Outcome after laparoscopic cholecystotomy and cholecystectomy in children with symptomatic cholecystolithiasis: a preliminary report

 Laparoscopic cholecystectomy (LCE) has become the procedure of choice for symptomatic gallstones in children. However, there is concern about the disadvantages of cholecystectomy. Numerous postoperative symptoms and a possible correlation of the procedure with a higher incidence of right-sided colon carcinoma have been described. Therefore, it has been suggested to remove the gallstones via a cholecystotomy, leaving the gallbladder in place. This is the first report on the functional and symptomatic outcome of laparoscopic cholecystotomy (LCO) versus LCE in a consecutive series of children. A follow-up study of all children who underwent surgery for symptomatic gallstone disease from 1993 to 1999 was performed. Nine underwent LCO and 8 standard LCE. The procedure was chosen according to the preference of the surgeon. Patients and parents underwent a standardized follow-up interview. The intensitiy of six gastrointestinal symptoms was graded from 0 to 3. The patients and parents scored the symptomatic outcome using a 100-point visual analogue scale. There were no intraoperative complications. Bleeding of a port site required suturing in 1 patient after LCO, and fever with a further uneventful course occurred in another after LCE. The mean duration of hospital stay was 3.0 days after LCO and 2.4 days after LCE. In 1 patient a missed gallstone was identified 4 weeks after LCO. The patient underwent LCE with a further uneventful course. At follow-up (mean 20.7 months after LCO, 28.3 months after LCE, P = n.s.) there was a tendency toward a lower incidence of symptoms after LCO. Symptoms were reported by 3 of 8 patients after LCO and 5 of 8 after LCE. The mean score of the symptomatic outcome was not statistically different. All patients with LCO were free of stones on ultrasound examination with normal contraction of the gallbladder. LCO thus represents an alternative approach. We consider LCO for children with symptomatic cholecystolithiasis before the onset of puberty. However, data on the long-term outcome from larger series are mandatory before a general recommendation can be given. Accepted: 11 August 2000     

腹腔镜下行胆囊切除术治疗急性胆囊炎并发胆结石患者的临床安全性及预后效果研究

目的 探讨腹腔镜下行胆囊切除术治疗急性胆囊炎并发胆结石患者的临床疗效。方法 选择我院2018年8月～2019年8月收治的92例患者,随机分为观察组46例和对照组46例。对照组采用开腹胆囊切除术治疗,观察组采用腹腔镜下胆囊切除术治疗。比较两组患者的肠鸣音恢复时间、肛门排气时间、排便时间及进食时间等胃肠功能指标,IL-6、IL-10、TNF-α等血清炎症因子水平变化及并发症发生情况。结果 观察组肠鸣音恢复时间为(13.17±2.56) h、肛门排气时间为(16.35±2.77) h、排便时间为(26.32±4.15) h、进食时间为(31.16±4.67) h,各项指标均短于对照组(t=-12.438,P=0.000;t=-12.570,P=0.000;t=-16.538,P=0.000;t=-14.349,P=0.000)。治疗后,两组IL-6、IL-10、TNF-α水平均升高(P0.05);观察组IL-6、IL-10、TNF-α水平显著低于对照组(t=-17.536,P=0.000;t=-10.664,P=0.000;t=-13.365,P=0.000)。观察组切口感染、出血、胆漏等并发症总发生率为8.70%,明显低于对照组的26.09%(χ2=4.842,P=0.028)。结论 腹腔镜下胆囊切除术治疗急性胆囊炎并发胆结石临床疗效显著,可有效促进患者胃肠功能恢复,降低炎症反应水平,并发症少,安全性高,值得推广应用。     

Intragastric single-port surgery (IGS) accesses the gastric remnant and allows ERCP for common bile duct stones after RYGB: a simple solution for a difficult problem

BackgroundPatients who have undergone a Roux-en-Ygastric bypass (RYGB) and suffer from choledocholithiasis postoperatively pose a medical dilemma. Treatment of the cholestasis can be complicated because of the altered anatomy in these patients. The gastric remnant and duodenum are isolated from the pancreaticobiliary limb, making endoscopic retrograde pancreatography (ERCP) challenging and often impossible.ObjectiveTo describe a method for safe introduction of the endoscope into the gastric remnant through intragastric single-port surgery (IGS), thus allowing for simultaneous cholecystectomy.SettingPilot clinical study.MethodsThe present study is a nonrandomized clinical series describing our preliminary results using a transgastric inserted single-port device for ERCP after RYGB. The series includes 8 patients who underwent IGS ERCP after RYGB.ResultsThe technique was successfully applied for intraoperative ERCP through a transgastric inserted single-port device (Gelpoint Mini, Applied Medical, Rancho Santa Margarita, CA). Papilotomy was easily achieved without complications. Average operative time was 144.75 minutes. The patients recovered without complications and could be discharged after a mean of 4.38 days.ConclusionsThe novel IGS technique is safe and effective and can be applied to perform ERCP in patients with RYGB anatomy. Transgastric single port ERCP was simple to perform, achieved excellent results, and allowed for endoscopic treatment and cholecystectomy to be performed in a single procedure. The technique can be indicated in patients with complicated gallstone obstruction under altered anatomy after RYGB.     

Laparoscopic cholecystectomy in a renal transplant recipient

Summary Laparoscopic cholecystectomy is a viable and safe alternative for the treatment of symptomatic gallstones and biliary colic. As surgeons gain more experience with this procedure, contraindications become fewer and indications increase. Well-documented advantages of this approach include less patient discomfort, less surgical scarring, and earlier return to employment. Not previously discussed in the literature, however, are the additional advantages that this procedure holds for a specific subset of patients—namely, those patients that have undergone successful organ transplantation and are receiving immunosuppressive drugs. We report a case of a laparoscopic cholecystectomy in such a patient.     

A Case-Control Study of Gallstones: A Major Risk Factor for Biliary Tract Cancer

Because of the strong association between gallstones and biliary tract cancer, we conducted a case-control study of gallstones at Niigata Cancer Center Hospital. Eighty-six cases with gallstones (33 males and 53 females) and 116 hospital controls (56 males and 60 females) were surveyed by means of a self-administered questionnaire. Gallstones were categorized into cholesterol stones (25 cases) and pigment stones (30 cases) based on the appearance of the stones. In multivariate analyses based on an unconditional logistic regression model, the risk of total gallstones was positively associated with a taste for salty food (relative risk (RR)=2.31, 95% confidence interval (CI): 1.10–4.84), an intake of lettuce and cabbage (RR = 2.98, 95% CI: 1.47–6.06) and a family history of biliary diseases (RR=5.63, 95% CI: 1.76–17.95), and inversely associated with an intake of salted and dried fish (RR=0.16, 95% CI: 0.04–0.64). When analyzed by type of stones, cholesterol stones were associated with a taste for oily food (RR = 3.87, 95% CI: 1.36–11.03) and pigment stones were positively associated with professional or administrative occupation (RR = 4.74, 95% CI: 1.35–16.68) and inversely associated with a taste for less greasy food (RR = 0.28, 95% CI: 0.10–0.83). Some of these results are consistent with the results of our previous study on biliary tract cancer.     

Cholelithiasis in early infancy

This report describes three children, age range 7 weeks to 5 months, who presented with obstructive jaundice secondary to gallstones. PreviousEscherichia coli septicaemia and frusemide therapy were predisposing risk factors in two of the patients. All three were successfully treated with cholecystectomy and exploration of the common bile duct.     

Less is more: an outcome assessment of patients operated for gallstone ileus without fistula treatment

BackgroundThe treatment of gallstone ileus (GI) consists of surgical removal of the impacted bilestone with or without cholecystectomy and repair of the biliodigestive fistula. The objective of this study was to assess whether sparing patients a definitive biliary procedure adversely influenced the outcome.Materials and methodsPatients with a diagnosis of GI were reviewed. Two groups were identified: patients who underwent a definitive biliary procedure with relieving the intestinal obstruction (group 1/G1) and those who did not have a definitive biliary procedure (group 2/G2). In G2, patients were evaluated on long-term follow-up for the risk of recurrent GI disease, cholecystitis, cholangitis and gallbladder cancer.ResultsAmong 1075 patients admitted for small bowel obstruction, 20 (1.9%) were diagnosed with gallstone ileus. 3 (15%) of these belong to G1, 17 (85%) to G2. The overall postoperative morbidity rate was 35% (7/20) with one complication exceeding grade II in each group. No deaths were reported. Mean follow-up was 50 months. During follow-up, one of G2 patients had recurrent disease. No biliary tract infections or gallbladder cancer were identified.ConclusionEnterolithotomy without fistula closure is confirmed to be safe and effective for the management of gallstone ileus both on a short- and long-term basis.     

大黄灵仙胶囊对慢性肝损伤后胆结石形成的干预作用研究

目的 探讨大黄灵仙胶囊对慢性肝损伤家兔胆结石形成的干预作用及其作用机制.方法 将46只家兔随机分为正常组、慢性肝损伤组、肝硬化组、大黄灵仙胶囊大剂量组、大黄灵仙胶囊小剂量组.采用皮下注射CCl4方法 进行慢性肝损伤造模,各组同时进行不同处理.最后观察各组胆囊成石率,肝脏功能生化指标,肝组织病理改变、超微结构改变,胆汁成分改变.结果 ①慢性肝损伤组、肝硬化组胆石形成阳性检出率较正常对照组显著增加(P＜0.05或P＜0.01).大黄灵仙胶囊大剂量组、大黄灵仙胶囊小剂量组胆石阳性检出率较肝硬化组有显著降低(P＜0.01或P＜0.05).②各模型组中肝脏超微结构均发生不同程度异常改变,大黄灵仙胶囊大、小剂量治疗组肝脏病理改变、肝细胞超微结构改变较模型组比较均有改善,大剂量组尤为明显.③大黄灵仙胶囊大、小剂量组血清AST,ALT,γ-GT,非结合胆红素均明显低于肝硬化组(P＜0.05或P<0.01);总胆红素、间接胆红素、钙离子大黄灵仙胶囊大、小剂量组较肝硬化组明显降低(P<0.01),大剂量组较小剂量组明显降低(P<0.01).结论 大黄灵仙胶囊对慢性肝损伤后胆结石形成具有明显的预防效果,其作用机制主要与抑制CCl4所致肝脏损伤的作用有关,同时与大黄灵仙胶囊在多层次、多途径调节参与结石形成各因素关系密切.     

猪胆石症模型制作及腹腔镜培训

目的:探讨猪胆石症模型的制作方法及腹腔镜手术的培训效果。方法:通过开腹或腹腔镜手术植入灭菌的人胆囊结石,完成造模。选择普通外科住院医师20名,体外培训合格后,用造模猪进行胆囊切除培训。结果:30头猪在开腹或腹腔镜下均顺利完成造模,造模猪情况良好,无一例死亡。培训前行B超检查均证实结石存在。与正常猪相比,模型猪胆囊周围粘连明显,尤以胆囊底较重,其中12例模型伴胆囊炎症,胆囊壁水肿增厚,可较真实地模拟人胆石症的临床病理变化。学员均顺利完成培训。4组学员因胆囊炎症造成胆囊撕裂,结石漏出;3组因胆囊周围粘连,分离层次不清造成胆囊床出血;2组胆囊动脉出血。学员通过操作,提高了腹腔镜手术技巧及意外情况的处理能力。结论:猪胆石症模型可真实地模拟人胆石症的临床病理变化,通过培训可增加学员对腹腔镜技术的理解,提高其腹腔镜操作水平。