Laparoscopic cholecystectomy in acute cholecystitis in the elderly.

BACKGROUND/AIMS: Benefits of using laparoscopic cholecystectomy (LC) in the elderly with acute cholecystitis (AC) is still questionable. Our aim is to carry out a comparative analysis of that intervention in two groups of patients: under 65 years old, and over or equal to 65 years old. METHODOLOGY: This study corresponds to 249 LCs carried out during 4 years at the Emergency and Surgery Department of Hospital de S. João; 2 groups of individuals were considered: group A--under 65 years old, and group B--65 years old or over. The first consisted of 168 cases (88 men and 80 women, mean age 48.34 years (+/- 11.80)); and the second included 81 patients (40 men and 41 women, mean age 75.73 years (+/- 6.87)). The diagnosis was made on the basis of clinical symptoms, leukocytosis and ultrasound. RESULTS: The comparative analysis between these two groups provided the following results: 1) Mortality: 0% in A vs. 4.76% in B (P = 0.007); 2) Overall postoperative complications: 5.36% in A vs. 22.2% in B (P < 0.001); 3) Surgical complications: 4.76% in A vs. 14.8% in B (P = 0.468); 4) Intraoperative complications: 4.76% in A vs. 4.94% in B (P = 0.007); 5) Reoperations: 2.98% in A vs. 7.41% in B (P = 0.022); 6) Conversion: 12.50% in A vs. 17.28% in B (P = 0.447); 7) Lesion of the Main Bile Duct: 1.79% in A vs. 2.47% in B (P = 0.447); 8) Hospital Stay, equal to or less than 4 days: 72.62% in A vs. 27.16% in B (P <0.001). CONCLUSIONS: LC is a safe and efficient intervention in the treatment of acute cholecystitis in the elderly, although with greater morbidity and longer hospital stay, when compared with younger patients.

[Laparoscopic cholecystectomy and open cholecystectomy in acute cholecystitis: critical analysis of 520 cases]. / Colecistectomia por Laparoscopia e por Laparotomia na Colecistite Aguda: Análise Crítica de 520 Casos.

INTRODUCTION: Despite the skepticism with which it was initially seen, laparoscopic cholecystectomy is now the technique of choice for acute cholecystitis. It is, however, important to evaluate the results in comparison with classic cholecystectomy, since the latter is still used by some surgeons in certain situations. MATERIAL AND METHODS: Our research corresponds to the analysis of 520 patients operated on for acute cholecystitis performed in the department of surgery at the SÉo JoÉo Hospital in Oporto - 412 (79.2%) laparoscopic cholecystectomies and 108 (20.8%) open cholecystectomies - from 2007 to 2013. We evaluated comorbidities, leukocytosis, time between diagnosis and surgery, ASA, per and postoperative complications, mortality, reoperations, lesion of main bile duct, conversion rate and hospital stay, in order to compare these two techniques. The conversion group was included in laparoscopic cholecystectomy. Statistical analysis was based on descriptive statistic procedures and the evaluation of contrast between groups was based on Fishers' exact test. Significant values were considered for p < 0.05. RESULTS: Laparoscopic Cholecystectomy versus Open Cholecystectomy: Mortality: 0.7% vs 3,7% (p = 0.0369); Peroperative complications: 3.6% vs 12.9% (p = 0.0006); Surgical postoperative complications: 7.7% vs 17.5% (p = 0.0055); Medical postoperative complications: 4.3% vs 5.5% (p = 0.6077); Lesion of the main bile duct: 0.9% vs 1.8% (p = 0.6091); Reoperation: 2.9% vs 5.5% (p = 0.2315); Hospital stay up to 4 days after surgery: 64.8% vs 18.5% (p < 0.001). The convertion rate was of 10.7%: 8.8% in early surgery (before 4 days after de diagnosis) and 13.7% in the late surgery (after this time but in the same stay) (p = 0.1425). Multiple causes led to convertion: surgical complications (biliary lesions, iatrogenic lesion of the small bowel, perfurations of the gallbladder with spillage of stones); complications during the pneumoperitoneum, unclear anatomy and scoliosis. Postoperative complications in laparoscopic cholecystectomies converted group vs non-converted: surgical 20.4% vs 6.2% (p = 0.0034) and medical 6.8% vs 4.1% (p = 0.4484). DISCUSSION: There are few investigations concerning the comparison of laparoscopic cholecystectomy vs acute cholecystitis in patients with acute cholecystitis, corresponding mostly to multicenter studies. For this reason, we carry out an analysis inherent to 520 patients operated on with that disease in the surgery department of Hospital S. JoÉo in Oporto of which 412 were by laparoscopic cholecystectomy and 108 by acute cholecystitis. We found better results in laparoscopic cholecystectomy than in acute cholecystitis with respect to mortality, per and post-operative surgical complications and hospital stay. The incidence of main bile duct injury, medicalcomplications and reoperations, although less evident in laparoscopic cholecystectomy, were not statistically significant. There were more complications in the group of laparoscopic cholecystectomy converted than in those where it was not be necessary the conversion. This raises the need, in complications during the laparoscopic cholecystectomy, not to perform the conversion too late. The analysis of this study, therefore, properly values laparoscopic cholecystectomy in the surgery of patients with acute cholecystitis. CONCLUSION: The results justify the frequency with which laparoscopic cholecystectomy is performed in acute cholecystitis, in comparison to open surgery, thus taking an increasingly prominent place in the treatment of this disease.

IntroduçÉo: Apesar do cepticismo com que inicialmente foi encarada, a colecistectomia laparoscópica é hoje a técnica de eleiçÉo na colecistite aguda. Torna-se, porém, importante avaliar os seus resultados, em comparaçÉo com a colecistectomia clássica, uma vez que esta última ainda é seguida por alguns cirurgiões em determinadas situações.Material e Métodos: No nosso estudo foram incluídos 520 doentes com colecistites agudas operados no Serviço de Cirurgia Geral do Hospital de S. JoÉo, entre 2007 e 2013, dos quais 412 (79,2%) por laparoscopia e 108 (20,8%) por via aberta, com uma incidência de conversÉo de 10,7%. Procedeu-se ao estudo relativo às doenças coexistentes, leucocitose, tempo decorrido entre o diagnóstico na urgência e a cirurgia, classificaçÉo ASA, complicações intra e pós-operatórias, mortalidade, reintervenções, lesÉo biliar e estadia hospitalar. Os doentes convertidos foram incluídos no grupo das colecistectomias laparoscópicas. A análise estatística baseou-se em processos descritivos e a avaliaçÉo das diferenças entre grupos foi realizada com base no teste exato de Fisher, sendo considerados valores significativos para p < 0,05.Resultados: Colecistectomia laparoscópica versus Colecistectomia aberta: Mortalidade: 0,7% vs 3,7% (p = 0,0369); Complicações per-operatórias: 3,6% vs 12,9% (p = 0,0006); Complicações pós-operatórias cirúrgicas: 7,7% vs 17,5% (p = 0,0055); Pós-operatórias médicas: 4,3% vs 5,5% (p = 0,6077); LesÉo da via biliar principal: 0,9% vs 1,8% (p = 0,6091); Reintervenções: 2,9% vs 5,5% (p = 0,2315); Internamento hospitalar inferior ou igual a quatro dias: 64,8% vs 18,5% (p < 0,0001). Na colecistectomia laparoscópica houve 10,7% de conversões: nas precoces (intervenções realizadas antes das 96 h após o diagnóstico na urgência) esta taxa foi de 8,8% e nas tardias (após aquele período de tempo mas no mesmo internamento) de 13,7% (p = 0,1425); Complicações nos doentes convertidos vs nÉo convertidos: nas cirúrgicas 20,4% vs 6,2% (p = 0,0034) e nas médicas 6,8% vs 4,1% (p = 0,4484). As causas de conversÉoforam condicionadas por complicações cirúrgicas (lesões biliares, lacerações entéricas, perfurações vesiculares com a disseminaçÉo de cálculos), intoler'ncia ao pneumoperitoneo, indefiniçÉo do pedículo biliar e escoliose.DiscussÉo: Há poucas investigações relativas à comparaçÉo da colecistectomia laparoscópica vs colecistectomia aberta nos doentes com colecistectomia aberta, correspondendo a maior parte delas a estudos multicêntricos. Por esta razÉo, julgamos de interesse proceder a uma análise inerente a 520 operados com aquela doença no Serviço de Cirurgia Geral do Hospital de S. JoÉo dos quais 412 por colecistectomia laparoscópica e 108 por colecistectomia aberta. Verificamos na colecistectomia laparoscópica melhores resultados do que na colecistectomia aberta no que se refere à mortalidade, complicações per e pós-operatórias cirúrgicas e estadia hospitalar. A incidência da via biliar principal, complicações médicas e reintervenções, embora menos evidentes na colecistectomia laparoscópica, nÉo se revelaram com significado estatístico. Merece referência o maior número de complicações no grupo das colecistectomias laparoscópicasconvertidas do que naquelas em que tal nÉo foi necessário confirmando-se, assim, o já referido em estudos multicêntricos citados na literatura. Este facto levanta a necessidade de, mediante complicações ocorridas durante a colecistectomia laparoscópica, nÉo se proceder à conversÉo tardiamente. A análise do presente estudo valoriza, assim, devidamente a colecistectomia laparoscópica na cirurgia dos doentes com colecistite aguda.ConclusÉo: Os resultados obtidos justificam a frequência com que a colecistectomia laparoscópica é realizada na colecistite aguda, em comparaçÉo com a via aberta, ocupando cada vez mais, um lugar primordial, no tratamento desta doença.

Durability of long-term outcome of laparoscopic Nissen - comparison of the results at 5 and 10 years after surgery .

BACKGROUND/AIMS: It is not sufficiently clear whether the continued good outcomes obtained with laparoscopic Nissen operation after a short follow-up will continue after several years. The aim of our re-search was to make a comparative analysis of the quality of life and presence of symptoms 5 and 10 years after surgery. METHODOLOGY: 123 cases (69 men and 74 women) average age of 49.78 years (+12.13) were studied with average follow-up of 10.15 years. The quality of life was assessed based on a personal modified Gigli questionnaire with 32 items. RESULTS: The overall analysis revealed that the levels of quality of life decreased from 2006 (74.72) to 2011 (70.04) but remain significantly higher than those recorded prior to surgery (57.28). Of the 123 cases, 115 were satisfied with the surgery (93.5%) and 8 were not (6.5%);of the latter, six were undergoing antidepressant treatment. In 4 cases it was necessary to re-operate, 1 for dysphagia and 3 due to relapse. CONCLUSIONS: Al-though the results recorded in 2011 are slightly lower than those obtained in 2006, they remain well above those recorded before surgery. Therefore, the laparoscopic Nissen operation continues to be an excellent operation in the treatment of GERD