Systematic intraoperative cholangiography during elective laparoscopic cholecystectomy: Is it a justifiable practice?

Backgrounds/Aims: Routine execution of intraoperative cholangiography (IOC) in laparoscopic cholecystectomy (LC) is considered a good practice to help early identification of biliary duct injuries (BDIs) or common bile duct (CBD) stones. This study aimed to determine the impact of IOC during LC. Methods: This is a retrospective, monocentric study, including patients with a LC performed from January 2020 to December 2021. Results: Of 303 patients, 215 (71.0%) were in the IOC group and 88 (29.0%) in the no-IOC group. IOC was incomplete or unclear in 10.7% of patients, with a failure rate of 14.7%. Operating time was 15 minutes longer in the IOC group (p = 0.01), and postoperative complications were higher (5.1% vs. 0.0%, p = 0.03). There were three BDIs (0.99%), all included in the IOC group; only one was diagnosed intraoperatively, and the other two were identified during the postoperative course. Regarding identifying CBD stones, IOC showed a sensitivity of 77%, a specificity of 98%, an accuracy of 97.2%, a positive predictive value of 63% and a negative predictive value of 99%. Conclusions: Systematic IOC has shown no specific benefits and prolonged operative duration. IOC should be performed on selected patients or in situations of uncertainty on the anatomy.

Validation of the albumin-indocyanine green evaluation model in patients with resected hepatocellular carcinoma and comparison with the albumin-bilirubin score.

BACKGROUND: The albumin-indocyanine green evaluation (ALICE) model based on serum albumin and indocyanine retention rate has been shown to be an effective method for predicting postoperative outcomes in hepatocellular carcinoma patients. Aim of the study was to validate the ALICE model in a large Western cohort of patients by comparing the albumin-bilirubin (ALBI) score and Child-Turcotte-Pugh (CTP) score. METHODS: A total of 400 patients who underwent hepatic resection from January 2005 to June 2016 at three centers were enrolled. The ALICE, ALBI, and CTP scores were computed for all patients. RESULTS: The ALICE score correlated better with ALBI (r = 0.428) than with CTP score (r = 0.302). Both the ALICE (grade 1: 49%; grade 2: 51%) and the ALBI (grade 1: 52.5%; grade 2: 47.5%) scores stratified the CTP class A patients into two distinct classes. The incidence of ascites (grades 1-3: ALICE 11%, 20%, 58%; ALBI 11%, 23%, 50%) and severe liver failure (ALICE 8.7%, 10.5%, 41.7%; ALBI 8.6%, 12%, 50%) increased with increasing ALBI and ALICE grade and were similar for the same grade. CONCLUSIONS: The ALICE model can assess hepatic functional reserve and predict postoperative outcomes with efficacy comparable with the ALBI grade and better than the CTP score.

Multiparametric Evaluation Predicts Different Mid-Term Outcomes in Crohn's Disease.

AIM: To evaluate if a single and/or combined (clinical, endoscopic and radiological) assessment could predict clinical outcomes in Crohn's disease (CD). METHODS: We prospectively evaluated 57 CD cases who underwent both a colonoscopy and a CT-enterography (CTE). Harvey-Bradshaw Index (HBi), SES-CD (and/or Rutgeerts score) and the radiological disease activity were defined to stratify patients according to clinical, endoscopic and radiological disease activity respectively. Hospitalizations, surgery, therapeutic changes and deaths were evaluated up to 36 months (time 1) for 53 patients. RESULTS: CTE and endoscopy agreed in stratifying disease activity in 47% of cases (k = -0.05; p = 0.694), CTE and HBi in 35% (k = 0.09; p = 0.08), endoscopy and HBi in 39% (k = 0.13; p = 0.03). Taken together, CTE, endoscopy and HBi agreed only in 18% of cases (k = 0.01; p = 0.41). Among the 11 cases with mucosal healing, only 3 (27%) showed transmural healing. Patients with endoscopic activity needed significantly more changes of therapy compared to patients with endoscopic remission (p = 0.02). Patients with higher transmural or clinical activity at baseline required significantly more hospitalizations (p < 0.01). Hospitalization rate decreases with an increase in the number of parameters indicating remissions at baseline (p = 0.04). CONCLUSIONS: Clinical, endoscopic and radiological assessments offer complementary information and could predict different mid-term outcomes in CD.

Rifaximin for the treatment of diarrhoea-predominant irritable bowel syndrome.

INTRODUCTION: Rifaximin is a non-absorbable, semisynthetic antibiotic that acts as an inhibitor of bacterial RNA synthesis, with a broad spectrum of antibacterial activity. Due to its poor absorption, rifaximin has an increased exposure to the intestine, thus it is suitable for the treatment of many gastrointestinal (GI) diseases. In irritable bowel syndrome (IBS) pathogenesis, gut microbiota impairment may play a major role. The possibility of modulating intestinal bacteria using antibiotics, in particular, rifaximin, has been demonstrated to improve IBS symptoms in non-constipation subtypes of IBS. AREAS COVERED: We reviewed the use of rifaximin in diarrhoea-predominant IBS, focusing on its pharmacokinetic characteristics, its absorption in GI disease, its lack of interaction with other drugs and its new extended release formulation. EXPERT OPINION: Rifaximin, with its low systemic absorption and no clinically significant interactions with other drugs, may represent a treatment of choice for IBS, mainly due to its ability to act on IBS pathogenesis, through the modulation of gut microbiota. Further studies to analyse the effect of rifaximin treatment on the composition of faecal microbiota are warranted. In particular, they need to evaluate whether resistant bacterial strains are selected and whether they are still present in the faecal sample even a long time after therapy.

Comparison between clinical and radiological evaluation before and after medical therapy in patients with Crohn's disease: new prospective roles of CT enterography.

PURPOSE: In recent years, CT enterography (CTE) has emerged as an important methodology to study patients with Crohn's disease (CD). The aim of this study was to evaluate the correlation between clinical response to therapy and CTE findings in CD patients. MATERIALS AND METHODS: Forty-five patients with proven CD underwent CTE before and after medical therapy. In CTE we evaluated bowel thickness, longitudinal extension of parietal thickening, presence of target signs and extraintestinal signs. The clinical response to therapy was judged based on clinical global assessment and classified as improved, worsened or stable disease. Radiological judgement was compared to clinical judgement. The Cohen kappa test, t test or Anova analysis and χ (2) test were used for comparisons. RESULTS: Among 45 enrolled patients, 21 (47 %) improved clinically, five (11 %) worsened, 19 (42 %) remained stable. Clinical improvement was significantly correlated to reduced intestinal thickness, reduced longitudinal extension of the disease, increased diameter of pathological bowel and reduced target signs (p < 0.05). Worsening conditions were significantly correlated to increased longitudinal extent, increased parietal thickness and reduced lumen diameter (p < 0.05). CT judgement was in agreement with physician's clinical assessment in 34 patients (76 %), showing improved disease in 16/21 patients (76 %), stable disease in 14/19 patients (74 %) and worsening in 4/5 patients (80 %). No agreement was observed in 11 (24 %) patients. CONCLUSIONS: CT enterography provide specific and measurable parameters in evaluating the response to therapy in CD patients.