LA CONSULTA SEMANAL

MAYO 2001

CONSULTA

1: Surg Endosc 2001 Jan;15(1):98
Wolf in sheep's clothing: spilled gallstones can cause severe complications after endoscopic surgery.
Gretschel S, Engelmann C, Estevez-Schwarz L, Schlag PM.
Department of Surgery and Surgical Oncology, Robert Rossle Hospital, Humboldt University, Lindenbergerweg 80, D-13122 Berlin, Germany.
Bile concrements may remain intraperitoneally after laparoscopic cholecystectomy. Previously, this was considered harmless, a view supported by some experimental studies. Recently, however, spilled gallstones have been identified as a source of rare but potentially serious complications. We report a case of a retrohepatic abscess and dorsal fistulation after laparoscopic cholecystectomy. Healing was achieved only by repeated surgery, including abscess drainage, stone removals, and fistula excision. Since 1990, 73 cases with gallstone-related complications after laparoscopic cholecystectomy have been reported in the literature. Among these complications, intra-abdominal abscesses and transabdominal fistulas were predominant. The interval between the cholecystectomy and the appearance of complications ranged from 4 days to 29 months, with a peak incidence at 4 months. Spillage of small bile concrements or fragments is, with the exception of multiple irremovable stones, not commonly an indication for conversion to an open procedure. However, the patient needs to be warned about the risk of gallstone loss and its associated complications at the time when informed consent is obtained. Furthermore, if gallstone loss has occurred, the patient should be informed, and the occurrence should be documented.


2: Clin Imaging 2000 Jul-Aug;24(4):204-6
Perforation of the small bowel as a complication of laparoscopic cholecystectomy: CT findings.
Ho AC, Horton KM, Fishman EK.
The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institution, 600 North Wolfe Street, 21287, Baltimore, MD, USA
Despite the widespread use of laparoscopic cholecystectomy, technical complications unique to the laparoscopic approach may lead to significant postoperative morbidity and mortality. We report a rare case of small bowel perforation due to trocar injury that led to extensive pneumoperitoneum and pneumomediastinum in a patient who underwent laparoscopic cholecystectomy. Small bowel injuries should be suspected when a large or an increasing amount of free air is detected following this procedure.


3: Surg Today 2000;30(3):277-81
Nonspecific ulcerated jejunitis as an unusual complication of laparoscopic cholecystectomy: report of a case.
Akkus MA, Cetinkaya Z, Ilhan YS, Caboglu SA, Bulbuller N.
School of Medicine, Department of General Surgery, Firat University, Elazig, Turkey.
We describe herein the case of a 65-year-old man in whom a lower gastrointestinal hemorrhage developed a few days after he underwent an elective laparoscopic cholecystectomy. A laparotomy was performed on postoperative day 16 and a jejunal segment containing mucosal changes and oozing ulcers was resected. Pathologic examination of the specimen revealed "nonspecific ulcerated jejunitis." There is no explanation for the etiopathogenesis of this pathology; however, we concluded that this clinical picture may be attributed to ischemia-reperfusion injury that occurred following an ischemic period caused by the pneumoperitoneum during laparoscopic surgery.


4: Dig Surg 2000;17(5):542-4
Embolism of a metallic clip: an unusual complication following laparoscopic cholecystectomy.
Ammann K, Kiesenebner J, Gadenstatter M, Mathis G, Stoss F.
Department of General Surgery, University Hospital, Innsbruck, Austria.
A 32-year-old woman underwent laparoscopic cholecystectomy during which there was severe bleeding from the bed of the gallbladder. As application of metallic clips to control the bleeding was not successful, the operation was converted to an open laparotomy. Cholecystectomy was successfully completed without further complications, and the post-operative course was uneventful and the patient was discharged. Eighteen months later, the patient complained of dyspnea. Plain radiograph and computed tomography of the thorax showed a metallic clip in the branch of the pulmonary artery supplying the posterior basal segment of the inferior lobe of the left lung. There was no connection between the patient's symptoms and the clip embolism. Nevertheless, clip migration or embolism could cause severe complications. Therefore, metallic clips should not be used to stop bleeding from the gallbladder bed. Copyright 2000 S. Karger AG, Basel.


5: HPB Surg 2000 Aug;11(6):373-8
Cholecystectomy, conversion and complications.
Thompson MH, Benger JR.
The Department of Surgery, Southmead Hospital, Bristol, United Kingdom.
BACKGROUND: Faced with a difficult laparoscopic cholecystectomy the surgeon may feel that conversion to open operation would risk greater complications because of the laparotomy. Information on the effect of conversion is lacking. The purpose of this study is to measure the complications of laparoscopic cholecystectomy and observe the effect of the conversion rate. METHODS: A total of 957 patients were studied. There were three consecutive series of patients; the first undergoing open cholecystectomy (384 patients), the second laparoscopic cholecystectomy with a 5.8% conversion rate (412 patients) and the third laparoscopic cholecystectomy with a 1.3% conversion rate (161 patients). Data was collected prospectively using a continuous audit, and the complication rate compared on an intention to treat basis. In addition a panel of experienced surgeons was asked to score the complications depending on their severity and a composite complication score calculated. Comparison between the 3 groups was then undertaken. RESULTS: Open cholecystectomy produced a post-operative complication rate of 6%. Initially this appeared to fall to 3.1% with the introduction of laparoscopic cholecystectomy, but when the complications occurring in the converted patients were included (i.e., on an intention to treat basis) the rate increased to 5.6% in the first group of laparoscopically-treated patients and 3.1% in the second. These differences were not statistically significant. A similar pattern emerged when scoring the severity of the complications as judged by the expert panel. The inclusion of intra-operative complications appears to remove any small advantage for laparoscopic cholecystectomy. The reduction in the conversion rate between the two laparoscopic groups from 5.8% to 1.2% was statistically significant. CONCLUSION: When considered on an intention to treat basis laparoscopic cholecystectomy offers no advantage over open operation in terms of the frequency or severity of complications. Reducing the frequency of conversion from a laparoscopic to an open procedure also has no significant effect on the complications encountered. We conclude, therefore, that the complication rate is independent of the conversion rate and that the surgeon, when faced with difficulty at laparoscopic cholecystectomy, should not be deterred from converting to open operation for fear of the post-operative consequences.


6: Surg Endosc 2000 Aug;14(8):755-60
Laparoscopic cholecystectomy for acute cholecystitis: can the need for conversion and the probability of complications be predicted? A prospective study.
Brodsky A, Matter I, Sabo E, Cohen A, Abrahamson J, Eldar S.
Department of Surgery, Bnai Zion Medical Center, the Faculty of Medicine, and the Faculty of Industrial Engineering and Management, the Technion, Israel Institute of Technology 47 Golomb Street, Post Office Box 4940, Haifa 31048, Israel.
BACKGROUND: Laparoscopic cholecystectomy (LC) in acute cholecystitis is associated with a relatively high rate of conversion to an open procedure as well as a high rate of complications. The aim of this study was to analyze prospectively whether the need to convert and the probability of complications is predictable. METHODS: A total of 215 patients undergoing LC for acute cholecystitis were studied prospectively by analyzing the data accumulated in the process of investigation and treatment. Factors associated with conversion and complications were assessed to determine their predictive power. RESULTS: Conversion was indicated in 44 patients (20.5%), and complications occurred in 36 patients (17%). Male gender and age >60 years were associated with conversion, but these factors had no sensitivity and no positive predictive value. The same factors, together with a disease duration of >96 h, a nonpalpable gallbladder, a white blood count (WBC) of >18,000/cc(3), and advanced cholecystitis, predicted conversion with a sensitivity of 74%, a specificity of 86%, a positive predictive value of approximately 40%, and a negative predictive value of 96%. However, these data became available only when LC was underway. Male gender and a temperature of >38 degrees C were associated with complications, but these factors had no sensitivity and no positive predictive value. Progression along the stages of admission and therapy did not add predictive factors or improve the predictive characteristics. Male gender, abdominal scar, bilirubin >1 mg%, advanced cholecystitis, and conversion to open cholecystectomy were associated with infectious complications. Their sensitivity and positive predictive value remained 0 despite progression along the stages of admission and therapy. CONCLUSION: Although certain preoperative factors are associated with the need to convert a LC for acute cholecystitis, they have limited predictive power. Factors with higher predictive power are obtained only during LC. The need to convert can only be established during an attempt at LC. Preoperative and operative factors associated with total and infectious complications have no predictive power.


7: Eur J Surg 2000;Suppl 585:18-21
Complications of laparoscopic cholecystectomy as recorded in the Swedish laparoscopy registry.
Hjelmqvist B.
Department of Surgery, Lanssjukhuset, Kalmar, Sweden.
The Swedish laparoscopy registry prospectively recorded 11,164 laparoscopic cholecystectomies during the years 1991-1993 with the aim of monitoring bile duct injuries and other complications of the new technique. In total 57 bile ducts were injured; 35 of these were merely incision of the common bile duct. Serious injuries with tissue loss occurred in 11 cases and clipping or electrocautery damage in another 11.


8: Rev Hosp Clin Fac Med Sao Paulo 1999 Nov-Dec;54(6):209-12 [Texto completo]
Elimination of biliary stones through the urinary tract: a complication of the laparoscopic cholecystectomy.
Castro MG, Alves AS, Oliveira CA, Vieira Junior A, Vianna JL, Costa RF.
Division of General Surgery, Felicio Rocho Hospital, Belo Horizonte, Brazil.
The introduction and popularization of laparoscopic cholecystectomy has been accompanied with a considerable increase in perforation of gallbladder during this procedure (10% - 32%), with the occurrence of intraperitoneal bile spillage and the consequent increase in the incidence of lost gallstones (0.2% - 20%). Recently the complications associated with these stones have been documented in the literature. We report a rare complication occurring in an 81-year-old woman who underwent laparoscopic cholecystectomy and developed cutaneous fistula to the umbilicus and elimination of biliary stones through the urinary tract. During the cholecystectomy, the gall bladder was perforated, and bile and gallstones were spilled into the peritoneal cavity. Two months after the initial procedure there was exteriorization of fistula through the umbilicus, with intermittent elimination of biliary stones. After eleven months, acute urinary retention occurred due to biliary stones in the bladder, which were removed by cystoscopy. We conclude that efforts should be concentrated on avoiding the spillage of stones during the surgery, and that no rules exist for indicating a laparotomy simply to retrieve these lost gallstones.


9: Am J Surg 2000 Apr;179(4):316-9
Relaparoscopy for the detection and treatment of complications of laparoscopic cholecystectomy.
Dexter SP, Miller GV, Davides D, Martin IG, Sue Ling HM, Sagar PM, Larvin M, McMahon MJ.
Leeds Institute for Minimally Invasive Therapy, Centre for Digestive Diseases, and the University of Leeds, Wellcome Wing, The General Infirmary, Leeds, UK.
BACKGROUND: Laparotomy remains the commonest intervention in patients with abdominal complications of laparoscopic surgery. Our own policy is to employ relaparoscopy to avoid diagnostic delay and unnecessary laparotomy. The results of using this policy in patients with suspected intra-abdominal complications following laparoscopic cholecystectomy are reviewed. METHODS: Data were collected from laparoscopic cholecystectomies carried out by five consultant surgeons in one center. Details of relaparoscopy for complications were analyzed. RESULTS: Thirteen patients underwent relaparoscopy within 7 days of laparoscopic cholecystectomy for intra-abdominal bleeding (2 patients) or abdominal pain (11 patients). The causes of pain were subhepatic haematoma (1), acute pancreatitis (1), small bowel injury (1), and minor bile leakage (6). In 2 patients no cause was identified. Twelve patients were managed laparoscopically and 1 patient required laparotomy. Median stay after relaparoscopy was 7 days (range 2 to 19). CONCLUSIONS: Exploratory laparotomy can be avoided by prompt relaparoscopy in the majority of patients with abdominal complications of laparoscopic cholecystectomy.


10: Surg Endosc 2000 Apr;14(4):373-4
Is the loss of gallstones during laparoscopic cholecystectomy an underestimated complication?
Gerlinzani S, Tos M, Gornati R, Molteni B, Poliziani D, Taschieri AM.
Divisione di Chirurgia Generale II, Universita degli Studi di Milano, Ospedale Luigi Sacco, Cattedra di Chirurgia Generale, Via G. B. Grassi 74, 20157 Milan, Italy. massimo.tos@unimi.it
Laparoscopic cholecystectomy entails an increased risk of gallbladder rupture and consequent loss of stones in the abdominal cavity. Herein we report the case of a 51-year-old male patient, who underwent laparoscopic cholecystectomy 2 years before presentation to our hospital. He had experienced tension sensation and epigastric pain since 4 months postoperatively. A well-defined epigastric mass, which was hard and painful on palpation, was detected and later confirmed by ultrasonography and CT scan.Explorative laparotomy revealed a mass in the area of the gastrocolic ligament,resulting from biliary gallstones in conjunction with a perimetral inflammatory reaction. A review of the literature showed that the incidence of gallbladder lesions during laparoscopy is 13-40%. In order to prevent this complication, meticulous isolation of the gallbladder, proper dissection of the cystic duct and artery, and careful extraction through the umbilical access are required. Ligation after the rupture or use of an endo-bag may be helpful. The loss of gallstones and their retention in the abdominal cavity should be noted in the description of the surgical procedure.


11: AJR Am J Roentgenol 2000 May;174(5):1441-5
Radiologic features of complications arising from dropped gallstones in laparoscopic cholecystectomy patients.
Morrin MM, Kruskal JB, Hochman MG, Saldinger PF, Kane RA.
Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
OBJECTIVE: Because laparoscopic cholecystectomy has become the accepted treatment for symptomatic cholelithiasis, radiologists frequently encounter patients who have had this surgery. Although the radiologic features of postoperative bile duct injury are well documented, the imaging features of less well-known complications remain poorly described. One such unusual complication is abscess formation caused by dropped gallstones. CONCLUSION: Although the incidence of dropped gallstones is an uncommon complication of laparoscopic cholecystectomy, it should be recognized as a potential source of both intraabdominal and intrathoracic abscess formation in any patient presenting months to years after undergoing laparoscopic cholecystectomy. These abscesses are not necessarily confined to the right upper quadrant.


12: Am Fam Physician 2000 Mar 15;61(6):1673-80, 1687-8 [Texto completo]
Management of gallstones and their complications.
Ahmed A, Cheung RC, Keeffe EB.
Stanford University School of Medicine, California, USA.
The accurate differentiation of gallstone-induced biliary colic from other abdominal disease processes is the most crucial step in the successful management of gallstone disease. Despite the availability of many imaging techniques to demonstrate the presence of gallstones, clinical judgment ultimately determines the association of symptoms with cholelithiasis and its complications. Adult patients with silent or incidental gallstones should be observed and managed expectantly, with few exceptions. In symptomatic patients, the intervention varies with the type of gallstone-induced complication. In this article, we review the salient clinical features, diagnostic tests and therapeutic options employed in the management of gallstones and their complications.
Publication Types:
Review
Review, tutorial


13: Eur J Surg 2000 Feb;166(2):136-40
Laparoscopic cholecystectomy for acute cholecystitis: how do fever and leucocytosis relate to conversion and complications?
Halachmi S, DiCastro N, Matter I, Cohen A, Sabo E, Mogilner JG, Abrahamson J, Eldar S.
Department of Surgery, Bnai Zion Medical Center and the Faculty of Medicine, Technion, Israel Institute of Technology, Haifa.
OBJECTIVE: To find out whether fever and raised white cell count (WCC) are associated with conversion and complications of laparoscopic cholecystectomy in acute cholecystitis, and whether their presence could help in deciding the place of laparoscopic procedures. DESIGN: Prospective study. SETTING: Teaching hospital, Israel. SUBJECTS: 256 patients who were treated for clinical acute cholecystitis between January 1994 and November 1997. INTERVENTIONS: Emergency laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: Raised temperature and WCC; incidence of conversion and complications. RESULTS: Raised temperature (>38 degrees C) was independently associated with advanced cholecystitis (p = 0.002, odds ratio [OR] 2.7) and a palpable gallbladder preoperatively (p = 0.02, OR 2.1). Total complications correlated with a temperature of >38 degrees C. Raised WCC (>15 x 10(9)/L) was independently associated with age >45 years (p = 0.02, OR 2.4), a palpable gallbladder preoperatively (p = 0.001, OR 2.9), and a raised temperature (>38 degrees C) (p < 0.0001, OR 6.2). Conversion was associated with a WCC >18 x 10(9)/L (p = 0.0, OR 3.2). CONCLUSION: A WCC of >18 x 10(9)/L may assist in predicting conversion, and fever of >38 degrees C may assist in predicting the development of complications.
Publication Types:
Clinical trial


14: Br J Surg 2000 Mar;87(3):362-73
Biliary complications associated with laparoscopic cholecystectomy: analysis of common misconceptions
Bingham J, McKie LD, McLoughlin J, Diamond T.
Mater Hospital, Belfast, UK.
AIMS: General surgeons often express the view that the majority of biliary complications following laparoscopic cholecystectomy are caused by trainee surgeons; complications occur most often in the presence of difficult anatomy or pathology; biliary injuries occur more proximally in the biliary tree than at open cholecystectomy; most injuries are recognized at the time of surgery; and most complications can be managed non-operatively. The aim of this study was to determine if these views are substantiated in clinical practice. METHODS: Thirty consecutive patients were referred to a specialist hepatobiliary unit over a 7-year period with biliary complications following laparoscopic cholecystectomy. The mode of presentation, management and outcome of these patients were analysed. RESULTS: In 21 cases the initial operator was a consultant. Four of the 30 complications occurred in the presence of an anatomical variation or unusually difficult pathology. Only patients in whom a previous attempt at repair had been made had injuries at or proximal to the bile duct confluence; the only two deaths occurred in this group. Only 41 per cent of injuries were detected at the time of surgery and 89 per cent required further surgical intervention, hepaticojejunostomy being the most common procedure performed (75 per cent). CONCLUSIONS: The majority of bile duct injuries are not caused by trainees, do not occur because of unusual anatomy or pathology, do not occur in the proximal biliary tree, are not recognized at the time of the initial operation and often require major reconstructive procedures for their management.


15: Endoscopy 2000 Jan;32(1):S3
Surgical clips incorporated into a duodenal ulcer: a rare complication after elective laparoscopic cholecystectomy.
Reis LD.
Dept. of Surgery, Hospital Nossa Senhora da Saude, Santo Antonio da Platina, Parana, Brazil. fmliareis@uol.com.br


16: Abdom Imaging 2000 Mar-Apr;25(2):190-3
Complications of "dropped" gallstones after laparoscopic cholecystectomy: technical considerations and imaging findings.
Bennett AA, Gilkeson RC, Haaga JR, Makkar VK, Onders RP.
Department of Diagnostic Radiology, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA.
New laparoscopic techniques have revolutionized the practice of surgery. Laparoscopic cholecystectomy has become one of the most commonly performed surgeries worldwide. Although shorter hospital stays and patient comfort have offered clear advantages over open cholecystectomy, the technique has resulted in several specific complications, including bile duct injury and gallbladder perforation. Although rarely clinically significant, intraperitoneal gallstone spillage can cause abscess formation and adhesions. Although these patients can present with a confusing clinical picture, their characteristic radiologic features should be recognized. We present two cases of complicated intraperitoneal gallstone spillage radiologically diagnosed and treated with laparoscopic and interventional radiologic techniques.


17: Br J Radiol 1999 Feb;72(854):201-3
Peritoneal abscess formation as a late complication of gallstones spilled during laparoscopic cholecystectomy.
Frola C, Cannici F, Cantoni S, Tagliafico E, Luminati T.
Department of Radiology, Ospedale Evangelico Internazionale, Genova, Italy.
The case is described of a 74-year-old woman who presented with an abdominal abscess 1.5 years after laparascopic cholecystectomy. CT and ultrasound showed the presence of gallstones within the abscess. Spillage of gallstones from perforation of the gallbladder is a well recognized complication of laparascopic cholecystectomy, although subsequent abscess formation is unusual especially after a long delay as in this case.


18: Ann Surg 1999 Apr;229(4):449-57
Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study.
Fletcher DR, Hobbs MS, Tan P, Valinsky LJ, Hockey RL, Pikora TJ, Knuiman MW, Sheiner HJ, Edis A.
Department of Surgery, University of Western Australia and Fremantle Hospital, Australia.
BACKGROUND: Previous studies suggest that laparoscopic cholecystectomy (LC) is associated with an increased risk of intraoperative injury involving the bile ducts, bowel, and vascular structures compared with open cholecystectomy (OC). Population-based studies are required to estimate the magnitude of the increased risk, to determine whether this is changing over time, and to identify ways by which this might be reduced. METHODS: Suspected cases of intraoperative injury associated with cholecystectomy in Western Australia in the period 1988 to 1994 were identified from routinely collected hospital statistical records and lists of persons undergoing postoperative endoscopic retrograde cholangiopancreatography. The case records of suspect cases were reviewed to confirm the nature and site of injury. Ordinal logistic regression was used to estimate the risk of injury associated with LC compared with OC after adjusting for confounding factors. RESULTS: After the introduction of LC in 1991, the proportion of all cholecystectomy cases with intraoperative injury increased from 0.67% in 1988-90 to 1.33% in 1993-94. Similar relative increases were observed in bile duct injuries, major bile leaks, and other injuries to bowel or vascular structures. Increases in intraoperative injury were observed in both LC and OC. After adjustment for age, gender, hospital type, severity of disease, intraoperative cholangiography, and calendar period, the odds ratio for intraoperative injury in LC compared with OC was 1.79. Operative cholangiography significantly reduced the risk of injury. CONCLUSION: Operative cholangiography has a protective effect for complications of cholecystectomy. Compared with OC, LC carries a nearly twofold higher risk of major bile, vascular, and bowel complications. Further study is required to determine the extent to which potentially preventable factors contribute to this risk.


19: Surgery 1999 Feb;125(2):223-31
Laparoscopic and open cholecystectomy in New York State: mortality, complications, and choice of procedure.
Hannan EL, Imperato PJ, Nenner RP, Starr H.
Department of Health Policy, Management and Behavior, State University of New York, Albany, USA.
BACKGROUND: With the advent of laparoscopic cholecystectomy patient outcomes and choice of procedure (laparoscopic vs open) are of vital interest. The purpose of this study was to examine the mortality and complication rates for patients undergoing laparoscopic and open cholecystectomy in New York State and to test for differences among hospital peer groups and regions of the state in the tendency to use the laparoscopic approach. METHODS: A population-based, retrospective cohort study of laparoscopic and open cholecystectomy was conducted in which data were analyzed on all 30,968 patients who underwent cholecystectomy as a principal procedure in New York State in 1996. RESULTS: A total of 78.7% of the 30,968 patients who underwent cholecystectomy as a principal procedure in New York State in 1996 underwent laparoscopic cholecystectomy. The mortality rate was lower for laparoscopic cholecystectomy than for the open procedure (0.23% vs 1.90%, P < .0001) and remained significantly lower after patient characteristics related to patient survival (odds ratio 0.34, P < .0001) were controlled for. The prevalence rate of the 8 most common complications among cholecystectomy patients was also much lower among patients undergoing laparoscopic cholecystectomy. Patients undergoing cholecystectomy in public hospitals, Bronx County, and Kings County were found to be significantly less likely to have laparoscopic procedures, and patients undergoing cholecystectomy on Long Island were found to be significantly more likely to have laparoscopic procedures than were other patients in the state. CONCLUSIONS: There are reasonably large differences among hospitals, hospital groups, and regions of the state in the type of cholecystectomy used, even after adjustment for differences in patient comorbidities and indications for type of procedure.