Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial

OBJECTIVE

To assess whether laparoscopic cholecystectomy is superior to percutaneous catheter drainage in high risk patients with acute calculous cholecystitis.

DESIGN

Multicentre, randomised controlled, superiority trial.

SETTING

11 hospitals in the Netherlands, February 2011 to January 2016.

PARTICIPANTS

142 high risk patients with acute calculous cholecystitis were randomly allocated to laparoscopic cholecystectomy (n=66) or to percutaneous catheter drainage (n=68). High risk was defined as an acute physiological assessment and chronic health evaluation II (APACHE II) score of 7 or more.

MAIN OUTCOME MEASURES

The primary endpoints were death within one year and the occurrence of major complications, defined as infectious and cardiopulmonary complications within one month, need for reintervention (surgical, radiological, or endoscopic that had to be related to acute cholecystitis) within one year, or recurrent biliary disease within one year.

RESULTS

The trial was concluded early after a planned interim analysis. The rate of death did not differ between the laparoscopic cholecystectomy and percutaneous catheter drainage group (3% v 9%, P=0.27), but major complications occurred in eight of 66 patients (12%) assigned to cholecystectomy and in 44 of 68 patients (65%) assigned to percutaneous drainage (risk ratio 0.19, 95% confidence interval 0.10 to 0.37; P<0.001). In the drainage group 45 patients (66%) required a reintervention compared with eight patients (12%) in the cholecystectomy group (P<0.001). Recurrent biliary disease occurred more often in the percutaneous drainage group (53% v 5%, P<0.001), and the median length of hospital stay was longer (9 days v 5 days, P<0.001).

CONCLUSION

Laparoscopic cholecystectomy compared with percutaneous catheter drainage reduced the rate of major complications in high risk patients with acute cholecystitis.

TRIAL REGISTRATION

Dutch Trial Register NTR2666.

[Complication rate in laparoscopic cholecystectomy not different for residents in training and surgeons]

OBJECTIVE

To assess the difference in safety of laparoscopic cholecystectomy performed by residents and staff surgeons.

SETTING

St. Antonius Hospital, Nieuwegein, the Netherlands.

DESIGN

Retrospective study.

METHOD

Results of 649 laparoscopic cholecystectomies performed by staff surgeons experienced in laparoscopic surgery, by residents under supervision of a staff surgeon, by residents without supervision and by inexperienced surgeons, were compared.

RESULTS

Patients were comparable, except for liver function disorders and raised sedimentation rates, of which there were more in the group operated by the non-supervised residents, compared with the staff surgeons. Average operation time was 57 minutes in all four groups. Non-supervised residents had more retained stones than staff surgeons (19 vs 6%) and reported more bleeding during surgery than staff surgeons (21 vs 8%). Conversion rate was the same (3.9%) in all four groups. Complications occurred in 5.7%; this also was the same in the four groups.

CONCLUSION

Residents following a traditional surgical training without practice on animals, perform laparoscopic cholecystectomy as quickly as and with the same conversion and complication rates as their teachers.

Intraoperative digital subtraction angiography after thromboembolectomy: preliminary experience

PURPOSE

To evaluate the potential influence of intraoperative digital subtraction angiography (DSA) on surgical strategy after balloon thromboembolectomy for acute lower limb ischemia.

METHODS

Thirty-six consecutive patients with critical limb ischemia were treated with balloon catheter thromboembolectomy assessed by intraoperative digital subtraction angiography. The need for further intervention was determined by the surgeon based on the DSA information. Primary completion DSAs were made in every procedure; subsequent completion DSAs were performed after reinterventions at the discretion of the surgeon.

RESULTS

Initial treatment in this patient group consisted of 14 embolectomies and 26 thrombectomies. From the completion DSAs of these 40 procedures, a reintervention was judged necessary in 27 (68%). Of these 27 reinterventions, 17 underwent a secondary DSA; evidence supporting a third intervention was found in 11 (64%). Overall, a total of 69 DSAs were performed in these patients. Mortality was 22% (8 patients); 38% (5) in embolectomy patients and 13% (3) in the thrombectomy cohort. Eighty-eight percent of the embolectomy survivors had an uneventful recovery, while only 25% of the thrombectomy survivors experienced an uncomplicated follow-up. In one quarter of the surviving thrombectomy patients, a surgical revascularization resulted in limb salvage; in 45%, a major amputation was the outcome.

CONCLUSIONS

In this study, the completeness of balloon catheter thromboembolectomy was assessed by intraoperative DSA. As a result, 68% of the procedures required one or more reinterventions for residual lesions. Intraoperative DSA is a simple and quick technique that may be a promising adjunct to intraoperative balloon thromboembolectomy.

Preputial necrosis as an unusual cutaneous manifestation of cholesterol crystal embolization

We report a case of the cholesterol crystal embolization syndrome concomitant with an unusual cutaneous localization. Extensive embolization of cholesterol crystals caused severe necrosis of the prepuce. Circumcision was performed and histopathological examination confirmed the diagnosis.

A case of cystic adventitial disease of the popliteal artery demonstrated by magnetic resonance imaging

In a 45-year-old man, who was free of symptoms after a 3 1/2-month period of calf claudication, a diagnosis of cystic adventitial disease was confirmed by magnetic resonance imaging. At operation a 12 cm long intramural cyst of the popliteal artery, continuous with a cyst around a genicular arterial branch, was found. Total resection of the cyst and its branch was performed. We recommend computed tomography or magnetic resonance imaging as the diagnostic tools of first choice in young patients who are free of arteriosclerosis and who have episodes of intermittent claudication of the calf.

Locked intramedullary nailing of humeral fractures

Of 46 patients, 30 with fresh fractures of the humerus, nine with non-unions and seven with pathological fractures were treated with a new locked intramedullary nail. Of 30 patients with a fresh humeral fracture, three were lost to follow-up. All fresh fractures healed within 4 months. Functional results of the fresh fracture group were excellent in eighteen patients and satisfactory in three patients. Two patients with Neer type 6 fractures had unsatisfactory shoulder function; in the four other patients poor shoulder function resulted from a pre-existing condition. Out of nine non-unions, six united within 6 months. The three other patients with atrophic non-union required bone-grafting later, after which consolidation was obtained. The long functional recovery period of the non-union group was related to the pre-existing limited shoulder function. The seven patients with a pathological fracture died within 8 months of operation. While alive they were free from pain and could be nursed well.

Phosphorus magnetic resonance spectroscopy of the calf muscle in patients with peripheral arterial occlusive disease

RATIONALE AND OBJECTIVES

To investigate the potential of 31P magnetic resonance spectroscopy (MRS) in the management of severe peripheral ischemic disease, phosphocreatine:inorganic phosphate (PCr:Pi) and PCr:adenosine triphosphate (PCr:ATP) ratios were compared with a clinical ranking of arterial insufficiency.

METHODS

31P MR spectra of the muscles in the lower and upper leg were measured in a group of healthy volunteers (n = 21) and in a group of patients (n = 42) with arterial occlusive disease. The patients were graded according to the categories advised by the Ad Hoc Committee on Reporting Standards (AHCRS). Spectra were obtained 12 and 20 cm below and 15 cm above the knee joint.

RESULTS

The PCr:Pi ratio showed a significant decrease between measurements 12 and 20 cm below the knee joint for patients with severe arterial insufficiency (AHCRS 4-6), whereas this decrease was not found in patients with mild or moderate arterial insufficiency (AHCRS 1-3).

CONCLUSIONS

Although the observed spatial variation in PCr:Pi ratio measured at rest does not offer profound insight into muscle physiology, the authors' results suggest that MRS may be useful in assessing the severity of peripheral vascular disease.