(1/893) Perforation of the gallbladder: analysis of 19 cases.
Perforation of the gallbladder occurred in 19 (3.8%) of 496 patients with acute cholecystitis treated at one hospital in an 8-year period. The average age of the 19 patients was 69 years and the female:male ratio was 3:2. Most had a history suggestive of gallbladder disease and most had coexisting cardiac, pulmonary, renal, nutritional or metabolic disease. The duration of the present illness was short, perforation occurring within 72 hours of the onset of symptoms in half the patients; the diagnosis was not suspected preoperatively in any. In the elderly patient with acute cholecystitis who has a long history of gallbladder disease, cholecystectomy should be performed early, before gangrene and perforation of the gallbladder can occur. (+info)
(2/893) Gallstones, cholecystectomy and risk of cancers of the liver, biliary tract and pancreas.
To examine the association between gallstones and cholecystectomy, we conducted a nationwide population-based cohort study in Denmark. Patients with a discharge diagnosis of gallstones from 1977 to 1989 were identified from the Danish National Registry of Patients and followed up for cancer occurrence until death or the end of 1993 by record linkage to the Danish Cancer Registry. Included in the cohort were 60 176 patients, with 471 450 person-years of follow-up. Cancer risks were estimated by standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) stratified by years of follow-up and by cholecystectomy status. Among patients without cholecystectomy, the risks at 5 or more years of follow-up were significantly elevated for cancers of liver (SIR = 2.0, CI = 1.2-3.1) and gallbladder (SIR = 2.7, CI = 1.5-4.4) and near unity for cancers of extrahepatic bile duct (SIR = 1.1), ampulla of Vater (SIR = 1.0) and pancreas (SIR = 1.1). The excess risk of liver cancer was seen only among patients with a history of hepatic disease. Among cholecystectomy patients, the risks at 5 or more years of follow-up declined for cancers of liver (SIR = 1.1) and extrahepatic bile duct (SIR = 0.7), but were elevated for cancers of ampulla of Vater (SIR = 2.0, CI = 1.0-3.7) and pancreas (SIR = 1.3, CI = 1.1-1.6). These findings confirm that gallstone disease increases the risk of gallbladder cancer, whereas cholecystectomy appears to increase the risk of cancers of ampulla of Vater and pancreas. Further research is needed to clarify the carcinogenic risks associated with gallstones and cholecystectomy and to define the mechanisms involved. (+info)
(3/893) How can videolaparoscopy be used in a peritoneal dialysis programme?
BACKGROUND: Recently videolaparoscopy is considered to have a vaster use in surgery due to the undeniable benefits such as low operatory traumatism, quick recovery of canalization, a short stay in the hospital and minor scarring. METHODS: Forty patients were treated with peritoneal dialysis (PD); 15 videolaparoscopic procedures were performed on 13 patients before starting PD and two during the course of PD. The videolaparoscopy procedure was started by inducing pneumoperitoneum after initiation of general anaesthesia through endotracheal intubation. RESULTS: Peritoneal catheter placement was carried out in 11 ESRD patients showing abdominal scars due to previous laparotomies; their abdominal condition precluded safe PC placement using conventional non-laparoscopic procedures with local anaesthesia. Release of adhesions was performed only in two patients. Videolaparoscopy was also used in three patients for elective cholecystectomy; 2/3 underwent concomitant PC insertion. One patient was submitted to cholecystectomy during the course of CAPD; following the procedure we left the peritoneum dry overnight and then we started temporary IPD, using small volumes, avoiding haemodialysis (HD). Regular CAPD was resumed 6 days later. Finally, videolaparoscopy was also used for diagnostic purpose i.e. in one 59-year-old man patient who had a peritoneal catheter obstruction. Repeated rescue attempts using urokinase solution to irrigate the peritoneal catheter had been used in vain attempts prior to the procedure. CONCLUSIONS: Videolaparoscopy proves to be a useful tool in a PD programme. Firstly, it may be used as a technique for catheter implantation, not as a routine procedure but in patients with extensive abdominal scars due to previous laparotomy, i.e. at risk for accidental viscera perforation due to the possibility of adhesions between intestinal loops and parietal peritoneum. Secondly, videolaparoscopy used for abdominal surgery allows the resumption of PD immediately after surgical procedure and thus avoiding HD. Videolaparoscopy is fundamental for diagnosis and rescue of catheter dysfunction and has an integral role in the successful management of these patients in extending catheter function and permitting safe replacement of peritoneal catheter if it becomes necessary. Along with the undeniable advantages, remains the disadvantages that it must be carried out by an expert surgeon in an operating theatre while the patient is under general anaesthesia. (+info)
(4/893) Evidence for validity of a health status measure in assessing short term outcomes of cholecystectomy.
OBJECTIVE: To assess the validity of the Nottingham health profile (NHP) as an indicator of short term outcome of cholecystectomy. DESIGN: Prospective assessment of outcome. SETTING: One teaching hospital. Patients--161 consecutive patients admitted for cholecystectomy between January 1989 and September 1990. MAIN MEASURES: Patients' reported symptoms and self assessed NHP scores before cholecystectomy and at follow up at three and 12 months (76 patients); assessment before admission (19). RESULTS: Complete data were obtained preoperatively and at three months' follow up from 154 patients; seven did not respond to the follow up questionnaire. 76/84(90%) patients in the study 12 months or more answered the 12 month follow up questionnaire; eight did not respond. Significant changes in score before and at three months after the operation were observed for four of the six dimensions: energy (35.34 v 19.53, p < 0.0001), pain (27.38 v 9.8, p < 0.0001), sleep (26.99 v 17.51, p = 0.0002), and emotional reactions (16.12 v 7.56, p = 0.001). The mean scores for 76 patients followed up at three and 12 months showed little subsequent change. Scores in readmitted patients were all significantly higher, suggesting poor health. Patients with five reported symptoms had significantly worse scores for all dimensions. Scores were similar before cholecystectomy whether the questionnaire was completed before or after admission. CONCLUSION: The NHP is an appropriate tool for monitoring changes in health after cholecystectomy. (+info)
(5/893) Comparison of short term outcomes of open and laparoscopic cholecystectomy.
OBJECTIVE: To compare the three month outcome of open and laparoscopic cholecystectomy. DESIGN: Prospective assessment of outcome for a series of patients encompassing the introduction of the laparoscopic technique. SETTING: One teaching hospital. PATIENTS: 269 patients admitted for open cholecystectomy between January 1989 and March 1992 and 122 admitted for laparoscopic cholecystectomy between January 1991 and March 1992. MAIN MEASURES: Patients' reported symptoms and self assessed scores with the Nottingham health profile before operation and at three month follow up. Incidence of complications and adverse events after discharge. RESULTS: Similar improvements in symptom rates and health scores were seen regardless of surgical technique. A lower rate of postoperative complications was seen in the patients given laparoscopic surgery (6/95(6%) v 45/235(19%)), and their mean length of stay was lower (4.5 v 9.8 days). Similar results were obtained when the analysis was restricted to a subset of fairly uncomplicated cases (patients aged 60 or less without other illnesses on admission who were not undergoing emergency or urgent surgery), which constituted a larger proportion of the group given laparoscopy (35/95(37%) v 40/235(17%)). Between these two groups no significant difference was seen in the frequency of relevant readmissions to hospital or visits to general practitioners or accident and emergency departments. CONCLUSION: Ideally, a new surgical technique would be evaluated in a randomised trial. In the absence of such a trial, this observational study provides some evidence that the switch from open to laparoscopic cholecystectomy has brought benefits, particularly in terms of reduced length of stay in hospital. A range of clinical and patient derived indicators suggests that these gains have not been associated with a reduction in the quality of the outcome at three months. (+info)
(6/893) Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study.
BACKGROUND: Previous studies suggest that laparoscopic cholecystectomy (LC) is associated with an increased risk of intraoperative injury involving the bile ducts, bowel, and vascular structures compared with open cholecystectomy (OC). Population-based studies are required to estimate the magnitude of the increased risk, to determine whether this is changing over time, and to identify ways by which this might be reduced. METHODS: Suspected cases of intraoperative injury associated with cholecystectomy in Western Australia in the period 1988 to 1994 were identified from routinely collected hospital statistical records and lists of persons undergoing postoperative endoscopic retrograde cholangiopancreatography. The case records of suspect cases were reviewed to confirm the nature and site of injury. Ordinal logistic regression was used to estimate the risk of injury associated with LC compared with OC after adjusting for confounding factors. RESULTS: After the introduction of LC in 1991, the proportion of all cholecystectomy cases with intraoperative injury increased from 0.67% in 1988-90 to 1.33% in 1993-94. Similar relative increases were observed in bile duct injuries, major bile leaks, and other injuries to bowel or vascular structures. Increases in intraoperative injury were observed in both LC and OC. After adjustment for age, gender, hospital type, severity of disease, intraoperative cholangiography, and calendar period, the odds ratio for intraoperative injury in LC compared with OC was 1.79. Operative cholangiography significantly reduced the risk of injury. CONCLUSION: Operative cholangiography has a protective effect for complications of cholecystectomy. Compared with OC, LC carries a nearly twofold higher risk of major bile, vascular, and bowel complications. Further study is required to determine the extent to which potentially preventable factors contribute to this risk. (+info)
(7/893) Gastrointestinal surgical workload in the DGH and the upper gastrointestinal surgeon.
Workload implications of upper gastrointestinal (UGI) subspecialisation within the district general hospital (DGH) have been assessed by prospective data collection over a 12-month period in a DGH with six general surgeons serving a population of 320,000. The single UGI surgeon (UGIS) performed all ten oesophageal resections, ten of 11 gastric resections for malignancy and all eight pancreatic operations. He also performed 91 of the 182 cholecystectomies, 164 of the 250 endoscopic retrograde cholangiopancreatograms (ERCP) and all endoscopic procedures for the palliation of unresected oesophageal tumours. The UGIS was responsible for the management of all patients with severe pancreatitis, yet he also performed 51 colorectal resections over the 12-month period. Successful management of severely ill patients with upper GI disease requires consultant supervision on a day-to-day basis. If such UGI disease is to be managed in the DGH, two surgeons with UGI experience will be required if high quality care and reasonable working conditions are to be achieved. Such UGIS will continue to perform some colorectal surgery. (+info)
(8/893) Ultrasonographic evaluation of the common bile duct in biliary acute pancreatitis patients: comparison with endoscopic retrograde cholangiopancreatography.
We compared the morphologic findings of the common bile duct by ultrasonography and endoscopic retrograde cholangiopancreatography in patients with biliary acute pancreatitis. Forty-five patients were studied. The diagnosis of acute pancreatitis was based on the presence of characteristic abdominal pain associated with an elevation of serum amylase and lipase concentrations. All patients underwent ultrasonography and subsequently urgent endoscopic retrograde cholangiopancreatography and eventually endoscopic sphincterotomy. Ultrasonography showed gallstones in 33 patients and sludge of the gallbladder in seven patients. In the common bile duct, lithiasis was found in two patients and sludge in 25. Endoscopic retrograde cholangiopancreatography showed choledocolithiasis in eight patients and sludge of the common bile duct in 32. In 27 cases (60%) concordance occurred between ultrasonographic and endoscopic retrograde cholangiopancreatographic detection of lithiasis or sludge of the common bile duct. The average diameter of the common bile duct determined by sonography was significantly smaller (P < 0.001) than that obtained by endoscopic retrograde cholangiopancreatography. The evaluation of this parameter indicated that a good correlation existed between the values obtained with the two techniques (r(s) = 0.765, P < 0.001). Both ultrasonography and endoscopic retrograde cholangiopancreatography can provide reliable measurements of the common bile duct diameter. Ultrasonography is the technique of choice in the initial investigation of patients with biliary acute pancreatitis. (+info)