Laparoscopic cholecystectomy decreases extra surgical site morbidity compared with open cholecystectomy: a propensity matched analysis

Background: The ideal way to show treatment effectiveness is through randomized controlled trials the 'gold standard' in evidence-based surgery. Indeed, not all surgical studies can be designed as randomized trials, sometimes for ethical and otherwise, for practical reasons. This article aimed to compare laparoscopic cholecystectomy to open cholecystectomy, according to data from an administrative database, managed by a propensity matched analysis

Methods: Were included all patients with cholelithiasis admitted in Department B between June 1st, 2008 and December 31st, 2009. In this study, the propensity score represented the probability that a patient would be treated by a procedure based on variables that were known or suspected to influence group assignment and was developed using multivariable logistic regression used here to match patients who had laparoscopic cholecystectomy to a control patient who had open cholecystectomy. The main outcome measure was morbidity. This was expressed as the number of patients with 1 or more complications occurring during the hospital stay or within 30 days following discharge

Results:According to intention to treat, 535 patients had a laparoscopic approach [LC group] and 60 patients had a traditional open approach [OC group] regarding associated cardiac disease, previous laparotomy or when choledocholithiasis was suspected, however intra operative cholangiography showed that there was no choledocolithiasis. According to the propensity score, 28 patients in OC were matched with 58 in LC. Comparison between OC and LC before and after propensity matched analysis showed that OC was associated with a higher rate of Extra Surgical Site morbidity [p= 0.010], a longer median duration of intervention, post-operative stay and overall hospital stay [p= 0. 0001]

Conclusion: LC should be considered as first-line therapy to treat cholelithiasis surgically even if it becomes necessary to convert to OC because of intra operative findings

[Spinal anesthesia versus general anesthesia for inguinal hernia repair: propensity score analysis]

Administrative database, used previously for control of cost, patient flow and invoicing, offer to researchers a large sample of patients representative of population providing interesting information's in the field of descriptive and analytic epidemiology with less cost. To compare spinal to general anesthesia for inguinal hernia repair concerning a population extracted from administrative database after propensity matched analysis. Prospective study concerning 4690 hospitalizations in Department B of General Surgery of Charles Nicolle hospital during a period of 18 months, between June 1st, 2008 and December 31st, 2009. A descriptive analysis followed by a comparison between spinal and general anesthesia according propensity matched analysis were performed. 595 inguinal hernias were operated on. Mean age was 55 +/- 15.We mentioned a male predominance: 326 men [84.2%] and 61 women [15.8%]. 137 patients had previous medical diseases [35.4%]. 47[12.1%] patients were operated on in emergent situation on the other hand 340[87.9%] had elective surgery. 264[68.2%] were ASA I, 110[28.4%] ASA II, 13[3.4%] ASA III. Post operative course were uneventful in 96.1% [372] and complicated in 11 patients [2.9%].Four deaths were observed [1%]. Comparison before and after propensity matched analysis showed a statistical difference regarding postoperative stay and all hospital stay in favor of spinal anesthesia [p=0.007]. Postoperative stay is significantly shorter in the group of spinal anesthesia [p=0.007]. A randomized clinical trial comparing spinal anesthesia to general anesthesia is needed

[Assessment of care quality in department of general surgery: usefulness of administrative database]

Administrative database, used previously for control of cost, patient flow and invoicing, offer to researchers a large sample of patients representative of population providing interesting informations in the field of descriptive and analytic epidemiology with less cost. To assess the usefulness of administrative database for quality of care and research. It was a prospective study concerning 4690 hospitalisations in Department B of General Surgery of hôpital Charles Nicolle during a period of 18 months, between June 1st, 2008 and December 31st, 2009. A descriptive analysis followed by a pronostic study with a univariate and multivariate analysis was performed. Our study showed the usefulness of an administrative database in assessing the quality of care, it allowed us to determine postoperative mortality rate [2.7%], deep morbidity [2.5%], parietal morbidity [1.2%], medical complications [6%], nosocomial infections [3.6%] and re intervention [2.7%], with independent predictive factors of these events. To reduce the incidence of these events we should reduce length of pre-operative stay, prevent intra operative accidents, avoid intra operative bleeding in order to reduce intra operative transfusions and avoid as far as possible the stay in ICU Independent predictors of post trauma death are multiple trauma [OR: 6.14, 95% [from 1.68 to 16.94], p = 0.002], a traumatized patient in distress on arrival [OR: 8.74, 95% [3.59 -27.77], p = 0.000] and overall medical complications [OR: 13.18, 95% [from 4.01 to 31.25], p=0.000]. The ISS is a good discriminative indice to assess the severity and life-threatening risk. Administrative databases provide information on the efficiency of care, it helps to realise observational studies on large samples representative of the population at low cost. They are very useful in the research, despite the lack of clinical data

[Parietal abscess revealing calculation forget eight years after laparoscopic cholecystectomy]

Laparoscopic cholecystectomy is the treatment of choice for symptomatic gall stone disease. The perforation of the gallbladder happens in 40% of cases. Stones spilled remain there in 20% of cases in view of their number and location. These lost stones can cause adhesions, abscess, peritonitis, digestive fistula or else cutaneous fistula. to report a new observation of a cutaneous fistula resulting from a gallstone lost during laparoscopic cholecystectomy, eight year later. A 57-year-old women, underwent 8 years ago laparoscopic cholecystectomy for acute cholecystitis. A cholecystectomy was performed without incidence and with uneventful post-operative course. She was admitted to hospital again for an inflammatory painful swelling of the right renal fossa which had been developing for one week without any fever or transit disorder. The abdominal C.T.scan performed revealed a subcutaneous collection of 8 CM. She underwent an excision of the collection with drainage of pus and numerous small stones. She was diagnosed with lost gallstone complicated with cutaneous fistula. The control C.T scan made 3 months later showed a small collection at the level of the right parieto-colic gutter. She was operated on again, laparoscopy excision of the fistulous tract was performed without showing stones. Healing was achieved two months later. She re-presented 3 months later for a swelling of the old scar which fistulized spontaneously with pus leaking. The abdominal C T scan was normal. She underwent an excision of a collection wish containing a large stone of two centimetres. The patient was regularly seen afterwards at the outpatients' department. She was feeling well 18 months later. A lost gallstone can cause serious complications. Spillage of gallstones should be avoided. When does occur, every effort should be made to withdraw spilled gallstones and especially to mention the event in the post-operative report