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M1502 Single Incision Laparoscopic Cholecystectomy Using a Flexible Endoscope
for patients who have failed conservative therapy or as a salvage procedure for high-risk patients. Methods: Data on consecutive patients admitted with the diagnosis of acute cholecystitis was prospectively collected from January 01, 2005, through Jun, 31, 2006. Demographic, clinical, laboratory and imaging results were collected. Admission parameters, and parameters at 24 and 48 hours, were compared between patients who were successfully treated conservatively and those who required percutaneous cholecystostomy (PC). Logistic regression analysis was performed to identify predictors for failure of conservative treatment. Results: The study population consisted of 103 patients (59 females, 57.3%) with a median age of 60 (range 18-97) who were treated for acute calculus cholecystitis during the study period. Twentyseven patients (26.2%) required percutaneous drainage. Gender, length of symptoms, and the degree of abdominal tenderness were not different between the groups. On univariate analysis, age >70 years, diabetes mellitus, elevated white blood cell count (WBC) and tachycardia at admission, and sonographic findings of a distended gallbladder were found to be significantly more common in the PC group then in the conservative group (p<0.001). Tachycardia and elevated WBC were significantly higher in the PC group throughout the initial 48 hours. On multivariate analysis age >70 (odds ratio [OR] 3.6), diabetes mellitus (OR 9.4), tachycardia at admission (OR 5.6), and a distended gallbladder (OR 8.5) were found to be predictors for the need for early cholecystostomy (p<0.001). Age >70 (OR 5.2) and WBC>15000 (OR 13.7) were predictors for failure of conservative treatment after 24 and 48 hours (p<0.001). Conclusions: The majority of patients suffering from acute cholecystitis can be successfully treated conservatively. Diabetes, age above 70, and a distended gallbladder are predictors for failure of conservative treatment and such patients should be considered for early cholecystostomy. Persistently elevated WBC (>15000) is a marker of refractory disease and should play a more crucial role in the clinical follow-up and decisionmaking process of patients with acute cholecystitis.
Access was obtained through a 1.5 cm periumbilical incision. A dual-channel flexible endoscope (Olympus) was inserted into the peritoneal cavity. A 5mm trocar was inserted through the same incision. In all but one case, dissection of the gallbladder and hilum was performed in a retrograde fashion using flexible endoscopic instruments, while ligation of the cystic duct and artery was accomplished with a standard laparoscopic clip applier. RESULTS: All procedures were completed through the single incision. There were no conversions to either traditional laparoscopic or open technique. Operative time ranged from 1 hour 50 minutes to 4 hours. Six of eight patients were discharged home on the same day of surgery; the other two were kept for observation overnight and were discharged the next morning. There were no complications. CONCLUSION: SILC is a technically challenging though feasible option in select patients requiring laparoscopic cholecystectomy. With fewer incisions, improved cosmetic outcome is an obvious advantage over traditional laparoscopic cholecystectomy. However, further studies are needed to establish its overall safety as well as to evaluate other potential benefits. Additionally, this approach avoids the potential risks of transgastric and transvaginal access while affording surgeons the opportunity to develop advanced endoscopic skills. M1503
Introduction: Standardized, efficient surgical training is increasingly confronted with the public demand for high quality of surgical care in modern teaching hospitals. The aim of this study was to compare perioperative morbidity and mortality of laparoscopic cholecystectomy (LC) as a highly standardized teaching operation when being performed by junior and senior surgical residents (SR) as opposed to those performed by attending surgeons (AS), in a hospital with high percentage of laparoscopic operations. Materials and methods: 1220 LC were performed in a university-affiliated Swiss community hospital between 1999 and 2006. There were 788 (65%) female and 432 (35%) male patients, with an average age of 55 years (range 16-93 years); 874 operations were performed electively, 346 cases were urgent operations. All LC performed by resident surgeons were assisted by attending surgeons or chief residents. Intraoperative cholangiography was routinely performed. Observed parameters were the duration of operation and of hospital stay, 30-day perioperative morbidity, mortality, and readmission rate. Results are stated as mean ± SEM, with p<0.05 defined as statistically significant. Results: Overall length of operation was 92 ± 2 minutes for SR vs. 80 ± 2 minutes by AS (p<0.001). Elective operations were shorter (91 ± 2 [SR] vs. 76 ± 2 [AS] minutes, p<0.001) than urgent operations (96 ± 3 [SR] vs. 90 ± 3 [AS] minutes, p= 0.3). Length of hospital stay was shorter in patients treated by SR as compared to those treated by AS (elective LC: 5.2 ± 0.3 days [SR] vs. 6.7 ± 0.2 days [AS], p<0.001; urgent LC: 6.8 ± 0.6 days [SR] vs. 8.2 ± 0.5 days [AS], p=0.1). Intraoperative complications occured in 4.2%, and were independent of surgeon's experience. Bile duct lesions occurred in 0.2% of all patients. Conversion to an open cholecystectomy for technical difficulties was performed in 24 patients (1.9%). Thirty day morbidity was 8.7% in urgent LC versus 3.3% in elective LC (p<0.001). Overall mortality was 0.4% in elective LC and 1.9% in urgent LC (p>0.001), again independent of surgical expertise. Discussion: Surgical residents are able to perform LC under appropriate supervision with results comparable to those of experienced surgeons. No differences could be detected with respect to perioperative morbidity or mortality; in particular, serious surgical complications such as bile duct injury are rare and are again independent of surgeon's' experience. A structured residency quality control program can improve the quality of surgical care and pinpoint weaknesses of surgical training at individual institutions.
M1501 Polypoid Lesions of Gallbladder: Diagnosis and Follow-Up Hiromichi Ito, Lucy E. Hann, Michael D'Angelica, Yuman Fong, Ronald P. DeMatteo, David S. Klimstra, Leslie H. Blumgart, William R. Jarnagin Background: Polypoid lesions of the gallbladder (PLG) are commonly seen on ultrasonography (US) but optimal management of them is ill-defined. The aims of this study were to assess the natural history and the histological characteristics of US-detected PLG. Methods: Patients with PLG detected by US from were identified retrospectively. Patients with suspected gallbladder cancer were excluded. Histologic findings were analyzed in patients who underwent cholecystectomy and change in polyp size was determined in patients who underwent serial US imaging. Results: From 1996 through 2007, 418 patients with PLG detected on abdominal US were identified. Two hundred and thirty patients (55%) were women and the median age was 59 years (range 20-94). Two hundred and sixty-five patients (64%) were found to have PLG on US during the work-up of unrelated disease while 94 patients (23%) had abdominal symptoms. Three hundred and ninety patients (93%) had PLGs ≤1cm while 28 patients (7%) had PLGs >1cm; 59% of patients had a single polyp and 12% had associated gallstones. Among 141 patients who had repeat US followup, growth was observed in 9 patients (7%), no change in 120 patients (85%) and regression in 12 patients (9%). Eighty patients underwent cholecystectomy and the histological diagnoses are shown in the Table. Most patients had no polyps (32%) or pseudopolyps (57%) (including cholesterol, inflammatory or hyperplastic polyps). Adenomas were seen in 9% of patients while invasive or in situ cancer was only seen in 2 patients, both with lesions ≥11mm. Conclusion: Small PLG (less than 10mm in diameter) detected by US are infrequently associated with symptoms and can be safely observed. The risk of cancer is size dependent, and cholecystectomy is warranted for lesions greater than 10 mm. Pathological diagnosis of PLG and the size on US
M1504 Malignant Melanoma of Lung and Gallbladder, Presenting with Hemoptysis: A Case Report and Review of Literature Ming-Chin Yu, Miin-Fu Chen, Yi-Yin Jan Background: Malignant melanoma (MM) has the potential to spread to virtually any organ. We reported a case of MM presenting as hemoptysis, with two suspicious primary foci, lung and gallbladder, confirmed by histology. Case Presentation: A 56 year-old female smoker presented with productive cough and hemoptysis for half a year. She denied any dyspnea, fever, malaise, abdominal discomfort, and any personal history of lung or gastrointestinal disease. Chest film disclosed patchy opacity over right lower lung. Thorough physical examination of all skin surfaces, including her oral mucosa, was negative. The patient underwent the right lower lung lobectomy without complication, and a black, firm MM measured 4.7x 4.5x4 cm was found. For searching other possible primary or metastatic site, PET-CT was performed and showed F-18 FDG avid lesions in the gallbladder. Partial hepatectomy and cholecystectomy were done and revealed one black, fragile and polypoid tumor measuring 9.0x4.0x3.4 cm. Both specimens were proved of MM. Discussion: The pathologic diagnosis of MM in tumors from lung and gallbladder is confirmed by immunochemical study of S-100 and HMB-45. The imaging study of endoscopic ultrasound, computed tomography, and MRI was reported. Surgical therapy should be performed aggressively for complete removal. PET-CT plays a crucial role in detecting asymptomatic MM in gallbladder for this patient, and certainly help for more accurate patient selection for surgical excision. A series of image studies, including CT, MRI, endoscopic ultrasound, and abdominal ultrasound will be presented. After review of the literature, surgical resection is mandatory for improve survival in limited metastatic melanoma.
*including one adenoma with carcinoma in situ M1502 Single Incision Laparoscopic Cholecystectomy Using a Flexible Endoscope Glenn Forrester, Eugenius J. Harvey, Steven Binenbaum, John N. Afthinos, Grace J. Kim, Julio Teixeira BACKGROUND: The development of a purely NOTES cholecystectomy will be limited by the safety profile of access techniques and the sophistication of flexible instrumentation. Although NOTES cholecystectomy in humans has been reported, in all cases some form of percutaneous transperitoneal assistance has been required. We report our experience with 8 cases performing a laparoscopic cholecystectomy through a single periumbilical incision using flexible endoscopy. METHOD: From August to October 2007, a total of 8 patients (7 women, 1 man) underwent elective single incision laparoscopic cholecystectomy (SILC) using flexible endoscopic instruments. The patients' ages ranged from 19 to 67 years old.
A-861
SSAT Abstracts
SSAT Abstracts
Laparoscopic Cholecystectomy As a Standardized Teaching Operation: A Comparison of Operative Complications and Short-Term Outcome Between Surgical Residents and Attending Surgeons in 1220 Patients Rene Fahrner, Matthias Turina, Valentin Neuhaus, Thomas Kostler, Othmar Schöb
Access was obtained through a 1.5 cm periumbilical incision. A dual-channel flexible endoscope (Olympus) was inserted into the peritoneal cavity. A 5mm trocar was inserted through the same incision. In all but one case, dissection of the gallbladder and hilum was performed in a retrograde fashion using flexible endoscopic instruments, while ligation of the cystic duct and artery was accomplished with a standard laparoscopic clip applier. RESULTS: All procedures were completed through the single incision. There were no conversions to either traditional laparoscopic or open technique. Operative time ranged from 1 hour 50 minutes to 4 hours. Six of eight patients were discharged home on the same day of surgery; the other two were kept for observation overnight and were discharged the next morning. There were no complications. CONCLUSION: SILC is a technically challenging though feasible option in select patients requiring laparoscopic cholecystectomy. With fewer incisions, improved cosmetic outcome is an obvious advantage over traditional laparoscopic cholecystectomy. However, further studies are needed to establish its overall safety as well as to evaluate other potential benefits. Additionally, this approach avoids the potential risks of transgastric and transvaginal access while affording surgeons the opportunity to develop advanced endoscopic skills. M1503
Introduction: Standardized, efficient surgical training is increasingly confronted with the public demand for high quality of surgical care in modern teaching hospitals. The aim of this study was to compare perioperative morbidity and mortality of laparoscopic cholecystectomy (LC) as a highly standardized teaching operation when being performed by junior and senior surgical residents (SR) as opposed to those performed by attending surgeons (AS), in a hospital with high percentage of laparoscopic operations. Materials and methods: 1220 LC were performed in a university-affiliated Swiss community hospital between 1999 and 2006. There were 788 (65%) female and 432 (35%) male patients, with an average age of 55 years (range 16-93 years); 874 operations were performed electively, 346 cases were urgent operations. All LC performed by resident surgeons were assisted by attending surgeons or chief residents. Intraoperative cholangiography was routinely performed. Observed parameters were the duration of operation and of hospital stay, 30-day perioperative morbidity, mortality, and readmission rate. Results are stated as mean ± SEM, with p<0.05 defined as statistically significant. Results: Overall length of operation was 92 ± 2 minutes for SR vs. 80 ± 2 minutes by AS (p<0.001). Elective operations were shorter (91 ± 2 [SR] vs. 76 ± 2 [AS] minutes, p<0.001) than urgent operations (96 ± 3 [SR] vs. 90 ± 3 [AS] minutes, p= 0.3). Length of hospital stay was shorter in patients treated by SR as compared to those treated by AS (elective LC: 5.2 ± 0.3 days [SR] vs. 6.7 ± 0.2 days [AS], p<0.001; urgent LC: 6.8 ± 0.6 days [SR] vs. 8.2 ± 0.5 days [AS], p=0.1). Intraoperative complications occured in 4.2%, and were independent of surgeon's experience. Bile duct lesions occurred in 0.2% of all patients. Conversion to an open cholecystectomy for technical difficulties was performed in 24 patients (1.9%). Thirty day morbidity was 8.7% in urgent LC versus 3.3% in elective LC (p<0.001). Overall mortality was 0.4% in elective LC and 1.9% in urgent LC (p>0.001), again independent of surgical expertise. Discussion: Surgical residents are able to perform LC under appropriate supervision with results comparable to those of experienced surgeons. No differences could be detected with respect to perioperative morbidity or mortality; in particular, serious surgical complications such as bile duct injury are rare and are again independent of surgeon's' experience. A structured residency quality control program can improve the quality of surgical care and pinpoint weaknesses of surgical training at individual institutions.
M1501 Polypoid Lesions of Gallbladder: Diagnosis and Follow-Up Hiromichi Ito, Lucy E. Hann, Michael D'Angelica, Yuman Fong, Ronald P. DeMatteo, David S. Klimstra, Leslie H. Blumgart, William R. Jarnagin Background: Polypoid lesions of the gallbladder (PLG) are commonly seen on ultrasonography (US) but optimal management of them is ill-defined. The aims of this study were to assess the natural history and the histological characteristics of US-detected PLG. Methods: Patients with PLG detected by US from were identified retrospectively. Patients with suspected gallbladder cancer were excluded. Histologic findings were analyzed in patients who underwent cholecystectomy and change in polyp size was determined in patients who underwent serial US imaging. Results: From 1996 through 2007, 418 patients with PLG detected on abdominal US were identified. Two hundred and thirty patients (55%) were women and the median age was 59 years (range 20-94). Two hundred and sixty-five patients (64%) were found to have PLG on US during the work-up of unrelated disease while 94 patients (23%) had abdominal symptoms. Three hundred and ninety patients (93%) had PLGs ≤1cm while 28 patients (7%) had PLGs >1cm; 59% of patients had a single polyp and 12% had associated gallstones. Among 141 patients who had repeat US followup, growth was observed in 9 patients (7%), no change in 120 patients (85%) and regression in 12 patients (9%). Eighty patients underwent cholecystectomy and the histological diagnoses are shown in the Table. Most patients had no polyps (32%) or pseudopolyps (57%) (including cholesterol, inflammatory or hyperplastic polyps). Adenomas were seen in 9% of patients while invasive or in situ cancer was only seen in 2 patients, both with lesions ≥11mm. Conclusion: Small PLG (less than 10mm in diameter) detected by US are infrequently associated with symptoms and can be safely observed. The risk of cancer is size dependent, and cholecystectomy is warranted for lesions greater than 10 mm. Pathological diagnosis of PLG and the size on US
M1504 Malignant Melanoma of Lung and Gallbladder, Presenting with Hemoptysis: A Case Report and Review of Literature Ming-Chin Yu, Miin-Fu Chen, Yi-Yin Jan Background: Malignant melanoma (MM) has the potential to spread to virtually any organ. We reported a case of MM presenting as hemoptysis, with two suspicious primary foci, lung and gallbladder, confirmed by histology. Case Presentation: A 56 year-old female smoker presented with productive cough and hemoptysis for half a year. She denied any dyspnea, fever, malaise, abdominal discomfort, and any personal history of lung or gastrointestinal disease. Chest film disclosed patchy opacity over right lower lung. Thorough physical examination of all skin surfaces, including her oral mucosa, was negative. The patient underwent the right lower lung lobectomy without complication, and a black, firm MM measured 4.7x 4.5x4 cm was found. For searching other possible primary or metastatic site, PET-CT was performed and showed F-18 FDG avid lesions in the gallbladder. Partial hepatectomy and cholecystectomy were done and revealed one black, fragile and polypoid tumor measuring 9.0x4.0x3.4 cm. Both specimens were proved of MM. Discussion: The pathologic diagnosis of MM in tumors from lung and gallbladder is confirmed by immunochemical study of S-100 and HMB-45. The imaging study of endoscopic ultrasound, computed tomography, and MRI was reported. Surgical therapy should be performed aggressively for complete removal. PET-CT plays a crucial role in detecting asymptomatic MM in gallbladder for this patient, and certainly help for more accurate patient selection for surgical excision. A series of image studies, including CT, MRI, endoscopic ultrasound, and abdominal ultrasound will be presented. After review of the literature, surgical resection is mandatory for improve survival in limited metastatic melanoma.
*including one adenoma with carcinoma in situ M1502 Single Incision Laparoscopic Cholecystectomy Using a Flexible Endoscope Glenn Forrester, Eugenius J. Harvey, Steven Binenbaum, John N. Afthinos, Grace J. Kim, Julio Teixeira BACKGROUND: The development of a purely NOTES cholecystectomy will be limited by the safety profile of access techniques and the sophistication of flexible instrumentation. Although NOTES cholecystectomy in humans has been reported, in all cases some form of percutaneous transperitoneal assistance has been required. We report our experience with 8 cases performing a laparoscopic cholecystectomy through a single periumbilical incision using flexible endoscopy. METHOD: From August to October 2007, a total of 8 patients (7 women, 1 man) underwent elective single incision laparoscopic cholecystectomy (SILC) using flexible endoscopic instruments. The patients' ages ranged from 19 to 67 years old.
A-861
SSAT Abstracts
SSAT Abstracts
Laparoscopic Cholecystectomy As a Standardized Teaching Operation: A Comparison of Operative Complications and Short-Term Outcome Between Surgical Residents and Attending Surgeons in 1220 Patients Rene Fahrner, Matthias Turina, Valentin Neuhaus, Thomas Kostler, Othmar Schöb