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PubMed1998

Effect of endoscopic sphincterotomy and interval cholecystectomy on late outcome after gallstone pancreatitis.

BACKGROUND: Endoscopic sphincterotomy alone, or followed by cholecystectomy, are options in patients with gallstone pancreatitis. METHODS: Ninety-six patients of median age 74 (range 30-93) years with gallstone pancreatitis had endoscopic retrograde cholangiography and were followed for a median of 84 (range 33-168) months. Forty-eight of 49 patients with, and nine of 47 without, common bile duct (CBD) stones had urgent endoscopic sphincterotomy. One patient with, and six without, CBD stones had delayed endoscopic sphincterotomy a median of 35 (range 12-111) days after acute pancreatitis. Thus, 64 patients had endoscopic sphincterotomy (group 1) and 32 did not (group 2). Fifteen and 16 patients in each group respectively had interval cholecystectomy after a median of 3 months and 1 month. RESULTS: Patients in groups 1 and 2 had similar rates of interval cholecystectomy (15 of 64 versus 16 of 32 patients respectively) or required cholecystectomy (15 of 49 versus five of 16 patients), recurrent CBD calculi (three of 64 versus three of 32 patients) or total length of hospitalization after interval cholecystectomy (median 15.5 and 15 days) or required (median 22 and 24 days) cholecystectomy. The overall incidence of recurrent pancreatitis was one of 64 patients in group 1 and five of 32 in group 2 (P = 0.02), but after interval cholecystectomy the recurrence rate of biliopancreatic symptoms was similar (one of 15 patients versus three of 16 patients respectively). CONCLUSION: Endoscopic sphincterotomy, but not interval cholecystectomy, reduced the overall incidence of recurrent pancreatitis, but not of late biliary complications. Some 31 per cent of the patients required cholecystectomy, suggesting that routine cholecystectomy should be considered in fit patients following acute pancreatitis.

Adult↗

PubMed2000

Laparoscopic subtotal cholecystectomy: a review of 56 procedures.

BACKGROUND AND PURPOSE: The essential surgical steps in laparoscopic cholecystectomy remain similar to those of open cholecystectomy. Positive identification of the biliary anatomy, safe clipping or ligature of the cystic duct and artery, and dissection of the gallbladder from the liver bed form the basis of cholecystectomy. Subtotal cholecystectomy is a definitive and safe operation under certain adverse conditions intraoperatively for dissection of the gallbladder from the liver bed. We reviewed our experience with laparoscopic cholecystectomy over a 2-year period between June 1996 and May 1998, when 1,680 operations were performed. The objective was to analyze the pathology, review surgical procedures, and trace the outcome of laparoscopic subtotal cholecystectomy. PATIENTS AND METHODS: In 56 of 1,680 patients, laparoscopic subtotal cholecystectomy was performed, which constituted 3.33% of the laparoscopic cholecystectomies performed at our institution. Dense fibrosis and adhesions were present in 32 patients; 12 patients had Mirizzi syndrome, 6 patients had a sessile gallbladder, and 6 patients had a gangrenous gallbladder. The Endo-GIA 30 stapler was used in 40 patients, sequential clips were used in 9 patients, and a suture for stump closure was used in 5 patients. A subhepatic drain was inserted in 50 patients. RESULTS: Two conversions to open surgery were needed because of gangrene of the gall bladder wall and one conversion as a result of continued bleeding from the cystic artery after application of the Endo-GIA 30 stapler. The mean postoperative stay in hospital was 2.5 days. One patient had a solitary bile duct calculus extracted at endoscopic retrograde cholangiopancreatography 3 months after surgery. Three patients had biliary drainage that lasted for a week, and four patients had epigastric port-site infections that resolved with antibiotics, dressings and postural drainage. CONCLUSION: Laparoscopic subtotal cholecystectomy is safe, feasible, and effective and may help prevent conversion to open surgery in carefully selected patients with difficult cholecystectomies.

Cholecystectomy, Laparoscopic↗

PubMed1993

Open cholecystectomy. A contemporary analysis of 42,474 patients.

OBJECTIVE: This study evaluated, in a large, heterogeneous population, the outcome of open cholecystectomy as it is currently practiced. SUMMARY BACKGROUND AND DATA: Although cholecystectomy has been the gold standard of treatment for cholelithiasis for more than 100 years, it has recently been challenged by the introduction of several new modalities including laparoscopic cholecystectomy. Efforts to define the role of these alternative treatments have been hampered by the lack of contemporary data regarding open cholecystectomy. METHODS: A population-based study was performed examining all open cholecystectomies performed by surgeons in an eastern and western state during a recent 12-month period. Data compiled consisted of a computerized analysis of Uniformed Billing (UB-82) discharge analysis information from all non-Veterans Administration (VA), acute care hospitals in California (Office of Statewide Planning and Development [OSHPD]) and in Maryland (Health Services Cost Review Commission [HSCRC]) between January 1, 1989, and December 31, 1989. This data base was supplemented with a 5% random sample of Medicare UB-82 data from patients who were discharged between October 1, 1988, and September 30, 1989. Patients undergoing cholecystectomy were identified based on diagnosis-related groups (DRG-197 and DRG-198), and then classified by Principal Diagnosis and divided into three clinically homogeneous subgroups: acute cholecystitis, chronic cholecystitis, and complicated cholecystitis. RESULTS: A total of 42,474 patients were analyzed, which represents approximately 8% of all patients undergoing cholecystectomy in the United States in any recent 12-month period. The overall mortality rate was 0.17% and the incidence rate of bile duct injuries was approximately 0.2%. The mortality rate was 0.03% in patients younger than 65 years of age and 0.5% in those older than 65 years of age. Mortality rate, length of hospital stay, and charges were all significantly correlated (p < 0.001) with age, admission status (elective, urgent, or emergent), and disease status. CONCLUSIONS: These data indicate that open cholecystectomy currently is a very safe, effective treatment for cholelithiasis and is being performed with near zero mortality. The ultimate role of laparoscopic cholecystectomy needs to be defined in the context of current and contemporary data regarding open cholecystectomy.

Acute Disease↗

PubMed1994

Endoscopic retrograde cholangiopancreatography following laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is the preferred method of treatment for symptomatic choledocholithiasis. Since its introduction there has been an increase in postoperative diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to assess the indications and results of ERCP following laparoscopic cholecystectomy. Sixty-one patients had an ERCP following laparoscopic cholecystectomy. Two broad groups were identified: Group 1 (35 patients) had filling defects (consistent with stones) noted on operative cholangiography, which were not successfully flushed or extracted at the time of laparoscopic cholecystectomy; Group 2 consisted of patients who developed problems following laparoscopic cholecystectomy. Nine patients had post-laparoscopic cholecystectomy pain with abnormal liver function tests (LFT), four of whom had common bile duct (CBD) injuries and three had CBD stones. Eleven patients had post-laparoscopic cholecystectomy pain with a normal diameter common bile duct on ultrasound and normal LFT; only one had a CBD stone. Five patients with a persisting bile leak following laparoscopic cholecystectomy had an ERCP and endoscopic sphincterotomy. In three the leak ceased, while two required subsequent open surgery to drain bile collections and ligate the cystic duct. One patient presented with an episode of transient jaundice but had a normal ERCP. There were six post-ERCP complications; three patients had mild pancreatitis, two had a minor haemorrhage and one an asymptomatic duodenal perforation. Endoscopic retrograde cholangiopancreatography post-laparoscopic cholecystectomy was most valuable for the management of retained stones and the diagnosis and management of post-laparoscopic cholecystectomy pain in association with abnormal LFT. The diagnostic yield was low (9%) when the LFT were normal.

Adolescent↗

PubMed1996

Laparoscopic cholecystectomy in the geriatric population.

OBJECTIVE: To assess effectiveness and conversion rates of inpatient laparoscopic cholecystectomy in older people living in the community. SETTING AND SUBJECTS: All acute care hospitals providing cholecystectomy in a single state. Medicare patients who underwent inpatient cholecystectomy in fiscal year 1994 in Arkansas. METHODS: A random sample comprising 449 of 2182 geriatric patients who underwent inpatient cholecystectomy in fiscal year 1994, stratified by hospital bed size, had charts reviewed for type of cholecystectomy performed, occurrence of conversion from a laparoscopic to an open cholecystectomy, surgical complications, and need for transfusion. RESULTS: Eighty-two percent of nonincidental cholecystectomies were initially laparoscopic. Total conversion rate for all inpatient laparoscopic cases was 20%. Forty-two percent of this group suffered acute cholecystitis with male patients exhibiting a higher rate of acute cholecystitis than female patients. Conversion rates for elective cholecystectomy for both sexes was between 13 and 14%. Conversion rate to an open procedures was 28% for patients with acute disease, with male patients again having a higher rate than female patients (40% vs 19%, P < .001). Surgical complications and intraoperative transfusions were rare. Conversion rates did not vary between large and small hospitals or among different age groups within the older population. CONCLUSIONS: Inpatient laparoscopic cholecystectomy is common in older people both for acute and chronic gallbladder conditions. Conversion rates ranged from 13% for elective cholecystectomy to 28% for acute disease. These rates are higher than published literature, which focuses on younger populations undergoing elective procedures. Audit committees need to be aware of this higher conversion rate in older people when assessing surgical proficiency.

Acute Disease↗

PubMedDate not supplied

Symptomatic outcome after laparoscopic cholecystectomy.

AIMS: Patients with gallstones often present with multiple complaints. We wanted to study the major complaints of our patients undergoing laparoscopic cholecystectomy and the symptomatic relief afforded by the operation. METHODS: We studied 113 patients with symptomatic gallstone disease who underwent laparoscopic cholecystectomy in a single surgical unit. Patients with proven common bile duct stones, obstructive jaundice, cholangitis, present or past associated abdominal pathology or cholecystoenteric fistula were excluded from the study. The mean follow up period was 18 months (range 10-22 months). A detailed account of the symptoms of gallstones, length of post-operative stay, persistence of symptoms, development of fresh symptoms and resumption of fat containing diet were assessed. RESULTS: The male to female ratio was 1:4. Common presenting symptoms were abdominal pain (96%), flatulence or feeling of fullness of abdomen (85%), heartburn (66%), belching (62%), sour eructation (52%), vomiting (48%) and nausea (45%). Mean postoperative hospital stay was 28 hours (range 9-68 hours). Biliary pain was relieved in 99% of patients after laparoscopic cholecystectomy (p < 0.001). The non-pain symptoms which are relieved significantly (p < 0.001) included nausea (98%), vomiting (96%) and sour eructation (92%) had better outcome than belching (64%) flatulence (61%) and heart burn (59%). None of the patients developed jaundice after cholecystectomy. Fresh symptoms that developed after laparoscopic cholecystectomy were heart-burn (6%), belching (3.5%), sour eructation (1%) and vomiting (0.5%). Post-cholecystectomy post-prandial diarrhoea occurred in 20% of the patients. The patients' appreciation of a satisfactory cosmetic result of operation scars was 100 percent. Fifteen female patients (13.5%) complained of increased weight gain of more than 5 kg after laparoscopic cholecystectomy [(p > 0.05; not significant (NS)]. CONCLUSION: Laparoscopic cholecystectomy significantly relieved symptoms of gall stone disease. Biliary pain, nausea, vomiting and sour eructations had better outcome compared to belching, flatulence and heartburn, which are also relieved in majority. Postcholecystectomy post-prandial diarrhea was a significant new symptom after cholecystectomy. Pre-operative flatulence and heartburn are risk factors for poor symptom relief. All patients should be pre operatively counselled about the risk of persistence of some non-pain symptoms after laparoscopic cholecystectomy.

Adolescent↗

PubMed2000

[Cholecystectomy with microlaparotomy and innovation of the ROMICRO R-set].

Gallstone disease is a major health problem, 10-15% of the adult population of Hungary are afflicted, and each year about 20,000 cholecystectomies are undertaken. There are two essential and widely accepted methods for the removal of gallbladder: conventional open cholecystectomy and laparoscopic cholecystectomy. Since 1988 the authors worked on a new surgical technique and equipment (ROMICRO R-set) for cholecystectomy using a single 2-4 cm microlaparotomy inside the infrasternal triangle. They demonstrate the innovation's phases of this new technique and ROMICRO R-set. Till 1999 more than 7000 microlaparotomy cholecystectomy were undertaken in Hungary. The benefits of laparoscopic cholecystectomy can be achieved with less expense and risk by microlaparotomy cholecystectomy. Most patients are often not willing to accept conventional open cholecystectomy, but the microlaparotomy cholecystectomy alternative is unknown to the public and to most physicians. All countries have experienced a fast growth in their health care expenses over the last decades which will continue in the future. But spending an ever larger share of our nation's resources on health care cannot be afforded. As a consequence, making choices will became more and more unavoidable, also in galltree surgery. Therefore economic evaluation compares the different techniques of cholecystectomy necessary not only in terms on surgical and on patients aspect, but also in term of costs.

Adult↗

PubMedDate not supplied

Surgical infections after laparoscopic cholecystectomy: ceftriaxone vs ceftazidime antibiotic prophylaxis. A prospective study.

The incidence of surgical infections after laparoscopic cholecystectomy is reported to be <2%, because of the minimal trauma due to this approach. We report the results of a prospective study of antibiotic prophylaxis in laparoscopic cholecystectomy, comparing ceftriaxone vs ceftazidime. From Jan 1 to Dec 31 2002 a consecutive series of 242 cholecystectomies were performed, consisting in 18 open cholecystectomies and 224 laparoscopic cholecystectomies, 7 of which (3.1%) were converted to open cholecystectomies for technical and/or anatomical reasons. One hundred and eleven patients received 1 g i.v. ceftazidime 1 h before surgery, and 105 patients 1 g i.v. ceftriaxone on an alternate basis. Thirty-nine patients (17.4%) with acute cholecystitis received at least one booster dose at the end of the operation; 30 out of 39 were given further therapy for 2-3 days, i.e. 1 g i.v. bid. Twenty-two patients treated elsewhere with ceftriaxone or ceftazidime before surgery were transferred to another prophylactic regimen. The final diagnosis in the laparoscopic cholecystectomy group was 219 bile stones, 3 adenomas, and 2 occult carcinomas. We had 4 complications (1.8% of 217 laparoscopic cholecystectomies), 2 of which were minor (infection of the umbilical access by S. aureus) and 2 major (1 biliary fistula [accessory duct] and 1 acute pancreatitis), both treated conservatively. Positive bile cultures (27 cases) were unrelated to the clinical course. The incidence of infections after laparoscopic cholecystectomy in our prospective series was <2%. Ceftriaxone is confirmed as the gold standard in biliary tract surgery, but ceftazidime was equivalent (no statistical difference between the two antibiotics, P=0.59 NS). Ultra-short prophylaxis is enough in most cases, except in cholecystitis. We found no correlation between positive bile cultures and surgical infections after laparoscopic cholecystectomy. The umbilicus was the preferred site of infection in obese patients after the laparoscopic procedure. Major complications are usually related to technical pitfalls.

Aged↗

PubMed1987

Cholecystectomy in morbidly obese patients.

Indications for performing cholecystectomy simultaneously with a gastric bariatric operation remain controversial. The extremes are to always perform cholecystectomy or to perform cholecystectomy only when there are palpable stones or the gallbladder is grossly diseased. Since 1975, 136 cholecystectomies have been performed simultaneously in 724 patients who had a gastric bariatric operation. Cholecystectomy had been performed before the bariatric operation in 120 and was required later in 18 patients. The clinical records, anesthesia, pathology, and operative reports provide the data for this study. Simultaneous cholecystectomy was done through the vertical midline incision used for gastric bariatric operation. No patients had the gallbladder bed closed or were drained. Operative cholangiogram were not performed because this procedure would have been difficult and significantly prolonged because of the obesity. No patients have developed postoperative choledocholithiasis. One patient developed a complication related to cholecystectomy, a common bile duct stricture. The length of the operation and the postoperative hospitalization with and without simultaneous cholecystectomy were compared. The results of intraoperative ultrasound studies performed upon these patients are described and discussed. It is concluded that cholecystectomy should be performed simultaneously with all gastric bariatric operations when there is gross or echogenic evidence of gallbladder disease. Cholecystectomy does not significantly prolong or complicate the gastric bariatric operation.

Adult↗

PubMed1993

[Laparoscopic cholecystectomy].

Traditional cholecystectomy has been the standard surgical treatment of the gallstone disease for more than 100 years. The technical development led to a new surgical procedure and its rapid acceptance. This is laparoscopic cholecystectomy. Its application is becoming widespread in therapy too. But most of the surgeons are lack of technical experiences in this field. Currently it restricts the indications those are anyway the same of standard cholecystectomy. Besides its many advantages, laparoscopic cholecystectomy has its own disadvantages and being an invasive procedure, there are possibilities of complications. The latest can be reduced by the adequate choice of patients, the careful learning of the operative technic and by turning to open surgery (conversion) when it is necessary. Its morbidity is nearly equal to complications of standard cholecystectomy, but mortality rate is lower (0.05-0.2%). Our morbidity of performed 300 laparoscopic cholecystectomies was 6.4%. We had no death. The hospitalization became as short as 4 days. Our early clinical results (90%) are the same of traditional cholecystectomy. Laparoscopic cholecystectomy as a new surgical procedure involves the efficiency of the standard cholecystectomy and the noninvasive endoscopic technic. Laparoscopic cholecystectomy performed by well trained surgeons is a safe surgical procedure, its early results are excellent and makes the choice of surgical treatment, used in bile surgery richer.

Acute Disease↗

PubMedDate not supplied

Extended cholecystectomy for carcinoma of the gall bladder.

Resection was performed in 158 (70%) out of 227 patients with carcinoma of the gall bladder treated over 22 years between 1971 and 1993; 59 had simple cholecystectomy, 66 extended cholecystectomy (including 2 cm wedge resection of the liver at the gall bladder bed and regional lymphadenectomy in the hepatoduodenal ligament, behind the superior part of the pancreatic head and in the common hepatic artery region) and 33 had a more extended operation. Staging as proposed by the Japanese Society of Biliary Surgery (JSBS) was followed. Simple cholecystectomy was performed in 35 patients with stage I, 6 with stage II, 6 with stage III and 11 with stage IV disease while extended cholecystectomy was performed in 28 patients with stage I, 11 with stage II, 12 with stage III and 14 patients with stage IV disease. Survival was calculated using Kaplan - Meier method and log rank test was used for analysis of survival rates. The cumulative 5 year survival after extended cholecystectomy was 79% in stage I, 64% in stage II, 44% in stage III and 8% in stage IV. There was no difference in survival between stage I and II but survival in stage I was significantly better than that in stage III (p = 0.05). There was no statistically significant difference in survival after extended or simple cholecystectomy in stage I disease although incidence of recurrence was less after extended than after simple cholecystectomy (7% vs 17%). Extended cholecystectomy produced better survival than simple cholecystectomy in stage II disease (p = 0.04) but there was no difference between extended and simple cholecystectomy in stage III and IV disease. Retrospective analysis was performed to identify significant prognostic indicators. The significant factors for pior survival were N2, Hinf 1, Binf 1 and invasive cancer.

Cholecystectomy↗

PubMed1997

Effect of a no-conversion policy on patient outcome following laparoscopic cholecystectomy.

BACKGROUND: One of the potential drawbacks of laparoscopic cholecystectomy is lack of experience with open cholecystectomy. The aim of this study was to examine the effect of a no-conversion policy on patient outcome following laparoscopic cholecystectomy. METHODS: One hundred and sixty-one patients underwent laparoscopic cholecystectomy in the no-conversion period and were compared with 127 operated on during a period in which there was a low threshold for conversion from laparoscopic to open cholecystectomy. All operations in the no-conversion period were performed by surgeons in training assisted by one consultant. RESULTS: One patient in the no-conversion group had a gallbladder carcinoma and the operation was converted to open surgery. All others underwent total cholecystectomy except for one patient who had part of a severely diseased gallbladder left in situ. Operating time was significantly lower, median 65 versus 50 min (P = 0.004), as was postoperative hospital stay, 3 versus 2 days (P = 0.001), in favour of the no-conversion group. There was no bile duct injury and postoperative complications were similar in both groups (6 versus 8 per cent; P not significant). CONCLUSION: Laparoscopic cholecystectomy can be performed safely without converting to open cholecystectomy. As surgeons become more experienced with laparoscopic cholecystectomy, the need to perform open cholecystectomy in an elective setting may disappear.

Adult↗

PubMed2002

Laparoscopic or open conventional cholecystectomy: clinical and economic considerations.

OBJECTIVE: To compare clinical aspects and financial costs of open conventional and laparoscopic cholecystectomy. DESIGN: Retrospective analysis of hospital records of patients who were operated on electively for symptomatic gallstone disease. SETTING: University clinic, Germany. SUBJECTS: 153 consecutive patients who had open conventional (1991-92) and 222 who had laparoscopic cholecystectomy (1993-96). A total of 251 cholecystectomies were done during 1991-92 and 523 cholecystectomies during 1993-96. INTERVENTION: Cholecystectomy. MAIN OUTCOME MEASURES: Clinical aspects: operating time, complications, postoperative stay; financial aspects: total cost of hospital stay after cholecystectomy. RESULTS: When open conventional was compared with laparoscopic cholecystectomy: operating time was 66 and 92 minutes; complications, 9 and 6 cases; postoperative stay, 8 and 3 days; and total cost of hospital stay, US $ 3434 and US $ 2808 respectively. CONCLUSION: The cost of laparoscopic cholecystectomy was 18% less than for open conventional cholecystectomy, principally because of the shorter postoperative stay.

Adolescent↗

PubMed1995

The introduction of laparoscopic cholecystectomy--audit of transition period with late follow-up.

The operative treatment of 356 consecutive patients with gallstone related disease who presented in the thirty months following the introduction of laparoscopic cholecystectomy was reviewed. A standard questionnaire, with emphasis on total hospital stay (including convalescence), late postoperative morbidity and time to return to work/full activity was sent to all patients. Two hundred and ninety-eight patients responded (83%). The median duration of follow-up was 19 months, (range 6-36 months). Patients who underwent laparoscopic cholecystectomy spent significantly less time in hospital post-operatively (median 3 days, interquartile range 2-4) than either those who required conversion to open cholecystectomy (median 7.5 days, interquartile range 5.5-10) or those who had planned open cholecystectomy (median 9.5 days, interquartile range 5-13), (p < 0.001, Kruskal-Wallis). Planned gall bladder extraction through the umbilical port site was associated with a significantly higher probability of wound infection compared with extraction through the epigastric port site (chi 2 = 4.977, P < 0.05). The median time to return to work/full activity was significantly shorter after laparoscopic cholecystectomy (median 21 days, interquartile range 14-42), than after open cholecystectomy (median 42 days, interquartile range 21-60) or following conversion to open cholecystectomy (median 56 days, interquartile range 35-60). We conclude that laparoscopic cholecystectomy requires a significantly shorter hospitalisation than open cholecystectomy and facilitates early return to work/full activity.

Cholecystectomy↗

PubMed2001

Role of laparoscopic cholecystectomy in the management of gangrenous cholecystitis.

BACKGROUND: Laparoscopic cholecystectomy is increasingly being employed as the initial surgical approach in patients with acute cholecystitis. Gangrenous cholecystitis will be unexpectedly encountered in a proportion of these patients. The applicability of laparoscopic techniques and its outcome in this group of patients remain poorly defined. This paper presents our experience with laparoscopic cholecystectomy in the treatment of patients with gangrenous cholecystitis. METHODS: From January 1994 to March 1999, 281 patients underwent laparoscopic cholecystectomy for acute cholecystitis. Operative and histopathologic data were obtained and the subgroup with gangrenous cholecystitis identified (53 of 281, 18.8%). Laparoscopic cholecystectomy was the initial surgical approach in 44 (83%) and was successfully completed in 30 of 44 (68%) patients. Conversion to an open cholecystectomy became necessary in 14 of 44 (32%). A retrospective review comparing these two groups of patients was performed. RESULTS: Of the 44 patients, there were 25 males and 19 females, with a mean age of 64.6 years. Mean duration of symptoms prior to presentation was 2.3 and 2.9 days in the laparoscopic and conversion groups, respectively. Clinical presentation included the presence of right upper quadrant pain (98%), leukocytosis (91%), fever (16.3%), and jaundice (9%). Liver function test abnormalities included elevations of alkaline phosphatase (25%), aspartate aminotransferase (20.4%), alanine aminotransferase (22.7%), and total bilirubin (18.1%). Ultrasonography revealed the presence of gallstones (88.6%), gallbladder wall thickening (52.3%), and pericholecystic fluid (20.5%). Air in the gallbladder wall and intraluminal membranes were present in 2 patients and 1 patient, respectively. Nuclear scans performed in 29 patients revealed cystic duct obstruction in all 29. The rim sign was present in 1 patient. A laparoscopic cholecystectomy was attempted in 44 of 53 patients and was successfully completed in 30 (68%). Conversion to an open procedure became necessary in 14 of 44 (32%). No difference in preoperative factors was noted among the two groups. The mean duration of surgery in patients undergoing a successful laparoscopic cholecystectomy was 107 minutes versus 110 minutes when conversion was necessary. There were no deaths in the study population. Morbidity occurred in 40% of the laparoscopic group and 71% of the conversion group. No patient in the laparoscopic group required admission to the intensive care unit. In contrast, 4 of 14 patients in the conversion group required a mean of 2.6 days in the intensive care unit. Postoperative hospital stay was 3.3 versus 5.5 days in the two groups, respectively. CONCLUSIONS: Preoperative factors did not predict conversion in patients undergoing laparoscopic cholecystectomy for presumed acute cholecystitis who are found to have gangrenous cholecystitis. Duration of surgery is not significantly prolonged and outcome in terms of morbidity, admission to the intensive care unit, and hospital stay are significantly better in patients in whom laparoscopic cholecystectomy is successful.

Acute Disease↗

PubMed1999

Racial variation in the use of laparoscopic cholecystectomy in the Department of Veterans Affairs medical system.

BACKGROUND: While studies have found racial differences in the rates of use of established invasive cardiac and cerebrovascular procedures, no study has evaluated racial variation in the rates of adoption of new surgical procedures. For patients undergoing laparoscopic cholecystectomy, the procedure represents a new and safe option that shortens the duration of postoperative hospitalization by almost one week. In this study, we evaluated whether, in the equal access Veterans Affairs (VA) medical system, the rate of adoption of this procedure and improvements in the duration of postoperative hospitalization differed between African-American and Caucasian patients. STUDY DESIGN: Data were obtained from two sources-administrative claims files and prospectively compiled dinical data from medical records and patient interviews. In both data sets, frequency of use, length of stay, and outcomes for African-American and Caucasian patients undergoing minimally invasive and open gallbladder surgery were analyzed for the first four years of use of the procedure in the VA system (1992 to 1995). RESULTS: Analyses based on claims files indicated that, after adjustment for potentially confounding variables, African-American patients who underwent cholecystectomy in VA medical centers were 25% less likely to undergo a minimally invasive cholecystectomy during the first 4 years of use of the new procedure (adjusted odds ratio, 0.74; 95% confidence interval, 0.66-0.83). Shortening of the average postoperative length of stay from 9 days or more in the prelaparoscopic era to less than 4.5 days for patients undergoing the laparoscopic procedure occurred in the first year for Caucasian patients, but did not occur until the fourth year for African-American patients (p<0.001). The overall difference in postoperative length of stay between African-American and Caucasian patients more than doubled from 1.7 days before introduction of laparoscopic cholecystectomy to 3.8 days in the fourth year. In comparison, analyses based on nurse-compiled clinical data indicated that, after adjustment for relevant clinical factors, racial variations in the rate of laparoscopic surgery were even larger (adjusted odds ratio for laparoscopic versus open cholecystectomy for African-American versus Caucasian veterans, 0.68; 95% confidence interval, 0.55-0.84). CONCLUSIONS: Compared to Caucasian patients, African-American patients who underwent cholecystectomy in VA medical centers had an approximately 25% to 32% lower likelihood of undergoing minimally invasive cholecystectomy procedures. The differences in rates of adoption of laparoscopic surgery did not appear to be from more comorbid illnesses among African-American patients. African-American and Caucasian veterans may differ in their preference for new surgical procedures like laparoscopic cholecystectomy. Conversely, VA physicians may have been less likely to recommend laparoscopic cholecystectomies to African-American patients.

Adult↗

PubMed1994

A new minimally invasive technique for cholecystectomy. Subxiphoid "minimal stress triangle": microceliotomy.

OBJECTIVE: The authors devised a minimally invasive technique for cholecystectomy via microceliotomy that provides safety attainable with the open conventional approach and postoperative results comparable to laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA: Laparoscopic cholecystectomy has evolved as a minimally invasive outpatient procedure. Patients can return rapidly to preoperative status with minimal postoperative morbidity and pain, and the small scar size is cosmetically desirable. Unfortunately, there are reports of serious intraoperative complications, including injury to blood vessels, bowel, and the bile ducts, caused by failure to identify structures properly. The conventional cholecystectomy technique currently is relegated to patients on whom the laparoscopic procedure cannot be performed. METHODS: Cholecystectomy was performed through a 3-cm transverse high subxiphoid incision in the "minimal stress triangle." The location, anterior to Calot's triangle, was critical in providing a direct vertical view of the biliary ducts during dissection. Direct view cholecystectomy was performed using endoscopic instruments without pneumoperitoneum. Postoperative data were compared with both laparoscopic and open cholecystectomy results. RESULTS: Using the microceliotomy technique in the ambulatory setting, cholecystectomy was performed successfully in 99.3% (N = 143) of cases. Biliary leakage beyond the third postoperative day was caused by failure of clips or obstruction to bile flow. The postoperative morbidity, acceptability of scar, and analgesic requirements compare favorably with other techniques. Microceliotomy is cost effective. Portal hypertension is a contraindication for this procedure. CONCLUSIONS: The microceliotomy approach offers a viable, safe, and cost-effective alternative to the laparoscopic technique for cholecystectomy, especially when facilities for laparoscopy are not available or when the laparoscopic procedure cannot be performed.

Adult↗

PubMed1997

The effect of laparoscopic cholecystectomy on gastroduodenal reflux.

BACKGROUND: The present study evaluates the effect of laparoscopic cholecystectomy on biliary reflux in patients with cholelithiasis. METHODS: All patients over 18 years of age awaiting elective cholecystectomy for gallstone disease in one of two teaching hospitals were contacted by telephone, and those who gave informed consent were entered in the study. A total of 66 patients (43 females and 23 males) underwent milk 99mTc DIDA scans. Elective laparoscopic cholecystectomy was perfomed after a median of 28.5 days (range: 8-588 days) and patients were re-investigated with a milk 99mTc DIDA scan at a median time of 50 days (range: 18-370 days) postoperatively. Scans were carried out in the Nuclear Medicine Department of the Royal Adelaide Hospital. RESULTS: All but two patients had a functioning gall-bladder on milk 99mTc N-2, 6-dimethylphenyl-carbamoylmethyl iminodiacetic acid scanning prior to cholecystectomy. One of these patients was found to have a gall-bladder carcinoma at cholecystectomy. Fifty-seven of the 66 patients had a successful laparoscopic cholecystectomy (nine open cholecystectomies). Nineteen patients experienced gastroduodenal reflux into the stomach prior to cholecystectomy and 23 patients experienced it postoperatively. There was no significant difference in gastroduodenal reflux in both the open and laparoscopic groups. CONCLUSION: The present study demonstrated that laparoscopic cholecystectomy did not significantly alter gastroduodenal reflux.

Adult↗