Contributing factors to postoperative length of stay in laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy for gallbladder disease is a common surgical procedure performed in hospitals throughout the world. This study evaluates the major factors that contribute to postoperative length of stay for patients undergoing laparoscopic cholecystectomy. METHODS: We analyzed data for patients undergoing laparoscopic cholecystectomy in a 5-hospital community health system from December 1, 2008 to January 31, 2009. The natural logarithm of postoperative length of stay was modeled to evaluate significant factors and contributions. RESULTS: Included in the analysis were 232 patients. Three preoperative patient factors were significant contributors: body mass index was associated with decreased postoperative length of stay, while white blood cell count and the presence of biliary pancreatitis were associated with increased postoperative length of stay. The operative factors of fluids administered and ASA class were significant contributors to increased postoperative length of stay, with an increasing contribution with a higher ASA class. The utilization factor of nonelective status was a significant contributor to increased postoperative length of stay. CONCLUSION: Several factors were major contributors to postoperative length of stay, with ASA class and nonelective status having the most significant increased contribution. Efforts to optimize efficient elective care delivery for patients with symptomatic gallbladder disease may demonstrate a benefit of decreased hospital utilization.

The Mirizzi syndrome: multidisciplinary management promotes optimal outcomes.

The Mirizzi syndrome (MS) is a rare cause of obstructive jaundice produced by the impaction of a gallstone either in the cystic duct or in the gallbladder, resulting in stenosis of the extrahepatic bile duct and, in severe cases, direct cholecystocholedochal fistula formation. Sixteen patients were treated for MS in our center over the 12-year period 1993--2005 for a prevalence of 0.35% of all cholecystectomies performed. One patient was diagnosed only at the time of cholecystectomy. The other 15 patients presented with laboratory and imaging findings consistent with choledocholithiasis and underwent preoperative endoscopic retrograde cholangiopancreatography, which established the diagnosis in all but one patient. All patients underwent cholecystectomy. An initial laparoscopic approach was attempted in 14 patients, of whom 11 were converted to open procedures. MS was recognized operatively in 15 patients with definitive stone extraction and relief of obstruction in 13 patients. T-tubes were placed in 10 patients and 1 patient required a choledochoduodenostomy. Two patients required postoperative laser lithotripsy via a T-tube tract to clear their stones; and in another patient, MS was detected and treated via postoperative endoscopic retrograde cholangiopancreatography (ERCP). MS remains a serious diagnostic and therapeutic challenge for endoscopists and biliary surgeons.

Imaging in bariatric surgery: a guide to postsurgical anatomy and common complications.

OBJECTIVE: This article reviews the various bariatric surgical techniques and the associated imaging findings of normal postoperative anatomy and of common complications. CONCLUSION: Bariatric surgery is increasingly performed to control morbid obesity secondary to failed medical approaches. As a result, imaging plays an important role in postoperative evaluation and management. Practical knowledge of postsurgical anatomy allows accurate interpretation of imaging findings related to normal postsurgical anatomy and common postsurgical complications.

Metabolic aspects of bariatric surgery.

Insulin resistance is a nearly universal finding in morbid obesity. It may be compensated and latent or uncompensated with single or multiple clinical abnormalities. Although lifestyle interventions and medical measures alone may control most metabolic problems in the short term, the ultimate benefits of such an approach are usually limited by the complexity of available therapeutic regimens and the difficulty of maintaining full patient compliance. Many studies now document that bariatric surgery can effectively and safely control these complications in the short term and long term or even prevent their occurrence. Further investigations are needed to understand better the mechanisms involved and to define more clearly the appropriate indications and contraindications of the treatments proposed.

Heterogeneity of proliferative markers in pancreatic ß-cells of patients with severe hypoglycemia following Roux-en-Y gastric bypass.

AIMS: Severe postprandial hypoglycemia with neuroglycopenia is an increasingly recognized, debilitating complication of Roux-en-Y gastric bypass (RYGB) surgery. Increased secretion of insulin and incretin hormones is implicated in its pathogenesis. Histopathologic examination of pancreas has demonstrated increased islet size and/or nuclear diameter in post-RYGB patients who underwent pancreatectomy for severe refractory hypoglycemia with neuroglycopenia (RYGB + NG). We aimed to determine whether ß-cell proliferation or apoptosis is altered in RYGB + NG. METHODS: We performed an observational study to analyze markers of proliferation, apoptosis, cell cycle, and transcription factor expression in pancreatic tissue from affected RYGB + NG patients (n = 12), normoglycemic patients undergoing pancreatic surgery for benign lesions (controls, n = 6), and individuals with hypoglycemia due to insulinoma (n = 52). RESULTS: Proliferative cell nuclear antigen (PCNA) expression was increased in insulin-positive cells in RYGB + NG patients (4.5-fold increase, p < 0.001 vs. controls) and correlated with ß-cell mass. Ki-67 immunoreactivity was low in both RYGB + NG and controls, but did not differ between groups. Phospho-histone H3 levels did not differ between RYGB + NG and controls. PCNA and Ki-67 were both significantly lower in both controls and RYGB + NG than insulinomas. Markers of apoptosis and cell cycle (M30, p27, and p21) did not differ between groups. PDX1 and menin exhibited similar expression patterns, while FOXO1 appeared to be more cytosolic in RYGB + NG. CONCLUSIONS: Markers of proliferation are heterogeneous in patients with severe post-RYGB hypoglycemia. Increased ß-cell proliferation in some individuals may contribute to increased ß-cell mass observed in severely affected patients.

Non-developed external oblique aponeurosis in inguinal hernia repair: a case report and discussion of the literature.

Open inguinal hernia repair is one of the most commonly performed operations in the world. It relies heavily on the presence of an inguinal canal formed by the external oblique aponeurosis and conjoint tendon. Variations of the anatomy of this region are rarely described. We describe a patient with bilateral inguinal hernias and missing external oblique aponeurosis. The patient underwent open repair secondary to previous abdominal surgery and the inability to obtain laparoscopic access. A medline search was performed and we provide a synopsis of the literature. At operation, no clear external oblique aponeurosis could be identified and large defects of the transversalis fascia were corrected. CT images of the anatomic variations are provided. To the best of our knowledge, combined abnormalities of the external oblique aponeurosis and transversalis fascia have not been described before.

Who Will Be Able to Perform Open Biliary Surgery in 2025?

BACKGROUND: Although laparoscopic cholecystectomy (LC) is the gold standard, some patients still require an open cholecystectomy (OC). This study evaluates the mean number of OCs performed by each graduating general surgery resident during each of 3 decades. STUDY DESIGN: Data were obtained from all patients undergoing a cholecystectomy during 3 decades: prelaparoscopic era (1981 to 1990), first decade of LC (1991 to 2001), and recent decade of LC (2004 to 2013). Data were prospectively collected and retrospectively reviewed and analyzed by chi-square or Fisher's exact test. RESULTS: Compared with the prelaparoscopic decade, the number of patients undergoing an OC decreased considerably, by 67%, during the first decade of LC, and by 92% during the most recent decade at the 2 core teaching hospitals. Mean number of OCs performed per graduating chief general surgery resident decreased significantly for both laparoscopic decades compared with the prelaparoscopic decade (70.4, 22.4, and 3.6, respectively). In the last decade at the core institutions, 683 (8.8%) patients also underwent an intraoperative cholangiogram (IOC) and 36 (0.5%) underwent common bile duct exploration (CBDE). When biliary cases done at affiliated institutions during the last decade were included, the mean number of OCs (from 3.6 to 10.2), IOCs (from 683 to 2,098), and CBDEs (from 36 to 116) all increased (p < 0.001) per graduating chief general surgery resident. CONCLUSIONS: There has been a considerable decline in the number of OCs, IOCs, and CBDEs available to our trainees during the past 30 years. New training paradigms should include renewed focus on performing an IOC and/or CBDE as clinically indicated during LC; high-quality simulation programs for OC, IOC, and CBDE; and the availability of an advanced video library depicting complicated open biliary procedures.

Has intraoperative cholangiography during laparoscopic cholecystectomy become obsolete in the era of preoperative endoscopic retrograde and magnetic resonance cholangiopancreatography?

BACKGROUND: Preoperative ERCP, magnetic resonance cholangiopancreatography (MRCP), and intraoperative cholangiography (IOC) are standard procedures in evaluating patients with suspected choledocholithiasis. This study evaluates the changing practice patterns over time of these 3 procedures in a large cohort of patients undergoing laparoscopic cholecystectomy (LC) at a single tertiary care center. STUDY DESIGN: Data from all patients undergoing an LC with or without preoperative ERCP, MRCP, or an IOC from January 1, 2004 to December 31, 2013 were retrospectively reviewed from billing data obtained by CPT code and analyzed by chi-square testing. RESULTS: During 10 years, 7,427 patients underwent successful LC. The number of patients undergoing successful IOC (11.9% to 7.6%) or preoperative ERCP (7.2% to 1.5%) decreased significantly during that time interval (p < 0.01). In the last 6 years, 4,506 patients underwent successful LC. The number of patients from this group undergoing a preoperative MRCP (0.9% to 8.6%) or MRCP and ERCP (0.4% to 3.6%) increased significantly (p < 0.001). CONCLUSIONS: Despite a shift from IOC and preoperative ERCP to preoperative MRCP alone or with ERCP, a significant percentage (7.6%) of patients still underwent IOC in 2013. Use of IOC during LC has decreased but is not considered obsolete, rather, it remains a valuable tool for the evaluation of bile duct anatomy, bile duct injury, or suspected choledocholithiasis. Intraoperative cholangiography during uncomplicated LC should be emphasized in teaching programs to insure general surgery resident competency with the procedure.

Laparoscopic cholecystectomy for elderly patients: gold standard for golden years?

HYPOTHESIS: Laparoscopic cholecystectomy (LC) has known physiological benefits and positive socioeconomic effects over the open procedure. Although recent studies have questioned the technique's efficacy in elderly patients (>65 years), we hypothesize that LC is safe and efficacious in that patient group. METHODS: Five thousand eight hundred eighty-four consecutive patients (mean age, 40 years; 26% male) underwent an attempted LC (conversion rate, 5.2%) from 1991 to 2001 at a teaching institution. Of these, 395 patients (6.7%) were older than 65 years. Analysis included patient age, sex, American Society of Anesthesiologists classification, conversion rate, morbidity, mortality, and assessment of results over time. RESULTS: Elderly patients were predominantly male (64%). Septuagenarians had a 40% incidence of complicated gallstone disease, such as acute cholecystitis, choledocholithiasis, or biliary pancreatitis, and octogenarians had a 55% incidence. Overall mortality was 1.4%. The conversion rate was 17% for the first 5 years of the study period and 7% for the second half. The conversion rate was 22% for patients with complicated disease and 2.5% for patients with chronic cholecystitis. Average hospital stay decreased from 10.2 days to 4.6 days during the first and second half of the study period, respectively. CONCLUSIONS: The results of LC in patients aged 65 to 69 years are comparable with those previously reported in younger patients. Patients older than 70 years had a 2-fold increase in complicated biliary tract disease and conversion rates, but a low mortality rate (2%) compared with results of other authors (12%), despite an increase in American Society of Anesthesiologists classification. Increased technical experience with LC favorably affected outcomes over time. Early diagnosis and treatment prior to onset of complications are necessary for further improvement in the outcomes of elderly patients undergoing LC.

Reasons for conversion from laparoscopic to open cholecystectomy: a 10-year review.

Laparoscopic cholecystectomy is now considered the "gold standard" operation for patients with gallstone disease. A number of patients require conversion to an open cholecystectomy for the safe completion of the procedure. This study investigates how the etiology and incidence of conversion from laparoscopic to open cholecystectomy has changed over time. All 5884 patients undergoing laparoscopic cholecystectomy between March 1991 and June 2001 were prospectively collected in a database. A total of 310 patients (5.2%) had had their cholecystectomies converted to an open procedure. The mortality rate for these patients was 0.7%. Causes for conversion were inability to correctly identify anatomy (50%), "other" indications (16%), bleeding (14%), suspected choledocholithiasis (11%), and suspected bile duct injury (8%). After an initial learning curve in thin patients with symptomatic cholelithiasis, inclusion of patients with acute cholecystitis, morbid obesity, or a prior celiotomy resulted in a peak conversion rate of 11% by 1994. From 1994 to the first half of 2001, the conversion rate has declined significantly for all patients (10% to 1%), as well as for patients with acute cholecystitis (26% to 1%). Although unclear anatomy secondary to inflammation remains the most common reason for conversion, the impact of acute cholecystitis on the operative outcome has decreased with time.

Does the correlation of acute cholecystitis on ultrasound and at surgery reflect a mirror image?

BACKGROUND: It remains unclear if sonography accurately describes the severity of gallstone disease. METHODS: Patients were prospectively enrolled if urgent cholecystectomy was indicated. Two radiologists, blinded to operative findings, evaluated the patients' ultrasound imagings. Laparoscopic cholecystectomy was performed within 48 hours. The operative findings regarding gallbladder wall thickness and inflammation were compared to ultrasound results and histology. RESULTS: Fifty-five patients completed the study. Ultrasound studies exhibited a sensitivity of 60% for the diagnosis of acute cholecystitis compared to the findings at operation and 52% relative to the histologic findings. Specificity for acute cholecystitis diagnosed on ultrasound examination was 77% compared to findings at operation and 71% relative to histologic findings. The correlation coefficient of the wall thickness at ultrasound and surgery was 0.18: 0.24 for ultrasound and histology and 0.5 for surgery and histology. CONCLUSIONS: Ultrasound's ability to predict acute cholecystitis in patients with clinical symptoms appears limited.

Adhesion formation after laparoscopic ventral incisional hernia repair with polypropylene mesh: a study using abdominal ultrasound.

OBJECTIVE: Laparoscopic repair of ventral incisional hernias is feasible and safe. Polypropylene mesh is often preferred because of its ease of handling and lower cost. Complications like adhesion and fistula formation can occur. The goal of this study was to determine whether bowel adhesions and their attendant complications could be prevented by interposition of omentum. METHODS: Thirty patients underwent laparoscopic ventral incisional hernias repair with polypropylene mesh. Omentum was always positioned over the loops of bowel for protection. At a mean follow-up of 14 months, 20 patients underwent ultrasonic examination using the previously described visceral slide technique to detect adhesions. RESULTS: The mean size of the hernias in the study was 50.3 cm2, and the mean size of the mesh applied was 275 cm2. Thirteen patents (65%) had no sonographically detectable adhesions. Five patients demonstrated adhesions between the mesh and omentum, 1 patient developed adhesions between the left lobe of the liver and the mesh, and only 1 case of bowel adhesion to the edge of the mesh was found. CONCLUSION: Laparoscopic ventral incisional hernias repair with polypropylene mesh and omental interposition is not associated with visceral adhesions in the majority of patients. Polypropylene mesh can be used safely when adequate omental coverage is available.