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PubMed1981

Increased risk of colorectal cancer after cholecystectomy.

The relative risk of developing colorectal cancer after cholecystectomy has been assessed in a retrospective autopsy study using controls individually matched for age and sex. Of the 304 patients dying with colorectal cancer and undergoing autopsy examination at the Helsinki University Central Hospital, 45 had undergone previous cholecystectomy. The corresponding number for the matched-pair controls without colorectal cancer was 32, indicating that the relative risk of developing colorectal cancer is slightly (1.59), but significantly (p less than 0.05), increased after cholecystectomy. The relative risk was highest for cancer of the right colon (3.00). In contrast, no difference in the autopsy incidence of unoperated gallstones was observed between the two groups, suggesting that, rather than lithogenic bile alone, the predisposing factor is related to the cholecystectomy procedure itself.

Bile Acids and Salts↗
PubMed1992

Selective cholangiography. Current role in laparoscopic cholecystectomy.

The initial 22-month experience with laparoscopic cholecystectomy in 400 patients employing an algorithm of selective cholangiographic evaluation is reported. Preoperative or postoperative endoscopic retrograde cholangiography was performed whenever stones were suspected clinically. Preoperative endoscopic retrograde cholangiography was performed in 44 patients (11%), in whom 14 (3.5%) had an endoscopic sphincterotomy with extraction of common bile duct stones. Intraoperative cholangiography was performed in only eight patients (2%) almost exclusively to acquire experience with the technique, and all cholangiograms were normal. Laparoscopic cholecystectomy was successfully completed in 96% of the patients. There were no deaths in this series, and major complications occurred in only 5% of patients. Two patients (0.5%) had a significant common bile duct injury that was recognized and successfully repaired at the initial operation. No late common bile duct strictures have been recognized. Six patients (1.5%) underwent postoperative endoscopic retrograde cholangiography for suspected common bile duct stones, with three patients requiring endoscopic sphincterotomy and stone extraction. This experience suggests that the use of preoperative and postoperative endoscopic retrograde cholangiography can be based on clinical presentation and laboratory evaluation and does not need to be performed routinely. Routine intraoperative cholangiography is not necessary in most patients undergoing laparoscopic cholecystectomy. The authors conclude that laparoscopic cholecystectomy can be performed safely with the selective use of cholangiography.

Adolescent↗
PubMed1997

Laparoscopic cholecystectomy-related bile duct injuries: a health and financial disaster.

OBJECTIVE: This study was designed to evaluate the total costs associated with repair of laparoscopic cholecystectomy (LC)-related bile duct injuries. SUMMARY BACKGROUND DATA: The popularity of LC with both patients and surgeons is such that this procedure now exceeds open cholecystectomy by a ratio of approximately 4 to 10:1. However, costs associated with LC-related injuries, particularly regarding treatment patterns, have up to now not been explored fully. METHODS: The complete hospital and interventional radiology (IR) billing records for 49 patients who have completed treatment for laparoscopic cholecystectomy-related bile duct injuries were divided into 8 categories. These records were totaled for comparison of costs between patient groups that experienced different injuries and treatment patterns. RESULTS: Patients with LC-related bile duct injuries were billed a mean of $51,411 for all care related to repair of their bile duct injury. Patients incurred an average of 32 days of inpatient hospitalization and 10 outpatient care days. Postoperative treatment included long-term chronic biliary intubation averaging 378 days. Two patients (4%) died as a result of their LC-related complications. Patients with bile duct injuries that were recognized immediately at the time of the initial surgery ultimately experienced a total cost for their repair and hospitalization of 43% to 83% less than for patients in whom recognition of the injury was delayed (p < 0.019 to 0.070). In addition, the total hospitalization and outpatient care days was reduced by as much as 76% with early recognition of an iatrogenic injury. CONCLUSIONS: Repair of cholecystectomy-related bile duct injuries can run 4.5 to 26.0 times the cost of the uncomplicated procedure and carries a significant mortality rate. Intraoperative recognition of such an injury with immediate conversion to an open procedure for definitive repair can result in significant cost savings and relates directly to a decreased morbidity, mortality, length of hospitalization, and number of outpatient care days.

Adult↗
PubMed2002

Changing methods of imaging the common bile duct in the laparoscopic cholecystectomy era in Western Australia: implications for surgical practice.

OBJECTIVE: To assess changes in the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography (IOC), and surgical exploration of the common bile duct (CBD) associated with the introduction of laparoscopic cholecystectomy (LC). SUMMARY BACKGROUND DATA: The optimal strategy for dealing with potential stones of the CBD during LC remains controversial. METHODS: The authors conducted a population-based study of all cases of cholecystectomy (20,084) in Western Australia in the periods before, during, and after the introduction of LC (1988-1994). Index admissions were linked to previous or subsequent admissions for ERCP. Factors associated with ERCP were analyzed by multivariate regression models. RESULTS: Between 1988 and 1994, admissions for ERCP almost doubled, whereas the use of IOC decreased from 71% to 51%. Different trends were found for open and laparoscopic procedures. Exploration of the CBD declined because of the infrequent use of this procedure in LC. Preoperative ERCP was significantly more common in older patients and men; the reverse was found for IOC. There was an adjusted 3.5-fold increase in preoperative ERCP both during and after the introduction of LC. The adjusted odds ratios for IOC were 0.48 and 0.52 for these periods. CONCLUSIONS: The introduction of LC was associated with increasing reliance on ERCP to image the CBD and a decrease in the use of IOC. These changes were observed in both LC and open cholecystectomy. They suggest that the use of ERCP before cholecystectomy has partly replaced IOC for visualization of the CBD for suspected stones. Although more than 40% of patients undergoing LC had IOC, surgeons appear to be reluctant to perform surgical exploration of the CBD when stones are present. Savings in terms of both complications and cost can be expected if preoperative ERCPs performed for suspicion of uncomplicated CBD stones are replaced by IOC.

Acute Disease↗
PubMed1993

Scintigraphic detection of bile leaks after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is widely accepted as an alternative to traditional open cholecystectomy. Its advantages are a shorter hospital stay, earlier return to normal activity, less pain, and improved cosmetic results. However, in the initial experience with this technique, biliary leaks were several times more frequent than in traditional cholecystectomy. Four cases of scintigraphic detection of biliary leaks after laparoscopic cholecystectomy are described. The results of the examination are compared in two cases with endoscopic retrograde cholangiography and in the remaining two with intraoperative findings. Hepatobiliary scintigraphy is suggested for early evaluation of postoperative complications involving the biliary system.

Adult↗
PubMed1991

Incidence and indications for cholecystectomy in a public health district of a small town in central Italy.

There are major differences in cholecystectomy rates between different countries. We prospectively recorded all gallbladder operations in L'Aquila, Italy (a small town in central Italy with a population of about 98,700 inhabitants) from June 15, 1987 to June 14, 1988. During that year 210 cholecystectomies were performed (women and girls = 71.4%), for a calculated yearly incidence rate of 0.212%. Cholecystectomy was elective in 85.2%, urgent in 8.6%, and was performed in the course of other abdominal operations (mainly colon cancer) in the remaining 6.2%. Half (44.3%) of the patients were operated on because of at least one episode of biliary colic, and 9.0% because of an acute complication. Respectively 16.2% and 30.5% were operated on because of dyspeptic symptoms or to prevent symptoms or complications. Gallstones were not found in six, while exploration of the common bile duct revealed gallstones in seven patients. The chemical analysis showed that 84.7% were cholesterol stones (mixed or pure). We presume that most observed differences in cholecystectomy rates between different Western countries are more likely owing to differences in indications for surgery rather than to differences in prevalence of gallstones.

Cholecystectomy↗
PubMed1998

Gastric pathology in cholecystectomy patients: role of Helicobacter pylori and bile reflux.

The data regarding the role of Helicobacter pylori infection in patients with bile reflux are conflicting. Bile reflux is often observed after cholecystectomy. This study focuses on the role of H. pylori in gastric pathology of patients who had undergone cholecystectomy. Eighty-seven consecutive patients were included in the study. An upper gastrointestinal endoscopy was performed, and biopsy specimens were taken in the antrum, incisura angularis, and in the gastric body. The presence of bile reflux in gastric fluid at endoscopic examination was recorded. The overall H. pylori infection rate was 62%, with no difference between patients with (59.7%) and without (64%) endoscopic bile reflux (p = 0.67). The intestinal metaplasia rate in gastric mucosa was significantly higher in patients with both H. pylori and bile reflux than in patients without infection and bile reflux (36.4% vs. 5.6%, p = 0.02). Moreover, the mean number of years after cholecystectomy in patients with intestinal metaplasia was significantly higher than in those without metaplasia (21.1 +/- 7 vs. 11.5 +/- 8 years, p < 0.0001), whereas mean age did not differ significantly between groups (60.3 +/- 12 vs. 55.8 +/- 11 years, p = 0.14). Furthermore, we found four cases of gastric cancer, three with H. pylori infection. The mean number of years after cholecystectomy was significantly higher in patients with gastric cancer than in other patients (21.8 +/- 4 vs. 12.2 +/- 8 years, p = 0.009). This study found that H. pylori infection is frequent in cholecystectomized patients, also in the presence of endoscopic bile reflux. Bile reflux seems to act synergistically with H. pylori infection on gastric pathology.

Adult↗
PubMed1992

Laparoscopic cholecystectomy: a community experience.

Minimally invasive surgery appears to be gaining popularity, and removal of the gallbladder by laparoscopic methods is one such procedure for which there is recent enthusiasm. The concerns about safety, morbidity, and mortality in contrast to standard cholecystectomy are being evaluated. To address these concerns we reviewed the first 230 laparoscopic cholecystectomies done by one surgical group from October 1990 to September 1991. There were 161 women and 69 men with an average age of 50 years. The average length of stay was 2.1 days, most patients being discharged in 24 hours. Complications occurred in 14 patients (6%). The one death was unrelated to the gallbladder surgery. Operative cholangiograms were done as frequently as possible. It appears that laparoscopic cholecystectomy can be done safely and with a shorter hospital stay. Complications are similar to those seen with standard cholecystectomy.

Adolescent↗
PubMed1994

Laparoscopic cholecystectomy: what's so special?

One hundred seventy-one laparoscopic cholecystectomies were done by senior surgery residents who received only traditional "hands-on" training. Eight patients (5%) required conversion to open cholecystectomy, and two had complications requiring immediate celiotomy (one common bile duct injury, one "dropped" gallbladder). The average operative time was 91 minutes (range, 30 to 245 minutes). There were no deaths and only five postoperative complications related to the procedure (retained common bile duct stone in four cases, intra-abdominal hemorrhage in one). There were three complications unrelated to the procedure. Data acquired from recent resident training program graduates show that these practicing surgeons are doing laparoscopic cholecystectomy with a 95% success rate and have yet to encounter appreciable complications. We concluded that a large-volume general surgery resident training program provides adequate opportunity for training surgeons in the techniques of laparoscopic cholecystectomy; there is no need to attend an expensive and time-consuming classroom and animal laboratory course.

Adolescent↗
PubMed1998

Laparoscopic cholecystectomy.

Cholelithiasis is being recognized more frequently in the pediatric population. Although hemolytic diseases have an identifiable etiology, the origin of gallstones in approximately 80% of pediatric patients remains unknown. Infants with cholelithiasis can be managed expectantly unless symptoms develop because many of these stones will resolve spontaneously. The 2- to 12-year age group is more likely to present with chronic cholecystitis and will require cholecystectomy at some point, since there is little chance of spontaneous resolution of these gallstones. Teenagers tend to present in a similar manner to adults and are managed much the same way. Although plain radiographs are more useful in children than in adults, abdominal ultrasonography remains the most useful tool to document cholelithiasis. Safe access to the abdominal cavity is the first step to successful laparoscopic cholecystectomy, and the arrangement of secondary ports varies with the age and size of the patient. Choledocholithiasis can be managed laparoscopically in experienced hands, and endoscopic retrograde cholangiopancreatography plays a diagnostic as well as therapeutic role for this problem. Laparoscopic cholecystectomy has become the standard of care for all children in whom cholecystectomy is required.

Adolescent↗
PubMed2002

Effect of cholecystectomy for gallstones on the surface of the papilla of Vater and the diameter of the common bile duct.

BACKGROUND AND STUDY AIMS: To date, little is known about changes in the size of the papilla of Vater in patients with gallstones. Most of the research concerning these patients has investigated changes in the diameter of the common bile duct and pressure in the sphincter of Oddi region. The latest research has not confirmed the prevalent opinion that the common bile duct dilates after cholecystectomy; moreover, knowledge about changes in the form and size of the papilla of Vater remains poor. The aim of our research was to measure the surface of the papilla of Vater and the diameter of the periampullary pancreatic part of the common bile duct before surgery, then 3 months and 6 months after surgery, using endoscopic ultrasound. PATIENTS AND METHODS: In patients with symptomatic gallstones but with no evidence of cholestasis or stones in the common bile duct, the surface of the papilla of Vater and the diameter of the periampullary pancreatic part of the common bile duct were measured before surgery by endoscopic ultrasound. In the postoperative period, measurements were repeated in patients with an early occurrence of nausea, distension, bloating and pain in the upper abdomen and in patients without any symptoms in the same time period. The surface of the normal papilla of Vater and the diameter of the periampullary pancreatic part of the common bile duct were determined in healthy subjects. RESULTS: In all the patients included in our study, the surface of the papilla of Vater was enlarged before surgery and, after 3 months, was even larger. However, after 6 months, it was practically the same as before surgery. The diameter of the periampullary pancreatic part of the common bile duct before surgery and 6 months after surgery was within normal limits. However, a statistically significant and transient increase in the diameter was noticed in the third month after cholecystectomy. The results were almost the same for symptomatic and asymptomatic patients. CONCLUSION: In patients with symptomatic gallstones, the surface of the papilla of Vater is increased while the diameter of the periampullary pancreatic part of the common bile duct is normal. Cholecystectomy is an intervention that causes an additional transient increase in the surface of the papilla of Vater and a transient increase in the diameter of the periampullary pancreatic part of the common bile duct. The surface of the papilla of Vater does not reach normal values but the diameter of the periampullary pancreatic part of the common bile duct is normalized 6 months after surgery. There is no relation between clinical disorders and changes in the morphology of the papilla of Vater and the periampullary pancreatic part of the common bile duct after cholecystectomy.

Adult↗
PubMed1999

Bile duct injuries in laparoscopic cholecystectomy: nursing perspective.

The advent of laparoscopic cholecystectomy brought a new approach with many advantages to patients for the treatment of symptomatic gallstones. What was not anticipated was an increase in bile duct injuries as a major complication of this new technique. The advanced practice nurse (APN) must understand the technical aspects of a laparoscopic cholecystectomy and routine perioperative care, because this knowledge provides a basis to recognize signs and symptoms of potential postoperative problems characteristic of a bile duct injury. The APN may be the initial healthcare provider who examines a patient or who is contacted by the patient with reports of symptoms that must be heeded and acted on. The APN responds to the patient by providing symptom management, initiating and coordinating care, and alerting the healthcare team. The APN at a specialty center may also be the consistent member of the healthcare team caring for a patient through nonoperative management and operative repair of the bile duct injury. Knowledge of the spectrum of bile duct injuries, their various manifestations, diagnostic tests, nonoperative management, and complex surgical repair is necessary for the APN to educate patients, coordinate care along the continuum, and support a patient with a bile duct injury. The medicolegal aspect of bile duct injury during laparoscopic cholecystectomy is also a topic the APN may encounter that requires thoughtful consideration and response. The recognition of subtle postoperative symptoms of a laparoscopic cholecystectomy may mean the difference between early diagnosis of and intervention in a minor injury or a major complication.

Bile Ducts↗
PubMed2001

Role of laparoscopic cholecystectomy in the management of polypoid lesions of the gallbladder.

This retrospective clinicohistopathologic study was performed to delineate the role of laparoscopic cholecystectomy in the management of polypoid lesions of the gallbladder. One hundred forty-three consecutive patients who had a preoperative sonographic diagnosis of polypoid lesions of the gallbladder with a diameter less than 1.5 cm and who underwent laparoscopic cholecystectomy at Cathay General Hospital were included in the analysis. Histopathologic study showed that 22 (15.4%) patients had true tumors, including adenoma (16), adenoma with focal adenocarcinoma (2), adenocarcinoma (3), and carcinoid tumor (1). Tumorlike lesions were found in 121 (84.6%) patients and included cholesterol polyp (106), adenomyomatous hyperplasia (10), inflammatory polyp (3), and papillary hyperplasia (2). The mean diameter of malignant polypoid lesions of the gallbladder was 1.35 +/- 0.42 cm, which was significantly larger than that of cholesterol polyps (0.66 +/- 0.40 cm, P = 0.0001) but not significantly larger than that of adenomyomatous hyperplasias (1.12 +/- 0.42 cm) and adenomas (1.08 +/- 0.47 cm). The mean age of patients with malignant polypoid lesions of the gallbladder (61.2 +/- 13.3 years old) was significantly older than that of patients with adenomyomatous hyperplasia (46.6 +/- 13.4 years, P = 0.03), cholesterol polyps (44.5 +/- 10.5 years, P = 0.0003), and adenomas (41.4 +/- 9.4 years, P = 0.0008). Clinical follow-up showed that most (98.6%) patients benefited from the minimal invasiveness of laparoscopic cholecystectomy with satisfactory surgical results. We conclude that laparoscopic cholecystectomy is a reliable, safe, and minimally invasive biopsy procedure and definite management of polypoid lesions of the gallbladder with a diameter less than 1.5 cm.

Adult↗
PubMed2001

Two-trocar laparoscopic cholecystectomy: a reproducible technique.

Laparoscopic cholecystectomy is usually performed with a four-trocar technique. From December 1998 to March 1999, 25 of 42 admitted patients underwent a two-trocar laparoscopic cholecystectomy. In our technique, after establishing umbilical carbon dioxide pneumoperitoneum, a 30 degree scope was inserted, and a second 5-mm trocar was positioned below and to the left of the xiphoid process. Then two stitches with nonabsorbable sutures were passed: one at the fundus to pull up the gallbladder, and the second through the neck of the gallbladder to expose the structure of the Calot triangle. Intraoperative cholangiography was performed with a percutaneous catheter in 15 patients. Retrograde cholecystectomy was performed and the gallbladder was extracted through the umbilical port. Scars were closed with glue, and bupivacaine was injected to reduce pain. The technique was feasible in approximately 84% (25 of 30) of patients. The mean operative time was 42 minutes, and the mean hospital stay was 1.6 days. We conclude that this method is similar to four-port laparoscopic cholecystectomy in terms of safety and operation time. This technique seems to be well reproducible and offers better results in terms of postoperative pain, hospital stay without considering better cosmetic results, and cost-effectiveness.

Adult↗
PubMed2001

Brief clinical report: duodenal laceration presenting as massive hematemesis and multiple intraabdominal abscesses after laparoscopic cholecystectomy.

SUMMARY: Laparoscopic cholecystectomy is considered the gold standard for gallstone disease. Nevertheless, possible severe complications must not be underestimated. Bowel injuries are uncommon, but they are one of the most lethal technical complications of laparoscopic surgery. These injuries were commonly unrecognized at the time of procedures and were diagnosed later when the patients experienced sepsis, peritonitis, intraabdominal abscess, or enterocutaneous fistula. Although duodenal lacerations have been reported with laparoscopic cholecystectomies, they seem to be rare; approximately 30 such cases have been documented previously in the English literature. We report the case of a patient with thermal duodenal injury caused by elective laparoscopic cholecystectomy at an outside center presenting as massive hematemesis and multiple intraabdominal abscesses on the ninth postoperative day. The diagnosis and management of this rare complication of laparoscopic cholecystectomy are described, and the literature is reviewed.

Abdominal Abscess↗
PubMed2002

Feasibility of robot-assisted laparoscopic surgery: an evaluation of 35 robot-assisted laparoscopic cholecystectomies.

Laparoscopic surgery offers patients distinct benefits but is not without its disadvantages to surgeons in terms of maneuverability and visualization. Robotic telemanipulation systems were introduced with the objective of providing a solution to the problems in this field of surgery. The feasibility of robot-assisted surgery was assessed by performing 35 laparoscopic cholecystectomies with the da Vinci robotic system. Time necessary for system setup and operation was recorded, as were complications, technical problems, postoperative hospital stay, morbidity, and mortality. Thirty-four of 35 cholecystectomy procedures were completed laparoscopically with the da Vinci system. Technical problems occurred in three cases, resulting in one intraoperative complication (a minilaparotomy caused by the loss of an instrument part). Median hospitalization was 2 days. There were no postoperative deaths or morbidity within 30 days after surgery. System setup time decreased as the experience of the operating team increased. Operating times were comparable with those reported for standard laparoscopic cholecystectomy. Robot-assisted surgery was repeatedly proven as a safe and feasible approach to laparoscopic cholecystectomy.

Adult↗
PubMed2002

Value and consequences of routine intraoperative cholangiography during cholecystectomy.

Since the introduction of laparoscopic cholecystectomy (LC), an increase in accidental common bile duct (CBD) injuries of up to 1.2-1.6% has been reported. In the present prospective study of 1,710 patients undergoing cholecystectomy (1,241 LC procedures and 469 open cholecystectomies [OC]), we tested the predicative value of routine intraoperative cholangiography (IOC). The IOC was feasible in 92.4% of the cases in the LC group and in 83% of cases in the OC group and presented a complete depiction of the extrahepatic bile system in 98.3%. Anatomic variations of the bile duct system, which influenced the operative management, were found in 13.2% of cases (13.4% LC versus 12.8% OC). In 2.5% of the patients, preoperatively undetected CBD stones were also found. Method-specific complications did not occur in any of the patients. Additionally, in a controlled subgroup analysis of 163 patients, we evaluated preoperative intravenous cholangiography (IVC) and IOC. Intravenous cholangiography showed only 72.4% of the operation-relevant anatomic variations (vs. 100% by IOC); in 6.1% of the cases, there were reactions to the dye (vs. none in IOC), and in only 28.6% of the patients, CBD stones were detected (vs. 71.4% IOC). There were four bile duct injuries (0.29%) during LC and two (0.4%) during OC. All injuries were detected intraoperatively and fixed in the same setting without postoperative complications. In conclusion, we recommend the use of routine IOC during cholecystectomy. By this technique, anatomic variations of the bile duct system will be visualized and therefore accidental injuries will be avoided.

Adolescent↗
PubMed2002

Preoperative selective endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy without cholangiography.

The aim of this study was to show that laparoscopic cholecystectomy can be performed safely without routine intraoperative cholangiography. We performed a retrospective analysis of 1750 consecutive patients (1170 females and 580 males with a mean age of 51 years) who underwent laparoscopic cholecystectomy between January 1991 and January 2000. In all, 193 patients (11%) were selected to undergo preoperative endoscopic retrograde cholangiopancreatography (ERCP) on the basis of several criteria for risk of stones. No patients underwent intraoperative cholangiography. ERCP allowed us to make a diagnosis of biliary stones in 62.7% (121 cases). Extraction of the stones was successful in 96% of the cases. In 12% of cases ERCP findings were normal; in the remaining 26.3%, useful diagnostic information was obtained. There were three complications (bleeding and pancreatitis) after endoscopy (complication rate: 1.5%). Laparoscopic cholecystectomy was successful in 92.7% of patients, with a postoperative morbidity rate of 3% (0.5% of major complications). There were no deaths in this series. During a mean follow-up of 60 months (range, 12-120), 7 patients (0.43%) were found to have residual biliary stones (5 had not had preoperative ERCP). The study confirms the hypothesis that laparoscopic cholecystectomy can be safely performed without routine intraoperative cholangiography, with selective use of preoperative ERCP.

Adolescent↗