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PubMed2000

Selective use of tube cholecystostomy with interval laparoscopic cholecystectomy in acute cholecystitis.

HYPOTHESIS: Tube cholecystostomy followed by interval laparoscopic cholecystectomy is a sale and efficacious treatment option in critically ill patients with acute cholecystitis. DESIGN: Retrospective cohort study within a 4 1/2%-year period. SETTING: University hospital. PATIENTS: Of 324 patients who underwent laparoscopic cholecystectomy, 65 (20%) had acute cholecystitis; 15 of these 65 patients (mean age, 75 years) underwent tube cholecystostomy. INTERVENTION: Thirteen patients at high risk for general anesthesia because of underlying medical conditions underwent percutaneous tube cholecystostomy with local anesthesia. Laparoscopic tube cholecystostomy was performed on 2 patients during attempted laparoscopic cholecystectomy because of severe inflammation. Interval laparoscopic cholecystectomy was attempted after an average of 12 weeks. MAIN OUTCOME MEASURES: Technical details and clinical outcome. RESULTS: Prompt clinical response was observed in 13 (87%) of the patients after tube cholecystostomy. Twelve patients (80%) underwent interval cholecystectomy. Laparoscopic cholecystectomy was attempted in 11 patients and was successful in 10 (91%), with 1 conversion to open cholecystectomy. One patient had interval open cholecystectomy during definitive operation for esophageal cancer and another had emergency open cholecystectomy due to tube dislodgment. Two patients (13%) had complications related to tube cholecystostomy and 2 patients died from sepsis before interval operation. One patient died from sepsis after combined esophagectomy and cholecystectomy. Postoperative minor complications developed in 2 patients. At a mean follow-up of 16.7 months (range, 0.5-53 months), all patients were free of biliary symptoms. CONCLUSIONS: Tube cholecystostomy allowed for resolution of sepsis and delay of definitive surgery in selected patients. Interval laparoscopic cholecystectomy was safely performed once sepsis and acute infection had resolved in this patient group at high risk for general anesthesia and conversion to open cholecystectomy. Just as catheter drainage of acute infection with interval appendectomy is accepted in patients with periappendiceal abscess, tube cholecystostomy with interval laparoscopic cholecystectomy should have a role in the management of selected patients with acute cholecystitis.

Acute Disease↗
PubMed2001

Bile duct injury during laparoscopic cholecystectomy: results of a national survey.

OBJECTIVE: To determine whether surgical residency training has influenced the occurrence of common bile duct injuries during laparoscopic cholecystectomy, and to asses the anatomic and technical details of bile duct injuries from the practices of surgeons trained in laparoscopic cholecystectomy after residency versus surgeons trained in laparoscopic cholecystectomy during residency. SUMMARY BACKGROUND DATA: Shortly after the introduction of laparoscopic cholecystectomy, the rate of injury to the common bile duct increased to 0.5%, and injuries were more commonly reported early in each surgeon's experience. It is not known whether learning laparoscopic cholecystectomy during surgery residency influences this pattern. METHODS: An anonymous questionnaire was mailed to 3,657 surgeons across the United States who completed an Accreditation Council for Graduate Medical Education (ACGME)-approved residency between 1980 and 1990 (group A) or 1992 and 1998 (group B). All surgeons in group A learned laparoscopic cholecystectomy after residency, and all those in group B learned laparoscopic cholecystectomy during residency. Information obtained included practice description, number of laparoscopic cholecystectomies completed since residency, postgraduate training in laparoscopy, and annual volume of laparoscopic cholecystectomy in the surgeon's hospital. In addition, technical details queried included the completion of a cholangiogram, the interval between injury and identification, the method of repair, and the site of definitive treatment. The primary endpoint was the occurrence of a major bile duct injury during laparoscopic cholecystectomy (bile leaks without a major bile duct injury were not tabulated). RESULTS: Forty-five percent (n = 1,661) of the questionnaires were completed and returned. Mean practice experience was 13.6 years for group A and 5.4 years for group B. At least one injury occurrence was reported by 422 surgeons (37.6%) in group A and 143 surgeons (26.5%) in group B. Forty percent of the injuries in group A occurred during the first 50 cases compared with 22% in group B. Thirty percent of bile duct injuries in group A and 32.9% of all injuries in group B occurred after a surgeon had performed more than 200 laparoscopic cholecystectomies. Independent of the number of laparoscopic cholecystectomies completed since residency, group A surgeons were 39% more likely to report one or more biliary injuries and 58% more likely to report two or more injuries than their counterparts in group B. Bile duct injuries were more likely to be discovered during surgery if a cholangiogram was completed than if cholangiography was omitted (80.9% vs. 45.1%). Sixty-four percent of all major bile duct injuries required biliary reconstruction, and most injuries were definitively treated at the hospital where the injury occurred. Only 14.7% of injuries were referred to another center for repair. CONCLUSIONS: Accepting that the survey bias underestimates the true frequency of bile duct injuries, residency training decreases the likelihood of injuring a bile duct, but only by decreasing the frequency of early "learning curve" injuries. If one accepts a liberal definition of the learning curve (200 cases), it appears that at least one third of injuries are not related to inexperience but may reflect fundamental errors in the technique of laparoscopic cholecystectomy as practiced by a broad population of surgeons in the United States. Intraoperative cholangiography is helpful for intraoperative discovery of injuries when they occur. Most injuries are repaired in the hospital where they occur and are not universally referred to tertiary care centers.

Adult↗
PubMed2006

Laparoscopic versus small-incision cholecystectomy for patients with symptomatic cholecystolithiasis.

BACKGROUND: Cholecystectomy is one of the most frequently performed operations. Open cholecystectomy has been the gold standard for over 100 years. Small-incision cholecystectomy is a less frequently used alternative. Laparoscopic cholecystectomy was introduced in the 1980s. OBJECTIVES: To compare the beneficial and harmful effects of laparoscopic versus small-incision cholecystectomy for patients with symptomatic cholecystolithiasis. SEARCH STRATEGY: We searched TheCochrane Hepato-Biliary Group Controlled Trials Register (6 April 2004), The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), Web of Science (1988 to January 2004), and CINAHL (1982 to January 2004) for randomised trials. SELECTION CRITERIA: All published and unpublished randomised trials in patients with symptomatic cholecystolithiasis comparing any kind of laparoscopic cholecystectomy versus small-incision or other kind of minimal incision open cholecystectomy. No language limitations were applied. DATA COLLECTION AND ANALYSIS: Two authors independently performed selection of trials and data extraction. The methodological quality of the generation of the allocation sequence, allocation concealment, blinding, and follow-up was evaluated to assess bias risk. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate. MAIN RESULTS: Thirteen trials randomised 2337 patients. Methodological quality was relatively high considering the four quality criteria. Total complications of laparoscopic and small-incision cholecystectomy are high: 26.6% versus 22.9%. Total complications (risk difference, random-effects -0.01, 95% confidence interval (CI) -0.07 to 0.05), hospital stay (weighted mean difference (WMD), random-effects -0.72 days, 95% CI -1.48 to 0.04), and convalescence were not significantly different. High-quality trials show a quicker operative time for small-incision cholecystectomy (WMD, high-quality trials 'blinding', random-effects 16.4 minutes, 95% CI 8.9 to 23.8) while low-quality trials show no significant difference. AUTHORS' CONCLUSIONS: Laparoscopic and small-incision cholecystectomy seem to be equivalent. No differences could be observed in mortality, complications, and postoperative recovery. Small-incision cholecystectomy has a significantly shorter operative time. Complications in elective cholecystectomy are prevalent.

Cholecystectomy↗
PubMed1999

Laparoscopic and open cholecystectomy in New York State: mortality, complications, and choice of procedure.

BACKGROUND: With the advent of laparoscopic cholecystectomy patient outcomes and choice of procedure (laparoscopic vs open) are of vital interest. The purpose of this study was to examine the mortality and complication rates for patients undergoing laparoscopic and open cholecystectomy in New York State and to test for differences among hospital peer groups and regions of the state in the tendency to use the laparoscopic approach. METHODS: A population-based, retrospective cohort study of laparoscopic and open cholecystectomy was conducted in which data were analyzed on all 30,968 patients who underwent cholecystectomy as a principal procedure in New York State in 1996. RESULTS: A total of 78.7% of the 30,968 patients who underwent cholecystectomy as a principal procedure in New York State in 1996 underwent laparoscopic cholecystectomy. The mortality rate was lower for laparoscopic cholecystectomy than for the open procedure (0.23% vs 1.90%, P < .0001) and remained significantly lower after patient characteristics related to patient survival (odds ratio 0.34, P < .0001) were controlled for. The prevalence rate of the 8 most common complications among cholecystectomy patients was also much lower among patients undergoing laparoscopic cholecystectomy. Patients undergoing cholecystectomy in public hospitals, Bronx County, and Kings County were found to be significantly less likely to have laparoscopic procedures, and patients undergoing cholecystectomy on Long Island were found to be significantly more likely to have laparoscopic procedures than were other patients in the state. CONCLUSIONS: There are reasonably large differences among hospitals, hospital groups, and regions of the state in the type of cholecystectomy used, even after adjustment for differences in patient comorbidities and indications for type of procedure.

Adult↗
PubMed2001

Cholecystitis in the octogenarian: is laparoscopic cholecystectomy the best approach?

Management of biliary disease in the octogenarian has evolved over the last decade. Laparoscopic cholecystectomy is now more commonly performed in this patient population. Octogenarians with biliary pathology frequently present with complications of acute disease such as biliary pancreatitis, choledocholithiasis, and acute cholecystitis. As a result, laparoscopic management in this patient population can frequently be more challenging than in younger patients. We retrospectively reviewed 70 patients who were 80 years of age and older who underwent cholecystectomy at our institution for biliary tract disease. Seventeen patients presented to the Day Surgery unit for elective management of chronic biliary disease. Sixteen (94%) of these patients were attempted laparoscopically and one (6%) underwent open cholecystectomy. Two patients attempted laparoscopically were converted to open surgery (conversion rate 12.5%). Average length of hospital stay was 3.7 days for those treated laparoscopically and 11 days for patients treated with open cholecystectomy. There were three complications (19%) in this group and no deaths. The remaining 53 patients presented via the emergency room with acute complications of cholelithiasis. Laparoscopic cholecystectomy was attempted in 28 (52%) and open cholecystectomy was performed in 25 (48%) patients. Ten (37%) of the patients attempted laparoscopically were converted to an open procedure. Average length of stay in this group was 11.7 days for those treated laparoscopically and 15.7 days for patients managed with open technique. There were ten (56%) complications in the laparoscopic group and five (14%) complications in the open group. There were four deaths (22%) among those treated laparoscopically and three deaths (8.6%) in the open cholecystectomy group. Comorbid conditions were common in the patients with acute biliary pathology and those presenting for elective cholecystectomy. Laparoscopic cholecystectomy is the procedure of choice in the elective management of biliary tract disease in the octogenarian. Laparoscopic cholecystectomy has no benefit with respect to morbidity and mortality over open cholecystectomy in the management of acute biliary tract disease in this elderly population. When possible, chronic cholecystitis in the elderly should be managed with elective laparoscopic cholecystectomy rather than waiting for complications to develop.

Age Factors↗
PubMed2002

Proinflammatory cytokines in open versus laparoscopic cholecystectomy.

OBJECTIVE: Laparoscopic cholecystectomy, a minimal access surgery, is fast replacing open cholecystectomy and is being associated with less trauma. The objective of this study was to compare the proinflammatory cytokine levels in both laparoscopic cholecystectomy and open cholecystectomy. METHODS: This study was carried out at Aseer Central Hospital, Aseer region, Abha Private Hospital and the College of Medicine and Medical Sciences, King Khalid University, Abha, Kingdom of Saudi Arabia, during the time period October 1998 through to November 2000. Sixty-one patients were included in the study, 27 of them had laparoscopic cholecystectomy and 34 had open cholecystectomy. Cytokines [Interleukin-6 Interleukin-1b, Tumor necrosis factor -a and Interleukin- 8] were measured in blood samples collected from the patients before, at and 24 hours post surgery, using commercially available kits. RESULTS: Interleukin-6 levels were significantly increased at 24 hours post surgery in the open cholecystectomy group of patients compared to the laparoscopic cholecystectomy group (P<0.04). No differences were found in the other cytokines levels (Interleukin-1b, tumor necrosis factor -a and Interleukin-8) between the open cholecystectomy and laparoscopic cholecystectomy groups. CONCLUSION: Laparoscopic cholecystectomy, a minimal access surgery, is associated with lower levels of the proinflammatory interleukin-6 cytokine compared to open cholecystectomy.

Cholecystectomy↗
PubMed1996

A prospective audit of cholecystectomy in a single health district.

Laparoscopic cholecystectomy is becoming the treatment of choice for patients presenting with gallstones. A prospective audit of all patients undergoing cholecystectomy in a single health district over a six-month period was carried out. The aim was to define those patients not having laparoscopic cholecystectomy and determine the morbidity and mortality associated with open and laparoscopic procedures. Cholecystectomy was performed on 173 patients; 149 operations were attempted laparoscopically, of which 134 were successful, giving a conversion rate of 10%. Elective open cholecystectomy was performed on 24 patients. Twenty of these patients were under the care of a consultant who only performs open cholecystectomy and the others were not offered a laparoscopic procedure because of previous abdominal operations. The median time taken for open cholecystectomy was significantly shorter (P < 0.05) than for laparoscopic cholecystectomy or for converted procedures. Laparoscopic cholecystectomy resulted in bile duct injury in one patient (0.7%). This study shows that the majority of patients with gallstones are being offered laparoscopic cholecystectomy, although some patients will undergo open cholecystectomy. The latter include patients under the care of surgeons not performing laparoscopic cholecystectomy, those presenting as an emergency where laparotomy is performed and those where laparoscopy is contra-indicated. The findings of this study are probably representative of other health districts where a similar mix of surgical practice exists.

Adult↗
PubMed1998

The changing face of cholecystectomy.

Previous reports in selected patient populations have noted an increase in the number of cholecystectomies since the introduction of laparoscopic cholecystectomy. To assess the impact of laparoscopic cholecystectomy in a more general population, 6473 consecutive cholecystectomies from 7/1/86 to 6/30/95 were reviewed to assess changes in rate of cholecystectomy, diagnosis leading to cholecystectomy, and general patient demographics. During the 9-year period, the number of cholecystectomies increased from 618 to 800 per year (29%; P < 0.002). Even more striking was the redistribution of cholecystectomies performed for acalculous disease (P < 0.0001), with the rate of increase more than doubling for each individual diagnosis (biliary dyskinesia, 348%; acute acalculous cholecystitis, 139%; chronic acalculous cholecystitis, 138%). When comparing patient characteristics, there was a significant increase in the number of cholecystectomies performed on females when compared with males. When compared with other races, whites underwent cholecystectomy for chronic acalculous cholecystitis at a higher rate (120%; P < 0.0003). The introduction of laparoscopic cholecystectomy was followed by a dramatic increase in cholecystectomies performed for acalculous disease and less so for cholelithiasis. Accompanying the increase were significant alterations in patient demographics. The study provides indirect evidence for lowering thresholds and changing indications with reasons for the increases yet to be determined.

Cholecystectomy↗
PubMed1998

Incidence of deep vein thrombosis after laparoscopic vs minilaparotomy cholecystectomy.

OBJECTIVES: To determine the frequency of deep vein thrombosis (DVT) associated with minimally invasive cholecystectomy and to determine, using minilaparotomy cholecystectomy as a control operation, the influence of the laparoscopic pneumoperitoneum on DVT formation. DESIGN: Prospective nonrandomized control trial. SETTING: Tertiary care university hospital. PATIENTS: One hundred consecutive patients intended to undergo either laparoscopic cholecystectomy (59 patients) or minilaparotomy cholecystectomy (41 patients) with either of 2 surgeons were prospectively enrolled between April 1996 and April 1997. The minilaparotomy cholecystectomy group served as controls to isolate the effect of the pneumoperitoneum. Patient details, operative details, and any thromboembolic or bleeding complications were recorded. The same thromboprophylaxis regimen was prescribed for each group; namely, preoperative and postoperative subcutaneous low-molecular-weight heparin (LMWH), graduated compression stockings, and intraoperative intermittent calf compression. INTERVENTION: Minimally invasive cholecystectomy. MAIN OUTCOME MEASURE: Frequency of DVT. Bilateral lower limb venous color duplex scanning was used to detect DVT. Scans were performed on 3 occasions: (1) preoperatively on admission to hospital, (2) on the first postoperative day, and (3) between 2 and 4 weeks postoperatively. RESULTS: Three patients in the laparoscopic group and 2 patients in the minilaparotomy group underwent conversion to conventional open cholecystectomy. There were no significant differences between patients in the 2 groups for age, sex, body mass index, preoperative white blood cell count, platelet count, prothrombin time, or activated partial thromboplastin time. There were no significant differences between the 2 groups for elective vs emergency operations, public hospital vs private hospital admissions, or consultant vs resident surgeon. Macroscopic gallbladder pathology grades for both groups were not significantly different, and there was no significant difference in the duration of postoperative hospital stay. Operative cholangiography was performed in a significantly larger proportion of laparoscopic cases (86% vs 66% in the minilaparotomy group; chi(2) test, P=.002), and the duration of anesthesia was significantly longer for the laparoscopic operation (118 minutes vs 98 minutes; t test, P=.05). Ninety-seven patients received preoperative LMWH and all patients received graduated compression stockings, intraoperative intermittent calf compression, and postoperative LMWH. Two of the 100 patients had postoperative DVT, 1 after laparoscopic cholecystectomy and 1 after minilaparotomy cholecystectomy. Both DVTs were detected by duplex examination on the first postoperative day. The DVT found after laparoscopic cholecystectomy was in 1 of the 3 patients who did not receive preoperative LMWH. There were no DVTs in any of the 40 patients who had an additional duplex scan between 2 and 4 weeks after operation. CONCLUSIONS: Despite the theoretical risk of thromboembolic disease due to use of the laparoscopic pneumoperitoneum, the frequency of DVT after either laparoscopic cholecystectomy or minilaparotomy cholecystectomy is low if adequate thromboprophylaxis is provided.

Cholecystectomy, Laparoscopic↗
PubMed2006

Small-incision versus open cholecystectomy for patients with symptomatic cholecystolithiasis.

BACKGROUND: Cholecystectomy is one of the most frequently performed operations. Open cholecystectomy has been the gold standard for over 100 years. Small-incision cholecystectomy is a less frequently used alternative. OBJECTIVES: To compare the beneficial and harmful effects of small-incision versus open cholecystectomy for patients with symptomatic cholecystolithiasis. SEARCH STRATEGY: We searched TheCochrane Hepato-Biliary Group Controlled Trials Register (6 April 2004), The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), Web of Science (1988 to January 2004), and CINAHL (1982 to January 2004) for randomised trials. SELECTION CRITERIA: All published and unpublished randomised trials in patients with symptomatic cholecystolithiasis comparing any kind of small-incision or other kind of minimal incision cholecystectomy versus any kind of open cholecystectomy. No language limitations were applied. DATA COLLECTION AND ANALYSIS: Two authors independently performed selection of trials and data extraction. The methodological quality of the generation of the allocation sequence, allocation concealment, blinding, and follow-up was evaluated to assess bias risk. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate. MAIN RESULTS: Seven trials randomised 571 patients. Bias risk was high in the included trials. No mortality was reported. The total complication proportions are respectively 9.9% and 9.3% in the small-incision and open group, which is not significantly different (risk difference all trials, random-effects 0.00, 95% confidence interval (CI) -0.06 to 0.07). There are also no significant differences considering severe complications and bile duct injuries. However, small-incision cholecystectomy has a shorter hospital stay (weighted mean difference, random-effects -2.8 days (95% CI -4.9 to -0.6)) compared to open cholecystectomy. AUTHORS' CONCLUSIONS: Small-incision and open cholecystectomy seem to be equivalent regarding risks of complications, but the latter method is associated with a significantly longer hospital stay. The quicker recovery of small-incision cholecystectomy compared with open cholecystectomy confirms the existing preference of this technique over open cholecystectomy.

Cholecystectomy↗
PubMed2003

Cholecystectomy in patients with Crohn's ileitis.

PURPOSE: Gallstone disease is reported to be higher in patients with Crohn's disease than in the general population. This study was designed to determine the prevalence of cholecystectomy in patients with Crohn's ileitis, attempt to identify any associated risk factors, and determine whether it is justified to perform prophylactic cholecystectomy during ileocolic resection. METHODS: A total of 191 patients with Crohn's ileitis who were treated medically or who had an ileocolic resection were retrospective reviewed. A questionnaire survey was performed. Telephone interviews were conducted for the non respondents. Further review of medical records was performed to determine the details of admissions for any gallstone disease and/or subsequent cholecystectomy. A control group matched for age and gender was obtained. RESULTS: A total of 191 questionnaires were mailed, and the overall response rate was 70.2 percent (134/191) after telephone interview follow-up. There were 2 of 45 medical and 18 of 89 surgical patients with symptomatic cholelithiasis, i.e., 14.9 percent (20/134) of respondents. As a result, 2 patients (1.5 percent) required endoscopic sphincterotomy, 17 patients (12.7 percent) needed cholecystectomy, and 1 patient (0.7 percent) did not have any intervention. Only five patients had a cholecystectomy after their ileal resections. In the control group of 150 patients, 15 patients (14 females; mean age, 51.9 years; range, 34-78 years) had previous cholecystectomy. There was no significant difference with prevalence of cholecystectomy in Crohn's patients compared with controls (17/134 vs. 15/150; P = not significant). Furthermore, the number of ileal resections did not affect the cholecystectomy rate, but patients who had >30 cm of ileum resected were more likely to have cholecystectomy (P = 0.056). CONCLUSIONS: The prevalence of gallstone disease in Crohn's ileitis requiring cholecystectomy is similar to that of the general population with a female predominance. In addition, the number of patients requiring cholecystectomy after ileal resection was low. Thus, synchronous prophylactic cholecystectomy during ileocolic resection for Crohn's ileitis is not justified.

Adolescent↗
PubMed2002

Predictive factors for conversion of laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy has replaced open cholecystectomy for the treatment of gallbladder disease. However, certain cases still require conversion to open procedures. Identifying these patients at risk for conversion remains difficult. This study identifies risk factors that may predict conversion from a laparoscopic to an open procedure. METHODS: From January 1996 to January 2000, a total of 1,347 laparoscopic cholecystectomies were performed at the Cleveland Clinic Foundation (CCF). A retrospective analysis of 34 parameters including patient demographics, clinical history, laboratory data, ultrasound results, and intraoperative details was performed. Stepwise, multivariate logistic regression was used to determine those variables predicting conversion of laparoscopic cholecystectomy. RESULTS: Seventy-one (5.3%) laparoscopic cholecystectomies required conversion. Multivariate analysis revealed that for all cases, a white blood cell count >9 (2.9 greater odds ratio [OR] of conversion P = 0.006) and a gallbladder wall thickness >0.4 cm (7.2 OR, P <0.001) predicted conversion to open cholecystectomy. However, when patients with acute cholecystitis were evaluated only a body mass index >30 kg/m(2) (5.6 OR, P = 0.02) predicted conversion. For patients undergoing elective cholecystectomy, a body mass index >40 kg/m(2) (33.1 OR, P = 0.01) and a wall thickness >0.4 cm (24.7 OR, P <0.004) predicted conversion. Finally, an ASA >2 (5.3 OR, P = 0.01) predicted conversion in patients undergoing nonelective cholecystectomies. CONCLUSIONS: Obese patients with acute cholecystitis undergoing laparoscopic cholecystectomy have an increased chance of conversion. Likewise, patients with multiple comorbid diseases undergoing nonelective laparoscopic cholecystectomy are more likely to require conversion. Finally, in an elective laparoscopic cholecystectomy, morbidly obese patients with chronic cholecystitis and a thickened gallbladder wall are more likely to require conversion. These factors can help counsel patients undergoing laparoscopic cholecystectomy with regards to the probability of conversion to an open procedure.

Cholecystectomy, Laparoscopic↗
PubMedDate not supplied

Early laparoscopic cholecystectomy for acute cholecystitis: a safe procedure.

Acute cholecystitis is increasingly managed by laparoscopic cholecystectomy. Some reports have shown conversion and complication rates that are increased in comparison to elective laparoscopic cholecystectomy. This study reviews the combined experience of two hospitals where the intention was to perform early laparoscopic cholecystectomy for acute cholecystitis. A total of 152 cases of laparoscopic cholecystectomy for acute cholecystitis (evidence of acute inflammation clinically and pathologically) were identified. Conversion to open cholecystectomy was required in 14 cases (9%) in the total series. Laparoscopic cholecystectomy was performed within 2 days of admission in 76% (115 of 152) of patients. Conversion was significantly less likely in patients undergoing laparoscopic cholecystectomy within 2 days of admission (4 of 115) compared to those undergoing surgery beyond 2 days (10 of 37; P<0.0001). Eleven patients (7%) had postoperative complications; however, there were no cases of injury to the biliary system and no perioperative deaths. This series shows that laparoscopic cholecystectomy can be performed safely in patients with acute cholecystitis and suggests that early laparoscopic cholecystectomy is preferable to delaying surgery. Although the conversion rate to open surgery is higher than for elective cholecystectomy, the majority of patients (91%) still derive the well-recognized benefits of laparoscopic cholecystectomy. Early laparoscopic cholecystectomy is an acceptable approach to acute cholecystitis for the experienced laparoscopic surgeon.

Acute Disease↗
PubMed1996

Mortality and complications associated with laparoscopic cholecystectomy. A meta-analysis.

OBJECTIVE: The purpose of this study was to perform a meta-analysis of large laparoscopic cholecystectomy case-series and compare results concerning complications, particularly bile duct injury, to those reported in open cholecystectomy case-series. SUMMARY BACKGROUND DATA: Since the introduction of laparoscopic cholecystectomy in the United States, hundreds of reports about the technique have been published, many including statements about the advantages of laparoscopic cholecystectomy compared with those of open cholecystectomy. There is an unevenness in scope and quality of the studies. Nevertheless, enough data have accumulated from large series to permit analyses of data regarding some of the most important issues. METHODS: Articles identified via a MEDLINE (the National Library of Medicine's computerized database) search were evaluated according to standard criteria. Data regarding the patient sample, study methods, and outcomes of cholecystectomy were abstracted and summarized across studies. RESULTS: Outcomes of laparoscopic cholecystectomy are examined for 78,747 patients reported on in 98 studies and compared with outcomes of open cholecystectomy for 12,973 patients reported on in 28 studies. Laparoscopic cholecystectomy appears to have a higher common bile duct injury rate and a lower mortality rate. Estimated rates of other types of complications after laparoscopic cholecystectomy generally were low. Most conversions followed operative discoveries (e.g., dense adhesions) and were not the result of injury. CONCLUSIONS: There is wide variability in the amount and type of data reported within any single study, and patient populations may not be comparable across studies. Except for a higher common bile duct injury rate, laparoscopic cholecystectomy appears to be at least as safe a procedure as that of open cholecystectomy.

Cholecystectomy, Laparoscopic↗
PubMed1996

Postoperative complications of cholecystectomy in Victorian public hospitals.

Cholecystectomies in Victorian public hospitals were evaluated by analysis of hospital morbidity data. The Victorian Inpatient Minimum Dataset (VIMD) contains data on postoperative complications from all cholecystectomies in Victorian public hospitals. Hospital separations associated with cholecystectomy were identified according to Australian national diagnosis-related groups and the procedures were grouped as open, laparoscopic or conversion from laparoscopic to open cholecystectomy (conversion). Postoperative complications were identified by ICD9-CM external-cause codes (E-codes) in the VIMD. The 35593 cholecystectomies performed between 1987-88 and 1993-94 were analysed. A further detailed analysis of all cholecystectomies performed in 1993 was based on logistic regression. This identified the adjusted odds (AOR) of occurrence of complications and included covariates of age, sex, admission type, diagnosis-related group and hospital identification code. The annual frequency of cholecystectomy increased after introduction of laparoscopic cholecystectomy in 1990, and was associated with an increase in rates of separations having adverse events, but laparoscopic cholecystectomy had the lowest rate (66.7 per 1000 separations). Adverse-event rates for open procedures increased to 157.5 per 1000 in 1993-94, and for conversions to 290.0 per 1000. Of 5627 cholecystectomies in 1993, 74.4 per cent were laparoscopic, 21.5 per cent open and 4.1 per cent conversions. Postoperative complications were more likely in males (AOR 1.67, 95 per cent confidence interval (CI) 1.38 to 2.04), in patients admitted as an emergency (1.27, CI 1.01 to 1.60), and in those having open cholecystectomies (2.25, 1.78 to 2.85) or conversions (4.29, 3.05 to 6.03). Analysis of the VIMD has provided information for the evaluation of cholecystectomy. The VIMD is a useful tool for monitoring postoperative complications and the quality of care in Victorian hospitals.

Cholecystectomy↗
PubMedDate not supplied

Gallstones and laparoscopic cholecystectomy.

The National Institutes of Health Consensus Development Conference on Gallstones and Laparoscopic Cholecystectomy brought together surgeons, endoscopists, hepatologists, gastroenterologists, internists, radiologists, and epidemiologists as well as other health care professionals and the public to address (1) the indications for treatment of patients with gallstones; (2) the role of laparoscopic cholecystectomy in treating patients with gallstones; (3) the role of alternative medical and surgical treatments for gallstones; (4) the comparative results of laparoscopic cholecystectomy with open cholecystectomy and other available treatments; (5) techniques for detecting and treating bile duct stones with or without laparoscopic cholecystectomy; and (6) future directions for research in prevention and management of gallstone disease and in laparoscopic cholecystectomy. Following 2 days of presentations by experts and extensive discussion by the audience, a consensus panel weighed the evidence and prepared their consensus statement. Among their findings, the panel concluded that (1) most patients who experience symptoms of gallstones should be treated; (2) in comparison with open cholecystectomy, laparoscopic cholecystectomy provides a safe and effective treatment for most patients with symptomatic gallstones and has become the treatment of choice for many patients; (3) patients who are not good candidates for laparoscopic cholecystectomy include those with generalized peritonitis, septic shock from cholangitis, severe acute pancreatitis, endstage cirrhosis, and gallbladder cancer; (4) laparoscopic cholecystectomy decreases pain and disability without increasing mortality and morbidity and can be performed at an equal or lower cost than open cholecystectomy; and (5) every effort should be made to ensure that surgeons performing laparoscopic cholecystectomy are properly trained and credentialed. The full text of the consensus panel's statement follows.

Bile Acids and Salts↗
PubMed2005

Two-port needlescopic cholecystectomy: prospective study of 100 cases.

OBJECTIVE: To test the feasibility of needlescopic cholecystectomy using a two-port technique with 3-mm miniaturised instruments. DESIGN: Prospective study. SETTING: Regional hospital, Hong Kong. PATIENTS: One hundred consecutive patients undergoing elective cholecystectomy from September 2001 to August 2002. INTERVENTION: Two-port needlescopic cholecystectomy all performed or supervised by a single laparoscopic surgeon. MAIN OUTCOME MEASURES: Conversion of the procedure, the operating time, postoperative analgesic requirement, pain score using the 10-cm visual analog scale, complications, and the postoperative stay. To determine the technical difficulty of this new technique, the data from the first 50 patients were compared with those of the latter 50. Outcome variables were also compared with a group of 58 patients operated on with the standard two-port laparoscopic cholecystectomy in a previous randomised trial. RESULTS: One conversion to open cholecystectomy was reported. Three patients required the enlargement of epigastric port to a size of 5 mm and six patients required an additional port to complete the operation. The median operating time was 62 minutes (range, 33-168 minutes). The median pain score was 3.5 (range, 0-9) and the median postoperative stay was 2 days (range, 1-14 days). Six patients had postoperative complications. When the first 50 patients were compared with the latter 50, there were no differences in the conversion rate, operating time, complication rate, and duration of hospital stay. However, the latter 50 patients had significantly lower pain scores (median, 3.5 vs 4.9; P=0.007) and faster resumption of diet (median, 5 vs 9 hours; P<0.001). The median operating time of needlescopic cholecystectomy was notably longer (62 vs 46 minutes; P<0.001) compared with that of the two-port laparoscopic cholecystectomy. Patients undergoing needlescopic cholecystectomy had a better resumption of diet (median, 5 vs 7 hours; P<0.001) and less postoperative pain (overall pain score, median, 3.5 vs 4.8; P=0.052) than the two-port laparoscopic cholecystectomy group. Pain scores at individual port sites were also lower in needlescopic cholecystectomy group (umbilical port: median, 3 vs 4.4, P=0.015; epigastric port: median, 2.0 vs 3.6, P=0.036). CONCLUSION: Two-port needlescopic cholecystectomy is technically feasible and may further improve the surgical outcomes in terms of postoperative pain and cosmesis. It can be considered for routine practice by surgeons who are familiar with the two-port laparoscopic cholecystectomy technique.

Aged↗
PubMed2006

National trends in the utilization of cholecystectomy in children.

BACKGROUND: Previous studies have suggested that indications for cholecystectomy in children have evolved over the past three decades contributing to an increased frequency of this procedure. The purpose of this study was to evaluate recent trends in utilization of cholecystectomy in children in the laparoscopic era. MATERIALS AND METHODS: Children (<15 year) undergoing cholecystectomy between 1996 and 2003 were identified in the Nationwide Inpatient Sample. Underlying medical illness and related biliary tract conditions and procedures were identified using ICD-9 codes. Census data were used to calculate population-based rates stratifying by age and risk factors for cholelithiasis. Univariate and multivariate analyses were performed accounting for survey design. RESULTS: During the study period, an estimated 11,823 cholecystectomies were performed nationwide. While the population frequency of children with hemolytic anemia undergoing cholecystectomy did not significantly change, the frequency of children undergoing cholecystectomy without this risk factor increased from 1.5 to 2.5 procedures/100,000 population (P = 0.03). The percentage undergoing cholecystectomy by a laparoscopic approach increased from 77 to 91% (P < 0.001), with the largest increase being observed in children <5 years old (36% versus 90%, P < 0.001). While no significant differences in in-hospital surgical complications or mortality were observed, laparoscopic cholecystectomy was associated with a 2.3 d (P < 0.001) shorter length of stay than open cholecystectomy. CONCLUSIONS: The indications for cholecystectomy have continued to evolve in the laparoscopic era. While the increased use of laparoscopic cholecystectomy has been associated with decreased length of stay, this approach has not been associated with changes in in-hospital outcomes. The effect of these trends on rates of operative biliary tract injury and long-term outcome require additional study.

Adolescent↗