[Laparoscopic cholecystectomy in day-surgery analysis of feasibility in 166 consecutive patients]

BACKGROUND

Day-Surgery (DS) is a widely spreading reality, both for clinical advantages to patients and organizational and economic profit to hospitals. In the last years, DS has been proposed for the treatment of a large number of diseases as inguinal and crural hernias, varicose vein, benign anorectal and thyroid pathologies. Recently, also laparoscopic cholecystectomy (LC) has been realised as DS procedure, and the initial results are promising.

OBJECTIVES

To determine both the clinical feasibility of LC in DS and the factors that can predict an extension of hospital stay.

MATERIALS AND METHODS

The present study is a retrospective analysis of 166 patients who underwent surgery because of symptomatic cholelithiasis in a three-year period; all patients underwent elective LC in ordinary hospital-stay. In order to identifying the patients potentially eligible for LC in DS, we carried on a selection by means of 3 consecutive stages: stage A, selection on the basis of preoperative data, stage B, selection on the basis of intraoperative factors and stage C, selection on the basis of postoperative parameters.

RESULTS

Out of 166 patients, only 33 (19,8%) would have been successfully treated in DS.

CONCLUSIONS

This study showed that LC in DS can be realised in strictly selected patients, on the basis of rigorous clinical and organizational criteria; furthermore, a continuous training of surgeons and nursing staff, the implementation of tele-medical facilities and the improvement of anesthesiological techniques will allow to the best results.

[Isolated agenesis of the gallbladder: case report]

The gallbladder agenesis is a rare congenital abnormality which is frequently mistaken with cholecystolithiasis, regardless of the imaging modality used. The diagnosis is confirmed at laparoscopic surgery with intraoperative sonography and intraoperative cholangiography and postoperative MRI-cholangiography. Intraoperative cholangiography may be risky because the absence of normal anatomical structures and the impossibility of pulling on the gallbladder to dissect the triangle of Calot represents an increased risk of iatrogenic injury to biliary or portal structures. Therefore postoperative MRI-cholangiography seems to be a more suitable approach to confirm the diagnosis.

[The surgical needs of elderly patients in day-surgery]

AIM

The possibility of carrying out surgery in day-surgery (DS) conditions is gradually becoming reality in most branches of surgery; in recent years, DS has also found a place in general surgery, with unquestionable advantages for the management of patients, particularly the elderly. The purpose of the present study is to investigate general surgery needs in DS conditions in elderly patients in order to analyse the clinical-administrative feasibility of DS procedure and the level of its acceptability in this group of patients.

METHODS

A specially drafted questionnaire was submitted to patients admitted over a period of 18 months to the General Surgery Division of the University of L'Aquila. The details investigated in the questionnaire were: age, sex, educational qualification, working activity (independent or employee), presence in the patient's relational entourage of health workers willing to serve the patient at home, the patient's willingness to undergo the surgery for which he was admitted to the DS. The questionnaires of the over-64s were examined and the percentage of patients willing to undertake DS intervention instead of normal hospitalisation was evaluated; this willingness was then compared with the parameters sex, educational qualification, working activity and presence in the patient's relational entourage of health workers willing to assist the patient at home.

RESULTS

317 questionnaires were compiled. In 78 cases (24.6%) the patient was older than 64; the data for these patients were extrapolated. Willingness to undergo surgery in DS conditions was expressed by 23 patients (29%), whereas 55 patients (71%) stated that they were not available. In relation to sex, willingness to use the DS was 29.7% in the 37 male patients and 29.2% in the 41 females. With reference to the qualification, willingness was expressed by 71.4% of patients with a degree, 26.9% of patients with a high school leaving certificate and 15.7% of patients with a lower qualification. DS-willingness was 28% in the 75 pensioners and 66.6% in the 3 patients who worked for themselves. As regards the presence in the relational entourage of the patient of health workers ready to assist at home, DS-willingness was 23.9% in the 71 patients who did not have anyone in their relational entourage and 85.7% in the 7 patients who had such a health worker in their entourage.

CONCLUSIONS

Willingness to undergo DS by elderly patients is mainly influenced by three factors: educational qualification, working activity and possibility to have home assistance from someone in the relational entourage; these parameters can be considered veritable selection criteria for DS in the elderly. The quality improvement in assistance levels and the introduction in the near future of telematic communication system could lead to an extension of DS indications to the elderly.

Bile duct injuries during laparoscopic cholecystectomy: a 1994-2001 audit on 13,718 operations in the area of Rome

BACKGROUND

Bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC) still are reported with greater frequency than during open cholecystectomy (OC).

METHODS

In 1999, a retrospective study evaluating the incidence of BDIs during LC in the area of Rome from 1994 to 1998 (group A) was performed. In addition, a prospective audit was started, ending in December 2001 (group B).

RESULTS

In group A, 6,419 LCs were performed (222 were converted to OC; 3.4%). In group B, 7,299 LCs were performed (225 were converted to OC; 3.1%). Seventeen BDIs (0.26%) occurred in group A and 16 (0.22%) in group B. Overall, mortality and major morbidity rates were 12.1% and 30.3%, respectively, without significant differences between the two groups.

CONCLUSIONS

The incidence and clinical relevance of BDIs during LC in the area of Rome appeared to be stable over the past 8 years and were not influenced by the use of a prospective audit, as compared with a retrospective survey.

[Intraoperative cholangiography during laparoscopic cholecystectomy: selective or routine?]

Since its presentation by Mirizzi in 1931, the role of intraoperative cholangiography (ICHO) has been controversial and has become an argument even more disputed with the introduction of laparoscopic cholecystectomy (VLC) in 1988. The Authors reviewed their experience to determine the most appropriate use of ICHO during VLC on the basis of a retrospective analysis of cases of selective ICHO. From December 1991 to January 2001, 597 patients, 552 elective procedure and 45 emergency procedure, were reviewed. Of 552 patients 62 presented with at least one diagnostic criterion for symptomatic gallstone disease and were treated by means of ERCP completed with endoscopic sphincterectomy (ES) when a stone of the common bile duct was found, while the remaining 490 patients underwent VLC; a total of 10 ICHO were performed, two of which in the ERCP group and 8 in the VLC group. The 45 patients treated in emergency underwent VLC; in 43 cases ICHO was performed. Of all patients, there were 2 cases of common bile duct injuries (0.33%) and in both cases ICHO was not performed. A cholangiogram added 27 min to the average duration of surgery. On the basis of both the literature and Authors' experience, it can be stated that the routine use of ICHO is not useful to reduce bile duct injuries, while it significantly increases the cost of the surgical procedure due to the increase of average operative time. The use of ICHO seems to be effective to demonstrate clinically unsuspected choledocholitiasis, although, at present, the real clinical advantage deriving from the detection of these stones is not clear. The Authors conclude that further prospective, randomized studies are necessary to assess the precise role of ICHO with regard to VLC.

[Prognostic value of C reactive protein in acute pancreatitis]

Controversy still exists regarding the clinical features of acute pancreatitis: it is not known whether this is a disease which progresses from mild to severe forms or which arises immediately as severe acute pancreatitis. An early diagnosis, however, is regarded as mandatory for successful treatment. Over the years many Authors have proposed different scoring systems for the early assessment of the clinical evolution of acute pancreatitis. The most widely used scoring systems (Ranson, Osborne, Apache II) are often cumbersome and difficult to use in clinical practice because of their multifactorial nature. Thus, a number of unifactorial prognostic indices have been employed in routine hospital practice, such as C-reactive protein, serum amylase and serum lipase. These serum enzymes are easy to obtain in normal clinical practice and many authors consider them as reliable as multifactorial scoring systems. One hundred and five patients affected by acute pancreatitis have been hospitalised in the Surgical Department of San Giacomo Hospital (Rome) over an nine-year period. All patients underwent C-reactive protein, amylase, and lipase serum assays on days 1, 3 and 5 after admission. The results show that C-reactive protein assay is highly sensitive in detecting necrotic forms of acute pancreatitis. The authors conclude that C-reactive protein, together with both serum amylase and serum lipase, often provides a precise picture of the clinical situation in patients with acute pancreatitis. On this basis the best therapeutic option can be chosen.

[Necrotizing fasciitis after laparoscopic adhesion surgery. A clinical case]

A case of a fulminating necrotizing cellulitis after a laparoscopic adhesiolysis performed for ileal obstructive disease, is presented. During operation, a very little intestinal perforation was caused by an "atraumatic grasper", and intestinal fluid flooded into the peritoneum; the lesion was sutured. A copious peritoneal lavage was performed and the operation ended by positioning a peritoneal drain. The patient was going well, passing flatus on the second postoperative day; on the fourth postoperative day erythematous edema close one of the trocar wound appeared. In spite of an aggressive medical and surgical therapy the infection had a very rapid spreading and the patient died six days later. A literature review is reported and simple intraoperative remedies are proposed.