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PubMed1985

Subtotal cholecystectomy: for the difficult gallbladder in portal hypertension and cholecystitis.

An easy, safe, and definitive operation for the "difficult gallbladder" is described and has been termed subtotal cholecystectomy. Eighteen patients underwent subtotal cholecystectomy during a 30-month period, which constitutes approximately 7% of cholecystectomies performed at our institution. The indications were cholecystitis with severe fibrosis or inflammatory changes that prevented safe dissection in Calot's triangle in 11 patients and portal hypertension in seven patients (liver cirrhosis [two patients] and segmental portal hypertension caused by chronic pancreatitis [five patients]) to prevent massive blood loss from the gallbladder bed. The operation entails leaving the posterior wall of the gallbladder attached to the liver and securing the cystic duct at its origin from within the gallbladder with a purse string technique. The latter obviates the need for dangerous dissection in Calot's triangle. Control of bleeding from the remaining gallbladder edge is greatly facilitated by the use of a running suture after each stage of piecemeal excision of the gallbladder. All patients survived the operation and wound infection occurred in only two patients (11%). One patient required a laparotomy 1 month after surgery for adhesive small bowel obstruction related to the remaining gallbladder wall and site of a liver biopsy. No patients have so far developed postcholecystectomy symptoms (median follow-up 12.2 months; range 3 to 31 months). Subtotal cholecystectomy is a definitive operation that prevents recurrent gallstone formation, as no residual diseased gallbladder mucosa is left in continuity with the biliary system. It provides a simple, safe option in patients in whom cholecystectomy could be hazardous.

Aged↗
PubMed1985

[Relationship between cholecystectomy and the subsequent development of colorectal carcinoma].

In order to clarify the presence or absence of a relationship between cholecystectomy and the subsequent development of colorectal carcinoma, we compared the incidence of previous cholecystectomy in 448 patients with colorectal cancer and in 1627 with gastric cancer, who had been treated in our clinic during the 21 year period through 1963 to 1983. There was no statistically significant difference in the incidence of previous cholecystectomy between patients with colorectal and gastric cancer. We then performed an historical cohort study covering 461 patients undergoing cholecystectomy for gallstone during the 32 year period from 1949 to 1981 for the subsequent occurrence of carcinoma of the colorectum and stomach. The observed incidence was one in colon cancer and six in gastric cancer, showing a similar proportion of the development of both carcinomas in our district. The present study showed no evidence of cholecystectomy being an increased risk for the development of colorectal carcinoma.

Adolescent↗
PubMed1984

Surgonomics: the cost of cholecystectomy.

Health care costs presently comprise more than one tenth of the nation's gross national product: One third of these expenditures are made by Medicare-Medicaid. National reimbursement changes for Medicare under a Diagnostic-Related Group system began October 1, 1983. Hospital charges (excluding physician charges) for all patients who underwent cholecystectomy without common bile duct exploration (Diagnostic-Related group 197 and 198) from Jan. 1, 1983 to March 31, 1983 were examined to quantify mean charges, variances, and components of hospital charges. Twenty-one patients (mean age 46.1 years) underwent elective cholecystectomy and 24 patients (mean age 64.9 years) underwent emergency cholecystectomy. The mean charge for elective cholecystectomy was $4763 +/- $1656; the mean length of stay (LOS) was 8.0 +/- 3.2 days. Low and high trim points were $3211 to $10,639 and 5 to 19 days LOS. Quartile cost analysis of the cost per patient showed that Q1 = 18.5%, Q2 = 21.2%, Q3 = 24.0%, and Q4 = 36.3%. Analysis of services showed that laboratory work (urinalysis, hematology, coagulation, microbiology, and biochemistry) averaged $451 +/- $298 (9.5% of total), room and board $2635 +/- $1044 (55.3% of total), operating and recovery room $924 +/- $167 (19.4% of total), and central supply-pharmacy $350 +/- $158 (7.4% of total). The mean charge for patients undergoing emergency cholecystectomy was $11,436 +/- $4185; mean LOS was 17.8 +/- 6.5 days. Low and high trim points were $6353 to $19,734; LOS was 9 to 30 days. Services as percent of total were laboratory 15.8%, room and board 53.7%, operating and recovery room 9.14%, central supply-pharmacy 7.3%, and radiology 8.2%. Several important findings are noted: (1) For a given disease there is marked variance of hospital charges. (2) Mean charges of emergency patients were 240% that of elective patients. (3) Consumption of services varies significantly within each group and between groups. This study demonstrates the importance of in depth financial analysis of therapies. This is a first step to identify the components of variance where reduction will not affect quality of care.

Aged↗
PubMed1984

The effect of cholecystectomy on duodenogastric reflux in dogs and humans.

A prospective study of the effect of cholecystectomy on duodenogastric reflux (DGR) in dogs and humans has been performed and compared with patients presenting with persisting symptoms following cholecystectomy several years earlier. After an intravenous injection of 99mTc EHIDA, assessment of DGR was made by measuring Bilirubin Output and the percentage of 99mTc EHIDA recovered in gastric juice over fifteen minute periods. Cholecystectomy resulted in a significant increase in both amount and frequency of DGR in dogs and patients. Patients with persisting symptoms following cholecystectomy showed the greatest amount and frequency of DGR. We suggest that increased DGR may be an aetiological factor in some patients with persisting symptoms following cholecystectomy.

Animals↗
PubMed1995

[Laparoscopic cholecystectomy: a prospective study of 1,775 unselected patients].

1775 patients with symptomatic cholecystolithiasis were treated by laparoscopic cholecystectomy without selection or contraindications. Complications should be compared with those of conventional cholecystectomy. 73.5% of our patients were female, the median age was 62 years (min. 9, max. 91 years). They presented uncomplicated cholecystolithiasis in 85%, acute cholecystitis in 11% and cirrhotic gallbladder in 4.5%. The rate of conversion to laparotomy was 2.9% for uncomplicated cholecystolithiasis and 11% for each cholecystitis and cirrhotic gallbladders. In general 4.4% were converted. These conversions were due to complications in 0.9% (bile duct lesions 0.7%, bowel perforation 0.2%), due to adhesions or inflammatory alterations in 3%. Perioperative letality was 0.3%, but only 0.15% were related directly to the operation. Other complications were bile duct strictures 0.3%, postoperative hemorrhage 0.3%, ileus 0.2%, perforation of diaphragm/pneumothorax 0.1%. Suspected bile duct stones were proved and treated by preoperative ERCP in 5.6%. Routinely performed intraoperative cholangiography detected unsuspected stones in 4%. These were removed mostly by postoperative ERCP. We consider laparoscopic cholecystectomy a safe method for the treatment of every stage of symptomatic cholecystolithiasis. There are no contraindications, if the operation is performed by an experienced team. Intraoperative cholangiography should remain standard. Complications in unselected patients are comparable to those of conventional cholecystectomy. The rate of bile duct lesions is equal (0.7%), a further decrease is expected (learning curve). According to this data, it is no longer justified, to perform cholecystectomy primarily by laparotomy, if there is experience with the laparoscopic method. Laparotomy by itself is no complication, it should be applied only, if the surgeon considers the operation inadequate to be continued laparoscopically.

Adolescent↗
PubMed1994

[To avoid complications during laparoscopic cholecystectomy].

Laparoscopic cholecystectomy is now becoming a safe procedure for the benign cholecystic diseases. But the differences, for example in the method of access to peritoneal cavity, visual field, and tools, between laparoscopic surgery and open surgery results in different complications. The purpose of this paper is to discuss how to avoid complications during laparoscopic cholecystectomy. A hundred consecutive patients were expected to receive an elective laparoscopic cholecystectomy from April 1991 to November 1992 in our clinic. Two patients were converted to open cholecystectomy. The reasons for conversion were uncontrollable bleeding from cystic artery and common-bile duct injury. Two other patients were obliged to undergo laparotomy due to post-operative bile leakage. Arterial bleeding from abdominal wall caused by inserting trocar was experienced in one case. Improvement of the equipment and surgical technique have got rid of these complications. We think it is still necessary to do intra-operative examinations such as cholangiography or ultrasonography. The previous two cases with complication of biliary injury underwent laparoscopic cholecystectomy without intraoperative examinations. We could have avoided these complications if intraoperative examinations were used. To prevent the complication of bleeding from abdominal wall, we have been carrying out a unique method. After the introduction of these procedures, we have never experienced any of these complications.

Bile Ducts↗
PubMed1995

Open cholecystectomy: muscle splitting versus muscle dividing incision: a randomized study.

While laparoscopic cholecystectomy has become the standard procedure for symptomatic gallstones, it is likely that 10% of patients will require an open cholecystectomy whether owing to contraindications to the laparoscopic approach or because conversion to the open technique became necessary following laparoscopy. Although the trend towards smaller open cholecystectomy incisions has led to a reduced hospital stay, much of the postoperative morbidity can be ascribed to wound pain. Muscle splitting incisions tend to be less painful than muscle dividing incisions. This randomized consecutive study of elective and emergent open cholecystectomies compared a muscle splitting incision with the traditional muscle dividing technique. The muscle splitting technique was significantly (P < 0.001) less painful than the muscle dividing method as evaluated by the short form of the McGill pain questionnaire. Similarly, a significantly greater proportion of patients were fully mobile on the first and second postoperative day in the muscle splitting group compared with the muscle dividing group. Analgesia requirements, however, were not statistically significant between the two groups. We recommend that when open cholecystectomy is necessary the muscle splitting technique should be employed.

Analgesia↗
PubMed1994

[Laparoscopic cholecystectomy].

The author presents a new surgical procedure-laparoscopic cholecystectomy. Comparing the time interval from introduction to widespread adaption of other new operations this century, such as vagotomy and open cardiac procedures, it took remarkably little time for the surgical community to accept laparoscopic cholecystectomy. To perform endoscopic surgery, surgeons had to improve eye-hand coordination, adapt to a new tactile sensation and lack of depth perception. The laparoscopic cholecystectomy is "here to stay". The author reports preintervention program as well as the procedure and its technique with necessary instruments. Laparoscopic cholecystectomy is a recently developed alternative to open cholecystectomy that is rapidly gaining popularity because patients have experienced reduced stay in hospital, decreased wound pain and early return to normal activity.

Cholecystectomy, Laparoscopic↗
PubMedDate not supplied

[The current controversies over video laparoscopic cholecystectomy as the treatment of choice for cholelithiasis].

Recently, the widespread use of laparoscopic cholecystectomy allowed to reach several goals such as a minimal invasive approach, a minimal operative trauma, the absence of aesthetic or functional damage of the abdominal wall, and a quick return to full activities. On the other hand, as all innovations, laparoscopic cholecystectomy is matter of debate and a number of controversies have recently appeared in the Scientific Literature. On the basis of their experience and through a critical review of the Literature, the Authors have therefore analyzed possible solutions to such controversies. Particularly, current indications and contraindications of this approach, surgical technique and relative sites of insertion of the trocars, the need to drain or not, the pre- and intra-operative study of the bile duct and the approach in case of bile duct stones pre- or intra-operatively demonstrated, have been evaluated as possible answers. The Authors conclude that indications to laparoscopic cholecystectomy are the same of those for laparotomy, contraindications are represented by coagulopathies, liver cirrhosis and plastic peritonitis. At present it is still impossible to affirm which is the best surgical technique, the best position for the surgeon, and the best site for the insertion of the trocars, while drainage must be used only in those cases in which further manoeuvres on the bile duct are required. At last the Authors underline there is no need for a routine intraoperative cholangiography during laparoscopic cholecystectomy, however such technique must be known by laparoscopic surgeons since it may be mandatory in some selected cases. ERCP, on the contrary, is a valid support to laparoscopic cholecystectomy in the treatment of gallbladder stones associated with bile duct stones.

Adult↗
PubMed1995

Routine outpatient laparoscopic cholecystectomy.

OBJECTIVE: To determine what proportion of patients booked for elective cholecystectomy can be treated on an outpatient basis and what criteria will predict the need for hospital admission. DESIGN: A prospective analysis. SETTING: A 306-bed, nonteaching, acute-care community hospital on the outskirts of a major urban centre. PATIENTS: One hundred consecutive patients in private referral practice scheduled for outpatient laparoscopic surgery between November 1992 and January 1994. INTERVENTION: Laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: The proportion of patients who successfully avoided hospital admission, the degree of discomfort, complications and the objective criteria that assist in predicting the need for initial or eventual hospital admission. RESULTS: Outpatient cholecystectomy was successful in 87% of the patients, and patient acceptance of the procedure was good. Advanced age, major associated health problems, acute cholecystitis and longer operations were the criteria most likely to lead to hospital admission, although none of these factors, alone or in combination, was a contraindication to outpatient cholecystectomy. CONCLUSIONS: Outpatient laparoscopic cholecystectomy can be performed successfully in most patients. There are four criteria that increase the likelihood of hospital admission after this procedure.

Adult↗
PubMed1994

Management of cholelithiasis in heart and kidney transplant patients: with review of laparoscopic cholecystectomy.

The purpose of this study was to determine the incidence of cholelithiasis among heart and kidney transplant recipients. Since recommendations for cholecystectomy in transplant recipients varies widely, we discuss guidelines for surgery including laparoscopic techniques. We reviewed the records of 114 patients who underwent heart transplantation from 1984 to 1993 and 539 kidney transplant patients from 1972 to 1993. Recipients of heart and kidney transplants were found to have an incidence of cholelithiasis of 12% and 3% respectively. Pretransplantation ultrasound surveillance was used in heart transplant recipients and 64% of these with asymptomatic cholelithiasis have not required surgery with close follow-up from six months to six years. Thirty-six percent of the heart patients underwent cholecystectomy. All symptomatic renal transplant patients undergoing ultrasound with the findings of cholelithiasis underwent cholecystectomy. Open cholecystectomies were performed prior to the advent of laparoscopic surgery in six of the first seven attempts. Laparoscopic cholecystectomy on heart and kidney transplant recipients was well tolerated with admission the same day of surgery, a one to two day hospital stay and maintenance of oral immunosuppression. There was a single complication of leg thrombophlebitis, no mortality, and allograft rejection did not occur.

Adult↗
PubMed1994

Trends in incidence, clinical findings and outcome of acute and elective cholecystectomy, 1970-1986.

OBJECTIVE: To assess time trends in the incidence, clinical findings, and outcome of conventional acute and elective cholecystectomy. DESIGN: Single-institution time series analysis. SETTING: University hospital, Sweden. SUBJECTS: A consecutive series of 2926 patients operated on for acute or chronic gallbladder disease in a defined Swedish population. MAIN OUTCOME MEASURES: Changes in the incidence and outcome of acute and elective cholecystectomy. RESULTS: From period I (1970-1978) to period II (1979-1986), the mean rate of acute operations increased from 10 to 30/100,000 inhabitants/year and that of elective operations decreased from 190 to 120/100,000 inhabitants/year. There was therefore a negative correlation between the rate of elective and acute operations (r = -0.58, p < 0.02). This was strongest when the rate of elective operations in any one year was correlated with the rate of acute operations two years later (r = -0.71, p < 0.01). In both groups the proportion of patients over 70 years old increased significantly. The female:male ratio decreased significantly for acute but not elective operations (mean 2.6 in period I and 1.0 in period II). The length of history and the number of previous admissions to hospital with gallstone disease decreased significantly for both groups, as did prevalence of common bile duct stones detected at cholecystectomy. Morbidity did not seem to change, though a general improvement may have been concealed, because patients were older in period II and postoperative mortality was lower than in period I. Complications were least common among patients with a short or no previous history of symptoms attributable to gallstones. CONCLUSIONS: The rate of elective cholecystectomy seems to have some influence on the future rate of acute cholecystectomy. When symptoms of gallstone disease develop, treatment should not be delayed unnecessarily.

Age Factors↗
PubMed1994

Quality of life after treatment of gallstones: results of a randomised study of lithotripsy and open cholecystectomy.

OBJECTIVE: To compare quality of life after extracorporeal shock wave lithotripsy (ESWL) and open cholecystectomy for symptomatic gallstones. DESIGN: Randomised study. SETTING: University hospital, The Netherlands. SUBJECTS: 49 Patients, 23 of whom were randomized to undergo ESWL and 26 to undergo open cholecystectomy. INTERVENTIONS: Health questionnaires were filled out before, and at 3, 6 and 12 months after treatment. MAIN OUTCOME MEASURE: Improvements of quality of life after one year. RESULTS: Both treatments improved quality of life. Open cholecystectomy improved quality of life significantly better than ESWL (median percentage gains in Nottingham Health Profile scores at 1 year 17.1 and 10.5, respectively, p = 0.003). CONCLUSION: Open cholecystectomy is superior to ESWL in improving quality of life, so cholecystectomy remains the treatment of choice for symptomatic gallstones. For patients who are unfit or unwilling to undergo operation, however, ESWL is adequate because most patients have some benefit from it in terms of quality of life.

Activities of Daily Living↗
PubMed1994

[Acute cholecystitis and laparoscopic cholecystectomy. Comparison with non-complicated cholelithiasis].

Laparoscopic cholecystectomy has become the treatment of choice for symptomatic cholelithiasis. However, the indication of the laparoscopic approach for acute inflammation of the gallbladder in unclear and further analysis of the results is required. The aim of our study was to compare the results of laparoscopic cholecystectomy after uncomplicated cholelithiasis and after acute cholecystitis. Data from 201 patients who underwent laparoscopic cholecystectomy were collected prospectively. Uncomplicated cholelithiasis was present in 149 patients and 52 individuals had acute cholecystitis. No differences in age, sex distribution or associated diseases were observed between groups. The mean operative time was significantly higher in patients with acute cholecystitis. However, no difference was observed regarding conversion rate (7.3%-7.6%) and morbidity rate (8.7%-9.6%). No mortality has occurred in any group. The average hospital stay after laparoscopic cholecystectomy was greater when acute cholecystitis was present (2.6 days-4.9 days; p < 0.01). But in this case hospitalization was shorter than after elective conversion (8 days; p < 0.001 and p < 0.05). We conclude that patients with acute cholecystitis can undergo laparoscopic cholecystectomy safely, with low morbidity and mortality rates and reduced hospital stay.

Acute Disease↗
PubMed1994

[Use of ultrasonic surgery in laparoscopic cholecystectomy].

INTRODUCTION: Laparoscopic cholecystectomy now represents a valid alternative to traditional surgery in the treatment of gallstone diseases. For the past twenty years laparotomic cholecystectomy has represented the golden standard of gallstone treatment given its extremely low mortality rate (0.5%) and equally acceptable morbidity rate. Laparoscopic cholecystectomy now appears to have taken over the position of elective treatment. Sophisticated techniques, such as ultrasound scalpels make this form of surgery particularly safe. MATERIALS AND METHODS: The authors report a series of 50 patients who underwent laparoscopic cholecystectomy in which ultrasound surgery was used in 40 cases using the CUSA system. The gallbladder hilus is prepared using ultrasound manipulation following the secure identification, respect and clipping of the cystic artery and duct. DISCUSSION AND CONCLUSIONS: Laparoscopic cholecystectomy appears to be the ideal treatment for gallstone diseases. In the series reported here the use of the ultrasound scalpel allowed the gallbladder hilus to be reach skeletization, preserving the main structures and keeping the operating field clean and blood-free, without increasing operating times. The possibility of severe accidents, such as vascular lesions to the hepatic artery or vena portae, or damage to the common bile duct or other abdominal organs are reduced using this technique.

Adult↗
PubMed1993

Laparoscopic cholecystectomy: the Japanese experience.

We investigated the current status of laparoscopic cholecystectomy in Japan. A retrospective survey of laparoscopic cholecystectomy was performed involving 1989 patients from eight Japanese institutions. The preoperative work-up and the operative technique were largely identical to those in the United States. Conversion to open cholecystectomy was required in 54 patients (2.7%) because of unexpected intraoperative findings such as inflammation and adhesions in 40 patients (2.0%) and intraoperative complications in 14 patients (0.7%). There were no deaths, and postoperative complications occurred in 34 of 1935 patients (1.75%) in whom laparoscopic cholecystectomy was completed. Only 10 patients (0.51%) had serious complications (hemorrhage and bile duct injury, for example) that required laparotomy. The incidence of bile duct injury was 11 of 1989 (0.55%). We conclude that the adoption of laparoscopic cholecystectomy in Japan has been highly successful.

Cholecystectomy, Laparoscopic↗
PubMed1994

Comparison of laparoscopic cholecystectomy in obese and non-obese patients.

Results of laparoscopic cholecystectomy in obese and non-obese patients were analyzed prospectively. Laparoscopic cholecystectomy was performed in 841 patients-179 obese (Group I) and 662 non-obese (Group II). Operative time averaged 73.1 minutes in Group I and 73.7 minutes in Group II. There were no statistically significant differences in the ability to perform cholangiography (99.4% Group I; 97.9% Group II), conversion rate (1.1% Group I; 1.5% Group II), or complications (4.5% Group I; 3.8% Group II). In Group I no pulmonary complications were noted, nor any cases of venous thromboembolic disease. Risk of laparoscopic cholecystectomy appears comparable in obese and non-obese patients. Based on historical comparisons, laparoscopic cholecystectomy may be safer than traditional cholecystectomy in obese patients.

Adolescent↗
PubMed1994

Intraoperative sonography of biliary tree during laparoscopic cholecystectomy.

The use of routine cholangiography during laparoscopic cholecystectomy is still under debate. Previous reports have suggested that intraoperative sonography can replace cholangiography in the evaluation of common duct lithiasis during open cholecystectomy. The present study was performed to evaluate the possible role of sonography during laparoscopic cholecystectomy. Thirty patients underwent intraoperative sonography of the biliary tree during laparoscopic cholecystectomy. In cases with a diagnosis of common bile duct lithiasis, intraoperative cholangiography was performed. In 26 cases, sonography did not show the presence of stones; in three cases, stones were identified at both sonography and cholangiography; in one case, stones were diagnosed by sonography alone. In this last case, stones were confirmed on later review of cholangiogram. No complications related to the method were observed. We suggest that intraoperative sonography can represent an adequate substitute for intraoperative cholangiography as a screening procedure for stone identification during laparoscopic cholecystectomy.

Adult↗