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Total laparoscopic cholecystectomy in moderate to severe acute cholecystitis: still a safe procedure

Juan D Hernandez, MD, FACS1, Gabriela L Larios, MD, FACS2, Diana C Quintero2, Gabriel Herrera, MD, FACS1, Roosevelt Fajardo, MD, FACS1, Felipe Perdomo, MD3, Francisco J Diaz, MD1, Ricardo M Nassar, MD3. 1Hospital Universitario Fundacion Santa Fe de Bogota, Universidad de los Andes School of Medicine, 2Universidad de los Andes School of Medicine, 3Hospital Universitario Fundacion Santa Fe de Bogota

Introduction: Cholecystectomy is one of the most common procedures in general surgery and was responsible for the dissemination of laparoscopy among surgeons from the late 1980’s. Due to the catastrophic implications of bile duct injury, major efforts such as SAGES safe cholecystectomy program have been put forth to reduce this risk in laparoscopic cholecystectomy (LC), especially in severe cases. Also, bleeding and infection are major concerns. However, it is feared that an excess of precaution may lead to unnecessary conversions or partial cholecystectomies, procedures that can carry their own complications. A case series of LCs in complex cholecystitis and the incidence of intraoperative and postoperative complications is presented.

Methods: A prospectively maintained database was queried for patients who underwent LC at a tertiary care university hospital between January 2017 and June 2018, all conducted by surgeons with laparoscopic expertise. Inclusion criteria were patients with moderate or severe cholecystitis according to Tokyo guidelines 2018 (TG18). Exclusion criteria are age under 17 years, cholecystectomy as a secondary procedure, open cholecystectomy, mild cholecystitis according to TG18, pregnancy and incomplete records. The primary outcomes were three main complications: bile duct injury, hemorrhage or bleeding and infection. The secondary outcomes were conversion and mortality.

Results: Of 764 consecutive patients, 149 were identified as having moderate cholecystitis (19.5%), and 5 as severe cholecystitis (0.65%), and comprised the study group. The frequency of main complications reported in our study was 1 infection and 1 major bleeding (1.29% total); there were no bile duct injuries. There were two conversions, one due to technical difficulties and associated medical conditions of the patient. The other one was due to difficult bleeding control, also requiring subtotal cholecystectomy. There was only one other subtotal cholecystectomy, performed because Calot triangle was unidentifiable. It was completed laparoscopically. Only one mortality was found and it was not associated with the procedure (leukemia).

Discussion: This series of patients with moderate to severe cholecystitis who underwent total LC shows good outcomes with low incidence of complications and no bile duct injuries. This incidence was not superior to that in international literature. Conversion to open or subtotal was decided only in truly severe disease or when the anatomy was impossible to discern. TG18 frequently did not correlate to severity or difficulty.  A consensus on the indications or findings to decide conversion or subtotal cholecystectomy should be achieved to prevent overuse and the complications associated to them. 


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 95840

Program Number: P239

Presentation Session: Poster Session (Non CME)

Presentation Type: Poster

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