Underwent Emergency Laparoscopic Cholecystectomy Research Articles

INDURG TRIAL Protocol: A Randomized Controlled Trial Using Indocyanine Green during Cholecystectomy in Acute Cholecystitis.

Laparoscopic cholecystectomy is one of the most common gastrointestinal surgeries, and bile duct injury is one of its main complications. The use of real-time indocyanine green fluorescence cholangiography allows the identification of extrahepatic biliary structures, facilitating the procedure and reducing the risk of bile duct lesions. A better visualization of the bile duct may help to reduce the need for conversion to open surgery, and may also shorten operating time. The main objective of this study was to determine whether the use of indocyanine green is associated with a reduction in operating time in emergency cholecystectomies. Secondary outcomes are the postoperative hospital stay, the correct intraoperative visualization of the Calot's Triangle structures with the administration of indocyanine green, and the intraoperative complications, postoperative complications and morbidity according to the Clavien-Dindo classification. This is a randomized, prospective, controlled, multicenter trial with patients diagnosed with acute cholecystitis requiring emergency cholecystectomy. The control group will comprise 220 patients undergoing emergency laparoscopic cholecystectomy applying the standard technique. The intervention group will comprise 220 patients also undergoing emergency laparoscopic cholecystectomy for acute cholecystitis with prior administration of indocyanine green. Due to the lack of published studies on ICG in emergency laparoscopic cholecystectomy, this study may help to establish procedures for its use in the emergency setting.

Evaluating the predictive value of NSQIP surgical risk calculator in patients undergoing emergency laparoscopic cholecystectomy at a single UK centre

Evaluating the predictive value of NSQIP surgical risk calculator in patients undergoing emergency laparoscopic cholecystectomy at a single UK centre

EGS P05 Evaluating the predictive value of NSQIP surgical risk calculator in patients undergoing emergency laparoscopic cholecystectomy at a single UK centre

Abstract Background Machine learning algorithms for surgical risk predictions have been utilised as an informed consent tool for surgeons and patients. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is a surgical risk calculator utilising machine learning to predict adverse postoperative outcomes with surgeon adjustment of risk. However, there is a paucity of validation studies for laparoscopic cholecystectomy data. This study aimed to evaluate the predictive value of the NSQIP calculator in patients undergoing emergency laparoscopic cholecystectomy at a single UK-based centre. Methods Preoperative patient characteristics and postoperative outcome data was collected from patients who underwent emergency laparoscopic cholecystectomy between January 2022 and January 2023. NSQIP surgical risk scores were retrospectively calculated using preoperative characteristics and risk factor data. Surgeon adjustment of risk was set at the default for all patients. The predicted rates of postoperative complications, serious complications (definition as per the NSQIP calculator), and hospital readmission were compared to the observed rates using Brier scores. Results Eighty-five patients were analysed. The median age was 50 (range 19-91) and BMI was 29 (range 21-44). The NSQIP predicted an overall complication rate of 4.2%. Overall observed complication rate was 3.7% and included hospital-acquired pneumonia (n=1), pancreatitis (n=1), and postoperative atrial fibrillation (n=1). The predicted and observed complication rates were comparable (4.2% vs 3.7% respectively, Brier score 0.066). Likewise, the observed rate was also lower than predicted rate for serious complications (2.4% vs. 3.4% respectively, Brier score 0.047). The observed rate of hospital readmission was similar to predicted risk (3.7% vs. 4.0% respectively, Brier score 0.033). Conclusions In this cohort, the NSQIP surgical risk calculator demonstrated acceptable predictive ability for the risk of postoperative complications after emergency laparoscopic cholecystectomy. There was a propensity of the NSQIP calculator to overestimate the risk of complications, within the limitations of the small sample size and retrospective nature of this study. Further studies are warranted to assess the ability of the NSQIP tool to predict the risk of surgery-specific complications.

Preoperative antibiotic prophylaxis in acute cholecystectomy: a systematic review and meta-analysis of randomised controlled trials.

Laparoscopic cholecystectomy (LC) in patients admitted with acute cholecystitis is considered the preferred, feasible and safe mode of managing gallstone disease. The objective of this study is to evaluate the role of single-dose pre-operative prophylactic antibiotics in patients undergoing emergency LC for mild to moderate acute cholecystitis. All randomized control trials (RCTs) reporting the use of single-dose pre-operative prophylactic antibiotics in patients undergoing acute cholecystectomy were retrieved from the search of standard medical electronic databases and analysis was conducted by using the principles of meta-analysis on the statistical software RevMan version 5. Standard medical databases search produced only 3 RCTs on 781 patients undergoing acute cholecystectomy. There were 384 patients in single dose pre-operative antibiotics group whereas 397 patients were recruited in the no-antibiotics group. In the random effects model analysis, the use of single-dose preoperative prophylactic antibiotics in patients undergoing acute cholecystectomy for mild to moderate cholecystitis failed to demonstrate any extra advantage of reducing the risk of [risk ratio (RR) =0.69; 95% confidence interval (CI): 0.46-1.03; Z=1.80; P=0.07] infective complications. There was no heterogeneity [Tau2 =0; Chi2 =1.74, df =2 (P=0.42; I2=0%)] among included studies. A preoperative single dose of prophylactic antibiotics in patients undergoing acute LC for mild to moderate acute cholecystitis does not offer extra benefits to reduce infective complications.

The enhanced recovery after surgery (ERAS) protocol in elderly patients with acute cholecystitis: A retrospective study.

Enhanced recovery after surgery (ERAS) protocol is a perioperative management theory aimed at reducing the injury of surgical patients and accelerating postoperative recovery. It has been widely recognized and applied in elective surgery. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. This study aimed to evaluate the clinical value of the ERAS protocol during the perioperative period of laparoscopic cholecystectomy in elderly patients with acute cholecystitis. We collected medical data from 126 elderly patients with acute cholecystitis from October 2018 to August 2021. Among the 126 patients, 70 were included in the ERAS group and 56 in the traditional group. We analyzed the clinical data and postoperative indicators of the 2 groups. No significant differences were observed regarding the general characteristics of the 2 groups (P > .05). The ERAS group had significantly earlier time to first flatus, time to first ambulation, and time to solid intake, compared with the traditional group (P < .001); additionally, the ERAS group had significantly shorter stay and gentler feeling of postoperative pain (P < .001). Furthermore, the ERAS group had significant incidences of lower postoperative lung (P = .029) and abdominal cavity infection (P = .025) compared to the traditional group. No significant difference was observed regarding the incidences of other postoperative complications between the 2 groups (P > .05). The ERAS protocol helps reduce elderly patients' stress reactions and accelerate postoperative recovery. Thus, it is effective and beneficial to implement the ERAS protocol during the perioperative period of elderly patients with acute cholecystitis.

Gall bladder perforation: critical analysis of management at tertiary care centre

Background: Gall bladder perforation (GBP) is a rare complication of acute cholecystitis. Despite considerable advancements in diagnostic and therapeutic modalities, morbidity and mortality continues to be high, owing to delay in diagnosis and ill-defined treatment protocols. Methods: We reviewed demographic profile, diagnosis and management strategies employed in 28 patients at our centre from Jan 2018 till Jul 2020. Patients were classified based on Niemeier classification. Results: A total of 28 patients were identified but 3 excluded due to paucity of data. There were 21 patients of Niemeier type II perforation and 02 each of type I and III. Diagnosis of GBP was based on CECT in 18 patients. In patients with type II perforation, 03 underwent emergency laparoscopic cholecystectomy (LC) though one required conversion. Twelve patients were managed conservatively followed by interval cholecystectomy after mean duration of 14 weeks. Of these 08 successfully underwent LC and 03 were converted to open surgery. One patient underwent open radical cholecystectomy due to intraoperative suspicion of carcinoma. 06 patients of type II perforation underwent percutaneous drainage of collection followed by LC after mean duration of 23 weeks. Histopathology revealed chronic cholecystitis in 16 patients, acute cholecystitis in 05, carcinoma in 02 and xantho-granulomatous cholecystitis in one patient. Conclusions: CECT should be employed early for diagnosis in suspected cases and percutaneous intervention should be used in cases unresponsive to conservative measures alone. There are higher chances of success in performing LC after 14 weeks leading to better outcomes.

Emergency versus elective cholecystectomy: Experience at a university hospital in the Eastern Province, Saudi Arabia.

Laparoscopic cholecystectomy (LC), the procedure of choice for treating most gallbladder pathology, has become the most trusted elective procedure for treating gallstone disease because of its effectiveness and safety. While the timing is an important factor in those cases, our aim in this study was to compare emergency and elective LC, determine the differences in postoperative complications, and assess the conversion rate to open cholecystectomy. This study included a total of 627 patients who had undergone laparoscopic cholecystectomy during 2017-2019 at King Fahd Hospital of the University (KFHU). Records of both emergency and elective cases were reviewed from Quadra-med (software package). All demographic data of the patients, presenting complaint, laboratory and inflammatory marker, type of the operation, intraoperative complications, procedure time, conversion rate from laparoscopic to open cholecystectomy, postoperative period, length of hospital stay, and pathological diagnosis were entered into an Excel sheet. The data was analyzed using SPSS 23.0. Qualitative variables were described as frequencies and percentages, and continuous variables were summarized with mean and standard deviation (SD). Chi-square test, t-test, and the Mann-Whitney U-test were applied to test for statistical significance at P ≤ 0.05. The mean age for patients undergoing elective LC was 39.94 years (SD=13.56) whereas, mean age of patients undergoing emergency LC was 40.64 years (SD=13.02). About 71% of cases in elective LC group were females compared to 55% in the emergency LC group. There was a significant difference in C-reactive protein (CRP) in relation to the type of surgery where P < 0.05. Twelve (1.9%) patients had subtotal cholecystectomy and two cases converted from LC to open. There was a significant association between postoperative complication and the type of surgery. The length of hospital stay (LOS) was also found to be significantly more in patients having emergency LC (6.0 vs. 4.5 d; P < 0.05). The relation between conversion to an open procedure and type of surgery (elective or emergency) in our study was nonsignificant. There was a significant association between preoperative CRP, postoperative complication, length of hospital stay, and type of surgery. Further multicenter studies are required for further investigation.

Achievement of Critical View of Safety and Preoperative Characteristics: A Step Toward Acknowledging the Inflection Point

INTRODUCTION: The critical view of safety (CVS) is a surgical strategy that helps prevent bile duct injury (BDI) during laparoscopic cholecystectomy (LC). Bail-out procedure is indicated when the CVS cannot be achieved. The decision to halt the attempt of total cholecystectomy is termed inflection point. Few studies have analyzed operative difficulty as the ability to obtain the CVS, its relation to preoperative characteristics and postoperative complication. METHODS: Retrospective review of 119 patients who underwent emergency LC from March 2020 to July 2021. Patients with previous upper abdominal operation and hepatic disease were excluded. All LCs were performed by attendings. CVS was considered achieved by a 2-step review, including operative dictation and surgical video. A univariate analysis was conducted comparing the 2 groups. RESULTS: We found failure to obtain CVS in 42% of the cases; this was associated with male sex, odds ratio (OR) 2.38 (95% CI 1.13 to 5.03), BMI >35 kg/m2, OR 4.58 (95% CI 1.36 to 15.39), and a moderate/severe grade of cholecystitis OR 9.11 (95% CI 3.78 to 21.92). These patients had longer length of stay (LOS) 3.38 vs 1.68 days (p < 0.001) and higher incidence of complication, 10% vs 0% (p = 0.001), including major BDI and death (Table ). Table. - Results of the Univariate Analysis of Preoperative Characteristics for Achievement of Critical View of Safety Preoperative characteristic Failure to achieve CVS (n = 50) CVS achieved(n = 69) Odds ratio (95% CI) p Value Male sex 56% (28) 35% (24) 2.38(1.13–5.03) 0.02 Age >60 26% (13) 16% (11) 1.85(0.75–4.57) 0.18 BMI >35 kg/m2 22% (11) 6% (4) 4.58(1.36–15.39) 0.01 Moderate/severe AC (Grade II/III TG18) 82% (41) 33% (23) 9.11(3.78–21.92) <0.0001 WBC count (×103/μL) 9.59 (SD 3.37) 9.2 (SD 4.24) — 0.58 CONCLUSION: An association was found between preoperative values (male sex, BMI >35 kg/m2, and grade II/III acute cholecystitis) and failure to achieve CVS These preoperative clues may allow us to readily acknowledge the inflection point during emergency laparoscopic cholecystectomy to perform the safest surgical method. Our findings also support the association between failure of achieving CVS, increased LOS, and complication.

Routine preoperative MRCP in screening choledocholithiasis in acute cholecystitis compared to selective approach: a population-based study.

Choledocholithiasis is more common in acute cholecystitis than in elective situations. Preoperative diagnosis of choledocholithiasis is essential to facilitate adequate planning of CBD (common bile duct) stone removal, preferably performed as a single-stage procedure. The purpose of this study was to test the feasibility of routine preoperative magnetic resonance cholangiopancreatography (MRCP) in acute cholecystitis followed by consequent cholecystectomy. A total of 180 consecutive patients operated for acute cholecystitis between January 2019 and December 2019 were prospectively enrolled. Preoperative routine MRCP was performed for bile duct evaluation when feasible. The control cohort consisted of 180 consecutive patients undergoing emergency laparoscopic cholecystectomy before the study period. Intraoperative cholangiography was used routinely in both groups when technically achievable. We examined the proportion of patients recruited in preoperative MRCP, possible time delay to MRCP and surgery, and the incidence of CBD stones compared to the control cohort. Routine MRCP in acute cholecystitis was achieved in 114/180 (63%) patients compared to 42/180 (23.3%) patients of the control group. The triage time from emergency to MRCP and the operating theatre was similar in both cohorts. The percentage of patients diagnosed with choledocholithiasis in the study group was notably higher (almost 18% vs 11%), p < 0.05. After a median follow-up time of 2.5years in the study group and almost 4years in the control group, recurrent choledocholithiasis was not detected in either group. Routine MRCP in patients with acute cholecystitis can be implemented with a fair execution rate in a population-based setting with minor effects on hospital stay and delays but higher detection of choledocholithiasis. We observed no additional benefit compared to the selective use of MRCP. However, routine preoperative MRCP allows an advantage when considering the appropriate exploration method if choledocholithiasis is detected.

Maximum Diameter of the Gallbladder Determined Presurgically Using Computed Tomography as a Risk Factor for Difficult Emergency Laparoscopic Cholecystectomy in Patients With Mild to Moderate Acute Cholecystitis.

Early or emergency laparoscopic cholecystectomy (LC) was recommended in the 2018 Tokyo Guidelines for patients with mild to moderate acute cholecystitis (AC). Although surgical difficulty is frequently encountered during these surgeries, risk factors for predicting surgical difficulties have not been fully investigated, especially based on computed tomography (CT) findings. We investigated 72 patients who underwent emergency LC with mild (n=45) to moderate (n=27) AC. Patients who previously underwent presurgical percutaneous or endoscopic biliary drainage were excluded from this study. Difficult LC was defined using any of the following surgical factors: surgical duration ≥180 minutes, blood loss ≥300g, or a conversion to open cholecystectomy. Subsequently, several presurgical clinical factors were analyzed, including sex, age at surgery, experience of the surgeon, interval between symptom onset and surgery, body mass index, diabetes history, presurgical white blood cell count, and C-reactive protein level. Moreover, stones in the cystic duct or perigallblader fluid and the maximum thickness and diameter of the gallbladders were evaluated via presurgical CT. Finally, logistic regression analysis was performed to compare the relationship between surgical difficulty and each clinical factor. The average age at surgery of the included patients was 60.3 (range: 25 to 88y), surgical duration was 112.2 (range: 29 to 296min), and surgical blood loss was 55.2 (range: 0 to 530g). Furthermore, 4 (5.6%) had to undergo open cholecystectomy, whereas postsurgical complications occurred in 5 (6.9%) patients. In addition, the mean postsurgical admission duration was 7 (range: 3 to 63d). Thus, 12 patients experienced difficult LC, whereas 60 experienced nondifficult LC. Of the evaluated clinical factors, patients who experienced difficult LC showed higher presurgical C-reactive protein levels (10.78 vs. 6.76mg/dL, P =0.01) and wider gallbladder diameters (48.4 vs. 41.8mm, P <0.01) than those who experienced nondifficult LC. By univariate logistic regression analysis, results also showed that patients with a maximum gallbladder diameter had a higher risk of experiencing difficulty during emergency LC ( P =0.02). Moreover, the gallbladder diameter's cutoff value was 43mm after the receiver operating characteristic curve analysis. In patients with mild to moderate AC, emergency LC can safely be performed. However, performing LC might be technically difficult in patients with AC after the identification of severe gallbladder swelling during presurgical CT.

Is Antibiotic Therapy Necessary after Emergency Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis?

Background: While preoperative antibiotic therapy is standard to prevent surgical site infections in acute calculous cholecystitis, prescribing antibiotics after discharge is controversial. This study aimed to investigate the effect of antibiotic administration in discharge prescription on surgical site infections.&#x0D; Methods: Data from patients who underwent emergency laparoscopic cholecystectomy for acute calculous cholecystitis between January 2018 and February 2020 were retrospectively reviewed. Those with a decompensated systemic disease, those who were converted to open cholecystectomy, those with stage 3 disease, and those who underwent open cholecystectomy and cholecystostomy were excluded. Ampicillin-sulbactam 1 g was administered parenterally three times a day before and after surgery.&#x0D; The patients were divided into two groups according to their discharge prescriptions: those who were given antibiotics (AB group) and those who were not given antibiotics (NA group). The primary outcome was the development of surgical site infections.&#x0D; Results: 107 patients in the AB group and 109 in the NA group. Surgical site infection developed in 29 (13.4%) patients, 11 (10.3%) in the AB group, and 18 (16.5%) in the NA group. No significant difference was found between the two groups regarding surgical site infection rate (p&gt;0.05). In logistic regression analysis, obesity was a risk factor for surgical site infections.&#x0D; Conclusions: Failure to prescribe ampicillin-sulbactam to acute calculous cholecystitis patients discharged after laparoscopic surgery does not increase surgical site infections. However, prescribing ampicillin-sulbactam to obese patients may reduce surgical site infections.&#x0D; Keywords: Surgical site infections, acute calculous cholecystitis, emergency laparoscopic cholecystectomy, obesity

SP8.2.7 Is “Hot” Laparoscopic Cholecystectomy in patients with high BMI a safe option? - Outcomes of Emergency Laparoscopic Cholecystectomy in obese vs non-obese patients

Abstract Aim NICE guidelines currently recommend offering patients presenting with acute cholecystitis a laparoscopic cholecystectomy within 1 week of diagnosis. We compared peri-operative outcomes for patients undergoing emergency laparoscopic cholecystectomy with a BMI of &amp;lt;30 kg/m2 (Group 1) and ≥30 kg/m2 (Group 2). Methods A retrospective review of patients undergoing an emergency laparoscopic cholecystectomy at a District General Hospital between January 2018 and November 2020. Results 159 patients were included. Group 1 had 97 patients (BMI range 18.8–29.9 kg/m2, age range 27–82 years, 56 females: 41 males). Group 2 had 62 patients (BMI range 30–56.3 kg/m2, age range 19–88 years, 38 females: 24 males). ASA breakdown was 1(25.8%), 2(64.9%) and 3(9.3%) for Group 1 and 2(71%) and 3(29%) for Group 2. Indications for surgery included biliary colic, acute cholecystitis and gallstone pancreatitis. Operating surgeons had training in both Upper GI and Bariatric surgery. There were no significant differences between Group 1 and Group 2 for anaesthetic time (minutes, 32.74 vs 32.50 p=0.91), operative time (minutes, 95.82 vs 93.67 p=0.75), total length of stay (days, 6.15 vs 5.17 p=0.30) or readmission rate within 30 days (22.68% vs 19.35% p=0.62). 4 patients in each group had acute complications during the index admission. Conclusion Emergency laparoscopic cholecystectomy for patients with a BMI ≥30 kg/m2 has similar peri-operative outcomes when compared to patients with a BMI &amp;lt;30 kg/ m2 and is safe to be performed in a District General Hospital by operating surgeons with an interest in Upper GI and Bariatric surgery.

WE2.8 Improving Management for Acute Cholecystitis and Biliary Pancreatitis – the ‘Hot Gallbladder Pathway’

Abstract Aim There is a wide variation between National Health Service (NHS) hospitals in the management of patients with acute cholecystitis and biliary pancreatitis. 20–33% of patients will make repeat visits to hospital with gallstone-related symptoms before any surgical intervention performed. We established a ‘Hot Gallbladder Pathway’ with the aim for improving outcome and decreasing complications of these patients. The aim of this quality improvement project was to assess if a district general hospital (DGH) could provide a safe and effective ‘hot gallbladder’ service with a clear pathway. Method Quality improvement methods were used to integrate the ‘hot gallbladder pathway’ to manage patients with acute calculous cholecystitis and biliary pancreatitis. A prospective observational study with strict inclusion/ exclusion criteria and secure online data was conducted during a 13-month period. The data were then compared against existing National Institute for Health and Clinical Excellence (NICE) guidelines and further changes were recommended. Results We achieved almost 70% of the patients undergoing emergency laparoscopic cholecystectomy in both group of patients who met the pathway criteria within the expected time frame, compared with the pre-implementation result of 23% and national average of only 16% in England. None of the patients suffered from intraoperative complications or 30-day mortality. Conclusion A clear ‘hot gall bladder pathway’ is effective at improving care for patients requiring emergency laparoscopic cholecystectomy and potentially useful for other acute Trusts which their standard is below the NICE guideline.

Short and long term outcomes of laparoscopic fenestrating or reconstituting subtotal cholecystectomy versus laparoscopic total cholecystectomy in the management of acute cholecystitis.

Strasberg proposed classifying subtotal cholecystectomy techniques into fenestrating (fSC) and reconstituting (rSC) subtypes. The aim of this study is to compare our outcomes of laparoscopic subtotal cholecystectomies of both subtypes against laparoscopic total cholecystectomy (TC) in difficult emergency laparoscopic cholecystectomies. Patients undergoing emergency laparoscopic cholecystectomy were identified over 2 years and all Nassar scale 3 and 4 cholecystectomies were included for analysis. 108 fSC and 24 rSC were compared against 317TC. Patients undergoing fSC and rSC were older and more likely to be male. fSC (128min) and rSC (141min) recorded longer median operative times than TC (109). Post-operative ERCP was more common after rSC (16.7%). Patients undergoing fSC (2 days) and rSC (3.5 days) had longer post-operative stays. Bile leaks were more likely in fSC (9.3%) and rSC (8.3%) compared to TC (1.9%), Long term morbidity was higher in the rSC group (12.5% vs 10%). And these were solely due to gallbladder remnant complications. Laparoscopic fSC and rSC techniques are associated with a higher rate of bile leaks and rSC has more long term morbidty as compared to TC.

8 Improving Management for Acute Cholecystitis and Biliary Pancreatitis – the ‘Hot Gallbladder Pathway’

Abstract Aim There is a wide variation between National Health Service (NHS) hospitals in the management of patients with acute cholecystitis and biliary pancreatitis. 20–33% of patients will make repeat visits to hospital with gallstone-related symptoms before any surgical intervention performed. We established a ‘Hot Gallbladder Pathway’ with the aim for improving outcome and decreasing complications of these patients. The aim of this quality improvement project was to assess if a district general hospital (DGH) could provide a safe and effective ‘hot gallbladder’ service with a clear pathway. Method Quality improvement methods were used to integrate the ‘hot gallbladder pathway’ to manage patients with acute calculous cholecystitis and biliary pancreatitis. A prospective observational study with strict inclusion/ exclusion criteria and secure online data was conducted during a 13-month period. The data were then compared against existing National Institute for Health and Clinical Excellence (NICE) guidelines and further changes were recommended. Results We achieved almost 70% of the patients undergoing emergency laparoscopic cholecystectomy in both group of patients who met the pathway criteria within the expected time frame, compared with the pre-implementation result of 23% and national average of only 16% in England. None of the patients suffered from intraoperative complications or 30-day mortality. Conclusions A clear ‘hot gall bladder pathway’ is effective at improving care for patients requiring emergency laparoscopic cholecystectomy and potentially useful for other acute Trusts which their standard is below the NICE guideline.

The impact of obesity on outcomes in patients undergoing emergency cholecystectomy for acute cholecystitis.

BackgroundObesity is a perceived risk factor for poorer surgical outcomes, including increased complication rates and mortality. As obesity rates rise annually, evaluating surgical outcomes in the obese population has become increasingly important. This study examines the impact of obesity on outcomes following emergency laparoscopic cholecystectomy (LC) for acute cholecystitis.MethodsA retrospective review of patients who underwent emergency LC for acute cholecystitis between March 2018 and March 2021 was performed. A total of 326 patients were included and stratified by body mass index (BMI) into two groups: obese (BMI ≥30 kg/m2, n = 156) and non‐obese (BMI <30 kg/m2, n = 170). Primary outcomes included length of stay, time to definitive surgery, and postoperative complications. Secondary outcomes included total operative time and intraoperative findings.ResultsObese patients were younger than non‐obese patients (median, 45 [34.3–56.8] and 48.5 [34.0–66.3] years; p < 0.001) and had a higher prevalence of diabetes (13.5% versus 6.5%; p = 0.034). Higher American Society of Anesthesiologists (ASA) classification (p < 0.001) and operative grading scores were observed in the obese group (76.3% versus 40.6%, p < 0.001), who were more likely to have a distended gallbladder (19.9% versus 11.2%, p = 0.030) and gallstone impaction (23.1% versus 11.8%, p = 0.007) in comparison to the non‐obese group. Length of hospital stay, time to definitive surgery, and postoperative complication rates were similar between groups.ConclusionAlthough obesity is associated with greater technical difficulty during surgery than non‐obese patients, similar postoperative outcomes were achieved. Obesity should not be a contraindication for LC and can be safely performed in the emergency setting.

Complicated Acute Cholecystitis: The Role of C-Reactive Protein and Neutrophil-Lymphocyte Ratio as Predictive Markers of Severity.

ObjectivesThe clinical diagnosis of complicated acute cholecystitis (CAC) remains difficult with several pathological or ultrasonography criteria used to differentiate it from uncomplicated acute cholecystitis (UAC). This study aims to evaluate the use of combined inflammatory markers C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR) as surrogate markers to differentiate between UAC and CAC.MethodsWe identified 600 consecutive patients admitted with biliary symptoms during an acute surgical take from our electronic prospectively maintained database over a period of 55 months. Only patients undergoing emergency cholecystectomy performed during the index admission were included. The primary outcome was the finding of CAC versus UAC.ResultsA total of 176 patients underwent emergency laparoscopic cholecystectomy (ELC) during the index admission, including 118 (67%) females with a median age of 51 years (range: 21-97 years). The proportion of UAC (130 [74%]) and CAC (46 [26%]) was determined along with demographic data. Multivariate regression analysis showed that patient’s age (OR=1.047; p=0.003), higher CRP (OR=1.005; p=0.012) and NLR (OR=1.094; p=0.047) were significant independent factors associated with severity of cholecystitis. Receiver operating characteristic (ROC) analysis for CRP showed an AUC (area under the curve) of 0.773 (95% CI: 0.698- 0.849). Using a cut-off value of 55 mg/L for CRP, the sensitivity of CAC was 73.9% and specificity was 73.1% in predicting CAC. The median post-operative length of stay was four days. The conversion rate from laparoscopic cholecystectomy to open surgery was 2% (4/176), and 5% (9/176) patients suffered post-operative complications with no mortality at 30 days.ConclusionCRP, NLR and age were independent factors associated with the severity of acute cholecystitis. NLR and CRP can be used as surrogate markers to predict patients at risk of CAC during emergency admission, which can inform future guidelines. Moreover, ELC for CAC can be safely performed under the supervision of dedicated upper GI surgeons.

Hartmann's Pouch Stones and Laparoscopic Cholecystectomy: The Challenges and the Solutions.

Background & Objective:Hartmann's pouch stones (HPS) encountered during laparoscopic cholecystectomy (LC) may hinder safe dissection of the cystic pedicle or be complicated by mucocele, empyema, or Mirizzi syndrome; distorting the anatomy and increasing the risk of bile duct injury. We studied the incidence, presentations, operative challenges, and outcomes of HPS.Methods:A cohort study of a prospectively maintained database of LCs and bile duct explorations performed by a single surgeon. Patients were divided into two groups: those with HPS and those without. Patients' demographics, clinical presentation, intra-operative findings, and postoperative outcomes were compared.Results:Of the 5136 patients, 612 (11.9%) had HPS. The HPS group were more likely to present with acute cholecystitis (27.9% vs 5.9%, P = .000) and more patients underwent emergency LC (50.7% vs 41.5%, P = .000). The HPS group had more difficult cholecystectomies, with 46.1% vs 11.8% in the non-HPS group being operative difficulty grade 4 and 5. Mucocele, empyema, and Mirizzi syndrome were more common in the HPS group (24.0% vs 3.7% P = .000, 30.9% vs 3.7% P = .000, 1.8% vs 0.9% P = .000, respectively). There was no significant difference in the open conversion rate or complications.Conclusion:HPS increase the difficulty of LC. Surgeons should be aware of their presence and should employ appropriate dissection strategies. Sharp or diathermy dissection should be avoided. Dislodging the stone into the gall bladder, stone removal, swab dissection, and cholangiography are useful measures to avoid ductal injury and reduce the conversion rate.

The impact of antithrombotic therapy in patients undergoing emergency laparoscopic cholecystectomy for acute cholecystitis - A single center experience.

The risk of developing hemorrhagic complications during or after surgery in patients receiving antithrombotic therapy remains uncertain. Moreover, the impact of antithrombotic therapy under an acute inflammatory status is unclear. We investigated the impact of antithrombotic therapy in patients undergoing emergency laparoscopic cholecystectomy for acute cholecystitis. This record-based retrospective study included patients who underwent emergency laparoscopic cholecystectomy for acute cholecystitis between September 2015 and January 2019. Patients who received elective laparoscopic cholecystectomy, open cholecystectomy, or gallbladder drainage before surgery were excluded. We evaluated the diseases for which antithrombotic therapy was administered, background characteristics, laboratory parameters and perioperative outcomes of patients with acute cholecystitis. The primary outcomes were intraoperative bleeding, blood transfusion requirement, conversion to an open procedure, and postoperative complications, including bleeding. One hundred and twenty-one patients (non-antithrombotic therapy, n = 92; antithrombotic therapy, n = 29) were analyzed. There were differences in age and American Association of Anesthesiologists class (P < .05), but not in the grade of acute cholecystitis (P = .19). There were no differences in the operation time (non-antithrombotic vs antithrombotic therapy: 142 [58-313] vs 146 minutes [65-373], P = .85), bleeding (17.5 mL [1-1400] vs 25 mL [1-1337], P = .58), blood transfusion requirement (n = 3 [3.2%] vs n = 2 [6.9%], P = .59) and the number of cases converted to open surgery (n = 8 [9%] vs n = 2 [7%], P = 1). The rates of postoperative complications, including bleeding, did not differ between the two groups and there was no mortality in either group. Emergency laparoscopic cholecystectomy could be planned for patients receiving single antithrombotic therapy, similar to patients who were not receiving antithrombotic therapy.

Predictive Factors for a Long Postoperative Stay after Emergency Laparoscopic Cholecystectomy Using the 2013 Tokyo Guidelines: A Retrospective Study.

Laparoscopic cholecystectomy (LC) is widely used for treating early acute cholecystitis (AC) and substantially reduces hospital costs. This study aimed to identify and evaluate risk factors associated with long postoperative hospital stays (PHSs) in patients undergoing emergency LC for AC according to the 2013 Tokyo Guidelines (TG13). Clinical data of patients who underwent emergency LC for AC between 2011 and 2017 were retrospectively collected. Patients were divided into early discharge (ED, discharge in three days or less postoperatively) and late discharge (LD, discharge in more than three days postoperatively) groups based on clinical progression and PHS after LC. Preoperative characteristics and perioperative outcomes were analysed as potential risk factors for LD. Among 149 patients, 104 (69.8%) were discharged within 3 days postoperatively, whereas 45 (30.2%) had long PHSs. Main causes of LD were fever and inflammation. Univariate analysis of preoperative risk factors revealed significant differences in age, white blood cell count, C-reactive protein, total bilirubin (T-bil), and alkaline phosphatase (ALP) levels; anticoagulation therapy; and TG13 severity grade. Multivariate analysis revealed that TG13 severity grade II, age >65 years, and elevated T-bil and ALP levels are independent factors for long PHS. Older age, worse biliary function, and increased TG13 severity grade might predict prolonged PHSs in AC patients undergoing emergency LC.