A H Sain
One real issue that continues to befall laparoscopic cholecystectomy and still is a matter of current rigorous debate is the question of safety, especially with regard to the risk of bile duct injury. It is well known that the risk of bile duct injury at least quadruples in laparoscopic cholecystectomy versus open cholecystectomy.
Despite the favorable results published by the authors, I believe that early laparoscopic cholecystectomy still is an experimental adventure that needs proper prospective, randomized, controlled trials to test the efficacy and safety of early versus late operations.
Unnecessary Surgery Fraud Confirmed
Author goes on to confirm unnecessary suggestions form diagnose most likely made incorrectly (fraud) . Training or revenue is the question?
I wonder what made the authors decide to perform early laparoscopic cholecystectomy within 5 days of clinical diagnosis compared with delayed operation? The authors also mentioned that all 27 patients who underwent early operations had histologic confirmation of acute cholecystitis. On retrospective review of these 27 patients, not all of them satisfied a clinical diagnosis of acute cholecystitis. There were only 19 patients with fever > 37.5 C, 20 with leukocytes > 10 X I09/ L, 24 with edematous gallbladder, and 23 with ultrasonographic Murphy’s signs. The number of patients who actually presented with upper abdominal pain with tenderness under the right costal margin were not actually stated in the paper. The authors mentioned that there were nine patients with “previous biliary symptoms.” It is important, in my opinion, to specify these symptoms and the substantiated reasons as to why these symptoms were labelled biliary. Painless dyspepsia currently is considered not to be peculiar to gallstone diseases alone.4 From clinical experience, it is well known that sometimes it is very difficult to distinguish with confidence between the two clinical syndromes of”biliary colic” and “acute cholecystitis,” despite the hematologic and imaging studies. I wonder how the authors resolve this issue in their practice, especially in the context of this study. Pathologically, one can envision that the acutely inflamed gallbladder presenting as an acute abdomen can have a spectrum of disease processes, from the mild (chemical) cholecystitis, which may actually take place in “biliary colic” syndrome to the most severe gallbladder empyema, with all the systemic manifestations. This heterogeneity in pathologic processes is clinically important with regard to decision making of the appropriate therapy, especially the timing of surgical intervention. Any future study to establish
the role of early (acute) laparoscopic cholecystectomy in the treatment of acute cholecystitis should address this issue clearly.
References
1. Lo C-M, Liu C-L, Lai ECS, et al. Early versus delayed laparoscopic cholecystectomy for treatment of acute cholecystitis. Ann Surg 1996; 223:37-42.
2. Grace PA, Bouchier-Hayes D. Laparoscopic cholecystectomy. In: Darzi A, Grace PA, Pitt HA, et al. Techniques in the Management ofGallstone Disease. 1st ed. Blackwell Science; 1995: 90-97.
3. Lee VS, Chari RS, Cucchiaro G, et al. Complications of laparoscopic cholecystectomy. Am J Surg 1993; 165:527-532.
4. Rome Group for the Epidemiology and Prevention ofCholelithiasis (GREPCO). The epidemiology of gallstone disease in Rome, Italy: part I, prevalence data in men. Hepatology 1988; 8:904-906. ABD.
HAMID MAT SAIN, F.R.C.S.ED. Edinburgh, United Kingdom
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