Acute cholecystitis: comparing clinical outcomes with TG13 severity and intended laparoscopic versus open cholecystectomy in difficult operative cases

Efficacy of bailout surgery for preventing intraoperative biliary injury in acute cholecystitis

BACKGROUND

Bailout surgery (BOS; partial cholecystectomy, open conversion, and fundus-first approach) has been recommended for difficult cases to ensure safe performance of cholecystectomy. However, the efficacy of BOS for preventing intraoperative massive bleeding and bile duct injury (BDI) remains unclear, especially in the context of acute cholecystitis (AC). This study aimed to retrospectively validate the feasibility of BOS for AC.

METHODS

We enrolled 479 patients who underwent emergency cholecystectomies for AC between 2011 and 2021. Univariate and multivariate analyses were performed to detect the risk factors for BOS in patients with AC. Perioperative variables were compared between patients who underwent total cholecystectomy (TC) and those who underwent BOS. Propensity score matching analysis was performed to compare the two groups.

RESULTS

Significant differences in American Society of Anesthesiologists physical status and Charlson Comorbidity Index scores, TG18 severity grading, white blood cell count, and albumin and C-reactive protein (CRP) levels were found between the TC and BOS groups. Preoperative CT imaging demonstrated severe inflammation evidenced by gallbladder wall thickness, enhancement of the liver bed, and duodenal edema in the BOS group compared to the TC group. Postoperative complications were significantly higher in the BOS group than in the TC group. Further, BDI was completely prevented by BOS. Multivariate analysis identified TG18 grade ≥ II, CRP ≥ 7.7, and duodenal edema as independent risk factors for BOS. After PSM analysis, postoperative complications were not worse in patients who underwent BOS rather than TC. Among BOS procedures, laparoscopic BOS (lap-BOS) was the most efficacious in preventing intraoperative blood loss and postoperative bile leakage.

CONCLUSION

Severity grading > II, elevated CRP levels, or duodenum edema revealed by CT were determined to be risk factors impeding total cholecystectomy. BOS is a safe, feasible, and efficacious procedure for preventing BDI. Among BOS procedures, lap-BOS showed better postoperative outcomes.

Effect of innovative nursing practice on stress response of patients undergoing laparoscopic cholecystectomy

BACKGROUND

Laparoscopic surgery has the advantages of less trauma, less bleeding, fewer complications, and faster postoperative recovery. Although laparoscopic surgery has become mature, many patients still show unique characteristics of high psychological sensitivity and strong surgical stress, and worry about postoperative syndrome, such as poor appetite, diarrhea and so on. The concept of homogeneous medical care is a team jointly established by medical staff to carry out clinical medical care. In this study, the innovative nursing model based on the concept of homogeneous medical care was applied to the actual nursing of patients undergoing cholecystectomy in order to provide a reference for clinical staff.

AIM

To explore the influence of innovative nursing practice on stress response of patients undergoing laparoscopic cholecystectomy.

METHODS

A total of 80 patients who underwent laparoscopic cholecystectomy at Yiwu Central Hospital of Zhejiang Province from April 2017 to April 2019 were selected as the subjects of the study. The patients were randomly divided into either a control group or an observation group with 40 cases each. Both groups were given routine nursing care, such as health education, psychological counseling, diet nursing, preoperative nursing and evaluation, condition nursing, medication nursing, intraoperative and postoperative routine nursing, and vital sign monitoring. The observation group was additionally given innovative nursing care based on the homogeneous medical concept. Changes in stress indicators, including heart rate (HR), mean arterial pressure (MAP), and blood glucose, were observed at one day before surgery (T₀), 10 min after pneumoperitoneum (T₁), and 5 min after surgery (T₂) in the two groups, and venous blood was collected to detect plasma noradrenaline (NE), adrenaline (E), and cortisol levels.

RESULTS

In the control group, HR, MAP, and blood glucose at T₁ and T₂ were all significantly higher than those at T₀ (P < 0.05), but their levels at T₂ were slightly lower those at T1 and still higher than those at T₀ (P < 0.05). The change trends of HR, MAP, and blood glucose in the observation group were similar to those in the control group, but the differences were not statistically significant among different time points (P > 0.05). HR, MAP, and blood glucose at T₁ and T₂ in the observation group were all significantly lower than those in the control group (P < 0.05). Compared with those at T₀, the concentrations of NE, E, and cortisol in the control group significantly increased at T₁ and T₂ (P < 0.05). In the observation group, the concentrations of NE, E, and cortisol increased at T₁ (P < 0.05) and decreased at T₂ (P < 0.05). Compared with the control group, the concentrations of NE, E, and cortisol at T₁ and T₂ were all decreased in the observation group (P < 0.05).

CONCLUSION

Innovative nursing care based on the concept of homogenous medical treatment can significantly reduce the perioperative stress response of patients undergoing laparoscopic cholecystectomy, which is beneficial to promote the postoperative physical recovery of patients.

Robotic-assisted versus laparoscopic cholecystectomy for benign gallbladder diseases: a systematic review and meta-analysis

BACKGROUND

Robotic surgery, an emerging technology, has some potential advantages in many complicated endoscopic procedures compared with laparoscopic surgery. But robot-assisted cholecystectomy (RAC) is still a controversial issue on its comparative merit compared with conventional laparoscopic cholecystectomy (LC). The aim of this study was to evaluate the safety and efficacy of RAC compared with LC for benign gallbladder disease.

METHODS

A systematic literature search was conducted using the PubMed, EMBASE, and Cochrane Library databases (from their inception to December 2017) to obtain comparative studies assessing the safety and efficacy between RAC and LC. The quality of the literature was assessed, and the data analyzed using R software, random effects models were applied.

RESULTS

Twenty-six studies, including 5 RCTs and 21 NRCSs (3 prospective plus 18 retrospective), were included. A total of 4004 patients were included, of which 1833 patients (46%) underwent RAC and 2171 patients (54%) underwent LC. No significant differences were found in intraoperative complications, postoperative complications, readmission rate, hospital stay, estimated blood loss, and conversion rate between RAC and LC groups. However, RAC was related to longer operative time compared with LC (MD = 12.04 min, 95% CI 7.26-16.82) in RCT group, which was consistent with NRCS group; RAC also had a higher rate of incisional hernia in NRCS group (RR = 3.06, 95% CI 1.42-6.57), and one RCT reported that RAC was similar to LC (RR = 7.00, 95% CI 0.38-129.84).

CONCLUSIONS

The RAC was not found to be more effective or safer than LC for benign gallbladder diseases, which indicated that RAC is a developing procedure instead of replacing LC at once. Given the higher costs, the current evidence is in favor of LC in cholecystectomy.