Anders Thune

Management of acute cholecystitis in the laparoscopic era: Results of a prospective, randomized clinical trial

The aim of this prospective, randomized study was to determine whether laparoscopic cholecystectomy should be performed as an early or a delayed operation in patients with acute cholecystitis. After diagnostic workup, patients were randomized to one of two groups: (1) early laparoscopic cholecystectomy (i.e., within 7 days after onset of symptoms) or (2) initial conservative treatment followed by delayed laparoscopic cholecystectomy 6 to 8 weeks later. Seventy-four patients were placed in the early-operation group, and 71 patients were assigned to the delayed-operation strategy. There was no significant difference in conversion rates (early 31% vs. delayed 29%), operating times (early 98 [range 30 to 355] minutes vs. delayed 100 [45 to 280] minutes), or complications. Failure with the conservative treatment strategy was noted in 26% of these patients. The total hospital stay was significantly shorter in the early group (5 [range 3 to 63] days) vs. the delayed group (8 [range 4 to 50] days; P < 0.05). Despite a high conversion rate, early laparoscopic cholecystectomy offered significant advantages in the management of acute cholecystitis compared to a conservative strategy. The greatest advantage was a reduced total hospital stay.

Randomized clinical trial of open versus laparoscopic cholecystectomy in the treatment of acute cholecystitis.

The aim of this prospective trial was to determine whether surgical approach (open versus laparoscopic) had an impact on morbidity and postoperative recovery after cholecystectomy for acute cholecystitis.

Randomized clinical trial of day‐care versus overnight‐stay laparoscopic cholecystectomy

Laparoscopic cholecystectomy has been performed as a day‐care procedure for many years. Few studies have been conducted with primary focus on patient acceptance and preferences in terms of quality of life for this practice compared with overnight stay.

Palliation of Malignant Gastroduodenal Obstruction with Open Surgical Bypass or Endoscopic Stenting: Clinical Outcome and Health Economic Evaluation

Gastroduodenal outlet obstruction is a complication of advanced gastrointestinal malignant disease. In the past it was usually treated by an open surgical bypass procedure. During the last decade, endoscopic self-expandable stents (SEMS) have been used. The aim of this study was to compare these two palliative strategies concerning clinical outcome and health economy. A series of 36 patients with incurable malignant disease and gastroduodenal outlet obstruction syndrome were treated in a prospective study. According to the attending hospital and endoscopist on duty, 21 of the 36 patients were endoscopically treated with SEMS and 15 underwent an open surgical gastroenteroanastomosis. Health economic evaluation was based on the monetary charges for each patient associated with the procedure, postoperative care, and hospital stay. The hospital stay was 7.3 days for the stented group compared with 14.7 days for the open surgery group (p > 0.05). The survivals were 76 and 99 days, respectively (NS). In the stented group all 15 patients (100%) alive after 1 month were able to eat or drink, and 11 (73%) of them tolerated solid food. In the surgical bypass group,9 out of 11 (81%) patients alive after 1 month could eat or drink, and 5 of them (45%) could eat solid food. The mean charges (U.S. dollars) during the hospital stay were

Efficacy of an anterior as compared with a posterior laparoscopic partial fundoplication: results of a randomized, controlled clinical trial.

7215 for the stented group and

EUS-guided drainage is more successful in pancreatic pseudocysts compared with abscesses

10,190 for the open surgery group (p < 0.05). Palliation of the gastroduodenal obstruction in patients with malignant disease were at least as good, and the charges were lower for the endoscopic stenting procedure than for an open surgical bypass.

Impact of Choice of Therapeutic Strategy for Acute Cholecystitis on Patient’s Health-Related Quality of Life

Objective The aim of the study was to compare the efficacy and mechanical consequences of 2 partial fundoplications performed laparoscopically under the framework of a randomized, controlled clinical trial. Summary Background Data Although laparoscopic total fundoplication procedures have proven their effectiveness in the control of gastroesophageal reflux, problems remain with the functional consequences after a supra-competent gastric cardia high-pressure zone. Partial fundoplications have been found to be associated with fewer mechanical side effects. Patients and Methods During a 2-year period, 95 patients with gastroesophageal reflux disease were enrolled into a randomized, controlled single-institution clinical trial comparing a partial posterior (Toupét, n = 48) fundoplication and an anterior partial wrap (Watson, n = 47). All patients were assessed postoperatively at predefined time points, and the 12-month follow-up data are presented in terms of clinical results and 24-hour pH monitoring variables. Results Both patient groups were strictly comparable at the time of randomization. All operations were completed laparoscopically, and no serious complications were encountered. During the first postoperative year, a difference regarding the control of reflux symptoms was observed in favor of the posterior fundoplication. Esophageal acid exposure (% time pH <4) was substantially reduced by both operations but to a significantly lower level after a Toupét compared with the Watson partial fundoplication (1.0 ± 0.3 vs. 5.6 ± 1.1 mean ± SEM; p < 0.001). Postfundoplication symptoms were infrequently recorded with no difference between the groups. Conclusions When performing a laparoscopic partial fundoplication, the posterior modification (Toupét) offers advantages in terms of better reflux control compared with an anterior type (Watson).

VIP-antiserum inhibits fluid secretion by the inflamed gallbladder mucosa

AIM To compare the results for endoscopic ultrasound (EUS)-guided drainage of clear fluid pancreatic pseudocysts with the results for abscess drainage. METHODS All patients referred for endoscopic drainage of a fluid collection were prospectively included. The outcome was recorded. RESULTS Altogether 26 pseudocysts or abscesses were treated in 25 (6 female) patients. One endoscopist performed the procedures. Non-infected pseudocysts were present in 15 patients and 10 patients had infected fluid collections. The cyst size ranged between 28 cm × 13 cm and 5 cm × 5 cm. The EUS drainage was successful in 94% of the pseudocysts and in 80% of the abscesses (P = 0.04). The complication rate in pseudocysts was 6% and in abscesses was 30% (P = 0.02). Recurrence of a pseudocyst occurred in one patient (4%) after 6 mo; the patient was successfully retreated. CONCLUSION EUS-guided drainage of pseudocysts is associated with a higher success rate and a lower complication rate compared with abscess drainage.

Sympathetic and VIP-ergic control of calcium and bicarbonate transport in the feline gall bladder mucosa in vivo.

Background: The aim of this prospective, randomized study was to determine if health related quality of life is affected by the choice of surgical strategy in the management of acute cholecystitis. Material and Methods: After diagnostic workup, patients were randomized to one of two groups: (1) early laparoscopic cholecystectomy (i.e. within 7 days after onset of symptoms) or (2) initial conservative treatment followed by delayed laparoscopic cholecystectomy. Seventy-four patients entered the early operation group and 71 patients were assigned to the delayed operation strategy. Assessments of quality of life were made at 1, 3 and 6 months after surgery, and in the delayed operation group also one month after the initial conservative treatment. Results: The gastrointestinal symptom scores were significantly better in three dimensions (diarrhea, indigestion, abdominal pain) one month after surgery for the acute operation group (p < 0.01). Three and 6 months after the operation we were unable to detect any significant differences between the groups. The patients in the delayed operation group did not appear to suffer from more symptoms in the period of time waiting for their elective operation. Psychological general well-being showed no major differences between the groups. Conclusion: Cholecystectomy in the acute phase of acute cholecystitis offers a significant reduction of gastrointestinal symptoms during the first postoperative month and to that associated improved quality of life in this group of patients.

Role of nitric oxide in induction of inflammatory fluid secretion by the mucosa of the feline gallbladder

The inflammatory fluid secretion by the gallbladder mucosa in experimental cholecystitis is induced by an increased prostaglandin formation and is mediated by intramural nerves. In the present study the effect of VIP-antiserum on the inflammatory fluid secretion in the gallbladder was tested in a validated experimental model in cats. The animals were studied in acute experiments 6 weeks after a procedure when the cystic duct was tied and gallstones were implanted in the gallbladder. During basal conditions there was a continuous secretion of fluid into the lumen of the inflamed gallbladder averaging 0.43 +/- 0.18 ml/h. Injection of VIP antiserum, obtained from immunized rabbits and diluted with saline 1:10 in a bolus of 4 ml into the coeliac artery reversed this secretion into an absorption of 1.72 +/- 0.44 ml h-1 (P < 0.001). VIP-antiserum did not affect the fluid adsorption in control animals with an intact gallbladder and injection of control serum from rabbits not immunized to VIP did not affect fluid secretion in the inflamed gallbladders. The results support the idea that the inflammatory fluid secretion in the gallbladder mucosa is mediated by VIP-ergic nerve fibres.