Etiology and mortality in severe acute pancreatitis: A multicenter study in Japan.

BACKGROUND/OBJECTIVES: Severe acute pancreatitis (SAP) has a high mortality rate despite ongoing attempts to improve prognosis through a various therapeutic modalities. This study aimed to delineate etiology-based routes that may guide clinical decisions for the treatment of SAP. METHODS: Using data from a recent retrospective multicenter study in Japan, we analyzed the association between clinical outcomes, mainly in-hospital mortality and pancreatic infection, and various etiologies while considering confounding factors. We performed additional multivariate analyses and built decision tree models. RESULTS: The 1097 participating patients were classified into the following groups by etiology: alcohol (n = 436, 39.7%); cholelithiasis (n = 230, 21.0%); idiopathic (n = 227, 20.7%); and others (n = 204, 18.6%). Mortality at hospital discharge was 8.4%, 12.2%, 16.7%, and 16.2% in the alcohol, cholelithiasis, idiopathic, and others groups, respectively. According to multivariable analysis, early enteral nutrition (EN) was significantly associated with reduced in-hospital mortality only in the cholelithiasis group. However, there was a consistent association between age and the need for mechanical ventilation and increased mortality, regardless of etiology. Our decision tree models presented different contributing factors depending on the etiology and patient background. Interaction analysis showed that EN and the use of prophylactic antibiotics may influence these results differently according to etiology. CONCLUSIONS: No study has yet used comprehensive models to investigate etiology-related prognostic factors for SAP; our results can, therefore, be used as a reference for improving clinical decisions.

Pyogenic Liver Abscess of Biliary Origin: The Existing Problems and Their Strategies.

Pyogenic liver abscess (PLA) of biliary origin in Southeast Asia mainly occurs in patients with intrahepatic bile duct stone (IBDS) and extrahepatic bile duct stone (EBDS), bilioenteric anastomosis, or biliary stent. IBDS, as an endemic to Southeast Asia, remains a frequent etiology of acute cholangitis and PLA. PLA related to IBDS is characterized by high incidences of PLA recurrence and death related to infection, and difficulties in diagnosis of concomitant cholangicarcinoma. PLA of biliary origin is more likely caused by Escherichia coli, more often presented as polymicrobial infections, and more associated with extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae isolates. In this review, the authors summarize the differences on the presumed causes, pathogens, multidrug resistance, treatment, and prognosis of PLA between biliary origin and cryptogenic origin, the latter serving as a first and foremost presumed etiology of PLA. The authors also discuss the existing problems on early diagnosis of concomitant cholangicarcinoma related to IBDS.

How Safe is Performing Cholecystectomy in the Oldest Old? A 15-year Retrospective Study from a Single Institution.

BACKGROUND: Globally, the number of people aged 80 years or over, the "oldest old," is the fastest growing population group. Because of the strong association between age and gallstone disease, both prevalence and incidence of this disease are increasing. The feasibility of the cholecystectomy in octogenarians has been evaluated in several studies that confirmed the safety of the operation. However, the safety of this procedure in nonagenarians is still controversial. The aim of this study was to evaluate the safety of cholecystectomies in nonagenarians and identify related predictors for postoperative hospital length of stay (LOS) and in-hospital mortality up to 30 days postoperatively. METHODS: More than 500 cholecystectomies, both open and laparoscopic, were performed between January 2000 and September 2015 at our institution in patients 80 years and older. These statistics include both elective and emergent admissions. A retrospective review of charts over the last 15 years was conducted to compare mortality and length of postoperative stay among two patient groups: 319 octogenarians and 36 nonagenarians. Parameters evaluated include demographics, surgical presentation, American Society of Anesthesiologists (ASA) score, main diagnosis, comorbidities, type of surgery performed, LOS and in-hospital mortality. All data were analyzed with STATA (v.13) software, using a multivariate logistic regression after determining the statistically significant variables through a stepwise regression. CONCLUSIONS: We found out that being nonagenarian, compared to octogenarian, is not a significant risk factor in terms of LOS and in-hospital mortality within 30 days postoperatively. Despite that, the mortality rate among nonagenarians is still remarkably high as almost every patient was admitted in an emergent setting. The most remarkable predictor for mortality among the two groups was an "afternoon/night emergency" surgical presentation (OR 25.5, CI 1.53-42.35, p = 0.02). Thus, the surgical emergency management for gallbladder disease at our institution should be critically reevaluated. Performing the procedure in laparoscopy predicted a significant reduction (-5 days, CI -8.5 to -1.4, p = 0.006) of LOS, while presenting with "gallbladder and bile duct stones" (+6.3 days, CI 1.5-11.1, p = 0.01) or "acalculous cholecystitis" (+4.7 days, CI 0.4-9.2, p = 0.03) had the opposite effect. Despite the remarkable mortality rate of our series, being nonagenarian should not be considered as a reason to avoid gallbladder surgery in case of need. Our study suggests that nonagenarians are more suitable surgical candidates than may have previously expected.

Admission after the gold interval in acute calculous cholecystitis: Should we really cool it off?

PURPOSE: The aim of this study was to compare early and delayed cholecystectomy for the treatment of acute calculous cholecystitis (ACC). MATERIALS AND METHODS: The medical records of patients who were diagnosed to have ACC by combined clinical and radiological examination were evaluated retrospectively. The patients were divided into two non-randomized groups according to the duration between the onset of symptoms and cholecystectomy. Group 1 included the patients who underwent cholecystectomy within the first 72 h after the onset of symptoms and Group 2 those who underwent beyond the 72nd hour after the onset of symptoms. RESULTS: We reviewed records for 203 patients. There were 109 patients in Group 1 and 74 patients in Group 2. Access-related complications occurred in four patients. One patient in Group 1 and two patients in Group 2 had trocar site bleeding. In one patient in Group 1, liver trauma occurred. Two patients had bile duct injury in Group 1 as Type D injury according to the Strasberg classification in one patient and E2 injury in other. CONCLUSION: Early cholecystectomy in acute cholecystitis with biliary stones could be performed regardless of time with similar complication, mortality and conversion rates.

[The role of laparoscopy in cholecystectomy in patients 80 years old and older]. / A laparoszkópia szerepe a 80 évesnél idosebb betegek epekövességének megoldásában.

INTRODUCTION: The incidence of cholelithiasis increases with age, however, there is still little data about the outcomes of cholecystectomy in patients with age of 80 and above. Population ageing presents tremendous challenges for surgeons. AIM: The aim of the authors was to compare emergency and elective cholecystectomies performed in these elderly patients. METHOD: This retrospective study was based on the analysis of operation type, conversion rate, complications, mortality, length of hospital stay of all patients over 80 who underwent cholecystectomy in the last 6 years at the 1st Department of Surgery, Semmelweis University. RESULTS: 69 elective and 51 emergency operations were performed. In the emergency group pancreatitis was found in 9.8%, liver abscess in 14%, and common bile duct stones in 27% of the patients on admission. Laparoscopic cholecystectomy could be performed in 84% of patients in the elective group, while in 17.7% of patients in the emergency group. The length of stay at the intensive care unit was 9.1 and 1 days, while the total length of hospital stay was 12 and 3.6 days for the elective and emergency groups, respectively. In the emergency group mortality was 20% and reoperation was performed in 16% of patients, while at the elective group none of these occurred. CONCLUSION: Laparoscopic cholecystectomy is safe as elective surgery for patients with age of 80 and above. For this reason the authors recommend elective cholecystectomy in this age group.

Muerte de un pasajero en un vuelo comercial. Muerte inesperada por colangitis supurada / Death of a passenger on a commercial flight. Unexpected death from pyogenic cholangitis

Un pasajero de un vuelo comercial desde un país del Magreb a otro del norte de Europa fallece durante el vuelo. El avión aterriza en el aeropuerto más próximo en ese momento, que es el de nuestra ciudad. Comunicado el hecho a la autoridad judicial local, esta ordena la práctica de la autopsia médico-legal. En el presente caso no se pudo conseguir ninguna información de los antecedentes patológicos del fallecido antes de la autopsia. Esta reveló la existencia de una colangitis supurada, debida a litiasis residual del colédoco, como causa de la muerte (AU)

A passenger on a commercial flight from a country in Maghreb to another one in Northern Europe dies during the flight. The plane landed at Malaga Airport (that was the nearest airport at that moment). Statements made to the local judicial authorities ordered the practice of a forensic autopsy. In this case no medical history information from the deceased before the autopsy could be gathered. This revealed the existence of a pyogenic cholangitis due to residual bile duct stones, as the cause of death (AU)

Deaths Following Cholecystectomy and Herniotomy: An Analysis of Nationwide German Hospital Discharge Data From 2009 to 2013.

BACKGROUND: In 2010, 158 000 cholecystectomies and 207 000 herniotomies (without bowel surgery) were performed in Germany as inpatient procedures, generally on a routine, elective basis. Deaths following such operations are rare events. We studied the potential association of death after cholecystectomy or herniotomy with risk factors that could have been detected beforehand, and we examined the types of complications that were documented in these cases. METHODS: Using nationwide hospital discharge data (DRG statistics) for the years 2009-2013, we analyzed the characteristics of patients who died in the hospital after undergoing a cholecystectomy for cholelithiasis or the repair of an inguinal, femoral, umbilical, or abdominal wall hernia. We compared these data with those of patients who survived and studied the impact of the coded comorbidities on the risk of death. RESULTS: In Germany, in the years 2009-2013, there were 2957 deaths after a total of 731 000 cholecystectomies (in-hospital mortality, 0.4%) and 1316 deaths after a total of 1 023 000 herniotomies without bowel surgery (0.13%). The patients who died were markedly older than those who did not, and they more commonly had comorbidities. Factors associated with a higher risk of death were age over 65 years, and comorbidities such as congestive heart failure, chronic pulmonary or hepatic disease, or poor nutritional status. Complications were coded much more often for the patients who died than for those who did not. CONCLUSION: These findings suggest that there is potential for improvement in preoperative risk identification, complication avoidance, and the early recognition and treatment of complications, as well as in safe surgical technique. Measures to lower the mortality associated with herniotomy and cholecystectomy would lessen patients' individual risk and thereby improve patient safety.

Mortality after a cholecystectomy: a population-based study.

BACKGROUND: The trade-off between the benefits of surgery for gallstone disease for a large population and the risk of lethal outcome in a small minority requires knowledge of the overall mortality. METHODS: Between 2007 and 2010, 47 912 cholecystectomies for gallstone disease were registered in the Swedish Register for Cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) (GallRiks). By linkage to the Swedish Death Register, the 30-day mortality after surgery was determined. The age- and sex-standardized mortality ratio (SMR) was estimated by dividing the observed mortality with the expected mortality rate in the Swedish general population 2007. The Charlson Comorbidity Index (CCI) was estimated by International Classification of Diseases (ICD) codes retrieved from the National Patient Register. RESULTS: Within 30 days after surgery, 72 (0.15%) patients died. The 30-day mortality was close [SMR = 2.58; 95% confidence interval (CI): 2.02-3.25] to that of the Swedish general population. In multivariable logistic regression analysis, predictors of 30-day mortality were age >70 years [odds ratio (OR) 7.04, CI: 2.23-22.26], CCI > 2 (OR 1.93, CI: 1.06-3.51), American Society of Anesthesiologists (ASA) > 2 (OR 13.28, CI: 4.64-38.02), acute surgery (OR 10.05, CI:2.41-41.95), open surgical approach (OR 2.20, CI: 1.55-4.69) and peri-operative complications (OR 3.27, CI: 1.74-6.15). DISCUSSION: Mortality after cholecystectomy is low. Co-morbidity and peri-operative complications may, however, increase mortality substantially. The increased mortality risk associated with open cholecystectomy could be explained by confounding factors influencing the decision to perform open surgery.

Percutaneous cholecystostomy is an effective treatment option for acute calculous cholecystitis: a 10-year experience.

BACKGROUND: Percutaneous cholecystostomy (PC) can be used to treat patients with acute calculous cholecystitis (ACC) who are considered to be unfit for surgery. However, this procedure has been insufficiently investigated. This paper presents the results of a 10-year experience with this treatment modality. METHODS: A retrospective observational study of all consecutive patients treated with PC for ACC in the period from 1 May 2002 to 30 April 2012 was conducted. All data were collected from patients' medical records. RESULTS: A total of 278 patients were treated with PC for ACC. Of these, 13 (4.7%) died within 30 days, 28 (10.1%) underwent early laparoscopic cholecystectomy and three (1.1%) patients were lost from follow-up. Of the remaining 234 patients, 55 (23.5%) were readmitted for the recurrence of cholecystitis. In 128 (54.7%) patients, PC was the definitive treatment (median follow-up time: 5 years), whereas 51 (21.8%) patients were treated with elective laparoscopic cholecystectomy. The frequency of recurrence of cholecystitis in patients with contrast passage to the duodenum on cholangiography was lower than that in patients without contrast passage (21.1% versus 36.7%; P = 0.037). CONCLUSIONS: The present study, which is the largest ever conducted in this treatment area, supports the hypothesis that PC is an effective treatment modality for critically ill patients with ACC unfit for surgery and results in a low rate of 30-day mortality.

[Hepatolithiasis].

The authors present an analysis of treatment results in 14 patients with hepatolithiasis. An influence of chronic opisthorchosis invasion on the frequency was determined. Hepatolithiasis was detected in 8 (0.14%) out of 5757 patients, who underwent the operation for cholelithiasis and its complications. The disease was found out in 6 (0.31%) patients out of 1965, who had cholelithiasis and accompanying chronic opisthorchosis. It was 2,2 times more frequent due to proliferative sclerotic changes of biliary system. The trasdermal teanshepatic cholangiography was contraindicated for opisthorchiasis injuries, because of the danger of subcapsular cholangioectates damage. The endoscopic retrograde cholangiopancreatography and the endopapillosphincterotomy were complicated due to extensive structures of the large duodenal papilla and distal section of the general bile duct. The patients were treated by using the cholecystectomy, extraction of stones from ducts, reconstruction of liver passage. Choledochoduodenostomy was performed with compulsory external drainage for ducts sanation from infections and helminthes in the case of the opisthorchiasis. Interportal infusions were carried out. The surgical, conservative and endoscopic treatment was required for multiple colangiolithiasis. The lethality consisted of 7.1%.

[Choice of surgical method of treatment of cholelithiasis].

This article presents results of surgical treatment of 2963 patients with cholelithiasis. The majority of them (71.8%) had an elective surgery, though 28.2% of patients underwent an emergency operation. A comparative assessment of obligate treatment criteria was made in 2 groups. A first group consisted of 803 patients and it was before introduction of Roman selection criteria used for surgical treatment of patients. A second group included 2963 patients in the period after introduction of selection criteria. Preoperative planning of surgery with evaluation of technical complexity of all stages of intervention with prognosis for possible complications should be the base of reasonable choice of surgical method of treatment of cholelithiasis and safety protection of surgery. The study completed and results obtained allowed decrease of the rate of postoperative complications to 1.4% and lethality--to 0.3%, respectively.

Surgical management of recurrent pyogenic cholangitis: 10 years of experience in a tertiary referral centre in Hong Kong.

BACKGROUND: Recurrent pyogenic cholangitis (RPC) is common in Asia. Its management differs from centre to centre. METHODS: A retrospective review of 80 patients undergoing surgery for RPC was performed. Immediate and longterm outcomes were analysed. RESULTS: All patients underwent hepaticocutaneousjejunostomy (HCJ) for biliary drainage and stone removal. Additional hepatectomy was performed in 38 patients with intrahepatic ductal stricture or liver segmental atrophy. Twenty-three patients had residual stones and 25 had recurrent stones. All patients with residual stones underwent repeated choledochoscopy (median: four sessions) for stone removal and obtained confirmation of ductal clearance. Four patients developed cholangiocarcinoma, of which two died. The complication rate was 17.5%. Most of the complications were wound infections. No mortality related to surgery occurred. Multivariate analysis found that gender, disease extent (unilobar versus bilobar) and surgery type (HCJ alone versus HCJ with hepatectomy) were not associated with increased risk for residual or recurrent stones. A raised preoperative bilirubin level was the only risk factor identified as associated with an increased risk for recurrent stones (P < 0.001); it was not associated with an increased risk for residual stones. CONCLUSIONS: Recurrent pyogenic cholangitis is a distinct disease, the management of which requires a high level of surgical expertise. Hepaticojejunostomy is recommended as the primary drainage procedure, but hepatectomy should be reserved for complicated RPC.

Intervenciones de enfermería en la atención del adulto con colelitiasis y colecistitis crónica agudizada / Interventions Nursing Care Adult Chronic cholecystitis with cholelithiasis erxacerbated

Introducción. Los trastornos de la vía biliar afectan una proporción importante de la población mundial; más del 95% son atribuibles a la colecistitis aguda. La principal manifestación es el dolor agudo abdominal por lo que el 50% de los pacientes han tenido este síntoma al menos 48 horas antes de su ingreso.Método. Se realizaron cuatro búsquedas sistematizadas de información donde arrojo meta análisis, ensayos clínicos aleatorizados y/o estudios de cohorte publicados que dieron respuesta a las preguntas planteadas, de los cuales se seleccionaran las fuentes con mayor puntaje obtenido, en la evaluación de su metodología, las de mayor nivel en cuanto a gradación de evidencias y recomendaciones.Resultado. El signo de Murphy positivo en la colecistitis presenta una sensibilidad del 97%; el 95% de la colecistitis se asocia con la colelitiasis y aumenta riesgo de complicaciones, la Escala Visual Análoga (EVA) permite establecer una base de control y alivio del dolor y del 1 al 3% de las mujeres embarazadas presentan litios vesiculares.Conclusión. La colecistitis aguda ocurre entre los 30 y 80 años, siendo más frecuente en mujeres, es de importancia la valoración de los signos y síntomas, además de identificar complicaciones secundarias con la finalidad que el personal de enfermería elabore un plan de cuidados especifico ante los problemas reales del paciente, contemplando intervenciones en la ministración de medicamentos, preparación quirúrgica garantizando la seguridad del paciente y cuidados postquirúrgicos para minimizar factores de riesgo de infección y las recomendaciones del autocuidado para su egreso.

Introduction. The biliary disorders affect a significant proportion of the world population; more than 95% are attributable to acute cholecystitis. The main manifestation is abdominal pain so sharp 50% of patients have this symptom at least 48 hours before admission.Method. Four systematized information searches were performed which threw meta-analysis, randomized clinical trials and / or studies published cohort that provided answers to the questions, of which the sources were selected with the highest score obtained in the evaluation methodology ,the highest level as to grading evidence and recommendations.Result. The positive sign of cholecystitis Murphy has a sensitivity of 97%; 95% of cholecystitis and cholelithiasis associated with increased risk of complications, the Visual Analogue Scale (VAS) allows us to set a base control and pain relief and 1 to 3% of pregnant women have vesicular lithiums.Conclusion. Acute cholecystitis occurs between 30 and 80 years, being more common in women, it is important the assessment of signs and symptoms, and identify secondary complications in order that nurses develop a specific plan of care to actual problems of the patient, contemplating interventions in the ministration of medicines, surgical preparation ensuring patient safety and postoperative care to minimize infection risk factors and recommendations for self discharge.

Introdução. Os distúrbios biliares afetar uma proporção significativa da população mundial; mais de 95% são atribuíveis a colecistite aguda. A principal manifestação é a dor abdominal tão acentuada de 50% dos pacientes apresentam este síntoma pelo menos 48 horas antes da admissão.Método. quatro informações sistematizadas pesquisas onde eu jogo meta-análise, ensaios clínicos randomizados e / ou estudos publicados coorte que forneceram respostas para as perguntas, das quais as fontes foram selecionados com a maior pontuação obtida na metodologia de avaliação foram feitas, maior nível de evidências e recomendações de classificação.Resultado. O sinal positivo de colecistite Murphy tem uma sensibilidade de 97%; 95% de colecistite e colelitíase associada ao aumento do risco de complicações, a Escala Analógica Visual (VAS) permite que você defina um controle base e alívio da dor e 1 a 3% das mulheres grávidas têm lithiums vesiculares.Conclusão. colecistite aguda ocorre entre 30 e 80 anos, sendo mais comum em mulheres, é importante a avaliação de sinais e sintomas, e identificar complicações secundárias com as enfermeiras objectivo q desenvolver um plano específico de atendimento a problemas paciente real, contemplando intervenções no ministério de medicamentos, preparo cirúrgico, garantindo a segurança do paciente e cuidados pós-operatórios para minimizar os fatores de risco de infecção e recomendações para a auto descarga.

Causas de mortalidad por colecistectomía tradicional y laparoscópica 1991-2010 / Mortality associated with open and laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy is nowadays the standard surgical treatment for cholelithiasis. Aim: To determine surgical mortality of laparoscopic cholecystectomy as compared with the open procedure. Material and Methods: Review of medical records of all patients subjected to open or laparosco-pic surgery in a surgical service of a clinical hospital, in a period of 20 years. Results: The records of 26.441 patients were reviewed. The figures for overall, open and laparoscopic surgery mortality were 0.16, 0.39 and 0.07 percent respectively. Only two of the 43 deceased patients, died as a direct complication of the surgical procedure. In the rest, the causes of mortality were underlying severe medical conditions. Conclusions: La-paroscopic cholecystectomy has a very low mortality that depends mostly on underlying medical conditions and advanced age.

Introducción: La colecistectomía laparoscópica se ha convertido en el gold standard de la cirugía biliar y se emplea masivamente en todo Chile. Objetivos: Determinar la mortalidad operatoria en 4 períodos de 5 años de la colecistectomía laparoscópica comparada con la colecistectomía tradicional. Material y Método: Se incluyó a todos los pacientes sometidos a colecistectomía, ya sea laparotómica o laparoscópica, entre enero de 1991 y diciembre de 2010 (20 años). Se analizó las causas de mortalidad, el grupo etario en que ocurrió y el tipo de abordaje quirúrgico. Resultados: Se operaron un total de 26.441 pacientes, con un promedio de 1.322 operados por año. La mortalidad global de la colecistectomía laparotómica fue de 0,39 por ciento y de la laparoscópica de 0,07 por ciento, con un promedio general de 0,16 por ciento. Las principales causas de mortalidad fueron patologías médica severas. Sólo 2 pacientes de los 43 fallecidos (5 por ciento) tuvieron una complicación directamente derivada de la cirugía como causa de la mortalidad. Conclusiones: La colecistectomía laparoscópica es una operación de muy baja mortalidad (7 de 10.000 operados). Esta complicación se presenta principalmente en pacientes con grave patología biliar, de edad avanzada y con múltiples complicaciones médicas.

Anatomic hepatectomy as a definitive treatment for hepatolithiasis: a cohort study.

BACKGROUND: Treatment requirements in hepatolithiasis may vary and may involve a multidisciplinary approach. Surgical resection has been proposed as a definitive treatment. OBJECTIVES: This study aimed to evaluate the clinical results of anatomic liver resection among Chilean patients with hepatolithiasis. METHODS: An historical cohort study was conducted. Patients who underwent hepatectomy as a definitive treatment for hepatolithiasis from January 1990 to December 2010 were included. Patients with a preoperative diagnosis of cholangiocarcinoma were excluded. Preoperative, operative and postoperative variables were evaluated. RESULTS: A total of 52 patients underwent hepatectomy for hepatolithiasis. The mean ± standard deviation patient age was 49.8 ± 11.8 years (range: 24-78 years); 65.4% of study subjects were female. A total of 75.0% of subjects had a history of previous cholecystectomy. The main presenting symptom was abdominal pain (82.7%). Hepatic involvement was noted in the left lobe in 57.7%, the right lobe in 34.6% and bilaterally in 7.7% of subjects. The rate of postoperative clearance of the biliary tree was 90.4%. Postoperative morbidity was 30.8% and there were no postoperative deaths. Three patients had recurrence of hepatolithiasis, which was associated with Caroli's disease in two of them. Overall 5-year survival was 94.5%. CONCLUSIONS: Anatomic liver resection is an effective treatment in selected patients with hepatolithiasis and is associated with low morbidity and no mortality. At longterm follow-up, anatomic hepatectomy in these patients was associated with a lower rate of recurrence.

Hepatic resection for primary hepatolithiasis: a single-center Western experience.

BACKGROUND: The incidence (0.6% to 1.3%) of primary hepatolithiasis (PHL), also known as Oriental cholangiohepatitis, is increasing in Western countries and the treatment remains challenging. We analyzed the outcomes of patients undergoing hepatic resection (HR) for PHL at a single Western center. STUDY DESIGN: The records of all patients undergoing HR for PHL between August 1998 and January 2012 were reviewed. Patients were required to have preserved liver function (Child-Pugh class A) with no evidence of portal hypertension. Diagnosis of disease recurrence was based on radiographic and clinical findings. RESULTS: Of the 30 patients who underwent HR, 63.3% presented with earlier failed therapeutic strategies. The majority of the patients were female (63.3%), presented with cholangitis (66.6%), left-sided (66.6%), and unilateral (90.0%) disease, and underwent left-sided hepatic resection (76.6%). Previously created choledochoduodenostomies (13.3%) were all revised into Roux-en-Y hepaticojejunostomy anastomoses in conjunction with the HR. The incidence of concomitant cholangiocarcinoma was 23.3%, with a mean tumor size of 4.2 cm. Perioperative morbidity and mortality rates were 6.6% and 0%, respectively. At a median follow-up of 35 months, all patients had complete intrahepatic stone clearance. One patient required postoperative ERCP. Of the 7 patients with cholangiocarcinoma, 2 had cancer recurrence within the first year of the HR. The remaining patients are disease-free at a median follow-up of 21 months. CONCLUSIONS: Hepatic resection is a safe and definitive treatment option in the management of PHL. It achieves excellent short- and long-term results. The high incidence of concomitant cholangiocarcinoma makes a compelling argument for resection of all involved hepatic segments, when possible.

Laparoscopic cholecystectomy in a single, non-teaching hospital: an analysis of 1557 patients.

BACKGROUND: Laparoscopic cholecystectomy may lead to serious complications, although it is the gold standard treatment for gallstones. In this article, the aim was to review our experience with laparoscopic cholecystectomies. SUBJECTS AND METHODS: All laparoscopic cholecystectomies were performed in a single, non-teaching hospital between January 2000 and October 2010 and were reviewed retrospectively to analyze the effect of preoperative risk factors on outcome and the associated major complications. RESULTS: This study included 1557 laparoscopic cholecystectomies, and the mean age of the patients was 54.1±12.3 years. The mean duration of the operation and the mean length of stay were 43.4 minutes and 1.2 days, respectively. Conversion to an open cholecystectomy was necessary in 39 patients, and thus the conversion rate was 2.5%. In total, 57 (3.7%) complications occurred in 51 patients. Serious common bile duct injury was seen in 4 (0.27%) cases. The other common complications included bile leakage in 10 (0.64%) and postoperative bleeding in 7 (0.45%) patients. The mortality rate was 0.13%. Risk factors for conversion to open surgery were male gender, age >55 years, emergency admission due to acute cholecystitis, and a history of previous acute cholecystitis attacks. Factors that increased the morbidity rate were male gender, an American Society of Anesthesiologists score of III, emergency admission due to acute cholecystitis, and a history of previous acute cholecystitis attacks. CONCLUSIONS: Our results may serve as a baseline for comparison with future studies done at single, non-teaching hospitals where surgical teams perform laparoscopic cholecystectomies over a long period of time.

Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes and meta-analysis of randomized trials.

BACKGROUND: Cholecystectomy is associated with increased risks in patients with cirrhosis. The well-established advantages of laparoscopic surgery may be offset by the increased risk for complications relating particularly to portal hypertension and coagulopathy. METHODS: A systematic search was undertaken to identify studies comparing open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) in patients with cirrhosis. A meta-analysis was performed of the available randomized controlled trials (RCTs). RESULTS: Forty-four studies were analysed. These included a total of 2005 patients with cirrhosis who underwent laparoscopic (n= 1756) or open (n= 249) cholecystectomy, with mortality rates of 0.74% and 2.00%, respectively. A meta-analysis of three RCTs involving a total of 220 patients was conducted. There was a reduction in the overall incidences of postoperative complications and infectious complications and a shorter length of hospital stay in LC. However, frequencies of postoperative hepatic insufficiency did not differ significantly. CONCLUSIONS: There are few RCTs comparing OC and LC in patients with cirrhosis. These studies are small, heterogeneous in design and include almost exclusively patients with Child-Pugh class A and B disease. However, LC appears to be associated with shorter operative time, reduced complication rates and reduced length of hospital stay.

Laparascopic cholecstectomy at Myungsung Christian Medical Center, Ethiopia: a five-years experience.

BACKGROUND: Laparoscopic cholecystectomy is a recent entry in the treatment of gall bladder disease in Ethiopia mainly in private hospitals of the capital city, Addis Ababa, and is slowly gaining acceptance. Like all new techniques, it has generated considerable controversy and debate on its merits over the traditional open operation. OBJECTIVE: The aim of this study was to review our experience of laparoscopic cholecystectomy at Myungsung Christian Medical in, Ethiopia MATERIAL AND METHODS: A hospital based retrospective cross sectional analysis was conducted in Myungsung Christian Medical Center, Addis Ababa, Ethiopia. Patients' medical records and operation theater registers of 681 patients for whom laparoscopic cholecystectomy were done for symptomatic and complicated cholelithiasis, between January 2005 and December 2009 were analyzed using computer based statistical software SPSS version 11.0. Difference in proportions were examined using Chi-square test with its conventional criterion for statistical significance (p < 0.05). RESULTS: The female to male ratio was 6.6:1 with mean age of 44.4 [Standard Deviation, 0.53] years. Of the six hundred eighty-one patients admitted and planned for laparoscopic cholecystectomy, 661 (97.1%) patients completed the procedure successfully (p < 0.0001) and the procedure was converted to open surgery in 20 (2.9%) for various reasons. Mean duration of operation and hospital stay were 58.9 +/- 18.2 [SD] minutes and 36.9 +/- 10.9 [SD] hours respectively. Postoperative mortality and complication rate were 0.15% and 2.94% respectively. CONCLUSION: LC is safe and effective procedure even in difficult cholelithasis (p < 0.0001), in addition the merit of laparoscopic cholecstectomy include fast recovery, minimal tissue trauma, less postoperative hospital stay (p < 0.0001). Hence, LC could be practiced by general surgeons working in third world countries.