Two cases of laparoscopic deroofing of giant liver cysts using indocyanine green fluorescence imaging.

Laparoscopic deroofing (LD) for giant liver cysts using indocyanine green (ICG) fluorescence imaging was performed in two patients: a 53-year-old man with a 26-cm, symptomatic cyst and a 50-year-old woman with a 13-cm, symptomatic cyst. ICG fluorescence imaging can be used to easily identify the boundary between the liver parenchyma and the liver cyst. No postoperative bile leakage was observed in both patients. ICG fluorescence imaging is expected to become a desirable procedure in LD for giant liver cysts to reduce the occurrence of perioperative complications.

Validation of a surgical difficulty grading system in laparoscopic cholecystectomy for acute cholecystitis.

BACKGROUND: The surgical difficulty of laparoscopic cholecystectomy (LC) for acute cholecystitis varies from case to case, and appropriate intraoperative evaluation would help prevent bile duct injury (BDI). METHODS: We analyzed 178 patients who underwent LC for acute cholecystitis. Expert surgeons and trainees individually evaluated the surgical difficulty. The inter-rater agreement was analyzed using Conger's κ and Gwet's agreement coefficient (AC). Furthermore, we analyzed the predictive surgical difficulty item for performing subtotal cholecystectomy (STC). RESULTS: Regarding the inter-rater agreement between expert surgeons and trainees, 15 of the 17 surgical difficulty items had a Gwet's AC of 0.5 or higher, indicating "moderate" agreement or higher. Furthermore, the highest and total surgical difficulty scores were deemed "substantial" agreement. Scarring and dense fibrotic changes around the Calot's triangle area with easy bleeding with/without necrotic changes were predictive of whether STC should be performed. CONCLUSIONS: This surgical difficulty grading system is expected to be a tool that can be used by any surgeon with LC experience. STC should be performed to prevent BDI according to the changes around the Calot's triangle area.

Rapid identification of bacteria using a multiplex polymerase chain reaction system for acute abdominal infections.

Purpose: Acute abdominal infections can be fatal if the causative organism (s) are misidentified. The spread of antimicrobial-resistant bacteria has become a serious problem worldwide, making antibiotic selection extremely difficult. Using quantitative metagenomic analysis, we evaluated a commercial multiplex polymerase chain reaction (PCR) system (FilmArray™, bioMérieux, Marcy-l'Étoile, France) for the rapid identification of causative bacteria. Methods: The cases of 10 patients with acute abdominal infections were enrolled in this retrospective study. There were six cases of perforated peritonitis and four cases of intraabdominal abscess. Fluid collected from the acute surgical abdominal infections were examined. Results: All specimens tested positive for microorganisms in culture, and six involved two or more microorganisms. Using the multiplex PCR system, nine of ten specimens were found to involve at least one microorganism. One specimen was not included in the multiplex PCR system panel. Nineteen of 21 microorganisms (90.5%) isolated by culture were detected by the multiplex PCR system. Microorganisms with very small numbers of reads (19 reads) were detectable. Conclusion: This multiplex PCR system showed a high detection rate for causative microorganisms in ascites and intraabdominal abscesses. This system may be suitable as an affordable rapid identification system for causative bacteria in these cases.

Quick detection of causative bacteria in cases of acute cholangitis and cholecystitis using a multichannel gene autoanalyzer.

PURPOSES: Acute cholangitis and cholecystitis can become severe conditions as a result of inappropriate therapeutic administration and thereafter become increasingly resistant to antimicrobial treatment. The simultaneous detection of the bacterial nucleic acid and antimicrobial resistance gene is covered by the national health insurance program in Japan for sepsis. In this study, we evaluate the use of a multichannel gene autoanalyzer (Verigene system) for the quick detection of causative bacteria in cases of acute cholangitis and cholecystitis. METHODS: This study included 108 patients diagnosed with acute cholangitis or cholecystitis between June 2015 and November 2018. A bacterial culture test and Verigene assay were used to evaluate the bile samples. RESULTS: The most commonly isolated bacteria were Escherichia coli, which includes six extended-spectrum beta-lactamase (ESBL)-producing E. coli. Among the patients with positive bile cultures, bacteria were detected in 35.7% of cases via the Verigene system. The detection rates of the Verigene system significantly increased when the number of bacterial colonies was ≥ 106 colony-forming unit (CFU)/mL (58.1%). Cases with a maximum colony quantity of ≥ 106 CFU/mL exhibited higher inflammation, suggesting the presence of a bacterial infection. CONCLUSIONS: The Verigene system might be a new method for the quick detection of causative bacteria in patients with infectious acute cholangitis and cholecystitis.

Comprehensive Diagnosis of Bacterial Infection Associated with Acute Cholecystitis Using Metagenomic Approach.

Acute cholecystitis (AC), which is strongly associated with retrograde bacterial infection, is an inflammatory disease that can be fatal if inappropriately treated. Currently, bacterial culture testing, which is basically recommended to detect the etiological agent, is a time-consuming (4-6 days), non-comprehensive approach. To rapidly detect a potential pathogen and predict its antimicrobial susceptibility, we undertook a metagenomic approach to characterize the bacterial infection associated with AC. Six patients (P1-P6) who underwent cholecystectomy for AC were enrolled in this study. Metagenome analysis demonstrated possible single or multiple bacterial infections in four patients (P1, P2, P3, and P4) with 24-h experimental procedures; in addition, the CTX-M extended-spectrum ß-lactamase (ESBL) gene was identified in two bile samples (P1 and P4). Further whole genome sequencing of Escherichia coli isolates suggested that CTX-M-27-producing ST131 and CTX-M-14-producing novel-ST were identified in P1 and P4, respectively. Metagenome analysis of feces and saliva also suggested some imbalance in the microbiota for more comprehensive assessment of patients with AC. In conclusion, metagenome analysis was useful for rapid bacterial diagnostics, including assessing potential antimicrobial susceptibility, in patients with AC.

Evaluating the timing of laparoscopic cholecystectomy for acute cholecystitis in an experienced center based on propensity score matching.

INTRODUCTION: This study evaluates the therapeutic outcomes for laparoscopic cholecystectomy for acute cholecystitis based on the time from symptom onset to surgery. METHODS: This study enrolled 224 patients. Patients' characteristics and operative outcomes were compared between patient groups based on the timing of laparoscopic cholecystectomy from symptom onset: ≤72 h versus >72 h, and ≤7 days versus ≥8 days. Then, we performed propensity score matching of 13 relevant variables, including patient demographics, examination findings, and therapeutic factors. RESULTS: The early surgery groups (≤72 h and ≤7 days) had significantly younger patients with fewer comorbidities and a shorter duration from symptom onset to presentation before performed propensity score matching. These groups also had shorter surgery, postoperative hospital stay, and total length of stay. Other operative outcomes, including blood loss, conversion to open surgery, bile duct injury, and postoperative complications, did not significantly differ among the groups. After propensity score matching, all therapeutic outcomes, including duration of surgery, showed no significant differences in either analysis. CONCLUSIONS: In a center with sufficient experience, performing laparoscopic cholecystectomy at the earliest possible time after presentation was a safe therapeutic strategy for each patient with acute cholecystitis, regardless of the time from symptom onset.