Surgical and endoscopic management of remnant cystic duct lithiasis after cholecystectomy--a case series.

INTRODUCTION: Postcholecystectomy syndrome (PCS) as a result of remnant cystic duct lithiasis (RCDL), or gallstones within the cystic duct after cholecystectomy, can cause persistent or recurrent symptoms after cholecystectomy. STUDY DESIGN: A retrospective descriptive analysis was performed for all patients with RDCL at a single institution between 2001 and 2012. Details of presentation, diagnosis, and surgical and endoscopic treatments, and outcomes were collected and analyzed. RESULTS: Twelve patients with RCDL were identified. The interval between cholecystectomy to RCDL discovery was 34.2 months (range 0.5-168 months). On a standard liver enzyme panel, 75% of patients had derangements in ≥1 indices, with the most common single laboratory test abnormality occurring in gamma-glutamyl transferase (GGT) (80%). Eight operative reports noted that the cystic duct was noticeably dilated at the time of cholecystectomy. Two patients developed a cystic duct leak (Strasberg type A bile duct injury) postoperatively, which was managed nonoperatively. Six cases of RCDL required surgery, and six were managed endoscopically. CONCLUSION: RCDL is a potential cause of postcholecystectomy syndrome, but the true incidence is unknown. Laboratory analysis and imaging are helpful in establishing the diagnosis of RCDL. Endoscopic therapy has a role in the treatment of RCDL, but surgical excision of the remnant cystic duct lithiasis may be required.

Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2,285 patients.

BACKGROUND: Despite rigorous manual counting protocols and the classification of retained surgical items (RSIs) as potential "never events," RSIs continue to occur in approximately 1 per 1,000 to 18,000 operations. This study's goals were to evaluate the incorporation of a radiofrequency detection system (RFDS) into existing laparotomy sponge- and Raytec-counting protocols for the detection of RSIs and define associated risk factors. STUDY DESIGN: All patients undergoing surgery at the University of North Carolina Hospitals from September 2009 to August 2010 were enrolled consecutively. The performance of an RFDS-incorporated accounting protocol for detecting RSIs was prospectively evaluated. Several operative metrics were recorded to identify risk factors for miscounts. RESULTS: A total of 2,285 patients were enrolled. One near miss was detected by the RFDS. Thirty-five miscounts occurred, for a rate of 1.53%. The ultimate locations of miscounted items were surgical site (n = 11), within operative suite (n = 10), surgical drapes (n = 2), and emergency protocol deviations (n = 12). Perioperative variables associated with miscounts were higher estimated volume of blood lost, longer operations, higher number of laparotomy sponges used, open surgical approach, "after hours" operations, change of surgical team during operation, weekend or holiday operations, unanticipated changes in operative plan during surgery, and emergency operations. Body mass index was not associated with miscounts. Surveys completed by participating surgical staff suggested high confidence in the RFDS for prevention of RSIs. CONCLUSIONS: The incorporation of the RFDS assisted in the resolution of a near-miss event (1 of 2,285) not detected by manual counting protocols and assisted in the resolution of 35 surgical-sponge miscounts. No known RSIs occurred during the study period. Risk factors for miscounts were identified and can help identify at-risk surgical populations.

Can residents safely and efficiently be taught single incision laparoscopic cholecystectomy?

OBJECTIVE: Single incision laparoscopic cholecystectomy (SILC) has recently emerged as an option for selected patients undergoing gallbladder removal. While SILC appears safe when performed by experienced surgeons under controlled conditions, there are no studies evaluating the SILC learning curve for incorporation into resident education and the effect on OR efficiency. DESIGN, SETTING, AND PARTICIPANTS: Chief residents were taught and evaluated by a single attending surgeon facile with SILC techniques. Residents were transitioned from assistants to primary surgeon during their clinical rotation. Outcomes data were prospectively tabulated compared with data from standard laparoscopic SLC and attending surgeon SILC outcomes. The setting was an academic, tertiary care teaching hospital. Participants were chief residents rotating on hepatobiliary surgery service. Residents previously had demonstrated mastery of basic laparoscopic surgical techniques. RESULTS: Seven chief residents were evaluated with a total of 49 SILCs with a mean of 7 (range 5-12) SILCS/resident. Five conversions to SLC occurred, all within the first 3 SILCs performed by the resident as operative surgeon. Mean blood loss was 30 mL. Median length of stay was <1 day. Average length of operation increased after the first 2 cases, reflecting the transition of the attending surgeon from primary surgeon to assistant role. By the fifth case, operative times returned to the attending surgeon SILC baseline and historical operative times for SLC at our institution. Factors associated with longer-length of surgery were increasing BMI and presence of acute or chronic cholecystitis, choledocholithiasis, and use of intraoperative cholangiogram. Five postoperative complications occurred and were not associated with position along the resident's learning curve. One death occurred due to metastatic laryngeal cancer within 30 days of SILC. CONCLUSIONS: Residents can safely be taught the techniques of SILC with minimal disruption to operating room efficiency. Residents already proficient in the use of standard laparoscopic techniques transition to SILC quickly with a short learning curve and proper instruction.

Single incision laparoscopic cholecystectomy is associated with a higher bile duct injury rate: a review and a word of caution.

OBJECTIVE: To compare the incidence of bile duct injuries during single incision laparoscopic cholecystectomy (SILC) in relation to the accepted historic rate of 0.4% to 0.5% for standard laparoscopic cholecystectomy (SLC). BACKGROUND: Technically, SILC is more challenging than SLC. The role and benefit of SILC in patient care has yet to be defined. Bile duct injuries have been reported in several series of SILC. METHOD: A comprehensive database search of MEDLINE, EMBASE, CINAHL, and PubMed Central was performed to generate all reported cases of SILC to present. The search was limited to reports of 20 or more patients based on current literature of existing SILC learning curves. Data were analyzed using the Student t test and χ analyses where appropriate. RESULTS: A total of 76 candidate studies were identified; 45 studies met inclusion criteria for an aggregate total of 2626 patients. Most SILCs were performed in the absence of acute cholecystitis (90.6%). The aggregate complication rate was 4.2%, and complications were graded according to the Dindo-Clavien Classification System. Nineteen bile duct injuries were identified for a SILC-associated bile duct injury rate of 0.72%. CONCLUSIONS: There seems to be an increase in the rate of bile duct injuries during SILC when compared with historic rates during SLC. Because most SILCs are performed in optimal conditions, such as lack of acute inflammation, we urge caution in applying this technique to inflamed gallbladder pathology. Controlled trials are needed before conclusions are made regarding safety of SILC.

Single-incision laparoscopic cholecystectomy: a combined analysis of resident and attending learning curves at a single institution.

Single-incision laparoscopic cholecystectomy (SILC) is a recent technical modification on standard laparoscopic cholecystectomy that has been shown to be safe and feasible. Recent studies suggest that experienced laparoscopic surgeons have a short learning curve to become proficient in SILC. However, little is known about the interaction of the learning curves of residents and attending surgeons at academic programs. We prospectively evaluated various metrics of both attending and resident surgeons as they progressed in their experience with SILC. Patients were placed into cohorts of 25 based on teaching surgeon experience. Data recorded included patient-specific and operative variables along with complications, conversion to standard laparoscopic cholecystectomy, and outcomes. One hundred one patients underwent SILC. Twelve per cent of patients required conversion to standard laparoscopic cholecystectomy. No significant difference was found in operative times compared within the experience-based cohorts (P = 0.21). A reduction in operative time was shown in residents who were proficient in standard laparoscopic cholecystectomy (SLC) along their learning curve. Operative times remained the same for the teaching surgeon regardless of experience of resident surgeon. SILC has a short learning curve for resident surgeons who are proficient in standard laparoscopic surgery. SILC can be effectively taught with few complications and outcomes similar to SLC with preservation of operative efficiency and safety. Further studies are warranted, however, at a national/international level to define the place and use for SILC as well as the incorporation of single-incision techniques into resident curriculum.

Single incision laparoscopic cholecystectomy using a "two-port" technique is safe and feasible: experience in 101 consecutive patients.

Single incision laparoscopic cholecystectomy (SILC) is a new minimally-invasive technique that has recently been developed to address several disease processes of the gallbladder. However, the safety and feasibility of this technique are still being evaluated. Utilizing a "two-port" technique with transabdominal suture retraction and a rigorous adherence to the critical view of safety, we evaluated our experience in a prospectively maintained database and compared this with standard laparoscopic cholecystectomy (SLC) over the same period. SILC was completed successfully in 87 per cent of patients. Operative times were found to be similar between SLC and SILC (75 and 76 minutes, respectively; P = 0.12). Operative blood loss, hospital stay, and short-term complications were not statistically different between SILC and SLC. Cholangiograms, obtained on a selective basis, were performed in 19 per cent of SILCs. No bile duct injuries occurred during SILC or SLC. Although our aggregate number is not enough to accurately assess the rate or safety of bile duct injuries, SILC seems to be safe and feasible when evaluating other metrics and does not seem to interfere with operative efficiency compared with SLC.

Extended lymphadenectomy in the surgery of pancreatic adenocarcinoma and its relation to quality improvement issues.

Extended lymphadenectomy has been proposed for loco-regional control of pancreatic adenocarcinoma. While retrospective series suggested a benefit, subsequent prospective trials have not shown a survival benefit. Methods to improve loco-regional control of pancreatic body/tail cancer have not been extensively investigated. Lymph node status is an important surrogate of survival but is not a driving factor for adjuvant chemotherapy. Quality improvement in pancreatic cancer surgery is discussed, focusing on the impact of lymph nodes in determining prognosis.

Cryothermic and hyperthermic treatments of human leiomyomata and adjacent myometrium and their implications for laparoscopic surgery.

STUDY OBJECTIVE: To evaluate the effects and feasibility of direct cryothermic and hyperthermic therapy on leiomyomata and adjacent myometrium, and to contribute to evidence-based treatment thresholds based on measurements of direct cell injury. DESIGN: Experimental study (Canadian Task Force classification II-2). SETTING: University hospital. SUBJECTS: Leiomyoma and myometrium tissue from 10 women undergoing total abdominal hysterectomy with or without bilateral salpingo-oophorectomy. INTERVENTION: In vitro cryothermic or hyperthermic therapy was performed with representative leiomyoma and myometrium tissue samples. Using a directional solidification stage to simulate cryothermic therapy, 10 leiomyoma and 6 myometrium specimens were cooled in vitro at a rate of -5 degrees C/minute to end temperatures of -20 degrees, -40 degrees, -60 degrees, and -80 degrees C with a 15-minute hold period and then rapidly thawed to 21 degrees C. Hyperthermic therapy was simulated using a preheated 45 degrees, 55 degrees, 60 degrees, 65 degrees, 70 degrees, 75 degrees, and 80 degrees C constant temperature copper heating block with a 10-minute treatment period. In conjunction with tissue culturing and control tissues, cell death was assessed with routine histology and viability dyes (ethidium homodimer/Hoechst). MEASUREMENTS AND MAIN RESULTS: In cryothermic results, leiomyomata cell death (LCD) increased from 12% to 27% by histology and 26% to 38% by viability dye assay over the thermal range from -20 degrees to -80 degrees C, respectively. Myometrial cell death (MCD) increased from 10% to 12% and 4% to 20% for the same measurements, respectively. Whereas MCD appeared relatively stable from -40 degrees to -80 degrees C, it was significantly less than LCD over this range (p <0.05). For hyperthermic results, LCD increased from 17% to 88% by histology with progressive temperature increase from 45 degrees to 80 degrees C, respectively. The MCD showed a similar increase from 16% to 91% by histology over this temperature range. Hyperthermic histology and dye assay results were similar for LCD and MCD. CONCLUSIONS: In comparison with myometrium, leiomyomata showed greater direct cryothermic and equal hyperthermic cell injury. Whereas cell death increased up to 70 degrees C and down to -80 degrees C, the interval increases in cell injury diminished with more extreme temperatures. In vivo studies of combined direct and ischemic vascular injury thresholds have yet to be performed, but direct LCD matrixes determined in this study will help provide guidelines for minimally invasive surgical techniques for the treatment of leiomyomata.

Cryosurgical changes in the porcine kidney: histologic analysis with thermal history correlation.

Advances in minimally invasive renal cryosurgery have renewed interest in the relative contributions of direct cryothermic and secondary vascular injury-associated ischemic cell injury. Prior studies have evaluated renal cryolesions seven or more days post-ablation and postulated that vascular injury is the primary cell injury mechanism; however, the contributions of direct versus secondary cell injury are not morphologically distinguishable during the healing/repair stage of a cryolesion. While more optimal to evaluate this issue, minimal acute (< or = 3 days) post-ablation histologic data with thermal history correlation exists. This study evaluates three groups of porcine renal cryolesions: Group (1) in vitro non-perfused (n = 5); Group (2) in vivo 2-h post-ablation perfused (n = 5); and Group (3) in vivo 3-day post-ablation perfused (n = 6). The 3.4 mm argon-cooled cryoprobe's thermal history included a 75 degrees C/min cooling rate, -130 degrees C end temperature, 60 degrees C/min thawing rate, and 15-min freeze time. An enthalpy-based mathematical model with a 2-D transient axisymmetric numerical solution with blood flow consideration was used to determine the thermal history within the ice ball. All three groups of cryolesions showed histologically similar central regions of complete cell death (CD) and transition zones of incomplete cell death (TZ). The CD had radii of 1.4, 1.1, and 1.0 cm in the non-perfused, 2-h and 3-day lesions, respectively. Capillary thrombosis was present in the 2-h perfused cryolesions with the addition of TZ arteriolar/venous thrombosis in the 3-day perfused lesions. Thermal modeling revealed the outer CD boundary in all three groups experienced similar thermal histories with an approximately -20 degrees C end temperature and 2 degrees C/min cooling and thawing rates. The presence of similar CD histology and in vitro/in vivo thermal histories in each group suggests that direct cryothermic cell injury, prior to or synchronous with vascular thrombosis, is a primary mediator of cell death in renal cryolesions.