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ObjectiveThis study provided an objective survey by an outside auditing group of a large, complete patient population undergoing laparoscopic cholecystectomies, determined the frequency of complications, especially bile duct injuries, and presented a system for classifying and comparing the severity of bile duct injuries. Summary Background DataThis is the first study of laparoscopic cholecystectomy to encompass a large and complete patient population and to be based on objectively collected data rather than self-reported data. The Civilian External Peer Review Program (CEPRP) of the Department of Defense health care system conducted a retrospective study of 5642 patients who underwent laparoscopic cholecystectomies at 89 military medical treatment facilities from July 1990 through May 1992. MethodsThe study sample consisted of the complete records of 5607 (99.38%) of the 5642 laparoscopic cholecystectomy patients. ResultsOf the sample, 6.87% of patients experienced complications within 30 days of surgery, 0.57% sustained bile duct injuries, and 0.5% sustained bowel injuries. Among 5154 patients whose procedures were completed laparoscopically, 5.47% experienced complications. Laparoscopic procedures were converted to open cholecystectomies in 8.08% of cases. Intraoperative cholangiograms were attempted in 46.5% of cases and completed in 80.59% of those attempts. There were no intraoperative deaths; 0.04% of the patients died within 30 days of surgery. ConclusionsThe frequency of complications found in this study is comparable to the frequency of complications reported in recent large civilian studies and earlier, smaller studies. The authors present a system for classifying bile duct injuries, which is designed to standardize references to such injuries and allow for accurate comparison of bile duct injuries in the future.

Pressures were measured in the carotid arteries of 61 patients proximal and distal to atherosclerotic plaques which were carefully studied by angiography and anatomical dissection. (1) An atherosclerotic plaque causing a constriction of less than 47% luminal diameter leaving a lumen greater than 3.0 mm in diameter never caused pressure drops of greater than 10 mm Hg. Stenoses of greater than 63% luminal diameter leaving lumens less than 1.0 mm in diameter always caused pressure drops. (2) Atherosclerotic plaques producing defects which narrowed the lumen fell into a distinct pattern: (a) Type 1 lesions—This basic lesion filled the bulb of the internal carotid artery near its origin, causing a 1 to 2 cm smooth elliptical encroachment on the lumen. (b) Type 2 lesions—Short localized areas of thickening in addition to the basic lesion caused bar-like defects of the lumen at the origin of the internal carotid artery or near the distal end of the lesion. (c) Type 3 lesions—Multiple bar-like defects were sometimes seen. (d) Type 4 lesions—The areas of increased thickening of the lesion were sometimes quite narrow, producing diaphragm-like defects on the lumen. Although theoretically these various types of stenoses should produce different hemodynamic changes, insufficient numbers of observations were made to corroborate these presumptions. (3) Angiograms in general mimicked the gross appearance of the plaques and predicted the actual degree of stenosis produced but did not identify many diaphragm defects, ulcerations, or small thrombi.

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Twelve patients with chronic common carotid artery (CCA) occlusion were studied. There were 8 patients with TIAs (3 hemispheric and 5 vertebral-basilar), one with a completed stroke, and 3 were asymptomatic. The ipsilateral internal carotid artery (ICA) was confirmed patent in 6 patients at the time of operation, although angiograms had demonstrated patency in only two. The ipsilateral external carotid artery (ECA) was patent in all but one patient. Arterial reconstructions were done on 7 patients. The carotid bifurcation was revascularized by subclavian-to-carotid bypass grafts in 5 patients, 3 with vertebral-basilar (V-B) TIAs, one with hemispheric TIAs, and one with a completed stroke. Vertebral revascularization was done on 2 patients, one with V-B TIAs and one who was asymptomatic. All revascularized patients had satisfactory results. Symptomatic patients can be treated by cerebral revascularization through either the ICA, if patent, the ECA via the ophthalmic collaterals, or through the vertebrals when hypoperfused. The ICA is preferentially revascularized and exploration often reveals a patent ICA that was not visualized angiographically. Recently, directional Doppler studies have proved useful in determining ICA patency.

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