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Ito R, Yoshioka R, Gyoda Y, Miyashita M, Furuya R, Fujisawa M, Kawano F, Takeda Y, Ichida H, Mise Y, Saiura A. Utilization of the modified Kama scoring system for predicting bail-out cholecystectomy: a valuable tool in the era of rising laparoscopic surgery prevalence. Surg Today 2024:10.1007/s00595-024-02854-6. [PMID: 38734830 DOI: 10.1007/s00595-024-02854-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/02/2024] [Indexed: 05/13/2024]
Abstract
PURPOSE Recently, bail-out cholecystectomy (BOC) during laparoscopic cholecystectomy to avoid severe complications, such as vasculobiliary injury, has become widely used and increased in prevalence. However, current predictive factors or scoring systems are insufficient. Therefore, in this study, we aimed to test the validity of existing scoring systems and determine a suitable cutoff value for predicting BOC. METHODS We retrospectively assessed 305 patients who underwent laparoscopic cholecystectomy and divided them into a total cholecystectomy group (n = 265) and a BOC group (n = 40). Preoperative and operative findings were collected, and cutoff values for the existing scoring systems (Kama's and Nassar's) were modified using a prospectively maintained database. RESULTS The BOC rate was 13% with no severe complications. A logistic regression analysis revealed that the Kama's score (odds ratio, 0.93; 95% confidence interval 0.91-0.96; P < 0.01) was an independent predictor of BOC. A cutoff value of 6.5 points gave an area under the curve of 0.81, with a sensitivity of 87% and a specificity of 67%. CONCLUSIONS Kama's difficulty scoring system with a modified cutoff value (6.5 points) is effective for predicting BOC.
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Affiliation(s)
- Ryota Ito
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Ryuji Yoshioka
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Yu Gyoda
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Mamiko Miyashita
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Ryoji Furuya
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Masahiro Fujisawa
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Fumihiro Kawano
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Yoshinori Takeda
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Hirofumi Ichida
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Yoshihiro Mise
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan.
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Balbaloglu H, Tasdoven I. Can gallbladder wall thickness and systemic inflammatory index values predict the possibility of conversion from laparoscopy to open surgery? Niger J Clin Pract 2023; 26:1532-1537. [PMID: 37929531 DOI: 10.4103/njcp.njcp_216_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Background/Objective This study aims to develop an objective marker that predicts the risk of conversion from laparoscopy to open surgery using gallbladder wall thickness and inflammatory index values. Materials and Methods A total of 2,920 cholecystectomy patients were screened, including those whose operations were converted to open and those who underwent laparoscopy. A total of 700 cholecystectomy patients who met the study criteria were included in the study. The same team of surgeons performed all operations. The conversion probability from laparoscopic to open cholecystectomy was calculated using the ratio obtained by evaluating inflammatory markers and gallbladder wall thickness (K). The preoperative complete blood count and abdominal ultrasound data of the patients were obtained from our university patient registry system. Results Age, neutrophil count, gallbladder wall thickness, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), KxNLR, and KxPLR values were all significantly higher in the conversion from laparoscopy to open surgery group compared with the laparoscopic cholecystectomy group. According to the ROC analysis performed on the gallbladder wall thickness values according to the probability of conversion to open surgery, the cutoff value was determined as >3 mm. Gallbladder wall thickness >KxPLR >KxNLR was defined as the diagnostic value order according to the area under the curve. Conclusions The results of this study showed that gallbladder wall thickness effectively determines the probability of conversion from laparoscopy to open cholecystectomy and multiplying the gallbladder wall thickness (mm) by NLR increased the sensitivity.
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Affiliation(s)
- H Balbaloglu
- Department of General Surgery, Zonguldak Bulent Ecevit University, School of Medicine, Zonguldak, Turkey
| | - I Tasdoven
- Department of General Surgery, Zonguldak Bulent Ecevit University, School of Medicine, Zonguldak, Turkey
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Porras Fimbres DC, Nussbaum DP, Mosca PJ. Racial disparities in time to laparoscopic cholecystectomy for acute cholecystitis. Am J Surg 2023; 226:261-270. [PMID: 37149406 DOI: 10.1016/j.amjsurg.2023.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/25/2023] [Accepted: 05/02/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Disparities in healthcare exist, yet few data are available on racial differences in time from admission to surgery. This study aimed to compare time from admission to laparoscopic cholecystectomy for acute cholecystitis between non-Hispanic Black and non-Hispanic White patients. METHODS Patients who underwent laparoscopic cholecystectomy for acute cholecystitis from 2010 to 2020 were identified using NSQIP. Time to surgery and additional preoperative, operative, and postoperative variables were analyzed. RESULTS In the univariate analysis, 19.4% of Black patients experienced a time to surgery >1 day compared with 13.4% of White patients (p < 0.0001). In the multivariable analysis, controlling for potential confounding factors, Black patients were found to be more likely than White patients to experience a time to surgery >1 day (OR 1.23, 95% CI 1.17-1.30, p < 0.0001). CONCLUSIONS Further investigation is indicated to better define the nature and significance of gender, race, and other biases in surgical care. Surgeons should be aware that biases may adversely impact patient care and should strive to identify and proactively address them to promote health equity in surgery.
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Affiliation(s)
| | - Daniel P Nussbaum
- Duke University School of Medicine, Duke University Health System, Durham, NC, USA; Department of Surgery, Duke University School of Medicine, Duke University Health System, Durham, NC, USA; Duke Network Services, Duke University Health System, Durham, NC, USA
| | - Paul J Mosca
- Duke University School of Medicine, Duke University Health System, Durham, NC, USA; Department of Surgery, Duke University School of Medicine, Duke University Health System, Durham, NC, USA; Duke Network Services, Duke University Health System, Durham, NC, USA.
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Tongyoo A, Liwattanakun A, Sriussadaporn E, Limpavitayaporn P, Mingmalairak C. The Modification of a Preoperative Scoring System to Predict Difficult Elective Laparoscopic Cholecystectomy. J Laparoendosc Adv Surg Tech A 2023; 33:269-275. [PMID: 36445743 PMCID: PMC9997034 DOI: 10.1089/lap.2022.0407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Laparoscopic cholecystectomy (LC) is one of the most common abdominal operations. The difficult cases are still challenging for surgeons. There had been many studies providing several preoperative models to predict difficult LC or conversion. Randhawa's scoring system was a simple and practical predictive model for clinicians. The modification was reported to be more preferable for delayed LC. This study aimed to confirm the advantage of modified predictive model in larger sample size. Materials and Methods: This retrospective cohort study reviewed medical records of patients who underwent LC since January 2017 to December 2021. The difficulty of operation was categorized into three groups: easy, difficult, and very difficult. Multivariate analysis was performed to define significant factors of very difficult and converted cases. The predictive scores were calculated by using the original Randhawa's model and the modification, then compared with actual outcome. Results: There were 567 cases of delayed LC in this study, with 44 cases (7.8%) converted to open cholecystectomy. Four factors (previous cholecystitis, previous endoscopic retrograde cholangiopancreatography, higher ALP, and gallbladder wall thickening) for very difficult group and five factors (previous cholecystitis, previous cholangitis, higher white blood cell count, gallbladder wall thickening, and contracted gallbladder) for conversion were significant. The modification provided the better correlation and higher area of receiver operating characteristic (ROC) curve comparing with the original model. Conclusion: The modification of Randhawa's model was supposed to be more preferable for predicting the difficulty in elective LC. Thai Clinical Trials Registry No. 20220712006.
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Affiliation(s)
- Assanee Tongyoo
- Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | | | - Ekkapak Sriussadaporn
- Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Palin Limpavitayaporn
- Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Chatchai Mingmalairak
- Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
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Alotaibi AM. Gallbladder wall thickness adversely impacts the surgical outcome. Ann Hepatobiliary Pancreat Surg 2023; 27:63-69. [PMID: 36536504 PMCID: PMC9947375 DOI: 10.14701/ahbps.22-067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/17/2022] [Accepted: 10/12/2022] [Indexed: 12/24/2022] Open
Abstract
Backgrounds/Aims To evaluate surgical outcomes of patients with gallbladder wall thickness (GBWT) > 5 mm. Methods Patients who underwent cholecystectomy were classified into two groups according to their GBWT status (GBWT+ vs. GBWT-). Results Among 1,211 patients who underwent cholecystectomy, GBWT+ was seen in 177 (14.6%). The GBWT+ group was significantly older with more males, higher ASA score, higher alkaline phosphatase level, higher international normalized ratio, and lower albumin level than the GBWT- group. On ultrasound, GBWT+ patients had larger stone size, more pericholecystic fluid, more common bile duct stone, and more biliary pancreatitis. Compared with the GBWT- group, the GBWT+ group had more urgent surgeries (12.4% vs. 3.2%, p = 0.001), higher conversion rate (4.5% vs. 0.3%, p = 0.001), prolonged operative time (67 ± 38 vs. 54 ± 29 min; p = 0.001), more bleeding (3.4% vs. 0.5%, p = 0.002), and more need of drain (21.5% vs. 10.5%, p = 0.001). By multivariate analysis, factors associated with increased length of hospital stay were GBWT+ (HR: 1.97, 95% CI: 1.19-3.25, p = 0.008), urgent surgery (HR: 10.2, 95% CI: 4.07-25.92, p = 0.001), prolonged surgery (HR: 1.01, 95% CI: 1.0-1.02, p = 0.001), and postoperative drain (HR: 11.3, 95% CI: 6.40-20.0, p = 0.001). Conclusions Variables such as GBWT ≥ 5 mm, urgent prolonged operation, and postoperative drains are independent predictors of extended hospital stay. GBWT+ patients are twice likely to stay in hospital for more than 72 hours and more prone to develop complications than GBWT- patients.
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Affiliation(s)
- Abdulrahman Muaod Alotaibi
- Department of Surgery, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia,Department of Surgery, Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia,Corresponding author: Abdulrahman Muaod Alotaibi, MD Department of Surgery, Faculty of Medicine, University of Jeddah, Al Madinah Street, Alsharafiah District, Jeddah 21959, Saudi Arabia Tel: +966-504707351, Fax: +966-126951044, E-mail: ORCID: https://orcid.org/0000-0001-8444-7229
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Magnano San Lio R, Barchitta M, Maugeri A, Quartarone S, Basile G, Agodi A. Preoperative Risk Factors for Conversion from Laparoscopic to Open Cholecystectomy: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:408. [PMID: 36612732 PMCID: PMC9819914 DOI: 10.3390/ijerph20010408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/08/2022] [Accepted: 12/23/2022] [Indexed: 06/17/2023]
Abstract
Laparoscopic cholecystectomy is a standard treatment for patients with gallstones in the gallbladder. However, multiple risk factors affect the probability of conversion from laparoscopic cholecystectomy to open surgery. A greater understanding of the preoperative factors related to conversion is crucial to improve patient safety. In the present systematic review, we summarized the current knowledge about the main factors associated with conversion. Next, we carried out several meta-analyses to evaluate the impact of independent clinical risk factors on conversion rate. Male gender (OR = 1.907; 95%CI = 1.254−2.901), age > 60 years (OR = 4.324; 95%CI = 3.396−5.506), acute cholecystitis (OR = 5.475; 95%CI = 2.959−10.130), diabetes (OR = 2.576; 95%CI = 1.687−3.934), hypertension (OR = 1.931; 95%CI = 1.018−3.662), heart diseases (OR = 2.947; 95%CI = 1.047−8.296), obesity (OR = 2.228; 95%CI = 1.162−4.271), and previous upper abdominal surgery (OR = 3.301; 95%CI = 1.965−5.543) increased the probability of conversion. Our analysis of clinical factors suggested the presence of different preoperative conditions, which are non-modifiable but could be useful for planning the surgical scenario and improving the post-operatory phase.
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Affiliation(s)
- Roberta Magnano San Lio
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, 95123 Catania, Italy
| | - Martina Barchitta
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, 95123 Catania, Italy
| | - Andrea Maugeri
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, 95123 Catania, Italy
| | - Serafino Quartarone
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, 95123 Catania, Italy
| | - Guido Basile
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, 95123 Catania, Italy
| | - Antonella Agodi
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, 95123 Catania, Italy
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Tomihara H, Tomimaru Y, Hashimoto K, Fukuchi N, Yokoyama S, Mori T, Tanemura M, Sakai K, Takeda Y, Tsujie M, Yamada T, Miyamoto A, Hashimoto Y, Hatano H, Shimizu J, Sugimoto K, Kashiwazaki M, Matsumoto K, Kobayashi S, Doki Y, Eguchi H. Preoperative risk score to predict subtotal cholecystectomy after gallbladder drainage for acute cholecystitis: Secondary analysis of data from a multi-institutional retrospective study (CSGO-HBP-017B). Asian J Endosc Surg 2022; 15:555-562. [PMID: 35302288 DOI: 10.1111/ases.13051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/14/2022] [Accepted: 02/19/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Subtotal cholecystectomy (STC) has become recognized as a "bailout procedure" to prevent bile duct injury in patients undergoing laparoscopic cholecystectomy (LC). Predictors of conversion to STC have not been identified because LC difficulty varies based on pericholecystic inflammation. We analyzed data from patients enrolled in a previously performed multi-institutional retrospective study of the optimal timing of LC after gallbladder drainage for acute cholecystitis (AC). These patients presumably had a considerable degree of pericholecystic inflammation. METHODS In total, 347 patients who underwent LC after gallbladder drainage for AC were analyzed to examine preoperative and perioperative factors predicting conversion to STC. RESULTS Three hundred patients underwent total cholecystectomy (TC) and 47 underwent conversion to STC. Eastern Cooperative Oncology Group Performance Status (ECOG PS) (P < .01), severity of cholecystitis (P = .04), previous history of treatment for common bile duct stones (CBDS) (P < .01), and surgeon experience (P = .03) were significantly associated with conversion to STC. Logistic regression analyses showed that ECOG PS (odds ratio 0.2; P < .0001) and previous history of treatment for CBDS (odds ratio 0.37; P = .0073) were independent predictors of conversion to STC. Our predictive risk score using these two variables suggested that a score ≥2 could discriminate between TC and STC (P < .0001). CONCLUSION Poor ECOG PS and previous history of treatment for CBDS were significantly associated with conversion to STC after gallbladder drainage for AC.
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Affiliation(s)
- Hideo Tomihara
- Department of Surgery, Faculty of Medicine, Nara Hospital, Kindai University, Ikoma, Japan.,Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan
| | - Yoshito Tomimaru
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Kazuhiko Hashimoto
- Department of Surgery, Faculty of Medicine, Nara Hospital, Kindai University, Ikoma, Japan.,Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan
| | - Nariaki Fukuchi
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Suita Municipal Hospital, Suita, Japan
| | - Shigekazu Yokoyama
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya, Japan
| | - Takuji Mori
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Tane General Hospital, Osaka, Japan
| | - Masahiro Tanemura
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Osaka Police Hospital, Osaka, Japan.,Department of Surgery, Rinku General Medical Center, Osaka, Japan
| | - Kenji Sakai
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Japan Community Health Care Organization, Osaka Hospital, Osaka, Japan
| | - Yutaka Takeda
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Kansai Rosai Hospital, Amagasaki, Japan
| | - Masanori Tsujie
- Department of Surgery, Faculty of Medicine, Nara Hospital, Kindai University, Ikoma, Japan.,Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Osaka Rosai Hospital, Sakai, Japan
| | - Terumasa Yamada
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
| | - Atsushi Miyamoto
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan.,Department of Surgery, Sakai City Medical Center, Sakai, Japan
| | - Yasuji Hashimoto
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Yao Municipal Hospital, Yao, Japan
| | - Hisanori Hatano
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Osaka Police Hospital, Osaka, Japan.,Department of Surgery, Ashiya Municipal Hospital, Ashiya, Japan
| | - Junzo Shimizu
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan.,Department of Surgery, Osaka Rosai Hospital, Sakai, Japan
| | - Keishi Sugimoto
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Minoh City Hospital, Minoh, Japan.,Department of Surgery, Kawanishi City Hospital, Kawanishi, Japan
| | - Masaki Kashiwazaki
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Surgery, Osaka General Medical Center, Osaka, Japan.,Department of Surgery, Otemae Hospital, Osaka, Japan
| | - Kenichi Matsumoto
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Shogo Kobayashi
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Yuichiro Doki
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hidetoshi Eguchi
- Hepato-Biliary-Pancreatic Group, Clinical Study Group of Osaka University, Osaka, Japan.,Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
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Patient and surgeon factors contributing to bailout cholecystectomies: a single-institutional retrospective analysis. Surg Endosc 2022; 36:6696-6704. [PMID: 34981223 DOI: 10.1007/s00464-021-08942-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/06/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomies continue to pose trouble for surgeons in the face of severe inflammation. In the advent of inability to perform an adequate dissection, a "bailout cholecystectomy" is advocated. Conversion to open or subtotal cholecystectomy is among the standard bailout procedures in such instances. METHODS We performed a retrospective single institution review from January 2016 to August 2019. All patients who underwent a cholecystectomy were included, while those with a concurrent operation, malignancy, planned as an open cholecystectomy, or performed by a low volume surgeon were excluded. Patient characteristics, operative reports, and outcomes were collected, as were surgeon characteristics such as years of experience, case volume, and bailout rate. Univariable and multivariable analysis were performed. RESULTS 2458 (92.6%) underwent laparoscopic total cholecystectomy (LTC) and 196 (7.4%) underwent a bailout cholecystectomy (BOC). BOC patients tended to be older (p < 0.001), male (p < 0.001), have a longer duration of symptoms (p < 0.001), and higher ASA class (p < 0.001). They also had more signs of biliary inflammation, as evidenced by increased leukocytosis (p < 0.001), tachycardia (p < 0.001), bilirubinemia (p = 0.003), common bile duct dilation (p < 0.001), and gallbladder wall thickening (p < 0.001). The BOC cohort also had increased rates of complications, including bile leak (16%, p < 0.001), retained stone (5.1%, p = 0.005), operative time (114 min vs 79 min, p < 0.001), and secondary interventions (22.7%, p < 0.001). Male gender (aOR = 2.8, p < 0.001), preoperative diagnosis of acute cholecystitis (aOR = 2.2, p = 0.032), right upper quadrant tenderness (aOR = 3.0, p = 0.008), Asian race (aOR = 2.7, p = 0.014), and intraoperative adhesions (aOR = 13.0, p < 0.001) were found to carry independent risk for BOC. Surgeon bailout rate ≥ 7% was also found to be an independent risk factor for conversion to BOC. CONCLUSIONS Male gender, signs of biliary inflammation (tachycardia, leukocytosis, dilated CBD, and diagnosis of acute cholecystitis), as well as surgeon bailout rate of 7% were independent risk factors for BOC.
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9
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ATABEY M, AYKOTA MR, YILMAZ S. May complete blood count parameters be predictive in estimation of gallbladder wall thickness? Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.20.05200-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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10
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Conversion to open surgery during laparoscopic common bile duct exploration: predictive factors and impact on the perioperative outcomes. HPB (Oxford) 2022; 24:87-93. [PMID: 34167893 DOI: 10.1016/j.hpb.2021.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/15/2021] [Accepted: 05/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (LCBDE) is an effective treatment for choledocholithiasis. The aim of this study was to determine the predictive factors associated with conversion during LCBDE and to assess the implications of conversion on the patients' postoperative course. METHODS A retrospective cohort study based on patients undergoing LCBDE between 2000 and 2018 was conducted. Uni- and multivariate regression analyses were performed. RESULTS A total of 357 patients underwent LCBDE, and the conversion rate was 14.2%. The main reasons for conversion were lithiasis extraction (21; 41%) and difficult dissection (13; 26%). Independent predictors for conversion were increasing levels of serum bilirubin prior to surgery (OR=4.745, 95% CI: 1.390-16.198; p=0.013), and emergency setting (OR=4.144, 95% CI: 1.449-11.846; p=0.008). Age was independently associated with lower odds of conversion (OR=0.979, 95% CI: 0.960-0.999; p=0.036). Conversion had a negative impact on the patients' postoperative course, including severe complication (21.6% vs. 5.2% p<0.001) and surgical reintervention (11.8% vs. 2.6% p=0.002) rates. CONCLUSION Conversion to open surgery during LCBDE was associated with increased postoperative morbidity. Emergency surgery and increasing levels of serum bilirubin previous to surgery independently increase the probability of conversion; however age was independently associated with lower odds of conversion.
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Tchernin N, Paran M, Funkaz L, Zilbermintz V, Kessel B, Aranovich D. Biliary Tract Instrumentations Prior to Elective Cholecystectomy: Effect on Biliary Microbiome. Surg Infect (Larchmt) 2021; 23:35-40. [PMID: 34569856 DOI: 10.1089/sur.2021.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Background: Calculus biliary disease is a common condition that requires invasive procedures in complicated cases. The effect of biliary instrumentation on the biliary microbiome and its impact on surgical complications after elective cholecystectomy remains unclear. This study aimed to assess the impact of prior biliary instrumentation on the biliary microbiome, as well as on the clinical outcomes of cholecystectomy. Patients and Methods: This retrospective study included all patients who underwent elective cholecystectomy for calculus biliary disease between 2015 and 2020 in a single medical center. Data regarding biliary instrumentation prior to cholecystectomy, biliary cultures obtained during cholecystectomy, and clinical outcomes were collected. A comparison between patients with and without prior instrumentation was performed with regard to biliary cultures and clinical outcomes. Results: Of the 508 patients studied, 109 patients underwent biliary instrumentation prior to cholecystectomy. Patients with prior instrumentation were older and more likely to be men (p < 0.0001). Prior instrumentation was also associated with higher rates of conversion to open surgery (p < 0.0001). Positive biliary cultures and polymicrobial growth were both more common among patients with prior instrumentation (p < 0.0001). Prior instrumentation was associated with longer length of hospital stay, as well as higher rates of perioperative complications and surgical site infection (p < 0.0001). Conclusions: Prior instrumentation was associated with poorer clinical outcomes and affected the biliary microbiome. The different results of biliary cultures in these patients may suggest that an alternative empiric antibiotic regimen should be considered when treating patients with biliary instrumentation.
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Affiliation(s)
- Neev Tchernin
- Department of General Surgery, Hillel Yaffe Medical Center, affiliated with The Rapaport School of Medicine, Technion Haifa, Israel
| | - Maya Paran
- Department of General Surgery, Hillel Yaffe Medical Center, affiliated with The Rapaport School of Medicine, Technion Haifa, Israel
| | - Leonid Funkaz
- Anesthesiology Department, Hillel Yaffe Medical Center, affiliated with The Rapaport School of Medicine, Technion Haifa, Israel
| | - Veacheslav Zilbermintz
- Department of General Surgery, Hillel Yaffe Medical Center, affiliated with The Rapaport School of Medicine, Technion Haifa, Israel
| | - Boris Kessel
- Department of General Surgery, Hillel Yaffe Medical Center, affiliated with The Rapaport School of Medicine, Technion Haifa, Israel
| | - David Aranovich
- Department of General Surgery, Hillel Yaffe Medical Center, affiliated with The Rapaport School of Medicine, Technion Haifa, Israel
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12
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Orabi A, Di Mauro D, Njere I, Ratano M, Thavakumar S, Reece-Smith A, Wajed S, Manzelli A. Can Preoperative Characteristics Predict the Outcomes of Laparoscopic Cholecystectomy? J Laparoendosc Adv Surg Tech A 2021; 32:532-537. [PMID: 34357804 DOI: 10.1089/lap.2021.0398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Intraoperative findings during laparoscopic cholecystectomy (LC) are highly unpredictable and operative difficulty varies from straightforward to very challenging procedures. Several studies described predictors of technical difficulty and graded intraoperative findings of LC; however, none specifically reported on the effect of such factors on clinical outcomes. This study aims to evaluate if preoperative characteristics of patients undergoing LC predict how likely they are to fail to be day case (DC). Methods: Data of patients who underwent LC from 2015 to 2017 were retrospectively analyzed. Subjects were divided into four groups, according to Nassar's classification of intraoperative difficulty. Differences in frequencies were evaluated with the the chi square and post hoc chi square tests or Fisher's exact test; logistic regression analysis was used to identify independent variables that were predictors of intraoperative complexity, postoperative morbidity, and length of stay. Results: A total of 1043 patient were included with male to female ratio of 1:2.5. Older age, male gender, and comorbidities were associated with higher Nassar score (P < .0001); Nassar 3 and 4 were predictors of postoperative morbidity (P < .05). The DC rate was 74.2% (Nassar 1), 75.8% (Nassar 2), 61.1% (Nassar 3), and 26.2% (Nassar 4), respectively. Age ≥60 years (P < .05), body mass index ≥35 (P < .05), and Nassar 3 and 4 (P < .05) were predictors of increased conversion from DC to inpatient (IP) stay. Conclusion: LC can be safely performed on a DC basis even when surgery is technically challenging. The need of IP stay can be predicted in comorbid old adult men with anticipated higher Nassar's score.
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Affiliation(s)
- Amira Orabi
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Davide Di Mauro
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Ikechukwu Njere
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Marco Ratano
- Department of Surgery, San Liberatore di Atri Hospital, Teramo, Italy
| | - Sankavi Thavakumar
- Department of Surgery, Nottingham Univeristy Hospital, Nottingham, United Kingdom
| | - Alex Reece-Smith
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Shahjehan Wajed
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Antonio Manzelli
- Department of Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
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13
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Cianci P, Restini E. Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches. World J Gastroenterol 2021; 27:4536-4554. [PMID: 34366622 PMCID: PMC8326257 DOI: 10.3748/wjg.v27.i28.4536] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/02/2021] [Accepted: 06/25/2021] [Indexed: 02/06/2023] Open
Abstract
Gallstone disease and complications from gallstones are a common clinical problem. The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment. Bile duct stones are a frequent condition associated with cholelithiasis. Amidst the total cholecystectomies performed every year for cholelithiasis, the presence of bile duct stones is 5%-15%; another small percentage of these will develop common bile duct stones after intervention. To avoid serious complications that can occur in choledocholithiasis, these stones should be removed. Unfortunately, there is no consensus on the ideal management strategy to perform such. For a long time, a direct open surgical approach to the bile duct was the only unique approach. With the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques, however, therapeutic choices have increased in number, and the management of this pathological situation has become multidisciplinary. To date, there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis, but a debate still exists on how to cure the two diseases at the same time. In the era of laparoscopy and mini-invasiveness, we can say that therapeutic approaches can be performed in two sessions or in one session. Comparison of these two approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay, and more cost benefits. The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology, clinical and diagnostic aspects, and possible treatments and their advantages and limitations.
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Affiliation(s)
- Pasquale Cianci
- Department of Surgery and Traumatology, Hospital Lorenzo Bonomo, Andria 76123, Italy
| | - Enrico Restini
- Department of Surgery and Traumatology, Hospital Lorenzo Bonomo, Andria 76123, Italy
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14
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Kawano F, Yoshioka R, Gyoda Y, Ichida H, Mizuno T, Ishii S, Fujisawa T, Imamura H, Mise Y, Isayama H, Saiura A. Laparoscopic cholecystectomy after endoscopic trans-papillary gallbladder stenting for acute cholecystitis: a pilot study of surgical feasibility. BMC Surg 2021; 21:184. [PMID: 33827521 PMCID: PMC8028236 DOI: 10.1186/s12893-021-01182-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/28/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Percutaneous transhepatic gallbladder drainage (PTGBD) is indicated for patients with acute cholecystitis (AC) who are not indicated for urgent surgery, but external tubes reduce quality of life (QOL) while waiting for elective surgery. The objective of the present study was to investigate the feasibility of laparoscopic cholecystectomy after endoscopic trans-papillary gallbladder stenting (ETGBS) comparing with after PTGBD. METHODS Intraoperative and postoperative outcomes of patients with ETGBS and PTGBD were retrospectively compared. RESULTS Eighteen ETGBS and ten PTGBD patients were compared. Differences in the duration of ETGBS and PTGBD [median 209 min (range 107-357) and median 161 min (range 130-273), respectively, P = 0.10], median blood loss [ETGBS 2 (range 2-180 ml) and PTGBD 24 (range 2-100 ml), P = 0.89], switch to laparotomy (ETGBS 11% and PTGBD 20%, P = 0.52), and median postoperative hospital stay [ETGBS 8 (range 4-24 days) and ETGBS 8 (range 4-16 days), P = 0.99]. Thickening of the cystic duct that occurred in 60% of the ETGBS patients and none of the PTGBD patients (P = 0.005) interfered with closure of the duct by clipping. No obstruction occurred in ETGBS patients. CONCLUSION ETGBS did not make laparoscopic cholecystectomy less feasible than after PTGBD. This is a pilot study, and further investigations are needed to validate the results of the present study.
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Affiliation(s)
- Fumihiro Kawano
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Ryuji Yoshioka
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yu Gyoda
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hirofumi Ichida
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Tomoya Mizuno
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Shigeto Ishii
- Department of Gastroenterology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Toshio Fujisawa
- Department of Gastroenterology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hiroshi Imamura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yoshihiro Mise
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
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15
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Ábrahám S, Németh T, Benkő R, Matuz M, Váczi D, Tóth I, Ottlakán A, Andrási L, Tajti J, Kovács V, Pieler J, Libor L, Paszt A, Simonka Z, Lázár G. Evaluation of the conversion rate as it relates to preoperative risk factors and surgeon experience: a retrospective study of 4013 patients undergoing elective laparoscopic cholecystectomy. BMC Surg 2021; 21:151. [PMID: 33743649 PMCID: PMC7981808 DOI: 10.1186/s12893-021-01152-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/11/2021] [Indexed: 01/11/2023] Open
Abstract
Background Our aim is to determine the relationships among patient demographics, patient history, surgical experience, and conversion rate (CR) during elective laparoscopic cholecystectomies (LCs). Methods We analyzed data from patients who underwent LC surgery between 2005 and 2014 based on patient charts and electronic documentation. CR (%) was evaluated in 4013 patients who underwent elective LC surgery. The relationships between certain predictive factors (patient demographics, endoscopic retrograde cholangiopancreatography (ERCP), acute cholecystitis (AC), abdominal surgery in the patient history, as well as surgical experience) and CR were examined by univariate analysis and logistic regression. Results In our sample (N = 4013), the CR was 4.2%. The CR was twice as frequent among males than among females (6.8 vs. 3.2%, p < 0.001), and the chance of conversion increased from 3.4 to 5.9% in patients older than 65 years. The detected CR was 8.8% in a group of patients who underwent previous ERCP (8.8 vs. 3.5%, p < 0.001). From the ERCP indications, most often, conversion was performed because of severe biliary tract obstruction (CR: 9.3%). LC had to be converted to open surgery after upper and lower abdominal surgeries in 18.8 and 4.8% cases, respectively. Both AC and ERCP in the patient history raised the CR (12.3%, p < 0.001 and 8.8%, p < 0.001). More surgical experience and high surgery volume were not associated with a lower CR prevalence. Conclusions Patient demographics (male gender and age > 65 years), previous ERCP, and upper abdominal surgery or history of AC affected the likelihood of conversion. More surgical experience and high surgery volume were not associated with a lower CR prevalence.
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Affiliation(s)
- Szabolcs Ábrahám
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Center, University of Szeged, Semmelweis u. 8, 6725, Szeged, Hungary.
| | - Tibor Németh
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Center, University of Szeged, Semmelweis u. 8, 6725, Szeged, Hungary
| | - Ria Benkő
- Department of Clinical Pharmacy, University of Szeged, Szeged, Hungary
| | - Mária Matuz
- Department of Clinical Pharmacy, University of Szeged, Szeged, Hungary
| | - Dániel Váczi
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Center, University of Szeged, Semmelweis u. 8, 6725, Szeged, Hungary
| | - Illés Tóth
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Center, University of Szeged, Semmelweis u. 8, 6725, Szeged, Hungary
| | - Aurél Ottlakán
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Center, University of Szeged, Semmelweis u. 8, 6725, Szeged, Hungary
| | - László Andrási
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Center, University of Szeged, Semmelweis u. 8, 6725, Szeged, Hungary
| | - János Tajti
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Center, University of Szeged, Semmelweis u. 8, 6725, Szeged, Hungary
| | - Viktor Kovács
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Center, University of Szeged, Semmelweis u. 8, 6725, Szeged, Hungary
| | - József Pieler
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Center, University of Szeged, Semmelweis u. 8, 6725, Szeged, Hungary
| | - László Libor
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Center, University of Szeged, Semmelweis u. 8, 6725, Szeged, Hungary
| | - Attila Paszt
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Center, University of Szeged, Semmelweis u. 8, 6725, Szeged, Hungary
| | - Zsolt Simonka
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Center, University of Szeged, Semmelweis u. 8, 6725, Szeged, Hungary
| | - György Lázár
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Center, University of Szeged, Semmelweis u. 8, 6725, Szeged, Hungary
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16
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Fong ML, Urriza Rodriguez D, Elberm H, Berry DP. Are Type and Screen Samples Routinely Necessary Before Laparoscopic Cholecystectomy? J Gastrointest Surg 2021; 25:447-451. [PMID: 31993966 DOI: 10.1007/s11605-020-04515-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/03/2020] [Indexed: 01/31/2023]
Abstract
AIMS Type and screen (T&S) samples are routinely requested before all laparoscopic cholecystectomies (LCs) at our centre despite the low reported risk of major vascular injury and peri-operative transfusion. Our retrospective case series aimed to identify local transfusion need to inform policy. METHODS Emergency and elective LC performed at a single tertiary centre between March 2014 and October 2016 (30 months) were analysed. This included all patients aged ≥ 16, and procedures converted to open where LC was the primary procedure. Peri-operative complications and transfusion data were obtained from electronic records. RESULTS In total, 1002 consecutive patients met inclusion criteria; 12 patients were transfused during index admission (1.20%). No patients required emergency transfusion or had major vascular injuries. Despite local policy, 106 patients (10.6%) did not have a valid T&S sample prior to their procedure. Transfused patients were more likely to be emergency admissions (n = 10/12). The most common indications for transfusion were pre-operative anaemia (n = 7/12) and septic coagulopathy (n = 2/12). CONCLUSIONS Peri-operative transfusions at our centre were low. No patients required intra-operative blood transfusions dependent on a pre-operative T&S sample. Patients requiring transfusion were predictable from their pre-operative clinical status. We propose that a highly selective T&S policy is safe and can reduce costs.
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Affiliation(s)
- M L Fong
- Department of Surgery, Southampton General Hospital, Tremona Rd, Southampton, SO16 6YD, UK.
| | - D Urriza Rodriguez
- Department of Surgery, Southampton General Hospital, Tremona Rd, Southampton, SO16 6YD, UK
| | - H Elberm
- Department of Surgery, Southampton General Hospital, Tremona Rd, Southampton, SO16 6YD, UK
| | - D P Berry
- Department of Surgery, Southampton General Hospital, Tremona Rd, Southampton, SO16 6YD, UK
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17
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Tongyoo A, Chotiyasilp P, Sriussadaporn E, Limpavitayaporn P, Mingmalairak C. The pre-operative predictive model for difficult elective laparoscopic cholecystectomy: A modification. Asian J Surg 2021; 44:656-661. [PMID: 33349555 DOI: 10.1016/j.asjsur.2020.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/19/2020] [Accepted: 11/22/2020] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Although LC is a common operation, difficult cases are still challenging. Several studies have identified factors for the difficulty and conversion. Many scoring systems have been established for pre-operative prediction. This study aimed to investigate significant factors and validity of Randhawa's model in our setting. METHODS This prospective study enrolled LC patients in Hepato-Pancreato-Biliary Surgery unit between March 2018 and October 2019. The difficulty of operation was categorized into 3 groups by intra-operative grading scale. Multivariate analysis was performed to define significant factors of very-difficult and converted cases. The difficulty predicted by Randhawa's model were compared with actual outcome. Area under ROC curve was calculated. RESULTS Among 152 patients, difficult and very-difficult groups were 59.2% and 15.1%, respectively. Sixteen cases needed conversion. Four factors (cholecystitis, ERCP, thickened wall, contracted gallbladder) for very-difficult group and 3 factors (obesity, biliary inflammation or procedure, contracted gallbladder) for conversion were significant. After some modification of Randhawa's model, the modified scoring system provided better prediction in terms of higher correlation coefficient (0.41 vs 0.35) and higher AUROC curve (0.82 vs 0.75) than original model. DISCUSSION Randhawa's model was feasible for pre-operative preparation. The modification of this model provided better prediction on difficult cases.
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Affiliation(s)
- Assanee Tongyoo
- Department of Surgery, Faculty of Medicine, Thammasat University, 99/209 Paholyotin Road, Klongluang, Pathumthani, 12120, Thailand.
| | - Parm Chotiyasilp
- Department of Surgery, Faculty of Medicine, Thammasat University, 99/209 Paholyotin Road, Klongluang, Pathumthani, 12120, Thailand
| | - Ekkapak Sriussadaporn
- Department of Surgery, Faculty of Medicine, Thammasat University, 99/209 Paholyotin Road, Klongluang, Pathumthani, 12120, Thailand
| | - Palin Limpavitayaporn
- Department of Surgery, Faculty of Medicine, Thammasat University, 99/209 Paholyotin Road, Klongluang, Pathumthani, 12120, Thailand
| | - Chatchai Mingmalairak
- Department of Surgery, Faculty of Medicine, Thammasat University, 99/209 Paholyotin Road, Klongluang, Pathumthani, 12120, Thailand
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18
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Balduzzi A, van der Heijde N, Alseidi A, Dokmak S, Kendrick ML, Polanco PM, Sandford DE, Shrikhande SV, Vollmer CM, Wang SE, Zeh HJ, Hilal MA, Asbun HJ, Besselink MG. Risk factors and outcomes of conversion in minimally invasive distal pancreatectomy: a systematic review. Langenbecks Arch Surg 2020; 406:597-605. [PMID: 33301071 PMCID: PMC8106568 DOI: 10.1007/s00423-020-02043-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 11/20/2020] [Indexed: 12/16/2022]
Abstract
Purpose The reported conversion rates for minimally invasive distal pancreatectomy (MIDP) range widely from 2 to 38%. The identification of risk factors for conversion may help surgeons during preoperative planning and patient counseling. Moreover, the impact of conversion on outcomes of MIDP is unknown. Methods A systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR). The PubMed, Cochrane, and Embase databases were searched for studies concerning conversion to open surgery in MIDP. Results Of the 828 studies screened, eight met the eligibility criteria, resulting in a combined dataset including 2592 patients after MIDP. The overall conversion rate was 17.1% (range 13.0–32.7%) with heterogeneity between studies associated with the definition of conversion adopted. Only one study divided conversion into elective and emergency conversion. The main indications for conversion were vascular involvement (23.7%), concern for oncological radicality (21.9%), and bleeding (18.9%). The reported risk factors for conversion included a malignancy as an indication for surgery, the proximity of the tumor to vascular structures in preoperative imaging, higher BMI or visceral fat, and multi-organ resection or extended resection. Contrasting results were seen in terms of blood loss and length of stay in comparing converted MIDP and completed MIDP patients. Conclusion The identified risk factors for conversion from this study can be used for patient selection and counseling. Surgeon experience should be considered when contemplating MIDP for a complex patient. Future studies should divide conversion into elective and emergency conversion.
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Affiliation(s)
- A Balduzzi
- Department of Surgery, University Hospital, Verona, Italy
| | - N van der Heijde
- Department of Surgery, Southampton University Hospital, Southampton, UK.,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Alseidi
- Department of Surgery, University of California, San Francisco, CA, USA
| | - S Dokmak
- Department of Surgery, Beaujon Hospital, Paris, France
| | - M L Kendrick
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - P M Polanco
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - D E Sandford
- Department of Surgery, Washington University, St. Louis, MO, USA
| | - S V Shrikhande
- Department of Surgery, Tata Memorial Hospital, Mumbai, India
| | - C M Vollmer
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - S E Wang
- Department of Surgery, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - H J Zeh
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - M Abu Hilal
- Department of Surgery, Southampton University Hospital, Southampton, UK.,Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - H J Asbun
- Hepatobiliary and Pancreas, Miami Cancer Institute, Miami, FL, USA
| | - M G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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19
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Predicting the difficult laparoscopic cholecystectomy: development and validation of a pre-operative risk score using an objective operative difficulty grading system. Surg Endosc 2020; 34:4549-4561. [PMID: 31732855 DOI: 10.1007/s00464-019-07244-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/28/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND The prediction of a difficult cholecystectomy has traditionally been based on certain pre-operative clinical and imaging factors. Most of the previous literature reported small patient cohorts and have not used an objective measure of operative difficulty. The aim of this study was to develop a pre-operative score to predict difficult cholecystectomy, as defined by a validated intra-operative difficulty grading scale. METHOD Two cohorts from prospectively maintained databases of patients who underwent laparoscopic cholecystectomy were analysed: the CholeS Study (8755 patients) and a single surgeon series (4089 patients). Factors potentially predictive of difficulty were correlated to the Nassar intra-operative difficulty scale. A multivariable binary logistic regression analysis was then used to identify factors that were independently associated with difficult laparoscopic cholecystectomy, defined as operative difficulty grades 3 to 5. The resulting model was then converted to a risk score, and validated on both internal and external datasets. RESULT Increasing age and ASA classification, male gender, diagnosis of CBD stone or cholecystitis, thick-walled gallbladders, CBD dilation, use of pre-operative ERCP and non-elective operations were found to be significant independent predictors of difficult cases. A risk score based on these factors returned an area under the ROC curve of 0.789 (95% CI 0.773-0.806, p < 0.001) on external validation, with 11.0% versus 80.0% of patients classified as low versus high risk having difficult surgeries. CONCLUSION We have developed and validated a pre-operative scoring system that uses easily available pre-operative variables to predict difficult laparoscopic cholecystectomies. This scoring system should assist in patient selection for day case surgery, optimising pre-operative surgical planning (e.g. allocation of the procedure to a suitably trained surgeon) and counselling patients during the consent process. The score could also be used to risk adjust outcomes in future research.
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20
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Vaccari S, Cervellera M, Lauro A, Palazzini G, Cirocchi R, Gjata A, Dibra A, Ussia A, Brighi M, Isaj E, Agastra E, Casella G, Di Matteo FM, Santoro A, Falvo L, Tarroni D, D'andrea V, Tonini V. Laparoscopic cholecystectomy: which predicting factors of conversion? Two Italian center's studies. MINERVA CHIR 2020; 75:141-152. [PMID: 32138473 DOI: 10.23736/s0026-4733.20.08228-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy represents the gold standard technique for the treatment of lithiasic gallbladder disease. Although it has many advantages, laparoscopic cholecystectomy is not risk-free and in special situations there is a need for conversion into an open procedure, in order to minimize postoperative complications and to complete the procedure safely. The aim of this study was to identify factors that can predict the conversion to open cholecystectomy. METHODS We analyzed 1323 patients undergoing laparoscopic cholecystectomy over the last five years at St. Orsola University Hospital-Bologna and Umberto I University Hospital-Rome. Among these, 116 patients (8.7%) were converted into laparotomic cholecystectomy. Clinical, demographic, surgical and pathological data from these patients were included in a prospective database. A univariate analysis was performed followed by a multivariate logistic regression. RESULTS On univariate analysis, the factors significantly correlated with conversion to open were the ASA score higher than 3 and the comorbidity, specifically cardiovascular disease, diabetes and chronic renal failure (P<0.001). Patients with a higher mean age had a higher risk of conversion to open (61.9±17.1 vs. 54.1±15.2, P<0.001). Previous abdominal surgery and previous episodes of cholecystitis and/or pancreatitis were not statistically significant factors for conversion. There were four deaths in the group of converted patients and two in the laparoscopic group (P<0.001). Operative morbility was higher in the conversion group (22% versus 8%, P<0.001). Multivariate analysis showed that the factors significantly correlated to conversion were: age <65 years old (P=0.031 OR: 1.6), ASA score 3-4 (P=0.013, OR:1.8), history of ERCP (P=0.16 OR:1.7), emergency procedure (P=0.011, OR:1.7); CRP higher than 0,5 (P<0.001, OR:3.3), acute cholecystitis (P<0.001, OR:1.4). Further multivariate analysis of morbidity, postoperative mortality and home discharge showed that conversion had a significant influence on overall post-operative complications (P=0.011, OR:2.01), while mortality (P=0.143) and discharge at home were less statistically influenced. CONCLUSIONS Our results show that most of the independent risk factors for conversion cannot be modified by delaying surgery. Many factors reported in the literature did not significantly impact conversion rates in our results.
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Affiliation(s)
- Samuele Vaccari
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy
| | - Maurizio Cervellera
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy
| | - Augusto Lauro
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy -
| | - Giorgio Palazzini
- Department of Surgical Sciences, Umberto I University Hospital, Sapienza University, Rome, Italy
| | | | - Arben Gjata
- Department of General Surgery, University of Medicine, Tirana, Albania
| | - Arvin Dibra
- Department of General Surgery, University of Medicine, Tirana, Albania
| | - Alessandro Ussia
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy
| | - Manuela Brighi
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy
| | - Elton Isaj
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy
| | - Ervis Agastra
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy
| | - Giovanni Casella
- Department of Surgical Sciences, Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Filippo M Di Matteo
- Department of Surgical Sciences, Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Alberto Santoro
- Department of Surgical Sciences, Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Laura Falvo
- Department of Surgical Sciences, Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Danilo Tarroni
- Department of Surgical Sciences, Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Vito D'andrea
- Department of Surgical Sciences, Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Valeria Tonini
- Department of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum, Bologna, Italy
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Chand P, Kaur M, Bhandari S. Preoperative Predictors of Level of Difficulty of Laparoscopic Cholecystectomy. Niger J Surg 2019; 25:153-157. [PMID: 31579368 PMCID: PMC6771185 DOI: 10.4103/njs.njs_3_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic gallbladder stone disease. This is due to its safety, reliability, cost-effectiveness, negligible mortality, shorter duration of hospitalization (early return to work), better cosmesis, minimal wound complications, and temporary paralytic ileus. In spite of these, conversion to open cholecystectomy which is sometimes required in difficult cases could be challenging. Aims and Objectives The aim of the present study is to aid the prediction of difficult cases undergoing LC, thereby better selection of patients with the least conversion rates. Materials and Methods This prospective study was conducted on 100 consecutive patients with cholecystitis, over a 2-year period from January 1, 2017, to December 31, 2018, having undergone LC. Various preoperative parameters, including age, sex, previous attacks of cholecystitis, deranged liver functions, and ultrasonographic findings, were analyzed for their effects for predicting the level of difficulty during LC. Results Twenty-five percent of the cases were correctly predicted as difficult in the age group of >65 years. Cholecystitis was more common (79%) in females, but difficulties were encountered more frequently while performing LC in males. Abnormal serum hepatic and pancreatic enzyme profiles were associated with difficulties during surgery as about 83.3% of the patients predicted as moderately difficult peroperatively had deranged liver functions. The preoperative ultrasonography findings were helpful for predicting the degree of difficulty involved in the procedure. About 33.3% of the patients that had pericholecystic fluid on ultrasound preoperatively were correctly predicted to have moderately difficult surgeries. The Chi-square test and P value were used to determine statistical significance. Conclusions Females, the absence of previous repeated attacks of cholecystitis and hospitalizations, no upper abdominal surgery in the past, normal liver function tests, normal amylase levels, nondistended and uncontracted gallbladder, absence of pericholecystic collection, afebrile, and single stone are positive preoperative predictors of safe LC in symptomatic gallbladder stone disease.
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Affiliation(s)
- Prem Chand
- Department of Surgery, Government Medical College, Patiala, Punjab, India
| | - Manpreet Kaur
- Department of Surgery, Government Medical College, Patiala, Punjab, India
| | - Sumit Bhandari
- Department of Surgery, Government Medical College, Patiala, Punjab, India
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Predictive Factors for Long Operative Duration in Patients Undergoing Laparoscopic Cholecystectomy After Endoscopic Retrograde Cholangiography for Combined Choledochocystolithiasis. Surg Laparosc Endosc Percutan Tech 2018; 27:491-496. [PMID: 29112097 PMCID: PMC5732633 DOI: 10.1097/sle.0000000000000461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE Choledochocystolithiasis and its associated complications such as cholangitis and pancreatitis are managed by endoscopic retrograde cholangiography (ERC), with endoscopic stone extraction followed by laparoscopic cholecystectomy (LC). However, affected patients present with complex conditions linked to operative difficulties in performing LC. The aim of this study was to elucidate the predictive factors for a prolonged LC procedure following ERC for treating patients with choledochocystolithiasis. MATERIALS AND METHODS The medical records of 109 patients who underwent LC after ERC for choledochocystolithiasis from September 2012 to August 2014 were evaluated retrospectively. The cases were divided into long and short operative duration groups using a cutoff operative time of 90 minutes. We used univariate and multivariate analyses to investigate predictive factors associated with long operative duration according to clinical variables, ERC-related factors, and peak serum levels of laboratory test values between the initial presentation and LC (intervening period). RESULTS Seventeen patients needed >90 min to complete LC. The presence of acute cholecystitis, placement of percutaneous transhepatic gallbladder drainage, higher peak serum white blood cell count and levels of C-reactive protein (CRP), and lower peak serum levels of lipase during the intervening period were associated with prolonged operative duration. Multivariate analysis showed that the independent predictive factors for long operative duration were the presence of acute cholecystitis (hazard ratio, 5.418; P=0.016) and higher peak levels of CRP (hazard ratio, 1.077; P=0.022). CONCLUSION When patients with choledochocystolithiasis are scheduled for LC after ERC, the presence of acute cholecystitis and high CRP levels during the intervening period could predict a protracted operation.
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23
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Preoperative risk factors for conversion and learning curve of minimally invasive distal pancreatectomy. Surgery 2017; 162:1040-1047. [DOI: 10.1016/j.surg.2017.07.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/19/2017] [Accepted: 07/20/2017] [Indexed: 01/28/2023]
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Hu ASY, Menon R, Gunnarsson R, de Costa A. Risk factors for conversion of laparoscopic cholecystectomy to open surgery - A systematic literature review of 30 studies. Am J Surg 2017; 214:920-930. [PMID: 28739121 DOI: 10.1016/j.amjsurg.2017.07.029] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 07/10/2017] [Accepted: 07/16/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND The study aims to evaluate the methodological quality of publications relating to predicting the need of conversion from laparoscopic to open cholecystectomy and to describe identified prognostic factors. METHOD Only English full-text articles with their own unique observations from more than 300 patients were included. Only data using multivariate analysis of risk factors were selected. Quality assessment criteria stratifying the risk of bias were constructed and applied. RESULTS The methodological quality of the studies were mostly heterogeneous. Most studies performed well in half of the quality criteria and considered similar risk factors, such as male gender and old age, as significant. Several studies developed prediction models for risk of conversion. Independent risk factors appeared to have additive effects. CONCLUSION A detailed critical review of studies of prediction models and risk stratification for conversion from laparoscopic to open cholecystectomy is presented. One study is identified of high quality with a potential to be used in clinical practice, and external validation of this model is recommended.
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Affiliation(s)
- Alan Shiun Yew Hu
- Cairns Clinical School, College of Medicine and Dentistry, James Cook University, QLD, 4870, Australia.
| | - R Menon
- Cairns Clinical School, College of Medicine and Dentistry, James Cook University, QLD, 4870, Australia.
| | - R Gunnarsson
- Cairns Clinical School, College of Medicine and Dentistry, James Cook University, QLD, 4870, Australia; Research and Development Unit, Primary Health Care and Dental Care, Narhalsan, Southern Älvsborg County, Region Västra Götaland, Sweden; Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - A de Costa
- Cairns Clinical School, College of Medicine and Dentistry, James Cook University, QLD, 4870, Australia.
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Sutcliffe RP, Hollyman M, Hodson J, Bonney G, Vohra RS, Griffiths EA. Preoperative risk factors for conversion from laparoscopic to open cholecystectomy: a validated risk score derived from a prospective U.K. database of 8820 patients. HPB (Oxford) 2016; 18:922-928. [PMID: 27591176 PMCID: PMC5094477 DOI: 10.1016/j.hpb.2016.07.015] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 07/25/2016] [Accepted: 07/28/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy is commonly performed, and several factors increase the risk of open conversion, prolonging operating time and hospital stay. Preoperative stratification would improve consent, scheduling and identify appropriate training cases. The aim of this study was to develop a validated risk score for conversion for use in clinical practice. PATIENTS AND METHODS Preoperative patient and disease-related variables were identified from a prospective cholecystectomy database (CholeS) of 8820 patients, divided into main and validation sets. Preoperative predictors of conversion were identified by multivariable binary logistic regression. A risk score was developed and validated using a forward stepwise approach. RESULTS Some 297 procedures (3.4%) were converted. The risk score was derived from six significant predictors: age (p = 0.005), sex (p < 0.001), indication for surgery (p < 0.001), ASA (p < 0.001), thick-walled gallbladder (p = 0.040) and CBD diameter (p = 0.004). Testing the score on the validation set yielded an AUROC = 0.766 (p < 0.001), and a score >6 identified patients at high risk of conversion (7.1% vs. 1.2%). CONCLUSION This validated risk score allows preoperative identification of patients at six-fold increased risk of conversion to open cholecystectomy.
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Affiliation(s)
- Robert P Sutcliffe
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Marianne Hollyman
- West Midlands Research Collaborative, Academic Department of Surgery, Birmingham University, UK
| | - James Hodson
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Glenn Bonney
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ravi S Vohra
- Nottingham Oesophago-Gastric Unit, Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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26
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Beksac K, Turhan N, Karaagaoglu E, Abbasoglu O. Risk Factors for Conversion of Laparoscopic Cholecystectomy to Open Surgery: A New Predictive Statistical Model. J Laparoendosc Adv Surg Tech A 2016; 26:693-6. [PMID: 27385483 DOI: 10.1089/lap.2016.0008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Although laparoscopic cholecystectomy is currently the standard treatment for benign gallbladder pathologies, some cases still require conversion to open cholecystectomy. Since open cholecystectomy has a significantly higher morbidity rate and a lengthier stay in the hospital compared with laparoscopic surgery, predicting this conversion would grant a great advantage in the management of cholecystitis. Therefore, in this study, we aimed to develop a predictive statistical model. MATERIALS AND METHODS Between August 2006 and January 2011, 1335 laparoscopic cholecystectomies were initiated at the General Surgery Department of Hacettepe University. One hundred four of these cases were started as laparoscopic surgeries, but converted to open cholecystectomies. In our study, we randomly chose 104 laparoscopically completed cases and compared them with the 104 converted cases. We used 31 parameters, including demographics, ultrasonographic findings, and laboratory values, to compare groups. These parameters were later included in a logistic regression analysis to create a statistical model that predicts conversion to open cholecystectomy. RESULTS Among the 1335 laparoscopically started cases, 104 (7.7%) were converted to open surgery. In our study, we found age, gender, ultrasonographic findings of acute cholecystitis, history of choledocolithiasis, history of abdominal surgery, and alkaline phosphatase (ALP) levels to be significant risk factors. By using a receiver operating characteristic curve, we found that the risk significantly increases after 55 years of age and an ALP over 80 IU/L. DISCUSSION Using four parameters-age, gender, history of abdominal surgery, and ALP-in our statistical model, we were able to predict the conversion from laparoscopic to open cholecystectomy with 70% sensitivity and 79% specificity.
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Affiliation(s)
- Kemal Beksac
- 1 Department of General Surgery, Hacettepe University , Ankara, Turkey
| | - Nihan Turhan
- 1 Department of General Surgery, Hacettepe University , Ankara, Turkey
| | - Ergun Karaagaoglu
- 2 Department of Biostatistics, Hacettepe University , Ankara, Turkey
| | - Osman Abbasoglu
- 1 Department of General Surgery, Hacettepe University , Ankara, Turkey
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Tosun A, Hancerliogullari KO, Serifoglu I, Capan Y, Ozkaya E. Role of preoperative sonography in predicting conversion from laparoscopic cholecystectomy to open surgery. Eur J Radiol 2014; 84:346-349. [PMID: 25579475 DOI: 10.1016/j.ejrad.2014.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 12/05/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy is the first step treatment in cholelithiasis. The purpose of this study was to establish a radiologic view on prediction of conversion from laparoscopic cholecystectomy to open surgery. METHODS This study included 176 patients who had undergone laparoscopic cholecystectomy. Preoperative ultrasonographic findings were assessed and we gave points to each finding according to results from correlation analysis. After the scoring we investigated the relationship between ultrasonographic findings and conversion from laparoscopic cholecystectomy to open surgery. RESULTS Scoring significantly predicted failure in laparoscopic approach (AUC=0.758, P=0.003,). Optimal cut off score was found to be 1.95 with 67% sensitivity and 78% specificity. Score>1.95 was a risk factor for failure in laparoscopic approach [odds ratio=7.1(95% CI,2-24.9, P=0.002)]. There were 8 subjects out of 36(22%) with high score underwent open surgery while 4 out of 128 (3%) subjects with low score needed open surgery (p=0.002). Negative predictive value of 128/132=97%. Mean score of whole study population was 1.28 (range 0-8.8) and mean score of subjects underwent open surgery was 3.6 while it was 1.1 in successful laparoscopic approach group (p<0.001). Mean Age and BMI were similar between groups (p>0.05). Sex of subjects did not affect the success of surgery (p>0.05). CONCLUSION The contribution of preoperative ultrasonography is emphasized in many studies. Our study suggests quantitative results on conversion from laparoscopic cholecystectomy to open surgery. We believe that radiologists have to indicate the risk of conversion in their ultrasonography reports.
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Affiliation(s)
| | | | | | - Yavuz Capan
- Gaziantep Primer Hospital, Department of Surgery
| | - Enis Ozkaya
- Dr. Sami Ulus Maternity and Children's Health Training and Research Hospital, Department of Obstetrics and Gynecology
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ElGeidie AA. Single-session minimally invasive management of common bile duct stones. World J Gastroenterol 2014; 20:15144-15152. [PMID: 25386063 PMCID: PMC4223248 DOI: 10.3748/wjg.v20.i41.15144] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 03/06/2014] [Accepted: 06/26/2014] [Indexed: 02/06/2023] Open
Abstract
Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones. To avoid serious complications, these stones should be removed. There is no consensus about the ideal management strategy for such patients. Traditionally, open surgery was offered but with the advent of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) minimally invasive approach had nearly replaced laparotomy because of its well-known advantages. Minimally invasive approach could be done in either two-session (preoperative ERCP followed by LC or LC followed by postoperative ERCP) or single-session (laparoscopic common bile duct exploration or LC with intraoperative ERCP). Most recent studies have found that both options are equivalent regarding safety and efficacy but the single-session approach is associated with shorter hospital stay, fewer procedures per patient, and less cost. Consequently, single-session option should be offered to patients with cholecysto-choledocholithiaisis provided that local resources and expertise do exist. However, the management strategy should be tailored according to many variables, such as available resources, experience, patient characteristics, clinical presentations, and surgical pathology.
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Vivek MAKM, Augustine AJ, Rao R. A comprehensive predictive scoring method for difficult laparoscopic cholecystectomy. J Minim Access Surg 2014; 10:62-7. [PMID: 24761077 PMCID: PMC3996733 DOI: 10.4103/0972-9941.129947] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 06/15/2013] [Indexed: 01/11/2023] Open
Abstract
CONTEXT: Laparoscopic cholecystectomy (LC) is the gold standard cholecystectomy. LC is the most common difficult laparoscopic surgery performed by surgeons today. The factors leading to difficult laparoscopic cholecystectomy can be predicted. AIMS: To develop a scoring method that predicts difficult laparoscopic cholecystectomy. SETTINGS AND DESIGN: Bidirectional prospective study in a medical college setup. MATERIALS AND METHODS: Following approval from the institutional ethical committee, cases from the three associated hospitals in a medical college setup, were collected using a detailed proforma stating the parameters of difficulty in laparoscopic cholecystectomy. Study period was between May 10 and June 12. Preoperative, sonographic and intraoperative criteria were considered. STATISTICAL ANALYSIS USED: Chi Square test and Receiver Operater Curve (ROC) analysis. RESULTS: Total 323 patients were included. On analysis, elderly patients, males, recurrent cholecystitis, obese patients, previous surgery, patients who needed preoperative Endoscopic retrograde cholangiopancreatography (ERCP), abnormal serum hepatic and pancreatic enzyme profiles, distended or contracted gall bladder, intra-peritoneal adhesions, structural anomalies or distortions and the presence of a cirrhotic liver on ultrasonography (USG) were identified as predictors of difficult LC. A scoring system tested against the same sample proved to be effective. A ROC analysis was done with area under receiver operator curve of 0.956. A score above 9 was considered difficult with sensitivity of 85% and specificity of 97.8%. CONCLUSIONS: This study demonstrates that a scoring system predicting the difficulty in LC is feasible. There is scope for further refinement to make the same less cumbersome and easier to handle. Further studies are warranted in this direction.
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Affiliation(s)
| | - Alfred Joseph Augustine
- Department of Surgery, Kasturba Medical College, Manipal University, Mangalore, Karnataka - 575 001, India
| | - Ranjith Rao
- Department of Surgery, Kasturba Medical College, Manipal University, Mangalore, Karnataka - 575 001, India
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30
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Daskalaki D, Fernandes E, Wang X, Bianco FM, Elli EF, Ayloo S, Masrur M, Milone L, Giulianotti PC. Indocyanine green (ICG) fluorescent cholangiography during robotic cholecystectomy: results of 184 consecutive cases in a single institution. Surg Innov 2014; 21:615-21. [PMID: 24616013 DOI: 10.1177/1553350614524839] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND/AIM Laparoscopic cholecystectomy is currently the gold standard treatment for gallstone disease. Bile duct injury is a rare and severe complication of this procedure, with a reported incidence of 0.4% to 0.8% and is mostly a result of misperception and misinterpretation of the biliary anatomy. Robotic cholecystectomy has proven to be a safe and feasible approach. One of the latest innovations in minimally invasive technology is fluorescent imaging using indocyanine green (ICG). The aim of this study is to evaluate the efficacy of ICG and the Da Vinci Fluorescence Imaging Vision System in real-time visualization of the biliary anatomy. METHODS A total of 184 robotic cholecystectomies with ICG fluorescence cholangiography were performed between July 2011 and February 2013. All patients received a dose of 2.5 mg of ICG 45 minutes prior to the beginning of the surgical procedure. The procedures were multiport or single port depending on the case. RESULTS No conversions to open or laparoscopic surgery occurred in this series. The overall postoperative complication rate was 3.2%. No biliary injuries occurred. ICG fluorescence allowed visualization of at least 1 biliary structure in 99% of cases. The cystic duct, the common bile duct, and the common hepatic duct were successfully visualized with ICG in 97.8%, 96.1%, and 94% of cases, respectively. CONCLUSIONS ICG fluorescent cholangiography during robotic cholecystectomy is a safe and effective procedure that helps real-time visualization of the biliary tree anatomy.
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Affiliation(s)
- Despoina Daskalaki
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Eduardo Fernandes
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Xiaoying Wang
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | | | | | - Subashini Ayloo
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Mario Masrur
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Luca Milone
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
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Sreeramulu PN, Agrawal V. Laparoscopic cholecystectomy: Our experience in a rural setup. MEDICAL JOURNAL OF DR. D.Y. PATIL UNIVERSITY 2014. [DOI: 10.4103/0975-2870.122767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Risk Factors for Conversion from Laparoscopic to Open Surgery: Analysis of 2138 Converted Operations in the American College of Surgeons National Surgical Quality Improvement Program. Am Surg 2013. [DOI: 10.1177/000313481307900930] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Minimal access procedures have influenced surgical practice and patient expectations. Risk of laparoscopic conversion to open surgery is frequently cited but vaguely quantified. The present study examines three common procedures to identify risk factors for laparoscopic conversion to open (LCO) events. Cross-sectional analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP; 2005 to 2009) identified cases with laparoscopic procedure codes for appendectomy, cholecystectomy, and bariatric procedures. The primary outcome was conversion of a laparoscopic procedure to its open equivalent. Summary statistics for laparoscopic and LCO groups were compared and logistic regression analysis was used to estimate patient and operative risk factors for conversion. Of 176,014 selected laparoscopic operations, 2,138 (1.2%) were converted. Most patients were female (68%) and white (71.2%); mean age was 45.1 years. LCO cholecystectomy was significantly more likely (n = 1526 [1.9%]) and LCO bariatric procedures were less likely (n = 121 [0.3%]); appendectomy was intermediate (n = 491 [1.0%], P < 0.001). Patient factors associated with LCO included male sex ( P < 0.001), age 30 years or older ( P < 0.025), American Society of Anesthesiologists Class 2 to 4 ( P < 0.001), obesity ( P < 0.01), history of bleeding disorder ( P = 0.036), or preoperative systemic inflammatory response syndrome or sepsis ( P < 0.001). LCO was associated with greater incidence of postoperative complications, including death, organ space surgical site infection, sepsis, wound dehiscence, and return to the operating room ( P < 0.001). Overall LCO incidence is low in hospitals participating in ACS-NSQIP. Conversion risk factors include patient age, sex, obesity, and preoperative comorbidity as well as the procedure performed. This information should be valuable to clinicians in discussing conversion risk with patients.
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Malik AM, Laghari AA, Mallah Q, Hashmi F, Sheikh U, Talpur KAH. [Not Available]. J Minim Access Surg 2013; 4:5-8. [PMID: 19547669 PMCID: PMC2699055 DOI: 10.4103/0972-9941.40990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Accepted: 01/08/2008] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To deteremine the incidence, nature and management of extra-biliary complications of laparoscopic cholecystectomy. MATERIALS AND METHODS This study presents a retrospective analysis of extra-biliary complications occuring during 1046 laparoscopic cholecystectomies performed from August 2003 to December 2006. The study population included all the patients with symptomatic gallstone disease in whom laparoscopic cholecystectomy was performed. The extra-biliary complications were divided into two distinct categories: (i) Procedure related and (ii) Access related. RESULTS The incidence of access-related complications was 3.77% and that of procedure-related complications was 6.02%. Port-site bleeding was troublesome at times and demanded a re-do laparoscopy or conversion. Small bowel laceration occurred in two patients where access was achieved by closed technique. Five cases of duodenal and two of colonic perforations were the major complications encountered during dissection in the area of Calot's triangle. In 21 (2%) patients the procedure was converted to open surgery due to different complications. Biliary complications occurred in 2.6% patients in the current series. CONCLUSION Major extra-biliary complications are as frequent as the biliary complications and can be life-threatening. An early diagnosis is critical to their management.
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Affiliation(s)
- Arshad M Malik
- Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro, Hyderabad, Pakistan
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Ashitate Y, Stockdale A, Choi HS, Laurence RG, Frangioni JV. Real-time simultaneous near-infrared fluorescence imaging of bile duct and arterial anatomy. J Surg Res 2012; 176:7-13. [PMID: 21816414 PMCID: PMC3212656 DOI: 10.1016/j.jss.2011.06.027] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 06/08/2011] [Accepted: 06/13/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND We hypothesized that two independent wavelengths of near-infrared (NIR) fluorescent light could be used to identify bile ducts and hepatic arteries simultaneously, and intraoperatively. MATERIALS AND METHODS Three different combinations of 700 and 800 nm fluorescent contrast agents specific for bile ducts and arteries were injected into N = 10 35-kg female Yorkshire pigs intravenously. Combination 1 (C-1) was methylene blue (MB) for arterial imaging and indocyanine green (ICG) for bile duct imaging. Combination 2 (C-2) was ICG for arterial imaging and MB for bile duct imaging. Combination 3 (C-3) was a newly developed, zwitterionic NIR fluorophore ZW800-1 for arterial imaging and MB for bile duct imaging. Open and minimally invasive surgeries were imaged using the fluorescence-assisted resection and exploration (FLARE) surgical imaging system and minimally invasive FLARE (m-FLARE) imaging systems, respectively. RESULTS Although the desired bile duct and arterial anatomy could be imaged with contrast-to-background ratios (CBRs) ≥ 6 using all three combinations, each one differed significantly in terms of repetition and prolonged imaging. ICG injection resulted in high CBR of the liver and common bile duct (CBD) and prolonged imaging time (120 min) of the CBD (C-1). However, because ICG also resulted in high background of liver and CBD relative to arteries, ICG produced a lower arterial CBR (C-2) at some time points. C-3 provided the best overall performance, although C-2, which is clinically available, did enable effective laparoscopy. CONCLUSIONS We demonstrate that dual-channel NIR fluorescence imaging provides simultaneous, real-time, and high resolution identification of bile ducts and hepatic arteries during biliary tract surgery.
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Affiliation(s)
- Yoshitomo Ashitate
- Department of Medicine, Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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A 10-step intraoperative surgical checklist (ISC) for laparoscopic cholecystectomy-can it really reduce conversion rates to open cholecystectomy? J Gastrointest Surg 2012; 16:1318-23. [PMID: 22528572 DOI: 10.1007/s11605-012-1886-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 04/03/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The recent introduction of a Surgical Safety Checklist has significantly reduced the morbidity and mortality of surgery. Such a simple measure that can impact so highly on surgical outcomes causes all surgeons to pause for thought. This paper documents the introduction of a 10-step intraoperative surgical checklist (ISC) to standardize performance, decision-making, and training during laparoscopic cholecystectomy (LC). The checklist's impact on conversion rates to open cholecystectomy (OC) is presented. METHODS In 2004, a 10-step ISC was introduced by a single consultant surgeon for the performance of LCs. Data were collected comparing LCs between 1999-2003 (period 1) and 2004-2008 (period 2). Data on sex, age, American Society of Anesthesiology grade, previous abdominal surgery, severity of gallbladder pathology, and conversion to OC were recorded. The chi-squared test with Yates correction was used to compare groups. RESULTS In total, 637 LCs were performed, 277 during period 1 and 360 during period 2. Risk factors for conversion (gender, age, previous abdominal surgery, and severity of gallbladder pathology) were not significantly different in the two periods studied. The overall conversion rate to OC fell significantly in period 2 (p=0.001). Subgroup analysis also showed a significant reduction in conversion rates in female patients (p=0.002) and patients with grades III and IV gallbladder disease (p=0.001). CONCLUSIONS The introduction of a 10-step ISC was temporally related to reduced conversion rates to OC. The standardization of a frequently performed operation such as a LC that could potentially lead to an impact as great the one we observed warrants further attention in prospective, appropriately designed studies.
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The degree of gallbladder wall thickness and its impact on outcomes after laparoscopic cholecystectomy. Surg Endosc 2012; 26:3174-9. [PMID: 22538700 DOI: 10.1007/s00464-012-2310-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Accepted: 04/04/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy is the gold-standard procedure for management of symptomatic gallstone disease. Increased rates of conversion to an open procedure, increased postoperative complications, and longer lengths of stay are seen in thick-walled gallbladders. Previous studies have only evaluated gallbladder walls as being thick or not thick, without looking at the degree of thickness. We hypothesized that, the more severe the wall thickening, the greater the chance of conversions and complications, and the longer the lengths of stay. METHODS All attempted laparoscopic cholecystectomies in our institution between 2006 and 2009 were retrospectively reviewed. Patients undergoing cholecystectomy for reasons other than gallstones (e.g., polyps or cancer) and those without preoperative ultrasounds were excluded. Patients were divided into four groups based on the degree of gallbladder wall thickness: normal (1-2 mm), mildly thickened (3-4 mm), moderately thickened (5-6 mm), and severely thickened (7 mm and above). Outcomes were compared amongst the groups. RESULTS 874 patients were included in the study. There were 68 conversions (7.8 %) and 58 complications (6.6 %). The incidence of conversions was 3.1, 5.1, 14.9, and 16.8 % in the four groups, respectively (p < 0.001, χ (2)), and the incidence of complications was 1.8, 6.7, 9.1, and 13.1 %, respectively (p = 0.001, χ (2)). The mean (± standard deviation, SD) length of stay in days was 1.09 ± 1.42, 1.83 ± 3.24, 2.54 ± 3.40 and 3.54 ± 4.61, respectively [p < 0.001, analysis of variance (ANOVA)]. CONCLUSIONS A greater degree of gallbladder wall thickness is associated with an increased risk of conversion, increased postoperative complications, and longer lengths of stay. Classifying patients according to degree of gallbladder wall thickness gives more accurate assessment of the risk of surgery, as well as potential outcomes.
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Kaushik R. Bleeding complications in laparoscopic cholecystectomy: Incidence, mechanisms, prevention and management. J Minim Access Surg 2011; 6:59-65. [PMID: 20877476 PMCID: PMC2938714 DOI: 10.4103/0972-9941.68579] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Accepted: 06/16/2010] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) has established itself firmly as the 'gold standard' for the treatment of gallstone disease, but it can, at times, be associated with significant morbidity and mortality. Existing literature has focused almost exclusively on the biliary complications of this procedure, but other complications such as significant haemorrhage can also be encountered, with an immediate mortality if not recognized and treated in a timely manner. MATERIALS AND METHODS Publications in English language literature that have reported the complication of bleeding during or after the performance of LC were identified and accessed. The results thus obtained were tabulated and analyzed to get a true picture of this complication, its mechanism and preventive measures. RESULTS Bleeding has been reported to occur with an incidence of up to nearly 10% in various series, and can occur at any time during LC (during trocar insertion, dissection technique or slippage of clips/ ligatures) or in the postoperative period. It can range from minor haematomas to life-threatening injuries to major intra-abdominal vessels (such as aorta, vena cava and iliacs). CONCLUSION Good surgical technique, awareness and early recognition and management of such cases are keys to success when dealing with this problem.
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Affiliation(s)
- Robin Kaushik
- Department of Surgery, Government Medical College and Hospital, Chandigarh, India
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Kanakala V, Borowski DW, Pellen MGC, Dronamraju SS, Woodcock SAA, Seymour K, Attwood SEA, Horgan LF. Risk factors in laparoscopic cholecystectomy: a multivariate analysis. Int J Surg 2011; 9:318-23. [PMID: 21333763 DOI: 10.1016/j.ijsu.2011.02.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2010] [Revised: 01/10/2011] [Accepted: 02/04/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is the operation of choice in the treatment of symptomatic gallstone disease. The aim of this study is to identify risk factors for LC, outcomes include operating time, length of stay, conversion rate, morbidity and mortality. METHODS All patients undergoing LC between 1998 and 2007 in a single district general hospital. Risk factors were examined using uni- and multivariate analysis. RESULTS 2117 patients underwent LC, with 1706 (80.6%) patients operated on electively. Male patients were older, had more co-morbidity and more emergency surgery than females. The median post-operative hospital stay was one day, and was positively correlated with the complexity of surgery. Conversion rates were higher in male patients (OR 1.47, p = 0.047) than in females, and increased with co-morbidity. Emergency surgery (OR 1.75, p = 0.005), male gender (OR 1.68, p = 0.005), increasing co-morbidity and complexity of surgery were all positively associated with the incidence of complications (153/2117 [7.2%]), whereas only male gender was significantly associated with mortality (OR 5.71, p = 0.025). CONCLUSION Adverse outcome from LC is particularly associated with male gender, but also the patient's co-morbidity, complexity and urgency of surgery. Risk-adjusted outcome analysis is desirable to ensure an informed consent process.
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Affiliation(s)
- Venkatesh Kanakala
- Department of Surgery, North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust, Rake Lane, North Shields, Tyne and Wear NE29 8NH, United Kingdom.
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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: 1.8] [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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Stanisić V, Bakić M, Magdelinić M, Kolasinac H, Vlaović D, Stijović B. [A prospective evaluation of laparoscopic cholecystectomy in the treatment of chronic cholelithiasis--a five-year experience]. MEDICINSKI PREGLED 2011; 64:77-83. [PMID: 21548274 DOI: 10.2298/mpns1102077s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Laparoscopic cholecystectomy is a method of choice in the treatment of symptomatic cholecystolithiasis because of less postoperative pain, shorter hospitalization and lower cost of treatment. The study was aimed at analysing the outcome of laparoscopic cholecystectomy in patients surgically treated for chronic calculous cholecystitis (symptomatic cholelithiasis). MATERIAL AND METHODS The research was done in the period from December 2003 to December 2008. In the prospective study of 386 patients, we analyzed operative and postoperative complications, the reasons for conversion to open cholecystectomy, duration of hospitalization and mortality. RESULTS The average duration of laparoscopic cholecystectomy was 31.9 +/- 14.5 min: dissection of adhesions 3.2 +/- 0.7 min., elements of Calot's triangle 9.8 +/- 3.2 min., gallbladder releasing from its bed 12.8 +/- 2.8 min., the abdominal cavity lavage and removal of gallbladder from the abdomen 6.8 +/- 0.9 min. Some operative difficulties emerged in 22 (5.7%) patients--4 (1%) during releasing of gallbladder adhesions from the surrounding structures, 9 (2.3%) during dissection of elements of the Calot's triangle, 6 (1.5%) during gallbladder releasing from its bed, 3 (0.7%) during gallbladder removal from the abdomen. Some post-operative complications, single or associated, occurred in 36 (9.3%) patients: perforation of gallbladder 21 (5.4%), bleeding from gallbladder bed 18 (4.6%)/ injury of extra hepatic bile ducts 1 (0.20%), 9 (2.3%) spillage of stones; 3 (0.7%) conversions were made. The average duration of preoperative and postoperative hospitalization was 1.1 +/- 0.3 and 1.4 +/- 0.5 days, respectively. The pathohistological examination revealed 2 (0.5%) adenocarcinoma of gallbladder. There were no lethal outcomes. CONCLUSION Laparoscopic cholecystectomy is a safe procedure and rational choice in the treatment of biliary dyskinesia and symptomatic biliary calculosis with an acceptable rate of conversion.
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Ercan M, Bostanci EB, Teke Z, Karaman K, Dalgic T, Ulas M, Ozer I, Ozogul YB, Atalay F, Akoglu M. Predictive factors for conversion to open surgery in patients undergoing elective laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 2010; 20:427-34. [PMID: 20518694 DOI: 10.1089/lap.2009.0457] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) has become the standard surgical procedure for symptomatic gallbladder disease. The aim of this study was to identify factors that may be predictive of cases that would require a conversion to laparotomy. METHODS In the period of 2002-2007, 2015 patients who underwent elective LC were included in the study. Patients were divided into two groups. Group 1 (n = 1914) consisted of patients whose operation was successfully completed with LC. Group 2 (n = 101) consisted of patients who had a conversion. A prospective analysis of parameters, including patient demographics, laboratory values, radiologic data, and intraoperative findings, was performed. Multivariate stepwise logistic regression was used to determine those variables predicting conversion. RESULTS One-hundred and one (5.0%) patients required a conversion. Significant predictors of conversion to open cholecystectomy in univariate analysis were increasing age, male gender, previous upper abdominal or upper plus lower abdominal incisions, an elevated white blood cell count, high aspartate transaminase, alkaline phosphatase and total bilirubin levels, preoperative ultrasound findings of a thickened gallbladder wall and dilated common bile duct, preoperative endoscopic retrograde cholangiopancreatography (ERCP), high-grade adhesion, and scleroatrophic appearance of the gallbladder intraoperatively. Multivariate analysis revealed that a history of previous abdominal surgery, preoperative ERCP, high-grade adhesion, and scleroatrophic appearance of the gallbladder predicted conversion. CONCLUSIONS Patient selection is very important for efficient, safe training in LC. Based on the presented data, pathways could be suggested that enable the surgeon to precisely decide, during LC, when to convert to open surgery.
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Affiliation(s)
- Metin Ercan
- Department of Gastroenterological Surgery, Turkey Yuksek Ihtisas Teaching and Research Hospital, Ankara, Turkey.
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Timing of elective laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreaticography with sphincterotomy: a prospective observational study of 308 patients. Langenbecks Arch Surg 2010; 395:661-6. [PMID: 20526779 DOI: 10.1007/s00423-010-0653-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 05/18/2010] [Indexed: 02/06/2023]
Abstract
PURPOSE Endoscopic retrograde cholangiopancreaticography (ERCP) with sphincterotomy is associated with higher rates of conversion to open surgery during subsequent laparoscopic cholecystectomy (LC). The mechanisms of this association are unclear. The aim of this study was to investigate whether the time interval between the two procedures can affect the course of LC in terms of conversion rate or complications. METHODS In this prospective observational study, 308 consecutive patients underwent ERCP with sphincterotomy followed at various intervals by elective LC. According to these intervals, the patients' data were assigned to one of three groups: short-interval (2 days or less), medium-interval (3-42 days), or long-interval (43 days or more). Groups were also defined in terms of whether gallstones were extracted during ERCP and in terms of the number of ERCPs performed (single or multiple) prior to LC. The main outcome measures for all groups were the frequency of complications during or after LC and the frequency of conversions to open surgery. RESULTS Of the 308 patients, 43 required conversion to open cholecystectomy (14%). The short-interval (95 patients), medium-interval (100 patients), and long-interval (113 patients) groups did not differ significantly in terms of intraoperative complications, postoperative complications, or conversion to open surgery (p = 0.985, 0.340, and 0.472, respectively). The conversion rate also did not differ significantly according to the presence or absence of gallstones on ERCP (14.7% versus 12.8%, respectively, p = 0.392). However, compared with patients who underwent single ERCP (n = 290), those who underwent multiple ERCPs (n = 18) experienced significantly more conversion to open surgery (p = 0.026). CONCLUSIONS The length of time between endoscopic sphincterotomy and LC did not affect the latter procedure in terms of complications or conversion to open surgery. However, the lack of an association between conversion rate and gallstone presence on ERCP and the higher conversion rate among patients who underwent multiple ERCPs, suggest that ERCP with sphincterotomy itself may be a factor in the higher conversion rates that have been observed after this procedure.
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Abstract
Laparoscopic cholecystectomy (LC) is the method of choice of surgical treatment of gallbladder diseases. Operations in elderly people over 65 years because of chronic diseases, are often associated with high operative and postoperative morbidity and mortality. The aim of this study was to analyze the outcome of LC in the treatment of cholelithiasis in patients older than 65 years. For evaluation of LC effectiveness and security in old patients, we did this prospective analysis of 81 patients surgically treated because of symptomatic cholelithiasis. We had analyzed associated diseases, operative and postoperative complications, the reasons of conversion to open cholecystectomy. The research points to the small percentage of operative and postoperative complications, short hospital stay, less postoperative pain, quick recovery and savings in treatment. The age can not be contraindication for LC in older patients. In uncomplicated symptomatic cholelithiasis in elderly people, LC is a successful and safe procedure. Complicated symptomatic cholelithiasis, because of longer duration of operations is looking for a good assessment of general condition and associated diseases for LC.
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Gholipour C, Fakhree MBA, Shalchi RA, Abbasi M. Prediction of conversion of laparoscopic cholecystectomy to open surgery with artificial neural networks. BMC Surg 2009; 9:13. [PMID: 19698100 PMCID: PMC2745364 DOI: 10.1186/1471-2482-9-13] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Accepted: 08/21/2009] [Indexed: 01/02/2023] Open
Abstract
Background The intent of this study was to predict conversion of laparoscopic cholecystectomy (LC) to open surgery employing artificial neural networks (ANN). Methods The retrospective data of 793 patients who underwent LC in a teaching university hospital from 1997 to 2004 was collected. We employed linear discrimination analysis and ANN models to examine the predictability of the conversion. The models were validated using prospective data of 100 patients who underwent LC at the same hospital. Results The overall conversion rate was 9%. Conversion correlated with experience of surgeons, emergency LC, previous abdominal surgery, fever, leukocytosis, elevated bilirubin and alkaline phosphatase levels, and ultrasonographic detection of common bile duct stones. In the validation group, discriminant analysis formula diagnosed the conversion in 5 cases out of 9 (sensitivity: 56%; specificity: 82%); the ANN model diagnosed 6 cases (sensitivity: 67%; specificity: 99%). Conclusion The conversion of LC to open surgery is effectively predictable based on the preoperative health characteristics of patients using ANN.
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Affiliation(s)
- Changiz Gholipour
- Department of General Surgery, Sinaea Hospital, Tabriz University of Medical Sciences Tabriz, Iran.
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Sasmal PK, Tantia O, Jain M, Khanna S, Sen B. Primary access-related complications in laparoscopic cholecystectomy via the closed technique: experience of a single surgical team over more than 15 years. Surg Endosc 2009; 23:2407-15. [PMID: 19296168 DOI: 10.1007/s00464-009-0437-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Revised: 02/17/2009] [Accepted: 02/27/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC), a common laparoscopic procedure, is a relatively safe invasive procedure, but complications can occur at every step, starting from creation of the pneumoperitoneum. Several studies have investigated procedure-related complications, but the primary access- or trocar-related complications generally are underreported, and their true incidence may be higher than studies show. Major vascular or visceral injury resulting from blind access to the abdominal cavity, although rare, has been reported. Of the two methods for creating pneumoperitoneum, the open access technique is reported to have the lower incidence of these injuries. The authors report their experience with the closed method and show that if performed with proper technique, it can be as rapid and safe as other techniques. However, injuries still happen, and the search for the predisposing factors must be continued. METHODS Between January 1992 and December 2007, a retrospective study examined 15,260 cases of LC performed for symptomatic gallstone disease in the authors' institution by a single team of surgeons. The primary access-related injuries in these cases were retrospectively analyzed. RESULTS In 15,260 cases of LC, 63 cases of primary access-related complications were identified, for an overall incidence of 0.41%. Major injuries in 11 cases included major vascular and visceral injuries, and minor injuries in 52 cases included omental and subcutaneous emphysema. For the closed method, the findings showed an overall incidence of 0.14% for primary access-related vascular injuries and 0.07% for visceral injuries. CONCLUSION Primary access-related complications during LC are common and can prove to be fatal if not identified early. The incidence of these injuries with closed methods is no greater than with open methods. No evidence suggests abandonment of the closed-entry method in laparoscopy.
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Affiliation(s)
- Prakash Kumar Sasmal
- Department of Minimal Access Surgery, ILS Multispeciality Clinic, DD-6, Sector-I, Salt Lake City, Kolkata, 700 064, India
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Shinohara T, Fujita T, Misawa T, Sakamoto T, Yoshida K, Kashiwagi H, Yanaga K. Impact on laboratory training in subsequent performance of laparoscopic cholecystectomy. Langenbecks Arch Surg 2008; 394:557-62. [DOI: 10.1007/s00423-008-0411-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Accepted: 08/06/2008] [Indexed: 01/22/2023]
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Al-Mulhim AA. Male gender is not a risk factor for the outcome of laparoscopic cholecystectomy: a single surgeon experience. Saudi J Gastroenterol 2008; 14:73-9. [PMID: 19568504 PMCID: PMC2702894 DOI: 10.4103/1319-3767.39622] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2007] [Accepted: 01/28/2008] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND/AIM Previous studies regarding the outcome of laparoscopic cholecystectomy (LC) in men have reported inconsistent findings. We conducted this prospective study to test the hypothesis that the outcome of LC is worse in men than women. MATERIALS AND METHODS Between 1997 and 2002, a total of 391 consecutive LCs were performed by a single surgeon at King Fahd Hospital of the University. We collected and analyzed data including age, gender, body mass index (kg/m(2)), the American Society of Anesthesiologists (ASA) class, mode of admission (elective or emergency), indication for LC (chronic or acute cholecystitis [AC]), comorbid disease, previous abdominal surgery, conversion to open cholecystectomy, complications, operation time, and length of postoperative hospital stay. RESULTS Bivariate analysis showed that both genders were matched for age, ASA class and mode of admission. The incidences of AC (P = 0.003) and comorbid disease (P = 0.031) were significantly higher in men. Women were significantly more obese than men (P < 0.001) and had a higher incidence of previous abdominal surgery (P = 0.017). There were no statistical differences between genders with regard to rates of conversion (P = 0.372) and complications (P = 0.647) and operation time (P = 0.063). The postoperative stay was significantly longer in men than women (P = 0.001). Logistic regression analysis showed that male gender was not an independent predictor of conversion (Odds ratio [OR] = 0.37 and P = 0.43) or complications (OR = 0.42, P = 0.42). Linear regression analysis showed that male gender was not an independent predictor of the operation time, but was associated with a longer postoperative stay (P = 0.02). CONCLUSION Male gender is not an independent risk factor for satisfactory outcome of LC in the experience of a single surgeon.
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Affiliation(s)
- Abdulmohsen A. Al-Mulhim
- Department of Surgery, King Fahd Hospital of the University, Al-Khobar, Saudi Arabia,Address: Dr. Abdulmohsen A. Al-Mulhim, P.O. Box 1917, Al-Khobar 31952, Saudi Arabia. E-mail:
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Biscione FM. Reply to Chen et al. Infect Control Hosp Epidemiol 2008. [DOI: 10.1086/524912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Outcome Analysis of Laparoscopic Cholecystectomy in Patients Aged 80 Years and Older with Complicated Gallstone Disease. J Laparoendosc Adv Surg Tech A 2007; 17:731-5. [DOI: 10.1089/lap.2007.0018] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Rosenmüller M, Haapamäki MM, Nordin P, Stenlund H, Nilsson E. Cholecystectomy in Sweden 2000-2003: a nationwide study on procedures, patient characteristics, and mortality. BMC Gastroenterol 2007; 7:35. [PMID: 17705871 PMCID: PMC2040147 DOI: 10.1186/1471-230x-7-35] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2007] [Accepted: 08/17/2007] [Indexed: 12/15/2022] Open
Abstract
Background Epidemiological data on characteristics of patients undergoing open or laparoscopic cholecystectomy are limited. In this register study we examined characteristics and mortality of patients who underwent cholecystectomy during hospital stay in Sweden 2000 – 2003. Methods Hospital discharge and death certificate data were linked for all patients undergoing cholecystectomy in Sweden from January 1st 2000 through December 31st 2003. Mortality risk was calculated as standardised mortality ratio (SMR) i.e. observed over expected deaths considering age and gender of the background population. Results During the four years of the study 43072 patients underwent cholecystectomy for benign biliary disease, 31144 (72%) using a laparoscopic technique and 11928 patients (28%) an open procedure (including conversion from laparoscopy). Patients with open cholecystectomy were older than patients with laparoscopic cholecystectomy (59 vs 49 years, p < 0.001), they were more likely to have been admitted to hospital during the year preceding cholecystectomy, and they had more frequently been admitted acutely for cholecystectomy (57% Vs 21%, p < 0.001). The proportion of women was lower in the open cholecystectomy group compared to the laparoscopic group (57% vs 73%, p < 0.001). Hospital stay was 7.9 (8.9) days, mean (SD), for patients with open cholecystectomy and 2.6 (3.3) days for patients with laparoscopic cholecystectomy, p < 0.001. SMR within 90 days of index admission was 3.89 (3.41–4.41) (mean and 95% CI), for patients with open cholecystectomy and 0.73 (0.52–1.01) for patients with laparoscopic cholecystectomy. During this period biliary disease accounted for one third of all deaths in both groups. From 91 to 365 days after index admission, SMR for patients in the open group was 1.01 (0.87–1.16) and for patients in the laparoscopic group 0.56 (0.44–0.69). Conclusion Laparoscopic cholecystectomy is performed on patients having a lower mortality risk than the general Swedish population. Patients with open cholecystectomy are more sick than patients with laparoscopic cholecystectomy, and they have a mortality risk within 90 days of admission for cholecystectomy, which is four times that of the general population. Further efforts to reduce surgical trauma in open biliary surgery are motivated.
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Affiliation(s)
| | | | - Pär Nordin
- Department of Surgery Östersunds Hospital, Östersund, Sweden
| | - Hans Stenlund
- Epidemiology and Public Health Sciences, Umeå International School of Public Health, Sweden
| | - Erik Nilsson
- Department of Surgery, Umeå University Hospital, Sweden
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