Intraoperative Cholangiogram Research Articles

Multicentric validation of EndoDigest: a computer vision platform for video documentation of the critical view of safety in laparoscopic cholecystectomy.

A computer vision (CV) platform named EndoDigest was recently developed to facilitate the use of surgical videos. Specifically, EndoDigest automaticallyprovides short video clipsto effectively document the critical view of safety (CVS) in laparoscopic cholecystectomy (LC). The aim of the present study is to validate EndoDigest on a multicentric dataset of LC videos. LC videos from 4 centers were manually annotated with the time of the cystic duct division and an assessment of CVS criteria. Incomplete recordings, bailout procedures and procedures with an intraoperative cholangiogram were excluded. EndoDigest leveraged predictions of deep learning models for workflow analysis in a rule-based inference system designed to estimate the time of the cystic duct division. Performance was assessed by computing the error in estimating the manually annotated time of the cystic duct division. To provide concise video documentation of CVS, EndoDigest extracted video clips showing the 2min preceding and the 30s following the predicted cystic duct division. The relevance of the documentation was evaluated by assessing CVS in automatically extracted 2.5-min-long video clips. 144 of the 174 LC videos from 4 centers were analyzed. EndoDigest located the time of the cystic duct division with a mean error of 124.0 ± 270.6s despite the use of fluorescent cholangiography in 27 procedures and great variations in surgical workflows across centers. The surgical evaluation found that 108 (75.0%) of the automatically extracted short video clips documented CVS effectively. EndoDigest was robust enough to reliably locate the time of the cystic duct division and efficiently video document CVS despite the highly variable workflows. Training specifically on data from each center could improve results; however, this multicentric validation shows the potential for clinical translation of this surgical data science tool to efficiently document surgical safety.

Repeat Laparoscopic Cholecystectomy for Duplicated Gallbladder After 16-Year Interval.

Gallbladder duplication can present a diagnostic challenge, particularly in patients who have had prior cholecystectomy with a missed duplicated gallbladder. Presented is the case of a man with 16 years of recurrent, persistent right upper quadrant pain after cholecystectomy who was found to have a duplicated gallbladder. Gallbladder duplication can be difficult to diagnose and frequently evades preoperative visualization. In particular, patients who have had prior operations or infections that may lead to epigastric adhesions are at higher risk for a missed gallbladder duplication at time of operation. An intraoperative cholangiogram should be routinely performed when the inferior liver margin is poorly visualized due to scarring or patient habitus. Gallbladder anomalies should be considered in the differential preoperatively for all patients undergoing hepatobiliary procedures and for postoperative patients with persistent biliary symptoms.

A UK survey on variation in the practice of management of choledocholithiasis and laparoscopic common bile duct exploration (ALiCE Survey).

The practice of managing suspected/confirmed common bile duct stones (CBDS) can vary significantly in the UK. We aimed to assess this variability in practice and challenges to form a basis for future consensus. An electronic survey containing 40 questions on various aspects of management of CBDS was sent to surgeons who perform cholecystectomies via five surgical associations. A total of 132 surgeons responded to the survey. The speciality of surgeons includes upper gastro-intestinal (68%), general (18%), colorectal (12%), and others (2%). For patients with suspected CBD stones, 80% would choose magnetic resonance cholangio-pancreatography, and 14.4% would proceed to intra-operative imaging. Most surgeons preferred intra-operative cholangiogram over intra-operative ultrasound (83%vs 17%). For the treatment, 62.1% preferred a two-stage approach [endoscopic retrograde cholangio-pancreatography (ERCP) followed by laparoscopic cholecystectomy (LC)] and 33.4% chose a single-stage approach [LC + laparoscopic common bile duct exploration (LCBDE)]. Eighty (60.6%) responders performed LCBDE, and 19 (23.8%) of them performed > 10 LCBDEs in a year. Two third of surgeons (62.5%) preferred a trans-choledochal approach to CBDS.Half of the surgeons that perform LCBDE use a T-tube selectively and 1.6% routinely. The"availability of very good ERCP service" and "lack of formal training" were the two main reasons for surgeons not performing LCBDE. Both surgeons' speciality and whether they perform other complex laparoscopic surgery were significantly associated with choosing a two-stage approach over a one-stage approach (χ2 test, speciality p = 0.033, complex surgery p = 0.011). Our survey confirms the significant variability in the diagnosis and management of CBDS. The two-stage approach is still the most common way of managing CBDS in the UK. The main reasons for the low uptake of the single-stage approach are the availability of good ERCP service, lack of equipment and lack of formal training in the technique of LCBDE.

The Liver Biopsy in Neonatal Cholestasis: Just a Cherry on Top?

Content available: Author Audio Recording.

The second 'gallbladder operation'.

Subtotal cholecystectomy has been reported in 8% and 3.3% of patients undergoing open and laparoscopic cholecystectomy, respectively. According to a recent nationwide survey, the utilisation of subtotal cholecystectomy in the treatment of acute cholecystitis is on the rise. In 1.8% of subtotal cholecystectomies, a reoperation is required. Reoperations for residual gallbladder (GB), gallstones, and related complications accounted for half of the reoperations described in the literature after subtotal cholecystectomy. The purpose of this study was to evaluate the clinical profile, risk of complications, and feasibility of laparoscopic approaches and surgical procedures in patients with recurrent symptoms from a residual GB that necessitated a completion cholecystectomy. Patients who underwent surgery for residual GB with stones and/or complications between January 2007 and January 2020 were included in the study group. A prospectively maintained database was used to review patient information retrospectively. The demographic profile, operation details of the index surgery, current presentation, investigations performed, surgery details, morbidity and mortality were all included in the clinical information. There were 13 patients who underwent completion cholecystectomy. The median age was 55 years (22-63 years). Prior operative notes mentioned subtotal cholecystectomy in only seven patients. The average time between the index surgery and the onset of symptoms was 30 months (2-175 months). A final diagnosis of residual GB with or without calculi was made by ultrasound (USG) in 11 patients and by magnetic resonance cholangiopancreatography (MRCP) in two others. Choledocholithiasis (n = 4, 30.7%), acute cholecystitis (n = 2, one with empyema and GB perforation) and Mirizzi syndrome (n = 1) were seen as complications of residual gallstones in seven patients. All 13 patients underwent successful laparoscopic procedures. A fifth port was used in all. A critical view of safety was achieved in 12 patients. Two patients required laparoscopic common bile duct (CBD) exploration for CBD stones. Intraoperative cholangiograms were done in eight patients (61.5%). There were no conversions, injuries to the bile duct or deaths. Morbidity was seen in one. The patient required therapeutic endoscopic retrograde cholangiography for cholangitis and CBD clearance on the fifth post-operative day. The median hospital stay was 4 days (3-7 days). At a median follow-up of 99 months, symptom resolution was seen in all 13 patients. Gallstones in the residual GB are associated with more complications than conventional gallstones. The diagnosis requires a high level of suspicion. MRCP is more accurate in establishing the diagnosis and identifying the associated complications, even if the diagnosis is made on USG in most patients. A pre-operative roadmap is provided by the MRCP. For patients with residual GB, laparoscopic completion cholecystectomy is a feasible and safe option.

Is It a Bird? Is It a Plane? It's a Tumour – Operative Transcystic Choledochoscopy for Differentiation of Biliary Duct Filling Defect and New Early Diagnosis of Insidious Pancreatic Adenocarcinoma

Background: Operative Transcystic Choledochoscopy (OTC) during Laparoscopic Cholecystectomy (LC) is a one-procedure solution for clearance of Common Bile Duct (CBD) calculi under vision and allows identification and biopsy of biliary neoplasms. Success and complication rates in high-volume centres are similar or superior to Endoscopic Retrograde Cholangiopancreatography (ERCP). Preference for ‘minimally-invasive’ techniques like ERCP has led to infrequent use and resultant deskilling. Its ongoing role is therefore currently unclear. Case: A well 65-year-old male with epigastric pain and raised lipase, and Computed Tomography (CT) showing cholelithiasis and ‘focal pancreatitis involving the uncinate process’, underwent LC for gallstone-induced pancreatitis 6 days after presentation. Pre-operative bilirubin was normal and ALKP (133 U/L) and GGT (270 U/L) newly raised. An oedematous stone-containing gallbladder and a distal CBD filling defect on Intraoperative Cholangiogram were found. OTC demonstrated a CBD wall growth but biopsy equipment was unavailable. No peritoneal or liver metastases were seen. Ca19.9 (588 kU/L) was elevated. Pancreas-protocol CT/MRI showed a 14x14mm ‘indeterminate abnormality’ in the head/uncinate process without vascular involvement, and staging CT was negative for metastases. Endoscopic Ultrasound-guided biopsy diagnosed pancreatic adenocarcinoma following non-diagnostic ERCP. A Whipple’s procedure was planned but later abandoned as liver metastases were confirmed on frozen section at staging laparoscopy. Discussion: Despite recent movement away from OT during LC, this study highlights its utility in early identification of insidious biliary neoplasmswith the first case of preliminary pancreatic adenocarcinoma diagnosed with OTC during LC in a non-obstructed patient.

Indocyanine Green Near-Infrared Fluorescence Cholangiogram During Pure Laparoscopic Living Donor hepatectomy For Optimal Bile Duct Division

Introduction: Biliary complications in living donor liver transplantation are most common and troubled problem to liver transplant surgeons, various method to decease biliary complications has been studied and determining the optimal bile duct division point is important to decrease complication rate. Intraoperative cholangiogram has been standard method to determine the optimal bile duct division point for conventional donor hepatectomy, but in laparoscopic donor hepatectomy, indocyanine green(ICG) near-infrared fluorescence cholangiogram is alternative option of intraoperative cholangiogram. We compared conventional cholangiogram and ICG near-infrared fluorescence cholangiogram to determine optimal bile duct division point in pure laparoscopic living donor hepatectomy. Method: From May 2016 to October 2019, 80 cases of pure laparoscopic donor hepatectomy has been performed in Kyungpook national university hospital. Conventional cholangiogram was used in 45 cases, ICG near-infrared fluorescence cholangiogram was used in 35 cases. We compared two groups in preoperative bile duct anomaly of donor, operative time and postoperative complications. Result: In bile duct anomaly of donors, there were no differences between two groups. Operative time was much longer in conventional cholangiogram group because conventional cholangiogram procedure itself was time consuming. In one donor of conventional group, biliary complication occurred. Bile leakage from the cutting edge of the remnant right hepatic duct was identified, resolved by ERBD insertion. Conclusion: ICG near-infrared fluorescence cholangiogram is more easier and convenient method to determine proper bile duct division point and is helpful to decrease biliary complications by confirming the real time fluorescence image of bile duct.

Predictive Values of Intraoperative Cholangiogram for Choledocholithiasis in Patients with Normal Liver Function Test – A Prospective Study

Introduction: Cholecystectomy is an accepted treatment for cholelithiasis. IOC is not regularly done in patients with normal liver function test (LFT). However, up to 11.6% of cholecystectomies have incidental choledocholithiasis on IOC. In this study, we examine the predictive values of routine IOC in detecting choledocholithiasis with normal LFT. Methodology: This is a prospective study which includes patients with normal LFT who underwent cholecystectomies and IOC between October 2019 to December 2020. Patients with choledocholithiasis had ERCP and stone clearance. Patients with stones on ERCP are true positive whilst patients with normal ERCP are false positive. Patients with normal IOC and LFT at 2 weeks follow-up are true negative whilst patients with normal IOC and abnormal LFT were subjected to ERCP (false negative). Sensitivity, specificity and predictive values were calculated. Results: One hundred and eighty patients were analysed. 25.6 % (n = 46) were found to have filling defect on IOC and were confirmed after ERCP. 74.4% (n = 134) did not have choledocholithiasis. 65.6% (n = 118) had normal IOC and LFT on follow up whilst 8.9% (n=16) of patients had abnormal LFT on follow up and ERCP was done. IOC showed a specificity of 85.5%, NPV of 88.1% and AUC of 73.7%. The PPV and sensitivity was 56.5% and 61.9% respectively. Conclusion: Routine IOC is a specific diagnostic tool with good negative predictive value. Routine IOC is useful to exclude incidental choledocholithiasis when LFT is normal. This will reduce the incidence of undetected retained stones and its complications.

P-BN27 Novel technique for safe and efficient cannulation of the cystic and common bile duct

Abstract Background Concomitant stones in the common bile duct (CBD) at the time of laparoscopic cholecystectomy (LC) are present in up to 15% of patients. In conjunction with intra-operative cholangiogram (IOC), transcystic common bile duct exploration (TCBDE) enables diagnosis and management of ductal stones in a single stage procedure. However, cannulation of the cystic duct (CD) and CBD can be challenging. With repeated attempts at cannulation, there is increased risk of iatrogenic injury by creating a false passage or perforating the duct. We propose a novel technique for the safe cannulation of the CD and CBD. Methods Once critical view of safety is achieved, a clip is placed distally in the CD and opened with scissors. A flexible tip 80cm guidewire is then preloaded into 5-French ureteric catheter. The complex is then passed into the introducer through the lateral port. A grasper placed at Hartmann’s pouch is used to retract the gallbladder and straighting the CD. Only the guidewire is advanced out of the catheter, traversing the CD and CBD. Once safely advanced, the catheter can then be slid over the guidewire and the guidewire can be removed. IOC and TCBDE can then be performed if indicated. Results This technique was performed on 18 patients who failed CD cannulation during elective and emergency LC for symptomatic gallstone disease in a single center performed by the same surgical team. Median age was 46 years and there was 15 females. A total of 34 cannulations were attempted (in 18 patients) which 100% success rate. There was no added time required for the technique. In majority of cases it decreased the operative time due to quick intubation of CBD. None of the cases required conversion to open surgery. Conclusions The novel technique described for cannulation of the cystic duct uses a Seldinger ‘like’ approach. This is a safe an effective strategy for cannulation of the CD, making the skills more accessible and more time efficient. This should encourage more surgeons to perform IOC and TCBDE where indicated.

P-BN50 Transcystic CBD Exploration: The First-Line Treatment of CBD Stone - A Single Centre 12-month Review of Practice

Abstract Background In the UK around 15% of the population will have gallstones and as such biliary pathology makes up a significant proportion of emergency and elective general surgical practice. Within this 10% will have choledocholithiasis; the management of which remains widely varied. A single-stage laparoscopic cholecystectomy with transcystic common bile duct exploration has been shown to be a safe and efficient option avoiding a choledochotomy and risks associated with ERCP. The aim of this study was a 12-month review of data following the adoption of this approach; assuming that laparoscopic transcystic CBD exploration was the ideal treatment for CBD stones. Methods This was a retrospective, single-centre, observational study. All patients who underwent a laparoscopic transcystic CBD exploration from June 2020 to June 2021 were included both in the elective and emergency setting. Patient demographics were varied with ages ranging from 15 to 76 and ASA classification of 1 -3, showing a significant proportion with comorbidities. Data collection was done through a review of a contemporaneous operative database and a follow-up morbidity period of 30 days was cross-referenced with electronic healthcare records. The primary outcome studied was CBD stone clearance. With secondary outcomes measures including complications, length of stay and the role of preoperative imaging versus intraoperative cholangiogram. Results A total of 49 patients were included within the study, of which 61% were emergency. The primary outcome of CBD stone clearance was achieved in all elective patients with one emergency patient requiring ERCP for a retained fragment at day 8. There were no other complications in the remaining 48 patients, making the 30-day morbidity 2% upon review of electronic care records. One patient was converted to open due to concern with regards to potential CBD injury but this was demonstrated not to be the case. The median duration of hospital admission was 3 days with a range from 0- 15, with the median stay for elective cases being 1 day. Finally, 39 patients underwent intraoperative cholangiograms prior to duct exploration as a means of identifying CBD calculi and delineating anatomy. Those 10 that did not; all had an MRCP within 30 days of surgery demonstrating CBD calculi and as such proceeded straight to CBD exploration. Conclusions Laparoscopic cholecystectomy and transcystic CBD exploration, with adequate training and exposure, is a viable and safe first-line approach for all cases of choledocholithiasis both in the elective and emergency setting; demonstrating advantages by avoiding additional procedures thereby reducing costs, inpatient bed days and a risk of further complications and being truly minimally invasive. The principal findings of this study were that the transcystic CBD exploration route can achieve successful CBD stone clearance rates in close to 98 per cent of patients with a low morbidity rate, and a short median length of hospital stay. This study of course has several potential limitations; given it was a retrospective single-centre observational study there is likely a degree of selection bias and although follow up was complete in all patients to 30 days via electronic care record it was not routine practice to offer face to face follow up given the low incidence of delayed complications. On the basis of this review, the transcystic approach has become the primary strategy for patients with common bile duct stones within this unit.

TP9.2.3Laparoscopic Cholecystectomy with Intraoperative Cholangiogram and Antegrade Biliary Stenting in Acute Gall Stone Pancreatitis: A Cohort Study

Abstract Aims To demonstrate feasibility and efficacy of laparoscopic cholecystectomy (LC), intraoperative (IOC) and antegrade biliary stenting (ABS) as compared to selective pre-operative biliary investigation and intervention in acute gallstone pancreatitis (AGP). Methods A cohort study was performed comparing patients who had IOC+/-ABS during LC versus those who had only LC in the treatment of AGP. 74 consecutive AGP patients were included in this study from January 2016 to October 2018. All patients were included in a prospective database with follow-up for one year. Results 47 (64.5%) patients underwent IOC during LC (7 required ABS insertion), with a mean age 51 years (SEM: 2.7), 72.3% were female. The median admission bilirubin was 24 (IQR:14-54). The average number of ERCP and MRCP per patient was 0.30 and 0.15 respectively. 27 (36.5%) patients underwent LC with selective pre-operative biliary investigation with a mean age 48 years (SEM: 2.9), 66.7% were female. The median admission bilirubin was 27 (IQR:14-48). The average number of ERCP and MRCP per patient was 0.41 and 0.52 respectively. Discussion In our pilot study comparing LC with IOC versus LC with selective pre-operative biliary investigation we demonstrate that, there is marked reduction in biliary investigations required in IOC group. Length of hospital admissions and rate of post-operative complications were comparable. An analytic study with a larger cohort may demonstrate further seniority of IOC.

SP6.1.6 Rule of systematic intraoperative cholangiogram in patients undergoing emergency cholecystectomy

Abstract Aims Incidence of gall stone disease is estimated at 10-15%of population. Intraoperative cholangiography (IOC) diagnose choledocholithiasis, delineates the anatomy of the biliary ducts, facilitate the dissection and reduces injuries. Our aim is to assess the feasibility and role of IOC and the incidence of choledocholithiasis in acute cholecystitis (ACC). Methods Retrospective analysis of prospectively collected data for patients admitted with ACC and undergoing same-hospital-stay laparoscopic cholecystectomy (LC). IOC was systematically attempted in all cases. Results 475cases included. Female to male ratio1.9:1. Conversion to open was done in 3 cases. Preoperative cholelithiasis was confirmed in 439cases versus 34cases with no stones. USS CBD abnormality (dilated or contain stone) found in 53 cases, out of which 8(15%) cases had CBD stones. Jaundice was found in 69cases, where 25(39%) cases had confirmed choledocholithiasis. IOC was successful in all cases except one. Abnormal IOC was found in 99(21%) cases. Of those; CBD stones were confirmed in 76 (77%) cases regardless the presence of cholelithisasis on USS. Empyema was found in 237 cases and it was associated with higher risk of abnormal IOC in 59(25%) cases where CBD stones were confirmed in 45(76%) cases. Cystic duct (CD) stones found in 80cases, of those 27(34%)cases had choledocholithiasis. Conclusions Females have double the risk of ACC. Preoperative jaundice and CD stones are stronger indicators than CBD diameter for presence of choledocholithiasis. The incidence of choledocholithiasis in ACC is (20-25%) regardless the presence of gall stones on USS. IOC is feasible and highly recommended in emergency LC.

Validation of choledocholithiasis predictors from the "2019 ASGE Guideline for the role of endoscopy in the evaluation and management of choledocholithiasis."

Identifying patients likely to have CDL is an important clinical dilemma because endoscopic retrograde cholangiopancreatography (ERCP), carries a 5-7% risk of adverse events. The purpose of this study was to compare the diagnostic test performance of the 2010 and 2019 ASGE criteria used to help risk stratify patients with suspected CDL. Consecutive patients evaluated for possible CDL from 2013 to 2019 were identified from surgical, endoscopic, and radiologic databases at a single academic center. Inclusion criteria included all patients who underwent ERCP and/or cholecystectomy with intraoperative cholangiogram (IOC) for suspected CDL. We calculated the diagnostic test performance of criteria from both guidelines and compared their discrimination using the receiver operator curve. Univariate and multivariate analysis was used to identify the strongest component predictors. 1098 patients [age 57.9 ± 19.0 years, 62.8% (690) F] were included. 66.3% (728) were found to have CDL on ERCP and/or IOC. When using the 2019 guidelines, the sensitivity, specificity, PPV, NPV, and accuracy are 65.8, 78.9, 86.3, 54.1, and 70.4%, respectively. Using the 2010 guidelines, the sensitivity, specificity, PPV, NPV, and accuracy are 50.5, 78.9, 82.5, 44.8, and 60.1%, respectively. The AUC for high-risk criteria using the 2019 guidelines [0.726 (0.695, 0.758)] was greater than for the 2010 guidelines [0.647 (0.614, 0.681)]. The key difference providing the increased discrimination was the inclusion of stones on any imaging modality, which increased the sensitivity to 55.0% from 29.1%. Not including CDL on imaging or cholangitis, a dilated CBD was the strongest individual predictor of CDL on multivariate analysis (OR 3.70, CI 2.80, 4.89). Compared to 2010, the 2019 high-risk criterion improves diagnostic test performance, but still performs suboptimally. Less invasive tests, such as EUS or MRCP, should be considered in patients with suspected CDL prior to ERCP.

Cost-effectiveness analysis of optimal diagnostic strategy for patients with symptomatic cholelithiasis with intermediate probability for choledocholithiasis

EUS, MRCP, and intraoperative cholangiogram (IOC) are the recommended diagnostic modalities for patients with intermediate probability for choledocholithiasis (IPC). The relative cost-effectiveness of these modalities in patients with cholelithiasis and IPC is understudied. We developed a decision tree for diagnosing IPC (base-case probability, 50%; range, 10%-70%); patients with a positive test were modeled to undergo therapeutic ERCP. The strategies tested were laparoscopic cholecystectomy with IOC (LC-IOC), MRCP, single-session EUS+ ERCP, and separate-session EUS+ ERCP. Costs and probabilities were extracted from the published literature. Effectiveness was assessed by assigning utility scores to health states, average proportion of true-positive diagnosis of IPC, and the mean length of stay (LOS) per strategy. Cost-effectiveness was assessed by extrapolating a net-monetary benefit (NMB) and average cost per true-positive diagnosis. LC-IOC was the most cost-effective strategy to diagnose IPC (base-case probability of 50%) among patients with cholelithiasis in health state-based effectiveness analysis (NMB of $34,612), diagnostic test accuracy-based effectiveness analysis (average cost of $13,260 per true-positive diagnosis), and LOS-based effectiveness analysis (mean LOS of 4.13) compared with strategies 2 (MRCP), 3 (single-session EUS+ ERCP), and 4 (separate-session EUS+ ERCP). These findings were robust on deterministic and probabilistic sensitivity analyses. For patients with cholelithiasis with IPC, LC-IOC is a cost-effective approach that should limit preoperative testing and may shorten hospital LOS. Our findings may be used to design institutional and organizational management protocols.

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.

Comparison between Laparoscopic Ultrasound and Intraoperative Cholangiogram in Detection of Common Bile Duct Stones during Laparoscopic Cholecystectomy for Cholelithiasis: A Prospective Study

Comparison between Laparoscopic Ultrasound and Intraoperative Cholangiogram in Detection of Common Bile Duct Stones during Laparoscopic Cholecystectomy for Cholelithiasis: A Prospective Study

Avoiding the Falciform Ligament Sign during the Intraoperative Cholangiogram

Avoiding the Falciform Ligament Sign during the Intraoperative Cholangiogram

Gallbladder clear cell carcinoma: A case report

Worldwide, the highest incidence rates (up to 7.5 per 100,000 in male and 23 per 100,000 in female) occur among populations in the Western part of South America (Chile and Peru), in North American Indians, in Mexican Americans, and in Northern India. The best characterized risk factor for the development of gallbladder cancer is chronic inflammation associated with gallstones. Metastatic clear cell carcinoma in the gallbladder is extremely rare, with reported frequencies of less than 0.6% in large autopsy reviews. Patient was a 54 year old female. Patient was right upper abdominal pain and epigastric middle pain. Nausea and vomiting, pain was started 10 days ago, after ate dumplings. No history of previous any gastrointestinal disease. The physical examination: Tenderness in right hypochondrium. Lump in the hypochondrium. Murphy's sign was positive. The patient's in blood test increased white blood cell and C-reactive protein. Abdominal ultrasound examination: Gallbladder is enlargement, about 6.0 cm × 3.0 cm like the mudstone in the gallbladder. GB wall thickening/double, common bile duct is dilated 1.2 cm. Abdominal contrast computed tomography examination: Moderate thickening with surrounding mild edematous changes in wall of the gallbladder. Size of the GB is moderated dilated with diffuse. We were emergency surgery of under general anesthesia open cholecystectomy and intraoperative cholangiogram. During surgery gallbladder was distended and gallbladder wall very thickness, hardness. In cholangiogram common bile duct no obstructive sign. Clear cell carcinoma very rare disease. Our team diagnosed during surgery and histological analysis.

Creation of a Pediatric Choledocholithiasis Prediction Model.

Definitive non-invasive detection of pediatric choledocholithiasis could allow more efficient identification of those patients who are most likely to benefit from therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction. To craft a pediatric choledocholithiasis prediction model using a combination of commonly available serum laboratory values and ultrasound results. A retrospective review of laboratory and imaging results from 316 pediatric patients who underwent intraoperative cholangiogram or ERCP due to suspicion of choledocholithiasis were collected and compared to presence of common bile duct stones on cholangiography. Multivariate logistic regression with supervised machine learning was used to create a predictive scoring model. Monte-Carlo cross-validation was used to validate the scoring model and a score threshold that would provide at least 90% specificity for choledocholithiasis was determined in an effort to minimize non-therapeutic ERCP. Alanine aminotransferase (ALT), total bilirubin, alkaline phosphatase, and common bile duct diameter via ultrasound were found to be the key clinical variables to determine the likelihood of choledocholithiasis. The dictated specificity threshold of 90.3% yielded a sensitivity of 40.8% and overall accuracy of 71.5% in detecting choledocholithiasis. Positive predictive value was 71.4% and negative predictive value was 72.1%. Our novel pediatric choledocholithiasis predictive model is a highly specific tool to suggest ERCP in the setting of likely choledocholithiasis.

Fungal liver abscesses in an immunocompetent patient post cholecystectomy – a case report

Candida albicans is known to colonise the biliary tract but rarely causes invasive candidiasis post gastrointestinal or hepatobiliary surgery in the absence of host immunosuppression. This case study reports a 33-year-old immunocompetent female with a past surgical history of sleeve gastrectomy, omega loop (mini) gastric bypass and gastric ulcer repair. Two weeks post laparoscopic cholecystectomy and intraoperative cholangiogram (IOC) the patient presented with right upper quadrant abdominal pain, rigors, nausea, vomiting, fevers (39.5 degrees) and tachycardia. Liver function tests were mildly deranged, the white cell count was 10×109/L and the C-reactive protein was elevated at 327 mg/L. Computed tomography (CT) revealed multiple right lobe liver abscesses and mild splenomegaly. The patient underwent ultrasound guided drainage and Candida albicans was subsequently grown from the aspirate sample. After a 4-week course of oral fluconazole, a repeat CT abdomen and pelvis showed good resolution with 3-4 remaining small liver collections. An abdominal ultrasound 8-weeks post initial presentation showed complete resolution and subsequent gastroscope, echocardiogram and ophthalmological examination were unremarkable. Although liver abscesses caused by Candida albicans rarely occur in immunocompetent patients, it should be included in the differential diagnosis in such patients presenting with suspicious features post laparoscopic cholecystectomy and IOC.