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PubMed2000

Cholecystectomy, conversion and complications.

BACKGROUND: Faced with a difficult laparoscopic cholecystectomy the surgeon may feel that conversion to open operation would risk greater complications because of the laparotomy. Information on the effect of conversion is lacking. The purpose of this study is to measure the complications of laparoscopic cholecystectomy and observe the effect of the conversion rate. METHODS: A total of 957 patients were studied. There were three consecutive series of patients; the first undergoing open cholecystectomy (384 patients), the second laparoscopic cholecystectomy with a 5.8% conversion rate (412 patients) and the third laparoscopic cholecystectomy with a 1.3% conversion rate (161 patients). Data was collected prospectively using a continuous audit, and the complication rate compared on an intention to treat basis. In addition a panel of experienced surgeons was asked to score the complications depending on their severity and a composite complication score calculated. Comparison between the 3 groups was then undertaken. RESULTS: Open cholecystectomy produced a post-operative complication rate of 6%. Initially this appeared to fall to 3.1% with the introduction of laparoscopic cholecystectomy, but when the complications occurring in the converted patients were included (i.e., on an intention to treat basis) the rate increased to 5.6% in the first group of laparoscopically-treated patients and 3.1% in the second. These differences were not statistically significant. A similar pattern emerged when scoring the severity of the complications as judged by the expert panel. The inclusion of intra-operative complications appears to remove any small advantage for laparoscopic cholecystectomy. The reduction in the conversion rate between the two laparoscopic groups from 5.8% to 1.2% was statistically significant. CONCLUSION: When considered on an intention to treat basis laparoscopic cholecystectomy offers no advantage over open operation in terms of the frequency or severity of complications. Reducing the frequency of conversion from a laparoscopic to an open procedure also has no significant effect on the complications encountered. We conclude, therefore, that the complication rate is independent of the conversion rate and that the surgeon, when faced with difficulty at laparoscopic cholecystectomy, should not be deterred from converting to open operation for fear of the post-operative consequences.

Cholecystectomy↗

PubMedDate not supplied

A trend for reduced 15-day wound infection and 6 months' mortality in laparoscopic relative to open cholecystectomy: the Israeli Study of Surgical Infections.

OBJECTIVE: To utilize a naturally occurring "experiment," when introduction to laparoscopic cholecystectomy occurred in Israel; to compare the concurrent outcomes (wound infection and mortality) of laparoscopic versus open cholecystectomy; to adjust for patients' characteristics and procedural factors while making the comparisons. DESIGN: Multicenter prospective follow up, including patients' interviews prior to the operation, daily information on postoperative care, a summary of the operation report and postdischarge telephone interview 15 days after surgery. SETTINGS: A sample of 100 consecutive cholecystectomy patients from all 20 acute-care hospitals in the country, where such operations were performed. PATIENTS: 1,785 consecutive patients during 1991 and 1992; 1,184 had open cholecystectomy, and 601 had laparoscopic cholecystectomy. RESULTS: Crude wound infection rates at 15 days were 2.3% for laparoscopic cholecystectomy and 6.3% for open cholecystectomy (odds ratio [OR], 2.8; P < .001). Crude mortality rates at 6 months were 0.17% and 3.0% for laparoscopic and open procedures, respectively (OR, 18.5; P < .004). Logistic models for infection and mortality were used to adjust for case-mix and procedural factors in the comparisons between the two operations. Adjusted ORs for open versus laparoscopic cholecystectomy were 1.9 (P = .06) for wound infection and 4.3 (P = .17) for mortality. Stratification of patients on the basis of the models into high- and low-risk strata indicated that the protective effect of laparoscopic cholecystectomy was mainly evident in the high-risk group: 1.8% versus 8.3% (P < .001) for 15-day infections and 0.6% versus 4.4% (P = .017) for 6 months mortality. CONCLUSION: We conclude that, although the P values for the adjusted comparisons were of borderline significance (due to the small number of deaths in the laparoscopic group), our results suggest advantageous outcomes for laparoscopic cholecystectomy, especially among the high-risk patients.

Adult↗

PubMedDate not supplied

[Surgical trauma in laparoscopic and classical cholecystectomy].

INTRODUCTION: Accidental or surgical trauma stimulates a response and its intensity is proportional to extent of trauma. The aim of this prospective study was to compare the intensity of the acute-phase reaction and metabolic changes in patients undergoing elective cholecystectomy for chronic cholecystitis. PATIENTS AND METHODS: Sixty patients with cholelithiasis were divided into two groups: thirty patients underwent laparoscopic cholecystectomy (LC group) and thirty patients open cholecystectomy (OC group). Glucose concentration, mean cortisol concentration, C-reactive protein, albumin levels and lactate-dehydrogenase activity were measured preoperatively and postoperatively for up to 48 hours. RESULTS AND DISCUSSION: The examined groups of patients were comparable in regard to age and sex. The duration of operation was similar in both groups. Postoperative hospital stay after laparoscopic operation was significantly shorter than after open cholecystectomy (p < 0.05). The mean glucose concentration (s.e.m.) during the initial 24 hours after surgery was significantly higher (p < 0.05) following open cholecystectomy. The mean cortisol concentration was significantly higher (p < 0.05) following open in regard to laparoscopic operation. Increase in plasma C-reactive protein was significantly higher (p < 0.05) after open cholecystectomy, with maximal levels 48 h after operation. There was a statistically significant decrease (p < 0.05) in albumin concentration after open cholecystectomy. Serum concentration of intracellular enzyme lactate-dehydrogenase increased significantly (p < 0.05) following open in regard to laparoscopic cholecystectomy. CONCLUSION: According to these results, aspects of metabolic and acute-phase responses and tissue damage are reduced following laparoscopic cholecystectomy. The mean postoperative hospital stay was significantly shorter after laparoscopic cholecystectomy with rapid patient recovery.

Acute-Phase Proteins↗

PubMedDate not supplied

[Laparoscopic versus mini-cholecystectomy: analysis of hospital costs and social costs in a prospective randomized study].

The aim of the study was to calculate the hospital and social costs in relation to efficacy of clinical outcome, hospital stay and time off work in two groups of patients randomly treated with laparoscopic or mini-cholecystectomy. One hundred and eighty-one patients with simple, symptomatic gallstone disease were included in the study; of these, 9 cases were excluded because of conversion to conventional cholecystectomy. Eighty-six cases underwent laparoscopic cholecystectomy and 86 mini-cholecystectomy. Operative time (median time: 35 minutes) and hospital stay (median stay: 3 days) were the same for both surgical procedures. The median time off work was 10 days for laparoscopic cholecystectomy and 20 days for mini-cholecystectomy (P = 0.007). Hospital expenses showed a saving of 820.48 euros for each patient undergoing mini-cholecystectomy. Since laparoscopic cholecystectomy is associated with a shorter period off work, it seems to be cheaper with a daily saving of 164.96 and 146.51 Euros per patient, according to cost/effectiveness and cost/utility analyses, respectively. Consequently, although laparoscopic cholecystectomy shows a better outcome in terms of socioeconomic aspects and patient compliance, in an attempt to rationalize hospital expenditure, we would advocate mini-cholecystectomy for those patients who do not need to return to work early.

Adult↗

PubMedDate not supplied

Serum leptin levels and their response during laparoscopic and open cholecystectomy.

We compared serum leptin responses during and after laparoscopic and open cholecystectomy, and assessed their correlation with the responses of inflammatory cytokines. Serum levels of leptin, interleukin-1alpha (IL-1alpha), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) were measured by an enzyme-linked immunoassay in 31 patients who underwent laparoscopic cholecystectomy and in 24 patients who underwent open cholecystectomy. Serum samples were obtained preoperatively, at 10 and 30 min after the commencement of surgery, and at 6 and 24 h after the operation. The cumulative responses of leptin, IL-1alpha, IL-6 and TNF-alpha to surgery were calculated and the associations between them were evaluated. Serum leptin levels were significantly increased at 24 h after both procedures. The serum leptin concentration at this time point and the cumulative leptin response were significantly lower after laparoscopic cholecystectomy than after open cholecystectomy. Changes in serum IL-1alpha, TNF-alpha and IL-6 concentrations showed similar kinetics in both groups, with postoperative IL-6 levels being consistently lower in the laparoscopic cholecystectomy group. Cumulative IL-6 and TNF-alpha responses were significantly lower after laparoscopic cholecystectomy than after open cholecystectomy. The cumulative responses of leptin, IL-1alpha and IL-6 correlated significantly with each other. Leptin may be involved in the systemic inflammatory response to surgical injury, and the postoperative leptin elevation and cumulative leptin response are significantly lower after laparoscopic cholecystectomy than after open cholecystectomy.

Adult↗

PubMed1994

Effects of surgical trauma of laparoscopic vs. open cholecystectomy.

The effects of surgical trauma resulting from laparoscopic cholecystectomy and open cholecystectomy, were compared by assessing the postoperative acute phase alterations of selected plasma proteins, hormones and lymphocyte subpopulations in fifty-seven patients prior to elective cholecystectomy. Patients were prospectively randomized to undergo either laparoscopic cholecystectomy (n = 30) or open cholecystectomy (n = 27). Duration of operation and general anesthesia was similar in the two patient groups. The laparoscopic cholecystectomy patients had a shorter postoperative stay in hospital (3.1 (0.5) days vs. 7.1 (1.6) days; p < 0.001). In open cholecystectomy patients a significantly greater postoperative acute phase increase in plasma C-reactive protein (p < 0.001), cortisol (p < 0.05), and prolactin blood level (p < 0.001) was recorded. The postoperative acute phase decrease in the blood total-T-lymphocyte count (CD3 cells) and in the activated-lymphocyte count (OKDR cells) was significantly greater after open cholecystectomy (p < 0.05). These results, showing that acute phase responses are less marked after laparoscopic cholecystectomy than after open cholecystectomy, support the concept that the laparoscopic procedure is less traumatic.

Acute-Phase Reaction↗

PubMed1994

Bile duct injury during laparoscopic and conventional cholecystectomy.

It has been suggested that the risk of injury to the bile duct is higher after laparoscopic cholecystectomy than after conventional cholecystectomy. The results of previous studies on laparoscopic cholecystectomy showed no difference but they were limited (positive) selections from highly specialized centers. Thus, a questionnaire was sent to all surgical departments in The Netherlands to analyze the number of repair procedures for bile duct injury, the techniques and complications of this treatment and the number of cholecystectomies performed during 1991 to determine the "actual" risk of bile duct injury. The response was 88.4 percent (122 of 138 centers). A total of 11,712 cholecystectomies were performed, of which 2,932 were laparoscopic and 8,780 were conventional. Thirty-two bile duct injuries resulted from laparoscopic cholecystectomy (1.09 percent) and 45 resulted from conventional cholecystectomy (0.51 percent) (p < 0.001). Thirty-six injuries (46.7 percent) were detected during the procedure or within 24 hours and 41 (53.2 percent) after a mean period of ten days. The bile duct lesion consisted of transection in 35 patients (45.5 percent), a stenosis or clips in 17 patients (22.1 percent) and a lesion with bile leakage in 25 patients (32.5 percent). The repair procedure included primary closure or end to end anastomosis in 33 patients (42.8 percent) and hepatojejunostomy in 31 patients (40.2 percent). Hepatojejunostomy was performed upon 17 percent of the injuries detected early and in 61 percent of the injuries detected after a delay. Complications were found in 31.1 percent and the mortality rate was 7.8 percent. In summary, the risk of bile duct injury after laparoscopic cholecystectomy was significantly (p < 0.001) higher than after conventional cholecystectomy, which was probably related to the relative inexperience (all units from one country). The risk of bile duct injury after conventional cholecystectomy was slightly higher than that found in literature, which probably reflects the fact that we studied the number of "repair procedures" instead of registration of complications (injury). Repair procedures for lesion detected after a delay are more complicated (hepatojejunostomy) than for the injury detected early.

Cholecystectomy↗

PubMed1997

Systemic stress response after laparoscopic or open cholecystectomy: a randomized trial.

BACKGROUND: Surgical injury induces a systemic endocrine-metabolic response which is proportional to the severity of surgical stress. Laparoscopic cholecystectomy is associated with a favourable clinical outcome compared with open cholecystectomy suggesting that surgical injury is reduced. METHODS: In a randomized clinical trial of 41 patients undergoing laparoscopic cholecystectomy and 42 patients undergoing open cholecystectomy, the neuroendocrine and metabolic stress responses were compared. Plasma levels of cortisol, adrenaline, noradrenaline, glucose, interleukin (IL) 6 and C-reactive protein (CRP) were measured before, during and at 4, 8 and 24 h after operation. RESULTS: Plasma levels of cortisol and catecholamines increased during and after both laparoscopic and open cholecystectomy; however, their postoperative responses during and after both laparoscopic and open cholecystectomy; however, their postoperative responses were significantly higher (P < 0.05) after open cholecystectomy. Glucose, IL-6 and CRP levels also increased after operation and were significantly higher (P < 0.05) in the open cholecystectomy group. CONCLUSION: The neuroendocrine stress response and inflammatory response following laparoscopic cholecystectomy were significantly reduced compared with those after open cholecystectomy.

Blood Glucose↗

PubMed1997

Laparoscopic versus open cholecystectomy in acute cholecystitis.

Elective laparoscopic cholecystectomy is established as the treatment of choice for symptomatic cholecystolithiasis and is now proposed for the treatment of acute cholecystitis. We initiated the present study in order to clarify the question of safety of the procedure in the presence of an inflamed gallbladder, and to compare the results with those of a traditionally treated group with acute cholecystitis. We compared the preoperative, operative, and postoperative courses of 146 patients with acute cholecystitis, managed laparoscopically between 1994 and 1996, with those of 97 patients, treated traditionally by open cholecystectomy for the same diagnosis between 1992 and 1993. In the acute cholecystitis cases, when laparoscopic cholecystectomy was successfully performed, the operative and postoperative courses were superior to those of open cholecystectomy. The use of drains and NG tubes, the need for antibiotics and analgesia, the associated morbidity, and the hospital stay were significantly reduced. Following conversion, the postoperative course was similar to that of open cholecystectomy. Of the group of acute cholecystitis cases laparoscopically approached 39 (27%) needed conversion. Twenty-five complications occurred in 24 (16.5%) patients of the laparoscopic group, whereas 30 complications occurred in 25 (26%) patients of the traditionally operated group. Male sex, older patients, and larger bile stones were found to be associated with a higher conversion rate as well as a higher complication rate. A nonpalpable gallbladder and gangrenous cholecystitis were associated with conversion while fever was associated with complications. Laparoscopic cholecystectomy can be performed safely in selected cases of acute cholecystitis, with acceptable conversion and low complication rates. When laparoscopic cholecystectomy is successfully performed, the operative and postoperative courses are superior to those of open cholecystectomy. Following conversion, the postoperative course is similar to that of open cholecystectomy. According to this study, male sex, older age, large bile stones, a nonpalpable gallbladder, and gangrenous cholecystitis may be regarded as predictors of conversion, while male sex, older age, large bile stones, and fever may be regarded as predictors of complications. The timing of laparoscopic cholecystectomy should be within 96 h from onset of the inflammation.

Acute Disease↗

PubMed1998

[Cholecystectomy using a minilaparotomy].

Recent randomized studies have shown that laparoscopic cholecystectomy has little or even no advantage when compared to minilaparotomy cholecystectomy. The authors report the results of a prospective study of minilaparotomy performed at Dahr el Bacheq governmental hospital where laparoscopic equipment was not available. From July 1994 to July 1997 minilaparotomy cholecystectomy was performed on one hundred consecutive patients (75 women and 25 men with an age varying between 26 and 93 years). However, the cholecystectomy could be accomplished through the mini-incision in only 88 cases. Lengthening of the incision was necessary in 12 cases: common duct stones (8 cases), cancer (2 cases), cholecystoduodenal fistula (2 cases). Intraoperative cholangiography was not performed in 3 cases: very thin cystic duct (2 cases), technical problem (1 case). Two patients operated for acute cholecystitis had wound infection. Postoperative course of the 88 completed minilaparotomy cholecystectomies was uneventful: no mortality, no biliary complications, little pain with low analgesia requirement, oral intake on day 1, discharge from hospital on day 2, return to normal activity between day 8 and day 14. Results of minilaparotomy cholecystectomy compare favorably with those of laparoscopic cholecystectomy. It should be an alternative to laparoscopic cholecystectomy especially when cost is a problem or when laparoscopic equipment is not available and an alternative to conventional open cholecystectomy in the case of contraindication to laparoscopic cholecystectomy.

Acute Disease↗

PubMed2006

Iatrogenic bile duct injury: a population-based study of 152 776 cholecystectomies in the Swedish Inpatient Registry.

HYPOTHESIS: Older age, male sex, and low yearly hospital volume of cholecystectomy may increase the risk of bile duct injury (BDI), whereas the use of intraoperative cholangiography may decrease the risk. The incidence of BDI at cholecystectomy may have increased after the introduction of laparoscopic cholecystectomy. DESIGN: Nationwide population-based study of all cholecystectomies registered in the Swedish Inpatient Registry from 1987 through 2001. SETTING: All hospitals performing inpatient cholecystectomies in Sweden. PATIENTS: Cholecystectomies were identified using International Classification of Diseases, Ninth and 10th Revisions surgical procedure codes. After exclusion of patients with hepatobiliary and pancreatic malignancies, patients with codes indicating reconstructive bile duct operations within 1 year after cholecystectomy were considered BDI cases. Risk factors for BDI were analyzed using multivariate logistic regression. The incidence proportion of BDI was calculated by dividing the number of cases by the number of cholecystectomies. MAIN OUTCOME MEASURES: Relative risks were estimated using odds ratios with 95% confidence intervals, and incidence proportion was used to describe incidence. RESULTS: Among 152 776 cholecystectomies, 613 reconstructed BDIs (0.40%) were identified. Older age and male sex were positively associated with BDI, whereas intraoperative cholangiography was negatively associated with BDI. The incidence proportion of BDI was 0.40% from 1987 to 1990, decreased to 0.32% from 1991 to 1995, and increased to 0.47% from 1996 to 2001. The mean yearly hospital volume did not affect the risk of BDI. CONCLUSIONS: Older age and male sex increased the risk of BDI, whereas intraoperative cholangiography was protective. There was a small to moderate long-term increase in the risk of BDI after the introduction of laparoscopic cholecystectomy compared with the pre-laparoscopic era.

Adolescent↗

PubMed1993

Symptomatic outcome after laparoscopic cholecystectomy.

To evaluate the symptomatic outcome after laparoscopic cholecystectomy, a standard symptom questionnaire was sent to three patient groups at least 1 year after surgery: 115 patients had undergone laparoscopic cholecystectomy; 200 had undergone open cholecystectomy; and 200 had had inguinal hernia repair. Return of questionnaires was higher after laparoscopic cholecystectomy (100 of 115; 87.0 per cent) than the open procedure (167 of 200; 83.5 per cent) or hernia repair (163 of 200; 81.5 per cent). There was no difference in the number of patients who considered the operation to have cured or improved their preoperative symptoms after laparoscopic cholecystectomy (94 of 100; 94.0 per cent), open cholecystectomy (157 of 167; 94.0 per cent) or hernia repair (154 of 163; 94.5 per cent). Similar numbers considered their operation to have been a success (94.0, 95.2 and 94.5 per cent respectively). The prevalence of abdominal pain, nausea, flatulence, food intolerance and heartburn was similar in all groups of patients following operation. Diarrhoea occurred more often following laparoscopic (6.0 per cent) and open (4.2 per cent) cholecystectomy than hernia repair (1.2 per cent). Patients who underwent laparoscopic cholecystectomy tended to have a higher incidence of nausea or vomiting than those undergoing the open procedure, and consumed significantly more antacids (23.0 versus 12.0 per cent, P < 0.02). Laparoscopic cholecystectomy achieved the same rate of patient satisfaction as open cholecystectomy, with no apparent symptomatic advantage.

Cholecystectomy, Laparoscopic↗

PubMed2001

Transitions in laparoscopic cholecystectomy: the impact of ambulatory surgery.

BACKGROUND: Ambulatory laparoscopic cholecystectomy is a common practice in the United States, but its development remains slow in most other countries. The objective of the current study was to report the impact of ambulatory surgery on the practice of laparoscopic cholecystectomy in a major teaching hospital since the inception of the service. METHODS: The hospital database of patients who underwent cholecystectomies for benign hepatobiliary pathologies was reviewed between January 1993 and December 1999. Changes in the practice of laparoscopic cholecystectomy and the length of hospital stay were analyzed. Clinical characteristics of the ambulatory and inpatient groups were compared. RESULTS: Of 2,891 laparoscopic cholecystectomies involved in the current study, 888 (31%) were performed as day cases, and 2,003 (69%) were performed as inpatient laparoscopic cholecystectomies. The annual number of ambulatory laparoscopic cholecystectomies increased from 3 (0.6%) in 1993 to 212 (48%) in 1997. This was followed by a plateau in the next 3 years. The ambulatory group comprised a significantly higher prevalence of young women (87%) who underwent surgery mainly for biliary colic (88%). CONCLUSIONS: The current study demonstrated a net trend toward ambulatory laparoscopic cholecystectomy and a shorter length of hospital stay. Almost half of our patients with gallstone disease currently are using the ambulatory laparoscopic cholecystectomy service, with young women constituting the majority. We predict that ambulatory laparoscopic cholecystectomy heralds the wave of the future, and our experience may serve as a blueprint for other institutions wishing to embark on this journey.

Adult↗

PubMed1997

Impact of laparoscopic cholecystectomy on indications for surgical treatment of gallstones.

BACKGROUND: The objective of this study was to compare the histology of gallbladders removed prior to the introduction of laparoscopic cholecystectomy with that found after the introduction of the laparoscopic technique to determine if there has been a change in the indications for surgical treatment of gallbladder disease. METHODS: A retrospective review of all patients undergoing cholecystectomy during 1989, 1992, and 1993 was completed at two large community teaching hospitals in two different geographic regions of the United States. Patients who underwent cholecystectomy as the primary procedure were studied. A total of 1,815 cases met the criteria for analysis. Histological diagnoses were categorized as acute cholecystitis with or without cholelithiasis, or chronic cholecystitis with cholelithiasis. RESULTS: The number of cholecystectomies performed increased by 58% from 1989 to 1993 (p < 0.05). The number of cholecystectomies for acute cholecystitis did not change. CONCLUSIONS: With the advent of laparoscopic cholecystectomy, the number of cholecystectomies significantly increased and the proportion of cholecystectomies performed for chronic disease also increased. There has been a significant change in the surgical management of gallbladder disease with increased willingness to recommend elective cholecystectomy. Further study is needed to determine if there is real benefit from earlier elective cholecystectomy.

Cholecystectomy, Laparoscopic↗

PubMed1999

Cost effectiveness of routine type and screen testing before laparoscopic cholecystectomy.

BACKGROUND: The aim of this study was to assess the cost effectiveness of routine preoperative blood type and screen testing before laparoscopic cholecystectomy. METHODS: All 2,589 laparoscopic cholecystectomies and 603 open cholecystectomies performed at our institution between January 1990 and December 1996 were retrospectively reviewed to identify the incidence and causes of blood transfusions. With the use of ICD-9-CM coding, a computerized retrospective research was done to match the corresponding codes for the aforementioned operations and blood transfusion. Individual charts were reviewed to identify the indications for blood transfusion. RESULTS: Of the 2,589 laparoscopic cholecystectomies performed, 12 patients required blood transfusion, and of the 603 open cholecystectomies, 33 patients required blood transfusion. The incidence of blood transfusions was 0.46% for laparoscopic cholecystectomy and 5.47% for open cholecystectomy. Two of the blood transfusions given intraoperatively were due to major vascular injury in the laparoscopic cholecystectomy group. The remaining blood transfusions were found to be the result of preexisting medical conditions including sickle-cell anemia, end-stage renal disease, and chronic iron deficiency anemia. CONCLUSIONS: Laparoscopic cholecystectomy has become a widely used therapeutic modality in general surgery. The procedure is safe, effective, and well tolerated by the patient. In the era of managed healthcare, the cost effectiveness of commonly ordered tests is frequently questioned. In the absence of preoperative indications, routine preoperative blood type and screen testing should be eliminated for laparoscopic cholecystectomy. The elimination of routine preoperative blood type and screen testing could have saved our institution $79,800 during a 6-year period.

Blood Grouping and Crossmatching↗

PubMed1983

Cholecystectomy after tube cholecystostomy.

Seventy-nine patients with cholecystostomy tubes underwent cholecystectomies. Twenty-nine had cholecystectomies and common bile duct exploration and 50 had cholecystectomies only. The 50 who had cholecystectomies alone were compared with 50 patients who had elective cholecystectomies. The comparison defined any differences in morbidity and mortality between the two groups. Thirty-five (70 percent) of the 50 patients with cholecystostomy cholecystectomies and 34 (68 percent) of the 50 patients having elective cholecystectomies had no operative or postoperative morbidity. The cholecystostomy cholecystectomies did require more operative time, and more patients required blood transfusion. Both these differences were identified as being secondary to a more difficult operative dissection through adhesions. No differences in length of hospitalization, length of postoperative stay, or mortality were present. A cholecystostomy cholecystectomy can be performed with morbidity and mortality rates that are no different than those of an elective cholecystectomy.

Acute Disease↗

PubMed2005

Elective cholecystectomy after Roux-en-Y gastric bypass: why should asymptomatic gallstones be treated differently in morbidly obese patients?

BACKGROUND: Gallbladder management in bariatric surgery varies. Some surgeons perform routine cholecystectomy with bariatric surgery, and others selectively base that decision on routine preoperative ultrasound findings. Both approaches treat bariatric patients differently than the normal-weight population in whom cholecystectomy is not performed in asymptomatic patients. We hypothesized that it is possible to apply the commonly used indications for cholecystectomy in the nonobese population safely to a Roux-en-Y gastric bypass cohort. METHODS: Data were collected prospectively and retrospectively on consecutive patients at our center undergoing Roux-en-Y gastric bypass from April 1, 2003 to March 31, 2004. Asymptomatic patients underwent neither preoperative gallbladder ultrasonography nor concomitant cholecystectomy. Age, body mass index, gender, length of follow-up, compliance to ursodiol therapy for 6 months, need for subsequent cholecystectomy, complications, and pathologic diagnoses were recorded. RESULTS: A total of 692 primary Roux-en-Y gastric bypass procedures were performed, of which 661 (95.5%) were completed laparoscopically. Complete data were collected on 417 patients (60.3%). A total of 98 patients (23.5%) had had prior or concomitant cholecystectomy and were excluded from additional study. Of the remaining 319 patients, 47 (14.7%) required subsequent cholecystectomy and 272 (85.3%) did not. The risk of subsequent cholecystectomy correlated inversely with the duration of ursodiol prophylaxis. All pathologic specimens had cholecystitis but gallstones were present in only 48.8%. Two complications (abscess and port-site bleed) occurred, but no common duct stones developed and no patient died. The mean follow-up was 7.5 months (range 13-25). CONCLUSION: Asymptomatic gallstones in bariatric patients may be treated safely with secondary cholecystectomy. After a 6-month regimen of ursodiol prophylaxis, 14.7% will require subsequent cholecystectomy. Asymptomatic gallstones in the bariatric patient may be safely managed identically to those in the nonobese population.

Adult↗

PubMed1998

Cholecystectomy in patients aged 80 and older.

BACKGROUND: We assessed whether the increase in performance of laparoscopic cholecystectomy has affected patients aged 80 and older and if outcomes of a laparoscopic approach in this population would show improvement over those for open surgery. METHODS: We analyzed an 11-state discharge database obtained from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Release 1 contains a 20% sample of United States hospitals for the period 1988 to 1992. Diagnosis-related group (DRG) codes 197 and 198 were searched, and demographics, type of surgery, and outcome measures were analyzed. RESULTS: In 5 years, 350,451 patients underwent cholecystectomy with the DRG codes listed. Of those, 18,500 patients were aged 80 to 105. The total number of cholecystectomies increased each year. Performance of laparoscopic cholecystectomy rose rapidly and that of open cholecystectomy decreased. Overall mortality with laparoscopic cholecystectomy was 1.8%, was lower than that of open cholecystectomy, was lower in women, and decreased with time. CONCLUSIONS: Patients aged 80 and older have participated in the increased performance of cholecystectomy and the switch to laparoscopic cholecystectomy. This has a low mortality, low length of stay, and higher proportion of patients being discharged to home compared with patients having open cholecystectomy.

Aged↗