Complications of laparoscopic cholecystectomy: an analysis of 200 cases.

Complications of the initial 200 cases of laparoscopic cholecystectomy (LC) at the Cathay General Hospital within a period of 11 months were reviewed from video documents of the operations and clinical records. The major complication rate was 3.5%, including one common bile duct (CBD) injury (0.5%), three retained CBD stones (1.5%), one subphrenic fluid accumulation (0.5%), one liver abscess (0.5%) and one cystic duct stump bile leakage (0.5%). All major complications were cholecystectomy-related, and only one of the seven occurred in cases of acute cholecystitis. Age and sex were not related to its occurrence. The rate of minor complications ranged from 0.5% to 10%; they were: shoulder and back pain (10%), gall bladder perforation (10%), retained stones in the abdominal cavity (5%), transient nausea and diarrhea (5%), extension of umbilical port to a mini-laparotomy (3.5%), prolonged operation time > three hours (2%), subcutaneous emphysema (1.5%), wound infection (1.5%) and prolonged ileus (0.5%). The minor complications occurred largely in patients with acute cholecystitis. The complications occurred mostly during the early period of our study, indicating a learning period phenomenon. These could have been avoided if we had had a thorough knowledge of the potential complications and had strictly followed the principles of laparoscopic surgery. We conclude that LC is safe and the complication rate is not higher than that for open cholecystectomy. Most of the complications are preventable if LC is performed by qualified biliary surgeons following strict precautions.     

Routine intraoperative cholangiogram

The value of a routine intraoperative cholangiogram is controversial. We reviewed 352 consecutive instances of cholecystectomy for nonmalignant disease during a period of three years to assess the diagnostic accuracy and additional cost of the roentgenographic technique. Intraoperative cholangiogram was done in all except 11 patients. Forty-nine of 341 patients underwent exploration of the common bile duct. The diagnosis was determined by the cholangiogram and was correct in 46 patients with three false-positive results. The other 292 patients did well without exploration of the common bile duct. The cholangiocatheter and a special cholangioclamp made the procedure easy and minimized additional operation time (five minutes with no mortality and negligible morbidity). Clinical indications for exploration of the common bile duct correlated poorly with abnormal findings in the bile duct. Unsuspected common duct stones were detected by cholangiogram in 17 (5 per cent) patients. Possible iatrogenic trauma to the common duct was prevented when significant abnormal findings were demonstrated by cholangiogram. The results of this study indicate that routine intraoperative cholangiogram is: accurate for diagnosis of common bile duct stones; useful in identification of bile duct anomalies and, thus, aids in preventing injury to the common bile duct; safe with negligible risk, and neither expensive nor time consuming if done correctly as a routine procedure.     

Cholecystitis during pregnancy. A case report and brief review of the literature

Cholecystitis is an inflammation of the gallbladder caused by obstruction of the cystic duct. A gallstone usually causes the obstruction (calculus cholecystitis). However, in some cases the obstruction may be acalculous or caused by sludge. The clinical course of biliary sludge varies, from complete resolution to gallbladder obstruction. This obstruction can result in gallbladder distension and acute cholecystitis. When inflammation occurs it could either be aseptic or bacterial. Biliary disease during pregnancy is relatively rare and occurs mainly during the last trimester. Whether women who are pregnant or have multiple pregnancies are more likely to develop stones or whether they are simply more symptomatic with stones is unknown. We present a 33-year-old obese pregnant woman with fever, moderately elevated bile acids, and leukocytosis in the 28th week of pregnancy. Since need for surgery in these cases is controversial, the patient has been treated conservatively. In our case cholecystitis responded very well to treatment with amoxicillin, with no detrimental effects for mother and child. A healthy child was born at term. In the differential diagnosis of liver function abnormalities during pregnancy, cholelithiasis should be included.     

Laparoscopic cholecystectomy in a community hospital setting.

Recently, laparoscopic cholecystectomy has become the preferred surgical procedure for removal of the gallbladder. However, many surgeons believe that the safety and efficacy have yet to be proved in the community hospital setting. To address this concern, a retrospective chart review of the initial 271 instances of inpatient laparoscopic cholecystectomy within a community hospital was undertaken. All procedures were performed by 15 general surgeons in private practice and residents in general surgery. Of the 271 patients, 11 were converted to open cholecystectomy. Surgical complications occurred in six of the 260 instances of laparoscopic cholecystectomy (2.3 percent), with only one injury to the common bile duct. Major postoperative complications occurred in 23 patients, including severe postoperative pain (nine patients), prolonged ileus (seven patients), bile leakage (three patients), retained common duct stones (two patients), respiratory failure (one patient) and postoperative myocardial infarction (one patient). The period of hospitalization ranged from one to 64 nights with a median of one night. The operative mortality rate was zero percent. Multivariate analysis identified two factors associated with an increased risk of postoperative complications. Patients 70 years of age or older and patients whose operating times were greater than one hour and 45 minutes were at increased risk for postoperative complications. We believe that these data represent the general outcomes of the laparoscopic procedure in a community hospital setting and lend support to the argument that the procedure can be performed safely and effectively in this setting.     

Incidence of common bile duct stones in patients with acute and chronic cholecystitis

In this study, a series of 705 patients with chronic cholecystitis and 203 with acute cholecystitis were surgically treated. The age distribution for the two groups was similar. Operative cholangiography was performed upon 661 patients (94.0 per cent) with chronic cholecystitis and upon 182 patients (90 per cent) with acute cholecystitis. The common bile duct was explored in 146 patients (20.7 per cent) with chronic cholecystitis and in 41 patients (20.1 per cent) with acute cholecystitis, and bile duct calculi were found in 106 patients (15 per cent) with chronic cholecystitis and in 29 patients (14.2 per cent) with acute inflammation of the gallbladder. The total number of postoperative complications and the operative mortality were similar for the two groups. It is concluded that the incidence of common bile duct stones in patients with acute cholecystitis is the same as for those with chronic cholecystitis.     

Biliary tract disease in Thailand

One hundred and eighty-nine patients were documented as having biliary tract disease. Two hundred and nine lesions were found. The prevalence of malignant disease of the biliary tract was represented by 30.1 per cent, and cholangiocarcinoma was a leading cause. The carcinogenesis of cholangiocarcinoma has been speculated. Acute cholecystitis represented 55 per cent of biliary tract disease in Thailand, which consisted of acute calculous cholecystitis and acute noncalculous cholecystitis, 94.8 and 5.2 per cent, respectively. Among acute calculous cholecystitis, the prevalence of cholelithiasis, choledocholithiasis and intrahepatic stones were 58.5, 68.8 and 15.6 per cent, respectively. The high prevalence of choledocholithiasis and intrahepatic stones requires elucidation. In the remaining surgical disease of the biliary tract, opisthorchiatic cyst was the most common cause. The diagnosis of opisthorchiatic cyst was made roentgenologically in association with the identification of Opisthorchis ova in the aspirated bile. Opisthorchiatic cyst appears to be a unique clinical entity, differing from other types of intrahepatic cysts. Another form of presentation of biliary tract opisthorchiasis is through obstruction of the common bile duct by an aggregated mass of dead worms. This condition is cured by surgical removal of the worms. It is worth while to mention that, among 189 patients with biliary tract disease, there were three documented instances of choledochal cysts. This probably indicates a high prevalence of choledochal cysts when compared with that for the United States. In the present study, a 36 year old female with a diagnosis of Caroli's disease, ascariasis of the common bile duct and choledocholithiasis is presented.     

Choledocholithiasis in Chinese immigrants with cholelithiasis

During the period from January 1987 to December 1989, admissions for biliary tract disease at the New York Infirmary--Beekman Downtown Hospital were split almost evenly between Chinese immigrants from southeast Asia and all other ethnic groups (Caucasian, Hispanic, black, et cetera). However, the incidence of choledocholithiasis in patients undergoing cholecystectomy for cholelithiasis was much higher in the Chinese immigrant population, 37.2 versus 11.8 per cent, a highly significant difference (p = 0.001). In addition, we often found the disease to be of greater severity in Chinese patients. They were more likely to have large numbers of stones in the duct and more likely to have significant ductal enlargement. This increased risk was essentially constant regardless of age. Because of this threefold risk of choledocholithiasis when operating on a Chinese immigrant from southeast Asia for cholelithiasis, intraoperative cholangiography is mandatory, even in those without other indications for common bile duct exploration.     

Surgical treatment for cholelithiasis.

In a retrospective study, the results of 1,631 consecutive operations for cholelithiasis were analyzed. With an overall mortality rate of 0.18 percent and a reoperation rate of 1.3 percent, conventional cholecystectomy proved to be a safe method. Mortality proved to be age dependent, with a zero mortality rate for patients less than 60 years of age. Choledochotomy had a 13-fold greater mortality rate than simple cholecystectomy (0.92 versus 0.07 percent). For acute cholecystitis, we observed an unusual zero mortality rate, whereas the mortality rate in chronic cholecystitis was 0.2 percent. All three patients who died had an accompanying cirrhosis of the liver. Morbidity, defined as reoperation during the same period of hospitalization, was mainly the result of retained stones after choledochotomy; endoscopic papillotomy was the treatment of choice. Cholecystectomy remains the "gold standard" in the treatment of cholelithiasis.     

Initial experience with laparoscopic cholecystectomy at the Beth Israel Medical Center.

Laparoscopic cholecystectomy has changed the treatment of symptomatic gallstones. We present an initial experience with this technique. From March 1990 to March 1991, there were 250 patients who were studied. There were 182 females and 68 males, with most classified as American Society of Anesthesiology Index Class I or II. All procedures were done using electrocautery. There was a definite learning curve for the procedure as evidenced by the duration of the operation. The mean time to perform the procedure was 112 minutes for the first 50 patients and 79 minutes for the last 50 patients. We converted 12 percent of the procedures to an open cholecystectomy for a variety of reasons, the most common being inflammation and adhesions in the triangle of Calot. However, we only had a 4 percent conversion rate in the last 50 patients. There were nine serious complications, with no deaths. The most frequent was a bile leak from the cystic duct stump. Other complications included a pneumothorax, requiring chest tube drainage and an unobserved carcinoma of the stomach. There were no injuries to the common bile duct. The results of our current experience confirm the safety and efficacy of laparoscopic cholecystectomy for the treatment of symptomatic gallstones. The use of electrocautery is safe during laparoscopy and the need for a laser is optional. Laparoscopic cholecystectomy will continue to evolve as more experience is gained and new instruments are introduced.     

Selective contraindications based on multivariate analysis for operative cholangiography in biliary lithiasis

This study was done to select patients with a low risk of common bile duct (CBD) stones in whom operative cholangiography could be avoided. Operative cholangiography was performed upon 511 patients. Two different groups of patients were identified--patients with CBD stones visualized by CBD exploration (n = 90) and patients with no CBD stones at the time of operative cholangiography (n = 421). Multivariate analysis (stepwise logistic regression) showed that five variables were correlated with the presence of CBD stones--size of CBD equal to or greater than 12 millimeters, gallstones equal to or less than 10 millimeters, advanced age, chronic or acute cholecystitis and past history of biliary colic. Using a scoring system, a group of patients with a low risk (less than 2 percent) of CBD stones could be easily determined. In this group of patients, operative cholangiography may be avoided.     

Laparoscopic cholecystectomy during pregnancy. Case report and literature review

The outors report of two cases of sucsessfully done laparoscopic cholecystectomy in pregnant women with cholelithiasis. The first patient was pregnant with 6 lunar months and suffering of acute cholecystitis, and the second woman is pregnant in 4-th lunar month whith cholelithiasis. During both postoperative periods--no complications. The pregnancies in both cases ended in therm and healthy mature children was born. We make a brief literature review and present whith the opinion that with strong indications and good prepared and experienced surgents, laparoscopic cholecystectomy is a method of choice.     

Cholecystectomy with concomitant exploration of the common bile duct

One hundred and four patients undergoing concomitant cholecystectomy and exploration of the common bile duct were retrospectively reviewed. Exploration of the common bile duct retrieved stones in only 17 patients, all of whom had clearly positive findings from operative cholangiography. Of 87 patients who had negative results 57 underwent exploration of the common bile duct on the basis of clinical factors and 21 on the basis of equivocal cholangiographic findings.     

Excretion of cefuroxime in biliary disease

Cefuroxime is a broad spectrum B-lactamase stable cephalosporin antibiotic. An intravenous injection of cefuroxime sodium 1.5 grams was administered to 45 patients after induction of anesthesia for cholecystectomy. Twenty-five patients had elective operations for chronic cholecystitis and 20 underwent urgent operations for acute cholecystitis. Of the 25 patients who underwent elective treatment, the cystic duct was patent in 13 and obstructed in 12. Antibiotic concentrations were measured by microbiologic assay in plasma, common bile duct bile, gallbladder bile and gallbladder wall. Organisms grown from the bile (Escherischia coli, eight; Proteus morganii, one; Streptococcus species, three, and Staphylococcus aureus, one) were sensitive to cefuroxime with the exception of one instance of Streptococcus faecalis. Cefuroxime levels were the same in specimens of patients with chronic or acute cholecystitis and reached therapeutic levels in the gallbladder wall, the main site of the inflammatory reaction. There was no difference in bile levels from gallbladders with patent or obstructed cystic ducts, suggesting that cefuroxime diffuses into the gallbladder and bile from the blood stream. There were no wound infections in this study when only a single dosage of antibiotic was administered intravenously.     

Cholelithiasis: Presentation and Management

Cholelithiasis affects approximately 15% of the US population. Rising trends in obesity and metabolic syndrome have contributed to an increase in diagnosis of cholelithiasis. There are several risk factors for cholelithiasis, both modifiable and nonmodifiable. Women are more likely to experience cholelithiasis than are men. Pregnancy, increasing parity, and obesity during pregnancy further increase the risk that a woman will develop cholelithiasis. The classic presentation of persons experiencing cholelithiasis, specifically when gallstones obstruct the common bile duct, is right upper quadrant pain of the abdomen that is often elicited upon palpation during physical examination and documented as a positive Murphy's sign. Referred pain to the right supraclavicular region and/or shoulder, nausea, and vomiting are also frequently reported by persons with cholelithiasis. Cholelithiasis can result in complications, including cholecystitis (inflammation of the gallbladder) and cholangitis (inflammation of the bile duct). Lack of physical examination findings does not rule out a diagnosis of cholelithiasis. Laboratory tests such as white blood cell count, liver enzymes, amylase, and lipase may assist the clinician in diagnosing cholelithiasis; however, ultrasonography is the gold standard for diagnosis. Management is dependent on severity and frequency of symptoms. Lifestyle and dietary modifications combined with medication management, such as use of gallstone dissolution agents, may be recommended for persons who have a single symptomatic episode. If symptoms become severe and/or are recurrent, laparoscopic cholecystectomy is recommended. It is recommended that individuals with an established diagnosis of cholelithiasis be referred to a surgeon and/or gastroenterologist within 2 weeks of initial presentation regardless of severity or frequency of symptoms.     

急性胆囊炎腹腔镜胆囊切除术120例体会

目的探讨急性胆囊炎行腹腔镜胆囊切除术的治疗体会。方法:120例急性胆囊炎患者行腹腔镜胆囊切除术。CO2气体建立气腹常规四孔法。结果 110例患者成功完成腹腔镜胆囊切除术,10例患者中转开腹。结论严格掌握手术适应症,急性胆囊炎行腹腔镜手术安全、可行。     

Risk factors for wound infection after cholecystectomy.

BACKGROUND AND PURPOSE: Surgical site infection (SSI) after cholecystectomy is a common problem. The aim of this study was to identify the possible risk factors for the development of SSI. METHODS: 545 consecutive patients who received open (125) or laparoscopic (420) cholecystectomy due to gallbladder disease during the years 1998 to 2000 were included in the study. Potential risk factors including clinical features, biochemical data, and operative types were analyzed by univariate and multivariate analysis. RESULTS: The overall incidence of SSI was 4.4% (24/545). The wound complication rate was significantly lower in the laparoscopic group than in the open group (1.4% vs 14.4%, respectively). Factors associated with SSI found by univariate analysis (p < 0.05) included age, gender, acute cholecystitis, white blood cell count, serum albumin, blood glucose and bilirubin level, type of surgery, operative time and positive bile culture. Stepwise logistic regression analysis showed that abnormal blood glucose [odds ratio (OR), 4.7; 95% confidence interval (CI), 1.6 to 13.5], positive bile culture (OR, 3.5; 95% CI, 1.2 to 10.4), and open cholecystectomy (OR, 4.3; 95% CI, 1.3 to 13.6) were the most significant predictors of SSI. CONCLUSION: Poor control of diabetes mellitus before surgery, positive bile culture and open cholecystectomy significantly increased the rate of SSI. These findings indicate that better control of diabetes mellitus, and appropriate selection of surgical procedure and antibiotic regimen in the management of high-risk patients may reduce the incidence of postoperative SSI.     

Combined gynecologic surgical procedures and cholecystectomy

This report presents our experiences with combined gynecologic surgical procedures and cholecystectomy from 1976 to 1983. The review evaluated risks, cost, and hospital stay in combined surgical procedures. Hospital charts were reviewed in 46 cases. The patients were compared with 178 patients undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy in 1981. Of the 46 patients reviewed, 22 (47.8%) had preoperative diagnosis of cholelithiasis. We believe it appropriate to combine gynecologic surgical procedures with cholecystectomy when indicated. This eliminates a significant postoperative complication, cholecystitis, a second general anesthetic, and future hospitalization with additional time off work and patient recovery time.     

Twenty-two year experience with the diagnosis and treatment of intrahepatic calculi

Intrahepatic cholelithiasis is commonly associated with suppurative cholangitis and occurs equally in males and females. Patients usually present with a history of recurrent symptoms and a differential diagnosis which includes viral hepatitis, pancreatitis, myocardial infarction and perforated ulcer. Cholangiography including stereocholangiography is essential for localizing intrahepatic stones and ductal strictures. The guiding operative principle is to drain all infected bile distal to ducts obstructed with stones or stricture. This may also necessitate a bilioenterostomy with or without partial hepatic resection. Although these procedures are formidable in an acutely ill patient, a more simple but inappropriate choledocholithotomy and t-tube drainage done proximal to an obstructed intrahepatic duct will be ineffective and may result in continued sepsis and death.     

Assessing the role of routine choledochoscopy during exploration of the bile duct

Two hundred and five consecutive explorations of the common bile duct were evaluated to assess the value of routine choledoschoscopic examination in preventing retained stones. Conventional exploration was performed in 139 instances (group 1), while routine choledochoscopy was added in 66 procedures (group 2). Preoperative temperature, leukocyte count, total bilirubin, amylase and alkaline phosphatase levels were not significantly different between the groups. Nine retained stones were demonstrated by postoperative cholangiography among the patients in group 1 as compared with three retained stones noted in those in group 2. This difference was not significant. Postoperative mortality and complication rates were unaffected by the performance of an endoscopic study of the biliary tract during ductal exploration. Choledochoscopy added an average of 36 minutes to the duration of the operative procedure (p less than 0.001). Choledochoscopy may prove helpful in selected instances, but the current data do not support its routine use during exploration of the common bile duct.     

Comparison of early postoperative results for laparoscopic versus standard open cholecystectomy.

Alternative (nonresective) therapies of symptomatic cholelithiasis have been followed by frequent recurrence of gallstones. Great interest has been generated by the recent development of laparoscopic cholecystectomy, which in addition to preventing recurrence, may be associated with less patient discomfort, shorter hospital stays and more rapid return to work than standard cholecystectomy. We compared the first 25 patients who underwent laparoscopic cholecystectomy at our institution to the most recent 25 patients undergoing standard cholecystectomy by the same surgeon. The results of analysis of the two patient groups showed that they were similar in age, weight and gallstone burden. A slightly longer operative time (mean plus or minus S.E.M., 122 +/- 9 minutes versus 95 +/- 5 minutes, p) was required to perform laparoscopic cholecystectomy than standard cholecystectomy during this early experience. However, patients undergoing laparoscopic cholecystectomy had a markedly diminished usage of parental narcotic analgesia during the first 24 hours postoperatively (1.7 +/- 0.5 milligrams of morphine sulfate versus 34.5 +/- 4.1 milligrams of morphine sulfate). They also were discharged from the hospital (1.0 +/- 0 days versus 4.1 +/- 0.3 days) and returned to work or unrestricted activity (8.5 +/- 1.1 days versus 35.6 +/- 4.5 days) much sooner postoperatively than those treated by standard open cholecystectomy. Based on these favorable results, we conclude that laparoscopic cholecystectomy should be the procedure of choice for most patients with symptomatic cholelithiasis.