By V. Navaras. Montana State University College of Technology, Great Falls.
The intracardiac defect should be seen readily buy seroquel 300mg, along with bidirectional shunting purchase seroquel paypal. Cardiac catheterization not only provides direct measurement of the pulmonary artery pressure order discount seroquel online, documenting the existence of severe pulmonary hypertension, but can also allow assessment of the reactivity of the pulmonary vasculature. Administration of pulmonary arterial vasodilators (O , nitric2 oxide, prostaglandin I [epoprostenol]) can determine which patients have contraindications to surgical2 repair and which patients have reversible pulmonary hypertension and may benefit from surgical or even catheter repair. Radiographic contrast material may cause hypotension and worsening cyanosis and should be used cautiously. Open-lung biopsy is seldom used in the current era, and should be considered only when reversibility of the pulmonary hypertension is uncertain from the hemodynamic data. An expert opinion will be necessary to determine the severity of the changes, often using the Heath-Edwards classification. Indications for Intervention Historically, the underlying principle of clinical management in patients with Eisenmenger syndrome was to avoid any factors that may destabilize the delicately balanced physiology. Since then, a number of trials of agents in various classes have provided evidence of benefit 11 from these “advanced therapies. As a general rule, the first episode of hemoptysis should be considered an indication for investigation. Bed rest is usually recommended; although usually self-limiting, each such episode should be regarded as potentially life threatening, and a treatable cause should be sought. When patients are severely incapacitated from severe hypoxemia or congestive heart failure, the main intervention available is lung transplantation (plus repair of the cardiac defect) or, with somewhat better results, heart-lung transplantation. This is generally reserved for individuals without contraindications who are thought to have a 1-year chance of survival of less than 50%. Such assessment is fraught with difficulty because of the unpredictability of the time course of the disease and the risk of sudden death. Noncardiac surgery should be performed only when absolutely necessary because of its high associated mortality rates. Eisenmenger syndrome patients are particularly vulnerable to alterations in hemodynamics induced by anesthesia or surgery, such as a minor decrease in systemic vascular resistance that can increase right-to-left shunting and possibly potentiate cardiovascular collapse. Avoidance of prolonged fasting and, especially, dehydration, the use of antibiotic prophylaxis when appropriate, and careful intraoperative monitoring are recommended. An experienced cardiac anesthetist with an understanding of Eisenmenger syndrome physiology should administer anesthesia. Additional risks of surgery include excessive bleeding, postoperative arrhythmias, and deep venous thrombosis with paradoxical emboli. An “air filter” or “bubble trap” should be used for most intravenous lines in cyanotic patients. Interventional Options and Outcomes Oxygen Supplemental nocturnal oxygen has been shown to have no impact on exercise capacity or on survival rates in adult patients with Eisenmenger syndrome. Supplemental oxygen during commercial air travel is often recommended, but the scientific basis for this recommendation is lacking. Transplantation Lung transplantation may be undertaken in association with repair of existing cardiovascular defect(s). Alternatively, heart-lung transplantation may be required if the intracardiac anatomy is not correctable. The subgroup of patients with Eisenmenger syndrome may do better, with a 50% 5-year survival rate. Since then, several trials have demonstrated improved outcomes of various types in Eisenmenger patients using the three different drug classes of pulmonary vasodilators: endothelin receptor antagonists; phosphodiesterase inhibitors; and prostacyclins. Avoidance of over-the-counter medications, dehydration, smoking, high- altitude exposure, and excessive physical activity should be stressed. Avoidance of pregnancy with appropriate contraceptive methods is of paramount importance. Annual flu shots, a single dose of pneumococcal vaccine, and use of endocarditis prophylaxis together with proper oral hygiene are recommended. A yearly assessment of the complete blood cell count and uric acid, creatinine, and ferritin levels should be done to monitor treatable causes of deterioration. Arrhythmias can be a major clinical challenge in adolescent and adult congenital heart patients. They are the most frequent reason for emergency department visits and hospital admissions, and they are usually recurrent and may worsen or become less responsive to treatment with time. Atrial Arrhythmias Atrial flutter and, to a lesser degree, atrial fibrillation are the most common arrhythmias (see Chapter 38). Atrial flutter tends to reflect right atrial abnormalities, and atrial fibrillation, left atrial abnormalities. Atrial flutter in such patients is often atypical in appearance and behavior and is better called intraatrial reentrant tachycardia. Recognition of atrial flutter can be difficult, and the observer must be vigilant in recognizing 2 : 1 conduction masquerading as sinus rhythm (typically with a resting heart rate of ≈ 100 beats/min). Recurrence is likely and should not necessarily be assumed to represent failure of the management strategy. Atrial flutter may reflect hemodynamic deterioration in patients who have had Mustard, Senning, tetralogy of Fallot, or Fontan repairs. The pharmaceutical agents most commonly used in therapy are warfarin, beta blockers, amiodarone, sotalol, propafenone, and digoxin. As a rule, patients with good ventricular function can receive sotalol or propafenone, whereas those with depressed ventricular function should receive amiodarone. Other therapies, including pacemakers, ablative procedures, and innovative surgery, are being both applied and refined. Sustained ventricular tachycardia or ventricular fibrillation occurs less often, usually in the setting of ventricular dilation, dysfunction, and scarring. Although sudden death is common in several conditions, the mechanism is poorly understood. In particular, sustained ventricular tachycardia has occurred in patients with repaired tetralogy of Fallot, where it is seen as a manifestation of hemodynamic problems (usually severe pulmonary regurgitation) requiring repair; as a reflection of right ventricular dilation and dysfunction; and in relation to ventricular scarring. Sudden Death Unlike adults, children seldom die suddenly and unexpectedly of cardiovascular disease. Nonetheless, sudden death at any age has been reported with arrhythmias, aortic stenosis, hypertrophic obstructive cardiomyopathy, idiopathic pulmonary arterial hypertension, Eisenmenger syndrome, myocarditis, congenital complete heart block, primary endocardial fibroelastosis, and when there are specific 12 anomalies of the coronary artery origin and course (see also Chapter 42). When pacing is required, epicardial leads are usually placed in cyanotic patients because of the risk of paradoxical embolism. Recent guidelines for endocarditis prophylaxis have substantially altered clinical practice. Chest Pain Angina pectoris is an uncommon symptom of congenital cardiac disease, although when there is typical pain a full surveillance for coronary abnormalities (e. Pain caused by pericarditis is commonly of acute onset and associated with fever, and can be identified by specific physical, radiographic, and echocardiographic findings.
It is bilateral and requires the use of either the operating microscope or magnifying loupes cheap seroquel 200mg visa. Usual preop diagnosis: Infertility 2° vasectomy Hydrocelectomy: The testis purchase seroquel 50 mg mastercard, with the surrounding hydrocele (Fig purchase 300mg seroquel mastercard. The wall of the hydrocele is excised and the edges sutured around the epididymis to prevent recurrence. Variant procedure or approach: Aspiration used as a temporizing approach because recurrence is almost 100%. Usual preop diagnosis: Hydrocele Spermatocelectomy: A spermatocele is a cyst of the epididymis, usually excised with the part of the epididymis from which it arises. Variant procedure: Aspiration as a temporizing maneuver until the operation can be performed. Usual preop diagnosis: Spermatocele or epididymal cyst Insertion of testicular prosthesis: A small incision is made in the scrotal skin, and a pouch is created by blunt dissection in dartos fascia. The prosthesis is placed in the pouch and fixed to the dartos fascia to prevent prosthesis migration. Usual preop diagnosis: Absent testis, either congenital or following orchiectomy Reduction of testicular torsion is an emergency operation that must be performed within 6 h of occurrence to prevent irreversible ischemic damage to the testis. Through a small scrotal incision, the testis is reduced and fixed to the dartos fascia to prevent retorsion. Many of these procedures are done on an outpatient basis, and the anesthetic should be appropriately planned to facilitate early discharge. A transverse or longitudinal perineal incision is made and carried down to the urethra, which is dissected free from surrounding tissues. The strictured area is excised and end-to-end anastomosis is performed over a catheter. Repair of a long urethral stricture may require placement of a patch from the scrotum, foreskin, or buccal mucosa. Variant procedure: Transurethral incision and dilation, which is associated with a 30–50% recurrence rate. Usual preop diagnosis: Urethral stricture, usually posttraumatic Urethrectomy: Partial or total urethrectomy is done through a longitudinal perineal incision. The urethra is dissected free of surrounding tissues and followed proximally and distally from the membranous urethra to the external urethral meatus. In total urethrectomy, a tubularized skin graft is interposed between membranous urethra and perineal skin. Usual preop diagnosis: Urethral carcinoma Insertion of artificial urinary sphincter, performed for incontinence, consists of a perineal incision, through which a cuff is inserted around the bulbar urethra. A suprapubic incision is made to place the reservoir and pump, which inflates and deflates the cuff. Usual preop diagnosis: Urinary incontinence Transperineal prostate seed implantation (brachytherapy): High doses of radiation can be delivered to the prostate by implanting radioactive seeds directly into the prostate gland. Using a transrectal ultrasound probe, radioactive seeds (iodine 125 or palladium 103) are implanted into the prostate (Fig. The patient is placed in lithotomy position, and a rectal ultrasound probe, with a perineal grid attached, is introduced to image the prostate. This procedure is done by a combined team of radiation oncologists and urologists. Lumbar epidural anesthesia may be less reliable at providing sacral anesthesia and offers no advantages over the above techniques for shorter procedures, although caudal anesthesia may be an acceptable alternative. They include the following: Repair of vesicovaginal fistulas: The vaginal approach is usually recommended for small and distally located vesicovaginal fistulas; otherwise, a transabdominal repair is performed (see Open Bladder Operations, p. An incision is made in the anterior vaginal wall around the fistula, which is excised. Bladder and vaginal walls are separated and closed with interposition of tissues or flaps to separate the incisions and prevent recurrence. Variant approach: Transabdominal repair of vesicovaginal fistula (see Open Bladder Operations, p. Usual preop diagnosis: Vesicovaginal fistula Operations to correct stress urinary incontinence: Many procedures have been designed to correct female urinary incontinence. They fall into two basic groups: (a) operations to correct hypermobility of the urethra and (b) operations to correct nonfunctioning urethra. The operation most commonly used by urologists to correct hypermobility is the Stamey procedure (Fig. The operation is performed through two small suprapubic incisions, one on each side of the midline, and an anterior vaginal incision. A nylon suture is placed in a loop from either side of the bladder neck and not around it. Cystoscopy is used to ensure proper placement and to prevent the suture from transversing the bladder. When the sutures are pulled up and tied over the anterior rectus sheath, they pull the bladder neck up to its original position behind the symphysis pubis and restore the acute posterior ureterovesical angle. A variant of this procedure is the Raz bladder neck suspension, where bolsters are not used. Operations to correct a nonfunctioning urethra include submucosal collagen injection at the bladder neck or construction of a sling. Rectus fascia, fascia lata of the thigh, or the vaginal wall can be used to construct a sling around the urethra. Sling operations are the most common procedures done for correction of stress incontinence. Many modifications have been made with reference to the placement of anchorage of the sling; therefore, there are a large number of procedures with different names utilizing the same principle. Variant approach: The Marshall-Marchetti-Krantz operation, which is performed retropubically, sutures the anterior portion of the urethra, bladder neck, and bladder to the pubic bone. Some patients have cystoceles and rectoceles, which can be repaired at the same time as the vaginal sling surgery. An incision is made in the anterior vaginal wall over the urethral diverticulum, which is dissected all around until it is attached only by its neck. A vaginal incision (anterior for cystocele, posterior for rectocele) is made and dissected laterally to free the bladder or rectum from the vagina. A block level of T9–T10 is recommended for operations involving the bladder, whereas somewhat higher levels of anesthesia may be necessary if a suprapubic incision is made. Epidural anesthesia may be less reliable than spinal in providing sacral anesthesia. The distal 2 cm of the ulna is resected subperiosteally, and local soft tissues are used to stabilize and cover the remaining ulna. It is commonly performed in patients who have had a disruption of the distal radioulnar joint with subluxation of the ulna. It also is indicated for patients who have had a malunion of a distal radius fracture such that the radius has shortened relative to the ulna or is abnormally angulated, resulting in dorsal subluxation of the ulna and impingement of the ulnar head upon the carpus. This causes painful motion of the wrist and forearm and posttraumatic degenerative arthritis of the ulnar head, carpus, and sigmoid notch of the distal radius. Disorders of the distal radioulnar joint and degeneration of the ulnar head, which may lead to attrition rupture of the overlying extensor tendons, are common in rheumatoid arthritis.
It is the practice of evidence-based medicine as well as accountability of care best seroquel 50mg, both of which help define professionalism discount seroquel 50 mg line. Quality (or performance) improvement is increasingly central to clinical training buy seroquel 50mg without a prescription, lifelong medical education, and reimbursement. Quality measurement and improvement are now an essential part of cardiovascular practice, as well as for the broader health care system. Quality measures, whether structural, process, outcome, value, or composite, depend on the extent of underlying scientific evidence, the validity of data sources, and clear specification. Only in this way will quality of care efforts truly promote health care that is more effective, safe, equitable, timely, efficient, and patient centered and that translates into improved patient outcomes. American College of Cardiology and American Heart Association methodology for the selection and creation of performance measures for quantifying the quality of cardiovascular care. Standards for statistical models used for public reporting of health outcomes: an American Heart Association scientific statement from the Quality of Care and Outcomes Research Interdisciplinary Writing Group. Cosponsored by the Council on Epidemiology and Prevention and the Stroke Council Endorsed by the American College of Cardiology Foundation. Standards for measures used for public reporting of efficiency in health care: a scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research and the American College of Cardiology Foundation. Association of hospital coronary artery bypass volume with processes of care, mortality, morbidity, and the Society of Thoracic Surgeons composite quality score. Association between operator procedure volume and patient outcomes in percutaneous coronary intervention: a systematic review and meta-analysis. Standards for measures used for public reporting of efficiency in health care: a scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research and the American College of Cardiology Foundation. The need for multiple measures of hospital quality: results from the Get With the Guidelines heart failure registry of the American Heart Association. Incremental value of clinical data beyond claims data in predicting 30-day outcomes after heart failure hospitalization. Accuracy of electronically reported “meaningful use” clinical quality measures: a cross-sectional study. A report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Does performance-based remuneration for individual health care practitioners affect patient care? Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: a randomized trial. Public release of performance data in changing the behaviour of healthcare consumers, professionals or organisations. Impact of public reporting of coronary artery bypass graft surgery performance data on market share, mortality, and patient selection. Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction. Impact of Lean Six Sigma process improvement methodology on cardiac catheterization laboratory efficiency. Therapeutic recommendations are no longer based on nonquantitative pathophysiologic reasoning but instead are evidence based. Rigorously performed trials are required before gaining regulatory approval and clinical acceptance of new treatments (drugs, devices, biologics) and 3 biomarkers. Thus the design, conduct, analysis, interpretation, and presentation of clinical trials constitute a central feature of the professional life of the contemporary cardiovascular specialist and will 3,4 need to keep pace with the technology of the future. Case-control studies and analyses from registries are integral to epidemiologic and outcomes research but are not strictly clinical trials and are not 5,6 discussed in this chapter. They should also familiarize themselves with the processes of designing and implementing a research project, good clinical 7-10 practice, and drawing conclusions from the findings (eFig. A clinical trial may be designed to test for superiority of the investigational treatment over the control therapy but also may be designed to show therapeutic similarity between the investigational and the control treatments (noninferiority design) (Fig. The margin (M) for noninferiority is prespecified based on previous trials comparing the standard drug with placebo. Examples of hypothetical trials A to F are shown, of which some (trials B and C) satisfy the definition of noninferiority. P ) in population of patients with same clinical clinical characteristics and disease state. Generalizability to Related to enrollment criteria; the more Enrollment criteria of prior trials and medical practice Related to enrollment criteria; the more universe of all restrictive they are, the less generalizable are concurrent with those trials determine generalizability of restrictive they are, the less generalizable are patients with the the results to the entire universe of patients estimate of Pstandard − Pplacebo to contemporary practice. H ,0 Null hypothesis; H ,A alternative hypothesis; M, noninferiority margin; N/A, not available. In both superiority and noninferiority trials, the investigators propose a null hypothesis (H ) with the goal of the trial being to reject0 H in favor of the alternative hypothesis (H ). In superiority trials, α is usually two-sided, whereas it is one-sided in noninferiority trials. In a noninferiority trial, investigators specify a noninferiority criterion (M) and consider the investigational treatment to be therapeutically similar to control (standard) therapy if, with a high degree 11,12 of confidence, the true difference in treatment effects is less than M (see Fig. Specification of the noninferiority margin M involves considerable discussion between the investigators (advocating for clinical perception of minimally important difference) and regulatory authorities (advocating for assurance that the investigational treatment maintains a reasonable fraction of the efficacy of the standard 11-13 treatment based on previous trials). The investigational therapy may satisfy the definition of 14 noninferiority and may or may not also show superiority over the control therapy. Thus, superiority can be considered a special case of noninferiority in which the entire confidence interval for the difference in treatments falls in favor of the investigational treatment (see Fig. Investigators can stipulate that a trial is being designed to test both noninferiority and superiority (see Table 5. For a trial that is configured as a noninferiority trial, it is acceptable to test for superiority conditional on having 15 demonstrated noninferiority. The reverse is not true—trials configured for superiority cannot later test for noninferiority unless the margin M was prespecified. Regardless of the design of the trial, it is essential that investigators provide a statement of the hypothesis being examined, using a format that permits biostatistical assessment of the results (see eFig. By convention, α is set at 5%, indicating a willingness to accept a 5% probability that a significant difference will occur by chance when there is no true difference in efficacy. Regulatory authorities may on occasion demand a more stringent level of α—for example, when a single large trial is being proposed rather than two smaller trials—to gain approval of a new treatment. The value of β represents the probability that a specific difference in treatment efficacy might be missed, so that the investigators incorrectly fail to reject H when there is a true difference in efficacy0. The power of the trial is given by the quantity (1 − β) and is selected by the investigators, typically between 80% and 16 90%. Using the quantities α, β, and the estimated event rates in the control group, the sample size of the trial can be calculated with formulas for comparison of dichotomous outcomes or for a comparison of the rate of development of events over a follow-up period (time to failure). The allocation of subjects to control and test treatments is not determined but is based on an impartial scheme (usually a computer algorithm). Randomization reduces the likelihood of patient selection bias in allocation of treatment, enhances the likelihood that any baseline differences between groups are random so that comparable groups of subjects can be compared, and validates the use of common statistical tests. Randomization may be fixed over the course of the trial or may be adaptive, based on the distribution of treatment assignments in the trial to a given point, 15,19 baseline characteristics, or observed outcomes (Fig. Fixed randomization schemes are more common and are specified further according to the allocation ratio (equal or unequal assignment to study groups), stratification levels, and block size (i.
This procedure has largely been replaced by transhepatic and endoscopic techniques cheap 100 mg seroquel mastercard. Choledochoduodenostomy is an archaic procedure in which the bile duct is incised longitudinally and anastomosed directly to the adjacent duodenum purchase 50mg seroquel fast delivery. This was performed historically in patients with gallstones impacted at the ampulla generic 50 mg seroquel mastercard. However, loss of the normal sphincter mechanism at the ampulla allows reflux of duodenal contents directly into the bile duct. Patients may suffer from repeated episodes of cholangitis or obstructive jaundice from debris occluding the anastomosis. Secondary biliary cirrhosis may occur, and the author has seen one case proceed to liver transplantation in which a cast of the biliary tree comprised of fibrous food material was extracted from the choledochoduodenal anastomosis. Roux-en-Y choledochojejunostomy or hepaticojejunostomy remains the gold standard by which all other biliary drainage procedures are measured. An anastomosis is fashioned between the common bile duct, common hepatic duct, or even the lobar or segmental bile ducts and a Roux-en-Y loop of jejunum. This is often a relatively demanding operation because it requires dissection deep in the porta hepatis to gain access to the bile duct. Furthermore, many patients have had previous surgery in the porta hepatis with extensive formation of adhesions. Long-term results are more reliable, however, and thus surgical drainage is preferred to less-invasive procedures for benign disease. The bile duct is dissected free from the surrounding structures in the porta hepatis and traced proximally into the liver to healthy tissue above the level of obstruction. Variant procedure or approaches: Endoscopic or transhepatic placement of temporary or permanent biliary stents is an increasingly common alternative to surgical drainage in patients with incurable pancreatic or biliary tract disease. Cholecystojejunostomy: malignant obstruction of the distal common bile duct, usually due to pancreatic cancer. Choledochojejunostomy or hepaticojejunostomy: benign strictures of the distal bile duct; long-standing stone disease; pancreatitis; iatrogenic injury; Oriental cholangiohepatitis; after resection of some tumors of the pancreas or bile duct. Such tumors are usually classified as being proximal bile duct tumors, involving the hepatic bifurcation and above; middle bile duct tumors, involving the midportion of the common hepatic and common bile duct; and distal bile duct tumors, which involve the distal bile duct, including the intrapancreatic or intraduodenal portion of the bile duct (Fig. Distal bile duct tumors, which carry a significantly higher cure rate than either proximal bile duct or pancreatic tumors, may be treated by pancreaticoduodenectomy. Biliary drainage usually is established by anastomosing the proximal bile duct to a Roux loop of jejunum. For proximal bile duct tumors, most of the extrahepatic bile ducts are excised and biliary drainage is established by anastomosis of the right and left hepatic ducts or even multiple segmental ducts to a Roux loop of jejunum. These are often technically demanding operations with the potential for major blood loss. It may be necessary to perform a major hepatic resection at the same time, and the possibility of this should always be assumed when an operation of this sort is carried out. Often, a transhepatic catheter will have been placed radiographically preoperatively to provide relief of jaundice and to facilitate identification of the bile ducts. Colonization of the biliary tract with enteric bacteria or yeast is common and may result in bacteremia during surgical manipulation. Prolonged cholestasis may lead to fat-soluble vitamin deficiencies, in particular vitamin K deficiency, which may cause coagulopathy. Long-standing biliary obstruction may cause moderate atrophy and portal venous compromise. Surgical exposure for any of these operations usually is achieved through a long midline or transverse subcostal incision with midline extension and the use of self- retaining retractors. The liver and gallbladder are retracted superiorly while downward traction is placed on the duodenum. For proximal bile duct tumors and mid- bile duct tumors not requiring pancreaticoduodenectomy, the bile duct is divided distally, just above the duodenum, and the pancreatic portion of the bile duct is oversewn. The bile duct is then resected proximally to the level of the bifurcation of the hepatic ducts. A Roux-en-Y loop of jejunum is anastomosed to the hepatic ducts to establish biliary drainage. Variant procedure or approaches: Endoscopic or transhepatic stenting of areas of stricture often is used as a palliative alternative to surgical excision. Adults with long-standing obstructive jaundice from a choledochal cyst may present with secondary biliary cirrhosis. Although four types of cysts are commonly recognized, the vast majority consist of fusiform dilatation of much or most of the extrahepatic biliary tree. Although the traditional description of choledochal cyst is that of an infant with a palpable abdominal mass and jaundice or cholangitis, this is a relatively rare presentation today. Today, many cysts are found in adults undergoing evaluation for symptoms thought to be due to gallbladder disease. Cyst-enteric bypass, usually to a Roux loop of jejunum, is almost never performed today because of the small but real risk of developing malignancy in these cysts. Only in an elderly patient under unusual technical circumstances would this be appropriate. Choledochal Cyst Excision or AnastomosisThe operation is performed through a midline or right subcostal incision. The liver is retracted superiorly and the duodenum inferiorly, exposing the biliary tree. Intraoperative cholangiogram demonstrates the transition from cyst to normal biliary tract. The duct is divided as distally as possible, just above the duodenum, and the cyst reflected superiorly. The entire cyst should be excised to prevent the development of malignancy in the remnant. This not infrequently requires excision to the hepatic bifurcation, and an anastomosis is performed at this level, often between the common orifice of the right and left hepatic ducts and a Roux loop of jejunum. Diffuse involvement of the intrahepatic bile ducts (Caroliís disease) may require liver resection or transplantation. Variant procedure or approaches: There is an increasing tendency among gastroenterologists to perform endoscopic sphincterotomy in these patients, rather than to refer them for surgical resection, particularly in older patients. It remains to be seen if these patients will develop cancer in the retained cysts. Usual preop diagnosis: Choledochal cyst, the most common type involving fusiform enlargement of the entire extrahepatic biliary tree Suggested Readings 1. With the increasing popularity of laparoscopic surgery, open cholecystectomies will be performed rarely, or when it is not possible to complete the laparoscopic procedure. Cirrhosis, even of a mild degree, substantially increases the risk of cholecystectomy, with hemorrhage and postoperative liver failure being the greatest danger. Patients with bile duct tumors are usually jaundiced at presentation and have undergone transhepatic and/or endoscopic studies for diagnostic purposes.