Clinical efficacy of laparoscopic cholecystectomy combined with endoscopic papillary balloon dilation in treatment of gallbladder stones with common bile duct stones: A retrospective study.

BACKGROUND: The incidence of cholelithiasis has been on the rise in recent years, but the choice of procedure is controversial. AIM: To investigate the efficacy of laparoscopic cholecystectomy (LC) combined with endoscopic papillary balloon dilation (EPBD) in patients with gallbladder stones (GS) with common bile duct stones (CBDS). METHODS: The clinical data of 102 patients with GS combined with CBDS were selected for retrospective analysis and divided into either an LC + EPBD group (n = 50) or an LC + endoscopic sphincterotomy (EST) group (n = 52) according to surgical methods. Surgery-related indexes, postoperative recovery, postoperative complications, and expression levels of inflammatory response indexes were compared between the two groups. RESULTS: Total surgical time, stone free rate, rate of conversion to laparotomy, and successful stone extraction rate did not differ significantly between the LC + EPBD group and LC + EST group. Intraoperative hemorrhage, time to ambulation, and length of hospitalization in the LC + EPBD group were lower than those of the LC + EST group (P < 0.05). The rate of total complications of the two groups was 9.80% and 17.65%, respectively, and the difference was not statistically significant. No serious complications occurred in either group. At 48 h postoperatively, the expression levels of interleukin-6, tumor necrosis factor-α, high-sensitivity C-reactive protein, and procalcitonin were lower in the LC + EPBD group than in the LC + EST group (P < 0.05). At 3 d postoperatively, the expression levels of aspartate transaminase, alanine transaminase, and total bilirubin were lower in the LC + EPBD group than in the LC + EST group (P < 0.05). CONCLUSION: LC combined with EPBD and LC combined with EST are both effective procedures for the treatment of GS with CBDS, in which LC combined with EPBD is beneficial to shorten the patient's hospitalization time, reduce the magnitude of elevated inflammatory response indexes, and promote postoperative recovery.

Prediction of intraoperative surgical difficulty during laparoscopic cholecystectomy using drip infusion cholangiography with computed tomography.

BACKGROUND: Although findings from drip infusion cholangiography with computed tomography (DIC-CT) are useful in preoperative anatomic evaluation for laparoscopic cholecystectomy (LC), their relationship with intraoperative surgical difficulty based on the difficulty score (DS) proposed by Tokyo Guidelines 2018 is unclear. We examined this relationship. METHODS: Data were collected from 202 patients who underwent LC for benign gallbladder (GB) disease with preoperative DIC-CT in our department. DIC-CT findings were classified into GB-positive and GB-negative groups based on GB opacification, and clinical characteristics were compared. DS assessed only on findings from around Calot's triangle was considered "cDS", and patients were divided into cDS ≤2 and ≥3 groups. Preoperative data including DIC-CT findings were evaluated using multivariate analysis. RESULTS: DIC-CT findings showed 151 (74.8%) GB-positive and 51 (25.2%) GB-negative patients. Surgical outcomes were significantly better in the GB-positive versus GB-negative group for operation time (107 vs. 154 min, p < .001), blood loss (8 vs. 25 mL, p < .001), cDS (0.8 vs. 2.2, p < .001), and critical view of safety score (4.0 vs. 3.1, p < .001). cDS was ≤2 in 174 (86.1%) and ≥3 in 28 (13.9%) patients. By multivariate analysis, DIC-CT findings and alkaline phosphatase values were independent factors predicting intraoperative difficulty. CONCLUSION: DIC-CT findings are useful for predicting cDS in LC.

Postcholecystectomy Duodenal Injuries, Their Management, and Review of the Literature.

Backgrounds: Laparoscopic cholecystectomy (LC) is the gold standard for treating gallstones; however, it is not free of complications. Postcholecystectomy duodenal injuries are rare but challenging complications after cholecystectomy. The objective of this study was to analyze the management of postcholecystectomy duodenal injuries and to review the related literature. Materials and methods: An observational and retrospective study was conducted. We included all patients with postcholecystectomy duodenal injuries treated at a reference center, from January 2019 to December 2023. In addition, a review of the literature was carried out. Results: Fifteen patients were found, mostly women; with gallbladder wall thickening on ultrasound (mean of 8 mm). The majority were emergency (n = 12, 80%) and LCs (n = 8, 53.33%). Cholecystectomies were reported to be associated with excessive difficulty (n = 10, 66.66%). The most injured duodenal portion was the first portion (n = 9, 60%), and blunt dissection was the most common mechanism of injury (n = 7, 46.66%). Most of these injuries were detected in the operating room (n = 9, 60%), and treated with primary closure (n = 11, 73.33%). Three patients with delayed injuries died (20%). According to the literature reviewed, 93 duodenal injuries were found, mostly detected intraoperatively, in the second portion, and treated with primary closure. A minority of patients were treated with more complex procedures, for a mortality rate of 15.38%. Conclusion: Postcholecystectomy duodenal injuries are rare. Most of these injuries are detected and repaired intraoperatively. However, a high percentage of patients have high morbidity and mortality. How to cite this article: Diaz-Martinez J, Pérez-Correa N. Postcholecystectomy Duodenal Injuries, Their Management, and Review of the Literature. Euroasian J Hepato-Gastroenterol 2024;14(1):44-50.

The Multifaceted Impact of Gallstones: Understanding Complications and Management Strategies.

Gallstones, or cholelithiasis, represent a prevalent gastrointestinal disorder characterized by the formation of calculi within the gallbladder. This review aims to provide a comprehensive analysis of the complications associated with gallstones, with a focus on their pathophysiology, clinical manifestations, diagnostic methodologies, and management strategies. Gallstone-related complications encompass a broad spectrum, including biliary colic, acute cholecystitis, choledocholithiasis, acute pancreatitis, and cholangitis. The pathogenesis of these complications primarily involves biliary obstruction and subsequent infection, leading to significant morbidity and potential mortality. Diagnostic evaluation of gallstone complications employs various imaging techniques, such as ultrasonography, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP), each with distinct advantages and limitations. Therapeutic approaches are discussed, ranging from conservative management with pharmacotherapy and bile acid dissolution agents to interventional procedures like extracorporeal shock wave lithotripsy (ESWL) and percutaneous cholecystostomy. Surgical management, particularly laparoscopic cholecystectomy, remains the gold standard for definitive treatment. Additionally, advancements in endoscopic techniques, including endoscopic sphincterotomy (EST) and cholangioscopy, are highlighted. This review synthesizes current research findings and clinical guidelines, aiming to enhance the understanding and management of gallstone-related complications among healthcare professionals, thereby improving patient outcomes and reducing the burden of this common ailment.

Early laparoscopic cholecystectomy in acute mild gallstone pancreatitis. Is there a role for routine admission contrast-enhanced CT Scan?

PURPOSE: This study aims to evaluate the efficacy of admission contrast-enhanced CT scans in formulating strategies for performing early laparoscopic cholecystectomy in cases of acute gallstone pancreatitis. METHODS: Patients diagnosed with acute gallstone pancreatitis underwent a CT scan upon admission (after at least 24 h from symptom onset) to confirm diagnosis and assess peripancreatic fluid, collections, gallstones, and common bile duct stones. Patients with mild acute gallstone pancreatitis, following the Atlanta classification and Baltazar score A or B, were identified as candidates for early cholecystectomy (within 72 h of admission). RESULTS: Within the analyzed period, 272 patients were diagnosed with mild acute gallstone pancreatitis according to the Atlanta Guidelines. A total of 33 patients (12.1%) were excluded: 17 (6.25%) due to SIRS, 10 (3.6%) due to local complications identified in CT (Balthazar D/E), and 6 (2.2%) due to severe comorbidities. Enhanced CT scans accurately detected gallstones, common bile duct stones, pancreatic enlargement, inflammation, pancreatic collections, and peripancreatic fluid. Among the cohort, 239 patients were selected for early laparoscopic cholecystectomy. Routine intraoperative cholangiogram was conducted in all cases, and where choledocholithiasis was present, successful treatment occurred through common bile duct exploration. Only one case required conversion from laparoscopic to open surgery. There were no observed severe complications or mortality. CONCLUSION: Admission CT scans are instrumental in identifying clinically stable patients with local tomographic complications that contraindicate early surgery. Patients meeting the criteria for mild acute gallstone pancreatitis, as per Atlanta guidelines, without SIRS or local complications (Baltazar D/E), can safely undergo early cholecystectomy within the initial 72 h of admission.

Analysis of quality of life in patients after transgastric natural orifice transluminal endoscopic gallbladder-preserving surgery.

BACKGROUND: At present, laparoscopic cholecystectomy (LC) is the main surgical treatment for gallstones. But, after gallbladder removal, there are many complications. Therefore, it is hoped to remove stones while preserving the function of the gallbladder, and with the development of endoscopic technology, natural orifice transluminal endoscopic surgery came into being. AIM: To compare the quality of life, perioperative indicators, adverse events after LC and transgastric natural orifice transluminal endoscopic gallbladder-preserving surgery (EGPS) in patients with gallstones. METHODS: Patients who were admitted to The First Affiliated Hospital of Xinjiang Medical University from 2020 to 2022 were retrospectively collected. We adopted propensity score matching (1:1) to compare EGPS and LC patients. RESULTS: A total of 662 cases were collected, of which 589 cases underwent LC, and 73 cases underwent EGPS. Propensity score matching was performed, and 40 patients were included in each of the groups. In the EGPS group, except the gastrointestinal defecation (P = 0.603), the total score, physical well-being, mental well-being, and gastrointestinal digestion were statistically significant compared with the preoperative score after surgery (P < 0.05). In the LC group, except the mental well-being, the total score, physical well-being, gastrointestinal digestion, the gastrointestinal defecation was statistically significant compared with the preoperative score after surgery (P < 0.05). When comparing between groups, gastrointestinal defecation had significantly difference (P = 0.002) between the two groups, there was no statistically significant difference in the total postoperative score and the other three subscales. In the surgery duration, hospital stay and cost, LC group were lower than EGPS group. The recurrence factors of gallstones after EGPS were analyzed: and recurrence was not correlated with gender, age, body mass index, number of stones, and preoperative score. CONCLUSION: Whether EGPS or LC, it can improve the patient's symptoms, and the EGPS has less impact on the patient's defecation. It needed to, prospective, multicenter, long-term follow-up, large-sample related studies to prove.

A Systematic Review and Meta-Analysis of the Management of Gallstone Cholecystitis and Common Biliary Duct Stones to Reduce the Incidence of Complications in Elderly Patients.

As the age increases particularly above the age of 50 years, there is a significantly higher risk of developing gallstone-related complications especially cholecystitis and common bile duct stones with its associated consequences. Complications that arise after surgical operations for cholecystitis have been reported to have negative impacts on senior patients. These effects include a higher rate of complications, a longer hospital stay, higher expenditures, and decreased patient satisfaction. Therefore, finding the most effective treatment for cholecystitis in older patients is still a challenge. The aim of the study was carried out in order to identify many approaches that can be taken in the treatment of cholecystitis and stones in the common bile duct in older patients. A search was conducted through Medline (PubMed), EMBASE, ProQuest, and Cochrane using relevant Medical Subject Heading (MeSH) terms and keywords (elderly, age over 50, cholecystitis, bile duct stones, cholecystectomy, ERCP, surgical, conservative management, and open). The searches were limited to studies on elderly individuals over 50 who had cholecystectomy and endoscopic retrograde cholangiopancreatography between January 2000 and December 2022. The meta-analysis used the Mantel-Haenszel odds ratio (MHOR) and 95% confidence interval (CI). Aries Systems Corporation's Editorial Manager® (Aries Systems Corporation, North Andover, USA) and ProduXion Manager® (Aries Systems Corporation, North Andover, USA) facilitated the study. Out of 102 citations, 39 studies were selected for further study. After that, 18 studies were eliminated, leaving 21 for meta-analysis. The study found a protective risk of cholecystitis in cholecystectomy patients (MHOR = 0.16; 95%, CI = 0.10 to 0.25; p 0.001). Developing cholecystitis was substantially lower in early cholecystectomy patients (MHOR = 0.16; 95%, CI = 0.10 to 0.25; p 0.001). There was no significant difference in cholecystitis risk between open and laparoscopic surgery (MHOR = 0.65; 95%, CI = 0.41 to 1.04; p 0.07). Cholecystectomy performed at an earlier stage protects elderly patients from developing recurrent cholecystitis. In contrast to late cholecystitis, in which the patient would experience several attacks of cholecystitis, early cholecystectomy protects against the recurrence of the condition.

The effects of previous abdominal surgery and the utilisation of modified access techniques on the operative difficulty and outcomes of laparoscopic cholecystectomy and bile duct exploration.

BACKGROUND: Early reports suggested that previous abdominal surgery was a relative contraindication to laparoscopic cholecystectomy (LC) on account of difficulty and potential access complications. This study analyses different types/systems of previous surgery and locations of scars and how they affect access difficulties. As modified access techniques to minimise risk of complications are under-reported the study details and evaluates them. METHOD: Prospectively collected data from consecutive LC and common bile duct explorations (LCBDE) performed by a single surgeon over 30 years was analysed. Previous abdominal surgery was documented and peri-operative outcomes were compared with patients who had no previous surgery using Chi-squared analysis. RESULTS: Of 5916 LC and LCBDE, 1846 patients (31.2%) had previous abdominal surgery. The median age was 60 years. Those with previous surgery required more frequent duodenal (RR 1.07; p = 0.023), hepatic flexure (RR 1.11; p = 0.043) and distal adhesiolysis (RR 3.57; p < 0.001) and had more access related bowel injuries (0.4% vs. 0.0%; p < 0.001). Previous upper gastrointestinal and biliary surgery had the highest rates of adhesiolysis (76.3%), difficult cystic pedicles (58.8%), fundus-first approach (7.2%), difficulty grades (64.9% Grades 3-5) and utilisation of abdominal drains (71.1%). Previous open surgery resulted in longer operative time compared to previous laparoscopic procedures (65vs.55 min; p < 0.001), increased difficulty of pedicle dissection (42.4% vs. 36.0%; p < 0.05) and required more duodenal, hepatic flexure and distant adhesiolysis (p < 0.05) and fundus-first dissection (4% vs 2%; p < 0.05). Epigastric and supraumbilical access and access through umbilical and other hernias were used in 163 patients (8.8%) with no bowel complications. CONCLUSION: The risks of access and adhesiolysis in patients with previous abdominal scars undergoing biliary surgery are dependent on the nature of previous surgery. Previous open, upper gastrointestinal and biliary surgery carried the most significant risks. Modified access techniques can be adopted to safely mitigate these risks.

Ultrasound-Guided External Oblique Intercostal Block as Part of Multimodal Analgesia for Unplanned Open Cholecystectomy.

We present the case of a 56-year-old female with a significant medical history of cholelithiasis and recurrent choledocholithiasis. Following an elective cholecystectomy, an obstructing gallstone in the common bile duct led to a series of interventions, including endoscopic retrograde cholangiopancreatography and stent placement. The patient was scheduled for a robot-assisted laparoscopic common bile duct exploration. Due to severe adhesions, the procedure was converted to open with a large right upper quadrant incision. Intraoperative continuous external oblique block and catheter placement were performed at the end of surgery in the OR. Peripheral nerve blocks have become an integral part of multimodal pain management strategies. This case report describes the successful implementation of an ultrasound-guided right external oblique intercostal block and catheter placement for postoperative pain control and minimization of opioids. This case highlights the efficacy and safety of ultrasound-guided peripheral nerve blocks for postoperative pain management. Successful pain control contributed to the patient's overall postoperative recovery.

Pediatric Gallstone Disease - Management Difficulties In Clinical Practice.

BACKGROUND: Gallstone disease (GD) is no longer an exclusive condition of adulthood, and its prevalence is increasing in pediatric age. The management and the extent of the etiological investigation of GD in children and adolescents remains controversial. This aimed to analyze the difficulties in the work-up and management of pediatric GD patients. METHODS: A retrospective study performed in a single tertiary center enrolled sixty-five patients with GD followed from January 2014 to June 2021. Patients were categorized conveniently according to their age at diagnosis: Group A (< 10 years, n = 35) and Group B (≥ 10 years, n = 30). We analyzed demographic, clinical and laboratory data, ultrasonographic findings at presentation, therapeutics and complications. RESULTS: Symptoms were more frequent in patients > 10 years old (p = 0,001). Cholecystectomy was performed in 31 patients (47,7%). A multivariate regression logistic model identified the age > 10 years (OR = 6.440, p = 0.005) and underlying entities (OR = 6.823, p = 0.017) as independent variables to perform surgery. Spontaneous resolution of GD was more common in children < 2 years old. A multivariate regression logistic model showed a trend for those > 10 years old to develop more complications. Two out of 18 patients were diagnosed with ABCB4 gene mutations in heterozygosity. CONCLUSIONS: Decision-making on cholecystectomy remains challenging in asymptomatic patients. Identifying predictive factors for the development of complications has proven difficult. However, we found a trend toward the development of complications in individuals older than 10 years.

Single stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography for cholecysto-choledocholithiasis. Lesson learnt from the COVID-19 pandemic.

Introduction: Choledocholithiasis, a common complication of gallstone disease, poses significant risks including cholangitis and pancreatitis. Various treatment approaches exist, including single-stage and two-stage techniques, with recent literature suggesting advantages of the single-stage approach in terms of outcomes and cost-effectiveness. This study evaluates the feasibility, efficacy, and safety of single-stage laparoscopic cholecystectomy combined with intraoperative endoscopic retrograde cholangiopancreatography (LC + iERCP) compared to the previously adopted two-stage approach. Methods: A retrospective analysis was conducted on patients undergoing single-stage LC + iERCP for cholecysto-choledocholithiasis during the COVID-19 pandemic (2020-2022). Data on demographics, preoperative assessments, intraoperative parameters, and postoperative outcomes were collected and compared with an historical control group undergoing the two-stage approach (LC + preopERCP). Hospitalization costs were also compared between the two groups. Results: A total of 190 patients were included, with 105 undergoing single-stage LC + iERCP. The single-stage approach demonstrated successful completion without cystic duct cannulation, with no conversions to open surgery. Operative time was comparable to the two-stage approach, while hospital stay, and costs were significantly lower in the single-stage group. Complication rates were similar between the groups. Conclusions: Single-stage LC + iERCP appears to be a feasible, effective, and safe approach for treating cholecysto-choledocholithiasis, offering potential benefits in terms of reduced hospital stay, OR occupation time, and costs compared to the two-stage approach. Integration of this approach into clinical practice warrants consideration, unless there are logistical challenges that cannot be overcome or lack of endoscopic expertise also for treating challenging urgent cases.

Enhancing Intraoperative Cholangiography Interpretation Skills: A Perceptual Learning Approach for Surgical Residents.

OBJECTIVE: Laparoscopic cholecystectomy is a commonly performed surgery with risk of serious complications. Intraoperative cholangiography (IOC) can mitigate these risks by clarifying the anatomy of the biliary tree and detecting common bile duct injuries. However, mastering IOC interpretation is largely through experience, and studies have shown that even expert surgeons often struggle with this skill. Since no formal curriculum exists for surgical residents to learn IOC interpretation, we developed a perceptual learning (PL)-based training module aimed at improving surgical residents' IOC interpretation skills. DESIGN: Surgical residents were assessed on their ability to identify IOC characteristics and provide clinical recommendations using an online training module based on PL principles. This research had 2 phases. The first phase involved pre/post assessments of residents trained via the online IOC interpretation module, measuring their IOC image recognition and clinical management accuracy (percentage of correct responses), response time and confidence. During the second phase, we explored the impact of combining simulator-based IOC training with the online interpretation module on same measures as used in the first phase (accuracy, response time, and confidence). SETTING: The study was conducted at Rush University Medical College in Chicago. The participants consisted of surgical residents from each postgraduate year (PGY). Residents participated in this study during their scheduled monthly rotation through Rush's surgical simulation center. RESULTS: Total 23 surgical residents participated in the first phase. A majority (95.7%) found the module helpful. Residents significantly increased confidence levels in various aspects of IOC interpretation, such as identifying complete IOCs and detecting abnormal findings. Their accuracy in making clinical management decisions significantly improved from pretraining (mean accuracy 68.1 +/- 17.3%) to post-training (mean accuracy 82.3 +/- 10.4%, p < 0.001). Furthermore, their response time per question decreased significantly from 25 +/- 12 seconds to 17 +/- 12 seconds (p < 0.001). In the second phase, we combined procedural simulator training with the online interpretation module. The 20, first year residents participated and 88% found the training helpful. The training group exhibited significant confidence improvements compared to the control group in various aspects of IOC interpretation with observed nonsignificant accuracy improvements related to clinical management questions. Both groups demonstrated reduced response times, with the training group showing a more substantial, though nonsignificant, reduction. CONCLUSION: This study demonstrated the effectiveness of a PL-based training module for improving aspects of surgical residents' IOC interpretation skills. The module, found helpful by a majority of participants, led to significant enhancements in clinical management accuracy, confidence levels, and decreased response time. Incorporating simulator-based training further reinforced these improvements, highlighting the potential of our approach to address the lack of formal curriculum for IOC interpretation in surgical education.

Surgical Cholecystectomy Score (SCS) for grading the difficulty of laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard of care for symptomatic gall stone disease. A good scoring system is necessary to standardize the reporting. Our aim was to develop and validate an objective scoring system, the Surgical Cholecystectomy Score (SCS) to grade the difficulty of LC. METHODS: The study was conducted in a single surgical unit at a tertiary care hospital in two phases from January 2017 to April 2021. Retrospective data was analysed and the difficulty of each procedure was graded according to the modified Nassar's scoring system. Significant preoperative and intraoperative data obtained was given a weightage score. In phase II, these scores were validated on a prospective cohort. Each procedure was classified either as easy, moderately difficult or difficult. STATISTICAL ANALYSIS: A univariate analysis was performed on the data followed by a multivariate regression analysis. Bidirectional stepwise selection was done to select the most significant variables. The Beta /Schneeweiss scoring system was used to generate a rounded risk score. RESULTS: Data of 800 patients was retrieved and graded. 10 intraoperative parameters were found to be significant. Each variable was assigned a rounded risk score. The final SCS range for intraoperative parameters was 0-15. The scoring system was validated on a cohort of 249 LC. In the final scoring, cut off SCS of > 8 was found to correlate with difficult procedures. Score of < 2 was equivalent to easy LC. A score between 2 and 8 indicated moderate difficulty. The area under ROC curve was 0.98 and 0.92 for the intraoperative score indicating that the score was an excellent measure of the difficulty level of LCs. CONCLUSION: The scoring system developed in this study has shown an excellent correlation with the difficulty of LC. It needs to be validated in different cohorts and across multiple centers further.

Safety of robotic cholecystectomy as index training procedure: the UK experience.

AIMS: To evaluate the safety profile of robotic cholecystectomy performed within the United Kingdom (UK) Robotic Hepatopancreatobiliary (HPB) training programme. METHODS: A retrospective evaluation of prospectively collected data from eleven centres participating in the UK Robotic HPB training programme was conducted. All adult patients undergoing robotic cholecystectomy for symptomatic gallstone disease or gallbladder polyp were considered. Bile duct injury, conversion to open procedure, conversion to subtotal cholecystectomy, length of hospital stay, 30-day re-admission, and post-operative complications were the evaluated outcome parameters. RESULTS: A total of 600 patients were included. The median age was 53 (IQR 65-41) years and the majority (72.7%; 436/600) were female. The main indications for robotic cholecystectomy were biliary colic (55.5%, 333/600), cholecystitis (18.8%, 113/600), gallbladder polyps (7.7%, 46/600), and pancreatitis (6.2%, 37/600). The median length of stay was 0 (IQR 0-1) days. Of the included patients, 88.5% (531/600) were discharged on the day of procedure with 30-day re-admission rate of 5.5% (33/600). There were no bile duct injuries and the rate of conversion to open was 0.8% (5/600) with subtotal cholecystectomy rate of 0.8% (5/600). CONCLUSION: The current study confirms that robotic cholecystectomy can be safely implemented to routine practice with a low risk of bile duct injury, low bile leak rate, low conversion to open surgery, and low need for subtotal cholecystectomy.

Benefits and risks of using laparoscopic ultrasonography versus intraoperative cholangiography during laparoscopic cholecystectomy for gallstone disease: a systematic review and meta-analysis.

BACKGROUND: Intraoperative laparoscopic ultrasonography (LUS) or intraoperative cholangiography (IOC) can be used for visualisation of the biliary tract during laparoscopic cholecystectomy. The aim of this systematic review was to compare use of LUS with IOC. METHODS: PubMed, Embase, the Cochrane Library, and Web of Science were searched (last update: April 2024). PICO: P = patients undergoing intraoperative imaging of the biliary tree during laparoscopic cholecystectomy for gallstone disease; I = intervention: LUS; C = comparison: IOC; O = outcomes: mortality, bile duct injury, retained gallstone, conversion to open cholecystectomy, procedural failure, operation time including imaging time. Included articles were critically appraised using checklists. Conclusions were based on studies without major risk of bias. Meta-analyses were performed using random effects models. Certainty of evidence was assessed according to GRADE. RESULTS: Sixteen non-randomised studies met the PICO. Two before/after studies (594 versus 807 patients) contributed to conclusions regarding mortality (no events; very low certainty evidence), bile duct injury (1 versus 0 events; very low certainty evidence), retained gallstone (2 versus 2 events; very low certainty evidence), and conversion to open cholecystectomy (6 versus 21 events; risk ratio: 0.38 (95% confidence interval: 0.15-0.95); I2 = 0%; low certainty evidence). Seven additional studies, using intra-individual comparisons, contributed to conclusions regarding procedural failure; risk ratio: 1.12 (95% confidence interval: 0.70-1.78; I2 = 83%; very low certainty evidence). No studies reported operation time. Mean imaging time for LUS and IOC, reported in 12 studies, was 4.8‒10.2 versus 10.9‒17.9 min (mean difference: - 7.8 min (95% confidence interval: - 9.3 to - 6.3); I2 = 95%; moderate certainty evidence). CONCLUSION: It is uncertain whether there is any difference in mortality/bile duct injury/retained gallstone using LUS compared with IOC, but LUS may be associated with fewer conversions to open cholecystectomy and is probably associated with shorter imaging time.

The evaluation of feasibility of ambulatory laparoscopic cholecystectomy using intraoperative instillation of bupivacaine: a retrospective observational study.

Purpose: This study aimed to compare outcomes of opioid patients-controlled anesthesia (PCA) and intraoperative local anesthesia in terms of postoperative pain, lab results, patient surveys, and discharge scores to evaluate the feasibility of ambulatory laparoscopic cholecystectomy (LC). Methods: Patients who underwent LC for acute cholecystitis were assigned to the outpatient surgery (OPS) group or inpatient surgery (IPS) group according to the surgeon. In the OPS group, a mixture of bupivacaine and epinephrine was injected into trocar sites and sprayed on the surgical dissection field. Oral opioid and analgesics were given twice a day. In the IPS group, patients received opioid PCA. Numeric rating scale (NRS) for walking, erythrocyte sedimentation rate (ESR), CRP, self-assessed survey on general physical condition and discharge, and discharge score of ambulatory surgery were assessed postoperatively. Results: NRS was significantly lower in the OPS group. There were no significant differences in ESR and CRP between the groups. Self-assessed survey on general conditions and the possibility of discharge were significantly better in the OPS group. The discharge scores at 3, 6, and 9 hours were significantly higher in the OPS group. Conclusion: Intraoperative instillation of bupivacaine at port sites and dissection fields had a better effect on short-term postoperative pain, patient surveys, and discharge criteria of ambulatory surgery than opioid PCA.

Gallbladder Diverticulum as a Rare Disease and a Therapeutic Challenge: A Case Report.

This case report details a rare instance of gallbladder diverticulum, highlighting the diagnostic and therapeutic challenges associated with this condition. Gallbladder diverticulum is an uncommon anomaly that often mimics the symptoms of more prevalent gallbladder diseases, making an accurate diagnosis challenging. The patient, a 55-year-old female, presented with atypical abdominal pain and was initially suspected to have chronic cholecystitis. Ultrasound examinations and subsequent enhanced computed tomography imaging revealed a gallbladder diverticulum without the presence of gallstones or polyps. Given the rarity of this condition and the potential for complications, a laparoscopic cholecystectomy was performed. The surgery was successful, and the patient's symptoms were completely resolved postoperatively, confirming the diagnosis. This report underscores the importance of considering gallbladder diverticulum in the differential diagnosis for atypical gallbladder symptoms and advocates for prompt surgical intervention to prevent complications. Our findings contribute to the limited literature on this rare condition and emphasize the need for awareness among clinicians to achieve optimal patient outcomes.

Comparative Analysis of Monopolar Electrocautery and Ultrasonic Activated Scalpel in Laparoscopic Cholecystectomy: A Comprehensive Evaluation Using Clinical, Laboratory, and Imaging Techniques.

Introduction Laparoscopic cholecystectomy has long been the cornerstone of gallstone treatment. Both monopolar cautery and ultrasonically activated scalpel (UAS, also known as harmonic scalpel) have been employed in the dissection of the gallbladder from its fossa during laparoscopic cholecystectomy. Material and methods The prospective study was conducted in the Department of Surgery at Vivekananda Institute of Medical Sciences including 200 patients equally divided among the monopolar cautery and harmonic scalpel group. Patients were observed for 48 hours post-surgery, during which temperature and pain assessment were done. Acute phase reactants were measured during this period and compared with preoperative values. On the seventh day ultrasonography was done to look for the inflammatory changes. Results In a study involving 200 patients, the majority fell within the age bracket of 31 to 50 years, with females constituting the predominant demographic. Notably, patients who underwent surgery with a harmonic scalpel exhibited a reduced need for analgesics. Furthermore, the use of harmonic scalpels led to noteworthy alterations in acute phase reactants, including a significant decrease in the total leucocyte count (TLC) (p=0.03), neutrophils (p=0.005), and lymphocytes (p=0.02). Additionally, patients in the UAS group experienced a significantly lesser increase in erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values (p=0.0001). Conversely, ultrasound imaging conducted on the seventh day post-surgery did not reveal any significant differences between the two groups. Conclusion Laparoscopic cholecystectomy performed with a harmonic scalpel is associated with a reduced tissue response and less tissue damage compared to the monopolar group.

Laparoscopic cholecystectomy for a gallbladder with a short cystic duct draining to the accessory right anterior hepatic duct using indocyanine green fluorescence imaging: A case report.

INTRODUCTION: Gallbladder with a short cystic duct draining to the accessory right anterior hepatic duct is a rare variation. It is frequently associated with bile duct injury during laparoscopic cholecystectomy. We present a case of a gallbladder with this variation safely treated with laparoscopic cholecystectomy using indocyanine green (ICG) fluorescence imaging. PRESENTATION OF CASE: A 57-year-old man had right upper quadrant pain and showed a gallbladder stone on a preoperative computed tomography. Bile duct anomaly was not detected before operation. However, a short cystic duct draining to the accessory right anterior hepatic duct intraoperatively was found using ICG fluorescence imaging. To confirm the exact anatomy, we firstly detached the gallbladder from the liver with a "fundus first technique" and visualized the whole course of the short cystic duct and the accessory right anterior with ICG fluorescence imaging. Laparoscopic cholecystectomy was completed safely. No bile leakage was detected on ICG fluorescence imaging. The patient had no postoperative complication. DISCUSSION: Accessory right hepatic duct is one of the rare variations of bile duct. It can be related to bile duct injury during laparoscopic cholecystectomy. Although it can be injured easily because of its smaller size, we can identify the short cystic duct from it with the aid of ICG fluorescence imaging without injuring the accessory right anterior hepatic duct. CONCLUSION: Laparoscopic cholecystectomy for gallbladder with a short cystic duct draining to the accessory right anterior hepatic duct can be safely performed by identifying biliary anatomy with ICG fluorescence imaging.

Subtotal laparoscopic cholecystectomy versus conversion to open as a bailout procedure: a cohort study.

BACKGROUND: The aim of this study is to evaluate morbidity and mortality in patients taken to conversion to open procedure (CO) and subtotal laparoscopic cholecystectomy (SLC) as bailout procedures when performing difficult laparoscopic cholecystectomy. METHOD: This observational cohort study retrospectively analyzed patients taken to SLC or CO as bailout surgery during difficult laparoscopic cholecystectomy between 2014 and 2022. Univariable and multivariable logistic regression models were used to identify prognostic factors for morbimortality. RESULTS: A total of 675 patients were included. Of the 675 patients (mean [SD] age 63.85 ± 16.00 years; 390 [57.7%] male) included in the analysis, 452 (67%) underwent CO and 223 (33%) underwent SLC. Overall, neither procedure had an increased risk of major complications (89 [19.69%] vs 35 [15.69%] P.207). However, CO had an increased risk of bile duct injury (18 [3.98] vs 1 [0.44] P.009), bleeding (mean [SD] 165.43 ± 368.57 vs 43.25 ± 123.42 P < .001), intestinal injury (20 [4.42%] vs 0 [0.00] P.001), and wound infection (18 [3.98%] vs 2 [0.89%] P.026), while SLC had a higher risk of bile leak (15 [3.31] vs 16 [7.17] P.024). On the multivariable analysis, Charlson comorbidity index (odds ratio [OR], 1.20; CI95%, 1.01-1.42), use of anticoagulant agents (OR, 2.56; CI95%, 1.21-5.44), classification of severity of cholecystitis grade III (OR, 2.96; CI95%, 1.48-5.94), and emergency admission (OR, 6.07; CI95%, 1.33-27.74) were associated with presenting major complications. CONCLUSIONS: SLC was less associated with complications; however, there is scant evidence on its long-term outcomes. Further research is needed on SLC to establish if it is the safest in the long-term as a bailout procedure.