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The impossible gallbladder: aspiration as an alternative to conversion

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Abstract

Background

Laparoscopic cholecystectomy is the standard of care for symptomatic gallstone disease but when laparoscopic removal proves impossible the standard advice is to convert to open surgery. This jettisons the advantages of laparoscopy for a procedure which surgeons no longer perform routinely, so it may no longer be the safest practice. We hypothesised that gallbladder aspiration would be a safer alternative when laparoscopic removal is impossible.

Methods

A retrospective analysis was performed of all laparoscopic cholecystectomies attempted under one surgeon’s care over 19 years, and the outcomes of gallbladder aspiration were compared with the standard conversion-to-open procedure within the same institution.

Results

Of 757 laparoscopic cholecystectomies attempted, 714 (94.3%) were successful, while 40 (5.3%) were impossible laparoscopically and underwent gallbladder aspiration. Interval cholecystectomy was later performed in 34/40 (85%). Only 3/757 (0.4%) were converted to open. No aspiration-related complications occurred and excessive bile leakage from the gallbladder was not observed. During this time 1209 laparoscopic cholecystectomies were attempted by other surgeons in the institution of which 55 (4.55%) were converted to open and 22 (40%) had procedure-associated complications. There was a significant difference in the mean (± SEM) post-operative hospital stay between laparoscopic gallbladder aspiration [3.12 (± 0.558) days] and institutional conversion-to-open cholecystectomy [9.38 (± 1.04) days] (p < 0.001), with attendant cost savings.

Conclusion

Laparoscopic gallbladder aspiration is a safe alternative to conversion when inflammation makes cholecystectomy impossible laparoscopically, especially in the sickest patients and for surgeons with limited open surgery experience. This approach minimises morbidity and permits laparoscopic cholecystectomy in the majority after a suitable interval or referral of predicted difficult cases to specialist hepatobiliary centres.

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References

  1. Zacks SL, Sandler RS, Rutledge R, Brown RS Jr (2002) A population-based cohort study comparing laparoscopic cholecystectomy and open cholecystectomy. Am J Gastroenterol 97(2):334–340

    Article  PubMed  Google Scholar 

  2. Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ (2006) Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 18(4):CD006231

    Google Scholar 

  3. Chau CH, Siu WT, Tang CN, Ha PY, Kwok SY, Yau KK et al (2006) Laparoscopic cholecystectomy for acute cholecystitis: the evolving trend in an institution. Asian J Surg 29(3):120–124

    Article  PubMed  Google Scholar 

  4. Wijsmuller AR, Leegwater M, Tseng L, Smaal HJ, Kleinrensink GJ, Lange JF (2007) Optimizing the critical view of safety in laparoscopic cholecystectomy by clipping and transecting the cystic artery before the cystic duct. Br J Surg 94(4):473–474

    Article  CAS  PubMed  Google Scholar 

  5. Rattner DW, Ferguson C, Warshaw AL (1993) Factors associated with successful laparoscopic cholecystectomy for acute cholecystitis. Ann Surg 217(3):233–236

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Livingston EH, Rege RV (2004) A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Surg 188(3):205–211

    Article  PubMed  Google Scholar 

  7. Visser BC, Parks RW, Garden OJ (2008) Open cholecystectomy in the laparoendoscopic era. Am J Surg 195(1):108–114

    Article  PubMed  Google Scholar 

  8. Ballal M, David G, Willmott S, Corless DJ, Deakin M, Slavin JP (2009) Conversion after laparoscopic cholecystectomy in England. Surg Endosc 23(10):2338–2344

    Article  CAS  PubMed  Google Scholar 

  9. Sakpal SV, Bindra SS, Chamberlain RS (2010) Laparoscopic cholecystectomy conversion rates two decades later. JSLS 14(4):476–483

    Article  PubMed  PubMed Central  Google Scholar 

  10. McGillicuddy EA, Schuster KM, Barre K, Suarez L, Hall MR, Kaml GJ et al (2012) Non-operative management of acute cholecystitis in the elderly. Br J Surg 99(9):1254–1261

    Article  CAS  PubMed  Google Scholar 

  11. Kaafarani HM, Smith TS, Neumayer L, Berger DH, Depalma RG, Itani KM (2010) Trends, outcomes, and predictors of open and conversion to open cholecystectomy in Veterans Health Administration hospitals. Am J Surg 200(1):32–40

    Article  PubMed  Google Scholar 

  12. Lengyel BI, Panizales MT, Steinberg J, Ashley SW, Tavakkoli A (2012) Laparoscopic cholecystectomy: what is the price of conversion? Surgery 152(2):173–178

    Article  PubMed  Google Scholar 

  13. Bass G, Walsh TN (2012) Non-operative management of acute cholecystitis in the elderly. Br J Surg 99(1254):1261 (Br J Surg. 2012;99(12):1742; author reply)

    Google Scholar 

  14. Sirinek KR, Willis R, Schwesinger WH (2016) Who will be able to perform open biliary surgery in 2025? J Am Coll Surg 223(1):110–115

    Article  PubMed  Google Scholar 

  15. CholeS Study Group WMRC (2016) Population-based cohort study of outcomes following cholecystectomy for benign gallbladder diseases. Br J Surg 103(12):1704–1715

    Article  Google Scholar 

  16. McCain S, Jones C, Taylor M, Morris-Stiff G (2015) Trainee experience of open cholecystectomy in the laparoscopic era. Ulster Med J 84(1):53–54

    PubMed  Google Scholar 

  17. McNamee L, Quinn EM, Boland M, Kirby J, Walsh TN (2017) Percutaneous cholecystostomy in critically Ill patients. Irish J Med Sci 186:S87

    Google Scholar 

  18. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP et al (2007) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370(9596):1453–1457

    Article  Google Scholar 

  19. Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gomi H, Yoshida M et al (2013) TG13: updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 20(1):1–7

    Article  PubMed  Google Scholar 

  20. Yamashita Y, Takada T, Kawarada Y, Nimura Y, Hirota M, Miura F et al (2007) Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 14(1):91–97

    Article  PubMed  PubMed Central  Google Scholar 

  21. Wakabayashi G, Iwashita Y, Hibi T, Takada T, Strasberg SM, Asbun HJ et al (2018) Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 25(1):73–86

    Article  PubMed  Google Scholar 

  22. Hirota M, Takada T, Kawarada Y, Nimura Y, Miura F, Hirata K et al (2007) Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat 14(1):78–82

    Article  Google Scholar 

  23. Henneman D, da Costa DW, Vrouenraets BC, van Wagensveld BA, Lagarde SM (2013) Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review. Surg Endosc Other Interv Tech 27(2):351–358

    Article  Google Scholar 

  24. Berber E, Engle KL, String A, Garland AM, Chang G, Macho J et al (2000) Selective use of tube cholecystostomy with interval laparoscopic cholecystectomy in acute cholecystitis. Arch Surg 135(3):341–346

    Article  CAS  PubMed  Google Scholar 

  25. Elshaer M, Gravante G, Thomas K, Sorge R, Al-Hamali S, Ebdewi H (2015) Subtotal cholecystectomy for “difficult gallbladders”: systematic review and meta-analysis. JAMA Surg 150(2):159–168

    Article  PubMed  Google Scholar 

  26. Le Blanc-Louvry I, Coquerel A, Koning E, Maillot C, Ducrotte P (2000) Operative stress response is reduced after laparoscopic compared to open cholecystectomy: the relationship with postoperative pain and ileus. Dig Dis Sci 45(9):1703–1713

    Article  PubMed  Google Scholar 

  27. Demirer S, Karadayi K, Simsek S, Erverdi N, Bumin C (2000) Comparison of postoperative acute-phase reactants in patients who underwent laparoscopic v open cholecystectomy: a randomized study. J Laparoendosc Adv Surg Tech A 10(5):249–252

    Article  CAS  PubMed  Google Scholar 

  28. Karayiannakis AJ, Makri GG, Mantzioka A, Karousos D, Karatzas G (1996) Postoperative pulmonary function after laparoscopic and open cholecystectomy. Br J Anaesth 77(4):448–452

    Article  CAS  PubMed  Google Scholar 

  29. Lord RV, Ling JJ, Hugh TB, Coleman MJ, Doust BD, Nivison-Smith I (1998) Incidence of deep vein thrombosis after laparoscopic vs minilaparotomy cholecystectomy. Arch Surg 133(9):967–973

    Article  CAS  PubMed  Google Scholar 

  30. Ambe PC, Jansen S, Macher-Heidrich S, Zirngibl H (2016) Surgical management of empyematous cholecystitis: a register study of over 12,000 cases from a regional quality control database in Germany. Surg Endosc 30(12):5319–5324

    Article  PubMed  Google Scholar 

  31. Blackbourne LH (2008) Defining combat damage control surgery. US Army Med Dep J 36:67–72

    Google Scholar 

  32. Chovanes J, Cannon JW, Nunez TC (2012) The evolution of damage control surgery. Surg Clin North Am 92(4):859–875

    Article  PubMed  Google Scholar 

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Funding

Funding

No funding was sought nor obtained for the conduct of this study.

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Authors and Affiliations

  1. Department of Surgery, Connolly Hospital, RCSI Academic Centre, Blanchardstown, Dublin 15, Ireland

    Natallia Kharytaniuk, Gary A. Bass, Bogdan D. Dumbrava, Paul P. Healy, Dylan Viani-Walsh, Tej N. Tiwary, Tahir Abassi, Matthew P. Murphy, Emma Griffin & Thomas N. Walsh

  2. Royal College of Surgeons in Ireland, 122 St Stephen’s Green, Dublin 2, Ireland

    Gary A. Bass & Thomas N. Walsh

Authors
  1. Natallia Kharytaniuk
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  2. Gary A. Bass
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  3. Bogdan D. Dumbrava
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  6. Tej N. Tiwary
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Contributions

Authors contributions

Due to a long time span of the study and frequent rotations of surgical trainees, the study was carried out over several years, involving several authors who performed data collection and drafting of the manuscript at various stages of this study. Their contribution is acknowledged by their authorship (BDD, PPH, TNT, TA, MPM, EG). NK carried out the literature search, data collection and analysis, and wrote the paper. GAB gave statistical advice, supervised data analysis, contributed to writing the paper, and commented on the manuscript drafts. DVW carried out the literature search and contributed to data analysis and to writing the section on Methodology. TNW was the consultant in charge of the unit, had the original idea for the paper, formulated the study protocol, and supervised the writing of the paper. All the authors were asked to offer advice and comments on various drafts of the paper. The final version of the manuscript was revised by all the authors prior to its submission.

Corresponding author

Correspondence to Natallia Kharytaniuk.

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Disclosures

The authors (N Kharytaniuk, GA Bass, BD Dumbrava, PP Healy, D Viani-Walsh, TN Tiwary, T Abassi, MP Murphy, E Griffin, TN Walsh) declare to have no competing interests.

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Description of the laparoscopic gallbladder aspiration procedure. Supplementary material 1 (MP4 28692 kb)

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Kharytaniuk, N., Bass, G.A., Dumbrava, B.D. et al. The impossible gallbladder: aspiration as an alternative to conversion. Surg Endosc 34, 1868–1875 (2020). https://doi.org/10.1007/s00464-019-07268-x

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