Laparoscopic Cholecystectomy in Patients With Cirrhosis of the Liver and Symptomatic Cholelithiasis

Background:

The indications and benefits of laparoscopic cholecystectomy (LC) in patients with liver cirrhosis and symptomatic cholelithiasis have not been satisfactorily documented. The aim of this study was to investigate its efficacy and safety in such patients.

Methods:

Medical records of 38 patients with liver cirrhosis (stages Child-Pugh A and B) who underwent LC were retrospectively reviewed. Demographic characteristics and other parameters including initial presentation, conversion rate, complication rate, mortality, and duration of hospital stay were investigated and compared with noncirrhotic patients'' parameters in our database.

Results:

Cirrhotic patients who underwent LC were older than noncirrhotic patients (P=0.021). Both the conversion rate (15.78%) and the duration of hospital stay were increased in the cirrhotic group, but without significant differences. Major complications occurred more often in the cirrhotic group (P=0.027), increasing morbidity; however, the mortality was zero.

Conclusions:

LC can be safely performed in Child-Pugh A and B cirrhotic patients with symptomatic gallstone disease, with acceptable complication and conversion rates. The increased risk for a major complication, however, demands more attention than usual.     

Laparoscopic Cholecystectomy in Cirrhotic Patients

Background and Objectives:

Gallstones are twice as common in cirrhotic patients as in the general population. Although laparoscopic cholecystectomy (LC) has become the gold standard for symptomatic gallstones, cirrhosis has been considered an absolute or relative contraindication. Many authors have reported on the safety of LC in cirrhotic patients. We reviewed our patients retrospectively and assessed the safety of LC in cirrhotic patients at a tertiary care hospital in Pakistan.

Methods:

From January 2003 to December 2005, a retrospective study was conducted at SU IV, Liaquat University of Medical & Health Sciences Jamshoro. All the cirrhotic patients with Child-Pugh class A and B cirrhosis undergoing LC were included in the study. Cirrhosis was diagnosed based on clinical, biochemical, ultrasonography, and intraoperative findings of the nodular liver and histopathological study.

Results:

Of 250 patients undergoing laparoscopic cholecystectomy, 20 (12.5%) were cirrhotic. Of these 20, 12 (60%) were Childs group A and 8 (40%) were group B. Thirty percent were hepatitis B positive, and 70% were hepatitis C positive. Preoperative diagnosis of cirrhosis was possible in 80% of cases, and 20% were diagnosed during surgery. Morbidity rate was 15% and mortality rate was 0%. Two patients developed postoperative ascites, and mean hospital stay was 2.8±0.1 days. Of the 20 cases, 2 (10%) were converted to open cholecystectomy. The mean operation time was 70.2±32.54 minutes.

Conclusion:

Laparoscopic cholecystectomy is an effective and safe treatment for symptomatic gallstone disease in select patients with Child-Pugh A and B cirrhosis. The advantages over open cholecystectomy are the lower morbidity rate and reduced hospital stay.     

Laparoscopic Cholecystectomy in an Academic Hospital: Evaluation of Changes in Perioperative Outcomes

Objective:

Evaluate changes in perioperative outcomes over an 82-month period in patients undergoing laparoscopic cholecystectomy by a single attending surgeon in an academic hospital.

Methods:

A retrospective review of 1025 consecutive patients undergoing laparoscopic cholecystectomy from September 1992 to February 1997 was compared to the initial 600 patients from May 1990 to August 1992. Statistical analysis included Chi square with Yates correction and Fischer''s exact test.

Results:

Over the 82-month period there were no significant differences in the overall conversion rate to open cholecystectomy (p=0.26), intraoperative complications (p = 0.81), postoperative complications (p = 0.054) or mortality rates (p=0.66). There were 3 (0.5%) bile duct injuries in the initial 600 patients and only 1 (0.1%) in the group of 1025 patients (p=0.065). There was an increase (p<0.001) in laparoscopic cholecystectomies performed for acute cholecystitis and biliary dyskinesia and an increase (p<0.001) in the percentage of cases performed overall and for acute cholecystitis by the surgery residents over the last 54 months. Despite this, the conversion rates to open cholecystectomy in patients with acute cholecystitis decreased (p < 0.001) over the last 54 months. Additionally, more patients (p < 0.001) were discharged on the day of surgery in the most recent group.

Conclusion:

Laparoscopic cholecystectomy can be performed safely by surgery residents under the direct super-vision of an experienced laparoscopist without significant changes in perioperative outcomes. Despite an increased percentage of cases being performed for acute cholecystitis over the last 54 months, conversion rates to open cholecystectomy and biliary tract injury rates have decreased, and the perioperative morbidity has remained the same.     

Post–Endoscopic Retrograde Cholangiography Laparoscopic Cholecystectomy: Challenging but Safe

Background and Objectives:

Up to 19% of patients undergoing laparoscopic cholecystectomy (LC) have common bile duct stones and may require endoscopic retrograde cholangiography (ERCP) before LC. The risk of complications of LC after ERCP is higher, and the optimal interval between ERCP and LC is disputed. In our unit, LC is performed approximately 6 weeks after ERCP. This study aims to compare outcomes between subsets of patients undergoing LC with or without prior ERCP.

Methods:

All patients undergoing ERCP and elective laparoscopic cholecystectomy (ELC) over a 1-year period were included. Outcome measures included ERCP outcomes, duration of surgery, intraoperative findings, and postoperative outcomes. Two groups of patients were compared: LC after ERCP and ELC.

Results:

The study included 190 ELC patients and 43 patients with LC after ERCP (ERCP-LC) (December 2008 to December 2009). At ERCP, 25 patients (58%) had ductal stones. The post-ERCP complication rate was 5%. The median time to LC was 42 days, and 6 patients (14%) were readmitted before LC. There were more severe adhesions and longer median operating times in the ERCP-LC group (75 minutes for ELC vs 110 minutes for ERCP-LC, P = .013). We found no significant differences in rates of conversion to open surgery, postoperative complications, lengths of stay, and readmission rates.

Conclusion:

Interval LC after ERCP is a more technically challenging procedure but is associated with a low rate of complications. Although there is emerging evidence that early LC after ERCP is feasible, our study shows that our current practice of delaying LC by approximately 6 weeks is safe.     

Operative timing of laparoscopic cholecystectomy for acute cholecystitis in a Japanese institute

Background and Objectives:

In patients with acute cholecystitis who cannot undergo early laparoscopic cholecystectomy (within 72 hours), 6 weeks to 12 weeks after onset is widely considered the optimal timing for delayed laparoscopic cholecystectomy. However, there has been no clear consensus about it. We aimed to determine optimal timing for delayed laparoscopic cholecystectomy for acute cholecystitis.

Methods:

Medical records of 100 patients who underwent standard laparoscopic cholecystectomy were reviewed retrospectively. Patients were divided into group 1, patients undergoing laparoscopic cholecystectomy within 72 hours of onset; group 2, between 4 days to 14 days; group 3, between 3 weeks to 6 weeks; group 4, >6 weeks.

Results:

No significant differences existed between groups in conversion rate to open surgery, operation time, blood loss, or postoperative morbidity, and hospital stay. However, total hospital stay in groups 1 and 2 was significantly shorter than that in groups 3 and 4 (P<.01). In addition, the total hospital stay in group 3 was also significantly shorter than that in group 4 (P<.01).

Conclusions:

Best timing of laparoscopic cholecystectomy for acute cholecystitis may be within 72 hours, and the delayed timing of laparoscopic cholecystectomy in patients who cannot undergo early laparoscopic cholecystectomy is probably as soon as possible after they can tolerate laparoscopic cholecystectomy.     

Low ninety-day re-admission rates after emergency and elective laparoscopic cholecystectomy in a district general hospital

INTRODUCTION

Re-admission rate following laparoscopic cholecystectomy is currently defined as within 30 days of the initial operation. This may underestimate the true incidence and financial cost of postoperative morbidity. This study aimed to analyse re-admissions within 90 days of elective and emergency laparoscopic cholecystectomy at a district general hospital, and to compare outcomes to larger teaching centres.

PATIENTS AND METHODS

We undertook a retrospective analysis of all patients re-admitted within 90 days of laparoscopic cholecystectomy during an 18-month period (June 2006 to December 2007). Patient characteristics, details of the primary operation, and reasons for re-admission were identified, and a comparison of re-admissions following elective versus emergency procedures was performed.

RESULTS

A total of 326 laparoscopic cholecystectomies were performed during the 18-month period (246 elective, 80 emergency). No operations required conversion to an open procedure. Twenty-five patients were re-admitted within 90 days of their operation, of whom only 14 had complications directly related to their surgery (overall re-admission rate 4.3%). There was no statistical difference in re-admission rate or cause of re-admission between elective and emergency procedures. However, the mean time to re-admission following elective procedures was significantly longer (36 days; P = 0.0003).

CONCLUSIONS

Re-admission rates at our district general hospital are comparable to those reported by larger teaching centres. Current 30-day re-admission data may significantly underestimate morbidity rates and socio-economic cost following elective laparoscopic cholecystectomy.     

Factors Influencing the Successful Completion of Laparoscopic Cholecystectomy

Objective:

To analyze the preoperative factors contributing to the decision to convert laparoscopic to open cholecystectomy.

Methods:

Retrospective identification of 324 consecutive patients undergoing laparoscopic cholecystectomy, with univariate and multivariate analysis of the following parameters: age, gender, obesity, previous abdominal surgery, presentation with acute cholecystitis, pancreatitis or obstructive jaundice, gallbladder wall thickening, gallbladder or common bile duct stones.

Results:

Thirty-nine patients (12%) underwent conversion to open cholecystectomy. Patients aged over 65 years were four times more likely to require conversion than patients under 50 years of age. Under 50 years of age, males had equal conversion rates to females, and above this age there was a non-significant increased conversion rate in males. Obese patients had higher conversion rates than non-obese patients (23% versus 9%, P < 0.003). Thirty-eight percent of patients with choledocholithiasis required conversion. Age, acute cholecystitis and choledocholithiasis independently predicted conversion. A patient aged less than fifty years with neither acute cholecystitis nor choledocholithiasis had a conversion rate of just 2%, while almost 60% of those over 65 years of age with acute cholecystitis or choledocholithiasis required conversion.

Conclusion:

The parameters of age, acute cholecystitis and choledocholithiasis must be considered in the clinical decision making process when planning laparoscopic cholecystectomy.     

Outcomes of Laparoscopic Cholecystectomy in Octogenarians

Background and Objectives:

Extremely elderly patients usually present with complicated gallstone disease and are less likely to undergo definitive treatment. The purpose of this study was to evaluate the results of laparoscopic cholecystectomy in octogenarians, with an interest in patients presenting initially with complicated gallstone disease and pancreatitis who underwent laparoscopic cholecystectomy during the same hospitalization.

Methods:

Data for 42 patients ≥80 years who underwent an elective laparoscopic cholecystectomy between January 2007 and August 2011 were retrospectively reviewed. Indications for the procedure were stratified into 2 groups: Outpatients, who were admitted electively to undergo cholecystectomy, and Inpatients, who came to our Emergency Room due to complicated biliary diseases. Data analysis included age, sex, ASA score, conversion to open surgery, time spent under general anesthesia, and length of hospital stay.

Results:

Mean age was 83.9 years; 19 (45.2%) were men. Thirteen patients (30.9%) were in the outpatient group, and 13 (30.9%) had a preoperative ASA of 3. Fourteen patients (33.3%) needed ICU. Two patients (4.8%) had their surgery converted. There were 7 (16.7%) postoperative complications, all of them classified as Dindo-Clavien I or II. No differences were noted between groups regarding conversion rates or complications. We had no mortalities in this series. There was no difference in hospital length of stay between the groups.

Conclusion:

Laparoscopic cholecystectomy in the extremely elderly is safe, with acceptable morbidity. Patients with complicated gallstone disease seem not to have worse postoperative outcomes once the initial diagnosis is properly treated and would benefit from definitive therapy during the same hospitalization.     

How Managed Care May Choose Hospitals for Contracts for Laparoscopic Cholecystectomy

Background and Objectives:

Maricopa Medical Center (MMC) was found to have higher charges and length-of-stays than 16 other regional hospitals in an analysis of DRG categories for gallbladder disease. These comparative figures identified MMC as being inefficient and demanded review to determine the reasons for the inefficiencies.

Methods:

In an attempt to determine the reason for inefficiency of charges and length-of-stay for the laparoscopic portion of laparoscopic cholecystectomy, matched pairs of open cholecystectomy and converted laparoscopic cholecystectomy from a data base of 633 patients with cholecystectomies were reviewed. Thirty-five matches for age, sex and similar diagnosis were successful.

Results:

Matched pair evaluation disclosed a $6,880 difference in charges, which was attributed solely to the charge for laparoscopy. Subsequent chart analysis showed a high charge for instrumentation, prolonged anesthesia and operative times and longer preoperative delays before surgery. Moreover, no matter what the conversion rate is, open cholecystectomy was more cost effective. However, if there is a conversion rate of 5%, total hospital charges for laparoscopic cholecystectomy would have to be reduced to $12,679 (a reduction of $3,332 from $16,011) to make laparoscopic cholecystectomy cost-effective.

Conclusions:

Cost-effective decision tree analysis of matched pair comparisons and sensitivity analysis proves to be an effective technique in evaluating the cost-effectiveness of laparoscopic cholecystectomy in a hospital population.     

Resident Training in Single-Incision Compared with Traditional Cholecystectomy

Introduction:

As attending surgeons'' comfort with single-incision laparoscopic surgery (SILS) grows, and with continued improvement in surgical instruments, advanced laparoscopic techniques are increasingly being incorporated into surgical training. The aim of our study was to evaluate resident performance and patient outcomes in patients undergoing resident-performed SILS versus a resident-performed traditional laparoscopic cholecystectomy (LC).

Methods:

A retrospective case-control study of 80 patients undergoing elective surgical intervention with a resident-performed SILS (n = 20) or a resident-performed traditional LC (n = 60) for gallbladder disease over a 15-month period was performed. Surgical indications, common perioperative variables, complications, and length of stay were reviewed, and all variables were evaluated for statistical significance.

Results:

Median operative times were similar for the resident-performed SILS cohort and the resident-performed traditional LC cohort (70.0 minutes and 66.0 minutes, respectively; P = .54). There were no complications in either the resident-performed SILS or resident-performed traditional LC groups. There was no difference in mean length of hospital stay between the resident-performed SILS group and resident-performed traditional LC group (0.95 days and 1.10 days, respectively; P = .50).

Conclusion:

Our data strongly support the ability to train senior residents to complete a SILS technique safely and with the same efficacy as with traditional LC.     

Postoperative Symptoms, After-Care, and Return to Routine Activity After Laparoscopic Cholecystectomy

Background:

Surgeons are usually not involved in the postdischarge care of patients after uncomplicated laparoscopic cholecystectomy (LC). The aim of this study was to document the symptomatic recovery of patients following LC, because this has a bearing on the planning of a postoperative care package.

Methods:

Consecutive patients undergoing uncomplicated LC were followed up by a weekly telephone questionnaire survey for 6 weeks.

Results:

The study cohort comprised 102 patients who all completed the study. Postoperatively, only 2.9% of the patients had postoperative nausea/vomiting lasting ≥2 days. Pain was symptomatic in 11.7% of patients. Port-site wounds were a source of significant symptoms in 70.5% of the patients. Postoperative review by a community nurse and primary-care doctor were necessary in 77.4% and 32% patients, respectively, with a combined average of 3.1 reviews per patient. Less than 4% of patients believed that they would benefit from a surgeon''s review 6 weeks after LC. Median time taken to return to routine preoperative activity after surgery was 22 days (IQR, 17 to 34), which was affected by the degree of activity undertaken, wound-related symptoms persisting for ≥3 weeks, planned follow-up clinic appointment, and discharge as an outpatient.

Conclusion:

Wound-related symptoms are common after LC, require substantial input from the community health service in their management, and may delay return to preoperative routine.     

Urgent Cholecystectomy for Acute Cholecystitis in a District General Hospital – Is it Feasible?

INTRODUCTION

Laparoscopic cholecystectomy has become the gold standard for treatment of symptomatic gall stone disease. However, its place remains controversial in the management of acute cholecystitis due to a high reported incidence of bile leaks and conversion rate. Tertiary referral centres have reported good results. We present a series of cases after the introduction of an urgent cholecystectomy pathway in a district general hospital.

PATIENTS AND METHODS

A practice of urgent cholecystectomy for acute cholecystitis was introduced by three consultant general surgeons. All prospective patients having an urgent laparoscopic cholecystectomy for acute cholecystitis, over an 8-month period were entered into a database. A dedicated ultrasound service was instituted to provide prompt diagnosis in these patients. Their demographic details, operative findings, laboratory results were recorded in a prospective database. Timing of ERCP, postoperative complications and conversion rate and hospital stay were also noted.

RESULTS

There were 64 patients in the study with a median age of 51 years (range, 21–84 years). There were 21 males and 43 females. All patients underwent laparoscopic cholecystectomy during the index admission. Eleven patients had pre-operative ERCP and 12 patients had on-table cholangiogram. There were no conversions. Postoperative ERCP was required in six patients. The median time interval between admission and operation was 3 days (range, 2–7 days). There were two bile leaks but no common bile duct injury. There were two cases of superficial wound infection. One patient required re-operation for smail bowel obstruction secondary to a port site hernia.

CONCLUSIONS

Urgent laparoscopic cholecystectomy for acute cholecystitis is a feasible treatment option in a district general hospital. A safe practice can be ensured by adherence to a care pathway and a multidisciplinary, consultant-delivered service. Urgent cholecystectomy service can be provided safely in a district general hospital with outcomes comparable to previously published literature.     

Laparoscopic Splenectomy Coupled with Laparoscopic Cholecystectomy

Background and Objectives:

The aim of this study was to evaluate the results of laparoscopic surgery performed for coexisting spleen and gallbladder surgical diseases.

Methods:

Between May 2004 and October 2012, 12 patients underwent concomitant laparoscopic splenectomy and cholecystectomy. Indications for surgery included idiopathic thrombocytopenic purpura in 5 patients, hereditary spherocytosis in 4 patients, and thalassemia intermedia in 3 patients.

Results:

The mean operative time was 100 minutes (range, 80–160 minutes), and the blood loss ranged from 0 to 150 mL (mean, 50 mL). The mean longitudinal diameter of the spleen was 14 cm. One patient required conversion to open procedure. An accessory spleen was detected and removed in one case. The mean length of hospital stay was 5 days. No deaths or other major intraoperative and/or postoperative complications occurred.

Conclusion:

Provided that the technique is performed by an experienced surgical team, concomitant laparoscopic splenectomy and cholecystectomy is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder diseases.     

A New Modified Layout for Laparoscopic Cholecystectomy

Objective:

The aim of this study is to present an economic and convenient modification of the layout for laparoscopic cholecystectomy, utilizing a three-port technique.

Methods:

The surgeon stands on the left side of the patient, while the assistant stands between the patient''s legs. The scrub nurse stands on the right side of the patient facing the surgeon. The assistant also operates the camera. Only three ports are used. This technique was used in 119 consecutive patients over a 24-month period. Endoscopic retrograde chlolangiopancreotography (ERCP) was done preoperatively in patients suspected to have choledocholithiasis.

Results:

Sixteen patients had ERCP done preoperatively and in 12 of them sphincterotomy and stone removal was carried out. Laparoscopic cholecystectomy was successfully completed in 115 patients. The mean operative time was 35 minutes. Four cases were converted (3.6%), one due to bile duct injury, two others due to extensive adhesions, and a fourth due to cholecystoduodenal fistula. The total morbidity rate was 4.2%. The mean hospital stay was 1.8 days.

Conclusions:

Laparoscopic cholecystectomy can be safely and conveniently done using only three ports in the modified position described. You need only one assistant, only one monitor and one less trocar. There is no prolongation of the operative time and the results are comparable to the classic four-trocar technique.     

Removing symptomatic gallstones at their first emergency presentation

INTRODUCTION

Early operations for symptomatic gallstones are gaining favour as the complication rate is thought to be lower and it reduces the overall morbidity. This study was performed to clarify how frequently early operations were being performed and what benefits resulted.

PATIENTS AND METHODS

Case notes of 171 patients who underwent laparoscopic cholecystectomy at Princess Alexandra Hospital Harlow were retrospectively reviewed. They were grouped according to their initial diagnosis (cholelithiasis, acute cholecystitis) and the delay to surgery (early, interval). Forty-one cases were excluded as they either had incomplete notes or the initial diagnosis was a different manifestation of gallstones such as pancreatitis. Those receiving interval operations were then grouped according to the mode of their initial presentation. A total of 130 case notes were analysed.

RESULTS

The delay for an interval operation was 3–6 months compared with less than 2 weeks for early operations. Of patients with acute cholecystitis, 43% had early operations but only 12% of patients with cholelithiasis. Waiting for interval operations was associated with multiple re-admissions equivalent to an average of one extra presentation to accident and emergency per patient. This was particularly marked if the initial presentation was to accident and emergency rather than out-patients (P = 0.003). Complication rates were also higher in the interval group.

CONCLUSIONS

Early cholecystectomy on the next available list is likely to reduce morbidity and the long-term in-patient burden so should be recommended for all patients presenting as an emergency with symptomatic gallstones.     

Comparison of Outcomes After Single-Port Laparoscopic Cholecystectomy in Relation to Patient Body Mass Index

Background and Objectives:

Single-port laparoscopic cholecystectomy may contribute to a paradigm shift in the field of laparoscopic cholecystectomy surgery by providing patients with benefits beyond those observed after other surgical procedures. This study was designed to evaluate clinically meaningful differences in operative outcomes between obese and nonobese patients after single-port laparoscopic cholecystectomy.

Methods:

Data were collected retrospectively from 172 patients who had undergone single-port laparoscopic cholecystectomy performed by the same surgeon at a single medical center between January and December 2011. For the outcome analysis, patients were divided into nonobese and obese patient groups according to their body mass index (<25 kg/m² vs ≥25 kg/m²).

Results:

Demographic and clinical data did not differ significantly between obese patients (n = 65) and nonobese patients (n = 107). In addition, statistically significant differences pertaining to most measured surgical outcomes including postoperative hospital stay, bile spillage, additional port use, and open conversion were not detected between the groups. However, the two groups differed significantly regarding operative time such that nonobese patients had shorter operative times than obese patients (P < .05).

Conclusion:

The results of this study showed that operative time for single-port laparoscopic cholecystectomy was the only difference between obese and nonobese patients. Given this result, body mass index may not be as relevant a factor in patient selection for single-port laparoscopic cholecystectomy as previously thought.     

Male Gender Impact on the Outcome of Laparoscopic Cholecystectomy

Background and Objectives:

Our aim was to assess the impact of male gender on the outcomes of laparoscopic cholecystectomy by eliminating associated risk factors for conversion.

Methods:

A quantitative comparative study was set up on the background of our null hypothesis that male gender has no impact on the outcomes of laparoscopic cholecystectomy. We performed a retrospective study of 241 patients and recorded the duration of surgery, length of postoperative hospital stay, conversion rate, and procedure-specific complications. Risk factors for conversion were excluded. Inferential statistics were applied, and a 2-sided P value of < .05 was considered the cutoff point to indicate the amount of evidence against the null hypothesis. We used SPSS for Windows, version 12 (IBM, Armonk, New York). Parametric data were analyzed with the independent-samples t test, and nonparametric data were analyzed with the χ² test.

Results:

A total of 175 women (72.6%) and 66 men (27.4%) underwent laparoscopic cholecystectomy. The mean age was 51.4 ± 14.8 years for women and 55 ± 12.7 years for men (P = .08). Women had a higher body mass index (28.4 ± 4.5) than men (26.8 ± 3.5) (P < .005). There were no statistically significant differences in the conversion rate and perioperative morbidity rate. The conversion rate was 2.9% for women and 7.5% for men (P = .142); the morbidity rate was 10.2% and 12.1%, respectively (P = .66). The mean duration of surgery was longer in men, at 67.9 ± 27.8 minutes, than in women, at 56.5 ± 23.98 minutes (P < .002). Both genders had an equal length of postoperative hospital stay, with 1.9 ± 1.8 days for men and 1.9 ± 2.1 days for women (P = .8).

Conclusions:

Male gender has no impact on the outcomes of laparoscopic cholecystectomy. Gender affects the duration of surgery. Larger-scale studies may disclose the factors responsible for variations in the operative time.     

Laparoscopic Cholecystectomy in Elderly Patients

Background and Objective:

In this study, we investigated whether laparoscopic cholecystectomy, a minimally invasive procedure, is advantageous in elderly patients.

Methods:

Data from 595 patients who underwent laparoscopic cholecystectomy between January 2003 and December 2007 were prospectively collected in a database. The patients were separated into 2 groups; patients >70 years of age (group A), and patients <70 years of age (group B). Group A was further divided into 3 subgroups, ages 70 to 74, 75 to 79, and 80 and above. Comparison between the groups was made with Mann-Whitney U and chi-square tests where appropriate.

Results:

ASA scores increased in conjunction with increased age (P<0.001). Of patients with an operative time longer than one hour, 26 patients aged 70 or older, and 152 patients aged 69 or younger had no difference with respect to PaCO₂ and pH measurements (P>0.05). In patients aged 80 or older, the rates of acute cholecystitis, conversion to open surgery, and postoperative complications were significantly higher than in other groups (P>0.05).

Conclusion:

We believe that in elderly patients, laparoscopic surgery can be applied safely without further increasing the surgical risks. The complications can be minimized by carefully selecting the patients aged 80 or older and by experienced teams with high technical capabilities operating on such patients.     

Liver cirrhosis grading Child-Pugh class B: a Goliath to challenge in laparoscopic liver resection?—prior experience and matched comparisons

Background

Laparoscopic hepatectomy (LH) is highly difficult in the background of liver cirrhosis. In this case series, we aimed to summarize our prior experience of LH in liver cirrhosis grading Child-Pugh class B.

Methods

In the LH database of Sir Run Run Shaw Hospital in Zhejiang, China, patients who were pathologically diagnosed with cirrhosis and graded as Child-Pugh class B or C were reviewed.

Results

Five patients grading Child B were included. There was no Child C case in our LH database. For included cases, median blood loss (BL) was 800 (range, 240-1,000) mL, median operative time was 135 (range, 80-170) minutes, and median length of hospital stay was 9 (range, 7-15) days. Forty percent (2/5) of patients was converted to open. The postoperative complication (PC) rate was 20.0% (1/5). When these Child B cases were compared with Child A cases undergoing LH, there was no statistical significance in BL, complication rate, operative time, open rate and hospital stay (HS) (P>0.05). This finding was confirmed by two ways of matched comparisons (a 1:2 comparison based on age and gender, and a 1:1 propensity score matching).

Conclusions

Although relevant literatures had suggested feasibility of LH in cirrhotic cases grading Child A, this study was the first one to discuss the value of LH in Child B cases. Our prior experience showed that in selected patients, LH in Child B patients had the potential to be as safe as in Child A cases. The efficacy of LH in Child C patients needs further exploration.     

Irrigation with bupivacaine at the surgical bed for postoperative pain relief after laparoscopic cholecystectomy

Purpose:

The aim of this study was to evaluate the effect of bupivacaine irrigated at the surgical bed on postoperative pain relief in laparoscopic cholecystectomy patients.

Methods:

This study included 60 patients undergoing elective laparoscopic cholecystectomy who were prospectively randomized into 2 groups. The placebo group (n=30) received 20cc saline without bupivacaine, installed into the gallbladder bed. The bupivacaine group (n=30) received 20cc of 0.5% bupivacaine in at the same surgical site. Pain was assessed at 0, 6, 12, and 24 hours by using a visual analog scale (VAS).

Results:

A significant difference (P=.018) was observed in pain levels between both groups at 6 hours postoperatively. The average analgesic requirement was lower in the bupivacaine group, but this did not reach statistical significance.

Conclusions:

In our study, the use of bupivacaine irrigated over the surgical bed was an effective method for reducing pain during the first postoperative hours after laparoscopic cholecystectomy.