Uncomplicated Cholecystectomy Research Articles

Successful Use of Therapeutic Plasma Exchange Following Red Blood Cell Exchange for Severe Acute Chest Syndrome: A Single Institution Experience

Introduction: Severe acute chest syndrome (ACS) is a potentially fatal complication of sickle cell disease (SCD) that can progress to multiorgan failure. Treatment includes red blood cell (RBC) exchange to improve oxygenation and reduce vaso-occlusion by decreasing the proportion of hemoglobin (Hb) S. Patients with poor response to RBC exchange are at high risk for mortality. Therapeutic plasma exchange (TPE) may be beneficial in cases of severe organ dysfunction refractory to RBC exchange. TPE is postulated to remove pro-inflammatory cytokines, reduce circulating free hemoglobin, and decrease complement products that contributes to vaso-occlusion and inflammation. The use of TPE for severe ACS and multiorgan failure has been rarely described in adult patients and is even less commonly described for pediatric patients. Aim: To describe use of TPE for the management of severe ACS with multiorgan failure in two pediatric patients and one young-adult patient who did not respond to standard medical management with RBC exchange transfusion. Methods: Case reports Case 1: A six-year-old male with homozygous SCD (HbSS) and moderate persistent asthma was admitted for ACS. His course was complicated by hypoxemia requiring intubation, oliguria, and hypotension. On hospital day 3, he underwent RBC exchange with four units of RBCs. Despite decrease of Hb S to 15%, he remained hypoxic on high ventilatory support and developed acute respiratory distress syndrome. After multidisciplinary discussion, TPE was trialed in hopes of improving oxygenation and reversing multiorgan dysfunction. He underwent 3 TPEs, each with 1.5 total plasma volume (TPV) using 5% albumin (days 4, 5 and 7). After a single session of TPE, his oxygenation saturations improved to the 90s, and his ventilator support was weaned. He was extubated on day 8 and was discharged on day 13 in stable condition. Case 2: A sixteen-year-old male with HbSS, recurrent hyper-hemolytic syndrome, and sickle cell hepatopathy was admitted for medical optimization before scheduled cholecystectomy. His Hb was raised pre-operatively with erythropoietin, in lieu of RBC transfusion, due to history of severe refractory hyper-hemolysis with transfusions. He underwent uncomplicated cholecystectomy on hospital day 2. On day 3, he developed ACS, septic shock, and an exacerbation of known hepatopathy. He was intubated and underwent RBC exchange with 8 units of RBCs. His Hb S decreased to 20% but he had no improvement in clinical status. High-dose steroids and TPE were then trialed. The use of TPE was dual purposed to reduce inflammatory cytokines contributing to systemic dysfunction and to prevent hyper-hemolysis following exchange transfusion. He underwent 3 TPEs each with 1.5 TPV using 5% albumin for three days (days 5, 6, and 7). Throughout his course of TPE, he was extubated (day 6), weaned off pressor support (day 6), and his liver dysfunction began to improve (day 7). He was discharged home on day 16. Case 3: A thirty-five-year-old female with HbSS without chronic complications was transferred from an outside hospital where she presented 3 days prior with ACS and progressive neurologic deterioration with minimal responsiveness. Imaging revealed diffuse pulmonary infiltrates and extensive cerebral micro emboli consistent with fat embolism syndrome. She underwent RBC exchange on the day of arrival to our facility (hospital day 4) with 5 units of RBCs. Her Hb S decreased to 20% but she had no improvement in neurologic function. After multidisciplinary evaluation, TPE was trialed alongside high-dose steroids. She underwent 5 TPEs each with 1.0 TPV using 5% albumin (days 5, 6, 8, 9, and 12). Shortly after initiating TPE, she began recovering neurologically with eye-opening, response to noxious stimuli, and tracking (day 6). After 3 days of TPE, CRP fell from 21 to 5 and ESR from 49 to 23 (day 8). She followed commands on day 10 and was taken off oxygen on day 15. She was discharged to a rehabilitation facility on day 30 with significant improvements in mental status, cognition, and functional abilities. Conclusions: TPE for three to five days should be considered in patients with severe ACS and multiorgan failure with high risk of mortality when standard management fails. The early initiation of TPE likely contributed to the successful recoveries of these three cases. Further studies are needed to delineate the role of TPE in the management of acute complications of SCD.

The COVID-19 pandemic had significant impact on duration of surgery and hospitalization time for patients after cholecystectomy

The COVID-19 pandemic made substantial changes in medical care necessary. The aims of this study were to find out what influence the pandemic had on the perioperative course in patients with cholecystectomy (CHE) and to highlight possible residual consequences. From 1 July 2018 to 31 December 2021 a total of 735 patients with CHE were analyzed. Up to 21 March 2020 patients were assigned to the regular patient group (Reg, n = 430), patients after this date (first lockdown 22 March 2020) to the Cov19 patient group (Cov19, n = 305) and the 2 groups were compared. The average age of all patients was 59 years and 63% were women. The average length of hospitalization (KrVD, time period between surgery and discharge) was 4.4 days. The patient groups Reg and Cov19 did not differ with respect to age, gender or KrVD. The total number of CHEs carried out was reduced by 21.4% in the Cov19 group. This affected elective and emergency CHE to the same extent. The length of surgery significantly increased in the Cov19 group from 64 min (SD 34 min) to 71 min (SD 38 min). The number of short and long hospital stays (KrVD 2 or >4 days) significantly increased in the Cov19 group from 4 % to 20 % (short stay, p < 0.01) and from 23 % to 27 % (long stay, p < 0.01). This was particularly observed for patients >70 years old with an increase in long stays from 43 % to 56 % in the Cov19 group. The COVID-19 pandemic led to a clear reduction in CHE both for elective and emergency interventions. Furthermore, a significant lengthening of the surgery and hospitalization times could be observed for older patients. The residual consequences of the pandemic could be shortened hospitalization times after uncomplicated CHE and more interventional treatment procedures in complex cases.

Telehealth follow-up after cholecystectomy is safe in veterans.

BackgroundThe COVID-19 pandemic has brought many challenges including barriers to delivering high-quality surgical care and follow-up while minimizing the risk of infection. Telehealth has been increasingly utilized for post-operative visits, yet little data exists to guide surgeons in its use. We sought to determine safety and efficacy of telehealth follow-up in patients undergoing cholecystectomy during the global pandemic at a VA Medical Center (VAMC). MethodsThis was a retrospective review of patients undergoing cholecystectomy at a level 1A VAMC over a 2-year period from August 2019 to August 2021. Baseline demographics, post-operative complications, readmissions, emergency department (ED) visits and need for additional procedures were reviewed. Patients who experienced a complication prior to discharge, underwent a concomitant procedure, had non-absorbable skin closure, had new diagnosis of malignancy or were discharged home with drain(s) were ineligible for telehealth follow-up and excluded.ResultsOver the study period, 179 patients underwent cholecystectomy; 30 (17%) were excluded as above. 20 (13%) missed their follow-up, 52 (35%) were seen via telehealth and 77 (52%) followed-up in person. There was no difference between the two groups regarding baseline demographics or intra-operative variables. There was no significant difference in post-operative complications [4 (8%) vs 6 (8%), p > 0.99], ED utilization [5 (10%) vs 7 (9%), p = 0.78], 30-day readmission [3 (6%) vs 6 (8%), p = 0.74] or need for additional procedures [2 (4%) vs 4 (5%), p = 0.41] between telehealth and in-person follow-up.ConclusionTelehealth follow-up after cholecystectomy is safe and effective in Veterans. There were no differences in outcomes between patients that followed up in-person vs those that were seen via phone or video. Routine telehealth follow-up after uncomplicated cholecystectomy should be considered for all patients.

The Effect of Polymorphisms in the CYP2D6 and CYP2C9 Genes on the Clinical Efficacy of Tramadol and Ketorolac When Using the Accelerated Recovery Protocol in Patients With Uncomplicated Acute Calculous Cholecystitis Who Underwent Cholecystectomy

Relevance. One of the key components of the accelerated recovery protocols (ARP), in addition to minimizing the surgical approach, is an adequate postoperative analgesia. Despite this, applied postoperative analgesia combinations are not devoid of drawbacks, such as lack of effective postoperative analgesia and the presence of side effect. The use of a pharmacogenetic approach to analgesic therapy for the purpose of its personalization may increase the effectiveness and safety of the use of analgesics. In particular, the presence of an inactive CYP2D6*4 allele , in which the conversion of tramadol to its active metabolite is reduced, contributes to the insufficient efficacy of the drug. As for non-steroidal anti-inflammatory drugs, the presence of CYP2C9*2/*3 polymorphisms leads to a decrease in drug metabolism and a longer half-life, resulting in the increase of the clinical effect and the risk of adverse reactions. Thus, genotyping of patients with the determination of the presence of specific genetic factors can rationalize the postoperative analgesia.Aim of study. Evaluation of the possible association of polymorphisms of the CYP2D6 and CYP2C9 genes with the clinical efficacy of tramadol and ketorolac in relation to postoperative pain.Material and methods. This observational clinical study involved 107 patients with uncomplicated acute calculous cholecystitis who underwent videolaparoscopic cholecystectomy and perioperative treatment according to ARP. All patients underwent whole blood sampling followed by real-time polymerase chain reaction genotyping. Analgesic efficacy was assessed using a visual analog scale (VAS) and McGill Pain Questionnaire.Results. In CYP2D64* carriers pain was higher than that of wild-type carriers, according to VAS and McGill Pain Questionnaire in all investigated periods. In carriers of CYP2C9*2, the pain syndrome was lower than in carriers of the wild type at all intervals studied. In carriers of CYP2C9*3 pain was lower only after 2 and 6 hours, also according to McGill Pain Questionnaire.Conclusion. 1. The presence of the polymorphic marker CYP2D6*4 may reduce the efficacy of postoperative tramadol analgesia compared with wild type. 2. The presence of the polymorphic marker CYP2C9*2 and CYP2C9*3 may increase the efficacy of ketorolac pain relief compared to wild type.

1322 A Known Complication With a Delayed Presentation: A Rare Case of Biloma Formation Post-Cholecystectomy

INTRODUCTION: Biloma is an uncommon complication post cholecystectomy with a reported incidence of approximately 0.3-1.5%. While biloma formation is typically seen within weeks of surgery, there are very few documented cases of biloma formation seen years after an uncomplicated cholecystectomy, as seen in the case below. CASE DESCRIPTION/METHODS: A 35-year-old female with a medical history of cholelithiasis requiring cholecystectomy eight years prior presented with worsening dull right upper quadrant pain with early satiety and abdominal distention for two months. Vitals were stable with her exam notable for a palpable abdominal mass. Labs revealed a mild transaminitis. MRI demonstrated dilated bile ducts and a large 16.1 cm cystic lesion in the gallbladder fossa consistent with a biloma. 1.5 liters of proteinaceous material was drained by interventional radiology. Cultures and cytology were negative for an infectious or malignant process. HIDA scan revealed a bile leak for which she underwent an ERCP where two biliary stents were placed for a segmental duct leak. The patient clinically improved and was discharged home on antibiotics. Two outpatient ERCPs were performed, the first revealing a persistent small leak requiring stent exchange and the subsequent ERCP three months later demonstrating complete closure of the leak. DISCUSSION: A biloma is a demarcated collection localized outside the biliary tree often secondary to iatrogenic, traumatic and even spontaneous injury to the biliary tree. With the introduction of laparoscopic cholecystectomy, incidence of biliary injury has increased from 0.1% to about 0.3-1.5%. The pathophysiology is often secondary to either a leakage of bile from an improper closure of a cystic duct stump, transection of an accessory bile duct or duct of Luschka, or rarely from inadvertent injury of the segmental ducts. Presentation varies and can manifest with abdominal pain, nausea, fever and if large enough can result in obstructive jaundice. Diagnosis is typically 1-2 weeks post-surgery with few cases reported years post-op as seen here. Management is dependent on the size of the biloma and leak. Large bilomas often require percutaneous catheter drainage combined with ERCP with sphincterotomy and biliary stenting whereas small bilomas are treated conservatively. If refractory to endoscopic intervention, surgery may be warranted. We present this case to raise awareness of this uncommon, pathologic entity to help facilitate prompt diagnosis and treatment to avoid poor outcomes.

1267 Recurrent Mantle Cell Lymphoma to the Gall Bladder: A Peculiar PET CT

INTRODUCTION: Mantle Cell Lymphoma (MCL) is a B-cell non-Hodgkin lymphoma that has a variable course. The initial presentation of MCL is usually nonspecific and varies based on the organ involved. Initial treatment includes a variety of chemotherapeutic options; however, almost all patients will have refractory or recurrent disease due to the rapid development of chemotherapy resistance. In this case report, we present a rare presentation of recurrent mantle cell lymphoma in the gall bladder. CASE DESCRIPTION/METHODS: Our patient is a 61-year-old female with history of mantle cell lymphoma diagnosed in 2008. At that time patient was treated with Rituxan/hyper-CVAD with an excellent response to treatment. Patient had a disease recurrence in 2012 on axillary lymph node biopsy and received 6 cycles of Bendamustine and Rituximab and achieved remission as determine by PET CT. The patient decided against allogeneic hematopoietic stem cell transplant (HCT) and was started on Rituximab maintenance therapy by 2013. Patient had another recurrence on axillary lymph node biopsy in 2017 and was placed on Ibrutinib with no FDG noted on subsequent PET-CTs in 2/2018 and 5/2018. A surveillance PET CT performed in 12/2018 showed intense avid FDG uptake involving the gallbladder (Figure 1). A MRI was performed that showed an enhancing lesion in the dorsal aspect of the descending duodenum measuring 18 mm. Upper endoscopy revealed a prominent fold with biopsies taken with no histopathologic abnormality. The patient was subsequently taken for uncomplicated cholecystectomy with one lymph node associated and sent for pathology. Pathology results showed the cystic duct lymph node and gallbladder wall involved by MCL with 40 mitoses per 15HPF and Ki-67 proliferative index of 34% (Figures 2 and 3). This suggested a more aggressive MCL. The patient was started on Revlimid and Rituximab, and will be awaiting clinical trial eligibility at a nearby facility. DISCUSSION: MCL typically follows an aggressive clinical course with high risk of recurrence regardless of chemotherapeutic regimen. One previous case with MCL to the gallbladder was found incidentally as a lymphomatous polyp. An additional case presented with intussception with a mass noted during surgical repair. Overall, there have been approximately 66 cases of B-cell lymphoma noted to the gallbladder, and two prior cases as above of MCL. Our case represents a rare presentation of relapsed MCL to the gall bladder and the wide possibility of metastasis associated with recurrent MCL.

Quality of Life in Patients with Background of Iatrogenic Bile Duct Injury.

There are only a few reports regarding the quality of life of patients who underwent a complicated cholecystectomy with an iatrogenic bile duct injury (IBDI); the results have been heterogeneous and realized with unspecific measures. The objective was to determine whether the quality of life of the subjects with a history of IBDI repaired with bilioenteric derivation is modified in the long term with respect to a control group, for which a group of patients with a history of IBDI (group A) was compared with a group of patients with a history of uncomplicated cholecystectomy (group B). Two different measures were used: on the one hand, the SF-12 questionnaire and on the other hand, a questionnaire was implemented where the patient could determine by himself which variables define his quality of life. A total of 46 patients were included in group A and 51 in group B. The analysis of the SF-12 questionnaire showed a statistical significant reduction in 4 of 8 of the evaluated parameters (general health, physical functioning, physical role and social functioning) in group A in comparison with group B. If a more specific questionnaire is used, the results are similar, with a statistically significant reduction in the quality of life within the group A (0.03). We conclude that the quality of life of patients with a history of bilioenteric derivation due to an IBDI decreases significantly compared to patients with uncomplicated cholecystectomy.

Heroic Measures for an American Hero: Attempting to save the Life of General Douglas MacArthur

General Douglas MacArthur was a towering public figure on an international stage for the first half of the 20th century. He was healthy throughout his life but developed a series of medical problems when he entered his 80s. This article reviews the General's medical care during two separate life-threatening medical crises that required surgical intervention. The first episode occurred in 1960 when MacArthur presented with renal failure due to an obstructed prostate. Four years later after his 84th birthday, MacArthur developed bile duct obstruction from common duct stones. He underwent an uncomplicated cholecystectomy and common duct exploration but developed variceal bleeding requiring an emergent splenorenal shunt. His terminal event was precipitated by strangulated bowel in long-ignored very large inguinal hernias. MacArthur died, despite state-of-the-art surgical intervention, due to renal failure and hepatic coma.

How Laparoscopic cholecystectomy can be made near hundred percent Safe

Laparoscopic cholecystectomy was introduced by Erich Muhe in 1985 and it has gained worldwide acceptance within a short period of time to become the gold standard treatment for cholelithiasis. The incidence of bile duct injuries have definitely increased compared with the open technique due to new procedure involving “Hand &amp; Eye Coordination”. No doubt with subsequent improvements in the equipment and training in the laparoscopy, the incidence of these injuries has decreased. However, worldwide incidence of Common Bile Duct (CBD) injury has remained fairly constant around 0.5%, as reported in literature. Even in the United States, 34 to 49% of surgeons have caused a major bile duct injury with an individual experience of one to two such cases. Bile duct injuries affect the quality of human life because these injuries often demand several invasive procedures and subsequent surgeries. These patients continue to have a higher incidence of death as compared with those who have an uncomplicated cholecystectomy. There is a major increase in healthcare expenses associated with the complications.

Editorial Comment on: Andrzej Smereczyński, Teresa Starzyńska, Katarzyna Kołaczyk and Józef Kładny Role of sonography in assessing complications after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) was introduced to the arsenal of surgical techniques in 1987 and has become the gold standard in treating cholecystolithiasis. In spite of undoubted benefits for patients, it is not a complication-free procedure. The type of complications after a classical, i.e. “open” surgery and LC do not differ in a significant way. The difference lies in their prevalence. One of the most common complications is a fluid collection in the gallbladder bed under the liver. To prevent it from developing, a drain is usually placed under the liver. For many years, it was believed that such a practice is correct, but recent reports indicate that leaving the drain after a planned laparoscopic cholecystectomy may do more damage rather than be beneficial. Moreover, it may give a false impression of safety since we are convinced that we remain in control over the situation in case of, for instance, a hemorrhage(1). In fact, when the postoperative bleeding to the peritoneal cavity is intense, a thin Redon drain, which usually remains inserted after the procedure, may become occluded by a thrombus. Decisions are made based on the patient's clinical condition or imaging examinations (including sonography) which can reveal not only a fluid collection under the liver, but also free fluid in the peritoneal cavity. The peritoneum secretes considerable amounts of peritoneal fluid daily. It becomes absorbed completely mainly via the lymphatic channels in the diaphragmatic region. Therefore, detection of a collection of serous fluid should not be alarming. It will absorb with no consequences for the patient. It has been observed that leaving a drain in the gallbladder bed causes increased fluid secretion. Moreover, Fraser et al. claim that such a practice may provoke bile leakage form slight bile ducts in the gallbladder bed(2). If it is a suction drain the risk of bile leakage is significant. Thiebe and Eggert observed that leaving the drain caused fluid to accumulate in the gallbladder bed in 44% of cases compared to 4.1% in the group without the drain(3). Their results were confirmed in ultrasound examinations which revealed that the fluid collection that developed within 24 hours after the surgery appeared considerably more frequently in the group with the drain. When, apart from ultrasound findings, patients also manifest symptoms of peritoneal irritation, the clinical picture becomes slightly different. In such a situation, we deal with bile leakage, either from damaged bile ducts of from the duct of Luschka. This can be managed by an endoscopic intervention or a US-guided puncture and drainage of the fluid collection. If the presence of fluid is concomitant with elevated temperature and general symptoms of inflammation, an abscess may be suspected to have formed under the liver. In such a situation, a surgical intervention is also necessary. To conclude, benefits of leaving a drain in the gallbladder bed after uncomplicated cholecystectomy are not significant. Numerous studies reveal that removing the drain results in fewer pain complaints, better comfort of patients, lower rate of complications and faster discharge from hospital. Furthermore, pain complaints associated with the presence of the drain restrict chest movement at the right side and result in more frequent respiratory infections. The role of sonography in the assessment of fluid collections in the peritoneal cavity following laparoscopic cholecystectomy is not overrated. An ultrasound examination is simple, repeatable, safe and can be a remarkable diagnostic and therapeutic tool in experienced hands. However, ultrasound findings must not be interpreted separately from the clinical picture. Thanks to a skillful combination of these elements, it is possible to avoid numerous unneeded instrumental actions which do not always give an expected therapeutic effect. The remarks and tips presented by Smereczynski et al.(4) regarding the usage of various diagnostic tools in the post-operative period, particularly in diagnosing complications, are of considerable practical value and are useful for every surgeon irrespective of his or her experience.

Frequency of Bile Bacteria in Gallstone Disease

Introduction: Gallstone disease is among the bread and butter surgery for most general surgeons but role of bacteria in its formation is still an enigma. Methods: Bile was obtained during cholecystectomy from the patients admitted for uncomplicated cholecystectomy which was cultured in standard culture medium. Demographic profile and nature of stones obtained were also compared. Results: This study involved micro biological analysis of bile obtained from 528 patients undergoing cholecystectomy without other complication for duration of one year in BP Koirala institute of health sciences, Dharan. Study showed that incidence biliary infection was 4.8% with commonest organism being E coli followed by K pneumonia. Among various types of stones pigment stone were mainly found to be associated with infection than other types of stones. Conclusion: The study shows that though biliary infection in patients with gallstone disease is not uncommon but its exact role in the pathogenesis of gallstone disease is not elusive.

Feasibility, safety and benefit of no drip after cholecystectomy: a prespective observational study

Background: traditionally intravenous fluid is continued after cholecystectomy till resumption of oral intake. This practice seems unnecessary given the fast recovery following uncomplicated cholecystectomy. Objective: To observe feasibility, safety and benefit of no drip after cholecystectomy. Methods: After ethical approval, one hundred cholecystectomy patients were prospectively enrolled in the study. Complicated gall stones were excluded. In consultation with anesthetists, intravenous fluid was calculated based on body weight, maintenance etc. and infused till completion of surgery. Drip was discontinued. Patients were shifted out of operation room with IV lock. Nurses, family members and patients were detailed about this change in practice. Patients were monitored as per our existing standard practice. Anesthetists compulsorily signed out patients to the ward. After 4 hours of surgery patients were encouraged to start oral fluid. Data on fluid requirement, post operative complications and satisfaction of patients were analyzed. Results: One hundred cholecystectomy patients were studied. Average age was 39.8 years, weight 57 kg. Female were 85. Elective cases were 86 and acute 14. Average surgery time was 66 minutes and fluid required was 1313 ml. Open cholecystectomy was 71, laparoscopic 28 and 1-conversion. One laparoscopic patient was reopened due to bleeding. Four patients required drip, 2 for low blood pressure, 1 for vomiting and 1 for low oral intake. There was no mortality in this series. All concerned welcomed this change in practice. Conclusion: discontinuing intravenous drip after uncomplicated cholecystectomy is safe, and well accepted by all concerned. DOI: http://dx.doi.org/10.3126/hren.v10i3.7133 Health Renaissance; September-December 2012; Vol 10 (No.3);187-191

Acute Cholecystitis Complicating Cardiac Surgery: Case Series Involving More Than 16,000 Patients

Acute cholecystitis after cardiac surgery is rare but carries a high mortality. Its management remains controversial. We reviewed all cases of calculous cholecystitis (CC) and acalculous cholecystitis (ACC) encountered at our institution over the past 11 years. Data collection included preoperative variables, details of performed procedures, postoperative course, and outcome. The overall incidence was 0.03% for CC and 0.08% for ACC (5 and 13 of 16,576 patients, respectively). Patients in the ACC group appeared to be sicker patients whereas most patients in the CC group had an uncomplicated recovery from cardiac surgery. The diagnosis was straightforward with typical presentation and ultrasonographic findings in the CC group. In the ACC group, the presentation was less specific, and although useful as diagnostic tool, ultrasonography findings were not as consistent as in the CC group. In the CC group, 3 patients underwent surgery, and 2 patients were treated conservatively. One patient died of cardiac causes after uncomplicated cholecystectomy. In the ACC group, 7 patients were treated medically and 6 patients underwent surgery. The overall mortality was 23% (3 patients). All deaths occurred in patients treated surgically. Given the low incidence of CC, we do not recommend preoperative screening or intervention for cholelithiasis. Treatment should be according to established guidelines. Patients with ACC, without overt peritonitis, should initially be treated conservatively with appropriate antibiotics. However, failure of significant improvement within 48 hours or a worsening clinical picture should lead to surgical intervention.

???Biliary stenting alone versus biliary stenting plus sphincterotomy for the treatment of post-laparoscopic cholecystectomy bile leaks???

Strong evidence is presented in this randomized, prospective study that biliary stenting alone is as effective as biliary stenting with sphincterotomy in the treatment of uncomplicated post-laparoscopic cholecystectomy bile leaks.

Postoperative hypophosphataemia

The possible mechanisms of postoperative hypophosphataemia were studied in women undergoing uncomplicated cholecystectomy. Six patients were allocated to each of three groups. Group I received no intravenous fluids, group II received dextrose/saline solution alone and group III received dextrose/saline solution with phosphorus supplementation. The serum concentration of inorganic phosphorus fell in all three groups, the greatest fall being in the group receiving dextrose/saline solution. However, the lowest level reached (0.82 mmol/l) was within the normal range for our laboratory. Concentrations of red blood cell adenosine triphosphate and 2,3-diphosphoglycerate showed similar changes. The operations were not associated with a large catabolic response nor with an increase in urinary phosphorus excretion. The postoperative reduction in serum concentration of inorganic phosphorus appeared to be due mainly to haemodilution. There is no indication for routine phosphorus supplementation following uncomplicated elective surgery.

Arginine vasopressin release following surgical operations.

A study of plasma arginine vasopressin (AVP) concentrations in 16 patients undergoing uncomplicated cholecystectomy was carried out to determine the relative importance of the various stimuli to AVP secretion during and after an operation. Eight of the 16 patients were given a high epidural blockade from T4 and T12 and blood samples were taken before, at frequent intervals during and for two days after operation for determination of plasma AVP and osmolarity; systolic blood pressure was measured each time a blood sample was taken. In the 16 patients there was a 1.8-fold rise of plasma AVP after induction of anaesthesia (from 1.7 pmol/l median basal value to 13.1 pmol/l) and an 8.8-fold rise after skin incision, the highest concentration during operation being 102 pmol/l. There was no significant difference in AVP concentrations, urine volumes or plasma osmolality in the control and epidural groups. Systolic blood pressure fell in all patients during operation by between 14 and 54 per cent, the fall being significantly greater in the epidural group. Notwithstanding the evidence that certain nervous impulses do cause an increased secretion of AVP during operation, these results clearly show that in the absence of such stimuli there is still an increased secretion, almost certainly caused by a fall in the blood pressure.

The aldosterone response to surgery and the relationship of the response to postoperative sodium retention.

Abstract To investigate whether the aldosterone response to surgery is ‘inevitable’ and whether it is the prime cause of postoperative sodium retention, 30 patients undergoing uncomplicated cholecystectomy were givaen four different postoperative intravenous intakes (either ‘low’ or ‘high’ sodium, with and without dextran). Patients on the low sodium intake–a conventional intake of approximately 75 mmol of sodium daily – had a sixfold increase in their plasma aldosterone levels on the day of operation, which slowly declined to the preoperative level by the fifth day after operation, Patients on a high sodium intake, which was between two and three times the low sodium intake, showed only a modest rise (two-fold), which returned to the preoperative level within 8 h of operation. These aldosterone responses appeared to be caused by at least two stimuli, with the evidence suggesting that ACTH and renin were both involved. Patients on the high sodium intake had the highest positive sodium balance, amounting to approximately 400 mmol of sodium retained by day 4 after operation, despite the fact that the plasma aldosterone level had returned to the preoperative level within 8 h of operation, and thereafter remained below it. No clear evidence was found to show that the plasma aldosterone level had any significant relationship to the amount of sodium each patient retained. The sodium retained was found to be a similar proportion of the sodium intake whether the intake was low or high, the addition of dextran making no consistent difference. Analysis of the data produced the incidental finding of an increasingly significant correlation, over the 5 postoperative days studied, between the proportion of sodium retained and the patient's preoperative systolic blood pressure. It has long been known that patients with a raised blood pressure excrete a sodium load more rapidly than normotensive patients, but this effect on sodium balance after operation has not previously been recorded.

Management of asymptomatic cholelithiasis for patients awaiting renal transplantation

There is no consensus regarding the most appropriate management of asymptomatic cholelithiasis in patients awaiting renal transplantation. Cholecystectomy is considered before renal transplantation because of potential worsened complications from cholelithiasis with posttransplantation immunosuppression. This study reviewed the outcomes for operative and nonoperative management of asymptomatic cholelithiasis in patients awaiting renal transplantation. A retrospective chart review of all patients who received renal transplant at the authors' institution during the period 1994 to 2000 was completed. All patients underwent pretransplantation abdominal ultrasound. Of the 411 patients receiving renal transplants (242 men and 169 women with a mean age of 45.7 years), 32 had cholelithiasis at the pretransplantation workup (7.8%), and 35 had gallbladder abnormalities (8.5%): polyps, thickened wall, sludge, bile duct dilation. Before transplantation, 12 of the 32 patients (38%) with cholelithiasis underwent uncomplicated cholecystectomy. None of the remaining 19 patients with cholelithiasis required cholecystectomy after renal transplantation (mean follow-up period 6.2 years). Of the 35 patients with gallbladder abnormalities, 2 required post transplantation elective cholecystectomy. No evidence was found for increased morbidity related to cholelithiasis or gallbladder abnormalities after renal transplantation. As in the general population, the risks associated with asymptomatic cholelithiasis do not appear to warrant prophylactic cholecystectomy for patients awaiting renal transplantation.

Safety and risks of laparoscopy in pregnancy.

The purpose of this review is to evaluate the indications, and the safety and efficacy of operative laparoscopy in pregnancy with a particular attention to the pregnancy outcome. Hemodynamics changes during laparoscopic surgery in pregnancy are similar to those observed in the nonpregnant state. The procedure appears to be safe and reduces hospital admissions and frequency of premature labor. The safest time to perform laparoscopic surgery in pregnancy is at the second trimester. However, it can be complicated by injury to the gravid uterus and pregnancy loss. This is illustrated by a recent report of accidental gas insufflation into the amniotic cavity leading to the fetal loss. The most common indications of laparoscopy in pregnancy are cholelithiasis, appendicitis, persistent ovarian cyst and adnexal torsion. In general, it is associated with a good maternal and fetal outcome. The occurrence of a miscarriage, premature labor or fetal death appears to be related to the underlying pathology, independent of the operative intervention. Due to the displacement of the appendix by the gravid uterus and the physiologic elevation of white blood cell count in pregnancy, diagnosis of appendicitis in pregnancy can be delayed with its sequelle. In one report, the incidence of fetal loss is 1.5% in uncomplicated appendicitis and 35% in the presence of ruptured appendicitis. Similarly, the fetal loss rate in uncomplicated cholecystectomy is 4%, but the fetal mortality in gallstone pacreatitis could be up to 60%. Laparoscopy in pregnancy should be performed with utmost care. In the second trimester of pregnancy, open laparoscopic approach is strongly recommended.

MR imaging of upper abdomen following cholecystectomy. Normal and abnormal findings.

To describe the normal MR appearance after cholecystectomy and the findings in patients with postoperative complications using fast pulse sequences in abdominal MR imaging. In a prospective study of 119 patients, 64 were examined with MR after cholecystectomy. In total, 56 patients with uncomplicated cholecystectomy were examined with MR 1--5 days (mean 1.6 days) after cholecystectomy. Nine patients had an abdominal postoperative complication and 8 of these were examined with MR after the complication commenced 1--12 days after the cholecystectomy. Oedema in the gallbladder fossa was the only finding in 39 patients (61%), all with uneventful recovery. Small fluid collections in an area consistent with the gallbladder fossa were seen in 9/64 (14%) patients, of which 3 had surgical complications: 1 bleeding and 2 bile duct leakage. Twenty-two (34%) patients had small locally situated fluid collections adjacent to the liver, 14 were uneventful and 8 showed postoperative surgical complications. Seven patients had fluid in the rest of the abdomen of which 5 had surgical complications; 4 due to bile duct leakage and 1 acute pancreatitis. One patient had a postoperative bleeding not seen on MR images. MR is very sensitive in detecting fluid collections. Early MR findings following cholecystectomy are normally only subtle changes, mainly in the gallbladder fossa. Fluid collections diagnosed elsewhere than in the gallbladder fossa usually indicate a surgical complication and a surgical complication is unlikely if MR fails to show a fluid collection.