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.     

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.     

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.     

Timing of laparoscopic cholecystectomy in acute cholecystitis: Any controversy?

Objective: The timing of laparoscopic cholecystectomy for acute cholecystitis remains controversial. This article reviews the latest evidence for the timing of laparoscopic cholecystectomy in the management of acute cholecystitis. Methodology: Trials comparing early laparoscopic cholecystectomy (ELC; carried out within 1 week of onset of symptoms) versus delayed laparoscopic cholecystectomy (DLC; carried out at least 6 weeks after symptoms settled) for acute cholecystitis were identified from Ovid Medline, Cochrane Library and PubMed database. Only meta‐analyses and randomized clinical trials were reviewed. Results: A total of seven prospective randomized trials including 670 patients and four meta‐analyses were reviewed. ELC was superior to DLC in terms of a shorter hospital stay without any significant difference in perioperative mortality and morbidity. Conclusions: Current evidence supports ELC as the preferred treatment strategy for acute cholecystitis. It allows a shorter hospital stay, but shares similar operative morbidity, mortality and conversion rate as DLC.     

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.     

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.     

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.     

Does gender affect laparoscopic cholecystectomy?

The relationship between sex and outcome after laparoscopic surgery for symptomatic cholelithiasis remains unclear. The purpose of this study was to determine the influence of sex on the clinical presentation of patients with symptomatic gallstone disease and the clinical outcomes of laparoscopic cholecystectomy. The rates of conversion to open cholecystectomy, complication rates, operative times, and lengths of hospital stay were compared between the sexes. Compared with female patients, males were significantly older and more likely to have coexisting cardiovascular disease, previous upper abdominal surgery, previous hospitalization for acute cholecystitis and pancreatitis, acute cholecystitis, and suppurative cholecystitis (such as empyema), conversions, and complications. The mortality rate was nil. Analyses revealed an independent effect of sex on the prevalence of complications, even when including all of the major confounding factors in the model. In contrast, the effect of sex on conversion to open cholecystectomy was not significant when controlling for patient age. Operative time and postoperative hospital stay were significantly longer in males than in females. The tendency of male patients to have cholecystitis of greater severity should remind surgeons of the need to inform patients about the higher conversion rate among male patients, to reduce the disappointment of a large laparotomy wound or prolonged recovery period. On the other hand, there may be an increased need for surgeons to strongly advice male patients with symptomatic cholelithiasis to undergo early intervention.     

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.     

Laparoscopic cholecystectomy for acute cholecystitis: Can the need for conversion and the probability of complications be predicted?

Background: Laparoscopic cholecystectomy (LC) in acute cholecystitis is associated with a relatively high rate of conversion to an open procedure as well as a high rate of complications. The aim of this study was to analyze prospectively whether the need to convert and the probability of complications is predictable. Methods: A total of 215 patients undergoing LC for acute cholecystitis were studied prospectively by analyzing the data accumulated in the process of investigation and treatment. Factors associated with conversion and complications were assessed to determine their predictive power. Results: Conversion was indicated in 44 patients (20.5%), and complications occurred in 36 patients (17%). Male gender and age >60 years were associated with conversion, but these factors had no sensitivity and no positive predictive value. The same factors, together with a disease duration of >96 h, a nonpalpable gallbladder, a white blood count (WBC) of >18,000/cc³, and advanced cholecystitis, predicted conversion with a sensitivity of 74%, a specificity of 86%, a positive predictive value of ∼40%, and a negative predictive value of 96%. However, these data became available only when LC was underway. Male gender and a temperature of >38°C were associated with complications, but these factors had no sensitivity and no positive predictive value. Progression along the stages of admission and therapy did not add predictive factors or improve the predictive characteristics. Male gender, abdominal scar, bilirubin >1 mg%, advanced cholecystitis, and conversion to open cholecystectomy were associated with infectious complications. Their sensitivity and positive predictive value remained 0 despite progression along the stages of admission and therapy. Conclusion: Although certain preoperative factors are associated with the need to convert a LC for acute cholecystitis, they have limited predictive power. Factors with higher predictive power are obtained only during LC. The need to convert can only be established during an attempt at LC. Preoperative and operative factors associated with total and infectious complications have no predictive power. Received: 14 July 1999/Accepted: 21 December 1999/Online publication: 10 July 2000     

What is the optimal time for laparoscopic cholecystectomy in gallbladder empyema?

Purpose

With the accumulating experience in laparoscopic surgery, early laparoscopic cholecystectomy (LC) is increasingly offered for acute cholecystitis. However, early LC without percutaneous transhepatic gallbladder drainage (PTGBD) for gallbladder empyema is still believed to be unsafe. The purpose of this study was to determine the optimal time for LC in gallbladder empyema.

Methods

A retrospective analysis was carried out of patients who underwent LC without PTGBD for gallbladder empyema between August 2007 and December 2010. All cases were confirmed by biopsy. The patients were divided into two groups on the basis of a cutoff of 72 h.

Results

LC for gallbladder empyema was performed without PTGBD in 61 patients during the study period. The overall conversion rate was 6.6 %. Based on the 72 h cutoff, there were 33 patients in the early group and 28 in the delayed group. There were no significant differences between early and late patients with respect to operation duration (75.5 vs. 71.4 min, p = 0.537), postoperative hospital stay (4.2 vs. 3.3 days, p = 0.109), conversion rate (12.1 vs. 0 %, p = 0.118), and complication rate (12.1 vs. 3.6 %, p = 0.363). However, the early group had a significantly shorter total hospital stay (5.3 vs. 8.7 days, p = 0.001).

Conclusions

Early LC without PTGBD is safe and feasible for gallbladder empyema and is associated with a low conversion rate. Delayed LC for gallbladder empyema has no advantages and results in longer total hospital stays. LC should be performed as soon as possible within 72 h after admission to decrease length of hospital stay.     

Does a special interest in laparoscopy affect the treatment of acute cholecystitis?

BACKGROUND: We tested the hypothesis that the treatment of patients with acute cholecystitis (AC) would be improved under the care of laparoscopic specialists. METHODS: The records of patients undergoing cholecystectomy for AC from 1 January 1996 to 31 December 1998 were reviewed retrospectively. Of 170 patients, 48 were cared for by three laparoscopic specialists (LS group), whereas 122 were treated by nine general surgeons who perform only laparoscopic cholecystectomy (LC) (GS group). The rates of successful LC, complications, and length of hospital stay were compared. Multivariate analysis was used to control for baseline differences. RESULTS: The patients in the GS group were older (median age, 63 vs 53 years; p = 0.01). In all, 31 LS patients (65%), as compared with 44 GS patients (36%), had successful laparoscopic treatment (p = 0.001). The operating time was the same (median, 70 min). The proportion of patients with postoperative complications was similar in the two groups (37% in the GS vs 31% in the LS group; p = 0.6). The median postoperative hospital stay (3 vs 5 days; p <0.01) was shorter in the LS group. On logistic regression analysis, significant predictors of a successful laparoscopic operation included LS group (p <0.01) and age (p = 0). Predictors of prolonged length of hospital stay were age (p <0.01) and comorbidity score (p <0.01), with LS group status not a significant factor (p = 0.21). CONCLUSIONS: Patients with AC are more likely to undergo successful LC if cared for by a surgeon with an interest in laparoscopy. However, length of hospital stay is influenced more by patient factors in a multivariate model.