Factores de riesgo prequirúrgicos para una colecistectomía laparoscópica difícil / Preoperative risk factors for difficult laparoscopic cholecystectomy

RESUMEN Antecedentes: varios estudios observacionales han identificado factores de riesgo (FR) para una colecistectomía laparoscópica difícil (CLD). Objetivo: identificar los FR preoperatorios para CLD en un hospital público de mediana complejidad. Material y métodos: estudio prospectivo de cohorte transversal. Se analizaron 80 pacientes mayores de 18 años sometidos a colecistectomía laparoscópica, entre enero y diciembre de 2019. Se analizaron las variables: edad, sexo, IMC (índice de masa corporal), litiasis vesicular, pancreatitis aguda, colecistitis aguda o crónica, síndrome de Mirizzi, CPRE dentro del mes, numero de cólicos en el último mes, si presentó al menos un cólico en la última semana, leucocitos, enzimas hepáticas mayores, bilirrubina total, hallazgos de ecografía prequirúrgicos, antecedentes de cirugías abdominales previas. Resultados: la incidencia de CLD fue de 47,5%. La tasa de conversión a cirugía convencional fue del 11,25%, el 100% fueron CLD. Los FR para CLD incluyeron sexo masculino (OR: 4,50, IC 95%:1,60-12,62, p: 0,004), cólico en la semana previa a la cirugía (OR:7,17, IC 95%:1,89-27,23, p: 0,004), paredes engrosadas de la vesícula (OR: 4.90, IC 95%:1,90-12,70, p: 0,001), edema perivesicular (OR: 7,14 IC 95%:1,45-35,13 p: 0,016), la vesícula hidrópica (OR: 4,94, IC 95%:1,44-16,88, p: 0,011) y las cirugías previas (OR: 4.38 IC 95%:1,27-15,10 p: 0,001). En el análisis multivariado vemos que los pacientes de sexo masculino y pacientes con cirugías previas presentaban un riesgo elevado para CLD (OR: 6,63 IC 95%:1,75-25,08 p: 0.005; OR: 11.70 IC 95%:1,48-92,37 p: 0,020). Conclusión: se deben centrar los esfuerzos en identificar los pacientes con sospecha de CLD, pudiendo planificar la cirugía y un equipo quirúrgico experimentado.

ABSTRACT Background: The risk factors (RF) for difficult laparoscopic cholecystectomy (DLC) have been identified in many observational studies. Objective: The aim of this study is to identify the preoperative RF for DLC in a secondary care public hospital. Material and methods: We conducted a prospective cross-sectional cohort study of patients > 18 years undergoing laparoscopic cholecystectomy between January and December 2019. The following variables were analyzed: age, sex, body mass index (BMI), cholelithiasis, acute pancreatitis, acute or chronic cholecystitis, Mirizzi syndrome, ERCP within the previous month, episodes of biliary colic in the last month, presence of at least one colic within one week before surgery, white blood cell count, liver enzymes, total bilirubin, preoperative ultrasound and history of upper abdomen surgery. Results: The rate of DLC was 47.5%. Conversion rate to conventional surgery was 11.25% and 100% were categorized as DLC. The RF for DLC included male sex (OR, 4.50; 95% CI,1.60-12.62; p = 0.004), colic within 1 week before surgery (OR, 7.17; 95% CI,1.89-27.23; p = 0.004), gallbladder wall thickening (OR, 4.90; 95% CI,1.90-12.70; p = 0.001), edema around the gallbladder (OR, 7.14; 95% CI, 1.45-35.13; p = 0.016), hidrops gallbladder (OR, 4.94; 95% CI,1.44-16.88; p = 0.011) and previous surgeries (OR, 4.38; 95% CI, 1.27-15.10; p = 0.001). On multivariate analysis, male sex and previous surgery were associated with higher risk of DLC (OR, 6.63; 95% CI,1.75-25.08; p = 0.005; and OR, 11.70, 95% CI,1.48-92.37; p = 0.020, respectively). Conclusion: Efforts should focus on identifying patients with suspicion of DLC to plan surgery with an experienced surgical team.

Can difficulties in laparoscopic cholecystectomy be anticipated preoperatively: evaluation of a scoring system

Background: Laparoscopic cholecystectomy is often associated with intra operative difficulties leading to increased intra and post-operative morbidity. Accurate prediction of a difficult laparoscopic cholecystectomy can reduce the complication rate, rate of conversion and overall medical cost. This study was an attempt to validate a scoring system developed to predict difficult laparoscopic cholecystectomy.Methods: 100 patients undergoing laparoscopic cholecystectomy were included. Details such as age, sex, BMI, previous surgical history, history of hospitalisation for biliary disease, sonographical wall thickness, pericholecystic collection and presence of impacted stone were noted. With these, pre-operative score was calculated using the scoring system. Intra operative details and complications were noted and were classified as easy, difficult and very difficult. Student t test and chi square test was used to test the difference of significance (p<0.05).Results: Male sex, higher BMI, a history of previous surgery, a history of prior hospitalisation for biliary disease, a palpable gall bladder, a thickened gall bladder wall, impacted stone and pericholecystic collection all had a statistically significant accurate prediction of the difficulty in laparoscopic cholecystectomy. The mean duration of surgery was 62.7±33.15 minutes. The scoring system developed by Randhawa et al predicted difficult laparoscopic cholecystectomy with a sensitivity of 77.8%, specificity of 78.1%, positive predictive value of 66.7% and a negative predictive value of 86.2%.Conclusions: The proposed scoring system predicted difficult laparoscopic cholecystectomy with a sensitivity of 77.8%, specificity of 78.1%, positive predictive value of 66.7% and a negative predictive value of 86.2%.

Clinical Characteristics of the Patients with a Long Operative Time in a Laparoscopic Cholecystectomy

BACKGROUND: Almost all cholecystectomies these days are performed using laparoscopic equipment. Recently, this has been applied in all possible pathologies of the gallbladder by many surgeons. However, we occasionally have had bitter experiences, difficult operations and long operative times, when doing laparoscopic cholecystectomies. The aim of this study was to detect the factors causing long operative times, conversions to open surgery, and higher postoperative complication rates, when difficult laparoscopic cholecystectomies are encountered. METHODS: From among the 250 patients who had undergone laparoscopic cholecystectomies during the recent 5 years (from November 1992 to January 1998), the clinical data of the 58 patients who had undergone laparoscopic cholecystectomies with operative times over 120 minutes (a long operative time) were compared with those of 45 patients with operative times of 60 minutes or less (short operative time). RESULTS: Clinical data for the patients with long operative times showed a higher incidence of steady pain (29.3 versus 0%), fever (36.2 versus 4.4%), previous history of upper abdominal surgery (6.9 versus 4.4%), tenderness (48.3 versus 4.4%), rebound tenderness (20.0 versus 0%), palpable tender mass (12.1 versus 0%), thick abdominal wall (13.8 versus 4.4%), leukocytosis (36.2 versus 8.9%), elevated bilirubin level (10.3 versus 0%), wall thickening of the gallbladder (34.5 versus 6.7%), fibrous adhesion after gastric surgery (5.1 versus 0%), inflammatory adhesion (39.7 versus 2.2%), and contracted gallbladder (1.2 versus 0%), as well as a higher required level of surgical experience (5.2 versus 2.2%). The surgical complication rate was 13.8% in the long-operation group and 0% in the short-operation group. Laparoscopic cholecystectomy was completed successfully in 250 of the 258 patients and the overall conversion rate to open surgery was 3.1%; that of the long-operation group was 7.9%. CONCLUSIONS: A laparoscopic cholecystectomy with a long operative time is inevitable in patients with acute severe inflammation of the gallbladder, previous history of gastric surgery, and a contracted gall-bladder. Also, the surgeon needs a learning period to be able to overcome the long operation. In spite of the higher rates complications and conversions to open surgery in the long-operation group, a difficult laparoscopic cholecystectomy with a long operative time is a clinically acceptable procedure in patients who need a cholecystectomy.