Delayed laparoscopic cholecystectomy after more than 6 weeks on easily controlled cholecystitis patients

BACKGROUNDS/AIMS: There is debate on the timing of cholecystectomy in acute cholecystitis. Although there is a recent trend toward early laparoscopic cholecystectomy (eLC), that is, within 72 hours of symptom onset, some surgeons still prefer delayed operations, or operations after several weeks, expecting subsidence of the inflammation and therefore a higher chance of avoiding open conversion and minimizing complications. Our experience of LC for 10 years was reviewed retrospectively for the timing of the operation and perioperative outcomes, focusing on evaluating the feasibility of delayed LC (dLC). METHODS: The severity of the acute cholecystitis was classified into three grades: easily responding to antibiotics and mostly symptom-free (mild, grade I), symptoms persisting during the treatment (moderate, grade II), and worsening into a septic state (severe, grade III). RESULTS: Among 353 cholecystectomy patients, grade I (N=224) patients had eLC in 152 cases and dLC in 72 cases. Grade II (N=117) patients had eLC in 103 cases and 12 had dLC. All grade III patients (N=12) underwent open cholecystectomy. In Grade I patients, when the operation was delayed, there were fewer open conversion cases compared to eLC patients (20.45% vs 7.69%) (p0.05). Grade II patients' rate of open conversions (58.3% vs 44.2%) and complications (25.0% vs 19.5%) increased when the operations were delayed compared with eLC patients (p<0.05). In grade I and II patients, the most common reason for open conversion was bleeding, and the most common complication was also bleeding. CONCLUSIONS: For patients with cholecystits that easily responds to antibiotics (grade I), dLC showed a higher laparoscopic success rate than eLC at the expense of prolonged treatment time and examinations, With moderate to severe cholecystitis (grade II, III), however, there was no room for delayed operations.

Fate of lost gallstones during laparoscopic cholecystectomy

BACKGROUNDS/AIMS: The fate of gallstones that remain in the peritoneal cavity due to perforation of the gallbladder during laparoscopic cholecystectomy (LC) has been studied vigilantly since the early 1990s when this surgical procedure started to be used. But the complication statistics vary with each report. So we reviewed our 47 cases of lost stones that were traceable from 1998 to 2007. METHODS: Stones entered the peritoneal cavity through the perforation site during dissection of the body or Hartmann's pouch of gallbladder from the liver bed, despite trials of stone removal like irrigation and using a glove finger pouch especially in the case of numerous small stones. There were nine cases of lost stones that were caused by fragments of stone breaking from a large stone during its retrieval. RESULTS: No patient was forced into revision surgery or intervention for the missing stones but only negative suction drains were inserted, and information to the patients was given. Most of the stones (N=42, 89.4%) remained silent during the follow-up period of 10.4+/-3.6 years, and 5 patients (10.6%) developed inflammatory complications in the peritoneal cavity and abdominal wall. Two intraperitoneal abscesses were found in the right subhepatic area and a cul-de-sac and these were managed by laparotomy. Subhepatic abscess was later associated with intestinal obstruction. Two patients suffered an umbilical portal site fistula and a right flank portal fistula respectively, requiring prolonged wound care. One patient suffered immediate postoperative peritonitis that was cured by antibiotics. CONCLUSIONS: Lost stones should be retrieved or fragmented as much as possible for removal through a drain, and caution should be exercised during dissection of the gallbladder to avoid perforating the gallbladder. Considering the approximately 10% incidence of serious inflammatory complications of lost stones, the complications should be explained to patients to allow for earlier diagnosis of complications later.

Ten-year experience on common bile duct exploration without T-tube insertion

BACKGROUNDS/AIMS: Common bile duct (CBD) exploration has been a procedure necessary to remove stones which are not removable by endoscopic sphincterotomy (EST). T-tube was installed mainly in the concern of bile leakage after procedure. But T-tube itself can only cause bile peritonitis and thus, prolonged discomfort and care after operation. In addition, in the era of laparoscopy, T-tube insertion adds much operation time and is technically difficult for installation during the procedure. METHODS: Our case of open cholecystectomy and primary closure of CBD not leaving T-tube (n=28, group I) with reports dating from July 1998 to June 2007 is presented here to see whether primary closure without T-tube is safe as compared with T-tube inserted cases performed at the same center (n=15, group II). Operative cholangiography, CT scan, ultrasound and biochemical data were followed up for both groups and surveyed on operative complications as well to determine the outcomes. RESULTS: Bile leakage in 1, recurrent stone in 2 and obstructive jaundice in 1 were all considered during the follow up period among 28 group I patients (n=6), when compared to T-tube inserted group II patients with 2 bile peritonitis, 1 residual stones and 1 pancreatitis (n=4), showing no meaningful differences (p=0.07). CONCLUSIONS: CBD exploration and direct primary closure not leaving T-tube is an acceptable operational option as recently tried in many choledochotomies.

Cholecystectomy in octogenarians: recent 5 years' experience

BACKGROUNDS/AIMS: Aging of population is leading to more operative treatments on elderly patients in various aspects. Growing numbers of patients are going through operations about cholecystitis in the same sense. We tried to survey them anew about remarkably increasing octogenarian patients and the outcome after operative management for cholecystitis seeking to improve treatment result. METHODS: For 5 years, from March 2007 to Febraury 2012, 57 octogenarian patients had cholecystectomy among total 380 cases. Patients were compared between total patients and octogenarians on perioperative follow-up findings in medical records. RESULTS: Underlying diseases were prevailing in octogenarian by more than 70% of cases. Severe acute cholecystitis was more often observed in octogenarians and procedures like endoscopic retrograde cholangiopancreaticography were more often performed preoperatively, showing more frequent conversion to open method from laparoscopic procedure. Complications such as peritonitis, sepsis, wound problem, including mortality were much more common in octogenarian cholecystectomy patients. When compared to total cholecystectomy patient group, octogenarian patients had more problems in every items significantly (p<0.05). CONCLUSIONS: High rates of complications and mortality accompanying prolonged symptoms and examinations was inevitable for octogenarian patients after cholecystectomy. Operative treatment per se appears to be inevitable, thus it should make the patients be informed about risks with more attention to every aspect of care.

Experience with partial cholecystectomy in severe cholecystitis

BACKGROUNDS/AIMS: Partial cholecystectomy (PC) is often an inevitable operative procedure when Calot triangle is severely inflamed and fibrosed with conglomerated structures. We reviewed our clinical outcomes of PC to compare its feasibility with conventional total cholecystectomy (TC), especially for its possible application to laparoscopic procedure. METHODS: From Aug. 2000 to July 2008, 20 cases of PC by laparotomy were performed, including converted cases during laparoscopic cholecystectomy. Sixty-eight cases of TC by open method during the same period were compared in a mean follow-up period of 108 months. RESULTS: Bile fistula was observed in 3 cases of PC; one case needed endoscopic biliary stent for management and a second case showed fistula that closed by supportive care in 2 months. The last patient died from peritonitis. No bile fistula was observed in PC. Morbidities were found in 9 cases of PC (45%) and in 11 cases of TC (16.2%). Bile fistula (n=3) and wound infection (n=3) were prominent in the PC group, and wound infection (n=7) in the TC group. Reoperations were necessary for 5 (25.0%) and 4 (5.9%) patients from PC and TC, respectively. Mortality occurred in 2 (2/10 10%) and 4 cases (4/68 5.9%) of PC and TC, respectively. Two mortalities in each group resulted from direct extension of cholecystitis. CONCLUSIONS: Considering the higher risks of complications and mortality, PC should be avoided as long as possible, and patients should always be informed of its clinical outcomes postoperatively. Further elaboration of a safer operative plan should be sought.

Cystic duct closure during partial cholecystectomy: ten years' experience

BACKGROUNDS/AIMS: When surgeons face difficulties in dissecting the Calot triangle during cholecystectomy due to severe inflammation or fibrosis, the proximal portion of the gallbladder is left in place to avoid injury to the bile duct; this procedure is called partial cholecystectomy (PC), and it is associated with a much higher complication rate after the operation. METHODS: We surveyed the clinical outcomes of 25 cases of PC by laparotomy during ten years from January 1998 to December 2007, for a total of 95 months of the mean follow-up period. Patients were separated in two groups for comparison: group I (n=15), in which cystic duct closure was tried from the intraluminal cystic ductal opening; and group II (n=10), in which cystic ductal circumferential ligation was possible. RESULTS: Bile fistula occurred in 4 cases of group I, while no fistula occurred in group II. Postoperative peritonitis was observed in 4 cases from group I, with 3 of them caused by leakage of bile when the cystic duct could not be properly managed by stitches or staples. One of these peritonitis cases was fatal, but no case in group II showed peritonitis postoperatively. Wound infection, retained stone, and reoperations were also more frequent in group I, in 4, 2, and 5 cases. The mortality was 3 in group I and 1 in group II. CONCLUSIONS: When inevitable partial cholecystectomy is carried out, more attention should be focused on secure ligation of the cystic duct, with the expectation of an improved outcome of the operation on a large scale. Otherwise, patients should be clearly informed about the high risks of postoperative complications.

Simple Ligation of Stump without Embedding Suture during Appendectomy Caused No Increased Complication Rates

PURPOSE: There have been several reports claiming benefits for the simplified method of appendectomy over the traditional method of embedding suture at the stump, without contradictory opinions ever having been published. Nevertheless, most surgeons continue to carry out purse-string sutures in daily practices of open appendectomy as long as the stump situation permits. In case where the cecum near the stump is friably swollen due to the spread of inflammation in advanced appendicitis, we have often faced uncomfortable pulling of cecal stitches during embedding procedures experiencing tearing or incomplete approximation of the pulled wall. To avoid this difficulty and shorten the procedure, we have been performing simple double ligations of the stump and observed the results. METHODS: Prospectively we assigned patients to an operative method of either simple ligations or embedding sutures, alternatively upon admission, and performed this method of stump management with two surgeons for 4 years, and postoperative complications were observed in 362 and 273 cases respectively. RESULTS: There was no advantage of one method over the other in recovery course, and in view of the complication rates associated with stump inadequacy and adhesive ileus, even in cases of perforated appendicitis also. CONCLUSION: When possible, Stump ligations simplify appendectomy procedure without increased operative sequelae, even in cases of perforated appendicitis. So this procedure could be recommended instead of purse-string sutures, especially in cases of thick and friable cecal wall due to acutely disseminated appendiceal inflammation.

Vitamin A Effect to Nitrofen Induced Congenital Diaphragmatic Hernia and Pulmonary Hypoplasia in Rats

PURPOSE: Vitamin A has been introduced recently for its feasible effect in curing diaphragmatic defect and accelerating lung development during the perinatal period of experimental rats or humans suffering from congenital diaphragmatic hernia (CDH). Despite continual research attention since the fifties to elucidate the influence and mechanisms of vitamin A on pulmonary growth, many presumptive hypotheses remain, along with an inherently high mortality. So we wondered whether prenatal vitamin A alone or combined with dexamethasone could accomplish better results than dexamethasone against the diaphragmatic defect or lung hypoplasia in neonatal rats. METHODS: Pregnant Sprague-Dawley rats exposed to Nitrofen were classified into 5 groups according to the different treatment options. Studies were performd in 2 phases. In study 1, the 24-hour survival rate and preliminary results were observed. In study 2, the incidence and site of CDH, lung/body weight ratio (L/BWR), radial saccular counts (RSC) and maturation of alveolar sac in 3 histomorphologic grades were evaluated among the 5 groups. RESULTS: Vitamin A treated neonatal rats (group III) showed improved lung development compared with rats without treatments (group II) in 24-hour survival rate, L/BWR and alveolar maturation (P<0.001), leading to lung development that was comparable in every aspect to that of the dexamethasone treated rats (group IV). Combined treatment by vitamin A and dexamethasone (group V) improved the incidence of CDH, L/BWR (P<0.001), RSC (P<0.05) and alveolar maturation (P<0.001) when compared with rats treated alone by vitamin A (group III) or dexamethasone (group IV), leading to a level of development that was closest to that of the normal control lungs (group I). CONCLUSION: Vitamin A had a therapeutic effect on pulmonary hypoplasia in the experimental rats, and when combined with dexamethasone it accomplished a better outcome in the treatment of CDH itself or pulmonary hypoplasia. After the problem of vitamin A toxicity is settled, the future of vitamin A as a prenatal therapeutic agent for CDH might gain in appeal.

Peritoneal Saline Irrigation and Infective Complications in Perforated Appendicitisin at a Single Center

PURPOSE: Until recently, the surgical treatment of perforated appendicitis in South Korea showed a relatively high incidence of postoperative infectious complications compared with centers having protocols for managements. Authors have been performing appendectomies for perforated cases under the principle of massive irrigation of the peritoneal cavity and primary closure of incision wound that leaves a suction drain from pelvic cavity, expecting reducing chance of infective complications and thus reducing the stress faced by operators. METHODS: Among 788 cases of appendicitis from September 1997 to December 2002, 172 patients showing perforation and peritonitis in the operative field were reviewed retrospectively. All the operations were performed by the principle mentioned above, and data were collected on various major complications, especially infective wound and intra-abdominal complications. RESULTS: There were 7 cases of suppurative wound infection, and 5 cases of intra-abdominal abscess, representing a total incidence of 7.0% (n=12) in 172 patients. Other major complications such as adhesive ileus (n=3), intestinal fistula (n=1), or remote organ infective event (n=1) were also recognized. CONCLUSION: Massive saline irrigation during appendectomy of perforated appendicitis-without antibiotic mixture-that leaves a negative suction drain from the pelvic cavity and the primary closure of incision wounds have yielded satisfactory results concerning various aspects, especially in lessening infective postoperative complications.

Carotid Endarterectomy Using Patch Angioplasty without Routine Completion Duplex Scan

PURPOSE: Routine intraoperative duplex color-flow ultrasound carotid examination as a completion study has been welcomed by many vascular surgeons as the most recent, high proficiency tool to detect unsuspected remaining operative defects before the patient leaves the operating room, thereby improving operative outcome after Carotid Endarterectomy (CEA). However, after many years of experience gaining added knowledge about the clinical course and standardization of operative procedures of CEA for mainly occidental patients, the adherence to strict operative procedures using patch angioplasty and liberally added continuous-wave Doppler confirmation has been found to achieve well beyond acceptable operative results in our patients without routine intraoperative duplex scanning (IDS). METHODS: A retrospective review of 455 surgical patients who underwent patch angioplasty in a five year period, from January 1996, was performed to evaluated their operative outcome. Their perioperative morbidity, mortality, and follow up Duplex scan findings on restenosis for a mean of 20.8 months were observed for a comparison between our experience and recently reported results using routine IDS. RESULTS: We had a perioperative combined stroke-death rate of 2.0% (n=9), consisting of death in 0.9% (n=4) and stroke in 1.1% (n=5). Residual stenosis was confirmed by first follow up Duplex scanning in 13 patients a (4.2%), 6 of whom were resolved with time. Twenty-three (5.6%) recurrent stenoses, including 2 occlusions and 1 high grade stenotic internal carotid artery (ICA), and 1 occlusion with 2 severe stenoses in external carotid artery (ECA), appeared among 414 cases during follow up. Except for 2 patients who suffered perioperative stroke, one of whom died, all residual stenosis and recurrent stenosis patients stayed clinically symptom free. Among 5 immediate postoperative transient ischemic attacks (TIA) cases and 5 strokes, one residual stenosis accompanying stroke appeared during follow up. Of five cases that were re-explored in the operating room by continuous wave Doppler information with conversion of primary closure to patching (n=2) and revision of distal arteriotomy (n=2), all remained normal during follow up by duplex scan. CONCLUSION: Routine patch angioplasty, meticulous surgical technique and continuous-wave Doppler information were enough to achieve an acceptable clinical outcome in our patients. IDS might be necessary selectively for concerned cases only.

Carotid Endarterectomy Using Patch Angioplasty without Routine Completion Duplex Scan

PURPOSE: Routine intraoperative duplex color-flow ultrasound carotid examination as a completion study has been welcomed by many vascular surgeons as the most recent, high proficiency tool to detect unsuspected remaining operative defects before the patient leaves the operating room, thereby improving operative outcome after Carotid Endarterectomy (CEA). However, after many years of experience gaining added knowledge about the clinical course and standardization of operative procedures of CEA for mainly occidental patients, the adherence to strict operative procedures using patch angioplasty and liberally added continuous-wave Doppler confirmation has been found to achieve well beyond acceptable operative results in our patients without routine intraoperative duplex scanning (IDS). METHODS: A retrospective review of 455 surgical patients who underwent patch angioplasty in a five year period, from January 1996, was performed to evaluated their operative outcome. Their perioperative morbidity, mortality, and follow up Duplex scan findings on restenosis for a mean of 20.8 months were observed for a comparison between our experience and recently reported results using routine IDS. RESULTS: We had a perioperative combined stroke-death rate of 2.0% (n=9), consisting of death in 0.9% (n=4) and stroke in 1.1% (n=5). Residual stenosis was confirmed by first follow up Duplex scanning in 13 patients a (4.2%), 6 of whom were resolved with time. Twenty-three (5.6%) recurrent stenoses, including 2 occlusions and 1 high grade stenotic internal carotid artery (ICA), and 1 occlusion with 2 severe stenoses in external carotid artery (ECA), appeared among 414 cases during follow up. Except for 2 patients who suffered perioperative stroke, one of whom died, all residual stenosis and recurrent stenosis patients stayed clinically symptom free. Among 5 immediate postoperative transient ischemic attacks (TIA) cases and 5 strokes, one residual stenosis accompanying stroke appeared during follow up. Of five cases that were re-explored in the operating room by continuous wave Doppler information with conversion of primary closure to patching (n=2) and revision of distal arteriotomy (n=2), all remained normal during follow up by duplex scan. CONCLUSION: Routine patch angioplasty, meticulous surgical technique and continuous-wave Doppler information were enough to achieve an acceptable clinical outcome in our patients. IDS might be necessary selectively for concerned cases only.