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PubMed1995

Impact of laparoscopic cholecystectomy in a major teaching hospital: clinical and hospital outcomes.

OBJECTIVE: To compare the clinical, training and cost implications of laparoscopic cholecystectomy with open cholecystectomy. SETTING: A university teaching hospital. DESIGN: A retrospective review of all patients who underwent cholecystectomy in 1989, before the introduction of the laparoscopic technique, and in 1993, after the learning curve for laparoscopic cholecystectomy had been overcome. MAIN OUTCOME MEASURES: Surgical indications, feasibility of laparoscopic approach, type of surgeon, operating time, hospital stay, postoperative complications, and cost analysis. RESULTS: 240 cholecystectomies were performed in 1989 and 293 in 1993. This is a 22% increase in overall workload and includes a significant increase (85%; P < 0.0001) in elective caseload. In 1993, 89% of patients underwent laparoscopic surgery, with conversion to open cholecystectomy in 6.8% of elective patients and 33% of emergency patients. Surgical indications remained the same, as did the time from diagnosis to cholecystectomy. There were significant changes in median length of hospital stay (from 10 days in 1989 to 4 days in 1993; P < 0.0001), successful intraoperative cholangiography (93% versus 73%; P < 0.0001), and exploration of the common bile duct (15% versus 5% of patients; P = 0.0005). The number of cholecystectomies performed by surgeons-in-training decreased from 65% to 40%, individual treatment costs were reduced by 62% and overall hospital costs were reduced by 53%. Complications fell from 12% to 7% (P = 0.07), with the only major bile duct injury occurring in 1989. There were three deaths in 1989 and two deaths in 1993. All deaths followed open surgery. CONCLUSIONS: Laparoscopic cholecystectomy is associated with improved patient outcomes and, despite the increased workload, significant savings for hospitals.

Cholecystectomy↗

PubMed1995

Laparoscopic cholecystectomy: its impact on national health economics.

OBJECTIVE: To assess whether sound economic reasons exist for the wider introduction of laparoscopic cholecystectomy in Australia. DESIGN: A retrospective survey of patients who underwent laparoscopic cholecystectomy. We compared time of hospital stay and time off work after laparoscopic cholecystectomy with data for open cholecystectomy. PATIENTS AND SETTING: Seventeen participating surgeons in four Australian States allowed access to patients treated between May 1990 and November 1991 (1254 patients in all). MAIN OUTCOME MEASURES: Patient acceptability of the procedure, average length of postoperative in-hospital stay, and the savings associated with earlier return to work compared with open cholecystectomy. RESULTS: Almost 90% of patients (1127) replied and 1088 responses were considered appropriate for analysis. Serious complications were rare; 96% of patients thought the technique was successful. The mean length of in-hospital stay was 2.6 days (range, 1-120), compared with a mean of 8.7 days for open cholecystectomy. Among working patients, the mean time to return to work was 11.6 days (range, 10.7-13.1), an estimated 27 days sooner than after open cholecystectomy. Extrapolating from these results, replacing 95% of open cholecystectomies with laparoscopic procedures would have 133,285 hospital bed-days and 500,000 work-days each year. CONCLUSION: Laparoscopic cholecystectomy is safe and effective. Its wider use in Australia would result in savings to both the individual and the national economy.

Absenteeism↗

PubMed1997

Cholecystectomy-induced gastroesophageal reflux: is it reduced by the laparoscopic approach?

OBJECTIVE: The incidence of gastroesophageal reflux and esophagitis increases significantly following cholecystectomy. Laparoscopic technique minimizes the metabolic and mechanical disturbances of cholecystectomy, but there has been no study of its effects on gastroesophageal reflux. The aim of this study was to examine the effect of laparoscopic cholecystectomy on the indices of gastroesophageal reflux. METHODS: A prospective study was carried out on patients scheduled for cholecystectomy. Informed consent was obtained. Preoperative 24-h pH studies and manometry were performed. Studies were repeated 3 months after surgery. Pathological acid reflux was defined in terms of the DeMeester acid score. RESULTS: Pre- and postoperative studies were carried out on 28 patients who had open cholecystectomy and on 22 patients who had laparoscopic cholecystectomy. The mean (SEM) DeMeester acid score increased from 14.8 (2.4) to 34.0 (6.7) following open cholecystectomy (p = 0.006) and from 13.9 (2.5) to 28.9 (4.3) following laparoscopic cholecystectomy (p = 0.002). Decrease in mean lower esophageal sphincter pressure in both groups was not significant. CONCLUSIONS: A significant increase in the incidence of gastroesophageal reflux occurred within 3 months after surgery in both study groups. Despite the less invasive nature of laparoscopic cholecystectomy, the type of surgery did not influence the degree of esophageal dysfunction.

Adult↗

PubMed2006

Early versus delayed laparoscopic cholecystectomy for acute cholecystitis.

BACKGROUND: Gallstones are present in about 10% to 15% of the adult western population. Between 1% and 4% become symptomatic in a year. Cholecystectomy for symptomatic gallstones is mainly performed after the acute cholecystitis episode settles because of the fear of higher morbidity and conversion from laparoscopic cholecystectomy to open cholecystectomy during acute cholecystitis. OBJECTIVES: The aim was to compare the early laparoscopic cholecystectomy (less than seven days of onset of symptoms) versus delayed laparoscopic cholecystectomy (more than six weeks after index admission) with regards to benefits and harms. SEARCH STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation IndexExpanded until November 2005. SELECTION CRITERIA: We considered for inclusion all randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis. DATA COLLECTION AND ANALYSIS: We collected the data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, conversion rate, operating time, and hospital stay from each trial. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the odds ratio (OR) with 95% confidence intervals (CI) based on intention-to-treat analysis. MAIN RESULTS: We included five trials with 451 patients randomised: 223 to the early group and 228 to the delayed group. Surgery was performed on 222 patients in the early group and on 216 patients in the delayed group. There was no mortality in any of the trials. Four of the five trials were of high methodological quality. There was no statistically significant difference between the two groups for any of the outcomes including bile duct injury (OR 0.63, 95% CI 0.15 to 2.70) and conversion to open cholecystectomy (OR 0.84, 95% CI 0.53 to 1.34). Various other analyses including 'available case analysis', risk difference, statistical methods to overcome the 'zero-event trials' showed no statistically significant difference between the two groups in any of the outcomes measured. A total of 40 patients (17.5%) from the delayed group had to undergo emergency laparoscopic cholecystectomy due to non-resolving or recurrent cholecystitis; 18 (45%) of these had to undergo conversion to open procedure. The total hospital stay was about three days shorter in the early group compared with the delayed group. AUTHORS' CONCLUSIONS: Early laparoscopic cholecystectomy during acute cholecystitis seems safe and shortens the total hospital stay. The majority of the outcomes occurred rarely; hence, the confidence intervals are wide. Therefore, further randomised trials on the issue are needed.

Adult↗

PubMed1995

Introduction of laparoscopic cholecystectomy in a large teaching hospital: independent audit of the first 3 years.

Commencing with the introduction of laparoscopic cholecystectomy, a detailed independent prospective audit of all cholecystectomies attributable to 12 general consultant surgeons has been carried out over a period of 3 years. Of 650 operations 502 were intended laparoscopic cholecystectomies. In the first year 58 per cent were intended laparoscopic cholecystectomies; this rose to 80 per cent in the second year and to 90 per cent in the third. The conversion rate was 21 per cent in the first year, 21 per cent in the second and 15 per cent in the third. The mean operating time for laparoscopic cholecystectomy was 133 min for year 1, 123 min for year 2 and 115 min for year 3, compared with 92, 101 and 95 min respectively for open cholecystectomy. The overall complication rate was 10 per cent for laparoscopic and 21 per cent for open cholecystectomy. This included six bile duct injuries (1.2 per cent) in the patients undergoing the laparoscopic procedure and one (0.7 per cent) in those having open cholecystectomy. This unselected audit of a group of general surgeons introducing laparoscopic cholecystectomy into their practice has revealed complication and conversion rates that are higher than those reported in most of the published literature, but may be representative of practice throughout the UK.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed2003

Abdominal symptoms: do they disappear after cholecystectomy?

OBJECTIVE: To evaluate the effect of cholecystectomy in patients with gallstones on preoperative abdominal symptoms. METHODS: A systematic search was made of the Medline database in combination with reference checking. Articles were excluded if patients aged <18 years, symptom relief rates could not be calculated, if follow-up after cholecystectomy was less than 1 month, or when the included patients were at extraordinary risk for a complicated outcome. Potential differences in relief rates due to patient selection, retrospective versus prospective design, duration of follow-up, or intervention were analyzed using logistic regression. RESULTS: The pooled relief rate for "biliary pain" was high 92% (95% confidence interval 86 to 96%). Symptom relief rates were consistently higher in studies that included acute cholecystectomies. For upper abdominal pain--without restrictions for intensity or duration--pooled relief rates ranged from 72% (66 to 77%) after elective cholecystectomy, to 86% (83 to 91%) after acute cholecystectomy. The relief rate of food intolerance was higher in studies with a follow-up < or =12 months (88%, 76 to 91%) compared to studies with a follow-up of more than 12 months (65%, 55 to 74%). CONCLUSION: In almost all patients with gallstones biliary pain disappeared after cholecystectomy. There is insufficient evidence, however, that this relief was due to cholecystectomy. Relief rates of other isolated symptoms were low in patients with an elective cholecystectomy. A proper evaluation of the effectiveness of cholecystectomy in terms of abdominal symptom relief rates requires a randomized trial.

Abdominal Pain↗

PubMed2004

Is drip infusion cholecystocholangiography (DIC) an acceptable modality at cholecystectomy for cholecystolithiasis, considering the frequency of bile duct maljunction and intraoperative bile duct injury?

BACKGROUND/PURPOSE: Knowledge of the configuration of the extrahepatic bile duct is indispensable to avoid bile duct injury during cholecystectomy. Various methods of examining the biliary tract have been developed; however, the most appropriate preoperative diagnostic modality at cholecystectomy for cholecystolithiasis has not yet been reported. Considering the frequency of bile duct maljunction (BDM) and operative bile duct injury, in addition to the cost and invasiveness of the various examination methods, we evaluated the usefulness of drip infusion cholecystocholangiography (DIC) as the optimal method of examination at cholecystectomy for cholecystolithiasis. METHODS: Preoperative diagnostic accuracy of BDM was analyzed in relation to operative bile duct injury using 469 patients with benign biliary diseases who was diagnosed with DIC and endoscopic retrograde cholecystography and underwent cholecystectomy. BDM was classified according to Hisatsugu criteria. RESULTS: Out of 469 consecutive patients who underwent a cholecystectomy for biliary stones between January 1, 1995, and September 30, 1998, at Ohta Nishinouchi General Hospital, 21 (4.48%) had a cystic duct maljunction (CDM) and 12 (2.56%) had an aberrant bile duct (ABD). The most common variants were types C and D for CDM, and types II and III for ABD, according to Hisatsugu's classification. Fourteen patients (42.4%) were diagnosed before the surgery; 13 of them received preoperative endoscopic retrograde cholangiography (ERC), and the remaining patient underwent preoperative drip infusion cholecystocholangiography (DIC). Nineteen patients could not be correctly diagnosed based on their preoperative examinations, but were diagnosed during surgery. Operative bile duct injury occurred in 1 patient (0.2%) whose maljunction could not be diagnosed before the operation. CONCLUSIONS: Taking into account the medical cost and invasiveness, and the frequency of BDM and related bile duct injuries, we conclude that DIC is an acceptable preoperative diagnostic modality to employ at cholecystectomy for cholecystolithiasis. Knowledge of the configuration of the extrahepatic bile duct is indispensable to avoid bile duct injury during cholecystectomy. Various methods of examining the biliary tract have been developed; however, the most appropriate preoperative diagnostic modality at cholecystectomy for cholecystolithiasis has not yet been reported. Considering the frequency of bile duct maljunction (BDM) and operative bile duct injury, in addition to the cost and invasiveness of the various examination methods, we evaluated the usefulness of drip infusion cholecystocholangiography (DIC) as the optimal method of examination at cholecystectomy for cholecystolithiasis.

Bile Ducts, Extrahepatic↗

PubMed1993

Laparoscopic cholecystectomy in patients admitted with acute biliary symptoms.

Laparoscopic cholecystectomy has become the standard of care for the elective management of cholelithiasis. Little information exists, however, regarding the appropriateness of this procedure in the setting of acute symptomatology. We retrospectively reviewed our experience with 516 laparoscopic cholecystectomies performed at a single institution from May 1990 to May 1991. Seventy-five (14.5%) of these patients were admitted from the emergency department with acute abdominal pain (100%), fever (4 of 75, 5%), and/or an elevated white blood cell count (22 of 75, 29%). There were 54 females and 21 males, with a mean age of 50.0 +/- 2.4 years (range: 17 to 89 years). Laparoscopic cholecystectomy was attempted in all patients, and was successful in 68 of 75 patients (91%). Seven procedures were converted to open cholecystectomy because of the difficulty in dissection precluding safe laparoscopic cholecystectomy. The time from admission to surgery (mean: 3.4 +/- 0.3 days), as well as the total hospital stay (mean: 5.5 +/- 0.6 days), was much longer than in the elective circumstance. Mean laboratory values for the group as a whole were as follows: white blood cell count (mean: 9.6 IU/L +/- 0.4 IU/L, range: 4.1 IU/L to 19.5 IU/L), alkaline phosphatase (mean: 97.0 IU/L +/- 13.7 IU/L, range: 27 IU/L to 375 IU/L), and alanine aminotransferase (mean: 78.3 IU/L +/- 13.7 IU/L, range: 15 IU/L to 701 IU/L). Patients requiring open cholecystectomy were older (mean: 61.4 +/- 4.4 versus 48.8 +/- 2.6), were more likely to be febrile (3 of 7, 42%, versus 1 of 68, 1%), and were more likely to have a significant leukocytosis (mean: white blood cell count 12.9 +/- 1.8 x 10(3) cells/mm3 versus 9.2 +/- 0.4 x 10(3) cells/mm3) than were those undergoing successful laparoscopic cholecystectomy. Laparoscopic cholecystectomy can be performed safely in the majority of patients presenting with acute biliary symptoms. Patients with a triad of acute abdominal pain, fever, and elevated white blood cell count, particularly elderly patients, are more likely to require conversion to open cholecystectomy, however.

Acute Disease↗

PubMed2004

The role of cholecystectomy in reducing recurrent gallstone pancreatitis.

BACKGROUND AND STUDY AIM: Endoscopic sphincterotomy (ES) or cholecystectomy can prevent recurrent acute pancreatitis (RAP) in patients with gallstone-related pancreatitis. However, it is unknown whether cholecystectomy after ES offers additional benefit in preventing RAP in these patients. This is a retrospective study to assess whether cholecystectomy can decrease the incidence of RAP in patients with gallstone-related pancreatitis. PATIENTS AND METHODS: Records from 139 patients with gallstone-related pancreatitis were analyzed. Of these, 58 patients had gallbladder stones with concomitant common bile duct (CBD) stones and 81 patients had gallbladder stones without CBD stones. Of the 58 patients who had both gallbladder and CBD stones, 37 (63.8 %) did not undergo cholecystectomy after ES (group 1) and 21 patients (36.2 %) did undergo cholecystectomy after ES (group 2). Of the 81 patients who had gallbladder stones but who did not have CBD stones, 54 (66.7 %) did not undergo cholecystectomy (group 3) and 27 (33.3 %) did undergo cholecystectomy (group 4). RESULTS: At the time of analysis, three patients (8.1 %) in group 1 and three patients (14.3 %) in group 2 developed RAP. There was no significant difference in the estimated probability of occurrence of RAP over time between group 1 and group 2 ( P = 0.41). However, there was a significantly higher probability of patients developing RAP over time in group 3 compared with group 4 (6/54 vs. 0/27 respectively, P = 0.04). CONCLUSION: In patients with gallbladder stones without CBD stones, cholecystectomy can decrease the incidence of RAP. In patients with both gallbladder and CBD stones, however, the risk of RAP was not further reduced by cholecystectomy after ES and complete removal of CBD stones.

Aged↗

PubMed2005

Cholecystectomy in Sweden 1987-99: a nationwide study of mortality and preoperative admissions.

OBJECTIVE: Information on mortality after cholecystectomy in defined populations is limited. In this study we examined the case fatality rates and mortality ratios, based on register data. MATERIAL AND METHODS: Hospital discharge and death certificate data were linked for all patients undergoing cholecystectomy in Sweden in 1987-99. Mortality risk was calculated as the standardized mortality ratio (SMR). RESULTS: From 1 January 1987 to 1 December 1999, 123,099 patients underwent cholecystectomy for acute or chronic gallbladder disease. Between 1987-91 and 1995-99, the incidence of cholecystectomy increased by 13%, median age of patients decreased and the proportion of women increased. From 1995 to 1999, 32% of all cholecystectomies were completed as open cholecystectomy. During this period, 82% of patients aged 70 years or older with acute gallstone disease had an open cholecystectomy. For patients with chronic gallstone disease, the proportion was 43%. Postoperative crude mortality within 30 days for all patients was 0.4%. Patients with acalculous gallbladder disease had double the mortality risk compared with patients with calculous disease, and patients with acute cholecystitis had double the risk compared with patients with chronic disease. High age, previous hospital admission for conditions other than gallbladder disease, and cholecystectomy completed as an open procedure increased the risk, whereas gender and calendar year did not significantly affect the mortality risk. Biliary tract diseases accounted for 61% of all postoperative deaths, whereas 26% were due to cardiovascular diseases. CONCLUSIONS: During the 1990s, cholecystectomy incidence increased, whereas postoperative mortality risk remained unchanged. In order to further reduce the mortality risk, particular attention should be paid to elderly and frail patients and to patients with acalculous gallbladder disease.

Age Distribution↗

PubMed1997

Complications of laparoscopic cholecystectomy: the experience of a university-affiliated teaching hospital.

BACKGROUND: In most published reports on laparoscopic cholecystectomy, the cases have been accrued from small community hospitals in a multicenter fashion. The purpose of this study was to compare the rate of complication following laparoscopic cholecystectomy performed at a single university-affiliated teaching hospital to those quoted in the literature. STUDY DESIGN: A retrospective review of the first 1300 laparoscopic cholecystectomies performed at the Videoscopic Surgery Center at Pennsylvania Hospital from May 1990 through January 1994 was undertaken. Complications were classified as those related to creation of the initial pneumoperitoneum and those related to cholecystectomy. RESULTS: A 3% conversion rate to open cholecystectomy (n = 40) was noted due to the presence of dense adhesions, gangrenous cholecystitis, or difficult anatomic relationships. There were 18 complications (1.4%) related to creation of the initial pneumoperitoneum and 14 complications (1.1%) related to cholecystectomy. Complications related to laparoscopy included bleeding from the abdominal wall (n = 2), trocar site hernia (n = 11), hollow viscus injury (n = 1), and wound infection (n = 4). Complications related to cholecystectomy included unanticipated retained CBD stone (n = 5), symptomatic bile leak (n = 6), hollow viscus injury (n = 1), intraabdominal abscess (n = 1), and a retained portion of gallbladder (n = 1). There were no perioperative deaths related to laparoscopic cholecystectomy, and the overall morbidity was 2.4%. Long-term follow-up revealed no cases of benign biliary strictures. CONCLUSIONS: With attention to anatomy, technique, and meticulous dissection, laparoscopic cholecystectomy can be safely performed in a university-affiliated teaching hospital setting.

Adolescent↗

PubMed1991

Open versus laparoscopic cholecystectomy. A comparison of postoperative pulmonary function.

Upper abdominal surgery is associated with characteristic changes in pulmonary function which increase the risk of lower lobe atelectasis. Sixteen patients undergoing open cholecystectomy and 20 patients undergoing laparoscopic cholecystectomy were prospectively evaluated by pulmonary function tests (forced vital capacity [FVC], forced expiratory volume [FEV-1], and forced expiratory flow [FEF] 25% to 75%) before operation and on the morning after surgery to determine if the laparoscopic technique lessens the pulmonary risk. Fraction of the baseline pulmonary function was calculated by dividing the postoperative pulmonary function by the preoperative pulmonary function and multiplying by 100%. Postoperative FVC measured 52% of preoperative function for open cholecystectomy and 73% for laparoscopic cholecystectomy (p = 0.002). Postoperative FEV-1 measured 53% of baseline function for open cholecystectomy and 72% for laparoscopic cholecystectomy (p = 0.006). Postoperative FEF 25% to 75% measured 53% for open cholecystectomy and 81% for laparoscopic cholecystectomy (p = 0.07). It is concluded that laparoscopic cholecystectomy offers improved pulmonary function compared to the open technique.

Adult↗

PubMed1996

Incidence of persistent symptoms after laparoscopic cholecystectomy: a prospective study.

BACKGROUND AND AIMS: Laparoscopic cholecystectomy is the standard treatment for symptomatic gall stone disease. This study aimed to assess the effect of the operation on patients' symptoms. METHODS: One hundred consecutive patients undergoing laparoscopic cholecystectomy between June 1994 and June 1995 were evaluated using standard questionnaires examining demographic details, indication for laparoscopic cholecystectomy, characteristics of pain, and other associated dyspeptic and colonic symptoms. A history of psychiatric disturbances and of hysterectomy were also recorded. The same questionnaires were administered again six months after the operation. Operation notes and histological reports were reviewed. RESULTS: Three patients were converted to open surgery and were excluded from analysis. The median age of the remaining 97 patients was 50.9 (19-85) years; 19 were men. There was one complication each of bleeding and biliary leak. Indications for laparoscopic cholecystectomy were biliary type pain (66 patients) and complicated gall stone disease (acute cholecystitis 21, cholestatic jaundice six, and pancreatitis four). Thirteen patients (13%) had persistent pain and two (3%) developed diarrhoea at follow up. Only one patient with persistent pain after laparoscopic cholecystectomy originated from the complicated gall stone disease group. Logistic discriminant analysis showed that bloating (p < 0.001), constipation (p < 0.05), and previous and current use of psychotrophic drugs (p < 0.001) were significantly more common among those with a poor outcome after laparoscopic cholecystectomy. Heartburn was unaffected. Of patients with persistent symptoms after cholecystectomy 77% had no or mild histological changes of cholecystitis as compared with 30% in the pain free group. CONCLUSIONS: The incidence of persistent pain after laparoscopic cholecystectomy was 13%. Abdominal bloating and psychiatric medications were predictive for persistence of pain after laparoscopic cholecystectomy.

Adult↗

PubMed2001

Is cholecystectomy necessary after ERCP for bile duct stones in patients with gallbladder in situ?

BACKGROUND: The requirement for subsequent cholecystectomy in patients with gallbladder in situ after endoscopic removal of stones from the common bile duct (CBD) is controversial. The aims of this study were to assess the requirement for subsequent cholecystectomy for gallbladder-related symptoms, and to identify the patients who develop symptoms after the endoscopic removal of CBD stones. METHODS: Of 241 patients with gallbladder in situ following endoscopic removal of stones from the CBD, 146 patients (78 men and 68 women; mean age 69 +/- 13 years, range 20-93) with a follow-up time of more than three months without elective cholecystectomy were enrolled in the study. Fifty-nine patients had gallbladder stones (single stones in 27 and multiple stones in 32) and 87 patients had gallbladder in situ without stones. The time from entry to the occurrences of death or cholecystectomy was evaluated retrospectively. Cox regression analysis was used to evaluate the risk factors associated with these events. RESULTS: The mean duration of follow-up was 24.1 +/- 18.0 months (range 3-70 months). During follow-up, seven patients (4.8%) underwent cholecystectomy, on average 18.4 months after CBD stone removal, as the result of acute cholecystitis in four cases, biliary pain in two cases and acute pancreatitis in one case. Laparoscopic cholecystectomy was performed in four patients and open cholecystectomy in three patients. Post-operative morbidity occurred in two patients, with improvement after conservative management. Nine patients (6.2%) died as the result of unrelated biliary disease. Age, sex, presence of gallbladder stones, multiplicity of gallbladder stones and underlying disease did not correlate with subsequent cholecystectomy by Cox regression analysis. CONCLUSION: Elective cholecystectomy is not warranted in patients with bile duct stones when the common duct can be cleared of stones by endoscopic sphincterotomy. We could not find any clinical predictors of further symptoms or complications arising from the retained gallbladder.

Adult↗

PubMed1992

Laparoscopic cholecystectomy. A prospective study of outcome in 100 unselected patients.

OBJECTIVE: To describe the outcome of laparoscopic (percutaneous) cholecystectomy in the management of gallbladder stones. PATIENTS AND METHODS: One hundred unselected consecutive patients referred for cholecystectomy, or admitted as emergencies with complicated gallbladder disease. Ten patients had acute cholecystitis, three had empyema, three had gallstone pancreatitis, and 11 had a history of recent jaundice. Common bile duct stones were dealt with by endoscopic sphincterotomy. OUTCOME MEASURES: Intraoperative and postoperative complications, 30-day mortality rate, duration of hospital stay, and length of postoperative disability. RESULTS: Three patients were excluded and underwent open cholecystectomy. Laparoscopic cholecystectomy was attempted in the remaining 97, and successfully completed in 87; 10 were converted to open cholecystectomy. There were no significant intraoperative complications. Two patients had a postoperative haemorrhage and one had a transient bile leak; none required reoperation. There was one death from myocardial infarction 12 days after operation. Minor complications occurred in 12 patients. Mean operating time was 88 minutes. The average length of hospital stay was 72 hours, and most patients returned to normal activities after seven days. CONCLUSIONS: Laparoscopic cholecystectomy offers an outcome comparable to standard cholecystectomy and is applicable to 90% of patients requiring removal of the gallbladder. Laparoscopic cholecystectomy has significant advantages over open cholecystectomy in terms of reduced postoperative pain and disability.

Adolescent↗

PubMedDate not supplied

[Is cell-mediated immunity affected by laparoscopic cholecystectomy?].

It is well known that surgery significantly decreases cell-mediated immunity. Laparoscopic cholecystectomy is a so-called minimally invasive surgical procedure, and on the basis of this consideration we investigated whether and how the immune system is modified in patients after laparoscopic cholecystectomy compared to those undergoing open cholecystectomy. Immune activity (neutrophils, total lymphocyte count, lymphocyte subpopulations, multiple skin tests) was evaluated in 82 patients on postoperative day 1 and on postoperative days 1, 3 and 6. Forty-two patients underwent open cholecystectomy and 40 laparoscopic cholecystectomy. On postoperative day 1 patients treated by open cholecystectomy showed a significant increase (P < 0.05) in plasma neutrophils, whereas this parameter was unchanged in patients undergoing laparoscopic cholecystectomy. Skin tests revealed a hypo- or anergic response in the majority of patients (81.8%) undergoing open surgery compared to those treated laparoscopically (10.5%). Total lymphocyte count and lymphocyte subpopulations were normal in the two groups. Four cases of respiratory tract infection (4.8%) were detected after open cholecystectomy. Laparoscopic cholecystectomy substantially reduces postoperative pain and hospitalisation, promotes an earlier recovery and return to normal activity and is not associated with postoperative immunosuppression, with a more positive postoperative morbidity profile compared to open surgery.

Adult↗

PubMed2000

Safety and success of early laparoscopic cholecystectomy for acute cholecystitis.

Although elective laparoscopic cholecystectomy is today's gold standard for the treatment of symptomatic cholelithiasis, its safety and effectiveness for acute cholecystitis remain controversial. The authors present a retrospective study comparing laparoscopic cholecystectomy in the acute versus the elective setting. A total of 605 patients were treated surgically for gallstone disease between August 1991 and January 1999. A total of 269 patients (44.5%) underwent surgery for acute cholecystitis as soon as possible after diagnosis, and elective cholecystectomy was performed on 336 patients (55.5%) for symptomatic gallstones. Initial open cholecystectomy was performed on 52 (19.3%) of the acute patients and 16 (4.8%) of the elective patients. Laparoscopic cholecystectomy was attempted on 217 of the acute patients (80.7%), with 11 cases (5.1%) converted to open cholecystectomy, and on 320 (95.2%) of the elective patients, with 6 cases (1.9%) converted to open cholecystectomy. The mean (+/-SD) operative time for the acute and elective patients was 105 (+/-38) and 85 (+/-21) minutes, respectively (P < 0.05). There was no perioperative mortality in either laparoscopic group. Surgical complications related to laparoscopic cholecystectomy in the acute and elective groups occurred in six (2.9%) and eight (2.5%) cases, respectively (P = NS). The current study shows that early laparoscopic cholecystectomy for acute cholecystitis is safe and efficient. Low conversion rates can be maintained with strict guidelines for appropriate patient selection, adequate experience, and proper laparoscopic technique.

Acute Disease↗

PubMedDate not supplied

[Difficult laparoscopic cholecystectomy].

From 2505 cases operated between 1994-2000, the authors selected a lot of 889 cases of difficult cholecystectomy, which after classical criteria would have been classified as contraindications of laparoscopic procedure. This study analyzed of intraoperative incidents, the conversion rate and particularities of operative tactics and techniques. The lot of patients includes 889 cases of difficult laparoscopic cholecystectomy. The patients were selected according to classical contraindications of laparoscopic cholecystectomy: obesity, liver cirrhosis, previous operated abdomen, severe cardio-pulmonary diseases, ages over 70 years, acute cholecistitis. The rate of intraoperative incidents and accidents was 19.9% (177 cases), in comparison to intraoperative incidents and accidents rate in "easy" laparoscopic chole-cystectomy which was 15.5% (251 cases from 1616 patients). The conversion rate in case of difficult laparoscopic cholecystectomy was 6.1% (55 patients) and 3.2% in the lot of "easy" cholecystectomy. The postoperative morbidity was 6.4% (57 patients) and 5.5% (147 patients) in the lot of "easy cholecystectomy. The postoperative mortality was 0.6% (6 deaths) and 0.3% (5 deaths) in the lot of "easy" cholecystectomy. In this paper are discussed the modalities and the technical particularities of a difficult laparoscopic cholecystectomy, able to lowering the risk of operative incidents and postoperative complications. In conclusion, laparoscopic cholecystectomy can be safely performed to the majority of patients with lithiasic cholecistitis, by an experienced surgical team.

Adult↗