Laparoscopic cholecystectomy is the best treatment choice for acute cholecystitis. However, it still carries high conversion and mortality rates. The purpose of this study was to find out better treatment strategies for high surgical risk patients with acute cholecystitis.
Materials and Methods
Between January 2002 and June 2008, we performed percutaneous cholecystostomy instead of emergency cholecystectomy in 44 patients with acute cholecystitis and American Society of Anesthesiologists (ASA) classification 3 or greater. This was performed in 31 patients as a bridge procedure before elective cholecystectomy (bridge group) and as a palliative procedure in 11 patients (palliation group).
The mean age of patients was 71.6 years (range 52-86 years). The mean ASA classifications before and after percutaneous cholecystostomy were 3.3 ± 0.5 and 2.5 ± 0.6, respectively, in the bridge group, and 3.6 ± 0.7 and 3.1 ± 1.0, in the palliation group, respectively. Percutaneous cholecystostomy was technically successful in all patients. There were two deaths after percutaneous cholecystostomy in the palliation group due to underlying ischemic heart disease and multiple organ failure. Resumption of oral intake was possible 2.9 ± 1.8 days in the bridge group and 3.9 ± 3.5 days in the palliation group after percutaneous cholecystostomy. We attempted 17 laparoscopic cholecystectomies and experienced one failure due to bile duct injury (success rate: 94.1%). The postoperative course of all cholecystectomy patients was uneventful.
Percutaneous cholecystostomy is an effective bridge procedure before cholecystectomy in patients with acute cholecystitis and ASA classification 3 or greater.
Percutaneous cholecystectomy; acute cholecystitis; American Society of Anesthesiologists classification
To evaluate the outcomes of laparoscopic cholecystectomy in elderly patients at a single institution.
A retrospective chart review was conducted of all patients ≥65 years of age who underwent laparoscopic cholecystectomy over a 5-year period (January 1995 to December 1999). Four-trocar site laparoscopic cholecystectomy using the open Hasson technique were performed in all patients. The demographic data (age, sex), associated comorbidities, American Society of Anesthesiologist's (ASA) score, postoperative morbidity, mortality, and length of stay were recorded for each patient. Statistical analysis was done using Fisher's exact test and chi-square analysis. Statistical significance was defined as P≤0.05.
The patient cohort included 46 patients with a median age of 71 years (range, 65 to 87). Seventeen (37%) patients were ≤70 years of age, and twenty-nine (63%) patients were ≥70 years of age. Twenty-two (48%) patients had ASA scores of ≥3. Patients ≥70 had significantly higher ASA scores. Eighteen patients ≥70 years had ASA ≥3 compared with 4 patients ≤70 with ASA≥3 (P<0.05). Twenty-two patients ≥70 and 8 patients ≤70 required urgent surgery P<0.05). Fifteen (33%) patients presented with acute cholecystitis, and 31 (67%) patients presented with a greater number of chronic symptoms. Four (9%) patients had pancreatitis on presentation, and 6 patients underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP). Two of these 6 patients also underwent sphincterotomy. Urgent surgery was performed in 30 (65%) patients. The mean operative time was 103±37(SD) minutes. One (2%) conversion to open cholecystectomy was required. The mean postoperative stay was 7 days (range, 1 to 46). Fourteen (30%) patients had only a 1-night postoperative stay. Patients ≥70 had significantly longer postoperative stays. Nine patients ≥70 and only 1 patient ≤70 stayed in the hospital for more than 7 days. Postoperative complications were noted in 6 (13%) patients, most of which were chest infections. Five patients ≥70 and only 1 patient ≤70 developed postoperative complications. No mortalities occurred.
Laparoscopic cholecystectomy is safe and feasible in elderly patients. Patients ≥70 years seem to have a longer postoperative stay and slightly more postoperative complications. Age alone should not be a contraindication to laparoscopic cholecystectomy in the elderly patient.
Laparoscopic cholecystectomy; Elderly; Outcomes
Gastric decompression by suctioning often shows greenish/greenish-yellow-coloured gastric aspirates following cholecystectomy under general anaesthesia (GA). Possible intraoperative regurgitation of duodenal contents into stomach because of surgical manipulation may be the reason for such alteration in colour of the gastric secretions.
We conducted this study to determine whether there were any pH changes of gastric secretions during laparotomic cholecystectomy operation to confirm our hypothesis of regurgitation of duodenal contents into the stomach.
Settings and Designs:
Prospective observational controlled study in the Department of Anaesthesiology and Critical Care in a tertiary care university teaching hospital.
Fifty adult ASA I and II patients scheduled for open cholecystectomy operation under GA were included in the study group and another 50 non-abdominal surgical patients without any gall bladder disease were taken as controls. Three to five milliliters of gastric secretions were aspirated just after intubation and also before reversal of residual neuromuscular blockade for analysis of pH.
Analysis of variance test and Chi-square test with Fisher's exact correction were used for statistical analysis. Differences were significant when the P value was <0.05.
Post-operative values of pH in the study group were significantly higher than their pre-operative values (2.40±1.10 vs. 4.04±1.6, P≤0.001). Forty-nine patients (98%) in the study group had altered coloured post-operative gastric aspirations, while no patient in the control group had such changes (P<0.001).
A significant change in gastric pH takes place during laparotomic cholecystectomy due to reflux of duodenal content into the stomach.
Anaesthesia; cholecystectomy; gastric pH; post operative nausea and vomiting
The first option for gallbladder surgery is laparoscopic cholecystectomy. The aim of this study is to analyze the outcomes for all patients who underwent laparoscopic cholecystectomy at a secondary level of care.
Patients and Methods:
Between 2005 and 2008, 968 consecutive laparoscopic cholecystectomies were performed at King Fahad Hospital. We collected and analyzed data including age, gender, body mass index (kg/m2), the American Society of Anesthesiologists (ASA) class, mode of admission (elective or emergency), indication for LC (chronic or acute cholecystitis [AC]), co-morbid disease, previous abdominal surgery, conversion to open cholecystectomy, complications, operation time, and length of postoperative hospital stay.
Nine hundred and sixty-eight patients had laparoscopic cholecystectomy at the center. There were 824 females and 144 males; the age range was 15-64 (mean 32.9± 12.7 years). The operating time was 45 to 180 min (median 85 min); the complication rate was 4.03% (39 patients).
Laparoscopic cholecystectomy could be performed safely in the majority of patients with cholelithiasis, by an experienced surgical team at a secondary level of care.
Complications; laparoscopic cholecystectomy; morbidity
Hemodynamic responses of laryngoscopy and laparoscopy should be attenuated by the appropriate premedication, smooth induction, and rapid intubation. The present study evaluated the clinical efficacy of oral premedication with pregabalin or clonidine for hemodynamic stability during laryngoscopy and laparoscopic cholecystectomy.
A total of 180 healthy adult consented patients aged 35 to 52 years with American Society of Anesthesiologist (ASA) physical status I and II of both gender, who met the inclusion criteria for elective laparoscopic cholecystectomy, were randomized to receive placebo Group I, pregabalin (150 mg) Group II, or clonidine (200 μg) Group III, given 75 to 90 minutes before surgery as oral premedication. All groups were compared for preoperative sedation and anxiety level along with changes of heart rate and mean arterial pressure prior to premedication, before induction, after laryngoscopy, pneumoperitoneum, release of carbon dioxide, and extubation. Intraoperative analgesic drug requirement and any postoperative complications were also recorded.
Pregabalin and clonidine proved to have sedative and anxiolytic effects as oral premedicants and decreased the need of intraoperative analgesic drug requirement. Clonidine was superior to pregabalin for attenuation of the hemodynamic responses to laryngoscopy and laparoscopy, but it increased the incidence of intra-and postoperative bradycardia. No significant differences in the parameters of recovery were observed between the groups. None of the premedicated patient has suffered from any postoperative side effects.
Oral premedication with pregabalin 150 mg or clonidine 200 μg causes sedation and anxiolysis with hemodynamic stability during laryngoscopy and laparoscopic cholecystectomy, without prolongation of recovery time and side effects.
Clonidine; hemodynamic response; laparoscopic cholecystectomy; laryngoscopy; pneumoperitoneum; pregabalin
Evaluate changes in perioperative outcomes over an 82-month period in patients undergoing laparoscopic cholecystectomy by a single attending surgeon in an academic hospital.
A retrospective review of 1025 consecutive patients undergoing laparoscopic cholecystectomy from September 1992 to February 1997 was compared to the initial 600 patients from May 1990 to August 1992. Statistical analysis included Chi square with Yates correction and Fischer's exact test.
Over the 82-month period there were no significant differences in the overall conversion rate to open cholecystectomy (p=0.26), intraoperative complications (p = 0.81), postoperative complications (p = 0.054) or mortality rates (p=0.66). There were 3 (0.5%) bile duct injuries in the initial 600 patients and only 1 (0.1%) in the group of 1025 patients (p=0.065). There was an increase (p<0.001) in laparoscopic cholecystectomies performed for acute cholecystitis and biliary dyskinesia and an increase (p<0.001) in the percentage of cases performed overall and for acute cholecystitis by the surgery residents over the last 54 months. Despite this, the conversion rates to open cholecystectomy in patients with acute cholecystitis decreased (p < 0.001) over the last 54 months. Additionally, more patients (p < 0.001) were discharged on the day of surgery in the most recent group.
Laparoscopic cholecystectomy can be performed safely by surgery residents under the direct super-vision of an experienced laparoscopist without significant changes in perioperative outcomes. Despite an increased percentage of cases being performed for acute cholecystitis over the last 54 months, conversion rates to open cholecystectomy and biliary tract injury rates have decreased, and the perioperative morbidity has remained the same.
Laparoscopy; Laparoscopic cholecystectomy; Perioperative outcomes
Background and Objectives:
The incidence of postoperative vomiting in patients undergoing laparoscopic cholecystectomy is compared in females versus males. The report also compares the prophylactic action of ondansetron versus metoclopramide.
A total of 85 American Society of Anesthesiologists (ASA) I and II patients were enrolled in the study. Patients were divided into two groups according to sex: Group I 53 females, and Group II 32 males. After anaesthetic induction, subjects received intravenously either 4 mg ondansetron or 10 mg metoclopramide.
The incidence of vomiting as well as the frequency of emetic episodes over 24 hours were analyzed in each group using X2 analysis. Data analysis revealed a significantly higher incidence (P<0.05) of postoperative emesis in females 10:53 (18.9%) as compared to males 0:32 (0%). In the male group, no patient vomited postoperatively, whether prophylactic ondansetron or metoclopramide was used. While the incidence of emesis in the female group was lower (P<0.05) in the ondansetron group (17.6%) than the metoclopramide group (29.6%).
These results may indicate prophylactic antiemetic therapy in female patients undergoing laparoscopic cholecystectomy; ondansetron appears to be superior to metoclopramide.
Laparoscopic cholecystectomy; Vomiting; Sex; Ondansetron; Metoclopramide
Previous studies regarding the outcome of laparoscopic cholecystectomy (LC) in men have reported inconsistent findings. We conducted this prospective study to test the hypothesis that the outcome of LC is worse in men than women.
Materials and Methods:
Between 1997 and 2002, a total of 391 consecutive LCs were performed by a single surgeon at King Fahd Hospital of the University. We collected and analyzed data including age, gender, body mass index (kg/m2), the American Society of Anesthesiologists (ASA) class, mode of admission (elective or emergency), indication for LC (chronic or acute cholecystitis [AC]), comorbid disease, previous abdominal surgery, conversion to open cholecystectomy, complications, operation time, and length of postoperative hospital stay.
Bivariate analysis showed that both genders were matched for age, ASA class and mode of admission. The incidences of AC (P = 0.003) and comorbid disease (P = 0.031) were significantly higher in men. Women were significantly more obese than men (P < 0.001) and had a higher incidence of previous abdominal surgery (P = 0.017). There were no statistical differences between genders with regard to rates of conversion (P = 0.372) and complications (P = 0.647) and operation time (P = 0.063). The postoperative stay was significantly longer in men than women (P = 0.001). Logistic regression analysis showed that male gender was not an independent predictor of conversion (Odds ratio [OR] = 0.37 and P = 0.43) or complications (OR = 0.42, P = 0.42). Linear regression analysis showed that male gender was not an independent predictor of the operation time, but was associated with a longer postoperative stay (P = 0.02).
Male gender is not an independent risk factor for satisfactory outcome of LC in the experience of a single surgeon.
Acute cholecystitis; complications; conversion; experience; gender; laparoscopic cholecystectomy
Objective: To evaluate the feasibility and safety of the operation of transumbilical single-port laparoscopic cholecystectomy (TSPLC) by traditional laparoscopic instruments and summarize the initial experience. Methods: Sixty subjects with cholelithiasis were divided into two groups. One group (36 cases) underwent TSPLC and the control group (24 cases) underwent traditional three-port laparoscopic cholecystectomy (LC). Postoperative complications were observed and operation time, hospital days, visual analogue scale (VAS) after 6 and 24 h of operation, and subject satisfaction score were measured. Results: TSPLC and traditional LC were performed successfully in the two groups. The operation time in the TSPLC group was significantly longer than that in the control group. There was no statistically significant difference in hospital stay and VAS between the TSPLC and control groups. The subject satisfaction score in the TSPLC group was 91.2, significantly higher than that in the control group (P<0.01). All subjects recovered from the operation and no postoperative complication occurred during the period of two weeks after operation. Conclusions: TSPLC is a feasible and safe method for cholecystectomy, although it may be more time-consuming. However, it is welcomed by patients who are more concerned with cosmetic outcomes. Future studies are needed to confirm its disadvantages and contraindications.
Laparoscopic cholecystectomy; Single-incision laparoscopic cholecystectomy; Minimally invasive surgery; Traditional laparoscopic instruments
Laparoscopic cholecystectomy in octogenarians appears to be safe with acceptable morbidity.
Background and Objectives:
Extremely elderly patients usually present with complicated gallstone disease and are less likely to undergo definitive treatment. The purpose of this study was to evaluate the results of laparoscopic cholecystectomy in octogenarians, with an interest in patients presenting initially with complicated gallstone disease and pancreatitis who underwent laparoscopic cholecystectomy during the same hospitalization.
Data for 42 patients ≥80 years who underwent an elective laparoscopic cholecystectomy between January 2007 and August 2011 were retrospectively reviewed. Indications for the procedure were stratified into 2 groups: Outpatients, who were admitted electively to undergo cholecystectomy, and Inpatients, who came to our Emergency Room due to complicated biliary diseases. Data analysis included age, sex, ASA score, conversion to open surgery, time spent under general anesthesia, and length of hospital stay.
Mean age was 83.9 years; 19 (45.2%) were men. Thirteen patients (30.9%) were in the outpatient group, and 13 (30.9%) had a preoperative ASA of 3. Fourteen patients (33.3%) needed ICU. Two patients (4.8%) had their surgery converted. There were 7 (16.7%) postoperative complications, all of them classified as Dindo-Clavien I or II. No differences were noted between groups regarding conversion rates or complications. We had no mortalities in this series. There was no difference in hospital length of stay between the groups.
Laparoscopic cholecystectomy in the extremely elderly is safe, with acceptable morbidity. Patients with complicated gallstone disease seem not to have worse postoperative outcomes once the initial diagnosis is properly treated and would benefit from definitive therapy during the same hospitalization.
Laparoscopic cholecystectomy; Elderly; Gallstone disease; Octogenarians
This study was performed to evaluate the effectiveness of intravenous low dose ketamine for reducing the incidence and severity of postoperative sore throat (POST).
This was a prospective, randomized, double-blind clinical trial. The study population consisted of 70 patients between 20 and 70 years old who were classified as American Society of Anesthesiologists I-II and were scheduled for elective laparoscopic cholecystectomy. The patients were divided randomly into two groups. Patients in the ketamine group received an intravenous injection of 0.5 mg/kg of ketamine just before induction, followed by 10 µg/kg/min throughout the operation. Patients in the control group received intravenous saline instead of ketamine. The patients were interviewed 1, 6, and 24 h after the operation. The incidence and severity of POST were recorded.
No significant differences in the incidence and severity of POST during the 24 h after the operation were found between the two groups (21/31 in the ketamine group vs. 26/34 in the control group, P = 0.398).
Intravenous injection of low dose ketamine was not effective for reducing POST.
Complications; Intubation; Ketamine
Laparoscopic Cholecystectomy is the gold standard treatment for gallbladder diseases. However, for various reasons there is a finite chance of conversion to open cholecystectomy in some patients. To assess preoperative factors which might predict the chances of conversion and the intraoperative reason which resulted in the conversion. The SAGAR APOLLO HOSPITAL patient database was searched for patients who underwent laparoscopic cholecystectomy between July 2003 and November 2006. Sagar Apollo hospital is an urban tertiary care hospital. The records of 526 patients who underwent laparoscopic cholecystectomy were reviewed retrospectively. 14 (2.6%) of the 526 patients were converted to open cholecystectomy. Preoperative Alkaline phosphatase values were raised in patients who underwent conversion and were found to be statistically significant. The most common intraoperative reason for conversion was difficulty in delineating the anatomy at the Calot’s triangle. It is difficult to preoperatively predict the factors responsible for conversion.
Laparoscopic cholecystectomy; Conversion; Predictive factors
Laparoscopic cholecystectomy remains the standard treatment for cholelithiasis. Ever increasing number of patients with myriad of medical illness is being treated by this technique. However, significant concern prevails among the surgical community regarding its safety in patients with cardiac co-morbidity. Patients with significant cardiac dysfunction and multiple co-morbidities were prospectively evaluated. Patients were assessed by cardiologists and anesthesiologists and laparoscopic cholecystectomy was performed. Patient demographics, details of peri-operative management and post-operative complications were studied. Between March 2005 and January 2009, 28 patients (M:F = 21:7) with mean age of 60 years (range 26–78) and having significant cardiac dysfunction had undergone laparoscopic cholecystectomy. Of these, 24 patients were in NYHA class-II, while 4 belonged to class-III. Left ventricular ejection fraction, as recorded by transthoracic echocardiography, was 20–30% in 13 (46%) patients and 30–40% in the rest 15 (54%). In addition, 13 (46%) patients had regional wall motion abnormalities, 11 (39%) patients had cardiomyopathy, 2 (7%) patients had valvular heart disease while 12 (43%) patients had prior cardiac interventions. Following laparoscopic cholecystectomy, hypertension (3), tachyarrhythmia (4) and bradycardia (1) were the commonest events encountered. One patient required laparotomy to deal with peritonitis in the immediate postoperative period and succumbed to myocardial infarction, but all other patients made an uneventful recovery. With appropriate cardiological support, laparoscopic cholecystectomy may be safely performed in patients with significant cardiac dysfunction.
Laparoscopy; Cholecystectomy; Cardiac dysfunction
Optiscope™ is a newly developed video stylet device. This study evaluated and compared the hemodynamic changes observed after endotracheal intubation with video stylet and after conventional laryngoscopic endotracheal intubation.
Fifty-eight adult patients with American Society of Anesthesiologists (ASA) physical status class 1 or 2, undergoing general anesthesia, were randomized into two groups: one group of patients were intubated using video stylet (n = 29) and the other group were intubated using direct laryngoscope (n = 29). Systolic blood pressure (SBP), mean arterial pressure (MAP), diastolic blood pressure (DBP), heart rate (HR), POGO (percentage of glottic opening) score, time for intubation and degree of sore throat were recorded.
There were no significant differences in the SBP, MAP, DBP, HR, and the sore throat incidence between the two groups. Optiscope™ produced better POGO scores, but time for intubation was longer than with conventional laryngoscope.
Optiscope™, when compared with conventional laryngoscope for intubation, does not modify the hemodynamic response, but it provides a better view of the vocal cords.
Bronchoscopes; Endotracheal intubation; Fiberoptics; Hemodynamics; Laryngoscope; Video recording
AIM: To investigate the safety and efficacy of implanting fibrin sealant with sustained-release ropivacaine in the gallbladder bed for pain after laparoscopic cholecystectomy (LC).
METHODS: Sixty patients (American Society of Anesthesiologists physical status was I or II and underwent LC) were randomly divided into three equal groups: group A (implantation of fibrin sealant in the gallbladder bed), group B (implantation of fibrin sealant carrying ropivacaine in the gallbladder bed), and group C (normal saline in the gallbladder bed). Postoperative pain was evaluated, and pain relief was assessed by visual analog scale (VAS) scoring.
RESULTS: The findings showed that 81.7% of patients had visceral pain, 50% experienced parietal, and 26.7% reported shoulder pain after LC. Visceral pain was significantly less in group B patients than in the other groups (P < 0.05), and only one patient in this group experienced shoulder pain. The mean VAS score in group B patients was lower than that in the other groups.
CONCLUSION: Visceral pain is prominent after LC and can be effectively controlled by implanting fibrin sealant combined with ropivacaine in the gallbladder bed.
Analgesia; Fibrin sealant; Laparoscopic cholecystectomy; Pain; Ropivacaine
To evaluate the efficacy and safety of laparoscopic renal cryoablation (LRC) of small endophytic renal cell carcinoma, for which surgical treatment is technically difficult.
Materials and Methods
We enrolled patients with endophytic tumors from a prospectively collected database of 45 renal tumors in 39 patients who had undergone LRC from June 2005 to May 2009. An endophytic tumor was defined as less than 40% of the lesion extending off the surface of the kidney. We evaluated surgical and oncological outcomes.
Among the treated tumors, 17 tumors (37.8%) were defined as endophytic tumors and 15 tumors from 14 patients were confirmed as renal cell carcinoma (RCC) in the pathologic examination of the tissue biopsy that was conducted at the time of LRC. The mean American Society of Anesthesiologists (ASA) score of the whole patient group was 2.9 (range, 1-4), and 85.7% (12/14) of the patients had an ASA physical status score over 3. The mean tumor size was 2.8 cm (range, 1.7-3.7 cm). The layout of the cryoprobe was carefully planned preoperatively on the basis of radiologic evaluation in all tumors. Multiple cryoprobes (mean, 3.2; range, 2-5) were used. No major complications, including open surgical conversion and nephrectomy due to bleeding, occurred. No patient experienced clinical symptoms of collecting system injuries. During the mean follow-up of 32.6 months (range, 12-51 months), radiologic evidence of tumor recurrence was found in one patient (6.7% for RCC). With the exception of this patient, all other patients have remained free of recurrence or metastasis, as determined by periodic radiologic workups.
In this series of patients with intermediate-term follow-up, LRC for endophytic renal cell carcinoma showed acceptable oncological and surgical outcomes without sequelae in the collecting system.
Cryosurgery; Kidney collecting tubules; Renal cell carcinoma; Ultrasonography
Deciding to operate on high risk patients suffering catastrophic surgical emergencies can be problematic. Patients are frequently classed as American Society of Anesthesiologists (ASA) grade 5 and, as a result, aggressive but potentially lifesaving intervention is withheld. The aim of our study was to review the short-term outcomes in patients who were classed as ASA grade 5 but subsequently underwent surgery despite this and to compare the ASA scoring model to other predictors of surgical outcome.
All patients undergoing emergency surgery with an ASA grade of 5 were identified. Patient demographics, indications for surgery, intraoperative findings and outcomes were recorded. In addition to the ASA scores, retrospective Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P POSSUM) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated and compared to the observed outcomes.
Nine patients (39%) survived to discharge. ASA grade was a poor predictor of outcome. P POSSUM and APACHE II scores correlated significantly with each other and with observed outcomes when predicting surgical mortality. The median stay for survivors in the intensive care unit was nine days.
In times of an ageing population, the number of patients suffering catastrophic surgical events will increase. Intervention, with little hope of a cure, a return to independent living or an acceptable quality of life, leads to unnecessary end-of-life suffering for patients and their relatives, and consumes sparse resources. The accuracy and reliability of ASA grade 5 as an outcome predictor has been questioned. P POSSUM and APACHE II scoring systems are significantly better predictors of outcome and should be used more frequently to aid surgical decision-making in high risk patients.
ASA 5; Outcome prediction scores; P POSSUM
Due to the increase of cardiovascular diseases acetylsalicylic acid (ASA) has become one of the most frequently prescribed drugs these days. Despite the rising number of patients with ASA medication presenting for elective general and abdominal surgery and the potentially increased risk of hemorrhage in these patients, there are no clear, evidence-based guidelines for the perioperative use of antiplatelet agents. The present randomised controlled trial was designed to evaluate the safety and optimize the use of ASA in the perioperative management of patients undergoing general and abdominal surgery.
This is a two-arm, monocenter randomised controlled trial. Patients scheduled for elective surgical treatment (i.e. inguinal hernia repair, cholecystectomy and colorectal resections) with ASA as a permanent medication are randomised equally to perioperative continuation or discontinuation of ASA. Patients who are randomised in the discontinuation group stop the administration of ASA five days prior to surgical treatment and start intake of ASA on postoperative day 5. Fifty-two patients will be enrolled in this trial. The primary outcome is the incidence of postoperative bleeding and cardiovascular events at 30 days after surgery. In addition a set of general as well as surgical variables are analysed.
This is a randomised controlled two-group parallel trial designed to assess the safety and optimize the use of ASA in the perioperative management of patients undergoing general and abdominal surgery. The results of this pilot study build the basis for a confirmative randomised controlled trial that may help to clarify the use and potential risk/benefits of perioperative ASA medication in patients undergoing elective surgery.
The trial is registered with Current Controlled Trials ISRCTN45810007.
In recent years, there has been an increased emphasis on the role of anesthesiologists as perioperative physicians. However, a new group of physicians called hospitalists has emerged and established a role as perioperative physicians. Most hospitalists have specialized in internal medicine and its subspecialties. We reviewed American medical literature over the last 13 years on the roles of anesthesiologists and hospitalists as perioperative physicians. Results showed that the concept of the anesthesiologist as the perioperative physician is strongly supported by the American Board of Anesthesiology and the leaders of the specialty. However, most anesthesiologists limit their practice to intraoperative care and immediate acute postoperative care in the postanesthesia care unit. The hospitalists may fill a different role by caring for patients in the preoperative and sometimes in the postoperative period, allowing the surgeon to focus on surgery. These roles of the anesthesiologists and the hospitalists as perioperative physicians may be complementary. We conclude that if anesthesiologists and hospitalists work together as peri-operative physicians, with each specialty bringing its expertise to the care of the perioperative patient, care is likely to improve. It is necessary to be proactive and identify areas of future cooperation and collaboration.
Background and Objectives:
Laparoscopic cholecystectomy (LC) is increasingly being used as an appropriate early treatment in patients with cholecystitis. This study evaluated the safety, effectiveness, and complications of LC in all cases of acute cholecystitis.
A retrospective study involved the patients who underwent LC for acute cholecystitis within 72 hours of admission. The preoperative diagnosis was based on clinical, laboratory, and echographic examinations, while the final diagnosis was confirmed by histopathological examination of the excised gallbladder.
We identified 184 patients with acute cholecystitis. Intraoperative cholangiography (IOC) was not performed. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 62 patients (33.7%), and postoperative ERCP in 13 patients (7.1%). Conversion to open cholecystectomy was necessary in 19 patients (10.3%); 16 patients for severe inflammation and adhesions and 3 patients because of uncontrolled bleeding. The mean operative time was 68 minutes. No deaths occurred. The overall complication rate was 6% with 3 postoperative bile leakages and 2 nonbilious subhepatic collections. The mean postoperative hospital stay was 2.8 days.
LC is a safe, effective procedure for the early management of patients with acute cholecystitis. LC can be safely performed without routine IOC when ERCP is performed preoperatively on the basis of specific indications. Meticulous dissection and good exposure of Calot's triangle may prevent bile duct injuries.
Laparoscopic cholecystectomy; Acute cholecystitis; Open cholecystectomy; Intraoperative cholangiography
We analyzed circulating TNF-α and IL-6 to determine systemic inflammatory responses associated with transvaginal cholecystectomy in a porcine model.
Six female pigs were used for a survival study after transvaginal cholecystectomy (NOTES group) using endoscopic submucosal dissection (ESD) instruments and a single-channel endoscope. Blood was drawn preoperatively and 24 hours and 48 hours postoperatively. Four pigs were used as controls. In addition, laparoscopic cholecystectomy was performed in 2 pigs for laparoscopic control.
In all 6 pigs in the NOTES group, no major intraoperative complications occurred. No significant differences were found between control, laparoscopic, and NOTES groups in terms of preoperative IL-6 level (P=0.897) and at 24 hours (P=0.790), and 48 hours postoperatively (P=0.945). Similarly, there was no significant difference in mean preoperative (P=0.349) and mean day 2 postoperative TNF-α levels (P=0.11). But a significant increase in day 1 postoperative TNF-α levels in the laparoscopic group compared with that in the control and NOTES groups was observed (P=0.049). One limitation of our study is that the sample size was relatively small.
NOTES is safe in animal models in terms of anatomical and cellular level changes with minimal systemic inflammatory host responses elicited. Further study needs to be carried out in humans before NOTES can be recommended for routine use.
NOTES; Natural orifice translumenal endoscopic surgery; Transvaginal surgery; Cholecystectomy; Cytokines; Acute inflammatory response
The use of bupivacaine irrigated over the surgical bed was found to be an effective method for reducing pain following laparoscopic cholecystectomy.
The aim of this study was to evaluate the effect of bupivacaine irrigated at the surgical bed on postoperative pain relief in laparoscopic cholecystectomy patients.
This study included 60 patients undergoing elective laparoscopic cholecystectomy who were prospectively randomized into 2 groups. The placebo group (n=30) received 20cc saline without bupivacaine, installed into the gallbladder bed. The bupivacaine group (n=30) received 20cc of 0.5% bupivacaine in at the same surgical site. Pain was assessed at 0, 6, 12, and 24 hours by using a visual analog scale (VAS).
A significant difference (P=.018) was observed in pain levels between both groups at 6 hours postoperatively. The average analgesic requirement was lower in the bupivacaine group, but this did not reach statistical significance.
In our study, the use of bupivacaine irrigated over the surgical bed was an effective method for reducing pain during the first postoperative hours after laparoscopic cholecystectomy.
Bupivacaine; Irrigation; Laparoscopic cholecystectomy; Postoperative pain
PURPOSE: To study the safety and efficacy of simultaneous bilateral laser in-situ keratomileusis (LASIK) METHODS: Data were obtained from 254 consecutive patients that were randomized to simultaneous or sequential bilateral LASIK. RESULTS: 146 patients were enrolled in the simultaneous group and 108 patients were enrolled in the sequential group. Mean follow-up was 10 months (range 6-18). There was no significant difference in intraoperative complication rate (p = 0.34), loss of two or more lines of spectacle corrected visual acuity (p = 0.9), or percentage of eyes within +/- 0.50 D of intended (p = 0.63) between simultaneous and sequential groups. CONCLUSIONS: The risk of performing bilateral simultaneous LASIK is not significantly different from that of sequential treatments.
To assess the efficacy and safety of Insuflow® (Georgia BioMedical, Inc.) filter heater hydrator device in reducing the incidence, severity and extent of hypothermia, length of recovery room stay and postoperative pain at the time of laparoscopy.
Prospective, randomized, blinded, controlled multi-center study. Patients underwent gynecologic procedures via laparoscopy; surgeons, anesthesiologists and recovery room personnel assessed the results.
Seven North American institutions.
Seventy-two women for safety evaluation and efficacy studies.
Intraoperative pre-conditioning of laparoscopic gas with the Insuflow® device (treatment) or standard raw gas (control) during laparoscopic surgery and postoperatively.
Main Outcome Measures:
Incidence, severity and extent of hypothermia, postoperative pain perception and length of recovery room stay.
The Insuflow® group had significantly less intra-operative hypothermia, reduced length of recovery room stay and reduced postoperative pain. Pre-conditioning of laparoscopic gas by filtering heating and hydrating was well tolerated with no adverse effects. The safety profile of the Insuflow® pre-conditioned gas showed significant benefits compared to currently used raw gas.
Pre-conditioning laparoscopic gas by filtering heating and hydrating with the Insuflow® device was significantly more effective than the currently used standard raw gas and was safe in reducing or eliminating laparoscopic-induced hypothermia, shortening recovery room length of stay and reducing postoperative pain.
Gas hydration; Laparoscopic hypothermia; Pain; Length of stay; Laparoscopy; Peritoneum
Prophylactic cholecystectomy (PC) is advised after ES and clearance of ductal calculi on the basis of a randomized controlled trial that showed a requirement for cholecystectomy in 36% of patients who defer surgery. Other studies suggest the cholecystectomy rate to be as low as 8%.
To determine the proportion of patients who deferred cholecystectomy and the outcome, we reviewed 870 consecutive patients who underwent endoscopic retrograde cholangiography and sphincterotomy; the gallbladder of 420 of these remained in situ. Patients were assigned to PC or deferred cholecystectomy (DC) groups.
Cholecystectomy was deferred in 180 of 310 eligible patients. DC patients were significantly older (66.4 v. 49.8 yr) and sicker (according to the American Society of Anesthesiology [ASA] physiological status score) and had a significantly higher mortality rate than did PC patients. Deaths were principally cardiovascular and not biliary related. After a follow-up of 24.2 (< 1–82.3) months, eventual cholecystectomy was required in 46 (24.7%) DC patients at a mean of 6 months after ES. The subgroup undergoing eventual cholecystectomy was younger (57.6 v. 69.4 yr; p < 0.001) fitter (ASA score of 1.98 v. 2.26; p = 0.015) and more likely to have residual cholecystolithiasis than were those who continued deferral. Recurrent pancreatitis was more common in DC (30%) than in PC (4.8%) patients if pancreatitis was the indication for sphincterotomy.
PC is advised for patients with residual cholecystolithiasis after ES. In patients with relative contraindications, the choice is balanced in favour of cholecystectomy if there is a history of pancreatitis and in favour of deferral if more than 6 months have elapsed since ES.