Elective laparoscopic cholecystectomy: recurrent biliary admissions predispose to difficult cholecystectomy

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.

Acute cholecystitis: Delayed cholecystectomy has lesser perioperative morbidity compared to emergency cholecystectomy

“…Recurrent admissions ultimately result in increased morbidity that may actually outweigh the benefit of DLC. 11 Prompt DLC 6 to 8 weeks after discharge would ensure timely intervention and may avoid the morbidity, inconvenience, and expense of readmission. This should be emphasized and may be achieved by confirming the date of surgery before discharge.…”

“…Although the TG18 guidelines are generally seen as being supportive of ELC for AC, it must be recognized that most of the nonrandomized studies included in the guidelines suffer from low sample sizes and do not conduct multivariate analysis to adjust for preoperative variables, thus subjecting them to significant bias. 3,11 The randomized studies reported in TG18 also depend on small sample sizes, short follow-up times and are largely outdated. 4e7 It must be acknowledged that some of the randomized studies listed in the TG18 guidelines such as Ozkardes ¸et al and Kolla et al actually found higher rates of operation-related adverse outcomes in the ELC group, a finding replicated in this study.…”

“…8e10 The traditional surgical literature also has a strong emphasis on conversion-to-open as an endpoint, an increasingly uncommon event, particularly as the laparoscopic subtotal approach gains increasing popularity. 11 A large contemporary cohort study of AC patients is indicated to compare perioperative morbidity between the 2 approaches. Proponents of ELC argue that readmission before DLC with further episodes of AC increases the difficulty of cholecystectomy due to repeated episodes of inflammation.…”

“…Proponents of ELC argue that readmission before DLC with further episodes of AC increases the difficulty of cholecystectomy due to repeated episodes of inflammation. 11 Currently, the risk of readmission before DLC is unreported in AC patients. Quantifying this risk would help surgeons and institutions decide whether to aggressively pursue ELC versus DLC, especially in conjunction with acknowledgment of the relative risks of outcomes between the 2 groups.…”

Laparoscopic Lumen-guided cholecystectomy in face of the difficult gallbladder

“…This avoids the risk of both recurrent cholecystitis and the potential problems of new stones forming in the gallbladder remnant. This also avoids a completion cholecystectomy at a later stage which may be indicated but would likely be even more challenging due to further episodes of inflammation and additional adhesions [17,18]. Fundus-first dissection offers an alternative retrograde dissection technique.…”