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PubMed1995

A prospective comparative study between conventional and laparoscopic cholecystectomy.

A prospective, comparative study was made between 371 patients undergoing laparoscopic cholecystectomy and 100 patients undergoing conventional cholecystectomy. Post-operative pain was assessed subjectively by a single observer using a visual analog score and objectively by assessment of parenteral analgesic used. Patients who underwent laparoscopic cholecystectomy required significantly less analgesia (46.7 mg vs 223.9mg mean pethidine dose, p < 0.01) and were observed to have mobilised earlier and had a shorter mean post-operative stay (3.5 days vs 5.9 days, p < 0.01). Laparoscopic cholecystectomy objectively reduces post-operative pain significantly and should be the new standard for treatment of gallstones.

Adult↗

PubMed1997

Incidence and significance of subdiaphragmatic air following laparoscopic cholecystectomy.

Subdiaphragmatic free-air may be indicative of a perforated viscus; however, it is normally present after open abdominal surgery. The objective of this study was to determine the significance and incidence of subdiaphragmatic free air following laparoscopic cholecystectomy (LC). Cases of intestinal perforation following laparoscopic cholecystectomy from 1991 to 1995 at The University of Texas Health Science Center at San Antonio were reviewed and their association with subdiaphragmatic free air was determined. Twenty-five patients undergoing LC and 20 patients undergoing open cholecystectomy (OC) were prospectively evaluated with chest radiographs to determine the incidence and quantity of nonpathologic postoperative free air. Four cases of intestinal perforation resulting from trocar injuries or electrocautery burns occurred among 1603 LCs during this study period, for an incidence of 0.2 per cent. Three of the four patients with perforations were diagnosed postoperatively (2-5 days), and two patients had a moderate volume of subdiaphragmatic free air that aided the diagnosis. The incidence of subdiaphragmatic air following LC was 24 per cent, compared to 60 per cent for OC (P < 0.05). Eighty-three per cent of patients with retained air after LC had a minimal volume, compared to 67 per cent of patients after OC (P < 0.05). Nonpathologic subdiaphragmatic free air may normally be present following laparoscopic cholecystectomy but is uncommon 24 hours after the operation. When present, only a small volume is usually detectable. In the rare situation of intestinal perforation resulting from LC, subdiaphragmatic free air may be an important diagnostic finding.

Adult↗

PubMed1996

A prospective randomised study of laparoscopic v. open cholecystectomy in aged patients with cholecystolithiasis.

Between August 1992 and July 1993, 27 patients aged 70 years of older with cholelithiasis were prospectively randomised into 2 groups. Fifteen patients underwent laparoscopic cholecystectomy and 12 patients underwent open cholecystectomy. Shorter operation time (93.3 +/- 25.3 minutes v. 176.3 +/- 26.1 minutes, P < 0.00001), fewer postoperative analgesic requirements (0.53 +/- 0.52 days v. 2.00 +/- 0.74 days, P < 0.00001), shorter postoperative hospital stay (3.93 +/- 1.71 days v. 7.92 +/- 0.79 days, P < 0.00001) and better cosmesis were found in the laparoscopic cholecystectomy group. The above data suggest that laparoscopic cholecystectomy is the treatment of choice for cholecystolithiasis in elderly patients.

Aged↗

PubMed1997

Lymphocytic subpopulation changes after open and laparoscopic cholecystectomy: a prospective and comparative study on 38 patients.

Up to now it has been unclear whether laparoscopic surgery has fewer immunosuppressive effects than traditional laparotomic procedures. In a series of 38 patients affected by symptomatic gallstone disease and operated on either by laparoscopy (group 1) or by traditional open surgery (group 2), we determined the postoperative changes in lymphocyte subpopulations up to postoperative day (POD) 30. We collected 15 ml of venous blood from all patients in both groups on the day before surgery and on POD 1, 7, 15, and 30. A control group (group 3) comprised 56 healthy volunteers; the control group was used only to ensure that baseline values were totally comparable with a normal population; only one blood sample was obtained from the subjects in group 3. Patients undergoing open cholecystectomy had a significant decrease in total lymphocyte count on POD 1. Basal levels of lymphocyte subpopulations did not differ significantly in the study and control groups. No differences were found in the preoperative lymphocyte cell counts in the two groups who underwent cholecystectomy. Pan-T cells (CD3) showed a statistically significant marked reduction throughout the observation period. The counts of helper (CD4), suppressor (CD8), and natural killer NK (CD16) T cells were reduced on POD 1; the NK cell (CD16) count remained low until POD 30, B lymphocytes showed no postoperative reduction. In patients who underwent laparoscopic cholecystectomy, a significant postoperative decrease in total lymphocyte count, and in CD3, CD4, and CD8 subpopulations was observed on day 1 only. There was no reduction in CD16 and CD19 subpopulations. A comparative statistical analysis of lymphocyte subpopulations in the two groups was carried out: In the open cholecystectomy group, compared with the laparoscopy group, CD3, CD4, CD8, and CD16 lymphocyte subpopulations showed marked reductions at different time points. In particular, statistically significant differences were found in CD3 levels from POD 1 through POD 30, in CD4 from day 1 through day 7, and in CD8 and CD16 only on day 1.

B-Lymphocytes↗

PubMed1997

Can medical school-affiliated hospitals compete with private hospitals in the age of managed care? An 11-state, population-based analysis of 351,201 patients undergoing cholecystectomy.

BACKGROUND: The purpose of this study was to use an 11-state, population-based hospital discharge database to assess the charges for care of patients undergoing cholecystectomy at both medical school affiliated hospitals (MSAHs) and private hospitals (nonMSAHs). It was our hypothesis that MSAHs could indeed provide efficient, competitively priced patient care. STUDY DESIGN: Data were obtained from the Healthcare Cost Utilization Project of the Agency for Health Care and Policy Research. The database tracks information on all hospitalized patients from 11 states for the years 1988-1992. RESULTS: Represented in the study were 849 nonMSAHs (82%) and 191 MSAHs (18%). During the 5 years of the study, 351,201 patients underwent cholecystectomy. The mean charges and the lengths of stay were similar in the two diagnosis related groups (DRGs) studied (197,198). The analysis demonstrated that during this same period, MSAHs led in both the adoption of laparoscopic cholecystectomy and decreased use of intraoperative cholangiography. CONCLUSIONS: Others have reported that MSAHs cannot compete with nonMSAHs in providing competitively priced care. The present study shows that for cholecystectomy, charges and length of hospital stay are comparable in MSAHs and nonMSAHs. This study supports the hypothesis that the leadership provided at United States medical schools may also extend to the area of cost-efficient care and hints at further areas of improvement.

Cholangiography↗

PubMed1997

Laparoscopic versus open cholecystectomy in cirrhotic patients: a prospective study.

The results of open cholecystectomy ([OC] n = 7) versus laparoscopic cholecystectomy ([LC] n = 7) in cirrhotic patients were analyzed prospectively. Groups were well matched for surgical indication, presence of ascites/bleeding tendency, and Child's grade. There was no mortality. Mean operating time was significantly longer in the LC group (155 +/- 47 vs. 103 +/- 25 min, p < 0.05). Operative blood loss was significantly greater in the OC group (128 +/- 125 vs. 642 +/- 467 ml, p < 0.05). No patient in LC group required blood transfusion in contrast to three patients in OC group. Compared with 0% postoperative complications in LC group, wound infections developed in 43% of the patients in OC group (p < 0.05). Mean hospital stay in LC group was significantly less (6.7 +/- 4 vs. 17.4 +/- 7.3 days, p < 0.01). Thus, contrary to previous belief, cirrhosis per se is not a contraindication to LC. Laparoscopic cholecystectomy may be the procedure of choice whenever cholecystectomy is indicated in a cirrhotic patient because it may be associated with less bleeding and fewer incision-related complications.

Blood Loss, Surgical↗

PubMed1998

Resistance to venous outflow during laparoscopic cholecystectomy and laparoscopic herniorrhaphy.

The effects of pneumoperitoneum on peak venous flow velocity in the common femoral vein and the vena cava have already been studied. The results suggested that venous stasis occurs during surgical pneumoperitoneum. This study determines the effects of pneumoperitoneum on the overall venous outflow resistance of the lower limbs. Venous outflow resistance was measured during surgical procedures by impedance plethysmography in 12 patients undergoing laparoscopic cholecystectomy, 4 patients undergoing laparoscopic herniorrhaphy, 4 patients undergoing conventional cholecystectomy, and 2 patients undergoing conventional herniorrhaphy. Venous outflow resistance did not change significantly during laparoscopic cholecystectomy or herniorrhaphy. No difference in venous outflow resistance between laparoscopic cholecystectomy and herniorrhaphy was found. During pneumoperitoneum, no obstruction to total lower limb venous outflow could be demonstrated, indicating that venous stasis in the limbs did not occur, and consequently, flow in the iliac and inferior caval veins was not compromised. Hypothetically, active vasodilatation resulting from mild compression may explain this. In our view, no special measures to prevent deep venous thrombosis have to be taken during laparoscopic procedures.

Adult↗

PubMed1998

[Surgical trauma induced by laparoscopic cholecystectomy].

The objective demonstration of improved postoperative recovery suggests that surgical injury induced by the laparoscopic approach is less intense than that after open surgery. Forty-two patients diagnosed as having noncomplicated gallstones were studied prospectively. They were operated on by laparoscopy (LC, n = 21) or open surgery (OC, n = 21). Both surgical procedures induced significant changes of investigated parameters (acute-phase response, free radical mediated reactions, neutrophil functions). Comparison of the results of the two cholecystectomy techniques showed that laparoscopic cholecystectomy induced a significantly less intense acute-phase response, a more attenuated oxidative stress characterising by free radical mediated reactions and that is less disruptive to neutrophil function. The results and the data from the literature suggest that surgical injury causing by the laparoscopic cholecystectomy is less intense than that after open cholecystectomy, which can explain partially the better clinical outcome following laparoscopic versus open procedure.

Cholecystectomy↗

PubMed1998

[Antibiotic prophylaxis in cholecystectomy--necessary and cost saving?].

The effectiveness of antimicrobial prophylaxis was evaluated on the basis of data collected in a study on quality management carried out in 28 East German hospitals, involving 4477 laparoscopic and conventional cholecystectomies (197 of which with revision of the common bile duct). In 3128 patients a laparoscopic procedure (with consecutive conversion to an open cholecystectomy in 236 cases) and in 1349 patients a primarily conventional open cholecystectomy had been performed (a total of 2217 cases with and 2260 cases without antibiotic cover). The results obtained were significantly better in the group receiving prophylaxis than in patients not under antimicrobial cover. This applied to septic wound healing disorders, general and specific postoperative complications, postoperative chest infections, re-operations and postoperative lethality. On the basis of these results, it is strongly recommended that, in the future, neither laparoscopic nor open conventional cholecystectomy should be carried out without proper perioperative antimicrobial prophylaxis-this all the more so since such measures also result in a shorter hospital stay and thus reduced costs.

Adult↗

PubMed2001

Prophylaxis with oral granisetron for the prevention of nausea and vomiting after laparoscopic cholecystectomy: a prospective randomized study.

HYPOTHESIS: Laparoscopic cholecystectomy is associated with a relatively high incidence of postoperative nausea and vomiting when no prophylactic antiemetic is given. This study assesses the efficacy and safety of oral granisetron hydrochloride for the prevention of nausea and vomiting after laparoscopic cholecystectomy. DESIGN: A prospective, randomized, double-blind, placebo-controlled study. SETTING: University teaching hospital. PATIENTS: The study comprised 120 patients, 92 women and 28 men, undergoing laparoscopic cholecystectomy. INTERVENTIONS: Patients received orally either placebo or granisetron at 3 different doses (1 mg, 2 mg, and 4 mg; n = 30 of each) 60 minutes before surgery. A standard general anesthetic technique and postoperative analgesia were used. MAIN OUTCOME MEASURES: Emetic episodes were recorded during the first 24 hours after anesthesia. RESULTS: The incidence of patients who were emesis-free 24 hours after anesthesia was 60% with 1 mg of granisetron (P =.40), 83% with 2 mg of granisetron (P =.01), and 83% with 4 mg of granisetron (P =.01), compared with placebo (53%). No clinically important adverse effects were observed in any of the groups. CONCLUSION: Preoperative oral granisetron in doses higher than 2 mg is effective for the prevention of nausea and vomiting after laparoscopic cholecystectomy.

Administration, Oral↗

PubMed2003

Minilaparoscopic and laparoscopic cholecystectomy: a comparative study.

HYPOTHESES: To evaluate the feasibility and safety of the minilaparoscopic cholecystectomy (MLC) and to compare the clinical benefits experienced by patients who undergo MLC with those who undergo laparoscopic cholecystectomy (LC) or 5-mm laparoscopic cholecystectomy (5-mm LC). DESIGN: Prospective consecutive study. SETTING: A tertiary referral center. PATIENTS: From September 1, 2000, through June 30, 2001, 90 patients with symptomatic gallstones were randomized to undergo 1 of these 3 procedures. INTERVENTION: Minilaparoscopic cholecystectomy, LC, and 5-mm LC. MAIN OUTCOME MEASURES: Duration of surgery, loss of blood, length of hospital stay, resumption of solid food intake, quantity of analgesic dosage administered, development of complications, degree of pain at ports 24 and 48 hours after surgery, and overall cosmetic result. RESULTS: Subsequent to excluding 6 patients who were converted to LC, there were 30 patients in the LC group, 29 patients in the 5-mm LC group, and 25 patients in the MLC group. The MLC necessitated a longer time to complete the procedure than was the case for the other 2 procedures. There was no notable difference in the mean dosage of the meperidine hydrochloride (Pethidine) administered between the LC and MLC groups, but an apparent increase in the analgesia requirements for the 5-mm LC group was noted when compared with those of the other 2 groups. There was no remarkable difference in terms of blood loss, resumption of solid food intake, hospital stay subsequent to surgery, or surgical-related complication between these 3 groups. The MLC group did have a lower pain score in the subxyphoid port only at 24 hours after surgery compared with the other 2 groups. The cosmetic results were evaluated and no notable difference was noted at 1 week, 1 month, and 6 months after surgery. CONCLUSIONS: Although this study has demonstrated the feasibility and safety of the MLC, it does require a longer surgical time and reflects a reasonably high possibility for the conversion to LC. Furthermore, the MLC did not provide any notable clinical benefit for the tested patients compared with those patients in the LC group. We concluded that there is no reason for the MLC to become the universally accepted mode of treatment for symptomatic gallstones before further improvements are made in the technique and instrumentation.

Adult↗

PubMed2004

Quality-of-life assessment of surgical reconstruction after laparoscopic cholecystectomy-induced bile duct injuries: what happens at 5 years and beyond?

HYPOTHESIS: Quality of life of patients after biliary reconstruction for laparoscopic injuries is comparable to that of patients after laparoscopic cholecystectomy. DESIGN: Outcomes study. SETTING: Tertiary referral center. PATIENTS: Records of 59 consecutive patients undergoing surgical reconstruction of the biliary tract after injury induced by laparoscopic cholecystectomy between 1990 and 1997 were reviewed. Hepp-Couinaud technique or Roux-en-Y hepaticojejunostomy was used in 53 patients; other procedures included cholangiojejunostomy, choledochorrhaphy, and hepaticoduodenostomy. INTERVENTIONS: Quality-of-life questionnaires (36-Item Short-Form Health Survey [SF-36]) were mailed to each patient in the group and to patients who underwent uneventful laparoscopic cholecystectomy, matched individually by year, sex, and age group. Values from the general population matched by age and sex were gathered (national norms). Minimum time of follow-up was 5 years. RESULTS: Eighty-nine (81%) of 110 potential respondents to the survey completed the SF-36 questionnaires. All 8 values evaluated in the SF-36 questionnaire (physical functioning, role-physical, bodily pain, general health perceptions, vitality, social functioning, role-emotional, and mental health index) for patients undergoing biliary reconstruction were similar to those of both their matched controls (all P >.10) and national norms (all P >.05). The standardized physical component scale was also similar between the 2 groups (cases vs controls, 51 vs 48; P =.47), as was the standardized mental component scale (cases vs controls, 55 vs 55; P =.60). CONCLUSIONS: With a minimum of 5 years of follow-up, the quality of life after surgical biliary reconstruction compares favorably with that of both patients undergoing uneventful laparoscopic cholecystectomy and national norms.

Adult↗

PubMed2006

The value of chemoprophylaxis against Enterococcus species in elective cholecystectomy: a randomized study of cefuroxime vs ampicillin-sulbactam.

HYPOTHESIS: Cephalosporins are widely used and considered to be effective as prophylaxis in biliary surgery. Nevertheless, they lack activity against enterococci. We conducted a study to compare the efficacy of ampicillin-sulbactam vs cefuroxime in preventing surgical site infections following elective cholecystectomy. DESIGN: A prospective randomized controlled trial. SETTING: A major tertiary care hospital. PATIENTS: Four hundred eighteen randomized patients (of 549 total), who from July 2002 to August 2004 underwent elective open or laparoscopic cholecystectomy with prospective assessment for development of surgical site infections for 1 month postoperatively. INTERVENTION: A single intravenous dose of 1.5 g of cefuroxime (group A, n = 207) or 3 g of ampicillin-sulbactam (group B, n = 211) was administered during induction of anesthesia. Bile and gallbladder mucosal cultures were taken intraoperatively from all patients. MAIN OUTCOME MEASURE: Number of postoperative surgical site infections. RESULTS: A postoperative surgical site infection was noted in 19 (4.5%) of 418 patients, 18 from group A and 1 from group B (P<.001). In the group that received cefuroxime, 15 (83.3%) of 18 surgical site infections were due to Enterococcus species. Intraoperative bactibilia as well as intraoperative gallbladder rupture were associated with surgical site infections (P<.001). CONCLUSIONS: A single dose of ampicillin-sulbactam favored better compared with cefuroxime for prevention of postoperative surgical site infections due to Enterococcus species after elective cholecystectomy. Ampicillin-sulbactam may be a better agent for antimicrobial prophylaxis in high-risk patients undergoing elective cholecystectomy, especially in a setting where the incidence of enterococcal infections is higher.

Ampicillin↗

PubMed1987

Does cholecystectomy affect colonic tumorigenesis?

To determine if cholecystectomy predisposes to colon cancer, & study of this operation's influence on chemically induced murine colonic neoplasia was conducted. One hundred mice underwent cholecystectomy or a sham operation. Equal groups received either ten weekly injections of 1,2-dimethylhydrazine (DMH) or injections of saline. Twenty-four weeks after operation, the site, histologic findings, and number of tumors were noted. Crypt metaphase index (CMI) and proliferative zone size (PZS) determinations served as markers of preneoplasia. Tumors were found in the majority of animals receiving DMH while no tumors were found in the saline groups. Both CMI and PZS were significantly increased by DMH administration. Within the saline group, cholecystectomy increased CMI and PZS two and three times, respectively, over levels seen in the sham-operated animals. This suggests that cholecystectomy alone induces preneoplastic changes in the murine colonic crypt.

Animals↗

PubMed1989

Concomitant cholecystectomy for asymptomatic cholelithiasis.

The outcome of 68 patients with asymptomatic cholelithiasis undergoing laparotomy for other conditions was reviewed to determine those most likely to become symptomatic postoperatively. Thirty-seven patients (54%) became symptomatic postoperatively. Eight patients (22%) required cholecystectomy within 30 days of operation or within the same hospitalization. These patients fasted for a longer period of time postoperatively (15 +/- 21 vs 4 +/- 3 days) than those undergoing later cholecystectomy. Significantly more of these patients required transfusion (38% vs 7%), mechanical ventilation (50% vs 11%), and total parenteral nutrition (50% vs 18%). Cholelithiasis frequently becomes symptomatic after laparotomy for other intra-abdominal conditions. Patients who require mechanical ventilation, transfusions, and parenteral nutrition and who are slow to resume enteral nutrition are more likely to require early cholecystectomy. Concomitant cholecystectomy adds minimal morbidity to other procedures and should be undertaken unless specific contraindications exist, particularly in this high-risk group.

Adult↗

PubMed1991

Analysis of the hemodynamic and ventilatory effects of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy uses carbon dioxide, a highly diffusable gas, for insufflation. With extended periods of insufflation, patient arterial carbon dioxide levels may be adversely altered. Patients were selected for laparoscopic cholecystectomy using the same criteria as for open cholecystectomy. Twenty patients (group 1) had normal preoperative cardiopulmonary status (American Society of Anesthesiologists class I), while 10 patients (group 2) had previously diagnosed cardiac or pulmonary disease (class II or III). Demographic, hemodynamic, arterial blood gas, and ventilatory data were collected before peritoneal insufflation and at intervals during surgery. Patients with preoperative cardiopulmonary disease demonstrated significant increases in arterial carbon dioxide levels and decreases in pH during carbon dioxide insufflation compared with patients without underlying disease. Results of concurrent noninvasive methods of assessing changes in partial arterial pressures of carbon dioxide (end-tidal carbon dioxide measured with mass spectrographic techniques) may be misleading and misinterpreted because changes in partial arterial pressures of carbon dioxide are typically much smaller than changes in arterial blood levels and, unlike arterial gas measurements, do not indicate the true level of arterial hypercarbia. During laparoscopic cholecystectomy, patients with chronic cardiopulmonary disease may require careful intraoperative arterial blood gas monitoring of absorbed carbon dioxide.

Aged↗

PubMed1993

Routine cholangiography is not warranted during laparoscopic cholecystectomy.

The role of intraoperative cholangiography during laparoscopic cholecystectomy was prospectively evaluated in 514 patients undergoing laparoscopic cholecystectomy. Before surgery, all patients were assigned to one of three groups depending on the likelihood of their having common bile duct stones. Stratification was based on objective historical, laboratory, or radiologic criteria. In 453 patients deemed unlikely to have stones, laparoscopic cholecystectomy was performed without cholangiography. Of these patients, four had retained stones (0.9%). In 25 patients likely to have stones, preoperative endoscopic retrograde cholangiopancreatography identified stones in six patients (24%). In 36 patients whose likelihood of having stones was deemed indeterminate, intraoperative cholangiography was performed at laparoscopic cholecystectomy. A common bile duct stone was identified in one patient (2.8%). One common bile duct injury occurred in the group deemed unlikely to have stones, and this injury would not have been prevented by intraoperative cholangiography. We conclude that preoperative assessment will identify common bile duct stones and that routine cholangiography is not warranted. Meticulous dissection of the cystic duct at its origin at the infundibulum will prevent common bile duct injury.

Adolescent↗

PubMed1996

Laparoscopic cholecystectomy in acute cholecystitis. What is the optimal timing for operation?

OBJECTIVE: To review the results of laparoscopic cholecystectomy (LC) in patients with acute cholecystitis with attention to cost and clinical outcome. DESIGN: Retrospective study. SETTING: Large private metropolitan teaching hospital. PATIENTS: Four hundred forty-six patients had LCs at our institution between January 1993 and February 1995. Acute cholecystitis, confirmed by clinical, laboratory, operative, and histopathological findings, was present in 60 patients. MAIN OUTCOME MEASURES: The medical history, laboratory findings, gallbladder ultrasounds, timing of operation from the onset of symptoms, conversion rates to open procedures, operative times, intraoperative findings, complications, postoperative length of stay, cost of operative procedures and hospitalizations, and convalescence times were collected. RESULTS: Laparoscopic cholecystectomy was attempted in 16 patients within 72 hours of the onset of symptoms of acute cholecystitis (group 1), in 19 patients with symptoms between 4 and 7 days (group 2), and in 25 patients with symptoms lasting more than 7 days (group 3). The only factor (eg, preoperative laboratory and ultrasound findings) that affected the outcome of the operation was duration of symptoms prior to operation. Patients who had LC done within 72 hours of the onset of symptoms had lower rates of conversion to open procedures, less difficult operations, shorter operative times, less costly procedures, and a shorter convalescence than those with symptoms for longer than 72 hours prior to operation. The conversion rates in patients operated within and after 72 hours were 12% and 30%, respectively. There were no bile duct injuries and no mortalities. CONCLUSIONS: Laparoscopic cholecystectomy can be performed safely in most patients with acute cholelithiasis. However, we found that the duration of symptoms prior to LC affected the outcome; the conversion rates, hospital costs, and convalescence times increased in operated-on patients with symptoms for more than 72 hours. In our opinion, interval cholecystectomy may be a superior option in this latter group of patients.

Acute Disease↗