Laparoscopy experience in East, Central, and Southern Africa: insights from operative case volume analysis.

BACKGROUND: With the primary objective of addressing the disparity in global surgical care access, the College of Surgeons of East, Central, and Southern Africa (COSECSA) trains surgeons. While sufficient operative experience is crucial for surgical training, the extent of utilization of minimally invasive techniques during COSECSA training remains understudied. METHODS: We conducted an extensive review of COSECSA general surgery trainees' operative case logs from January 1, 2015, to December 31, 2020, focusing on the utilization of minimally invasive surgical procedures. Our primary objective was to determine the prevalence of laparoscopic procedures and compare this to open procedures. We analyzed the distribution of laparoscopic cases across common indications such as cholecystectomy, appendicitis, and hernia operations. Additionally, we examined the impact of trainee autonomy, country development index, and hospital type on laparoscopy utilization. RESULTS: Among 68,659 total cases, only 616 (0.9%) were laparoscopic procedures. Notably, 34 cases were conducted during trainee external rotations in countries like the United Kingdom, Germany, and India. Gallbladder and appendix pathologies were most frequent among the 582 recorded laparoscopic cases performed in Africa. Laparoscopic cholecystectomy accounted for 29% (276 of 975 cases), laparoscopic appendectomy for 3% (76 of 2548 cases), and laparoscopic hernia repairs for 0.5% (26 of 5620 cases). Trainees self-reported lower autonomy for laparoscopic (22.5%) than open cases (61.5%). Laparoscopy usage was more prevalent in upper-middle-income (2.7%) and lower-middle-income countries (0.8%) compared with lower-income countries (0.5%) (p < 0.001). Private (1.6%) and faith-based hospitals (1.5%) showed greater laparoscopy utilization than public hospitals (0.5%) (p < 0.001). CONCLUSIONS: The study highlights the relatively low utilization of minimally invasive techniques in surgical training within the ECSA region. Laparoscopic cases remain a minority, with variations observed based on specific diagnoses. The findings suggest a need to enhance exposure to minimally invasive procedures to ensure well-rounded training and proficiency in these techniques.

Outcomes of Laparoscopic Cholecystectomy in a Tertiary Hospital in Nepal.

Background Laparoscopic Cholecystectomy (LC) is the gold-standard surgery for symptomatic cholelithiasis with low mortality and morbidity. Objective The main objective of this study is to study the outcomes of laparoscopic cholecystectomy in Dhulikhel Hospital over the period of seven years. Method The records of all the patients who underwent laparoscopic cholecystectomy in Dhulikhel Hospital from January 1, 2015, to December 31, 2021 were reviewed. Patient demographics, indication of surgery, hospital stay, and number of conversions to open cholecystectomy were collected. The percentage, mean and median were calculated for socio-demographic information and Chi-square test was performed to measure the association between socio-demographic characteristics, duration of hospital stay, and operative procedure. Result Out of 2106 patients who underwent laparoscopic cholecystectomy from January 1, 2015, to December 31, 2021, 584 (27.73%) were male, and 1522 (72.27%) were female. The female-to-male ratio was 2.6:1. The median age of the patients was 40 years (IQR=52-30). Most common indications for surgery were symptomatic cholelithiasis in 1740 (82.62%) patients along with chronic cholecystitis in 268 (12.73%) patients, and Post ERCP Cholecystectomy in 92 (4.37%) patients. Median hospital stay was three days. Out of 2106 cases, 24 cases were converted to open cholecystectomy. Conclusion Laparoscopic cholecystectomy is the gold standard treatment for benign diseases of the gallbladder and can be performed safely as day care surgery to reduce the cost, length of hospital stay, and long waiting list in low and middle-income countries.

Outcomes Following Cholecystectomy on a Service Designed to Maximize Chief Resident Entrustment.

BACKGROUND: The chief resident service provides surgical trainees in their final year of training the opportunity to maximize responsibility, continuity, and decision-making. Although supervised, chief residents operate according to personal preferences instead of adapting to their attendings' preferences. We hypothesized that outcomes following cholecystectomy are equivalent between the chief resident service and standard academic services. METHODS: We matched adults undergoing cholecystectomy from 07/2016-06/2019 on the chief resident service to two standard academic service patients based on operative indication and age. We compared demographics, operative details, and 30-d complications. RESULTS: This study included 186 patients undergoing cholecystectomy. Body mass index (32.4 versus 32.0, P = 0.49) and Charlson comorbidity index (0.9 versus 1.4, P = 0.16) were similar between chief resident and standard academic services, respectively. Operative approach was similar (95.2% laparoscopic on chief resident service versus 94.4% on standard service), but residents on the chief resident service performed cholangiograms more often (48.4% versus 22.6%, P < 0.01) and averaged longer operative times during laparoscopic cholecystectomy with cholangiogram (146±28 versus 85±22 min, P < 0.01) and without (94±31 versus 76±35 min, P < 0.01) compared with standard academic services, respectively. 30-d complication rates were similar (5.2% chief resident versus 5.0% standard, P = 0.95). No patients suffered bile leak, bile duct injury, or reoperation. Emergency Department visits were similar (12.1% chief resident versus 7.4% standard, P = 0.32); readmissions were less frequent on the chief resident service (0.0% versus 5.0% standard, P = 0.03). CONCLUSIONS: With appropriate supervision, chief residents provide safe care for patients undergoing cholecystectomy while directing medical decisions and practicing according to their preferences.

The Impact of Laparoscopic Cholecystectomy on 30-Day Readmission Rate for Acute Cholangitis Patients: A Single-Center Study.

OBJECTIVES: Laparoscopic cholecystectomy (LC) following acute gallstone cholangitis reduces the recurrence of biliary symptoms; however, the timing of LC has not been determined yet. The aim of our study was to evaluate the impact of performing LC during admission on the 30-day readmission rate. METHODS: We conducted a retrospective cohort study of acute gallstone cholangitis patients who underwent endoscopic clearance (EC) of the bile duct through endoscopic retrograde cholangiopancreatography between April 2013 and May 2018. Patients were classified into two groups: EC only group and EC followed by LC during admission (EC + LC) group. The primary outcome was the 30-day readmission rate. RESULTS: A total of 95 patients with acute cholangitis were included in the analysis. Of these patients, 35 patients (36.8%) underwent LC during admission. The 30-day readmission rate was significantly lower in the EC + LC group compared to the EC group (2.9% vs. 26.7%, P 0.003). In a multivariate regression analysis, patients who underwent LC during admission had 90% lower odds of readmission within 30 days compared to patients who did not (OR 0.1, 95% CI (0.01-0.9), P 0.04). CONCLUSIONS: Performing laparoscopic cholecystectomy during admission for acute gallstone cholangitis patients following endoscopic clearance of the bile duct significantly reduced the 30-day readmission rate without affecting the length of stay.

Risk factors for 30-day readmission and indication for ERCP following laparoscopic cholecystectomy: a retrospective NSQIP cohort study.

BACKGROUND: Laparoscopic cholecystectomy (LC) is one of the safest, most commonly performed surgical procedures, but postoperative complications including bile leak, retained stone, cholangitis, and gallstone pancreatitis following LC occur in up to 2.6% of cases and may require readmission with possible endoscopic retrograde cholangiopancreatography (ERCP) intervention. There is a paucity of literature on factors predictive of need for ERCP following LC. The goal of this study is to describe the prevalence and risk factors for readmission with indication for ERCP. METHODS: We queried the ACS/NSQIP 2012-2017 Participant User Files for patients who underwent LC. Patient demographics, comorbidities, operative characteristics, and postoperative outcomes were evaluated. Multivariate logistic regression was used to identify risk factors for readmission with indication for ERCP intervention. RESULTS: Of 275,570 patients, 11,010 (4.00%) were readmitted within the 30-day postoperative period. Among these, 930 (8.44%) were admitted with indication for ERCP intervention. On multivariate regression, readmissions were more likely in older patients, inpatients, and patients with baseline comorbidities, acute preoperative morbidity, and those discharged to care facilities. The use of intraoperative cholangiogram was associated with lower odds of readmission. Less than 10% of readmitted patients had an indication for ERCP. Those who were readmitted with an indication for ERCP were more likely to have undergone emergency surgery, experienced longer operative times, and had elevated preoperative LFTs or gallstone pancreatitis prior to surgery. The risk of 30-day mortality was significantly higher among patients who experienced any complications after their surgery (OR 13.03, 95% CI 10.57-16.07, p < 0.001). CONCLUSIONS: Older patients, patients with greater preoperative morbidity, and those discharged to care facilities were more likely to be readmitted for any reason following laparoscopic cholecystectomy, whereas patients with evidence of complicated gallstone disease were more likely to be readmitted with an indication for ERCP, even when controlling for the use of intraoperative cholangiogram. Initiatives aimed at reducing readmission with indication for ERCP should focus on these patient subgroups.

Bilateral Erector Spinae Plane Block for Postoperative Analgesia in Laparoscopic Cholecystectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Erector spinae plane (ESP) block is a novel regional anesthetic technique. Its application for postoperative analgesia has been increasing since 2016; however, its effectiveness remains uncertain and varies according to the type of surgery. This meta-analysis aimed to assess the analgesic efficacy of ESP block in patients undergoing laparoscopic cholecystectomy. METHODS: Literature searches of electronic databases and manual searches up to June 1, 2020 were performed. Review Manager Version 5.3 was used for pooled estimates. We included only randomized controlled trials (RCTs) in this meta-analysis. The random-effects meta-analysis model was used, and metaregression was applied when appropriate. RESULTS: A total of five RCTs consisting of 250 patients were included (124 in the ESP block group vs. 126 in the control group). Bilateral ESP block showed a significant reduction in postoperative intravenous opioid consumption reported up to 24 hours after surgery (mean difference [MD] = -4.46, 95% confidence interval [CI] [-5.50 to -3.42], P < 0.001) and in the time to first rescue analgesic (MD = 73.27 minutes, 95% CI [50.39 to 96.15], P < 0.001). According to the results of four studies, the postoperative pain score was lower in the ESP group compared with the control group at both rest and movement. There were no differences between the two groups as concerns nausea (odds ratio [OR] = 0.45, 95% CI [0.13 to 1.52], P = 0.20) and vomiting (OR = 0.37, 95% CI [0.10 to 1.35], P = 0.13). No block-related complications were noted. CONCLUSION: This meta-analysis showed that bilateral ultrasound-guided ESP block could be considered as an effective option to reduce opioid consumption and the time to first rescue analgesic and seems to be also a safe technique in adults undergoing laparoscopic cholecystectomy.

Risk Factors for Early Readmission After Acute Pancreatitis: Importance of Timely Interventions.

BACKGROUND: Despite improvements in the diagnosis and care of acute pancreatitis, the mortality, morbidity, and long-term complications of this disease currently account for an annual cost of $10 billion in the United States. Lack of high-quality consolidated clinical data about this ever-increasing national and global burden makes it challenging to be able to recognize at-risk populations and intervene to avoid early readmission (ER) (i.e., readmission within 30 d of hospital discharge or ER). METHODS: We reviewed the National Readmission Database for 2016. We retrieved 25,476 ER out of a total of 188,757 patients admitted with acute pancreatitis (ICD-10 diagnosis of K85), alive at discharge. Patients younger than 18 at the time of initial admission were excluded. Diagnostic characteristics and procedures performed were extracted from ICD-10 data. Based on patient demographics and the diagnostic and procedural profiles from their initial admission, we identified clusters of risk factors for ER using agglomerative hierarchical clustering. These are depicted in a correlation matrix. RESULTS: Acute pancreatitis is associated with a 13.5% overall ER rate. Certain pre-existing chronic diseases, particularly cardiovascular disease diagnoses and interventions at initial presentation increase the odds of ER. In contrast to interventions on the pancreas, interventions on the biliary system correlated with lower odds of ER. Furthermore, the earlier the biliary system intervention was performed during the initial hospitalization, the lower the odds of ER. We identified five clusters of interrelationships: age/comorbidity cluster, cirrhosis cluster, sepsis/pulmonary complication cluster, biliary intervention cluster, and high-risk of mortality cluster. CONCLUSIONS: We identified several potentially modifiable risk factors for ER of patients hospitalized with acute pancreatitis, which included timing of biliary interventions. Furthermore, we identified clusters of interrelationships that further illuminate which complications tend to occur concomitantly and ultimately contribute to ER. By identifying risk factors and elucidating their interactions, we have improved our understanding of this highly morbid disease and offer potential points of intervention to reduce ER.

Normalization of Serum Lipase Levels Versus Resolution of Abdominal Pain: A Comparison of Preoperative Management in Children With Biliary Pancreatitis.

BACKGROUND: Controversy exists over the timing of cholecystectomy for biliary pancreatitis in children. Some surgeons await normalization of serum lipase levels while others are guided by resolution of abdominal pain; however, there are minimal data to support either practice. We hypothesized that resolution of abdominal pain is equivalent in outcome to awaiting normalization of lipase levels in patients undergoing cholecystectomy for biliary pancreatitis. METHODS: After institutional review board (IRB) approval, the medical record was retrospectively queried for all cases of cholecystectomy for biliary pancreatitis at our institution from 2007 to 2017. Patients undergoing chemotherapy, admitted for another cause, or who had severe underlying comorbidities like ventilator dependence were excluded. Patients were stratified into two cohorts: those managed preoperatively by normalization of serum lipase levels versus resolution of abdominal pain. Demographics, serum lipase levels, postoperative complications, cost of stay, readmissions, and return to the emergency department were collected and analyzed using multivariate regression. RESULTS: Seventy-four patients met inclusion: 29 patients had lipase levels trended until normalization compared with 45 patients who had resolution of abdominal pain prior to cholecystectomy. Among the two cohorts there was no statistical difference in age, gender, race, ethnicity, or type of preoperative imaging used. Trended patients were found to have more serum lipase levels tested (8.5 ± 6.2 versus 3.4 ± 2.5, P < 0.0001). The trended lipase cohort was significantly more likely to require preoperative total parenteral nutrition (48% versus 11%, P = 0.007) and consequently a longer time before resuming a diet (10 ± 7.3 versus 4.6 ± 2.4 d, P < 0.0001). When comparing the two groups, we found no significant difference in the duration of surgery, postoperative complications, or readmissions. Lipase trended patients had a significantly longer length of stay compared with nontrended patients (11.5 ± 8.1 versus 4.2 ± 2.3 d, P < 0.0001) and had a higher total cost of stay ($38,094 ± 25,910 versus $20,205 ± 5918, P = 0.0007). CONCLUSIONS: Our data suggest that in children with biliary pancreatitis, proceeding with cholecystectomy after resolution of abdominal pain is equivalent in outcomes to trending serum lipase levels but is more cost-effective with a decreased length of stay and decreased need for preoperative total parenteral nutrition.

Bile duct injuries: a contemporary survey of surgeon attitudes and experiences.

INTRODUCTION: The incidence of bile duct injury (BDI) during laparoscopic cholecystectomy has not changed significantly in the past 2 decades despite increased operative experience and technical refinement. We sought to evaluate surgeon-specific factors associated with BDI and to assess how surgeons manage injuries. METHODS: An online survey was sent to surgeons belonging to the Society of American Gastrointestinal and Endoscopic Surgeons via e-mail. Survey items included personal experience with BDI and how injuries were addressed. Statistical analysis was performed to identify factors associated with BDI. RESULTS: The survey was sent to 3411 surgeons with 559 complete responses (16.5%). The mean age of respondents was 48.7 years with an average time in practice of 16.1 years. Most respondents (61.2%) had fellowship training. Forty-seven percent of surgeons surveyed experienced a BDI in their career with 17.1% of surgeons experiencing multiple BDIs. The majority of BDIs were identified in the operating room (64.5%); most injuries (66.9%) were repaired immediately. When repair was undertaken immediately, 77.4% of these repairs were performed in an open technique. A majority of surgeons (57.7%) felt that BDIs could theoretically be repaired laparoscopically and 25% of those surgeons had done so in practice. In multivariate logistic regression, any type of fellowship training was associated with a decreased risk of BDI (OR 0.51, 95% CI 0.34-0.76). Compared with those in non-academic practice, surgeons in academic practice were at a significantly decreased risk of having experienced a BDI (OR 0.62, 95% CI 0.42-0.92). CONCLUSION: Nearly half of those surveyed, experienced a BDI during a laparoscopic cholecystectomy. Community and private practice setting were associated with an increased risk of BDI, while fellowship training and academic practice setting conferred a protective effect. A majority of surgeons felt that BDI could be repaired laparoscopically and 25% had done so in practice.

Outcomes following early versus delayed cholecystectomy performed for acute cholangitis.

BACKGROUND: Early cholecystectomy following an episode of gallstone pancreatitis is data supported, however, there is minimal literature regarding the optimal timing for cholecystectomy following an episode of acute cholangitis. Our study aims to determine the ideal timing for laparoscopic cholecystectomy following an episode of acute cholangitis. METHODS: A retrospective chart review was done on cholecystectomies performed for cholangitis at our institution from 2008 to 2015. Patients were compared based on timing of cholecystectomy (i.e., index admission versus delayed) and Tokyo severity grade (I-III). RESULTS: We identified 151 patients who underwent cholecystectomy for cholangitis at our institution from 2008 to 2015. Cholecystectomy was performed during the index admission for 61.6% of patients and Tokyo grade (TG) did not affect the rate of cholecystectomy during index admission (TG1 65.2%, TG2 64.1%, TG3 52.8%; p = 0.46). There was no difference in average operative time (89.0 min vs. 96.6 min; p = 0.36) or conversion to open cholecystectomy (5.4% vs. 10.3%; p = 0.34) between early and late cholecystectomy groups. There was also no statistically significant difference in intra-operative complications (9.7% vs. 15.5%; p = 0.28) or overall complication rates (16.1% vs. 29.3%; p = 0.05) based on timing of cholecystectomy; however, post-operative complications were significantly higher for the delayed cholecystectomy group (20.7% vs. 6.5%; p = 0.01). CONCLUSIONS: Early cholecystectomy after cholangitis is safe to perform and is not associated with higher operative times or rate of conversion to open, regardless of Tokyo grade. Due to the risk of developing recurrent cholangitis and a higher rate of post-operative complications seen with delayed cholecystectomy, our recommendation is to perform cholecystectomy during the index admission.

Hospital Variation in Cholecystectomies in The Netherlands: A Nationwide Observational Study.

BACKGROUND: Practice variation generally raises concerns about the quality of care. This study determined the longitudinal degree of hospital variation in proportion of patients with gallstone disease undergoing cholecystectomy, while adjusted for case-mix, and the effect on clinical outcomes. METHODS: A nationwide, longitudinal, database study was performed in all hospitals in the Netherlands in 2013-2015. Patients with gallstone disease were collected from the diagnosis-related group database. Hospital variation in case-mix-adjusted cholecystectomy rates was calculated per year. Clinical outcomes after cholecystectomy were compared between hospitals in the lowest/highest 20th percentile of the distribution of adjusted cholecystectomy rates in all 3 subsequent years. RESULTS: In total, 96,673 patients with gallstones were included. The cholecystectomy rate was 73.6%. In 2013-2015, the case-mix-adjusted performance of cholecystectomies was in hospitals with high rates 1.5-1.6 times higher than in hospitals with low rates. Hospitals with a high adjusted cholecystectomy rate had a higher laparoscopy rate, shorter time to surgery, and less emergency department visits after a cholecystectomy compared to hospitals with a low-adjusted cholecystectomy rate. CONCLUSION: Hospital variation in cholecystectomies in the Netherlands is modest, cholecystectomy rates varies by <2-fold, and variation is stable over time. Cholecystectomies in hospitals with high adjusted cholecystectomy rates are associated with improved outcomes.

Gallbladder Retrieval From Epigastric Versus Umbilical Port in Laparoscopic Cholecystectomy: A PRISMA-Compliant Meta-Analysis.

Purpose. To date, no evidence supports the retrieval of the gallbladder through a specific trocar site, and this choice is left to surgeons' preference. The aim of this meta-analysis was to investigate the influence of the trocar site used to extract the gallbladder on postoperative outcomes. Methods. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search of PubMed, Google Scholar, Cochrane Library, and EMBASE databases was performed. Terms used were: ("gallbladder" OR "cholecystectomy") AND "umbilical" AND ("epigastric" OR "subxiphoid"). Randomized trials comparing the gallbladder retrieval from different trocar sites were considered for further analysis. Results. Literature search revealed 145 articles, of which 7 matched inclusion criteria and reported adequate data about postoperative pain, operative time, port-site infections, and hernias. A total of 876 patients were included, and the gallbladder was extracted through epigastric or umbilical trocar site in 441 and in 435 patients, respectively. A statistically significant difference among groups was noted in terms of postoperative pain at 1, 6, 12, and 24 hours in favor of the umbilical trocar site (P < .001). No significant differences were noted in postoperative hernia and infection rate, nor in terms of operative time. Conclusions. This meta-analysis shows a statistically significant reduction in terms of postoperative pain at 1, 6, 12, and 24 hours after surgery when the gallbladder is extracted through the umbilical port. Retrieval time, infections, and hernias rate implicate no contraindication for the choice of a specific trocar site to extract specimens. Despite limitations of this study, the umbilical trocar should be favored as the first choice to retrieve the gallbladder.

Is Specialisation Needed in Laparoscopic Cholecystectomy? A Retrospective Cohort Study of 5122 Patients.

Background: Gallstone disease is a common problem and laparoscopic cholecystectomy (LC) is a common elective procedure. This operation was performed by a general surgeon, colorectal surgeons, breast and vascular surgeons according to the largest UK's audit (CholeS study). Objectives: To compare the outcomes of laparoscopic cholecystectomy performed by a specialist upper gastrointestinal (UGI) surgeon to that of CholeS and large international studies. Our hypothesis is: UGI specialist is producing better outcomes for LC patients. Methods: All patient who underwent LC between 1999 and 2019 at one hospital by an UGI consultant and 2014-2019 at another hospital by another UGI consultant surgeon were included. The inclusion criteria were LC performed by UGI surgeon. Lost to follow up, procedures done by trainees and gallbladder cancer patients were excluded. The outcome measures of bile leak, bile duct injuries, bleeding, infectious complications, bowel injuries, vascular injuries and pseudoaneurysms, neuralgia, port site hernia, mesenteric haematoma, 30-day mortality and conversion to open were reported. Statistical tests were used to assess the significant differences, the confidence interval was 95% and the p-value was taken as 0.05. Results: Two UGI specialists performed 5122 LC, 4396 (86%) were female and 715 (14%) male. The age was 13-93 year (median of 48 years). 3681 (72 %) was done as a day surgery case. 1431(28%) as an inpatient and 287 (5.6%) emergency LC. There was no death in the 30 days periods of surgery, 8 (0.15%) biliary leak from the duct of Luschka, 4 (0.19%) common bile duct (CBD) injuries, 9(0.02%) conversions and 17(0.33%) procedures were abandoned. There were significant differences in the above complications between our study and the CholeS report. Conclusions: Laparoscopic cholecystectomy is associated with acceptable outcomes, low risk of bile duct injury and no mortality when performed by a specialist upper GI surgeon.

Development and practice of laparoscopic surgery in a Nigerian tertiary hospital.

BACKGROUND: For the benefits of less postoperative pain, early recovery and discharge, and better cosmesis, laparoscopic surgery is rapidly gaining acceptance amongst surgeons as a better alternative to traditional open procedures. In January 2015, bookings for laparoscopic surgery became a more regular feature on our operation list. AIMS: We reported the indications, management outcome, and challenges in patients who had laparoscopic surgery in our institution. This is to document the trends in our surgical practice. METHODOLOGY: This is a descriptive study of 137 patients who had laparoscopic surgery for general surgical indications in our institution over a period of 5 years. Patients data as collected from the records department were evaluated for demographic characteristics, medical comorbidities, type of procedures done, and perioperative outcome. Data analysis was performed using Statistical Package for Social Sciences (SPSS). RESULTS: A total of 137 Patients had laparoscopic general surgery between January 2015 and December 2019. There were 48 males and 89 females with a male-to-female ratio of 1:1.9. The mean age of the patients was 38.8 ± 3.4 years (range 16-87 years). Laparoscopic cholecystectomy (35%) and laparoscopic appendicectomy (29.9%) were the most common procedures performed. Five (3.7%) cases were converted to open surgery. Superficial surgical site infection (5.8%) following laparoscopic appendicectomy was the most common postoperative complication. There was no 30-day postoperative mortality. CONCLUSION: Laparoscopic surgery is safe and can be applied to wide variety of general surgical conditions in developing countries. Minimal postoperative morbidity of laparoscopy is a major benefit to the patients.

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy.

BACKGROUND: A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. METHODS: Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall's tau for dichotomous variables, or Jonckheere-Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. RESULTS: A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). CONCLUSION: We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty.

Barriers to adoption of laparoscopic cholecystectomy in a county hospital in Guatemala.

BACKGROUND: Despite international efforts to increase performance of laparoscopic cholecystectomy (LC) in rural Guatemala, the vast majority of cholecystectomies are still performed via the open cholecystectomy (OC) approach. Our goal was to explore barriers to the adoption of LC in Guatemala as well as possible mechanisms to overcome them. METHODS: We reviewed 9402 cholecystectomies performed over 14 years by surgeons at the Hospital Nacional de San Benito (HNSB) in El Peten, Guatemala, with either an open or a laparoscopic approach. We conducted personal interviews with all the surgeons who perform cholecystectomies at HNSB to determine current practice and barriers to adopting LC. RESULTS: Overall, seven general surgeons were interviewed who regularly perform cholecystectomy. Of the total number of cholecystectomies reviewed, 8440 (90%) were open and 962 (10%) were laparoscopic. The mean number of cholecystectomies performed per surgeon was 1341.1 ± 1244.9, with OC at 1205.7 ± 1194.9, and LC at 137.4 ± 188.0. Lack of formal training in laparoscopy was identified in 57% of surgeons. Lack of government funds to implement a laparoscopic program was noted by 71% of surgeons (29% felt there was insufficient ancillary staff, 29% poor allocation of hospital funding to purchase laparoscopic equipment/training). Lack of sufficient laparoscopic equipment was identified by 71% of surgeons. CONCLUSIONS: Ninety percent of cholecystectomies performed by surgeons at HNSB continue to be OC. The major limitation is the lack of funding to provide sufficient equipment or ancillary staff. The majority of surgeons preferred to perform LC if these problems could be addressed.

Laparoscopy in Rwanda: A National Assessment of Utilization, Demands, and Perceived Challenges.

BACKGROUND: Laparoscopy has proven to be feasible and effective at reducing surgical morbidity and mortality in low resource settings. In Rwanda, the demand for and perceived challenges to laparoscopy use remain unclear. METHODS: A mixed-methods study was performed at the four Rwandan national referral teaching hospitals. Retrospective logbook reviews (July 2014-June 2015) assessed procedure volume and staff involvement. Web-based surveys and semi-structured interviews investigated barriers to laparoscopy expansion. RESULTS: During the study period, 209 laparoscopic procedures were completed: 57 (27.3%) general surgery cases; 152 (72.7%) ob/gyn cases. The majority (58.9%, 125/209) occurred at the private hospital, which performed 82.6% of cholecystectomies laparoscopically (38/46). The three public hospitals, respectively, performed 25% (7/28), 15% (12/80), and 0% (denominator indeterminate) of cholecystectomies laparoscopically. Notably, the two hospitals with the highest laparoscopy volume relied on a single surgeon for more than 85% of cases. The four ob/gyn departments performed between 4 and 87 laparoscopic cases (mostly diagnostic). Survey respondents at all sites listed a dearth of trainers as the most significant barrier to performing laparoscopy (65.7%; 23/35). Other obstacles included limited access to training equipment and courses. Equipment and material costs, equipment functionality, and material supply were perceived as lesser barriers. Twenty-two interviews revealed widespread interest in laparoscopy, insufficient laparoscopy exposure, and a need for trainers. CONCLUSION: While many studies identify cost as the most prohibitive barrier to laparoscopy utilization in low resource settings, logbook review and workforce perception indicate that a paucity of trainers is currently the greatest obstacle in Rwanda.

Safety and outcomes of laparoscopic cholecystectomy in the extremely elderly: a systematic review and meta-analysis.

Background: Gallstones are a common cause of morbidity in the elderly. Operative treatment is often avoided due to concerns about poor outcomes but the evidence for this is unclear. We aim to consolidate available evidence assessing laparoscopic cholecystectomy outcomes in the extreme elderly (>80s) compared to younger patients. Methods: Studies comparing laparoscopic cholecystectomy in >80s with younger patients were considered. Total complications, mortality, conversion, bile duct injury, and length of stay were compared between the two groups. Results: Twelve studies including 366,522 patients were included. They were of moderate overall quality. The elderly group had more complicated gallbladder disease and also had more co-morbidities and a higher ASA grade. The risk of morbidity was lower in the younger group (RR 0.58 (95% CI 0.58-0.59)) with a slightly lower risk of conversion (RR 0.96 (0.94-0.98)) Length of stay was significantly longer for the elderly patients. Differences in mortality and bile duct injury were non-significant in all but one study. Conclusion: Laparoscopic cholecystectomy is safe and effective in the extreme elderly. Higher complication rates are predominantly related to increased co-morbidities and more complex gallbladder disease. Patients should be carefully selected, and cholecystectomy performed at an earlier stage to minimize these problems.

Determinants of variability in management of acute calculous cholecystitis.

BACKGROUND: While evidence supports early compared to delayed cholecystectomy as optimal management of acute calculous cholecystitis (ACC), significant variability in practice remains. The purpose of this study was to identify variables associated with early cholecystectomy, to target opportunities to improve adherence to best practices. METHODS: Adult patients admitted to surgical units with ACC at two hospitals in a university hospital network between June 2010 and January 2015 were reviewed. Patients with concurrent pancreatitis, cholangitis or severe ACC (with organ system failure) were excluded. Early cholecystectomy was defined as surgery performed during same admission and within 7 days of presentation. Non-operative management was defined as admission for ACC treated conservatively, with or without eventual delayed cholecystectomy. The primary outcome was early cholecystectomy versus initial non-operative management; secondary outcomes included time to cholecystectomy, complications, and total hospital length of stay (LOS). RESULTS: A total of 374 patients were included. Two hundred and forty six patients (66%) underwent early cholecystectomy, 60 (16%) were treated non-operatively and had delayed cholecystectomy, and 68 (18%) were only treated non-operatively. Median time to OR from initial presentation was 38 h [22-63] for early cholecystectomy patients and 69 days [29-116] for the non-operative patients who had delayed cholecystectomy. When comparing both groups, early cholecystectomy patients were younger and were treated more often at site 1. There were no differences in complications during hospitalization, but early cholecystectomy patients had a lower median total LOS (3 [2-5] vs. 5 [4-9], p < 0.001), and they had fewer gallstone-related events after discharge (1 vs. 18%, p < 0.001). On multiple logistic regression analysis, lower age, hospital site and lower risk of concurrent choledocholithiasis were all significantly associated with early cholecystectomy (p < 0.05). CONCLUSION: Our data supports early cholecystectomy as best practice in management of ACC with no differences in complications during hospitalization, shorter median LOS and fewer gallstone-related events compared to non-operative management. We identified patient and institutional factors associated with early cholecystectomy. This suggests that multiple strategies will be necessary to promote adherence to best practices in the management of ACC within our institution.

An observational study of the timing of surgery, use of laparoscopy and outcomes for acute cholecystitis in the USA and UK.

BACKGROUND: Evidence supports early laparoscopic cholecystectomy for acute cholecystitis. Differences in treatment patterns between the USA and UK, associated outcomes and resource utilization are not well understood. METHODS: In this retrospective, observational study using national administrative data, emergency patients admitted with acute cholecystitis were identified in England (Hospital Episode Statistics 1998-2012) and USA (National Inpatient Sample 1998-2011). Proportions of patients who underwent emergency cholecystectomy, utilization of laparoscopy and associated outcomes including length of stay (LOS) and complications were compared. The effect of delayed treatment on subsequent readmissions was evaluated for England. RESULTS: Patients with a diagnosis of acute cholecystitis totaled 1,191,331 in the USA vs. 288 907 in England. Emergency cholecystectomy was performed in 628,395 (52.7% USA) and 45,299 (15.7% England) over the time period. Laparoscopy was more common in the USA (82.8 vs. 37.9%; p < 0.001). Pre-treatment (1 vs. 2 days; p < 0.001) and total ( 4 vs. 7 days; p < 0.001) LOS was lower in the USA. Overall incidence of bile duct injury was higher in England than the USA (0.83 vs. 0.43%; p < 0.001), but was no different following laparoscopic surgery (0.1%). In England, 40.5% of patients without an immediate cholecystectomy were subsequently readmitted with cholecystitis. An additional 14.5% were admitted for other biliary complications, amounting to 2.7 readmissions per patient in the year following primary admission. CONCLUSION: This study highlights management practices for acute cholecystitis in the USA and England. Despite best evidence, index admission laparoscopic cholecystectomy is performed less in England, which significantly impacts subsequent healthcare utilization.