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Laparoscopic Cholecystectomy in Acalculous Biliary Disease

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Duncan J., 1884, North J. Med; 2:151-2. Femoral hernia; gangrene of gall bladder; ... Acute acalculous cholecystits associated with major trauma, burns, sepsis ... – PowerPoint PPT presentation

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Title: Laparoscopic Cholecystectomy in Acalculous Biliary Disease


1
Laparoscopic Cholecystectomy in Acalculous
Biliary Disease
  • Anthony Freeman
  • April 2000

2
Acalculous Biliary Disease
  • First described gt100 years ago
  • Duncan J., 1884, North J. Med 2151-2
  • Femoral hernia gangrene of gall bladder
  • extravasation of bile peritonitis death.
  • Acute acalculous cholecystits associated with
    major trauma, burns, sepsis
  • Chronic acalculous cholecytitis increasing
    recognised in otherwise healthy outpatients
  • Savoca P.E. et al., 1990, Ann Surg 211433-7

3
Acalculous Biliary Disease
  • 5-10 patients with classic biliary colic
  • Absence of calculi (USS/pathology)
  • Absence of other pathology (PUD)
  • Two proposed entities
  • Cholecystitis/cholesterosis/adenomyosis (path)
  • Biliary dyskinesia (functional)

4
Laparoscopic Cholecystectomy
  • Acalculous cholecystitis
  • benefit with open cholecystectomy
  • Yap L. et al., 1991, Gastroenterology 101786-93
  • Laparoscopic cholecystectomy
  • Less morbidity
  • Shortened hospital stay
  • Earlier return to work

5
Hepatobiliary Scanning
  • Noninvasive
  • Assesses excretion of bile into GIT
  • 99mTechnecium injection
  • Cholecystokinin administration
  • Objective GB ejection fraction (Ngt35)
  • Subjective reproduction of symptoms (IBS)

6
Question
  • Which patients with a clinical diagnosis of
    biliary colic and a normal ultrasound will loose
    their symptoms after laparoscopic
    cholecystectomy?
  • Can these patients be distinguished prior to
    surgery?

7
Literature Review
  • Medline search 54
  • Laparoscopic cholecysectomy
  • Acalculous cholecystitis
  • Biliary dyskinesia
  • Cholecystokinin
  • English/Human/1990-Feb2000 48

8
Literature Review
  • 48 Citations
  • 18 Abstracts
  • 8 Papers and 2 Cited Papers
  • 1 Study presented
  • Journal impact factor and availability
  • Sample size, methodology and results
  • Does it answer our question?

9
  • Laparoscopic cholecystectomy alleviates pain in
    patients with acalculous biliary disease
  • Paul Frassinelli et al.
  • Pennsylvania, USA
  • Surgical Laparoscopy and Endoscopy 830-34
  • 1998

10
Methods
  • Retrospective review of patients with acalculous
    biliary disease who had a laparoscopic
    cholecystectomy (1990-1994)
  • Follow-up telephone interview of symptoms
  • ? Duration of follow-up
  • ? Chi-squared method

11
Patients
  • 2557 laparoscopic cholecystectomies
  • 243 (9.5) with acalculous biliary disease
  • 195 (80.2) chronic acalculous cholecystitis
  • 30 (12.3) acute acalculous cholecystitis
  • 18 (7.4) biliary dyskinesia
  • 184 (75.5) female 59 (24.3) male
  • Age 14-80 (43.715.5)
  • 181 (75) successfully followed-up

12
Results
  • Hospital Stay 3.93.0 days
  • Post-operative stay 1.71.6 days (0-12)

13
Symptom Outcome
  • Pre-op symptoms 1-660 days (35.884.6)

14
Hepatobiliary Scanning
  • 177 (72.8) HIDA Scans
  • Ejection fraction 1814.2 (0-92)
  • 99 (55.9) symptomatic with CCK
  • 238 (97.5) symptomatic CCK or EFlt40
  • No association between ejection fraction and
    symptom relief/pathological findings

15
Duration of symptoms
  • Patients who suffered longer were more likely to
    obtain relief from cholecystectomy
  • (p0.05)
  • 25 of patients will improve spontaneously
  • with a duration of symptoms lt 6 months
  • Goncalves R.M. et al., 1998, The Am Surgeon
    64493-497

16
Conclusion
  • A test has not been identified which accurately
    and reliably selects patients with acalculous
    biliary colic for cholecystectomy
  • Hepatobiliary Scan
  • sensitivity 0.56 specificity 0.57
  • Smythe A.W. et al., 1998, Gut 43571-574
  • positive p.v. 0.78 negative p.v. 0.20
  • Adams D.B. et al., 1998, The Am Surgeon 641-5

17
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18
  • History
  • Symptoms
  • Duration
  • Sex/Age

Acalculous Biliary Disease
Hepatobiliary Scan
Abdominal Ultrasound
Exclude alt. diagnosis
Stones
Cholecystectomy
19
Caution
  • Increase in the proportion of patients having
    cholecystectomy for acalculous disease
  • Johanning J.M., 1998, The Am Surgeon 64643-647
  • 1985-1990 90/3247 (2.3)
  • 1990-1995 211/3247 (4.2)
  • Jones-Monahan K., 1999, JSLS 3221-224
  • 3 of patients will need another operation

20
Studies
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