Consecutive Cholecystectomies Research Articles

Single stage management of suspected gallbladder cancer guided by intraoperative frozen section analysis: A retrospective cohort study.

The management of radiologically suspected gallbladder cancers (GBC) that lack definitive radiological features usually involves performing a first-stage routine laparoscopic cholecystectomy, followed by an open second-stage liver resection (segments IVB and V) and hilar lymphadenectomy (extended cholecystectomy) if subsequent formal histology confirms a malignancy. Performing a cholecystectomy with an intraoperative frozen section to guide the need for conversion to an extended cholecystectomy as a single-stage procedure has multiple benefits compared to a two-stage approach. However, the safety and efficacy of this approach have not yet been evaluated in a tertiary setting. A retrospective cohort study was performed using a database of all consecutive patients with suspected GBC who had been referred to our tertiary unit. Following routine cholecystectomy, depending on the operative findings, the gallbladder specimen was removed and sent for frozen-section analysis. If malignancy was confirmed, the depth of tumour invasion was evaluated, followed by simultaneous extended cholecystectomy, when appropriate. The sensitivity and specificity of frozen section analysis for the diagnosis of GBC were measured using formal histopathology as a reference standard. A total of 37 consecutive cholecystectomies were performed. In nine cases, GBC was confirmed by intraoperative frozen section analysis, three of which had standard cholecystectomy only as their frozen section showed adenocarcinoma to be T1a or below (n=2) or were undetermined (n=1). In the remaining six cases, malignant invasion beyond the muscularis propria (T1b or above) was confirmed; thus, a synchronous extended cholecystectomy was performed. The sensitivity (95% CI 66.4%-100%) and specificity (95% CI 87.7%-100%) for identifying GBC using frozen section analysis were both 100%. The net cost of the single-stage pathway in comparison to the two-stage pathway resulted in overall savings of £3894. Intraoperative frozen section analysis is a reliable tool for guiding the use of a safe, single-stage approach for the management of GBC in radiologically equivocal cases. In addition to its lower costs compared to a conventional two-stage procedure, intraoperative analysis also affords the benefit of a single hospital admission and single administration of general anaesthesia, thus greatly enhancing the patient's experience and relieving the burden on waiting lists.

Eosinophilic Cholecystitis and Eosinophils in Gallbladder Injuries: A Clinicopathological Analysis of 1050 Cholecystectomies.

"Eosinophilic cholecystitis" has been an elusive concept. Around 1050 consecutive cholecystectomies with chronic (CC, n = 895), subacute (SAC, n = 100), and acute cholecystitis (AC, n = 55) were reviewed for eosinophilic infiltration. Eosinophilic hot spots (>40 eosinophils/HPF) were seen in 63% of SAC and 35% of AC (vs. 6% of CC, p < 0.001). Eosinophils were mostly encountered in areas of wall thickening, revealing edema with early collagenization and young tissue-culture-type fibroblasts. However, in ten chronic cholecystitis patients (<1%), prominent eosinophilia with eosinophil-rich foci (>100 eosinophils/HPF) was noted. These ten cases, classified as "eosinophilic cholecystitis", were analyzed further: The patients were relatively young (mean age = 43 years), with a 9:1 female:male ratio. None had blood eosinophilia/eosinophilia syndromes. Although one had ulcerative colitis, others did not have any autoimmune diseases. The mean gallbladder wall thickness was 3.5 mm (vs. 4.2 mm in ordinary CC). In conclusion, eosinophils are a part of especially subacute injuries in the gallbladder. They are typically condensed in the areas of healing and appear to signify a distinctive state of injury in which there are erosions leading to slow/sustained exposure of the mural tissues to the bile contents that induce chemical injury/recruit eosinophils. Eosinophilic cholecystitis is a very uncommon occurrence and appears to be an exaggerated response in allergic patients who are prone to recruit eosinophils in reaction to injury.

Identification of the ideal weight-based indocyanine green dose for fluorescent cholangiography.

Ideal visualization of fluorescent cholangiography during laparoscopic cholecystectomy is when maximum fluorescence into biliary ducts and absent signal into liver parenchyma, defined as "signal to background ratio" (SBR), is obtained. Such condition is mainly dependent by indocyanine green (ICG) dose and timing. The aim of this study was to identify the ideal ICG dose to obtain the best possible intraoperative visualization of the extra-hepatic biliary tree. The first part of the study was used to define a range of small weight-based ICG dosages using the mathematical function bisection method. During the second part of the study, the midpoint dose of the identified range, was tested in 50 consecutive cholecystectomies using a laser-based fluorescence laparoscopic camera (SynergyID system by Arthrex, Naples, FL, USA). Timing administration was set at 1h before surgery, since this is the most common situation in clinical practice. Fluorescence intensity of bile ducts and liver parenchyma were assessed both subjectively, by blinded operative surgeon, as well as objectively, using an image analysis software (Fiji plugin), before and after Calot's triangle dissection. Fourteen patients were included in the first part of the study and ICG dose between 0.01191406 and 0.0119873mg/kg was identified. The second part confirmed previous results after testing the dosage equal to 0.0119mg/kg (midpoint of the defined range) in 50 consecutive cholecystectomies. Cystic duct was identified in 66 and 100% of cases before and after dissection of Calot's triangle respectively. On the other hand, common bile duct was identified in 82 and 92% before and after dissection respectively. Subjective and objective SBRs confirmed the benefit of the identified ICG dose. ICG dose calculated by 0.0119mg/kg administered one hour before surgery allows an ideal intraoperative visualization of the extra-hepatic biliary tree. ISRCTN10190039.

Laparoscopic subtotal cholecystectomy; change in practice over a 10-year period.

Laparoscopic subtotal cholecystectomy is a recognised safe, alternative strategy when a critical view of safety cannot be obtained. This study audits the change in practice at a District General Hospital following the adoption of subtotal cholecystectomy in 2013. Retrospective case series included consecutive cholecystectomies over a ten-year period in a single institution. Cases were divided into subgroups based on operation date. Primary outcome was the proportion of patients undergoing laparoscopic total cholecystectomy, laparoscopic subtotal and laparoscopic converted to open cholecystectomy. Secondary outcomes included incidence of bile leak, complication rate, return to theatre, and length of stay. There were 4217 cases: 1381 in Group A (pre-adoption of subtotal cholecystectomy 2009-2012), and 2836 in Group B (post-adoption of subtotal cholecystectomy 2013-2019). The rate of laparoscopic total cholecystectomy was higher in Group A than Group B (95.4% vs. 92.8%, p<0.001). In the subtotal group (n=114, 14 (12.3%) patients had bile leak, 6 (5.3%) underwent re-laparoscopy, and median length of stay was 2 days. Laparoscopic subtotal cholecystectomy appears to be an acceptable alternative technique at this centre, reducing the rate of open conversion and length of stay, with a low reintervention rate for bile leak.

SP6.1.10 Can gallbladder polyp surveillance be justified? Experience of a large DGH

Abstract Aims Gallbladder polyps are typically an incidental finding on sonographic or pathological examination with an estimated prevalence of 0.3 – 9.5%. Their role as a precursor to gallbladder malignancy is disputed. The 2017 European Joint Society Guidelines (ESGAR/EAES/EFISDS/ESGE) aim to standardise management of gallbladder polyps detected prior to cholecystectomy. We aim to describe our experience in the management of gallbladder polyps in a district general hospital. Methods This single centre retrospective case series included consecutive cholecystectomies over an 8-year period, identified through pathology records. Medical records were interrogated to identify the presence of gallbladder polyps identified pre-operatively and at subsequent histopathological analysis. Results 3835 cases were included. Four cases (0.1%) had an adenocarcinoma identified; none of these had pre-operatively identified polyps. Two cases (0.05%) were found to have lesions with high-grade dysplasia, 1 of which had a 17mm polyp preoperatively. One case (0.03%) had cellular atypia, without a pre-operative polyp. Forty six cases (1.2%) were found to have low-grade dysplasia; 1 (2.2%) of these had adenomyomatosis pre-operatively but none had pre-operative polyps. Overall, 53 patients (1.4%) had abnormal pathology with only 1 (1.9%) of these having a pre-operative polyp identified. Conclusions Our results suggest that in the real-world setting, intensive surveillance of gallbladder polyps has limited utility in identifying cases of gallbladder malignancy. The burden on services produced by adherence to strict surveillance guidelines is difficult to justify and a less arduous approach is unlikely to significantly influence the management or outcome in patients with gallbladder malignancy.

TP6.1.2 Laparoscopic subtotal cholecystectomy; change in practice over a 10-year period

Abstract Aim Laparoscopic subtotal cholecystectomy is a safe strategy to avoid bile duct injury when a critical view of safety cannot be obtained. This technique may result in fewer open conversions and was introduced in our DGH in 2013. This study describes the change in practice at our centre following introduction of subtotal cholecystectomy. Method Retrospective case series included consecutive cholecystectomies over a ten-year period in a single institution. Cases were divided into subgroups based on operation date; 2009-2012 (Group A) and 2013-2019 (Group B). These groups represent pre- (Group A) and post- (Group B) introduction of laparoscopic subtotal cholecystectomy. Primary outcome was the proportion of patients undergoing laparoscopic total cholecystectomy, laparoscopic sub-total and lap-converted to open cholecystectomy. Secondary outcomes included incidence of bile leak, complication rate, return to theatre, and length of stay. Results There were 4248 cases; 1387 in Group A, and 2861 in Group B. The rate of open conversions was higher in Group A than Group B (4.7% vs. 2.8%, p = 0.003). The rate of laparoscopic total cholecystectomy was higher in Group A than Group B (95.3% vs. 92.8%, p = 0.013). In the subtotal group (n = 114, 3.9% of Group B); 14 (12.3%) patients had bile leak requiring ERCP, 6 (5.3%) underwent re-laparoscopy for inadequate biliary drainage, and median LOS was 2 days. Conclusion Laparoscopic subtotal cholecystectomy has proven to be a safe technique at our centre, reducing the rate of open conversion and length of stay, with a low rate of reintervention for bile leak.

Routine postoperative blood tests fail to reliably predict procedure-related complications after laparoscopic cholecystectomy

PurposeLaparoscopic cholecystectomy is a highly standardized surgical procedure with a low risk of complications. However, once complications develop, they can be life-threatening. The aim of this study was to evaluate the value of blood tests on postoperative day one regarding their potential to predict postoperative complicationsMethodsA cohort study of 1706 consecutive cholecystectomies performed at a tertiary hospital and teaching facility over a 5-year period between 2014 and 2019.ResultsPatients that had open CCE or conversion CCE were excluded. One thousand five hundred eighty-six patients were included in the final analysis that received a laparoscopic cholecystectomy (CCE). One thousand five hundred twenty-three patients had blood tests on POD 1. Forty-one complications were detected including 14 bile leaks, 2 common bile duct injuries, 13 choledocholithiasis, 9 hematomas, and 2 active bleedings. Bilirubin was elevated in 351 patients on POD 1. A drop of more than 3 mg/dl of hemoglobin was reported in 39 patients. GPT was elevated 3 × above the upper limit in 102 patients. All three tests showed a low sensitivity and specificity in detecting postoperative complications.ConclusionsEarly postoperative blood tests alone show a low specificity in detecting postoperative complications after laparoscopic CCE. Their main benefit appears to be the negative predictive value, when they are normal. Routine blood testing appears to be unnecessary and should be based on the intraoperative diagnosis and postoperative clinical findings.

Mural Intracholecystic Neoplasms Arising in Adenomyomatous Nodules of the Gallbladder: An Analysis of 19 Examples of a Clinicopathologically Distinct Entity.

Intracholecystic neoplasms (ICNs) (pyloric gland adenomas and intracholecystic papillary neoplasms, collectively also called intracholecystic papillary/tubular neoplasms) form multifocal, extensive proliferations on the gallbladder mucosa and have a high propensity for invasion (>50%). In this study, 19 examples of a poorly characterized phenomenon, mural papillary mucinous lesions that arise in adenomyomatous nodules and form localized ICNs, were analyzed. Two of these were identified in 1750 consecutive cholecystectomies reviewed specifically for this purpose, placing its incidence at 0.1%. Median age was 68 years. Unlike other gallbladder lesions, these were slightly more common in men (female/male=0.8), and 55% had documented cholelithiasis. All were characterized by a compact multilocular, demarcated, cystic lesion with papillary proliferations and mucinous epithelial lining. The lesions' architecture, distribution, location, and typical size were suggestive of evolution from an underlying adenomyomatous nodule. All had gastric/endocervical-like mucinous epithelium, but 5 also had a focal intestinal-like epithelium. Cytologic atypia was graded as 1 to 3 and defined as 1A: mucinous, without cytoarchitectural atypia (n=3), 1B: mild (n=7), 2: moderate (n=2), and 3: severe atypia (n=7, 3 of which also had invasive carcinoma, 16%). Background gallbladder mucosal involvement was absent in all but 2 cases, both of which had multifocal papillary mucosal nodules. In conclusion, these cases highlight a distinct clinicopathologic entity, that is, mural ICNs arising in adenomyomatous nodules, which, by essentially sparing the "main" mucosa, not displaying "field-effect/defect" phenomenon, and only rarely (16%) showing carcinomatous transformation, are analogous to pancreatic branch duct intraductal papillary mucinous neoplasms.

Current Scenario of Postcholecystectomy Bile Leak and Bile Duct Injury at a Tertiary Care Referral Centre of Nepal.

Objective With the adoption of safe cholecystectomy principles at an academic institute, the risk of major bile duct injury has decreased. This study aims at evaluating the present status of bile duct injury, compared to the study published in 2013 by index centre. Methods This is a retrospective review of a prospectively maintained database of bile leak and bile duct injury from 2014 to 2019. Patients who completed postcholecystectomy bile leak or bile duct injury treatment and were on regular follow-up were included. Results Eighteen patients (0.78%) among 2,300 consecutive cholecystectomies presented with bile duct injury, including 8 (0.35%) major bile duct injuries and 10 (0.43%) bile leaks compared to major bile duct injury rate of 0.68% (92/11,345 cholecystectomies) between 2001 and 2010. Injuries were classified as Strasberg's type A (52.9%), type D (5.9%), and type E (41.1%). Eight patients (47%) of bile leak were managed conservatively with drains, while two required laparotomy and lavage. The mean time for spontaneous closure of bile leak was 11 days. Intraoperative repair was done in three cases: Roux en Y hepaticojejunostomy in 2 and end-to-end repair over T-tube in 1 for sharp transection of the duct. Delayed repair (Roux-en-Y hepaticojejunostomy) was done in five patients. The median postcholecystectomy hospital stay was 8 days, with no mortality. There was no restricture at a median follow-up of 13 months. Conclusion With the adoption of a safe culture of cholecystectomy, the major bile duct injury rate has decreased currently. Repair of bile duct injury by experienced hepatobiliary surgeon results in excellent outcome.

Age-adjusted charlson comorbidity index associated with post-cholecystectomy short-term outcomes

Background: Frailty indexes (Charlson comorbidity index, CCI, age-adjusted Charlson, AACCI) and cholecystectomy outcomes have scarcely been analysed in recent literature. Patients and Methods: Prospective observational study including consecutive cholecystectomies performed by single young HPB surgeon or his supervised trainees from July 2017 to November 2018. Main outcomes: conversion to open surgery, postoperative immediate admission at Surgical Intensive Care Unit (SICU), postoperative morbidity (thoroughly registered according to Clavien´s classification) up to discharge, length of stay (LOS). Different preoperative variables were tested, including CCI, AACCI, type of procedure. Results: 60 patients, 60.4±15.5 year-old, males 38.3%. BMI: 27.2±4.1 Kg/m2 (38.3% lost data, thus excluded for analysis). CCI: 0.37±0.64, AACCI: 1.95±1.55. Emergent cholecystectomies: 20%. Initial laparoscopic approach: 98.3%(n=59). Conversion: 15.3%(n=9/59). ICU admission: 3.4%. Morbidity: Clavien I 26.7% (mostly were increased pain and postoperative nausea/vomiting), Clavien II 5.0%. Median LOS: 2 days (IQR=1-3). Re-admission: n=1 (1.7%, residual choledocholithiasis). Age, CCI and AACCI showed no statistical differences for elective/emergent surgery, initial laparoscopic approach, conversion, overall morbidity. Higher CCI and AACCI were found in patients admitted at SICU: 0.32±0.57 vs. 2.00±0 (p<0.001) and 1.84±1.47 vs. 5.00±1.41 (p=0.004). Older age was found among patients suffering Clavien II vs. Clavien I morbidity: 59.4±13.3 vs. 81.3±8.3 (p=0.019), as well as higher AACCI: 2.00±1.51 vs. 4.33±1.53 (p=0.047). Weak but significant correlation was found between age and LOS: r=0.281 (p=0.031), as well as AACCI: r=0.265 (p=0.042). Longer LOS was associated with emergent cholecystectomy (median 3 vs. 1 days,p<0.001) and conversion (median 4 vs. 1 days,p<0.001). Besides, conversion itself was associated with SICU admission (0% vs 22%,p=0.022) and non-statistically with Clavien II morbidty (7.1% vs. 50%, p=0.1) Conclusions: We confirm that frailty indexes, particularly AACCI, are associated with worse short-term outcomes after cholecystectomy (immediate SICU admission, Clavien II morbidity, longer LOS). Conversion, but not emergency surgery, may also play a role.

Is Final Histopathological Examination the Only Diagnostic Criteria for Xanthogranulomatous Cholecystitis?

Background:Xanthogranulomatous cholecystitis (XGC) is an uncommon inflammatory disease of gallbladder (GB) and can mimic GB cancer in extensive form. This study aims to assess the predictability of XGC on the basis of clinical presentation, laboratory tests, and radiological or intraoperative findings on frozen section analysis.Materials and Methods:This is a retrospective study, conducted over a period of 4 years from October 2013 to November 2017. In this study, all patients with histopathological reports of XGC, who underwent cholecystectomy or a radical cholecystectomy, were included. Clinical records of these patients were reviewed for clinical features, laboratory tests, and findings on radiological imaging.Results:Out of 700 consecutive cholecystectomies reviewed, 34 had histologically proven XGC (4.85%). Two patients had simultaneous presence of GB carcinoma with XGC. The most common presenting symptoms were right upper quadrant pain in 32 (94%) patients, jaundice in 9 (36%) patients, and fever in 5 (14%) patients. The most common radiological finding was cholelithiasis in 85.2% of cases. Thick-walled GB was present in 79.4% of patients; irregular wall thickening was present in 20.5% of patients. Intramural nodule was present in two patients, whereas hepatic invasion was observed in 11% and pericholecystic infiltration was present in 8.8% of patients. Regional lymphadenopathy was present in 9 (26.4%) patients.Conclusion:Clinical presentation and laboratory parameters were unequivocal due to considerable overlap. Despite recent advances in radiology, none have significant sensitivity and specificity to accurately diagnose XGC preoperatively. Intraoperative frozen section can add to the diagnosis with limited accuracy. The diagnosis of XGC can be confirmed only on histopathological examination.

Cholecystectomy in the laparoscopic era; more than 200 consecutive cholecystectomies with zero conversion rate; is there a necessity for conversion?

Background: Laparoscopic Cholecystectomy (LC) is the gold standard surgical procedure for removal of gall bladder. However in difficult situations, it is customary to convert it to an open procedure. Methods: A prospective data analysis was done for 208 consecutive cases of LC performed in a surgical unit at National Hospital of Sri Lanka from September 2012 to January 2017. Results: Out of 208 patients, 152 were women (73.1%) with a mean age of 47.6 years (range 21-79). Biliary colic (37.5%), chronic cholecystitis (31.6%) and acute cholecystitis (10.1%) were the commonest indications for LC. Eighteen patients who had CBD stones underwent CBD exploration simultaneously. Among 208 cases 19 had empyema, 8 had mucocoele and 1 had choledochoduodenal fistula. In 31 difficult cases retrograde cholecystectomy was performed and out of them 9 patients underwent subtotal cholecystectomy. All cases were successfully managed laparoscopically with zero conversion rate. Bile spillage was the commonest complication (21.4%) and average postoperative hospital stay was 2.9 days. Conclusion: With safe dissection and timely resorting to retrograde cholecystectomy in experienced hands, there seems to be no reason for conversion to open cholecystectomy. Most of the complicated cases can be successfully managed laparoscopically without conversion to open procedure.

Cholecystectomy in the laparoscopic era; more than 200 consecutive cholecystectomies with zero conversion rate; is there a necessity for conversion?

Cholecystectomy in the laparoscopic era; more than 200 consecutive cholecystectomies with zero conversion rate; is there a necessity for conversion?

Is there a difference in laparoscopic cholecystectomy performed in a teaching hospital or a general hospital in The Netherlands?

Introduction: Laparoscopic cholecystectomy may have a complicated course with severe complications such as bile duct injury. Studies in other countries than the Netherlands report ambivalent results regarding the influence of a residency program on patient safety, efficacy and financial consequences. This study aims to determine whether there is a difference between laparoscopic cholecystectomy performed in a teaching hospital or a non-teaching general hospital in Dutch clinics.Materials and methods: A prospective cohort study was performed to examine the safety of laparoscopic cholecystectomies in a teaching hospital with a residency program and a general hospital without surgical residents. All consecutive cholecystectomies in these two hospitals between September 2014 and March 2015 were included. Patient characteristics, operative procedure, level of experience, operation time, per- and postoperative complications, mortality, length of hospital stay, re-admittance and conversions to laparotomy were analyzed.Results: A total of 294 consecutive cholecystectomies were performed in both hospitals. Cholecystectomies performed in the teaching hospital took an average of 25 min longer to complete compared with a non-residency setting. Both the number of conversions and the number of re-admissions were not significantly different between both clinics. The residency program showed smaller peroperative liver lesions along with more postoperative complications, with most complications in patients that required a conversion.Discussion: Current practice where residents perform supervised cholecystectomies should not be discouraged. We believe that is safe and lead to an acceptable increase in operation time.

Can a surgeon perform a macroscopic inspection of a gallbladder?

Introduction: Routine histopathologic gallbladder examination after cholecystectomy has been a point of discussion for several decades. Recent changes in national guidelines suggest a selective histopathologic examination gallbladders. The aim of this study was to evaluate the macroscopic examination by the surgeon in relation to the final histology outcome. Method: A prospective study was conducted in a Dutch teaching hospital to investigate the practice of macroscopic gallbladder examination by a surgeon compared to routine histopathology by a pathologist. All consecutive cholecystectomies were included between November 2009 and February 2011. Patient characteristics, operative procedure, conversions to laparotomy, macroscopic examination of the gallbladder mucosa, alleged necessity for microscopic analysis and final histopathology of the gallbladder were analyzed. Results: A total of 319 consecutive cholecystectomies were performed. Twenty-nine patients were treated for acute cholecystitis. Of all macroscopic examinations the surgeon identified 62 gallbladders with macroscopic abnormalities, ranging from polyps to wallthickening or ulcers. Including acute cholecystitis a total of 55 (17,2%) could have had reasons for further microscopic evaluation by the pathologist. Macroscopic examination agreement between surgeon and the pathologist was rated as “strong agreement” (κ = 0,822). The surgeon and the pathologist had disagreement on the macroscopic examination of 18 gallbladders. In these gallbladders, however, the additional histology was not relevant to clinical outcome. Conclusions: The present prospective study shows that the surgeon is capable of adequate macroscopic gallbladder examination postoperatively. We suggest to only perform selective microscopic gallbladder examination, which can result in about 80% reduction of this kind of routine histology.

Outcome of Surgical Inspection of the Gallbladder in Relation to Final Pathology

IntroductionRoutine histopathologic gallbladder examination after cholecystectomy has been a point of discussion. The aim of this study was to evaluate the macroscopic examination by the surgeon in relation to the final histology. MethodsA prospective study was conducted to investigate the practice of macroscopic gallbladder examination by a surgeon compared to routine histopathology by a pathologist. All consecutive cholecystectomies were included between November 2009 and February 2011. ResultsA total of 319 consecutive cholecystectomies were performed. Of all macroscopic examinations, the surgeon identified 62 gallbladders with macroscopic abnormalities, ranging from polyps to wall thickening or ulcers. In 55 (17.2%) cases, the surgeon judged that further examination of the specimen by the pathologist could possibly lead to additional and relevant findings. There was a strong agreement between the surgeon and the pathologist concerning the macroscopic examination (κappa = 0.822). The surgeon and the pathologist had disagreement on the macroscopic examination of 18 gallbladders, without clinical consequences for the patient. DiscussionThe present prospective study shows that the surgeon should be able to select those gallbladders needing a microscopic gallbladder examination. Potentially, about 80% of this kind of routine histology can be reduced.

Laparoscopic cholecystectomy versus transvaginal natural orifice transluminal endoscopic surgery cholecystectomy: results of a prospective comparative single-center study

Laparoscopic cholecystectomy (LC) in female individuals has been challenged recently by transvaginal natural orifice transluminal endoscopic surgery cholecystectomy (TVC). TVC has not been widely accepted as a standard procedure, even though it is reported to be a safe and painless alternative to LC. This prospective comparative study aims to not only prove equality of TVC and LC but to underline the advantages of TVC over LC with regard to postoperative pain. This study presents an analysis of a single-center and single-surgeon study with 226 unselected consecutive cholecystectomies performed as either TVC or LC. A total of 226 female patients underwent surgery with either LC (136 cases) or TVC (90 cases). There were no postoperative adverse events. Twenty-two patients (24.2%) in the TVC group indicated 0 (no pain) on a visual analog scale postoperatively, whereas only 5 patients (3.7%) did so in the LC group (P=< .0001). Overall consumption of non-steroidal anti-inflammatory drugs was significantly less (P< .0001; t test) in the TVC group (mean, 1.2 ± 0.11 g) compared with the LC group (mean, 2.1 ± 0.1 g). Twenty-three patients (25.5%) in the TVC group needed no postoperative analgesics at all. TVC is a safe and painless procedure for patients with symptomatic cholelithiasis who are from various ethnic and cultural origins. This benefit, along with an equal safety profile compared with LC, should pave the way for wider application of TVC in women.

Bile duct injuries after laparoscopic cholecystectomy: 11-year experience in a tertiary center

Incidence of bile duct injuries (BDI) is low but remains a dramatic complication after laparoscopic cholecystectomy (LC). This study aimed to assess BDI incidence and management strategies. All patients treated in our institution for BDI after LC between 2000 and 2011 were retrospectively analyzed. Patients referred from others centers were excluded. Strasberg classification was used to determine the type of lesion. Thirteen patients presented iatrogenic BDI among 2,840 consecutive cholecystectomies performed (0.46%). Four cases were classified Strasberg type A, 4 type D, and 5 type E. Injury was recognized intraoperatively in 6 cases (46%). Three of these 6 required conversions to open surgery and all but one were primary sutured on a drain; the remaining patient required immediate biliodigestive anastomosis. In 7 patients, the injury was discovered postoperatively (54%). Among them, one was treated by direct closure of a cystic leak through immediate re-laparoscopy. Six underwent initially main bile duct stenting, but 4 required delayed secondary surgery (mean time 115 days), 2 to improve bile duct drainage and 2 for biliodigestive derivation. BDI incidence remains low but management depends on the time of diagnosis. BDI are complex and require tailored treatment usually in a tertiary center for a multidisciplinary approach.

Cystic duct remnant calculi after cholecystectomy

Unrecognized lithiasis of the cystic duct (CDL) may be responsible for post cholecystectomy. This retrospective study looked at the incidence of CDL during cholecystectomy, as well as the context of its occurrence; recommendations for a practical surgical approach are offered. Over a period of 30 months, 143 consecutive cholecystectomies (103 women, 40 men; mean age: 57 years) were performed by the same surgeon: 142 by laparoscopy, and one by laparotomy due to a history of previous gastrectomy. The cystic duct was always opened and milked upward in search of CDL before immediate clip occlusion or performance of cholangiography (106 times, 74.1%). In seven cases, cholangiography was impossible because the cystic duct was too narrow. There was no mortality. CDL was found in 21 cases (14.7%) and removed. This had not been identified by preoperative imaging (ultrasound or CT). Pain in the month preceding cholecystectomy occurred more frequently in cases of CDL (19/21[90.4%] vs 36/122 [29.5%]; P<0.001). Similarly, liver function tests were more often abnormal with CDL (10/21 [47.6%] vs 30/122 [24.5%]; P<0.05). However, neither jaundice nor gallbladder inflammation was predictive of CDL in this study. Echoendoscopy (EUS) was performed more often for suspected common duct lithiasis migration (CBDL) in patients with CDL than for those without (9/21 [42.8%] vs 26/122 [21.3%]; P<0.05). CBDL was present in 12 of 143 patients (8.3%). This was treated by preoperative endoscopic sphincterotomy in 10 cases, and twice by trans-cystic stone extraction during the laparoscopic intervention. CBDL occurred more frequently in association with CDL (5/21 [23.8%] vs 7/122 [5.7%]; P<0.01). In addition, CDL was still present at cholecystectomy in the four patients who underwent preoperative endoscopic sphincterotomy. Cystic duct lithiasis is found frequently during cholecystectomy; CDL is often associated with preoperative pain, abnormal liver function tests and choledocholithiasis. It can persist despite preoperative sphincterotomy. The search for and treatment of CDL should be routinely performed during cholecystectomy.

Laparoscopic and Open Cholecystectomy in Surgical Training

Background: Open cholecystectomy (OC) may still be necessary in surgical training to perform safe conversions of laparoscopic cholecystectomy (LC). Our aim was to study the outcome of LCs and OCs performed by surgical trainees. Methods: All consecutive cholecystectomies (1,581 LCs and 984 OCs) were retrospectively analyzed from 1995 until 2008. Operative complications were compared between the cholecystectomies performed by 20 trainees alone (n = 822), assisted operations (n = 754, trainees/specialist surgeons) and 9 specialists alone (n = 989). Results: Surgical trainees performed 787 (50%) LCs and 789 (80%) OCs either alone or assisted. The conversion rate of LC for trainees and specialist surgeons were 34 (7.0%) and 44 (5.5%), respectively. Complication rates and mortality were similar between the trainees and specialist surgeons. No bile duct injuries were associated with LCs or OCs performed by trainees alone. LCs were associated with 9 (0.57%) cases of bile leakage from cystic stump and 2 (0.13%) other bile duct injuries. Conclusion: Surgical trainees performed over half of our cholecystectomies with good results. The patient selection for LC versus OC was good, because no total transection of the common bile duct was observed in over 1,500 LC operations.