-
The American Surgeon Mar 2024This systematic review and meta-analysis aimed to compare clinical outcomes in patients with complicated acute cholecystitis undergoing laparoscopic total vs subtotal... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
This systematic review and meta-analysis aimed to compare clinical outcomes in patients with complicated acute cholecystitis undergoing laparoscopic total vs subtotal cholecystectomy.
METHODS
This systematic review and meta-analysis was conducted according to PRISMA guidelines and queried PubMed, Embase, ProQuest, Google Scholar, and Cochrane databases from inception to May 2023. The primary outcome was complication rates including common bile duct injury, wound infection, reoperation, bile leak, retained stones, and subhepatic collection, whereas secondary outcomes were in-hospital mortality and hospital length of stay.
RESULTS
A total of 7 studies with 135,233 cases were included for meta-analysis. Patients who underwent laparoscopic total cholecystectomy had a significantly lower risk of postoperative bile leaks (RR: .15; 95% CI: .03, .80) and subhepatic fluid collection (RR: 0.19; 95% CI: .06, .63) and were 2.94 times less likely to die compared to those who underwent subtotal cholecystectomy (RR .34; 95% CI: .15, .77). Patients who underwent subtotal cholecystectomy had significantly longer hospital length of stay (mean difference 1.0 days; 95% CI: .5 days, 1.4 days).
CONCLUSIONS
In adult patients presenting with complicated cholecystitis, management with laparoscopic subtotal cholecystectomy presents a unique complication profile with increased risk of postoperative bile leak and subhepatic fluid collection, in-hospital mortality, and longer hospital length-of-stay when used as an alternative approach to laparoscopic total cholecystectomy. Further research into the most appropriate clinical scenarios and patient populations for the use of the subtotal cholecystectomy approach may prove useful in improving its associated outcomes.
Topics: Adult; Humans; Cholecystectomy; Laparoscopy; Cholecystectomy, Laparoscopic; Cholecystitis, Acute; Cholecystitis
PubMed: 37966455
DOI: 10.1177/00031348231216482 -
Cureus Oct 2023Cholecystectomy is a widespread surgical procedure for gallbladder diseases. Evolving techniques and technologies, such as intraoperative cholangiography (IOC), enhance... (Review)
Review
Cholecystectomy is a widespread surgical procedure for gallbladder diseases. Evolving techniques and technologies, such as intraoperative cholangiography (IOC), enhance safety and outcomes by providing real-time biliary system visualization during surgery. This systematic review explored available data on using IOC during cholecystectomy, highlighting its effectiveness, safety, and cost-effectiveness. To perform this systematic review, a thorough literature search was conducted using relevant keywords in electronic databases, such as PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Library, Web of Science, and Google Scholar. We included studies published during the last 10 years exploring the use of IOC during cholecystectomy. The findings showed success rates of up to 90% with a median time of 21.9 minutes without complications. Most (90%) patients with acute gallstone pancreatitis underwent cholecystectomy with IOC, with unclear IOC results in 10.7% and failure in 14.7%. IOC failure factors included age, body mass index (BMI), male sex, concurrent acute cholecystitis, common bile duct (CBD) stone evidence on imaging, CBD diameter of >6 mm, total bilirubin of >4 mg/dL, abnormal liver tests, and gallstone pancreatitis. The detection of choledocholithiasis by IOC prompted trans-cystic duct exploration and endoscopic retrograde cholangiopancreatography (ERCP). Biliary abnormalities and stone identification were observed using IOC, and routine use increased bile duct stone detection while decreasing bile duct injury and readmission rates. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of IOC for common bile duct stone detection were reported at 77%, 98%, 97.2%, 63%, and 99%, respectively. Routine IOC was projected to provide substantial quality-adjusted life years (QALY) and cost-effectiveness gains compared to selective IOC. Regarding safety, IOC was generally associated with reduced complication and open surgery conversion risks, with similar rates of CBD injury and bile leaks. These findings indicate that IOC enhances cholecystectomy outcomes through precision and decreasing complications.
PubMed: 37899894
DOI: 10.7759/cureus.47646 -
Gastrointestinal Endoscopy Mar 2024EUS-guided gallbladder drainage using lumen-apposing metal stents (EUS-GBD-LAMSs) and percutaneous cholecystostomy for gallbladder drainage (PTGBD) are the alternative... (Meta-Analysis)
Meta-Analysis
Safety and adverse events of EUS-guided gallbladder drainage using lumen-apposing metal stents and percutaneous cholecystostomy tubes: a systematic review and meta-analysis.
BACKGROUND AND AIMS
EUS-guided gallbladder drainage using lumen-apposing metal stents (EUS-GBD-LAMSs) and percutaneous cholecystostomy for gallbladder drainage (PTGBD) are the alternative treatment modalities in high-risk surgical patients with acute cholecystitis (AC). The aim of this study was to compare the safety of these procedures for AC in surgically suboptimal candidates.
METHODS
Six studies compared the 2 groups' early, delayed, and overall adverse events; they also compared length of hospital stay, re-interventions, and re-admissions rate. A random effect model calculated odds ratios (ORs) with a 95% confidence interval (CI).
RESULTS
The 2 groups had similar early adverse events; however, EUS-GBD-LAMS was associated with a lower rate of delayed (OR, .21; 95% CI, .07-.61; P ≤ .01) and overall (OR, .43; 95% CI, .30-.61; P ≤ .01) adverse events. Patients with EUS-GBD-LAMSs had a shorter hospital stay than PTGBD.
CONCLUSIONS
EUS-GBD-LAMS is a safer option than PTGBD and is associated with a shorter hospital stay in nonsurgical candidates with AC.
Topics: Humans; Gallbladder; Cholecystostomy; Endosonography; Drainage; Cholecystitis, Acute; Stents; Treatment Outcome
PubMed: 37871846
DOI: 10.1016/j.gie.2023.10.043 -
Annals of Emergency Medicine Mar 2024Acute cholecystitis accounts for up to 9% of hospital admissions for acute abdominal pain, and best practice entails early surgical management. Ultrasound is the... (Meta-Analysis)
Meta-Analysis
Acute cholecystitis accounts for up to 9% of hospital admissions for acute abdominal pain, and best practice entails early surgical management. Ultrasound is the standard modality used to confirm diagnosis. Our objective was to perform a systematic review and meta-analysis to determine the diagnostic accuracy of emergency physician-performed point-of-care ultrasound for the diagnosis of acute cholecystitis when compared with a reference standard of final diagnosis (informed by available surgical pathology, discharge diagnosis, and radiology-performed ultrasound). We completed a systematic review and meta-analysis, registered in PROSPERO, in adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched 7 databases as well as gray literature in the form of select conference abstracts from inception to February 8, 2023. Two independent reviewers completed study selection, data extraction, and risk of bias (QUADAS-2) assessment. Disagreements were resolved by consensus with a third reviewer. Data were extracted from eligible studies to create 2 × 2 tables for diagnostic accuracy meta-analysis. Hierarchical Summary Receiver Operating Characteristic models were constructed. Of 1855 titles/abstracts, 40 were selected for full-text review. Ten studies (n=2356) were included. Emergency physician-performed point-of-care ultrasound with final diagnosis as the reference standard (7 studies, n=1,772) had a pooled sensitivity of 70.9% (95% confidence interval [CI] 62.3 to 78.2), specificity of 94.4% (95% CI 88.2 to 97.5), positive likelihood ratio of 12.7 (5.8 to 27.5), and negative likelihood ratio of 0.31 (0.23 to 0.41) for the diagnosis of acute cholecystitis. Emergency physician-performed point-of-care ultrasound has high specificity and moderate sensitivity for the diagnosis of acute cholecystitis in patients with clinical suspicion. This review supports the use of emergency physician-performed point-of-care ultrasound to rule in a diagnosis of acute cholecystitis in the emergency department, which may help expedite definitive management.
Topics: Humans; Sensitivity and Specificity; Point-of-Care Systems; Point-of-Care Testing; Cholecystitis, Acute; Emergency Medicine
PubMed: 37855790
DOI: 10.1016/j.annemergmed.2023.09.005 -
Langenbeck's Archives of Surgery Sep 2023Fluorescence-based imaging has found application in several fields of elective surgery, but there is still a lack of evidence in the literature about its use in... (Review)
Review
PURPOSE
Fluorescence-based imaging has found application in several fields of elective surgery, but there is still a lack of evidence in the literature about its use in emergency setting. The present review critically summarizes currently available applications and limitations of indocyanine green (ICG) fluorescence in abdominal emergencies including acute cholecystitis, mesenteric ischemia, and trauma surgery.
METHODS
A systematic review was performed according to the PRISMA statement identifying articles about the use of ICG fluorescence in the management of the most common general surgery emergency. Only studies focusing on the use of ICG fluorescence for the management of acute surgical conditions in adults were included.
RESULTS
Thirty-six articles were considered for qualitative analysis. The most frequent disease was occlusive or non-occlusive mesenteric ischemia followed by acute cholecystitis. Benefits from using ICG for acute cholecystitis were reported in 48% of cases (clear identification of biliary structures and a safer surgical procedure). In one hundred and twenty cases that concerned the use of ICG for occlusive or non-occlusive mesenteric ischemia, ICG injection led to a modification of the surgical decision in 44 patients (36.6%). Three studies evaluated the use of ICG in trauma patients to assess the viability of bowel or parenchymatous organs in abdominal trauma, to evaluate the perfusion-related tissue impairment in extremity or craniofacial trauma, and to reassess the efficacy of surgical procedures performed in terms of vascularization. ICG injection led to a modification of the surgical decision in 50 patients (23.9%).
CONCLUSION
ICG fluorescence is a safe and feasible tool also in an emergency setting. There is increasing evidence that the use of ICG fluorescence during abdominal surgery could facilitate intra-operative decision-making and improve patient outcomes, even in the field of emergency surgery.
Topics: Adult; Humans; Fluorescence; Mesenteric Ischemia; Surgery, Computer-Assisted; Elective Surgical Procedures; Cholecystitis, Acute; Indocyanine Green
PubMed: 37743419
DOI: 10.1007/s00423-023-03109-7 -
Therapeutic Advances in... 2023Acute calculous cholecystitis (ACC) represents about one-third of all surgical emergencies. The gold standard management of ACC is laparoscopic cholecystectomy. Although...
BACKGROUND AND AIMS
Acute calculous cholecystitis (ACC) represents about one-third of all surgical emergencies. The gold standard management of ACC is laparoscopic cholecystectomy. Although cholecystectomy is a safe procedure, it may be dangerous and contraindicated in patients with complex comorbidities. Endoscopic transpapillary gallbladder stenting (ETGBS) and drainage had been widely used to manage patients suffering from ACC with comorbidities.
METHODS
We searched PubMed, SCOPUS, Web of Science, and Cochrane Library for relevant studies assessing the use of ETGBS in patients suffering from ACC with various comorbidities. Risk of bias assessment was performed using the National Institues of Health (NIH) tool. We included the following outcomes: clinical success, technical success, late complications, and pancreatitis.
RESULTS
We included seven studies that met our inclusion criteria. We found that the pooled proportion of clinical success, technical success, late complications, and pancreatitis was [91.3%, 95% confidence interval (CI) (86.8%, 95.9%)], [92.8%, 95% CI (89%, 96.5%)], [5.4%, 95% CI (2.9%, 7.9%)], and [3.5%, 95% CI (1.2%, 5.8%)], respectively.
CONCLUSION
We found that an ETGBS was an effective and well-tolerated method for the treatment of cholecystitis, especially in high-risk individuals.
PubMed: 37664530
DOI: 10.1177/26317745231192177 -
Journal of Clinical Medicine Jul 2023This systematic review aims to investigate whether percutaneous transhepatic gallbladder biliary drainage (PTGBD) is superior to emergency cholecystectomy (EC) as a... (Review)
Review
Management of Acute Cholecystitis in High-Risk Patients: Percutaneous Gallbladder Drainage as a Definitive Treatment vs. Emergency Cholecystectomy-Systematic Review and Meta-Analysis.
BACKGROUND
This systematic review aims to investigate whether percutaneous transhepatic gallbladder biliary drainage (PTGBD) is superior to emergency cholecystectomy (EC) as a definitive treatment in high-risk patients with acute cholecystitis (AC).
MATERIAL AND METHODS
A systematic literature search was performed until December 2022 using the Scopus, Medline/PubMed and Web of Science databases.
RESULTS
Seventeen studies have been included with a total of 783,672 patients (32,634 treated with PTGBD vs. 4663 who underwent laparoscopic cholecystectomy, 343 who had open cholecystectomy and 746,032 who had some form of cholecystectomy, but without laparoscopic or open approach being specified). An analysis of the results shows that PTGBD, despite being less invasive, is not associated with lower morbidity with respect to EC (RR 0.77 95% CI [0.44 to 1.34]; I = 99%; = 0.36). A lower postoperative mortality was reported in patients who underwent EC (2.37%) with respect to the PTGBD group (13.78%) (RR 4.21; 95% CI [2.69 to 6.58]; < 0.00001); furthermore, the risk of hospital readmission for biliary complications (RR 2.19 95% CI [1.72 to 2.79]; I = 48%; < 0.00001) and hospital stay (MD 4.29 95% CI [2.40 to 6.19]; < 0.00001) were lower in the EC group.
CONCLUSIONS
In our systematic review, the majority of studies have very low-quality evidence and more RCTs are needed; furthermore, PTGBD is inferior in the treatment of AC in high-risk patients. The definition of high-risk patients is important in interpreting the results, but the methods of assessment and definitions differ between studies. The results of our systematic review and meta-analysis failed to demonstrate any advantage of using PTGBD over ER as a definitive treatment of AC in critically ill patients, which suggests that EC should be considered as the treatment of choice even in very high-risk patients. Most likely, the inferiority of PTGBD versus early LC for high-risk patients is related to an association of various patient-side factor conditions and the severity of acute cholecystitis.
PubMed: 37568306
DOI: 10.3390/jcm12154903 -
Annals of the Royal College of Surgeons... Mar 2024Laparoscopic subtotal cholecystectomy (LSTC) is a bailout procedure that is undertaken when it is not safe to proceed with a laparoscopic total cholecystectomy owing to...
INTRODUCTION
Laparoscopic subtotal cholecystectomy (LSTC) is a bailout procedure that is undertaken when it is not safe to proceed with a laparoscopic total cholecystectomy owing to dense adhesions in Calot's triangle. The main aim of this review was to investigate the early (≤30 days) and late (>30 days) morbidity and mortality of LSTC.
METHODS
A literature search of the PubMed (MEDLINE), Google Scholar™ and Embase databases was conducted to identify all studies on LSTC published between 1985 and December 2020. A systematic review was then performed.
RESULTS
Overall, 45 studies involving 2,166 subtotal cholecystectomy patients (51% female) were identified for inclusion in the review. The mean patient age was 55 years (standard deviation: 15 years). Just over half (53%) of the patients had an elective procedure. The conversion rate was 6.2% (=135). The most common indication was acute cholecystitis (49%). Different techniques were used, with the majority having a closed cystic duct/gallbladder stump (71%). The most common closure technique was intracorporeal suturing (53%), followed by endoloop closure (15%). Four patients (0.18%) died within thirty days of surgery. Morbidity within 30 days included bile duct injury (0.23%), bile leak (18%) and intra-abdominal collection (4%). Reoperation was reported in 23 patients (1.2%), most commonly for unresolving intra-abdominal collections and failed endoscopic retrograde cholangiopancreatography to control bile leak. Long-term follow-up was reported in 30 studies, the median follow-up duration being 22 months. Late morbidity included incisional hernias (6%), symptomatic gallstones (4%) and common bile duct stones (2%), with 2% of cases requiring completion of cholecystectomy.
CONCLUSIONS
LSTC is an acceptable alternative in patients with a "difficult" Calot's triangle.
Topics: Humans; Cholecystectomy; Cholecystectomy, Laparoscopic; Cystic Duct; Gallstones; Morbidity
PubMed: 37365939
DOI: 10.1308/rcsann.2023.0008 -
Indian Journal of Gastroenterology :... Aug 2023Endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is widely used for various target samples, but its efficacy in gallbladder (GB) lesions is unknown. The aim of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is widely used for various target samples, but its efficacy in gallbladder (GB) lesions is unknown. The aim of the present meta-analysis was to assess the pooled adequacy, accuracy and safety of EUS-TA of GB lesions.
METHODS
A literature search from January 2000 to August 2022 was done for studies analyzing the outcome of EUS-guided TA in patients with GB lesions. Pooled event rates were expressed with summative statistics.
RESULTS
The pooled rate of sample adequacy for all GB lesions and malignant GB lesions was 97.0% (95% CI: 94.5-99.4) and 96.6% (95% CI: 93.8-99.3), respectively. The pooled sensitivity and specificity for the diagnosis of malignant lesions were 90% (95% CI: 85-94; I = 0.0%) and 100% (95% CI: 86-100; I = 0.0%), respectively, with an area under the curve of 0.915. EUS-guided TA had a pooled diagnostic accuracy rate of 94.6% (95% CI: 90.5-96.6) for all GB lesions and 94.1% (95% CI: 91.0-97.2) for malignant GB lesions. There were six reported mild adverse events (acute cholecystitis = 1, self-limited bleeding = 2, self-limited episode of pain = 3) with a pooled incidence of 1.8% (95% CI: 0.0-3.8) and none of the patients had serious adverse events.
CONCLUSION
EUS-guided tissue acquisition from GB lesions is a safe technique with high sample adequacy and diagnostic accuracy. EUS-TA can be an alternative when traditional sampling techniques fail or are not feasible.
Topics: Humans; Gallbladder; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Endosonography; Sensitivity and Specificity
PubMed: 37280409
DOI: 10.1007/s12664-023-01374-4 -
The Surgeon : Journal of the Royal... Aug 2023Acute cholecystitis is one of the most common causes of acute abdomen. Early laparoscopic cholecystectomy is the gold standard treatment, still burdened by a risk of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Acute cholecystitis is one of the most common causes of acute abdomen. Early laparoscopic cholecystectomy is the gold standard treatment, still burdened by a risk of intraoperative biliary duct injury. An alternative strategy to manage patients with severe acute cholecystitis is the percutaneous gallbladder drainage (PGBD).
METHODS
The Italian Society of Emergency Surgery and Trauma performed a systematic review and meta-analysis with the aim to clarify controversies about the preoperative use of PGBD. We extracted 32 studies: 9 Randomized Control Trial Studies (RCTs) and 23 no RCTs.
RESULTS OF CRITICAL OUTCOMES
The incidence of post-operative complications was lower in the PGBD associated at LC than in the LC alone (RCTs: RR 0.28, 95% CI 0.14 to 0.56, I2 = 63%). The incidence of the post-operative biliary leakage was higher in late PGBD' group (RCTs: RR 0.18, 95% CI 0.04 to 0.80).
RESULTS OF OTHER OUTCOMES
The incidence of intraabdominal abscess, blood loss, conversion to open, subtotal cholecystectomy, operative time and wound infection was lower in PGBD' group. The total hospital stay was the same.
CONCLUSION
A strong recommendation is performed to the use of the PGBD + LC than upfront LC to reduce biliary leakage (recommendation "strong positive") in high risk acute cholecystitis especially in patients with higher perioperative risks or longstanding acute cholecystitis. For post-operative complications a recommendation "positive weak" suggests that PGBD + LC could be used than upfront LC to reduce the rate of post-operative complications.
Topics: Humans; Cholecystostomy; Cholecystitis, Acute; Cholecystectomy; Cholecystectomy, Laparoscopic; Drainage; Postoperative Complications; Treatment Outcome; Retrospective Studies
PubMed: 36577652
DOI: 10.1016/j.surge.2022.12.003