Laparoscopic Cholecystectomy Research Articles

BN SO12 - Management Strategies for Complications in Common Bile Duct Exploration: A Single Unit Comprehensive Analysis

Abstract Background 10-20% of individuals with systemic gallstones are estimated to have common bile duct stones (CBDS)(1). Laparoscopic common bile duct exploration (LCBDE) and two stage laparoscopic cholecystectomy (LC) with subsequent endoscopic retrograde cholangiopancreatography (ERCP) are clinically equivalent in their purpose but associated with different risks and require different skill sets, training and facilities. This study has retrospectively reviewed all LCBDE in our Benign Upper Gastrointestinal Surgery Unit, in particular analysing complications, the management strategies employed, and the impact associated with these interventions. Method A retrospective analysis was conducted on all patients (n=427) who underwent LCBDE between November 2013 and May 2024 at our benign Upper Gastrointestinal Surgery Department to evaluate complications. Comparison is made with British Benign Upper Gastrointestinal Surgical Society (BBUGSS) standards. Results 16.6% (n=71) experienced complications; 3.28% (n=14) retained stone, 3.74% (n=16) bile leak, 9.6% (n=41) non-specific surgical complications. Bile leak approaches were transcystic (n=2), transcystic converted to cholecdochotomy (n= 3), and choledochotomy n=11. Leaks were diagnosed on ERCP (50%), drains (n=3), CT (n=4) and clinical suspicion (n=1). 50% (n=8) were managed by ERCP, n=6 laparoscopic washout, and n=2 conservatively. Of retained stones, n=5 were indicated intraoperatively, n=7 on readmission with pain, n=1 on tubogram, and n=1 due to increased drain output. 80% (n=12) managed via ERCP with sphincterotomy +/- stenting. Of the remainder n=1 underwent open exploration, and n=1 managed conservatively. Conclusion Bile duct complications can be life altering and thus early identification and management is paramount. BBUGSS’ recommended performance standards for LCBDE state that frequency of retained stones should be <15%, bile leaks <5% and return to theatre <5% (2). In our trust rates are 3.51%, 3.74% and 1.64% respectively. Our stone clearance rate is 96.49%, higher than the BBUGSS standard of >85% (2). Our findings conclude that a benign UGI unit in a District General Hospital can deliver a one stage approach with good management of complications from LCBDE.

EGS SO08 - How best to time the operative management of acute cholecystitis: Is there a difference in outcomes between hot and smouldering cholecystectomy?

Abstract Background Laparoscopic Cholecystectomy (LC) is the main treatment for symptomatic gallstone disease. Acute cholecystitis (AC) is a common emergency presentation in the UK and the 2015 AUGIS guidelines recommend emergency cholecystectomy within 72 hours of admission if the patient is fit. On a practical level this can sometimes be difficult to implement and often patients are discharged to return for an elective procedure (the smouldering gallbladder). We aimed to analyse our practice at a large district general hospital for the management of patients with AC and their post-operative outcomes. Method All patients undergoing LC between 1st July 2020 and 30th June 2022 were identified. Patients with an ICD-10 code of K81 (AC) associated with an inpatient stay within a year of their operation were included. Those admitted and operated on during that admission were classified as hot cholecystectomies (HC), whereas those admitted and discharged for an elective procedure were termed smouldering cholecystectomies (SC). Patient and operative details were retrieved from their electronic record and a Charlson co-morbidity index was calculated. Statistical analysis was performed using SPSS with Chi-squared tests performed for categorical data and ANOVA for continuous data. Results 276 patients underwent cholecystectomy for AC with 52.2% elective and 47.8% emergency (91% within 72 hours of admission). HC patients were younger (52.3 vs. 57.5, p<0.01) and less-comorbid (1.67 vs 2.12, p<0.05). The subtotal cholecystectomy rate was comparable between the groups (9.8% vs 16.0%, p=0.131). HC patients had more post-operative drains (38.6% vs 27.1%, p<0.05) and thick-walled gallbladders (92.4% vs 64.6%, p<0.001). Median post-operative length of stay was 1 day for HC and 0 days for SC. No difference was observed for 30-day readmission (4.5% vs 7.6%, p=0.286), morbidity (12.9% vs 11.8%, p=0.786) or mortality (0.8% vs 0.7%, p=0.951). Conclusion This study adds to the evidence that emergency cholecystectomy is as safe an option as discharging patients to return for an elective procedure in the future. Although a proportion of those discharged to return for an elective operation will have thin-walled gallbladders, the rate of subtotal cholecystectomy remains similar, if not slightly higher in the elective group (although not reaching statistical significance). Most emergency cholecystectomy patients were discharged the following day, therefore demonstrating that they do not significantly contribute to bed blocking and reduce the burden on already strained elective waiting lists.

BN SO38 - Bile Duct Injuries Referrals and Management in a Tertiary Centre in UK– A 6-year study

Abstract Background Laparoscopic Cholecystectomy (LC) is the standard treatment for symptomatic cholelithiasis. It has been associated with serious complications, such as vascular/biliary injuries (0.4-0.7% of cases) requiring surgical, endoscopic or radiological interventions. Objective To evaluate the management, intervention and outcomes post bile duct injuries (BDI) Methods We conducted a retrospective analysis on all patients referred with BDIs from regional centres, following a planned LC operation and treated at the HPB unit of Queen Elizabeth Hospital Birmingham between 2018 - 2023. Patients were followed up for at least one year. Results In our unit, 22 (12 male) patients, with a median age of 60 years (16-85) were treated, primarily for gallstone disease (n=14). Most sustained grade E injury (n=19) and were recognised and transferred on average in 4 days (0-43 days). 20 patients had a hepaticojejunostomy. Using the Clavien-Dindo classification, three patients had grade III complications requiring intervention, and one had grade IV complication with sepsis and cardiac failure, necessitating ITU transfer for inotropic support. Discharge occurred within 10 days (4-96), with follow-up over 18.8 months (5-65). Seven await further follow-up, six were discharged and two await PTC for anastomotic stricture. Conclusion Our cohort underscores the complexity and critical nature of these injuries. Most patients required hepaticojejunostomy, with a median recognition and transfer of four days. While the early discharge and follow-up outcomes are promising, ongoing monitoring is essential, as patients might commonly develop anastomotic strictures, requiring conservative, radiological or surgical management. These findings highlight the necessity for prompt recognition and referral to specialised HPB units to optimise patient outcomes and reduce the long-term complications associated with BDIs.

BN SO15 - Post Cholecystectomy Syndrome: Definition, Aetiology, Investigation & Management – A Systematic Review

Abstract Background Post-cholecystectomy syndrome (PCS) is a term commonly used to refer to the persistence of abdominal symptoms following cholecystectomy, or de-novo symptoms that develop post operatively. Despite the common use of the term, there is no widely agreed upon consensus definition. PCS is reported to affect between 5-40% of patients that undergo cholecystectomy representing a large populational burden. Despite this, there are no guidelines or protocols in place for the routine investigation and management of this large heterogenous patient group. In this study we systematically review the literature describing definition, aetiology, investigation and up-to-date management of PCS. Method An updated systematic search of the Medline, EMBASE and Cochrane databases was undertaken to identify studies where patients underwent cholecystectomy and subsequently were diagnosed with PCS. Included papers were published between 2016-2024, had a minimum of 10 cases of PCS following laparoscopic or open cholecystectomy. Excluded studies were case reports, narrative and systematic reviews, paediatric patient population or papers unavailable in the English language. Paper characteristics were extracted and where present, the definition of PCS, aetiology, investigations and management of these patients was both extracted and analysed. Results 145 papers were identified of which 13 were included after title, abstract and full text screening. Definition of PCS, where present, was highly heterogenous between papers. Aetiology was often divided into biliary and non-biliary causes, with some papers claiming early-PCS and late-PCS as distinct clinical phenomena. In such papers, early-PCS was most commonly attributed to gastro-oesophageal pathologies and late-PCS to biliary pathologies. Investigation strategy is sparingly reported and without guideline or protocol. Most frequently used tests include LFTs, USS, MRCP, CT, ERCP and OGD. Some studies also used 99m Tc-Mebrofenin Hepatobiliary Scintigraphy, sphincter manometry and colonoscopy. Conclusion PCS has a widely reported prevalence in the published literature. This is potentially due to the heterogeneity of definitions used to cover the syndrome. The effective management of such patients depends on both the accurate diagnosis of the underlying cause, as well as exclusion of procedure related complications. There are currently no guidelines or protocols available for the investigation and management of patients presenting with symptoms post cholecystectomy despite the large populational burden. Further studies should aim to provide a consensus definition of PCS, and work towards guidelines for the investigation and management of this patient group.

OGC SO16 - International upper GI robotic fellowship on the CMR Versius platform

Abstract Background The impetus for UGI surgery trainees to attain skills in robotic surgery is likely to increase following the global acceptance and utilisation of robotic platforms. UGI robotic fellowship programs are few in number and highly desirable providing trainees with a unique selling point when embarking on independent consultant practice. We describe the first UGI robotic surgery fellowship on the CMR Versius platform at the Gloucestershire Royal Hospital which has the largest experience of UGI robotic surgery on the CMR Versius platform in the UK, having performed over 200 cases including the first robot assisted minimally invasive oesophagectomy. Method A structured robotic training curriculum was created in collaboration with CMR Versius. It consists of a pre-clinical phase of E-learning (10 modules), simulator training (16 assessed tasks) and dry-laboratory training (a two-day course encompassing robotic system set-up, bed-side assist and assessed dry lab practical tasks). The clinical phase begins with bed-side assisting of robotic cases followed by supervised operating on the console. Operations performed on the console are recorded for review and evaluation. The videos will be scored by two independent surgeons using the modified Global Evaluation Assessment of Robotic Skills (mGEARS) score to track growth and progress. Results The E-learning modules and assessments were completed prior to commencement of the fellowship. The remainder of the pre-clinical phase of the curriculum were completed within 4 weeks of commencement followed by bed-side assisting. Once competent at bed-side assisting and able to demonstrate proficiency in set-up (selecting port site placement, docking, arm spacing and configuration), supervised console training was commenced 6 weeks into the fellowship. Console training began with robotic assisted laparoscopic assisted cholecystectomy to gain familiarity, confidence, and efficiency. After 6 cases as the only console surgeon, the surgical complexity of cases was progressed to hiatal surgery and Heller’s cardiomyotomy Conclusion A structured training curriculum with defined phases provides a feasible and effective framework for robotic fellowship training. Adherence to the pre-clinical phase of training allows safe and efficient progression to hands-on console experience. This is achievable within relatively short timeframe to allow for ample independent console surgeon experience and the development of proficiency within a 12-month fellowship period.

HPB SO36 - Diagnostic Accuracy in Detecting Gall Bladder Polyps: A Retrospective Study

Abstract Background Gallbladder polyps are outgrowths of the gallbladder mucosal wall. They are usually found incidentally on ultrasonography or after cholecystectomy, but can lead to symptoms similar to those caused by gallbladder stones1. It is important to differentiate pseudo-polyps (cholesterol, adenomyomatosis, inflammatory, hyperplastic) from true-polyps (adenomas, adenocarcinomas2,3). The vast majority of polyps detected by ultrasound are pseudo-polyps, with no risk of malignancy. Ultrasound has been considered the gold standard for diagnosis,. However, it is limited by several factors4,5. The primary objective of this study is to assess the accuracy of ultrasound in diagnosing true polyps in patients undergoing surgery for this condition. Method Retrospective review carried out on all US scans reporting Gallbladder polyps for patients who underwent cholecystectomy, with additional data from MRI and CT scans. Sample size 44 patients Time period: From 2019 to present. Analysis was done on Excel Inclusion Criteria: Patients who had cholecystectomies with USS results confirming GB polyps, and have histology reports.Patients who had cholecystectomies with USS results confirming GB stones, and polyps as a co-existing pathology, and have histology reports. Results We included 44 patients our study, all had polyps on USS, and elective laparoscopic cholecystectomy, the mean age was 52 Years, and 63.6 % were women. Out of 44 USS patients, 24 (54.5%) showed features of polyps on histopathology. However, only 6 (13.6%) specimens were identified as adenomas. 18 USS showed polyps measuring 10mm or more. The majority (55.6%) were benign pathologies (pseudo-polyps). Interestingly, only 3 showed features of adenomas (16.7%). 22 Patients had multiple USS for surveillance, Histology showed polyps in 12 specimens (54.5%), out of which only 4 were adenomas (18.2%). Conclusion The accuracy of transabdominal ultrasound in diagnosing true polyps is limited. However, the sensitivity to distinguish adenomas slightly increases in larger polyps This low diagnostic accuracy underscores the need for caution among surgeons when making clinical decisions based on ultrasound-detected polyps. The high false positive rate suggests that more diagnostic criteria are necessary to improve the reliability of ultrasound in the diagnosis and screening of polyps, which is crucial to help reduce unnecessary procedures in asymptomatic patients who had negative histology reports postoperatively.

HPB SO08 - Safety of Robotic cholecystectomy as index training procedure – the UK experience

Abstract Background A recent large retrospective cohort study reported a higher risk of bile duct injury associated with robotic cholecystectomy when compared to the laparoscopic approach. Considering that most robotic training pathways, including the one followed in the UK, utilise robotic cholecystectomy as index training procedure, such findings mandate evaluation of the safety profile of robotic cholecystectomy in the UK to ensure its use as an alternative approach to laparoscopic cholecystectomy is not putting patients at risk. We aimed to conduct a multi-centre observational study to evaluate the safety profile of robotic cholecystectomy performed within the UK HPB Robotic training program. Method A retrospective analysis of prospectively collected data from eleven centres participating in the UK robotic HPB training program was conducted. All adult patients undergoing robotic cholecystectomy for symptomatic gallstone disease or gallbladder polyp were considered. Bile duct injury, conversion to open procedure, conversion to subtotal cholecystectomy, length of hospital stay, 30-day re-admission, and post-operative complications were the evaluated outcome parameters. Results A total of 600 patients were included. The median age was 53 (IQR 65 - 41) years and the majority (72.7%; 436/600) were female. The main indications for robotic cholecystectomy were biliary colic (55.5%, 333/600), cholecystitis (18.8%, 113/600), gallbladder polyps (7.7%, 46/600) and pancreatitis (6.2%, 37/600). The median length of stay was 0 (IQR: 0-1) days. Of the included patients, 88.5% (531/600) were discharged on the day of procedure with 30-day re-admission rate of 5.5% (33/600). There were no bile duct injuries and the rate of conversion to open was 0.8% (5/600) with subtotal cholecystectomy rate of 0.8% (5/600). Conclusion This current study confirms that robotic cholecystectomy can be safely implemented to routine practice with a low risk of bile duct injury, low conversion to open surgery and low need for subtotal cholecystectomy.

BN SO43 - The impact of dedicated “hot cholecystectomy lists” on rates of early cholecystectomy and its outcomes

Abstract Background Surgical management of gallstone disease is evolving with NICE guidelines emphasising on early cholecystectomy following an index admission with biliary symptoms. Despite an attempt at adhering to these recommendations, many centres find operating theatre capacity as a potential significant constraint to offer a same admission or early cholecystectomy. We assess the impact of a dedicated theatre capacity provided by a specialist upper gastrointestinal surgical team on rates of early cholecystectomy and its outcomes. Method A pathway for patients presenting with symptomatic gallstone disease was designed and implemented trust wide, with two theatre lists per week dedicated to performing “hot cholecystectomies”. Retrospective analysis was performed from a prospectively maintained database of patients with symptomatic gallstone disease admitted to a district general hospital over two equal (30 days) but chronologically independent time periods. Data was collected from prior and after service reconfiguration and analysed with descriptive statistics. Results 19 patients (F:M ratio 0.82:1) were referred for the consideration of receiving a hot cholecystectomy. Nine of the 12 patients (75%) who were deemed to be suitable as per NICE guidelines underwent a cholecystectomy within the recommended time frame. There was a significant difference in the number of admissions over the two time periods with a shorter time from index admission to surgery (median 62 days to 5 days (P<0.01)); with correspondingly fewer re-admissions from 14 to 2 (P<0.01) following service reconfiguration. Conclusion With adequate theatre resources together with surgical expertise, early laparoscopic cholecystectomy can be proved to be an effective and sustainable model for the management acute biliary disease. Continue ahead, we aim to improve our computer-based referral system which will be better suited to record referrals, and the patient pathway. This data will be developed into a dashboard, thereby keeping a contemporaneous record of acute admissions and their management; subsequently improving the number and quality of referrals.

Factors Influencing Bile Duct Injuries: A Dreaded Complication of Laparoscopic Cholecystectomy.

Bile duct injuries (BDIs) are dreaded complications of one of the most common general surgical procedures. The injury impacts the quality of life and may have several long-term complications. In some cases, it can also lead to mortality. This paper aims to review works that have already been published about bile duct injuries and elaborate on the factors leading to it. This includes elaborating on both surgical and non-surgical factors. It also plans to highlight practices and methods to avoid BDIs. Medical research databases were searched using cholecystectomy and bile duct injuries as keywords. Papers including pre-operative or intraoperative factors, that may cause bile duct injuries, were further shortlisted for this study. Understanding and knowledge of anatomy plays a key role in bile duct injuries and is essential before performing the surgery. Factors related to the patients, surgeons, and logistics also play a major role in causing bile duct injuries. Bile duct injuries can be reduced using certain strategies like the B SAFE strategy, R4U line, bail-out methods, imaging techniques along with referrals to Hepatobiliaryspecialist centers to avoid bile duct injuries.

EGS SO34 - Idiopathic pancreatitis - a myth or a reality?

Abstract Background Acute pancreatitis is characterized by frequent episodes of inflammation in the pancreas.The most common causes are alcohol abuse and gallstones but approximately 30% of cases are defined as idiopathic because initial evaluation fails to detect the aetiology.This study aims to investigate the aetiology and the reasons for the incorrect labelling of patients with pancreatitis as idiopathic. Method This is a retrospective study and included patients with a diagnosis of idiopathic pancreatitis (IP) between 1 May 2019 and 31 April 2023.Cases were eligible for inclusion if they had been discharged as IP. Data were collected following review of patient notes into Microsoft Excel. Results A total of 129 patients were identified of whom the majority of patients did not find to have gallstones (88%), did not report alcohol use (91%), and did not experience trauma (87%). However, MRCP and EUS were not performed in all patients before they are labelled as idiopathic. Ultrasound was the most commonly performed diagnostic procedure (98%), while MRCP (40%) and EUS (8%) were less frequently utilized. Surprisingly, a quarter of patients underwent a laparoscopic cholecystectomy. Nutritional referrals were lacking in a significant portion of cases and the readmission rates were high (65%). Conclusion The most surprising elements in the data include the high incidence of unperformed diagnostic procedures to exclude the common causes of pancreatitis.Also,the underutilization of nutritional referrals and the high readmission rates suggest potential areas for improvement in the diagnostic workup and management of IP, as well as raising questions about the current clinical practices and their efficacy in this cohort.

Short-Term Efficacy of LCBDE+LC Versus ERCP/EST+LC in the Treatment of Cholelithiasis Combined with Common Bile Duct Stones: A Retrospective Cohort Study.

Background: Minimally invasive treatments for cholelithiasis have gained popularity. The complexity of diagnosing and treating choledocholithiasis offers multiple surgical options, including laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) and endoscopic retrograde cholangiopancreatography and/or endoscopic sphincterotomy plus laparoscopic cholecystectomy (ERCP/EST+LC). Objective: To compare outcomes in patients with typical signs, symptoms, laboratory, and imaging features of cholelithiasis combined with common bile duct stones, we retrospectively analyzed the short-term outcomes of LCBDE+LC and ERCP/EST+LC. Methods: We analyzed 318 patients with gallbladder stones treated between January 2022 and May 2024. Of these, 152 underwent LCBDE+LC, and 166 underwent ERCP/EST+LC. We compared patients' baseline characteristics, perioperative outcomes, and short-term complications between the two groups. The primary outcome was the effectiveness of choledochal stone removal, while secondary outcomes included length of stay, hospitalization costs, and patient satisfaction. Results: Patients' baseline characteristics were similar between the LCBDE+LC and ERCP/EST+LC groups. Stone clearance rates were comparable (97.37% versus 95.18%, P = .306), with a slight advantage in the LCBDE+LC group. The length of hospitalization was significantly shorter in the LCBDE+LC group (6.49 ± 1.18 days versus 6.77 ± 1.11 days, P < .05). The LCBDE+LC group also had lower total hospitalization costs ($5188.78 ± 861.26 versus $6498.76 ± 1190.58 P < .01). Additionally, the incidence of pancreatitis was lower in the LCBDE+LC group (0.66% versus 6.02%, P < .01). There were no significant differences between the groups in other short-term complications such as abdominal infection, cholangitis, biliary bleeding, or bile leakage. Postoperative follow-up indicated higher patient satisfaction and acceptance in the LCBDE+LC group (SSQ-8, 85.84 ± 4.31 points versus 81.20 ± 4.54 points, P < .01). Conclusion: Our findings suggest that the LCBDE+LC holds promise as a safe and efficacious approach for the management of cholelithiasis combined with common bile duct stones. However, further prospective clinical trials are essential to corroborate these results and confirm their broader applicability.

Surgical Management in Patients With Liver Cirrhosis: A Multidisciplinary Approach

Objective: The objective of this study is to conduct a systematic review on the surgical management of patients with liver cirrhosis, aiming to investigate strategies that can optimize perioperative care and reduce associated complications. Theoretical Framework: This section addresses fundamental concepts related to liver cirrhosis, including severity classification through the Child-Pugh and MELD systems. The review considers clinical and observational studies discussing surgical interventions and multidisciplinary approaches, establishing a solid foundation for understanding the clinical context. Method: The methodology employed comprises a systematic literature review, selecting studies published between 2010 and 2023. The search was conducted across six databases and supplemented by specialized literature, prioritizing surgical interventions and multidisciplinary team approaches. Results and Discussion: The findings reveal significant challenges, such as elevated morbidity and mortality rates, particularly in patients classified as Child-Pugh B and C. Laparoscopic cholecystectomy emerges as the preferred approach, demonstrating lower complication rates when performed in specialized centers. The discussion contextualizes these findings within the theoretical framework, considering the study's limitations. Implications of the Research: The practical implications suggest the necessity for a multidisciplinary team and careful risk assessment, emphasizing the adoption of minimally invasive surgical techniques and stringent control of ascites to enhance clinical outcomes. Originality/Value: This study contributes to the literature by highlighting the complexity of surgical management in cirrhotic patients and the importance of specific strategies. The relevance of this research is underscored by the need for the development of less invasive techniques and a better understanding of the specific complications faced by these patients.

Critical view of safety approach vs. infundibular technique in laparoscopic cholecystectomy, which one is safer? A systematic review and meta-analysis.

Laparoscopic cholecystectomy (LC) remains the gold standard procedure for the management of benign gallbladder disease. Recognizing the need to mitigate complications, mainly bile duct injury(BDI), various techniques for ductal identification during LC have emerged, including the "Critical View of Safety" (CVS) and the infundibular technique (IT). In this systematic review and meta-analysis, we assess and compare the outcomes of both techniques, with a primary focus on evaluating their impact on BDIs. A comprehensive search was conducted using PubMed and Scopus databases. The search focused on the surgical technique, incidences of minor and major BDIs, operative time, conversion rate, and length of stay, among patients undergoing LC for benign gallbladder disease. Our initial search retrieved 264 studies. After screening the unique studies against our predefined inclusion/exclusion criteria, only five met our criteria and were included. Additionally, a manual search identified eight more relevant studies, bringing the total number of included studies to 13. The total number of included patients was 4,837. Approximately two-thirds underwent LC using the CVS approach (61.1%), and 66.3% were female, with a mean age of 44.4 ± 11.2 years. The CVS approach was associated with a significant reduction in overall BDIs (RR = 0.36; 95% CI 0.18-0.71) and major BDIs (RR = 0.28; 95% CI 0.13-0.63). However, there were no significant differences in terms of minor BDIs, operative time, conversion rates, or length of stay. Our study demonstrated the superiority of the CVS approach in terms of reducing the incidence of overall and major BDIs compared to IT. However, our study revealed no other significant differences between the two techniques. Further research, including multicentric randomized controlled trials, will be necessary to further evaluate the efficacy of these techniques.

Evaluating the Role of Indocyanine Green Fluorescence Imaging in Enhancing Safety and Efficacy During Laparoscopic Cholecystectomy: A Systematic Review.

Laparoscopic cholecystectomy (LC) is the standard treatment for gallbladder disease, offering less invasive treatment and quicker recovery. However, bile duct injury (BDI) remains a critical complication. Indocyanine green (ICG) fluorescence imaging has emerged as a valuable technique to improve biliary structure visualization and potentially reduce BDI during LC. This systematic review assesses the efficacy of ICG in reducing BDI over the past decade. A comprehensive search of studies comparing ICG fluorescence and conventional white light (WL) in LC identified 14 studies. Key outcomes such as operative time, incidence of BDI, and visualization of biliary anatomy were analyzed. The results indicate that ICG significantly reduced operative times in complex cases, with an average reduction of approximately 20 minutes compared to WL (p<0.0001). In routine cases, no significant difference in operative time was observed between the two methods. ICG consistently enhanced visualization of key biliary structures, such as the cystic duct and common bile duct, with the greatest benefits seen in anatomically challenging cases. Although the overall incidence of BDI was low, use of ICG showed a trend toward lower BDI rates compared to WL, though the difference was not statistically significant. In conclusion, the use of ICG fluorescence in LC offers notable advantages, particularly in improving visualization of biliary anatomy and reducing operative time in complex cases. While the overall reduction in BDI rates may appear marginal, the clinical importance of avoiding even a single BDI should not be understated, given the serious complications associated with BDI. Our review suggests that the benefits of ICG are most pronounced in more complex cases where biliary anatomy is challenging to identify.

Biodegradable Stents: A Breakthrough in the Management of Complex Biliary Tract Injuries: A Case Report

Background and Clinical Significance: Biliary tract injuries are a recognized complication of laparoscopic cholecystectomy. Early diagnosis and prompt management are crucial to minimize complications such as bile leaks, strictures, and fistula formation. This case report highlights the use of a biodegradable biliary stent in managing a complex biliary injury and discusses the impact of delayed diagnosis on treatment outcomes. Case Presentation: We present the case of a 30-year-old male who sustained a Strasberg E2 biliary tract injury during a laparoscopic cholecystectomy. Initially misdiagnosed, the injury was only recognized on the fourth postoperative day. The patient underwent a Roux-en-Y hepaticojejunostomy and subsequently developed a postoperative biliary fistula, which was managed with percutaneous drainage. A biodegradable biliary stent was later placed to address a stricture and minimize the need for future interventions. One year later, the patient presented with symptoms of cholangitis, and radiological findings revealed a narrowing of the biliary lumen. The stricture was resolved and an endoscopic gastrojejunal shunt was placed to prevent further complications. The patient is currently in good condition with no signs of further complications. Conclusions: This case emphasizes the importance of early diagnosis in managing biliary tract injuries and highlights the potential of biodegradable stents to reduce the need for repeat interventions. Despite a delayed diagnosis necessitating complex surgical procedures, the use of a biodegradable stent proved effective in managing postoperative complications. Further studies are needed to evaluate the long-term efficacy of biodegradable stents in similar clinical scenarios.

Actinomycosis of the gallbladder: A rare case report and literature review

Actinomycosis of the gallbladder is rare, with only a few documented cases in the medical literature. Actinomyces is typically part of the normal flora of the cervicofacial region, gastrointestinal tract, and urogenital tract. Here, we report a case of a 31-year-old female who presented with pain abdomen. Radiological investigation revealed a contracted gallbladder with multiple calculi and a thickened wall. A provisional diagnosis of acute cholecystitis was considered preoperatively and hence planned for laparoscopic cholecystectomy. Histopathological examination showed moderate lymphocytic infiltrate within the muscular layer of the gallbladder along with colonies of filamentous bacteria suggestive of actinomycosis. The relevant stains, including Gram and Giemsa, highlighted the Gram-positive bacteria and confirmed the diagnosis. Post-cholecystectomy, the patient received prolonged antibiotic therapy to prevent recurrence.

Trends and Outcomes of the Management of Common Bile Duct Stones at KIST Medical College Teaching Hospital

Introduction: Common bile duct (CBD) stones are found in 10% to 15% of patient having cholelithiasis. Various surgical methods including endoscopic, laparoscopic and open surgical techniques are practiced but there is no consensus on the management. This cross-sectional study aims to analyze the demographics and trends un management of CBD stones at KIST Medical College. Methods: Patient undergoing CBD stone management from 15 June 2021 to 31 December 2023 were included in the study. Different treatment methods applied and outcomes were analyzed. Results: Fifty-one patients were included in the study with 18 (25.3 %) males and 33 (64.7%) females. Abdominal pain was the most common symptom. Laparoscopic cholecystectomy(LC) with intraoperative(io)-ERCP was done in 30 (58.8%) patients, while LC + Laparoscopic CBD exploration(LCBDE) was done in 11 (21.6 %) and Endoscopic Retrograde Cholangiopancreatography(ERCP) only was done in 10 (19.6%) patients. The significant difference was observed in the length of hospital stay [5.03 ± 2.13 vs 6.36 ± 2.29, p=0.046] and the number of days the drain was kept [2.20 ±0.45 vs 4 ± 1.90, p=0.037] both favoring LC + io-ERCP group. Stone clearance, post-operative complications and operative time were comparable between the two groups. Conclusion: Single-stage management of cholelithiasis and choledocholithiasis is feasible at our center. Both LC with io-ERCP and LC + LCBDE can be performed selectively with acceptable and comparable outcomes.

Combined Laparoscopic Cholecystectomy and Transcystic Common Bile Duct Exploration for Choledocholithiasis

Abstract Background: There is no consensus on the ideal approach for managing patients with common bile duct (CBD) stones. The combined approach is less popular, possibly due to the complexity of the surgical technique and the availability of choledochoscope. Aim: We aim to assess the safety and feasibility of transcystic (TC) CBD exploration using the flexible bronchoscope for choledocholithiasis. Methods: Forty patients with symptomatic calculus gallbladder with concomitant CBD stones were randomized into two groups. Single-session laparoscopic cholecystectomy (LC) and laparoscopic TC CBD exploration were performed for one group using the flexible bronchoscope. Endoscopic retrograde cholangiopancreatography followed by LC after 4–6 weeks was conducted for the other group. Results: Twenty patients were randomized to each group. The clearance rate of CBD stones was significantly higher in the single-session Group A (95%) than in the two-session Group B (70%). Group B was associated with a significantly prolonged operative (P = 0.01). The total hospital stay and operative time were significantly longer in Group B than in Group A (P = 0.004). There was no significant difference between both groups regarding the intraoperative or postoperative complications. Conclusion: Combined LC and TC CBD exploration is a safe and feasible approach and is associated with significantly shorter operative time and length of hospital stay.

Postoperative Opioid Consumption After Discharge: An Update From the Michigan Surgical Quality Collaborative Registry

Objective: To evaluate opioid consumption for 21 procedures over 4 years from the Michigan Surgical Quality Collaborative (MSQC) registry and update post-discharge prescribing guidelines. Background: Opioids remain a common treatment for postoperative pain of moderate-to-severe intensity not adequately addressed by nonopioid analgesics, but excessive prescribing correlates with increased usage. This analysis provides updates and compares patient-reported consumption in response to new guidelines. Methods: We examined data from the MSQC registry for opioid-naive adult patients undergoing surgery between January 1, 2018, and October 31, 2021. The primary outcome was patient-reported opioid consumption in oxycodone 5 mg equivalents. Guidelines were anchored to the 75th percentile of consumption, updating previous guidelines from January 2020 based on data from January 1, 2018, to May 31, 2019. Results: 39,493 opioid-naive surgical patients (average age 53.8 years [SD 16.4], 56.3% female, 19.1% non-White, 43.9% with public insurance) were included. Guidelines did not change for 7 of the 16 procedures including the most common procedures: minor hernia, laparoscopic cholecystectomy, laparoscopic appendectomy, and laparoscopic hysterectomy. Recommended prescribing ranges were lower for 9 procedures, with most (8) procedures having a reduction of 5 pills. Prescribing guidelines were developed for 5 new procedures. All procedures had upper-limit guidelines of 10 pills or less. Conclusions: For most procedures, patient-reported opioid consumption decreased between 2018 and 2021 when compared to the period between 2018 and 2019. New guidelines were established for a dozen procedures to balance maximizing pain control with reducing harms from inappropriate prescribing.

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.