The role of biomarkers in predicting perforated cholecystitis cases: Can the c-reactive protein albumin ratio be a guide?

BACKGROUND: Gallbladder perforation (GBP) is a rare but life-threatening complication of acute cholecystitis. Despite advancements in imaging technology and biochemical analysis, perforations are still diagnosed intraoperatively in some cases. This situation has revealed the need for new markers in the diagnosis of perforation. In this study, we aimed to analyze the role of biomarkers in the diagnosis of perforated cholecystitis cases. METHODS: In this retrospective study, blood samples (white blood cells (WBC), hemoglobin, platelet count, C-reactive protein (CRP), albumin, CRP/albumin ratio (CAR), neutrophil-lymphocyte ratio (NLR), urea, creatinine, glucose, amylase, lipase, aspartate ami-notransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), total bilirubin, direct bilirubin) were analyzed in patients who were diagnosed with acute cholecystitis in the emergency department. RESULTS: One hundred seventy patients were divided into two groups according to the presence or absence of gallbladder perforation. Sixty-three (37.1%) patients had perforation. Transition from laparoscopy to open operation, intensive care unit admission, length of hospital stay, and mortality were higher in the perforated group compared to the non-perforated group. When we analyzed the patients according to laboratory findings, there was a difference in WBC, NLR, CRP, albumin, and CAR parameters in the perforation group. In regression analysis, CRP and CAR performed better. CONCLUSION: Our study showed that CRP and CAR may be diagnostic biomarkers with low specificity and sensitivity in predicting GBP in patients with acute cholecystitis. This marker is a low-cost and easily accessible parameter that may help clinicians make an early diagnosis and plan appropriate treatment for this condition with high morbidity and mortality.

Cholecystopleural fistula: A case report and literature review.

INTRODUCTION: Gallstone with acute cholecystitis is one of the most common diseases in the clinic. If the disease is serious, gallbladder gangrene, perforation, and sepsis may be caused. Gallbladder diseases rarely cause thoracic-related complications, especially pleural fistula, which is very rare in clinical practice. PATIENT CONCERNS: A 52-year-old male patient was admitted to the emergency department for 1 month with recurrent right middle and upper abdominal pain. DIAGNOSIS: Computed tomography diagnosis: cholecystitis and peri-inflammation, small abscess around the base of the gallbladder, local peritonitis, and bilateral pleural effusion. INTERVENTIONS: After admission, conservative treatment was given. On the 4th day of admission, the symptoms worsened, and an emergency catheter drainage was performed on the right thoracic cavity to extract 900 mL of dark yellow effusion. After the operation, a large amount of bili-like fluid was continuously drained from the thoracic drainage tube. After the iatrogenic biliary fistula caused by thoracic puncture was excluded, cholecystopleural fistula was considered to be cholecystopleural fistula. On the 6th day of admission, endoscopic retrograde cholangiopancreatography (ERCP) + cholecystography + Oddi sphincterotomy + laminating biliary stent was performed in the emergency department, and cholecystopleural fistula was confirmed during the operation. OUTCOMES: The patient recovered well after surgery, computed tomography examination on the 20th day after surgery indicated that pleural effusion was significantly reduced, and the patient was cured and discharged. The patient returned to the hospital 8 months after the ERCP operation to pull out the bile duct-covered stent. The patient did not complain of any discomfort after the postoperative follow-up for 3 years, and no recurrence of stones, empyema, and other conditions was found. CONCLUSION: Cholecystopleural fistula is one of the serious complications of acute cholecystitis, which is easy to misdiagnose clinically. If the gallbladder inflammation is severe, accompanied by pleural effusion, the pleural effusion is bili-like liquid, or the content of bilirubin is abnormally elevated, the existence of the disease should be considered. Once the diagnosis is clear, active surgical intervention is needed to reduce the occurrence of complications. Endoscopic therapy (ERCP) can be used as both a diagnostic method and an important minimally invasive treatment.

Standardization of a goal-oriented approach to acute cholecystitis: easy-to-follow steps for performing subtotal cholecystectomy.

BACKGROUND: A critical view of safety (CVS) is important to ensure safe laparoscopic cholecystectomy. When the CVS is not possible, subtotal cholecystectomy is performed. While considering subtotal cholecystectomy, surgeons are often concerned about preventing bile leakage from the cystic ducts. The two main types of subtotal cholecystectomy for acute cholecystitis are fenestrating and reconstituting. Previously, there were no selection criteria for these two; therefore, open conversion was performed. This study aimed to evaluate our goal-oriented approach to choose fenestrating or reconstituting subtotal cholecystectomy for acute cholecystitis. METHODS: We introduced our goal-oriented approach in April 2019. Before introducing this approach, laparoscopic cholecystectomy for acute cholecystitis was performed without criteria for subtotal cholecystectomy. After our approach was introduced, laparoscopic cholecystectomy for acute cholecystitis was performed according to the subtotal cholecystectomy criteria. We retrospectively reviewed the medical records of patients who underwent laparoscopic cholecystectomy for acute cholecystitis between 2015 and 2021. Laparoscopic cholecystectomy for acute cholecystitis was performed by surgeons regardless of whether they were novices or veterans. RESULTS: The period from April 2015 to March 2019 was before the introduction (BI) of our approach, the period from April 2019 to December 2021 was after the introduction (AI) of our approach. There were 177 and 186 patients with acute cholecystitis during the BI and AI periods, respectively. There were no significant differences between groups in terms of preoperative characteristics, operative time, and blood loss. No difference in the laparoscopic subtotal cholecystectomy rate between groups (10.2% [BI] vs. 13.9% [AI]; p = 0.266) was obserbed. The open conversion rate during the BI period was significantly higher than that during the AI period (7.4% vs. 1.6%; p = 0.015). CONCLUSIONS: Our goal-oriented approach is feasible, safe, and easy for many surgeons to understand.

[Experience of indocyanine green use in acute calculous cholecystitis]. / Opyt primeneniya indotsianina zelenogo pri ostrom kal'kuleznom kholetsistite.

OBJECTIVE: To assess the safety and effectiveness of the indocyanine green use in acute cholecystitis for identification of anatomical variants of the biliary tree; prevention and timely detection of intraoperative complications. MATERIAL AND METHODS: The medication of indocyanine green made by OOO «Ferment¼ domestic manufacturer was used. The drug dose from 2.5 mg to 10 mg was applied according to studied materials (8). Time of the surgery beginning was from 2 to 6 hours after intravenous injection of aqueous solution, respectively. In addition, it has been established that the optimal drug dose is 5 mg. The surgery should be performed not earlier than 3 hours after, but no later than 6 hours. This allows to achieve the most comfortable fluorescence of the extrahepatic biliary tract. The drug concentration in the liver cells decreases by this time and increases in the biliary tract. It is not always possible to perform the operation strictly within the specified time limit considering the urgency of the surgical intervention. In this connection, the surgery was carried out not earlier than 3 hours after the drug injection, but not later than 6 hours. Endoscopic equipment with the ability to display near-infrared fluorescence was used. A laser light source with a wavelength of 820 nm in the Arthrex imaging system with 4K resolution as well as the Olympus imaging system with HD resolution were used for fluorescence excitation. RESULTS: The implementation of intraoperative fluorescent navigation with indocyanine green contributes to the improvement of safety and effectiveness of surgical treatment through visualization of topography and identification of anatomical variants of the biliary tree; possibilities of prevention and timely detection of intraoperative complications. The use of indocyanine green allows to intraoperatively reveal atypical location and different variations of the extrahepatic biliary tract.

Diagnosis and Treatment of a 64-Year-Old Man with Chyle Leak Following Laparoscopic Cholecystectomy: A Case Report.

BACKGROUND Chyle leakage with chylous ascites is a rare complication of abdominal surgery, and few cases have been reported following cholecystectomy. This report is of a 64-year-old man with chyle leak following laparoscopic cholecystectomy and describes the diagnosis and approach to treatment. Immediate diagnosis, although challenging, remains imperative. Frequently, patients manifest nonspecific symptoms, such as abdominal discomfort or nausea. They can also exhibit milky discharge from drains and wounds. Abdominal fluid analysis is fundamental for diagnosis. The existence of elevated triglyceride levels in peritoneal fluid is indicative of chyle leakage. CASE REPORT We present a case report of a 64-year-old man with chyle leakage after laparoscopic cholecystectomy for acute cholecystitis, on postoperative day 2. A milky-white fluid was drained, and diagnosis was confirmed with elevated triglycerides upon fluid analysis. Chyle leakage decreased gradually until complete resolution at postoperative day 7, after dietary modifications and the closed-suction silicone drain was removed. The patient was symptom-free at a 2-month follow-up. CONCLUSIONS Although chyle leakage is a rare postoperative complication of laparoscopic cholecystectomy, early diagnosis and rapid multidisciplinary management are required. It is vital to consider this diagnosis even if the course of laparoscopic cholecystectomy was uncomplicated and with no anatomical variation. Thus, a closed-suction silicone drain and close monitoring of output is essential for early diagnosis. The dietary modification constitutes a cornerstone in the management of chyle leakage, and a surgical approach should be preserved for patients for whom the conservative approach fails or who have large volumes of chyle.

Timely cholecystectomy: important factors to improve guideline adherence and patient treatment.

OBJECTIVE: Cholecystectomy is one of the most frequently performed surgeries in Germany and is performed as a treatment of acute cholecystitis (guideline S3 IIIB.8) and after endoscopic retrograde cholangiopancreatography for choledocholithiasis with simultaneous cholecystolithiasis (guideline S3 IIIC.6). This article examines the effects of a guideline update from 2017, which recommends prompt cholecystectomy within 24 hours of admission due to cholecystitis or within 72 hours after bile duct repair. In addition, it aims to identify reasons (eg, financial disincentives) and potential for improvement for non-adherence to the guidelines. DESIGN: Methodologically, a retrospective analysis based on routine billing data from 84 Helios Group hospitals from 2016 and 2022, with a total of 45 393 included cases, was applied. The guideline adherence rate is used as the main outcome measure. RESULTS: Results show the guideline updates led to a statistically significant increase in the proportion of cholecystectomy performed in a timely manner (guideline S3 IIIB.8: increase from 43% to 49%, p<0.001; guideline S3 IIIC.6: increase from 7% to 20%, p<0.001). Medical, structural and financial reasons for non-adherence could be identified. CONCLUSION: As possible reasons for non-adherence, medical factors such as advanced age, multimorbidity and frailty could be identified. Analyses of structural factors revealed that hospitals in very rural regions are less likely to perform timely cholecystectomies, presumably due to infrastructural and personnel-capacity bottlenecks. A similar picture emerges for maximum-care hospitals, which might be explained by more severe and complex cases on average. Further evaluation indicates that an increase in and better hospital-internal participation of gastroenterologists in remuneration could lead to even greater adherence to the S3 IIIC.6 guideline.

Remote ischaemic preconditioning on gene expression and circulating proteins after subacute laparoscopic cholecystectomy: randomized clinical trial.

BACKGROUND: Surgical stress may lead to postsurgical hypercoagulability, endothelial dysfunction and systemic inflammation, which can impact on patient recovery. Remote ischaemic preconditioning is a procedure that activates the body's endogenous defences against ischaemia and reperfusion injury. Studies have suggested that remote ischaemic preconditioning has antithrombotic, antioxidative and anti-inflammatory effects. The hypothesis was that remote ischaemic preconditioning reduces surgery-induced systemic stress response. METHOD: During a 24-month period (2019-2021), adult patients undergoing subacute laparoscopic cholecystectomy due to acute cholecystitis were randomized to remote ischaemic preconditioning or control. Remote ischaemic preconditioning was performed less than 4 h before surgery on the upper arm. It consisted of four cycles of 5 min ischaemia and 5 min reperfusion. The gene expression of 750 genes involved in inflammatory processes, oxidative stress and endothelial function was investigated preoperatively and 2-4 h after surgery in both groups. In addition, changes in 20 inflammation- and vascular trauma-associated proteins were assessed preoperatively, 2-4 h after surgery and 24 h after surgery. RESULTS: A total of 60 patients were randomized. There were no statistically significant differences in gene expression 2-4 h after surgery between the groups (P > 0.05). Remote ischaemic preconditioning did not affect concentrations of circulating proteins up to 24 h after surgery (P > 0.05). CONCLUSION: The study did not demonstrate any effect of remote ischaemic preconditioning on expression levels of the chosen genes or in circulating immunological cytokines and vascular trauma-associated proteins up to 24 h after subacute laparoscopic cholecystectomy in patients with acute cholecystitis.

Updates on Antibiotic Regimens in Acute Cholecystitis.

Acute cholecystitis is one of the most common surgical diseases, which may progress from mild to severe cases. When combined with bacteremia, the mortality rate of acute cholecystitis reaches up to 10-20%. The standard of care in patients with acute cholecystitis is early laparoscopic cholecystectomy. Percutaneous cholecystostomy or endoscopic procedures are alternative treatments in selective cases. Nevertheless, antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis. Patients with acute cholecystitis have a bile bacterial colonization rate of 35-60%. The most frequently isolated microorganisms are Escherichia coli, Klebsiella spp., Streptococcus spp., Enterococcus spp., and Clostridium spp. Early empirical antimicrobial therapy along with source control of infection is the cornerstone for a successful treatment. In these cases, the choice of antibiotic must be made considering some factors (e.g., the severity of the clinical manifestations, the onset of the infection if acquired in hospital or in the community, the penetration of the drug into the bile, and any drug resistance). Furthermore, therapy must be modified based on bile cultures in cases of severe cholecystitis. Antibiotic stewardship is the key to the correct management of bile-related infections. It is necessary to be aware of the appropriate therapeutic scheme and its precise duration. The appropriate use of antibiotic agents is crucial and should be integrated into good clinical practice and standards of care.

[Potentially preventable causes of mortality in acute calculous cholecystitis: a population-based study]. / Potentsial'no predotvratimye prichiny letal'nosti pri ostrom kal'kuleznom kholetsistite: populyatsionnoe issledovanie.

OBJECTIVE: To analyze potentially preventable causes of mortality from acute calculous cholecystitis (ACC) at the population level. MATERIAL AND METHODS: A retrospective study of causes of ACC-related mortality was conducted. We used online survey of state hospitals and estimated fatal outcomes following ACC considering appropriate annual e-database. RESULTS: There were 1.500 deaths among 142.975 patients aged ≥18 years with acute cholecystitis. We received responses to the proposed questionnaire about 1154 deaths (76.9%). Analysis included 648 cases of ACC (K80.0). Mean age of patients was 76.0 years (31-100). There were 256 (39.5%) men and 392 (60.5%) women. ACC severity was assessed according to the Tokyo guidelines (2018). Mild (I) degree was noted in 24 (3.7%) cases, moderate (II) - 270 (41.7%), severe (III) - 354 (54.6%) patients. Cardiovascular diseases and complications caused death in mild ACC regardless of treatment method in 16 (66.7%) cases, in moderate ACC - 106 (39.3%), in severe ACC - 97 (27.4%) cases. ACC caused death in 3 (12.5%) patients with mild disease, 111 (41.1%) with moderate disease and 200 (56.5%) ones with severe disease. Postoperative complications caused death in 4 (16.7%) patients with mild disease, 29 (10.7%) ones with moderate disease and 30 (8.5%) patients with severe disease. Other causes comprised 4.1% (n=1), 8.9% (n=24) and 7.6% (n=27), respectively. Potentially preventable causes of death were identified in 33.0% of cases. CONCLUSION: ACC-related mortality is mainly associated with comorbidity in elderly and senile patients, late presentation and complicated course of disease. Delayed surgical treatment due to diagnostic and tactical problems, as well as technical intraoperative errors is potentially preventable causes of death.

Blunt dissection method using HiQ+ soft coagulation system for laparoscopic cholecystectomy in acute cholecystitis.

INTRODUCTION: During laparoscopic cholecystectomy for acute cholecystitis, it is often difficult to keep the surgical view dry because of inflammation-related tissue fragility and susceptibility to bleeding. The resulting inadequate surgical view can lead to bile duct or vascular injury. Soft coagulation systems are used to achieve hemostasis during various surgeries; however, the usefulness of soft coagulation during laparoscopic cholecystectomy for acute cholecystitis is unclear. We here demonstrate the usefulness and feasibility of blunt dissection and soft coagulation during this procedure. MATERIALS AND SURGICAL TECHNIQUE: We used blunt dissection and soft coagulation when performing laparoscopic cholecystectomy on two patients with acute cholecystitis. As with conventional laparoscopic cholecystectomy, four ports were inserted. After cutting the serosa by electrocautery, blunt dissection using soft coagulation was performed, exposing the inner subserosa. Maintaining this layer using blunt dissection with soft coagulation achieved a sufficiently clear view for safety. After resecting the cystic artery and duct, the gallbladder bed was also dissected by blunt dissection with soft coagulation. Blood loss was <20 mL in both patients. DISCUSSION: Blunt dissection with soft coagulation may be a useful and feasible means of keeping the surgical view dry and minimizing blood loss during laparoscopic cholecystectomy for acute cholecystitis.

The Success Rate Is Lower but Completion Rate of Laparoscopic Cholecystectomy Is higher in Endoscopic Transpapillary Gallbladder Drainage than Percutaneous Gallbladder Drainage for Acute Cholecystitis.

BACKGROUND: We investigated the success and complication rates of endoscopic transpapillary gallbladder drainage (ETGBD) and percutaneous transhepatic gallbladder drainage (PTGBD) and the outcomes of subsequent cholecystectomy for acute cholecystitis. METHODS: Patients (N=178) who underwent cholecystectomy after ETGBD or PTGBD were retrospectively assessed. RESULTS: ETGBD was successful in 47 (85.5%) of 55 procedures, whereas PTGBD was successful in 123 (100%) of 123 sessions ( P <0.001). Complications related to ETGBD and PTGBD occurred in 6 (12.8%) of 47 and 16 (13.0%) of 123 patients, respectively ( P =0.97). After propensity matching, 43 patients from each group were selected. Median time from drainage to cholecystectomy was 48 (14 to 560) days with ETGBD and 35 (1 to 90) days with PTGBD ( P =0.004). Laparoscopy was selected more often in the ETGBD group (97.7%) than in the PTGBD group (79.1%) ( P =0.007), and conversion from laparoscopy to open cholecystectomy was more common with PTGBD (41.2%) than with ETGBD (7.1%) ( P <0.001). Mean operation time was significantly shorter with ETGBD (135.8±66.7 min) than with PTGBD (195.8±62.2 min) ( P <0.001). The incidence of Clavien-Dindo grade ≥III postoperative complications was 9.3% with ETGBD and 11.6% with PTGBD ( P =0.99). CONCLUSIONS: The success rate is lower but completion of laparoscopic cholecystectomy is more in endoscopic gallbladder drainage than percutaneous gallbladder drainage for acute cholecystitis.

Revolutionizing outcomes: endoscopic ultrasound-guided gallbladder drainage using innovative electrocautery enhanced-lumen apposing metal stents for high-risk surgical patients.

This study retrospectively evaluated the outcomes of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using novel electrocautery-enhanced lumen-apposing metal stents (LAMS) in high-risk patients with acute cholecystitis (AC). Between January 1, 2021, and November 30, 2022, 58 high-risk surgical patients with AC underwent EUS-GBD with the novel electrocautery-enhanced LAMS. The technical success rate was 94.8% (55/58), with one case of duodenal perforation requiring surgery with complete stent migration and two of partial stent migration into the gallbladder. However, the clinical success rate was 100% (55/55). Recurrent AC occurred in 3.6% of the cases (2/55), managed with double pigtail plastic stents through the LAMS. Early AEs observed in 1.8% (1/55) due to stent obstruction. Late AEs occurred in 5.4% (3/55), including two cases of cholangitis and one of stent obstruction. For 33 patients followed over 6 months, LAMS maintenance was sustained in 30 cases. Two patients underwent double-pigtail plastic stent replacement after LAMS removal, and one underwent LAMS removal during surgery following tumor stage regression after chemotherapy for cholangiocarcinoma. The novel electrocautery-enhanced LAMS demonstrated high technical and clinical success rates in high-risk surgical patients with AC, maintaining effective gallbladder drainage with minimal AEs during long-term follow-up, thus highlighting its efficacy and safety in challenging patients.

Immunohistochemical inflammation in histologically normal gallbladders containing gallstones.

BACKGROUND: The aim of this study was to establish features of inflammation in histologically normal gallbladders with gallstones and compare the expression of inflammatory markers in acutely and chronically inflamed gallbladders. METHODS: Immunohistochemistry was performed on formalin-fixed paraffin-embedded gallbladders for tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-2R, and substance p in three groups: Group I (n = 60) chronic cholecystitis, Group II (n = 57) acute cholecystitis and Group III (n = 45) histologically normal gallbladders with gallstones. Expression was quantified using the H-scoring system. RESULTS: Median, interquartile range expression of mucosal IL-2R in Groups I (2.65, 0.87-7.97) and II (12.30, 6.15-25.55) was significantly increased compared with group III (0.40, 0.10-1.35, p < 0.05). Submucosal IL-2R expression in Groups I (2.0, 1.12-4.95) and II (10.0, 5.95-14.30) was also significantly increased compared with Group III (0.50, 0.15-1.05, p < 0.05). There was no difference in the lymphoid cell IL-6 expression between Groups I (5.95, 1.60-18.15), II (6.10, 1.1-36.15) and III (8.30, 2.60-26.35, p > 0.05). Epithelial IL-6 expression of Group III (8.3, 2.6-26.3) was significantly increased compared with group I (0.5, 0-10.2, p < 0.05) as was epithelial TNF-α expression in Group III (85.0, 70.50-92.0) compared with Groups I (72.50, 45.25.0-85.50, p < 0.05) and II (61.0, 30.0-92.0, p < 0.05). Lymphoid cell Substance P expression in Groups I (1.90, 1.32-2.65) and II (5.62, 2.50-20.8) was significantly increased compared with Group III (1.0,1.0-1.30, p < 0.05). Epithelial cell expression of Substance P in Group III (121.7, 94.6-167.8) was significantly increased compared with Groups I (75.7, 50.6-105.3, p < 0.05) and II (78.9, 43.5-118.5, p < 0.05). CONCLUSION: Histologically normal gallbladders with gallstones exhibited features of inflammation on immunohistochemistry.

Acute Cholecystitis Due to Lactococcus lactis and Single-Center Experience With Infections Due to Lactococcus spp.

Background: Lactococcus species are used to ferment milk to yogurt, cheese, and other products. The gram-positive coccus causes diseases in amphibia and fish and is a rare human pathogen. Patients and Methods: A 51-year-old male underwent laparoscopic cholecystectomy for acute and chronic calculous cholecystitis. Lactococcus lactis was isolated from pus from his gallbladder empyema. Results: Our institutional database was searched for other cases of Lactococcus spp. infections and four patients (2 males, 2 females; aged 51, 64, 78, and 80 years) were identified during a four-year period. The three other patients had positive blood cultures associated with pneumonia, toxic megacolon, and severe gastroenteritis. All isolates were monocultures with Lactococcus lactis (2), Lactococcus garvieae (1) and Lactococcus raffinolactis (1). Two patients died related to their sepsis. We report the second case of cholecystitis involving Lactococcus. Conclusions: Lactococcus is a very rare pathogen mainly causing blood stream infections but needs to be considered to cause serious surgical infections in humans.

Endoscopic Ultrasonography-Guided Gallbladder Drainage.

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has emerged as a popular alternative to percutaneous cholecystostomy and endoscopic transpapillary gallbladder drainage for patients suffering from acute calculous cholecystitis who are at high risk for surgery. Multiple cohorts, meta-analyses, and a randomized controlled trial have shown that EUS-GBD has lower rates of recurrent cholecystitis and unplanned reinterventions, while achieving similar technical and clinical success rates than transpapillary cystic duct stenting. The essential steps, precautions in performing EUS-GBD and long-term management will be discussed in this article.

The difficult cholecystectomy: What you need to know.

ABSTRACT: This review discusses the grading of cholecystitis, the optimal timing of cholecystectomy, adopting a culture of safe cholecystectomy, understanding the common error traps that can lead to intraoperative complications, and how to avoid them. 1-28 The Tokyo Guidelines, American Association for the Surgery of Trauma, Nassar, and Parkland scoring systems are discussed. The patient factors, physiologic status, and operative findings that predict a difficult cholecystectomy or conversion from laparoscopic to open cholecystectomy are reviewed. With laparoscopic expertise and patient conditions that are not prohibitive, early laparoscopic cholecystectomy is recommended. This is ideally within 72 hours of admission but supported up to the seventh hospital day. The majority of bile duct injuries are due to misidentification of normal anatomy. Strasberg's four error traps and the zones of danger to avoid during a cholecystectomy are described. The review emphasizes the importance of a true critical view of safety for identification of the anatomy. In up to 15% of operations for acute cholecystitis, a critical view of safety cannot be achieved safely. Recognizing these conditions and changing your operative strategy are mandatory to avoid harm. The principles to follow for a safe cholecystectomy are discussed in detail. The cardinal message of this review is, "under challenging conditions, bile duct injuries can be minimized via either a subtotal cholecystectomy or top-down cholecystectomy if dissection in the hepatocystic triangle is avoided". 21 The most severe biliary/vascular injuries usually occur after conversion from laparoscopic cholecystectomy. Indications and techniques for bailout procedures including the fenestrating and reconstituting subtotal cholecystectomy are presented. Seven percent to 10% of cholecystectomies for acute cholecystitis currently result in subtotal cholecystectomy. Level of evidence: III.

Acute cholecystitis with double gall bladder diaphragm.

Gall bladder diaphragm is a rare congenital malformation of the gall bladder, entailing its segmentation in several chambers. Functioning as a non-return valve, it interferes with drainage, leading to gallstone formation and cholecystitis. We are reporting a rare case of acute cholecystitis with a double vesicular diaphragm.

Challenges, Preoperative Assessment, and Surgical Strategies for the Left-Sided Gallbladder.

Left-sided gallbladder positioning, or sinistroposition, is a rare anatomical variation that poses challenges during surgical intervention due to associated vascular and biliary anomalies. While existing literature suggests an incidence of approximately 0.04-1.1%, it remains an underreported phenomenon that falls well outside the realm of "expected" anatomical variation and are rarely identified on preoperative imaging. Here, we present a case of acute cholecystitis in a patient with unexpected left-sided gallbladder, highlighting the associated challenges and outlining both preoperative and intraoperative strategies for managing this rare but consequential anatomical variant. In this case, a 49-year-old woman with a prior history of bilateral ovarian cysts presented with clinical, laboratory, and imaging findings consistent with acute cholecystitis. She underwent laparoscopic cholecystectomy and was found to have a severely inflamed left-sided gallbladder that was obscured by omentum. Her gallbladder was found in the midline immediately beneath the falciform ligament, with most of the gallbladder body and fundus attached to liver segment III, situated to the left of the midline. An additional left-sided mid-abdominal port was required to enhance retraction, and an intraoperative cholangiogram (IOC) was performed given the elevated risk of structural injury. This case underscores the heightened intraoperative risk associated with deviations in vascular and biliary anatomy and provides recommendations for intraoperative adaptations to mitigate these risks.

Preoperative difficulty factors in delayed laparoscopic cholecystectomy: Tokyo Guidelines 2018 surgical difficulty score analysis.

INTRODUCTION: Tokyo Guidelines 2018 (TG18) recommend early laparoscopic cholecystectomy (LC) for low-risk acute cholecystitis (AC); however, some patients undergo delayed LC (DLC) after conservative treatment. DLC, influenced by chronic inflammation, is a difficult procedure. Previous studies on LC difficulty lacked objective measures. Recently, TG18 introduced a novel 25 findings difficulty score, which objectively assesses intraoperative factors. The purpose of this study was to use the difficulty score proposed in TG18 to identify and investigate the predictors of preoperative high-difficulty cases of DLC for AC. METHODS: We retrospectively reviewed 100 patients with DLC after conservative AC treatment. The surgical difficulty of DLC was evaluated using a difficulty score. Based on previous studies, the highest scores in each category were categorized as grades A-C. RESULTS: The severity of AC was mild in 51 patients and moderate in 49. Surgical outcomes revealed a distribution of difficulty scores, with grade C indicating high difficulty, showing significant differences in operative time, blood loss, achieving a critical view of safety, bailout procedures, and postoperative hospital stay compared with grades A and B. Regarding the preoperative risk factors, multivariate analysis identified age >61 years (p = .008), body mass index >27.0 kg/m2 (p = .007), and gallbladder wall thickness >6.2 mm (p = .001) as independent risk factors for grade C in DLC. CONCLUSION: The difficulty score proposed in TG18 provides an objective framework for evaluating surgical difficulty, allowing for more accurate risk assessments and improved preoperative planning in DLC for AC.

Application of 3-Step Laparoscopic Cholecystectomy in Acute Difficult Cholecystitis.

BACKGROUND: With the aging of the global population, the incidence rate of acute cholecystitis is increasing. Laparoscopic cholecystectomy is considered as the first choice to treat acute cholecystitis. How to effectively avoid serious intraoperative complications such as bile duct and blood vessel injury is still a difficult problem that puzzles surgeons. This paper introduces the application of laparoscopic cholecystectomy, a new surgical concept, in acute difficult cholecystitis. METHODS: This retrospective analysis was carried out from January 2019 to January 2021. A total of 36 patients with acute difficult cholecystitis underwent 3-step laparoscopic cholecystectomy. The general information, clinical features, surgical methods, surgical results, and postoperative complications of the patients were analyzed. RESULTS: All patients successfully completed the surgery, one of them was converted to laparotomy, and the other 35 cases were treated with 3-step laparoscopic cholecystectomy. Postoperative bile leakage occurred in 2 cases (5.56%), secondary choledocholithiasis in 1 case (2.78%), and hepatic effusion in 1 case (2.78%). No postoperative bleeding, septal infection, and other complications occurred, and no postoperative colon injury, gastroduodenal injury, liver injury, bile duct injury, vascular injury, and other surgery-related complications occurred. All 36 patients were discharged from hospital after successful recovery. No one died 30 days after surgery, and there was no abnormality in outpatient follow-up for 3 months after surgery. CONCLUSIONS: Three-step laparoscopic cholecystectomy seems to be safer and more feasible for acute difficult cholecystitis patients. Compared with traditional laparoscopic cholecystectomy or partial cholecystectomy, 3-step laparoscopic cholecystectomy has the advantages of safe surgery and less complications, which is worth trying by clinicians.