The degree of gallbladder wall thickness and its impact on outcomes after laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is the gold-standard procedure for management of symptomatic gallstone disease. Increased rates of conversion to an open procedure, increased postoperative complications, and longer lengths of stay are seen in thick-walled gallbladders. Previous studies have only evaluated gallbladder walls as being thick or not thick, without looking at the degree of thickness. We hypothesized that, the more severe the wall thickening, the greater the chance of conversions and complications, and the longer the lengths of stay. METHODS: All attempted laparoscopic cholecystectomies in our institution between 2006 and 2009 were retrospectively reviewed. Patients undergoing cholecystectomy for reasons other than gallstones (e.g., polyps or cancer) and those without preoperative ultrasounds were excluded. Patients were divided into four groups based on the degree of gallbladder wall thickness: normal (1-2 mm), mildly thickened (3-4 mm), moderately thickened (5-6 mm), and severely thickened (7 mm and above). Outcomes were compared amongst the groups. RESULTS: 874 patients were included in the study. There were 68 conversions (7.8 %) and 58 complications (6.6 %). The incidence of conversions was 3.1, 5.1, 14.9, and 16.8 % in the four groups, respectively (p < 0.001, χ (2)), and the incidence of complications was 1.8, 6.7, 9.1, and 13.1 %, respectively (p = 0.001, χ (2)). The mean (± standard deviation, SD) length of stay in days was 1.09 ± 1.42, 1.83 ± 3.24, 2.54 ± 3.40 and 3.54 ± 4.61, respectively [p < 0.001, analysis of variance (ANOVA)]. CONCLUSIONS: A greater degree of gallbladder wall thickness is associated with an increased risk of conversion, increased postoperative complications, and longer lengths of stay. Classifying patients according to degree of gallbladder wall thickness gives more accurate assessment of the risk of surgery, as well as potential outcomes.

The impact of body mass index on outcomes after laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard of care for gallstone disease. Some cases will be converted to open surgery and others will have complications, both leading to worse outcomes. The purpose of this study was to evaluate whether an increased body mass index (BMI) is associated with increased rates of conversion or complication. METHODS: A retrospective chart review of 1,027 patients who underwent an attempted LC between January 2006 and December 2009 was performed. Patients were divided into five groups depending on their BMI: 18.5-24.9, 25-29.9, 30-34.9, 35-39.9, and ≥ 40. The primary endpoints were conversion rates, complication rates, and postoperative length of stay (LOS). Multivariate logistic regression was used to identify independent risk factors for worse outcomes. RESULTS: There were 211 (20.5%), 325 (31.6%), 268 (26.1%), 135 (13.1%), and 88 (8.6%) patients in the groups with BMI values of 18.5-24.9, 25-29.9, 30-34.9, 35-39.9, and ≥ 40, respectively. Seventy-three patients (7.1%) required conversion to open surgery, and 64 patients (6.2%) developed complications. The rate of conversion was similar amongst all the BMI groups (P = 0.366), as was the rate of complication (P = 0.483). Mean (± SD) postoperative LOS was 1.74 ± 3.87 days, and there was no difference between the BMI groups (P = 0.596). Male gender and emergent cholecystectomy were independent predictors of increased conversions and complications. Diabetes was a risk factor for conversion, whereas age >65 years was a risk factor for complications. CONCLUSIONS: Increased BMI was not associated with worse outcomes after LC. Compared with normal weight patients, obese and even morbidly obese patients have no increased risk of conversion to open surgery, nor is there an increased risk of perioperative complications. Obese and morbidly obese patients who require a cholecystectomy should be considered in the same category as normal weight patients, and LC should be the standard of care.

Is there a role for a strict incision length criterion for determining conversions during laparoscopic colorectal resection?

PURPOSE: There's no consensus about what defines a conversion for laparoscopic-assisted colorectal resection (LACR). This study's goal was to assess the utility of a strict incision length (IL) definition of conversion (incision > 7 cm) and compare it with results obtained when the surgeon determined (SD) if a LACR had been successfully completed. METHODS: The demographic and perioperative data for 580 elective LACRs were reviewed. The short-term outcomes for each conversion definition were determined and compared. RESULTS: Conversion rates were 22% using the IL definition and 16% via the SD method. Both methods detected significant differences between completed and converted groups regarding the following: incision size, hospital stay, time to flatus, bowel movement, and regular diet as well as rate of wound infection and ileus. The IL method alone detected significant differences in the rate of pulmonary complications and BMI between the completed and converted groups. CONCLUSIONS: The 2 methods yielded similar results for most parameters. The IL method better separated the patients in regard to 2 parameters. This method is objective and easy to apply; however, it may discriminate against obese patients whose extraction incisions are often longer. A conversion definition that considers BMI and IL is needed.

Does prior abdominal surgery influence conversion rates and outcomes of laparoscopic right colectomy in patients with neoplasia?

PURPOSE: The study investigated the impact of prior abdominal surgery on conversions and outcomes of laparoscopic right colectomy. METHODS: A consecutive series of 414 patients with cancer or adenomas who underwent a laparoscopic right colectomy from March 1996 to November 2006 were studied for surgical conversions and outcomes. Conversion was defined as an incision length > 7 cm. RESULTS: Patients with prior abdominal surgery (n = 191) were compared with patients with no prior abdominal surgery (n = 223), and showed no significant differences in age, ASA classification, length of stay, operative time, blood loss, harvested nodes, tumor size, and specimen length. Significantly more wound infections occurred in the prior abdominal surgery group (22 vs.12, P = 0.023). Body mass index > 30 showed a three-fold increased risk of conversion. Fifteen percent of the no prior abdominal surgery patients and 17 percent of the prior abdominal surgery patients were converted (P > 0.05). Conversion was associated with a longer mean length of stay (8.8 days) relative to laparoscopically completed cases (6.3 days) regardless of prior abdominal surgery history (P < 0.0001). CONCLUSIONS: Laparoscopic right colectomy for neoplasia was not associated with a higher conversion rate or morbidity in patients with prior abdominal surgery. Prior abdominal surgery is not a contraindication to laparoscopic right colectomy.