Gallbladder Bed Research Articles

Endoscopic retrograde cholangiopancreatography versus conservative treatment of biliary leakage due to injury of Luschka duct during laparoscopic cholecystectomy

Background Gallstones remain the most common disease of gastrointestinal tract in the world. Laparoscopic cholecystectomy is one of the most common performed surgical operations. Bile leaks remain a significant cause of morbidity for patients undergoing laparoscopic cholecystectomy and these occur in 0.3–0.8% of cases. The ducts of Luschka, or subvesical ducts, are small ducts originate from the right hepatic lobe, course along the gallbladder bed, and usually drain into the extrahepatic bile ducts. Injury of these ducts is the second most frequent cause of postcholecystectomy bile leakage after cystic duct leak. Aim The aim of this study is to compare between conservative and endoscopic retrograde cholangiopancreatography (ERCP) treatment of leaked injured Luschka duct as regarding outcomes, effectiveness, and cost. Patients and methods Retrospective study included patients with postcholecystectomy biliary leakage due to Luschka duct injury from June 2015 to December 2022. Results A total of 20 patients were included in this study and classified into two groups: group A with conservative treatment was successful in eight cases within 2–3 weeks and two cases reoperated, one with relaparoscopy with drainage and one cases reoperated with open exploration and ligation of leaked duct while group B with 10 cases treated with ERCP, all patients treated successfully with ERCP sphincterotomy and stent placement and leaks stopped and discharged within third or fourth day without any morbidity, no mortality in both groups. Conclusion Treatment of biliary leakage due to injured Luschka (subvesical duct) with ERCP sphincterotomy and stent placement is safe and effective without any morbidity or mortality.

Incidence, Risk Factors and Outcome of Gallbladder Perforation during Laparoscopic Cholecystectomy

Background and Aim: Gallbladder perforation has been recorded in patients undergoing laparoscopic cholecystectomy and associated with the development of gallstones and bile leakage. The present study investigated the incidence, risk factors, and outcome of gallbladder perforation in patients undergoing elective laparoscopic cholecystectomy. Patients and Methods: This prospective study was conducted on 156 patients who underwent laparoscopic cholecystectomy in the department of General Surgery, Federal Government Polyclinic Hospital, Islamabad from January 2021 to July 2022. Gallbladder stone patients with chronic symptoms such as vomiting, recurrent episodes of epigastric, nausea, and hypochondrial pain on right side were included. Acute cholecystitis patients with single or multiple gallstone disease were also enrolled. All the patients were prepared for laparoscopic cholecystectomy and investigations such as blood sugar, liver function test, CBC, blood urea and creatinine, ultrasound of gallbladder, and ECG were done. SPSS version 26 was used for data analysis. Results: Of the total 156 patients, there were 126 (80.8%) females and 30 (19.2%) male. Age-wise distribution of patients were as follows: 66 (42.3%) in 20-35 years, 52 (33.3%) in 36-50 years, and 38 (24.4%) in 51-65 years. The incidence of single gall stone (SGS), multi gallstones (MGS), and acute cholecystitis was 48 (30.8%), 88 (56.4%), and 20 (12.8%) respectively. The overall mean age was 36 years. The incidence of gallbladder perforation was 26.9% (n=42) among all patients. Patients distribution based on gallbladder perforation were as follows: 17 (10.9%) in MGS, 14 (9.0%) in SGS, and 11 (7.1%) in acute cholecystitis cases. Conclusion: The present study found that the prevalence of gallbladder perforation was 26.9% among SGS, MGS, and acute cholecystitis. Majority of GB perforation occurred during gallbladder bed dissection. Acute cholecystitis patients are more prone to GB perforation. GB perforation can be reduced by utilization of harmonic scalpel in laparoscopic cholecystitis. Keywords: Elective laparoscopic cholecystectomy, Gallbladder perforation, Outcomes

Laparoscopic cholecystectomy using the subserosal layer dissection technique in dogs: 34 cases (2015-2021).

To describe a standardised subserosal layer dissection technique and evaluate its outcomes in canine laparoscopic cholecystectomy. Medical records of dogs undergoing laparoscopic cholecystectomy using the standardised subserosal layer dissection technique for the treatment of cholecystolithiasis, cholecystitis, and gall bladder mucocele at a single veterinary hospital from January 2015 to September 2021 were extracted. Operative time, subserosal layer dissection achievement rate, open conversion rate, and complication rate were evaluated. Thirty-four dogs were included. The most common preoperative diagnosis was cholecystolithiasis (n=29). Operative time was 190 minutes (range: 110 to 330 minutes). Subserosal layer dissection of more than 90% of the gall bladder bed was achieved in 27 (79%) dogs. Conversion to open surgery was required in three (8.8%) dogs. There were no cases of intraoperative bleeding, bile duct injury, or reoperation. This study showed that laparoscopic cholecystectomy using the standardised subserosal layer dissection technique could be performed successfully in dogs. Future prospective clinical studies are needed to determine safety and effectiveness of this technique compared to standard techniques.

Bupivacaine Irrigation at the Gall Bladder Bed for Postoperative Pain Relief after Laparoscopic Cholecystectomy

Purpose: Gallbladder is highly innervated by parasympathetic and sympathetic nervous system through anterior and posterior hepatic plexus and the phrenic nerves. The aim of this study was to evaluate the effect of bupivacaine irrigated at the surgical bed on postoperative pain relief in laparoscopic cholecystectomy patients. and reducing analgesic consumption following laparoscopic cholecystectomy. Methods: This randomized controlled prospective study included 150 patients undergoing elective laparoscopic cholecystectomy who were prospectively randomized into 2 groups. The placebo group (n=75) received 50cc normal saline in- stalled into the gallbladder bed after removal of the gall bladder. The bupivacaine group (n=75) received 20cc of 0.5% bupivacaine in at the same surgical site. Pain was assessed at 1,2 ,6, 12, and 24 hours by using a visual analog scale (VAS). Results: The postoperative visual analogue score within the first 24 hour for visceral pain at rest, during coughing, and movement was significantly lower in the infiltration group than the control group, but it was similar for somatic pain. Time to first rescue analgesia was significantly longer in the infiltration than the control group. significant difference (P=.011) was observed in pain levels between both groups at 2, and 6 hours postoperatively. The average analgesic requirement was lower in the bupivacaine group. Conclusions: In our study, the use of bupivacaine irrigated over the surgical bed was an effective method to decreased visceral pain intensity at rest, coughing, and movement with reduced analgesic consumption in the first postoperative 24 hours after laparoscopic cholecystectomy.

Irrigation with Bupivacaine at the Surgical Bed for Postoperative Shoulder Tip and Abdominal Pain Relief after Laparoscopic Cholecystectomy

Gallstones in western countries are primarily composed of cholesterol. However, mixed or pigment stones, which contain a higher proportion of bilirubin, are more frequently seen in developing nations and Asia than in western countries. Abdominal and shoulder tip pains (STPs) are common complaints following the standard laparoscopic cholecystectomy procedure. To date, all pain management modalities have proven variable outcomes. This prospective randomized study included 82 patients who underwent elective laparoscopic cholecystectomy. The control group received 20 mL of normal saline, whereas the study group received a 20-mL instillation of 0.5% bupivacaine at the gallbladder bed after surgical resection. The Visual Analog Scale (VAS) was used to analyze abdominal pain and STP. The mean age ranged from 20 to 80 years. Abdominal VAS at 6, 12, 18, 24, 30, 36, and 48 hours were statistically insignificant. The majority were discharged on postoperative day 1 (32 studies, 37 control). Follow-up VAS after 1 week for STP VAS and abdominal pain VAS in both groups were statistically insignificant. Even with small numbers of a well-conducted randomized trial, we demonstrated that bupivacaine irrigation at the gallbladder bedpost laparoscopic cholecystectomy does not affect pain relief.

S1764 Localized Truncal Xanthoderma Secondary to Bile Leakage Post Laparoscopic Cholecystectomy

Introduction: Xanthoderma is a yellow to yellow-orange discoloration of the skin. The 2 main pathologies leading to xanthoderma are jaundice and carotenoderma. Although the most common mechanism for jaundice is the elevation of serum bilirubin, localized jaundice can rarely occur in the settings of bile leakage into the retroperitoneal space. Case Description/Methods: A 40-year-old female patient presented with biliary pain. Examination showed right upper quadrant tenderness. Initial labs revealed total bilirubin of 49 µmol/L, with a direct bilirubin of 47µmol/L (Table). The US abdomen showed cholelithiasis. MRCP showed a small distal CBD stone; CBD diameter was 9 mm. She underwent laparoscopic cholecystectomy with an intraoperative cholangiogram. The small distal CBD stone was pushed to the duodenum. Repeated IOC showed a smooth passage of contrast. Her clinical status didn’t improve postoperatively, and her bilirubin was persistently elevated. Localized yellowish discoloration of the right side of the abdominal wall and the suprapubic area was observed 5 days after the surgery (Figure A). Repeated MRCP showed suspicious distal CBD stone with gall bladder bed collection and diffuse inflammatory change of the right abdominal wall. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a bile leak at the site of the cystic stump (Figure A) and a small filling defect in the distal CBD. Sphincterotomy and CBD stenting were performed. The bilirubin improved gradually after ERCP, but the abdominal pain persisted. CT abdomen showed large perihepatic and perisplenic fluid collection measuring 10x 17.6x 20 cm, necessitating US-guided percutaneous drainage. Turbid yellow fluid was drained, confirming that the collection was a biloma related to the bile leak. Four weeks later, the percutaneous drain was removed after the collection resolved. Repeated ERCP showed no biliary leak. Discussion: In our patient, the localized xanthoderma post laparoscopic cholecystectomy was secondary to bile leakage from the cystic duct stump. In a similar case report, the authors explained that the localized xanthoderma occurred as a result of bile staining of the tissues deep to the membranous layer of the superficial fascia (fascia of Scarpa) after the bile has leaked from the cystic duct through the hepatoduodenal ligament. The management of our patient involved sphincterotomy and bile duct stenting combined with percutaneous drainage of the collections.Figure 1.: A: Localized yellowish discoloration of the anterior abdominal wall. B: An ERCP fluoroscopic image showing contrast leakage near the cystic stump. Table 1. - Laboratory investigations Laboratory test Patient's value Normal range Total bilirubin 49 µmol/L 0-21 Direct bilirubin 47 µmol/L 0-9 AST 287 U/L 0-32 ALT 249 U/L 0-33 Alkaline phosphatase 264 U/L 35-104

214 Laparoscopic Cholecystectomy: Most Primeval and Pervasive Yet Least Congruent

Abstract Aim Laparoscopic Cholecystectomy is one of the commonest surgical procedures performed worldwide. However, there is considerable variation in laparoscopic cholecystectomy practice, and a lack of robust data on variations in practices. Method A 45-item electronic survey was designed to capture global variations in practice of laparoscopic cholecystectomy. The survey was disseminated to the global community of surgeons performing laparoscopic cholecystectomy through professional surgical and training organizations and social media. Results 638 surgeons from 70 countries completed the survey. Pre-operatively 5.6% routinely performed an endoscopy to rule out peptic ulcer disease. Cholecystectomy theatre lists were provided acutely by 58.6%, with 61.2% (n=389) performing index admission cholecystectomy for gallstone pancreatitis. Peri-operative practice included the use of prophylactic antibiotics (n=362) and elastic compression stocking routinely by over half of the respondents. However, 69.7% do not use pharmacological DVT prophylaxis preoperatively. Open juxta umbilical is the preferred method of pneumoperitoneum (n=410, 64.6%). The most common approach to difficult Calot's triangle is retrograde dissection from fundus (49.2%, n= 312). Transection of the gallbladder in the middle and retrograde dissection is practiced by about 18% of surgeons (n=114). Local anesthetic is instilled into the gallbladder bed by 14.2% of surgeons. Half of the surgeons discharge their patients on the following day, while around 44% would discharge them on the same day. Conclusions This study highlights significant variations in practices concerning various aspects of laparoscopic cholecystectomy and stressed on the need for developing consensus guidelines.

Successful conversion surgery for locally advanced gallbladder cancer after gemcitabine and nab-paclitaxel chemotherapy.

ObjectiveGallbladder cancer (GBC) is highly malignant and is often diagnosed at the advanced stage. Lack of opportunity to surgery results in an unsatisfactory outcome. This pilot study employed gemcitabine combined with nab-paclitaxel (AG) as a conversion therapeutic measure for locally advanced GBC and successfully achieved conversion surgery in three initially unresectable GBC patients. We will introduce our experience on improving the outcome of this dismal disease.MethodsRadiology and nuclear medicine imaging were performed in each patient, and resectability was evaluated by joint consultation of our multi-disciplinary team (MDT). Patients evaluated as unresectable were treated with the AG regimen and re-evaluated for treatment response. When complete or partial response is achieved, MDT opinion would be required to assess the possibility of performing conversion surgery with R0 resection.ResultsThree GBC patients who were initially evaluated as unresectable successfully underwent R0 resection after conversion therapy with the AG regimen. The first case was a recurrent GBC patient evaluated as locally advanced and eventually achieved pathological complete response. The second case was a GBC patient who underwent R1 resection with residual lesions in the gallbladder bed and isolated No. 16 lymph node metastasis and who had a pathologically complete response after treatment. The third case had multiple but resectable liver metastases; both objective response and partial pathologic response were achieved. None of the patients experienced serious treatment-related adverse events. All cases revealed no evidence of recurrence or metastasis after a median follow-up of 12 months.ConclusionsConversion therapy shows a favorable efficacy in those unresectable GBC patients. Gemcitabine plus nab-paclitaxel has the potential to be used as a preoperative treatment option for GBC patients at the advanced stage. To further explore the efficacy of AG on conversion therapy for GBC patients, a prospective clinical trial has been registered (ChiCTR2200055698).

Endovideosurgery Potential in the Treatment of Liver Cysts

Non-parasitic cystic lesions of the liver are asymptomatic for a long time and appear to be an accidental diagnostic finding. It should also be noted that when choosing a treatment strategy, it is necessary to carry out differential diagnostics with parasitic cysts in echinococcosis and opisthorchiasis, as well as decay areas in alveococcosis and liver cancer. The paper describes a clinical case of successful management of a patient with a liver cyst. Prior to admission, the patient was examined outpatiently: ultrasound examination, spiral computed tomography of the abdominal organs detected a liquid formation in the projection of liver segments IIIII measuring 89x79x88 mm. In addition, immunological studies were carried out to differentiate the origin of cystic formation. The presence of IgG antibodies to Toxocara was confirmed, the fact allowing for the parasitic origin of the cyst. The patient was admitted to the Surgical Clinic named after I.I. Grekov, North-Western State Medical University named after I.I. Mechnikov, for planned surgical treatment - en bloc resection of liver segments II-III and cholecystectomy, due to concomitant cholelithiasis. The resected edge of the liver and the gallbladder bed were processed using argon plasma coagulation. The postoperative period appeared unremarkable. The histopathological examination finding was a solitary cyst of the bile duct, with chronic active inflammation in the surrounding liver tissue. The patient was discharged in a satisfactory condition on the eleventh day after the operation under the supervision of a surgeon, therapist and infectious disease specialist. Thus, an interdisciplinary approach is a key in the treatment of patients with liver cysts and allows choosing the optimal treatment tactics.Endovideosurgical technologies allow conducting radical surgical interventions for liver cysts, even in cases when their parasitic origin cannot be excluded.

Real-Time Laparoscopic Cholecystectomy Simulation Using a Particle-Based Physical System

Laparoscopic cholecystectomy is used to treat cholecystitis and cholelithiasis. Because the high risk of the surgery prevents novice doctors from practicing it on real patients, VR-based surgical simulation has been developed to simulate surgical procedures to train surgeons without patients, cadavers, or animals. In this study, we propose a real-time system designed to provide plausible visual and tactile simulation of the main surgical procedures. To achieve this, the physical properties of organs are modeled by particles, and cluster-based shape matching is used to simulate soft deformation. The haptic interaction between tools and soft tissue is modeled as a collision between a capsule and particles. Constraint-based haptic rendering is used to generate feedback force and the non-penetrating position of the virtual tool. The proposed system can simulate the major steps of laparoscopic cholecystectomy, such as the anatomy of Calot's triangle, clipping of the cystic duct and biliary artery, disjunction of the cystic duct and biliary artery, and separation of the gallbladder bed. The experimental results show that haptic rendering can be performed at a high frequency (> 900 Hz), whereas mesh skinning and graphics rendering can be performed at 60 frames per second (fps).

Bleeding Origin and Its Frequency in Laparoscopic Cholecystectomy

Objective: Laparoscopic cholecystectomy (LC) has recognized itself as the ‘gold standard’ treatment of gallstone disease, but it can, sometimes, be related with considerable complication leads to mortality and morbidity. Therefore, this study was intended to assess the frequency of many sources of bleeding in patients underwent laparoscopic cholecystectomy.
 Methodology: This was a cross sectional study conducted in the Department of Surgery, Bhitai Dental and Medical College Hospital by using consecutive sampling technique. The duration of study was about one year from Feb 2021 to Dec 2021. A total of 163 patients of age between 30 to 55 years of both genders of diagnosed cholecystitis with cholelithiasis, disease duration of >6 weeks identified by patient’s history were included in the study. To assess the effect modification, age, gender, duration of disease, and amount of bleeding and operative time were stratified followed by application of chi-square with a p value < 0.05 considered as significant.
 Results: The study results showed that out of 163 cases of laparoscopic cholecystectomy, 141(87%) were females and 22(13%) were males with their mean age were 38.99±10.96 years. Bleeding in laparoscopic cholecystectomy from gallbladder bed was reported in 128(79%) cases followed by cystic artery in 28(17%) cases. There were78(80.4%) cases reported bleeding from gallbladder bed in < 40 years of age and 50(75.75%) cases reported in >40 years of age although with an insignificant association between them (p=0.477). 109(77.3%) cases reported bleeding from gallbladder bed in female and 19(86.3%) cases reported in males with an insignificant association between them (p=0.336). 
 Conclusion: This study concluded that the most frequent bleeding site was the gallbladder bed followed by cystic artery in laparoscopic cholecystectomy. Furthermore, bleeding from gallbladder bed was common in females and < 40 years of age although there was an insignificant association observed with respect to age and gender.

Pain after Laparoscopic Cholecystectomy: Effect of IntraperitonealInfiltration of Injection Bupivacaine

Objective: The aim of this study is to determine the effectiveness of intraperitoneal bupivacaine in patients undergoing laparoscopic cholecystectomy. Study Design: Prospective randomized study Place and Duration: Study was conducted at the department of SurgeryDow University Hospital (Ojha), Karachi for duration of six months from May 2021 to October 2021. Methods: There were 70 patients of both genders were presented in this study. Adult patients above 16 years of age, ASA class 1 & 2, undergoing elective cholecystectomy were included in this study. Informed written consent was taken from all the patients for detailed demographics age, sex and body mass index. Patients were categorized into 2 groups. Group A had 36 patients and received 40 ml of intraperitoneal infiltration 0.25% Bupivacaine at Gall Bladder bed and Right Subphrenic space. Group B control group with 34 patients received no intraperitoneal Bupivacaine. Both groups received 20 ml of 0.25% Bupivacaine at ports site incisions. All patients were educated about the standard Visual Analogue Score (VAS) pain score of 0 – 10, during pre anaesthetic evaluation visit. SPSS 23.0 version was used to analyze data. Results: There were 28 (77.8%) females in group A and in group B females were 31 (91.2%). 43.55±13.93 years were the mean age in group A and in group B mean age was 39.94±11.54 years. Mean body mass index of group A was 26.14±13.41 kg/m2 and in group II mean BMI was 25.06±11.53 kg/m2. In group B close technique was used in 26 (72.2%) while in group B 24(70.6%) cases received closed technique. Post-operatively low pain score was observed in study group as compared to group B. Frequency of rescue analgesic was higher in group B as compared to group A. Conclusion: We concluded in this study that the use of intraperitoneal bupivacaine for laparoscopic cholecystectomy was significantly effective in terms of low pain and is an effective method for improving the quality of life within the early recovery period.

EFFECTS OF INTRAPERITONEAL BUPIVACAINE VERSUS PLACEBO ON POSTOPERATIVE PAIN AFTER LAPAROSCOPIC CHOLECYSTECTOMY: A RANDOMISED DOUBLE BLIND STUDY

Background & Aims: Postoperative abdominal and visceral pain after elective Laparoscopic Cholecystectomy (LC) is of prime concern to patients as it causes signicant distress. (1)(2) The aim of our study was to evaluate the benet of intraperitoneal bupivacaine irrigation on the surgical bed versus placebo. Methods: 50 patients undergoing elective laparoscopic cholecystectomy were included in the study. They were prospectively randomised into 2 groups. The placebo group (Group P, n = 25) received 35 cc saline without bupivacaine, installed into the gallbladder bed. The bupivacaine group (Group B, n =25) were given 35 cc of 0.25% bupivacaine at the same location. Pain was evaluated at regular intervals of 0, 5, 10, and 24 hours using the visual analogue scale (VAS). Result: Asignicant difference (P=) was seen on VAS to evaluate post-operative pain between two groups at 5 hours post operatively. Conclusion: Irrigation of local anaesthetic bupivacaine at the gall bladder bed can be an effective method for decreasing post-operative pain in the rst 5 hours after laparoscopic surgery.

Intracholecystic papillary neoplasm associated with invasive carcinoma of the remnant gallbladder after subtotal cholecystectomy: a case report

BackgroundIntracholecystic papillary neoplasm (ICPN) of the gallbladder is a rare tumor and a relatively new concept. Therefore, the natural history and imaging characteristics of ICPN have not yet been fully documented. Moreover, cases who underwent curative resection for remnant gallbladder cancer, including ICPN with associated invasive carcinoma, have been rarely reported. We report a resected case of ICPN of the remnant gallbladder with associated invasive carcinoma for which we could observe a temporal change in imaging findings until malignant transformation.Case presentationA 79-year-old female patient with a surgical history of subtotal cholecystectomy for acute cholecystitis was an ambulatory patient of our institution because of postoperative surveillance for colon cancer. Ultrasonography and computed tomography incidentally detected a small nodule in the cystic remnant gallbladder. The nodule had increased in size 3 months later; thus, additional investigations were performed. Magnetic resonance imaging revealed a 10-mm enhanced nodule without evidence of extraluminal invasion. Diffusion-weighted magnetic resonance imaging revealed restricted diffusion of the lesion, and positron emission tomography revealed marked accumulation in the lesion. The lesion was diagnosed as suspicious for a malignant remnant gallbladder tumor. Therefore, remnant cholecystectomy with gallbladder bed resection was performed. Because preoperative endoscopic retrograde cholangiography revealed a relatively long intact cystic duct, extrahepatic bile duct resection was planned to be omitted. Intraoperatively, the hepatic and duodenal side bile duct where the cystic duct diverged was taped. Using these tapes, which permitted pulling the bile duct, the cystic duct located behind the bile duct could be safely exposed. The lesion was pathologically diagnosed as biliary morphologic ICPN with associated invasive carcinoma.ConclusionsBecause remnant cholecystectomy is an uncommon procedure and technically difficult, accurate preoperative investigation and surgical planning are important to prevent bile duct injury and omit extrahepatic bile duct resection. In the present case, intracystic change could be detected incidentally at an early stage because of previous remnant gallbladder producing (reconstituting) subtotal cholecystectomy and surveillance for other disease. This case suggests the existence of ICPN that can progress to invasive carcinoma during a short period.

Gallbladder Burkitt’s lymphoma mimicking gallbladder cancer: A case report

BACKGROUNDMalignant lymphoma is a rare form of gallbladder malignancy. Most of these malignancies are diffuse large B-cell lymphomas or mucosa-associated lymphoid tissue-type lymphomas; however, Burkitt’s lymphoma of the gallbladder is extremely rare, and only two previous reports are available in the literature. Herein, we report a rare case of Burkitt’s lymphoma of the gallbladder mimicking gallbladder adenocarcinoma.CASE SUMMARYAn 83-year-old man with no abdominal complaints was found to have a gallbladder tumor and periportal lymph node enlargement on computed tomography (CT) performed for hypertension screening. His laboratory data revealed slightly elevated serum levels of carcinoembryonic antigen and soluble interleukin 2 receptor. Imaging examinations revealed two irregular and contrast-enhanced masses extending into the gallbladder lumen, but these did not infiltrate the serosa. Moreover, a periportal lymph node had enlarged to 30 mm. Based on these findings, we diagnosed the patient as having gallbladder adenocarcinoma with lymph node metastasis, which was treated using bile duct resection with gallbladder bed resection and periportal lymph node dissection. However, the patient was finally diagnosed as having Burkitt’s lymphoma. Although the surgical margin was pathologically negative, recurrence was noted at the hepatic radical margin and superior pancreaticoduodenal lymph nodes on positron emission tomography/CT soon after discharge. Thus, he was referred to a hematologist and started receiving treatment with reduced-dose cyclophosphamide, doxorubicin, vincristine, and prednisone.CONCLUSIONBurkitt’s lymphoma can occur in the gallbladder. Biopsy can be useful in cases with findings suggestive of gallbladder malignant lymphoma.

Feasibility and Safety of Laparoscopic Gallbladder Resection for Gallbladder Tumours.

The laparoscopic approach is not widely used for gallbladder tumours because of the high degree of malignancy associated with gallbladder cancer and technical difficulties. This study aimed to clarify the feasibility and safety of laparoscopic gallbladder resection for gallbladder tumours. This retrospective study enrolled patients who underwent laparoscopic whole-layer cholecystectomy or laparoscopic gallbladder bed resection for gallbladder tumours between April 2010 and December 2020. We analysed the perioperative and oncological outcomes of patients with gallbladder carcinoma. The cohort comprised 31 patients, including 13 who underwent laparoscopic whole-layer cholecystectomy and 18 who underwent laparoscopic gallbladder bed resection. Twenty patients were diagnosed with gallbladder cancer. Three patients (15%) had metastases in harvested lymph nodes. No postoperative complications were observed. Recurrence occurred in four patients; the primary location was the liver in three patients and lymph node in two. The 1-, 3-, and 5-year recurrence-free survival and overall survival rates were 87%, 78.3%, and 58.8%, and 100%, 70.5%, and 70.5%, respectively. Our surgical strategy enables safe and curative gallbladder resection for gallbladder tumours, without excess or insufficient resection.

Pathological complete response achieved by gemcitabine plus cisplatin therapy for initially unresectable advanced gallbladder cancer: a case report

BackgroundConversion surgery for initially unresectable gallbladder cancer is rarely performed due to the low response rate for systemic chemotherapy, and a pathological complete response is seldom achieved.Case presentationA 67-year-old woman with jaundice was referred to our hospital and diagnosed with unresectable gallbladder cancer with extra-regional lymph node metastasis after examinations. After biliary decompression, gemcitabine plus cisplatin therapy was started. The tumor marker levels markedly decreased, and imaging studies revealed a reduction in the primary tumor and metastatic lymph nodes. The primary tumor and metastatic lymph node were still shrunk at 4 years after the start of gemcitabine plus cisplatin therapy, so we decided to perform conversion surgery. Gallbladder bed resection and lymph node dissection were performed. The pathological findings of the resected specimen showed only partial fibrosis in the gallbladder wall and no malignant findings in the dissected lymph nodes, indicating a pathological complete response. As of 24 months after the operation, she is alive without recurrence.ConclusionAlthough there have been only a few reports of conversion surgery for initially unresectable gallbladder cancer, it may be worthwhile to perform chemotherapy with the potential goal of subsequent conversion surgery.

Postoperative Analgesia in Laparoscopic Cholecystectomy following Intraperitoneal Magnesium Sulphate: A Prospective Cohort Study

Introdution: Postoperative pain and discomfort after laparoscopic cholecystectomy is partly because of distension, tearing, separation of parietal peritoneum and surgical manipulation. Intraperitoneal administration of Magnesium Sulphate (MgSO4 ) is thought to desensitise the after effects of pneumoperitoneum in addition to providing analgesia. Aim: To analyse the effect of intraperitoneal magnesium sulphate on postoperative analgesia and occurrence of shoulder pain after laparoscopic cholecystectomy. Materials and Methods: The present study was a prospective cohort study which was conducted at the Government Medical College, Kozhikode, Kerala, India, from February 2019 to December 2020, included 60 adult patients scheduled for elective laparoscopic cholecystectomy under general anaesthesia were selected and they were divided into two groups, group M and group N. Patients in group M received 30 mg/kg MgSO4 which was instilled into the gallbladder bed intraperitoneally by the surgeon after resection of gallbladder and patients who did not receive MgSO4 were included in group N. Postoperative pain was assessed using Visual Analog Scale (VAS) and VAS score> 3 was managed with Intravenous (IV) paracetamol 15 mg/kg. If pain was not relieved by this, IV tramadol 50 mg was supplemented. Time to first rescue analgesic, the total analgesic requirement and the incidence of shoulder pain in 24 hours were noted. Haemodynamics, recovery profile, incidence of Postoperative Nausea and Vomiting (PONV), any adverse events were also noted and analysed. Results: Mean pain scores (VAS) were significantly lower in group M and time to first analgesic requirement was longer in group M (4.23±2.31 hours) compared with group N (1.07±0.67 hours), PONV was significantly higher in group N. Sedation scores were significantly high in group M and there were no significant differences in haemodynamic and recovery profile and incidence of shoulder pain in both the groups. Conclusion: Intraperitoneal instillation of MgSO4 provides effective postoperative analgesia and reduces nausea and vomiting in patients undergoing laparoscopic cholecystectomy without any significant side-effects.

Outcome of laparoscopic cholecystectomy in terms of intraoperative complications in a tertiary care hospital.

Objectives: The main objective was to evaluate the outcome of laparoscopic cholecystectomy in terms of intra-operative complications and the rate and reasons of conversion to open cholecystectomy. Study Design: Descriptive Study. Setting: Hayatabad Medical Complex, Peshawar. Period: June 2018 to May 2019. Material & Methods: After taking consent of Hospital ethical & research committee, patients admitted with clinical diagnosis of cholelithiasis and chronic cholecystitis, confirmed by abdominal ultrasound, undergoing laparoscopic cholecystectomy fulfilling inclusion criteria were selected. Results: A total of 150 were included in the study. Mean age was 39.2yrs with female to male ratio of 9.75:1. Laparoscopic cholecystectomy was successfully accomplished in 98% cases. In 2% (3 patients) converted cases the most common cause of conversion observed was dense adhesions in the calots triangle. Intra-operative complications were noted in 1.4% patients, those included bile duct injury and leakage from the gallbladder bed. However other complications such as bowel injury, blood vessel injury, and post operative hemorrhage did not occur. Overall morbidity was 1.4% with no mortality. Conclusion: Laparoscopic cholecystectomy is a safe and effective procedure in our setup to the accepted standards, as evident by the national and international studies. And it can be accomplished with minimal morbidity and low rate of conversion with the increasing surgeon’s experience.

Postoperative complications of laparoscopic cholecystectomy in children: two cases report

Only a few studies have investigated the complications of laparoscopic cholecystectomy in children. Therefore, relevant case reports will be of interest to pediatric surgeons.
 The patient was a 10-month-old boy diagnosed with calculous cholecystitis who underwent laparoscopic cholecystectomy. He had peripheral edema and adhesions in the neck of the gallbladder. After 10 h, a clinical picture of intra-abdominal bleeding developed. During relaparoscopy in the area of the gallbladder bed, arterial bleeding from the liver vessel was noted, which was eliminated by coagulation. The postoperative period was uneventful, and the child was discharged on day 8. In the second case, a 10-year-old girl was admitted for chronic calculous cholecystitis, and laparoscopic cholecystectomy was performed, in which a pronounced adhesion process was noted in the gallbladder neck region. On day 8, the child was discharged home; however, after 26 days, the patient was admitted again, with a clinical picture of diffuse biliary peritonitis. During laparoscopy, bile outflow from the gallbladder bed was noted, which only partially eliminated by monopolar electrocoagulation. Drainages were installed, through which bile began to be abundantly secreted in the postoperative period. Laparoscopy with a transition to open surgery was performed, during which a perforation in the wall of the common bile duct was found, and stenting and suturing of the defect were performed. In the postoperative period, active infusional infusion and antibacterial therapy were given. The patient was discharged on day 29.
 Postoperative complications of the ClavienDindo type IIIb are associated both with the presence of congenital anatomical features and inflammatory-adhesive changes in the Calo triangle zone and with the possibility of latent lesions during monopolar coagulation in both cases. The evaluation of the tactics of eliminating biliary peritonitis in the second patient emphasized the necessity to switch to open laparotomy during the second operation.
 These cases indicate the need to comply with the principles of safe laparoscopic cholecystectomy, including the availability of modern endoscopic equipment and the experience of surgeons in endosurgery. This requires the concentration of patients with cholelithiasis in specialized clinics.