Improved outcome after laparoscopic cholecystectomy with ultrasonic dissection: a randomized multicenter trial.

BACKGROUND: In conventional laparoscopic cholecystectomy, dissection with electrocautery starts at the triangle of Calot. In a randomized single-center trial, the fundus-first method (dome down) using ultrasonic dissection was faster, involved less pain or nausea, and had a shorter postoperative sick leave. This may relate to the fundus-first method or to the ultrasonic dissection. METHODS: In a multicenter trial, 243 elective patients were randomized to conventional laparoscopic cholecystectomy using electrocautery (n = 85) or the fundus-first method using either electrocautery (n = 81) or ultrasonic dissection (n = 77). RESULTS: The fundus-first method had a shorter operating time with ultrasonic dissection (58 min) than with electrocautery (74 min; p = 0.002). The fundus-first method using ultrasonic dissection compared with electrocautery or the conventional method produced less blood loss (12 vs. 53 or 36 ml; p < 0.001) and fewer gallbladder perforations (26% vs. 46% or 49%; p = 0.005). Also, the pain and nausea scores at 4 and 6 h were lower, and the sick leave was shorter (6.1 vs. 9.4 and 9 days, respectively; p < 0.001). CONCLUSION: The fundus-first method using ultrasonic dissection is associated with less blood loss, fewer gallbladder perforations, less pain and nausea, and shorter sick leave than the conventional and fundus-first method using electrocautery. The difference seems related to the use of ultrasonic dissection.

Ten years of Swedish experience with intraductal electrohydraulic lithotripsy and laser lithotripsy for the treatment of difficult bile duct stones: an effective and safe option for octogenarians.

BACKGROUND: Endoscopic procedures using electrohydraulic lithotripsy (EHL) or intraductal laser lithotripsy (ILL) are the methods of choice for managing difficult common bile duct (CBD) stones. This retrospective study examined 10 years of Swedish experience using a mother-baby endoscopic system to assist in the fragmentation of CBD stones by EHL and ILL. METHODS: Between 1995 and 2006, 44 patients with a median age of 80 years underwent EHL or ILL at two Swedish centers after conventional endoscopic fragmentation of CBD stones had failed. Long-term follow-up assessment was conducted for 9 to 126 months (median, 53 months). RESULTS: Final stone clearance after EHL or ILL treatment with or without additional conventional endoscopic retrograde cholangiopancreatography (ERCP) was achieved for 34 (77%) of 44 patients. The results for 10 patients (23%) were defined as failures. Complete or partial stone fragmentation and definitive duct clearance were achieved in one session for 23 patients (52%). A second EHL or ILL attempt made in five cases of primary failure led to definitive stone clearance in three cases. Two patients experienced perioperative complications (stone basket impaction). Mild post-ERCP pancreatitis occurred for one patient and cholangitis for two patients. During long-term follow-up evaluation, recurrent CBD stones were found in one patient. CONCLUSIONS: Peroral endoscopic EHL or ILL, under direct cholangioscopic visualization by a mother-baby endoscopic system, is an effective treatment for difficult CBD stones. The technique can be used safely even in frail and elderly patients. However, several endoscopic attempts may be required before final stone clearance is achieved. The vast majority of patients may be expected to remain symptom free for a prolonged period.

Analysis of patient selection and external validity in the Swedish contribution to the COLOR trial.

OBJECTIVE: The colon cancer laparoscopic or open resection (COLOR) trial is an international, randomised controlled trial comparing outcomes of open and laparoscopic surgery for colon cancer. The main purpose of this study was to determine representability by comparing included and nonincluded patients in the participating Swedish centres. DESIGN: At eight centres, which included 391 of the 422 Swedish patients, a local database search was performed to identify retrospectively all patients (n = 2,384) who underwent surgery for colon cancer during the inclusion period, and data was retrieved from medical records. RESULTS: Four hundred fifty-six patients were randomised, 65 of whom were excluded post randomisation (group 2), leaving 391 patients in the study (group 1). For 1,566 patients, valid exclusion criteria were found (group 3). Thus, 362 patients were eligible but not included (group 4). Relative to group 1, patients in group 4 had a significantly higher American Society of Anaesthesiologists (ASA) score, more advanced tumour stage and difference regarding the resections performed. Results showed that 1470 patients (62%) could be calculated as feasible for laparoscopic colon resection (LCR) in a clinical, nontrial situation. CONCLUSIONS: The study population in the Swedish part of the COLOR trial was representative of the eligible population with the exception of comorbidity, where those actually included had less severe comorbidity than the nonincluded but eligible patients. In Sweden, 50-60% of colon cancer patients can be operated on by laparoscopy.