Laparoscopy: the preferred method of cholecystectomy in the morbidly obese.

BACKGROUND: Morbid obesity has been considered a contraindication to laparoscopic cholecystectomy (LC). METHODS: To evaluate this we reviewed our first 201 patients undergoing LC and compared the operative procedure and outcome in morbidly obese (greater than or equal to 100 pounds over ideal body weight [IBW]) and nonobese patients. We also compared a group of morbidly obese patients who underwent standard open cholecystectomy (n = 11) with the obese group undergoing LC (n = 21). All groups were comparable in terms of age, sex, and symptoms (acute vs chronic). The obese groups undergoing LC and open cholecystectomy had similar weights (134.0 +/- 9.4 pounds over IBW [range, 100 to 286 pounds] and 133.8 +/- 6.0 pounds over IBW [range, 108 to 170 pounds], respectively) and were significantly different from the nonobese group undergoing LC (28.3 +/- 2.0 pounds over IBW [range, 23 to 98 pounds]). Parameters evaluated included operative time, resumption of normal diet, length of postoperative hospitalization, complications, conversion to open procedure, and ability to perform cholangiography. RESULTS: There were no statistically significant differences between the obese and nonobese groups undergoing LC in any parameters studied (operative time, 151.7 +/- 4.0 minutes vs 160.7 +/- 9.9 minutes; tolerance of diet, 1.2 +/- 0.1 days vs 1.1 +/- 0.1 days; time to discharge, 2.0 +/- 0.1 days vs 1.8 +/- 0.2 days; complications, 7.0% vs 0.0%). Operative time (117.6 +/- 11.6 minutes) was shorter (p = 0.45) in obese patients undergoing open cholecystectomy. However, time to normal diet and length of postoperative hospitalization were significantly longer (3.1 and 4.6 days, respectively; p less than 0.01), and there were more complications (18.2%). CONCLUSIONS: Rather than being contraindicated in the morbidly obese, LC appears to be the preferred method of cholecystectomy.

The diagnosis of osteomyelitis in patients with pressure sores.

A prospective blind trial was undertaken to assess the usefulness of commonly used tests to diagnose osteomyelitis underlying pressure sores. Sixty-one pressure sores were studied, with a histopathologic diagnosis from the ostectomy specimen being available in 52. White cell count, erythrocyte sedimentation rate, plain pelvic x-ray, technetium-99m bone scan, computerized tomography, and Jamshidi needle bone biopsy were studied. The most useful individual test was a needle bone biopsy, with a sensitivity of 73 percent and a specificity of 96 percent. Technetium-99m bone scans and computerized tomography are not indicated in the diagnosis of osteomyelitis associated with pressure sores. Plain pelvic x-ray, white cell count, and erythrocyte sedimentation rate, with a diagnosis of osteomyelitis if any test is positive, is the most sensitive (89 percent), specific (88 percent), noninvasive workup. Jamshidi needle biopsy may be useful where these tests are negative and a clinical suspicion of osteomyelitis remains. Extent of surgical debridement and antibiotic therapy can then be rationally decided on the basis of this information.