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1.
Daniel Henneman David W. da Costa Bart C. Vrouenraets Bart A. van Wagensveld Sjoerd M. Lagarde 《Surgical endoscopy》2013,27(2):351-358
Background
In the setting of difficult dissection of Calot’s triangle during laparoscopic cholecystectomy, conversion is commonly advocated. An alternative approach aimed at preventing bile duct injury is laparoscopic partial cholecystectomy (LPC). The safety and efficacy of this procedure are unclear.Methods
A systematic review of the literature was performed independently by three researchers. The outcomes were conversion rate, hospital length of stay (LOS), bile duct injury, bile leak, symptomatic gallstones in the remnant gallbladder, need for reoperation, postoperative endoscopic retrograde cholangiopancreaticography (ERCP), percutaneous intervention, and mortality.Results
The review included 15 publications, which reported on 625 patients. Four different operative techniques could be distinguished. Conversion to open (partial) cholecystectomy was performed in 10.4 % of the cases. The median LOS was 4.5 days (range, 0–48 days). The most common complication was postoperative bile leak, which occurred in 66 patients (10.6 %). One case of bile duct injury occurred. During the follow-up period, 2.2 % of the patients experienced recurrent symptoms of gallstones. Eight patients (2.7 %) underwent reoperation. Postoperative ERCP was performed for 26 (7.5 %) of 349 patients. A percutaneous intervention was performed for 5 (1.4 %) of 353 patients. Three deaths were described in the reviewed series (1 of pulmonary sepsis and 2 of myocardial infarctions). A rough comparison showed that fewer bile leaks, less need for ERCP, and less recurrent symptoms of gallstones seemed to occur when the cystic duct and gallbladder remnant were closed.Conclusions
Literature concerning LPC is scarce. Four different LPC techniques can be distinguished. When a difficult gallbladder is encountered during LC, LPC seems to be a safe and feasible alternative to conversion. Closing of the cystic duct, gallbladder remnant, or both seems to be preferable. 相似文献2.
Rutger M. Schols Nicole D. Bouvy Ad A. M. Masclee Ronald M. van Dam Cornelis H. C. Dejong Laurents P. S. Stassen 《Surgical endoscopy》2013,27(5):1530-1536
Background
Laparoscopic cholecystectomy (LC) is one of the most commonly performed laparoscopic procedures. Bile duct injury is a rare but serious complication during this procedure, mostly caused by misidentification of the extrahepatic bile duct anatomy. Intraoperative cholangiography may be helpful to reduce the risk of bile duct injury; however, this is not a common procedure worldwide. Near-infrared fluorescence cholangiography (NIRFC) using indocyanine green (ICG) is a promising alternative for the identification of the biliary tree. This prospective observational study was designed to assess the feasibility and image quality of intermittent NIRFC during LC, using a newly developed laparoscopic fluorescence system.Methods
Consecutive patients undergoing elective LC were included and received a single intravenous injection of ICG directly after induction of anesthesia. During dissection of the base of the gallbladder and the cystic duct, the extrahepatic bile ducts were visualized by using a dedicated laparoscope, which offers both conventional state-of-the-art imaging and fluorescence imaging. Intraoperative recognition of the biliary structures was registered at set time points, as well as the establishment of the critical view of safety.Results
Fifteen patients were included between December 2011 and May 2012. ICG was visible in the liver and bile ducts within 20 min after intravenous administration and remained for approximately 2 h, using the fluorescence mode of the laparoscope. The common bile duct and cystic duct could be clearly identified at an early stage of the operation and, more important, significantly earlier than with the conventional camera mode. No per- or postoperative complications occurred as a consequence of ICG use.Conclusions
Intermittent fluorescence imaging using a newly developed laparoscope and preoperative administration of ICG seems a useful aid in accelerating visualization of the extrahepatic bile ducts during laparoscopic cholecystectomy. 相似文献3.
Jun Nakajima Akira Sasaki Toru Obuchi Shigeaki Baba Hiroyuki Nitta Go Wakabayashi 《Surgery today》2009,39(10):870-875
Purpose
To evaluate the efficacy and outcome of laparoscopic subtotal cholecystectomy (LSC) for patients with severe cholecystitis.Methods
Between April 1992 and May 2008, 1226 patients underwent laparoscopic cholecystectomy (LC). From 2000 onward 60 patients with severe cholecystitis underwent LSC. The outcomes of LC were compared between patients who underwent the procedure between 1992 and 1999 (group A; n = 643) and those who underwent the procedure between 2000 and 2008 after the introduction of LSC (group B; n = 583), respectively. In Group B, operative outcomes were also compared between the LC and LSC groups.Results
The incidence of bile duct injury (1.6% vs 0.3%, P = 0.040) and conversion to open cholecystectomy (2.2% vs 0.3%, P = 0.046) was significantly lower in group B. The mean operative time was significantly longer (119.6 min vs 71.0 min., P < 0.001), and the mean blood loss was significantly higher (53.4 ml vs 12.9 ml, P < 0.001) in the LSC group. No significant differences were observed between LC and LSC in the incidence of postoperative morbidities or postoperative hospital stay. No patient had remnant gallstones or gallbladder cancers after a median follow-up of 42 months.Conclusions
Laparoscopic subtotal cholecystectomy is safe and effective for preventing bile duct injuries and lowering the conversion rate in patients with technically difficult severe cholecystitis. 相似文献4.
Hiroshi Yajima Hideki Kanai Kyonsu Son Kazuhiko Yoshida Katsuhiko Yanaga 《Surgery today》2014,44(1):80-83
Purpose
The aim of this study was to analyze the reasons and risk factors for intraoperative conversion from laparoscopic cholecystectomy to open cholecystectomy.Methods
The study involved 407 patients in whom laparoscopic cholecystectomy was planned between January 1998 and July 2006. The patients were divided into two groups (the LC completed group and the conversion group), and the two groups were compared.Results
Laparoscopic surgery was intraoperatively converted to open surgery in 47 cases (11.6 %). The reasons for the conversion consisted of adhesions (15 cases), inflammation (8 cases), adhesion plus inflammation (9 cases), bleeding (8 cases), common bile duct injury (4 cases), suspected common bile duct injury (1 case), injury of the duodenal bulb (1 case) and respiratory disorder (1 case). The group of patients who required conversion to open surgery had a significantly higher percentage of males (P = 0.042) and prevalence of acute cholecystitis (P < 0.001) than the group of patients for whom laparoscopic surgery could be completed. A multivariate logistic regression analysis of these significant predictors showed that male sex [odds ratio (OR) 1.95] and acute cholecystitis (OR 8.45) were significant.Conclusion
Particular attention is needed when laparoscopic surgery is considered for male patients with acute cholecystitis. 相似文献5.
Rutger M. Schols Nicole D. Bouvy Ronald M. van Dam Ad A. M. Masclee Cornelis H. C. Dejong Laurents P. S. Stassen 《Surgical endoscopy》2013,27(12):4511-4517
Background
Bile duct injury in patients undergoing laparoscopic cholecystectomy is a rare but serious complication. Concomitant vascular injury worsens the outcome of bile duct injury repair. Near-infrared fluorescence imaging using indocyanine green (ICG) is a promising, innovative, and noninvasive method for the intraoperative identification of biliary and vascular anatomy during cholecystectomy. This study assessed the practical application of combined vascular and biliary fluorescence imaging in laparoscopic gallbladder surgery for early biliary tract delineation and arterial anatomy confirmation.Methods
Patients undergoing elective laparoscopic cholecystectomy were enrolled in this prospective, single-institutional study. To delineate the major bile ducts and arteries, a dedicated laparoscope, offering both conventional and fluorescence imaging, was used. ICG (2.5 mg) was administered intravenously immediately after induction of anesthesia and in half of the patients repeated at establishment of critical view of safety for concomitant arterial imaging. During dissection of the base of the gallbladder and the cystic duct, the extrahepatic bile ducts were visualized. Intraoperative recognition of the biliary structures was registered at set time points, as well as visualization of the cystic artery after repeat ICG administration.Results
Thirty patients were included. ICG was visible in the liver and bile ducts within 20 minutes after injection and remained up to approximately 2 h, using the ICG-filter of the laparoscope. In most cases, the common bile duct (83 %) and cystic duct (97 %) could be identified significantly earlier than with conventional camera mode. In 13 of 15 patients (87 %), confirmation of the cystic artery was obtained successfully after repeat ICG injection. No per- or postoperative complications occurred as a consequence of ICG use.Conclusion
Biliary and vascular fluorescence imaging in laparoscopic cholecystectomy is easily applicable in clinical practice, can be helpful for earlier visualization of the biliary tree, and is useful for the confirmation of the arterial anatomy. 相似文献6.
R. C. Mclntyre D. D. Bensard G. V. Stiegmann N. W. Pearlman J. Durham 《Surgical endoscopy》1996,10(1):41-43
Background
Exposure for open cholecystectomy entails lateral, caudal traction on the gallbladder infundibulum, which results in opening the angle between the cystic and hepatic ducts. Laparoscopic cholecystectomy (LC), as initially described, is done with cephalad traction on the gallbladder. We hypothesized LC exposure technique narrows the angle between the cystic and hepatic ducts, placing them at increased risk of injury.Methods
Twenty-three patients had routine LC. Cystic duct cholangiography (IOC) was done with a flexible 5-Fr catheter via a percutaneous introducer placed anterior to the gallbladder. Exposure of Calot’s triangle was maintained with cephalad traction on the gallbladder fundus. IOC was repeated after allowing the organ to assume the anatomic position. The cholangiograms were inspected for significant differences, and the angle of the cystic to the hepatic duct (CDHD) was measured by a blinded radiologist.Results
The mean angle of the cystic to hepatic duct was 30? ± 19? in the IOCs taken with cephalad traction on the gallbladder fundus vs 59? ± 22?,P < 0.001, in the cholangiograms taken without traction. A filling defect at the cystic-hepatic duct junction was present in 39% of IOC taken with traction vs none without traction. The intrahepatic ducts were seen in all films without traction, whereas the intrahepatic ducts were not visualized in 13% of IOCs taken with traction.Conclusions
From these data we conclude (1) extrahepatic biliary ducts may be at increased risk of injury during LC because of the exposure technique and (2) imaging bile ducts in the anatomic position may convey misleading information about the relative location of important structures. Optimal exposure for dissection of Calot’s triangle should utilize a second clamp on the infundibulum with lateral, caudal traction. 相似文献7.
Background
Injuries to the bile duct during laparoscopic cholecystectomy are often a cause of malpractice litigations.Methods
A total of 13 legal verdicts as a result of bile duct injury from 1996 to 2009 were reviewed. Comments on the verdicts and the opinions of expert witnesses were analyzed.Results
Out of 13 claims, 7 were upheld and 6 were rejected. Most expert witnesses from 1996 to 2002 stated that not carrying out a cholangiography and insufficient preparation of the cystic duct constituted a performance below the standard of care expected. Expert witness testimonies from 2004 to 2009, however, regarded injury to the bile duct as predominantly inherent to treatment.Conclusion
With the expansion and acceptance of laparoscopic interventions, changes in the results of malpractice litigation have become evident. In contrast to the phase during establishment of the technology, an injury to the bile duct is nowadays judged predominantly as inherent to treatment. 相似文献8.
F. Prevot L. Rebibo C. Cosse F. Browet C. Sabbagh J.-M. Regimbeau 《Journal of gastrointestinal surgery》2014,18(8):1462-1468
Introduction
During cholecystectomy, intraoperative cholangiography using contrast fluid (IOC-CF) is still the “gold standard” for biliary tract identification but has many associated pitfalls. A new IOC technique using indocyanine green (IOC-IG) appears to be promising. Here, we studied the effectiveness of IOC-IG (vs IOC-CF) during day-case laparoscopic cholecystectomy.Materials and Methods
Over a 6-month period, we included 23 patients (with no cirrhosis or risk factors for choledocholithiasis) scheduled for day-case laparoscopic cholecystectomy. The primary efficacy criterion was the “analyzability rate” (i.e., the ability to identify the cystic duct, the cystic duct-hepatic duct junction, and the common bile duct) for the IOC-CF and IOC-IG procedures after dissection. Indocyanine green was infused under general anesthesia. The same near-infrared laparoscopic imaging system was used for IOC-IG and conventional visual inspection. IOC-CF was always attempted after dissection. Each patient served as his/her own control. Cholecystectomies were video-recorded for subsequent off-line, blind analysis.Results
The analyzability rate was 74 % for IOC-IG after dissection, 70 % for IOC-CF (p?=?0.03), 26 % for conventional visual inspection, and 48 % for IOC-IG before dissection. When each IOC modality (conventional visual inspection, IOC-IG before and after dissection) was considered as a diagnostic test, the accuracy for simultaneous identification of the three anatomic elements was respectively 48, 52, and 74 %. No adverse events occurred during the IOC-IG procedure.Conclusion
IOC-IG was feasible and safe. Our results suggest that this technique is more effective than IOC-CF for biliary tract identification after dissection and may constitute a powerful diagnostic test for the detection of extrahepatic ducts. 相似文献9.
Giuseppe Spinoglio Fabio Priora Paolo Pietro Bianchi Francesco Saverio Lucido Alessio Licciardello Valeria Maglione Federica Grosso Raul Quarati Ferruccio Ravazzoni Luca Matteo Lenti 《Surgical endoscopy》2013,27(6):2156-2162
Background
Bile duct injury is a rare but serious complication of laparoscopic cholecystectomy and the primary cause is misinterpretation of biliary anatomy. This may occur more frequently with a single-incision approach due to difficulties in exposing and visualizing the triangle of Calot. Intraoperative cholangiography was proposed to overcome this problem, but due to multiple issues, it is not used routinely. Indocyanine green (ICG) near-infrared (NIR) fluorescent cholangiography is non invasive and provides real-time biliary images during surgery, which may improve the safety of single-incision cholecystectomy. This study aims to evaluate the efficacy and safety of this technique during single-site robotic cholecystectomy (SSRC).Methods
Patients presenting with symptomatic biliary gallstones without suspicion of common bile duct stones underwent SSRC with ICG-NIR fluorescent cholangiography using the da Vinci Fluorescence Imaging Vision System. During patient preparation, 2.5 mg of ICG was injected intravenously. During surgery, the biliary anatomy was imaged in real time, which guided dissection of Calot’s triangle. Perioperative outcomes included biliary tree visualizations, operative time, conversion and complications rates, and length of hospital stay.Results
There were 45 cases between July 2011 and January 2012. All procedures were completed successfully; there were no conversions and at least one structure was visualized in each patient. The rates of visualization were 93 % for the cystic duct, 88 % for the common hepatic duct, and 91 % for the common bile duct prior to Calot’s dissection; after Calot’s dissection, the rates were 97 % for all three ducts. Mean hospital stay was 1.1 days and there were no bile duct injuries or any other major complications.Conclusion
Real-time high-resolution fluorescent imaging to identify the biliary tree anatomy during SSRC using the da Vinci Fluorescence Imaging Vision System was safe and effective. 相似文献10.
11.
Tao Wang Tao Chen Shu Zou Ning Lin Hong-yin Liang Hong-tao Yan Nan-lin Li Li-ye Liu Hao Luo Qi Chen Wei-hui Liu Li-jun Tang 《Surgical endoscopy》2014,28(7):2236-2242
Background
Cholecystolithiasis is the most common disease treated by general surgery, with an incidence of about 0.15–0.22 %. The most common therapies are open cholecystectomy (OC) or laparoscopic cholecystectomy (LC). However, with a greater understanding of the function of the cholecyst, more and more patients and surgeons are aware that preserving the functional cholecyst is important for young patients, as well as patients who would not tolerate anesthesia associated with either OC or LC. Based on these considerations, we have introduced a notable, minimally invasive treatment for cholecystolithotomy.Methods
We performed a retrospective review of patients with cholecystolithiasis who were unable to tolerate surgery or who insisted on preserving the functional cholecyst. Our particular approach can be simply described as ultrasound-guided percutaneous cholecystostomy combined with a choledochoscope for performing a cholecystolithotomy under local anesthesia.Results
Ten patients with cholecystolithiasis were treated via this approach. All except one patient had their gallbladder stones totally removed under local anesthesia, without the aggressive procedures associated with OC or LC. The maximum number of gallbladder stones removed was 16, and the maximum diameter was 13 mm without lithotripsy. After the minimally invasive surgery, the cholecyst contractile functions of all patients were normal, confirmed via ultrasound after a high-fat diet. Complications such as bile duct injury, biliary fistula, and bleeding occurred significantly less often than with OC and LC. The recurrence rates for each of 2 post-operative years were about 11.11 % (1/9, excluding a failure case) with uncertainty surrounding recurrence or residue, and 22.22 % (2/9, including one non-recurrence patient with follow-up time of 22 months), respectively.Conclusions
Ultrasound-guided percutaneous cholecystostomy combined with choledochoscope is a safe, efficient, and minimally invasive cholecystolithotomy method. We recommend this technique for the management of small stones (less than 15 mm) in high-risk surgical patients. 相似文献12.
Norihiro Sato Kazunori Shibao Yasuki Akiyama Yuzuru Inoue Yasuhisa Mori Noritaka Minagawa Aiichiro Higure Koji Yamaguchi 《Journal of gastrointestinal surgery》2013,17(4):668-674
Background
Single-incision laparoscopic cholecystectomy (SILC) has been increasingly performed as a potentially less invasive alternative to standard laparoscopic cholecystectomy. However, recent evidences suggest a higher incidence of complications, notably bile duct injuries, in SILC. We reviewed our experiences with routine intraoperative cholangiography (IOC) during SILC to investigate its feasibility and usefulness.Methods
Among 228 patients who underwent SILC at our institution from September 2009 to July 2012, a total of 196 patients in which an IOC was attempted were retrospectively reviewed.Results
IOC was successful in 178 of 196 patients, yielding a success rate of 90.8 %. There were no IOC-related complications. Common bile duct (CBD) stones were detected by IOC in 16 patients (8.2 %), all of which were treated by subsequent single-incision laparoscopic CBD exploration or postoperative endoscopic retrograde cholangiopancreatography with stone extraction. In addition, IOC revealed filling defects in the cystic duct (four patients) and poor passage of contrast medium into the duodenum (one patient). In one patient with severe acute cholecystitis, cholangiography via an endoscopic nasobiliary drainage tube revealed misinterpretation of CBD as cystic duct.Conclusions
We, thus, conclude that routine IOC during SILC is feasible and useful to detect biliary stones and to gain an accurate picture of biliary anatomy. 相似文献13.
Background
Transvaginal cholecystectomy with laparoscopic assistance has been performed safely in humans. The next goal was to develop a natural orifice transluminal endoscopic surgery (NOTES) technique to perform cholecystectomy without laparoscopic instruments using one flexible endoscope and flexible accessories. The aim of the study was to test the feasibility of the procedure in a survival porcine model.Methods
Cholecystectomies were attempted in five 88–130-lb. pigs with a planned 2-week survival. Prototype flexible instruments (NOTES Toolbox, Ethicon Endo-Surgery, Inc.) were used to aid in access, dissection, and removal of the gallbladder via the transvaginal route.Results
Cholecystectomy could be completed without abdominal incision using prototype instruments in four out of five pigs. The cystic duct could be exposed with a flexible hook knife and clips applied. The steerable trocar improved stability and the precision of the dissection. The critical view was established in all five pigs. Dissection of the gallbladder off the liver bed was imprecise resulting in gallbladder perforation in all pigs and liver hemorrhage in two. At necropsy, all clips on the cystic duct were secure and no bile leak, bowel injury, or adhesions were present.Conclusions
NOTES cholecystectomy without laparoscopic support is feasible but challenging using prototype flexible endoscopic devices. A prototype clip applier was effective in controlling the cystic duct. Further improvements in instrument design to ensure precision and safety are needed before flexible devices should be used for pure NOTES procedures in humans. 相似文献14.
Introduction
Although gallstone pancreatitis is initiated by the presence of stones in the common bile duct, the benefit associated with routine intraoperative cholangiography at the time of cholecystectomy in these patients is unclear. The purpose of this study, using population-based data, was to determine the impact of cholangiography on clinical outcomes after cholecystectomy for gallstone pancreatitis.Methods
All patients who were admitted to hospital from January 1, 1997 to December 31, 2001 in Nova Scotia, Canada with pancreatitis who underwent cholecystectomy during the same admission were identified. The rates of recurrent pancreatitis and biliary complications after surgery were compared between patients who underwent cholecystectomy with intraoperative cholangiography ± common bile duct exploration and those who underwent cholecystectomy alone, using three linked administrative databases.Results
Three hundred thirty-two patients were identified, 119 had cholangiography at the time of cholecystectomy and 213 did not. After a median follow-up of after 3.8?years, there was no difference in the rate of recurrent pancreatitis or biliary complications between those who had cholangiography ± common bile duct exploration at the time of surgery and those who did not; 13.4 versus 10.8?%, respectively (p?=?0.55).Conclusions
These data suggest that intraoperative cholangiography does not improve outcomes after cholecystectomy for gallstone pancreatitis. 相似文献15.
Caitlin Halbert Spyridon Pagkratis Jie Yang Ziqi Meng Maria S. Altieri Purvi Parikh Aurora Pryor Mark Talamini Dana A. Telem 《Surgical endoscopy》2016,30(6):2239-2243
Background
Early reports of higher complication rates, specifically bile duct injuries, raised concerns over the safety of laparoscopy over open cholecystectomy. This study aims to ascertain the rate, management, and perioperative outcomes of bile duct injury in an era beyond the laparoscopic learning curve.Methods
The New York State (NYS) Planning and Research Cooperative System longitudinal administrative database was used to identify patients. From 2005 to 2010, 156,315 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Patients were then tracked with unique identifiers for common bile duct injury. Common bile duct injury was identified by ICD-9 and CPT diagnosis and procedure codes for patients who subsequently underwent hepatectomy, hepaticojejunostomy, or other bile duct surgery.Results
From 2005 to 2010, 156,958 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Of the total patients, 149 patients underwent a biliary duct procedure within a year. Twenty-four of them were diagnosed with gallbladder cancer and excluded, leaving 125 for further analysis. The biliary injuries were identified at a rate of 0.080 %. Thirty-one of those patients (24.8 %) underwent hepatectomy, 40 patients (32.0 %) underwent hepaticoenterostomy, and 54 patients (43.2 %) underwent primary repair of the bile duct. Thirty-two (26 %) patients were repaired on the same day of their initial procedure. Of the remaining 93 patients, 38 (30 %) were repaired within 10 days, seven (6 %) repaired between 11 and 20 days, and 48 (38 %) patients over 21 days from injury.Conclusion
In NYS, the rate of bile duct injury has now decreased to 0.08 % and mirrors the historical figures quoted for open cholecystectomy. This improvement likely reflects increased experience, improved instrumentation, and movement beyond the “learning curve.”16.
Brij B. Agarwal Nayan Agarwal Krishna A. Agarwal Karan Goyal Juhil D. Nanvati Kumar Manish Himanshu Pandey Shruti Sharma Kamran Ali Sheikh T. Mustafa Manish K. Gupta Satish Saluja Sneh Agarwal 《Surgical endoscopy》2014,28(11):3059-3067
Objective
Laparoscopic cholecystectomy (LC), a gold standard procedure can be done without energized dissection (ED). We did a randomized study for the outcomes of LC done with ED or without ED, i.e., with cold dissection (CD).Methods and Procedures
At a tertiary level institution, open-ended prospective-randomized control study was conducted between September 2008 and June 2013. Consecutive, unselected, consenting candidates for LC were enrolled following standard ethics, informed consent, anesthesia, and clinical pathway protocol. They were allocated to control group (LC with ED) or study group (LC with CD, as per our published technique with the option for rescue ED). The study points were based upon Clavien–Dindo grading of postoperative complications. They were either, peri-operative events potentially affecting, hospital stay (Grade I) or Grade II–V, e.g., peri-operative hemodynamic instability, needing intervention/blood transfusion, injury to biliary ducts/hollow viscous, postoperative biliary leak, postoperative re-intervention, re-hospitalization, mortality, and any adverse event during a 90-day follow-up period. The data were prospectively collected in an integrated “hospital information system” that could be retrieved only by independent external coordinators.Results
Demographics, co-morbidities, and gallbladder inflammation profile of the control group (n = 361) and study group (n = 384) were comparable. There was no rescue ED usage in the study group. Hospital stay (Grade I adverse outcome dependent) was longer, i.e., 1.6 ± 1.03 in the control versus 1.35 ± 1.2 days in the study group (p < 0.001). Grade II–IV complications were significantly more (p < 0.009) in control group. There was one common bile duct (CBD) injury in each group. The index bilio-enteric anastomosis for CBD injury in control group failed and needed a revision with multiple interventions. There was one grade V adverse outcome, i.e., mortality in the control group.Conclusion
Avoiding the use of ED in LC is associated with better outcomes. 相似文献17.
Cinzia Tommasi Lapo Bencini Marco Bernini Riccardo Naspetti Giulia Cavallina Roberto Manetti Luca Talamucci Marco Farsi 《World journal of surgery》2013,37(5):999-1005
Background
The aim of the present work was to determine the feasibility and efficacy, in terms of equipment coordination and timing, of the laparoendoscopic intraoperative rendezvous technique (RVT) for the treatment of gallbladder and common bile duct stones (CBDS).Methods
The procedure was considered in 269 unselected patients with a suspicion or preoperative imaging demonstration of CBDS who were fit for laparoscopic cholecystectomy (LC). Common bile duct stones were confirmed by intraoperative laparoscopic cholangiography (IOC) in only 113 of these patients (42 %). In 17 (15 %) patients the planned procedure was aborted because of organizational problems, mainly the unavailability of endoscopists in the urgent setting. The remaining 96 patients (84 %) underwent a formal attempt at RVT. Intraoperative endoscopic retrograde cholangiography (ERC) was performed, during LC, by means of a guidewire that reached the duodenum through the cystic duct.Results
In 18 patients (19 %) the complete procedure failed, either because of difficulty in passing the guidewire through the papilla or because of other technical difficulties that required conversion to laparotomy. An intraoperative ERC was completed in six patients in the classical way (no guidewire) without conversion. No mortality and few complications were recorded (3 % overall: 1 perforation and 2 cholangitis). Retained stones were successively detected in 6 patients (6 %) and successfully retreated by a further ERC. Globally, the one-stage procedure (with and without the guidewire) was possible in 84 of 96 patients (87 %).Conclusions
The RVT appears to be effective and safe as it was performed at our institution, with an overall percentage of definitive success (passed guide wire and no further ERC) of 81 %. The RVT should be considered as a good option for the treatment of simultaneous gallstones and CBDS. 相似文献18.
Sophia K. McKinley L. Michael Brunt Steven D. Schwaitzberg 《Surgical endoscopy》2014,28(12):3385-3391
Background
Over 700,000 laparoscopic cholecystectomies are performed yearly in the US. Despite multiple advantages of laparoscopic surgery, the increased rate of bile duct injury (BDI) compared to the traditional, open approach to cholecystectomy remains problematic. Due to the seriousness of bile duct injury, the time has come for an aggressive educational campaign to better train laparoscopic surgeons in order to reduce the incidence of this life-threatening and expensive complication.Methods
We performed a literature review of what is currently known about the causes of bile duct injury during laparoscopic cholecystectomy. Based on these reviews, we identified educational theories of expertise that may be relevant in understanding variable rates of BDI between surgeons. Finally, we applied educational theories of expertise to the problem of BDI in laparoscopic cholecystectomy to propose how to develop and design an effective educational approach for the prevention of BDI.Results
Multiple studies demonstrate that the primary causes of BDI during laparoscopic cholecystectomy are non-technical. Additionally, there exists a learning curve in which the rates of BDI are higher in a surgeon’s earlier cases compared to later cases and that some surgeons perform laparoscopic cholecystectomy with significantly fewer injuries than others. Educational theories indicate that interventions that optimize novice to expert development require (1) revealing expert knowledge to novices and (2) scaffolding the mental habits of expert-like learners.Conclusions
BDI is an appropriate target for the application of educational theories of expertise. Designing better educational interventions for the prevention of BDI will require uncovering the hidden knowledge of expert surgeons and incorporating the processes of reinvestment and progressive problem solving that are inherent to expert performance. 相似文献19.
Elizaveta Ragulin-Coyne Elan R. Witkowski Zeling Chau Sing Chau Ng MS Heena P. Santry Mark P. Callery Shimul A. Shah Jennifer F. Tseng 《Journal of gastrointestinal surgery》2013,17(3):434-442
Introduction
Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, current surgeon IOC utilization practice patterns and outcomes are unclear.Methods
Nationwide Inpatient Sample 2004–2009 was queried for patients with acute biliary disease undergoing cholecystectomy (CCY). Analyses only included surgeons performing ≥10 CCY/year. We dichotomized surgeons into a routine IOC group vs. selective. Outcomes included bile duct injury, complications, mortality, length of stay, and cost.Results
Of the nonweighted patients, 111,815 underwent CCY. A total of 4,740 actual surgeon yearly volumes were examined. On average, each surgeon performed 23.6 CCYs and 7.9 IOCs annually, using IOC in 33 % of cases. The routine IOC group used IOC for 96 % of cases, whereas selective IOC group used IOC ~25 % of the time. Routine IOC surgeons had no difference in mortality (0.4 %) or rate of bile duct injury (0.25 vs. 0.26 %), but higher overall complications (7.3 vs. 6.8 %, p?=?0.04). Patients of routine IOC surgeons received more additional procedures and incurred higher costs.Conclusion
Routine IOC does not decrease the rate of bile duct injury, but is associated with significant added cost. Surgeons’ routine use of IOC is correlated with increased rates of postsurgical procedures, and is associated with increased overall complications. These data suggest routine IOC may not improve outcomes. 相似文献20.
Steven D. Schwaitzberg Daniel J. Scott Daniel B. Jones Sophia K. McKinley Johanna Castrillion Tina D. Hunter L. Michael Brunt 《Surgical endoscopy》2014,28(11):3068-3073