Endoscopic naso-gallbladder drainage versus gallbladder stenting before cholecystectomy in patients with acute cholecystitis and a high suspicion of choledocholithiasis: a prospective randomised preliminary study.

OBJECTIVE: Endoscopic transpapillary gallbladder drainage using a nasocystic tube or plastic stent has been attempted as an alternative to percutaneous drainage for patients with acute cholecystitis who are not candidates for urgent cholecystectomy. We aimed to assess the efficacy of single-step endoscopic drainage of the common bile duct and gallbladder, and to evaluate which endoscopic transpapillary gallbladder drainage method is ideal as a bridge before elective cholecystectomy. MATERIALS AND METHODS: From July 2011 to December 2014, 35 patients with acute moderate-to-severe cholecystitis and a suspicion of choledocholithiasis were randomly assigned to the endoscopic naso-gallbladder drainage (ENGBD) (n = 17) or endoscopic gallbladder stenting (EGBS) (n = 18) group. RESULTS: Bile duct clearance was performed successfully in all cases. No significant differences were found between the ENGBD and EGBS groups in the technical success rates [82.4% (14/17) vs. 88.9% (16/18), p = 0.658] and clinical success rates [by intention-to-treat analysis: 70.6% (12/17) vs. 83.3% (15/18), p = 0.443; by per protocol analysis of technically feasible cases: 85.7% (12/14) vs. 93.8% (15/16), p = 0.586]. Three ENGBD patients and two EGBS patients experienced adverse events (p = 0.658). No significant differences were found in operation time or rate of conversion to open cholecystectomy. CONCLUSIONS: Single-step endoscopic transpapillary drainage of the common bile duct and gallbladder seems to be an acceptable therapeutic modality in patients with acute cholecystitis and a suspicion of choledocholithiasis. There were no significant differences in the technical and clinical outcomes between ENGBD and EGBS as a bridge before cholecystectomy.

Short-Term Surgical Outcomes and Experience with 925 Patients Undergoing Robotic Cholecystectomy During A 4-Year Period At A Single Institution.

BACKGROUND/AIMS: Robotic cholecystectomy has emerged as an established technique for the treatment of gallbladder disease. We report our experience and surgical results of RC for patients with gallbladder polyps or minimal symptomatic gallstones, and with inflamed gallbladder diseases including acute cholecystitis, empyematous cholecystitis, and gangrenous cholecystitis. METHODOLOGY: 925 patients with gallbladder disease were selected to undergo RC at our institution. All procedures were performed using the da Vinci system. No technical difficulty in RC was experienced. Use these advantages, we performed cholecystectomy by placing the trocars transversally on the bikini line('Panty line', 'Bikini line'). RESULTS: From June 2010 to May 2014, 925 gallbladder disease patients underwent RC on the bikini line. Excluding the effects of BMI produced no correlation between operating time and white blood cell count (r = 0.062, p = 0.058). Surgical complications occurred in nine of the 925 patients (0.1%), including cystic duct leakage (n = 4), bleeding (n = 3), common bile duct injury (n = 1), and bladder injury (n = 1). Conversion to open cholecystectomy occurred in one patient due to common bile duct injury (0.01%). CONCLUSION: RC is technically an easy to learn, safe method of patients with gallbladder disease, regardless of BMI. In addition, RC can be a treatment for patients with acute inflammation in gallbladder disease.

Surgical outcomes for solid pseudopapillary neoplasm of the pancreas.

BACKGROUND/AIMS: Solid pseudopapillary neoplasm (SPN) is a rare exocrine tumor of the pancreas with low malignant potential. This study was designed to evaluate surgical outcome of solid pseudopapillary neoplasm (SPN). METHODOLOGY: From Between January 1994 to November 2013, 41 patients were diagnosed with SPN of the pancreas at Ajou University Medical Center and underwent surgical resection. RESULTS: Of the 41 patients, 33(80.5%) were female and 8(19.5%) were male with a mean age of 34.5 years (range, 12-63 years). The most common location of SPN was the tail (43.9%). Mean diameters of SPN was 5.5 cm (range, 1.2- 14.5 cm). Nineteen patients (46.3%) had non-specific abdominal symptoms that had been investigated. Surgical treatment included distal pancreatectomy in 21, pancreaticoduodenectomy in 11, segmental resection of pancreas in 4, enucleation in 2, excision in 2 and surgical biopsy in 1. Thirty-nine of the 41 patients were disease-free at a median follow-up of 59 months (range, 1-125 months). CONCLUSIONS: Patients diagnosed as SPN should receive surgical resection because of the excellent prognosis. Closed follow-up is recommended after surgery, even in patients without pathological malignant potential. For metastasis or recurrence, an aggressive surgical treatment is necessary because of the good possibility of long-term survival.

Surgical outcomes of distal pancreatectomy.

BACKGROUND/AIMS: Most efforts to minimize pancreatic fistula after distal pancreatectomy (DP) have been focused on techniques of pancreatic transection and management of the pancreatic remnant. However, an ideal method of handling remnant pancreas after resection does not exist. This study evaluates surgical outcome of DP and describes how to reduce pancreatic fistula (PF) after DP. METHODOLOGY: From March 1999 to May 2011, 142 DPs were performed at Ajou University Medical Center. RESULTS: The rate of pancreatic leak was 23.2% (33/142); grade A (n=18), grade B (n=15), and grade C (n=0). The remnant pancreas was managed by stapler in 44 patients (31.0%), suture in 45 (31.7%), and stapler with suture in 53 (37.3%). The morbidity and mortality rates were 38.0% and 0%. In patients who underwent surgery for extrapancreatic disease, the rate of PF was 50% (25/50). It was significantly higher than that (11.9%) in those with pancreatic disease (p = 0.003). Among closure methods for the remnant pancreas, the stapler with suture method reduced postoperative PF. In those with pancreatic disease, the PF rate after stapler with suture was significantly lower than that with stapler or suture alone. CONCLUSIONS: Surgery for extrapancreatic disease is an independent risk factor for PF after DP. Of the methods of handling pancreatic remnants, the stapler with suture method by an experienced hepatobiliary surgeon decreased the risk of PF.

Pain related to robotic cholecystectomy with lower abdominal ports: effect of the bilateral ultrasound-guided split injection technique of rectus sheath block in female patients: A prospective randomised trial.

BACKGROUND: Robotic cholecystectomy (RC) using port sites in the lower abdominal area (T12-L1) rather than the upper abdomen has recently been introduced as an alternative procedure for laparoscopic cholecystectomy. Therefore, we investigated the time course of different components of pain and the analgesic effect of the bilateral ultrasound-guided split injection technique for rectus sheath block (sRSB) after RC in female patients. METHODS: We randomly assigned 40 patients to undergo ultrasound-guided sRSB (RSB group, n = 20) or to not undergo any block (control group, n = 20). Pain was subdivided into 3 components: superficial wound pain, deep abdominal pain, and referred shoulder pain, which were evaluated with a numeric rating scale (from 0 to 10) at baseline (time of awakening) and at 1, 6, 9, and 24 hours postoperatively. Consumption of fentanyl and general satisfaction were also evaluated 1 hour (before discharge from the postanesthesia care unit) and 24 hours postoperatively (end of study). RESULTS: Superficial wound pain was predominant only at awakening, and after postoperative 1 hour in the control group. Bilateral ultrasound-guided sRSB significantly decreased superficial pain after RC (P < 0.01) and resulted in a better satisfaction score (P < 0.05) 1 hour after RC in the RSB group compared with the control group. The cumulative postoperative consumption of fentanyl at 6, 9, and 24 hours was not significantly different between groups. CONCLUSIONS: After RC with lower abdominal ports, superficial wound pain predominates over deep intra-abdominal pain and shoulder pain only at the time of awakening. Afterwards, superficial and deep pain decreased to insignificant levels in 6 hours. Bilateral ultrasound-guided sRSB was effective only during the first hour. This limited benefit should be balanced against the time and risks entailed in performing RSB.

Robotic cholecystectomy with new port sites.

AIM: To introduce robotic cholecystectomy (RC) using new port sites on the low abdominal area. METHODS: From June 2010 to June 2011, a total of 178 RCs were performed at Ajou University Medical Center. We prospectively collected the set-up time (working time and docking time) and console time in all robotic procedures. RESULTS: Eighty-three patients were male and 95 female; the age ranged from 18 to 72 years of age (mean 54.6 ± 15.0 years). All robotic procedures were successfully completed. The mean operation time was 52.4 ± 17.1 min. The set-up time and console time were 11.9 ± 5.4 min (5-43 min) and 15.1 ± 8.0 min (4-50 min), respectively. The conversion rate to laparoscopic or open procedures was zero. The complication rate was 0.6% (n = 1, bleeding). There was no bile duct injury or mortality. The mean hospital stay was 1.4 ± 1.1 d. There was a significant correlation between the console time and white blood cell count (r = 0.033, P = 0.015). In addition, the higher the white blood cell count (more than 10000), the longer the console time. CONCLUSION: Robotic cholecystectomy using new port sites on the low abdominal area can be safely and efficiently performed, with sufficient patient satisfaction.