Laparoscopic biliary surgery

Perfect pair, scopes unite — laparoscopic-assisted transumbilical gastroscopy for gallbladder-preserving polypectomy: A case report

BACKGROUND

Gallbladder polyps are one indication for cholecystectomy, but this procedure carries some disadvantages, including the potential for severe injury and high risk of post-operative complications. Laparoscopy combined with endoscopic surgery is a minimally invasive treatment option. We herein report a young patient with a gallbladder polyp who was successfully discharged from the hospital after laparoscopic-assisted endoscopy. This procedure may offer an alternative in the management of such lesions.

CASE SUMMARY

A 24-year-old female patient was hospitalized primarily for a gallbladder polyp. Due to the surgical risk associated with cholecystectomy and the low post-operative quality of life, the woman underwent laparoscopic-assisted transumbilical gastroscopy for gallbladder-preserving polypectomy under endotracheal intubation and general anaesthesia. The operation went smoothly.

CONCLUSION

We conclude laparoscopic-assisted transumbilical gastroscopy for gallbladder-preserving polypectomy is a safe and effective technique for the treatment of gallbladder polyps.

Role of preoperative sonography in predicting conversion from laparoscopic cholecystectomy to open surgery

BACKGROUND

Laparoscopic cholecystectomy is the first step treatment in cholelithiasis. The purpose of this study was to establish a radiologic view on prediction of conversion from laparoscopic cholecystectomy to open surgery.

METHODS

This study included 176 patients who had undergone laparoscopic cholecystectomy. Preoperative ultrasonographic findings were assessed and we gave points to each finding according to results from correlation analysis. After the scoring we investigated the relationship between ultrasonographic findings and conversion from laparoscopic cholecystectomy to open surgery.

RESULTS

Scoring significantly predicted failure in laparoscopic approach (AUC=0.758, P=0.003,). Optimal cut off score was found to be 1.95 with 67% sensitivity and 78% specificity. Score>1.95 was a risk factor for failure in laparoscopic approach [odds ratio=7.1(95% CI,2-24.9, P=0.002)]. There were 8 subjects out of 36(22%) with high score underwent open surgery while 4 out of 128 (3%) subjects with low score needed open surgery (p=0.002). Negative predictive value of 128/132=97%. Mean score of whole study population was 1.28 (range 0-8.8) and mean score of subjects underwent open surgery was 3.6 while it was 1.1 in successful laparoscopic approach group (p<0.001). Mean Age and BMI were similar between groups (p>0.05). Sex of subjects did not affect the success of surgery (p>0.05).

CONCLUSION

The contribution of preoperative ultrasonography is emphasized in many studies. Our study suggests quantitative results on conversion from laparoscopic cholecystectomy to open surgery. We believe that radiologists have to indicate the risk of conversion in their ultrasonography reports.

Peritoneal chronic inflammatory mass formation due to gallstones lost during laparoscopic cholecystectomy

We here describe the radiologic findings of peritoneal chronic abscess formation due to gallstones lost within the peritoneum during laparoscopic cholecystectomy (LC). A radiologic workup 7 months after LC revealed a soft-tissue mass with contrast enhancement, harboring internal necrosis and punctate calcium located in the Morrison's pouch. The mass exhibited restricted water molecule diffusion, absence of fat deposition, and increased F-18 fluorodeoxy-D-glucose uptake, thus mimicking a malignant tumor. The biopsy revealed an inflammatory granuloma. Another patient with similar findings was treated with percutaneous abscess drainage. Thus, radiologists should be aware of this disease condition and its imaging findings.

Long-term follow-up of a randomized controlled trial of observation versus surgery for acute cholecystitis: non-operative management is an option in some patients

BACKGROUND

Cholecystectomy is routinely recommended to prevent recurrent disease after an initial episode of acute cholecystitis. Therefore, randomized controlled trials have mainly focused on the timing of surgery, but many patients scheduled for cholecystectomy have deferred surgery with long periods of symptom-free intervals. Our present aim is to examine the long-term feasibility and safety of observation compared with surgery.

METHODS

Trial of 64 patients with acute cholecystitis previously randomized to observation or cholecystectomy, which examined outcome in terms of completed randomized treatment and appearance of further symptoms and the need for surgical treatment. Thirty-three patients were randomized to observation and 31 patients to cholecystectomy. Median follow-up was 14 years.

RESULTS

Of the 33 patients randomized to observation, 11 (33%) experienced a new event of gallstone-related disease (eight (24.2%) had acute cholecystitis) and 11 (33%) were operated. No significant difference (p = 0.565) was found between the two randomized groups with regard to recurrent disease or complications. Virtually no surgery took place after 5 years of follow-up. The difference in completed randomized treatment between the groups was not significant (p = 0.077). Long-term mortality was equal in those operated and in those observed.

CONCLUSIONS

Twenty-four percent of the patients experienced recurrent cholecystitis, but escalation of disease severity or increased mortality was not observed. Long-term observation after acute cholecystitis was feasible in two-thirds of the patients as the risk for recurrent disease was negligible after 5 years.

A novel classification system to address financial impact and referral decisions for bile duct injury in laparoscopic cholecystectomy

Purpose. The study was undertaken to evaluate a novel classification system developed to estimate financial cost of bile duct injury (BDI) and to aid in decision making for referral. Study Design. A retrospective review of patients referred for BDI was performed. Grade I injuries involve the duct of Luschka or accessory right hepatic ducts, grade II includes all other biliary injuries, and grade III includes all vasculobiliary injuries. Groups were compared using standard statistical methods. Results. There were 14 grade I, 74 grade II, and 20 grade III injuries. There was a significant difference in the cost and mortality of grade I ($12,457, 0%), grade II ($46,481, 1.4%), and grade III ($69,368, 15%, P = 0.002 and P = 0.030, resp.) injuries. Grade II and III injuries were significantly more likely to require surgical repair (OR 27.7, P < 0.001). Conclusion. We have presented a simple classification system that is able to accurately predict cost and need for surgical repair.

Indications for selective intraoperative cholangiography

The indications for selective intraoperative cholangiography (IOC) include a clinical history of jaundice, pancreatitis, elevated bilirubin level, abnormal liver function test results, increased amylase levels, a high lipase level, or dilated common bile duct on preoperative ultrasonography. Although these clinical features are widely accepted as indications for IOC, they have not been tested for their ability to predict choledocholithiasis. Charts were reviewed for a 6-month time period in 2003 at Parkland Memorial Hospital for all patients undergoing cholecystectomy. Univariate analysis and logistic regression were used to determine which factors predicted choledocholithiasis. Of the 572 patients undergoing cholecystectomies during the study period, 189 underwent IOC and common bile duct stones were found in 57. Only preoperative hyperbilirubinemia or ultrasonograph identification of common bile duct dilation reliably predicted choledocholithiasis. There were 13 cases of choledocholithiasis that would not have been identified by preoperative hyperbilirubinemia or an enlarged common bile duct. However, common bile duct stones were clinically significant in only 2 of the 13 cases. One of these was treated with postoperative endoscopic retrograde cholangiopancreatography, and the other was treated with laparoscopic common bile duct exploration. Preoperative identification of a dilated common bile duct or elevated bilirubin levels can be the sole criteria for performing IOC on a selective basis in patients without malignancy. Reliance on a history of remote jaundice, pancreatitis, elevated liver function test values, or pancreatic enzymes results in unnecessary IOCs.

Timing of cholecystectomy for acute calculous cholecystitis: a meta-analysis

OBJECTIVES

To compare early with delayed cholecystectomy for the treatment of acute lithiasic cholecystitis: a meta-analysis of prospective randomized trials.

METHODS

Pertinent studies were selected from the Medline, Embase, Cancerlit, HealthSTAR and Cochrane Library Databases, references from published articles, and reviews. Twelve prospective randomized trials (9 addressing open cholecystectomy and 3 laparoscopic cholecystectomy) were selected. Conventional meta-analysis according to the DerSimonian and Laird method was used for the pooling of the results. The rate difference (RD) (95% CI) and the number needed to treat (NNT) were used as a measure of the therapeutic effect.

RESULTS

Cumulative operative and perioperative mortality and morbidity were 0.9% and 17.8%, respectively, for open cholecystectomy and 0% and 13.1%, respectively, for laparoscopic cholecystectomy. The pooled RD for operative complications in early surgery was 1.37% (95% CI =-3.78% to 6.53%; p= 0.2) for open cholecystectomy and 3.11% (95% CI =-15.10% to 8.87%; p= 0.6) for laparoscopic cholecystectomy. In laparoscopic cholecystectomy the cumulative conversion rate to open cholecystectomy was 21.5%. The pooled RD for conversion rate in early laparoscopic cholecystectomy was -7.99% (95% CI =-18.46% to 2.47%; p= 0.1; NNT = 13). Total hospital stay (mean +/- SD) was significantly shorter in the early surgery group (9.6 +/- 2.5 days vs 17.8 +/- 5.8 days; p < 0.0001). More than 20% of patients referred to delayed surgery fail to respond to conservative management or suffer recurrent cholecystitis in the interval period.

CONCLUSIONS

Early operation (open or laparoscopic) does not carry a higher risk of mortality and morbidity compared to delayed operation and should be the preferred surgical approach for patients with acute lithiasic cholecystitis.

Diagnosis and management of cholecystitis and cholangitis

Cholelithiasis is a prevalent condition in Western populations. Most cases are asymptomatic but complications can occur. Acute cholangitis, cholecystitis, and gallstone pancreatitis are the most common biliary tract emergencies and are usually caused by biliary calculi. Whenever possible, acute cholecystitis should be treated with early LC. AAC is an uncommon condition usually affecting patients with significant comorbidities. Treatment is usually with percutaneous cholecystostomy, which often is also the only required therapy. Endoscopic drainage is the preferred form of biliary decompression in acute cholangitis and these patients should subsequently undergo elective LC unless unfit for surgery. Effective and optimal management of biliary tract emergencies relies on close cooperation between gastroenterologist, surgeon, and radiologist.

Current Management of Common Bile Duct Stones in a Teaching Community Hospital

The advent of laparoscopic cholecystectomy (LC) has complicated management of common bile duct (CBD) stones. While LC is routine, laparoscopic CBD exploration (LCBDE) is not, and an algorithm to manage suspected choledocholithiasis has not been uniformly accepted. We evaluated current management of choledocholithiasis. Patients suspected of having CBD stones over a 2-year period were evaluated, and 42 studies in the literature were reviewed. Thirty-two patients were identified. Fourteen patients (44%) had LC with intraoperative cholangiogram (IOC) with no preoperative studies. IOC revealed CBD stones in nine (64%). Seven had CBD exploration (CBDE) at cholecystectomy, and two had postoperative endoscopic retrograde cholangiopancreatography (ERCP). CBDE was successful in five cases, and ERCP was successful in one. Eighteen patients (56%) underwent preoperative ERCP. Five (28%) had no CBD stones. ERCP removed stones in nine patients, and four had open CBDE after failed ERCP. Current literature supports LC with IOC without any preoperative studies. Laparoscopic CBDE is highly successful but depends on surgeon experience. Removing CBD stones with ERCP is also very successful but is associated with increased cost, hospital stay, and complications. We conclude that LC with IOC should be performed without preoperative ERCP when choledocholithiasis is suspected. If found, stones should be removed laparoscopically if possible.

The fetal safety and clinical efficacy of gastrointestinal endoscopy during pregnancy

More than 12,000 pregnant patients in the United States per annum have conditions that are normally evaluated by EGD. More than 6000 pregnant patients in the United States per annum have conditions that are normally evaluated by sigmoidoscopy or colonoscopy. About one thousand more have symptomatic choledocholithiasis during pregnancy, which is a strong indication for endoscopic sphincterotomy in nonpregnant patients. Endoscopy during pregnancy raises the unique issue of fetal safety. Endoscopic medications comprise a significant component of fetal endoscopic risks. Safety of EGD during pregnancy has been examined in a case-controlled study of 83 patients, a mailed survey of 73 patients, and 28 case reports. Safety of sigmoidoscopy during pregnancy has been examined in a case-controlled study of 46 patients, a mailed survey of 13 patients, and 10 case reports. Safety of therapeutic ERCP during pregnancy has been analyzed in studies of 23, 10, 6, and 5 patients, and in 32 case reports. These studies suggested that EGD, sigmoidoscopy, and ERCP should be performed when strongly indicated: EGD for significant upper gastrointestinal bleeding, sigmoidoscopy for nonhemorrhoidal rectal bleeding, and ERCP for symptomatic choledocholithiasis when sphincterotomy is contemplated. PEG and colonoscopy are currently considered experimental during pregnancy because of insufficient data on fetal safety. Several cases of PEG and colonoscopy were successfully performed during pregnancy. Performance of endoscopy during pregnancy should increase with further technical refinements, and greater awareness of procedure safety.

Gallstones and biliary disease

Gallstones are common in the US and western countries. This article describes the pathogenesis of gallstone formation and the clinical manifestations and current approaches to diagnosis and treatment of the most common clinical conditions caused by gallstones: biliary colic, acute cholecystitis, choledocholithiasis, and acute gallstone pancreatitis. The role of widely used imaging techniques (transabdominal ultrasound, CT scan, MR imaging, and MRCP) and diagnostic and therapeutic endoscopy (endoscopic ultrasound, ERCP) is emphasized. This article is intended mainly for general practitioners, primary care physicians, and other specialists providing medical care to patients with gallstones and their complications.

Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique

BACKGROUND

The introduction of laparoscopic cholecystectomy has given rise to a debate as to whether endoscopic retrograde cholangiopancreatography (ERCP) should be performed before or after cholecystectomy in patients with bile duct stones.

METHODS

This study evaluated the efficacy of treatment of cholecystocholedocholithiasis in a single step by performing ERCP during surgery in 52 patients (35 women, 17 men; mean age 57.0 years; age range 20 to 89 years). Laparoscopic intraoperative cholangiography via the cystic duct was carried out to confirm the presence of duct stones. A soft-tipped guidewire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guidewire. Endoscopic sphincterectomy was performed and the stones removed with balloon and basket catheters.

RESULTS

Endoscopic stone removal was successful in 94% of cases without complications related to ERCP or surgery. Although operative time was lengthened by about 20 minutes, the hospital stay was as short and equal to that for simple laparoscopic cholecystectomy (3 days on average).

CONCLUSIONS

The single-step combined endoscopic-laparoscopic technique is safe and effective for treatment of patients with gallbladder and bile duct stones.

Use of a fluorescent bile acid to enhance visualization of the biliary tract and bile leaks during laparoscopic surgery in rabbits

BACKGROUND

We set out to determine whether intravenously administered cholylglycylaminofluorescein (CGF), a fluorescent bile acid, would enhance the visualization of the biliary tract and bile leaks in rabbits undergoing laparoscopic cholecystectomy (LC).

METHODS

CGF was infused at doses of 1, 5, and 10 mg/kg b.w. Biliary recovery was determined spectrophotometrically (six rabbits). For LC (seven rabbits), a blue (fluorescein) filter was attached to the light source, and a fluorescein-emission filter was attached to the charge coupled device (CCD) camera. The biliary tract and bile leak (made by incising the gallbladder) was observed under standard and fluorescent illumination.

RESULTS

Apple-green fluorescence appeared in 2 min and persisted for 30-60 min, enhancing visualization of bile duct anatomy as well as the bile leak. Biliary recovery of CGF at 90 min was high (86-96% of the infused dose).

CONCLUSION

In rabbits, CGF is secreted quantitatively in bile, induces biliary fluorescence, and enhances visualization of the bile ducts and bile leaks when viewed with appropriate filters.

Radiologic features of complications arising from dropped gallstones in laparoscopic cholecystectomy patients

OBJECTIVE

Because laparoscopic cholecystectomy has become the accepted treatment for symptomatic cholelithiasis, radiologists frequently encounter patients who have had this surgery. Although the radiologic features of postoperative bile duct injury are well documented, the imaging features of less well-known complications remain poorly described. One such unusual complication is abscess formation caused by dropped gallstones.

CONCLUSION

Although the incidence of dropped gallstones is an uncommon complication of laparoscopic cholecystectomy, it should be recognized as a potential source of both intraabdominal and intrathoracic abscess formation in any patient presenting months to years after undergoing laparoscopic cholecystectomy. These abscesses are not necessarily confined to the right upper quadrant.