Joel J. Roslyn

Open cholecystectomy. A contemporary analysis of 42,474 patients.

ObjectiveThis study evaluated, in a large, heterogeneous population, the outcome of open cholecystectomy as it is currently practiced. Summary Background and DataAlthough cholecystectomy has been the gold standard of treatment for cholelithiasis for more than 100 years, it has recently been challenged by the introduction of several new modalities including laparoscopic cholecystectomy. Efforts to define the role of these alternative treatments have been hampered by the lack of contemporary data regarding open cholecystectomy. MethodsA population-based study was performed examining all open cholecystectomies performed by surgeons in an eastern and western state during a recent 12-month period. Data compiled consisted of a computerized analysis of Uniformed Billing (UB-82) discharge analysis information from all non-Veterans Administration (VA), acute care hospitals in California (Office of Statewide Planning and Development [OSHPD]) and in Maryland (Health Services Cost Review Commission [HSCRC]) between January 1, 1989, and December 31, 1989. This data base was supplemented with a 5% random sample of Medicare UB-82 data from patients who were discharged between October 1,1988, and September 30, 1989. Patients undergoing cholecystectomy were identified based on diagnosis-related groups (DRG-197 and DRG-198), and then classified by Principal Diagnosis and divided into three clinically homogeneous subgroups: acute cholecystitis, chronic cholecystitis, and complicated cholecystitis. ResultsA total of 42,474 patients were analyzed, which represents approximately 8% of all patients undergoing cholecystectomy in the United States in any recent 12-month period. The overall mortality rate was 0.17% and the Incidence rate of bile duct injuries was approximately 0.2%. The mortality rate was 0.03% in patients younger than 65 years of age and 0.5% in those older than 65 years of age. Mortality rate, length of hospital stay, and charges were all significantly correlated (p < 0.001) with age, admission status (elective, urgent, or emergent), and disease status. ConclusionsThese data indicate that open cholecystectomy currently is a very safe, effective treatment for cholelithiasis and is being performed with near zero mortality. The ultimate role of laparoscopic

Gallbladder Disease in Patients on Long-Term Parenteral Nutrition

Recent anecdotal reports suggest that total parenteral nutrition may be associated with an increased incidence of both acalculous cholecystitis and cholelithiasis. The validity of this association, however, has not been tested in a large population of patients on long-term total parenteral nutrition. Therefore, we assessed the incidence of gallbladder disease among our patients 15 yr and older who had received a minimum of 3 mo of total parenteral nutrition. Of the patients meeting these criteria, 128 were on total parenteral nutrition a mean of 13.5 mo. Nineteen had gallbladder disease before receiving total parenteral nutrition, leaving 109 patients at risk. Of these patients, 25 (23%) developed gallbladder disease after the initiation of total parenteral nutrition. Because of their known propensity for cholelithiasis, 94 of our patients with ileal disorders (Crohns disease or ileal resection, or both) were considered separately. The 40% incidence of gallbladder disease in these 94 patients was significantly higher than expected from a series of similarly defined patients with ileal disorders not receiving total parenteral nutrition (p less than 0.05). We propose that the enhanced risk of gallbladder disease among patients on long-term total parenteral nutrition results from multiple factors working in concert to promote gallbladder stasis.

Increased risk of cholelithiasis with prolonged total parenteral nutrition

Patients who receive hyperalimentation undergo prolonged periods of fasting which may alter bile composition and lead to gallbladder stasis, both important factors in gallstone formation. Therefore, we tested the hypothesis that patients who receive long-term TPN are at increased risk for cholelithiasis by performing cholecystosonography on adult patients who had received a minimum of 3 months of intravenous hyperalimentation during 1981. Seventy-one patients whose mean age was 41.9 years, 41 percent of whom were men, met these criteria. Gallstones had been diagnosed in 11 of the 71 patients (15 percent) before the initiation of parenteral nutrition. Twenty-one of the remaining 60 at risk patients (35 percent) were discovered to have cholelithiasis after hyperalimentation was started. The 45 percent prevalence of gallstones in our 71 patients was significantly higher (p less than 0.001) than predicted from autopsy data. In addition, the 49 percent prevalence of cholelithiasis in our 53 patients with ileal disorders was significantly greater (p less than 0.02) than predicted from a study of patients with similarly defined ileal disorders. This analysis strongly suggests that patients who receive long-term TPN are at increased risk for the development of cholelithiasis.

Proximal bile duct cancer. Quality of survival.

A retrospective study of 97 patients with proximal bile duct cancer treated at the University of California, Los Angeles Medical Center was conducted to determine the benefits of different operative treatments. Eighty-nine patients were divided into three treatment groups: Group I, curative resection (29 patients); Group II, palliative resection (13 patients) and bypasses (8 patients); and Group III, operative intubation (39 patients). Two patients died before operation and six patients were treated without operation by percutaneous biliary decompression. High morbidity rate (53.8%) and mortality rate (69.2%) were encountered in 13 patients who had hepatic resection. Survival rates of the three treatment groups were comparable. For the 64 patients closely monitored after discharge, quality of survival was assessed according to six parameters: frequency of hospitalization for cholangitis; catheter-related problems; the percentage of days hospitalized; duration of jaundice; antibiotic requirements; and analgesic needs. Group I patients had the best qualitative survival, whereas Group II patients had the worst result when compared with either Group I (p less than 0.001) or Group III (p less than 0.005). Curative resection is recommended when it can be done without a concomitant hepatic resection. When noncurable disease is found on examination, operative intubation after dilatation is the preferred palliative measure.

Perforation of the gallbladder: a frequently mismanaged condition.

Abstract Gallbladder perforation is a lethal complication of cholecystitis, a relatively common disease, and has a mortality of 15 to 20 per cent. At UCLA Hospital seventeen patients with perforation of the gallbladder were evaluated and compared with patients who had previously been reported in the English literature. The purpose of this report was to: (1) establish a set of criteria to identify the patient who is at high risk for gallbladder perforation; (2) detail an appropriate course of diagnostic and therapeutic management; and (3) propose a unified concept of the pathogenesis of gallbladder perforation. The majority of patients were elderly men (mean age, 61 years) and women (mean age, 67 years) with significant atherosclerotic cardiovascular disease or underlying malignancy. Another important subset of patients consisted of young men who were receiving long-term steroid or immunosuppressive therapy for collagen vascular disease. Almost all of the patients with gallbladder perforation were subjected to an inordinate delay in diagnosis and surgical intervention (6.8 days), and this was responsible for a significant complication rate of 58 per cent as well as an extended postoperative hospitalization time (16 days). The mortality for the entire series was 17 per cent. The successful management of gallbladder perforation is based on early recognition of the patients who are at high risk for this condition. Preoperative diagnostic and therapeutic measures can usually be performed within 12 hours and should include ultrasonography or intravenous cholangiography, fluid resuscitation, nasogastric decompression, and broad spectrum antibiotic administration. A successful outcome in these patients, however, can be achieved only with operative intervention.

Gallbladder absorption increases during early cholesterol gallstone formation.

The hypothesis that the presence of cholelithogenic bile during the early stages of cholesterol gallstone formation promotes gallbladder absorption of water and electrolytes was tested in a prairie dog gallstone model. An increase in gallbladder transport of water and sodium was observed in cholesterol-fed prairie dogs at a time when cholesterol crystals were present, but before gallstone formation. These data suggest that in the presence of cholesterol-saturated bile, in vivo gallbladder absorption is increased during the early stages of cholesterol gallstone formation. The resulting increase in the solute concentration may promote nucleation and, therefore, be an important etiologic factor in cholesterol gallstone formation.

Parenteral nutrition-induced gallbladder disease: A reason for early cholecystectomy

Patients who receive long-term parenteral nutrition have an increased incidence of both calculous and acalculous cholecystitis. In an attempt to establish guidelines for the clinical management of patients with TPN-induced gallbladder disease, we have reviewed the records of 35 patients who have undergone cholecystectomy for this problem since 1976 at the UCLA Medical Center. The mean age of the 23 adult and 12 children who had cholecystectomy was 29.1 years. Forty percent of these patients required emergency cholecystectomy. The overall operative morbidity was 54 percent, and the hospital mortality was 11 percent. Significant factors contributing to this high rate of complications included a delay in diagnosis, especially in the young children, and increased operative difficulty due to extensive adhesions and intraoperative hemorrhage. Our analysis suggests that patients receiving long-term TPN should have a program of ultrasound surveillance for gallstone formation, elective cholecystectomy when stones first appear, and consideration of cholecystectomy at the time of laparotomy performed for other reasons. Whether TPN-induced gallstones can be prevented through daily stimulated gallbladder emptying awaits the results of future studies.

Pancreatitis Associated with Adult Choledochal Cysts

We reviewed the records of 32 adult patients with choledochal cysts (CDC) to determine the characteristics of the associated pancreatic disease. Eighteen patients (56%) had 30 documented episodes of pancreatitis with epigastric pain and elevated serum amylase levels. Three patients developed a prolonged course with a pancreatic phlegmon and one patient died secondary to a pancreatic abscess after endoscopic retrograde cholangi-opancreatography (ERCP). Pancreatitis occurred in all types of CDC and was not related to the age, gender, or race of the patient. There was an association with the size of the CDC: 90% of patients with CDC 3 5 cm developed pancreatitis compared with only 9% of patients with CDC < 5 cm (p < 0.0004). In addition, ERCP was performed in 14 patients and demonstrated an abnormal pancreatico-biliary duct junction in eight (57%). All eight patients with an abnormal pancreaticobiliary junction developed pancreatitis compared with only 2 out of 6 patients with normal pancreatic duct anatomy (p < 0.006). Patients under-going surgical bypass rather than resection also tended to have higher rates of pancreatitis (80 vs. 50%). One patient with a Type I CDC and chronic pancreatitis was treated with surgical resection of the CDC and pancreatic head; this combined procedure relieved the pain. Microscopic examination of the CDC and the abnormal “common channel” within the pancreas revealed identical fibrous thickening of the duct walls with focal chronic inflammation and loss of surface epithelium. In conclusion, these data stress the previously unrecognized high incidence of symptomatic pancreatic inflammatory disease that accompanies adult CDC. Diagnostic ERCP and surgical manipulations of the pancreas should be done with care to avoid precipitating pancreatitis. CDC resection is preferred to surgical bypass to avoid anastomotic stricture with cholangitis and to minimize the chance for ongoing pancreatitis.

Roles of lithogenic bile and cystic duct occlusion in the pathogenesis of acute cholecystitis

The hypothesis that the elements essential for the induction of acute cholecystitis are the presence of lithogenic bile and cystic duct occlusion was tested in the prairie dog gallstone model. Neither the presence of gallstones alone nor acute cystic duct occlusion alone resulted in acute inflammation of the gallbladder. Acute cholecystitis developed in prairie dog gallbladders containing cholesterol-saturated bile, with or without gallstones, shortly after cystic duct occlusion. These data suggest that the factors essential for the induction of acute cholecystitis are the presence of lithogenic bile and cystic duct occlusion and that gallstones, although frequently present, are not an essential prerequisite to acute inflammation.

Effects of cholecystokinin on gallbladder stasis and cholesterol gallstone formation

Abstract Recent studies suggest an etiologic role for gallbladder stasis in the genesis of cholesterol gallstones. The effect of periodic gallbladder emptying on stone prevention is not clear. Using the prairie dog model, we tested the hypothesis that daily cholecystokinin-octapeptide (CCK-OP) prevents gallbladder stasis and cholesterol gallstone formation. Prairie dogs were fed either a control or a 0.4% cholesterol-enriched chow for 6 weeks. Cholesterol-fed animals received a daily intramuscular injection of either saline, CCK-OP, 0.2 μg/kg or CCK-OP, 1.0 μg/kg. Gallbladder bile lithogenic index (LI), bile salt pool size (BSPS), and the degree of radioisotope equilibration between gallbladder and hepatic bile (Rsa-an index of stasis) were determined. The more physiologic dose of CCK-OP (0.2) significantly reduced BSPS and bile lithogenicity, prevented stasis and reduced the incidence of gallstones. Our data suggest that (1) periodic gallbladder emptying decreases bile lithogenicity, prevents stasis, and reduces the incidence of cholelithiasis, (2) stasis is essential to gallstone formation and (3) daily physiologic doses of CCK-OP may be useful for gallstone prophylaxis in high-risk patients.