Complications Of Cholecystectomy: Incidence, Clinical Manifestations, and Diagnosis

Artificial intelligence for phase recognition in complex laparoscopic cholecystectomy

BACKGROUND

The potential role and benefits of AI in surgery has yet to be determined. This study is a first step in developing an AI system for minimizing adverse events and improving patient's safety. We developed an Artificial Intelligence (AI) algorithm and evaluated its performance in recognizing surgical phases of laparoscopic cholecystectomy (LC) videos spanning a range of complexities.

METHODS

A set of 371 LC videos with various complexity levels and containing adverse events was collected from five hospitals. Two expert surgeons segmented each video into 10 phases including Calot's triangle dissection and clipping and cutting. For each video, adverse events were also annotated when present (major bleeding; gallbladder perforation; major bile leakage; and incidental finding) and complexity level (on a scale of 1-5) was also recorded. The dataset was then split in an 80:20 ratio (294 and 77 videos), stratified by complexity, hospital, and adverse events to train and test the AI model, respectively. The AI-surgeon agreement was then compared to the agreement between surgeons.

RESULTS

The mean accuracy of the AI model for surgical phase recognition was 89% [95% CI 87.1%, 90.6%], comparable to the mean inter-annotator agreement of 90% [95% CI 89.4%, 90.5%]. The model's accuracy was inversely associated with procedure complexity, decreasing from 92% (complexity level 1) to 88% (complexity level 3) to 81% (complexity level 5).

CONCLUSION

The AI model successfully identified surgical phases in both simple and complex LC procedures. Further validation and system training is warranted to evaluate its potential applications such as to increase patient safety during surgery.

Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5675 laparoscopic cholecystectomies

PURPOSE

The main sources of post-cholecystectomy bile leakage (PCBL) not involving major duct injuries are the cystic duct and subvesical/hepatocystic ducts. Of the many studies on the diagnosis and management of PCBL, few addressed measures to avoid this serious complication. The aim of this study was to examine the causes and mechanisms leading to PCBL and to evaluate the effects of specific preventative strategies.

METHODS

A prospectively maintained database of 5675 consecutive laparoscopic cholecystectomies was analysed. Risk factors for post-cholecystectomy bile leakage were identified and documented and technical modifications and strategies were adopted to prevent this complication. The incidence, causes and management of patients who suffered bile leaks were studied and their preoperative characteristics, operative data and postoperative outcomes were compared with patients where potential risks were identified and PCBL avoided and with the rest of the series.

RESULTS

Twenty-five patients (0.4%) had PCBL (7 expected and less than half requiring reintervention): 11 from cystic ducts (0.2%), 3 from subvesical ducts (0.05%) and 11 from unconfirmed sources (0.2%). The incidence of cystic duct leakage was significantly lower with ties (0.15%) than with clips (0.7%). Fifty-two percent had difficulty grades IV or V, 36% had empyema or acute cholecystitis and 16% had contracted gallbladders. Twelve patients required 17 reinterventions before PCBL resolved; 7 percutaneous drainage, 6 ERCP and 4 relaparoscopy. The median hospital stay was 17 days with no mortality. Hepatocystic ducts were encountered in 72 patients (1.3%) and were secured with loops (54.2%), ties (25%) or sutures (20.8%) with no PCBL. Eighteen sectoral ducts were identified and secured.

CONCLUSION

Ligation of the cystic duct reduces the incidence of PCBL resulting from dislodged endoclips. Careful blunt dissection in the proper anatomical planes avoiding direct or thermal injury to subvesical and sectoral ducts and a policy of actively searching for hepatocystic ducts during gallbladder separation to identify and secure them can reduce bile leakage from such ducts.

Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy

BACKGROUND

BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSIONS

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy

BACKGROUND

Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across six broad topics around cholecystectomy directed by a steering group and subject experts from five surgical societies (SAGES, AHPBA IHPBA, SSAT, and EAES). Evidence-based recommendations were formulated using the GRADE methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the Guideline Development Group (GDG) and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSION

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

Major Vascular Injury Secondary to Laparoscopy

Laparoscopic procedures are now performed by almost all surgeons. Major vascular injuries secondary to laparoscopy, which were anecdotal before 1990, are now seen more often. This article focuses on the authors' experience with arterial trauma related to laparoscopic procedures.

Their hospital is a regional center with a population base of 350,000 and six peripheral hospitals. Between August 1994 and March 1996, 6 patients inadvertently sustained major vascular injuries in the course of laparoscopic surgery. These incidents were shared by 5 different surgeons in four different hospitals.

Three patients sustained intestinal perforation and aortic transection during laparoscopic cholecystectomy, two related to insertion of the veress needle and one to insertion of a trocar. Two of these injuries were repaired by end-to-end anastomosis, while the third one required a synthetic aortic graft. A fourth patient sustained an aortic perforation during laparoscopic tubal ligation. The fifth and sixth patients had an iliac artery perforation-one during laparoscopic appendectomy and the other during abdominal hysterectomy. Blood lost in these patients varied between 3 and 26 liters, and the length of hospital stay varied from six days to three months. No deaths were reported.

Major vascular injuries may arise during laparoscopic procedures. The authors' experience suggests these incidents are underreported. By understanding the way they occur, they believe these injuries are preventable.

Iatrogenic injuries of the extrahepatic biliary system

BACKGROUND

Iatrogenic traumatic extrahepatic biliary tract injuries though rarely occur; they can lead to exceedingly morbid complications. The aim of this study was to evaluate the management strategies and outcomes of patients presented with iatrogenic bile duct injuries.

METHODS

This is a retrospective study. Over 19 y, 124 patients were managed for iatrogenic biliary injuries at our institution. The data related to the etiology of biliary tract injury, symptoms of injury, laboratory and radiologic studies, injury-to-diagnosis time, type of biliary tract injury, injury management, hospitalization time, and postoperative complications were reviewed.

RESULTS

The main clinical presentations were jaundice or recurrent cholangitis in 64 (51.61%) patients, followed by bile peritonitis in 34 (56.67%) and biliary fistula in 26 (43.33%) patients. Only in 23 (18.54%) cases, the injury was recognized intraoperatively. The most frequent surgical procedure was open cholecystectomy in 81 (65.32%) of 124 patients. The remaining patients were operated on laparoscopically. Good results were achieved in 99 of 101 patients with direct suture repair including hepaticojejunostomy, choledocoduodenostomy, and choledochocholedochostomy (98.02% success rate) at the first attempt. Three cases (2.97%) of biliary strictures after direct suture technique and four (3.96%) cases of postoperative mortalities were detected. The mortality rate was mostly affected by male gender, advanced age, and existence of bile peritonitis. Totally, 111 (89.52%) patients are still alive with a mean follow-up time of 78 ± 38 (2-230) mo.

CONCLUSIONS

Biliary injuries can be sometimes life-threatening complications. A successful repair may provide patients with a lifelong relief from symptoms, whereas a failed repair may result in recurrent biliary obstruction, reoperation, and even death.

Cholecystectomy in octogenarians: be careful

Cholecystectomy is the standard treatment for symptomatic gallstone or acute cholecystitis, and a growing number of elderly patients are undergoing resection. The aim of this study is to evaluate the clinical outcome of cholecystectomy in elderly patients. We retrospectively reviewed the medical records of 337 patients with symptomatic gallstone or acute cholecystitis who underwent cholecystectomies between January 2011 and June 2013. Perioperative data were compared between octogenarians and younger patients. A subgroup undergoing cholecystectomy for acute cholecystitis (n = 146, 43.3 %) was further analyzed. The octogenarian group included 34 patients (10.1 %), while the younger patient group included 303 patients (89.9 %). The octogenarian group was associated with higher rates of comorbidities and acute cholecystitis. The octogenarian group had significantly low laparoscopic completed rates, high postoperative complication rates, and longer postoperative hospital stays. Among the acute cholecystitis group, 24 patients (16.4 %) were octogenarians and 122 patients (83.6 %) were younger patients. No significant difference was found in the morbidity and postoperative hospital stay between the two groups. Only one patient (0.3 %), an octogenarian, died of pneumonia. Cholecystectomy for symptomatic gallstone or acute cholecystitis can be safely performed even in octogenarians. However, care should be taken because they have comorbidities and limited functional reserves.

Detection and localization of bile duct leaks after cholecystectomy using Gd-EOB-DTPA-enhanced MR cholangiography: retrospective study of 16 patients

OBJECTIVE

To determine if gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance (MR) cholangiography can detect and localize bile duct leaks in postcholecystectomy patients.

MATERIAL AND METHODS

Four blinded independent radiologists performed a retrospective review of 16 consecutive patients who underwent MR cholangiography with intravenous Gd-EOB-DTPA for the evaluation of possible biliary leak. Image quality, ductal opacification, and presence and location of any bile leak were evaluated. An independent observer determined the criterion standard using a consensus of all chart, clinical, and imaging findings.

RESULTS

All 6 bile leaks confirmed at endoscopic retrograde cholangiopancreatography were diagnosed by all reviewers (sensitivity, 100%). Of the 10 patients with no leak, only one reader incorrectly diagnosed a bile leak in a single case (specificity, 98%). The accuracy for detection of the site of leak with Gd-EOB-DTPA-enhanced MR cholangiography was 80%.

CONCLUSION

Gadolinium-EOB-DTPA-enhanced MR can detect bile leaks with a high sensitivity and specificity.

Radiologic assessment of hepatobiliary surgical complications

The complexity of hepatobiliary procedures continues to evolve at a rapid rate, with an increasing number of living donor liver transplants and extensive cancer resections being performed. The associated complications are a significant cause of morbidity and mortality, and are often complex injuries, involving both vascular and biliary structures. In this paper we describe the complications associated with laparoscopic cholecystectomy, liver transplant surgery, and hepatic resection. Focus is on the classical imaging appearances, imaging modality options, and varying management strategies for these injuries, to show how the radiologist's role is vital in ensuring the correct diagnosis is made and the appropriate treatment is instigated.

Laparoscopic cholecystectomy without handling the cystic artery: a new approach to minimize complications

INTRODUCTION

Although laparoscopy has now become the procedure of choice for removal of gallbladder, complications especially injury to cystic artery and ducts are thought to be higher. We describe a technique that avoids handling and injury of cystic artery and resultant duct injuries. The video length is 2 minutes 13 seconds.

MATERIALS AND METHODS

From October 7, 2005, to December 31, 2010, 17 patients were successfully operated by the cystic artery sparing technique. In this technique, dissection begins distal to cystic lymph node on the gallbladder wall using hook cautery, thereby clears the Calot's triangle without even touching the cystic artery. This maneuver eliminates the risk of injuring thus causing bleeding and any subsequent complications. Age, sex, and operative outcomes including follow-ups were evaluated.

RESULTS

Age of the patients ranged from 3.4 years to 16 years with an average of 10.12 years. Males were predominant (10:7). Average operative time was 40 minutes. There were no intraoperative or immediate postoperative complications. Patients were allowed feeding 4-6 hours after operation and discharged the following morning. Patients were asked to come for follow-up at 1 week, 1 month, 3 months, 6 months, and 1 year and thereafter yearly. Follow-up period ranged from 6 months to 5 years. There were no operation-related complications other than minor abdominal pain in 3 patients and port-site pain in 2 patients which resolved on conservative treatments.

CONCLUSION

During laparoscopic cholecystectomy, if handling of the main cystic artery is avoided then complications of hemorrhage and bile duct injuries can be minimized.

Open, small-incision, or laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis. An overview of Cochrane Hepato-Biliary Group reviews

BACKGROUND

Patients with symptomatic cholecystolithiasis are treated by three different techniques of cholecystectomy: open, small-incision, or laparoscopic. There is no overview on Cochrane systematic reviews on these three interventions.

OBJECTIVES

To summarise Cochrane reviews that assess the effects of different techniques of cholecystectomy for patients with symptomatic cholecystolithiasis.

METHODS

The Cochrane Database of Systematic Reviews (CDSR) was searched for all systematic reviews evaluating any interventions for the treatment of symptomatic cholecystolithiasis (Issue 4 2008).

MAIN RESULTS

Three systematic reviews that included a total of 56 randomised trials with 5246 patients are included in this overview of reviews. All three reviews used identical inclusion criteria for trials and participants, and identical methodological assessments.Laparoscopic versus small-incision cholecystectomy Thirteen trials with 2337 patients randomised studied this comparison. Bias risk was relatively low. There was no significant difference regarding mortality or complications. Total complications of laparoscopic and small-incision cholecystectomy were high, ie, 17.0% and 17.5%. Total complications (risk difference, random-effects model -0.01 (95% confidence interval (CI) -0.07 to 0.05)), hospital stay (mean difference (MD), random-effects -0.72 days (95% CI -1.48 to 0.04)), and convalescence were not significantly different. Trials with low risk of bias showed a quicker operative time for small-incision cholecystectomy (MD, low risk of bias considering 'blinding', random-effects model 16.4 minutes (95% CI 8.9 to 23.8)) while trials with high risk of bias showed no statistically significant difference.Laparoscopic versus open cholecystectomy Thirty-eight trials with 2338 patients randomised studied this comparison. Bias risk was high. Laparoscopic cholecystectomy patients had a shorter hospital stay (MD, random-effects model -3 days (95% CI -3.9 to -2.3)) and convalescence (MD, random-effects model -22.5 days (95% CI -36.9 to -8.1)) compared with open cholecystectomy but did not differ significantly regarding mortality, complications, and operative time.Small-incision versus open cholecystectomy Seven trials with 571 patients randomised studied this comparison. Bias risk was high. Small-incision cholecystectomy had a shorter hospital stay (MD, random-effects model -2.8 days (95% CI -4.9 to -0.6)) compared with open cholecystectomy but did not differ significantly regarding complications and operative time.

AUTHORS' CONCLUSIONS

No statistically significant differences in the outcome measures of mortality and complications have been found among open, small-incision, and laparoscopic cholecystectomy. There were no data on symptom relief. Complications in elective cholecystectomy are high. The quicker recovery of both laparoscopic and small-incision cholecystectomy patients compared with patients on open cholecystectomy justifies the existing preferences for both minimal invasive techniques over open cholecystectomy. Laparoscopic and small-incision cholecystectomies seem to be comparable, but the latter has a significantly shorter operative time, and seems to be less costly.

Laparoscopic treatment of stone recurrence in a gallbladder remnant: report of an additional case and literature review

Cholecystectomy is an effective treatment of gallstones. Nevertheless, recurrence of biliary symptoms following cholecystectomy, either laparotomic or laparoscopic, is quite common. Causes are either biliary or extrabiliary. Symptoms of biliary origin chiefly depend on bile duct residual stones or strictures. Rarely, they depend on stone recurrence in a gallbladder remnant. Diagnosis of gallstone recurrence in gallbladder remnant is difficult, mainly arising from ultrasonography, computed tomography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography.Incomplete gallbladder removal may be either voluntary or inadvertent: in the first case, it is performed to remove gallstones without dissecting a difficult Calot's triangle or an excessively bleeding posterior wall of gallbladder caused by liver cirrhosis. Available data do not support the hypothesis that laparoscopic cholecystectomy entails an increased incidence of this condition, in spite of some opposite opinions. Treatment of lithiasis in gallbladder remnants is chiefly surgical. Although technically demanding, completion cholecystectomy can be safely performed in a laparoscopic way. We report a case of stone relapse in a gallbladder remnant, discovered 16 years following laparoscopic cholecystectomy and successfully treated by laparoscopic completion cholecystectomy. We furthermore review literature data in order to ascertain whether recent large diffusion of laparoscopic surgery causes an increase of such cases.

Long-term prognosis of patients after endoscopic sphincterotomy for choledocholithiasis

INTRODUCTION

The aims of the present study were to clarify the long-term prognosis of endoscopic sphincterotomy (EST) for choledocholithiasis and to evaluate the need for cholecystectomy after EST.

METHODS

Between 1993 and 2007, 262 patients who underwent successful EST for choledocholithiasis were followed up for more than 6 months). Eighteen patients had previously undergone cholecystectomy (Group A), 129 had a calculous gallbladder (GB) and underwent cholecystectomy after EST (Group B), 46 had a calculous GB in situ (Group C), and 69 had an acalculous GB in situ (Group D). Late complications, including recurrence of choledocholithiasis, acute cholecystitis and biliary carcinoma, were evaluated.

RESULTS

Of the 262 patients, late complications occurred in 34 patients (13.0%) and recurrence of choledocholithiasis occurred in 29 patients (11.1%). The rate of late complications was higher in Group C (23.9%) than in Group B (7.8%) (P < 0.001). The rate of recurrent choledocholithiasis was higher in Group C (17.4%) than in Group B (7.8%) (P < 0.05). Univariate analysis indicated that pneumobilia after EST was associated with the recurrence of choledocholithiasis (P < 0.001). Acute cholecystitis occurred in eight (7.0%) of 115 patients with intact GB. A gallbladder carcinoma was found after EST. Late complications were not serious and endoscopically or surgically manageable.

CONCLUSIONS

EST for choledocholithiasis is safe and effective. Cholecystectomy after EST is recommended in patients with calculous GB, but is not necessary in patients with acalculous GB. Pneumobilia was associated with the recurrence of choledocholithiasis.

Systematic review: open, small-incision or laparoscopic cholecystectomy for symptomatic cholecystolithiasis

BACKGROUND

Laparoscopic cholecystectomy has become the method of choice for gallbladder removal, although evidence of superiority over open and small-incision cholecystectomy is lacking.

AIM

To compare the effects of open, small-incision and laparoscopic cholecystectomy techniques for patients with symptomatic cholecystolithiasis.

METHODS

We conducted updated searches until January 2007 in multiple databases. We assessed bias risk.

RESULTS

Fifty-nine trials randomized 5556 patients. No significant differences in primary outcomes (mortality and complications) were found among all three techniques. Both minimal invasive techniques show advantages over open cholecystectomy in terms of convalescence. Small-incision cholecystectomy showed shorter operative time compared with laparoscopic cholecystectomy (random effects, weighted mean difference, 16.4 min; 95% confidence interval, 8.9-23.8), but the two techniques did not differ regarding hospital stay and conversions.

CONCLUSIONS

No significant differences in mortality and complications were found among all three techniques. Laparoscopic cholecystectomy and small-incision cholecystectomy are preferred over open cholecystectomy for quicker convalescence. Laparoscopic cholecystectomy and small-incision cholecystectomy show no clear differences on patient outcomes.

A 14-year Analysis of Laparoscopic Cholecystectomy

BACKGROUND

Contraindications to laparoscopic cholecystectomy diminished over the last decade but still conversion is about 5% to 6% in elective cases and higher in acute cholecystitis. The aim of this study was to analyze the reason for conversion in all patients operated on in our department and to create strategies for critical moments, which may need conversion.

METHODS

From 1990 to 2004, operations have been divided in 3 groups: primary open cholecystectomy (OC), laparoscopic cholecystectomy, and conversion. These groups were analyzed regarding the reason for conversion and postoperative complications.

RESULTS

Of the 5376 patients who underwent cholecystectomy, 327 had concomitant OC without further evaluation and 544 OC (11%). Of the 4505 patients (3159 women, 1346 men) who were all started by laparoscopy 5.4% [245 patients (123 women, 3.9%; 122 men, 9.1%; P<0.05)] were converted to OC. Acute cholecystitis (29.4%), difficulties with the anatomy in Calot's triangle (17.1%), and adhesions (14.3%) have been the main reasons for conversion beside difficulties in establishing pneumoperitoneum (3.7%).

CONCLUSIONS

The key scenes for conversion are the creation of the pneumoperitoneum, intra-abdominal adhesions, and difficulties in Calot's triangle, especially in acute cholecystitis. Conversion should not be seen as a complication.

Laparoscopic versus small-incision cholecystectomy for patients with symptomatic cholecystolithiasis

BACKGROUND

Cholecystectomy is one of the most frequently performed operations. Open cholecystectomy has been the gold standard for over 100 years. Small-incision cholecystectomy is a less frequently used alternative. Laparoscopic cholecystectomy was introduced in the 1980s.

OBJECTIVES

To compare the beneficial and harmful effects of laparoscopic versus small-incision cholecystectomy for patients with symptomatic cholecystolithiasis.

SEARCH STRATEGY

We searched TheCochrane Hepato-Biliary Group Controlled Trials Register (6 April 2004), The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), Web of Science (1988 to January 2004), and CINAHL (1982 to January 2004) for randomised trials.

SELECTION CRITERIA

All published and unpublished randomised trials in patients with symptomatic cholecystolithiasis comparing any kind of laparoscopic cholecystectomy versus small-incision or other kind of minimal incision open cholecystectomy. No language limitations were applied.

DATA COLLECTION AND ANALYSIS

Two authors independently performed selection of trials and data extraction. The methodological quality of the generation of the allocation sequence, allocation concealment, blinding, and follow-up was evaluated to assess bias risk. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate.

MAIN RESULTS

Thirteen trials randomised 2337 patients. Methodological quality was relatively high considering the four quality criteria. Total complications of laparoscopic and small-incision cholecystectomy are high: 26.6% versus 22.9%. Total complications (risk difference, random-effects -0.01, 95% confidence interval (CI) -0.07 to 0.05), hospital stay (weighted mean difference (WMD), random-effects -0.72 days, 95% CI -1.48 to 0.04), and convalescence were not significantly different. High-quality trials show a quicker operative time for small-incision cholecystectomy (WMD, high-quality trials 'blinding', random-effects 16.4 minutes, 95% CI 8.9 to 23.8) while low-quality trials show no significant difference.

AUTHORS' CONCLUSIONS

Laparoscopic and small-incision cholecystectomy seem to be equivalent. No differences could be observed in mortality, complications, and postoperative recovery. Small-incision cholecystectomy has a significantly shorter operative time. Complications in elective cholecystectomy are prevalent.

Laparoscopic cholecystectomy: a report from a single center

AIM

To review and evaluate our experience in laparoscopic cholecystectomy.

METHODS

A retrospective analysis was performed on data collected during a 13-year period (1992-2005) from 1220 patients who underwent laparoscopic cholecystectomy.

RESULTS

Mortality rate was 0%. The overall morbidity rate was 5.08% (n = 62), with the most serious complications arising from injuries to the biliary tree and the cystic artery. In 23 (1.88%) cases, cholecystectomy could not be completed laparoscopically and the operation was converted to an open procedure. Though the patients were scheduled as day-surgery cases, the average duration of hospital stay was 2.29 d, as the complicated cases with prolonged hospital stay were included in the calculation.

CONCLUSION

Laparoscopic cholecystectomy is a safe, minimally invasive technique with favorable results for the patient.

Gallstone disease: Surgical aspects of symptomatic cholecystolithiasis and acute cholecystitis

Indications for cholecystectomy are limited to clearly symptomatic gallstones. Relatively high failure rates of pain relief are probably caused by incorrect selection of patients for the operation. Contraindications for (laparoscopic) cholecystectomy are related to anaesthesiological considerations. Laparoscopic cholecystectomy was accepted by consensus as the gold standard within 5 years of its introduction. Nevertheless, both the classical open and small-incision cholecystectomies are safe alternatives, and superiority of any one of the three techniques over the others has not been proven. Primary outcome measures (mortality, complications, and symptom relief) seem to be equal for the three techniques. Acute cholecystitis is a complication of gallstones. Generally it is recommended that early cholecystectomy be performed, as delayed cholecystectomy is associated with longer total hospital stay and convalescence due to recurrent cholecystitis episodes. Cholecystostomy is an alternative technique for patients unfit for general anaesthesia. Reported complication and conversion rates in cholecystectomy for acute cholecystitis vary, but are higher than for symptomatic cholecystolithiasis. New developments--such as robot-assisted surgery--are expected to have a significant impact in the near future.

POSSUM scoring for laparoscopic cholecystectomy in the elderly

BACKGROUND

Physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) scoring is a validated scoring system in the audit of surgical outcomes; however, evaluation of this system has mostly been applied to open surgical techniques. The present study examines the validity of POSSUM in predicting morbidity and mortality in patients undergoing laparoscopic cholecystectomy (LC) with the recognized risk factor for postoperative mortality of advanced age.

METHODS

All patients aged 80 years or over undergoing LC in one surgical unit between January 1993 and December 1999 were identified from the surgical operations database of the hospital. Case-note review was used to collate data in terms of clinical and operative factors as described in POSSUM. Observed/POSSUM estimated (O/E) ratio of morbidity and 30-day mortality were calculated.

RESULTS

Laparoscopic cholecystectomy was performed in 76 patients aged 80 years or over during the study period. Of these patients, case notes for 70 patients (92%) were available for review. Median (range) age was 83 years (80-93 years) and median (range) American Society of Anesthesiologists score was 2 (2-4). Twenty-six (34%) of 70 patients underwent cholecystectomy during an acute admission. The mean physiology severity score was 23 and operative severity score, 8. A significant postoperative morbidity was observed in 15 (22%) of 70 patients. There was no 30-day mortality. Using exponential analysis, POSSUM predicted morbidity in 15 patients and mortality in seven patients. Thus, O/E ratios for morbidity and mortality were 1 and 0, respectively.

CONCLUSION

POSSUM scoring performs well in predicting morbidity, but overpredicts mortality, after LC in patients aged over 80 years. An assessment of its application to other laparoscopic procedures merits evaluation.

Bursting Tension of Medium and Large Canine Arteries Sealed with Ultrasonic Energy or Suture Ligation

OBJECTIVE

To compare bursting tension of arteries > or =3 mm in diameter sealed with ultrasonic energy (UE) with arteries ligated with suture.

STUDY DESIGN

Experimental, nested factorial design.

SAMPLE POPULATION

Vascular segments from canine cadavers.

METHODS

Arterial segments (12) were collected from each of 16 canine cadavers and equally divided into 2 groups based on vessel diameter (medium, 3.0- < 4.5 mm; large, 4.5 - < or =6.0 mm). Arterial specimens (3) from each group were sealed with either UE (Harmonic Scalpel, HS, power level 3) or suture ligation. The mean bursting pressure and tension were determined and compared.

RESULTS

Bursting tension was significantly higher (P< .0001) for sutured arteries than UE-occluded arteries, irrespective of size. Bursting tension was significantly higher (P=.0013) for medium than large UE-occluded arteries, whereas there was no difference associated with size for ligated arteries. UE energy failed to seal 1 medium artery and 7 large arteries. Compared with normal blood pressure, bursting pressures were 3.5 times greater for sutured arteries irrespective of size, 1.8 times greater for medium UE-occluded arteries, and approached normal blood pressure for large UE-occluded arteries.

CONCLUSION

At the power level tested, UE should not be used to seal arteries > 4.5 mm in diameter. Suture provided an optimal seal for arteries < or =6.0 mm in diameter.

CLINICAL RELEVANCE

Use of UE to occlude arteries during laparoscopic surgery is advantageous because only 1 instrument is required to simultaneously cut and coagulate tissue, but care should be exercised where large arteries might be encountered.

Early biliary complications of laparoscopic cholecystectomy: evaluation on T2-weighted MR cholangiography in conjunction with mangafodipir trisodium-enhanced 3D T1-weighted MR cholangiography

OBJECTIVE

Our aim was to assess preliminary experience with combined conventional T2-weighted and mangafodipir trisodium (MnDPDP)-enhanced T1-weighted MR cholangiography in evaluating early biliary complications of laparoscopic cholecystectomy.

SUBJECTS AND METHODS

Conventional heavily T2-weighted MR cholangiography with MnDPDP-enhanced T1-weighted MR cholangiography and ERCP were performed in seven patients with high clinical suspicion of biliary complications after laparoscopic cholecystectomy. The final diagnoses of complications were classified according to the presence and degree of bile duct injury, bile leakage, and retained stones.

RESULTS

The diagnoses on MR cholangiography were as follows: complete transection and occlusion of the common bile duct with bile leakage (n = 3), partial strictures of the common bile duct with bile leakage (n = 1), cystic duct leakage (n = 1), partial ligation of an aberrant right hepatic duct (n = 1), and hemorrhage without biliary complication (n = 1). The final diagnoses at surgery (n = 2) and ERCP (n = 5) were as follows: complete transection and occlusion of the common bile duct with bile leakage (n = 2), partial strictures of the common bile duct with bile leakage (n = 2), cystic duct leakage (n = 1), partial ligation of an aberrant right hepatic duct (n = 1), and hemorrhage without biliary complication (n = 1). MR cholangiography accurately yielded the same findings as the final diagnoses, except in one case with partial stricture of the bile duct with bile leakage (overdiagnosed as complete occlusion on MR cholangiography).

CONCLUSION

Combined conventional T2-weighted and MnDPDP-enhanced T1-weighted MR cholangiography may eliminate the use of other studies for the imaging of biliary complications after cholecystectomy if this preliminary data can be verified in a larger study.

Imaging patients with "post-cholecystectomy syndrome": an algorithmic approach

AIM

To assess the role of ultrasound (US), magnetic resonance cholangiopancreatography (MRCP) and liver function tests (LFTs) in the evaluation of selected patients presenting with late post-cholecystectomy syndrome (PCS) who were referred for endoscopic retrograde cholangiopancreatography (ERCP).

MATERIALS AND METHODS

In a retrospective study a final group of 42 patients with PCS referred for diagnostic ERCP underwent MRCP and abdominal US. ERCP and MRCP images were assessed for bile duct diameters and the presence of strictures and stones. A common bile duct (CBD) diameter of < 10mm was considered normal, whereas > or = 10mm was considered abnormal on US. Findings were correlated to LFTs with contingency table results performed for single techniques and combination of methods.

RESULTS

In total 14 stones and one stricture were seen. US had a high negative predictive value (86.4%). MRCP had a sensitivity of 100% and specificity of 88.0%. ERCP is the most accurate test but failed in 11 patients, five of whom had a stone. The accuracy of US and LFTs increases to 93.8% if test results agree in either negative or positive outcome.

CONCLUSION

US and LFTs are first-line tests in PCS. If the CBD on US is > or = 10mm, but no cause is identified, MRCP should be performed. If US and LFTs are normal then MRCP is not necessary. The availability of LFTs raises the diagnostic value of imaging.

Value of MR Cholangiography in Patients with Iatrogenic Bile Duct Injury After Cholecystectomy

OBJECTIVE

Our aim was to determine the diagnostic role of MR cholangiography in the evaluation of iatrogenic bile duct injuries after cholecystectomy.

SUBJECTS AND METHODS

Nineteen patients (14 women and five men; mean age, 47 years; age range, 24-75 years) with suspected bile duct injury as a result of laparoscopic cholecystectomy (17 patients) and open cholecystectomy (two patients) underwent MR cholangiography. MR images were evaluated for bile duct discontinuity, presence or absence of biliary dilation, stricture, excision injury, free fluid, and collections. Bile duct excision and stricture were classified according to the Bismuth classification. Final diagnosis was made on the basis of findings at surgery in 15 patients, on percutaneous transhepatic cholangiography (PTC) in one patient, and on endoscopic retrograde cholangiography (ERC) and at clinical follow-up until hospital discharge in the remaining three patients.

RESULTS

In 16 patients, injury of the bile duct was observed. Two patients had Bismuth type I injury; one patient, type II injury; 11 patients, type III injury; and one patient each, type IV and V injuries. Three patients showed findings suggestive of leakage from the cystic duct remnant, which were confirmed on ERC.

CONCLUSION

MR cholangiography is an accurate diagnostic technique in the identification of postoperative bile duct injuries. This technique allows exploration above and below the level of obstruction, a resource provided by neither ERC nor PTC, and allows the accurate classification of these injuries, which is essential for treatment planning.

Outcome of laparoscopic cholecystectomy in patients 80 years and older

Advanced age is associated with an increase in postoperative complications. This study assesses the indications and outcome for laparoscopic cholecystectomy (LC) in patients aged 80 years or older. Consecutive, unselected patients aged 80 years or over undergoing LC between 1991 and 2000 were included. A retrospective case review enabled analysis of clinical and operative factors together with in-hospital morbidity, 30-day mortality, and duration of hospital stay. A series of 117 patients, 79 women and 38 men with a median age of 83 years (range 80-93 years), underwent LC. Indications for LC were chronic cholecystitis in 62 (53%) patients, acute cholecystitis in 28 (24%), gallstone pancreatitis in 12 (10%), and other conditions in 15 (13%). Six (5%) patients required conversion to an open procedure. Overall, 26 (22%) patients developed a postoperative complication. There were no bile leaks or bile duct injuries. One patient, with gangrenous cholecystitis, died after LC. The median postoperative hospital stay was 3 days (range 1-31 days). LC can be performed safely with low morbidity in patients over age 80 years.

Evaluation of a visual risk communication tool: effects on knowledge and perception of blood transfusion risk

BACKGROUND

Effective risk communication in transfusion medicine is important for health-care consumers, but understanding the numerical magnitude of risks can be difficult. The objective of this study was to determine the effect of a visual risk communication tool on the knowledge and perception of transfusion risk.

STUDY DESIGN AND METHODS

Laypeople were randomly assigned to receive transfusion risk information with either a written or a visual presentation format for communicating and comparing the probabilities of transfusion risks relative to other hazards. Knowledge of transfusion risk was ascertained with a multiple-choice quiz and risk perception was ascertained by psychometric scaling and principal components analysis.

RESULTS

Two-hundred subjects were recruited and randomly assigned. Risk communication with both written and visual presentation formats increased knowledge of transfusion risk and decreased the perceived dread and severity of transfusion risk. Neither format changed the perceived knowledge and control of transfusion risk, nor the perceived benefit of transfusion. No differences in knowledge or risk perception outcomes were detected between the groups randomly assigned to written or visual presentation formats.

CONCLUSION

Risk communication that incorporates risk comparisons in either written or visual presentation formats can improve knowledge and reduce the perception of transfusion risk in laypeople.

Hydro-Jet-assisted laparoscopic cholecystectomy: a prospective randomized clinical study

BACKGROUND

A new dissection technique with high-pressure water stream (Hydro-Jet) has recently been applied for selective dissection during various surgical procedures. The aim of this study was to compare Hydro-Jet with the conventional technique for laparoscopic cholecystectomy.

METHODS

Eighty patients were randomized to undergo laparoscopic cholecystectomy with standard (n = 40) or Hydro-Jet-assisted (n = 40) dissection techniques. The rates of intraoperative complications, including blood loss and injury to the adjacent organs, were compared between the groups. The versatility of this technique and the features of surgical dissection were also evaluated and compared.

RESULTS

Laparoscopic cholecystectomy was successfully completed in all subjects. The mean operative times were 78 minutes (range, 52-120 minutes) and 81 minutes (range, 45-135 minutes) for Hydro-Jet versus conventional dissection, respectively (P = not significant). Complications included gallbladder perforation in 15% and 30% (P <.1) and liver laceration in 0% and 10% (P <.04) with Hydro-Jet and conventional techniques, respectively. Increased hemorrhage from the gallbladder bed that necessitated fulguration occurred in 12 patients with the conventional technique as compared with none in the Hydro-Jet group (P <.001). Hydro-Jet resulted in a selective dissection of connective tissue preserving blood vessels and the cystic duct. The continuous water flow allowed a clear view for the operator, and the dissection was performed in a relatively bloodless field. The ease of blunt dissection with the bent-tip dissector represents another advantage.

CONCLUSION

This study shows that Hydro-Jet dissection represents an excellent alternative to the conventional technique for laparoscopic cholecystectomy. The improved anatomic dissection combined with an almost bloodless operating field as the result of continuous water flow decreased the rate of dissection-related complications.

Iatrogenic bile duct injury: the scourge of laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) has become the first-line surgical treatment of calculous gall-bladder disease and the benefits over open cholecystectomy are well known. In the early years of LC, the higher rate of bile duct injuries compared with open cholecystectomy was believed to be due to the 'learning curve' and would dissipate with increased experience. The purpose of the present paper was to review a tertiary referral unit's experience of bile duct injuries induced by LC.

METHODS

A retrospective analysis was performed on all patients referred for management of an iatrogenic bile duct injury from 1981 to 2000. For injuries sustained at LC, details of time between LC and recognition of the injury, time from injury to definitive repair, type of injury, use of intraoperative cholangiography (IOC), definitive repair and postoperative outcome were recorded. The type of injury sustained at open cholecystectomy was similarly classified to allow the severity of injury to be compared.

RESULTS

There were 131 patients referred for management of an iatrogenic bile duct injury that occurred at open cholecystectomy (n = 62), liver resection (n = 5) and at LC (n = 64). Only 39% of bile duct injuries were recognized at the time of LC. Following conversion to open operation, half the subsequent procedures were considered inappropriate. When the injury was not recognized during LC, 70% of patients developed bile leak/peritonitis, almost half of whom were referred, whereas the rest underwent a variety of operative procedures by the referring surgeon. The remainder developed jaundice or abnormal liver function tests and cholangitis. An IOC was performed in 43% of cases, but failed to identify an injury in two-thirds of patients. The bile duct injuries that occurred at LC were of greater severity than with open cholecystectomy. Following definitive repair, there was one death (1.6%). Ninety-two per cent of patients had an uncomplicated recovery and there was one late stricture requiring surgical revision.

CONCLUSIONS

The early prediction that the rate of injury during LC would decline substantially with increased experience has not been fulfilled. Bile duct injury that occurs at LC is of greater severity than with open cholecystectomy. Bile duct injury is recognized during LC in less than half the cases. Evidence is accruing that the use of cholangiography reduces the risk and severity of injury and, when correctly interpreted, increases the chance of recognition of bile duct injury during the procedure. Prevention is the key but, should an injury occur, referral to a specialist in biliary reconstructive surgery is indicated.

Non-operative management of haemobilia

BACKGROUND

The aim was to evaluate a non-operative approach to the management of haemobilia.

METHODS

This was a retrospective analysis of patients presenting over 10 years with haemobilia. All patients had upper gastrointestinal endoscopy, abdominal ultrasonography and digital subtraction angiography. Superselective coil and/or Gelfoam embolization was done as close as possible to the bleeding site. Completion angiography was performed routinely to confirm adequate embolization.

RESULTS

There were 23 patients with liver trauma and six with inflammatory conditions. All patients required resuscitation with fluids and blood transfusion, and had the haemobilia controlled successfully by angiographic embolization. There was one death from fulminant hepatic sepsis.

CONCLUSION

This series attests to the efficacy of a non-operative approach to haemobilia using radiological diagnosis and intervention.

Long-term outcome of endoscopic papillotomy for choledocholithiasis with cholecystolithiasis

BACKGROUND

Although endoscopic papillotomy is now considered established treatment for choledocholithiasis, therapeutic results of endoscopic papillotomy alone without subsequent cholecystectomy in patients with cholecystolithiasis have not been well evaluated. The aim of this study was to assess the long-term outcome of endoscopic papillotomy for these patients.

METHODS

Patients admitted with choledocholithiasis and cholecystolithiasis from 1976 to 1993 were studied retrospectively. Of 385 patients in whom the bile duct was cleared by endoscopic papillotomy and endoscopic stone extraction, 371 patients (195 men and 176 women; mean age 65.4 years) were followed. Predisposing risk factors for late complications were analyzed.

RESULTS

The mean duration of follow-up was 7.7 years. Cholecystitis and recurrence of choledocholithiasis as late complications occurred in 22 cases (5.9%) and 36 cases (9.7%), respectively. Cholecystitis, including 1 severe case, resolved with conservative treatment. Recurrent choledocholithiasis was successfully treated endoscopically except in 1 case. No significant risk factors were identified for cholecystitis. The presence of pneumobilia (p = 0.0016) and the need for lithotripsy (p = 0.0342) were found to be significant risk factors for the recurrence of choledocholithiasis.

CONCLUSIONS

Long-term outcome of endoscopic papillotomy in patients with choledocholithiasis and cholecystolithiasis was found to be relatively favorable. Cholecystectomy after endoscopic papillotomy is not always necessary in the management of cholecystolithiasis.

Laparoscopic subtotal cholecystectomy: a review of 56 procedures

BACKGROUND AND PURPOSE

The essential surgical steps in laparoscopic cholecystectomy remain similar to those of open cholecystectomy. Positive identification of the biliary anatomy, safe clipping or ligature of the cystic duct and artery, and dissection of the gallbladder from the liver bed form the basis of cholecystectomy. Subtotal cholecystectomy is a definitive and safe operation under certain adverse conditions intraoperatively for dissection of the gallbladder from the liver bed. We reviewed our experience with laparoscopic cholecystectomy over a 2-year period between June 1996 and May 1998, when 1,680 operations were performed. The objective was to analyze the pathology, review surgical procedures, and trace the outcome of laparoscopic subtotal cholecystectomy.

PATIENTS AND METHODS

In 56 of 1,680 patients, laparoscopic subtotal cholecystectomy was performed, which constituted 3.33% of the laparoscopic cholecystectomies performed at our institution. Dense fibrosis and adhesions were present in 32 patients; 12 patients had Mirizzi syndrome, 6 patients had a sessile gallbladder, and 6 patients had a gangrenous gallbladder. The Endo-GIA 30 stapler was used in 40 patients, sequential clips were used in 9 patients, and a suture for stump closure was used in 5 patients. A subhepatic drain was inserted in 50 patients.

RESULTS

Two conversions to open surgery were needed because of gangrene of the gall bladder wall and one conversion as a result of continued bleeding from the cystic artery after application of the Endo-GIA 30 stapler. The mean postoperative stay in hospital was 2.5 days. One patient had a solitary bile duct calculus extracted at endoscopic retrograde cholangiopancreatography 3 months after surgery. Three patients had biliary drainage that lasted for a week, and four patients had epigastric port-site infections that resolved with antibiotics, dressings and postural drainage.

CONCLUSION

Laparoscopic subtotal cholecystectomy is safe, feasible, and effective and may help prevent conversion to open surgery in carefully selected patients with difficult cholecystectomies.

Bile duct injuries in laparoscopic cholecystectomy: nursing perspective

The advent of laparoscopic cholecystectomy brought a new approach with many advantages to patients for the treatment of symptomatic gallstones. What was not anticipated was an increase in bile duct injuries as a major complication of this new technique. The advanced practice nurse (APN) must understand the technical aspects of a laparoscopic cholecystectomy and routine perioperative care, because this knowledge provides a basis to recognize signs and symptoms of potential postoperative problems characteristic of a bile duct injury. The APN may be the initial healthcare provider who examines a patient or who is contacted by the patient with reports of symptoms that must be heeded and acted on. The APN responds to the patient by providing symptom management, initiating and coordinating care, and alerting the healthcare team. The APN at a specialty center may also be the consistent member of the healthcare team caring for a patient through nonoperative management and operative repair of the bile duct injury. Knowledge of the spectrum of bile duct injuries, their various manifestations, diagnostic tests, nonoperative management, and complex surgical repair is necessary for the APN to educate patients, coordinate care along the continuum, and support a patient with a bile duct injury. The medicolegal aspect of bile duct injury during laparoscopic cholecystectomy is also a topic the APN may encounter that requires thoughtful consideration and response. The recognition of subtle postoperative symptoms of a laparoscopic cholecystectomy may mean the difference between early diagnosis of and intervention in a minor injury or a major complication.

Biliary tract imaging

In addition to the detection of gallstones, common bile duct stones, and narrowed and dilated bile ducts, recent advancements in imaging techniques now make it possible to diagnose microlithiasis, pathology of normal-size ducts, and dysfunction of the gallbladder and the sphincter of Oddi (SO). More and more frequently, noninvasive imaging techniques obviate the risk of invasive investigation. These techniques can also take the place of unsuccessful or contraindicated direct cholangiography, and they play an essential role in treatment planning and diagnosis of postoperative complications. Transabdominal ultrasonography (TUS) remains fundamental for initial assessment of the biliary tract. Technical developments make magnetic resonance cholangiopancreatography the most promising diagnostic technique of the biliary tract. Endoscopic ultrasonography (EUS) is most helpful for detection of microlithiasis and evaluation of the ampullary region, the periductal structures, and the regional lymph nodes in neoplastic diseases. Cholescintigraphy is most valuable to assess bile dynamics in the diagnosis of gallbladder and SO dysfunction and in postoperative bile leakage.

Comparison of coagulation modalities in surgery

The increase in laparoscopic surgery has resulted in an increased need for a safe and reliable method of obtaining minimally invasive operative hemostasis. Because the traditional "open" methods of controlling bleeding (pressure, tying, and suture ligating) are not as easily applied in the laparoscopic arena, a heavy reliance on forms of tissue and vessel coagulation is necessary. To better assess these forms, we compare monopolar, bipolar, and ultrasound energy, in addition to laser energy used in a novel application. In the first part, 20 rabbit mesenteric arteries that measured 1 to 1.5 mm in diameter were coagulated using each of the technologies. We measured the time to coagulation, the efficacy of hemostasis, lateral tissue damage, and local tissue temperature of the vessels when exposed. Part 2 consisted of a survival study using 12 New Zealand white rabbits. In each of these two groups splenectomies were performed. A laser-heated forceps was compared to a monopolar electrosurgery device for the speed of the operation, blood loss, and adhesion grade at necrosectomy. In addition, the speed to cauterization of the iliac vessels and the amount of tissue damage was measured. These vessels were also examined for the extent of microscopic damage. Bipolar electrosurgery was much slower than the other modalities, while monopolar electrosurgery caused significantly more tissue damage and elevation in lateral tissue temperature. The ultrasound technology and the laser-heated forceps were equally safe and efficacious instruments. There was no significant difference in the ability of the laser-heated forceps or the monopolar cautery to perform the splenectomy safely. However, the forceps cauterized the iliac vessels faster and with less lateral thermal injury than the ultrasound device. Although each instrument has its place in the surgical armamentarium, the ultrasound technology appears to be the safest and most efficacious commercially available device for obtaining hemostasis. The laser, as it is applied in this setting, was also highly effective, but still a prototype device.

Surgical therapy for 101 patients with acquired immunodeficiency syndrome and symptomatic cholecystitis

BACKGROUND

Hepatobiliary disease in patients with acquired immunodeficiency syndrome (AIDS) has been well documented. Cytomegalovirus and Cryptosporidium are the pathogens most frequently associated. Previous reports of cholecystectomies and AIDS have had conflicting results on morbidity and mortality.

METHOD

Retrospective review of 101 patients with AIDS and symptomatic cholecystitis who underwent cholecystectomy from December 1989 to May 1995.

RESULTS

All patients had symptoms characteristic of gallbladder disease, the most common being abdominal pain and fever. Thickening of the gallbladder was the most common diagnostic finding. Fifty-six patients underwent open cholecystectomy and 45 laparoscopic cholecystectomy. Pathologic examination revealed an abnormal gallbladder in all cases and gallstones in 29%. A specific pathogen or malignancy was identified as the etiologic agent in 44% of patients. Perioperative morbidity was similar (<5%) in both surgical groups. Perioperative mortality was 4% among all the patients treated.

CONCLUSIONS

Both open and laparoscopic cholecystectomy improved the quality of life of these patients and should be considered as the treatment for persistent hepatobiliary symptoms in patients with AIDS.

Embolization of an hepatic artery pseudoaneurysm following laparoscopic cholecystectomy

Vascular injuries during laparoscopic cholecystectomy can occur in an analogous fashion to biliary injuries, with potential laceration, transection, and occlusion of blood vessels. A patient presented with symptomatic hemobilia 1 month following laparoscopic cholecystectomy and was found to have a right hepatic artery pseudoaneurysm which communicated with the common bile duct. This was successfully embolized with several embolic agents, resulting in rapid resolution of all signs and symptoms. The patient has been free of symptoms during a follow-up period of 1 year. A brief discussion of hepatic artery pseudoaneurysms is presented.