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PubMed2001

Incidence of cancer of the pancreas, extrahepatic bile duct and ampulla of Vater in the United States, before and after the introduction of laparoscopic cholecystectomy.

BACKGROUND: Some epidemiologic studies have identified cholecystectomy as a risk factor for pancreatic and biliary cancer. METHODS: We compared the incidence of cancers of the pancreas, extrahepatic bile duct and ampulla of Vater before and after the widespread adoption of laparoscopic cholecystectomy in the United States in 1991, when the use of cholecystectomy increased dramatically. RESULTS: Compared with 1980 to 1991, there was no increase in the incidence of cancer of the pancreas (adjusted incidence rate ratio [IRR] 0.97, 95% confidence interval [CI] 0.94 to 0.99) or extrahepatic bile duct (IRR 0.80, 95% CI 0.74 to 0.87) during 1992 to 1996. There was a small increase in the incidence of ampullary cancer (IRR 1.14, 95% CI 1.03 to 1.26). CONCLUSIONS: We did not find clear evidence of a short-term increase in the incidence of cancers of the pancreas, bile duct, and ampulla of Vater, that was attributable to the increased use of cholecystectomy.

Adult↗
PubMed2003

Early minilaparoscopic cholecystectomy in patients with acute cholecystitis.

BACKGROUND: Recently, techniques using fine-caliber instruments (2 or 3 mm in diameter) for laparoscopic cholecystectomy, called minilaparoscopic cholecystectomy (MLC), were reported to be superior to conventional LC (CLC, using 5 mm instruments) in postoperative course and cosmetic outcome. However, the use of MLC to date has been largely restricted to uncomplicated situations. Since CLC has been proved to be a safe and efficient technique for acute cholecystitis especially if conducted early, this study tests the feasibility and safety of MLC for acute cholecystitis. METHODS: Sixty-nine consecutive patients with acute cholecystitis were prospectively randomized to minilaparoscopic (n = 38) or conventional laparoscopic (n = 31) cholecystectomy, and the operations were conducted within 2 days of admission whenever possible. Despite different operative techniques, both groups of patients received identical preoperative preparation, evaluation and postoperative care. The two groups were compared for patient characteristics, results of laboratory tests, predictive score for LC difficulties, operative time, operative complications, hospitalization days and need for meperidine injection for wound pain. RESULTS: The conversion rate was 7.9% (3 of 38) for the MLC group and 6.5% (2 of 31) for the CLC group. Nine patients in the MLC group and 7 in the CLC group had concomitant choledocholithiasis and underwent endoscopic stone retrieval before operation. The age, sex, predictive score for LC difficulties, preoperative leukocyte count, length of hospital stay and requirement of intramuscular meperidine injections were similar for both groups of patients, while, the operative times were marginally longer in the MLC group (113.8 +/- 30.8 versus 98.2 +/- 33.2 minutes, P = 0.056). No major complications occurred in either group. CONCLUSIONS: The results of cholecystectomy for acute cholecystitis by MLC are as good as those of CLC if the operation is performed early, with obvious smaller incisions and minimal complications. MLC is a safe and effective procedure for patients with acute cholecystitis, and has an acceptable low conversion rate.

Acute Disease↗
PubMed2003

Surgeons' anonymous response after bile duct injury during cholecystectomy.

BACKGROUND: Bile duct injuries remain one of the most devastating injuries during laparoscopic cholecystectomy. Few studies target surgeons who have experienced bile duct injuries for their insight, their perspective, and their suggestions concerning this problem. METHODS: A confidential questionnaire was sent to all practicing general surgeons under the age of 65 years in British Columbia, Canada. RESULTS: Seventy-five percent of surgeons responded to the survey. Of the 114 questionnaires completed, more than 97% of respondents had completed formal training in laparoscopic cholecystectomy. One half of surgeons reported experience with laparoscopic bile duct injury. A significant difference in years in practice between surgeons with injury and surgeons without injury was noted. The majority of injuries occurred after the surgeons's first 100 cholecystectomies performed. The first thoughts of surgeons after injury uniformly concerned the patient's well being. The next most common thoughts were in relation to obtaining help or a second opinion from another surgeon. Surgeons cited inflammation and short or anomalous cystic ducts as the most responsible factors contributing to injury. The majority of surgeons felt that these injuries are unavoidable and less than half felt that it was always a surgical error. Fewer than 15% thought injuries could be avoided by performing a cholangiogram. Surgeons suggested meticulous dissection and less haste to divide structures may prevent an injury. Surgeons recommend educating colleagues to remove the stigma of failure associated with conversion to laparotomy. CONCLUSIONS: General surgeons in British Columbia have a one in two chance of experiencing a bile duct injury in their career. There were more injuries in surgeons who had already been in practice for 10 years at the time of introduction of laparoscopic cholecystectomy. The injuries are likely to occur despite high volumes of procedures and increased experience. The incidence of bile duct injuries does not seem to be different in surgeons who perform routine cholangiography and most surgeons feel that cholangiography would have little effect on injury incidence. Surgeons tend to have patient-centered concerns after injury and little concern for medicolegal issues. The majority of surgeons felt that these injuries could not be anticipated and as such it is an inherent risk of this procedure.

Bile Ducts↗
PubMed1994

Medicolegal analysis of bile duct injury during open cholecystectomy and abdominal surgery.

To understand the medicolegal impact of bile duct injury, we analyzed 68 cases of biliary injury resulting from open cholecystectomy and abdominal surgery. Cases were litigated within the US civil justice system between 1970 and 1991. Operations resulting in bile duct complications included cholecystectomy for cholelithiasis in 49 patients (72%), common bile duct exploration in 5 patients (7%), and other abdominal operations in 7 patients (10%); 7 operations were of unknown type. The average delay in recognition of injury was 16 days (range 3 to 42). The mortality rate was 18% (12 of 68). Median jury verdict awards in successfully litigated cases were twice that of out-of-court settlements ($500,000 versus $250,000, P = 0.01). Bile duct injury after open cholecystectomy and abdominal surgery has a high mortality rate when diagnosed late, and is expensive to litigate. This review may be useful in defining the medicolegal outcome of similar injuries from laparoscopic cholecystectomy.

Adult↗
PubMed1994

Cholecystectomy for cholecystitis in patients with acquired immune deficiency syndrome.

Acalculous cholecystitis, a recognized manifestation of acquired immune deficiency syndrome (AIDS), causes abdominal pain which can be relieved by cholecystectomy. The indications for cholecystectomy have remained undefined, however, because the cholecystitis is usually accompanied by generalized cholangitis and it is difficult to distinguish the relative clinical importance of the two problems. Since 1985, we have performed cholecystectomy on 8 patients with AIDS who had clinical manifestations of acute cholecystitis associated with a thickening of the gallbladder wall by 5 mm to 12 mm. Two of the 8 had gallstones and 4 had associated cholangitis. All had been treated with antibiotics for 20 to 180 days before surgery, but physical deterioration had progressed in every case. At the moment of surgical intervention, 4 patients had multiple organ failure. One patient died 3 days postoperatively, but the rest recovered rapidly with resolution of the abdominal pain and sepsis. Two patients died 20 days after surgery due to complications of AIDS. The remaining 5 died due to AIDS at 6, 9, 10, 12, and 14 months after surgery. Two of this group developed progressive cholangitis with raised serum alkaline phosphatase. Our experience indicates that cholecystectomy should be considered for the treatment of severe and persistent symptoms of hepatobiliary manifestations of AIDS notwithstanding the presence of cholangitis.

AIDS-Related Opportunistic Infections↗
PubMed1993

Spectrum and management of major complications of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has become the most prevalent method of treating uncomplicated, symptomatic cholelithiasis in the United States and elsewhere. As experience with this procedure grows, certain pitfalls are becoming apparent. Since October 1990, we have treated 22 patients for major injuries incurred during laparoscopic cholecystectomy, including 15 women and 7 men (range: 23 to 85 years). One patient had previous upper abdominal surgery; no other patient had any relative contraindication to laparoscopic surgery. The most frequent site of injury (19 patients) was the extrahepatic biliary tract. There was one fatal duodenal perforation. All but two patients whose injuries went unrecognized at laparoscopy were symptomatic during the immediate postoperative period. The biliary injuries included complete transection of the common hepatic or common bile duct in 10 patients, complete ductal occlusion in 3, a cystic duct stump leak in 2, and a partially retained gallbladder with a contained intraperitoneal bile leak in 2. The site and extent of biliary injuries were delineated with transhepatic or endoscopic retrograde cholangiography. Reconstruction or repair of the biliary tract was accomplished with Roux-en-Y hepaticojejunostomy or cholangiojejunostomy in 11 and 1 patients, respectively, completion cholecystectomy in 2, and temporary transhepatic stenting, primary choledochocholedochostomy, and primary choledochorrhaphy over a T-tube in 1 patient each. One patient with a cystic duct stump leak was managed successfully with endoscopic sphincterotomy, whereas another required operative ligation. Laparoscopic injuries during cholecystectomy can lead to serious morbidity and mortality, thus emphasizing the need for adequate training and credentialing for surgeons and for a heightened clinical awareness of the potential complications, their long-term sequelae, and how to avoid them.

Adult↗
PubMed1990

Evaluation of duodenogastric reflux in gallstone disease before and after simple cholecystectomy.

Duodenogastric reflux (DGR) has been suggested as an etiopathogenic factor in gastric disease in patients with gallstones. We evaluated the DGR levels in 15 patients before and after simple cholecystectomy for gallstones and compared the results with those of 15 healthy subjects. Gastric juice was obtained by continuous nasogastric suction for 24 hours. The bile acids (BA) present in the samples were quantified by thin-layer chromatography and in situ spectrofluorometry. The mean BA concentration for the control subjects was 2.25 mumol reflux/hour, whereas the mean value for the 15 patients with cholelithiasis was 8.86 mumol reflux/hour before cholecystectomy and 24.55 mumol reflux/hour after cholecystectomy. Five patients did not have detectable BA in the gastric juice in both analyses; the remaining 10 patients showed a significant increase in the BA after surgery. From these data, we conclude that gallstone disease is not always accompanied by an increased DGR. However, in patients in whom DGR is present, its level is higher than in control subjects and increases significantly after cholecystectomy. This is probably due to the greater amount of bile in the duodenum that may reflux through an incompetent pyloric channel.

Adult↗
PubMed1988

Cholecystectomy in the elderly.

A series of 347 elderly patients undergoing cholecystectomy has been presented. The older a patient is at the time of cholecystectomy, the more likely it is for that patient to present with an acute biliary complication. The elderly tolerate biliary tract operations quite well, especially before acute complications of cholelithiasis occur. Early cholecystectomy can prevent the morbidity associated with the natural progression of cholelithiasis. Whether prophylactic cholecystectomy for asymptomatic cholelithiasis would be cost effective is an issue that can be resolved only when further data regarding the natural history and incidence of cholelithiasis in the elderly is known.

Age Factors↗
PubMed1988

Large bowel cancer after cholecystectomy.

In a large, population-based case control study of colorectal cancer, 65 of 715 patients and 57 of 727 control subjects had a previous cholecystectomy (chi-square = 0.6, relative risk 1.18, 95 percent confidence interval 0.81 to 1.70, p = 0.45). There was no statistically significant association between previous cholecystectomy and the risk of colorectal cancer, colon cancer, right colon cancer, any of the subsites of colon cancer, rectal cancer, age, or sex. Although there is some evidence from other studies of an association between previous cholecystectomy and right colon cancer in women, this may have resulted from confounding symptoms. Based on the present evidence, we believe that previous cholecystectomy is unlikely to be a risk factor for colorectal cancer.

Aged↗
PubMed1988

Cholecystectomy in the elderly.

A 4-year retrospective review of 212 patients over 70 years of age who underwent elective and emergency cholecystectomies was undertaken. Elective procedures were performed in 119 patients (76 women, 43 men) whereas 93 patients (43 women, 50 men) underwent emergency surgery. Complications developed in 25 and 34 patients, respectively. In the elective group, the most common complication involved the cardiovascular system, whereas sepsis with multiple organ failure accounted for all of the deaths in the emergency group. Among the 212 patients studied, there was a 3 percent mortality rate in the elective group and a 10 percent mortality rate in the emergency group, with an overall mortality rate of 6 percent. The results indicated that since the risks of elective cholecystectomy are relatively low in the elderly and the risks of cholecystectomy performed as an emergency are considerably higher (10 percent), symptomatic elderly patients with gallstones should be considered good candidates for early elective cholecystectomy.

Aged↗
PubMed1995

The utility of prophylactic laparoscopic cholecystectomy in transplant candidates.

BACKGROUND: This study addresses the impact of laparoscopic cholecystectomy prior to kidney or pancreas transplant. PATIENTS AND METHODS: Between January 1991 and July 1993, 551 patients were listed for transplant. Gallbladder ultrasound became part of the standard evaluation for all transplant candidates in October 1991. Pretransplant laparoscopic cholecystectomy was recommended for all patients found to have gallstones. To assess the benefit of this policy, patients transplanted prior to routine ultrasound (Group I; n = 88) were compared to those listed or transplanted after routine ultrasound (Group II; n = 406). RESULTS: In Group I, 18% developed gallstone complications requiring surgery. Surgical morbidity occurred in 14% and mortality in 7% of these operations. Graft loss occurred in 20% having biliary complications versus 7% among other recipients. In Group II, gallstones were detected in 10%, and 9% subsequently had laparoscopic cholecystectomy with no morbidity or mortality. CONCLUSIONS: Transplant recipients with unsuspected gallstones were found to have a high incidence of acute biliary complications. Urgent biliary surgery carried significant morbidity and mortality in these immunosuppressed patients and appeared to increase the risk of graft failure as well. A policy of screening gallbladder ultrasound and pretransplant laparoscopic cholecystectomy seems to reduce these concerns and is recommended for all transplant candidates.

Adolescent↗
PubMed1995

What symptoms does cholecystectomy cure? Insights from an outcomes measurement project and review of the literature.

BACKGROUND: The increasing application of cholecystectomy has increased the need to assess the effects of cholecystectomy on presenting symptoms. PATIENTS AND METHODS: Three surgeon-derived and two patient-derived data forms were collected for each patient in a series of 225 laparoscopic cholecystectomies. RESULTS: Eighty-two percent of patients had documented gallstones preoperatively, 91% had biliary pain, and 77% had both biliary pain and documented gallstones prior to surgery. Fifteen percent of patients were believed to have acalculous cholecystitis. Eighty-two percent also had bothersome nonpain symptoms (gassiness, bloating, indigestion, fatty-food intolerance, and nausea). The cure rate for biliary colic was 82% if stones were documented preoperatively, and 52% when they were not (P = 0.002). Atypical pain was cured 80% of the time, and nonpain symptoms, 44% of the time. CONCLUSIONS: Most patients (82%) with biliary colic and gallstones have complete relief of upper abdominal pain after cholecystectomy. Pain relief in patients felt to have acalculous cholecystitis was only 52%. Nonpain symptoms were common preoperatively (82%) and were relieved in 44% of patients.

Abdominal Pain↗
PubMed2005

[Intraoperative factors predictive of failure of the ambulatory regimen after laparoscopic cholecystectomy].

OBJECTIVES: To determine which intraoperative factors during ambulatory laparoscopic cholecystectomy predict postoperative admission. MATERIAL AND METHOD: Between January 1999 and August 2003, we attempted 410 consecutive laparoscopic cholecystectomies. Intraoperative variables were analyzed using univariate and multivariate methods. An intraoperative score was applied to determine the probability of successful ambulatory surgery in each patient. RESULTS: A total of 88.5% of the patients were strictly ambulatory. Forty-two patients required overnight admission, mostly due to social factors, and five patients required admission after 24-48 hours. Intraoperative variables predictive of postoperative admission were an operating time of more than 60 minutes (p = 0.011), gallbladder dissection with anatomic difficulty (p = 0.001), and cystic artery hemorrhage (p = 0.041). Surgical access to the abdominal cavity, gallbladder perforation, trocar wound or hepatic bed bleeding, intensity or grade of hemorrhage, and gallbladder extraction were not predictive variables. CONCLUSIONS: Ambulatory laparoscopic cholecystectomy is a safe and effective procedure. Operating time, correct dissection of gallbladder structures and hemorrhage of the gallbladder hilus, especially of the cystic artery, play a major role in the success or failure of ambulatory laparoscopic cholecystectomy.

Ambulatory Surgical Procedures↗
PubMed1993

Abdominal ultrasonography following laparoscopic cholecystectomy: a prospective study.

Laparoscopic cholecystectomy has gained widespread acceptance as the operation of choice for symptomatic gall-stones. We prospectively performed ultrasonography on 100 consecutive patients after laparoscopic cholecystectomy to determine the effect of this procedure on common bile duct diameter. This study also examines the incidence and clinical significance of intra-abdominal fluid collections after laparoscopic cholecystectomy. Our results show that 24% of patients had dilatation of the common duct (greater than 6 mm) when scanned 48 h post-operatively. The incidence of dilated common ducts fell to 9% when the patients were scanned 1 month later. This transient dilatation of the common duct, occurring post-operatively, has not been previously described. Intra-abdominal fluid collections were demonstrated in 10% of our patients but were clinically significant in only 1%. This study suggests that routine ultrasonography has a low yield immediately after laparoscopic cholecystectomy.

Abdomen↗
PubMed1995

The value of ultrasound measurement of gallbladder wall thickness in predicting laparoscopic operability prior to cholecystectomy.

We prospectively analysed 51 consecutive cases who underwent laparoscopic cholecystectomy from June 1992 to February 1993. There were 35 cases of chronic cholecystitis and 16 cases of acute cholecystitis. All underwent pre-operative ultrasonography, complete blood cell count, liver function test and endoscopic retrograde cholangiopancreatography. Of those 44 had post-operative ultrasound within the first 2 d and again on the seventh day. In 35 cases of chronic cholecystitis, 31 of 32 cases with a pre-operative gallbladder (GB) wall thickness of less than 6 mm were successfully resected laparoscopically. All three cases with a GB wall thicker than 6 mm were converted to open cholecystectomy. In acute cholecystitis, the wall thickness of the laparoscopic cholecystectomy group ranged from 2 to 9 mm (average 4 mm) and the wall thickness of the conversion group was 4-7 mm (average 6 mm). Post-operative fluid accumulation was noted in 28 (63.6%) cases. There was no correlation between post-operative pyrexia, duration of post-operative pain, clinical complications and the presence of fluid accumulation in the GB fossa. However, of four cases with increasing fluid on the seventh day, three developed complications. We conclude that ultrasonography is valuable in chronic cholecystitis for selecting cases for laparoscopic cholecystectomy.

Adult↗
PubMed1998

Unsuspected choledocholithiasis first diagnosed at laparoscopic cholecystectomy: treatment by trans-cystic duct stenting and elective stent-guided sphincterotomy.

BACKGROUND: Despite advances in laparoscopic surgery, management of unsuspected choledocholithiasis diagnosed at laparoscopic cholecystectomy is controversial. We propose a simple maneuver of laparoscopic trans-cystic duct stenting of the papilla during cholecystectomy, followed by elective stent-guided sphincterotomy, as an expedient option. METHODS: We studied retrospectively 16 patients with choledocholithiasis first diagnosed in the course of laparoscopic cholecystectomy, treated with laparoscopic stenting of the papilla via the cystic duct using a short Cotton-Leung stent before completion of cholecystectomy. Elective stent-guided, needle-knife sphincterotomy and stone clearance was performed 2 to 3 weeks postoperatively. RESULTS: Of 16 patients attempted, the procedure failed in one due to an impacted stone that prevented passage of the guidewire. Stenting time was 13 +/- 5 minutes (n = 15). Two stented patients had no stones at endoscopic retrograde cholangiography. Thirteen patients had successful elective stent-guided sphincterotomy with stone clearance without complications. CONCLUSIONS: Laparoscopic biliary stenting combined with stent-guided sphincterotomy is a simple, safe, and cost-effective option for the management of uncomplicated choledocholithiasis.

Adult↗
PubMed1998

Endoscopic intervention for biliary leaks after laparoscopic cholecystectomy: a multicenter review.

BACKGROUND: Endoscopic therapy of biliary tract leaks was uncommon before laparoscopic cholecystectomy. Studies have demonstrated the efficacy of endoscopic drainage by endoscopic sphincterotomy or stent placement. Various endoscopic therapeutic modalities and long-term follow-up of this problem were studied. METHODS: Members of the Midwest Pancreaticobiliary Group reviewed all patients referred for endoscopic therapy of biliary leaks after laparoscopic cholecystectomy from 1990 to 1994. Long-term follow-up was by direct patient contact. RESULTS: Fifty patients were referred for endoscopic therapy of biliary leaks. Abdominal pain was present in 94%. The mean time from laparoscopic cholecystectomy to referral was 6.9 days. Therapy consisted of sphincterotomy only in 6 patients, stent only in 13, and sphincterotomy with stent in 31. Biliary leaks were healed in 44 patients at a mean of 5.4 weeks. A second or third endoscopic procedure was necessary to achieve healing in five patients. Two stent-related complications were noted. Percutaneous or surgical drainage of biliary fluid collections was required in 16 patients. The mean hospital stay for treatment of the leak was 11.1 days after endoscopic therapy. On follow-up (mean 17.5 months), all patients were well except two with mild abdominal discomfort. CONCLUSIONS: Endoscopic sphincterotomy, stent placement, or sphincterotomy with stent are effective in healing biliary leaks after laparoscopic cholecystectomy. Despite prolonged treatment for the leak, patients did well on long-term follow-up.

Bile↗
PubMed1999

Does cholecystectomy after endoscopic sphincterotomy prevent the recurrence of biliary complications?

BACKGROUND: The intact gallbladder after endoscopic sphincterotomy is thought to be a potential risk factor for recurrent biliary complications. The aim of this non-randomized prospective study was to investigate whether cholecystectomy soon after endoscopic sphincterotomy could prevent the recurrence of biliary complications. METHODS: From January 1991 to October 1995, 140 patients with intact gallbladder underwent endoscopic sphincterotomy for clearance of stones in the bile duct. Of the 140 patients, 46 underwent elective cholecystectomy soon after sphincterotomy (group A) and 94 did not (group B). All 140 patients had quantitative cholescintigraphy after normalization of liver function and were followed on a regular basis with liver biochemistry, sonography, and/or computed tomography. Endoscopic retrograde cholangiography was also performed if a recurrent biliary problem was suspected. RESULTS: After a median 43 months (range 23 to 80) of follow-up, 5 patients in group A developed bile duct stones whereas 12 patients in group B had recurrent stones; 4 patients in group A versus 6 patients in group B had recurrent biliary symptoms. One patient in group A and 5 patients in group B with recurrent biliary stones were without symptoms. In group B, the age, gender, diameter of the bile duct, preexisting cholelithiasis, abnormal filling of the gallbladder on quantitative cholescintigraphy, and presence of juxtapapillary diverticulum were not found to be the significant factors affecting the recurrence of biliary symptoms or stones. Endoscopic removal of recurrent biliary stones was successful in all patients. Three patients in group B underwent cholecystectomy after abatement of symptoms. CONCLUSION: Elective cholecystectomy after endoscopic sphincterotomy does not reduce the incidence of recurrent biliary complications.

Aged↗