Concurrent Cholecystectomy Research Articles

Treatment of Common Bile Duct Stones in Sweden 1989–2006: An Observational Nationwide Study of a Paradigm Shift

The preferred strategies for treatment of common bile duct stones have changed from choledochotomy with cholecystectomy to sphincterotomy with or without cholecystectomy. The aim of the present study was to compare the effectiveness of these treatment strategies on a nationwide level in Sweden. All patients with hospital care for benign biliary diagnoses 1988-2006 were identified in Swedish registers. Patients with common bile duct stones and a first admission with choledochotomy and or endoscopic sphincterotomy from 1989 through 2006 comprised the study group. These patients were analyzed with respect to readmission for biliary diagnoses and acute pancreatitis. Incidence of open and laparoscopic choledochotomy decreased from 19.4 to 5.2, whereas endoscopic sphincterotomy increased from 5.1 to 26.1 per 100,000 inhabitants per year, respectively. Among patients treated for common bile duct stones (n = 26,815), 60.0 % underwent cholecystectomy during the first hospital admission in 1989-1994, compared to 30.1 % in 2001-2006. The treatment strategy that included endoscopic sphincterotomy was associated with more readmissions for biliary diagnoses and increased risk for acute pancreatitis than the treatment strategy with choledochotomy. However, patients treated with endoscopic sphincterotomy and concurrent cholecystectomy at the index admission had the lowest risk of readmission. Cholecystectomy has been increasingly separated from treatment of bile duct stones, and endoscopic sphincterotomy has superseded choledochotomy as a first alternative for bile duct clearance in Sweden. In patients fit for surgery, clearance of the common bile duct can be combined with cholecystectomy, as it probably reduces the need for biliary related readmissions.

Isolated metastasis to the gallbladder from hepatocellular carcinoma

Metastasis to gallbladder (GB) from hepatocellular carcinoma (HCC) is rare, and it is difficult to determine indications for surgery. We report eight cases of synchronous isolated GB metastasis, and analyze their features retrospectively. Among 439 HCC patients who underwent hepatectomy from 1998 to 2008 at our institution, 393 (89.5%) underwent concurrent cholecystectomy. Among them, eight (1.8%) had GB metastasis without other distant metastases. None of these cases showed evidence of direct invasion. All cases had advanced portal vein thrombus (PVTT) and their main tumor located near the GB bed. Five cases had apparent tumor mass in the GB wall, and the other three cases had only tumor thrombus in the GB veins. Six cases were treated postoperatively with local infusion therapy with interferon, and three of them showed long-term survival. Our eight cases of GB metastasis from HCC were closely related to PVTT. Surgical resection and multimodal treatment would be necessary for long-term survival in cases with isolated GB metastasis.

Is Routine Cholecystectomy Indicated for Asymptomatic Cholelithiasis in Patients Undergoing Gastric Bypass?

The purpose of this study was to evaluate the natural history of patients undergoing Roux-en-Y gastric bypass (RYGBP) with known asymptomatic cholelithiasis in whom prophylactic cholecystectomy was not performed at the time of surgery. The records of 144 consecutive patients from a single year experience in RYGBP surgery at the University of California, Davis Medical Center were reviewed. Patients undergoing RYGBP were routinely screened for cholelithiasis by ultrasound. Patients who did not have cholecystectomy were managed with ursodiol for 6 months postoperatively. 13 males (9.0%) and 131 females (91%) underwent RYGBP. The mean age was 43 years (SD 8.55), and mean BMI was 46 kg/m2 (SD 6.5). The comorbidities of our patient population included diabetes (14%), hypertension (48%), gastroesophageal reflux disease (50%), dyslipidemia (35%), obstructive sleep apnea (31%), and musculoskeletal complaints (69%). 22 patients were diagnosed with cholelithiasis by ultrasonography preoperatively. 9 of these patients (41%) were symptomatic and underwent concurrent cholecystectomy and RYGBP. The remaining 13 patients (59%) had asymptomatic cholelithiasis preoperatively but did not undergo cholecystectomy at the time of surgery. Only one of these asymptomatic patients eventually developed symptoms necessitating cholecystectomy at up to 1 year follow-up. Our data suggest that it may not be absolutely indicated to perform prophylactic cholecystectomy at the time of RYGBP surgery for asymptomatic cholelithiasis. We believe that this phenomenon needs to be further studied in a randomized trial.

Gallbladder disease in patients undergoing laparoscopic adjustable gastric banding

Background Patients undergoing weight loss surgery may have an increased incidence of subsequent gallbladder disease. Management options include treatment of symptomatic disease only, preoperative ultrasonography and concurrent cholecystectomy in presence of stones, routine concurrent cholecystectomy, and choleretic therapy postoperatively. Here we report our approach to patients undergoing laparoscopic adjustable gastric banding (LAGB) and subsequent outcomes. Methods A retrospective review of all consecutive patients undergoing LAGB at our institution was performed. Only symptomatic patients were preoperatively evaluated for cholelithiasis and underwent concurrent cholecystectomy. No choleretics were used postoperatively. Weight loss data were collected when patients returned for band adjustments. All band adjustments were patient-driven and performed under fluoroscopic guidance. Results Between November 2001 and July 2004, 324 patients underwent LAGB. Mean starting weight was 143.6 kg (range, 92.3 to 250.5 kg), and mean body mass index was 50.5 kg/m 2 (range, 35.6 to 80 kg/m 2). Fifty-six patients had undergone previous cholecystectomy, and 7 other patients underwent concurrent cholecystectomy. Average follow-up was 12.5 months (range, 1.3 to 31 months). Absolute weight loss for all patients ranged from − 2.7 to 102.3 kg. Of the remaining patients, 3 underwent subsequent uneventful laparoscopic cholecystectomy for symptomatic cholelithiasis. No independent predictors for post-LAGB gallbladder disease were identified. Conclusion Despite significant weight loss, few patients require cholecystectomy after LAGB. Routine preoperative ultrasonography, empiric cholecystectomy, and choleretic therapy are of questionable value in LAGB patients. Considering the magnitude of weight loss in our patients, empiric cholecystectomy for all bariatric procedures may merit further investigation.

Gallbladder management in obesity surgery.

In the 1980s, some surgeons recommended routine cholecystectomy for patients undergoing bariatric surgery. This was based on the high prevalence of gallstones in the obese and concern that rapid weight loss would increase the risk of gallbladder disease. Others recommended waiting for a lower weight and a definite need. With increasing prevalence and severity of obesity and increased use of gastric reduction surgery for weight control, it seemed appropriate to review the current standard of care for cholecystectomy. A survey was also made of ursodeoxycholic acid usage for prevention of gallstone formation. Data collected from active contributors for the 28th Report of the International Bariatric Surgery Registry (IBSR) were examined. Two questionnaires were also sent to members of the American Society for Bariatric Surgery (ASBS). The first (Q1) asked about the indications for cholecystectomy. The second (Q2) asked about ursodeoxycholic acid usage for prevention of gallstone formation during rapid weight loss following surgical treatment of obesity. There has been an increase in concurrent cholecystectomy during the last 15 years. Some of this is due to a shift from simple gastric restrictive operations to gastric bypass with gastric restriction. When the most extensive bypass of intestine is used, as in distal Roux-en-Y gastric bypass (RYGBP-X) or biliopancreatic diversion with a duodenal switch (BPD-DS), all patients were reported to have undergone cholecystectomy. Only 30% of surgeons performing standard Roux-en-Y gastric bypass (RYGBP) remove normal-appearing gallbladders. Ursodeoxycholic acid is used to prevent gallstone formation in one-third of patients when a normal-appearing gallbladder is left in place. Prophylactic cholecystectomy is left to the discretion of the surgeon when RYGBP is used. There has been an increase in cholecystectomy and malabsorptive operations during the last 15 years. When most of the small bowel is bypassed, all remaining gallbladders are removed. For patients with simple restriction operations, normal-appearing gallbladders are usually left in place. Urso-deoxycholic acid during rapid weight loss for prevention of gallstone formation is used in one-third of patients with remaining gallbladders.

Conversions and complications of laparoscopic treatment of gastroesophageal reflux disease

Background: Although several authors have documented the safety and efficacy of laparoscopic fundoplication, it is important to determine the rate of conversions and complications of this procedure.Study Design: We retrospectively reviewed the protocol sheets of 503 consecutive patients with gastroesophageal reflux disease who underwent laparoscopic fundoplication over a period of 5 years. A Nissen-Rosetti procedure was performed in 492 patients (97.8%) and a Toupet procedure in 11 (2.2%). Sixty-four patients were also subjected to a concurrent cholecystectomy, and one patient had a concurrent cervical pharyngoesophageal diverticulectomy with cricopharyngeal myotomy. Thirty-one patients had previous upper abdominal operations.Results: The period of hospitalization varied from 12 hours to 16 days, with an average of 1.2 days. The operation was converted to an open procedure in 10 patients (2%). The main cause of conversion was the presence of adhesions. The most frequent intraoperative complication was pneumothorax. All pneumothoraces occurred in the first 100 patients. Five patients had significant operative bleeding; two of them required laparotomy for bleeding control. Gastric ulcer was diagnosed in six patients. One alcoholic patient died of acute pancreatitis. Other major complications were two intraabdominal abscesses, one esophageal perforation, one sepsis from gastric perforation, one hemorrhagic shock, and one gastric obstruction from fundoplication herniation.Conclusions: Conversions and complications of laparoscopic fundoplication are low and decrease significantly with the surgeon experience, but severe and lethal complications may occur.

Complicações do tratamento laparoscópico da doença do refluxo gastroesofágico: experiência com 600 casos

O objetivo do presente estudo é apresentar as complicações que ocorreram em seiscentos pacientes consecutivos com doença do refluxo gastroesofágico submetidos à fundoplicatura laparoscópica. O procedimento de Nissen-Rosetti (fundoplicatura de 360°) foi realizado em 587 pacientes (97,8%) e o de Toupet (fundoplicatura de 270°) em 13 (2,2%). Oitenta e um pacientes também foram submetidos à colecistectomia no mesmo ato operatório, e um a diverticulectomia faringoesofágica cervical com miotomia cricofaringeana. Trinta e nove pacientes tinham operação prévia no abdome superior. O período de internação hospitalar variou de 12 horas a 23 dias, com média de 1,2 dias. A via de acesso foi convertida em laparotomia em dez pacientes (1,7%). A principal causa de conversão foi a presença de aderências. A complicação intra- operatória mais freqüente foi pneumotórax, que foi observado em oito pacientes. Todos os pneumotóraces ocorreram nos cem primeiros casos. Cinco pacientes apresentaram hemorragia significante, sendo que dois deles necessitaram laparotomia para controle do sangramento. Úlcera gástrica foi diagnosticada em sete pacientes. Um paciente etilista morreu de pancreatite aguda e outro de síndrome de disfunção de múltiplos órgãos e sistemas conseqüente à perfuração gástrica. Outras complicações importantes foram: dois abscessos intra-abdominais, uma perfuração esofágica, uma sepse secundária à perfuração gástrica, um choque hemorrágico e uma obstrução gástrica secundária à herniação da fundoplicatura. Concluímos que a taxa de complicações da fundoplicatura laparoscópica é baixa e diminui significativamente com a experiência do cirurgião.