Challenges, Preoperative Assessment, and Surgical Strategies for the Left-Sided Gallbladder.

Left-sided gallbladder positioning, or sinistroposition, is a rare anatomical variation that poses challenges during surgical intervention due to associated vascular and biliary anomalies. While existing literature suggests an incidence of approximately 0.04-1.1%, it remains an underreported phenomenon that falls well outside the realm of "expected" anatomical variation and are rarely identified on preoperative imaging. Here, we present a case of acute cholecystitis in a patient with unexpected left-sided gallbladder, highlighting the associated challenges and outlining both preoperative and intraoperative strategies for managing this rare but consequential anatomical variant. In this case, a 49-year-old woman with a prior history of bilateral ovarian cysts presented with clinical, laboratory, and imaging findings consistent with acute cholecystitis. She underwent laparoscopic cholecystectomy and was found to have a severely inflamed left-sided gallbladder that was obscured by omentum. Her gallbladder was found in the midline immediately beneath the falciform ligament, with most of the gallbladder body and fundus attached to liver segment III, situated to the left of the midline. An additional left-sided mid-abdominal port was required to enhance retraction, and an intraoperative cholangiogram (IOC) was performed given the elevated risk of structural injury. This case underscores the heightened intraoperative risk associated with deviations in vascular and biliary anatomy and provides recommendations for intraoperative adaptations to mitigate these risks.

ROBOtic Care Outcomes Project for acute gallbladder pathology.

BACKGROUND: Robotic cholecystectomy is being increasingly used for patients with acute gallbladder disease who present to the emergency department, but clinical evidence is limited. We aimed to compare the outcomes of emergent laparoscopic and robotic cholecystectomies in a large real-world database. METHODS: Patients who received emergent laparoscopic or robotic cholecystectomies from 2020 to 2022 were identified from the Intuitive Custom Hospital Analytics database, based on deidentified extraction of electronic health record data from US hospitals. Conversion to open or subtotal cholecystectomy and complications were defined using ICD10 and/or CPT codes. Multivariate logistic regression with inverse probability treatment weighting (IPTW) was performed to compare clinical outcomes of laparoscopic versus robotic approach after balancing covariates. Cost analysis was performed with activity-based costing and adjustment for inflation. RESULTS: Of 26,786 laparoscopic and 3,151 robotic emergent cholecystectomy patients being included, 64% were female, 60% were ≥45 years, and 24% were obese. Approximately 5.5% patients presented with pancreatitis, and 4% each presenting with sepsis and biliary obstruction. After IPTW, distributions of all baseline covariates were balanced. Robotic cholecystectomy decreased odds of conversion to open (odds ratio, 0.68; 95% confidence interval, 0.49-0.93; p = 0.035), but increased odds of subtotal cholecystectomy (odds ratio, 1.64; 95% confidence interval, 1.03-2.60; p = 0.037). Surgical site infection, readmission, length of stay, hospital acquired conditions, bile duct injury or leak, and hospital mortality were similar in both groups. There was no significant difference in hospital cost. CONCLUSION: Robotic cholecystectomy has reduced odds of conversion to open and comparable complications, but increased odds of subtotal cholecystectomy compared with laparoscopic cholecystectomy for acute gallbladder diseases. Further work is required to assess the long-term implications of these differences. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Cost-effectiveness analysis of robotic cholecystectomy in the treatment of benign gallbladder disease.

BACKGROUND: Laparoscopic cholecystectomy is the current standard of care treatment for benign gallbladder disease. Robotic cholecystectomy is another approach for performing cholecystectomy that offers a surgeon better dexterity and visualization. However, robotic cholecystectomy may increase cost without sufficient evidence to suggest an improvement in clinical outcomes. The purpose of this study was to construct a decision tree model to compare cost-effectiveness of laparoscopic cholecystectomy and robotic cholecystectomy. METHODS: Complication rates and effectiveness associated with robotic cholecystectomy and laparoscopic cholecystectomy over a 1-year time frame were compared using a decision tree model populated with data from the published literature. Cost was calculated using Medicare data. Effectiveness was represented by quality-adjusted life-years. The primary outcome of the study was incremental cost-effectiveness ratio, which compares the cost per quality-adjusted life-year of the 2 interventions. The willingness-to-pay threshold was set at $100,000/quality-adjusted life-year. Results were confirmed with 1-way, 2-way, and probabilistic sensitivity analyses varying branch-point probabilities. RESULTS: The studies used in our analysis included 3,498 patients who underwent laparoscopic cholecystectomy, 1,833 patients who underwent robotic cholecystectomy, and 392 patients who required conversion to open cholecystectomy. Laparoscopic cholecystectomy produced 0.9722 quality-adjusted life-years, costing $9,370.06. Robotic cholecystectomy produced an additional 0.0017 quality-adjusted life-years at an additional $3,013.64. These results equate to an incremental cost-effectiveness ratio of $1,795,735.21/quality-adjusted life-year. This exceeds the willingness-to-pay threshold, making laparoscopic cholecystectomy the more cost-effective strategy. Sensitivity analyses did not alter results. CONCLUSION: Traditional laparoscopic cholecystectomy is the more cost-effective treatment modality for benign gallbladder disease. At present, robotic cholecystectomy is not able to improve clinical outcomes enough to justify its added cost.

Global burden of gallbladder and biliary diseases: A systematic analysis for the Global Burden of Disease Study 2019.

BACKGROUND AND AIM: Gallbladder and biliary diseases (GBDs) are one of the most prevalent medical issues in the digestive system. This study was designed to describe the characteristics of prevalence, death, and disability-adjusted life years (DALYs) of GBDs during 1990-2019 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019. METHODS: Prevalence, death, and DALYs for GBDs in different locations, years, sex, and age groups were estimated using DisMod-MR 2.1 and a generic Cause of Death Ensemble Modeling approach. Countries and territories were categorized according to socio-demographic index (SDI) quintiles. RESULTS: The prevalence cases (127 345 732 to 193 493 378), death cases (82 430 to 124 941), and DALYs (4 604 821 to 6 352 738) of GBDs increased from 1990 to 2019. However, the age-standardized rates of indicators decreased over the 30-year period (prevalence, 2851.84 to 2350.78 per 100 000 population; death, 2.40 to 1.65 per 100 000 population; DALYs, 106.76 to 78.25 per 100 000 population). In 2019, the high and middle-high SDI regions had higher age-standardized prevalence rates, the low SDI region had the highest age-standardized death rate, and the middle SDI region had the highest DALYs and age-standardized DALYs rate of GBDs. Being female, older age, and high body mass index were important risk factors for the burden of GBDs. CONCLUSIONS: Globally, there were improvements in overall health with regard to GBDs over the 30 years. However, the prevention of GBDs should be promoted in middle, middle-high, and high SDI regions, while more medical resources should be provided to improve treatment levels in low SDI region.

The effect of surgical strategy in difficult cholecystectomy cases on postoperative complications outcome: a value-based healthcare comparative study.

BACKGROUND: In patients undergoing laparoscopic cholecystectomy (LC) for complicated biliary disease, complication rates increase up to 30%. The aim of this study is to assess the effect of differences in surgical strategy comparing outcome data of two large volume hospitals. METHODS: A prospective database was created for all the patients who underwent a LC in two large volume hospitals between January 2017 and December 2018. In cases of difficult cholecystectomy in clinic A, regular LC or conversion were surgical strategies. In clinic B, laparoscopic subtotal cholecystectomy was performed as an alternative in difficult cases. The difficulty of the cholecystectomy (score 1-4) and surgical strategy (regular LC, subtotal cholecystectomy, conversion) were scored. Postoperative complications, reinterventions, and ICU admission were assessed. For predicting adverse postoperative complication outcomes, uni- and multivariable analyses were used. RESULTS: A total of 2104 patients underwent a LC in the study period of which 974 were from clinic A and 1130 were from clinic B. In total, 368 procedures (17%) were scored as a difficult cholecystectomy. In clinic A, more conversions were performed (4.4%) compared to clinic B (1.0%; p < 0.001). In clinic B, more subtotal laparoscopic cholecystectomies were performed (1.8%) compared to clinic A (0%; p = < 0.001). Overall complication rate was 8.2% for clinic A and 10.2% for clinic B (p = 0.121). Postoperative complication rates per group for regular LC, conversion, and subtotal cholecystectomy in difficult cholecystectomies were 45 (15%), 12 (24%), and 7 (35%; p = 0.035), respectively. The strongest predictor for Clavien-Dindo grade 3-5 complication was subtotal cholecystectomy. CONCLUSION: Surgical strategy in case of a difficult cholecystectomy seems to have an important impact on postoperative complication outcome. The effect of a subtotal cholecystectomy on complications is of great concern.

The price is right: Routine fluorescent cholangiography during laparoscopic cholecystectomy.

BACKGROUND: Early experience with indocyanine green-based fluorescent cholangiography during laparoscopic cholecystectomy suggests the potential to improve outcomes. However, the cost-effectiveness of routine use has not been studied. Our objective was to evaluate the cost-effectiveness of fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy for noncancerous gallbladder disease. METHODS: A Markov model decision analysis was performed comparing fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy alone. Probabilities of outcomes, survival, toxicities, quality-adjusted life-years, and associated costs were determined from literature review and pooled analysis of currently available studies on fluorescent cholangiography (n = 37). Uncertainty in the model parameters was evaluated with 1-way and probabilistic sensitivity analyses, varying parameters up to 40% of their means. Cost-effectiveness was measured with an incremental cost-effectiveness ratio expressed as the dollar amount per quality-adjusted life-year. RESULTS: The model predicted that fluorescent cholangiography reduces lifetime costs by $1,235 per patient and improves effectiveness by 0.09 quality-adjusted life-years compared to standard bright light laparoscopic cholecystectomy. Reduced costs were due to a decreased operative duration (21.20 minutes, P < .0001) and rate of conversion to open (1.62% vs 6.70%, P < .0001) associated with fluorescent cholangiography. The model was not influenced by the rate of bile duct injury. Probabilistic sensitivity analysis found that fluorescent cholangiography was both more effective and less costly in 98.83% of model iterations at a willingness-to-pay threshold of $100,000/quality-adjusted life year. CONCLUSION: The current evidence favors routine use of fluorescent cholangiography during laparoscopic cholecystectomy as a cost-effective surgical strategy. Our model predicts that fluorescent cholangiography reduces costs while improving health outcomes, suggesting fluorescence imaging may be considered standard surgical management for noncancerous gallbladder disease. Further study with prospective trials should be considered to verify findings of this predictive model.

Longitudinal Ultrasound Assessment of Changes in Size and Number of Incidentally Detected Gallbladder Polyps.

BACKGROUND. Previous European multisociety guidelines recommend routine follow-up imaging of gallbladder polyps (including polyps < 6 mm in patients without risk factors) and cholecystectomy for polyp size changes of 2 mm or more. OBJECTIVE. The purpose of this study was to assess longitudinal changes in the number and size of gallbladder polyps on serial ultrasound examinations. METHODS. This retrospective study included patients who underwent at least one ultrasound examination between January 1, 2010, and December 31, 2020 (as part of a hepatocellular carcinoma screening and surveillance program) that showed a gallbladder polyp. Number of polyps and size of largest polyp were recorded based primarily on review of examination reports. Longitudinal changes on serial examinations were summarized. Pathologic findings from cholecystectomy were reviewed. RESULTS. Among 9683 patients, 759 (8%) had at least one ultrasound examination showing a polyp. Of these, 434 patients (248 men, 186 women; mean age, 50.6 years) had multiple examinations (range, 2-19 examinations; mean, 4.8 examinations per patient; mean interval between first and last examinations, 3.6 ± 3.1 [SD] years; maximum interval, 11.0 years). Among these 434 patients, 257 had one polyp, 40 had two polyps, and 137 had more than two polyps. Polyp size was 6 mm or less in 368 patients, 7-9 mm in 52 patients, and 10 mm or more in 14 patients. Number of polyps increased in 9% of patients, decreased in 14%, both increased and decreased on serial examinations in 22%, and showed no change in 55%. Polyp size increased in 10% of patients, decreased in 16%, both increased and decreased on serial examinations in 18%, and showed no change in 56%. In 9% of patients, gallbladder polyps were not detected on follow-up imaging; in 6% of patients, gallbladder polyps were not detected on a follow-up examination but were then detected on later studies. No gallbladder carcinoma was identified in 19 patients who underwent cholecystectomy. CONCLUSION. Gallbladder polyps fluctuate in size, number, and visibility over serial examinations. Using a 2-mm threshold for growth, 10% increased in size. No carcinoma was identified. CLINICAL IMPACT. European multisociety guidelines that propose surveillance of essentially all polyps and a 2-mm size change as the basis for cholecystectomy are likely too conservative for clinical application.

Patterns of prevalence and contemporary clinical management strategies in complicated acute biliary calculous disease: an ESTES 'snapshot audit' of practice.

BACKGROUND: Acute complications of biliary calculi are common, morbid, and complex to manage. Variability exists in the techniques utilized to treat these conditions at an individual surgeon and unit level. AIM: To identify, through an international prospective nonrandomized cohort study, the epidemiology and areas of practice variability in management of acute complicated calculous biliary disease (ACCBD) and to correlate them against reported outcomes. METHODS: A preplanned analysis of the European Society of Trauma and Emergency Surgery (ESTES) 2018 Complicated Biliary Calculous Disease audit was performed. Patients undergoing emergency hospital admission with ACCBD between 1 October 2018 and 31 October 2018 were included. All eligible patients with acute complicated biliary calculous disease were recorded contemporaneously using a standardized predetermined protocol and a secure online database and followed-up through to 60 days from their admission. ENDPOINTS: A two-stage data collection strategy collecting patient demographics, details of operative, endoscopic and radiologic intervention, and outcome metrics. Outcome measures included mortality, surgical morbidity, ICU stay, timing of operative intervention, and length of hospital stay. RESULTS: Three hundred thirty-eight patients were included, with a mean age of 65 years and 54% were female. Diagnosis at admission were: cholecystitis (45.6%), biliary pancreatitis (21%), choledocholithiasis with and without cholangitis (13.9% and 18%). Index admission cholecystectomy was performed in just 50% of cases, and 28% had an ERCP performed. Morbidity and mortality were low. CONCLUSION: This first ESTES snapshot audit, a purely descriptive collaborative study, gives rich 'real world' insights into local variability in surgical practice as compared to international guidelines, and how this may impact upon outcomes. These granular data will serve to improve overall patient care as well as being hypothesis generating and inform areas needing future prospective study.

Association Between Trimester and Outcomes after Cholecystectomy During Pregnancy.

BACKGROUND: Conventional philosophy promotes the second trimester as the ideal time during pregnancy for cholecystectomy. However, literature supporting this belief is sparse. The purpose of this study is to examine the association of trimester and clinical outcomes after cholecystectomy during pregnancy. STUDY DESIGN: The National Inpatient Sample was queried for pregnant women who underwent cholecystectomy between October 2015 and December 2017. Patients were categorized by trimester. Multivariable logistic and continuous outcome regression models were used to evaluate the association of trimester and outcomes, including maternal and fetal complications, length of stay, and hospital charges. The primary outcome was any complication-a composite of specific clinical complications, each of which were designated as secondary outcomes. RESULTS: A total of 819 pregnant women satisfied our inclusion criteria. Of these, 217 (26.5%) were in the first trimester, 381 (47.5%) were in the second trimester, and 221 (27.0%) were in the third trimester. Median age was 27 years (interquartile range: 23-31 years). Compared with the second trimester, cholecystectomy during the first trimester was not associated with higher rates of complications (adjusted odds ratio [AOR] 0.88, 95% confidence interval [CI]: 0.47-1.63, p = 0.68). However, cholecystectomy during the third trimester was associated with a higher rate of preterm delivery (AOR 7.20, 95% CI 3.09-16.77, p < 0.001) and overall maternal and fetal complications (AOR 2.78, 95% CI 1.71-4.53, p < 0.001). Compared with the second trimester, the third trimester was associated with 21.3% higher total hospital charges (p = 0.003). CONCLUSIONS: Our results suggest that cholecystectomy can be performed in the first trimester without significantly increased risk of maternal and fetal complications, compared to the second trimester. In contrast, cholecystectomy during pregnancy should not be delayed until the third trimester.

Comparative Safety Assessment Study for Drospirenone Induced Gallbladder Diseases Using the Adverse Drug Reaction Database of USA, Europe, and Canada.

BACKGROUND: Gallstone disease (GSD) is one of the most common gastroenterological disorders. It is known that drospirenone causes small increased risk of gallbladder diseases. However, the risk may vary between different adverse drug reaction databases. OBJECTIVE: The purpose of this studty is to examine the safety and risk association between hormonal contraceptive drospirenone and gallbladder diseases using adverse drug reaction database of USFDA's Federal Adverse Events Reporting System (FAERS), Europe's Eudravigilance (EV) and Canada's Canada Vigilance Adverse Reaction Online Database (CVARD). METHODS: Individual Case Safety Reports of patients till October 2019 were downloaded from the Federal Adverse Event Reporting System, Eudravigilance, and Canadian database. These reports contained information on adverse events associated with all other drugs inclusive of drospirenone. The disproportionality method of data mining was used to calculate the risk association. RESULTS: The lower limit of 95% CI of PRR was 3.27, 3.47 and 3.76, PRR was 33.08, 41.35 and 115.42, ROR was 37.20, 44.61 and 127.19, Chi-square value was 126572.89, 110392.95 and 362.46, and IC-2SD value was 0.16, 0.17, and 1.21 for FAERS, EU, and CVARD respectively indicating a week signal. Also, all the calculated parameters were above the threshold value. CONCLUSION: From our study, it was clear that the risk between drospirenone and gallbladder diseases was very low among three databases. There was no harm in prescribing this drug for a contraceptive action.

The Impact of FASTPASS: A Collaboration With Emergency Department to Improve Management of Patients With Gallbladder Disease and Acute Appendicitis.

BACKGROUND: Efficient Emergency Department (ED) throughput depends on several factors, including collaboration and consultation with surgical services. The acute care surgery service (ACS) collaborated with ED to implement a new process termed "FASTPASS" (FP), which might improve patient-care for those with acute appendicitis and gallbladder disease. The aim of this study was to evaluate the 1-year outcome of FP. METHODS: FASTPASS is a joint collaboration between ACS and ED. ED physicians were provided with a simple check-list for diagnosing young males (<50-year old) with acute appendicitis (AA) and young males or females (<50-year old) with gallbladder disease (GBD). Once ED deemed patients fit our FP check-list, patients were directly admitted (FASTPASSed) to the observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after the institution of the FP. Outcomes of interest were ED length of stay (LOS), time from ED to the operating room (OR) (door-to-knife), hospital LOS (HLOS), and cost. RESULTS: During our 1-year study period, for those patients who underwent GBD/AA surgery, 56 (26%) GBD and 27 (26%) AA patients met FP criteria. Compared to the non-FP patients during FP period, FP halved ED LOS for GBD (7.4 ± 3.0 versus 3.5 ± 1.7 h, P < 0.001) and AA (6.7 ± 3.3 versus. 1.8 ± 1.6 h, P < 0.001). Similar outcome benefits were observed for door-to-knife time, HLOS, and costs. CONCLUSIONS: In this study, the FP process improved ED throughput in a single, highly-trained ER leading to an overall improved patient care process. A future study involving multiple EDs and different disease processes may help decrease ED overcrowding and improve healthcare system efficiency.

Patient Factors Lead to Extensive Variation in Outcomes and Cost From Cholecystectomy.

BACKGROUND: Cholecystectomy is a common procedure with significantly varied outcomes. We analyzed differences in comorbidities, outcomes, and cost of cholecystectomy by acute care surgery (ACS) versus hepatopancreaticobiliary (HPB) surgery. STUDY DESIGN: Patients were retrospectively identified between 2008 and 2015. Exclusion criteria included the following: (1) part of another procedure; (2) abdominal trauma; (3) ICU admission; vasopressors. RESULTS: One hundred and twenty-six ACS and 122 HPB patients were analyzed. The HPB subset had higher burden of comorbid disease and significantly lower projected 10-year survival (87.4% ACS vs 68.5% HPB, P < .0001). Median lengths of stay were longer in HPB patients (2 vs 5 days, P < .0001) as were readmission rates (30-day 5.6% vs 13.1%, P = .040; 90-day 7.9% vs 20.5%, P = .005). Median cost was higher including operative supply cost ($969.42 vs $1920.66, P < .0001) and total cost of care ($7340.66 vs $19 338.05, P < .0001). A predictive scoring system for difficult gallbladders was constructed and a phone application was created. CONCLUSION: Cholecystectomy in a complicated patient can be difficult with longer hospital stays and higher costs. The utilization of procedure codes to explain disparities is not sufficient. Incorporation of comorbidities needs to be addressed for planning and reimbursement.

Outcomes after Cholecystectomy in Patients with Sickle Cell Disease: Does Acuity of Presentation Play a Role?

BACKGROUND: Cholecystectomy is the most commonly performed procedure in sickle cell disease (SCD) patients, but outcomes after cholecystectomy have not been well studied. Our aim was to explore the characteristics and outcomes of cholecystectomy in patients with SCD compared with patients without SCD, and assess whether acuity of presentation played a role. STUDY DESIGN: Patients younger than age 35, with the primary diagnosis of gallbladder disease, who underwent cholecystectomy, were identified in the Nationwide Inpatient Sample (2005 to 2014). Patients were grouped into treatment groups by sickle cell status and acuity of surgery. Patient demographics, length of stay, hospital charges, and complications were evaluated. Descriptive and multivariate regression analyses were performed to compare these groups. RESULTS: There were 149,415 patients analyzed; 1,225 (0.82%) had SCD. SCD was associated with higher complication rates (2.69% vs 1.12%), longer lengths of stay (3 days vs 2 days), and higher median hospital charge ($29,170 vs $25,438) (all p < 0.01). Stratified by level of acuity, comparing the SCD group with the non-SCD group, higher complication rates were seen in the acute presentation group (3.92% vs 1.00%, p < 0.01), but were not demonstrated in the elective group (0.98% vs 1.95%, p = 0.114). CONCLUSIONS: SCD patients appear to have a longer length of stay, higher hospital spending, and increased complication rates compared with non-SCD patients undergoing cholecystectomy. This difference is pronounced among patients who underwent surgery in the acute setting. The data suggest that planned cholecystectomy may be beneficial in improving postoperative outcomes in SCD patients.

Laparoscopic Versus Open Cholecystectomy in Pediatric Patients: A Propensity Score-Matched Analysis.

Background: As minimally invasive pediatric surgery becomes standard approach to many surgical solutions, access has become an important point for improvement. Laparoscopic cholecystectomy (LC) is the gold standard for many conditions affecting the gallbladder; however, open cholecystectomy (OC) is offered as the initial approach in a surprisingly high percentage of cases. Materials and Methods: The Kids' Inpatient Database (1997-2012) was searched for International Classification of Disease, 9th revision, Clinical Modification procedure code (51.2x). LC and OC performed in patients <20 years old were identified. Propensity score-matched analyses using 39 variables were performed to isolate the effects of race, income group, location, gender, payer status, and hospital size on the percentage of LCs and OCs offered. Cases were weighted to provide national estimates. Results: A total of 78,578 cases were identified, comprising LC (88.1%) and OC (11.9%). Girls were 1.6 (CI: 1.4, 1.7) times more likely to undergo LC versus boys. Large facilities were 1.4 (1.3, 1.7) times more likely to perform LCs than small facilities. Children in lower income quartiles were 1.2 (1.1, 1.3) times more likely to undergo LC compared with those in higher income quartiles. Rates of LC were not affected by race, hospital location, or payer status. Conclusions: Risk-adjusted analysis of a large population-based data set demonstrated evidence that confirms, but also refutes, traditional disparities to minimally invasive surgery access. Despite laparoscopic gold standard, OC remains the initial approach in a surprisingly high percentage of pediatric cases independent of demographics or socioeconomic status. Additional research is required to identify factors affecting the distribution of LC and OC within the pediatric population.

Histological examination of the gallbladder following routine cholecystectomy? A selective analysis is justified.

BACKGROUND: It was hitherto common practice to analyse each removed gallbladder for the presence of gall bladder cancer (GBC) although this approach may be questioned. The aim of this study was to determine whether a policy of selective histopathological analysis (Sel-HPA) is oncologically safe and cost effective. METHODS: This retrospective study was conducted in a single Dutch teaching hospital. Immediately following cholecystectomy, the surgeon decided on the basis of inspection and palpation whether histological examination was indicated. The Dutch Comprehensive Cancer Organisation (IKNL) registry was used to identify the number of GBC during this time period. RESULTS: Of 2271 patients who underwent a cholecystectomy in our institution between January 2012 and December 2017, 1083 (47.7%) were deemed indicated for histopathological analysis. Sixteen pathological gallbladders (1.5%) were identified in that period (intestinal metaplasia, n = 3; low grade dysplasia n = 7; carcinoma n = 6). During follow-up, no patient was found to have GBC recurrence in the population whose gallbladder was not sent for pathology (52.3%, n = 1188, median 49 months of follow up). The percentage of gallbladders that were analysed decreased over the six years of observation from 83% to 38%. Our policy of Sel-HP saved over €65 000. CONCLUSIONS: A policy of selective histopathology after cholecystectomy is oncologically safe and reduces costs.

Reduced Port Laparoscopic Cholecystectomy: An Innovative, Cost-Effective Technique with Superior Cosmetic Outcomes.

INTRODUCTION: Patient demand for cosmetically superior surgical outcomes has driven minimally invasive technique development like single incision laparoscopic cholecystectomy (SILC). Implementation has been hindered by equipment factors, compromise of ergonomics, increased cost, and larger primary incision, leading to the associated risk of postoperative wound complications, incisional hernia, and fascial dehiscence. We present a method of reduced port laparoscopic cholecystectomy (RPLC), which utilises existing laparoscopic conventional equipment and an innovative MiniLap® grasper (Teleflex Incorporated, Wayne, Pennsylvania). The aim of the approach being enhanced cosmesis, cost equivalence with existing methods, and preservation of surgical ergonomics. MATERIALS AND METHODS: Twenty consecutive patients presenting to a single-surgeon practice with pathology requiring cholecystectomy and favourable body habitus were offered an RPLC procedure. Abdominal access was obtained via two laparoscopic working ports placed through a single incision within the umbilicus and with a 2.3mm port-less MiniLap® inserted via stab incision in the right upper quadrant utilised for retraction. Operative time, cost, cosmesis, postoperative pain, and patient demographics were compared with the standard four-port cholecystectomy. RESULTS: Twenty patients underwent RPLC with age ranging from 20 to 67 with a mean body mass index (BMI) of 31kg/m2. Mean operative time of 36.3 minutes was comparable to conventional multi-port laparoscopic cholecystectomy (LC). All operations were completed as RPLC, and no conversion to conventional four-port laparoscopic cholecystectomy was required. Gall bladder retraction with Teleflex grasper and an innovative swirling technique provides adequate exposure of the hepato-cystic triangle. Patient response regarding cosmetic outcome of the procedure was overwhelmingly positive. A single complication of the RPLC technique was documented-a superficial umbilical site wound infection, which was treated with oral antibiotics. Instrumental cost of the RPLC was $80 (AUD) greater than standard 4LP due to reduced port number but higher MiniLap® cost. CONCLUSION: The RPLC method utilises an ergonomically attractive technique with outcomes and a safety profile equal to the standard multi-port LC whilst minimizing the complications and prohibitive economic penalties of traditional SILC. A well-designed prospective randomised trial can provide more insight into the pros and cons of this innovative technique.

Feasibility and safety of single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy in an ambulatory setting.

BACKGROUND: Single-incision laparoscopic surgery has emerged as an alternative to conventional laparoscopic cholecystectomy (LC) in the clinical setting. Limited information is available on the possibility of performing single-incision laparoscopic surgery as an ambulatory procedure. This study aimed to determine the feasibility and safety of single-incision laparoscopic cholecystectomy (SILC) versus conventional LC in an ambulatory setting. METHODS: Ninety-one patients were randomized to SILC (n = 49) or LC (n = 42). The success rate, operative duration, blood loss, hospital stay, gallbladder perforation, drainage, delayed discharge, readmission, total cost, complications, pain score, vomiting, and cosmetic satisfaction of the two groups were then compared. RESULTS: There were significant differences in the operative time (46.89 ±â€¯10.03 min in SILC vs. 37.24 ±â€¯10.23 min in LC; P < 0.001). As compared with LC, SILC was associated with lower total costs (8012.28 ±â€¯752.67 RMB vs. 10258.91 ± 1087.63 RMB; P < 0.001) and better cosmetic satisfaction (4.94 ± 0.24 vs. 4.74 ± 0.54; P = 0.031). There were no significant differences between-group in terms of general data, success rate, blood loss, hospital stay, gallbladder perforation, drainage, delayed discharge, readmission, complications, pain score, and vomiting (P > 0.05). CONCLUSIONS: Ambulatory SILC is safe and feasible for selected patients. The advantages of SILC as compared with LC are improved cosmetic satisfaction and lower total costs.

Evaluating the early impact of Medicaid expansion on trends in diagnosis and treatment of benign gallbladder disease in Kentucky.

BACKGROUND: In January 2014, Kentucky expanded Medicaid coverage in an effort to improve access to healthcare. This study evaluated the early impact of Medicaid expansion on diagnosis and treatment of benign gallbladder disease in Kentucky. METHODS: Administrative claims data were queried for patients undergoing cholecystectomy for benign gallbladder disease between 2011 and 2015. Demographic, procedure, and outcome variables from 2011 to 2013 (PRE) and 2014-2015 (POST) were compared. RESULTS: After Medicaid expansion, patients were more likely to have their operation performed as an outpatient (80.0% vs. 78.2%, p < 0.001). A significant trend was noted toward a shorter hospital stay (p < 0.001) among inpatients. For both inpatients and outpatients, a significant shift was noted toward increased hospital charges (p < 0.001). CONCLUSIONS: The expansion of Kentucky Medicaid in 2014 has been associated with an increase in outpatient cholecystectomy, shorter hospital stays for inpatients, and increased hospital charges for both inpatients and outpatients. Increased charges for all procedures may represent a mechanism for hospitals to offset the cost of providing global care for more patients.