difficult cholecystectomy
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Author(s):  
James Lucocq ◽  
John Scollay ◽  
Pradeep Patil

Abstract Introduction Patients undergoing elective laparoscopic cholecystectomy (ELLC) represent a heterogeneous group making it challenging to stratify risk. The aim of this paper is to identify pre-operative factors associated with adverse peri- and post-operative outcomes in patients undergoing ELLC. This knowledge will help stratify risk, guide surgical decision making and better inform the consent process. Methods All patients who underwent ELLC between January 2015 and December 2019 were included in the study. Pre-operative data and both peri- and post-operative outcomes were collected retrospectively from multiple databases using a deterministic records-linkage methodology. Patients were divided into groups based on clinical indication (i.e. biliary colic versus cholecystitis) and adverse outcomes were compared. Multivariate regression models were generated for each adverse outcome using pre-operative independent variables. Results Two-thousand one hundred and sixty-six ELLC were identified. Rates of peri- and post-operative adverse outcomes were significantly higher in the cholecystitis versus biliary colic group and increased with number of admissions of cholecystitis (p < 0.05). Rates of subtotal (29.5%), intra-operative complication (9.8%), post-operative complications (19.6%), prolonged post-operative stay (45.9%) and re-admission (16.4%) were significant in the group of patients with ≥ 2 admissions with cholecystitis. Conclusion Our data demonstrate that patients with repeated biliary admission (particularly cholecystitis) ultimately face an increased risk of a difficult ELLC with associated complications, prolonged post-operative stay and readmissions. These data provide robust evidence that individualised risk assessment and consent are necessary before ELLC. Strategies to minimise recurrent biliary admissions prior to LC should be implemented.


2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Hywel Room ◽  
Anna Wood ◽  
Chen Chen Ji ◽  
Hannah Dowell ◽  
Simon Toh

Abstract Aims Ultrasound has long been the radiological investigation of choice for right upper quadrant pain for the detection of gallstones and cholecystitis. However, previously reported sensitivity, specificity and other diagnostic metrics have varied widely and the underlying patient numbers have been small. We present robust and exhaustive diagnostic metrics based on a large series of 793 patients. Methods All laparoscopic cholecystectomies at our university hospital were prospectively logged between 2017 and 2020. The ultrasound findings, Nassar operative difficulty and histopathological findings were all collected in addition to patient biometrics. Results In our large patient series, sensitivity of ultrasound for cholecystitis was lower than previously reported at 75.7% for acute cholecystitis, 34.6% for chronic cholecystitis and 42.7% overall. Moreover, we show that sensitivity degrades with the time between ultrasound and cholecystectomy, falling below 50% at 140 days. Finally, we show that ultrasound strongly predicts Nassar difficulty grade of cholecystectomy and that its ability to do so is greatest where the interval between ultrasound and cholecystectomy is less than 27 days. Conclusions We present robust diagnostic metrics for ultrasound in the diagnosis of cholecystitis. These should caution the clinician that ultrasound may miss a quarter of cases of acute cholecystitis and over half of all cases of cholecystitis. Conversely, the finding of a thickened gallbladder on ultrasound can predict a “difficult cholecystectomy” and highlight the need for appropriate expertise and resources. Both this prediction and the diagnostic sensitivity are best if the ultrasound is done less than 27 days before cholecystectomy.


2021 ◽  
Vol 8 (8) ◽  
pp. 2382
Author(s):  
Bhupen Songra ◽  
Amit Kumar ◽  
Mohit Jain ◽  
Gaurav Jalendra

Background: Laparoscopic cholecystectomy is the procedure of choice for majority of patients with gall bladder disease. The aim of the study was to investigate the role of male gender as an isolated risk factor responsible for the increased peri-operative morbidity of laparoscopic cholecystectomy by excluding associated risk factors.Methods: This was a prospective observational descriptive study 60 cases of elective laparoscopic cholecystectomy admitted to the S. M. S. Hospital from July 2019 to May 2020 were included.Results: The most common age group in male was 41-50 years and in female was 51-60 years. Impacted stones and gall bladder wall thickness >4 mm was causes of difficult cholecystectomy and evenly distributed in both sexes. Operative time (p value=0.268), visual analogue score on day 1 (p value=0.307) and hospital stay (p value=0.376) was more in male group but not statistically significant.Conclusions: Impacted stone and gall bladder wall thickness >4 mm were only factors associated with difficult laparoscopic cholecystectomy and excludes male gender as an isolated risk factor for difficult cholecystectomy however large-scale studies may provide different results.


Author(s):  
Samir Paruthy ◽  
Shivani B. Paruthy

Background: ‘Gold standard’ for symptomatic cholelithiasis is laparoscopic cholecystectomy (LC) with advantagesof minimal access surgery, early return to activity with cosmetic scar. However, this may not always holdtrue in all cases. Conversion to open procedure in challenging circumstances would be in better interest of the patient even after the learning curve of the surgeon has surpassed several years. Methods: Forty patients undergoing symptomatic gall stone disease without any acute episode in past six weeks were investigated. All cases were evaluated with clinical examinations, biochemical parameters and preoperative ultrasonography done a day prior for prediction of difficult LC. All cases correlated with preoperative USG parameters and Nassar per operative grade (1-4 and 5) and analyzed for prediction to open method in difficult challenging situations. Complications associated with in 30 day of surgical interventions were also recorded. Results: Difficult cholecystectomy was anticipated with USG parameters in 20 cases, and Nassar operative grading of difficulty (Grade-3, 4 and 5) predicted in 13 cases; the latter was correlated with conversion to open methods. p<0.05 in USG parameters and Nassar grading of operative difficulty was considered significant. There were no complications nor any surgical interventions required during 30 days interval.Conclusions: Per operative Nassar grading and prior USG parameters for prediction of likelihood of difficult cholecystectomy helps in guiding surgeon in challenging situation to safely proceed to complete cholecystectomy procedure either by laparoscope or open method in the better interest of the patient.  


2021 ◽  
Author(s):  
Reinhold Függer

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.


HPB ◽  
2021 ◽  
Vol 23 ◽  
pp. S559
Author(s):  
U.Y. Panni ◽  
G.A. Williams ◽  
S.M. Strasberg

2020 ◽  
Vol 112 (2) ◽  
pp. 171-177
Author(s):  
Matías H. Loccisano ◽  
◽  
Martín Drago ◽  
Hernán Todeschini ◽  
Luis E. Sarotto

Background: laparoscopic cholecystectomy is one of the most common procedures performed in general surgery. The anatomical differences of the gallbladder and the presence of factors related to inflammation can cause technical issues during surgery. Objective: the aim of the present study was to determine the value of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) as predictors of difficult cholecystectomy and to evaluate their application during presurgical planning within a university residency program. Material and methods: we conducted a retrospective and analytical study in a tertiary university hospital. A total of 104 adult patients undergoing laparoscopic cholecystectomy due to symptomatic cholelithiasis between January and July 2019 were included. The patients were categorized into two groups: difficult cholecystectomy and non-difficult cholecystectomy. Results: there were statistically significant differences in ESR and CRP values between both groups (p < 0.001). Sensitivity of ESR was 100%, specificity was 45%, with a PPV of 40% and NPV of 100%. Sen- sitivity of CRP was 87.5%, specificity was 86.3%, with a PPV of 70% and NPV of 95%. Both parameters were elevated in 14 of 16 difficult cholecystectomies and in 2 of 44 non-difficult cholecystectomies. Sensitivity of CRP was 87.5%, specificity was 86.3%, with a PPV of 70% and NPV of 95%. Conclusion: measuring ESR and CRP has proved to be a reliable method to predict difficult chole- cystectomies due to symptomatic cholelithiasis. This could be applied for surgical planning within a university residency program.


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