Benign Gallbladder Disease Research Articles

Benign gallbladder diseases: Imaging techniques and tips for differentiating with malignant gallbladder diseases.

Benign gallbladder diseases usually present with intraluminal lesions and localized or diffuse wall thickening. Intraluminal lesions of the gallbladder include gallstones, cholesterol polyps, adenomas, or sludge and polypoid type of gallbladder cancer must subsequently be excluded. Polyp size, stalk width, and enhancement intensity on contrast-enhanced ultrasound and degree of diffusion restriction may help differentiate cholesterol polyps and adenomas from gallbladder cancer. Localized gallbladder wall thickening is largely due to segmental or focal gallbladder adenomyomatosis, although infiltrative cancer may present similarly. Identification of Rokitansky-Aschoff sinuses is pivotal in diagnosing adenomyomatosis. The layered pattern, degree of enhancement, and integrity of the wall are imaging clues that help discriminate innocuous thickening from gallbladder cancer. High-resolution ultrasound is especially useful for analyzing the layering of gallbladder wall. A diffusely thickened wall is frequently seen in inflammatory processes of the gallbladder. Nevertheless, it is important to check for coexistent cancer in instances of acute cholecystitis. Ultrasound used alone is limited in evaluating complicated cholecystitis and often requires complementary computed tomography. In chronic cholecystitis, preservation of a two-layered wall and weak wall enhancement are diagnostic clues for excluding malignancy. Magnetic resonance imaging in conjunction with diffusion-weighted imaging helps to differentiate xathogranulomatous cholecystitis from gallbladder cancer by identifying the presence of fat and degree of diffusion restriction. Such distinctions require a familiarity with typical imaging features of various gallbladder diseases and an understanding of the roles that assorted imaging modalities play in gallbladder evaluations.

Comparison of laparoscopic cholecystectomy with and without abdominal drainage in patients with non-complicated benign gallbladder disease: A protocol for systematic review and meta analysis.

To evaluate whether conventional postoperative drainage is more effective than not providing drainage in patients with non-complicated benign gallbladder disease following laparoscopic cholecystectomy (LC). A search of the electronic databases MEDLINE, EMBASE, Web of science, Cochrane Library, and Chinese Biomedical Database (CBM) was conducted for randomized controlled trials (RCTs) reporting outcomes of LC surgery with and without an abdominal drain. Twenty-one RCTs involving 3246 patients (1666 with drains vs 1580 without) were included in the meta-analysis. There were no statistically significant differences in the rates of incidence of intra-abdominal fluid (RR: 1.10; 95% CI: 0.81-1.49; P = .54) or post-surgical mortality (RR: 0.44; 95% CI: 0.04-4.72; P = .50) between the two groups. Abdominal drains did not reduce the overall incidence of nausea and vomiting (RR: 1.16; 95% CI: 0.95-1.42; P = .15) or shoulder tip pain (RR: 1.03; 95% CI: 0.76-1.38; P = .86). The abdominal drain group displayed significantly higher pain scores (MD: 1.07; 95% CI: 0.69-1.46; P < .001) than the non-drainage patients. Abdominal drains prolonged the duration of the surgical procedure (MD: 5.69 min; 95% CI: 2.51-8.87; P = .005) and postoperative hospital stay (MD: 0.47 day; 95% CI: 0.14-0.80; P = .005). Wound infection was found to be associated with the use of abdominal drains (RR: 1.97; 95% CI: 1.11-3.47; P = .02). Currently, there is no evidence to support the use of routine drainage after LC in non-complicated benign gallbladder disease. Further well-designed randomized clinical trials are required to confirm this finding.

Long-term follow-up of the incisional hernia rate after single-incision laparoscopic cholecystectomy: a prospective observational study

Purpose To evaluate the long-term occurrence rate of incisional hernias following single-incision laparoscopic cholecystectomy (SILC). Background Since the 90 s, SILC has emerged as a less invasive alternative to standard laparoscopic cholecystectomy in selected patients. But concerns over port-incisional hernias have not been addressed. Methods Between February 2009 and February 2011, 142 patients referred for gallstones who agreed to undergo SILC were included in a monocenter prospective observational study. All of the procedures were carried out using a single-port access technique. The occurrence rates of incisional hernias were analyzed with the Kaplan-Meier actuarial method. Statistical significance was set at p < .05. Results A total of 142 patients with gallbladder pathology were included in the study; 138 of them underwent SILC and 4 were converted to standard multiport cholecystectomy. Twelve patients (8%) were found to have developed a port-site incisional hernia (PSH) by physical examination or by imaging. The Kaplan-Meier curve showed that the rate of PSH development was 83% in the first 2 years after surgery. After 2 years, this risk becomes quite low. Conclusions Our results indicate that the SILC procedure is a safe option for treatment of benign gallbladder diseases for selected patients, albeit with a high incisional hernia rate.

Perioperative complications of laparoscopic cholecystectomy: a cross-sectional observational study

Background: Laparoscopic cholecystectomy (LC) has now become the gold standard in treatment of benign gall bladder disease. The intraoperative and immediate postoperative complication cannot be disregarded and remain of concern. The study aims to evaluate the perioperative complications of LC in patients undergoing the surgery.Methods: A total of 100 patients were included in this prospective analytical study from a June 2017 to September 2019. They were adequately evaluated and underwent LC in General surgery department of Geetanjali Medical College and Hospital, Udaipur. The relevant clinical details of all the patients were recorded and analysed.Results: Among the patients who underwent LC, majority were females. In case of 86 patients, LC was done due to chronic calculous cholecystitis. The conversion rate from laparoscopic to open was 6%. The most frequent intraoperative complication was trocar site bleeding and liver bed injury, 7%, followed by bile leakage from gallbladder 6%, bleeding from calots triangle in 4% and spilled gallstones in 2% cases. There was no case of injury to common bile duct, bowel injury or major vascular injury. Amongst the post-operative complications, wound infection was in 1% case. No perioperative mortality was present. The overall rate of complication was 18%.Conclusions: LC is a safe and effective procedure in almost all patients presenting with symptomatic gallbladder disease and remains one of the most frequently performed laparoscopic operations. It has a low rate of mortality and morbidity making this operation a safe procedure with favourable results.

Classification and Management of iatrogenic bile duct injury

The laparoscopic cholecystectomy is considered the gold standard for the treatment of benign gall bladder disease, which is associated with an increased incidence of biliary injuries. These types of injuries are multicausal, and anatomical variations or anatomical perception errors are the most common risk factors. Iatrogenic bile duct injuries are complex alterations and constitute one of the most serious complications of a cholecystectomy and require a comprehensive approach, proper drainage and timely referral to adequate treatment to improve long-term prognosis. Reconstruction and treatment techniques have been evolving. The selection of adequate treatment will impact on the patient, s quality of life.&#x0D; Journal of Surgical Sciences (2017) Vol. 21 (2): 110-114

Clinical significance of serum miR-187 and miR-143 in the diagnosis of gallbladder cancer

Objective To investigate the clinical significance of serum miR-187 and miR-143 in the development and diagnosis of gallbladder cancer. Methods 75 serum samples in patients with gallbladder cancer were selected as gallbladder cancer group. 75 serum samples in patients with gallbladder benign disease and 45 serum samples in healthy physical examinations at same period were selected as the benign gallbladder disease group and healthy control group. Quantitative RT-PCR was used to detect the serum miR-187 and miR-143 expression in each group, and the expression of those related with the clinicopathological factors, the proliferation and migration of gallbladder cancer cells, and the efficacy in diagnosis of gallbladder cancer was observed. Results The serum miR-187 expression in gallbladder cancer group was significantly higher than that in benign gallbladder disease and healthy control; the serum expression of that in benign gallbladder disease was significantly higher than that in healthy control; after surgery , the expression of that was significantly lower than that before treatment (all P 0.05), and were significantly correlated with Nevin stage, TNM stage, differentiation and lymphatic metastasis (all P<0.05). Furthermore, it was confirmed that miR-187 promoted the proliferation and migration of gallbladder cancer cells in vitro, while miR-143 inhibited the proliferation and migration. In the diagnosis of gallbladder, the diagnostic efficacy of miR-187 and miR-143 was significantly better than that of CA199 and CA242 (both P<0.05). Combined detection could further improve the efficacy in diagnosis of gallbladder cancer. Conclusions miR-187 and miR-143 are involved in the development of gallbladder cancer. Combined detection of serum miR-187 and miR-143 in gallbladder cancer has a high diagnostic efficiency in the diagnosis of gallbladder cancer. Key words: Gall bladder neoplasm; MiR-187; MiR-143; Diagnosis; Real-time -PCR

Robotic multiport versus robotic single-site cholecystectomy: a retrospective single-centre experience of 142 cases

Robotic cholecystectomy with the da Vinci Xi® system (Intuitive Surgical, Sunnyvale, CA, USA) can be performed either as a multiport or a single-incision procedure with the da Vinci Single-Site® platform. The value of robotic single-site cholecystectomy is still under debate. The aim of this study was to compare perioperative measures and postoperative outcomes of both robotic assisted approaches. 142 patients with benign gallbladder disease underwent da Vinci multiport (DVMPC; n = 111) or da Vinci Single-Site® cholecystectomy (DVSSC; n = 31) in our institution between October 2015–December 2018. Patient demographics and characteristics, perioperative measures, complications and outcomes were retrospectively analysed. Patients with DVSSC had a significant lower BMI an were younger compared to DVMPC patients (BMI: 25.2 versus 28.1, p = 0.004; age: 44.5 versus 54.2 years, p = 0.007). Operative time was longer in the DVSSC group (84.9 versus 69.9 minutes, p = 0.007). In the DVSSC group there were significantly more superficial surgical site infections (16.6 versus 3.6%, p = 0.024), more overall complications according to Clavien-Dindo (29.0 versus 9.9%, p = 0.016), and more pain on postoperative day 3 (numeric rating scale, 1.3 versus 0.4, p = 0.026). In both groups there were no injuries of hepatic hilar structures such as the common bile duct or of the right hepatic artery. DVSSC could be performed safely even in patients with acute cholecystitis and previous abdominal surgery. However, the da Vinci Single-Site® approach for cholecystectomy should not be considered as the standard of care procedure for benign gallbladder disease, due to a higher incidence of superficial surgical site infections, more overall complications and more postoperative pain compared to DVMPC.

TRANSUMBILICAL LAPAROSCOPIC CHOLECYSTECTOMY VERSUS STANDARD 4-PORT LAPAROSCOPIC CHOLECYSTECTOMY – RESULTS FROM PROSPECTIVE RANDOMIZED TRIAL AND 7 YEARS OF FOLLOW-UP

PURPOSE: Laparoscopic cholecystectomy is a standard of care for patients with benign gallbladder disease. Recently single-incision techniques gained popularity in order to decrease surgical trauma and to improve cosmetic results and patient satisfaction. The aim of this study is to compare the results of our own modification of transumbilical cholecystectomy versus standard 4-port cholecystectomy in patients with uncomplicated gallstone disease. METHODS: 80 patients (14 male, 66 female) at a mean age of 35±2,5 years (range 18-80) were randomly assigned to either standard 4-port cholecystectomy (n=40) or transumbilical cholecystectomy (n=40). Operative times, intraoperative complications, conversion rate, postoperative complications, pain, vomiting and cosmetic results were compared between two groups. RESULTS: The total mean operative time in the SILC group was 43.63 ± 7.49 min., while in the SLC group it was 37.95 ±8.06 min., (p=0.002). Intraoperative complications and conversions were not recorded in this series. The mean postoperative pain assessed by VAS was: at 6th hour 3.35 (2-5) vs. 3.53 (2-6) (p=0.439), at 24th hour 2.58 (1-4) vs. 2.2 (1-5) (p=0.04), at 48th hour 1.63 (1-3) vs. 1.78 (1-5) (p=0.544). The mean 10-point pain scores for SILC patients at 6 hours was 5.78 (3-9) vs. 6.33 (1-10) in SLC (p=0.161), at 24 hours 4.05 (1-7) vs. 3.58 (1-5) (p=0.122), at 48 hour 2.83 (1-5) vs. 2.4 (1-5) (p=0.093). Postoperative vomiting was observed in 2 (5%) of patients with SILC and 3 (7.5%) of those with SLC by the end of the second hour after surgery. In the early postoperative period up to 72h, no complications were reported. In the late postoperative period up to 7 years 1 (2.5%) operative wound surgery in the area of umbilical incision was reported in the SLC group and the presence of an umbilical hernia in 2 (5%) of patients with SILC. Results of the cosmetic result evaluation at the end of the first month - Body Image Score - mean score of 10.35 ± 1.48 (min. 7, max. 12) for SILC and 10.38 ± 1.41 (min. 6, max. 13) for SLC (p = 0.776). Cosmetic score - mean of the sum of points 20 ± 1,87 (min.17-max. 24) for SILC and 19.08 ± 2,1 (min. 14-max. 23) for SLC (p = 0,577). On a scale of 1 to 10, where 1 is "very ugly" and 10 is "almost imperceptible" (question N8), the mean for patients in the SILC group is 8.3 ± 0.79 (min. 7-max. 10) and at SLC 7.93 ± 0.73 (min. 6-max. 9) (p = 0.125). CONCLUSION: The results of this study demonstrated that both transumbilical cholecystectomy and standard 4-port cholecystectomy are equally safe and effective in the treatment of uncomplicated gallstone disease.

Clinical value of diffusion-weighted MRI for differentiation between benign and malignant gallbladder disease: A systematic review and meta-analysis

Clinical value of diffusion-weighted MRI for differentiation between benign and malignant gallbladder disease: A systematic review and meta-analysis

Impacts on outcomes and management of preoperative magnetic resonance cholangiopancreatography in patients scheduled for laparoscopic cholecystectomy: for whom it should be considered?

PurposeWe evaluated the impact of preoperative magnetic resonance cholangiopancreatography (MRCP) on patient outcomes, and found which patients should be considered for MRCP before cholecystectomy.MethodsWe performed retrospective analysis of 2,072 patients that underwent cholecystectomy for benign gallbladder disease from January 2014 to June 2017. Patients were grouped as CT only group (n = 737) and MRCP group (n = 1,335), including both CT and MRCP (n = 1,292) or MRCP only (n = 43). The main outcome measure was associated with complications after cholecystectomy, and the secondary outcomes were hospital stay, readmission, and events that could impact patient management due to addition of MRCP.ResultsThere were no statistical differences in occurrence of intraoperative or postoperative complications or readmission rate between the 2 groups. Hospital stay was about 0.6 days longer in the MRCP group. However, MRCP group was more susceptible to complications due to underlying patient demographics (older age, higher frequency of diabetes, and higher level of the inflammatory markers). MRCP diagnosed common bile duct (CBD) stones in 6.5% of patients (84/1,292) without CBD stones in CT, and bile duct anomalies were identified in 41 patients (3.2%). Elevated γ-GT was the only independent factor for additional detection of CBD stones (adjusted odds ratio [OR], 2.89; P = 0.029) and subsequent biliary procedures (adjusted OR, 3.34; P = 0.018) when additional MRCP was performed.ConclusionMRCP is valuable for identification of bile duct variation and CBD stones. Preoperative MRCP can be considered, particularly in patients with elevated γ-GT, for proper preoperative management and avoidance of complications.

Effects of definitive repair surgery on health-related quality of life in patients with bile duct injury after laparoscopic cholecystectomy

Objective To investigate the effects of definitive repair surgery on health-related quality of life (HRQOL) in patients with bile duct injury after laparoscopic cholecystectomy (LC). Methods The retrospective case-control study was conducted. The clinicopathological data of 181 patients with bile duct injury caused by LC for benign gallbladder diseases who underwent definitive repair surgery and 50 patients without complications after LC for benign gallbladder diseases in the Mianyang Central Hospital from January 2000 to December 2017 were collected. There were 82 males and 99 females of 181 patients with bile duct injury, aged from 31 to 68 years, with an average age of 47 years. Definitive repair surgery was performed according to different types of bile duct injury, and questionnaire of HRQOL was conducted preoperatively and one year after operation. There were 18 males and 32 females of 50 patients without complications after LC, aged from 35 to 69 years, with an average age of 41 years. Questionnaire of HRQOL was conducted on LC patients without complications one year after operation. Observation indicators: (1) classification of bile duct injury; (2) intraoperative situations of definitive repair surgery; (3) postoperative situations of definitive repair surgery; (4) follow-up; (5) results of the SF-36 scale assessment. Follow-up was conducted by outpatient examination and telephone interview up to December 2018. Patients were reexamined liver function and color Doppler ultrasonography once every 6-12 months, and further magnetic resonance cholangiopancreatography (MRCP) or computed tomography examination to detect recurrence of anastomotic biliary stricture and cholangitis. Measurement data with normal distribution were expressed as Mean±SD, and comparison between groups was analyzed by the paired t test. Measurement data with skewed distribution were described as M (range), and count data were described as absolute numbers. Results (1) Classification of bile duct injury: of the 181 patients with bile duct injury, there were 64 cases of E1 type, 70 cases of E2 type, 35 cases of E3 type, 9 cases of E4 type, and 3 cases of E5 type. (2) Intraoperative situations of definitive repair surgery: all the 181 patinets with bile duct injury underwent definitive repair surgery successfully, including 61 undergoing end-to-end biliary anastomosis, 109 undergoing Roux-en-Y choledojejunostomy, 11 undergoing hemi-hepatectomy combined with Roux-en-Y anastomosis. There were 52 patients combined with hilar cholangioplasty. The operation time and volume of intraoperative blood loss of 181 patients were (190±126) minutes and 601.5 mL (range, 150.0-2 100.0 mL). There were 24 cases with blood transfusion and 18 cases with T-tube stent. (3) Postoperative situations of definitive repair surgery: 40 of 181 patients had complications, including 14 cases of incisional infection, 10 cases of bile leakage, 8 cases of perihepatic effusion, 7 cases of pulmonary infection, and 1 case of abdominal hemorrhage. The patient with postoperative abdominal hemorrhage underwent reoperation for hemostasis, and other patients with complications were cured after ultrasound-guided puncture and drainage or conservative treatment. Duration of postoperative hospital stay of 181 patients with bile duct injury was 12.6 days (range, 6.0-34.0 days). There was no perioperative death occurred. (4) Follow-up: 157 of 181 patients were followed up for 8.2-201.3 months, with a median follow-up time of 92.7 months. Twenty-eight patients had anastomotic stricture recurred, 16 of which were treated with reoperation, 10 were treated with endoscopic stent implantation, and 2 cases were treated with balloon dilatation in interventional department; the stricture was repaired again in all cases. Thirteen patients had recurrent cholangitis, showing no obvious anastomotic stricture on MRCP, and symptoms can be effectively controlled after conservative treatment. (5) Results of the SF-36 scale assessment: 181 patients with bile duct injury completed the SF-36 scales before definitive repair surgery, and 157 completed one year after definitive repair surgery. All the 50 patients without complications completed SF-36 scales one year after LC. The scores of HRQOL in physiological function, role functioning, somatic pain, general health, vitality, social function, emotional function, mental health, the scores of physical component summary, and mental component summary of 181 patients with bile duct injury before surgery were 79±15, 65±12, 40±17, 42±14, 59±20, 27±15, 48±23, 56±22, 60±11, and 56±11, respectively. The above indices one year after definitive repair surgery were 87±10, 78±15, 71±20, 64±20、68±19, 70±25, 67±21, 69±23, 71±13, 68±15, respectively. The above indices of 50 patients without complications one year after LC were 90±13, 81±20, 87±16, 72±20, 73±15, 86±17, 79±22, 77±19, 82±18, 79±18, respectively. The 181 patients with bile duct injury had significant elevation in above indices one year after definitive repair surgery (t=2.051, 2.016, 3.875, 3.014, 2.563, 3.225, 2.964, 2.357, 2.150, 2.203, P 0.05). Conclusion Definitive repair surgery can significantly improve HRQOL in patients with bile duct injury caused by LC. Key words: Bile duct injury; Bile duct stricture; Cholangitis; Cholecystectomy; Health-related quality of life; Definitive repair surgery; Laparoscopy

A Comparative Study of Needlescopic Grasper Assisted Single Incision versus Three-Port versus Pure Single Incision Laparoscopic Cholecystectomy.

PurposeSingle incision laparoscopic cholecystectomy (SILC) is a surgical method to treat gallbladder disease designed to reduce postoperative pain and improve cosmetic results. However, pure SILC (pSILC) has several inherent limitations. In this study, we report the surgical outcomes of SILC with needlescopic grasper (nSILC) compared with those of pSILC and conventional three-port laparoscopic cholecystectomy (TPLC).MethodsThis retrospective study enrolled 103 patients who underwent laparoscopic cholecystectomy for benign gallbladder disease in our hospital between January 2013 and January 2015. Among them, 33 patients underwent pSILC, 35 underwent nSILC, and 35 underwent TPLC. We collected demographic characteristics and operative data to analyze outcomes between groups.ResultsAll procedures were done by laparoscopy and the gallbladder of each patient was completely removed. Women and younger patients were more to undergo SILC than TPLC. Analysis showed that the operation time of the nSILC group was longer than that of the TPLC group, but shorter than that of the pSILC group (skin to skin operation time [pSILC: 65.2±19.1 min, nSILC: 49.7±12.9 min, and TPLC: 43.4±14.7 min, p<0.001], and major procedure time [pSILC: 42.2±18.7 min, nSILC: 25.9±8.9 min, and TPLC: 23.4±12.7 min, p<0.001]). There were no significant differences between the groups for patient visual analogue scale score, length of hospital stay, or intraoperative blood loss.ConclusionnSILC is feasible surgical method in patients with benign gallbladder disease compared to TPLC, and that is an effective procedure to overcome the disadvantage of pSILC.

Complications of Laparoscopic Cholecystectomy

Background: laparoscopic cholecystectomy is now regarded as the "Gold Standard" treatment option for benign gallbladder disease. But it is not free of procedure related complications. Objective: To review the complications of laparoscopic cholecystectomy for gall stone disease.&#x0D; Materials &amp; Method: A prospective observational study was carried out over a period of 9 years beginning from 1st of July 2003 till 30th of June 2012 in Comilla Medical College Hospital and several private hospitals of Comilla. A total of 946 patients who underwent laparoscopic cholecystectomy for symptomatic and asymptomatic gallstone disease as confirmed by ultrasound scan were included. Patient having cirrhosis of liver, ischaemic heart disease, suspected carcinoma of gall bladder were excluded from the study. The outcome including the complications was analyzed.&#x0D; Result: Out of 946 patients 632 (66.80%) were females and 314 (33.19%) were males. Most (92.3%) of them were between 21-50 years of age. The commonest immediate complication was bleeding from liver bed (9.40%), from vascular injury in Callot's triangle (5.17%) and from the trocar site (4%). There was spillage of gallstones in 104(10.99%) cases. Bowel injury was seen in only one (0.10%) case. Bile leakage was observed in 4(.42%) cases that also include CBD injury .in 3 cases. The procedure was converted to open surgery in 11(1.17%) cases. Port site infection was seen in 43 (4.54%) cases. Late complications include port site hernia in 6 (0.63%) cases, port site keloid in 1 (.1%) case and CBD stricture in 5 (0.54%) cases. Mortality was unavoidable in in 2(0.21%) cases.&#x0D; Conclusion: With increasing experience laparoscopic cholecystectomy can be a safe and effective procedure for most patients with cholelithiasis. Proper training and sound knowledge of possible complications can yield favorable results and lesser complications.&#x0D; Journal of Surgical Sciences (2013) Vol. 17 (2) :73-79

Minimally Invasive Single-Site Cholecystectomy in Obese Patients: Laparoscopic vs. Robotic.

PurposeLaparoscopic cholecystectomy is treatment method for management of benign gallbladder diseases. Further attempts are made to operate single-port laparoscopic cholecystectomy. However, single-port laparoscopic cholecystectomy, the procedure remains technically difficult, especially in obese patient. Recently, a robotic surgical system for minimal invasive surgery was introduced to overcome the limitations of conventional laparoscopic surgery.MethodsFrom April 2009 to August 2017, we retrospectively reviewed the medical records of patients with single-site, minimally invasive (laparoscopic and robotic) cholecystectomy with high BMI (>25 kg/m2). We analyzed general characteristics and perioperative outcomes between the single-fulcrum laparoscopic cholecystectomy group and the robotic single-site cholecystectomy (RSSC) group.ResultsOperation time (57.56±11.10 vs 98.5±12.28 p<0.001) was significantly longer and postoperative pain score (3.61 vs 5.15 p=0.000) was significantly higher in the robotic single-site cholecystectomy (RSSC) group, but the actual dissection time (25.85±11.09 vs 25.79±13.35 p=0.978) was not significantly different between the two approaches. Iatrogenic gallbladder perforation, (13 vs 6 p=0.005), patients undergoing RSSC showed a significantly smaller amount than did those undergoing single-fulcrum laparoscopic cholecystectomy (SFLC).ConclusionIt is difficult to say for certain that RSSC is clearly better than SFLC in obese patients. However, because of the technical convenience and efficiency of surgery with RSSC, RSSC can be practically worthwhile. Further study is mandatory.

Incidental Gallbladder Cancer: A Clinicopathological Study

Abstract Objectives Incidental gallbladder cancer (iGBC) is defined as gallbladder cancer (GBC) diagnosed at the time of or after cholecystectomy, performed for unsuspected benign gallbladder disease. Being rare, it is found in 0.2% to 2.9% cases of cholecystectomies performed for cholecystitis and represents approximately 40% of all GBCs. Here, we present the clinical and pathological features of iGBC diagnosed at our institute over a 10-year period. Methods The pathology reports of GBC in patients who underwent simple cholecystectomies due to sole complain of cholecystitis between 2008 and 2018 were retrieved from electronic medical records. Cases with dysplasia (without invasive component), clinically suspected gallbladder malignancy, polyp (nonincidental), or cholecystectomies performed as a part of any other procedure were excluded. Results Twenty-two cases of iGBC were diagnosed during the study period. Average patient age was 69.59 (range; 48-91) years, with a slight female (n = 12, 54.5%) predominance. Most common site was body (n = 7), followed by fundus (n = 4), neck (n = 2), and unknown (n = 9). Mean tumor size was 1.6 cm, where measurement of tumor size was possible (n = 16). Histopathological diagnoses were adenocarcinoma (n = 21) and carcinosarcoma (n = 1). The AJCC tumor staging was pT1a (n = 3), pT1b (n = 3), pT2 (n = 12), pT3 (n = 3), and unidentifiable (n = 1). Four cases were identified with N1 lymph node status. Cystic duct margin was positive in two cases. Perineural invasion was identified in three cases. Conclusion iGBC after a cholecystectomy for clinically benign condition is a rare finding. Although cholecystitis is much more frequent in female, iGBC had only a slight predominance for female population in our study. It is more common in people over 60 years of the age, which is comparable to the literature. This entity still remains a diagnostic and therapeutic challenge, and management is often more complicated in cases with advanced stage.

Outcomes of laparoscopic cholecystectomy for xanthogranulomatous cholecystitis.

Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder with distinct histopathological characteristics. Laparoscopic cholecystectomy (LC) is currently the standard treatment for gallbladder disease. However, the outcomes of LC for XGC have not been completely investigated, due to the rarity of XGC. The present study aimed to assess the surgical outcomes of LC for XGC. Among 3,037 patients undergoing cholecystectomy between 2005 and 2017 at our institution, 58 patients (1.9%) were diagnosed with XGC based on histopathology. Of the patients, LC was performed in 38 (65.5%), and they were enrolled in the present study. The outcome of LC for XGC in the cases was assessed, and was compared with outcomes of LC for other diseases. The average operation time was 109±36 min, and average intraoperative blood loss was 58±85 ml. LC was converted to open cholecystectomy in 6 (15.8%) of the 38 cases. No operative mortality occurred. One patient developed postoperative complications greater than grade II in the Clavien-Dindo classification, and the mean postoperative hospital stay was 6.1±5.8 days. Based on previous reports and the nature of XGC itself, the outcomes reported herein of LC for XGC seemed acceptable. It should be also noted that LC for XGC exhibited a higher conversion rate compared with LC than other benign gallbladder diseases, implying that LC for XGC remains challenging.

Role of Ultrasound in the Diagnosis and Management of Gall Bladder Diseases

Background &amp; objective: The majority of published data on the sensitivity and specificity of ultrasound (US) in the diagnosis of gallbladder pathology was conducted over 30 years ago. Since then the quality and resolution of ultrasonography has improved significantly. It is, therefore, essential to asses afresh whether the progression in technology has translated into improved diagnostic accuracy. The present study was undertaken to find the usefulness of US in diagnosing gallbladder diseases with particular reference to cholecystitis and gall bladder carcinoma.&#x0D; Methods: This cross-sectional observational study was conducted at the Department of Radiology and Imaging, Rajshahi Medical College, Rajshahi in collaboration with the Departments of General Surgery and Histopathology of the same Medical College between July 2016 to June 2018. A total of 128 patients were initially included on the basis of signs and symptoms of gallbladder diseases. All these patients were subjected to abdominal US to achieve a ultrasonic diagnosis of gall bladder disease followed by histopathological examination of biopsy material taken from the gall bladder or specimen of the operated gall bladder. The accuracy of ultrasound in the diagnosis of gall bladder diseases was determined by comparing the ultrasound sound diagnosis with that of histopathological diagnosis. In particular, the role of ultrasound was evaluated in the differentiation of benign gall bladder diseases from those of malignant ones.&#x0D; Result: Age distribution of the patients shows that over one-third (35.9%) was ≥50 years old followed by 24.9% 40-50 years, 21.9% 30 - 40 years and 16.4% 20 – 30 years old with mean age of the patients being 43.8(range: 18-80) years. Females outnumbered males by roughly 11:9. In terms of BMI, 6.2% were underweight, 16.4% overweight, and 4.7% obese. The predominant complaints reported by the patients were pain in the right upper abdomen (95.3%), epigastric pain (94.7%), abdominal discomfort (96.9%) followed by nausea (75%), low-grade fever (37.5%), jaundice (26.6%) and vomiting (26.6%). Approximately 44% of the patients exhibited anaemia. Nearly half (46.1%) of the patients exhibited sonographic Murphy’s sign. Hyperechoic echo character was invariably obtained with 12.5% cases having hypoechoeic character as well. Over 90% of the patients had gall-stones, 62.5% cholecystitis (thickened gall-bladder wall). Ultrasound comment on the type of diseases revealed that 112(87.5%) were benign diseases and 16(12.5%) malignant cases. Approximately 55% of the gall bladder diseases diagnosed by histopathology were cholecystitis. Histopathological comment shows that about 90% of the diseases were benign and the rest (10.2%) were malignant. The sensitivity of ultrasound in diagnosing cholecystitis was 85.9%, while the specificity of the test was 60.9% with overall diagnostic accuracy of the test being 73.4%. The US had a optimum sensitivity (84.6%) and high specificity (95.6%) in diagnosing gall-bladder carcinoma.&#x0D; Conclusion: The study concluded that US could be considered as the preferred initial imaging technique for patients who are clinically suspected of having acute calculous cholecystitis. It is also a useful imaging modality for diagnosing gall-bladder malignancy. Thus, US can be dependably used in the primary evaluation of heptobilliary pathology.&#x0D; Ibrahim Card Med J 2017; 7 (1&amp;2): 70-75

Correction to: Authors' Reply: Routine Pathology and Postoperative Follow-Up are not Cost-Effective in Cholecystectomy for Benign Gallbladder Disease.

In the original article, Madelon J. H. Metman's given name is incorrect. It is correct as reflected here.

Evaluating the early impact of Medicaid expansion on trends in diagnosis and treatment of benign gallbladder disease in Kentucky.

In January 2014, Kentucky expanded Medicaid coverage in an effort to improve access to healthcare. This study evaluated the early impact of Medicaid expansion on diagnosis and treatment of benign gallbladder disease in Kentucky. Administrative claims data were queried for patients undergoing cholecystectomy for benign gallbladder disease between 2011 and 2015. Demographic, procedure, and outcome variables from 2011 to 2013 (PRE) and 2014-2015 (POST) were compared. After Medicaid expansion, patients were more likely to have their operation performed as an outpatient (80.0% vs. 78.2%, p < 0.001). A significant trend was noted toward a shorter hospital stay (p < 0.001) among inpatients. For both inpatients and outpatients, a significant shift was noted toward increased hospital charges (p < 0.001). The expansion of Kentucky Medicaid in 2014 has been associated with an increase in outpatient cholecystectomy, shorter hospital stays for inpatients, and increased hospital charges for both inpatients and outpatients. Increased charges for all procedures may represent a mechanism for hospitals to offset the cost of providing global care for more patients.

Teaching and learning of laparoendoscopic hernia surgery in India: A challenge – problems and solutions

INTRODUCTION: One German surgeon (Eric Muhe in 1985)* and three French surgeons** (Philippe Mouret in 1987, Jacque Perissat in 1989, and Dubois F in 1990) are credited with having performed first* laparoscopic cholecystectomy and first** video-assisted laparoscopic cholecystectomy, respectively. Laparoscopic cholecystectomy became the procedure of choice (gold standard) for benign symptomatic gallbladder disease as well as asymptomatic gallbladder stones in India. There have been adoption and acceptance for laparoendoscopic incisional/ventral hernia repair. Actually, laparoendoscopic repair of incisional/ventral hernia, laparoscopic solid organ removal (spleen and adrenal), and laparoscopic fundoplication (gold standard) have been standard of care even in the absence of Level 1 evidence over the past three decades. AIM: However, acceptance, adoption, adaptation, and performance of laparoendoscopic groin hernia surgery have been slow over the past three decades among practicing surgeons and surgical trainees. RESULTS: The laparoendoscopic groin hernia repair has yet not gained the same status as for the procedures mentioned above (VS). The reasons are multifactorial and relate to obtaining adequate and proper training covering laparoendoscopic groin hernia repair. The first and foremost reason is that endoscopic repair of groin hernia is considered an advanced laparoscopic procedure as opposed to open hernia repair. Preceptorship–proctorship (PP) model, which worked extremely effectively for teaching and learning of laparoscopic cholecystectomy, could not be established for groin hernia yet. There is no effective simulator developed for any of the standardized techniques, i.e., totally extraperitoneal (TEP) and/or transabdominal preperitoneal repair (TAPP). The complications, for example, intestinal obstruction and major vascular injury, which were never seen during open era, also brought about criticism as well hampered the growth of laparoendoscopic groin hernia repair. In emerging economies such as India and other Asian countries, high cost of laparoendoscopic repair (tacker and specialized meshes) has been responsible for reduced penetration among practicing surgeons and patients. Therefore, the laparoendoscopic repair of groin hernia has been limited to major metropolitan corporate hospitals and small number of tertiary care public hospitals in metropolitan cities. The advantages of minimally invasive approaches for the repair of groin hernias have not benefited the masses in rural and semi-urban geographic areas of India. CONCLUSION: Training opportunities for the teaching and learning laparoendoscopic repair of groin hernia have remained limited for vast majority of practicing surgeons and surgical trainees in India. With development of cadaveric (TEP and TAPP) and live anesthetized animal model (TAPP), it has been possible to establish training opportunities for practicing surgeons at few institutions. We also recommend and encourage expert surgeons to provide training opportunities for those who wish to learn the surgical skills of laparoendoscopic repair of groin hernia by giving their time for PP model. Furthermore, establishment of specialized hernia centers will go a long way to fill this void.