Bile leaks after cholecystectomy: the significance of patient selection.

OBJECTIVE: A retrospective analysis of laparoscopic and open cholecystectomies, with introduction of selection criteria and estimation of postoperative bile leaks. METHOD: All patients who underwent cholecystectomy in a tertiary surgical unit from January 2007 to June 2008 formed 2 categories, laparoscopic and open. The choice of operation was based on patient's present status and past medical history, whereas the decision to convert came from intraoperative findings. All surgeons were experienced in both open and laparoscopic surgeries. RESULTS: Laparoscopic cholecystectomy was initially attempted in 230 patients. In 218 of these patients, cholecystectomy was accomplished laparoscopically (group A), whereas in 12 laparoscopic was converted to open cholecystectomy (group B). In 36 patients open cholecystectomy was the first choice according to predecided criteria (group C). Patients of groups B and C were older (P=0.0001), presented higher incidence of cholecystitis (P=0.0001), and required longer postoperative hospitalization (P=0.0001) compared with patients of group A. Postoperative bile leak was evident in 8 patients; no patient from group A, 2 patients from group B, and 6 patients from group C. Patients with bile leak were older (P=0.0001), they required a longer hospitalization (P=0.0001), and cholecystitis was more frequent (P=0.007). Regarding treatment followed, 4 patients required no intervention, whereas 1 required computed tomography-guided drainage of a biloma. Two patients with persistent bile leak, required stenting of the common bile duct with endoscopic sphincterotomy, whereas one, suffering from common bile duct injury, was cured with hepatojejunostomy. CONCLUSIONS: The study highlights the significance of patient selection based on clinical criteria with respect to the type of operation performed. It seems that when patients are selected for laparoscopy according to carefully chosen criteria, the expected postoperative bile leaks could be minimal.

Acute cholecystitis: when is the best time for laparoscopic cholecystectomy?

Laparoscopic cholecystectomy is no more an elective procedure. The question is when to perform laparoscopic cholecystectomy in the face of acute cholecystitis. The last decade (1995-2004) 297 patients had a laparoscopic cholecystectomy for acute cholecystitis. One hundred forty six of them were operated in the first 24-48h after the onset of symptoms (group I), 68 were operated in less than 4 weeks time after the attack of the acute cholecystitis (group II), while the rest 83 patients had a history of acute cholecystitis at least four weeks before their elective laparoscopic cholecystectomy (group III). Analysis of the operative time, complications and hospital stay showed that laparoscopic cholecystectomy in acute cholecystitis is the recommended surgical procedure. The success of the operation depends on the degree of the inflammatory changes in the gallbladder and the expertise of the operator both in emergency and laparoscopic surgery. Timing of the operation is crucial to executing a successful procedure. The operation is easier, faster and safer when performed in first 4-5 days of the onset of symptoms.

The management of acute gastric volvulus.

Acute gastric volvulus occurs when the stomach or a part of it rotates more than 180 degrees which leads to obstruction (closed loop syndrome), that finally concludes to incarceration and ischemia of the organ. It can be observed as a result of diaphragmatic hernia, a gap of the diaphragm, pancreatic or gastric cancers, traumatic injuries and fixation anomalies. Parï first described acute gastric volvulus in 1579, in a patient with diaphragmatic injury after trauma. The first reports of successful surgical repair and anatomo-pathologic findings were published in 1866 and 1897.