Impact of laparoscopy on frequency of surgery for treatment of gallstones

Bile Duct Injuries during Laparoscopic Cholecystectomy: Management and Outcome

The aim of this study is to analyze our experience with the management of bile duct injuries (BDIs) following laparoscopic cholecystectomy (LC). From 1996 to 2004, 21 patients with BDI after LC were treated in our department. The BDIs were graded according to the classification of Strasberg. Ten patients had minor BDI. Minor injuries were classified as A in six and D in four patients. In three patients, endoscopic retrograde cholangiopancreatography sphincterotomy and stent placement was adequate treatment. Six patients required laparotomy and bile duct ligation or suturing, and one patient underwent laparoscopy with additional ligation of a duct of Luschka. Eleven patients had major BDIs. These injuries were classified as E1 in two, E2 in three, E3 in four, and E4 in two patients. Among the patients with a major BDI, Roux- en-Y hepaticojejunostomy was performed. After a median follow-up of 69.45 months, no evidence of biliary disease has been detected among our patients. BDIs should be managed in a specialist unit where surgeons skilled to perform such repairs should undertake definitive treatment. Roux- en-Y hepaticojejunostomy is the procedure of choice in the management of major BDIs as it is accompanied by satisfactory results.

Comparison of outcomes after single-port laparoscopic cholecystectomy in relation to patient body mass index

Background and Objectives:

Single-port laparoscopic cholecystectomy may contribute to a paradigm shift in the field of laparoscopic cholecystectomy surgery by providing patients with benefits beyond those observed after other surgical procedures. This study was designed to evaluate clinically meaningful differences in operative outcomes between obese and nonobese patients after single-port laparoscopic cholecystectomy.

Methods:

Data were collected retrospectively from 172 patients who had undergone single-port laparoscopic cholecystectomy performed by the same surgeon at a single medical center between January and December 2011. For the outcome analysis, patients were divided into nonobese and obese patient groups according to their body mass index (<25 kg/m² vs ≥25 kg/m²).

Results:

Demographic and clinical data did not differ significantly between obese patients (n = 65) and nonobese patients (n = 107). In addition, statistically significant differences pertaining to most measured surgical outcomes including postoperative hospital stay, bile spillage, additional port use, and open conversion were not detected between the groups. However, the two groups differed significantly regarding operative time such that nonobese patients had shorter operative times than obese patients (P < .05).

Conclusion:

The results of this study showed that operative time for single-port laparoscopic cholecystectomy was the only difference between obese and nonobese patients. Given this result, body mass index may not be as relevant a factor in patient selection for single-port laparoscopic cholecystectomy as previously thought.

Increased rate of cholecystectomies performed with doubtful or no indications after laparoscopy introduction: a single center experience

Background

During recent years laparoscopic cholecystectomy has dramatically increased, sometimes resulting in overtreatment. Aim of this work was to retrospectively analyze all laparoscopic cholecystectomies performed in a single center in order to find the percentage of patients whose surgical treatment may be explained with this general trend, and to speculate about the possible causes.

Methods

831 patients who underwent a laparoscopic cholecystectomy from 1999 to 2008 were retrospectively analyzed.

Results

At discharge, 43.08% of patients were operated on because of at least one previous episode of biliary colic before the one at admission; 14.08% of patients presented with acute lithiasic cholecystitis; 14.68% were operated on because of an increase in bilirubin level; 1.56% were operated on because of a previous episode of jaundice with normal bilirubin at admission; 0.72% had gallbladder adenomas, 0.72% had cholangitis, 0.36% had biliodigestive fistula and one patient (0.12%) had acalculous cholecystitis. By excluding all these patients, 21.18% were operated on without indications.

Conclusions

The broadening of indications for laparoscopic cholecystectomy is undisputed and can be considered a consequence of new technologies that have been introduced, increased demand from patients, and the need for practice by inexperienced surgeons. If not prevented, this trend could continue indefinitely.

Registration of health-related quality of life in a cohort of patients undergoing cholecystectomy

Background. Assessment of gallstone surgery's impact on quality of life (QoL) requires a reliable instrument with sufficient responsiveness. The instrument should also enable estimation of each individual's expected condition in an unaffected state. Materials and Methods. The Swedish Register for Gallstone Surgery and ERCP (GallRiks) registers indications, complications, results, and QoL-outcome of gallstone surgery. In 2008, 68 hospitals were registered in GallRiks. Between 2007 and 2008, SF-36 (a short form health survey) was filled in 1-2 weeks pre- and 6–9 months postoperatively at five of the units. Expected scores were determined from an age- and gender-matched Swedish population (AGMSP). Results. Of the 330 patients, 212 responded to SF36 pre- and postoperatively (RR = 64%; 212/330). Standardized response means ranged from 0.20 to 0.93 for the SF-36 subscores. Highest responsiveness was seen for bodily pain. Preoperatively, all subscores were significantly lower than in the AGMSP (all P < .05). Six months postoperatively, there was no significant difference between any of the observed and expected quality of life subscales. Conclusion. SF-36 is a useful instrument for measuring the impact of gallstone surgery on QoL. The postinterventional health status equalled or even exceeded the AGMSP for all subscales.

Laparoscopic versus open cholecystectomy in diabetic patients and postoperative outcome

BACKGROUND

Diabetes mellitus is associated with an increased risk of complications after abdominal surgery. We evaluated retrospectively the impact of preoperative risk factors and outcome of diabetic patients after laparoscopic cholecystectomy (LC) compared with open cholecystectomy (OC) for symptomatic gallstones.

METHODS

Altogether 2,548 consecutive patients (1,581 LC, 967 OC) with symptomatic gallstones underwent cholecystectomy at our secondary referral center, being the only operative unit in the catchment area. Between the years 1995 and 2008, we operated 227 (9%) patients with diabetes, of whom 45 (20%) had type 1 diabetes. Preoperative data and operative outcome of the diabetic patients undergoing LC (n = 102) and OC (n = 125) were compared. The effect of comorbidities of diabetes on the risk for postoperative complications was analyzed by multiple logistic regression analysis.

RESULTS

The percentage of morbidly obese diabetic patients did not change during the study period. Almost half of the cholecystectomies (n = 111) in diabetics were performed as acute surgery due to cholecystitis. Conversion to open surgery was required in 16% of the diabetic patients undergoing LC compared with 7% in the nondiabetic controls (p < 0.0001). Mortality rate was zero and nine patients (7.2%), respectively, in the LC and OC groups (p < 0.01). Other complications were also more frequently observed in the OC than LC groups. This outcome difference was unchanged during time. On multivariate analysis, comorbidities of diabetes were associated with an elevated risk for complications, but obesity or acute surgery was not independently associated with postoperative complications.

CONCLUSIONS

When feasible, LC was a safe procedure in diabetes. Open surgery with comorbidities increased the operative risks. Our study was not randomized, and therefore selection bias to type of procedure may affect the results.

Cholelithiasis in patients on the kidney transplant waiting list

OBJECTIVES

To evaluate the prevalence of cholecystopathy in chronic renal patients awaiting kidney transplants.

INTRODUCTION

The prevalence and management of cholelithiasis in renal transplant patients is not well established.

METHODS

A total of 342 chronic renal failure patients on the waiting list for a kidney transplant were studied. Patients were evaluated for the presence of cholelithiasis and related symptoms, previous cholecystectomies and other abdominal surgeries, time on dialysis, and general data (gender, age, number of pregnancies, and body mass index).

RESULTS

Cholelithiasis was found in 41 out of 342 patients (12%). Twelve of these patients, all symptomatic, had previously undergone cholecystectomies. Five out of 29 patients who had not undergone surgery were symptomatic. Overall, 17 patients (41.5%) were symptomatic. Their mean age was 54 (range 32-74) years old; 61% were female, and their mean body mass index was 25.4. Nineteen (76%) out of 25 women had previously been pregnant, with an average of 3.6 pregnancies per woman.

CONCLUSIONS

The frequency of cholelithiasis was similar to that reported in the literature for the general population. However, the high frequency of symptomatic patients points toward an indication of routine pre-transplant cholecystectomy to avoid serious post-transplant complications.

Does Cholecystectomy Prior to the Diagnosis of Pancreatic Cancer Affect Outcome?

Early diagnosis and curative resection are significant predictors of survival in patients with pancreatic cancer. We hypothesize that cholecystectomy within 12 months of pancreatic cancer affects 1-year survival. The Surveillance Epidemiology and End Result (SEER) database linked to Medicare data was used to identify patients diagnosed with pancreatic cancer who underwent cholecystectomy 1 to 12 months prior to cancer diagnosis. The SEER database identified 32,569 patients from 1995 to 2002; 415 (1.3%) underwent cholecystectomy prior to cancer diagnosis. Patients who underwent cholecystectomy had a higher proportion of diabetes (40.2% vs 20.5%; P < 0.01), obesity (8.9% vs 3.1%; P < 0.01), jaundice (17.3% vs 0.7%; P < 0.01), cholelithiasis (70.4% vs 4.2%; P < 0.01), choledocholithiasis (0.7% vs 0.0%; P < 0.01), weight loss (17.3% vs 4.7%; P < 0.01), abdominal pain (79.5% vs 22.5%), steatorrhea (0.7% vs 0.0%; P < 0.01), and cholecystitis (32.3% vs 1.7%; P < 0.0001). After controlling for tumor stage, patient demographics, and symptoms, survival at 1 year was significantly lower in patients undergoing cholecystectomy (OR, 0.75; 95% CI, 0.58–0.97). Recent cholecystectomy is associated with decreased 1-year survival among patients with pancreatic cancer. For patients older than 65 years of age, further evaluation prior to cholecystectomy may be necessary to exclude pancreatic cancer, especially patients with jaundice, weight loss, and steatorrhea.

Laparoscopic Cholecystectomy Without Intraoperative Cholangiography

BACKGROUND

The aim of this retrospective study was to evaluate the outcome of laparoscopic cholecystectomies (LCs) performed in our Academic Surgical Unit, and the impact of our policy not to perform intraoperative cholangiograms (IOCs) on the incidence of bile duct injuries (BDIs).

MATERIALS AND METHODS

Data was collected for the time period from 1992 (when the laparoscopic procedure was first introduced in our Unit) until 2005. During this time, 1851 patients underwent an LC. Patients with a history of jaundice, ultasonographic bile duct dilatation, bile duct stones, or deranged liver function tests were referred initially for an endoscopic retrograde cholangiopancreatography procedure. An IOC was not performed on any patient.

RESULTS

The conversion rate was 23.9% among the patients with acute cholecystitis and 1.6% among the patients with a noninflamed gallbladder. This difference was statistically significant. The morbidity reached 1.1%, as minor or major complications were present in 22 of 1851 patients. Complications consisted of BDI in 7 patients (0.37%). Six patients presented with minor BDI. Two of the BDIs occurred among the group of patients with acute cholecystitis, whereas the remaining 5 occurred in the group of patients with a noninflamed gallbladder. This distribution was not statistically significant.

CONCLUSIONS

The low BDI rate in our series allowed us to recommend an LC procedure without an IOC. Performing a cholangiogram either routinely or selectively is not wrong. However, adherence to a meticulous hemostatic technique, thorough knowledge of the anatomy, and a low threshold for conversion may also enable satisfactory results to be achieved.

Improvement in gastrointestinal symptoms and quality of life after cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the accepted treatment for symptomatic cholelithiasis but has been criticized as an overused procedure. This study assesses the effectiveness of LC on reduction in gastrointestinal (GI) symptoms and the impact on quality of life (QOL).

METHODS

A prospective cohort of subjects evaluated for gallstone disease between August 2001 and July 2004 completed preoperative and postoperative GI gallbladder symptom surveys (GISS) and SF36 QOL surveys. The GISS was developed to quantify the magnitude, severity, and distressfulness of 16 GI symptoms. Surveys were scored and evaluated using paired t tests.

RESULTS

Fifty-five subjects were included in the final analysis. The GISS revealed significant improvement in biliary type symptoms but not reflux or irritable bowel symptoms after LC (P > .05). Significant improvement was seen in QOL (P < .01).

CONCLUSION

This study supports the utility of LC by showing not only a significant reduction of GI symptoms but also marked improvement in patients' general QOL.

Twenty years after Erich Muhe: Persisting controversies with the gold standard of laparoscopic cholecystectomy

This review article is a tribute to the genius of Professor Erich Muhe, a man ahead of his times. We trace the development of laparoscopic cholecystectomy and detail the tribulations faced by Muhe. On the occasion of the twentieth anniversary of the first laparoscopic cholecystectomy, we take another look at some of the controversies surrounding this gold standard in the management of gallbladder disease.

Long-Term Follow-up after Robotic Cholecystectomy

Most surgeons gain their first clinical experience with surgical robots when performing cholecystectomies. Although this procedure is rather easily applicable for the da Vinci surgical system, the long-term outcome after this operation has not yet been clarified. This study follows up our institutional first series of robotic cholecystectomies (June to November 2001). Patients were assessed on the basis of standardized management including a quality-of-life questionnaire, clinical examination, blood tests, and abdominal sonogram. The follow-up rate for 23 patients after robotic cholecystectomy was 100 per cent and the median follow-up time 33 (30–35) months. There was one (4%) recurrence of gallstone disease in a patient who suffered from solitary choledocholithiasis 29 months after robotic cholecystectomy. Abdominal sonogram, clinical examinations, and blood tests revealed no post-cholecystectomy-specific pathological findings. The main long-term symptoms were bloating (57%), heartburn (43%) and nausea (30%). Of the patients, 96 per cent (22 patients) felt that the operation had cured or significantly improved their specific preoperative symptoms. Long-term results after robotic laparoscopic cholecystectomy are excellent and comparable to those for the conventional laparoscopic procedure. The advanced vision control and instrument maneuverability of robotic surgery might open minimally invasive surgery also for complicated gallstone disease and bile duct surgery.