Factors associated with successful laparoscopic cholecystectomy for acute cholecystitis

We have assessed the relationship between bone density, biochemistry and life-style factors in a cross-sectional study of 434 pre- and 357 postmenopausal women. Bone-mineral content (BMC) was measured in the non-dominant forearm using single-photon densitometry. Bone mass was corrected for bone size (BMC2) in a sub-set of 263 subjects. Correlation statistics and multiple regression analyses were used to identify physical and biochemical measurements that could be used to best predict BMC or BMC2. These were combined with lifestyle factors, using multiple logistic regression analysis, to identify women at risk of low bone density. Cut-off values were taken as the 5th percentile of the bone density distributions in pre-menopausal women. In postmenopausal women, using BMC2 values to define "risk", and using age, creatinine, alkaline phosphatase, thyroxine treatment, and calcium supplementation as predictors, a sensitivity of 73% and a specificity of 95% were achieved. Such a model may be of use as a "first pass" screening test for osteoporosis.     

Oesophageal dysmotility is not associated with poor outcome after laparoscopic Nissen fundoplication

BACKGROUND: Nissen fundoplication has become the standard operation in the surgical management of gastro-oesophageal reflux disease. Postoperative dysphagia is thought to occur more commonly in patients with oesophageal dysmotility and it has been recommended that fundoplication be modified or avoided in these patients. The aim of this study was to determine the outcome of patients with normal motility and dysmotility undergoing laparoscopic Nissen fundoplication. METHODS: This was a single-centre prospective cohort study with 1-year follow-up, using dysphagia as the main outcome variable. Of 81 patients who underwent laparoscopic surgery, 48 had normal motility and 33 had oesophageal dysmotility (defined as percentage peristalsis, using ten wet swallows, of 50 per cent or less and/or a mean distal pressure of less than 40 mmHg). RESULTS: Dysphagia was present before operation in 14 of 48 patients with normal motility and 15 of 33 in the dysmotility group (P=0.2). At 3-month follow-up, new or worse dysphagia was present in 13 of 48 patients in the normal group and four of 33 in the dysmotility group (P=0.17). At 1 year the incidence of dysphagia was six of 48 in the normal group and five of 33 in the dysmotility group (P=0.9). CONCLUSION: Preoperative manometric assessment of oesophageal motility does not correlate with postoperative outcome, and oesophageal dysmotility should not be regarded as a contraindication to laparoscopic Nissen fundoplication.     

Gynecologic laparoscopic surgery is not associated with an increase of serotonin metabolites excretion

Gynecologic laparoscopic surgery is associated with a high incidence of postoperative nausea and vomiting (PONV). The specific antagonists of the 5-hydroxytryptamine-3 (5-HT3) receptor have been progressively introduced in anesthesiology to prevent or treat PONV. Although a large increase of serotonin has been documented after cisplatin treatment, the link between serotonin and PONV in surgery/anesthesiology is unknown. In a prospective study, we compared the excretion of the serotonin metabolite 5-hydroxyindoacetic acid (5-HIAA) in 40 women undergoing either gynecologic laparoscopic surgery (laparoscopy group) or traditional open laparotomy surgery (laparotomy group). Premedication, anesthetic technique, and postoperative pain treatment were standardized. The excretion of 5-H IAA corrected to creatinine was measured in all patients immediately after the induction of anesthesia and was repeated regularly until 9 h after induction. The excretion of 5-HIAA/creatinine was similar in the two groups; no increase was observed in either group. The incidence of nausea and vomiting was 40% and 35%, respectively, in the laparoscopy group versus 60% and 15%, respectively, in the laparotomy group (not significantly different). The excretion of 5-HIAA/creatinine was comparable in patients of both groups among those who vomited and those who did not. We conclude that the creation of a pneumoperitoneum during gynecologic laparoscopic surgery is not associated with an increase of 5-HIAA excretion. PONV after gynecologic laparoscopic surgery is not explained by an increase of serotonin secretion. IMPLICATIONS: The mechanism leading to the high incidence of postoperative nausea and vomiting after gynecologic laparoscopic surgery is unknown. The excretion of the serotonin metabolite 5-hydroxyindoacetic acid did not increase during the creation of the pneumoperitoneum and the first 9 h postoperatively. Increase of serotonin secretion from the gut may not explain postoperative nausea and vomiting associated with this surgery.     

Pneumoperitoneum risk prognosis and correction of venous circulation disturbances in laparoscopic surgery. A pilot study

BACKGROUND: This study was initiated to find a method of determining the prognosis for possible changes in hemodynamic and respiratory parameters in patients with pneumoperitoneum (PP). METHODS: We devised a model for a pseudopneumoperitoneum (PPP), which is created by encircling the wide pneumochamber on the entire abdomen and inflating it to a preset pressure. To verify the prognostic possibilities of the proposed model, we studied the pneumotachygraphy parameters, noninvasive and invasive monitoring parameters of PPP after induction of anaesthesia, and venous circulation disturbances, as well as the medical effect of the intermittent sequential compression device. RESULTS: In healthy patients, the restrictive lung syndrome did not approach the risky limit. In patients >/=60 years old, this syndrome was very close to the limit. In a number of patients with serious cardiovascular and pulmonary pathology, the pressure of >10 mmHg was considered to be intolerable. Lung compliance, which was the parameter most sensitive to the increased intraabdominal pressure, was 47 +/- 10 at baseline, and 29 +/- 4 (p > 0.05) at both PPP and real PP (14 mmHg). CONCLUSIONS: The PPP model is quite similar to the real PP and can be used for preoperative prognosis in laparoscopic surgery. The elevated intraabdominal pressure results in a significant disturbance of venous blood flow in the lower extremities. The use of the device for peristaltic pneumomassage of the lower limbs is effective in correcting negative changes in venous hemodynamics in laparoscopic surgery.     

A tactile sensor for laparoscopic cholecystectomy

During laparoscopic surgery, surgeons observe the three-dimensional abdominal cavity on a two-dimensional TV monitor, which is a limitation. Another limitation is that surgeons are unable to estimate the softness of organs or tissues during laparoscopic surgery as they are only allowed to use instruments which touch objects and direct palpation is not permitted during the procedure. The tactile sensor which we used displays the object softness immediately as a digital score, which can then be superimposed on a TV monitor as a graph. With the tactile sensor, we were able to ascertain the presence of a gallstone in the gallbladder or cholecystic duct during laparoscopic cholecystectomy and also able to discriminate between a stone and an air bubble during intraoperative cholangiography. We were convinced that the tactile sensor would be useful in laparoscopic surgery, which does not permit surgeons to palpate objects with human fingers.     

Mirizzi syndrome type II: is laparoscopic cholecystectomy justified?

We have studied cell mediated and humoral response on the synovial fluid and peripheral blood of a 60-year-old man affected by ochronosis. Results showed raised percentages of CD3+, CD8+, HLA-DR+ and CD25+ T cells, presence of TNF, enhanced levels of immunoglobulins and low levels of C3 in the synovial fluid, and a higher rate of HLA-DR+ and CD25+ T lymphocytes in peripheral blood. These data suggest a possible role of immunological response the evolution of an ochronotic arthropathy.     

Splenic hypofunction in cirrhosis is not associated with increased risk for infections

Femoral artery pseudoaneurysm is a major problem in patients undergoing cardiac catheterization. This study describes our experience with 5 French (5 F) and 7 French (7 F) introduction sheaths and 7 investigators at our institution regarding the incidence of pseudoaneurysms. During 54 months (1/1990-6/1994) 8715 consecutive patients after diagnostic cardiac catheterization were first clinically checked for pseudoaneurysm and in case of suspicion a duplex sonography was performed. In 86 (1%) patients, 44 (52%) women and 42 (48%) men, mean age 63 +/- 9.7 years we observed this complication by duplex ultrasound. 54 (62%) patients had arterial hypertension, 18 (20%) diabetes and only 3 (3.6%) had peripheral arteriosclerosis. An antithrombotic medication was used in 60% (52 patients). As compared to a control group of 450 consecutive patients a pseudoaneurysm was significantly more likely to occur in patients with a history of hypertension (63% vs 25%, p < 0.0001). Women are also at higher risk representing 51% of all pseudoaneurysms as compared to 29% in the control group (p < 0.0001). Using 7-F catheters more pseudoaneurysms occurred (82/7183; 1%) than using 5 F (4/1532; 0.2%) introduction sheaths (p = 0.0005). There were also significantly more pseudoaneurysms caused by investigator 1 (21/787; 2.7%) as compared to the other investigators (65/7829; 0.8%), (p = 0.0002). Investigator 1 had a more distal puncture technique than the others. Pseudoaneurysms complicating cardiac catheterization occur 5-times more frequent using 7 F (1%) as compared to 5 F catheters (0.2%). Moreover distal puncture site is associated with a higher frequency of pseudoaneurysms.     

Comparison of laparoscopic and minilap cholecystectomy for acute cholecystitis

The charts of all patients with acute cholecystitis undergoing either laparoscopic or minilap cholecystectomy at the Chinle Comprehensive Health Care Facility between October 1, 1991, and August 15, 1993, were retrospectively reviewed. During that period, 54 patients underwent laparoscopic cholecystectomy and 45 patients had minilap procedures. The two groups had similar mean age, sex distribution, temperature, leukocyte count, gallbladder wall thickness, and duration of preoperative symptoms. While laparoscopic cholecystectomy took an average of 16 min longer to perform than minilap cholecystectomy, patients who had laparoscopic cholecystectomy had less blood loss, reduced postoperative narcotic needs, and shorter hospital stays.     

The case for routine operative cholangiography during laparoscopic cholecystectomy

The debate over routine versus selective intraoperative cholangiography during laparoscopic cholecystectomy continues because of a paucity of objective data to support or refute the case for either approach. The introduction of fluoroscopic techniques during the performance of cholangiography is an important step forward because it decreases the operative time for the technique and because real-time visualization may also diminish the number of false-positive and false-negative results. Routine cholangiography improves the surgeon's ability to delineate the biliary anatomy when the need arises and undoubtedly facilitates the development of skills useful for the laparoscopic management of common bile duct calculi. Normal results on intraoperative cholangiography are also reassuring to the surgeon, given the current visual and tactile limitations of laparoscopy. As a result of these considerations as well as our procurement of a digital fluoroscopic system and the need to train surgical residents in cholangiographic techniques, we have adopted a policy of routine fluoroscopic intraoperative cholangiography on all patients undergoing laparoscopic cholecystectomy.     

Immediate laparoscopic cholecystectomy as definitive therapy for acute cholecystitis

The objective of this study was to determine the safety and efficacy of immediate laparoscopic cholecystectomy in the management of acute calculous cholecystitis. A prospective data collection was performed on all patients admitted to one surgical service over a 2-year period. The patients were managed by a uniform protocol consisting of (1) preoperative ERCP when common duct stones were suspected; (2) operation within 24 h of diagnosis; and (3) selective operative cholangiography. Previous surgery was not a contraindication to inclusion. The setting was an urban teaching hospital. There were 52 patients, 34 females and 18 males. Nineteen had undergone previous abdominal surgery. Five patients had preoperative ERCP and five had intraoperative cholangiography. The patients underwent laparoscopic cholecystectomy 0.8 +/- 0.4 days postadmission. Four (7.7%) were converted to open cholecystectomy. Fifty-eight percent had spillage of bile and/or stones. Patients went home 2.3 +/- 1.6 days postoperatively. There were no deaths and two complications: a subhepatic biloma and a superficial wound infection. Follow-up of all patients has revealed no late complications. We conclude: (1) Immediate laparoscopic cholecystectomy is safe and effective for acute cholecystitis even when complicated by previous surgery, inflammatory adhesions, and gangrene. (2) Intraoperative spillage of bile and stones does not lead to an increase in early complications. (3) Cholangiography is needed only when clinically indicated. (4) Laparoscopic cholecystectomy should be the treatment of choice for patients admitted for acute cholecystitis.     

Endoscopic sphincterotomy and laparoscopic cholecystectomy in an infant with cholecysto-choledocholithiasis

Laparoscopic cholecystectomy (LC) and endoscopic sphincterotomy (EST) are widely accepted procedures for cholecysto-choledocholithiasis in adults. However, their use in infants has not been reported. An 8-month-old girl presented with high fever and obstructive jaundice. Ultrasound scan showed acute cholecystitis with stones in the bile duct. After 2-week-long antibiotic therapy the acute cholecystitis and hepatic impairment resolved. An endoscopic retrograde cholangiopancreatography (ERCP) confirmed choledocholithiasis and cholecystolithiasis. Risk factors for the development of biliary calculi were not detected. One month after the restoration of her liver function, she underwent EST using a side-viewing endoscope with a small sphincterotome. A common bile duct stone was extracted using a basket catheter. LC was then carried out. The time interval between the EST and LC was 34 days. No complications have been noted for 6 months.     

腹腔镜及开腹胆囊切除术治疗胆囊炎的对比分析

目的:比较腹腔镜胆囊切除术和开腹胆囊切除术治疗胆囊炎的疗效及并发症.方法:将2010年1月～2011年3月收治的80例患者作为研究对象,随机分成腹腔镜胆囊切除术组和开腹胆囊切除术组,两组各40例,观察两组术后恢复情况及并发症.结果:开腹组术后疼痛时间长于腹腔镜组(P <0.05),开腹组术后肛门排气明显晚于腹腔镜组 (P <0.05),开腹组术后下床活动时间明显晚于腹腔镜组 (P <0.05),开腹组术后感染等并发症的发生率明显高于腹腔镜组(P <0.05).结论:腹腔镜胆囊切除术比开腹胆囊切除术创伤小、疗效高、并发症少、疼痛轻、恢复快,且对患者的免疫功能影响较小,腹腔镜胆囊切除术的综合优势较明显,适用于临床推广使用.     

Intraperitoneal normal saline infusion for postoperative pain after laparoscopic cholecystectomy

After laparoscopic surgery carbon dioxide remains within the peritoneal cavity for a few days, commonly causing pain. This prospective randomized study was performed to determine the efficacy of intraperitoneal infusion of normal saline on postoperative pain after laparoscopic cholecystectomy. Altogether 300 patients were randomly assigned to one of five groups of 60 patients each. Group A: control group, no peritoneal infusion, no subhepatic drain. Group B: no peritoneal infusion but a subhepatic closed brain was left for 24 hours. Group C: normal saline 25 to 30 ml/kg body weight at a temperature of 37 degrees C was infused under the right hemidiaphragm and left in the peritoneal cavity. Group D: normal saline in a room temperature was infused under the right hemidiaphragm and suctioned after the pneumoperitoneum was deflated. Group E: normal saline was infused and suctioned as in group D, but a subhepatic closed drain was left for 24 hours. Postoperatively, analgesic medication usage, nausea, vomiting, and pain scores were determined at 2, 6, 12, 24, 48, and 72 hours (during hospitalization and at home). Postoperative pain was reduced significantly (p < 0.001) in the patients of groups C, D, and E versus controls, whereas no difference was observed between groups A and B. Among groups C < D and E, group E (p < 0.01) had the best results followed by group D and then group C. Intraperitoneal normal saline offered a detectable benefit to patients undergoing laparoscopic cholecystectomy. The beneficial effect was better when the fluid was suctioned after deflation of the pneumoperitoneum and even better when a subhepatic closed drain continued fluid suction during the first postoperative hours.     

An unusual complication of establishing a capnoperiteoneum for laparoscopic cholecystectomy

The authors describe the case history of a female patient indicated for laparoscopic cholecystectomy. In the patient with progressing muscular dystrophy and thickening of the peritoneum it did not prove possible to establish a capnoperitoneum at the onset of the operation.