Risk factors for biliary tract events during elective cholecystectomy waiting time after endoscopic retrograde cholangiopancreatography for choledocholithiasis.

Objectives: Endoscopic lithotripsy and elective cholecystectomy, followed by endoscopic retrograde cholangiopancreatography, are the first-line treatments for patients with common bile duct (CBD) stones (CBDS) and gallstones. However, this approach entails acute cholecystitis and recurrent cholangitis risk while patients await surgery. We aimed to identify acute cholecystitis and cholangitis risk factors during the waiting time for elective cholecystectomy. Methods: This study comprised 151 patients with CBDS combined with gallstones who underwent cholecystectomy within 90 days of the first endoscopic retrograde cholangiopancreatography at two tertiary care centers between January 2019 and October 2021. Results: The incidence of biliary tract events (acute cholecystitis, acute cholangitis, or any complications requiring unplanned cholangiopancreatography) was 28% (43 cases). In univariate and multivariate analyses, plastic stent placement as a bridge to surgery for the first treatment of CBDS was an independent risk factor for biliary tract events during the waiting time for surgery (odds ratio 4.25, p = 0.002). A subgroup analysis among those with plastic stent placement revealed a CBD diameter of ≤ 10 mm as an independent risk factor for acute cholecystitis (odds ratio 4.32; p = 0.027); a CBD diameter ≥ 11 mm was an independent risk factor for acute cholangitis and unplanned re-endoscopic retrograde cholangiopancreatography (odds ratio 5.66; p = 0.01). Conclusions: Plastic stent placement for CBDS before elective cholecystectomy increases the risk of acute cholecystitis or acute cholangitis during the waiting time for elective cholecystectomy.

The Hanging Strap Method: A Safe and Easy-to-Use Surgical Technique for Surgeons-in-Training Performing Difficult Laparoscopic Cholecystectomy.

Introduction Surgeons-in-training (SIT) perform laparoscopic cholecystectomy (LC); however, it is challenging to complete the procedure safely in difficult cases. We present a surgical technique during difficult LC, which we named the hanging strap method. Methods We retrospectively compared the perioperative outcomes between patients undergoing difficult LC with the hanging strap method (HANGS, n = 34), and patients undergoing difficult LC without the hanging strap method (non-HANGS, n = 56) from 2022 and 2024. Difficult LC was defined as cases classified as more than grade II cholecystitis by the Tokyo Guidelines 18 and cases when LC was undergoing over five days after the onset of cholecystitis. Results The proportion of SIT with post-graduate year (PGY) ≤ 7 was significantly higher in the HANGS group than in the non-HANGS group (82.4% vs. 33.9%, P < 0.001). The overall rate of bile duct injury (BDI), postoperative bile leakage and operative mortality were zero in the whole cohort. There were no significant differences between the HANGS and non-HANGS groups in background characteristics, operative time (122 min vs. 132 min, P = 0.830) and surgical blood loss (14 mL vs. 24 mL, P = 0.533). Conclusions Our findings suggested that the hanging strap method is safe and easy to use for difficult LC. We recommend that the current method be selected as one of the surgical techniques for SIT when performing difficult LC.

Successful management of a ruptured cystic artery pseudoaneurysm with embolization and cholecystectomy: A case report.

Key Clinical Message: Cystic artery pseudoaneurysm is a rare phenomenon associated with cholecystitis. We describe the successful management of angioembolisation and cholecystectomy. Abstract: Cystic artery pseudoaneurysm (CAP) is a rare but clinically significant condition with various etiological factors. Cholecystitis is a prominent cause, often leading to inflammation-induced arterial wall erosion and pseudoaneurysm formation. CAP can present with a range of symptoms, including hemobilia, upper GI bleeding, and jaundice. Despite its rarity, CAP warrants attention in emergency care due to its potential for life-threatening arterial bleeding. Timely diagnosis is crucial, with imaging techniques playing a key role. Depending on the clinical context, management options include endovascular embolization and surgical intervention. Due to the limited cases, standard protocols remain elusive. A 64-year-old woman presented with abdominal pain, anorexia, and weight loss, prompting an evaluation for possible gallbladder cancer. She experienced sudden abdominal pain and upper gastrointestinal bleeding (hematemesis). Laboratory findings revealed leukocytosis, anemia, and abnormal liver function tests. Imaging showed gallbladder wall thickening, luminal contraction, and a pseudoaneurysm in the cystic artery. The patient underwent angioembolization followed by cholecystectomy, confirming acute cholecystitis and CAP with thrombosis. This case underscores the importance of early recognition and appropriate management in CAP, particularly when accompanied by acute cholecystitis.

Conquering the common bile duct: outcomes in minimally invasive transcystic common bile duct exploration versus ERCP.

INTRODUCTION: Given the increasing interest for surgeons to reclaim the common bile duct in managing choledocholithiasis, there is a growing movement to perform common bile duct exploration (CBDE). Advantages of concomitant CBDE with cholecystectomy include fewer anesthetic events and decreased length of stay. As there is a paucity of literature evaluating the use of the robotic platform for CBDE, our study aims to compare intraoperative and post-operative outcomes between robotic-assisted one-stage and two-stage management of choledocholithiasis. METHODS: A retrospective chart review was performed from May 1, 2022 to December 31, 2023, identifying patients with choledocholithiasis who underwent robot-assisted laparoscopic cholecystectomy and transcystic CBDE with choledochoscopy (one-stage management). Preoperative, intraoperative, and post-operative variables were compared to a control group of subjects with choledocholithiasis who underwent laparoscopic cholecystectomy with pre- or post-operative ERCP (two-stage management). Statistical analysis was performed using Chi-squared, Fisher's exact, Student's T, or Mann-Whitney test. RESULTS: Fifty-three subjects who underwent one-stage management and 101 subjects who underwent two-stage management met inclusion criteria. Groups had similar demographics and medical history. Time to CBD clearance (45.2 h vs 47.0 h, p = .036), total length of stay (3.9 days vs 5.1 days, p = .007), fluoroscopy time (70.3 s vs 151.4 s, p < .001), and estimated radiation dose (23.0 mSv vs 40.3 mSv, p = .002) were significantly lower in the one-stage group compared to two-stage. Clearance rates, complication rates, and 30-day readmission rates were similar for both groups. Total length of stay and radiation exposure remained significantly lower on subanalysis comparing one-stage management to two-stage management with ERCP either before or after cholecystectomy. CONCLUSION: Robotic-assisted laparoscopic cholecystectomy with transcystic common bile duct exploration via choledochoscopy is a safe and feasible option in the management of choledocholithiasis. It offers a shorter time to duct clearance, shorter length of stay, and less radiation exposure when compared to two-stage management.

Patient and hospital factors influence surgical approach in treatment of acute cholecystitis.

BACKGROUND: Minimally invasive (MIS) cholecystectomies have become standard due to patient and hospital advantages; however, this approach is not always achievable. Acute and gangrenous cholecystitis increase the likelihood of conversion from MIS to open cholecystectomy. This study aims to examine patient and hospital factors underlying differential utilization of MIS vs open cholecystectomies indicated for acute cholecystitis. METHODS: This is a retrospective, observational cohort study of patients with acute cholecystitis who underwent a cholecystectomy between 2016 and 2018 identified from the California Office of Statewide Health Planning and Development database. Univariate analysis and multivariable logistic regression models were used to analyze patient, geographic, and hospital variables as well as surgical approach. RESULTS: Our total cohort included 53,503 patients of which 98.4% (n = 52,673) underwent an initial minimally invasive approach and with a conversion rate of 3.3% (n = 1,759). On multivariable analysis advancing age increased the likelihood of either primary open (age 40 to < 65 aOR 2.17; ≥ 65 aOR 3.00) or conversion to open cholecystectomy (age 40 to < 65 aOR 2.20; ≥ 65 aOR 3.15). Similarly, male sex had higher odds of either primary open (aOR 1.70) or conversion to open cholecystectomy (aOR 1.84). Hospital characteristics increasing the likelihood of either primary open or conversion to open cholecystectomy included teaching hospitals (aOR 1.37 and 1.28, respectively) and safety-net hospitals (aOR 1.46 and 1.33, respectively). CONCLUSIONS: With respect to cholecystectomy, it is well-established that a minimally invasive surgical approach is associated with superior patient outcomes. Our study focused on the diagnosis of acute cholecystitis and identified increasing age as well as male sex as significant factors associated with open surgery. Teaching and safety-net hospital status were also associated with differential utilization of open, conversion-to-open, and MIS. These findings suggest the potential to create and apply strategies to further minimize open surgery in the setting of acute cholecystitis.

Unplanned hospital readmission after cholecystectomy in adults with cerebral palsy.

BACKGROUND: Adults with cerebral palsy (CP) are a largely understudied, growing population with unique health care requirements. We sought to establish a deeper understanding of the surgical risk in adults with CP undergoing a common general surgical procedure: cholecystectomy. METHODS: Data were obtained from the State Inpatient Database developed for the Healthcare Cost and Utilization Project. Inclusion criteria included patients ≥ 18 years with CP and a primary ICD-9 procedure code indicating open or laparoscopic cholecystectomy. Demographics, procedure-related factors, and comorbid conditions were analyzed, and unplanned 30 and 90 day readmission rates calculated for each variable. Reasons for readmission based on ICD-9 diagnosis codes were grouped into relevant categories. Univariate analysis identified factors significantly associated with readmission rates. RESULTS: A total of 802 patients with CP met the inclusion criteria. Unplanned 30 and 90 day readmission rates after laparoscopic cholecystectomy were 11.4% and 18.1%, respectively. Average length of stay (LOS) after laparoscopic cholecystectomy was 7.1 days. After open cholecystectomy, 30 and 90 day readmission rates were 16.9% and 30.3% with an average LOS of 14.6 days. Infection was the most common cause for 30 and 90 day readmission. Factors associated with 30 day readmission included type of cholecystectomy, LOS, discharge to skilled nursing facility, and comorbid diabetes and malnutrition. Factors associated with 90 day readmission included type of cholecystectomy, LOS, discharge to skilled nursing facility, and comorbid heart failure, renal disease, epilepsy, and malnutrition. CONCLUSION: Unplanned readmission rates after open and laparoscopic cholecystectomy in adult patients with CP are much higher than previously demonstrated rates in the general population. These patients frequently suffer multiple comorbid conditions that significantly complicate their surgical care. As more and more of these patients live longer into adulthood, further study is warranted to grasp the perioperative risk of simple and complex surgical procedures.

Derivation and validation of a predictive model for subtotal cholecystectomy.

INTRODUCTION: Rates of subtotal cholecystectomy (STC) are increasing in response to challenging cases of laparoscopic cholecystectomy (LC) to avoid bile duct injury, yet are associated with significant morbidity. The present study identifies risk factors for STC and both derives and validates a risk model for STC. METHODS: LC performed for all biliary pathology across three general surgical units were included (2015-2020). Clinicopathological, intraoperative and post-operative details were reported. Backward stepwise multivariable regression was performed to derive the most parsimonious predictive model for STC. Bootstrapping was performed for internal validation and patients were categorised into risk groups. RESULTS: Overall, 2768 patients underwent LC (median age, 53 years; median ASA, 2; median BMI, 29.7 kg/m2), including 99 cases (3.6%) of STC. Post-operatively following STC, there were bile leaks in 29.3%, collections in 19.2% and retained stones in 10.1% of patients. Post-operative intervention was performed in 29.3%, including ERCP (22.2%), laparoscopy (5.0%) and laparotomy (3.0%). The following variables were positive predictors of STC and were included in the final model: age > 60 years, male sex, diabetes mellitus, acute cholecystitis (AC), increased severity of AC (CRP > 90 mg/L), ≥ 3 biliary admissions, pre-operative ERCP with/without stent, pre-operative cholecystostomy and emergency LC (AUC = 0.84). Low, medium and high-risk groups had a STC rate of 0.8%, 3.9% and 24.5%, respectively. DISCUSSION: The present study determines the morbidity of STC and identifies high-risk features associated with STC. A risk model for STC is derived and internally validated to help surgeons identify high-risk patients and both improve pre-operative decision-making and patient counselling.

Mirizzi Syndrome and Its Surgical Interventions: A Case Report.

A rare side effect of cholelithiasis, called Mirizzi syndrome (MS), arises when gallstones that are impacted in the Hartmann's pouch or the cystic duct extrinsically compress the common bile duct. This condition is typically managed with a cholecystectomy. In this case report, different surgical approaches are described according to each type of Mirizzi. We report a 62-year-old female who presented with abdominal pain. She underwent endoscopic retrograde cholangiopancreaticography (ERCP) and was diagnosed with MS. We performed a subtotal cholecystectomy with a choledochoduodenostomy.

Robotic-Assisted Cholecystoduodenal Fistula and Bile Leak Repair.

Cholelithiasis and its complications are among the most prevalent and costly medical conditions in the United States. Chronic gallbladder disease can progress into more complicated conditions, such as a cholecystoenteric fistula and, more specifically, a cholecystoduodenal fistula (CDF). Repair of these fistulas is complex and usually performed with an open approach. However, if discovered pre-operatively, they can be referred to a hepatobiliary surgery center, where surgeons have specialized training to do such procedures laparoscopically. Here, we present a case of a 57-year-old female with a past medical history of migraines, arthritis, chronic back pain, and fibromyalgia, with no prior surgical history. She presented with an approximately six-month history of colicky right upper quadrant pain and symptomatology consistent with symptomatic cholelithiasis. She elected to have a robotic-assisted laparoscopic cholecystectomy performed. Intraoperatively, she was found to have a CDF and subsequent bile duct leak that were successfully repaired. While more research is required to further characterize and more quickly identify this complication of gallbladder disease, this case highlights the value of robotic-assisted surgery in technically challenging cases. We aim to describe and advocate for the adoption of a robotic approach in patients with comparable presentations, allowing for excellent visualization and control in the removal of inflamed gallbladders, repair of fistulized tissues, and stabilization of bile leaks.

Collaborative Implementation of Robotic Surgery Into an Academic Pediatric Surgery Practice.

INTRODUCTION: Robotic surgery continues to drive evolution in minimally invasive surgery. Due to the confined operative fields encountered, pediatric surgeons may uniquely benefit from the precise control offered by robotic technologies compared to open and laparoscopic techniques. We describe a unique collaborative implementation of robotic surgery into an academic pediatric surgery practice through adult robotic surgeon partnership. We compare robotic cholecystectomy (RC) and laparoscopic cholecystectomy (LC) outcomes, hypothesizing that RC will be equivalent to LC in key quality outcomes. METHODS: We evaluate 14 mo of systems development and training, and 24 mo of collaborative operative experience evoking a purposeful tiered case progression, establishing core robotic competencies, prior to advancing operative complexity. Univariate analyses compared LC versus RC. RESULTS: 36 robotic operations were performed in children aged 8-18 y, in a tiered progression from 24 cholecystectomies to 2 ileocecectomies, 2 paraesophageal hernia repairs, 1 anterior rectopexy, 1 spleen-preserving distal pancreatectomy, 1 Heller myotomy, 1 choledochal cyst resection with roux-en-y hepaticojejunostomy, 1 median arcuate ligament release, and 1 thoracic esophageal duplication cyst resection. For LC and RC, there were no significant differences in procedure duration, discharge opioids, hospital readmission, or rates of surgical site infection or bile duct injury. CONCLUSIONS: Robotic surgery has potential to significantly enhance pediatric surgery. RC appears equivalent to LC but presents multiple additional theoretical benefits in pediatric patients. Our pilot program experience supports the feasibility and safety of pediatric robotic surgery. We emphasize the importance of a stepwise progression in operative difficulty and collaboration with adult robotic surgery experts.

The effect of lung-recruitment maneuver on postoperative shoulder pain in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial.

PURPOSE: Lung-recruitment maneuvers (LRM) have been shown to reduce postoperative pain after laparoscopic surgery. This study aimed to investigate the association of LRM with the incidence of shoulder pain after laparoscopic cholecystectomy. METHODS: A randomized controlled study was conducted with 110 patients undergoing elective laparoscopic cholecystectomy from July 2022 to March 2023. Participants were randomized to receive either routine exsufflation or LRM at pneumoperitoneum release. The postoperative shoulder pain and abdominal pain were assessed at 1, 4, 6, 12, and 24 h after surgery using a numeric rating scale. Analgesic consumption and postoperative nausea or vomiting (PONV) were evaluated during the first 24 h after surgery. RESULTS: The incidence of shoulder pain during the first 24 h after surgery was significantly lower in the LRM group compared to the control group (26.9 vs. 59.3%; P = 0.001). The median [interquartile range] score of worst shoulder pain was significantly lower compared to the control group (3 [2-3] vs 4 [3-5.5]; P = 0.003). Participants in the LRM group showed reduced abdominal pain at rest at 4 and 24 h after surgery, and experienced significantly lower intensities of abdominal pain during mobilization at all time points over 24 h after surgery. There were no significant differences in opioid consumption or the incidence of PONV between the groups. CONCLUSIONS: LRM reduces both the incidence and intensity of shoulder pain during 24 h after laparoscopic cholecystectomy. Additionally, LRM was associated with reduced intensity of abdominal pain during mobilization over the study period.

Radical cholecystectomy without liver resection for peritoneal side early incidental gallbladder cancer.

Gallbladder cancer (GBC) is a rare disease with a poor prognosis. Simple cholecystectomy may be an adequate treatment only for very early disease (Tis, T1a), whereas reoperation is recommended for more advanced disease (T1b and T2). Radical cholecystectomy should have two fundamental objectives: To radically resect the liver parenchyma and to achieve adequate clearance of the lymph nodes. However, recent studies have shown that compared with lymph node dissection alone, liver resection does not improve survival outcomes. The oncological roles of lymphadenectomy and liver resection is distinct. Therefore, for patients with incidental GBC without liver invasion, hepatic resection is not always mandatory.

Intracholecystic Papillary Neoplasm: A Case Report.

We present a case of a 30-year-old female with symptomatic gallstones and associated gallbladder polyps. An incidental finding of intracholecystic papillary neoplasm (ICPN) with high-grade dysplasia was found after pathological examination of the gallbladder after robotic cholecystectomy. This rare condition can be associated with malignant transformation. In this case report, we discuss this rare entity and share our experience and review of the literature.

Alteration of ascending colon mucosal microbiota in patients after cholecystectomy.

BACKGROUND: Cholecystectomy is a successful treatment option for gallstones, although the incidence of colorectal cancer (CRC) has notably increased in post-cholecystectomy (PC) patients. However, it remains uncertain whether the altered mucosal microbiota in the ascending colon is related. AIM: To investigate the potential correlation between gut microbiota and the surgical procedure of cholecystectomy. METHODS: In total, 30 PC patients and 28 healthy controls underwent colonoscopies to collect mucosal biopsy samples. PC patients were divided based on their clinical features. Then, 16S-rRNA gene sequencing was used to analyze the amplicon, alpha diversity, beta diversity, and composition of the bacterial communities. Additionally, the Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) database, sourced from the Kyoto Encyclopedia of Genes and Genomes, was used to predict the functional capabilities of the bacteria. RESULTS: PC patients were comparable with healthy controls. However, PC patients older than 60 years had a distinct composition compared to those under 60 years old. Bacteroidetes richness was considerably higher at the phylum level in PC patients. Bacteroides, Parabacteroides, and Bilophila were more abundant in the PC group than in the control group. Furthermore, PC patients exhibited greater enrichment in metabolic pathways, specifically those related to lipopolysaccharide biosynthesis and vancomycin group antibiotic production, than controls. CONCLUSION: This study indicated that the mucosal microbiota in PC patients was altered, perhaps offering new perspectives on the treatment possibilities for CRC and diarrhea following cholecystectomy.

Mastering nonobstetric surgery in pregnancy: Insights, guidelines evaluation, and point-by-point discussion.

For surgeons and clinicians, nonobstetric surgery during pregnancy has certain difficulties and considerations. In order to aid in decision-making in these situations, this manuscript offers a thorough review of the guidelines currently in place from renowned obstetric and surgical societies, such as the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians & Gynecologists, and others. Using AGREE II-S methodology, a comprehensive analysis of guidelines reveals differences in recommendations for anesthetics, surgical procedures, imaging modalities, and thromboembolic prophylaxis. Furthermore, a thorough discussion of strategic surgical planning is provided, covering aspects such as patient positioning, trocar placement, pneumoperitoneum generation, and thromboembolic risk management. The publication highlights that in order to maximize the results for both the mother and the fetus after nonobstetric surgery performed during pregnancy, a multidisciplinary approach and evidence-based decision-making are essential.

Early Versus Delayed Laparoscopic Cholecystectomy, after Percutaneous Gall Bladder Drainage, for Grade II Acute Cholecystitis TG18 in Patients with Concomitant Cardiopulmonary Disease.

Background: The advancement in medical care has led to an increase in patients with acute cholecystitis (AC) and cardiopulmonary comorbidities referred for surgery. Grade II AC, according to Tokyo Guidelines in 2018 (TG18), is characterized by severe local inflammation with no systemic affection. The optimal treatment for patients with high-risk grade II AC has not yet been clearly established, which is still a dilemma. For these patients, laparoscopic cholecystectomy (LC), despite being the only definitive treatment, is still a challenge. The introduction of percutaneous cholecystostomy as a temporary minimally invasive alternative technique allows an immediate gallbladder decompression with a rapid clinical improvement. However, the next step after percutaneous transhepatic gall bladder drainage (PTGBD) in these high-risk patients is still a debate, with no definitive consensus about the ideal treatment of choice as well as its optimal timing. In our study, we followed a treatment algorithm for high-risk patients that involved early gallbladder decompression by PTGBD, followed by LC at different intervals once the patient is considered fit for surgery. Method: A retrospective study of 58 patients with high-risk grade II AC with cardiopulmonary comorbidity from our medical records was included. They were managed initially with PTGBD, an LC was then performed either within 7 days after drain insertion (early group, 26 patients), while an LC was performed later for the remaining patients within 6-8 weeks after PTGBD (late group, 32 patients). The results of the two groups were analyzed. Result: Procalcitonin and C-reactive protein were significantly higher in the late group. No significant difference was found between both groups with regard to operative time, PTGBD-related complications, and major perioperative complications. Timing after PTGBD did not affect the incidence of operative complications. Total hospital stay was significantly shorter in the early group. Conclusion: PTGBD is a safe initial intervention for high-risk patients with AC with a low morbidity and high success rate. Urgent LC after PTGBD can be performed safely for well-selected high-risk patients with the timing of surgery is personalized according to each patient's clinical situation. Early LC (after PTGBD) has the advantage of shorter hospital stay, low cost, as well as avoiding the risk of biliary complications and mortality if waiting a delayed surgery with no significant difference in morbidity compared with late LC.

Initial Experience with Disposable Single-Use Cholangioscope During Laparoscopic Common Bile Duct Exploration.

Introduction: For patients with choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) is more cost effective than endoscopic retrograde cholangiopancreatography (ERCP) and results in shorter hospital length of stay. As LCBDE can be technically challenging to perform, utilizing a disposable single-use cholangioscope (DSUC) for LCBDE through a cystic ductotomy has several advantages, such as potentially avoiding a choledochotomy and expanding access to cholangioscopes as a DSUC is disposable and does not require infrastructure for cleaning or maintenance. Methods: An IRB-approved, retrospective chart review from 2021 to 2023 was conducted for patients who underwent concurrent laparoscopic cholecystectomy (LC) and LCBDE with a DSUC (SpyGlass™ Discover, Boston Scientific, Natick, MA) for the management of choledocholithiasis diagnosed either preoperatively or during intraoperative cholangiogram (IOC). Primary endpoint was successful clearance of biliary duct stones. Results: Twelve patients with a mean age of 55.3 years (SD ±13.9) and mean body mass index of 33.8 (SD ±10.8) were found to have filling defects on IOC for LC and underwent LCBDE with DSUC. Of these, 10 patients had stones. Complete stone clearance was achieved in all 10 patients with various stone extraction maneuvers. The mean operative time was 189 minutes (SD ±63.6) and mean hospital length of stay postoperatively was 1 day (SD ±.8). Mean length of follow-up postoperatively was 26.9 (SD ±16.0) days. There were no intraoperative complications, no need for repeat procedures, and only one postoperative complication involving a superficial surgical site infection requiring oral antibiotics. Conclusions: LCBDE with a DSUC is safe and efficacious for clearing stones and identifying pathology of the CBD. Familiarity with this device is especially useful for surgeons who want to simultaneously manage choledocholithiasis at the same time as cholecystectomy to reduce hospital stay and overall cost.

The Rationale of sub-hepatic drainage on a specialist biliary unit: a review of 6140 elective and urgent laparoscopic cholecystectomies and bile duct explorations.

BACKGROUND: Drains are used to reduce abdominal collections after procedures where such risk exists. Using abdominal drains after cholecystectomy has been controversial since the open surgery era. Universally accepted indications and agreement exist that routine drainage is unnecessary but the role of selective drainage remains undetermined. This study evaluates the indications and benefits of sub-hepatic drainage in patients undergoing laparoscopic cholecystectomy (LC) and bile duct exploration (BDE) in a specialist unit with a large biliary emergency workload. METHODS: Prospectively collected data from 6,140 LCs with a 46.6% emergency workload over 30 years was reviewed. Demographic factors, pre-operative presentations, imaging and operative details in patients with and without drains were compared. Sub-hepatic drains were inserted after all transductal explorations, subtotal cholecystectomies, almost all open conversions and 94% of LC for empyemas. Adverse or beneficial postoperative drain-related outcomes were analysed. RESULTS: Abdominal drains were utilised in 3225/6140 (52.5%). Patients were significantly older with more males. 59.4% were emergency admissions. Preoperative imaging showed thick-walled gallbladders in 25.2% and bile duct stones or dilatation in 36.2%. At operation they had cystic duct stones in 19.8%, acute cholecystitis, empyema or mucocele in 28.4% and operative difficulty grades III or higher in 59%. 38% underwent BDE, 5.4% had fundus-first dissection and the operating times were longer ( 80 vs.45 min). Drain related complications were rare; 3 abdominal pains after anaesthetic recovery settling when drains were removed, 2 drain site infections and one re-laparoscopy to retrieve a retracted drain. 55.8% of 43 bile leaks and 35% of 20 other collections in patients with drains resolved spontaneously. CONCLUSIONS: The utilisation of drains in this study was relatively high due to the high emergency workload and interest in BDE. While drains allowed early detection of bile leakage, avoiding some complications and monitoring conservative management to allow early reinterventions, the study has identified operative criteria that could potentially limit drain insertion through a selective policy.

The effect of shoulder massage on shoulder pain and sleep quality in patients after laparoscopic cholecystectomy: a randomized controlled trial.

BACKGROUND: Laparoscopic cholecystectomy patients may suffer from sleep disturbances due to this postoperative pain. Postoperative pain and low sleep quality can lead to various unpredictable complications, including anxiety.The aim of this study is to determine the effect of shoulder massage administered to patients after laparoscopic cholecystectomy on pain and sleep quality. METHODS: The study was designed as a randomized controlled trial.This study was carried out with 60 patients who underwent surgery at the General Surgery Department of a university's Faculty of Medicine between January 2020 and March 2021. The study was completed with 60 patients (30 in the intervention group and 30 in the control group). The patients in the intervention group received shoulder massage twice at 6-hour intervals. The data for the study were collected using the "Individual Introduction Form", the "VAS", and the "Richard Campbell Sleep Scale". RESULTS: It was found that the pain of the patients in the intervention group significantly decreased compared to the control group 30 min after the massage (p˂0.05). However, 6 h after the massage, the pain levels in both groups were similar. The sleep quality of the patients in the intervention group was significantly higher compared to those in the control group (p˂0.05). CONCLUSIONS: It was determined that the massage therapy yielded a short-term alleviation of shoulder pain among the patients while also enhancing their sleep quality. These results suggest that shoulder massage could be effectively incorporated into nursing practice as a means to ameliorate pain levels and enhance sleep quality in postoperative patients. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT06480149 (retrospectively registered, Protocol ID: 2019/06-8Last Update Posted 2024-06-28) https://ctv.veeva.com/study/shoulder-massage-after-cholecystectomy .

The Influence of Obesity on Cholecystectomy Outcomes: A Systematic Review of Laparoscopic and Open Approaches.

This systematic review evaluates the impact of obesity on the outcomes of laparoscopic versus open cholecystectomy, analyzing data from five key studies. The review explores differences in operative times, complication rates, conversion rates, and recovery times among obese patients undergoing these surgical procedures. The findings indicate that while laparoscopic cholecystectomy in obese patients tends to require longer operative times, it does not significantly increase complication rates compared to open cholecystectomy. However, the risk of conversion to open surgery is modestly elevated. The review highlights the necessity for surgical guidelines to adapt to the challenges posed by obesity, recommending advanced training and innovative technologies to improve surgical outcomes. Limitations such as study design heterogeneity and variability in defining obesity underscore the need for further research. This review contributes to optimizing surgical care strategies and improving patient outcomes in the growing demographic of obese surgical patients.