Challenging situations in cholecystectomy and strategies to overcome them

Best Practice ◽

Clinical Symptoms ◽

Major Morbidity ◽

Conversion To Open Surgery ◽

Delayed Cholecystectomy ◽

Difficult Cholecystectomy ◽

Underlying Diseases ◽

Bail Out

Summary Background Cholecystectomy may be difficult and hazardous, causing major morbidity and mortality. This review aims to identify situations increasing the probability of difficult gallbladders and present today’s best practice to overcome them. Methods Review of the literature and expert comment. Results One in six gallbladders is expected to be a difficult cholecystectomy. The majority can be predicted by patient history, clinical symptoms, and pre-existing comorbidities. Acute cholecystitis, mild biliary pancreatitis, prior endoscopic sphincterotomy, and liver cirrhosis are the predominant underlying diseases. Early or delayed cholecystectomy, percutaneous cholecystostomy, and pure conservative treatment are evidence-based options. Early laparoscopic cholecystectomy is of advantage in patients fit for surgery, with subtotal cholecystectomy or conversion to open surgery as bail-out strategies. The choice of the procedure depends on the experience of the surgeon. Conclusion Clinical decisions should follow a pathway based on patients’ risk, favoring laparoscopic cholecystectomy whenever possible. The implementation of an institutional pathway to deal with difficult gallbladders is recommended.

Time to abandon the old dictum of delayed laparoscopic cholecystectomy after acute cholecystitis has settled in Caribbean practice

Tropical Doctor ◽

10.1177/00494755211010002 ◽

2021 ◽

pp. 004947552110100

Author(s):

Shamir O Cawich ◽

Avidesh H Mahabir ◽

Sahle Griffith ◽

Patrick FaSiOen ◽

Vijay Naraynsingh

Keyword(s):

Acute Cholecystitis ◽

Gold Standard ◽

Standard Treatment ◽

Gallstone Disease ◽

Acute Attack ◽

Delayed Laparoscopic Cholecystectomy

Delayed Surgery ◽

Delayed Cholecystectomy ◽

Although laparoscopic cholecystectomy is the gold standard treatment for acute cholecystitis, many Caribbean surgeons are reluctant to operate during the acute attack. We collected data for all consecutive patients who underwent laparoscopic cholecystectomy for acute cholecystitis from January 1 to 31 December 2018. Delayed cholecystectomy was done >6 weeks after acute cholecystitis settled. We compared data between early and delayed groups. Delayed laparoscopic cholecystectomy was performed in 54 patients, and 42 had early laparoscopic cholecystectomy. Delayed surgery resulted in significantly more complications requiring readmission (39% vs 0), longer operations (2.27 vs 0.94 h) and lengthier post-operative hospitalisation (1.84 vs 1.1 days). Caribbean hospitals should abandon the practice of delayed surgery after cholecystitis has settled. Early laparoscopic cholecystectomy would be financially advantageous for our institutions, and it would save patients recurrent attacks of gallstone disease.

LAPAROSCOPIC CHOLECYSTECTOMY;

The Professional Medical Journal ◽

10.29309/tpmj/2013.20.02.689 ◽

2013 ◽

Vol 20 (02) ◽

pp. 313-318

Author(s):

MOHAMMAD ADNAN NAZEER ◽

HASAAN IMTIAZ ◽

HARUN MAJID DAR ◽

Zulfiqar Ali ◽

Asma Samreen

Keyword(s):

Acute Cholecystitis ◽

Controlled Trial ◽

Delayed Cholecystectomy ◽

Laparoscopic Cholecystectomy Group ◽

Delayed Laparoscopic Cholecystectomy ◽

Delayed Group ◽

Group 2 ◽

Group 1

Introduction: The role of laparoscopic cholecystectomy in treatment of acute cholecystitis is still controversial. Objective:The objective of this prospective randomized controlled trial was to evaluate the outcomes of early laparoscopic cholecystectomy foracute cholecystitis and to compare the results with delayed cholecystectomy. Setting: Sheikh Zayed Hospital, Lahore. Period: 1st Feb,2012 to 31st July 2012. Materials & Methods: 60 diagnosed patients of acute cholecystitis were randomly allocated to two groups,Group 1 underwent early laparoscopic cholecystectomy (Group 1, n = 30) and Group 2 to initial conservative treatment followed bydelayed laparoscopic cholecystectomy, 6 to 12 weeks later (Group 2 , n = 30). Results: The overall complication rate was 3.3% (01) inearly group and 16.7% (05) in the delayed group. There was no common bile duct injury in both groups. The complications includedwound infection and intraperitoneal collection. Conclusions: According to the results our study we concluded that early laparoscopiccholecystectomy can safely be carried out for acute cholecystitis as the complications for early laparoscopic cholecystectomy are lessas compared to delayed laparoscopic cholecystectomy. Early laparoscopic cholecystectomy has also an edge over delayed because ofsingle hospital stay.

Impact of a dedicated emergency surgical unit on early laparoscopic cholecystectomy for acute cholecystitis

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2016.0049 ◽

2016 ◽

Vol 98 (2) ◽

pp. 107-115 ◽

Cited By ~ 8

Author(s):

S Bokhari ◽

U Walsh ◽

K Qurashi ◽

L Liasis ◽

J Watfah ◽

...

Keyword(s):

Acute Cholecystitis ◽

Best Practice ◽

District General Hospital ◽

Emergency General Surgery ◽

Before And After ◽

One Year ◽

The Impact ◽

Surgical Unit

Introduction Emergency general surgery (EGS) accounts for 50% of the surgical workload, and yet outcomes are variable and poorly recorded. The management of acute cholecystitis (AC) at a dedicated emergency surgical unit (ESU) was assessed as a performance target for EGS. Methods The outcomes for AC admissions were compared one year before and after inception of the ESU. The impact on cost and compliance with national guidance recommending early laparoscopic cholecystectomy (ELC) within seven days of diagnosis was assessed. Results The overall ELC rate increased from 26% for the 126 patients admitted in the pre-ESU period to 45% for the 152 patients admitted in the post-ESU period (p=0.001). With those unsuitable for ELC excluded, the ELC rate increased from 34% to 82% (p<0.001). The proportion of patients precluded from ELC for avoidable reasons, particularly owing to ‘surgeon preference/skill’, was reduced from 69% to 18% (p<0.001). The mean total length of stay (LOS) and postoperative LOS fell by 1.7 days (from 8.3 to 6.6 days, p=0.040) and 2 days (from 5.6 to 3.6 days, p=0.020) respectively. The higher ELC rate and the reduction in LOS produced additional tariff income (£111,930) and estimated savings in bed day (£90,440) and readmission (£27,252) costs. Conclusions A dedicated ESU incorporating national recommendations for EGS improves alignment of best practice with best evidence and can also result in financial rewards for a busy district general hospital.

Timing of early laparoscopic cholecystectomy for acute calculous cholecystitis revised: Protocol of a systematic review and meta-analysis of results

World Journal of Emergency Surgery ◽

10.1186/s13017-019-0285-7 ◽

2020 ◽

Vol 15 (1) ◽

Cited By ~ 2

Author(s):

Giuseppe Borzellino ◽

Safi Khuri ◽

Michele Pisano ◽

Subhi Mansour ◽

Niccolò Allievi ◽

...

Keyword(s):

Systematic Review ◽

Early Intervention ◽

Conservative Treatment ◽

Acute Cholecystitis ◽

Meta Analysis ◽

Early Cholecystectomy ◽

Pooled Data ◽

Delayed Cholecystectomy

Abstract Background Early laparoscopic cholecystectomy has been adopted as the treatment of choice for acute cholecystitis due to a shorter hospital length of stay and no increased morbidity when compared to delayed cholecystectomy. However, randomised studies and meta-analysis report a wide array of timings of early cholecystectomy, most of them set at 72 h following admission. Setting early cholecystectomy at 72 h or even later may influence analysis due to a shift towards a more balanced comparison. At this time, the rate of resolving acute cholecystitis and the rate of ongoing acute process because of failed conservative treatment could be not so different when compared to those operated with a delayed timing of 6–12 weeks. As a result, randomised comparison with such timing for early cholecystectomy and meta-analysis including such studies may have missed a possible advantage of an early cholecystectomy performed within 24 h of the admission, when conservative treatment failure has less potential effects on morbidity. This review will explore pooled data focused on randomised studies with a set timing of early cholecystectomy as a maximum of 24 h following admission, with the aim of verifying the hypothesis that cholecystectomy within 24 h may report a lower post-operative complication rate compared to a delayed intervention. Methods A systematic review of the literature will identify randomised clinical studies that compared early and delayed cholecystectomy. Pooled data from studies that settled the early intervention within 24 h from admission will be explored and compared in a sub-group analysis with pooled data of studies that settled early intervention as more than 24 h. Discussion This paper will not provide evidence strong enough to change the clinical practice, but in case the hypothesis is verified, it will invite to re-consider the timing of early cholecystectomy and might promote future clinical research focusing on an accurate definition of timing for early cholecystectomy for acute cholecystitis.

Akutno vnetje žolčnika – zgodnja operacija ali poskus konzervativnega zdravljenja?

Slovenian Medical Journal ◽

10.6016/zdravvestn.2496 ◽

2018 ◽

Vol 86 (9-11) ◽

Author(s):

Jurij Janež

Keyword(s):

Acute Cholecystitis ◽

Clinical Symptoms ◽

Common Disease ◽

Common Complication ◽

Tokyo Guidelines ◽

Good Physical Condition ◽

Current Guidelines ◽

Ultrasound Evidence

Acute cholecystitis is a common disease, which ofen requires admission to hospital and surgical treatment. Acute cholecystitis is defined as inﬂammation of the gallbladder and usually occurs due to cystic duct obstruction from stones or sludge. It is a relatively common complication of gallstones, but it can also occur without gallstones. A combination of relevant clinical symptoms and ultrasound evidence is required to make a diagnosis of acute cholecystitis. Early surgery is recommended for all patients that are in good physical condition. There is still a debate how to treat high-risk and critically ill patients. Laparoscopic cholecystectomy is the method of choice for treatment of patients with acute cholecystitis. Early laparoscopic cholecystectomy should be done within 72 hours from the onset of symptoms.This article presents current guidelines according to the Tokyo guidelines and the World Society of Emergency Surgery guidelines, and at the end, experiences of some clinical trials.

EARLY LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS: OPTIMAL TIMING OF OPERATION AND PREDICTIVE FACTORS FOR CONVERSION

Annals of the College of Surgeons Hong Kong ◽

10.1046/j.1442-2034.2001.00098.x ◽

2001 ◽

Vol 5 (2) ◽

pp. A15

Author(s):

K.F. Cheung ◽

K.S. Yuen ◽

T.K. Ng ◽

Y.S. Sze ◽

K.W. Lui ◽

...

Keyword(s):

Early Laparoscopic Cholecystectomy

Acute Cholecystitis ◽

Predictive Factors ◽

Optimal Timing ◽

Timing Of Operation ◽

APPLICATION OF PERMANENT PACEMAKERS AND OPTIMAL PROGRAMMATION IN HUE UNIVERSITY OF MEDICINE AND PHARMACY HOSPITAL

Journal of Medicine and Pharmacy ◽

10.34071/jmp.2018.3.18 ◽

2018 ◽

pp. 114-121

Author(s):

Van Minh Huynh ◽

Anh Tien Hoang ◽

Khanh Hung Doan ◽

Vu Phong Nguyen ◽

Viet Lam Ngo ◽

...

Keyword(s):

Sick Sinus Syndrome ◽

Clinical Symptoms ◽

Jugular Vein ◽

Pacemaker Implantation ◽

Heart Association ◽

External Jugular Vein ◽

Permanent Pacemaker ◽

Male Gender ◽

Inclusion Criteria ◽

Underlying Diseases

Aim: To evaluate the application of permanent pacemaker and optimal programmation associated with Nora G. checklist in pacemaker implantation. Patients and methods: we analyse the 35 cases who were implanted the permanent pacemakers we analyse the 35 cases who were implanted the permanent pacemakers in 2017. For inclusion criteria, we used the recomendation of ACC/AHA/ HRS and Vietnam Heart Association. Apply the C arm fluoroscopy to perform the implantation of the permanent pacemaker. Most of patients were performed the subclavian vein and cephalic vein as the main way but some cases we choosed the external jugular vein as the alternative route. Results: male gender was 60%, mean age was 71.97±12.55. Mostly cardiac arrhythmia were sick sinus syndrome (42.86%), atrial fibrillation with slow rate response (17.14%), blocAVII nd degree Mobitz II (14.28%), bloc AV III rd (11.42%), the underlying diseases were arterial hypertension 42.86%, coronary disease (20%), diabetes mellitus (14.29%). The implanted pacemekers were predominantly one chamber VVIR type (47.5%). The complications was rare and there were a clear recovery of clinical symptoms and mortality death following the Nora checklist. Conclusion: VT technology is an integral part of the treatment of arrhythmias, especially the optimal combination of programming and the Nora checklist, which makes it more effective. Key words: permanent pacemaker, optimal programmation

Iatrogenic Bile Duct Injury. A Significant Surgical Problem. Assessment of Treatment Outcomes in the Department's Own Material

Polish Journal of Surgery ◽

10.1515/pjs-2015-0004 ◽

2015 ◽

Vol 86 (12) ◽

Cited By ~ 2

Author(s):

Adam Bobkiewicz ◽

łukasz Krokowicz ◽

Tomasz Banasiewicz ◽

Tomasz Kościński ◽

Maciej Borejsza-Wysocki ◽

...

Keyword(s):

Bile Duct ◽

Retrospective Analysis ◽

Bile Duct Injury ◽

Clinical Symptoms ◽

Open Cholecystectomy ◽

Multidisciplinary Treatment ◽

Laparoscopic Technique ◽

Primary Surgery ◽

Iatrogenic Bile Duct Injury

AbstractIatrogenic bile duct injuries (BDI) are still a challenging diagnostic and therapeutic problem. With the introduction of the laparoscopic technique for the treatment of cholecystolithiasis, the incidence of iatrogenic BDI increased.was a retrospective analysis of 69 patients treated at the department due to iatrogenic BDI in the years 2004-2014.. In this paper, we presented the results of a retrospective analysis of 69 patients treated at the Department due to iatrogenic BDI in the years 2004-2014. The data were analysed in terms of age, sex, type of biliary injury, clinical symptoms, the type of repair surgery, the time between the primary surgery and the BDI management, postoperative complications and duration of hospital stay.. 82.6% of BDI occurred during laparoscopic cholecystectomy, 8.7% occurred during open cholecystectomy, whereas 6 cases of BDI resulted from surgeries conducted for other indications. In order to assess the degree of BDI, Bismuth and Neuhaus classifications were used (for open and laparoscopic cholecystectomy respectively). 84.1% of patients with confirmed BDI, were transferred to the Department from other hospitals. The average time between the primary surgery and reoperation was 6.2 days (SD 4). The most common clinical symptom was biliary fistula observed in 78.3% of patients. In 28 patients, unsuccessful attempts to manage BDI were made prior to the admission to the Department in other centres. The repair procedure was mainly conducted by laparotomy (82.6%) and by the endoscopic approach (15.9%). Hepaticojejunostomy was the most common type of reconstruction following BDI (34.7%).. The increase in the rate of iatrogenic bile duct injury remains a challenging surgical problem. The management of BDI should be multidisciplinary treatment. Referring patients with both suspected and confirmed iatrogenic BDI to tertiary centres allows more effective treatment to be implemented.

P17 An audit of Trakcare discharge times for Laparoscopic Cholecystectomy

BJS Open ◽

10.1093/bjsopen/zrab032.016 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

Author(s):

Jacob Rapier ◽

Steven Hornby ◽

Jacob Rapier

Keyword(s):

Elective Laparoscopic Cholecystectomy

Length Of Stay ◽

Initial Data ◽

Best Practice ◽

Average Length ◽

Accurate Data ◽

Day Case ◽

Average Length Of Stay ◽

Number Of Patients ◽

Abstract Introduction Nationally 61,220 Laparoscopic Cholecystectomies are carried out annually. Those carried out as day-cases reduce providers’ costs and increase income through the best practice tariff. The system in our trust to record discharges is ‘Trakcare’. The aim of this audit was to accurately measure the discharge times of patients undergoing elective Laparoscopic Cholecystectomies, to try and reduce the number of patients recorded as having an overnight stay by accurate data collection. Methods Initial data was collected for all elective Laparoscopic Cholecystectomy discharge times on Trakcare, over a 1 month period. This data was then re-audited prospectively both from Trakcare and discharges reported by nurses/patients. A comparison was then made of Trakcare against reported discharge times. Results Initially 54 operations were recorded, with 30 completed as day cases (55.6%). The re-audited data (on Trakcare) recorded 47 operations, with 15 completed as day cases (37.91%). Of these discharges we were able to capture 26 (55.32%) manually, and 11 were completed as day cases (42.31%). Measuring these 26 with the same operations on Trakcare we were unable to show a difference in the number of cases completed as a day case (11 vs 11), with only a 33 minute decrease in the average length of stay. Conclusion Trakcare is a reliable tool for measuring the date of discharge for patients. The recommendations in are: scheduling surgery for a time pre-13:00 shows a higher proportion of patients discharged the same day, and continue to use Trakcare to record discharge times.

SP3.2.10 Establishing an Emergency Surgical Ambulatory Care (ESAC) pathway for acute laparoscopic cholecystectomies: a single centre experience from a District General Hospital

British Journal of Surgery ◽

10.1093/bjs/znab361.076 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Neil Donald ◽

Lavanya Varatharajan ◽

Kumaran Ratnasingham ◽

Shashi Irukulla

Keyword(s):

Length Of Stay ◽

Ambulatory Care ◽

Operating Time ◽

District General Hospital ◽

Gallstone Pancreatitis ◽

Patient Demographics ◽

Day Range ◽

Cost Efficiencies

Abstract Aims Early laparoscopic cholecystectomy is the gold standard for acute cholecystitis and gallstone pancreatitis. In order to deliver this service, a local Emergency Surgical Ambulatory Care (ESAC) pathway with a dedicated ESAC theatre list was established. The aim of this audit was to determine whether ESAC was associated with (1) improved length of stay and (2) cost efficiencies. Methods Consecutive patients who underwent an emergency laparoscopic cholecystectomy between October 2018 to October 2019 were identified. Data related to patient demographics, operating time, complications length of stay (LOS), reason for inpatient stay and re-admissions were collected. A dedicated ESAC service was introduced in July 2020. Outcomes were re-audited (July – December 2020). Results Prior to the introduction of ESAC, 142 patients (42% male, mean age 51 years (range 14 -82 years)) underwent an acute cholecystectomy, of which 13% were discharged on the same day. Median pre-operative LOS was 2 days (range 0-12 days) and median post-operative LOS was 1 day (range 1-16 days). Following the introduction of ESAC, 78 patients (32% male, mean age 49 years (range 22 – 89 years)) underwent an acute cholecystectomy, of which 76% were discharged on the same day and 90% within 1 day. Median pre-operative LOS was 0 days (range 0 to 7 days) and median post-operative LOS was 0 days (range 0-16 days). Conclusions Our results show that the introduction of a dedicated ESAC pathway improved both pre- and post-operative LOS. This subsequently saves approximately £80,000 per annum in hospital bed days.