Chronic Gallbladder Disease Research Articles

A Systematic Review and Meta-Analysis of the Outcomes of Laparoscopic Cholecystectomy Compared to the Open Procedure in Patients with Gallbladder Disease.

Background Conflicting evidence regarding the laparoscopic versus open cholecystectomy outcomes in scientific literature impacts the medical decision-making for patients with gallbladder disease. This study aimed to compare a range of primary and secondary outcomes between patients receiving laparoscopic cholecystectomy and those with open intervention. Methods Articles published from 1993 to 2023 were explored by utilizing advanced filters of PubMed Central/Medline, Web of Science, CINAHL, JSTOR, Cochrane Library, Scopus, and EBSCO. The gallbladder disease was determined by the presence of one or more of the following conditions: 1) Gangrenous cholecystitis, 2) acute cholecystitis, 3) chronic gallbladder diseases, and 4) cholelithiasis. The primary end-point was mortality, while the secondary outcome included (1) bile leakage, 2) common bile duct injury, 3) gangrene, 4) hospital stay (days), 5) major complications, 6) median hospital stay (days), (7) pneumonia, 8) sick leaves (days), and 9) wound infection. Results Statistically significant reductions were observed in mortality (odds ratio [OR]: 0.30, 95% confidence interval [CI]: 0.30, 0.45, p < 0.00001), mean hospital stay duration (mean difference: -2.68, 95% CI: -3.66, -1.70, p < 0.00001), major complications (OR: 0.35, 95% CI: 0.19, 0.64, p = 0.0005), post/intraoperative wound infection (OR: 0.29, 95% CI: 0.16, 0.51, p < 0.0001), and sick leaves (OR: 0.34, 95% CI: 0.14, 0.80, p = 0.01) in patients who underwent laparoscopic cholecystectomy compared with those with the open intervention. No statistically significant differences were recorded between the study groups for bile leakage, common bile duct injury, gangrene, median hospital stay days, and pneumonia ( p > 0.05). Conclusions The pooled outcomes favored the use of laparoscopic cholecystectomy over the open procedure in patients with gallbladder disease. The consolidated findings indicate the higher impact of laparoscopic cholecystectomy in improving patient outcomes, including safety episodes, compared with open cholecystectomy.

Intracholecystic versus Intravenous Indocyanine Green (ICG) Injection for Biliary Anatomy Evaluation by Fluorescent Cholangiography during Laparoscopic Cholecystectomy: A Case-Control Study.

(1) Background: Fluorescence cholangiography has been proposed as a method for improving the visualization and identification of extrahepatic biliary anatomy in order to possibly reduce injuries and related complications. The most common method of indocyanine green (ICG) administration is the intravenous route, whereas evidence on direct ICG injection into the gallbladder is still quite limited. We aimed to compare the two different methods of ICG administration in terms of the visualization of extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC), analyzing differences in the time of visualization, as well as the efficacy, advantages, and disadvantages of both modalities. (2) Methods: A total of 35 consecutive adult patients affected by acute or chronic gallbladder disease were enrolled in this prospective case–control study. Seventeen patients underwent LC with direct gallbladder ICG injection (IC-ICG) and eighteen subjects received intravenous ICG administration (IV-ICG). (3) Results: The groups were comparable with regard to their demographic and perioperative characteristics. The IV-ICG group had a significantly shorter overall operative time compared to the IC-ICG group (p = 0.017). IV-ICG was better at delineating the duodenum and the common hepatic duct compared to the IC-ICG method (p = 0.009 and p = 0.041, respectively). The cystic duct could be delineated pre-dissection in 76.5% and 66.7% of cases in the IC-ICG and IV-ICG group, respectively, and this increased to 88.2% and 83.3% after dissection. The common bile duct could be highlighted in 76.5% and 77.8% of cases in the IC-ICG and IV-ICG group, respectively. Liver fluorescence was present in one case in the IC-ICG group and in all cases after IV-ICG administration (5.8% versus 100%; p < 0.0001). (4) Conclusions: The present study demonstrates how ICG-fluorescence cholangiography can be helpful in identifying the extrahepatic biliary anatomy during dissection of Calot’s triangle in both administration methods. In comparison with intravenous ICG injection, the intracholecystic ICG route could provide a better signal-to-background ratio by avoiding hepatic fluorescence, thus increasing the bile duct-to-liver contrast.

Single-Port Cholecystectomy for Cholecystitis Versus Non-Cholecystitis.

Background and Objectives:To assess the safety and efficacy of single-port laparoscopic cholecystectomy (SPLC) for the treatment of symptomatic cholelithiasis in different gallbladder pathologic conditions.Methods:All patients who underwent SPLC in our department between October 1, 2017 and March 31, 2020 were registered consecutively in a prospective database. Patients’ charts were retrospectively divided according to histological diagnosis: normal gallbladder (NG) (n = 13), chronic cholecystitis (CC) (n =47), and acute cholecystitis (AC) (n = 10). The parameters for assessing the procedure outcome included operative time, blood loss, use of additional trocars, conversion to laparotomy, intraoperative and postoperative complications, and length of hospital stay. Patient groups were statistically compared.Results:Seventy patients underwent SPLC. Duration of surgery increased from NG (55 ± 22.7 min) to CC (70 ± 33.5 min), and to AC patients (110.5 ± 50.5 min), which is statistically significant (P = .001). Postoperative complication rates were 7.6% in NG patients, 17% in CC, and 30% in AC (P = .442). Length of hospitalization was shorter for NG patients (1.0 ± 0.6 days) versus CC (2.0 ± 1.1 days) and AC patients (2.0 ± 4.7 days), with statistical significance (P = .020). Multivariate analysis found that pathology type and the occurrence of postoperative complications were independent predictors for prolonged operative times and prolonged hospital stay, respectively.Conclusion:SPLC is feasible for acute and chronic cholecystitis with good procedural outcomes. Since SPLC technique itself can be sometimes challenging with the existing technology, its application, especially in cases of acute cholecystitis, should be done with caution. Only prospective randomized studies on this approach for acute and chronic gallbladder diseases will assess the complete reliability of this technique.

Cholesterosis: is it related to pancreatology?

Gallbladder (GB) cholesterosis is a disease characterized by impaired cholesterol metabolism with its predominant deposition in the GB wall. GB cholesterosis is considered as a component of lipid distress syndrome, i. e. a combination of a range of pathological conditions caused by lipid metabolism disorders (atherosclerosis, lipogenic pancreatitis, GB cholesterosis, fatty hepatosis). Indeed, GB cholesterosis is often detected in patients with coronary atherosclerosis, hypertension, obesity, and non-alcoholic steatohepatitis. This allows us to consider the GB as a target organ in atherogenic dyslipidemia and point out that its lesion is not as an independent disease, but a systemic manifestation of impaired cholesterol metabolism in the liver.&#x0D; Considering the general pathogenetic factors of the development of gallstone disease and GB cholesterosis, as well as its frequent combination with cholecystolithiasis, some authors consider GB cholesterosis a specific option of gallstone disease or the pre-stage of cholecystolithiasis, justifying this by the decrease in nucleation time of GB bile upon the absence of stones in patients with GB cholesterosis, as well as with gallstone disease.&#x0D; Clinical manifestations of GB cholesterosis have not been sufficiently studied. They are nonspecific and do not allow differentiating it from other chronic GB diseases. The relevant symptoms in GB cholesterosis are due to the addition of cholecystitis, cholecystolithiasis or dysfunction of the biliary tract.&#x0D; Sonography is considered the most informative technique for diagnosing GB cholesterosis. This study is especially informative in case of polypous form of GB cholesterosis. According to the results of sonography, reticular, polypous (pseudopolypous), calculous and mixed forms of GB cholesterosis are distinguished.&#x0D; The use of ursodeoxycholic acid preparations in GB cholesterosis is pathogenetically substantiated. Ursonost (Organosyn LTD) is one of the best drugs.

S3474 Symptomatic Cholelithiasis in the Setting of Porcelain Gallbladder and SARS-CoV-2 (COVID-19) Infection

Introduction: Porcelain gallbladder, a rare entity with female preponderance, is a manifestation of chronic inflammation of the gallbladder. It is an incidental finding characterized by calcification of the gallbladder wall on imaging studies. The affinity of SARS-CoV-2 for angiotensin converting enzyme 2 (ACE2) which is widely expressed in the lungs, heart, intestines, gallbladder, kidneys, and adipose tissue may account for its ability to accentuate indolent inflammation in the gastrointestinal tract. Case Description/Methods: 56 year old African American female with medical history of gastroesophageal reflux disease, obesity and hypertension presented with a 3 day history of fever, shortness of breath, cough and sudden onset intermittent, burning epigastric and right upper quadrant (RUQ) pain with no aggravating or relieving factors. Vital signs at presentation; Temperature 100.8 F, Respiratory rate 20 breaths/ minute, pulse of 89beats/min, oxygen saturation 97% on room air and blood pressure 147/105mmHg. Physical examination findings were reduced air entry at the lower lung zones bilaterally and moderate epigastric and RUQ tenderness. She was positive for SARS-CoV-2 RNA. Chest X-ray showed large bilateral lower lobe atelectasis and increased interstitial process in the lower lung fields. She was admitted for COVID pneumonia. On admission day 1 patient continued to complain of RUQ pain, warranting RUQ ultrasound scan which showed prominent gallbladder calculus with posterior shadowing, likely porcelain gallbladder in the setting of existing gallstones. Patient was managed with vitamins, ceftriaxone, azithromycin, remdesivir, famotidine and tylenol for pain. Abdominal pain improved and she was discharged home on day 3 of hospitalization for outpatient follow up. Discussion: Our patient presented with symptomatic cholelithiasis, in the setting of COVID infection and porcelain gallbladder. We believe this finding bolsters the assertion that COVID infection accentuates gallbladder inflammation which consequently leads to precipitation/ worsening of symptoms of underlying chronic gall bladder disease. In light of the aforementioned, we believe the diagnostic challenge is the ability to make a clear distinction between de novo inflammation of the gallbladder and accentuation of an ongoing chronic inflammatory process. Given that there is a risk of porcelain gallbladder progressing to gallbladder cancer, should routine surveillance be performed in this population of patients?

Association of hospital and surgeon operative volumes and surgeon pediatric subspecialization with pediatric laparoscopic cholecystectomy outcomes: A population-based cohort study

BackgroundMost pediatric cholecystectomies are performed by adult general surgeons, but it is unclear whether outcomes differ by surgeon pediatric subspecialization, hospital procedure volume, or surgeon procedure volume. We aimed to determine whether higher hospital or surgeon laparoscopic cholecystectomy (LC) volume or surgeon pediatric subspecialization is associated with better outcomes after LC in children. MethodsWe performed a retrospective cohort study using statewide hospital discharge databases from the states of Florida, Georgia, and Iowa. We included children aged 4–18 years who underwent inpatient or outpatient LC for acute or chronic gallbladder disease in January 2010–August 2015.Propensity score weighting was used to estimate relationships between operative volumes or surgeon pediatric subspecialization and rates of readmission or emergency department (ED) visit within 30 days. ResultsA total of 5391 children were included (mean age 15.9 years, 81.6% female). Children operated on by surgeons with high LC volumes in hospitals with high LC volumes were less likely to experience a readmission or ED visit within 30 days (10.8% vs. 13.7%, p = 0.04). Additionally, children operated on by adult general surgeons in hospitals with high LC volumes were less likely to experience a readmission or ED visit within 30 days (10.9% vs. 13.8%, p = 0.03). ConclusionsChildren are less likely to be readmitted to the hospital or present to the ED after laparoscopic cholecystectomy if they receive their care from adult general surgeons at hospitals that frequently perform this procedure in both adults and children. Level of evidenceIII

If Chronic Gallbladder Diseases Increase the Incidence of PEC

If Chronic Gallbladder Diseases Increase the Incidence of PEC

Ksantogranulomatozni holecistitis - dijagnostika i hirurško lečenje serije bolesnika

Objective. Xanthogranulomatous cholecystitis (XGC) is a rare, benign variant of chronic gallbladder disease characterized by marked proliferative fibrosis and it causes significant difficulties in performing cholecystectomy. Methods. A total of 18 XGC cases were confirmed by retrospective analysis of the medical files of 562 patients undergoing cholecystectomy in our ward from January 2012 to May 2016. The median patients' age was 62 years (44-79) and the ratio of women to men was 2.6 : 1. Results. The clinical picture most often corresponds to chronic cholecystitis (61.1% of patients), and less frequently to acute cholecystitis (38.9%). Palpable mass below the right rib arch (33.3%) and jaundice (16.7%) was also observed. Gallbladder wall thickening, detected by ultrasound or computerized tomography scans, was observed in all patients. Gallbladder stones were present in 94.4% of patients. There were no confirmed cases of gallbladder cancer. All surgeries were technically difficult. The rate of laparoscopic conversion to open procedures was high (57.1%). The percentage of postoperative complications was also high (27.8%). There were no fatal outcomes in the analyzed series of patients. Conclusion. XGC creates difficulties during surgery, so any preoperative suspicion of XGC should prompt the surgeon to choose an open procedure as the main treatment choice. Rescue surgeries such as subtotal cholecystectomy should not be avoided. In the case of suspected gallbladder cancer intraoperative pathohistological examination is advised.

Scintigraphic Findings Beyond Ejection Fraction on Hepatobiliary Scintigraphy: Are They Correlated With Chronic Gallbladder Disease?

To determine if classically reported findings associated with chronic cholecystitis on hepatobiliary scintigraphy (HBS), such as delayed small bowel (SB) transit, slow gallbladder (GB) filling, and reversal of the normal GB and SB transit, are associated with a depressed GB ejection fraction (GBEF). The secondary objectives were to determine whether GBEF is correlated with the time of GB filling, time of SB transit, or reversal of normal GB/SB filling sequence. We hypothesize that an association between a depressed GBEF and these classical HBS findings could validate them as surrogate markers for chronic GB disease. We reviewed all HBS exams over a retrospective 16-month period. Data from 221 patients (mean age, 45.3 ± 15.2 years; 152 female and 69 male subjects) who underwent HBS with GBEF determination for evaluation of chronic symptoms concerning for biliary etiology met inclusion criteria. Classically reported findings for cholecystitis were recorded for each patient. Comparisons were made using t test and Fisher test analysis. Comparing exams with normal and abnormal GBEF values, there were no significant differences based on age, sex, GB fill time, normal versus delayed SB transit, and reversal of normal GB/SB filling sequence. Additionally, we did not see a correlation between the measured GBEF and GB fill time, SB transit time, or reversal of normal GB/SB filling sequence. Delayed SB transit, slow GB filling time, and reversal of the normal GB and SB filling sequence on HBS imaging are not associated with the measured GBEF and not predictive of chronic GB disease.

Laparoscopic cholecystectomy as a day surgery operation: two centers experience.

Background: Day-surgery laparoscopic cholecystectomy (DSLC) become the standard management of chronic gall bladder diseases worldwide due to its safety and feasibility. The aim of the present study was to study DSLC at two secondary care governmental hospitals in Saudi Arabia with a separate day-surgery unite in terms of complications, same-day discharge, to identify early discharge associated problems, and to determine patient satisfaction. Methods: Over a 3-years period, all patients undergoing elective laparoscopic cholecystectomy under the authors were prospectively studied. Patients fulfill criteria for DSLC were offered the procedure. All patients were asked on follow up postoperatively about their satisfaction and recommendation of DSLC for their relatives and friends. Results: Eight hundred and sixteen patients underwent elective day surgery laparoscopic cholecystectomies, predominantly female (89.7%) and ASA I (77.2%) with a mean age 38.1± 18.7 years. Eighty eight percent of the patients were discharged directly from the day surgery unite, and nearly 89.6% of the patients were discharged within 24 hours of the operation. Re-admission following hospital discharge was necessary for 3 patients (0.37%). The overall rate of complications was 1.35% (11patients). At follow-up, 701 patients (97.36%) were satisfied with their experience undergoing DSLC. Conclusions: Our findings support the evidence that DSLC is safe and feasible. Many patients satisfied with their length of stay and day surgery ward care although we extend the criteria for DSLC.

Applied hepatobiliary scintigraphy in chronic gallbladder diseases

Applied hepatobiliary scintigraphy in chronic gallbladder diseases

Pain provocation and low gallbladder ejection fraction with CCK cholescintigraphy are not predictive of chronic acalculous gallbladder disease symptom relief after cholecystectomy.

Chronic acalculous gallbladder disease (CAGD) falls within the spectrum of diseases associated with gallbladder dysmotility. Cholecystokinin-cholescintigraphy (CCK-CS) has been used to evaluate for CAGD, with a gallbladder ejection fraction (GBEF) of <35% being indicative of gallbladder dysfunction. The reproduction of biliary colic upon administration of CCK has been cited as indicative of CAGD. Our purpose was to determine whether low GBEF or reproduction of pain during CCK-CS was predictor of surgical outcomes related to resolution of symptoms or as a correlate to gallbladder pathology. A retrospective review of patients was performed to evaluate adults with a diagnosis of CAGD who underwent CCK-CS prior to surgical intervention. CPT and ICD-9 coding queries were used to identify the patient population. Patients with cholelithiasis were excluded. Sixty-four patients met inclusion criteria. Two patients were lost to follow-up and were excluded. During CCK-CS, 41 patients (66%) reported symptoms similar to their presenting complaint. Twenty-one patients reported no symptoms with CCK-CS. There was no significant relationship between gallbladder pathology and either GBEF or reproduction of symptoms with CCK-CS (p=0.14). About 81% of patients (n=50) had relief of symptoms following cholecystectomy. Sixty-six percentage of patients (n=33) with long-term symptom relief after cholecystectomy had reproduction of symptoms with CCK-CS. Nineteen percentage of all patients (n=12) had long-term symptom recurrence despite surgery. Eight of these patients (66%) had symptom reproduction with CCK-CS. There was no significant correlation with either the GBEF or symptoms reproduction with CCK-CS as a predictor of postoperative outcome (p=0.12). Provocation of pain by CCK-CS and low GBEF are unreliable predictors of postoperative relief of symptoms following cholecystectomy for biliary dyskinesia or chronic acalculous gallbladder disease.

Single-port versus multi-port cholecyastectomy for patients with acute cholecystitis: a retrospective comparative analysis

Trans-umbilical single-port laparoscopic cholecystectomy for chronic gallbladder disease is becoming increasingly accepted worldwide. But so far, no reports exist about the challenging single-port surgery for acute cholecystitis. The objective of this study was to describe our experience with single-port cholecystectomy in comparison to the conventional laparoscopic technique. Between August 2008 and March 2010, 73 patients with symptomatic gallbladder disease and histopathological signs of acute cholecystitis underwent laparoscopic cholecystectomy at our institution. Thirty-six patients were operated on with the single-port technique (SP group) and the data were compared with a control group of 37 patients who were treated with the multi-port technique (MP group). The mean age in the SP group was 61.5 (range 21-81) years and in the MP group was 60 (range 21-94) (P=0.712). Gender, ASA status and BMI were not significantly different. The number of white blood cells was different before [SP: 9.2 (range 2.8-78.4); MP: 13.2 (range 4.4-28.6); P=0.001] and after the operation [SP: 7.8 (range 3.5-184.8); MP: 11.1 (range 5-20.8); P=0.002]. Mean operating time was 88 (range 34-174) minutes in the SP group vs 94 (range 39-209) minutes in the MP group (P=0.147). Four patients (5%) required conversion to an open procedure (SP: 1; MP: 3; P=0.320). During the follow-up period of 332 (range 29-570) days in the SP group and 428 (range 111-619) days in the MP group (P=0.044), eleven (15%) patients developed postoperative complications (P=0.745) and two patients in the SP group required reoperation (P=0.154). Trans-umbilical single-port cholecystectomy for beginning acute cholecystitis is feasible and the complication rate is comparable with the standard multi-port operation. In spite of our good results, these operations are difficult to perform and should only be done in high-volume centers for laparoscopic surgery with experience in single-port surgery.

Single-Port-Cholezystektomie: Der neue Standard?

Single-port transumbilical laparoscopic cholecystectomy (SPTLC) may become a standard procedure in the surgical treatment of acute and chronic gallbladder diseases. The initial experience with this new technique is reported. 186 patients underwent laparoscopic single-port laparoscopic cholecystectomy between September 2008 and February 2010 at the Vivantes Klinikum Am Urban, Berlin, Germany. All these operations were performed with conventional straight laparascopic instruments using a single-port system. Conversion to a three-port technique or open procedure became necessary in four patients after failure to perform the single-port method. The average age of the 120 women (64%) and 66 men (36%) was 45 (range 15-88 years) years. The ASA grade (American Society of Anesthesiologists) averaged 2 (range, 1-3) and the BMI 28.5 (range 17-49). Mean operative time was 63 min (range, 28-17 min). 48 patients (26%) had histopathological evidence of acute cholecystitis. During a mean follow-up period of 39 weeks (range 1-78 weeks), 11 patients (6%) developed complications related to the surgery, five of these patients (3%) requiring a subsequent re-operation. Single-port transumbilical laparoscopic cholecystectomy for acute and chronic gallbladder disease is a feasible approach for routine cholecystectomy. After a short learning curve the operation time and rate of complications are comparable to standard multi-port laparoscopic cholecystectomy. A limitation of the procedure are very obese patients and multiple previously performed abdominal operations.

T1625 Is Pain Provocation With Cholecystokinin Administration on Cholescintigraphy Predictive of Relief of Symptoms for Biliary Dyskinesia Following Cholecystectomy?

Introduction Biliary dyskinesia, also referred to as chronic acalculous gallbladder disease (CAGD), falls within the spectrum of diseases associated with gallbladder dysmotility. Cholecystokinin cholescintigraphy (CCK-CS) has been used to evaluate for CAGD, with a gallbladder ejection fraction (GBEF) of <35% being indicative of gallbladder dysfunction. The reproduction of biliary colic upon administration of CCK has been cited as indicative of CAGD. Our purpose was to determine if reproduction of pain during CCK-CS is a predictor of surgical outcomes or as a correlate to pathology. Methods A retrospective review of patients was performed to evaluate adults with a diagnosis of CAGD who underwent CCK-CS prior to surgical intervention. CPT and ICD-9 coding queries were used to identify the patient population. Patients with cholelithiasis were excluded. This study was approved by the institutional Human Assurances Committee. Results 64 patients met inclusion criteria. Two patients were lost to follow up and were excluded. During CCK administration, 41 patients (66.13%) reported symptoms similar to their presenting complaint. 21 patients reported no symptoms with CCK administration. Pathology review demonstrated either normal histology (n=4), cholesterolosis (n=4), chronic cholecystitis (n=47), both cholesterolosis and chronic cholecystitis (n=6), or autolysis (n=1). There was no significant relationship between pathology and either GBEF or reproduction of symptoms with CCK administration. 81% of patients (n=50) had relief of symptoms following cholecystectomy (mean EF of 19.55% ± 12.16%). 33 of these patients (66.00%) had reproduction of symptoms with CCK-CS. Twelve patients had recurrence of symptoms (mean EF of 17.18% ± 7.59%) despite surgery. Eight of these patients (66.67%) had symptom reproduction with CCK administration. There was no significant correlation with either the EF or reproduction of symptoms following CCK administration as a predictor of postoperative outcome on assessment by unpaired Student's t-test. Conclusion Provocation of pain CCK-CS is an unreliable indicator of postoperative relief of symptoms than GBEF.

Combined Operation of Laparoscopic Cholecystectomy during Laparoscopic Appendectomy in Patient with Chronic Gallbladder Disease

Purpose: Laparoscopic cholecystectomy (LC) for asymptomatic gallbladder disease has been increasing since 1990 due to the development of LC technique. Moreover, it might be considered when someone with asymptomatic gallbladder disease needs emergency operation due to acute abdomen such as acute appendicitis. The aim of this study is to identify the efficacy of concurrent laparoscopic appendectomy with cholecystectomy. Methods: From January 1997 to June 2009, 40 patients underwent laparoscopic appendectomy with cholecystectomy at Ewha Womans University Mokdong Hospital. 40 patients were enrolled in this study. We analyzed, retrospectively, clinical and diagnostic information, time and open conversion rate in operation, length of postoperation hospital stay, and complication rate. Results: The mean age was 44.53±15.34 and male to female ratio was 1 to 1.86. 5% of all patients underwent abdominal surgery and 20% of all patients had associated diseases. Most common associated symptoms and final diagnosis were right lower abdominal pain (72.5%) and simple gallbladder stone (62.5%). Mean operation time was 98.75±33.14 min. and there was no open conversion. Mean length of postoperation hospital stay was 5±2 days. There was one (2.5%) postoperative complication. Conclusion: Combined operation of laparoscopic cholecystectomy during laparoscopic appendectomy can be a good modality for patients with chronic gallbladder disease.

Optimized transumbilical endoscopic cholecystectomy: a randomized comparison of two procedures

Natural orifice transluminal endoscopic surgery (NOTES) and transumbilical endoscopic surgery (TUES) are being developed to improve minimally invasive surgery further. In 2006, the authors developed TUES using a single triple-channel trocar or single-trocar (ST) technique. To minimize the risk and improve the surgical efficiency further, the procedure was optimized using a two-trocar (TT) technique, with both trocars in the umbilicus. This study compared the clinical results for the TT and ST techniques. For this study, 32 patients with chronic gallbladder disease and indications for cholecystectomy were randomly assigned to undergo surgery with either the TT technique (17 patients) or the ST technique (15 patients). With the TT procedure, two modified 5-mm trocars with small handles were inserted through the navel, one above and one below the umbilicus. Another 2-mm trocar was inserted for a grasper in the right upper abdomen. With the ST procedure, one 15-mm umbilical incision was made for insertion of a previously developed triple-channel trocar to apply the laparoscope, grasper, and dissector individually. Operation time, postoperative hospital stay, and postoperative pain were compared between the two procedures. The mean operative time was significantly shorter with the TT technique (35.71 +/- 9.74 min) than with the ST technique (125.25 +/- 18.9 min (p < 0.001). Use of analgesics after surgery also was less in the TT group than in the ST group (0 vs. 7, respectively; p < 0.05). The postoperative hospital stay did not differ significantly between the two groups (p > 0.05). Although both procedures were based on the transumbilical approach, the TT approach was found to be faster and less painful than the ST approach. The difference in the cosmetic result was minimal.

Xanthogranulomatous cholecystitis: the use of preoperative CT findings to differentiate it from gallbladder carcinoma

A retrospective analysis was performed on 32 patients with histologically confirmed xanthogranulomatous cholecystitis (XGC) and 21 patients with gallbladder carcinoma who underwent surgical treatment between 1998 and 2007. All patients underwent preoperative CT scanning. The CT features analyzed were: the presence of intramural hypoattenuated nodules or bands, mucosal line, the patterns of wall thickening and enhancement, and the presence of stones in the gallbladder. The variables of the CT findings with XGC were analyzed using multivariate logistic regression analysis. Intramural hypoattenuated nodules were observed in 21 patients (65%) with XGC, but in only six patients (29%) with gallbladder carcinoma (P < 0.01). The mucosal line was observed in 27 patients (84%) with XGC and in only four patients (19%) with gallbladder carcinoma (P < 0.0001). Gallstones were noted in 24 patients (75%) with XGC and five patients (24%) with gallbladder carcinoma (P < 0.001). There was no significant difference in the pattern of gallbladder wall thickening (diffuse or focal) and the presence of changes outside the gallbladder. Multivariate logistic regression analysis revealed from the CT features that the enhanced continuous mucosal line (P = 0.0013) and the presence of gallstones (P = 0.0072) were independently correlated with XGC. CT features of the enhanced continuous mucosal line in a thickened gallbladder wall, together with gallstones in a patient with chronic gallbladder disease, are highly suggestive of XGC. Accurate diagnosis of XGC may therefore indicate the need to select a less aggressive surgical approach.

A Clinical Analysis of about 2,000 Cases for the Laparoscopic Cholecystectomy: Single Center Experiences - A Change in the Indication for Laparoscopic Cholecystectomy according to Period

Purpose: Laparoscopic cholecystectomy has become the standard modality of acute and chronic gallbladder disease. This study was performed to evaluate a change in the indication for laparoscopic cholecystectomy according to period by analyzing our experiences. Methods: We retrospectively analyzed 2,096 cases of laparoscopic cholecystectomy that were treated at the Department of Surgery, Dong-A University. They were divided into 3 groups from October 1992 to December 1996 (Group 1), from January 1997 to December 2001 (Group 2) and from January 2002 to March 2007 (Group 3). Results: The mean age was 50.14±13.89 years and the male-to-female ratio was 1：1.23. Previous abdominal surgery was noted in 12.24% from Group 1, 14.96% from Group 2 and 21.48% from Group 3. Chronic cholecystitis was the most common pathologic diagnosis in all cases. However, while the incidence of acute cholecystitis and gallbladder empyema in Group 1 was 3.36% and 0%, that of Group 2 was 12.52% and 3.88% and that of Group 3 was 31.79% and 7.59%, which was increased. The mean operation time of each group was 101.00±51.00, 69.86±40.55, 78.01±45.55 minutes (P＜0.05). The conversion rate of each group was nine cases (6.04%), 21 cases (3.02%), and 51 cases (4.07%). The surgical complication rate was 7.38%, 3.88% and 4.71%, respectively. The length of hospital stay was 6.08±3.65, 3.16±2.99 and 2.91±3.34 days, which was significantly decreased (P＜0.05). Conclusion: As surgical experience increased and laparoscopic surgical skills developed, the indication for laparoscopic cholecystectomy changed. The results of this study showed that laparoscopic cholecystectomy was feasible for the treatment of complicated gallbladder lesion.

Glutathione system in erythrocytes and plasma in viral hepatites

In all 5 acute (AVHs) and chronic viral hepatites (CVHs) there was the increase of erythrocyte activities of glutathione peroxidase (GPx) and glutathione reductase (GR), and the decrerase in GSH concentration. In blood plasma there was accumulation of GPx, glutathione S-transferase (GST) and y-glutamyl transferase (gammaGT). GSH and GR increased in plasma only in AVHs. In CVH C erythrocyte GST increased. Evidently changes in the erythrocyte glutathione system are reactions to oxidative stress and in blood plasma they are consequences of inflammation and hepatocyte cytolysis. Changes were more pronounced in middle-heavy course than in the heavy one. These changes have pathogenic importance and can be used in addition to complex diagnostics. They are significantly differed from changes in chronic gall-bladder diseases. Necessity of separate investigation of glutathione system in erythrocytes and blood plasma but not in whole blood is argued.