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Bhatia M, Thomas B, Azir E, Al-Maliki D, Ballal K, Tantrige P, Yusuf GT, El-Hasanii S. Percutaneous Cholecystostomy to Manage a Hot Gallbladder: A Single Center Experience. Cureus 2023; 15:e45348. [PMID: 37724097 PMCID: PMC10505269 DOI: 10.7759/cureus.45348] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2023] [Indexed: 09/20/2023] Open
Abstract
Objective A percutaneous cholecystostomy (PC) is a suitable option for treating acutely inflamed gallbladders. Its use has been postulated before for treating acute cholecystitis (AC), especially in elderly populations. The primary aim of our study is to analyze and present the positive results of PC as a bridge to laparoscopic cholecystectomy. Methods All patients who underwent PC at our hospital, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR, from October 2020 were reviewed using a retrospective approach. Results Our study comprises 123 patients, with 72 females (58.5%) and 51 males (41.4%). In our study, many patients had significant comorbidities, and some of them were categorized as high-risk due to their frailty and medical conditions. The majority of the patients were in American Society of Anaesthesiologists' (ASA) groups II and III (45, 61), respectively. Though hospital stays can depend on variable factors, in our experience, the mean hospital length of stay was 12.7 days. In our study, 119 patients (96.8%) had the procedure through the interventional radiological approach, while only four patients had it through the laparoscopic approach. The transhepatic route for drainage was more commonly practiced at our center and was used in 108 patients. At the time of writing this article, 54 patients have already had a laparoscopic cholecystectomy (LC) done as an interval procedure after surpassing the acute attack of cholecystitis, while 42 patients are still awaiting their surgical procedure. Conclusion Our results show that PC is a viable option, especially in cases of AC that are not responding to conservative treatments. Our study has shown low complications and conversion rates after PC. We believe PC is a safe and effective tool for managing severe and refractory cases of AC.
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Affiliation(s)
- Mohit Bhatia
- Surgery, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR
| | - Bindhiya Thomas
- Surgery, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR
| | - Elia Azir
- Surgery, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR
| | - Doaa Al-Maliki
- Surgery, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR
| | - Khalid Ballal
- Intervention Radiology, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR
| | - Priyan Tantrige
- Intervention Radiology, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR
| | - Gibran Timothy Yusuf
- Intervention Radiology, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR
| | - Shamsi El-Hasanii
- Upper Gastrointestinal Surgery, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR
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Early Versus Delayed Cholecystectomy for Acute Biliary Pancreatitis: A Systematic Review and Meta-Analysis. World J Surg 2022; 46:1359-1375. [DOI: 10.1007/s00268-022-06501-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 12/15/2022]
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The Need for Standardizing Diagnosis, Treatment and Clinical Care of Cholecystitis and Biliary Colic in Gallbladder Disease. Medicina (B Aires) 2022; 58:medicina58030388. [PMID: 35334564 PMCID: PMC8949253 DOI: 10.3390/medicina58030388] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
Gallstones affect 20% of the Western population and will grow in clinical significance as obesity and metabolic diseases become more prevalent. Gallbladder removal (cholecystectomy) is a common treatment for diseases caused by gallstones, with 1.2 million surgeries in the US each year, each costing USD 10,000. Gallbladder disease has a significant impact on the logistics and economics of healthcare. We discuss the two most common presentations of gallbladder disease (biliary colic and cholecystitis) and their pathophysiology, risk factors, signs and symptoms. We discuss the factors that affect clinical care, including diagnosis, treatment outcomes, surgical risk factors, quality of life and cost-efficacy. We highlight the importance of standardised guidelines and objective scoring systems in improving quality, consistency and compatibility across healthcare providers and in improving patient outcomes, collaborative opportunities and the cost-effectiveness of treatment. Guidelines and scoring only exist in select areas of the care pathway. Opportunities exist elsewhere in the care pathway.
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Evaluating the advantages of treating acute cholecystitis by following the Tokyo Guidelines 2018 (TG18): a study emphasizing clinical outcomes and medical expenditures. Surg Endosc 2020; 35:6623-6632. [PMID: 33258028 DOI: 10.1007/s00464-020-08162-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 11/15/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute cholecystitis (AC) is a common surgical emergency. The Tokyo Guidelines 2018 (TG18) provides a reliable algorithm for the treatment of AC patients to achieve optimal outcomes. However, the economic benefits have not been validated. We hypothesize that good outcomes and cost savings can both be achieved if patients are treated according to the TG18. METHOD This retrospective study included 275 patients who underwent cholecystectomy in a 15-month span. Patients were divided into three groups (group 1: mild AC; group 2: moderate AC with American Society of Anesthesiologists (ASA) physical status class ≤ 2 and Charlson Comorbidity Index (CCI) score ≤ 5; and group 3: moderate AC with ASA class ≥ 3, CCI score ≥ 6, or severe AC). Each group was further divided into two subgroups according to management (followed or deviated from the TG18). Patient demographics, clinical outcomes, and hospital costs were compared. RESULTS For group 1 patients, 77 (81%) were treated according to the TG18 and had a significantly higher successful laparoscopic cholecystectomy (LC) rate (100%), lower hospital cost ($1896 vs $2388), and shorter hospital stay (2.9 vs 8 days) than those whose treatment deviated from the TG18. For group 2 patients, 50 (67%) were treated according to the TG18 and had a significantly lower hospital cost ($1926 vs $2856), shorter hospital stay (3.9 vs 9.9 days), and lower complication rate (0% vs 12.5%). For group 3 patients, 62 (58%) were treated according to the TG18 and had a significantly lower intensive care unit (ICU) admission rate (9.7% vs 25%), but a longer hospital stay (12.6 vs 7.8 days). However, their hospital costs were similar. Early LC in group 3 patients did not have economic benefits over gallbladder drainage and delayed LC. CONCLUSION The TG18 are the state-of-the-art guidelines for the treatment of AC, achieving both satisfactory outcomes and cost-effectiveness.
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Argiriov Y, Dani M, Tsironis C, Koizia LJ. Cholecystectomy for Complicated Gallbladder and Common Biliary Duct Stones: Current Surgical Management. Front Surg 2020; 7:42. [PMID: 32793627 PMCID: PMC7385246 DOI: 10.3389/fsurg.2020.00042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/08/2020] [Indexed: 12/12/2022] Open
Abstract
Gallstone disease accounts for the vast majority of acute surgical admissions in the UK, with a major treatment being cholecystectomy. Practice varies significantly as to whether surgery is performed during the acute symptomatic phase, or after a period of recovery. Differences in practice relate to operative factors, patient factors, surgeon factors and hospital and trust wide policies. In this review we summarize recent evidence on management of gallstone disease, particularly with respect to whether cholecystectomy should occur during index presentation or following recovery. We highlight morbidity and mortality studies, cost, and patient reported outcomes. We speculate on barriers to change in service delivery. Finally, we propose potential solutions to optimize care.
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Affiliation(s)
- Yanna Argiriov
- Cutrale Perioperative and Ageing Research Group, Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Melanie Dani
- Cutrale Perioperative and Ageing Research Group, Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Christos Tsironis
- Department of Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Louis J Koizia
- Cutrale Perioperative and Ageing Research Group, Department of Bioengineering, Imperial College London, London, United Kingdom
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Index Admission Emergency Laparoscopic Cholecystectomy and Common Bile Duct Exploration: Results From a Specialist Center in the United Kingdom. Surg Laparosc Endosc Percutan Tech 2018; 29:113-116. [PMID: 30520814 DOI: 10.1097/sle.0000000000000602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The incidence of common bile duct (CBD) stones is between 10% to 18% in people undergoing cholecystectomy for gallstones. Laparoscopic exploration of the CBD is now becoming routine practice in the elective setting, however its safety and efficacy in emergencies is poorly understood. METHODS We analyzed our results for index emergency admission laparoscopic cholecystectomy within a specialist center in the United Kingdom. Data from all emergency cholecystectomies in our unit, between 2011 to 2016 were collected and analyzed retrospectively. RESULTS In total, 494 patients underwent emergency laparoscopic cholecystectomy; 53 (10.7%) patients underwent common bile duct exploration (CBDE), with 1 conversion and 1 bile leak. Indications for CBDE were based on preoperative imaging (41 cases, 81%) or intra-operative cholangiogram (44 cases, 83%) findings. CONCLUSIONS Index admission laparoscopic cholecystectomy and concomitant CBDE is safe and should be the gold standard treatment for patients presenting with acute biliary complications, reducing readmissions and the need for a 2-stage procedure.
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Poole GH, Jacobson AB, Hill AG. Index acute cholecystectomy: what's the problem? ANZ J Surg 2018; 88:1226-1227. [PMID: 30516011 DOI: 10.1111/ans.14853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 08/05/2018] [Accepted: 08/12/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Garth H Poole
- Department of Surgery, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - Alexandra B Jacobson
- Department of Surgery, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - Andrew G Hill
- Department of Surgery, The University of Auckland, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
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Blythe J, Herrmann E, Faust D, Falk S, Edwards-Lehr T, Stockhausen F, Hanisch E, Buia A. Acute cholecystitis - a cohort study in a real-world clinical setting (REWO study, NCT02796443). Pragmat Obs Res 2018; 9:69-75. [PMID: 30498388 PMCID: PMC6207389 DOI: 10.2147/por.s169255] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background For decades, the optimal timing of surgery for acute cholecystitis has been controversial. Recent meta-analyses and population-based studies favor early surgery. One recent large randomized trial has demonstrated that a delayed approach increases morbidity and cost compared to early surgery within 24 hours of hospital admission. Since cases of severe cholecystitis were excluded from this trial, we argue that these results do not reflect real-world clinical situations. From our point of view, these results were in contrast to the clinical experience with our patients; so, we decided to analyze critically all our patients with the null hypothesis that the patients treated with a delayed cholecystectomy after an acute cholecystitis have a similar or even better outcome than those treated with an early operative approach. Patients and methods We retrospectively analyzed clinical data from all patients with cholecystectomies in the period between January 2006 and September 2015. A total of 1,723 patients were categorized into four groups: early (n=138): urgent surgery of patients with acute cholecystitis within the first 72 hours of the onset of symptoms; intermediate (n=297): surgery of patients with acute cholecystitis within an average of 10 days after the onset of symptoms; delayed (n=427): initial non-surgical treatment of acute cholecystitis with surgery performed within 6-12 weeks of the onset of symptoms; and elective (n=868): cholecystectomy within a symptom-free interval of choice in patients with symptomatic cholecystolithiasis without signs of acute cholecystitis. Results In a real-world scenario, early/intermediate cholecystectomy in acute cholecystitis was associated with a significant increase in morbidity and mortality (Clavien-Dindo score) compared to a delayed approach with surgery performed 6-12 weeks after the onset of symptoms. The adjusted linear rank statistics showed a decrease in the complication score with values of 2.29 in the early group, 0.48 in the intermediate group, -0.26 in the delayed group and -2.12 in the elective group. The results translate into a continuous decrease of the complication score from early over intermediate and delayed to the elective group. Conclusion These results demonstrate that delayed cholecystectomy can be performed safely. In cases with severe cholecystitis, early and/or intermediate approaches still have a relatively high risk of morbidity and mortality.
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Affiliation(s)
- Jennifer Blythe
- Department of Internal Medicine, Bürgerhospital Frankfurt, Frankfurt, Germany
| | - Eva Herrmann
- Institute for Biostatistics and Mathematical Modelling, University Hospital Goethe University, Frankfurt, Germany
| | - Dominik Faust
- Department of Gastroenterology, Hepatology and Infectious Disease, Asklepios Klinik Langen, Langen, Germany
| | - Stephan Falk
- OptiPath Pathology Associates Frankfurt, Frankfurt, Germany
| | - Tina Edwards-Lehr
- Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Langen, Germany,
| | | | - Ernst Hanisch
- Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Langen, Germany,
| | - Alexander Buia
- Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Langen, Germany,
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Bazzi ZT, Kinnear N, Bazzi CS, Hennessey D, Henneberg M, Otto G. Impact of an acute surgical unit on outcomes in acute cholecystitis. ANZ J Surg 2018; 88:E835-E839. [DOI: 10.1111/ans.14802] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Zacharia T. Bazzi
- Department of Surgery; Lyell McEwin Hospital; Adelaide South Australia Australia
| | - Ned Kinnear
- Department of Surgery; Lyell McEwin Hospital; Adelaide South Australia Australia
- Department of Urology; Austin Health; Melbourne Victoria Australia
| | - Ciara S. Bazzi
- Department of Surgery; Modbury Hospital; Adelaide South Australia Australia
| | - Derek Hennessey
- Department of Urology; Austin Health; Melbourne Victoria Australia
| | - Maciej Henneberg
- Department of Medical Sciences; The University of Adelaide; Adelaide South Australia Australia
| | - Greg Otto
- Department of Surgery; Lyell McEwin Hospital; Adelaide South Australia Australia
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Kerwat D, Zargaran A, Bharamgoudar R, Arif N, Bello G, Sharma B, Kerwat R. Early laparoscopic cholecystectomy is more cost-effective than delayed laparoscopic cholecystectomy in the treatment of acute cholecystitis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2018; 10:119-125. [PMID: 29497322 PMCID: PMC5822851 DOI: 10.2147/ceor.s149924] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background This economic evaluation quantifies the cost-effectiveness of early laparoscopic cholecystectomy (ELC) versus delayed laparoscopic cholecystectomy (DLC) in the management of acute cholecystitis. The two interventions were assessed in terms of outcome measures, including utilities, to derive quality-adjusted life years (QALYs) as a unit of effectiveness. This study hypothesizes that ELC is more cost-effective than DLC. Materials and methods In this economic evaluation, existing literature was compiled and analyzed to estimate the incremental cost-effectiveness of ELC versus DLC. Six randomized controlled trials were used to schematically represent the probabilities of each decision tree branch. To calculate health outcomes, quality of life scores were sourced from three articles and multiplied by the expected length of life postintervention to give QALYs. From an National Health Service (NHS) perspective, one QALY may be sacrificed if the incremental cost-effectiveness ratio is above £20,000–£30,0000 in cost savings. Results This economic evaluation calculated the average net present values of ELC to be £3920 and DLC to be £4565, demonstrating that ELC is the less-expensive intervention, with potential cost savings of £645 per operation. When scaling these savings up to a population approximately comparable to the size of the UK, full-scale implementation of ELC rather than DLC will potentially save the NHS £30,000,000 per annum. Conclusion ELCs are cost-effective from the perspective of the NHS. As such, policy should review existing guidelines and consider the merits of ELC versus DLC, improving resource allocation. The findings of this article advocate that ELC should become a standard practice.
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Affiliation(s)
| | | | | | - Nadia Arif
- Department of Medicine, Brighton and Sussex Medical School, Brighton
| | - Grace Bello
- Department of Medicine, St George's University of London, London
| | | | - Rajab Kerwat
- Department of Medicine, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, London, UK
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Yang DJ, Lu HM, Guo Q, Lu S, Zhang L, Hu WM. Timing of Laparoscopic Cholecystectomy After Mild Biliary Pancreatitis: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2017; 28:379-388. [PMID: 29271689 DOI: 10.1089/lap.2017.0527] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the safety of cholecystectomy in early laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC). METHODS We systematically searched PubMed, EMBASE, and Cochrane Library for studies that were published from January 1992 to March 2017. We included studies on patients with mild biliary pancreatitis and that reported the timing of cholecystectomy and the number of complications, readmissions, and conversion to open cholecystectomy. Moreover, we assessed the quality and bias risks of the included studies. RESULTS After screening 4651 studies, we included 3 randomized clinical trials and 10 retrospective studies. The included studies described 2291 patients, of whom 1141 (49.8%) underwent ELC and 1150 (50.2%) underwent DLC. The reported rate of complications for ELC (6.8%) was lower than that for DLC (13.45%). The reported rate of readmission for ELC was lower than that for DLC. The length of hospital stay was longer with DLC than with ELC. ELC and DLC did not have significantly different rates of conversion to open cholecystectomy and duration of surgery. CONCLUSION This meta-analysis provides evidence that ELC is better than DLC in many aspects for acute mild pancreatitis patients undergoing laparoscopic cholecystectomy. ELC associated with few complications and readmissions, as well as a short length of hospital stay.
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Affiliation(s)
- Du-Jiang Yang
- 1 Department of Pancreatic Surgery, West China Hospital, Sichuan University , Chengdu, China
| | - Hui-Min Lu
- 1 Department of Pancreatic Surgery, West China Hospital, Sichuan University , Chengdu, China
| | - Qiang Guo
- 2 Department of Vascular Surgery, West China Hospital, Sichuan University , Chengdu, China
| | - Shan Lu
- 1 Department of Pancreatic Surgery, West China Hospital, Sichuan University , Chengdu, China
| | - Ling Zhang
- 1 Department of Pancreatic Surgery, West China Hospital, Sichuan University , Chengdu, China
| | - Wei-Ming Hu
- 1 Department of Pancreatic Surgery, West China Hospital, Sichuan University , Chengdu, China
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Gomes CA, Junior CS, Di Saverio S, Sartelli M, Kelly MD, Gomes CC, Gomes FC, Corrêa LD, Alves CB, Guimarães SDF. Acute calculous cholecystitis: Review of current best practices. World J Gastrointest Surg 2017; 9:118-126. [PMID: 28603584 PMCID: PMC5442405 DOI: 10.4240/wjgs.v9.i5.118] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 03/03/2017] [Accepted: 04/10/2017] [Indexed: 02/06/2023] Open
Abstract
Acute calculous cholecystitis (ACC) is the most frequent complication of cholelithiasis and represents one-third of all surgical emergency hospital admissions, many aspects of the disease are still a matter of debate. Knowledge of the current evidence may allow the surgical team to develop practical bedside decision-making strategies, aiming at a less demanding procedure and lower frequency of complications. In this regard, recommendations on the diagnosis supported by specific criteria and severity scores are being implemented, to prioritize patients eligible for urgency surgery. Laparoscopic cholecystectomy is the best treatment for ACC and the procedure should ideally be performed within 72 h. Early surgery is associated with better results in comparison to delayed surgery. In addition, when to suspect associated common bile duct stones and how to treat them when found are still debated. The antimicrobial agents are indicated for high-risk patients and especially in the presence of gallbladder necrosis. The use of broad-spectrum antibiotics and in some cases with antifungal agents is related to better prognosis. Moreover, an emerging strategy of not converting to open, a difficult laparoscopic cholecystectomy and performing a subtotal cholecystectomy is recommended by adept surgical teams. Some authors support the use of percutaneous cholecystostomy as an alternative emergency treatment for acute Cholecystitis for patients with severe comorbidities.
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Felício SJO, Matos EP, Cerqueira AM, Farias KWSFD, Silva RDA, Torres MDO. MORTALITY OF URGENCY VERSUS ELECTIVE VIDEOLAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 30:47-50. [PMID: 28489169 PMCID: PMC5424687 DOI: 10.1590/0102-6720201700010013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/13/2016] [Indexed: 11/22/2022]
Abstract
Background: Surgical approach is still controversial in patients with acute cholecystitis: to treat clinically the inflammatory process and operate electively later or to operate immediately on an emergency basis? Aim: To test the hypothesis that urgent laparoscopic cholecystectomy in acute cholecystitis has a higher mortality than elective laparoscopic cholecystectomy. Methods: From the data available in Datasus, mortality was compared between patients undergoing elective laparoscopic cholecystectomy for cholelithiasis and in urgency. Calculations were made of the relative reduction in risk of death, absolute reduction of risk of death and number needed to treat. Results: From 2009 to 2014 in Brazil, there were 250.439 laparoscopic cholecystectomy and 74.6% were electives. Mortality in the emergency group was 4.8 times higher compared to the elective group (0.0023% vs. 0.00048%). Despite the relative reduction in risk of death (RRR) was 83%, in the calculation of absolute risk was found 0.0018 and number needed to treat of 55,555. Conclusions: Despite the relative risk reduction for mortality was high comparing elective vs. urgent basis, the absolute risk reduction was minimal, since this outcome is very low in both groups, suggesting that mortality should not have much influence on surgical decision.
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14
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Outcomes of early versus delayed cholecystectomy in patients with mild to moderate acute biliary pancreatitis: A randomized prospective study. Asian J Surg 2016; 41:47-54. [PMID: 27530927 DOI: 10.1016/j.asjsur.2016.07.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 05/26/2016] [Accepted: 05/30/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND In patients with acute biliary pancreatitis (ABP), cholecystectomy is mandatory to prevent further biliary events, but the precise timing of cholecystectomy for mild to moderate disease remain a subject of ongoing debate. The aim of this study is to assess the outcomes of early versus delayed cholecystectomy. We hypothesize that early cholecystectomy as compared to delayed cholecystectomy reduces recurrent biliary events without a higher peri-operative complication rate. METHODS Patients with mild to moderate ABP were prospectively randomized to either an early cholecystectomy versus a delayed cholecystectomy group. Recurrent biliary events, peri-operative complications, conversion rate, length of surgery and total hospital length of stay between the two groups were evaluated. RESULTS A total of 72 patients were enrolled at a single public hospital. Of them, 38 were randomized to the early group and 34 patients to the delayed group. There were no differences regarding peri-operative complications (7.78% vs 11.76%; p = 0.700), conversion rate to open surgery (10.53% vs 11.76%; p = 1.000) and duration of surgery performed (80 vs 85 minutes, p = 0.752). Nevertheless, a greater rate of recurrent biliary events was found in the delayed group (44.12% vs 0%; p ≤ 0.0001) and the hospital length of stay was longer in the delayed group (9 vs 8 days, p = 0.002). CONCLUSION In mild to moderate ABP, early laparoscopic cholecystectomy reduces the risk of recurrent biliary events without an increase in operative difficulty or perioperative morbidity.
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15
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van Dijk AH, de Reuver PR, Tasma TN, van Dieren S, Hugh TJ, Boermeester MA. Systematic review of antibiotic treatment for acute calculous cholecystitis. Br J Surg 2016; 103:797-811. [PMID: 27027851 DOI: 10.1002/bjs.10146] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 11/16/2015] [Accepted: 02/05/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intravenous antibiotics are frequently used in the initial management of acute calculous cholecystitis (ACC), although supportive care alone preceding delayed elective cholecystectomy may be sufficient. This systematic review assessed the success rate of antibiotics in the treatment of ACC. METHODS A systematic search of MEDLINE, Embase and Cochrane Library databases was performed. Primary outcomes were the need for emergency intervention and recurrence of ACC after initial non-operative management of ACC. Risk of bias was assessed. Pooled event rates were calculated using a random-effects model. RESULTS Twelve randomized trials, four prospective and ten retrospective studies were included. Only one trial including 84 patients compared treatment with antibiotics to that with no antibiotics; there was no significant difference between the two groups in terms of length of hospital stay and morbidity. Some 5830 patients with ACC were included, of whom 2997 had early cholecystectomy, 2791 received initial antibiotic treatment, and 42 were treated conservatively. Risk of bias was high in most studies, and all but three studies had a low level of evidence. For randomized studies, pooled event rates were 15 (95 per cent c.i. 10 to 22) per cent for the need for emergency intervention and 10 (5 to 20) per cent for recurrence of ACC. The pooled event rate for both outcomes combined was 20 (13 to 30) per cent. CONCLUSION Antibiotics are not indicated for the conservative management of ACC or in patients scheduled for cholecystectomy.
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Affiliation(s)
- A H van Dijk
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - P R de Reuver
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - T N Tasma
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - S van Dieren
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.,Department of Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands
| | - T J Hugh
- Upper Gastrointestinal Surgery Unit, Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - M A Boermeester
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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El-Sharkawy AM, Sahota O, Lobo DN. Acute and chronic effects of hydration status on health. Nutr Rev 2015; 73 Suppl 2:97-109. [DOI: 10.1093/nutrit/nuv038] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Koti RS, Davidson CJ, Davidson BR. Surgical management of acute cholecystitis. Langenbecks Arch Surg 2015; 400:403-19. [PMID: 25971374 DOI: 10.1007/s00423-015-1306-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 05/04/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute cholecystitis occurs in approximately 1% of patients with known gallstones. It presents as a surgical emergency and usually requires hospitalisation for treatment. It is associated with significant morbidity and mortality, particularly in the elderly. Cholecystectomy is advocated for acute cholecystitis; however, the timing of cholecystectomy and the value of the additional treatments have been a matter of debate. This review examines the available evidence regarding the optimal surgical management of patients with acute cholecystitis. METHODS A literature search was performed on the MEDLINE, EMBASE and WHO International Clinical Trials Registry Platform, databases for English language publications. The MeSH headings 'cholecystitis', 'acute', 'gallbladder', 'inflammation', 'surgery', 'cholecystectomy', 'laparoscopic', 'robotic', 'telerobotic' and 'computer-assisted' were used. RESULTS Data from eight randomised controlled trails and three population-based analyses show that early cholecystectomy for acute cholecystitis performed on the index admission is safe and not associated with increased conversion rates or morbidity in comparison to conservative treatment followed by elective cholecystectomy. Delaying cholecystectomy increases readmissions for gallstone-related events, complications, hospital stay and mortality in the elderly. Early cholecystectomy is also more cost-effective. Randomised trials addressing antibiotic use in acute cholecystitis suggest that antibiotics should be stopped on the day of cholecystectomy. Insufficient trials have been performed to address the optimal analgesia regime post cholecystectomy. Similarly, a lack of trials on intraoperative cholangiography and management of common bile duct stones in patients with acute cholecystitis means that treatment of concomitant bile duct stones should be based on institutional expertise and resource availability. As regards acute cholecystitis in elderly and high-risk patients, case series and retrospective studies would suggest that cholecystectomy is more effective and of lower mortality than percutaneous cholecystostomy. There is not enough evidence to support the routine use of robotic surgery, single-incision laparoscopic cholecystectomy or natural orifice transluminal endoscopic surgery (NOTES) in the treatment of acute cholecystitis. CONCLUSIONS Trial evidence would favour a policy of early laparoscopic cholecystectomy following admission with acute cholecystitis. The optimal approach to support early cholecystectomy is suggested but requires evidence from further randomised trials.
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Affiliation(s)
- Rahul S Koti
- University Department of Surgery, Royal Free Hospital and UCL Medical School, Pond Street, London, NW3 2QG, UK
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Dave RV, Pathak S, Cockbain AJ, Lodge JP, Smith AM, Chowdhury FU, Toogood GJ. Management of gallbladder dyskinesia: patient outcomes following positive ⁹⁹mtechnetium (Tc)-labelled hepatic iminodiacetic acid (HIDA) scintigraphy with cholecystokinin (CCK) provocation and laparoscopic cholecystectomy. Clin Radiol 2015; 70:400-7. [PMID: 25588803 DOI: 10.1016/j.crad.2014.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 11/17/2014] [Accepted: 12/03/2014] [Indexed: 12/26/2022]
Abstract
AIMS To evaluate clinical outcomes in patients with typical biliary pain, normal ultrasonic findings, and a positive (99m)technetium (Tc)-labelled hepatic iminodiacetic acid analogue (HIDA) scintigraphy with cholecystokinin (CCK) provocation indicating gallbladder dyskinesia, as per Rome III criteria, undergoing laparoscopic cholecystectomy (LC). METHODS AND MATERIALS Consecutive patients undergoing LC for gallbladder dyskinesia were identified retrospectively. They were followed up by telephone interview and review of the electronic case records to assess symptom resolution. RESULTS One hundred consecutive patients (median age 44; 80% female) with abnormal gallbladder ejection fraction (GB-EF <35%) were followed up for a median of 12 months (range 2-80 months). Following LC, 84% reported symptomatic improvement and 52% had no residual pain. Twelve percent had persisting preoperative-type pain of either unchanged or worsening severity. Neither pathological features of chronic cholecystitis (87% of 92 incidences when histology available) nor reproduction of pain on CCK injection were significantly predictive of symptom outcome or pain relief post-LC. CONCLUSION In one of the largest outcome series of gallbladder dyskinesia patients in the UK with a positive provocation HIDA scintigraphy examination and LC, the present study shows that the test is a useful functional diagnostic tool in the management of patients with typical biliary pain and normal ultrasound, with favourable outcomes following surgery.
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Affiliation(s)
- R V Dave
- Department of Transplant and HPB Surgery, St James University Hospital, Leeds, UK
| | - S Pathak
- Department of Transplant and HPB Surgery, St James University Hospital, Leeds, UK
| | - A J Cockbain
- Department of Transplant and HPB Surgery, St James University Hospital, Leeds, UK
| | - J P Lodge
- Department of Transplant and HPB Surgery, St James University Hospital, Leeds, UK
| | - A M Smith
- Department of Transplant and HPB Surgery, St James University Hospital, Leeds, UK
| | - F U Chowdhury
- Department of Clinical Radiology, St James University Hospital, Leeds, UK; Department of Nuclear Medicine, St James University Hospital, Leeds, UK.
| | - G J Toogood
- Department of Transplant and HPB Surgery, St James University Hospital, Leeds, UK
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Keltie K, Cole H, Arber M, Patrick H, Powell J, Campbell B, Sims A. Identifying complications of interventional procedures from UK routine healthcare databases: a systematic search for methods using clinical codes. BMC Med Res Methodol 2014; 14:126. [PMID: 25430568 PMCID: PMC4280749 DOI: 10.1186/1471-2288-14-126] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 11/18/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Several authors have developed and applied methods to routine data sets to identify the nature and rate of complications following interventional procedures. But, to date, there has been no systematic search for such methods. The objective of this article was to find, classify and appraise published methods, based on analysis of clinical codes, which used routine healthcare databases in a United Kingdom setting to identify complications resulting from interventional procedures. METHODS A literature search strategy was developed to identify published studies that referred, in the title or abstract, to the name or acronym of a known routine healthcare database and to complications from procedures or devices. The following data sources were searched in February and March 2013: Cochrane Methods Register, Conference Proceedings Citation Index - Science, Econlit, EMBASE, Health Management Information Consortium, Health Technology Assessment database, MathSciNet, MEDLINE, MEDLINE in-process, OAIster, OpenGrey, Science Citation Index Expanded and ScienceDirect. Of the eligible papers, those which reported methods using clinical coding were classified and summarised in tabular form using the following headings: routine healthcare database; medical speciality; method for identifying complications; length of follow-up; method of recording comorbidity. The benefits and limitations of each approach were assessed. RESULTS From 3688 papers identified from the literature search, 44 reported the use of clinical codes to identify complications, from which four distinct methods were identified: 1) searching the index admission for specified clinical codes, 2) searching a sequence of admissions for specified clinical codes, 3) searching for specified clinical codes for complications from procedures and devices within the International Classification of Diseases 10th revision (ICD-10) coding scheme which is the methodology recommended by NHS Classification Service, and 4) conducting manual clinical review of diagnostic and procedure codes. CONCLUSIONS The four distinct methods identifying complication from codified data offer great potential in generating new evidence on the quality and safety of new procedures using routine data. However the most robust method, using the methodology recommended by the NHS Classification Service, was the least frequently used, highlighting that much valuable observational data is being ignored.
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Affiliation(s)
- Kim Keltie
- />Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- />Institute of Cellular Medicine, Newcastle University, Kragujevac, UK
| | - Helen Cole
- />Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mick Arber
- />York Health Economics Consortium, York, UK
| | - Hannah Patrick
- />National Institute for Health and Care Excellence, London, UK
| | - John Powell
- />National Institute for Health and Care Excellence, London, UK
| | - Bruce Campbell
- />National Institute for Health and Care Excellence, London, UK
| | - Andrew Sims
- />Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- />Institute of Cellular Medicine, Newcastle University, Kragujevac, UK
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Badia JM, Nve E, Jimeno J, Guirao X, Figueras J, Arias-Díaz J. Tratamiento quirúrgico de la colecistitis aguda. Resultados de una encuesta a los cirujanos españoles. Cir Esp 2014; 92:517-24. [DOI: 10.1016/j.ciresp.2014.01.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 01/25/2014] [Indexed: 12/23/2022]
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Rogers PN. Long-term outcome of patients with acute cholecystitis receiving antibiotic treatment: a retrospective cohort study. World J Surg 2014; 38:355-6. [PMID: 24280976 DOI: 10.1007/s00268-013-2344-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Flexer SM, Peter MB, Durham-Hall AC, Ausobsky JR. Patient outcomes after treatment with percutaneous cholecystostomy for biliary sepsis. Ann R Coll Surg Engl 2014; 96:229-33. [PMID: 24780790 PMCID: PMC4474055 DOI: 10.1308/003588414x13814021679799] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2013] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Acute cholecystitis is among the most common general surgical presentations. There is a cohort of patients who develop systemic sepsis and complications of acute cholecystitis. These patients are often elderly and co-morbid. Conservative management with percutaneous cholecystostomy has been shown to be a safe and effective management option in the acute setting. However, there is currently no consensus for the further management of these patients. In particular, there is a paucity of data on readmission rates and subsequent operative or non-operative management. METHODS A retrospective study was carried out of patients treated with a percutaneous cholecystostomy for biliary sepsis over a three-year period in a UK teaching hospital. Outcome measures were subsequent operative or conservative management, conversion rates, operative complications and readmission rates. RESULTS Twenty-five patients had a percutaneous cholecystostomy for the treatment of acute biliary sepsis. The median follow-up duration was 35 months. Thirteen patients (52%) had operative treatment. In the operative group, 6/13 had a laparoscopic cholecystectomy, 2/13 had a planned open cholecystectomy, 2/13 had abandoned procedures and 3/13 had a converted procedure. Complications in the operative group included: postoperative mortality (1/13), common bile duct injury requiring drainage and endoscopic stenting (1/13) and one patient required readmission with recurrent pain. In the non-operative group, 5/12 patients were readmitted with biliary sepsis, 5/12 had no readmissions, 1/12 died in the community and 1/12 was readmitted with biliary colic. CONCLUSIONS Percutaneous cholecystostomy is a recognised treatment modality for elderly, co-morbid patients with biliary sepsis. Nevertheless, the readmission rate in this group is relatively high at 5/12 (42%). Patients who undergo subsequent operative management have a conversion rate of 3/13 (23%) and a significant complication rate of 2/13 (15%). The further management of patients having undergone percutaneous cholecystostomy requires careful consideration on an individual case basis. The P-POSSUM (Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) may aid decision making.
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Affiliation(s)
- S M Flexer
- Bradford Teaching Hospitals NHS Foundation Trust, UK.
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Gurusamy KS, Vaughan J, Rossi M, Davidson BR. Fewer-than-four ports versus four ports for laparoscopic cholecystectomy. Cochrane Database Syst Rev 2014; 2014:CD007109. [PMID: 24558020 PMCID: PMC10773887 DOI: 10.1002/14651858.cd007109.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Traditionally, laparoscopic cholecystectomy is performed using two 10-mm ports and two 5-mm ports. Recently, a reduction in the number of ports has been suggested as a modification of the standard technique with a view to decreasing pain and improving cosmesis. The safety and effectiveness of using fewer-than-four ports has not yet been established. OBJECTIVES To assess the benefits (such as improvement in cosmesis and earlier return to activity) and harms (such as increased complications) of using fewer-than-four ports (fewer-than-four-ports laparoscopic cholecystectomy) versus four ports in people undergoing laparoscopic cholecystectomy for any reason (symptomatic gallstones, acalculous cholecystitis, gallbladder polyp, or any other condition). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 8, 2013), MEDLINE, EMBASE, Science Citation Index Expanded, and the World Health Organization International Clinical Trials Registry Platform portal to September 2013. SELECTION CRITERIA We included all randomised clinical trials comparing fewer-than-four ports versus four ports, that is, with standard laparoscopic cholecystectomy that is performed with two ports of at least 10-mm incision and two ports of at least 5-mm incision. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials and extracted the data. We analysed the data using both the fixed-effect and the random-effects models. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis, whenever possible. MAIN RESULTS We found nine trials with 855 participants that randomised participants to fewer-than-four-ports laparoscopic cholecystectomy (n = 427) versus four-port laparoscopic cholecystectomy (n = 428). Most trials included low anaesthetic risk participants undergoing elective laparoscopic cholecystectomy. Seven of the nine trials used a single port laparoscopic cholecystectomy and the remaining two trials used three-port laparoscopic cholecystectomy as the experimental intervention. Only one trial including 70 participants had low risk of bias. Fewer-than-four-ports laparoscopic cholecystectomy could be completed successfully in more than 90% of participants in most trials. The remaining participants were mostly converted to four-port laparoscopic cholecystectomy but some participants had to undergo open cholecystectomy.There was no mortality in either group in the seven trials that reported mortality (318 participants in fewer-than-four-ports laparoscopic cholecystectomy group and 316 participants in four-port laparoscopic cholecystectomy group). The proportion of participants with serious adverse events was low in both treatment groups and the estimated RR was compatible with a reduction and substantial increased risk with the fewer-than-four-ports group (6/318 (1.9%)) and four-port laparoscopic cholecystectomy group (0/316 (0%)) (RR 3.93; 95% CI 0.86 to 18.04; 7 trials; 634 participants; very low quality evidence). The estimated difference in the quality of life (measured between 10 and 30 days) was imprecise (standardised mean difference (SMD) 0.18; 95% CI -0.05 to 0.42; 4 trials; 510 participants; very low quality evidence), as was the proportion of participants in whom the laparoscopic cholecystectomy had to be converted to open cholecystectomy between the groups (fewer-than-four ports 3/289 (adjusted proportion 1.2%) versus four port: 5/292 (1.7%); RR 0.68; 95% CI 0.19 to 2.35; 5 trials; 581 participants; very low quality evidence). The fewer-than-four-ports laparoscopic cholecystectomy took 14 minutes longer to complete (MD 14.44 minutes; 95% CI 5.95 to 22.93; 9 trials; 855 participants; very low quality evidence). There was no clear difference in hospital stay between the groups (MD -0.01 days; 95% CI -0.28 to 0.26; 6 trials; 731 participants) or in the proportion of participants discharged as day surgery (RR 0.92; 95% CI 0.70 to 1.22; 1 trial; 50 participants; very low quality evidence) between the two groups. The times taken to return to normal activity and work were shorter by two days in the fewer-than-four-ports group compared with four-port laparoscopic cholecystectomy (return to normal activity: MD -1.20 days; 95% CI -1.58 to -0.81; 2 trials; 325 participants; very low quality evidence; return to work: MD -2.00 days; 95% CI -3.31 to -0.69; 1 trial; 150 participants; very low quality evidence). There was no significant difference in cosmesis scores at 6 to 12 months between the two groups (SMD 0.37; 95% CI -0.10 to 0.84; 2 trials; 317 participants; very low quality evidence). AUTHORS' CONCLUSIONS There is very low quality evidence that is insufficient to determine whether there is any significant clinical benefit in using fewer-than-four-ports laparoscopic cholecystectomy compared with four-port laparoscopic cholecystectomy. The safety profile of using fewer-than-four ports is yet to be established and fewer-than-four-ports laparoscopic cholecystectomy should be reserved for well-designed randomised clinical trials.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Jessica Vaughan
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Michele Rossi
- Azienda Ospedaliero‐Universitaria CareggiEndoscopia ChirurgicaLargo Brambilla, 3FirenzeFirenzeItaly50121
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Wang CH, Chou HC, Liu KL, Lien WC, Wang HP, Wu YM. Long-Term Outcome of Patients with Acute Cholecystitis Receiving Antibiotic Treatment: A Retrospective Cohort Study. World J Surg 2013; 38:347-54. [DOI: 10.1007/s00268-013-2311-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Risk Factors for Conversion from Laparoscopic to Open Surgery: Analysis of 2138 Converted Operations in the American College of Surgeons National Surgical Quality Improvement Program. Am Surg 2013. [DOI: 10.1177/000313481307900930] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Minimal access procedures have influenced surgical practice and patient expectations. Risk of laparoscopic conversion to open surgery is frequently cited but vaguely quantified. The present study examines three common procedures to identify risk factors for laparoscopic conversion to open (LCO) events. Cross-sectional analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP; 2005 to 2009) identified cases with laparoscopic procedure codes for appendectomy, cholecystectomy, and bariatric procedures. The primary outcome was conversion of a laparoscopic procedure to its open equivalent. Summary statistics for laparoscopic and LCO groups were compared and logistic regression analysis was used to estimate patient and operative risk factors for conversion. Of 176,014 selected laparoscopic operations, 2,138 (1.2%) were converted. Most patients were female (68%) and white (71.2%); mean age was 45.1 years. LCO cholecystectomy was significantly more likely (n = 1526 [1.9%]) and LCO bariatric procedures were less likely (n = 121 [0.3%]); appendectomy was intermediate (n = 491 [1.0%], P < 0.001). Patient factors associated with LCO included male sex ( P < 0.001), age 30 years or older ( P < 0.025), American Society of Anesthesiologists Class 2 to 4 ( P < 0.001), obesity ( P < 0.01), history of bleeding disorder ( P = 0.036), or preoperative systemic inflammatory response syndrome or sepsis ( P < 0.001). LCO was associated with greater incidence of postoperative complications, including death, organ space surgical site infection, sepsis, wound dehiscence, and return to the operating room ( P < 0.001). Overall LCO incidence is low in hospitals participating in ACS-NSQIP. Conversion risk factors include patient age, sex, obesity, and preoperative comorbidity as well as the procedure performed. This information should be valuable to clinicians in discussing conversion risk with patients.
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Gurusamy KS, Vaughan J, Ramamoorthy R, Fusai G, Davidson BR. Miniports versus standard ports for laparoscopic cholecystectomy. Cochrane Database Syst Rev 2013; 2013:CD006804. [PMID: 23908012 PMCID: PMC11747961 DOI: 10.1002/14651858.cd006804.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND In conventional (standard) port laparoscopic cholecystectomy, four abdominal ports (two of 10 mm diameter and two of 5 mm diameter) are used. Recently, use of smaller ports, miniports, have been reported. OBJECTIVES To assess the benefits and harms of miniport (defined as ports smaller than the standard ports) laparoscopic cholecystectomy versus standard port laparoscopic cholecystectomy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until February 2013 to identify randomised clinical trials of relevance to this review. SELECTION CRITERIA Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing miniport versus standard port laparoscopic cholecystectomy were considered for the review. DATA COLLECTION AND ANALYSIS Two review authors collected the data independently. We analysed the data with both fixed-effect and random-effects models using RevMan analysis. For each outcome we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI). MAIN RESULTS We included 12 trials with 734 patients randomised to miniport laparoscopic cholecystectomy (380 patients) versus standard laparoscopic cholecystectomy (351 patients). Only one trial which included 70 patients was of low risk of bias. Miniport laparoscopic cholecystectomy could be completed successfully in more than 80% of patients in most trials. The remaining patients were mostly converted to standard port laparoscopic cholecystectomy but some were also converted to open cholecystectomy. These patients were included for the outcome conversion to open cholecystectomy but excluded from other outcomes. Accordingly, the results of the other outcomes are on 343 patients in the miniport laparoscopic cholecystectomy group and 351 patients in the standard port laparoscopic cholecystectomy group, and therefore the results have to be interpreted with extreme caution.There was no mortality in the seven trials that reported mortality (0/194 patients in miniport laparoscopic cholecystectomy versus 0/203 patients in standard port laparoscopic cholecystectomy). There were no significant differences between miniport laparoscopic cholecystectomy and standard laparoscopic cholecystectomy in the proportion of patients who developed serious adverse events (eight trials; 460 patients; RR 0.33; 95% CI 0.04 to 3.08) (miniport laparoscopic cholecystectomy: 1/226 (adjusted proportion 0.4%) versus standard laparoscopic cholecystectomy: 3/234 (1.3%); quality of life at 10 days after surgery (one trial; 70 patients; SMD -0.20; 95% CI -0.68 to 0.27); or in whom the laparoscopic operation had to be converted to open cholecystectomy (11 trials; 670 patients; RR 1.23; 95% CI 0.44 to 3.45) (miniport laparoscopic cholecystectomy: 8/351 (adjusted proportion 2.3%) versus standard laparoscopic cholecystectomy 6/319 (1.9%)). Miniport laparoscopic cholecystectomy took five minutes longer to complete than standard laparoscopic cholecystectomy (12 trials; 695 patients; MD 4.91 minutes; 95% CI 2.38 to 7.44). There were no significant differences between miniport laparoscopic cholecystectomy and standard laparoscopic cholecystectomy in the length of hospital stay (six trials; 351 patients; MD -0.00 days; 95% CI -0.12 to 0.11); the time taken to return to activity (one trial; 52 patients; MD 0.00 days; 95% CI -0.31 to 0.31); or in the time taken for the patient to return to work (two trials; 187 patients; MD 0.28 days; 95% CI -0.44 to 0.99) between the groups. There was no significant difference in the cosmesis scores at six months to 12 months after surgery between the two groups (two trials; 152 patients; SMD 0.13; 95% CI -0.19 to 0.46). AUTHORS' CONCLUSIONS Miniport laparoscopic cholecystectomy can be completed successfully in more than 80% of patients. There appears to be no advantage of miniport laparoscopic cholecystectomy in terms of decreasing mortality, morbidity, hospital stay, return to activity, return to work, or improving cosmesis. On the other hand, there is a modest increase in operating time after miniport laparoscopic cholecystectomy compared with standard port laparoscopic cholecystectomy and the safety of miniport laparoscopic cholecystectomy is yet to be established. Miniport laparoscopic cholecystectomy cannot be recommended routinely outside well-designed randomised clinical trials. Further trials of low risks of bias and low risks of random errors are necessary.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - Jessica Vaughan
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - Rajarajan Ramamoorthy
- Royal Free Hospital and University College School of MedicineUniversity Department of Surgery9th Floor, Royal Free HospitalPond StreetLondonUKNW3 2QG
| | - Giuseppe Fusai
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
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Sandzén B, Haapamäki MM, Nilsson E, Stenlund HC, Oman M. Surgery for acute gallbladder disease in Sweden 1989-2006--a register study. Scand J Gastroenterol 2013; 48:480-6. [PMID: 23356689 DOI: 10.3109/00365521.2012.763177] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Since early 1970s, prospective randomized controlled trials have emphasized the advantages of early cholecystectomy in patients with acute cholecystitis, compared to elective delayed cholecystectomy. The aim of this investigation was to study surgery for acute gallbladder disease in Sweden during a 15-year period when open cholecystectomy was replaced by a laparoscopic procedure. MATERIAL AND METHODS Data from the Swedish National Patient Register and the Cause of Death Register 1988-2006 comprising hospital stays with a primary diagnosis of gallbladder/gallstone disease in Sweden were retrieved. Patients were analyzed with reference to timing of cholecystectomy, length of hospital stay, and mortality. RESULTS Emergency cholecystectomy at index (first) admission or at readmission within 2 years of index admission was performed in 32.2% and 6.1% of patients, respectively. Elective cholecystectomy within 2 years of index admission was performed in 20.3% patients, whereas 41.3% of all patients did not undergo cholecystectomy within 2 years. Standardized mortality ratio did not significantly change during the audit period. Total hospital stay (days at index stay and subsequent stay(s) for biliary diagnoses within 2 years) was shorter for patients who had emergency cholecystectomy at first admission compared to patients with later or no cholecystectomy within 2 years. CONCLUSIONS Around 30% of patients with acute gallbladder disease were operated with cholecystectomy during the first admission with no time trend from 1990 through 2004. A total of 40% of patients with acute gallbladder disease were not cholecystectomized within 2 years. Analysis of outcome of long-term conservative treatment is warranted.
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Affiliation(s)
- Birger Sandzén
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
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Epidemiological study of provision of cholecystectomy in England from 2000 to 2009: retrospective analysis of Hospital Episode Statistics. Surg Endosc 2012; 27:162-75. [DOI: 10.1007/s00464-012-2415-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 05/18/2012] [Indexed: 12/21/2022]
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Navez B, Ungureanu F, Michiels M, Claeys D, Muysoms F, Hubert C, Vanderveken M, Detry O, Detroz B, Closset J, Devos B, Kint M, Navez J, Zech F, Gigot JF. Surgical management of acute cholecystitis: results of a 2-year prospective multicenter survey in Belgium. Surg Endosc 2012; 26:2436-45. [PMID: 22407152 DOI: 10.1007/s00464-012-2206-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Accepted: 01/27/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy is considered nowadays as the standard management of acute cholecystitis (AC). However, results from multicentric studies in the general surgical community are still lacking. METHODS A prospective multicenter survey of surgical management of AC patients was conducted over a 2-year period in Belgium. Operative features and patients' clinical outcome were recorded. The impact of independent predictive factors on the choice of surgical approach, the risk of conversion, and the occurrence of postoperative complications was studied by multivariate logistic regression analysis. RESULTS Fifty-three surgeons consecutively and anonymously included 1,089 patients in this prospective study. A primary open approach was chosen in 74 patients (6.8%), whereas a laparoscopic approach was the first option in 1,015 patients (93.2%). Independent predictive factors for a primary open approach were previous history of upper abdominal surgery [odds ratio (OR) 4.13, p < 0.001], patient age greater than 70 years (OR 2.41, p < 0.05), surgeon with more than 10 years' experience (OR 2.08, p = 0.005), and gangrenous cholecystitis (OR 1.71, p < 0.05). In the laparoscopy group, 116 patients (11.4%) required conversion to laparotomy. Overall, 38 patients (3.5%) presented biliary complications and 49 had other local complications (4.5%). Incidence of bile duct injury was 1.2% in the whole series, 2.7% in the open group, and 1.1% in the laparoscopy group. Sixty patients had general complications (5.5%). The overall mortality rate was 0.8%. All patients who died were in poor general condition [American Society of Anesthesiologists (ASA) III or IV]. CONCLUSIONS Although laparoscopic cholecystectomy is currently considered as the standard treatment for acute cholecystitis, an open approach is still a valid option in more advanced disease. However, overall mortality and incidence of bile duct injury remain high.
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Affiliation(s)
- Benoit Navez
- Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Avenue Hippocrate, 10, 1200 Brussels, Belgium.
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Donkervoort SC, Dijksman LM, de Nes LCF, Versluis PG, Derksen J, Gerhards MF. Outcome of laparoscopic cholecystectomy conversion: is the surgeon's selection needed? Surg Endosc 2012; 26:2360-6. [PMID: 22398961 DOI: 10.1007/s00464-012-2189-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Accepted: 01/23/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Risk factors for conversion in cholecystectomy may be of clinical value. This study aimed to investigate whether a set of risk factors, including the surgeon's specialization, can be used for the development of a preoperative strategy to optimize conversion outcome. METHODS The data for all patients who underwent laparoscopic cholecystectomy at a single institution between January 2004 and December 2008 were retrospectively reviewed. Factors predictive for conversion were identified, and a preoperative strategy model was deduced. RESULTS Of the 1,126 patients analyzed, 106 (9%) underwent laparoscopic cholecystectomy in an emergency setting. Delayed surgery was performed for 63 (46%) of 138 patients (12%) with acute cholecystitis. Preoperative endoscopic retrograde cholangiography was achieved for 161 of the patients (14%). Risk factors predictive of conversion (for 65 patients) were male gender [odds ratio (OR), 2.3; 95% confidence interval (CI), 1.3-3.9; p = 0.004], age older than 65 years (OR, 2.6; 95% CI, 1.4-4.8; p = 0.002), body mass index (BMI) exceeding 25 kg/m(2) (OR, 3.4; 95% CI, 1.7-7.1; p < 0.001), history of complicated biliary disease (HCBD) (OR, 5.6; 95% CI, 3.2-9.8; p = < 0.001), and surgery by a non-gastrointestinal (non-GI) surgeon (OR, 4.9; 95% CI, 2.2-10.6; p < 0.001). The conversion rate for patients with a history of no complications who had two or more risk factors (gender, age, BMI > 25) and for patients with a HCBD who had one or more risk factors was significantly higher if the surgery was performed by non-GI rather than GI surgeons. CONCLUSION Male gender, age older than 65 years, BMI exceeding 25 kg/m(2), HCBD, and surgery by a non-GI surgeon are predictive for conversion. A preoperative triage for surgeon selection based on risk factors and a HCBD is proposed to optimize conversion outcome.
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Affiliation(s)
- Sandra C Donkervoort
- Department of Surgery, Onze Lieve Vrouwe Gasthuis (OLVG), 95500, 1090 Amsterdam, HM, The Netherlands.
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Sakowska MM, Connor S. Index cholecystectomy for management of acute gallstone disease: a change of practice at a major New Zealand metropolitan centre. HPB (Oxford) 2011; 13:687-91. [PMID: 21929668 PMCID: PMC3210969 DOI: 10.1111/j.1477-2574.2011.00345.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 05/22/2011] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study aimed to examine the effects of a change in practice in index cholecystectomy on waiting lists at a New Zealand metropolitan hospital. METHODS Patients presenting with gallstone disease from January 2004 to October 2010 were identified. Data on acute and elective cholecystectomies were collated and analysed for length of stay. Waiting lists for cholecystectomy were compared. RESULTS During the study period, 3999 patients were admitted with acute gallbladder disease. The median number of admissions decreased from 49 to 40 per month (P < 0.01). The median number of index cholecystectomies increased from three to 22 per month (P < 0.01). Total monthly bed days for all cholecystectomies decreased from 175 days to 124 days (P < 0.01), but only median postoperative bed days for acute cholecystectomy showed a similar trend, decreasing from 4 days to 3 days (P < 0.01). The number of patients on the waiting list decreased from 334 in January 2004 to 132 in January 2006 as a result of government-imposed cuts. The number of patients wait-listed for elective cholecystectomy remained unchanged. CONCLUSIONS An increasing number of index cholecystectomies have been performed at this centre. An effect on waiting list numbers is yet to be shown, but the wait list has not ballooned to previous numbers, although the number of patients joining the wait list remains unchanged. Monthly bed days have decreased for all patients with acute gallstone disease, probably in response to a combination of the changes implemented.
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Affiliation(s)
- Magdalena M Sakowska
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand.
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Scollay JM, Mullen R, McPhillips G, Thompson AM. Mortality associated with the treatment of gallstone disease: a 10-year contemporary national experience. World J Surg 2011; 35:643-7. [PMID: 21181471 DOI: 10.1007/s00268-010-0908-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Gallstones remain a common clinical problem requiring skilled operative and nonoperative management. The aim of the present population-based study was to investigate causes of gallstone-related mortality in Scotland. METHODS Surgical deaths were peer reviewed between 1997 and 2006 through the Scottish Audit of Surgical Mortality (SASM); data were analyzed for patients in whom the principal diagnosis on admission was gallstone disease. RESULTS Gallstone disease was responsible for 790/43,271 (1.83%) of the surgical deaths recorded, with an overall mortality for cholecystectomy of 0.307% (176/57,352), endoscopic retrograde cholangiopancreatography (ERCP) of 0.313% (117/37,345), and cholecystostomy of 2.1% (12/578) across the decade. However, the majority of patients who died were elderly (47.6% ≥ 80 years or older) and were managed conservatively. Deaths following cholecystectomy usually followed emergency admission (76%) and were more likely to have been associated with postoperative medical complications (n = 189) than surgical complications (n = 36). DISCUSSION Although cholecystectomy is a relatively safe procedure, patients who die as a result of gallstone disease tend to be elderly, to have been admitted as emergency cases, and to have had co-morbidities. Future combined medical and surgical perioperative management may reduce the mortality rate associated with gallstones.
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Affiliation(s)
- John M Scollay
- Department of Surgery, Ninewells Hospital and Medical School, Dundee D1 9SY, UK.
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An Effective Approach to Improving Day-Case Rates following Laparoscopic Cholecystectomy. Minim Invasive Surg 2011; 2011:564587. [PMID: 22091360 PMCID: PMC3197003 DOI: 10.1155/2011/564587] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 02/14/2011] [Indexed: 01/10/2023] Open
Abstract
Background. Day-case laparoscopic cholecystectomy (LC) is a safe and cost-effective treatment for gallstones. In 2006, our institution recorded an 86% laparoscopic, 10% day-case, and 5% readmission rate. A gallbladder pathway was therefore introduced in 2007 with the aim of increasing daycase rates. Methods. Patients with symptomatic gallstones, proven on ultrasound, were referred to a specialist-led clinic. Those suitable for surgery were consented, preassessed, and provided with a choice of dates. All defaulted to day case unless deemed unsuitable due to comorbidity or social factors. Results. The number of cholecystectomies increased from 464 in 2006 to 578 in 2008. Day-case rates in 2006, 2007, 2008, and June 2009 were 10%, 20%, 30%, and 61%, respectively. Laparoscopic and readmission rates remained unchanged. Conversion rates for elective cholecystectomy fell from 6% in 2006 to 3% in 2009. Conclusions. Development of a gallbladder pathway increased day-case rates sixfold without an associated increase in conversion or readmission rates.
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Borowski D, Knox M, Kanakala V, Richardson S, Seymour K, Attwood S, Slater B. Referral pathways of patients with gallstones: a potential source of financial waste in the U.K. National Health Service? Int J Health Care Qual Assur 2011; 23:248-57. [PMID: 21388103 DOI: 10.1108/09526861011017139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE Gallstone-related illnesses are one of the most common reasons for emergency hospital admissions, often with serious complications. Standard treatment of uncomplicated gallstone-disease is by laparoscopic cholecystectomy, which can be safely and cost-effectively performed during a short hospital stay or as day-case. This paper aims to evaluate the referral pattern of patients with gallstones, which treatment is given and whether patients admitted as emergency could have benefited from earlier elective referral. The management of these patients is examined in the context of payment by results to determine cost and potential savings. DESIGN/METHODOLOGY/APPROACH The approach takens was prospective clinical audit and patient questionnaire in a district general hospital. Cost comparisons were made using secondary care income (NHS tariff) and estimated cost of hospitalisation, investigations and treatment. FINDINGS Between May and July 2007, 114 patients were admitted with symptomatic gallstones, 62 (54.4 per cent) were emergencies. Cholecystectomy was performed in all 52 elective patients and performed or planned for 59/62 (95.2 per cent) emergencies. A total 17/62 emergencies (27.4 per cent) presented with complications of gallstones. 38/62 (61.3 per cent) had similar symptoms before, with 21/38 (55.3 per cent) diagnosed in primary care or by another hospital department. 11 (52.4 per cent) of these had not been referred for a surgical opinion; taking account of age, co-morbidity and data acquired for elective admissions, the cost of their treatment could have been reduced by at least pounds 16,194. ORIGINALITY/VALUE A large proportion of patients admitted with symptomatic biliary disease could have been referred earlier and electively. Such referral practice could improve the quality of care and reduce cost for the NHS both in primary and secondary care.
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Affiliation(s)
- David Borowski
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK.
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Kanakala V, Borowski DW, Pellen MGC, Dronamraju SS, Woodcock SAA, Seymour K, Attwood SEA, Horgan LF. Risk factors in laparoscopic cholecystectomy: a multivariate analysis. Int J Surg 2011; 9:318-23. [PMID: 21333763 DOI: 10.1016/j.ijsu.2011.02.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2010] [Revised: 01/10/2011] [Accepted: 02/04/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is the operation of choice in the treatment of symptomatic gallstone disease. The aim of this study is to identify risk factors for LC, outcomes include operating time, length of stay, conversion rate, morbidity and mortality. METHODS All patients undergoing LC between 1998 and 2007 in a single district general hospital. Risk factors were examined using uni- and multivariate analysis. RESULTS 2117 patients underwent LC, with 1706 (80.6%) patients operated on electively. Male patients were older, had more co-morbidity and more emergency surgery than females. The median post-operative hospital stay was one day, and was positively correlated with the complexity of surgery. Conversion rates were higher in male patients (OR 1.47, p = 0.047) than in females, and increased with co-morbidity. Emergency surgery (OR 1.75, p = 0.005), male gender (OR 1.68, p = 0.005), increasing co-morbidity and complexity of surgery were all positively associated with the incidence of complications (153/2117 [7.2%]), whereas only male gender was significantly associated with mortality (OR 5.71, p = 0.025). CONCLUSION Adverse outcome from LC is particularly associated with male gender, but also the patient's co-morbidity, complexity and urgency of surgery. Risk-adjusted outcome analysis is desirable to ensure an informed consent process.
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Affiliation(s)
- Venkatesh Kanakala
- Department of Surgery, North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust, Rake Lane, North Shields, Tyne and Wear NE29 8NH, United Kingdom.
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'Critical view of safety' as an alternative to routine intraoperative cholangiography during laparoscopic cholecystectomy for acute biliary pathology. J Gastrointest Surg 2010; 14:1280-4. [PMID: 20535578 DOI: 10.1007/s11605-010-1251-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 05/31/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The study aims to evaluate the use of "critical view of safety" (CVS) for the prevention of bile duct injuries during laparoscopic cholecystectomy for acute biliary pathology as an alternative to routine intraoperative cholangiography (IOC). METHODS A policy of routine CVS to identify biliary anatomy and selective IOC for patients suspected to have common bile duct (CBD) stone was adopted. Receiver operator curves (ROCs) were used to identify cutoff values predicting CBD stones. RESULTS Four hundred forty-seven consecutive, same admission laparoscopic cholecystectomies performed between August 2004 and July 2007 were reviewed. CVS was achieved in 388 (87%) patients. Where CVS was not possible, the operation was completed open. CBD stones were identified in 22/57 patients who underwent selective IOC. Preoperative liver function and CBD diameter were significantly higher in those with CBD stones (P < .001). ROC curve analysis identified preoperative cutoff values of bilirubin (35 mumol/L), alkaline phosphatase (250 IU/L), alanine aminotransferase (240 IU/L), and a CBD diameter of 10 mm, as predictive of CBD stones. No bile duct injuries occurred in this series. CONCLUSION In acute biliary pathology, the use of CVS helps clarify the anatomy of Calot's triangle and is a suitable alternative to routine IOC. Selective cholangiography should be employed when preoperative liver function and CBD diameter are above defined thresholds.
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Saeb-Parsy K, Mills A, Rang C, Reed JB, Harris AM. Emergency laparoscopic cholecystectomy in an unselected cohort: a safe and viable option in a specialist centre. Int J Surg 2010; 8:489-93. [PMID: 20633707 DOI: 10.1016/j.ijsu.2010.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 06/15/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Patients presenting acutely with symptomatic gallstone-related disease have historically had their laparoscopic cholecystectomy (LC) deferred due to perceived increased operative risks in the acute setting, particularly conversion to open surgery. The aim of this study was to compare morbidity and mortality between unselected cohorts of patients undergoing elective and 'emergency' LC in a District General Hospital. METHODS All gallstone-related elective and emergency admissions under the care of two specialist laparoscopic surgeons during a two-year period were included. Patients admitted acutely with a diagnosis of biliary colic, acute cholecystitis or gallstone pancreatitis underwent 'emergency' LC during the same admission. Data were collected prospectively on patient demographics, inpatient stay, post-operative course and POSSUM scores. RESULTS 423 patients underwent LC, of which 301 (71.1%) were elective and 122 (28.9%) were 'emergency' procedures. ASA grades and POSSUM physiologic scores were similar between the two groups. The overall morbidity rates were similar in the emergency and elective groups (13.1% vs. 7.3%, p = 0.088), and there was no significant difference in the rates of major complications including conversion to open surgery (0% vs. 0.3%, NS), bile leak or re-operation between the two groups. 30-day mortality rates were similar in the two groups (0.8% vs. 0%, NS). CONCLUSION When performed by specialist laparoscopic surgeons, LC in the acute setting is safe with mortality and morbidity rates, including conversion to open surgery, comparable to elective LC.
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Affiliation(s)
- K Saeb-Parsy
- Hinchingbrooke Hospital, Hinchingbrooke Park, Huntingdon, Cambridgeshire, PE29 6NT, United Kingdom.
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Shaikh IAA, Abdel-Fattah M, Yalamarthi S, Daniel T, Amin AI. Should colorectal surgeons perform laparoscopic cholecystectomy in a district general hospital? ANZ J Surg 2010; 80:304-5. [PMID: 20557498 DOI: 10.1111/j.1445-2197.2010.05293.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Down SK, Nicolic M, Abdulkarim H, Skelton N, Harris AH, Koak Y. Low ninety-day re-admission rates after emergency and elective laparoscopic cholecystectomy in a district general hospital. Ann R Coll Surg Engl 2010; 92:307-10. [PMID: 20385048 DOI: 10.1308/003588410x12664192075053] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Re-admission rate following laparoscopic cholecystectomy is currently defined as within 30 days of the initial operation. This may underestimate the true incidence and financial cost of postoperative morbidity. This study aimed to analyse re-admissions within 90 days of elective and emergency laparoscopic cholecystectomy at a district general hospital, and to compare outcomes to larger teaching centres. PATIENTS AND METHODS We undertook a retrospective analysis of all patients re-admitted within 90 days of laparoscopic cholecystectomy during an 18-month period (June 2006 to December 2007). Patient characteristics, details of the primary operation, and reasons for re-admission were identified, and a comparison of re-admissions following elective versus emergency procedures was performed. RESULTS A total of 326 laparoscopic cholecystectomies were performed during the 18-month period (246 elective, 80 emergency). No operations required conversion to an open procedure. Twenty-five patients were re-admitted within 90 days of their operation, of whom only 14 had complications directly related to their surgery (overall re-admission rate 4.3%). There was no statistical difference in re-admission rate or cause of re-admission between elective and emergency procedures. However, the mean time to re-admission following elective procedures was significantly longer (36 days; P = 0.0003). CONCLUSIONS Re-admission rates at our district general hospital are comparable to those reported by larger teaching centres. Current 30-day re-admission data may significantly underestimate morbidity rates and socio-economic cost following elective laparoscopic cholecystectomy.
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Affiliation(s)
- Sue K Down
- Department of General Surgery, Hinchingbrooke Hospital NHS Trust, Hinchingbrooke Park, Huntingdon, UK
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Sanjay P, Kulli C, Polignano FM, Tait IS. Optimal surgical technique, use of intra-operative cholangiography (IOC), and management of acute gallbladder disease: the results of a nation-wide survey in the UK and Ireland. Ann R Coll Surg Engl 2010; 92:302-6. [PMID: 20501016 DOI: 10.1308/003588410x12628812458617] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION There is debate on optimal techniques that reduce bile duct injury during laparoscopic cholecystectomy (LC). A national survey of Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS) members was carried out to determine current surgical practice for gallstones, including the use of intra-operative cholangiography (IOC) or critical view of safety to reduce the risk of bile duct injury. SUBJECTS AND METHODS An anonymous postal survey was sent to all 417 AUGIS members. Data on grade of surgeon, place of work (district general hospital, teaching), subspecialty, number LC per year, use of IOC, critical view of safety, and management of stones detected during surgery were collated. RESULTS There was a 36% (152/417) response - 134 (88%) from consultant surgeons (36, HPB; 106,OG; 64, DGH; 88, teaching hospital). Of these, 38% performed > 100 LC per year, 36% 50-100 LC per year, and 22% 25-50 LC per year. IOC was routine for 24%; and selective for 72%. Critical view of Calot's triangle was advocated by 82%. Overall, 55% first clip and divide the cystic artery, whereas 41% first clip and divide the cystic duct. Some 39% recommend IOC and 23% pre-operative MRCP if dilated common bile duct (CBD) is noted on pre-operative ultrasound. When bile duct stones are identified on IOC, 61% perform laparoscopic CBD exploration (LCBDE), 25% advise postoperative ERCP, and 13% perform either LCBDE or ERCP. Overall, 88% (n = 134) recommend index cholecystectomy for acute pathology, and this is more likely in a teaching hospital setting (P = 0.003). Laparoscopic CBD exploration was more likely to be performed in university hospitals (P < 0.05). CONCLUSIONS A wide dissection of Calot's triangle to provide a critical view of safety is the technique most commonly recommended by AUGIS surgeons (83%) to minimise risk of bile duct injury, in contrast to 24% that recommend routine IOC. The majority (88%) of AUGIS surgeons advise index admission cholecystectomy for acute gallbladder disease.
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Affiliation(s)
- P Sanjay
- Department of Surgery, Ninewells Hospital and Medical School, Dundee, UK
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Young AL, Cockbain AJ, White AW, Hood A, Menon KV, Toogood GJ. Index admission laparoscopic cholecystectomy for patients with acute biliary symptoms: results from a specialist centre. HPB (Oxford) 2010; 12:270-6. [PMID: 20590897 PMCID: PMC2873650 DOI: 10.1111/j.1477-2574.2010.00163.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Index admission laparoscopic cholecystectomy (ALC) is the treatment of choice for patients admitted with biliary symptoms but is performed in less than 15% of these admissions. We analysed our results for ALC within a tertiary hepatobiliary centre. METHODS Data from all cholecystectomies carried out under the care of the two senior authors from 1998 to 2008 were prospectively collected and interrogated. RESULTS 1710 patients underwent cholecystectomy of which 439 (26%) were ALC. Patients operated on acutely did not have a significantly different complication rate (P= 0.279; 4% vs.3%). Factors predicting complications were abnormal alkaline phosphatase (ALP) (P= 0.037), dilated common bile duct (CBD) (P= 0.026), cholangitis (P= 0.040) and absence of on table cholangiography (OTC) (P= 0.011). There were no bile duct injuries. Patients undergoing ALC had a higher rate of conversion to an open procedure (P < 0.001:10% vs.3%). The proportion of complicated disease was higher in the ALC group (P < 0.001; 70% vs.31%). Only complicated disease (P= 0.006), absence of OTC (P < 0.001) and age greater than 65 years (P < 0.001) were predictive of conversion on multivariate analysis. CONCLUSIONS Laparoscopic cholecystectomy can be performed safely in patients with acute biliary symptoms and should be considered the gold standard for management of these patients thus avoiding avoidable readmissions and life-threatening complications. A higher conversion rate to an open procedure must be accepted when treating more complicated disease. It is the severity of disease rather than timing of surgery which most probably predicts complications and conversions.
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Affiliation(s)
- Alastair L Young
- Hepatobiliary and Transplant Unit, Lincoln Wing, St James's University Hospital, Leeds, UK
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Gurusamy KS, Samraj K, Ramamoorthy R, Farouk M, Fusai G, Davidson BR. Miniport versus standard ports for laparoscopic cholecystectomy. Cochrane Database Syst Rev 2010:CD006804. [PMID: 20238350 DOI: 10.1002/14651858.cd006804.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND In conventional (standard) laparoscopic cholecystectomy, four abdominal ports (two of 10 mm diameter and two of 5 mm diameter) are used. Recently, use of smaller ports have been reported. OBJECTIVES To assess the benefits and harms of miniport (defined as ports smaller than conventional ports) laparoscopic cholecystectomy versus standard laparoscopic cholecystectomy. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until September 2009 for identifying the randomised trials. SELECTION CRITERIA Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing miniport versus standard ports laparoscopic cholecystectomy were considered for the review. DATA COLLECTION AND ANALYSIS Two authors collected the data independently. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI). MAIN RESULTS We included thirteen trials with 803 patients randomised to miniport (n = 416) versus standard ports laparoscopic cholecystectomy (n = 387). In twelve trials, four ports were used. In one trial, three ports were used. The bias risk of all trials was high. Miniport laparoscopic cholecystectomy could be completed successfully in 87% of patients. The remaining patients were mostly converted to standard laparoscopic cholecystectomy but some were also converted to open cholecystectomy. Further information about these patients who underwent conversion to open cholecystectomy was not available in most trials. In the patients on whom information was available, there was no mortality reported; and there was no significant difference in the surgery-related morbidity or conversion to open cholecystectomy. Most trials excluded the patients who were converted to standard laparoscopic cholecystectomy. In patients who underwent successful miniport laparoscopic cholecystectomy, the pain was significantly lower in the miniport group than in the standard port at various time points. AUTHORS' CONCLUSIONS Miniport laparoscopic cholecystectomy can be completed successfully in more than 85% of patients. Patients, in whom elective miniport laparoscopic cholecystectomy was completed successfully, had lower pain than those who underwent standard laparoscopic cholecystectomy. However, because of the lack of information on its safety, miniport laparoscopic cholecystectomy cannot be recommended outside well-designed, randomised clinical trials.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG
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Gurusamy K, Samraj K, Gluud C, Wilson E, Davidson BR. Meta-analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 2010; 97:141-50. [PMID: 20035546 DOI: 10.1002/bjs.6870] [Citation(s) in RCA: 223] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND : In many countries laparoscopic cholecystectomy for acute cholecystitis is mainly performed after the acute episode has settled because of the anticipated increased risk of morbidity and higher conversion rate from laparoscopic to open cholecystectomy. METHODS : A systematic review was performed with meta-analysis of randomized clinical trials of early laparoscopic cholecystectomy (ELC; performed within 1 week of onset of symptoms) versus delayed laparoscopic cholecystectomy (performed at least 6 weeks after symptoms settled) for acute cholecystitis. Trials were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded and reference lists. Risk ratio (RR) or mean difference was calculated with 95 per cent confidence intervals (c.i.) based on intention-to-treat analysis. RESULTS : Five trials with 451 patients were included. There was no significant difference between the two groups in terms of bile duct injury (RR 0.64 (95 per cent c.i. 0.15 to 2.65)) or conversion to open cholecystectomy (RR 0.88 (95 per cent c.i. 0.62 to 1.25)). The total hospital stay was shorter by 4 days for ELC (mean difference -4.12 (95 per cent c.i. -5.22 to -3.03) days). CONCLUSION : ELC during acute cholecystitis appears safe and shortens the total hospital stay.
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Affiliation(s)
- K Gurusamy
- Hepatopancreatobiliary and Liver Transplant Surgery, University Department of Surgery, Royal Free and University College School of Medicine, London, UK.
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Sanjay P, Moore J, Saffouri E, Ogston SA, Kulli C, Polignano FM, Tait IS. Index laparoscopic cholecystectomy for acute admissions with cholelithiasis provides excellent training opportunities in emergency general surgery. Surgeon 2010; 8:127-31. [PMID: 20400020 DOI: 10.1016/j.surge.2009.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Accepted: 10/22/2009] [Indexed: 12/21/2022]
Abstract
BACKGROUND There is minimal data on the outcome of early laparoscopic cholecystectomy (LC) for acute gallbladder disease when performed by trainees. This study assesses the outcomes of a policy of same admission LC incorporated into a surgical training programme in a major teaching hospital. METHODS 447 index LCs performed over a 3-year period were reviewed retrospectively. The indications, operating surgeon, operating time, use of IOC, conversion rates, reasons for conversion and post-operative stay were analysed. Multivariate analysis of reasons for conversion was performed. RESULTS 150 LCs were performed by consultants and 297 by registrars; 67 were performed by year 1-3 specialist registrars (SpR) and 230 by year 4-6 SpRs. The indications were biliary colic (n=7), acute cholecystitis (n=180), chronic cholecystitis (n=260), carcinoma (n=1). No difference was found in demographics, operating time (105 min Vs 115 min), use of IOC (34% Vs 29%; P=0.2) and post-operative stay (2 days Vs 1 day) between consultants and registrars. The conversion rates were higher for consultants compared to registrars (29 (19%) Vs 28 (9%), P=0.004). The overall conversion rate was 11%. There were no bile duct injuries. Predictors for conversion were CRP>50 at admission and acute cholecystitis. CONCLUSION In a teaching hospital setting most acute admission LCs (66%) were performed by trainees. A step wise training programme with active consultant supervision of all index LCs results in low morbidity, low conversion rates, and a short post-operative stay for acute gallbladder disease. This model of same admission cholecystectomy provides a good training opportunity in emergency general surgery.
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Affiliation(s)
- P Sanjay
- Directorate of General Surgery, Ninewells Hospital & Medical School, Ninewells Avenue, Dundee, Scotland DD1 9SY
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Farooq T, Buchanan G, Manda V, Kennedy R, Ockrim J. Is early laparoscopic cholecystectomy safe after the "safe period"? J Laparoendosc Adv Surg Tech A 2009; 19:471-4. [PMID: 19489677 DOI: 10.1089/lap.2008.0363] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Early laparoscopic cholecystectomy (ELC) in acute cholecystitis improves hospital stay and outcome. Operative difficulty is said to increase with delay, and surgery is usually advised within 3 days of presentation. It can be difficult to accommodate all these patients within 3 days; this study evaluates results within and after this "safe period." MATERIALS AND METHODS In total, 137 patients (male:female 45:92) presenting as an emergency due to acute cholecystitis over 45 months from August 1, 2003, who then underwent ELC with an on-table cholangiogram (OTC) or laparoscopic ultrasound were prospectively studied. Outcome was compared between those who underwent surgery within 72 hours (group 1) or after 72 hours (group 2). RESULTS There were 87 patients in group 1 versus 50 in group 2. There was no significant difference with reference to ASA grading, length of operation (median 90 vs. 90 minutes; P = 1.000), conversion rates (7 vs. 10%; P = 0.523), median postoperative stay (2 vs. 3 days; P = 0.203), or 30-day readmission rates [5/87 [6%] vs. 3/50 [6%]; P = 1.000] between groups, respectively. There was no mortality. One patient had a biliary leak from a duct of Lushka in group 2, which settled after endoscopic stenting. CONCLUSION In experienced hands, ELC is safe even after 72 hours.
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Affiliation(s)
- Tahir Farooq
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, United Kingdom
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Agrawal S, Battula N, Barraclough L, Durkin D, Cheruvu CVN. Early laparoscopic cholecystectomy service provision is feasible and safe in the current UK National Health Service. Ann R Coll Surg Engl 2009; 91:660-4. [PMID: 19686614 DOI: 10.1308/003588409x464478] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Despite increasing evidence of the benefits and safety of early laparoscopic cholecystectomy (LC) in acute gallstone disease, it is not widely practised in England. The Royal College of Surgeons of England support the separation of emergency and elective surgical care. The aim of this prospective study was to examine the impact of the implementation of 'Surgeon of the Week (SoW)' model on the number of early LCs performed and the efficiency of the emergency theatre activity in our hospital. This study also looked into its implications on specialist registrar training for early LC, and the financial impact to the hospital. PATIENTS AND METHODS Between January 2007 and May 2008, demographic data, admission and discharge dates, complications, conversions to an open operation and deaths were collected for all patients who underwent early laparoscopic cholecystectomies. For ease of comparison, patients were divided into Group A representing before introduction of SoW (1 January 2007 to 30 August 2007) and Group B representing after introduction of SoW (1 October 2007 to 31 May 2008). The total numbers of operations performed in the emergency theatre list in the two groups were also calculated. RESULTS A total of 1361 emergency operations were performed on the emergency theatre list in Group A, of which 951 were general surgical procedures. In Group B, the numbers of emergency procedures were 1537, of which 1138 were general surgical operations. There was a significant increase in the number of general surgical operations after introduction of SoW (P = 0.013). Before introduction of the SoW rota, 45 early LCs were performed. This increased to 118 after SoW which was significant (P < 0.001). In Group A, the number of early LCs performed by surgical trainees was 10 (22%). In Group B, the number of LCs performed by surgical trainees was 35 (30%; not significant). CONCLUSIONS This study has demonstrated an increase in the efficiency of the emergency theatre with an increase in the number of early LCs on their index admission without extra morbidity following implementation of the SOW model in our hospital. We recommend the introduction of a suitable emergency surgical consultant on-call model separating emergency and elective surgical care depending on local circumstances. This can lead to significant cost savings and reduce re-admissions with gallstone-related complications.
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Affiliation(s)
- S Agrawal
- Department of General Surgery, University Hospital of North Staffordshire, Newcastle Road, Stoke-on-Trent ST4 6QG, UK.
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Abstract
BACKGROUND/AIM It is now 60 years since early cholecystectomy was advocated for acute cholecystitis (AC). Yet, surgical opinion remains divided regarding its optimal timing. Furthermore, recent surveys have shown low utilization of early laparoscopic cholecystectomy (LC) for AC. AIM This survey aimed to assess the current management of AC in Eastern Saudi Arabia. MATERIALS AND METHODS A postal survey was conducted by means of a questionnaire sent to 95 surgeons practicing LC. The questionnaire addressed the surgical management of AC in relation to the subspecialty of interest, duration of consultant status, number of cholecystectomies performed per year, and the percentage performed laparoscopically. RESULTS There were 87 responders (92%); two were excluded from the analysis for different reasons. Early LC was preferred by 71% of the responders. With regard to the timing of LC, there was no significant difference in relation to the surgeon's subspecialty of interest or duration of consultant status. However, increased number of cholecystectomies and percentage of cholecystectomies performed with a laparoscopic approach were significantly associated with early LC. CONCLUSION Early LC for AC is practiced by th e majority of surgeons in Eastern Saudi Arabia. This practice is significantly associated with increased number of cholecystectomies performed as well as with the percentage performed with a laparoscopic approach. According to the current literature, early LC for AC results in a shorter total hospital stay and reduced cost of treatment.
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Affiliation(s)
- Abdulmohsen A. Al-Mulhim
- Department of Surgery, King Fahd Hospital of the University, Al-Khobar, Saudi Arabia,Address for correspondence: Dr. Abdulmohsen A. Al-Mulhim, P.O. Box 1917, Al-Khobar 31952, Saudi Arabia. E-mail:
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Conversion after laparoscopic cholecystectomy in England. Surg Endosc 2009; 23:2338-44. [PMID: 19266237 DOI: 10.1007/s00464-009-0338-1] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2008] [Accepted: 12/27/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy is the procedure of choice for the treatment of symptomatic gallstones. Conversion to open surgery is reported to be necessary in 5-10% of cases. This study aimed to define those factors associated in English hospitals with the need to convert a laparoscopic cholecystectomy to an open procedure. These included patient-related and particularly nonpatient-related factors. METHODS Using data derived from a national administrative database, Hospital Episode Statistics, patients undergoing cholecystectomy in acute National Health Service (NHS) hospitals in England during the financial years 2004-2006 were studied. The individual surgeon caseload and the hospital conversion rate were calculated using data from the first (baseline) year. Factors affecting the need for conversion were analyzed using data from the second (index) year. RESULTS The study included 43,821 laparoscopic cholecystectomies undertaken from 2005 to 2006 in English hospitals. The overall conversion rate was 5.2%: 4.6% for elective procedures and 9.4% for emergency procedures. Patient-related factors that were good predictors of conversion included male sex, emergency admission, old age, and complicated gallstone disease (p < 0.001). Nonpatient-related factors that were good predictors of conversion included the laparoscopic cholecystectomy caseload of individual consultant surgeons and the overall hospital conversion rate in the previous year (all p < 0.001). CONCLUSIONS Conversion after laparoscopic cholecystectomy is less common as consultant caseload increases. This suggests that operation should be undertaken only by surgeons with an adequate caseload. There is a wide variation in conversion rates among hospitals. This has important implications for training as well as for the organization and accreditation of cholecystectomy services on a national basis.
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Are we performing enough emergency laparoscopic cholecystectomies? An experience from a district general hospital. Int J Surg 2009; 7:482-4. [DOI: 10.1016/j.ijsu.2009.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2009] [Revised: 07/05/2009] [Accepted: 08/08/2009] [Indexed: 11/23/2022]
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Improved Management of Acute Gallstone Disease After Regional Surgical Subspecialization. World J Surg 2008; 32:2690-4. [DOI: 10.1007/s00268-008-9749-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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