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PubMed2002

[Outpatient laparoscopic cholecystectomy].

UNLABELLED: OUTPATIENT LAPAROSCOPIC CHOLECYSTECTOMY: The laparoscopic technique is the procedure of choice for cholecystectomy. This procedure is done on ambulatory setting in the United States and Europe but no experience was reported in France. AIM OF THE STUDY: To report the organisation and results of our initial 100 consecutive patients operated for a laparoscopic cholecystectomy on an outpatient basis. PATIENTS AND METHODS: After assessment of the prevention of pain and nausea or vomiting after laparoscopic cholecystectomy on hospitalized patients, a prospective trial was done on our first 100 patients for outpatient laparoscopic cholecystectomy on routine basis. RESULTS: During the period, 27.4% of patients were entered on an ambulatory basis. 72% of patients did not need any medication post-operatively in the structure. 17 patients were admitted: in five cases, decision was done pre-operatively, one patient went back home against medical advising; in three cases, peroperatively, and in 10 cases postoperatively. Four patients were readmitted between the fifth and sixteenth post-operatoire day. CONCLUSION: An adequate organisation for day case surgery, a good selection of patients on medical, surgical and environmental criteria, simple procedures to prevent pain or nausea vomiting post-operatively allow use to assert that hospitalisation is unjustified for laparoscopic cholecystectomy in a quater of patients.

Adult↗

PubMed2006

[Utility of magnetic resonance cholangiography prior to cholecystectomy in acute biliary pancreatitis].

AIM: To analyze the role of magnetic resonance cholangiography (MRC) in candidates for cholecystectomy after acute biliary pancreatitis (ABP). METHODS: We performed a prospective study of patients with mild ABP (Atlanta criteria) admitted to our hospital from January 2004 to March 2005. Diagnosis of ABP was based on clinical features, serum amylase levels more than 3 times higher than the upper level of normality, and gallstones detected by ultrasonography. In all patients, MRC was performed preoperatively. If positive for common bile duct stones (CBDS), endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) was performed, followed by laparoscopic cholecystectomy (LC). When MRC was negative, LC was performed directly. Intraoperative cholangiography was not routinely performed . RESULTS: Of the 31 patients admitted, 27 were included (mean age 66.4 +/- 18 years, 78% female). Four patients were excluded: 2 refused to undergo cholecystectomy and two had severe ABP. The mean interval between onset of ABP and cholecystectomy was 1.7 months +/- 1.2. Three patients (11.1%) experienced recurrence within 4 weeks of the index admission. MRC revealed CBDS in four patients (14.8%). In 3 patients, all the gallstones were removed by ERCP and ES. In one patient, 12 gallstones were retrieved but attempts to remove a stone from the cystic duct were unsuccessful. One patient with preoperative CBDS was readmitted 4 weeks after cholecystectomy due to recurrence. Another patient with negative findings on preoperative MRC was also readmitted with postcholecystectomy ABP. Twenty-five of the 27 patients (93%) have remained asymptomatic after cholecystectomy (median follow-up: 16 months [8-22 months]). CONCLUSIONS: MRC should not be routinely used in the preoperative evaluation of patients with ABP but is an accurate tool in selected patients with this disease.

Acute Disease↗

PubMed1997

The management of choledocholithiasis in children in the era of laparoscopic cholecystectomy.

Although laparoscopic cholecystectomy has become the procedure of choice for gallbladder removal in children, the treatment of children who have choledocholithiasis remains unclear. For adults who have suspected choledocholithiasis, preoperative endoscopic retrograde cholangiopancreatography (ERCP) is a well-described and effective approach, however, its use for common bile duct stones in children has not been defined. The authors reviewed the records of 131 consecutive children undergoing laparoscopic cholecystectomy on two surgical services to define the efficacy of ERCP followed by laparoscopic cholecystectomy in managing choledocholithiasis in children. Fourteen children were suspected of having common duct stones noted on preoperative ultrasound scan and laboratory data. At ERCP, six children had no stones visualized; eight had stones and underwent stone extraction and sphincter dilation or sphincterotomy. All 14 underwent laparoscopic cholecystectomy a mean of 3.8 days after ERCP. None of the 14 had evidence of retained stones. Only one of 117 children undergoing primary laparoscopic cholecystectomy had unsuspected common bile duct stones and was treated with laparoscopic common bile duct exploration and stone removal. A management plan incorporating ERCP followed by early laparoscopic cholecystectomy is a safe and effective strategy for children who have choledocholithiasis.

Adolescent↗

PubMed2004

Impact of the case payment reimbursement method on the utilization and costs of laparoscopic cholecystectomy.

The purpose of this study was to examine the relationship between adoption of case payment for laparoscopic cholecystectomy (LC) and the growth rate of LC, outcomes of patients undergoing LC, and total healthcare expenditures on cholecystectomy. We used the claims data from Bureau of National Health Insurance (BNHI) to identify patients who underwent LC and open cholecystectomy (OC). Data were available from January 1996 to October 1997 and from January 1998 to October 1999, enabling use to compare data from before and after the introduction of the new case payment system. Results showed that the volume and the proportion of LCs increased after adoption of the new payment method. We did not find a sharp increase in the cholecystectomy rate during the study period. In terms of outcomes, the admission rate for emergencies decreased; the surgery mortality rate decreased, but the readmission rate increased. The average cost and length of hospital stay for LC subjects decreased; however, the total cost of cholecystectomy increased. The impact on LC of the introduction of a case payment method failed to reduce total health expenditures for cholecystectomy.

Adolescent↗

PubMed2005

Cancer after cholecystectomy: record-linkage cohort study.

We investigated whether cholecystectomy is associated with subsequent cancer and, if so, whether the association is likely to be causal, by undertaking a retrospective cohort study using linked medical statistics, comprising a cholecystectomy group (n=39 254) and a reference cohort admitted for a range of other medical and surgical conditions (n=334 813). We found a short-term significant elevation of rates of cancers of the colon, pancreas, liver, and stomach after cholecystectomy, but no long-term elevation. Excluding colon cancers within 2 years of admission to hospital, the rate ratio for colon cancer after cholecystectomy, compared with the reference cohort, was 1.01 (95% confidence interval 0.90-1.12) and after 10 years or more follow-up it was 0.94 (0.79-1.10). It is highly improbable that the short-term associations between cholecystectomy and gastrointestinal cancers are causal, and we conclude that cholecystectomy does not cause cancer.

Adult↗

PubMed1999

Gallstones, cholecystectomy and risk of cancers of the liver, biliary tract and pancreas.

To examine the association between gallstones and cholecystectomy, we conducted a nationwide population-based cohort study in Denmark. Patients with a discharge diagnosis of gallstones from 1977 to 1989 were identified from the Danish National Registry of Patients and followed up for cancer occurrence until death or the end of 1993 by record linkage to the Danish Cancer Registry. Included in the cohort were 60 176 patients, with 471 450 person-years of follow-up. Cancer risks were estimated by standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) stratified by years of follow-up and by cholecystectomy status. Among patients without cholecystectomy, the risks at 5 or more years of follow-up were significantly elevated for cancers of liver (SIR = 2.0, CI = 1.2-3.1) and gallbladder (SIR = 2.7, CI = 1.5-4.4) and near unity for cancers of extrahepatic bile duct (SIR = 1.1), ampulla of Vater (SIR = 1.0) and pancreas (SIR = 1.1). The excess risk of liver cancer was seen only among patients with a history of hepatic disease. Among cholecystectomy patients, the risks at 5 or more years of follow-up declined for cancers of liver (SIR = 1.1) and extrahepatic bile duct (SIR = 0.7), but were elevated for cancers of ampulla of Vater (SIR = 2.0, CI = 1.0-3.7) and pancreas (SIR = 1.3, CI = 1.1-1.6). These findings confirm that gallstone disease increases the risk of gallbladder cancer, whereas cholecystectomy appears to increase the risk of cancers of ampulla of Vater and pancreas. Further research is needed to clarify the carcinogenic risks associated with gallstones and cholecystectomy and to define the mechanisms involved.

Aged↗

PubMed2001

Duodenogastric reflux following cholecystectomy in the dog: role of antroduodenal motor function.

BACKGROUND: Duodenogastric reflux has been implicated in the pathogenesis of gastric ulcer and gastritis. Duodenogastric reflux after cholecystectomy is also a possible cause of post-cholecystectomy syndrome. AIM: To investigate the role of antroduodenal motor function in increased duodenogastric reflux following cholecystectomy and the effect of trimebutine maleate (trimebutine) on the duodenogastric reflux in conscious dogs. METHODS: Antropyloric and duodenal motility and bile acids content in the gastric juice were measured for 3 h during the inter-digestive state in dogs with or without cholecystectomy. RESULTS: Bile acids content in the gastric juice of cholecystectomized dogs was significantly higher than that of non-cholecystectomized dogs. The frequency of pyloric relaxation during phase II of the migrating motor complex was significantly increased following cholecystectomy. Intravenous infusion of trimebutine inhibited both the increased duodenogastric reflux and the frequency of pyloric relaxation in the cholecystectomized dog. CONCLUSION: Duodenogastric reflux and frequency of pyloric relaxations were increased in cholecystectomized dogs and trimebutine suppressed both of them. These findings suggest that the increased frequency of pyloric relaxation contributes to the duodenogastric reflux following cholecystectomy.

Animals↗

PubMed2003

Systematic review and meta-analysis: does gall-bladder ejection fraction on cholecystokinin cholescintigraphy predict outcome after cholecystectomy in suspected functional biliary pain?

BACKGROUND: Patients with suspected functional biliary pain often undergo cholecystectomy if a decreased gall-bladder ejection fraction (GBEF <35%) is demonstrated by cholecystokinin cholescintigraphy. However, the validity of GBEF in predicting which patients will have symptomatic relief following cholecystectomy is unclear. AIM: To determine whether patients with suspected functional biliary pain with decreased GBEF have a better symptomatic outcome after cholecystectomy than those with normal GBEF. METHODS: Systematic review and meta-analysis of the published literature through MEDLINE and EMBASE databases. RESULTS: We included nine studies with a total of 974 patients with suspected functional biliary pain; 362 patients underwent cholecystectomy. Most studies assessed outcome by direct patient interview. Mean ages across the studies ranged from 35 to 47 years; 78% of all patients were female. Mean duration of follow-up after surgery ranged from 1 to 2.5 years. After cholecystectomy, 94% of the patients with reduced GBEF had a positive outcome compared to 85% among those with normal GBEF. The pooled Mantel-Haenszel odds ratio for positive outcome was 1.37 (95% confidence interval 0.56-3.34), P=0.56. CONCLUSION: These data do not support the use of GBEF to select patients with suspected functional biliary pain for cholecystectomy. Prospective randomized trials are required if this practice is to be evidence-based.

Cholecystectomy↗

PubMed1998

Prophylactic splenectomy and cholecystectomy in mild hereditary spherocytosis: analyzing the decision in different clinical scenarios.

OBJECTIVES: Patients with mild hereditary spherocytosis (HS), i.e. with haemolysis without anaemia. have an increased risk of gallstone formation, erythroid aplasia and haemolytic crisis. Since the effect of prophylactic splenectomy on life expectancy has not been established, we conducted a decision analysis comparing prophylactic splenectomy and cholecystectomy with no surgery. DESIGN: The available data on surgery and disease outcomes were modelled to estimate the effects of the different interventions on the quality-adjusted life expectancy. The early phase outcomes depicted surgery-related mortality and incorporated compliance and the adverse effects of prophylaxis against post splenectomy infections. The late phase outcomes were framed by a Markov cohort analysis. RESULTS: For patients without gallstones, surgery was of no benefit. For those with gallstones the preferred strategies were found to be splenectomy and cholecystectomy before the age of 39 when asymptomatic, and before 52 when accompanied by occasional biliary colic. Cholecystectomy alone proved to be the preferred strategy in older patients with occasional biliary colic. For patients of up to 52 years of age and candidates for cholecystectomy because of recurrent biliary colic, the best strategy was to combine this procedure with splenectomy. Sensitivity analysis showed that the results were sensitive to the incidence of post cholecystectomy syndrome. Most remarkably an extreme sensitivity to compliance with post splenectomy infection prophylaxis was demonstrated. CONCLUSIONS: Our model suggested that combined prophylactic splenectomy and cholecystectomy provide a substantial gain in quality-adjusted life expectancy for young patients and adults with mild HS and gallstones.

Adolescent↗

PubMed1999

Sphincter of Oddi manometry before and after laparoscopic cholecystectomy.

BACKGROUND AND STUDY AIMS: In animal studies cholecystectomy has been found to alter the normal effect of cholecystokinin (CCK) on sphincter of Oddi (SO) function. This could be of importance with regard to the development of postcholecystectomy biliary pain. We therefore investigated the effect of laparoscopic cholecystectomy on SO motility before and after infusion with CCK. PATIENTS AND METHODS: A prospective study of SO motility, under basal conditions and during CCK (ceruletide) infusion, was carried out in eight women with uncomplicated gallstone disease, before and after laparoscopic cholecystectomy. RESULTS: Laparoscopic cholecystectomy increased common bile duct pressure (P = 0.01) and decreased the frequency of phasic contractions (P=0.05). However, the inhibitory effect of CCK was preserved as infusion of CCK was associated with a significant reduction in SO phasic amplitude and frequency, both before and after cholecystectomy. CONCLUSIONS: Following laparoscopic cholecystectomy an indisputable inhibitory effect of CCK in the SO was found. Common bile duct pressure increased and minor modifications in basal SO motility were seen.

Ceruletide↗

PubMed2004

Insufficient cholecystectomy diagnosed by endoscopic ultrasonography.

Recurrent attacks of upper right quadrant pain after cholecystectomy are not infrequent. In most of these cases, the cause of the pain remains undiagnosed. Insufficient cholecystectomy has been described as a rare cause of post-cholecystectomy pain, although the true incidence is unknown. It is difficult to diagnose a residual gallbladder or a large cystic duct with residual stones, due to the size of the remaining structures. This report presents three patients who had experienced a long period of agonizing biliary-type pain after cholecystectomy. Abdominal ultrasound examinations, and magnetic resonance cholangiopancreatography (MRCP) in one patient, were normal. Endoscopic ultrasonography (EUS) demonstrated the presence of a small cystic structure with echogenic foci compatible with a residual gallbladder containing small gallstones. Two of the three diagnoses were confirmed by repeat surgery. EUS thus appears to be a valuable method for diagnosing insufficient cholecystectomy, and should be considered in patients with persistent pain attacks after cholecystectomy.

Cholecystectomy↗

PubMed1991

[Laparoscopic cholecystectomy and continuing surgical education].

The rapid spread of laparoscopic cholecystectomy as standard operative treatment of cholelithiasis raises the question whether this new technique can be learned as prescribed for the traditional training of surgeons. To answer this question traditional methods of instruction were used for the first consecutive 100 laparoscopic cholecystectomies after the instructors had seen the method elsewhere and learned by operations on animals. 15 surgeons operated on these 100 patients (23 men and 77 women; mean age 50 [20-79] years). In accordance with the concept of early integration of laparoscopic cholecystectomy into surgical training, two trainee surgeons who had not yet performed a conventional cholecystectomy also took part in laparoscopic cholecystectomies. There were one serious (damage to the hepatocholedochal duct) and two mild (postoperative colics) complications. The median duration of operation was 95 (30-240) min. In eight patients the intervention was continued as a conventional cholecystectomy. This experience demonstrates that training in laparoscopic surgery can follow the same path as that for conventional surgery. A prerequisite is responsible assistance by an experienced operator, after the method has been introduced into the hospital.

Cholecystectomy↗

PubMed1991

A prospective analysis of 1518 laparoscopic cholecystectomies.

BACKGROUND AND METHODS: The Southern Surgeons Club conducted a prospective study of 1518 patients who underwent laparoscopic cholecystectomy for treatment of gallbladder disease in order to evaluate the safety of this procedure. RESULTS: Seven hundred fifty-eight operations (49.9 percent) were performed at academic hospitals, and 760 (50.1 percent) at private hospitals. In 72 patients (4.7 percent) the operation was converted to conventional open cholecystectomy; the most common reason for the change was the inability to identify the anatomy of the gallbladder as a result of inflammation in the region of this organ. A total of 82 complications occurred in 78 (5.1 percent) of the patients; this is comparable with the rates of 6 to 21 percent that have been reported for conventional cholecystectomy. Overall, the most common complication was superficial infection of the site of insertion of the umbilical trocar. A total of seven injuries to the common bile duct or the hepatic duct occurred during the operation, for a rate of 0.5 percent. Four of the seven injuries were simple lacerations, which were repaired after conversion to conventional cholecystectomy. The incidence of bile-duct injury in the first 13 patients operated on by each surgical group was 2.2 percent, as compared with 0.1 percent for subsequent patients. No complications were attributed directly to either cautery or laser-surgical technique, and similar numbers of complications occurred in academic and private hospitals. The mean hospital stay for the entire group was 1.2 days (range, 6 hours to 30 days). CONCLUSIONS: The results of laparoscopic cholecystectomy compare favorably with those of conventional cholecystectomy with respect to mortality, complications, and length of hospital stay. A slightly higher incidence of biliary injury with the laparoscopic procedure is probably offset by the low incidence of other complications.

Adolescent↗

PubMed1999

Recreational physical activity and the risk of cholecystectomy in women.

BACKGROUND: Physical activity may be an important determinant of the risk of gallstone disease in women, both independently and as a result of its role in maintaining body weight. METHODS: We prospectively studied recreational physical activity (such as jogging, running, and bicycling) and sedentary behavior (such as spending hours watching television) in relation to the risk of cholecystectomy, a surrogate for symptomatic cholelithiasis, in a cohort of 60,290 women who were 40 to 65 years of age in 1986 and had no history of gallstone disease. As part of the Nurses' Health Study, the women reported on questionnaires mailed to them every two years both their activity level and whether they had undergone cholecystectomy. During a 10-year follow-up period (1986 to 1996), 3257 cases of cholecystectomy were documented. RESULTS: Recreational physical activity was inversely related to the risk of cholecystectomy. The multivariate relative risk for women in the highest as compared with the lowest quintile of physical activity was 0.69 (95 percent confidence interval, 0.61 to 0.78). In contrast, sedentary behavior was independently related to an increased risk of cholecystectomy. As compared with women who spent less than 6 hours per week sitting while at work or driving, women who spent 41 to 60 hours per week sitting had a multivariate relative risk of 1.42 (95 percent confidence interval, 1.06 to 1.89), and women who spent more than 60 hours per week sitting while at work or driving had a multivariate relative risk of 2.32 (95 percent confidence interval, 1.26 to 4.26). These associations persisted after we controlled for body weight and weight change. CONCLUSIONS: In women, recreational physical activity is associated with a decreased risk of cholecystectomy. The association is independent of other risk factors for gallstone disease, such as obesity and recent weight loss.

Adult↗

PubMed2001

MR imaging of upper abdomen following cholecystectomy. Normal and abnormal findings.

PURPOSE: To describe the normal MR appearance after cholecystectomy and the findings in patients with postoperative complications using fast pulse sequences in abdominal MR imaging. MATERIAL AND METHODS: In a prospective study of 119 patients, 64 were examined with MR after cholecystectomy. In total, 56 patients with uncomplicated cholecystectomy were examined with MR 1--5 days (mean 1.6 days) after cholecystectomy. Nine patients had an abdominal postoperative complication and 8 of these were examined with MR after the complication commenced 1--12 days after the cholecystectomy. RESULTS: Oedema in the gallbladder fossa was the only finding in 39 patients (61%), all with uneventful recovery. Small fluid collections in an area consistent with the gallbladder fossa were seen in 9/64 (14%) patients, of which 3 had surgical complications: 1 bleeding and 2 bile duct leakage. Twenty-two (34%) patients had small locally situated fluid collections adjacent to the liver, 14 were uneventful and 8 showed postoperative surgical complications. Seven patients had fluid in the rest of the abdomen of which 5 had surgical complications; 4 due to bile duct leakage and 1 acute pancreatitis. One patient had a postoperative bleeding not seen on MR images. CONCLUSION: MR is very sensitive in detecting fluid collections. Early MR findings following cholecystectomy are normally only subtle changes, mainly in the gallbladder fossa. Fluid collections diagnosed elsewhere than in the gallbladder fossa usually indicate a surgical complication and a surgical complication is unlikely if MR fails to show a fluid collection.

Abdomen↗

PubMed1999

Port site metastases from gallbladder cancer after laparoscopic cholecystectomy. Results of a Swedish survey and review of published reports.

OBJECTIVE: To investigate the incidence of port site metastases from unsuspected gallbladder cancer after laparoscopic cholecystectomy. DESIGN: Retrospective national multicentre study, 1991-94. SETTING: All 8 university and 24 central hospital, Sweden. SUBJECTS AND INTERVENTIONS: All 32 hospitals were interviewed by means of a written questionnaire. The registers of all Swedish Oncological Centres and the registers of the National Board of Health and Welfare were checked for reported cases of gallbladder cancer and surgical classification codes for cholecystectomy. To detect laparoscopic interventions incorrectly registered as open operations, all cholecystectomies registered as open were matched against the Swedish Registry of Laparoscopic Cholecystectomy for the years 1991-93 and all patients records for 1994 were scrutinised. RESULTS: Replies were obtained from 30/32 clinics (94%) and 11976 laparoscopic cholecystectomies were done. Of 447 patients with verified gallbladder carcinoma 270 had their gallbladders removed, 55 (20%) laparoscopically. 9 of these (16%) developed port site metastases and 6 died from their disease at a median of 18 months (range 5-22). Two patients are alive, 54 and 45 months after cholecystectomy. One patient has been lost to follow-up. CONCLUSIONS: Port site metastases from gallbladder cancer may be more common than previously thought. A laparoscopic procedure should not be done if cancer of the gallbladder is suspected.

Adult↗

PubMed2001

Pericholecystic adhesions in single v multiple gallstones and their consequences for laparoscopic cholecystectomy.

BACKGROUND: Adhesions are amongst the common reasons for open conversion of laparoscopic cholecystectomy. It is not clear whether this problem is more common with single or multiple gallstones. PATIENTS AND METHODS: The clinical records of 110 patients with chronic cholelithiasis harboring multiple stones in the gallbladder (multiple stone group; MSG) and 45 patients with single stones in the gallbladder (SSG) undergoing laparoscopic cholecystectomy were analyzed for differences in the clinical presentation and outcome with special reference to the incidence of pericholecystic adhesions, size of the stones, and their implications for conversion and complications. RESULTS: Patients in the SSG had a significantly higher incidence of dense pericholecystic adhesions in the region of the porta hepatis (P = 0.003). Eleven patients in the SSG (24.4%) were converted to open cholecystectomy. Dense pericholecystic adhesions around the porta hepatis alone contributed to nine of these conversions (81.8%). The size of the stones was significantly greater (P < 0.001) in those patients of the SSG who required conversion to open cholecystectomy. Thirteen patients of the MSG (11.8%) required conversion to open cholecystectomy. Dense pericholecystic adhesions alone contributed to conversion in four cases (30.7%), and the size of the gallstones was not significantly different (P = 0.981) in patients with or without conversion to open cholecystectomy. There was no difference in the clinical presentation or complications in the two groups of patients. CONCLUSION: Dense adhesions in the porta hepatis are significantly more common in patients with single stones and are the most common reason for open conversion.

Adult↗

PubMed2006

Role of fundus-first laparoscopic cholecystectomy in the management of acute cholecystitis in elderly patients.

BACKGROUND: Conversion from laparoscopic cholecystectomy to open cholecystectomy leads to the loss of the advantages of this minimally invasive procedure and significantly increases length of hospital stay as well as cost. The conversion from laparoscopic to open cholecystectomy is more frequent among patients with acute cholecystitis and in elderly patients. This study evaluated whether fundus-first laparoscopic cholecystectomy could lower the conversion rate in geriatric patients with acute cholecystitis. MATERIALS AND METHODS: During a twelve-month period, 112 patients (36 of them age 65 years or older) underwent fundus-first laparoscopic cholecystectomy for acute cholecystitis in a tertiary care university hospital in central Taiwan. RESULTS: The conversion rate in the elderly patients was 2.7% (1/36). No major perioperative complications were observed. Minor complications--port-site infection and subhepatic fluid collection-occurred in two patients (5.5%). CONCLUSION: Laparoscopic cholecystectomy with a fundus-first approach is a safe, effective operative procedure for elderly patients with acute cholecystitis when performed by an experienced laparoendoscopic surgeon.

Aged↗