Abscesses caused by "dropped" stones after laparoscopic cholecystectomy for cholelithiasis: a report of three cases

This presentation gives an overview about the factors involved in the regulation of gluconeogenesis. Then, based on these regulatory principles, the changes seen in impaired liver function are discussed. Gluconeogenesis from lactate and pyruvate is mediated through pyruvate carboxylase (PC) and phosphoenolpyruvate carboxykinase (PEPCK) activity. The PC mediated pathway depends on substrate supply and on the downregulation of the oxidative pathway for pyruvate. Both enzymes need ATP or GTP and, thus, depend on the cellular energy charge. Tissue anoxia can reduce the energy charge and limit the flow through the PEPCK pathway. Thus, one expects a coupling between reduced splanchnic blood flow, limited oxygen supply to the liver, resulting tissue anoxia, and reduced gluconeogenesis. Conditions are shown, where this coupling exists. Since gluconeogenesis is concentrated in the periportal region of the liver, the local oxygen tension is sufficient under many circumstances to maintain a high glucose production level. Also, the enzyme activity of PEPCK can compensate for long term anoxia. Thus, gluconeogenesis is sufficient in most cases, as seen in critically ill patients. However, this could be associated with a reduction in the perivenous oxygen tension, possibly below critical levels. Beta-adrenergic stimulation increases gluconeogenesis. Examples are shown where this stimulation can overlay the dependency on the oxygen tension and substrate supply. Catecholamines are generally used to stabilize the hemodynamic system. This treatment could limit splanchnic bloodflow and, as a consequence, the oxygen supply to the liver with a simultaneous stimulation of gluconeogenesis and can cause severe anoxia in the perivenous region. These negative side effects of catecholamine treatment should be avoided and the ideal treatment should aim at improving splanchnic flow without stimulation of gluconeogenesis.     

Combined laparoscopic and endoscopic approach in patients with cholelithiasis and choledocholithiasis

BACKGROUND: The Optimal management of common bile duct stones in patients undergoing laparoscopic cholecystectomy remains controversial. METHODS: A prospective study was conducted in 145 of the 481 patients who had a preoperative endoscopic retrograde cholangiogram before their laparoscopic cholecystectomy. RESULTS: Endoscopic retrograde cholangiogram was successful in 138 patients (95%), and common duct calculi were found in 72 (50%) of them. Endoscopic sphincterotomy with ductal clearance was achieved in 62 of 67 patients during a mean of 1.4 sessions (range, 1 to 5). Five (3.4%) patients had complications after endoscopic intervention, all of which resolved uneventfully . Fourteen patients underwent laparoscopic common duct exploration, five had failed endoscopic extraction, five had their common duct stones left intentionally for laparoscopic intervention, and, in addition, four of the seven patients who had a failed endoscopic retrograde cholangiogram had stones identified by intraoperative cholangiogram. Ten of these 14 patients underwent a successful laparoscopic common duct exploration. Laparoscopic cholecystectomy was successfully completed in 134 of the 145 patients, and none had major intraoperative or postoperative complications. The mean postoperative stay was 2.7 days for those patients who underwent a successful laparoscopic procedure. The overall mean number of admissions for completing the treatment was 2.3. CONCLUSIONS: Combined laparoscopic and endoscopic approach is a viable option for patients with gallstones and choledocholithiasis.     

Combined laparoscopic and endoscopic management of cholelithiasis and choledocholithiasis

With the advent of laparoscopic cholecystectomy, optimal management of common duct stones remains controversial. Seven hundred six patients underwent laparoscopic cholecystectomy in our institution from January 1990 through January 1992. From this group of patients, 50 were identified as having clinical or radiographic evidence of common duct stones. Thirty-one patients demonstrated preoperative risk factors for common duct stones and underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP). The risk factors included jaundice (19%), pancreatitis (23%), elevated liver function tests (52%), and ultrasound evidence of choledocholithiasis (6%). Preoperative ERCP was performed in 94% of patients. There were two failures due to periampullary diverticula. Common duct stones were identified in 18 patients (62%) and successfully removed by endoscopic sphincterotomy in all of these patients. Nineteen patients were found to have unsuspected common duct stones on intraoperative cholangiography. Eighteen patients (95%) underwent successful ERCP and endoscopic sphincterotomy with stone extraction. Overall, major morbidity was 2% and included one patient who experienced endoscopic sphincteroplasty. The three endoscopic failures were managed by open common duct exploration, laparoscopic duct exploration, and combined laparoscopic and open common duct exploration. We conclude that combined laparoscopic and endoscopic therapy is a viable option for the management of cholelithiasis with choledocholithiasis.     

Ultrasonography in the preoperative assessment of candidates for laparoscopic cholecystectomy: examination technique and results]

We have investigated the use of a microwave cavity (Labwell AB, Sweden) to improve the radiochemical yield of 2-[18F]fluoro-2-deoxyglucose (2-[18F]FDG). After characterizing the heating properties of the cavity, three steps of the Hamacher 2-[18F]FDG synthesis which require heating--azeotropic distillation of the target water, nucleophilic substitution, and hydrolysis of the product--were investigated separately. The average radiochemical yield of 2-[18F]FDG for the microwave synthesis, using the phase transfer reagent tetrabutylammonium bicarbonate, was 62 +/- 4% (72 +/- 5%, decay corrected, synthesis time = 31 min).     

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.     

A case with subcapsular hematoma of the liver following laparoscopic cholecystectomy

The occurrence of intracerebral hemorrhage during an acute attack of migraine remains questionable. A normotensive migrainous woman experienced multiple intracerebral hemorrhages. No drug abuse was recorded, but bleeding occurred after the use of several antimigrainous drugs. Angiography revealed severe vasospasm of both anterior cerebral arteries. Subsequent brain MRI and MRI angiography failed to show any vascular abnormalities. Echocardiography and an exhaustive biological evaluation ruled out an alternative condition favoring intracerebral hemorrhage. Multiple intracerebral hemorrhages in migraine may exceptionally be related to vasospasm leading to arterial wall injury. Intracranial arterial vasospasm could be precipitated by excessive vasoactive therapy.     

The effect of pentoxifylline on treatment results and course of rehabilitation of patients after ischemic stroke

The study has been taken up to compare the effect of treatment with pentoxifylline and typical treatment in early ischaemic stroke. The study included 107 patients aged 42-85, with the ischaemic stroke confirmed by CT scan, in early stage of stroke (within 24 hours after onset). Excluded from the study were patients with severe physical diseases. The patients were divided into two groups. Group I was treated typically, group II had been profited from a typical, appropriate therapy and pentoxifylline delivery during 30 days as well, with a daily dose of 1200 mg i.v. within the first 5 days followed by an oral dose of 800 mg subsequent days. Such a treatment has been continued until 12th month. The neurological state was assessed according to the European Stroke Scale (ESS) and Mathew Scale (MS), general fitness according to the Kamofsky Scale (KS) and Barthel Index (IB) at the admission, after 30 days and 12 months of the treatment. Quality of life assessment using by Oxford Handicap Scale and Frenchay Activities Index. After 30 days and 12 months of the treatment, no statistically significant differences between all study groups was found in: 1) mortality, 2) mean survival time, 3) neurological and functional state, 4) quality of life. According to the above results the beneficial influence of pentoxifylline treatment of ischaemic stroke was not confirmed.     

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.     

The value of laparoscopic cholecystectomy in the treatment of gallbladder pathologies]

We have prospectively studied all cholecystectomies performed in one year in our clinic in two groups: 190 cases performed laparoscopically and 98 open. We used standardized records and the EPI 5 program on an IBM compatible computer. There were no significant differences between groups regarding weight, sex and proportion of cases with acute cholecystitis. There were however major differences regarding age, type of habitat, ASA score and association with acute pancreatitis, obstructive jaundice and angiocholitis. Conversion of laparoscopic cholecystectomy to open procedure was imposed in 17 cases (not included in statistical analysis) due to technical difficulties (12 cases), haemorrhagic accidents (6 cases), injury of the common bile duct (1 case), stones lost in the abdominal cavity (3 cases), local peritonitis (5 cases). Laparoscopic cholecystectomy lasted a mean of 74 minutes. We encountered 3 specific complications: one CBD injury recognized intraoperatively and managed by Kehr's procedure (one CBD injury in the open cholecystectomy group), one small bowel perforation and one of biloma. Mortality averaged 0.5% in the LC group (one case of late postoperative stroke considered not related to the procedure) and 1% in the open cholecystectomy group. The hospital admission period was significantly reduced in the LC group (5 days vs. 12 days). LC appears as a safe procedure with a low complication rate. Conversion to open procedure is not a complication. Our study recommend LC as the method of choice in the treatment of gallbladder lithiasis.     

Comparison of laparoscopic ultrasonography and fluorocholangiography in 300 patients undergoing laparoscopic cholecystectomy

BACKGROUND: This study compares laparoscopic ultrasonography to fluorocholangiography in detecting common bile duct (CBD) stones and delineating biliary anatomy. METHODS: A prospective nonrandomized study of 300 consecutive patients undergoing laparoscopic cholecystectomy in a university hospital was performed. After port placement but before dissection, laparoscopic ultrasonography of the extrahepatic CBD was performed in both transverse and longitudinal planes. Cystic duct fluorocholangiography was attempted in all patients. RESULTS: Of 300 patients, CBD stones were detected in 26 (9%) with 25 of these (96%) detected on laparoscopic ultrasonography. Sonography identified the location and size of the CBD as well as anomalous anatomy prior to dissection. No CBD injuries were encountered. End-fire transducers were easier to use than rigid or flexible side-fire transducers; all gave excellent image quality. CONCLUSIONS: In this large study, laparoscopic ultrasonography and fluorocholangiography were equally sensitive in detecting CBD stones. Sonography delineates the biliary anatomy noninvasively and does not require dissection or opening of the biliary system. Laparoscopic ultrasonography may improve the safety of laparoscopic cholecystectomy, especially in cases of acute inflammation or distorted anatomy.     

The princess and the pea. An unusual complication after a laparoscopic cholecystectomy

A vena porta choledochal fistula caused by an adenocarcinoma arising from a type I choledochal cyst was detected in a 42-year-old woman. The diagnostic and therapeutic aspects of this malignancy are discussed.     

The effect of chenotherapy on the reservoir function of the gallbladder in cholelithiasis patients]

The effect of chenodeoxycholic acid (CDCA) on the reservoir function of the gallbladder was studied in 46 patients with cholesterol cholelithiasis. There was a dependence between a clear increase of filling of the gallbladder in patients treated by this method with subsequent sharp reduction of its size and development of dyspepsia and diarrhea. In 14 patients increase of the gallbladder against the background of chemotherapy was not authentic but no dyspeptic phenomena occurred. Thus, decompensation of the reservoir function of the gallbladder in patients with cholelithiasis against the background of chemotherapy are manifested by a significant increase of the gallbladder size with subsequent emptying of bile into the duodenum and development of collagenous diarrhea.     

The role of relaparoscopy in the management of bile leaks after laparoscopic cholecystectomy

An ultrasound phantom is described which allows practice of ultrasound-guidance of needle placement over variable depths and into targets of variable size. The phantom mimics a solid organ in its echogenicity and can be cheaply and easily made from resources of the domestic kitchen.     

Standard means in laparoscopic surgery. The peculiar case of cholecystectomy

Legal suits against visceral surgeons have increased since the advent of laparoscopic surgery. The duties of physicians have not however changed with the development of laparoscopic techniques. Since the decree promulgated in 1936, physicians have a legal commitment to provide the means required for patient care. This obligation has been recalled in different court judgements and in the new deontology code. In addition, jurisprudence tends more and more towards responsibility without risk. Laparoscopic cholecystectomy is not risk-free. Although morbidity and mortality have not risen with laparoscopic procedures, the types of complications encountered have changed. Reported accidents have become more frequent. The number of suits against surgeons has also increased. Surgeons must therefore be highly prudent and diligent. Precautions concerning personnel management, the choice of material and its upkeep. Special care must be given to the peroperative pneumoperitoneum and the use of monopolar electrocoagulation. A peroperative cholangiogram should be obtained. A careful operative report is very important. The surgeon must be able to justify his competence. Finally, the surgical community should publish more results concerning the rate of complications in order to establish reference material for experts.     

Influence of laparoscopic and conventional cholecystectomy upon cell-mediated immunity

Surgery, trauma and anaesthesia induce a state of transient immunosuppression. Laparoscopic cholecystectomy has several well documented clinical advantages over traditional cholecystectomy and provokes a lower acute phase response, thought to be a result of the smaller wound size. The influence of laparoscopic cholecystectomy (21 patients) and conventional open cholecystectomy (13 patients) upon components of the cell-mediated immune system was investigated. Cell-mediated immunity was studied by in vitro assays of T lymphocyte proliferation to different mitogens, and by natural killer cell cytotoxicity using a standard 51Cr release assay. Blood samples were taken before and 24 h after the start of the operation. In the sample taken after operation there was significant depression of T lymphocyte proliferation to phytohaemagglutinin (stimulation index 149.4 versus 33.3, P < 0.002), staphylococcal enterotoxin B (85.2 versus 52.6, P = 0.01) and toxic shock syndrome toxin (48.4 versus 14.8, P = 0.08) in the group of patients who underwent open surgery, but not in the group treated by laparoscopic surgery. There was a small but statistically insignificant decrease of natural killer cell cytotoxicity in both groups of patients. These findings suggest that laparoscopic cholecystectomy causes less depression of cell-mediated immunity than open cholecystectomy.     

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 standards of care in laparoscopic surgery. The specific case of cholecystectomy

Legal suits against visceral surgeons have increased since the advent of laparoscopic surgery. The duties of physicians have not however changed with the development of laparoscopic techniques. Since the decree promulgated in 1936, physicians have a legal commitment to provide the means required for patient care. This obligation has been recalled in different court judgements and in the new deontology code. In addition, jurisprudence tends more and more towards responsibility without risk. Laparoscopic cholecystectomy is not risk-free. Although morbidity and mortality have not risen with laparoscopic procedures, the types of complications encountered have changed. Reported accidents have become more frequent. The number of suits against surgeons has also increased. Surgeons must therefore be highly prudent and diligent. Precautions concerning personnel management, the choice of material and its upkeep. Special care must be given to the peroperative pneumoperitoneum and the use of monopolar electrocoagulation. A peroperative cholangiogram should be obtained. A careful operative report is very important. The surgeon must be able to justify his competence. Finally, the surgical community should publish more results concerning the rate of complications in order to establish reference material for experts.