Laparoscopic Cholecystectomy is Safe in Emergency General Surgery Patients with Cirrhosis

Cirrhosis is associated with adverse outcomes after emergency general surgery (EGS). The objective of this study was to determine the safety of laparoscopic cholecystectomy (LC) in EGS patients with cirrhosis. We performed a two-year retrospective cohort analysis of adult patients who underwent LC for symptomatic gallstones. The primary outcome was the incidence of intraoperative complications. Of 796 patients, 59 (7.4%) were cirrhotic, with a median model for end-stage liver disease (MELD) score of 15 (IQR, 7). On unadjusted analysis, patients with cirrhosis were older, more likely to be male (both P < 0.01), diabetic ( P < 0.001), had a higher incidence of preadmission antithrombotic therapy use ( P < 0.02), and experienced a longer time to surgery (3.2 vs 1.8 days, P < 0.001). Coarsened exact matching revealed no difference in intra- or postoperative complications between groups ( P = 0.67). Operative duration was longer in patients with cirrhosis (162 vs 114 minutes, P = 0.001), who also had a nonsignificant increase in the rate of conversion to an open cholecystectomy (14% vs 4%, P = 0.07). The results of this study indicate that LC may be safely performed in EGS patients with cirrhosis.

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Comment on “Trainee Participation Is Associated With Adverse Outcomes in Emergency General Surgery

Annals of Surgery ◽

10.1097/sla.0000000000001104 ◽

2016 ◽

Vol 263 (3) ◽

pp. e41 ◽

Cited By ~ 1

Author(s):

Leon J. Graat ◽

Jan A. Roukema ◽

Jaap F. Hamming

Keyword(s):

General Surgery ◽

Adverse Outcomes ◽

Emergency General Surgery

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Prolonged (Longer than 3 Hours) Laparoscopic Cholecystectomy: Reasons and Results

The American Surgeon ◽

10.1177/000313481107700814 ◽

2011 ◽

Vol 77 (8) ◽

pp. 981-984 ◽

Cited By ~ 10

Author(s):

Gokulakkrishna Subhas ◽

Aditya Gupta ◽

Jasneet Bhullar ◽

Linda Dubay ◽

Lorenzo Ferguson ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Bile Duct ◽

Bile Duct Injury ◽

Operative Time ◽

Intraoperative Complications ◽

Open Cholecystectomy ◽

Stepwise Logistic Regression ◽

Intraabdominal Adhesions ◽

Average Operative Time ◽

Prolonged Surgery

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), intraabdominal 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.

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Venous thromboembolism in children undergoing surgery: incidence, risk factors and related adverse events

World Journal of Pediatric Surgery ◽

10.1136/wjps-2019-000084 ◽

2020 ◽

Vol 3 (1) ◽

pp. e000084

Author(s):

Elbert Johann Mets ◽

Ryan Patrick McLynn ◽

Jonathan Newman Grauer

Keyword(s):

Risk Factors ◽

Venous Thromboembolism ◽

Adverse Events ◽

General Surgery ◽

Elective Surgery ◽

Cohort Analysis ◽

Adverse Outcomes ◽

Trauma Patients ◽

Improvement Project ◽

Increased Risk

BackgroundAlthough less common in adults, venous thromboembolism (VTE) in children is a highly morbid, preventable adverse event. While VTE has been well studied among pediatric hospitalized and trauma patients, limited work has been done to examine postoperative VTE in children undergoing surgery.MethodsUsing data from National Surgical Quality Improvement Project Pediatric database (NSQIP-P) from 2012 to 2016, a retrospective cohort analysis was performed to determine the incidence of, and risk factors for, VTE in children undergoing surgery. Additionally, the relationships between VTE and other postoperative adverse outcomes were evaluated.ResultsOf 361 384 pediatric surgical patients, 378 (0.10%) were identified as experiencing postoperative VTE. After controlling for patient and surgical factors, we found that American Society of Anesthesiologists (ASA) class of II or greater, aged 16–18 years, non-elective surgery, general surgery (compared with several other surgical specialties), cardiothoracic surgery (compared with general surgery) and longer operative time were significantly associated with VTE in pediatric patients (p<0.001 for each comparison). Furthermore, a majority of adverse events were found to be associated with increased risk of subsequent VTE (p<0.001).ConclusionIn a large pediatric surgical population, an incidence of postoperative VTE of 0.10% was observed. Defined patient and surgical factors, and perioperative adverse events were found to be associated with such VTE events.

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Is Trainee Participation Really Associated With Adverse Outcomes in Emergency General Surgery?

Annals of Surgery ◽

10.1097/sla.0000000000001376 ◽

2017 ◽

Vol 266 (2) ◽

pp. e35-e36

Author(s):

Mandy Mak ◽

Sarah Ashford-Wilson ◽

Abdul R. Hakeem ◽

Vivek Chitre

Keyword(s):

General Surgery ◽

Adverse Outcomes ◽

Emergency General Surgery

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Index laparoscopic cholecystectomy for acute admissions with cholelithiasis provides excellent training opportunities in emergency general surgery

The Surgeon ◽

10.1016/j.surge.2009.10.021 ◽

2010 ◽

Vol 8 (3) ◽

pp. 127-131 ◽

Cited By ~ 7

Author(s):

P. Sanjay ◽

J. Moore ◽

E. Saffouri ◽

S.A. Ogston ◽

C. Kulli ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

General Surgery ◽

Emergency General Surgery ◽

Training Opportunities ◽

Acute Admissions

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Can Sarcopenia Quantified by CT Predict Adverse Outcomes in Emergency General Surgery?

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2017.07.170 ◽

2017 ◽

Vol 225 (4) ◽

pp. S80 ◽

Cited By ~ 1

Author(s):

Cathy Ho ◽

Faisal Jehan ◽

Joseph V. Sakran ◽

Terence O'Keeffe ◽

Narong Kulvatunyou ◽

...

Keyword(s):

General Surgery ◽

Adverse Outcomes ◽

Emergency General Surgery

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Can the MELD Score Predict Perioperative Morbidity for Patients with Liver Cirrhosis Undergoing Laparoscopic Cholecystectomy?

The American Surgeon ◽

10.1177/000313480807400215 ◽

2008 ◽

Vol 74 (2) ◽

pp. 156-159 ◽

Cited By ~ 4

Author(s):

Juliane Bingener ◽

Diane Cox ◽

Joel Michalek ◽

Alejandro Mejia

Keyword(s):

Liver Transplantation ◽

Liver Cirrhosis ◽

Laparoscopic Cholecystectomy ◽

Significant Variation ◽

Meld Score ◽

Morbidity Rate ◽

Perioperative Morbidity ◽

End Stage Liver Disease ◽

The Mean ◽

End Stage

The Model for End Stage Liver Disease (MELD) score is a mortality predictor in patients awaiting liver transplantation. We evaluated the MELD score's ability to predict morbidity for patients with cirrhosis undergoing laparoscopic cholecystectomy. From March 1991 to February 2004, data of all patients undergoing laparoscopic cholecystectomy were prospectively collected. Data of patients with liver cirrhosis were reviewed. The MELD and Child scores were correlated with outcome variables. Of 7859 patients undergoing laparoscopic cholecystectomy, 99 patients (1.3%) exhibited liver cirrhosis, 44 women and 55 men. The mean age was 55 years (range, 28 to 92 years). The mortality rate was 6.3 per cent, morbidity rate 18 per cent, and conversion rate 11 per cent. Laboratory values on 55 patients were available to calculate MELD scores. The mean MELD score was 11 (range, 6 to 23). There was no significant variation in MELD scores with gender ( P = 0.61) or cirrhosis etiology, alcoholic and nonalcoholic ( P = 0.52). MELD and Child's score correlated well ( P < 0.001); however, the risk of complication was not related to the MELD ( P = 0.94) or Child-Pugh-Turcotte score ( P = 0.26). Morbidity for patients with liver cirrhosis undergoing laparoscopic cholecystectomy remains high. The MELD score is useful for transplant risk stratification for but requires further investigation regarding morbidity prediction for laparoscopic cholecystectomy.

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Reply to: Prediction of Adverse Outcomes After Emergency General Surgery in Older Patients

Journal of the American Geriatrics Society ◽

10.1111/jgs.15743 ◽

2019 ◽

Vol 67 (4) ◽

pp. 853-854

Author(s):

Davide Zattoni ◽

Nicole Marie Saur ◽

Isacco Montroni

Keyword(s):

General Surgery ◽

Older Patients ◽

Adverse Outcomes ◽

Emergency General Surgery

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Comparison Between Outcomes of Laparoscopic Cholecystectomy in Patients With Liver Cirrhosis or With Normal Liver Function

International Surgery ◽

10.9738/intsurg-d-17-00133.1 ◽

2017 ◽

Vol 102 (11-12) ◽

pp. 489-495

Author(s):

Masayuki Akita ◽

Tetsuo Ajiki ◽

Kimihiko Ueno ◽

Daisuke Tsugawa ◽

Kenta Shinozaki ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Liver Disease ◽

Perioperative Complications ◽

Operation Time ◽

Normal Liver ◽

Meld Score ◽

Primary Biliary Cholangitis ◽

Clinicopathologic Characteristics ◽

Cirrhotic Patients ◽

End Stage

Objective and Background: The safety of laparoscopic cholecystectomy in patients with Child–Pugh A and B cirrhosis is well-established, but perioperative complications are frequently observed in patients with cirrhosis. Technical challenges of this operation in cirrhotic patients remain in need of resolution. Methods: Twenty-one patients preoperatively diagnosed as having cirrhosis underwent laparoscopic cholecystectomy mainly using the French approach and were retrospectively reviewed. Their clinicopathologic characteristics were compared with 74 continuous patients with gallstone but no cirrhosis who underwent laparoscopic cholecystectomy using the American approach. Results: Most cirrhotic patients (19/21, 90.5%) had a chronic liver disease such as hepatitis B/C, alcoholic hepatitis, or primary biliary cholangitis. On imaging, the Chilaiditi sign and gallbladder bed pocket score, previously proposed to be informative in these patients, were significantly higher in the cirrhosis group than in the no cirrhosis group. Although the Child–Pugh score was higher in patients with cirrhosis, the model for end-stage liver disease (MELD) score was similar for the 2 groups. There were no differences in the operation time or the amount of intraoperative blood transfused. Postoperative hospital stay and postoperative morbidity rates were significantly greater in the cirrhosis group, although severe complications with a Clavien–Dindo score ≥ IIIa occurred in only 1 patient in each group. Conclusions: The safety of laparoscopic cholecystectomy in cirrhotic patients was confirmed. Because the gallbladder is completely covered in patients with cirrhosis, the French style approach, which enables surgeons to more easily access the gallbladder pocket, is assumed to be one of the operative options.

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