Comparison of open and laparoscopic cholecystectomy.
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Cholecystectomy↗
Biomedical subjects
T R Gadacz
Publications and source records attributed to T R Gadacz.
Selective cholangiography. Current role in laparoscopic cholecystectomy.
The initial 22-month experience with laparoscopic cholecystectomy in 400 patients employing an algorithm of selective cholangiographic evaluation is reported. Preoperative or postoperative endoscopic retrograde cholangiography was performed whenever stones were suspected clinically. Preoperative endoscopic retrograde cholangiography was performed in 44 patients (11%), in whom 14 (3.5%) had an endoscopic sphincterotomy with extraction of common bile duct stones. Intraoperative cholangiography was performed in only eight patients (2%) almost exclusively to acquire experience with the technique, and all cholangiograms were normal. Laparoscopic cholecystectomy was successfully completed in 96% of the patients. There were no deaths in this series, and major complications occurred in only 5% of patients. Two patients (0.5%) had a significant common bile duct injury that was recognized and successfully repaired at the initial operation. No late common bile duct strictures have been recognized. Six patients (1.5%) underwent postoperative endoscopic retrograde cholangiography for suspected common bile duct stones, with three patients requiring endoscopic sphincterotomy and stone extraction. This experience suggests that the use of preoperative and postoperative endoscopic retrograde cholangiography can be based on clinical presentation and laboratory evaluation and does not need to be performed routinely. Routine intraoperative cholangiography is not necessary in most patients undergoing laparoscopic cholecystectomy. The authors conclude that laparoscopic cholecystectomy can be performed safely with the selective use of cholangiography.
Adolescent↗
Laparoscopic approach to cholecystectomy.
Laparoscopic cholecystectomy is a combined endoscopic-operative technique for removal of the gallbladder. Patients with symptomatic gallstones are candidates for this procedure. Current absolute contraindications include pregnancy, acute cholangitis, peritonitis or abdominal sepsis, and a major bleeding disorder. Safe use of the procedure requires specific training and subsequent animal and proctored clinical experience. The technique is guided by video-endoscopy, and is performed through four cannulas/ports. Potential complications include bleeding, injury to the common bile duct, trocar injury to the bowel, and spillage of bile and/or stones. The length of hospital stay and postoperative recovery are significantly shortened compared to standard cholecystectomy. Patients appear to prefer this procedure over lithotripsy or dissolution because the gallbladder and stones are removed and additional or continued treatment is not necessary. This procedure offers notable advantages to the patient, and is becoming a standard procedure for qualified general surgeons.
Adolescent↗
Laparoscopic guided cholecystectomy.
Cholecystectomy remains the most effective form of therapy for patients with symptomatic cholelithiasis. An alternative method of gallbladder removal, laparoscopic guided cholecystectomy, was attempted in 100 patients. Five patients required conversion of the laparoscopic procedure to an open laparotomy for the following reasons: discovery of a pancreatic malignancy in one patient, extensive adhesions in one, presence of an aberrant accessory right hepatic duct in one, common hepatic duct injury in one, and avulsion of the cystic duct in one. Both ductal injuries occurred during the early phase of the clinical program. In those patients undergoing laparoscopic cholecystectomy, 93 were discharged within 24 hours of surgery and 94 returned to normal activity within 1 week. Laparoscopic guided cholecystectomy appears to offer a number of advantages in patient care as well as a significant reduction in health care expenses for gallbladder disease. Appropriate training in laparoscopic surgery is necessary in order to avoid operative complications.
Adolescent↗
Traditional versus laparoscopic cholecystectomy.
Laparoscopic cholecystectomy is a minimally invasive procedure whereby the gallbladder is removed using laparoscopic techniques. The indications are similar to those for elective traditional cholecystectomy, but selection of patients is important for success. Contraindications are currently evolving. Patients with advanced cholecystitis, abdominal sepsis, ileus, bleeding disorders, pregnancy, and morbid obesity should not undergo this procedure. The procedure requires good traditional surgical skills, as well as additional laparoscopic (and laser) skills. Operative time is slightly longer than for traditional cholecystectomy, but decreases with experience. Morbidity is low, but there is a concern about bile duct injuries. Mortality is very low (0%) and is comparable to traditional cholecystectomy (0.4%). The major advantages of laparoscopic cholecystectomy are the short hospital stay (average: 2 days) and early return to normal activity (7 days). This results in a reduction in hospital costs. Adequate training and credentialing are important processes to foster good patient outcomes.
Cholecystectomy↗
Cost-effectiveness of extracorporeal shock-wave lithotripsy versus cholecystectomy for symptomatic gallstones.
To evaluate the cost-effectiveness of extracorporeal shock-wave lithotripsy vs. cholecystectomy for symptomatic gallstones, a model was constructed that projects charges and survival for both treatments. For a 45-year-old woman with one small stone, treatment with extracorporeal shock-wave lithotripsy rather than cholecystectomy is projected to result in an average gain of only 3 days of life and an average increase in direct medical charges of $1729 over 5 years of follow-up. The resulting marginal cost-effectiveness of extracorporeal shock-wave lithotripsy vs. cholecystectomy is $216,000 of extra charges per year of life gained with extracorporeal shock-wave lithotripsy. Extracorporeal shock-wave lithotripsy is projected to be much more cost-effective for elderly than for young patients (10-20-fold difference), but considerably less cost-effective for multiple stones than a single stone (2-4-fold difference), and less cost-effective for women than men (twofold difference). Adjusting for effects of morbidity on quality of life, extracorporeal shock-wave lithotripsy is projected to have slightly better quality-adjusted survival than cholecystectomy for the small subset of patients with one stone (by 8 to 43 days at 5 years) but not for young patients with multiple stones. It is concluded that decisions about appropriate use of extracorporeal shock-wave lithotripsy should consider the effects of patient characteristics on clinical and economic outcomes.
Aged↗
Reoperation versus alternatives in retained biliary calculi.
Retained common bile duct stones can be treated by operation, dissolution, extraction, fragmentation, papillotomy, and reoperation. Each approach requires some expertise, and the likelihood of success of most depends on the composition and size of the stones. Good results often can be obtained nonoperatively, especially with a multidisciplinary team. Reoperation is rarely necessary.
Combined Modality Therapy↗
Laparoscopic cholecystectomy.
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Cholecystectomy↗
Gallstone dissolution.
Many methods are available for gallstone dissolution, including oral bile salts; cholesterol solvents such as mono-octanoin or methyl tert-butyl either; and calcium or pigment solvents such as EDTA and polysorbate. Which of these approaches will be appropriate for an individual patient depends on the type of stones; whether they are in the gallbladder or the bile ducts; whether access to the biliary tree is available; the patient's age and general medical condition; and the availability of necessary expertise. In the US, both chenodeoxycholate and ursodeoxycholate are now available. Ursodeoxycholate is more expensive but appears to produce fewer side effects and may be more efficacious. These agents are most effective in thin women with small floating, radiolucent cholesterol stones in a functioning gallbladder. Only about half of the small subset of patients will experience partial or complete dissolution of stones within a year. Stone recurrence and the potential toxicity of long-term therapy are problems with this approach. Therefore, for most patients, cholecystectomy, either in the traditional fashion or using a laparoscopic approach (see article later in this issue by Gadacz et al), is the most cost-effective and perhaps the safest option. Intragallbladder instillation of methyl tert-butyl ether probably will be applicable only to a small subset of patients, and treatment is likely to be followed by a high recurrence rate. In patients with retained common duct cholesterol stones and access to the biliary tree, mono-octanoin therapy is advantageous in that it can be initiated as soon as cholangiography demonstrates no extravasation. In properly selected patients, a 90% success rate with this technique can be expected within 7 days.
Bile Acids and Salts↗
Laparoscopic cholecystectomy.
Laparoscopic cholecystectomy is a combined endoscopic-operative technique for removing the gallbladder. Patients with symptomatic gallstones are eligible for this procedure. Contraindications include pregnancy, acute cholangitis, advanced cholecystitis, acute pancreatitis, peritonitis, significant bleeding disorder, portal hypertension, and a prior major upper abdominal operation. The procedure does require experience and specialized training. It is guided by an endoscope, camera, and video monitor, and is performed through four cannulas. The gallbladder is dissected from the hepatic bed under observation on a monitor. The possible complications are bleeding, injury to the common bile duct, and technical problems, such as perforation of the gallbladder. The length of the hospital stay and the postoperative recovery time are markedly shortened compared with standard cholecystectomy. The procedure has an advantage over stone dissolution and biliary lithotripsy in that the gallbladder is removed, and additional or continued treatment is not necessary. This procedure offers sufficient advantages to the patient that it will likely become a standard for qualified abdominal surgeons.
Cholecystectomy↗
Adenocarcinoma of the ileostomy: the latent risk of cancer after colectomy for ulcerative colitis and familial polyposis.
A case of a primary adenocarcinoma of an ileostomy is reported along with 15 other cases collected from the literature. These rare tumors are seen on the average 24 years after colectomy with ileostomy and in all cases are associated with a past history of ulcerative colitis or familial polyposis. Most of the reported cases of these tumors have appeared in the literature within the past 5 years, suggesting that there is a rising incidence of this disease corresponding to completion of a biologic latency period that began when the Brooke ileostomy was introduced for ulcerative colitis in 1951. In our case a mucinous adenocarcinoma occurred at the ileostomy site 34 years after colectomy. Adjacent to the tumor was mucosa showing colonic metaplasia and focal dysplasia. Subsequent biopsy specimens of the revised stoma showed inflammatory lesions morphologically suggestive of inflammatory (pseudo) polyps. The clinical and morphologic features in this case suggest that there is transition from ileal mucosa to colonic mucosa to colonic dysplasia to adenocarcinoma. Annual evaluation of the ileostomy for colonic metaplasia, inflammatory lesions consistent with ulcerative colitis and dysplasia, is recommended. In the presence of dysplasia, stomal revision is advised. Wide local excision is advised for adenocarcinoma.
Adenocarcinoma↗
Fragmentation of human gallstones using ultrasound and electrohydraulic lithotripsy: experimental and clinical experience.
In vitro fragmentation of gallstones was performed by means of ultrasound (n = 89) and electrohydraulic lithotripsy (n = 83) with success rates of 100% and 93%, respectively. The fragmentation time was 21.9 +/- 52 seconds (mean +/- SEM) for ultrasound and 2.5 +/- 3.4 seconds for electrohydraulic lithotripsy. The energies required were similar to those used safely in the fragmentation of renal and bladder stones. Fragmentation was not related to the composition of the gallstones; there was no statistical difference between the fragmentation times or rates (p greater than 0.05) in cholesterol stones and pigment stones by either method. Fragmentation time was linearly related to gallstone weight for both methods. Comparison of ultrasound and electrohydraulic lithotripsy, using the two-way analysis of variance model, revealed no statistical difference between the two methods in times and rates of fragmentation (p greater than 0.05). Both ultrasound and electrohydraulic lithotripsy offer distinct advantages over the dissolution of gallstones by chemical methods because they are rapid and independent of gallstone composition. In vivo fragmentation of a large pigment common duct stone was also accomplished by means of an electrohydraulic lithotriptor. The stone was discovered in a 79-year-old patient on post-operative T-tube cholangiogram. Chemical analysis of the gallstones removed from the patient during cholecystectomy had revealed a very low cholesterol content. Since the remaining stone could not be dissolved and was too large to be mechanically extracted, it was fragmented through a T-tube, under fluoroscopic guidance and the small fragments were extracted with a dormia basket. The electrohydraulic lithotriptor was selected because it has a flexible probe.
Bile Pigments↗
The importance to the practicing surgeon of knowing the human immunodeficiency virus status of patients.
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AIDS Serodiagnosis↗
Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. Veterans Administration Cooperative Study on Treatment of Alcoholic Cirrhosis with Ascites.
The optimal management of severe ascites in patients with alcoholic cirrhosis has not been defined. in a 5 1/2-year study, we randomly assigned 299 men with alcoholic cirrhosis, who had persistent or recurrent severe ascites despite a standard medical regimen, to receive either intensive medical treatment or peritoneovenous (LeVeen) shunting. We identified three risk groups: Group 1 had normal or mildly abnormal results on liver-function tests, Group 2 had more severe liver dysfunction or previous complications, and Group 3 had severe prerenal azotemia without kidney disease. For the patients who received the medical treatment and those who received the surgical treatment combined, the median survival times were 1093 days in Group 1, 222 days in Group 2, and 37 days in Group 3 (P less than or equal to 0.01) for all comparisons). For all the groups combined, the median time to the resolution of ascites was 5.4 weeks for medical patients and 3.0 weeks for surgical patients (P less than 0.01). Within each risk group, mortality during the initial hospitalization and median long-term survival were similar among patients receiving either treatment. However, the median time to the recurrence of ascites in Group 1 was 4 months in medical patients, as compared with 18 months in surgical patients (P = 0.01); in Group 2 it was 3 months in medical patients as compared with 12 months in surgical patients (P = 0.04). The median duration of hospitalization was longer in medical patients than in surgical patients (6.1 vs. 2.4 weeks in Group 1 [P less than 0.001] and 5.0 vs. 3.1 weeks in Group 2 [P less than 0.01]). Group 3 was too small to permit a meaningful comparison. During the initial hospitalization, the incidence of infections, gastrointestinal bleeding, and encephalopathy was similar among the medical and surgical patients. We conclude that peritoneovenous shunting alleviated disabling ascites more rapidly than medical management. However, survival was closely related to the severity of the illness at the time of randomization and was not altered by shunting.
Ascites↗
Bile salt binding by maalox, sucralfate, and meciadanol: in vitro and clinical comparisons.
Inhibition of gastric acid secretion is a major factor in protecting the gastric mucosa, although other mechanisms such as bile salt binding may contribute to the protective properties of individual agents. Sucralfate, antacid (Maalox), and Meciadanol, a new flavonoid, were compared with cholestyramine resin for binding bile salts. The free, glycine, and taurine conjugates of the human bile salts, cholate, chenodeoxycholate, and deoxycholate, were incubated with each of the above. Cholestyramine resin adsorbed 91-97% of all bile salts tested. Meciadanol adsorbed all of the bile salts fairly well except for the free forms of chenodeoxycholate and deoxycholate. Meciadanol (53 to 84%) adsorbed bile salts better than sucralfate (4.2 to 61%), and significantly (P less than 0.05) better than Maalox (10 to 47%). In our in vitro studies, sucralfate was not as effective in binding bile salts as previously reported. Patients in the surgical intensive care unit were randomized prospectively to receive nasogastric instillation of Maalox, sucralfate, or Meciadanol to prevent gastrointestinal bleeding. The gastric aspirates were analyzed for bile salt concentration. The mean bile salt concentration of those treated with Maalox (0.24 mM), Meciadanol (0.24 mM), or sucralfate (0.35 mM) was significantly lower than those treated with nasogastric aspiration (0.87 mM) alone (P less than 0.01). This suggests that these substances bind bile salts and may provide additional protection to the gastric mucosa along with their ability to neutralize gastric acid.
Adsorption↗
Porcine model for the development of interventional techniques in the gallbladder.
A technique that permits repeated access to the porcine gallbladder through a surgically placed 18 French latex catheter is described and experience with this system in 22 swine is discussed. This porcine gallbladder model produces a reliable and reproducible means for studying clinically applicable interventional procedures.
Abdominal Muscles↗
Quantitative infrared spectroscopy of common bile duct gallstones.
The aim of this study was to determine the composition of gallstones from the common bile duct of patients from the United States and the relationship of stone type to the time interval after cholecystectomy. We analyzed 56 sets of common bile duct gallstones collected over a 10-yr period using infrared and atomic absorption spectroscopy and chemical methods. Twenty-four sets (43%) of stones were cholesterol stones containing 85.3% cholesterol, 3.2% pigment, 0.6% phosphate, and 1.3% total calcium. Ten sets (18%) were black pigment stones containing 36.5% pigment, 11.4% cholesterol, 7.6% carbonate, 3.0% phosphate, and 6.2% total calcium. Twenty-two sets (39%) were brown pigment stones containing 52.7% pigment, 16.5% calcium palmitate, 10.1% cholesterol, 0.4% phosphate, and 3.4% total calcium. Most of the 26 stones found at the same time as or within several months after cholecystectomy were either cholesterol (69%) or black pigment (19%). In contrast, the majority (59%) of the 22 common duct stones that were diagnosed greater than or equal to 21 mo after cholecystectomy were brown pigment stones. In conclusion, brown pigment stones are a distinct type of pigment stone characterized by their content of substantial amounts of calcium palmitate. They comprise a significant proportion of common duct stones in this series of United States patients, particularly of those found greater than or equal to 21 mo after cholecystectomy.
Calcium Carbonate↗
Adjuncts and modifications to basket retrieval of retained biliary calculi.
Although current techniques for percutaneous biliary stone extraction are highly successful, many patients require manipulation of the calculi before such extraction is possible. This article describes several adjunctive techniques for biliary stone retrieval that have proven to be effective. These include the modification of angiographic catheters for catheterization of ipsilateral ducts from the transhepatic approach, extractions of calculi from smaller ducts using constant irrigation and balloon catheters, and balloon-aided transampullary expulsion.
Bile Duct Diseases↗