preserved after laparoscopic surgery compared to open surgery. The aim of this study was to examine the effect of open versus laparoscopic surgery on cellular immunity in a swine model. Twenty domestic female pigs were randomly selected for laparoscopic cholecystectomy (LC) or open cholecystectomy (OC). Cellular immune functions were evaluated with delayed-type hypersensitivity (DTH) skin test and serial phytohemoagglutinin (PHA)-induced T-cell proliferation of the peripheral blood. There was a significant reduction in PHA-induced T-cell proliferation in both LC and OC groups on days 1 and 3 compared to preoperative values (p < 0.05). The reduction of mitogen-induced T-cell proliferation after LC was significantly less than after OC on day 1 (p = 0.03). The mean DTH reaction was 29.7 ± 3.7 mm2 in the LC group compared to 13.9± 1.2 mm2 in the OC group (p < 0.001). There was no difference in postoperative white blood count values between the two groups. Suppression of cellular immunity occurred after both LC and OC. The magnitude and duration of impaired cellular immunity after laparoscopic surgery was less than after open surgery as measured by T-cell proliferation and DTH response.

Systemic and Cell-Mediated Immune Response after Laparoscopic and Open Cholecystectomy in Patients with Chronic Liver Disease

Background: As impaired immune function observed in cirrhotic patients is known to increase the risk of postoperative complications, the immunological response to surgery was investigated. Methods: Twenty-eight patients with postnecrotic liver cirrhosis or chonic hepatitis C and symptomatic gallstone disease were randomly allocated to laparoscopic (LC) or open cholecystectomy (OC). Changes in concentrations of cytokines (TNF-α, IL-1β, IL-6, IL-8 and IL-10) were followed and the effect of surgical trauma on the distribution of lymphocyte subpopulations (CD3, CD4, CD8, CD16 and CD19) and NK cell cytotoxicity were measured. Results: After OC a decrease in circulating CD3 (p < 0.05) and CD4 (p < 0.05) and an increase in CD19 (p < 0.05) cells were detected in contrast to LC after which only CD16 cells decreased (p = 0.05). The number of CD3 cells was higher after LC than after OC (p < 0.01), whereas the number of CD19 cells was higher after OC than after LC (p < 0.01). NK cell cytotoxicity was reduced after LC (p < 0.05). In cirrhotic patients circulating cytokines were unaffected by OC, whereas TNF-α (p < 0.05) and IL-1β (p < 0.05) were reduced after LC. In chronic hepatitis IL-1β decreased after OC (p = 0.05) and IL-10 was significantly higher after LC than following OC (p < 0.05). Conclusion: The immune response is less pronounced after a laparoscopic procedure compared to a conventional approach in patients with chronic liver disease.

Multivariate Comparison of Complications After Laparoscopic Cholecystectomy and Open Cholecystectomy

To answer the question whether laparoscopic cholecystectomy (LC) or open cholecystectomy (OC) is safer in terms of complications, the authors evaluated complications relating to 1440 cholecystectomies performed by the same surgeons in a retrospective study. A definite pronouncement on whether LC truly is superior to OC is not possible because prospective trials are burdened with problems of recruitment. After the introduction of LC at the authors' institution in April 1991 and until October 1993, 94.6% (700/740) of all patients admitted for operation because of symptomatic gallstone disease could be treated laparoscopically. The clinical records of the last 700 patients who underwent OC before the introduction of LC were re-evaluated with regard to both overall complications and the grade of complication (severity grade 1-4). A comparison of the incidence of complications relating to the two surgical methods, age, sex, common bile duct stones, acute cholecystitis, concomitant illness, Apache score, and length of operation was calculated by multivariate analysis using the logistic regression model. The total rate of complications in the OC group was 7.7%, with five postoperative deaths, compared with 1.9% and one postoperative death in the LC group. Multivariate analysis for OC revealed that both old age (p = 0.014) and the existence of common bile duct stones (p = 0.02) had independent prognostic influences in increasing the overall complication rate, whereas only old age (p = 0.019) influenced the overall complication rate after LC. Multivariate analysis of all cholecystectomies (n = 1440) showed that the overall complication rate was influenced independently by OC as a detrimental factor. As this analysis emphasizes, LC can be performed safely with an overall complication rate that is distinctly lower than that of OC. For selective surgery, LC is undoubtedly superior to OC and can probably be seen as a new "gold standard" for cholecystectomies.

Cholecystectomy

Laparoscopic cholecystectomy (LC), which results in less postoperative pain, disability, and scarring, has become an attractive alternative method of surgical management of the ambulatory patient with gallbladder disease. The best procedure for severely ill patients who are poor operative risks but require cholecystectomy, however, is unknown since the operative morbidity and mortality of LC in this group of patients had not been studied. All patients (177) undergoing cholecystectomy at one institution were evaluated. Based on their preoperative state of health as defined by a modified acute physiologic score (APS), patients were divided into two groups; one group was defined by an APS of less than 10, indicating they were in good health, and the other had an APS greater than or equal to 10, indicating that the group had multiple risk factors, predicting an increased postoperative morbidity and mortality. Selection for either procedure, LC or open cholecystectomy (OC), was made independently of the patient's preoperative status. Patients' past medical histories; demographic, physiologic, and laboratory data; and postoperative complications were evaluated. When all cholecystectomy patients were arranged into the respective risk groups, the age and severity of illness scores (APS) between LC and OC were not statistically different. Intraoperative and postoperative complications were not significantly different when patients undergoing LC were compared to patients undergoing OC. Laparoscopic cholecystectomy was associated with decreased hospitalization when compared to patients undergoing OC. The overall mortality of the patients undergoing OC was significantly greater than those undergoing LC. LC is an acceptable surgical alternative for high-risk patients requiring cholecystectomy.