Intraoperative Bile Research Articles

Application of Indocyanine Green Fluorescence Imaging During Laparoscopic Reoperations of the Biliary Tract Enhances Surgical Precision and Efficiency.

A history of abdominal surgery is considered a contraindication for laparoscopic procedures. However, the advancements in laparoscopic instruments and techniques have facilitated the performance of increasingly intricate operations, even in patients with prior abdominal surgeries. ICG fluorescence imaging technology offers advantages in terms of convenient operation and clearer intraoperative bile duct imaging, as confirmed by numerous international clinical studies on its feasibility and safety. The application of ICG fluorescence imaging technology in repeat laparoscopic biliary surgery, however, lacks sufficient reports. The clinical data of patients who underwent elective reoperation of the biliary tract in our department between January 2020 and June 2022 were retrospectively analyzed. ICG was injected peripherally before the operation, and near-infrared light was used for 3-dimensional imaging of the bile duct during the operation. Altogether, 143 patients were included in this study and divided into the fluorescence and nonfluorescence groups according to the inclusion criteria. Among the 26 patients in the fluorescence group, cholangiography was successfully performed in 24 cases, and the success rate of intraoperative biliary ICG fluorescence imaging was 92.31%. The intraoperative biliary tract identification time was significantly different between the fluorescence and nonfluorescence groups, but no statistical difference was observed in the final operation method, operative time, and intraoperative blood loss between the 2 groups. Although there was no significant difference in the postoperative ventilation rate, incidence of bile leakage, and stone recurrence rate at 6 months postoperatively between the 2 groups (P>0.05), a significant difference in postoperative hospitalization days was observed (P=0.032). The application of ICG fluorescence imaging technology in laparoscopic reoperation of the biliary tract is useful for the early identification of the biliary tract during operation, thereby shortening the operative time and reducing the risk of damage to nonoperative areas. This approach also enhances the visualization of the biliary system and avoids secondary injury intraoperatively due to poor identification of the biliary system. This technique is safe for repeat biliary tract surgery and has a good application prospect.

The use of indocyanine green fluorescence imaging in preventing postoperative bile leakage of the hepaticojejunostomy in robot-assisted pancreatic surgery

BackgroundPostoperative bile leakage (POBL) due to insufficiency of the hepaticojejunostomy (HJ) after pancreatico-duodenectomy (PD) is associated with high morbidity and mortality. The aim of this cohort study was to determine the clinical relevance of ICG in detecting and preventing POBL of the HJ in robotic minimal invasive pancreatic surgery (R-MIPS). MethodsAll consecutive robot- and ICG-assisted HJ-anastomoses between 2019 and 2022 were included. Biliary leakage was objectified with near infrared technology. Only clinically relevant POBL were considered in this study. ResultsSixty patients who underwent a PD between 2019 and 2022 were included. In ten patients, fluorescence imaging revealed an intra-operative hepaticojejunostomy insufficiency (HJI). Five of these patients developed POBL despite revision but preventing POBL in five patients. Detection of HJI with ICG predicted POBL with a sensitivity and specificity of 41.6% and 89.6% respectively. There was a significant higher chance of developing a POBL if the hepatic duct diameter was less than 5 mm (relative risk = 4.68 (p = 0.0345)), or if an intra-operative HJI was detected (relative risk = 3.57 (p = 0.009)). ConclusionICG is a simple and useful tool for detecting intra-operative bile leakage. This study shows that bile illumination with ICG in R-MIPS could prevent postoperative bile leakage.

The Clinical Impact of Different Types of Preoperative Biliary Intervention on Postoperative Biliary Tract Infection of Patients Undergoing Pancreaticoduodenectomy.

Background: For patients with obstructive jaundice and who are indicated for pancreaticoduodenectomy (PD) or biliary intervention, either endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography and drainage (PTCD) may be indicated preoperatively. However, the possibility of procedure-related postoperative biliary tract infection (BTI) should be a concern. We tried to evaluate the impact of ERCP and PTCD on postoperative BTI. Methods: Patients diagnosed from June 2013 to March 2022 with periampullary lesions and with PD indicated were enrolled in this cohort. Patients without intraoperative bile culture and non-neoplastic lesions were excluded. Clinical information, including demographic and laboratory data, pathologic diagnosis, results of microbiologic tests, and relevant infectious outcomes, was extracted from medical records for analysis. Results: One-hundred-and-sixty-four patients from the cohort (164/689) underwent preoperative biliary intervention, either ERCP (n = 125) or PTCD (n = 39). The positive yield of intraoperative biliary culture was significantly higher in patients who underwent ERCP than in PTCD (90.4% vs. 41.0%, p < 0.001). Although there was no significance, a trend of higher postoperative BTI (13.8% vs. 2.7%) and BTI-related septic shock (5 vs. 0, 4.0% vs. 0%) in the ERCP group was noticed. While the risk factors for postoperative BTI have not been confirmed, a trend suggesting a higher incidence of BTI associated with ERCP procedures was observed, with a borderline p-value (p = 0.05, regarding ERCP biopsy). Conclusions: ERCP in patients undergoing PD increases the positive yield of intraoperative biliary culture. PTCD may be the favorable option if preoperative biliary intervention is indicated.

Robotic-assisted cholecystectomy versus conventional laparoscopic cholecystectomy for benign gallbladder disease: a systematic review and meta-analysis.

Laparoscopic cholecystectomy (LC) is the established gold standard treatment for benign gallbladder diseases. However, robotic cholecystectomy is still controversial. Therefore, we aimed to compare intraoperative and postoperative outcomes in LC and robotic-assisted cholecystectomy (RAC) in patients with nonmalignant gallbladder conditions. PubMed, Scopus, Cochrane Library, and Web of Science were systematically searched for studies comparing RAC to LC in patients with benign gallbladder disease. Only randomized trials and non-randomized studies with propensity score matching were included. Mean differences (MDs) were computed for continuous outcomes and odds ratios (ORs) for binary endpoints, with 95% confidence intervals (CIs). Heterogeneity was assessed with I2 statistics. Statistical analysis was performed using Software R, version 4.2.3. A total of 13 studies comprising 22,440 patients were included, of whom 10,758 patients (47.94%) underwent RAC. The mean age was 48.5years and 65.2% were female. Compared with LC, RAC significantly increased operative time (MD 12.59min; 95% CI 5.62-19.55; p < 0.01; I2 = 79%). However, there were no significant differences between the groups in hospitalization time (MD -0.18days; 95% CI - 0.43-0.07; p = 0.07; I2 = 89%), occurrence of intraoperative complications (OR 0.66; 95% CI 0.38-1.15; p = 0.14; I2 = 35%) and bile duct injury (OR 0.99; 95% CI 0.64, 1.55; p = 0.97; I2 = 0%). RAC was associated with an increase in operative time compared with LC without increasing hospitalization time or the incidence of intraoperative complications. These findings suggest that RAC is a safe approach to benign gallbladder disease.

Relationship between Intraoperative Bile Culture Outcomes and Subsequent Postoperative Infectious Complications: A Retrospective Cohort Study.

The presence of positive bile culture during intraoperative procedures has been associated with elevated morbidity and mortality rates in hepatobiliopancreatic surgeries, contributing to increased healthcare expenditures. However, the precise impact of bactobilia on the development of postoperative complications remains uncertain due to existing disparities in the published literature. In this retrospective cohort study, we assessed 137 patients who underwent major hepatobiliopancreatic surgery to examine the relationship between intraoperative bile culture outcomes and subsequent postoperative infectious complications. Among patients with bactobilia, a significant 35.1% exhibited systemic or local infectious complications, whereas only 11.1% of those with negative culture results experienced any infectious complications (p = 0.002). Similarly, a notable difference was observed in the incidence of surgical site infections, with 24.3% in the bactobilia group compared to 7.9% in the negative culture group (p = 0.01). A total of 74 monomicrobial cultures with microbiological growth were isolated, predominantly featuring Gram-negative microorganisms, primarily Enterobacteriaceae in 49 cultures. Escherichia coli was identified in 37.8% of positive cultures, while Klebsiella pneumoniae was evident in 21.6%. Gram-positive microorganisms were present in 10 cultures, with Enterococcus emerging as the prevailing species. The logistic regression model identified a positive bile culture as an independent factor significantly associated with infection development (OR: 2.26; 95% confidence interval: 1.23-11; p = 0.02). Considering the limitations of the study, these findings underscore the critical importance of conducting bile cultures during the intraoperative phase to enable vigilant monitoring and prompt management of infectious complications.

Efficacy of different indocyanine green doses in fluorescent laparoscopic cholecystectomy: A prospective, randomized, double-blind trial.

Intraoperative bile duct injury is a significant complication in laparoscopic cholecystectomy (LC). Near-infrared fluorescence cholangiography (NIFC) can reduce this complication. Therefore, determining the optimal indocyanine green (ICG) dosage for effective NIFC is crucial. This study aimed to determine the optimal ICG dosage for NIFC. This was a prospective, randomized, double-blind clinical trial at a single tertiary referral center, including 195 patients randomly assigned to three groups: lower dose (0.01 mg/BMI) ICG (n = 63), medium dose (0.02 mg/BMI) ICG (n = 68), and higher dose (0.04 mg/BMI) ICG (n = 64). Surgeon satisfaction and detection rates for seven biliary structures were compared among the three dose groups. Demographic parameters did not significantly differ among the groups. The medium dose (72.1%) and higher dose ICG groups (70.3%) exhibited superior visualization of the common hepatic duct compared to the lower dose group (41.3%) (p < 0.001). No differences existed between the medium and higher dose groups. Similar trends were observed for the common bile duct and cystic common bile duct junction. In patients undergoing fluorescent laparoscopic cholecystectomy, the 0.02 mg/BMI dose of indocyanine green demonstrated better biliary structure detection rates than the 0.01 mg/BMI dose and was non-inferior to the 0.04 mg/BMI dose.

Safety and feasibility of cystic duct control with suture ligation during laparoscopic cholecystectomy

Background Securing the cystic duct in laparoscopic cholecystectomy (LC) can be achieved through suturing ligation (intracorporeal or extracorporeal), clips, electrocautery, and ultramodern vessel sealing energy devices. Suturing ligation is a safe and a cost-effective measure in low-resource settings such as developing countries. Patients and methods The rationale of this current prospective study was to establish the safety and feasibility of intracorporeal suturing ligation for securing the cystic duct during LC in the local setting. Patients who were eligible for LC at the Aswan University Hospital’s General Surgery Department were included. Results In all, 260 patients were included in our study. Most of the participants were females, representing 92.69% of patients. The mean age of participants was 39.82±9.96 years, and 95.77% were overweight or obese. The mean±SD time for cystic duct ligation and closure was 3.03±0.64, and the median [interquartile range (IQR)] was 2.90 min (1.11 min). The mean±SD operative time was 88.19±27.81 min, and the median (IQR) was 84 min (31.75 min). Also, the mean±SD hospital stay was 1.11±0.55 days, and the median (IQR) was 1 day (0 day). There was no intraoperative significant bile duct injury, bile leak, or bleeding. No visceral injury was encountered. The success rate of the operation was 100%. None needed to be redone. No case needed conversion to open surgery. No bile leakage or other complication was seen during the follow-up period. Conclusion In resource-constrained settings, suture ligation of the cystic duct is a safe technique with low rates of postoperative complications. Cystic duct control with intracorporeal suture ligation is an essential technique that can be learned, requiring knot-tying skills.

Abstract 7615: Epithelial-mesenchymal-transition gene signature changes and poor oncological outcome in Candida-positive pancreatic ductal adenocarcinoma

Abstract Candida are commonly found in bile collected during surgery in pancreatic ductal adenocarcinoma (PDAC) patients. However, their significance in tumor biology and oncological outcome is unclear. PDAC patients receiving neoadjuvant therapy and pancreatectomy with intraoperative bile fungal culture were identified (N=40) in a prospective single-institution cohort. Tumor regression scores (TRS) were abstracted from pathology reports and correlated with bile fungal cultures. Bulk tumor RNASeq data were obtained from the Oncology Research Information Exchange Network (ORIEN). Tumor microbiome data of non-metastatic PDAC patients with upfront surgery were extracted using the {exotic} tool (Hoyd et al. Cancer Res. Commun., 2023). Gene expression profiles were compared between Candida+ and Candida- tumors, defined by a cutoff microbial count of 0. Overall survival (OS) of resected PDAC patients with Candida+ and Candida- tumors was compared using Kaplan Meier survival analysis. From the single-institution PDAC cohort, Candida+ bile was associated with poor pathological response to neoadjuvant therapy (Table 1). Using the ORIEN cohort, Candida were detected in 67% (106/158) of the PDAC tumors. Patients with Candida+ tumors had worse OS (median 28 vs. 56 months, Log-Rank p&amp;lt;0.008). Gene Set Enrichment Analysis (GSEA) using Hallmark gene sets showed an enrichment of epithelial-mesenchymal-transition (EMT) gene set and a reduction of metabolic and DNA repair gene sets in Candida+ tumors. GSEA for Immune signature and Tumor Immune Microenvironment Deconvolution (TIMEx) cell types showed an enrichment of Stromal-Fibroblast and EMT signature in Candida+ tumors. Further investigations are underway to determine the causal and metabolic relationship between Candida and this tumor microenvironment with EMT and stromal fibroblasts which is a well-known contributor to poor chemotherapy response and oncological outcome of PDAC. Table 1: Pathological Response to Neoadjuvant Therapy for PDAC Bile Culture TRS0/1 TRS2 TRS3 Candida - 5 (25%) 15 (75%) 0 (0%) Candida + 1 (5%) 11 (55%) 8 (40%) TRS: Tumor Regression Score (TRS0: complete response; TRS1: near-complete response; TRS2: partial response; TRS3: no response). Chi-Square Test, P=0.0035. Citation Format: Po Hien Ear, Min Hu, Jonathan S. Shilyansky, Naomi H. Fei, Sam Coleman, Rebecca Hoyd, Caroline E. Wheeler, Kelsey L. Steckly, Michelle L. Churchman, Nicholas Denko, Rebecca D. Dodd, Sheetal Hardikar, Ning Jin, Qin Ma, Martin D. McCarter, Abdul Rafeh Naqash, Afaf E. Osman, Gregory Riedlinger, Lary A. Robinson, Bryan P. Schneider, Eric A. Singer, Ahmad A. Tarhini, Gabriel Tinoco, Cornelia M. Ulrich, Yousef Zakharia, Daniel Spakowicz, Aik Choon Tan, Carlos H. Chan. Epithelial-mesenchymal-transition gene signature changes and poor oncological outcome in Candida-positive pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 7615.

Intraoperative transcystic laparoscopic common bile duct stone clearance with SpyGlass™ discover during emergency and elective cholecystectomy: a single-center case series

Background and study aimThe development of a new cholangioscope, the SpyGlass™ Discover (Boston Scientific), has allowed the laparoscopic transcystic common bile duct exploration and stone clearance. The possibility of simultaneous treatment of choledocholithiasis during early laparoscopic cholecystectomy offers the opportunity to enormously reduce the time between acute cholecystitis diagnosis and the execution of cholecystectomy with better outcomes for patients. Furthermore, an altered anatomy of the gastrointestinal tract is not an obstacle to this technique. The aim of the study was to determine whether this new procedure is feasible, safe, and effective.Patients and methodsThe investigation employs a retrospective case series study including all consecutive patients with a diagnosis of common bile duct stones undergoing cholecystectomy and intraoperative laparoscopic common bile duct clearance using SpyGlass™ Discover at IRCCS Policlinico San Matteo in Pavia (Italy). Eighteen patients were included from May 2022 to May 2023.ResultsA complete clearance of the common bile duct was obtained in 88.9% of patients. The mean postoperative length of stay was 3 days. No major complications occurred. After a median follow-up of 8 months, no recurrence of biliary events or readmissions occurred.ConclusionThis procedure has proven to be feasible, safe, and effective.

Influence of antibiotic prophylaxis on wound infection incidence after elective laparoscopic cholecystectomy.

There have been controversies about whether prophylactic antibiotics are necessary in elective laparoscopic cholecystectomy. The aim of this study is to analyse the effect of different risk factors and antibiotic prophylaxis on the rate of wound infection following elective laparoscopic cholecystectomy. This is a retrospective study of patients with elective laparoscopic cholecystectomy from January 2021 to December 2022. The evaluated factors were: gender, age, diabetes, smoking, body mass index, haemoglobin level, American Society of Anesthesiologists physical status classification, surgery duration, intraoperative bile spillage and use of antibiotic prophylaxis. This study included 243 patients. The incidence of wound infection was significantly higher in male patients (p = 0.021). There was no statistically significant correlation between other risk factors and postoperative wound infection. Elective laparoscopic cholecystectomy patients do not benefit from antibiotic prophylaxis, which should be limited to complicated and acute cases.

Clinical application of magnetic anchor technique in laparoscopic cholecystectomy: the first retrospective study in China.

Magnetic anchor technique (MAT) is frequently used in laparoscopic cholecystectomy. However, there are few reports on its clinical application in China. In this study, we retrospectively analyzed the clinical application of MAT in laparoscopic cholecystectomy in China. 25 patients (4 males, 21 females) who underwent laparoscopic cholecystectomy assisted by MAT at the First Affiliated Hospital of Xi'an Jiaotong University were enrolled from November 2020 to March 2021. Their records were retrospectively analyzed. The magnetic anchor device was independently designed and developed by the authors and consisted of the anchor magnet and magnetic grasping apparatus. Surgical time, intraoperative blood loss, intraoperative accidents, operator experience, postoperative incision pain score, postoperative complications, and other indicators were evaluated and analyzed. All patients successfully underwent laparoscopic cholecystectomy, including 3 cases of MAT-assisted transumbilical single-port LC, 16 cases of MAT-assisted 2-port LC and 6 cases of conventional 3-port LC. The median operation time was 50 min (range 30-95 min); intraoperative bleeding was less than 30 ml. The median score of surgical incision on day 1 and 3 after the operation was 3 (range 1-4) and 1 (range 1-3), respectively. All patients had no intraoperative bile duct injury, vascular injury, postoperative bleeding, bile leakage, biliary stricture and other complications. No adverse events (such as injury to adjacent organs or failure of the magnetic anchor device) occurred either during or after the operation. The MAT-assisted laparoscopic cholecystectomy appears to be safe, feasible and effective and exhibits unique assistance in transumbilical single-port laparoscopic cholecystectomy.

Role of Mesohepatectomy for Pediatric Centrally Located Liver Tumors.

Mesohepatectomy (MH) or central hepatectomy (CH) is a recognized surgical technique for centrally located pediatric liver tumors. This technique of liver resection avoids extended liver resections and thereby helps in the preservation of liver parenchyma. In this article, we aim to analyze our experience and outcome with this technique of liver resection. A retrospective analysis of patients who underwent MH from January 2015 to June 2023 at our institute was performed. The variables analyzed include demographics, preoperative treatment, perioperative management, and postoperative outcome. A total of five patients underwent CH. Four patients had hepatoblastoma, and one patient had mesenchymal hamartoma. All four patients with hepatoblastoma received neoadjuvant chemotherapy. All five patients had negative surgical margins, and one of the five developed disease recurrences necessitating resurgery and ultimately died of metastasis. one patient sustained intraoperative major bile duct injuries, and one patient had postoperative Abnormal, well-circumscribed, extra-biliary collection of bile. MH with clear margins is feasible in the selected subset of pediatric liver tumors involving segments IV, V, and VIII with outcomes equivalent to extended hepatic resections.

Usefulness of intraoperative bile culture in patients with acute calculous cholecystitis with previous biliary events: does the postoperative management change?

The aim of our study wasto determine the usefulness of intraoperative gallbladder cultures in the postoperative course in surgically treated patients with acute calculous cholecystitis and previous biliary events (ACC-PBE). Retrospective unicenter study on surgically treated ACC-patients between January 2014 and December 2018. Clinical benefit was defined as a > 20% change in postoperative antibiotic treatment.Secondary endpoints: postoperative morbidity and length-of-stay (LOS) in ACC-PBE patients with positive intraoperative biliary culture (IBC). Statistical significance was defined as p < 0.05. Out of the initial 711 patients, 203 met the study's inclusion criteria, with 139 of them having IBC results (72 positive, 67 negative). Our analysis revealed no significant difference in the incidence of positive-IBC between patients with ACC-PBE. Among this group, only 6% changed postoperative antibiotic treatment based on IBC results. There were no statistically significant differences in postoperative complications (p: 0.21) or LOS (p: 0.23) in the ACC-PBE group. In multivariate analysis, age > 70years old (p: 0.00; HR 3.1, 95% IC [1.6-6.4]), prior ERCP (p: 0.02; HR 5.9, 95% IC [1.25-27.5]) and prior antibiotic treatment (p: 0.01; HR 3.6, 95% IC [1.32-9.86]) were identified as independent factors that influenced PBC. IBC in operated ACC-PBE do not alter postoperative management. While positive-IBC was associated with age, prior ERCP, and prior antibiotic treatment, these findings did not have a significant impact on postoperative morbidity or LOS.

HPB P42 Case Report: Laparoscopic Cholecystectomies in patients with a Ventriculoperitoneal shunt: key considerations for surgeons

Abstract Background Laparoscopic surgery has evolved to become the preferred mode of access for intraperitoneal surgery and is the gold standard approach to cholecystectomy. With the high prevalence of laparoscopic procedures to definitively treat gallstones and their associated complications, an increasing number of patients with co-morbidities are undergoing these procedures, including patients with cerebrospinal fluid (CSF) shunts in situ. These shunts pose unique challenges due to the paucity of guidelines, research and data to optimally manage these patients. Methods We report a case of a patient who underwent a successful, but technically challenging laparoscopic cholecystectomy whilst having a Ventriculoperitoneal (VP) shunt present. Important considerations are necessary, including the additional risks of: shunt failure and impaired CSF drainage, retrograde insufflation leading to increased intracranial pressure and herniation, and the risk of bile leak which could result in ascending meningitis (thereby making intra-operative cholangiogram a relative contraindication). We will discuss what unique measures were implemented pre-operatively, peri-operatively and post-operatively to prevent these complications, in consultation with both the patient and the wider multidisciplinary healthcare team. Results A 39-year-old female with gallstone pancreatitis, underwent an ERCP, and was subsequently listed for elective laparoscopic cholecystectomy. From childhood, she had a VP shunt in place for an Arnold Chiari II malformation. A literature review was conducted and a CT scan was arranged. Her case was discussed with neurosurgery, radiology, microbiology and anaesthetics, with multiple safety recommendations proposed; including US guided marking of the shunt tubing on the skin, appropriate pre-operative antibiotics, lower than normal pneumoperitoneum pressures, no attempt at intra-operative cholangiogram or bile duct exploration, avoidance of gallbladder perforation, minimal washout, neuro-observations in the post-operative period and post-operative antibiotics. Conclusions Our report shows that with thorough pre-operative planning involving communication with multidisciplinary team and with informed consent, laparoscopic cholecystectomy can be performed in this patient sub-group with relative safety without the need for shunt manipulation or peri-operative intracranial pressure monitoring. It is however, technically challenging, and should be considered by experienced laparoscopic surgeons, and perhaps reserved for those with subspecialty biliary interests.

Real-time fluorescence imaging with indocyanine green during laparoscopic duodenum-preserving pancreatic head resection

BackgroundLaparoscopic duodenum-preserving pancreatic head resection (LDPPHR) is a surgical method used to treat benign and low-grade malignant pancreatic head tumors. This study aimed to determine the protective effect of common bile duct in LDPPHR using indocyanine green (ICG) fluorescence imaging. MethodsA retrospective analysis of 30 patients treated with LDPPHR at the Second Affiliated Hospital of Nanchang University between January 2015 and November 2022 was performed. Patients were divided into two groups based on ICG use: ICG and non-ICG. ResultsThirty patients received LDPPHR, 11 males and 19 females, and the age was 50.50 (M (IQR)) years (range: 19–76 years). LDPPHR was successfully performed in 27 (90 %) patients, LPD was performed in 1 (3 %) patient, and laparotomy conversion was performed in 2 (7 %) patients. One patient (3 %) died 21 days after surgery. The incidence of intraoperative bile duct injury in the ICG group was lower than that in the non-ICG group (10 % vs 60 %, P = 0.009), and the operation time in the ICG group was shorter than that in the non-ICG group (311.9 ± 14.97 vs 338.05 ± 18.75 min, P < 0.05). Postoperative pancreatic fistula occurred in 16 patients (53 %), including 10 with biochemical leakage (62.5 %), four with grade B (25 %), and two with grade C (12.5 %). Postoperative bile leakage occurred in four patients (13 %). ConclusionsThe ICG fluorescence imaging technology in LDPPHR helps protect the integrity of the common bile duct and reduce the occurrence of intraoperative bile duct injury, postoperative bile leakage, and bile duct stenosis.

Feasibility and safety of intraoperative bile duct clearance by antegrade transcystic balloon sphincteroplasty: A prospective observational pilot study.

Concomitant cholecystolithiasis and choledocholithiasis are common. Standard treatments are endoscopic retrograde cholangiography (ERC) followed by cholecystectomy or laparoendoscopic rendezvous. Endoscopic retrograde cholangiography has drawbacks, such as post-ERC pancreatitis or bleeding, and potentially more than one intervention is required to address common bile duct (CBD) stones. Safety and feasibility of an intraoperative antegrade transcystic single-stage approach during cholecystectomy with balloon sphincteroplasty and pushing of stones to the duodenum has not been evaluated prospectively. The aim of this pilot study was to evaluate this procedure regarding safety, feasibility, and stone clearance rate. Prospective single-center intervention study (SUPER Reporting-Guideline). Main inclusion criterion was confirmed choledocholithiasis (stones ≤6 mm) at intraoperative cholangiography. Success of the procedure was defined as CBD stone clearance at intraoperative control cholangiography, absence of symptoms and no elevated cholestasis parameters at 6 weeks follow-up. Simon's two-stage design was used to determine sample size. From January 2021 to April 2022, a total of 57 patients fulfilled the final inclusion criteria and were included. Mild pancreatitis or cholangitis were present upon admission in 15 (26%) and 15 (26%) patients, respectively. Median number of CBD-stones was 1 (1-6). Median stone diameter was 4 mm (0.1-6 mm). Common bile duct stone clearance was achieved in 54 patients (94%). The main reason for failed CBD clearance was the inability to push the guidewire along the biliary stone into the duodenum. Median intervention time was 28 minutes (14-129 minutes). While there was no postoperative pancreatitis, two patients (3.5%) had asymptomatic hyperlipasemia 4 hours postoperatively. Intraoperative CBD stone clearance by antegrade balloon sphincteroplasty appears to be safe and highly feasible. Its overall superiority to the current standards warrants evaluation by a randomized controlled trial. Therapeutic/Care Management, Level V.

Comparison of Cefazolin and Ceftriaxone as Antimicrobial Prophylaxis in Pancreatoduodenectomy with Preoperative Drainage: Incidence of Surgical Site Infection and Susceptibility of Bacteria in Bile.

The optimal perioperative antimicrobial agent for preventing surgical site infection (SSI) in pancreatoduodenectomy (PD) with preoperative biliary drainage (PBD) remains unclear. We retrospectively reviewed 288 patients who underwent PD after PBD between 2010 and 2020 at our institution. Patients were classified into two groups according to the perioperative antimicrobial agent used (cefazoline [CEZ] group [n = 108] and ceftriaxone [CTRX] group [n = 180]). The incidence of SSI, type of bacteria in intraoperative bile culture (IBC), and antimicrobial susceptibility to prophylactic antimicrobial agents were analyzed. The incidence of incisional SSI was significantly lower in the CTRX group than in the CEZ group (18% vs. 31%, P = 0.021), whereas the incidence of organ/space SSI in the two groups did not differ to a statistically significant extent (35% vs. 44%, P = 0.133). Gram-negative rod (GNR) bacteria in the IBC showed better antimicrobial susceptibility in the CTRX group than in the CEZ group. In multivariate analysis, antimicrobial resistance due to GNR was a significant risk factor for incisional SSI (odds ratio, 3.50; P < 0.001). CTRX had better antimicrobial coverage than CEZ for GNR cultured from intraoperative bile samples. In addition, CTRX provides better antimicrobial prophylaxis than CEZ against superficial SSI in patients with PD after PBD. This study was not a clinical trial and had no registration numbers.

Continuous suture closure using a LapraTy® suture clips is an effective method for reconstruction of cystic duct stump after laparoscopic subtotal cholecystectomy

ObjectiveRecently, number of laparoscopic subtotal cholecystectomy (LSC) has been increasing. Summary background dataLSC is suitable as a treatment as it can avoid intraoperative bile duct injury and bleeding for difficult laparoscopic cholecystectomy. On the other hand, improper handling of remnant of GB can lead to postoperative bile leakage. MethodsHere, we report our positive experience utilizing new technique of continuous suture closure and omental covering using Lapra Ty® suture clips on the remnant of GB. ResultsFrom January 2016 to July 2021, we experienced 30 cases of LSC for LC patients who had difficulty securing critical view of safety (CVS). In six of the 30 cases, we repaired remnant of GB using continuous suture closure and omental covering with Lapra Ty® suture clips. The median operating time was 136 min (range 112–199 ml), and amount of bleeding was 1 ml (range 1–100). There were no cases of postoperative bile leakage (postope. BL), remnant cystic duct stone, and abscess formation in abdomen. Conclusionwe recommend this new suturing technique for closure of remnant of GB as it was very effective in preventing postope. BL after LSC.

Anatomical variations of cystic artery, cystic duct, and gall bladder and their associated intraoperative and postoperative complications: an observational study.

It was a prospective observational study on patients undergoing laparoscopic cholecystectomy in the department of General Surgery at the tertiary center of India. The calculated sample size was 298. Variations of the cystic artery, CD, and gall bladder along with intraoperative and postoperative complications were noted. The comparative analysis of intraoperative and postoperative complications and a subgroup analysis between anatomical variants and normal patients were performed. The most common variations were found in cystic arteries (16.8%). CD anomalies were present in 11.4% of patients, and gall bladder anomalies were the least common of all (5.4%). Intraoperative and postoperative complications were compared between patients with anatomical variations and normal anatomy. Intraoperative complications in patients with anatomical variations were significantly higher. Bile leak (15.7% vs. 6.4%) (P=0.01), haemorrhage (16.8% vs. 1.9%) (P-value <0.001), conversion to open (3 vs. 0 patients) (P-value =0.03). Subgroup analysis revealed a strong association between intraoperative haemorrhage and bile leak with cystic artery and CD anomalies, respectively. Cystic artery anomalies are the most common variations. Patients with anatomical variations had significant intraoperative and postoperative complications compared to patients with normal anatomy.

One-stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiography bile duct stone extraction is a feasible option in Indonesia within the National Health Insurance System.

Bile duct stones are a widespread condition that can pose a significant risk to life due to the occurrence of complications. In recent years, there has been a growing inclination toward the use of one-stage minimally invasive procedures for the treatment of this condition. However, it is important to note that in developing countries, such as Indonesia, where the National Healthcare Insurance System is established, the implementation of these procedures is still relatively uncommon due to limitations in healthcare facilities. This study presents a case series involving 13 patients who underwent a consecutive initial attempt of one-stage Laparoscopic Cholecystectomy with subsequent Intraoperative Endoscopic Retrograde Cholangiopancreatography (LC-ERCP) for the extraction of bile duct stones. These patients were among the 124 individuals treated for bile duct stones at our hospital for one year (June 2022 to May 2023). All the participants in this study were covered by the National Health Insurance. Among the 124 patients diagnosed with bile duct stones, thirteen (10.5%) were subjected to an initial attempt of one-stage LC-ERCP procedure, which had a success rate of 76.4%. However, three of them experienced difficulties during the cannulation of bile duct, leading to the failure of this approach. The patients included in the study had a mean age of 46.5years, with average serum levels of total bilirubin and direct bilirubin measuring 2.1 and 1.4mg/dL, respectively. The average duration of successful and unsuccessful procedures was 121.5min and 183.3min, respectively. The average length of postoperative hospital stay was 3.5days, and no instances of mortality or complications were recorded during the study. One-stage LC-ERCP procedure offered a promising treatment option for bile duct stones in Indonesia, particularly for patients registered under the National Healthcare Insurance System. This approach could serve as a viable alternative for facilities that lack proficiency in LC-CBDE skills. Furthermore, the ability to perform ERCP in a supine position is crucial in achieving a high success rate. The results of this study showed the need for advancements in Indonesian public healthcare facilities to meet the growing demand for improved treatment modalities.