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Psk. M. Berk KARAOĞLU
■ Çocuk ve Ergen Psikolojisi
■ Aile Terapileri
■ Bireysel Psikoterapi
■ Cinsel Terapiler
Safra Kesesi ve Laparoskopik Kolesistektomi
MAKALE #5824 © Yazan Op.Dr.Barış ZAMANDAR | Yayın Ekim 2010 | 5,353 Okuyucu
The Turkish Journal of Gastroenterology2001, Volume 12, No 2, Page(s) 110-112[ Summary ] [ Similar Articles ] [ Mail to Editor ] Complications in rats created by human bile and gallstonesZamandar Barış1, Akgün Erhan1, Güler Adem1, İlkgül Özer1, İçöz Gökhan1, Özütemiz Ömer2Ege University Medical School, Departments of General Surgery1 and Gastroenterology2, İzmirKeywords: Laparoscopic cholecystectomy, bile, gallstones, adhesions, Laparoskopik kolesistektomi, safra, safra taşı, adezyon.SummaryBackground/aims: In this study human bile and stones were placed into the abdominal cavities of rats to observe if complications such as adhesions, abscesses and fistulas would occur.
Methods: Stones and bile samples used were taken under sterile conditions from a patient who did not have any previous gallbladder disease such as acute attack or perforation.
Results: During the eight-week study period, the following observations were made: adhesion in the bile and stone implant group 84% (p<0. 05); adhesion in the bile only implant group: 50%, adhesion in the stone only implant group: 59%. No other pathological findings such as abscesses or fistula formation were found.
Conclusion:The utmost care must be taken not to perforate the gallbladder during laparoscopic cholecystectomy.
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IntroductionLaparoscopic cholecystectomy has replaced the open surgery method in the treatment of symptomatic gallbladder stones method at a rapidly increasing rate. This method, which was used by the French for the first time in 1987, is now in widespread use and has become the treatment of choice throughout the world, especially for gallbladder stones (1). It has been found that the laparoscopic method causes patients less pain and that length of hospital stay and cost is reduced in the postoperative period. As with all surgical techniques, complications of this method may also occur. These include bile tract injuries, bile leakage, biliary strictures, arterial injuries, gallbladder perforation, organ injuries, pancreatitis, wound infection and incisional hernia (2). The aim of this study was to experimentally induce abdominal adhesions and other complications by the implantation of bile and stones into the abdomen during laparoscopic cholecystectomy, and to determine the strategy required for such complications.

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Materials And MethodsThis experimental study was carried out at Ege University Medical Faculty Experimental Surgery Laboratories on 48 albino rats, with weights varying between 200gm - 250 gm.
After obtaining bile and stone samples from one patient, 16G branules were used to implant samples percutaneously into the rats, abdomens. General anesthesia was induced by ketamine. These rats were divided into four groups.
Group 1: (n=12) (control group) 2 ml normal saline,
Group 2: (n=12) 2 ml bile liquid,
Group 3: (n=12) stones, smaller than 2 mm,
Group 4 (n=12) stones, smaller than 2 mm. and 2 ml bile liquid.
At the end of an eight-week observation period, the abdomens were opened under ketamine anesthesia and evaluated for the existence of adhesions and/or other complications. The number and location of adhesions was noted. All observations were made in a blinded manner. Kruskal - Wallis and Mann - Whitney U test was used statistical evaluation.

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ResultsIn the first group (control), abdominal adhesions ( intestine - intestine, intestine - pelvis) were encountered in only one of the rats.
In the second group of rats (bile group), six had no adhesions and the following adhesions were found in the others (p=0. 003): intestine - intestine, intestine - omentum, intestine - liver (one rat), intestine - intestine, intestine - liver (two rats) and intestine – pelvis (three rats).
In the third group (stone group), five rats had no adhesions, while the following were found in others (p=0. 01): intestine – intestine (five rats) intestine - intestine, intestine - liver (one rat) intestine - intestine, intestine - pelvis (one rat) and intestine - intestine, intestine – omentum (one rat).
In the fourth group (bile and stone group), two rats were normal, while the following adhesions were encountered in the others (p=0. 0003): intestine - intestine, intestine - liver intestine - omentum (four rats), intestine - intestine (three rats), intestine - intestine, intestine – pelvis (two rats) and omentum – pelvis (one-rat). These results were statistically significant. Among the complications studied within the four groups, when ratios of abdominal adhesions were examined, it was found that adhesion ratios in the second (bile group) and third group (stone group) were not significant when compared to the control group (p=0.003, p=0.01) but that adhesion ratio seen in the fourth group (bile + stone) (p=0. 0003) was significant compared to the control group (p<0. 005).

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DiscussionThe aim of this experimental study was to determine the complications created by bile and stones falling into the abdomen during laparoscopic cholecystectomy. During laparoscopic cholecystectomy, gall bladder perforation and bile and stones falling into the abdomen occurs at a higher rate than open cholecystectomy. Although not frequent, this complication is important and has been found to cause microabscesses, liver abscesses, adhesions and fistulas (3,4). Adhesions have been found to involve the intestines at a significant rate, appearing only after about eight weeks (5) and this finding was confirmed in our study. In Jones study on rats, where stones were placed in the abdomen, he demonstrated a 73 % adhesion rate (6) whereas in our study, this rate was found to be only 59%. The proportion has a direct relationship with the chemical structure of stones and it has been demonstrated that pigment stones lead to a more serious inflammatory reaction (7). Table 1: Distribution of complications
Figure 1: Distribution of complications
Figure 2: The complications created by bile stones during Laparoscopic cholecystectomy.

In our study, a 50% adhesion rate was found with only bile while an 84 % (p= 0.0003) adhesion rate occurred with both bile and stones. It has been reported that bile falling into the abdomen can be adequately removed from the abdominal cavity by washing and irrigation (8). Depending on the amount of bile and stones that fall into the abdomen, the development period of complications such as abscess or fistula etc. may be between two months and four years (8). In our study, no pathological find ing apart from adhesions was encountered. We believe the reason for this to be that samples were examined at the end of an eight weeks period. Marc et al have shown in a series of 1,130 laparoscopic cholecystectomy cases, that abscesses developed in humans at a proportion of 0. 3 %, depending on whether stones fall into the abdomen (4).
Pfeifer has stated that stones left in the abdomen would present with abdominal and pelvic pain either immediately after surgery or a few months later and that associated abscess formation could develop at a later date (9). This inflammation within the pelvic cavity could imitate acute appendicitis and pelvic inflammatory disease in many patients (9, 10). Cases of known gallbladder perforation should therefore attend long-term follow-up and it should be born in mind that continuing pain in the postoperative period may be due to a stone left in the abdomen. In conclusion, it is recommended that in order to prevent postoperative complications developing in association with bile and stones falling into the abdomen during laparoscopic cholecystectomy, the removal of bile and stones should be undertaken as soon as possible (3, 8). To avoid this potential problem, the gall bladder should be removed from the abdomen with special pouches called 'endocatch' wherever possible, which should reduce the risk to a minimum.

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References
1) Bass EB, Pitt HA, Lillemoe KD, Cost effectiveness of laparoscopic cholecystectomy (LC) versus open cholecystectomy. Am J Surg 1993; 165: 466-71.
<A name=r2>2) Ponsky JL. Complications of laparoscopic cholecystectomy. Am J Surg 1991; 161: 393-5.
<A name=r3>3) Johnston SB, Kieran O'Malley. The need to retrieve the dropped stone during laparoscopic cholecystectomy. Am J Surg 1994; 167: 608-10.
<A name=r4>4) Horton M, Michele G. Unusual abscess patterns following dropped gallstones during laparoscopic cholecystectomy. Am J Surg 1998; 175: 375-9.
<A name=r5>5) Andreas P, Ernst P. Bowel obstruction by a free intraperitoneal gallstones a late complications after laparoscopic cholecystectomy. Surgery 1995; 117: 595-6.
<A name=r6>6) Jones DB, Dunnegan DL. The influence of intraoperative gallblader perforation on long-term outcome after laparoscopic cholecystectomy. Surg Endosc 1995; 9: 977-80.
<A name=r7>7) Gürleyik E, Gürleyik G. Does chemical composition have an influence on the fate of intraperitoneal gallstone in rat? Surg Laparosc Endosc 1998; 8:113-6. <A name=r8>8) Gallinaro RN, Miller FB. The lost gallstone, complication after laparoscopic cholecystectomy. Surg Endosc 1994; 20: 913-4. <A name=r9>9) Pfeifer ME, Hansen KA. Ovarian cholelithiasis after laparoscopic cholecystectomy associated with chronic pelvic pain. Fertil Steril 1996; 66: 1031-2. <A name=r10>10) Taurel P, Messens D. Dropped gallstones after laparoscopic cholecystectomy mimicking appendicitis. Journal of CT 1995; 19: 138-9.

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Psk. M. Berk KARAOĞLU
■ Çocuk ve Ergen Psikolojisi
■ Aile Terapileri
■ Bireysel Psikoterapi
■ Cinsel Terapiler
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