a golden period for cholecystectomy · gallbladder wall 7 mm ... the primary pathophysiology...

A Golden Period for Cholecystectomy

Fact or Myth ?

Marilyn Ng, MD

Dept. of Surgery M&M Conference

Downstate Medical Center

Aug 9, 2012

www.downstatesurgery.org

Case Presentation

36 yo woman with 1 day hx of

worsening RUQ pain

Nausea & episodes bilious emesis

No fevers, chills or LUTS


Case Presentation

PMHx: asthma, HTN, spina bifida,

hydrocephalus & seizure disorder

SHx: open appendectomy, VP

shunt placement, VP shunt

revision (‘87, ‘98)

SocHx: 6 kids; shelter


On Physical Exam

Vitals: normal

Skin: multiple abdominal scars

Abd: soft, ND, RUQ tenderness,

(+) Murphy’s sign, no hernias

Back: no CVAT


RUQ Sonogram

Gallbladder wall 7 mm thick

Pericholecystic fluid

Cholelithiasis

Common bile duct 4 mm

Acute cholecystitis


Labs

CBC: 8.2>12.1/38.8<355

BMP: 141/3.3/109/23/11/1<117

LFT: 7.7/4.4/25/14/83.0.3 A 102 L 59

U/A: normal


Open Cholecystectomy

RUQ subcostal incision

Loculated ascites

Distended intrahepatic gallbladder

Jackson – Pratt drain


Hospital Course

POD#0:

Advanced to regular diet

JP drainage serosanguinous

POD#1:

JP drain removed

SW case review & discharged to shelter


Timing of Cholecystectomy

Acute cholecystitis (AC)

History of AC management

Timing of cholecystectomy

Conclusion


U.S. Epidemiology

20 million U.S. adults have gallstones

1 - 4% become symptomatic each year

Acute cholecystitis develops in 20% of untreated patients

500,000 cholecystectomies per year


Diagnosis

RUQ abd pain, fever, leukocytosis

Murphy’s sign

Sonographic diagnosis


AC Pathophysiology

Early stages edema & hyperemia

Later stages adhesions, fibrosis, necrosis

Triangle of Calot


Management

Supportive - IV fluid & analgesia

Antibiotics

Gram-negative aerobes

Anaerobes

Surgery is only definitive treatment


History of Cholecystectomy

1882 – 1st successful open cholecystectomy (OC) by Dr. Langenbuch

1st half 20th century – Delayed open cholecystectomy


History of Cholecystectomy

1966 – Dr. Essenhigh advocated superiority of early OC

1985 – 1st laparoscopic cholecystectomy (LC) by Dr. Muhe


Presenter

Presentation Notes

Jarvinen et al (1980). - prospective RCT comparing early (n=83) vs delayed (n=82) OPEN cholecystectomies. -no difference in the incidence of operative complications and duration of operation -post-operative morbidity was similar between groups (13.8 vs 17.3%) -EC reduced hospital stay to 7.5 days and convalescence to 14.4 days In 1985, surgical management of gallbladder disease was vaulted into the laparoscopic era when Dr. Muhe performed the first successful laparoscopic cholecystectomy.

Work Leave (days)

Laparoscopic vs. Open

No observed difference in mortality, complications & operative time

Hos

pita

l St

ay (

days

) www.downstatesurgery.org

Presenter

Presentation Notes

LC significantly associated with shorter hospital stay and quicker convalescence

Timing of Surgery

Early surgery – 24 hrs to 7 days of onset of symptoms

Delayed surgery – at least 6 weeks after symptoms settled

Timing of open cholecystectomy translate similarly with laparoscopy?


** Clinically significant !

Golden 72 Hours

NS

(2/16)

(6/19) (7/25)

Koo et al. Arch Surg, 1996


Presenter

Presentation Notes

***while the conversion rate is not statistically significant, the difference is clinically significant! Conclusions reached by Koo and colleagues: -Group 1 (with LC within 72 hrs of symptoms) had lower conversion rate, shorter and less costly operations and signficantly convalescent rates -Koo et al attributed the increase in conversion rate to progression of more severe inflammation associated with AC over time -Based on these findings, this group recommended LC for presenting within 72 hours from symptom onset -Whereas those patients presenting after 72 hrs should be considered for elective delayed LC 6-8 weeks later While this study adds credence our “golden 72 hour” rule, this study was limited due to it retrospective study design and small sample size. To address this issue…

Lo et al.

NS P=0.174

NS P=0.07

** P<0.001

** P<0.001

Lo et al. Ann Surg, 1998


Presenter

Presentation Notes

-Objective: compare ELC with DLC for AC in a prospective randomized trail of 90 patients, -who were dx’ed with AC with follow inclusion criteria (acute RUQ abd pain, fever and/or leukocytosis, -The early treatment group underwent LC within 72 hrs of admission compared those receiving -Delayed LC 8-12 weeks after resolution of acute AC attack -There were no significant demographic differences between pts receiving ELC and DLC -44% of patients had symptoms for >3days -The was a trend toward greater conversion rate in the DLC, and in both groups conversion was primarily due to difficulty in gallbladder exposure and difficulty in dissection in Calot’s triangle. -Moreover, the DLC had an increased conversion rate owing to dense, fibrotic adhesions on the gallbladder. -Notably, approximately 16% of patients in the DLC failed conservative treatment and required urgent LC -Lo et al also determined that there was a significant decrease in the total hospital stay by 5 days in the ELC compared to the DLC group, and similarly there was a significant longer recovery period in the DLC group by a week. -Lo et al concluded that the he optimal time of LC is soon after diagnosis or within 72 hours of admission.

Secondary Outcomes

Operating time

CBD stones

Hospital stay

Work days lost

Quality of life

Cochrane Review 2010

Primary Outcomes

Mortality

Surgery-related morbidity

Wait-time complications

Conversion to OC


Presenter

Presentation Notes

-For the next two decades the matter of timing of cholecystectomy was hotly debated and many studies were published. The aim of this meta-analysis performed by Guthusamy and colleagues was to determine whether patients with acute cholecystitis should be offered ELC or offered a DLC. -Total of 535 references were reviewed. Only 5 completed randomized trials fulfilled the inclusion criteria of at least one primary and secondary outcomes

Cochrane Review 2010

No significant difference in terms of bile duct injury or conversion to OC

ELC resulted in 4 - day significantly shorter total hospital stay


Presenter

Presentation Notes

For the next two decades the matter of timing of cholecystectomy was hotly debated and many studies were published.

Objective: Compare various outcomes of LC for AC at different time points after hospital admission

Study Design: Large, prospective cohort

6 subgroups based on time of surgery


Presenter

Presentation Notes

Although subgroup evaluation in the meta-analysis by Guthusamy et al failed to show any difference for patients operated within the 4 or 7 days after symptom onset, the exact time-point of LC remains a matter of great debraine.

11.9 %

27.9 % *

* P < 0.001


Presenter

Presentation Notes

-Overall conversion rate is 15.5% -

5.7 % 13 % *

* P < 0.001

0.9 % 3 % *

* P < 0.001


Presenter

Presentation Notes

-Overall rate of surgical postoperative complication was 6.1% -In this study, the post-op complication rate was 2 times greater on day 6 compared to day of admission. -And the re-operation rate was 3 times greater if the operation occurred after 6 hospital days

* P < 0.001

*


Presenter

Presentation Notes

Prolonging surgery from the time-point of of symptom onset increases length of hospital stay by 2 days as we see here when comparing day of admission to >6days


Presenter

Presentation Notes

When outcomes were adjusted for age and ASA classification: -Odds of having an intraoperative complication was 2 times greater on day 3 compared to DOA -Moreover, the longer one prolonged surgery the odds were signficantly 2.45 times greater of having post-operative complications on >6days as was the need to re-operate -The conversion rate was significantly greater starting day 2 and worsened with prolonged pre-operative stay -And as the edema and inflammatory changes progressed so too did the length of the operation -Lastly, the length of postoperative hospital stay increased the time of operation was on Day 4 of after 6 days

Banz et al - Conclusions

Largest population-based study to date

Delayed LC for AC has no advantage

Early LC avoids increase in:

Conversion rate

Post-operative complications

Postoperative hospital stay


Presenter

Presentation Notes

50% local recurrences in 1st 2 yrs, 20% after 5 yrs

Summary

Know your patient (ASA class)

OC - standard from which to compare

Golden 72 hrs for better outcomes

Converting to open is not a failure

Earlier LC is safe & shortens LOS

Golden 24 hrs for better outcomes


Which of the following is an event in the pathophysiology of acute calculus cholecystitis ?

A. Increased biliary lysolecithin

B. Gallbladder ischemia

C. Bacterial infection

D. Prostaglandin depletion

E. CCK receptor depletion


Presenter

Presentation Notes

AC is thought to be initiated by GB obstruction and activation of various inflammatory mediators, which lead to mucosal damage, GB distention and eventually ischemia. Bacteria can be identified in the bile of about 50% (30-70%) of pats with AC, but bacterial infection is a secondary phenomenon. The primary pathophysiology depends on the biochemical events that take place. Some of the mediators that may be involved in the inflammatory process of AC are bile acids, litogenic bile, phospholipase, and levels are elevated in pts with AC. The of prostaglandins as mediators in this process has also received considerable attention.

Which is the preferred treatment of acute calculus cholecystitis?

A. Early laparoscopic cholecystectomy

B. Delayed laparoscopic cholecystectomy

C. Early open cholecystectomy

D. Delayed open cholecystectomy

E. Intravenous antibiotics


Which time-point group in Banz et al. study had fewer overall complications and shorter length of stay?

A. Day of admission

B. Day 1

C. Day 2

D. Day 3

E. Day 4-5

F. Day > 6


References Banz et al. Population-based analysis of 4113 patients wth acute

cholecystitis: defining the optimal time-point for laparoscopic cholecystectomy Ann Surg 2011;254:964-970

Current Surgical Therapy, 10th Ed, pp 408-412

Gurusamy K et al. Meta-analysis of randomized controlled trials on the safety and effectiveness of early versus delayed larparoscopic cholecystectomy for acute cholecystitis. Br J Surg 2010; 97: 141-150

Keus F et al. Laparoscopic versus open cholecystectomy for patient with symptomatic cholecystolithiasis. Cochrane Database Syst Rev. 2006 18;(4): CD006231


References Koo KP et al. Laparoscopic cholecystectomy in acute cholecysitis:

What is the optimal time for operation? Arch Surg 1996; 131:540-545

Lo CM et al. Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Ann Surg 1998 (227)4:461-467.

Reynolds W Jr. The first laparoscopic cholecystectomy. JSLS 2001 (5)1:89-94.

Strasberg SM. Acute calculus cholecystitis. N Engl J Med 2008: 358;2804-2811.


a golden period for cholecystectomy · gallbladder wall 7 mm ... the primary pathophysiology...

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