Is emergent laparoscopic cholecystectomy for acute cholecystitis safe
in a low volume resource poor setting?
Shamir O. Cawicha,*
, Sanjib K. Mohantyb
, Lindberg K. Simpsonc
, Kimon O. Bonadied
aThe Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad and Tobago bThe Department of Surgery, Cayman Islands Hospital, Grand Cayman, British West Indies, Cayman Islands
cDepartment of Surgery, Kingston Public Hospital, Kingston, WI, Jamaica dDepartment of Surgery, McGill University Hospital, Montreal, Quebec, Canada
h i g h l i g h t s
We reviewed records of 74 consecutive emergent cholecystectomies for acute cholecystitis. There were 3 (4.1%) conversions and 6 (8.1%) complications with no CBD injuries or deaths. Emergent LC for acute cholecystitis is effective and safe in a low-volume setting in the Caribbean. These technically demanding operations should be performed by trained laparoscopic surgeons.
a r t i c l e i n f o
Received 13 February 2014 Received in revised form 1 May 2014
Accepted 5 June 2014 Available online 16 June 2014 Keywords: Gallbladder Cholecystectomy Laparoscopic Low-volume Caribbean
a b s t r a c t
Background: The outcomes of emergent laparoscopic cholecystectomy (LC) for acute cholecystitis have not been documented in the low-volume, resource-poor Caribbean setting.
Settings and design: This study was carried out in a low-resource setting across three islands in the Anglophone Caribbean.
Methods and materials: The records of all consecutive patients who had emergency LC for acute chole-cystitis over 82 months were examined. The data were extracted and analysed using SPSS version 14. Results: There were 74 patients with acute cholecystitis at a mean age of 45 (SD 11.8) years. The mean duration of operation was 99 (SD 45) min. There were 3 (4.1%) conversions and 6 (8.1%) complications. No bile duct injuries or deaths were recorded. There was more morbidity in patients with complicated disease, longer mean operation times and longer mean intervals between admission and operation. Conclusions: Emergent LC for acute cholecystitis is effective and safe in a low-volume setting in the Caribbean. However, the operations are technically demanding and should be performed by trained laparoscopic surgeons.
© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Elective laparoscopic cholecystectomy (LC) is performed routinely in the Caribbean with good outcomes [1e8], but the technique is generally not applied in the emergency setting for acute cholecystitis. The majority of Caribbean patients with acute cholecystitis who require operation are treated with open cholecystectomy.
Attempts to establish the laparoscopic approach as a reasonable alternative to open cholecystectomy for emergency treatment of acute cholecystitis have been met with resistance by policy makers, who make the point that health care in the Caribbean differs signiﬁcantly from that in developed countries. Without docu-mented evidence that this approach is feasible in the low-volume, resource-poor Caribbean setting, it is difﬁcult to change this posi-tion. Therefore, this retrospective audit was carried out to evaluate the safety of emergent LC to treat acute cholecystitis in the Carib-bean setting. A secondary aim of the study was to identify factors that were associated with the development of complications in these patients.
* Corresponding author.
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This was a retrospective study that evaluated all consecutive LC performed for acute cholecystitis in a Caribbean setting over 82 months. In this setting, all patients with a clinical suspicion of acute cholecystitis (right upper quadrant pain, fever>38C and
leuko-cytosis>11) were routinely imaged with abdominal ultrasound. A diagnosis of acute cholecystitis was considered present when a clinical suspicion was accompanied by any two of the following ultrasoundﬁndings: peri-cholecystic ﬂuid, wall thickening >4 mm, sonographic Murphy's sign; gallbladder distention or impacted stones at Hartmann's pouch.
We utilized the standardized deﬁnition of complicated acute cholecystitis proposed by Meekin et al.. Complicated acute cholecystitis was considered to be present when there were oper-ative or histopathologicﬁndings of gallbladder ulceration, ﬁbrous exudation, necrosis, perforation and/or empyema. These patients were expected to have more challenging operations than those with uncomplicated cholecystitis with only gallbladder distention, mural oedema and transmural cellular inﬁltration.
In this setting, patients with acute cholecystitis were generally managed by a trial of conservative management. Patients who failed to settle were taken to the operating theatre for emergent cholecystectomy. The decision for operation intervention, the operative approach and the need for conversion was made wholly by the attending surgeons based on clinical scenarios.
The operating theatre registers at all participating centres were reviewed to identify all consecutive LCs performed emergently to treat patients with acute cholecystitis from January 1, 2007 to November 30, 2013. The patients' hospital records were retrieved and the following data were extracted: patient demographics, intra-operativeﬁndings, operative details, morbidity, mortality and duration of hospital stay.
The data were analysed using SPSS version 14. Descriptive an-alyses were generated as appropriate. We compared two groups of patients: patients who experienced morbidity and those without morbidity. A two-tailed P value was calculated for variables of in-terest in each group using Fisher's exact test. Continuous variables in each group were compared using paired T-Test. A P value<0.05 was considered statistically signiﬁcant.
Over the study period, 74 patients had emergent LC performed for acute cholecystitis. There was a preponderance of women in this series (4:1 female to male ratio) at a mean age of 45 (SD± 11.8) years and mean body mass index of 32.5 (SD± 6.4) kg/m2.
On average, there was an interval of 2.4 (SD± 2.1) days between the onset of symptoms and presentation to hospital and a further delay of 3.2 (SD± 5.9) days between hospital admission and LC. By the time the patients were taken to the operating theatre, 20 (27%) had developed complicated acute cholecystitis: necrosis (3), perforation (5) and/or empyema (12).
The mean duration of operation was 99 (SD± 45) min and the mean blood loss was 93 (SD± 109) ml. The surgeons reported the following intra-operativeﬁndings: dense adhesions obscuring the gallbladder in 40 cases, intra-hepatic gallbladders in 26, empyema in 12, gangrene in 3 and perforations in 5. Strasberg's critical view was demonstrated in 66 (89%) cases. Subtotal cholecystectomies were performed in 6 (8%) cases. There were 3 (4.1%) conversions for unclear anatomy with failure to progress in two cases and the need to repair a duodenal injury in another.
Overall, six patients (8.1%) experienced a complication associ-ated with emergent laparoscopic cholecystectomy, but there were no deaths and no bile duct injuries recorded (Table 1). We
attempted to identify factors that were predictive of a complication by comparing the groups with and without morbidity (Table 2). Three factors were found to be predictive of complications: complicated cholecystitis, longer intervals between symptom onset and operation and longer duration of operations.
Caribbean surgeons accept LC as the gold standard elective operation for benign gallbladder disease [1e8], but it is still not accepted as a viable alternative to treat acute cholecystitis.
The ﬁrst LC was performed by Eric Mühe in Germany on September 12, 1985. In theﬁrst decade after its debut, acute cholecystitis was considered a contraindication to LC. It is not difﬁcult to understand that early position because these operations can be technically difﬁcult for several reasons: the gallbladder may be obscured by phlegmon formation (Fig. 1), surrounding viscera may be densely adherent (Fig. 2), obligatory oedema and erythema in the operative ﬁeld makes identiﬁcation of biliary structures difﬁcult (Fig. 3), the thick-walled distended gallbladder may be difﬁcult to handle with laparoscopic instruments, the inﬂamed tissues may be friable and there may increased bleeding from tissue handling (Fig. 4).
In the mid 1990s, data began to accrue demonstrating that LC was feasible and safe for acute cholecystitis[12e18]. A paradigm shift followed where surgeons began to perform early LC for acute cholecystitis, abandoning the traditional practice of interval LC when patients settled after conservative management. This was supported by data from prospective randomized trials that demonstrated a deﬁnite advantage with early LC over delayed LC for patients with acute cholecystitis [19e22]. A subsequent Cochrane systematic reviewthat compared early or delayed LC for acute cholecystitis in 488 patients across 6 prospective ran-domized controlled trials demonstrated similar bile duct injury rates (0.4% vs 0.9% respectively; RR 0.49; 95% CI 0.05e4.72), mor-tality (0), serious complications (6.5% vs 5.0% respectively; RR 1.29; 95% CI 0.61e2.72) and conversions (19.7% vs 22.1% respectively; RR 0.89; 95% CI 0.63e1.25). The deﬁnite advantages with early LC were signiﬁcant reductions in hospitalization by 4.12 days and return to normal activity by 11 days. In addition, 18.3% of the patients who had LC postponed developed recurrent cholecystitis and needed emergent LC, with signiﬁcantly higher conversions at 45%
However, the paradigm shift toward early LC did notﬁlter down to surgical practice in the Caribbean. Dan et al.noted that a signiﬁcant “lag effect” existed in Caribbean surgical practice when compared to therapeutic standards in developed nations. Theﬁrst LC in the Caribbean was performed in 1991, six years after its debut on the world stage. But few procedures were performed in the subsequent years, as low as 2 per week in 2006[7,24]. Even in the year 2012, 77% of elective cholecystectomies in some of the Table 1
Complications after emergent laparoscopic cholecystectomy. Parameter n (%) Comment
Morbidity 6 (8.1%) Diaphragmatic cautery injury 1 (1.35%)
Bile leak from hepatic bed 1 (1.35%) Minor leak from ducts of Lushka Bleeding liver laceration 1 (1.35%) Intra-hepatic gallbladder Duodenal laceration 1 (1.35%) Dense adhesions Urinary tract infection 1 (1.35%)
Respiratory tract infection 1 (1.35%) Bile duct injury 0
larger Caribbean territories were being performed by open surgery
. Several reasons for the stagnation in the Caribbean were identiﬁed including institutional limitations, healthcare workers' attitudes, equipment deﬁciencies and/or absence of expertise
[24,25]. It was not surprising, therefore, that LC for acute chole-cystitis was not being practiced commonly in the region.
At the start of the 21st century, coincident with the repatriation of fellowship trained surgeons to several countries in the region, the Caribbean saw their laparoscopic revolution lunging forward with many advanced procedures being reported: bariatric pro-cedures commenced in 2003[26e28], colectomies in 2005, inguinal hernia repairs in 2006, Heller's myotomies in 2007
[31,32], splenectomy in 2008 , single incision cholecystec-tomies in 2009[34,35], Nissen's fundoplications in 2009and liver resections in 2011[37e39]. These data now complement the existing reports of advanced minimally invasive operations being performed, strengthening the foothold of the laparoscopic revolu-tion in the region.
Khanday et al.suggested that acute inﬂammation created an oedematous plane in the submucosa of the gallbladder, which facilitated its dissection from the liver bed. But this was not our experience as 37% of patients had intrahepatic gallbladders that were difﬁcult to dissect. Although these patients had copious bleeding from the liver bed, it was always controllable with high-energy cautery and topical haemostats. Khanday et al.  did not report on the number of intra-hepatic gallbladders in their series, but they went on to say that signiﬁcant bleeding from liver bed was seen in 34% of their cases with acute cholecystitis.
We encountered dense adhesions in 54% of cases, but they did not prevent successful LC. In the literature, problematic adhesions are found in 20%to 63%of cases and are easiest to take down at early LC<48 h[17,40,41]. We were able to demonstrate Strasberg's critical view in 89% of cases (Figs. 5 and 6). This is in keeping with reports in literature that in acute cholecystitis, even in Table 2
Comparison of patients with and without complications after laparoscopic cholecystectomy for acute cholecystitis. The bold type indicates statistically signiﬁcant values.
Parameter No morbidity (n¼ 68) Morbidity (n¼ 6) P value
Complicated cholecystitis 15 (22%) 5 (83%) 0.005
Uncomplicated cholecystitis 53 (78%) 1 (17%) 0.005
Operation time in minutese mean (SD) 95.7 (44.6) 136.7 (25.4) 0.030 Interval between admission and
operation in dayse mean (SD)
2.9 (5.2) 6.5 (11.5) 0.149
Interval between symptom onset and operation in dayse mean (SD)
5.0 (6.0) 11.3 (10.9) 0.023
BMI in kg/m2e mean (SD) 32.3 (6.5) 35.3 (5.4) 0.270
Age in yearse mean (SD) 45.3 (11.9) 42.0 (10.7) 0.517
Female gender 53 (77.9%) 6 (100%) 0.337
Male gender 15 (22.1%) 0 0.337
Fig. 1. Gallbladder phlegmon (GB). The gallbladder is seen plastered against the anterior abdominal wall (A) and has phlegmonous omentum (B) stuck onto the visceral surface, precluding visualization.
Fig. 2. An inﬂamed gallbladder (GB) is being retracted anteriorly, pulling with it the adherent duodenum (D). An instrument is being used to develop a plane between the duodenum and the gallbladder wall in an attempt to expose Calot's triangle.
Fig. 3. An inﬂamed gallbladder (GB) retracted anteriorly. Thick adhesions (B) are being dissected from the inﬂamed, friable gallbladder surface in an attempt to expose structures in Calot's triangle.
complicated cases, the inﬂammation is limited to fundus and body in 71% cases, leaving Calot's triangle relatively uninvolved and amenable to dissection.
Although the mean number of operations performed for acute cholecystitis in this setting was small (11 cases per year), there were good outcomes with 8.1% overall morbidity. This is in keeping with the world literature where the overall morbidity for acute chole-cystitis ranges from 6.5%to 31%. It was also comparable to other Caribbean reports that document 8% morbidity for elective LC
. The conversion rates (4.1%) were also comparable to large series from high volume centres that looked speciﬁcally at LC for acute cholecystitis[17,40,43,44], in which conversions ranged from 1.9%
 to 20% . Our conversion rate was lower than existing Caribbean series where conversion rates up to 6% have been re-ported for elective cases.
We were able to identify factors that were associated with increased morbidity. It is not surprising that complicated chole-cystitis was one of these factors since the resultant sequelae represent the late stage of pathological changes associated with this disease. Other predictors for morbidity included a longer operation time and a longer mean interval between the onset of symptoms and operation.
These were complex cases that required advanced laparoscopic expertise and many technical modiﬁcations, such as dome down dissection, trans-abdominal biliary decompression, intra-corporeal suturing of the common duct or gallbladder remnant and hepatic drainage. All operations were performed by trained laparoscopic surgeons. This has been shown to be statistically signiﬁcant pre-dictor of good outcomes when LC is performed for acute chole-cystitis.
Early LC for acute cholecystitis has been shown to be safe and effective when done in a low volume setting in the Caribbean. However, these operations are technically demanding and should be reserved for trained laparoscopic surgeons. Factors that were predictive of developing complications included a longer interval between symptom onset and operation, presence of complicated disease and longer duration of operation.
Ethical approval to carry out this study was granted by the local institutional review board at the University of the West Indies and a copy of the approval letter is available upon request.
Source of funding
No funding was received for the preparation of this manuscript. Author contribution
SC conceptualized the study and wrote the manuscript. SM, LS and KB collected data, performed statistical analyses, assisted to write the paper and approved the intellectual content.
Conﬂict of interest
No competing interests are declared. Sources of support
None. Fig. 4. Hartmanns' pouch is being retracted with a grasper in an attempt to expose the
structures in Calot's triangle. However, bleeding, tissue oedema and the friable gall-bladder wall obscure structures in Calot's triangle.
Fig. 5. Dissection of Calot's triangle of an acutely inﬂamed gallbladder. Laparoscopic instruments were not able to grasp the thick walled Hartmann's pouch (A). Therefore, a latex tape has been introduced intra-corporeally and passed behind the presumed cystic duct (B) and the cystic node (C) in order to facilitate further dissection.
Fig. 6. Further dissection of Calot's triangle has allowed Strasberg's critical view to be demonstrated in this case despite the inﬂammatory changes. The cystic duct (A) and artery (B) are demonstrated.
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