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      Efficacy and feasibility of laparoscopic subtotal cholecystectomy for acute cholecystitis

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          Abstract

          Backgrounds/Aims

          For patients with acute cholecystitis, conversion from laparoscopic cholecystectomy to open surgery is not uncommon due to possibilities of serious hemorrhage at the liver bed and bile duct injury. Recent studies reported successful laparoscopic subtotal cholecystectomy for acute cholecystitis. The purpose of this study was to determine the efficacy and feasibility of such an operation based on the experience of surgeons at our facility.

          Methods

          In this study, we enrolled 144 patients who had received either laparoscopic subtotal cholecystectomy (LSC), laparoscopic cholecystectomy (LC), or open cholecystectomy (OC) for acute cholecystitis from January 2004 to December 2009 at the Department of Surgery of our hospital. Their symptoms, signs, operative findings, pathologic results and postoperative results were compared and analyzed.

          Results

          There were 26 patients in the LSC group 80 in the LC group and 38 in the OC group. There were no differences in mean age, sex, and symptoms of acute cholecystitis. The LSC group showed higher CRP levels ( p<0.001) and a higher grade according to the Tokyo criteria ( p=0.001). The mean operative time was 115.6 minutes and mean blood loss was 158.9 ml without intra-operative or postoperative transfusion. There weren't any bile duct injuries during the operation. No group suffered bile leakage. Drains were removed 3.3 days after the operation in the LC group, the shortest time compared to the other groups ( p<0.001). LC and LSC groups demonstrated shorter postoperative hospital days and time to diet resumption than the OC group ( p<0.001).

          Conclusions

          LSC appears to be a safe and effective treatment in cases of severe acute cholecystitis that require consideration of conversion to open surgery.

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          Most cited references19

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          Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines

          Masahiko Hirota, Tadahiro Takada, Yoshifumi Kawarada … (2007)
          The aim of this article is to propose new criteria for the diagnosis and severity assessment of acute cholecystitis, based on a systematic review of the literature and a consensus of experts. A working group reviewed articles with regard to the diagnosis and treatment of acute cholecystitis and extracted the best current available evidence. In addition to the evidence and face-to-face discussions, domestic consensus meetings were held by the experts in order to assess the results. A provisional outcome statement regarding the diagnostic criteria and criteria for severity assessment was discussed and finalized during an International Consensus Meeting held in Tokyo 2006. Patients exhibiting one of the local signs of inflammation, such as Murphy’s sign, or a mass, pain or tenderness in the right upper quadrant, as well as one of the systemic signs of inflammation, such as fever, elevated white blood cell count, and elevated C-reactive protein level, are diagnosed as having acute cholecystitis. Patients in whom suspected clinical findings are confirmed by diagnostic imaging are also diagnosed with acute cholecystitis. The severity of acute cholecystitis is classified into three grades, mild (grade I), moderate (grade II), and severe (grade III). Grade I (mild acute cholecystitis) is defined as acute cholecystitis in a patient with no organ dysfunction and limited disease in the gallbladder, making cholecystectomy a low-risk procedure. Grade II (moderate acute cholecystitis) is associated with no organ dysfunction but there is extensive disease in the gallbladder, resulting in difficulty in safely performing a cholecystectomy. Grade II disease is usually characterized by an elevated white blood cell count; a palpable, tender mass in the right upper abdominal quadrant; disease duration of more than 72 h; and imaging studies indicating significant inflammatory changes in the gallbladder. Grade III (severe acute cholecystitis) is defined as acute cholecystitis with organ dysfunction.
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            Randomized clinical trial of open versus laparoscopic cholecystectomy in the treatment of acute cholecystitis.

            M. Johansson, A Thune, L Nelvin … (2005)
            The aim of this prospective trial was to determine whether surgical approach (open versus laparoscopic) had an impact on morbidity and postoperative recovery after cholecystectomy for acute cholecystitis. Seventy patients who met the criteria for acute cholecystitis were randomized to open or laparoscopic cholecystectomy. The type of operation was unknown to the patient and all hospital staff involved in the postoperative care. The two groups were similar with respect to demographic and clinical characteristics. There were no significant differences in rate of postoperative complications, pain score at discharge and sick leave. In eight patients a laparoscopic procedure was converted to open cholecystectomy. Median operating time was 90 (range 30-155) and 80 (range 50-170) min in the laparoscopic and open groups respectively (P = 0.040). The direct medical costs were equivalent in the two groups. Although median postoperative hospital stay was 2 days in each group, it was significantly shorter in the laparoscopic group (P = 0.011). Cholecystectomy for acute cholecystitis can be performed by either laparoscopic or open techniques without any major clinically relevant differences in postoperative outcome. Both techniques offer low morbidity and rapid postoperative recovery.
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              Laparoscopic cholecystectomy in cirrhotic patients: the role of subtotal cholecystectomy and its variants.

              P Rajan, Palanisamy Senthilnathan, R. Parthasarthi … (2006)
              Open cholecystectomy is associated with considerable morbidity and mortality in cirrhotic patients. Laparoscopic cholecystectomy may offer a better option because of the magnification available and the availability of newer instruments like the ultrasonic shears. We present our experience of 265 laparoscopic cholecystectomies and attempt to identify the difficulties encountered in this group of patients. Between 1991 and 2005, 265 cirrhotic patients of Child-Pugh Classification A and B, with symptomatic gallstones, were subjected to laparoscopic cholecystectomy. We describe here our tailored approach and our techniques of subtotal cholecystectomy. Features of acute cholecystitis were present in 35.1% of the patients, and 64.9% presented with chronic cholecystitis. In 81.5% of the patients, the diagnosis of cirrhosis was established preoperatively. In 8.3% of the patients, a fundus first method was adopted when the hilum could not be approached despite additional ports. Modified subtotal cholecystectomy was performed in a total of 206 patients. Mean operative time in the subtotal cholecystectomy group was 72 minutes; in the standard group, it was 41 minutes. There was no mortality. In 15% of patients, postoperative deterioration in liver function occurred. Worsening of ascites, port site infection, port site bleeding, intraoperative hemorrhage, bilious drainage, and stone formation in the remnant were the other complications encountered. Laparoscopic cholecystectomy is a safe and effective treatment for calculous cholecystitis in cirrhotic patients. Appropriate modification of subtotal cholecystectomy should be practiced, depending on the risk factors present, to avoid complications.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Korean J Hepatobiliary Pancreat Surg
                Journal ID (iso-abbrev): Korean J Hepatobiliary Pancreat Surg
                Journal ID (publisher-id): KJHBPS
                Title: Korean Journal of Hepato-Biliary-Pancreatic Surgery
                Publisher: Korean Association of Hepato-Biliary-Pancreatic Surgery
                ISSN (Print): 1738-6349
                ISSN (Electronic): 2288-9213
                Publication date (Print): November 2011
                Publication date (Electronic): 15 December 2011
                Volume: 15
                Issue: 4
                Pages: 225-230
                Affiliations
                Department of Surgery, Inha University College of Medicine, Incheon, Korea.
                Author notes
                Corresponding author: Seung-Ik Ahn. Department of Surgery, Inha University College of Medicine, Sinheung-dong 3-ga, Jung-gu, Incheon 400-712, Korea. Tel: +82-32-890-2114, Fax: +82-32-890-3999, siahn@ 123456inha.ac.kr
                Article
                DOI: 10.14701/kjhbps.2011.15.4.225
                PMC ID: 4582466
                PubMed ID: 26421043
                SO-VID: 1b11d74b-a902-41ad-8d06-24ad865e4954
                Copyright © Copyright © 2011 by The Korean Association of Hepato-Biliary-Pancreatic Surgery
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 04 August 2011
                Date revision received : 20 September 2011
                Date accepted : 20 October 2011
                Funding
                Funded by: Inha University
                Categories
                Subject: Original Article

                Keywords: acute cholecystitis,laparoscopic subtotal cholecystectomy
                Data availability:
                Keywords: acute cholecystitis, laparoscopic subtotal cholecystectomy

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