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PubMed2000

[Videolaparoscopic cholecystectomy. Experience and results in 1019 cases].

BACKGROUND: Laparoscopic cholecystectomy is now worldwide considered the elective therapy for biliary lithiasis. Morbidity, mortality and conversion rates reported in the literature are assessed between 1 and 6%, 0 and 0.9%, 3.6 and 7.2% respectively. Data on personal experience with 1019 attempted laparoscopic cholecystectomy are reported. METHODS: In the period between 1991 and 1997 1019 laparoscopic cholecystectomy were performed. Patients were 361 males and 658 females (ratio M:F 1:2), with an average age of 51 years (range 5-85). Indications were: 647 symptomatic cholelithiasis, 28 hydrops, 121 empyemas, 76 cholecystocholedocolithiasis and 13 alithiasic cholecystopathy. RESULTS: Conversion was necessary in 61 cases, with a conversion rate of 6%. Mean duration of surgery was 65 minutes (range 30-240) with a mean hospital stay of 2.1 days (range 1-10). No deaths occurred in our series, with a morbidity rate of 1.8% (18 cases, 7 major and 11 minor). Only 1 case of bile duct injury (0.1%) is reported. CONCLUSIONS: In consideration of low conversion rate, low early and late morbidity, absence of bile duct injury, advantages for the patient and the opportunity of evolution of this surgery, laparoscopic cholecystectomy can be considered the standard treatment for biliary lithiasis.

Adolescent↗
PubMed2000

Same-session endoscopic retrograde cholangiopancreatography and cholecystectomy.

The objective was to determine the efficacy and safety of same-session endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy. Twenty-two patients who had ERCP and cholecystectomy performed in the same session under one general anesthetic were compared with 77 patients who had ERCP followed by surgery in the ensuing days. In the 93 patients who underwent attempted laparoscopic cholecystectomy, there was no difference in conversion to open rates between the same-session group and the delayed group. The length of stay after ERCP was longer in the delayed group. Same-session ERCP and cholecystectomy is safe and efficacious, and its routine use should be considered.

Anesthesia, General↗
PubMedDate not supplied

Laparoscopic cholecystectomy and perioperative ERCP.

BACKGROUND/AIMS: Study of acceptance of simultaneous laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography for treatment of cholelithiasis with choledocholithiasis. METHODOLOGY: There were 25 patients. Ten patients had acute pancreatitis of biliary etiology, accompanied by transitory icterus. In 15 patients, choledocholithiasis was suspected preoperatively both on ultrasonography and i.v. cholangiography. In all patients laparoscopic cholecystectomy with perioperative endoscopic retrograde cholangiopancreatography and sphincterotomy were performed for the treatment of cholelithiasis and choledocholithiasis. RESULTS: Simultaneous laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography was successfully done in all patients. The patients were discharged home on the 4th day after the surgery. Concerning early complications, there where 3 early complications, e.g., prolonged hemorrhage after papillotomy in a patient with choledocholithiasis with stenotic papillitis. Conservative therapy (fresh frozen plasma, local hemostats) was used in this patient. In 4 patients with choledocholithiasis, transitory hyperamylasemia was observed, with no clinical symptoms of pancreatitis. The symptoms disappeared with conservative therapy 3 days after the beginning of treatment. CONCLUSIONS: Simultaneous laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography for treatment of cholelithiasis and choledocholithiasis is a safe and acceptable treatment.

Ampulla of Vater↗
PubMed2000

A prospective, randomised trial of prophylactic antibiotics versus bag extraction in the prophylaxis of wound infection in laparoscopic cholecystectomy.

Septic complications are rare following laparoscopic cholecystectomy if prophylactic antibiotics are given, as demonstrated in previous studies. Antibiotic treatment may be unnecessary and, therefore, undesirable, so we compared two forms of prophylaxis: a cephalosporin antibiotic and bag extraction of the dissected gallbladder. A total of 76 patients undergoing laparoscopic cholecystectomy were randomised to either receive an antibiotic or to have their gallbladder removed from the abdomen in a plastic bag. Complicated cases were excluded. There was a total of 6 wound infections (7.9%), 3 in each of the study groups. All these were associated with skin commensals. There were no other septic complications. Bacteriological studies grouped the organisms isolated from the bile and the wound as potential pathogens and likely commensals. A total of 10 potential pathogens were isolated, 9 of which were found in the group receiving antibiotics. We conclude that septic sequelae of uncomplicated laparoscopic cholecystectomy are uncommon, but clearly not entirely prevented by antibiotic or mechanical prophylaxis. Prophylactic antibiotics may not be required in uncomplicated laparoscopic cholecystectomy. Further study is warranted.

Antibiotic Prophylaxis↗
PubMed2000

[Fibrinolytic system after laparoscopic cholecystectomy].

BACKGROUND: Deep-vein thrombosis (DVT) and pulmonary embolism (PE) are the most important causes of morbility and mortality in patients submitted to surgical intervention: some peculiar factors of laparoscopic surgery can modify their risk. The aim of this study is to evaluate possible variations of the fibrinolytic system after cholecystectomy. METHODS: Eighteen patients affected by symptomatic and non-complicated gallstones have been included in this study. They were divided into two groups of nine patients each: the first group was submitted to laparoscopic cholecystectomy (LC) and the second to open cholecystectomy (OC). Antitrombin III (ATIII), fibrinogen degradation products (FDP), tissue plasminogen activator (tPA), and plasminogen activator inhibitor (PAI) have been evaluated preoperatively and 6, 12, 24 and 48 hours after the operation. RESULTS: The levels of ATIII did not present significantly variations. The FDP in both groups were significantly increased 48 hours after open cholecystectomy. Levels of PAI instead were increased in comparison to the basal values at 6, 12, 24, 48 hours with p < 0.05; p < 0.01 and p < 0.05 respectively in patients submitted to OC, in the LC group no variations were observed; a comparison between the groups showed a significant modification (p < 0.05) only at the 12th hour. CONCLUSIONS: The early mobilization of patients in the postoperative course and the lower invasion of LC can oppose the prothrombotic effect in the lower limbs.

Cholecystectomy, Laparoscopic↗
PubMedDate not supplied

Treatment of choledocholithiasis: therapeutic ERCP versus peroperative extraction during laparoscopic cholecystectomy.

Limitation for preoperative ERCP/ES before laparoscopic cholecystectomy in patients scheduled for laparoscopic cholecystectomy are (1) Additional invasiveness of endoscopic procedures in patients supposed to be fitted for surgery, (2) A high rate of useless procedures due to the low predictive value of suspicion criteria for common bile duct stones (CBDS), (3) an inability to detect and treat all patients with CBDS, and (4) so far, an absence of demonstration of the superiority of this split therapeutic approach versus a one stage surgical treatment. Published series of CBDS extraction during laparoscopic cholecystectomy have included more than 2000 patients. Results and complications of this one stage laparoscopic approach compares favourably to the conventional open surgical treatment. In one randomized trial endoscopy plus laparoscopy was not demonstrated superior to laparoscopy alone. Intraoperative diagnosis and treatment of CBDS during laparoscopic cholecystectomy is the most cost efficient approach for patients with or without preoperative suspicion of CBDS, provide they are fitted for surgery.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMedDate not supplied

Laparoscopic cholecystectomy: what are the factors determining difficulty?

BACKGROUND/AIMS: The experience in laparoscopic cholecystectomy is increasing, more difficult cases are performed even by the junior surgeons. This policy has led the investigators to look for methods to identify potentially difficult laparoscopic cholecystectomy. METHODOLOGY: A prospective study was performed to find out the factors that determine technical difficulty in laparoscopic cholecystectomy. Two hundred and twenty-seven patients (170 females and 57 males) with symptomatic gallbladder stones were recruited for this study from June 1995 to September 1997. The overall difficulty score as a dependent variable was based on the following operative parameters: duration of surgery, bleeding, dissection of gallbladder wall, adhesions, spillage of bile, spillage of stones and difficulty of gallbladder extraction. Multiple regression analysis was used to assess the significance of the following potential difficulty variables (Independent) in predicting the variation in the overall difficulty score: age, sex, body mass index, gallbladder size, common bile duct diameter, gallbladder wall thickness, liver size and the presence of adhesions. RESULTS: Gallbladder wall thickness, presence of adhesions, liver size and gallbladder size were found to be significant predictors of the variation in overall difficulty score (Adjusted R2 = 0.48). CONCLUSIONS: We believe that the above-mentioned four difficulty factors are important, however, experience of the surgeon plays a major role in reducing difficult laparoscopic cholecystectomy and consequently decreasing it's complications.

Cholecystectomy, Laparoscopic↗
PubMedDate not supplied

Report of laparoscopic cholecystectomy in two patients with left-sided gallbladders.

Laparoscopic cholecystectomy has been widely performed since its introduction in 1987 by Mouret. However, conversion to open cholecystectomy is common when the surgeon encounters variant anatomy. We report 2 cases of cholecystitis and cholelithiasis in patients with left-sided gallbladders that were treated with laparoscopic cholecystectomy by the same surgeon at this institution. The patient in the first case had the condition of situs inversus totalis, and the gallbladder of the second patient was located to the left of the round ligament. In both instances, successful laparoscopic cholecystectomy was performed, and the patients recovered uneventfully.

Adult↗
PubMed2001

Outpatient laparoscopic cholecystectomy in Hong Kong: patient acceptance.

The authors performed a prospective evaluation of 60 Hong Kong Chinese patients with symptomatic gallstones and gallbladder polyps undergoing outpatient laparoscopic cholecystectomy in a regional hospital in Hong Kong from March 1996 to May 1998 to determine the feasibility, satisfaction, and acceptance of this procedure among Chinese patients. Patients with American Society of Anesthesiologists grade I and II gallstones or polyps were selected. Exclusion criteria included 1) history of upper abdominal operations, attacks of acute cholecystitis, cholangitis, or pancreatitis; 2) abnormal liver function; and 3) ultrasonographic evidence of contracted gallbladder, thickened gallbladder wall, dilated common bile duct, or common bile duct stones. Patients discharged at 5:00 PM on the day of cholecystectomy were defined as having undergone outpatient procedure. Patients were asked about procedure acceptance, rated on a scale of 1 to 10 (best), using a standardized questionnaire 4 weeks after operation. The study included 21 men and 39 women with mean age of 40.5 years (range, 27-59). There were no conversions to open procedures in the series. There were 6 (10%) unanticipated postoperative hospital admissions; all patients were discharged on the first postoperative day. Another patient was readmitted 3 days after operation because of a common bile duct stone. Overall patient acceptance of outpatient laparoscopic cholecystectomy was good, with a mean score of 8.6 of 10. Thirteen patients (22%) expressed dissatisfaction with being discharged earlier than they had expected, and 9 (15%) would have preferred inpatient care. Forty-eight patients (80%) resumed full daily activities by the first postoperative day; the remaining 12 did so by the end of the first week. Among the 44 working patients, only 4 (9%) resumed full duty within the first postoperative week; 29 (66%) did so by the second week and the remaining 11 (25%) returned to work after the third week. By selecting appropriate subjects, outpatient laparoscopic cholecystectomy is feasible and highly accepted among Hong Kong Chinese patients. Approximately one quarter of the patients preferred a longer postoperative stay or inpatient care.

Adult↗
PubMed2001

[Changes in chest wall and lung compliance during laparoscopic cholecystectomy].

INTRODUCTION: The performance of laparoscopic cholecystectomy leads to hemodynamic and gasometric changes as well as to mechanical changes in respiration. The last phenomenon has been less studied in spite of its impact on the patient during surgery. OBJECTIVE: To study changes in chest wall compliance (Ccw) and lung compliance (CL) during laparoscopic cholecystectomy. Material and methods. Nine patients scheduled for laparoscopic cholecystectomy were enrolled. Tidal volume, plateau pressure (Pt) and esophageal (Pes) were measured and the data were used to calculate respiratory system compliance (Crs), Ccw and CL. Measurements were taken at three moments: T1, with the patients in supine decubitus position; T2, in anti-Trendelenburg position with pneumoperitoneum; T3, after withdrawal of pneumoperitoneum with the patient in supine decubitus position. RESULTS: Pt was seen to increase 57%, with a 100% increase in Pes when the patient was placed in anti-Trendelenburg position and pneumoperitoneum was established. Crs changed 44%, with a greater increase taking place in Ccw (52%) than in CL (32%). Baseline values for both pressure and compliance were recovered by T3. CONCLUSIONS: Reduced respiratory compliance occurs during laparoscopic cholecystectomy mainly at the chest wall, with much less reduction taking place in the lung. Thus, intrathoracic pressure increases will be greater than transpulmonary pressure increases.

Adolescent↗
PubMed2001

[Duodeno-gastric reflux in gallbladder stones and after laparotomic cholecystectomy].

BACKGROUND: Duodeno gastric reflux (DGR) is still a not well-defined condition, even though it has been the subject of different studies for many years. METHODS: The authors examine its relation with gallstones before and after the surgical removal of the gallbladder. After examining various study techniques, they present their experience of DRG. In this work the methodology used in a group of 40 patients suffering from gallstones and operated by laparotomic cholecystectomy is presented. All patients have been subjected to a clinical questionnaire in order to evaluate their symptoms, before and after cholecystectomy, and at the same time they have been subjected to an endoscopic exam. It s not easy to comment the RESULTS. RESULTS: Actually, of 32 patients (80%) showing DGR symptoms before surgical treatment, 20 showed their persistence, worsening, or the appearance of new symptoms after cholecystectomy, while 12 were completely asymptomatic. Of 8 patients with no symptoms before cholecystectomy, 3 developed a typical DGR symptomatology while 5 were asymptomatic. CONCLUSIONS: So 57% of patients were DGR symptomatic after surgical treatment. The compromised function of cholecystitis with calculi, antrum-pyloric-duodenal motility, continuous bile flux in the duodenum, surgical trauma all interact in determining DGR.

Bilirubin↗
PubMedDate not supplied

[Bile duct injuries in laparoscopic cholecystectomy].

Bile duct injuries are the most serious complications of laparoscopic cholecystectomy. Although the overall complications rate in laparoscopic cholecystectomy is significantly lower than in open cholecystectomy, bile duct injuries are more frequent. In this article we analyzed why and how they occur and if their prevention was possible. From May 1992 to May 1999, laparoscopic cholecystectomy was performed in 5651 patients by 17 surgeons and residents, with different experience but similar operative technique. In this period nine (0.16%) bile duct injuries occurred. Injuries were caused by seven operators. Number of operations by single surgeon before injury varied from 8 to 1477. Three patients with uncomplicated chronic cholecystitis had puncture or small bile duct laceration. Complete transection of main bile duct occurred in three patients and in one transection of right hepatic duct. The operative findings in two of them were acute cholecystitis, one had fibrosis in the triangle of Calot and one uncomplicated chronic cholecystitis. Bile duct strictures were found in two patients. Both had fibrosis in the triangle of Calot and in hepatic port. Dangerous pathologic findings were the main cause of injuries in 5 and inadequate surgical technique in 4 patients. In our opinion the education, critical state and experience are of main importance in avoidance and prevention of bile duct injures. We also plead for selective use of intraoperative cholangiography. In our opinion the intraoperative cholangiography has to be performed in all cases where the anatomy of the triangle of Calot is not clear.

Adult↗
PubMedDate not supplied

[Biliary lesions after laparoscopic cholecystectomy].

Laparoscopic cholecystectomy is the suitable treatment for symptomatic cholelithiasis, even if the incidence of biliary lesions following this procedure may be up to threefold higher than that of open cholecystectomy. We report our experience concerning the incidence, aetiopathogenesis, diagnosis and treatment of complications in a homogeneous group of laparoscopic cholecystectomies. In a total of 492 laparoscopic cholecystectomies only three bile duct lesions were observed (0.6%); they were classified according to Bismuth and re-assessed according to Strasberg. They consisted in two biliary leakages and one bile duct stricture. All patients were evaluated by full blood test, ultrasonography and endoscopic retrograde cholangiopancreatography. Endoscopic treatment was successful in the two patients with biliary leakage, while the patient with a stricture required surgical therapy. In conclusion, we suggest that a correct knowledge of the aetiopathogenesis together with a multidisciplinary approach to the diagnosis appear to be the best method for the detection, complete classification and most suitable treatment of symptomatic cholelithiasis.

Adolescent↗
PubMedDate not supplied

Ultrasonographic evaluation of common duct diameter in pre and post cholecystectomy patients.

Thirty four patients with gall bladder disease and normal common duct were investigated prospectively by ultrasonography just before cholecystectomy and at periodic intervals of 1 months, 2 months, 3 months and once in 4-6 months after cholecystectomy. The pre and post cholecystectomy common duct diameters were measured at each visit and compared with each other to determine the statistical significance. No significant change (p > 0.05) occurred in common duct diameter following cholecystectomy.

Adolescent↗
PubMed2001

Gallstones and laparoscopic cholecystectomy in hepatitis C patients.

Our aims were to determine the incidence of gallstones in a cohort of patients infected with hepatitis C for 20 years, and to analyse the outcome of all patients infected with hepatitis C undergoing laparoscopic cholecystectomy. A hepatitis C screening programme in place in Ireland since 1994 identified 965 patients with hepatitis C antibodies out of 62,667 patients screened. The hepatology unit of Cork University Hospital has 318 patients with hepatitis C. Of patients identified by screening, 201 were post partum women infected via contaminated Anti-D immunoglobulin administered in 1977. Thirty-five (17.4%) of two hundred and one patients with hepatitis C since 1977 had developed gallstones after twenty years. A total of 34 patients with hepatitis C underwent laparoscopic cholecystectomy. One patient required conversion to open cholecystectomy. There were no complications and no mortality. There was a low rate of cirrhosis (11%) on examining liver histology. The incidence of gallstones in a cohort of patients infected with hepatitis C for twenty years approximates to that of the general population. The low rate of cirrhosis in this group may be related to a low consumption of alcohol. Laparoscopic cholecystectomy is a safe procedure in patients with mild chronic liver disease caused by hepatitis C.

Cholecystectomy, Laparoscopic↗
PubMed2001

Cost-effectiveness of ambulatory laparoscopic cholecystectomy.

The merits of laparoscopic cholecystectomy include faster recovery, less postoperative pain, earlier return to work, and decreased cost. However, there are few economic data comparing laparoscopic cholecystectomy in an ambulatory versus overnight stay setting. In a 12-month period, 74 consecutive cholecystectomies were performed laparoscopically by one surgeon. The ambulatory group consisted of 36 patients who were discharged from the hospital the same day after a mean recovery time of 5 hours (range, 2.25-10.33). Of the remaining 38 patients, 19 were admitted after surgery on 23-hour observation status, and 19 were inpatients. The average hospital cost was significantly less in the ambulatory group than in the observation group, with an 11% mean reduction in cost per patient (P = 0.0061). No patient in either group was readmitted to the hospital within 30 days of surgery. Laparoscopic cholecystectomy can be performed safely in an outpatient setting. The cost savings of ambulatory care versus observation are clearly shown in this study.

Adult↗
PubMed2001

Endoscopic stenting in the treatment of bile leakage after laparoscopic cholecystectomy.

BACKGROUND: Bile leakage is one of the most common complications after laparoscopic cholecystectomy surgery, and biliary decompression is a key factor in treatment. We retrospectively investigated 6 patients with bile leakage after laparoscopic cholecystectomy who were treated with endoscopic stent. METHODS: From March 1995 to May 1999, six patients (4 men and 2 women) aged 30-64 years (mean, 51 years) with bile leakage after laparoscopic cholecystectomy were enrolled. Biliary stent (10 French, 6-10 cm) placement with (n = 4) or without (n = 2) sphincterotomy was attempted. The symptoms, results and outcomes were reviewed. RESULTS: The interval from operation to presentation of bile leakage ranged from 1 to 10 days. Bile leakage was detected from cystic duct stump in 5 patients (83%) and from right IHD in 1 patient (17%). Plastic stent placement was successfully in all patients. Endoscopic stenting healed bile leakage successfully in 5 cases (83%). One patient required surgical correction due to persistent bile leakage. The mean duration between stent placement and cessation of bile leakage was 6.8 days (range 1 to 24 days). CONCLUSIONS: Endoscopic stenting is a safe, rapid and effective treatment for bile leakage after laparoscopic cholecystectomy.

Adult↗
PubMed2001

Outpatient laparoscopic cholecystectomy. Four years of experience.

OBJECTIVE: To evaluate the feasibility of an ambulatory laparoscopic cholecystectomy program. DESIGN: Prospective analysis of ambulatory cases, overnight stay percentage, unexpected admission rate, postoperative complications and readmissions. PATIENTS: 271 consecutive patients undergoing elective laparoscopic cholecystectomy. RESULTS: Ambulatory laparoscopic cholecystectomy was completed in 193 out of 271 patients, reaching a 71.2 percent for the whole series. Ambulatory patients increased along with the experience of the team from a 22.9 percent in 1997 to 91.4 per cent in 2000. Sixty four patients (23.6%) had to be hospitalized overnight. Finally 14 patients had to be admitted (5.2%). The percentage of postoperative complications was 7.7%. CONCLUSIONS: Ambulatory laparoscopic cholecystectomy is a feasible and safe procedure with no increase in morbidity that can be performed in up to 90 per cent of patients.

Adult↗