Laparoscopic cholecystectomy can be safely performed in a resource-limited setting: the first 49 laparoscopic cholecystectomies in Yemen.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard for gallstone disease. Many studies have confirmed the safety and feasibility of LC and have shown that it is comparable regarding complications to open cholecystectomy (OC). The aim of this study was to evaluate the outcomes of LC including safety, feasibility in a resource-poor setting like Yemen, and also to compare the outcomes of LC with those of OC. METHODS: This was a prospective, nonrandomized, comparative study of 112 patients who were admitted to Alburaihy Hospital with a diagnosis of gallstone disease and underwent cholecystectomy from July 1998 to March 2004. Hospital stay, duration of operation, postoperative analgesia, and morbidity due to wound infection, bile leak, common bile duct (CBD) injury, missed CBD stone, bleeding, subphrenic abscess, and hernia were evaluated. Patients were followed up on an outpatient basis. RESULTS: Forty-nine patients underwent LC and 63 patients underwent OC. The mean age of LC patients was 43.96 years and of OC patients was 44.63 years. The 2 groups were similar in terms of age (p=0.740) and sex (p=0.535). No significant difference was found in the incidence of acute cholecystitis between the 2 groups (p=0.000). The mean operative duration for LC was 39.88 minutes versus 56.76 minutes for OC (p=0.000), and the mean hospital stay was 1.63 and 5.38 days for LC and OC, respectively (p=0.000). A drain was used frequently in OC (p=0.000). LC patients needed less analgesia (p=0.000). The morbidity rate in LC was 12.2% versus 6.3% for OC, which was not statistically significant (p=0.394), (p>0.05). Wound infection and bile leak were more common with LC. No mortalities were reported in either group. CONCLUSION: An experienced surgeon can perform LC safely and successfully in a resource-limited setting. As in other studies, LC outcomes were better than OC outcomes.     

Changing management of gallstone disease during pregnancy

Background: Symptomatic gallstones may be problematic during pregnancy. The advisability of laparoscopic cholecystectomy (LC) is uncertain. The objective of this study is to define the natural history of gallstone disease during pregnancy and evaluate the safety of LC during pregnancy. Methods: Review of medical records of all pregnant patients with gallstone disease at the University of California, San Francisco, from 1980 to 1996. Results: Of approximately 29,750 deliveries, 47 (0.16%) patients were treated for gallstone disease, including biliary colic in 33, acute cholecystitis in 12, and pancreatitis in two. Conservative treatment was attempted in all patients but failed in 17 (36%) cases. Two patients required combined preterm Cesarean-section cholecystectomy and 10 required surgery in the early postpartum period for persistent symptoms. Seventeen patients required cholecystectomy during pregnancy for biliary colic (10), acute cholecystitis (six), and pancreatitis (one). Three patients were treated with open cholecystectomy. Fourteen patients underwent LC at a mean gestational age of 18.6 weeks, mean OR time of 74 min, and mean length of stay of 1.2 days. Hasson cannulation was utilized in 11 patients. Reduced-pressure pneumoperitoneum (6–10 mmHg) was used in seven patients. Prophylactic tocolytics were used in seven patients, with transient postoperative preterm labor observed in one. There were no open conversions, preterm deliveries, fetal loss, teratogenicity, or maternal morbidity. Conclusions: In past years, symptomatic gallstones during pregnancy were managed conservatively or with open cholecystectomy. LC is a feasible and safe method for treating severely symptomatic patients. Received: 3 April 1997/Accepted: 5 July 1997     

Endoscopic sphincterotomy for the treatment of gallstone pancreatitis during pregnancy

Background: Gallstones are the most common cause of acute pancreatitis during pregnancy. Without intervention, gallstone pancreatitis during pregnancy is associated with an antepartum recurrence rate of 70%, which exposes the mother and fetus to an increased risk of morbidity and mortality. A safe, effective means to prevent recurrent gallstone pancreatitis during pregnancy is desirable. Methods: Since 1991, we have managed gallstone pancreatitis in three pregnant patients with endoscopic retrograde cholangiogram (ERC), followed by spincterotomy, despite the absence of common bile duct stones. Results: All patients were judged to have mild pancreatitis by modified Ranson criteria and the Multiorgan System Failure criteria. During cholangiogram, fetal shielding was employed and fluoroscopy times ranged from 36 s to 7.2 min. One patient experienced postprocedure pancreatitis of 48-h duration. None of the patients experienced further episodes of pancreatitis and none underwent predelivery cholecystectomy. Conclusions: In pregnancy-associated gallstone pancreatitis, endoscopic sphincterotomy prevents recurrence of pancreatitis and the need for cholecystectomy during gestation. We believe endoscopic sphincterotomy represents a promising management alternative for gallstone pancreatitis during pregnancy. Further investigation is warranted. Received: 30 December 1996/Accepted: 12 September 1997     

Selective Intraoperative Cholangiography and Single-Stage Management of Common Bile Duct Stone in Laparoscopic Cholecystectomy

Background There are still debates and controversies in the detection and the management of common bile duct (CBD) stones in the era of laparoscopic cholecystectomy (LC). This prospective study was performed to evaluate a single-stage management of CBD stone during LC. Methods Between May 1998 and January 2000, 249 consecutive patients with gallstone and cholecystitis were enrolled in this study. The mean age was 52.5 ± 12.4 years. Male to female ratio was 106:143. All patients underwent abdominal sonography and the determination of the serum biochemical profile preoperatively. Patients presented with sepsis or with total bilirubin ≥ 6 ng/dL were excluded from the study. Results 244 (98%) patients underwent LC and 5 (2%) patients were converted to open cholecystectomy. Intraoperative cholangiogram (IOC) was only performed in patients who fulfilled our predetermined criteria. Among 90 patients who had IOC, only 23 patients had CBD stones that were removed either by transcystic duct stone extraction (61%) or CBD exploration (39%). The additional procedures to remove CBD stone did not prolong the hospitalization. There were four wound infections and one cystic stump leakage. One patient developed CBD stone during the follow-up period up to 37 months. Conclusions Our study indicates that routine use of IOC during LC is not necessary. In addition, single-stage approach for the management of CBD stone during LC is feasible and should be considered by laparoscopic surgeons.     

Die chirurgische Therapie der Cholecysto-/Choledocholithiasis Ergebnisse einer deutschlandweiten Umfrage an 859 Kliniken mit 123.090 Cholecystektomien

BACKGROUND: With the advent of laparoscopic cholecystectomy, the choice of procedure (laparoscopic vs open) and surgical management in gallstone disease are of interest. The purpose of this study was to examine the current approach and various strategies for cholecystectomy in Germany. METHODS: A retrospective survey at 859 (of 1,200, 67.6%) hospitals in Germany was conducted. Data from 123,090 patients that had undergone cholecystectomy were analyzed. RESULTS: 71.9% of the procedures were finished laparoscopically (LC: 88.537), whereas 22.5% (27.727) were done in the open technique (KC). Conversion to open surgery was required in 7.1% of the laparoscopically started operations, mainly in cases of adhesions and unclear anatomic situations (64.3%). When common bile duct (CBD) stones were diagnosed preoperatively, 74.4% of the participants favored primary endoscopic extraction (ERC), followed by LC. In cases of intraoperative diagnoses, the LC was finished and postoperative ERC and extraction were carried out in more than half of the hospitals (58.4%). Sixteen percent were converted to an open operation with simultaneous exploration of the CBD. Laparoscopic desobstruction of the CBD was extremely rare (4.4%). The intraoperative cholangiography (IOC) was the most strongly recommended approach for intraoperative diagnostics, but was generally routine practice in only 6% of the hospitals conducting LCs. Forty-nine percent of the respondents reported the use of IOC in selected cases and 43% of the hospitals did not perform any intraoperative diagnostics in LC. Compared with OC, the results show a lower incidence of postoperative reinterventions (0.9 vs 1.8%) and fatal outcomes (0.04 vs 0.53%) for LC. In contrast, CBD injuries were more frequent in the LC group (0.32 vs 0.12%). The median duration of hospitalization was 6.1 days (range 2.8-12) in the LC group compared with 10.4 days (range 3-28) in the OC group. CONCLUSIONS: LC is the standard procedure for the treatment of uncomplicated gallstone disease. Even after adjustment for differences in patient comorbidities, there are logical differences between the hospitals as to the type of cholecystectomy used for acute cholecystitis, the management of CBD stones, and the intraoperative diagnostics in LC.     

Acute biliary pancreatitis

Since January 1990, we have treated 113 patients for gallstone pancreatitis; 59 with laparoscopic cholecystectomy (LC), 50 with open cholecystectomy, and 4 with ERCP/sphincterotomy only. In the LC group, 47 had LC during the index admission and 12 underwent delayed LC. Fifty patients had open cholecystectomy, 47 during the index admission. ERCPs were performed in 43 of the 113 patients; CBD stones were identified in 19/43 (44%) and removed endoscopically in 18 (95%). The ERCP complication rate was 6.5%. In total, CBD stones were identified in 29/113 patients (26%). Patients who had imaging of the CBD within the first 4 days from onset of symptoms were more likely to have stones identified than were those patients who were studied after 5 days. Recurrent pancreatitis occurred in five of 11 patients (45%) who had a 30-day delay to definitive treatment. We conclude that LC can be safely performed in most patients during the index admission for gallstone pancreatitis. This policy should reduce the 30–50% risk of recurrent pancreatitis associated with a delayed operation. ERCP is a helpful adjunct for CBD stones.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, TN, USA, 18–19 April 1994     

Effect of intraoperative cholangiography during cholecystectomy on outcome after gallstone pancreatitis

Acute gallstone pancreatitis has traditionally been managed by early cholecystectomy with intraoperative cholangiography (IOC). To evaluate the effect of IOC on patient outcome, we analyzed all patients operated on for acute gallstone pancreatitis at our institution over a 3-year period. A total of 200 patients (37 open, 163 laparoscopic) were evaluated. Nineteen of 34 patients who underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) were found to have common bile duct (CBD) stones. The 59 patients who underwent cholecystectomy with IOC had significantly longer operative times compared to the 141 patients who underwent cholecystectomy alone (167 vs. 105 minutes for open [P= 0.008] and 89 vs. 68 minutes for laparoscopic [P< 0.0001] operations). Of the 59 patients who underwent IOC, only nine (15%) had abnormal cholangiograms, and CBD exploration in seven revealed stones in four patients, edematous ampullae in two, and no abnormality in one. Six of eight patients (5 IOC, 3 no IOC) who required immediate postoperative ERCP were noted to have CBD stones. Patients who underwent IOC had significantly longer postoperative hospital stays (3.8 vs. 2.0 days [P= 0.007]). The incidence of retained CBD stones following surgery was similar (5.1% IOC, 2.8% no IOC). Although 7 of 122 patients who underwent laparoscopic cholecystectomy without IOC were readmitted, only one was found on ERCP to have a retained CBD stone. Age, sex, preoperative days, procedure type, and biliary-pancreatic complications after discharge did not differ significantly between patients with and without IOC. We conclude that IOC in patients operated on for acute gallstone pancreatitis results in a longer operative time and a prolonged postoperative course, but has no effect on the incidence of retained CBD stones. Presented at the Annual Meeting of the Southern California Chapter of the American College of Surgeons, Huntington Beach, California, January 21–23, 2000.     

The acute abdomen in the pregnant patient

Background: The acute abdomen in the pregnant patient poses a difficult diagnostic and therapeutic challenge to the surgeon. Appendicitis, cholecystitis, and bowel obstruction account for the majority of the abdominal pain syndromes which require surgical intervention. Laparoscopy is being used increasingly in the diagnosis and operative management of these disorders. Methods: We examine our experience over the last 3 years with 47 women who developed significant abdominal pain during pregnancy. Thirty-four patients had symptomatic gallstone disease, nine had appendicitis, two had incarcerated inguinal hernias, and two had pelvic masses. Twenty-two patients with biliary colic and two patients with acute cholecystitis were managed conservatively during pregnancy. Twenty-three of these underwent laparoscopic cholecystectomy in the postpartum period. A total of 23 women required surgical intervention during pregnancy and 15 underwent a variety of laparoscopic procedures. Ten patients underwent laparoscopic cholecystectomy, and five had laparoscopic appendectomy. The remaining five patients had open appendectomy. Among the 15 laparoscopic procedures, four were performed in the first trimester, seven were performed in the second trimester, and four were performed in the third trimester. Results: Laparoscopy didn't result in increased maternal morbidity. There were no congenital malformations, fetal losses, or premature deliveries in the pregnant patients who underwent laparoscopy. Conclusions: Laparoscopy can be a useful means of diagnosis and in addition a therapeutic tool in selected pregnant patients with abdominal pain. Close maternal and fetal monitoring is essential during and after the procedure. Laparoscopic cholecystectomy is safe and can be performed without additional risk to the fetus for those who require surgical intervention during pregnancy.     

The role of intraoperative cholangiogram in the management of patients recovering from acute biliary pancreatitis

Background Use of the standard management for gallstone-associated acute pancreatitis calls for cholecystectomy with cholangiography performed during the same hospitalization after acute symptoms has decreased. No previous studies, however, have objectively addressed the usefulness of intraoperative cholangiography (IOC) for the management of this condition. This study aimed to determine the incidence of common bile duct (CBD) stones after an acute episode of gallstone pancreatitis. Methods The medical records of all patients who underwent a cholecystectomy and IOC after an episode of gallstone pancreatitis during the same admission between 1999 and 2004 at the University of Alberta and Royal Alexandra hospitals were examined to determine the incidence of CBD stones after resolution of gallstone pancreatitis. Results After a chart review for a series of 86 patients, 63 met the inclusion criteria. All except for one patient had undergone successful IOC (98%). Among the patients who had no evidence of CBD obstruction on preoperative imaging or lab work, three were found to have a filling defect on IOC and stones on their postoperative endoscopic retrograde cholangiopancreatography (ERCP) (3/63, 5%). This is not significantly different from the 4.6% incidence of CBD stones among patients with cholelithiasis who had normal preoperative imaging and blood work. Conclusion In the setting of normal preoperative imaging and lab work, the incidence of CBD stones among patients recovering from acute mild to moderate gallstone pancreatitis is not significantly higher than among patients with no history of pancreatitis. Therefore, an IOC for post-gallstone pancreatitis does not alter management. Presented in oral form at the Canadian Surgery Forum, Montreal, Quebec, September 2005     

The role of endoscopic retrograde cholangiopancreatography and cholangiography in the laparoscopic era.

OBJECTIVE: The authors reviewed the results of endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative cholangiography in a series of patients who underwent laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA: The indications for preoperative and postoperative ERCP and intraoperative cholangiography as adjuncts to laparoscopic cholecystectomy are evolving. The debate regarding the use of selective or routine intraoperative cholangiography has intensified with the advent of laparoscopic cholecystectomy. METHODS: The authors reviewed the records of 343 consecutive patients who underwent laparoscopic cholecystectomy during a 1-year period. Historical, biochemical, and radiologic findings for the patients who underwent ERCP and intraoperative cholangiography were analyzed. RESULTS: Three hundred forty- three patients underwent laparoscopic cholecystectomy during the period reviewed. Preoperative ERCP was performed in 42 patients. Twenty-seven of these patients (64%) had common bile duct (CBD) stones, which were cleared with a sphincterotomy. Intraoperative cholangiography was performed for 101 patients (29%). Three cholangiograms had false- positive results (3%), leading to two CBD explorations, in which no CBD stones were found, and one normal ERCP. Six patients underwent postoperative ERCP, three for the removal of retained CBD stones (0.9%), all of which were cleared with a sphincterotomy. Fifteen patients had gallstone pancreatitis, six of whom had CBD stones (40%) that were cleared by ERCP. There were 33 complications (10%) and no CBD injuries. CONCLUSION: The use of routine intraoperative cholangiography is discouraged in view of its low yield and the significant rate of false positive cholangiogram results.     

The laparoscopic management of appendicitis and cholelithiasis during pregnancy

BACKGROUND: Laparoscopic management of appendicitis and symptomatic cholelithiasis during pregnancy remains controversial. We report the single largest series of laparoscopic cholecystectomies and appendectomies during pregnancy. METHODS: Medical records of all pregnant patients who underwent open or laparoscopic management of appendicitis/cholelithiasis at LDS Hospital from 1990 to 1998 were reviewed. RESULTS: Eighteen open appendectomies (OA) and 13 open cholecystectomies (OC) were performed. Forty-five laparoscopic cholecystectomies (LC) and 22 laparoscopic appendectomies (LA) were performed without birth defects, fetal loss or uterine injury. Preterm delivery rates (PTD) in the LA and OA groups were similar (15.8% versus 11.8%, P>0.9). The PTD rate in the LC group was not significantly different than in the OC group (11.9% versus 10.0%, P>0.9). Neither birth weights nor Apgar scores were significantly different across groups. CONCLUSIONS: Laparoscopic management of appendicitis and symptomatic cholelithiasis during pregnancy can be performed with minimal fetal and maternal morbidity when accepted management guidelines are followed.     

The learning curve of laparoscopic cholecystectomy and changes in indications: one institutions's experience with 2,650 cholecystectomies

PURPOSE: In a prospective series of 2,650 consecutive patients undergoing cholecystectomy, we analyzed the learning curve since the introduction of laparoscopic cholecystectomy (LC) in terms of operating time, conversion rate, morbidity, mortality, and consequent changes in indications for either laparoscopic or open cholecystectomy (OC). PATIENTS AND METHODS: Between July 1990 and June 1997, LC was performed in 1,929 patients (73%), 203 of whom (7.5%) had to be converted to OC, while 518 patients (19.5%) had primary OC. Patients having LC were predominantly female, younger, with less comorbidity and less complicated gallstone disease than patients having OC. RESULTS: Barring a learning curve during the first 6 months of LC, operating time remained constant at an average of 71 minutes while operating on ever more complex pathologies. The conversion rate decreased from 9.4% to 6.7% during the 7-year period. A relatively constant team of surgeons with growing experience as well as constantly improving technical equipment allowed the complication rate to remain low. The total morbidity of LC was 2.5% (0.1% bile duct injury), that of conversions 5%, and that of OC 12.5%. The mortality was 0 for LC, 0.5% for conversions, and 1% for OC. CONCLUSION: The indications for primary OC decreased from 50% to 8.5% and the indications for LC could be broadened over the years.     

胆囊切除术对胆囊结石患者术后排便功能的影响

目的：比较内镜微创保胆取石术（EGPCL）与胆囊切除术对胆囊结石患者术后排便功能的影响。方法：采用分层随机抽样的方法选取2001—2011年间收治胆囊结石患者330例（术后1年以上）进行问卷进行随访调查,分析患者术后腹泻与便秘的发生情况。结果：共收回有效问卷298例,其中腹腔镜胆囊切除术（LC）28例,开腹胆囊切除术（OC） 108例,EGPCL 162例。LC,OC,EGPCL组腹泻的发生率分别为3.57%（1/28）,6.48%（7/108）,0.62%（1/162）;便秘的发生率分别为10.71%（3/28）,9.26%（10/108）,2.47%（4/162）;腹泻并便秘的发生率分别为35.18%（38/108）,21.43%（6/28）,16.67%（27/162）。EGPCL组以上3种情况的发生率均明显低于胆囊切除术组（OC组+LC组）（均P<0.01）。无论是胆囊切除术还是EGPCL,腹泻与便秘的发生率与患者年龄无明显关系（均P>0.05）。结论：胆囊切除可导致腹泻或便秘的发生,对术前有排便异常的患者,应重视胆囊功能的保留。     

Limits and advantages of fundus-first laparoscopic cholecystectomy: lessons learned

BACKGROUND: Fundus-first cholecystectomy is well recognized as a safe technique during open cholecystectomy (OC) because it minimizes the risk of injuries to the biliary structures at the Calot's triangle. Fundus-first laparoscopic cholecystectomy (FFLC), like the OC, has been proposed as a safe method to approach the cystic duct in cases of difficult anatomy in order to limit biliary injuries and to reduce the conversion rate. The aim of our study was to highlight the limits and advantages of the FFLC, in order to evaluate whether the potential complications are counterbalanced by the expected reduction of the conversion rate. METHODS: We retrospectively analyzed 1965 consecutive cases of laparoscopic cholecystectomies performed for gallbladder disease from 1994 to 2005. Reasons for adoption of the FFLC, conversion to OC, and complications were compiled. RESULTS: The FLC was performed in 29 cases (1.5%) and was successful in 23 patients (80%). The median operating time for the FFLC was 65 minutes (range, 40-170). In 6 patients (20%), FFLC was eventually converted to open operation. Intraoperative cholangiography (IOC) was performed successfully in 17 cases (74%). Common bile duct (CBD) stones were found in 6 cases (20%). Minor complications occurred in 6 patients (20%). No CBD injuries occurred. Two cases of residual CBD stones were treated postoperatively. Mortality rate was nil. CONCLUSIONS: The FLC remains a safe option when dealing with patients with difficult anatomy at the Calot's triangle, but its adoption needs a good surgical judgment. Considering the high incidence of CBD stones in this series, the high failure rates in performing an IOC represent the most important limiting factor.     

Cholelithiasis and cholecystitis

Gallstone disease remains one of the most common medical problems leading to surgical intervention. Every year, approximately 500,000 cholecystectomies are performed in the US. Cholelithiasis affects approximately 10% of the adult population in the United States. It has been well demonstrated that the presence of gallstones increases with age. An estimated 20% of adults over 40 years of age and 30% of those over age 70 have biliary calculi. During the reproductive years, the female-to-male ratio is about 4:1, with the sex discrepancy narrowing in the older population to near equality. The risk factors predisposing to gallstone formation include obesity, diabetes mellitus, estrogen and pregnancy, hemolytic diseases, and cirrhosis. A study of the natural history of cholelithiasis demonstrates that approximately 35% of patients initially diagnosed with having, but not treated for, gallstones later developed complications or recurrent symptoms leading to cholecystectomy. During the last two decades, the general principles of gallstone management have not notably changed. However, methods of treatment have been dramatically altered. Today, laparoscopic cholecystectomy, laparoscopic common bile duct exploration, and endoscopic retrograde management of common bile duct (CBD) stones play important roles in the treatment of gallstones. These technological advances in the management of biliary tract disease are not infrequently accomplished by a multidisciplinary team of physicians, including surgeons trained in laparoscopic techniques, interventional gastroenterologists, and interventional radiologists. With the evolution of laparoscopic cholecystectomy, there has been a global reeducation and retraining program of surgeons. However, the treatment of choice for gallstones remains cholecystectomy. In recognition of the revolutionary advances in the treatment of cholelithiasis, it is the purpose of this collective review to describe recent information on the following topics: types of gallstones, asymptomatic gallstones, symptomatic gallstones, chronic cholecystitis, acute cholecystitis, and other complications of gallstones. Gross and compositional analysis of gallstones allows them to be classified as cholesterol, mixed, and pigment gallstones. When asymptomatic gallstones are detected during the evaluation of a patient, a prophylactic cholecystectomy is normally not indicated because of several factors. Only about 30% of patients with asymptomatic cholelithiasis will warrant surgery during their lifetime, suggesting that cholelithiasis can be a relatively benign condition in some people. However, there are certain factors that predict a more serious course in patients with asymptomatic gallstones and warrant a prophylactic cholecystectomy when they are present. These factors include patients with large (>2.5 cm) gallstones, patients with congenital hemolytic anemia or nonfunctioning gallbladders, or during bariatric surgery or colectomy. Epigastric and right upper quadrant pain occurring 30-60 minutes after meals is frequently associated with gallstone disease. The diagnosis of chronic cholecystitis is made by the presence of biliary colic with evidence of gallstones on an imaging study. Ultrasonography is the diagnostic test of choice, being 90-95% sensitive. The surgical literature suggests that 3-10% of patients undergoing cholecystectomy will have CBD stones. Intraoperative laparoscopic ultrasonography has recently replaced cholangiography as the method of choice for detecting CBD stones. Ultrasonography and radionuclide cholescintigraphy (HIDA scan) are useful in establishing a diagnosis of acute cholecystitis. Laparoscopic cholecystectomy should also be used in the treatment of acute cholecystitis. Laparoscopic cholecystectomy is more likely to be successful when performed within 3 days of the onset of symptoms. It is important to remember that gallstones can lead to a variety of other complications including choledocholithiasis, gallstone ileus, and acute gallstone pancreatitis.     

Value and consequences of routine intraoperative cholangiography during cholecystectomy

Since the introduction of laparoscopic cholecystectomy (LC), an increase in accidental common bile duct (CBD) injuries of up to 1.2-1.6% has been reported. In the present prospective study of 1,710 patients undergoing cholecystectomy (1,241 LC procedures and 469 open cholecystectomies [OC]), we tested the predicative value of routine intraoperative cholangiography (IOC). The IOC was feasible in 92.4% of the cases in the LC group and in 83% of cases in the OC group and presented a complete depiction of the extrahepatic bile system in 98.3%. Anatomic variations of the bile duct system, which influenced the operative management, were found in 13.2% of cases (13.4% LC versus 12.8% OC). In 2.5% of the patients, preoperatively undetected CBD stones were also found. Method-specific complications did not occur in any of the patients. Additionally, in a controlled subgroup analysis of 163 patients, we evaluated preoperative intravenous cholangiography (IVC) and IOC. Intravenous cholangiography showed only 72.4% of the operation-relevant anatomic variations (vs. 100% by IOC); in 6.1% of the cases, there were reactions to the dye (vs. none in IOC), and in only 28.6% of the patients, CBD stones were detected (vs. 71.4% IOC). There were four bile duct injuries (0.29%) during LC and two (0.4%) during OC. All injuries were detected intraoperatively and fixed in the same setting without postoperative complications. In conclusion, we recommend the use of routine IOC during cholecystectomy. By this technique, anatomic variations of the bile duct system will be visualized and therefore accidental injuries will be avoided.     

Routine intraoperative laparoscopic ultrasonography with selective cholangiography reduces bile duct complications during laparoscopic cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy (LC) is the preferred treatment for gallstone disease, even in many complicated cases. Perhaps the only downside to LC is a two- to threefold increase in common bile duct (CBD) injuries compared with open cholecystectomy (OC). Intraoperative cholangiography may prevent inj uries, but its routine use remains controversial. Our institution adopted a policy of selective intraoperative cholangiography in 1993. When intraoperative laparoscopic ultrasonography (IOUS) emerged as a viable diagnostic adjunct, it was hypothesized that the routine use of IOUS would facilitate dissection, detect occult choledocholithiasis, and prevent bile duct injuries during LC. STUDY DESIGN: The experience with LC at our university-affiliated teaching hospital was reviewed. Over a 4 1/2-year period (June 1, 1995, to January 31, 2000), two surgeons used IOUS routinely during LC (ultrasonography [US] group, n = 248); three other surgeons did not (non-US group, n = 594). We compared patient data and outcomes between the two groups. Continuous, data are expressed as mean +/- SEM. RESULTS: During the study period, 842 LCs were attempted. Patient age (37+/-1 years) and gender (85% female) did not differ between the groups. In the US group, more patients had acute cholecystitis (p < 0.05). More LCs were performed per year by non-US surgeons than US surgeons (45 versus 37). Despite this, all bile duct complications occurred in non-US cases (2.5% overall): five CBD injuries (0.8%), six bile leaks (1%), and four retained CBD stones (0.7%). In the subgroup of patients with acute cholecystitis, there were fewer conversions to OC in US compared with non-US cases (24% versus 36%, p = 0.09). CONCLUSIONS: IOUS is noninvasive, fast, repeatable, and can corroborate real-time visualization of the operative field. We have found that LC with IOUS is associated with fewer bile duct complications (CBD injuries, bile leaks, and retained CBD stones) than LC without adjunctive imaging. The success rate of LC in cases of acute cholecystitis is slightly higher when IOUS is used as an aid to dissection. In the absence of definitive prospective data, we recommend routine use of IOUS when performing LC, particularly in patients with acute cholecystitis.     

Intraoperative cholangiography can be safely omitted during laparoscopic cholecystectomy: a prospective study of 413 consecutive patients.

BACKGROUND AND AIMS: The aim of the study was to show that laparoscopic cholecystectomy (LC) can be performed safely without intraoperative cholangiography (IOC). MATERIAL AND METHODS: We conducted a prospective study of 413 consecutive patients with symptomatic gallstone disease, who underwent LC. According to the preoperative clinical, laboratory and ultrasound criteria, 38 patients (9.2%) were selected for preoperative endoscopic retrograde cholangiography (ERC). All patients were followed postoperatively for symptoms and signs of common bile duct (CBD) stones. RESULTS: Preoperative ERC allowed to make a diagnosis of choledocholithiasis in 22 (58%) of the 38 selected patients. Stone clearance was achieved with endoscopic sphincterotomy (ES) in all cases. Three patients (7.9%) had an episode of mild self-limited pancreatitis after the procedure. Eight patients (1.9%) of 413 required conversion from LC to open cholecystectomy. There were no CBD injuries and no death cases. Of the postoperative complications, 1.5% were recorded during hospital stay. During the follow-up period, for at least 2 years after surgery, retained CBD stones were verified in 6 patients (1.5%); however, the supposed rate of residual stones was 2.4%. CONCLUSIONS: This study demonstrates that performance of selective preoperative ERC with ES when necessary, followed by LC, is an appropriate and safe approach to the treatment of patients with cholecystolithiasis and unsuspected choledocholithiasis. This approach allows to omit IOC and to perform LC safely without biliary duct injuries, ensuring low rate of retained CBD stones in the late follow-up period.     

Current Status of Surgical Management of Acute Cholecystitis in the United States

BACKGROUND: We attempted to determine population-based outcomes of laparoscopic (LC) and open cholecystectomy (OC) for acute cholecystitis (AC). METHODS: We used the National Hospital Discharge Surveys from 2000 through 2005. Annual medical and demographic data from a national sample of discharge records from nonfederal, short-stay hospitals were queried. We identified all patients who underwent LC or OC for AC. The main outcome measures were the rate of LC or OC and in-hospital morbidity and mortality. One million patients underwent cholecystectomy (859,747 LCs; 152,202 OCs) for AC during 2000-2005. RESULTS: Of the cases started laparoscopically, 9.5% were converted to OC. Compared to OC, patients who underwent LC were more likely to be discharged home (91% vs. 70%), carry private insurance (47% vs. 30%), suffer less morbidity (16% vs. 36%), and have a lower unadjusted mortality (0.4% vs. 3.0%). OC was associated with a 1.3-fold increase (95% confidence interval 1.1-1.4) in perioperative morbidity compared to LC after adjusting for patient and hospital factors. CONCLUSIONS: Most patients in the 21st century with AC undergo LC with a low conversion rate and low morbidity. In the general population with acute cholecystitis, LC results in lower morbidity and mortality rates than OC even in the setting of open conversion.     

The use of ERCP in the management of common bile duct stones in patients undergoing laparoscopic cholecystectomy

Summary The purpose of this study was to evaluate the indications and results of endoscopic retrograde cholangiopancreatography (ERCP) for gallstone disease since the advent of laparoscopic cholecystectomy. In our personal series of 410 consecutive cases of laparoscopic cholecystectomy, we found 17 common bile duct (CBD) stones; seven were identified by preop ERCP, nine at laparoscopy by intraoperative cholangiography, and one postop by ERCP. We have performed preop ERCP in 21 patients (5.1%); CBD stones were found in seven. Our indications for preop ERCP were elevated liver function tests, dilatation of the common duct by ultrasound, or a history of jaundice/pancreatitis, and all stones were successfully removed by endoscopic sphincterotomy. At laparoscopic cholecystectomy nine patients were found to have stones; one was treated with laparoscopic methods, four with open CBD exploration, and four by postop endoscopic sphincterotomy. Post-laparoscopic cholecystectomy, five patients underwent ERCP for pain or increased liver function tests suggestive of common duct stones. One of the five was found to have stones and these were successfully removed by endoscopic sphincterotomy. ERCP is very useful as a diagnostic and therapeutic modality in laparoscopic cholecystectomy patients with suspected CBD stones. Elevated liver function tests and dilated CBD by ultrasound are the most accurate predictors of stones. Endoscopic sphincterotomy is a more effective route, at present, for stone removal than a laparoscopic approach.