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PubMed1993

Gallstones, cholecystectomy, and colorectal cancer.

PURPOSE: To examine the controversial association of gallstones, cholecystectomy and colorectal cancer. Methodologic explanations for the association include ascertainment bias, unequal diagnostic testing, and necropsy selection bias. Necropsy screening, which eliminates unequal diagnostic testing and ascertainment bias and reduces necropsy selection bias, was used to study this controversy. METHODS: Adult necropsies at the University of Kansas Medical Center from 1950 to 1984 were reviewed. Patients with colorectal cancer, gallstones, or who had cholecystectomy during life were excluded. The remaining patients were those in whom neither colorectal cancer nor gallstones were suspected during life (reducing selection bias). The occurrence of gallstones and colorectal cancer among these individuals was then determined (reducing ascertainment bias and unequal diagnostic testing). RESULTS: Of 7485 persons receiving necropsy, 239 had colorectal cancer diagnosed during life and an additional 604 had gallstones or cholecystectomy, leaving 6642 patients available for study. Overall, no association between colorectal cancer and gallstones was found. In women, gallstones were associated with colorectal cancer; 6/447 (1.3%) with gallstones had colorectal cancer compared with 11/2259 (0.4%) without gallstones who had colorectal cancer, p = 0.048, odds ratio 2.78 (95% CI 0.84-8.25). A stronger association was found between right-sided colorectal cancer and gallstones (odds ratio 6.79, 95% CI 1.14-46.46). CONCLUSIONS: These data suggest an association between gallstones and colorectal cancer among women. Gallstones may indicate patients at higher risk for colorectal cancer. Studies associating cholecystectomy with colorectal cancer may be explained--not by ascertainment bias--but, rather, by susceptibility bias. The reason for the cholecystectomy (gallstones) may be the correct association and not the cholecystectomy itself.

Adult↗
PubMed1993

Laparoscopic cholecystectomy. A prospective analysis of the potential causes of failure.

Most experienced laparoscopic units suggest a rate of conversion to open cholecystectomy of about 5%. Some failures are predictable preoperatively. We have reviewed the prospective data collected on our first 285 laparoscopic cholecystectomies to provide a basis for advising patients about the likelihood of conversion (failure) if laparoscopic cholecystectomy is attempted. Risk factor analysis was performed to assess the effect on the conversion rate of clinical presentation, preoperative ultrasound features, previous abdominal surgery, and morbid obesity. The overall conversion rate was 4.9%. We identified three preoperative clinical parameters associated with a high risk of failure at laparoscopic cholecystectomy: a contracted gallbladder on ultrasound, gallstone pancreatitis, and a previous history of upper abdominal surgery. Factors that did not predict failure were: an ultrasound report of a thick gallbladder wall, morbid obesity, or acute cholecystitis. It is concluded that laparoscopic cholecystectomy is technically feasible in most patients, but those having the above-mentioned risk factors should be warned of a higher than usual chance of conversion to open cholecystectomy.

Cholecystectomy, Laparoscopic↗
PubMed1993

[The indications and results of laparoscopic cholecystectomy].

Laparoscopic cholecystectomy was successfully achieved in 93% of the patients, who required removal of the gallbladder, in our institution. Other reports have also shown that more than 90% of patients who required cholecystectomy, were candidates for laparoscopic cholecystectomy. Serious complications occurred in 2.1% of our series and in 2-4% of the literature. The complications included bile duct injury (around 0.5%) and visceral injury (0.2-0.4%). The incidence of complications resulting from technical failure seems to be higher in laparoscopic cholecystectomy than in conventional cholecystectomy but is acceptable for initial experience. Laparoscopic cholecystectomy will become the standard therapy of gallstone for its effectiveness and less invasiveness.

Cholecystectomy, Laparoscopic↗
PubMed1993

[Endoscopic retrograde cholangiopancreatography combined with laparoscopic cholecystectomy].

In 11 of 82 patients undergoing laparoscopic cholecystectomy, preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed. Indications were biliary pancreatitis in 5 and suspected common bile duct (CBD) stones in the other 6 (based on US or liver function tests, or both). The biliary tree was normal in 9 and laparoscopic cholecystectomy was performed. In 8 there was uneventful recovery but in the ninth open surgery was required when the attempted cholecystectomy resulted in uncontrolled cystic artery bleeding. Of the remaining 3 patients, 1 underwent sphincterotomy via ERCP and 3 weeks later, laparoscopic cholecystectomy. In the others, we intended to explore the CBD by laparoscopy, but had to resort to open cholecystectomy due to technical difficulties resulting from unsuspected acute cholecystitis. Based on our short experience, ERCP combined with laparoscopic cholecystectomy seems to be both safe and effective.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1993

Open cholecystectomy: its morbidity and mortality as a reference standard.

In a retrospective study of 10,471 cholecystectomies, performed between 1971 and 1990, the incidence and causes of death and morbidity of cholecystectomy were analysed. There were 47 postoperative deaths (0.4%); 6 deaths occurred in 5841 patients less than 50 years old, 23 in 3898 patients between 50 and 70 years old and 18 in 732 patients more than 70 years old. Death rates in each group were, respectively, 0.1%, 0.6% and 2.5% (p < 0.001). The death rate in 9339 patients who had cholecystectomy alone was 0.3% and the death rate in 1132 patients who had a concomitant common bile duct exploration (CBDE) was 1.6% (p < 0.001). Cardiovascular complications were the main cause of death, and biliary, pulmonary and wound complications were the most common. There were 614 complications in 529 patients; 176 of these patients were less than 50 years old, 252 were between 50 and 70 years old and 101 were more than 70 years old. Complication rates were, respectively, 3.0%, 6.5% and 13.8% (p < 0.001). For patients with cholecystectomy alone the morbidity was 3.6% and for patients who had a concomitant CBDE the morbidity was 17% (p < 0.001). The mortality and morbidity of cholecystectomy increase significantly with age and a concomitant CBDE. However, patients who underwent cholecystectomy electively or for acute cholecystitis had comparable mortality and morbidity.

Acute Disease↗
PubMed1993

[Biliary pancreatitis--a good indication for laparoscopic cholecystectomy].

Recently the indication for laparoscopic cholecystectomy has been enlarged to include biliary pancreatitis. While a majority of reports recommend early open cholecystectomy for biliary pancreatitis the use of laparoscopic cholecystectomy in this disease has not yet been discussed. We retrospectively reviewed 52 patients with biliary pancreatitis being admitted to our ward in the last five years. Cholecystectomy was performed in 48 patients. Ten had undergone laparoscopic cholecystectomy. Postoperative complications occurred in 8 of the 48 patients (16.6%). Four patients (8.3%) died due to necrotizing pancreatitis or rupture of pseudocysts. We found a correlation between morbidity and mortality and the prognostic score as well as the presence of pseudocysts. We conclude that biliary pancreatitis is a good indication for laparoscopic cholecystectomy in patients with a low prognostic score. The presence of pseudocysts in our view is no contraindication for laparoscopy. Although it may increase postoperative morbidity. Choledocholithiasis has to be ruled out either by preoperative ERCP or during laparoscopy with intraoperative cholangiography.

Acute Disease↗
PubMed1993

[Prophylactic cholecystectomy in bariatric surgery].

In this paper the authors discuss about prophylactic cholecystectomy in bariatric surgery. Having analyzed the mechanisms that increase bile lithogenicity after bariatric surgery, they evaluate advantages and disadvantages of prophylactic cholecystectomy. They present 53 obese patients submitted to biliopancreatic diversion and prophylactic cholecystectomy for surgical treatment of morbid obesity, because of the high incidence of pathological findings in the specimens and the absence of surgical complications related to cholecystectomy, the authors, in agreement with the literature, suggest routine cholecystectomy as an obvious adjunct to bariatric surgery. This attitude protects against the higher risk of subsequent cholecystectomy and against the misinterpretation of non-invasive diagnostic tests too, because of known limits of echography in obese people.

Adolescent↗
PubMedDate not supplied

[Costs of cholecystectomy after the arrival of video-laparoscopic surgery].

The authors proceeded to point out the hospital stay costs and the operating-room costs of the cholecystectomy after the introduction of the laparoscopic technique, underlining the higher economic advantages. The total unit cost for laparoscopic cholecystectomy, even if there are higher costs due to the surgical equipment, thanks to the mini-invasive approach and to the reduced hospital stay, results lower (17%) then the total unit cost for laparotomic cholecystectomy (L. 3.982.489 vs. L. 4.825.300). Let us suppose that in the Emilia Romagna Region an 80% of patients underwent to laparoscopic cholecystectomy and only a 20% underwent to laparotomic cholecystectomy: in this case there could be the economic savings of L. 3.777.478.902 and concerning the hospital stay there could be the savings of 17.928 days too. This cost estimation is important if we consider that the rate of cholecystectomy procedures, in our local area, per 1000 inhabitants, increased from 2.29 in 1990 to 3.99 in 1992 (rate of increase: 74%).

Adult↗
PubMed1997

Bile duct injury during laparoscopic cholecystectomy: a prospective nationwide series.

BACKGROUND: The risk of bile duct injury in laparoscopic cholecystectomy has been a concern since the procedure became part of the surgical armamentarium. Our study assesses the incidence, types, and treatment for laparoscopic bile duct injury. STUDY DESIGN: Prospective case registration in a national database with participation by all departments of surgery performing laparoscopic cholecystectomy in Denmark since the first operation in January 1991. The case notes for bile duct injury have been reviewed. RESULTS: From 1991 through 1994, 57 of 7,654 patients sustained bile duct injury (0.74 percent; 95 percent confidence interval, 0.55 percent to 0.94 percent), including nine injuries occurring after conversion. The annual incidence did not decrease. Thirty-nine percent of the laparoscopic bile duct injuries were incisions, 39 percent were transections, and 12 percent were clip injuries or strictures. One patient, who sustained transection during open reoperation for bleeding after a converted procedure, died. Bile leaks for reasons other than bile duct injury occurred in 2.1 percent; 71 percent of these were cystic duct leaks. Acute cholecystitis was the indication for laparoscopic cholecystectomy in 968 patients, with 1.3 percent sustaining laparoscopic bile duct injury (95 percent confidence interval, 0.62 percent to 2.08 percent), while the incidence in patients with other indications for laparoscopic cholecystectomy was 0.62 percent (95 percent confidence interval, 0.44 percent to 0.82 percent) (p > 0.05). Preoperative knowledge of bile duct anatomy was available by means of preoperative endoscopic retrograde cholangiopancreatography or intravenous cholangiography in 26 percent of patients undergoing laparoscopic cholecystectomy but this did not reduce the risk of bile duct injury. The frequency of bile duct injury in patients who had intraoperative cholangiography was not significantly different from those who did not. Intraoperative cholangiography was done in 14 cases of injury (diagnostic for injury in 8, misinterpreted in 2, and normal in 4 patients). The case notes described operative difficulties in 11 of 48 cases of laparoscopic bile duct injury, most often because of fibrosis or difficulty delineating the anatomy. CONCLUSIONS: The incidence of bile duct injury in laparoscopic cholecystectomy is higher than previously generally anticipated and did not decrease from 1991 through 1994. Risk factors and possible preventive measures should be evaluated in prospective studies.

Bile Ducts↗
PubMedDate not supplied

Laparoscopic cholecystectomy in cirrhotic patients.

BACKGROUND/AIMS: Laparoscopic and open cholecystectomy are the safest procedures for all diseases related to stones in the gallbladder as they have a low morbidity and mortality rate. However, the safety of laparoscopic cholecystectomy in cirrhotic patients has not been investigated. The goal of this study was to evaluate the safety of laparoscopic cholecystectomy in cirrhotic patients. METHODOLOGY: A retrospective study of laparoscopic cholecystectomy in cirrhotic versus non-cirrhotic patients was performed. Between January 1991 and November 1994, 605 laparoscopic cholecystectomies for symptomatic gallbladder diseases were performed. There were 21 patients in the cirrhotic (group A) and 584 patients in the non-cirrhotic (group B). RESULTS: There was no operative mortality in either group and the postoperative complication rates were 4.8% and 5.8% in group A and B, respectively (p > 0.05). Prolonged operative time in group A was 84.47 +/- 36.01 min vs group B 62.20 +/- 25.37 min (p < 0.01). The estimated intraoperative blood loss in group A was larger than in group B (140.76 +/- 201.19 ml vs 35.02 +/- 50.11 ml, p < 0.01). The readmission rate was higher in group A (9.5%) than in group B (1.37%) (p < 0.05). The hospital stay in group A and B were 4.12 +/- 2.15 D, 3.50 +/- 1.50 D respectively (p > 0.05). The incidence of conversion and re-operation rates indicated no difference between cirrhotic and non-cirrhotic groups. CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed in mild cirrhotic patients with more operative times and meticulous management of intraoperative bleeding.

Adolescent↗
PubMed1998

Is cholecystectomy effective treatment for symptomatic gallstones? Clinical outcome after long-term follow-up.

The expectation that cholecystectomy is effective treatment for symptomatic gallstones is not always achieved in surgical practice. The impact of cholecystectomy on the relief of gastrointestinal symptoms was evaluated in 92 patients followed up after surgery for a mean of 31.1 months (range 12-83 months). Abdominal pain continued to be present, or arose de novo, in 28 (30.4%) patients. Pain-free outcome after cholecystectomy was associated with a preoperative clinical diagnosis of biliary colic, fatty food intolerance, and a thick-walled gallbladder on ultrasound (P = 0.02). Logistic regression associated a thick-walled gallbladder, elevated gamma-glutamyl transpetidase, body mass index < 26, fat intolerance, and normal bowel habit with good postoperative results (P = 0.001). Application of each of these five factors to a clinical index failed to predict long-term pain-free outcome after cholecystectomy. Abdominal bloating (P = 0.03), dyspepsia (P < 0.001), heartburn (P < 0.007), fat intolerance (P < 0.001), nausea (P = 0.001) and vomiting (P < 0.001) were significantly improved after cholecystectomy, but diarrhoea, constipation and excessive flatus were not. Outcome benefit ratios confirmed that vomiting (0.96), nausea (0.87), dyspepsia (0.67), fat intolerance (0.57) and heartburn (0.51) were relieved by surgery. Cholecystectomy improved symptoms compared with a matched control group, suggesting that surgery remains the gold standard treatment of symptomatic gallstones.

Adult↗
PubMed1997

Complications of laparoscopic cholecystectomy in China: an analysis of 39,238 cases.

OBJECTIVE: To investigate the complications of laparoscopic cholecystectomy in China. METHODS: All Chinese articles about laparoscopic cholecystectomy published between April 1994 and November 1995 were identified through CMCC (Chinese Medical Computerized Contents). From more than 600 titles, 105 articles were screened for analysis. Another 21 articles from the 6th Biliary Surgical Congress and 300 cases from the General Hospital of PLA were added. A total of 39,238 cases of laparoscopic cholecystectomy from 91 hospitals were studied. RESULTS: Severe complications of laparoscopic cholecystectomy were identified in 409 (1.04%) patients, including bile duct injury (in 0.32% of patients), postoperative cystic duct leak (0.11%), postoperative bile leak (0.20%), peritoneal abscess (0.07%), bowel injury (0.06%) and postoperative hemorrhage (0.1%). Fourteen postoperative deaths (0.04%) resulted from operative injury. CONCLUSIONS: The data demonstrate that laparoscopic cholecystectomy is an operation associated with low morbidity and mortality rate, but bile duct injury is still a major problem. Complications of laparoscopic cholecystectomy can be minimized by improving operative procedure.

Bile Ducts↗
PubMed1998

Laparoscopic management of acute cholecystitis with subtotal cholecystectomy.

Approximately 20 per cent of laparoscopic cholecystectomies performed for acute cholecystitis require conversion to open cholecystectomy because of severe inflammation. In a retrospective review of 125 consecutive patients undergoing laparoscopic surgery for gallbladder disease from January 1995 through June 1997, 31 had acute cholecystitis. Eight patients underwent a subtotal cholecystectomy because of severe inflammation. There were no conversions to open cholecystectomy and no intraoperative complications. Selected patients were evaluated and treated for common duct stones with preoperative endoscopy to avoid intraoperative cholangiography. One patient had a retained common duct stone successfully managed with postoperative endoscopy. Laparoscopic subtotal cholecystectomy is a safe and effective alternative to conversion to open cholecystectomy for severe inflammation associated with acute cholecystitis. Endoscopic assessment and treatment of common duct stones when indicated either before or after surgery omits the use of intraoperative cholangiography and potential injury to the inflamed ducts.

Acute Disease↗
PubMed1995

How should polypoid lesions of the gallbladder be treated in the era of laparoscopic cholecystectomy?

BACKGROUND: Definitive criteria for choosing the most appropriate treatment for each type of polypoid lesion of the gallbladder (PLG) have yet to be established. METHODS: The shapes, sizes, echo patterns, and echogenicities of PLGs that had been evaluated by means of ultrasonography in 72 patients who had undergone resective surgery were analyzed retrospectively to elucidate the ultrasonic characteristics of polypoid cancers and to establish criteria for selecting the most suitable treatment such as laparoscopic cholecystectomy for each type of PLG. RESULTS: Histologic examinations showed cholesterol polyps in 47 patients, adenomas in 8, cancers in 16, and an inflammatory polyp in 1. The diameters of 61% of the benign PLGs were less than 10 mm, whereas those of 88% of the cancers were more than 10 mm; 80% of the former were pedunculated and 56% of the latter were sessile. Seven of eight early-stage cancers had diameters less than 18 mm, whereas those of all eight more advanced cancers were greater than 18 mm. Five of the eight early-stage cancers were pedunculated, and six of the eight more advanced cancers were sessile. Cholecystectomy with or without full-thickness dissection were main surgical procedures used to resect benign PLGs and early-stage cancers, whereas cholecystectomy with partial liver resection was used for more advanced cancers. Laparoscopic cholecystectomy was performed in the recent 34 patients, four of whom had early-stage cancers. CONCLUSIONS: A PLG with a diameter of less than 18 mm is a potential early-stage cancer and therefore can be resected by laparoscopic cholecystectomy with full-thickness dissection. However, when cancer invades the subserosal layer or beyond, a second-look operation is necessary. A PLG with a diameter of greater than 18 mm may be an advanced cancer and should be removed by using cholecystectomy with partial liver resection or a more extended procedure with lymph node dissection.

Adenocarcinoma↗
PubMed1995

Operative Cholangiogram at Laparoscopic Cholecystectomy.

In the open cholecystectomy era, the established principle for treating biliary calculi was to perform intraoperative cholangiography to diagnose and treat the concomitant common duct stone at the time of cholecystectomy. To reduce unnecessary cholangiograms, a selective cholangiogram policy based on preoperative and operative criteria was sometimes used. Although both time and cost were saved, a 4% to 10% chance of missing unsuspected common duct stones was associated with this policy. The introduction of laparoscopic cholecystectomy in Australia initially led to an abandonment of the principles of biliary surgery. Rates of intraoperative cholangiography declined as stones were either ignored or diagnosed preoperatively by endoscopic retrograde cholangiopancreatography and/or intravenous cholangiography. When stones were identified, they were treated by preoperative endoscopic sphincterotomy. This decline in cholangiography was associated with a twofold to fourfold rise in serious bile duct injury as well as a delay in its diagnosis. Over the past two years, as laparoscopic cholecystectomy has become established in Australia, practice is returning to the standards of the open cholecystectomy era. Intraoperative cholangiography rates have been increasing along with the proportion of patients having their duct stones removed laparoscopically. To succeed, this practice depends on the use of fluoroscopic cholangiography, which should be the standard of care in the laparoscopic era. With laparoscopic cholecystectomy, intraoperative cholangiography is no longer optional, but mandatory. Not only does it reduce the incidence and severity of bile duct injury, but it also trains the surgeon to develop techniques of laparoscopic duct exploration.

Journal Article↗
PubMed2004

[Frequency of serious complications following laparoscopic cholecystectomy.].

UNLABELLED: In the the last decade laparoscopic cholecystectomy has emerged as the prefered method in the treatment of gallbladder stones. It has proved to be safe and has a relatively low rate of complications. However, major bile duct injuries occur more frequently during laparoscopic cholecystectomy when compared to the open procedure. The aim of this study was to examine the types and frequency of complications occurring during the initial period of laparoscopic cholecystectomy (1991-1998) at Landspitali University Hospital with a special emphasis on major bile duct injuries. MATERIALS AND METHODS: A retrospective analysis was performed on patients charts and operative notes of those who underwent laparoscopic cholecystectomy during the years 1991-1998. RESULTS: 1008 consecutive patients were included in the study of which 727 (72%) were females. Bile leak from the cystic duct or the gallbladder bed was the most common complication and occurred in 23 patients (2.3%). Twenty patients (2%) had an intra-abdominal bleeding postoperatively. Seventeen (1.5%) of the patients had retained stones. Four patients (0.4%) developed a haematoma in the gallbladder bed. Two patients (0.2%) had a lesion of a bile duct and three patients (3%) died in the postperative phase. One hundred and six (10.5%) laparoscopic cholecystectomies were converted to an open procedure with the number of conversions highest in the second year (23%) of the procedure but thereafter the conversion rate was between 5 and 10%. Of the operations which required conversion from a laparoscopic procedure to an open one 74 (70%) were operations done urgently or as an emergency. CONCLUSION: Laparoscopic cholecystectomy at Landspitali University Hospital is a safe procedure with a low incidence of complications including major biliary injury. These findings are in accordance with results from other similar studies.

English Abstract↗
PubMed1992

Physiological and metabolic responses to open and laparoscopic cholecystectomy.

This study examined respiratory function and metabolic and subjective responses in patients undergoing laparoscopic (n = 10) and open (n = 11) cholecystectomy for chronic cholecystitis and biliary colic. Patient groups were matched for age, sex, weight and height. The duration of operation was similar in both groups. Respiratory function tests (vital capacity, forced expiratory volume in 1 s, peak flow and arterial blood gases), urinary cortisol, vanillylmandelic acid, metanephrines and nitrogen loss, serum complement component C3 and C-reactive protein (CRP), full blood count, erythrocyte sedimentation rate (ESR) and subjective responses as assessed on a pain analogue scale and by analgesic usage were determined for up to 48 h after surgery. Deterioration in perioperative respiratory function was significantly less for laparoscopic surgery. Arterial blood gas determinations indicated a greater perioperative decrease in arterial pH, with carbon dioxide retention in patients undergoing open cholecystectomy (P < 0.02), reflecting poorer respiratory performance. Hormonal profile changes demonstrated an increase in urinary vanillylmandelic acid in the laparoscopic cholecystectomy group (P < 0.04); no differences were detected in urinary cortisol, metanephrine or nitrogen excretion. Acute-phase responses were greatest in patients undergoing open cholecystectomy as determined by ESR and CRP level (P < 0.02 and P < 0.003, respectively). Pain and analgesic usage were significantly decreased in the laparoscopic cholecystectomy group (P < 0.0009) and P < 0.0001), which led to a decreased hospital stay after operation in these patients (P < 0.0001). These data indicate improved respiratory and subjective responses and diminished acute-phase responses associated with laparoscopic surgery. Catabolic hormone release may, however, be increased.

Acute-Phase Reaction↗
PubMed1994

Comparison of laparoscopic and minilap cholecystectomy for acute cholecystitis.

The charts of all patients with acute cholecystitis undergoing either laparoscopic or minilap cholecystectomy at the Chinle Comprehensive Health Care Facility between October 1, 1991, and August 15, 1993, were retrospectively reviewed. During that period, 54 patients underwent laparoscopic cholecystectomy and 45 patients had minilap procedures. The two groups had similar mean age, sex distribution, temperature, leukocyte count, gallbladder wall thickness, and duration of preoperative symptoms. While laparoscopic cholecystectomy took an average of 16 min longer to perform than minilap cholecystectomy, patients who had laparoscopic cholecystectomy had less blood loss, reduced postoperative narcotic needs, and shorter hospital stays.

Acute Disease↗