Cholecystectomy Concomitant with Laparoscopic Gastric Bypass: A Trend Analysis of the Nationwide Inpatient Sample from 2001 to 2008

Background  

Gallstone formation is common in obese patients, particularly during rapid weight loss. Whether a concomitant cholecystectomy should be performed during laparoscopic gastric bypass surgery is still contentious. We aimed to analyze trends in concomitant cholecystectomy and laparoscopic gastric bypass surgery (2001–2008), to identify factors associated with concomitant cholecystectomy, and to compare short-term outcomes after laparoscopic gastric bypass with and without concomitant cholecystectomy.     

免气腹三孔法腹腔镜胆囊切除术的探讨

目的:探讨硬膜外阻滞下免气腹三孔法腹腔镜胆囊切除术(laparoscop ic cholecystectomy,LC)在临床上的应用。方法:回顾性分析2002年4月~2006年10月386例胆囊结石或胆囊息肉患者在连续硬膜外阻滞下施行免气腹腹腔镜胆囊切除术的临床资料。结果:386例中除5例中转手术外,381例均顺利完成LC。术后无酸中毒、肩痛、心肺功能的进一步损伤及其他并发症发生。结论:免气腹三孔法LC非常适用于心肺功能差、肾功能不全及肝硬化等不能耐受气腹的老年患者,手术费用降低,并发症发生率下降。     

Is concomitant cholecystectomy necessary in obese patients undergoing laparoscopic gastric bypass surgery?

Background  Morbid obesity is associated with a high prevalence of cholecystopathy, and there is an increased risk of cholelithiasis during rapid weight loss following gastric bypass. In the era of open gastric bypass prophylactic cholecystectomy was advocated. However, routine cholecystectomy at laparoscopic gastric bypass is controversial. Methods  We performed a retrospective review of a prospectively maintained database of morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) from February 2000 to August 2006. All had routine preoperative biliary ultrasonography. Concomitant cholecystectomy at LRYGB was planned in patients with proven cholelithiasis and/or gallbladder polyp ≥1 cm diameter. Results  1711 LRYGBs were performed. Forty-two patients (2.5%) had a previous cholecystectomy and were excluded from further analysis. Two hundred and five patients (12%) had gallbladder pathology: cholelithiasis in 190 (93%), sludge in 14 (6.8%), and a 2 cm polyp in 1 (0.5%). One hundred and twenty-three patients with cholelithiasis (65%) had a concomitant cholecystectomy at LRYGB, while 68 (35.7%) did not. Of these, 123 (99%) were completed laparoscopically. Concomitant cholecystectomy added a mean operative time of 18 min (range 15–23 min). One patient developed an accessory biliary radicle leak requiring diagnostic laparoscopic transgastric endoscopic retrograde cholangiopancreatography (LTG-ERCP). Of the 68 patients with cholelithiasis who did not undergo cholecystectomy 12 (17.6%) required subsequent cholecystectomy. A further 4 patients with preoperative gallbladder sludge required cholecystectomy. All procedures were completed laparoscopically. One patient required laparoscopic choledochotomy and common bile duct exploration (CBDE) with stone retrieval. Eighty-eight patients (6%) with absence of preoperative gallbladder pathology developed symptomatic cholelithiasis after LRYGB; 69 (78.4%) underwent laparoscopic cholecystectomy; 3 presented with gallstone pancreatitis and 2 with obstructive jaundice, requiring laparoscopic transcystic CBDE in 4 and LTG-ERCP in one. Conclusion  In our experience, concomitant cholecystectomy at LRYGB for ultrasonography-confirmed gallbladder pathology is feasible and safe. It reduces the potential for future gallbladder-related morbidity, and the need for further surgery. Competing Interests Declared: None     

Laparoscopic surgery with carbon dioxide insufflation causes respiratory acidosis.

This study analyzes the changes in cardiopulmonary parameters of patients undergoing laparoscopic cholecystectomy. Six healthy females with normal preoperative cardiopulmonary status were selected for laparoscopic surgery using the same criteria as for traditional cholecystectomy. Respiratory and cardiovascular parameters were collected and compared prior to peritoneal insufflation and just before desufflation. Patients experienced significant elevations of arterial and end-tidal CO2, accompanied by decreased pH. Bicarbonate concentration, blood pressure and pulse rate remained constant. Based on these results, and on our laboratory investigations, we have introduced helium as an alternate agent for insufflation, and present the data from the first two patients so managed. No change was observed in EtCO2, PaCO2 or pH in either of these two patients during the course of surgery. We conclude that hypercarbia occurs in those undergoing laparoscopic cholecystectomy with CO2 insufflation. This acidosis requires compensation by increased minute ventilation to prevent decline in pH. In our initial experience, helium did not produce these changes, and therefore merits further investigation as an alternate agent for abdominal insufflation.     

Infected aortic pseudoaneurysm following laparoscopic cholecystectomy

A 38-year-old hemodialysis-dependent diabetic female patient underwent a laparoscopic cholecystectomy for symptomatic cholelithiasis. Postoperatively, she developed chronic back pain. Eight months following laparoscopic cholecystectomy, she developed fevers and recurrent bacteremia with methicillin-resistant Staphylococcus aureus, despite removal of all indwelling intravenous dialysis access. An abdominal CT scan demonstrated a 7-cm pseudoaneurysm extending from the right anterolateral lower abdominal aorta. Following resection of her infected aneurysm and extraanatomic bypass, she cleared her bacteremia and recovered. This first report of an aortic pseudoaneurysm following laparoscopic cholecystectomy is presented in the context of other vascular complications reported following the same procedure.     

Bile duct injuries at laparoscopic cholecystectomy: early repair results

STUDY AIM: To compare the early repair results in bile duct injuries at laparoscopic cholecystectomy to a later repair and so the early reconstruction by an end-to-end anastomosis to a Roux-en-Y bypass. PATIENTS AND METHOD: From 1990 to 2003, twelve patients were treated for bile duct injury, not diagnosed at the time of cholecystectomy and had an early repair within 30 days after the cholecystectomy. They had either a duct to duct anastomosis or a Roux-en-Y bypass at the time of the reconstruction. RESULTS: The level of the injury was Bismuth II (N=7), III (N=1), IV (N=2) and V (N=1) referral to Bismuth classification and one isolated right sectoral duct injury. Four patients had an duct to duct anastomosis and eight an hepaticojejunostomy at a median of 15.3 days after cholecystectomy. With one patient lost to follow up, the overall success rate in this series was 81.8% after reconstruction with a mean 40 months follow up. The reconstruction by an end to end anastomosis was successful in 100% of patients (with a mean 31.2 months follow up) and in 71.4% of patients after a Roux-en-Y biliary reconstruction (with a mean 45 months follow up). CONCLUSION: Good results may be performed, by an early repair in bile duct injuries at laparoscopic cholecystectomy, either by an duct to duct anastomosis or a Roux-en-Y bypass.     

Analysis of the hemodynamic and ventilatory effects of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy uses carbon dioxide, a highly diffusable gas, for insufflation. With extended periods of insufflation, patient arterial carbon dioxide levels may be adversely altered. Patients were selected for laparoscopic cholecystectomy using the same criteria as for open cholecystectomy. Twenty patients (group 1) had normal preoperative cardiopulmonary status (American Society of Anesthesiologists class I), while 10 patients (group 2) had previously diagnosed cardiac or pulmonary disease (class II or III). Demographic, hemodynamic, arterial blood gas, and ventilatory data were collected before peritoneal insufflation and at intervals during surgery. Patients with preoperative cardiopulmonary disease demonstrated significant increases in arterial carbon dioxide levels and decreases in pH during carbon dioxide insufflation compared with patients without underlying disease. Results of concurrent noninvasive methods of assessing changes in partial arterial pressures of carbon dioxide (end-tidal carbon dioxide measured with mass spectrographic techniques) may be misleading and misinterpreted because changes in partial arterial pressures of carbon dioxide are typically much smaller than changes in arterial blood levels and, unlike arterial gas measurements, do not indicate the true level of arterial hypercarbia. During laparoscopic cholecystectomy, patients with chronic cardiopulmonary disease may require careful intraoperative arterial blood gas monitoring of absorbed carbon dioxide.     

Heart arrest caused by CO2 embolism during a laparoscopic cholecystectomy

A 41-year-old woman developed a gas embolism while inserting a Veress needle to achieve pneumoperitoneum for laparoscopic cholecystectomy. The embolism led to asystole, which was corrected after advanced cardiopulmonary resuscitation maneuvers, and was followed by sequelae and a prolonged hospital stay. The anesthesiologist should be vigilant during laparoscopic surgery and be ready and able to act in case of major complications.     

Almost Routine Prophylactic Cholecystectomy During Laparoscopic Gastric Bypass is Safe

Background Morbidly obese patients are at high risk to develop gallstones, and rapid weight loss after bariatric surgery further enhances this risk. The concept of prophylactic cholecystectomy during gastric bypass has been challenged recently because the risk may be lower than reported earlier and because cholecystectomy during laparoscopic gastric bypass may be more difficult and risky. Methods A review of prospectively collected data on 772 patients who underwent laparoscopic primary gastric bypass between January 2000 and August 2007 was performed. The charts of patients operated before 2004 were retrospectively reviewed regarding preoperative echography and histopathological findings. Results Fifty-eight (7.5%) patients had had previous cholecystectomy. In the remaining patients, echography showed gallstones or sludge in 81 (11.3%). Cholecystectomy was performed at the time of gastric bypass in 665 patients (91.7%). Gallstones were found intraoperatively in 25 patients (3.9%), for a total prevalence of gallstones of 21.2%. The age of patients with gallstones was higher than that of gallstone-free patients (43.5 vs 38.7 years, p < 0.0001). Of the removed specimens, 81.8% showed abnormal histologic findings, mainly chronic cholecystitis and cholesterolosis. Cholecystectomy was associated with no procedure-related complication, prolonged duration of surgery by a mean of 19 min (4–45), and had no effect on the duration of hospital stay. Cholecystectomy was deemed too risky in 59 patients (8.3%) who were prescribed a 6-month course of ursodeoxycolic acid. Conclusion Concomitant cholecystectomy can be performed safely in most patients during laparoscopic gastric bypass and does not prolong hospital stay. As such, it is an acceptable form of prophylaxis against stones forming during rapid weight loss. Whether it is superior to chemical prophylaxis remains to be demonstrated in a large prospective randomized study.     

Laparoscopic cholecystectomy in cirrhotic patients

Background: This study aimed to evaluate the safety of laparoscopic cholecystectomy for patients with cirrhosis. Methods: The records of 22 laparoscopic cholecystectomies performed in patients with cirrhosis Child–Pugh A and B, from January 1995 to July 2001 were retrospectively reviewed. Results: No deaths occurred. Conversion to open cholecystectomy was necessary in two cases. The average operative time was 115 min, which was significantly shorter than that for patients undergoing open cholecystectomy. None of the patients required blood transfusion. Intraoperative problems occurred in two patients who experienced liver bed bleeding. Postoperative morbidity occurred in 36% of the patients and included hemorrhage, wound complications, intraabdominal collections, and cardiopulmonary complications, but all were controlled. The patients were dismissed after an average of 4 days. Conclusion: The authors believe laparoscopic cholecystectomy can be performed safely in selected patients with cirrhosis Child–Pugh A and B who manifest indication for surgery. Laparoscopic cholecystectomy offers several advantages over open cholecystectomy: lower morbidity, shorter operative time, and reduced hospital stay.     

联合手术治疗胆囊结石合并2型糖尿病55例

目的探讨采用胆囊切除加Y型胃肠短路联合手术治疗胆囊结石合并2型糖尿病(T2DM)的临床疗效。方法对2008年5月—2010年6月间收治的55例胆囊结石合并T2DM分别采用开腹或腹腔镜胆囊切除联合Roux-en-Y型胃肠短路术,随访1年,分析其临床资料包括手术前后体质指数(BMI),空腹血糖水平(FBG),空腹胰岛素水平(FINS),胰岛素功能指数(HOMA-IR),糖化血红蛋白(HbA1c)的变化及术后1年糖尿病转归情况。结果胆囊结石55例全部治愈。I,II组患者术后BMI较术前无明显变化(P>0.05);全组患者从术后1个月开始空腹血糖水平即出现持续而稳定下降的趋势(P<0.05);伴随着术后血糖水平及胰岛素功能指数的改善,糖化血红蛋白亦出现明显下降(P<0.05)。结论胆囊切除术联合Roux-en-Y型胃肠短路术除可治愈胆囊结石外,对2型糖尿病也具较好的疗效。     

Laparoscopic cholecystectomy and open-heart surgery at the same time

BACKGROUND: Abdominal procedures in patients with coronary artery disease or severe valvular disease have high risk of mortality and morbidity. AIMS: In order to prevent bile peritonitis after cardiac surgery, to reduce the hospitalization course, and to decrease the mortality and morbidity after the surgery, laparoscopic cholecystectomy and open-heart surgery were performed at the same time. METHODS: Laparoscopic cholecystectomy and open-heart surgery were performed on two patients who had been referred to Cardiothoracic Ward of Modarres Hospital, Tehran, Iran. RESULTS: Simultaneous classic laparoscopic cholecystectomy was successfully performed on two different open-heart patients, one with coronary artery disease for coronary artery bypass surgery and the other with severe mitral valve disorder for mitral valve replacement. CONCLUSIONS: Abdominal procedures are suggested to be done with cardiac surgery at the same time with laparoscopic technique to reduce mortality and morbidity in these patients.     

Patient state index during a cardiac arrest in the operating room

A 53-yr-old man undergoing laparoscopic cholecystectomy experienced cardiac arrest intraoperatively. Patient state index values decreased to single digits during the cardiac arrest and returned to baseline after successful cardiopulmonary resuscitation.     

Concomitant coronary artery bypass and cholecystectomy: a case report

A case is reported in which simultaneous surgical correction of coronary atherosclerosis and cholelithiasis was performed. A 71-year-old man was admitted with severe stable angina and right hypochondrial dull pain. Coronary angiograms disclosed severe triple vessel disease, and abdominal echography demonstrated gallstone. He underwent bypass of left anterior descending, diagonal, obtuse marginal, and right coronary arteries with autogenous saphenous vein on cardiopulmonary bypass. The procedure was followed immediately by cholecystectomy. His postoperative course was uneventful.     

Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass

OBJECTIVE: To analyze long-term weight loss, changes in comorbidities and quality of life, and late complications after laparoscopic and open gastric bypass. SUMMARY BACKGROUND DATA: Early results from our prospective randomized trial comparing the outcome of laparoscopic versus open gastric bypass demonstrated less postoperative pain, shorter length of hospital stay, fewer wound-related complications, and faster convalescence for patients who underwent laparoscopic gastric bypass. METHODS: Between May 1999 and March 2001, 155 morbidly obese patients were enrolled in this prospective trial, in which 79 patients were randomized to laparoscopic gastric bypass and 76 to open gastric bypass. Two patients in the laparoscopic group required conversion to open surgery; their data were analyzed within the laparoscopic group on an intention-to-treat basis. The 2 groups were well matched for body mass index, age, and gender. Outcome evaluation included weight loss, changes in comorbidities and quality of life, and late complications. RESULTS: The mean follow-up was 39+/-8 months. There were no significant differences in the percent of excess body weight loss between the 2 groups at the 3-year follow-up (77% for laparoscopic versus 67% for open). The rate of improvement or resolution of comorbidities was similar between groups. Improvement in quality of life, measured by the Moorehead-Ardelt Quality of Life Questionnaire, was observed in both groups without significant differences between groups. Late complications were similar between groups except for the rate of incisional hernia, which was significantly greater after open gastric bypass (39% versus 5%, P<0.01), and the rate of cholecystectomy, which was greater after laparoscopic gastric bypass (28% versus 5%, P=0.03). CONCLUSIONS: In this randomized trial with a 3-year follow-up, we found that laparoscopic gastric bypass was equally effective as open gastric bypass with respect to weight loss and improvement in comorbidities and quality of life. A major advantage at long-term follow-up for patients who underwent laparoscopic gastric bypass was the reduction in the rate of incisional hernia.     

Laparoscopic cholecystectomy in patients with mild cirrhosis and symptomatic cholelithiasis

BACKGROUND: Our goal was to support the emerging opinion that laparoscopic cholecystectomy is safe and well tolerated in selected cirrhotic patients with indications for surgery. We present our experience with 50 laparoscopic cholecystectomies performed on patients with mild cirrhosis. METHODS: We retrospectively reviewed and analyzed the outcomes of 50 laparoscopic cholecystectomies performed between January 1995 and May 2006 in patients with Child-Pugh A and B cirrhosis. RESULTS: Laparoscopic cholecystectomy was uneventful for 35 cirrhotic patients. Conversion to an open procedure was necessary in two Child-Pugh B patients with chronic cholelcystitis. One Child-Pugh B cirrhotic patient required blood transfusion. Postoperative complications occurred in 12 patients, including hemorrhage, wound infection, intra-abdominal collection, and cardiopulmonary complications. The mean postoperative stay was 5 days (range, 3 to 13). No deaths occurred. CONCLUSIONS: Laparoscopic cholecystectomy is a safe procedure in well-selected Child-Pugh A and B cirrhotic patients and should be the gold standard for patients with mild cirrhosis and symptomatic cholelithiasis.     

The decline of training in open biliary surgery: effect on the residents' attitude toward bile duct surgery

BACKGROUND: After more than a decade of growth for laparoscopic cholecystectomy and decline in open cholecystectomy, the impact on the training of resident's in other open biliary operations can be analyzed quantitatively. METHODS: The national operative statistics for residents' operations from 1988 to 2001 (data in the public domain) were analyzed by regression analysis to establish trends and to calculate the rate of change. For laparoscopic biliary operations, the changes in laparoscopic and open operations over time and the number of operations per trainee each year were used to measure the growth of a laparoscopic operation and to predict future trends. A survey of attitude, management algorithm, and self-confidence for coping with unexpected events in laparoscopic cholecystectomy also was conducted for senior residents and recent graduates. RESULTS: In 2001, open cholecystectomy decreased to 28%, open common duct exploration to 27%, sphincteroplasty to 20%, of 1988 (baseline year) levels. Cholecystostomy and choledochoenteric bypass decreased to 70% and 75%, respectively. The decline began before the era of laparoscopic cholecystectomy, but accelerated after its introduction. Many of the recent graduates surveyed in one program indicated a preference for a nonsurgical, mainly endoscopic, approach for all bile duct conditions, but also for the assistance of senior surgeons in the operative management of unexpected events. CONCLUSION: The popularity of noninvasive therapy in biliary surgery significantly reduced the resident's exposure to open biliary surgery, adversely affecting their confidence in the management of unexpected events encountered during laparoscopic operations. Supplemental and remedial education measures must be instituted in training programs.     

Laparoscopic surgery without pneumoperitoneum

Laparoscopic surgery using pneumoperitoneum to create an operating field is known to have cardiopulmonary side effects. Conventional laparoscopic techniques require operating in a sealed environment. In July 1992, we initiated an investigation of the use of an electric-powered abdominal-wall lifter to expose an operating field. In our preliminary study, we have sucessfully completed 16 of 20 cases (80%) using this method of exposure. One trocar-related small-bowel injury was recognized immediately and repaired uneventfully. Two patients with dense adhesions made laparoscopic cholecystectomy impossible. One case of laparoscopic cholecystectomy was completed by conversion to pneumoperitoneum. Conventional instruments can be used through small incisions. Digital examination of abdominal contents can be achieved through the periumbilical incision or through other small incisions with the guidance of this retractor; this is superior to pneumoperitoneum since the surgeon can use more than just visual examination of intraabdominal pathology in laparoscopic surgery.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Phoenix, Arizona, USA, 31 March-3 April 1993     

The decline of training in open biliary surgery

Background: After more than a decade of growth for laparoscopic cholecystectomy and decline in open cholecystectomy, the impact on the training of resident's in other open biliary operations can be analyzed quantitatively. Methods: The national operative statistics for residents' operations from 1988 to 2001 (data in the public domain) were analyzed by regression analysis to establish trends and to calculate the rate of change. For laparoscopic biliary operations, the changes in laparoscopic and open operations over time and the number of operations per trainee each year were used to measure the growth of a laparoscopic operation and to predict future trends. A survey of attitude, management algorithm, and self-confidence for coping with unexpected events in laparoscopic cholecystectomy also was conducted for senior residents and recent graduates. Results: In 2001, open cholecystectomy decreased to 28%, open common duct exploration to 27%, sphincteroplasty to 20%, of 1988 (baseline year) levels. Cholecystostomy and choledochoenteric bypass decreased to 70% and 75%, respectively. The decline began before the era of laparoscopic cholecystectomy, but accelerated after its introduction. Many of the recent graduates surveyed in one program indicated a preference for a nonsurgical, mainly endoscopic, approach for all bile duct conditions, but also for the assistance of senior surgeons in the operative management of unexpected events. Conclusion: The popularity of noninvasive therapy in biliary surgery significantly reduced the resident's exposure to open biliary surgery, adversely affecting their confidence in the management of unexpected events encountered during laparoscopic operations. Supplemental and remedial education measures must be instituted in training programs.     

Routine Preoperative Ultrasonography and Selective Cholecystectomy in Laparoscopic Roux-en-Y Gastric Bypass. Why Not?

Background Preoperative evaluation and treatment of biliary lithiasis in morbid obese patients who are candidates to bariatric surgery raise a series of questions which to date has no clear consensus. The aim of this study was to evaluate the results of routine preoperative abdominal ultrasonography and selective cholecystectomy comparing patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) with and without simultaneous cholecystectomy. Methods The prospective database of all the patients who underwent laparoscopic RYGBP in our institution was reviewed. The demographic characteristics, comorbidities, operative time, hospital stay, and postoperative complications were analyzed. Results From August 2001 to December 2006, 1,311 patients underwent laparoscopic RYGBP, 137 (10.4%) of them were excluded due to previous cholecystectomy. In 128 (10.9%) of the remaining 1,174 patients, a cholecystectomy associated to laparoscopic RYGBP was performed. The mean age was 38.5 ± 10.1 years, and 106 (82.8%) were women. The mean operative time in patients with and without simultaneous cholecystectomy was 129.8 ± 45 and 108.5 ± 43 min, respectively (p < 0.001). The hospital stay was 3.6 ± 0.8 days in patients with simultaneous cholecystectomy and 4 ± 3 days in patients without simultaneous cholecystectomy (p = 0.003). There were no deaths. Postoperative complications were observed in 9 (7%) and 73 (6.9%) patients with and without simultaneous cholecystectomy respectively (p = NS). Postoperative complications were not related to the cholecystectomy. Conclusion Cholecystectomy associated to laparoscopic RYGBP should be considered in all patients with preoperative ultrasound diagnosis of cholelithiasis.