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Pulitanò C, Parks RW, Ireland H, Wigmore SJ, Garden OJ. Impact of concomitant arterial injury on the outcome of laparoscopic bile duct injury. Am J Surg 2011; 201:238-44. [PMID: 21266217 DOI: 10.1016/j.amjsurg.2009.07.038] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Revised: 07/09/2009] [Accepted: 07/10/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Concomitant injury to the bile duct and hepatic artery is an increasingly recognized complication of laparoscopic cholecystectomy (LC). The impact of a concomitant arterial injury in patients with a bile duct injury (BDI) remains debatable. Early reports described a high incidence of septic complications, difficulty of biliary repair, and increased the risk of recurrent stricture. DATA SOURCES A literature search on the clinical significance and management of a concomitant hepatic artery injury (HAI) to the outcome of biliary-enteric reconstruction following BDI was reviewed. Relevant articles were extracted through MEDLINE, with secondary references obtained from key articles. CONCLUSIONS The association between failure of biliary repair and concomitant arterial injuries is not confirmed by the largest studies, which showed no difference in anastomotic stricture rate between patients who had an isolated BDI and those who had a combined HAI and BDI. However, right arterial injury associated with liver necrosis or damage to the right hepatic duct may require right hepatectomy.
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Affiliation(s)
- Carlo Pulitanò
- Department of Clinical and Surgical Sciences, Royal Infirmary of Edinburgh, University of Edinburgh, UK
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152
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Zhang X, Tian Y, Xu Z, Wang L, Hou C, Ling X. Healing Process of the Guinea Pig Common Bile Duct after End-to-End Anastomosis: Pathological Evaluation after 6 Months. Eur Surg Res 2011; 46:194-206. [DOI: 10.1159/000325451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 02/11/2011] [Indexed: 01/01/2023]
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153
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The quality of cholecystectomy in Denmark: outcome and risk factors for 20,307 patients from the national database. Surg Endosc 2010; 25:1630-41. [DOI: 10.1007/s00464-010-1453-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Accepted: 09/07/2010] [Indexed: 12/15/2022]
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154
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Haglund U, Norén A. Routine Intraoperative Cholangiography in Elective Laparoscopic Cholecystectomy. Scand J Surg 2010; 99:195-6. [DOI: 10.1177/145749691009900402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Ulf Haglund
- Department of Surgery Uppsala University Uppsala University Hospital SE - 751 85 Uppsala Sweden
| | - Agneta Norén
- Department of Surgery Uppsala University Uppsala University Hospital SE - 751 85 Uppsala Sweden
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155
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Khan OA, Balaji S, Branagan G, Bennett DH, Davies N. Randomized clinical trial of routine on-table cholangiography during laparoscopic cholecystectomy. Br J Surg 2010; 98:362-7. [PMID: 21254008 DOI: 10.1002/bjs.7356] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND A randomized clinical trial was undertaken to assess the utility of routine on-table cholangiography (OTC) during laparoscopic cholecystectomy for gallstone disease. METHODS Some 190 patients with a history of biliary colic or cholecystitis and a low predictive risk for choledocholithiasis were randomized to undergo elective laparoscopic cholecystectomy alone (99 patients) or elective laparoscopic cholecystectomy with OTC (91). Intraoperative findings and postoperative outcomes for the two groups were compared. The primary outcome measure was the incidence of common bile duct (CBD) stones. RESULTS Of the patients undergoing OTC, ten had abnormal cholangiograms; three had CBD stones and seven had abnormalities without stones. OTC was associated with a significantly longer mean(s.e.m.) operating time (66(2) versus 54(3) min; P < 0·001), but there was no association between performance of OTC and postoperative morbidity. During a 1-year follow-up, no patient in the OTC group re-presented to hospital with recurrent biliary symptoms. In contrast, four of the patients allocated to surgery alone re-presented with symptoms suggestive of CBD obstruction; all settled with conservative treatment and the difference in readmission rate was not significant (P = 0·122). CONCLUSION Routine cholangiography in patients with a low risk for CBD stones does not seem justified from the results of this trial. REGISTRATION NUMBER NCT00806780 (http://www.clinicaltrials.gov).
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Affiliation(s)
- O A Khan
- Department of Upper Gastrointestinal Surgery, Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK.
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156
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Santos EG, Neto GPB. [Learning curve and iatrogenic injuries in laparoscopic cholecystectomies]. Rev Col Bras Cir 2010; 37:184-9. [PMID: 21079890 DOI: 10.1590/s0100-69912010000300005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Accepted: 04/30/2009] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of this study is to analyze surgeon's proficiency, based on the different aspects of his learning curve as a risk factor for iatrogenic biliary tract injuries associated with Laparoscopic Cholecystectomy. METHODS a retrospective study was conducted using the report information from charts of patients January 1992 through December 2007; at Hospital Universitário Clementino Fraga Filho da Universidade Federal do Rio de Janeiro. Analysis from data collected from charts of 2285 patients who had undergone laparoscopic cholecystectomies. Data from surgeons involved with this type of surgery was also analyzed. RESULTS a total of six injuries (0.26%) were found. This result is similar to that found in international publications. All injuries had occurred in the surgeon's second phase of the learning curve with more than 50 video surgeries. CONCLUSION it was conclude that Video surgery Certificate and previous training are not related to biliary tract injuries in this series. Surgeon's age was not a risk factor in this study. There was statistical significance between surgeons' experience and injuries.
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Affiliation(s)
- Elizabeth Gomes Santos
- Serviço de Cirurgia Geral, Universitário Clementino Fraga Filho, Rio de Janeiro, RJ, BR.
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157
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Giger U, Ouaissi M, Schmitz SFH, Krähenbühl S, Krähenbühl L. Bile duct injury and use of cholangiography during laparoscopic cholecystectomy. Br J Surg 2010; 98:391-6. [PMID: 21254014 DOI: 10.1002/bjs.7335] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2010] [Indexed: 01/07/2023]
Abstract
BACKGROUND Bile duct injury (BDI) remains the most serious complication of laparoscopic cholecystectomy (LC). A Swiss database was used to identify risk factors for BDI and to assess the effect of intraoperative cholangiography (IOC). METHODS Data for patients from 114 Swiss institutions who underwent LC for acute or chronic cholecystitis between 1995 and 2005 were used in univariable and logistic regression analyses. RESULTS In total 31 838 patients, mean(s.d.) age 54·4(15·9) years, were analysed. The incidence of BDI was 0·3 per cent (101 patients), which did not change over time (P = 0·560). Univariable analysis revealed that male patients had a higher risk of BDI (0·5 per cent versus 0·2 per cent in female patients; P = 0·001), as did patients whose operation lasted at least 150 min (1·1 per cent versus 0·1 per cent for operating time of less than 150 min; P < 0·001). Logistic regression confirmed male sex (odds ratio (OR) 1·89, 95 per cent confidence interval 1·27 to 2·81) and prolonged surgery (OR 12·60, 10·87 to 23·81) as independent risk factors. Comparison of groups with and without intraoperative cholangiography showed no difference in the incidence of BDI (both 0·3 per cent; P = 0·755) and BDIs missed during surgery (10 versus 8 per cent; P = 0·737). CONCLUSION Male sex and prolonged laparoscopic surgery are independent risk factors for BDI during LC. Frequent use of IOC does not seem to reduce BDI or the number of injuries missed during surgery.
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Affiliation(s)
- U Giger
- Swiss Association of Laparoscopic and Thoracoscopic Surgery Study Group, Zurich, Switzerland.
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158
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Chiruvella A, Sarmiento JM, Sweeney JF, Lin E, Davis SS. Iatrogenic combined bile duct and right hepatic artery injury during single incision laparoscopic cholecystectomy. JSLS 2010; 14:268-71. [PMID: 20932382 PMCID: PMC3043581 DOI: 10.4293/108680810x12785289144593] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Numerous recent reports describe the performance of laparoscopic procedures through a single incision. Although the feasibility of this approach for a variety of procedures is currently being established, little data are available regarding safety. CASE REPORT A 65-year-old female patient who was transferred from an outside institution had undergone a single incision laparoscopic cholecystectomy that resulted in biliary tract and vascular injuries. METHODS The patient was transferred with a known bile duct injury on the first postoperative day following single incision laparoscopic cholecystectomy. Review of her magnetic resonance imaging and percutaneous transhepatic cholangiogram studies showed a Bismuth type 3 bile duct injury. Hepatic angiogram demonstrated an occlusion of the right hepatic artery with collateralization from the left hepatic artery. She was initially managed conservatively with a right-sided external biliary drain, followed 6 weeks later by a Hepp-Couinaud procedure to reconstruct the biliary tract. CONCLUSION As new techniques evolve, it is imperative that safety, or potential side effects, or both safety and side effects, be monitored, because no learning curve is established for these new techniques. In these initial stages, surgeons should have a low threshold to add additional ports when necessary to ensure that procedures are completed safely.
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Affiliation(s)
- Amareshwar Chiruvella
- Department of Surgery, Suite H-124, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA 30322, USA.
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159
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On the road to single-site laparoscopic adjustable gastric banding: lessons learned from 60 cases. Surg Endosc 2010; 25:947-53. [PMID: 20953885 DOI: 10.1007/s00464-010-1259-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Accepted: 07/13/2010] [Indexed: 12/29/2022]
Abstract
BACKGROUND Single-site laparoscopic surgery is a promising emerging technique with potential to decrease postoperative pain, reduce port-site complications, and improve cosmetic results. Laparoscopic adjustable gastric banding (LapGB) is a procedure that lends itself well to single-site laparoscopic surgery because the surgery is confined to a single region of the body, the need for a larger incision for port implantation and the fact that bariartric patients are more likely to be body image conscious. The procedure is, however, technically challenging and potentially more time consuming and hazardous. To simplify learning, a hybrid technique that used multiple conventional trocars and laparoscopic equipment through a single periumbilical incision while retaining the use of the Nathanson retractor via a separate epigastric incision was developed. The authors' experience and results with this technique are described. METHODS This retrospective review describes the prospectively collected data for the first 60 consecutive cases completed using the minimally invasive technique described. RESULTS The 60 cases in this study comprised 12 men and 48 women with an average age of 39 years (range 20-59 years). Their average body mass index (BMI) was 39.1 kg/m(2) (range 32-52 kg/m(2)). Four patients (6.7%) needed an additional port either for hemostasis or for access difficulties. Concomitant hiatal hernia repair was performed for 13 patients. Five patients (8.3%) had superficial wound infection requiring oral antibiotic therapy and dressings. No other complications were observed. Overall, the average operating time was 55 min (range 30-160 min). For both surgeons, the learning curve was six cases, with a significant difference in the operating times between the first six cases and the remaining cases (p < 0.0001, Mann-Whitney U test). CONCLUSIONS The authors' early experience with the minimally invasive LapGB technique shows that it is feasible and safe. It can be used either as a bridging technique to single-site LapGB or on its own as a minimally invasive technique.
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160
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Fatima J, Barton JG, Grotz TE, Geng Z, Harmsen WS, Huebner M, Baron TH, Kendrick ML, Donohue JH, Que FG, Nagorney DM, Farnell MB. Is there a role for endoscopic therapy as a definitive treatment for post-laparoscopic bile duct injuries? J Am Coll Surg 2010; 211:495-502. [PMID: 20801692 DOI: 10.1016/j.jamcollsurg.2010.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 06/11/2010] [Accepted: 06/11/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND Excellent results of surgical reconstruction of major bile duct injuries (BDIs) have been well-documented. Reports of successful definitive management of central bile duct leakage and stenoses have been reported infrequently. The aim of this study was to assess treatment and outcomes for operative and endoscopic treatment of BDI after laparoscopic cholecystectomy (LC) and define the role of endoscopy in management. STUDY DESIGN All patients undergoing treatment for post-laparoscopic BDI from 1998 to 2007 at Mayo Clinic, Rochester, Minnesota were reviewed. Outcomes of surgical and endoscopic intervention were analyzed. RESULTS BDI was identified in 159 patients (mean age 51 years). Injury was recognized intraoperatively in 39 (25%) patients. Primary intervention was surgical in 59 (37%) and endoscopic in 100 (63%) patients. Class A BDIs (n = 77) were successfully treated endoscopically in 76 (99%) patients. Seven had class D BDIs; 4 were managed surgically, and 3 endoscopically. Of 66 patients with E1 to E4 BDI, 44 (67%) were initially managed surgically and 22 (33%) endoscopically. Thirteen of the latter 22 underwent sustained endoscopic therapy (median stent time 7 months), which was successful in 10 (77%). Four patients with E5 were managed surgically. Median follow-up was 45 months. Sixty-three patients underwent Roux-en-Y hepaticojejunostomy reconstruction at Mayo; 3 (5%) failed and required stenting. None required operative revision. CONCLUSIONS Endoscopic management of class A BDI has excellent outcomes. Although surgical management remains the preferred therapy, short-term endoscopic treatment for class E1 to E4 can optimize the patient and operative field for reconstruction. Prolonged stenting in select patients with E1 to E4 characterized by stenosis is successful in the majority.
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161
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Wang ZY, Xu F, Liu YD, Xu CG, Wu JL. Prevention of Biliary Duct Injury in Laparoscopic Cholecystectomy Using Optical Fiber Illumination in Common Bile Duct. Gastroenterology Res 2010; 3:207-212. [PMID: 27956998 PMCID: PMC5139717 DOI: 10.4021/gr249e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2010] [Indexed: 11/30/2022] Open
Abstract
Background Biliary duct injury (BDI) is one of the most common complications in laparoscopic cholectecystomy (LC), in this study, we have tried to place an illuminating optical fiber via endoscopy in the CBD during LC, the biliary duct anatomy can be clearly delineated, thus CBD injury is avoided. Methods Sixteen patients with chronic cholecystitis or/and cholelithiasis from February 2007 to June 2008 were performed LC with placement of optical fiber in CBD, the fiber with cold light illuminates the whole extrahepatic biliary system. Three 6-mm titanium clips were applied to the soft tissue surrounding the hepatic duct, CBD and the cystic duct confluence with CBD, respectively; one titanium clip was applied to the surface of cystic duct near the infundibulum of gallbladder. The cytic duct, CBD and common hepatic duct were clearly identified and delineated in the operating field and LC was performed. Results All the 16 patients were performed LC using this procedure successfully, there were no LC-related complications, nor complications related to endoscopic retrograde cholangiopanceatography (ERCP). Conclusions The endoscopically placed optical fiber in the CBD can clearly identify the CBD, Calot’s triangle and the common hepatic duct, this can reduce the bile duct injury in LC and imporve the safety of LC.
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Affiliation(s)
- Zhi Yong Wang
- Department of Digestive Diseases, Affiliated Hospital of Hangzhou Normal University (the Second People's Hospital of Hangzhou City), Hangzhou, Zhejiang, China
| | - Fang Xu
- Department of General Surgery, Affiliated Hospital of Hangzhou Normal University (the Second People's Hospital of Hangzhou City), Hangzhou, Zhejiang, China
| | - Ya Dong Liu
- Department of General Surgery, Affiliated Hospital of Hangzhou Normal University (the Second People's Hospital of Hangzhou City), Hangzhou, Zhejiang, China
| | - Cheng Gang Xu
- Department of General Surgery, Affiliated Hospital of Hangzhou Normal University (the Second People's Hospital of Hangzhou City), Hangzhou, Zhejiang, China
| | - Jiang Liang Wu
- Department of Digestive Diseases, Affiliated Hospital of Hangzhou Normal University (the Second People's Hospital of Hangzhou City), Hangzhou, Zhejiang, China
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162
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Ruiz Gómez F, Ramia Ángel JM, García-Parreño Jofré J, Figueras J. Lesiones iatrogénicas de la vía biliar. Cir Esp 2010; 88:211-21. [DOI: 10.1016/j.ciresp.2010.03.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 02/21/2010] [Accepted: 03/12/2010] [Indexed: 12/20/2022]
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163
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Ishizawa T, Bandai Y, Ijichi M, Kaneko J, Hasegawa K, Kokudo N. Fluorescent cholangiography illuminating the biliary tree during laparoscopic cholecystectomy. Br J Surg 2010; 97:1369-77. [PMID: 20623766 DOI: 10.1002/bjs.7125] [Citation(s) in RCA: 233] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although intraoperative cholangiography has been recommended for avoiding bile duct injury during laparoscopic cholecystectomy, radiographic cholangiography is time consuming and may itself cause injury to the bile duct. Recently, a novel fluorescent cholangiography technique using the intravenous injection of indocyanine green (ICG) has been developed. METHODS In 52 patients undergoing laparoscopic cholecystectomy, 2.5 mg ICG was injected intravenously 30 min before the patient entered the operating room or following intubation. A fluorescent imaging system, which consisted of a xenon light source and a laparoscope with a charge-coupled device camera that could filter out light wavelengths below 810 nm, was used. Fluorescent cholangiography was performed during dissection of Calot's triangle, and its ability to delineate biliary anatomy was compared with that of preoperative cholangiography. RESULTS Fluorescent cholangiography delineated the cystic duct in all 52 patients, and the cystic duct-common hepatic duct junction was visible before dissection of Calot's triangle in 50 patients. Fluorescent imaging also identified all accessory bile ducts that had been diagnosed before surgery in eight patients. CONCLUSION Fluorescent cholangiography enables real-time identification of biliary anatomy during dissection of Calot's triangle. This simple technique may become standard practice for avoiding bile duct injury during laparoscopic cholecystectomy, replacing radiographic cholangiography.
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Affiliation(s)
- T Ishizawa
- Department of Surgery, Central Hospital of Social Health Insurance, University of Tokyo, Bunkyo-ku, Tokyo, Japan
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164
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165
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Epari KP, Mukhtar AS, Fletcher DR, Samarasam I, Semmens JB. The outcome of patients on the cholecystectomy waiting list in Western Australia 1999-2005. ANZ J Surg 2010; 80:703-9. [DOI: 10.1111/j.1445-2197.2010.05428.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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166
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Mohandas S, John AK. Role of intra operative cholangiogram in current day practice. Int J Surg 2010; 8:602-5. [PMID: 20673816 DOI: 10.1016/j.ijsu.2010.06.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2010] [Accepted: 06/15/2010] [Indexed: 12/19/2022]
Abstract
The role of Intra Operative Cholangiogram during laparoscopic cholecystectomy remains controversial. This review discusses the modalities used in the pre- and peri-operative assessment of Common Bile Duct. It also discusses the advantages and disadvantages of selective and routine IOC. In this review we explore the role of Intra Operative Cholangiogram in current day practice.
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Affiliation(s)
- Shailesh Mohandas
- Hepatobiliary and Pancreatic Surgery, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 7XX, United Kingdom.
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167
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Famaey N, Verbeken E, Vinckier S, Willaert B, Herijgers P, Sloten JV. In vivo soft tissue damage assessment for applications in surgery. Med Eng Phys 2010; 32:437-43. [DOI: 10.1016/j.medengphy.2010.04.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 03/11/2010] [Accepted: 04/02/2010] [Indexed: 11/29/2022]
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168
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A safe laparoscopic cholecystectomy depends upon the establishment of a critical view of safety. Surg Today 2010; 40:507-13. [PMID: 20496131 DOI: 10.1007/s00595-009-4218-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Accepted: 10/22/2009] [Indexed: 12/20/2022]
Abstract
Bile duct injuries (BDI) during a laparoscopic cholecystectomy (LC) occur more frequently than during an open cholecystectomy. Many expert surgeons learn to perform procedures safely based on their experience. Above all, the critical view of safety (CVS) introduced by Strasberg in 1995 is the standard practice to prevent BDI during an LC. The CVS is achieved by clearing all fat and fibrous tissue in Calot's triangle, after which the cystic structures can be clearly identified, occluded, and divided. Failure to successfully create this view may be an indication for conversion to an open cholecystectomy. The Japan Society for Endoscopic Surgery (JSES) introduced an accreditation examination in 2004. The critical view is an important factor used to judge a safe dissection. The annual ratios of successful applicants were 63% in 2004, 45% in 2005, 36% in 2006, 39% in 2007, and 44% in 2008. Biennial questionnaire surveys by JSES show that the laparoscopic BDI rates were 0.66% in 1990-2001, 0.79% in 2002, 0.77% in 2003, 0.66% in 2004, 0.77% in 2005, 0.65% in 2006, and 0.58% in 2007. Therefore, 2007 was the first year in which the rate was below 0.6%. A decreasing BDI rate is therefore expected because successful candidates will introduce technical improvements to colleagues in their hospitals and local regions.
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169
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Rawlings A, Hodgett SE, Matthews BD, Strasberg SM, Quasebarth M, Brunt LM. Single-incision laparoscopic cholecystectomy: initial experience with critical view of safety dissection and routine intraoperative cholangiography. J Am Coll Surg 2010; 211:1-7. [PMID: 20610242 DOI: 10.1016/j.jamcollsurg.2010.02.038] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Revised: 02/03/2010] [Accepted: 02/03/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND Single-incision laparoscopic cholecystectomy (SILC) is emerging as a potentially less invasive alternative to standard laparoscopic cholecystectomy and natural orifice transluminal endoscopic surgery cholecystectomy. As this technique is more widely used, it is important to maintain well-established practices of the critical view of safety (CVS) dissection and intraoperative cholangiography (IOC). We present our initial experience with SILC using CVS dissection and routine IOC. STUDY DESIGN Fifty-four patients with biliary colic were offered SILC, which was performed through the umbilicus. CVS with photo documentation was attained before clipping and transecting the cystic structures. IOC was done using various needle puncture techniques. Assessment of CVS was carried out by independent surgeon review of operative still photos or videos using a 3-point grading scale: visualization of only 2 ductal structures entering the gallbladder; a clear triangle of Calot; and separation of the base of the gallbladder from the cystic plate. RESULTS SILC was performed in 54 patients (15 male and 39 female). Six patients required 1 supplementary 3- or 5-mm port. Complete IOC was successful in 50 of 54 patients (92.6%). CVS was achieved at the time of operation in all 54 patients. Photo documentation review confirmed 3 of 3 CVS criteria in 32 (64%) patients, 2 of 3 in 12 patients (24%), 1 of 3 in 3 patients (6%), and 0 in 3 patients (6%). CONCLUSIONS As laparoscopic cholecystectomy becomes less invasive, proven safe dissection techniques should be maintained. Dissection to obtain the CVS should be the goal of every patient and IOC can be accomplished in a high percentage of patients. This approach places patient safety considerations foremost in the evolution of minimally invasive cholecystectomy.
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Affiliation(s)
- Arthur Rawlings
- Department of Surgery and Institute for Minimally Invasive Surgery, Washington University School of Medicine, St Louis, MO 63110 , USA
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170
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Chong VH, Chong CF. Biliary complications secondary to post-cholecystectomy clip migration: a review of 69 cases. J Gastrointest Surg 2010; 14:688-96. [PMID: 20049550 DOI: 10.1007/s11605-009-1131-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Accepted: 12/04/2009] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Post-cholecystectomy clip migration (PCCM) is rare and can lead to complications which include clip-related biliary stones. Most have been reported as case reports. This study reviews cases of clip migration reported in the literatures. METHOD Searches and reviews of the literatures from "PubMed," "EMBASE," and "Google Scholar" search engines using the keywords "clip migration" and "bile duct stones" were carried out. Eighty cases from 69 publications were identified but details for only 69 cases were available for the study. RESULTS The median age at presentations of PCCM was 60 years old (range, 31 to 88 years; female, 61.8%) and the median time from the initial cholecystectomy to clinical presentations was 26 months (range, 11 days to 20 years). Of primary surgeries, 23.2% was for complicated gallstones disease. The median number of clips placed during surgery was six (range, two to more than ten clips). Common diagnoses at presentations of PCCM were obstructive jaundice (37.7%), cholangitis (27.5%), biliary colic (18.8%), and acute pancreatitis (8.7%). The median number of migrated clip was one (range, one to six). Biliary dilatation and strictures were encountered in 74.1% and 28.6%, respectively. Of the 69 cases of PCCM-associated complications, 53 (77%) were successfully treated with endoscopic retrograde cholangiopancreatography (ERCP), 14 (20.2%) with surgery, and one (1.4%) with successful percutaneous transhepatic cholangiography treatment. One patient had spontaneous clearance of PCCM. There was no reported mortality related to PCCM. CONCLUSION PCCM can occur at any time but typically occur at a median of 2 years after cholecystectomy. Clinical presentations are similar to those with primary or secondary choledocholithiasis. Most can be managed successfully with ERCP.
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Affiliation(s)
- Vui Heng Chong
- Endoscopy Unit, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, BA 1710 Brunei Darussalam.
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171
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Ergonomics and Technical Aspects of Minimal Access Surgery in Acute Surgery. Eur J Trauma Emerg Surg 2010; 36:3-9. [PMID: 26815561 DOI: 10.1007/s00068-010-9226-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 12/04/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND Following the general trend in the evolution of minimal access surgery (MAS), the place of laparoscopy for diagnostic and therapeutic procedures in the emergency setting is well defined. As for all laparoscopic procedures, the ergonomic and technical aspects of MAS in acute surgery are important issues. METHODS Review of the literature. RESULTS The ergonomic and technical aspects of emergency laparoscopy include the surgeon's and the patient's position; the operating room setup, including the table, the monitor, and the specific equipment; patient preparation adapted as required to potential changes necessary as adapted to the pathology and conversion; the trocar setup, also adapted to the organ and pathology. Specific needs and variations can be necessary, dependent on the patient status, body build, and the pathology being treated. The operating room used for acute surgery should be adapted to evolving laparoscopic techniques, as well as new intraoperative diagnostic and therapeutic modalities. CONCLUSION High-tech equipment and associated procedures have modified the needs for a modern operating room setup. Laparoscopic procedures for emergency surgery must make use of well-known ergonomic principles and be adapted to the patient and the pathology.
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172
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Abstract
Laparoscopic cholecystectomy (LC) has supplanted open cholecystectomy for most gallbladder pathology. Experience has allowed the development of now well-established technical nuances, and training has raised the level of performance so that safe LC is possible. If safe cholecystectomy cannot be performed because of acute inflammation, LC tube placement should occur. A systematic approach in every case to open a window beyond the triangle of Calot, well up onto the liver bed, is essential for the safe completion of the operation.
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Affiliation(s)
- Demetrius E M Litwin
- Department of Surgery, University Campus, 55 Lake Avenue North, The University of Massachusetts Medical School, Worcester, MA 01655, USA.
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173
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McPartland KJ, Pomposelli JJ. Iatrogenic biliary injuries: classification, identification, and management. Surg Clin North Am 2009; 88:1329-43; ix. [PMID: 18992598 DOI: 10.1016/j.suc.2008.07.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Iatrogenic biliary injuries most commonly occur during laparoscopic cholecystectomy. Biliary injuries are complex problems requiring a multidisciplinary approach with surgeons, radiologists, and gastroenterologists knowledgeable in hepatobiliary disease. Mismanagement can result in lifelong disability and chronic liver disease. Given the unforgiving nature of the biliary tree, favorable outcome requires a well-thought-out strategy and attention to detail.
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Affiliation(s)
- Kenneth J McPartland
- Division of Hepatobiliary Surgery and Liver Transplantation, Lahey Clinic Medical Center, 41 Mall Road, Burlington, MA 01805, USA
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174
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Abstract
Collections of routine, or ‘administrative’, hospital data have many applications in health care and are now recognised as valuable sources of information. In recent decades, administrative data have been seen primarily as funding and billing tools to assist with the reimbursement of hospitals for services provided; this purpose remains the primary focus of the clinical coder workforce. More recently, hospital data have been recognised as valuable resources for a range of health system improvement processes beyond funding. The focus of this paper is to review and demonstrate the diverse uses of administrative data in health services research and quality improvement. By gaining an understanding of how the data are used, we can appreciate the importance of good quality data from the perspective of its multiple uses. This paper describes a sample of the studies conducted in Australia using administrative data in health care improvement.
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Affiliation(s)
- Jude L Michel
- Jude L Michel BHIthlnfoManagt(Hons), Australian Centre for Economic Research on Health, (ACERH), School of Medicine, University of Queensland, Herston Road, Herston, Brisbane 4006 QLD, AUSTRALIA
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175
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Avgerinos C, Kelgiorgi D, Touloumis Z, Baltatzi L, Dervenis C. One thousand laparoscopic cholecystectomies in a single surgical unit using the "critical view of safety" technique. J Gastrointest Surg 2009; 13:498-503. [PMID: 19009323 DOI: 10.1007/s11605-008-0748-8] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Accepted: 10/28/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Bile duct injuries have been substantially increased after the introduction of laparoscopic cholecystectomy (LC). They are accompanied by major morbidity, occasional mortality, lengthening of hospital stay, additional health costs, and deterioration of patients' quality of life and life expectancy. The aim of this study was to present the method of "critical view of safety" (CVS) as safe and feasible for the prevention of bile duct injuries during laparoscopic cholecystectomy. PATIENTS AND METHODS During a 6-year period from January 2002 till December 2007, 1,046 LCs (369 men and 677 women) were performed mainly for symptomatic gallstone disease. The CVS technique recommends clearing the triangle of Calot of fat and fibrous tissue and taking the gallbladder off the lowest part of its attachment to the gallbladder bed. The "infundibular" technique (identification of cystic duct and gallbladder junction) was used whenever CVS was not possible to perform. RESULTS The CVS was performed in 998 patients (95.4%). Overall, 27 patients needed conversion to the open approach (2.6%). This rate was higher in patients with acute inflammation undergoing early operation (nine of 128, 7%) compared with patients operated later or electively (18 of 914, 1.9%). There was no bile duct injury in the 1,046 cholecystectomies. Postoperatively, five patients had bile leaks which were transient and stopped spontaneously after 2-14 days. Two reoperations were performed because of severe bleeding. CONCLUSION CVS clarifies the relations of the anatomic structures that should be divided, and therefore, it should be ideally and routinely applied in all LCs because of its highly protective role against bile duct injuries.
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Affiliation(s)
- C Avgerinos
- 1st Surgical Department, Agia Olga Hospital, 3-5 Agias Olgas Str, Athens 14233, Greece
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176
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Abstract
BACKGROUND The optimal treatment for patients with suspected biliary dyskinesia is controversial. Some studies found that cholecystectomy produced symptomatic improvement in patients with gallbladder dyskinesia (diagnosed by low gallbladder ejection fraction) while others found no significant benefit. Some studies have shown that gallbladder ejection fraction can discriminate patients who would benefit from cholecystectomy. Other studies have not confirmed this. OBJECTIVES The aim of this review was to compare the benefits and harms of cholecystectomy for patients with suspected gallbladder dyskinesia. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2008. SELECTION CRITERIA We considered for inclusion all randomised clinical trials comparing cholecystectomy versus no cholecystectomy on patients with gallbladder dyskinesia. DATA COLLECTION AND ANALYSIS We collected the data on the characteristics, methodological quality, mortality, number of patients in whom symptoms were improved or cured from the one identified trial. We planned to analyse the data using the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we planned to calculate the risk ratio (RR) with 95% confidence intervals based on intention-to-treat analysis. MAIN RESULTS We included one trial with 21 patients randomised: 11 to cholecystectomy and 10 to control (no cholecystectomy). This trial was considered to be of high risk of bias as patients were not blinded and the procedure-related morbidity was not reported. There was no mortality in either group. All patients in the cholecystectomy group and only one patient in the control group had improvement in symptoms (P = 0.0001) after a mean follow-up period of 33.6 months. AUTHORS' CONCLUSIONS The evidence for the benefits and harms of cholecystectomy in gallbladder dyskinesia from randomised clinical trials is based on a single small trial at risk of bias. Further randomised clinical trials with improved bias control are necessary to confirm or reject the promising results.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
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177
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Abstract
BACKGROUND The management of gallbladder polyps is controversial. Cholecystectomy has been recommended for gallbladder polyps larger than 10 mm because of the association with gallbladder cancer. Cholecystectomy has also been suggested for gallbladder polyps smaller than 10 mm in patients with biliary type of symptoms. OBJECTIVES The aim of this review is to compare the benefits (relief of symptoms, decreased incidence of gallbladder cancer) and harms (surgical morbidity) of cholecystectomy in patients with gallbladder polyp(s). SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until July 2008 to identify the randomised trials. SELECTION CRITERIA Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing cholecystectomy and no cholecystectomy were considered for the review. DATA COLLECTION AND ANALYSIS We planned to collect the data on the characteristics, methodological quality, mortality, number of patients in whom symptoms were improved or cured from the one identified trial. We planned to analyse the data using the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we planned to calculate the risk ratio (RR) with 95% confidence intervals based on intention-to-treat analysis. MAIN RESULTS We were unable to identify any randomised clinical trials comparing cholecystectomy versus no cholecystectomy in patients with a gallbladder polyp. AUTHORS' CONCLUSIONS There are no randomised trials comparing cholecystectomy versus no cholecystectomy in patients with gallbladder polyps. Randomised clinical trials with low bias -risk are necessary to address the question of whether cholecystectomy is indicated in gallbladder polyps smaller than10 mm.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
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178
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Abstract
BACKGROUND Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of a benign disease. A significant proportion of cases develop end-stage liver disease and a liver transplant is required. The aim of this study was to analyze the indications and results of liver transplantation as treatment for BDI. METHODS Between January 1988 and May 2007, 20 patients with end-stage liver disease secondary to BDI were included on the liver transplant waiting list. Retrospective charts were analyzed and survival was estimated by the Kaplan-Meier test. RESULTS Four patients died while on the waiting list and 16 received a transplant. Injury to the bile duct occurred during a cholecystectomy in 13 of 16 patients, with the main cause of the lesion being duct division in six patients and resection in four. All patients had received some surgical treatment (median = 2 procedures) before being considered for a transplant. The liver transplant came from a cadaveric donor for all patients and the median time between BDI and liver transplant was 60 months. Two patients died in the postoperative period and nine had complications. Three patients died in the late postoperative period. Median follow-up was 62 (range = 24-152) months. One-, three-, and five-year survival rates were 81, 75, and 75%, respectively. CONCLUSION Complex bile duct injuries and bile duct injuries with previous repair attempts can result in end-stage liver disease. In these cases, liver transplantation provides long-term survival.
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179
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Is routine MR cholangiopancreatography (MRCP) justified prior to cholecystectomy? Langenbecks Arch Surg 2008; 394:1005-10. [PMID: 19084990 DOI: 10.1007/s00423-008-0447-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2008] [Accepted: 09/16/2008] [Indexed: 12/20/2022]
Abstract
PURPOSE We investigated routinely the bile ducts by magnetic resonance cholangiopancreaticography (MRCP) prior to cholecystectomy. The aim of this study was to analyze the rate of clinically inapparent common bile duct (CBD) stones, the predictive value of elevated liver enzymes for CBD stones, and the influence of the radiological results on the perioperative management. METHODS In this prospective study, 465 patients were cholecystectomized within 18 months, mainly laparoscopically. Preoperative MRCP was performed in 454 patients. RESULTS With MRCP screening, clinically silent CBD stones were found in 4%. Elevated liver enzymes have only a poor predictive value for the presence of CBD stones (positive predictive value, 21%; negative predictive value, 96%). Compared to the recent literature, the postoperative morbidity in this study was low (0 bile duct injury, 0.4% residual gallstones). CONCLUSIONS Although MRCP is diagnostically useful in the perioperative management in some cases, its routine use in the DRG-era may not be justified due to the costs.
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180
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Intraoperative fluorescent cholangiography using indocyanine green: a biliary road map for safe surgery. J Am Coll Surg 2008; 208:e1-4. [PMID: 19228492 DOI: 10.1016/j.jamcollsurg.2008.09.024] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2008] [Revised: 09/23/2008] [Accepted: 09/24/2008] [Indexed: 12/24/2022]
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181
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Tzovaras G, Liakou P, Fafoulakis F, Baloyiannis I, Zacharoulis D, Hatzitheofilou C. Is there a role for drain use in elective laparoscopic cholecystectomy? A controlled randomized trial. Am J Surg 2008; 197:759-63. [PMID: 18926516 DOI: 10.1016/j.amjsurg.2008.05.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2008] [Revised: 05/30/2008] [Accepted: 05/30/2008] [Indexed: 01/29/2023]
Abstract
BACKGROUND Although the issue of drain use in open cholecystectomy has been adequately addressed by prospective randomized trials, there is lack of evidence on the usefulness of drains in elective laparoscopic cholecystectomy, and the surgeons follow their beliefs and bias on this debate. Therefore, a controlled randomized trial was designed to assess the value of drains in elective laparoscopic cholecystectomy. METHODS During a 5-year period (January 2002 to December 2006), 284 patients were randomized to have a drain placed (group A), whereas 281 patients were randomized not to have a drain (group B) placed in the subhepatic space. End points of this trial were to detect any differences in morbidity, postoperative pain, and hospital stay between the 2 groups. RESULTS There was no mortality in either group and no statistically significant difference in morbidity or hospital stay between the 2 groups. However, postoperative pain was significantly increased in patients who had a drain placed; median visual analog scale (VAS) score was 5 (range 1 to 8) versus 3 (range 1 to 8), in the non-drained group (P < .0001). Interestingly, in 2 of 3 patients in whom a drain was placed against randomization because of bile leak suspicion, a bile leak occurred. CONCLUSIONS The routine use of a drain in elective laparoscopic cholecystectomy has nothing to offer; in contrast, it is associated with increased pain. It would be reasonable, however, to leave a drain if there is a worry about an unsolved or potential bile leak, bearing in mind that drain placement, although sometimes providing a false sense of security, does not guarantee either prevention or treatment of postoperative bile collections, bleeding, or bile peritonitis.
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Affiliation(s)
- George Tzovaras
- Department of Surgery, University Hospital of Larissa, Larissa, Greece.
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182
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Massarweh NN, Devlin A, Elrod JAB, Symons RG, Flum DR. Surgeon knowledge, behavior, and opinions regarding intraoperative cholangiography. J Am Coll Surg 2008; 207:821-30. [PMID: 19183527 DOI: 10.1016/j.jamcollsurg.2008.08.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2008] [Revised: 08/12/2008] [Accepted: 08/13/2008] [Indexed: 01/12/2023]
Abstract
BACKGROUND The risk of common bile duct injury during laparoscopic cholecystectomy (LC) is 50% to 70% lower when an intraoperative cholangiogram (IOC) is used, and this effect is exaggerated among less experienced surgeons. Routine IOC is not universal, and barriers to its use, including surgeon knowledge, behavior, and attitudes, should be understood in developing quality-improvement interventions aimed at increasing IOC use. STUDY DESIGN There were 4,100 general surgeons randomly selected from the American College of Surgeons who were mailed a survey about IOC. Surveys with a valid exclusion (retired, no LC experience) were considered responsive but were excluded from data analysis. RESULTS Forty-four percent responded, with 1,417 surveys analyzed (mean age 51.8+/-9.6 years; 89.2% men; 55.3% private practice). Twenty-seven percent of respondents defined themselves as routine IOC users and 91.3% of routine users reported IOC use in more than 75% of LCs performed. Academic surgeons were less often routine users compared with nonacademics (15% versus 30%; p < 0.001). Selective users were more often low-volume (less than 20 LC/year) surgeons (8% versus 15%) as compared with routine users, who were more often high-volume (more than 100 LC/year) surgeons (27% versus 20%). Routine users had more favorable and accurate opinions about IOC (less costly and more protective of injury) than did selective users. Thirty-nine percent of routine users thought IOC decreased the risk of common bile duct injury by at least half compared with 10% of selective users. CONCLUSIONS Surgeons at greatest risk for causing common bile duct injury (inexperienced, low-volume surgeons) and those who have the greatest opportunity to train others are less likely to use IOC routinely. These represent target groups for quality-improvement interventions aimed at broader IOC use.
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Affiliation(s)
- Nader N Massarweh
- Department of Surgery, University of Washington, Seattle, WA 98195-6410, USA
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183
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Malik AM, Laghari AA, Talpur AH, Khan A. Iatrogenic biliary injuries during laparoscopic cholecystectomy. A continuing threat. Int J Surg 2008; 6:392-5. [DOI: 10.1016/j.ijsu.2008.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Accepted: 07/30/2008] [Indexed: 12/30/2022]
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Abstract
OBJECTIVE To evaluate our experience with more than 500 minimally invasive hepatic procedures. SUMMARY BACKGROUND DATA Recent data have confirmed the safety and efficacy of minimally invasive liver surgery. Despite these reports, no programmatic approach to minimally invasive liver surgery has been proposed. METHODS We retrospectively reviewed all patients who underwent a minimally invasive procedure for the management of hepatic tumors between January 2001 and April 2008. Patients were divided into 3 groups: laparoscopy with intraoperative ultrasound and biopsy only, laparoscopic radiofrequency ablation (RFA), and minimally invasive resection. To compare the various forms of surgery, we analyzed the incidence of complications, tumor recurrence, mortality, and cost. Statistical analysis was performed using chi(2) analysis, Student t test, Kaplan-Meier survival analysis with the log-rank test, and multivariable Cox models. RESULTS A total of 590 minimally invasive hepatic procedures were performed during 489 operative interventions. The representative tumor histologies were: hepatocellular carcinoma (HCC; N = 210), colorectal carcinoma (N = 40), miscellaneous liver metastases (N = 42), biliary cancer (N = 20), and benign tumors (N = 176). Thirty-five patients underwent laparoscopic ultrasound and confirmatory biopsy alone; 201 patients underwent 240 laparoscopic RFAs, and 253 patients underwent 306 minimally invasive resections. Conversion rates to open surgery for the RFA and resection group were 2% overall. One hundred ninety-nine (40.6%) patients were cirrhotic; 31 resections were performed in cirrhotic patients. Complication and mortality rates for RFA and resection were comparable (11% vs. 16%, and 1.5% vs. 1.6%). However, complication rates (14% vs. 29%; P = 0.02) and mortality (0.3% vs. 9.7%; P = 0.006) rates were higher in the cirrhotic versus noncirrhotic resection group. Overall recurrence rates for RFA and resection groups were 24% and 23%, respectively. Local recurrence rates were higher in the RFA group (6.3% versus 1.5%; P < 0.06). Overall patient survival differed between HCC patients receiving RFA alone and those receiving RFA and OLT (P < 0.0001). Overall survival for cancer patients receiving RFA versus resection differed significantly when unadjusted for other covariates (P = 0.01), and remained marginally significant in a multivariable model (P = 0.056). CONCLUSIONS Minimally invasive hepatic surgery has become a viable alternative to open hepatic surgery. Our present data are equivalent or superior to those encountered in any large open series. Our experience with RFA confirms a low local recurrence rate and an excellent technique for bridging patients to transplantation. Morbidity and mortality rates for minimally invasive hepatic resections in cirrhotics, is similar to other reported open resection series. This series confirmed excellent interim survival rates after laparoscopic HR and superiority over RFA in the treatment of cancer, with significantly lower local tumor recurrence rate.
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185
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Grönroos JM, Laine S, Salminen P, Karvonen J, Lavonius M, Gullichsen R. Female gender may give rise to difficulties in endoscopic and laparoscopic biliary surgery. Surg Endosc 2008; 22:2761-2. [DOI: 10.1007/s00464-008-0091-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 05/14/2008] [Indexed: 12/28/2022]
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Long-term outcome and risk factors of failure after bile duct injury repair. J Gastrointest Surg 2008; 12:1412-7. [PMID: 18493825 DOI: 10.1007/s11605-008-0538-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Accepted: 04/14/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND The real long-term outcome of a hepaticojejunostomy (HJ) to repair bile duct injury (BDI) is unclear, and the risk factors for repair failure are partially defined. STUDY DESIGN A retrospective, nonrandomized study of the long-term outcome of biliary reconstructions after major BDIs. All injuries occurred in association with cholecystectomy. RESULTS Twenty-nine patients were referred with complete transection of the common (n = 16), right (n = 5), or right sectoral (n = 4) hepatic ducts or of >1 major duct (n = 4) between October 2002 and January 2007. Mean follow-up was 24 months, range 12-60 months. Original repairs were "immediate" in 14, "delayed" (within 24-72h) in 5, and "elective" (after >8 weeks) in 10, and strictures developed in 9, 5, and 1 of those HJs, respectively. The surgical outcomes were significantly better when the intervention took place electively (p = 0.003). Original HJ repairs were done by a hepatobiliary surgeon (n = 23) or by a general surgeon (n = 6): the outcome was significantly better for the former (p < 0.001). CONCLUSIONS The 51.7% incidence of strictures after BDI repair in this study was higher than reported in the literature, probably because of selection bias secondary to the referral pattern. The timing of repair and the surgeon's expertise are significant risk factors of failure.
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187
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Vazquez RM. Common sense and common bile duct injury: common bile duct injury revisited. Surg Endosc 2008; 22:1743-5. [PMID: 18594920 DOI: 10.1007/s00464-008-0045-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Accepted: 06/10/2008] [Indexed: 01/06/2023]
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The routine use of laparoscopic ultrasound decreases bile duct injury: a multicenter study. Surg Endosc 2008; 23:384-8. [PMID: 18528611 DOI: 10.1007/s00464-008-9985-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2008] [Revised: 03/26/2008] [Accepted: 05/03/2008] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Laparoscopic ultrasound (LUS) has been used for over 15 years to screen the bile duct (BD) for stones and to delineate anatomy during laparoscopic cholecystectomy (LC). LUS as a modality to prevent BD injury has not been investigated in a large series. This study evaluated the routine use of LUS to determine its effect on preventing BD injury. METHODS A multicenter retrospective study was performed by reviewing clinical outcome of LC in which LUS was used routinely. RESULTS In five centers, 1,381 patients underwent LC with LUS. LUS was successful to delineate and evaluate the BD in 1,352 patients (98.0%), although it was unsuccessful or incomplete in 29 patients (2.0%). LUS was considered remarkably valuable to safely complete LC, avoiding conversion to open, in 81 patients (5.9%). The use of intraoperative cholangiography (IOC) varied depending on centers; IOC was performed in 504 patients (36.5%). For screening of BD stones (which was positive in 151 patients, 10.9%), LUS had a false-positive result in two patients (0.1%) and a false-negative result in five patients (0.4%). There were retained BD stones in three patients (0.2%). There were minor bile leaks from the liver bed in three patients (0.2%). However, there were no other BD injuries including BD transection (0%). Retrospectively, IOC was deemed necessary in 25 patients (1.8%) to complete LC in spite of routine LUS. CONCLUSION LUS can be performed successfully to delineate BD anatomy in the majority of patients. The routine use of LUS during LC has obviated major BD injury, compared to the reported rate (1 out of 200-400 LCs). LUS improves the safety of LC by clarifying anatomy and decreasing BD injury.
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189
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Tanaka E, Choi HS, Humblet V, Ohnishi S, Laurence RG, Frangioni JV. Real-time intraoperative assessment of the extrahepatic bile ducts in rats and pigs using invisible near-infrared fluorescent light. Surgery 2008; 144:39-48. [PMID: 18571583 DOI: 10.1016/j.surg.2008.03.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2007] [Accepted: 03/25/2008] [Indexed: 11/15/2022]
Abstract
BACKGROUND Currently, only x-ray fluoroscopy is available for visualization of the extrahepatic bile ducts intraoperatively. We hypothesized that with an appropriate fluorophore and imaging system, invisible near-infrared (NIR) light could be used for image-guided procedures on the extrahepatic bile ducts. METHODS We quantified the performance of three 800 nm NIR fluorophores, differing primarily in their degree of hydrophilicity, for real-time imaging of the extrahepatic bile ducts in rats and pigs: IR-786, indocyanine green (ICG), and the carboxylic form of IRDyetrade mark 800CW (CW800-CA). The signal-to-background ratio (SBR) of the common bile duct relative to liver and pancreas was measured as a function of the dose of contrast agent, injection site, and kinetics using an intraoperative NIR fluorescence imaging system described previously. Bile samples were examined by high performance liquid chromatography tandem mass spectrometry (HPLC/MS) to determine the chemical form of fluorophores in bile. RESULTS Non-sulfonated (IR-786) and di-sulfonated (ICG) NIR fluorophores had poor efficiency and kinetics of excretion into bile. Tetra-sulfonated CW800-CA, however, provided sensitive, specific, and real-time visualization of the extrahepatic bile ducts after a single low-dose given either intraportally or intravenously via systemic vein. A SBR >/=2 provided sensitive assessment of extrahepatic bile duct anatomy and function for over 30 min post-injection, including the detection of millimeter-sized, radiolucent inclusions in pigs. CW800-CA remained intact chemically after secretion into bile. CONCLUSION The combination of invisible NIR light and an IV injection of CW800-CA provides prolonged, real-time visualization of the extrahepatic bile duct, without ionizing radiation and without changing the look of the operative field.
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Affiliation(s)
- Eiichi Tanaka
- Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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190
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Brook EL, Rosman DL, Holman CDJ. Public good through data linkage: measuring research outputs from the Western Australian Data Linkage System. Aust N Z J Public Health 2008; 32:19-23. [PMID: 18290908 DOI: 10.1111/j.1753-6405.2008.00160.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To measure the 'public good' by retrieving, collating, reviewing and assessing outputs from projects using information supplied from the Western Australian Data Linkage System (WADLS) during 1995-2003. METHODS Using WADLS project application records, all investigators were contacted and requested to submit research outputs for review. RESULTS 708 outputs comprising journal articles, reports, presentations, conference proceedings, media, theses and other items were reported. During the review, consequential policy reforms in mental health, crystalline silica exposure guidelines and surgical mortality audit were identified. Consequential clinical practice reforms had occurred in laparoscopic, cholecystectomy and acute coronary care. CONCLUSIONS Data linkage can make a substantial and quantifiable contribution to population health and policy development.
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Affiliation(s)
- Emma L Brook
- School of Population Health, University of Western Australia, Crawley, Western Australia.
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191
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Kholdebarin R, Boetto J, Harnish JL, Urbach DR. Risk factors for bile duct injury during laparoscopic cholecystectomy: a case-control study. Surg Innov 2008; 15:114-9. [PMID: 18448447 DOI: 10.1177/1553350608318144] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Common bile duct injury is a serious but uncommon complication of laparoscopic cholecystectomy. A case-control epidemiologic study of patients who had undergone cholecystectomy in Ontario, Canada, between 1991 and 1997 was performed. Four patients who had undergone a laparoscopic cholecystectomy at the same hospital 2 months prior to a case were selected as controls. The risk of bile duct injury associated with various exposures was estimated by unconditional logistic regression. There were 28 cases and 88 controls. Emergency operation (adjusted odds ratio = 5.0; 95% confidence interval, 1.4-17.8) and failure to identify the cystic duct (adjusted odds ratio = 13.7; 95% confidence interval, 2.5-76.3) were statistically significant risk factors for operative bile duct injury. No other characteristics were independent risk factors for bile duct injury. Failure to identify the cystic duct and the emergency surgery are independent risk factors for bile duct injury.
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Affiliation(s)
- Ramin Kholdebarin
- Division of Clinical Decision Making and Health Care, Toronto General Hospital
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192
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Georgiades CP, Mavromatis TN, Kourlaba GC, Kapiris SA, Bairamides EG, Spyrou AM, Kokkinos CN, Spyratou CS, Ieronymou MI, Diamantopoulos GI. Is inflammation a significant predictor of bile duct injury during laparoscopic cholecystectomy? Surg Endosc 2008; 22:1959-64. [PMID: 18443865 DOI: 10.1007/s00464-008-9943-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Accepted: 03/27/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bile duct injuries (BDI) have been reported to occur more frequently during laparoscopic cholecystectomy (LC) compared to open cholecystectomy (OC). Several studies have demonstrated various potential predisposing factors for BDI. However, there is a controversy as to whether gallbladder inflammation is a significant predictor for BDI. Therefore, out primary aim was to investigate the relationship between inflammation and BDI at LC, and secondarily to present the management and clinical outcome of BDI. METHODS We recorded all consecutive LC performed between 1993 and 2005 in our institution by nine staff surgeons. BDI were classified according to Strasberg's classification. Simple and multivariate logistic regression analysis was performed to evaluate the association between inflammation and BDI occurrence during LC. RESULTS There were 2,184 patients. Among those, 344 had inflammation (16%). The conversion rate was 5% and was higher among male, elder patients, and those with inflammation. The BDI incidence was 0.69% (0.14% for major and 0.55% for minor injuries) and it was significantly higher in those with inflammation compared to those without inflammation (p = 0.01). In particular, the risk for BDI was almost 3.5 times higher in those with inflammation (OR = 3.61, 95% CI 1.27-10.21). Inflammation remained an independent risk factor for BDI even after adjustment for potential confounders. Among patients sustaining injury, one died and two have recurrent cholangitis. No association was observed between clinical outcome and management of BDI, time of diagnosis, sex, and inflammation. CONCLUSION We revealed that inflammation is an independent predictor of BDI occurrence during LC. Therefore, it would be advisable for surgeons to not hesitate to convert a LC to an OC in the presence of inflammation.
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Affiliation(s)
- Christos P Georgiades
- 3rd Surgical Department and Laparoscopic Unit, Evangelismos General Hospital, Athens, Greece.
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193
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Gurusamy KS, Kumar Y, Farouk M, Davidson BR. Methods of management of high-risk surgical patients with acute cholecystitis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2008. [DOI: 10.1002/14651858.cd007088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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194
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Hakamada K, Narumi S, Toyoki Y, Nara M, Oohashi M, Miura T, Jin H, Yoshihara S, Sugai M, Sasaki M. Intraoperative ultrasound as an educational guide for laparoscopic biliary surgery. World J Gastroenterol 2008; 14:2370-6. [PMID: 18416464 PMCID: PMC2705092 DOI: 10.3748/wjg.14.2370] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the efficacy of routine intraoperative ultrasound (IOUS) as a guide for understanding biliary tract anatomy, to avoid bile duct injury (BDI) after laparoscopic cholecystectomy (LC), as well as any burden during the learning period.
METHODS: A retrospective analysis was performed using 644 consecutive patients who underwent LC from 1991 to 2006. An educational program with the use of IOUS as an operative guide has been used in 276 cases since 1998.
RESULTS: IOUS was highly feasible even in patients with high-grade cholecystitis. No BDI was observed after the introduction of the educational program, despite 72% of operations being performed by inexperienced surgeons. Incidences of other morbidity, mortality, and late complications were comparable before and after the introduction of routine IOUS. However, the operation time was significantly extended after the educational program began (P < 0.001), and the grade of laparoscopic cholecystitis (P = 0.002), use of IOUS (P = 0.01), and the experience of the surgeons (P = 0.05) were significant factors for extending the length of operation.
CONCLUSION: IOUS during LC was found to be a highly feasible modality, which provided accurate, real-time information about the biliary structures. The educational program using IOUS is expected to minimize the incidence of BDI following LC, especially when performed by less-skilled surgeons.
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195
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Brekalo Z, Innocenti P, Duzel G, Liddo G, Ballone E, Simunović VJ. Ten years of laparoscopic cholecystectomy: a comparison between a developed and a less developed country. Wien Klin Wochenschr 2008; 119:722-8. [PMID: 18157606 DOI: 10.1007/s00508-007-0906-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Accepted: 08/27/2007] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the specific features and outcomes of laparoscopic cholecystectomy in two university hospitals, one in a developing country, Bosnia-Herzegovina, and the other in a well developed country, Italy. METHODS Between January 1996 and December 2005, a total of 2018 patients underwent laparoscopic cholecystectomy in Mostar Clinical Hospital, Bosnia-Herzegovina (1066) and in Chieti University Hospital, Chieti, Italy (952). Differences in patients' presentations, diagnostic protocols, medication, surgical treatment, complications and outcomes were analyzed. RESULTS The number of patients with life-threatening conditions was lower in Italy (15 or 1.5% vs. 53 or 4.9%; P<0.001), as was the use of analgesia and antibiotics (131 or 13.96% vs. 873 or 81.97%; P<0.001). Open-access biliary surgery was rare in Italy, where the vast majority of patients were operated laparoscopically; only 44 (4.41%) patients had open-access surgery, including 35 (3.61%) conversion patients. In comparison, 1669 (61%) patients in Bosnia-Herzegovina underwent open-access operations. There was a significant difference, in favor of the Italian hospital, in the number of surgical complications (8 or 0.84% vs. 40 or 3.75%; P<0.002) and also in the number of postoperative infections following surgical incision (0 or 0.0% vs. 6 or 0.56%; P<0.033). CONCLUSIONS It is encouraging for surgeons in Bosnia-Herzegovina to find that satisfactory results can be achieved in a developing country. However, the number of complications encountered in the Mostar hospital emphasizes the need for further improvement of surgical technique through better structured training combined with strict supervision of junior staff. The finding of postoperative infections in the Bosnia-Herzegovina hospital, despite that their occurrence was relatively rare, highlights the necessity for further improvement of hospital infection control.
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Affiliation(s)
- Zdrinko Brekalo
- Mostar Clinical Hospital and School of Medicine, Mostar University, Mostar, Bosnia-Herzegovina
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196
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[Anatomic variants of the biliary tree with MR Cholangiography: feasibility and surgical applications]. ACTA ACUST UNITED AC 2008; 144:505-7. [PMID: 18235361 DOI: 10.1016/s0021-7697(07)79775-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To assess the usefulness of MR Cholangiography for evaluation of anatomic variants of the biliary tree before biliary surgery. MATERIALS AND METHODS Our study group consisted of 45 consecutive patients (29 males, 16 females; mean age 57 years), who were referred for MR evaluation of malignant (n=26) and benign (n=19) cholangiopancreatic diseases. MR Cholangiography studies were independently reviewed by two radiologists. RESULTS Anatomic variants of the biliary tree were observed in 9 patients (20%); 6 variants involved the biliary confluence and 4 the cystic duct (one patient had both). Anatomic variants involved principally the right posterior duct: 1 (2,2%) drainage of right posterior duct into left hepatic duct; 2 (4,4%) triple confluence of right posterior duct, right anterior duct, and left hepatic duct, and 3 (6,6%) aberrant drainage of right posterior duct into common hepatic duct. Observed cystic duct anomalies included: 2 (7,44%) low insertion of the cystic duct into the common hepatic duct and 3 (11,1%) medial insertion of the cystic duct into the common hepatic duct. CONCLUSION MR Cholangiography accurately shows anatomic variants of the biliary tree. Noninvasive preoperative evaluation of the biliary anatomy may be important for the detection of anatomic variants that may increase the complexity of hepatic surgical procedures and biliary interventions.
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Ortega-Deballon P, Cheynel N, Benoit L, Di Giacomo G, Favre JP, Rat P. [Iatrogenic biliary injuries during cholecystectomy]. ACTA ACUST UNITED AC 2008; 144:409-13. [PMID: 18065896 DOI: 10.1016/s0021-7697(07)73996-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIM OF THE STUDY To analyze our experience with biliary injuries during cholecystectomy in order to determine associated risk factors, morbidity, and results after reconstruction. PATIENTS AND METHODS Review of the series of patients referred to our department for biliary injury during cholecystectomy over a 9-year period. Items regarding the type of lesion, risk factors, management, morbidity, and late results were recorded. RESULTS Fifteen patients were referred to our department for bile duct injury during cholecystectomy between 1997 and 2005 (14 by laparoscopy and four by laparotomy; nine women and nine men). The main surgical indication was biliary colic (n=8). Three patients were operated on in an emergency setting (for acute cholecystitis). In nine patients the gallbladder wall was inflammatory. Intraoperative cholangiography was performed in nine patients, but revealed just one injury. Lateral injury to the bile duct was the most frequent type of lesion. In nine patients, the injury was detected intraoperatively and a biliary drainage was left in place; five of them had a synchronic repair and three required later reconstruction. Nine patients had a delayed identification of biliary injury; six of them required a biliodigestive anastomosis. Two patients died, three had several episodes of acute cholangitis after reconstruction and two presented incisional hernia. CONCLUSION An inflammatory environment is the main risk factor for biliary injury during cholecystectomy. Bile duct injury is more frequent with laparoscopic cholecystectomy but can also occur with an open approach. Intraoperative cholangiography does not prevent biliary injuries nor detect them accurately. Biliary drainage can reduce morbidity for intraoperatively detected injuries and may be a sensitive approach for the surgeon with no hepatobiliary experience. Morbidity is increased in patients with delayed identification of the injury.
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Affiliation(s)
- P Ortega-Deballon
- Service de Chirurgie Digestive, Thoracique et Cancérologique, CHU du Bocage - Dijon, France.
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Iatrogenic biliary injury: 13,305 cholecystectomies experienced by a single surgical team over more than 13 years. Surg Endosc 2008; 22:1077-86. [PMID: 18210186 DOI: 10.1007/s00464-007-9740-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Revised: 10/29/2007] [Accepted: 11/28/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biliary injuries during laparoscopic cholecystectomy (LC) are complications better avoided than treated. These injuries cause long-lasting morbidity and can be fatal. The authors present their experience with biliary injury in LC during a period exceeding 13 years. METHODS Between January 1992 and December 2005, 13,305 LCs were performed at the authors' institution. The biliary injuries in these cases were recorded and analyzed retrospectively. RESULTS A total of 52 biliary injuries were identified in 13,305 LCs, for an overall incidence of 0.39%. Of these, 32 (0.24%) were diagnosed intraoperatively and 20 (0.15%) were diagnosed postoperatively. The perioperative bile duct injuries (BDIs) included 6 complete transections (5 treated by hepaticojejunostomy and 1 by primary T-tube repair (TTR), all performed by conversion to open procedure), 11 lateral BDIs (2 treated by laparoscopic choledochojejunostomy [CJ], 1 by open CJ, 5 by laparoscopic TTR, 1 by open TTR, and 2 by primary suture repair, both performed laparoscopically), 11 duct of Luschka injuries, and 4 sectoral duct injuries. The BDIs detected postoperatively included 6 patients with bilioma (treated with ultrasonography-guided aspiration), 4 patients with biliary peritonitis (requiring relaparoscopy and peritoneal lavage and drainage followed by endoscopic retrograde cholangiography [ERC] and biliary stenting), and 10 patients with persistent biliary leak-controlled biliary fistula (requiring ERC and stenting). There was no mortality related to BDI in the series. Patients with Strasberg type A/C/D injuries (46 cases) were followed 3 months to 3 years with no major complaints. Two patients with complete transection were lost to follow-up evaluation, whereas the other four patients, followed 18 months to 3 years, were asymptomatic. CONCLUSIONS According to the findings, LC is a safe procedure with an incidence of biliary injury comparable with that for open cholecystectomy. Single-center studies such as this are important to ensure that standards of surgery are maintained in the community.
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Wu YH, Liu ZS, Mrikhi R, Ai ZL, Sun Q, Bangoura G, Qian Q, Jiang CQ. Anatomical variations of the cystic duct: Two case reports. World J Gastroenterol 2008; 14:155-7. [PMID: 18176982 PMCID: PMC2673385 DOI: 10.3748/wjg.14.155] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Anatomical variations of the cystic duct often occur and may be encountered during cholecystectomy. Knowledge of the variable anatomy of the cystic duct and cysticohepatic junction is important to avoid significant ductal injury in biliary surgery. Here, we present two unusual cases with an anomalous cystic duct, namely, low lateral insertion and narrow-winding of the cystic duct. The first case was a 64-year-old man with cholelithiasis and chronic cholecystitis. During surgery, the entrance of the cystic duct was misidentified as being short and leading into the right hepatic duct. Further exploration showed multiple calculi in the right and common hepatic ducts. Cholecystectomy was completed, followed by T-tube drainage of the common and right hepatic ducts. Postoperative T-tube cholangiography demonstrated that the two T tubes were respectively located in the cystic and common hepatic duct. Six weeks later, the retained stones in the distal choledochus were extracted by cholangioscopy through the sinus tract of the T-tube. The second case was a 41-year-old woman, in which, preoperative endoscopic retrograde cholangiopancreatography (ERCP) revealed a long cystic duct, with a narrow and curved-in lumen. The patient underwent open cholecystectomy. Both patients were cured. The authors propose that preoperative ERCP or magnetic resonance cholangiopancreatography (MRCP), and intraoperative cholangiography or cholangioscopy constitute a useful and safe procedure for determining anatomical variations of the cystic duct.
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Factors Influencing Frequency of Conversion During Laparoscopic Cholecystectomy. POLISH JOURNAL OF SURGERY 2008. [DOI: 10.2478/v10035-008-0003-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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