Risks Of Laparoscopic Cholecystectomy Research Articles

ACUTE CHOLECYSTITIS IN HIGH-RISK PATIENTS. SURGICAL, RADIOLOGICAL, OR ENDOSCOPIC TREATMENT? BRAZILIAN COLLEGE OF DIGESTIVE SURGERY POSITION PAPER.

Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as empyema, gangrene, perforation of the gallbladder, and sepsis. The gold standard treatment for AC is laparoscopic cholecystectomy. However, for a small group of AC patients, the risk of laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these critically ill patients, percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to cholecystectomy. The objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons, endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological, and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise; c) Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous or endoscopic gallbladder drainage is not available; d) Percutaneous cholecystostomy and endoscopic gallbladder drainage should be performed only in well-equipped hospitals with experienced interventional radiologist and/or endoscopist; e) Cholecystostomy catheter should be removed after resolution of AC. However, in patients who have no clinical condition to undergo cholecystectomy, the catheter may be maintained for a prolonged period or even definitively; f) If the cholecystostomy catheter is maintained for a long period of time several complications may occur, such as bleeding, bile leakage, obstruction, pain at the insertion site, accidental removal of the catheter, and recurrent AC; g) The ideal waiting time between cholecystostomy and cholecystectomy has not yet been established and ranges from immediately after clinical improvement to months. h) Long waiting periods between cholecystostomy and cholecystectomy may be associated with new episodes of acute cholecystitis, multiple hospital readmissions, and increased costs. Finally, when selecting the best treatment option other aspects should also be considered, such as costs, procedures available at the medical center, and the patient's desire. The patient and his family should be fully informed about all treatment options, so they can help making the final decision.

SP6.1.5 Morbidity following emergency and elective laparoscopic cholecystectomy for cholecystitis: a retrospective comparative cohort study

Abstract Aims A comprehensive comparison of post-operative outcomes between emergency and elective laparoscopic cholecystectomy (LC) for cholecystitis has not been conducted and the relative morbidity associated with emergency LC remains uncertain. Our aim was to evaluate the difference in early post-operative outcomes between emergency and elective LC for patients with cholecystitis. Method LC performed for cholecystitis across three surgical units between January 2015 and January 2020 were analysed retrospectively from multiple regional databases using deterministic records-linkage methodology. Rates of complications, further imaging, re-intervention, prolonged post-operative stay and re-admissions over a 100-day follow-up period were compared between emergency and elective groups using univariate and multivariate analysis. Results LC were performed for cholecysitits in 962 cases (median age, 52 years; M:F, 1:2.7; emergency:elective; 1:3.9). Emergency cholecystectomy had higher rates of complication (15.8% versus 8.8%;p<0.0001), prolonged post-operative stay (40.3% vs. 12.7%;p<0.0001), post-operative imaging and intervention (19.1% vs. 9.4%;p<0.0001) and readmission (11.1% vs. 7.0%;p=0.017). In the multivariate regression analysis, emergency LC was associated with prolonged admission (OR,5.7;p<0.0001), complication (OR,2.97;p<0.0001), post-operative imaging and intervention (OR,2.4;p=0.002) and readmission (OR,1.9; p = 0.06). Conclusions Despite current guidance, an emergency cholecystectomy remains a morbid procedure and we demonstrate increased risks of emergency LC versus elective LC. The increased risk of an emergency LC needs to be weighed up against the risk of further attacks from biliary pathology until elective surgery. Our data indicates that we need to readjust our selection criteria for the ‘emergency cholecystectomy patient’ and identify patients who will specifically benefit from earlier surgery.

Assessment of clinical, hematological, radiological parameters for prediction of difficult laparoscopic cholecystectomy at a tertiary health care centre

Background: Since its introduction in the mid 1980’s, laparoscopic cholecystectomy (LC) has been widely used for symptomatic cholelithiasis. In recent years it has been considered as a gold standard for treatment of symptomatic cholelithiasis. Recent studies have reported that the rate of conversion of LC to open cholecystectomy (OC) is 1.5-19%. The aim of the present study was to predict the difficulties of performing laparoscopic cholecystectomy in symptomatic cholelithiasis. Further, the possibility of converting LC to open cholecystectomy was also investigated using various haematological, clinical, and radiological tool such as USG.Methods: The present prospective study was conducted in in Nehru Hospital of BRD Medical College, Gorakhpur, India over a period of 12 months on in-patients from various surgical wards undergoing LC. The patients were primarily divided into two groups consisting of those undergoing LC and those converted to OC respectively. Parameters like gender, age, body mass index, associated complains, total leukocyte count (TLC) and levels of alkaline phosphatase (ALP) were assessed as potential risk factors for conversion.Results: 50 patients were considered for this study. Results indicated that rate of conversion of LC to OC was found to be maximum for patients belonging to male gender, 31-40 years old, were obese, had previous history of upper abdominal surgery and had raised levels of TLC and ALP. Patients having multiple stones and contracted gall bladder also had a higher incidence of conversion to OC.Conclusions: From results obtained in this study, it could be concluded that parameters like age, gender, obesity, history of upper abdominal surgery, raised levels of TLC and ALP, incidences of multiple stones and contracted gall bladder posed significant risk for LC and acted as predictors for conversion to OC.

End-stage renal disease is a risk factor for complex laparoscopic cholecystectomy in patients waiting for renal transplantation.

Introduction:To date, there are no studies investigating whether laparoscopic cholecystectomy (LC) is technically more complex in patients waiting for kidney transplant. The aim of this study is to create a user-friendly score to identify high-risk cases for complex LC integrating end-stage renal disease (ESRD).Materials and Methods:We retrospectively analysed 321 patients undergoing LC during the period 2014–2016. Two groups were compared: ESRD group (n = 25) versus control group (n = 296). Concerning statistical analysis, continuous variables were compared using Kruskal–Wallis’ test, dummy variables with Chi-square test or Fisher's exact test when appropriate. A multivariable logistic regression analysis was performed to identify risk factors for complex LC. A backward conditional method was used to design the final model.Results:Seventy out of 321 (21.8%) cases were considered as complex, with a higher prevalence in the ESRD group (32.0 vs. 20.9%; P = 0.2). Using a multivariable logistic regression analysis, we formulated a score based on the independent risk factors for complex LC: 4×(previous cholecystitis) +5 × (previous ESRD) +1 × (age per decade) +2 × (previous open abdominal surgery). High-risk cases (score ≥ 10) were more commonly reported in the ESRD group (72.0 vs. 24.7%; P < 0.0001).Conclusion:Although several scores investigating the risk for complex LC have been proposed, none of them has focused on ESRD. This is the first series demonstrating that ESRD is an independent risk factor for technical complexity in LC. We developed a score to offer surgeons an extra tool for pre-operative evaluation of patients requiring LC.

Prevention and treatment of laparoscopic cholecystectomy in patients with liver cirrhosis

Objective To explore the risk and treatment of laparoscopic cholecystectomy(LC) in patients with liver cirrhosis and cholelithiasis. Methods To summarize the clinical data of 28 patients with liver cirrhosis and cholelithiasis. The patients were repeated right upper quadrant pain, including 4 cases of gallbladder neck stones incarcerated, gallbladder effusion. Among them, there were 20 cases of hepatitis B cirrhosis, 5 cases of schistosomiasis cirrhosis, 3 cases of alcohol. Results There were 6 patients with hemorrhage during operation. Among them, 5 patients were treated with gelatin sponge, hemostatic gauze and bio-glue spray to stop bleeding, 1 case was transferred to open surgery because of bleeding. The remaining 27 cases of LC were successful. Complications occurred in 8 patients, 3 cases of increased liver function abnormalities, 1 case of upper gastrointestinal bleeding, 1 case of mild hepatic encephalopathy, 2 cases of significant ascites formation, 1 patient underwent subtotal resection of the gallbladder with Hartmanns bag, and bile was found in the ascites after surgery, but the bile disappeared after five days. All patients with complications after symptomatic treatment were cured, no death, no major bleeding and liver failure, bile duct injury, severe biliary fistula and other serious complications. Conclusion Although the risk of LC in patients with liver cirrhosis is higher than that in the general population, with the help of current high-tech surgical instruments, we can safely accomplish this with an improved surgical procedure. As these patients require high technical requirements of surgery, surgeons must have a wealth of experience and familiar laparoscopic liver and gallbladder anatomy. Key words: Cholecystectomy; Laparoscopic; Liver cirrhosis

The risks of laparoscopic cholecystectomy, the consistent inconsistency of surgical consenting

The risks of laparoscopic cholecystectomy, the consistent inconsistency of surgical consenting

Impact of Obesity and Associated Diseases on Outcome After Laparoscopic Cholecystectomy

Obesity is a risk factor for operative treatment. This study examined the impact of obesity and associated comorbidities on complications after laparoscopic cholecystectomy (LC). Altogether, 1581 consecutive patients with symptomatic gallstones underwent LC between the years 1995 and 2008. Preoperative data and operative outcome of the 437 obese patients [302 with body mass index (BMI) 30 to 35 kg/m² and 135 with BMI ≥ 35.1 kg/m²] and 1144 nonobese controls (BMI ≤ 29.9 kg/m²) undergoing LC were compared. The impact of obesity, diabetes, cholecystitis, coronary heart disease, pulmonary disease, hypertension, and renal insufficiency on the postoperative outcome was analyzed by using multiple logistic regression analysis. The percentage of obese patients undergoing LC did not change during the study period. Over half of obese patients (63%) had 1 or multiple comorbidities, but only 15% of the patients had an acute surgery because of cholecystitis. Conversion to open surgery was required in 11.7% of the obese patients compared with 6.1% in the nonobese controls (P=0.0003). Acute cholecystitis increased the conversions in class II and III obese patients (50%) compared with elective surgery (8.7%, P<0.001). Mortality rate was 0 in obese patients and the rate of complications, except surgical site infections, comparable with nonobese patients. In multivariate analysis, obesity or any of the comorbidities did not associate with an elevated risk for postoperative complications. In symptomatic gallstone disease, obesity and related comorbidities increased the conversion rate, but not the operative risks of LC.

Прогнозування перебігу пневмоперитонеуму та тактика хірургічого лікування хворих на гострий і хронічний холецистит із супутньою патологією серцево-судинної системи

The share of elderly and senile patients with acute cholecystitis concomitant cardiovascular pathology whom the laparoscopic cholecystectomy has been provided is increased. The heightened intraabdominal pressure has negative influence at the cardiovascular system, so the alternative ways for treatment of this group of patients are used in clinic. We propose the pneumoperitoneum model using the pneumatic belt which is fixed at the abdomen in preoperative period in patients with an acute and chronic cholecystitis. This model is useful to forecast cardiovascular disorders during future laparoscopic cholecystectomy. The arterial pressure level, pulse score and ECG are monitored during the test (90 min). Myocardial ischemia appearance seems that the risk of laparoscopic cholecystectomy with pneumoperitoneum is high. The alternative method of surgery in such group of patients (no pneumoperitoneum is applied) is laparoscopic assisted cholecystectomya from miniaccess. This method allows to reducing frequency of intra- and postoperative complications connected with pneumoperitoneum negative influence at the patients with concomitant pathology of cardiovascular system.

Laparoscopic versus open cholecystectomy in cirrhotic patients: A prospective randomized study

Background Improved laproscopic experience and techniques have made laparoscopic cholecystectomy (LC) feasible options in cirrhotic patients. This study was designed to compare the risk and benefits of open cholecystectomy (OC) versus LC in compensated cirrhosis. Method A randomized prospective study, in the period from October 2002 till December 2006, where 110 cirrhotic patients with symptomatic gallstone were randomly divided into OC group (55 patients) and LC group (55 patients). Results There was no operative mortality. In LC group 4 (7.33%) patients were converted to OC. Mean surgical time was significantly longer in OC group than LC group (96.13 + 17.35 min versus 76.13 + 15.12) P < 0.05, associated with significantly higher intraoperative bleeding in OC group ( P < 0.01), necessitating blood transfusions to 7 (12.72%) patients in OC group. The time to resume diet was 18.36 + 8.18 h in LC group which is significantly earlier than in OC group 47.84 + 14.6 h P < 0.005. Hospital stay was significantly longer in OC group than LC group (6 + 1.74 days versus 1.87 + 1.11 days) P < 0.01 with low postoperative morbidity. Conclusion LC in cirrhotics is still complicated and highly difficult which associates with significant morbidity compared with that of patients without cirrhosis. However, it offers lower morbidity, shorter operative time; early resume dieting with less need for blood transfusion and reducing hospital stay than OC.

Unsuspected gallbladder carcinoma after laparoscopic cholecystectomy

Many cases have been reported of disastrous port-site recurrence after laparoscopic cholecystectomy (LC) revealed unsuspected gallbladder carcinoma (GBC). Some investigators have reported that the prognosis of patients after LC showed unsuspected GBC is not worsened by laparoscopic procedures. We retrospectively reviewed our cases and the literature to reconfirm the intrinsic risks of LC for unsuspected GBC. Of 1663 patients who underwent LC from January 1991 to December 2003 in a single institution, 9 (0.54%) with unsuspected GBC were reviewed. These 9 patients consisted of 5 men and 4 women, whose ages ranged from 58 to 87 years, with a median age of 73 years. Two patients with a pT1a tumor (limited to mucosa) and 2 patients with a pT1b tumor (muscle layer) underwent no further operation. The remaining 5 patients with a pT2 tumor (subserosa) underwent further operations with lymph node dissection. Five patients (2 patients with pT1b and 3 patients with pT2) developed recurrence and all of them died within a median period of 19 months (range 14-37 months) after LC. The causes of death were bone metastases in 1 patient (pT2), local recurrence in 2 patients (pT1b and pT2), and peritoneal metastasis in 2 patients (one elderly patient with pT1b who underwent laparoscopic common bile duct exploration, and one patient with pT2 in whom the cystic duct was damaged during surgery). Four patients (2 with pT1 and 2 with pT2) have been doing well with a median follow-up of 39.5 months (range 12-99 months) after LC. Surgeons should always prevent bile spillage during LC and when removing the resected gallbladder. When laparoscopic common bile duct exploration is planned, especially for elderly women, surgeons should also bear in mind the increasing possibility of unsuspected GBC.

Risk of Laparoscopic Cholecystectomy

Bereits die Eröffnung der Peritonealhöhle zur Anlage des Kapnoperitoneums birgt schwerwiegende, potenziell letale Komplikationsmöglichkeiten, die sich auch bei Berücksichtigung aller Sicherheitsmaßnahmen und Beherrschung der Technik nicht vollständig vermeiden lassen. Insbesondere bei blinder Punktion der Bauchhöhle mittels Verres-Kanüle und nachfolgender blinder Punktion mit dem ersten Trokar sind Verletzungen nahezu aller intraabdomineller und retroperitonealer Organe beschrieben. Häufige Folgen sind eine Peritonitis nach unerkannter Darmperforation sowie starke Blutungen mit Schocksymptomatik bei signifikannten Gefäßverletzungen. Darmverletzungen werden mit einer Häufigkeit zwischen 1/1000 und 1/1250, Gefäßverletzungen zwischen 1/1300 und 1/2500 angegeben [1] [2]. Konsequenterweise ist das offene Einbringen des Optiktrokares über eine Minilaparotomie zu bevorzugen.

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.

Laparoscopic Cholecystectomy in Cirrhosis: Contraindication or Privileged Indication?

Until recently, cirrhosis has been considered to be an absolute or relative contraindication of laparoscopic cholecystectomy. An evaluation of benefits and risks of laparoscopic cholecystectomy in the treatment of gall bladder lithiasis in cirrhotic patients is presented. Thirty-three consecutive laparoscopic cholecystectomies in patients with cirrhosis were performed between March 1990 and March 1997. During the same period, no open cholecystectomy was performed in patients with cirrhosis. There was no morbidity or mortality; the conversion rate was 6% (2/33). No patient received blood transfusion, and the mean hospital stay was 2.8 days. These results favorably compare with the results of open cholecystectomy. Specific advantages of laparoscopic cholecystectomy in patients with cirrhosis include the absence of wound infection and a lower rate of postoperative hepatic failure. Finally, laparoscopic surgery reduces the risk of viral contamination (the hepatitis B virus, the hepatitis C virus, or the human immunodeficiency virus) of the surgical staff.

The Risks of Laparoscopic Cholecystectomy in Capd Compared with Hemodialysis Patients: A Study of Ten Patients

The Risks of Laparoscopic Cholecystectomy in Capd Compared with Hemodialysis Patients: A Study of Ten Patients

Is Previous Abdominal Surgery a Contraindication to Laparoscopic Cholecystectomy?

Previous abdominal surgery has been reported as a relative contraindication to laparoscopic cholecystectomy. An analysis of 193 laparoscopic cholecystectomies was undertaken to determine whether this relative contraindication led to increased morbidity, an increased rate of conversion to open cholecystectomy, or longer operating time. The results of 55 patients who had previous abdominal surgery were compared with those of 138 patients without previous abdominal surgery. Morbidity, conversion rate, and operating time were not increased in patients with previous abdominal surgery. We found both previous upper and previous lower abdominal surgery to be risk for laparoscopic cholecystectomy. Laparoscopic cholecystectomy can be performed safely in patients with previous abdominal surgery if we (1) use the cutdown technique initially, (2) dissect the adhesion before the upper midline port is inserted, (3) retrogradely dissect the gallbladder from the liver bed, and (4) divide the cystic artery and duct last.