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.

The dynamics of recovery of external breathing function in patients after laparoscopic cholecystectomy in the acute period under the influence of the rehabilitation program.

OBJECTIVE: Aim: To determine the dynamics of renewal of the function of external respiration in patients after laparoscopic cholecystectomy at the acute stage of rehabilitation under the influence of a rehabilitation program. PATIENTS AND METHODS: Materials and Methods: The study is randomized, simple with blinded assessors. The forced vital capacity (FVC, l), forced expiratory volume in the first second (FEV1, l) and peak expiratory flow rate (PEFR, l/s) were assessed. Spirometry was performed 120 patients on the first day of admission of patients to the surgical department for surgical intervention, on the second day and on the day of discharge. Methods of mathematical statistics: arithmetic mean (M) and standard error of the mean (}m), Student's t-test were calculated, differences at p<0,05 were considered statistically significant. RESULTS: Results: It has been established that laparoscopic cholecystectomy leads to a statistically significant decrease in the parameters of respiratory function in all age categories. More pronounced positive dynamics of respiratory function in the group of respiratory therapy. It was established that without respiratory therapy on the day of discharge there was no restoration (р<0.05) in groups of elderly patients of group of FVC l, FEV1 l, PEFR l/s; in middle-aged patients did no restoration FEV1, l, PEFR, l/s; in younger patients there was no recovery of FEV1, l. CONCLUSION: Conclusions: The results of the study indicate the effectiveness of the introduction of diaphragmatic breathing exercises in combination with early mobilization at the acute and subacute stages of rehabilitation in patients after laparoscopic cholecystectomy in order to restore the function of the respiratory system.

[Expert consensus on the laparoscopic radical resection of gallbladder cancer(2023)].

The incidence of gallbladder cancer has been increasing. Radial resection is still the most promising curable treatment for patients with gallbladder cancer. Although the techniques required for laparoscopic radical resection of gallbladder cancer have matured, the number of reports is also on the rise, and laparoscopic radical resection of gallbladder cancer is still controversial. To standardize laparoscopic radical resection of gallbladder cancer, the Biliary Surgery Branch, Chinese Society of Surgery, Chinese Medical Association, together with the Chinese Medical Doctor Association in Chinese Committee of Biliary Surgeons, gathered experts to formulate recommendations and consensus on laparoscopic radical resection of gallbladder cancer. This consensus includes several parts: safety, preoperative evaluation, indications, surgical team, positioning of patient and trocars, intraoperative frozen examination, lymph node dissection, liver resection,bile duct resection, etc. Furthermore, suggestions on the principle of treatment, surgical procedures, and precautions were also provided for patients with delayed diagnoses of gallbladder cancer undergoing resection. This consensus aims to offer valuable suggestions for the standardization of laparoscopic radical resection of gallbladder cancer.

[Clinical and economic justification of icg-cholangiography in «difficult¼ laparoscopic cholecystectomy]. / Kliniko-ekonomicheskoe obosnovanie kholangiografii s indotsianinom zelenym pri «trudnoi¼ laparoskopicheskoi kholetsistektomii.

OBJECTIVE: To prove from a clinical and economic point of view the expediency of using ICG cholangiography in patients with «difficult¼ laparoscopic cholecystectomy for the prevention of damage to the bile ducts. MATERIAL AND METHODS: The results of treatment of 173 patients with cholelithiasis at various levels of health care providing were analyzed with regard to assessment of indicators of surgery complexity, developed complications and economic costs. RESULTS: The effectiveness of the original scale of «difficult¼ laparoscopic cholecystectomy has been proved. The financial and economic costs of treatment of patients with damage of biliary ducts and patients with cholelithiasis without development of complications have been analyzed and evaluated. A comparative description of financial costs for patients with «difficult¼ laparoscopic cholecystectomy with the use of ICG-cholangiography has been given. A program on care delivery for patients suffering from cholelithiasis in the conditions of region with regard to safety and economic effectiveness has been developed. CONCLUSION: The implementation of this program provides the minimization of postoperative complications and fatality at all levels of surgical care delivery. It has been established that a rational approach to reducing the number of biliary ducts damages is their prevention by prediction of «difficult¼ laparoscopic cholecystectomy and performance of such interventions in medical organizations of III level with the possibility of modern technologies use.

Modified thoracoabdominal nerves block through perichondrial approach for laparoscopic cholecystectomy.

OBJECTIVE: A new block, namely, modified thoracoabdominal nerves block through perichondrial approach, is administered below the costal cartilage. We sought to compare the analgesic efficacy of the modified thoracoabdominal nerves block through perichondrial approach block with local anesthetic infiltration at the port sites in an adult population who underwent laparoscopic cholecystectomy. METHODS: Patients who will undergo laparoscopic cholecystectomy were randomized to receive bilateral ultrasound-guided modified thoracoabdominal nerves block through perichondrial approach blocks or local anesthetic infiltration at the port insertion sites. The primary outcome was the total amount of tramadol used in the first 12 h postoperatively. The secondary outcomes were total IV tramadol consumption for the first postoperative 24 h and visual analog scale scores. RESULTS: The modified thoracoabdominal nerves block through perichondrial approach group had significantly less tramadol use in the first 12 h postoperatively (p<0.001). The modified thoracoabdominal nerves block through perichondrial approach group's visual analog scale scores at rest (static) and with movement (dynamic) were significantly lower compared with the port infiltration group (p<0.05). CONCLUSION: Patients who received modified thoracoabdominal nerves block through perichondrial approach block had significantly less analgesic consumption and better pain scores than those who received port-site injections after laparoscopic cholecystectomy.

A novel comparison of erector spinae plane block and paravertebral block in laparoscopic cholecystectomy.

OBJECTIVE: Erector spinae plane block is an updated method than paravertebral block, possessing a lower risk of complications. This study aimed to compare erector spinae plane and paravertebral blocks to safely reach the most efficacious analgesia procedure in laparoscopic cholecystectomy cases. METHODS: The study included 90 cases, aged 18-70 years, classified as American Society of Anesthesiologists I-II, who underwent an laparoscopic cholecystectomy procedure. They were randomly separated into three groups, namely, Control, erector spinae plane, and paravertebral block. No block procedure was applied to Control, and a patient-controlled analgesia device was prepared containing tramadol at a 10 mg bolus dose and a 10-min locked period. The pain scores were recorded with a visual analog scale for 24 h postoperatively. RESULTS: The visual analog scale values at 1, 5, 10, 20, and 60 min at rest and 60 min coughing were found to be significantly higher in Control than in paravertebral block. A significant difference was revealed between Control vs. paravertebral block and paravertebral block vs. erector spinae plane in terms of total tramadol consumption (p=0.006). Total tramadol consumption in the first postoperative 24 h was significantly reduced in the paravertebral block compared with the Control and erector spinae plane groups. CONCLUSION: Sonography-guided-paravertebral block provides sufficient postoperative analgesia in laparoscopic cholecystectomy surgery. Erector spinae plane seems to attenuate total tramadol consumption.

BILE DUCT INJURY REPAIR IN A PATIENT WITH SITUS INVERSUS TOTALIS.

BACKGROUND: Bile duct injury (BDI) causes significant sequelae for the patient in terms of morbidity, mortality, and long-term quality of life, and should be managed in centers with expertise. Anatomical variants may contribute to a higher risk of BDI during cholecystectomy. AIMS: To report a case of bile duct injury in a patient with situs inversus totalis. METHODS: A 42-year-old female patient with a previous history of situs inversus totalis and a BDI was initially operated on simultaneously to the lesion ten years ago by a non-specialized surgeon. She was referred to a specialized center due to recurrent episodes of cholangitis and a cholestatic laboratory pattern. Cholangioresonance revealed a severe anastomotic stricture. Due to her young age and recurrent cholangitis, she was submitted to a redo hepaticojejunostomy with the Hepp-Couinaud technique. To the best of our knowledge, this is the first report of BDI repair in a patient with situs inversus totalis. RESULTS: The previous hepaticojejunostomy was undone and remade with the Hepp-Couinaud technique high in the hilar plate with a wide opening in the hepatic confluence of the bile ducts towards the left hepatic duct. The previous Roux limb was maintained. Postoperative recovery was uneventful, the drain was removed on the seventh post-operative day, and the patient is now asymptomatic, with normal bilirubin and canalicular enzymes, and no further episodes of cholestasis or cholangitis. CONCLUSIONS: Anatomical variants may increase the difficulty of both cholecystectomy and BDI repair. BDI repair should be performed in a specialized center by formal hepato-pancreato-biliary surgeons to assure a safe perioperative management and a good long-term outcome.

[Current Status of ICG Fluorescence Navigation in Laparoscopic Liver Resection].

The indocyanine green(ICG)fluorescence navigation that we have standardized for laparoscopic liver resection is useful for partial liver resection and anatomical liver resection for liver cancer, and extended cholecystectomy for gallbladder cancer. In partial liver resection we believe that it is possible to secure a resection margin by not exposing the fluorescence emission around the tumor. In anatomical liver resection, real-time navigation becomes possible by transecting the liver at the boundary between colored and non-colored area, which contributes to precise liver surgery. In extended cholecystectomy, it is difficult to inject ICG from the cystic artery which was performed in open liver resection. So, we encircled Calot's triangle using the Glissonean approach from the ventral side of the gallbladder plate and then taped the hilar Glissonean pedicles. After clamping this tape, ICG was injected into the vein. By using this method, laparoscopic surgery has become possible in the same way as open surgery. With further spread in the future, it is hoped that liver resection using ICG fluorescence navigation will not only be precise, but also safe and highly curative surgery.

Impact of the COVID-19 pandemic on outcomes of cholecystectomy for acute cholecystitis: a national cohort study.

BACKGROUND: The COVID-19 pandemic was associated with significant disruptions to healthcare provision globally and in Aotearoa New Zealand. It remains unclear how this disruption affected the surgical management of acute cholecystitis and whether there are ongoing impacts. METHODS: We conducted a secondary analysis of two multicentre cohort studies (CHOLECOVID and CHOLENZ) on patients who underwent cholecystectomy for acute cholecystitis. Participants were categorized into pre-pandemic (September-November 2019), pandemic (March-May 2020), and late-pandemic (August-October 2021) phases. Baseline demographics, clinical management, and 30-day postoperative complications were assessed between phases. Multivariable logistic regression was used to explore the impact of timing of operation on rates of hospital readmission and postoperative complications. RESULTS: 517 participants were included, of whom 85 (16%) were in the pre-pandemic-phase, 52 (10%) were in the pandemic phase, and 380 (73%) were in the late-pandemic phase. Pandemic and late-pandemic phase participants were more comorbid and had higher rates of obesity and deranged blood results than pre-pandemic. After multivariable adjustment, there were no differences in rates of hospital readmission or postoperative complications at 30-day follow-up across phases. CONCLUSION: The COVID-19 pandemic had minimal impacts on the provision of cholecystectomy for acute cholecystitis in Aotearoa New Zealand. However, patients managed during the COVID-19 pandemic were more comorbid and had higher rates of obesity and elevated inflammatory markers.

[Can laparoscopic surgery be the preferred strategy for gallbladder cancer?]

Gallbladder cancer, notoriously known for its high malignancy, predominantly requires radical surgery as the treatment of choice. Although laparoscopic techniques have become increasingly prevalent in abdominal surgeries in recent years, the progress of laparoscopic techniques in gallbladder cancer is relatively slow. Due to the anatomical complexity, technical difficulty, and biological features of gallbladder cancer that is prone to metastasis and dissemination, traditional open surgery is still the main surgical approach. This study aims to reappraisal the current state of laparoscopic surgery for gallbladder cancer by appraising clinical practice and research evidence. Laparoscopic surgery for various stages of gallbladder cancer, including early, advanced, incidental, and unresectable gallbladder cancer were discussed. The promise and limitations of laparoscopic techniques are systematically explored.

Textbook outcome in urgent early cholecystectomy for acute calculous cholecystitis: results post hoc of the S.P.Ri.M.A.C.C study.

INTRODUCTION: A textbook outcome patient is one in which the operative course passes uneventful, without complications, readmission or mortality. There is a lack of publications in terms of TO on acute cholecystitis. OBJETIVE: The objective of this study is to analyze the achievement of TO in patients with urgent early cholecystectomy (UEC) for Acute Cholecystitis. and to identify which factors are related to achieving TO. MATERIALS AND METHODS: This is a post hoc study of the SPRiMACC study. It´s a prospective multicenter observational study run by WSES. The criteria to define TO in urgent early cholecystectomy (TOUEC) were no 30-day mortality, no 30-day postoperative complications, no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile), and full laparoscopic surgery. Patients who met all these conditions were taken as presenting a TOUEC. OUTCOMES: 1246 urgent early cholecystectomies for ACC were included. In all, 789 patients (63.3%) achieved all TOUEC parameters, while 457 (36.6%) failed to achieve one or more parameters and were considered non-TOUEC. The patients who achieved TOUEC were younger had significantly lower scores on all the risk scales analyzed. In the serological tests, TOUEC patients had lower values for in a lot of variables than non-TOUEC patients. The TOUEC group had lower rates of complicated cholecystitis. Considering operative time, a shorter duration was also associated with a higher probability of reaching TOUEC. CONCLUSION: Knowledge of the factors that influence the TOUEC can allow us to improve our results in terms of textbook outcome.

Outcomes after laparoscopic cholecystectomy in patients older than 80 years: two-years follow-up.

BACKGROUND: The laparoscopic cholecystectomy is the treatment of choice for patients with benign biliary disease. It is necessary to evaluate survival after laparoscopic cholecystectomy in patients over 80 years old to determine whether the long-term mortality rate is higher than the reported recurrence rate. If so, this age group could benefit from a more conservative approach, such as antibiotic treatment or cholecystostomy. Therefore, the aim of this study was to evaluate the factors associated with 2 years survival after laparoscopic cholecystectomy in patients over 80 years old. METHODS: We conducted a retrospective observational cohort study. We included all patients over 80 years old who underwent laparoscopic cholecystectomy. Survival analysis was conducted using the Kaplan‒Meier method. Cox regression analysis was implemented to determine potential factors associated with mortality at 24 months. RESULTS: A total of 144 patients were included in the study, of whom 37 (25.69%) died at the two-year follow-up. Survival curves were compared for different ASA groups, showing a higher proportion of survivors at two years among patients classified as ASA 1-2 at 87.50% compared to ASA 3-4 at 63.75% (p = 0.001). An ASA score of 3-4 was identified as a statistically significant factor associated with mortality, indicating a higher risk (HR: 2.71, CI95%:1.20-6.14). CONCLUSIONS: ASA 3-4 patients may benefit from conservative management due to their higher risk of mortality at 2 years and a lower probability of disease recurrence.

Comparative analysis of robotic single-site cholecystectomy outcomes between novice and expert surgeons.

Single-incision laparoscopic cholecystectomy (SILC) has declined in popularity, posing a challenge for novice surgeons. However, robotic single-site cholecystectomy (RSSC) has gained popularity in hepatopancreatic surgery, suggesting a paradigm shift in minimally invasive procedures due to the advantages of robotic platforms. The purpose of this study was to compare the surgical outcomes and learning curves between experts and novices without SILC experience, and discuss the utility and potential of RSSC for novice surgeons. A total of 235 patients underwent RSSC between April 2019 and June 2023 at the OOO University Hospital. Among them, 31 cases from novice and expert surgeons were selected to compare their initial experience. Comprehensive demographic and perioperative factors were analyzed and statistical comparisons were made, including cumulative sum analysis (CUSUM) for learning curves. The demographic factors showed no statistically significant differences between the two groups. Although the docking time (P < 0.001) and hospital stay (P = 0.014) were statistically significant, the total operative time and other perioperative factors were comparable. Novice surgeons demonstrated a shorter absolute total operative time, primarily attributed to differences in docking time. The CUSUM analysis indicated a shorter learning curve for novice surgeons. This study shows that the inherent benefits of the robotic platform make it an accessible and reproducible technique for novices. The benefits of integrating observational learning into robotic surgery training programs and the intrinsic advantages of the robotic platform in minimizing the learning curve for RSSC were also highlighted.

Early Versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis: A Single Center Experience.

Introduction: Acute cholecystitis (AC) represents a public health problem, increasing hospitalization costs, especially determined by the surgical treatment of these patients. Laparoscopic cholecystectomy (LC) has become the therapeutic gold standard, the timing of the intervention: early (ELC) versus late (DLC), is still debated, impacting the results. The primary objective of the study was to compare postoperative outcomes between ELC and DLC. Secondary objectives assessed surgical outcomes from the pre-pandemic period with those from the Covid-19 pandemic. Material and methods: A retrospective observational study is presented of 266 patients diagnosed with AC who were admitted to Clinic I of General Surgery, County Emergency Clinical Hospital of T #226;rgu Mure #351;, from 2018 to 2022. They were classified into the ELC group ( 72 hours from the onset of symptoms) and DLC ( 72 hours from symptom onset) and were further stratified into prepandemic and pandemic cohorts. Data on clinical symptoms, paraclinical data, surgical details, and postoperative course were collected and analyzed. Discussion: The results confirm fewer conversions to open surgery and reduced hospitalization in the ELC group. The pandemic did not significantly alter the timing of surgeries or patient demographics. Conclusion: In conclusion, ELC for AC patients offers significant advantages, justifying its preference over DLC Despite the decrease in the incidence of AC hospitalizations during the pandemic, postoperative outcomes are comparable to those in the pre-pandemic period. Future multicenter studies are recommended for a broader analysis of the efficacy of laparoscopic surgery in emergency settings.

How I Do It: Robotic Choledochoscopy.

BACKGROUND: As the use of the robotic platform increases among general surgeons, the amount of robotic cholecystectomies is expected to increase as well. The use of intraoperative cholangiography is valuable in assessing for choledocholithiasis. We describe our technique of performing robotic intraoperative cholangiograms with choledochoscopy. Out technique aids in efficiency since no undocking is required. METHODS: Preoperatively, the decision to perform a cholangiogram is made based on physical exam, labs, and imaging findings. The procedure begins with obtaining a critical view of safety. The robotic arms are positioned in a manner that allows all 4 robotic arms to remain docked. A ductotomy is made and the cholangiocatheter is introduced. The cholangiogram images are then interpreted and if a stone is seen in the common bile duct we will then perform a transcystic common bile duct exploration using the SpyGlass Discover digital. A complete cholangiogram is then performed. The cystic duct is secured and the gallbladder is removed from the liver bed. The patients are watched overnight and discharged on postoperative day 1. CONCLUSIONS: A robotic approach to performing a transcystic common bile duct exploration is a safe and reproducible treatment method for choledocholithiasis. Our approach offers an advantage since no undocking is required.

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.

Curative surgical treatment of common bile duct stones: Retrospective cohort study.

BACKGROUND: In the event of symptomatic common bile duct (CBD) stones with dilated CBD, one possible curative treatment option is stone extraction through choledocotomy associated with cholecystectomy. Endoscopic treatment is only reserved for residual stones at 6 weeks. The aim of this study was to evaluate the results from laparoscopic curative surgical treatment of CBD stones with dilated CBD. METHODS: This is a retrospective single-centered cohort study. All consecutive patients admitted for laparoscopic cholecystectomy with evidence of CBD stones with dilated CBD from January 2010 to December 2020 at our center were included. Success was defined by CBD clearance at 6 weeks. Need for additional procedures, such as endoscopic sphincterotomy, immediate, and end-of-procedure morbi-mortality as well as factors associated with procedure failure, were also studied. RESULTS: A total of 246 patients who received curative treatment were included in the study. The success rate for the curative treatment was 93.1% (229 patients). Immediate postoperative morbidity was 24.4% with a 5.3% reintervention rate. Immediate and 6-week postoperative mortality rates were zero and 0.4%, respectively. The mean length of stay was 11.3 days. Factors associated with procedure failure appeared to be the occurrence of an early postoperative complication and the need for readmission during the period between surgery and drain removal. CONCLUSION: This study indicates that laparoscopic curative surgical treatment for symptomatic CBD stones may be performed with acceptable results without routine need for additional procedures.

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.

Elective Cholecystectomy After Endoscopic Gallbladder Stenting for Acute Cholecystitis: A Propensity Score Matching Analysis.

OBJECTIVE: To investigate the influence of endoscopic gallbladder stenting (EGBS) on subsequent cholecystectomy. We retrospectively compared the surgical outcomes of EGBS, followed by elective cholecystectomy with those of immediate cholecystectomy (IC). PATIENTS AND METHODS: A total of 503 patients were included in this study. Patients who underwent EGBS as initial treatment for acute cholecystitis, followed by elective cholecystectomy, were included in the EGBS group and patients who underwent IC during hospitalization were included in the IC group. Propensity score matching analysis was used to compare the surgical outcomes. In addition, the factors that increased the amount of bleeding were examined by multivariate analysis after matching. RESULTS: Fifty-seven matched pairs were obtained after propensity matching the EGBS group and the IC group. The rate of laparoscopic cholecystectomy in the EGBS versus IC groups was 91.2% versus 49.1% ( P < 0.001). The amount of bleeding was 5 mL in the EGBS versus 188 mL in the IC group ( P < 0.001). In the EGBS and IC groups, multivariate analysis of factors associated with more blood loss revealed IC (odds ratio: 4.76, 95% CI: 1.25-20.76, P = 0.022) as an independent risk factor. CONCLUSION: EGBS as the initial treatment for acute cholecystitis and subsequent elective cholecystectomy after the inflammation has disappeared can be performed in minimally invasive procedures and safely.

Active gas aspiration in reducing pain after laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Postoperative pain is a common issue following laparoscopic cholecystectomy. This meta-analysis aimed to determine if active gas aspiration is more effective than passive gas aspiration in reducing postoperative pain and analgesic requirements. METHODOLOGY: The study conducted a systematic search of various databases, including Embase, Medline, and Cochrane Central Register of Controlled Trials (CENTRAL) via Ovid. It also searched trial registries and reference lists of included studies, with no date restrictions but limited to English language, up to December 21, 2022. The study included all randomized clinical trials that had documented elective laparoscopic cholecystectomy procedure and reported at least one relevant outcome. Articles that included subdiaphragmatic drain, intraperitoneal normal saline infusion, or pulmonary recruitment maneuver were excluded from the analysis. Two reviewers independently and in duplicate assessed the eligibility of studies and extracted data. The study reported findings according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The risk of bias of the included trials was assessed using the Revised Cochrane Risk of Bias Assessment Tool. The study used a random-effects model to pool data. RESULTS: This meta-analysis included 5 randomized clinical trials with 367 participants and found that active gas aspiration resulted in significantly lower residual gas volume and total analgesia requirements compared to passive gas aspiration. Active gas aspiration also led to significantly lower shoulder pain scores at 24 h postoperatively. However, no significant differences were observed in hospital stay duration or abdominal pain scores. CONCLUSION: The study found that active gas aspiration can be effective in reducing postoperative shoulder pain and analgesic requirements after laparoscopic cholecystectomy, which has important implications for patient care and healthcare costs. Importantly, this intervention does not impose any additional time or financial burden. However, further research is needed to evaluate its impact on other laparoscopic procedures.