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BleedingComplicationsinCholecystectomy
ARegisterStudyofOver22000CholecystectomiesinFinland
S.SuuronenA.KivivuoriJ.TuimalaH.Paajanen
BMCSurg.201515(97)
Abstract
Background:Majorbleedingisrarebutamongthemostseriouscomplicationsoflaparoscopicsurgery.Stillverylittleis
knownonbleedingcomplicationsandrelatedbloodcomponentuseinlaparoscopiccholecystectomy(LC).Theaimofthis
studyistocomparebleedingcomplications,transfusionratesandrelatedcostsbetweenLCandopencholecystectomy(OC).
Methods:DataconcerningLCsandOCsandrelatedbloodcomponentusebetween2002and2007werecollectedfrom
existingcomputerizedmedicalrecords(FinnishRedCrossRegister)oftenFinnishhospitaldistricts.
Results:Registerdataincluded17175LCsand4942OCs.IntheLCgroup,1.3%ofthepatientsreceivedredbloodcell(RBC)
transfusioncomparedto13%ofthepatientsintheOCgroup(p<0.001).Similarly,theproportionsofpatientswithplatelet
(0.1%vs.1.2%,p<0.001)andfreshfrozenplasma(FFP)products(0.5%vs.5.8%)transfusionswererespectivelyhigherin
theOCgroupthanintheLCgroup.ThemeantransfuseddoseofRBCs,PTLsandFFPproductOctaplasorthemeancostof
thetransfusedbloodcomponentsdidnotdiffersignificantlybetweentheLCandOCgroups.
Conclusions:Laparoscopiccholecystectomywasassociatedwithlowertransfusionratesofbloodcomponentscomparedto
opensurgery.TheseverityofbleedingcomplicationsmaynotdiffersubstantiallybetweenLCandOC.
Background
Duringthelasttwodecadeslaparoscopiccholecystectomy(LC)hasbecomethegoldenstandardofthetreatmentof
symptomaticgallbladderdisease.Comparedtothetraditionalopencholecystectomy(OC),LCisassociatedwithlower
morbidity [1]andmortality, [2]shorterlengthofhospitalstayandfasterreturntonormalactivities. [3]HoweverLCisassociated
withhigherincidenceofiatrogenicbileductinjuriesthanOC. [46]
Still,accordingtoregisterstudies,some10to30%ofallcholecystectomiesareperformedusingopentechnique,particularly
inelderlypopulation[7]andinacutecholecystitis. [2,8]Inaddition,theopentechniqueisstillneeded,whenthelaparoscopic
operationcannotbecompletedsafelyandtheconversiontoopenprocedureisrequired.Accordingtotheliterature,current
conversionratevariesbetween5and10%. [912]Themajorityofconversionsareperformedbecauseofobscureanatomy
(difficultcholecystitis)orbleedingcomplications.
Theincidenceofbleedingcomplicationsrequiringtransfusionorreoperationhasbeenreportedtoberelativelyrare,occurringin
0.1%inpatientsundergoingLC. [13]Focusintheliterature,however,hasbeenonbiliarycomplicationsofLC.Yet,major
vascularcomplications,eventhoughrare,arealsoseriouscomplicationsoflaparoscopy. [14,15]Inaddition,bleedingremainsa
frequentreasonforconversion. [9,10,16,17]RegardingOC,onlyfewstudieshavereportedtheincidenceofbleedingcomplications
inthelaparoscopicera.Bleedinghasbeenreportedtooccurin0.4%ofpatientsundergoingOC. [4]Thereareverylittledataon
transfusionratesofredbloodcells(RBCs)andhospitalcostsrelatedtobleedingincholecystectomies.
Thepurposeofthisstudyistocomparetransfusionrates,amountsoftransfusionsandrelatedcostsbetweenLCandOCina
largeFinnishregisterbasedcohort.NopriordataofbloodtransfusionandrelatedcostsinLCiscurrentlyavailable.
Methods
Datafrompotentiallytransfusedpatientswascollectedtoaseparate"OptimalUseofBlood"(VOK)registryinajointeffort
betweentheFinnishRedCrossBloodServiceandten(outof21)Finnishhospitaldistricts.Fiveofthehospitaldistrictswere
teachinguniversityconnectedhospitaldistricts(C,F,G,IandJ)andfivecentralhospitaldistricts(A,B,D,EandH)(Fig.1).
Thebleedingregistrywasstartedin2002andcontinuallyupdatedbetween2002and2011,buttheregistryhasbeen
permanentlyterminatedanderasedin2012.ThedatacollectionsystemisdescribedinmoredetailsbyPaloandcoworkers.
[18]Datawerecollectedfromhospitalswhichfulfilledthetechnicalprerequisitesandcoulddelivertherequireddata.Altogether
thesehospitaldistrictshaveabout620000inpatientepisodesannually,constituting63%ofallFinnishpublicinpatienthospital
episodes.Patientdatacamefrompreexistingelectronicmedicalregisters.Computerfilesprovidedinformationonhospital
admissions,diagnoses,surgicaloperations,testresults,andbloodcomponentsaswellasontransfusions.Theoriginally
collected90transfusionrelatedvariableswereprocessedandcombinedinto149variablestodescribeanepisode.Systematic
auditofdatavariablewasdone. [18]
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auditofdatavariablewasdone. [18]
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Figure1.
ParticipatedFinnishhospitaldistricts
Forthisstudy,patientswhovisitedanystudyhospitaldistrictforLCorOCbetweenJanuary1st2002andDecember31st2007
wereextractedfromtheoriginalVOKregistry(20022011).Inthisresearchregistry,datafromthehospitaldistrictJisonly
availablefromJan1st2004toDecember31st2007.
ICD10(InternationalStatisticalClassificationofDiseasesandRelatedHealthProblems,10thRevision,2003)wasusedto
categorizediagnoses.SurgicalprocedurewasdefinedaccordingtotheNCSP(TheNOMESCO,NordicMedicoStatistical
Committee,ClassificationofSurgicalProcedures)classification(NCSPtheNOMESCOClassificationofSurgicalProcedures
version1.7,2005).Allpatientsover15yearsofagewhounderwentLC(JKA21)orOC(JKA20)asaprimarysurgicalprocedure
wereincludedinthisstudy.NCSPdoesnothaveaseparateprocedurecodeforconversionofLCconvertedintoOC.Thus,
conversionscannotbeidentifiedfromthisdataandtheyarereportedintheOCgroup.Cholecystectomiesassociatedwith
biliaryorpancreaticneoplasmswereexcludedbasedonthemaindiagnosisoftheoperationanddiagnosesforthehospital
admission.Allprocedurecodesanddiagnosesweresetbytreatingphysicians.
Thefollowingdatawascollectedforeachpatient:age,sex,AmericanSocietyofAnaesthesiologists(ASA)class,themain
diagnosis,theprimarysurgicalprocedure,secondarysurgicalprocedures,thestatusoftheoperation(either
elective/prescheduledoremergent/acutecase),thelengthoftheoperation,theusageofbloodcomponentsduringthehospital
stay,inhospitalmortality,thelengthofhospitalstay,thehospital,thehospitaldistrictandreoperationsperformedwithin60
daysofthecholecystectomy(notreported).Emergentoperationswereperformedmostlybecauseofacutecholecystitisor
longlastingpainfulbiliarycolic,whichrequiredhospitaladmission.Therecordedusageofbloodcomponentsincludedthe
numberoftransfusedredbloodcell(RBC)units,numberoftransfusedplatelets(PLT),numberoftransfusedfreshfrozen
plasmaproductsandthetotalcostofthetransfusedbloodcomponents.Theseverityofacutecholecystitis
(flegmonous/perforated)wasnotincluded,becausenodetailedoperationfilesorpathologicalreportsfromremovedgallbladders
wereavailable.
TheFinnishRedCrossBloodServicecollectsanddistributesbloodproductsfromnonremunerateddonorsnationwidein
Finland. [19]EachRBCproductisequivalentof1unit.ThePLTproductwaspreparedusingabuffycoatprocedureandmostof
thetransfusedPLTswerebuffycoatderived.ThemeannumberofPLTsperfourdonorproductwas296109andthevolume
wasabout320ml. [20]EachPLTproductisequivalentof(3)4units.
Thefreshfrozenplasmaproductsconsistedoffreshfrozenplasma(FFP)andOctaplas(OctapharmaNordicAB).TheFFP
referstowholebloodrecoveredleukodepletedfreshplasma(volume,approximately270ml).Oneproductwasequalto1unitof
FFP. [21]Duringthestudyperiod,OctaplaswasavailableinFinlandfrom2005untiltheendofthestudy.Theusageofthe
FFPandOctaplasarepresentedseparatelyinthisstudy,becausetheunitsizeandthustheamountofcoagulationfactors
perunitissmallerinOctaplascomparedtoFFP.
ThenumberofallcholecystectomiesperformedinFinlandin20002007wasobtainedfromtheNationalInstituteforHealthand
Welfare(NIHW)registry.
PermissiontousetheBleedingregistrydatawasobtainedfromtheinstitutionalreviewboardoftheFinnishRedCrossBlood
Service.Wedidnotusepatients'identificationdetails(nameorsocialsecuritynumber)inthisregisterstudy.
TheaimsandcontentofthisstudyareinaccordancewiththeHelsinkiDeclaration.Therespectiveethicscommitteeofthe
FinnishRedCrossBloodServiceapprovedthestudyprotocol.
ThedatawasanalyzedusingIBMSPSSStatistics22.0(IBM,USA2015).Theindependenceoftwocategoricalvariableswas
testedforwith 2test.MeanvaluesofcontinuousvariableswerecomparedwitheitherStudent'sttestorMannWhitneyU
testwhereappropriate.Statisticalsignificancewasdefinedasapvaluelessthan0.05.
Results
Thetotalof22117cholecystectomiescomprisethefinaldatasetforthisstudyaccountingfor43%allcholecystectomies(51
094)performedinFinlandin20022007.Oftheincludedcholecystectomies,78%(17175)wereLCsand22%(4942)were
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OCs.ThenumberofLCsandOCsbyhospitaldistrictisshowninFig.2.
Figure2.
Numberoflaparoscopiccholecystectomies(LC)andopencholecystectomies(OC)byhospitaldistrictsin20022007(from
hospitaldistrictJdataavailableonlyfrom2004to2007)
Demographicandperioperativedataofthecholecystectomypatientsisshownin.ComparedtotheOCpatients,theLC
patientswereyounger,moreoftenfemaleandmoreoftenbelongedtothelowerASAclasses.Theyalsounderwentanelective
operationmoreoftenthantheOCpatients(88%vs.38%,p<0.001).ThemeanlengthoftheoperationwasshorterforLCs
thanforOCs.Intraoperativecholangiographies(IOC)andcommonbileductexplorationsweremorecommonintheOCgroup.
Inaddition,themeanlengthofhospitalstaywaslongerandinhospitalmortalitywashigheramongtheOCpatients(2.5%vs.
0.3%,p>0.001).
Table1.Demographicandperioperativedataofpatientswhounderwentopencholecystectomy(OC)orlaparoscopic
cholecystectomy(LC)in20022007
LCn=17175(%)
OCn=4942(%)
Males/females
4702/12473(27/73)
2429/2513(49/51)
<0.001
MeanageSD(range)
5215(1694)
6315(1697)
<0.001
ASAaI
5842(34.0)
673(13.6)
<0.001
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II
6424(38.0)
1564(31.6)
<0.001
III
2753(16.0)
1756(35.5)
<0.001
IV
183(1.1)
409(8.3)
<0.001
0(0.0)
31(0.6)
<0.001
Elective/emergency
MeanoperativetimeSD(min) 7037
9950
<0.001
Intraoperativecholangiography
862(5.0)
1009(20.0)
<0.001
Commonbileductexploration
156(0.9)
369(7.5)
<0.001
Inhospitalmortality
59(0.3)
122(2.5)
<0.001
8.04.7
<0.001
LengthofhospitalstaySD(d) 2.82.4
aASAAmericanSocietyofAnaesthesiologists,SDStandarddeviation
aDatamissingfrom1974patientsintheLCgroupand509patientsintheOCgroup
bDatamissingfrom43patients
c Datamissingfrom33patients
ThebloodcomponentuseassociatedwithLCandOCisshownin.OftheOCpatients,asmanyas16%ofpatientsreceived
transfusionofanybloodcomponentcomparedto1.6%ofthepatientsintheLCgroup.Similarly,theproportionsofpatientwith
RBC(13%vs.1.3%,p<0.001),PLT(1.2%vs.0.1%,p<0.001),FFP(4.9%vs.0.4%,p<0.001)andOctaplas(0.9%
vs.0.1%,p<0.001)transfusionswererespectivelyhigherinOCgroupcomparedtotheLCgroup.Alsothemeantransfused
doseoftheFFPwassignificantlyhigherintheOCgroupcomparedtotheLCgroups.However,themeantransfuseddoseof
theotherbloodcomponentsandthemeancostofthetransfusedbloodcomponentsdidnotdiffersignificantlybetweenthe
groups().
Table2.Theuseofbloodcomponentsinopencholecystectomies(OC)andlaparoscopiccholecystectomies(LC)in20022007
LCn=17175(%) OCn=4942(%) p
ProportionofpatientswithRBCtransfusion
216(1.3)
641(13)
<0.001
MeantransfusedRBCdose(range)(unit)
3.4(118)
3.6(146)
ns
ProportionofpatientswithPTLtransfusion
15(0.1)
59(1.2)
<0.001
MeantransfusedPTLdose(range)(unit)
16(448)
21(3104)
ns
ProportionofpatientswithFFPtransfusion
74(0.4)
241(4.9)
<0.001
MeantransfusedFFPdose(range)(unit)
3.2(110)
4.3(142)
0.008
ProportionofpatientswithOctaplastransfusion
14(0.1)
43(0.9)
<0.001
MeantransfusedOctaplasdose(range)(unit)
3.2(112)
4.2(115)
ns
Proportionofpatientswithbloodcomponenttransfusion 276(1.6)
774(16)
<0.001
Meancostoftransfusedbloodcomponents(range)()
394(5110607) ns
284(511310)
RBCRedbloodcell,PTLPlatelet,FFPFreshfrozenplasma,nsnotsignificant
Table2.Theuseofbloodcomponentsinopencholecystectomies(OC)andlaparoscopiccholecystectomies(LC)in20022007
LCn=17175(%) OCn=4942(%) p
ProportionofpatientswithRBCtransfusion
216(1.3)
641(13)
<0.001
MeantransfusedRBCdose(range)(unit)
3.4(118)
3.6(146)
ns
ProportionofpatientswithPTLtransfusion
15(0.1)
59(1.2)
<0.001
MeantransfusedPTLdose(range)(unit)
16(448)
21(3104)
ns
ProportionofpatientswithFFPtransfusion
74(0.4)
241(4.9)
<0.001
MeantransfusedFFPdose(range)(unit)
3.2(110)
4.3(142)
0.008
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ProportionofpatientswithOctaplastransfusion
14(0.1)
43(0.9)
<0.001
MeantransfusedOctaplasdose(range)(unit)
3.2(112)
4.2(115)
ns
Proportionofpatientswithbloodcomponenttransfusion 276(1.6)
774(16)
<0.001
Meancostoftransfusedbloodcomponents(range)()
394(5110607) ns
284(511310)
RBCRedbloodcell,PTLPlatelet,FFPFreshfrozenplasma,nsnotsignificant
Massivetransfusionreferstotheadministrationoftenormoreredbloodcellunits.Inthiscohort,48patients(0.002%)
receivedmassivetransfusion.Demographicandoperativedataofthesepatientsispresentedin.Themeanageofthemassive
transfusionpatientswere48yearsand33(69%)ofthemwerefemale.Mostofthecases(81%)wererelatedtoOCand72%
ofthecasestoemergentoperations.InadditiontoRBCs,78%ofthepatientsreceivedfreshfrozenplasmaproducts(FFPor
Octoplas)and46%PLTs.Themassivetransfusionswereassociatedwithmarkedinhospitalmortality(15%).
Table3.Demographicandoperativedata,andtheuseofotherbloodcomponentproductsinpatientswhowereadministered
massiveRBCtransfusion(10units)
PatientswithmassiveRBCtransfusionn=48(%)
Males/females
33/15(69/31)
MeanageSD(range)
4816(3490)
ASAaI
2(4.2)
II
7(15)
III
13(27)
IV
14(29)
7(15)
OC/LC
39/9(81/19)
Elective/emergencyb
13/34(28/72)
MeanoperativetimeSD(min)
12274
Intraoperativecholangiography
8(17)
Commonbileductexploration
6(13)
ProportionofpatientswithPTLtransfusion
22(46)
ProportionofpatientswithFFPtransfusion
30(63)
ProportionofpatientswithOctaplastransfusion 7(15)
Inhospitalmortality
7(15)
LengthofhospitalstaySD(d)
2314
ASAAmericanSocietyofAnaesthesiologists,SDStandarddeviation,RBCRedbloodcell,PTLPlatelet,FFPFreshfrozen
plasma
aDataregardingASAclassmissingfromfivepatients
bDatamissingfromonepatient
Discussion
Accordingtothepresentstudy,OCisassociatedwithhighertransfusionrateofbloodcomponentsthanLC.Inthecurrent
data,13%oftheOCpatientsand1.3%ofLCpatientsreceivedRBCtransfusion.Also,fortheotherbloodcomponent
products(PLTs,FFPandOctaplas),thetransfusionratesweresignificantlyhigherintheOCgroup.Inadditiontomore
invasivenatureofOC,thismaybepartlyduetothefactthattheOCpatientswereolderandthusmorelikelytoreceive
anticoagulanttherapy.TheOCpatientsalsounderwentemergentoperationmoreoftenthanLCpatients.
ThelackofsystemicclassificationofbleedingcomplicationsinLCmakesthecomparisonoftheresultsofthecurrentstudyto
theexistingbodyofliteraturechallenging.Someauthorshaveassessedandreportedonlymajorvascularinjuries(usually
includinginjuriestotheaortaanditsmainbranches,venacavaandtheportalvein),whilelifethreateningbleedingmayalso
occurfromtheliverbed. [14]Vascularinjuriesmayalsohavebeenreportedastrocarinjuries.Otherauthorshavedocumented
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occurfromtheliverbed. [14]Vascularinjuriesmayalsohavebeenreportedastrocarinjuries.Otherauthorshavedocumented
bleedingrequiringeithertransfusionorreoperationorlessseriousintraoperativeandpostoperativebleeding.Intraoperativeand
postoperativebleedingmayhavebeenfurtherdividedintointernal(peritonealcavityofretroperitonealspace)andexternal
(abdominalwall)bleedingbasedonthelocalization.
Theincidenceofpostoperativeintraabdominalbleedinghasbeenreportedtobe0.691.05%inLCpatients. [9,16]Inthe
analysisof10174LCsbyZ'graggenandcoworkers, [9]bleedingwasalsothemostfrequentintraoperativecomplication
occurringin1,97%ofthecases.InaFinnishseriesof1581LCs,incidenceofallbleedingcomplicationswas1.1% [22]and
bleedingcomplicationsrequiringreoperationoccurredin0.5%ofthecases. [23]Roslynandcoworkers [4]reportedtheoverall
incidenceofbleedingcomplicationsof0.4%intheanalysisof42474OCs.Intheirseries,intraoperativebleedingwasalso
associatedwithasignificantriskofdeath.Inthecurrentstudy,thedataonmassivetransfusionsindicates,thatmajorbleeding
remainsararebutseriouscomplicationofcholecystectomywithsignificantassociatedmortality.Newadvantagesof
technology,suchasultrasonicdissectionandanticoagulantpadsmaydecreasethebleedingcomplicationsinfutureregister
studies.
PreviousstudieshavehardlyreportedtheneedofbloodtransfusionrelatedtoLCsandOCs.However,fewpublications
reportingtransfusionratesforgenerallaparoscopicoperationsexist.Intheiranalysisof14243generallaparoscopicoperations
(ofwhich59.4%wereLCs),Schferandcoworkers [14]reported33patientswithintraoperativeand63patientswith
postoperativebleedingcomplicationsrequiringbloodtransfusion.Theoverallrateofbleedingcomplicationsrequiringtransfusion
was0.7%intheirseries,theoverallrateofbleedingcomplications(includingminorbleedingsuchaslacerationofminor
vessels)being4.1%.Opitzandcoworkers [15]reportedanoverallbleedingrateof3.3%inanLCdominant(52%)sampleof
43028ofgenerallaparoscopicoperations.Intheirstudy,thehighertransfusionrate(24%)wasobservedinpatientswith
postoperativebleedingcomparedtopatientswithintraoperativebleeding(7%,p<0.0001).
TransfusionratesforLCinthisstudy,1.3%RBCsand1.6%forallbloodcomponentproducts,arehigherthanreportedfor
abovementionedLCdominantgenerallaparoscopysamples. [14,15]About30%ofpatientsinthesetwolaparoscopysamples
underwentherniotomyorappendectomy,bothproceduresthatdonotinvolvethedissectionoftheliverbed,apotentsourceof
bleeding.Thismayexplaininpartthehigherobservedtransfusionrateinthisstudy.Inaddition,apreviousreportshowsthat
therateofRBCusageinFinlandhasbeenratherhighcomparedtothatinotherEuropeancountriespartly,becausethe
sufficientbloodsupplyhasnotlimitedtheavailabilityofbloodcomponentproductsandbecauseofthelowriskfortransfusion
transmittedviralinfectionsinFinland. [19]
Bleedingdataofourtransfusionregisterandparticularplatelettransfusionsinthepatientsundergoinggeneralsurgeryhasbeen
publishedearlier. [20]Onefourth(27.1%)ofthesurgeryrelatedplatelettransfusionswenttopatientswhohadalimentarytract
operations,11%inorthopedicsurgery,butmainlytopatientsundergoingcardiacoperations.Surgeryrelatedbleeding
complicationsandplatelettransfusionsoccurredmostfrequentlybetweentheagegroups50and79years,andmoreoftenin
malesthanfemales. [20]Inobstetricprocedures,plateletswereusedin267/17916(1.5%)operations.
Thereareseverallimitationsinthisstudy.Oneistheregisterbasednatureofthisstudy.First,thecurrentdatacoversonlythe
transfusionsassociatedwiththehospitalstayduringwhichthecholecystectomytookplace,andthuscasesofdelayed
postoperativebleedingrequiringtransfusionmayhavebeenmissed.Second,reoperationsarenotreported.Majorbleedingis
oftendefinedasableedingcomplicationrequiringtransfusionorareoperation.However,therewasasubstantialnumberof
missingdiagnosiscodesfor60dayreoperationsinthedata.Combinedwiththelackofuniformpracticefordiagnosisand
procedurecodeentries,whenacomplicationoccurs,itwouldhavebeenhighlybiasedtoreporttherateofreoperations,
especiallythoseperformedbecauseofbleeding.Third,conversionscouldnotbeidentifiedfromthedataduetothelackofa
separateprocedurecodeforconversioninNCSP.Consequently,casesofLCconvertedintoOCareincludedintheOCgroupin
thisstudy.Sincebleedingisafrequentreasonforconversion, [9,10,16,17]conversionswouldhavebeendeservedtobeanalyzed
asagroupofitsown.
Inaddition,becauseoftheregisterbasednatureofthisstudy,patientspecificpredisposingfactorsforbleedingcomplications,
suchasanticoagulantorantiplatelettherapyorlivercirrhosis,couldnotbeidentifiedfromtheavailabledata.Ahighincidence
ofpostoperativebleedinghasbeenreportedinpatientsonlongtermanticoagulanttherapyundergoingLC,evenwhenthe
anticoagulanttherapywasdiscontinuedlongenoughfortheinternationalnormalizedratiotobenormalized. [24]Additionally,ina
Swedishregisterstudy,systemicthromboprophylaxisincreasedtheriskofbleedingcomplicationsinLC,buttheincidenceof
thromboemboliccomplicationwasnotsignificantlyreduced. [25]Ontheotherhand,theassociationbetweenantiplatelet
therapyandbleedingcomplicationsiscontroversial,especiallyinthecaseofemergencysurgery.Inarecentretrospective
casecontrolstudy,longtermaspirinantiplatelettherapywasnotassociatedwithincreasedriskofbleedingcomplicationsin
emergentLCforacutecholecystitis. [26]Basedontheresults,theauthorsconcludedthatlongtermaspirinuseshouldnotbe
usedasanindependentfactortodelayanemergentLC.TheimpactofthenewnonvitaminKantagonistoralanticoagulantson
theincidenceofbleedingcomplicationsassociatedwithLCremainsaninterestingtopicforfutureresearch.
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Conclusions
Thepresentstudyshowsthat,inadditionstoothervirtues,LCisassociatedwithlowertransfusionratesofRBCs,PLTsand
FFPproductscomparedtoOC.ThemeantransfuseddoseforRBCs,PLTsorOctaplasandthemeancostoftransfused
bloodcomponentproductspertransfusedpatientdidnotdiffersignificantlybetweenLCsandOCsindicatingtheseverityof
bleedingcomplicationmaynotvarysubstantiallybetweenOCandLC.Nevertheless,theobservedhighertransfusionrateinOC
increasestheaveragecostsofOCcomparedtoLC.
References
1. BarkunJS,BarkunAN,MeakinsJL.Laparoscopicversusopencholecystectomy:TheCanadianexperience.TheMcGill
GallstoneTreatmentGroup.AmJSurg.1993165:4558.
2. DolanJP,DiggsBS,SheppardBC,HunterJG.Thenationalmortalityburdenandsignificantfactorsassociatedwith
openandlaparoscopiccholecystectomy:19972006.JGastrointestSurg.200913:2292301.
3. KeusF,deJongJAF,GooszenHG,vanLaarhovenCJHM.Laparoscopicversusopencholecystectomyforpatientswith
symptomaticcholecystolithiasis.CochraneDatabaseSystRev.20064(4):CD006231.
4. RoslynJJ,BinnsGS,HughesEF,SaundersKirkwoodK,ZinnerMJ,CatesJA.Opencholecystectomy.Acontemporary
analysisof42,474patients.AnnSurg.1993218:12937.
5. NuzzoG,GiulianteF,GiovanniniI,ArditoF,D'AcapitoF,VelloneM,etal.Bileductinjuryduringlaparoscopic
cholecystectomy:resultsofanItaliannationalsurveyon56591cholecystectomies.ArchSurg.2005140:98692.
6. FletcherDR,HobbsMS,TanP,ValinskyLJ,HockeyRL,PikoraTJ,etal.Complicationsofcholecystectomy:risksof
thelaparoscopicapproachandprotectiveeffectsofoperativecholangiography:apopulationbasedstudy.AnnSurg.
1999229:44957.
7. SaiaM,MantoanD,BujaA,BertoncelloC,BaldovinT,CallegaroG,etal.Timetrendandvariabilityofopenversus
laparoscopiccholecystectomyinpatientswithsymptomaticgallstonedisease.SurgEndosc.201327:325461.
8. RosenmllerM,HaapamkiMM,NordinP,StenlundH,NilssonE.CholecystectomyinSweden20002003:a
nationwidestudyonprocedures,patientcharacteristics,andmortality.BMCGastroenterol.20077:35.
9. Z'graggenK,WehrliH,MetzgerA,BuehlerM,FreiE,KlaiberC.Complicationsoflaparoscopiccholecystectomyin
Switzerland.Aprospective3yearstudyof10,174patients.SwissAssociationofLaparoscopicandThoracoscopic
Surgery.SurgEndosc.199812:130310.
10. BingenerCaseyJ,RichardsML,StrodelWE,SchwesingerWH,SirinekKR.Reasonsforconversionfromlaparoscopic
toopencholecystectomy:a10yearreview.JGastrointestSurg.20026:8005.
11. BallalM,DavidG,WillmottS,CorlessDJ,DeakinM,SlavinJP.Conversionafterlaparoscopiccholecystectomyin
England.SurgEndosc.200923:233844.
12. HarboeKM,BardramL.ThequalityofcholecystectomyinDenmark:outcomeandriskfactorsfor20,307patientsfrom
thenationaldatabase.SurgEndosc.201125:163041.
13. HuangX,FengY,HuangZ.ComplicationsoflaparoscopiccholecystectomyinChina:ananalysisof39,238cases.Chin
MedJ(Engl).1997110:7046.
14. SchferM,LauperM,KrhenbhlL.ANation'sexperienceofbleedingcomplicationsduringlaparoscopy.AmJSurg.
2000180:737.
15. OpitzI,GantertW,GigerU,KocherT,KrhenbhlL.Bleedingremainsamajorcomplicationduringlaparoscopic
surgery:analysisoftheSALTSdatabase.LangenbecksArchSurg.2005390:12833.
16. SheaJa,HealeyMJ,BerlinJa,ClarkeJR,MaletPF,StaroscikRN,etal.Mortalityandcomplicationsassociatedwith
laparoscopiccholecystectomy.AnnSurg.1996224:60920.
17. LengyelBI,AzaguryD,VarbanO,PanizalesMT,SteinbergJ,BrooksDC,etal.Laparoscopiccholecystectomyaftera
quartercentury:whydowestillconvert?SurgEndosc.201226:50813.
http://www.medscape.com/viewarticle/852679_print
8/9
1/20/2016
www.medscape.com/viewarticle/852679_print
18. PaloR,AliMelkkilT,HanhelaR,JnttiV,KrusiusT,LeppnenE,etal.Developmentofpermanentnationalregisterof
bloodcomponentuseutilizingelectronichospitalinformationsystems.VoxSang.200691:1407.
19. CapraroL,NuutinenL,MyllylaG.TransfusionthresholdsincommonelectivesurgicalproceduresinFinland.VoxSang.
200078:96100.
20. PaloR,CapraroL,HanhelaR,KoivurantaM,NikkinenL,SalmenperM,etal.Platelettransfusionsinadultpatients
withparticularreferencetopatientsundergoingsurgery.TransfusMed.201020:307.
21. PaloR,CapraroL,HovilehtoS,KoivurantaM,KrusiusT,LoponenE,etal.Populationbasedauditoffreshfrozen
plasmatransfusionpractices.Transfusion.200646:19215.
22. SuuronenS,NiskanenL,PaajanenP,PaajanenH.Decliningcholecystectomyrateduringtheeraofstatinusein
Finland:apopulationbasedcohortstudybetween1995and2009.ScandJSurg.2013102:15863.
23. SuuronenS,KoskiA,NordstromP,MiettinenP,PaajanenH.Laparoscopicandopencholecystectomyinsurgical
training.DigSurg.201027:38490.
24. ErcanM,BostanciEB,OzerI,UlasM,OzogulYB,TekeZ,etal.Postoperativehemorrhagiccomplicationsafterelective
laparoscopiccholecystectomyinpatientsreceivinglongtermanticoagulanttherapy.LangenbecksArchSurg.
2010395:24753.
25. PerssonG,StrmbergJ,SvennbladB,SandblomG.Riskofbleedingassociatedwithuseofsystemicthromboembolic
prophylaxisduringlaparoscopiccholecystectomy.BrJSurg.201299:97986.
26. JosephB,RawashdehB,AzizH,KulvatunyouN,PanditV,JehangirQ,etal.Anacutecaresurgerydilemma:emergent
laparoscopiccholecystectomyinpatientsonaspirintherapy.AmJSurg.2015209:68994.
Acknowledgements
WeacknowledgeMrs.LisaKivelaforrevisingEnglish.Noexternalfundingwasreceivedforthismanuscript.
BMCSurg.201515(97)2015BioMedCentral,Ltd.
19992006BioMedCentralLtd
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