Laparoscopic cholecystectomy for complicated gallstone disease

After performing selectively 25 laparoscopic cholecystectomies (LC) to determine the place of LC in the management of complicated gallstones, all patients presenting with gallstones were evaluated by the authors for LC. Eighty-six consecutive patients were evaluated and 84 were studied. Follow-up in every case exceeded 6 months. In three of 10 patients with acute cholecystitis, LC was not possible; each had a history longer than 48 h and all had gangrene of the gallbladder. In four patients with empyema, LC was successful, but operative cholangiography failed. Operative cholangiography was successful in 76 of the remaining 77. Of eight patients suspected of having stones in the CBD, cholangiography excluded stones in six and confirmed them in two. Cholangiography identified three other patients with totally unsuspected CBD stones. Of the five patients with CBD stones, four had them flushed to the duodenum at LC following transcystic balloon dilatation of the papilla and one had a post-op. ERCP. Of four patients with acute pancreatitis, three had LC in the same admission. LC was possible in all three patients with morbid obesity. We conclude that with experience, LC is possible for complicated gallstones. In acute cholecystitis, the probability of success is higher with earlier operative intervention. Operative cholangiography is essential. It not only identifies unsuspected CBD stones but also allows LC without ERCP in those with suspected CBD stones and with modification it allows treatment of those stones.     

Residual gallstone disease — Laparoscopic management

Background  

A few patients who continue to suffer antecedent symptoms following laparoscopic cholecystectomy (LC) may harbor residual gallstones. The incidence of residual gallstones following cholecystectomy is <2.5%. Many of these patients require a completion cholecystectomy to ameliorate their symptoms.     

Laparoscopic reintervention in colorectal surgery

Laparoscopic colorectal surgery has developed in the 1990's and beginning of 2000. The favourable results and great progress in the development of laparoscopic techniques have expanded the indications of laparoscopic colorectal surgery. More and more complicated colorectal cases are treated laparoscopically, including those having had previous laparotomies. Surgical reinterventions after colorectal procedures are common. Reinterventions are either intended to treat complications of colorectal surgery or to treat colorectal disease after previous abdominal or pelvic surgery. Laparoscopic reinterventions face surgeons with specific challenges related to morphological changes in the abdomen. Adhesions are primarily responsible for these changes and evoke various complications such as trocar injury, bleeding, enterotomy and conversion to laparotomy. Trocars and Veress needle are responsible for up to half of all bowel injuries in laparoscopic surgery and adhesion formation is the most important risk factor for bowel injury. The risks of adhesions are often underestimated. The first clinical results on laparoscopic reinterventions are promising. Routine use of anti-adhesion agents and diagnostics is advocated to prevent adhesion formation and make reintervention more safe reducing serious complications as inadvertent enterotomy, bleeding and trocar injuries. More research is needed to develop better tools for mapping adhesions, as none of the trocar placing techniques can rule out bowel injury. Improved diagnostic tools for mapping adhesions will also facilitate patient selection for laparoscopic treatment of SBO.     

Laparoscopic cholecystectomy in cirrhotic patients with symptomatic gallstone disease

Background: The aim of this study was to evaluate the outcome in patients with liver cirrhosis who underwent laparoscopic cholecystectomy for symptomatic gallstone disease. Methods: Retrospective analysis of prospectively collected data of 34 patients operated between March 1998 and April 2006. Results: There were 19 male and 15 female patients with a median age of 62 years. Cirrhosis aetiology was viral hepatitis in 25 patients, alcohol in 6, primary biliary cirrhosis in 2 and in 1 patient the cause was not identified. Twenty‐three were classified as Child–Pugh–Turcotte stage A and 11 as Child–Pugh–Turcotte stage B. The median Model For End‐Stage Liver Disease score was 12. Median operating time was 96 min. In three patients there was conversion to open cholecystectomy. Postoperatively, one patient died and six more patients had complications. Median postoperative stay was 3 days. Patients with acute cholecystitis did not have increased morbidity, but had significantly longer hospital stay. Conclusion: Laparoscopic cholecystectomy can be carried out with acceptable morbidity in selected patients with well‐compensated Child A and B stages liver cirrhosis. Patients with evidence of significant portal hypertension and severe coagulopathy should avoid surgery.     

腹腔镜治疗复杂性胆囊结石的临床分析

目的 评估腹腔镜胆囊切除术治疗复杂性胆囊结石的疗效,总结手术操作的技巧和经验.方法 回顾分析3年间腹腔镜手术治疗256例复杂性胆囊结石患者的临床资料.结果 所有患者均痊愈出院,无中转开腹手术及手术死亡.结论掌握手术适应证及处理各种复杂情况的操作技巧对腹腔镜胆囊切除术治疗复杂性胆囊结石大有帮助.     

Laparoscopic cholecystectomy for symptomatic gallstone disease. Experience of the first 200 cases.

Laparoscopic cholecystectomy was carried out in 200 patients between January 1991 and September 1992 at the Second Department of Surgery, Helsinki University Central Hospital. Mortality was nil. The overall major complication rate was 4% (n = 8). The incidence of common bile duct lesions was 0.5% (n = 1). In seven (3.5%) patients the procedure had to be converted into open cholecystectomy. Repeat surgery was needed in two patients. The average hospital stay was 3.0 +/- 1.5 days and the average sick leave 14 +/- 4 days. Obese and high-risk patients tolerated the procedure well without significant increase in complication rate or hospital stay. Laparoscopic cholecystectomy may be regarded as the treatment of choice for symptomatic gallstone disease.     

残余胆囊的腹腔镜手术

目的:探讨残余胆囊腹腔镜手术的可行性。方法:回顾分析为6例残余胆囊患者施行腹腔镜手术的临床资料。结果:6例患者均顺利完成腹腔镜手术。手术时间30～110min,平均58min,术中出血20～100ml,平均40ml,4例放置腹腔引流管,引流量20～60ml,术后2d拔除,术后住院3～6d,平均4d,术中无出血及胃肠道、胆道损伤等并发症发生。结论:残余胆囊患者行腹腔镜手术安全、可行、有效。     

Laparoscopic management of gallstone ileus.

Gallstone ileus is an uncommon entity that was first described by Bartholin in 1654. Despite advances in perioperative care, morbidity and mortality remain high in patients with gallstone ileus because: 1) they are geriatric patients; 2) they often have multiple comorbidities; 3) presentation to the hospital is delayed; 4) many are volume depleted with electrolyte abnormalities; and 5) the diagnosis of gallstone ileus is difficult to make. Traditional management has entailed open laparotomy with relief of intestinal obstruction by enterotomy and stone extraction. Cholecystectomy and takedown of the cholecystoenteric fistula can be performed. We propose an alternative method of management in an attempt to limit operative trauma and improve morbidity and mortality. We review the literature and describe two patients with gallstone ileus who were managed laparoscopically. One patient underwent laparoscopic assisted enterolithotomy, and the other patient underwent diagnostic laparoscopy with disimpaction of the gallstone into the large bowel. They were discharged after their ileus had resolved on the fourth and sixth postoperative day, respectively. Laparoscopy is a powerful diagnostic and therapeutic tool that can be effectively used to treat gallstone ileus.     

Laparoscopic cholecystectomy and interventional endoscopy for gallstone complications during pregnancy

Background: Symptomatic or complicated gallstone disease is the most common reason for nongynecological operations during pregnancy. Gallstones are present in 12% of all pregnancies, and more than one-third of patients fail medical treatment and therefore require surgical endoscopy or laparoscopy. Gallstone pancreatitis and jaundice during pregnancy is associated with a high recurrence rate, exposing both fetus and mother to an increased risk of morbidity and mortality. Methods: During a 4-year period, all pregnant patients (n= 37) with symptomatic or complicated gallstone disease were studied prospectively at the Landeskrankenhaus in Salzburg, Austria. Five patients had an endoscopic retrograde cholangiopancreatogram (ERCP) for biliary pancreatitis or jaundice; two of these underwent subsequent laparoscopic cholecystectomy. Another seven patients required laparoscopic cholecystectomy for severe pain or cholecystitis; all were in their 13th–32nd gestational week. Access was established by Veress needle in all cases. Insufflation pressure was 8–10 mmHg, and mean operative time was 62 min. Results: All patients delivered full-term, healthy babies. There were no postendoscopic or postoperative complications. All patients enjoyed full relief from their symptoms; there were no recurrences of pancreatitis or jaundice. Conclusions: The combination of ERCP and laparoscopic cholecystectomy offers a safe and effective option for the definitive treatment of complicated gallstone disease and intractable pain during pregnancy, and there is sufficient access for the combined treatment to be employed. Received: 7 September 1998/Accepted: 2 June 1999     

Laparoscopic reintervention for failed antireflux surgery: subjective and objective outcomes in 176 consecutive patients

HYPOTHESIS: Laparoscopy has become the standard approach for surgical treatment of uncomplicated gastroesophageal reflux disease. Laparoscopic reintervention following failure of primary antireflux surgery (ARS) remains controversial. The purposes of this study were to assess outcomes in patients operated on for failed ARS, to describe reasons for failure of the primary surgery, and to identify factors predictive of failure of the revision. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Tertiary-care teaching hospital. PATIENTS: A total of 176 patients (20 with multiple ARS) undergoing laparoscopic reintervention between September 12, 1993, and August 1, 2006, for failed ARS. INTERVENTIONS: Patients had preoperative subjective and/or objective documentation of failure after primary ARS: 131 patients had reoperative Nissen fundoplication, 28 patients had a partial wrap, and 17 patients had other procedures. MAIN OUTCOME MEASURES: Preoperative and postoperative symptom scores and results of objective studies were prospectively collected. Postoperative patients with symptom scores of 2 or greater and/or abnormal 24-hour pH study results (DeMeester score > 14.7) were considered to have treatment failures. Logistic regression was performed to identify variables significant for poor outcomes. RESULTS: Median follow-up was 9.2 months in 145 patients (82.4%). One hundred eight patients (74.5%) demonstrated excellent symptomatic outcomes (P = .001). Twenty of 37 patients with failures had reflux symptoms and 23 experienced dysphagia. Sixty-seven patients had 24-hour pH and manometry studies; 18 (11 asymptomatic) patients had a DeMeester score greater than 14.7. Odds of failure were higher among patients presenting with dysphagia (odds ratio, 3.38; 95% confidence interval, 1.35-8.40; P = .009) or requiring an esophageal-lengthening procedure (odds ratio, 5.77; 95% confidence interval, 1.38-24.11; P = .02). CONCLUSIONS: Laparoscopic reintervention following failed primary ARS provides excellent subjective and objective outcomes in most patients. Patients having laparoscopic reintervention for dysphagia relief or those requiring an esophageal-lengthening procedure have a significantly greater chance of a poor outcome.     

Prevalence and risk factors for gallstone disease

Gallstone disease is a main public health problem. The overall prevalence data range from 3.9% in the pre-echographic era to 13.7% when ultrasonography was used as a diagnostic tool. This study is aimed to determine the prevalence of gallstone disease in a medium income level population in Lima, as well as the relationship with some risk factors: age, sex, familiar history and obesity. A total of 534 adult men and women from a medium economic level underwent ultrasonographic examination of abdomen for detection of gallstone disease (July 2003). The echographic evaluation was performed by 10 general surgeons trained in ultrasonography. Likewise, 4 risk factors--age, gender, familial history, and obesity--were analyzed. Pearson chi2 test (2-sided) was used with a probability of <0.05 for statistical significance and logistic regression analyses for assessment of confounding factors. The prevalence founded was 15%. Eighty-one of 534 participants had lithiasis. Compared to the age group under 30, the odds ratio for the 31 to 50 years and >50 years of age group was 0.9 and 1.1, respectively. The female-male ratio was 1.07 and the odds ratio 0.8. The prevalence of gallstone disease in people reporting a first-degree relative with lithiasis was 21%, whereas in participants without such a condition, it was 13%. On the other hand, a familial history was present in 38% of the lithiasis group and in 25% of the nonlithiasis group. The odds ratio for familial history was 1.8 (P = 0.01, 95% confidence interval 1.1-2.9). The prevalence of the disease for body mass index <24, 25 to 29, and higher than 30 was 17%, 14% and 13%, respectively. Compared to the reference group (body mass index <24), the other 2 groups (body mass index 25-29 and >30) both had a similar odds ratio, 0.8. Logistic regression analyses showed an odds ratio of 1.9 for familiar history (95% confidence interval 1.1-3.2), whereas the odds ratio of the overweight (body mass index 25-29) and obese group (body mass index >30) when compared to the normal group, BMI <24, was 0.7 and 0.9, respectively. The prevalence data for gallstone disease remain slightly higher than those previously reported. Although the familiar history was the only characteristic with a statistically significant positive relationship with lithiasis, additional studies are needed because few biases could not be completely avoided and some confounding factors were not controlled.