Gangrenous Gallbladder Research Articles

Single versus multiple gall stone disease in patients undergoing laparoscopic cholecystectomy

The aim of this paper is to compare single versus multiple gall stone disease in patients undergoing laparoscopic cholecystectomy. A total of one hundred and thirty patients (males- 52, females- 78) within age group 20-65 years presented with cholelithiasis were divided into 2 groups. Group 1 comprised of single stone patients and group II had multiple stones. Each group had 65 patients. Parameters compared were symptoms and operative findings between both groups, Analysis of results was carried with chi0 square test. Most common clinical symptoms found to be fever in both groups (87%- group 1, 90%- group 2). Other symptoms were dyspepsia seen in 25% and 30%, nausea/ vomiting in 45% and 38% in group 1 and 2 patients respectively. Females were commonly affected and maximum case were observed in age group 40-50 years. Multiple gall stones patients had more symptoms and prevalence of conversion to open surgery was more in these patients. Group 1 patients showed gall bladder distention in 56 and group 2 in 62 patients, gall bladder contraction was seen in 6 patients in group 1 and 3 in group 2, adhesions were exhibited by 11 patients in group 1 and 20 in group 2. 4 patients in group 2 converted to open surgery. Gangrenous gall bladder was seen in 1 in group 1 and 5 in group 2.

Effect of the COVID-19 Pandemic on the Management of Acute Cholecystitis and Assessment of the Crisis Approach: A Multicenter Experience in Egypt.

IntroductionThe covid‐19 pandemic has had a drastic impact on all medical services. Acute cholecystitis is a serious condition that accounts for a considerable percentage of general surgical acute admissions. Therefore, the Royal College of Surgeons' Commissioning guidance' recommended urgent admission to secondary care and early cholecystectomy. During the first wave of hospital admissions associated with COVID‐19, most guidelines recommended conservative treatment in order to limit the admission rates and free up spaces for COVID‐19‐infected patients. However, reviews of this approach have not been widely done to assess the results and, in turn, planning our future management approach when future pressures on in‐patient admissions are inevitable.MethodsOur study included all acute cholecystitis patients who needed surgical intervention in one Centre in the UK over three distinct periods (pre‐COVID‐19, during the first lockdown, and lockdown ease). Comparison between these groups were done regarding intraoperative and postoperative results.ResultsThe conservative management led to a high rate of readmission. Moreover, delayed cholecystectomy was associated with increased operative difficulties such as extensive adhesions, intraoperative blood loss, and/or complicated gall bladder pathologies such as perforated or gangrenous gall bladder (29.9%, 16.7%, and 24.8%, respectively). The resulting postoperative complications of surgical and nonsurgical resulted in a longer hospital stay (13.5 d).ConclusionThe crisis approach for acute cholecystitis management failed to deliver the hoped outcome. Instead, it backfired and did the exact opposite, leading to longer hospital stays and extra burden to the patient and the healthcare system.

Marbelization of the gallbladder, a variant of acute gangrenous cholecystitis

Cholelithiasis can present from a milder form of biliary colic to a more severe and complicated one like empyema gallbladder and a lesser-known variant of gangrenous gallbladder called marbleization of the gallbladder. The clinical signs and symptoms are similar to acute cholecystitis. Diabetes mellitus could have a role in the process of marbleization. Diagnosing marbleization of the gall bladder is not easy preoperatively. Computerized tomography is a better diagnostic modality when compared to laboratory investigations. Urgent cholecystectomy is the only option, and there is no role of conservative treatment. We report a case of a 36-year-old man with newly diagnosed Diabetes Mellitus diagnosed initially as acute cholecystitis and managed conservatively. He did not respond to treatment and hence underwent cholecystectomy and intraoperatively was found to have marbleization of the gall bladder.

Preoperative conversion from a laparoscopic to an exploratory laparotomy cholecystectomy

Introduction: Acute cholecystitis (AC) with cholelithiasis is commonly presented as right upper quadrant pain with radiation to the scapula. A lethal complication before any surgical intervention in a patient with AC is sepsis. Presentation of Case: We present a rare case of a patient who had AC complicated with sepsis. Patient was surgically prepared for a laparoscopic cholecystectomy but later changed to an exploratory laparotomy cholecystectomy due to complaints of preoperative diffuse abdominal pain and concerns of intra-abdominal sepsis. A central line for antibiotics, metronidazole, and vancomycin, was placed during surgery to treat his sepsis. Patient had an uneventful postop recovery. Discussion: Surgical solutions should be discussed during preoperative work-up with any changes in potential signs of sepsis and abdominal pain. Laparoscopic cholecystectomy is a less invasive procedure but carries a risk with potential intraoperative complications in treating gangrenous cholecystitis with biliary sludge; therefore exploratory laparotomy should be discussed as a potential intervention. Conclusion: Conversion to an exploratory laparotomy seems inevitable when concerns of complications arise before surgery to reduce morbidity and mortality. Severe peritonitis with a gangrenous gallbladder posed an increased risk for a laparoscopic procedure and therefore a conversion to an exploratory laparotomy was initiated.

S1406 Right Hepatic Artery Pseudoaneurysm Causing Hemobilia: A Rare Complication of Laparoscopic Cholecystectomy

INTRODUCTION: Laparoscopic cholecystectomy is considered the gold standard for cholecystitis and symptomatic cholelithiasis. However, it poses a risk of bile duct injury and injury to the right (R) hepatic artery when compared to the open operation. While injuries including bile leakage of aberrant ducts, cystic stump injury, or main bile duct injury have been documented, hemobilia secondary to hepatic artery pseudoaneurysm is a rare complication of laparoscopic cholecystectomy. This case represents delayed gastrointestinal bleeding sustained from laparoscopic cholecystectomy with injury to the common bile duct (CBD). CASE DESCRIPTION/METHODS: An 82 year-old male presented to the hospital with mid-epigastric abdominal pain and melena beginning two months after a cholecystectomy that was converted to an open procedure secondary to complications from a gangrenous gallbladder. During that procedure, a leak within the Duct of Luschka noted and closed with placement of a T-tube (draining tube). This would stay in until two weeks prior to admission. On initial presentation, the patient had an elevated temperature of 100.3 F. Initial hemoglobin (Hgb) was 13 g/dL, which dropped to 9 g/dL after 24 hours. Liver enzymes were elevated (total bilirubin 5.4, AST 194, ALT 149, and alkaline phosphatase 188). Computed tomography revealed dilation of both the intra and extrahepatic bile ducts and hyperdense material within an 18 mm dilated common bile duct. Magnetic resonance cholangiopancreatography confirmed the findings above. Endoscopic retrograde cholangiopancreatography revealed blood emanating from the ampullary orifice. A small sphincterotomy was performed and a 10 french × 5 cm plastic biliary stent was placed. Interventional radiology was consulted and angiography revealed a large pseudoaneurysm of a branch of the R hepatic artery in the region of the cystic artery communicating with the bile duct. This was subsequently embolized. The patient’s Hgb stabilized and he was subsequently discharged home. DISCUSSION: R hepatic artery pseudoaneurysm is an uncommon complication from laparoscopic cholecystectomy, however, the incidence is increased if there is injury to the bile duct during the operation. This case raises the awareness of hemobilia secondary to right hepatic artery pseudoaneurysm as an important bile duct injury that can predispose the patient to long-term complications. Prompt recognition using radiographic and endoscopic modalities helped make a diagnosis which lead to the appropriate management.Figure 1.: Endoscopic view with side-viewing duodenoscope showing hemobilia.Figure 2.: CT abdomen and pelvis showing the hepatic artery pseudoaneurysm communicating with the biliary system.Figure 3.: Another view of the right hepatic artery pseudoaneurysm communicating with the biliary system on CT abdomen and pelvis.

Histopathological findings in a COVID-19 patient affected by ischemic gangrenous cholecystitis

BackgroundSince its first documentation, a novel coronavirus (SARS-CoV-2) infection has emerged worldwide, with the consequent declaration of a pandemic disease (COVID-19). Severe forms of acute respiratory failure can develop. In addition, SARS-CoV-2 may affect organs other than the lung, such as the liver, with frequent onset of late cholestasis. We here report the histological findings of a COVID-19 patient, affected by a tardive complication of acute ischemic and gangrenous cholecystitis with a perforated and relaxed gallbladder needing urgent surgery.Case presentationA 59-year-old Caucasian male, affected by acute respiratory failure secondary to SARS-CoV-2 infection was admitted to our intensive care unit (ICU). Due to the severity of the disease, invasive mechanical ventilation was instituted and SARS-CoV-2 treatment (azithromycin 250 mg once-daily and hydroxychloroquine 200 mg trice-daily) started. Enoxaparin 8000 IU twice-daily was also administered subcutaneously. At day 8 of ICU admission, the clinical condition improved and patient was extubated. At day 32, patient revealed abdominal pain without signs of peritonism at examination, with increased inflammatory and cholestasis indexes at blood tests. At a first abdominal CT scan, perihepatic effusion and a relaxed gallbladder with dense content were detected. The surgeon decided to wait and see the evolution of clinical conditions. The day after, conditions further worsened and a laparotomic cholecystectomy was performed. A relaxed and perforated ischemic gangrenous gallbladder, with a local tissue inflammation and perihepatic fluid, was intraoperatively met. The gallbladder and a sample of omentum, adherent to the gallbladder, were also sent for histological examination.Hematoxylin-eosin-stained slides display inflammatory infiltration and endoluminal obliteration of vessels, with wall breakthrough, hemorrhagic infarction, and nerve hypertrophy of the gallbladder.The mucosa of the gallbladder appears also atrophic. Omentum vessels also appear largely thrombosed. Immunohistochemistry demonstrates an endothelial overexpression of medium-size vessels (anti-CD31), while not in micro-vessels, with a remarkable activity of macrophages (anti-CD68) and T helper lymphocytes (anti-CD4) against gallbladder vessels. All these findings define a histological diagnosis of vasculitis of the gallbladder.ConclusionsIschemic gangrenous cholecystitis can be a tardive complication of COVID-19, and it is characterized by a dysregulated host inflammatory response and thrombosis of medium-size vessels.

Histopathological spectrum of gall Bladder diseases in cholecystectomy specimens at a Rural tertiary hospital of Purvanchal in North India-Does it differ from South India?

Gall Bladder (GB) diseases are one of the most common digestive system diseases, the prevalence of which is variable within India and ranges from 2-29%. Cholelithiasis (gallstones) is the commonest lesion and accounts for more than 95% of GB diseases. Gall bladder carcinoma showed regional differences in India with prevalence ranging from 0.52% in southern India and as high as 9.6% in northern India. 1)To identify the morphological spectrum of diseases affecting the gall bladder. 2)To identify the most common histopathological lesion and its correlation with clinical and demographic data of the patient. 3)T o identify the frequency of Gall Bladder Carcinoma (GBC) and its correlation with clinical and demographic data of the patient and pre-existing lesions if any. This study was non-participatory descriptive study carried out retrospectively for a period of one year in the Dept. of Pathology, HIMS,from August 2018 to July 2019. All the specimens received in the study period were included in the study. The gross and microscopic findings on H & E slide were included in the study. The descriptive statistics w as applied to analysed data. Total 86 cholecystectomy specimens were received in the Department of Pathology during one year study period. Non-neoplastic lesions (97.67%) of gall bladder outnumbered the neoplastic lesions (2.33%). Most common histopathological lesion was chronic cholecystitis (95.34%). Varied histopathological spectrum was seen comprising of chronic calculous cholecystitis (73.26%), chronic acalculous cholecystitis (13.95), chronic cholecystitis with cholesterosis (13.95%), Xanthogranulomatous cholecystitis (2.33)%), Acute calculous cholecystitis (1.16%), acute gangrenous GB (1.16%), GBC (2.33%). In non-neoplastic lesions, female predilection (70.24%) was seen over male (29.76%) accounting for F:M ratio of 2.4:1, two cases of GBC exclusively seen in females associated with gall stones. Non-neoplastic lesions were common between the age group of 26-50 years accounting for 67.45% where as neoplastic lesions were common in the age group of >60years. Chronic cholecystitis with pigmented gall stone was the commonest GB disease in the present study. The study also revealed that females have increased preponderance for the development of all the gall bladder diseases including malignancy. Non-neoplastic lesions were more common till 5 decade in the present study whereas females in the 5th and 6th decade of life were prone for malignancy of gall bladder which was associated with gall stones.

Presentation and outcome of typhoid cholecystitis in children

Background: Typhoid cholecystitis is an extra-intestinal manifestation of Salmonella typhi infection. It is rarely suspected even in environments where typhoid intestinal perforation is common. It poses a diagnostic challenge as history, physical examination and laboratory findings are not usually specific.Materials and Method: This was retrospective review of 10 patients below 16 years of age managed for typhoid cholecystitis over a period of 7 years at Federal Medical Centre Lokoja, Kogi State. Information on presentation, treatment, and outcomes were retrieved from case notes of the patients.Results: There were 7 males and 3 females with age range of 5-13 years, mean duration of symptoms was 10.5 ± 5.38 days, all presented with pyrexia, vomiting and generalized abdominal pain. Mean body temperature at presentation was 38.4 ± 0.56 oC, the abdomen was distended in 100% of the patients with associated generalized tenderness. A pre-op diagnosis of typhoid intestinal perforation was made in 50% of cases, ruptured appendix in 30% and acute cholecystitis in 20%. Eight had gallbladder gangrene with perforations, 2 had inflamed gall bladder without perforation. All patients (80%) with gangrenous gallbladder had cholecystectomy, 20% had aspiration of the gall bladder content. Nine patients were discharged home, 1 died. Mean duration of hospital stay was 12.4 ± 4.03 days.Conclusion: A high index of suspicion is required in diagnosing typhoid cholecystitis in children. The outcome of typhoid cholecystitis is good with timely and appropriate surgical intervention.Keywords: Acalculous cholecystitis, typhoid cholecystitis, typhoid peritonitis

Laparoscopic Cholecystectomy- A Safe treatment option for Gangrenous Cholecystitis 48 and Empyema Gallbladder in experienced hands

Background: Laparoscopic cholecystectomy has become the gold standard of treatment for gall stone disease and in acute cholecystitis. But controversy persists regarding laparoscopic approach to gangrenous gallbladder and empyema gallbladder due to the risk of life threatening complications. We share our experience in a tertiary care multidisciplinary diabetic hospital where we encounter significant number of patients with empyema Gallbladder and gangrenous gallbladder because most of our patients are diabetic and hence immunocompromised. Purpose of this study was to evaluate the safety of laparoscopic procedure for the treatment of empyema of gallbladder and gangrenous gallbladder in an experienced hand.
 Methods & Materials: Between January 2013 and January 2015 we performed 1191 cases of laparoscopic cholecystectomy. Empyema gallbladder and gangrenous gallbladder were found per operatively in 345 and 53 cases respectively.All were managed by laparoscopic procedure except two cases, where conversion to open cholecystectomy was needed.
 Result: The mean operating time was 72 minutes(45-100 minutes) in empyema gallbladder. In gangrenous cholecystitismean operating time was 80 minutes(60-100 minutes). Total number of patients (including empyema gallbladder 345 and gangrenous cholecystitis 53) were 398. Among them 52 patients (13%) had excessive bleeding(>100ml) from calot’s triangle or gallbladder bed in liver. Spillage of stones occurred in 28 patients (7%). 1 patient had common bile duct injury (.25%). Gallbladder retrieval was difficult in 71 patients (18%). In the post operative period 21 patient (5%) developed minor port infection in the umbilical port. 9 patients (2%) developed chest infection, and 1 patient (.25%) developed MI. 356 patients (89%) were discharged within 72 hours of surgery.
 Conclusions: Innovative technique, appropriate instruments, knowledge about the possible risks and way to manage them, with expertise in intracorporeal suturing and knotting are an essential pre requisites to attempt these cases. Operating time is more but post operative recovery is prompt. Hospital stay is significantly less than open cholecystectomy. Laparoscopic cholecystectomy is a safe procedure in cases of Empyema and gangrenous gallbladder, provided the surgeon is experienced enough and has a low threshold to convert to open cholecystectomy at anypoint of time.
 Journal of Surgical Sciences (2015) Vol. 19 (2) : 48-51

2336 Multiple Uncommon Complications After TACE

INTRODUCTION: TransarteriaL chemoembolization (TACE) is a widely-used treatment for unresectable hepatocellular cancer (HCC). Although TACE is minimally invasive, major complications occur in 5% of cases. These include acute cholecystitis, which is self-limiting and rarely requires surgical intervention. Liver abscess is a rare complication but can increase length-of-stay and morbidity. Our case focuses on multiple uncommon complications of TACE occurring in conjunction; gangrenous cholecystitis requiring emergent cholecystectomy, liver abscess and portal vein thrombosis. CASE DESCRIPTION/METHODS: A 67-year-old male with history of hepatitis C, cirrhosis and HCC status-post recent successful TACE who presented to the ER with right upper quadrant pain associated with fever. Physical examination with right upper quadrant tenderness and positive murphy’s sign. Laboratories showed leukocytosis and elevated alkaline phosphatase. Normal bilirubin, liver and pancreatic enzymes. Abdominopelvic CT with hydropic gallbladder with enhancing walls and pericholecystic inflammatory changes, new ill-defined hypodensities suggestive of abscess and extensive thrombus in the right portal vein. The patient received antibiotics and underwent an uneventful cholecystectomy. Post-operation findings consistent with a gangrenous gallbladder with severe adherent hepatic flexure and omentum to the gallbladder fundus. The patient was discharged on antibiotics and anticoagulation. Follow up MRI showed resolution of fluid filled lesions with almost complete resolution of the portal vein thrombosis. DISCUSSION: Cholecystitis is a complication of TACE due to reflux of the embolic material into the cystic artery. In most cases, management can be conservative. Our case is rare given that the patient developed gangrenous cholecystitis which is a serious complication that requires immediate surgical intervention. Liver abscess occurs infrequently unless there is a history of prior biliary reconstruction unlike our patient. Management includes antibiotics and percutaneous drainage for larger abscesses. In our case, our patient responded well to antibiotics. Because symptoms are non-specific, these complications may be mistaken for post embolization syndrome, which is usually self-limiting and abates by one week. Normal post-TACE CT findings can also confound the diagnosis of hepatic abscess formation. This case highlights the importance of being aware of complications of TACE as failure to recognize these may confer a higher mortality risk.

2191 EUS-Directed Transgastric ERCP (EDGE) for Removal of Cystic Duct Coils: A Novel Application of an Emerging Technique

INTRODUCTION: Presence of obesity as well as sudden weight loss, both predispose to gallstone disease. Post roux-en-y gastric bypass (RYGB) anatomy creates additional challenges for endoscopy and surgery. We present a captivating case of post-RYGB complicated gallbladder (GB) surgery, which eventually ends with coiling of cystic duct. The coil formed a nidus for infection and biliary obstruction, and the novel technique of EUS directed trans-gastric ERCP (EDGE) comes to the rescue. CASE DESCRIPTION/METHODS: A 27-year-old male with morbid obesity underwent RYGB. Over next 6 months, he lost 130 lbs (35% of total body weight). Three years after RYGB, he presented with acute calculous cholecystitis; requiring laparoscopic-converted to open cholecystectomy due to gangrenous GB and extensive adhesions. Postoperatively, a large cystic duct leak developed, requiring percutaneous transhepatic biliary drainage. Due to persistent leak IR-guided coil embolization of the cystic remnant was successfully done.After three years he presented again with RUQ pain, nausea and fever. CT showed cystic duct coil migration into the CBD with upstream dilation. An EDGE procedure with a 20 mm lumen apposing metal stent was performed with successful biliary sphincterotomy and biliary stones and sludge removal. The migrated coils were removed with a rotating action of the biopsy forceps advanced intraductally which facilitated wrapping of the coils around the forceps, and then removed with a snare. DISCUSSION: Obesity pauses high risk for cholelithiasis due to change in fat metabolism, hormonal regulation and GB motility. Significant weight loss further leads to gallstone formation. Our patient presented with acute calculous cholecystitis. Cholecystectomy was complicated by bile leak and led to percutaneous biliary (PTC) drainage. Lap-assisted ERCP could not be performed due to high risk of morbidity in this patient. Instead of PTC and coil placement, EDGE may have been a better option at that point. Patient ended up requiring EDGE due to development of cholangitis associated with biliary obstruction due to migrating cystic duct coils. In this complicated young patient with abdominal adhesions, EGDE was a saving grace, as the alternative may be to live with PTC drain lifelong.

Diagnostic laparoscopy to investigate unexplained lactic acidosis in critically ill patients - A descriptive single centre cohort study.

IntroductionUnexplained lactic acidosis (LA) in a critically ill patient often prompts investigations to rule out any reversible intra-abdominal cause. Equivocal results can lead to an emergency laparotomy (EL) with subsequent high morbidity and mortality rates. Our objective was to determine the clinical impact of urgent diagnostic laparoscopy (UDL) in such patients.MethodsThis was a descriptive single-centre cohort study. UDL on 28 consecutive critically ill patients with unexplained LA who were referred to a single surgeon over 16 years period were analysed. UDL was proformed either at bedside or in theatre without prior computerised tomography (CT) scan. Patient's demographics, ASA grade, referral route and intraoperative findings were analysed.ResultsEighteen patients underwent bedside UDL in the critical care setting and further 10 had UDL in theatre. Fourteen patients had normal UDL, out of these 10 had LA secondary to low cardiac output states. Fourteen patients had positive UDL findings. Seven patients had features of mesenteric ischaemia, two had gangrenous gallbladder, two had hepatic ischaemia, one patient had acute pancreatitis, one had gangrenous uterus and one had gastric volvulus. Five of the 14 patients with positive UDL were converted to laparotomy for definitive management. In total, of the 28 patients in the cohort, 23 patients avoided EL.ConclusionUDL is useful and feasible investigation for unexplained LA in the critically ill patients and it can avoid unnecessary EL in many patients. We would recommend the use of UDL as a safe and feasible investigation in such patients.

Differential proteomics analysis of bile between gangrenous cholecystitis and chronic cholecystitis

To establish human biliary protein expression profiles of gangrenous cholecystitis, chronic cholecystitis, and to discover differently expressed proteins for gangrenous cholecystitis by comparative proteomics, we gathered human gallbladder bile samples from gangrenous cholecystitis and chronic cholecystitis patients, respectively After removing the bile salts and lipid peptide fragments were identified by the iTRAQ-coupled LC-MS/MS technology,then identified in SwissProt with Mascot software. A total of 2251 proteins from chronic cholecystitis patients and 2180 proteins from gangrenous cholecystitis patients were identified. A total of 575 differential proteins were found between gangrenous cholecystitis and chronic cholecystitis, 159 proteins were over-expressed and 416 proteins were under-expressed in gangrenous cholecystitis. By bio-informatics analysis, in gangrenous cholecystitis, cell death, necrosis,immune response of neutrophils, apoptosis and degranulation of cells were activated; while cell survival, fatty acid metabolism, transport of molecular and proliferation of cells were inhibited, which might reflect the de-compensatory phase. Pathway analysis showed acute phase proteins were changed, indicating the role of the inflammatory response in the pathogenesis of gangrenous cholecystitis. Six acute phase proteins were found up-regulated,implying a close linkage to gangrenous gallbladder. Our study could be applicable in the biomarker discovery of gangrenous cholecystitis.

Conversion and complications of elective laparoscopic cholecystectomy in a West African population

Background Laparoscopic cholecystectomy (LC) is increasingly adopted in Nigeria, but the procedure is limited due to the low incidence of gallstone diseases. This study aims to determine the incidence of conversion and complications following elective LC. Patients and methods Consecutive patients undergoing elective LC at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria, were the participants. Patients’ preoperative characteristics including ultrasonographic findings, instances of conversions, and intraoperative and postoperative complications were documented. The influence of gallbladder wall thickness on the outcome was analyzed. Results There were 150 patients, including 124 (82.7%) women and 26 (17.3%) men aged 18–82 years (mean=45.4, SD=13.38). Indications for LC were chronic calculous cholecystitis in 101 (67.3%), 45 (30%) acute calculous cholecystitis, whereas four (2.7%) had acalculous cholecystitis. Gallbladder wall thickness was normal (≤3 mm) in 98 (65.3%), thick (4–9 mm) in 35 (23.6%), and very thick (≥10 mm) in 17 (11.3%) patients, whereas 11 patients had pericholecystic fluid collection. Gallbladder mucocele was encountered in nine (6%), empyema in six (4%), and gangrenous gallbladder in two (1.3%) cases. Ten (6.7%) procedures were converted to laparotomy including two patients with hemoglobinopathies. Postoperatively, bile leaks occurred in two patients, bleeding requiring reeploration in one, and bile duct dilatation after 4 months in one patient. Acute cholecystitis, hemoglobinopathy, and thickened gallbladder wall significantly influenced conversions and occurrence of complications in this series. Conclusion We observed a low rate of conversion and complication following LC. Acute cholecystitis and thickened gallbladder wall significantly influence the conversion of LC to open procedure in our setting.

Laparoscopic cholecystectomy during pregnancy: A case series

ObjectiveTo study safety, feasibility and short term outcomes of laparoscopic cholecystectomy during pregnancy. MethodsBetween January 2013 to December 2016, all patients undergoing laparoscopic cholecystectomy during pregnancy at our hospital were retrospectively identified. Eight patients underwent laparoscopic cholecystectomy for symptomatic biliary disease during first and second trimester of pregnancy. Laparoscopic cholecystectomy was performed under general anesthesia. ResultsDuring the study period of 4 years from January 2013 to December 2016, 8 patients with gestational ages ranging from 11 to 28 weeks underwent laparoscopic cholecystectomy during pregnancy. Of them 2 patients were in the first trimester and 6 patients in the second trimester. The indication for surgical intervention was unrelenting biliary colic unresponsive to medical management and cholecystitis in 7 patients and gangrenous gall bladder in one patient. The latter patient had undergone successful Endoscopic Retrograde Cholangio Pancreatography (ERCP) followed by laparoscopic cholecystectomy after 5 days. There were no conversions to open. All patients had an uneventful post-operative recovery. There were no miscarriage or premature births in this group. There was one fetal demise 5 weeks following surgery due to severe oligoamnios, incidence of which is unrelated to laparoscopy. ConclusionLaparoscopic cholecystectomy during pregnancy is safe for both the mother and the unborn fetus. Surgery is indicated in unrelenting biliary colic or complications of cholelithiasis. Extreme caution during access to the abdominal cavity and keeping pneumoperitoneum pressures and operating times to a minimum should be kept in mind at all times.

Got a Leak! Letʼs Glue It

Introduction: The procedure of choice for management of acute cholecystitis is laparoscopic cholecystectomy (LC). LC has it's distinct advantages; however, post-operative refractory bile leaks present a significant therapeutic challenge. Herein, we report a case of endoscopic occlusion of high grade bile leak from the gall bladder remnant that failed all standard endoscopic maneuvers via the use of human pooled plasma fibrinogen and thrombin (HPF) (Tissel, Baxter, CA) as a sealant. Case: A 65-year-old male presented with abdominal pain and was found to have CT and HIDA scan findings consistent with acute cholecystitis. Laparoscopic evaluation revealed severely inflamed and gangrenous gall bladder, hence he underwent an open subtotal cholecystectomy. Post operatively, patient had increased bilious output from the JP drain, therefore, a CT scan abdomen was done which revealed a biloma in the gall bladder fossa. ERCP revealed a high grade bile leak from the gall bladder remnant and suggestion of ampullary stenosis. Biliary sphincterotomy was performed and a 10 Fr x 5 cm plastic stent was placed in the common bile duct (CBD). Due to persistent high output from the JP drain, a repeat ERCP was done 4 weeks later; occlusion cholangiogram revealed low grade bile leak from the gall bladder remnant. Balloon sweep with clearance of biliary sludge was performed and the plastic stent was interchanged with a 10 mm x 6 cm fully covered self-expanding metal stent (FC-SEMS). Six weeks after placement of the FC-SEMS, patient still had persistent bilious drainage from the JP drain therefore a third ERCP was done. The previously placed biliary stent was removed and cholangiogram revealed a high grade bile leak. No filing defects or stricture were noted in the CBD. The CBD was dilated to 10 mm and the cystic duct stump was successfully cannulated and injected with 3 ml of HPF for the purpose of sealing the leak. Repeat cholangiogram demonstrated no leak. A 10 mm x 80 mm FC-SEMS was placed in the common bile duct. Follow up ERCP 3 months later revealed normal cholangiogram with no evidence of ongoing bile leak and the FC-SEMS was removed. Discussion: To our knowledge this a first report demonstrating use of HPF endoscopically for successful management of refractory bile leak. HPF should note be injected into vascular structures due to concern for vascular thrombosis. Further studies and reports are needed to evaluate the safety and efficacy of this technique.

Gangrenous cholecystitis: innovative laparoscopic techniques to facilitate subtotal fenestrating cholecystectomy when a critical view of safety cannot be achieved.

Gangrenous cholecystitis is associated with a higher conversion rate of conversion from laparoscopic to open than acute non-gangrenous cholecystitis. New strategies and techniques are needed to decrease conversion rates and improve outcomes. In this article, we provide a richly detailed, illustrated description of a modified fundus-first technique that we have developed over the last 15years and now use routinely with rare conversions. We also compared outcomes of laparoscopic (LC) and open (OC) approaches for pathologically confirmed gangrenous cholecystitis in 146 patients during 1995-2005, the first 10years during which these two approaches were performed contemporaneously at our institution on comparable patients. Among the 142 patients that met the inclusion criteria, laparoscopic procedures were started in 112 (79%) of these patients, with successful completion in 72 resulting in an overall conversion rate of 36%. During the last 5years, however, in cases where the described laparoscopic technique was used, no patient has required conversion. The laparoscopic LC group had shorter average ICU stay (p<0.05) and overall length of stay (2 vs 6days, p<0.001). Intraoperative cholangiography was completed in 37 of 72 LC patients (52%) versus 6 of 30 OC (20%). In five of the LC patients, a filling defect was seen on the cholangiogram and laparoscopic transcystic common bile duct stones, thereby avoiding a second anesthetic and endoscopic procedure. In the setting of severe inflammation, a number of procedural modifications can be incorporated to allow the surgeon to approach dissection of the gangrenous gallbladder using a flexible operative plan designed to optimize safe completion of this challenging procedure, with the expected improvement in surgical outcomes.

Laparoscopic modified subtotal cholecystectomy for difficult gall bladders: A single-centre experience.

AIM:Laparoscopic cholecystectomy (LC) is considered the ‘gold standard’ intervention for gall bladder (GB) diseases. However, to avoid serious biliovascular injury, conversion is advocated for distorted anatomy at the Calot's triangle. The aim is to find out whether our technique of laparoscopic modified subtotal cholecystectomy (LMSC) is suitable, with an acceptable morbidity and outcome.PATIENTS AND METHODS:A retrospective analysis of prospectively collected data of 993 consecutive patients who underwent cholecystectomy was done at a large District General Hospital (DGH) between August 2007 and January 2015. The data are as follows: Patient's demographics, operative details including intra- and postoperative complications, postoperative stay including follow-up that was recorded and analysed.RESULTS:A total of 993 patients (263 males and 730 female) were included. The median age was 52*(18-89) years. Out of the 993 patients, 979 (98.5%) and 14 (1.5%) were listed for laparoscopic and open cholecystectomy, respectively. Of the 979 patients, 902 (92%) and 64 (6.5%) patients underwent LC ± on-table cholangiography (OTC) and LMSC ± OTC, respectively, with a median stay of 1* (0-15) days. Of the 64 patients, 55 (86%) had dense adhesions, 22 (34%) had acute inflammation, 19 (30%) had severe contraction, 12 (19%) had empyema, 7 (11%) had Mirizzi's syndrome and 2 (3%) had gangrenous GB. The mean operative time was 120 × (50-180) min [Table 1]. Six (12%) patients required endoscopic retrograde cholangiopancreatography (ERCP) postoperatively, and there were four (6%) readmissions in a follow-up of 30 × (8-76) months. The remaining 13 (1.3%) patients underwent laparoscopic cholecystectomy converted to an open cholecystectomy. The median stay for open/laparoscopic cholecystectomy converted to open cholecystectomy was 5 × (1-12) days.CONCLUSION:Our technique of LMSC avoided conversion in 6.5% patients and believe that it is feasible and safe for difficult GBs with a positive outcome.

Gallbladder torsion: A case study

Introduction: torsion of the gallbladder is a rare condition and an important differential of an acute surgical abdomen. While early surgical intervention reduces the risk of disease progression to life-threatening complications, and thus avoids high morbidity and mortality, it is difficult to make a preoperative diagnosis of gallbladder torsion. case report: In this report, we describe a case of acute gallbladder torsion in an elderly male whose clinical presentation mimicked acute acalculous cholecystitis with local inflammatory reaction resulting from gangrenous gallbladder. the 81-year-old male was treated with emergency exploratory laparotomy. Except for developing an ileus requiring longer term recovery his postoperative period was otherwise uneventful and

Gallbladder torsion within incisional hernia: an original cholecystitis

Gallbladder torsion with ischemic wall necrosis is a rare condition, as gallbladder herniation. We describe here an original case of a patient with a symptomatic incisional hernia containing a gangrenous gallbladder twisted about its pedicle. We report preoperative findings on CT-scan and emergency surgical management.