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.