Intraoperative cholangiogram during laparoscopic cholecystectomy: A clinical trial in rural setting.

OBJECTIVE: The routine use of intraoperative cholangiogram (IOC) in laparoscopic cholecystectomy (LC) remains a contentious issue. IOC helps to delineate biliary tree anatomy, prevent bile duct injury and image stones in the common bile duct (CBD). It may prove to be a valuable alternative to ERCP or MRCP, especially in the rural setting with limited resources. DESIGN/SETTING/PARTICIPANTS/INTERVENTIONS/MAIN OUTCOME MEASURES: All patients undergoing laparoscopic cholecystectomy during a 12-month period were audited. For the first 6 months, patients were recruited for routine IOC and for the second 6 months, routine IOC was not performed. Cases were analysed with regard to patient demographics, operative details and clinical outcomes. RESULTS: A total of 75 patients were analysed within the 12-month period. The majority were women aged 41-50. Ultrasound suggested common bile duct stones in 6.7% of cases. IOC was attempted in 50.7% of cases. Of these, 29 (76.3%) were successful. IOC added an average of 28 min to total theatre time. A total of 75% (n = 22) of IOCs showed normal flow of contrast into the intra- and extra-hepatic biliary systems. In 17% (n = 5) of patients, stones within the CBD were suspected, and these were referred for further management. ERCP/MRCP confirmed CBD stones in 60% (n = 3) of these patients. There was poor correlation between pre-operative suspicion and confirmed CBD stones (two patients only with pre-operative suspected CBD stone confirmed on IOC and ERCP). There were no operative complications related to IOC. There were no post-operative complications in cases where no IOC was done. CONCLUSION: The majority of patients treated in our centre were women, middle-aged patients booked for elective laparoscopic cholecystectomy. Although only 6.7% cases were suspicious for CBD stones pre-operatively, a total of 17% of patients with routine IOC suggested CBD stones. IOC was found to be safe, taking only an additional 28 min of total theatre time. Routine rather than selective use of IOC could be considered to improve patient safety and long-term results.

Outcomes of laparoscopic colorectal cancer surgery in a non-metropolitan Australian hospital: audit of 120 patients with long-term follow-up results.

BACKGROUND: Laparoscopic colorectal cancer surgery has been shown to produce comparable oncological long-term results as well as improved short-term outcomes compared to open surgery in multicentre trials. Limited information is available whether these results are reproduced in non-metropolitan surgery. METHODS: Audit of prospectively collected follow-up data in a rural surgical centre in South Australia. Short- and long-term results of colorectal cancer patients undergoing elective laparoscopic surgery for cure. Outcomes are compared with results of open surgery. RESULTS: Survival and clinical data of 120 patients after laparoscopic resection were analysed and then benchmarked against results of 157 open resections. Conversion rate was 10.8% (N = 13). Mean patient age was 69.9 years. Mean number of lymph nodes analysed was 15.5. Mean follow-up is 53.0 months. Thirty-day mortality was 0.36% (n = 1) and 90-day mortality was 0.72% (n = 2). No differences in complications rates, long term survival or procedures performed were observed. This is a single centre audit of clinical and oncological outcomes and a number of exclusion criteria were applied. Patient gender, cancer stages as well as number of patients undergoing neoadjuvant radio-chemotherapy differ significantly between the study and the benchmarking group. Patients were not randomized and the benchmarking group is in part a historical control. CONCLUSIONS: This audit of clinical outcomes and survival after laparoscopic CRC resection for cure indicates that minimal invasive surgery may be suitable for adequately staffed and equipped rural centres.

Laparoscopic cholecystectomy--comparison of early postoperative results in an Australian rural centre and a German university hospital.

BACKGROUND: Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstone disease. Cultural as well as organisational differences can result in significant variations of postoperative length of stay. AIM OF THE PRESENT STUDY: The aim of this study is to evaluate whether differences in postoperative length of stay and early postoperative outcome can be observed by comparison of an Australian rural centre and a German university hospital. RESULTS: Between February 2006 and August 2007 (18 months), 359 patients (140 Australia, 219 Germany) underwent laparoscopic cholecystectomy. Mean patient age was 50.4 +/- 1.5 and 53.5 +/- 1.0 years, respectively. Seventy-seven percent of the Australian and 62% of the German patients were female. Twenty-one percent and 20% of the procedures were emergencies, respectively. Median American Society of Anaesthesiologists score of all patients was two. The conversion rate was 8% in both centres. A 4% complication rate was observed in Australia (N = 5, 3x bile leak, 1x postoperative bleeding and 1x wound infection) as opposed to 3% in Germany (N = 7, 2x bile leak, 2x postoperative bleeding and 3x wound infection). Postoperative length of stay in Australia was 1.8 +/- 0.1 days (median 1 day) and was significantly longer in patients after emergency surgery (1.6 +/- 0.1 versus 2.6 +/- 0.3 days, p < 0.018). Postoperative length of stay in Germany was 3.7 +/- 0.2 days (median 3 days), and no significant differences were observed when elective and emergency procedures were compared (3.5 +/- 0.2 versus 3.9 +/- 0.5 days, p > 0.05). Comparison of treatment results indicates a significantly shorter postoperative stay in Australia (3 days versus 1 day, p < 0.001). DISCUSSION/CONCLUSION: In rural Australia, a median postoperative stay of 1 day after laparoscopic cholecystectomy can be safely achieved. Postoperative length of stay is significantly longer in the German setting with otherwise comparable patients and surgical techniques. Simple changes of pre- and postoperative management of elective as well as emergency laparoscopic cholecystectomy will allow, for substantial cost savings, for the German health system.

Five-year results of surgical colorectal cancer treatment in rural Australia.

BACKGROUND: The incidence of colorectal cancer in Australia is among the highest worldwide. We investigate whether similar treatment results for colorectal cancer can be achieved in rural surgery as reported from metropolitan centres. METHODS: Retrospective analysis of prospectively collected follow-up data in a rural surgical centre in South Australia has been carried out. Results of all patients undergoing surgical treatment for colorectal cancer are analysed, and all cancer stages and interventions over a 5-year period are included. RESULTS: Five-year survival of all patients (n = 194) treated for colorectal cancer independent of stage and cause of death was 56%, cancer-specific 5-year survival was 64%. Perioperative mortality was 1.7%. Overall survival was 96% in stage 1, 92% in stage 2, 58% in stage 3 and 0% for patients with metastatic disease at the time of diagnosis. Cancer-specific survival ranged from 100% in stage 1 to 0% for patients with metastatic disease. CONCLUSIONS: Assessment of overall and cancer-specific survival of all patients undergoing surgery for colorectal cancer over a 5-year time period in a rural South Australian centre shows that good long-term results can be achieved with low perioperative mortality. These findings compare well with the results of other groups.