Laparoscopic cholecystectomy in a resource limited setting: Factors associated with difficult surgeries at the National Referral Hospital, Bhutan

Abstract Background Prediction of difficult laparoscopic cholecystectomy may help in making necessary arrangements for optimal intraoperative requirements and postoperative care. This study was conducted to examine the factors associated with and outcomes of difficult laparoscopic cholecystectomy performed at the Bhutan's largest hospital in 2020. Methods This was a cross‐sectional study with a convenience sampling method. Data on clinical features, ultrasonography and intraoperative factors of patients who underwent laparoscopic cholecystectomy were extracted from their medical records, investigation reports and intraoperative surgery note. Difficult laparoscopic cholecystectomy was defined on the basis of the duration of the surgery, injury to bile duct or artery, or conversion to open cholecystectomy. Data were double entered and validated in EpiData 3.1 and analysed in STATA 13.0. Results Data from 134 patients were extracted. The mean age of the sample was 43 (±SD 13) years. “Difficult laparoscopic cholecystectomy” was reported in 83 patients (62%) and easy laparoscopic cholecystectomy in 51 patients (38%). Those patients having simple adhesions up to the body of the gall bladder were 1.6 times more likely to encounter difficult laparoscopic cholecystectomy (adjusted PR = 1.60, 95% CI 1.04–2.48, p = 0.034). The majority did not have any post‐operative complications (130 cases, 97%). The indications of laparoscopic cholecystectomy were symptomatic gall stone disease (129, 96%), acalculous cholecystitis (2, 1%) and gall bladder polyp (3, 2%). Conclusions The proportion of difficult laparoscopic cholecystectomy is high, but the rates of post‐operative complications were minimal with no mortality or injury to bile duct or arteries

Outcomes and Their State-level Variation in Patients Undergoing Surgery With Perioperative SARS-CoV-2 Infection in the USA. A Prospective Multicenter Study

Objective: To report the 30-day outcomes of patients with perioperative SARS-CoV-2 infection undergoing surgery in the USA. Background: Uncertainty regarding the postoperative risks of patients with SARS-CoV-2 exists. Methods: As part of the COVIDSurg multicenter study, all patients aged ≥17 years undergoing surgery between January 1 and June 30, 2020 with perioperative SARS-CoV-2 infection in 70 hospitals across 27 states were included. The primary outcomes were 30-day mortality and pulmonary complications. Multivariable analyses (adjusting for demographics, comorbidities, and procedure characteristics) were performed to identify predictors of mortality. Results: A total of 1581 patients were included; more than half of them were males (n = 822, 52.0%) and older than 50 years (n = 835, 52.8%). Most procedures (n = 1261, 79.8%) were emergent, and laparotomies (n = 538, 34.1%). The mortality and pulmonary complication rates were 11.0 and 39.5%, respectively. Independent predictors of mortality included age ≥70 years (odds ratio 2.46, 95% confidence interval [1.65-3.69]), male sex (2.26 [1.53-3.35]), ASA grades 3-5 (3.08 [1.60-5.95]), emergent surgery (2.44 [1.31-4.54]), malignancy (2.97 [1.58-5.57]), respiratory comorbidities (2.08 [1.30-3.32]), and higher Revised Cardiac Risk Index (1.20 [1.02-1.41]). While statewide elective cancelation orders were not associated with a lower mortality, a sub-analysis showed it to be associated with lower mortality in those who underwent elective surgery (0.14 [0.03-0.61]). Conclusions: Patients with perioperative SARS-CoV-2 infection have a significantly high risk for postoperative complications, especially elderly males. Postponing elective surgery and adopting non-operative management, when reasonable, should be considered in the USA during the pandemic peaks