Visceral adiposity but not subcutaneous fat associated with improved outcome of patients with acute cholecystitis.

BACKGROUND: The aim of this study to study the effect of visceral and subcutaneous fat tissue mass on short- and long-term prognosis of patients with acute calculus cholecystitis (ACC). METHODS: Retrospective analysis of medical records. Included were all patients admitted because of ACC. Computed tomography images at the level of L3 were analyzed for body composition using designated software (Slice-O-matic; TomoVision, Montreal, Quebec, Canada). General linear model was used to analyze the effect of body composition on length of hospital stay, and Cox regression analysis was used to ascertain the effect of the different parameters on 1-y survival. RESULTS: Included were 159 patients (mean age: 71.7 ± 15.8 y, 54.7% males). Fat was the most abundant tissue (401 ± 175 cm2 of the computed tomography slices surface area), and visceral fat was 45.8 ± 14.1% of the fat area measured. Using the general linear model, we found that American Society of Anesthesiologists score, disease severity index, and age were positively associated with higher length of stay, whereas high visceral fat was associated with lower length of stay (estimated marginal means at 7.4 ± 1.4 d compared to 12.7 ± 1.4 d among patients with lower visceral fat surface area, P = 0.010). The Cox regression model showed that 1-y survival risk was significantly reduced by age, the Charlson Comorbidity Index and high muscle mass. High visceral adiposity was associated with improved survival (odds ratio: 0.216, 95% confidence interval: 0.064-0.724, P = 0.013). Subcutaneous adiposity did not affect prognosis. CONCLUSIONS: Visceral adiposity is associated with shorter length of stay and improved 1-y survival among patients hospitalized with ACC.

Laparoscopic cholecystectomy is more difficult after a previous endoscopic retrograde cholangiography.

BACKGROUND: Endoscopic retrograde cholangiography (ERCP) with endoscopic sphincterotomy (ES) followed by a laparoscopic cholecystectomy (LC) is generally accepted as the treatment of choice for patients with choledochocystolithiasis who are eligible for surgery. Previous studies have shown that LC after ES is associated with a high conversion rate. The aim of the present study was to assess the complexity of LC after ES compared with standard LC for symptomatic uncomplicated cholecystolithiasis. METHODS: The study population consisted of two patient cohorts: patients who had undergone a previous ERCP with ES for choledocholithiasis (PES) and patients with cholecystolithiasis who had no previous intervention prior to LC (NPES). RESULTS: The PES group consisted of 93 patients and the NPES group consisted of 83 consecutive patients. Patients in the PES group had higher risks for longer [more than 65 min, odds ratio (OR) = 4.21 (95% confidence interval (CI) 1.79-9.91)] and more complex [higher than 6 points, on a 0-10 scale, OR 3.12 (95% CI 1.43-6.81)] surgery. The conversion rate in the PES and NPES group (6.5% versus 2.4%, respectively) and the complication rate (12.9% versus 9.6%, respectively) were not significantly different. DISCUSSION: A laparoscopic cholecystectomy after ES is lengthier and more difficult than in uncomplicated cholelithiasis and should therefore be performed by an experienced surgeon.

Minilaparotomy for treatment of choledocholithiasis.

BACKGROUND: Minilaparotomy has been reported to be an alternative minimally invasive option to laparoscopy. However, the quality of available data on the effectiveness of minilaparotomy to treat choledocholithiasis is poor. MATERIALS AND METHODS: Two hundred and twenty-eight patients with choledocholithiasis underwent surgical exploration of the common bile duct via minilaparotomy from 1995 to 2010. Of these, 193 patients had choledocho/cholecystolithiasis with previous ineffective attempts at endoscopic clearance and 29 patients had choledocho/cholecystolithiasis without previous attempts at endoscopic clearance. Six other patients had recurrent/residual choledocholithiasis despite ineffective attempts at endoscopic clearance. Peri-operative adverse events were analyzed in accordance with the revised Satava classification for intra-operative events while post-operative complications were graded according to the Accordion classification. RESULTS: Conversion was needed in 3.9% of procedures. The mean operative time was 86 min. Post-operative complications occurred in 6.1%, 2.2% of which were major (Accordion grade 4-6). Mortality was 0.9%. CONCLUSION: Minilaparotomy is an effective minimally invasive approach for the surgical treatment of choledocholithiasis. This approach could be considered as an alternative to the laparoscopic approach for surgical exploration of the common bile duct in patients with choledocholithiasis.

[How safe is laparoscopic cholecystectomy?]. / Wie sicher ist die laparoskopische Cholezystektomie?

INTRODUCTION: Laparoscopic cholecystectomy (LCE) is the standard treatment for symptomatic non-complicated cholecystolithiasis. However, there is still an ongoing debate about the appropriate surgical approach in cases with complicated cholecystolithiasis. As a result, an initial decision whether to use the open or laparoscopic approach must be primarily based on patient safety. Additional indications favouring the use of LCE must not lead to an increase in the rate of serious complications. METHODS: All patients who underwent operations for cholecystolithiasis performed in a single surgical centre, from 1 / 1 / 1994 to 12 / 31 / 2007, were considered in this analysis. Parameters for the characterisation of the results were intervention-associated hospital mortality and iatrogenic transsection of the common bile duct. RESULTS: 5 084 cholecystectomies were performed during the study period, 84 % (n = 4 272) intended as laparoscopic and 16 % (n = 812) as open procedures. The LCE operations were done by 36 surgeons. The conversion rate to open surgery was 6.2 % (n = 265), in cases of acute cholecystitis, however, it was 26.3 % (n = 86). One LCE procedure involved an iatrogenic bile duct transsection (0.02 %). The in-hospital mortality rate for LCE was 0.05 % (n = 2). CONCLUSIONS: In the hands of experienced surgeons LCE is a safe procedure for the treatment of symptomatic, non-complicated cholecystolithiasis. Associated with complicated cholecystolithiasis however are an increase in conversion rate and thus the risk of severe complications.