Chole Power Point

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    CHOLECYSTECTOMYCHOLECYSTECTOMY

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    INTRODUCTIONINTRODUCTION

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    -- is theis the inflammationinflammation of theof the gall bladdergall bladder..

    CholecystitisCholecystitis is often caused byis often caused bycholelithiasischolelithiasis (the presence of(the presence of cholelithscholeliths,,

    or gallstones, in the gallbladder), withor gallstones, in the gallbladder), with

    cholelithscholeliths most commonly blocking themost commonly blocking the

    cystic ductcystic duct directly. This leads todirectly. This leads to

    inspissationinspissation (thickening) of(thickening) ofbilebile, bile, bile

    stasisstasis, and secondary infection by gut, and secondary infection by gut

    organisms, predominantlyorganisms, predominantlyE. coliE. coliandandBacteroidesBacteroides species.species.

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    Stones in the gallbladder may causeStones in the gallbladder may causeobstruction and the accompanying acuteobstruction and the accompanying acute

    attack.attack.

    The patient might develop a chronic, lowThe patient might develop a chronic, low--

    level inflammation which leads to alevel inflammation which leads to a

    chronicchronic cholecystitischolecystitis, where the, where the

    gallbladder is fibrotic and calcified andgallbladder is fibrotic and calcified and

    the need to undergo surgery is advisedthe need to undergo surgery is adviseddue to the severe symptoms that are feltdue to the severe symptoms that are felt

    by the patient.by the patient.

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    Cholecystectomy is an operation toCholecystectomy is an operation toremove the gallbladder. Surgical removalremove the gallbladder. Surgical removal

    of the gallbladder along with the stonesof the gallbladder along with the stones

    has been the standard of care forhas been the standard of care for

    gallstones.gallstones.

    The gallbladder is not a necessary organThe gallbladder is not a necessary organ

    and patients are not expected to incurand patients are not expected to incurpermanent functional impairment afterpermanent functional impairment after

    its removal.its removal.

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    AMERICAAMERICA PHILIPPINESPHILIPPINES

    WITHADIAGNOSISOFWITHADIAGNOSISOF

    CHOLECYSTITISCHOLECYSTITIS//CHOLELITHIASISCHOLELITHIASIS 5050--75%75% 2020--40%40%

    SICKLECELLDISEASEPATIENTSWHOSICKLECELLDISEASEPATIENTSWHO

    DEVELOPEDDEVELOPEDCALCULOUSCALCULOUS CHOLECYSTITISCHOLECYSTITIS 3434-- 70%70% 3030--37%37%

    Statistical basis:

    #1 Occurrence ofCalculousCholecystitis

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    LCLC OCOC

    DURATIONOFOPERATION 64 MINUTESDURATIONOFOPERATION 64 MINUTES 81.4 MINUTES81.4 MINUTES

    (RANGE: 42TO 1(RANGE: 42TO 103MINUTES) (RANGE: 5503MINUTES) (RANGE: 55--125MIN)125MIN)

    SPANOFRECOVERY WITHIN24 HOURSPOSTOP TOSPANOFRECOVERY WITHIN24 HOURSPOSTOP TO 5DAYSPOSTOP5DAYSPOSTOP

    #2Duration ofOperation vs. Recovery days of

    LC and OC

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    Anatomy and PhysiologyAnatomy and Physiology

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    The gallbladder is a small, pear-

    shaped pouch, non-vital organ in the

    upper-right part of your abdomen(tummy) that aids in the digestive

    process and storesbileproduced in

    the liver.

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    It is divided into three sections:fundus, body, and neck. The neck

    tapers and connects to thebiliary

    tree via the cystic duct, which then

    joins the common hepatic duct to

    become the common bile duct.

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    The adult human gallbladder storesabout 50 mL ofbile, which is

    released when food containing fat

    enters the digestive tract, stimulatingthe secretion ofcholecystokinin

    (CCK). Thebile, produced in the

    liver, emulsifies fats in partly

    digested food.

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    After being stored in the gallbladder,

    thebilebecomes more concentratedthan when it left the liver, increasing

    its potency and intensifying its effect

    on fats. Bile is made fromcholesterol, bile salts and waste

    products. When these substances are

    out of balance, small, hard stones

    called gallstones can form.

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    Gallbladder obstructedGallbladder obstructed

    by gallstonesby gallstones

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    DiagnosticProcedures

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    Cholecystitis is usually diagnosed by a

    history of presenting symptoms as well

    examination findings:fever (usually low grade in uncomplicated

    cases)

    tender right upper quadrant +/- Murphy'ssign

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    Laboratory tests CBC and liver function test)

    frequently show raised hepatocellularliver

    enzymes with a high white cell count (WBC).

    Sonography is a sensitive and specific modality

    for diagnosis of acute cholecystitis; adjusted

    sensitivity and specificity for diagnosis of acutecholecystitis are 88% and 80%, respectively.

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    CT scan findings are in the range of 90-95%. CT

    is more sensitive than ultrasonography.

    X ray of the gallbladder and biliary channels,

    following the administration of a radiopaque dye,

    one of the techniques ofdiagnostic imaging. In

    oral cholecystography, the dye is ingested,

    absorbed by the intestine, and concentrated by the

    gallbladder, which normally appears well opacifiedin the X ray.Abnormalities (e.g., gallstones) may

    be demonstrated by radiolucent areas.

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    The electrocardiogram (ECG) is a graphicrecording of the electrical activity of the heart

    detected at the body surface and amplified. The

    ECG is of greatest use in diagnosing cardiac

    arrhythmias, acute and prior myocardial

    infarctions, pericardial disease, cardiac

    enlargement (atrial and ventricular), and various

    electrolyte disturbances and drug effects.

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    Urinalysis - Laboratory examination of a sample

    ofurine to obtain clinical information. Most ofthe substances normally excreted in the urine are

    metabolic products dissolved or suspended in

    water.A deviation from normal in the

    concentration of urinary constituents or the

    abnormal presence of specific substances may

    thus be indicative of bodily disorders. Changes in

    urine colour, specific gravity, and volume mayalso provide evidence of a specific disease or

    body injury.

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    Cardiopulmonary Clearance or CPclearance is an additional diagnostic test to

    rule out other disease a patient may have. It

    is often used to patients who exhibit riskfactors such as old age >40, gender, etc. that

    may consider them as candidates for

    developing such diseases affecting the heartand lungs.

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    Cholangiogram or injecting of

    dye during the procedure to detect

    some stones

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    OR

    ORTECHNIQUESTECHNIQUES

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    ORTechniques

    There are two ways of performing acholecystectomy:

    Laparoscopic (keyhole) cholecystectomyThis is the most common way of having

    your gallbladder removed. The operation is

    carried out using a tiny camera and surgicalinstruments that are inserted through small

    incisions (cuts) in your abdomen.

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    The laparoscopic approach has been

    proven to be superior to conventional

    open cholecytectomy because of lesspain, quicker recovery, fewer

    problems with incisions and better

    cosmetic appearance.

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    It has even been proven to be safe for

    pregnant patients if certain precautions aretaken. It must be emphasized that both

    laparoscopic and open cholecystectomy

    may have complications such as bile ductinjury, bleeding, bile spillage, hernia,

    spillage of stones, missed bile duct stones

    and complications related to general

    anesthesia.

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    In the US and in most advanced centers

    elsewhere, laparoscopic cholecystectomyhas become the gold standard. In the

    Philippines, the laparoscopic approach is

    slowly but surely replacing the open orconventional cholecystectomy as the

    procedure of choice.

    Length of hospital stay: Eighty-eightpercent of the patients were discharged

    within 24 hours of operation.

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    Open cholecystectomy

    The gallbladder is removed through onelarge cut in your abdomen. This technique

    is called open surgery. It is a more

    invasive operation than keyhole surgery,

    you need to be in hospital for longer and

    it takes longer to recover. Open surgery isa traditional approach and is rare in

    modern practice.

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    A traditional open cholecystectomy is a