Closing the book on open cholecystectomy in cirrhosis

Here is my highlight from the December edition of the journal HPB which is out now.

Offer most surgeons the opportunity to take out the gall bladder in a patient with cirrhosis and they will run a mile. The perceived wisdom for many years was that if you were forced to perform a cholecystectomy in a cirrhotic patient this would be better done as an open procedure as the potential for rapid control of bleeding was much better. The trouble was that no single centre had enough cases to test this anecdotal opinion.

Chmielecki and colleagues in this month’s edition of HPB have undertaken a population based study to address the question of whether it is better to undertake a laparoscopic or an open cholecystectomy in a patient with cirrhosis. Using Nationwide Inpatient Sample data, they identified over 3000 patients with cirrhosis who had undergone cholecystectomy. Twelve percent of these patients had open cholecystectomy with the majority having an attempt at laparoscopic cholecystectomy. Conversion rates to open surgery were high with 14% converted, but outcomes were much better in those patients undergoing laparoscopic surgery. Specifically, transfusion requirements, postoperative liver failure and infection rates were all lower in laparoscopically treated patients. The stand out result, however, was a 6 fold lower operative mortality in laparoscopic (1.3%) versus open cholecystectomy patients (8.3%).

The dataset does not allow analysis of severity of liver disease which would have allowed greater confidence in excluding selection bias. The message seems fairly clear, however, if your patient has cirrhosis and they need a cholecystectomy – unless there are compelling reasons otherwise, this should be attempted laparoscopically.

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