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BACKGROUND: Dense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder. METHODS: A multicenter, multinational retrospective cohort study of patients who underwent bailout procedures for severe cholecystitis. Procedures were compared using one-way analysis of variance/Kruskal-Wallis tests and χ2 tests with multiple pairwise comparisons, maintaining a family-wise error rate at 0.05. Multiple multivariate linear/logistical regression models were created. RESULTS: In 11 centers, 727 bailout procedures were conducted: 317 laparoscopic subtotal cholecystectomies, 172 open subtotal cholecystectomies, and 238 open cholecystectomies. Baseline characteristics were similar among subgroups. Bile leak was common in laparoscopic and open fenestrating subtotal cholecystectomies, with increased intraoperative drain placements and postoperative endoscopic retrograde cholangiopancreatography(P < .05). In contrast, intraoperative bleeding (odds ratio = 3.71 [1.9, 7.22]), surgical site infection (odds ratio = 2.41 [1.09, 5.3]), intensive care unit admission (odds ratio = 2.65 [1.51, 4.63]), and length of stay (Δ = 2 days, P < .001) were higher in open procedures. Reoperation rates were higher for open reconstituting subtotal cholecystectomies (odds ratio = 3.43 [1.03, 11.44]) than other subtypes. The overall rate of bile duct injury was 1.1% and was not statistically different between groups. Laparoscopic subtotal cholecystectomy had a bile duct injury rate of 0.63%. CONCLUSION: Laparoscopic subtotal cholecystectomy is a feasible surgical bailout procedure in cases of severe cholecystitis where standard laparoscopic cholecystectomy may carry undue risk of bile duct injury. Open cholecystectomy remains a reasonable option.
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Background: Chyle leak (CL) is an infrequent but potentially serious complication of oesophagectomy. Sarcopenia is an increasingly recognised prognostic factor in oesophageal cancer surgery. The aim of this study was to identify the influence of body composition measures on CL following oesophagectomy. Methods: Patients who developed CL after oesophagectomy between January 2006-December 2020 were identified retrospectively from a prospectively maintained dataset. A control group of patients undergoing oesophagectomy, who did not experience chyle leak during the same time period, was also collected. Relationships between CL and demographics, operative factors and body composition measures were investigated as primary outcomes. Risk factors for severe CL were evaluated as a secondary outcome. Results: There were 26 patients who developed a CL following an oesophagectomy. On univariate analysis, preoperative body mass index (BMI) (P=0.001), subcutaneous fat index (P=0.001) and total fat index (P=0.004) were significantly associated with CL. On multivariate analysis, a lower preoperative subcutaneous fat index was a significant independent predictor of CL (P=0.003). Sarcopenia, as an overall measure, was not found to be a significant predictor of developing CLs. No significant predictors of severe CL were identified. Conclusions: A reduced preoperative BMI and body fat composition are risk factors for CL after oesophagectomy. Sarcopenia does not predict either the occurrence or severity of CL. This presents potentially modifiable risk factors for CL after oesophagectomy and emphasises the importance of physiological and nutritional optimisation before oesophagectomy.
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BACKGROUND: Our study aimed to compare the comprehensive complication index (CCI) to the conventional Clavien-Dindo classification (CDC) in patients undergoing surgery for primary retroperitoneal sarcoma (RPS). METHODS: Data were collected for patients who underwent surgery from 2008 to 2019 at a tertiary institution. The length of hospital stay (LOS) was used as a surrogate marker for clinical outcomes, and associations with CDC and CCI were assessed. RESULTS: Data were available for 191 patients, with the highest CDC Grade of I, II, III, and IV in 18.3%, 41.9%, 17.8%, and 4.2%, respectively; the 30-day postoperative mortality (CDC Grade V) was 1.6% (N = 3). Whilst both classification systems were significantly correlated with LOS, this association was significantly stronger for CCI (Spearman's ρ: 0.768 vs. 0.648, p < 0.001). Increasing Charlson Comorbidity Index, tumor size, and organ weighted resection scores were independently associated with longer LOS. However, the association between LOS and both the CDC and CCI remained significant, even after adjusting for these factors (both p < 0.001). CONCLUSION: The CCI is more strongly associated with LOS than the CDC, and represents a useful tool to quantify the total burden of postoperative complications after surgery for RPS.
