Atypical Methods of Laparoscopic Cholecystectomy for Acute Cholecystitis Complicated by Dense Infiltrate

The study is dedicated to the development and evaluation of atypical methods of laparoscopic cholecystectomy for acute cholecystitis complicated by dense pericholecystic infiltrate. The relevance of the work is due to the high rate of conversion to laparotomy during standard laparoscopic cholecystectomy in the setting of destructive acute cholecystitis, which is accompanied by an increased risk of complications and mortality. The aim of the study is to improve the treatment outcomes for this category of patients through the widespread application of atypical surgical methods, including cholecystectomy "from the fundus," cholecystectomy according to Przybram, and subtotal cholecystectomy. The work develops technical features and indications for the application of each atypical method depending on the nature of the infiltrate, as well as studies the short-term results of their application based on a large clinical material.

Relevance of the Topic

Laparoscopic cholecystectomy (LC) over the last decade has become the "golden standard" in the treatment of acute calculous cholecystitis within the first few days from the onset of the disease, as it is characterized by low traumatization and a low rate of complications in the early postoperative period (A.E. Borisov et al., 2002; N.A. Maistrenko, V.V. Stukalov, 2002; O.E. Lutsevich et al., 2003; S.I. Emelyanov et al., 2004; V.P. Sazhin et al., 2006; B.K. Shurkalin et al., 2004; T. Manger et al., 1999; M. Suter, A. Meyer, 2001; J. Bender et al., 2002; L. Feldman et al., 2003).

Despite the great successes of endovideo surgery in gallstone disease, many authors classify certain forms of acute cholecystitis (phlegmonous and gangrenous cholecystitis with a paravascular infiltrate in the area of the gallbladder neck) as contraindications to LC (A.S. Balalykin, 1996; I.V. Fedorov et al., 1998; A.E. Borisov et al., 2002; Z.I. Chagaeva, 2004; A.N. Kuritsyn et al., 2005; P.Ya. Sandakov et al., 2005; R. Bailer, J. Flowers, 1995; S. Frantzides, 2000). This is due to the complexity of performing LC in destructive forms of acute cholecystitis complicated by dense infiltrate, which often leads to conversion to laparotomy and the development of severe complications during surgery and in the early postoperative period. Thus, the rate of conversion to laparotomy during LC increases from 2% in chronic cholecystitis (B.K. Shurkalin et al., 2001) to 9.6–14.9% in acute cholecystitis (R.K. Dzhordzhikiya et al., 2003; A. Warshau et al., 1994; T. Koperna et al., 1999; K. Michalowski et al., 1999; G. Borzellino et al., 2002). Moreover, according to C. Kum et al. (1996), injuries of the hepatic duct after LC in patients with chronic cholecystitis were observed in 0.2% of cases, whereas in patients with acute cholecystitis — in 5.5% of cases. Similar data are reported by other authors (V.V. Strizhelets'kyi, A.P. Mikhailov, 2004; T. Kiviluoto et al., 1998). At the same time, conversion to laparotomy is not the optimal solution to the problem of treating acute cholecystitis complicated by infiltrate. This is because "open" cholecystectomy in acute cholecystitis is accompanied by a significantly higher rate of fatal outcomes ranging from 1.0% to 10.6% (B.A. Korolev, D.L. Pikovskii, 1990; N. Burhenne, 1989), whereas after LC performed for acute cholecystitis, fatal outcomes are observed significantly less frequently — from 0.2% to 0.5% of cases (M.M. Vinokurov et al., 2004; S.V. Lokhvitskii, S.I. Tokpanov, 2004; B.K. Shurkalin et al., 2004; V.P. Sazhin et al., 2006; G. Borzellino et al., 2002).

Given that a paravascular infiltrate is observed in 8.0–40.7% of patients with acute destructive cholecystitis (S.S. Slesarenko et al., 1995; V.V. Egorov, 1997; Z.I. Chagaeva, 2004; S.A. Kasumian et al., 2005; A.N. Bukharin et al., 2006; L.Yu. Podgornyi et al., 2006; A.N. Tokin et al., 2006; K. Zucker et al., 1993), the development of atypical methods of LC that allow avoidance of conversion to laparotomy and a reduction in the frequency of hepatic duct injuries is of great practical interest.

In recent years, publications have appeared devoted to the application of atypical methods of LC in acute destructive cholecystitis complicated by dense infiltrate (B.S. Danzapov et al., 2003; I.S. Malkov et al., 2003; S.I. Tokpanov et al., 2003; R.T. Medzhidov et al., 2005; A.K. Khaburzaniia et al., 2005; P. Chowbey et al., 2000; S. Mahmud et al., 2002; G. Beldi, A. Glattli, 2003; T. Ichihara et al., 2004; Y. Cengiz et al., 2005; J. Dolan et al., 2005; Y. Wang et al., 2006). In these publications, the authors propose that when standard LC is impossible, one of the atypical methods of LC should be performed: cholecystectomy "from the fundus," cholecystectomy according to Przybram, or subtotal cholecystectomy. At the same time, it appears practically significant to develop indications for each atypical method of LC depending on various causes, as well as to study the early results of their performance. This testifies to the necessity of further study of various aspects of performing LC in acute cholecystitis complicated by dense paravascular infiltrate.

The goal of the study is to improve the treatment outcomes for patients with acute cholecystitis complicated by dense paravascular infiltrate through the widespread application of atypical methods of LC.

Tasks of the study:

1. To evaluate the possibilities of performing LC by standard and atypical methods in acute cholecystitis complicated by dense paravascular infiltrate.

2. To study local complications after the application of standard and atypical methods of LC in acute cholecystitis complicated by dense paravascular infiltrate.

3. To study general complications after the application of standard and atypical methods of LC in acute cholecystitis complicated by dense paravascular infiltrate.

4. To evaluate the effect of introducing atypical methods of LC into practice on the frequency of hepatic duct injuries in acute cholecystitis.

5. To evaluate the effect of introducing atypical methods of LC into practice on postoperative mortality in acute cholecystitis.

Scientific Novelty

Technical features of performing atypical methods of LC in acute cholecystitis complicated by dense paravascular infiltrate depending on the nature of the infiltrate have been developed.

Indications for the application of atypical methods of LC in acute cholecystitis complicated by dense paravascular infiltrate, depending on the nature of the infiltrate, have been developed.

For the first time, early results of performing atypical methods of LC in acute cholecystitis complicated by dense paravascular infiltrate have been studied on a large clinical material.

It has been proven that the application of atypical methods of LC in acute cholecystitis complicated by dense paravascular infiltrate reduces the frequency of complications and fatal outcomes.

A complex of measures for the prevention and treatment of complications arising during the performance of atypical methods of LC has been developed.

Practical Significance

It has been established that atypical methods of LC are not accompanied by a higher rate of postoperative complications compared to the standard method of LC in acute cholecystitis complicated by dense paravascular infiltrate.

The application of atypical methods of LC in acute cholecystitis complicated by dense paravascular infiltrate is accompanied by a lower rate of hepatic duct injuries compared to the standard method of LC.

The application of atypical methods of LC in acute cholecystitis complicated by dense paravascular infiltrate allows for a statistically significant reduction in postoperative mortality due to a decrease in the frequency of conversion to laparotomy.

Main Propositions for Defense

1. In acute cholecystitis complicated by dense paravascular infiltrate, conversion to laparotomy is not indicated; instead, atypical methods of LC should be performed: cholecystectomy "from the neck," cholecystectomy according to Przybram, or subtotal cholecystectomy.

2. The application of atypical methods of LC in acute cholecystitis complicated by dense paravascular infiltrate allows for a substantial reduction in the risk of hepatic duct injuries.

3. The application of "open" cholecystectomy, standard LC, and atypical methods of LC as indicated allows for improved early treatment outcomes for patients with acute cholecystitis.

Dissertation Defense

Materials of the dissertation were presented at a scientific-practical conference in Petropavlovsk-Kamchatsky (2006) and at a scientific-practical conference on evidence-based medicine in Khabarovsk (2006) at the Krai Scientific-Practical Society of Surgeons of Khabarovsk Krai (2006). Four printed works have been published on the topic of the dissertation.

Implementation into Practice

The main provisions and developments of the study have been implemented into the practice of surgical departments of GKБ № 11 in the city of Khabarovsk, MUZ GKБ № 7 in the city of Komsomol-on-Amur. Materials of the dissertation are used in the educational process at the surgery departments of DVGMU.

Volume and Structure of the Dissertation