Interval Laparoscopic Cholecystectomy Research Articles

Arterial complications after laparoscopic cholecystectomy: single centre experience

Laparoscopic cholecystectomy is one of the most common surgeries done in general surgical practice. Arterial complications after laparoscopic cholecystectomy are not uncommon and usually results due to iatrogenic injury. Mostly patients are managed by interventional radiological procedures, but very rarely we may have to resort to surgical procedures also. Our first patient a 40-year-old female patient presented with haemetemesis and malena. She was diagnosed with a right hepatic artery aneurysm following a laparoscopic cholecystectomy done 2 months back. Due to sudden haemodynamic instability, the patient underwent laparotomy aneurysmal excision and T tube drainage. Later T tube was removed. Another patient, a 41-year-old female patient presented to us with haemetemesis and malena 2 weeks after laparoscopic cholecystectomy. She developed a post-operative biliary leak and was managed with USG-guided pigtail drainage. She was later diagnosed with a GDA aneurysm along with mid-CBD transection. The patient was later managed with hepatico jejunostomy. Our third patient is a 52-year-old gentleman, underwent interval laparoscopic cholecystectomy following acute calculus cholecystitis. Intra operatively following profuse bleeding, RHA artery sectoral branch repair was done. Patient continued to have bleeding and he underwent emergency angioembolisation of right hepatic artery pseudo aneurysm. Arterial complications following laparoscopic cholecystectomy result either from direct arterial or combined Bilio arterial injuries. Interventional radiological procedures are still considered the standard of care in these situations. Surgical interventions hold equally good in ongoing bile leak and in failure of embolization techniques. Management strategy depends on the clinical profile of the patient and the injuries associated with it.

Outcomes of early and interval laparoscopic cholecystectomy for acute cholecystitis at a teaching hospital in Kerala: A prospective observational comparative study

Timing of laparoscopic cholecystectomy, a widely used treatment modality for acute cholecystitis remains controversial. This prospective observational comparative study investigated patient outcomes for early (ELC) and interval laparoscopic cholecystectomy (ILC) in patients with acute cholecystitis admitted to the General Surgery Department at a tertiary care centre in Thrissur, Kerala, between December 2018 and June 2020. Of 67 patients, 34 were assigned to ELC and 33 to ILC groups and followed up for 2 weeks post-surgery. Patient characteristics, clinical features, investigations, intra operative details and post operative outcomes were tabulated. Comparison of age was statistically analyzed using student’s ‘t’ test, demographics and morbidity data using Fisher’s exact test/ Chi-square test and length of hospital stay using Mann Whitney U test. Mean age was significantly higher in the ILC group. 66% of study participants were females with a higher proportion of females observed in the ILC group. Post-surgical complications were not significantly higher in ELC group compared to ILC group. Total length of hospital stay was significantly longer in the ILC group than in ELC group (10.2 ±4.5 vs. 7.1 ±3.0) days, p value: 0.001). Duration of hospital stay for the laparoscopic cholecystectomy procedure taken separately, was longer in ELC group comparatively, 7 ±3.01 versus 4 ±-2.38, (p value: <0.001). There was no mortality. It was observed in the present study that ELC is preferable to ILC for acute cholecystitis with added benefit of shorter hospital stay. Further large randomized trials would be valuable to make recommendations for future management. Keywords: acute cholecystitis; laparoscopic cholecystectomy; hospital stay; conversion rate

Evaluation of the Common bile duct (CBD) Diameter After Laparoscopic Cholecystectomy (LC) and Laparoscopic Common Bile Duct Exploration (LCBDE): A Retrospective Study.

Common Bile duct (CBD) measurement is a crucial aspect in the evaluation of the biliary tree. Whether the CBD undergoes any compensatory change in diameter after laparoscopic cholecystectomy or laparoscopic common bile duct exploration is still up for discussion. The aim of this study was to investigate CBD diameter changes after laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) on magnetic resonance cholangiopancreatography (MRCP). Our retrospective study is divided into 2 sections. The first part assessing CBD diameter changes after laparoscopic cholecystectomy due to gallstones or gallbladder polyps, involved 85 patients, who underwent MRCP procedures. These patients aged between 30 and 85 were divided into an interval LC group (group A, n=56) and a remote LC group (group B, n=29). In group A, the common CBD diameters were measured at their widest portions on MRCP obtained before and after laparoscopic cholecystectomy. Measurements of the CBD diameters were repeated on MRCP obtained twice after the surgery in group B.Section 2 consisted of 38 patients who had choledocholithiasis and were treated with laparoscopic CBD exploration and T-tube placement. These patients aged 26 to 86 formed the interval LCBDE group (group C). The CBD widest diameters were measured on MRCP before LCBDE and after T-tube cholangiography for these individuals.Patients in groups A and C were further divided into 5 and those in group B into 4 age-related subgroups to facilitate statistical analysis. The Pearson correlation test was performed to find any relationship between CBD diameters and age in groups A and B. Paired sample T test was used to compare the significant difference between the 2 sets of CBD diameters in each study group and their subgroups. In the interval LC group, the post-LC mean CBD diameter was significantly wider when compared with the preoperative mean diameter (P<0.05). There was a significant difference between the first and second post-LC means CBD diameter in the remote LC group (P<0.05). In group C, the mean CBD diameter measured on T-tube cholangiography after LCBDE was significantly smaller than the preoperative dilated mean diameter (P<0.05). This study demonstrated significant dilation occurring in the common bile duct diameter after laparoscopic cholecystectomy. Furthermore, our remote LC group also supported that claim by showing significant dilation between the first and second post-cholecystectomy CBD diameter values. And lastly, our interval LCBDE sample's initial dilation of the CBD diameters was reduced after surgery and stone extraction.

Role of Cholecystostomy Drain in Severe Acute Cholecystitis in Critically Ill Patients

Aims: To investigate the outcome of Cholecystostomy drains in the management of Acute Cholecystitis at Cumberland Infirmary. To develop a Cholecystostomy Pathway for patient selection, management and post procedure management. Method: A retrospective study of all patients with Cholecystostomy drains over the last 3 years at Cumberland Infirmary. 58 Inpatients at Cumberland Infirmary and West Cumberland Hospital who had cholecystostomy drains inserted for Acute Cholecystitis from January 2019 to January 2022 were included in the study. The patient list was collected from the Information Department at Cumberland Infirmary, with the Cholecystostomy code J 24.1 used in the search. Results: CRP ranged from 10-450 (mean 200) pre-insertion and on 5th post-procedure day, 37(63.79%) patients had a CRP of less than 50. Similar trends have been observed with the WBC counts. Follow-up investigations post drain insertion varied between CT abdomen, ultrasound abdomen and tubogram. The overall morality in the study group was 8(13.79%). Non of the mortalities were Cholecystostomy related. Reported over all complications were 2 (3.44%) which were sub-phrenic abscess and Cholo-Cutaneous fistula. Conclusion: We conclude that Insertion of a Cholecystostomy drain is a useful and safe procedure for the management of Severe Cholecystitis, especially in critically ill patients, with good early and late outcomes, and a low mortality rate. It can be used as a temporary management option with plan for Interval Laparoscopic Cholecystectomy, or can be the Definitive Management, especially in those patients with High Operative Risk

Analysis of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography for choledocholithiasis-a prospective study

Background: Endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) remains the cornerstone of treatment worldwide for coexisting CBD and gall bladder calculi. The interval between ERCP and LC is disputed. In our study, LC is performed at or more than 6 weeks after ERCP keeping in view by allowing the gall bladder to recover from the acute inflammatory changes if operated upon earlier.Methods: We conducted a prospective observational study in the postgraduate department of general surgery government medical college Srinagar J and K India over a period of 2 years. The 25 patients above age of 18 years and with cholecysto-choledocholithiasis who underwent ERCP and LC at or more than 6 weeks were included.Results: In our study the mean age was 45.3 years. Male: female ratio was 1:3.2. the distribution of patients as per Nassar grading scale 1 (4%) patient had grade I,12 (48%) patients had grade II, 5 (20%) patients had grade III and 7 (28%) patients had grade IV. In patients with grade I, the mean duration of surgery was 36.0 minutes, in grade II the duration of surgery ranged from 34-60 minutes with mean duration of surgery of 43.4 min (SD±8.9), in grade III duration of surgery ranged from 42-68 minutes with mean duration of surgery of 55.2 min (SD±10.06) and in grade IV duration of surgery ranged from 68-116 minutes with mean duration of surgery of 91.3 min (SD±17.66). We observed a definite relationship between the intraoperative Nassar grading scale and the post ERCP interval, 1 patient of grade I scale operated at 12 weeks post ERCP. 12 patients were between the post ERCP interval of 8-12 weeks (mean 10.1 weeks) and they had grade II. In grade III we had 5 patients with post ERCP interval of 7-11 weeks (mean 9.2 weeks). In grade IV we had 7 patients with post ERCP interval of 6-10 weeks (mean 7.9 weeks). p=0.008.Conclusions: Interval LC after ERCP is safe but challenging, longer the interval time between ERCP and LC lesser the chances of encountering intra-operative complications. We recommend LC more than 6 weeks after ERCP is safe.

Systematic review and meta-analysis of early vs late interval laparoscopic cholecystectomy following percutaneous cholecystostomy.

High risk surgical patients with acute cholecystitis are commonly treated with percutaneous cholecystostomy (PTC) drainage. The optimal timing of subsequent interval laparoscopic cholecystectomy (LC) remains unclear. Medline, EMBASE, and Scopus were searched to identify studies published between 01/01/2000 and 31/12/2020, reporting on interval LC outcomes in patients initially treated by PTC. Early and late interval LC were defined as <30 and≥30 days respectively. The Methodological Index for Nonrandomized Studies was used for quality assessment. Meta-analysis of proportions was conducted using a random-effects model. A total of 512 studies were screened, 41 met the inclusion criteria. There were 22 studies in both early and late interval LC groups, with 3 included studies reporting both early and late groups. Following quality assessment, 29 studies were included in the meta-analysis. There were no significant differences between early and late interval LC in terms of conversion rates (7.2% vs 8.3%, p=0.854), 90-day morbidity (12.8% vs 15.9%, p=0.496), and 90-day mortality (0.25% vs 0.32%, p=0.704). Heterogeneity was significant (I2>50%) in all groups. Current evidence of interval LC within or beyond 30 days demonstrates no significant impact on outcomes. Patient factors, clinical experience, and hospital facilities may prove more important predictors.

Pyogenic Liver Abscess Complicating Acute Cholecystitis: Different Management Options

Acute cholecystitis, which is usually associated with gallstones is one of the most common surgical causes of emergency hospital admission and may be further complicated by mural necrosis, perforation and abscess formation. Perforation of the gallbladder is a relatively uncommon complication of acute cholecystitis (0.8–3.2% in recent reviews). The intrahepatic perforation causing a liver abscess is an extremely rare condition, anecdotally reported in the scientific literature, even in the rare types of subacute or acute perforation. Liver abscess caused by gallbladder perforation can be a life-threatening complication with a reported mortality of 5.6%. The treatment of synchronous pyogenic liver abscess and acute cholecystitis may be challenging. We reported three cases of liver abscess due to acute cholecystitis in which different therapeutical approaches were employed. The first case was treated with antibiotics and interval laparoscopic cholecystectomy; the second case was treated with emergency cholecystectomy; and the third case with percutaneous aspiration of the abscess only. The appropriate therapeutical method in these cases depends on the patient’s clinical condition, the on-site expertise that is available in the hospital, and the experience of the surgeon.

Early Versus Interval Cholecystectomy in Mild Acute Biliary Pancreatitis. A Retrospective Study in Tertiary Care Hospital

Objective: The objective is to determine the adequacy of early cholecystectomy (EC) versus interval cholecystectomy (IC) in terms of recurrence, duration of hospital admission, and perioperative complications after mild acute biliary pancreatitis (MABP). Methodology: After endorsement from the ethical committee, clinical data and files of all the admitted patients having MABP in the general surgery department of Holy Family Hospital, Rawalpindi, was collected retrospectively from August 2017 to July 2020. The patients’ demographic profile, clinical findings, diagnostic investigations, timing of cholecystectomy, operating surgeons, operative time, biliary complications, intraoperative bleeding, conversion rate, duration of admission, and recurrence were reviewed. Patients presented with abdominal pain, vomiting, jaundice, or fever. The diagnosis was confirmed on the basis of a CT scan of the abdomen showing an inflamed pancreas and stones in the gallbladder. Outcomes were compared and reviewed between the two groups. Results: In this research proposal, 263 patients admitted were analyzed. EC was performed were discharged after conservative management and followed up after 12 weeks for interval laparoscopic cholecystectomy (IC). It was observed in patients of IC (EC 2 [1.2%] vs IC 7[7%]; p value &lt;0.01) while duration of hospitalization was prolonged as compared to patients of EC (EC 5.53+0.58days vs IC 5.82+0.78days; p value &lt;0.001). lar in both EC and IC. Conclusion: EC performed after MABP is associated with shorter duration of hospitalization and reduced recurrence with similar rate of perioperative complications.

Effects of COVID-19 pandemic on management of acute cholecystitis: A single tertiary center's experience

Following the spread of novel coronavirus (COVID-19) pandemic, surgical associations have issued their different recommendations for managing the acute cholecystitis (AC) clinic during the pandemic. We aimed to examine the effects of the COVID-19 pandemic period on our clinical approach in patients who presented to the emergency department with abdominal pain and were diagnosed with AC. Medical records of patients diagnosed with AC in the emergency room between 11 March 2020 and 10 March 2021 and in the same period of one year before the pandemic were retrospectively reviewed. Patients were divided into 2 groups as COVID-19 period (Group 1) and non-COVID period (Group 2). Demographics and clinical characteristics, treatment modalities, and outcomes of these two groups were compared. The number of patients diagnosed with AC in the emergency department decreased during the ongoing COVID-19 pandemic. When the time between the onset of the complaints and the admission to the emergency service was evaluated, no statistically significant difference was found between the groups (p&gt;0.05). The distribution of cholecystitis type and TG18 severity grading for AC were similar in both groups (p&gt;0.05). While percutaneous cholecystostomy (PC) is more preferred in the treatment of AC during the pandemic period and the number of delayed interval laparoscopic cholecystectomy decreased, AC management was similar in both periods with no significant statistical difference (P&gt;0.05). In conclusion, our clinical approach and management in the treatment of AC did not differ when compared to the pre-pandemic period.

EP.WE.46Stentolith as an uncommon complication of loss to follow up after endoscopic biliary stenting

Abstract Introduction Endoscopic biliary stenting is a common procedure, with indications from malignant obstruction to benign stone disease. We discuss a patient who re-presented after endoscopic stenting having been lost to follow up, with a large ‘stentolith’ requiring open CBD exploration. Case Presentation A 56-year-old female presented in 2013 with obstructive jaundice and a 2-week history of abdominal pain. She was a smoker, but otherwise had no past medical, surgical, or relevant family history. After initial workup, ERCP with sphincterotomy and pigtail stent placement was performed with interval laparoscopic cholecystectomy in 2014. Post-operative follow up was not arranged, the patient subsequently re-presented in 2020 with fatigue. MRCP confirmed a proximal CBD stone and linear artefact. Open exploration facilitated removal of the stone-stent complex. Discussion Complications of stenting include cholangitis, stent occlusion and migration. Stenting for failed biliary stone extraction is considered a temporary measure, with removal or exchange at three months. However, patients may be lost to follow up and return with non-specific symptoms. A rare cause is de novo formation of a gallstone calculus encasing the stent, a phenomenon termed “stentolith”. Proposed pathophysiology is through promotion of bacterial proliferation by the stent, with biofilm formation and calcium bilirubinate precipitation. Variation in formation has been described, with plastic stents developing circumferential stones, due to potential space between the wall and stent. Conclusion This highlights the importance of robust inter-disciplinary working, careful patient follow up and implementation of a mandatory registry at all hospitals for stented patients.

106 Stentolith As an Uncommon Complication of Loss to Follow Up After Endoscopic Biliary Stenting

Abstract Introduction Endoscopic biliary stenting is a common procedure, with indications from malignant obstruction to benign stone disease. We discuss a patient who re-presented after endoscopic stenting having been lost to follow up, with a large ‘stentolith’ requiring open CBD exploration. Case Presentation A 56-year-old female presented in 2013 with obstructive jaundice and a 2-week history of abdominal pain. She was a smoker, but otherwise had no past medical, surgical, or relevant family history. After initial workup, ERCP with sphincterotomy and pigtail stent placement was performed with interval laparoscopic cholecystectomy in 2014. Post-operative follow up was not arranged, and the patient subsequently re-presented in 2020 with fatigue. MRCP confirmed a proximal CBD stone and linear artefact. Open exploration facilitated removal of the stone-stent complex. Discussion Complications of stenting include cholangitis, stent occlusion and migration [2]. Stenting for failed biliary stone extraction is considered a temporary measure, with removal or exchange at three months (1). However, patients may be lost to follow up and return with non-specific symptoms. A rare cause is de novo formation of a gallstone calculus encasing the stent, a phenomenon termed “stentolith” [4]. Proposed pathophysiology is through promotion of bacterial proliferation by the stent, with biofilm formation and calcium bilirubinate precipitation [6]. Variation in formation has been described, with plastic stents developing circumferential stones [12-25], due to potential space between the wall and stent. Conclusions This highlights the importance of robust inter-disciplinary working; careful patient follows up and implementation of a mandatory registry at all hospitals for stented patients.

Outcomes of patients presenting with Cholecystitis in terms of Early vs Delayed Cholecystectomy

Introduction: Biliary tract diseases comprise the most frequently occurring pathology in the abdomen, among which cholelithiasis affects 10-15% of the population. Early laparoscopic cholecystectomy, performed within 72 hours 2) Interval laparoscopic cholecystectomy, performed within 72 hours to 6 weeks 3) Delayed laparoscopic cholecystectomy in which patients are treated with antibiotics and given date of surgery within 6-8 weeks according to international criteria.&#x0D; Objective: To find out the variability between hot, urgent, and delayed laparoscopic cholecystectomy in terms of clinical complications and to find out the readmission rate, the persistence of symptoms, and the safety of the procedure.&#x0D; Materials and Methods: This is a retrospective study carried out in the Surgical Unit ll, Holy Family Hospital, Rawalpindi from January 2018 to March 2018. All adult male and female patients presenting with acute cholecystitis and pancreatitis were included in the study.&#x0D; Results: Total number of patients included in our study is 82. Most of the patients were female 80.5% with a mean age of 44 years. Most of the patients were categorized under delayed laparoscopic cholecystectomy 93.9%, 6.1% underwent interval/urgent cholecystectomy, and 1.2% early/hot cholecystectomy. Diagnosis in the study showed acute cholecystitis in 79.3% of patients, pancreatitis in 7.3%, empyema /gangrene of gallbladder in 6.1% mucocele in 6.1%, and choledocholithiasis in 1.2% of patients. Hence we figured out that performing early cholecystectomy leads to lesser complications.&#x0D; Conclusion: Early laparoscopic cholecystectomy was found out to be a safe and cost-effective procedure. There is an increased incidence of readmission and complications with delayed laparoscopic cholecystectomy. We suggest that measures must be taken in Pakistan to follow international guidelines in health practices to improve patient care.

Duplicated extrahepatic duct type Vb in a patient with gallstone pancreatitis

As rates of childhood obesity rise, the frequency of laparoscopic cholecystectomy to treat gallbladder disease in the pediatric population is increasing. Knowledge of biliary anatomy and its variants is vital to performing this operation safely. Duplication of the extrahepatic biliary tree is a rare but important variant. The significance of duplicated common bile duct anatomy is important as these variations may pre-dispose patients to stone formation and obstruction. Here we present the case of an 11-year-old girl with gallstone pancreatitis and a duplicated common bile duct. The patient underwent interval laparoscopic cholecystectomy following resolution of pancreatitis. A duplicated common bile duct type Vb was identified on intraoperative cholangiogram and subsequent endoscopic retrograde cholangiopancreatography.

The optimal timing of interval laparoscopic cholecystectomy following percutaneous cholecystostomy based on pathological findings and the incidence of biliary events.

The incidence of biliary events (BE) following percutaneous cholecystostomy (PC) in acute cholecystitis (AC) patients is high. Therefore, definitive laparoscopic cholecystectomy (LC) is recommended. We aimed to investigate the optimal timing of LC following PC with regard to the clinical course and pathological findings. All 744 AC patients with PC were included. The incidence and median number of BE were investigated with the concept of competing risks. The 344 patients with interval LC were divided into two groups based on the pathological findings of resected gallbladders: the acute/acute-and-chronic group (AANC group) (n=221) and the chronic group (n=123). A comparative analysis of the demographic data and perioperative outcomes was performed. Among the 744 AC patients with PC, 142 patients experienced recurrent BE. The cumulative incidence of BE was 26.6%, and the median time to recurrence was 67.5days. The PC-to-LC days of the chronic group were longer than those of the AANC group (73.51 vs 63.00, P<.001). The multivariate analysis indicated that the operation time was longer in the AANC group than in the chronic group (P=.040). In terms of the clinical course and sequential pathological changes in the gallbladder, a 9- to 10-week interval after PC is the optimal timing for LC.

EARLY VERSUS DELAYED LAPAROSCOPIC CHOLECYSTECTOMY IN PATIENTS WITH MILD ACUTE BILIARY PANCREATITIS

Background: Acute biliary pancreatitis and timing of cholecystectomy has always been a challenge for surgeons dealing with biliary pathology. Both the diagnosis and treatment have evolved over the last years with the introduction, and universal application of advanced imaging modalities, as well as endoscopic and laparoscopic procedures. Objective: To compare between index and interval laparoscopic cholecystectomy in the management of acute mild biliary pancreatitis. Patients and methods: This study was carried out on 50 patients with mild acute biliary pancreatitis, period from April 2020 to December 2020. The study had been carried out at Al-Hussein Hospital, Al-Azhar University, and Damanhour National Medical Institute. They were divided into two equal groups: Group A underwent early cholecystectomy within a week of admission, and group B underwent delayed (interval) cholecystectomy 4-6 weeks after discharge. Results: Early group included 3 males (12%) and 22 females (88%), while interval group included 5 males (20%) and 20 females. (80%) ,Regarding age (p=0.209) , mean age ±SD for the index group was 39.40 ± 10.46 years, and range 23 – 59 years , while in the interval group mean age ±SD was 43.40 ± 11.69 years ,and range 22 – 59 years. All cases were subjected to through history taking and complete clinical examination. Abdominal pain was the presenting symptom in all patients (100%), jaundice was present in 10cases (40%) in group A and in 8 cases (32%) in group B. Laparoscopic cholecystectomy (LC) was completed to all patients in group A and group B without conversion to open cholecystectomy. Peristalsis was audible and patients started oral fluid intake in the same day of surgery in all cases. No intraoperative complications took place, and no postoperative complications were recorded. Patients were followed for 3 months post-operatively, no mortality, and no complications were recorded. Conclusion: Laparoscopic cholecystectomy in mild acute biliary pancreatitis was safe and feasible during index admission with no added risks. Postponing cholecystectomy did not alter intra-operative complications.

Endoscopic treatment including a single-operator peroral cholangioscopy-guided electrohydraulic lithotripsy and endoscopic nasogallbladder drainage combined laparoscopic cholecystectomy for Mirizzi syndrome

Mirizzi Syndrome (MS) is rare among gallbladder diseases and may be difficult to treat. In particular, endoscopic treatment often fails owing to unable to access or capture the impacted cystic duct stone. We report a case of MS grade III that were successfully managed by an endoscopic treatment and interval laparoscopic cholecystectomy. A 59-year-old women was admitted our hospital presenting with upper abdominal pain and fever up to 38.5℃. She was mildly jaundiced with scleral icterus with a positive Murphy's sign. An abdomen computed tomography scan and T2-weight magnetic resonance cholangiopancreatography image demonstrated about 1.4cm stone at junction of the cystic duct and mid-common bile duct with cholecysto-choledochal fistula, compatible with MS type III and acute calculus cholecystitis. A digital single-operator cholangioscopy (DSOC)-guided eletrohydraulic lithotripsy (EHL) was performed. Elective laparoscopic cholecystectomy was performed after the stones were completely removed. The patient was discharged without any complications on the 5th day after surgery. The treatment of MS is mainly surgical and consists of partial or complete cholecystectomy with or without common bile duct exploration. However, in the era of minimal invasive treatment, laparoscopy treatment for low grade MS is being tried steadily. In our case, through preoperative intervention using DSOC guided EHL, the effect of downgrading MS could be achieved, and this resulted in a safe laparoscopic surgical approach. In conclusion, DSOC guided EHL with ENGBD may allow a minimally invasive approach for management of high grade MS.

Minimally Invasive Approach Using Digital Single-Operator Peroral Cholangioscopy-Guided Electrohydraulic Lithotripsy and Endoscopic Nasogallbladder Drainage for the Management of High-Grade Mirizzi Syndrome

Mirizzi syndrome is a rare complication of gallbladder disease that can be difficult to treat. In particular, endoscopic treatment often fails because of the inability to access or to capture the impacted cystic duct stone. We report a case of Mirizzi syndrome grade III that was successfully managed by digital single-operator peroral cholangioscopy-guided electrohydraulic lithotripsy with endoscopic nasogallbladder drainage and interval laparoscopic cholecystectomy. Based on our experience, digital single-operator peroral cholangioscopy-guided electrohydraulic lithotripsy with endoscopic nasogallbladder drainage is a feasible minimally invasive approach for the management of high-grade Mirizzi syndrome.

3D Laparoscopic common bile duct exploration with primary repair by absorbable barbed suture is safe and feasible

Endoscopic retrograde cholangiopancreatography (ERCP), with interval laparoscopic cholecystectomy (LC), is the most common treatment approach for common bile duct (CBD) stones. However, recent studies show that single-stage laparoscopic CBD exploration (LCBDE) is safe and feasible. Three-dimensional (3D) laparoscopy enhances depth perception and facilitates intracorporeal suturing. The application of 3D technology for LCBDE is emerging, and we report our case series of 3D LCBDE. We audited the 27 consecutive 3D LCBDE performed from July 2017 to January 2020. We have a liberal policy for magnetic resonance cholangiopancreatography (MRCP) in patients with deranged liver function tests (LFT). All CBD explorations were done through choledochotomy with a 5 mm flexible choledochoscope and primarily repaired with an absorbable barbed suture without a stent or T-tube. The mean age of patients was 68 (range 44-91) years, and 12 (44%) were male. The indications for surgery were choledocholithiasis 67% (n=18), cholangitis 22% (n=6), and gallstone pancreatitis 11% (n=3). About 67% (n=18) had pre-operative ERCP. About 37% (n=10) had pre-operative biliary stent. Pre-operative MRCP was done in 74% (n=20), and the mean diameter of CBD was 14.5 mm (range 7-30). The median operative time was 160 (range 80-265) min. The operative drain was inserted in 18 patients. One patient each (4%) had a bile leak and a retained stone. There was no open conversion, readmission, or mortality. 3D LCBDE with primary repair by an absorbable barbed suture is safe and feasible. This paper emphasized that one stage LCBDE should be a treatment option which is comparable with two stage ERCP followed by LC to treat CBD stones. In addition, 3D technology and barbed sutures use in LCBDE are safe and useful.

Case report: xanthogranulomatous cholangitis mimicking cholangiocarcinoma

Presenter: Jenny Q Zhang MD | Rhode Island Hospital Background: Xanthogranulomatous cholangitis is an extremely rare diagnosis and is believed to be an extension of xanthogranulomatous cholecystitis, a benign inflammatory process characterized by lipid-laden macrophages. Here, we report a case of isolated xanthogranulomatous cholangitis mimicking cholangiocarcinoma. Methods: A 72-year-old male who was previously admitted to the hospital for gallstone pancreatitis, cholangitis s/p ERCP with plastic stent placement, and Klebsiella bacteremia underwent interval laparoscopic cholecystectomy with liver biopsy. His pathology revealed chronic cholecystitis and no fibrosis, steatosis or inflammation in the liver biopsy. Postoperatively, he continued to endorse night sweats, unintentional weight loss, and jaundice. He underwent ERCP with exchange of the common bile duct stent multiple times with no alleviation of symptoms. Liver function tests remained mildly elevated (Tbili 1.3, AST 78, ALT 64, Alk Phos 673). CEA was normal (1.1) but CA19-9 was significantly elevated at 160. CT abdomen/pelvis showed new intrahepatic duct dilation and portal vein thrombus. ERCP with SpyGlass revealed right hepatic system underfilling, narrowing of the right intrahepatic duct takeoff, and abnormal biliary tract mucosa characterized by nodularity, scarring, purulence, and decreased vascularity. Cytology of the right main hepatic duct showed atypical cells. Given the constellation of findings, there was high clinical suspicion of early intrahepatic cholangiocarcinoma and he was consented for liver resection. Results: The patient subsequently underwent right hepatectomy and portal lymphadenectomy. Pathology showed xanthogranulomatous cholangitis of large hepatic bile ducts, bile granuloma, hepatic parenchyma with features of large bile duct obstruction, chronic cholestasis, and biliary pattern of fibrosis with bridging septa. Dedicated stains for bacteria and fungi were negative, and there was no evidence of malignancy. He tolerated the procedure well and was discharged home with services on postoperative day 4. Conclusion: We present a patient with initial workup concerning for intrahepatic cholangiocarcinoma. Final pathology showed xanthogranulomatous cholangitis with no malignancy. Interestingly, he did not have xanthogranulomatous cholecystitis. Xanthogranulomatous cholangitis is a very rare phenomenon that can lead to benign strictures of the bile ducts, especially in the setting of recurrent cholangitis.

Early versus Interval Laparoscopic Cholecystectomy in Acute Calcular Cholecystitis in Grade I and Grade II According to Tokyo Guidelines

Abstract Background: Gall stone-related disease is one of the most common ailments that general surgeons treat. Between 10% and 15% of the population have gallstones, and of these, between 1% and 4% will be become symptomatic each year. Aim of Study: The aim of this prospective study is to compare between early and interval laparoscopic cholecystec-tomy for treatment of acute cholecystitis in grade I and grade II according to Tokyo guide lines in post-operative complica-tions hospital stay quality of life and cost. Patients and Methods: This study was analytical prospec-tive study; it was carried out on 20 patients presented with acute calcular cholecystitis admitted in the General Surgery Department at Al-Zahraa University Hospital in the period from April 2018 to November 2019. Results: According to Tokyo guidelines 2013, 12 patients undergone and completed early laparoscopic cholecystectomy (6 patients from mild group and 6 patient from moderate group) while 4 patients treated by delayed laparoscopic cholecystectomy. Only 3 patients (2 in mild group and 2 in moderate group) needed intraoperative conversion. Operative time was longer in open surgery and statistically significant in early lap and conversed cases. Post-operative pain was severe in majorty of patients with open surgery and mild in laparoscopic group. The mean time of starting oral feeding and hospital stay was longer in open surgery than lap chole-cystectomy. Conclusion: These results clarify that application of Tokyo guidelines 2013 was successful in guiding us in determining the proper time of laparoscopic cholecystectomy according to severity.