Patient Experience With Gallstone Disease in a National Health Service District Hospital

Background:

The prevalence of gallstone disease in the community makes it an important area of service in district general hospitals. Laparoscopic surgical techniques in synergy with modern imaging and endoscopic and interventional techniques have revolutionized the treatment of gallstone disease, making it possible to provide prompt and definitive care to patients.

Methods:

Patients with gallstone disease were treated based on a predetermined protocol by a special-interest team depending on the patient''s mode of presentation. Data were collected and analyzed prospectively.

Results:

Our team treated 1332 patients with gallstone disease between September 1999 and December 2007. Patients (249) with acute symptoms presented through Accident and Emergency (A&E). Despite varied presentations, laparoscopic treatment was possible in all but 8 patients. The study comprised 696 patients who underwent laparoscopic cholecystectomy (LC) as in-hospital (23 hour) cases in a stand-alone center, and 257 outpatients and 379 inpatients. Sixty-seven patients with acute cholecystitis had their surgery within 96 hours of acute presentation. Seventy patients had laparoscopic subtotal cholecystectomy. The overall morbidity was 2.33% with 3 patients having residual common bile duct stones; 3 patients had biliary leak from cystic or accessory duct stumps and one had idiopathic right segmental liver atrophy; 19 had wound infections, 5 had port-site hernia. No mortalities occurred during the 30-day follow-up.

Conclusion:

We believe that prompt investigation with imaging and endoscopic intervention if needed along with LC at the earliest safe opportunity by a specialized dedicated team represents an effective method for treating gallstone disease in district general hospitals. Our experience with over 1000 patients has offered us the courage of conviction to say that justice is finally here for gallstone sufferers.     

Definitive management of gallstone pancreatitis in England

INTRODUCTION

The aim of this study was to investigate whether definitive treatment of gallstone pancreatitis (GSP) by either cholecystectomy or endoscopic sphincterotomy in England conforms with British Society of Gastroenterology (BSG) guidelines and to validate these guidelines.

METHODS

Hospital Episode Statistics data were used to identify patients admitted for the first time with GSP between April 2007 and April 2008. These patients were followed until April 2009 to identify any who underwent definitive treatment or were readmitted with a further bout of GSP as an emergency.

RESULTS

A total of 5,454 patients were admitted with GSP between April 2007 and April 2008, of whom 1,866 (34.2%) underwent definitive treatment according to BSG guidelines, 1,471 on the index admission. Patients who underwent a cholecystectomy during the index admission were less likely to be readmitted with a further bout of GSP (1.7%) than those who underwent endoscopic sphincterotomy alone (5.3%) or those who did not undergo any form of definitive treatment (13.2%). Of those patients who did not undergo definitive treatment before discharge, 2,239 received definitive treatment following discharge but only 395 (17.6%) of these had this within 2 weeks. Of the 505 patients who did not undergo definitive treatment on the index admission and who were readmitted as an emergency with GSP, 154 (30.5%) were admitted during the 2 weeks immediately following discharge.

CONCLUSIONS

Following an attack of mild GSP, cholecystectomy should be offered to all patients prior to discharge. If patients are not fit for surgery, an endoscopic sphincterotomy should be performed as definitive treatment.     

Contributing factors to postoperative length of stay in laparoscopic cholecystectomy

Background:

Laparoscopic cholecystectomy for gallbladder disease is a common surgical procedure performed in hospitals throughout the world. This study evaluates the major factors that contribute to postoperative length of stay for patients undergoing laparoscopic cholecystectomy.

Methods:

We analyzed data for patients undergoing laparoscopic cholecystectomy in a 5-hospital community health system from December 1, 2008 to January 31, 2009. The natural logarithm of postoperative length of stay was modeled to evaluate significant factors and contributions.

Results:

Included in the analysis were 232 patients. Three preoperative patient factors were significant contributors: body mass index was associated with decreased postoperative length of stay, while white blood cell count and the presence of biliary pancreatitis were associated with increased postoperative length of stay. The operative factors of fluids administered and ASA class were significant contributors to increased postoperative length of stay, with an increasing contribution with a higher ASA class. The utilization factor of nonelective status was a significant contributor to increased postoperative length of stay.

Conclusion:

Several factors were major contributors to postoperative length of stay, with ASA class and nonelective status having the most significant increased contribution. Efforts to optimize efficient elective care delivery for patients with symptomatic gallbladder disease may demonstrate a benefit of decreased hospital utilization.     

Large subcapsular liver hematoma following single-incision laparoscopic cholecystectomy

Background and Objectives:

Many laparoscopic surgeons are now transitioning from standard multiple-port laparoscopic cholecystectomy to single-incision laparoscopic surgery (SILS) in an attempt to improve cosmetic outcomes and decrease postoperative morbidity. However, little has been published regarding the potential complications of SILS operations.

Methods:

We report the case of a patient undergoing SILS cholecystectomy who developed the complication of a large hepatic hematoma, resulting in significant postoperative morbidity, blood transfusion requirement, and reoperation.

Results:

After an in-depth internal review of the postoperative morbidity of this case, it appears that the causative factor may be instrument shaft torque on the liver surface.

Conclusion:

Single-incision laparoscopic surgery may pose significant and unique risks that warrant additional operative caution. Quantitative comparison of SILS to the gold-standard laparoscopic cholecystectomy is needed to further elucidate definitive benefits and complications of this novel technique.     

Comparative analysis of iatrogenic injury of biliary tract in laparotomic and laparoscopic cholecystectomy

Background

Iatrogenic injury to the bile ducts is the most feared complication of cholecystectomy and several are the possibilities to occur.

Aim

To compare the cases of iatrogenic lesions of the biliary tract occurring in conventional and laparoscopic cholecystectomy, assessing the likely causal factors, complications and postoperative follow-up.

Methods

Retrospective cohort study with analysis of records of patients undergoing conventional and laparoscopic cholecystectomy. All the patients were analyzed in two years. The only criterion for inclusion was to be operative bile duct injury, regardless of location or time of diagnosis. There were no exclusion criteria. Epidemiological data of patients, time of diagnosis of the lesion and its location were analyzed.

Results

Total of 515 patients with gallstones was operated, 320 (62.1 %) by laparotomy cholecystectomy and 195 by laparoscopic approach. The age of patients with bile duct injury ranged from 29-70 years. Among those who underwent laparotomy cholecystectomy, four cases were diagnosed (1.25 %) with lesions, corresponding to 0.77 % of the total patients. No patient had iatrogenic interventions with laparoscopic surgery.

Conclusion

Laparoscopic cholecystectomy compared to laparotomy, had a lower rate of bile duct injury.     

Operative timing of laparoscopic cholecystectomy for acute cholecystitis in a Japanese institute

Background and Objectives:

In patients with acute cholecystitis who cannot undergo early laparoscopic cholecystectomy (within 72 hours), 6 weeks to 12 weeks after onset is widely considered the optimal timing for delayed laparoscopic cholecystectomy. However, there has been no clear consensus about it. We aimed to determine optimal timing for delayed laparoscopic cholecystectomy for acute cholecystitis.

Methods:

Medical records of 100 patients who underwent standard laparoscopic cholecystectomy were reviewed retrospectively. Patients were divided into group 1, patients undergoing laparoscopic cholecystectomy within 72 hours of onset; group 2, between 4 days to 14 days; group 3, between 3 weeks to 6 weeks; group 4, >6 weeks.

Results:

No significant differences existed between groups in conversion rate to open surgery, operation time, blood loss, or postoperative morbidity, and hospital stay. However, total hospital stay in groups 1 and 2 was significantly shorter than that in groups 3 and 4 (P<.01). In addition, the total hospital stay in group 3 was also significantly shorter than that in group 4 (P<.01).

Conclusions:

Best timing of laparoscopic cholecystectomy for acute cholecystitis may be within 72 hours, and the delayed timing of laparoscopic cholecystectomy in patients who cannot undergo early laparoscopic cholecystectomy is probably as soon as possible after they can tolerate laparoscopic cholecystectomy.     

Single-Incision Laparoscopic Combined Cholecystectomy and Appendectomy

Background and Objectives:

Single-incision laparoscopic surgery is becoming more widely used, but few combined procedures have been reported. Herein we share our experience with single-incision laparoscopic combined cholecystectomy and appendectomy.

Methods:

We reviewed data from 26 patients who underwent single-incision laparoscopic combined cholecystectomy and appendectomy between May 1, 2009 and June 1, 2013 at Shengjing Hospital. All the procedures were performed with conventional laparoscopic instruments placed through a single operating portal of entry created within the umbilicus.

Results:

All the operations were successfully completed without conversion to conventional laparoscopic or open surgery. No intraoperative complications occurred. Patients were satisfied with the therapeutic and cosmetic outcomes.

Conclusions:

Single-incision laparoscopic combined cholecystectomy and appendectomy appear to be a technically feasible alternative to the standard laparoscopic procedure in simultaneous management of coexisting benign gallbladder and appendix pathologies. Larger studies are required to confirm these findings.     

Laparoscopic Appendectomy and Cholecystectomy During Pregnancy: Six Case Reports

Background:

Pregnancy was once considered a contraindication to laparoscopic cholecystectomy and appendectomy. The progression of laparoscopic techniques has resulted in a continued reassessment of laparoscopic procedures during pregnancy. There still exists some controversy as to the safety of laparoscopic procedures during pregnancy. This paper reviews our series of six pregnant patients treated laparoscopically for appendicitis and cholecystitis.

Methods:

Charts were reviewed of all pregnant patients who underwent laparoscopic cholecystectomy or appendectomy at St Clare''s Hospital Schenectady, New York between 1992 and 1996. Six patients were identified. Patients and obstetricians were contacted to investigate the results of the pregnancy.

Results:

All patients and fetuses survived the procedure. Two patients delivered prematurely but remote from the operative procedure. All infants were healthy postpartum. One patient underwent an elective abortion as she had planned. The abortion was remote from the surgical procedure.

Conclusion:

Our series adds to the growing evidence that laparoscopic cholecystectomy and laparoscopic appendectomy can be performed safely during pregnancy.     

Laparoscopic Cholecystectomy in Cirrhotic Patients

Background and Objectives:

Gallstones are twice as common in cirrhotic patients as in the general population. Although laparoscopic cholecystectomy (LC) has become the gold standard for symptomatic gallstones, cirrhosis has been considered an absolute or relative contraindication. Many authors have reported on the safety of LC in cirrhotic patients. We reviewed our patients retrospectively and assessed the safety of LC in cirrhotic patients at a tertiary care hospital in Pakistan.

Methods:

From January 2003 to December 2005, a retrospective study was conducted at SU IV, Liaquat University of Medical & Health Sciences Jamshoro. All the cirrhotic patients with Child-Pugh class A and B cirrhosis undergoing LC were included in the study. Cirrhosis was diagnosed based on clinical, biochemical, ultrasonography, and intraoperative findings of the nodular liver and histopathological study.

Results:

Of 250 patients undergoing laparoscopic cholecystectomy, 20 (12.5%) were cirrhotic. Of these 20, 12 (60%) were Childs group A and 8 (40%) were group B. Thirty percent were hepatitis B positive, and 70% were hepatitis C positive. Preoperative diagnosis of cirrhosis was possible in 80% of cases, and 20% were diagnosed during surgery. Morbidity rate was 15% and mortality rate was 0%. Two patients developed postoperative ascites, and mean hospital stay was 2.8±0.1 days. Of the 20 cases, 2 (10%) were converted to open cholecystectomy. The mean operation time was 70.2±32.54 minutes.

Conclusion:

Laparoscopic cholecystectomy is an effective and safe treatment for symptomatic gallstone disease in select patients with Child-Pugh A and B cirrhosis. The advantages over open cholecystectomy are the lower morbidity rate and reduced hospital stay.     

Post-Laparoscopic Vomiting in Females versus Males: Comparison of Prophylactic Antiemetic Action of Ondansetron versus Metoclopramide

Background and Objectives:

The incidence of postoperative vomiting in patients undergoing laparoscopic cholecystectomy is compared in females versus males. The report also compares the prophylactic action of ondansetron versus metoclopramide.

Methods:

A total of 85 American Society of Anesthesiologists (ASA) I and II patients were enrolled in the study. Patients were divided into two groups according to sex: Group I 53 females, and Group II 32 males. After anaesthetic induction, subjects received intravenously either 4 mg ondansetron or 10 mg metoclopramide.

Results:

The incidence of vomiting as well as the frequency of emetic episodes over 24 hours were analyzed in each group using X2 analysis. Data analysis revealed a significantly higher incidence (P<0.05) of postoperative emesis in females 10:53 (18.9%) as compared to males 0:32 (0%). In the male group, no patient vomited postoperatively, whether prophylactic ondansetron or metoclopramide was used. While the incidence of emesis in the female group was lower (P<0.05) in the ondansetron group (17.6%) than the metoclopramide group (29.6%).

Conclusion:

These results may indicate prophylactic antiemetic therapy in female patients undergoing laparoscopic cholecystectomy; ondansetron appears to be superior to metoclopramide.     

Irrigation with bupivacaine at the surgical bed for postoperative pain relief after laparoscopic cholecystectomy

Purpose:

The aim of this study was to evaluate the effect of bupivacaine irrigated at the surgical bed on postoperative pain relief in laparoscopic cholecystectomy patients.

Methods:

This study included 60 patients undergoing elective laparoscopic cholecystectomy who were prospectively randomized into 2 groups. The placebo group (n=30) received 20cc saline without bupivacaine, installed into the gallbladder bed. The bupivacaine group (n=30) received 20cc of 0.5% bupivacaine in at the same surgical site. Pain was assessed at 0, 6, 12, and 24 hours by using a visual analog scale (VAS).

Results:

A significant difference (P=.018) was observed in pain levels between both groups at 6 hours postoperatively. The average analgesic requirement was lower in the bupivacaine group, but this did not reach statistical significance.

Conclusions:

In our study, the use of bupivacaine irrigated over the surgical bed was an effective method for reducing pain during the first postoperative hours after laparoscopic cholecystectomy.     

Is laparoscopic cholecystectomy safe for acute cholecystitis in the presence of ventriculo-peritoneal shunt?

Introduction

In patients with ventriculo-peritoneal shunts, laparoscopic procedures were previously contraindicated for the potential risks of elevating intra-cranial pressure resulting from increased intra-abdominal pressure and shunt malfunction/infection.

Presentation of case

Here we present a case of a patient with ventriculo-peritoneal shunt who successfully and uneventfully underwent laparoscopic cholecystectomy for acute cholecystitis without any shunt manipulation or intra-cranial pressure monitoring.

Discussion

Several methods have been suggested to decrease the risks of increased intra-cranial pressure during laparoscopic cholecystectomy in patients with ventriculo-peritoneal shunts, but have not been routinely used.

Conclusion

Standard technique laparoscopic cholecystectomy can be safely used to manage patients with VP shunts presenting with acute gall bladder disease.     

Angiodysplasia of the gallbladder

Introduction

Angiodysplasia is a term used to describe distinct mucosal vascular ectasias found mainly in the gastrointestinal tract. Angiodysplasia of the gallbladder is exceedingly rare.

Presentation of case

We encountered a patient who presented with biliary colic and subsequently underwent an elective laparoscopic cholecystectomy. The angiodysplasia of the gallbladder was found incidentally on histopathological examination of the excised gallbladder.

Discussion

Review of the literature showed only one other reported case of angiodysplasia of the gallbladder. The condition may be found incidentally after histopathological examination of the gallbladder removed for gallstone; or it may present with haemobilia.

Conclusion

We presented an extremely rare case of angiodysplasia of the gallbladder, which was found incidentally after histopathological examination of the gallbladder removed for gallstone. Angiodysplasia of the gallbladder has the potential to bleed. Laparoscopic cholecystectomy is effective in providing a definitive cure.     

A Technique for Simultaneous Cholecystectomy During Bariatric Surgery

Background and Objectives:

Cholecystectomy performed during bariatric surgery is technically demanding. Herein is described a technique we term the Glissonian approach along with an evaluation of its effectiveness and safety.

Methods:

From April 1, 2009, through February 28, 2014, laparoscopic cholecystectomy was performed during laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) in 38 patients with proven cholecystopathy on diagnostic imaging. Perioperative outcomes were compared between the patients operated on with the Glissonian approach and those who underwent conventional laparoscopic cholecystectomy.

Results:

The Glissonian approach was adopted in 13 patients—11 during LRYGB and 2 during LSG—and the conventional operation was performed on 16 patients during LRYGB and 9 during LSG. Mean body mass indexes were 40.1 kg/m² in the Glissonian-approach group and 37.6 kg/m² in the conventional group. Laparoscopic cholecystectomy by the Glissonian approach saved a mean operative time of 7 minutes compared with the operative time of the conventional operation. No surgical complications related to cholecystectomy were noted in either group.

Conclusion:

This simple technique can be performed safely in morbidly obese patients, with low resultant morbidity and acceptable operation times.     

Laparoscopic Cholecystectomy in Patients With Cirrhosis of the Liver and Symptomatic Cholelithiasis

Background:

The indications and benefits of laparoscopic cholecystectomy (LC) in patients with liver cirrhosis and symptomatic cholelithiasis have not been satisfactorily documented. The aim of this study was to investigate its efficacy and safety in such patients.

Methods:

Medical records of 38 patients with liver cirrhosis (stages Child-Pugh A and B) who underwent LC were retrospectively reviewed. Demographic characteristics and other parameters including initial presentation, conversion rate, complication rate, mortality, and duration of hospital stay were investigated and compared with noncirrhotic patients'' parameters in our database.

Results:

Cirrhotic patients who underwent LC were older than noncirrhotic patients (P=0.021). Both the conversion rate (15.78%) and the duration of hospital stay were increased in the cirrhotic group, but without significant differences. Major complications occurred more often in the cirrhotic group (P=0.027), increasing morbidity; however, the mortality was zero.

Conclusions:

LC can be safely performed in Child-Pugh A and B cirrhotic patients with symptomatic gallstone disease, with acceptable complication and conversion rates. The increased risk for a major complication, however, demands more attention than usual.     

Risk Factors for Perioperative Anxiety in Laparoscopic Surgery

Background and Objectives:

Our aim is to investigate the anxiety status of the patient before elective cholecystectomy and to analyze the relation between the level of anxiety for a given operation type (laparoscopic and open cholecystectomy) and the corresponding demographic and social data.

Methods:

A total of 333 patients undergoing cholecystectomy due to cholelithiasis were included in the study; 218 patients (66.1%) received laparoscopic cholecystectomy and 115 patients (33.9%) were treated with open cholecystectomy. The Beck Anxiety Inventory was given to all patients to be completed. We evaluated levels of anxiety in 3 groups as follows: 0 to 15, low to mild anxiety; 16 to 25, moderate anxiety; 26 to 63, severe anxiety. The following patient information remained confidential and was recorded: age and sex, associated disease, civil status, educational status, having open/laparoscopic cholecystectomy, previous knowledge of the operation, job status, economic status, health insurance, and having a child in need of care.

Results:

The following criteria were determined: the most determinant factors in differentiating between the score groups were having a low level of education, being of the female sex, being single, and having laparoscopic operation; the factors of being a homemaker and over the age of 25 years were determined to have significant effects.

Conclusions:

When analyzing the results that may appear during the intraoperative and postoperative period, understanding preoperative anxiety, analyzing the risk factors in depth, and taking the necessary precautions are all considerations that need to be the primary objectives of operators who are involved with laparoscopic, endoscopic, and robotic surgery.     

Laparoscopic Cholecystectomy and Newer Techniques of Gallbladder Removal

Objectives:

To describe the surgical complications associated with laparoscopic cholecystectomy, as performed by a single surgeon over an 8-year period and to discuss how this compares to newer methods of cholecystectomy, such as single-incision surgery and natural orifice transluminal endoscopic surgery.

Methods:

The charts of 1000 consecutive patients who underwent consecutive cholecystectomies were reviewed to gather the following information: age, sex, prior abdominal procedures, type of procedure performed (laparoscopic vs open, with or without cholangiography), pre and postoperative diagnosis, and complications directly related to surgical technique, such as biliary injury, bile leak, infection, trocar-related injury, and incisional hernia.

Results:

The laparoscopic approach was attempted in all but one patient and was successful in 94.1% of patients. The conversion rate was higher with acute cholecystitis than with other forms of biliary tract disease. Successful cholangiography was accomplished in over 97% of patients. Nineteen complications directly related to the surgical procedure were found, including one bile duct injury.

Conclusion:

Laparoscopic cholecystectomy continues to offer a safe and effective treatment for patients with symptomatic biliary tract disease. Although other forms of minimally invasive cholecystectomy are being studied, there is little data to suggest any additional benefit, other than a slight improvement in cosmesis. Until larger series demonstrate that these techniques have a complication rate similar to those cited in the surgical literature, traditional 4-port laparoscopic cholecystectomy should remain the standard of care.     

Day-case laparoscopic Nissen fundoplication

Introduction:

For day-case laparoscopic surgery to be successful, patient selection is of the utmost importance. This study aimed to assess the feasibility of day-case laparoscopic Nissen fundoplication and to identify factors that may lead to readmission and overstay.

Methods:

A retrospective review of all patients who underwent day-case laparoscopic Nissen fundoplication over a 4-year period (2006 through 2010) was undertaken. Patient age, social circumstances, and other demographics were recorded as well as any comorbidities and ASA score. The primary endpoint measured was rate of readmission and overstay.

Results:

A total of 72 patients fulfilled the inclusion criteria for day-case surgery. Five patients (6.94%) required admission immediately following the procedure, ie, overstayed or were readmitted. The rates were 1.38% (P=.05, CI 95%) for readmission and 5.55% (P=.05, CI 95%) for overstay. Six (8.33%) patients were classified as ASA III, and 3 (50%) were readmitted or overstayed.

Conclusion:

Day-case laparoscopic Nissen fundoplication is a feasible, safe option. The authors conclude that ASA score of III and increasing age correlate with an increasing incidence of overstay and readmission. Therefore, we would recommend the use of integrated pathways and advanced planning to reduce these rates.     

Percutaneous cholecystostomy as an alternative to cholecystectomy in high risk patients with biliary sepsis: a district general hospital experience

INTRODUCTION

Cholecystectomy is the standard treatment for patients with acute cholecystitis. However, percutaneous cholecystostomy (PC) is an alternative for patients at high risk for surgery. We present our five-year clinical experience with the aim of evaluating the efficacy of PC in high risk patients.

METHODS

A retrospective review was performed on 30 consecutive patients who underwent PC at our institution. The indications for cholecystostomy, route of insertion, technical success, clinical improvement, length of hospitalisation, in-hospital or 30-day mortality, complications, subsequent admissions and performance of interval cholecystectomy were recorded. The median follow-up period was 25 months (range: 1–52 months).

RESULTS

Thirty-two PCs were performed in thirty patients (mean age: 76.1 years; range: 52–90 years). The indications for PC were acute calculous cholecystitis (29/32), acalculous cholecystitis (1/32) and emphysematous cholecystitis (2/32). The route of insertion was transperitoneal for 22/32 PCs (68.8%) and transhepatic for 10/32 (31.2%). The procedure was technically successful in all patients although 2/22 transperitoneal drains (9.1%) were dislodged subsequently. Twenty-seven PCs (84.4%) resulted in clinical improvement within five days. The in-hospital or 30–day mortality rate was 16.7% (5/30). Eleven patients (36.7%) had a subsequent cholecystectomy: 6 were laparoscopic and 5 converted to open procedures at a median interval of 58 days (range: 1–124 days).

CONCLUSIONS

PCs are straightforward with few complications. Most patients improve clinically and the procedure can therefore be used as a definitive treatment in unfit patients or as a bridge to surgery in those who might subsequently prove fit for a definitive operation.