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Fehring L, Brinkmann H, Hohenstein S, Bollmann A, Dirks P, Pölitz J, Prinz C. Timely cholecystectomy: important factors to improve guideline adherence and patient treatment. BMJ Open Gastroenterol 2024; 11:e001439. [PMID: 39053927 DOI: 10.1136/bmjgast-2024-001439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024] Open
Abstract
OBJECTIVE Cholecystectomy is one of the most frequently performed surgeries in Germany and is performed as a treatment of acute cholecystitis (guideline S3 IIIB.8) and after endoscopic retrograde cholangiopancreatography for choledocholithiasis with simultaneous cholecystolithiasis (guideline S3 IIIC.6). This article examines the effects of a guideline update from 2017, which recommends prompt cholecystectomy within 24 hours of admission due to cholecystitis or within 72 hours after bile duct repair. In addition, it aims to identify reasons (eg, financial disincentives) and potential for improvement for non-adherence to the guidelines. DESIGN Methodologically, a retrospective analysis based on routine billing data from 84 Helios Group hospitals from 2016 and 2022, with a total of 45 393 included cases, was applied. The guideline adherence rate is used as the main outcome measure. RESULTS Results show the guideline updates led to a statistically significant increase in the proportion of cholecystectomy performed in a timely manner (guideline S3 IIIB.8: increase from 43% to 49%, p<0.001; guideline S3 IIIC.6: increase from 7% to 20%, p<0.001). Medical, structural and financial reasons for non-adherence could be identified. CONCLUSION As possible reasons for non-adherence, medical factors such as advanced age, multimorbidity and frailty could be identified. Analyses of structural factors revealed that hospitals in very rural regions are less likely to perform timely cholecystectomies, presumably due to infrastructural and personnel-capacity bottlenecks. A similar picture emerges for maximum-care hospitals, which might be explained by more severe and complex cases on average. Further evaluation indicates that an increase in and better hospital-internal participation of gastroenterologists in remuneration could lead to even greater adherence to the S3 IIIC.6 guideline.
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Affiliation(s)
- Leonard Fehring
- Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany
- Gastroenterology, HELIOS Universitätsklinikum Wuppertal, Wuppertal, Nordrhein-Westfalen, Germany
| | - Hendrik Brinkmann
- Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany
| | | | | | | | - Jörg Pölitz
- Helios Health Institute GmbH, Leipzig, Germany
| | - Christian Prinz
- Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany
- Gastroenterology, HELIOS Universitätsklinikum Wuppertal, Wuppertal, Nordrhein-Westfalen, Germany
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Wu H, Liao B, Cao T, Ji T, Huang J, Luo Y, Ma K. Comparison of the safety profile, conversion rate and hospitalization duration between early and delayed laparoscopic cholecystectomy for acute cholecystitis: a systematic review and meta-analysis. Front Med (Lausanne) 2023; 10:1185482. [PMID: 38148916 PMCID: PMC10750350 DOI: 10.3389/fmed.2023.1185482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 11/13/2023] [Indexed: 12/28/2023] Open
Abstract
Background Although the past decade has witnessed unprecedented medical progress, no consensus has been reached on the optimal approach for patients with acute cholecystitis. Herein, we conducted a systematic review and meta-analysis to assess the differences in patient outcomes between Early Laparoscopic Cholecystectomy (ELC) and Delayed Laparoscopic Cholecystectomy (DLC) in the treatment of acute cholecystitis. Our protocol was registered in the PROSPERO database (registration number: CRD42023389238). Objectives We sought to investigate the differences in efficacy, safety, and potential benefits between ELC and DLC in acute cholecystitis patients by conducting a systematic review and meta-analysis. Methods The online databases PubMed, Springer, and the Cochrane Library were searched for randomized controlled trials (RCTs) and retrospective studies published between Jan 1, 1999 and Jan 1, 2022. Results 21 RCTs and 13 retrospective studies with a total of 7,601 cases were included in this research. After a fixed-effects model was applied, the pooled analysis showed that DLC was associated with a significantly high conversion rate (OR: 0.6247; 95%CI: 0.5115-0.7630; z = -4.61, p < 0.0001) and incidence of postoperative complications (OR: 0.7548; 95%CI: 0.6197-0.9192; z = -2.80, p = 0.0051). However, after applying a random-effects model, ELC was associated with significantly shorter total hospitalization duration than DLC (MD: -4.0657; 95%CI: -5.0747 to -3.0566; z = -7.90, p < 0.0001). Conclusion ELC represents a safe and feasible approach for acute cholecystitis patients since it shortens hospitalization duration and decreases the incidence of postoperative complications of laparoscopic cholecystectomy. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=389238, identifier (CRD42023389238).
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Affiliation(s)
- Hongsheng Wu
- Department of Hepatobiliary Pancreatic Surgery, Affiliated Huadu Hospital, Southern Medical University, Guangzhou, China
| | | | | | | | | | | | - Keqiang Ma
- Department of Hepatobiliary Pancreatic Surgery, Affiliated Huadu Hospital, Southern Medical University, Guangzhou, China
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Ángel-González MS, Díaz-Quintero CA, Aristizabal-Arjona F, Turizo Agámez Á, Molina-Céspedes I, Velásquez-Martínez MA, Isaza-Gómez E, Ocampo-Muñoz M. Controversias en el manejo de la colecistitis aguda tardía. REVISTA COLOMBIANA DE CIRUGÍA 2019. [DOI: 10.30944/20117582.516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
La colecistitis aguda es la inflamación de la vesícula biliar, en la mayoría de los casos, explicada por la presencia de cálculos mixtos o de colesterol que producen obstrucción y desencadenan factores inflamatorios diversos. La colecistectomía por vía laparoscópica se ha convertido en su tratamiento estándar y definitivo. El procedimiento quirúrgico debe realizarse idealmente en las primeras 72 horas después de iniciados los síntomas, lo que habitualmente se denomina como cuadro agudo. Existe controversia sobre cuál es el manejo más adecuado cuando han pasado más de 72 horas del inicio de los síntomas, condición denominada ‘colecistitis aguda tardía’, cuando se considera que el proceso inflamatorio es mayor y, el procedimiento, técnicamente más complejo y peligroso. Para esta condición, se han establecido dos estrategias iniciales de manejo: la cirugía temprana –durante la hospitalización inicial– o el tratamiento conservador con antibióticos para la supuesta resolución completa de la inflamación, es decir, ‘enfriar el proceso’; varias semanas después, se practica una colecistectomía laparoscópica tardía –diferida o electiva–. Existen muchas publicaciones sobre ambas estrategias, en las que se exponen los beneficios y probables complicaciones de cada una; en la actualidad, se sigue debatiendo sobre el momento óptimo para practicar la intervención quirúrgica. Los trabajos más recientes y con mayor peso epidemiológico, resaltan los beneficios de la cirugía temprana pues, aunque las complicaciones intraoperatorias ocurren en las mismas proporciones, la cirugía en la hospitalización inicial reduce los costos, los reingresos y los tiempos hospitalarios. Después de revisar la literatura disponible a favor y en contra, este artículo pretende recomendar el procedimiento temprano, inclusive cuando hayan pasado más de tres días de iniciados los síntomas y, solo en casos muy seleccionados, diferir la cirugía.
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Gurusamy KS, Davidson BR. Gallstone Disease. EVIDENCE‐BASED GASTROENTEROLOGY AND HEPATOLOGY 4E 2019:342-352. [DOI: 10.1002/9781119211419.ch22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Frazee R, Regner J, Truitt MS, Agrawal V, Swope M, Burlew CC, Dissanaike S, Vangipurum D, Bruns B, O'Meara L, Stivers J, Kwok A, Grover BT, Kothari SN, Cibari C, Dunn J, McIntyre RC, Wright F, Scherer EP, Crane C, Schroeppel TJ, Callaghan E, Gordy S, Todd R. The southwestern surgical congress multi-center trial on suspected common duct stones. Am J Surg 2019; 217:1006-1009. [PMID: 30654919 DOI: 10.1016/j.amjsurg.2018.12.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 10/15/2018] [Accepted: 12/29/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Choledocholithiasis is present in up to 15% of cholecystectomy patients. Treatment can be surgical, endoscopic, or via interventional radiology. We hypothesized significant heterogeneity between hospitals exists in the approach to suspected common duct stones. METHODS A retrospective review of patients that had a preoperative MRCP, endoscopic ultrasound, endoscopic retrograde cholangiopancreatogram (ERCP), or intra-operative cholangiogram was performed. Comparisons were by Wilcoxon-Mann-Whitney tests with significance of p < 0.05 for paired variables and p < 0.017 for multiple comparisons. RESULTS Twelve participating institutions identified 1263 patients (409 men and 854 women) with a median age of 49 years (IQR: 31-94). Liver function tests (LFT's) were elevated in 939 patients (75%), median bilirubin level 1.75 mg/dl (IQ: 0.8-3.7 mg/dl) and median common duct size 7 mm (IQR 5-10 mm). The most common initial procedure was cholecystectomy with IOC at seven institutions, endoscopy at four and MRCP at one. CONCLUSION Significant variation exists within the surgical community regarding suspected common duct stones. These results underscore the need for a protocol for common duct stones to minimize multiple, redundant interventions.
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Affiliation(s)
| | | | | | | | | | | | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health, Sciences Center Lubbock TX, USA
| | - Divya Vangipurum
- Department of Surgery, Texas Tech University Health, Sciences Center Lubbock TX, USA
| | | | | | - John Stivers
- Department of Surgery, University of California San Francisco-Fresno, USA
| | - Amy Kwok
- Department of Surgery, University of California San Francisco-Fresno, USA
| | | | | | | | | | | | - Frank Wright
- University of Colorado Hospital, Aurora, Colorado, USA
| | | | | | - Thomas J Schroeppel
- University of Colorado Health - Memorial Hospital, Colorado Springs, CO, USA
| | - Emma Callaghan
- University of Colorado Health - Memorial Hospital, Colorado Springs, CO, USA
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Evaluating the Diagnostic Accuracy and Management Protocols: In Reply to Strasberg. J Am Coll Surg 2018; 227:624-626. [PMID: 30470280 DOI: 10.1016/j.jamcollsurg.2018.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 09/19/2018] [Indexed: 12/07/2022]
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Friesen J, Friesen B, Tan ES. Ultrasound for the Diagnosis of Acute Calculous Cholecystitis, and the Impact of Analgesics: A Retrospective Cohort Study. RESEARCH IDEAS AND OUTCOMES 2018. [DOI: 10.3897/rio.4.e28069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Tan JKH, Goh JCI, Lim JWL, Shridhar IG, Madhavan K, Kow AWC. Delayed Presentation of Acute Cholecystitis: Comparative Outcomes of Same-Admission Versus Delayed Laparoscopic Cholecystectomy. J Gastrointest Surg 2017; 21:840-845. [PMID: 28243979 DOI: 10.1007/s11605-017-3378-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 01/23/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Studies have shown that same-admission laparoscopic cholecystectomy (SALC) is superior to delayed laparoscopic cholecystectomy (DLC) for acute cholecystitis (AC). However, no studies have compared both modalities in patients with delayed presentation. The aim of the study was to compare outcomes between SALC and DLC in AC patients with more than 7-day symptom duration. METHODS A retrospective analysis of 83 AC patients who underwent LC after presenting with >7 days of symptoms from June 2010 to June 2015 was performed. Patients were divided into L-SALC and L-DLC, defined as LC performed within the same admission and between 4 and 24 weeks after discharge, respectively. Peri-operative outcomes were evaluated. RESULTS In L-SALC patients, the intra-operative severity was higher (p < 0.001) and median operative time was longer (L-SALC, 107 min (46-220) vs L-DLC, 95 mins (25-186)) (p = 0.048). Conversion rates were also higher in L-SALC than that in L-DLC (L-SALC, 21.4% vs L-DLC, 4.9%) (p = 0.048). While post-operative morbidity was similar, L-SALC was associated with a longer post-operative length of stay as compared to L-DLC (L-SALC, 2 (1-17) vs L-DLC, 1 (1-6)) (p < 0.001). CONCLUSION DLC provides lower conversion rates and shorter length of stay in AC patients presenting beyond 7 days of symptoms. This group of patients should be offered DLC.
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Affiliation(s)
- Jarrod K H Tan
- Division of Hepatopancreaticobiliary Surgery and Liver Transplantation, Department of Surgery, National University Health System Singapore, Singapore, Singapore
| | - Joel C I Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Janice W L Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Iyer G Shridhar
- Division of Hepatopancreaticobiliary Surgery and Liver Transplantation, Department of Surgery, National University Health System Singapore, Singapore, Singapore
| | - Krishnakumar Madhavan
- Division of Hepatopancreaticobiliary Surgery and Liver Transplantation, Department of Surgery, National University Health System Singapore, Singapore, Singapore
| | - Alfred W C Kow
- Division of Hepatopancreaticobiliary Surgery and Liver Transplantation, Department of Surgery, National University Health System Singapore, Singapore, Singapore.
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Jung BH, Park JI. Impact of scheduled laparoscopic cholecystectomy in patients with acute cholecystitis, following percutaneous transhepatic gallbladder drainage. Ann Hepatobiliary Pancreat Surg 2017; 21:21-29. [PMID: 28317042 PMCID: PMC5353909 DOI: 10.14701/ahbps.2017.21.1.21] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 09/15/2016] [Accepted: 09/26/2016] [Indexed: 01/25/2023] Open
Abstract
Backgrounds/Aims Frequently encountered in practice, the first-line treatment for acute cholecystitis is early or urgent cholecystectomy, with laparoscopic cholecystectomy (LC) being the preferred method. Percutaneous transhepatic gallbladder drainage (PTGBD) is considered as a safe alternative therapeutic option for resolving acute cholecystitis in surgically high-risk patients. We evaluated the surgical outcomes of acute cholecystitis, focusing on the differences between emergent LC without PTGBD, and scheduled LC following PTGBD. Methods Between March 2010 and December 2014, 294 patients with acute cholecystitis who had undergone LC, were retrospectively studied. Group I included 166 patients who underwent emergency LC without PTGBD. Group II included 128 patients who underwent scheduled LC after PTGBD. Clinical outcomes were analyzed according to each group. Results On admission, Group II had a higher mean level of c-reactive protein than Group I. According to the classification of the American Society of Anesthesiologists (ASA), group II had a greater number of high-risk patients than group I. There was no significant difference on perioperative outcomes between the two groups, including open conversion rate and complications. Analysis as per the ASA classes revealed no statistically remarkable finding between the groups. Conclusions There are no significant differences in the surgical outcomes of emergency LC group without PTGBD, and scheduled LC group following PTGBD. Comparison between two groups according to ASA classification reflecting the comorbidity and severity of condition of the patients also revealed no significant differences. However, scheduled LC following PTGBD is important for patients having acute cholecystitis with concurrent comorbidity.
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Affiliation(s)
- Bo-Hyun Jung
- Department of Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jeong-Ik Park
- Department of Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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Acar T, Kamer E, Acar N, Atahan K, Bağ H, Hacıyanlı M, Akgül Ö. Laparoscopic cholecystectomy in the treatment of acute cholecystitis: comparison of results between early and late cholecystectomy. Pan Afr Med J 2017; 26:49. [PMID: 28451027 PMCID: PMC5398876 DOI: 10.11604/pamj.2017.26.49.8359] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 07/04/2016] [Indexed: 01/11/2023] Open
Abstract
Introduction Laparoscopic cholecystectomy has become the gold standard in the treatment of symptomatic gallstones. The common opinion about treatment of acute cholecystitis is initially conservative treatment due to preventing complications of inflamation and following laparoscopic cholecystectomy after 6- 8 weeks. However with the increase of laparoscopic experience in recent years, early laparoscopic cholecystectomy has become more common. Methods We aimed to compare the outcomes of the patients to whom we applied early or late cholecystectomy after hospitalization from the emergency department with the diagnosis of AC between March 2012-2015. Results We retrospectively reviewed the files of totally 66 patients in whom we performed early cholecystectomy (within the first 24 hours) (n: 33) and to whom we firstly administered conservative therapy and performed late cholecystectomy (after 6 to 8 weeks) (n: 33) after hospitalization from the emergency department with the diagnosis of acute cholecystitis. The groups were made up of patients who had similar clinical and demographic characteristics. While there were no statistically significant differences between the durations of operation, the durations of hospitalization were longer in those who underwent early cholecystectomy. Moreover, more complications were seen in the patients who underwent early cholecystectomy although the difference was not statistically significant. Conclusion Early cholecystectomy is known to significantly reduce the costs in patients with acute cholecystitis. However, switching to open surgery as well as increase of complications in patients who admitted with severe inflammation attack and who have high comorbidity, caution should be exercised when selecting patients for early operation.
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Affiliation(s)
- Turan Acar
- General Surgery, MD, Ỉzmir Katip Çelebi University Atatürk Training and Research Hospital General Surgery Clinic, Turkey
| | - Erdinç Kamer
- General Surgery, MD, Ỉzmir Katip Çelebi University Atatürk Training and Research Hospital General Surgery Clinic, Turkey
| | - Nihan Acar
- General Surgery, MD, Ỉzmir Katip Çelebi University Atatürk Training and Research Hospital General Surgery Clinic, Turkey
| | - Kemal Atahan
- General Surgery, MD, Ỉzmir Katip Çelebi University Atatürk Training and Research Hospital General Surgery Clinic, Turkey
| | - Halis Bağ
- General Surgery, MD, Ỉzmir Katip Çelebi University Atatürk Training and Research Hospital General Surgery Clinic, Turkey
| | - Mehmet Hacıyanlı
- General Surgery, MD, Ỉzmir Katip Çelebi University Atatürk Training and Research Hospital General Surgery Clinic, Turkey
| | - Özgün Akgül
- General Surgery, MD, Ỉzmir Katip Çelebi University Atatürk Training and Research Hospital General Surgery Clinic, Turkey
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Same admission laparoscopic cholecystectomy for acute cholecystitis: is the "golden 72 hours" rule still relevant? HPB (Oxford) 2017; 19:47-51. [PMID: 27825751 DOI: 10.1016/j.hpb.2016.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 10/04/2016] [Accepted: 10/12/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Studies have shown that same admission laparoscopic cholecystectomy (SALC) is superior to delayed laparoscopic cholecystectomy for acute cholecystitis (AC). While some proposed a"golden 72-hour" for SALC, the optimal timing remains controversial. The aim of the study was to compare the outcomes of SALC in AC patients with different time intervals from symptom onset. METHODS A retrospective analysis of 311 patients who underwent SALC for AC from June 2010-June 2015 was performed. Patients were divided into three groups based on the time interval between symptom onset and surgery: <4 days (E-SALC), 4-7 days (M-SALC), >7 (L-SALC). RESULTS The mean duration of symptoms was 2(1-3), 5(4-7) and 9 (8-13) days for E-SALC, M-SALC and L-SALC, respectively (p < 0.001). Conversion rates were higher in the L-SALC group [E-SALC, 8.2% vs M-SALC, 9.6% vs L-SALC, 21.4%] (p = 0.048). The total length of stay was longer in patients with longer symptom duration [E-SALC, 4 (2-33) vs M-SALC, 2 (2-23) vs L-SALC, 7 (2-49)] (p < 0.001). CONCLUSION Patients with AC presenting beyond 7 days of symptoms have higher conversion rates and longer length of stay associated with SALC. However, patients with less than a week of symptoms should be offered SALC.
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González-Muñoz JI, Franch-Arcas G, Angoso-Clavijo M, Sánchez-Hernández M, García-Plaza A, Caraballo-Angeli M, Muñoz-Bellvís L. Risk-adjusted treatment selection and outcome of patients with acute cholecystitis. Langenbecks Arch Surg 2016; 402:607-614. [DOI: 10.1007/s00423-016-1508-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 08/30/2016] [Indexed: 12/11/2022]
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EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol 2016; 65:146-181. [PMID: 27085810 DOI: 10.1016/j.jhep.2016.03.005] [Citation(s) in RCA: 333] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/09/2016] [Indexed: 02/06/2023]
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Conversion cholecystectomy in patients with acute cholecystitis—it’s not as black as it’s painted! Langenbecks Arch Surg 2016; 401:479-88. [DOI: 10.1007/s00423-016-1394-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 02/29/2016] [Indexed: 12/07/2022]
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15
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Cao AM, Eslick GD, Cox MR. Early laparoscopic cholecystectomy is superior to delayed acute cholecystitis: a meta-analysis of case-control studies. Surg Endosc 2016; 30:1172-1182. [PMID: 26139487 DOI: 10.1007/s00464-015-4325-4] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 06/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Since the advent of laparoscopic cholecystectomy (LC) there has been continued debate regarding the management of acute cholecystitis with either early or delayed LC. Nearly all studies have demonstrated that early LC has a significantly shorter total length of hospital stay compared with delayed LC. Although previous randomized controlled trials and meta-analysis have shown clinical outcomes to favour early surgery, clinical practice continues to vary significantly worldwide. In addition, there is much confusion in the optimal timing for early LC with definitions of early varying from 72 h to 7 days. There have been numerous case-control studies investigating the timing of LC in acute cholecystitis. The aim of this paper is to pool the results from all case-control studies to investigate outcomes including mortality rates, complication rates, length of hospital stay and conversion rates to open procedures. METHODS A search of electronic databases was performed for case-control studies published between 1985-February 2015. RESULTS Results from 77 case-control studies showed statistically significant reductions in mortality, complications, bile duct leaks, bile duct injuries, wound infections, conversion rates, length of hospital stay and blood loss associated with early LC. Although LC within the 72-h window is optimal, patients operated after this window still benefit from early surgery compared to delayed surgery. The duration of symptoms in acute cholecystitis should not influence the surgeons' willingness to operate acutely. CONCLUSIONS Early LC is clearly superior to delayed LC in acute cholecystitis. The most recent evidence-based practice strongly suggests that early LC should be standard of care in the management of acute cholecystitis.
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Affiliation(s)
- Amy M Cao
- The Whiteley-Martin Research Centre, Discipline of Surgery, Nepean Hospital, The University of Sydney, Level 5, South Block, P.O. Box 63, Penrith, NSW, 2751, Australia
| | - Guy D Eslick
- The Whiteley-Martin Research Centre, Discipline of Surgery, Nepean Hospital, The University of Sydney, Level 5, South Block, P.O. Box 63, Penrith, NSW, 2751, Australia.
| | - Michael R Cox
- The Whiteley-Martin Research Centre, Discipline of Surgery, Nepean Hospital, The University of Sydney, Level 5, South Block, P.O. Box 63, Penrith, NSW, 2751, Australia.
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Cao AM, Eslick GD, Cox MR. Early laparoscopic cholecystectomy is superior to delayed acute cholecystitis: a meta-analysis of case-control studies. Surg Endosc 2016; 30:1172-1182. [PMID: 26139487 DOI: 10.1007/s00464-015-4471-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 06/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Since the advent of laparoscopic cholecystectomy (LC) there has been continued debate regarding the management of acute cholecystitis with either early or delayed LC. Nearly all studies have demonstrated that early LC has a significantly shorter total length of hospital stay compared with delayed LC. Although previous randomized controlled trials and meta-analysis have shown clinical outcomes to favour early surgery, clinical practice continues to vary significantly worldwide. In addition, there is much confusion in the optimal timing for early LC with definitions of early varying from 72 h to 7 days. There have been numerous case-control studies investigating the timing of LC in acute cholecystitis. The aim of this paper is to pool the results from all case-control studies to investigate outcomes including mortality rates, complication rates, length of hospital stay and conversion rates to open procedures. METHODS A search of electronic databases was performed for case-control studies published between 1985-February 2015. RESULTS Results from 77 case-control studies showed statistically significant reductions in mortality, complications, bile duct leaks, bile duct injuries, wound infections, conversion rates, length of hospital stay and blood loss associated with early LC. Although LC within the 72-h window is optimal, patients operated after this window still benefit from early surgery compared to delayed surgery. The duration of symptoms in acute cholecystitis should not influence the surgeons' willingness to operate acutely. CONCLUSIONS Early LC is clearly superior to delayed LC in acute cholecystitis. The most recent evidence-based practice strongly suggests that early LC should be standard of care in the management of acute cholecystitis.
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Affiliation(s)
- Amy M Cao
- The Whiteley-Martin Research Centre, Discipline of Surgery, Nepean Hospital, The University of Sydney, Level 5, South Block, P.O. Box 63, Penrith, NSW, 2751, Australia
| | - Guy D Eslick
- The Whiteley-Martin Research Centre, Discipline of Surgery, Nepean Hospital, The University of Sydney, Level 5, South Block, P.O. Box 63, Penrith, NSW, 2751, Australia.
| | - Michael R Cox
- The Whiteley-Martin Research Centre, Discipline of Surgery, Nepean Hospital, The University of Sydney, Level 5, South Block, P.O. Box 63, Penrith, NSW, 2751, Australia.
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Feasibility and Safety of Urgent Laparoscopic Cholecystectomy for Acute Cholecystitis After 4 Days from Symptom Onset. J Gastrointest Surg 2015; 19:1787-93. [PMID: 26129654 DOI: 10.1007/s11605-015-2878-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 06/15/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND It is preferable to perform laparoscopic cholecystectomy for acute cholecystitis in the acute phase, within 72 h of symptom onset. The feasibility and safety of performing urgent laparoscopic cholecystectomy in the late phase (4-7 days after symptom onset) are unclear. The aim of this study was to clarify the feasibility and safety of late phase urgent laparoscopic cholecystectomy. METHODS Between 2005 and 2014, 233 patients underwent urgent laparoscopic cholecystectomy for acute cholecystitis within 7 days. We compared clinical features and perioperative outcomes between patients who underwent laparoscopic cholecystectomy within 3 days (early phase group) and 4-7 days after symptom onset (late phase group). RESULTS There were 193 patients in the early phase group and 40 patients in the late-phase group. Performing laparoscopic cholecystectomy in the late phase did not influence operation time, postoperative complications, or postoperative hospital stay. The rate of conversion to open surgery and blood loss were slightly higher in the late-phase group (8 % and 140 ml) compared with the early phase group (3 % and 69 ml) but were still acceptable. CONCLUSIONS Late phase urgent laparoscopic cholecystectomy for acute cholecystitis was feasible and safe.
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Evaluation of Early versus Delayed Laparoscopic Cholecystectomy in Acute Cholecystitis. Surg Res Pract 2015; 2015:349801. [PMID: 25729775 PMCID: PMC4333337 DOI: 10.1155/2015/349801] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 01/05/2015] [Indexed: 11/17/2022] Open
Abstract
Background. The role of early laparoscopic cholecystectomy for acute cholecystitis with cholelithiasis is not yet established. The aim of our prospective randomized study was to evaluate the safety and feasibility of early LC for acute cholecystitis and to compare the results with delayed LC. Methods. Between March 2007 to December 2008, 50 patients with diagnosis of acute cholecystitis were assigned randomly to early group, n = 25 (LC within 24 hrs of admission), and delayed group, n = 25 (initial conservative treatment followed by delayed LC, 6-8 weeks later). Results. We found in our study that the conversion rate in early LC and delayed LC was 16% and 8%, respectively, Operation time for early LC was 69.4 min versus 66.4 min for delayed LC, postoperative complications for early LC were 24% versus 8% for delayed LC, and blood loss was 159.6 mL early group versus 146.8 mL for delayed group. However early LC had significantly shorter hospital stay (4.1 days versus 8.6 days). Conclusions. Early LC for acute cholecystitis with cholelithiasis is safe and feasible, offering the additional benefit of shorter hospital stay. It should be offered to the patients with acute cholecystitis, provided that the surgery is performed within 96 hrs of acute symptoms by an experienced surgeon.
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Can it wait until morning? A comparison of nighttime versus daytime cholecystectomy for acute cholecystitis. Am J Surg 2014; 208:911-8; discussion 917-8. [DOI: 10.1016/j.amjsurg.2014.09.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 09/14/2014] [Accepted: 09/15/2014] [Indexed: 12/29/2022]
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20
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Tan CHM, Pang TCY, Woon WWL, Low JK, Junnarkar SP. Analysis of actual healthcare costs of early versus interval cholecystectomy in acute cholecystitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 22:237-43. [PMID: 25450622 DOI: 10.1002/jhbp.196] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Healthcare cost modeling have favored early (ELC) over interval laparoscopic cholecystectomy (ILC) for acute cholecystitis (AC). However, actual costs of treatment have never been studied. The aim of the present study was to compare actual hospital costs involved in ELC and ILC in patients with AC. METHODS Retrospective study of patients who underwent laparoscopic cholecystectomy for AC was conducted. Demographic, clinical, operative data and costs were extracted and analyzed. RESULTS Between 2011 and 2013, 201 had laparoscopic surgery for AC at Tan Tock Seng Hospital, Singapore. One hundred and thirty-four (67%) patients underwent ELC (≤7 days of presentation, within index admission). Median total length of stay (LOS) was 4.6 and 6.8 days for ELC and ILC groups, respectively (P = 0.006). Patients who had ELC also had significantly lesser total number of admissions (P < 0.001). The median (IQR) total inpatient costs were €4.4 × 10(3) (3.6-5.6) and €5.5 × 10(3) (4.0-7.5) for ELC and ILC patients, respectively (P < 0.007). Costs associated with investigations were significantly higher in the ILC group (P = 0.039), of which serological costs made most difference (P < 0.005). The ward costs were also significantly higher in the ILC group. CONCLUSION The cost differences reflect the significantly increased total LOS, and repeat presentations associated with ILC. Therefore, ELC should be the preferred management strategy for AC.
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Affiliation(s)
- Cheryl H M Tan
- Department of General Surgery, Tan Tock Seng Hospital, Annex 1, 11 Jalan Tan Tock Seng, Singapore, 308433; School of Medicine, University of Aberdeen, Aberdeen, Scotland
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21
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Gurusamy KS, Davidson C, Gluud C, Davidson BR. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database Syst Rev 2013:CD005440. [PMID: 23813477 DOI: 10.1002/14651858.cd005440.pub3] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gallstones are present in about 10% to 15% of the adult western population. Between 1% and 4% of these adults become symptomatic in a year (the majority due to biliary colic but a significant proportion due to acute cholecystitis). Laparoscopic cholecystectomy for acute cholecystitis is mainly performed after the acute cholecystitis episode settles because of the fear of higher morbidity and of need for conversion from laparoscopic to open cholecystectomy. However, delaying surgery exposes the people to gallstone-related complications. OBJECTIVES The aim of this systematic review was to compare early laparoscopic cholecystectomy (less than seven days of clinical presentation with acute cholecystitis) versus delayed laparoscopic cholecystectomy (more than six weeks after index admission with acute cholecystitis) with regards to benefits and harms. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and World Health Organization International Clinical Trials Registry Platform until July 2012. SELECTION CRITERIA We included all randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy in participants with acute cholecystitis. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS We identified seven trials that met the inclusion criteria. Out of these, six trials provided data for the meta-analyses. A total of 488 participants with acute cholecystitis and fit to undergo laparoscopic cholecystectomy were randomised to early laparoscopic cholecystectomy (ELC) (244 people) and delayed laparoscopic cholecystectomy (DLC) (244 people) in the six trials. Blinding was not performed in any of the trials and so all the trials were at high risk of bias. Other than blinding, three of the six trials were at low risk of bias in the other domains such as sequence generation, allocation concealment, incomplete outcome data, and selective outcome reporting. The proportion of females ranged between 43.3% and 80% in the trials that provided this information. The average age of participants ranged between 40 years and 60 years. There was no mortality in any of the participants in five trials that reported mortality. There was no significant difference in the proportion of people who developed bile duct injury in the two groups (ELC 1/219 (adjusted proportion 0.4%) versus DLC 2/219 (0.9%); Peto OR 0.49; 95% CI 0.05 to 4.72 (5 trials)). There was no significant difference between the two groups (ELC 14/219 (adjusted proportion 6.5%) versus DLC 11/219 (5.0%); RR 1.29; 95% CI 0.61 to 2.72 (5 trials)) in terms of other serious complications. None of the trials reported quality of life from the time of randomisation. There was no significant difference between the two groups in the proportion of people who required conversion to open cholecystectomy (ELC 49/244 (adjusted proportion 19.7%) versus DLC 54/244 (22.1%); RR 0.89; 95% CI 0.63 to 1.25 (6 trials)). The total hospital stay was shorter in the early group than the delayed group by four days (MD -4.12 days; 95% CI -5.22 to -3.03 (4 trials; 373 people)). There was no significant difference in the operating time between the two groups (MD -1.22 minutes; 95% CI -3.07 to 0.64 (6 trials; 488 people)). Only one trial reported return to work. The people belonging to the ELC group returned to work earlier than the DLC group (MD -11.00 days; 95% CI -19.61 to -2.39 (1 trial; 36 people)). Four trials did not report any gallstone-related morbidity during the waiting period. One trial reported five gallstone-related morbidities (cholangitis: two; biliary colic not requiring urgent operation: one; acute cholecystitis not requiring urgent operation: two). There were no reports of pancreatitis during the waiting time. Gallstone-related morbidity was not reported in the remaining trials. Forty (18.3%) of the people belonging to the delayed group had either non-resolution of symptoms or recurrence of symptoms before their planned operation and had to undergo emergency laparoscopic cholecystectomy in five trials. The proportion with conversion to open cholecystectomy was 45% (18/40) in this group of people. AUTHORS' CONCLUSIONS We found no significant difference between early and late laparoscopic cholecystectomy on our primary outcomes. However, trials with high risk of bias indicate that early laparoscopic cholecystectomy during acute cholecystitis seems safe and may shorten the total hospital stay. The majority of the important outcomes occurred rarely, and hence the confidence intervals are wide. It is unlikely that future randomised clinical trials will be powered to measure differences in bile duct injury and other serious complications since this might involve performing a trial of more than 50,000 people, but several smaller randomised trials may answer the questions through meta-analyses.
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Laparoscopic cholecystectomy within one week from the onset of acute cholecystitis: A 6-year experience. J Taibah Univ Med Sci 2013. [DOI: 10.1016/j.jtumed.2013.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Kim IG, Kim JS, Jeon JY, Jung JP, Chon SE, Kim HJ, Kim DJ. Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis. J Laparoendosc Adv Surg Tech A 2012; 21:941-6. [PMID: 22129145 DOI: 10.1089/lap.2011.0217] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Many surgeons have found it difficult to decide whether to apply percutaneous transhepatic gallbladder drainage (PTGBD) in patients with acute cholecystitis that is not responsive to initial medical management (IMMx), because the indications of PTGBD are ambiguous. The aim of this study was to evaluate the appropriate treatment for acute cholecystitis that is not responsive to IMMx. Specifically, we focused on differences in surgical outcomes between elective and emergency laparoscopic surgeries. Between March 2006 and February 2009, 738 patients with acute cholecystitis who had undergone laparoscopic cholecystectomy (LC) at our institution were retrospectively studied. We divided them into 3 groups. Group I included 494 patients who underwent elective LC without pre-operative PTGBD, group II included 97 patients who intended to undergo elective LC after preoperative PTGBD, and group III included 147 patients who underwent emergency LC without preoperative PTGBD. We compared age, sex, symptom duration, body temperature, leukocyte counts, and American Society of Anesthesiologists (ASA) class on admission as clinical characteristics. We compared the time interval from symptom development and admission to surgery, operative time, the conversion rate to open surgery, postoperative complications, the total length of stay, and the postoperative length of stay as perioperative surgical outcomes. For patients with ASA 2 and 3, the conversion rate to open surgery in group II was significantly less than that in group III (P<.05, P<.01, respectively). We recommend PTGBD as the first choice for acute cholecystitis in patients who show no improvement after IMMx, to allow the patient to undergo an elective LC rather than emergency surgery for patients with ASA 2 and 3.
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Affiliation(s)
- In-Gyu Kim
- Department of Surgery, Hallym University Medical Center, Hallym University College of Medicine, Seoul, Korea
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Chong CCN, Chiu PWY, Lee KF, Lai PBS. Timing of laparoscopic cholecystectomy in acute cholecystitis: Any controversy? SURGICAL PRACTICE 2012. [DOI: 10.1111/j.1744-1633.2011.00576.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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van der Steeg HJJ, Alexander S, Houterman S, Slooter GD, Roumen RMH. Risk factors for conversion during laparoscopic cholecystectomy - experiences from a general teaching hospital. Scand J Surg 2011; 100:169-73. [PMID: 22108744 DOI: 10.1177/145749691110000306] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Laparoscopic cholecystectomy (LC) is the gold standard for treating symptomatic cholelithiasis. Conversion, however, is sometimes necessary. The aim of this study was to determine predictive factors of conversion in patients undergoing LC for various indications in elective and acute settings in a general teaching hospital. MATERIAL AND METHODS A retrospective analysis was performed on 972 consecutive patients who underwent a laparoscopic cholecystectomy in Máxima Medical Centre in Veldhoven, the Netherlands, from January 2000 till January 2006. Recorded data were sex, age, indication for LC, conversion to open cholecystectomy, reason for conversion, performing surgeon, co-morbidity, type of complication, length of hospital stay and 30-day mortality. RESULTS Conversion to open cholecystectomy was performed in 121 patients (12%). The most frequent reasons for conversion were infiltration/fibrosis of Calot's triangle (30%) and adhesions (27%). In the multivariate analyses male gender (OR 1.67, 95% CI 1.07-2.59), age >65 years (OR 2.10, 95% CI 1.32-3.34), acute cholecystitis (OR 11.8, 95% CI 6.98-20.1), recent acute cholecystitis (OR 4.71, 95% CI 2.42-9.18) and recent obstructive jaundice (OR 20.6, 95% CI 4.52-94.1) were independent predictive factors for conversion. CONCLUSIONS Male gender, age >65 years, (recent) acute cholecystitis and recent obstructive jaundice are independent predictive risk factors for conversion. By appreciating these risk factors for conversion, preoperative patient counselling can be improved.
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Comparative quality of laparoscopic and open cholecystectomy in the elderly using propensity score matching analysis. Gastroenterol Res Pract 2010; 2010:490147. [PMID: 21234395 PMCID: PMC3014686 DOI: 10.1155/2010/490147] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 10/08/2010] [Accepted: 11/21/2010] [Indexed: 01/04/2023] Open
Abstract
The safety of laparoscopic cholecystectomy (LC) in patients ≥65 years of age requires further investigation of postoperative outcomes before it becomes more widely accepted as a safe technique. The advantages of using LC versus open cholecystectomy (OC) in elderly patients were analyzed using propensity score matching. The demographics, cholecystitis severity, comorbidities, complications, and admission and discharge Barthel Index (BI) scores of patients with benign gallbladder diseases were analyzed. Outcomes were analyzed by age, length of stay (LOS), total charges (TCs), BI improvement, and postoperative complications. OC, which was indicated in severe disease cases, increased hospital resource use and caused more complications than LC, but did not improve BI. Advanced age and OC resulted in greater LOS and TCs and was the best indicator of BI deterioration. Whenever possible, surgeons should use LC in elderly patients to minimize postoperative complications and allow them to regain a good quality of life.
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Variations in the preoperative resources use and the practice pattern in Japanese cholecystectomy patients. Surg Today 2010; 40:334-46. [DOI: 10.1007/s00595-009-4062-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 02/20/2009] [Indexed: 12/21/2022]
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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: 233] [Impact Index Per Article: 15.5] [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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29
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Hepatobiliary and splenic infection. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00039-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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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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Impact of delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis. Surg Laparosc Endosc Percutan Tech 2009; 19:20-4. [PMID: 19238061 DOI: 10.1097/sle.0b013e318188e2fe] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Laparoscopic cholecystectomy (LC) for complicated acute cholecystitis is associated with high rates of complications and conversion to open cholecystectomy. Percutaneous transhepatic gallbladder drainage (PTGBD) is a safe and effective treatment for acute inflammation of the gallbladder. This study was a retrospective analysis of patients who underwent an LC with or without PTGBD for complicated acute cholecystitis at our hospital between January 2002 and January 2007. Patients were classified into 3 groups: group 1, patients who underwent an LC without preoperative PTGBD (n=60); group 2, patients who underwent an early scheduled LC within 7 days of PTGBD (n=35); and group 3, patients in whom the LC was delayed for a mean of 19.9 days (range, 14 to 39 d) after PTGBD (n=38). The conversion rate to open cholecystectomy and the postoperative complication rate were lower in group 3 than in group 1 (P<0.05). Elective delayed LC after PTGBD may lower the conversion and complication rates of patients with complicated acute cholecystitis.
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Macafee DAL, Humes DJ, Bouliotis G, Beckingham IJ, Whynes DK, Lobo DN. Prospective randomized trial using cost-utility analysis of early versus delayed laparoscopic cholecystectomy for acute gallbladder disease. Br J Surg 2009; 96:1031-40. [PMID: 19672930 DOI: 10.1002/bjs.6685] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This randomized controlled trial compared the cost-utility of early laparoscopic cholecystectomy with that for conventional management of newly diagnosed acute gallbladder disease. METHODS Adults admitted to hospital with a first episode of biliary colic or acute cholecystitis were randomized to an early intervention group (36 patients, operation within 72 h of admission) or a conventional group (36, elective cholecystectomy 3 months later). Costs were measured from a National Health Service and societal perspective. Quality-adjusted life year (QALY) gains were calculated 1 month after surgery. RESULTS The mean(s.d.) total costs of care were pound 5911(2445) for the early group and pound 6132(3244) for the conventional group (P = 0.928), Mean(s.d.) societal costs were pound 1322(1402) and pound 1461(1532) for the early and conventional groups respectively (P = 0.732). Visual analogue scale scores of health were 72.94 versus 84.63 (P = 0.012) and the mean(s.d.) QALY gain was 0.85(0.26) versus 0.93(0.13) respectively (P = 0.262). The incremental cost per additional QALY gained favoured conventional management at a cost of pound 3810 per QALY gained. CONCLUSION In this pragmatic trial, the cost-utilities of both the early and conventional approaches were similar, but the incremental cost per additional QALY gained favoured conventional management.
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Affiliation(s)
- D A L Macafee
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK
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Low SW, Iyer SG, Chang SKY, Mak KSW, Lee VTW, Madhavan K. Laparoscopic cholecystectomy for acute cholecystitis: safe implementation of successful strategies to reduce conversion rates. Surg Endosc 2009; 23:2424-9. [PMID: 19263131 DOI: 10.1007/s00464-009-0374-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Revised: 12/30/2008] [Accepted: 01/12/2009] [Indexed: 11/28/2022]
Abstract
INTRODUCTION A higher rate of conversion to open surgery is a well-known problem in patients with acute cholecystitis undergoing laparoscopic cholecystectomy. The aim of this study is to analyze factors which may impact on conversion rates, and to analyze our outcomes following implementation of a departmental strategy in reducing conversion rates. MATERIALS AND METHODS 122 patients with acute cholecystitis were considered for laparoscopic cholecystectomy from July 2003 to July 2007. An audit of the results of laparoscopic cholecystectomy was done in July 2005 and a departmental strategy aimed at reducing the conversion rates was introduced. The strategies included early laparoscopic cholecystectomy (within 72 hours of admission), performed or supervised by specialist hepatobiliary surgeons, and modifications of operative techniques. This study compares the conversion rates before and after that audit. Forty-eight patients (group A) were from the preaudit period and the remaining 74 (group B) were from the postaudit period. A multivariate analysis was performed to identify risk factors for conversion to open surgery and whether the strategies implemented resulted in decrease in conversion rates. RESULTS In the group A patients, there was a conversion rate of 29.2%. Gallbladder wall thickness of greater than 5 mm was found to be a statistically significant (p = 0.028) risk factor for conversion to open surgery. In group B patients, the conversion rates were significantly lower at 6.75% (p = 0.001). Analyzing both groups of patients, using multivariate analysis, gallbladder wall thickness, increasing age, and preaudit operative period were found to be independently associated with conversion to open surgery. CONCLUSIONS This study demonstrated that, with specific strategies to decrease conversion and with technical improvements, the conversion rates can be decreased with no demonstrable difference in postoperative complications. Gallbladder wall thickness and increasing age are risk factors for conversion to open surgery.
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Affiliation(s)
- Shiong-Wen Low
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery Yong Loo Lin School of Medicine, National University Hospital, Singapore, 119074, Singapore
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Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K, Hayashida K. Impact of timing of cholecystectomy and bile duct interventions on quality of cholecystitis care. Int J Surg 2009; 7:243-9. [DOI: 10.1016/j.ijsu.2009.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Revised: 03/24/2009] [Accepted: 04/05/2009] [Indexed: 10/20/2022]
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Zhang WJ, Li JM, Wu GZ, Luo KL, Dong ZT. RISK FACTORS AFFECTING CONVERSION IN PATIENTS UNDERGOING LAPAROSCOPIC CHOLECYSTECTOMY. ANZ J Surg 2008; 78:973-6. [DOI: 10.1111/j.1445-2197.2008.04714.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Anwar HA, Ahmed QA, Bradpiece HA. Removing symptomatic gallstones at their first emergency presentation. Ann R Coll Surg Engl 2008; 90:394-7. [PMID: 18634735 DOI: 10.1308/003588408x301037] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Early operations for symptomatic gallstones are gaining favour as the complication rate is thought to be lower and it reduces the overall morbidity. This study was performed to clarify how frequently early operations were being performed and what benefits resulted. PATIENTS AND METHODS Case notes of 171 patients who underwent laparoscopic cholecystectomy at Princess Alexandra Hospital Harlow were retrospectively reviewed. They were grouped according to their initial diagnosis (cholelithiasis, acute cholecystitis) and the delay to surgery (early, interval). Forty-one cases were excluded as they either had incomplete notes or the initial diagnosis was a different manifestation of gallstones such as pancreatitis. Those receiving interval operations were then grouped according to the mode of their initial presentation. A total of 130 case notes were analysed. RESULTS The delay for an interval operation was 3-6 months compared with less than 2 weeks for early operations. Of patients with acute cholecystitis, 43% had early operations but only 12% of patients with cholelithiasis. Waiting for interval operations was associated with multiple re-admissions equivalent to an average of one extra presentation to accident and emergency per patient. This was particularly marked if the initial presentation was to accident and emergency rather than outpatients (P = 0.003). Complication rates were also higher in the interval group. CONCLUSIONS Early cholecystectomy on the next available list is likely to reduce morbidity and the long-term in-patient burden so should be recommended for all patients presenting as an emergency with symptomatic gallstones.
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Affiliation(s)
- Hanny A Anwar
- Department of General and Laparoscopic Surgery, Princess Alexandra Hospital, Harlow, UK.
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Kim JH, Kim JW, Jeong IH, Choi TY, Yoo BM, Kim JH, Kim MW, Kim WH. Surgical outcomes of laparoscopic cholecystectomy for severe acute cholecystitis. J Gastrointest Surg 2008; 12:829-35. [PMID: 18327625 DOI: 10.1007/s11605-008-0504-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Accepted: 02/05/2008] [Indexed: 01/31/2023]
Abstract
The aim of this study was to evaluate the surgical outcomes of laparoscopic cholecystectomy (LC) in patients who were diagnosed with severe acute cholecystitis (SAC) and to clarify the useful treatment modalities of SAC. Of 112 patients who presented SAC, we selected 99 patients and divided them into 3 groups: 37 patients who underwent preoperative percutaneous transhepatic gallbladder drainage (PTGBD; group 1), 62 patients with SAC but not indicated for PTGBD (group 2), and 59 patients with acute and chronic cholecystitis (group 3). The conversion rate was 2.7% (1/37) in group 1, 6.5% (4/62) in group 2, and 1.7% (1/59) in group 3. In groups 1 and 2, the postoperative stay and operative time were longer than those in group 3 with significant difference, respectively (P<0.05). In group 2, there was correlation not only between postoperative stay and age but also between postoperative stay and ASA class (P<0.05). In group 2, there was no correlation between time to operation and operative time and also between time to operation and postoperative stay, however, there was surprisingly significant correlation between time to operation and conversion rate in SAC (P=0.018). In conclusion, PTGBD should selectively be performed in patients with severe comorbidities rather than improving surgical outcomes of LC for severe acute cholecystitis. If patients are not indicated for PTGBD, an early laparoscopic cholecystectomy is recommended because it can decrease conversion rate, although it cannot decrease operative time and postoperative stay.
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Affiliation(s)
- Ji Hun Kim
- Department of Surgery, School of Medicine, Ajou University, San-5, Wonchondong, Yeongtonggu, Suwon 442-749, South Korea
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Low JK, Barrow P, Owera A, Ammori BJ. Timing of Laparoscopic Cholecystectomy for Acute Cholecystitis: Evidence to Support a Proposal for an Early Interval Surgery. Am Surg 2007. [DOI: 10.1177/000313480707301123] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We evaluated the safety and feasibility of delayed urgent laparoscopic cholecystectomy (LC) performed beyond 72 hours to overcome the logistical difficulties in performing early urgent LC within 72 hours of admission with acute cholecystitis (AC), and to avoid earlier readmission with recurrent AC in patients awaiting delayed interval. Patients admitted with AC were scheduled for urgent LC. Patients who underwent early urgent LC were compared with those who had delayed urgent surgery. Fifty consecutive patients underwent urgent LC for AC within 2 weeks of admission. There were no conversions and no bile duct injuries. Delayed surgery (n = 36) neither prolonged operating time (90 vs 85 minutes), nor increased operative morbidity (9.7% vs 7.7%) or mortality (2.4% vs 7.7%) compared with early surgery (n = 14). Although delayed surgery was associated with shorter postoperative hospital stay (1 vs 2 days, P = 0.029), it prolonged total hospital stay (9 vs 5 days, P < 0.0001). Delay of LC beyond 72 hours neither increases operative difficulty nor prolongs recovery. It might be more cost effective to schedule patients who could not undergo early urgent LC but are responding to conservative treatment for an early interval LC within 2 weeks of presentation with AC.
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Affiliation(s)
- Jee K. Low
- Department of Surgery, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Paul Barrow
- Department of Surgery, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Anas Owera
- Department of Surgery, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Basil J. Ammori
- Department of Surgery, Manchester Royal Infirmary, Manchester, United Kingdom
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Scharlau U, Prinz C, Patrzyk M, Bernhardt J, Ludwig K. Diagnostik und Therapie der akuten Cholezystitis. Visc Med 2007. [DOI: 10.1159/000111068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Lima EC, Queiroz FL, Ladeira FN, Ferreira BM, Bueno JGP, Magalhães EA. Análise dos fatores implicados na conversão da colecistectomia laparoscópica. Rev Col Bras Cir 2007. [DOI: 10.1590/s0100-69912007000500008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Analisar os fatores implicados na conversão da colecistectomia laparoscópica. MÉTODO: Análise retrospectiva dos protocolos dos pacientes submetidos a colecistectomia laparoscópica no período de janeiro de 2000 a dezembro de 2004. RESULTADOS: Foram realizadas 1734 colecistectomias laparoscópicas neste período. A taxa de conversão foi de 5,7%, sendo de 5,44% nas cirurgias eletivas e de 14% nas cirurgias de urgência. (p=0,019). Não houve diferença na taxa de conversão em relação ao sexo, 7,46% nos pacientes do sexo masculino e 5,39% do sexo feminino. (p=0,178). A conversão foi necessária em 4,41% dos pacientes com menos de 60 anos e em 11,11% dos pacientes maiores de 60 anos (p=0,01). O principal motivo responsável pela conversão foi inflamação e aderência entre as estruturas do pedículo biliar (42,53%), outras causas foram coledocolitíase (17,24%) e suspeita ou lesão da via biliar (9,19%). Um tempo operatório maior que 120 minutos foi observado em 71,43% dos pacientes convertidos, e em apenas 8,2% dos pacientes não-convertidos. Dos pacientes convertidos 79,31% tiveram alta após 48 horas, e entre os pacientes não-convertidos apenas 10,8% tiveram alta após este período.(p=0,001). CONCLUSÃO: Os fatores de risco para conversão observados neste estudo foram idade> 60 anos, cirurgia em caráter de urgência e pacientes com colecistite aguda.
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Hadad SM, Vaidya JS, Baker L, Koh HC, Heron TP, Hussain K, Thompson AM. Delay from Symptom Onset Increases the Conversion Rate in Laparoscopic Cholecystectomy for Acute Cholecystitis. World J Surg 2007; 31:1298-01; discussion 1302-3. [PMID: 17483986 DOI: 10.1007/s00268-007-9050-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Randomized trials suggest that laparoscopic cholecystectomy should be performed on first admission for acute cholecystitis. However, this is not widely practiced, possibly because of a perceived high conversion rate. We hypothesized that delay from onset of symptoms may increase the conversion rate. METHODS We performed a retrospective case note review of patients undergoing emergency cholecystectomy in a single institution between January 2002 and December 2005. We analyzed whether delay from onset of symptoms was related to the conversion rate in patients with a histopathological diagnosis of acute cholecystitis. RESULTS Of patients who underwent emergency laparoscopic cholecystectomy in our institution, 32.4% (197/608) had acute cholecystitis on histopathology. The conversion rate of those with acute cholecystitis was considerably higher (24.4%) than for those with other pathologies (6.3%). For patients with acute cholecystitis, the conversion rates increased with duration of symptoms: 9.5%, 16.1%, 38.9%, and 38.6% for delays of 0-2 days, 3-4 days, 5-6 days, and > 6 days from symptom onset, respectively (chi-square for trend = 14.27, DF = 1, p = 0.00016). Most conversions were due to the presence of acute inflammatory adhesions. CONCLUSIONS Early intervention for acute cholecystitis (preferably within 2 days of onset of symptoms) is most likely to result in successful laparoscopic cholecystectomy; increasing delay is associated with conversion to open surgery.
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Affiliation(s)
- Sirwan M Hadad
- Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee, UK.
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Tsushimi T, Matsui N, Takemoto Y, Kurazumi H, Oka K, Seyama A, Morita T. Early Laparoscopic Cholecystectomy for Acute Gangrenous Cholecystitis. Surg Laparosc Endosc Percutan Tech 2007; 17:14-8. [PMID: 17318047 DOI: 10.1097/01.sle.0000213752.23396.45] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Treatment of severe acute cholecystitis by laparoscopic cholecystectomy remains controversial because of technical difficulties and high rates of complications and conversion to open cholecystectomy. We investigated whether early laparoscopic cholecystectomy is appropriate for acute gangrenous cholecystitis. Pathologic diagnoses and outcomes were analyzed in patients who underwent laparoscopic or open cholecystectomy at our hospital, January 2002 to September 2005. Of 30 patients with acute gangrenous cholecystitis, 16 underwent early laparoscopic cholecystectomy, 10 underwent open cholecystectomy, and 4 were converted to open cholecystectomy (conversion rate, 20.0%). There was no significant difference in operation time or intraoperative bleeding. The requirement for postoperative analgesics was significantly lower (6.4+/-7.3 vs. 1.5+/-1.2 doses, P<0.05) and hospital stay significantly shorter (8.6+/-2.1 vs. 15.6+/-6.3 d, P<0.01) after laparoscopic cholecystectomy. There were no postoperative complications in either group. Thus, early laparoscopic cholecystectomy seems appropriate for acute gangrenous cholecystitis. Conversion to open cholecystectomy may be required in difficult cases with complications.
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Affiliation(s)
- Takaaki Tsushimi
- Department of Surgery, Shutoh General Hospital, 1000-1 Kogaisaku, Yanai, Yamaguchi 742-0032, Japan.
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Soffer D, Blackbourne LH, Schulman CI, Goldman M, Habib F, Benjamin R, Lynn M, Lopez PP, Cohn SM, McKenney MG. Is there an optimal time for laparoscopic cholecystectomy in acute cholecystitis? Surg Endosc 2006; 21:805-9. [PMID: 17180290 DOI: 10.1007/s00464-006-9019-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Revised: 05/29/2006] [Accepted: 07/05/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is safe in acute cholecystitis, but the exact timing remains ill-defined. This study evaluated the effect of timing of LC in patients with acute cholecystitis. METHODS Prospective data from the hospital registry were reviewed. All patients admitted with acute cholecystitis from June 1994 to January 2004 were included in the cohort. RESULTS Laparoscopic cholecystectomy was attempted in 1,967 patients during the study period; 80% were women, mean patient age was 44 years (range, 20-73 years). Of the 1,967 LC procedures, 1,675 were successful, and 292 were converted to an open procedure (14%). Mean operating time for LC was 1 h 44 min (SD +/- 50 min), versus 3 h 5 min (SD +/- 79 min) when converted to an open procedure. Average postoperative length of stay was 1.89 days (+/- 2.47 days) for the laparoscopic group and 4.3 days (+/- 2.2 days) for the conversion group. No clinically relevant differences regarding conversion rates, operative times, or postoperative length of stay were found between patients who were operated on within 48 h compared to those patients who were operated on post-admission days 3-7. CONCLUSIONS The timing of laparoscopic cholecystectomy in patients with acute cholecystitis has no clinically relevant effect on conversion rates, operative times, or length of stay.
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Affiliation(s)
- D Soffer
- Division of Trauma, University of Miami-Miller School of Medicine, P.O. Box 016960 (D-40), Miami, Florida 33101, USA
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Ibrahim S, Hean TK, Ho LS, Ravintharan T, Chye TN, Chee CH. Risk factors for conversion to open surgery in patients undergoing laparoscopic cholecystectomy. World J Surg 2006; 30:1698-704. [PMID: 16927065 DOI: 10.1007/s00268-005-0612-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy is the gold standard treatment for most gallbladder diseases. Conversion to open cholecystectomy is necessary in some patients for any of a number of factors. Identifying these factors will help the patient, the surgeon, and the hospital. METHODS One thousand laparoscopic cholecystectomies were performed from May 1998 to May 2004 in Changi General Hospital, Singapore; 103 patients (10.3%) required conversion to open cholecystectomy. All data were kept prospectively and analyzed retrospectively. RESULTS The patients who had conversion were mostly men (P < 0.0001), were heavier (P < 0.05), had acute cholecystitis (P < 0.0001), and had a history of upper abdominal surgery (P < 0.001). There were no differences in terms of race (P = 0.315) and presence of diabetes mellitus (P = 0.126). Diabetic patients who had conversion had a significantly higher glycosylated hemoglobin (Hba1c) (8.9% +/- 0.6%; P < 0.038). Patients who had conversion had a higher total white count (P < 0.05), but liver function tests were similar between the two groups. There was a higher conversion rate among the junior surgeons than the more experience surgeons (P < 0.032). CONCLUSIONS The significant risk factors for conversion were male gender, advanced age (> 60 years), higher body weight > 65 kg, acute cholecystitis, previous upper abdominal surgery, junior surgeons, and diabetes associated with Hba1c > 6. Chronic liver disease was not found to be a risk factor (P = 0.345), and performing laparoscopic cholecystectomy in cirrhotic patients is safe. Identifying risk factors will help the surgeon to plan and counsel the patient and introduce new policies to the unit. Some of the risk factors are similar to those reported from international centers, but others may be unique to our department.
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Affiliation(s)
- Salleh Ibrahim
- Department of Surgery, Changi General Hospital, 2nd Simei Street 3, Singapore 529889.
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Abstract
BACKGROUND Gallstones are present in about 10% to 15% of the adult western population. Between 1% and 4% become symptomatic in a year. Cholecystectomy for symptomatic gallstones is mainly performed after the acute cholecystitis episode settles because of the fear of higher morbidity and conversion from laparoscopic cholecystectomy to open cholecystectomy during acute cholecystitis. OBJECTIVES The aim was to compare the early laparoscopic cholecystectomy (less than seven days of onset of symptoms) versus delayed laparoscopic cholecystectomy (more than six weeks after index admission) with regards to benefits and harms. 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 IndexExpanded until November 2005. SELECTION CRITERIA We considered for inclusion all randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis. DATA COLLECTION AND ANALYSIS We collected the data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, conversion rate, operating time, and hospital stay from each trial. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the odds ratio (OR) with 95% confidence intervals (CI) based on intention-to-treat analysis. MAIN RESULTS We included five trials with 451 patients randomised: 223 to the early group and 228 to the delayed group. Surgery was performed on 222 patients in the early group and on 216 patients in the delayed group. There was no mortality in any of the trials. Four of the five trials were of high methodological quality. There was no statistically significant difference between the two groups for any of the outcomes including bile duct injury (OR 0.63, 95% CI 0.15 to 2.70) and conversion to open cholecystectomy (OR 0.84, 95% CI 0.53 to 1.34). Various other analyses including 'available case analysis', risk difference, statistical methods to overcome the 'zero-event trials' showed no statistically significant difference between the two groups in any of the outcomes measured. A total of 40 patients (17.5%) from the delayed group had to undergo emergency laparoscopic cholecystectomy due to non-resolving or recurrent cholecystitis; 18 (45%) of these had to undergo conversion to open procedure. The total hospital stay was about three days shorter in the early group compared with the delayed group. AUTHORS' CONCLUSIONS Early laparoscopic cholecystectomy during acute cholecystitis seems safe and shortens the total hospital stay. The majority of the outcomes occurred rarely; hence, the confidence intervals are wide. Therefore, further randomised trials on the issue are needed.
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Affiliation(s)
- K S Gurusamy
- Royal Free Hospital, Surgery, 291 Greenhaven Drive, Thamesmead, London, UK.
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Tzovaras G, Zacharoulis D, Liakou P, Theodoropoulos T, Paroutoglou G, Hatzitheofilou C. Timing of laparoscopic cholecystectomy for acute cholecystitis: A prospective non randomized study. World J Gastroenterol 2006; 12:5528-31. [PMID: 17006993 PMCID: PMC4088238 DOI: 10.3748/wjg.v12.i34.5528] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the timing of laparoscopic cholecy-stectomy for patients with acute cholecystitis.
METHODS: Between January 2002 and December 2005, all American Society of Anesthesiologists classification (ASA)I,IIand III patients with acute cholecystitis were treated laparoscopically during the urgent (index) admission. The patients were divided into three groups according to the timing of surgery: (1) within the first 3 d, (2) between 4 and 7 d and (3) beyond 7 d from the onset of symptoms. The impact of timing on the conversion rate, morbidity and postoperative hospital stay was studied.
RESULTS: One hundred and twenty-nine patients underwent laparoscopic cholecystectomy for acute cholecystitis during the index admission. Thirty six were assigned to group 1, 58 to group 2, and 35 to group 3. The conversion rate and morbidity for the whole cohort of patients were 4.6% and 10.8%, respectively. There was no significant difference in the conversion rate, morbidity and postoperative hospital stay between the three groups.
CONCLUSION: Laparoscopic cholecystectomy for acute cholecystitis during the index admission is safe, regardless of the time elapsed from the onset of symptoms. This policy can result in an overall shorter hospitalization.
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Affiliation(s)
- George Tzovaras
- Department of Surgery, University of Thessaly School of Medicine, University Hospital of Larissa, 19 Agorogianni A. Street, Larissa 41335, Greece.
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Ishizaki Y, Miwa K, Yoshimoto J, Sugo H, Kawasaki S. Conversion of elective laparoscopic to open cholecystectomy between 1993 and 2004. Br J Surg 2006; 93:987-91. [PMID: 16739098 DOI: 10.1002/bjs.5406] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic gallbladder disease. The identification of factors that reliably predict the likely need to convert LC to an open procedure would provide short-term benefits in terms of patient education and postoperative expectations. METHODS Between 1993 and 2004, 1179 elective LCs were attempted from a total of 1339 elective cholecystectomies. The change in conversion rate between 1993-1999 and 2000-2004 was analysed. Factors predictive of higher risk for conversion were also identified. RESULTS Eighty-nine LCs (7.5 per cent) required conversion. Gallbladder wall thickness and a history of common bile duct (CBD) stones, treated by preoperative endoscopic sphincterotomy, were predictors of conversion. The proportion of patients who underwent LC was the same in 1993-1999 (87.5 per cent) and 2000-2004 (88.8 per cent), but the conversion rate increased significantly from 5.3 to 10.6 per cent in these two time intervals. In addition, the proportion of patients with a history of CBD stones rose significantly, from 6.4 per cent in 1993-1999 to 11.0 per cent in 2000-2004. CONCLUSION The conversion rate increased over the 12-year interval of the study. A history of preoperative endoscopic sphincterotomy and a thickened gallbladder wall contributed to the likelihood of conversion.
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Affiliation(s)
- Y Ishizaki
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan.
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Tang B, Cuschieri A. Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome. J Gastrointest Surg 2006; 10:1081-91. [PMID: 16843880 DOI: 10.1016/j.gassur.2005.12.001] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2005] [Revised: 12/01/2005] [Accepted: 12/05/2005] [Indexed: 01/31/2023]
Abstract
In view of the substantial, at times conflicting, literature on conversion to open surgery during laparoscopic cholecystectomy (LC), we have considered it timely to review the subject to identify the risk factors for conversion and its consequences. The review is based on a complete literature search covering the period 1990 to 2005. The search identified 109 publications on the subject: 68 retrospective series, 16 prospective nonrandomized studies, 8 prospective randomized clinical trials, 5 prospective case-controlled studies, 5 reviews and 7 others (3 observational, 2 population-based studies, 1 national survey, and 1 editorial). As the majority of reported studies are retrospective, firm conclusions cannot be reached. Single factors that appear to be important include male gender, extreme old age, morbid obesity, cirrhosis, previous upper abdominal surgery, severe/advanced acute and chronic disease, and emergency LC. The combination of patient- and disease-related risk factors increases the conversion risk. In the training of residents, the number of cases needed for reaching proficiency exceeds 200 cases. The value of predictive scoring systems is important in the selection of cases for resident training. Conversion exerts adverse effects on operating time, postoperative morbidity, and hospital costs, especially when it is enforced. There appears to be no absolute contraindication to LC that is agreed upon by all. There is consensus on certain individual risk factors and their additive effect on the likelihood of conversion. Predictive systems based on these factors appear to be useful in selection of cases for resident training.
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Affiliation(s)
- Benjie Tang
- Cuschieri Skills Centre, University of Dundee, Scotland
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Shikata S, Noguchi Y, Fukui T. Early versus delayed cholecystectomy for acute cholecystitis: a meta-analysis of randomized controlled trials. Surg Today 2005; 35:553-60. [PMID: 15976952 DOI: 10.1007/s00595-005-2998-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2004] [Accepted: 11/16/2004] [Indexed: 10/25/2022]
Abstract
PURPOSE We performed a meta-analysis of randomized controlled trials to determine the optimal timing of laparoscopic cholecystectomy and open cholecystectomy for acute cholecystitis. METHODS We retrieved randomized controlled trials (RCTs) that compared early with delayed cholecystectomy for acute cholecystitis by systematically searching Medline and the Cochrane Library for studies published between 1966 and 2003. The outcomes of primary interest were mortality and morbidity. RESULTS The ten trials we analyzed comprised 1 014 subjects; 534 were assigned to the early group and 480 assigned to the delayed group. The combined risk difference of mortality appeared to favor open cholecystectomy in the early period (risk difference, -0.02; 95% confidence interval, -0.44 to -0.00), but no differences were found among laparoscopic procedures or among all procedures. The combined risk difference of morbidity showed no differences between the open and laparoscopic procedures. The combined risk difference of the rate of conversion to open surgery showed no differences in the included laparoscopic studies; however, the combined total hospital stay was significantly shorter in the early group than in the delayed group. CONCLUSIONS There is no advantage to delaying cholecystectomy for acute cholecystitis on the basis of outcomes in mortality, morbidity, rate of conversion to open surgery, and mean hospital stay. Thus, early cholecystectomy should be performed for patients with acute cholecystitis.
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Affiliation(s)
- Satoru Shikata
- Department of Surgery, Division of Digestive Surgery, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
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