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PubMed1990

Bile duct size after cholecystectomy: an endoscopic retrograde cholangiopancreatographic study.

Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 43 patients before and 4-14 months after cholecystectomy. All patients had a normal common bile duct and were asymptomatic after the operation. Preoperative and postoperative films of adequate quality were available for scrutiny in 35 patients. The largest mean(s.d.) diameter of the common duct, after correcting for magnification, was 0.96(0.27) cm before cholecystectomy and 1.16(0.29) cm after surgery (P less than 0.0001). Thirty-one of the 35 patients showed increased duct size after cholecystectomy, and the difference was 1 mm or more in 26 patients. There was a positive correlation between the increase in bile duct size and the time interval after cholecystectomy. After cholecystectomy a small but significant increase in bile duct diameter is demonstrable on ERCP.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1990

Duodenogastric reflux and gastric histology after cholecystectomy with or without sphincteroplasty.

Sixteen patients who had undergone cholecystectomy plus sphincteroplasty, 14 cholecystectomized patients and ten control patients were studied to evaluate whether differences existed in duodenogastric reflux and whether these were related to morphological damage of the gastric mucosa. Duodenogastric bile reflux during fasting was evaluated by measuring the concentration of total bile acids (by an enzymatic method) and single bile acids in the gastric juice by high performance liquid chromatography. The damage was evaluated histologically by systematic endoscopic biopsy of the antrum and body of the stomach. There was a statistically significant difference in fasting bile reflux between the three groups (Kruskal-Wallis test, P less than 0.001), and the group that underwent cholecystectomy plus sphincteroplasty had a significantly higher median value than the cholecystectomized group (P less than 0.05) and the control group (P less than 0.01). The distribution of chronic antral atrophic and superficial gastritis was different in the three groups (chi 2 test, P less than 0.005). Chronic atrophic gastritis was associated with cholecystectomy plus sphincteroplasty (P less than 0.01), while chronic superficial gastritis was more frequent in cholecystectomized patients. These results suggest that there may be more duodenogastric reflux after cholecystectomy plus sphincteroplasty than after cholecystectomy alone, and that there may be a correlation between the amount of duodenogastric reflux and the severity of mucosal damage.

Adult↗
PubMed1997

Thromboembolism prophylaxis during laparoscopic cholecystectomy.

BACKGROUND: The aim of this study was to determine current UK practice with regard to thromboembolism prophylaxis during laparoscopic cholecystectomy. METHODS: Postal questionnaires were sent to 800 members of the Association of Surgeons; replies were received from 551 surgeons (69 per cent) of whom 417 practised laparoscopic cholecystectomy. RESULTS: Heparin was prescribed to all patients by 74 per cent, and selectively by 20 per cent, of respondents. Surgeons who performed fewer than ten laparoscopic cholecystectomies per annum were significantly less likely to use heparin (P < 0.001) and more likely to believe that heparin produces significant adverse bleeding (P < 0.01). Thirty per cent of respondents used low molecular weight heparin. Stocking to deter thromboembolism were used by 74 per cent, and pneumatic compression by 37 per cent. Indications for heparin varied considerably and were not influenced by Thromboembolic Risk Factors (THRIFT) guidelines. Only 20 per cent of respondents considered that thromboembolism was a problem; 91 per cent reported that they had never experienced a thromboembolic complication following laparoscopic cholecystectomy. CONCLUSION: The rate of thromboembolism after laparoscopic cholecystectomy is unknown but most surgeons believe the risk is very low. Surgeons' attitudes towards thromboembolism prophylaxis are variable, but most experienced surgeons use low-dose heparin.

Adult↗
PubMed2003

Predictors of improvement in health-related quality of life in patients undergoing cholecystectomy.

BACKGROUND: Few studies have assessed health-related quality of life (HRQoL) among patients undergoing cholecystectomy. This study aimed to determine clinical variables that predict changes in HRQoL following cholecystectomy. METHODS: This was a prospective study of consecutive patients undergoing elective cholecystectomy for gallstones in six hospitals. Patients were asked to complete two questionnaires-the Short Form 36 (SF-36) and the Gastrointestinal Quality of Life Index (GIQLI)-before and 3 months after cholecystectomy. Multivariate linear regression models were used to examine factors potentially contributing to changes in HRQoL. RESULTS: Patients with symptomatic cholelithiasis and low surgical risk experienced the highest HRQoL gains in several SF-36 and GIQLI domains, with significant improvements in physical function detected by both instruments, compared with asymptomatic individuals at high surgical risk. Patients with asymptomatic cholelithiasis or high surgical risk experienced least improvement. CONCLUSION: These data indicate that cholecystectomy is appropriate for patients with symptomatic cholelithiasis and low surgical risk. In terms of HRQoL, the risk to benefit ratio seems poor for patients with asymptomatic gallstones.

Aged↗
PubMed1995

Long-term effects of cholecystectomy on bile acid metabolism.

Comparative studies between different patient groups have suggested that cholecystectomy enhances bacterial dehydroxylation of the primary bile acid cholic acid (CA) to the secondary bile acid deoxycholic acid (DCA). DCA may exert a cocarcinogenic effect on the colonic mucosa. In a short-term follow-up study on nine female patients we found no alterations of the CA or DCA pools after cholecystectomy. However, in the long term, cholecystectomy could promote changes of the intestinal bacterial flora and thereby lead to enhanced conversion of CA to DCA, causing an expansion of the DCA pool size and a reduction of the CA pool size. To test this hypothesis, pool sizes, fractional turnover rates (FTR), and synthesis or input rates of CA, chenodeoxycholic acid (CDCA) and DCA were determined in 12 female patients before and again 5 to 8 years after cholecystectomy. In the long term, pool size and synthesis rate of CA had not changed and DCA pool size had expanded by only 7.5% (not significant [NS]). DCA input increased by 32% (NS) but was balanced by an increase in FTR of 36%. Pool size (-17%) and synthesis rate (-5%) of CDCA were not significantly diminished. Overall, the sizes of the total bile acid pool (-6%, NS; 50 +/- 8 vs. 53 +/- 13 mumol/kg) and the pool fractions of CA (44.7 +/- 10.3% vs. 42.8 +/- 7.6%) and DCA (25.5 +/- 14.1% vs. 23.6 +/- 9.3%) remained similar. In conclusion, cholecystectomy causes no changes in bile acid pool composition and thus has no adverse effects on bile acid metabolism in the long term.

Adult↗
PubMed2001

Postgraduate year does not influence operating time in laparoscopic cholecystectomy.

BACKGROUND: Surgical resident education may contribute to increased operating time, thus increasing costs at teaching institutions. It is possible that junior residents, in particular, with less experience could contribute to longer operating times for laparoscopic cholecystectomy. We hypothesized that all general surgery residents, regardless of level of training and with proper supervision, could complete a laparoscopic cholecystectomy in a safe and timely fashion. MATERIALS AND METHODS: A retrospective study was performed using data collected from laparoscopic cholecystectomies completed under the supervision of one attending surgeon over a 2-year period. Operating times were recorded, the operating surgeon was identified, and cases were assigned an acuity level based on pathologic findings. Operative times were compared after dividing surgeons into three groups (junior residents, senior residents, and staff). RESULTS: Seventy-one cases were entered into the study. There were no differences when comparing mean operating times among the three groups (P = 0.2, analysis of variance). The pathologic acuity in each group was similar (P = 0.8, Fisher's exact test). There was a difference when evaluating the operating times for the pathologic level of acuity (P = 0.002, Kruskal-Wallis test). CONCLUSIONS: Resident level does not affect the operating time in performing laparoscopic cholecystectomy. The pathologic acuity of the gallbladders was distributed similarly for all three groups. There was a difference in mean operating time based on pathologic acuity. Laparoscopic cholecystectomy can be performed in a safe and efficient manner at a teaching institution.

Acute Disease↗
PubMed1992

[Intestinal motility after laparoscopic vs conventional cholecystectomy. An animal experiment study and clinical observation].

First descriptions of clinical courses after laparoscopic cholecystectomy indicate a shorter period of postoperative ileus in comparison to conventional cholecystectomy. Early postoperative motility was registered in dogs (n = 10) by implanted serosal electrodes. Further on clinical signs of postoperative motility were documented in patients (n = 100) after laparoscopic and conventional cholecystectomy. In animal experiments a significantly reduced period of postoperative ileus (5.5 +/- 1 h) occurred after laparoscopic cholecystectomy in comparison with the conventional technique (46 +/- 5 h). Experimental data correlate well with earlier clinical signs of normal motility after laparoscopic cholecystectomy in patients. The shorter period of postoperative ileus is a further evidence for the minor abdominal trauma of laparoscopic techniques.

Adult↗
PubMed1996

False aneurysm of a hepatic artery branch and a recurrent subphrenic abscess: two unusual complications after laparoscopic cholecystectomy.

Although laparoscopic cholecystectomy has become a safe and effective alternative for open cholecystectomy as treatment of symptomatic cholelithiasis, it may be followed by different complications. Two cases are presented with unusual complications after laparoscopic cholecystectomy. One patient was readmitted 11 days after laparoscopic cholecystectomy with severe upper abdominal pain and a false aneurysm of a branch of the right hepatic artery. The other patient developed a recurrent subphrenic abscess 10 months after the initial operation, which eventually was shown to be caused by a lost gallstone. Although these are rare complications of laparoscopic cholecystectomy, they should be recognized as potential causes of recurrent abdominal pain, even months after the procedure.

Aged↗
PubMed1996

Laparoscopic cholecystectomy in the transplant population.

BACKGROUND: The results of laparoscopic cholecystectomy in a group of transplant recipients were reviewed to determine the safety and efficacy of the procedure in the setting of immunosuppression. METHODS: All solid-organ-transplant recipients who underwent laparoscopic cholecystectomy over a 3-year period were reviewed. Indication for operation, conversion to open procedure, length of stay, and complications were characterized. These results were compared to the registry data of all laparoscopic cholecystectomies performed at the same institution. RESULTS: There were 26 transplant patients who underwent laparoscopic cholecystectomy including renal, heart, double lung, and heart-lung recipients. The mean age was 47 years. Symptomatic cholelithiasis was the most common indication in 73% of patients followed by acute cholecystitis in 11%. Seven patients (27%) underwent conversion to an open procedure. Three patients (11.5%) experienced a minor complication in hospital. Median length of stay was 2.5 days. One patient died during a subsequent unrelated operation. These results compared favorably to the registry experience at the same institution where the mean age was 49 years, 24% of cases were performed for acute cholecystitis, there was a 10% complication rate, median length of stay was 2 days, and 3 deaths occurred in hospital. The only statistically significant difference was a lower conversion rate (11% vs 27%) in the registry vs transplant group. CONCLUSIONS: This experience confirms that laparoscopic cholecystectomy is as safe in the transplant population as the general population. Despite a slightly higher conversion rate to an open procedure, the advantages of short hospital stay, low morbidity, and early return to preoperative routines remain equivalent.

Adult↗
PubMed1996

The role of ERCP in laparoscopic cholecystectomy-related cystic duct stump leaks.

BACKGROUND: Laparoscopic cholecystectomy has resulted in an increase in the incidence of cystic duct stump leaks. To assess the role of endoscopic retrograde cholangiopancreatography (ERCP) a review of 14 cystic duct stump leaks following laparoscopic cholecystectomy was carried out. METHODS: A retrospective chart review of fourteen patients was carried out. There were 11 females and 3 males. Laparoscopic cholecystectomy was carried out without any difficulty. Three patients became very ill soon after surgery while 11 patients were minimally ill. All were still hospitalized after the cholecystectomy. RESULTS: Urgent ERCP on the 3 very ill patients demonstrated a cystic duct bile leak. In the 11 minimally ill patients, ultrasonography demonstrated intraabdominal fluid collections and initial treatment was percutaneous drainage. Only 2 of the 11 patients improved. The remaining nine patients developed a septic course. ERCP was carried out and demonstrated cystic duct bile leak in all 9 patients. Endoscopic papillotomy alone or endoscopic papillotomy plus stenting resolved the clinical picture. CONCLUSIONS: Patients who are ill post laparoscopic cholecystectomy should have urgent ERCP. Cystic duct bile leaks should be managed by endoscopic papillotomy and in select cases, stenting.

Adult↗
PubMed1995

Is outpatient laparoscopic cholecystectomy wise?

The authors report a prospective analysis of their experience with 506 consecutive laparoscopic cholecystectomies to examine the appropriateness of outpatient or same-day laparoscopic cholecystectomy. Thirty-eight patients experienced at least one postoperative complication. The complication was clinically evident or suspected in only 4 of these 38 patients within 8 h following surgery. Thirty-nine percent and 76% of complications were clinically detected at 24 and 48 h, respectively. Nausea and vomiting occurred among 32% of all patients on the day of operation and extended into the 1st postoperative day in 10%. Compared to predicted values, forced vital capacity was 61 +/- 5% 1 h postoperatively in 32 patients studied. At 6 and 24 h postoperatively, forced vital capacity was 63 +/- 7% and 66% respectively. Postoperative analgesic medication requirement was determined in 220 patients who were provided with a patient-controlled intravenous morphine analgesia machine with no basal rate. Consumption of morphine was highly variable but substantial on the day of operation: 17 +/- 16 mg. Most complications of laparoscopic cholecystectomy, including life-threatening complications, are not apparent by 8 h postoperatively and may not be apparent at 24 h. The potential for delay in the diagnosis and treatment of complications, variable but substantial analgesic requirements, impaired postoperative ventilation, and postoperative gastrointestinal dysfunction argue for the need to use great caution in selecting patients for outpatient laparoscopic cholecystectomy. Criteria are proposed to identify patients who are safest for outpatient laparoscopic cholecystectomy.

Administration, Oral↗
PubMedDate not supplied

The use of ERCP in the management of common bile duct stones in patients undergoing laparoscopic cholecystectomy.

The purpose of this study was to evaluate the indications and results of endoscopic retrograde cholangiopancreatography (ERCP) for gallstone disease since the advent of laparoscopic cholecystectomy. In our personal series of 410 consecutive cases of laparoscopic cholecystectomy, we found 17 common bile duct (CBD) stones; seven were identified by preop ERCP, nine at laparoscopy by intraoperative cholangiography, and one postop by ERCP. We have performed preop ERCP in 21 patients (5.1%); CBD stones were found in seven. Our indications for preop ERCP were elevated liver function tests, dilatation of the common duct by ultrasound, or a history of jaundice/pancreatitis, and all stones were successfully removed by endoscopic sphincterotomy. At laparoscopic cholecystectomy nine patients were found to have stones; one was treated with laparoscopic methods, four with open CBD exploration, and four by postop endoscopic sphinecterotomy. Post-laparoscopic cholecystectomy, five patients underwent ERCP for pain or increased liver function tests suggestive of common duct stones. One of the five was found to have stones and these were successfully removed by endoscopic sphincterotomy. ERCP is very useful as a diagnostic and therapeutic modality in laparoscopic cholecystectomy patients with suspected CBD stones. Elevated liver function tests and dilated CBD by ultrasound are the most accurate predictors of stones. Endoscopic sphincterotomy is a more effective route, at present, for stone removal than a laparoscopic approach.

Adolescent↗
PubMedDate not supplied

Bile duct complications after laparoscopic cholecystectomy.

A retrospective review and analysis of patients referred to the Division of Gastroenterology and the Section of Gastrointestinal Surgery with common bile duct complications after laparoscopic cholecystectomy was undertaken in order to identify injury patterns, management, and outcome. Sixteen patients were identified over a 20-month period. Twelve patients had major common bile duct injuries and four had minor injuries (cystic duct leaks). Seventy-one percent of injuries occurred with surgeons who had done more than 13 laparoscopic cholecystectomies. Eighty-three percent of patients who had major ductal injury did not have a cholangiogram prior to the injury. Sixteen percent of patients with major common bile duct injuries had findings of acute cholecystitis and 58% of these major injuries were "easy" gallbladders. One-third of major injuries were recognized at operation. Two-thirds of immediate repairs failed. All cystic duct leaks were managed nonoperatively. It appears that bile duct complications after laparoscopic cholecystectomy are more common in the community than is reported. Bile duct complications occur with surgeons who are experienced and inexperienced with laparoscopic cholecystectomy. Common bile duct injuries, unrecognized at laparoscopic cholecystectomy in the majority of cases, usually occur with "easy" gallbladders. Operative cholangiography is not utilized in the majority of common bile duct injuries. When immediate repair of common bile duct injuries is undertaken, the majority are unsuccessful. Endoscopic retrograde cholangiopancreatography (ERCP) is invaluable in the diagnosis and management of bile duct complications. Cystic duct leaks may be managed successfully with endoscopic stents.

Adult↗
PubMed1991

Lithotripsy versus cholecystectomy for management of gallstones. A decision analysis by Markov process.

Extracorporeal shock-wave lithotripsy is a new treatment method that effectively distintegrates radiolucent gallstones and is associated with a low complication rate. Using the model of a Markov process for decision analysis, survival and costs under four possible strategies to treat gallstones were compared: expectant management with cholecystectomy (EC) or lithotripsy (EL) reserved for symptomatic gallstones; prophylactic cholecystectomy (PC) or lithotripsy (PL) for all gallstones. Life expectancy for the different strategies varies by few days. Only if high annual rates of pain and complication occurred in subjects with silent gallstones would both prophylactic procedures marginally increase life expectancy. Prophylactic cholecystectomy then would be more cost-effective than prophylactic lithotripsy. Expectant strategies remain much cheaper than prophylactic management over a broad range of probability values and procedural costs. Expectant use of lithotripsy costs less than cholecystectomy. A low success rate of lithotripsy would raise the direct costs of lithotripsy above those of cholecystectomy but leave total costs of both strategies in the same order of magnitude. Lithotripsy appears to be a feasible alternative to treat symptomatic but not asymptomatic gallstones.

Adult↗
PubMedDate not supplied

Cholecystectomy and drainage: ultrasonographic and radioisotopic evaluation.

Eighty patients undergoing cholecystectomy were either assigned deliberately (n = 30) or randomized (n = 50) to drainage (n = 38) or nondrainage (n = 42). Subhepatic collections were seen on ultrasonography (US) after 48 to 72 hours in 12 of 35 patients with drainage and 24 of 42 patients without drainage (p < 0.05). Only two patients with subhepatic collections were symptomatic, and none required treatment. Postoperative infective complications were seen in 13 of 38 patients with drainage and with a collection, and none of the 18 patients without drainage and without a collection had postoperative infective complications (p < 0.05). Cholecystectomy was then performed in 100 patients without using a drain. BULIDA radioisotope scans revealed a bile leak in only 4 of 34 patients studied. Subhepatic collections were seen on US after 48 to 72 hours in 42 patients. The collection resolved in 22 patients and was smaller in 6 on repeat US. None of the patients with collection was symptomatic, and none required treatment. Postoperative infective complications were seen in 7 of 42 patients with a collection and 5 of 58 patients without a collection (not significant). We conclude that (1) cholecystectomy with drainage is associated with more infective complications than when a drain is not used; (2) cholecystectomy without drainage is safe; and (3) asymptomatic nonbilious subhepatic collections are common after cholecystectomy without drainage but do not require treatment, resolving spontaneously.

Adult↗
PubMedDate not supplied

Abdominal wall retraction during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has represented a potentially more morbid procedure than open cholecystectomy. Some of this morbidity has been due to complications associated with pneumoperitoneum. We have developed a technique that employs abdominal wall retraction during laparoscopic cholecystectomy and allows access to the right upper part of the abdomen without maintenance of pneumoperitoneum. Among 151 patients who underwent laparoscopic cholecystectomy using abdominal wall retraction there were no recognized adverse effects. Abdominal wall retraction enables the surgeon to minimize the risk of serious complications associated with pneumoperitoneum during laparoscopic cholecystectomy.

Abdominal Muscles↗
PubMedDate not supplied

Highly selective vagotomy combined with cholecystectomy: is there an increased risk of diarrhea?

The addition of cholecystectomy to truncal vagotomy and a drainage procedure increases the incidence and severity of postvagotomy diarrhea. This study attempts to establish whether diarrhea is more common after highly selective vagotomy (HSV) and cholecystectomy than after HSV alone. The incidence of diarrhea in 729 patients who underwent HSV without cholecystectomy was found to be 8.8% whereas, in 66 patients in whom HSV was combined with cholecystectomy, the incidence of diarrhea was 9.3%. In most patients, the diarrhea was very mild and in none was it severe. We conclude that the addition of cholecystectomy to HSV does not result in an increased incidence of diarrhea.

Adult↗
PubMedDate not supplied

Laparoscopic cholecystectomy: treatment of choice for cholelithiasis in children.

Laparoscopic cholecystectomy is rapidly replacing traditional cholecystectomy as the standard treatment for cholelithiasis and cholecystitis in adults. Over a period of 16 months, 14 children with a clinical diagnosis of cholelithiasis, ranging in age from 4 to 15 years (mean 12.2), were treated. All had symptoms of abdominal pain or vomiting; one had jaundice and recurrent cholecystitis. Five children (35%) had associated metabolic or hemolytic diseases. The 14 children were operated on using the laparoscopic cholecystectomy technique. No operation was converted to open cholecystectomy, but two patients required laparotomy: one because of suspected injury to the common duct, and the other because of nonvisualization of the gallbladder during laparoscopy. The mean post-operative hospital stay for the 11 children who underwent only laparoscopic cholecystectomy (one patient also had a simple mastectomy) was 50 hours (range 48-72 hours). All children resumed their normal activities almost immediately after discharge from hospital. No long-term biliary or other complications were seen in any patient throughout an average follow-up period of 6.2 months (range 3-16 months). The benefits of this operation in children are obvious: It is safe, effective, and well tolerated.

Adolescent↗