Frequency of difficult cholecystectomy in patients with thick walled gall bladder

Background: Laparoscopic cholecystectomy is the procedure of choice for cholecystitis. There are variable rates of conversion of laparoscopic cholecystectomy to open cholecystectomy. Various studies have highlighted gall bladder wall thickness and age as independent risk factors for conversion from laparoscopic to open procedure. This study was done to determine the frequency of conversion of laparoscopic cholecystectomy to open cholecystectomy in patients undergoing laparoscopic cholecystectomy with a gall bladder wall thickness of more than 3mm as determined on pre operative ultrasound

Objective: To find frequency of conversion to open procedure in patients undergoing laparoscopic cholecystectomy with a gall bladder wall thickness of more than 3mm as determined on pre operative Ultrasound

Methods: This Case series was conducted at the Surgical Unit IV Civil Hospital Karachi, Pakistan from 15th July 2012 to 15th January 2013. A total of 129 patients were included in the study with gall bladder wall thickness of more than 3mm on Ultrasound. Patients were stratified according to age, sex, gall bladder wall thickness, frequency of difficult cholecystectomy and duration of disease

Results: A total of 129 patients were included in the study. Female to male ratio is 5.7:1. The mean age of patients was 43.33 +/- 11.5 years. The average gall bladder wall thickness was 4.07 +/- 0.63 mm and duration of disease was 4.53 +/- 4.67 years. Regarding preoperative findings, bleeding during separation from liver bed was the commonest finding in general i.e. 35.7% followed by local adhesions 33.3% and perforation of gall bladder was observed in 7.8% cases. All [n=13] patients who had conversion to an open procedure had wall thickness between 4.1 to 6 mm. Similarly rate of conversion was found to be in higher in patients with symptoms for more than 5 years [i.e. 9 out of 24]

Conclusion: Ultrasound for gall bladder wall thickness is a good predictor for difficult cholecystectomy. It should be used as anticipative measure for difficult cases and patient should be properly counseled regarding chances of conversion

Laparoscopic cholecystectomy with and without prior ERCP

To find out operative difficulties in patients undergoing laparoscopic cholecystectomy after ERCP in comparison with those without prior ERCP. Comparative study. Surgical Unit IV Civil Hospital Karachi, from June 2011 to June 2013. Patients were divided into 2 groups. Group 1 consisted of 40 patients with choledocholithiasis, who underwent ERCP followed by laparoscopic cholecystectomy while in Group 2 there were 40 patients with uncomplicated gallstones who had no intervention prior to laparoscopic cholecystectomy. A total of 80 patients underwent laparoscpic cholecystectomy. Male: female ratio was 8:32 and 5:35 and mean age was 40.20 +/- 11.27 year and 39.58 +/- 11.29 year in Groups 1 and 2 respectively. Statistically significant difficulties were encountered during operation between the groups. Such difficulties were found in 29 [72.5%] and 3 [7.5%] patients in Group 1 and 2 respectively [p<0.0001]. The laparoscopic procedure was converted to open in eight [20%] patients in Group 1 and 1 [2.5%] patient in Group 2 [p=0.01]. Patients with difficult laparoscopic cholecystectomy had a mean ERCP frequency of 1.34 +/- 0.74 while those with no difficulty encountered had a mean ERCP frequency of 1.15 +/- 0.38 [p=0.05]. Statistically significant difference was found when comparing the operative difficulties encountered in patients who underwent ERCP and surgery in the same settings and in those where surgery was delayed after ERCP [p<0.001]. Laparoscopic cholecystectomy after ERCP was difficult and challenging. To minimize the complications and conversion, these patients should be operated in same sitting as for ERCP

Diagnosis of Proximal Biliary Strictures: Role of serum bilirubin, alkaline phosphatase and abdominal ultrasound

To determine the role of serum bilirubin, alkaline phosphatase and abdominal ultrasound in the diagnosis of proximal biliary strictures. Cross sectional Place and Duration: Surgical Unit IV, Civil Hospital Karachi, from Jan 2007 to August 2008. A total of 407 patients with obstruction of the biliary tree on ultrasound and raised serum levels of alkaline phosphatase had ERCP performed on them. Serum bilirubin and alkaline phosphatase levels were recorded prior to the procedure. A total of 75 patients with strictures on ERCP were included in the study. Jaundice and abdominal pain were present in 68 [90.6%] and 41 [54.6%] of the total 75 patients respectively. A statistically significant difference was present in the mean bilirubin levels of different stricture groups [p=.024]]. Receiver Operator Curve analysis of serum bilirubin level of 19.2gm/dl showed a sensitivity of 43% and specificity of 77% with area under curve= 0.6. Abdominal ultrasound was found to be 31.8% sensitive and 79.2% specific in predicting the presence of proximal biliary strictures. Serum levels of total bilirubin and alkaline phosphatase and abdominal ultrasound have minor role in the diagnosis of proximal biliary strictures