The obesity paradox: Underweight patients are at the greatest risk of mortality after cholecystectomy.
Rudasill Sarah E,Dillon Dustin,Karunungan Krystal,Mardock Alexandra L,Hadaya Joseph,Sanaiha Yas,Tran Zachary,Benharash Peyman
BACKGROUND:Elevated body mass index is a risk factor for gallstone disease and cholecystectomy, but outcomes for low body mass index patients remain uncharacterized. We examined the association of body mass index with morbidity, mortality, and resource use after cholecystectomy. METHODS:The 2005 to 2016 American College of Surgeons National Surgical Quality Improvement Program was retrospectively analyzed for adult patients undergoing laparoscopic and open cholecystectomy. Patients were stratified into 5 groups: body mass index <18.5 (underweight), body mass index 18.5 to 24.9 (normal weight), body mass index 25 to 29.9 (overweight), body mass index 30 to 34.9 (class I obesity), body mass index 35 to 39.9 (class II obesity), and body mass index ≥40 (class III obesity). Multivariable regressions identified independent associations of covariates with 30-day mortality, complications, and resource use. RESULTS:Of 327,473 cholecystectomy patients, 1.0% were underweight, 19.5% normal weight, 30.3% overweight, 24.0% class I obesity, 13.5% class II obesity, and 11.7% class III obesity. After multivariable analysis, underweight patients had a higher risk of mortality (adjusted odds ratio = 1.53; P = .029) and postoperative bleeding (adjusted odds ratio = 1.45; P = .011) relative to normal weight patients. Conversely, class III obesity patients had lower mortality (adjusted odds ratio = 0.66; P = .005) but increased operative time (β = 10.2 minutes; P < .001), wound infection (adjusted odds ratio = 1.38; P < .001), and wound dehiscence (adjusted odds ratio = 2.20; P < .001). Hospital duration of stay and readmission rates were highest for underweight patients. CONCLUSION:Underweight patients experience increased risk of mortality and readmission, while class III obesity patients have higher rates of wound infection and dehiscence as well as prolonged operative time. These findings may guide choice of intervention.
The Analysis of Risk Factors in the Conversion from Laparoscopic to Open Cholecystectomy.
Warchałowski Łukasz,Łuszczki Edyta,Bartosiewicz Anna,Dereń Katarzyna,Warchałowska Marta,Oleksy Łukasz,Stolarczyk Artur,Podlasek Robert
International journal of environmental research and public health
Laparoscopic cholecystectomy is a standard treatment for cholelithiasis. In situations where laparoscopic cholecystectomy is dangerous, a surgeon may be forced to change from laparoscopy to an open procedure. Data from the literature shows that 2 to 15% of laparoscopic cholecystectomies are converted to open surgery during surgery for various reasons. The aim of this study was to identify the risk factors for the conversion of laparoscopic cholecystectomy to open surgery. A retrospective analysis of medical records and operation protocols was performed. The study group consisted of 263 patients who were converted into open surgery during laparoscopic surgery, and 264 randomly selected patients in the control group. Conversion risk factors were assessed using logistic regression analysis that modeled the probability of a certain event as a function of independent factors. Statistically significant factors in the regression model with all explanatory variables were age, emergency treatment, acute cholecystitis, peritoneal adhesions, chronic cholecystitis, and inflammatory infiltration. The use of predictive risk assessments or nomograms can be the most helpful tool for risk stratification in a clinical scenario. With such predictive tools, clinicians can optimize care based on the known risk factors for the conversion, and patients can be better informed about the risks of their surgery.
Safety and outcomes of laparoscopic cholecystectomy in the extremely elderly: a systematic review and meta-analysis.
Lord Amy C,Hicks Georgina,Pearce Belinda,Tanno Lulu,Pucher P H
Acta chirurgica Belgica
Gallstones are a common cause of morbidity in the elderly. Operative treatment is often avoided due to concerns about poor outcomes but the evidence for this is unclear. We aim to consolidate available evidence assessing laparoscopic cholecystectomy outcomes in the extreme elderly (>80s) compared to younger patients. Studies comparing laparoscopic cholecystectomy in >80s with younger patients were considered. Total complications, mortality, conversion, bile duct injury, and length of stay were compared between the two groups. Twelve studies including 366,522 patients were included. They were of moderate overall quality. The elderly group had more complicated gallbladder disease and also had more co-morbidities and a higher ASA grade. The risk of morbidity was lower in the younger group (RR 0.58 (95% CI 0.58-0.59)) with a slightly lower risk of conversion (RR 0.96 (0.94-0.98)) Length of stay was significantly longer for the elderly patients. Differences in mortality and bile duct injury were non-significant in all but one study. Laparoscopic cholecystectomy is safe and effective in the extreme elderly. Higher complication rates are predominantly related to increased co-morbidities and more complex gallbladder disease. Patients should be carefully selected, and cholecystectomy performed at an earlier stage to minimize these problems.
Early Versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis with Mild Pancreatitis.
Wang Lu,Yu Hai-Feng,Guo Tong,Xie Peng,Zhang Zhi-Wei,Yu Ya-Hong
Current medical science
The safety and feasibility of early laparoscopic cholecystectomy (LC) for acute cholecystitis with mild pancreatitis were explored. A total of 973 patients with acute pancreatitis, including 651 mild cases and 322 moderate or severe cases were retrospectively studied from July 2014 to December 2018 in our department. And 426 mild pancreatitis cases with acute cholecystitis were enrolled in this study, of which 328 patients underwent LC during the same-admission (early LC group), and 98 patients underwent LC a period of time after conservative treatment (delayed LC group). Clinical characteristics, operative findings and complications were recorded and followed up. The two groups were comparable in age, gender, the grade of American Society of Anesthesiologist (ASA), biochemical findings and Balthazar computer tomography (CT) rating (P>0.05). The operation interval and hospital stay in early LC group were significantly shorter than in delayed LC group (5.83±1.62 vs. 41.36±8.44 days; 11.38±2.43 vs. 16.49±3.48 days, P<0.01). There was no significant difference in the average operation time between the two groups. No preoperative biliary related events recurred in early LC group but there were 21 cases of preoperative biliary related events in delayed LC group (P<0.01). There was no significant difference in conversion rate (3.85 vs. 5.10%, P=0.41) and surgical complication rate (3.95 vs. 4.08%, P=0.95) between early LC group and delayed LC group. During the postoperative follow-up period of 375 cases, biliary related events recurred in 4 cases in early LC group and 3 cases in delayed LC group (P=0.37). The effect of early LC during the same-admission is better than delayed LC for acute cholecystitis with mild pancreatitis.
Predictive factors for conversion of laparoscopic cholecystectomy in patients with acute cholecystitis.
Yetkin Gurkan,Uludag Mehmet,Citgez Bulent,Akgun Ismail,Karakoc Sinan
Bratislavske lekarske listy
OBJECTIVES:Laparoscopic management of acute cholecystitis may still be associated with increased risk of complications and the conversion rate to open cholecystectomy is accordingly higher when compared to elective cases. The aim of this study was to evaluate preoperative factors associated with conversion in acute cholecystitis. PATIENTS:The records of 108 patients who underwent early laparoscopic cholecystectomy for acute cholecystitis. RESULTS:Of 108 patients, 19 (17.59%) needed conversion to open cholecystectomy. Fifteen patients who required conversion to open cholecystectomy had severe inflammation and adhesions obscuring the plane of dissection and anatomy around Calot's triangle. For the remaining four patients, conversion was also necessary because of uncontrolled bleeding. Linear regression analysis revealed that advanced age (p = 0.029), obesity (p = 0.024) and pericholecystic fluid at the USG (p = 0.009) were statistically significant risk factors for conversion. CONCLUSION:The identified risk factors do not contraindicate laparoscopic cholecystectomy; however surgeons should avoid laparoscopy-associated complications by performing open operations when appropriate (Tab. 3, Ref. 26). Full Text (Free, PDF) www.bmj.sk.
The impact of body mass index on laparoscopic cholecystectomy in Taiwan: an oriental experience.
Chang Wen-Tsan,Lee King-Teh,Huang Meng-Chuan,Chen Jong-Shyone,Chiang Hung-Che,Kuo Kung-Kai,Chuang Shin-Chang,Wang Sen-Ren,Ker Chen-Guo
Journal of hepato-biliary-pancreatic surgery
BACKGROUND/PURPOSE:The outcome analysis of obese patients undergoing laparoscopic cholecystectomy (LC) in Asia-Pacific countries is rarely reported. This study examined associations between body mass index (BMI) and clinical outcomes of elective LC in Taiwan. METHODS:A total of 627 patients with gallbladder disease due to gallstones undergoing LC were divided into three groups based on BMI: <25.0 kg/m2 (normal, NO; n = 310), 25.0-29.9 kg/m2 (overweight, OW; n = 252), and >30 kg/m2 (obese, OB; n = 65). RESULTS:Both overweight and obesity were not associated with conversion and complication rates. The conversion rates of the three groups were 5.5 (NO), 6.0 (OW), and 4.6% (OB), and the complication rates were 3.2 (NO), 2.4% (OW), and 4.6% (OB), respectively. However, overweight and obesity were related to a trend toward longer operating time (NO 67.4 +/- 31.8; OW 77.8 +/- 35.6; OB 79.0 +/- 37.9 min) (P trend <0.001). One death (BMI 40.6 kg/m2) was due to septic complications. In the multivariable logistic analysis, only acute cholecystitis, but not BMI, was a predictor for conversion and complications. CONCLUSIONS:Based on these results, it appears that BMI was not associated with clinical outcomes and that LC is a safe procedure in obese patients with uncomplicated gallstone disease in Taiwan.
Factors influencing the successful completion of laparoscopic cholecystectomy.
Chandio Ashfaq,Timmons Suzanne,Majeed Aamir,Twomey Aongus,Aftab Fuad
JSLS : Journal of the Society of Laparoendoscopic Surgeons
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.
Gallbladder Disease in Children: A 20-year Single-center Experience.
Pogorelić Zenon,Aralica Maja,Jukić Miro,Žitko Vanda,Despot Ranka,Jurić Ivo
OBJECTIVE:Aim of this study was to examine the changes in incidence of pediatric cholecystectomies. METHODS:Based on a review of hospital-records, children were divided into two groups regarding year of surgery (Group I: 1998-2007; Group II: 2008-2017) and their characteristics were compared. RESULTS:Number of cholecystecomies increased from 11 to 34. Median age increased from 11 to 15.5 years and mean BMI increased from 19.2 cm/m2 to 23.0 cm/m2. Hereditary spherocytosis decreased from 63.6% to 11.8% (P=0.001) of indications for cholecystectomy, while proportion of cholesterol stones increased from 27.3% to 70.6% (P=0.006). Frequency of laparoscopic cholecystectomy increased from 36.4% to 85.3% (P=0.001). Duration of hospital stay shortened from 8 to 4 days (P=0.008). CONCLUSIONS:Number of pediatric cholecystectomies has significantly increased in the last 20 years, as well as average BMI of the observed population This probably signifies a correlation between rising obesity rates and increase in frequency of symptomatic cholelithiasis in children.
Retrospective Analysis of Complications Associated with Laparoscopic Cholecystectomy for Symptomatic Gallstones.
Amreek Fnu,Hussain Syed Zohaib Maroof,Mnagi Munawar H,Rizwan Amber
Introduction Gallstones are the major cause of global morbidity. Laparoscopic approach has well-established advantages as compared to the conventional open procedure. It promises better recovery, lower morbidity, and lower postoperative pain, shortens the duration of hospital stay, and has a lower mortality rate. The aim of this study is to assess the frequency of complications in laparoscopic cholecystectomies indicated for symptomatic gallstones and also evaluate the rate of conversion. Methods In this retrospective analysis, all records of laparoscopic cholecystectomy, in patients of age ≥18 years, for symptomatic gallstones, from January 2015 till December 2018 in one of the largest public tertiary care hospitals in Pakistan were included. Results The rate of complications associated with laparoscopic cholecystectomy was 6.8%. Older age, obesity, and multiple pre-operative risk factors were associated with complications. The most common intra-operative complication was hemorrhage (1.3%) and most common postoperative complication was surgical site infection (2.7%). Our conversion rate was 3.6%. Both intra-operative and postoperative complications were more common in procedures which were converted to open. Conclusion The rate of complication and conversion to open in laparoscopic cholecystectomy is not very high. Older age, obesity, and multi-morbidity was associated with complications. Complicated procedures were more commonly needed to be converted to open.
Laparoscopic cholecystectomy in obese and non-obese children.
Garey Carissa L,Laituri Carrie A,Keckler Scott J,Ostlie Daniel J,Stagg Hayden W,Little Danny C,St Peter Shawn D
The Journal of surgical research
BACKGROUND:Obesity is an increasing problem in the pediatric population. Despite abundant data on the impact of obesity in adults, little data exist that examines the impact of obesity on surgical outcomes in children. We reviewed our experience with laparoscopic cholecystectomy to evaluate the impact of obesity. METHODS:We performed a retrospective chart review of patients who underwent laparoscopic cholecystectomy between September, 2000 and June, 2009. Demographics, indication, length of operation, length of stay, and complications were examined. Body mass index (BMI) was calculated and BMI percentage according to gender and age was determined. RESULTS:There were 312 patients identified, 150 patients were normal weight (BMI less than 85%), 65 patients were overweight (BMI = 85%-95%), and 97 patients were obese (BMI > 95%). The mean age of the patients was 14 y (range 0-20), and 76% were female. The overweight and obese groups had more females (P = 0.022 and P = 0.0016) and the obese group was older (P = 0.0003). No differences were found between the groups in the indication for cholecystectomy. There was no difference in operative time, length of stay, or complications between normal weight patients and overweight or obese patients. CONCLUSION:Despite the known surgical challenges with overweight patients, laparoscopic cholecystectomy is a safe and equally beneficial procedure in overweight children.
Changes of inflammatory mediators in obese patients after laparoscopic cholecystectomy.
Di Vita Gaetano,Patti Rosalia,Famà Fausto,Balistreri Carmela Rita,Candore Giuseppina,Caruso Calogero
World journal of surgery
BACKGROUND:Obesity is associated with the impairment of immunological functions. The aim of this study was to analyze some inflammatory mediators in obese subjects who underwent laparoscopic cholecystectomy. METHODS:Seventeen consecutive female patients with a BMI ranging from 35 to 45 kg/m(2) (obese) and 17 consecutive female patients with BMI ranging from 20 to 25 kg/m(2) (nonobese) were included in the study. All patients were affected by symptomatic gallbladder stone disease and underwent laparoscopic cholecystectomy. Changes in levels of leukocytes, neutrophils, IL-6, IL-10, leptin, and adiponectin were evaluated. RESULTS:We observed a significant increase in leukocyte and neutrophil levels in the obese subjects compared to the nonobese subjects. The serum levels of leptin and IL-6 were higher in the postoperative period (compared to the baseline values in both groups), and always higher in the obese. Both adiponectin and IL-10 increased in the postoperative period in nonobese subjects and was always higher than in the obese. CONCLUSIONS:Obese patients have a stronger acute inflammatory response than do nonobese subjects in reaction to surgical stress.
Prolonged (longer than 3 hours) laparoscopic cholecystectomy: reasons and results.
Subhas Gokulakkrishna,Gupta Aditya,Bhullar Jasneet,Dubay Linda,Ferguson Lorenzo,Goriel Yousif,Jacobs Michael J,Kolachalam Ramachandra B,Silapaswan Sumet,Mittal Vijay K
The American surgeon
For the experienced surgeon, the average operative time for a laparoscopic cholecystectomy is less than 1 hour. There has been no study documenting the causes and results of prolonged (longer than 3 hours) surgery. A retrospective study was done of patients who underwent cholecystectomy between January 2003 and December 2007. A total of 3126 cholecystectomies were done. After excluding patients who had a planned open cholecystectomy and patients who had additional laparoscopic surgeries, we identified 70 patients who had a planned laparoscopic cholecystectomy with operative time exceeding 3 hours. Multivariate stepwise logistic regression was performed analyzing the various factors leading to prolonged surgery. Of the 70 patients, ranging in age from 21 to 92 years (mean, 57 years), most (n = 53) were female. Operative time ranged from 3 hours to 6 hours 40 minutes (mean, 3 hours 37 minutes). Emergency:elective admission ratio was 9:5 and acute cholecystitis (n = 40) was the most common indication. Common characteristics were obesity (n = 44, P = 0.031), intra-abdominal adhesions (n = 43, P = 0.004), and previous abdominal surgeries (n = 40, P = 0.002). Intraoperative complications included spillage of stones (n = 6), bile duct injury (n = 3), and bleeding (n = 3). The possibility of prolonged laparoscopic cholecystectomy should be anticipated in patients with obesity and previous abdominal operations. Prolonged surgery increases the risk of complications (bile duct injury, bleeding) and prolongs the postoperative hospital stay.
Meta-analysis of prospective randomized studies comparing single-incision laparoscopic cholecystectomy (SILC) and conventional multiport laparoscopic cholecystectomy (CMLC).
Pisanu Adolfo,Reccia Isabella,Porceddu Giulia,Uccheddu Alessandro
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract
BACKGROUND:Single-incision laparoscopic cholecystectomy (SILC) has gained acceptance among surgeons as there is a trend to minimize the invasiveness of laparoscopy. The aim of this meta-analysis has been to assess the feasibility and safety of SILC when compared to conventional multiport laparoscopic cholecystectomy (CMLC). METHODS:A literature search for trials comparing SILC and CMLC was performed. Studies were reviewed for the outcomes of interest: patient characteristics; operative time and conversion rate; postoperative pain; length of hospital stay; postoperative complications; and patient satisfactory score (0-10). Standardized mean difference (SMD) was calculated for continuous variables and odds ratio for qualitative variables. RESULTS:Twelve prospective randomized trials comparing SILC and CMLC were analyzed. Overall, 892 patients were randomized to either SILC (465) or CMLC (427). Operative time was significantly longer in SILC (63.0 vs. 45.8 min, SMD = 1.004, 95% CI = 0.434-1.573). Patient satisfactory score significantly favored SILC (8.2 vs. 7.2, SMD = -0.759, 95% CI = -1.064 to -0.455). No other difference was found. CONCLUSIONS:SILC is a safe and effective procedure for the treatment of uncomplicated benign gallbladder disease with a significant patient satisfaction. New multicenter randomized trials are expected to evaluate SILC in more complex circumstances such as acute cholecystitis, previous abdominal surgery, and severe obesity.
Gallstone disease in young population: incidence, complications, therapeutic approach.
Constantinescu T,Huwood Al Jabouri Abdul Kariem H,Brãtucu E,Olteanu C,Toma M,Stoiculescu A
Chirurgia (Bucharest, Romania : 1990)
OBJECTIVE:The purpose of this study is to highlight the high incidence of gallstones and the etiology in young people, as well as the fact that the onset is associated with complications: i.e. acute pancreatitis, jaundice. MATERIAL AND METHODS:This retrospective study was conducted between January 2007 and February 2012 on patients admitted to the two surgical wards of Pitesti District Hospital and was based on the analysis of observation charts and theatre records. A total of 1905 cholecystectomies were performed, 1023 laparoscopic and 882 classic, respectively. RESULTS:A total of 36 patients aged between 16 and 25 years were included in the study. Laparoscopic cholecystectomy was performed in 34 patients, only two patients being operated by the classical open approach. 6 patients developed postoperative jaundice, which resolved under medical treatment in 3 patients within 3-5 days. The remaining 3 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) 4-5 days postoperatively. CONCLUSIONS:The most important risk factors for gallstones are: age, female gender, pregnancy and obesity. Common complications of gallstones in young people are: duct stones and acute pancreatitis.
Factors Associated With Outcomes and Costs After Pediatric Laparoscopic Cholecystectomy.
Akhtar-Danesh Gileh-Gol,Doumouras Aristithes G,Bos Cecily,Flageole Helene,Hong Dennis
Importance:The prevalence of pediatric cholelithiasis is increasing with the epidemic of childhood obesity. With this rise, the outcomes and costs of pediatric laparoscopic cholecystectomy become an important public health and economic concern. Objective:To assess patient and health system factors associated with the outcomes and costs after laparoscopic cholecystectomy among Canadian children. Design, Setting, and Participants:This was a retrospective, population-based study of children 17 years and younger undergoing laparoscopic cholecystectomy from April 1, 2008, until March 31, 2015. The data source was the Canadian Institute for Health Information. The Canadian Institute for Health Information Discharge Abstract Database includes data from all Canadian hospitals. The analysis was limited to inpatient cholecystectomies. All Canadian children undergoing laparoscopic cholecystectomy were included. Exposure:The exposure in this study was laparoscopic cholecystectomy. Main Outcomes and Measures:The primary outcome was all-cause morbidity, a composite outcome of any complication that prolonged length of stay by 24 hours or required a second, unplanned procedure. The cost of the index admission was also calculated as a secondary outcome. These outcomes of interest were determined before data analysis. Odds ratios and 95% CIs were estimated using multilevel logistic regression models. Results:During the study period, 3519 laparoscopic cholecystectomies were performed; of these, 79.1% (n = 2785) were in girls, and 98.0% (n = 3450) were for gallstone disease. The overall morbidity rate was 3.9% (n = 137). After adjustment, patients with comorbidities were more susceptible to morbidity (odds ratio, 2.68; 95% CI, 1.78-3.86; P < .001). Operations for gallstones were less morbid. High-volume general surgeons had lower morbidity rates compared with low-volume pediatric surgeons (odds ratio, 0.32; 95% CI, 0.12-0.69; P = .005) independent of pediatric volumes. The mean (SD) unadjusted cost of a laparoscopic cholecystectomy was $4115 ($7273). Operative indication, complications, comorbidities, emergency admission, and surgeon volume were associated with cost. Conclusions and Relevance:The high-volume nature of adult general surgery translated to lower morbidity and cost after pediatric laparoscopic cholecystectomy, suggesting that adult volume is associated with pediatric outcomes. As the rate of pediatric gallstone disease increases, surgeon volume, rather than specialty training, should be considered when pursuing operative management.
Laparoscopic versus open cholecystectomy in diabetic patients and postoperative outcome.
Paajanen Hannu,Suuronen Satu,Nordstrom Pia,Miettinen Pekka,Niskanen Leo
BACKGROUND:Diabetes mellitus is associated with an increased risk of complications after abdominal surgery. We evaluated retrospectively the impact of preoperative risk factors and outcome of diabetic patients after laparoscopic cholecystectomy (LC) compared with open cholecystectomy (OC) for symptomatic gallstones. METHODS:Altogether 2,548 consecutive patients (1,581 LC, 967 OC) with symptomatic gallstones underwent cholecystectomy at our secondary referral center, being the only operative unit in the catchment area. Between the years 1995 and 2008, we operated 227 (9%) patients with diabetes, of whom 45 (20%) had type 1 diabetes. Preoperative data and operative outcome of the diabetic patients undergoing LC (n = 102) and OC (n = 125) were compared. The effect of comorbidities of diabetes on the risk for postoperative complications was analyzed by multiple logistic regression analysis. RESULTS:The percentage of morbidly obese diabetic patients did not change during the study period. Almost half of the cholecystectomies (n = 111) in diabetics were performed as acute surgery due to cholecystitis. Conversion to open surgery was required in 16% of the diabetic patients undergoing LC compared with 7% in the nondiabetic controls (p < 0.0001). Mortality rate was zero and nine patients (7.2%), respectively, in the LC and OC groups (p < 0.01). Other complications were also more frequently observed in the OC than LC groups. This outcome difference was unchanged during time. On multivariate analysis, comorbidities of diabetes were associated with an elevated risk for complications, but obesity or acute surgery was not independently associated with postoperative complications. CONCLUSIONS:When feasible, LC was a safe procedure in diabetes. Open surgery with comorbidities increased the operative risks. Our study was not randomized, and therefore selection bias to type of procedure may affect the results.
Robotic single-site cholecystectomy in the obese: outcomes from a single institution.
Svoboda Shane,Qaqish T Robert,Wilson Ana,Park Habeeba,Youssef Yassar
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery
BACKGROUND:Robotic single-site cholecystectomy (RSSC) has been shown to be a safe alternative to the laparoscopic approach in selected patients. Patient exclusion criteria have prevented RSSC as a surgical option in many obese patients. This study reports the feasibility of performing RSSC in obese patients (body mass index [BMI] ≥ 30). METHODS:Between November 2012 and February 2014, a total of 200 patients underwent RSSC at our institution. All patients were offered the robotic procedure regardless of their BMI, age, previous surgery, and acuity of their disease with no exclusion criteria. All patients with BMI ≥ 30 were included in the study and were compared to nonobese patients for demographic characteristics, co-morbidities, and postoperative outcomes. Data were compared to RSSC performed in nonobese patients by the same surgeon, as well to published data for standard laparoscopic cholecystectomy (LC). RESULTS:A total of 112 cholecystectomies were successfully performed with the robotic approach in patients with BMI ≥ 30 without conversion to open, laparoscopic, or multiport procedures. The mean BMI was 39.5 (range 30.1-62.3). Twenty-eight patients had a BMI ≥ 40 (25%), and 13 patients had a BMI ≥ 50 (11.6%). Fifty-two patients (46.4%) had a history of prior abdominal surgery. Most procedures were nonelective (78.6%) with patients presenting with acute symptoms. Pathology showed chronic cholecystitis and cholelithiasis in 79 patients (70.5%), acute cholecystitis in 26 patients (23.3%), cholelithiasis in 4 patients (3.5%), and gangrenous cholecystitis in 3 patients (2.7%). Total mean operative time was 69.8 (26) minutes for obese patients compared to 59.2 (19.7) minutes in the nonobese, which was statistically significant (P = .0012). After a mean follow-up of 6 months, there were no major complications recorded including bile leak, hematoma, or ductal injury. There was 1 umbilical (incisional) hernia (0.9%) reported, and zero wound infections. When comparing RSSC performed in obese patients, RSSC in nonobese patients, and published data for standard LC, we found no difference in operative time, with less conversion to open. CONCLUSIONS:Robotic single-site cholecystectomy is a feasible option in the obese patient population with excellent short-term outcomes. Patients should not be excluded based on their high BMI although further study is needed to determine long-term outcomes.
Day-surgery versus overnight stay surgery for laparoscopic cholecystectomy.
Vaughan Jessica,Gurusamy Kurinchi Selvan,Davidson Brian R
The Cochrane database of systematic reviews
BACKGROUND:Laparoscopic cholecystectomy is used to manage symptomatic gallstones. There is considerable controversy regarding whether it should be done as day-surgery or as an overnight stay surgery with regards to patient safety. OBJECTIVES:To assess the impact of day-surgery versus overnight stay laparoscopic cholecystectomy on patient-oriented outcomes such as mortality, severe adverse events, and quality of life. SEARCH METHODS:We searched the Cochrane Hepato-Biliary Group Controlled Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and mRCT until September 2012. SELECTION CRITERIA:We included randomised clinical trials comparing day-surgery versus overnight stay surgery for laparoscopic cholecystectomy, irrespective of language or publication status. DATA COLLECTION AND ANALYSIS:Two authors independently assessed trials for inclusion and independently extracted the data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5 analysis. We calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat or available case analysis. MAIN RESULTS:We identified a total of six trials at high risk of bias involving 492 participants undergoing day-case laparoscopic cholecystectomy (n = 239) versus overnight stay laparoscopic cholecystectomy (n = 253) for symptomatic gallstones. The number of participants in each trial ranged from 28 to 150. The proportion of women in the trials varied between 74% and 84%. The mean or median age in the trials varied between 40 and 47 years.With regards to primary outcomes, only one trial reported short-term mortality. However, the trial stated that there were no deaths in either of the groups. We inferred from the other outcomes that there was no short-term mortality in the remaining trials. Long-term mortality was not reported in any of the trials. There was no significant difference in the rate of serious adverse events between the two groups (4 trials; 391 participants; 7/191 (weighted rate 1.6%) in the day-surgery group versus 1/200 (0.5%) in the overnight stay surgery group; rate ratio 3.24; 95% CI 0.74 to 14.09). There was no significant difference in quality of life between the two groups (4 trials; 333 participants; SMD -0.11; 95% CI -0.33 to 0.10).There was no significant difference between the two groups regarding the secondary outcomes of our review: pain (3 trials; 175 participants; MD 0.02 cm visual analogue scale score; 95% CI -0.69 to 0.73); time to return to activity (2 trials, 217 participants; MD -0.55 days; 95% CI -2.18 to 1.08); and return to work (1 trial, 74 participants; MD -2.00 days; 95% CI -10.34 to 6.34). No significant difference was seen in hospital readmission rate (5 trials; 464 participants; 6/225 (weighted rate 0.5%) in the day-surgery group versus 5/239 (2.1%) in the overnight stay surgery group (rate ratio 1.25; 95% CI 0.43 to 3.63) or in the proportion of people requiring hospital readmissions (3 trials; 290 participants; 5/136 (weighted proportion 3.5%) in the day-surgery group versus 5/154 (3.2%) in the overnight stay surgery group; RR 1.09; 95% CI 0.33 to 3.60). No significant difference was seen in the proportion of failed discharge (failure to be discharged as planned) between the two groups (5 trials; 419 participants; 42/205 (weighted proportion 19.3%) in the day-surgery group versus 43/214 (20.1%) in the overnight stay surgery group; RR 0.96; 95% CI 0.65 to 1.41). For all outcomes except pain, the accrued information was far less than the diversity-adjusted required information size to exclude random errors. AUTHORS' CONCLUSIONS:Day-surgery appears just as safe as overnight stay surgery in laparoscopic cholecystectomy. Day-surgery does not seem to result in improvement in any patient-oriented outcomes such as return to normal activity or earlier return to work. The randomised clinical trials backing these statements are weakened by risks of systematic errors (bias) and risks of random errors (play of chance). More randomised clinical trials are needed to assess the impact of day-surgery laparoscopic cholecystectomy on the quality of life as well as other outcomes of patients.
Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
Loozen Charlotte S,van Santvoort Hjalmar C,van Duijvendijk Peter,Besselink Marc Gh,Gouma Dirk J,Nieuwenhuijzen Grard Ap,Kelder Johannes C,Donkervoort Sandra C,van Geloven Anna Aw,Kruyt Philip M,Roos Daphne,Kortram Kirsten,Kornmann Verena Nn,Pronk Apollo,van der Peet Donald L,Crolla Rogier Mph,van Ramshorst Bert,Bollen Thomas L,Boerma Djamila
BMJ (Clinical research ed.)
OBJECTIVE:To assess whether laparoscopic cholecystectomy is superior to percutaneous catheter drainage in high risk patients with acute calculous cholecystitis. DESIGN:Multicentre, randomised controlled, superiority trial. SETTING:11 hospitals in the Netherlands, February 2011 to January 2016. PARTICIPANTS:142 high risk patients with acute calculous cholecystitis were randomly allocated to laparoscopic cholecystectomy (n=66) or to percutaneous catheter drainage (n=68). High risk was defined as an acute physiological assessment and chronic health evaluation II (APACHE II) score of 7 or more. MAIN OUTCOME MEASURES:The primary endpoints were death within one year and the occurrence of major complications, defined as infectious and cardiopulmonary complications within one month, need for reintervention (surgical, radiological, or endoscopic that had to be related to acute cholecystitis) within one year, or recurrent biliary disease within one year. RESULTS:The trial was concluded early after a planned interim analysis. The rate of death did not differ between the laparoscopic cholecystectomy and percutaneous catheter drainage group (3% 9%, P=0.27), but major complications occurred in eight of 66 patients (12%) assigned to cholecystectomy and in 44 of 68 patients (65%) assigned to percutaneous drainage (risk ratio 0.19, 95% confidence interval 0.10 to 0.37; P<0.001). In the drainage group 45 patients (66%) required a reintervention compared with eight patients (12%) in the cholecystectomy group (P<0.001). Recurrent biliary disease occurred more often in the percutaneous drainage group (53% 5%, P<0.001), and the median length of hospital stay was longer (9 days 5 days, P<0.001). CONCLUSION:Laparoscopic cholecystectomy compared with percutaneous catheter drainage reduced the rate of major complications in high risk patients with acute cholecystitis. TRIAL REGISTRATION:Dutch Trial Register NTR2666.
Risk factors for conversion of laparoscopic cholecystectomy.
Costantini Raffaele,Caldaralo Francesco,Palmieri Carmela,Napolitano Luca,Aceto Liberato,Cellini Carlo,Innocenti Paolo
Annali italiani di chirurgia
BACKGROUND:Conversion during laparoscopic cholecystectomy has adverse effects on operating time, postoperative morbidity and hospital costs. Identifying risk factors for conversion is thus important to help surgeons to plan and counsel the patient and arranging operating schedules accordingly. This study evaluated retrospectively preoperative and intraoperative risk factors for conversion in 906 laparoscopic cholecystectomies for gallbladder calculosis. METHODS:Examined preoperative variables were: age, sex, obesity, arterial hypertension, diabetes, previous acute myocardial infarction, chronic obstructive pulmonary disease, non-ischemic heart disease, chronic hepatitis, hepatic cirrhosis, previous pancreatitis, biliary colics, endoscopic retrograde cholangiopancreatography (ERCP) and abdominal or cardiac surgery,as well as pain, fever, a high white blood cell count, ultrasound signs of cholecystitis at hospitalization. Intraoperative variables were: adhesiolysis, associated hepatic biopsy. RESULTS:Twenty-five operations were converted (conversion rate: 2.76%). Factors significantly associated with conversion were: age over 60 years, diabetes, previous supramesocolic abdominal surgery, ultrasound signs of cholecystitis, white cell count over 9x10(3)/dl, previous acute myocardial infarction and preoperative ERCP, intraoperative adhesiolysis (0.001<p<0.05). CONCLUSION:Systematic evaluation of these factors in patients scheduled for laparoscopic cholecystectomy may help predict difficulties of the procedure, allow patients to be better informed about possible conversion, and optimize the planning of interventions for cases at risk.
Impact of risk factors for prolonged operative time in laparoscopic cholecystectomy.
Zdichavsky Marty,Bashin Yasser A,Blumenstock Gunnar,Zieker Derek,Meile Tobias,Königsrainer Alfred
European journal of gastroenterology & hepatology
OBJECTIVE:Laparoscopic cholecystectomy (LC) remains one of the most frequent surgical therapies for symptomatic gallstone disorders. Prolonged operative time is frequently associated with increased complication rates. The aim of this study was to identify the risk factors for prolonged operative times to minimize perioperative morbidity and optimize clinical management. METHODS:A total of 677 consecutive patients underwent LC. The exclusion criteria were conversion to an open procedure, intraoperative cholangiography, and liver cirrhosis (n=81). Data were analyzed retrospectively with respect to age, sex, BMI, ASA score, previous abdominal surgery, preoperative endoscopic retrograde cholangiopancreatography, acute cholecystitis, and surgeon's experience. Univariate and multivariate analyses were performed. RESULTS:A total of 596 patients, mean (± SD) age of 52.2 ± 16.7 years, were analyzed. In all, 29% of the patients were obese (BMI ≥ 30 kg/m); 11% had ASA III. Five percent of patients had undergone previous upper abdominal surgery. Overall, 105/596 patients had an acute cholecystitis. Residents of general surgery performed 58% of all operations. The median operative time was 80 min (range, 15-281 min). No statistical significance was found between intraoperative and postoperative complications by surgeon's experience. Statistically, independent preoperative predictors for prolonged operative time as identified through multivariate analysis were acute cholecystitis, obesity, previous upper abdominal surgery, male sex, and low degree of surgical expertise. CONCLUSION:The risk for prolonged operative times in LC can be assessed on the basis of patients' characteristics. Assessment of these factors not only helps to optimize the individual outcome for each patient but also improves the decision process toward operative training for junior surgeons.
Impact of obesity and associated diseases on outcome after laparoscopic cholecystectomy.
Paajanen Hannu,Käkelä Pirjo,Suuronen Satu,Paajanen Juuso,Juvonen Petri,Pihlajamäki Jussi
Surgical laparoscopy, endoscopy & percutaneous techniques
Obesity is a risk factor for operative treatment. This study examined the impact of obesity and associated comorbidities on complications after laparoscopic cholecystectomy (LC). Altogether, 1581 consecutive patients with symptomatic gallstones underwent LC between the years 1995 and 2008. Preoperative data and operative outcome of the 437 obese patients [302 with body mass index (BMI) 30 to 35 kg/m² and 135 with BMI ≥ 35.1 kg/m²] and 1144 nonobese controls (BMI ≤ 29.9 kg/m²) undergoing LC were compared. The impact of obesity, diabetes, cholecystitis, coronary heart disease, pulmonary disease, hypertension, and renal insufficiency on the postoperative outcome was analyzed by using multiple logistic regression analysis. The percentage of obese patients undergoing LC did not change during the study period. Over half of obese patients (63%) had 1 or multiple comorbidities, but only 15% of the patients had an acute surgery because of cholecystitis. Conversion to open surgery was required in 11.7% of the obese patients compared with 6.1% in the nonobese controls (P=0.0003). Acute cholecystitis increased the conversions in class II and III obese patients (50%) compared with elective surgery (8.7%, P<0.001). Mortality rate was 0 in obese patients and the rate of complications, except surgical site infections, comparable with nonobese patients. In multivariate analysis, obesity or any of the comorbidities did not associate with an elevated risk for postoperative complications. In symptomatic gallstone disease, obesity and related comorbidities increased the conversion rate, but not the operative risks of LC.
Validation of a scoring system to predict difficult laparoscopic cholecystectomy.
Gupta Nikhil,Ranjan Gyan,Arora M P,Goswami Binita,Chaudhary Poras,Kapur Arun,Kumar Rajeev,Chand Tirlok
International journal of surgery (London, England)
INTRODUCTION:Laparoscopic cholecystectomy (LC) is one of the most common laparoscopic procedures being performed by general surgeons all over the world. Preoperative prediction of the risk of conversion or difficulty of operation is an important aspect of planning laparoscopic surgery. The purpose of our prospective study was to analyze various risk factors and to predict difficulty and degree of difficulty preoperatively by the use of a scoring system. MATERIALS:This prospective study was conducted in the department of surgery, Lady Hardinge Medical College and associated Dr Ram Manohar Lohia Hospital, Delhi, India. The parameters considered in the preoperative scoring method were old age, male sex, history of hospitalization, obesity, previous abdominal surgery scar, palpable gall bladder, wall thickness of gall bladder, pericholecystic collection and impacted stone. A total of 210 patients were included in the study. RESULTS:We found that history of hospitalization, palpable gall bladder, impacted stone and gall bladder wall thickness were statistically significant factors for prediction of difficult laparoscopic cholecystectomy. Sensitivity and specificity of this preoperative scoring method were found to be 95.74% and 73.68% respectively. Positive predictive values of this scoring method were 90% and 88% for easy and difficult cases respectively. Area under ROC curve was 0.86. Conversion rate from laparoscopic to open cholecystectomy was found to be 4.28%. CONCLUSION:With the help of accurate prediction, high risk patient may be informed before hand regarding the probability of conversion and hence they may have a chance to make arrangements accordingly. On the other hand, surgeons also may have to schedule the time and team for the operation appropriately. Surgeons can also be aware about the possible complications that may arise in high risk patients.
Obesity does not increase morbidity of laparoscopic cholecystectomy.
Afaneh Cheguevara,Abelson Jonathan,Rich Barrie S,Dakin Gregory,Zarnegar Rasa,Barie Philip S,Fahey Thomas J,Pomp Alfons
The Journal of surgical research
BACKGROUND:Obesity has historically been a positive predictor of surgical morbidity, especially in the morbidly obese. The purpose of our study was to compare outcomes of obese patients undergoing laparoscopic cholecystectomy (LC). METHODS:We reviewed 1382 consecutive patients retrospectively who underwent LC for various pathologies from January 2008 to August 2011. Patients were stratified based on the World Health Organization definitions of obesity: nonobese (body mass index [BMI] < 30 kg/m(2)), obesity class I (BMI 30-34.9 kg/m(2)), obesity class II (BMI 35-39.9 kg/m(2)), and obesity class III (BMI ≥ 40 kg/m(2)). The primary end points were conversion rates and surgical morbidity. The secondary end point was length of stay. RESULTS:There were significantly more females in the obesity II and III groups (P = 0.0002). American Society of Anesthesiologists scores were significantly higher in the obesity I, II, and III groups compared with the nonobese (P < 0.05; P < 0.01; and P < 0.0001, respectively). Independent predictors of conversion on multivariate analysis (MVA) included age (P = 0.01), acute cholecystitis (P = 0.03), operative time (P < 0.0001), blood loss (P < 0.0001), and fellowship-trained surgeons (P < 0.0001). Independent predictors of intraoperative complications on MVA included age (P = 0.009), white patients (P = 0.009), previous surgery (P = 0.001), operative time (P < 0.0001), and blood loss (P = 0.01). Independent predictors of postoperative complications on MVA included American Society of Anesthesiologists score (P < 0.0001), acute cholecystitis (P < 0.0001), and a postoperative complication (P < 0.0001). BMI was not a predictor of conversions or surgical morbidity. Length of stay was not significantly different between the four groups. CONCLUSIONS:This study demonstrates that overall conversion rates and surgical morbidity are relatively low following LC, even in obese and morbidly obese patients.
Age and Obesity are Independent Predictors of Bile Duct Injuries in Patients Undergoing Laparoscopic Cholecystectomy.
Aziz Hassan,Pandit Viraj,Joseph Bellal,Jie Tun,Ong Evan
World journal of surgery
INTRODUCTION:Iatrogenic bile duct injury is a serious complication of cholecystectomy. The aim of this study was to assess predictors of bile duct injury using a national database. METHODS:The Nationwide Inpatient Sample (2010-2012) was queried for laparoscopic cholecystectomy. We used a) diagnoses for bile duct injury and b) bile duct injury repair procedure codes as a surrogate marker for bile duct injuries. RESULTS:A total of 1,015 patients had bile duct injury. The mean age was 58.2 ± 19.7 years, 53.5 % were males, and median Charlson co-morbidity score was 2 [2, 3]. Multivariate analysis revealed morbid obesity [2.8 (2.1-4.3); p = 0.03] and age >65 [1.5 (1.05-2.1); p = 0.01] as the independent predictors for bile duct injury in patients undergoing cholecystectomy. CONCLUSION:Our study finds a new association between obesity, aging, and bile duct injuries which has never been reported in literature before.
Assessment of the correlation between gender, age, body mass index and the severity of postoperative pain, nausea and vomiting in patients undergoing laparoscopic cholecystectomy.
Torres Kamil,Szukała Magdalena,Torres Anna,Pietrzyk Łukasz,Maciejewski Ryszard
Polski merkuriusz lekarski : organ Polskiego Towarzystwa Lekarskiego
UNLABELLED:Obesity has become one of the leading epidemic diseases in the world. Obesity is acknowledged as a risk factor for postoperative pain, nausea and vomiting (PONV), especially in obese patients undergoing laparoscopic procedures. AIM:The aim of the study was to evaluate the correlation between gender, age, BMI values and the severity of postoperative pain and PONV in patients undergoing laparoscopic cholecystectomy. MATERIALS AND METHODS:The study enrolled 244 patients with cholelithiasis who underwent scheduled laparoscopic cholecystectomy. Patients were assigned to 3 groups according to BMI values. Patients were assessed for the presence of PONV and severity of pain in the 6(th) and 24(th) hour after surgery. RESULTS:BPONV was reported more frequently in female than in male patients in the 1(st) time period. In the first time point the postoperative pain was significantly higher in group O in comparison to group H and N. Postoperative pain significantly decreased in the 24(th) postoperative hour in comparison to its level assessed in the 6th postoperative hour in all three groups. CONCLUSIONS:Female gender is a risk factor of PONV, so women should receive antiemetic prophylactic. There is a positive relationship between BMI and postoperative pain, so obese patients undergoing laparoscopic procedures should receive prophylactic application of analgesic drugs.
Predicting conversion from laparoscopic to open cholecystectomy presented as a probability nomogram based on preoperative patient risk factors.
Goonawardena Janindu,Gunnarsson Ronny,de Costa Alan
American journal of surgery
BACKGROUND:We aim to develop a risk stratification tool to preoperatively predict conversion (CONV) from a laparoscopic to open cholecystectomy. METHODS:Multiple risk factors were analyzed with multivariate logistic regression and presented as probability nomograms. RESULTS:Of 732 patients, 47 (6.4%) required CONV. Among 40 preoperative risk factors evaluated, 5 variables were found to have significant association with CONV: 2 clinical variables, previous upper abdominal surgery (odds ratio [OR] 95.2) and obesity defined as body mass index greater than 30 kg/m(2) (OR 12.3), and 3 ultrasound parameters, visible choledocholithiasis (OR 19.8), impacted stone at the neck of the gallbladder (OR 5.9), and gallbladder wall width in millimeters (OR 2.1). Nomograms based on this multivariate model demonstrate the individual preoperative probability of CONV. Internal validation using receiver operator curve analysis showed an area under the curve of .97. CONCLUSION:Four probability nomograms were developed as a practical individual risk stratification tool to predict probability of CONV.
The analysis of 146 patients with difficult laparoscopic cholecystectomy.
International journal of clinical and experimental medicine
INTRODUCTION:Laparoscopic cholecystectomy (LC) is very commonly performed surgical intervention. Acute or chronic cholecystitis, adhesions due to previous upper abdomen surgeries, Mirrizi's syndrome and obesity are common clinical conditions that can be associated with difficult cholecystectomy. In this study, we evaluated and scored the patients with difficult surgical exploration during laparoscopic cholecystectomy. MATERIAL AND METHOD:All patients who underwent LC from 2010 to 2015 were retrospectively rewieved. According to intraoperative findings DLC cases were described and classified. Class I difficulty: Adhesion of omentum majus, transverse colon, duodenum to the fundus of the gallbladder. Class II difficulty: Adhesions in Calot's triangle and difficulty in dissection of cystic artery and cystic duct Class III difficulty: Difficulty in dissection of gallbladder bed (scleroathrophic gallbladder, hemorrhage from liver during dissection of gallbladder, chirotic liver). Class IV difficulty: Difficulty in exploration of gallbladder due to intraabdominal adhesions including technical problems. RESULTS:A total of 146 patients were operated with DLC. The most common difficulty type was Class I difficulty (88 patients/60.2%). Laparoscopic cholecystectomy was converted to laparotomy in 98 patients. Operation time was found to be related with conversion to open surgery (P<0.05). Wound infection rate was also statistically higher in conversion group (P<0.05). The opertion time was found to be longest with Class II difficulty. Conversion rate to open surgery was also highest with Class II difficulty group. CONCLUSION:Class II difficulty characterized by severe adhesions in calot's triangle is most serious problem among all DLC cases. They have longer operation time and higher conversion rate.
Exclusion criteria for assuring safety of single-incision laparoscopic cholecystectomy.
Kawaguchi Yoshikuni,Ishizawa Takeaki,Nagata Rihito,Kaneko Junichi,Sakamoto Yoshihiro,Aoki Taku,Sugawara Yasuhiko,Hasegawa Kiyoshi,Kokudo Norihiro
Despite increasing popularity of single-incision laparoscopic cholecystectomy (SILC), indication criteria assuring safety of SILC has yet to be established. In the present study, the subjects consisted of 146 consecutive patients undergoing conventional laparoscopic cholecystectomy (CLC) or SILC. SILC was indicated after excluding patients who met following criteria: age > 75 years, obesity, operative scar, cardiopulmonary diseases, acute cholecystitis, choledocholithiasis and abnormal bile duct anatomy. Thirty-four patients were excluded from the SILC candidates (moderate/high-risk CLC group). Among the 112 potential candidates, SILC was indicated for 23 patients (21%, SILC group) and the remaining 89 patients (79%) underwent CLC (low-risk CLC group). In the SILC group, operation time was longer than in the low-risk CLC group (171 [113-286] vs. 126 [72-240] min, p < 0.01), but the periods requiring painkiller was shorter. That led to reduced length of hospital stay compared to low-risk CLC group (2 [2-4] vs. 4 [2-12] days, p < 0.01). Between the low-risk CLC and moderate/high-risk CLC group, operation time was significantly longer and amount of blood loss was larger in the latter group. No complications were encountered in the SILC group. SILC can be indicated safely as far as appropriate criteria is adopted for excluding patients in whom complicated laparoscopic procedures are needed.
Management of gallstones and its related complications.
Portincasa P,Di Ciaula A,de Bari O,Garruti G,Palmieri V O,Wang D Q-H
Expert review of gastroenterology & hepatology
The majority of gallstone patients remain asymptomatic; however, interest toward the gallstone disease is continuing because of the high worldwide prevalence and management costs and the development of gallstone symptoms and complications. For cholesterol gallstone disease, moreover, a strong link exists between this disease and highly prevalent metabolic disorders such as obesity, dyslipidemia, type 2 diabetes, hyperinsulinemia, hypertriglyceridemia and the metabolic syndrome. Information on the natural history as well as the diagnostic, surgical (mainly laparoscopic cholecystectomy) and medical tools available to facilitate adequate management of cholelithiasis and its complications are, therefore, crucial to prevent the negative outcomes of gallstone disease. Moreover, some risk factors for gallstone disease are modifiable and some preventive strategies have become necessary to reduce the onset and the severity of complications.
The role of body mass index class in cholecystectomy after acute cholecystitis: An American College of Surgeons National Surgical Quality Improvement Program analysis.
Neylan Christopher J,Damrauer Scott M,Kelz Rachel R,Farrar John T,Dempsey Daniel T,Lee Major K,Karakousis Giorgos C,Tewksbury Colleen M,Pickett-Blakely Octavia E,Williams Noel N,Dumon Kristoffel R
BACKGROUND:Obesity is a risk factor for cholelithiasis leading to acute cholecystitis which is treated with cholecystectomy. The purpose of this study was to analyze the associations between body mass index class and the intended operative approach (laparoscopic versus open) for and outcomes of cholecystectomy for acute cholecystitis. METHODS:We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program data from 2008-2013. The effects of body mass index class on intended procedure type (laparoscopic versus open), conversion from laparoscopic to open operation, and outcomes after cholecystectomy were examined using multivariable logistic regression. RESULTS:Data on 20,979 patients who underwent cholecystectomy for acute cholecystitis showed that 18,228 (87%) had a laparoscopic operation; 639 (4%) of these patients required conversion to an open approach; and 2,751 (13%) underwent intended open cholecystectomy. There was an independent association between super obesity (body mass index 50+) and an intended open operation (odds ratio 1.53, 95% confidence interval 1.14-2.05, P = .01). An intended open procedure (odds ratio 3.10, 95% confidence interval 2.40-4.02, P < .0001) and conversion (odds ratio 3.45, 95% confidence interval 2.16-5.50, P < .0001) were associated with increased risk of death/serious morbidity in a model, even when controlling for all other important factors. In the same model, body mass index class was not associated with increased death/serious morbidity. Outcomes after conversion were not substantially worse than outcomes after intended open cholecystectomy. CONCLUSION:This study supports the possibility that an intended open approach to acute cholecystitis, not body mass index class, is associated with worse outcomes after cholecystectomy. An initial attempt at laparoscopy may benefit patients, even those at the highest end of the body mass index spectrum.
Single-incision laparoscopy surgery: a systematic review.
Far Sasan Saeed,Miraj Sepide
BACKGROUND:Laparoscopic surgery is a modern surgical technique in which operations are performed far from their location through small incisions elsewhere in the body. OBJECTIVE:This systematic review is aimed to overview single-incision laparoscopy surgery. METHODS:This systematic review was carried out by searching studies in PubMed, Medline, Web of Science, and IranMedex databases. The initial search strategy identified about 87 references. In this study, 54 studies were accepted for further screening and met all our inclusion criteria [in English, full text, therapeutic effects of single-incision laparoscopy surgery and dated mainly from the year 1990 to 2016]. The search terms were "single-incision," "surgery," and "laparoscopy." RESULTS:Single-incision laparoscopy surgery is widely used for surgical operations in cholecystectomy, sleeve gastrectomy, cholecystoduodenostomy, hepatobiliary disease, colon cancer, obesity, appendectomy, liver surgery, rectosigmoid cancer, vaginal hysterectomy, vaginoplasty, colorectal lung metastases, pyloroplasty, endoscopic surgery, hernia repair, nephrectomy, rectal cancer, colectomy and uterus-preserving repair, bile duct exploration, ileo-ileal resection, lymphadenectomy, incarcerated inguinal hernia, anastomosis, congenital anomaly, colectomy for cancer. CONCLUSION:Based on the findings, single-incision laparoscopy surgery is a scarless surgery with minimal access. Although it possesses lots of benefits, including less incisional pain and scars, cosmesis, and the ability to convert to standard multiport laparoscopic surgery, it has some disadvantages, for example, less freedom of movement, fewer number of ports that can be used, and the proximity of the instruments to each other during the operation.
Clinical value and pitfalls of fluorescent cholangiography during single-incision laparoscopic cholecystectomy.
Igami Tsuyoshi,Nojiri Motoi,Shinohara Kentaro,Ebata Tomoki,Yokoyama Yukihiro,Sugawara Gen,Mizuno Takashi,Yamaguchi Junpei,Nagino Masato
PURPOSE:To clarify the clinical value and pitfalls of fluorescent cholangiography (FC) during single-incision laparoscopic cholecystectomy (SILC). METHODS:Our SILC procedure utilized the SILS-Port with additional 5-mm forceps through an umbilical incision. A laparoscopic fluorescent imaging system developed by Karl Storz Endoskope was utilized for fluorescent cholangiography. RESULTS:We performed fluorescent cholangiography during SILC in 21 patients. All procedures were completed successfully without biliary injury. The detectability of the running course of the cystic duct, the confluence between the cystic duct and the common hepatic duct, and the common hepatic duct before the dissection in Calot's triangle was 47.6, 71.4, and 81.0 %, respectively. The detectability of biliary structures was worse in 9 obese patients (body mass index ≥ 25.0 kg/m) than in 12 non-obese patients. The mean operative time for the patients in whom fluorescent cholangiography could identify the running course of the cystic duct before dissection in Calot's triangle (68 ± 16 min) was shorter than that for the other patients (91 ± 35 min; p = 0.037). CONCLUSIONS:Fluorescent cholangiography can prevent biliary injury during SILC and facilitate SILC. Obesity is the most important factor that can prevent identification of biliary structures under fluorescent cholangiography.
Safety and feasibility of single-incision laparoscopic cholecystectomy in obese patients.
Wakasugi Masaki,Tanemura Masahiro,Tei Mitsuyoshi,Furukawa Kenta,Suzuki Yozo,Masuzawa Toru,Kishi Kentaro,Akamatsu Hiroki
Annals of medicine and surgery (2012)
BACKGROUND:Current literature frequently indicates that experienced laparoscopic surgeons can safely perform single-incision laparoscopic cholecystectomy, but there have been few reports evaluating the feasibility and safety of performing single-incision laparoscopic cholecystectomy for obese patients. Therefore, a large single-center database was retrospectively reviewed to evaluate the feasibility and safety of single-incision laparoscopic cholecystectomy for obese patients by comparing the outcomes of normal-weight and obese patients undergoing single-incision laparoscopic cholecystectomy. METHODS:A retrospective analysis of 608 patients undergoing SILC between May 2009 and May 2015 at Osaka Police Hospital was performed, and the outcomes of obese [body mass index (BMI) ≥ 30 kg/m] and normal-weight patients (18.5 ≤ BMI < 25 kg/m) were compared. RESULTS:Thirty-eight obese patients (mean BMI 32.5 kg/m) were compared to 362 normal-weight patients (mean BMI 22.0 kg/m). The American Society of Anesthesiologists (ASA) scores of the obese patients were significantly higher than those of normal-weight patients. The mean operative times in the normal-weight and the obese groups were 110 min vs. 127 min, respectively ( < 0.05). There were no significant differences in the bleeding volume and the conversion rate to a different operative procedure. Perioperative complications were seen in 6% (23/362) of the patients in the normal-weight group and 8% (3/38) of the patients in the obese group ( = 0.7). The mean postoperative hospital stay was 4.5 days for the normal-weight group and 4.4 days for the obese group ( = 0.8). CONCLUSIONS:Single-incision laparoscopic cholecystectomy, which offers good cosmetic outcomes, seems feasible and safe in obese patients.
[Technical features of laparoscopic cholecystectomy in patients with overweight and obesity].
Mikhin I V,Vorobiyov А А,Doronin M B,Kosivtsov O A,Ryaskov L A
AIM:To improve surgical treatment of patients with cholelithiasis and obesity by using of different technologies of laparoscopic cholecystectomy. MATERIAL AND METHODS:There were 88 (16.4%) patients with overweight and obesity among 538 patients who underwent laparoscopic cholecystectomy. Conventional laparoscopic cholecystectomy was performed in 33 (6.1%) cases, cholecystectomy through single laparoscopic access - in 12 (2.3%), cholecystectomy via single laparoscopic access with trocar support - in 43 (8.0%) patients with body mass index 25-52.3 kg/m2. The article describes the technical features of laparoscopic cholecystectomy. RESULTS:Complications were absent in 83 (94.3%) of 88 cases after laparoscopic cholecystectomy. The lowest pain severity in early postoperative period was noted in case of single laparoscopic access (p<0.05). CONCLUSION:Conventional and single-port laparoscopic cholecystectomy is advisable in patients with calculous cholecystitis, overweight and obesity.
Risk factors for acute cholecystitis and for intraoperative complications.
Andercou Octavian,Olteanu Gabriel,Mihaileanu Florin,Stancu Bogdan,Dorin Marian
Annali italiani di chirurgia
BACKGROUND:Acute cholecystitis is still frequent in emergency surgical departments. As surgical technique, nowadays laparoscopy is widely used and with low complications and with low postoperative morbidity. MATERIAL AND METHODS:We perform an analytical study about the safety of laparoscopic surgery in patients with acute cholecystitis in a single Surgical Department with an experience of over 20 years in laparoscopic surgery. We included 193 patient admitted in our department during 2014 and 2015. RESULTS:Of the 193 patients, 43% were diagnosed with acute lithiasic cholecystitis (ALC) whereas 56% had chronic lithiasic cholecystitis (CLC). We assessed the comorbidities of the patient via Pearson's Chi-Square test and we found out that there is a significant relationship between acute cholecystitis and high blood tension, obesity and diabetes. Surgical techniques performed were in 95% of cases laparoscopic cholecystectomy and only in 5% we performed open surgery. DISCUSSIONS:Experienced surgeons have a lower conversion rate as compared to less experienced surgeons. For this reason, postoperative assessment criteria have been proposed, with a view to identify the risk of conversion CONCLUSION: In our study laparoscopic surgery for acute cholecystitis is a safe procedure with low intraoperative complication rate and with a reduced hospital stay. KEY WORDS:Acute cholecystitis, Intraoperative adhesion, Intraoperative bleeding, Laparoscopic cholecystectomy.
Risk Factors for Surgical Site Infection After Cholecystectomy.
Warren David K,Nickel Katelin B,Wallace Anna E,Mines Daniel,Tian Fang,Symons William J,Fraser Victoria J,Olsen Margaret A
Open forum infectious diseases
BACKGROUND:There are limited data on risk factors for surgical site infection (SSI) after open or laparoscopic cholecystectomy. METHODS:A retrospective cohort of commercially insured persons aged 18-64 years was assembled using (ICD-9-CM) procedure or Current Procedural Terminology, 4th edition codes for cholecystectomy from December 31, 2004 to December 31, 2010. Complex procedures and patients (eg, cancer, end-stage renal disease) and procedures with pre-existing infection were excluded. Surgical site infections within 90 days after cholecystectomy were identified by ICD-9-CM diagnosis codes. A Cox proportional hazards model was used to identify independent risk factors for SSI. RESULTS:Surgical site infections were identified after 472 of 66566 (0.71%) cholecystectomies; incidence was higher after open (n = 51, 4.93%) versus laparoscopic procedures (n = 421, 0.64%; < .001). Independent risk factors for SSI included male gender, preoperative chronic anemia, diabetes, drug abuse, malnutrition/weight loss, obesity, smoking-related diseases, previous infection, laparoscopic approach with acute cholecystitis/obstruction (hazards ratio [HR], 1.58; 95% confidence interval [CI], 1.27-1.96), open approach with (HR, 4.29; 95% CI, 2.45-7.52) or without acute cholecystitis/obstruction (HR, 4.04; 95% CI, 1.96-8.34), conversion to open approach with (HR, 4.71; 95% CI, 2.74-8.10) or without acute cholecystitis/obstruction (HR, 7.11; 95% CI, 3.87-13.08), bile duct exploration, postoperative chronic anemia, and postoperative pneumonia or urinary tract infection. CONCLUSIONS:Acute cholecystitis or obstruction was associated with significantly increased risk of SSI with laparoscopic but not open cholecystectomy. The risk of SSI was similar for planned open and converted procedures. These findings suggest that stratification by operative factors is important when comparing SSI rates between facilities.
Obesity Increases Operative Time in Children Undergoing Laparoscopic Cholecystectomy.
Pandian T K,Ubl Daniel S,Habermann Elizabeth B,Moir Christopher R,Ishitani Michael B
Journal of laparoendoscopic & advanced surgical techniques. Part A
INTRODUCTION:Few studies have assessed the impact of obesity on laparoscopic cholecystectomy (LC) in pediatric patients. MATERIALS AND METHODS:Children who underwent LC were identified from the 2012 to 2013 American College of Surgeons' National Surgical Quality Improvement Program Pediatrics data. Patient characteristics, operative details, and outcomes were compared. Multivariable logistic regression was utilized to identify predictors of increased operative time (OT) and duration of anesthesia (DOAn). RESULTS:In total, 1757 patients were identified. Due to low rates of obesity in children <9 years old, analyses were limited to those 9-17 (n = 1611, 43% obese). Among obese children, 80.6% were girls. A higher proportion of obese patients had diabetes (3.0% versus 1.0%, P < .01) and contaminated or dirty/infected wounds (15.1% versus 9.4%, P < .01). Complication rates were low. The most frequent indications for surgery were cholelithiasis/biliary colic (34.3%), chronic cholecystitis (26.9%), and biliary dyskinesia (18.2%). On multivariable analysis, obesity was an independent predictor of OT >90 (odds ratio [OR] 2.02; 95% confidence interval [95% CI] 1.55-2.63), and DOAn >140 minutes (OR 1.86; 95% CI 1.42-2.43). CONCLUSIONS:Obesity is an independent risk factor for increased OT in children undergoing LC. Pediatric surgeons and anesthesiologists should be prepared for the technical and physiological challenges that obesity may pose in this patient population.
Obesity and its implications for morbidity and mortality after cholecystectomy: A matched NSQIP analysis.
Augustin Toms,Moslim Maitham A,Brethauer Stacy,Aminian Ali,Kroh Matthew,Schneider Eric,Walsh R Matthew
American journal of surgery
BACKGROUND:The risks from super obesity (SO) following cholecystectomy have not been studied. METHODS:NSQIP analysis of patients undergoing cholecystectomy from 2005 to 2011. Non-obese (NO) patients (BMI 18.5-30) were matched 1:1 by age, sex, race and comorbidities to morbidly obese (MO) (BMI 35-50), and separately to SO (BMI≥50) individuals. Clavien 4 complications and 30-day mortality were compared. RESULTS:13780 MO and 1410 SO patients were matched to NO patients. Obese patients were more likely to present with chronic (CC) rather than acute cholecystitis (AC). Compared to NO patients, Clavien 4 complications were significantly increased among SO patients overall especially with AC where rate of open surgery was significantly higher. CONCLUSION:SO patients have an increased risk of serious morbidity after cholecystectomy especially with AC where rate of open surgery remains high. Aggressive recommendation for cholecystectomy to reduce presentation with AC and increase likelihood for laparoscopic surgery may be beneficial in SO patients.
Incidence of gallstone disease and complications.
Shabanzadeh Daniel Mønsted
Current opinion in gastroenterology
PURPOSE OF REVIEW:The purpose of this review was to describe the epidemiology of gallstone disease in the era of ultrasound screening and laparoscopic cholecystectomy. RECENT FINDINGS:Recent general population cohorts, including ultrasound screenings, have contributed to our understanding of formation and clinical course of gallstone disease. Cohorts of symptomatic gallstone disease have been informative about symptom recurrence and need of treatment. Preventive targets for gallstone formation may include obesity and the associated metabolic changes. The presence of gallstone disease is best described as a continuum from asymptomatic to symptomatic disease, with the latter including both pain attacks and complicated disease. Symptomatic disease causes a persistent high risk of symptom recurrence and need of cholecystectomy. The majority of gallstone carriers will remain asymptomatic and about one in five will develop symptoms. Determinants of disease progression from asymptomatic to symptomatic disease include sex, age, body mass index, and gallstone ultrasound characteristics. SUMMARY:Because of the absence of effective gallstone formation prevention, targets against the metabolic changes in obesity should be further explored in randomized controlled trials. To optimize patient selection for cholecystectomy, treatment algorithms including identified determinants of symptomatic disease in gallstone carriers should be explored in prospective clinical trials.
Impact of obesity on surgical outcome after single-incision laparoscopic cholecystectomy.
Obuchi Toru,Kameyama Noriaki,Tomita Masato,Mitsuhashi Hiroaki,Miyata Ryohei,Baba Shigeaki
Journal of minimal access surgery
Introduction:Single-incision laparoscopic cholecystectomy (SILC) is widely used as a treatment option for gallbladder disease. However, obesity has been considered a relative contraindication to this approach due to more advanced technical difficulties. The aim of this report was to review our experience with SILC to evaluate the impact of body mass index (BMI) on the surgical outcome. Patients and Methods:Between May 2009 and February 2013, 237 patients underwent SILC at our institute. Pre- and post-operative data of the 17 obese patients (O-group) (BMI ≥30 kg/m) and 220 non-obese patients (NO-group) (BMI <29.9 kg/m) were compared retrospectively. SILC was performed under general anaesthesia, using glove technique. Indications for surgery included benign gallbladder disease, except for emergent surgeries. Results:Mean age of patients was significantly higher in the NO-group than O-group (58.9 ± 13.5 years vs. 50.8 ± 14.0 years, P = 0.025). SILC was successfully completed in 233 patients (98.3%). Four patients (1.7%) in the NO-group required an additional port, and one patient was converted to an open procedure. The median operative time was 70 ± 25 min in the NO-group and 75.2 ± 18.3 min in the O-group. All complications were minor, except for one case in the NO-group that suffered with leakage of the cystic duct stump, for which endoscopic nasobiliary drainage was need. Conclusion:Our findings show that obesity, intended as a BMI ≥30 kg/m, does not have an adverse impact on the technical difficulty and post-operative outcomes of SILC. Obesity-related comorbidities did not increase the risks for SILC.
Cholesterol cholelithiasis: part of a systemic metabolic disease, prone to primary prevention.
Di Ciaula Agostino,Wang David Q-H,Portincasa Piero
Expert review of gastroenterology & hepatology
INTRODUCTION:Cholesterol gallstone disease have relationships with various conditions linked with insulin resistance, but also with heart disease, atherosclerosis, and cancer. These associations derive from mechanisms active at a local (i.e. gallbladder, bile) and a systemic level and are involved in inflammation, hormones, nuclear receptors, signaling molecules, epigenetic modulation of gene expression, and gut microbiota. Despite advanced knowledge of these pathways, the available therapeutic options for symptomatic gallstone patients remain limited. Therapy includes oral litholysis by the bile acid ursodeoxycholic acid (UDCA) in a small subgroup of patients at high risk of postdissolution recurrence, or laparoscopic cholecystectomy, which is the therapeutic radical gold standard treatment. Cholecystectomy, however, may not be a neutral event, and potentially generates health problems, including the metabolic syndrome. Areas covered: Several studies on risk factors and pathogenesis of cholesterol gallstone disease, acting at a systemic level have been reviewed through a PubMed search. Authors have focused on primary prevention and novel potential therapeutic strategies. Expert commentary: The ultimate goal appears to target the manageable systemic mechanisms responsible for gallstone occurrence, pointing to primary prevention measures. Changes must target lifestyles, as well as experimenting innovative pharmacological tools in subgroups of patients at high risk of developing gallstones.
Single-Port Laparoscopic and Robotic Cholecystectomy in Obesity (>25 kg/m).
Jang Eun Jeong,Roh Young Hoon,Kang Chang Moo,Kim Dong Kyun,Park Ki Jae
JSLS : Journal of the Society of Laparoendoscopic Surgeons
Background and Objectives:Single-port cholecystectomy has emerged as an alternative technique to reduce the number of ports and improve cosmesis. Few previous studies have assessed obesity-related surgical outcomes following single-port cholecystectomy. In this study, technical feasibility and surgical outcomes of single-port laparoscopic cholecystectomy (SPLC) and robotic single-site cholecystectomy (RSSC) in obese patients were investigated. Methods:We conducted a two-center collaborative study and retrospectively reviewed initial experiences of RSSC and SPLC in patients whose body mass index was over 25 kg/m. Medical records of patients were reviewed. Clinical characteristics and short-term oncologic outcomes were considered and compared between SPLC and RSSC groups. Results:RSSC and SPLC were performed in 39 and 78 patients, respectively. In comparative analysis, the total operative time was longer in the RSSC group (109.92 minutes vs. 60.99 minutes; < .001).However, requiring additional port for completion of surgical procedure was less frequent in the RSSC group (0% vs. 12.8%; = .029). Immediate postoperative pain score was not significantly different between the two groups (4.95 vs. 5.00; = .882). However, pain score was significantly lower in the RSSC group at the time of discharge (1.79 vs. 2.38; = .010). Conversion to conventional multiport cholecystectomy, intraoperative bile spillage, or complication rate was not significantly different between the two groups ( > .05). Conclusions:SPLC and RSSC could be safely performed in selected patients with high body mass index, showing no significant clinical differences.
Cholelithiasis: Presentation and Management.
Littlefield Amber,Lenahan Christy
Journal of midwifery & women's health
Cholelithiasis affects approximately 15% of the US population. Rising trends in obesity and metabolic syndrome have contributed to an increase in diagnosis of cholelithiasis. There are several risk factors for cholelithiasis, both modifiable and nonmodifiable. Women are more likely to experience cholelithiasis than are men. Pregnancy, increasing parity, and obesity during pregnancy further increase the risk that a woman will develop cholelithiasis. The classic presentation of persons experiencing cholelithiasis, specifically when gallstones obstruct the common bile duct, is right upper quadrant pain of the abdomen that is often elicited upon palpation during physical examination and documented as a positive Murphy's sign. Referred pain to the right supraclavicular region and/or shoulder, nausea, and vomiting are also frequently reported by persons with cholelithiasis. Cholelithiasis can result in complications, including cholecystitis (inflammation of the gallbladder) and cholangitis (inflammation of the bile duct). Lack of physical examination findings does not rule out a diagnosis of cholelithiasis. Laboratory tests such as white blood cell count, liver enzymes, amylase, and lipase may assist the clinician in diagnosing cholelithiasis; however, ultrasonography is the gold standard for diagnosis. Management is dependent on severity and frequency of symptoms. Lifestyle and dietary modifications combined with medication management, such as use of gallstone dissolution agents, may be recommended for persons who have a single symptomatic episode. If symptoms become severe and/or are recurrent, laparoscopic cholecystectomy is recommended. It is recommended that individuals with an established diagnosis of cholelithiasis be referred to a surgeon and/or gastroenterologist within 2 weeks of initial presentation regardless of severity or frequency of symptoms.
Preoperative and Operative Risk Factors for Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy in Pakistan.
Amin Amina,Haider Muhammad Ijlal,Aamir Iram S,Khan Muhammad Sohaib,Khalid Choudry Usama,Amir Mohammad,Sadiq Abdullah
Introduction The currently available literature suggests a wide range of conversion (4.9-20%) from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) despite the increase in surgical expertise. Open cholecystectomy is important as the last resort for safe surgical practice in complicated cases. Increased number of pre-operative and perioperative risk factors need to be identified to pre-empt conversion. However, there has been a significant decrease in conversion rates over the past few decades. This study was conducted to determine conversion rates in our population and to identify any significant risks for conversion. Methods This prospective study was conducted at the Shifa International Hospital, Islamabad, Pakistan, including 1081 cholecystectomies, performed over a two-year period from January 2017 to January 2019. Comparison of risk factors between the two groups; laparoscopic cholecystectomy (LC) group and conversion to open cholecystectomy (OC) group was done. Statistical analysis was done using SPSS 24.0.1. P<0.05 were considered significant. Results In our study, the overall conversion rate was 7.78%. Factors of conversion to open cholecystectomy (OC) included age ≥65, morbid obesity, diabetes mellitus, and previous abdominal surgery. Deranged alkaline phosphatase (ALP), increased total bilirubin, increased common bile duct (CBD) diameter, and multiple stones in ultrasonography showed a statistically significant association with the conversion. Per-operative findings of increased adhesions >50%, empyema gallbladder (GB), perforated GB, and scleroatrophic GB showed a higher risk of conversion too (p <0.05). However, there was no statistical association with preoperative endoscopic retrograde cholangiopancreatography (ERCP) to OC in our population. Conclusion An open cholecystectomy is a safe approach for patients with complicated gallbladder disease. No doubt laparoscopic cholecystectomy is the gold standard having its outstanding benefits. This study identifies predictors of choice for OC in addition to the decision to convert to OC. In view of the raised morbidity and mortality associated with open cholecystectomy, distinguishing these predictors will serve to decrease the rate of OC and to address these factors preoperatively.
Safety and Efficiency of Single-Incision Laparoscopic Cholecystectomy in Obese Patients: A Case-Matched Comparative Analysis.
Raakow Jonas,Klein Denis,Barutcu Atakan Görkem,Biebl Matthias,Pratschke Johann,Raakow Roland
Journal of laparoendoscopic & advanced surgical techniques. Part A
Single-incision laparoscopic surgery (SILS) is feasible and safe for most situations that indicate a need for cholecystectomy in normal-weight patients. SILS might offer several potential benefits over multiport laparoscopy. However, the effect of obesity on the surgical outcomes of single-incision laparoscopic cholecystectomy (SILC) has not been sufficiently investigated and is controversial. The aim of this study was to compare normal-weight and obese patients who had undergone SILC. All single-incision laparoscopic cholecystectomies performed between December 2008 and December 2014 were reviewed and grouped according to patient's body mass index (BMI). Obese patients with a BMI ≥30 kg/m who had undergone SILC were matched in a 1:2 ratio with non-obese patients. One hundred six obese patients after SILC were compared with 212 non-obese patients according to age, gender, and indication for operation. Operation in obese patients was longer but without significant difference (53.9 minutes versus 62.3 minutes; = .189). In each group, 4 patients needed conversion to multiport laparoscopy or open procedure (1.9% versus 3.8% for non-obese versus obese; = .236). No significant difference was noted for postoperative complications (4.3% versus 5.7% for non-obese versus obese; = .790) and the length of hospital stay (3.3 days versus 3.3 days; = .958). Obese patients have a significantly ( = .027) higher incisional hernia rate (9.8%) than non-obese patients (1.9%), with obesity being a risk factor for hernia development in the univariate analysis. SILC in obese patients is technically feasible and safe compared with non-obese patients in regard to postoperative complications, conversion rates, and length of hospital stay but with an almost sixfold risk of umbilical incisional hernia on the long run.
Laparoscopic cholecystectomy: do risk factors for a prolonged length of stay exist?
Ripetti Valter,Luffarelli Paolo,Santoni Simone,Greco Santi
Updates in surgery
Gallstones are one of the most common morbidities in the world. Laparoscopic cholecystectomy is the gold standard for gallbladder stones' removal. Few studies focus on the existence of predictive factors aimed at facilitating cholecystectomy in a day surgery setting. The aim of this retrospective study was to identify clinical factors that could guide day-surgery laparoscopic cholecystectomy safety. The study included 985 consecutive patients who underwent elective laparoscopic cholecystectomy for gallstone disease between May 2006 and February 2015. Patients were divided into two groups: group A with a length of stay ≤ 2 days (922 patients); group B with a length of stay > 2 days (63 patients). Univariate analysis showed that age, sex and the presence of obesity, cardiological, and nephrological comorbidities had a higher likelihood of a longer hospital stay. The logistic regression model showed that only age was a significant predictor of a longer stay. No complication has reached the statistical significance of extending the length of stay in group B. Conversely, the presence of such comorbidities has influenced the hospitalization. Our results allow the identification of a category of patients at high risk of hospitalization within 1 or 2 days from treatment. Moreover, we reported that there is no complication specifically affecting the length of stay. Our findings support the idea that a prolonged length of stay is not linked to the surgical procedure but to the patient's comorbidities.
[Impact of Grade I obesity on respiratory mechanics during video laparoscopic surgery: prospective longitudinal study].
Araujo Orlandira Costa,Espada Eloisa Bonetti,Costa Fernanda Magalhães Arantes,Vigiato Julia Araujo,Carmona Maria José Carvalho,Otoch José Pinhata,Silva João Manoel,Martins Milton de Arruda
Brazilian journal of anesthesiology (Elsevier)
INTRODUCTION AND OBJECTIVES:The association pneumoperitoneum and obesity in video laparoscopy can contribute to pulmonary complications, but has not been well defined in specific groups of obese individuals. We assessed the effects of pneumoperitoneum in respiratory mechanics in Grade I obese compared to non-obese. METHODS:Prospective study including 20 patients submitted to video laparoscopic cholecystectomy, normal spirometry, divided into non-obese (BMI ≤ 25kg.m) and obese (BMI > 30kg.mg), excluding Grade II and III obese. We measured pulmonary ventilation mechanics data before pneumoperitoneum (baseline), and five, fifteen and thirty minutes after peritoneal insufflation, and fifteen minutes after disinflation (final). RESULTS:Mean BMI of non-obese was 22.72 ± 1.43kg.m and of the obese 31.78 ± 1.09kg.m, p < 0.01. Duration of anesthesia and of peritoneal insufflation was similar between groups. Baseline pulmonary compliance (Crs) of the obese (38.3 ± 8.3mL.cm HO) was lower than of the non-obese (47.4 ± 5.7mL.cm HO), p = 0.01. After insufflation, Crs decreased in both groups and remained even lower in the obese at all moments assessed (GLM p < 0.01). Respiratory system peak pressure and plateau pressure were higher in the obese, albeit variations were similar at moments analyzed (GLM p > 0.05). The same occurred with elastic pressure, higher in the obese at all times (GLM p = 0.04), and resistive pressure showed differences in variations between groups during pneumoperitoneum (GLM p = 0,05). CONCLUSIONS:Grade I obese presented more changes in pulmonary mechanics than the non-obese during video laparoscopies and the fact requires mechanical ventilation-related care.
Surgical treatment of acute cholecystitis in obese patients.
Kebkalo Andrey,Tkachuk Olha,Reyti Andrian,Chanturidze Archil,Pashunskyi Yaroslav
Polski przeglad chirurgiczny
<b>Introduction:</b> In today's technological climate, science and medicine have entered a new era. At the level of technological progress, we have identified millennia of "new" problems and diseases. If earlier diseases had a certain individuality then, in the third millennium, we face compliance and synergistic influence of diseases. Obesity is a problem of the third millennium. It is known that obesity is the main factor in the development of various chronic diseases [1-3]. With excess weight and obesity, bile is oversaturated with cholesterol, resulting in an increase of its lipogenicity index. As a result, frequency of gallstone disease increases; findings from this study document an increase of disease frequency as high as 50% to 60% . In 20% of patients, housing concerns are combined with obesity . Thus, obesity is one of the factors in the development of cholelithiasis and cholecystitis . The presence of acute cholecystitis represents the most difficult situation for patients with gallstones. When obesity is also present, the patient's risk of surgical complications increases due to altered homeostasis and reduced reserve capacity . A retrospective study of this issue  posed a number of questions about the possibility of influencing the course of disease in the preoperative period as well as the improvement and impact of surgical technicalities in patients with acute cholecystitis and obesity. Addressing these and additional questions is the main goal of this study. <br><b>Aim: </b>The aim of the study was to study and select the optimal method of surgery in patients with acute cholecystitis and obesity. <br><b>Materials and methods:</b> In our study, a prospective analysis was used. We analyzed 67 cases with diagnosis of acute cholecystitis and obesity; all were treated at Kyiv Regional Clinical Hospital in the period from September 2018 to March 2020. Patients with acute cholecystitis and obesity received either traditional or modified laparoscopic cholecystectomy. <br><b>Results:</b> Retrospective analysis indicates traditional laparoscopic cholecystectomy is technically difficult and costly in patients with acute cholecystitis and obesity. A modified laparoscopic cholecystectomy has been proposed to improve and enhance surgery in patients with acute cholecystitis and obesity. Surgical duration was shortened by 9.01 ± 0.41 minutes (p = 0.001; αα= 0.05) when a modified laparoscopic cholecystectomy was performed. <br><b>Conclusions:</b> Performing a modified laparoscopic cholecystectomy reduced the duration of surgery by 9.01 ± 0.41 minutes (p = 0.001; α = 0.05), prevents development of metabolic acidosis pH 7.39 ± 0.03 vs 7.30 ± 0.005 = 0.001; αα= 0.05, pCO2 5.05 ± 0.36 vs 6.03 ± 0.38 (p = 0.02; αα= 0.05), reducing the risk of hypercoagulation. Modified laparoscopic cholecystectomy (LHE) is effective in II and III degrees of obesity (p = 0.001; α = 0.05).
Acute cholecystitis: predictive clinico-radiological assessment for conversion of laparoscopic cholecystectomy.
Jang Young Rock,Ahn Su Joa,Choi Seung Joon,Lee Ki Hyun,Park Yeon Ho,Kim Keon Kuk,Kim Hyung-Sik
Acta radiologica (Stockholm, Sweden : 1987)
BACKGROUND:Previous studies evaluating predictive factors for the conversion from laparoscopic to open cholecystectomy have reported conflicting conclusions. PURPOSE:To create a risk assessment model to predict the conversion from laparoscopic to open cholecystectomy in patients with acute calculous cholecystitis. MATERIAL AND METHODS:A retrospective review of patients with acute calculous cholecystitis with available preoperative contrast-enhanced computed tomography (CT) findings who underwent laparoscopic cholecystectomy was performed. Forty-four parameters-including demographics, clinical history, laboratory data, and CT findings-were analyzed. RESULTS:Among the included 581 patients, conversion occurred in 113 (19%) cases. Multivariate analysis identified obesity (odd ratio [OR] 2.58, = 0.04), history of abdominal surgery (OR 1.78, = 0.03), and prolonged prothrombin time (OR 1.98, = 0.03) as predictors of conversion. In preoperative CT findings, the absence of gallbladder wall enhancement (OR 3.15, = 0.03), presence of a gallstone in the gallbladder infundibulum (OR 2.11, = 0.04), and inflammation of the hepatic pedicle (OR 1.71, = 0.04) were associated with conversion. Inter-observer agreement for CT study interpretation was very good (range 0.81-1.00). A model was created to calculate the risk for conversion, with an area under the receiver operating characteristic curve of 0.87. The risk for conversion, estimated based on the number of factors identified, was in the range of 5.3% (with one factor) to 86.4% (with six factors). CONCLUSION:Obesity, history of abdominal surgery, prolonged prothrombin time, absence of gallbladder wall enhancement, presence of a gallstone in the gallbladder infundibulum, and inflammation of the hepatic pedicle are associated with conversion of laparoscopic to open cholecystectomy.
The pre-operative predictive model for difficult elective laparoscopic cholecystectomy: A modification.
Tongyoo Assanee,Chotiyasilp Parm,Sriussadaporn Ekkapak,Limpavitayaporn Palin,Mingmalairak Chatchai
Asian journal of surgery
BACKGROUND:Although LC is a common operation, difficult cases are still challenging. Several studies have identified factors for the difficulty and conversion. Many scoring systems have been established for pre-operative prediction. This study aimed to investigate significant factors and validity of Randhawa's model in our setting. METHODS:This prospective study enrolled LC patients in Hepato-Pancreato-Biliary Surgery unit between March 2018 and October 2019. The difficulty of operation was categorized into 3 groups by intra-operative grading scale. Multivariate analysis was performed to define significant factors of very-difficult and converted cases. The difficulty predicted by Randhawa's model were compared with actual outcome. Area under ROC curve was calculated. RESULTS:Among 152 patients, difficult and very-difficult groups were 59.2% and 15.1%, respectively. Sixteen cases needed conversion. Four factors (cholecystitis, ERCP, thickened wall, contracted gallbladder) for very-difficult group and 3 factors (obesity, biliary inflammation or procedure, contracted gallbladder) for conversion were significant. After some modification of Randhawa's model, the modified scoring system provided better prediction in terms of higher correlation coefficient (0.41 vs 0.35) and higher AUROC curve (0.82 vs 0.75) than original model. DISCUSSION:Randhawa's model was feasible for pre-operative preparation. The modification of this model provided better prediction on difficult cases.
Obesity is not a risk factor for either mortality or complications after laparoscopic cholecystectomy for cholecystitis.
Enami Yuta,Aoki Takeshi,Tomioka Kodai,Hakozaki Tomoki,Hirai Takahito,Shibata Hideki,Saito Kazuhiko,Takano Yojiro,Seki Junichi,Oae Sonoko,Shimada Shoji,Nakahara Kenta,Takehara Yusuke,Mukai Shumpei,Sawada Naruhiko,Ishida Fumio,Murakami Masahiko,Kudo Shin-Ei
Obesity is a positive predictor of surgical morbidity. There are few reports of laparoscopic cholecystectomy (LC) outcomes in obese patients. This study aimed to clarify this relationship. This retrospective study included patients who underwent LC at Showa University Northern Yokohama Hospital between January 2017 and April 2020. A total of 563 cases were examined and divided into two groups: obese (n = 142) (BMI ≥ 25 kg/m) and non-obese (n = 241) (BMI < 25 kg/m). The non-obese group had more female patients (54%), whereas the obese group had more male patients (59.1%). The obese group was younger (56.6 years). Preoperative laboratory data of liver function were within the normal range. The obese group had a significantly higher white blood cell (WBC) count (6420/μL), although this was within normal range. Operative time was significantly longer in the obese group (p = 0.0001). However, blood loss and conversion rate were not significantly different among the groups, neither were surgical outcomes, including postoperative hospital stay and complications. Male sex and previous abdominal surgery were risk factors for conversion, and only advanced age (≥ 79 years) was an independent predictor of postoperative complications as observed in the multivariate analysis. Although the operation time was prolonged in obese patients, operative factors and outcomes were not. Therefore, LC could be safely performed in obese patients with similar efficacy as in non-obese patients.