Elective laparoscopic cholecystectomy: recurrent biliary admissions predispose to difficult cholecystectomy

Relapse in gallstone disease after non-operative management of acute cholecystitis: a population-based study

OBJECTIVE

Non-operative management (NOM) of acute cholecystitis (ACC) may be preferable in patients with advanced inflammation, long duration of symptoms or severe comorbidities. This study aims to investigate time to recurrence and patient factors predicting relapse in gallstone complications after NOM.

METHODS

Records of 1634 patients treated for ACC at three Swedish centres between 2017 and 2020 were analysed, with 909 managed non-operatively. Data were linked to the National Gallstone Surgery registry for those who later underwent surgery. The time to relapse of gallstone complications was calculated and Cox proportional hazards regression was used to analyse new gallstone complications and adjust for multiple variables.

RESULTS

Of the 909 non-operatively managed patients, 348 patients suffered a new gallstone complication. The median time to recurrence was 82 days. Of those who recurred, 27% did so within 30 days, 17% between 31 and 60 days, 27% between 61 days and 6 months, 16% between 6 months and 1 year and 13% later than 1 year. Younger patients with their first gallstone complication had a lower risk of new complications compared with those with previous gallstone complications. In older individuals, there was no difference in the risk of relapse regardless of previous gallstone complications, but they were more likely to be readmitted than younger patients.

CONCLUSION

Delayed cholecystectomy should be prioritised for younger patients with a history of gallstone disease if early cholecystectomy is not feasible. Delayed cholecystectomy should be scheduled without a prior outpatient clinic visit to minimise delays.

Association of day-case rates with post COVID-19 recovery of elective laparoscopic cholecystectomy activity across England

INTRODUCTION

The aim of this study was to investigate the safety of day-case laparoscopic cholecystectomy, and the association between day-case rates and, post the COVID-19 pandemic, recovery of activity to prepandemic levels for integrated care boards (ICBs) in England.

METHODS

This was a retrospective observational study of the Hospital Episodes Statistics (HES) data set. Elective laparoscopic cholecystectomies for the period 1 January 2019 to 31 December 2022 were identified. Activity levels for 2022 were compared with those for the whole of 2019 (baseline). Day-case activity was identified where the length of stay recorded in the HES was zero days.

RESULTS

Data were available for 184,252 patients across the 42 ICBs in England, of which 120,408 (65.3%) were day-case procedures. By December 2022, activity levels for the whole of England had returned to 88.2% of prepandemic levels. The South West region stood out as having recovered activity levels to the greatest extent, with activity at 97.3% of prepandemic levels during 2022. The South West also had the highest postpandemic day-case rate at 74.9% of all patients seen as a day-case during 2022; this compares with an England average of 65.3%. At an ICB level, there was a significant correlation between day-case rates and postpandemic activity levels (r = 0.362, p = 0.019). There was no strong or consistent evidence that day-case surgery had poorer patient outcomes than inpatient surgery.

CONCLUSIONS

Recovery of elective laparoscopic cholecystectomy activity has been better in South West England than in other regions. Increasing day-case rates may be important if ICBs in other regions are to increase activity levels up to and beyond prepandemic levels.

Derivation and validation of a predictive model for subtotal cholecystectomy

INTRODUCTION

Rates of subtotal cholecystectomy (STC) are increasing in response to challenging cases of laparoscopic cholecystectomy (LC) to avoid bile duct injury, yet are associated with significant morbidity. The present study identifies risk factors for STC and both derives and validates a risk model for STC.

METHODS

LC performed for all biliary pathology across three general surgical units were included (2015-2020). Clinicopathological, intraoperative and post-operative details were reported. Backward stepwise multivariable regression was performed to derive the most parsimonious predictive model for STC. Bootstrapping was performed for internal validation and patients were categorised into risk groups.

RESULTS

Overall, 2768 patients underwent LC (median age, 53 years; median ASA, 2; median BMI, 29.7 kg/m2), including 99 cases (3.6%) of STC. Post-operatively following STC, there were bile leaks in 29.3%, collections in 19.2% and retained stones in 10.1% of patients. Post-operative intervention was performed in 29.3%, including ERCP (22.2%), laparoscopy (5.0%) and laparotomy (3.0%). The following variables were positive predictors of STC and were included in the final model: age >  60 years, male sex, diabetes mellitus, acute cholecystitis (AC), increased severity of AC (CRP > 90 mg/L), ≥ 3 biliary admissions, pre-operative ERCP with/without stent, pre-operative cholecystostomy and emergency LC (AUC = 0.84). Low, medium and high-risk groups had a STC rate of 0.8%, 3.9% and 24.5%, respectively.

DISCUSSION

The present study determines the morbidity of STC and identifies high-risk features associated with STC. A risk model for STC is derived and internally validated to help surgeons identify high-risk patients and both improve pre-operative decision-making and patient counselling.

Global evaluation and outcomes of cholecystectomy: protocol for a multicentre, international, prospective cohort study (GlobalSurg 4)

INTRODUCTION

Cholecystectomy is one of the most common operations performed worldwide. Although laparoscopic surgery has been the 'gold-standard' approach for this operation, there is a paucity of global evidence around the variations of safe provision of cholecystectomy, including low-income and middle-income countries. This international collaborative study will allow contemporaneous data collection on the quality of cholecystectomies using measures covering infrastructure, care processes and outcomes, with the primary aim define the global variation in compliance with preoperative, intraoperative and postoperative audit standards.

METHODS AND ANALYSIS

Global Evaluation of Cholecystectomy Knowledge and Outcomes is a prospective, international, multicentre, observational cohort study delivered by the GlobalSurg Collaborative. Consecutive patients undergoing cholecystectomy between 31 July 2023 and 19 November 2023 will be recruited, with follow-up at 30 days and 1-year postoperatively. The study will be undertaken at any hospital providing emergency or elective surgical services for biliary disease. The primary endpoint of this study is compliance with preoperative, intraoperative and postoperative audit standards. Secondary outcomes include rates of 30-day complications, achievement of critical view of safety and rates of gallbladder cancer.

ETHICS AND DISSEMINATION

This project will not affect clinical practice and has been classified as clinical audit following research ethics review at University Hospital Birmingham NHS Trust. The protocol will be disseminated through the international GlobalSurg and CovidSurg network.

TRIAL REGISTRATION NUMBER

NCT06223061.

Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event

BACKGROUND

Gallstone disease will affect 15% of the adult population with concomitant common bile duct stone (CBDS) occurring in up to 30%. Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for removal of CBDS, as cholecystectomy for the prevention of recurrent biliary event (RBE). RBE occurs in up to 47% if cholecystectomy is not done. The goal of this study was to evaluate the timing of occurrence of RBE after common bile duct clearance with ERCP and associated outcomes.

METHODS

The records of all patients who underwent ERCP for gallstone disease followed by cholecystectomy, in a single center from 2010 to 2022, were reviewed. All RBE were identified. Actuarial incidence of RBE was built. Patients with and without RBE were compared.

RESULTS

The study population is composed of 529 patients. Mean age was 58.0 (18-95). There were 221 RBE in 151 patients (28.5%), 39/151 (25.8%) having more than one episode. The most frequent RBE was acute cholecystitis (n = 104) followed by recurrent CBDS (n = 95). Median time for first RBE was 34 days. Actuarial incidence of RBE started from 2.5% at 7 days to reach 53.3% at 1 year. Incidence-rate of RBE was 2.9 per 100 person-months. Patients with RBE had significant longer hospitalisation time (11.7 vs 6.4 days; P < 0.0001), longer operative time (66 vs 48 min; P < 0.0001), longer postoperative stay (2.9 vs 0.9 days; P < 0.0001), higher open surgery rate (7.9% vs 1.3%; P < 0.0001), and more complicated pathology (23.8% vs 5.8%; P < 0.0001) and cholecystitis (64.2% vs 25.9%; P < 0.0001) as final diagnoses.

CONCLUSIONS

RBE occurred in 28.5% of the subjects at a median time of 34 days, with an incidence of 2.5% as early as 1 week. Cholecystectomy should be done preferably within 7 days after common bile duct clearance in order to prevent RBE and adverse outcomes.

Analysis of risk factors for complications after laparoscopic cholecystectomy

To analyze the risk factors of complications after laparoscopic cholecystectomy in 478 patients in our hospital.

METHODS

The clinical data of 478 patients who underwent laparoscopic cholecystectomy in our hospital from March 2018 to September 2022 were collected, and the occurrence of postoperative complications and related risk factors were analyzed.

RESULTS

A total of 36 patients (7.53%) had complications, including 9 cases (1.88%) of abdominal hemorrhage, 8 cases (1.67%) of bile duct injury, and 19 cases (3.97%) of biliary fistula. Univariate analysis showed that adhesions of Calot triangle, anatomical variation and gallbladder wall thickness greater than 5 mm were associated with postoperative complications (all P < 0.05). Multivariate analysis showed that: Calot triangle adhesion (OR = 3.041, 95%CI = 1.422-6.507), anatomical variation (OR = 4.368, 95%CI = 1.764-10.813) and gallbladder wall thickening (OR = 2.827, 95%CI = 1.422-6.507). 95%CI = 1.274-6.275) were independent risk factors for complications after laparoscopic cholecystectomy (all P < 0.05).

CONCLUSION

In order to reduce the occurrence of postoperative complications, the risk factors of LC should be well understood and the preoperative preparation should be made.

The Modification of a Preoperative Scoring System to Predict Difficult Elective Laparoscopic Cholecystectomy

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.

Index Admission Cholecystectomy for Biliary Colic Precludes the Risk of Readmissions with Biliary Complications and should be Standard Treatment

BACKGROUND

Emergency biliary colic admissions can be managed with an index or elective laparoscopic cholecystectomy (LC). Opting to perform an elective LC may have significant repercussions such as the risk of readmissions before operation with further attacks or with biliary complications (e.g. cholecystitis, pancreatitis, choledocholithiasis). The risk of readmission and biliary complications in patients admitted with biliary colic but scheduled for elective surgery has never been investigated. The secondary aim was to compare rates of peri-operative morbidity between the index admission, elective and readmission LC cohorts.

METHOD

All patients admitted with a diagnosis of biliary colic over a 5-year period and proceeding to LC were included in the study (n = 441). The risk of being readmitted and suffering further morbidity whilst awaiting elective LC was investigated. Peri-operative morbidity was compared between the index admission, elective and readmitted LC groups using univariate and multivariate analysis.

RESULTS

Following a biliary colic admission, the risk of readmission whilst awaiting elective LC is significant (2 months-25%; 10 months-48%). In this group, the risks of subsequent biliary complications (18.0%) and the requirement for ERCP (6.5%) were significant. Patients who are readmitted before LC, suffer a more complicated peri-operative course (longer total length of stay, higher post-operative complications, imaging and readmission).

DISCUSSION

Index admission LC for biliary colic avoids the significant risk of readmission and biliary complications before surgery and should be the gold standard. Readmitted patients are likely to have higher rates of peri-operative adverse outcomes. Patients should be counselled about these risks.

Laparoscopic Lumen-guided cholecystectomy in face of the difficult gallbladder

BACKGROUND

Where the critical view of safety cannot be established during cholecystectomy, certain salvage techniques are indicated to reduce the likelihood of bile duct injury. The present study describes a salvage technique termed the "laparoscopic lumen-guided cholecystectomy" (LLC) and reports its peri-operative outcomes.

METHOD

A summary of the technique is as follows: (1) Hartmann's pouch is incised and stones are evacuated; (2) the cystic anatomy is inspected from the inside of the gallbladder; (3) the lumen is used to guide retrograde dissection towards the cystic pedicle; (4) cystic duct control is achieved if deemed safe. LLC cases performed between June 2020 and January 2022 in a single health board were included. The operative details and peri-operative outcomes of the technique are reported and compared to cases of similar difficulty where the LLC was not attempted.

RESULTS

LLC was performed in 4.6% (27/587) of cases. In all 27 cases, LLC was performed for a "frozen" cholecystohepatic triangle. Hartmann's pouch was completely excised in all cases (27/27) and cystic duct control was achieved in 85.2% of cases (23/27). No cases of bile leak or ductal injury were reported. Rates of bile leak, post-operative complications and ERCP were lower following LLC compared to the group where LLC was not attempted (p < 0.01).

CONCLUSION

LLC is a safe salvage technique and should be considered in cases where the critical view of safety cannot be established. The technique achieves cystic duct control in the majority of cases and favourable outcomes in the face of a difficult cholecystectomy.

Acute cholecystitis: Delayed cholecystectomy has lesser perioperative morbidity compared to emergency cholecystectomy

BACKGROUND

In comparison to delayed laparoscopic cholecystectomy, emergency laparoscopic cholecystectomy has a shorter length of stay and eliminates the risk of recurrent episodes of acute cholecystitis. Nevertheless, there is concern that emergency laparoscopic cholecystectomy is associated with higher morbidity in acute cholecystitis patients. The present large cohort study compares operation-related adverse outcomes between emergency and delayed laparoscopic cholecystectomy and determines the risk of readmission before delayed laparoscopic cholecystectomy to guide surgical decision-making.

METHODS

Patients diagnosed with acute cholecystitis who underwent emergency or delayed laparoscopic cholecystectomy between 2015 and 2019 were included. Perioperative outcomes were compared using univariate and multivariate analysis, adjusting for preoperative variables. The rate of readmission before delayed laparoscopic cholecystectomy was determined.

RESULTS

In total, 811 patients were included (median age, 58 years; male:female, 1:1.5): 227 emergency laparoscopic cholecystectomies (28.0%), 555 delayed laparoscopic cholecystectomies (68.4%), and 29 emergency laparoscopic cholecystectomies whilst awaiting delayed laparoscopic cholecystectomy (3.6%). Emergency laparoscopic cholecystectomy was associated with increased incidences of subtotal cholecystectomy (OR 1.94; P = .011), bile leak (OR 2.38; P = .013), intraoperative drains (OR 2.54; P < .001), prolonged postoperative length of stay (OR 7.26; P < .001), postoperative imaging (OR 1.83, P = .006), and postoperative readmission (OR 1.90; P = .005). There was a 13.5% risk of readmission over 2 months while waiting delayed laparoscopic cholecystectomy and a 22.5% risk over the median waiting time (5 months, 9 days).

CONCLUSION

Emergency laparoscopic cholecystectomy is positively associated with a multitude of operation-related adverse outcomes in acute cholecystitis, compared to delayed laparoscopic cholecystectomy. The benefit of delayed laparoscopic cholecystectomy should be balanced against the significant readmission risk before delayed laparoscopic cholecystectomy. Emergency laparoscopic cholecystectomy may be the most pragmatic strategy for centers dealing with high volumes of biliary admissions and long elective-surgery waiting times. When opting for delayed laparoscopic cholecystectomy, confirming the date of surgery before discharge may ensure timely intervention and avoid the morbidity and expense of readmission.