P-EGS21 The impact of COVID-19 on operative difficulty and outcomes of laparoscopic cholecystectomy

Abstract Background The COVID-19 pandemic resulted in substantial delays to surgery among patients with symptomatic gallstones due to cessation of elective surgical procedures. As this exposed patients to a longer period of time during which complications from gallstones could develop, we hypothesised that the operative difficulty and complication rate of laparoscopic cholecystectomy (LC) increased following the first wave of the pandemic. Methods This was a retrospective cohort study of patients receiving emergency or elective LC at a single NHS trust comprising three sites. We included patients undergoing surgery in the pre-pandemic period (July-September 2019) and after resumption of elective surgical services following the first wave of the pandemic (July-September 2020). We compared data on operative duration, length of hospital stay, complications (bile leak, bile duct injury and mortality) and need for subtotal cholecystectomy. Categorical data are reported as n(%) and were compared with Fisher’s exact test. Continuous data are reported as median with interquartile range and compared with Mann-Whitney U Test. Results 220 patients were included; 106 in the pre-pandemic group and 114 in the pandemic group. There were no significant differences in median operative times between the pre-pandemic (91 (71-121 minutes) and post-first wave (86 (69-114) minutes) groups (p = 0.48). The proportion of prolonged operations (over two hours) was similar in the pre-pandemic and pandemic groups (50% versus 46%, respectively, p = 0.59). Median length of hospital stay was 0 days for both groups (pre-pandemic 0 (0-1) days; pandemic 0 (0-1) days, p = 0.42)). There were no significant differences in the rates of bile leak, bile duct injury, mortality, or the conversion to subtotal cholecystectomy. Conclusions Interruption of elective surgery following the first wave of the COVID-19 pandemic did not result in a discernible change in the technical difficulty or complication rate of LC at our centre. Longer term studies are required to assess the effect of prolonged delays to surgery and the impact of subsequent waves of the pandemic.

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Surgical Management of Complex Bile Duct Injuries in Specialized Hepatopancreatobiliary (HPB) Unit

10.53350/pjmhs211571700 ◽

2021 ◽

Vol 15 (7) ◽

pp. 1700-1702

Author(s):

Muhammad Khawar Shahzad ◽

Tariq Ali Bangash ◽

Amer Latif ◽

Hussam Ahmed ◽

Muhammad Asif Naveed ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Retrospective Study ◽

Bile Duct ◽

Hospital Stay ◽

Surgical Management ◽

Bile Duct Injury ◽

Surgical Repair ◽

Open Cholecystectomy ◽

Tube Placement ◽

Bile Duct Injuries

Objective: To describe the surgical management of complex bile duct injuries in a specialized hepatopancreatobiliary unit. Design of the Study: It was a retrospective study. Study Settings: This study was carried out at Department of Anaesthesia and Hepatobiliary Unit, Sheikh Zayed Hospital Lahore from August 2017 to August 2019. Material and Methods: This retrospective study includes 80 patients of bile duct injury who underwent surgical correction of bile duct injury at specialized Hepatopancreatobiliary [HPB] and liver transplant department of Shaikh Zayed Hospital Lahore. All the subjects were evaluated by retrospectively. The information regarding primary operative procedure, drain placement, T-tube placement, presentation, hospital stay, Liver Function Tests [LFTs], level of biliary tract injury and type of surgical procedure obtained from patients records. Results of the Study: During the study period 80 patients – 65 females and 15 male were operated for bile duct injury. Mean age was 39.89 years range 21 to 65 years. Hospital stay ranges from 9 to 36 days with mean of 16.18 days. Patients underwent open cholecystectomy, 43.8% laparoscopic cholecystectomy and in 3 patients procedure was converted from laparoscopic to open. 52.5% patients underwent open cholecystectomy, 43.8 laparoscopic cholecystectomy and in 3 patient’s procedure was converted from laparoscopic to open. Conclusion: It is concluded that the correct long lasting and physiological method to treat injuries of bile duct is only surgical repair. Although, surgical repair of bile duct must be operated by skilled hepatopancreaticobiliary surgeons. A practical method which is selected appropriately and implemented successfully has surely improved surgical outcome without any problem faced during the operation. Keywords: Hepatopancreatobiliary, Bile Duct Injury, Surgical Management

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An Algorithm for the Management of Bile Leak Following Laparoscopic Cholecystectomy

Annals of The Royal College of Surgeons of England ◽

10.1308/003588407x160864 ◽

2007 ◽

Vol 89 (1) ◽

pp. 51-56 ◽

Cited By ~ 32

Author(s):

F Ahmad ◽

RN Saunders ◽

GM Lloyd ◽

DM Lloyd ◽

GSM Robertson

Keyword(s):

Laparoscopic Cholecystectomy ◽

Minimally Invasive ◽

Hospital Stay ◽

Bile Leak ◽

Median Hospital Stay ◽

Management Protocol ◽

The Impact ◽

Median Hospital ◽

Bile Leaks

INTRODUCTION The management of bile leaks following laparoscopic cholecystectomy has evolved with increased experience of ERCP and laparoscopy. The purpose of this study was to determine the impact of a minimally invasive management protocol. PATIENTS AND METHODS Twenty-four patients with a bile leak following laparoscopic cholecystectomy were recorded consecutively between 1993 and 2003. Between 1993–1998, 10 patients were managed on a case-by-case basis. Between 1998–2003, 14 patients were managed according to a minimally invasive protocol utilising ERC/biliary stenting and re-laparoscopy if indicated. RESULTS Bile leaks presented as bile in a drain left in situ post laparoscopic cholecystectomy (8/10 versus 10/14) or biliary peritonitis (2/10 versus 4/14). Prior to 1998, neither ERC nor laparoscopy were utilised routinely. During this period, 4/10 patients recovered with conservative management and 6/10 (60%) underwent laparotomy. There was one postoperative death and median hospital stay post laparoscopic cholecystectomy was 10 days (range, 5–30 days). In the protocol era, ERC ± stenting was performed in 11/14 (P = 0.01 versus pre-protocol) with the main indication being a persistent bile leak. Re-laparoscopy was necessary in 5/14 (P = 0.05 versus preprotocol). No laparotomies were performed (P < 0.01 versus pre-protocol) and there were no postoperative deaths. Median hospital stay was 11 days (range, 5–55 days). CONCLUSIONS The introduction of a minimally invasive protocol utilising ERC and re-laparoscopy offers an effective modern algorithm for the management of bile leaks after laparoscopic cholecystectomy.

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Laparoscopic subtotal cholecystectomy in severe cholecystitis with unclear anatomy

International Surgery Journal ◽

10.18203/2349-2902.isj20205345 ◽

2020 ◽

Vol 7 (12) ◽

pp. 3929

Author(s):

Maged Rihan

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Bile Duct Injury ◽

Common Bile Duct Stones ◽

Hospital Length Of Stay ◽

Safe Procedure ◽

Female Ratio ◽

Subtotal Cholecystectomy ◽

Port Site Hernia ◽

Significant Difference

Background: Aim of the study was to determine the differences between laparoscopic cholecystectomy and laparoscopic subtotal cholecystectomy as regards bile duct injury and post-operative complications rates in patients with severe cholecystitis and obscure anatomy.Methods: We retrospectively reviewed the charts and postoperative outcomes of 293 patients with severe cholecystitis who underwent either laparoscopic cholecystectomy or laparoscopic subtotal cholecystectomy between September 2011 and January 2020. Patients with intraoperative altered anatomy which leaded to difficult dissection were defined as having severe cholecystitis.Results: There were 304 cholecystectomies done for patients with severe cholecystitis. Of those, 203 underwent laparoscopic cholecystectomy (LC group), 90 underwent laparoscopic subtotal cholecystectomy (LSC group). There was no significant difference in male to female ratio, age, cases performed on an elective or emergency basis, hospital length of stay or initial operative findings. There were 5 patients with detected intraoperative biliary injury in LC group only. Postoperative bile leaks were significantly higher in the LSC (11.1%) than in the LC group (3.9%). Postoperative collections which needed percutaneous aspiration were also significantly higher in the LSC group (18.9%) than in the LC group (7.4%). Reoperation for collection was required in 8 patients in LC group and in 5 patients in LSC group. The rates of retained common bile duct stones, port site hernia, wound infections, and total complications were not significantly different between the two groups (28.1% v. 45.6%).Conclusions: Our study demonstrated that laparoscopic subtotal cholecystectomy is a safe procedure which reduces the risk of bile duct injury and is comparable to laparoscopic cholecystectomy in patients with severe cholecystitis with unclear anatomy.

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Bile Duct Injury Repairs after Laparoscopic Cholecystectomy: A Five-Year Experience in a Highly Specialized Community Hospital

The American Surgeon ◽

10.1177/000313481908501016 ◽

2019 ◽

Vol 85 (10) ◽

pp. 1150-1154

Author(s):

Massimo Arcerito ◽

Mazen M. Jamal ◽

Harvey A. Nurick

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Bile Duct Injury ◽

Stent Placement ◽

Community Hospital ◽

Balloon Dilation ◽

Bile Leak ◽

Type A ◽

Tube Placement ◽

Team Approach

Bile duct injury represents a complication after laparoscopic cholecystectomy, impairing quality of life and resulting in subsequent litigations. A five-year experience of bile duct injury repairs in 52 patients at a community hospital was reviewed. Twenty-nine were female, and the median age was 51 years (range, 20–83 years). Strasberg classification identified injuries as Type A (23), B (1), C (1), D (5), E1 (5), E2 (6), E3 (4), E4 (6), and E5 (1). Resolution of the bile duct injury and clinical improvement represent main postoperative outcome measures in our study. The referral time for treatment was within 4 to 14 days of the injury. Type A injury was treated with endobiliary stent placement. The remaining patients required T-tube placement (5), hepaticojejunostomy (20), and primary anastomosis (4). Two patients experienced bile leak after hepaticojejunostomy and were treated and resolved with percutaneous transhepatic drainage. At a median follow-up of 36 months, two patients (Class E4) required percutaneous balloon dilation and endobiliary stent placement for anastomotic stricture. The success of biliary reconstruction after complicated laparoscopic cholecystectomy can be achieved by experienced biliary surgeons with a team approach in a community hospital setting.

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Successful Endoscopic Management of Bile Leak: A Single-Center Experience

Journal of Digestive Endoscopy ◽

10.4103/jde.jde_57_17 ◽

2017 ◽

Vol 08 (04) ◽

pp. 170-175 ◽

Cited By ~ 1

Author(s):

Vinay Pawar ◽

Nikhil Sonthalia ◽

Sunil Pawar ◽

Ravindra Surude ◽

Qais Contractor ◽

...

Keyword(s):

Bile Duct ◽

Liver Abscess ◽

Bile Duct Injury ◽

Care Center ◽

Tertiary Care ◽

Bile Leak ◽

Magnetic Resonance Cholangiopancreatography ◽

Endoscopic Management ◽

Western India ◽

The Impact

ABSTRACT Background and Aims: Bile leak is a rarely encountered complication most commonly occurring in the setting of biliary tract surgery. Site of leak may be from the gallbladder bed, the cystic duct, or rarely from injury to a major bile duct. Management has evolved with from radical surgery prevalent in earlier days to recent increased expertise in biliary endoscopy. This study aims to determine the impact of endoscopic management in treating symptomatic bile leak and discusses the role of surgery. Patients and Methods: In this retrospective study, patients with symptomatic bile leak admitted between 2012 and 2015 to the Department of Gastroenterology of a tertiary care center in Western India were analyzed. Site and extent of bile leak was evaluated using contrast enhanced computed tomography or magnetic resonance cholangiopancreatography. Endoscopic retrograde cholangiopancreatography (ERCP) was mainly used as a therapeutic tool rather than a diagnostic tool. ERCP was used as a primary mode of treatment wherever feasible. Percutaneous biliary drainage was used in technically difficult cases. Results: Twenty-seven patients with symptomatic bile leak were identified in aforesaid period. Bile leak in 21 (77.88%) patients was due to postlaparoscopic cholecystectomy injury, while in 6 (22.22%) patients, it was associated with liver abscess. Major bile duct injury was seen in 10 patients with postcholecystectomy status and in 5 patients with liver abscess. Out of 27 cases, 25 (92.59%) were treated with ERCP and 2 (7.40%) with percutaneous drainage. Surgery was not required in any of the patients. Sphincterotomy with stent placement for 6 weeks was effective in 23 (92%) patients, and only sphincterotomy was effective in 2 (8%) patients undergoing ERCP. There was no mortality due to bile leak. Conclusion: Most patients presenting with bile leak including major bile duct injury without complete bile duct transection can be successfully treated by endoscopic therapy without the need for surgery.

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Impact of surgical delays on pre-operative complications in primary GBM patients- a 5-year study

Neuro-Oncology ◽

10.1093/neuonc/noab195.038 ◽

2021 ◽

Vol 23 (Supplement_4) ◽

pp. iv15-iv15

Author(s):

Thaaqib Nazar ◽

Stephen Price

Keyword(s):

Hospital Stay ◽

Complication Rate ◽

Length Of Hospital Stay ◽

P Value ◽

Complication Rates ◽

Inclusion Criteria ◽

Roc Curve Analysis ◽

Who Grade ◽

Operative Complication ◽

The Impact

Abstract Aims Glioblastoma Multiforme (GBM) is one of the most aggressive primary brain tumors with poor prognosis (median survival 18 months) and no cure. Management strategies often involve maximum safe resection followed by chemoradiotherapy. There has been a move from managing such patients electively rather than the traditional model of treating them as an emergency. While this may have advantages, this can delay the time from presentation to operation. This delay has recently been further compounded by the current COVID-19 pandemic. There is no data available as to whether the surgical delays that are currently occurring have an impact on patient care, and may outweigh the benefits of elective management on health services. We aimed to conduct a single centre observational study to assess how long patients should be waiting prior to surgery. We hypothesised that the longer the wait, the higher the pre-operative complication rate and worse the outcomes. Method 698 patients in a GBM database over a 5-year period (29/10/14- 8/11/19) were studied. All patient data was accessed via electronic patient records Surgical delay was defined as the interval between date of being put on the waiting list (the date seen in the neuro-oncology clinic) to date of surgery. Primary outcome measure was preoperative complications, which was categorised into transient neurological decline, stroke, seizures, diabetes/erratic blood sugars, emergency admission, others (e.g., cardiovascular compromise, steroid complications, blood disorders) Inclusion criteria included: First presentation supratentorial WHO Grade 4 GBM confirmed on histology (this included histological variants such as Gliosarcoma and Epithelioid Glioblastoma), and all patients who had been seen in the neuro-oncology clinic prior to surgery. Exclusion criteria included all patients who were not thought to have a GBM or high-grade glioma on initial imaging, those admitted as an emergency without being seen in a neuro-oncology clinic, recurrent or secondary GBMs. Results 460 patients met the inclusion criteria in this study. There was a pre-operative complication rate of 14.6% (67/460). 55% of complications were due to a transient neurological decline (37/67) with 16.4 % (11/67) of patients presenting with seizures. For those with surgical delays ≤7 days pre-operative complication rates were 2.2 % vs 15.9% in those with delays >7 days, p value 0.012, Odds ratio 8.53 (95% CI 1.48- 88.09). Results were statistically significant in those with delays greater than 10 and 14 days (p values 0.0026 and 0.0004 respectively) ROC Curve analysis revealed an AUC of 0.66 with sensitivities of 99%, 90% and 76% at surgical delays of 7,10 and 14 days respectively. The median length of hospital admission in both groups of patients was 5 days (p= 0.2065) All statistical analysis was carried out using Prism 9 and SPSS Conclusion In spite of unchanged length of hospital stay, we note a significant increase in pre-operative complication rates as a result of surgical delays greater than 7,10 and 14 days, which introduces an interesting debate in the merit of delaying operations for further assessment in clinic. Our objectives would be to minimize complication rate, therefore a high sensitivity i.e. true positive rate would be most desirable. The 99% levels achieved at 7 days In the ROC analysis lends weight to introducing policy to fast-track admissions for primary GBM patients. Further directions could include assessing the impact reduced surgical services and redeployment might have had on complications rates and length of hospital stay on patients admitted over the COVID 19 pandemic.

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P-BN51 Subtotal cholecystectomy: risk factors and patient outcomes

British Journal of Surgery ◽

10.1093/bjs/znab430.049 ◽

2021 ◽

Vol 108 (Supplement_9) ◽

Author(s):

James Lucocq ◽

David Hamilton ◽

John Scollay ◽

Pradeep Patil

Keyword(s):

Bile Duct ◽

Bile Duct Injury ◽

Cystic Duct ◽

Univariate Analysis ◽

Bile Leak ◽

Significant Risk ◽

Patient Specific ◽

Subtotal Cholecystectomy ◽

Patients At Risk ◽

Open Versus

Abstract Background A subtotal cholecystectomy (SC) is indicated when a total cholecystectomy (TC) cannot be achieved without the risk of causing significant harm, the most feared complication being a bile duct injury. The aims of the present study were to identify patients at risk of SC, to compare the peri- and post-operative course between SC and TC and to compare outcomes between fenestrated and reconstituting subtypes. Methods All planned laparoscopic cholecystectomies across three surgical units over a population of 493,000 between 2015 and 2019 were considered. Data were collected retrospectively using electronic databases and included pre-operative, operative and post-operative data over a 100-day follow-up period. Variables associated with SC were identified using multivariate logistic regression. Outcomes following SC were compared with TC using univariate analysis, specifically chi-squared and Mann-Whitney U tests. The subtype of SC was documented and outcomes were compared between groups. Results The rate of SC was 3.4% (94/2768). Variables positively associated with SC included male sex (OR-2.33;p<0.001), age≥60 (OR-1.79;p=0.009), 2 previous admissions (OR-1.76;p=0.043), ≥3 previous admissions (OR-3.10;p=0.003), emergency cholecystectomy (OR-2.01;p=0.002); cholecystitis (OR-4.92;p<0.001) and pre-operative ERCP (OR-2.23;p<0.002). Patients with SC versus TC were more likely to suffer intra-operative complications (RR-13.1;p<0.001), post-operative complication (RR-6.7;p<0.001), require post-operative imaging/intervention (RR-4.0;p<0.001) and be re-admitted (RR-4.2; p < 0.001). The rate of bile duct injury was 0% in SC patients. The rate of post-operative bile leak was higher where the cystic duct was left open versus closed (RR-2.9;p=0.03) and in fenestrating SC versus reconstituting SC (35.7% versus 0%;p=0.002). Drain duration was reduced in reconstituting SC (p < 0.001). Conclusions The risk of SC can be explained by a number of patient specific factors and the risk should be emphasized in these patients during the consent process and should influence surgical decision making. The morbidity following a subtotal cholecystectomy is markedly higher than that of a total cholecystectomy but can be performed without significant risk of bile duct injury. Reconstituting SC and closure of the cystic duct reduces rates of post-operative bile leaks and duration of drains.

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Omentoplasty Combined With Endoscopic Stenting in the Treatment of Lateral Duct Injury at Hepatic Duct Bifurcation

The American Surgeon ◽

10.1177/0003134820945231 ◽

2020 ◽

pp. 000313482094523

Author(s):

Wei Wei ◽

Medhat Fanous

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Bile Duct Injury ◽

Hepatic Duct ◽

Bile Leak ◽

Endoscopic Stenting ◽

Common Bile Duct Injury ◽

Endoscopic Retrograde ◽

Omental Patch ◽

Clinical Challenge

Background Common bile duct injury (CBDI) is a devastating complication from laparoscopic cholecystectomy. The endoscopic retrograde cholangiopancreatography (ERCP)-based sphincterotomy and stenting were reportedly effective in treating low or distal lateral CBDI. However, in the circumstance of proximal lateral CBDI, the routine biliary stent may not provide coverage of the leak site, which posed a unique clinical challenge when such proximal CBDI occurred. Methods This patient is an 85-year-old man who underwent laparoscopic cholecystectomy for acute cholecystitis. The gallbladder was contracted and atrophic with extensive dense adhesions in the infundibular area. A dome-down approach was attempted, and a small side hole was identified from a tubular structure with minimal bilious leakage. The intraoperative cholangiogram showed a bile leak at the hepatic duct confluence. A vascularized omental patch was fashioned and secured to the vicinity of the CBDI in a tension-free manner. Two drains were placed. ERCP and endoscopic stenting were undertaken the following day. Results There was minimal bilious fluid output from the Jackson-Pratt drains in the first 24 hours. This was reduced further following ERCP and resolved in 2 days while tolerating a regular diet. All laboratory studies were normal. The drains were removed week postoperatively. The patient was seen in the clinic at 12 months, and there was no evidence of bile leak or stricture. Conclusion The combination of omentopexy and endoscopic stenting is safe in managing high lateral bile duct injury. Prospective studies are needed to further validate this technique.

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LAPAROSCOPIC CHOLECYSTECTOMY

The Professional Medical Journal ◽

10.29309/tpmj/2011.18.02.2059 ◽

2011 ◽

Vol 18 (02) ◽

pp. 237-242

Author(s):

AWAIS SHUJA ◽

ABID BASHIR ◽

ABID RASHID

Keyword(s):

Laparoscopic Cholecystectomy ◽

Hospital Stay ◽

Complication Rate ◽

Conversion Rate ◽

Gall Stone ◽

Significant Difference ◽

Group A ◽

The Mean ◽

Group B ◽

The Impact

Laparoscopic cholecystectomy is the gold standard treatment for patients presenting with acute gall stone disease necessitating hospital admission. Objective: To assess the impact of timing of laparoscopic cholecystectomy on conversion rate, hospital stay and morbidity. Period: Jan 2008-2010. Setting: Department of Surgery, Independent University Hospital, Faisalabad. Study Design: Experimental study. Material & Methods: The subjects were included by consecutive sampling technique. 81 cases were divided into 3 groups. Group A (Surgery within 72 hrs of onset symptoms). Group B (surgery between 72hrs to 96 hours of onset of symptoms). Group C (surgery after 96 hours of onset of symptoms). Results: The mean age was 41-95 years. Female to male ratio was 4.5:1. The overall complication rate was 12.69%. Mean hospital stay was 2.85 days. The open conversion rate was 8.64%. In group A the complication rate was 6%, group B 11.5% and group C 12.8&. The mean hospital stay and conversion rate had no significant difference. Conclusions: The timing of laparoscopic cholecystectomy has no significant impact on the conversion rate and length of hospital stay in cases with acute cholecystitis. However the complication rate was higher when surgery performed after 72 hours of onset of symptoms.

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Early Re- Laparoscopy in Suspected Bile Duct Injuries after Laparoscopic Cholecystectomy

Birat Journal of Health Sciences ◽

10.3126/bjhs.v6i1.37645 ◽

2021 ◽

Vol 6 (1) ◽

pp. 1396-1400

Author(s):

Roshan Ghimire ◽

Dhiresh Maharjan ◽

Prabin Thapa

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Bile Duct Injury ◽

Bile Leak ◽

Early Postoperative Period ◽

Female Ratio ◽

Medical College ◽

Bile Duct Injuries ◽

Definitive Repair ◽

Operative Findings

Introduction: Management of patients with suspected bile leak or bile duct injury after laparoscopic cholecystectomy is challenging. Early laparoscopy in these groups of patients will benefit in terms of diagnostic as well therapeutic purpose. Objective: This study is done to assess utility of early re-laparoscopy in suspected bile duct injury in early postoperative period following laparoscopic cholecystectomy. Methodology: It is a descriptive study of all consecutive patients who underwent diagnostic as well therapeutic re-laparoscopy when required in suspected bile duct injury in early postoperative laparoscopic cholecystectomy that is within 72 hours of presentation. Study was conducted over a period from June 2019 to December 2020 at Kathmandu medical College, Sinamangal, Kathmandu, Nepal. Relaparoscopic operative findings and therapeutic intervention done were recorded. Result: The mean age at presentation was 34.6 years and male to female ratio was 1:1.8. During the study period, eleven patients underwent re-laparoscopy out of which one had no bile leak. Six out of ten were managed definitely in the same time of re-laparoscopy. However, four patients underwent definitive biliary reconstruction as they had already undergone arteriography in CT scan. Conclusions: Early re-laparoscopy may be beneficial prior to detail radiological investigations in suspected bile leak patients. Early re-laparoscopy can be an effective diagnostic as well therapeutic tool; and also it can help in planning for definitive repair in later date.

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