Complications in laparoscopic and open cholecystectomy: a prospective comparative trial

The Frequency of Anatomical Variants of the Bile Ducts: A Review Based on a Single Classification as Support for Cholangiographic Examinations

Complications arising from hepatobiliary surgery can have adverse effects on both the quality of life and the survival of patients. Magnetic resonance cholangiography (MRC) techniques are highly effective at revealing anatomical variants of the bile ducts and thus play a vital role in minimizing the occurrence of complications. The aims of this review are threefold: to ascertain the classifications utilized for categorizing anatomical variants of the bile ducts, to present the reported results on the prevalence of these anatomical variants, and to explore the diagnostic modalities employed to visualize these anatomical variants and associated complications during surgical procedures. A review of the literature was carried out using the Cochrane Library database and the PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Google Scholar platforms. We conducted a comprehensive review of relevant studies to categorize the different anatomical variants according to the Huang classification. According to the Huang classification, our study showed type A1, 60.44%; type A2, 11.76%; type A3, 11.73%; type A4, 5.47%; type A5, 0.26%; and type B, which was identified in insignificant numbers (0.16%) or does not appear; additionally, variants that do not fit into the Huang classification have also been identified (10.18%). The Huang classification serves as an invaluable presurgical guide, aiding in the strategic planning of biliary interventions and effectively reducing the risk of iatrogenic complications, morbidity, mortality, and postoperative length of stay. MRC is still considered the noninvasive gold standard method for evaluating the bile ducts and their anatomical variations.

The effect of surgical strategy in difficult cholecystectomy cases on postoperative complications outcome: a value-based healthcare comparative study

BACKGROUND

In patients undergoing laparoscopic cholecystectomy (LC) for complicated biliary disease, complication rates increase up to 30%. The aim of this study is to assess the effect of differences in surgical strategy comparing outcome data of two large volume hospitals.

METHODS

A prospective database was created for all the patients who underwent a LC in two large volume hospitals between January 2017 and December 2018. In cases of difficult cholecystectomy in clinic A, regular LC or conversion were surgical strategies. In clinic B, laparoscopic subtotal cholecystectomy was performed as an alternative in difficult cases. The difficulty of the cholecystectomy (score 1-4) and surgical strategy (regular LC, subtotal cholecystectomy, conversion) were scored. Postoperative complications, reinterventions, and ICU admission were assessed. For predicting adverse postoperative complication outcomes, uni- and multivariable analyses were used.

RESULTS

A total of 2104 patients underwent a LC in the study period of which 974 were from clinic A and 1130 were from clinic B. In total, 368 procedures (17%) were scored as a difficult cholecystectomy. In clinic A, more conversions were performed (4.4%) compared to clinic B (1.0%; p < 0.001). In clinic B, more subtotal laparoscopic cholecystectomies were performed (1.8%) compared to clinic A (0%; p =  < 0.001). Overall complication rate was 8.2% for clinic A and 10.2% for clinic B (p = 0.121). Postoperative complication rates per group for regular LC, conversion, and subtotal cholecystectomy in difficult cholecystectomies were 45 (15%), 12 (24%), and 7 (35%; p = 0.035), respectively. The strongest predictor for Clavien-Dindo grade 3-5 complication was subtotal cholecystectomy.

CONCLUSION

Surgical strategy in case of a difficult cholecystectomy seems to have an important impact on postoperative complication outcome. The effect of a subtotal cholecystectomy on complications is of great concern.

An analysis of early postoperative complications following biliary reconstruction of major bile duct injuries using the Modified Accordion and Anatomic, Timing Of and Mechanism classifications

Background

Few studies have reported patient outcome after surgical repair of bile duct injury using a standardized, validated classification system. This is the first analysis to investigate the correlation between the Anatomic, Timing Of and Mechanism classification of bile duct injury and severity of postoperative complications classified using the Modified Accordion Grading System.

Methods

Patients undergoing index hepaticojejunostomy repair of bile duct injury in laparoscopic cholecystectomy at a tertiary referral center from 1993-2018 were included. Patient demographics, geographic distance from referral center, time to referral, Anatomic, Timing Of and Mechanism classification and highest Modified Accordion Grade complication were retrieved from a prospective database. The primary outcome was determined using correlation statistics to assess the relationship between level of injury and severity of postoperative complication.

Results

One hundred and twenty-eight patients were included. There was no correlation between level of injury and severity of postoperative complication (r_s(128) = –0.113, P = .203). Seventy (54.7%) patients had an injury less than 2 cm from the hepatic duct bifurcation and 52% of patients developed a postoperative complication, most mild to moderate in severity. Geographic distance resulted in substantial delays in referral (P < .001) but did not affect complication rate (P = .523).

Conclusion

In this prospective analysis the short-term complication rate was higher than previous retrospective reports, but the distribution of the severity of complications and spectrum of injury type were similar. There was no correlation between severity of injury and postoperative complications. Geographic distance from referral center resulted in substantial differences in referral delay but had no statistically significant effect on outcome.

How to predict difficult laparoscopic cholecystectomy? Proposal for a simple preoperative scoring system

BACKGROUND

Few studies have used operative time as a reflection of the surgical difficulty to create a preoperative score of operative difficulty in laparoscopic cholecystectomies (DiLCs score).

METHODS

Patients who benefited from cholecystectomy between 2010 and 2015 were reviewed. Difficult procedures were identified using the deviations from the operative time for simple cholecystectomies. Logistic regression analyses were carried out to build risk-assessment models and derive the DiLC score.

RESULTS

Overall, 644 patients were identified. Multivariate analyses identified male sex, previous cholecystitis attack, fibrinogen, neutrophil, and alkaline phosphatase count to be predictive of operative difficulties. Risk-assessment model was generated with an area under the receiver-operator curve of .80. Internal validation was performed using the bootstrap method.

CONCLUSIONS

The DiLC score is a simple and reliable tool which could be used to improve patient counseling, optimize surgical planning, detect procedures at risk, identify patients eligible for outpatient care, and enhance resident training.

Primary cholecystectomy is feasible in elderly patients with acute cholecystitis

BACKGROUND

While early cholecystectomy is generally accepted as the standard procedure for young and fit patients with acute cholecystitis, controversy exits on the management of elderly and severely sick patients. We postulated that primary cholecystectomy is feasible in this subgroup. The aim of this study was to compare the outcomes of young and fit patients to those of elderly patients undergoing surgery for acute cholecystitis.

METHODS

The outcomes of elderly patients (≥70 years) undergoing surgery for acute cholecystitis in a primary care center in Germany were retrospectively compared to those of younger patients (<70 years).

RESULTS

152 patients, 74 aged ≥ 70 years (study group) and 78 < 70 years (control) were included for analysis. The study group was significantly older at the time of surgery (78 vs. 68 years, p = 0.02). Severe cholecystitis was seen in a significant number of cases in the study group, p = 0.01. Equally, the mean WBC (19.5 vs. 17, p = 0.02), CRP (26 vs. 22, p = 0.04) and APACHE II score (17 vs. 8, p = 0.01) were significantly higher in the study group. There was no significant difference in the duration of anesthesia (123 vs. 133 min, p = 0.70) and surgery (72 vs. 81 min, p = 0.90) amongst both groups. There was no significant difference in rate of complication amongst both groups (24 vs. 14%, p = 0.11). Two cases of mortality were recorded (1.3%) in the study group.

CONCLUSION

The age of the patient cannot be the sole factor in deciding whether or not a patient with acute cholecystitis is fit for surgery.

[Choledochal lithiasis and stenosis secondary to the migration of a surgical clip]

The migration of a clip to the common bile duct after cholecystectomy is an uncommon, usually late, complication that can lead to diverse complications like stone formation, stenosis, and obstruction in the bile duct. We present the case of a patient who presented with signs and symptoms of cholangitis due to clip migration one year after laparoscopic cholecystectomy; endoscopic retrograde cholangiopancreatography and biliary tract stent placement resolved the problem.

Surgical treatment for morbid obesity: the laparoscopic Roux-en-Y gastric bypass

Over the past 20 years bariatric surgery proved to be a valid treatment for reduction and elimination of obesity-related diseases and long-term sustainable weight loss. Minimally invasive or laparoscopic techniques such as laparoscopic Roux-en-Y (LRNY) have replaced open procedures. Many factors play important roles in the small intricacies and variations of the procedure, chief of which is the creation and size of the gastrojejunostomy. Regardless of the variations in technique, the LRNY remains the gold standard for the surgical treatment of clinically severe or morbid obesity, with relatively low morbidity and mortality.

The impact of body mass index on outcomes after laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the standard of care for gallstone disease. Some cases will be converted to open surgery and others will have complications, both leading to worse outcomes. The purpose of this study was to evaluate whether an increased body mass index (BMI) is associated with increased rates of conversion or complication.

METHODS

A retrospective chart review of 1,027 patients who underwent an attempted LC between January 2006 and December 2009 was performed. Patients were divided into five groups depending on their BMI: 18.5-24.9, 25-29.9, 30-34.9, 35-39.9, and ≥ 40. The primary endpoints were conversion rates, complication rates, and postoperative length of stay (LOS). Multivariate logistic regression was used to identify independent risk factors for worse outcomes.

RESULTS

There were 211 (20.5%), 325 (31.6%), 268 (26.1%), 135 (13.1%), and 88 (8.6%) patients in the groups with BMI values of 18.5-24.9, 25-29.9, 30-34.9, 35-39.9, and ≥ 40, respectively. Seventy-three patients (7.1%) required conversion to open surgery, and 64 patients (6.2%) developed complications. The rate of conversion was similar amongst all the BMI groups (P = 0.366), as was the rate of complication (P = 0.483). Mean (± SD) postoperative LOS was 1.74 ± 3.87 days, and there was no difference between the BMI groups (P = 0.596). Male gender and emergent cholecystectomy were independent predictors of increased conversions and complications. Diabetes was a risk factor for conversion, whereas age >65 years was a risk factor for complications.

CONCLUSIONS

Increased BMI was not associated with worse outcomes after LC. Compared with normal weight patients, obese and even morbidly obese patients have no increased risk of conversion to open surgery, nor is there an increased risk of perioperative complications. Obese and morbidly obese patients who require a cholecystectomy should be considered in the same category as normal weight patients, and LC should be the standard of care.

Biliary complications secondary to post-cholecystectomy clip migration: a review of 69 cases

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.

The accordion severity grading system of surgical complications

BACKGROUND

A severity grading system is essential to reporting surgical complications. In 1992, we presented such a system (T92). Its use and that of systems derived from it have increased exponentially. Our purpose was to determine how well T92 and its modifications have functioned as a severity grading system and to develop an improved system for reporting complications.

METHODS

129 articles were studied in detail. Twenty variables were searched for in each article with particular emphasis on type of study, substitution of qualitative terms for grades, grade compression, and cut-points if grade compression was used. We also determined relative distribution of complications and manner of presentation of complications.

RESULTS

T92 and derivative classifications have received wide use in surgical studies ranging from small studies with few complications to large studies of complex operations that describe many complications. There is a strong tendency to contract classifications and to substitute terms with self evident meaning for the numerical grades. Complications are presented in a large variety of tabular forms some of which are much easier to follow than others.

CONCLUSIONS

Current methods for reporting the severity of complications incompletely fulfill the needs of authors of surgical studies. A new system-the Accordion Severity Grading System-is presented. The Accordion system can be used more readily for small as well as large studies. It introduces standard definition of simple quantitative terms and presents a standard tabular reporting system. This system should bring the field closer to a common severity grading method for surgical complications.

Liver test patterns in patients with acute calculous cholecystitis and/or choledocholithiasis

BACKGROUND

Liver tests are utilized to determine the presence of biliary obstruction.

AIM

To examine our hypothesis that liver tests aid in elucidating whether patients have simple calculous cholecystitis (ACC) or choledocholithiasis (CDL).

METHODS

We performed a retrospective study of patients admitted to two University of Texas Southwestern teaching hospitals with a clinical picture consistent with 'acute gallstone disease', i.e. cholecystitis +/- choledocolithiasis. The presence of ACC and CDL was based on defined clinical criteria.

RESULTS

The cohort consisted of 154 patients meeting specific entry criteria, primarily with right upper quadrant pain; 62 ACC, 79 both ACC and CDL and 13 CDL alone. Approximately 30% of patients with ACC had abnormal alkaline phosphatase (ALP) and/or bilirubin level and approximately 50% had abnormal aminotransferase levels. Among patients with ACC/CDL, 77% had abnormal ALP, 60% had abnormal bilirubin and 90% had abnormal aminotransferase levels. By multivariate analysis, increasing common bile duct size and an abnormal ALP and alanine aminotransferase (ALT) were excellent predictors of having ACC with CDL.

CONCLUSIONS

Liver test patterns can aid in elucidating CDL, including in ACC patients. Fundamentally, patients with CDL were more likely to have more abnormal liver tests, whether they had CDL only, or CDL and ACC. A dilated CBD, and abnormal ALP and ALT had modest sensitivity and high specificity for identification of patients with ACC and CDL.

Outcome of laparoscopic cholecystectomy is not influenced by chronological age in the elderly

AIM: To evaluate the outcome of laparoscopic cholecystectomy (LC) in patients aged 80 years and older.

METHODS: A total of 353 patients aged 65 to 79 years (group 1) and 35 patients aged 80 years and older (group 2) underwent LC. Patients were further classified into two other groups: those with uncomplicated gallbladder disease (group A) or those with complicated gallbladder disease (group B).

RESULTS: There were no significant differences between the age groups (groups 1 and 2) with respect to clinical characteristics such as age, gender, comorbid disease, or disease presentation. Mean operative time, conversion rate, and the incidence of major postoperative complications were similar in groups 1 and 2. However, the percentage of high-risk patients was significantly higher in group 2 than in group 1 (20.0% vs 5.7%, P < 0.01). Group A comprised 322 patients with a mean age of 71.0 ± 5.3 years, and group B comprised 51 patients with a mean age of 69.9 ± 4.8 years. In group B, mean operative time (78.4 ± 49.3 min vs 58.3 ± 35.8 min, P < 0.01), mean postoperative hospital stay (7.9 ± 6.5 d vs 5.0 ± 3.7 d, P < 0.01), and the incidence of major postoperative complications (9.8% vs 3.1%, P < 0.05) were significantly greater than in group A. The conversion rate tended to be higher in group B, but this difference was not significant.

CONCLUSION: Perioperative outcomes in elderly patients who underwent LC seem to be influenced by the severity of gallbladder disease, and not by chronologic age. In octogenarians, LC should be performed at an earlier, uncomplicated stage of the disease whenever possible to improve perioperative outcomes.

Does gender affect laparoscopic cholecystectomy?

The relationship between sex and outcome after laparoscopic surgery for symptomatic cholelithiasis remains unclear. The purpose of this study was to determine the influence of sex on the clinical presentation of patients with symptomatic gallstone disease and the clinical outcomes of laparoscopic cholecystectomy. The rates of conversion to open cholecystectomy, complication rates, operative times, and lengths of hospital stay were compared between the sexes. Compared with female patients, males were significantly older and more likely to have coexisting cardiovascular disease, previous upper abdominal surgery, previous hospitalization for acute cholecystitis and pancreatitis, acute cholecystitis, and suppurative cholecystitis (such as empyema), conversions, and complications. The mortality rate was nil. Analyses revealed an independent effect of sex on the prevalence of complications, even when including all of the major confounding factors in the model. In contrast, the effect of sex on conversion to open cholecystectomy was not significant when controlling for patient age. Operative time and postoperative hospital stay were significantly longer in males than in females. The tendency of male patients to have cholecystitis of greater severity should remind surgeons of the need to inform patients about the higher conversion rate among male patients, to reduce the disappointment of a large laparotomy wound or prolonged recovery period. On the other hand, there may be an increased need for surgeons to strongly advice male patients with symptomatic cholelithiasis to undergo early intervention.

Peritoneal acidosis mediates immunoprotection in laparoscopic surgery

BACKGROUND

We have shown previously that abdominal insufflation with CO(2) increases serum levels of IL-10 and TNFalpha and increases survival among animals with lipopolysaccharide (LPS)-induced sepsis, even after a laparotomy. We demonstrated previously that the effect of CO(2) is not from changes in systemic pH, although the peritoneum is locally acidotic during abdominal insufflation with CO(2) even when systemic pH is corrected. We hypothesized that acidification of the peritoneum via means other than CO(2) insufflation would produce alterations in the inflammatory response similar to those associated with CO(2) pneumoperitoneum.

METHODS

In total, 42 rats were randomized into 7 groups (n = 6): 1) LPS only, 2) anesthesia control, 3) helium pneumoperitoneum, 4) CO(2) pneumoperitoneum, 5) buffered mild acid lavage, 6) buffered strong acid lavage, and 7) buffered strong acid lavage + helium pneumoperitoneum. Animals received anesthesia with vaporized isoflurane (except the LPS-only group) and their respective abdominal treatment (pneumoperitoneum and/or lavage) for 30 min followed immediately by stimulation with systemic LPS (1 mg/kg, IV). Blood was harvested via cardiac puncture 60 min after LPS injection, and serum levels of IL-10 and TNFalpha levels were determined by enzyme-linked immunosorbent assay.

RESULTS

Mean peritoneal pH decreased (P < .05) after CO(2) pneumoperitoneum, buffered strong acid lavage, and buffered strong acid lavage + helium pneumoperitoneum, and it decreased (P = .1) after helium pneumoperitoneum alone and buffered mild acid lavage. IL-10 levels were increased (P < .01), and TNFalpha levels decreased (P < .001) among animals with acidic peritoneal cavities compared with animals with pH-normal peritoneal cavities. Decreasing peritoneal pH correlated with both increasing IL-10 levels (r = -.465, P < .01) and decreasing TNFalpha levels (r = 0.448, P < .01). Among animals with peritoneal acidosis, there were no differences in levels of IL-10 or TNFalpha regardless of insufflation status (P > .05 for both cytokines).

CONCLUSIONS

Acidification of the peritoneal cavity whether by abdominal insufflation or by peritoneal acid lavage increases serum IL-10 and decreases serum TNFalpha levels in response to systemic LPS challenge. The degree of peritoneal acidification correlates with the degree of inflammatory response reduction. These results support the hypothesis that pneumoperitoneum-mediated attenuation of the inflammatory response after laparoscopic surgery occurs via a mechanism of peritoneal cell acidification.

Carbon dioxide pneumoperitoneum prevents mortality from sepsis

BACKGROUND

Carbon dioxide (CO2) pneumoperitoneum has been shown to attenuate the inflammatory response after laparoscopy. This study tested the hypothesis that abdominal insufflation with CO2 improves survival in an animal model of sepsis and investigated the associated mechanism.

METHODS

The effect of CO2, helium, and air pneumoperitoneum on mortality was studied by inducing sepsis in 143 rats via intravenous injection of lipopolysaccharide (LPS). To test the protective effect of CO2 in the setting of a laparotomy, an additional 65 animals were subjected to CO2 pneumoperitoneum, helium pneumoperitoneum, or the control condition after laparotomy and intraperitoneal LPS injection. The mechanism of CO2 protection was investigated in another 84 animals. Statistical significance was determined via Kaplan-Meier analysis for survival and analysis of variance (ANOVA) for serum cytokines.

RESULTS

Among rats with LPS-induced sepsis, CO2 pneumoperitoneum increased survival to 78%, as compared with using helium pneumoperitoneum (52%; p < 0.05), air pneumoperitoneum (55%; p = 0.09), anesthesia control (50%; p < 0.05), and LPS-only control (42%; p < 0.01). Carbon dioxide insufflation also significantly increased survival over the control condition (85% vs 25%; p < 0.05) among laparotomized septic animals, whereas helium insufflation did not (65% survival). Carbon dioxide insufflation increased plasma interleukin-10 (IL-10) levels by 35% compared with helium pneumoperitoneum (p < 0.05), and by 34% compared with anesthesia control (p < 0.05) 90 min after LPS stimulation. Carbon dioxide pneumoperitoneum resulted in a threefold reduction in tumor necrosis factor-alpha (TNF-alpha) compared with helium pneumoperitoneum (p < 0.05), and a sixfold reduction with anesthesia control (p < 0.001).

CONCLUSION

Abdominal insufflation with CO2, but not helium or air, significantly reduces mortality among animals with LPS-induced sepsis. Furthermore, CO2 pneumoperitoneum rescues animals from abdominal sepsis after a laparotomy. Because IL-10 is known to downregulate TNF-alpha, the increase in IL-10 and the decrease in TNF-alpha found among the CO2-insufflated animals in our study provide evidence for a mechanism whereby CO2 pneumoperitoneum reduces mortality via IL-10-mediated downregulation of TNF-alpha.

Role of liver function tests in predicting common bile duct stones in acute calculous cholecystitis

BACKGROUND

The role of liver function tests (LFTs) in evaluating common bile duct (CBD) stones in patients with cholelithiasis has been studied widely. However, it is not clear whether these predictive models are useful in inflammatory gallstone disease.

METHODS

A review was undertaken of 385 consecutive patients admitted as an emergency for acute calculous gallbladder disease. The diagnosis of calculous cholecystitis was confirmed by ultrasonography or histological confirmation of acute or chronic inflammation of the gallbladder. Patients with obvious jaundice, defined as a bilirubin level above 80 micromol/l, and gallstone pancreatitis were excluded.

RESULTS

Some 216 patients met the inclusion criteria, of whom 28 (13.0 per cent) were found to have CBD stones. LFT results were not significantly different in patients with chronic, acute or complicated acute cholecystitis. Using several cut-off levels, gamma-glutamyl transpeptidase (GGT) had the highest specificity, positive predictive value and negative predictive value, comparable to a scoring system that combined all LFTs. Bilirubin was the least specific and predictive. A cut-off point for GGT at 90 units/l produced a sensitivity of 86 per cent (24 of 28), specificity of 74.5 per cent (140 of 188), and positive and negative predictive values of 33 per cent (24 of 72) and 97.2 per cent (140 of 144) respectively. This represented a one in three chance of CBD stones when the GGT level was above 90 units/l and a one in 30 chance when the level was less than 90 units/l.

CONCLUSION

Selection criteria based on GGT can be used in acute calculous cholecystitis to identify high-risk patients who would benefit most from further imaging to exclude choledocholithiasis.

Carbon dioxide pneumoperitoneum–mediated attenuation of the inflammatory response is independent of systemic acidosis

BACKGROUND

The purpose of this study was to determine if systemic acidosis induced by peritoneal absorption of carbon dioxide (CO2 ) during laparoscopy plays a role in CO2 pneumoperitoneum-mediated attenuation of the acute phase inflammatory response associated with perioperative sepsis. The influence of hepatic polymorphonuclear (PMN) leukocyte infiltration on this phenomenon was also investigated.

METHODS

Forty-five rats were randomized into 5 groups: anesthesia control, open cecal ligation and puncture (OCLP), laparoscopic cecal ligation and puncture using helium for insufflation (He LCLP), LCLP using CO2 with continued spontaneous ventilation (LCLP-SV), and LCLP using CO2 with intubation and positive pressure ventilation (LCLP-PPV).

RESULTS

After 30 minutes, arterial blood gas parameters remained normal in control, OCLP rats, and He LCLP rats, while CO2 LCLP-SV rats developed significant hypercarbic acidosis. This acidosis was corrected in CO2 LCLP-PPV rats ( P < .0001 vs CO2 LCLP-SV for both). Expression of the rat acute phase gene alpha 2 -macroglobulin was greater after OCLP and He LCLP than after either CO2 LCLP-SV or CO2 LCLP-PPV ( P < .0001 vs either CO2 OCLP-SV for both). However, levels of alpha 2 -macroglobulin were not significantly different between the acidotic (LCLP-SV) and normocarbic (LCLP-PPV) CO2 groups. Infiltration of the hepatic parenchyma by PMNs did not differ significantly between groups.

CONCLUSIONS

CO2 insufflation-induced systemic acidosis is not responsible for the reduction in the acute phase inflammatory response observed in laparoscopic animal models of sepsis. Hepatic PMN infiltration also does not appear to mediate this effect.

Transumbilical approach for shunt insertion in the pediatric population: an improvement in cosmetic results

OBJECTIVE

In spite of the recent interest in endoscopic third ventriculostomy, ventriculoperitoneal (VP) shunt is still the gold standard in treating non-obstructive hydrocephalus in children. The peritoneal cavity remains the optimal site for cerebrospinal fluid (CSF) diversion. Shunt insertion and re-interventions carry a high risk of inaesthetic abdominal scars and long-term morbidity. We report a technique of transumbilical shunt insertion, which provides better cosmetic results and without many more complications. This approach has been performed for a long period in a wide variety of intra-abdominal conditions by pediatric surgeons.

METHODS

Between March and October 2003, we inserted 12 VP shunts in children. For eight consecutively treated children the follow-up is more than 3 months. All the shunts were inserted through the umbilicus. These eight children are the subjects of this study. Indications for shunting were: communicating hydrocephalus (6 cases), subdural hematoma (1 case), and hygroma associated with an arachnoid cyst (1 case). The population consisted of 7 boys and 1 girl, ranging in age between 6 weeks and 47 months (mean age: 15 months), and their body weights varied between 2,110 g and 18,000 g (mean weight: 8,470 g). All children were examined twice a day for 3 days, and wounds were examined daily to check for the absence of sepsis or dehiscence. Clinical controls were performed 1 month after discharge. The operating surgeon was invited to comment on any difficulties encountered in making or closing this incision afterwards.

RESULTS

The average length of clinical follow-up was 6 months (range 4-7 months). One infection of the VP shunt occurred. It was treated with external drainage and antibiotics. After 1 week, a second VP shunt was inserted using the same technique without particular difficulty and with a nice cosmetic result. Concerning the seven other children, the cosmetic results were optimal, with no puckered abdominal scars or wound dehiscence, and with no perioperative or long-term complications related to the umbilical approach.

CONCLUSION

At this early follow-up, umbilical incision for shunt insertion is a safe and easy technique. It provides an optimal cosmetic result, even in cases of re-intervention. This minimally invasive surgery does not require long specialized training. We have not shown an increase in complications associated with a "learning curve." Longer follow-up is needed to evaluate the risk of infection.

Videoendoscopic endotracheal intubation in the rat: A comprehensive rodent model of laparoscopic surgery1,2

BACKGROUND

Peritoneal absorption of CO(2) during abdominal insufflation in laparoscopy may disrupt the acid-base equilibrium and alter the physiological response to stress. Current nonventilated rodent models of laparoscopy do not manage the CO(2) load of pneumoperitoneum, but ventilated surgical rodent models are invasive (tracheotomy) and may independently induce the inflammatory response.

MATERIALS AND METHODS

A comprehensive rodent model of laparoscopy was developed. Rats were randomized to receive anesthesia alone, anesthesia plus CO(2) pneumoperitoneum, or anesthesia plus CO(2) pneumoperitoneum with videoendoscopic intubation and mechanical ventilation. Arterial blood-gas analysis was performed at baseline and after 30 min of intervention.

RESULTS

Baseline pH, pCO(2), and HCO(3)(-) arterial blood gas parameters were normal for all rats. After 30 min, pCO(2) and pH changed slightly but remained normal among rats receiving anesthesia alone (pCO(2) = 46.5 +/- 1.9; pH = 7.365 +/- 0.009) whereas animals receiving anesthesia plus CO(2) pneumoperitoneum that were dependent on spontaneous respiration for ventilation developed significant hypercarbic acidosis (pCO(2) = 53.2 +/- 1.9, P < 0.05; pH = 7.299 +/- 0.011, P < 0.001). This acidosis was completely corrected with increased minute ventilation in intubated rats receiving mechanical ventilation (pCO(2) = 36.8 +/- 1.5, P < 0.001; pH = 7.398 +/- 0.011, P < 0.001).

CONCLUSIONS

CO(2) pneumoperitoneum induces significant hypercarbic acidosis in nonventilated rats. Noninvasive endotracheal intubation is feasible in the rat with videoendoscopic assistance. Our noninvasive rodent model of laparoscopic surgery controls for anesthesia- and capnoperitoneum-related acid-base changes and provides an environment in which the biological response to pneumoperitoneum can be studied precisely.

New tools for laparoscopic division of the pancreas: a comparative animal study

We tested the hypothesis that the pancreas can be safely divided laparoscopically using non-suture devices. Twelve pigs were randomized into 4 groups: 1) laparoscopic distal pancreatectomy (LDP) using an ultrasonic scalpel; 2) LDP using an ultrasonic scalpel with pancreatic stump suture reinforcement; 3) LDP using a 35-mm laparoscopic linear vascular stapler; 4) LDP using a prototype 35-mm radio-frequency laparoscopic linear vascular stapler. There were no serious complications related to distal pancreatectomy. All groups gained weight by postoperative day (POD) 14. Serum amylase, glucose, electrolytes and total bilirubin levels were measured preoperatively and on POD 1, 3, 7, and 14, and peripancreatic peritoneal fluid amylase levels were measured on POD 7 and 14; all remained normal in all groups. Fewer adhesions to the pancreatic stump were found in the ultrasonic scalpel groups as compared with the stapler groups. Ultrasonic dissection may be the superior means oflaparoscopic transection of the pancreas.

Multiservice laparoscopic surgical training using the daVinci surgical system

BACKGROUND

The daVinci surgical system affords surgeons a magnified three-dimensional videoscopic view of the operative field and precise articulating laparoscopic instruments. The learning curve for this advanced surgical robotics system is poorly characterized.

METHODS

Twenty-three surgeons representing seven surgical subspecialties participated in a surgical robotics training program consisting of standardized daVinci system training (phase 1) followed by self-guided learning in a porcine model (phase 2).

RESULTS

The average number of recorded procedures performed per surgeon during phase 2 was 5.5. The mean daVinci system set-up time was 45 minutes and decreased by an average of 56.1% by the third successive set-up (r = -0.702, P <0.005). Operative times decreased 39.0% by the third successive practice operation (r = -0.860, P <0.0005).

CONCLUSIONS

New use of the daVinci robot is associated with a rapid learning curve and preclinical animal model training is effective in developing surgical robotics skills.

AM. Complicações pós-operatórias de colecistectomias: análise comparativa em relação ao sexo

OBJETIVO: Analisar a incidência das complicações pós-operatórias das colecistectomias por via aberta e laparoscópica, em relação ao sexo. Método: Estudo retrospectivo de 1123 pacientes submetidos a colecistectomia eletiva, por via aberta ou laparoscópica, no Departamento de Cirurgia da Santa Casa de Misericórdia de São Paulo, no período de Janeiro/1997 a Janeiro/2001. Foi realizada uma avaliação comparativa das complicações pós-operatórias, relacionando os resultados com a idade, ASA, via de acesso, tempo de cirurgia, acidentes intra-operatórios, necessidade de drenagem, período de permanência hospitalar, resultado anátomo-patológico e mortalidade. RESULTADOS: Houve predominância do sexo feminino na população estudada, com 82,5% dos casos. A média de idade foi de 48,8 anos (14 a 97 ). Das operações realizadas, 693 (61,7%) foram por via laparoscópica, sendo a maior proporção de abordagens abertas no sexo masculino (p=0,0014). A taxa global de conversão foi de 2,31%, sem diferença entre os sexos, assim como a realização de procedimentos associados e a ocorrência de acidentes intra-operatórios. A duração da intervenção, a drenagem, a permanência hospitalar pós-operatória, complicações e mortalidade foram significativamente mais freqüentes entre os homens. Neste grupo, observou-se duração maior do ato operatório e permanência hospitalar pós-operatória, com significância estatística, principalmente quando se realizou o tratamento tradicional. CONCLUSÕES: O sexo masculino mostrou-se como provável fator de risco para complicações nas colecistectomias, resultando em operações prolongadas, maior período de permanência hospitalar, necessidade de drenagem mais freqüente e mortalidade elevada em relação ao sexo feminino.

[Effect of pneumoperitoneum on venous hemodynamics during laparoscopic cholecystectomy. Influence of patients' age and time of surgery]

BACKGROUND AND OBJECTIVE

Abdominal hyperpressure developed during laparoscopic cholecystectomy by the effect of pneumoperitoneum represents an obstacle to the venous return that may facilitate thromboembolic complications. The aim of this study was to establish the effect of pneumoperitoneum in venous hemodynamics during laparoscopy.

PATIENTS AND METHOD

Prospective study of 31 consecutive patients who underwent laparoscopic cholecystectomy. Venous occlusion plethysmography was performed preoperatively, after anaesthetic induction, after insufflation, before pneumoperitoneum release and at the end of surgery. Changes of plethysmography were compared with preoperative values and according to age, obesity, presence of varicose veins and pneumoperitoneum time. Bilateral lower limb venous Duplex scanning was performed at days 1, 7 and 30 to detect deep venous thrombosis (DVT).

RESULTS

Average age was 56 years, 66.6% females, 40% obese, 16% with varicose veins and the pneumoperitoneum time was < 45 min in 22.5% patients. Capacitance decreased progressively during surgery and was significantly reduced with pneumoperitoneum. The maximum venous outflow in the first second was reduced significantly at the end of pneumoperitoneum. These reductions were more evident in older patients.

CONCLUSIONS

Pneumoperitoneum produces plethysmographic changes on venous hemodynamics with a diminished venous return in lower limbs. Older patients have higher risk of thromboembolic complications, while obesity can also increase this risk. However, no DVT was demonstrated in this study.

CO2 Pneumoperitoneum modifies the inflammatory response to sepsis

OBJECTIVE

To analyze the effect of CO2 pneumoperitoneum on the inflammatory response induced by sepsis during laparoscopy.

SUMMARY BACKGROUND DATA

A growing body of evidence challenges the once generally accepted notion that smaller incisions alone account for the observed benefits of the laparoscopic approach. Furthermore, laparoscopic surgery is now being applied to a broad spectrum of patients, including those in whom the inflammatory response is ignited. Delineation of the effects of CO2 pneumoperitoneum on the inflammatory response induced by sepsis is needed.

METHODS

Sepsis was induced in rats by cecal ligation and puncture (CLP) performed either open or laparoscopically using CO2 or helium as insufflation gases. Animals were killed 24 hours postoperatively, at which time whole blood was collected for complete blood cell counts and livers were harvested for analysis of hepatic expression of the rat acute phase genes alpha2-macroglobulin and beta-fibrinogen.

RESULTS

Laparoscopic CLP using CO2 resulted in significantly reduced hepatic expression of the rat acute phase gene alpha2-macroglobulin compared to both laparoscopic CLP using helium and open CLP. Hepatic expression of another rat acute phase gene, beta-fibrinogen, paralleled that of alpha2-macroglobulin and was significantly reduced following laparoscopic CLP using CO2 compared to laparoscopic CLP using helium. Total white blood cell and neutrophil counts following CLP were both significantly higher when CLP was performed laparoscopically using CO2 than when CLP was performed open or laparoscopically using helium.

CONCLUSIONS

Intra-abdominal CO2 present during laparoscopy attenuates the acute phase inflammatory response associated with perioperative sepsis.

Predictive factors for conversion of laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy has replaced open cholecystectomy for the treatment of gallbladder disease. However, certain cases still require conversion to open procedures. Identifying these patients at risk for conversion remains difficult. This study identifies risk factors that may predict conversion from a laparoscopic to an open procedure.

METHODS

From January 1996 to January 2000, a total of 1,347 laparoscopic cholecystectomies were performed at the Cleveland Clinic Foundation (CCF). A retrospective analysis of 34 parameters including patient demographics, clinical history, laboratory data, ultrasound results, and intraoperative details was performed. Stepwise, multivariate logistic regression was used to determine those variables predicting conversion of laparoscopic cholecystectomy.

RESULTS

Seventy-one (5.3%) laparoscopic cholecystectomies required conversion. Multivariate analysis revealed that for all cases, a white blood cell count >9 (2.9 greater odds ratio [OR] of conversion P = 0.006) and a gallbladder wall thickness >0.4 cm (7.2 OR, P <0.001) predicted conversion to open cholecystectomy. However, when patients with acute cholecystitis were evaluated only a body mass index >30 kg/m(2) (5.6 OR, P = 0.02) predicted conversion. For patients undergoing elective cholecystectomy, a body mass index >40 kg/m(2) (33.1 OR, P = 0.01) and a wall thickness >0.4 cm (24.7 OR, P <0.004) predicted conversion. Finally, an ASA >2 (5.3 OR, P = 0.01) predicted conversion in patients undergoing nonelective cholecystectomies.

CONCLUSIONS

Obese patients with acute cholecystitis undergoing laparoscopic cholecystectomy have an increased chance of conversion. Likewise, patients with multiple comorbid diseases undergoing nonelective laparoscopic cholecystectomy are more likely to require conversion. Finally, in an elective laparoscopic cholecystectomy, morbidly obese patients with chronic cholecystitis and a thickened gallbladder wall are more likely to require conversion. These factors can help counsel patients undergoing laparoscopic cholecystectomy with regards to the probability of conversion to an open procedure.

Cusum analysis of trends in operative selection and conversion rates for laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) requires a high degree of technical ability, spatial resolution and dexterity. Assessing trainees and competent operators is an important aspect of quality assurance in patient care. Most institutions quote mean conversion rate as a method of comparing operators' performance. The purpose of the present study was to use the technique of cumulative sum (cusum) analysis to determine whether a learning curve phenomenon exists in operators performing LC.

METHODS

Data were obtained retrospectively by reviewing the operative records of all patients undergoing elective and acute cholecystectomy for a 30-month period coinciding with the commencement of LC at North Shore Hospital. Patients' age and gender, date and type of operative procedure, duration of operation, and name of operator were recorded. Mean and cusum-transformed data were derived for all operations as well as for four individual operators' performances.

RESULTS

Over the study period a total of 614 cholecystectomies was performed, with 85% attempted laparoscopically. A total of 9.8% required conversion to the open technique. Time trend analysis with the cusum technique for all surgeons revealed an inverse relationship between selection rate and conversion rate. Analysis of four individual surgeons revealed three different time trend profiles.

CONCLUSION

There was a direct inverse relationship between conversion rate and selection rate, in that careful selection is associated with a low conversion rate. Comparison of individual surgeons' performance showed wide variation, with only one surgeon exhibiting the phenomenon of a learning curve. Contrary to other reports, we found that performance on LC was not always related to operative experience. This highlights the need for a more objective method to analyse operator competence than operator experience alone.

Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity

OBJECTIVE

To evaluate the short-term outcomes for laparoscopic Roux-en-Y gastric bypass in 275 patients with a follow-up of 1 to 31 months.

SUMMARY BACKGROUND DATA

The Roux-en-Y gastric bypass is a highly successful approach to morbid obesity but results in significant perioperative complications. A laparoscopic approach has significant potential to reduce perioperative complications and recovery time.

METHODS

Consecutive patients (n = 275) who met NIH criteria for bariatric surgery were offered laparoscopic Roux-en-Y gastric bypass between July 1997 and March 2000. A 15-mL gastric pouch and a 75-cm Roux limb (150 cm for superobese) was created using five or six trocar incisions.

RESULTS

The conversion rate to open gastric bypass was 1%. The start of an oral diet began a mean of 1.58 days after surgery, with a median hospital stay of 2 days and return to work at 21 days. The incidence of early major and minor complications was 3.3% and 27%, respectively. One death occurred related to a pulmonary embolus (0.4%). The hernia rate was 0.7%, and wound infections requiring outpatient drainage only were uncommon (5%). Excess weight loss at 24 and 30 months was 83% and 77%, respectively. In patients with more than 1 year of follow-up, most of the comorbidities were improved or resolved, and 95% reported significant improvement in quality of life.

CONCLUSION

Laparoscopic Roux-en-Y gastric bypass is effective in achieving weight loss and in improving comorbidities and quality of life while reducing recovery time and perioperative complications.

Hospital credentialing and quality of care

The purpose of this study was to evaluate the impact of hospital credentialing standards on surgical outcomes for selected procedures. The study used hospital credentialing practices from a 1996 survey of North Carolina community hospitals, with surgical outcomes derived from a statewide database of inpatient surgical discharges in 1995. Hospital mortality, complications and elevated lengths of stay were used as outcome indicators in an analysis of 6 surgical procedures. Multivariate logit analysis was used to calculate the effects of hospital credentialing stringency and nine credentialing practices on outcomes, controlling for patient demographic characteristics, type of admission, severity of illness and hospital characteristics. Teaching hospitals adopted more stringent credentialing practices, with almost no difference between metropolitan and nonmetropolitan nonteaching facilities in their use of various credentialing policies. Surgical outcomes typically were not related to stringency of the hospital credentialing environment. Generally, the effect of specific practices was inconsistent (associated with improved outcomes for certain procedures and significantly worse outcomes for others) or counterintuitive (showing worse outcomes for selected surgical procedures where effects were statistically significant). More stringent hospital credentialing does not appear likely to improve patient outcomes.

Duplicate gallbladder cholecystitis after open cholecystectomy

A 42-year-old man presented with acute right upper quadrant abdominal pain 2 years after open cholecystectomy. Evaluation revealed cholecystitis in a second gallbladder and a second cholecystectomy was performed. Acute right upper quadrant abdominal pain after cholecystectomy presents a wide differential diagnosis, including the often idiopathic and difficult to manage postcholecystectomy syndrome. Emergency physicians should be aware of the most common causes of pain in these patients. Previously unrecognized congenital abnormalities of the biliary system should be considered when the diagnosis is not clear, as highlighted by this case report.

Outpatient laparoscopic cholecystectomy

INTRODUCTION

The results of laparoscopic cholecystectomy performed as an outpatient procedure were evaluated in a prospective study.

METHODS

Initially, only well motivated and healthy patients were offered outpatient laparoscopic cholecystectomy. After 50 procedures, all patients referred to the hospital, except those with American Society of Anesthesiologists (ASA) grade IV and those living alone, were included. Some 200 procedures were studied.

RESULTS

Twelve patients (6 per cent) were admitted, and 188 (94 per cent) were discharged 4-8 h after operation. Fifteen patients (8 per cent) who had early discharge were readmitted, nine with complications; in six no complications were documented. The frequency of minor complications was 2 per cent and of major complications 5 per cent. Some 173 patients who had successful outpatient laparoscopic cholecystectomy completed a questionnaire: 164 (95 per cent) characterized their experience as excellent, five (3 per cent) as good, two (1 per cent) as intermediate and two (1 per cent) as unacceptable.

DISCUSSION

This high achievement of day-case treatment, even in patients with ASA grade III, is explained by a new anaesthetic regimen together with good surgical technique and close follow-up.