Cirrhosis is not a contraindication to laparoscopic cholecystectomy: results and practical recommendations

Background

Gallstones appear more frequently in patients with cirrhosis and open cholecystectomy in this patient population is associated with higher morbidity and mortality. The aim of the present study was to evaluate experience with laparoscopic cholecystectomy in patients with cirrhosis and to provide recommendations for management.

Methods

Retrospective review of laparoscopic cholecystectomy in patients with cirrhosis from March 1999 to May 2008 was performed. Peri-operative characteristics and subgroup analysis were performed in patients with Child–Pugh''s classes A, B and C cirrhosis.

Results

A total of 68 patients were reviewed in this study. In all, 69% of the patients were Child''s class A. The most common indication for cholecystectomy was chronic/symptomatic cholelithiasis (68%). Compared with patients with Child''s class B and C, laparoscopic cholecystectomy in patients with Child''s class A was associated with significantly decreased operative time (P= 0.01), blood loss (P= 0.001), conversion to open cholecystectomy (P= 0.001) and length of hospital stay (P= 0.001).

Conclusions

Laparoscopic cholecystectomy in patients with cirrhosis is feasible with no mortality and low morbidity, especially in patients with Child''s class A cirrhosis.     

Laparoscopic cholecystectomy is the preferred approach in cirrhosis: a nationwide,population-based study

Background/aim

To assess the impact of open versus laparoscopic surgery in cirrhotic patients undergoing a cholecystectomy using the Nationwide Inpatient Sample (NIS).

Methods

All patients with cirrhosis who underwent a cholecystectomy (open or laparoscopic) between 2003 and 2006 were queried from the NIS. Associated complications including infection, transfusion, reoperation, liver failure and mortality were determined.

Results

A total of 3240 patients with cirrhosis underwent a cholecystectomy: 383 patients underwent an open cholecystectomy (OC) whereas 2857 patients underwent a laparoscopic cholecystectomy (LC), which included 412 patients converted (LCC) from a LC to an OC. Post-operative infection was higher in OC as opposed to a laparoscopic cholecystectomy (TLC) or LCC (3.5% versus 0.7% versus 0.2%, P < 0.0001). The need for a blood transfusion was significantly higher in the OC and LCC groups as compared with the TLC group (19.2% versus 14.4% versus 6.2%, P < 0.0001). Reoperation was more frequent after OC or LCC versus TLC (1.5% versus 2.5% versus 0.8%, P = 0.007). In-hospital mortality was higher after OC as compared with TLC and LCC (8.3% versus 1.3% versus 1.4%, P < 0.0001).

Conclusion

Patients with cirrhosis have increased in-hospital morbidity and mortality after an open as opposed to a laparoscopic or conversion to an open cholecystectomy. LC should be the preferred initial approach in cirrhotic patients.     

Are we getting the critical view? A prospective study of photographic documentation during laparoscopic cholecystectomy

Background

At laparoscopic cholecystectomy, most surgeons have adopted the operative approach where the ‘critical view of safety’ (CVS) is achieved prior to dividing the cystic duct and artery. This prospective study evaluated whether an adequate critical view was achieved by scoring standardized intra-operative photographic views and whether there were other factors that might impact on the ability to obtain an adequate critical view.

Methods

One hundred consecutive patients undergoing a laparoscopic cholecystectomy were studied. At each operation, two photographs were taken. Two independent experienced hepatobiliary surgeons scored the photographs on whether a critical view of safety was achieved. Inter-observer agreement was calculated using the weighted kappa coefficient. The Cochran–Mantel–Haenszel test was used to analyse the scores with potential confounding clinical factors.

Results

The kappa coefficient for adequate display of the cystic duct and artery was 0.49; 95% confidence interval (CI) 0.33 to 0.64; P = 0.001. No bias was detected in the overall scorings between the two observers (χ² 1.33; P = 0.312). Other clinical factors including surgeon seniority did not alter the outcome [odds ratio (OR) 0.902; 95% confidence interval 0.622 to 1.264].

Conclusion

Heightened awareness of the CVS through mandatory documentation may improve both trainee and surgeon technique.     

Management of choledocholithiasis in an emergency cohort undergoing laparoscopic cholecystectomy: a single-centre experience

Introduction

Minimally-invasive options for the management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy include laparoscopic and endoscopic approaches. This study reviews the effectiveness of both approaches in an emergency setting.

Methods

A retrospective chart review was performed for a cohort of patients who underwent laparoscopic cholecystectomy. Outcomes assessed were duct clearance, the number of procedures performed (NPP), length of stay (LOS) and complication rate.

Results

A total of 182 patients who underwent emergency laparoscopic cholecystectomies received intervention for choledocholithiasis. The duct clearance rate was lower in the laparoscopic group, 63% versus 86% (P = 0.001). However, the median NPP was also lesser in the laparoscopic group, 1 (interquartile range (IQR) 1–2) versus 2 (IQR 2–2) (P < 0.001), as was the median LOS, 5 days (IQR 3–8) versus 7 days (IQR 6–10) (P = 0.009). Forty-eight laparoscopic endobiliary stents were attempted; stent deployment was successful in 37 patients. A larger proportion of patients with laparoscopic endobiliary stents had duct clearance by endoscopic retrograde cholangiopancreatography (ERCP) compared with those without, although this was not statistically significant (P = 0.208).

Conclusion

Laparoscopic clearance is not as effective as post-operative ERCP in an emergency cohort, but is associated with fewer procedures required and a shorter inpatient stay. Thus, laparoscopic clearance may still be an attractive option for surgeons especially where conditions are favourable during an emergency laparoscopic cholecystectomy.     

Radical resection for T1b gallbladder cancer: a decision analysis

Background:

Gallbladder cancer is the most common malignancy of the biliary tract. Radical surgery (including liver resection and regional lymphadenectomy) is applied for some gallbladder cancers, but the benefits of these procedures are unproven. For patients with T1b cancers discovered incidentally on cholecystectomy specimens, the utility of radical surgery remains debated.

Methods:

A decision analytic Markov model was created to estimate and compare life expectancy associated with management strategies for a simulated cohort of patients with incidentally discovered T1b gallbladder cancer after routine cholecystectomy. In one strategy, patients were treated with no additional surgery; in another, patients were treated with radical resection. The primary (base-case) analysis was calculated based on a cohort of 71-year-old females and incorporated best available input estimates of survival and surgical mortality from the literature. Sensitivity analysis was performed to assess the effects of model uncertainty on outcomes.

Results:

In the base-case analysis, radical resection was favoured over no further surgical resection, providing a survival benefit of 3.43 years for patients undergoing radical resection vs. simple cholecystectomy alone. Sensitivity analysis on the age at diagnosis demonstrated that the greatest benefit in gained life-years was achieved for the youngest ages having radical resection, with this benefit gradually decreasing with increasing age of the patient. High peri-operative mortality rates (≥36%) led to a change in the preferred strategy to simple cholecystectomy alone.

Conclusions:

Decision analysis demonstrates that radical resection is associated with increased survival for most patients with T1b gallbladder cancer.     

Laparoscopic cholecystectomy is more difficult after a previous endoscopic retrograde cholangiography

Background

Endoscopic retrograde cholangiography (ERCP) with endoscopic sphincterotomy (ES) followed by a laparoscopic cholecystectomy (LC) is generally accepted as the treatment of choice for patients with choledochocystolithiasis who are eligible for surgery. Previous studies have shown that LC after ES is associated with a high conversion rate. The aim of the present study was to assess the complexity of LC after ES compared with standard LC for symptomatic uncomplicated cholecystolithiasis.

Methods

The study population consisted of two patient cohorts: patients who had undergone a previous ERCP with ES for choledocholithiasis (PES) and patients with cholecystolithiasis who had no previous intervention prior to LC (NPES).

Results

The PES group consisted of 93 patients and the NPES group consisted of 83 consecutive patients. Patients in the PES group had higher risks for longer [more than 65 min, odds ratio (OR) = 4.21 (95% confidence interval (CI) 1.79–9.91)] and more complex [higher than 6 points, on a 0–10 scale, OR 3.12 (95% CI 1.43–6.81)] surgery. The conversion rate in the PES and NPES group (6.5% versus 2.4%, respectively) and the complication rate (12.9% versus 9.6%, respectively) were not significantly different.

Discussion

A laparoscopic cholecystectomy after ES is lengthier and more difficult than in uncomplicated cholelithiasis and should therefore be performed by an experienced surgeon.     

Single-incision laparoscopic colectomy versus conventional multiport laparoscopic colectomy: a meta-analysis of comparative studies

Objective

This study aimed to compare single-incision laparoscopic colectomy (SILC) to conventional multiport laparoscopic colectomy (MLC).

Background

Single-incision laparoscopic surgery (SILS) is a minimally invasive technique being recently applied to colorectal surgery. A number of studies comparing SILC to conventional MLC have recently been published.

Methods

A literature search of PubMed and MEDLINE databases for studies comparing SILC to conventional MLC was conducted. The primary outcome measures for meta-analysis were postoperative complications, length of stay, and operative time. Secondary outcome measures were incision length, estimated blood loss, and number of lymph nodes harvested.

Results

Fifteen studies comparing 467 patients undergoing SILC to 539 patients undergoing conventional MLC were reviewed and the data pooled for analysis. Patients undergoing SILC had a shorter length of stay (pooled weighted mean difference (WMD)?=??0.68; 95 % CI?=??1.20 to ?0.16; p?=?0.0099), shorter incision length (pooled WMD?=??1.37; 95 % CI?=??2.74 to 0.000199; p?=?0.05), less estimated blood loss (pooled WMD?=??20.25; 95 % CI?=??39.25 to ?1.24; p?=?0.037), and more lymph nodes harvested (pooled WMD?=?1.75; 95 % CI?=?0.12 to 3.38; p?=?0.035), while there was no significant difference in the number of postoperative complications (pooled odds ratio?=?0.83; 95 % CI?=?0.57 to 1.20; p?=?0.33) or operative time (pooled WMD?=?5.06; 95 % CI?=??2.91 to 13.03; p?=?0.21).

Conclusion

SILC appears to have comparable results to conventional MLC in the hands of experienced surgeons. Prospective randomized trials are necessary to define the relative benefits of one procedure over the other.     

A Systematic Review of Conceptual Frameworks of Medical Complexity and New Model Development

BACKGROUND

Patient complexity is often operationalized by counting multiple chronic conditions (MCC) without considering contextual factors that can affect patient risk for adverse outcomes.

OBJECTIVE

Our objective was to develop a conceptual model of complexity addressing gaps identified in a review of published conceptual models.

DATA SOURCES

We searched for English-language MEDLINE papers published between 1 January 2004 and 16 January 2014. Two reviewers independently evaluated abstracts and all authors contributed to the development of the conceptual model in an iterative process.

RESULTS

From 1606 identified abstracts, six conceptual models were selected. One additional model was identified through reference review. Each model had strengths, but several constructs were not fully considered: 1) contextual factors; 2) dynamics of complexity; 3) patients’ preferences; 4) acute health shocks; and 5) resilience. Our Cycle of Complexity model illustrates relationships between acute shocks and medical events, healthcare access and utilization, workload and capacity, and patient preferences in the context of interpersonal, organizational, and community factors.

CONCLUSIONS/IMPLICATIONS

This model may inform studies on the etiology of and changes in complexity, the relationship between complexity and patient outcomes, and intervention development to improve modifiable elements of complex patients.KEY WORDS: patients, multiple chronic conditions, multimorbidity, complexity, resilience, patient goal     

Meta-analysis of one- vs. two-stage laparoscopic/endoscopic management of common bile duct stones

Background

The present study is a meta-analysis of English articles comparing one-stage [laparoscopic common bile duct exploration or intra-operative endoscopic retrograde cholangiopancreatography (ERCP)] vs. two-stage (laparoscopic cholecystectomy preceded or followed by ERCP) management of common bile duct stones.

Methods

MEDLINE/PubMed and Science Citation Index databases (1990–2011) were searched for randomized, controlled trials that met the inclusion criteria for data extraction. Outcomes were calculated as odds ratios (ORs) with 95% confidence intervals (CIs) using RevMan 5.1.

Results

Nine trials with 933 patients were studied. No significant differences was observed between the two groups with regard to bile duct clearance (OR, 0.89; 95% CI, 0.65–1.21), mortality (OR, 1.2; 95% CI, 0.32–4.52), total morbidity (OR, 0.75; 95% CI, 0.53–1.06), major morbidity (OR, 0.95; 95% CI, 0.60–1.52) and the need for additional procedures (OR, 1.58; 95% CI, 0.76–3.30).

Conclusions

Outcomes after one-stage laparoscopic/endoscopic management of bile duct stones are no different to the outcomes after two-stage management.     

Outcome of Laparoscopic Cholecystectomy at a Secondary Level of Care in Saudi Arabia

Background/Aim:

The first option for gallbladder surgery is laparoscopic cholecystectomy. The aim of this study is to analyze the outcomes for all patients who underwent laparoscopic cholecystectomy at a secondary level of care.

Patients and Methods:

Between 2005 and 2008, 968 consecutive laparoscopic cholecystectomies were performed at King Fahad Hospital. We collected and analyzed data including age, gender, body mass index (kg/m²), the American Society of Anesthesiologists (ASA) class, mode of admission (elective or emergency), indication for LC (chronic or acute cholecystitis [AC]), co-morbid disease, previous abdominal surgery, conversion to open cholecystectomy, complications, operation time, and length of postoperative hospital stay.

Results:

Nine hundred and sixty-eight patients had laparoscopic cholecystectomy at the center. There were 824 females and 144 males; the age range was 15-64 (mean 32.9± 12.7 years). The operating time was 45 to 180 min (median 85 min); the complication rate was 4.03% (39 patients).

Conclusion:

Laparoscopic cholecystectomy could be performed safely in the majority of patients with cholelithiasis, by an experienced surgical team at a secondary level of care.     

Laparoscopic repair of Morgagni hernia by artificial pericardium patch in an adult obese patient

Background

Morgagni hernia is a kind of rare congenital diaphragmatic hernia. We reported a case of Morgagni hernia repaired successfully with artificial pericardium patch via the laparoscopic approach.

Methods

The patient was admitted with a 3-month history of postprandial nausea and vomiting, and accompanied by epigastric pain. Computed tomography (CT) scans showed a large anteromedial diaphragmatic hernia. The hernial contents were reduced back into the abdominal cavity and the diaphragmatic defect was repaired with artificial pericardium patch by laparoscopic intracorporeal suture.

Results

We achieved satisfactory intracorporeal repair of this large diaphragmatic defect. The patient had excellent recovery and started on oral diet on the first postoperative day, and then was discharged just two days after operation.

Conclusions

The minimally invasive advantage of laparoscopic approach offers a secure, reliable and satisfactory way to confirm the diagnosis and achieve the repair of non-complicated Morgagni hernia.     

Medicolegal costs of bile duct injuries incurred during laparoscopic cholecystectomy

Background:

When laparoscopic cholecystectomy (LC) is performed successfully, recovery is faster than after open cholecystectomy. However, LC results in higher incidences of biliary, bowel and vascular injury.

Methods:

We performed a retrospective review of LC-related claims reported to the National Health Service Litigation Authority (NHSLA) during 2000–2005. The data were analysed from a medicolegal perspective to assess the effects of type of injury and delay in recognition on litigation costs.

Results:

A total of 208 claims following laparoscopic procedures in general surgery were reported to NHSLA during 2000–2005, of which 133 (64%) were related to LC. Bile duct injury (BDI) accounted for the majority of claims (72%); bowel injury and ‘others’ accounted for 9% and 19%, respectively. Only 20% of BDIs were recognized during surgery; the majority were missed and diagnosed later. Claims related to LC resulted in payments totalling £6 m, of which £4.3 m was paid out for BDIs. The average cost was higher for patients who suffered a delay in diagnosis, as was the chance of a successful claim.

Conclusions:

Bile duct injury incurred during LC remains a serious hazard for patients. The resulting complications have led to litigation that has caused a huge financial drain on the health care system. Delayed recognition appears to correlate with more costly litigation.     

Effects of Surgical Methods and Tumor Location on Survival and Recurrence Patterns after Curative Resection in Patients with T2 Gallbladder Cancer

Background/Aims

Extended cholecystectomy is generally recommended for patients with T2 gallbladder cancer. However, few studies have assessed the extent of resection relative to T2 gallbladder tumor location. This study analyzed the effects of surgical methods and tumor location on survival outcomes and tumor recurrence in patients with T2 gallbladder cancer.

Methods

Clinicopathological characteristics, extent of resection, survival rates, and recurrence patterns were retrospectively analyzed in 88 patients with pathologically confirmed T2 gallbladder cancer.

Results

The 5-year disease-free survival rate was 65.0%. Multivariate analysis showed that lymph node metastasis was the only independent risk factor for poor 5-year disease-free survival rate. Survival outcomes were not associated with tumor location. Survival tended to be better in patients who underwent extended cholecystectomy than in those who underwent simple cholecystectomy. Recurrence rate was not affected by surgical method or tumor location. Systemic recurrence was more frequent than local recurrence without distant recurrence. Gallbladder bed recurrence and liver recurrence were relatively rare, occurring only in patients with liver side tumors.

Conclusions

Extended cholecystectomy is the most appropriate treatment for T2 gallbladder cancer. However, simple cholecystectomy with regional lymph node dissection may be appropriate for patients with serosal side tumors.     

Minimally invasive versus the conventional open surgical approach of a radical cholecystectomy for gallbladder cancer: a retrospective comparative study

Background

Laparoscopic surgery has traditionally been contraindicated for the management of gall bladder cancer (GBC). This study was undertaken to determine the safety and feasibility of a laparoscopic radical cholecystectomy (LRC) for GBC and compare it with an open radical cholecystectomy (ORC).

Methods

Retrospective analysis of primary GBC patients (with limited liver infiltration) and incidental GBC (IGBC) patients (detected after a laparoscopic cholecystectomy) who underwent LRC between June 2011 and October 2013. Patients who fulfilled the study criteria and underwent ORC during the same period formed the control group.

Results

During the study period, 147 patients with GBC underwent a radical cholecystectomy. Of these, 24 patients (primary GBC– 20, IGBC – 4) who underwent a LRC formed the study group (Group A). Of the remaining 123 patients who underwent ORC, 46 matched patients formed the control group (Group B). The median operating time was higher in Group A (270 versus 240 mins, P = 0.021) and the median blood loss (ml) was lower (200 versus 275 ml, P = 0.034). The post-operative morbidity and mortality were similar (P = 1.0). The pathological stage of the tumour in Group A was T_1b (n = 1), T₂ (n = 11) and T₃ (n = 8), respectively. The median lymph node yield was 10 (4–31) and was comparable between the two groups (P = 0.642). During a median follow-up of 18 (6–34) months, 1 patient in Group A and 3 in Group B developed recurrence. No patient developed a recurrence at a port site.

Conclusion

LRC is safe and feasible in selected patients with GBC, and the results were comparable to ORC in this retrospective comparison.     

Primary versus delayed repair for bile duct injuries sustained during cholecystectomy: results of a survey of the Association Francaise de Chirurgie

Background

Bile duct injuries (BDIs) sustained during a cholecystectomy still remain a major surgical problem, and it is still not clear whether the injury should be repaired immediately or a delayed repair is preferred.

Methods

A retrospective national French survey was conducted to compare the results of immediate (at time of cholecystectomy), early (within 45 days after a cholecystectomy) and late (beyond 45 days after a cholecystectomy) surgical repair for BDI sustained during a cholecystectomy.

Results

Forty-seven surgical centres provided 640 cases of bile duct injury sustained during a cholecystectomy of which 543 were analysed for the purpose of the present study. The timing of repair was immediate in 194 cases (35.7%), early in 216 cases (39.8%) and late in 133 cases (24.5%). The type of repair was a suture repair in 157 cases (81%), and a bilio-digestive reconstruction in 37 cases (19%) for immediate repair; a suture repair in 119 cases (55.1%) and a bilio-digestive anastomosis in 96 cases (44.9%) for the early repair; and a bilio-digestive reconstruction in 129 cases (97%) and a suture repair in 4 cases (3%) for late repair. A second procedure was required in 110 cases (56.7%) for immediate repair, 80 cases (40.7%) for early repair (P < 0.05) and in 9 cases (6.8%) for late repair (P < 0.001).

Conclusion

The timing of surgical repair for a bile duct injury sustained during a cholecystectomy influences significantly the rate of a second procedure and a late repair should be preferred option.     

Single-incision laparoscopic versus traditional multiport laparoscopic colorectal surgery—a cumulative meta-analysis and systematic review

Purpose

The published data on the evaluation of feasibility and safety of single-incision laparoscopic colorectal surgery (SILC) compared with traditional multiport laparoscopic colorectal surgery (MLC) remained controversial. The present cumulative meta-analysis and systematic review were performed to provide a more objective and precise estimate.

Materials and methods

PubMed, the Cochrane Library, and also, manual searches were employed to identify potentially eligible studies which were published before June 7, 2012. The association was assessed by odds ratio (OR) and means with 95 % confidence intervals (CI).

Results

A total of 20 comparative studies were included, with 670 patients underwent SILC and 838 patients underwent MLC. For overall pooled estimates, no evidence of between trial differences was found in overall conversion rate (OR, 1.7; 95 % CI, 0.97 to 3.01), overall complication rate (OR, 0.82; 95 % CI, 0.63 to 1.08), and operative time (mean, ?3.59; 95 % CI, ?10.95 to 3.77); significantly between trial differences were found in estimated blood loss (mean, ?18.61; 95 % CI, ?31.33 to ?5.90) and post-operative hospital stay (mean, ?0.54; 95 % CI, ?0.95 to ?0.12). The cumulative meta-analysis identified a potentially increased conversion rate of SILC compared with MLC with the increased percentage of malignancies, but no significant differences could be identified in overall complication rate.

Conclusion

This meta-analysis suggested the feasibility and safety of SILC performed by experienced hands, though potentially higher overall conversion rate occurred in malignancies. SILC will benefit the patients much more with its superiority over MLC.     

Surgical management and longterm follow-up of non-parasitic hepatic cysts

Background:

Despite the increasing use of laparoscopic techniques, the optimal surgical approach for cystic liver disease has not been well defined. This study aims to determine the optimum operative approach for these patients.

Methods:

Data were identified from the Lothian Surgical Audit, case note review and general practitioner contact. Patients were contacted and asked to complete the SF-36 questionnaire on quality of life.

Results:

A total of 102 patients (67 with simple cysts, 31 with polycystic liver disease [PCLD], four with cystic tumours) underwent 62 laparoscopic deroofings, 15 open deroofings, 36 resections and one liver transplant between June 1985 and April 2006. The median follow-up was 77 months (range 3–250 months). Morbidity and recurrent symptom rates after laparoscopic surgery were greater in PCLD patients compared with simple cyst patients, at 31% (four patients) vs. 15% (seven patients) and 85% (11 patients) vs. 29% (24 patients), respectively. Four patients with simple cysts and eight with PCLD required further surgery. All patients with simple cysts had comparable quality of life after surgery. Patients with recurrent symptoms after surgery for PCLD had a significantly better quality of life following laparoscopic deroofing than after resection.

Conclusions:

Most simple cysts can be managed laparoscopically, but there is a definite role for open resection in some patients. Open deroofing is the preferred approach for a dominant cyst pattern in PCLD, whereas resection is necessary for diffuse cystic disease.     

Bile Duct Injuries Following Laparoscopic Cholecystectomy: A Clinical Study

Background/Aim:

This study aimed at assessing the outcome of laparoscopic cholecystectomy (LC) by determining the frequency of complications, especially of bile duct injuries.

Materials and Methods:

The case files of all patients undergoing laparoscopic cholecystectomy between 2002 and 2006 (inclusive) at King Hussein Medical Center (KHMC) were retrospectively analyzed. We evaluated the data according to outcome measures, such as bile duct injury, morbidity, mortality and numbers of patients whose resections had to be converted from laparoscopic to open.

Results:

During the four years (January 2002 and December 2006), 336 patients underwent LC for chronic cholecystitis (CC), of whom 22 (6.5%) developed complications. Among those who developed complications, two patients had major bile duct injuries (0.4%); 43 other patients (12.8%) had planned laparoscopic operations converted to open cholecystectomy intra-operatively. None of the patients in this study died as a result of LC.

Conclusion:

Bile duct injury is a major complication of LC. Anatomical anomalies, local pathology, and poor surgical techniques are the main factors responsible. The two patients who had severe common bile duct injury in this study had major anatomical anomalies that were only recognized during surgery.     

Risk Factors for Development of Biliary Stricture in Patients Presenting with Bile Leak after Cholecystectomy

Background/Aims

This study was aimed at determining the factors associated with the development of benign biliary stricture (BBS) in patients who had sustained a bile duct injury (BDI) at cholecystectomy and developed bile leaks.

Methods

A retrospective analysis of 214 patients with BDI who were referred to our center between January 1989 and December 2009 was done.

Results

One hundred fifty-three (71%) patients developed BBS (group I), and 61 (29%) were normal (group II). By univariate analysis, female gender (p=0.02), open cholecystectomy as the index operation (p=0.0001), delay in the referral from identification of injury (p=0.04), persistence of an external biliary fistula (EBF) beyond 4 weeks (p=0.0001), EBF output >400 mL (p=0.01), presence of jaundice (p=0.0001), raised serum total bilirubin level (p=0.0001), raised serum alkaline phosphatase level (p=0.0001), and complete BDI (p=0.0001) were associated with the development of BBS. Furthermore, open cholecystectomy as the index operation (p=0.04), delayed referral (p=0.02), persistent EBF (p=0.03), and complete BDI (p=0.001) were found to predict patient outcome in the multivariate analysis.

Conclusions

For the majority of patients with BDI, the risk of developing BBS could have been predicted at the initial presentation.     

Disseminated bony metastases following incidental gallbladder cancer detected after laparoscopic cholecystectomy

Background

In patients with gallbladder cancer bony metastases are usually a late feature.

Case outline

A 47-year-old woman presented with a 2-month history of right upper quadrant pain. Ultrasound scan showed gallstones and a thick-walled gallbladder. Laparoscopic cholecystectomy was performed. Histopathology showed poorly differentiated adenocarcinoma infiltrating the muscular layer and vascular invasion. She was referred for further surgery. Staging CT scan of the abdomen showed no local residual disease. However Tc-99 bone scan suggested disseminated bony metastases, which were confirmed by bone trephine biopsy. The cancer progressed rapidly and the patient died 4 months after the diagnosis.

Discussion

Bone metastases can occur with early gallbladder cancer and a radioisotope bone scan can avoid unnecessary extensive liver surgery.