Complication Of Gallstone Disease Research Articles

Symptomatic uncomplicated gallstone disease is associated with a high short-term risk of gallstone-related complications: a contemporary cohort study

Background The natural history of symptomatic uncomplicated gallstone disease is largely unknown. We examined the risk of progressing from symptomatic uncomplicated to complicated gallstone disease in a large regional cohort of patients, where disruptions in elective surgical capacities have led to the indefinite postponement of surgery for benign conditions, including cholecystectomies. Methods Patients with radiologically diagnosed incident symptomatic and uncomplicated gallstone disease were identified from outpatient clinics and emergency departments on the Island of Funen, Denmark. The absolute risk of complications (cholecystitis, cholangitis, pancreatitis, acute cholecystectomy for unremitting pain) was calculated using death and elective cholecystectomies as competing risks using the Aalen-Johansen method. Cox proportional hazards regression analysis was used to estimate hazard ratios (HRs) of gallstone complications associated with patient and gallstone characteristics. Results Two hundred eighty-six patients diagnosed with incident symptomatic, uncomplicated gallstone disease from 1 January 2020 to 1 July 2023 were identified. During 79,170 person-years of observation, 176 (61.5%) patients developed a gallstone-related complication. The 6-, 12- and 24-month risk of developing gallstone-related complications were 36%, 55% and 81%. The risk of developing complications related to common bile duct stones was lowest with larger stones (aHR per millimeter increase = 0.89 (0.82–0.97), p < 0.01), while no covariates were statistically significantly associated with the risk of cholecystitis. Eighty-five (30%) patients underwent elective laparoscopic cholecystectomy, with one patient (1.2%) developing a gallstone-related complication afterward. Conclusions The risk of developing complications to symptomatic gallstones in a general Scandinavian population is high, and prophylactic cholecystectomy should be considered.

The Diagnosis and Treatment of Acute Cholecystitis: A Comprehensive Narrative Review for a Practical Approach.

Acute cholecystitis (AC), generally associated with the presence of gallstones, is a relatively frequent disease that can lead to serious complications. For these reasons, AC warrants prompt clinical diagnosis and management. There is general agreement in terms of considering early laparoscopic cholecystectomy (ELC) to be the best treatment for AC. The optimal timeframe to perform ELC is within 72 h from diagnosis, with a possible extension of up to 7-10 days from symptom onset. In the first hours or days after hospital admission, before an ELC procedure, the patient's medical management comprises fasting, intravenous fluid infusion, antimicrobial therapy, and possible administration of analgesics. Additionally, concomitant conditions such as choledocholithiasis, cholangitis, biliary pancreatitis, or systemic complications must be recognized and adequately treated. The importance of ELC is related to the frequent recurrence of symptoms and complications of gallstone disease in the interval period between the onset of AC and surgical intervention. In patients who are not eligible for ELC, it is suggested to delay surgery at least 6 weeks after the clinical presentation. Critically ill patients, who are unfit for surgery, may require rescue treatments, such as percutaneous or endoscopic gallbladder drainage (GBD). A particular treatment approach should be applied to special populations such as pregnant women, cirrhotic, and elderly patients. In this review, we provide a practical diagnostic and therapeutic approach to AC, even in specific clinical situations, based on evidence from the literature.

Surgeon-Performed Percutaneous Endoscopic Biliary Lithectomy: Description of a Novel Technique and Initial Results.

Introduction: Percutaneous endoscopic biliary lithectomy (PEBL) can be performed through preexisting drain tracts, offering ductal clearance and definitive management for patients with complicated gallstone disease unable to undergo conventional therapy. The technique has not been widely adopted by general surgeons. Herein, we describe our technique with surgeon-performed PEBL and present initial results. Materials and Methods: A single institutional retrospective review of the electronic medical record was performed for patients who underwent percutaneous choledochoscopy between February 2019 and November 2020. All operations were performed by 1 of 2 board-certified general surgeons with fellowship training in surgical endoscopy. Preoperative, operative, and postoperative variables were analyzed using descriptive statistics. Results: Thirteen patients underwent PEBL. Seventeen total procedures were performed; 4 patients underwent repeat intervention. The diagnoses leading to PEBL were: cholelithiasis (8), choledocholithiasis (4), and recurrent pancreatitis (1). Complete ductal clearance was achieved in 9 patients (69.2%) during the initial procedure. The remaining 4 patients (30.8%) underwent repeat PEBL, at which point complete ductal clearance was then achieved. The percutaneous drain was removed at the time of final procedure in 5 patients (38.5%) or within 5 weeks in the remaining 8 (61.5%). No intraoperative complications occurred, and no pancreatic or biliary postoperative complications or recurrences were noted with a mean follow-up of 279 ± 240 days. Conclusion: Surgeon-performed PEBL is a safe and effective method of achieving biliary ductal clearance. The technique is readily achieved following basic endoscopic and fluoroscopic principles and should be understood by all physicians managing gallstone disease.

Comparative study of morbidity of open cholecystectomy vs laparoscopic cholecystectomy in complicated gall stone disease.

Objective: To evaluate the resist of minimally invasive surgery i.e. laparoscopic cholecystectomy versus open cholecystectomy in cases with complex gallstone diseases. Study Design: Prospective study. Setting: North Surgical Ward, Mayo Hospital Lahore. Period: 11th July 2020 till 10th January 2021. Material &amp; Methods: A total of 372 patient’s fulfilling the criterion was included for study in group-A Laparoscopic cholecystectomy was done. In group B open cholecystectomy was done which includes 86 patients. The entire patient received injection Ketorolac 30 mg i.e. 8 hourly and postoperative injection NeIbufin 6 mg i.v.12hourIy as standard in all patients and Post-operative pain was assessed Visual analogy scale after 24 hours. Results: The mean age of patients in open group was 41.28 ± 13.75 years and in Laparoscopic group was 43.46 ± 13.90 years. In Open group there were 80(43%) male and 106(57%) female cases while in Laparoscopic group there were 65(34.9%) male and 121(65.1%) female cases. The mean hospital stay was statistically shorter in Laparoscopic group (3.80 ± 1.37 days) as compared to Open group (5.12 ± 1.58 days), p-value &lt;0.001. In open group 77(41.4%) cases had post-operative pain and in Laparoscopic group 27(14.5%) cases had post-operative pain. The post-operative pain was statistically higher in open groups, p-value &lt; 0.001. Conclusion: Laparoscopic is an ideal treatment option in terms of less pain and shorter duration of hospital stay as compared to open cholecystectomy for patients with complicated gallstone disease.

New Developments in the Ultrasonography Diagnosis of Gallbladder Diseases

Gallbladder diseases are very common, and their diagnosis is based on clinical–laboratory evaluation and imaging techniques. Considering the different imaging diagnostic tools, ultrasound (US) has the advantage of high accuracy combined with easy availability. Therefore, when a gallbladder disease is suspected, US can readily assist the clinician in the medical office or the emergency department. The high performance of US in the diagnosis of gallbladder diseases is mainly related to its anatomic location. The most frequent gallbladder pathological condition is gallstones disease, easily diagnosed via US examination. Acute cholecystitis (AC), a possible complication of gallstone disease, can be readily recognized due to its specific sonographic features. Additionally, a number of benign, borderline or malignant gallbladder lesions may be detected via US evaluation. The combined use of standard B-mode US and additional sonographic techniques, such as contrast-enhanced ultrasonography (CEUS), may provide a more detailed study of gallbladder lesions. Multiparametric US (combination of multiple sonographic tools) can improve the diagnostic yield during gallbladder examination.

Mirizzi Syndrome-The Past, Present, and Future.

Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.

EGS P27 Twice Recurrent Gallstone Ileus Requiring 3 Laparotomies – A Case Report

Abstract Background Gallstone ileus is a well-known and not an uncommon complication of gall stone disease, with standard management being an enterotomy and extraction of the obstructing gallstone with management of the gallbladder and the billio-enteric fistula being deferred to an interval procedure if indicated. Recurrent gallstone ileus are not unheard of, but are quite rare and are the reason cited by the proponents of a single stage procedure. While a single stage procedure is possible - involving an enterotomy as well as a challenging cholecystectomy and the management and closure of a duodenal fistula – more commonly than not it is not performed. Methods Twice recurrent gallstone ileus is extremely rare and on performing a literature review only 1 published case report has been identified. Here we present the case of an 87-year-old Caucasian female, presenting with 3 incidences of gall stone ileus in a 30 day period requiring 3 laparotomies. Initial presentation to our institution was in November 2022 with a CT proven localised Gallbladder perforation. The first presentation with gallstone ileus was on 21/03/2023 with symptoms of bowel obstruction and CT proven obstructing 23mm gallstone 8 cm from the ileocaecal valve as well as pneumobillia and two other stones in the gallbladder. Results The index laparotomy was performed and no transition point was found, and bowel run-through from DJ to ICV revealed no intraluminal gall stones and the caecum was full of fluid. The gallstone had passed into the colon spontaneously and no enterotomy was performed. Two subsequent laparotomies were required due to CT proven incidence of recurrent Gallstone ileus on 30/03/2023 and 20/4/2023, were enterotomies were performed and the obstructing stones extracted each time. An informed decision not to tackle the gallbladder and the duodenal fistula was taken by a consensus of 3 consultant surgeons due to the frailty of our patient. Conclusions Our patient made a meaningful recovery after developing an entero-cutaneous fistula that resolved with conservative management and was discharged home on 15/05/2023. While our patient's frailty and previous gallbladder perforation made the decision not proceed with a cholecystectomy and repair of the duodenal fistula a straightforward one, the incidence of twice recurrent gallstone ileus in the span of a month raises questions as to whether other techniques should be considered in a more fit patient such as a single stage operation or a Cholecystolithotomy.

Cholecystectomy and ERCP in pregnancy: a nationwide register-based study.

The objective was to examine the outcomes of cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy and compare these outcomes with those in nonpregnant women of fertile age. Although both laparoscopic cholecystectomy and ERCP are considered safe and feasible in pregnant patients, there is still concern and uncertainty regarding gallstone intervention during pregnancy. This study aimed to investigate outcomes in pregnant patients compared to outcomes in nonpregnant patients. Data on all female patients aged 18-45 years were retrieved from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography. The patients were divided into groups according to intervention: cholecystectomy, ERCP, or a combination thereof. Differences between pregnant and nonpregnant patients were analyzed. A total of 21328 patients were included, with 291 cholecystectomy and 63 ERCP procedures performed in pregnant patients. At the 30-day follow-up, more complications after cholecystectomy were registered for pregnant patients. However, pregnancy was not a significant risk factor for adverse events when adjusting for previous complicated gallstone disease, intraoperative complications, emergency surgery, and common bile duct stones. There were no differences in outcomes when comparing cholecystectomy among the different trimesters. ERCP had no significant effect on outcomes at the 30-day follow-up. Cholecystectomy, ERCP, and combinations thereof are safe during pregnancy.

407 Robotic Assisted Cholecystectomy and Common Bile Duct Exploration for Single Stage Management of Complex Gallstone Disease

Abstract Aim Laparoscopic cholecystectomy and common bile duct exploration (LC-CBDE) is an alternative to endoscopic retrograde cholangiopancreatography (ERCP) for treatment of choledocholithiasis. The ‘Achilles heel’ of LC-CBDE is the choledochotomy incision and closure following duct clearance. Robotic assisted surgery (RAS) aspires to overcome these technical challenges by providing improved views (3D enhancement) and articulated instruments potentially improving surgical precision. We aim to scrutinise the outcomes of an early series of robotic assisted cholecystectomy and common bile duct exploration (RC-CBDE) cases performed at our institution. Method Retrospective analysis from a specialist benign pancreatico-biliary unit in the United Kingdom was undertaken from April 2022 – December 2022 inclusive. All patients who underwent RC-CBDE for complicated gallstone disease were included. Collated data included patient demographics, perioperative investigations, intraoperative approach, and postoperative outcomes. Results 10 patients were identified. Median (IQR) age was 51 (33 – 66) years. Median (IQR) BMI was 26 (21 – 32) kg/m2. Median (IQR) Charlson Co-morbidity Index (CCI) was 1 (0 – 4). 4 patients were operated on during the acute presentation, with median (IQR) bilirubin 51 (34 – 252.5). Median (IQR) operative time was 176 (124 – 222) minutes. Median (IQR) post-operative length of stay was 4 (1 – 5) days. One patient required reintervention for port site hernia repair from drain site. Conclusions RC-CBDE is a safe and effective treatment for choledocholithiasis with equivocal outcomes to LC-CBDE. Benefits of RAS include enhanced views and ergonomics aiding precise closure of choledochotomy, which may both reduce complications and promote wider uptake of common bile duct exploration – a previously underutilised, technically-challenging operative procedure.

Patients with complicated gallstone disease in the emergency department: clinical impact and cost-effectiveness of emergency department disposition decision.

ObjectiveThe objective of this study was to assess the 1‐year outcomes of emergency department (ED) patients with complicated gallstone disease, including surgery rates, initial admission rates, ED revisits, repeat hospitalizations, and cost.MethodsUsing 3 linked statewide databases from the Maryland Healthcare Cost and Utilization Project, we identified patients with a primary diagnosis of complicated gallstone disease treated in an ED between 2016 and 2018. We measured the healthcare use and direct costs in the ambulatory surgery, inpatient, and ED settings for 1 year after the initial ED visit. Finally, we performed a multivariate logistic regression analysis comparing initially admitted versus discharged patients.ResultsOf the 8751 patients analyzed, 86.8% were admitted to the hospital and 13.2% were discharged on their initial ED visit. Of the admitted patients, 78.7% received a cholecystectomy during the initial hospitalization plus 6.1% at a later date; of the discharged patients, 41.5% received a cholecystectomy. Admitted patients demonstrated lower recurrent gallbladder complications compared with those discharged (7.5% vs 44.5%), fewer ED revisits (4% vs 20.3%), and fewer repeat hospitalizations (4.5% vs 16.7%). Despite this, the 1‐year cost in the admitted patients was higher ($9448 vs $2933). Obesity, age, and mood disorders but not race, ethnicity, or zip code were associated with admission at initial ED visit.ConclusionsIn our single‐state analysis of ED patients with complications of gallstone disease, most patients are admitted on the initial visit and receive a cholecystectomy during that hospitalization. The discharged group had higher rates of 1‐year complications, ED revisits, and repeat hospitalizations but lower cost.

Experience of treating patients with complicated forms of gallstone disease on the background of liver cirrhosis

Annotation. In recent years, further improvement of minimally invasive surgical interventions has been noted. Surgical treatment of complicated gallstone disease has become quite standardized all over the world. However, accompanying cirrhosis of the liver remains the most severe comorbid condition. The purpose of this study is to determine the optimal treatment strategy of this category of patients. We analyzed the results of surgical treatment of 79 patients with complicated forms of gallstone disease and concomitant liver cirrhosis. All patients were conditionally divided into 2 groups: a control group of patients who were treated according to the standard program – 38 patients and the main group of patients who were treated using an improved diagnostic and treatment program – 41 patients. The patients of the retrospective group underwent a standard diagnostic and treatment program according to the recommendations for diagnosis and treatment of patients with complicated forms of gastrointestinal tract with correction of hepatorenal insufficiency. Since 2016, an updated diagnostic and treatment algorithm has been introduced in patients with complicated forms of gastrointestinal tract against the background of liver cirrhosis. All patients underwent a balanced approach in the analysis of manifestations of liver cirrhosis, which manifested itself in the introduction of the principles of controlled antibacterial therapy according to the level of C-reactive protein; differentiated implementation of thromboprophylaxis: according to the standard scheme and early postoperative thromboprophylaxis based on the risks of hemorrhagic complications. The results of this research were statistically analyzed using chi-square test and statistical comparison of both groups. According to the results of a comparative analysis of the results of the treatment of patients in both groups was performed, it was established that postoperative complications occurred both in patients of the main group and in the comparison group. However, the frequency of occurrence of complications in the groups of studied patients has a significant difference. In the main group, complications were 14.6% versus 34.2% (in the comparison group) at p≤0.05 (χ2=4.14), which indicates that the improved diagnostic and treatment program made it possible to significantly reduce postoperative complications, and the outcome of treatment of patients with complicated forms of gallstone disease.

Clinical Profile and Evaluation of Outcomes of Symptomatic Gallstone Disease in the Senior Citizen Population.

BackgroundThere is a heavy burden of gallstone disease on the world’s population. The incidence and severity of symptomatic cholelithiasis increase with age. There is often a delay in presentation, leading to complicated disease, diagnostic delay, and increased morbidity. There is a paucity of studies on the presentation and management of cholelithiasis in elderly persons from the western part of India. This study aimed to observe the spectrum of presentation and management of symptomatic cholelithiasis in senior citizens.Objectives The primary objective of this study was to describe the presentation, diagnosis and intraoperative findings of symptomatic gallstone disease (GSD) in patients aged over 60 years. The secondary objectives of this study were to find the association of GSD with age, sex, and comorbidities, including diabetes mellitus, hypertension, and thyroid disorders.MethodsAll patients above the age of 60 years presenting to the surgical outpatient and emergency departments from January 2020 to July 2021 with symptomatic GSD were included. Details of history, physical examination, blood investigations, and imaging of the abdomen (ultrasonography and Magnetic Resonance Cholangiopancreaticography, when indicated) were recorded. Patients were managed as per the advice of the treating consultant. Details of management and outcomes, including hospital stay, mortality, and morbidity, were noted. The descriptive data were organised into tables and percentages. The significance of various data and relationships between various variables was analysed using the Pearson chi-square test, Fischer exact test and scatter plots.ResultsA total of 76 patients were evaluated in this study, of which 73.7% were female. The mean age was 70.8 ± 1.7 years. The majority of patients (63.2%) were admitted through the outpatient department (OPD). The most common presenting complaint was abdominal pain (96.1%). Clinical jaundice was noted in 9.2%. Complicated Gall Stone Disease (GSD) was found more commonly in the female population (57.1%). Complicated GSD was more commonly found in patients with diabetes (p=0.075) and hypothyroidism (p=0.057). No association of age with intraoperative complications was noted (p = 0.446).ConclusionSenior citizens can present with both complicated and uncomplicated GSD. GSD, in the presence of hypothyroidism or diabetes mellitus, presents in a much more complicated form. Early surgical intervention in form of laparoscopic cholecystectomy can be beneficial to the patient if diagnosed with symptomatic gallstones. Patients of this age group need not be over investigated if a benign pathology is suspected.

Moynihan Prize 3 Financial implications of gallstone-related complications whilst awaiting elective cholecystectomy: a single institution experience of 900 patients.

AimsOver 65,000 cholecystectomies are performed each year in the United Kingdom with increasing waiting-list times due to the COVID-19 pandemic. This study set out to understand the cost to the NHS of complications experienced whilst awaiting cholecystectomy.MethodsA retrospective cohort study was carried out for all patients who had been awaiting elective cholecystectomy for more than 20 weeks on the 17th September 2021 at a large NHS Foundation Trust. Demographic data was collected at the time of listing. Re-admission data was collected from patient notes. It included clinical history, blood results and imaging investigations. Associated costs were calculated.Results900 patients included in the study (median age 56 years, 71.7% female). 138 patients (15.3%) re-presented to hospital whilst on the waiting list with complications of gallstone disease. Of these, 51 had more than one presentation to hospital with 18 patients having more than three presentations. This was equivalent to 625 days in hospital, with only 79 same day discharges, and multiple investigations were performed (ultrasound scan = 79; CT scan = 31, MRCP = 47, ERCP = 21). This was estimated to have cost a minimum of £364,917. Assuming an average time for an elective cholecystectomy of 90 mins at a cost of £1,200 per hour, 202 additional cholecystectomies could have been performed.ConclusionThis study highlights the enormous potential to reduce patient suffering by increasing the number of elective cholecystectomy lists, and at no overall additional cost to the trust.

Bile leakage and the number of metal clips on the cystic duct during laparoscopic cholecystectomy.

The most common way of closing the cystic duct in laparoscopic cholecystectomy is by using metal clips (>80%). Nevertheless, bile leakage occurs in 0.4%-2.0% of cases, and thus causes significant morbidity. However, the optimal number of clips needed to avoid bile leakage has not been determined. The primary aim of this study was to evaluate bile leakage and post-procedural adverse events after laparoscopic cholecystectomy concerning whether two or three clips were used to seal the cystic duct. Using a retrospective observational design, we gathered data from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (ERCP) (GallRiks). From 2006 until 2019, 124,818 patients were eligible for inclusion. These were nested to cohorts of 75,322 (60.3%) for uncomplicated gallstone disease and 49,496 (39.7%) with complicated gallstone disease. The cohorts were grouped by the number (i.e. two or three) of metal clips applied to the proximal cystic duct. The main outcome was 30-day bile leakage and post-procedural adverse events. No significant differences surfaced in the rate of bile leakage (0.8% vs 0.8%; P = .87) or post-procedural adverse events (three clips, 5.7% vs two clips, 5.4%; P = .16) for uncomplicated gallstone disease. However, for complicated disease, bile leakage (1.4% vs 1.0%; P < .001) and post-procedural adverse events (10.2% vs 8.6%; P < .001) significantly increased when the cystic duct was sealed with three clips compared with two. Because no differences in the rates of bile leakage or adverse events emerged in uncomplicated gallstone disease when a third clip was applied, a third clip for additional safety is not recommended in such cases. On the contrary, bile leakage and adverse events increased when a third clip was used in patients with complicated gallstone disease. This finding probably indicates a more difficult cholecystectomy rather than being caused by the third clip itself.

Unorthodox approach to management of Empyema Gallbladder during COVID pandemic in a developing country

Laparoscopic Cholecystectomy has established itself as the standard of care for treatment of gallstone disease. The management of high risk patients becomes challenging when they present in Emergency with complications of gallstone disease. These patients are generally elderly with multiple co-morbids; in particular cardiac patients with uncontrolled diabetes present late with acute cholecystitis and have systemic inflammation. The timing of surgery, extent of pre-operative optimization and use of laparoscopy for surgery continue to be utilized differently in such patients across the world especially in regard to COVID Pandemic. We report a case of elderly male with empyema gallbladder during first wave of COVID pandemic.

A206 GALLSTONE IMPACTION IN THE DESCENDING COLON WITH SUCCESSFUL ENDOSCOPIC REMOVAL

BackgroundGallstone impaction in the colon is a rare complication of cholelithiasis, typically because of gallstones migrating into the colon via a cholecystocolonic fistula. Gastrointestinal obstruction from gallstones only develops in 0.3–0.5% of patients with cholelithiasis and accounts for 0.095% of all mechanical bowel obstruction. Successful treatment has been described with endoscopic and surgical techniques.AimsThis report aims to present a case of colonic obstruction from gallstone that was successfully treated endoscopically.MethodsWe conducted a retrospective chart review on one patient including assessing the history of presenting illness along with biochemical, radiographic, and endoscopic results. We then conducted a narrative literature review on this subject matter.ResultsAn 85-year-old male with known cholelithiasis complicated by prior cholecystitis presented with a 2-day history of generalized abdominal pain. Computed tomography (CT) showed fistulisation between the gallbladder and hepatic flexure. Follow-up CT with rectal contrast showed lack of contrast beyond an impacted gallstone in the descending colon (Figure 1A, 1B). The patient was deemed a poor surgical candidate thus endoscopic gallstone extraction was attempted. With a pediatric colonoscope, the 41mm x 51mm gallstone was visualized 70cm from anal verge (1C). The stone was too large to be extracted en-block with snare or basket. Attempts to cut the stone at its surface with a polypectomy snare and other tools were unsuccessful because of the roundness and smoothness of the stone. Although we could chip away at the surface, we were unable to break the seal of the stone against the colon mucosa. We found the most effective method was tunneling through the stone’s centre using a closed rat-tooth forceps, then angling the tip of the scope and pulling the scope back to break off fragments from within. A polypectomy snare was used to further breakup larger fragments to prevent repeat impaction (1D). There was underlying diverticular disease and mild ischemic changes to the mucosa but no stricture. The patient did well post-procedure and was able to tolerate oral intake, pass flatus, and pass bowel movements. He was discharged 3 days later.A recent systematic review found a total of 38 cases of gallstone obstruction of the colon. Majority of patients (73.6%) ultimately required surgical intervention. Overall mortality is 13.1%.ConclusionsGallstone impaction in the colon is uncommon with successful endoscopic treatment seldomly described. This report describes a rare complication of gallstone disease that was successfully treated with widely available endoscopic tools. Funding AgenciesNone

Role of Dual-Energy Computed Tomography in Gallbladder Disease: A Review

AbstractGallbladder diseases are common and include a spectrum ranging from benign to cancer. Imaging plays an integral role in the diagnosis and in guiding appropriate management. While most patients with gallstone (GS) diseases can be evaluated with ultrasound, those with complicated GS disease, suspicion of cancer, or staging of cancer need additional cross-sectional imaging. Computed tomography (CT) is widely available and is often the imaging test of choice following an equivocal ultrasound or negative ultrasound in patients with unexplained symptoms. Conventional CT has limited sensitivity in detecting GS or common bile duct stones. In other scenarios, including diagnosis of acute cholecystitis (AC) and characterization of gallbladder wall thickening, an increase in accuracy using novel techniques is desirable. Dual-energy computed tomography (DECT) is increasingly incorporated into clinical practice. DECT has shown promising results in the detection of cholesterol stones that otherwise go unnoticed on conventional CT. However, its role beyond GS disease has largely been unexplored. In this review, we discuss the available literature on the DECT in biliary diseases and discuss the potential applications of this technique.

A Challenging Case of Postcholecystectomy Pseudoaneurysm at an Uncommon Location

AbstractHepatic artery pseudoaneurysm in postcholecystectomy choleduodenal fistula is an extremely rare but clinically significant complication. A 52-year-old male presented with hematemesis and melena several weeks after open cholecystectomy for complicated gallstone disease. Upper gastrointestinal endoscopy revealed bleeding from the choledochoduodenal fistula site. On computed tomography angiography, a small right hepatic artery pseudoaneurysm close to fistula site was identified. Endovascular embolization failed due to nonopacification of the proximal right hepatic artery. Endoscopic ultrasound-guided embolization was also unsuccessful due to the small size of the aneurysm and inadequate visualization. Following this, percutaneous n-butyl cyanoacrylate glue was successfully injected into the pseudoaneurysm. The patient recovered and was planned for hepaticojejunostomy to restore biliary continuity.

Dyspepsia and Gut Microbiota in Female Patients with Postcholecystectomy Syndrome.

BackgroundGallstone disease (GSD) represents one of the most frequent digestive disorders, highly reported in female gender. The purpose of the study was to explore the clinical and gut microbiota particularities of female patients with postcholecystectomy syndrome (PCS) and the possible relationship between gut dysbiosis (DB) and abdominal complaints.Patients and MethodsIn total, 129 female participants: 104 outpatients divided into two equal groups, 52 PCS (+), 52 PCS (−) and 25 healthy controls were consecutively enrolled in this observational study. Patients underwent clinical examination with assessment of pain, bloating, transit disturbances, abdominal ultrasound/computer tomography/magnetic resonance imaging/endoscopic retrograde cholangiopancreatography, upper and lower digestive endoscopies. Laboratory work-ups and stool microbiology assessments were performed for all study participants (patients and controls). Stool microorganisms were identified by matrix-assisted laser desorption ionization – time-of-flight– mass spectrometry and in patients with DB also by next-generation sequencing.ResultsOlder age, complicated gallstones disease, associated conditions like diabetes mellitus/impaired glucose tolerance and irritable bowel syndrome were significantly present in PCS (+) group, as well as sedentary lifestyle and diets characterized by a low fiber intake (p<0.0001). PCS (+) patients displayed significant differences related to the incidence and severity of overall gut microbiota DB, decreased H index of biodiversity and the unbalanced Firmicutes/Bacteroidetes (F/B) ratios by comparison to the PCS (−) group (p<0.0001). Strong positive correlations of the severity of overall DB with bloating and the intestinal habit disorders, as well as of F/B ratios to all abdominal symptoms were noted.ConclusionPCS in female patients was associated with older age, sedentary lifestyle, specific dietary habits, history of complicated gallstone disease, diabetes mellitus/impaired glucose tolerance and irritable bowel syndrome, as well as gut microbiota particularities. Overall DB and unbalanced F/B ratios were strongly correlated to abdominal complaints.

HISTORY OF DEVELOPMENT OF LAPAROSCOPIC AND ENDOSCOPIC SURGERY IN LVIV CLINICAL EMERGENCY CARE HOSPITAL

Aim. The analysis of the history of minimally invasive surgery in a clinical emergency care hospital and the clinical cases associated with first robot-assisted operations.&#x0D; Materials and Methods. We have analyzed 10180 inpatients' maps and protocols of surgical operations from 2002 to 2019. We have also studied the first minimally invasive interventions in the Clinic of Surgery and Endoscopy affiliated to the Faculty of Postgraduate Education of Danylo Halytsky Lviv National Medical University and the municipal non-profit institution "Lviv Clinical Emergency Care Hospital".&#x0D; Results and Discussion. Until the early 1990s, the development of surgical technology took place mainly due to the talents of individual surgeons and their persistence in implementing new treatment methods. The directions of work of our Department of Endoscopic Surgery included the introduction of minimally invasive (laparoscopic) surgical interventions and endoscopic interventions using flexible endoscopy. Robot-assisted operation on a patient with diaphragmatic hernia using da Vinci surgical system was performed with three 8.5 mm robotic instruments and two 5 mm laparoscopic ones. The operation lasted for 6 hours. There were no intra- and postoperative complications. The patient was discharged home in satisfactory condition on the 3rd post-op day. Robot-assisted surgery for complicated gallstone disease was performed with three 8.5 mm robotic instruments and one 5 mm laparoscopic one. The operation lasted for 3 hours.&#x0D; Conclusions.&#x0D; 1. The introduction of modern technologies and minimally invasive interventions results primarily from activities of the clinic's staff, the head of the structural unit and the hospital administration, as well as from the high professional level of surgeons.&#x0D; 2. The usage of minimally invasive, laparoscopic, endoscopic techniques, as well as that of da Vinci surgical system in clinical practice will improve therapeutic outcomes and quality of life among patients with surgical disorders.