Comparison of Endoscopy First and Laparoscopic Cholecystectomy First Strategies for Patients With Gallstone Disease and Intermediate Risk of Choledocholithiasis: Protocol for a Clinical Randomized Controlled Trial.

BACKGROUND: The optimal approach for patients with gallbladder stones and intermediate risk of choledocholithiasis remains undetermined. The use of endoscopic retrograde cholangiopancreatography for diagnosis should be minimized as it carries considerable risk of postprocedural complications, and nowadays, less invasive and safer techniques are available. OBJECTIVE: This study compares the two management strategies of endoscopic ultrasound before laparoscopic cholecystectomy and intraoperative cholangiography for patients with symptomatic cholecystolithiasis and intermediate risk of choledocholithiasis. METHODS: This is a randomized, active-controlled, single-center clinical trial enrolling adult patients undergoing laparoscopic cholecystectomy for symptomatic gallbladder stones with intermediate risk of choledocholithiasis. The risk of choledocholithiasis is calculated using an original prognostic score (the Vilnius University Hospital Index). This index in a retrospective evaluation showed better prognostic performance than the score proposed by the American Society for Gastrointestinal Endoscopy in 2010. A total of 106 participants will be included and randomized into two groups. Evaluation of bile ducts using endoscopic ultrasound and endoscopic retrograde cholangiography on demand will be performed before laparoscopic cholecystectomy for one arm ("endoscopy first"). Intraoperative cholangiography during laparoscopic cholecystectomy and postoperative endoscopic retrograde cholangiopancreatography on demand will be performed in another arm ("cholecystectomy first"). Postoperative follow-up is 6 months. The primary endpoint is the length of hospital stay. The secondary endpoints are accuracy of the different management strategies, adverse events of the interventions, duct clearance and technical success of the interventions (intraoperative cholangiography, endoscopic ultrasound, and endoscopic retrograde cholangiography), and cost of treatment. RESULTS: The trial protocol was approved by the Vilnius Regional Biomedical Research Ethics Committee in December 2017. Enrollment of patients was started in January 2018. As of June 2020, 66 patients have been enrolled. CONCLUSIONS: This trial is planned to determine the superior strategy for patients with intermediate risk of common bile duct stones and to define a simple and safe algorithm for managing choledocholithiasis. TRIAL REGISTRATION: ClinicalTrials.gov NCT03658863; https://clinicaltrials.gov/ct2/show/NCT03658863. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18837.

Three-port retroperitoneoscopic necrosectomy in management of acute necrotic pancreatitis.

INTRODUCTION: Because of major morbidity and mortality after open surgery in acute necrotic pancreatitis, an interest in minimally invasive necrosectomy approaches has increased. We report the results of a recently developed minimally invasive technique that we adopted in 2007. MATERIAL AND METHODS: This article contains a retrospective analysis of cases and description of original retroperitoneoscopic necrosectomy technique. There were eight patients aged 25-58 years, who underwent retroperitoneoscopic pancreatic necrosectomy in the Center of Abdominal Surgery, Vilnius University Hospital Santariskiu Klinikos, between 2007 and 2009. All patients had at least 30% pancreatic necrosis with extensive retroperitoneal fluid collections on the left side, proved by CT scan. Operations were performed on the 21st-56th days of illness (median, 36th day). RESULTS: The mean postoperative hospital stay was 49 days (range, 14-99 days). All patients survived. Two patients underwent three additional procedures; two patients, one additional procedure due to remaining infected necrosis. Three patients had no requirement for additional procedures. One patient underwent laparotomy because of bleeding. CONCLUSIONS: We assume that minimally invasive techniques should be considered a first-choice surgical option in patients with acute necrotic pancreatitis, whenever it is possible. Pancreatic necrosis less than 30% with large fluid collections in the left retroperitoneal space facilitates employment of three-port retroperitoneoscopic necrosectomy.

Risk assessment of choledocholithiasis prior to laparoscopic cholecystectomy and its management options.

BACKGROUND: Accurate risk evaluation of choledocholithiasis prior to laparoscopic cholecystectomy is essential to determine optimal management strategy. OBJECTIVE: Our study aimed to evaluate the accuracy of separate predictors and Vilnius University Hospital Index (VUHI = A/30 + 0.4 × B; A = total bilirubin concentration (µmol/l), B = common bile duct (CBD) diameter (mm) measured by ultrasound) diagnosing choledocholithiasis and to assess different management strategies (cholecystectomy with intraoperative cholangiography and endoscopic retrograde cholangiopancreatography (ERCP)). METHODS: The retrospective study included 350 patients admitted to a tertiary care centre for laparoscopic cholecystectomy for cholecystolithiasis who were investigated for concomitant choledocholithiasis. RESULTS: Choledocholithiasis was diagnosed in 182 (76.2%) cases in the high-risk group (VUHI value ≥4.7) and 44 (39.6%) in the low, odds ratio is 4.86 (95% CI: 3.00-7.88). Its sensitivity was 80.5%, specificity 54.0%, accuracy 71.1%. Dilated CBD had the highest sensitivity (92.5%) of predictors.ERCP showed better diagnostic performance than intraoperative cholangiography. Complications of ERCP were more frequent for patients without stones. There was no significant difference of outcomes between the two management strategies. CONCLUSION: The prognostic index has good diagnostic accuracy but dividing patients into two risk groups is insufficient. The suggested model allows determining an intermediate-risk group, which requires additional investigation. Both management approaches are appropriate.

Prospective analysis of risk for hypothyroidism after hemithyroidectomy.

Objectives. To evaluate risk factors and to develop a simple scoring system to grade the risk of postoperative hypothyroidism (PH). Methods. In a controlled prospective study, 109 patients, who underwent hemithyroidectomy for a benign thyroid disease, were followed up for 12 months. The relation between clinical data and PH was analyzed for significance. A risk scoring system based on significant risk factors and clinical implications was developed. Results. The significant risk factors of PH were higher TSH (thyroid-stimulating hormone) level and lower ratio of the remaining thyroid weight to the patient's weight (derived weight index). Based on the log of risk factor, preoperative TSH level greater than 1.4 mU/L was assigned 2 points; 1 point was for 0.8-1.4 mU/L. The derived weight index lower than 0.8 g/kg was assigned 1 point. A risk scoring system was calculated by summing the scores. The incidences of PH were 7.3%, 30.4%, and 69.2% according to the risk scores of 0-1, 2, and 3. Conclusion. Risk factors for PH are higher preoperative TSH level and lower derived weight index. Our developed risk scoring system is a valid and reliable tool to identify patients who are at risk for PH before surgery.

Endoscopic retroperitoneal adrenalectomy for adrenal metastases.

Objectives. To evaluate whether retroperitoneal approach for adrenalectomy is a safe and effective treatment for adrenal metastases (AM). Methods. From June 2004 to January 2014, nine consecutive patients with AM were treated with endoscopic retroperitoneal adrenalectomy (ERA). A retrospective study was conducted, and clinical data, tumor characteristics, and oncologic outcomes were acquired and analyzed. Results. Renal cancer was the primary site of malignancy in 44.4% of cases. The mean operative time was 132 ± 10.4 min. There were 5 synchronous and 4 metachronous AM. One patient required conversion to transperitoneal laparoscopic procedure. No mortality or perioperative complications were observed. The median overall survival was 11 months (range: 2-42 months). Survival rates of 50% and 25% were identified at 1 and 3 years, respectively. At the end of the study, 4 patients were alive with a mean observed follow-up of 20 months. No patients presented with local tumor relapse or port-site metastases. Conclusions. This study shows that ERA is a safe and effective procedure for resection of AM and advances the surgical treatment of adrenal disease. The use of the retroperitoneal approach for adrenal tumors less than 6 cm can provide very favorable surgical outcomes.

Two-stage bilateral laparoscopic adrenalectomy for large pheochromocytomas.

A 66-year-old Lithuanian female patient with a history of hypertension was diagnosed with bilateral adrenal tumors during a routine sonoscopy. Scintigraphy with metaiodobenzylguanidine and computed tomography scan revealed right 130/116/93 mm and left 85/61/53 mm pheochromocytomas. The patient suffered from hypertension with blood pressure over 240/100 mm Hg and heartbeat disturbances. Blood adrenaline levels exceeded the norm 10-fold. After possible spread of tumors was rejected, laparoscopic transperitoneal adrenalectomy was planned in 2 stages, starting on the right then followed by the left side. After preoperative treatment with adrenoblockers, 2-stage bilateral laparoscopic adrenalectomy was performed. 13 cm × 12 cm × 9.5 cm right adrenal and, 3 months later, 8.5 cm × 8 cm × 6 cm left adrenal pheochromocytomas were removed. Histologically - radical extirpation, pheochromocytomas with possible malignant potential. Stable remission of hypertension was achieved postoperatively. Laparoscopic transperitoneal adrenalectomy is a safe and feasible method of treatment of large benign and possible malignant, but noninvasive pheochromocytomas.

Surgical treatment options for aldosteronomas.

INTRODUCTION: Single access retroperitoneoscopic adrenalectomy (SARA) is the most feasible approach for removing aldosteronomas. AIM: To analyse the advantages and disadvantages of surgical approaches to treating small adrenal tumours. MATERIAL AND METHODS: In the period 2002-2011, 31 patients were operated on at Vilnius University Hospital Santariskiu Clinics for aldosteronomas. Adrenalectomies were performed in the lateral laparoscopic (group A, n = 6), the endoscopic retroperitoneal (group B, n = 20), and the single incision laparoscopic surgery (SILS) and SARA (group C, n = 5) approaches. Seventy five percent of patients were operated on by the same surgeon. The duration of adrenalectomies, and intraoperative and postoperative complications were compared. The possibility of minimally invasive adrenalectomies was evaluated. RESULTS: According to the patients' age, body mass index and tumour size, the groups were equal. The average duration of surgery in group A was shorter than in groups B and C (91 ±23 min vs. 118 ±57 min vs. 144 ±88 min). Right laparoscopic adrenalectomy was longer than the left (105 ±26 min vs. 77 ±6 min), whereas right endoscopic retroperitoneal adrenalectomy was shorter than the left (109 ±50 min vs. 126 ±57 min). The best cosmetic view was in group C. The SARA method was converted into the endoscopic retroperitoneal approach and then into the laparoscopic for one patient. There were no intraoperative or postoperative complications. CONCLUSIONS: Evaluating the minimal invasion of the method, its abilities and simplicity of conversion into another type of endoscopic surgical way, the SARA approach should be the first option for removing aldosteronomas.