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Re: GB agenesis - Ärzteforum

Post#21 »

I disagree but understand your point of view. With the bubbles i could see
that it "was" leaking but not exactly where. When i inspected it i was
really shocked to see a > 1cm defect posterior in the middle. With the low
volume of bubbles i hadn't suspected such a large hole.

Of say...who cares *where* its leaking...or even how
leaks and you've got to fix it, or, as Er would do..."automatic diversion".

Maybe the only thing it achieved was showing me exactly "where" the problem
was and the degree of the defect. Of course i knew there was a problem, but
what is the big deal about wanting to look directly at it?

All the materials that i used were reusable, i've *never* charged the
patient for intraop scope and it took 3 minutes. If i'd used 300$ worth of
disposable equipment, charged the patient 500$ extra for the proceedure and
taken 30 minutes it might be a different story. But that is not the case.

I actually found it somewhat educational and enlightening...and that is
*always* an *achievement*.

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Re: GB agenesis - Ärzteforum

Post#22 »

John Dissector wrote: And if anyone again
mentions a concern with what the lawyers will say (i.e. who the heck cares!) I
think I'll finally be driven to fall on a sword--you will again have made me
lose faith in our profession, allowing another profession to dictate to you
how to practice what you have been trained and they have not. To me, this is
the whine of the insecure.

How about pre-approvals from HMO, insurance companies and Medicare/Medicaid?
I expect some difficulty to convince them to finance cholecystectomy in the
absence of documented cholelithiasis or acute cholecystitis. I will be
interested in hearing of your experience dealing with those folks under
these circumstances. I should also say that if you are successful with them
in that regard because of your position and experience, probably other
surgeons will not have much luck in a similar fashion.


Re: GB agenesis - Ärzteforum

Post#23 »

My only caveat is that I am not absolutely sure that this
patients symptoms are biliary, and I have missed both a colonic tumour
and a jejunal tumour by jumping in too early with the laparoscope. For
that reason, and that reason alone, I will proceed to OGD and CT
(remember I do not have the financial constraints that you do) before
proceeding to Lap chole with low threshold to convert if I could not
find the GB.
Despite that I absolutely agree that we should treat a patient
on the basis primarily of clinical acumen, and not on the basis of tests
which can be inappropriate, irrelevant, or even sometimes wrong. That
was the point of my question.
It follows therefore that routine upper intestinal endoscopy is
unnecessary, and should only be done if one is in doubt about the

John Dissector

Re: GB agenesis - Ärzteforum

Post#24 »

I have yet to ever have cholecystectomy in this setting challenged by a third
party payor--have you ever been challenged for removing a normal appendix?
What's the difference--the indication is well proven.?
Also--does third party reimbursement of your wallet REALLY determine how you
practice medicine? Would you really not perform a medically indicated
simply because you may not be reimbursed?
And thirdly--your perception of insurance carriers is woefully naive if you
think they pay any attention to who the surgeon is, how experienced, or in
what position -- as any of us Americans on the list will attest, this is
totally inaccurate

John Dissector

Re: GB agenesis - Ärzteforum

Post#25 »

I do agree that true biliary colic is the basis of this approach--all bets are
off if you are dealing with nonspecific abdominal complaints
I also agree that you should not jump right into cholecystectomy in this
setting--I too tend to do more of a workup of the GI tract in view of the
greater uncertainty of this presentation

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Doctor Green

Re: GB agenesis - Ärzteforum

Post#26 »

I do agree with you in principle. A clinical diagnosis of acute appendicitis is a straightforward indication for the operation, regardless of the pathologic findings thereafter. No third-party payor will ever challenge that. What I am trying to learn is whether the same applies on someone with chronic symptoms that will be attributed to gallbladder disease in the absence of documented objective criteria like cholelithisais. Your answer indicates that that really is the case, and it will NOT be challenged either. Good to know!

No, it's not MY wallet. Most patient will not welcome receiving a hefty bill from the Hospital (not for my services) when their insurance doesn't reimburse. My personal wallet is not the issue. If precertification/preapproval for the procedure is not secured, what will you tell the patient? Go for it and disregard the Hospital bill (not MY bill) that will follow? Or challenge your insurance company?

Here's a story: I failed that day to get pre-approval for colonoscopy for a 57 y/o F who had a 3-4 week history of change in bowel habits, being more constipated (never had a colon study in the past, heme negative!). They will approve sigmoidoscopy &/or barium enema (quite insulting). I appealed with documented references from the literature about the relative sensitivity of colonoscopy & BE, etc. Guess what, the response was a computer-generated message indicating that there's no medical necessity. I am still fighting for that but the patient clearly said I will do ONLY what my insurance will pay for. And all that hassle is for nothing more than a colonoscopy. Anyone had similar experiences? If not yet, I'm afraid someone probably will.


Re: GB agenesis - Ärzteforum

Post#27 »

you were interested how many people do a routine G scope before
cholecystectomy. In the department I worked from 2011 till 2014 ( a
university clinic) an OGD was done (in our own department) routinely (!)
in every patient scheduled for laparoscopic cholecystectomy. In the
department I am working now in, we also did routine OGD's for about 2
years (2014 - 2016) but abandoned this after seeing no clear benefit. I
now ask for an OGD only in those patient with a history of peptic ulcers
or no clearly established diagnosis of cholecystolithiasis or
cholecystitis. In patients scheduled for laparoscopic cholecystectomy
and uncharacteristic symtpoms we had more patients with an unsuspected
cancer of the ascending or transverse colon than patients with an
unknown duodenal ulcer. I therefore readily ask for a CT scan (which we
also obtain easily) if I have any doubts about my diagnosis!


Re: GB agenesis - Ärzteforum

Post#28 »

Well "almost always" is a bit fact I have relatively "often" (I
am sorry that I cannot give you real figures..) encountered a cystic duct
crossing over or under the common bile duct and entering the CBD from the left
side. This particular variation (among the other known ones) is shown in

1. Principles of Surgery, Schwartz, Shires, Spencer, Stores, 4th edition p.
1308, Fig. 31-1 G, H
2. Chirurgische Operationslehre, Kremer et al, Vol. 4, p. 40, Fig. 4 and 5

Having no technical possibility of doing an intraoperative laparoscopic
ultrasound I rely on a preoperative intravenous cholangiogram to show me the
variations of the cystic duct (25% (!) of all cases, Chirurgische
Operationslehre, as above quoted, p. 40). This knowledge has helped me greatly
in identifying the cystic duct intraoperatively!
Of course this would not influence the need of "dissecting" the CBD looking for
a cystic duct in the case of a "missing" gallbladder. On the other hand I have
never seen a left sided gallbladder and would be interested to know whether the
cystic duct of a left sided gallbladder opens to the left side of the CBD or
crosses the CBD and opens to the right side?? Do you (or anybody else!) have any
knowledge of this?

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Re: GB agenesis - Ärzteforum

Post#29 »

John Dissector wrote:Also--does third party reimbursement of your wallet REALLY determine how you
practice medicine? Would you really not perform a medically indicated

That's not quite fair. Regardless of whether we are willing to forego our
reimbursement to "do the right thing" the patient will still receive bills
from the hospital, the anesthesiologist and others. If their carrier has not
authorized the procedure they are going to be stuck for a bill much larger
than simply the surgeon's fee.

Though, I must agree with you on the whole, I haven't found an insurance
carrier yet that wouldn't approve an operation for symptomatic biliary

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Old surgeon

Re: GB agenesis - Ärzteforum

Post#30 »

I would like to thank you for your interest and clarification
of this point, as you have seen it your self I can't argue with you.

I personally have never seen a cystic duct opening on the left
side of CBD in all biliary or pancreatic (Whipple) surgery, and ERCP
(quite a large number) I have done.

I quoted this statement from an article published in:

J Clin Gastroenterol 1993 Apr;16(3):231-233

Agenesis of the gallbladder in symptomatic adults. A case and review of
the literature.
Richards RJ, Taubin H, Wasson D

Department of Medicine, Bridgeport Hospital, Yale University School of
Medicine, Connecticut.

Where in page 232 at the end of discussion they stated "Regardless of
the gallbladder's location, the cystic duct always crosses to the right
side and joins the common duct in a comparatively normal way (3)".

(3) is Lindner HH, Green RB, Embryology and surgical anatomy of the
extrahepatic biliary tract.
Surg Clin North Am 1964;44:1273-85.

I looked for this point in Maingot's Abdominal Operations, ninth
edition, volume II, PP 1344, Figure 62-14 C. Gallbladder on the left
side. When the gallbladder is situated on the left side, the cystic duct
may drain into the left hepatic duct or the common hepatic duct.( No
comment from left or right side) but in the drawing the cystic duct of a
left sided gallbladder is joining the CHD from the left side. No comment
on this particular point in the text.

As you see I really do not know where is the truth, but if you
saw it your self this will be enough evidence for me.

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