Management of symptomatic cholelithiasis: a systematic review

Evaluation of Risk Factors Leading to Conversion from Laparoscopic Cholecystectomy to Open Surgery: A Retrospective Controlled Study

Background: Laparoscopic cholecystectomy (LC) is one of the most frequently performed operations in surgical practice. Despite increasing experience and technological advances, conversion to open surgery is still necessary in some cases. Although several studies have identified factors associated with increased risk of conversion, debates continue in the literature. This study aimed to evaluate the factors affecting the risk of conversion to open cholecystectomy. Materials and Methods: Patients who underwent surgery for cholelithiasis between 2020 and 2023 were analyzed retrospectively. Patients who underwent open cholecystectomy, those who had cholecystectomy as part of another surgical procedure, and patients with gallbladder malignancy (except incidental cases) were excluded from the study. Patients were analyzed based on demographic, clinical, laboratory, radiological, and histopathological data. This study was registered at ClinicalTrials.gov (NCT06244589). Results: A total of 1695 patients were included in the study. The median age was 50 years, and 66.6% of patients were female. Conversion from LC to open surgery occurred in 44 patients (2.6%). Multivariate analysis identified male sex, a history of major abdominal surgery, the need for emergency surgery due to acute cholecystitis, an elevated leukocyte count, and gallbladder wall thickening on abdominal ultrasonography as independent risk factors for conversion to open cholecystectomy. Conclusion: Male gender, previous major abdominal surgery, emergency surgery due to acute cholecystitis, high leukocyte count, and gallbladder wall thickening on abdominal ultrasonography are independent risk factors for conversion from LC to open surgery. It should be kept in mind in the treatment of patients planned for LC.

Age-period-cohort analysis of gallbladder and biliary diseases epidemiological trends from 1990 to 2021 and forecasts for 2035: a systematic analysis from the global burden of disease study 2021

BACKGROUND

Gallbladder and biliary diseases (GABD) represent prevalent disorders of the digestive system.

METHODS

Data on age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR), and age-standardized disability-adjusted life years (DALYs) rate (ASDR) were extracted from the Global Burden of Disease (GBD) 2021 study. The estimated annual percentage change (EAPC) was utilized to quantify temporal trends in GABD. Age-period-cohort analysis was conducted to determine the effects attributable to age, period, and birth cohort. Additionally, we projected global trends to 2035.

RESULTS

Globally, GABD incident cases, mortality cases, and DALYs increased by 60.11%, 71.71%, and 56.90%, respectively. However, all corresponding age-standardized rates (ASRs) demonstrated overall downward trends with estimated annual percentage changes (EAPC) of -0.32 (-0.38 to -0.26), -0.95 (-1.08 to -0.83), and - 0.69 (-0.74 to -0.65), respectively. The number of incident cases was higher in females than in males across all age groups. The age effect indicated that older individuals had higher age-specific incidence and death rates. Both period and cohort effects showed declining risk across incidence and mortality. The ASIR and ASMR of GABD are projected to continue decreasing over the next 15 years.

CONCLUSION

GABD continue to pose a significant global public health challenge, particularly affecting women and the elderly population. Consequently, the implementation of effective interventions to mitigate the GABD burden is of paramount importance.

Open versus laparoscopic completion cholecystectomy in patients with previous open partial cholecystectomy: a retrospective comparative study

Background

Some patients report recurrence or persistence of their manifestations after cholecystectomy, and retained gallstones may be a relevant etiology for their complaint. Completion cholecystectomy is advised for these cases to alleviate their manifestations. No previous studies have compared the outcomes of open versus laparoscopic outcomes in these patients, especially in patients who had initial open partial procedures. That is why we performed this study to report the perioperative outcomes of the two approaches in such patients.

Methodology

This is a retrospective analysis of 80 patients who had a completion cholecystectomy in the authors' center (40 open and 40 laparoscopic cases) after initial open partial cholecystectomy.

Results

The duration elapsed since the primary procedure had an average of 18 months in the open group and 21 months in the laparoscopic group. Abdominal pain and dyspepsia were the most common presentations. Some patients had stump cholecystitis or jaundice. The intraoperative assessment revealed either the residual gallbladder or a long cystic duct stump. Laparoscopy yielded shorter operative time, earlier oral intake, and shorter hospitalization periods compared to the open approach (P<0.05). The latter was associated with a 20% wound infection rate that was never encountered after laparoscopy (P =0.003).

Conclusion

Previous open partial cholecystectomy does not hinder subsequent laparoscopic completion cholecystectomy. Additionally, laparoscopy is associated with better perioperative outcomes than the open approach.

Socially vulnerable patients are more likely to fail outpatient management of symptomatic cholelithiasis

BACKGROUND

Symptomatic cholelithiasis is a common surgical problem, with many patients requiring multiple gallstone-related emergency department (ED) visits before cholecystectomy. The Social Vulnerability Index (SVI) identifies vulnerable patient populations. This study aimed to assess the association between social vulnerability and outpatient management of symptomatic cholelithiasis.

METHODS

Patients with symptomatic cholelithiasis-related ED visits were identified within our health system from 2016 to 2022. Clinical outcomes data were merged with SVI census track data, which consist of 4 SVI subthemes (socioeconomic status, household characteristics, racial and ethnic minority status, and housing type and transportation). Multivariate analysis was used for statistical analysis.

RESULTS

A total of 47,292 patients presented to the ED with symptomatic cholelithiasis, of which 6103 patients (13.3 %) resided in vulnerable census tract regions. Of these patients, 13,795 (29.2 %) underwent immediate cholecystectomy with a mean time to surgery of 35.1 h, 8250 (17.4 %) underwent elective cholecystectomy at a mean of 40.6 days from the initial ED visit, and 2924 (6.2 %) failed outpatient management and returned 1.26 times (range, 1-11) to the ED with recurrent biliary-related pain. Multivariate analysis found social vulnerability subthemes of socioeconomic status (odds ratio [OR], 1.29; 95 % CI, 1.09-1.52) and racial and ethnic minority status (OR, 2.41; 95 % CI, 2.05-2.83) to be associated with failure of outpatient management of symptomatic cholelithiasis.

CONCLUSION

Socially vulnerable patients are more likely to return to the ED with symptomatic cholelithiasis. Policies to support this vulnerable population in the outpatient setting with timely follow-up and elective cholecystectomy can help reduce delays in care and overutilization of ED resources.

ROBOtic Care Outcomes Project for acute gallbladder pathology

BACKGROUND

Robotic cholecystectomy is being increasingly used for patients with acute gallbladder disease who present to the emergency department, but clinical evidence is limited. We aimed to compare the outcomes of emergent laparoscopic and robotic cholecystectomies in a large real-world database.

METHODS

Patients who received emergent laparoscopic or robotic cholecystectomies from 2020 to 2022 were identified from the Intuitive Custom Hospital Analytics database, based on deidentified extraction of electronic health record data from US hospitals. Conversion to open or subtotal cholecystectomy and complications were defined using ICD10 and/or CPT codes. Multivariate logistic regression with inverse probability treatment weighting (IPTW) was performed to compare clinical outcomes of laparoscopic versus robotic approach after balancing covariates. Cost analysis was performed with activity-based costing and adjustment for inflation.

RESULTS

Of 26,786 laparoscopic and 3,151 robotic emergent cholecystectomy patients being included, 64% were female, 60% were ≥45 years, and 24% were obese. Approximately 5.5% patients presented with pancreatitis, and 4% each presenting with sepsis and biliary obstruction. After IPTW, distributions of all baseline covariates were balanced. Robotic cholecystectomy decreased odds of conversion to open (odds ratio, 0.68; 95% confidence interval, 0.49-0.93; p = 0.035), but increased odds of subtotal cholecystectomy (odds ratio, 1.64; 95% confidence interval, 1.03-2.60; p = 0.037). Surgical site infection, readmission, length of stay, hospital acquired conditions, bile duct injury or leak, and hospital mortality were similar in both groups. There was no significant difference in hospital cost.

CONCLUSION

Robotic cholecystectomy has reduced odds of conversion to open and comparable complications, but increased odds of subtotal cholecystectomy compared with laparoscopic cholecystectomy for acute gallbladder diseases. Further work is required to assess the long-term implications of these differences.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.