Timing of laparoscopic cholecystectomy for acute cholecystitis： A prospective non randomized study

INTRODUCTION Laparoscopic cholecystectomy (LC) has been established as the treatment of choice for the management of acute cholecystitis (AC), despite initial reservations, regarding the impact of this policy on the conversion rate and morbid- ity[1]. Sev…     

Is gallbladder cancer decreasing in view of increasing laparoscopic cholecystectomy?

Background. Gallstone disease affects over 20 million people in the U.S. and is a major risk factor for gallbladder cancer (GBC). In 1988, a less invasive, low-cost procedure, laparoscopic cholecystectomy (LC), was introduced and became the standard of care for management of gallstones.Methods. GBC incidence (1973-2007) and mortality rates (1969-2006) were calculated using SEER Program data. LC rates (1993-2008) were obtained from NAMCS, NHAMCS, and HCUP. Annual percent change was estimated by gender, age, and race, and the statistical significance was assessed at p < 0.05. Correlation analysis was performed on GBC and LC trends.Results. Since the early 1970s, GBC incidence and mortality rate have declined. Women and older age groups continue to have the highest risk for GBC, despite having greater declines. Incidence significantly decreased among whites, but did not among blacks. The number of inpatient LC procedures increased by 15% between 1994 and 2008; however, inpatient and outpatient LC rates remained stable. LC rate was not significantly correlated with either GBC incidence or mortality.Conclusions. The decline in incidence and mortality of GBC began decades before the introduction of LC and apparently has stabilized in the past decade. No temporal relationship existed between LC rate and the incidence and mortality rates of GBC. Our study suggests that prevention of a rare tumor may be extremely difficult if the surgical removal of a risk factor is involved.     

Are we getting the point? Needlestick injuries-an ongoing problem

The pattern of glove perforation using hollow needles is unknown and the incidence, using sensitive electronic methods has not been described. We wished to identify the glove perforation rate following the use of hollow needles in our Emergency Department. Two hundred and eighty-nine gloves were collected over three months. These gloves were electronically tested and compared with one hundred unused control gloves. There were 28/298 perforations (9.7%) vs 1/100 in the control group (P<0.01 Fisher's exact probability). Most perforations were located on the thumb and index fingers. There were no needlestick injuries reported during this period. The glove perforation rate following hollow needle use in our Emergency Department is higher than previously reported. The pattern of perforation suggests injury by the needle held in the dominant hand.     

Efficacy of perioperative parecoxib injection on postoperative pain relief after laparoscopic cholecystectomy： A prospective, randomized study

AIM： To determine the efficacy of perioperative parecoxib injection on postoperative pain relief after laparoscopic cholecystectomy. METHODS： A prospective, double-blind, randomized, placebo-controlled study was conducted on 70 patients who underwent elective laparoscopic cholecystectomy under general anesthesia at Siriraj Hospital, Bangkok, from January 2006 to December 2007. Patients were randomized to receive either 20 mg parecoxib infusion 30 min before induction of anesthesia and at 12 h after the first dose （treatment group）, or normal saline infusion, in the same schedule, as a placebo （control group）. The degree of the postoperative pain was assessed every 3 h in the first 24 h after surgery, and then every 12 h the following day, using a visual analog scale. The consumption of analgesics was also recorded. RESULTS： There were 40 patients in the treatment group, and 30 patients in the control group. The pain scores at each time point, and analgesic consumption did not differ between the two groups. However,there were fewer patients in the treatment group than placebo group who required opioid infusion within the first 24 h （60% vs 37%, P = 0.053）. CONCLUSION： Perioperative administration of parecoxib provided no significant effect on postoperative pain relief after laparoscopic cholecystectomy. However, preoperative infusion 20 mg parecoxib could significantly reduce the postoperative opioid consumption.     

Are we ready for a prospective study to investigate the role of chylomicrons in cardiovascular disease?

Intestinal chylomicrons and their remnants are believed to contribute both directly and indirectly to the onset and development of atherosclerosis. Measurement of postprandial triglyceridemia or the plasma concentration of apoB-48 (the principle structural protein of chylomicrons) is not however standard clinical practice. The reason is that a standardized fat tolerance test has not been established, and age- and gender-specific normal ranges have not been determined. Appropriate cost-benefit analysis is also lacking, although such analysis depends upon reliable prospective data demonstrating that plasma parameters measured after a defined oral fat load can predict the presence of cardiovascular disease (CVD) better than existing lipid and non-lipid risk factors. In addition to being of prognostic value, positive prospective data linking plasma chylomicron levels and CVD would be of therapeutic importance and would reemphasize advice to restrict the size, frequency and fat content of individual meals.     

Is intraoperative cholangiography necessary during laparoscopic cholecystectomy for cholelithiasis?

AIM:To determine the efficacy and safety benefits of performing intraoperative cholangiography(IOC)during laparoscopic cholecystectomy(LC)to treat symptomatic cholelithiasis.METHODS:Patients admitted to the Minimally Invasive Surgery Center of Tianjin Nankai Hospital between January2012 and January 2014 for management of symptomaticcholelithiasis were recruited for this prospective randomized trial.Study enrollment was offered to patients with clinical presentation of biliary colic symptoms,radiological findings suggestive of gallstones,and normal serum biochemistry results.Study participants were randomized to receive either routine LC treatment or LC+IOC treatment.The routine LC procedure was carried out using the standard four-port technique;the LC+IOC procedure was carried out with the addition of meglumine diatrizoate(1:1 dilution with normal saline)injection via a catheter introduced through a small incision in the cystic duct made by laparoscopic scissors.Operative data and postoperative outcomes,including operative time,retained common bile duct(CBD)stones,CBD injury,other complications and length of hospital stay,were recorded for comparative analysis.Inter-group differences were statistically assessed by theχ2 test(categorical variables)and Fisher’s exact test(binary variables),with the threshold for statistical significance set at P0.05.RESULTS:A total of 371 patients were enrolled in the trial(late-adolescent to adult,age range:16-70 years),with 185 assigned to the routine LC group and 186 to the LC+IOC group.The two treatment groups were similar in age,sex,body mass index,duration of symptomology,number and size of gallstones,and clinical symptoms.The two treatment groups also showed no significant differences in the rates of successful LC(98.38%vs97.85%),CBD stone retainment(0.54%vs 0.00%),CBD injury(0.54%vs 0.53%)and other complications(2.16%vs 2.15%),as well as in duration of hospital stay(5.10±1.41 d vs 4.99±1.53 d).However,the LC+IOC treatment group showed significantly longer mean operative time(routine LC group:43.00±4.15 min vs 52.86±4.47 min,P0.01).There were no cases of fatal complications in either group.At the one-year follow-up assessment,one patient in the routine LC group reported experiencing diarrhea for three months after the LC and one patient in the LC+IOC group reported ongoing intermittent epigastric discomfort,but radiologicalexamination provided no abnormal findings.CONCLUSION:IOC addition to the routine LC treatment of symptomatic cholelithiasis does not improve rates of CBD stone retainment or bile duct injury but lengthens operative time.     

Management of gallbladder stones during pregnancy: conservative treatment or laparoscopic cholecystectomy?

BACKGROUND/AIMS: Safety of laparoscopic cholecystectomy (LC) during pregnancy is still controversial, we report our experience in the management of 42 pregnant patients suffering from symptomatic gallbladder stones. METHODOLOGY: Between June 1993 and July 1998, we performed 1700 LC's. During this period we dealt with 42 pregnant patients who had symptoms of gallbladder stones. Following an initial period of conservative management, only 16 patients underwent LC during pregnancy and 26 patients responded to medical management and were operated upon later on after delivery. RESULTS: Sixteen patients were operated upon successfully during pregnancy, 2 in the 1st trimester, 10 in the 2nd trimester and 4 in the 3rd trimester. No complications occurred and all patients carried on their pregnancies to term and delivered healthy babies. CONCLUSIONS: From our experience and from the review of the literature on this subject, LC during pregnancy is safe, however the indications should be restricted to patients with complications or to those suffering from repeated and persistent symptoms not responding to medical management.     

Surveillance of colonic polyps: Are we getting it right?

Colorectal cancer(CRC) is the third most commonly diagnosed cancer worldwide. The identification of colonic polyps can reduce CRC mortality through earlier diagnosis of cancers and the removal of polyps: the precursor lesion of CRC. Following the finding and removal of colonic polyps at an initial colonoscopy, some patients are at an increased risk of developing CRC in the future. This is the rationale for postpolypectomy surveillance colonoscopy. However, not all individuals found to have colonic adenomas have a risk of CRC higher than that of the general population. This review examines the literature on post-polypectomy surveillance including current international clinical guidelines. The potential benefits of surveillance procedures must be weighed against the burden of colonoscopy: resource use, the potential for patient discomfort, and the risk of complications. Therefore surveillance colonoscopy is best utilised in a selected group of individuals at a high risk of developing cancer. Further study is needed into the specific factors conferring higher risk as well as the efficacy of surveillance in mitigating this risk. Such evidence will better inform clinicians and patients of the relative benefits of colonoscopic surveillance for the individual. In addition, the decision to continue with surveillance must be informed by the changing profile of risks and benefits of further procedures with the patient’s advancing age.     

Timing of laparoscopic cholecystectomy for subacute calculous cholecystitis: early or interval — a prospective study

Background/Purpose

The aim of this prospective study was to evaluate the safety and feasibility of early laparoscopic cholecystectomy for subacute cholecystitis and to compare it with interval laparoscopic cholecystectomy.

Methods

The study was performed in 74 patients who had been diagnosed with subacute cholecystitis between January 2000 and June 2005. The patients were divided into two groups. The early laparoscopic cholecystectomy group was composed of 31 patients who underwent laparoscopic cholecystectomy 24?h after admission to the hospital. The interval laparoscopic cholecystectomy group was composed of 43 patients who underwent laparoscopic cholecystectomy 8–12 weeks after medical treatment.

Results

There was no significant difference between the conversion rate, intraoperative bleeding, need for intraoperative cholangiography, minor bile duct injury, and postoperative complications in the two groups. Eleven patients in the interval group underwent urgent laparoscopic cholecystectomy or additional procedures because of recurrent cholecystitis, choledocholithiasis, or biliary pancreatitis. The early group had a significantly shorter total hospital stay (P = 0.031), lower cost of treatment (P = 0.042), and less difficulty with Calot's triangle dissection (P = 0.008).

Conclusions

Early laparoscopic cholecystectomy can be done without hesitation in patients with subacute cholecystitis, in the light of obstacles observed in the interval group, such as dissection difficulty, lack of success in “cooling down”, and additional problems such as choledocholithiasis and biliary pancreatitis.     

Near-infrared fluorescent cholangiography – real-time visualization of the biliary tree during elective laparoscopic cholecystectomy

Background

The purpose was to evaluate the efficacy of near-infrared fluorescent cholangiography (FC) in real-time visualization of the biliary tree during elective laparoscopic cholecystectomy.

Training in GI endoscopy: can we objectively predict the performance of trainees? A prospective correlation study

BACKGROUND: No objective criteria have hitherto been available for assessing the individual talents and skills of trainees involved in GI endoscopy. The aim of our study was to compare the correlation of various psychological, psychomotor and cognitive tests (psy-tests) and of the subjective assessment of the trainer (expert assessment) at the beginning of the training with the objective performance of the trainees at the end of a one-week training period in upper GI endoscopy. METHODS: In a prospective study including 12 endoscopic centers, a total of 58 participants without any prior endoscopic experience were analyzed. During a practical training week in each center with the "Erlangen Endo-Trainer," an assessment using a "score card" protocol was used as reference method. Prior to the start of the training, various psy-tests (personality test, vigilance endurance test, test of spatial thinking and two tests of sensorimotor coordination) as well as assessment of the trainer were obtained. These parameters were compared with a blinded analysis of the performance at the end of the training. RESULTS: There was significant overall improvement during the training course. Multiple logistic regression analysis revealed that testing sensorimotoric coordination was significantly associated with defined improvement margins (odds ratio 11.46, p = 0.035). An expert's judgment on the prognosis correlated also significantly with the trainee's improvement (OR = 41.46; p = 0.018). Self-assessments were not significantly associated with performance or progress. CONCLUSIONS: Sensorimotoric tests may provide a reliable prediction of the trainee's learning progress. In contrast to self-assessment, the judgement of an experienced endoscopist provides the best guidance for the young candidate endoscopists prior to the start of his/her endoscopic training program.     

Are we underestimating the nephrotoxicity of drugs?

In the submitted review the authors discuss the nephrotoxicity of drugs which is a serious danger of pharmacotherapy. Clinically it may be manifested in different ways from acute deterioration of renal functions to the picture of chronic renal insufficiency. It is particularly important to know the nephrotoxic potential of different drug groups and to ensure a careful stratification of patients. The most frequent drug groups which lead to affection of the kidneys are radiocontrasting substances, aminoglycoside antibiotics, non-steroid analgesics-antiphlogistics and ACE inhibitors. With the increasing number of transplantations the problem of nephrotoxicity of immunosuppressives is becoming important. The authors analyze in each group risk factors, the pathogenesis, clinical picture and prognosis of damage. Special emphasis is laid on adherence to preventive measures and careful monitoring of the laboratory and clinical picture, in particular in risk groups of patients as treatment of already developed nephrotoxic sequelae of pharmacotherapy is frequently difficult.     

Factors influencing the progress of mobilization in hip fracture patients during the early postsurgical period?—A prospective observational study

ObjectiveThe aim of the present study was to determine the independent factors influencing mobilization progress after geriatric hip fractures.Patients and Methods392 Hip fracture patients older than 60 years were included in this prospective, observational, cohort study. The progress of mobilization was measured with walking ability 4 days post-surgery, ability to climb stairs until discharge and the Tinetti test at discharge. Factors correlated with the progress of mobilization were determined using multivariate analyses.ResultsThe independent factors influencing walking ability 4 days post-surgery were the pre-fracture Charlson Comorbidity Index (OR = 0.834, p = 0.005), the American Society of Anesthesiologists Score (OR = 0.550, p = 0.013), pre-fracture Barthel Index ([BI], OR = 1.019, p = 0.012) and risk for depression, as measured by the Geriatric Depression Scale, (OR = 0.896, p = 0.013). The probability of climbing stairs until discharge was influenced by the patient's age (OR = 0.840, p < 0.001), pre-fracture BI (OR = 1.047, p = 0.042), cognitive impairment, as measured by the mini mental state examination (OR = 1.182 p = 0.008), pre surgical hemoglobin (OR = 1.026, p = 0.044), time until surgery (OR = 0.961, p = 0.023), duration of surgery (OR = 0.982, p = 0.014), and surgery type (prosthesis, OR = 4.545, p = 0.001). Similar variables influenced the Tinetti test ad discharge.ConclusionWhile pre-fracture co-morbidities and function cannot be changed, the treatment of patients with cognitive impairment and depressive symptoms should be optimized. Efforts should be undertaken to ensure early surgery for all hip fractures.     

Can sonographic signs predict long-term results of laparoscopic cholecystectomy?

BACKGROUND/AIMS: To determine whether sonographic signs of the gallbladder can predict the long-term outcome of laparoscopic cholecystectomy (LC). METHODOLOGY: All 346 patients, who underwent LC at our institution between January 1, 1993 and March 1, 1996, were interviewed using a structured questionnaire on the persistence of pre-operative abdominal symptoms. Patients without a sonographic examination 6 months prior to surgery were excluded. Sonographic parameters, scored on the pre-operative examination, were evaluated by univariate analysis using the relief of abdominal symptoms as a dependent variable. RESULTS: The response rate of correctly returned questionnaires was 68%. The follow-up ranged from 14-53 months. Fourteen percent (18/133) of all patients reported persistence of abdominal complaints after cholecystectomy. Grit in the gallbladder on the pre-operative ultrasound examination was significantly associated with a higher relative risk (RR) for persistence of pre-operative abdominal symptoms (RR 4.5, 95% confidence intervals (CI) 2.0-10.1). The presence of echogenic bile (RR 1.9, 95% CI 0.8-4.9), gallbladder distention (RR 1.9, 95% CI 0.6-5.7), and gallbladder wall thickening (RR 1.5, 95% CI 0.5-4.1) were associated with the persistence of symptoms. A contracted gallbladder (RR 0.6, 95% CI 0.4-1.1) and stone impaction (RR 0.44, 95% CI 0.1-1.8) were associated with the relief of abdominal symptoms. None of these sonographic signs reached significance. There was no difference in the post-operative symptoms rate between patients with a laparoscopic cholecystectomy and those who were converted to an open cholecystectomy. CONCLUSIONS: This retrospective study showed that the sonographic sign of grit in the gallbladder is associated with a high relative risk for persistent abdominal symptoms after cholecystectomy. These findings will be re-evaluated in a prospective study to estimate the definitive clinical importance.