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.

Identifying community safety and policy-based injury prevention opportunities to reduce golf cart injuries.

BACKGROUND: In small US communities, golf cart utilization has become increasingly more common. In the past 3 years, the incidence and severity of pediatric golf cart-related trauma evaluated at our trauma center have noticeably increased. Thus, the aim of this study was to analyze trends, identify risk and protective factors, and provide community-level recommendations to improve golf cart safety for children in a coastal community. METHODS: A retrospective cross-sectional study of our institutional trauma registry was performed. The registry was queried for golf cart injuries between 2012 and 2022. Demographics, accident details, hospital course, and outcomes were reviewed. Data analysis involved quantitative statistics. Incident locations were mapped, including additional data from the County emergency medical service. In addition, customer education at four prominent golf rental shops was observed. RESULTS: Annual golf cart-related traumas doubled starting in 2020. Of 235 total patients, 105 (46%) were children. Median age was 11.5 years (range, 2-17 years). Fifty-five percent were female, and 67% were non-Hispanic White. Eighty percent were out-of-county residents. The most common injury location was extremity (56%). The median Injury Severity Score was 4, and 3% died. Only 10% of children were restrained. Forty-one percent were ejected, and most (84%) were front-facing passengers. Ejection was associated with more severe injury (odds ratio, 4.13; p = 0.01). Most injuries occurred during 5 to 10 pm (47%), weekends, and summertime. Nighttime injuries were more severe than daytime ( p = 0.04). A hotspot of crashes was identified in a zone where golf carts were restricted. Rental stores provided education on seat belt use, car seat use for infants, and off-limit zones. However, rules were not enforced. CONCLUSION: Our results inform the following golf cart injury prevention opportunities: raising awareness of injury risks to children in high-tourist areas, partnering with rental stores to enforce rules, improving signage, adding protected lanes, and adopting a no nighttime operation policy. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Faster Growth Enhances Low Carbon Fuel and Chemical Production Through Gas Fermentation.

Gas fermentation offers both fossil carbon-free sustainable production of fuels and chemicals and recycling of gaseous and solid waste using gas-fermenting microbes. Bioprocess development, systems-level analysis of biocatalyst metabolism, and engineering of cell factories are advancing the widespread deployment of the commercialised technology. Acetogens are particularly attractive biocatalysts but effects of the key physiological parameter-specific growth rate (µ)-on acetogen metabolism and the gas fermentation bioprocess have not been established yet. Here, we investigate the µ-dependent bioprocess performance of the model-acetogen Clostridium autoethanogenum in CO and syngas (CO + CO2+H2) grown chemostat cultures and assess systems-level metabolic responses using gas analysis, metabolomics, transcriptomics, and metabolic modelling. We were able to obtain steady-states up to µ ∼2.8 day-1 (∼0.12 h-1) and show that faster growth supports both higher yields and productivities for reduced by-products ethanol and 2,3-butanediol. Transcriptomics data revealed differential expression of 1,337 genes with increasing µ and suggest that C. autoethanogenum uses transcriptional regulation to a large extent for facilitating faster growth. Metabolic modelling showed significantly increased fluxes for faster growing cells that were, however, not accompanied by gene expression changes in key catabolic pathways for CO and H2 metabolism. Cells thus seem to maintain sufficient "baseline" gene expression to rapidly respond to CO and H2 availability without delays to kick-start metabolism. Our work advances understanding of transcriptional regulation in acetogens and shows that faster growth of the biocatalyst improves the gas fermentation bioprocess.