EAES rapid guideline: updated systematic review, network meta-analysis, CINeMA and GRADE assessment, and evidence-informed European recommendations on the management of common bile duct stones.

BACKGROUND: Choledocholithiasis presents in a considerable proportion of patients with gallbladder disease. There are several management options, including preoperative or intraoperative endoscopic cholangiopancreatography (ERCP), and laparoscopic common bile duct exploration (LCBDE). OBJECTIVE: To develop evidence-informed, interdisciplinary, European recommendations on the management of common bile duct stones in the context of intact gallbladder with a clinical decision to intervene to both the gallbladder and the common bile duct stones. METHODS: We updated a systematic review and network meta-analysis of LCBDE, preoperative, intraoperative, and postoperative ERCP. We formed evidence summaries using the GRADE and the CINeMA methodology, and a panel of general surgeons, gastroenterologists, and a patient representative contributed to the development of a GRADE evidence-to-decision framework to select among multiple interventions. RESULTS: The panel reached unanimous consensus on the first Delphi round. We suggest LCBDE over preoperative, intraoperative, or postoperative ERCP, when surgical experience and expertise are available; intraoperative ERCP over LCBDE, preoperative or postoperative ERCP, when this is logistically feasible in a given healthcare setting; and preoperative ERCP over LCBDE or postoperative ERCP, when intraoperative ERCP is not feasible and there is insufficient experience or expertise with LCBDE (weak recommendation). The evidence summaries and decision aids are available on the platform MAGICapp ( https://app.magicapp.org/#/guideline/nJ5zyL ). CONCLUSION: We developed a rapid guideline on the management of common bile duct stones in line with latest methodological standards. It can be used by healthcare professionals and other stakeholders to inform clinical and policy decisions. GUIDELINE REGISTRATION NUMBER: IPGRP-2022CN170.

A mass mimicking pancreatic adenocarcinoma, should hepatobiliary surgeons keep it in mind? a case report.

Isolated metastasis to pancreas from lung cancer is an extremely rare entity, usually reported in case series and case reports in the medical literature; estimated to account for up to 3-5% of all pancreatic lesions. Herein, we describe a case of a male patient suffering from metachronous metastatic lesion to the tail of the pancreas secondary to non small cell lung carcinoma treated 4 years prior to his presentation. The patient underwent pancreatic resection due to high clinical suspicion for the malignant nature of the mass, which was proved to be secondary lesion from its prior primary tumor. To the best of our insight this is one of the few reported cases of such type of pancreatic metastasis that may be misleading for hepatobiliary surgeons during preoperative evaluation.

An unusual cause of large bowel obstruction: are we aware of this?

Primary lymphomas of the colon account for 0.5% of all primary colon malignancies. Burkitt´s lymphoma is a B-cell lymphoma with aggressive clinical behavior. Herein, we describe a case of a male patient who presented with signs of large bowel obstruction, underwent surgery and found to suffer from Burkitt´s lymphoma of the ileocecal region. The histopathological examination was indicative for Burkitt´s lymphoma. To the best of our insight this is one of the few reported cases of such type of lymphoma in an adult patient presenting with bowel obstruction. Burkitt´s lymphoma is a rare malignancy in adults affecting gastrointestinal tract. It has a high proliferation potential and can rapidly progress to advanced disease. Early diagnosis is necessary to prevent complications and improve overall prognosis.

Laparoscopic transabdominal preperitoneal hernia repair (TAPP): stapling the mesh is not mandatory.

BACKGROUND: This report reviews our experience with 104 transabdominal preperitoneal (TAPP) hernia repairs, using a selective staple-free technique, over the period April 2003 to July 2007 (50 months). MATERIALS AND METHODS: Ninety-one patients underwent TAPP repair (13 bilateral). Eighty-one were males and 10 females. Mean age was 61 years. There have been 58 right inguinal hernias and 46 left. We had 47 indirect, 42 direct, 6 pantaloon, 4 supravesicular, 3 inguinal-scrotal, 2 sliding, and 1 femoral hernia. Twenty-three of the hernias we repaired were recurrences. We used a modified staple-free technique with the placement of a 15 x 10 cm polypropylene mesh in the preperitoneal space with sutured peritoneal closure. The mesh was stapled selectively only in very large defects (nine repairs; 9%). We used nondisposable instruments and trocars. RESULTS: We had no conversions. Mean operative time was 47 min/repair with a mean hospitalization of 1.2 nights. We had 1 recurrence (mean follow-up, 34 months). Postoperative complications were: preperitoneal hematoma 1, urinary retention 1, and inguinal seromas/hematomas 11. Mean return to normal activities was 7 days. CONCLUSIONS: TAPP repair is a technically demanding laparoscopic technique, but once mastered, is safe and effective with a high degree of patient satisfaction. Stapling the mesh is not necessary in most cases, thus resulting in a remarkably low cost. The rapid rehabilitation typically associated with laparoscopic surgery was seen in all our patients. The low recurrence rate (1% in our series) compares favorably to other tension-free techniques.

Is inflammation a significant predictor of bile duct injury during laparoscopic cholecystectomy?

BACKGROUND: Bile duct injuries (BDI) have been reported to occur more frequently during laparoscopic cholecystectomy (LC) compared to open cholecystectomy (OC). Several studies have demonstrated various potential predisposing factors for BDI. However, there is a controversy as to whether gallbladder inflammation is a significant predictor for BDI. Therefore, out primary aim was to investigate the relationship between inflammation and BDI at LC, and secondarily to present the management and clinical outcome of BDI. METHODS: We recorded all consecutive LC performed between 1993 and 2005 in our institution by nine staff surgeons. BDI were classified according to Strasberg's classification. Simple and multivariate logistic regression analysis was performed to evaluate the association between inflammation and BDI occurrence during LC. RESULTS: There were 2,184 patients. Among those, 344 had inflammation (16%). The conversion rate was 5% and was higher among male, elder patients, and those with inflammation. The BDI incidence was 0.69% (0.14% for major and 0.55% for minor injuries) and it was significantly higher in those with inflammation compared to those without inflammation (p = 0.01). In particular, the risk for BDI was almost 3.5 times higher in those with inflammation (OR = 3.61, 95% CI 1.27-10.21). Inflammation remained an independent risk factor for BDI even after adjustment for potential confounders. Among patients sustaining injury, one died and two have recurrent cholangitis. No association was observed between clinical outcome and management of BDI, time of diagnosis, sex, and inflammation. CONCLUSION: We revealed that inflammation is an independent predictor of BDI occurrence during LC. Therefore, it would be advisable for surgeons to not hesitate to convert a LC to an OC in the presence of inflammation.