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Laparoscopic cholecystectomy
801
REVIEW ARTICLE Laparoscopic cholecystectomy
In laparoscopic cholecystectomy the diseased gallbladder is removed by means of instruments introduced through
cannulas; vision of the operative field is maintained by use of
high resolution television camera-monitor system (video laparoscope). General or epidural anaesthesia can be used; and stomach after bladder decompression, a is pneumoperitoneum produced by way of periumbilical a
needle puncture and insufflation of carbon dioxide. A cannula is then inserted in place of the needle to provide and maintain insufflation adequate for surgery. The video laparoscope is inserted through the cannula and, under direct vision, three additional trocars or cannulas are inserted for placement and control of the instruments used to dissect the gallbladder. Intraoperative cholangiograms may be selectively done. The cystic duct and cystic artery are identified and clamped; the gallbladder is resected by means of electrosurgical or laser devices. The video laparoscope is then moved to an upper midline abdominal position to allow visualisation of gallbladder removal through the periumbilical cannula by means of claw forceps or extractor. Four small
(5-11 mm) incisions are required. Gynaecological surgeons have successfully used laparoscopic techniques for some time. The approach was adopted for other intra-abdominal procedures and in 1983 Semm described a series of appendicectomies carried out by laparoscopy.1 Use of the technique for the treatment of gallbladder disease was reported in 1989.Results for several thousand patients have now been published (see table). The complication rate is low and reported hospital stays average 2-0-2-5 days.6,7 Some patients have even been treated as outpatients,8 and Zucker et a113 discharged 93 of 95 patients within 24 h. Dubois and colleagues1O,11 reported 1 death, which occurred 17 days after the procedure. They believe that laparoscopic surgery causes minimum trauma and stress and is the procedure of choice for individuals with high operative risk, such as the elderly and those with severe cardiac or respiratory disease." Phillips et al 17 concluded that the most serious complication was common duct injury, the incidence of which could be reduced by cholangiography. The low rate of reported complications has been achieved despite the use of the technique in some patients over 80 years old.4,9,13 Meyers and colleagues16 reported a prospective study of 1518 patients who underwent this procedure. Their report included results gathered from twenty surgical groups and 59 surgeons, with cases almost equally distributed between academic and private hospitals. Complications were recorded in 5% of all cases (table). 1 patient died 3 days postoperatively from posterior rupture of a 3 cm undiagnosed aortic aneurysm (mortality rate 0-07%). The judgment of experienced surgeons on the risk/benefit ratio of laparoscopic compared with open cholecystectomy was shown by the fact that during this study period, the 59
participating surgeons carried out only 12% of cholecystectomies by the conventional open technique. No reports of randomised trials directly comparing laparoscopic with open cholecystectomy have yet been published. Case selection criteria have varied, generally becoming less stringent as surgeons’ experience with the newer technique increases.
Safety As interest in laparoscopic cholecystectomy grows, it is possible that the procedure may be attempted by surgeons who lack experience or training in the operation and the judgment to appreciate their lack of knowledge. In such circumstances, avoidable complications might arise, as may occur during the development of any new medical or surgical technique. However, in published series of more than 3000 patients laparoscopic cholecystectomy is associated with an extremely low rate of adverse effects (table). The major source of complication in the open procedure is the abdominal incisions which is not necessary for the laparoscopic procedure. RESULTS OF REPORTED LAPAROSCOPIC CHOLECYSTECTOMIES
*Complications laparotomy,
as
defined
by authors;
some
include conversions to open
Medicare data summarised by the Office of Research and Demonstrations, Health Care Financing Administration, on 94 056 patients who underwent open cholecystectomy in 1986 classified adverse events during the index stay into five groups: complications related to bile duct; other gastrointestinal complications; infectious complications related to surgery; general surgical complications; and "other" events.19 The overall adverse event rate was 22-4%, more than six times the rate of complication calculated from ADDRESS: Office of Health Technology Assessment, Agency for Health Care Policy and Research, United States Public Health Service, Rockville, Maryland 20857, USA (T. V. Holohan, MD).
802
the summary data on the laparoscopic procedure (table); the in-hospital mortality rate was 1-95%. Infectious complications related to surgery were reported in 11-8% of cases and general surgical complications in 5-4%. These complication and mortality rates are not inconsistent with data from other sources, although they are at the higher end of the range reported.17 Schwartz has summarised data indicating an overall incidence of wound dehiscence of 2-6% in abdominal operations, with frequencies of 1-3% for patients younger than 45 years and 5-4% in older patients.20 The occurrence of wound infections in operations in which the gastrointestinal tract was entered averaged 10,8%.20 Atelectasis occurs in 10-20% of operations on the upper abdomen, and the risk increases with age. Prolonged immobility after abdominal surgery is a significant risk factor for venous thrombosis and pulmonary embolism. Thrombi have been detected by radioactive fibrinogen scanning in 28% of patients subjected to elective surgical procedures .20 All of these risks are eliminated or minimised by use of the laparoscopic technique. Although laparoscopic cholecystectomy has been less commonly used than the open procedure, the data are consistent and show that it can be accomplished with a very acceptable risk/benefit ratio. The safety compares favourably with that of the open
procedure. Non-surgical treatments of gallbladder disease include drug therapy. Chenodeoxycholic acid has been used to dissolve gallstones, but substantial intrahepatic cholestasis occurs in 3% of patients so treated and raised cholesterol concentrations in 10%.21 Ursodeoxycholic acid has fewer side-effects, but neither drug is effective in most patients. No extracorporeal shock-wave biliary lithotripsy device has been granted marketing approval by the US Food and Drug Administration, but a German study of this method in 711 patients reported an overall adverse effect rate of 39%, with pancreatitis in 2 %, cholestasis in 1 %, and a cholecystectomy rate
of2%.22
rapid resumption of normal activities, and fewer postoperative complications than with the open laparotomy procedure. The acceptability to patients is therefore greater. with more
Patient selection Certain clinical features may limit the suitability of for cholecystectomy by laparoscope, they include
patients
cholangitis, severe acute cholecystitis, acute pancreatitis, peritonitis, portal hypertension, pregnancy, serious bleeding disorder, multiple previous upper abdominal operations, morbid obesity, and inability to tolerate general anaesthesia .4,9,11,13 Variation in patient selection criteria among investigators reflects personal experience, clinical judgment, and differences in expert opinion. However, all of these clinical conditions would also place patients at variably greater operative risk with the open procedure also. The decision to use laparoscopic cholecystectomy or open laparotomy or to defer any surgical procedure in an individual case is most appropriately made by the clinician in attendance, taking into account pertinent clinical variables, available resources, patient preferences, the surgeon’s expertise, and a rational assessment of the risk/benefit ratios of various techniques. The most appropriate choice of therapy may be facilitated by the establishment of patient registries.zs Training and experience in laparoscopic cholecystectomy are important factors in assessing the risk/benefit ratio of the method; several studies have reported an inverse relation between complication rates and the cumulative number of procedures completed. Both individual surgeons4,9,13 and professional groups such as the American College of Surgeons and the Society for Surgery of the Alimentary Tract25have published statements of the experience and qualifications believed to be appropriate for the performance of laparoscopic cholecystectomy. Since in up to 5% of attempted laparoscopic procedures conversion to laparotomy is required, provision for this contingency must be available, both in facilities and surgical expertise. acute
Efficacy Surgical removal of the gallbladder is universally acknowledged to be the most effective treatment of cholelithiasis and cholecystitis. Other therapies have been developed in an attempt to avoid the adverse effects of major abdominal surgery. Drug therapy is appropriate for only a fraction of patients, and the most optimistic data indicate that only 20-40% of carefully selected patients show stone dissolution within 2 years.21 Dissolution rates are higher for radiolucent stones, but radio-opaque stones or those containing more than 4% calcium are very resistant to drug treatment. Even when it is effective, pharmacotherapy does not address the problem of continuing or recurrent stone formation. The clinical usefulness of external shock-wave biliary lithotripsy also appears to be limited: in the German study, only 19% of 5824 patients were considered eligible for lithotripsy, and dissolution was incomplete in most of those with more than one stone.22 The effect of the addition of ursodeoxycholic acid to lithotripsy has also been studied. The rate of total dissolution was reported as 21 % in 6 months.23 The lithotripter is applicable in less than 25% of patients with gallstones, and the risk of recurrence after treatment remains high. The efficacy of laparoscopic cholecystectomy does not significantly differ from that of the open procedure.24 The technique accomplishes a cure for all types of gallstones with greatly reduced patient discomfort, shorter hospital stays
Conclusion There are sufficient published data to permit the conclusion that laparoscopic cholecystectomy can be accomplished with a risk/benefit ratio similar or superior to that of the open procedure. Moreover, the possibility of changing to open laparotomy as clinical circumstances may dictate makes it highly unlikely that laparoscopic complication rates will ever become worse than those of the open procedure. All available published evidence shows that the procedure is effective in treating disease of the gallbladder and is superior to non-surgical approaches. The significant reduction in morbidity minimises both inhospital and postdischarge recuperative time, and may allow surgical treatment of patients whose operative risk factors would make them marginal candidates for laparotomy. Moreover, reductions in the overall cost of gallbladder disease treatment may result from shorter hospital stays, fewer and less serious complications, shortened convalescence, and earlier return to work. REFERENCES 1. Semm K. Endoscopic appendectomy. Endoscopy 1983; 15: 58-64. 2. Perissat J, Collet DR, Belliard R. Gallstones: laparoscopic treatment,
lithotripsy followed by cholecystostomy or cholecystectomy—a personal technique. Endoscopy 1989; 21 (suppl 1): intracorporeal 373-74.
803
3. Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy—a comparison with mini-lap cholecystectomy. Surg Endosc 1989; 3: 131. 4. Gadacz TR, Talamini MA, Lillemoe KD, et al. Laparoscopic cholecystectomy. Surg Clin North Am 1990; 76: 1249-62. 5. Peters JH, Ellison EC, Innes JT, et al. Safety and efficacy of laparoscopic cholecystectomy. A prospective analysis of 100 initial patients. Ann
Surg 1991; 213: 3-12. 6. Dion Y-M, Morin J. Laparoscopic cholecystectomy: a report of 60 cases. Can J Surg 1990; 33: 483-86. 7. Snow LL, Weinstein LS, Hannon JK. Laparoscopic cholecystectomy. Ala Med 1990; 59: 18-22. 8. Reddick EJ, Olsen DO. Outpatient laparoscopic laser cholecystectomy. Am J Surg 1990; 160: 485-89. 9. Spaw AT, Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy: analysis of 500 procedures. Surg Laparoscop Endosc 1991; 1: 2-7. 10. Dubois F, Icard P, Bertholet G, et al. Coelioscopic cholecystectomy: preliminary report of 36 cases. Ann Surg 1990; 211: 60-62. 11. Dubois F, Berthelot G, Levard H. Laparoscopic cholecystectomy: historic perspective and personal experience. Surg Laparoscop Endosc 1991; 1: 52-57.
J, Collet D, Belliard R. Gallstones: laparoscopic treatmentcholecystectomy, cholecystostomy, and lithotropsy. Surg Endosc 1990;
12. Perissat
4: 1-5. 13. Zucker KA,
Bailey RW, Gadacz TR, et al. Laparosopic guided cholecystectomy. Am J Surg 1991; 161: 36-44. 14. Kusminsky RE, Tiley EH, Witsberger TA, et al. Laparoscopic cholecystectomy. West Virginia Med J 1990; 86: 336-37.
15.
16. 17.
O’Reilly MJ, Mooney M, Modesto V. Laparoscopic cholecystectomy: Operation Desert Shield. Surg Laparoscop Endosc (in press). Myers WC, Branum GD, Farouk M, et al. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991; 324: 1073-78. Phillips EH, Berci G, Carroll B, et al. The importance of intraoperative cholangiography during laparoscopic cholecystectomy. Am Surg 1990;
56: 792-95. 18. Merrill JR. Minimal trauma cholecystectomy. Am Surg 1988; 54: 256-61. 19. Health Care Financing Special Report. Health Care Financing Administration, Office of Research and Demonstrations, vol 3, June, 1990. 20. Schwartz SI, ed. Principles of surgery, 4th ed. New York: McGraw-Hill, 1984. 21. Drug Evaluations. Chicago, Illinois: American Medical Association, 1990. 22. Sackmann M, Pauletzki J, Sauerbruch T, et al. The Munich gallbladder lithotripsy study: results of the first five years with 711 patients. Ann Intern Med 1991; 114: 290-96. 23. Schoenfeld LJ, Berci G, Carnovale RI, et al. The effect of ursodiol on the efficacy and safety of extracorporeal shock-wave lithotripsy of gallstones: the Dornier National Biliary Lithotripsy study. N Engl J Med 1990; 323: 1239-45. 24. Way LW. Changing therapy for gallstone disease. N Engl J Med 1990; 323: 1273-74. 25. Tompkins RK. Laparoscopic cholecystectomy: threat or opportunity? Arch Surg 1990; 125: 1245.
VIEWPOINT Is
penicillin still the drug of choice for non-bullous impetigo?
In November, 1989, a six-year-old boy presented to our outpatient paediatric clinic with non-bullous impetigo (figure). He had been well until five days previously when a small, non-painful vesicle below his nose appeared. This lesion was followed by the development of additional vesicles and crusting. He had no history of trauma or contact with anyone else with similar lesions. The boy was afebrile and he had non-tender anterior cervical adenopathy. When treatment with oral penicillin was suggested by the attending physician, a medical student protested, stating that she had just learned from a 1990 dermatology textbook1 that penicillin or erythromycin were no longer the treatment of choice for non-bullous impetigo, although paediatric and medical textbooks published in the late 1980s continued to recommend penicillin.2-4 The student suggested starting therapy with an oral penicillinase-resistant antibiotic (eg, dicloxacillin, amoxycillin/clavulanate, or cephalexin) or local treatment with mupirocin ointment. This case prompted us to review the historical and present role of penicillin in the treatment of non-bullous impetigo. Impetigo (pyoderma) is a superficial bacterial infection of the skin that begins as 1 mm vesicles surrounded by rings of erythema. These vesicles rapidly pustulate and rupture, leaving thick crusts. The lesions, which are painless, most commonly occur over the extremities or face. Mild regional adenopathy is common. Fever and constitutional symptoms are rare. Cultures usually yield group A beta-haemolytic streptococci (GABHS), or a mixture of GABHS and Staphylococcus aureus (SA). By contrast, bullous impetigo,
due to SA, is characterised by 5-30 mm bullae, which rupture to leave thin crusts. Regional adenopathy is uncommon. Like non-bullous impetigo, bullous impetigo is rarely accompanied by pain, fever, and constitutional
symptoms.2-5 Past and present In the 1970s, most cases of non-bullous impetigo were due to GABHS or GABHS/SA. In a study of 43 cases of non-bullous impetigo from which GABHS or GABHS/SA were recovered, Esterly and Markowitz6 found that most cases responded to systemic penicillin, even though the SA was penicillin resistant. They also found that neosporin and gentamicin ointment were less effective than systemic penicillin. It should be noted that these investigators used selective media containing methylrosaniline to recover GABHS because small numbers may be overgrown by SA. This is the classic study showing that the SA of non-bullous impetigo resolves when the GABHS is treated. Dillon7 treated 110 patients with non-bullous impetigo (culturepositive for GABHS or GABHS/SA) with systemic
ADDRESSES: Departments of Family Medicine (Prof H. M. Feder Jr, MD), Pediatrics (Prof H. M. Feder Jr), and Medicine (L. M. Abrahamian, MD); and Division of Dermatology (J. M. Grant-Kels), University of Connecticut Health Center, Farmington, Connecticut 06032, USA. Correspondence to Prof H. M. Feder Jr.
REVIEW ARTICLE Laparoscopic cholecystectomy
In laparoscopic cholecystectomy the diseased gallbladder is removed by means of instruments introduced through
cannulas; vision of the operative field is maintained by use of
high resolution television camera-monitor system (video laparoscope). General or epidural anaesthesia can be used; and stomach after bladder decompression, a is pneumoperitoneum produced by way of periumbilical a
needle puncture and insufflation of carbon dioxide. A cannula is then inserted in place of the needle to provide and maintain insufflation adequate for surgery. The video laparoscope is inserted through the cannula and, under direct vision, three additional trocars or cannulas are inserted for placement and control of the instruments used to dissect the gallbladder. Intraoperative cholangiograms may be selectively done. The cystic duct and cystic artery are identified and clamped; the gallbladder is resected by means of electrosurgical or laser devices. The video laparoscope is then moved to an upper midline abdominal position to allow visualisation of gallbladder removal through the periumbilical cannula by means of claw forceps or extractor. Four small
(5-11 mm) incisions are required. Gynaecological surgeons have successfully used laparoscopic techniques for some time. The approach was adopted for other intra-abdominal procedures and in 1983 Semm described a series of appendicectomies carried out by laparoscopy.1 Use of the technique for the treatment of gallbladder disease was reported in 1989.Results for several thousand patients have now been published (see table). The complication rate is low and reported hospital stays average 2-0-2-5 days.6,7 Some patients have even been treated as outpatients,8 and Zucker et a113 discharged 93 of 95 patients within 24 h. Dubois and colleagues1O,11 reported 1 death, which occurred 17 days after the procedure. They believe that laparoscopic surgery causes minimum trauma and stress and is the procedure of choice for individuals with high operative risk, such as the elderly and those with severe cardiac or respiratory disease." Phillips et al 17 concluded that the most serious complication was common duct injury, the incidence of which could be reduced by cholangiography. The low rate of reported complications has been achieved despite the use of the technique in some patients over 80 years old.4,9,13 Meyers and colleagues16 reported a prospective study of 1518 patients who underwent this procedure. Their report included results gathered from twenty surgical groups and 59 surgeons, with cases almost equally distributed between academic and private hospitals. Complications were recorded in 5% of all cases (table). 1 patient died 3 days postoperatively from posterior rupture of a 3 cm undiagnosed aortic aneurysm (mortality rate 0-07%). The judgment of experienced surgeons on the risk/benefit ratio of laparoscopic compared with open cholecystectomy was shown by the fact that during this study period, the 59
participating surgeons carried out only 12% of cholecystectomies by the conventional open technique. No reports of randomised trials directly comparing laparoscopic with open cholecystectomy have yet been published. Case selection criteria have varied, generally becoming less stringent as surgeons’ experience with the newer technique increases.
Safety As interest in laparoscopic cholecystectomy grows, it is possible that the procedure may be attempted by surgeons who lack experience or training in the operation and the judgment to appreciate their lack of knowledge. In such circumstances, avoidable complications might arise, as may occur during the development of any new medical or surgical technique. However, in published series of more than 3000 patients laparoscopic cholecystectomy is associated with an extremely low rate of adverse effects (table). The major source of complication in the open procedure is the abdominal incisions which is not necessary for the laparoscopic procedure. RESULTS OF REPORTED LAPAROSCOPIC CHOLECYSTECTOMIES
*Complications laparotomy,
as
defined
by authors;
some
include conversions to open
Medicare data summarised by the Office of Research and Demonstrations, Health Care Financing Administration, on 94 056 patients who underwent open cholecystectomy in 1986 classified adverse events during the index stay into five groups: complications related to bile duct; other gastrointestinal complications; infectious complications related to surgery; general surgical complications; and "other" events.19 The overall adverse event rate was 22-4%, more than six times the rate of complication calculated from ADDRESS: Office of Health Technology Assessment, Agency for Health Care Policy and Research, United States Public Health Service, Rockville, Maryland 20857, USA (T. V. Holohan, MD).
802
the summary data on the laparoscopic procedure (table); the in-hospital mortality rate was 1-95%. Infectious complications related to surgery were reported in 11-8% of cases and general surgical complications in 5-4%. These complication and mortality rates are not inconsistent with data from other sources, although they are at the higher end of the range reported.17 Schwartz has summarised data indicating an overall incidence of wound dehiscence of 2-6% in abdominal operations, with frequencies of 1-3% for patients younger than 45 years and 5-4% in older patients.20 The occurrence of wound infections in operations in which the gastrointestinal tract was entered averaged 10,8%.20 Atelectasis occurs in 10-20% of operations on the upper abdomen, and the risk increases with age. Prolonged immobility after abdominal surgery is a significant risk factor for venous thrombosis and pulmonary embolism. Thrombi have been detected by radioactive fibrinogen scanning in 28% of patients subjected to elective surgical procedures .20 All of these risks are eliminated or minimised by use of the laparoscopic technique. Although laparoscopic cholecystectomy has been less commonly used than the open procedure, the data are consistent and show that it can be accomplished with a very acceptable risk/benefit ratio. The safety compares favourably with that of the open
procedure. Non-surgical treatments of gallbladder disease include drug therapy. Chenodeoxycholic acid has been used to dissolve gallstones, but substantial intrahepatic cholestasis occurs in 3% of patients so treated and raised cholesterol concentrations in 10%.21 Ursodeoxycholic acid has fewer side-effects, but neither drug is effective in most patients. No extracorporeal shock-wave biliary lithotripsy device has been granted marketing approval by the US Food and Drug Administration, but a German study of this method in 711 patients reported an overall adverse effect rate of 39%, with pancreatitis in 2 %, cholestasis in 1 %, and a cholecystectomy rate
of2%.22
rapid resumption of normal activities, and fewer postoperative complications than with the open laparotomy procedure. The acceptability to patients is therefore greater. with more
Patient selection Certain clinical features may limit the suitability of for cholecystectomy by laparoscope, they include
patients
cholangitis, severe acute cholecystitis, acute pancreatitis, peritonitis, portal hypertension, pregnancy, serious bleeding disorder, multiple previous upper abdominal operations, morbid obesity, and inability to tolerate general anaesthesia .4,9,11,13 Variation in patient selection criteria among investigators reflects personal experience, clinical judgment, and differences in expert opinion. However, all of these clinical conditions would also place patients at variably greater operative risk with the open procedure also. The decision to use laparoscopic cholecystectomy or open laparotomy or to defer any surgical procedure in an individual case is most appropriately made by the clinician in attendance, taking into account pertinent clinical variables, available resources, patient preferences, the surgeon’s expertise, and a rational assessment of the risk/benefit ratios of various techniques. The most appropriate choice of therapy may be facilitated by the establishment of patient registries.zs Training and experience in laparoscopic cholecystectomy are important factors in assessing the risk/benefit ratio of the method; several studies have reported an inverse relation between complication rates and the cumulative number of procedures completed. Both individual surgeons4,9,13 and professional groups such as the American College of Surgeons and the Society for Surgery of the Alimentary Tract25have published statements of the experience and qualifications believed to be appropriate for the performance of laparoscopic cholecystectomy. Since in up to 5% of attempted laparoscopic procedures conversion to laparotomy is required, provision for this contingency must be available, both in facilities and surgical expertise. acute
Efficacy Surgical removal of the gallbladder is universally acknowledged to be the most effective treatment of cholelithiasis and cholecystitis. Other therapies have been developed in an attempt to avoid the adverse effects of major abdominal surgery. Drug therapy is appropriate for only a fraction of patients, and the most optimistic data indicate that only 20-40% of carefully selected patients show stone dissolution within 2 years.21 Dissolution rates are higher for radiolucent stones, but radio-opaque stones or those containing more than 4% calcium are very resistant to drug treatment. Even when it is effective, pharmacotherapy does not address the problem of continuing or recurrent stone formation. The clinical usefulness of external shock-wave biliary lithotripsy also appears to be limited: in the German study, only 19% of 5824 patients were considered eligible for lithotripsy, and dissolution was incomplete in most of those with more than one stone.22 The effect of the addition of ursodeoxycholic acid to lithotripsy has also been studied. The rate of total dissolution was reported as 21 % in 6 months.23 The lithotripter is applicable in less than 25% of patients with gallstones, and the risk of recurrence after treatment remains high. The efficacy of laparoscopic cholecystectomy does not significantly differ from that of the open procedure.24 The technique accomplishes a cure for all types of gallstones with greatly reduced patient discomfort, shorter hospital stays
Conclusion There are sufficient published data to permit the conclusion that laparoscopic cholecystectomy can be accomplished with a risk/benefit ratio similar or superior to that of the open procedure. Moreover, the possibility of changing to open laparotomy as clinical circumstances may dictate makes it highly unlikely that laparoscopic complication rates will ever become worse than those of the open procedure. All available published evidence shows that the procedure is effective in treating disease of the gallbladder and is superior to non-surgical approaches. The significant reduction in morbidity minimises both inhospital and postdischarge recuperative time, and may allow surgical treatment of patients whose operative risk factors would make them marginal candidates for laparotomy. Moreover, reductions in the overall cost of gallbladder disease treatment may result from shorter hospital stays, fewer and less serious complications, shortened convalescence, and earlier return to work. REFERENCES 1. Semm K. Endoscopic appendectomy. Endoscopy 1983; 15: 58-64. 2. Perissat J, Collet DR, Belliard R. Gallstones: laparoscopic treatment,
lithotripsy followed by cholecystostomy or cholecystectomy—a personal technique. Endoscopy 1989; 21 (suppl 1): intracorporeal 373-74.
803
3. Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy—a comparison with mini-lap cholecystectomy. Surg Endosc 1989; 3: 131. 4. Gadacz TR, Talamini MA, Lillemoe KD, et al. Laparoscopic cholecystectomy. Surg Clin North Am 1990; 76: 1249-62. 5. Peters JH, Ellison EC, Innes JT, et al. Safety and efficacy of laparoscopic cholecystectomy. A prospective analysis of 100 initial patients. Ann
Surg 1991; 213: 3-12. 6. Dion Y-M, Morin J. Laparoscopic cholecystectomy: a report of 60 cases. Can J Surg 1990; 33: 483-86. 7. Snow LL, Weinstein LS, Hannon JK. Laparoscopic cholecystectomy. Ala Med 1990; 59: 18-22. 8. Reddick EJ, Olsen DO. Outpatient laparoscopic laser cholecystectomy. Am J Surg 1990; 160: 485-89. 9. Spaw AT, Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy: analysis of 500 procedures. Surg Laparoscop Endosc 1991; 1: 2-7. 10. Dubois F, Icard P, Bertholet G, et al. Coelioscopic cholecystectomy: preliminary report of 36 cases. Ann Surg 1990; 211: 60-62. 11. Dubois F, Berthelot G, Levard H. Laparoscopic cholecystectomy: historic perspective and personal experience. Surg Laparoscop Endosc 1991; 1: 52-57.
J, Collet D, Belliard R. Gallstones: laparoscopic treatmentcholecystectomy, cholecystostomy, and lithotropsy. Surg Endosc 1990;
12. Perissat
4: 1-5. 13. Zucker KA,
Bailey RW, Gadacz TR, et al. Laparosopic guided cholecystectomy. Am J Surg 1991; 161: 36-44. 14. Kusminsky RE, Tiley EH, Witsberger TA, et al. Laparoscopic cholecystectomy. West Virginia Med J 1990; 86: 336-37.
15.
16. 17.
O’Reilly MJ, Mooney M, Modesto V. Laparoscopic cholecystectomy: Operation Desert Shield. Surg Laparoscop Endosc (in press). Myers WC, Branum GD, Farouk M, et al. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991; 324: 1073-78. Phillips EH, Berci G, Carroll B, et al. The importance of intraoperative cholangiography during laparoscopic cholecystectomy. Am Surg 1990;
56: 792-95. 18. Merrill JR. Minimal trauma cholecystectomy. Am Surg 1988; 54: 256-61. 19. Health Care Financing Special Report. Health Care Financing Administration, Office of Research and Demonstrations, vol 3, June, 1990. 20. Schwartz SI, ed. Principles of surgery, 4th ed. New York: McGraw-Hill, 1984. 21. Drug Evaluations. Chicago, Illinois: American Medical Association, 1990. 22. Sackmann M, Pauletzki J, Sauerbruch T, et al. The Munich gallbladder lithotripsy study: results of the first five years with 711 patients. Ann Intern Med 1991; 114: 290-96. 23. Schoenfeld LJ, Berci G, Carnovale RI, et al. The effect of ursodiol on the efficacy and safety of extracorporeal shock-wave lithotripsy of gallstones: the Dornier National Biliary Lithotripsy study. N Engl J Med 1990; 323: 1239-45. 24. Way LW. Changing therapy for gallstone disease. N Engl J Med 1990; 323: 1273-74. 25. Tompkins RK. Laparoscopic cholecystectomy: threat or opportunity? Arch Surg 1990; 125: 1245.
VIEWPOINT Is
penicillin still the drug of choice for non-bullous impetigo?
In November, 1989, a six-year-old boy presented to our outpatient paediatric clinic with non-bullous impetigo (figure). He had been well until five days previously when a small, non-painful vesicle below his nose appeared. This lesion was followed by the development of additional vesicles and crusting. He had no history of trauma or contact with anyone else with similar lesions. The boy was afebrile and he had non-tender anterior cervical adenopathy. When treatment with oral penicillin was suggested by the attending physician, a medical student protested, stating that she had just learned from a 1990 dermatology textbook1 that penicillin or erythromycin were no longer the treatment of choice for non-bullous impetigo, although paediatric and medical textbooks published in the late 1980s continued to recommend penicillin.2-4 The student suggested starting therapy with an oral penicillinase-resistant antibiotic (eg, dicloxacillin, amoxycillin/clavulanate, or cephalexin) or local treatment with mupirocin ointment. This case prompted us to review the historical and present role of penicillin in the treatment of non-bullous impetigo. Impetigo (pyoderma) is a superficial bacterial infection of the skin that begins as 1 mm vesicles surrounded by rings of erythema. These vesicles rapidly pustulate and rupture, leaving thick crusts. The lesions, which are painless, most commonly occur over the extremities or face. Mild regional adenopathy is common. Fever and constitutional symptoms are rare. Cultures usually yield group A beta-haemolytic streptococci (GABHS), or a mixture of GABHS and Staphylococcus aureus (SA). By contrast, bullous impetigo,
due to SA, is characterised by 5-30 mm bullae, which rupture to leave thin crusts. Regional adenopathy is uncommon. Like non-bullous impetigo, bullous impetigo is rarely accompanied by pain, fever, and constitutional
symptoms.2-5 Past and present In the 1970s, most cases of non-bullous impetigo were due to GABHS or GABHS/SA. In a study of 43 cases of non-bullous impetigo from which GABHS or GABHS/SA were recovered, Esterly and Markowitz6 found that most cases responded to systemic penicillin, even though the SA was penicillin resistant. They also found that neosporin and gentamicin ointment were less effective than systemic penicillin. It should be noted that these investigators used selective media containing methylrosaniline to recover GABHS because small numbers may be overgrown by SA. This is the classic study showing that the SA of non-bullous impetigo resolves when the GABHS is treated. Dillon7 treated 110 patients with non-bullous impetigo (culturepositive for GABHS or GABHS/SA) with systemic
ADDRESSES: Departments of Family Medicine (Prof H. M. Feder Jr, MD), Pediatrics (Prof H. M. Feder Jr), and Medicine (L. M. Abrahamian, MD); and Division of Dermatology (J. M. Grant-Kels), University of Connecticut Health Center, Farmington, Connecticut 06032, USA. Correspondence to Prof H. M. Feder Jr.