A metaanalysis of laparoscopic cholecystectomy in patients with cirrhosis

Operative risks of digestive surgery in cirrhotic patients

Digestive surgery in cirrhotic patients has long been limited to the treatment of disorders related to the liver disease (portal hypertension, hepatocellular carcinoma and umbilical hernia). The improvement in cirrhotic patient management has allowed an increase in surgical procedures for extrahepatic indications. The aim of this study was to evaluate the operative risks of such surgical procedures. Extrahepatic surgery in cirrhotic patients is associated with high mortality and morbidity. Emergency surgery, gastrointestinal tract opening (esophagus, stomach and colon), <30 g/L serum albumin, transaminase levels more than three times the upper limit of normal, ascites, and intraoperative transfusions are the main risk factors for postoperative death. In Child A patients, the operative risk of elective surgery is moderate and surgical indications are not altered by the presence of cirrhosis. The laparoscopic approach should be recommended because of the potentially lower morbidity. In Child C patients, operative mortality is often higher than 40%; surgical indications must remain exceptional and non operative management has to be preferred. In Child B patients, preoperative improvement of liver function is mandatory for lower risk surgery.

Perioperative risk assessment for patients with cirrhosis and liver disease

Patients with cirrhosis are at an increased risk of complications of operative procedures. There is a growing understanding of the nature of the risks that cirrhotic patients experience, as well as more precise and objective tools to gauge the patients at risk for surgical complications. Surgical procedures that are common and high risk for patients with cirrhosis are cardiac surgery, cholecystectomy and hepatic resections, as well as other abdominal surgeries and orthopedic surgeries. The physicians who care for patients with cirrhosis who require a surgical procedure can apply an understanding of the type of surgery anticipated with knowledge of the severity of the patient's liver disease to predict those patients at risk for operative morbidity and mortality. A sound knowledge of the specific operative risks faced by patients with cirrhosis should prompt the clinician to take steps to prevent these complications.

[Cirrhosis and cholelithiasis. Laparoscopic or open cholecystectomy?]

Recently laparoscopic cholecystectomy has become the standard operation in case of cholelithiasis. The range of contraindications has decreased, a previous abdominal surgery, a severe cholecystitis or gravidity are not self-evident contraindications any more. The advantages and benefits of laparoscopic interventions in patients with hepatic cirrhosis are doubtful.

PATIENTS AND METHODS

Between 1996--2006, 52 patients were analyzed at the I. Department of Surgery of Semmelweis University in a retrospective study who underwent operations on hepatic cirrhosis and cholelithiasis. The female/male ratio was 2.7/1 and the mean age was 58.5 (31-87). The patients were classified according to the Child-Pugh score: A = 36, B = 14, C = 2. 23 traditional, open (OC) and 29 laparoscopic (LC) cholecystectomy were performed, in 4 out of the latter operations conversion had to be done.

RESULTS

In Child A and B cirrhotic patients the mean operative time was 86.5 minutes in the case of LC, whereas with the open intervention it was 86.21 minutes. In Child C cirrhotic patients, open cholecystectomy was performed in both cases, the average operative time was 81.5 minutes. Postoperative complications (Child A, B) occurred in 8 cases (LC/1), (OC/7), while in Child C patients in two cases. The average hospital stay was 7.6 (LC) and 12.45 (OC) days, respectively. The same with Child C patients increased to 28 days. In the postoperative phase 4 patients died: all of them had open cholecystectomy, suffered from Child B and Child C class hepatic cirrhosis, respectively, and they developed hepatorenal syndrome that could not be treated.

CONCLUSION

The results show that LC is a safe procedure in well-compensated Child A and B cirrhotic patients. Although hepatic cirrhosis greatly increases the surgical risks, as well as the likelihood of complications, and it also necessitates longer operative time and longer hospital stay, it is recommended that cirrhotic patients with symptomatic cholelithiasis should clearly be operated on.

Laparoscopic versus open cholecystectomy in cirrhotic patients: a prospective randomized study

BACKGROUND

Improved laparoscopic experience and techniques have made laparoscopic cholecystectomy (LC) feasible options in cirrhotic patients. This study was designed to compare the risk and benefits of open cholecystectomy (OC) versus LC in compensated cirrhosis.

METHOD

A randomized prospective study, in the period from October 2002 till December 2006, where 110 cirrhotic patients with symptomatic gallstone were randomly divided into OC group (55 patients) and LC group (55 patients).

RESULTS

There was no operative mortality. In LC group 4 (7.33%) patients were converted to OC. Mean surgical time was significantly longer in OC group than LC group (96.13+17.35 min versus 76.13+15.12) P<0.05, associated with significantly higher intraoperative bleeding in OC group (P<0.01), necessitating blood transfusions to 7 (12.72%) patients in OC group. The time to resume diet was 18.36+8.18 h in LC group which is significantly earlier than in OC group 47.84+14.6h P<0.005. Hospital stay was significantly longer in OC group than LC group (6+1.74 days versus 1.87+1.11 days) P<0.01 with low postoperative morbidity.

CONCLUSION

LC in cirrhotics is still complicated and highly difficult which associates with significant morbidity compared with that of patients without cirrhosis. However, it offers lower morbidity, shorter operative time; early resume dieting with less need for blood transfusion and reducing hospital stay than OC.

Type II gall bladder perforation with abdominal wall abscess in a cirrhotic patient: case report and review of the literature

Gallbladder perforation is a rare condition even in patients affected by acute cholecystitis. Most patients who present with gallbladder perforations are diagnosed preoperatively by radiologic imaging. Morbidity and mortality for this condition has improved significantly over the last few decades. We encountered a cirrhotic patient who was affected by primary sclerosing cholangitis and who developed a type II gallbladder perforation before undergoing a cadaveric liver transplantation. In this article, we report her clinical course and our review of the current literature on this rare condition.

Predicting the success of endoscopic transpapillary gallbladder drainage for patients with acute cholecystitis during pretreatment evaluation

INTRODUCTION

Although endoscopic transpapillary gallbladder drainage (ETGBD) has been reported to be an effective treatment for acute cholecystitis, technical difficulties have precluded more widespread use of this technique. Case evaluations that can predict the occurrence of such difficulties should increase the acceptance of ETGBD for acute cholecystitis treatment.

OBJECTIVE

To establish a pretreatment evaluation protocol for patients with acute cholecystitis.

METHODS

Eleven patients with acute cholecystitis who received ETGBD in 2003 or 2004 were enrolled in the present retrospective study. The frequency of success, complications and overall effectiveness of ETGBD for treatment of cholecystitis were measured. Factors that could affect ETGBD success, including clinical and laboratory parameters, and gallbladder ultrasonograms, were also evaluated.

RESULTS

ETGBD was successful in seven of 11 patients (success rate 63.6%). All seven patients who underwent ETGBD successfully were afebrile and asymptomatic within a few days. No clinical or laboratory variables were significantly associated with the success of ETGBD. In contrast, ultrasonographic measures of gallbladder minor-axis length and wall thickness in successful cases were significantly shorter (27.4 mm versus 38.0 mm; P=0.008) and thinner (4.2 mm versus 9.0 mm; P=0.041) relative to unsuccessful cases.

CONCLUSIONS

Ultrasonographic measures of gallbladder minor-axis length and wall thickness can serve as important predictors of ETGBD technical difficulties during pretreatment evaluation of patients with acute cholecystitis.

Laparoscopic cholecystectomy in cirrhotic patients with symptomatic cholelithiasis: a case-control study

BACKGROUND

In this study we retrospectively evaluated a group of symptomatic cirrhotic (n=30) and non-cirrhotic (n=60) patients submitted to laparoscopic cholecystectomy (LC) in a public hospital in Brazil.

METHODS

The groups were compared for surgical time, duration of hospitalization after surgery, period of permanence in the intensive care unit (ICU), use of blood derivatives, mortality rates, and transoperative and post-surgery complications. Other parameters, such as hepatic reserve capacity and presence of ascites, were also analyzed.

RESULTS

Twenty-three (76.7%) of the patients of the cirrhosis group (CG) were classified as Child-Pugh A, and seven (23.3%) were Child-Pugh B. Six of them (20%) had ascites. Differences between the two groups included surgery time (p=0.008), duration of hospitalization (p=0.014), and post-surgery (p=0.000) or ambulatory (p=0.008) complications. The worst results were observed among Child B patients and in those with ascites. Blood derivatives were used in only 3.3% of the CG patients. No cases of conversion to laparotomy were observed among the two groups of patients included in this study, nor were there any deaths.

CONCLUSIONS

These results indicate that videolaparoscopic cholecystectomy may be safely performed in public hospitals in Brazil, with low levels of complications, no associated mortality, and no need for blood derivatives.

Laparoscopic cholecystectomy in cirrhotic patients with symptomatic gallstone disease

BACKGROUND

The aim of this study was to evaluate the outcome in patients with liver cirrhosis who underwent laparoscopic cholecystectomy for symptomatic gallstone disease.

METHODS

Retrospective analysis of prospectively collected data of 34 patients operated between March 1998 and April 2006.

RESULTS

There were 19 male and 15 female patients with a median age of 62 years. Cirrhosis aetiology was viral hepatitis in 25 patients, alcohol in 6, primary biliary cirrhosis in 2 and in 1 patient the cause was not identified. Twenty-three were classified as Child-Pugh-Turcotte stage A and 11 as Child-Pugh-Turcotte stage B. The median Model For End-Stage Liver Disease score was 12. Median operating time was 96 min. In three patients there was conversion to open cholecystectomy. Postoperatively, one patient died and six more patients had complications. Median postoperative stay was 3 days. Patients with acute cholecystitis did not have increased morbidity, but had significantly longer hospital stay.

CONCLUSION

Laparoscopic cholecystectomy can be carried out with acceptable morbidity in selected patients with well-compensated Child A and B stages liver cirrhosis. Patients with evidence of significant portal hypertension and severe coagulopathy should avoid surgery.

Model for end-stage liver disease score versus Child score in predicting the outcome of surgical procedures in patients with cirrhosis

AIM: To determine factors affecting the outcome of patients with cirrhosis undergoing surgery and to compare the capacities of the Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) score to predict that outcome.

METHODS: We reviewed the charts of 195 patients with cirrhosis who underwent surgery at two teaching hospitals over a five-year period. The combined endpoint of death or hepatic decompensation was considered to be the primary endpoint.

RESULTS: Patients who reached the endpoint had a higher MELD score, a higher CTP score and were more likely to have undergone an urgent procedure. Among patients undergoing elective surgical procedures, no statistically significant difference was noted in the mean MELD (12.8 ± 3.9 vs 12.6 ± 4.7, P = 0.9) or in the mean CTP (7.6 ± 1.2 vs 7.7 ± 1.7, P = 0.8) between patients who reached the endpoint and those who did not. Both mean scores were higher in the patients reaching the endpoint in the case of urgent procedures (MELD: 22.4 ± 8.7 vs 15.2 ± 6.4, P = 0.0007; CTP: 9.9 ± 1.8 vs 8.5 ± 1.8, P = 0.008). The performances of the MELD and CTP scores in predicting the outcome of urgent surgery were only fair, without a significant difference between them (AUC = 0.755 ± 0.066 for MELD vs AUC = 0.696 ± 0.070 for CTP, P = 0.3).

CONCLUSION: The CTP and MELD scores performed equally, but only fairly in predicting the outcome of urgent surgical procedures. Larger studies are needed to better define the factors capable of predicting the outcome of elective surgical procedures in patients with cirrhosis.

Factors associated with time to laparoscopic cholecystectomy for acute cholecystitis

AIM: To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis.

METHODS: A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service (medical or surgical). Patients not undergoing cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery.

RESULTS: Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean ± SD time to surgery was 39.3 ± 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography (ERCP, P = 0.01) as well with admission to medical service without adjustment for ERCP (P < 0.05). Patients undergoing both magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier (30.4 ± 34.9 vs 82.7 ± 55.1 h, P < 0.01), had less post-operative complications (12% vs 58%, P < 0.01), and shorter length of stay (4.3 ± 3.4 vs 8.1 ± 5.2 d, P < 0.01).

CONCLUSION: Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed up time to surgery should be considered.

Can the MELD Score Predict Perioperative Morbidity for Patients with Liver Cirrhosis Undergoing Laparoscopic Cholecystectomy?

The Model for End Stage Liver Disease (MELD) score is a mortality predictor in patients awaiting liver transplantation. We evaluated the MELD score's ability to predict morbidity for patients with cirrhosis undergoing laparoscopic cholecystectomy. From March 1991 to February 2004, data of all patients undergoing laparoscopic cholecystectomy were prospectively collected. Data of patients with liver cirrhosis were reviewed. The MELD and Child scores were correlated with outcome variables. Of 7859 patients undergoing laparoscopic cholecystectomy, 99 patients (1.3%) exhibited liver cirrhosis, 44 women and 55 men. The mean age was 55 years (range, 28 to 92 years). The mortality rate was 6.3 per cent, morbidity rate 18 per cent, and conversion rate 11 per cent. Laboratory values on 55 patients were available to calculate MELD scores. The mean MELD score was 11 (range, 6 to 23). There was no significant variation in MELD scores with gender ( P = 0.61) or cirrhosis etiology, alcoholic and nonalcoholic ( P = 0.52). MELD and Child's score correlated well ( P < 0.001); however, the risk of complication was not related to the MELD ( P = 0.94) or Child-Pugh-Turcotte score ( P = 0.26). Morbidity for patients with liver cirrhosis undergoing laparoscopic cholecystectomy remains high. The MELD score is useful for transplant risk stratification for but requires further investigation regarding morbidity prediction for laparoscopic cholecystectomy.

HCV infection is a risk factor for gallstone disease in liver cirrhosis: an Italian epidemiological survey

We assessed the prevalence of gallbladder disease (i.e. gallstones plus cholecystectomy) among patients with liver disease and its association with the severity and aetiology of hepatic injury. Subjects, referred to 79 Italian hospitals, were enrolled in a 6-month period. The independent effect of the severity and aetiology of liver disease on gallstone disease prevalence was assessed by multiple logistic regression analysis. Overall, 4867 subjects tested anti-hepatitis C virus (HCV) positive alone, 839 were hepatitis B virus surface antigen (HBsAg) alone, and 652 had an excessive alcohol intake. The prevalence of gallstone disease was 23.3% in anti-HCV-positive patients, 12.4% in HBsAg positive and 24.2% in subjects reporting excessive alcohol intake, respectively. Gallstone disease prevalence increased by age in each aetiological category. The proportion of patients with gallstone disease who had a cholecystectomy was the highest in HCV+ subjects. After adjusting for the confounding effect of age and body mass index, compared with patients with less severe liver disease, subjects with HCV-related cirrhosis, but not those with alcohol-related cirrhosis, were more likely to have gallstone disease. Subjects with HCV-related cirrhosis (OR 2.13, 95% CI: 1.38-3.26) were more likely to have gallstone disease when compared with those with HBV-related cirrhosis. HCV infection is a risk factor for gallstone disease. In Italy, the high prevalence of HCV infection among cirrhotic patients has important implications, as cholecystectomy in these subjects is associated with high risk of morbidity and mortality.

Laparoscopic cholecystectomy in cirrhotic patients: the role of subtotal cholecystectomy and its variants

BACKGROUND

Open cholecystectomy is associated with considerable morbidity and mortality in cirrhotic patients. Laparoscopic cholecystectomy may offer a better option because of the magnification available and the availability of newer instruments like the ultrasonic shears. We present our experience of 265 laparoscopic cholecystectomies and attempt to identify the difficulties encountered in this group of patients.

STUDY DESIGN

Between 1991 and 2005, 265 cirrhotic patients of Child-Pugh Classification A and B, with symptomatic gallstones, were subjected to laparoscopic cholecystectomy. We describe here our tailored approach and our techniques of subtotal cholecystectomy.

RESULTS

Features of acute cholecystitis were present in 35.1% of the patients, and 64.9% presented with chronic cholecystitis. In 81.5% of the patients, the diagnosis of cirrhosis was established preoperatively. In 8.3% of the patients, a fundus first method was adopted when the hilum could not be approached despite additional ports. Modified subtotal cholecystectomy was performed in a total of 206 patients. Mean operative time in the subtotal cholecystectomy group was 72 minutes; in the standard group, it was 41 minutes. There was no mortality. In 15% of patients, postoperative deterioration in liver function occurred. Worsening of ascites, port site infection, port site bleeding, intraoperative hemorrhage, bilious drainage, and stone formation in the remnant were the other complications encountered.

CONCLUSIONS

Laparoscopic cholecystectomy is a safe and effective treatment for calculous cholecystitis in cirrhotic patients. Appropriate modification of subtotal cholecystectomy should be practiced, depending on the risk factors present, to avoid complications.

Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome

In view of the substantial, at times conflicting, literature on conversion to open surgery during laparoscopic cholecystectomy (LC), we have considered it timely to review the subject to identify the risk factors for conversion and its consequences. The review is based on a complete literature search covering the period 1990 to 2005. The search identified 109 publications on the subject: 68 retrospective series, 16 prospective nonrandomized studies, 8 prospective randomized clinical trials, 5 prospective case-controlled studies, 5 reviews and 7 others (3 observational, 2 population-based studies, 1 national survey, and 1 editorial). As the majority of reported studies are retrospective, firm conclusions cannot be reached. Single factors that appear to be important include male gender, extreme old age, morbid obesity, cirrhosis, previous upper abdominal surgery, severe/advanced acute and chronic disease, and emergency LC. The combination of patient- and disease-related risk factors increases the conversion risk. In the training of residents, the number of cases needed for reaching proficiency exceeds 200 cases. The value of predictive scoring systems is important in the selection of cases for resident training. Conversion exerts adverse effects on operating time, postoperative morbidity, and hospital costs, especially when it is enforced. There appears to be no absolute contraindication to LC that is agreed upon by all. There is consensus on certain individual risk factors and their additive effect on the likelihood of conversion. Predictive systems based on these factors appear to be useful in selection of cases for resident training.

Endoscopic gallbladder stent placement for treatment of symptomatic cholelithiasis in patients with end-stage liver disease

OBJECTIVES

Symptomatic cholelithiasis is a common disease in the general population with an increased prevalence in patients with cirrhosis. While cholecystectomy is the procedure of choice for the treatment of symptomatic cholelithiasis, cirrhotics have an increased risk of complications associated with this therapy. We have found that placement of an endoscopic gallbladder stent is an alternative, less invasive treatment for cirrhotic patients with symptomatic gallbladder disease and describe our experience here.

METHODS

A retrospective medical record review of 23 patients with cirrhosis who underwent endoscopic retrograde cholangiography with gallbladder stent placement for symptomatic gallbladder disease from July 1994 to August 2004.

RESULTS

Indications for stent placement included recurrent biliary colic (56.5%), acute calculous cholecystitis (39%), acalculous cholecystitis (8.6%), and gallstone pancreatitis (8.6%). All patients experienced resolution of their symptoms following stent placement. Twenty patients (87%) were asymptomatic from 5 days to 3 years post-procedure until transplantation, death, or end of study period. Nine patients (39%) underwent liver transplantation, 5 days to 34 months after the procedure. Eleven patients are well, with ten patients awaiting liver transplantation. Three patients developed late complications and were treated successfully with antibiotics.

CONCLUSION

Endoscopic stenting of the gallbladder may be a potential treatment for symptomatic gallbladder disease in patients with cirrhosis awaiting liver transplantation, considered to be high-risk for cholecystectomy.

Laparoscopic cholecystectomy in cirrhotic patients

BACKGROUND

Due to unacceptable increases in intra- and postoperative complications and associated morbidity, cirrhosis of the liver is often considered to be a contraindication for laparoscopic cholecystectomy (LC). However, recent advances have now made it increasingly possible for experienced surgeons to perform LC on this high-risk population. The aim of this study was to evaluate the impact of the coagulopathy associated with cirrhosis on the performance and results of LC. We hypothesized that the factors leading to hemorrhage, rather than Child's classification, would drive operating time and resource utilization.

METHODS

Between 1 July 1996 and 30 June 2003, 1,285 cholecystectomies were performed. Thirty one of these patients had evidence of cirrhosis at the time of operation. The 31 patients were divided into high, (low platelets, prolonged International Normalized Ratio) (n = 18), intermediate, (abnormal liver function tests, normal clotting) (n = 5), and low, (normal platelets, normal clotting, and normal liver function tests) (n = 8) surgical risk categories for further analysis. Based on the Child-Turcotte-Pugh (CTP) classification of cirrhosis, there were three grade C and 28 grade A or grade B patients.

RESULTS

There were 24 LC, three of which were started laparoscopically and then converted to open, and four open cholecystectomies. Operating room time ranged from 79 to 450 min, with the extent of coagulopathy correlating with the length of time needed to achieve satisfactory hemostasis. Median length of stay postoperatively in the high-risk group was 2 days (range, 0-20). Nine of the cholecystectomies were performed on an outpatient basis. One patient received a liver transplantation 5 months post-LC. There were no operative deaths, bile duct injuries, or returns to the operating room for bleeding. Blood product usage correlated with preexisting coagulopathy.

CONCLUSIONS

Currently, the classification of cirrhotic patients is normally done using the CTP score. However, preoperative platelet levels and INR more accurately predict the difficulty of cholecystectomy than CTP score, because intraoperative hemorrhage is the primary concern in these patients. This study demonstrates that preoperative degree of coagulopathy, and not Child's class, should guide the surgeon's approach and expectations when LC is performed in a cirrhotic patient.

Prevalence of gallbladder disease among persons with hepatitis C virus infection in the United States

Although cirrhosis is a known risk factor for gallstones, little is known about gallbladder disease (GBD) in individuals with hepatitis C virus (HCV) infection. We determined the association between chronic HCV infection and GBD in a representative sample of adults in the United States. Data on HCV infection and GBD were available for 13,465 persons 20 to 74 years of age who participated in the Third National Health and Nutrition Examination Survey. The presence of GBD (gallstones or cholecystectomy) was determined using abdominal ultrasonography, and HCV infection was assessed via a positive HCV antibody test and a positive HCV RNA test. Overall, 1.6% of adults (95% CI, 1.1-2.1) had chronic HCV infection and 12.5% (95% CI, 11.3-13.7) had GBD. After adjusting for potential confounding variables, the odds of gallstones (OR = 3.20; 95% CI, 1.08-9.45) and cholecystectomy (OR = 4.57; 95% CI, 1.57-13.27) among HCV-positive men was significantly higher compared with HCV-negative men. In contrast, the adjusted odds of gallstones (OR = 2.55; 95% CI, 0.58-11.25) and cholecystectomy (OR = 0.70; 95% CI, 0.21-2.37) among HCV-positive women was not significantly higher. The odds of GBD increased significantly with the severity of liver disease as assessed via elevated serum bilirubin levels and low levels of serum albumin and platelets. In conclusion, chronic HCV infection was strongly associated with GBD among men but not women in the United States, and GBD was more common in adults with severe liver disease.

A randomized controlled trial of laparoscopic versus open cholecystectomy in patients with cirrhotic portal hypertension

AIM: To evaluate the characters, risks and benefits of laparoscopic cholecystectomy (LC) in cirrhotic portal hypertension (CPH) patients.

METHODS: Altogether 80 patients with symptomatic gallbladder disease and CPH, including 41 Child class A, 32 Child class B and 7 Child class C, were randomly divided into open cholecystectomy (OC) group (38 patients) and LC group (42 patients). The cohorts were well-matched for number, age, sex, Child classification and types of disease. Data of the two groups were collected and analyzed.

RESULTS: In LC group, LC was successfully performed in 36 cases, and 2 patients were converted to OC for difficulty in managing bleeding under laparoscope and dense adhesion of Calot’s triangle. The rate of conversion was 5.3%. The surgical duration was 62.6±15.2 min. The operative blood loss was 75.5±15.5 mL. The time to resume diet was 18.3±6.5 h. Seven postoperative complications occurred in five patients (13.2%). All patients were dismissed after an average of 4.6±2.4 d. In OC group, the operation time was 60.5±17.5 min. The operative blood loss was 112.5±23.5 mL. The time to resume diet was 44.2±10.5 h. Fifteen postoperative complications occurred in 12 patients (30.0%). All patients were dismissed after an average of 7.5±3.5 d. There was no significant difference in operation time between OC and LC group. But LC offered several advantages over OC, including fewer blood loss and lower postoperative complication rate, shorter time to resume diet and shorter length of hospitalization in patients with CPH.

CONCLUSION: Though LC for patients with CPH is difficult, it is feasible, relatively safe, and superior to OC. It is important to know the technical characters of the operation, and pay more attention to the meticulous perioperative managements.

Endoscopic stent insertion into the gallbladder for symptomatic gallbladder disease in patients with end-stage liver disease

BACKGROUND

Endoscopic stent insertion into the gallbladder entails placement of a double-pigtail polyethylene stent between the gallbladder and the duodenum at ERCP. This procedure may be an effective temporary measure in patients with severe comorbid conditions, especially end-stage liver disease, that subsequently allows more definitive therapy, including liver transplantation.

METHODS

The records for 29 patients who underwent attempted endoscopic gallbladder stent insertion between May 1999 and May 2004 were reviewed retrospectively.

RESULTS

Mean patient age was 47 years; 86% of the patients were listed for liver transplantation, with a mean model for end-stage liver disease score of 15; 72% had Child's class B cirrhosis. Indications for gallbladder stent placement included recurrent biliary colic (69%), acute cholecystitis (17%), acalculous cholecystitis (7%), and gallstone pancreatitis (7%). Of the 29 patients who underwent ERCP, stent placement was successful in 26 (90%). Median follow-up was 9.4 months (range 0.1-40.5 months). Of those who had a stent placed, 6 (22%) subsequently underwent liver transplantation and another 15 (56%) were alive, most awaiting liver transplantation. Only 3 patients had late a complication or recurrence of biliary symptoms after stent placement.

CONCLUSIONS

Endoscopic stent placement in the gallbladder is a safe and an effective palliative treatment for patients with symptoms caused by gallbladder disease who are poor surgical candidates.

Laparoscopic cholecystectomy: early and late complications and their treatment

Laparoscopic cholecystectomy gained wide acceptance as treatment of choice for gallstone disease and cholecystitis. With this new technique, not only did the new era of minimal invasive surgery begin, but also the spectrum of complications changed. Laparoscopy-related complications such as access injuries and procedure-related problems are discussed in our article. Typical mishaps are reviewed according to the literature. Set-up of the pneumoperitoneum (morbidity up to 0.2%); bleeding-from trocar sites and vascular injury (mortality up to 0.2%); biliary leaks and bile duct injuries are the main topics in this article (still on a level of 0.2%-0.8%). Aetiology, diagnosis and treatment are discussed, and an overview of the most cited classifications of bile duct injuries is summarised graphically. Finally, bowel injuries as a specific complication in laparoscopy are discussed (incidence up to 0.87%).

CONCLUSION

Careful selection of patients, the knowledge of typical procedure-related complications, and their best treatment are the key points for a safe laparosopic cholecystectomy.