Is Routine Intraoperative Cholangiogram Necessary in Patients With Mild Acute Biliary Pancreatitis Undergoing Index Admission Cholecystectomy?

Background: There is controversy about whether intraoperative cholangiogram (IOC) should be performed routinely during laparoscopic cholecystectomy for patients with acute biliary pancreatitis, given significant false positive and negative rates and increased resource utilization. The aim of this study was to clarify the role of IOC in cases of mild biliary pancreatitis in patients undergoing index admission cholecystectomy, its impact on patient outcomes, and the impact of blood tests, imaging, and preoperative intervention on the detection of choledocholithiasis.Methods: A retrospective review of all patients presenting with acute mild biliary pancreatitis between January 2006 and December 2019 was conducted. Data collected included patient demographics, serum chemistry, IOC, and Endoscopic Retrograde Cholangiopancreatography (ERCP) findings, imaging findings, length of stay, operative length, and long-term follow-up outcomes.Results: 284 patients met the inclusion criteria for the study. The overall false positive IOC rate was 7.4%. Worsening bilirubin trend was a positive predictive value (PPV) for positive IOC and ERCP outcomes with a relative risk of 2.93 (P < .01) and 2.32 (P = .013), respectively. Improving preoperative bilirubin trend had a significant negative predictive value in IOC with a relative risk of .59 (P = .02). Positive IOC was shown to significantly increase operative length with a relative risk of 2.03 (P < .001).Discussion: A rising preoperative bilirubin is a predictor of a positive IOC and patients with normalizing bilirubin levels or a preoperative ERCP are less likely to have choledocholithiasis. These features may be used to select patients that would benefit from an IOC for index admission cholecystectomy.

Outcomes of patients with gallbladder cancer presenting with acute cholecystitis.

The main purpose of this study is to explore the outcomes of patients found to have gallbladder cancer during investigation and diagnosis of acute cholecystitis. The incidence of primary gallbladder cancer co-existing in acute cholecystitis is not well defined in the literature, with anecdotal reports suggesting that they experience worse outcomes than patients with gallbladder cancer found incidentally. METHODS: A retrospective review of all patients with gallbladder cancer managed at the Canberra Health Service between 1998 and May 2022 were identified and reviewed. RESULTS: A total of 65 patients were diagnosed with primary gallbladder cancer during the study period with a mean age of 70.4 years (SD 11.4, range 59-81.8 years) and a female preponderance (74% versus 26%) with a ratio of 2.8. Twenty (31%) patients presented with acute calculus cholecystitis and were found to have a primary gallbladder cancer. This group of patients were older and predominantly female, but the difference was not statistically significant. The overall 5-year survival in the cohort was 20% (stage 1 63%, stage 2 23%, stage 3 16%, and stage 4 0%). There was no statistically significant difference in survival between those who presented with acute cholecystitis vs other presentations. CONCLUSIONS: A third of the patients with gallbladder cancer presented with acute cholecystitis. There was no statistically significant difference in survival in those with bile spillage during cholecystectomy as well those presenting with acute cholecystitis.

IgG4-related sclerosing cholangitis mimicking cholangiocarcinoma.

A man in his 70s presented to the emergency department with painless obstructive jaundice. Initial blood test results show a predominantly cholestatic picture with elevated tumour markers, and imaging findings are concerning for a pancreatic head neoplasm or cholangiocarcinoma with involvement of the entire common bile duct. The patient underwent staging laparoscopy and biopsies including peritoneal washing, but did not identify any features of malignancy. Immunoglobulin G and immunoglobulin G4 testing were subsequently tested and shown to be elevated. The provisional diagnosis of immunoglobulin G4-related sclerosing cholangitis was made, and steroid treatment was empirically started. Treatment with steroids was successful, with complete resolution of symptoms and abnormal imaging findings and near complete resolution of liver function test results after 1 month.

Intraoperative Cholangiography in Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis.

Background/Objectives: Routine intraoperative cholangiography (IOC) for laparoscopic cholecystectomy (LC) remains controversial. The primary outcomes of this meta-analysis were detection rates of choledocholithiasis, bile duct injuries (BDI), and missed stones in LCs. Methods: A systematic literature search was conducted for the time period January 1, 1990 to July 31, 2022. Some studies reported LCs with conversion to open therefore subgroup analysis in BDI rates was performed for studies which included LCs with and without conversion to open. Studies including primary open cholecystectomies were excluded. I2 statistics were used for heterogeneity analysis. Results: Fourteen studies involving 440659 patients were included. In studies comparing routine and selective IOC policies in LC, 61.1% of patients underwent routine IOC; 38.9% underwent selective IOC. In studies comparing IOC to no IOC in LC, 17.3% of patients had IOC; 82.7% did not. Between the selective and routine IOC groups there was no difference in choledocholithiasis detection rate (odds ratio [OR] = 1.33, p = 0.20, 95% confidence interval [CI] = 0.86 - 2.04), no difference in the rate of missed stones (OR = 1.59, p = 0.58; 95% CI = 0.31 - 8.29), and no difference in BDI rates in selective compared to routine IOC (OR = 0.92, p = 0.92; 95% CI = 0.20 - 4.22). There was no difference in the BDI detection rates in LC with and without IOC (OR = 1.12, p = 0.77; 95% CI = 0.52 - 2.38). Conclusion: This is the largest meta-analysis on this topic to date. There was no statistically significant difference in choledocholithiasis detection, missed stones, or BDI rates in the analyzed groups.

The Clinical Significance of Hemorrhagic Cholecystitis.

Background: Hemorrhagic cholecystitis (HC) is a rare complication of acute cholecystitis. HC is difficult to diagnose pre-operatively and previous case reports suggest a strong association with anticoagulation and an increased morbidity. The purpose of the study is to determine the clinical presentation and outcomes of patients with HC in a large cohort of patients. Method: A retrospective review of HC patients diagnosed following review of the clinical and pathological database between January 1, 2000 - June 30, 2021 at two hospitals. A search of the histopathology database, patient medical records, laboratory results, and imaging was conducted. Results: Thirty-five patients were diagnosed on the histopathology report from approximately 6458 patients who had cholecystectomies. Thirty-one had emergency presentation and four patients (11.4%) had elective surgery. Twenty-one patients (60%) were female and 15 patients (40%) were male. The median age was 51 years. All patients had laparoscopic cholecystectomy, four patients were converted to open and five patients required postoperative endoscopic retrograde cholangiopancreatography. Two patients (5.7%) were on anticoagulation therapy. Twenty-three (65.7%) had ultrasound, 12 patients (34.2%) had computed tomography, three patients (8.5%) had magnetic resonance cholangiopancreatography, and one patient with a pre-operative diagnosis of HC. Conclusion: HC is a rare form of acute cholecystitis. Anticoagulation only accounts for a small fraction of these patients. Pre-operative diagnosis of HC is not often made. Patients were treated with cholecystectomies and made a full recovery with no complications. Our study seems to show HC is a histological diagnosis with no clinical consequences for the patients.

Ruptured Pancreaticoduodenal Artery Aneurysm with Median Arcuate Ligament Compression: A Two Staged Approach to Management.

Introduction: Pancreaticoduodenal artery (PDA) aneurysms represent a small portion of rare visceral artery aneurysms. Rupture of these aneurysms results in fatal haemorrhage in up to 50% of cases, necessitating prompt endovascular or open intervention. As highlighted by a recent retrospective review, median arcuate ligament (MAL) release is an important part of management when these aneurysms are diagnosed in conjunction with median arcuate ligament compression (MALC). Two cases of successful urgent management of a ruptured inferior pancreatoduodenal artery aneurysm with staged MAL release are reported. Report: A 65 year old male presented with a ruptured PDA aneurysm in the context of MALC. The patient was treated by emergency transcatheter arterial embolisation (TAE). Staged laparoscopic MAL release required open conversion and stenting one month after rupture. A 73 year old male presented to the same institution with a ruptured PDA aneurysm, again in the context of MALC. This patient was similarly managed by emergency TAE and later had an uncomplicated laparoscopic MAL release. On table mesenteric angiography confirmed successful release. Both patients have since recovered without any recurrence of bleeding or new aneurysm formation. Discussion: Ruptured true PDA aneurysms, while uncommon, may be managed successfully using urgent endovascular techniques. Concomitant coeliac axis stenosis due to MALC requires secondary treatment and can be managed effectively using a staged approach following the urgent presentation.

Inadvertent placement of a nasogastric tube following traumatic nasal tube intubation.

Adequate nutrition is necessary in head and neck surgery. Enteral feeding via a nasogastric tube is often required due to the altered anatomy and to allow sufficient intraoral healing. Insertion of a nasogastric tube is commonly performed without complication and confirmation of its position by a number of different methods. Incorrect positioning can cause significant morbidity with associated mortality. This case report describes the inadvertent placement of a nasogastric tube in a patient with a mandibular squamous cell carcinoma, into the abdominal cavity following a failed traumatic nasal tube intubation. Chest radiography and auscultation failed to identify the abnormal position with subsequent commencement of feeds for a number of days. Following a laporotomy and insertion of abdominal drains, the patient recovered and was discharged from hospital. To prevent recurrence, it is suggested that direct laryngoscopy or direct visualisation of the upper aspect be performed.

An uncommon presentation of a sinister entity.

A case of a female patient presenting with clinical findings ominous for a neoplastic bowel obstruction is reported. Abdominal computed tomography demonstrated a bowel obstruction with evidence of intussusception. Laparotomy revealed an irreducible ileoileal intussusception and segments of the jejunum infiltrated with pigmented deposits. There was no perforation and no evidence of an ulcerating or fungating mass. Intestinal melanoma is not an uncommon sequela of cutaneous melanoma, yet the disease can occur as a primary intestinal process, albeit this is a rarity. Surgical resection is the primary treatment modality and may offer the hope of increased symptom-free survival and overall survival for those patients suffering from metastatic or primary melanoma of the small intestine.

The AGITG GAP Study: A Phase II Study of Perioperative Gemcitabine and Nab-Paclitaxel for Resectable Pancreas Cancer.

BACKGROUND: While combination therapy with nab-paclitaxel/gemcitabine (nab-gem) is effective in pancreatic ductal adenocarcinoma (PDAC), its efficacy as perioperative chemotherapy is unknown. The primary objective of this multicenter, prospective, single-arm, phase II study was to determine whether neoadjuvant therapy with nab-gem was associated with higher complete resection rates (R0) in resectable PDAC, while the secondary objectives were to determine the utility of radiological assessment of response to preoperative chemotherapy and the safety and efficacy of nab-gem as perioperative therapy. METHODS: Patients were recruited from eight Australian sites, and 42 patients with radiologically defined resectable PDAC and an Eastern Cooperative Oncology Group performance status of 0-2 were enrolled. Participants received two cycles of preoperative nab-paclitaxel 125 mg/m2 and gemcitabine 1000 mg/m2 on days 1, 8, and 15 (28-day cycle) presurgery, and four cycles postoperatively. Early response to chemotherapy was measured with fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) scans on day 15. RESULTS: Preoperative nab-gem was completed by 93% of participants, but only 63% postoperatively. Thirty-six patients had surgery: 6 (17%) were unresectable, 15 (52%) had R0 (≥ 1 mm) resections, 14 (48%) had R1 (< 1 mm) resections, and 1 patient did not have PDAC. Median progression-free survival was 12.3 months and median overall survival (OS) was 23.5 months: R0 patients had an OS of 35 months versus 25.6 months for R1 patients after surgery. Seven patients had not progressed after 43 months. CONCLUSIONS: The GAP trial demonstrated that perioperative nab-gem was tolerable. Although the primary endpoint of an 85% R0 rate was not met, the R0 rate was similar to trials using a > 1 mm R0 resection definition, and survival rates were comparable with recent adjuvant studies.

Minimally invasive McKeown's vs open oesophagectomy for cancer: A meta-analysis.

BACKGROUND: The effectiveness of minimally invasive oesophagectomy (MIO) compared to open oesophagectomy (OO) remains controversial. Various techniques for performing MIO are currently used, but the evidence for them is lacking. The objective of this meta-analysis was to compare the safety, efficacy and oncological outcomes of McKeown's minimally invasive oesophagectomy (McKeown's-MIO) to OO. METHODS: PubMed, Embase and Cochrane Library databases were searched up to December 2016 for relevant articles comparing McKeown's-MIO to OO. As no randomised control trials (RCTs) currently exist, only cohort and case control studies were included. Fixed or random-effects models were used to calculate summary odds ratios (ORs) or relative risks (RRs) for binary outcomes, and hazard ratios (HRs) for time-to-event outcomes. Heterogeneity among studies were evaluated using I2 statistics. RESULTS: Four studies, which consisted a total of 573 patients, were included in the meta-analysis. In comparison to patients undergoing OO, those who were treated with McKeown's-MIO had a reduced incidence of pneumonia and total respiratory complications, however, there were no statistically significant differences for other measures of safety such as RLN palsy and anastomotic leak. In terms of efficacy data, MIO had significantly less blood loss and a shorter duration of hospital stay but a longer operating time. Lymph node retrieval trended towards favouring McKeown's-MIO, but was not statistically significant. There was insufficient data to report on other oncological outcomes. CONCLUSIONS: McKeown's-MIO is a safe and effective procedure that has comparable outcomes to OO. However, RCTs with large sample sizes are needed to confirm these results.

Cholecystitis after yttrium-90 resin microsphere radioembolization treatment: Clinical and pathologic findings.

BACKGROUND: Radioembolization with yttrium microspheres is an established therapeutic modality for primary and secondary hepatic malignancies, with studies demonstrating improved overall survival. There remains a paucity of data on cholecystitis as a complication of radioembolization. We describe a small series of patients who developed cholecystitis as a result of radioembolization. METHODS: Patients who had developed cholecystitis as a complication of radioembolization in our institution between 2001 and 2012 were retrospectively reviewed. Patient demographics, cancer details including treatment history, and procedural details of radioembolization and complications of cholecystitis were collected. RESULTS: Of 74 patients who underwent radioembolization using yttrium-90emitting microspheres, four (5.4%) presented with acute cholecystitis as a result of their treatment. All patients presented over 4 weeks following radioembolization and did not settle with conservative treatment. At surgery, the gallbladder was fibrotic and contracted in all cases making surgery difficult. CONCLUSION: The incidence of symptomatic radiation cholecystitis after radioembolization is low, and prophylactic cholecystectomy is not routinely recommended for patients undergoing radioembolization. Radiation cholecystitis should be suspected in patients presenting with symptoms of biliary colic or cholecystitis following radioembolization. Early cholecystectomy can be considered in patients undergoing surgery for other indications, especially in high-risk surgical patients in whom there is a high likelihood of radioembolization in the future as they do not respond to conservative treatment.

Endovascular stenting of mesenterico-portal vein stenosis to reduce blood flow through venous collaterals prior to pancreatoduodenectomy.

BACKGROUND: When the mesenterico-portal vein is stenosed due to tumor related compression, venous collaterals develop and flow occurs antegrade towards the portal vein through the collateral tributaries. Undertaking pancreatoduodenectomy for pancreatic cancer in this setting may result in significant blood loss during the process of ligation of these tributaries. DESCRIPTION OF TECHNIQUE: We describe the technique of endovascular stenting of the mesenterico-portal vein to reduce flow within these collateral tributaries and hence blood loss, to facilitate extended pancreatoduodenectomy and vein resection. CONCLUSION: Percutaneous transhepatic placement of endovascular stent into a stenotic mesentero-portal vein facilitates pancreatoduodenectomy by reducing operative time, which would otherwise be required in dealing with the extensive venous collaterals and hence also reducing blood loss.

Peripancreatic pseudoaneurysms: a management-based classification system.

BACKGROUND: Peripancreatic pseudoaneurysms can arise in a number of different clinical settings but are associated mostly with pancreatitis and pancreatobiliary surgery. The aim of this study is to review the current literature and to propose a management classification system based on the pathophysiological processes and the exact anatomical site of peripancreatic pseudoaneurysms. METHODS: A systematic review of the literature from 1995 to 2012 was performed. Articles on studies describing peripancreatic pseudoaneurysms in the setting of pancreatitis or major hepatic or pancreatic surgery with more than ten patients were included. Seventeen eligible studies were identified and reviewed. RESULTS: The demographic characteristics of the patients in all studies were similar with a predominance of males and a mean age of 55 years. The overall mortality rate varied greatly among the studies, ranging from 0 to 60%. Embolisation was the first line of management in the majority of the studies, with surgery reserved for failed embolisation or for haemodynamically unstable cases. Embolisation of the hepatic artery or its branches was associated with high rates of morbidity (56%) and hepatic failure (19%). More recent studies show that stents are used increasingly for vessels that cannot be embolised safely. Late bleeding, a major cause of mortality and morbidity, is generally underreported. The proposed classification system is based on three factors: (1) the type of artery from which the pseudoaneurysm arises, (2) whether communication with the gastrointestinal tract is present, and (3) whether there is high concentration of pancreatic juice at the bleeding site. CONCLUSION: The management of peripancreatic pseudoaneurysms usually comprises a combination of interventional radiology and surgery and this may be assisted by a logical classification system.