Laparoscopic subtotal cholecystectomy for the difficult gallbladder: Evolution of technique at a single teaching hospital.

BACKGROUND: We have developed an algorithmic approach to laparoscopic cholecystectomy, including subtotal cholecystectomy, as a bailout strategy when the Critical View of Safety cannot be safely achieved due to significant inflammation and fibrosis of the hepatocystic triangle. METHODS: This is a retrospective cohort study comparing postoperative outcomes in patients with severe cholecystitis who underwent laparoscopic cholecystectomy or laparoscopic subtotal cholecystectomy at St. Joseph's Health Centre from May 2016 to July 2021, as well as against a historical cohort. We further stratified laparoscopic subtotal cholecystectomy cases based on fenestrating or reconstituting subtype. RESULTS: The cohort included a total of 105 patients who underwent laparoscopic cholecystectomy and 31 patients who underwent laparoscopic subtotal cholecystectomy. Bile leaks (25.8% vs 1.0%, relative risk 3.5, 95% confidence interval 3.5-208.4) were more common in the laparoscopic subtotal cholecystectomy group. Postoperative endoscopic retrograde cholangiopancreatography (22.6% vs 3.8%, relative risk 5.9, 95% confidence interval 1.9-18.9) and biliary stent insertion (19.4% vs 1.0%, relative risk 20.3, 95% confidence interval 2.5-162.5) were also more common in the laparoscopic subtotal cholecystectomy group. Bile leaks in laparoscopic subtotal cholecystectomy were only documented in the fenestration subtype, most of which were successfully managed with endoscopic retrograde cholangiopancreatography and biliary stenting. Compared to our previous study of laparoscopic cholecystectomy and subtotal cholecystectomy for severe cholecystitis between 2010 and 2016, there has been a decrease in postoperative laparoscopic cholecystectomy complications, subtotal cholecystectomy cases, and no bile duct injuries. CONCLUSION: Following our algorithmic approach to safe laparoscopic cholecystectomy has helped to prevent bile duct injury. Laparoscopic cholecystectomy remains the gold standard for the management of severe cholecystitis; however, in extreme cases, laparoscopic subtotal cholecystectomy is a safe bailout strategy with manageable morbidity.

Thinking Your Way Through a Difficult Laparoscopic Cholecystectomy: Technique for High-Quality Subtotal Cholecystectomy.

Laparoscopic subtotal cholecystectomy (LSC) is a bailout strategy to prevent bile duct injury in difficult gallbladder cases. It is associated with acceptable morbidity that is readily managed with postoperative interventions. Here we share our techniques for LSC. We begin with landmarking, which includes the line of safety, a theoretical line the sulcus of Rouvière and the junction of the cystic and hilar plates. If the fundus can be grasped, then the gallbladder is dissected off the cystic plate using the top-around approach. The gallbladder is then amputated, creating a short cuff of proximal gallbladder. This cuff can be left patent (2A) or cinched close with an ENDOLOOP (Ethicon) if it is small, ideally less than 1 cm (1A). If the fundus cannot be grasped, then an inverted T incision is made on the anterior gallbladder wall. The longitudinal incision is extended toward the fundus, and the transverse incision is extended superiorly along the cystic plate edge. Two "bunny ears" are developed and ultimately resected to excise the anterior gallbladder wall at an oblique angle while leaving the posterior wall intact (2B). If the remaining cuff is small, then it can be sutured closed against the gallbladder back wall (1B). In the setting of extensive bowel adhesion to the anterior gallbladder, we perform a fundectomy, from which we extend two incisions along the cystic plate to open the gallbladder like a clamshell. Our paper describes and illustrates our St Joseph's Health Centre institutional LSC approach and subtype classification (1A, 1B, 2A, and 2B).

Total Kidney Volume Measurements in ADPKD by 3D and Ellipsoid Ultrasound in Comparison with Magnetic Resonance Imaging.

BACKGROUND AND OBJECTIVES: Total kidney volume is a validated prognostic biomarker for autosomal dominant polycystic kidney disease. Total kidney volume by magnetic resonance imaging (MRI) and manual segmentation is considered the "reference standard," but it is time consuming and not readily accessible. By contrast, three-dimensional (3D) ultrasound provides a promising technology for total kidney volume measurements with unknown potential. Here, we report a comparative study of total kidney volume measurements by 3D ultrasound versus the conventional methods by ultrasound ellipsoid and MRI ellipsoid. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This single-center prospective study included 142 patients who completed a standardized 3D ultrasound and MRI. Total kidney volumes by 3D ultrasound and ultrasound ellipsoid were compared with those by MRI. We assessed the agreement of total kidney volume measurements by Bland-Altman plots and misclassification of the Mayo Clinic imaging classes between the different imaging methods, and we assessed prediction of Mayo Clinic imaging classes 1C-1E by average ultrasound kidney length >16.5 cm. RESULTS: Compared with MRI manual segmentation, MRI ellipsoid, 3D ultrasound, and ultrasound ellipsoid underestimated total kidney volume (mean difference: -3%, -9%, and -11%, respectively), with Mayo Clinic imaging classes misclassified in 11%, 21%, and 22% of patients, respectively; most misclassified cases by MRI ellipsoid (11 of 16), 3D ultrasound (23 of 30), and ultrasound ellipsoid (26 of 31) were placed into a lower Mayo Clinic imaging class. Predictions of the high-risk Mayo Clinic imaging classes (1C-1E) by MRI ellipsoid, 3D ultrasound, and ultrasound ellipsoid all yielded high positive predictive value (96%, 95%, and 98%, respectively) and specificity (96%, 96%, and 99%, respectively). However, both negative predictive value (90%, 88%, and 95%, respectively) and sensitivity (88%, 85%, and 94%, respectively) were lower for 3D ultrasound and ultrasound ellipsoid compared with MRI ellipsoid. An average ultrasound kidney length >16.5 cm was highly predictive of Mayo Clinic imaging classes 1C-1E only in patients aged ≤45 years. CONCLUSIONS: Total kidney volume measurements in autosomal dominant polycystic kidney disease by 3D ultrasound and ultrasound ellipsoid displayed similar bias and variability and are less accurate than MRI ellipsoid. Prediction of high-risk Mayo Clinic imaging classes (1C-1E) by all three methods provides high positive predictive value, but ultrasound ellipsoid is simpler to use and more readily available.

Benefits of dexmedetomidine on postoperative analgesia after bariatric surgery.

INTRODUCTION: Anesthetic management of morbidly obese patients is challenging, particularly in those undergoing bariatric surgery. Dexmedetomidine is a α2-adrenergic receptor agonist that is increasingly used in the perioperative setting for its beneficial properties including sedation, anxiolysis, analgesia with opioid-sparing effects, and minimal impact on respiration. The objective of this study was to evaluate the effect of dexmedetomidine on postoperative analgesia and recovery-related outcomes among patients undergoing bariatric surgery. EVIDENCE ACQUISITION: We conducted a systematic review and meta-analysis of MEDLINE, EMBASE, and CENTRAL databases from conception to September 2021 for randomized controlled trials (RCTs) using dexmedetomidine in bariatric patients on postoperative outcomes. Outcomes were pooled using random effects model and presented as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CI). EVIDENCE SYNTHESIS: In total, 20 RCTs with 665 patients in the dexmedetomidine group and 671 patients in the control groups were included. Among RCTs, the dexmedetomidine group had significantly lower opioid usage at 24-hours postoperatively (MD: -5.14, 95% CI: -10.18 to -0.10; moderate certainty), reduced pain scores on a 10-point scale at PACU arrival (MD: -1.69, 95% CI: -2.79 to -0.59; moderate certainty) and six hours postoperatively (MD: -1.82, 95% CI: -3.00 to -0.64; low certainty), and fewer instances of nausea (RR: 0.59, 95% CI: 0.45 to 0.75; moderate certainty) and vomiting (RR: 0.25, 95% CI: 0.15 to 0.43; moderate certainty), compared to control groups. CONCLUSIONS: Dexmedetomidine is an efficacious anesthesia adjunct in patients undergoing bariatric surgery. These benefits of dexmedetomidine may be considered in the multi-modal analgesic management and enhanced recovery pathways in this high-risk population.

Colorimetric approach to high-throughput mutation analysis.

High-throughput genomic mutation screening for primary tumors has characteristically been expensive, labor-intensive, and inadequate to detect low levels of mutation in a background of wild-type signal. We present a new, combined PCR and colorimetric approach that is inexpensive, simple, and can detect the presence of 1% mutation in a background of wild-type. We compared manual dideoxy sequencing of p53 for eight lung cancer samples to a novel assay combining a primer extension step and an enzymatic colorimetric step in a 96-well plate with covalently attached oligonucleotide sequences. For every sample, we were able to detect the presence or absence of the specific mutation with a statistically significant difference between the sample optical density (OD) and the background OD, with a sensitivity and specificity of 100%. This assay is straightforward, accurate, inexpensive, and allows for rapid, high-throughput analysis of samples, making it ideal for genomic mutation or polymorphism screening studies in both clinical and research settings.