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PubMed2006

Vascular injuries in laparoscopic cholecystectomy: an underestimated problem.

BACKGROUND: Bile duct injury is a severe complication of laparoscopic cholecystectomy and many reports focus on this topic, especially regarding the long-term success of repair of these injuries. There is some concern, however, as to whether concomitant vascular injuries can jeopardize reconstruction of a bile duct injury following laparoscopic cholecystectomy. METHODS: A review of the current literature on the clinical significance and management of a concomitant vascular injury to the outcome of reconstruction of bile duct injuries following laparoscopic cholecystectomy. Relevant articles were extracted through PubMed, with secondary references obtained from key articles. RESULTS: Although the relevant literature is generally poor, there is a trend of appearance of relatively large series on the topic over the last five years, as opposed to case reports or small series during the previous decade. CONCLUSION: The disruption of the hepatic arterial flow during laparoscopic cholecystectomy is usually well tolerated in an otherwise healthy patient. There is strong evidence that concomitant vascular injuries do not have any impact on mortality after biliary reconstruction. There is also evidence that does increase overall morbidity, but when it comes specifically to long-term anastomotic stricture formation, there is no strong evidence to support a negative impact of a concomitant vascular injury; this is especially true for centers/surgeons with HPB interest.

Bile Ducts↗
PubMed1991

Unchanged levels of keto bile acids in bile after cholecystectomy.

Cholecystectomy has been hypothesized to cause increased levels of potentially harmful secondary bile acids due to prolonged exposure of primary bile acids to intestinal bacteria. In the present study, we analyzed duodenal bile of the same patients before and after cholecystectomy for keto bile acids and hydroxy bile acids. The ratios of individual keto bile acids to their corresponding precursor hydroxy bile acids were not significantly different before and after cholecystectomy. Keto bile acids constituted 2.5 +/- 1.3 and 2.2 +/- 0.9 mol% of hydroxy bile acids in duodenal bile. 3 alpha-Hydroxy-12-oxo-5 beta-cholanoic acid derived from deoxycholic acid was the main keto bile acid in bile contributing 80 mol% to total keto bile acids. There was a strong positive correlation between 3 alpha-hydroxy-12-oxo-5 beta-cholanoic acid and its precursor deoxycholic acid in bile (r = 0.88; p less than 0.0005). Our findings prove that 7 weeks after cholecystectomy the percentage of keto bile acids in bile as compared to hydroxy bile acids is not increased.

Adult↗
PubMed1977

Biliary lipid secretion in cholesterol gallstone disease. The effect of cholecystectomy and obesity.

Cholesterol gallstone disease is initiated in a liver which produces abnormal bile with excess cholesterol relative to bile salts and phospholipid. To define the responsible secretory mechanism(s), the rate of biliary lipid secretion was measured by a duodenal marker perfusion technique, while the bile salt pool was simultaneously estimated by isotope dilution. Two groups of control patients expected to have normal biliary lipid composition--14 subjects without hepatobiliary disease and 6 patients with pigment gallstones, were compared to two experimental groups expected to have abnormal bile--10 nonobese patients with cholesterol gallstones and 7 obese subjects without gallstones. Both control groups had nearly identical biliary lipid secretion rates, and a corresponding low relative molar concentration of cholesterol. Two different secretory mechanisms were found to be responsible for the abnormal bile in the experimental groups. In the nonobese patients with cholesterol gallstones, bile salt and phospholipid secretion rates were both significantly reduced. Conversely, the grossly obese subjects had an increased cholesterol secretion. To determine how cholecystectomy improves biliary lipid composition, three groups of gallstone patients --6 with pigment stones, 4 grossly obese with cholesterol stones, and 13 nonobese with cholesterol stones --were all examined after full recovery from surgery. In the nonobese patients with cholesterol gallstones, both bile salt and phospholipid secretion significantly increased, causing a definite improvement in bile composition. Cholecystectomy produced a similar but less marked trend in the obese patients with cholesterol stones, and in the patients with pigment stones. Cholesterol secretion, however, was unaffected by surgery. The bile salt pool was definitely small in the nonobese patients with cholesterol gallstones and became slightly smaller after cholecystectomy. The pool was significantly reduced by cholecystectomyin the patients with cholesterol gallstones. Removal of the gallbladder in all three groups caused a greater fraction of the pool to cycle around the enterohepatic circulation each hour. This more rapid cycling produced the increase in bile salt and phospolipid secretion, and was responsible for the improved composition found after cholecystectomy.

Adult↗
PubMed1995

Postoperative adverse events of cholecystectomy in the Medicare population.

We explored the use of postoperative adverse events of cholecystectomy as possible screens for poor quality of care. Retrospective analysis of clinical data abstracted from hospital charts between 1985-1986 was conducted on a random sample of 3,182 cholecystectomy cases. Severity of illness models were developed predicting adverse events following cholecystectomy in patients with and without bile duct exploration. Outcome measures included 17 nonfatal adverse events and death within 30 days of admission. Adverse event rates were 23.2% for cases with bile duct exploration and 14.4% for cases without bile duct exploration. Cross-validated R-squareds and C-statistics showed that models had real, although modest, predictive power. We conclude that clinically meaningful adverse events of cholecystectomy can be successfully identified through chart abstraction.

Aged↗
PubMed2006

The effect of direct-from-recovery room discharge of laparoscopic cholecystectomy patients on recovery room workload.

Ambulatory laparoscopic cholecystectomy pathways move patients through the hospital without encountering delays caused by congested inpatient bed units. However, redirecting patients to a direct discharge pathway might not be beneficial if recovery capacity is further taxed by additional workload. In this study, we attempt to assess the operational impact on recovery room workload of directly discharging laparoscopic cholecystectomy patients to home. We conducted a retrospective case-control review of recovery room flow sheets to determine recovery room time and effort required for laparoscopic cholecystectomy patients. The study was restricted to patients of a single surgeon to minimize confounds from surgical technique. Fifty-seven case patients (May 1, 2004, through November 30, 2004), all managed with intent to directly discharge from the recovery room, were compared with control patients (n = 81) from the corresponding 6 months in the year before the direct-discharge plan. The times (mean; 95% confidence interval) to meet objective criteria for adequate pain control (3.5 minutes [2.1 to 5.9] versus 4.0 minutes [2.6 to 6.1]) and readiness for discharge from phase 1 recovery (8.1 minutes [4.8 to 13.6] versus 6.1 minutes [4.0 to 9.5]) were not different between the groups. The number and distribution of interventions documented in the recovery process were not different between groups, nor was there a difference in recovery room length of stay (158 minutes [138 to 182] versus 149 minutes [132 to 167]). In our study, recovery room records reveal little if any increased workload associated with the direct-to-home discharge of laparoscopic cholecystectomy patients.

Cholecystectomy, Laparoscopic↗
PubMed1992

Pulmonary function and stress response after laparoscopic cholecystectomy: comparison with subcostal incision and influence of thoracic epidural analgesia.

Laparoscopic cholecystectomy (LPC) is increasingly used to treat symptomatic cholelithiasis. We compared the effects of cholecystectomy by subcostal incision to those of LPC on lung function and endocrine metabolic response. The effects of thoracic epidural analgesia for LPC were studied as well. Thirty patients undergoing elective cholecystectomy under general anesthesia were allocated to three study groups: group I, cholecystectomy by subcostal incision; group II, LPC; group III, LPC and epidural analgesia with 0.5% bupivacaine with epinephrine, followed by continuous epidural infusion of 6 mL of 0.5% bupivacaine. Forced vital capacity (FVC), peak expiratory flow, and forced expiratory volume in 1 s were measured with the patients in a half-sitting position. In all groups, sustained decreases in FVC, forced expiratory volume in 1 s, and peak expiratory flow were observed up to 24 h after surgery. Reduction of FVC was significantly more in group I compared with groups II and III (P less than 0.05). The FVC in group I decreased from 3.8 +/- 0.42 (SD) to 1.1 +/- 0.27 L (P less than 0.01), in group II from 3.6 +/- 1.46 to 2.1 +/- 0.94 L (P less than 0.05), and in group III from 3.8 +/- 0.92 to 2.8 +/- 0.90 L (P less than 0.05). In all groups, plasma glucose and cortisol increased after surgery compared with baseline levels (P less than 0.05). At 240 min after surgery, a small but significant decrease of cortisol was measured in group III (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1999

Laparoscopic cholecystectomy: proper utilization can make this a cost effective technique.

Laparoscopy has become the preferred operative treatment for the removal of gallbladders containing symptomatic stones. Both length of stay and total unit cost has declined, through the use of the laparoscopic cholecystectomy procedure. However, the total cost of treating gallstones has increased. Consensus practice guidelines would indicate that there should be no increase in the number of gallbladder surgeries performed, as the indications for a closed cholecystectomy should be the same as those for open procedures. To correct for the variation in incidence of surgery, I propose a decision flow tree to control the rate of laparoscopic cholecystectomy within a provider organization. I also propose further studies of ablative methods versus surgical procedures to determine the cost effectiveness of expanding indications for laparoscopic cholecystectomy.

Cholecystectomy, Laparoscopic↗
PubMed2003

Selective cholangiography in 600 patients undergoing cholecystectomy with 5-year follow-up for residual bile duct stones.

BACKGROUND: The need for cholangiography to identify possible bile duct stones in all patients undergoing cholecystectomy is controversial. AIMS: To assess the results of a policy for selective pre-operative endoscopic retrograde cholangiography (ERC) in patients undergoing laparoscopic cholecystectomy and to determine the incidence of postoperative symptomatic bile duct stones. PATIENTS AND METHODS: Between 1993 and 1998, 600 patients underwent laparoscopic cholecystectomy under one consultant surgeon. Patients were selected for pre-operative or postoperative ERC based on symptoms, liver function tests and/or abnormalities on ultrasonography. A general practitioner questionnaire was used to assess follow-up of patients with postoperative stones. RESULTS: Of 600 patients, 107 (18%) with a median age of 57 years and male:female ratio of 1:2.1 were selected to undergo pre-operative ERC; of these, 41 patients (38%) had bile duct stones. Postoperative ERC was performed in 30 patients (5%) and stones were identified in seven (23.3%). Three patients (0.5%) had stones removed within 15 days of operation and four (0.7%) between 2.6 months and 1.8 years. Median follow-up was 5.0 years (range, 2.5-7.5 years). The overall incidence of bile duct stones was 48 cases (8%). The stone rate was 11% in males and 7.3% in females. Stones were successfully extracted at ERC in 43 patients (89.6%). CONCLUSIONS: A policy of selective pre-operative ERC is the most effective technique for identifying and removing bile duct stones and the incidence of symptomatic gallstones following laparoscopic cholecystectomy is very low. With an overall stone rate of 8%, routine peroperative cholangiography is unnecessary and, in a surgical unit providing an ERC service, laparoscopic exploration of the bile duct is not a technique required for the management of bile duct stones.

Adolescent↗
PubMed2003

A 10-year serial, prospective study of laparoscopic cholecystectomy training in a single region.

AIM: To determine how surgical registrar training in laparoscopic cholecystectomy evolved in a single region in the 10 years since the introduction of this technique. METHODS: In 1993, 1996, and 2001, identical, standardised postal questionnaires were sent to all general surgical registrars in the Oxford region. The questionnaire enquired about the number of laparoscopic cholecystectomies performed, performed with supervision or simply assisted at within a set time period. RESULTS: There has been a significant increase in the number of procedures performed by trainees between 1993 and 2000, in comparison to the number purely assisted at. CONCLUSIONS: After an initial learning period for the consultant trainers, laparoscopic cholecystectomy has been rapidly adopted, and is now a major training operation, much as open cholecystectomy was in the past.

Cholecystectomy, Laparoscopic↗
PubMed2004

Patients awaiting laparoscopic cholecystectomy--can preoperative complications be predicted?

AIMS: To determine the nature and incidence of gallstone-related complications arising in patients awaiting laparoscopic cholecystectomy and to formulate a strategy to detect those most in need of urgent intervention. PATIENTS AND METHODS: A retrospective analysis of the case notes of 337 consecutive patients undergoing laparoscopic cholecystectomy under a single surgeon in a district general hospital between 1995 and 1999. RESULTS: Of patients awaiting laparoscopic cholecystectomy, 65 (19.3%) were documented as suffering significant on-going symptoms, of whom 19 (5.6%) required hospital admission or urgent surgical review at median 8.9 weeks (range 0.1-32.3 weeks) after being placed on the waiting list. Factors predictive of symptom recurrence included: (i) initial acute presentation; (ii) diagnoses of jaundice, pancreatitis, or acute cholecystitis; (iii) elevation of amylase or liver function tests; and (iv) small stones on ultrasonography examination. CONCLUSIONS: A significant proportion of patients awaiting laparoscopic cholecystectomy experience stone-related complications requiring hospital admission. We feel it is possible to reduce this number by selecting those most at risk on the basis of their history and pre-operative investigations for more urgent intervention.

Adult↗
PubMed2006

Variations in consenting practice for laparoscopic cholecystectomy.

INTRODUCTION: To compare the variations in consenting practice amongst trainees and consultant surgeons for laparoscopic cholecystectomy with specific reference to the documentation of significant risks of surgery. PATIENTS AND METHODS: A proforma was devised which included significant and/or commonly recognised complications of laparoscopic cholecystectomy. This was then cross-referenced with the consent forms for the 80 patients included in the study and the documented risks explained in each case were noted. RESULTS: The results showed that there is considerable variation between the three grades of clinicians involved in obtaining a patient's consent for laparoscopic cholecystectomy. There was a clear difference in emphasis of the significant complications depending on the seniority of the consenter. Over 80% of the consents in this study were still being obtained by junior staff. CONCLUSIONS: More often than not, patients are not provided with consistent information to make an informed choice. We suggest that a preprinted consent form will provide a more uniform approach to consenting practice for laparoscopic cholecystectomy.

Cholecystectomy, Laparoscopic↗
PubMed2006

Laparoscopic cholecystectomy for chronic cholecystitis in Jamaican patients with sickle cell disease: preliminary experience.

Laparoscopic cholecystectomy, with its advantages of reduced postoperative pain and shorter hospitalization is the accepted standard of care for patients with symptomatic cholelithiasis. A retrospective study was done to assess the outcome of laparoscopic cholecystectomy in patients with sickle cell disease, a group known for its high postoperative morbidity. The study sample comprised of patients seen at the University Hospital of the West Indies during the period 1999 to 2004. Twelve patients were females and four were males. Their mean age was 28.5 years (range 13-43 years). Fifteen underwent elective cholecystectomy for recurrent episodes of cholecystitis while one patient required an emergency procedure. All patients underwent endoscopic retrograde cholangiopancreatography, which successfully removed common bile duct stones which were present in 25% of the cases. There were four conversions to open cholecystectomy as a result of obscure anatomy due to scarring and adhesions. The duration of surgery ranged from 70-150 minutes. Six patients developed postoperative complications, four of whom had acute chest syndrome. This resulted in death in one patient. The mean postoperative hospitalization period was 5.5 days. This report indicates that patients with sickle cell disease remain a high risk group with the potential for significant morbidity even when subjected to minimal access surgery.

Adolescent↗
PubMed2006

Bile duct injury during cholecystectomy requiring delayed liver transplantation: a case report and literature review.

Major bile duct injury during cholecystectomy represents potentially severe complications with unpredictable long-term results. If these lesions are not treated adequately, they can lead to hepatic failure or secondary biliary cirrhosis therefore requiring liver transplantation. We report a patient who required liver transplantation 15 years after open cholecystectomy. A l0-year old girl underwent open cholecystectomy and duodenal repair for cholelithiasis and cholecystoduodenal fistula. She required two surgical interventions, hepaticojejunostomy which was performed in another center and portoenterostomy for biliary stricture at our institution seven years after the cholecystectomy. Eight years after the third operation, she required recurrent hospitalization for treatment of hepatic abscesses. The extremely short intervals between the three life threatening episodes and the rapid progression to severe sepsis were taken into consideration and liver transplantation was performed at the age of 25. She is leading a healthy life at 4 years post transplantation. Although iatrogenic biliary injury can usually be treated successfully by a combination of surgery, radiological and endoscopic techniques, patients with severe injuries develop irreversible liver disease. This case report and review of the literature suggest that liver transplantation is a treatment modality for a selected group of patients with end-stage liver disease secondary to bile duct injury.

Adolescent↗
PubMed1989

Ethnic variation in cholecystectomy rates and outcomes, Manitoba, Canada, 1972-84.

We used population-based data from the Province of Manitoba's universal health insurance plan to compare the cholecystectomy experience of Native Americans and non-Natives from 1972 to 1984. The age-adjusted cholecystectomy rates for Native females were higher than for non-Native females with the peak rate occurring at age 30-39 for Native Americans and at age 60-69 for non-Natives. The rates for males were three times lower than for females and did not differ between Natives and non-Natives. Native Americans were more likely readmitted to hospital for surgical complications than non-Natives and this held true after controlling for age, sex, rural versus urban residence, teaching versus non-teaching hospital, multiple discharge diagnoses or complex versus simple cholecystectomy (relative odds 1.46, 95 per cent confidence interval 1.17, 1.18). The explanation for the relatively high rates of cholecystectomy among Native American females may be related to high rates of known risk factors for gallstone disease (such as obesity and high parity). However, the higher rates of surgical complications require further study.

Adult↗
PubMed2005

The utility of antiemetics in the prevention and treatment of postoperative nausea and vomiting in patients scheduled for laparoscopic cholecystectomy.

Postoperative nausea and vomiting (PONV) are distressing and frequent adverse events of anesthesia and surgery, with a relatively high incidence after laparoscopic cholecystectomy. Numerous antiemetics have been studied for the prevention and treatment of PONV in patients scheduled for laparoscopic cholecystectomy. Traditional antiemetics, including anticholinergics (e.g., scopolamine), antihistamines (e.g., dimenhydrinate), phenothiazines (e.g., promethazine), butyrophenones (e.g., droperidol), and benzamide (e.g., metoclopramide), are used for the control of PONV. The available nontraditional antiemetics for the prophylaxis against PONV are dexamethasone and propofol. Serotonin receptor antagonists (ondansetron, granisetron, tropisetron, dolasetron, and ramosetron), compared with traditional antiemetics, are highly efficacious for PONV. The prophylactic ondansetron, granisetron, tropisetron, and dolasetron in antiemetic efficacy are comparable. Ramosetron is effective for the long-term prevention of PONV. None of the available antiemetics is entirely effective, perhaps because most of them act through the blockade on one type of receptor. There is a possibility that combined antiemetics with different sites of activity would be more effective than one drug alone for the prophylaxis against PONV. Combination antiemetic therapy is often effective for the prevention of PONV following laparoscopic cholecystectomy. The efficacy of a combination of serotonin receptor antagonists (ondansetron and granisetron) and droperidol is superior to monotherapy with a serotonin receptor antagonist or droperidol. Similarly, adding dexamethasone to ondansetron or granisetron improves antiemetic efficacy in PONV. Knowledge regarding antiemetics is necessary to completely prevent and treatment of PONV in patients scheduled for laparoscopic cholecystectomy.

Antiemetics↗
PubMed2000

Sonography for selecting candidates for laparoscopic cholecystectomy: a prospective study.

OBJECTIVE: We assessed the value of sonography in predicting intraoperative difficulties for patients undergoing laparoscopic cholecystectomy and in identifying indicators for conversion to conventional cholecystectomy. SUBJECTS AND METHODS: Upper abdominal sonography was performed (according to a checklist) in 75 consecutive patients before laparoscopic cholecystectomy. Sonographic findings were verified by the surgeon in the operating room. RESULTS: Conversion from laparoscopic surgery to laparotomy was performed in five patients (6.7%). Of 75 patients, 19 had sonograms revealing gallbladder wall thickening (>4 mm); surgical preparation difficulties in 16 of these patients led to laparotomy in four patients. Sensitivity, specificity, positive predictive value, and accuracy of wall thickening as an indicator of technical difficulties were 66.7%, 94.1%, 84.2%, and 85.3%, respectively. Sensitivity, specificity, positive predictive value, and accuracy of wall thickening as an indicator of surgical conversion were 80.0%, 78.6%, 21.1%, and 78.7%, respectively. Technical difficulties at laparoscopy occurred in all five patients with pericholecystic fluid on sonography (sensitivity, 20.8%; specificity, 100%; positive predictive value, 100%; accuracy, 74.7%) and led to laparotomy in three patients (sensitivity 60.0%, specificity 97.1%, positive predictive value 60%, accuracy 94.7%). The accuracy of sonography for cholecystolithiasis was 100%. CONCLUSION: On sonography, gallbladder wall thickening is the most sensitive indicator and pericholecystic fluid is the most specific indicator of technical difficulties during laparoscopic cholecystectomy. Such difficulties may require conversion to laparotomy.

Abdomen↗
PubMed1998

Treatment of bile leaks from cystohepatic and common hepatic duct after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is widely accepted by patients and physicians despite the lack of controlled trials comparing this technology with conventional cholecystectomy. The cystohepatic ducts represent accessory bile ducts of variable size which frequently travel within the gallbladder fossa or in the posterior wall of the gallbladder. These ducts can be injured during laparoscopic cholecystectomy and can result in bile collection if transected. Recently, we have experienced two cases of injury to the bile duct during operation. One case was a transection of the accessory bile duct, the other one was an injury to the common hepatic duct. We present herein the clinical course of the two cases, in which biliary leakage, following laparoscopic cholecystectomy, was successfully managed by the end to end anastomosis of the bile duct.

Adult↗
PubMed1986

Gallstones, cholecystectomy, and duodenogastric reflux of bile acid.

It has earlier been suggested that cholecystectomy, by eliminating the reservoir function of the gallbladder, will induce reflux of bile to the stomach. In the present study 23 patients were studied for duodenogastric reflux of bile acid before and 3 months after cholecystectomy. At the test the gastric contents were continuously aspirated via a nasogastric tube, collected at 15-min intervals for 2 h in the fasting patient, and analyzed for volume and bile acid concentration. The results were compared with those in 14 control subjects. Significant duodenogastric reflux of bile acid (greater than 100 mumol/h) was seen more frequently in gallstone patients than in controls. This is explained by a high prevalence of bile acid reflux in patients with a reduced or absent opacification of the gallbladder at cholecystography. Cholecystectomy increased the prevalence of bile acid reflux in the patients with well-opacified gallbladders at cholecystography. The duodenogastric reflux of bile acid in patients with a poor filling of the gallbladder at cholecystography was not further enhanced by cholecystectomy. It is concluded that gallstone patients have an increased tendency to duodenogastric reflux of bile acid. This tendency is further enhanced by removal of a functioning gallbladder. The findings may explain some of the symptoms in patients with gallstones. The reflux may also be responsible for symptoms in the so-called postcholecystectomy syndrome.

Adult↗