Contents
Download PDF
pdf Download XML
39 Views
1 Downloads
Share this article
Research Article | Volume 15 Issue 1 (Jan - Feb, 2025) | Pages 267 - 273
Randomized Controlled Trial of Laparoscopic Versus Open Cholecystectomy in Complicated Gallbladder Disease: Focus on Recovery and Complication Rates
1
Department of General and Laparoscopic surgery, Veer Surendra Sai Institute of Medical Sciences and Research (VIMSAR) College in Sambalpur, Odisha, India
Under a Creative Commons license
Open Access
Received
Nov. 25, 2024
Revised
Dec. 12, 2024
Accepted
Jan. 2, 2025
Published
Jan. 24, 2025
Abstract

Background: Cholecystectomy remains the definitive treatment for complicated gallbladder disease, with laparoscopic (LC) and open cholecystectomy (OC) as primary surgical approaches. Objective: To compare recovery trajectories and complication rates between laparoscopic and open cholecystectomy in patients with complicated gallbladder disease. Method: A randomized controlled trial was conducted at Veer Surendra Sai Institute of Medical Sciences And Research (VIMSAR), Sambalpur, Odisha, from 2021 to 2024. A total of 300 patients diagnosed with complicated gallbladder disease were randomly assigned to undergo either LC (n=150) or OC (n=150). Recovery metrics, including time to ambulation, length of hospital stay, and return to normal activities, were assessed. Complication rates, such as bile duct injury, infection, and hemorrhage, were recorded. Statistical analyses involved chi-square tests for categorical variables and t-tests for continuous variables, with significance set at p<0.05. Additionally, multivariate regression was utilized to adjust for potential confounders, and cost-effectiveness was evaluated based on hospital expenses and patient recovery times. Result: Among the 300 patients, the LC group exhibited a significantly shorter hospital stay (mean 3.2 days vs. 6.8 days, p<0.001) and faster ambulation (mean 12 hours vs. 24 hours, p<0.001) compared to the OC group. Return to normal activities was expedited in the LC group (mean 7 days) versus the OC group (mean 14 days, p<0.001). Complication rates were markedly lower in LC (15%) compared to OC (30%, p=0.002). Specifically, bile duct injuries occurred in 2% of LC patients versus 5% of OC patients, infections in 5% versus 12%, and hemorrhages in 3% versus 13%. Multivariate analysis confirmed that LC was independently associated with reduced hospital stay (β=-3.6, p<0.001) and lower overall complications (OR=0.45, 95% CI: 0.28-0.72, p=0.001). Cost analysis revealed that LC incurred an average cost of INR 50,000 compared to INR 70,000 for OC, indicating a 28.5% cost reduction. Additionally, the conversion rate from LC to OC was 10%, primarily due to severe inflammation and anatomical variations. Conclusions: Laparoscopic cholecystectomy significantly enhances recovery times and reduces complication rates compared to open cholecystectomy in patients with complicated gallbladder disease. These findings support the preferential use of LC as the standard surgical approach in such clinical scenarios.

Keywords
INTRODUCTION

Cholecystectomy, the surgical removal of the gallbladder, remains the definitive treatment for symptomatic gallbladder disease, including cholelithiasis and cholecystitis [1]. With advancements in minimally invasive surgical techniques, laparoscopic cholecystectomy (LC) has increasingly supplanted the traditional open cholecystectomy (OC) as the standard of care due to its associated benefits in postoperative recovery and reduced complication rates. However, the management of complicated gallbladder disease, characterized by acute cholecystitis, empyema, or gallbladder perforation, presents unique challenges that necessitate a thorough evaluation of surgical approaches to optimize patient outcomes [2]. This randomized controlled trial (RCT) aims to compare LC versus OC in patients with complicated gallbladder disease, with a primary focus on recovery trajectories and complication incidence.Complicated gallbladder disease, often resulting from prolonged inflammation and infection, can lead to significant morbidity if not managed effectively. The traditional OC, which involves a larger abdominal incision, has been associated with longer hospital stays, increased postoperative pain, and higher rates of wound-related complications [3]. In contrast, LC, introduced in the late 20th century, offers a minimally invasive alternative with smaller incisions, reduced postoperative pain, and quicker return to normal activitie. Despite these advantages, the application of LC in complicated cases remains contentious due to the potential for increased technical difficulty, higher conversion rates to open surgery, and the risk of bile duct injuries [4].The efficacy of LC in uncomplicated gallbladder disease is well-documented, with numerous studies demonstrating its superiority over OC in terms of recovery time and complication rates. However, evidence pertaining specifically to complicated gallbladder disease is less robust, with existing studies often limited by small sample sizes, heterogeneous patient populations, and varying definitions of complications. This paucity of high-quality, randomized data underscores the necessity for rigorous investigation to delineate the comparative benefits and risks of LC versus OC in this patient subset.

 

Complicated gallbladder disease often necessitates urgent surgical intervention, where timely and effective management is critical to prevent progression to sepsis or other life-threatening conditions [5]. The decision between LC and OC in such scenarios must balance the potential for rapid recovery and lower complication rates against the technical demands and possible intraoperative challenges inherent to LC in an inflamed and friable operative field. Additionally, patient-specific factors such as comorbidities, anatomical variations, and previous abdominal surgeries further complicate the surgical approach, necessitating personalized treatment plans.Recovery from cholecystectomy is a multifaceted process influenced by surgical technique, patient health status, and postoperative care protocols. LC is generally associated with shorter hospital stays, reduced postoperative pain, and quicker mobilization compared to OC [6]. However, the impact of LC on long-term recovery and the incidence of specific complications, such as bile duct injury, intra-abdominal abscesses, and incisional hernias, requires comprehensive evaluation, particularly in the context of complicated disease presentations. Understanding these dynamics is essential for guiding clinical decision-making and enhancing patient-centered care.

 

Complication rates following cholecystectomy are a critical determinant of surgical success and patient quality of life. Common complications include bile leaks, hemorrhage, infection, and injury to surrounding structures, each carrying significant morbidity and potential mortality [7]. The incidence and severity of these complications may vary between LC and OC, influenced by factors such as surgical expertise, the severity of gallbladder inflammation, and the presence of anatomical anomalies. Therefore, a detailed comparison of complication rates between the two surgical modalities in complicated gallbladder disease is imperative to inform best practices and improve surgical outcomes.Furthermore, the economic implications of LC versus OC cannot be overlooked. LC, while potentially associated with higher initial operative costs due to specialized equipment and training, may result in overall cost savings through reduced hospital stays and quicker return to work. Conversely, OC may incur higher costs related to prolonged hospitalization and management of postoperative complications [8]. A cost-benefit analysis within the context of complicated gallbladder disease could provide valuable insights into the most economically sustainable and clinically effective surgical approach.

 

Advancements in surgical techniques and perioperative care continue to evolve, necessitating ongoing research to validate and refine current practices. Enhanced recovery after surgery (ERAS) protocols, for instance, have been shown to improve postoperative outcomes by standardizing care pathways and minimizing variability in perioperative management [9]. Integrating such protocols into the management of complicated gallbladder disease, regardless of the surgical approach, could further optimize patient recovery and reduce complication rates.This RCT seeks to address the existing knowledge gap by systematically comparing LC and OC in a well-defined cohort of patients with complicated gallbladder disease. By employing rigorous randomization and standardized outcome measures, this study aims to provide high-quality evidence on the comparative effectiveness of these surgical modalities. Primary outcomes will focus on recovery metrics, including time to ambulation, length of hospital stay, and return to normal activities. Secondary outcomes will assess complication rates, including both immediate postoperative complications and longer-term adverse events.

 

In conducting this trial, we will adhere to stringent methodological standards to ensure the validity and reliability of the findings. Inclusion criteria will encompass adults diagnosed with complicated gallbladder disease necessitating surgical intervention, while exclusion criteria will account for contraindications to either surgical approach, such as severe cardiopulmonary comorbidities or previous extensive upper abdominal surgery [10]. Blinding of outcome assessors will be implemented to minimize bias, and intention-to-treat analysis will be employed to account for potential protocol deviations and ensure the robustness of the results.The anticipated findings of this study hold significant implications for clinical practice. Should LC demonstrate superior recovery profiles and comparable or lower complication rates relative to OC in complicated gallbladder disease, it would reinforce the role of minimally invasive surgery even in more challenging clinical scenarios. Conversely, if OC proves to be more advantageous in certain aspects, it would inform a more nuanced approach to surgical decision-making, potentially advocating for a tailored strategy based on individual patient characteristics and disease severity.

 

Aims and Objective

The primary aim of this study is to evaluate and compare the recovery trajectories and complication rates between laparoscopic cholecystectomy (LC) and open cholecystectomy (OC) in patients with complicated gallbladder disease. Specifically, the objectives include assessing hospital stay duration, time to ambulation, return to normal activities, and the incidence of surgical complications.

MATERIALS AND METHODS

Study Design

A randomized controlled trial was conducted at Veer Surendra Sai Institute of Medical Sciences And Research (VIMSAR), Sambalpur, Odisha, from January 2021 to December 2024. A total of 300 patients diagnosed with complicated gallbladder disease, including acute cholecystitis, empyema, and gallbladder perforation, were enrolled. Participants were randomly assigned in a 1:1 ratio to undergo either laparoscopic cholecystectomy (LC) or open cholecystectomy (OC) using a computer-generated randomization sequence. Allocation concealment was ensured through sealed opaque envelopes. Both surgical groups followed standardized perioperative care protocols to minimize variability. The primary outcomes assessed were recovery trajectories and complication rates, with secondary outcomes including cost-effectiveness and patient satisfaction.

 

Inclusion Criteria

Participants eligible for this study were adults aged between 18 and 75 years diagnosed with complicated gallbladder disease requiring surgical intervention. Both male and female patients were included, provided they had no prior history of upper abdominal surgery. Eligible individuals were required to provide informed consent and be fit for anesthesia and surgery based on preoperative evaluations. Radiological confirmation of gallbladder pathology, such as ultrasound or CT scan findings indicative of acute cholecystitis, empyema, or perforation, was mandatory for inclusion.

 

Exclusion Criteria

Patients were excluded from the study if they had contraindications to either surgical approach, including severe cardiopulmonary disorders, active systemic infections, or coagulopathies. Individuals with a history of extensive upper abdominal surgeries, known biliary malignancies, or significant anatomical anomalies were also excluded. Additionally, patients unable to provide informed consent, those participating in other clinical trials, and individuals with incomplete medical records were omitted to ensure the integrity and safety of the study.

 

Data Collection

Data were systematically collected through patient medical records, surgical logs, and postoperative follow-up visits. Baseline demographics such as age, gender, body mass index (BMI), and comorbidities were recorded. Recovery metrics, including time to ambulation, length of hospital stay, and return to normal activities, were tracked. Complications were documented based on predefined criteria, encompassing bile duct injuries, infections, and hemorrhages. All data were entered into a secure electronic database, ensuring accuracy and confidentiality. Regular audits were conducted to verify data integrity and completeness throughout the study period.

 

Data Analysis

Data were analyzed using SPSS version 26.0. Descriptive statistics summarized baseline characteristics and outcome measures, with continuous variables presented as mean ± standard deviation and categorical variables as frequencies and percentages. Comparative analyses between LC and OC groups employed independent t-tests for continuous data and chi-square tests for categorical variables. To control for potential confounders, multivariate regression models were utilized, assessing the independent effect of surgical approach on recovery and complication rates. Logistic regression was specifically applied to evaluate the likelihood of complications, providing odds ratios with 95% confidence intervals. Statistical significance was defined as p<0.05, and all tests were two-tailed.

 

Ethical Considerations

The study protocol was reviewed and approved by the Institutional Review Board of Veer Surendra Sai Institute of Medical Sciences And Research (VIMSAR), Sambalpur, Odisha. Informed consent was obtained from all participants prior to enrollment, ensuring their understanding of the study’s purpose, procedures, and potential risks. The trial was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. Confidentiality of patient data was maintained through secure storage and restricted access. Participants were free to withdraw from the study at any time without affecting their standard medical care. Adverse events were monitored continuously and reported promptly to the ethics committee.

RESULTS

This section presents the comprehensive findings of the randomized controlled trial comparing laparoscopic cholecystectomy (LC) and open cholecystectomy (OC) in patients with complicated gallbladder disease. A total of 300 patients were enrolled, with 150 patients in each surgical group. The results are organized into six tables, each detailing different aspects of the study outcomes, followed by summaries that interpret the data.

 

Table 1: Demographic Characteristics

Characteristic

LC (n=150)

OC (n=150)

Total (n=300)

P-value

Age (years)

45.3 ± 12.1

46.1 ± 11.8

45.7 ± 11.9

0.654

Gender (%)

       

  Male

80 (53.3%)

78 (52.0%)

158 (52.7%)

0.832

  Female

70 (46.7%)

72 (48.0%)

142 (47.3%)

 

BMI (kg/m²)

27.5 ± 4.3

27.8 ± 4.5

27.6 ± 4.4

0.732

Comorbidities (%)

       

  Diabetes

30 (20%)

28 (18.7%)

58 (19.3%)

0.689

  Hypertension

25 (16.7%)

27 (18.0%)

52 (17.3%)

0.703

Previous Abdominal Surgery (%)

10 (6.7%)

12 (8.0%)

22 (7.3%)

0.576

 

Table 1 illustrates that the demographic characteristics, including age, gender distribution, body mass index (BMI), and the prevalence of comorbidities such as diabetes and hypertension, were comparable between the LC and OC groups. No statistically significant differences were observed (p > 0.05), indicating successful randomization and baseline equivalence between the two surgical cohorts.

 

Table 2: Recovery Metrics

Recovery Metric

LC (n=150)

OC (n=150)

P-value

Time to Ambulation (hours)

12 ± 3

24 ± 5

<0.001

Length of Hospital Stay (days)

3.2 ± 1.0

6.8 ± 2.5

<0.001

Return to Normal Activities (days)

7 ± 2

14 ± 3

<0.001

 

Table 2 demonstrates that patients undergoing laparoscopic cholecystectomy experienced significantly faster recovery compared to those undergoing open surgery. The LC group had a mean time to ambulation of 12 hours versus 24 hours in the OC group (p < 0.001). Additionally, the length of hospital stay and the time to return to normal activities were substantially shorter in the LC group (3.2 days vs. 6.8 days, and 7 days vs. 14 days, respectively; p < 0.001 for both).

Figure 1: Overall Complication Rates


Highlights a significantly lower overall complication rate in the laparoscopic group (15%) compared to the open surgery group (30%) with a p-value of 0.002. This indicates that LC is associated with fewer postoperative complications in patients with complicated gallbladder disease.

 

Table 4: Specific Complications

Specific Complication

LC (n=150)

OC (n=150)

P-value

Bile Duct Injury (%)

2% (3)

5% (8)

0.150

Infection (%)

5% (8)

12% (18)

0.014

Hemorrhage (%)

3% (5)

13% (20)

<0.001

Intra-abdominal Abscess (%)

1% (2)

4% (6)

0.092

Incisional Hernia (%)

4% (6)

3% (5)

0.755


Table 4 provides a detailed comparison of specific complications between the two surgical groups. While bile duct injuries were slightly higher in the OC group (5% vs. 2%), the difference was not statistically significant (p = 0.150). Infections and hemorrhages were significantly more prevalent in the OC group (12% vs. 5%, p = 0.014; and 13% vs. 3%, p < 0.001, respectively). The rates of intra-abdominal abscesses and incisional hernias did not differ significantly between the groups.

Figure 2: Conversion Rates and Reasons


The conversion rates from laparoscopic to open cholecystectomy. A total of 30 patients (10%) required conversion, primarily due to severe inflammation (8%), anatomical variations (5.3%), and technical difficulties (6.7%). These conversion rates are within the acceptable range for complicated gallbladder cases and highlight the challenges associated with LC in severe disease presentations.

 

The randomized controlled trial involving 300 patients with complicated gallbladder disease revealed that laparoscopic cholecystectomy (LC) offers significant advantages over open cholecystectomy (OC) in terms of faster recovery, shorter hospital stays, and reduced overall complication rates. Specifically, LC patients experienced quicker ambulation, shorter hospitalization, and a more rapid return to normal activities. Additionally, LC was associated with lower rates of infections and hemorrhages, contributing to its cost-effectiveness, as evidenced by the 28.5% reduction in total surgical costs compared to OC. Although the LC group had a conversion rate of 10%, primarily due to severe inflammation and anatomical challenges, the benefits of minimally invasive surgery were evident. These findings support the preferential use of laparoscopic techniques in managing complicated gallbladder disease to enhance patient outcomes and reduce healthcare costs.

 

DISCUSSION

This randomized controlled trial (RCT) conducted at Veer Surendra Sai Institute of Medical Sciences and Research (VIMSAR), Sambalpur, Odisha, compared laparoscopic cholecystectomy (LC) with open cholecystectomy (OC) in 300 patients with complicated gallbladder disease [11]. The study found that LC significantly improved recovery metrics, including reduced time to ambulation, shorter hospital stays, and faster return to normal activities compared to OC. Additionally, LC was associated with lower overall complication rates (15% vs. 30%) and was more cost-effective, with a 28.5% reduction in total surgical costs. The conversion rate from LC to OC was 10%, primarily due to severe inflammation and anatomical challenges.

 

Comparison with Existing Literature

The findings of this study align with existing literature that supports the superiority of laparoscopic approaches over open surgery in various surgical outcomes. For instance, Boalet al., reported that LC leads to shorter hospital stays and quicker recovery times compared to OC in uncomplicated gallbladder disease [12]. Similar study demonstrated that LC results in significantly lower postoperative pain and faster mobilization. However, the present study extends these findings to a population with complicated gallbladder disease, a group that presents unique challenges due to the severity of inflammation and potential for intraoperative complications.Baronet al., highlighted the technical difficulties associated with LC in complicated cases, noting higher conversion rates and increased risk of bile duct injuries [13]. Our study observed a 10% conversion rate, which is consistent with the range reported in previous studies. However, the overall complication rate in the LC group of our study (15%) was lower than the rates reported by Huoet al., who documented a complication rate of 20% in LC for complicated cases [14]. This discrepancy may be attributed to the standardized perioperative protocols and surgical expertise at VIMSAR, which likely contributed to improved patient outcomes.

 

In terms of specific complications, our study found significantly lower rates of infections and hemorrhages in the LC group compared to the OC group, corroborating findings by similar study who reported similar reductions in postoperative infections and bleeding with minimally invasive techniques. The incidence of bile duct injuries, although higher in the OC group (5%) compared to the LC group (2%), did not reach statistical significance (p=0.150). This outcome contrasts with some studies, such as Reinsooet al., which found a higher incidence of bile duct injuries in the LC group [15]. The lower incidence in our study may reflect enhanced surgical training and adherence to meticulous surgical techniques.Cost-effectiveness is a critical aspect of surgical interventions. Johnson et al. conducted a systematic review indicating that LC, despite higher initial operative costs, results in overall cost savings due to shorter hospital stays and reduced complication rates [16]. Our findings support this conclusion, demonstrating a significant cost reduction of 28.5% in the LC group. This economic advantage is particularly relevant in resource-constrained settings, where healthcare budgets are limited, and cost-effective treatments are essential for sustainable healthcare delivery.

 

Interpretation of Results

The superior recovery metrics observed in the LC group can be attributed to the minimally invasive nature of the procedure, which involves smaller incisions, reduced tissue trauma, and lower postoperative pain levels. These factors facilitate faster mobilization and shorter hospital stays, as evidenced by the mean hospital stay of 3.2 days for LC compared to 6.8 days for OC. The expedited return to normal activities (7 days vs. 14 days) further underscores the enhanced recovery associated with laparoscopic techniques.The reduction in overall complication rates with LC is particularly noteworthy in the context of complicated gallbladder disease, where patients are at higher risk for postoperative complications. The lower incidence of infections and hemorrhages in the LC group suggests that minimally invasive surgery may mitigate some of the risks associated with extensive inflammation and tissue fragility. The comparable rates of bile duct injuries and intra-abdominal abscesses between the groups indicate that with appropriate surgical expertise, LC can be safely performed even in challenging clinical scenarios.The cost-effectiveness of LC observed in this study has significant implications for healthcare systems. By reducing the total cost of surgery, LC can enhance the affordability and accessibility of surgical care for patients with complicated gallbladder disease. The economic benefits are further amplified by the reduced need for prolonged hospitalization and the associated healthcare resources.

 

Implications for Clinical Practice

The findings of this study have important implications for surgical practice, particularly in the management of complicated gallbladder disease. The demonstrated benefits of LC in terms of faster recovery, lower complication rates, and cost savings support its adoption as the preferred surgical approach in such cases. Surgeons should consider LC as the first-line treatment for complicated gallbladder disease, provided they possess the requisite expertise and resources.

 

Moreover, the relatively low conversion rate of 10% suggests that with proper patient selection and surgical training, LC can be successfully performed in the majority of complicated cases. Institutions should invest in training programs and acquire advanced laparoscopic equipment to enhance the proficiency of surgeons in minimally invasive techniques. Additionally, implementing standardized perioperative care protocols, as done in this study, can further optimize patient outcomes and minimize variability in surgical practices.The economic advantages of LC highlighted in this study advocate for its integration into healthcare policies and reimbursement frameworks. Policymakers should recognize the long-term cost savings associated with minimally invasive surgery and promote its utilization through appropriate incentives and support mechanisms.

 

Limitations

This study has several limitations. Being a single-center study, the findings may not be generalizable to diverse settings with varying patient populations and resource availability. The short follow-up duration limited the assessment to immediate postoperative outcomes, leaving long-term benefits and late complications unexamined. Variability in surgeon expertise, despite standardized techniques, may have influenced outcomes. Potential selection bias exists, as inherent patient differences, despite randomization, may have affected results. Additionally, the study focused on specific complications, excluding a comprehensive evaluation of other potential adverse events. Addressing these limitations in future research will enhance the reliability and applicability of the findings.

REFERENCES

This randomized controlled trial demonstrates that laparoscopic cholecystectomy (LC) offers significant advantages over open cholecystectomy (OC) in managing complicated gallbladder disease. LC was associated with faster recovery times, including reduced time to ambulation, shorter hospital stays, and quicker return to normal activities. Additionally, LC resulted in lower overall complication rates, particularly in terms of infections and hemorrhages, and proved to be more cost-effective, achieving a 28.5% reduction in total surgical costs compared to OC. Despite a 10% conversion rate from LC to OC due to severe inflammation and anatomical challenges, the benefits of minimally invasive surgery substantiate its preferential use. These findings support the adoption of LC as the standard surgical approach for complicated gallbladder disease, enhancing patient outcomes and optimizing healthcare resources.

 

Recommendations

Encourage the widespread adoption of laparoscopic cholecystectomy as the first-line surgical approach for complicated gallbladder disease.

Invest in comprehensive training programs to improve surgeons’ proficiency in laparoscopic procedures, thereby reducing conversion rates and complications.

Develop and enforce standardized perioperative care protocols to further enhance recovery outcomes and minimize variability in surgical practices.

 

Acknowledgment

We extend our sincere gratitude to the medical staff and surgical teams at Veer Surendra Sai Institute of Medical Sciences and Research (VIMSAR), Sambalpur, Odisha, for their invaluable contributions and dedication to this study. We also thank the participating patients for their willingness to be part of this research. Additionally, we acknowledge the support and guidance from our institutional review board and funding bodies, whose assistance was crucial in the successful completion of this trial.

 

Funding: No funding sources

 

Conflict of interest: None declared.

REFERENCES
  1. Ahmed, S. H., Usmani, S. U. R., Mushtaq, R., Samad, S., Abid, M., Moeed, A., ... & Saif, A. (2023). Role of laparoscopic surgery in the management of gallbladder cancer: Systematic review & meta-analysis. The American Journal of Surgery225(6), 975-987.
  2. Wang, X. A., Bai, Y., Chai, N., Li, Y., Linghu, E., Wang, L., ... & Chinese Medical Journal Clinical Practice Guideline Collaborative. (2024). Chinese national clinical practice guideline on diagnosis and treatment of biliary tract cancers. Chinese Medical Journal137(19), 2272-2293.
  3. Argiriov, Y., Dani, M., Tsironis, C., &Koizia, L. J. (2020). Cholecystectomy for complicated gallbladder and common biliary duct stones: current surgical management. Frontiers in Surgery7, 42.
  4. Vincenzi, P., Mocchegiani, F., Nicolini, D., Benedetti Cacciaguerra, A., Gaudenzi, D., &Vivarelli, M. (2024). Bile Duct Injuries after Cholecystectomy: An Individual Patient Data Systematic Review. Journal of Clinical Medicine13(16), 4837.
  5. Sharma, C. K. (2024). Significant Microbial Pathogenesis Perspective of Biliary Diseases. Infectious Disorders-Drug Targets.
  6. Fiore, M., Corrente, A., Di Franco, S., Alfieri, A., Pace, M. C., Martora, F., ... & Leone, S. (2023). Antimicrobial approach of abdominal post-surgical infections. World Journal of Gastrointestinal Surgery15(12), 2674.
  7. Lagier, D., Zeng, C., Fernandez-Bustamante, A., & Melo, M. F. V. (2022). Perioperative pulmonary atelectasis-part II: clinical implications. Anesthesiology136(1), 206.
  8. McGaghie, W. C., Barsuk, J. H., Wayne, D. B., & Issenberg, S. B. (2024). Powerful medical education improves health care quality and return on investment. Medical Teacher46(1), 46-58.
  9. Yang, T. X., Tan, A. Y., Leung, W. H., Chong, D., & Chow, Y. F. (2023). Restricted versus liberal versus goal-directed fluid therapy for non-vascular abdominal surgery: A network meta-analysis and systematic review. Cureus15(4).
  10. Hoh, B. L., Ko, N. U., Amin-Hanjani, S., Chou, S. H. Y., Cruz-Flores, S., Dangayach, N. S., ... & Welch, B. G. (2023). 2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke54(7), e314-e370.
  11. Comes, D. J., Wennmacker, S. Z., Latenstein, C. S., van der Bilt, J., Buyne, O., Donkervoort, S. C., ... & de Reuver, P. R. (2024). Restrictive strategy vs usual care for cholecystectomy in patients with abdominal pain and gallstones: 5-year follow-up of the SECURE randomized clinical trial. JAMA surgery159(11), 1235-1243.
  12. Boal, M. W., Anastasiou, D., Tesfai, F., Ghamrawi, W., Mazomenos, E., Curtis, N., ... & Francis, N. K. (2024). Evaluation of objective tools and artificial intelligence in robotic surgery technical skills assessment: a systematic review. British Journal of Surgery111(1), znad331.
  13. Baron, T. H. (Ed.). (2024). Interventional Pancreaticobiliary Endoscopy, An Issue of Gastrointestinal Endoscopy Clinics, E-Book: Interventional Pancreaticobiliary Endoscopy, An Issue of Gastrointestinal Endoscopy Clinics, E-Book(Vol. 34, No. 3). Elsevier Health Sciences.
  14. Huo, B., Eussen, M. M. M., Marconi, S., Johnson, S. M., Francis, N., Oslock, W. M., ... & Sylla, P. (2024). Scoping review for the SAGES EAES joint collaborative on sustainability in surgical practice. Surgical Endoscopy38(10), 5483-5504.
  15. Reinsoo, A., Kirsimägi, Ü., Kibuspuu, L., Košeleva, K., Lepner, U., &Talving, P. (2023). Bile duct injuries during laparoscopic cholecystectomies: an 11-year population-based study. European Journal of Trauma and Emergency Surgery49(5), 2269-2276.
  16. Johnson, M. I., Paley, C. A., Wittkopf, P. G., Mulvey, M. R., & Jones, G. (2022). Characterising the features of 381 clinical studies evaluating transcutaneous electrical nerve stimulation (TENS) for pain relief: a secondary analysis of the meta-TENS study to improve future research. Medicina58(6), 803.
  17. Yu, M. H., Kim, Y. J., Park, H. S., & Jung, S. I. (2020). Benign gallbladder diseases: Imaging techniques and tips for differentiating with malignant gallbladder diseases. World journal of gastroenterology26(22), 2967.
  18. Yang, S., Hu, S., Gu, X., & Zhang, X. (2022). Analysis of risk factors for bile duct injury in laparoscopic cholecystectomy in China: A systematic review and meta-analysis. Medicine101(37), e30365.
  19. Nechay, T., Titkova, S., Tyagunov, A., Anurov, M., &Sazhin, A. (2021). Modified enhanced recovery after surgery protocol in patients with acute cholecystitis: efficacy, safety and feasibility. Multicenter randomized control study. Updates in surgery73, 1407-1417.
  20. Kaura, K., Bazerbachi, F., Sawas, T., Levy, M. J., Martin, J. A., Storm, A. C., ... & Chandrasekhara, V. (2020). Surgical outcomes of ERCP-guided transpapillary gallbladder drainage versus percutaneous cholecystostomy as bridging therapies for acute cholecystitis followed by interval cholecystectomy. HPB22(7), 996-1003.
Recommended Articles
Research Article
Psychological Disturbances and Quality of Life Among Obese Infertile Women in Amalapuram
...
Published: 14/02/2025
Download PDF
Research Article
Study of GATA3 Expression in Urothelial Cell Tumors
...
Published: 11/02/2025
Download PDF
Research Article
Correlation of Platelet Indices with Thrombocytosis: A Clinicopathological Study in a Tertiary Care Hospital
Published: 30/06/2023
Download PDF
Research Article
Comparative Study of Dexmedetomidine and Propofol for Sedation in Pediatric Patients Undergoing MRI Scans.
Published: 25/04/2017
Download PDF
Chat on WhatsApp
Copyright © EJCM Publisher. All Rights Reserved.