Laparoscopic cholecystectomy for symptomatic cholelithiasis in children and adolescents: analysis of 50 cases from a single institution.

PURPOSE: To investigate the clinical characteristics of symptomatic cholecystolithiasis and laparoscopic cholecystectomy complications in pediatric patients. METHODS: The medical records of 50 children and adolescents who underwent laparoscopic cholecystectomy were analyzed. We evaluated gender, age, body mass index, preoperative clinical aspects, perioperative complications, and gallstone composition. RESULTS: Among the patients, 33 (66%) were female, and 17 (34%) were male. The mean age was 11.4 ± 3.6. All patients were diagnosed with cholecystolithiasis by abdominal ultrasonography. Twelve patients (24%) had hematological disease: eight (16%) with sickle cell anemia and four (8%) with hereditary spherocytosis. Thirteen patients (26%) were obese. Twelve patients (24%) had complicated biliary disease. During the intraoperative period, three patients (6%) had excessive bleeding in the hepatic hilum, and one had an accidental injury to the common bile duct. Three (6%) postoperative complications (acute pancreatitis, common bile duct stenosis, and intestinal obstruction) were observed. Among 28 patients (56%), 25 (50%) had cholesterol gallstones, and three (6%) had bile pigment gallstones. CONCLUSIONS: The evolution of cholecystolithiasis in the pediatric population can present serious complications, emphasizing the need to avoid temporizing cholecystolithiasis in children and adolescents because laparoscopic cholecystectomy in this group is safe, with low complication rates.

Laparoscopic cholecystectomy and laparoscopic common bile duct exploration for cholecystolithiasis and choledocholithiasis in a patient with situs inversus totalis: A case report.

Situs inversus complicates diagnosis and treatment due to the mirrored organ placement in relation to normal anatomy. This report describes a 78-year-old female patient with situs inversus totalis who underwent laparoscopic cholecystectomy and laparoscopic common bile duct exploration for cholecystolithiasis and choledocholithiasis. Utilizing the "French mirror technique" for port placement, the surgeon adeptly mirrored standard maneuvers with a 2-mm needle forceps in the left hand and a 5-mm forceps in the right in a reversed anatomical setting. This technique maintained familiar hand movements, despite the patient's unique anatomy. The surgeon applied transcystic ductal bile duct exploration, using choledochoscopy for duct exploration and a basket catheter for stone removal. Laparoscopic cholecystectomy and common bile duct exploration through the transcystic ductal route are viable and effective for patients with situs inversus.

Unraveling factors associated with textbook outcome after cholecystectomy in patients with uncomplicated cholecystolithiasis: A posthoc analysis of individual data of 1,124 patients.

BACKGROUND: A textbook outcome for the management of uncomplicated cholecystolithiasis is the targeted clinical scenario and is characterized by no recurrent biliary colic, absence of surgical and biliary complications, and absence or relief of abdominal pain. The aim of this study was to assess the incidence of textbook outcomes after cholecystectomy and identify associated baseline factors. METHODS: Patients from 2 Dutch multicenter prospective trials between 2014 and 2019 (SECURE and SUCCESS trial) were included. The primary outcome was the proportion of patients with textbook outcomes after cholecystectomy at 6-month follow-up. Regression analysis was used to identify which factors before surgery were associated with textbook outcomes. RESULTS: A total of 1,124 patients underwent cholecystectomy. A textbook outcome at 6-month follow-up was reached in 67.9% of patients. Persistent abdominal pain was the main reason for the failure to achieve textbook outcome. Patients who did achieve textbook outcomes more often reported severe pain attacks (89.4% vs 81.7%, P < .001) and/or biliary colic (78.6% vs 68.4%, P < .001) at baseline compared with patients without textbook outcomes. The presence of biliary colic at baseline (odds ratio = 1.56, 95% confidence interval: 1.16-2.09, P = .003) and nausea/vomiting at baseline (odds ratio = 1.33, 95% confidence interval: 1.01-1.74, P = .039) were associated with textbook outcome. The use of non-opioid analgesics (odds ratio = 0.76, 95% confidence interval: 0.58-0.99, P = .043) and pain frequency ≥1/month (odds ratio = 0.56, 95% confidence interval: 0.43-0.73, P < .001) were negatively associated with textbook outcome. CONCLUSION: Textbook outcome is achieved in two-thirds of patients who undergo cholecystectomy for uncomplicated cholecystolithiasis. Intensity and frequency of pain, presence of biliary colic, and nausea/vomiting at baseline are independently associated with achieving textbook outcomes. A more stringent selection of patients may optimize the textbook outcome rate in patients with uncomplicated cholecystolithiasis.

Hif-1α expression targets the TMA/Fmo3/TMAO axis to participate in gallbladder cholesterol stone formation in individuals living in plateau regions.

The incidence of gallbladder cholesterol stones (GCS) increases rapidly among people living in high-altitude hypoxic environments compared to those in normoxic areas. Upregulation of hepatic hypoxia inducible factor 1α (Hif-1α) plays a key role in the formation of GCS. High plasma trimethylamine-N-oxide (TMAO) levels are positively correlated with the occurrence of GCS. We hypothesized that HIF-1α may upregulate TMAO levels by promoting the transcription of flavin-containing monooxygenase 3 (Fmo3), which eventually leads to GCS formation. Our study shows that in women, high plasma total cholesterol and apolipoprotein B were positively correlated with cholecystolithiasis and hypoxia. Hif-1α binds to the Fmo3 promoter and promotes Fmo3 expression. Hypoxia and lithogenic diet induce the expression of Hif-1α, Fmo3, TMAO and cholesterol tube transporters in the livers of mice, disturb the proportion of bile and plasma components, and induce the formation of GCS. In cell experiments, silencing Hif-1α downregulates the expression of Fmo3, TMAO and cholesterol tube transporters. In a mouse model of hypoxic cholecystolithiasis, silencing Hif-1α downregulates the expression of related genes, restores the proportion of bile and plasma lipid components, and reduces the formation of GCS. Our study shows that Hif-1α binds to the promoter region of Fmo3 and promotes Fmo3 transcription. Thus, it mediates the transcriptional activation of the TMA/Fmo3/TMAO pathway, upregulates the expression of ATP-binding cassettes (Abc) g5 and g8, and participates in the regulation of the occurrence of GCS in the plateau region.

Efficacy and safety of double endoscopy combined with exploration in the treatment of elderly patients with cholecystolithiasis complicated with choledocholithiasis.

OBJECTIVE: To investigate the efficacy and safety of laparoscopy combined with choledochoscopy in the treatment of elderly patients with cholecystolithiasis complicated with choledocholithiasis. METHODS: A retrospective analysis of 114 patients admitted to our hospital from January 2020 to January 2023 was conducted. These patients underwent laparoscopic cholecystectomy combined with choledocholithiasis and were divided into an elderly group (≥ 60 years old) of 63 cases and a young and middle-aged group (< 60 years old) of 51 cases according to age. The efficacy and safety indicators of the two groups of patients were observed, and complications were followed up by telephone within 6 months after surgery. The follow-up deadline was June 2023. RESULTS: Among the eligible patients (53 men, 61 women, average age 57 years), all were successfully operated, and 1 case was converted to laparotomy. The elderly and young and middle-aged groups were compared concerning hospitalisation time, bowel sound recovery time, and total postoperative complications, and the differences were statistically significant (P-values were 0.009, 0.006, and 0.039). However, there was no statistically significant difference between the two groups of patients in terms of hospitalisation costs, intraoperative blood loss, operation time, drainage tube removal time, conversion to laparotomy rate, and stone clearance rate (P-values > 0 0.05). CONCLUSION: Strict adherence to surgical standards and enhanced postoperative care resulted in similar efficacy and safety results for double endoscopy combined with the exploration of treatment for elderly and young patients with cholecystolithiasis and choledocholithiasis.

Features of Metabolite Changes in Disease Evolution in Cholecystolithiasis.

BACKGROUND: Cholecystolithiasis is defined as a disease caused by complex and changeable factors. Advanced age, female sex, and a hypercaloric diet rich in carbohydrates and poor in fiber, together with obesity and genetic factors, are the main factors that may predispose people to choledocholithiasis. However, serum biomarkers for the rapid diagnosis of choledocholithiasis remain unclear. AIMS: This study was designed to explore the pathogenesis of cholecystolithiasis and identify the possible metabolic and lipidomic biomarkers for the diagnosis of the disease. METHODS: Using UHPLC-MS/MS and GC-MS, we detected the serum of 28 cholecystolithiasis patients and 19 controls. Statistical analysis of multiple variables included Principal Component Analysis (PCA). Visualization of differential metabolites was performed using volcano plots. The screened differential metabolites were further analyzed using clustering heatmaps. The quality of the model was assessed using random forests. RESULTS: In this study, dramatically altered lipid homeostasis was detected in cholecystolithiasis group. In addition, the levels of short-chain fatty acids and amino acids were noticeably changed in patients with cholecystolithiasis. They detected higher levels of FFA.18.1, FFA.20.1, LPC16.0, and LPC20.1, but lower levels of 1-Methyl-L-histidine and 4-Hydroxyproline. In addition, glycine and L-Tyrosine were higher in choledocholithiasis group. Analyses of metabolic serum in affected patients have the potential to develop an integrated metabolite-based biomarker model that can facilitate the early diagnosis and treatment of the disease. CONCLUSION: Our results highlight the value of integrating lipid, amino acid, and short-chain fatty acid to explore the pathophysiology of cholecystolithiasis disease, and consequently, improve clinical decision-making.

The diameter of the normal extrahepatic bile duct among patients diagnosed with cholecystolithiasis managed at the Philippine General Hospital

Background and Objective@#Understanding the normal anatomy and size of the extrahepatic biliary tree is vital for surgeons to make informed decisions regarding the necessity of additional procedures beyond cholecystectomy. The extrahepatic bile duct (EHBD) comprises the common hepatic duct (CHD) and the common bile duct (CBD), with the former formed by the convergence of the right and left hepatic ducts and the latter extending from the CHD to the duodenum. A normal diameter is indicative of the absence of any signs of obstruction in the EHBD, and the determination of the average range for these ducts are essential for identifying pathologies that may require further surgical intervention. Cholecystolithiasis is a common condition managed at the Philippine General Hospital (PGH). Trans-abdominal ultrasonography is frequently utilized to diagnose cholecystolithiasis, and it can also be used to determine the size of the common bile duct. Knowledge of the normal CBD diameter aids clinicians in distinguishing obstructed bile ducts from normal ones, prompting further diagnostic tests for improved patient management. However, there is limited data on the average diameter of the CBD among Filipino patients with this condition. The study aimed to determine the mean diameter of the common bile duct and common hepatic duct among patients diagnosed with cholecystolithiasis with no signs of obstruction in the EHBD managed at the Philippine General Hospital.@*Methods@#This prospective cross-sectional study included 80 patients who underwent cholecystectomy with intraoperative cholangiography. The CBD and CHD diameters were measured using intraoperative ultrasonography, and the data were analyzed using descriptive statistics and independent t-test.@*Results@#The mean diameter of the CBD was 5.17 mm, with a range of 2.7-10 mm (1.41) mm. The mean diameter of the CHD was 4.71 mm, with a range of 2.3- 10 mm (1.59) mm. There was no significant difference in the CBD and CHD diameters between male and female patients, and across different age groups.@*Conclusion@#In patients with cholecystolithiasis managed at the PGH, the mean diameter of the CBD and the CHD was 5.17 mm and 4.71 mm, respectively, with no significant difference between genders and age groups. The mean diameter of the CBD among Filipino patients with cholecystolithiasis is similar to those reported in other countries. These findings may have clinical implications for the management of patients with cholecystolithiasis, particularly in the planning of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy. Further studies with larger sample sizes and different populations are recommended to validate these results. These findings can aid clinicians in determining the need for pre-operative Magnetic Resonance Cholangiopancreatography (MRCP) or selective intraoperative cholangiography to detect extrahepatic bile duct obstruction.

The value of preoperative neutrophil/lymphocyte ratio in predicting the severity of cholecystolithiasis with cholecystitis in elderly patients.

BACKGROUND: This study aims to assess the effectiveness of neutrophil/lymphocyte ratio (NLR) and C-reactive protein (CRP) in diagnosing cholecystolithiasis with cholecystitis in elderly patients. Additionally, the study seeks to determine the predictive value of preoperative NLR in determining the severity of the condition in this population. METHODS: This study is a retrospective cohort study, including 160 elderly patients with cholecystolithiasis with cholecystitis (45 cases of simple cholecystitis, 58 cases of suppurative cholecystitis, 57 cases of gangrenous cholecystitis) and 60 cases of normal gallbladder histology. The study collected clinical data of the patients detected the preoperative CRP content, neutrophil, and lymphocyte levels through blood routine tests, and calculated the NLR value. The diagnostic value of NLR and CRP was determined by using the Receiver Operating Characteristic Curve (ROC), and the optimal value of preoperative NLR related to the severity of elderly patients with cholecystolithiasis with cholecystitis was identified. RESULTS: This study found that for elderly patients with cholecystolithiasis with cholecystitis, preoperative NLR and CRP levels can be used to distinguish the condition. The critical value for NLR was found to be 2.995 (95% CI, 0.9465-0.9853; P < 0.001) with an area under the ROC curve of 0.9659, while the critical value for CRP was 13.05 (95% CI, 0.9284-0.9830; P < 0.001) with an area under the ROC curve of 0.9557. Both NLR and CRP were found to have equivalent diagnostic abilities. Additionally, the study found that there were significant differences in neutrophil and lymphocyte levels in elderly patients with different severity levels, with NLR increasing as severity increased (P < 0.001). The study identified cut-off values for preoperative NLR that could distinguish Simple cholecystitis and Purulent cholecystitis, as well as Purulent cholecystitis and Gangrenous cholecystitis in elderly patients with cholecystolithiasis, with respective AUCs of 0.8441 (95% CI: 0.7642-0.9239; P < 0.001) and 0.7886(95% CI: 0.7050-0.8721, P < 0.001), sensitivities of 91.38% and 87.72%, and specificities of 73.33% and 63.79%. CONCLUSIONS: Preoperative NLR and CRP values can serve as indicators to detect cholecystolithiasis with cholecystitis in elderly patients. Additionally, NLR has been recognized as a potential tool to differentiate the severity of cholecystolithiasis with cholecystitis in the elderly population.

Persistent and new-onset symptoms after cholecystectomy in patients with uncomplicated symptomatic cholecystolithiasis: A post hoc analysis of 2 prospective clinical trials.

BACKGROUND: Laparoscopic cholecystectomy is the gold standard for treating biliary colic in patients with gallstones, but post-cholecystectomy abdominal pain is commonly reported. This study investigates which symptoms are likely to persist and which may develop after a cholecystectomy. METHODS: Patients from 2 previous prospective trials who underwent laparoscopic cholecystectomy for symptomatic cholecystolithiasis were included. Patients completed questionnaires on pain and gastrointestinal symptoms before surgery and at 6 months follow-up. The prevalence of persistent and new-onset abdominal symptoms was evaluated. RESULTS: A total of 820 patients received cholecystectomy and were included, 75.4% female (n = 616/820) mean age 49.4 years (standard deviation 13.7). At baseline, 74.1% (n = 608/820) of patients met all criteria for biliary colic. Cholecystectomy successfully resolved biliary colic in 94.8% (n = 327/345) of patients, but 36.5% (n = 299/820) of patients reported persistent abdominal pain after 6 months of follow-up. The prevalence of most abdominal symptoms reduced significantly. Symptoms such as flatulence (17.8%, n = 146/820) or restricted eating (14.5%, n = 119/820) persisted most often. New-onset symptoms were frequent bowel movements (9.6%, n = 79/820), bowel urgency (8.5%, n = 70/820), and new-onset diarrhea (8.4%, 69/820). CONCLUSION: Postcholecystectomy symptoms are mainly flatulence, frequent bowel movements, and restricted eating. Newly reported symptoms are mainly frequent bowel movements, bowel urgency, and diarrhea. The present findings give clinical guidance in informing, managing, and treating patients with symptoms after cholecystectomy.

Impacts of the zero mark-up policy on hospitalization expenses of T2DM and cholecystolithiasis inpatients in SC province, western China: an interrupted time series analysis.

Background: Since 2009, a series of ambitious health system reforms have been launched in China, including the zero mark-up drug policy (ZMDP); the policy was intended to reduce substantial medicine expenses for patients by abolishing the 15% mark-up on drugs. This study aims to evaluate the impacts of ZMDP on medical expenditures from the perspective of disease burden disparities in western China. Method: Two typical diseases including Type 2 diabetes mellitus (T2DM) in internal medicine and cholecystolithiasis (CS) in surgery were selected from medical records in a large tertiary level-A hospital in SC Province. The monthly average medical expenses of patients from May 2015 to August 2018 were extracted to construct an interrupted time series (ITS) model to evaluate the impact of policy implementation on the economic burden. Results: A total of 5,764 cases were enrolled in our study. The medicine expenses for T2DM patients maintained a negative trend both before and after the intervention of ZMDP. It had declined by 74.3 CNY (P < 0.001) per month on average in the pre-policy period and subsequently dropped to 704.4 CNY (P = 0.028) immediately after the policy. The level change of hospitalization expenses was insignificant (P = 0.197), with a reduction of 677.7 CNY after the policy, while the post-policy long-term trend was significantly increased by 97.7 CNY (P = 0.035) per month contrasted with the pre-policy period. In addition, the anesthesia expenses of T2DM patients had a significant increase in the level under the impact of the policy. In comparison, the medicine expenses of CS patients significantly decreased by 1,014.2 CNY (P < 0.001) after the policy, while the total hospitalization expenses had no significant change in level and slope under the influence of ZMDP. Furthermore, the expenses of surgery and anesthesia for CS patients significantly increased by 320.9 CNY and 331.4 CNY immediately after the policy intervention. Conclusion: Our study indicated that the ZMDP has been an effective intervention to reduce the excessive medicine expenses for both researched medical and surgical diseases, but failed to show any long-term advantage. Moreover, the policy has no significant impact on relieving the overall hospitalization burden for either condition.

Meta-analysis of the timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography in patients with cholecystolithiasis and choledocholithiasis.

Endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy plays an important role in the treatment of cholecystolithiasis combined with choledocholithiasis; however, there is no unified standard for the interval of ERCP before laparoscopic cholecystectomy. We conducted a literature search, data extraction and meta-analysis on this topic. Twelve articles with 1142 patients were included, including 567 patients in the E-laparoscopic cholecystectomy group (laparoscopic cholecystectomy performed within 72 h after ERCP) and 575 patients in the D-laparoscopic cholecystectomy group (laparoscopic cholecystectomy performed 72 h after ERCP). The results showed that: compared with the D-laparoscopic cholecystectomy group, the duration of cholecystectomy was shorter in the E-laparoscopic cholecystectomy group [weighted mean difference (WMD) = -16.18, 95% confidence interval (CI) (-22.27 to -10.08), P  < 0.00001], and the postoperative hospitalization was shorter [WMD = -1.24, 95% CI (-1.98 to -0.50), P  < 0.0001]. There were fewer complications [odds ratio (OR) = 0.25, 95% CI (0.39-0.62), P  < 0.0001], lower conversion rate [OR = 0.39, 95% CI (0.21-0.71), P  = 0.002], lower high sensitivity C-reactive protein at 3 days after surgery [WMD = -8.76, 95% CI (-12.59 to -4.93), P  < 0.00001], and fewer neutrophils in the ampulla of gallbladder specimen [WMD = -4.21, 95% CI (-4.55 to -3.88), P < 0.00001]. Therefore, in the treatment of cholecystolithiasis combined with choledocholithiasis by laparoscopic cholecystectomy within 72 h after ERCP, the degree of inflammation before and after surgery is less, the operation time and hospital stay are shortened, the postoperative complications and the conversion rate are reduced, which is a more appropriate time for surgery.

A case of accessory hepatic duct entering cystic duct successfully treated by laparoscopic cholecystectomy for cholecystolithiasis.

Although laparoscopic cholecystectomy is a well-established surgical procedure, an accessory hepatic duct (AcHD) entering the cystic duct is poorly understood. A 77-year-old woman with symptomatic cholecystlithiasis was referred to our hospital. Abdominal ultrasonography indicated several small stones in the gall bladder. Magnetic resonance cholangiopancreatography (MRCP) did not reveal an anomalous cystic duct. Dissecting the gall bladder bed at operation, AcHD entering the cystic duct was suspected. Intraoperative cholangiography revealed that B5 branch entered the cystic duct. We ligated the AcHD, and divided it. Laparoscopic cholecystectomy was completed, and the patient was discharged without any complication. A week after the operation, MRCP showed that ventral branch of B5 was dilated. The patient showed no symptom for more than a year. The present case exhibited extremely rare AcHD entering the cystic duct, which was hardly recognized before surgery. It is possible to recognize such anomalous variants with standard laparoscopic approach based on 2018 Tokyo Guidelines and with attention to the possibilities of AcHD entering the cystic duct.

Multiparameter diagnostic model based on 18F-FDG PET metabolic parameters and clinical variables can differentiate nonmetastatic gallbladder cancer and cholecystitis.

OBJECTIVE: To evaluate the diagnostic value of a multiparameter model based on 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) metabolic parameters and clinical variables in differentiating nonmetastatic gallbladder cancer (GBC) from cholecystitis. PATIENTS AND METHODS: In total, 122 patients (88 GBC nonmetastatic patients and 34 cholecystitis patients) with gallbladder space-occupying lesions who underwent 18F-FDG PET/CT were included. All patients received surgery and pathology, and baseline characteristics and clinical data were also collected. The metabolic parameters of 18F-FDG PET, including SUVmax (maximum standard uptake value), SUVmean (mean standard uptake value), SUVpeak (peak standard uptake value), MTV (metabolic tumour volume), TLG (total lesion glycolysis) and SUVR (tumour-to-normal liver standard uptake value ratio), were evaluated. The differential diagnostic efficacy of each independent parameter and multiparameter combination model was evaluated using the receiver operating characteristic (ROC) curve. The improvement in diagnostic efficacy using a combination of the above multiple parameters was evaluated by integrated discriminatory improvement (IDI), net reclassification improvement (NRI) and bootstrap test. Decision curve analysis (DCA) was used to evaluate clinical efficacy. RESULTS: The ROC curve showed that SUVR had the highest diagnostic ability among the 18F-FDG PET metabolic parameters (area under the curve [AUC] = 0.698; sensitivity = 0.341; specificity = 0.971; positive predictive value [PPV] = 0.968; negative predictive value [NPV] = 0.363). The combined diagnostic model of cholecystolithiasis, fever, CEA > 5 ng/ml and SUVR showed an AUC of 0.899 (sensitivity = 0.909, specificity = 0.735, PPV = 0.899, NPV = 0.758). The diagnostic efficiency of the model was improved significantly compared with SUVR. The clinical efficacy of the model was confirmed by DCA. CONCLUSIONS: The multiparameter diagnostic model composed of 18F-FDG PET metabolic parameters (SUVR) and clinical variables, including patient signs (fever), medical history (cholecystolithiasis) and laboratory examination (CEA > 5 ng/ml), has good diagnostic efficacy in the differential diagnosis of nonmetastatic GBC and cholecystitis.

Laparoscopic Transcystic Common Bile Duct Exploration: 8-Year Experience at a Single Institution.

BACKGROUND: Laparoscopic transcystic common bile duct exploration (LTCBDE) is used to treat cholecystolithiasis and choledocholithiasis. This study aimed to investigate the safety, effectiveness and generalisability of LTCBDE in patients with cholecystolithiasis and choledocholithiasis based on our LTCBDE experience within 8 years. METHODS: Four hundred patients with cholecystolithiasis and choledocholithiasis (including 62 of cholecystolithiasis and choledocholithiasis with common bile duct no-dilatation) treated with LTCBDE at a single centre from January 2014 to February 2022 were retrospectively evaluated. They were divided into the first 200 and last 200 LTCBDE cases. The disease characteristics, cystic duct incision methods, surgical outcomes and follow-up data were analysed retrospectively. Each patient was followed up for > 3 months. RESULTS: Four hundred patients underwent LTCBDE, including 188 males and 212 females aged from 15 to 91 years (average age: 56 years). LTCBDE was successful in 377 (94.3%) patients, while treatment was converted to laparoscopic choledocholithotomy with T-tube drainage in 23 (5.8%), owing to intraoperative choledochoscope insertion failure. The CBD diameter (10.89 ± 1.76 vs 9.97 ± 2.39, P < 0.05), cystic duct diameter (4.62 ± 1.03 vs 5.03 ± 1.29, P < 0.05), and operation time (164.60 ± 24.30 vs 135.34 ± 30.00, P < 0.05). Residual stones were found in six (1.5%) patients and removed during the second operation; post-operative bile leakage was found in one (0.3%) patient, who was discharged safely after the second operation. CONCLUSIONS: Phase I LTCBDE is safe and effective in treating cholecystolithiasis and choledocholithiasis. With continuous technological advances, LTCBDE has been effectively promoted and applied.

Laparoscopic cholecystectomy using the subserosal layer dissection technique in dogs: 34 cases (2015-2021).

OBJECTIVES: To describe a standardised subserosal layer dissection technique and evaluate its outcomes in canine laparoscopic cholecystectomy. MATERIALS AND METHODS: Medical records of dogs undergoing laparoscopic cholecystectomy using the standardised subserosal layer dissection technique for the treatment of cholecystolithiasis, cholecystitis, and gall bladder mucocele at a single veterinary hospital from January 2015 to September 2021 were extracted. Operative time, subserosal layer dissection achievement rate, open conversion rate, and complication rate were evaluated. RESULTS: Thirty-four dogs were included. The most common preoperative diagnosis was cholecystolithiasis (n=29). Operative time was 190 minutes (range: 110 to 330 minutes). Subserosal layer dissection of more than 90% of the gall bladder bed was achieved in 27 (79%) dogs. Conversion to open surgery was required in three (8.8%) dogs. There were no cases of intraoperative bleeding, bile duct injury, or reoperation. CLINICAL SIGNIFICANCE: This study showed that laparoscopic cholecystectomy using the standardised subserosal layer dissection technique could be performed successfully in dogs. Future prospective clinical studies are needed to determine safety and effectiveness of this technique compared to standard techniques.

Association of Laparoscopic Methods and Clinical Outcomes of Cholecystolithiasis Plus Choledocholithiasis: A Cohort Study.

> Background: Various surgical methods are available for cholecystolithiasis plus choledocholithiasis. The objective of this study is to explore the association between laparoscopic methods and clinical outcomes of cholecystolithiasis plus choledocholithiasis. METHODS: This cohort study retrospectively included patients who underwent laparoscopic surgery for cholecystolithiasis plus choledocholithiasis at our hospital (January 2017 to March 2021). The primary outcome was bile leakage. RESULTS: Totally 127 patients were enrolled. The time to get out of bed and the indwelling duration of the abdominal drainage tube in the patients who underwent laparoscopic cholecystectomy+lithotomy of common bile duct+common bile duct primary suture+endoscopic nasobiliary drainage were higher than the endoscopic retrograde cholangiopancreatography+laparoscopic cholecystectomy group, without differences in the laparoscopic common bile duct exploration group (all P < .05). All indexes decreased in the 3 groups after surgery (all P < .01). On the first day after surgery, only white blood cells (P < .001) and gamma-glutamyl transferase (P = .045) showed significant differences among the different surgical methods. The incidence of biliary leakage (P = .001) was higher in laparoscopic cholecystectomy+lithotomy of common bile duct+common bile duct primary suture+endoscopic nasobiliary drainage, while the occurrence of hyperamylasemia was higher with endoscopic retrograde cholangiopancreatography+laparoscopic cholecystectomy (P = .001). Compared with laparoscopic cholecystectomy+lithotomy of common bile duct+common bile duct primary suture+endoscopic nasobiliary drainage, laparoscopic common bile duct exploration was associated with fewer bile leakage (RR = 0.03, 95% CI: 0.003-0.37). CONCLUSION: Compared with laparoscopic cholecystectomy+lithotomy of common bile duct+common bile duct primary suture+endoscopic nasobiliary drainage, laparoscopic common bile duct exploration was associated with bile leakage.

Efficacy and safety of laparoscopic common bile duct exploration with primary closure and intraoperative endoscopic nasobiliary drainage for choledocholithiasis combined with cholecystolithiasis.

BACKGROUND: The need for intraoperative endoscopic nasobiliary drainage during laparoscopic cholecystectomy and laparoscopic common bile duct exploration with primary closure is controversial in the treatment of cholecystolithiasis combined with choledocholithiasis. The aim of this study was to evaluate the safety and efficacy of laparoscopic cholecystectomy + laparoscopic common bile duct exploration + intraoperative endoscopic nasobiliary drainage + primary closure (LC + LCBDE + IO-ENBD + PC). The safety of different intubation methods in IO-ENBD was also evaluated. METHOD: From January 2018 to January 2022, 168 consecutive patients with cholecystolithiasis combined with choledocholithiasis underwent surgical treatment in our institution. Patients were divided into two groups: group A (n = 96) underwent LC + LCBDE + IO-ENBD + PC and group B (n = 72) underwent LC + LCBDE + PC. Patient characteristics, perioperative indicators, complications, stone residual, and recurrence rates were analyzed. Group A was divided into two subgroups. In group A1, the nasobiliary drainage tube was placed in an anterograde way, and in group A2, nasobiliary drainage tube was placed in an anterograde-retrograde way. Perioperative indicators and complications were analyzed between subgroups. RESULTS: No mortality in the two groups. The operation success rates in groups A and B were 97.9% (94/96) and 100% (72/72), respectively. In group A, two patients were converted to T-tube drainage. The stone clearance rates of group A and group B were 100% (96/96) and 98.6% (71/72), respectively. Common bile duct diameter was smaller in group A [10 vs. 12 mm, P < 0.001] in baseline data. In perioperative indicators, group A had a longer operation time [165 vs.135 min, P < 0.001], but group A had a shorter hospitalization time [10 vs.13 days, P = 0.002]. The overall complications were 7.3% (7/96) in group A and 12.5% (9/72) in group B. Postoperative bile leakage was less in group A [0% (0/96) vs. 5.6% (4/72), P = 0.032)]. There were no residual and recurrent stones in group A. And there were one residual stone and one recurrent stone in group B (all 1.4%). The median follow-up time was 12 months in group A and 6 months in group B. During the follow-up period, 2 (2.8%) patients in group B had a mild biliary stricture. At subgroup analysis, group A1 had shorter operation time [150 vs. 182.5 min, P < 0.001], shorter hospitalization time [9 vs. 10 days, P = 0.002], and fewer patients with postoperative elevated pancreatic enzymes [32.6% (15/46) vs. 68% (34/50), P = 0.001]. CONCLUSION: LC + LCBDE + IO-ENBD + PC is safer and more effective than LC + LCBDE + PC because it reduces hospitalization time and avoids postoperative bile leakage. In the IO-ENBD procedure, the antegrade placement of the nasobiliary drainage tube is more feasible and effective because it reduces the operation time and hospitalization time, and also reduces injury to the duodenal papilla.

Analysis of risk factors for bile duct injury in laparoscopic cholecystectomy in China: A systematic review and meta-analysis.

BACKGROUND: To explore the risk factors of bile duct injury in laparoscopic cholecystectomy (LC) in China through meta-analysis. METHODS: The study commenced with a search and selection of case-control studies on the risk factors for bile duct injury in LC in China using the following databases: PubMed, EMBASE, ScienceNet.cn, CNKI, Wanfang Data, and VIP. Data were extracted from the collected documents independently by 2 researchers, following which a meta-analysis of these data was performed using Revman 5.3. RESULTS: The compilation of all data from a total of 19 case-control studies revealed that among 41,044 patients, 458 patients experienced bile duct injury in LC, accounting for the incidence rate of 1.12% for bile duct injury. The revealed risk factors for bile duct injury were age (≥40 years) (odds ratio [OR] = 6.23, 95% CI [95% confidence interval]: 3.42-11.33, P < .001), abnormal preoperative liver function (OR = 2.01, 95% CI: 1.50-2.70, P < .001), acute and subacute inflammation of gallbladder (OR = 8.35, 95% CI: 5.32-13.10, P < .001; OR = 4.26, 95% CI: 2.73-6.65, P < .001), thickening of gallbladder wall (≥4 mm) (OR = 3.18, 95% CI: 2.34-4.34, P < .001), cholecystolithiasis complicated with effusion (OR = 3.05, 95% CI: 1.39-6.71, P = .006), and the anatomic variations of the gallbladder triangle (OR = 11.82, 95% CI: 6.32-22.09, P < .001). However, the factors of gender and overweight (body mass index ≥ 25 kg/m2) were not significantly correlated with bile duct injury in LC. CONCLUSIONS: In the present study, age (≥40 years), abnormal preoperative liver function, gallbladder wall thickening, acute and subacute inflammation of the gallbladder, cholecystolithiasis complicated with effusion, and anatomic variations of the gallbladder triangle were found to be closely associated with bile duct injury in LC.