The long-term follow-up of patients with positive intraoperative cholangiograms during laparoscopic cholecystectomy.
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Cholangiography↗
Biomedical subjects
A H M Nassar
Publications and source records attributed to A H M Nassar.
Intraoperative cholangiography time in laparoscopic cholecystectomy: timing the radiographer.
BACKGROUND: The debate for and against the routine use of intraoperative cholangiography (IOC) continues. One of the main arguments against the routine use of the technique during laparoscopic cholecystectomy (LC) is the length of time it takes, which in turn increases the cost. In this study, we recorded the time spent by the radiographer providing IOC service in the context of optimizing the utilization of the radiographer and IOC time. METHODS: A total of 91 consecutive LCS, including 19 laparoscopic bile duct explorations, from April 2003 to January 2004 were included in the study. We recorded the time the radiographer took from receiving a call to arriving in the theater, the time he or she spent performing the IOC, and the total time spent in theater. We also recorded the total operative time. RESULTS: The mean time from call to arrival was 9 min (SD = 3, n = 91). The mean total time spent by the radiographer in the theater involved in performing the IOC during LC was 15 min (SD = 8, n = 72), and that during laparoscopic exploration was 46 min (SD = 20, n = 19). The mean operative time was 67 min (SD = 24) and 135 min (SD = 59), respectively. CONCLUSION: Radiographer services as well as IOC time could be optimized to facilitate the routine use of this important technique in LC. Optimizing the logistics and time factor in IOC is an integral component of single-stage management of patients with suspected bile duct stones.
Cholangiography↗
Voice recognition interfaces (VRI) optimize the utilization of theatre staff and time during laparoscopic cholecystectomy.
During laparoscopy, members of staff spend time setting up and de-activating the light source, camera and insufflator. Voice Recognition Interface (VRI) devices, such as HERMES (Stryker Europe, Montreux, Switzerland), enable the surgeon to perform and control these and other functions. They recognize the surgeon's voice and adjust the instruments in response to programmed verbal commands. The aim of this study was to evaluate HERMES with regards to the utilization of time and theatre staff during laparoscopic cholecystectomy. A total of 100 patients were randomized to either HERMES-assisted or standard laparoscopic cholecystectomy. Three time variables were measured for performing three VRI tasks: (1) The initial setting up of the light source and camera, (2) the activation of the insufflator, and (3) the deactivation of the insufflator and light source at the end of the operation. The mean (and standard deviation) of the time in seconds required for setting up the light source and camera was 27.6 (26.9) in non-HERMES operations and 11.7 (4.7) in HERMES-assisted cases (p<0.001). Insufflation time was 19.8 (13.3) vs. 6.7 (2.5) (p<0.001), and switch-off time was 19.5 (11.8) vs. 11.8 (5.7) (p<0.001). HERMES optimized the operating time and the utilization of theatre staff during laparoscopic cholecystectomy.
Journal Article↗
Intramural pseudodiverticulosis of the esophagus.
Esophageal intramural pseudodiverticulosis (EIPD) is a rare condition seen in the elderly, with a male-to-female ratio of 3:2. Multiple small outpouchings occur in the submucosa of the esophageal wall, caused by dilation of the excretory ducts of the mucus glands. This disorder may be associated with gastroesophageal reflux, motility disorders, candidiasis, or other conditions. Inflammation, resulting in periductal fibrosis and compression of the duct orifices, may be a causative factor. Usually, EPID presents with progressive dysphagia related to esophageal stenosis or strictures in the great majority of patients. Radiologic examination is more sensitive than endoscopy in detecting these tiny saccular diverticula in the esophageal wall. They often are noted to disappear after esophageal dilation, but may persist asymptomatically in some patients. We report two cases of dysphagia associated with reflux and Candida infection in elderly patients. The diagnosis of EIPD was made, and both patients were treated successfully. A review of the available literature suggests that EIPD may be missed easily because of subtle endoscopic and radiologic changes, but that once diagnosed, conservative management leads to satisfactory control of the symptoms.
Aged↗
Delayed cholangitis resulting from a retained T-tube fragment encased within a stone: a rare complication.
Inserting a T-tube after choledochotomy for the removal of bile duct stones remains a time-honored practice. Biliary drainage after bile duct exploration has some advantages. It minimizes bile leakage, provides access for cholangiography, and removes occasional retained stones. The use of T-tubes also has been associated with significant complications. Biliary sepsis, bile duct trauma during removal, bile leakage leading to peritonitis, retention of a fragment, stricture formation after removal have been reported. We report an unusual case of cholangitis caused by a T-tube fragment within a large stone, occurring 11 years after bile duct exploration. A 39-year-old woman underwent common bile duct exploration with insertion of a T-tube. Cholangiography was normal, but as the T-tube was removed, its horizontal limb was missing. The patient failed to present for endoscopic removal a few weeks after surgery Five years later, she presented with recurrent biliary pains and a mild episode of cholangitis. This last episode was associated with severe pain and jaundice. After initial conservative treatment, endoscopic retrograde cholangiopancreatography was performed, and endoscopic removal of the fragment and stone material was successful. Despite the declining numbers of bile duct explorations in the laparoscopic era and the tendency to use transcystic drainage or primary closure of a choledochotomy, the T-tube will continue to be a useful tool in biliary surgery, subject to consideration of the indications and the available alternatives. The reported case highlights the importance of careful tube preparation to prevent partial separation at removal, and early removal of a missing fragment to avoid potential serious complications.
Adult↗
Fundus-first laparoscopic cholecystectomy.
BACKGROUND: Fundus-first dissection (FFD) is an established technique to deal with difficult open cholecystectomies. Although the indications for such an approach are similar for laparoscopic cholecystectomy (LC), FFD is not widely practiced because of difficulties that arise with liver retraction, the dissection of dense adhesions, or obscured cystic pedicles, often necessitating conversion to an open procedure. METHODS: The aim of this study was to evaluate the indications for FFD and the technical aspects of the procedure in cases with a difficult cystic pedicle. Prospectively collected data and video recordings of cases of fundus-first laparoscopic cholecystectomy (FFLC) were analyzed. The great majority were difficult cases, so we also reviewed the safety aspects of this approach and assessed its effect on the conversion rate. RESULTS: FFLC was resorted to in 35 cases (5%) of 710 consecutive LCs with difficulty grade II (two cases), III (13 cases), or IV (20 cases). There were 16 male patients (46% vs 9% males in the whole), and the mean age was 56 years (ranges, 28-87). The reasons for FFD were dense adhesions preventing the exposure of the cystic pedicle in 14 cases, large Hartmann's pouch stones in 10 cases, short dilated cystic ducts in six cases, and Mirizzi syndrome in three cases. Two cases had contracted "burn-out" gallbladders. Intraoperative cholangiography (IOC) was possible in 24 patients, failed in 10 (29%), and was not attemped in one. Seven patients had bile duct stones and required bile duct exploration. FFLC was completed in 31 patients, 28 of whom were seriously considered for conversion prior to commencing FFD. Conversion was still necessary after trial FFD in four cases (11%) two with Mirizzi abnormalities, one with bile duct stones, and one with dense adhesions. The mean operative time was 125 min, (range, 50-230). There were no operative or technique-related complications. CONCLUSION: FFLC is feasible and is a safe option for cases with a difficult cystic pedicle. Its use reduced the conversion rate of the series from a potential 5.2% to 1.2%, However, subtotal cholecystectomy or conversion must not be delayed if, after the neck of the gallbladder is reached the anatomy is still unclear.
Adult↗