Response of serum cytokines in patients undergoing laparoscopic cholecystectomy

The clinical observation that a laparoscopic cholecystectomy is a minimally invasive operation has not been demonstrated on a biochemical basis. Interleukin-6, a known endogenous pyrogen and hepatocyte-stimulating protein, correlates with the significance of surgical trauma. Utilizing the IL-6 immunoassay, we studied this biochemical parameter of trauma to compare its response in laparoscopic vs open cholecystectomy. Sixteen patients who underwent only laparoscopic cholecystectomy showed peak IL-6 concentrations of 51 pg/ml (22–86) vs a peak IL-6 concentration of 124 pg/ml (56–225) for open cholecystectomy. Six additional patients who underwent an ERCP followed by laparoscopic cholecystectomy showed a dramatic rise in peak IL-6 concentration to 315 pg/ml (15–634). These results biochemically confirm the true minimal invasiveness of laparoscopic cholecystectomy. The findings in the ERCP-followed-by-laparoscopic-cholecystectomy group support the theory that two invasive procedures in close proximity may prime the cytokine system in its response to surgical trauma.Presented at the annual meeting of the Society of American Gastro-intestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994The opinions and assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Army or the Department of Defense.     

Risk factors affecting conversion in patients undergoing laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy is the gold standard in the treatment for cholelithiasis, but there are still some patients requiring conversion to open cholecystectomy for several factors. The objective of this study was to evaluate preoperative risk factors for conversion from laparoscopic to open cholecystectomy. Methods: One thousand two hundred and sixty‐five laparoscopic cholecystectomies were carried out from January 2005 to January 2006 in our hospital. Preoperative clinical, laboratory and radiographic parameters of these patients were kept prospectively and analysed retrospectively. Results: Conversion to open cholecystectomy was needed in 94 patients (7.4%). The main reason for conversion was inability to safely display and identify anatomical structures of Calot’s triangle correctly secondary to severe inflammation or dense adhesions, Multivariate analysis identified male sex, with Murphy’s sign positive, gall bladder wall thickness > 4 mm and previous upper abdominal surgery as independent predictors of conversion rate to laparotomy. Conclusion: Preoperative risk factors evaluated by the present study confirm the likelihood of conversion. Recognition of these factors was important for understanding the characteristics of patients at a higher risk of conversion. Identifying risk factors will help the surgeon to plan and counsel the patients and introduce new policies.     

Selective use of ERCP in patients undergoing laparoscopic cholecystectomy

With the advent of laparoscopic cholecystectomy (LCH) various strategies have been proposed for the management of common bile duct (CBD) stones. In a consecutive series of 1140 patients subjected to LCH, preoperative endoscopic retrograde cholangiopancreatography (ERCP) was attempted in 128 patients (11.2%) and successfully accomplished in 121 (94.5%). Based on the prediction of CBD stones by laboratory tests, ultrasonography, and intravenous cholangiography, prelaparoscopic ERCP was performed in 106 patients (9.3%). CBD stones were identified in 56 patients and benign papillary stenosis in 5 patients (57.5%). Of these 61 patients, 58 (95%) were treated by endoscopic sphincterotomy (ES) and stone extraction followed by LCH after a mean interval of 1.6 days. Three patients with failure of endoscopic ductal stone extraction required open CBD exploration. In 39 of the 106 patients (36.8%) ERCP was negative for ductal stones but revealed unexpected ampullary and pancreatic cancer in two cases. Six patients (of the 106) with preoperative ERCP cannulation failure (5.7%) were managed either by LCH and intraoperative cholangiography or by open CBD exploration. In 22 of the 1140 total patients (1.9%) ERCP was performed at various intervals after LCH. Retained CBD stones were found in eight patients, and ES and ductal clearance was achieved in all eight. There was no mortality among the entire surgical group who underwent perioperative ERCP/ES. Including two cases of ES-related pancreatitis, the overall morbidity was 5.5% (7 of 128). Perioperative ERCP/ES in conjunction with LCH is an attractive approach for patients with cholecystocholedocholithiasis, at least until laparoscopic ductal clearance becomes a standard procedure.

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Resumen Con el advenimiento de la colecistectomía laparoscópica se han propuesto diversas estrategias para el manejo de los cálculos del colédoco. En una serie consecutiva de 1140 pacientes sometidos a colecistectomía laparoscópica se intentó colangiopancreatografía (ERCP) en 128 (11.2%) y se logró completar el procedimiento en forma exitosa en 121 (94.5%). Con base en la predicción de coledocolitiasis mediante examenes de laboratorio, ultrasonografía y colangiografía intravenosa prelaparoscópica, se realizó ERCP en 106 casos (9.3%). Se identifícaron cálculos coledocianos en 56 y estenosis benigna de la papila en 5 pacientes (57.5%); 58 (95%) fueron tratados mediante esfinterotomía endoscópica y extracción de los cálculos, sequida de colecistectomía laparoscópica luego de un intervalo medio de 1.6 días. Tres pacientes con falla de la extracción endoscópica de cálculos requirieron exploración abierta del colédoco. En 39 pacientes (36.8%) la ERCP fue negativa en cuanto a los cálculos del colédoco pero reveló la presencia de cáncer ampular y pancreatico en dos casos. Seis pacientes con falla de la canulación del colédoco en ERCP (5.7%) fueron manejados bien con colecistectomía laparoscópica y colangiografía intraoperatioria o bien con exploración abierta del colédoco. En 22 pacientes (1.9%) la ERCP fue realizada en varios intervalos luego de la colecistectomía laparoscópica. Se hallaron cálculos retenidos en 8 pacientes y la esfinterostomía endoscópica con limpieza del colédoco fue exitosa en los 8. No se registró mortalidad en la totalidad del Grupo quirúrgico que recibió ERCP/esfinterostomía endóscópica. La morbilidad global fue 5.5% (7/128), incluyendo 2 casos de pancreatitìs secundaria a la esfinterostomía endoscópica. La ERCP/esfinterotomía endoscópica en conjunción con colecistectomía laparoscópica aparece como un método atractivo en pacientes con colecistocoledocolitiasis, por lo menos hasta cuando la limpieza laparoscópica del colédoco se convierta en procediiniento estándar.

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Résumé A l'heure de la cholécystectomie sous coelioscopie (CC), on a élaboré plusieurs tactiques pour traiter la lithiase de la voie biliaire principale (VBP). Dans une séric consécutive de 1140 patients ayant eu une CC, une cholangiopancréatographie rétrograde endoscopique (CPRE) a été envisagée chez 128 patients (11.2%) et pratiquée avec succès chez 121 (taux de réussite de 94.5%). Indiquée selon des critères de prédiction de lithiase de la VBP par des examens de laboratoire, de l'échographie et de la cholangiographie préopératoire avant la CC, la CPRE a été demandée chez 106 patients (9.3%) avec la découverte de lithiase de la VBP chez 56 et d'une sténose de la papille bénigne chez cinq (57.5%). Une sphinctérotomie endoscopique (SE) avec extraction de calculs et CC ont été pratiquée successivement chez 58 (95%) des patients après un intervalle moyen de 1.6 jours. Trois patients ont nécessité une exploration chirurgicale de la VBP après échec du traitement endoscopique. Chez 39 patients (36.8%), la CPRE n'a pas retrouvé de lithiase mais a mis en évidence une tumeur de la papille ou un cancer du pancréas non soupçonnés jusqu'à là chez deux patients. Six patients ayant eu un échec de cannulation de la CPRE ont eu une CC avec cholangiographie peropératoire et/ou extraction de leur calculs à ciel ouvert. Chez 22 patients (1.9%), la CPRE a été pratiquée à des intervalles variables après la CC. L'extraction des calculs de la VBP a été complète chez les huit patients avec calculs résiduels. II n'y a eu aucune mortalité parmi les patients ayant eu une CPRE périopératoire. La morbidité globale a été de 5.5% (7/128) y compris les deux cas de pancréatite. La CPRE périopératoire combinée à la CC est une approche attrayante de la lithiase vésiculaire et cholédocienne, au moins en attendant que l'évacuation de la VBP par coelioscopie devienne une pratique courante.

     

胆囊结石患者行腹腔镜胆囊切除术临床分析

目的:探讨腹腔镜胆囊切除术治疗胆囊结石的临床效果.方法:回顾我院收治的胆囊结石患者,经B超以及CT检查确诊,随机分为对照组和观察组,对照组为58例患者,采取传统开腹手术,观察组为71例患者,采取腹腔镜手术治疗.结果:两组患者在手术时间、术中出血量、并发症、术后疼痛时间以及平均住院时间比较,P＜ 0.05,具有统计学意义.两组患者术后48h内拔除引流管,观察组患者1例发生胆漏,对照组患者3例发生胆漏,1例发生感染,经过处理后痊愈.结论:在手术过程中熟练掌握处理技巧,明确胆囊三角的解剖关系,掌握中转开腹的时机,胆囊结石患者行腹腔镜胆囊切除术安全、有效,值得临床广泛使用.     

Comparison of laparoscopic ultrasonography and fluorocholangiography in 300 patients undergoing laparoscopic cholecystectomy

Background: This study compares laparoscopic ultrasonography to fluorocholangiography in detecting common bile duct (CBD) stones and delineating biliary anatomy.     

腹腔镜胆囊切除术450例临床分析

目的:总结腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的经验教训,以减少手术并发症的发生。方法:回顾分析2012~2015年共450例LC患者的临床资料。结果:450例LC中,432例(96%)手术获得成功,18例(4%)中转开腹,其中胆囊三角充血水肿、解剖不清12例,胆囊床渗血3例,胆管损伤2例,右肝管畸形1例。手术时间35~130 min,平均(51.0±21.2)min。术后并发症包括:胆囊动脉钛夹松动出血2例,胆漏6例,肺部感染1例,心率失常1例,均通过相应手段治愈。无手术死亡病例。平均住院(4.2±1.2)d。结论:LC具有损伤小、痛苦少、康复快等优点,但也应重视其并发症,术前全面评估,根据术者的经验个体化选择,术中耐心仔细地操作,适时中转开腹,以减少并发症的发生。     

异丙酚对腹腔镜胆囊切除病人术后恶心呕吐的防治作用

目的 探讨异丙酚的镇吐作用及可能的作用机制。方法 60例ASAⅠ－Ⅱ级行择期腹腔镜胆囊切除术患者,随机分为三组;对照组（C组）行常规气管插管吸入全麻,恩丹西酮组（O组）入室后静脉注射恩丹西酮4mg,其他处理C组,异丙酚组（P组）诱导插管同C组,麻醉维持用异丙酚微泵静滴。分别测定入室（基础值）、气管插管后、术毕、术后6h血浆胃动素的水平,并观察术后恶心呕吐程度及发生率。结果 C组20例中9例发生Ⅱ－Ⅲ级恶心、呕吐,发生率为56．7％,O组为4例,P组为3例,发生率分别为20％、13．3％。围术期胃动素水平：C组术毕明显高于基础值（P＞0．01）,术后P明显低于C组及O组。结论 异丙酚静脉麻醉能降低腹腔镜胆囊切除术后恶心呕吐发生率,可能与抑制血浆胃动素合成及分泌有关。     

Evaluation of operative cholangiography in 2043 patients undergoing laparoscopic cholecystectomy

Background

There is still some controversy over whether to use laparoscopic operative cholangiograms routinely (RLOC) or selectively (SLOC). Due to their high cost as well as other issues, in March 1997 we converted from RLOC to SLOC. The purpose of this study was to validate that decision.

Methods

The results of 2043 laparoscopic cholecystectomies (LC) were compiled and analyzed. The results of RLOC in 1556 patients undergoing LC from March 1990 through February 1997 were compared to the results of SLOC in 16 patients undergoing LC from March 1989 through February 1990 and 471 patients undergoing LC from March 1997 through December 1998. The literature was reviewed and data were compiled. Reasons that are typically given for operative cholangiograms (OC) were collected and scrutinized. Finally, cost surveys for RLOC and related procedures were obtained.

Results

Overall, laparoscopic operative cholangiogram (LOC) was attempted in 1661 patients and was successful in 1656 cases (99.7%). Bile duct stones (BDS) were evident in 166 patients. Laparoscopic bile duct exploration (LBDE) was attempted in all cases. None were referred for preoperative endoscopic retrograde cholangiopancreatography (ERCP). In the RLOC group, evidence of BDS was observed in 136 patients (9%). Forty-two were unsuspected (2.8%) and five were false positive (0.3%). In a collection of other RLOC studies, the average rate of unsuspected BDS was 2.9%, while the average rate of false positive cholangiograms was 1.6%. In the SLOC group, LOC was indicated in 139 of 487 patients (28.6%). None of the patients who did not have a LOC developed symptomatic residual BDS in ?11 years of follow-up. In a large collection of other SLOC studies, the rate of symptomatic residual BDS was 0.3%. A cost survey in February 1997 revealed that the average minimum global charge (MGC) for an OC was $1283.21; for a transcystic duct LBDE it was $1055.10, and for a transcholedochal LBDE it was $31263.61. The MGC for an ERCP with papillotomy was $4303.00. Thus, to avoid one patient with symptomatic residual BDS, 354 unnecessary procedures (333 RLOC, 18 LBDE, and three postoperative ERCP) costing $473,927.52 would be performed. There were no false negatives, bile duct injuries, or other complications attributable to RLOC or SLOC.

Conclusions

The increased morbidity and cost of RLOC to avoid symptomatic residual BDS is not justified. All other reasons given for RLOC are either flawed or indicate that the procedure can be safely employed selectively. SLOC is an effective method of verifying suspected BDS and is safer and less expensive than RLOC.     

颊针在老年患者腹腔镜胆囊切除术中的效果

目的 探讨颊针在老年患者腹腔镜胆囊切除术(LC)中的应用效果.方法 选择择期行LC的老年患者97例,男55例,女42例,年龄65～74岁,BMI 20～30 kg/m2,ASAⅠ—Ⅲ级.采用随机数字表法将患者分为两组:对照组(n=48)和颊针组(n=49).麻醉诱导前,颊针组给予颊针疗法,一直带针,每隔5 min行针一...     

Hepatic blood flow and function in elderly patients undergoing laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) has been widely accepted as an alternative to laparotomy and has many advantages, including short hospital stay and very limited surgical invasion. However, this procedure may impair hepatic function in elderly patients because high pressure is maintained in the peritoneal cavity for an extended period. We observed the effect of pneumoperitoneum on the middle hepatic venous blood flow (MHVBF) in elderly patients undergoing LC. LC patients were anesthesized with inhaled and epidural anesthesia, after which MHVBF was continuously measured by transesophageal echocardiography. MHVBF decreased significantly during a period of high intraperitoneal pressure, and recovery of MHVBF after deflation was significantly lower in elderly patients (65-75 yr), but not in younger patients (24-62 yr). In contrast, MHVBF remained almost constant in elderly patients during open cholecystectomy, and thus was significantly different from that in patients who underwent LC with pneumoperitoneum. Laparoscopic cholecystectomy may impair hepatic function in elderly patients because high pressure is maintained in the peritoneal cavity for an extended period.     

腹腔镜胆囊切除术中胆囊破裂的临床分析(附305例报告)

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中胆囊破裂的原因及处理措施。方法:回顾分析2007年10月至2011年10月LC术中305例患者发生胆囊破裂的临床资料。结果:术中选择性胆囊破裂195例,包括胆囊穿刺抽吸减压104例,胆囊萎缩部分切除76例,胆囊造瘘15例;术中胆囊意外破裂110例,包括解剖胆囊时抓破36例,胆囊床剥离时破裂45例,胆囊取出时破裂29例。136例行腹腔冲洗,125例放置腹腔引流。术后发生膈下积液1例、胆囊窝积液3例、脐部切口感染4例、脐部切口结石残留并感染1例,余均无腹腔内感染、脓肿及败血症等并发症发生。结论:选择性胆囊破裂利于手术的顺利完成,提高手术技巧并选择合适的病例可避免胆囊意外破裂,正确处理破裂胆囊可减少并发症的发生。     

i-gel喉罩用于腹腔镜胆囊手术患者气道管理的效果

目的 评价i-gel喉罩用于腹腔镜胆囊手术患者气道管理的效果.方法 择期全麻下拟行腹腔镜胆囊手术患者120例,性别不限,ASA分级Ⅰ或Ⅱ级,年龄34～62岁,体重45～90 kg,随机分为2组(n=60):ProSeal喉罩组(P组)和i-gel喉罩组(Ⅰ组).根据体重选择喉罩型号,麻醉诱导后置入喉罩,行机械通气,并经引流管放置胃管.记录喉罩置入次数、喉罩及胃管置入情况、纤支镜检查评分,测定喉罩密封压,观察术中口咽部漏气、低氧血症的发生情况.术中监测SpO2、PETCO2、气道峰压,观察拔除喉罩后恶心、呕吐、呛咳、声嘶、咽喉痛、返流误吸的发生情况,记录麻醉时间、手术时间、拔除喉罩时间及苏醒时间.结果 两组麻醉时间、手术时间、拔除喉罩时间及苏醒时间差异无统计学意义(P＞0.05).两组术中SpO2、PETCO2、气道峰压均在正常范围内.与P组比较,Ⅰ组喉罩首次置入成功率和纤支镜检查评分升高,喉罩置入时间缩短(P＜0.05).两组喉罩和胃管置入成功率均为100%;Ⅰ组和P组喉罩密封压比较差异无统计学意义(P＞0.05);Ⅰ组咽喉痛发生率低于P组(P＜0.05),恶心呕吐、呛咳发生率差异无统计学意义(P＞0.05),两组无一例发生声嘶、返流误吸.结论 i-gel喉罩易于置入,气道密封性可靠,通气效果好,不良反应少,可安全有效地用于腹腔镜胆囊手术患者的气道管理.     

Value of contrast-enhanced magnetic resonance cholangiography in patients undergoing laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) is the preferred treatment for symptomatic gallstone disease. Biliary injury during LC is still a serious problem. Knowledge of anatomic detail is important for not encountering the injury. Magnetic resonance cholangiography (MRC) is a noninvasive method for imaging the biliary ducts. However, MRC has many drawbacks such as not showing anatomic structures in detail and respiratory motion. In this study, contrast-enhanced MRC was used to show cystic ducts that are not seen on MRC. Reasons for patient referral for MRC and contrast-enhanced MRC included suspicion of cholecystolithiasis, adenomyomatosis, and gallbladder polyp. Our results show that routine MRC revealed cystic ducts in 38 patients (77.5%) and contrast-enhanced MRC in 46 patients (93.8%). Intraoperative cholangiography (IOC) was taken as gold standard for all patients. We found that contrast-enhanced MRC can provide a useful supplement to MRC in patients with cystic ducts not seen on MRC. To our knowledge, this is the first study of visualization of a cystic duct in patients undergoing LC depicted by both MRC and contrast-enhanced MRC.     

Value of contrast-enhanced magnetic resonance cholangiography in patients undergoing laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) is the preferred treatment of symptomatic gallstone disease. Biliary injury during LC is still a serious problem. Knowledge of anatomic detail is important for not encountering the injury. Magnetic resonance cholangiography (MRC) is a noninvasive method for imaging the biliary ducts. However, MRC has many drawbacks such as not showing anatomic structures in detail and respiratory motion. In this study, contrast-enhanced MRC is used to show cystic ducts that are not seen by MRC. Reasons for patient referral for MRC and contrast-enhanced MRC included suspicion of cholecystolithiasis, adenomyomatosis, and gallbladder polyp. Our results show that routine MRC revealed cystic ducts in 38 patients (77.5%) and contrast-enhanced MRC in 46 patients (93.8%). Intraoperative cholangiography (IOC) was taken as gold standard for all patients. We found that contrast-enhanced MRC can provide a useful supplement to MRC in patients with nonvisualized cystic ducts by MRC. To our knowledge, this is the first study of visualization of cystic duct in patients undergoing LC depicted by both MRC and contrast-enhanced MRC.     

术前超声对腹腔镜胆囊切除术难度的预测

目的：评估术前腹部超声对腹腔镜胆囊切除术难度预测的价值。方法：对连续394例腹腔镜胆囊切除手术的难度和术前腹部超声进行前瞻性临床研究。术前超声检查包括胆囊壁厚度、胆囊周围有无积液、胆囊大小、胆总管直径和胆囊结石。腹腔镜胆囊切除术的难易程度是根据中转剖腹手术病例在腹腔镜下解剖胆囊三角和／或剥离胆囊床的最短时间为标准来划分。结果：术前超声对胆囊结石诊断正确率为99．7％。16例（4．1％）中转剖腹前腹腔镜下解剖胆囊三角和／或剥离胆囊床的最短时间为29．3min。超声检查胆囊壁增厚（＞3mm）113例中有99例（87．6％）是LC手术困难的，而胆囊壁小于或等于3mm的281例中只有52例（18．5％）为LC手术困难的，两者差异有显著性（P＜0．05）；所有胆囊周围积液均为LC手术困难，其中有75％还中转剖腹手术；17例胆囊积液中有16例为LC手术困难的（94．1％），20例萎缩性胆囊炎中有18例（90％）在LC手术遇到了困难。结论：术前超声检查中胆囊壁增厚是预测LC手术困难较精确的指标，而胆囊周围积液、胆囊积液、胆囊萎缩对预测LC手术困难都具有较高的特异性和阳性预测值。     

Identification of bile duct stones in patients undergoing laparoscopic cholecystectomy.

To identify patients with common bile duct stones, all patients considered for laparoscopic cholecystectomy in this unit undergo intravenous cholangiography (IVC) with tomography and, more recently, operative cholangiography. To date 100 consecutive patients with symptomatic gallstones have undergone laparoscopic cholecystectomy with no specific exclusion criteria. Eight patients of 100 were found to have duct stones on IVC with one false-positive. These IVC data were compared with data from 52 patients who also had operative cholangiograms performed. One stone was detected on operative cholangiography that was not identified on IVC. No additional information was gained from operative cholangiography. These data suggest that preoperative IVC is adequate for the detection of duct stones in patients considered for laparoscopic cholecystectomy.     

Management of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy

The common and distressing complications of postoperative nausea and vomiting (PONV) are the main concern of 40–70% of patients undergoing laparoscopic cholecystectomy (LC). The first step in preventing PONV after LC is to reduce the risk factors involving patient characteristics, surgical procedure, anesthetic technique, and postoperative care. Particularly, the use of propofol-based anesthesia can reduce the incidence of PONV after LC. Second, prophylactic antiemetics including antihistamines (dimenhydrinate), phenothiazines (perphenazine), butyrophenones (droperidol), benzamides (metoclopramide), dexamethasone, and serotonin receptor antagonists (ondansetron, granisetron, tropisetron, dolasetron, and ramosetron) are available for preventing PONV after LC. Third, antiemetic therapy combined with a serotonin receptor antagonist (ondansetron, granisetron) and droperidol or dexamethasone is highly effective in the prevention of PONV after LC. Fourth, acupressure at the P6 point is a nonpharmacologic technique that is as effective as ondansetron for preventing PONV after LC. Knowledge regarding the risk factors for PONV and antiemetics is needed for the management of PONV after LC.