Increased Gallbladder Wall Thickness Research Articles

Clinical analysis of infectious mononucleosis complicated with acute acalculous cholecystitis.

This study aimed to investigate specific clinical diagnostic methods for children with infectious mononucleosis (IM) complicated by acute acalculous cholecystitis (AAC). We conducted a retrospective analysis of 171 cases of IM diagnosed in the infectious disease ward of Children's Hospital of Nanjing Medical University between January 2020 and December 2020. All IM patients underwent abdominal ultrasound examinations to assess the liver, gallbladder, and spleen. Fourteen patients with symptoms of AAC underwent a follow-up assessment one week later. The estimated incidence of AAC in hospitalized IM children was 8.2%. Both groups of patients presented with fever, abdominal pain, and eyelid edema upon admission. Characteristic radiological findings of AAC were observed, including gallbladder (GB) distention, increased GB wall thickness and increased common bile duct diameter. Analysis of laboratory results revealed no statistically significant differences in leukocyte, absolute lymphocyte count, CD3+, CD3 + CD4+, CD3+ CD8+, Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT), or Gamma-Glutamyl Transferase (GGT) levels between the AAC(+) and AAC(-) groups on admission. However, these parameters were not significant risk factors for AAC. After discharge, relevant indicators in non-AAC patients gradually decreased to normal levels, while those in AAC(+) patients did not show a significant decrease. While cases of IM complicated by AAC are relatively uncommon, the utilization of abdominal ultrasound offers a reliable tool for confirming this diagnosis. Routine abdominal ultrasound examinations are recommended for IM patients to improve early detection and treatment of associated conditions.

Preoperative predictive factors of difficult laparoscopic cholecystectomy

Background Laparoscopic cholecystectomy is a routine start-up procedure for any surgeon interested in the field of laparoscopy. However, one may encounter complex cases that may increase the risk of perioperative complications. It is crucial to identify these cases preoperatively for better surgical planning. Herein, we studied preoperative risk factors for difficult cholecystectomy procedures in our Egyptian tertiary care center. Methodology One hundred patients were enrolled in our study, and their cholecystectomy procedures were classified as easy, difficult, or very difficult based on two parameters; preoperative scoring system and intraoperative findings. Results There was a significant agreement between preoperative difficulty prediction score and intraoperative findings (k=0.858, P<0.001). Procedure difficulty was associated with patient hospitalization (P<0.001), previous supraumbilical surgeries (P=0.004), previous acute cholecystitis (P<0.001), previous jaundice (P=0.049), previous endoscopic biliary clearance (P=0.022), increased gallbladder wall thickness (P=0.001), and pericholecystic fluid collection (P=0.014). Conversion to the open approach was needed in 6 cases (6%). Age, sex, BMI, and impacted stone did not significantly impact procedure difficulty (P>0.05). Conclusion Multiple preoperative parameters have been significantly associated with the increased difficulty of the laparoscopic cholecystectomy procedure. Properly identifying these parameters and their inclusion into a scoring system would be greatly helpful in determining difficult cases during the preoperative period.

Risk Factors and Prevalence Associated With Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy: A Tertiary Care Hospital Experience in Western Mexico.

Introduction Laparoscopic cholecystectomy (LC) is a common procedure used for the treatment of different pathologies caused by gallstones in the gallbladder, and one of the most common indications is acute cholecystitis. The definitive treatment for acute cholecystitis is surgery, and LC is the gold standard. Nevertheless, transoperative complications (like intraoperative bleeding, anatomical abnormalities of the gallbladder, etc.) of LC and some other preoperative factors (like dilatation of bile duct, increased gallbladder wall thickness, etc.) can cause or be a risk factor for conversion to open cholecystectomy (OC). The objective of this study was to determine the risk factors and prevalence associated with the conversion from LC to OC in patients with gallbladder pathology and the indication for LC. Materials and methods This was a prospective cohort study. We included patients of both sexes over 18 years of age with gallbladder disease. To determine the risk factors associated with conversion, we performed a bivariate analysis and then a multivariate analysis. Results The rate of conversion to OC was 4.54%. The preoperative factors associated with conversion, in the bivariate analysis, were common bile duct dilatation (p=0.008), emergency surgery (p=0.014), and smoking (p=0.001); the associated intraoperative variables were: laparoscopic surgery duration (p <0.0001), Calot triangle edema (p=0.033), incapacity to hold the gallbladder with atraumatic laparoscopic tweezers (p=0.036), and choledocholithiasis (p=0.042). Laparoscopic Surgery duration was the only factor with a significant association in the multivariate analysis (p=0.0036); we performed a receiver operating characteristic (ROC) curve analysis and found a cut-off point of 120 minutes for the duration of laparoscopic surgery with a sensitivity and a specificity of 67 and 88%, respectively. Conclusion The prevalence of conversion from LC to OC is similar to that reported in the international literature. The risk factors associated with conversion to OC, in this study, should be confirmed in future clinical studies, in this same population, with a larger sample size.

A Study of the Degree of Gall Bladder Wall Thickness and Its Impact on Patients Undergoing Laparoscopic Cholecystectomy.

Background The gold standard management for symptomatic gallstone disease is elective laparoscopic cholecystectomy, which has replaced open cholecystectomy. The wall thickness of the gallbladder is an indicator of cholecystitis in patients who have presented with symptoms of gallstone disease. The aim of this study was to evaluate preoperative gall bladder wall thickness by ultrasonography and assess its impact on the outcome of laparoscopic cholecystectomy, including conversion rate, complications, operative time, and postoperative hospital stay. Method This prospective study was conducted on 350 patients with symptomatic gallstone disease, those who had undergone laparoscopic cholecystectomy in Dr. Sampurnanand Medical College, Jodhpur, and attached hospitals from July 2019 to November 2021. On the basis of ultrasonography findings of gallbladder wall thickness, patients were divided into four groups: normal thickness - up to 2 mm, mild thickness - 3-4mm, moderate thickness - 5-6mm, and severe wall thickness - more than 6mm). Up to 2 millimeters thickness was considered as normal. Results The incidence of conversion rate, as well as intra or postoperative complications, were higher in moderate and severe wall thickness groups. The maximum incidence of complication rate is seen in moderately thickened group (33.33%). In severely thickened group, complication was seen in 100% of patients. Operative time, as well as postoperative hospital stay, were more in higher thickness groups. There was a statistically significant correlation between gallbladder wall thickness and conversion rate, complications operative time, and postoperative length of stay. Conclusion Increased gallbladder wall thickness causes increased intra as well as postoperative complications, more conversion to open procedure rate, increased operative time, and enhanced postoperative hospital stay. Among the total study population, 29.71% of patients had increased gallbladder wall thickness. In our study, a positive correlation was seen among gallbladder wall thickness, complication rate, conversion rate, intraoperative time, and postoperative hospital stay.

Predictive factors and importance of Critical View of Safety in difficult elective laparoscopic cholecystectomy

Knowing the surgical anatomy and related variations, revealing the factors that indicate difficult cholecystectomy, knowing and applying various safe surgical cholecystectomy techniques and guidelines recommended to prevent injuries can prevent complications. This study, it is aimed to evaluate the preoperative factors that will predict difficult elective cholecystectomy. We retrospectively analyzed the data of patients treated for cholelithiasis by an experienced hepatobiliary surgeon or under his supervision between March 2018 and March 2020. Clinical, laboratory, and imaging data obtained from patients' files were evaluated. According to the Modified Nassar Scale (MNS), 140 (79.5%) patients were considered grade 1-2 (easy) and 36 (20.5%) grade 3-5 (difficult) patients within the framework of intraoperative findings. Critical View of Safety was successfully performed in 170 (96.6%) of the patients. Converting laparoscopic cholecystectomy to open was performed in two (1.1%) patients who had an MNS of 4 and 5. The most common comorbidity was hypertension. Male gender, previous cholecystitis and ERCP, and increased gall bladder wall thickness from preoperative USG findings are independent risk factors for difficult cholecystectomy in patients scheduled for laparoscopic cholecystectomy. In addition, it should be kept in mind that LC can be difficult in patients with hypertension and coronary artery disease.

Prevalence of gallbladder disease in type 2 DM and prediabetes in Somali Mogadishu: A single center experience.

Objective: To assess the clinical and ultrasonographic findings of gallbladder disease in diabetic, prediabetic, and non-diabetic patients. Study Design: Retrospective Cross-Sectional Study. Setting: Somali Mogadishu Hospital. Period: January 2017 and June 2019. Material &amp; Methods: T2DM, prediabetes, demographic data, and gall bladder findings. Results: The study included 1,020 patients, 65.6% of whom were female, with a mean age of 50.51 ± 17.98. In our study, in which the number of non-diabetic people was 425 (41.7%), the rate of T2DM was found to be 36.3%, and the rate of prediabetic patients was found to be 22.1%. The frequency of T2DM (41%) and prediabetes (23.9%) was found to be higher in men with GBD than in women (33.8% and 21.1% in women, respectively). Increased gallbladder wall thickness frequency was also found to be more common in the T2DM and prediabetic groups than in the non-DM group (p&lt;0.001). Conclusions: Patients with GBD have a significantly increased T2DM frequency (one in 3 patients) and prediabetes (one in five patients). More than half of patients have 2 or more gallstones, and a third have bile sludge. Impaired glucose tolerance is considered to be a major factor in the development of GBD in Somali patients.

Pathological gallbladder wall thickening is associated with advanced chronic liver disease and independent of serum albumin.

Increased gallbladder wall thickness (GBWT) is a common finding. Reported causes include advanced chronic liver disease (ACLD), ascites and hypalbuminemia. GBWT is a marker for the prediction of esophageal varices. It remains unclear which of these factors is the decisive driver of GBWT. We aim to investigate whether there is a predominant factor associated with the GBWT. We enrolled 258 patients with ascites, hypalbuminemia and/or ACLD and 98 healthy volunteers that underwent abdominal ultrasound. Differences of mean GBWT in subgroups of patients with ACLD, ascites, and/or hypalbuminemia were analyzed. Correlation between various parameters and GBWT were calculated using multiple regression analysis. GBWT in patients with ACLD + ascites + hypalbuminemia (n=59; 5.70 ± 2.05 mm) was pathologically increased compared to patients with hypalbuminemia + ascites without ACLD (n=36; 2.14 ± 0.66 mm; p < .001) and to patients with only hypalbuminemia (n=76; 2.02 ± 0.80 mm; p < .001). GBWT of patients with ACLD + hypalbuminemia (n=30; 3.42 ± 1.52 mm) and with ACLD and normal albumin level were not different (n=46; 3.10 ± 1.62 mm; p > .999). Significant correlation was seen between GBWT and ACLD (r=.53; p < .001) and ascites (r=.51; p < .001) but not albumin level (r=.04; p=.510). We demonstrate that ACLD is predominantly associated with GBWT. In contrast to the current literature, serum albumin level appears not to be associated with pathological GBWT.

The management of xanthogranulomatous cholecystitis.

Xanthogranulomatous cholecystitis (XGC) is a rare variant of chronic cholecystitis. This rare pathology is characterized by severe and progressive fibrosis of the gallbladder wall as well as infiltration of fat-laden macrophages. The final pathology report of 8213 cholecystectomies performed between 2011 and 2019 was evaluated retrospectively, and patients whose pathology result was reported as XGC were included in the study. Patients' demographic characteristics, pathology results, and surgical methods were evaluated. Logistic regression analysis was performed for risk factors on conversion to open cholecystectomy. The rate of XGC among cholecystectomies was 0.91%. Mean age of the patients was 57.32 years. Laparoscopic cholecystectomy was applied to 92% (n: 69) of the patients. None of the patients had cancer suspicion in the preoperative period, but cancer suspicion was found in 10.6% of the patients during the operation. With the frozen test, unnecessary surgeries were prevented in these patients. Conversion rate to open cholecystectomy was found to be 26.09%. The most common reason for conversion to open cholecystectomy (66.7%) was intense fibrosis. Increased gallbladder wall thickness and acute cholecystitis were found to be statistically significant risk factors in ultrasonography (p <0.05). Total complication rate in XGC cases was 3.9%. XGC is an extremely rare disease and is difficult to diagnose before cholecystectomy. Especially in preoperative USG, in cases with no suspicion of malignancy, but with suspected malignancy during the operation, histopathological examination with frozen method before extensive surgery may prevent unnecessary dissection and related morbidities.

Physio-pathological risk factors from gallbladder affecting the conversion from laparoscopic cholecystectomy to open cholecystectomy

Aim: Laparoscopic cholecystectomy is the first-line treatment method in the surgical treatment of gallbladder pathologies. Predicting conversion from laparoscopic to open cholecystectomy is still an important problem in the world. In our study, we aimed to investigate the gallbladder-derived physiopathological risk factors that affect the conversion from laparoscopic to open cholecystectomy.Materials and Methods: 370 patients who underwent cholecystectomy with the indications of symptomatic gallstone, acute cholecystitis, asymptomatic gallstones and gallbladder polyps were included in the study. Patients' demographic data such as age and sex, and pathological diagnoses, gallbladder wall thickness, and gallbladder volumes were obtained from pathology results. The effects of physiological parameters on conversion to open cholecystectomy were compared.Results: The most common indication for surgery is symptomatic gallstones (227 patients, 74.9%). The first preferred surgical technique is laparoscopic cholecystectomy with 86.5%. The conversion rate was 10.5% (n=39). The rate of conversion to open cholecystectomy was found to be high and a statistically significant difference was observed in patients with high gallbladder wall thickness and large sac volume (p0.001 for wall thickness, p=0.008 for gallbladder volume)Conclusions: We determined that the wall thickness and volume of the gallbladder had a significant effect on the conversion rate of laparoscopic cholecystectomy to open cholecystectomy. We believe that, patients who can be detected ultrasonographically prior to surgery with increased gallbladder wall thickness, and gallbladder volumes are more likely to conversion to open surgery and that patients should be informed in detail.

A retrospective assessment of the complications and associated risk factors of laparoscopic cholecystectomy

Aim: The aim of the present study to assess the risk factors and complications of Laparoscopic Cholecystectomy. Material and Methods: This was a retrospectively analysed study conducted in the Department of General Surgery, Shri Shankaracharya Institute of Medical Sciences, Bhilai, Chhattisgarh, India, from December 2018 to November 2019. 100 patients who were diagnosed with cholelithiasis and had laparoscopic cholecystectomy were included in this study. We analysed the type and frequency of intraoperative and postoperative complications, as well as factors that increase the risk for development of complications. We noted causes and incidence of conversions and the way they resolved. We noted gender, age, body mass index (BMI), white blood cell count, and level of C-reactive protein (CRP), preoperative ultrasonographic findings, Patho histological findings of the surgically removed gallbladder, as well as their correlation with the occurrence of complications. Results: Out of the 100 patients in the study, 68 were female (68%), and 32 were male (32%). The most common complications noted were: iatrogenic perforations of the gallbladder- 5 (5%), bleeding from the tissues adjacent to the gallbladder 3 (3%), gallstones spilt into the peritoneal cavity 2 (2%). Intraoperative bleeding from the cystic artery occurred in 1 (1%), bleeding from the port in 1 (1%) and bleeding from the ligaments of the liver in 1 patients (1%). The transection of the common bile duct, a major complication, occurred in only one patient (1%). The most common postoperative complications were: bleeding from the abdominal cavity more than 100 ml/24h (in 3 patients or 3%), bile leaks through the drain > 50-100 ml/24h (2 patients, or 2%). In addition, the ultrasonographic findings of empyema, gangrene of the gallbladder wall, and increased gallbladder wall thickness > 3 mm (group II) is a significant predictor of complications and conversion (OR = 4.92, 95% CI 1.61-18.13, p< 0.001). Patho histologic analysis of the surgically extracted gallbladder with the diagnosis of acute cholecystitis was also the significant predictor for complications and conversion (OR 1.82, 95% CI 2.52-16.66, P< 0.001). Conclusion: the laparoscopic cholecystectomy as a new technique for treatment of cholelithiasis, introduced a new spectrum of complications. Major biliary and vascular complications are life threatening, while minor complications cause patient discomfort and prolongation of the hospital stay.

S2852 Tissue Invasive Cytomegalovirus Enteritis With Gastric Outlet Obstruction in an Immunocompetent Patient

INTRODUCTION: Cytomegalovirus (CMV) usually causes asymptomatic or mononucleosis-like syndrome in immunocompetent individuals. We present a case of severe tissue invasive gastrointestinal CMV in an immunocompetent individual complicated by gastric outlet obstruction. CASE DESCRIPTION/METHODS: A 72-year-old man with a history of hypertension presented with vomiting, postprandial abdominal pain, and hematochezia for one week. He had also lost 40lbs in three months. Physical examination was normal except for epigastric tenderness. The previous colonoscopy done 5 years ago was normal. No personal or family history of inflammatory bowel disease, gastrointestinal malignancy, or lymphoma. He had never had immunosuppressive therapy, organ transplantation, or any other biological agent. Initial blood work revealed Hemoglobin 10.9 g/dl, AST 64 IU/l, ALT 83 IU/l, and ALP 350 IU/l. His HIV and Tuberculosis screening were negative. Ultrasound and CT scan of the abdomen and pelvis were normal except for increased gallbladder wall thickness (3mm). An Esophagogastroduodenoscopy (EGD) revealed esophagitis, pyloric channel ulcer, and duodenal ulcer. Colonoscopy revealed an ulcer at the ileocecal valve. The biopsy of all the ulcers revealed ulcerated mucosa, architectural distortion, and reactive epithelial atypia suspicious of CMV infection which was later confirmed by immunohistochemical staining (IHC) [Figure 1]. Quantitative CMV DNA PCR analysis showed levels of 1739 IU/ml. He was started on intravenous ganciclovir while inpatient and sent home on oral valganciclovir for 21 days. His symptoms improved significantly after treatment. CMV DNA levels decreased to 1230 IU/ml post-treatment. The patient returned with symptoms of gastric outlet obstruction a few months later which were getting worse. His barium X-ray revealed a delayed gastric emptying time with pyloric stenosis and partial malrotation of the small bowel [Figure 2]. A repeat EGD revealed pyloric stenosis with an inner diameter of 11 mm, which was dilated endoscopically. The biopsy taken from an antral ulcer was negative for CMV on IHC staining. There were no other signs of prior CMV infection on the EGD. DISCUSSION: The gastric outlet obstruction in the patient is likely a long term sequela of CMV. Due to the undertreatment and delay in diagnosis, CMV infections can lead to long term and potentially life-threatening complications. Therefore, gastrointestinal CMV should be considered in immunocompetent patients and aggressively treated.Figure 1.: Medium power (100×) Immunohistochemical staining for CMV with hematoxylin counter-stain. A representative high power view demonstrating strong focal CMV immunoreactivity.Figure 2.: Barium Xray reveals pyloric stenosis (black arrow) and malrotation with the first loop of jejunum to the right.

High-Volume, Low-Concentration Intraperitoneal Bupivacaine Study in Emergency Laparoscopic Cholecystectomy: A Double-Blinded, Prospective Randomized Clinical Trial.

Background. Laparoscopic cholecystectomy (LC) often results in postoperative pain, especially in the abdomen. Intraperitoneal local anesthesia (IPLA) reduces pain after LC. Acute cholecystitis-associated inflammation, increased gallbladder wall thickness, dissection difficulties, and a longer operative time are several reasons for assuming a benefit in pain scores in urgent LC with IPLA application. The aim was to determine the postoperative analgesic efficacy of high-volume, low-dose intraperitoneal bupivacaine in urgent LC. Materials and Methods. Fifty-seven patients who were American Society of Anesthesiologists physical status I or II were randomly assigned to receive either normal saline (control group) or intraperitoneal bupivacaine (test group) at the beginning or end of urgent LC. The primary outcome was the postoperative pain score of the Visual Analogue Scale (VAS). The secondary outcomes included Visual Rating Prince Henry Scale (VRS), patient satisfaction, and analgesic consumption. Results. Postoperative VAS scores at the first and fourth hours were significantly lower in the test group than in the control group (P < .001). Postoperative VRS scores at the first, fourth, and eighth hours were significantly lower in the test group than in the control group (P < .001, P = .002, P = .004, respectively). Analgesic use was significantly higher in the control group at the first postoperative hour (P < .001). Shoulder pain was significantly lower, and patient satisfaction was significantly higher in the test group relative to the control group (both P < .001). Conclusion. High-volume, low-concentration intraperitoneal bupivacaine resulted in better postoperative pain control and reduced incidence of shoulder pain and analgesic consumption in urgent LC.

Epstein-Barr virus infection with acute acalculous cholecystitis in previously healthy children.

Acute acalculous cholecystitis (AAC), an inflammatory process of the gallbladder (GB) in the absence of gallstones, typically occurs in seriously ill patients. AAC can complicate primary Epstein-Barr virus (EBV) infection, but it is an atypical clinical presentation. The aim of our study was to analyse AAC occurrence in children with primary symptomatic EBV infection who had been admitted to the hospital. We retrospectively evaluated the medical documentation of 181 children with EBV infection who were diagnosed based on the presence of viral capsid antigen IgM antibodies. All EBV-positive patients underwent transabdominal ultrasonography of the liver in the supine and right anterior oblique positions. Fifteen children who presented with AAC symptoms, including abdominal pain and a positive Murphy's sign, were analysed as a subsample and re-evaluated after 2-3months. The incidence of AAC in children hospitalised with infectious mononucleosis (IM) was estimated at 8.3%. Analysis of the laboratory results confirmed that the C-reactive protein (CRP) concentration was the only parameter which was higher in children who presented with AAC symptoms. The mean number of leucocytes and monocytes and liver enzyme activities were not significantly higher. The radiological findings of AAC were evident: increased GB wall thickness, non-shadowing echogenic sludge and pericholecystic fluid collection. AAC during primary EBV infection appears to be a more common pathology than previously suspected. Its relatively mild nature and the lack of laboratory abnormalities mean that ultrasonographic examination is required for diagnosis. This might explain why the prevalence in children is underestimated.

Ultrasound Assessment of Hepatobiliary and Splenic Changes in Patients With Dengue and Warning Signs During the Acute and Recovery Phases.

To evaluate whether abdominal ultrasound (US) with a gallbladder (GB) contractility study or motor function test can be used as a diagnostic tool in patients with dengue and warning signs in acute and recovery phases. Fifty-one individuals in the acute phase of dengue presenting with warning signs (dengue group) and 49 healthy individuals without a history of dengue or hepatobiliary disease (control group) were studied with abdominal US and a GB contractility study. Statistical differences in US measurements of the liver (right lobe, P = .012; left lobe, P = .001) and spleen (P = .008) dimensions, GB wall thickness (P < .001), and the GB emptying fraction (P < .001) were observed in dengue during the acute phase compared with the control group. After 60 days, abdominal US of the dengue group showed a statistical difference in liver (right lobe, P < .001; left lobe, P = .078) and spleen (P < .001) dimensions, GB wall thickness, and the GB emptying fraction (P < .001) compared with the results obtained during the acute phase. Furthermore, a statistical difference in the spleen volume and GB emptying fraction (P < .001) was observed when comparing dengue after clinical recovery and the control group. Abdominal pain in patients with dengue was positively associated with hepatomegaly (P = .031), splenomegaly (P = .008), increased GB wall thickness (P = .016), and a reduced GB emptying fraction (P = .038) during the acute phase and with splenomegaly (P = .001) and a reduced GB emptying fraction (P = .003) after clinical recovery. Abdominal US with a GB motor function test can be used as a diagnostic tool in patients with dengue during acute and recovery phases.

Pre-operative factors for predicting a difficult laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy is a very safe procedure yet there are instances where serious complications can be avoided and better managed if the surgeon is forewarned or prepared in advance for them. So, a need is felt to identify pre-operative parameters for anticipating a difficult cholecystectomy.Methods: This study was carried over a period of two years (2007- 2009). Patients having symptomatic cholelithiasis willing to undergo laparoscopic cholecystectomy were enrolled in the study. The following pre-operative parameters were evaluated in the study: age, sex, body mass index, history of previous abdominal surgery, history of acute cholecystitis, history of biliary colic, palpable lump in right hypochondrium, experience of the surgeon and abdominal ultrasonogram (following parameters were noted increased gallbladder wall thickness, number of stones, size of largest stone and its location).Results: Acute cholecystitis, palpable gall bladder, increased gallbladder wall thickness, biliary colic, gall stones &gt;2 cm in size, gall stone impacted at gallbladder neck and BMI &gt;30 kg/m2 had a significant p-value in a difficult laparoscopic cholecystectomy.Conclusions: Further research is needed to formulate a score based on the variables mentioned above to predict a difficult laparoscopic cholecystectomy and hence letting the surgeon be better prepared for any eventualities that he encounters whilst performing laparoscopic cholecystectomy.

Point-of-care biliary ultrasound in the emergency department (BUSED): implications for surgical referral and emergency department wait times

BackgroundPatients with uncomplicated biliary disease frequently present to the emergency department for assessment. To improve bedside clinical decision making, biliary point-of-care ultrasound (POCUS) in the emergency department has emerged as...

P152: Point of care biliary ultrasound in the emergency department (BUSED): implications for surgical referral and emergency department wait times

Introduction: Patients with uncomplicated biliary disease frequently present to the emergency department for assessment. To improve bedside clinical decision making many emergency medicine physicians have pursued specialized training to perform point of care biliary ultrasound in the emergency department (BUSED). The purpose of this study was to determine the usefulness of BUSED in predicting the need for surgical consultation and intervention for biliary disease. Methods: A retrospective study of 283 consecutive patients visiting the emergency department who received a BUSED scan from December 1, 2016 to July 16, 2017. Physician interpretations of the BUSED scans were collected from the electronic image storage and interpretation system. Additional data was collected from the electronic health record including lab values, the subsequent use of diagnostic imaging, and outcomes data including disposition, surgical consultation or intervention, and 28 day follow up for representation or complication. Descriptive statistics and logistic regression were performed. Results: Of the patients who received a biliary POCUS scan, 29% were referred to general surgery, and 43% of those referred proceeded to eventual cholecystectomy. Factors found to be independently predictive of surgical intervention on point of care BUSED scans included presence of gall stones (OR 13.01, 95%CI 5.02 to 27.1) and increased gallbladder wall thickness (OR 6.01, 95%CI 1.7 to 11.1). A total of 30% of patients receiving BUSED required at least one additional, radiology based imaging test (CT or diagnostic US). Average emergency department length of stay was substantially longer for those who required additional imaging as compared to those who were able to be diagnosed by BUSED alone (16.1 versus 5.2 hours, 10.9 hours 95%CI 10.6 11.2, p&lt;0.05) . Conclusion: Point of care biliary ultrasound performed by emergency physicians provides timely access to diagnostic information. Positive findings of gall stones and increased gall bladder wall thickness are highly predictive of the need for surgical intervention. Future, prospective studies are warranted to determine if point of care sonography is sufficient to proceed to surgery in select cases of uncomplicated biliary disease.

Emergency Medicine Resident versus Radiologist in Detecting the Ultrasonographic Signs of Acute Cholecystitis; a Diagnostic Accuracy Study.

Dependence of ultrasonography on the operator's skill plays a major role in the differences between various studies in reporting its diagnostic accuracy. Therefore, the present study was done with the aim of comparing the ultrasonography findings performed by emergency medicine resident and radiologist in evaluation of acute cholecystitis. The present diagnostic accuracy study has been carried out on patients presenting to the emergency department with complaint of pain in the right upper quadrant of abdomen suspected with acute cholecystitis. All the patients underwent gallbladder ultrasonography by a trained emergency medicine resident and a radiologist and their findings were compared with surgical and pathology findings regarding gallstone and increased gallbladder wall thickness. 51 patients with the mean age of 42.3±15.8 (17-81) years were analyzed (82.4% female). The overall agreement between emergency medicine resident and radiologist in ultrasonographic diagnosis of cholecystitis was 0.421 (95% CI: 0.118-0.724). Based on the pathology and surgical findings, acute cholecystitis was confirmed for all 51 (100%) patients. Meanwhile, based on the ultrasonographic report of radiologist and emergency medicine resident only 45 (88.2%) and 34 (66.7%) patients, respectively, were diagnosed with cholecystitis. Screening performance characteristics of ultrasonography by radiologist for detection of gallbladder stone (p = 0.010) and gallbladder wall thickness (p < 0.0001) were significantly better than emergency medicine resident. The screening performance characteristics of ultrasonography by radiologist in detection of gallstones and increased wall thickness of gallbladder were significantly better.

Preoperative prediction of difficult laparoscopic cholecystectomy using a scoring system

Background: Laparoscopic cholecystectomy (LC) has become gold standard for the surgical treatment of gallbladder disease. 2% to 15% of patients require conversion to open surgery for various reasons. Pre-operative prediction of “difficult laparoscopic cholecystectomy” may not only improve patient safety but also be useful in reducing the overall cost of therapy. The aim of this study is to study the factors determining the preoperative predictability of difficult laparoscopic cholecystectomy.Method: 30 cases of laparoscopic cholecystectomy operated by a single experienced surgeon. There are total 15 score from history, clinical and sonological findings. They were evaluated and scored on the basis of scoring system of Randhawa and Pujahari. Score up to 5 is defined as easy, 6-10 as difficult and 11-15 as very difficult.Result: Previous history of hospitalization for cholecystitis and increased gall bladder wall thickness were found statistically significant in predicting difficult LC.Conclusion: The scoring system had a positive prediction value for easy prediction of 81.9% and for difficult prediction of 75%.

Factors determining conversion of laparoscopic to open cholecystectomy

Background and objectives: Laparoscopic cholecystectomy (LC) has virtually replaced conventional open cholecystectomy (OC) as the standard procedure of treatment for cholelithiasis and cholecystitis. However, OC sometimes becomes a necessity considering the feasibility and safety of the surgical procedure. But the factors that demand conversion from LC to OC differ widely. The present study aimed to determine the prevalence of conversion from LC to OC and to assess the causes of conversion and risk factors related to conversion.Methods: The study was conducted in a referral hospital – ‘Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorder (BIRDEM)’ from September 2014 to September 2016. Cases of cholelithiasis with or without cholecystitis, and other gall bladder pathology were included in the study. A team of experienced surgeon performed LC of all selected cases. The causes of conversion to OC were systematically recorded by the surgical team and the risk factors (age, sex, obesity, history of previous abdominal surgery, gallbladder thickness) related to conversion from LC to OC was investigated.Results: A total of 261 (M / F = 87 /174) patients were considered eligible for the study. The mean age of all patients was 43 (±1.75) years. For the male and female groups the mean ages were 44±1.9 and 42±1.6 years respectively. Of the total 261 cases, 210 (80.5%) patients had cholelithiasis with chronic cholecystitis, 47 (18.0%) had gallbladder stone plus acute cholecystitis and 4 (1.5%) had gallbladder polyp. Open conversion was required in case of 19 patients. Thus, overall conversion rate was 7.3%. The common causes of conversion were a) difficulty in defining Calot’s triangle (42.1%), b) injury to cystic artery (21.1%) and c) injury to bile duct (15.8%). Both male and female had equal risk for conversion. The investigated risk factors like history of previous abdominal surgery, preoperative ERCP, acute cholecystitis, obesity, increased gallbladder-wall thickness and older age showed no significant association with conversion.Conclusion: The study revealed that a very few patents (7.5%) needed conversion from LC to OC. The commonest cause of conversion was difficulty in defining Calot’s triangle, injury to cystic artery and bile duct. The risk factors like previous abdominal surgery, preoperative ERCP, gallbladder wall thickness, obesity and old age were not found associated with conversion to OC.IMC J Med Sci 2017; 11(2): 32-35