Bailout Procedure Research Articles

An additional port in difficult laparoscopic cholecystectomy for surgical safety.

Tokyo Guidelines 2018, clinical practice guidelines for acute cholangitis and cholecystitis, recommend bailout procedures to prevent bile duct injury (BDI) during laparoscopic cholecystectomy (LC) for difficult gallbladder. We first insert an additional port (AP) for difficult gallbladder that may require bailout procedures. Because the usefulness of an AP during LC is unclear, we therefore examined the efficacy of the AP during LC in this study. Data were collected from 115 patients who underwent LC for acute cholecystitis in our department. The indications for AP were excessive bleeding, scarring, and poor visual field around Calot's triangle. AP was inserted into the right middle abdomen so as not to interfere with other trocars and was used by the assistant. Surgical outcomes were evaluated based on AP use during LC. AP was inserted in 19 patients during LC (AP group). The indications for AP were excessive bleeding in nine patients, scarring around Calot's triangle in seven patients, and poor visual field around Calot's triangle in three patients. Open conversion was performed in two patients in the non-AP group. BDI occurred in one patient in the non-AP group. In patients with Difficulty Score 3, operation time was significantly shorter (P=.038) and Critical View of Safety (CVS) score was significantly higher in the AP group (P=.046). AP is useful in patients with excessive bleeding to shorten operation time and increase the CVS score. AP may be one useful option for difficult gallbladder.

Preoperative risk score to predict subtotal cholecystectomy after gallbladder drainage for acute cholecystitis: Secondary analysis of data from a multi-institutional retrospective study (CSGO-HBP-017B).

Subtotal cholecystectomy (STC) has become recognized as a "bailout procedure" to prevent bile duct injury in patients undergoing laparoscopic cholecystectomy (LC). Predictors of conversion to STC have not been identified because LC difficulty varies based on pericholecystic inflammation. We analyzed data from patients enrolled in a previously performed multi-institutional retrospective study of the optimal timing of LC after gallbladder drainage for acute cholecystitis (AC). These patients presumably had a considerable degree of pericholecystic inflammation. In total, 347 patients who underwent LC after gallbladder drainage for AC were analyzed to examine preoperative and perioperative factors predicting conversion to STC. Three hundred patients underwent total cholecystectomy (TC) and 47 underwent conversion to STC. Eastern Cooperative Oncology Group Performance Status (ECOG PS) (P< .01), severity of cholecystitis (P= .04), previous history of treatment for common bile duct stones (CBDS) (P< .01), and surgeon experience (P= .03) were significantly associated with conversion to STC. Logistic regression analyses showed that ECOG PS (odds ratio 0.2; P< .0001) and previous history of treatment for CBDS (odds ratio 0.37; P= .0073) were independent predictors of conversion to STC. Our predictive risk score using these two variables suggested that a score ≥2 could discriminate between TC and STC (P< .0001). Poor ECOG PS and previous history of treatment for CBDS were significantly associated with conversion to STC after gallbladder drainage for AC.

Evaluation of the knowledge of the critical view of safety and recognition of the transoperative complexity during the laparoscopic cholecystectomy.

Since the establishment of the Critical view of safety (CVS), different strategies have been created such as bailout procedures (SC, subtotal cholecystectomy), classifications for preoperative and intraoperative complexity (The Parkland grading scale, PGS) and objective evaluation of the CVS (doublet score, DS) to establish a "Culture of Safety in Cholecystectomy, COSIC"; to avoid complications. A multiple choice questionnaire was applied to residents and graduated surgeons from different Hospitals in Mexico during different national meetings; evaluating the knowledge of this different concepts (CVS, SC, PGS, DS), univariate logistic regression was used to assess the association of the knowledge with adverse events (AE) like the Bile duct injury. A total of 744 questionnaires were evaluated; 284 (38.17%) women and 460 (61.83%) men; 436 (58.6%) were residents and 308 (41.4%) graduated surgeons. 708 (95.16%) reported knowing the CVS; however, only (51.98%, p ≤ 0.001) defined the concept correctly, while 136 (18.28%) reported knowing the DS, but only 44 (5.91%) defined it correctly. Regarding the PGS, 398 (53.49%) mentioned knowing it, but only 262 defined it correctly. The concept of SC 642 (86.29%) reported knowing it; however, only (56.7%, p ≤ 0.001) correctly defined the techniques, being the reconstituting technique the preferred one (42.37% vs 34.89%). In this survey, the correct knowledge of the CVS (OR 0.47, p < 0.001), the subtotal techniques (OR 0.71 p = 0.07), the DS (OR 0.48 p < 0.001) and of the PGS (OR 0.28, p < 0.001) decreased the risk of presenting BDI. Despite the COSIC and the timing of publication of the CVS; the percentage of people who can correctly define basic safety concepts is low among residents and licensed surgeons. Therefore, it is important to emphasize the dissemination of these concepts to obtain safe LC and thus reduce the incidence of complications.

Early Australian experience with intravascular lithotripsy treatment of severe calcific coronary stenosis: IVL in acute/chronic coronary syndromes.

Calcified coronary stenoses are a serious impediment to optimal stent expansion and can lead to stent failure and catastrophic adverse outcomes. We hereby present early Australian experience with intravascular lithotripsy for the treatment of calcific lesions in acute and chronic coronary syndromes. This was a single-centre retrospective study of all patients treated with intravascular lithotripsy (IVL) between October 2019 and June 2021. Patient demographics, procedural variables, and treatment safety/efficacy outcomes were evaluated. During this period, there were 40 patients and 41 coronary lesions with IVL-assisted percutaneous coronary intervention (PCI) (70% male; mean age 72.8±9.5 years). Indications for PCI were acute coronary syndromes in 25 patients (62.5%), and stable angina in 15 patients (37.5%). Upfront IVL usage occurred in 5% of cases with the rest being bailout procedures due to suboptimal initial balloon predilatation or stent underexpansion. Angiographic success (<20% residual stenosis) occurred in 37 cases (92.5%), with mean residual stenosis of 8.25%±8.5%. Two patients experienced procedural complications (5%). IVL appears to be a safe and effective modality in modifying coronary calcium to achieve optimal stent expansion in real-world practice. This device obviates the need for more complex lesion preparation strategies such as rotational or orbital atherectomy.

Multicentric validation of EndoDigest: a computer vision platform for video documentation of the critical view of safety in laparoscopic cholecystectomy.

A computer vision (CV) platform named EndoDigest was recently developed to facilitate the use of surgical videos. Specifically, EndoDigest automaticallyprovides short video clipsto effectively document the critical view of safety (CVS) in laparoscopic cholecystectomy (LC). The aim of the present study is to validate EndoDigest on a multicentric dataset of LC videos. LC videos from 4 centers were manually annotated with the time of the cystic duct division and an assessment of CVS criteria. Incomplete recordings, bailout procedures and procedures with an intraoperative cholangiogram were excluded. EndoDigest leveraged predictions of deep learning models for workflow analysis in a rule-based inference system designed to estimate the time of the cystic duct division. Performance was assessed by computing the error in estimating the manually annotated time of the cystic duct division. To provide concise video documentation of CVS, EndoDigest extracted video clips showing the 2min preceding and the 30s following the predicted cystic duct division. The relevance of the documentation was evaluated by assessing CVS in automatically extracted 2.5-min-long video clips. 144 of the 174 LC videos from 4 centers were analyzed. EndoDigest located the time of the cystic duct division with a mean error of 124.0 ± 270.6s despite the use of fluorescent cholangiography in 27 procedures and great variations in surgical workflows across centers. The surgical evaluation found that 108 (75.0%) of the automatically extracted short video clips documented CVS effectively. EndoDigest was robust enough to reliably locate the time of the cystic duct division and efficiently video document CVS despite the highly variable workflows. Training specifically on data from each center could improve results; however, this multicentric validation shows the potential for clinical translation of this surgical data science tool to efficiently document surgical safety.

Measures for preventing bile duct injuries during difficult cholecystectomies-Bail-out procedures

Cholecystectomies can sometimes be very complex operations, which place high demands on the surgeon. Are there preoperative and intraoperative procedures available for reducing the risk of intraoperative bile duct injuries during a complex cholecystectomy? The complexity of the operation should be estimated preoperatively. Extended diagnostic examinations, preoperative biliary stenting and the performance of the operation by an experienced surgeon may help to reduce the operative risk. In high-risk patients, postponing the cholecystectomy may be indicated. The timely intraoperative recognition of the impossibility to perform aregular cholecystectomy is of decisive importance. In this situation, so-called bail-out procedures, such as fundus-down cholecystectomy or subtotal cholecystectomy are warranted. Conversion from laparoscopic to open surgery is not always necessary. Bail-out procedures are useful to reduce the risk of bile duct injuries during complex cholecystectomy and can enable a safe completion of the operation.

Patient and surgeon factors contributing to bailout cholecystectomies: a single-institutional retrospective analysis

Laparoscopic cholecystectomies continue to pose trouble for surgeons in the face of severe inflammation. In the advent of inability to perform an adequate dissection, a "bailout cholecystectomy" is advocated. Conversion to open or subtotal cholecystectomy is among the standard bailout procedures in such instances. We performed a retrospective single institution review from January 2016 to August 2019. All patients who underwent a cholecystectomy were included, while those with a concurrent operation, malignancy, planned as an open cholecystectomy, or performed by a low volume surgeon were excluded. Patient characteristics, operative reports, and outcomes were collected, as were surgeon characteristics such as years of experience, case volume, and bailout rate. Univariable and multivariable analysis were performed. 2458 (92.6%) underwent laparoscopic total cholecystectomy (LTC) and 196 (7.4%) underwent a bailout cholecystectomy (BOC). BOC patients tended to be older (p < 0.001), male (p < 0.001), have a longer duration of symptoms (p < 0.001), and higher ASA class (p < 0.001). They also had more signs of biliary inflammation, as evidenced by increased leukocytosis (p < 0.001), tachycardia (p < 0.001), bilirubinemia (p = 0.003), common bile duct dilation (p < 0.001), and gallbladder wall thickening (p < 0.001). The BOC cohort also had increased rates of complications, including bile leak (16%, p < 0.001), retained stone (5.1%, p = 0.005), operative time (114min vs 79min, p < 0.001), and secondary interventions (22.7%, p < 0.001). Male gender (aOR = 2.8, p < 0.001), preoperative diagnosis of acute cholecystitis (aOR = 2.2, p = 0.032), right upper quadrant tenderness (aOR = 3.0, p = 0.008), Asian race (aOR = 2.7, p = 0.014), and intraoperative adhesions (aOR = 13.0, p < 0.001) were found to carry independentrisk for BOC. Surgeon bailout rate ≥ 7% was also found to be an independent risk factor for conversion to BOC. Male gender, signs of biliary inflammation (tachycardia, leukocytosis, dilated CBD, and diagnosis of acute cholecystitis), as well as surgeon bailout rate of 7% were independent risk factors for BOC.

P-BN60 Predicting post-operative length of stay following laparoscopic cholecystectomy: derivation and validation of a pre-operative risk score

Abstract Background To predict the post-operative length of stay following laparoscopic cholecystectomy (LC) will help guide the utilisation of resources, particularly the allocation of day surgery beds. Prolonged post-operative stay (PPS) is associated with morbidity and the acknowledgement of pre-operative factors predisposing to morbidity and PPS will influence surgical decision-making. The aim of the present study was to determine pre-operative factors associated with PPS and both derive and validate a risk score to predict the risk of PPS following LC. Methods Patients who underwent emergency and elective LC between January 2015 and December 2019 across three surgical centres were included. Pre-operative, operative and post-operative data were collected retrospectively from multiple databases using a deterministic records-linkage methodology. The cohort was randomly divided into a derivation and validation cohort, by a 3:1 ratio, respectively. The derivation cohort was used to create a risk score for PPS (≥3 days post-operatively) using multivariate logistic regression. The risk score was then applied to the smaller set or ‘validation cohort’ for internal validation purposes and the predictive accuracy was assessed using a ROC curve. Results The rate of PPS was 10.6% (294/2768). PPS was associated with intra-operative complication (RR-17.0;p&amp;lt;0.001), bail-out procedures (RR-47.1;p&amp;lt;0.001) post-operative complications (RR-11.9;p&amp;lt;0.001), re-admission (RR-2.4;p&amp;lt;0.001) and post-operative imaging/intervention (RR6.5;p&amp;lt;0.001). Variables associated with PPS included ag ≥ 60 (OR-1.56;p=0.011), male sex (OR-1.47;p=0.022), ASA 2 (OR-1.63;p=0.019, ASA≥3 (OR-3.27;p&amp;lt;0.001), 2 hospital admissions (OR-1.56;p=0.046), ≥3 hospital admissions (OR-2.11;p=0.024), cholecystitis (OR-3.19;p&amp;lt;0.001), pre-operative ERCP (OR-3.49;p&amp;lt;0.001) and cholecystostomy (OR-2.77;p=0.025) and emergency LC (OR-5.20;p&amp;lt;0.001). The AUC (area under curve) for the derivation and validation cohorts were 0.83 and 0.81 respectively. The risks of PPS in low-risk (0-5), medium-risk (5.5-10) and high-risk (&amp;gt;10) groups were 3.3%, 14.9% and 45.1%, respectively. Conclusions The rate of PPS following LC is significant and strongly associated with peri- and post-operative morbidity. Our model concludes that multiple pre-operative patient factors can predict the likelihood of prolonged post-operative stay. A patient’s risk score could be used to assess the risk of morbidity. Pragmatic patient selection in accordance with the above model could help surgical centres improve the allocation of beds between tertiary centres and day-surgery units.

New Scoring System for Prediction of Surgical Difficulty During Laparoscopic Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage.

BackgroundThe surgical difficulty of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD) remains unknown. This study aimed to establish a scoring system (SS) to predict the necessity of a bailout procedure during LC after PTGBD and to evaluate the relationship between SS and perioperative complications.MethodsWe retrospectively studied 70 patients who underwent LC after PTGBD. Preoperative factors potentially predictive of the need for the bailout procedure were analyzed. The SS included significantly predictive factors, with their cutoff values determined by receiver operating characteristic curves. Patients were assigned a score of 1 when exhibiting only one of these abnormalities. We compared the perioperative factors between three groups with scores of 0, 1, or 2. The SS was applied to another series of 65 patients for validation. We compared the score‐2 patient perioperative factors between LC with the bailout procedure and open cholecystectomy from the beginning (OC).ResultsIndependent predictors were time until PTGBD after symptom onset and the maximal wall gallbladder thickness (cutoff values: 3 days and 10 mm, respectively). The high‐score group was significantly associated with bile duct injury (BDI). The sensitivity and specificity of our SS were 75.0% and 98.1% in validation, respectively. The score‐2 OC and laparoscopic subtotal cholecystectomy (LSC) groups had no BDI.ConclusionsThe SS using time until PTGBD after symptom onset and gallbladder wall thickness for predicting the need for the bailout procedure correctly predicted the need. The scores might be associated with the risk of BDI, and LSC or OC might be a better choice for score‐2 patients.

Bailout Procedures for the Difficult Gallbladder: Comparing Outcomes of Laparoscopic Sub-total Fenestrated Cholecystectomy, with Open Cholecystectomy

Bailout Procedures for the Difficult Gallbladder: Comparing Outcomes of Laparoscopic Sub-total Fenestrated Cholecystectomy, with Open Cholecystectomy

Subsequent open-cardiac surgery after transcatheter aortic valve implantation-indications and outcomes

Abstract Background Transcatheter aortic valve implantation (TAVI) has been historically done in high-risk patients or patients who are deemed unfit for open-heart surgery. Despite high procedural success rates subsequent open surgery remains an issue, immediately after TAVI implantation or during follow-up as bailout strategy. Purpose Aim of this study was to report on indications and clinical outcomes of patients who underwent open-cardiac surgery following TAVI. Methods Between 01/2011 and 12/2020 our centre performed 3131 TAVI procedures. Twenty-seven patients (including patients in whom TAVI was performed in other centres) underwent subsequent open-heart surgery via cardiopulmonary bypass after previous TAVI. Demographic, intraprocedural data and indications for surgery were evaluated. The VARC-2 criteria were applied to report on clinical outcomes. Results Twenty-seven patients (aged 79 [IQR 76–84]; 59.3% male) were operated on for endocarditis (n=11; 40.7%), 3 patients for annular rupture, severe paravalvular leak and severe stenosis, respectively as well as 1 patient each for severe tricuspidal valve regurgitation, valve thrombosis, malpositioning, valve migration, ostial right coronary artery obstruction, left ventricular rupture and type A aortic dissection. The interval between the index TAVI procedure to open surgery was 3 months (IQR 0–26 months). Eight patients underwent emergency subsequent surgery on the same day immediately after TAVI. The surgical data including the procedures are shown in Figure 1. Four patients died intraoperatively due to uncontrolled bleeding. Immediate procedural and procedural mortality was 25.9% and 40.7%, respectively and all-cause mortality was 51.9% (11/12 died for cardiovascular reasons). Figure 2 shows the Kaplan-Meier estimator for survival. Intraoperative, immediate, procedural and all-cause mortality in patients operated on immediately after TAVI was 25.0%, 25.0%, 37.5%, and 50% respectively. No disabling stroke was observed while a non-disabling stroke occurred in 1 patient. New permanent pacemaker implantation was needed in 3 patients (11.1%). One patient required an additional, second operation to remove a left ventricular thrombus as bailout procedure. One patient suffered from a persisting endocarditis and was discharged on permanent antibiotic intake. Conclusions Subsequent open-heart surgery after TAVI is rare, but may urgently become necessary due to TAVI related complications or progressing other cardiac pathologies. Despite a substantial early attrition rate clinical outcome is acceptable and a relevant number of patients can be discharged after surgery for immediate life-threatening TAVI complications. The option of subsequent surgical conversion remains an indispensable tool in the setting of a modern heart team-based approach. These results substantiate recommendations regarding both, having a cardiac surgical service on site and performing TAVI as an interdisciplinary team. Funding Acknowledgement Type of funding sources: None. Surgical detailsKaplan-Meier estimator for survival

Percutaneous transaxillary access for endovascular aortic procedures in the multicenter international PAXA registry

BackgroundThe aim of the study was to demonstrate the safety and effectiveness of a suture-mediated vascular closure device to perform hemostasis after an axillary artery access during endovascular procedures on the aortic valve, the aorta and its side branches. MethodsA physician-initiated, international, multicenter, retrospective registry was designed to evaluate the success rate (VARC-2 reporting standards) of percutaneous transaxillary access closure with a suture-mediated closure device. Secondary end points were minor access vascular complications, transient peripheral nerve injury, stroke, and influence on periprocedural outcomes of puncture technique. ResultsThree hundred thirty-one patients (median age, 76 years; 69.2% males) in 11 centers received a percutaneous transaxillary access during endovascular cardiac (n = 166) or vascular (n = 165) procedures. The closure success rate was 84.6%, with 5 open conversions (1.5%), 45 adjunctive endovascular procedures (13.6%), and 1 nerve injury (0.3%). Secondary closure success was obtained in 325 patients (98%) after 7 bare stenting, 37 covered stenting, and 1 thrombin injection. Introducer sheaths 16F or larger (odds ratio, 3.70; 95% confidence interval, 1.22-11.42) and balloon-assisted hemostasis (odds ratio, 4.45; 95% confidence interval, 1.27-15.68) were associated with closure failure. A threshold of five percutaneous axillary accesses was associated with decreased rates of open conversion, but not with increased primary closure success. Primary closure success was 90.3% in the 175 patients with sheaths smaller than 16F, performed after the first 5 procedures in each center. Temporary nerve injury and stroke were observed in 2% and 4% of patients, respectively. ConclusionsPercutaneous transaxillary aortic procedures, in selected patients, can be performed with low rates of open conversion. The need for additional endovascular bailout procedures is not negligible when introducers sheaths 16F or larger are required.

Intraoperative Time-Out to Promote the Implementation of the Critical View of Safety in Laparoscopic Cholecystectomy: A Video-Based Assessment of 343 Procedures

The critical view of safety (CVS) is poorly adopted in surgical practices, although it is recommended ubiquitously to prevent major bile duct injuries during laparoscopic cholecystectomy (LC). This study aimed to investigate whether performing a short intraoperative time-out can improve CVS implementation. In this before vs after study, surgeons performing LCs at an academic center were invited to use a 5-second long time-out to verify CVS before dividing the cystic duct (5-second rule). The primary aim was to compare the rate of CVS achievement for LC performed in the year before vs the year after implementation of the 5-second rule. The CVS achievement rate was computed after exclusion of bailout procedures using a mediated video-based assessment made by 2 independent reviewers. Clinical outcomes, LC workflows, and postoperative reports were also compared. Three hundred and forty-three of 381 LC performed between December 2017 and November 2019 (171 before and 172 after implementation of the 5-second rule) were analyzed. The 5-second rule was associated with a significantly increased rate of CVS achievement (15.9% vs 44.1% before vs after the 5-second rule, respectively; p < 0.001). Significant differences were also observed with respect to the rate of bailout procedures (8.2% vs 15.7%; p= 0.04), median time (hours:minutes:seconds) to clip the cystic duct or artery (00:17:26; interquartile range 00:11:48 to 00:28:35 vs 00:23:12; interquartile range 00:14:29 to 00:31:45 duration; p= 0.007), and the rate of postoperative CVS reporting (1.3% vs 28.8%; p < 0.001). Postoperative morbidity was comparable (1.8% vs 2.3%; p= 0.68). Performing a short intraoperative time-out was associated with an improved CVS achievement rate. Systematic intraoperative cognitive aids should be studied to sustain the uptake of guidelines.

Transforming a pre-existing MRI environment into an interventional cardiac MRI suite.

AimsTo illustrate the practical and technical challenges along with the safety aspects when performing MRI‐guided electrophysiological procedures in a pre‐existing diagnostic magnetic resonance imaging (MRI) environment.Methods and ResultsA dedicated, well‐trained multidisciplinary interventional cardiac MRI team (iCMR team), consisting of electrophysiologists, imaging cardiologists, radiologists, anaesthesiologists, MRI physicists, electrophysiological (EP) and MRI technicians, biomedical engineers, and medical instrumentation technologists is a prerequisite for a safe and feasible implementation of CMR‐guided electrophysiological procedures (iCMR) in a pre‐existing MRI environment. A formal dry run “mock‐up” to address the entire spectrum of technical, logistic, and safety issues was performed before obtaining final approval of the Board of Directors. With this process we showed feasibility of our workflow, safety protocol, and bailout procedures during iCMR outside the conventional EP lab. The practical aspects of performing iCMR procedures in a pre‐existing MRI environment were addressed and solidified. Finally, the influence on neighbouring MRI scanners was evaluated, showing no interference.ConclusionTransforming a pre‐existing diagnostic MRI environment into an iCMR suite is feasible and safe. However, performing iCMR procedures outside the conventional fluoroscopic lab, poses challenges with technical, practical, and safety aspects that need to be addressed by a dedicated multi‐disciplinary iCMR team.

Funnel technique for wide infrarenal aneurysm neck with Lifetech Ankura™ Stent Graft System.

Background In this study, we present our mid-term results in patients undergoing treatment with the funnel technique and describe technical issues for this bailout technique in extra-wide infrarenal necks. Methods Between January 2018 and June 2020, a total of seven male, symptomatic patients (median: 74.5 years; range, 64 to 84 years) who had comorbidities and were in the American Society for Anesthesiologists Class IV and treated by the funnel technique in an endovascular fashion were included. Pre- and post-procedural data of the patients, early mortality and technical success rates were evaluated. Results There was no early mortality. Technical success rate was 100%. There was no type I or III endoleaks at the completion angiography. All patients were discharged without any problem on the second or third day of the procedure. The median follow-up was 13 (range, 6 to 28) months. The aneurysm sac shrinkage was achieved in all patients over six months of follow up. During the follow-up period, no proximal endoleak or infrarenal aortic neck diameter enlargement was found. Conclusion Based on our limited experience, the funnel technique may be considered more than a bailout procedure under special circumstances.

Use of Sutureless and Rapid Deployment Prostheses in Challenging Reoperations.

Sutureless and rapid-deployment bioprostheses have been introduced as alternatives to traditional prosthetic valves to reduce cardiopulmonary and aortic cross-clamp times during aortic valve replacement. These devices have also been employed in extremely demanding surgical settings, as underlined in the present review. Searches on the PubMed and Medline databases aimed to identify, from the English-language literature, the reported cases where both sutureless and rapid-deployment prostheses were employed in challenging surgical situations, usually complex reoperations sometimes even performed as bailout procedures. We have identified 25 patients for whom a sutureless or rapid-deployment prosthesis was used in complex redo procedures: 17 patients with a failing stentless bioprosthesis, 6 patients with a failing homograft, and 2 patients with the failure of a valve-sparing procedure. All patients survived reoperation and were reported to be alive 3 months to 4 years postoperatively. Sutureless and rapid-deployment bioprostheses have proved effective in replacing degenerated stentless bioprostheses and homografts in challenging redo procedures. In these settings, they should be considered as a valid alternative not only to traditional prostheses but also in selected cases to transcatheter valve-in-valve solutions.

Preoperative Magnetic Resonance Cholangiopancreatography for Detecting Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis.

Previous studies have shown that signal intensity variations in the gallbladder wall on magnetic resonance imaging (MRI) are associated with necrosis and fibrosis in the gallbladder of acute cholecystitis (AC). However, the association between MRI findings and operative outcomes remains unclear. We retrospectively identified 321 patients who underwent preoperative magnetic resonance cholangiopancreatography (MRCP) and early laparoscopic cholecystectomy (LC) for AC. Based on the gallbladder wall signal intensity on MRI, these patients were divided into high signal intensity (HSI), intermediate signal intensity (ISI), and low signal intensity (LSI) groups. Comparisons of bailout procedure rates (open conversion and laparoscopic subtotal cholecystectomy) and operating times were performed. The recorded bailout procedure rates were 6.8% (7/103 cases), 26.7% (31/116 cases), and 40.2% (41/102 cases), and the median operating times were 95, 110, and 138 minutes in the HSI, ISI, and LSI groups, respectively (both p < 0.001). During the multivariate analysis, the LSI of the gallbladder wall was an independent predictor of both the bailout procedure (odds ratio [OR] 5.30; 95% CI 2.11–13.30; p < 0.001) and prolonged surgery (≥144 min) (OR 6.10, 95% CI 2.74–13.60, p < 0.001). Preoperative MRCP/MRI assessment could be a novel method for predicting surgical difficulty during LC for AC.

Early Laparoscopic Cholecystectomy Using the Bailout Procedure for Acute Cholecystitis with Severe Local Inflammation

Introduction: The Tokyo Guidelines 2018 have proposed a bailout procedure that includes the fundus first technique and subtotal cholecystectomy to prevent bile duct injury and vasculo-biliary injury in acute cholecystitis (AC) with severe local inflammation, especially at Calot's triangle. The study aim was to assess the influence of laparoscopic cholecystectomy (LC) using the bailout procedure for AC with severe local inflammation. Patients and methods: A total of 362 patients were enrolled during 15-year study period. The median preoperative length of hospitalization was 1 day (range, 0-30 days). The patient's characteristics, therapeutic strategies, and operative results were compared between the former period (n = 260) and a recent 3-year period (n = 102). Results: In both groups, approximately 20% of the patients with taking antithrombotic agents, and approximately 30% of the patients had severe local inflammation, including gangrenous cholecystitis. Early LC within 4 days after admission was predominantly performed in the recent period (100 cases, 98.0%, p < 0.001). Conversion to open surgery decreased from 6.5% to 1.0%, and postoperative complication was decreased from 4.2% to 2.0%. The postoperative and total length of hospitalization were significantly shorter in the recent period than in the earlier period (3 days and 5 days, respectively). Conclusions: Active performance of the bailout procedure and technical modification were associated with fewer conversion to open surgery and postoperative complications, leading to significant decreases in the postoperative and total length of hospitalization for AC patients with severe local inflammation.

Early Operation for Acute Cholecystitis in the TG18 Era

Background: Tokyo Guidelines 2018: Updated Tokyo Guidelines for the management of acute cholangitis/acute cholecystitis (TG18) were released in January 2018. Early laparoscopic cholecystectomy (LC) is recommended for acute cholecystitis within 72 hours when possible or within one week at the latest. Aim: To assess current status of early operation for acute cholecystitis. Methods: From 2018 to 2019, 31 patients who underwent early operation for acute cholecystitis were reviewed retrospectively. Results: During the same period 185 cholecystectomies were performed. Early operations were performed in 17% including 21 males and 10 females, with an average age of 57.9 years. Median time from onset to admission was 1 day. Ultrasonography and CT scans were obtained for all patients and MRCP in 61%. X-ray showed stones in 65% of all patients. Severity score classified into Grade I; 25 patients (81%) and Grade II; 6 patients (19%). Median score of age adjusted Charlson Co-morbidity index was 3 points (0-7). Median time from admission to surgery was 1 day, and 61% underwent LC and 39% open cholecystectomy (OC). In Grade II patients, OC was performed in 83% because of a pericholecystic abscess with severe inflammation. Subtotal cholecystectomy was selected in 50% patients as a bailout procedure. Morbidity rate was 6%. Average postoperative hospital stay was 5.9 days. Conclusions: According to the flowcharts in TG18, early LC is recommended for all patients, but OC was chosen in 39% in this series. OC does not make cholecystectomy easier, but OC must be considered when OC is safer.

Factors that Predict the Need for Subtotal Cholecystectomy.

Subtotal cholecystectomy is a "damage control" or "bailout procedure" that is used in difficult gallbladder cases when severe inflammation distorts the local anatomy resulting in increased risk in damage to surrounding structures. Subtotal cholecystectomy rates increased nationally over the past decade. We aimed to determine provider experience and patient factors associated with the performance of subtotal cholecystectomies. All cholecystectomies from 2016 to 2019 were reviewed. Patient demographics, laboratory values, imaging, preoperative diagnosis, surgical technique (fenestrating vs. reconstituting), and years of attending and resident experience were collected. Multivariable regression analysis was performed to evaluate for factors that increase the likelihood of subtotal cholecystectomy. Of 916 cholecystectomies, 86 were subtotal. The likelihood of subtotal cholecystectomy did not increase based on attending experience of ≤5 vs. > 5years (odds ratio (OR) .66, P = .09). Older age (adjusted odds ratio (aOR) 1.23, P = .03), male sex (aOR 2.59, P < .01), white blood cells (WBC) above 10.3 (aOR 2.02, P = .02), and preoperative diagnosis of acute on chronic cholecystitis (aOR 5.47, P < .01) were associated with increased likelihood of subtotal cholecystectomy. Older age, male sex, WBC above 10.3, and preoperative diagnosis of acute on chronic cholecystitis were associated with the increased likelihood of subtotal cholecystectomies. The performance of subtotal cholecystectomy was not impacted by attending years of experience. In cases of severe gallbladder pathology, this technique is being used as an operative strategy among all surgeon levels.