Laparoscopic Biliary Surgery [antikvár]

Introduction It is now more than 100 years since Langenbuch performed the first cholecystectomy. This operation is the standard treatment of symptomatic gallstone-related disease as cholecystolithotomy alone leads to recurrence of stones and symptoms in the majority of patients. There is, however, no room for complacency since, despite the vast increase in the number of cholecystectomies performed in Western countries during the past three decades, the mortality from gallstone disease has not declined. Furthermore, a substantial cohort of cholecystectomized patients continue to experience chronic symptoms after this operation. Some of these patients have residual or recurrent biliary tract disease, but the majority have a radiologically normal demonstrable biliary tree and their complaints may be variously related to poorly understood disorders of sphincter fimction, altered physiology of the bUio-digestive system, or scar-related problems. Non-surgical treatment modalities Although extracorporeal shock wave lithotripsy (ESWL) has been an imdoubted significant advance in the treatment of renal calculi, the promise of the early reports of its value in gallstone disease has not materialized since it is now apparent that ESWL is applicable to only 15-20% of patients with gallstone disease overall. Furthermore in those patients in whom stone fragmentation and clearance is achieved, recurrence of stones is high, averaging 10% per annum with a plateau of 50% at 5 years despite oral bile salt maintenance therapy. Investment by an institution in a lithotriptor for the treatment of gallstones does not therefore seem justified. Percutaneous stone extraction (cholecystolithotomy) with or without stone fragmentation (lithotripsy) or chemical dissolution with methyl tert butyl ether (MTBE) have been used in patients with chronic symptoms as an alternative to ESWL, particularly in patients with large stone loads or calcified calculi. Although effective in 80% of patients, these procedures are not definitive and like ESWL are accompanied by a high recurrence rate despite oral bile salt therapy. Percutaneous cholecystostomy Open surgical cholecystectomy remains the treatment of choice for patients who develop acute biliary colic/cholecystitis or gallstone-associated acute pancreatitis. However, whilst the safety record of this operation in the fit adtilt is imdoubted, it carries an appreciable mortality in the elderly, in patients with co-existent cardiorespiratory disease and in cirrhotic individuals, the risk being particularly high for emergency cholecystectomy. In these high-risk groups, percutaneous drainage (cholecystostomy) of the inflamed gallbladder or empyema is a sensible option of proven benefit which tides the poor-risk patient over the critical episode.