Comparison of Alteration in Liver Function Tests in Patients undergoing High Pressure Laparoscopic Cholecystectomy Versus Low Pressure Cholecystectomy

Introduction: Cholelithiasis is one of the most commonsurgical diseases. Laparoscopic cholecystectomy has beenuniversally accepted as gold standard for treatment ofcholelithiasis. Although many studies have shown postoperative changes in liver function tests after high pressurepneumoperitoneum during laparoscopic cholecystectomy,but very few studies have investigated the effects of lowpressure pneumoperitoneum on hepatic functions.The presentstudy was designed to compare post-operative changes inliver function tests among patients randomized to either lowpressure laparoscopic cholecystectomy(LPLC) (i.e.8 mmHg)or high pressure laparoscopic cholecystectomy(HPLC) (i.e.14mmHg).Material and methods: After taking a well informed writtenconsent,150 cases undergoing laparoscopic cholecystectomywere enrolled in the study and randomised preoperatively intotwo groups (LPLC and HPLC). Liver function tests (LFTs)including Total Bilirubin, Conjugated Bilirubin, AspartateTransaminase (AST), Alkaline Phosphatase(ALP), AlanineTransaminase (ALT), Gamma-glutamyl Transferase (GGT),Total Serum Protein, Total Serum Albumin) were done onpost-operative day (POD) 1 and day 7 and compared withpreoperative LFTs in both groups.Results: The study demonstrated significant increase inConjugated bilirubin on POD 1(p < .001), AST on POD1 (p: .005), ALT on POD 1 (p <.001), ALP on POD 1(p < .001) in HPLC as compared to LPLC patients. LFTsin both groups were found to be normal on POD 7 withoutsignificant difference between the two groups.Conclusion: Low pressure laparoscopic cholecystectomy hasless adverse effects on liver functions as compared to the highpressure laparoscopic cholecystectomy

Management of Trans-Section of Right Hepatic Duct during Laparoscopic Cholecystectomy and Primary End to End Anastomosis-A Case Report

Laparoscopic cholecystectomy is standard treatment for cholelithiasis. It associates with high incidents of complications when compared to open cholecystectomy. Most common complication is bile duct injuries associate with high morbidity. Normally, proximal ductal injuries are repaired by hepatico-jejunostomy since the incidence of stricture is more common with end-to-end anastomosis. We came across one such case of right hepatic duct injury where the right hepatic duct was completely transected. Immediate end-to-end primary anastomosis was done on a 5F feeding tube. Post-operativecholangiogram (CGM) showed minimal leak at the anastomotic site, displaying the normal proximal ductal system of right lobe. Patient was normal after following for 18 months. It is our opinion that primary anastomosis is preferable particularly when duct is larger in caliber as in our case it was admitting 5F feeding tube. Primary end-to-end anastomosis will reduce the morbidity form leak since chances of leak are more hepatico-jejunostomy and prevent possible ascending cholangitis.

Comparisons of Oxidative Stress during Laparoscopic Cholecystectomy and Open Cholecystectomy

PURPOSE: During oxidative stress, the levels of oxygen free radical increase dramatically, which plays a role in apoptosis, aging and is chemic injury, but also leads to positive effects such as induction of host defense genes and mobilization of ion transport systems. It has been suggested that the advantages of laparoscopic surgery are closely related to the reduced oxidative stress that occurs during laparoscopic cholecystectomy (LC) when compared to open cholecystectomy (OC). This study was conducted to compare oxidative stress markers including total antioxidant status (TAS), superoxide dismutase (SOD) and gluthathione reductase (GR) between the LC group and OC group to determine if these surgical procedures result in different patterns of oxidative stress. METHODS: Our prospective study included fifty patients with symptomatic cholelithiasis and cholecystitis, of whom 25 underwent LC and 25 underwent OC. The plasma levels of oxidative stress markers (TAS, SOD, and GR) were measured preoperatively and on the 1st, 2nd and 3rd postoperative days. RESULTS: The postoperative hospitalization days differed significantly between the two groups (p0.05). An acceptable postoperative decrease in SOD was observed in the OC group, especially after the 2nd postoperative day (p0.05) upon analysis of covariance. A significant postoperative decrease in the level of SOD was observed in the OC group, especially after the 2nd postoperative day (p<0.01), and there was also a significant difference in the serial change in SOD between groups (p=0.020). The level of GR in the OC group decreased significantly on the 2nd postoperative day (p=0.022). Moreover, ANCOVA revealed a significant difference in the serial changes in thelevel of GR between the two groups (p=0.039). CONCLUSION: Our study compared oxidative stress between LC and OC groups based on the levels of TAS, SOD, and GR. We found that minimally invasive surgery, such as laparoscopic cholecystectomy, produced less oxidative stress than open surgery.

Rate of Conversion and Postoperative Complications of Laparoscopic Cholecystectomy in District Level Hospital of Bangladesh..

Laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gallbladder disease, but conversion to open cholecystectomy and postoperative complications are still inevitable in certain cases. Knowledge of the rate and underlying reasons for conversion and postoperative complications could help surgeons during preoperative assessment and improve the informed consent of patients. We decide to review the rate and causes of conversion and postoperative complications of our LC series. This study included 760 consecutive laparoscopic cholecystectomies from July 2006 to June 2011 at Faridpur Central Hospital and Faridpur Medical College Hospital. All patients had surgery performed by same surgeon. Conversion to open cholecystectomy required in 19 (2.5%) patients. The most common reasons for conversion were severe adhesions at calot's triangle (6, 0.83%) and acutely inflamed gallbladder (5, 0.66%). The incidence of postoperative complications was 1.58%. The most common complication was wound infection, which was seen in 5 (0.66%) patients followed by biliary leakage in 3 (0.40%) patients. Delayed complications seen in our series is port site incisional hernia (2, 0.26%). LC is the preferred method even in difficult cases. Our study emphasizes that although the rate of conversion to open surgery and complication rate are low in experienced hands, the surgeons should keep a low threshold for conversion to open surgery and it should not be taken as a step in the interest of the patient rather than be looked upon as an insult to the surgeon.

Significance of Intra & Extra Hepatic Duct Stone Removal via Percutaneous Transhepatic Biliary Drainage Tube in Patients Undergoing Laparoscopic Cholecystectomy

PURPOSE: One of the popular and widespread treatments for intra- & extra-hepatic duct (IEHD) stone associated gallbladder (GB) stone is laparoscopic cholecystectomy (LC) with stone removal through endoscopic retrograde cholangiopancreatography (below ERCP). Because LC with stone removal through percutaneous transhepatic biliary drainage (below PTBD) is well known for its safety and feasibility in removing IEHD stones, we did this study to see the significance (safety, feasibility, effectiveness etc) of PTBD and stone removal. METHODS: We compared the odds by collecting 71 retrospective cases, victims of IEHD stone associated GB stone from January, 2004 to December, 2007 in Chung-Ang University Hospital. Comparative analysis took place in 51 cases who underwent PTBD and 20 cases treated with ERCP. We excluded 6 patients who underwent PTBD for intra hepatic duct stone. Age, sex, American Society of Anesthesiologists score, pain, nausea, pre- and post- laboratory value, symptoms, size, location and number of stones, diameter of extra hepatic duct, recurrence and clearance rate, frequency of each procedure, complications, cost were investigated in this study. RESULTS: There were no statistical differences in each group in recurrence and clearance rate or frequency of procedure. However post-procedure pancreatitis and amylase level were significantly difference in each group. PTBD group experienced much longer hospital stay but was not significantly different. Although procedure cost is three times more expensive than that of PTBD group, there were no differences in total cost and patients' expenses between the two groups. CONCLUSION: PTBD would be an alternative solution in managing IEHD stone associated with GB stone for its lower rate of complication, higher clearance with minimal discomfort.

A case of port site metastasis of unexpected gallbladder carcinoma after laparoscopic cholecystectomy / 대한내과학회지

Laparoscopic cholecystectomy (LC) is considered as the gold standard operation for the removal of a nonmalignant, diseased gallbladder. With the increasing number of LCs, a number of gallbladder carcinomas have been unexpectedly found either during or following this procedure. The removal of unexpected gallbladder carcinomas by LC can cause also a new complication, port site metastasis (PSM), which is developed by the implantation of tumor cells into the abdominal wall at the port site. We report a rare case of PSM of gallbladder carcinoma which was unsuspected at the time of LC. A 65-year-old man underwent LC at another hospital for calculous cholecystitis. The histologic examination revealed an adenocarcinoma of the gallbladder infiltrating the muscle wall. Despite the surgeon's advice, the patient refused any additional treatment. Ten months after surgery, he visited our hospital because of a painful and palpable subcutaneous mass at the scar of the periumbilical trocar incision. The mass was biopsed and histological examination confirmed metastasis from the gallbladder carcinoma.

The significance of intraoperative cholangiography in laparoscopic cholecystectomy / 重庆医科大学学报

Objective:To evaluate the value of intraoperative transcystic cholangiography(IOC) during laparoscopic cholecystectomy(LC).Methods:IOC was conducted in 56 patients who underwent LC because of cholelithiasis with chronic or acute cholecystitis and biliary pancreatitis.The results were analyzed.Results:Cannulation was successfully completed in 54 out of 56 patients,and the success rate was 96.4%.All 54 patients underwent satisfactory visualization.The common bile duct stones were detected in 5 patients by IOC,and 2 of them were converted to common bile duct exploration and T-tube drainage by open cholecystectomy;3 of them were converted to common bile duct exploration and T-tube drainage by laparoscopic cholecystectomy.2 cases were found to have abnormal cystic duct by IOC,and 4 cases were detected for the biliary anatomy by IOC.The average time of IOC was about(15.5?3.7)minutes.No complication occurred.Conclusion:IOC is a safe and convenient procedure with a high success rate,and it can provide clear films of biliary tree.The benefit of IOC is the detection of common bile duct and cystic duct stones and abnormal biliary anatomy.It can reduce the rate of retained common bile duct stones and bile duct injuries,and increase the early identification of bile duct injuries.Therefore IOC can improve quality and security of LC.

Hypoxemia on transportation in elderly patients after laparoscopic cholecystectomy under general anesthesia / 中国微创外科杂志

Objective To explore hypoxemia on transportation in elderly patients who underwent laparoscopic cholecystectomy(LC) under general anesthesia. Methods SPO 2 was monitered continuously during peridecannulation period, especially within the first 5 minutes in case of incidence of hypoxemia. Results 15 out of 100 cases were found to undergo hypoxemia with SPO 2≤92%. The incidence rate of hypoxemia was 15%(15/100). Conclusions It is important to monitor SPO 2 and administer oxygen inhalation continuously on transfer from operation room back to ward to prevent hypoxemia in elderly patients.

Management of large cystic duct during laparoscopic cholecystectomy / 中国微创外科杂志

Objective To investigate the management of large cystic duct during laparoscopic cholecystectomy(LC). Methods 24 out of 1052 patients, whose cystic duct size in diameter are larger than 0.4cm, were reviewed retrospectively from March 1995 to December 2001. The diameter of cystic duct is 0 4cm～0 6 cm in 12 cases, 0 6cm～0 8cm in 8 ones, 0 8cm～1 0cm in 2 ones and larger than 1cm in 2 ones. Different methods were adopted. Two-clip method was used in 10 cases, three-clip method in 5 ones, ladder clip method in 6 ones and rotation clip method in 3 ones. Results LC was completed successfully in 21 cases. 3 cases were converted to open cholecystectomy due to blood loss. No complications such as bile leakage and subphrenic abscess occurred. Conclusions Large cystic duct during LC can be managed successfully by different methods.

The diagnosis and treatment of bile duct injury during laparoscopic cholecystectomy (A report of 22 cases) / 中国微创外科杂志

Objective To study the prevention and treatment of bile duct injury during laparoscopic cholecystectomy(LC). Methods 22 cases of bile duct injury during LC were reviewed retrospectively. The features, diagnosis, treatment and efficacy of injury were summarized. Results All patients were successfully treated by Roux-en-Y cholangio-jejunostomy. Besides, 8 patients underwent plastic operation of bile duct of hepatic portal and 3 patients middle lobectomy of liver. 22 cases were followed up at the 1st and 3rd year after surgery, and no bile duct stricture, recurrence of jaundice and cholangitis occurred. Conclusions It's a key to prevent bile duct injury during LC. The management of bile duct injury should be chosen according to injured time, sites and types.

Laparoscopic operation for calculous atrophic cholecystitis / 中国微创外科杂志

Objective To summarize our experience in the management of calculous atrophic cholecystitis by laparoscopic choleycystectomy(LC). Methods 56 cases of calculous atrophic cholecystitis treated by LC from 1997 to 2000 were analyzed retrospectively. Results 52 cases treated by LC including antergrade resection in 39 ones, retrograde resection in 13 ones were successfully completed. 4 patients were converted to open cholecystectomy, 3 of whom underwent choledochotomy and T-tube drainage. There was abdominal cavity drainage in 8 cases. 56 patients were an cured. Bile leakage occurred in 2 cases, and the patients were cured by conservative treatment. Conclusions It's key point to perform LC successfully for patients with calculous atrophic cholecystitis by getting well known of the junction site of ampulla and cystic duct, selecting indications of LC strictly, converting to open operation as necessary and putting preventive drainage- tube.

The value of laparoscope in the treatment of biliary leak after laparoscopic cholecystectomy / 中国微创外科杂志

Objective To explore the value of laparoscope in the treatment of biliary leak after laparoscopic cholecystectomy (LC). Methods 16 cases of biliary leak after LC from August 1996 to May 2001 were reviewed retrospectively. Results 14 patients with biliary leak without bile duct injury were operated on under laparoscope. 2 patients with biliary leak and bile duct injury were converted to open operation. Conclusions Laparoscope can confirm reasons of biliary leak and shorten hospitalization time of patients with biliary leak without bile duct injury.

The application of laparoscopic cholecystectomy with low pressure pneumoperitoneum for high risk patients with gallstone / 中国微创外科杂志

Objective To study the safety of laparoscopic cholecystectomy (LC) with low pressure pneumoperitoneum for high risk patients with gallstone. Methods 72 high risk patients with gallstones were undergone LC with low pressure pneumoperitoneum and their clinical data were analysed in our hospital during last three years. Results one of 72 patients was converted into open cholecystectomy due to bleeding, and two of them were converted due to severe adhesion. The others were performed successfully and no serious complications occurred. Conclusions LC is a safe method for high risk patients with gallstone. The key point is to use low pressure pneumoperitoneum during LC.

Laparoscopic cholecystectomy(LC) with three holes and external abdominal traction of the gallbladder by a thread / 中国微创外科杂志

Objective To look for a method of LC with minimal invasion and better exposure. Methods During laparoscopic cholecystectomy with three holes, a needle with a No.7 thread was pierced to the abdominal cavity at the right eighth intercostal space and the fundus of the gallbladder was sutured. The gallbladder traction was performed by the thread to help exposure of the operative filed. LC of 90 cases were operated on by the method. Results All of the 90 cases were cured without any complication. Conclusions External abdominal gallbladder traction is more effective with minimal invision and better exposure as compared with the routine LC.