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PubMed1995

[Results of the introduction of laparoscopic cholecystectomy on morbidity and mortality of gallbladder surgery in a large regional hospital].

OBJECTIVE: To analyse the impact of the introduction of laparoscopic cholecystectomy on overall morbidity and mortality of gall bladder surgery. DESIGN: Retrospective study. SETTING: Medisch Centrum Alkmaar, Alkmaar. METHODS: All cholecystectomies performed in our final 'prelaparoscopic' year 1990 were compared with all cholecystectomies performed in 1992, the year in which laparoscopic cholecystectomy has become a standard procedure, thus eliminating selection bias. The analysis included morbidity and mortality related to all procedures. RESULTS: In 1990, 173 open cholecystectomies were performed, in 1992 40, and 146 laparoscopic ones; the conversion rate was 4%. The number of patients undergoing investigation for common bile duct stones did not change, but there was a shift from intraoperative cholangiography to preoperative ERCP. In 1992 more endoscopic sphincterotomies were performed (13.5%, versus 5.4% in 1990; p = 0.02). One patient died from complications due to diagnostic ERCP. There was no difference in mortality rate of all procedures taken together, between the two years (3/186 in 1992 (1.6%); 2/173 in 1990 (1.2%)). The morbidity rate of all procedures in 1992 was slightly less than in 1990 (chi 2 = 1.91; p = 0.2). There were no common bile duct injuries caused by laparoscopy. In 1992, the mean operation time was longer than in 1990 (82 versus 46 min; p < 0.001) and the median postoperative hospital stay was significantly shorter than in 1990 (2 versus 6 days; p < 0.001). CONCLUSION: Introduction of laparoscopic cholecystectomy was responsible for shorter hospital stays and longer operation times. When common bile duct stones were predicted, endoscopic sphincterotomy was performed more frequently. These changes did not negatively influence morbidity and mortality rates for gall bladder surgery in general.

Adolescent↗

PubMed1995

Open versus laparoscopic cholecystectomy: a comparison of postoperative temperature.

Laparoscopic cholecystectomy has been shown to allow better postoperative pulmonary function than open cholecystectomy, with less incidence of lung atelectasis. As atelectasis following abdominal surgery is responsible for most febrile episodes in the first 48 h, it was postulated that with minimally invasive surgery there may be a parallel improvement in the incidence of postoperative fever. This study was designed to evaluate this hypothesis. Seventy-eight patients were randomly divided into two groups. Thirty-eight had an open cholecystectomy and 40 underwent the laparoscopic approach. Twenty-one of the 38 patients (55%) following open cholecystectomy had early febrile episodes compared with only 6 of the 40 (15%) in the laparoscopic cholecystectomy group. We concluded that there was a lower incidence of febrile episodes following laparoscopic cholecystectomy and suggest that this was related to improved pulmonary function and minimal surgical trauma.

Adult↗

PubMed1994

A case management experience with cholecystectomies.

Case Management can be used in developing plans to evaluate the care given to patients undergoing operative cholecystectomies. Although many cholecystectomies are now performed by laparoscope, some patients fail to meet the criteria for laparoscopic cholecystectomy and, therefore, require the open approach. This project was undertaken to scrutinize the time and activities of care for patients undergoing cholecystectomies to provide a baseline of information for the comparison of open cholecystectomy with laparoscopic cholecystectomy.

Cholecystectomy↗

PubMed1994

[Laparoscopic and open cholecystectomy in 954 patients. A prospective evaluation].

In 2 1/2 years we performed at the St. Clara Hospital in Basel 954 cholecystectomies; 661 were done laparoscopically. In the laparoscopic group we observed a morbidity of 2.3%, a reoperation rate of 0.6% and a mortality of 0.15%. In the group with open cholecystectomy the morbidity was 9.9% and the mortality 1.3%. In all 954 patients who had a cholecystectomy the morbidity was 4.6%, reoperation rate 0.4% and mortality 0.5%. Because of negative patient selection a comparison with the open cholecystectomy in our series is not possible. In summary we can say that the laparoscopic procedure has a low morbidity and low mortality. With the lesser operative trauma it allows a shorter hospital stay. We believe that laparoscopic cholecystectomy with good indication will replace open cholecystectomy as the gold standard therapy of symptomatic gallstone disease.

Adult↗

PubMed1994

Laparoscopic cholecystectomy for acute or gangrenous cholecystitis.

Over the past 4 years, laparoscopy has become the preferred approach for cholecystectomy in the majority of patients. Most of the early articles described laparoscopic cholecystectomy for chronic cholecystitis or presented only a limited number of patients with an acute process. This paper reviews our experience with laparoscopic cholecystectomy for acute and gangrenous cholecystitis. There were 460 attempted laparoscopic cholecystectomies, including 44 for acute nongangrenous cholecystitis and 24 for gangrenous cholecystitis. The conversion rate to open cholecystectomy was 2.8 per cent for chronic cholecystitis, 13.6 per cent for acute, and 75 per cent for gangrenous cholecystitis. The length of operation for laparoscopic compared with open cholecystectomy for acute cholecystitis was not significantly different. For gangrenous cholecystitis, the laparoscopic approach took significantly longer than the open method. The length of stay for acute cholecystitis was significantly shorter for laparoscopy compared with the open method. There was no significant difference in length of stay for gangrenous cholecystitis. With a conversion rate of 75 per cent, no shorter length of stay, and a significantly longer operation, the use of the laparoscopic approach when gangrenous cholecystitis is suspected should be questioned.

Acute Disease↗

PubMed1994

[Cholecystectomy today. A prospective study].

Between 13 June 1990 and 12 June 1993, we performed 1145 consecutive cholecystectomies. 127 patients who had undergone additional surgery were excluded from the prospective study. Of the remaining 1018 patients, 806 (78.2%) underwent laparoscopic cholecystectomy. The conversion rate to open procedure was 11.2% (90/806). The operative morbidity associated with laparoscopic cholecystectomy was 2.1% (17/806) and with open surgery 1.9% (4/212); mortality was 0.12% (1/806) and 0.47% (1/212) respectively. The reoperation rate after laparoscopic cholecystectomy was 0.6% (5/806). Reoperation was performed for lesions of the common bile duct, bleeding, and abscess formation. If the indications for open cholecystectomy are respected the morbidity and mortality were low for both laparoscopic and conventional cholecystectomy.

Adolescent↗

PubMedDate not supplied

Prospective analysis of 192 consecutive cholecystectomies: a comparative study between laparoscopy and laparotomy.

The hospital records of all the patients who underwent cholecystectomy because of specific biliary symptoms, between October 1990 and March 1993, were prospectively analyzed. The series consisted of 192 patients (159 women and 33 men), the mean age was 56 years and the mean body mass index was 26. Indication for surgery was uncomplicated gallstones in 113, common bile duct stones in 28 and cholecystitis in 51 patients. In those groups, respectively 94 (83%), 16 (57%) and 23 (45%) patients had a laparoscopic cholecystectomy. In total, laparoscopic cholecystectomy was successfully performed in 127 (95%) of the 133 patients in whom it was attempted. When compared with laparotomy, laparoscopic cholecystectomy was associated with shorter operative time: 88 +/- 41 min. (Mean +/- SD) versus 132 +/- 64 min. (p < 0,001), shorter postoperative hospital stay: 5 +/- 3 days versus 13 +/- 7 days (p < 0.001) and reduced cost of hospitalization: 103.301 +/- 51.062 BF versus 186.931 +/- 113.651 BF (p < 0.001). We noted an equivalent perioperative morbidity incidence in the two groups. The advantages of laparoscopy compared to laparotomy were recorded whatever the indication for cholecystectomy was. Therefore, with the increasing experience of surgeons and the improving quality of laparoscopic instruments, we think that laparoscopy can be considered for all patients requiring cholecystectomy.

Adult↗

PubMed1996

[Socioeconomic advantages of laparoscopic cholecystectomy].

A cohort of 100 consecutive patients cholecystectomized by laparoscopy was compared retrospectively under diverse socio-economic viewpoints to a cohort of 100 patients that underwent conventional cholecystectomy by means of the matched pair procedure. Laparoscopic cholecystectomy does not only combine enhanced comfort and less postoperative pain without loss of safety for the patient, but also offers objectively attainable socio-economic advantages in comparison to conventional, open cholecystectomy. Operation time was not prolonged in laparoscopic cholecystectomies. Patients stayed less long in the hospital and regained fitness for work earlier. The reduced time of inability to work could be lowered in the total cohort by 36% and was thus of great importance, particularly for working people. Costs saved by reduced time of hospitalization by laparoscopic cholecystectomy were balanced by higher additional costs of this procedure. Altogether, total costs for health insurance and other insurances induced by laparoscopic cholecystectomy were lower compared to those of conventional operation.

Absenteeism↗

PubMedDate not supplied

Preoperative endoscopic retrograde cholangiopancreatography: therapeutic impact in a general population of patients needing a cholecystectomy.

BACKGROUND/AIMS: The place of endoscopic retrograde cholangiopancreatography (ERCP) before open or laparoscopic cholecystectomy remains controversial. Most of the reports study highly selected series of patients and therefore do not give a survey of the actual situation in a general population. We describe here the therapeutic impact of preoperative ERCP in a continuous cohort of patients needing a cholecystectomy. MATERIAL AND METHODS: Data concerning a 2-year continuous and unselected series of 452 patients undergoing cholecystectomy were evaluated. RESULTS: Two hundred ninety-three patients (65%) presented with a chronic symptomatic biliary lithiasis and 159 patients (35%) with a complicated biliary lithiasis. A preoperative ERCP was performed in 206 patients, all presenting with a suspicion of associated lithiasis of the common bile duct (CBD). An endoscopic sphincterotomy was performed in 106 patients: 44 patients presented with CBD stones (9.7%), all successfully cleared by endoscopy. Laparoscopic cholecystectomy has been attempted in 367 patients (81%) and successfully performed in 333 patients (74%). Laparotomy as a first-choice procedure was performed in 85 patients (19%). Surgical choledochotomy was never performed. Postoperative ERCP was needed in 4 patients (0.88%) and in only 1 of them for a retained CBD stone (0.22%). CONCLUSIONS: In a continuous series of patients needing a cholecystectomy, preoperative ERCP was performed on the basis of suspected CBD disorders. It allows CBD stone detection and extraction in almost 10% of the patients and avoids peroperative CBD exploration, with a very low rate of retained stones after surgery. The association of preoperative ERCP with subsequent laparoscopic cholecystectomy (when feasible) offers the patient a quick recovery and a short hospital stay.

Adult↗

PubMed1997

Cholecystectomy following the introduction of laparoscopy: more, but for the same indication.

To assess whether indications for cholecystectomy might have changed after the introduction of laparoscopic cholecystectomy (LC), the data from patients undergoing cholecystectomy at the University of South Alabama Medical Center during 1988 (before LC) and 1993 (after the introduction of LC) were retrospectively analyzed and compared. In 1993, the number of patients undergoing cholecystectomy for gallstone-related disease was 18 per cent higher than in 1988 (87 vs 103, 1.4 per cent of all noncardiac operations vs 2.7 per cent, Chi square; P = 0.003). There was no difference in the mean Preoperative Severity Index, a quantitative evaluation of symptom complex, preoperative laboratory evaluation, and radiological findings. Besides obesity, there were also no differences between the groups in associated comorbidities that might affect the decision to proceed with operation. Furthermore, pathologic findings, including the distribution of patients with gallstone pancreatitis, symptomatic cholelithiasis, chronic cholecystitis, and acute cholecystitis, were similar in both groups. The indications for cholecystectomy did not broaden after the introduction of LC, but rather, more patients with similar indications are undergoing cholecystectomy now, as compared with the pre-laparoscopic era.

Alabama↗

PubMed1997

Progress with cholecystectomy: improving results in England and Wales.

BACKGROUND: The Comparative Audit Service of the Royal College of Surgeons of England studied laparoscopic cholecystectomy in England and Wales during 1990-1991. The follow-on study undertaken during 1994 provides data to assess progress. METHODS: Pro formas were sent to consultant surgeons, requesting data on open and laparoscopic cholecystectomies performed in their units during 1994 with data on mean stay, mortality, complications, and the use of peroperative cholangiography and bile duct exploration. The identity of the consultants was treated confidentially. RESULTS: Data were provided by 110 surgeons on 4823 cholecystectomies (1019 open and 3804 laparoscopic) and outcome was compared with that of 3319 attempted laparoscopic and 8035 open cholecystectomies carried out during 1990-1991. The proportion of cases attempted laparoscopically rose from 27.2 per cent in 1990-1991 to 78.9 per cent in 1994, and conversion to open cholecystectomy rose from 5.3 to 6.7 per cent respectively. During 1994 peroperative cholangiography was undertaken in 22.9 per cent of laparoscopic and 44.6 per cent of open cases. Complication rates were similar in the two study periods, except the number of reported haemorrhagic complications was reduced by 40 per cent and bile duct injuries by fivefold (from 0.33 to 0.07 per cent). CONCLUSION: During 1994 the audit sampled approximately 10 per cent of all cholecystectomies performed in England and Wales. The results suggest progress in surgical techniques compared with findings in 1990-1991.

Cholangiography↗

PubMed1998

[Response of interleukin-6 in patients undergoing a laparoscopic or laparotomic cholecystectomy].

BACKGROUND: It is well known that surgery induces an acute inflammatory response associated with significant increase of interleukin-6 (IL-6) and C reactive protein (CRP). Laparoscopic cholecystectomy (LC) is a so called "mini-invasive" surgical intervention and on the basis of this consideration it has been investigated if and how serological markers of inflammation are modified in patients after laparoscopic cholecystectomy compared to patients undergoing open cholecystectomy. METHODS: The acute phase of inflammation (IL-6, CRP and body temperature) was evaluated in 53 patients one day before surgery and p.o. after 1, 3 and 6 days; 26 patients underwent "open" cholecystectomy and 27 LC. RESULTS: One day after surgery patients with open cholecystectomy showed significant increase (p < 0.05) of IL-6, CRP and body temperature, while these parameters were almost unchanged in patients with LC. In patients with "open" cholecystectomy, 2 p.o. complications (pneumonia) were observed. CONCLUSIONS: In conclusion, LC, although it requires longer operative time, strongly reduces p.o. pain, hospitalization, promotes earlier recovery and return to normal activity, avoiding the acute phase of p.o. inflammation with better p.o. morbidity compared to open surgery.

Adult↗

PubMed2005

Outcome of laparoscopic cholecystectomy in acute cholecystitis.

OBJECTIVE: To evaluate the outcome of laparoscopic cholecystectomy in acute cholecystitis and to determine various pre-operative risk factors predicting conversion to open cholecystectomy. DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Surgery, Riyadh Medical Complex, Riyadh, Saudi Arabia over 5 years period from June 1, 1997 to May 30, 2002. PATIENTS AND METHODS: Consecutive patients admitted with clinical diagnosis of acute cholecystitis confirmed subsequently by abdominal ultrasonography and undergoing laparoscopic cholecystectomy during the same admission. Patients with symptoms of more than one week duration, or various uncontrolled co-morbid conditions requiring optimization before surgery were excluded. Parameters analyzed were morbidity, mortality, incidence and etiology of conversion. Various pre-operative risk factors predicting failure of laparoscopic procedure in acute cholecystitis were further analyzed. Statistical analyses were carried out employing Chi-square test, using IBM-compatible PC, utilizing SPSS 10.0 for Windows (SPSS Inc., Chicago). RESULTS: Three hundred and eleven patients qualified the inclusion criteria. Mean age was 43.7 years with female to male ratio of 4.5:1. Majority of the patients (91%) were operated within 72 hours of onset of symptoms. Laparoscopic cholecystectomy was successfully accomplished in 86.8 % cases. Out of the 41 converted cases, disturbed anatomy in the region of Calot's triangle was the most common cause of conversion observed in 41.5% patients. Male gender, age more than 65 years, very high leucocyte count, gallbladder wall thickness of more than 4 mm on ultrasonography and complicated disease were observed as most significant determinant for conversion to open procedure. Overall morbidity was 2.9% with no mortality. CONCLUSION: Laparoscopic cholecystectomy can be accomplished with minimal morbidity in acute cholecystitis. Knowledge of various factors predicting possible conversion helps in pre-operative selection and counseling for open procedure and early conversion to open technique, with further reduction in the overall morbidity of laparoscopic cholecystectomy.

Acute Disease↗

PubMed1993

Asymptomatic gallstones revisited. Is there a role for laparoscopic cholecystectomy?

OBJECTIVE: To compare the mortality effects of prophylactic laparoscopic cholecystectomy with that of expectant management in persons with asymptomatic gallstones. DESIGN: Decision analytic models of the two clinical strategies using input data from a review of the published medical literature pertaining to the epidemiology, natural history, and treatment outcomes related to gallstone disease. PATIENTS: Cohorts of men and women aged 30 and 50 years with asymptomatic gallstones. INTERVENTION: Prophylactic laparoscopic cholecystectomy performed at the time of diagnosis of asymptomatic gallstones or expectant management, defined as therapeutic intervention delayed until gallstone symptoms or complications spontaneously develop. MAIN OUTCOME MEASURES: Gallstone-related deaths and gallstone-related life-years lost for each age and gender cohort, by strategy. Models were subjected to rigorous sensitivity analysis to test the robustness of the results to changes in individual input variables. Outcomes were calculated with and without discounting nonfinancial benefits. RESULTS: The prophylactic laparoscopic cholecystectomy strategy led to fewer gallstone-related deaths than the expectant management strategy, but all of the deaths in the prophylactic laparoscopic cholecystectomy group occurred earlier in life. In cohorts older than age 30 years, the expectant management strategy resulted in fewer undiscounted gallstone life-years lost than the prophylactic laparoscopic cholecystectomy strategy. Discounting favored expectant management further because life-years lost were delayed compared with prophylactic surgery. Sensitivity analysis demonstrated the superiority of expectant management over a wide range of input assumptions. CONCLUSIONS: Prophylactic laparoscopic cholecystectomy should not be routinely recommended for individuals with asymptomatic gallstones.

Adult↗

PubMed1992

Bile leak after laparoscopic cholecystectomy. Diagnostic and therapeutic application of endoscopic retrograde cholangiopancreatography.

BACKGROUND: Laparoscopic cholecystectomy, introduced less than 2 years ago, is widely accepted by patients and physicians despite the lack of controlled trials comparing this technology with conventional cholecystectomy. Recent series have described a variable incidence of biliary tract injury with laparoscopic gallbladder removal. The primary interaction of endoscopic retrograde cholangiopancreatography with this technology is usually in the preoperative or postoperative diagnosis and treatment of common bile duct stones. METHODS: During a 12-month period, 597 patients underwent laparoscopic cholecystectomy by 20 general surgeons at six Puget Sound (Wash) hospitals. All patients with symptomatic postoperative biloma diagnosed by abdominal ultrasound or computed tomography with or without endoscopic retrograde cholangiopancreatography, as well as those who had acute bile duct injury diagnosed and repaired at the time of cholecystectomy, were retrospectively reviewed. RESULTS: Three bile duct transections were acutely recognized and treated with hepaticojejunostomy. Fourteen additional patients presented within 7 days with biloma, three of whom were treated with percutaneous drainage alone. Of the remaining 11 patients who underwent endoscopic retrograde cholangiopancreatography, six were noted to have common bile duct injuries; two, bile duct transections; and 3, cystic duct leaks that required a variety of endoscopic or surgical therapies. In all, 17 (2.9%) of 597 patients sustained a bile duct injury and, to date, seven (1.2%) of 597 patients required surgery for such injury. CONCLUSIONS: In a regional setting, laparoscopic cholecystectomy appears to be associated with a higher incidence of bile duct injury than previous reports of open cholecystectomy. Possible explanations include variant anatomy plus failure to obtain an operative cholangiogram, inadequate dissection, injudicious use of cautery or clip placement, inherent limitations of the procedure, or the learning curve associated with a new technology.

Bile↗

PubMed2000

Relationship between persistence of abdominal symptoms and successful outcome after cholecystectomy.

BACKGROUND: Patients frequently have persistent abdominal symptoms after undergoing cholecystectomy. The relationship between abdominal symptoms and biliary dysfunction is often unclear. OBJECTIVES: To describe the persistence rate of abdominal symptoms in a large cohort of patients after elective cholecystectomy, to identify predictors of symptom persistence and operative success, to understand which symptoms improve after cholecystectomy, and to describe the important determinants of an unsuccessful operation. METHODS: Secondary analysis of a prospective, multisite cohort study of 2481 patients undergoing elective cholecystectomy. RESULTS: The mean +/- SD number of abdominal symptoms per patient decreased from 3.1 +/- 2.0 to 1.1 +/- 1.3; 27% of patients who identified a symptom as most bothersome before surgery still had the symptom 6 months after surgery. Symptom persistence rates ranged from 5.6% (vomiting) to 40.2% (gas/flatulence). A balance score that quantified the abdominal symptom mix between dyspeptic and biliary symptoms shifted after surgery to the dyspeptic category. Predictors of persistence of a most bothersome symptom were dyspeptic symptom category, worse operative risk and self-rated health status, symptom duration longer than 6 months, and no previous episodes of acute cholecystitis. The major correlate of not achieving a very successful outcome (15.2% of patients) was the presence of postoperative abdominal pain. Other predictors included worse self-rated health status and physical functioning, symptom duration longer than 6 months before surgery, and no previous episodes of acute cholecystitis. CONCLUSIONS: Symptoms categorized as dyspeptic were more likely to persist than were biliary symptoms, although all symptoms showed a decrease in prevalence after cholecystectomy. More attention to the rationale for gallbladder removal and clarification of patient expectations for symptom relief might be necessary to improve outcomes after elective cholecystectomy.

Adolescent↗

PubMed1983

Cholecystectomy concomitant with other intra-abdominal operations. Assessment of risk.

In a retrospective study, 1,416 cholecystectomies performed during a three-year period were reviewed to define the risk of cholecystectomy when combined with another intra-abdominal procedure. Group 1, cholecystectomy alone (1,148 patients), with subsets of cholangiography and/or common bile duct exploration, had a complication rate of 14.29% and a mortality of 0.52%. Group 2, primary cholecystectomy combined with secondary intra-abdominal surgery (214 patients), had a complication rate of 19.63%. Group 3, primary intra-abdominal surgical procedure with incidental cholecystectomy (54 patients), had a complication rate of 20.37%. Mortality for groups 2 and 3 was 2.24%. The rate of nonfatal complications was increased slightly when a second surgical procedure was performed (14.29% v 19.78%). Pairing cholecystectomy with other intra-abdominal surgery is advised only when surgical exposure is adequate, the patient's condition is satisfactory, and operating time is not prolonged greatly.

Abdomen↗

PubMed1996

Factors affecting conversion of laparoscopic cholecystectomy to open surgery.

OBJECTIVE: To identify the risk factors predictive of conversion of laparoscopic cholecystectomy to open surgery. DESIGN: Demographic, ultrasonographic, and operative data of patients who underwent laparoscopic cholecystectomy were analyzed. Factors affecting conversion to open surgery were identified with statistical analysis. SETTING: A tertiary referral center. PATIENTS: Five hundred patients who underwent laparoscopic cholecystectomies at our institution between March 1991 and July 1994. The patients' data had been prospectively collected. INTERVENTION: Standard laparoscopic techniques with selective preoperative endoscopic retrograde cholangiopancreatography. MAIN OUTCOME MEASURE: Conversion of laparoscopic cholecystectomy to open surgery for management of technical difficulties or intraoperative complications. RESULTS: Increased risk of conversion with statistical significance was found in patients older than 65 years, obese patients, patients who underwent interval elective laparoscopic cholecystectomy for acute cholecystitis, patients with ultrasonographic findings of thickened gallbladder wall, patients seen during the early learning phase of the series, and patients whose surgery was performed by senior surgeons. Increased risk of conversion was not found with patients' sex, previous lower abdominal surgery, history of acute pancreatitis or cholangitis, impaired liver function on presentation, or emergency laparoscopic cholecystectomy for acute cholecystitis. CONCLUSIONS: Risk factors, including patient factors, presentation, preoperative ultrasonography, and surgical experience, all contributed to the possibility of conversion. Knowledge of these factors may help in arranging the operating schedule, psychological preparation for the procedure, and planning of the duration of convalescence.

Adult↗