American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Cholecystectomy should not be underestimated

OCTOBER 24, 2017
Clinical Congress Daily Highlights, Tuesday First Edition

A Tuesday panel session featured line drawings from Cervantes’ Don Quixote — an allusion to the “impossible” distorted gallbladder anatomy that sometimes confronts surgeons. The analogy was used to emphasize the occasional difficulty of the typically straightforward cholecystectomy, the most common operation performed by general surgery residents in the U.S.

“Often these operations are easy,” said moderator Nathaniel J. Soper, MD, FACS, Northwestern University, Chicago, IL. “An elective cholecystectomy can be a piece of cake, but it can also be very difficult due to severe acute or chronic inflammation. Surgeons are, or should be, concerned about the possibility of damaging the bile duct while performing these very difficult operations.”

The first presentation covered preoperatively predicting problems that might 1) result in the operation being interrupted or not completed safely, such as bile duct or vascular injury, or 2) dictate an alternative approach to the “gold standard” of laparoscopic cholecystectomy — such as conversion during the procedure to partial or total open removal of the organ. Daniel Deziel, MD, FACS, Rush University, Chicago, IL, said the predominant reason for conversion is severe local inflammation impairing anatomic definition. Major predictors of inflammation are acute cholecystitis or history of it, male gender, age, and obesity. Still, he noted a great deal of fluidity on the topic. For example, a scoring system for operative difficulty predicted only 40 percent of conversions, and more than 20 percent of cases scored at 100 percent probability of conversion actually were completed laparoscopically.

Taylor S. Riall, MD, PhD, FACS, Arizona Cancer Center, Phoenix, AZ, discussed trends and factors underlying  what Dr. Soper called the “hot topic” of cholecystostomy: percutaneous placement of a drainage tube in the gallbladder. She presented a proposed treatment algorithm for Grade II and III patients starting with antibiotics and supportive care, leading to delayed cholecystectomy, without a tube if possible. If first-line therapy fails, a drainage tube is recommended with subsequent cholecystectomy three months later.

L. Michael Brunt, MD, FACS, Washington University in St. Louis, MO, described a six-step “safe cholecystectomy program” describing steps such as recognition of aberrant anatomy, timeouts before clipping or cutting ductal structures, liberal use of diagnostic tools such as cholangiography and fluorescent imaging, and seeking help in difficult cases.

Shamila Dissanalke, MD, FACS, Texas Tech University, Lubbock, TX,  described her approach to subtotal cholecystectomy, both reconstituting and fenestrating approaches, encouraging her listeners to disregard  the mindset that they are somehow incomplete procedures, in favor of a “safety first” philosophy.

Kenneth R. Sirinek, MD, PhD, FACS, University of Texas Health, San Antonio, TX concluded the panel with a discussion of the once-dominant open, total cholecystectomy procedure, which now accounts for only 2 percent of cases, versus the “gold standard” of laparoscopic cholecystectomy. He said that he fears the loss of expertise to perform the procedure, especially when surgeons have to convert to it during other procedures because of complications. “We’re wondering who’s going to know how to do it in 2025,” he said. 

Additional Information:
The Panel Session, The Impossible Gallbladder: Is Cholecystectomy Always the Answer?, was held October 24, at the 2017 Clinical Congress of the American College of Surgeons in San Diego, CA. Program, webcast and audio information is available online at FACS.org/clincon2017.


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