Does the complication rate increase in laparoscopic cholecystectomy for acute cholecystitis?

BACKGROUND: Laparoscopic cholecystectomy (LC) has replaced open cholecystectomy for the treatment of gallbladder disease. Despite the well-accepted success of LC in chronic cholecystitis, the efficacy of this technique has been subject to some debate in acute cholecystitis (AC). This study was designed to evaluate our institution's experience with LC for AC and chronic symptomatic calculous cholecystitis (CC), based on complication and conversion rates to open surgery. PATIENTS AND METHODS: The records of 1158 patients with LC from September 1991 to December 2001 were analyzed. The parameters of age, gender, early and late complication rates, and conversion rates from LC to open cholecystectomy were compared in patients with AC and CC. RESULTS: During the study period, LC was performed in 1158 patients. Of these, 162 patients had AC (group 1) and 996 patients had CC (group 2). The conversion rates were 4.3% (7/162) in group 1 and 2.4% (24/996) in group 2. The complication rates were not significantly different (5.6% in group 1, 5.1% in group 2, P > 0.05). Difficulty in dissection around Calot's triangle and obscure anatomy were the main reasons for conversion to conventional open surgery. The mortality rate was 1.2% in group 1 and 0.01% in group 2. CONCLUSION: LC appears to be a reliable, safe, and effective treatment modality for AC and CC. The surgical approach should be performed carefully because of the spectrum of potential hazards of the laparoscopic procedure. Conversion and complication rates are similar in both AC and CC groups, and improve as surgeons gain experience.     

Factors for conversion in laparoscopic cholecystectomy for acute cholecystitis: Is timing important?

Aim: Laparoscopic cholecystectomy is regarded as the gold standard treatment for gallstones. Conversion to open cholecystectomy is still common, and preoperative factors to predict conversion are useful in clinical practice. The aim of this study was to evaluate preoperative factors that could predict conversion in acute cholecystitis. Methods: This is a retrospective review of 83 patients with a diagnosis of acute cholecystitis who had laparoscopic cholecystectomy carried out as an emergency operation. Clinical, biochemical, and operative factors were analyzed for association with conversion. Results: A total of 83 patients were recruited to this study. The overall conversion rate was 33.7% (28/83). A longer duration of symptoms before presentation (P = 0.005) and surgery that was carried out over 48 h after admission (P = 0.022) were associated with a higher conversion rate. Emergency operations that began between 20.00 hours and 08.00 hours were also associated with a higher rate of conversion (P = 0.003). Other factors that were associated with conversion included male sex (P = 0.004), low albumin level upon admission (P = 0.024), prolonged prothrombin time (P = 0.040), and a raised serum total bilirubin level (P = 0.024). ASA scores were found to be similar in both groups (P = 0.509). Multivariate analysis by logistic regression showed that the independent risk factors for conversion in emergency laparoscopic cholecystectomy were surgery >48 h after admission (P = 0.028), emergency operation started between 20.00 hours and 08.00 hours (P = 0.026), and longer duration of symptoms before presentation (P = 0.034). Conclusions: Laparoscopic cholecystectomy should be carried out within 48 h of the patient being admitted for acute cholecystitis. The operation should be carried out during the daytime.     

Is laparoscopic cholecystectomy safe for acute cholecystitis in the presence of ventriculo-peritoneal shunt?

Introduction

In patients with ventriculo-peritoneal shunts, laparoscopic procedures were previously contraindicated for the potential risks of elevating intra-cranial pressure resulting from increased intra-abdominal pressure and shunt malfunction/infection.

Presentation of case

Here we present a case of a patient with ventriculo-peritoneal shunt who successfully and uneventfully underwent laparoscopic cholecystectomy for acute cholecystitis without any shunt manipulation or intra-cranial pressure monitoring.

Discussion

Several methods have been suggested to decrease the risks of increased intra-cranial pressure during laparoscopic cholecystectomy in patients with ventriculo-peritoneal shunts, but have not been routinely used.

Conclusion

Standard technique laparoscopic cholecystectomy can be safely used to manage patients with VP shunts presenting with acute gall bladder disease.     

Is there an optimal time for laparoscopic cholecystectomy in acute cholecystitis?

Background Laparoscopic cholecystectomy (LC) is safe in acute cholecystitis, but the exact timing remains ill-defined. This study evaluated the effect of timing of LC in patients with acute cholecystitis. Methods Prospective data from the hospital registry were reviewed. All patients admitted with acute cholecystitis from June 1994 to January 2004 were included in the cohort. Results Laparoscopic cholecystectomy was attempted in 1,967 patients during the study period; 80% were women, mean patient age was 44 years (range, 20–73 years). Of the 1,967 LC procedures, 1,675 were successful, and 292 were converted to an open procedure (14%). Mean operating time for LC was 1 h 44 min (SD ± 50 min), versus 3 h 5 min (SD ± 79 min) when converted to an open procedure. Average postoperative length of stay was 1.89 days (± 2.47 days) for the laparoscopic group and 4.3 days (± 2.2 days) for the conversion group. No clinically relevant differences regarding conversion rates, operative times, or postoperative length of stay were found between patients who were operated on within 48 h compared to those patients who were operated on post-admission days 3–7. Conclusions The timing of laparoscopic cholecystectomy in patients with acute cholecystitis has no clinically relevant effect on conversion rates, operative times, or length of stay.     

What is the best timing to perform laparoscopic cholecystectomy in acute cholecystitis?

Early laparascopic cholecystectomy within five days of onset of symptoms of acute cholecystitis has proved superior to open cholecystectomy. Feasability is well established; the conversion rate to open cholecystectomy and the post-operative morbidity are no higher than with delayed laparascopy after initial medical management. Total hospitalization is, on the other hand, significantly shorter. Only one study showed an increase in operative time with early surgery (on average 15 minutes). Both preoperative and perioperative risk factors for conversion to laparotomy were identified. Prompt laparascopic intervention avoids the complications which may arise with initial medical management, i.e., failure of medical management or biliary peritonitis. Early laparascopic cholecystectomy should be considered the gold standard for management of acute cholecystitis.     

Urgent cholecystectomy in acute cholecystitis: laparoscopy or laparotomy?

Early cholecystectomy is the best policy in the case of acute cholecystitis. The aim of this retrospective study is to evaluate the current treatment of choice of acute calculous cholecystitis, as seen in our experience and in the literature data. Between January 1997 and July 2000, 150 patients were operated on for cholecystectomy. In the group of 30 patients (20%) with acute cholecystitis, 15 patients (50%) were managed with laparoscopic approach while 15 patients (50%) with traditional operation. At the beginning the Authors chose the open via for understand the pathologic findings of acute cholecystitis, then they always preferred the laparoscopic approach. Comparison between two groups concerned the interval between onset of symptoms and operation, postoperative mortality and morbidity rates, postoperative hospital stay and follow up. Statistical analysis was performed by the Student's t-test and the chi-square test. Both groups were homogeneous with regard to sex, age and onset of symptoms. There were no deaths and morbidity rate in the laparoscopic group was 20% versus 40% (p = ns). The average postoperative hospital stay in the laparoscopic group was 5.6 days versus 10.5 days (p = 0.046). The conversion rate into laparotomy was 6.6% (1 case). There has been one case of incisional hernia in the open group at a mean follow up of 20 month. Early laparoscopic cholecystectomy is the treatment of choice of acute cholecystitis because of a lower postoperative morbidity rate and a significant shorter hospital stay.     

Laparoscopic cholecystectomy. A recommendable indication in acute cholecystitis?

While laparoscopic cholecystectomy has become the procedure of choice for the elective treatment of symptomatic cholecystolithiasis the question whether patients with acute cholecystitis should be operated laparoscopically or conventionally is still debated. Nevertheless, more and more surgeons tend to use the laparoscopic approach even in patients with acute cholecystitis. Of 1006 laparoscopic cholecystectomies performed at our hospital 42 were done for acute cholecystitis. Conversion to an open procedure was necessary in only one patient because of severe inflammatory changes. The overall mortality was zero. The average age was 45.9 years for all patients and 50.4 years for those with acute cholecystitis. The average operating time in patients with acute cholecystitis was 81 minutes compared to 62 minutes in patients who underwent elective laparoscopic cholecystectomy. The complication rate and the average hospitalization time did not differ significantly between the two groups. Our own data as well as the data retrieved from the literature seem to indicate that laparoscopic cholecystectomy is superior to the open procedure in the treatment of acute cholecystitis. Prerequisite is that the operation is performed less than 72 hours after the onset of the symptoms by an experienced operating team and the readiness to convert to open procedure if necessary. Under those circumstances laparoscopic cholecystectomy seems to be the treatment of choice for acute cholecystitis.     

A 10-year experience with the use of laparoscopic cholecystectomy for acute cholecystitis: is it safe?

BACKGROUND: In the era of open surgery, emergency open cholecystectomy has been shown for many reasons to be preferred to delayed surgery for acute cholecystitis. Despite the fact that elective laparoscopic cholecystectomy (LC) has become the gold standard for the treatment of symptomatic gallstone disease, the same procedure remains controversial for the management of acute cholecystitis because it is considered to be associated with more complications and an increased risk of common bile duct injuries than interval LC after resolution of the acute episode. The purpose of this report is to describe our experience with LC for acute cholecystitis during a 10-year period. METHODS: Patients undergoing laparoscopic surgery have been entered prospectively into a database since 1995. Those who underwent surgery before 1995 were added retrospectively to the same database. Patients were included in this study if they underwent emergency laparoscopic cholecystectomy for suspected acute cholecystitis. The diagnosis was based on clinical, laboratory, and echographic examinations. Analysis was performed to identify risk factors associated with conversion or morbidity. RESULTS: Of the 1,212 patients subjected to LC between 1990 and 1999, 268 (151 women and 117 men), with a mean age of 53 years, underwent surgery on an emergency basis for suspected acute cholecystitis. Their mean age (p = 0.002) and the proportion of men (p < 0.001) were higher than in the elective group. Delay before admission and surgery varied widely, but 72% of the patients underwent surgery within 48 h of admission. An intraoperative cholangiography, attempted in 218 patients, was successful in 207 (95%). Histologic examination confirmed acute cholecystitis in 82% of the patients. Conversion was necessary in 15.6% of the cases. It occurred more frequently in patients who underwent surgery later than 48 (p = 0.03) or 96 h (p = 0.006) after admission. No other predictor of conversion was found. Overall morbidity was 15.3%, and major morbidity was 4.4%. The only risk factor for morbidity was a bilirubin level greater than 20 mmol/l (p = 0.02). Three partial lesions of the common bile duct occurred. All were recognised and repaired immediately with no adverse effect. There was no difference in the overall rate of biliary complications between the patients operated for acute cholecystitis and those who underwent elective surgery. No reoperation was necessary, and there was no mortality. CONCLUSIONS: Although LC is safe and effective for acute cholecystitis, its associated morbidity and conversion rate are higher than for elective LC. The conversion rate decreases with experience. When surgery is performed within 2 or maximally 4 days of admission, in experienced hands, LC represents the treatment of choice for acute cholecystitis. Intraoperative cholangiography should be performed in every case because it helps to clarify the anatomy and allows for early diagnosis and repair of bile duct injuries.     

Can we consider day-case laparoscopic cholecystectomy for acute calculous cholecystitis? Identification of potentially eligible patients

Background

Day-case laparoscopic cholecystectomy has not yet been validated for acute cholecystitis. We sought to identify a subgroup of acute cholecystitis patients having been hospitalized overnight after laparoscopic cholecystectomy but who could have been eligible for day-case surgery.

Methods

We identified patients treated for acute cholecystitis with laparoscopic cholecystectomy in our university medical center between May 1, 2010, and May 31, 2012, and who lacked contraindications for day-case surgery. In a second step, we assumed that patients hospitalized for <3 d would have been eligible for day-case surgery. We then compared patients hospitalized for ≤3 d with those hospitalized for >3 d in terms of demographic data, laboratory test results, and surgical procedures.

Results

The study population comprised 86 men and 82 women (median age: 57 y; age range: 18–90 y). Contraindications for day-case surgery were identified preoperatively in 23% of the cases (39 of 168) and intraoperatively in another 23% of the cases. The proportion of patients hospitalized for <3 d was 41% (69 of 168) when considering the intention-to-treat population and 57% (51 of 90) when considering patients with no contraindications to day-case surgery. Forty percent of the patients hospitalized for ≥3 d (16 of 39) suffered from postoperative pain that was poorly controlled by oral analgesics. Abdominal drainage was the only predictive factor for hospitalization <3 d (odds ratio [95% confidence interval] = 0.13 [0.02–0.71]; P = 0.01).

Conclusions

Day-case laparoscopic may be feasible in selected patients with mild or moderate acute calculous cholecystitis. Our present results may be of use in designing a study of day-case surgery for acute calculous cholecystitis and related changes in the management of these patients.     

How early is early laparoscopic treatment of acute cholecystitis?

BACKGROUND: Despite the well-accepted success of laparoscopic cholecystectomy in elective treatment of symptomatic cholelithiasis, the efficacy and timing of this technique has been subject to some debate in the setting of acute cholecystitis. This study was undertaken to evaluate our institution's experience with early cholecystectomy as a safe, effective treatment of acute cholecystitis. METHODS: Charts of all patients who had undergone laparoscopic cholecystectomy for the diagnosis of acute cholecystitis were reviewed. Patients were divided into two groups based on the length of time from onset of symptoms to surgical intervention: less than 48 hours in the early group (n = 14) and more than 48 hours in the late group (n = 31). RESULTS: Comparing the two groups, the conversion rate to an open procedure was significantly less (0 versus 29%, P <0.04) in the early treated patients. Furthermore, the operative time (73 versus 96 minutes, P <0.004), postoperative hospitalization (1.2 versus 3.9 days, P <0.001), and total hospital stay (2.1 versus 5.4 days, P <0.004) were significantly reduced in patients undergoing early laparoscopic cholecystectomy. CONCLUSIONS: Laparoscopic cholecystectomy performed by experienced surgeons is a safe, effective technique for treatment of acute cholecystitis. Patients treated within 48 hours of onset of symptoms experience a lower conversion rate to an open procedure, shorter operative time and reduced hospitalization.     

Acute cholecystitis: when is the best time for laparoscopic cholecystectomy?

Laparoscopic cholecystectomy is no more an elective procedure. The question is when to perform laparoscopic cholecystectomy in the face of acute cholecystitis. The last decade (1995-2004) 297 patients had a laparoscopic cholecystectomy for acute cholecystitis. One hundred forty six of them were operated in the first 24-48h after the onset of symptoms (group I), 68 were operated in less than 4 weeks time after the attack of the acute cholecystitis (group II), while the rest 83 patients had a history of acute cholecystitis at least four weeks before their elective laparoscopic cholecystectomy (group III). Analysis of the operative time, complications and hospital stay showed that laparoscopic cholecystectomy in acute cholecystitis is the recommended surgical procedure. The success of the operation depends on the degree of the inflammatory changes in the gallbladder and the expertise of the operator both in emergency and laparoscopic surgery. Timing of the operation is crucial to executing a successful procedure. The operation is easier, faster and safer when performed in first 4-5 days of the onset of symptoms.     

Is early laparoscopic cholecystectomy for acute cholecystitis preferable to delayed surgery?: Best evidence topic (BET)

A best evidence topic was written according to a structured protocol. The question addressed was whether early laparoscopic cholecystectomy (ELC) in patients presenting with a short history of acute cholecystitis provides better post-operative outcomes than a delayed laparoscopic cholecystectomy (DLC). A total of 92 papers were found using the reported searches of which 10 represented the best evidence; 3 meta-analyses, 4 randomized control trials, 1 prospective controlled study and 2 retrospective cohort studies were included. The authors, date, journal, study type, population, main outcome measures and results were tabulated. No significant difference in complication or conversion rates were shown between the ELC and the DLC group, in the meta-analyses of Gurusamy et?al, Lau et?al and Siddiqui et?al. The ELC group had a decreased hospital stay whereas the DLC group presented a considerable risk for subsequent emergency surgery during the interval period, with a high rate of conversion to open cholecystectomy. All three meta-analyses were based on the randomized control trials of Lo et?al, Lai et?al, Kolla et?al and Johansson et?al; the results of each study are summarized. We conclude that there is strong evidence that early laparoscopic cholecystectomy for acute cholecystitis offers an advantage in the length of hospital stay without increasing the morbidity or mortality. The operating time in ELC can be longer, however the incidence of serious complications (i.e. common bile duct injury), is comparable to the DLC group. Larger randomized studies are required before solid conclusions are reached.     

Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?

Background  

The aim if this study was to compare percutaneous drainage (PD) of the gallbladder to emergency cholecystectomy (EC) in a well-defined patient group with sepsis related to acute calculous/acalculous cholecystitis (ACC/AAC).     

CAGS and ACS Evidence Based Reviews in Surgery. 41: Cost�Cutility analysis of early versus delayed laparoscopic cholecystectomy for acute cholecystitis

Objective: To compare the cost-effectiveness of early laparoscopic choleystectomy (ELC) versus delayed laparoscopic cholecystectomy (DLC) in patients with acute cholecystitis. Design: A decision-tree model was developed using a series that modelled all potential outcomes for both treatment options. Probabilities were estimated from a Cochrane review. Costs were based on the UK National Schedule of Reference Costs for the year 2006. Setting: UK National Health Service. Patients: Patients with acute cholecystitis. Intervention: Either ELC or DLC with a time frame of 1 year. Main outcome: Outcomes were measured in quality-adjusted life years (QALY) gained over 1 year. Results: Early laparoscopic choleystectomy is less costly and results in better quality of life (+0.05 QALY per patient) than DLC. Given a willingness-to-pay threshold of £20 000 per QALY gained, there is a 70.9% probability that ELC is more cost-effective than DLC. Conclusion: On average, ELC is less expensive and results in better quality of life than DLC.     

Urinary catheter in laparoscopic cholecystectomy: is it necessary?

The aim of this prospective study was to evaluate the necessity or urinary catheterization in elective laparoscopic cholecystectomy. From April 1996 to April 1998, 261 patients undergoing elective laparoscopic cholecystectomy at a county hospital were randomized to either receive or not receive preoperative urinary bladder catheterization. Data analyzed included age and gender of patients, length of surgery, and intraoperative and perioperative complications such as visceral injury, urinary tract infection, and urinary retention. Our results showed, although not statistically significant, more urinary tract complications in the "with Foley" group than in the "without Foley" group (four vs one, respectively). There was no significant difference between the two groups with respect to length of operation and perioperative complications. There was no visceral injury or operative mortality in this study. We conclude that urinary catheterization can be omitted safely in elective laparoscopic cholecystectomy.     

Antibiotic prophylaxis in elective laparoscopic cholecystectomy: lack of need or lack of evidence?

Background: The need to administer antibiotic prophylaxis (ABP) during laparoscopic cholecystectomy (LC) is still a matter of significant controversy. The purpose of this study was to resolve this issue by performing a meta-analysis of the available randomized controlled trials (RCT) on this topic. Methods: Papers identified via a systematic literature search were evaluated according to standard criteria. Data regarding the patient sample, study methods, and outcomes were abstracted and summarized across studies. The outcome measures were the rates of all perioperative infections, the rates of surgical site infections, and the rates of infections at other sites. Results were examined for 974 patients randomized to ABP or placebo prior to LC in six RCT published from 1997 to 2001. Results: The cumulative rates of all infections were 2.8% in the ABP group and 4.4% in the placebo group. The pooled odds ratio (OR) (95% confidence interval [CI]) was 0.69 (0.34–1.43; p = 0.32). The cumulative rates of surgical site infections were 2.1% in the ABP group and 2.9% in the placebo group. The pooled OR (95% CI) was 0.82 (0.36–1.86; p = 0.63). The cumulative rates of infections at other sites were 0.7% in the ABP group and 1.5% in the placebo group. Pooled OR (95% CI) was 0.82 (0.18–1.90; p = 0.37). No significant heterogeneity was found in any data pooling. Conclusions: Based on the available evidence, there appears to be no need to administer routine ABP to low-risk patients during LC. However, the number of patients enrolled to date into RCT is insufficient to avoid a type II error. A large and well-designed trial is urgently needed to find a conclusive answer to this question.