Laparoscopic Cholecystectomy as a Day Surgery Procedure: Implementation and Audit of 136 Consecutive Cases in a University Hospital

Laparoscopic cholecystectomy (LC) has been routinely performed since 1989 at our institution, and patients were traditionally admitted for 2 days. In 1996 we implemented a protocol for LC as a day surgery procedure at our center. Although initially reported by others, it has not yet been introduced as routine in Switzerland. The objective of this prospective study was to determine acceptability and safety of LC as an outpatient procedure in a university hospital. Data were collected prospectively for 136 LCs between January 1996 and December 2001. Patients were selected for the study if they wanted to go home within less than 24 hours, had no previous jaundice, and had no anesthetic contraindication. Systematic preoperative liver function tests and hepatic ultrasonography were performed. All patients were admitted on the day of operation. LC was performed using a three-trocar technique. Systematic cholangiography was performed, and all the procedures were completed laparoscopically. There were no common bile duct explorations. Postoperative complications were the following: nausea in seven patients, a minor umbilical hematoma in two. According to patient preference, 101 (74%) were discharged after an overnight stay (less than 24 hours) and 32 (24%) on the same day. The unplanned admission rate was 2%, and none of the patients was subsequently readmitted. The reasons for unplanned admissions were two patients with persistent nausea and one patient for whom an overnight stay was scheduled who presented with a ruptured subcapsular hematoma of the liver. Altogether, 97% of the patients were satisfied with the care they received. Operative costs were not significantly different when comparing inpatient and outpatient LC. The main postoperative savings were in the postoperative costs. Our results confirm that LC as a day surgery procedure is safe, effective, and acceptable to patients and their relatives. These results were achieved by using selection criteria that considered not only the surgical pathology but also the individual and by using appropriate techniques and planned postoperative analgesia.     

Routine Intraoperative Cholangiography During Single-Incision Laparoscopic Cholecystectomy: a Review of 196 Consecutive Patients

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.     

Effect of intraoperative cholangiography during cholecystectomy on outcome after gallstone pancreatitis

Acute gallstone pancreatitis has traditionally been managed by early cholecystectomy with intraoperative cholangiography (IOC). To evaluate the effect of IOC on patient outcome, we analyzed all patients operated on for acute gallstone pancreatitis at our institution over a 3-year period. A total of 200 patients (37 open, 163 laparoscopic) were evaluated. Nineteen of 34 patients who underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) were found to have common bile duct (CBD) stones. The 59 patients who underwent cholecystectomy with IOC had significantly longer operative times compared to the 141 patients who underwent cholecystectomy alone (167 vs. 105 minutes for open [P= 0.008] and 89 vs. 68 minutes for laparoscopic [P< 0.0001] operations). Of the 59 patients who underwent IOC, only nine (15%) had abnormal cholangiograms, and CBD exploration in seven revealed stones in four patients, edematous ampullae in two, and no abnormality in one. Six of eight patients (5 IOC, 3 no IOC) who required immediate postoperative ERCP were noted to have CBD stones. Patients who underwent IOC had significantly longer postoperative hospital stays (3.8 vs. 2.0 days [P= 0.007]). The incidence of retained CBD stones following surgery was similar (5.1% IOC, 2.8% no IOC). Although 7 of 122 patients who underwent laparoscopic cholecystectomy without IOC were readmitted, only one was found on ERCP to have a retained CBD stone. Age, sex, preoperative days, procedure type, and biliary-pancreatic complications after discharge did not differ significantly between patients with and without IOC. We conclude that IOC in patients operated on for acute gallstone pancreatitis results in a longer operative time and a prolonged postoperative course, but has no effect on the incidence of retained CBD stones. Presented at the Annual Meeting of the Southern California Chapter of the American College of Surgeons, Huntington Beach, California, January 21–23, 2000.     

Prospective audit of laparoscopic cholecystectomy experience at a secondary referral centre in South australia

BACKGROUND: Laparoscopic cholecystectomy is now the gold standard procedure for symptomatic gallstone disease. Nevertheless, there are still several controversies such as the need for routine intraoperative cholangiogram (IOC), the indications for and results of early laparoscopic cholecystectomy in the setting of acute cholecystitis and the use of endoscopic retrograde cholangiopancreatography versus laparoscopic common bile duct (CBD) exploration for intraoperatively detected choledocholithiasis. The aim of this study was to investigate some of these controversies. METHODS: All laparoscopic cholecystectomies carried out at our institution, a secondary referral centre in Adelaide, South Australia, over a 9-month period were prospectively audited. Data were collected regarding indications for surgery, rate of conversion to open operation, use of IOC, rate of choledocholithiasis and complication rate. RESULTS: There were 202 patients, of whom 152 were women and 50 men. Age range was 15-83 years. Sixty-one per cent of emergency operations were for acute cholecystitis. The conversion rate for emergency operations was 20.6% and for elective procedures was 4.2% (P = 0.003).One hundred and eighty-four patients had an IOC performed. Twelve of these patients had choledocholithiasis. Six of these 12 patients had both normal preoperative ultrasound and liver function tests. Four of the patients went on to postoperative endoscopic retrograde cholangiopancreatography, four had successful laparoscopic CBD exploration, two had open CBD exploration and two had their distal CBD filling defects flushed away with normal saline. There was no morbidity associated with performance of the IOC. There were three patients with postoperative bile leak and one with a bile duct injury. CONCLUSION: Selective IOC would miss a proportion of patients with choledocholithiasis. Early laparoscopic cholecystectomy for acute cholecystitis is associated with a higher conversion rate than elective laparoscopic cholecystectomy. Overall complication rate is low, with 95% of patients having no complications. Laparoscopic CBD exploration is feasible with a reasonable success rate. This can all be achieved at a secondary referral centre staffed by general surgeons.     

The prevention of major bile duct injures in laparoscopic cholecystectomy: the experience with 13,000 patients in a single center

Major bile duct injury (MBDI) is one of the most serious complications associated with laparoscopic cholecystectomy (LC). This study reports our experience in preventing MBDI during LC. Between September 1991 and August 2004, 13,000 cases of LC were performed at Kunming General Hospital. Systemic strategies, including selection of proper patients for LC based on the surgeons' experience, dissection techniques in Calot's triangle, selective use of laparoscopic ultrasonography, and indication of conversion to an open approach were developed and introduced to avoid MBDI. In our series, the overall incidence of MBDI was 0.085%, 0.60% (3 of 500) over the first period from September 1991 to September 1992, 0.17% (5 of 3000) over the second period from October 1992 to September 1996, and 0.03% (3 of 9500) over the third period from October 1996 to August 2004. The MBDI included transection of the common bile duct (CBD) due to mistaking CBD for cystic duct (n=6), cautery injury (n=3), laceration of the CBD at the junction of cystic duct and CBD (n=1), and clip partially of common hepatic duct due to blind hemostasis (n=1). The incidence of MBDI in our institution is acceptable. We believe the system strategies are effective to avoid MBDI in LC. LC is a safe procedure with an incidence of biliary injury comparable with that for open cholecystectomy.     

Functional outcome and mortality in nonagenarians following hip fracture surgery

Introduction

The world’s population is ageing and the elderly population itself is growing older. This population shows a high incidence of hip fractures. We performed a retrospective study, reviewing the functional status, postoperative complications and mortality rate of nonagenarians who underwent surgery for hip fracture.

Methods and subjects

56 nonagenarian patients underwent hip fracture surgery in our institution between January 2000 and December 2010. Two of these patients had presented with hip fracture on separate occasions, giving a total of 58 hips for analysis. Patients with open fracture, subtrochanteric fracture, polytrauma and pathological fracture were excluded. The case notes, electronic records and X-rays for all those included in the study were reviewed. The main outcome measures were functional status, postoperative complications and mortality rate at 1 year.

Results

Patients with extracapsular hip fractures were associated with higher risks of postoperative complications (60.7 %; p = 0.037), mortality (25 %; p = 0.003) and more likely to be non-ambulant at 1 year (53.6 vs 16.7 %; p = 0.003). Females were more likely to suffer postoperative complications than males (p = 0.016). 46.6 % of the patients had immediate postoperative complications and most commonly due to urological complications (29.3 %). The 1-year mortality rate was 12.1 %. A notable proportion of patients (65.5 %) remained ambulant 1 year postoperatively, although almost half of the patients (48.3 %) who could ambulate independently pre-injury required a walking aid after hip fracture surgery.

Conclusion

Nonagenarians have good surgical outcomes after hip fracture surgery with low mortality rate. They should be treated similarly as their younger counterparts in terms of decision for surgery. Potential decline in functional status and rehabilitation options should be shared with the patient and family at an early stage.     

Laparoscopic choledochotomy with primary closure

Background: Thirty-three patients were candidates for laparoscopic choledochotomy. The indications for this operation are described. Methods: The procedure was completed 32 times (97%). We had 29 successful common bile duct (CBD) clearances, three negative explorations, and one failed clearance which needed to be converted to laparotomy. All the completed procedures ended with primary closure of the main duct. Median duration of surgery was 180 min (range 100–300), including three associated laparoscopic procedures. Results: There were three postoperative complications (9.4%), none major. Average postoperative hospital stay was 7.1 days (range 4–14). In May–June 1995 we controlled 31 out of the 32 consecutive patients (one patient was lost to follow-up) who had a successful laparoscopic choledochotomy from October 1991 to December 1994. Median follow-up was 22 months (range 5–44). Besides clinical control, 23 patients also had ultrasound (US) controls and 24 had blood tests. Eleven had intravenous cholangiotomography. Two patients died 11 and 22 months after the operation for unrelated causes and without biliary symptoms. Two patients had umbilical hernias. One had a small residual asymptomatic stone, which was removed endoscopically. None had signs of postoperative CBD stricture. At US, CBD was ≤7 mm in 15 patients, 8–10 mm in four patients, and 10–12 mm in three patients. The last group had preoperative CBD dilation, too. We could compare preoperative and postoperative CBD diameters in 22 patients: 11 had no change; in nine it decreased; and two had a slight increase (8–10 mm). Conclusions: We conclude that laparoscopic choledochotomy with primary closure is a very good operation: It has a high success rate and low morbidity. Mortality is nil so far. Medium-term results are very positive: We had no CBD stricture and only one case of asymptomatic residual stone, which could have been avoided. Our results suggest that intraductal biliary drainage is useless, and its specific complications are well known. Received: 20 October 1995/Accepted: 28 February 1996     

A 27-year experience with splenectomy for Gaucher's disease

Gaucher's disease is an inherited metabolic disorder caused by the defective activity of acid beta-glucosidase and the resultant accumulation of glucosyl ceramide-laden macrophages in the liver, bone, and spleen. Splenectomy is the preferred treatment for patients with Gaucher's disease who develop massive splenomegaly with accompanying hypersplenism and/or mechanical pressure symptoms. The charts of 48 patients with Gaucher's disease undergoing splenectomy at our institution between January 1963 and December 1989 were analyzed to determine the short- and long-term results of this procedure. Thirty-five (73%) patients had total splenectomy, whereas 13 (27%) patients had partial splenectomy. There was one postoperative death (after total splenectomy), and 13 patients (27%) had postoperative complications. Eleven patients (23%) presented with accelerated bone disease after total splenectomy (mean follow-up: 96 months). No patients having partial splenectomy (mean follow-up: 25 months) developed progressive bone disease. Eight patients have died since surgery. All four deaths due to malignant disease occurred in patients after total splenectomy. The results of this largest-ever reported series of splenectomy for Gaucher's disease confirm that while either total or partial splenectomy can be performed with minimal morbidity and mortality, total splenectomy is accompanied by more aggressive bone disease and a predisposition to malignancy. Prospective, randomized trials are needed to substantiate whether partial splenectomy is indeed the treatment of choice for splenomegaly associated with Gaucher's disease.     

Partial nephrectomy for patients with a solitary kidney: the Memorial Sloan-Kettering experience

OBJECTIVE: To report the experience of partial nephrectomy in patients with a solitary kidney at one institution, with analysis of renal function, complications, oncological efficacy and survival. PATIENTS AND METHODS: We identified 54 consecutive patients with a solitary kidney who had a partial nephrectomy between December 1989 and July 2003. Variables examined included patient age and gender, renal function, renal ischaemia time, surgical margin status and complications. Pathological features, e.g. tumour size, histological subtype and tumour stage, were also assessed. Disease-free probability and overall and cancer-specific survivals were determined. RESULTS: The histological subtype was clear cell in 35 cases (65%), papillary in 10 (19%), oncocytoma in four (7%), chromophobe in two (4%), unclassified in one (2%) and multiple subtypes in two (2%). The median creatinine level before surgery was 14 mg/L, which increased to 16 mg/L 6 months afterward, and at 1 and 2 years after surgery it was 15 mg/L. Two patients developed end-stage renal disease requiring haemodialysis, one soon after surgery and another 8 years after nephron-sparing surgery. In all, 26% of patients developed at least one perioperative complication, with acute renal failure and urinary fistula being the most common. At 5 years the overall and cancer-specific survival, and disease-free probability were 68%, 88% and 73%, respectively. CONCLUSIONS: Partial nephrectomy is safe in patients with a solitary kidney, with an acceptable decline in renal function and low likelihood of requiring temporary or permanent haemodialysis. After an initial decline, renal function appears to stabilize during the first year.     

Intraoperative cholangiography and postoperative pancreatitis

BACKGROUND: It has been suggested that intraoperative cholangiography (IOC) can cause postoperative pancreatitis. METHODS: We studied the relationship between IOC and pancreatitis by reviewing the case histories of 500 patients (1992-97) who underwent cholecystectomy at our institution. In 82% of cases, the cholecystectomies were done laparoscopically, whereas, 7% were converted to an open procedure. An IOC was performed in 435/500, or 87%. During these studies, common bile duct (CBD) stones (or the possibility of a stone) were noted in 14% of the cases. An intraoperative CBD investigation was required in nine of 435 cases or 8.5%, while 28/435 (9.2%) underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Follow-up was available in 90% of our patients (452/500). We found six cases of postoperative pancreatitis; only three of 452 (0.6%) occurred <1 year after cholecystectomy. None of these patients had a preoperative history of pancreatitis. In all six cases, there appeared to be an etiology for the pancreatitis unrelated to IOC. CONCLUSION: We could find no statistical association between IOC and postoperative pancreatitis. Postoperative pancreatitis is uncommon at our institution, where routine IOC is employed. Therefore, we conclude that IOC does not cause pancreatitis.     

Biliary complications in relation to the technique of biliary reconstruction in adult liver transplant recipients

Biliary complications are known as a weak point of liver transplantation. Their occurrence can be related to the practice of draining the biliary anastomosis performed at the time of transplantation. At our institution, routine of anastomotic biliary drainage was abandoned in June 2004. AIM: We sought to assess the occurrence and character of biliary complications following orthotopic liver transplantation in relation to the technique of anastomosis. MATERIALS AND METHODS: In two groups of transplantees: last 100 transplantations with biliary drainage (48 females and 52 males aged 17 to 64 years) and last 100 transplantations without drainage (52 females and 48 males aged 18 to 67 years). The results of treatment were compared, for biliary complications and their influence on further management. In both groups, the main indications for transplantation were various types of cirrhosis as well as cholestatic diseases. In most cases (167) we performed a cholangiojejunal Roux-en-Y (CBD) end-to-end anastomosis, less commonly (33 cases) hepaticojejunal anastomoses. RESULTS: In the first group, biliary complications (bile leak at the site of drainage, bile leak after T-tube removal, CBD strictures) requiring surgical or endoscopic intervention, occurred in 17% recipients. In one case, the biliary complication resulted in retransplantation. In the second group, biliary complications occurred in 11% patients. None of them caused organ loss. CONCLUSION: Abandoning drainage of the biliary anastomosis has reduced the occurrence of early biliary complications after orthotopic liver transplantation.     

APPRAISAL OF SURGICAL AND ENDOSCOPIC MANAGEMENT OF CHOLEDOCHOLITHIASIS

One hundred and ten patients with common bile duct (CBD) stones were treated in the Department of Surgical Gastroenterology at SGPGIMS, Lucknow, India between January 1989 and December 1992. The primary modality of treatment was surgery in 62 patients (group I) and endoscopic sphincterotomy (ES) in 48 (group II). The two groups were well matched with respect to clinical features and presence of medical risk factors. Surgical clearance of CBD stones was achieved in 58 patients (93.5%; group Ia). Four patients (7%) had retained stones following surgery (group Ib). In group II, the CBD was cleared by endoscopic means in 20 out of 48 patients (42%) and was categorized into group IIa. In the remaining patients ES was followed by CBD exploration (group IIb). Significantly higher morbidity was seen in patients needing CBD surgery following attempted endoscopic clearance, because of ES-related complications, such as bleeding, cholangitis, septicaemia and numerous others. Use of ES to treat CBD stones on a routine basis was therefore not found to be any better than one-time surgical exploration.     

Incidence and indications for reintubation during postoperative care following orthotopic liver transplantation

STUDY OBJECTIVE: To analyze the incidence and indications for reintubation during postoperative care following orthotopic liver transplantation (OLT). DESIGN: Retrospective chart review. SETTING: Large metropolitan teaching hospital. PATIENTS: 546 adult liver transplant recipients. MEASUREMENTS AND MAIN RESULTS: The medical charts of 546 patients who underwent OLT at our institution between January 1992 and September 1996 were reviewed for the incidence and indications of reintubation throughout primary hospitalization. Eighty-one of 546 patients (14.8%) required one or more episodes of reintubation after OLT. In the majority of cases, reintubation was performed for pulmonary complications (44.6%), followed by cerebral (19.1%) and surgical (14.5%) complications. Cardiac (9.1%) and peripheral neurologic (2.7%) complications were less frequent reasons for reintubation. Overall patient survival, according to the Kaplan-Meier estimates, was 89.9%, 87.5%, 86.5%, and 82.2% after 1, 2, 3, and 5 years, respectively. In patients with one or more episodes of reintubation, overall survival decreased to 62.5% after 1, 2, and 3 years, and to 56.4% after 5 years (p < 0.001). CONCLUSIONS: The main indications for reintubation after OLT were pulmonary, cerebral, and surgical complications. These reintubation events had a considerable influence on the patient's postoperative recovery, and were associated with a significantly higher rate of mortality, than for OLT patients who did not undo reintubation.     

Perioperative complications of robotic radical prostatectomy after the learning curve

PURPOSE: We assessed the incidence of and analyzed factors that contributed to perioperative complications in patients undergoing robotic radical prostatectomy, that is Vattikuti Institute prostatectomy (VIP), at our institution. MATERIALS AND METHODS: We recorded operative and postoperative data on 300 consecutive patients who underwent VIP at our institution during a 1-year period. All operations were performed by 1 of 2 surgeons (MM or JOP). We reviewed the complications seen in these patients. RESULTS: There was no operative mortality and no case was converted to open surgery. A total of 269 (89.7%) patients were considered to have an ideal postoperative course, ie they were discharged home within 48 hours with no unscheduled office visits or complications. There were 14 unscheduled postoperative visits (4.7%) for transient urinary retention after early catheter removal (13) or hematuria (1). There were 17 complications, of which 16 (5.3%) were related to surgery and 1 was related to anesthesia. A total of 11 complications (3.7%) were minor (grade I) and 5 (1.7%) were major (grade II). Of them 3 (1%) patients required reoperation. There were no grade III or IV complications. CONCLUSIONS: In our hands VIP is a safe operation with an overall complication rate of 5.3%, a major complication rate of less than 2% and a surgical re-intervention rate of 1%.     

The fate of patients who undergo “preoperative” ERCP to clear known or suspected bile duct stones

Background  There is debate as to whether recurrent biliary complications are more common in patients who do not have elective cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) management of common bile duct (CBD) stones. The aim of this study was to determine the fate of patients with intact gallbladders who have had CBD stones removed at ERCP, and to assess their risk of recurrent biliary symptoms. Methods  We retrospectively identified all patients in our large tertiary center population with intact gallbladders who had an ERCP for CBD stones from December 1999 to March 2002. We determined which patients had subsequent elective cholecystectomy, and the outcomes of patients who did not have elective surgery. Results  309 patients had CBD stones at ERCP during the study period, of which 139 had intact gallbladders at the time of ERCP. Of these 139 patients 59 had subsequent elective cholecystectomy, 11 by open operation and 48 laparoscopically. Of these 139 patients, 27 had cholecystectomy planned; 47 patients were managed with a wait-and-see strategy, 30 of whom were poor surgical candidates. Of these 47 patients in whom a wait-and-see policy was adopted, 9 (19%) developed complications including recurrent pain and/or abnormal liver function tests (LFTs), recurrent biliary colic, and pancreatitis. Eight of these nine patients were from the poor surgical candidate group. Sphincterotomy had been performed at initial ERCP in all patients. Conclusions  Over half of our population of 139 patients with CBD stones at ERCP and intact gallbladders had actual or planned elective cholecystectomy. For those patients in whom a decision to wait-and-see was made, almost 20% developed complications. Elective cholecystectomy after a finding of choledocholithiasis is supported by many and is a common strategy in our experience. Recurrent biliary complications are relatively common in those who do not undergo elective cholecystectomy, especially those patients who represent a high operative risk.     

Potential role of cholinesterases to predict short-term outcome after hepatic resection for hepatocellular carcinoma

Estimation of functional liver reserve in patients with hepatocellular carcinoma (HCC) is of paramount importance to properly select candidates for surgical resection. Together with the value of bilirubin, the presence/absence of ascites and esophageal varices, and the rate of residual liver volume, which are our current parameters to measure functional liver reserve, we sought to investigate the value of preoperative cholinesterases (CHE) in predicting postoperative outcome after hepatic resection for HCC. We reviewed the records of 279 consecutive patients who underwent hepatic resection for HCC in our Unit between 2001 and 2011. The value of preoperative CHE was analyzed against the occurrence of postoperative events. Receiver–operator characteristic curve analysis was used to identify cut-off values of CHE that predicted adverse outcomes. Univariate and multivariate analyses on clinically relevant variables, which included the MELD score among others, were performed. P < 0.05 was considered statistically significant. Eighty (29 %) of 279 patients had complications, of which 60 (21.5 %) were liver-related. Major morbidity occurred in 16 (6 %) patients. The 30-day postoperative mortality was 1 %. A value of CHE ≤ 5,900 UI/L had a sensitivity of 73 % and a specificity of 67 % in predicting liver-related postoperative complications (P = 0.001). The multivariate analysis revealed that only blood transfusion, major resections, and a value of CHE ≤ 5,900 UI/L independently predicted the risk of morbidity. The results indicated that CHE contributed important information in predicting postoperative outcome after hepatic resection for HCC. Thus, it should be included in the selection process of candidates to surgery for such disease.     

Caroli's disease: liver resection and liver transplantation. Experience in 33 patients

BACKGROUND: The aim of this study was to review and discuss our observations on 33 patients who underwent surgical treatment for Caroli's disease (CD), focusing on diagnosis, current surgical management, and long-term outcome. METHODS: Between May 1993 and June 2004, 642 liver resections and 286 liver transplantations in 252 patients were performed in our department of surgery. Thirty-three patients were referred to our center for diagnostic and therapeutic management of CD. Prior surgical interventions for hepatobiliary disorders, current diagnostic and surgical procedures, procedure-specific complications, duration of hospital stay, duration of follow-up, outpatient information, and long-term outcome were reviewed. RESULTS: Fifteen male and 18 female patients were treated in this study. Initial symptoms and signs of the disease noted in our patients included right upper quadrant pain, fever, and jaundice. In 2 of the 33 patients, we noted clinical evidence of cirrhosis followed by histologic confirmation. One patient suffered from variceal bleeding. In 26 patients, diagnoses were established by a combined endoscopic retrograde cholangiopancreatography, ultrasonography, and computed tomographic studies. The disease was localized in 25 and diffuse in 8 patients. Liver resection was carried out in 29 patients. Partial hepatectomies were performed in 27 of these 29 at our institution. Two female patients with the diffuse disease underwent orthotopic liver transplantation. Thirteen of the 31 patients who underwent surgery at our institution had an uneventful postoperative course. Fourteen patients had minor postoperative complications and responded well to medical management. Four patients had major complications that required further surgical treatment. Two patients died of complications related to postoperative hemorrhage and sepsis. Two patients with intrahepatic cholangiocarcinoma died because of primary tumor progress. One patient with cholangiocarcinoma died 1 year after a successful left hepatectomy because of metastatic disease recurrence. The long-term results of the 26 surviving patients were assessed during a mean follow-up of 3.7 years (range, 1-11 years). All 26 patients remained free of biliary symptoms or complications. In 25 patients, surgery including liver transplantation was curative. CONCLUSIONS: Partial hepatectomy for localized CD is potentially curative. In patients with diffuse CD, liver transplantation provides gratifying long-term results.     

Training current and future robotic surgeons simultaneously: initial experiences with safety and efficiency

Robotic surgery is experiencing a rapidly-increasing presence in the field of general surgery. The adoption of any new technology carries the challenge of training current and future surgeons in a safe and effective manner. We report our experience with the initiation of a robotic general surgery program at an academic institution while simultaneously incorporating surgical trainees. The initial procedure performed was robotic-assisted cholecystectomy (RAC). Concurrent with the introduction of a robotic general surgical program, our institution implemented a progressive surgical trainee curriculum for all active residents and fellows. Immediately after being credentialed to perform RAC, attending surgeons began incorporating surgical trainees into robotic procedures. We retrospectively reviewed our first 50 RACs and compared them with our previous 50 standard laparoscopic cholecystectomies (SLC) to determine the impact of rapid integration of surgical trainees on developing technologies. Despite new technology and novice surgeons, there was no difference in mean operative time between the SLC and RAC groups (75.3 vs. 84.1 min, p = 0.077). Two patients in the robotic-assisted group required intraoperative conversion. Hospital length of stay was similar between groups, with the majority of patients leaving the same day. There were no postoperative complications in either group. A robotic general surgery program can be initiated while concurrently instructing surgical trainees on robotic surgery in a safe and efficient manner. We report our initial experience with the adoption of this rapidly advancing technology and describe our training model.     

Complication rates after total ankle arthroplasty in one hundred consecutive prostheses

Introduction

Total ankle arthroplasty is increasingly used as an alternative to arthrodesis to treat advanced ankle arthritis. However, the outcomes and postoperative complications are poorly described.

Patients and methods

Between March 2005 and May 2010 114 S.T.A.R. prostheses were implanted by one surgeon at our institution. We retrospectively analysed the demographics, clinical outcomes and radiographic characteristics of 100 ankle prostheses (97 patients).

Results

The average follow up was 36 months. The average preoperative AOFAS score of 36.87 (22–58) significantly increased to 75.99 postoperative. A total of 87 % of the patients reported a better life quality. Twenty-seven ankles incurred complications after primary surgery, and 21 prostheses required revision surgery, including four patients who required arthrodesis.

Conclusion

Our study shows a high satisfaction rate after total ankle replacement and clear pain relief. Patients with a body mass Index higher than 30 showed a higher rate of complications. Compared with ankle fusion, the rates of complications are comparable.     

Laparoscopic approach as primary treatment of common bile duct stones in children

Background

Preoperative endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy (ES) are an effective strategy for choledocholithiasis, but complications such as pancreatitis and outcome in children are unknown. The laparoscopic cholecystectomy became the new gold standard in children for cholelithiasis. For the choledocholithiasis in children, the attitude is more controversial. We analyzed our series of laparoscopic approach for the management of choledocholithiasis in children to determine if it is an effective procedure.

Patients and Method

Between 1996 and 2001, 126 children were treated for cholelithiasis in our institution; 13 children (10.3%) were managed for a choledocholithiasis. We reviewed age at symptom onset results of paraclinical examinations, the type of laparoscopic management, and postoperative outcome.

Results

The mean age at clinical signs was 9.9 years (range, 3 months-15.5 years). One child was excluded because he had a preoperative ES. Twelve children had a laparoscopic cholecystectomy and cholangiogram at the same time. A choledocholithiasis was found in 10 cases. A flush of the common bile duct (CBD) was performed in all cases with a 3F or 5F ureteral catheter; the stone was pushed into the duodenum in 3 cases and successfully extracted in 3 with a 4F Dormia or Fogarty catheter. One child needed a conversion to open surgery. Three times, an ES was necessary in postoperative course in each case for clinical and biologic signs of CBD obstruction or pancreatitis (30%). All children are symptom-free with an average follow-up of 28 months.

Conclusion

Laparoscopic CBD exploration for choledocholithiasis can be performed safely in children at the time of cholecystectomy and can clear all of the stones in the CBD in two thirds of cases. If there is residual obstruction, a postoperative ES can be performed. We suggest primary treatment of choledocholithiasis by laparoscopic approach in children.