Methods of analysis and resources available for genetic trait mapping

Stones can be spilled from the gallbladder during laparoscopic cholecystectomy. These stones can be left in the peritoneal cavity or trapped at the trocar site. The potential late sequel and associated morbidity are not well documented. We reviewed the records of four patients who underwent laparoscopic cholecystectomy at Mount Sinai Medical Center in New York City who suffered from late complications attributed to gallstones left in the peritoneal cavity or abdominal wall. Four patients presented 1-14 months after laparoscopic cholecystectomy with intraabdominal and abdominal wall abscesses. The spillage of gallstones was noticed during the initial operation only in one of the patients. Three patients required laparotomy and open drainage of intraabdominal abscesses with drainage of pus and gallstones after failed attempts at percutaneous drainage. Two patients underwent local exploration of an abdominal wall abscess containing stones. Stones left in the abdominal cavity or trapped in trocar sites after laparoscopic cholecystectomy can cause serious late complications requiring repeated surgical interventions. Every effort should be made in order to avoid spillage of stones during dissection of the gallbladder and cystic duct and during retrieval of the gallbladder through the abdominal wall.     

Three major coronary artery-to-left ventricular shunts: report of three cases and review of literature

The gallbladder is perforated and stones are spilled more frequently during laparoscopic cholecystectomy than during open cholecystectomy. Recent reports have implicated spilled gallstones as a source of infrequent but serious complications of laparoscopic of laparoscopic cholecystectomy. They can cause serious morbidity, and in most cases the patient will require open surgery for management of these complications. The authors report the case of a patient who was ill for 14 months after laparoscopic cholecystectomy when spilled stones formed a nidus for intra-abdominal abscess and colocutaneous fistula. Every effort must be made to prevent gallbladder perforation. When it does occur, all stones should be retrieved. Attempts at repairing gallbladder perforations are often unsatisfactory. A simple solution to this potential problem is to retrieve all stones immediately, place them in an intraperitoneal specimen bag, and "park" the bag on the liver. As soon as the gallbladder is dissected off the liver it should be placed in the specimen bag with the stones and removed through the umbilical port opening.     

Training staff to provide a continence helpline

We report here the operative findings, the incidence of successful laparoscopic treatment, and the perioperative complications in patients with nonvisualized gallbladder on drip infusion cholangiography (DIC). Eighty-five patients with a nonvisualized gallbladder on DIC were entered into the study. None of the patients had a minimal adhesive gallbladder; 51 to 85 patients (60.0%) had moderate adhesive gallbladders, and 34 (40.0%) had severely adhesive ones. The rate of successful laparoscopic treatment, including laparoscopy-assisted abdominal surgery, was 97.6% (83 of 85 patients). Perioperative complications occurred in only three patients (3.5%), and there were no deaths related to the operation. Thus, when patients with a nonvisualized gallbladder on DIC undergo laparoscopic cholecystectomy, meticulous procedures must be carried out; however, as the rate of successful laparoscopic treatment is high, cholecystectomy under laparoscopy is feasible for experienced surgeons.     

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.     

Complications of laparoscopic cholecystectomy in China: an analysis of 39,238 cases

OBJECTIVE: To investigate the complications of laparoscopic cholecystectomy in China. METHODS: All Chinese articles about laparoscopic cholecystectomy published between April 1994 and November 1995 were identified through CMCC (Chinese Medical Computerized Contents). From more than 600 titles, 105 articles were screened for analysis. Another 21 articles from the 6th Biliary Surgical Congress and 300 cases from the General Hospital of PLA were added. A total of 39,238 cases of laparoscopic cholecystectomy from 91 hospitals were studied. RESULTS: Severe complications of laparoscopic cholecystectomy were identified in 409 (1.04%) patients, including bile duct injury (in 0.32% of patients), postoperative cystic duct leak (0.11%), postoperative bile leak (0.20%), peritoneal abscess (0.07%), bowel injury (0.06%) and postoperative hemorrhage (0.1%). Fourteen postoperative deaths (0.04%) resulted from operative injury. CONCLUSIONS: The data demonstrate that laparoscopic cholecystectomy is an operation associated with low morbidity and mortality rate, but bile duct injury is still a major problem. Complications of laparoscopic cholecystectomy can be minimized by improving operative procedure.     

Laparoscopic cholecystectomy for gallbladder stones

The authors describe the technique for the treatment of gallbladder stones using a laparoscopic approach and discuss the diagnostic and operative flow chart stressing complications and ways to avoid them. A total of 2517 non-selected patients underwent surgery since october 1990 up to september 1995. 252 were affected by acute cholecystitis (10%); 172 underwent emergency laparoscopic cholecystectomy. ERCP was performed in 278 patients (11.04%): 177 underwent endoscopic sphincterotomy and laparoscopic cholecystectomy, 21 underwent laparoscopic cholecystectomy before sphincterotomy, 8 laparoscopic cholecystectomy and ESWL. Laparoscopic cholecystectomy was converted into laparotomy in 37 patients (1.4%); surgery was abandoned in 3 patients following to onset of intense bradycardia. Major complications were observed in 0.63%; bile duct injury occurred in four patients (0.15%). One patient died following a massive intraoperative myocardial infarction. Average operative time was 21 minutes. Only 22.8% of patients required mild analgesia on the first day after surgery. The average hospital postoperative stay was 2.6 days. Return to work took place in 98% of non complicated patients within one week of being discharged from hospital.     

Retrieval of spilled stones during laparoscopic cholecystectomy

Laparoscopic cholecystectomy is now widely practised in the Western world. One of the more common and often neglected complications is perforation of the gallbladder and spillage of bile and stones. With careful attention to technique this should be a rare complication. The effect of bile and stone spillage may depend on the presence or absence of biliary infection at the time of operation. When stone spillage occurs a number of options are available for the retrieval of stones and these are highlighted in this paper.     

Laparoscopic cholecystectomy--analysis of the first 100 operations

Laparoscopic cholecystectomy is a surgical method of removing the gallbladder through four small incisions on the abdominal wall using laparoscopic technique with specially designed equipment and instruments. The method is characterized with the following: reduced operative trauma and postoperative pain, shorter hospital stay, quicker recovery and better cosmetic effect. This method is in surgical practice in the last 10 years, whereas in General Hospital in Senta, in the surgical department it was introduced in June 1995. In the period June 16, 1995-March 1, 1996 one hundred patients underwent laparoscopic cholecystectomy. The median age of patients was 48 years; 79% were females and 21% were males. There was no operative mortality. Four (4%) mild complications occurred. Conversion was performed in only one patient (1%). The average operation time was 54 minutes, while the postoperative hospital stay was 2.3 days.     

Factors that may increase morbidity in a model of intra-abdominal contamination caused by gallstones lost in the peritoneal cavity

OBJECTIVE: To assess the effect of intraperitoneal gallstones with and without Escherichia coli and sterile bile on the incidence of intraperitoneal complications in mice. DESIGN: Prospective randomised study. SETTING: Teaching hospital, Turkey. MATERIAL: 180 Swiss albino mice in five groups, n = 20 in the control group, and n = 40 in each of the experimental groups. INTERVENTIONS: Group A laparotomy alone (controls); group B, laparotomy amd intraperitoneal instillation of E. coli 4 x 10(6) 0.1 ml; group C, laparotomy and insertion of sterilised gallstones; group D, laparotomy, insertion of gallstones and instillation of E. coli 4 x 10(6) 0.1 ml; and group E, laparotomy, insertion of gallstones, and instillation of E. coli 4 x 10(6) 0.1 ml and sterile bile 0.1 ml. A quarter of each group was killed after 1, 2, 4, and 8 weeks. MAIN OUTCOME MEASURES: Intra-peritoneal abscesses, adhesions, perforations, fistula, or obstruction. RESULTS: No mice died. Adhesions were found in 3(15%), 7(18%), 30(75%), 25(63%), and 24(60%) in the five groups, respectively. No mice in groups A, B, or C developed an abscess, but 8 did in each of groups D and E (20%). One mouse in group D developed obstruction. Logistic regression showed that abscess formation was significantly increased by the addition of gallstones and E. coli to the peritoneal cavity (p < 0.001) but the addition of bile had no effect. Gallstones increased the rate of adhesions more than nine fold (p < 0.001) but E. coli with or without bile had no effect (p = 0.75). CONCLUSIONS: Free gallstones within the peritoneal cavity with or without E. coli or sterile bile, or both, increased the rate of formation of both abscesses and adhesions in mice. These results suggest that efforts should be made retrieve gallstones that are dropped into the peritoneal cavity during laparoscopic cholecystectomy, particularly in patients with acute cholecystitis.     

Does the "Bergetrokar" decrease the rate of intraoperative complications in laparoscopic cholecystectomy?

Several international surveys have proved the laparoscopic cholecystectomy as a safe surgical technique. In spite of the good results there still exist operation-specific technical problems. The perforation of the gallbladder during dissection or while extracting it from the abdominal cavity can lead to severe complications. We analysed retrospectively 352 extractions of the gallbladder carried out with our 'Bergetrokar'. In 1.4% occurred perforation of the gallbladder and in 0.85% we had trouble with the healing. In 3.5% extraction could not be performed with the 'Bergetrokar'. Regarding these results our rates have been lower as compared in literature. In our opinion the extraction of the gallbladder through the lateral incision using the Bergetrokar represents a further step toward a safe extraction of the stonefilled gallbladder. Further the infection rate at the umbilical incision is reduced.     

Laparoscopic cholecystectomy in pregnancy

Several recent literature reviews have shown that Laparoscopic cholecystectomy can be performed safely in pregnant females with symptomatic gallbladder disease. We have performed a retrospective analysis of all patients who underwent a cholecystectomy (6,080 patients) from January 1, 1990 until December 31, 1996 at San Pablo Medical Center. Lapa-cholecystecomy was performed in 4,252 (64%) and in the remaining 1,828 (36%) patients, an open cholecystectomy performed. Of the Laparoscopic cases, 5(0.1%) were performed in pregnant females with complicated gallbladder disease(GBD). The diagnosis of GBD was done with an abdominal sonogram. Four of the 5 patients had suffered from gallstones pancreatitis and one acute cholecystitis, prior to the operation. The records of patients were reviewed to secure the following variables, age, pre and post operative course and outcome. Intraoperative cholangiogram performed in 1 patient. No complications were seen in the mother or in the fetus in any of the five cases. Literature was reviewed to assess our reports. Conclusions: Pregnant females with complicated gallbladder disease can be safely managed with Laparoscopic cholecystectomy.     

Calibration of a reflectance pulse oximeter in fetal lambs for arterial oxygen saturations below 70%

Today, laparoscopic cholecystectomy is the method of choice for treatment of symptomatic gallbladder disorders. It minimizes effects of the operation that are independent of the gallbladder, such as trauma to the abdominal wall and other soft tissue. The surgical wounds were even smaller when 2-mm trocars were used. Laparoscopic cholecystectomy using 2-mm instruments was performed in a consecutive series of 14 patients with symptomatic gallstones. The procedure was completed in 12 cases, with conversion to open surgery in two cases. Intraoperative cholangiography was always performed. The postoperative course was always uneventful. The cosmetic effect was highly satisfactory. The procedure using 2-mm instruments could be indicated in selected patients with uncomplicated gallstone disease.     

Cholecystectomy with intraperitoneal drain. Presence and significance of conjugated bilirubin in the drainage fluid

The content of conjugated bilirubin in the drainage fluid of 85 patients, operated upon consecutively with cholecystectomy and intraperitoneal drain for nonacute gallbladder pathology was measured by the adapted method of Jendrassik and Grof. The measured amounts varied from 0 to 755 micromol. A weak correlation was found between the concentration of conjugated bilirubin and the total amount of drainage fluid (r = 0.37). In the majority of patients the evacuated amounts of conjugated bilirubin corresponded to the content of bilirubin in a few milliliters of hepatic bile. In 10% of the patients there were however greater amounts of conjugated bilirubin in the drainage fluid. Greater amounts of conjugated bilirubin were significantly more often evacuated from patients operated upon by surgeons with less than 3 years of surgical experience compared to patients operated upon by more experienced surgeons. The amount of conjugated bilirubin in the drainage fluid was not significantly correlated with operative blood loss, dryness of the operative field at the end of the operation or iatrogenic perforation of the gallbladder during operation. Higher (however not significant) temperatures and bilirubin levels in serum were observed in patients with greater amounts of conjugated bilirubin in the drainage fluid. Increased amounts of conjugated bilirubin in the drainage fluid were not significantly associated with increased postoperative morbidity. Two of the patients with large amounts of conjugated bilirubin in the drainage fluid were reoperated because of bile leakage/abscess but the remaining patients had no serious complication, which could be a result of efficiency of the intraperitoneal drain.     

Relation between postoperative infections and gallbladder bile leakage during laparoscopic cholecystectomies

BACKGROUND: In 1,577 laparoscopic cholecystectomies, 111 due to acute and 1,466 due to chronic cholecystitis, the incidence of intraoperative gallbladder rupture and its relationship with abdominal wound infections were evaluated. METHODS: A sampling test for binomial proportions and a binomial approximation test for discrete data were employed for statistical analysis. Gallbladder accidental opening took place in 250 (19%) out of the 1,466 chronic and in 44 (40%) out of the 111 acute cholecystitis, disclosing a statistically significant difference (p < 0.01). Postoperatively, there were 32 (2%) surgical wound infections, 17 (1.3%) in the absence of gallbladder injury and 15 (5%) when gallbladder injury was observed, likewise showing a statistically significant difference (p < 0.05). RESULTS: It should be pointed out that all 32 wound infections involved the umbilical incision, of which 3 with chronic suppuration required reintervention where remnants of stones were found in the parietal route. The seven with symptomatic abdominal fluid resolved without specific treatment. As regards the seven intraabdominal infections, two remitted with antibiotics and five required percutaneous drainage. There was no significant correlation between the presence of cavity fluid abdominal collections or infections and bile spillage. CONCLUSION: Gallbladder injury proved more frequent in laparoscopic cholecystectomies performed due to acute cholecystitis, while bile spillage increased the incidence of umbilical wound infection, particularly in the presence of remnants of stones, but there was no correlative increase in the incidence of intraabdominal collections or infections.     

Disposition of SDZ ENA 713, an acetylcholinesterase inhibitor, in the rabbit

AIM: Results evaluation of laparoscopic cholecystectomy in acute cholecystitis. MATERIAL AND METHOD: Between 1994-1997 we performed 65 laparoscopic cholecystectomies for histopathologically proved acute lithiasic cholecystitis. We studied clinic and echographic diagnosis, operative moment, conversion rate, operative time, postoperative morbidity and hospitalization. The cholecystectomy was performed within 72 hours in 18 patients (trial I), 4 to 7 days in 25 patients (trial II) and over 7 days in 22 patients (trial III). RESULTS: Diagnosis of acute lithiasic cholecystitis was always possible by clinical examination and ultrasonography. We performed 8 conversions in patients of trial II (2) and III (6). The mean operative time was 68 min. Postoperative morbidity consisted in 4 bile leakages in the liver bed, 1 subhepatic abscess, 5 right pleural effusions. The mean hospitalization was 4.4 days. CONCLUSIONS: Urgent laparoscopic cholecystectomy is a beneficial act for acute lithiasic cholecystitis. The operative moment is the most important factor of influence on conversion rate, operative time and postoperative morbidity.     

Preoperative diagnosis of laparoscopic cholecystectomy. Is there an indication for routine intravenous cholangiography?

In a retrospective study including 163 patients we investigated the necessity of i.v. cholangiography in preoperative routine diagnostic workup prior to laparoscopic cholecystectomy. We evaluated the evidence of i.v. cholangiography concerning the anatomy of the biliary system, the evidence of common bile duct or cystic duct stones and the influence on the further therapeutic procedure. While the common bile duct could be demonstrated in 96.3%, the cystic duct could be visualized in only 54.6%. One out of two patients with a short cystic duct was identified. Stones in the gallbladder were recognized in 72.4% of cases, while only two out of three patients with common bile duct stones were diagnosed. In nine cases a deep junction of the cystic duct was found, but there was no influence on further operative procedure. Thus we found no improvement after routine use of i.v. cholangiography concerning the evidence of common bile duct stones or avoidance of intraoperative lesions of the common bile duct. The routine use of i.v. cholangiography prior to laparoscopic cholecystectomy is therefore not justified.     

Laparoscopic cholecystectomy and lithiasis of the common bile duct: prospective study on the importance of preoperative endoscopic ultrasonography and endoscopic retrograde cholangiography

OBJECTIVES: Laparoscopic cholecystectomy is the standard treatment of symptomatic gallstones. At present, no consensus has been reached on the diagnostic and therapeutic methods of concomitant common bile duct stones. Systematic preoperative endoscopic ultrasonography followed, if necessary, by endoscopic retrograde cholangiography and sphincterotomy during the same anesthetic procedure could be a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct. METHODS: One hundred and twenty-five patients underwent a prospective endoscopic ultrasonographic evaluation prior to laparoscopic cholecystectomy for symptomatic gallstones. Fourty-four patients (35%) had at least one predictive factor for common bile duct stones. Endoscopic ultrasonography and cholecystectomy were performed on the same day. Endoscopic ultrasonography was followed by endoscopic retrograde cholangiography and sphincterotomy by the same endoscopist in case of common bile duct stones on endoscopic ultrasonography. Patients were routinely followed up between 3 and 6 months and one year after cholecystectomy. RESULTS: Endoscopic ultrasonography suggested common bile duct stones in 21 patients (17%). Endoscopic ultrasonography identified a stone in 17 of 44 patients (38.6%) with predictor of common bile duct stones and only in 4 of 81 patients (4.9%) without predictor of common bile duct stone. Among these 21 patients, one patient was not investigated with endoscopic retrograde cholangiography because of the high risk of sphincterotomy, 19 patients had a stone removed after sphincterotomy, one patient had no visible stone neither on endoscopic retrograde cholangiography, nor on exploration of the common bile duct after sphincterotomy. Endoscopic ultrasonography was normal in 104 patients (83%). However, two patients in this group were investigated with endoscopic retrograde cholangiography because endoscopic ultrasonography was incomplete in one case and because endoscopic ultrasonography was normal in the second case but a stone in the left hepatic duct was detected by ultrasonography. A stone was removed after endoscopic sphincterotomy in these two patients. In the group of 102 patients without stone, 91 out of 92, continued to be asymptomatic during a median follow-up of 8.5 months. One patient with symptoms one month after cholecystectomy underwent endoscopic sphincterotomy but no stone was found. CONCLUSIONS: Systematic preoperative endoscopic ultrasonography followed, if necessary with endoscopic retrograde cholangiography and sphincterotomy is a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct for all patients. This alternative is only justifiable in patients with predictor of common bile duct stones.     

The effects of cardiotoxic chemotherapy on blood pressure in patients with lymphoma

A retrospective study was carried in 1500 patients submitted to elective laparoscopic cholecystectomy to ascertain its feasibility in patients with previous abdominal surgery. In 411 patients (27.4%) previous infraumbilical intraperitoneal surgery had been performed, and 106 of them (7.06%) had 2 or more operations. Twenty five patients (1.66%) had previous supraumbilical intraperitoneal operations (colonic resection, hydatid liver cysts, gastrectomies, etc.) One of them had been operated 3 times. In this group of 25 patients the first trocar and pneumoperitoneum were performed by open laparoscopy. In 2 patients a Marlex mesh was present from previous surgery for supraumbilical hernias. Previous infraumbilical intraperitoneal surgery did not interfere with laparoscopic cholecystectomy, even in patients with several operations. There was no morbidity from Verres needle or trocars. In the 25 patients with supraumbilical intraperitoneal operations, laparoscopic cholecystectomy was completed in 22. In 3, adhesions prevented the visualization of the gallbladder and these patients were converted to an open procedure. In the 2 patients Marlex mesh prevented laparoscopic cholecystectomy because of adhesions to abdominal organs. We conclude that in most instances previous abdominal operations are no contraindication to laparoscopic cholecystectomy.     

Laparoscopic cholecystectomy. Do preoperative factors predict the need to convert to open?

We reviewed our experience with the last 587 laparoscopic cholecystectomies performed between May 1990 and January 1993 to correlate preoperative findings that may predict the conversion of a laparoscopic cholecystectomy to that of an open procedure. The prediction of a need to convert to an open cholecystectomy would allow the surgeon to discuss the higher risk of conversion with the patient and also allow for an earlier intraoperative decision to convert if difficulty was encountered. In addition to routine demographic data, ultrasound reports were available for 526 patients and the following information was recorded: presence of stones, thickened gallbladder wall, common bile duct dilatation, gallbladder sludge, and cystic duct impaction. Overall, a two times higher rate of conversion was found for male patients and patients with a body mass index > 27.2 kg/m2. Additionally, a thickened gallbladder wall on preoperative ultrasound was correlated with a six times higher conversion rate to open cholecystectomy. As expected, the positive intraoperative cholangiogram was associated with a higher incidence of conversion. Additionally, finding a dilated common bile duct on ultrasound was found to be associated with a nearly seven times higher rate of positive intraoperative cholangiogram. No statistical significance was found between conversion and age, previous abdominal operations, the presence of stones, common bile duct dilatation, gallbladder sludge, cystic duct impaction, or a distended gallbladder. Thus, these predictive findings allow the surgeon to preoperatively discuss the higher risk of conversion and allow for an earlier judgment decision to convert if intraoperative difficulty is encountered.     

Laparoscopic cholecystectomy in cirrhotic patients

BACKGROUND/AIMS: Laparoscopic and open cholecystectomy are the safest procedures for all diseases related to stones in the gallbladder as they have a low morbidity and mortality rate. However, the safety of laparoscopic cholecystectomy in cirrhotic patients has not been investigated. The goal of this study was to evaluate the safety of laparoscopic cholecystectomy in cirrhotic patients. METHODOLOGY: A retrospective study of laparoscopic cholecystectomy in cirrhotic versus non-cirrhotic patients was performed. Between January 1991 and November 1994, 605 laparoscopic cholecystectomies for symptomatic gallbladder diseases were performed. There were 21 patients in the cirrhotic (group A) and 584 patients in the non-cirrhotic (group B). RESULTS: There was no operative mortality in either group and the postoperative complication rates were 4.8% and 5.8% in group A and B, respectively (p > 0.05). Prolonged operative time in group A was 84.47 +/- 36.01 min vs group B 62.20 +/- 25.37 min (p < 0.01). The estimated intraoperative blood loss in group A was larger than in group B (140.76 +/- 201.19 ml vs 35.02 +/- 50.11 ml, p < 0.01). The readmission rate was higher in group A (9.5%) than in group B (1.37%) (p < 0.05). The hospital stay in group A and B were 4.12 +/- 2.15 D, 3.50 +/- 1.50 D respectively (p > 0.05). The incidence of conversion and re-operation rates indicated no difference between cirrhotic and non-cirrhotic groups. CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed in mild cirrhotic patients with more operative times and meticulous management of intraoperative bleeding.