Laparoscopic Cholecystectomy Group Research Articles

Laparoscopic cholecystectomy for early gallbladder carcinoma: long-term outcome in comparison with conventional open cholecystectomy

The role of laparoscopic surgery for malignant gallbladder tumors remains uncertain. This study compared the surgical results of laparoscopic versus conventional open cholecystectomy for patients with early-stage gallbladder carcinoma and examined the role of laparoscopic surgery for early gallbladder carcinomas. Data for the treatment of gallbladder carcinomas were gathered from Chang Gung Memorial Hospital (Linkou, Taiwan). A retrospective analysis of 40 patients with either stage 0 or stage 1 gallbladder carcinoma was performed. The patients were categorized into two groups on the basis of cholecystectomy procedures. The long-term outcomes for the two groups were compared. During the follow-up period, which ranged from 6.5 to 197.6 months, four patients in the conventional open cholecystectomy group encountered tumor recurrence, and one patient in the laparoscopic cholecystectomy group experienced distant tumor recurrence (p = 0.216). No local port-site tumor recurrence was identified in patients who underwent laparoscopic cholecystectomy. The overall 5-year survival rate in this series was 87.1%. A comparison of survival rates between the two groups demonstrated no significant difference (p = 0.340). The laparoscopic cholecystectomy procedure did not adversely influence the prognosis of patients with early-stage gallbladder carcinomas. Furthermore, meticulous removal of gallbladders during laparoscopic surgery, in which early gallbladder carcinoma can be managed successfully using laparoscopic cholecystectomy, achieved a satisfactory surgical result and a low port-site tumor recurrence rate.

Endoscopic sphincterotomy with or without cholecystectomy for choledocholithiasis in high‐risk surgical patients: a decision analysis

Laparoscopic cholecystectomy (LC) is recommended for patients with choledocholithiasis after ERCP with sphincterotomy (ES) and stone extraction. We designed a decision model to address whether ES alone versus ES followed by LC (ES + LC) is the optimal treatment in high-risk patients with choledocholithiasis. Our cohort were patients with obstructive jaundice who have undergone an ES with biliary clearance. Recurrent biliary complications over a 2-year period stratified by gallbladder status (in/out) and age-stratified surgical complication rates were obtained from the literature. Failure of therapy was defined as either recurrent symptoms or death attributed to biliary complications. For age 70-79 years, ES failed in 15% whereas ES + LC failed in 17% of cases. Mortality in the EC + LC group was 3.4 times that of the ES alone cohort. For age 80+ years, ES was dominant with an incremental success rate of 8%. Mortality in the ES + LC was 7.6 times that of ES. For age <70, ES + LC was the dominant strategy with an incremental success rate 5%. Sensitivity analysis in the groups confirmed our conclusions. Management of choledocholithiasis by ES and stone clearance, but without cholecystectomy, should be considered for patients aged 70+. For low-risk patients, ES + LC should be performed to prevent recurrent biliary complications.

Timing of laparoscopic cholecystectomy for subacute calculous cholecystitis: early or interval — a prospective study

The aim of this prospective study was to evaluate the safety and feasibility of early laparoscopic cholecystectomy for subacute cholecystitis and to compare it with interval laparoscopic cholecystectomy. The study was performed in 74 patients who had been diagnosed with subacute cholecystitis between January 2000 and June 2005. The patients were divided into two groups. The early laparoscopic cholecystectomy group was composed of 31 patients who underwent laparoscopic cholecystectomy 24 h after admission to the hospital. The interval laparoscopic cholecystectomy group was composed of 43 patients who underwent laparoscopic cholecystectomy 8-12 weeks after medical treatment. There was no significant difference between the conversion rate, intraoperative bleeding, need for intraoperative cholangiography, minor bile duct injury, and postoperative complications in the two groups. Eleven patients in the interval group underwent urgent laparoscopic cholecystectomy or additional procedures because of recurrent cholecystitis, choledocholithiasis, or biliary pancreatitis. The early group had a significantly shorter total hospital stay (P = 0.031), lower cost of treatment (P = 0.042), and less difficulty with Calot's triangle dissection (P = 0.008). Early laparoscopic cholecystectomy can be done without hesitation in patients with subacute cholecystitis, in the light of obstacles observed in the interval group, such as dissection difficulty, lack of success in "cooling down", and additional problems such as choledocholithiasis and biliary pancreatitis.

Endoscopic naso-gallbladder drainage in the treatment of acute cholecystitis: alleviates inflammation and fixes operator's aim during early laparoscopic cholecystectomy

In 1984, Kozarek first reported the use of endoscopic retrograde cholangiopancreatography (ERCP) to perform selective cannulation of the cystic duct, and since then this procedure has also been reported by others. With this procedure, disorders in the gallbladder can be examined in detail, using, for example, selective cytology, and drainage for acute cholecytitis can also be performed. With this procedure, we were able to successfully perform early laparoscopic cholecystectomy (LC). Although surgery is often problematic in patients with acute cholecystitis because of inflammation, making Callot's triangle difficult to distinguish, the use of endoscopic naso-gallbladder drainage (ENGBD) during surgery enables us to identify the cystic duct for catheter cannulation. We performed early LC for acute cholecystitis in 18 of 22 patients, while 18 other patients underwent open cholecystectomy during the same period (retrospective study). These two groups were then compared. The LC group had shorter pre- and postoperative periods and shorter hospitalization (P < 0.05). ENGBD resulted in very little bleeding. None of the ENGBD patients required conversion to open surgery, whereas 11.1% of the non-ENGBD patients were converted. ENGBD was successfully employed in 18 of the initial 22 (81.8%) patients. The favorable points in using ENGBD with LC were that (i) the gallbladder inflammation was alleviated even if patients had ascites, and (ii) use of ENGBD normally improved visualization and made cystic duct identification easier. However, if ERCP cannot be carried out, the performance of ENGBD must also be ruled out.

Changes in Breathing Control and Mechanics After Laparoscopic vs Open Cholecystectomy

We hypothesized that there might be different effects on breathing control and respiratory mechanics after laparoscopic vs open cholecystectomy. Randomized clinical trial. A general hospital in Greece. Of 53 patients assessed for eligibility, 18 and 10 were randomly allocated to the laparoscopic and open cholecystectomy groups, respectively. These 28 patients had normal spirometry measurements and American Society of Anesthesiologists' class I physical status. Measurements of breathing control and mechanics variables. Tidal volume, inspiratory time, breathing frequency, mean inspiratory flow, duty cycle, central respiratory drive, and mean inspiratory impedance were recorded before surgery on the second and eighth postoperative days. Airway resistance was recorded before surgery and on the eighth postoperative day, with all measurements being performed under no influence of analgesia. Two days after surgery, inspiratory time, breathing frequency, and central respiratory drive were significantly changed compared with preoperative values for both methods, whereas mean inspiratory impedance was significantly increased (P<.001) for the laparoscopic procedure. Eight days after surgery, changes were seen only for the laparoscopic group: duty cycle and airway resistance were significantly reduced (P = .01) and increased (P = .04), respectively, compared with preoperative data. Laparoscopic cholecystectomy seems to be associated with small but sustained alterations in the control of breathing and mechanics, which might have an unfavorable clinical impact on patients with compromised lung function.

Bile Duct Injuries Associated with Laparoscopic and Open Cholecystectomy: An 11-Year Experience in One Institute

Bile duct injury (BDI) represents the most serious complication of laparoscopic cholecystectomy (LC). The aim of this retrospective single-institution study was to evaluate the real incidence of BDI during laparoscopic and open cholecystectomy (OC) in a tertiary academic center in Athens, Greece. Between January 1991 and December 2001, 3637 patients underwent cholecystectomy in our department; as LC in 2079 patients (LC group) and as OC in 1558 patients (OC group). All the LCs were performed or supervised by five staff surgeons and all the OCs were performed or supervised by another five staff surgeons. There were 13 BDIs associated with LC (0.62%) and 6 associated with OC (0.38%) (P = 0.317). There was one death associated with BDI after LC. Only two (15.4%) of the BDIs associated with LC occurred within the proposed learning curve limit of 50 LCs per individual surgeon. Laparoscopic cholecystectomy is safe and is not associated with a higher incidence of BDI than OC. Moreover, we did not find that the learning curve for LC affected BDI occurrence.

Incidental gall bladder carcinoma: does the surgical approach influence the outcome?

The aim of the study was to evaluate the outcome in patients with unsuspected gall bladder carcinoma diagnosed after cholecystectomy, comparing the laparoscopic approach with open surgery. A retrospective study was done of 16 patients who were diagnosed with unsuspected gall bladder carcinoma out of the 2850 who had undergone cholecystectomy for symptomatic cholelithiasis at our institution between 1990 and 2004. Eight cases (seven women and one man, mean age 63 (range 49-75 years) ) were diagnosed after laparoscopic cholecystectomy (group A) and eight cases (six women and two men, mean age 63 (range 50-79 years) ) after open cholecystectomy (group B). We evaluated the outcome in the two groups correlating the cumulative survival rates with tumour stage and surgical technique. In group A, three patients had port-site recurrence (1 pT1a and 2 pT1b tumours) after 6, 7 and 9 months, one had intraperitoneal dissemination (pT2) after 3 months, and four had no recurrence (1 pTis, 2 pT1a and 1 pT1b). In group B, five patients had recurrences (4 pT1b and 1 pT2) after an average of 8 months (range 5-11) and three had no recurrence (1 pTis and 2 pT1a). Survival rate was statistically correlated with tumour stage but not with the surgical approach used to perform cholecystectomy. The surgical approach used for cholecystectomy would seem not to influence the outcome in patients with unsuspected gall bladder carcinoma. The tumour stage is the most important prognostic factor.

Oxidative Stress Markers After Laparoscopic and Open Cholecystectomy

Surgical injury is associated with oxidative stress, often due to ischemia/reperfusion injury. During laparoscopy, increased intra-abdominal pressure caused by pneumoperitoneum may cause splanchnic ischemia followed by reperfusion due to deflation. We measured several markers of oxidative stress in patients undergoing laparoscopic cholecystectomy (LC) versus open cholecystectomy (OC) to find if these surgical procedures result in different patterns of oxidative stress. This prospective study enrolled 43 patients with symptomatic cholelithiasis, of whom 21 underwent open, and 22 laparoscopic, cholecystectomy. Twenty healthy adults comprised the control group. Total antioxidant status (TAS), superoxide dismutase (SOD), endogenous peroxide level (POX), oxidized low density lipoprotein (oLDL) autoantibodies (oLAb), and neopterin were measured preoperatively and on postoperative days 1, 3, and 7. POX values decreased significantly on postoperative day 1 in the OC (P<0.01), but not in the LC, group. On postoperative day 7, POX values were higher than preoperatively in both groups (P<0.01) with no difference between the LC and OC groups. Significant postoperative elevations of oLAb and neopterin levels were observed only on postoperative day 7 in the OC group. There were no changes of oLAb and neopterin levels in the LC group. TAS and SOD levels did not change after either LC or OC. Cholecystectomy, either open or laparoscopic, caused only moderate oxidative stress. Open cholecystectomy caused changes of oLAb and neopterin, suggesting more severe oxidative stress, and a possible role of reactive oxygen species in the healing of the laparotomic wound.

Is Laparoscopic Cholecystectomy Cheaper?

As laparoscopic cholecystectomy is being used more and more frequently, a cost analysis was aimed to be performed to evaluate cost effectiveness in Turkey. Records of 376 patients who underwent cholecystectomy by various methods were analyzed retrospectively. Mean duration of postoperative hospital stay was 5.1 +/- 2.6 days for the open cholecystectomy group (OC group), composed of 177 patients; 5.6 +/- 2.1 days for the converted open cholecystectomy group (CC group) composed of 15 patients; and 2.5 +/- 1.8 days for the laparoscopic cholecystectomy group (LC group), which included 184 patients. The mean cost per patient was 778 dollars +/- 75, 1964 dollars +/- 82, and 2357 dollars +/- 80 for the OC, LC, and CC groups, respectively. It was concluded that laparoscopic cholecystectomy will gain economic feasibility over conventional cholecystectomy in our country only when costs of laparoscopic equipment lower and personnel wages increase sufficiently.

Colecistectomía laparoscópica frente a colecistectomía convencional por minilaparotomía

To describe differences in operating time, pain scores, analgesic consumption, complications, length of hospital stay, and quality of life in laparoscopic cholecystectomy (LC) vs mini-laparotomy cholecystectomy (MLC).Between 1991 and July 1999, we performed a study of 1041 patients with gallstones who underwent LC (group A, n = 421 patients) or MLC (group B, n = 620 patients). Age, sex, ASA score, pain scores (visual analog scale), analgesic and antiemetic consumption, operating time, complications and length of hospital stay were recorded. Nottingham Health Profile questionnaires were completed by a subgroup of 200 patients, and respiratory response was evaluated using a Fokuda spirometer before surgery and at 24 and 48 hours after surgery. Patient satisfaction and quality of life were evaluated. The results were interpreted using the SPSS program and descriptive statistics were performed with p = 0.05.The mean age was 48.9 +/- 14.2 years; 80.5% of the patients were women; 87.88% of the patients were ASA I. Elective surgery was performed in 89.78%. The mean operating time was 94 +/- 45 minutes in LC and was 108 +/- 48 minutes in MLC (p < 0.001). LC was associated with lower postoperative pain (0 = 68.88%), lower analgesic-antiemetic requirements (0 = 9.03%) and shorter length of hospital stay. Complications were significantly more frequent in group B (p = 0.05); two patients in group B died within 30 days of surgery (0.32%).LC appears to be associated with lower pain scores and analgesic-antiemetic requirements and shorter recovery times than MLC. The results in terms of quality of life in LC were excellent.

Endoscopic Sphincterotomy With or Without Cholecystectomy for Choledocholithiasis in High Risk Surgical Patients: A Decision Analysis

Background: Laparoscopic cholecystectomy (LC) is recommended for patients with choledocholithiasis after ERCP with endoscopic sphincterotomy (ES) and stone extraction in order to prevent cholecystitis, biliary obstruction, and infection. However patients at increased risk of surgical complications may fare better with ES alone. We designed a decision model to address whether ES alone versus ES followed by LC (ES + LC) is the optimal treatment modality in high-risk patients with choledocholithiasis. Methods: The base-case cohort comprised individuals age 70-79 with obstructive jaundice who have undergone a successful ERCP with ES and biliary clearance. Recurrent biliary complications over a 2-year period stratified by gallbladder status (in/out) and age-stratified surgical complication rates were obtained from the literature. Failure of therapy was defined as either recurrent symptoms or death attributed to a biliary complication. Multiple one-way and multi-way sensitivity analyses were performed to determine the patient ages and threshold complication rates that would alter treatment strategies. Results: Under base case assumptions, ES failed in 14% whereas ES + LC failed in 18% of cases, favoring ES alone as the dominant strategy in patients age 70-79. Mortality in the EC + LC group was 3.4 times that of the ES alone cohort. Sensitivity analysis determined a threshold surgical complication rate of 8.7%, above which ES was the dominant strategy. For the cohort of age 80+, ES was dominant with an incremental success rate of 8% over ES + LC. Three-way sensitivity analysis of recurrent complications in ES, ES + LC and surgical morbidity, identified ES as the dominant strategy in all cases except when biliary complications for ES exceeded 22.2% (range 6-24%). Mortality in the ES + LC was 7.6 times that of the ES cohort. For age < 70, ES + LC was the dominant strategy with an incremental success rate 5% compared to ES. Sensitivity analysis in this group identified a threshold surgical complication rate of 9.8%, above which ES was the dominant strategy. Conclusions: 1) Management of choledocholithiasis by ERCP with sphincterotomy and stone clearance, but without cholecystectomy, should be strongly considered for patients aged 70-79. 2) In patients age 80 and above, ERCP alone is the dominant strategy, largely due to increased surgical complication rates. 3) For low-risk patients, laparoscopic cholecystectomy should be performed to prevent recurrent biliary complications. Background: Laparoscopic cholecystectomy (LC) is recommended for patients with choledocholithiasis after ERCP with endoscopic sphincterotomy (ES) and stone extraction in order to prevent cholecystitis, biliary obstruction, and infection. However patients at increased risk of surgical complications may fare better with ES alone. We designed a decision model to address whether ES alone versus ES followed by LC (ES + LC) is the optimal treatment modality in high-risk patients with choledocholithiasis. Methods: The base-case cohort comprised individuals age 70-79 with obstructive jaundice who have undergone a successful ERCP with ES and biliary clearance. Recurrent biliary complications over a 2-year period stratified by gallbladder status (in/out) and age-stratified surgical complication rates were obtained from the literature. Failure of therapy was defined as either recurrent symptoms or death attributed to a biliary complication. Multiple one-way and multi-way sensitivity analyses were performed to determine the patient ages and threshold complication rates that would alter treatment strategies. Results: Under base case assumptions, ES failed in 14% whereas ES + LC failed in 18% of cases, favoring ES alone as the dominant strategy in patients age 70-79. Mortality in the EC + LC group was 3.4 times that of the ES alone cohort. Sensitivity analysis determined a threshold surgical complication rate of 8.7%, above which ES was the dominant strategy. For the cohort of age 80+, ES was dominant with an incremental success rate of 8% over ES + LC. Three-way sensitivity analysis of recurrent complications in ES, ES + LC and surgical morbidity, identified ES as the dominant strategy in all cases except when biliary complications for ES exceeded 22.2% (range 6-24%). Mortality in the ES + LC was 7.6 times that of the ES cohort. For age < 70, ES + LC was the dominant strategy with an incremental success rate 5% compared to ES. Sensitivity analysis in this group identified a threshold surgical complication rate of 9.8%, above which ES was the dominant strategy. Conclusions: 1) Management of choledocholithiasis by ERCP with sphincterotomy and stone clearance, but without cholecystectomy, should be strongly considered for patients aged 70-79. 2) In patients age 80 and above, ERCP alone is the dominant strategy, largely due to increased surgical complication rates. 3) For low-risk patients, laparoscopic cholecystectomy should be performed to prevent recurrent biliary complications.

Gallbladder cancer presenting with acute cholecystitis: a population-based study

The role of laparoscopic cholecystectomy (LC) in acute cholecystitis remains controversial. The aim of the present study was to determine the incidence, clinicopathological characteristics, and outcome of patients with gallbladder cancer presenting with acute cholecystitis. We performed a retrospective analysis of patients with gallbladder cancer who presented with acute cholecystitis and were treated at the public hospitals in Hong Kong between 1998 and 2002. Among 2,700 patients with acute cholecystitis managed with cholecystectomy (1,347 open and 1,353 LC), 63 patients (2.3%) were found to have gallbladder cancer. There were 44 women and 19 men with a mean age of 74.7 (+/-12.8) years. Adenocarcinoma (90.5%) was the most common cancer. The overall median survival was 5 months (95% CI = 2.6-7.4). The 5-year survival rate was 20.8%. Laparoscopic cholecystectomy was attempted in 11 patients and was completed successfully in six of them. There was no difference between the LC and open groups in the complication rate, hospital mortality rate, or survival rate. In the ethnic Chinese population of Hong Kong, the incidence of gallbladder cancer presenting with acute cholecystitis is higher than the same finding in patients undergoing elective cholecystectomy for cholelithiasis. Long-term survival is possible because such patients may be diagnosed at an early stage of the disease.

A randomized controlled trial of laparoscopic versus open cholecystectomy in patients with cirrhotic portal hypertension

To evaluate the characters, risks and benefits of laparoscopic cholecystectomy (LC) in cirrhotic portal hypertension (CPH) patients. Altogether 80 patients with symptomatic gallbladder disease and CPH, including 41 Child class A, 32 Child class B and 7 Child class C, were randomly divided into open cholecystectomy (OC) group (38 patients) and LC group (42 patients). The cohorts were well-matched for number, age, sex, Child classification and types of disease. Data of the two groups were collected and analyzed. In LC group, LC was successfully performed in 36 cases, and 2 patients were converted to OC for difficulty in managing bleeding under laparoscope and dense adhesion of Calot's triangle. The rate of conversion was 5.3%. The surgical duration was 62.6+/-15.2 min. The operative blood loss was 75.5+/-15.5 mL. The time to resume diet was 18.3+/-6.5 h. Seven postoperative complications occurred in five patients (13.2%). All patients were dismissed after an average of 4.6+/-2.4 d. In OC group, the operation time was 60.5+/-17.5 min. The operative blood loss was 112.5+/-23.5 mL. The time to resume diet was 44.2+/-10.5 h. Fifteen postoperative complications occurred in 12 patients (30.0%). All patients were dismissed after an average of 7.5+/-3.5 d. There was no significant difference in operation time between OC and LC group. But LC offered several advantages over OC, including fewer blood loss and lower postoperative complication rate, shorter time to resume diet and shorter length of hospitalization in patients with CPH. Though LC for patients with CPH is difficult, it is feasible, relatively safe, and superior to OC. It is important to know the technical characters of the operation, and pay more attention to the meticulous perioperative managements.

Informed consent and choice in cholecystectomy

As patients and parents seek more information and the threat of litigation increases, the process of informed consent has assumed greater importance. Data from large adult experiences indicate that the risk of bile duct injury, although small, is greater with laparoscopic cholecystectomy (LC) than open cholecystectomy. This complication has not yet been documented in pediatric practice, where cholecystectomy is relatively uncommon. What method do parents and patients choose if consent is truly informed? Of 57 consecutive children undergoing cholecystectomy, an open procedure was specifically indicated in 20 (previous major gastrointestinal surgery in 11, concomitant major abdominal operation in four, and complex biliary tract disease in five) and LC in two (cystic fibrosis, severe autism). The remaining 35 patients were counseled in a standard manner about the relative merits of LC versus mini-cholecystectomy (MC) and allowed to choose. Specifically, they were informed that LC offers better cosmesis, less postoperative discomfort, and a shorter hospital stay, but in adults is associated with a slightly increased rate of bile duct injury (0.3-0.5% vs. 0.2%). All MCs were performed through a 4-cm incision. Parents chose LC in 23 cases and MC in 12. The median age of both groups was similar. No surgical complications occurred, and there were no conversions in the LC group. No patient had retained stones. LC patients were discharged home after a mean of 1.7 days and MC patients after 2.3 days (0.1 > p > 0.05). If an open or laparoscopic technique is not specifically indicated and if parents/patients are fully informed, a significant minority may opt for mini-cholecystectomy.

Long-term detrimental effect of bile duct injury on health-related quality of life.

Long-term quality of life (QOL) in patients undergoing laparoscopic cholecystectomy (LC) incurring bile duct injury (BDI) and repair is comparable to that of patients undergoing uncomplicated LC. Case comparison study. Secondary and tertiary care centers. Eighty-six patients incurring BDI during LC between January 1, 1991, and July 31, 2003, were surveyed. Comparison subjects underwent uncomplicated LC during the same period. Health-related QOL as assessed by the Karnofsky Performance Scale, Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), and Psychosocial Adjustment to Illness Scale. Fifty patients with BDI (39 [78%] female; mean +/- SEM age, 55 +/- 2 years) and 74 patients with uncomplicated LC (51 [69%] female, mean +/- SEM age, 52 +/- 2 years) responded. Of the 50 BDI patients, 48 (96%) had no stricture and normal liver function at QOL assessment. The mean +/- SEM follow-up period to QOL assessment for the BDI and uncomplicated LC groups was 62 +/- 6 and 47 +/- 3 months, respectively. The mean +/- SD Karnofsky Performance Scale scores were 77 +/- 9 vs 93 +/- 8 for the 2 groups, respectively (P <.001). The mean +/- SD SF-36 physical component scale scores after BDI vs uncomplicated LC were 36 +/- 11 vs 47 +/- 12, respectively (P <.001), compared with 50 +/- 10 for the normal population (P <.001). The mean +/- SD SF-36 mental component scale scores were 43 +/- 14 vs 49 +/- 11 for the 2 groups, respectively (P =.02), compared with 50 +/- 10 for the normal population (P =.01). Patients with BDI scored poorer on the Psychosocial Adjustment to Illness Scale health care orientation and domestic environment scales (P=.01). After BDI and repair, there are long-term detrimental effects of BDI on health-related QOL.

Retrospective review on laparoscopic cholecystectomy in patients with acute cholecystitis in a community hospital

Aim: Since the first audit of laparoscopic cholecystectomy (LC) in patients suffering from acute cholecystitis in 1999–2000, the policy of early laparoscopic cholecystectomy was launched in Yan Chai Hospital. The present study aims to look at the conversion rate, complication and hospital stay.Methods: Retrospective review of laparoscopic cholecystectomies was done for patients presented with acute cholecystitis from January 2001 to June 2003. Only patients with both clinical and histopathological diagnosis of acute cholecystitis were included. Patients presented with acute cholangitis and pancreatitis were excluded. Predictive factors including age, sex, fever, WBC, duration of symptoms, timing of surgery were analysed. Chi‐Square test and Mann–Whitney test were used for statistical analysis with significance level set at 5%.Results: Total 141 patients with acute cholecystitis were operated with initial laparoscopic approach. Mean age was 60.1 years old. 70.9% of operation performed within 48 h after admission. The overall conversion rate was 33%. Significant predictive factors for conversion were: older patient (mean age for LC group was 58.2 years old [95%CI 54.5–61.8] and for conversion group was 64.5 years old [95% CI 60.1–68.9], P=0.046), delayed presentation (P=0.001), fever before operation (P=0.039), operation performed after 72 h after admission (P=0.026). Conversion rate for operation performed within first 24 h after admission was 26.2%. Conversion rate increased to 68% for operation performed 74 h after admission. For patients with body temperature ≥38°C before operation, conversion rate was significant higher (i.e. 50 vs 26%) (P=0.012). Conversion rates for patients with 1 day symptom and for patients with 3 days or longer symptom were 18.8% and 51%, respectively. Sex, ASA and WBC count were not significant predictive factors. The mean operation time for successful laparoscopic group was 101 min and 102 min for conversion group. Complications occurred in 14.8% of cases including chest infection (3), AMI (2), wound infection (6), CBD injury (1). Mean hospital stay was 6.6 day for successful LC group and was longer for conversion group (10.7 day).Conclusion: Older patient, delayed presentation and fever on presentation were associated with higher conversion rate. Earlier operation was associated with successful LC. Conversion rate was similar to previous study done in 1999–2000. In coming future, efforts should be made (i.e. 24 h liver function test, radiological support) to achieve an earlier diagnosis of acute cholecystitis and hence better operative outcome.**Multiple regression analysis in progress, data will be submitted as soon as possible.

Gallbladder cancer: laparoscopic and classic cholecystectomy.

Gallbladder carcinoma is an abdominal malignancy with an extraordinarily poor prognosis that depends on the stage at the time of the diagnosis. In the past 8 years, 3,158 laparoscopic cholecystectomies (LC), and 8 years before that, 3,083 classic cholecystectomies (CC) were performed in the authors' department. In 15 LC cases and 7 CC cases, gallbladder carcinoma was found. There was preoperative or intraoperative suspicion of malignancy in 3 LC and 5 CC cases. According to the tumor-node-metastasis (TNM) classification system, these cases were categorized as stage 3 (S3) or S4, and resumption of the operation was necessary. Two LC cases and five CC cases were inoperable malignancies requiring palliative treatment. The others were managed with surgery for the completion of an extended cholecystectomy. The survival rate for all the patients was less than 1 month. In 12 LC cases and 2 CC cases, malignancy was diagnosed postoperatively. The stages for the LC group were S1(T in situ) in four cases and S1(T1) in eight cases. The stage for the CC group was S1(T1) in both cases. After simple LC or CC, the survival time was more than 2 years for eight patients and more than 3 years for four patients. Two patients were still alive, respectively, 1 and 2 years postoperatively. The difference in the numbers of diagnosed and resected gallbladder carcinoma in the earlier stages between the LC and CC groups is statistically significant ( p < 0.01). With the increased use of LC for presumed gallstone disease, the diagnosis and removal of gallbladder carcinoma in the earlier stages could be more frequent.

Mini-Laparotorny Cholecystectomy in the Era of Laparoscopic Cholecystectomy: A Community-Based Hospital Perspective

Laparoscopic cholecystectomy is clearly the gold standard for symptomatic cholelithiasis. Open cholecystectomy is now reserved for difficult and problematic cases. The purpose of this paper is to propose that mini-laparotomy cholecystectomy (minicholecystectomy) can be as effective as laparoscopic cholecystectomy. This paper compares the two techniques in well-matched patients. In addition mastery of this technique is practical and rewarding and should be part of the repertoire of the general surgeon. We conducted a retrospective review of the experience of a single surgeon at a community-based teaching hospital over a 2-year period for minicholecystectomy and laparoscopic cholecystectomy. Sixty-six patients were matched for age, sex, body surface area, and Acute Physiology and Chronic Health Evaluation II score. The absolute cost was lower for the minicholecystectomy group than for the laparoscopic cholecystectomy group. The operating room times were not significantly different in the two groups ( P value 0.79). The average length of stay and the average amount of intramuscular analgesia required for the two groups were also not significantly different ( P values 0.69 and 0.35, respectively). Although subjective postoperative satisfaction was equal for both groups the minicholecystectomy group had no complications whereas the laparoscopic group had two (myocardial infarction and cystic duct stump leak) complications. We conclude that minicholecystectomy can be used as a viable alternative to laparoscopic cholecystectomy especially in patients who cannot tolerate laparoscopic procedures and in areas where cost containment is critical.

Cholecystectomy in a predominantly African population before and after the advent of the laparoscopic technique

There is a paucity of information on gallbladder disease in an African population. We, therefore, conducted a study to compare the immediate pre-laparoscopic era with the laparoscopic period in the predominantly African population at the King Edward VIII Hospital. Data from a retrospective analysis of 144 patients undergoing open cholecystectomy (OC) between January 1990 and December 1992 were compared with a prospective analysis of 156 patients who underwent laparoscopic cholecystectomy (LC) between February 1992 and December 1994. Demographic data, presentation, operative management and outcome were the main factors analysed. Eighty-two per cent were Black African and the rest of Indian origin. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed ductal stones in 11 patients in the OC and nine patients in the LC group. Endoscopic duct clearance was achieved in three and nine patients, respectively. Non biliary complications were rare. There were two major duct injuries in the OC group and one cystic duct leak in the LC group. The high conversion rate of 17.9% attests to the severity of their chronic disease making safe dissection in Calot's triangle problematic. The mortality in patients undergoing OC was 1 (0.07%) and 0% for LC. In South Africa, the hospital prevalence of calculous disease in African patients is increasing. However, cholecystectomy may be safely performed. The absence of any mortality and any major duct injury in the LC group allude to the safety of this procedure when appropriately applied to this population group.

Laparoscopic cholecystectomy for patients with chronic obstructive pulmonary disease.

Laparoscopic cholecystectomy (LC) is accepted as a "gold standard" for treating most gallbladder diseases because it is superior to the open method, causes less postoperative pulmonary dysfunction, and promotes earlier postoperative recovery. The laparoscopically associated adverse effects of a carbon dioxide (CO(2)) pneumoperitoneum, however, such as hypercarbia and arterial acidosis, are more pronounced in patients with chronic obstructive pulmonary disease (COPD). The clinical results of LC for patients with COPD are analyzed in this study. Twenty-two patients with COPD (group 1) and undergoing LC were compared with 25 control patients without COPD and also undergoing LC (group 2). Patient demographics, intraoperative end-tidal CO(2) (both before and after CO(2) insufflation), and clinical outcome, including surgical duration, length of postoperative hospital stay, and any associated complications, were analyzed. The procedure of one group 1 patient was converted to the open method, and this patient was excluded from the study. Comprising the COPD group were 20 patients with mild COPD and one patient with moderate COPD. With similar settings of tidal volume and ventilation rate for the two groups, the measured end-tidal CO(2) value was significantly greater for group 1 than for group 2 patients after the creation of a CO(2) pneumoperitoneum (34.2 +/- 2.7 vs. 30.7 +/- 3.6 mm Hg; P =.012). The duration of surgery was similar for groups 1 and 2 (88.9 +/- 36.0 vs. 83.2 +/- 38.3 minutes), as was the duration of the postoperative hospital stay (3.3 +/- 1.6 vs. 3.4 +/- 2.2 days). No pulmonary complications were noted for any of the patients. LC can be safely performed in COPD patients with mild or even a moderate degree of airway obstruction. Intraoperative CO(2) retention did not complicate the postoperative recovery in terms of the complication rate or the duration of the postoperative hospital stay.