Concerning Trends in Acute Care Surgeries Among General Surgery Trainees.

Abstract Introduction UK practice is to perform pre-operative magnetic resonance cholangiopancreatography (MRCP) in patients with risk factors to detect CBD stones. Intraoperative laparoscopic ultrasound (IOUS) of the CBD is an alternative diagnostic modality that can be performed during laparoscopic cholecystectomy. This study aimed to evaluate the cost-effectiveness of routine IOUS versus pre-operative MRCP in detecting CBD stones. Method We conducted a retrospective review of all laparoscopic cholecystectomies over 7 years 2018 to early 2025. Key outcomes included Cost effectiveness of the procedure, detection of CBD stones. We compared costs of the two strategies. This was also compared to our previously published data for the years 2015-2018. Results During our study 1065 cases had deranged liver function tests or dilated bile ducts on ultrasound warranting MRCP scan, out of which 47 had preoperative MRCP. 1018 patients were suspected to have common bile duct (CBD) stones, but they had IOUS instead. Only ten patients (0.9 %) required a postoperative MRCP due to signs of retained stones of those only 4 were positive. Showing a sensitivity of 98.9%. The IOUS strategy spared an estimated 1008 peri-operative MRCP scans. The approximate cost of imaging/procedures in the IOUS strategy was £132,000 compared to £368 k for the MRCP-first strategy, spared 420 hours of Magnetic resonance imaging. IOUS use also shortened hospital stay, by enabling definitive one-stop management. Conclusions This approach significantly reduces healthcare costs, avoids delays, and improves patient flow and comfort. Wider adoption of IOUS in gallstone disease management could confer both clinical and economic benefits.

Abstract Introduction Spontaneous perforation of the common bile duct (CBD) is an uncommon clinical entity, typically reported in infants. In adults, it is usually secondary to impacted choledocholithiasis or biliary tract malignancy, with most perforations occurring in the extra-hepatic biliary system. Case Presentation We present a case of spontaneous extra-hepatic CBD perforation in an otherwise well woman in her seventh decade, with a background of COPD, hypertension, and Mounjaro therapy. She had no prior abdominal surgery or trauma. She presented with a short history of systemic upset, fever, and generalized peritonism. CT imaging revealed intra-peritoneal free fluid in the upper abdomen without pneumoperitoneum, and no clear source identified. Emergency diagnostic laparoscopy, converted to upper midline laparotomy, confirmed free bile was found, prompting conversion to laparotomy. The supra-duodenal CBD appeared bile-stained, raising suspicion of perforation. The lesser sac was clear. After abdominal washout and drain placement, she was transferred to intensive care. She was nursed in ITU. On day 4, Endoscopic Retrograde Cholangio-Pancreatography confirmed a leak at the junction of the cystic duct and CBD. No filling defects or strictures were noted. Biliary brushings were negative, and two plastic biliary stents were placed. She recovered uneventfully, with cessation of drain output and subsequent discharge home. Biliary brushings revealed no evidence of malignancy. Discussion Although rare, spontaneous CBD perforation should be considered in the differential diagnosis of bile peritonitis without obvious cause. Management principles align with those for iatrogenic bile leaks: early source control, sepsis management, biliary decompression, and multidisciplinary input are key to favourable outcomes.

Abstract Aim Gallbladder disease is a prevalent surgical conditions, affecting approximately 15% of the population. Of these, about 15% develop common bile duct (CBD) stones. We have aimed to evaluate our current practice of managing this via ERCP followed by laparoscopy cholecystectomy (LC) looking at the operational and financial efficiency Method A retrospective review was conducted of patients undergoing the two-stage pathway (ERCP ± CBD stent ± stent removal followed by LC) between September 2023 and September 2024. Inclusion criteria covered all patients deemed fit for further surgical intervention. Data collected included demographics, admission type, timing and number of ERCPs, and surgical outcomes. Results Out of 500 patients screened, 61 met the inclusion criteria. The majority were female (77%), with a male-to-female ratio of 1:2.3. The mean age was 56.7 years (±15.9). The mean length of hospital stay was 6.5 days (±4.1), with a readmission rate of 11.7%. Ten patients had yet to undergo LC, and three had not had stent removal at the time of analysis. On average, each patient underwent 1.9 ERCPs. The cost for these 61 patients, based on national tariffs, was £350,233. Modelling suggests that a one-stage approach using LC + LCBDE could reduce this to approximately £160,000. Conclusions This review supports the growing body of evidence that a one-stage approach using LC + LCBDE offers greater clinical, and cost-efficiency compared to the traditional two-stage pathway. Where expertise and facilities allow, LC + LCBDE should be considered the standard of care to reduce healthcare costs, improve outcomes, and minimise patient burden.

Abstract Aim Evidence on timing of LC post ERCP for CBD stones is limited. Our aim was to determine the probability of recurrent gallstone events following ERCP ST in patients who did not have LC and to determine the interval from index ERCP at which they occur. Method We analysed ERCP procedures performed between 1/1/2022 and 31/12/2023 in a single DGH. We included patients who had ERCP ST for gallstone disease and did not have LC prior to index ERCP. We followed up patients to the date of LC or until 8/11/2024. Statistical analysis was performed using Welch’s t-test, Fisher’s exact test and chi-squared test. Results 142 patients were included (54% female). For 79 (56%) patients who did not have LC the median follow up was 647 days (131-1039). 17 (12%) suffered from further episodes of gallstone disease. 15 (88%) required hospital admissions. The median length of stay was 9 days (3-22 days). The median time from index ERCP to developing a gallstone complication was 86 days (11-592). Five (29%) developed recurrent gallstone events within 6 weeks. Univariable analyses showed no significant association between recurrence and age (mean 69.0 vs 66.9 years; p = 0.72), gender (p = 1.00), or post-ERCP complications (p = 1.00). Patients who had index ERCP ST for cholangitis had a higher recurrence rate of 21% (p = 0.09). Conclusions The probability of developing gallstone events following ERCP ST was 8% per year. 3.5% of patients suffered from a recurrent event within six weeks. Fit patients should be offered early LC.

Abstract Aim Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is increasingly recognised internationally as a safe, minimally invasive alternative for patients unfit for emergency cholecystectomy. It also offers value as a rescue option following failed biliary drainage. Despite growing use abroad, no standardised pathway currently exists in the UK. This study evaluates the feasibility and safety of EUS-GBD in both primary and rescue settings. Method A retrospective review was conducted of 15 patients who underwent EUS-GBD at a UK tertiary centre. Nine acutely unwell patients were deemed unfit for surgery and received EUS-GBD as primary management. Six underwent the procedure as a rescue intervention after failed common bile duct stenting. All were referred after consultant-led multidisciplinary review. Demographics, indications, procedural details, outcomes, and complications were analysed. Results Technical and clinical success was achieved in all 15 cases (100%). Median age in the primary group was 80 years (44.4% female), and 77 years (33.3% female) in the rescue group. Lumen-apposing metal stents were used in all cases. No complications related to the procedure were observed (0/15), either immediately or during follow-up. These findings demonstrate consistent success across both groups, supporting the safety and feasibility of EUS-GBD in a UK setting. A draft clinical outline and supporting procedural video were included to aid future integration into routine care. Conclusions EUS-GBD is a safe and effective option for gallbladder drainage in surgically unfit and rescue cases. These findings support broader consideration and future integration into UK practice.

When bile meets necrosis: Rare spontaneous communication of common bile duct with pancreatic WON.

The article is devoted to the treatment of patients with choledocholithiasis. The issues of treatment of complex choledocholithiasis – an unremovable calculus of the common bile duct were considered. The results of 7 patients with complex choledolithiasis were analyzed. A method of stenting the common bile duct was proposed; when analyzing the results, it was noted that the size of the stones decreased in most patients – during rehospitalization, stones were not found in 2 patients, in the remaining 5 patients, stones were removed; a conclusion was made about the effectiveness of the staged treatment of patients in such situation.

PurposeThis study aimed to construct and compare machine learning models for predicting recurrent extrahepatic bile duct stones after common bile duct exploration and to clarify the contribution of key risk factors using SHAP analysis, thereby providing a reliable tool for clinical risk assessment and intervention.MethodsRetrospective analysis of 1,363 patients (2010–2024, Huangshi Central Hospital/Honghu People’s Hospital) with extrahepatic bile duct stones (156 recurrent cases). LASSO regression selected 8 predictors; 9 machine learning models were built, evaluated by AUC, accuracy, etc., and SHAP interpreted the optimal model.ResultsRandom Forest (RF) performed best: training/validation/external cohort AUC 97.99%/93.66%/83.1%, accuracy 0.953/0.902/0.829. SHAP identified maximum stone diameter, common bile duct diameter, and direct bilirubin as top risks, with nonlinearity (stones >15 mm elevated risk) and synergistic interactions.ConclusionRandom Forest (RF) is confirmed as the most reliable tool for predicting recurrent extrahepatic bile duct stones post-common bile duct exploration, outperforming other models in generalization. SHAP analysis clarifies that max stone diameter, CBD diameter, and direct bilirubin (with nonlinear effects like stones >15 mm elevating risk) are key synergistic risks. This study enables personalized clinical risk assessment and targeted interventions to reduce postoperative recurrence.

Abstract Purpose Laparoscopic cholecystectomy (LC) in patients with situs inversus totalis (SIT) is technically challenging due to the reversed anatomical orientation of the thoracoabdominal organs, which can increase operative complexity and the risk of complications. Although the incidence of cholelithiasis and cholecystitis in SIT is similar to the general population, altered anatomy may lead to diagnostic and intraoperative uncertainty. We describe LC in a patient with SIT using intraoperative indocyanine green (ICG) fluorescence cholangiography to guide the identification of biliary structures. Methods Preoperative ultrasound, computed tomography, and magnetic resonance imaging are used to delineate anatomy and exclude biliary duct dilation or biliary anomalies. ICG (0.5 mL of 2.5 mg/mL) is administered intravenously one hour before surgery. A mirror-image port configuration is employed centered on the left hemiabdomen, with the surgeon standing on the patient’s right and the assistant on the left. During surgery, ICG fluorescence cholangiography is utilized intraoperatively to enhance visualization of the biliary anatomy and facilitate attainment of the critical view of safety. Results LC was successfully performed without complications. ICG imaging enabled clear identification of the cystic duct and common bile duct, mitigating the risks associated with anatomical variation in SIT. Conclusion LC in patients with SIT is rarely described and technically demanding due to reversed intra-abdominal anatomy. ICG fluorescence cholangiography is an innovative tool and valuable adjunct that improves biliary visualization and may enhance safety in complex anatomical settings.

This study aimed to assess the feasibility and safety of laparoscopy combined with ultra-fine choledochoscopy for treating cholecystolithiasis with Small-diameter choledocholithiasis (common bile duct ≤ 0.8 cm). Fifty-eight patients diagnosed from June 2020 to December 2022 were retrospectively analyzed. To validate the protocol, we retrospectively analyzed two groups of patients managed with either T-tube placement (n = 30) or primary suture (n = 28) following stone extraction. The T-tube group underwent laparoscopic cholecystectomy with transcystic stone extraction and T-tube drainage, while the primary suture group underwent the same procedure with primary closure. Baseline data (total bilirubin, AST, GGT, ALT, comorbidities, albumin, age, gender, BMI, alcohol use, smoking) and perioperative outcomes were recorded. Follow-ups of at least 12 months were conducted to monitor postoperative complications. The retrospective validation showed no significant differences in baseline characteristics between the two groups (P> 0.05). No significant differences were observed between groups in operative time, blood loss, stone size/number, infection, bile leakage, or hospital stay (P> 0.05). The overall complication rate was 10% (6/58), and no deaths occurred. Follow-up ranged from 12 to 40 months (median 24 months). During the follow-up period, which relied on clinical and biochemical monitoring, no symptomatic biliary strictures or stone recurrences were identified. These findings suggest that laparoscopic transcystic ultra-fine choledochoscopy is a safe, feasible, and effective approach for managing cholecystolithiasis with Small-Diameter choledocholithiasis, offering satisfactory perioperative outcomes and long-term safety.

Abstract Background The optimal timing for laparoscopic cholecystectomy (LC) following endoscopic common bile duct stone extraction remains controversial, with no definitive evidence establishing the best time for surgery. Timing ranges from early (within 72 h) to late (beyond 7 days or extending up to 4–6 weeks), but the outcomes of these timings are still debated. There is substantial concern regarding the recurrence of biliary events while waiting for surgery. Aim This study aims to evaluate the safety and feasibility of index laparoscopic cholecystectomy (performed during the same admission) after the successful clearance of common bile duct stones. Methods Fifty patients were randomly assigned to either the index or delayed group. In the index group, LC is performed on the next day after successful endoscopic clearance of stones from the common bile duct during the index (same) admission, whereas it is performed after 6 weeks for the delayed group. Results The incidence of recurrence of biliary events is 28% in the delayed group, which is significantly higher than in the index LC group ( p = 0.004 ). The delayed group carries a higher risk of morbidity (risk ratio 2, risk difference 0.28, 95% confidence interval 0.98 to 4.1, p = 0.04). The overall hospital stays are significantly shorter in the index group than in the delayed group (mean 3.28 ± 1.7 vs 5 ± 2.1 days, respectively). There is also no difference between the two groups in conversion to open. Conclusion Index laparoscopic cholecystectomy is a feasible procedure that can be performed safely, resulting in reduced overall morbidity, shorter hospital stays, and improved outcomes concerning intraoperative difficulty. Furthermore, it may help prevent future episodes of biliary events.

Isolated common bile duct dilation on pre-operative ultrasound is not a predictor of choledocholithiasis on intraoperative cholangiogram.

BackgroundThere has been a shift in the management of choledocholithiasis from laparoscopic common bile duct exploration to endoscopic retrograde cholangiopancreatography. This has led to an increase in hospital length of stay, costs, and specifically for rural hospitals, transfer to a tertiary center for ERCP. Given this shift of choledocholithiasis management to advanced GI endoscopists, general surgery residents are rarely performing laparoscopic transcystic common bile duct explorations.MethodsA retrospective study of 69 consecutive laparoscopic transcystic common bile duct explorations (LCBDE) performed by 2 general surgeons in a rural community over 5years between 2017 and 2022. Primary outcomes included successful duct cannulation, successful stone clearance, instruments used, operative time, and significant complications (pancreatitis, bile leak, bleeding, bile duct injury). Specific technique for laparoscopic transcystic common bile duct exploration is outlined in Appendix 1.ResultsThere was a median age of 54years (Range 17-91). There was successful cannulation in 97% and successful stone clearance in 82% of cases. In the vast majority of cases only a guide wire and biliary balloon dilation catheter were utilized to perform the procedure. Median operative time for laparoscopic cholecystectomy with cholangiogram was 40minutes. Median operative time for laparoscopic cholecystectomy with cholangiogram and transcystic common bile duct explorations was 64minutes (Range 39-168). Therefore, the median time added by performing LCBDE was 24minutes There were no complications during laparoscopic transcystic common bile duct explorations.ConclusionsLaparoscopic transcystic common bile duct exploration can be safely, efficiently, and successfully performed with 0.035-inch Roadrunner PC guidewire, TAUT intraducer and an Advance Biliary Balloon Catheter. In order to shift the management of choledocholithiasis back to the general surgeon to decrease the length of stay and cost, there needs to be a change at the residency training level.

Neighboring tissues as diagnostic windows: Neighborhood effects in radiomic detection of pancreatic ductal adenocarcinoma.

BackgroundSubtotal cholecystectomy (STC) is increasingly used as a safe technique for managing difficult gallbladders to reduce the risk of common bile duct (CBD) injury. However, techniques and outcomes vary across institutions, and standardised reporting remains limited.ObjectiveTo evaluate peri-operative and post-operative outcomes following STC at a single tertiary centre and to explore pre-operative factors associated with the need for STC, including the frequency of previous gallstone-related admissions and radiologic markers such as impacted infundibular or neck stones, thickened or contracted gallbladder, and imaging features suggestive of a frozen Calot’s triangle.MethodsRetrospective cohort study of consecutive patients undergoing STC between January 2021 and January 2024. Data included demographics, indications, operative technique (fenestrating vs. reconstituting), intra-operative findings, complications, and long-term biliary outcomes. The primary endpoint was clinically significant bile leak; secondary outcomes were reoperation, endoscopic retrograde cholangiopancreatography (ERCP) requirement, readmission, and mortality.ResultsThirty-nine patients underwent STC (97% laparoscopic, 3% open). Median age 49 years with a mean BMI of 39 kg/m2. Bile leak occurred in 2.6% (n = 1), reoperation 0%, ERCP 2.6% (n = 1), readmission 0%, and mortality 0%.ConclusionsSTC offers a safe alternative to total cholecystectomy in complex cases, though bile leak remains an important morbidity. Technique type and intra-operative factors influence outcomes, highlighting the need for standardised approaches and careful case selection.

Background. Cholestasis (bile stagnation) is known as a severe complication of many diseases of the liver and biliary tract. It occurs when the flow of bile from the liver into the duodenum is impaired resulting in digestive disorders (especially those of lipid metabolism) and accumulation of bile components (bilirubin, bile acids, cholesterol) in blood and then in the brain, the latter inducing the disturbances in the brain structure and functions. It was of interest to clarify the molecular mechanisms of the disorders, in particular the roles of c-fos protein and calbindin in the adaptation mechanisms of cingulate cortex neurons to cholestasis. Objective. To evaluate the effect of cholestasis on the content of c-fos protein and calbindin in neurons of the rat cingulate cortex. Material and methods. The object of the study were neurons of the small-cell and large-cell layers of the anterior cingulate cortex of the rat brain on days 2, 5, 10, 20, 45 and 90 after ligation/transection of the common bile duct (CBD) or sham surgery (a control group). Histological, immunohistochemical, morphometric and statistical methods were used. Results. An increase in the number of neurons with high c-fos immunoreactivity is observed even at early stages of cholestasis, reaching its maximum by the 5th day and remaining significantly elevated on the 10th-20th days (the peak of cholestasis), the number gradually decreasing with the elimination of cholestasis. The content of calbindin in neurons of both cingulate cortex layers of the rat brain increases significantly on the 10th and 20th days, then decreases on the 45th day. On the 90th day, the contents of c-fos and calbindin in neurons of the cingulate cortex normalize (do not differ from that of control). Conclusion. Cholestasis is marked by the growth in the number of neurons with increased immunoreactivity of c-fos protein and calbindin in the small-cell and large-cell layers of the rat cingulate cortex.

A novel endoscopic lithotripsy technique for a huge common bile duct stone: endoscopic snare lithotripsy.

Edwardsiella tarda (E. tarda) is a rare human pathogen. Extra-intestinal infections of E. tarda are particularly uncommon, with only one case of recurrent cholangitis caused by E. tarda reported to date. A 77-year-old man suffered acute calculous cholecystitis 5 days after eating eel and raw fish. Culture results from bile obtained via percutaneous gallbladder drainage revealed E. tarda infection, and an 8-day course of intravenous cefmetazole led to clinical resolution. However, the patient returned with fever and laboratory signs of obstructive cholangitis 5 weeks later. Contrast-enhanced computed tomography showed a migrated gallstone in the distal common bile duct. Endoscopic retrograde cholangiopancreatography drained the purulent bile, and cultures from the bile and blood were again positive for E. tarda. A 10-day course of cefmetazole, along with biliary stent placement resulted in complete recovery. E. tarda can cause relapsing biliary tract infections despite appropriate initial treatment. Clinicians should consider this rare pathogen in cases of recurrent cholangitis, especially for patients with recent consumption of raw or undercooked aquatic animals. A detailed dietary history and targeted microbiological testing are essential for accurate diagnosis and management.

Abstract Introduction Chronic ketamine abuse is a growing public health concern associated with severe organ damage. While ketamine‐induced uropathy and cholangiopathy are well‐documented complications individually, their simultaneous presentation is rare. This dual‐system involvement, however, provides a key diagnostic clue on imaging. Case Presentation A 37‐year‐old female with a long‐standing history of substance abuse presented with fever, right loin pain, and deranged liver function tests showing a cholestatic pattern. Urgent computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) were performed. Imaging revealed a distinct combination of findings: dilatation of the common bile duct and bilateral hydronephrosis. Key features included diffuse, smooth enhancement of the urothelium and the absence of mechanical obstruction in either the biliary or urinary systems. Conclusion The constellation of non‐obstructive biliary dilatation and inflammatory hydronephrosis is a classic presentation of ketamine‐induced cholangiopathy and uropathy. This case underscored the importance of recognizing this specific dual‐system injury pattern in a young patient. A high index of suspicion is crucial for diagnosis, as the history of illicit drug use is often underreported. Effective multidisciplinary communication is paramount to connect the clinical and radiological findings, ensuring an accurate and efficient diagnosis.