Emergency laparoscopic cholecystectomy in an unselected cohort: a safe and viable option in a specialist centre

MORTALITY OF URGENCY VERSUS ELECTIVE VIDEOLAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS

Background:

Surgical approach is still controversial in patients with acute cholecystitis: to treat clinically the inflammatory process and operate electively later or to operate immediately on an emergency basis?

Aim:

To test the hypothesis that urgent laparoscopic cholecystectomy in acute cholecystitis has a higher mortality than elective laparoscopic cholecystectomy.

Methods:

From the data available in Datasus, mortality was compared between patients undergoing elective laparoscopic cholecystectomy for cholelithiasis and in urgency. Calculations were made of the relative reduction in risk of death, absolute reduction of risk of death and number needed to treat.

Results:

From 2009 to 2014 in Brazil, there were 250.439 laparoscopic cholecystectomy and 74.6% were electives. Mortality in the emergency group was 4.8 times higher compared to the elective group (0.0023% vs. 0.00048%). Despite the relative reduction in risk of death (RRR) was 83%, in the calculation of absolute risk was found 0.0018 and number needed to treat of 55,555.

Conclusions:

Despite the relative risk reduction for mortality was high comparing elective vs. urgent basis, the absolute risk reduction was minimal, since this outcome is very low in both groups, suggesting that mortality should not have much influence on surgical decision.

Economic Implications of Providing Emergency Cholecystectomy for All Patients With Biliary Pathology: A Retrospective Analysis

INTRODUCTION

This study assessed the safety and efficacy of acute laparoscopic cholecystectomy (ALC) in patients presenting with biliary pathology. The potential savings plus income generation for the hospital were calculated.

METHODS

All patients undergoing emergency cholecystectomy were identified from computerized and hand-written theater records to ensure complete capture. Length of stay, procedure time, patient demographics, and postoperative complications were recorded. Tariffs for conservative versus acute management were calculated. Total admissions and readmissions with biliary pathology (acute cholecystitis, biliary colic, gallstone pancreatitis, and obstructive jaundice) over a 12-month period were recorded.

RESULTS

Eighty-four patients undergoing ALC were identified. There was only 1 major complication (1 postoperative bleed managed laparoscopically). ALC for all admissions would result in savings of £ 695,918 over 12 months. The implementation of ALC for all patients would result in a small loss in revenue when compared with elective laparoscopic cholecystectomy (£ 15,495) provided that all operations could be accommodated on established operating lists. Implementing ALC on all appropriate biliary admissions could generate up to 3 cholecystectomies daily for a population base of 1 million.

CONCLUSIONS

ALC is cost-effective and safe. It can be offered to all patients with biliary pathology provided they are fit enough for surgery.

Cholecystectomy for biliary dyskinesia: how did we get there?

BACKGROUND

The focus of biliary dyskinesia (BD) shifted within the last 30 years, moving from symptoms after cholecystectomy (CCY) to symptoms with morphological normal gallbladder, but low gallbladder ejection fraction.

METHODS

We searched the pubmed database to systematically review studies focusing on the diagnosis and treatment of gallbladder dysfunction.

RESULTS

Impaired gallbladder contraction can be found in about 20% of healthy controls and an even higher number of patients with various other disorders. Surgery for BD increased after introduction of laparoscopic CCY, with BD now accounting for >20% of CCY in adults and up to 60% in pediatric patients. The majority of cases reported were operated in the USA, which differs from surgical series for cholelithiasis. Postoperative outcomes do not differ between groups with abnormal or normal gallbladder function.

CONCLUSION

Functional gallbladder testing should not be seen as an indicator of relevant biliary tract disease or prognostic marker to identify patients who may benefit from operative intervention. Instead biliary dyskinesia should be considered as a part of a spectrum of functional disorders, which are generally managed conservatively. Small proof of concept studies have demonstrated effects of medical therapy on biliary dysfunction and should thus be never tested in appropriately designed trials.

Are we meeting the British Society of Gastroenterology guidelines for cholecystectomy post-gallstone pancreatitis?

BACKGROUND

The aim of this study was to audit the current management of patients suffering with gallstone pancreatitis (GSP) at a university teaching hospital for compliance with the British Society of Gastroenterology (BSG) guidelines regarding cholecystectomy post-GSP.

METHODS

Data were collected on all patients identified via the hospital coding department that presented with GSP between January 2011 and November 2013. Patients with alcoholic pancreatitis were excluded. The primary outcome was the length of time in days from diagnosis of GSP to cholecystectomy. Secondary outcomes included readmission with gallstone-related disease prior to definitive management and admitting speciality.

RESULTS

One hundred and fifty-eight patients were identified with a presentation of GSP during the study period. Thirty-nine patients were treated conservatively. One hundred and six patients underwent laparoscopic cholecystectomy a median (interquartile range) interval of 33.5 days (64 days) post-admission. Patients with a severe attack as classified by the Glasgow severity score (n = 16) waited a median of 79.5 days (71.5) for cholecystectomy. Only 32% (n = 34) of patients with mild disease underwent cholecystectomy during the index admission or within 2 weeks. When grouped by admitting speciality, patients admitted initially under hepatobiliary surgery waited significantly fewer days for definitive treatment compared with other specialities (P < 0.0001). Twenty-one patients (19.8%) re-presented with gallstone-related pathology prior to undergoing cholecystectomy.

CONCLUSIONS

Only 32.1% were treated as per BSG guidelines. About 19.8% (n = 21) of the patients suffered further morbidity as a result of a delayed operation and there is a clear difference between admitting speciality and the median time to operation.

Comparison of laparoscopic cholecystectomy for acute cholecystitis within and beyond 72 h of symptom onset during emergency admissions

BACKGROUND

Laparoscopic cholecystectomy (LC) performed for acute cholecystitis (AC) is usually advised within 72 h of symptom onset. It can be difficult to accommodate all these patients within 72 h. LC beyond this early phase potentially increases the chances of LC-related complications. The aim of this study was to evaluate the outcomes of LC both within and beyond 72 h of presentation during the emergency admission.

METHODS

A retrospective clinical study was performed from February 2004 to December 2009. A total of 133 patients underwent LC for AC during the emergency admission according to the protocol: 34 patients underwent early LC (ELC) (i.e., operation within 72 h of symptom onset) and 99 underwent late LC (LLC) (i.e., operation beyond 72 h of symptom onset). Pathologic type of cholecystitis, duration of the procedure, conversion rate, complications, length of hospital stay (LOS), and total charges were compared between the two groups.

RESULTS

Patients undergoing ELC experienced a significantly shorter operating time (44.1 ± 5.32 vs. 66.4 ± 3.05 min, p < 0.01). Most of the AC (95/133, 71 %) was pathologically simple cholecystitis. There was no significant difference regarding wound infection rates [1/34 (2.94 %) vs. 2/99 (2.02 %), p > 0.05] or postoperative hospital stay (6.50 ± 1.31 vs. 6.67 ± 0.73, p > 0.05) between groups. There were no conversions to open cholecystectomy, no biliary tract injury or biliary leak, no other complications, and no 30-day readmission rates in either group. ELC was less costly than LLC (6,692 ± 794 vs. 8,378 ± 802 RMB, p < 0.05).

CONCLUSIONS

Both ELC and LLC are safe for treating of AC, but the operative difficulty of LLC is greater. ELC is superior to LLC as it tends to shorten the total LOS and is less expensive.