Does laparoscopic cholecystectomy worsen the prognosis of unsuspected gallbladder cancer?

BACKGROUND: Several reports claim that there is a risk that laparoscopic cholecystectomy (LC) might worsen the prognosis of unsuspected gallbladder cancer. HYPOTHESIS: Several factors rather than LC could influence prognosis. METHODS: A retrospective clinicopathologic study was performed on 20 patients, 9 patients (3 men and 6 women, aged from 36 to 75 years [mean age, 62.3 years]) undergoing LC and 11 patients (2 men and 9 women, aged from 53 to 91 years [mean age, 65.3 years]) undergoing open cholecystectomy (OC), with postoperatively diagnosed gallbladder cancer. The correlation was evaluated between cumulative survival rates and the following 7 prognostic factors: age, sex, histopathological grade, pathologic stage, occurrence of bile spillage, type of cholecystectomy (LC or OC), and additional surgical treatments. RESULTS: Seven patients (87%) after LC and 9 patients (82%) after OC had cancer recurrence: the difference is of no statistical significance (P =.9). There were no recurrences of cancer in the abdominal wall after either LC or OC. Survival rate was statistically correlated to tumor stage (P =.007) and to the occurrence of bile spillage (P =.002). Survival rate did not change according to whether the operation was carried out using LC or OC (P =.60). CONCLUSION: These results would seem to lend support to the opinion that LC does not worsen the prognosis for unsuspected gallbladder cancer.     

Do resident duty hour restrictions reduce technical complications of emergency laparoscopic cholecystectomy?

BACKGROUND: The impact of resident duty hour restrictions on patient care has not been assessed. STUDY DESIGN: We studied 275 patients undergoing emergency cholecystectomy before and after duty hour regulations instituted by the Accreditation Council for Graduate Medical Education. Operations were stratified into 6-hour intervals from the time in-hospital call began. Procedure-related complications (bile duct injury, cystic duct leak, abdominal hemorrhage, trocar injury, intraabdominal/wound infection, unrecognized retained stone) were the primary outcomes variables. RESULTS: Complications occurred after 7 of 107 (6.5%) operations performed before duty hour restrictions, which was not different from 15 of 168 (8.9%) after duty hour restrictions. In both periods, all complications followed operations that began within the first 18 hours of duty. Patients with complications had longer operative times (p = 0.038) and a higher proportion of operations lasting 120 minutes or longer (p = 0.006). Comparing patients with and without complications, there were no significant differences in patient demographics, operative complexity, or PGY level of the surgeon. Only operative time of 120 minutes or longer retained significance in the multivariable model (p = 0.0023; odds ratio, 4.05; 95% CI, 1.65-9.97). CONCLUSIONS: There was no correlation between imposition of duty hour restrictions and technical complication rates in this study. Duration of operative time of 120 minutes or longer was the only independent marker, suggesting that technical complications are a function of operative complexity, not duration of duty. These data suggest that duty hour restrictions might not have a measurable influence on the surgical complication rate after emergency cholecystectomy.     

Is frozen section effective for diagnosis of unsuspected gallbladder cancer during laparoscopic cholecystectomy?

Background: Although frozen section is recommended to prevent tumor dissemination following laparoscopic cholecystectomy (LC) for unsuspected gallbladder cancer, there are no reports concretely demonstrating its effectiveness and outcome. Methods: Frozen section during LC was performed in 990 patients with gallstones. The sensitivity, specificity of frozen section, and false-negative cases were evaluated in comparison with postoperative entire cross sections. Results: In frozen section, 983 cases were diagnosed as benign and 7 cases as malignant. Of the benign cases, cancer was discovered in 4 patients postoperatively in which frozen section was diagnosed as regenerative epithelial severe atypia. Sensitivity was 64% and specificity was 100%. Concerning the results of frozen section by p-TNM classification, cancer was diagnosed in 40% of Tis lesions, whereas it was found in 83% of T2 or T3 lesions. Conclusion: Frozen section is effective in cases with T2 or greater lesions for which conversion to radical surgery should be required.     

What is the optimal time for laparoscopic cholecystectomy in gallbladder empyema?

Purpose

With the accumulating experience in laparoscopic surgery, early laparoscopic cholecystectomy (LC) is increasingly offered for acute cholecystitis. However, early LC without percutaneous transhepatic gallbladder drainage (PTGBD) for gallbladder empyema is still believed to be unsafe. The purpose of this study was to determine the optimal time for LC in gallbladder empyema.

Methods

A retrospective analysis was carried out of patients who underwent LC without PTGBD for gallbladder empyema between August 2007 and December 2010. All cases were confirmed by biopsy. The patients were divided into two groups on the basis of a cutoff of 72 h.

Results

LC for gallbladder empyema was performed without PTGBD in 61 patients during the study period. The overall conversion rate was 6.6 %. Based on the 72 h cutoff, there were 33 patients in the early group and 28 in the delayed group. There were no significant differences between early and late patients with respect to operation duration (75.5 vs. 71.4 min, p = 0.537), postoperative hospital stay (4.2 vs. 3.3 days, p = 0.109), conversion rate (12.1 vs. 0 %, p = 0.118), and complication rate (12.1 vs. 3.6 %, p = 0.363). However, the early group had a significantly shorter total hospital stay (5.3 vs. 8.7 days, p = 0.001).

Conclusions

Early LC without PTGBD is safe and feasible for gallbladder empyema and is associated with a low conversion rate. Delayed LC for gallbladder empyema has no advantages and results in longer total hospital stays. LC should be performed as soon as possible within 72 h after admission to decrease length of hospital stay.     

Does laparoscopy worsen the prognosis for incidental gallbladder cancer?

Background More than 75% of cholecystectomies are done laparoscopically and less than one-third of gallbladder carcinomas are known presurgically. It is supposed that the laparoscopic technique could adversely affect the prognosis of gallbladder cancer. Methods The C-A-E has started a register of all cases of cholecystectomy with a postoperative incidental finding of gallbladder carcinoma. The aim is to compare the prospectively collected follow-up data on the outcome of these patients and to answer the question of whether laparoscopic cholecystectomy affects the prognosis of incidental gallbladder cancer. Results A total of 377 cases have been recorded so far. These include 201 patients treated by the laparoscopic procedure, 119 by an open procedure, and 57 by an intraoperative conversion. The survival shows a significantly better life expectancy for the patients treated laparoscopically. Conclusion The life expectancy is higher for the laparoscopically treated patients and this cannot be explained by the fact that the laparoscopic technique is used to treat the earlier stages of cancer. The access technique does not seem to influence the prognosis for gallbladder carcinomas.     

Does laparoscopic surgery have a role in the treatment of gallbladder cancer?

Background/Purpose: This study was conducted to evaluate the role of laparoscopic surgery in the treatment of gallbladder cancer. Methods: A retrospective study was performed on 31 patients with a postoperative diagnosis of gallbladder cancer. The laparoscopic approach was initially applied to all of them. Results: Ten patients had a pT1a cancer, and all underwent laparoscopic cholecystectomy without recurrence. Nine patients had pT1b lesions, and three had to be converted to an open operation. There were two recurrences. In one of the converted patients the cystic node was invaded. Seven patients had a pT2 lesion, and in four of them the operation was converted to an open procedure. Recurrences were noted in three patients. In two patients with pT3 cancer, the opera-tions were converted; both cancers recurred. Only diagnostic laparoscopy or a palliative laparoscopic procedure was performed for pT4 cancers. The median follow-up time was 17.0 months. The 5-years survival rate was 100% for patients with stage pT1a, 100% for pT1b, and 68% for pT2 lesions. Conclusions: We suggest that when a polypoid lesion of the gallbladder is found on preoperative evaluation, laparoscopic surgery may be attempted initially. During the procedure it is important to open all specimens when a polypoid lesion is present and perform a frozen section biopsy. When a pT1a lesion is found, laparoscopic cholecystectomy is sufficient; however, when a pT1b or more advanced lesion is found, the operation might be converted to a radical cholecystectomy. Received: July 2, 2002 / Accepted: July 2, 2002 Offprint requests to: E.K. Kim     

Isolated metastatic melanoma to the gallbladder: is laparoscopic cholecystectomy indicated?: a case report and review of the literature

Metastatic involvement of the gallbladder in melanoma is rare, but constitutes the most common metastatic lesion involving this organ. The surgical management seems to be indicated for patients with isolated and resectable gallbladder metastases to avoid symptoms or tumor complications. We report on a case of a young woman with an isolated metastatic gallbladder melanoma who presented with symptoms of acute cholecystitis. The patient underwent laparoscopic cholecystectomy (LC) and lymphadenectomy of the hepatoduodenal ligament. Histology was characteristic for metastatic malignant melanoma. Nodes were negative for metastases. We emphasize the appropriateness of a laparoscopic approach, once ruled out a widespread metastatic disease. It can be done with a remarkably low rate of complications. Gentle manipulation, avoidance of perforation, and use of a retrieval bag for the removal of the gallbladder should be practiced to help minimize the chance of mechanical exfoliation or implantation of malignant cells during LC. In isolated metastatic localization, LC may be curative and provide adequate palliation of symptoms with a short convalescence and a fast recovery.     

Is laparoscopic cholecystectomy safe for lymphangioma of the gallbladder? A complicated case mimicking subhepatic abscess

Lymphangiomas are rare benign neoplasms of the lymphatic tissue generally occurring in the childhood. Cystic lymphangioma of the gallbladder is an extremely rare tumor with only eight cases having been reported in the literature. The aspecific and potentially misleading clinical presentation of these tumors requires complex preoperative imaging in the setting of clinical suspicion to make the correct diagnosis. The treatment of choice is complete excision with negative margins to avoid local recurrence. Their tendency to locally invade the surrounding tissues requires sometimes extended resections. Laparoscopic cholecystectomy can be a questionable choice in this setting; however, the procedures can be performed safely in most cases, although complicated. We report the case of a hemorrhagic cystic lymphangioma of the gallbladder mimicking a subhepatic abscess and operated in emergency with laparoscopic approach.     

What happens to the lost gallstone during laparoscopic cholecystectomy?

Iatrogenic gallbladder perforation with resultant spillage of bile and gallstones is common during laparoscopic cholecystectomy. Although it's assumed to be harmless, several complications may occur as a result of spillage. We present a 57-year-old woman with localized abdominal pain in the upper abdomen, jaundice, and itching because of retained stones in both common bile duct (CBD) and the abdominal cavity, who had undergone laparscopic cholecystectomy three years previously. After reoperation, stones in the CBD were removed after CBD exploration and a T-tube was inserted. A mass (8 x 5 cm) located in the gastrocolic omentum, which was not reported on imaging studies, was found coincidentally and was totally excised. Investigation of the mass resulted in the discovery of eight gallstones located in the abcess-like central cavity, which was surrounded by fibrous tissue. The patient had an uneventful recovery. Despite the unaffected long-term sequelae, any patients with gallbladder perforations and spillage should not be considered for extension of antibiotic prophylaxis to avoid early complications. Whenever gallstones are lost in the abdominal cavity, every effort should be made to find and remove them to prevent late complications.     

Should laparoscopic cholecystectomy be performed in patients with thick-walled gallbladder?

Background/Purpose Laparoscopic cholecystectomy is the procedure of choice for patients with symptomatic cholelithiasis. This procedure is contraindicated in patients with gall-bladder cancer (GBC) because of fear of dissemination of the disease. One of the findings raising the suspicion of GBC is a thick-walled gallbladder (TWGB).Methods A prospective study of patients with TWGB was done over a period of 10 months at a tertiary-level referral hospital in northern India. We studied the clinical profiles, investigations (ultrasound [US] and computerized tomography [CT]) and management plans in these patients.Results A total of 60 patients were included in the study. After cholecystectomy, histopathology of gallbladders showed GBC in 2 (3.3%) patients. The remaining 58 patients had chronic cholecystitis, of whom 28 (48%) had xanthogranulomatous variant chronic cholecystitis. Cholecystectomy by the laparoscopic method was attempted in 46 (77%) patients and by open technique in the remaining 14 (23%) patients. Laparoscopic cholecystectomy was successful in 40 of the 46 (87%) patients in whom it was attempted. Obscure anatomy, suspicion of GBC, and bile duct injury were the causes of conversion, in the remaining 13% (6/46). None of the 11 patients who had a CT examination because of clinical or US suspicion of malignancy turned out to have GBC at final histology. Both the cases of GBC in this study were incidental findings on final histopathology.Conclusions Laparoscopic cholecystectomy can be successfully performed in the majority of patients with diffuse TWGB, with appropriate selection. There is, however, an increased chance of conversion to open cholecystectomy in these patients. If there is an intraoperative suspicion of GBC, early conversion to open cholecystectmy and frozen section/imprint cytology will help to decide the further treatment during surgery.     

Who did the first laparoscopic cholecystectomy?

Laparoscopic cholecystectomy (LC) has served as the igniting spark in the laparoscopic surgery explosion; however, it is unclear who created the spark. The question remains: Who did the first LC?     

Does smoking status influence the prognosis of bladder cancer? A systematic review

OBJECTIVE: To summarize, in a systematic review, the evidence for the effect of stopping smoking on recurrence, cancer-specific and all cause-mortality among smokers with newly diagnosed bladder cancer. MATERIALS AND METHODS: Two electronic databases and the reference lists of identified primary studies and reviews were searched. Studies were included if a hazard ratio and its confidence intervals could be extracted. A predefined set of study characteristics was extracted which defined whether studies were giving valid prognostic data on the effects of smoking in reasonably homogenous cohorts. The results of studies were synthesized qualitatively. RESULTS: Fifteen relevant studies were identified; former and current smokers were combined in many studies. Many studies produced information on prognosis that was confounded by the mixing of incident and prevalent cases. Only three studies examined the influence of smoking on prognosis in only incident cases, most of whom had superficial disease. Of these, only one was of high quality. These three studies and the other 12 showed suggestive evidence that continued smoking or a lifetime of smoking constitutes a moderate risk factor for recurrence and death, and that stopping smoking could favourably change this. However, the evidence base for this is weak because of the methodological shortcomings and because most studies' results were not statistically significant. A life-table model showed that if stopping smoking altered the prognosis, the size of the benefit would be clinically worthwhile. CONCLUSION: There is suggestive evidence that stopping smoking might favourably alter the course of bladder cancer, but this is insufficient for clinicians to inform patients that doing so will improve their prognosis, and for providing specialized services to assist in stopping smoking to patients with bladder cancer.     

Mini-laparotomy cholecystectomy versus laparoscopic cholecystectomy: which way to go?

PURPOSE: The aim of this paper is to report the results of a prospective clinical trial investigating traditional laparoscopic cholecystectomy versus "mini-lap" cholecystectomy in a tertiary care University Hospital. MATERIALS AND METHODS: This is a prospective, randomized, single-center observational study. Forty-four patients were allocated in each group; patients in group L underwent laparoscopic cholecystectomy, whereas patients in group M had open "mini-laparotomy" cholecystectomy with a small incision through the rectus abdominis muscle. RESULTS: The operation lasted significantly longer in group L compared with group M, whereas patients of group L had a shorter hospital stay. There was no difference between groups regarding postoperative day on which patients commenced eating. There was no significant difference between groups regarding doses of analgesics used during surgery or in the recovery room. However, patients in group M used significantly more opioids in the postoperative period. Time to resume normal activity was significantly shorter in group L. A very good aesthetic result was obtained in 97.7% of patients in group L and 77.3% of patients in group M. CONCLUSIONS: Cholecystectomy through a mini-laparotomy incision is a lower-cost, versatile, and safe alternative to laparoscopic cholecystectomy.     

Does cholecystectomy prior to the diagnosis of pancreatic cancer affect outcome?

Early diagnosis and curative resection are significant predictors of survival in patients with pancreatic cancer. We hypothesize that cholecystectomy within 12 months of pancreatic cancer affects 1-year survival. The Surveillance Epidemiology and End Result (SEER) database linked to Medicare data was used to identify patients diagnosed with pancreatic cancer who underwent cholecystectomy 1 to 12 months prior to cancer diagnosis. The SEER database identified 32,569 patients from 1995 to 2002; 415 (1.3%) underwent cholecystectomy prior to cancer diagnosis. Patients who underwent cholecystectomy had a higher proportion of diabetes (40.2% vs 20.5%; P < 0.01), obesity (8.9% vs 3.1%; P < 0.01), jaundice (17.3% vs 0.7%; P < 0.01), cholelithiasis (70.4% vs 4.2%; P < 0.01), choledocholithiasis (0.7% vs 0.0%; P < 0.01), weight loss (17.3% vs 4.7%; P < 0.01), abdominal pain (79.5% vs 22.5%), steatorrhea (0.7% vs 0.0%; P < 0.01), and cholecystitis (32.3% vs 1.7% ; P < 0.0001). After controlling for tumor stage, patient demographics, and symptoms, survival at 1 year was significantly lower in patients undergoing cholecystectomy (OR, 0.75; 95% CI, 0.58-0.97). Recent cholecystectomy is associated with decreased 1-year survival among patients with pancreatic cancer. For patients older than 65 years of age, further evaluation prior to cholecystectomy may be necessary to exclude pancreatic cancer, especially patients with jaundice, weight loss, and steatorrhea.     

Is laparoscopic cholecystectomy cheaper?

As laparoscopic cholecystectomy is being used more and more frequently, a cost analysis was aimed to be performed to evaluate cost effectiveness in Turkey. Records of 376 patients who underwent cholecystectomy by various methods were analyzed retrospectively. Mean duration of postoperative hospital stay was 5.1 +/- 2.6 days for the open cholecystectomy group (OC group), composed of 177 patients; 5.6 +/- 2.1 days for the converted open cholecystectomy group (CC group) composed of 15 patients; and 2.5 +/- 1.8 days for the laparoscopic cholecystectomy group (LC group), which included 184 patients. The mean cost per patient was 778 dollars +/- 75, 1964 dollars +/- 82, and 2357 dollars +/- 80 for the OC, LC, and CC groups, respectively. It was concluded that laparoscopic cholecystectomy will gain economic feasibility over conventional cholecystectomy in our country only when costs of laparoscopic equipment lower and personnel wages increase sufficiently.     

Can early laparoscopic cholecystectomy be the optimal management of cholecystitis with gallbladder perforation? A single institute experience of 74 cases

Background

Gallbladder perforation is a rare but serious complication of cholecystitis. It was usually managed by percutaneous gallbladder drainage (PTGBD) followed by elective cholecystectomy. However, evidences are emerging that early laparoscopic cholecystectomy (LC) is still feasible under these conditions. We hypothesized that early LC may have comparable surgical results as to those of PTGBD?+?elective LC.

Material and methods

From January 2005 to October 2011, patients admitted to China Medical University Hospital with a diagnosis of perforated cholecystitis were retrospectively reviewed. The diagnosis of gallbladder perforation was made by image and/or intraoperative findings. Those patients who had unstable hemodynamics that were not fitted for general anesthesia or those who had concomitant major operations were excluded. Patients were divided into three groups: early open cholecystectomy (group 1), early LC (group 2), and PTGBD followed by elective LC (group 3). The demographic features, surgical results, and patient outcome were analyzed and compared between groups.

Results

A total of 74 patients were included. All patients had similar demographic features except that patients in group 2 were younger (62 vs. 72 and 73.5?years) compared with group 1 and group 3 (p?=?0.016). There were no differences in terms of operative time, blood loss, conversion, and complication rate between three groups. The length of hospital stay (LOS) was significant shorter in group 2 patients compared with that of groups 1 and 3.

Conclusions

Although PTGBD followed by elective LC was still the mainstay for the treatment of gallbladder perforation, early LC had comparable surgical outcomes as that of PTGBD?+?LC but with a significantly shorter LOS. Early LC should be considered the optimal treatment for gallbladder perforation, and PTGBD?+?LC can be preserved for those who carried a high risk of operation.     

Does using a laparoscopic approach to cholecystectomy decrease the risk of surgical site infection?

OBJECTIVE: To assess the impact of laparoscopy on surgical site infections (SSIs) following cholecystectomy in a large population of patients. SUMMARY BACKGROUND DATA: Previous investigations have demonstrated that laparoscopic cholecystectomy is associated with a shorter postoperative stay and fewer overall complications. Less is known about the impact of laparoscopy on the risk for SSIs. METHODS: Epidemiologic analysis was performed on data collected during a 7-year period (1992-1999) by participating hospitals in the National Nosocomial Infections Surveillance (NNIS) System in the United States. RESULTS: For 54,504 inpatient cholecystectomy procedures reported, use of the laparoscopic technique increased from 59% in 1992 to 79% in 1999. The overall rate of SSI was significantly lower for laparoscopic cholecystectomy than for open cholecystectomy. Overall, infecting organisms were similar for both approaches. Even after controlling for other significant factors, the risk for SSI was lower in patients undergoing the laparoscopic technique than the open technique. CONCLUSIONS: Laparoscopic cholecystectomy is associated with a lower risk for SSI than open cholecystectomy, even after adjusting for other risk factors. For interhospital comparisons, SSI rates following cholecystectomy should be stratified by the type of technique.     

Why laparoscopic cholecystectomy today?

Traditional open cholecystectomy became the gold standard of surgical treatment for symptomatic gallstone disease during the last century. In spite of its good results, clinicians have been trying to establish effective nonsurgical methods of eliminating gallstones. Although oral, percutaneous, or retrograde litholysis can be used effectively for cholesterol stones, these represent only 10% of all gallstones. Moreover, intracorporeal lithotripsy is an invasive method, and while extracorporeal shock wave lithotripsy is a promising procedure, even after careful selection, only 70%–80% of the patients become stone-free within 1 year. In fact, none of the methods which leave the gallbladder intact are free of complications, and they are followed by 50% stone recurrence within 5 years. Since 1987, laparoscopic cholecystectomy has become the procedure of choice as it is safe and only minimally invasive. We believe that the laparoscopic technique is a promising way to the surgery of the future.