Risk factors in laparoscopic cholecystectomy: a multivariate analysis

Propensity score-matched comparison of safety outcomes between high-risk and low-risk patients towards early hospital discharge after laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy (LC), a common treatment for symptomatic gallstones, has demonstrated safety in low-risk patients. However, existing data are scarce regarding the safety of LC in high-risk patients and the feasibility of early hospital discharge.

Materials and methods

This retrospective study included 2296 patients diagnosed with symptomatic gallstones who underwent LC at a tertiary care centre from January 2009 through December 2019. The authors employed propensity score matching to mitigate bias between groups. Statistical significance was set at P less than 0.05.

Results

The median age of the patients was 56 years (range 46-67), with a mean BMI of 25.2±4.3 kg/m2. Patients were classified as: American Society of Anesthesiologists (ASA) I (19.7%), II (68.3%), III (12.0%), and IV (0%). ASA I-II included low surgical risk patients (88%) and ASA III-IV comprised high-risk patients (12%). The LC-related 30-day reoperative rate was 0.2% and the readmission rate was 0.87%. Nine patients (0.4%) sustained major bile duct injuries, resulting in a conversion rate of 2.4%. The postoperative mortality rate was 0.04%, and the mean hospitalization time was 3.5 days. Patients in the high-risk group with a history of acute cholecystitis exhibited greater estimated blood loss, longer operative times, and were significantly more likely to be in the longer-stay group.

Conclusion

These findings suggest that LC can be conducted safely on high-risk patients, and early hospital discharge is achievable. However, specific factors, such as a history of acute cholecystitis, may result in prolonged hospitalization owing to increased blood loss and longer operative times.

Safe Implementation of a Next-Generation Surgical Robot: First Analysis of 2,083 Cases in the Versius Surgical Registry

OBJECTIVE

To present the first report of data from the Versius Surgical Registry, a prospective, multicenter data registry with ongoing collection across numerous surgical indications, developed to accompany the Versius Robotic Surgical System into clinical practice.

BACKGROUND

A data registry can be utilized to minimize risk to patients by establishing the safety and effectiveness of innovative medical devices and generating a thorough evidence base of real-world data.

METHODS

Surgical outcome data were collected and inputted through a secure online platform. Preoperative data included patient age, sex, body mass index, surgical history, and planned procedures. Intraoperative data included operative time, complications during surgery, conversion from robot-assisted surgery to an alternative surgical technique, and blood loss. Postoperative outcome data included length of hospital stay, complications following surgery, serious adverse events, return to the operating room, readmission to the hospital, and mortality within 90 days of surgery.

RESULTS

This registry analysis included 2083 cases spanning general, colorectal, hernia, gynecologic, urological, and thoracic indications. A considerable number of cases were recorded for cholecystectomy (n=539), anterior resection (n=162), and total laparoscopic hysterocolpectomy (n=324) procedures. The rates of conversion to an alternative technique, serious adverse events, and 90-day mortality were low for all procedures across all surgical indications.

CONCLUSIONS

We report the large-scale analysis of the first 2083 cases recorded in this surgical registry, with substantial data collected for cholecystectomies, anterior resections, and total laparoscopic hysterectomies. The extensive surgical outcome data reported here provide real-world evidence for the safe implementation of the surgical robot into clinical practice.

Increasing gallstone disease prevalence and associations with gallbladder and biliary tract mortality in the US

BACKGROUND AND AIMS

We examined gallbladder and biliary tract mortality predictors in the US National Health and Nutrition Examination Survey (NHANES), 1988-1994, with 31 years of linked mortality data, and gallstone disease prevalence trends and associations in NHANES 2017-March 2020 prepandemic data.

APPROACH AND RESULTS

In NHANES 1988-1994, 18,794 participants were passively followed for mortality, identified by death certificate underlying or contributing causes, by linkage to the National Death Index through 2019. In NHANES 2017-March 2020, gallstone disease history was ascertained from 9232 adults. During NHANES 1988-2019 follow-up (median, 23.3 y), 8580 deaths occurred from all causes and 72 deaths with gallbladder or biliary tract disease. In multivariable-adjusted analysis, older age, male sex, prediabetes or diabetes, and physical inactivity were associated with gallbladder and biliary tract mortality, and non-Hispanic Black and Mexican American race-ethnicity were inversely associated. Between 1988-1994 and 2017-March 2020, gallstone disease prevalence increased from 7.4% to 13.9% and gallbladder surgery from 6.0% to 11.6%. In 2017-March 2020 in multivariable-adjusted analysis, female sex, diabetes, liver disease, proton pump inhibitors, abdominal pain, increased age, BMI, and liver stiffness were associated with gallstone disease, and non-Hispanic Black and non-Hispanic Asian race and alcohol were inversely associated.

CONCLUSIONS

In the US population, gallstone disease prevalence doubled over 3 decades, possibly because of the worsening of metabolic risk factors and growth of laparoscopic cholecystectomy. Gallbladder and biliary tract mortality and gallstone disease associations included factors such as prediabetes or diabetes, liver stiffness and proton pump inhibitors.

A Study of the Degree of Gall Bladder Wall Thickness and Its Impact on Patients Undergoing Laparoscopic Cholecystectomy

Background The gold standard management for symptomatic gallstone disease is elective laparoscopic cholecystectomy, which has replaced open cholecystectomy. The wall thickness of the gallbladder is an indicator of cholecystitis in patients who have presented with symptoms of gallstone disease. The aim of this study was to evaluate preoperative gall bladder wall thickness by ultrasonography and assess its impact on the outcome of laparoscopic cholecystectomy, including conversion rate, complications, operative time, and postoperative hospital stay. Method This prospective study was conducted on 350 patients with symptomatic gallstone disease, those who had undergone laparoscopic cholecystectomy in Dr. Sampurnanand Medical College, Jodhpur, and attached hospitals from July 2019 to November 2021. On the basis of ultrasonography findings of gallbladder wall thickness, patients were divided into four groups: normal thickness - up to 2 mm, mild thickness - 3-4mm, moderate thickness - 5-6mm, and severe wall thickness - more than 6mm). Up to 2 millimeters thickness was considered as normal. Results The incidence of conversion rate, as well as intra or postoperative complications, were higher in moderate and severe wall thickness groups. The maximum incidence of complication rate is seen in moderately thickened group (33.33%). In severely thickened group, complication was seen in 100% of patients. Operative time, as well as postoperative hospital stay, were more in higher thickness groups. There was a statistically significant correlation between gallbladder wall thickness and conversion rate, complications operative time, and postoperative length of stay. Conclusion Increased gallbladder wall thickness causes increased intra as well as postoperative complications, more conversion to open procedure rate, increased operative time, and enhanced postoperative hospital stay. Among the total study population, 29.71% of patients had increased gallbladder wall thickness. In our study, a positive correlation was seen among gallbladder wall thickness, complication rate, conversion rate, intraoperative time, and postoperative hospital stay.

Defining Prolonged Length of Stay (PLOS) Following Elective Laparoscopic Cholecystectomy and Derivation of a Preoperative Risk Score to Inform Resource Utilization, Risk Stratification, and Patient Consent

OBJECTIVE

The present study defines prolonged length of stay (PLOS) following elective laparoscopic cholecystectomy (LC) and its relationship with perioperative morbidity. A preoperative risk tool to predict PLOS is derived to inform resource utilization, risk stratification and patient consent.

BACKGROUND

Surgical candidates for elective LC are a heterogeneous group at risk of various perioperative adverse outcomes. Preoperative recognition of high-risk patients for PLOS has implications on feasibility for day surgery, resource utilization, preoperative risk stratification, and patient consent.

METHODS

Data for all patients who underwent elective LC between January 2015 and January 2020 across 3 surgical centers (1 tertiary referral center and 2 satellite units) in 1 health board were collected retrospectively (n=2166). The optimal cut-off of PLOS as a proxy for operation-related adverse outcomes was found using receiver operating characteristic curves. Multivariate logistic regression was conducted on a derivation subcohort to derive a preoperative model predicting PLOS. Receiver operating characteristic curves were performed to validate the model. Patients were stratified by the risk tool and the risks of PLOS were determined.

RESULTS

A LOS of ≥3 days following elective LC demonstrated the best diagnostic ability for operation-related adverse outcomes [area under curve (AUC)=0.87] and defined the PLOS cut-off. The rate of PLOS was 6.6% (144/2166), 86.1% of which had a perioperative adverse outcome. PLOS was strongly associated with all adverse outcomes (subtotal, conversion-to-open, intraoperative complications, postoperative complication/imaging/intervention) ( P <0.001). The preoperative model demonstrated good diagnostic ability for PLOS in the derivation (AUC=0.81) and validation cohorts (AUC=0.80) and stratified patients appropriately.

CONCLUSIONS

Morbidity in PLOS patients is significant and pragmatic patient selection in accordance with the risk tool may help centers improve resource utilization, risk stratification, and their consent process. The risk tool may help select candidates for cholecystectomy in a strictly ambulatory/outpatient center.

Efficacy and Safety of Near-Infrared Florescence Cholangiography Using Indocyanine Green in Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis

Background: Achieving critical view of safety is a key for a successful laparoscopic cholecystectomy (LC) procedure. Near-infrared fluorescence cholangiography using indocyanine green (NIF-ICG) in LC has been extensively used and accepted as beneficial auxiliary tool to visualize extrahepatic biliary structures intraoperatively. This study aimed to analyze its safety and efficacy. Materials and Methods: Searching for potential articles up to March 25, 2022 were conducted on PubMed, Europe PMC, and ClinicalTrials.gov databases. Articles on the near infrared fluorescence during laparoscopy cholecystectomy were collected. Review Manager 5.4 software was utilized to perform the statistical analysis. Results: Twenty-two studies with a total of 3457 patients undergo LC for the analysis. Our meta-analysis revealed that NIF-ICG technique during LC was associated with shorter operative time (Std. Mean Difference -0.86 [95% confidence interval (CI) -1.49 to -0.23], P = .007, I2 = 97%), lower conversion rate (risk ratio [RR] 0.28 [95% CI 0.16-0.50], P < .0001, I2 = 0%), higher success in identification of cystic duct (CD) (RR 1.24 [95% CI 1.07-1.43], P = .003, I2 = 94%), higher success in identification of common bile duct (CBD) (RR 1.31 [95% CI 1.07-1.60], P = .009, I2 = 90%), and shorter time to identify biliary structures (Std. Mean Difference -0.52 [95% CI -0.78 to -0.26], P < .0001, I2 = 0%) compared with not using NIF-ICG. Conclusions: NIF-ICG technique beneficial for early real-time visualization of biliary structure, shorter operative time, and lower risk of conversion during LC. Larger randomized clinical trials are still needed to confirm the results of our study.

Evaluation of 30-day morbidity and mortality of laparoscopic cholecystectomy: a multicenter prospective observational Indian Association of Gastrointestinal Endoscopic Surgeons (IAGES) Study

BACKGROUND

Laparoscopic cholecystectomy (LC) is the standard of care for benign gallstone disease. There are no robust Indian data on the 30-day morbidity and mortality of this procedure. A prospective multicentre observational study was conducted by the Indian Association of Gastro-Intestinal Endo Surgeons (IAGES) to assess the 30-day morbidity and mortality of LC in India.

MATERIALS AND METHODS

Participating surgeons were invited to submit data on all consecutive LCs for benign diseases performed between 09/12/2020 and 08/03/2021 in adults. Primary outcome measures were 30-day morbidity and mortality. Univariate and multivariate analyses were performed to identify variables significantly associated with primary outcomes.

RESULTS

A total of 293 surgeons from 125 centres submitted data on 6666 patients. Of these, 71.7% (n = 4780) were elective. A total LC was carried out in 95% (n = 6331). Laparoscopic subtotal cholecystectomy was performed in 1.9% (n = 126) and the procedure were converted to open in 1.4% of patients. Bile duct injury was seen in 0.3% (n = 20). Overall, 30-day morbidity and mortality were 11.1% (n = 743) and 0.2% (n = 14), respectively. Nature of practice, ischemic heart disease, emergency surgery, postoperative intensive care, and postoperative hospital stay were independently associated with 30-day mortality. Age, weight, body mass index, duration of symptoms, nature of the practice, history of Coronavirus Disease-2019, previous major abdominal surgery, acute cholecystitis, use of electrosurgical or ultrasonic or bipolar energy for cystic artery control; use of polymer clips for cystic duct control; conversion to open surgery, subtotal cholecystectomy, simultaneous common bile duct exploration, mucocele, gangrenous gall bladder, dense adhesions, intraoperative cholangiogram, and use of drain were independently associated with 30-day morbidity.

CONCLUSION

LC has 30-day morbidity of 11.1%, 30-day mortality of 0.2%, conversion to open rate of 1.4%, and bile duct injury rate of 0.3% in India.

Elective laparoscopic cholecystectomy: recurrent biliary admissions predispose to difficult cholecystectomy

INTRODUCTION

Patients undergoing elective laparoscopic cholecystectomy (ELLC) represent a heterogeneous group making it challenging to stratify risk. The aim of this paper is to identify pre-operative factors associated with adverse peri- and post-operative outcomes in patients undergoing ELLC. This knowledge will help stratify risk, guide surgical decision making and better inform the consent process.

METHODS

All patients who underwent ELLC between January 2015 and December 2019 were included in the study. Pre-operative data and both peri- and post-operative outcomes were collected retrospectively from multiple databases using a deterministic records-linkage methodology. Patients were divided into groups based on clinical indication (i.e. biliary colic versus cholecystitis) and adverse outcomes were compared. Multivariate regression models were generated for each adverse outcome using pre-operative independent variables.

RESULTS

Two-thousand one hundred and sixty-six ELLC were identified. Rates of peri- and post-operative adverse outcomes were significantly higher in the cholecystitis versus biliary colic group and increased with number of admissions of cholecystitis (p < 0.05). Rates of subtotal (29.5%), intra-operative complication (9.8%), post-operative complications (19.6%), prolonged post-operative stay (45.9%) and re-admission (16.4%) were significant in the group of patients with ≥ 2 admissions with cholecystitis.

CONCLUSION

Our data demonstrate that patients with repeated biliary admission (particularly cholecystitis) ultimately face an increased risk of a difficult ELLC with associated complications, prolonged post-operative stay and readmissions. These data provide robust evidence that individualised risk assessment and consent are necessary before ELLC. Strategies to minimise recurrent biliary admissions prior to LC should be implemented.

Frailty Predicts Morbidity and Mortality After Laparoscopic Cholecystectomy for Acute Cholecystitis: An ACS-NSQIP Cohort Analysis

BACKGROUND

Current guidelines recommend laparoscopic cholecystectomy be offered for patients with acute cholecystitis except those deemed as high risk. Few studies have examined the impact of frailty on outcomes for patients undergoing laparoscopic cholecystectomy. Therefore, the aim of this study was to determine the association of frailty with postoperative morbidity and mortality in patients undergoing laparoscopic cholecystectomy for acute cholecystitis.

METHODS

Patients undergoing laparoscopic cholecystectomy for acute cholecystectomy were identified from 2005 to 2010 in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP). The Modified Frailty Index (mFI) was used a surrogate for frailty, and patients were stratified as non-frail (mFI 0), low frailty (mFI 1-2), intermediate frailty (mFI 3-4) and high frailty (mFI ≥ 5). Univariable and multivariable analyses were performed. Receiver operator curves (ROC) and an area under the curve (AUC) were generated to determine accuracy of mFI in predicting postoperative morbidity and mortality.

RESULTS

Of the 6898 patients undergoing laparoscopic cholecystectomy, 3245 (47%) patients were non-frail. There were 2913 (42%) patients with low-frailty, 649 (9%) patients with intermediate frailty, and 91 (2%) with high frailty. Clavien IV complications were higher for intermediate frail patients (OR 1.81, 95% CI 1.00-3.28, p = 0.050) and high-frail patients (OR 4.59, 95% CI 1.98-10.7, p < 0.001). Additionally, mortality was higher for patients with intermediate frailty (OR 4.69, 95% CI 1.37-16.0, p = 0.014) and high frailty (OR 12.2, 95% CI 2.67-55.5, p = 0.001). The mFI had excellent accuracy for mortality (AUC = 0.83) and Clavien IV complications (AUC = 0.73).

CONCLUSION

Frailty is associated with postoperative morbidity and mortality in patients undergoing laparoscopic cholecystectomy for acute cholecystitis.

A Simple Risk Score to Predict Clavien-Dindo Grade IV and V Complications After Non-elective Cholecystectomy

BACKGROUND

Non-elective cholecystectomies can lead to severe postoperative complications and mortality. Existing risk prediction tools do not meet the need to reliably predict these complications.

METHODS

Using the 2011-2016 American College of Surgeons National Surgical Quality Improvement Program datasets, we identified patients undergoing non-elective cholecystectomy with primary ICD 9/10 codes indicating the following diagnoses: symptomatic cholelithiasis, acute cholecystitis, choledocholithiasis, gallstone pancreatitis, and cholangitis. We randomly allocated patients to derivation and validation cohorts (80/20 split). Severe complications (Clavien-Dindo grades IV and V) included unplanned intubation, prolonged mechanical ventilation, pulmonary embolism, acute renal failure requiring dialysis, stroke, myocardial infarction, cardiac arrest, septic shock, and mortality. Logistic regression using backward selection identified predictors of severe complications and a risk score was generated based on this model.

RESULTS

Of 68,953 patients in the derivation cohort, 1.7% (N = 1157) suffered severe complications. The final multivariable risk score model included the following predictors: age (0-12 points), preoperative sepsis (5 points), planned open procedure (5 points), estimated glomerular filtration rate (0-13 points), and preoperative albumin level (0-8 points). The associated risk-score model yielded scores from 0 to 43 with 0.1-59.4% predicted probability of severe complications and had a C-statistic of 0.845 (95% CI 0.834, 0.857) in the derivation cohort and 0.870 (95% CI 0.851, 0.889) in the validation cohort.

CONCLUSION

A simple risk-score model predicts severe complications in patients undergoing unplanned cholecystectomy for common indications encountered in an acute care surgery service and identifies high-risk patients.

The Analysis of Risk Factors in the Conversion from Laparoscopic to Open Cholecystectomy

Laparoscopic cholecystectomy is a standard treatment for cholelithiasis. In situations where laparoscopic cholecystectomy is dangerous, a surgeon may be forced to change from laparoscopy to an open procedure. Data from the literature shows that 2 to 15% of laparoscopic cholecystectomies are converted to open surgery during surgery for various reasons. The aim of this study was to identify the risk factors for the conversion of laparoscopic cholecystectomy to open surgery. A retrospective analysis of medical records and operation protocols was performed. The study group consisted of 263 patients who were converted into open surgery during laparoscopic surgery, and 264 randomly selected patients in the control group. Conversion risk factors were assessed using logistic regression analysis that modeled the probability of a certain event as a function of independent factors. Statistically significant factors in the regression model with all explanatory variables were age, emergency treatment, acute cholecystitis, peritoneal adhesions, chronic cholecystitis, and inflammatory infiltration. The use of predictive risk assessments or nomograms can be the most helpful tool for risk stratification in a clinical scenario. With such predictive tools, clinicians can optimize care based on the known risk factors for the conversion, and patients can be better informed about the risks of their surgery.

Predicting the difficult laparoscopic cholecystectomy: development and validation of a pre-operative risk score using an objective operative difficulty grading system

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.

Day case laparoscopic cholecystectomy at Kilimanjaro Christian Medical Centre, Tanzania

INTRODUCTION

The Lancet Commission on Global Surgery has promoted the case for safe, affordable surgical care in low- and middle-income countries (LMICs). In 2017, Kilimanjaro Christian Medical Centre (KCMC) in Tanzania introduced a day case laparoscopic cholecystectomy (DCLC) service, the first of its kind in Sub-Saharan Africa (SSA). We aimed to evaluate this novel service in terms of safety, feasibility and acceptability by patients and staff.

METHODS

This study used mixed methods and was split into two stages. In stage 1, we reviewed records of all laparoscopic cholecystectomies (LCs) comparing day cases and admissions. These patients were followed up with a telephone questionnaire to investigate complication rates and receive service feedback. Stage 2 consisted of semi-structured interviews with staff exploring the challenges KCMC faced in implementing DCLC.

RESULTS

147 laparoscopic cholecystectomies were completed: 109 were planned for DCLC, 82 (75.2%) of which were successful, whilst 27 (24.8%) patients were admitted. No variables significantly predicted unplanned admission, the commonest causes for which were pain and nausea. In the DCLC group there was 1 readmission. 62 patients answered the follow up questionnaire, 60 (97%) of which were satisfied with the service. Stage 2 interviews suggested staff to be motivated for DCLC but revealed poor organisation of the day case pathway.

CONCLUSION

High rates of DCLC combined with low rates of complications and readmission suggests DCLC is feasible at KCMC. However, staff interviews alluded to administrative problems preventing KCMC from reaching its full DCLC potential. A dedicated day case surgery unit would address most of these problems.

Epidemiological and clinical assessment of patients undergoing Videolaparoscopic Cholecystectomy at a Curitiba teaching hospital

OBJECTIVE

to assess clinical and epidemiological factors of patients undergoing video cholecystectomy at the Hospital da Cruz Vermelha do Paraná, Curitiba unit, operated from September 2016 to September 2018, as well as the influence of comorbidities, sex and advanced age on the postoperative prognosis, while in the hospital.

METHODS

Analytic retrospective study. The analyzed variables were obtained by the review of medical records. Statistical analyses were performed considering the significance level p < 0.05.

RESULTS

389 patients, of whom 265 were women and 124 men, were included. The mean age was 51.5 years, 58.8% of the patients were diagnosed with at least one comorbidity, and 74.6% were overweight or obese. The incidence of intraoperative complications was 1.3%, postoperative 3.8% and, mortality, 0.3%. Some risk factors were identified as worse postoperative prognosis, such as Diabetes Mellitus, hypertension, presence of one or more comorbidities and mainly, advanced age, which was related to longer hospitalization times (p < 0,001), need of intensive therapy (p < 0,001), conversion to open surgery (p = 0,003) and postoperative complications (p < 0,001). Furthermore, the male sex was predictive of longer hospitalization times (p = 0,003) and need of intensive therapy (p = 0,01).

CONCLUSION

the presence of comorbidities, male sex, and advanced age are predictive factors of bad prognosis for patients undergoing video laparoscopic cholecystectomy.

Impact of General Anesthesia Guided by State Entropy (SE) and Response Entropy (RE) on Perioperative Stability in Elective Laparoscopic Cholecystectomy Patients-A Prospective Observational Randomized Monocentric Study

Laparoscopic cholecystectomy is one of the most frequently performed interventions in general surgery departments. Some of the most important aims in achieving perioperative stability in these patients is diminishing the impact of general anesthesia on the hemodynamic stability and the optimization of anesthetic drug doses based on the individual clinical profile of each patient. The objective of this study is the evaluation of the impact, as monitored through entropy (both state entropy (SE) and response entropy (RE)), that the depth of anesthesia has on the hemodynamic stability, as well as the doses of volatile anesthetic. A prospective, observational, randomized, and monocentric study was carried out between January and December 2019 in the Clinic of Anesthesia and Intensive Care of the “Pius Brînzeu” Emergency County Hospital in Timișoara, Romania. The patients included in the study were divided in two study groups: patients in Group A (target group) received multimodal monitoring, which included monitoring of standard parameters and of entropy (SE and RE); while the patients in Group B (control group) only received standard monitoring. The anesthetic dose in group A was optimized to achieve a target entropy of 40–60. A total of 68 patients met the inclusion criteria and were allocated to one of the two study groups: group A (N = 43) or group B (N = 25). There were no statistically significant differences identified between the two groups for both demographical and clinical characteristics (p > 0.05). Statistically significant differences were identified for the number of hypotensive episodes (p = 0.011, 95% CI: [0.1851, 0.7042]) and for the number of episodes of bradycardia (p < 0.0001, 95% CI: [0.3296, 0.7923]). Moreover, there was a significant difference in the Sevoflurane consumption between the two study groups (p = 0.0498, 95% CI: [−0.3942, 0.9047]). The implementation of the multimodal monitoring protocol, including the standard parameters and the measurement of entropy for determining the depth of anesthesia (SE and RE) led to a considerable improvement in perioperative hemodynamic stability. Furthermore, optimizing the doses of anesthetic drugs based on the individual clinical profile of each patient led to a considerable decrease in drug consumption, as well as to a lower incidence of hemodynamic side-effects.

Outcomes and risk factors of cholecystectomy in high risk patients: A case series

Introduction

Many studies looked at outcomes and risk factors in laparoscopic cholecystectomies in general, including a few studies on risk factors and scoring systems in predicting conversion to open surgery. Little data has been produced on high-risk patients undergoing cholecystectomy. Identifying risk factors in this group could help stratify decision making regarding best management strategies.

The aim of this study was to investigate outcomes of laparoscopic cholecystectomies in patients with ASA 3 and 4.

Methods

Data was collected and collated from a prospectively maintained database of all laparoscopic cholecystectomies performed by 13 general surgeons in a single unit. Case notes were reviewed for all patients with ASA 3 and 4 between 2013 and 2017. Data analysis was performed using R studio v 3.4.

Results

244 cases were reviewed. Common bile duct was dilated in 52 cases (21.31%). Gall bladder wall was thick in 102 (41.8%) of the patients. Surgery was elective in 203 (83.2%) of the patients. ERCP was performed in 41 (16.9%) of the patients prior to surgery. 150 patients (62.2%) stayed for 1 day while 36 (14.9%) stayed for 2 days and the remaining 55 (22.9%) stayed for 3 days or more. Complications occurred in 37 (15.16%) of the patients while 23 (9.43%) of the patients were readmitted. 7 patients (2.87%) returned to theatre and 8 (3.28%) stayed in ITU post-op. Two patients died (0.82%).

Conclusion

Laparoscopic cholecystectomies in higher risk populations are safe. Alternative methods such as cholecystostomy and ERCP may be of benefit in these patients.

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Gallstone disease represents a significant volume of elective and emergency work in the United Kingdom.

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The primary aim of the study was to explore the factors that lead to complications in high risk patients (ASA 3-4).

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Histological gallbladder thickness and emergency surgery were the factors most strongly associated with negative outcomes.

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Age greater than 65 as an independent variable does not lead to an increase in negative outcomes.

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Cholecystectomy is a relatively safe procedure in what is typically considered higher risk patients.

A new clinical-ultrasound score to predict difficult videolaparocholecystectomies: A prospective study

Background

The gold standard treatment of symptomatic cholelithiasis is videolaparoscopic cholecystectomy (VLC). The aim of this study is to produce a predictive clinical ultrasound (US) score for difficult VLC to reduce the rate of conversion to open cholecystectomy surgery and intra and/or post-operative complications.

Methods

In this prospective study carried out in 2017 we enrolled 135 patients (pts) who underwent VLC in our General Surgery Unit. A specific pre-operative abdominal ultrasound scan was performed to assess gallbladder characteristics for each patient. All US and patients' characteristics were recorded in a standard form in order to obtain a preoperative score and were then added to the intra-operative variables.

Results

The analysis revealed a statistical significance between post-operative characteristics and parietal thickness, adhesions, stratifications and volume of gallstones. Comparing the degree of difficulty VLC assessed in the pre-operative stage to the intraoperative score, the sensitivity of the preoperative US scan test is 91.8% while the specificity is 76.7%.

Conclusions

The variables which proved statistically significant in predicting a difficult cholecystectomy were: age, parietal thickness >3 mm, adhesions, stratifications, gallstones >2 cm and fixed gallstones. We have definitively defined a predictive score for difficult VLC for which a VLC is to be considered potentially difficult whenever it presents a pre-operative score equal or greater than 4 (and a "easy" one with a pre-operative score less than 4). These findings may prove helpful in further reducing the conversion rate and the rate of intra- and/or post-operative complications.

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The treatment of symptomatic cholelithiasis is videolaparoscopic cholecystectomy.

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A clinical ultrasound score for difficult VLC can reduce conversion rate.

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Intra and post-operative complications is challenging for inexperienced surgeons.

Advanced gallbladder inflammation is a risk factor for gallbladder perforation in patients with acute cholecystitis

Background

Acute perforated cholecystitis (APC) is probably the most severe benign gallbladder pathology with high rates of morbidity and mortality. The cause of APC has not been fully understood. We postulated that APC is a complication of advanced gallbladder inflammation. The aim of this study was to investigate the extent of gallbladder inflammation in patients with APC.

Methods

Patients with intraoperative and histopathologic diagnosis of APC were compared with cases with acute cholecystitis without perforation with respect to the extent of inflammation on histopathology as well as surgical outcomes.

Results

Fifty patients with APC were compared to 150 cases without perforation. Advanced age > 65 years and elevated CRP were confirmed on multivariate analysis as independent risk factors for APC. Advanced gallbladder inflammation was seen significantly more often in patients with APC (84.0 vs. 18.7%). Surgery lasted significantly longer 131.3 ± 55.2 min vs. 100.4 ± 47.9 min; the rates of conversion (22 vs. 4%), morbidity (24 vs. 7%), and mortality (8 vs. 1%) were significantly higher in patients with APC. ICU management following surgery was needed significantly more often in the APC group (56 vs. 15%), and the overall length of stay (11.2 ± 12.0 days vs. 5.8 ± 6.5 days) was significantly longer compared to the group without perforation.

Conclusion

Acute gallbladder perforation in patients with acute cholecystitis represents the most severe complication of cholecystitis. Acute perforated cholecystitis is a sequela of advanced gallbladder inflammation like empyematous and gangrenous cholecystitis and is associated with poor outcome compared to non-perforated cases.

Hispanic ethnicity and complication profile following laparoscopic and open cholecystectomy

BACKGROUND

Hispanic ethnicity is associated with increased incidence of gallbladder disease. Additionally, ethnicity has been shown to be an outcome determinant in several conditions and procedures but has never been studied as a potential determinant of morbidity or mortality after laparoscopic or open cholecystectomy.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, patients who underwent cholecystectomy and related procedures were studied in Hispanic and non-Hispanic cohorts. Mortality and postoperative complication rates were calculated and adjusted for patient demographics and comorbidities through multivariate analysis.

RESULTS

Hispanics had decreased morbidity following cholecystectomy as compared to non-Hispanics on univariate analysis in combined, laparoscopic, and open cohorts (RR 0.64, P value < 0.001; 0.68, <0.001; 0.77, <0.001, respectively). The reduction was not found to be statistically significant in multivariate analysis. A similar reduction was seen for mortality (RR 0.30, <0.001; 0.39, <0.001; 0.28, <0.001, respectively) which remained on multivariate analysis in both combined and open cohorts (RR 0.63, 0.008 and 0.48, 0.021, respectively). Additionally, the rates of several postoperative complications were found to be reduced in Hispanic patients. Though our study demonstrates a lower rate of established comorbidities for poor outcomes in Hispanics, after adjustment in multivariate analysis, the entirety of the reduced risk could not be accounted for.

CONCLUSIONS

While the Hispanic cohort has an increased incidence in gallbladder disease as compared to non-Hispanics, the complication, morbidity, and mortality rates are lower in unadjusted analysis. With adjustment, morbidity was not statistically significant and mortality was only significant in combined and open cohorts. This suggests that increased incidence rates do not equate with worse outcomes, but Hispanic ethnicity may be associated with better outcomes.

Risk factors for conversion of laparoscopic cholecystectomy to open surgery - A systematic literature review of 30 studies

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.

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.

Impact of comorbidities on the postoperative outcomes of acute cholecystitis following early cholecystectomy

PURPOSES

The purpose of this study was to evaluate the influence of comorbidities on the surgical outcomes of early cholecystectomy for acute cholecystitis.

METHODS

Data were retrospectively collected for patients with acute cholecystitis who underwent early cholecystectomy. Patients were separated into three groups based on the cholecystitis severity grade, and the surgical outcomes of early cholecystectomy were analyzed. Patients with mild and moderate cholecystitis were subdivided into a comorbidity group (n = 10) and a non-comorbidity group (n = 83).

RESULTS

There were 57 (55.3%) patients with mild cholecystitis, 36 (35.0%) with moderate cholecystitis, and 10 (9.7%) with severe cholecystitis. The surgical outcomes were significantly worse for patients with severe cholecystitis than for patients with mild or moderate cholecystitis. There were no postoperative deaths after cholecystectomy. There were no significant differences in the complication rate (P = 0.629), conversion rate (P = 0.114), or intraoperative blood loss (P = 0.147) between the comorbidity and non-comorbidity groups.

CONCLUSION

Our findings suggest that early cholecystectomy can be performed safely for patients with mild and moderate cholecystitis even if comorbidities are present. Early cholecystectomy may be an alternative treatment strategy for patients with severe cholecystitis who are candidates for anesthesia and surgery.

How to predict difficult laparoscopic cholecystectomy? Proposal for a simple preoperative scoring system

BACKGROUND

Few studies have used operative time as a reflection of the surgical difficulty to create a preoperative score of operative difficulty in laparoscopic cholecystectomies (DiLCs score).

METHODS

Patients who benefited from cholecystectomy between 2010 and 2015 were reviewed. Difficult procedures were identified using the deviations from the operative time for simple cholecystectomies. Logistic regression analyses were carried out to build risk-assessment models and derive the DiLC score.

RESULTS

Overall, 644 patients were identified. Multivariate analyses identified male sex, previous cholecystitis attack, fibrinogen, neutrophil, and alkaline phosphatase count to be predictive of operative difficulties. Risk-assessment model was generated with an area under the receiver-operator curve of .80. Internal validation was performed using the bootstrap method.

CONCLUSIONS

The DiLC score is a simple and reliable tool which could be used to improve patient counseling, optimize surgical planning, detect procedures at risk, identify patients eligible for outpatient care, and enhance resident training.

Surgical management of empyematous cholecystitis: a register study of over 12,000 cases from a regional quality control database in Germany

BACKGROUND

Acute cholecystitis is a common indication for surgery. Surgical outcomes depend among other factors on the extent of gallbladder inflammation. Data on the outcomes of patients undergoing cholecystectomy due to acute empyematous cholecystitis are rare.

METHODS

Data from a prospectively maintained quality control database in Germany were analyzed. Cases with empyematous cholecystitis were compared to cases without gallbladder empyema with regard to baseline features, clinical parameters and surgical outcomes.

RESULTS

A total of 12,069 patients with empyematous cholecystitis (EC) were compared to 33,296 patients without empyema. The male gender, advanced age, ASA score >2, elevated white blood count and fever were confirmed as risk factors for EC. The EC group differed significantly from the control group with regard to fever (28.0 vs. 9.5 %), elevated WBC (82.5 vs. 62.3 %) and positive findings from ultrasound sonography (87.4 vs. 76.9 %), p < 0001. Surgery lasted significantly longer in the EC group (86.1 ± 38.5 vs. 72.2 ± 33.6, p < 0.001). The rates of conversion (15.2 vs. 5.8 %), bile duct injury (0.8 vs. 0.4 %), re-intervention (5.5 vs. 2.6 %) and mortality (2.8 vs. 1.2 %) were significantly higher in the EC group, p < 0.001. Similarly, the length of stay (11.9 ± 10.5 vs. 8.8 ± 8.3, p < 0.001) was significantly longer in the EC group.

CONCLUSION

Empyematous cholecystitis is a severe form of acute cholecystitis with high rates of morbidity and mortality. Even the experienced laparoscopic surgeon should expect dissection difficulties, therefore the threshold for conversion in order to prevent bile duct injury should be low.

Critically ill patients with acute cholecystitis are at increased risk for extensive gallbladder inflammation

Background

Acute cholecystitis is a common diagnosis and surgery is the standard of care for young and fit patients. However, due to high risk of postoperative morbidity and mortality, surgical management of critically ill patients remains a controversy. It is not clear, whether the increased risk of perioperative complications associated with the management of critically ill patients with acute cholecystitis is secondary to reduced physiologic reserve per se or to the severity of gallbladder inflammation.

Methods

A retrospective analysis of prospectively collected data of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a university hospital over a three-year-period was performed. The ASA scores at the time of presentation were used to categorize patients into two groups. The study group consisted of critically ill patients with ASA 3 and 4, while the control group was made up of fit patients with ASA 1 and 2. Both groups were compared with regard to perioperative data, postoperative outcome and extent of gallbladder inflammation on histopathology.

Results

Two hundred and seventeen cases of acute cholecystitis with complete charts were available for analysis. The study group included 67 critically ill patients with ASA 3 and 4, while the control group included 150 fit patients with ASA 1 and 2. Both groups were comparable with regard to perioperative data. Histopathology confirmed severe cholecystitis in a significant number of cases in the study group compared to the control group (37 % vs. 18 %, p = 0.03). Significantly higher rates of morbidity and mortality were recorded in the study group (p < 0.05). Equally, significantly more patients from the study group were managed in the ICU (40 % vs. 8 %, p = 0.001).

Conclusion

Critically ill patients presenting with acute cholecystitis are at increased risk for extensive gallbladder inflammation. The increased risk of morbidity and mortality seen in such patients might partly be secondary to severe acute cholecystitis.

A proposal for a preoperative clinical scoring system for acute cholecystitis

BACKGROUND

Acute cholecystitis is a common diagnosis for which surgery is usually indicated. However, the heterogeneity of clinical presentation makes it difficult to standardize management. The variation in clinical presentation is influenced by both patient-dependent and disease-specific factors. A preoperative clinical scoring system designed to included patient-dependent and clinical factors might be a useful tool in clinical decision making.

METHODS

The data of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a university hospital were retrospectively reviewed. Patient-dependent factors (age, sex, body mass index, and American Society of Anesthesiologists score) and disease-specific factors (history of biliary colics, white blood count, C-reactive protein, and gallbladder wall thickness) were used to compute a clinical score between zero and nine for each patient. Cholecystitis was classified as mild (score ≤ 3), moderate (4 ≤ score ≤ 6), or severe (score ≥ 7).

RESULTS

Cholecystitis was mild in 45 cases, moderate in 105 cases, and severe in 27 cases. Among patient-dependent factors, the male gender, age >65 y, and American Society of Anesthesiologists score >2 correlated significantly with high scores, P = 0.001. Equally, high white blood count, elevated C-reactive protein, and gallbladder wall thickness >4 mm correlated significantly with high scores, P = 0.001. These findings were confirmed on multivariate analyses. High scores correlated significantly with the duration of surgery (P = 0.007), the need of intensive care unit management (P = 0.001) and the length of stay (P = 0.001). However, there was no significant association between the preoperative score and the rate of conversion (P = 0.103) or the rate of complication (P = 0.209).

CONCLUSIONS

This preoperative clinical scoring system has a potential to select patients with severe cholecystitis and therefore might be a useful tool in clinical decision making.

Is gallbladder inflammation more severe in male patients presenting with acute cholecystitis?

BACKGROUND

The male gender is considered a risk factor for complications in patients undergoing laparoscopic cholecystectomy. The reasons for this gender associated risk are not clearly understood. The extent of gallbladder inflammation has been shown to influence surgical outcome. The aim of this study was to investigate whether or not gallbladder inflammation is more severe in male patients presenting with acute cholecystitis.

METHODS

A retrospective gender dependent comparison of the data of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a primary care facility within a five-year period was performed.

RESULTS

138 patients, 69 males and 69 females were included for analysis. Severe gallbladder inflammation (gangrenous and necrotizing cholecystitis) was seen in a significant portion of the male population compared to the female population (p = 0.002). The male gender was confirmed in a multivariate analysis as an independent risk factor for severe cholecystits (p = 0.018).

CONCLUSION

The male gender is a risk factor for severe gallbladder inflammation. An early surgical intervention may be needed to prevent complications.

Effect of institutional volume on laparoscopic cholecystectomy outcomes: Systematic review and meta-analysis

AIM: To determine whether institutional laparoscopy cholecystectomy (LC) volume affects rates of mortality, conversion to open surgery, bile leakage and bile duct injury (BDI).

METHODS: Eligible studies were prospective or retrospective cohort studies that provided data on outcomes from consecutive LC procedures in single institutions. Relevant outcomes were mortality, conversion to open surgery, bile leakage and BDI. We performed a Medline search and extracted data. A regression analysis using generalized estimating equations were used to determine the influence of annual institutional LC caseload on outcomes. A sensitivity analysis was performed including only those studies that were published after 1995.

RESULTS: Seventy-three cohorts (127404 LC procedures) were included. Average complication rates were 0.06% for mortality, 3.23% for conversion, 0.44% for bile leakage and 0.28% for bile duct injury. Annual institutional caseload did not influence rates of mortality (P = 0.142), bile leakage (P = 0.111) or bile duct injury (P = 0.198) although increasing caseload was associated with reduced incidence of conversion (P = 0.019). Results from the sensitivity analyses were similar.

CONCLUSION: Institutional volume is a determinant of LC complications. It is unclear whether volume is directly linked to complication rates or whether it is an index for protocolised care.

Trends in cholecystectomy rates in a defined population during and after the period of transition from open to laparoscopic surgery

OBJECTIVE

To evaluate cholecystectomy rates in a Norwegian county during the transition time from open to laparoscopic surgery, with focus on the incident rate of laparoscopic operations, sex differences, age at operation, and indications for cholecystectomy.

MATERIAL AND METHODS

All 2615 patients living in North Trondelag County and operated with cholecystectomy for benign biliary disease between 1990 and 2011 were identified. Poisson regression was used to analyze factors associated with cholecystectomy incidence rate ratios (IRRs).

RESULTS

The proportion of completed laparoscopic cholecystectomies was 8% in 1992, 50% in 1994, 94% in 2003 and 99% in 2011. The incidence of cholecystectomy increased from 6.2 per 10 000 person-years in 1990-1992, 8.0 in 1993-1997, to 10.0 in 1998-2003 and remained at this level with a rate of 10.7 during 2004-2011. Adjusting for age at each year of surgery the IRR for females compared with males was 2.3(2.1-2.5) p < 0.001. The median age at operation was 60.2 years (13-90) in males, 50.1 years (12-93) in females p < 0.001. The median age diminished by 5 years in both males and females. A conversion from laparoscopic to open surgery decreased significantly by calendar year of surgery, increased with age of the patient, and was less often in surgery for gallstone colic than for other indications.

CONCLUSIONS

During the introduction of laparoscopic surgery, the rates of cholecystectomy increased and remained stable at a higher level during the later years of the study. The rate of completed laparoscopic operations increased from 8% in 1992 to 99% in 2011.

Gallbladder bed pocket score as a preoperative measure for assessing the difficulty of laparoscopic cholecystectomy

INTRODUCTION

Laparoscopic cholecystectomy (Lap-C) is a standard surgery for symptomatic gallbladder stones and acute or chronic cholecystitis. Resident surgeons often perform this operation early in their training, but they sometimes encounter difficulties for various technical reasons. Although encountering a gallbladder buried deep within the gallbladder bed is a common operative difficulty, literature on the subject scarcely exists.

METHODS

Forty-two patients underwent Lap-C at our hospitals and were analyzed retrospectively. We defined the gallbladder bed pocket score (GBPS) as the maximum ratio between the height and width of the gallbladder bed measured based on multi-detector computed tomography (MDCT) images. GBPS and clinical factors were assessed in terms of their correlation with the time required for gallbladder dissection from the gallbladder bed.

RESULTS

Of the 42 patients, 20 had histories of acute or chronic cholecystitis. The mean gallbladder dissection time was 14.9 min, and the mean GBPS was 0.43 in the coronal MDCT section and 0.56 in the sagittal section. The correlation coefficient between the GBPS and gallbladder dissection time was 0.40 (P = 0.01) in the coronal section and 0.38 (P = 0.02) in the sagittal section of the MDCT images. There was no statistically significant correlation between gallbladder dissection time and the surgeon's experience, patient's history of cholecystitis, gallstone size, or blood loss. However, GBPS > 0.4 predicted more difficult and prolonged dissection.

CONCLUSION

GBPS is a useful tool for preoperatively predicting the time needed to dissect the gallbladder from the gallbladder bed during Lap-C. Cases with GBPS < 0.4 seem more suitable for resident surgeons who are performing gallbladder dissection early in their Lap-C training.

[Typical intraoperative complications in laparoscopic surgery]

For all common laparoscopic procedures (e. g. cholecystectomy, appendectomy, inguinal hernia repair, fundoplication and colorectal resection) it has been possible to demonstrate in systematic reviews and meta-analyses that they produce better results in terms of perioperative outcome than open surgery. Accordingly, there are very few publications that report on intraoperative complications and their management. In this respect a distinction must be made between positioning complications, access complications and complications related to the pneumoperitoneum, which can manifest in all laparoscopic procedures, as well as the specific complications associated with individual procedures.The main focus of any consideration of intraoperative complications must of course be on strategies to prevent the occurrence. If intraoperative complications have occurred, the most important aspect is the diagnosis and control with prime importance accorded to which complications can still be controlled using a laparoscopic approach and when an open procedure must be used. In general a switch to open surgery should be made in the event of serious complications. Only a highly experienced laparoscopic surgeon will be able to safely manage complications once they have occurred without putting the patient at further risk. In doubtful situations the approach that poses least risk is open surgery for complications that have already occurred.

Laparoscopic cholecystectomy in a single, non-teaching hospital: an analysis of 1557 patients

BACKGROUND

Laparoscopic cholecystectomy may lead to serious complications, although it is the gold standard treatment for gallstones. In this article, the aim was to review our experience with laparoscopic cholecystectomies.

SUBJECTS AND METHODS

All laparoscopic cholecystectomies were performed in a single, non-teaching hospital between January 2000 and October 2010 and were reviewed retrospectively to analyze the effect of preoperative risk factors on outcome and the associated major complications.

RESULTS

This study included 1557 laparoscopic cholecystectomies, and the mean age of the patients was 54.1±12.3 years. The mean duration of the operation and the mean length of stay were 43.4 minutes and 1.2 days, respectively. Conversion to an open cholecystectomy was necessary in 39 patients, and thus the conversion rate was 2.5%. In total, 57 (3.7%) complications occurred in 51 patients. Serious common bile duct injury was seen in 4 (0.27%) cases. The other common complications included bile leakage in 10 (0.64%) and postoperative bleeding in 7 (0.45%) patients. The mortality rate was 0.13%. Risk factors for conversion to open surgery were male gender, age >55 years, emergency admission due to acute cholecystitis, and a history of previous acute cholecystitis attacks. Factors that increased the morbidity rate were male gender, an American Society of Anesthesiologists score of III, emergency admission due to acute cholecystitis, and a history of previous acute cholecystitis attacks.

CONCLUSIONS

Our results may serve as a baseline for comparison with future studies done at single, non-teaching hospitals where surgical teams perform laparoscopic cholecystectomies over a long period of time.