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A G Johnson - One of the best experts on this subject based on the ideXlab platform.
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Laparoscopic Cholecystectomy: a good buy? A cost comparison with small-incision (mini) Cholecystectomy.
The European journal of surgery = Acta chirurgica, 2000Co-Authors: Neill W. Calvert, Gill P. Troy, A G JohnsonAbstract:Objectives: To compare inpatient costs for laparoscopic and small-incision Cholecystectomy. Design: Retrospective analysis using results of a single blind prospective randomised trial. Setting: Teaching hospital, UK. Subjects: 200 patients having elective Cholecystectomy. Interventions: Standard laparoscopic Cholecystectomy with conversion to open Cholecystectomy if necessary. Small-incision Cholecystectomy using high right transverse epigastric incision, enlarged if necessary for safe exposure. Main outcome measures: Providers inpatient costs. Results: Small-incision Cholecystectomy cost £995 and was 29% less expensive than the laparoscopic procedure which cost £1397. Costs of equipment and operations themselves accounted for most of the difference. Results also suggest that costs to patients and society from time lost away from work may be lower for mini-Cholecystectomy. Conclusions: The national health service could be spending over £10m a year by encouraging laparoscopic rather than small-incision ope...
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A requiem for the cholecystokinin provocation test
Gut, 1999Co-Authors: A Smythe, A W Majeed, M Fitzhenry, A G JohnsonAbstract:Background—The cholecystokinin provocation test (CCKPT) has been claimed to predict a better symptomatic result after Cholecystectomy in patients with acalculous biliary pain. Aims—To examine the predictive value of the CCKPT for symptom relief after Cholecystectomy in both CCKPT positive and negative patients. Patients and methods—Fifty eight patients with acalculous biliary pain underwent CCKPT with serial ultrasound gall bladder volumetry. CCKPT positive patients were offered Cholecystectomy; negative patients were reassessed and were offered a Cholecystectomy if symptoms persisted. Six months after Cholecystectomy, the CCKPT was repeated. Results—Of 32 CCKPT positive patients, 27 underwent Cholecystectomy and of these, 18 (67%) became symptom-free. Postoperatively, 20 of 25 patients converted to CCKPT negative but five remained CCKPT positive and were symptomatic. Of the 26 CCKPT negative patients, nine became symptom-free without Cholecystectomy; six of 14 (42.8%) patients undergoing Cholecystectomy became asymptomatic and remained CCKPT negative. Cholecystectomy seemed to reduce symptoms in both groups, but there was no significant difference in the symptomatic outcome between preoperative CCKPT positive and negative patients. Conclusions—In this study, cholecystokinin provocation testing did not predict symptomatic benefit from Cholecystectomy and we suggest it should no longer be used in the evaluation of patients with acalculous biliary pain. Keywords: Cholecystectomy; cholecystokinin; symptoms
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A requiem for the cholecystokinin provocation test?
Gut, 1998Co-Authors: A Smythe, A W Majeed, M Fitzhenry, A G JohnsonAbstract:The cholecystokinin provocation test (CCKPT) has been claimed to predict a better symptomatic result after Cholecystectomy in patients with acalculous biliary pain. To examine the predictive value of the CCKPT for symptom relief after Cholecystectomy in both CCKPT positive and negative patients. Fifty eight patients with acalculous biliary pain underwent CCKPT with serial ultrasound gall bladder volumetry. CCKPT positive patients were offered Cholecystectomy; negative patients were reassessed and were offered a Cholecystectomy if symptoms persisted. Six months after Cholecystectomy, the CCKPT was repeated. Of 32 CCKPT positive patients, 27 underwent Cholecystectomy and of these, 18 (67%) became symptom-free. Postoperatively, 20 of 25 patients converted to CCKPT negative but five remained CCKPT positive and were symptomatic. Of the 26 CCKPT negative patients, nine became symptom-free without Cholecystectomy; six of 14 (42.8%) patients undergoing Cholecystectomy became asymptomatic and remained CCKPT negative. Cholecystectomy seemed to reduce symptoms in both groups, but there was no significant difference in the symptomatic outcome between preoperative CCKPT positive and negative patients. In this study, cholecystokinin provocation testing did not predict symptomatic benefit from Cholecystectomy and we suggest it should no longer be used in the evaluation of patients with acalculous biliary pain.
A Smythe - One of the best experts on this subject based on the ideXlab platform.
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A requiem for the cholecystokinin provocation test
Gut, 1999Co-Authors: A Smythe, A W Majeed, M Fitzhenry, A G JohnsonAbstract:Background—The cholecystokinin provocation test (CCKPT) has been claimed to predict a better symptomatic result after Cholecystectomy in patients with acalculous biliary pain. Aims—To examine the predictive value of the CCKPT for symptom relief after Cholecystectomy in both CCKPT positive and negative patients. Patients and methods—Fifty eight patients with acalculous biliary pain underwent CCKPT with serial ultrasound gall bladder volumetry. CCKPT positive patients were offered Cholecystectomy; negative patients were reassessed and were offered a Cholecystectomy if symptoms persisted. Six months after Cholecystectomy, the CCKPT was repeated. Results—Of 32 CCKPT positive patients, 27 underwent Cholecystectomy and of these, 18 (67%) became symptom-free. Postoperatively, 20 of 25 patients converted to CCKPT negative but five remained CCKPT positive and were symptomatic. Of the 26 CCKPT negative patients, nine became symptom-free without Cholecystectomy; six of 14 (42.8%) patients undergoing Cholecystectomy became asymptomatic and remained CCKPT negative. Cholecystectomy seemed to reduce symptoms in both groups, but there was no significant difference in the symptomatic outcome between preoperative CCKPT positive and negative patients. Conclusions—In this study, cholecystokinin provocation testing did not predict symptomatic benefit from Cholecystectomy and we suggest it should no longer be used in the evaluation of patients with acalculous biliary pain. Keywords: Cholecystectomy; cholecystokinin; symptoms
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A requiem for the cholecystokinin provocation test?
Gut, 1998Co-Authors: A Smythe, A W Majeed, M Fitzhenry, A G JohnsonAbstract:The cholecystokinin provocation test (CCKPT) has been claimed to predict a better symptomatic result after Cholecystectomy in patients with acalculous biliary pain. To examine the predictive value of the CCKPT for symptom relief after Cholecystectomy in both CCKPT positive and negative patients. Fifty eight patients with acalculous biliary pain underwent CCKPT with serial ultrasound gall bladder volumetry. CCKPT positive patients were offered Cholecystectomy; negative patients were reassessed and were offered a Cholecystectomy if symptoms persisted. Six months after Cholecystectomy, the CCKPT was repeated. Of 32 CCKPT positive patients, 27 underwent Cholecystectomy and of these, 18 (67%) became symptom-free. Postoperatively, 20 of 25 patients converted to CCKPT negative but five remained CCKPT positive and were symptomatic. Of the 26 CCKPT negative patients, nine became symptom-free without Cholecystectomy; six of 14 (42.8%) patients undergoing Cholecystectomy became asymptomatic and remained CCKPT negative. Cholecystectomy seemed to reduce symptoms in both groups, but there was no significant difference in the symptomatic outcome between preoperative CCKPT positive and negative patients. In this study, cholecystokinin provocation testing did not predict symptomatic benefit from Cholecystectomy and we suggest it should no longer be used in the evaluation of patients with acalculous biliary pain.
Brian R. Davidson - One of the best experts on this subject based on the ideXlab platform.
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Surgical management of acute cholecystitis
Langenbeck's Archives of Surgery, 2015Co-Authors: Rahul S. Koti, Christopher J. Davidson, Brian R. DavidsonAbstract:Background Acute cholecystitis occurs in approximately 1 % of patients with known gallstones. It presents as a surgical emergency and usually requires hospitalisation for treatment. It is associated with significant morbidity and mortality, particularly in the elderly. Cholecystectomy is advocated for acute cholecystitis; however, the timing of Cholecystectomy and the value of the additional treatments have been a matter of debate. This review examines the available evidence regarding the optimal surgical management of patients with acute cholecystitis. Methods A literature search was performed on the MEDLINE, EMBASE and WHO International Clinical Trials Registry Platform, databases for English language publications. The MeSH headings ‘cholecystitis’, ‘acute’, ‘gallbladder’, ‘inflammation’, ‘surgery’, ‘Cholecystectomy’, ‘laparoscopic’, ‘robotic’, ‘telerobotic’ and ‘computer-assisted’ were used. Results Data from eight randomised controlled trails and three population-based analyses show that early Cholecystectomy for acute cholecystitis performed on the index admission is safe and not associated with increased conversion rates or morbidity in comparison to conservative treatment followed by elective Cholecystectomy. Delaying Cholecystectomy increases readmissions for gallstone-related events, complications, hospital stay and mortality in the elderly. Early Cholecystectomy is also more cost-effective. Randomised trials addressing antibiotic use in acute cholecystitis suggest that antibiotics should be stopped on the day of Cholecystectomy. Insufficient trials have been performed to address the optimal analgesia regime post Cholecystectomy. Similarly, a lack of trials on intraoperative cholangiography and management of common bile duct stones in patients with acute cholecystitis means that treatment of concomitant bile duct stones should be based on institutional expertise and resource availability. As regards acute cholecystitis in elderly and high-risk patients, case series and retrospective studies would suggest that Cholecystectomy is more effective and of lower mortality than percutaneous cholecystostomy. There is not enough evidence to support the routine use of robotic surgery, single-incision laparoscopic Cholecystectomy or natural orifice transluminal endoscopic surgery (NOTES) in the treatment of acute cholecystitis. Conclusions Trial evidence would favour a policy of early laparoscopic Cholecystectomy following admission with acute cholecystitis. The optimal approach to support early Cholecystectomy is suggested but requires evidence from further randomised trials.
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Miniports versus standard ports for laparoscopic Cholecystectomy.
The Cochrane database of systematic reviews, 2013Co-Authors: Kurinchi Selvan Gurusamy, Jessica Vaughan, Rajarajan Ramamoorthy, Giuseppe Fusai, Brian R. DavidsonAbstract:In conventional (standard) port laparoscopic Cholecystectomy, four abdominal ports (two of 10 mm diameter and two of 5 mm diameter) are used. Recently, use of smaller ports, miniports, have been reported. To assess the benefits and harms of miniport (defined as ports smaller than the standard ports) laparoscopic Cholecystectomy versus standard port laparoscopic Cholecystectomy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until February 2013 to identify randomised clinical trials of relevance to this review. Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing miniport versus standard port laparoscopic Cholecystectomy were considered for the review. Two review authors collected the data independently. We analysed the data with both fixed-effect and random-effects models using RevMan analysis. For each outcome we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI). We included 12 trials with 734 patients randomised to miniport laparoscopic Cholecystectomy (380 patients) versus standard laparoscopic Cholecystectomy (351 patients). Only one trial which included 70 patients was of low risk of bias. Miniport laparoscopic Cholecystectomy could be completed successfully in more than 80% of patients in most trials. The remaining patients were mostly converted to standard port laparoscopic Cholecystectomy but some were also converted to open Cholecystectomy. These patients were included for the outcome conversion to open Cholecystectomy but excluded from other outcomes. Accordingly, the results of the other outcomes are on 343 patients in the miniport laparoscopic Cholecystectomy group and 351 patients in the standard port laparoscopic Cholecystectomy group, and therefore the results have to be interpreted with extreme caution.There was no mortality in the seven trials that reported mortality (0/194 patients in miniport laparoscopic Cholecystectomy versus 0/203 patients in standard port laparoscopic Cholecystectomy). There were no significant differences between miniport laparoscopic Cholecystectomy and standard laparoscopic Cholecystectomy in the proportion of patients who developed serious adverse events (eight trials; 460 patients; RR 0.33; 95% CI 0.04 to 3.08) (miniport laparoscopic Cholecystectomy: 1/226 (adjusted proportion 0.4%) versus standard laparoscopic Cholecystectomy: 3/234 (1.3%); quality of life at 10 days after surgery (one trial; 70 patients; SMD -0.20; 95% CI -0.68 to 0.27); or in whom the laparoscopic operation had to be converted to open Cholecystectomy (11 trials; 670 patients; RR 1.23; 95% CI 0.44 to 3.45) (miniport laparoscopic Cholecystectomy: 8/351 (adjusted proportion 2.3%) versus standard laparoscopic Cholecystectomy 6/319 (1.9%)). Miniport laparoscopic Cholecystectomy took five minutes longer to complete than standard laparoscopic Cholecystectomy (12 trials; 695 patients; MD 4.91 minutes; 95% CI 2.38 to 7.44). There were no significant differences between miniport laparoscopic Cholecystectomy and standard laparoscopic Cholecystectomy in the length of hospital stay (six trials; 351 patients; MD -0.00 days; 95% CI -0.12 to 0.11); the time taken to return to activity (one trial; 52 patients; MD 0.00 days; 95% CI -0.31 to 0.31); or in the time taken for the patient to return to work (two trials; 187 patients; MD 0.28 days; 95% CI -0.44 to 0.99) between the groups. There was no significant difference in the cosmesis scores at six months to 12 months after surgery between the two groups (two trials; 152 patients; SMD 0.13; 95% CI -0.19 to 0.46). Miniport laparoscopic Cholecystectomy can be completed successfully in more than 80% of patients. There appears to be no advantage of miniport laparoscopic Cholecystectomy in terms of decreasing mortality, morbidity, hospital stay, return to activity, return to work, or improving cosmesis. On the other hand, there is a modest increase in operating time after miniport laparoscopic Cholecystectomy compared with standard port laparoscopic Cholecystectomy and the safety of miniport laparoscopic Cholecystectomy is yet to be established. Miniport laparoscopic Cholecystectomy cannot be recommended routinely outside well-designed randomised clinical trials. Further trials of low risks of bias and low risks of random errors are necessary.
M Fitzhenry - One of the best experts on this subject based on the ideXlab platform.
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A requiem for the cholecystokinin provocation test
Gut, 1999Co-Authors: A Smythe, A W Majeed, M Fitzhenry, A G JohnsonAbstract:Background—The cholecystokinin provocation test (CCKPT) has been claimed to predict a better symptomatic result after Cholecystectomy in patients with acalculous biliary pain. Aims—To examine the predictive value of the CCKPT for symptom relief after Cholecystectomy in both CCKPT positive and negative patients. Patients and methods—Fifty eight patients with acalculous biliary pain underwent CCKPT with serial ultrasound gall bladder volumetry. CCKPT positive patients were offered Cholecystectomy; negative patients were reassessed and were offered a Cholecystectomy if symptoms persisted. Six months after Cholecystectomy, the CCKPT was repeated. Results—Of 32 CCKPT positive patients, 27 underwent Cholecystectomy and of these, 18 (67%) became symptom-free. Postoperatively, 20 of 25 patients converted to CCKPT negative but five remained CCKPT positive and were symptomatic. Of the 26 CCKPT negative patients, nine became symptom-free without Cholecystectomy; six of 14 (42.8%) patients undergoing Cholecystectomy became asymptomatic and remained CCKPT negative. Cholecystectomy seemed to reduce symptoms in both groups, but there was no significant difference in the symptomatic outcome between preoperative CCKPT positive and negative patients. Conclusions—In this study, cholecystokinin provocation testing did not predict symptomatic benefit from Cholecystectomy and we suggest it should no longer be used in the evaluation of patients with acalculous biliary pain. Keywords: Cholecystectomy; cholecystokinin; symptoms
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A requiem for the cholecystokinin provocation test?
Gut, 1998Co-Authors: A Smythe, A W Majeed, M Fitzhenry, A G JohnsonAbstract:The cholecystokinin provocation test (CCKPT) has been claimed to predict a better symptomatic result after Cholecystectomy in patients with acalculous biliary pain. To examine the predictive value of the CCKPT for symptom relief after Cholecystectomy in both CCKPT positive and negative patients. Fifty eight patients with acalculous biliary pain underwent CCKPT with serial ultrasound gall bladder volumetry. CCKPT positive patients were offered Cholecystectomy; negative patients were reassessed and were offered a Cholecystectomy if symptoms persisted. Six months after Cholecystectomy, the CCKPT was repeated. Of 32 CCKPT positive patients, 27 underwent Cholecystectomy and of these, 18 (67%) became symptom-free. Postoperatively, 20 of 25 patients converted to CCKPT negative but five remained CCKPT positive and were symptomatic. Of the 26 CCKPT negative patients, nine became symptom-free without Cholecystectomy; six of 14 (42.8%) patients undergoing Cholecystectomy became asymptomatic and remained CCKPT negative. Cholecystectomy seemed to reduce symptoms in both groups, but there was no significant difference in the symptomatic outcome between preoperative CCKPT positive and negative patients. In this study, cholecystokinin provocation testing did not predict symptomatic benefit from Cholecystectomy and we suggest it should no longer be used in the evaluation of patients with acalculous biliary pain.
A W Majeed - One of the best experts on this subject based on the ideXlab platform.
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A requiem for the cholecystokinin provocation test
Gut, 1999Co-Authors: A Smythe, A W Majeed, M Fitzhenry, A G JohnsonAbstract:Background—The cholecystokinin provocation test (CCKPT) has been claimed to predict a better symptomatic result after Cholecystectomy in patients with acalculous biliary pain. Aims—To examine the predictive value of the CCKPT for symptom relief after Cholecystectomy in both CCKPT positive and negative patients. Patients and methods—Fifty eight patients with acalculous biliary pain underwent CCKPT with serial ultrasound gall bladder volumetry. CCKPT positive patients were offered Cholecystectomy; negative patients were reassessed and were offered a Cholecystectomy if symptoms persisted. Six months after Cholecystectomy, the CCKPT was repeated. Results—Of 32 CCKPT positive patients, 27 underwent Cholecystectomy and of these, 18 (67%) became symptom-free. Postoperatively, 20 of 25 patients converted to CCKPT negative but five remained CCKPT positive and were symptomatic. Of the 26 CCKPT negative patients, nine became symptom-free without Cholecystectomy; six of 14 (42.8%) patients undergoing Cholecystectomy became asymptomatic and remained CCKPT negative. Cholecystectomy seemed to reduce symptoms in both groups, but there was no significant difference in the symptomatic outcome between preoperative CCKPT positive and negative patients. Conclusions—In this study, cholecystokinin provocation testing did not predict symptomatic benefit from Cholecystectomy and we suggest it should no longer be used in the evaluation of patients with acalculous biliary pain. Keywords: Cholecystectomy; cholecystokinin; symptoms
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A requiem for the cholecystokinin provocation test?
Gut, 1998Co-Authors: A Smythe, A W Majeed, M Fitzhenry, A G JohnsonAbstract:The cholecystokinin provocation test (CCKPT) has been claimed to predict a better symptomatic result after Cholecystectomy in patients with acalculous biliary pain. To examine the predictive value of the CCKPT for symptom relief after Cholecystectomy in both CCKPT positive and negative patients. Fifty eight patients with acalculous biliary pain underwent CCKPT with serial ultrasound gall bladder volumetry. CCKPT positive patients were offered Cholecystectomy; negative patients were reassessed and were offered a Cholecystectomy if symptoms persisted. Six months after Cholecystectomy, the CCKPT was repeated. Of 32 CCKPT positive patients, 27 underwent Cholecystectomy and of these, 18 (67%) became symptom-free. Postoperatively, 20 of 25 patients converted to CCKPT negative but five remained CCKPT positive and were symptomatic. Of the 26 CCKPT negative patients, nine became symptom-free without Cholecystectomy; six of 14 (42.8%) patients undergoing Cholecystectomy became asymptomatic and remained CCKPT negative. Cholecystectomy seemed to reduce symptoms in both groups, but there was no significant difference in the symptomatic outcome between preoperative CCKPT positive and negative patients. In this study, cholecystokinin provocation testing did not predict symptomatic benefit from Cholecystectomy and we suggest it should no longer be used in the evaluation of patients with acalculous biliary pain.