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PubMed1984

The effects of ileal resection with cholecystectomy on bile salt metabolism in the prairie dog.

The adverse effects of ileal resection on bile salt metabolism may be aggravated by cholecystectomy. Female prairie dogs had either sham laparotomy, cholecystectomy, distal 50% small bowel resection, or cholecystectomy and distal 50% small bowel resection. After 4 weeks the common bile duct was cannulated and bile collected for up to 12 hr. Bile salt pool size and synthetic rate were measured from the washout curve. Bile salt, phospholipid, and cholesterol concentrations were determined. Bile salt pool size was reduced after cholecystectomy and after ileal resection. Cholecystectomy plus ileal resection further lowered the pool size, increased the synthetic rate, and increased the proportion of secondary bile salts. Cholecystectomy increased the synthesis and the concentration of bile salts in hepatic bile and altered the proportions of biliary lipids. Ileal resection decreased the concentration of hepatic bile salts with the formation of noncholesterol stones. The drastic reduction in pool size with the combined operation might be expected to lead to fat malabsorption. The higher concentration of bile salts after the combined operation compared with ileal resection alone reflects a possible beneficial effect of cholecystectomy.

Animals↗

PubMed1992

Randomised controlled trial of cost-effectiveness of lithotripsy and open cholecystectomy as treatments for gallbladder stones.

Inpatient extracorporeal shockwave lithotripsy for treatment of gallbladder stones has not previously been compared with open cholecystectomy in terms of cost-effectiveness. In a randomised controlled trial, 163 patients, stratified by gallstone bulk (over 4 cm3 or not), were randomised to lithotripsy or cholecystectomy (38 large-bulk and 27 small-bulk cholecystectomy; 37 large-bulk and 61 small-bulk lithotripsy) and followed up for 1 year. Both treatments gave significant health gains in terms of a reduction in episodes of biliary pain, improved perceived health status, and symptom relief, but few differences between treatments were found. There was some evidence that biliary-pain episodes were less severe after cholecystectomy. Cholecystectomy patients also had greater improvements in mean health gain for three related symptoms: vomiting, feeling sick, and fatty-food upset. However, there were no differences between groups in perceived health status. Among lithotripsy patients, health gain was not related to stone clearance. Lithotripsy was more expensive than cholecystectomy, principally because of the costs of the inpatient stay and adjuvant bile-salt therapy. Conventional lithotripsy appears at least as cost-effective as cholecystectomy for patients with small-bulk stones but less cost-effective for those with large-bulk stones. To some extent treatment choice can be guided by patient preference.

Adult↗

PubMed1993

Cholecystectomy and colorectal cancer in China.

Colorectal cancer is a major public health problem in China: 79,800 new cases are estimated to occur each year, which ranks it among the five most common tumours in China. Although the association between cholecystectomy and colorectal cancer has been studied elsewhere, few studies have been conducted in the Chinese population, characterized by a lower fat intake, and low colorectal cancer incidence. We conducted this hospital-based case-control study to explore this association. The study included a total of 503 incident cases with pathologically diagnosed colorectal cancer in Drum Tower Hospital at Nanjing in China from 1965 to 1986, and 2188 healthy controls who had annual routine physical examinations at the same hospital. Diagnosis of cholelithiasis was confirmed by ultrasonography or X-ray cholecystography, and the information on cholecystectomy was obtained by checking medical charts for both cases and controls. The prevalence of cholelithiases was 5.8% for cases and 6.1% for controls (P > 0.05). Eight cases (1.6%) and 18 controls (0.8%) had a history of previous cholecystectomy. The period between cases' cholecystectomy and diagnosis of colorectal cancer ranged from 2.5 to 23 years, and the mean interval was 8.9 years. The crude odds ratio for patients having previous cholecystectomy is 1.95 (95% CI: 0.84-4.51) compared with controls. The odds ratio for female patients with previous cholecystectomy was 2.79 (95% CI: 1.03-7.59). When subsites were analysed, a significant association between right colon cancer and cholecystectomy was noted: the odds ratio was 6.2 (95% CI: 2.24-16.9), and that for females was even higher 8.61 (95% CI: 2.44-3.04) with statistical significance.(ABSTRACT TRUNCATED AT 250 WORDS)

Case-Control Studies↗

PubMed2004

Laparoscopic cholecystectomy in geriatric patients.

BACKGROUND: The results and advantages of laparoscopic cholecystectomy in the geriatric population have received minimal attention. Several early reports related high conversion rates complications and mortality. This case series review is focused on the results of laparoscopic cholecystectomy in the geriatric population in a private practice environment. METHODS: The records of all patients undergoing cholecystectomy by the author over the past 12 years were reviewed. The entire series consists of 248 patients in whom 239 procedures were completed laparoscopically, with 9 patients converted to an open cholecystectomy. This report identifies 82 patients who were aged 65 years or older at the time of the laparoscopic cholecystectomy. The results of this series are reported in three progressive geriatric age groups: 65 to 74, 75 to 84, and 85 to 95 years. RESULTS: All 82 geriatric patients reported from this series were symptomatic from their gallbladder disease. A majority of all patients in all age groups were female. Gallstones were present in 77 patients, and 5 patients had a gallbladder ejection fraction of less than 35%. In this series of laparoscopic cholecystectomy, 26.8% had an emergent procedure for acute cholecystitis and the remainder had an elective or semielective procedure for symptomatic cholecystitis. The majority of patients between the ages of 65 and 84 years had elective procedures whereas the majority of patients over age 85 had an emergent procedure. There were 2 deaths. The first death (age 86 years) was from extensive metastatic cancer from the gallbladder, and the second patient (age 91 years) died of sepsis and multiple system organ failure. Each patient in this entire series had an attempt at laparoscopic removal of the gallbladder. The conversion rate was 3.6% in the entire series of 248 patients and also 3.6% in the geriatric series. Ninety-one percent of the patients in this geriatric series were discharged home after only 24 to 48 hours of postoperative observation. CONCLUSIONS: Laparoscopic cholecystectomy is a safe procedure in the geriatric population. The procedure should be recommended for all geriatric patients who have symptomatic cholecystitis before the development of acute cholecystitis or severe fibrosis with dense adhesions from chronic cholecystitis.

Aged↗

PubMed2002

Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis.

BACKGROUND: The ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography (CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced open cholecystostomy for the treatment of acute cholecystitis in critically ill patients. METHODS: The aim of the present study was to evaluate the results of a 5-year protocol using PTHC followed by delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis in critically ill patients. We reviewed the charts of 55 patients who underwent PTHC at the Hadassah University Hospital Mount Scopus during the years 1994 to 1999. RESULTS: The main indications for PTHC among this group of severely sick and high-risk patients was biliary sepsis and septic shock in 23 patients (42%); and severe comorbidities in 32 patients (58%). The median age was 74 (32 to 98) years, 33 were female and 22 male. Successful biliary drainage by PTHC was achieved in 54 of 55 (98%) of the patients. The majority of the patients (31 of 55) were drained transhepaticlly under CT guidance. The rest, (24 of 55) were drained using ultrasound guidance followed by cholecystography for verification. Complications included hepatic bleeding that required surgical intervention in 1 patient and dislodgment of the catheter in 9 patients that was reinserted in 2 patients. Three patients died of multisystem organ failure 12 to 50 days following the procedure. The remaining 52 patients recovered well with a mean hospital stay of 15.5 plus minus 11.4 days. Thirty-one patients were able to undergo delayed surgery: 28 underwent laparoscopic cholecystectomy of whom 4 (14%) were converted to open cholecystectomy. This was compared with a 1.9% conversion rate in 1,498 elective laparoscopic cholecystectomies performed at the same time period (P = 0.012). Another 3 patients underwent planned open cholecystectomy, 1 urgent and 2 combined with other abdominal procedures. There was no surgery associated mortality, severe morbidity, or bile duct injury. CONCLUSIONS: The use of PTHC in critically ill patients with acute cholecystitis is both safe and effective.

Acute Disease↗

PubMed1999

Cholecystectomy is an effective treatment for biliary dyskinesia.

BACKGROUND: An increasing number of reports indicate symptomatic relief of biliary colic symptoms after cholecystectomy for biliary dyskinesia. Despite this, cholecystectomy as a treatment for biliary dyskinesia remains controversial. Our aim was to determine efficacy of cholecystectomy in alleviating biliary dyskinesia symptoms and the correlation with histologic findings. METHODS: Records of patients with gallbladder ejection fraction <35% between January 1994 and February 1999 were reviewed. Gallbladder pathology and degree of symptomatic improvement were determined on follow-up. RESULTS: Of the 27 cholecystectomy patients, 24 (89%) had significant improvement, 2 (7%) had partial improvement, and 1 (4%) had minimal improvement. Ten patients (43%) had normal gall-bladder, and 9 (90%) of them had significant improvement after cholecystectomy. Of the 6 nonsurgical patients, none had significant improvement, 4 (67%) had partial improvement, and 2 (33%) had minimal improvement. CONCLUSIONS: Biliary dyskinesia patients who underwent cholecystectomy had significantly greater symptom improvement compared with nonsurgical patients. Pathologic correlation suggests chronic inflammation may not be the only cause of gallbladder dysfunction. Cholecystectomy should be a first-line therapy for biliary dyskinesia patients.

Algorithms↗

PubMed1988

Gallstone pancreatitis and the effect of cholecystectomy: a population-based cohort study.

Although an association between gallstones and pancreatitis has been recognized for almost 100 years, the risk of acute pancreatitis in patients with gallstones and the effect of cholecystectomy on this risk have been unknown. The complete medical records of the 2,583 residents of Rochester, Minnesota, who had gallstones diagnosed between 1950 and 1970 were carefully reviewed to detect the development of acute pancreatitis. Acute pancreatitis developed in only 89 subjects (3.4% of the cohort); however, the relative risk for acute pancreatitis (before cholecystectomy) was increased 14 to 35 times in men and 12 to 25 times in women. The overall age- and sex-adjusted incidence of acute pancreatitis of the members of the cohort before cholecystectomy was 6.3 to 14.8 per 1,000 person-years of follow-up. Cholecystectomy in 1,560 patients without a prior attack of pancreatitis reduced the relative risk to 1.9 and 2.0 for men and women respectively. Of 58 patients who had a cholecystectomy after an attack of acute pancreatitis and underwent follow-up for a median of 15 years postoperatively, only 2 had another attack of acute pancreatitis, and the cause of the pancreatitis was unrelated to gallstones in both. In summary, patients with gallstones have a considerably increased relative risk for acute pancreatitis and, regardless of whether prior attacks of pancreatitis have occurred, cholecystectomy reduces this risk to almost the same level as in the general population. Because the overall incidence of pancreatitis is low, however, performance of cholecystectomy to prevent pancreatitis is indicated only if an attack of acute pancreatitis has already occurred.

Acute Disease↗

PubMed1996

Changing indications for laparoscopic cholecystectomy. Stones without symptoms and symptoms without stones.

In less than a decade, laparoscopic methods have dramatically improved the safety and convenience of cholecystectomy. As a result, the number of cholecystectomies performed nationwide has increased significantly. Whether this increase is a reflection of any major change in operative indications is unclear; the actual answer may vary from community to community. Silent gallstones continue to represent a sometimes contentious therapeutic dilemma. Because their natural history is unlikely to have changed, the management guidelines previously established for open cholecystectomy continue to have relevance today. Thus, it can be agreed that the majority of patients with silent gallstones do not require a cholecystectomy. The changing risk-benefit ratio suggests that some liberalization of these guidelines may now be in order. Already a number of transplantation surgeons have begun to recommend pretransplant cholecystectomy for asymptomatic patients who are found to have gallstones during screening. Available evidence also appears to support the use of pre-emptive laparoscopic cholecystectomy for other indications such as in selected women of childbearing age, young children, and patients with very large gallstones. The problem of silent gallstones in diabetics continues to be more enigmatic, but some complicated diabetics are probably best managed with operation. Other patient groups who are at high risk of having adverse outcomes from expectant management will be more precisely identified by future research efforts. Laparoscopic cholecystectomy should also be helpful in patients with various forms of acalculous biliary disease. However, special caution is advisable in approaching chronic acalculous cholecystitis until more specific and reproducible diagnostic methods are further validated.

Child↗

PubMedDate not supplied

Laparoscopic cholecystectomy as a "true" outpatient procedure: initial experience in 130 consecutive patients.

Laparoscopic cholecystectomy has received nearly universal acceptance and is currently considered the "gold standard" for the treatment of cholelithiasis. Many centers have employed "short-stay" units or "23-hour admissions" for postoperative observation following laparoscopic cholecystectomy. The practice of early discharge as "true" outpatients following this procedure has not been well defined. A retrospective analysis of 130 consecutive patients undergoing laparoscopic cholecystectomy in an outpatient surgery unit was performed. A follow-up telephone survey was carried out of patients who successfully completed the procedure as outpatients. One hundred thirty patients underwent outpatient laparoscopic cholecystectomy. The patient population consisted of 78% women, with an age range of 17 to 76 years (mean age 47.1 years). Symptomatic gallstone disease was the indication for laparoscopic cholecystectomy in 92% of the patients. All patients underwent successful completion of laparoscopic cholecystectomy with no conversions to an open procedure. The mean length of operation was 75 +/- 23 minutes (range 25 to 147 minutes). The mean length of stay in the postanesthesia care unit (PACU) ranged from 95 to 460 minutes with a mean length of stay of 200 +/- 79 minutes. A total of eight patients (6.2%) were admitted to the hospital directly from the PACU in the immediate postoperative period. Six of these eight patients were discharged on the first postoperative day. Following discharge from the PACU, an additional six patients (4.6%) required hospital admission. Three of these six patients were discharged after a single day of hospitalization. Ninety-eight of 116 eligible patients were available for follow-up telephone evaluation. The outpatient experience was rated as good by 75.5% of the patients, fair by 22.5%, and poor by 2%. In retrospect, 20.4% of the patients stated that they would have preferred an inpatient to an outpatient procedure. Laparoscopic cholecystectomy can be performed as a true outpatient procedure with patients discharged to home within hours of completion of the procedure. Less than 10% of patients will fail this protocol and another 5% of the patients may require hospitalization after returning to their homes.

Adolescent↗

PubMed2000

Epidemiology of cholecystectomy and irritable bowel syndrome in a UK population.

BACKGROUND: Some patients with irritable bowel syndrome (IBS) may undergo unnecessary cholecystectomy. This paper describes the prevalence of cholecystectomy and IBS in a sample of British adults in Teesside. Associations between the two conditions and their relationship to consultation behaviour and socioeconomic status are described. The results are compared with those from Bristol in an attempt to determine the influence of service-related factors on the prevalence of cholecystectomy. METHODS: A postal questionnaire was sent to 4432 adults aged 20-69 years registered with six general practices. The Standard Occupational Classification was used as a proxy for socioeconomic status. RESULTS: In Teesside cholecystectomy was reported by 4.1 per cent of women and 1.3 per cent of men. Some 22.9 per cent of the women had IBS, and 10.5 per cent of men. Cholecystectomy was more common in patients with IBS (odds ratio 1.9 (95 per cent confidence interval 1.2-3.2); P < 0.01). The prevalence of cholecystectomy, of IBS and of consultation for symptoms of IBS was not influenced by socioeconomic status. CONCLUSION: Symptoms of IBS may cause diagnostic confusion and unproductive surgery. Cholecystectomy may cause IBS-like symptoms, a single underlying disorder may produce symptoms in both gastrointestinal and biliary tracts, or the associations might be due to a combination of these factors.

Adult↗

PubMed2001

Feasibility of day-care open cholecystectomy: evaluation in an inpatient model.

BACKGROUND: Open cholecystectomy is still a fairly frequently performed operation worldwide, and is used where laparoscopic surgery has failed or is contraindicated, and where some surgeons do not operate laparoscopically for technical reasons. In developing countries laparoscopic cholecystectomy is costly and is available only in a few centres. The present study was conducted to assess the feasibility of day-care open cholecystectomy using an inpatient model. METHODS: Thirty patients were subjected to open cholecystectomy. Intraoperative nasogastric decompression and local wound infiltration with 0.25% bupivacaine was carried out. Postoperatively patients were encouraged to be ambulant, pass urine and start oral fluids. Intravenous fluids and parenteral medication were stopped at 8 p.m. when patients were assessed for feasibility for discharge. All patients were reassessed the next morning for any adverse effects that could have occurred had the patients been discharged on the evening of surgery. RESULTS: Prospectively, 73.3% of patients were considered to be dischargeable on the evening of surgery; but on reassessment the next morning, retrospectively, 93.3% of patients were actually dischargeable on the evening of surgery. A total of 76.6% of patients was actually discharged within 24 h of surgery. No patient required readmission. On follow up there were no complications that could be attributable to early discharge. A total of 83.3% of patients approved of day-care open cholecystectomy. CONCLUSIONS: Day-care open cholecystectomy is safe and feasible. In developing countries, where the use of laparoscopic surgery is limited due to resource constraints, day-care open cholecystectomy can lead to substantial savings in health-care resources.

Adult↗

PubMed2002

Iatrogenic bile duct injury: the scourge of laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the first-line surgical treatment of calculous gall-bladder disease and the benefits over open cholecystectomy are well known. In the early years of LC, the higher rate of bile duct injuries compared with open cholecystectomy was believed to be due to the 'learning curve' and would dissipate with increased experience. The purpose of the present paper was to review a tertiary referral unit's experience of bile duct injuries induced by LC. METHODS: A retrospective analysis was performed on all patients referred for management of an iatrogenic bile duct injury from 1981 to 2000. For injuries sustained at LC, details of time between LC and recognition of the injury, time from injury to definitive repair, type of injury, use of intraoperative cholangiography (IOC), definitive repair and postoperative outcome were recorded. The type of injury sustained at open cholecystectomy was similarly classified to allow the severity of injury to be compared. RESULTS: There were 131 patients referred for management of an iatrogenic bile duct injury that occurred at open cholecystectomy (n = 62), liver resection (n = 5) and at LC (n = 64). Only 39% of bile duct injuries were recognized at the time of LC. Following conversion to open operation, half the subsequent procedures were considered inappropriate. When the injury was not recognized during LC, 70% of patients developed bile leak/peritonitis, almost half of whom were referred, whereas the rest underwent a variety of operative procedures by the referring surgeon. The remainder developed jaundice or abnormal liver function tests and cholangitis. An IOC was performed in 43% of cases, but failed to identify an injury in two-thirds of patients. The bile duct injuries that occurred at LC were of greater severity than with open cholecystectomy. Following definitive repair, there was one death (1.6%). Ninety-two per cent of patients had an uncomplicated recovery and there was one late stricture requiring surgical revision. CONCLUSIONS: The early prediction that the rate of injury during LC would decline substantially with increased experience has not been fulfilled. Bile duct injury that occurs at LC is of greater severity than with open cholecystectomy. Bile duct injury is recognized during LC in less than half the cases. Evidence is accruing that the use of cholangiography reduces the risk and severity of injury and, when correctly interpreted, increases the chance of recognition of bile duct injury during the procedure. Prevention is the key but, should an injury occur, referral to a specialist in biliary reconstructive surgery is indicated.

Adult↗

PubMed2001

Cholecystectomy versus cholecystolithotomy for cholelithiasis in childhood: long-term outcome.

BACKGROUND/PURPOSE: The presence of cholelithiasis is being reported with increased frequency in childhood. Little is known about the natural history of the disease, and only a few studies have been published regarding long-term results of treated patients. Controversy still exists regarding optimal treatment. Both cholecystectomy and cholecystolithotomy with gallbladder preservation have been recommended as the preferred operative intervention. The purpose of this study was to compare the long-term outcome of cholecystectomy versus cholecystolithotomy for symptomatic gallbladder disease in children. METHODS: The charts of all patients with symptomatic cholelithiasis treated in the Dublin Paediatric Hospitals during a 25-year period from 1974 till 1999 were reviewed. Data obtained included age, sex, age at presentation of symptoms, methods of diagnosis, indications for operative treatment, time interval between presentation of symptoms and surgery, surgical technique, performance of a preoperative or intraoperative cholangiogram, stone biochemistry, gallbladder histology, radiologic follow-up, the presence of recurrent or residual stones and symptoms, and the need for reoperation. Patient data were grouped according to method of surgery. All parameters were compared and evaluated. Follow-up was by way of telephone contact with all patients and completion of a questionnaire. RESULTS: There were 18 patients over a 25-year period. Eight patients underwent cholecystectomy, and 10 patients had a cholecystolithotomy. Median follow-up was 2 years in the cholecystectomy group and 5 years in the cholecystolithotomy group. All patients in the cholecystectomy group are asymptomatic and have no recurrent or residual stones on follow-up ultrasound scan. Thirty percent of the patients in the cholecystolithotomy group have recurrent right upper quadrant pain, and 30% show recurrent stones 9.5 months (range, 7 to 12 months) postoperatively. One patient underwent cholecystectomy 8.5 months postcholecystolithotomy. CONCLUSIONS: The symptomatic high stone recurrence rate postcholecystolithotomy seen in our series suggest that cholecystectomy is the preferred treatment in patients with symptomatic gallbladder disease.

Adolescent↗

PubMed1992

Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy.

Preoperative cholangiography and subsequent removal of bile duct stones may increase the efficacy of laparoscopic cholecystectomy and reduce the rate of conversion to open cholecystectomy. Since there is little data on the incidence of choledocholithiasis in this group of patients, we undertook a prospective study on the routine performance of ERC in 288 patients selected for laparoscopic cholecystectomy. ERC succeeded in 264 of the 288 patients (91.7%) and showed a normal bile duct system in 227 (86.0%). Atypical bile duct anatomy was seen in eight patients. Open cholecystectomy was performed in seven of them but was judged to be absolutely necessary in only two cases (one patient each with Caroli syndrome and Mirizzi syndrome). ERC also revealed bile duct stones in 29 of 264 patients (11.0%) which had not been suspected on the basis of clinical, laboratory and ultrasonographic findings in nine cases (3.4%). EPT succeeded in all of the 29 patients with choledocholithiasis but open cholecystectomy was subsequently performed in four patients due to incomplete bile duct clearance (n = 3) or temporary bleeding after EPT (n = 1). The rate of ERC/EPT-related morbidity was 2.8%. It is concluded from a risk-benefit analysis in these patients that ERC should be restricted to patients with suspected bile duct stones. Following this strategy, small ductal concrements and bile duct abnormalities will be missed in 6.4% of cases but the clinical relevance of these findings is still unclear. In patients with combined gallbladder and common bile duct stones, preoperative EPT plus subsequent laparoscopic cholecystectomy appears to be an effective and time-saving therapeutic regimen which should be compared with open cholecystectomy plus common bile duct exploration in future studies.

Bile Duct Diseases↗

PubMed2000

Wound recurrence from gallbladder cancer after open cholecystectomy.

BACKGROUND: Reports of port site recurrences from gallbladder cancer after laparoscopic cholecystectomy have raised considerable concern as to whether the laparoscopic technique implies an increased risk of metastatic disease. In a previous study of gallbladder cancer and laparoscopic cholecystectomy, we reported a frequency of 16% port site metastases. The purpose of the present study was to determine the frequency of wound metastases from gallbladder cancer after open cholecystectomy. METHODS: The registers from the Swedish Oncological Centers and the National Board of Health and Welfare were checked for reported cases of gallbladder cancer and surgical classification codes for open cholecystectomy from 1991 to 1994. The study included all 8 university and 24 county hospitals in Sweden. The files from all patients with gallbladder cancer who had an open cholecystectomy were retrospectively reviewed. RESULTS: The study included 270 patients who had a cholecystectomy, of which 215 were classified as open and 55 as laparoscopic. Of the 215 patients, 11 patients were excluded because of an incorrect or deficient histopathologic or surgical classification. In 186 patients (91%), sufficient data were obtained for follow-up. Twelve patients (6.5%) had wound metastases from their gallbladder cancer. All patients with wound metastases died with a median survival of 10 months (range, 3 to 65 months). CONCLUSIONS: Wound metastases from gallbladder cancer after open cholecystectomy may be more common than previously assumed.

Aged↗

PubMed2002

Reintervention after laparoscopic and open cholecystectomy in Sweden 1987-1995: analysis of data from a hospital discharge register.

OBJECTIVE: To find out the incidence of cholecystectomy and of reintervention after cholecystectomy in Sweden 1987 to 1995, and to compare mortality and reintervention after simple laparoscopic and conventional open cholecystectomy (without exploration of the common bile duct or simultaneous operation). DESIGN: Analysis of data from Swedish national registers. SETTING: Two hospitals and government department, Sweden. MAIN OUTCOME MEASURES: Mortality and reintervention during readmission within one year after cholecystectomy classified as: reoperation on bile duct, endoscopic or percutaneous reintervention, or reoperation for wound complication, bleeding, or unspecified cause. RESULTS: Incidence of cholecystectomy rose between 1987-89 and 1993-95 from 0.97 to 1.04 for men and from 1.70 to 2.05 operations/1000 inhabitants for women. Reoperation on the bile ducts declined from 1987 to 1991 but returned to previous levels thereafter. Endoscopic reinterventions increased tenfold from 1987 to 1995, whereas those for general complications and mortality did not change significantly. Among simple cholecystectomies laparoscopic surgery was associated with an increased risk of endoscopic reintervention, odds ratio 1.8 (95% CI 1.2 to 2.6), and with a lower risk for postoperative mortality, odds ratio 0.5 (95% CI 0.3 to 0.8). CONCLUSIONS: Incidence, mortality, and readmission with reintervention are important endpoints in gallbladder surgery. Significant changes in these variables were identified after the introduction of laparoscopic cholecystectomy.

Adolescent↗

PubMed2003

National survey on cholecystectomy related bile duct injury--public health and financial aspects in Belgian hospitals--1997.

Public health and financial aspects of cholecystectomy related bile duct injury (BDI) are highlighted in a National Cholecystectomy Survey carried out through 'datamining' the Federal State Medical Records Summaries and Financial Summaries of all Belgian hospitals in 1997. All cancer diagnoses, children < or = 10 years, cholecystectomies performed as an abdominal co-procedure or patients having undergone other non-related surgery were excluded from the study. 10.595 laparoscopic (LC) and 1.033 open cholecystectomies (OC) as well as 137 secondary BDI treatments (LC/OC) were included in the survey (total 11.765). Both LC and OC groups turned out to be significantly different as to distribution of patient's age and APR-DRG severity classes. Composite criteria in terms of ICD-9-CM and billing codes were elaborated to classify: 1) primary, intra-operatively detected and treated BDI (N = 30), 2) primary delayed BDI treatments (N = 38), 3) secondary BDI treatments (N = 137), 4) non-BDI abdomino-surgical complications (N = 119), 4) uneventful laparoscopic (N = 7.476) and 5) uneventful open cholecystectomy (N = 681). Complication rates, community costs of LC and OC groups, incidence of preoperative ERCP and/or intra-operative cholangiography as well as interventions for complications were studied. Incidence of cholecystectomy related BDI was 0.37% in LC, 2.81% in OC and 0.58% overall. Average costs amounted to [symbol: see text] 1.721 for uneventful LC, [symbol: see text] 2.924 for uneventful OC, [symbol: see text] 7.250 for primary, intra-operatively detected and immediately treated BDI [symbol: see text] 9.258 for primary delayed BDI treatments, [symbol: see text] 6.076 for secondary BDI treatments and [symbol: see text] 10.363 for non-BDI abdomino-surgical complications. In conclusion BDI with cholecystectomy reveals to be a serious complication increasing the overall average cost factor ninefold if not detected intra-operatively, in which case the raise is only fourfold. As a consequence BDI should be avoided by all means. In this respect 4 crucial surgical guidelines are emphasised.

Belgium↗

PubMed1998

Untoward cardiac changes during CO2 insufflation in laparoscopic cholecystectomies in low-risk patients.

In the past decade, laparoscopic cholecystectomy has become the gold standard treatment for gallbladder disease. A debate has arisen about using CO2 to distend the abdomen because of negative effects on venous return to the heart and declining cardiac output. Some authors have supported the use of pulmonary artery catheters for intraoperative monitoring while others have recommended gasless techniques to avoid these negative effects for high-risk patients. In this study, four cases of bradycardia and/or asystole during CO2 pneumoinsufflation at the beginning of planned, elective laparoscopic cholecystectomies are described. These patients were ASA category II, without history of cardiac disease. To determine the frequency and any underlying common denominators, we analyzed these laparoscopic cholecystectomies. Each patient experienced bradycardia shortly after the start of the laparoscopic cholecystectomy. None had known cardiac disease or symptoms. Two were on antihypertensive medications, and one had experienced an episode of unexplained bradycardia 6 years earlier. These cases occurred during 725 laparoscopic cholecystectomies (0.6% approximately). Using the senior author's conversion rate of 10% to open cholecystectomies, the entire group would be approximately 800, and the risk of bradycardia upon induction of CO2 is 4 per 800, or 0.5%. Although cardiovascular changes were noted during laparoscopic gynecologic surgery approximately 20 years ago, only in the last few years have cardiovascular changes been reported during laparoscopic cholecystectomies. This study reviews four cases of bradycardia during CO2 insufflation in patients that were considered to be low-risk. Surgeons should be prepared to encounter such cardiovascular changes even with low-risk patients.

Adult↗