Intraoperative Bile Research Articles

HPB SO02 - Cutting surgical site infection rates in perihilar cholangiocarcinoma with informed changes to perioperative antibiotic prophylaxis: A quality improvement project in a UK hepatopancreatobiliary tertiary centre

Abstract Background Perihilar cholangiocarcinoma (pCCA) is the most common cancer of biliary epithelia. While potentially curative, surgical resection is associated with high morbidity and mortality. Surgical site infections (SSIs) are common and pernicious. Preoperative biliary instrumentation is universal: to confirm histological diagnosis and deploy stents to relieve jaundice. Patients receive multiple antibiotic courses as periprocedural prophylaxis and to treat cholangitis. They are at high risk of harbouring bacteria not quelled by perioperative prophylactic antibiotics given for other general surgical procedures. Studying the biliary microbiome, this quality improvement project sought to reduce SSIs through informed changes to local guidelines on perioperative antibiotic prophylaxis. Method Health records of all patients undergoing resection for pCCA in a UK hepatopancreatobiliary centre from February 2009 to January 2024 were analysed retrospectively (n=118). For all patients, we routinely sent intraoperative bile swabs for culture and sensitivity. Informed by these microbiology results, multidisciplinary discussion led to changes to local guidelines in March 2019. Formerly, cefuroxime and metronidazole were given on anaesthetic induction, with subsequent antibiotic choice and duration according to surgeon preference. New guidance stipulated teicoplanin and piperacillin/tazobactam be given on induction and for 72 hours postoperatively. We studied the impact of these changes on SSIs within 30 days. Results 75 patients received cefuroxime and metronidazole; 43 patients were given teicoplanin and piperacillin/tazobactam after the policy change. Proportions of patients who developed any SSI substantially fell following the guideline change (55% v 28%; p=0.0049), primarily owing to reductions in intraperitoneal collections (39% v 21%; p=0.047). Rates of deep (8% v 2%; p=0.21) and superficial incisional infections (8% v 5%; p=0.49) were not significantly affected. Associated secondary outcomes were drops in post-hepatectomy liver failure (17% v 5%; p=0.047), and 90-day mortality (16% v 5%; p=0.067), albeit the latter was not statistically significant. Conclusion Invasive investigative work-up, disease complications and exposure to multiple courses of antibiotics prior to resection of pCCA subject patients’ biliary systems to colonisation with antimicrobial-resistant bacteria. We urge centres that undertake these operations to introduce intraoperative bile cultures as a part of routine practice to inform local guidance on perioperative antimicrobial prophylaxis. We demonstrated effective antibiotics in the perioperative period can have enormous benefits to patient outcomes.

BN O04 - Trends in the management of bile duct stones in the United Kingdom: Are we following the evidence?

Abstract Background Common bile duct stones (CBDS) are typically managed in two stages: Endoscopic Retrograde Cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). However, access to ERCP can be limited or require referral, has a high failure rate, often necessitates additional imaging, and may involve multiple procedures. Increasing evidence suggests that single-stage management, involving LC with intraoperative imaging and bile duct exploration when indicated, is cheaper, more effective, and reduces overall length of stay. British Society of Gastroenterology guidance states that it is a valid alternative to ERCP. This study aimed to determine whether clinical practice aligns with this evidence. Method National Health Service (NHS) Admitted Patient Care publications summarise Hospital Episode Statistics by financial year and are openly accessible. OPCS4 Procedure Codes were screened by two authors and categorised as “operative” or “endoscopic.” Codes detailing the management of CBDS or bile duct exploration were included, while ambiguous codes or those for non-stone indications were excluded. Data pertaining to these codes were extracted from the Admitted Patient Care publications for 2012 to 2022 and summarised in a Microsoft Excel spreadsheet. Trends were analysed using a Non-Seasonal Mann-Kendall Trend Test Results A total of 249,475 procedures for CBDS were performed over the ten-year period, with a mean patient age of 67. Annually, the total number of procedures increased from 21,365 to 27,668 (p=0.002). Endoscopic procedures increased from 19,716 to 25,976 (p=0.002), while operative procedures remained stable (1,649 to 1,692, p=0.431). Consequently, the proportion of endoscopic management rose from 92.3% to 93.9% (p<0.001). The mean age of patients undergoing operative procedures was ten years younger than those undergoing endoscopic procedures (57 vs. 67 years) Conclusion Despite evidence and guidance supporting single-stage procedures, there is a trend towards endoscopic management of CBDS in the UK. This may be due to operational pressures on the NHS, including the sequelae of the COVID-19 pandemic, or reflect challenges within hospital culture, skill mix, or equipment availability.

VS 09 - HPB Laparoscopic Trans-Cystic Bile Duct Exploration is Safe and Feasible even after previous Cholecystectomy

Abstract Background Laparoscopic trans-cystic bile duct exploration is well know to have less comorbidity that conventional trans-ductal approach. A 56-year-old female underwent emergency laparoscopic cholecystectomy in 2019 for cholecystitis. Subsequently treated conservatively for ascending cholangitis due to large stone in the bile duct on MRCP. She underwent two unsuccessful ERCPs due to anatomical challenges; large hiatus hernia and duodenal diverticulum. The MDT determined bile duct exploration was necessary as no endoscopic options remained. After assessing previous imaging, laparoscopic trans-cystic exploration was chosen to minimise complications. This video highlights the feasibility of laparoscopic trans-cystic CBD post-cholecystectomy. Method Standard four-port technique with 10mm, 30-degree laparoscope. Blunt, sharp, energised and hydro-dissection were employed. Indocyanaine green(ICG) helped identify the bile duct(CBD) and the cystic duct(CD) stump. CD was dissected from the gallbladder bed and opened for a cholangiogram; confirming a large stone in the distal bile duct. A 3.5 mm choledochoscope with electrohydraulic lithotripsy(EHL) was used to explore the bile duct and fragment the stone for extraction. Remaining small fragments were flushed into the duodenum after 20mg buscopan intravenously. Final cholangioscopy and cholangiogram through the choledochoscope showed clear ducts with good flow into the duodenum. Results The patient was started on IV antibiotics due to pyrexia on the first night of admission. The abdominal drain was removed after 48 hours, and the patient was discharged on day three to complete a five-day course of antibiotics. Nine months post-operatively, she presented with a 3x5x7.5 cm sub-hepatic abscess, requiring interventional radiology (IR) drainage and a six-week course of antibiotics. The drain was removed after a follow-up CT scan three weeks post-drainage showed resolution. There have been no further episodes of cholangitis, and she has returned to her baseline quality of life. Conclusion This case shows laparoscopic trans-cystic approach remains viable post-cholecystectomy. Advanced imaging and tools including 3.5mm choledochoscope and EHL aid safer surgery with reduced morbidity, shorter stays and faster recovery. Antibiotics may be necessary for cases with longstanding bile duct stones. Furthermore, this case highlights the importance of intraoperative cholangiography and bile duct exploration. The patient had an MRCP in 2019 that showed no bile duct stones but a dilated CBD associated with deranged LFTs. This suggests that her journey might have been less complicated if a cholangiogram had been performed during the initial laparoscopic cholecystectomy.

A04 - EGS Evidenced competency in benign biliary surgery amongst UK general surgeons at certification: A JCST/ISCP study

Abstract Background Symptomatic gallstones are the most common reason for evaluation by an Emergency General Surgery (EGS) service, with laparoscopic cholecystectomy (LC) being performed by most general surgeons. Previous studies show that most LCs in the United Kingdom (UK) are performed by colorectal surgeons (CR). Emergency cholecystectomy requires advanced skills including intra-operative assessment of the bile ducts, and the ability to perform intra-operative cholangiogram (IOC) is part of the procedure-based assessment (PBA) that evidences competency for certificate of completion of training (CCT). This study aims to assess documented evidence of competency in benign biliary surgery amongst general surgeons in the UK. Method PBAs relating to LC and CBD exploration (CBDE) were retrieved for all UK general surgeons who received CCT between 2016 and 2021 from ISCP (702; 285 (41%) colorectal; 212 (30%) Upper GI (UGI)). All eLogbook entries relating to LC +/- IOC +/- CBDE were also retrieved. Subspecialty interest was determined from Part 2 of the FRCS examination. Competence (Level 4) as well as a granular assessment of IOC and CBDE was compared amongst trainees, taking into account their subspecialty interest. Results 11,733 LC and 553 CBDE assessments from 160,570 LC +/- IOC +/- CBDE procedures recorded on eLogbook were retrieved. Knowledge of IOC indication was assessed in 467 (94%) surgeons, but performance was only assessed in 380 (75%) surgeons. Median satisfactory IOC performance assessments was 3 (2-5). UGI were more likely to do this than colorectal (4 (2-7) vs 2 (1-4) P < 0.001). Satisfactory CBDE was achieved by 86 surgeons (12 CR and 74 UGI). 486 surgeons (97% CR; 94% UGI) received Level 4 (independence) despite never achieving satisfactory ability to perform IOC. Conclusion Competency in acute biliary surgery for general surgeons at certification is extensively assessed using PBAs. Cholecystectomy training and assessment in the UK does not seem to include intraoperative bile duct anatomy assessment or treatment of CBD stones. Assumed competency in cholecystectomy by trainers in the UK does not seem to include the need to do this, as 97% of CR and 94% of UGI trainees achieve documented competence without the ability to perform IOC. This may have an impact on EGS service delivery of acute and emergency gallbladder surgery including the ability to deal with difficult cases.

HPB O01 - Colonization of bile with gammaproteobacteria reduces survival after surgery for pancreatic cancer in patients receiving gemcitabine-based adjuvant chemotherapy

Abstract Background Evidence suggests that the biliary microbiome influences the progression of pancreatic ductal adenocarcinoma (PDAC) in patients undergoing adjuvant chemotherapy. Specifically, Gammaproteobacteria (GPB) has been shown to have the potential to develop mutations which can metabolise gemcitabine into an inactive form. This study hypothesised that GPB influences survival in patients with PDAC undergoing adjuvant gemcitabine-based chemotherapy following surgery. Method This was a retrospective study of patients undergoing pancreatoduodenectomy from 2010 to 2020. Associations between patient and tumour characteristics, survival data, and results of intraoperative bile cultures (GPB+ or GPB-) were investigated. Analysis of patients matched by chemotherapy regimen and numbers of cycles of adjuvant therapy was also performed. Survival was analysed using Kaplan–Meier curves and Cox regression analysis. Results Analysis of 359 patients revealed that adjuvant gemcitabine-based therapy improved overall survival (OS). Patients who receive gemcitabine-based chemotherapy with a GPB+ biliary culture had a shorter OS compared to those who were GPB-, and a median survival of 17.9 vs 26.1 months, P=0.006. After matching for key chemotherapy variables, survival was greater in the GPB- group 26.8 vs 19.8, P=0.016. This association was not seen among patients who received no adjuvant therapy or non-gemcitabine based therapy. Conclusion Patients receiving gemcitabine-based chemotherapy after surgery are likely to have reduction in OS if they have a biliary culture positive for GPB.

BN SO17 - When cholecystectomies go wrong: A single-centre review of post-operative complications over a two year period

Abstract Background Laparoscopic cholecystectomy (LC) is the main treatment for symptomatic gallstone disease with around 70,000 performed in the UK each year. The majority of these are day case procedures and patients recover well, however, there will always be a risk of more serious complication which can have serious negative effects on patients. The Clavien-Dindo classification of surgical complications is the most recognised method of grading post-operative complications by severity. The aim of our study was to identify our rates and severity of post-operative complication and their management. Method All patients who had LC between 1st July 2020 and 30th June 2022 were identified. Patient and operative details were retrieved from their electronic record. A complication was defined as any deviation from the standard post-operative course and was graded according to the Clavien-Dindo classification. 30-day readmission data was collected via hospital episode statistics and outcomes were reviewed on the patient record. Results 974 patients underwent LC. 30-day morbidity = 8.9%, 30-day readmission = 4.8% and 30-day mortality = 0.31%. Clavien-Dindo grade of complication: Grade 1= 44.7%, Grade 2 = 22.4%, Grade 3A = 12.9%, Grade 3B = 11.8%, Grade 4A = 1.2%, Grade 4B = 1.2%; and Grade 5 = 3.5%. 11 patients (1.1%) returned to theatre; bile leak was the most common indication (73%). Two intra-operative bile duct injuries were observed (0.21%) with one managed locally and the other transferred to the regional HPB centre. 7 patients required post-operative ERCP (0.72%), 57% for CBD stones and 43% for persistent bile leak. Conclusion Our study showed that the majority of post-operative morbidity following LC is related to post-operative pain (2.9%) or simple wound infection (1.8%). 2.6% of patients who underwent LC during had a significant complication requiring surgical, endoscopic or radiological intervention or admission to intensive care (Clavien-Dindo > 2). We report a 0.21% risk of bile duct injury and a 0.92% risk of post-operative bile leak. Overall our findings are in keeping with other studies but provide an insight into our local practice and that an area of potential improvement would be better management of post-operative pain.

HPB SO62 - Association of positive bile cultures and the incidence of pancreatic fistulas post pancreaticoduodenectomy[PD

Abstract Background Postoperative pancreatic fistula (POPF) remains a significant complication post pancreaticoduodenectomy (PD). Recent publications show no increased incidence of POPF due to positive bile cultures. A literature search on PubMed did not show any review on the relevance of specific cultures and their exact incidence of POPF. POPF is defined as Drain Amylase greater than three times its serum level on or after postoperative day 3. A relatively benign clinical course is grade A, moderately unwell patients requiring medical/minimal intervention (grade B), and critically ill patients with sepsis, requiring invasive intervention (grade C). Grade B + C is defined as CR-POPF. Method A retrospective single-centre analysis of all patients with pancreaticoduodenectomy between 2017 and 2021 was reviewed. The clinical data that were reviewed were age, gender, length of stay[LOS], tumour staging, mortality rates, Pancreatic duct[PD], Pre-op stenting, the documented incidence of POPF/CR-POPF, Intra-Operative Bile Cultures[IOBC] and antibiotic sensitivity. The primary outcome was POPF. Secondary outcomes were 90-day mortality, LOS, return to theatre, Postoperative haemorrhage (POPH), and organ-specific relevance of POPF. All data was analysed using SPSS IBM version 29. P< 0.05 was taken as clinically significant. Results 100 patients were included in the study. The mean age was 68.8 (SD-9.5). The M: F ratio was 54:46. The mean postoperative length of hospital stay was 19.38 days. 48 patients (48%) were diagnosed with a POPF, among which, 22 patients (47.8%) developed a CR-POPF. 57 patients had a positive IOBC. The incidence of POPF in patients with Positive IOBC was 43/57(75.43%) and that was 5/43(11.62%) of the patients with Negative IOBC (P < .0001).10% of patients had postoperative haemorrhage (POPH). 9% had 90-day mortality. All 9% of patients who had a return to theatre had POPF. Conclusion Univariate analysis and logistic regression demonstrated that a positive IOBC had a higher associated incidence of POPF who underwent PD, with Klebsiella being the most common and statistically significant[P<.005]. The most common antibiotic found to be sensitive was Gentamicin, which is 25 per cent and, in combination with Co-amoxiclav, was found to be sensitive in 21.8% of cases. However, this is a single-centre retrospective study with variable operative techniques for different patient groups. Further studies would be warranted before correlating any results to all populations of patients developing POPF post pancreaticoduodenectomy.

Comparison of low-pressure and standard-pressure pneumoperitoneum laparoscopic cholecystectomy in patients with cardiopulmonary comorbidities: a double blinded randomized clinical trial

BackgroundThe benefits of low-pressure laparoscopic cholecystectomy (LPLC) in patients with cardiopulmonary comorbidities remain unclear. This study aimed to explore the feasibility and pulmonary effects of LPLC in patients with cardiopulmonary comorbidities.MethodsThis was a multicenter, parallel, double-blind, randomized controlled trial. Eligible patients included patients with cardiac or pulmonary comorbidities, who were randomly assigned (1:1) to undergo LPLC (10 mmHg) or standard-pressure laparoscopic cholecystectomy (SPLC) (14 mmHg). The primary outcome was postoperative partial pressure of carbon dioxide (CO2). Surgical safety variables, patient recovery, pulmonary function parameters, and surgeon comfort were also compared between groups.ResultsThis study enrolled 144 participants, with 124 participants extracted for the final analysis (62 in LPLC and 62 in SPLC group, respectively). The median postoperative PaCO2 was similar in the LPLC (43.3 mmHg) and SPLC (43.0 mmHg) groups (p = 0.988). Pulmonary parameters including postoperative pH, PaCO2, HCO3, and lactate levels were similar between the two groups. Postoperative base excess was significantly higher in the LPLC group (− 0.6 mmol/L [− 6.9 ~ 7.5] vs. −1.9 mmol/L [− 6.6 ~ 5.4]; p = 0.031). There was no between-group difference regarding intraabdominal operative time, rate of intraoperative bile spillage, blood loss, surgeon comfort during surgery, and conversion rate. Moreover, postoperative major complication rates, the median time to the first flatus, postoperative hospital stay, or mean postoperative visual analog scale score for pain were similar in both groups.ConclusionsThis study found no reduction of partial pressure of CO2 with LPLC compared with SPLC for patients with cardiopulmonary comorbidities. LPLC with a pneumoperitoneum pressure of 10 mmHg may be safe and feasible for these patients when performed by experienced surgeons, although it does not improve pulmonary parameters.RegistrationThe trial is retrospectively registered at ClinicalTrials.gov (NCT04670952) on December 17, 2020.

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.