Gallstones as a cause in presumed acute alcoholic pancreatitis: observational multicentre study.

BACKGROUND: Data on the incidence and clinical relevance of gallstones in patients with suspected acute alcoholic pancreatitis are lacking and are essential to minimize the risk of recurrent acute pancreatitis. The aim of this study was to assess the incidence of gallstones and the associated rate of recurrent acute pancreatitis in patients with presumed acute alcoholic pancreatitis. METHODS: Between 2008 and 2019, 23 hospitals prospectively enrolled patients with acute pancreatitis. Those diagnosed with their first episode of presumed acute alcoholic pancreatitis were included in this study. The term gallstones was used to describe the presence of cholelithiasis or biliary sludge found during imaging. The primary outcome was pancreatitis recurrence during 3 years of follow-up. RESULTS: A total of 334 patients were eligible for inclusion, of whom 316 were included in the follow-up analysis. Gallstone evaluation, either during the index admission or during follow-up, was performed for 306 of 334 patients (91.6%). Gallstones were detected in 54 patients (17.6%), with a median time to detection of 6 (interquartile range 0-42) weeks. During follow-up, recurrent acute pancreatitis occurred in 121 of 316 patients (38.3%), with a significantly higher incidence rate for patients with gallstones compared with patients without gallstones (59% versus 34.2% respectively; P < 0.001), while more patients with gallstones had stopped drinking alcohol at the time of their first recurrence (41% versus 24% respectively; P = 0.020). Cholecystectomy was performed for 19 patients with gallstones (36%). The recurrence rate was lower for patients in the cholecystectomy group compared with patients who did receive inadequate treatment or no treatment (5/19 versus 19/34 respectively; P = 0.038). CONCLUSION: Gallstones were found in almost one in every five patients diagnosed with acute alcoholic pancreatitis. Gallstones were associated with a higher rate of recurrent pancreatitis, while undergoing cholecystectomy was associated with a reduction in this rate.

Simultaneous cholecystectomy for asymptomatic gallstones during elective colorectal cancer surgery.

BACKGROUND: Asymptomatic gallstones are commonly detected using preoperative imaging in patients with colorectal cancer (CRC), but its management remains a topic of debate. METHODS: Clinicopathologic characteristics of patients who had asymptomatic gallstones presenting during the colorectal procedure were retrospectively reviewed. Medical records, including postoperative morbidity, mortality, and long-term gallstone-related diseases, were assessed. RESULTS: Of 134 patients with CRC having asymptomatic gallstones, 89 underwent elective colorectal surgery only (observation group), and 45 underwent elective colorectal surgery with simultaneous cholecystectomy (cholecystectomy group). After propensity score matching (PSM), the complications were similar in the 2 groups. During the follow-up period, biliary complications were noted in 11 patients (12.4%) in the observation group within 2 years after the initial CRC surgery, but no case was found in the cholecystectomy group. After PSM, the incidence of long-term biliary complications remained significantly higher in the observation group than in the cholecystectomy group (26.5% vs 0.0%; P < .01). Multivariable logistic regression analysis identified female gender, old age (≥65 years old), and small multiple gallstones as independent risk factors for the development of long-term gallstone-related diseases in patients from the observation group. CONCLUSION: Simultaneous prophylactic cholecystectomy during prepared, elective CRC surgery did not increase postoperative morbidity or mortality but decreased the risk of subsequent gallstone-related complications. Hence, simultaneous cholecystectomy might be a preferred therapeutic option for patients with CRC having asymptomatic gallstones in cases of elective surgery, especially for older patients (≥65 years old), female patients, and those with small multiple calculi.

Erector spinae plane block as a rescue therapy in following cholecystectomy: a historical cohort study.

OBJECTIVE: The aim of this study is to evaluate the effect of erector spinae plane block (ESPB) as a rescue therapy in the recovery room. MATERIALS AND METHODS: This single-center historical cohort study included patients who received either ESPB or intravenous meperidine for pain management in the recovery room. Patients' numeric rating scale (NRS) scores and opoid consumptions were evaluated. RESULTS: One hundred and eight patients were included in the statistical analysis. Sixty-two (57%) patients received ESPB postoperatively (pESPB) and 46 (43%) patients were managed with IV meperidine boluses only (IV). The cumulative meperidine doses administered were 0 (0-40) and 30 (10-80) mg for the pESPB and IV groups, respectively (p < 0.001). NRS scores of group pESPB were significantly lower than those of Group IV on T30 and T60. CONCLUSION: ESPB reduces the frequency of opioid administration and the amount of opioids administered in the early post-operative period. When post-operative rescue therapy is required, it should be considered before opioids.

OBJETIVO: Evaluar el efecto del bloqueo del plano erector espinal (ESPB) como terapia de rescate en la sala de recuperación. MÉTODO: Este estudio de cohortes histórico de un solo centro incluyó a pacientes que recibieron ESPB o meperidina intravenosa para el tratamiento del dolor en la sala de recuperación. Se evaluaron las puntuaciones de la escala de calificación numérica (NRS) de los pacientes y los consumos de opiáceos. RESULTADOS: En el análisis estadístico se incluyeron 108 pacientes. Recibieron ESPB 62 (57%) pacientes y los otros 46 (43%) fueron manejados solo con bolos de meperidina intravenosa. Las dosis acumuladas de meperidina administradas fueron 0 (0-40) y 30 (10-80) mg para los grupos de ESPB y de meperidina sola, respectivamente (p < 0.001). Las puntuaciones de dolor del grupo ESPB fueron significativamente más bajas que las del grupo de meperidina sola en T30 y T60. CONCLUSIONES: El ESPB reduce la frecuencia de administración de opiáceos y la cantidad de estos administrada en el posoperatorio temprano. Cuando se requiera terapia de rescate posoperatoria, se debe considerar antes que los opiáceos.

Determining the patency of biliary tracts in dogs with gallbladder mucocele using near-infrared cholangiography with indocyanine green.

Cholecystectomy is indicated for gallbladder mucoceles (GBM). Evaluating the patency of the biliary duct and precise biliary tree visualization is crucial for reducing the risk of compromised bile flow after surgery. Therefore, intraoperative cholangiography (IOC) is recommended during cholecystectomy to prevent biliary tract injury. Although indocyanine green (ICG) cholangiography has been extensively reported in human medicine, only one study has been conducted in veterinary medicine. Therefore, this study aimed to demonstrate the use of ICG for IOC to identify fluorescent biliary tract images and determine the patency of the common bile duct during cholecystectomy in dogs. This study comprised 27 dogs, consisting of 17 with gallbladder mucoceles (GBM) and 10 controls, specifically including dogs that had undergone elective cholecystectomy for GBM. ICG injection (0.25 mg/kg) was administered intravenously at least 45 minutes before surgery. During the operation, fluorescent images from cholangiography were displayed on the monitor and obtained in black-and-white mode for the comparison of fluorescence intensity (FI). The FI values of the gallbladders (GBs) and common bile duct (CBD) were measured using FI analyzing software (MGViewer V1.1.1, MetapleBio Inc.). The results demonstrated successful CBD patency identification in all cases. Mobile GBM showed partial gallbladder visibility, whereas immobile GBM showed limited visibility. Additionally, insights into the adequate visualization of the remaining extrahepatic biliary tree anatomy were provided, extending beyond the assessment of CBD patency and gallbladder intensity. Our study demonstrates the potential of fluorescent IOC using intravenous injection of ICG for assessing the patency of the cystic duct and common bile duct during cholecystectomy in patients with GBM, eliminating the need for surgical catheterization and flushing of the biliary ducts. Further research is warranted to investigate and validate the broader applicability of ICG cholangiography in veterinary medicine.

Efficacy and safety of Chinese herbal medicine in treating postcholecystectomy diarrhea: A systematic review and meta-analysis.

BACKGROUND: Postcholecystectomy diarrhea (PCD) is among the most distressing and well-known clinical complications of cholecystectomy. Despite various available treatment options, clinical outcomes are greatly limited by unclear pathophysiological mechanisms. Chinese herbal medicine (CHM) is widely used as a complementary and alternative therapy for the treatment of functional diarrhea. Thus, we conducted a meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of CHM for the treatment of PCD. METHODS: Electronic database searches were conducted using the Cochrane Library, PubMed, Web of Science, Embase, Wanfang Data, China National Knowledge Infrastructure, and the Chinese Scientific Journal Database. All RCTs on CHMs for managing patients with PCD were included. The meta-analysis was performed using RevMan 5.4 software. RESULTS: The present meta-analysis included 14 RCTs published between 2009 and 2021 in China. The primary findings indicated that CHM had a higher total efficacy and cure rate as a monotherapy for PCD (P < .00001). Two trials reported the scores of the main symptoms with statistically significant differences in stool nature (P < .00001), defecation frequency (P = .002), and abdominal pain and bloating (P < .00001). In addition, CHM reduced CD3+ and CD4+ levels more effectively in terms of T lymphocyte subset determination (P < .00001). The main symptoms of PCD in traditional Chinese medicine (TCM) are splenic deficiency and liver stagnation. All treatments were used to strengthen the spleen and (or) soothing the liver. CONCLUSION: CHM had a favorable effect on PCD. No adverse events were observed. Larger, high-quality RCTs are warranted to draw definitive conclusions and standardize treatment protocols.

Combined cholecystotomy, retrograde hydropulsion, and choledochal stenting to treat extrahepatic biliary tract obstruction in 3 cats.

Extrahepatic biliary tract obstruction (EHBO) is uncommonly encountered in cats. Surgical treatment aims to decompress the biliary tract and insure bile duct patency. In veterinary medicine, cholecystotomy is not widely used in practice. The objective was to describe the use of cholecystotomy, retrograde hydropulsion of choleliths, and choledochal stenting to remove choleliths from the extrahepatic biliary tract back in the gallbladder. Three adult domestic shorthair cats were presented with anorexia, lethargy, and vomiting. Serum biochemistry revealed hyperbilirubinemia and increased hepatic enzymes. Abdominal ultrasonography showed evidence of EHBO requiring surgical intervention. Choleliths were localized in the proximal and middle portions of the common bile duct (CBD) in the first case, in the distal portion of the CBD and within the major duodenal papilla in the second case, and in the middle and distal portions of the CBD in the third case. Cholecystotomy was followed by retrograde hydropulsion of the choleliths into the gallbladder, after which choledochal stenting was performed. Complications were defined as major when requiring additional medical or surgical treatment, or minor when not. Three major complications were reported. In 2 cases, severe anemia requiring blood transfusion occurred 24 h postoperatively; in 1 case, EHBO recurrence was encountered 41 d postoperatively. All cats were discharged within 4 d following surgery. Two cats were still alive at 12 and 14 mo after surgery, respectively. In the last case, owners refused revision surgery and the cat was euthanized. Key clinical message: Cholecystotomy combined with retrograde hydropulsion of choleliths permitted removal of choleliths and decompression of the biliary tract in 3 cats. Major complications included severe anemia and EHBO recurrence.

Cholécystotomie combinée, hydropulsion rétrograde et pose de stent cholédocien pour traiter l'obstruction des voies biliaires extra-hépatiques chez 3 chats. Les obstructions biliaires extra-hépatiques (OBEH) sont peu fréquentes chez le chat. Le traitement chirurgical vise à lever l'obstruction et s'assurer de la perméabilité des voies biliaires. En médecine vétérinaire, la cholécystotomie est une technique peu pratiquée. L'objectif de ce rapport de cas était de décrire l'utilisation de la cholécystotomie, de l'hydropulsion rétrograde des cholélithes et d'une prothèse endoluminale cholédoquale (PEC) pour repousser les cholélithes présents dans les voies biliaires extrahépatiques dans la vésicule biliaire (VB).Trois chats européens adultes ont été présentés pour anorexie, léthargie et vomissements. La biochimie sérique a révélé une hyperbilirubinémie et une augmentation des enzymes hépatiques. L'échographie abdominale a mis en évidence une OBEH nécessitant une intervention chirurgicale. Les cholélithes étaient situés dans la portion proximale et moyenne du canal cholédoque pour le premier cas; dans la portion distale et la papille duodénale majeure dans le second cas; dans la portion moyenne et distale pour le troisième cas. Une cholécystotomie a été suivie d'une rétro-hydropulsion des cholélithes dans la VB, puis une PEC a été placée. Les complications ont été définies comme majeures lorsqu'elles nécessitaient un traitement médical ou chirurgical supplémentaire, ou mineures lorsqu'elles n'en nécessitaient pas.Trois complications majeures ont été rapportées : chez 2 cas, une anémie sévère a été observée 24 h après l'intervention, nécessitant une transfusion sanguine; chez un cas, une récidive d'obstruction biliaire a eu lieu à 41 jours postopératoire. Tous les patients sont sortis de l'hôpital dans les 4 jours suivant l'opération. Deux cas étaient encore en vie 12 et 14 mois après l'intervention. Pour le dernier cas, la seconde chirurgie a été refusée par les propriétaires et le chat a été euthanasié.Message clinique clé :La cholécystotomie combinée à l'hydropulsion rétrograde des cholélithes a permis le retrait de cholélithes obstructives (dont certaines distales) et la décompression du tractus biliaire chez 3 chats. Les complications majeures incluaient une anémie sévère et une récidive d'obstruction biliaire.(Traduit par les auteurs).

Acute pancreatitis in children and adolescents: diagnostic and therapeutic approach according to management guidelines in a group of pediatricians.

BACKGROUND: Acute pancreatitis is observed more frequently in the pediatric age. Currently, there are recommendation guidelines for its proper diagnosis and treatment. The objective of this study was to evaluate the level of knowledge of the international recommendations on acute pancreatitis in pediatrics of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition in a group of pediatricians. METHODS: Observational, multicenter study, through a survey applied to pediatricians and pediatric residents. RESULTS: 48.8% of physicians had prior knowledge of the guidelines for the treatment of acute pancreatitis in children. 72.4% knew the current criteria for the diagnosis of acute pancreatitis. There were no differences in the majority of responses between pediatricians and pediatric residents. CONCLUSIONS: Although only half of the respondents followed the guidelines for diagnosis and treatment of acute pancreatitis, about three-quarters adequately use the criteria for diagnosis. There is adequate knowledge about the prescription of antibiotics and pancreatitis follow-up. There is lack of knowledge on the recommendation of monitoring vital signs and the precise time to perform cholecystectomy in the pancreatitis of biliary origin.

INTRODUCCIÓN: La pancreatitis aguda se observa con mayor frecuencia en la edad pediátrica. Actualmente existen guías de recomendaciones para su adecuado diagnóstico y tratamiento. El objetivo de este estudio fue evaluar el nivel de conocimiento de las recomendaciones internacionales sobre pancreatitis aguda de la North American Society for Pediatric Gastroenterology, Hepatology and Nutrition en un grupo de pediatras. MÉTODOS: Estudio observacional, multicéntrico, mediante una encuesta aplicada a médicos pediatras y médicos pediatras en formación. RESULTADOS: El 48.8% de los médicos tenían conocimiento de las guías para tratamiento de pancreatitis aguda en niños. El 72.4% conocían los criterios actuales para el diagnóstico de pancreatitis aguda. No hubo diferencias en la mayoría de las respuestas entre médicos pediatras y médicos pediatras en formación. CONCLUSIONES: Aunque solo la mitad de los encuestados conocían la guía para el diagnóstico y el tratamiento de la pancreatitis aguda, cerca de tres cuartas partes utilizan adecuadamente los criterios para el diagnóstico. Existe adecuado conocimiento sobre la prescripción de antibióticos y el seguimiento posterior a la pancreatitis aguda. Hay déficit en el conocimiento sobre las recomendaciones de la monitorización de los signos vitales y el momento adecuado para realizar la colecistectomía ante una pancreatitis de origen biliar.

Patient-reported Outcome Measure (PROM) Rand-36-item Health Survey for Gallstone Disease Patients Five Years Following Surgery: A Prospective Randomized Study.

BACKGROUND/AIM: There are no studies assessing the long-term quality of life (QoL) following three-dimensional laparoscopy cholecystectomy (3D-LC) in patients with cholelithiasis (Chole). PATIENTS AND METHODS: A cohort of 200 patients with Chole were randomized into 3D-LC or minilaparotomy cholecystectomy (MC) groups. RAND-36 survey was performed before randomization, four weeks and five years postoperatively. RESULTS: Similar postoperative five years RAND-36 scores were reported in the 3D-LC and MC groups. The MC and 3D-LC groups combined analysis, social functioning (SF, p=0.007), mental health (MH, p=0.001), role physical (RP, p<0.001) and bodily pain (BP, p<0.001) domains increased significantly. In comparison to the Finnish reference RAND-36 (FRR) scores, the scores at five years increased significantly in the MH domain, while four RAND-36 domains; Physical functioning (PF), general health (GH), RP, BP remained significantly lower in comparison to the FRR scores. CONCLUSION: A relatively similar long-term outcome in the 3D-LC and MC patients is shown. Interestingly, five RAND-36 domains increased during five years follow-up, while four RAND-36 domains remained lower than FRR scores, which may indicate onset of possible new symptoms following cholecystectomy in long-term follow-up.

Prophylactic Cholecystectomy is Safe in Patients Undergoing Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND: While cholecystectomy is one of the most common operations performed in the United States, there is a continued debate regarding its prophylactic role in elective surgery. Particularly among patients with peritoneal carcinomatosis who undergo cytoreduction surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), further abdominal operations may pose increasing morbidity due to intraabdominal adhesions and potential recurrence. This bi-institutional retrospective study aims to assess postoperative morbidity associated with prophylactic cholecystectomy at the time of CRS-HIPEC. METHODS: We performed a bi-institutional retrospective analysis of 578 patients who underwent CRS-HIPEC from 2011 to 2021. Postoperative outcomes among patients who underwent prophylactic cholecystectomy at the time of CRS-HIPEC were compared to patients who did not, particularly rate of bile leak, hospital length of stay, rate of Clavien-Dindo classification morbidity grade III or greater, and number of hospital re-admissions within 30 days. RESULTS: Of the 535 patients available for analysis, 206 patients (38.3%) underwent a prophylactic cholecystectomy. Of the 3 bile leaks (1.5%) that occurred among patients who underwent prophylactic cholecystectomy, all 3 occurred in patients who underwent a concomitant liver resection. There were no significant differences in hospital length of stay, postoperative morbidity, and number of hospital re-admissions among patients who underwent prophylactic cholecystectomy compared to those who did not. CONCLUSION: Prophylactic cholecystectomy in patients undergoing CRS-HIPEC is not associated with increased morbidity or increased bile leak risk compared to historical data. While the benefits of prophylactic cholecystectomy are not yet elucidated, it may be considered to avoid potential future morbid operations for biliary disease.

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.

Standardizing process in acute biliary disease.

INTRODUCTION: The perioperative management of biliary disease (BD) is variable across institutions with suboptimal outcomes for patients and health care systems. This results in inefficient utilization of limited resources. The aim of the current study was to identify modifiable factors impacting patients' time to theater, intraoperative time, and time to discharge as the constituents of length of stay to guide creation of a perioperative management protocol to address this variability. METHODS: Data were prospectively captured at Christchurch Hospital for all adult patients presenting for cholecystectomy between May 2015 and May 2022. Pre, post, and intraoperative factors were assessed for their impact on time to theater, operative time, and postoperative hours to discharge. RESULTS: Four thousand five hundred seventy-seven patients underwent cholecystectomy during the study period, of which 2807 (61%) were acute presentations and made up the cohort for analysis. Time to theater was significantly impacted by preoperative imaging type, while operative grade and the procedure type had the most clinically significant impact on operative time. Postoperatively time to discharge was significantly impacted by drain placement. CONCLUSIONS: Standardizing management of BD would likely result in significant savings for the health care system and improved outcomes for patients. The data seen here evidence the importance of appropriate imaging selection, intraoperative difficulty operative grade identification, and low suction drain selection. These data have been incorporated in a perioperative management protocol as standardization of care across the patient workflow in BD is a sensible approach for ensuring optimal use of scarce resources.

Prediction of neoplastic gallbladder polyps in patients with different age level based on preoperative ultrasound: a multi-center retrospective real-world study.

BACKGROUND: The prevalence of neoplastic polyps in gallbladder polyps (GPs) increases sharply with age and is associated with gallbladder carcinoma (GBC). This study aims to predict neoplastic polyps and provide appropriate treatment strategies based on preoperative ultrasound features in patients with different age level. METHODS: According to the age classification of WHO, 1523 patients with GPs who underwent cholecystectomy from January 2015 to December 2019 at 11 tertiary hospitals in China were divided into young adults group (n=622), middle-aged group (n=665) and elderly group (n=236). Linear scoring models were established based on independent risk variables screened by the Logistic regression model in different age groups. The area under ROC (AUC) to evaluate the predictive ability of linear scoring models, long- and short- diameter of GPs. RESULTS: Independent risk factors for neoplastic polyps included the number of polyps, polyp size (long diameter), and fundus in the young adults and elderly groups, while the number of polyps, polyp size (long diameter), and polyp size (short diameter) in the middle-aged groups. In different age groups, the AUCs of its linear scoring model were higher than the AUCs of the long- and short- diameter of GPs for differentiating neoplastic and non-neoplastic polyps (all P<0.05), and Hosmer-Lemeshow goodness of fit test showed that the prediction accuracy of the linear scoring models was higher than the long- and short- diameter of GPs (all P>0.05). CONCLUSION: The linear scoring models of the young adults, middle-aged and elderly groups can effectively distinguish neoplastic polyps from non-neoplastic polyps based on preoperative ultrasound features.

Improving early cholecystectomy rate in acute cholecystitis with an evidence-based local multidisciplinary protocol and a surgical audit: single-center experience through an Acute Care Surgery Division.

PURPOSE: To analyze if, after implementation of an evidence-based local multidisciplinary protocol for acute cholecystitis (AC), an intermediate surgical audit could improve early cholecystectomy (EC) rate and other therapeutic indicators. METHODS: Longitudinal cohort study at a tertiary center. The local protocol, promoted, created, and periodically revised by the Acute Care Surgery Unit (ACSu) was updated and approved on March 2019. A specific registry was prospectively fulfilled with demographics, comorbidity, type of presentation, diagnostic items, therapeutic decision, and clinical course, considering both non-operative management (NOM) or cholecystectomy, early and delayed (EC and DC). Phase 1: April 2019-April 2021. A critical analysis and a surgical audit with the participation of all the involved Departments were then performed, especially focusing on improving global EC rate, considered primary outcome. Phase 2: May 2021-May 2023. Software SPSS 23.0 was used to compare data between phases. RESULTS: Initial EC rate was significantly higher on Phase 2 (39.3%vs52.5%, p < 0.004), as a significantly inferior rate of patients were initially bailed out from EC to NOM because of comorbidity (14.4%vs8%, p < 0.02) and grade II with severe inflammatory signs (7%vs3%, p < 0.04). A higher percentage of patients was recovered for EC after an initial decision of NOM on Phase 2, but without reaching statistical significance (21.8%vs29.2%, n.s.). Global EC rate significantly increased between phases (52.5%vs66.3%, p < 0.002) without increasing morbidity and mortality. A significant minor percentage of elective cholecystectomies after AC episodes had to be performed on Phase 2 (14%vs6.7%, p < 0.009). Complex EC and those indicated after readmission or NOM failure were usually performed by the ACSu staff. CONCLUSION: To adequately follow up the implementation of a local protocol for AC healthcare, registering and periodically analyzing data allow to perform intermediate surgical audits, useful to improve therapeutic indicators, especially EC rate. AC constitutes an ideal model to work with an ACSu.

Robotic management of primary cholecystoduodenal fistula: A case report and brief literature review.

BACKGROUND: Cholecystoduodenal fistula (CDF) arises from persistent biliary tree disorders, causing fusion between the gallbladder and duodenum. Initially, open resection was common until laparoscopic fistula closure gained popularity. However, complexities within the gallbladder fossa yielded inconsistent outcomes. Advanced imaging and robotic surgery now enhance precision and detection. METHOD: A 62-year-old woman with chronic cholangitis attributed to cholecystoduodenal fistula underwent successful robotic cholecystectomy and fistula closure. RESULTS: Postoperatively, the symptoms subsided with no complications during the robotic procedure. Existing studies report favourable outcomes for robotic cholecystectomy and fistula closure. CONCLUSIONS: Our case report showcases a rare instance of successful robotic cholecystectomy with CDF closure. This case, along with a review of previous cases, suggests the potential of robotic surgery as the preferred approach, especially for patients anticipated to face significant laparoscopic morbidity.

Initial experience of a single surgeon for safety and feasibility of the Versius Robotic System in robot-assisted cholecystectomy and hernia repair.

This study aimed to evaluate the feasibility, safety, and perioperative outcomes of cholecystectomy and hernia repair performed with the Versius Robotic System by a surgeon with no prior robotic surgery experience. A retrospective analysis was conducted on adult patients who underwent cholecystectomy, inguinal, or umbilical hernia repair using the Versius Robotic System between August 2021 and June 2023 et al. Zahra Hospital, Dubai, UAE. A total of 105 patients (mean age 38.9 ± 9.2 years) were included. Significant correlations existed between the number of robot-assisted cholecystectomies and the operative metrics. As the number increased, the duration of the total operative (r = - 0.755, p < 0.001), docking (r = - 0.683, p < 0.001), and console (r = - 0.711, p < 0.001) times decreased, indicating improved efficiency with experience. This study demonstrates the safety and feasibility of the Versius Robotic System for cholecystectomy and hernia repair, even for surgeons lacking prior robotic surgery experience.

[Cystic duct carcinoma in a patient with a history of cholecystectomy: a case report].

An 83-year-old Japanese man who underwent cholecystectomy for cholecystolithiasis 17 years ago visited our hospital owing to epigastric pain. He was initially diagnosed with choledocholithiasis and acute cholangitis following white blood cell, C-reactive protein, total bilirubin, alkaline phosphatase, and γ-glutamyltranspeptidase level elevations along with common bile duct stones on computed tomography (CT). Moreover, CT, magnetic resonance imaging, endoscopic retrograde cholangiography (ERC), and endoscopic ultrasonography (EUS) also revealed a 2-cm-diameter mass arising from the remnant cystic duct. The cytology of the bile at the time of ERC was not conclusive. However, EUS-assisted fine needle aspiration (EUS-FNA) of the mass confirmed the diagnosis of adenocarcinoma of the remnant cystic duct. The patient underwent extrahepatic bile duct resection. Cystic duct carcinoma following cholecystectomy is rare. We report a case diagnosed by EUS-FNA.

Three-arm robotic cholecystectomy: a novel, cost-effective method of delivering and learning robotic surgery in upper GI surgery.

Cholecystectomy is one of the commonest performed surgeries worldwide. With the introduction of robotic surgery, the numbers of robot-assisted cholecystectomies has risen over the past decade. Despite the proven use of this procedure as a training operation for those surgeons adopting robotics, the consumable cost of routine robotic cholecystectomy can be difficult to justify in the absence of evidence favouring or disputing this approach. Here, we describe a novel method for performing a robot-assisted cholecystectomy using a "three-arm" technique on the newer, 4th generation, da Vinci system. Whilst maintaining the ability to perform precision dissection, this method reduces the consumable cost by 46%. The initial series of 109 procedures proves this procedure to be safe, feasible, trainable and time efficient.

Asociación entre metaplasia, displasia y cáncer de vesícula biliar en una EPS de Bogotá, Colombia / Association between metaplasia, dysplasia and gallbladder cancer in an EPS in Bogotá, Colombia

Introducción. El cáncer de vesícula biliar es el más común en el tracto biliopancreático y una importante causa de mortalidad. La metaplasia y la displasia han sido mencionados como probables precursores relacionados con la secuencia metaplasia-displasia-cáncer. El objetivo de este estudio fue establecer las posibles asociaciones entre estas alteraciones histopatológicas y su relación con la edad y el sexo de los pacientes. Métodos. Estudio observacional retrospectivo descriptivo, con un componente analítico de corte transversal. Se incluyeron los informes de patología de pacientes llevados a colecistectomía laparoscópica electiva y ambulatoria, entre enero de 2015 y diciembre de 2020, con colecistitis crónica, colelitiasis o pólipos vesiculares, mayores de 18 años. Se describieron las características demográficas por sexo y edad utilizando medias, desviaciones estándar y porcentajes. Se emplearon la prueba de chi cuadrado y la prueba exacta de Fisher para evaluar la asociación entre las variables cualitativas. Resultados. Se incluyeron 4871 informes de patología. En esta cohorte se encontró asociación estadísticamente significativa entre metaplasia, displasia y cáncer de vesícula (p<0,05), al igual que con el sexo y la edad de los pacientes. Conclusiones. Los resultados sugieren una asociación entre metaplasia, displasia y cáncer de vesícula biliar en la población estudiada. Se recomienda la realización de investigaciones complementarias para definir la posible causalidad entre metaplasia, displasia y cáncer de vesícula biliar en una población más heterogénea.

Introduction. Gallbladder cancer is the most common cancer in the biliopancreatic tract and an important cause of mortality. Metaplasia and dysplasia have been mentioned as probable precursors related to the metaplasia-dysplasia-cancer sequence. The objective of this study was to establish the possible associations between these histopathological alterations and their relationship with the age and sex of the patients. Methods. Descriptive retrospective observational study, with a cross-sectional analytical component. Pathology reports of patients undergoing elective and outpatient laparoscopic cholecystectomy were included between January 2015 and December 2020, with chronic cholecystitis, cholelithiasis, or gallbladder polyps, over 18 years of age. Demographic characteristics by sex and age was performed using means, standard deviations, and percentages. The chi2 test and Fisher's exact test were used to evaluate the association between the qualitative variables. Results. 4871 pathology reports were included. In this cohort, a statistically significant association was found between metaplasia, dysplasia, and gallbladder cancer (p<0.05), as well as with the sex and age of the patients. Conclusions. The results suggest an association between metaplasia, dysplasia and gallbladder cancer in the study population. Additional research is recommended to define the possible causality between metaplasia, dysplasia, and gallbladder cancer in a more heterogeneous population.

Laparoscopic-Assisted Transvaginal Cholecystectomy - the US Military Experience With Long-Term Follow Up.

Objectives: We present our initial clinical experience applying Natural Orifice Transluminal Endoscopic Surgical (NOTES) technique to perform cholecystectomy in ten patients at a military institution. Methods: A posterior colpotomy was created to accommodate a single site working port used to facilitate dissection and gallbladder mobilization under direct visualization via an infraumbilical port. The specimen was retrieved through the vagina and the colpotomy was closed with absorbable suture under direct visualization. Long-term follow up was performed over the phone to assess quality of life with 2 widely used health-related quality of life (HRQoL) surveys including RAND-36 Health Item Survey (Version 1.0),1 and the Female Sexual Function Index (FSFI).2. Results: Ten women underwent a laparoscopic-assisted transvaginal cholecystectomy (TVC) with 7 available for long-term follow-up. The average age was 28.9 years (20-37) and the indications for surgery included symptomatic cholelithiasis (9) and biliary dyskinesia (1). The mean operative time was 129 mins (95-180), and median blood loss was 34 ml (5-400). There were no conversions and the average length of stay was 9.98 hours (2.4-28.8). Pain (analogue scale 1-10) on postoperative day three was minimal (mean 2.3) and was limited to the infraumbilical incision. On average patients returned to work by postoperative day six and resumed normal daily activities at seven days. Immediate postoperative complications included one incident of postoperative urinary retention requiring bladder catheterization. One intra-operative cholangiogram was successfully performed due to elevated preoperative liver enzymes without significant findings. Long-term complications included one asymptomatic incisional hernia repair at the infraumbilical port site. The RAND-36 survey demonstrated an average physical and mental health summary score of 82.2 and 63.7 with an average general health score of 63.6. The average FSFI total score was 21.8. Conclusion: TVC is safe and effective. Implementation may improve operational readiness by returning service members to normal activities more expeditiously than conventional laparoscopy.

[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.