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PubMed1997

Bile duct injuries during laparoscopic cholecystectomy.

BACKGROUND: With the introduction of laparoscopic cholecystectomy, an increase in the incidence of bile duct injury two to three times that seen in open cholecystectomy was witnessed. Although some of these injuries were blamed on the "learning curve," many occurred long after the surgeon had passed his initial experience. We are still seeing these injuries today. METHODS: To better understand the mechanism behind these injuries, in the hope of reducing the injury rate, 177 cases of bile duct injury during laparoscopic cholecystectomy were reviewed. All records were studied, including the initial operative reports and all subsequent treatments. Videotapes of the procedures were available for review in 45 (25%) of the cases. All X-ray studies, including interoperative cholangiograms and ERCPs, were reviewed. RESULTS: The vast majority of the injuries seen in this review (71%) were a direct result of the surgeon misidentifying the anatomy. This misidentification led to ligation and division of the common bile duct in 116 (65%) of the cases. Cholangiograms were performed in only 18% (32 patients) of cases, and in only two patients was the bile duct injury recognized as a result of the cholangiogram. Review of the X-rays showed that in each instance of common bile duct ligation and transection in which a cholangiogram was performed the impending injury was in evidence on the X-ray films but ignored by the surgeon. CONCLUSIONS: From this review, several conclusions can be drawn. First and foremost, the majority of bile duct injuries seen with laparoscopic cholecystectomy can either be prevented or minimized if the surgeon adheres to a simple and basic rule of biliary surgery; NO structure is ligated or divided until it is absolutely identified! Cholangiography will not prevent bile duct injury, but if performed properly, it will identify an impending injury before the level of injury is extended. And lastly, the incidence of bile duct injury is not related to the laparoscopic technique but to a failure of the surgeon to translate his knowledge and skills from his open experience to the laparoscopic technique.

Adult↗
PubMed1997

The dramatic reality of biliary tract injury during laparoscopic cholecystectomy. An anonymous multicenter Belgian survey of 65 patients.

BACKGROUND: Most reports concerning the outcome of patients with biliary tract injury during laparoscopic cholecystectomy come from tertiary referral centers, and results could be very different in the everyday practice of community surgeons. OBJECTIVE: The objective is to define the presentation, mechanisms, results of treatment, and long-term outcome of biliary tract injuries during laparoscopic cholecystectomy in the setting of a community surgeon's practice. METHODS: An anonymous retrospective multicenter survey of 9,959 patients who underwent laparoscopic cholecystectomy was conducted by the Belgian Group for Endoscopic Surgery, composed mainly of community general surgeons. RESULTS: Sixty-five patients with bile duct injury were reported on; the incidence was 0.5%, varying from 0. 35 to 1.3% according to the experience of the surgeon. Thirty-four percent of ductal injuries occurred with experienced surgeons, often in association with local predisposing risk factors. Injury occurred in 87% of cases during dissection of the Calot triangle, with severe injury occurring in 46% of patients. Intraoperative cholangiography was performed in 34% of patients and was associated with a significantly improved operative detection rate of injury (68% vs 32%, p = 0.007). Operative detection of injury occurred in 45% of patients; diffuse bile ascitis was encountered postoperatively in 29%. The overall mortality was 9%, the postoperative biliary complication rate 31%, and the reintervention rate 14%. During a median follow-up of 49 months (range, 3-78 months), 20 of the 61 surviving patients (33%) had recurrent biliary strictures. Multivariate analysis demonstrated that the age of the patient (odds ratio: 0.893) and the presence of biliary peritonitis (odds ratio: 0.061) were independent predictive factors for mortality and that the age of the patient (odds ratio: 1.049) and the occurrence of postoperative biliary complications (odds ratio: 0.161) after the initial biliary repair were independent predictive factors for late biliary stricture. CONCLUSIONS: Biliary tract injury is associated with significant mortality and complications in the practice of Belgian community surgeons. Intraoperative detection of ductal injury by the routine use and a correct interpretation of intraoperative cholangiography improved outcome. The impact of the primary biliary repair on long-term outcome is an argument to refer these patients to specialized multidisciplinary experts. The results highlight the importance of surgical experience, proper selection of patients for laparoscopic cholecystectomy, and conversion to laparotomy in difficult cases.

Adult↗
PubMed1999

The outcome of major biliary tract injury with leakage in laparoscopic cholecystectomy.

BACKGROUND: Concern has been expressed regarding the increased rates of biliary tract injury (BTI) at laparoscopic cholecystectomy. The aim of the present investigation was to analyze the outcome of laparoscopic biliary tract injury with leakage. METHODS: Sixteen patients having major laparoscopic BTI with leakage were treated. Thirteen of them were referred to our institution for further treatment. The follow-up was complete and focused on clinical outcome and biochemical analysis. RESULTS: Eight BTI were identified at the time of laparoscopic cholecystectomy, and the procedure was converted to a laparotomy. In eight additional patients, BTI was recognized postoperatively. In this group one patient died because of lately diagnosed biliary peritonitis, whereas in the seven surviving patients nine attempts to repair the BTI and eight other interventions were performed. In the conversion group 14 attempts to repair the BTI and 11 other interventions were needed to completely solve the problems. Final restoration of the BTI was done by Roux-en-Y hepaticojejunostomy in 11 patients and suture repair with T-tube drainage of the bile duct in 4. During a median follow-up time of 63 months, three patients suffered from recurrent segmental cholangitis. In the other patients, neither clinical nor biochemical evidence of biliary disease has been found up to this writing. CONCLUSIONS: Laparoscopic BTI has a high morbidity and mortality rate that seems comparable to BTI at open cholecystectomy. The number of attempts to repair the BTI as well as additional interventions is too high, but in this patient series the final outcome seemed to be similar after BTI recognized during and after laparoscopic cholecystectomy.

Adult↗
PubMed1999

The fate of the dropped gallstones during laparoscopic cholecystectomy.

Stones can be spilled from the gallbladder during laparoscopic cholecystectomy. These stones can be left in the peritoneal cavity or trapped at the trocar site. The potential late sequel and associated morbidity are not well documented. We reviewed the records of four patients who underwent laparoscopic cholecystectomy at Mount Sinai Medical Center in New York City who suffered from late complications attributed to gallstones left in the peritoneal cavity or abdominal wall. Four patients presented 1-14 months after laparoscopic cholecystectomy with intraabdominal and abdominal wall abscesses. The spillage of gallstones was noticed during the initial operation only in one of the patients. Three patients required laparotomy and open drainage of intraabdominal abscesses with drainage of pus and gallstones after failed attempts at percutaneous drainage. Two patients underwent local exploration of an abdominal wall abscess containing stones. Stones left in the abdominal cavity or trapped in trocar sites after laparoscopic cholecystectomy can cause serious late complications requiring repeated surgical interventions. Every effort should be made in order to avoid spillage of stones during dissection of the gallbladder and cystic duct and during retrieval of the gallbladder through the abdominal wall.

Abdominal Abscess↗
PubMed1999

Needlescopic or minisite cholecystectomy.

Needlescopic or minisite cholecystectomy is laparoscopic cholecystectomy done through tiny ports from 1.4 mm to 3 mm in size. This refinement of conventional laparoscopic cholecystectomy reduces further the invasiveness of the operation and gives an improved cosmetic effect. This series describes the result of 36 needlescopic cholecystectomies done between February 1996 and April 1997. Patients with acute cholecystitis were excluded. There were two conversions to conventional laparoscopic surgery and no conversions to open surgery. Thirty-four patients were successfully treated by this technique. Analgesic consumption and cosmetic result was superior compared to a previous published series of conventionally done cases in the same department.

Adult↗
PubMed1998

Managing bile duct injury during and after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is now the treatment of choice for gallstones, but there has been concern that bile leakage after a laparoscopic cholecystectomy is more frequent than after an open cholecystectomy. We have experienced 16 patients with bile duct injury after a laparoscopic cholecystectomy. Five patients had a circumferential injury to the major bile duct, and we employed a converted open technique for biliary reconstruction. The other 11 patients had partial injury to the major bile duct, and we performed laparoscopic restoration; all 11 of these patients received endoscopic retrograde cholangiography (ERC) on the day after the operation and stenting for biliary decompression and drainage. No complications were identified and the duration of hospitalization in these patients was significantly shorter than in those who had the converted procedure. If intraoperative cholangiography is performed routinely, the presence and form of bile duct injury can be clearly identified, and the decision to restore the site of injury or to convert to the open technique for biliary reconstruction can be made immediately.

Adult↗
PubMedDate not supplied

Predictions and associations of cholecystectomy in patients with cholecystolithiasis treated with extracorporeal shock wave lithotripsy.

Extracorporeal shock wave lithotripsy (ESWL) is effective in the treatment of symptomatic cholecystolithiasis in well-selected patients. We analyzed the predictors of cholecystectomy in a large series of gallstone patients after ESWL. This was a retrospective follow-up cohort-study of consecutive patients undergoing ESWL for symptomatic cholecystolithiasis over a 9-year period. It was possible to analyze a total of 297 patients; there were 211 women and 86 men, with a mean age of 52 years (range, 8-81 years). Patients that had been cholecystectomized after ESWL were compared to patients with their gallbladder still in situ and determinants of cholecystemctomy in terms of clinical, stone, and gallbladder parameters and symptoms analyzed. The mean duration of follow-up was 99 months (range, 27-134 months). During follow-up, 106 (36%) patients underwent a cholecystectomy at a mean of 34 months (range, 0-127 months) after ESWL. Histological data showed a normal gallbladder wall in only 4 cases; 101 examinations revealed some kind of (chronic) inflammation, which was not different from histological gallbladder results in patients without prior lithotripsy. Three gallbladder polyps were found, but no carcinoma. Cholecystectomy after ESWL of gallbladder stones was strongly associated with persitent and/or renewed biliary symtoms. Nevertheless, only three of four patients became asymptomatic after CE. Thus, ESWL proved to be a valuable organ-preserving alternative to cholecystectomy in selected patients.

Adolescent↗
PubMed2005

Influence of age and gender on quality-of-life outcomes after cholecystectomy.

Few studies have assessed the role of sociodemographic characteristics on outcomes after a cholecystectomy. Our goal was to evaluate the influence of age and gender on the health related quality of life (HRQoL) changes after cholecystectomy in this prospective observational study of consecutive patients undergoing cholecystectomy. Patients completed the SF-36 and the Gastrointestinal Quality of Life Index (GIQLI) before intervention and 3 months later. The influence of age, gender, and the pre-intervention health status on the HRQoL changes was studied by multivariate regression analysis. Older patients had poorer HRQoL and their post-intervention improvement was lower than younger patients. Compared with men, women had worse health status before the intervention measured with both HRQoL tools. In the unadjusted analysis women had greater improvements than men, measured by the GIQLI, but not with the SF-36. However, after controlling for other relevant variables, the SF-36 measured lower improvements in women more often than men, but the GIQLI showed similar results for both. For men and women, the lower the pre-intervention health status the higher the post-operative improvement. Women presented with worse health status before the intervention and less improvement post-operatively after adjustments. The pre-intervention health status has an important role explaining changes after the intervention. A gender-related difference exists between what a generic and a disease-specific HRQoL instrument captures when measuring HRQoL improvement after cholecystectomy.

Age Factors↗
PubMed1983

The stomach after cholecystectomy.

Removal of the gallbladder results in an accelerated enterohepatic circulation of bile salts. It has been suggested that reflux of bile into the stomach after cholecystectomy may predispose a patient to the development of gastric lesions. To examine this hypothesis, 349 patients with endoscopically proved gastric ulcers or mucosal lesions were age and sex matched with 349 patients with upper gastrointestinal symptoms who had normal endoscopic findings. The frequency of cholecystectomy was determined to be 4.3 percent in the gastric ulcer group (control 3.7 percent) and 3.8 percent in the mucosal lesions group (control 4.2 percent). There was no statistical difference between patients with gastric ulcer and the control subjects, mucosal lesions and controls in the frequency of cholecystectomy using individually matched case-control comparison. The relative risk for gastric ulcer-matched control comparison was 1.3 (95 percent confidence limit 0.3 to 6.3). The relative risk for mucosal lesion-matched control comparison was 0.85 (95 percent confidence limit 0.2 to 2.9). The data did not support the hypothesis that cholecystectomy increases the propensity to develop gastric lesions.

Bile↗
PubMed1986

Radionuclide evaluation of bile leakage and the use of subhepatic drains after cholecystectomy.

Our study addresses the question of efficacy of drainage after cholecystectomy by evaluation of the leakage of radiolabeled bile. Based on our data, drains placed at the time of surgery do not appear to reliably remove bile or to decrease morbidity. Our study reveals that bile leakage after cholecystectomy is frequent, cannot be accurately predicted at operation, is not related to the experience of the operating surgeons, and does not necessarily correlate with morbidity. The shorter postoperative hospital stay in the group of patients with subhepatic bile leakage compared with the group without evidence of leakage after cholecystectomy is not statistically significant. However, this trend does suggest that there is no increase in morbidity associated with bile leakage per se. A large, clinically significant bile leak can easily be treated by modern interventional radiologic techniques if drainage is indicated. A larger, double-blind study is necessary to further evaluate the issues surrounding bile leakage and drainage after cholecystectomy.

Adult↗
PubMed1989

The alkaline shift in gastric pH after cholecystectomy.

Previous studies using cholescintigraphy and measurement of bile salts in gastric juice have demonstrated that duodenogastric reflux is increased after cholecystectomy, a factor that may contribute to postoperative complaints in some patients. We studied 24-hour continuous gastric pH in healthy subjects, patients with cholelithiasis, and patients who had undergone cholecystectomy. Cholecystectomy decreased the percentage of time that gastric pH is below 2 and increased the time it is above 4 and 6. Furthermore, there was a greater increase in the more alkaline pH values in patients who were symptomatic than in those who were asymptomatic. The results demonstrated that cholecystectomy is associated with an alkaline shift in the 24-hour gastric pH profile that is most marked in symptomatic patients. This suggests that gastric alkaline episodes may be related to some postcholecystectomy symptoms.

Adolescent↗
PubMed1991

Avoidance of bile duct injury during laparoscopic cholecystectomy.

Common bile duct (CBD) injury during laparoscopic cholecystectomy appears to have a higher incidence than during open cholecystectomy. This may be a function of inadequate instruction, inadequate caution, or inexperience, or may represent an inherent flaw in laparoscopic exposure. The aim of this study was to identify several steps in laparoscopic exposure of the gallbladder, cystic duct, and Calot's triangle to minimize the risk of surgical disorientation and CBD injury. A review of the first 180 laparoscopic cholecystectomies from the author's series was performed. Maneuvers that provided optimal exposure of the critical anatomy were culled from the video record. These maneuvers were (1) routine use of a 30 degree forward oblique viewing telescope, (2) firm cephalic traction on the fundus of the gallbladder to reduce redundancy in the infundibulum of the gallbladder and best expose the cystic duct, (3) lateral traction on the infundibulum of the gallbladder to place the cystic duct perpendicular to the CBD, (4) dissection of the cystic duct at the infundibulum of the gallbladder, and (5) routine fluoroscopic cholangiography. If these steps do not provide the surgeon with comfortable anatomic orientation, the procedure should be converted to open cholecystectomy.

Cholangiography↗
PubMed1991

Laparoscopic guided cholecystectomy.

Cholecystectomy remains the most effective form of therapy for patients with symptomatic cholelithiasis. An alternative method of gallbladder removal, laparoscopic guided cholecystectomy, was attempted in 100 patients. Five patients required conversion of the laparoscopic procedure to an open laparotomy for the following reasons: discovery of a pancreatic malignancy in one patient, extensive adhesions in one, presence of an aberrant accessory right hepatic duct in one, common hepatic duct injury in one, and avulsion of the cystic duct in one. Both ductal injuries occurred during the early phase of the clinical program. In those patients undergoing laparoscopic cholecystectomy, 93 were discharged within 24 hours of surgery and 94 returned to normal activity within 1 week. Laparoscopic guided cholecystectomy appears to offer a number of advantages in patient care as well as a significant reduction in health care expenses for gallbladder disease. Appropriate training in laparoscopic surgery is necessary in order to avoid operative complications.

Adolescent↗
PubMed1991

Complications of laparoscopic cholecystectomy.

The emergence of laparoscopic cholecystectomy as a viable alternative to traditional cholecystectomy has been greeted with enthusiasm by the surgical community. This new technique is not without complications, both potential and real. The complications associated with diagnostic laparoscopy are well documented, as are those associated with traditional cholecystectomy. All of these may also be seen with laparoscopic cholecystectomy. The incidence of their occurrence, however, may vary. It remains too early to evaluate the complication rates from this new procedure, as reports of large series are just beginning to emerge. Early reports are encouraging but caution that bile duct injury, hemorrhage, and even death may occur. Early enthusiasm for this new method must be tempered with care in its practice if complication rates are to be maintained at an acceptable level and the procedure is to earn a permanent place in the armamentarium of the surgeon.

Bile↗
PubMed1991

Interruption of professional and home activity after laparoscopic cholecystectomy among French and American patients.

With a laparoscopic approach, patients can undergo cholecystectomy with a shorter hospitalization, minimal pain, and quicker recovery. It has not been demonstrated, however, that patients actually return to work after laparoscopic cholecystectomy faster than the traditional 4- to 6-week absence from work after a standard open procedure. A survey of 104 French and 84 American patients undergoing laparoscopic cholecystectomy revealed that postoperative discomfort was completely resolved in 2 weeks in 73% of French and 93% of American patients. All but 11 French and 5 American patients were back to normal home activities by 2 weeks after the operation. Of the 35 American and 40 French patients who had professional activity outside the home, 63% and 25%, respectively, returned to work within 14 days. Five (14%) of the American patients and 12 (30%) of the French patients returned to work 4 weeks or more after the operation. The amount of physical activity on the job correlated with the period off work, but, interestingly, at least six patients with very hard physical activity at work (including construction workers) were able to return to full work activity within 1 week. These data suggest that early return to work is possible and that pain resolves quickly after laparoscopic cholecystectomy. The economic benefit of having patients back on the job quickly, however, may be less than expected until cultural norms change with regard to leave of absence after major surgery.

Activities of Daily Living↗
PubMed1988

Increased risk of cholecystectomy in users of supplemental estrogen.

We report the results of an analysis of information from a prospective cohort study of women examining the association between cholecystectomy and use of supplemental estrogens (never, current, and past use). There were 55 cases of cholecystectomy in those who had never used estrogen and 105 cases in those who had ever used estrogen. After adjustment for age, the relative risk of cholecystectomy in those who had ever used estrogen was 2.1 (95% confidence interval, 1.5-3.0). In women classified as current users based on information available in 1977, the relative risk of gallbladder disease was 2.7 (95% confidence interval, 1.8-4.0) and in past users as of this date, it was 1.6 (95% confidence interval, 1.1-2.5). When cases known to have reinitiated estrogen use after 1977 are removed from the numerator for past users and added to the numerator for current users, the relative estimate for past use decreased to 1.1 (95% confidence interval, 0.7-1.8), and the risk estimate for current use increased to 3.9 (95% confidence interval, 2.6-5.9). Although an increase in the risk of gallbladder disease in women using supplemental estrogens has been consistently observed in previous studies, the risk after cessation of use has received little attention but could be important. Our data suggest the possibility that the risk of gallbladder disease in estrogen users persists after use of the drug ceases. An increase in the risk of cholecystectomy in estrogen users that persists after drug use ends is plausible if estrogen-induced increases in the lithogenicity of bile cause gallstones to form during drug use and if these gallstones fail to dissolve even after bile lithogenicity returns to normal upon cessation of use. The effect of estrogen use on the gallbladder should be considered in weighing the net risk-benefit ratio of these drugs.

Adult↗
PubMed1991

Cost-effectiveness of extracorporeal shock-wave lithotripsy versus cholecystectomy for symptomatic gallstones.

To evaluate the cost-effectiveness of extracorporeal shock-wave lithotripsy vs. cholecystectomy for symptomatic gallstones, a model was constructed that projects charges and survival for both treatments. For a 45-year-old woman with one small stone, treatment with extracorporeal shock-wave lithotripsy rather than cholecystectomy is projected to result in an average gain of only 3 days of life and an average increase in direct medical charges of $1729 over 5 years of follow-up. The resulting marginal cost-effectiveness of extracorporeal shock-wave lithotripsy vs. cholecystectomy is $216,000 of extra charges per year of life gained with extracorporeal shock-wave lithotripsy. Extracorporeal shock-wave lithotripsy is projected to be much more cost-effective for elderly than for young patients (10-20-fold difference), but considerably less cost-effective for multiple stones than a single stone (2-4-fold difference), and less cost-effective for women than men (twofold difference). Adjusting for effects of morbidity on quality of life, extracorporeal shock-wave lithotripsy is projected to have slightly better quality-adjusted survival than cholecystectomy for the small subset of patients with one stone (by 8 to 43 days at 5 years) but not for young patients with multiple stones. It is concluded that decisions about appropriate use of extracorporeal shock-wave lithotripsy should consider the effects of patient characteristics on clinical and economic outcomes.

Aged↗
PubMed1993

A meta-analysis of cholecystectomy and risk of colorectal cancer.

BACKGROUND: Over 60 studies have addressed the hypothesis that the risk of colorectal cancer is increased following cholecystectomy; these studies have yielded inconsistent findings. The aim of the present study was to quantitatively summarize the results from the collective studies. METHODS: A meta-analysis of the published studies addressing the relation between cholecystectomy and colorectal cancer was conducted. RESULTS: The combined results from 33 case-control studies showed an association between cholecystectomy and risk of colorectal cancer (pooled relative risk [RR] = 1.34; 95% confidence interval [CI] = 1.14-1.57), particularly when limited to the proximal colon (RR = 1.88; 95% CI = 1.54-2.30). In most studies, the risk was stronger when the first 5-15 years following the surgery were excluded. The results from 6 cohort studies, with follow-up to approximately 15 years postcholecystectomy, were generally null (RR = 0.97; 95% CI = 0.82-1.14). A more limited body of evidence suggests that cholelithiasis is related to an elevated risk of proximal colon cancer. CONCLUSIONS: Because the risks varied substantially by study design and because time since cholecystectomy or potentially confounding factors were often not considered, we could not firmly quantitate this risk. However, the findings are consistent with other evidence that suggests some characteristic of bile acid metabolism increases the risk of cancer of the proximal colon.

Case-Control Studies↗