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 Cholecystectomy for Acute Cholecystitis: Does Timing Matter?

Acute cholecystitis is a common cause of acute abdominal pain and the definitive treatment is laparoscopic cholecystectomy. When to perform surgery remains controversial. To find out whether laparoscopic cholecystectomy can be performed for acute cholecystitis irrespective of the time since onset of acute symptoms. A total of 200 laparoscopic cholecystectomies performed for acute cholecystitis were evaluated for duration of surgery, conversion rates, biliary and other organ injury, and postoperative stay. Kruskal–Wallis tests, Mann–Whitney tests, and paired t-tests using SPSS software. Thirty patients underwent laparoscopic cholecystectomy within 48 h of onset of symptoms (group 1), 60 patients underwent surgery between 48 h and 6 weeks of onset of symptoms (group 2), and 110 patients underwent surgery after 6 weeks of onset of symptoms (group 3). While the duration of surgery was significantly shorter in group 3 compared to groups 1 and 2 (57.5 min vs. 53.5 min vs. 34.2 min), there were no conversions or major biliary or other organ injury in any of the three groups. Postoperative stay was also comparable between the three groups (3 days vs. 3.1 days vs. 3.08 days). Laparoscopic cholecystectomy can safely be performed at any time after the onset of acute cholecystitis.     

Delayed Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis: Is it Time for a Change?

Background

Our aim was to evaluate the advantages and limitations of delayed laparoscopic cholecystectomy (LC) in a tertiary center.

Materials and methods

A retrospective analysis of all patients admitted to our institution with acute calculous cholecystitis (ACC) between January 2003 and December of 2012 was performed. Data collected included patient demographics and comorbidities, presenting symptoms, laboratory findings, imaging results, length of stay (LOS), time to surgery, and surgical complications.

Results

A total of 1078 patients were admitted with ACC. There were 593 females (55%), and the mean age was 57 ± 0.6 years. Mean LOS at initial admission, re-admission until surgery, and following surgery was 7.9 ± 0.2, 1.5 ± 0.1, and 3.4 ± 0.2 days, respectively. Percutaneous cholecystostomy (PC) tube was inserted in 24% of the patients. Only 640 (59%) patients eventually underwent LC. Mean time to surgery was 97 ± 9.8 days, and 16.4% of patients were readmitted in this time period resulting in a mean total LOS of 10.6 ± 0.2 days. Conversion rate to open surgery was 5.8% and bile duct injury occurred in 1.1%. Postoperative complications occurred in 9.8% of the patients, and 30-day mortality was 0.6%. Patients with more severe inflammation according to Tokyo Criteria grade were more likely to undergo PC, were more likely to be readmitted while waiting for LC, and also had more postoperative complications.

Conclusions

Delayed LC is associated with significant loss of follow-up, long LOS, and higher than expected use of PC. Conversion rates are lower than in the literature while rates of bile duct injury and mortality are comparable. We believe these data as well as the available literature are sufficient to change our hospital policy regarding the surgical treatment of ACC from delayed to early same admission surgery in appropriate cases.

     

Early Cholecystectomy after Acute Admission with Cholecystitis: How Much Work?

Background  

This study was designed to determine the number of cases and amount of operating room time required, for a population of 600,000, to provide definitive treatment in the form of cholecystectomy for all patients admitted as an emergency with cholecystitis.     

Is Therapy Necessary After Distal Biceps Tendon Repair?

The EndoButton technique of distal biceps tendon repair provides strong biomechanical fixation. This strength of fixation may allow earlier postoperative range of motion (ROM). A retrospective review of 15 male patients undergoing single incision EndoButton repairs was used. Six subjects participated in conventional supervised postoperative rehabilitation while nine subjects were allowed unrestricted ROM after 2 weeks. Final ROM, time to full ROM, and Disabilities of Arm Shoulder and Hand (DASH) scores were compared. There was a significant difference for time to full ROM (p < 0.05). The mean time to full ROM was 8.67 weeks for the supervised therapy group and 4.38 weeks for the unrestricted group. There were no reruptures in either group. There were no significant differences in final ROM or DASH scores. These data suggest that unrestricted ROM results in a quicker return to full ROM without an increased risk of rerupture.     

Is the Male Gender an Independent Risk Factor for Complication in Patients Undergoing Laparoscopic Cholecystectomy for Acute Cholecystitis?

This paper was designed to investigate the gender dependent risk of complication in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. Laparoscopic cholecystectomy is the standard procedure for benign gallbladder disorders. The role of gender as an independent risk factor for complicated laparoscopic cholecystectomy remains unclear. A retrospective single-center analysis of laparoscopic cholecystectomies performed for acute cholecystitis over a 5-year period in a community hospital was performed. Within the period of examination, 1884 laparoscopic cholecystectomies were performed. The diagnosis was acute cholecystitis in 779 cases (462 female, 317 male). The male group was significantly older (P = 0.001). Surgery lasted significantly longer in the male group (P = 0.008). Conversion was done in 35 cases (4.5%). There was no significant difference in the rate of conversion between both groups. However the rate of conversion was significantly higher in male patients > 65 years (P = 0.006). The length of postoperative hospital stay was significantly longer in the male group (P = 0.007), in the group > 65 years (P = 0.001) and following conversion to open surgery (P = 0.001). The male gender was identified as an independent risk factor for prolonged laparoscopic cholecystectomy on multivariate analysis. The male gender could be an independent risk factor for complicated or challenging surgery in patients undergoing laparoscopic cholecystectomy for acute cholecystitis.Key words: Acute cholecystitis, Gallbladder disease, Laparoscopic cholecystectomy, Cholecystolithiasis, GallstonesGallbladder disorders represent common medical problems for which surgery is usually indicated. With about 1 million procedures performed worldwide per year and close to 170,000 in Germany alone, laparoscopic cholecystectomy (LC) belongs to one of the most commonly performed surgical procedures.¹ Over the last decades this procedure has grown to be the standard procedure for the management of benign gallbladder disease.^2–4 The surgical challenges in LC, especially converting from laparoscopic to open surgery has been a matter of concern.^5–9 The gender-associated risk of complication in laparoscopic cholecystectomy has not been clearly defined.^2,10–11The aim of this study was to investigate whether the male gender is an independent risk factor for complication in patients undergoing laparoscopic cholecystectomy for acute cholecystitis (AC).     

Routine Testing of Liver Function Before and After Elective Laparoscopic Cholecystectomy: Is It Necessary?

Background and Objectives:

Liver function tests (LFTs) include alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), and bilirubin. The role of routine testing before and after laparoscopic cholecystectomy was evaluated in this study.

Patients and Methods:

A total of 355 patients were retrospectively analyzed by examining the LFTs the day before, the day after, and 3 weeks after the surgery. The Wilcoxon signed-rank test and Student t test were performed to determine statistical significance.

Results:

Alterations in the serum AST, ALT, and GGT were seen on the first postoperative day. Minor changes were seen in bilirubin and ALP. An overall disturbance in the LFTs was seen in more than two-thirds of the cases. Repeat LFTs performed after 3 weeks on follow-up were found to be within normal limits.

Conclusion:

Mild-to-moderate elevation in preoperative LFTs may not be associated with any deleterious effect, and, in the absence of clinical indications, routine preoperative or postoperative liver function testing is unnecessary.     

Is a Drain Necessary Routinely After Laparoscopic Cholecystectomy for an Acutely Inflamed Gallbladder? A Retrospective Analysis of 457 Cases

Background

During laparoscopic surgery for an acutely inflamed gallbladder, most surgeons routinely insert a drain. However, no consensus has been reached regarding the need for drainage in these cases, and the use of a drain remains controversial.

Methods

This retrospective study divided 457 cases into two groups according to whether or not a drain was inserted and reviewed the surgical outcomes and perioperative morbidity.

Results

In this study, 231 patients had no drains and 226 had drains. Both groups were comparable in terms of pathology, demographics, and operative details. There was no statistical difference in operating time, visual analog scale for pain, or postoperative hospital stay. Morbidity occurred in 49 cases (10.7 %) and did not differ significantly between the two groups. No mortality occurred in this study.

Conclusions

The routine use of a drain after laparoscopic cholecystectomy for an acutely inflamed gallbladder had no effect on the postoperative morbidity. Therefore, this retrospective study supports that it is feasible not to insert a drain routinely in laparoscopic cholecystectomy for patients who have an acutely inflamed gallbladder.     

How Does Cholecystectomy Influence Recurrence of Idiopathic Acute Pancreatitis?

Background

Idiopathic acute pancreatitis is diagnosed in approximately 10–30 % of cases of acute pancreatitis. While there is evidence to suggest that the cause in many of these patients is microlithiasis, this fact has not been translated into a resource efficient treatment strategy that is proven to reduce recurrence rates. The aim of this study was to examine the value of prophylactic cholecystectomy following an episode of acute pancreatitis in patients with no history of alcohol abuse and no stones found on ultrasound.

Methods

This was a retrospective study of 2236 patients who presented to a regional Australian hospital. Patients were included when diagnosed with acute pancreatitis with no confirmed cause. Recurrence of acute pancreatitis was compared between those that did and did not undergo cholecystectomy.

Results

One hundred ninety-five consecutive patients met the study definition of “idiopathic” acute pancreatitis. 33.8 % (66/195) underwent cholecystectomy. The patients who had cholecystectomy had a recurrence rate of 19.7 % (13/66) whereas, of those managed expectantly, 42.8 % (68/159) had at least one recurrence of acute pancreatitis (P?=?0.001).

Conclusions

Following an episode of acute pancreatitis with no identifiable cause, in patients fit for surgery, cholecystectomy should be considered to reduce the risk of recurrent episodes of pancreatitis.

     

Is Surgery Necessary for Femoral Insufficiency Fractures after Long-term Bisphosphonate Therapy?

Background  

Prolonged use of bisphosphonates in patients with osteoporosis reportedly induces femoral insufficiency fractures. However, the natural course of these fractures and how to treat them remain unknown.     

Is Routine Cholecystectomy Necessary at the Time of Roux-en-Y Gastric Bypass?

Background: Morbid obesity is associated with an increased incidence of gallstones. Rapid weight loss, as occurs after Roux-en-Y gastric bypass (RYGBP) may also increase gallstone development. Standard surgical treatments for gallbladder disease and its complications might be more difficult following RYGBP. Controversy still exists whether prophylactic cholecystectomy is indicated at the time of RYGBP. Methods: Retrospective analysis was performed on a database of 535 patients who underwent RYGBP for morbid obesity during a 5.5-year period. Patients were followed and medical records were reviewed. Ursodeoxycholic acid was not prescribed following surgery. Results: 8% of patients had had cholecystectomy before the RYGBP. 75 of 492 patients (15%) were found to have gallstones at RYGBP, and cholecystectomy was performed at the same time. 3 of these patients had bile leaks but only 1 required further intervention (percutaneous transhepatic drainage for 3 weeks). Following RYGBP, 14 patients (3%) have required cholecystectomy for symptomatic cholelithiasis in the postoperative period. All were performed laparoscopically and without complication. Conclusions: Symptomatic gallbladder disease after RYGBP has not been frequent. Prophylactic cholecystectomy for a normal gallbladder is not necessary at the time of RYGBP. Patients without biliary tract symptoms may not require routine preoperative sonogram. If an abnormal gallbladder or gallstones are found at the time of an RYGBP operation, concomitant cholecystectomy should be considered.     

Renal Replacement Therapy in Acute Kidney Injury: Intermittent Versus Continuous? How Much Is Enough?

Approximately 4% of all critically ill patients will require renal replacement therapy (RRT). Despite its potential reversibility, acute kidney injury has a significant impact on morbidity and mortality. Numerous studies have addressed the questions of modality choice and dose of RRT in the intensive care unit setting. There is no clear evidence that one renal replacement modality is superior to another. Two multicenter trials focusing on dialysis dose will probably be published in the next year, either confirming or invalidating the benefit of higher effluent rates. Another key aspect in the treatment of acute kidney injury is the consequence of RRT on long-term renal function. Although cohort studies have shown that continuous RRT shortens dialysis-dependence compared with intermittent hemodialysis, randomized trials and meta-analyses do not support these findings. Several unanswered questions, such as the timing of initiation and cessation of RRT, the modification of dialysis parameters over the course of acute kidney injury and the influence of fluid status need to be addressed in future trials in order to improve outcomes related to this condition.