Preoperative Endoscopic Retrograde Cholangiopancreatography Research Articles

An evaluation of horizontal equity in surgical care for gallstone disease in a Caribbean country

Background: The aim of this study was to identify social injustice by evaluating horizontal equity (allocation of similar resources to patients with the same clinical needs) in surgical care for gallstone disease in a Caribbean Country. Methods: We compared access to laparoscopic cholecystectomy (LC) for gallstone disease between a fee-for-service (private) and a government-funded (public) health-care system between 1st January and 31st August, 2018. We defined a prolonged waiting time as an interval of >90 days between the index diagnosis and LC. The data were examined using SPSS v23. Results: Ninety-nine patients underwent LC in public (60) or private (39) hospitals. There was a significantly longer mean waiting time in public hospitals (336.4 ± 647.9 days vs. 20.2 ± 25.5 days; P 0.002) and significantly more hospital readmissions while awaiting LC (72% vs. 0%). In the public hospital system, fewer patients had ambulatory operations (8.4% vs. 51.3%; P < 0.00001) and the mean duration of operation was longer (2.4 ± 0.88 vs. 0.92 ± 0.34 h; P < 0.0001). There were no differences in morbidity or mortality between the health-care systems. Thirty-eight patients had prolonged waiting times due to: long pre-existent waiting lists (13), consumables out of stock (10), equipment malfunction (6), patient request (3), pre-operative Endoscopic retrograde cholangiopancreatography (2), unspecified (2) and anaesthetic optimisation (1). One patient in the private hospital had a delay >90 days while awaiting insurance pre-authorisation. Conclusion: Horizontal inequity exists between the health-care systems. There is room for improvement through increased accountability for administrators, better resource allocation, proper equipment maintenance schedules and efforts to reduce waiting lists.

Routine laparoscopic management of common bile duct stones

Background: The prevalence of common bile duct stones associated with cholelithiasis increases with age and is about 15 % in the 8th decade of life but its management is still controversial. Some surgeons prefer the single-stage approach with laparoscopy while others suggest the two-stage management with preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy. Objective: The aim of the present study was to evaluate the efficacy of feasibility of single-stage laparoscopic surgery in patients with cholelithiasis and choledocholithiasis. Material and methods: We conducted a retrospective study with prospectively collected data between July 2008 and July 2018. Results: Of 2447 laparoscopic cholecystectomies performed during the study period, 416 presented common bile duct stones. The global success of the transcystic approach to clear common bile duct stones was 81.2%, 70.4% in the cases with preoperative diagnosis of choledocholithiasis and 92.9% for other diagnoses. The rate of complications was 4% without deaths or bile duct injuries. Conclusion: Single-stage laparoscopic surgery is an efficient and safe approach based on the high global success of transcystic exploration. The preoperative diagnosis of choledocholithiasis reduces the efficacy of the procedure due to greater indication of choledocotomy, with complications and longer length of hospital stay.

Jaundice as a clinical presentation in liver hydatidosis increases the risk of postoperative biliary fistula

Echinococcosis, also known as hydatidosis, is a zoonosis that is endemic in many countries worldwide. Liver hydatid cysts have a wide variety of clinical manifestations, among which obstructive jaundice is one of the rarer forms. The aims of the study were to analyze the preoperative management of these patients and to record the kind of surgical treatment performed and the short- and long-term postoperative results. A retrospective two-center observational study of patients operated upon for liver hydatidosis with initial symptoms of obstructive jaundice. Preoperative characteristics, surgical data, and postoperative complications, including biliary fistula, were recorded. Of 353 patients operated upon for liver hydatidosis, 44 were included in the study. Thirty-five patients (79.6%) were defined as CE2 or CE3 in the World Health Organization (WHO) classification. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 25 patients (56.8%) and identified intrabiliary communication in 29. Radical surgery was carried out in 29 of the total sample (65.9%). Severe postoperative complications (Clavien-Dindo grade IIIA or higher) were recorded in 25% of patients. The factors associated with greater postoperative morbidity were age above 65 (HR 8.76 [95% CI 0.78-97.85]), cyst location (HR 4.77 [95% CI 0.93-24.42]), multiple cysts (HR 14.58 [95% CI 1.42-149.96]), and cyst size greater than 5 cm (HR 6.88 [95% CI 0.95-50]). The presentation as obstructive jaundice causes greater postoperative morbidity. The main postoperative complication in these cases, despite radical surgery, is biliary fistula. In our series, routine preoperative ERCP did not show any benefit.

A Snapshot of the Practice of Laparoscopic Common Bile Duct Exploration in the United Kingdom - (CholeS Data Set)

Introduction: The aim was to describe the utilisation/practice of laparoscopic bile duct exploration(LCBDE) option for the management of common bile duct stones across the UK. The data were obtained from a population-based cohort study of outcomes following cholecystectomy for benign gallbladder diseases (CholeS study). Methods: We used the CholeS Study DataSet to analyse the use of LCBDE in the UK. Descriptive analysis and graphs were used to illustrate the current practice of LCBDE in the UK. Results: Seventy-seven (46%) out of 167 Hospitals that took part in the CholeS study performed LCBDE. Their LCBDE workload was 5.4% out of the total Laparoscopic Cholecystectomies(LC) performed. Almost 90% of LCBDE was performed by hospitals who performed less than five LCBDE in two months. Only 5.2% of hospitals performed more than 10 LCBDEs; this accounts for 19.8% of their LC workload compared to between 2 and 8% for the rest. Out of 8820 LC, a total of 256(2.9%) and 932(10.6%) patients underwent LCBDE and pre-operative endoscopic retrograde cholangio-pancreatography and sphincterotomy(ERCP+ES) respectively for CBDS. Eighty-four per cent of LCBDEs were performed by Upper gastrointestinal surgeons and 16% by other specialities including 10% colorectal surgeons. Interestingly, only just under 5% of the LCBDEs were performed by trainees. Conclusions: In the UK, a significant proportion of patients with CBDS are still treated in two stages: a pre-operative ERCP followed by LC. LCBDE remains an underutilised resource in the UK. Further studies are required to examine the possible reasons for the low utilisation of LCBDE.

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

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

Pre-operative stenting and complications following pancreatoduodenectomy for pancreatic cancer: an analysis of the ACS-NSQIP registry.

Historically, pre-operative biliary stenting has been associated with higher infectious complication rates following pancreatoduodenectomy. However, alleviation of biliary obstruction is necessary for consideration of pre-operative chemotherapy, which may improve disease-free survival, or for mitigation of symptoms while awaiting surgery. Our aim is to compare contemporary post-operative complication risk among patients with pre-operative endoscopic retrograde cholangiopancreatography (ERCP) stenting compared to those without. Patients who underwent a pancreatoduodenectomy for pancreatic cancer with biliary obstruction within the ACS-NSQIP registry from 2014 to 2017 were identified. The primary outcome was to compare the risk of 30-day complication (composite outcome) between patients with and without pre-operative ERCP stenting. Propensity score matching was used to ensure balanced baseline characteristics and log-binomial regression models were used to estimate risk ratios for overall perioperative complication between groups. From 6073 patients with obstructive jaundice undergoing pancreatoduodenectomy for pancreatic cancer, 92% (5564) were eligible for the study. After performing a propensity score matching on 20 baseline characteristics, 952 patients without stenting were matched to up to four patients who received pre-operative ERCP stenting (n = 3467) for a matched cohort of 4419. A total of 1901 (55%) patients with pre-operative ERCP stenting experienced a post-operative complication compared to 501 (53%) patients without stenting (risk ratio 1.04, 95% CI 0.97-1.11, p = 0.23). Pre-operative ERCP stenting was not associated with an increased risk of post-operative complication in patients undergoing pancreatoduodenectomy with obstructive jaundice. Biliary stenting may be safely considered for symptom relief and to potentially facilitate pre-operative chemotherapy for pancreatic cancer.

Preoperative ERCP has no impact on islet yield following total pancreatectomy and islet autotransplantation (TPIAT): Results from the Prospective Observational Study of TPIAT (POST) cohort

Background and aimsMany patients undergoing total pancreatectomy with islet autotransplant (TPIAT) for severe, refractory chronic pancreatitis or recurrent acute pancreatitis have a history of endoscopic retrograde cholangiopancreatography (ERCP). Using data from the multicenter POST (Prospective Observational Study of TPIAT) cohort, we aimed to determine clinical characteristics associated with ERCP and the effect of ERCP on islet yield. MethodsUsing data from 230 participants (11 centers), demographics, pancreatitis history, and imaging features were tested for association with ERCP procedures. Logistic and linear regression were used to assess association of islet yield measures with having any pre-operative ERCPs and with the number of ERCPs, adjusting for confounders. Results175 (76%) underwent ERCPs [median number of ERCPs (IQR) 2 (1-4). ERCP was more common in those with obstructed pancreatic duct (p = 0.0009), pancreas divisum (p = 0.0009), prior pancreatic surgery (p = 0.005), and longer disease duration (p = 0.004). A greater number of ERCPs was associated with disease duration (p < 0.0001), obstructed pancreatic duct (p = 0.006), and prior pancreatic surgery (p = 0.006) and increased risk for positive islet culture (p < 0.0001). Mean total IEQ/kg with vs. without prior ERCP were 4145 (95% CI 3621-4669) vs. 3476 (95% CI 2521-4431) respectively (p = 0.23). Adjusting for confounders, islet yield was not significantly associated with prior ERCP, number of ERCPs, biliary or pancreatic sphincterotomy or stent placement. ConclusionsERCP did not appear to adversely impact islet yield. When indicated, ERCP need not be withheld to optimize islet yield but the risk-benefit ratio of ERCP should be considered given its potential harms, including risk for excessive delay in TPIAT.

Predicting cholecystocholedochal fistulas in patients with Mirizzi syndrome undergoing endoscopic retrograde cholangiopancreatography.

BACKGROUNDMirizzi syndrome (MS) is defined as an extrinsic compression of the extrahepatic biliary system by an impacted stone in the gallbladder or the cystic duct leading to obstructive jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) could serve diagnostic and therapeutic purposes in patients with MS in addition to revealing the relationships between the cystic duct, the gallbladder, and the common bile duct (CBD). Cholecystectomy is a challenging procedure for a laparoscopic surgeon in patients with MS, and the presence of a cholecystocholedochal fistula renders preoperative diagnosis important during ERCP.AIMTo evaluate cholecystocholedochal fistulas in patients with MS during ERCP before cholecystectomy.METHODSFrom 2004 to 2018, all patients diagnosed with MS during ERCP were enrolled in this study. Patients with associated malignancy or those who had already undergone cholecystectomy before ERCP were excluded. In total, 117 patients with MS diagnosed by ERCP were enrolled in this study. Among them, 21 patients with MS had cholecystocholedochal fistulas. MS was further confirmed during cholecystectomy to check if cholecystocholedochal fistulas were present. The clinical data, cholangiography, and endoscopic findings during ERCP were recorded and analyzed. RESULTSGallbladder opacification on cholangiography is more frequent in patients with MS complicated by cholecystocholedochal fistulas (P < 0.001). Pus in the CBD and stricture length of the CBD longer than 2 cm were two additional independent factors associated with MS, as demonstrated by multivariate analysis (odds ratio 5.82, P = 0.002; 0.12, P = 0.008, respectively).CONCLUSIONGall bladder opacification is commonly seen in patients with MS with cholecystocholedochal fistulas during pre-operative ERCP. Additional findings such as pus in the CBD and stricture length of the CBD longer than 2 cm may aid the diagnosis of MS with cholecystocholedochal fistulas.

Outcomes of laparoscopic common bile duct exploration (LCBDE) after failed endoscopic retrograde cholangiopancreatography versus primary LCBDE for managing cholecystocholedocholithiasis.

ObjectiveThis study was performed to compare the outcomes of laparoscopic common bile duct exploration (LCBDE) after failed endoscopic retrograde cholangiopancreatography (ERCP) versus primary LCBDE for managing cholecystocholedocholithiasis.MethodsWe retrospectively analyzed data from 59 patients who underwent LCBDE during laparoscopic cholecystectomy (LC) for managing cholecystocholedocholithiasis from January 2013 to August 2019. The patients underwent either primary LCBDE plus LC (Group I) or LCBDE plus LC after failed ERCP (Group II). The demographics, reason for ERCP failure, perioperative details, and postoperative outcomes were evaluated.ResultsCBD stone removal using preoperative ERCP failed in 31 patients (Group II) because of remaining stones after ERCP (n = 9), failed cannulation (n = 6), failed sedation (n = 6), a periampullary diverticulum (n = 5), previous Billroth II gastrectomy (n = 3), a huge stone (n = 1), and an impacted stone (n = 1). The CBD stone clearance rate was >96% in both groups. The mean operative time, hospital stay, overall complication rate, and open conversion rate were not significantly different between the two groups.ConclusionsWhen extraction of CBD stones by ERCP is likely to be difficult or fail, primary LCBDE is an acceptable alternative treatment for managing cholecystocholedocholithiasis.

National trends and outcomes in timing of ERCP in patients with cholangitis

IntroductionGuidelines recommend early endoscopic retrograde cholangiopancreatography for the management of acute cholangitis, but the definition of the term “early” remains debatable. This study analyzed national trends in the timing of endoscopic retrograde cholangiopancreatography and identified the ideal time to perform preoperative endoscopic retrograde cholangiopancreatography in patients with acute cholangitis. MethodsThe 2005 to 2016 National Inpatient Sample was used to identify patients undergoing cholecystectomy for acute cholangitis. Severity of cholangitis was defined using the 2013 Tokyo Grading Criteria, where Tokyo grade III patients were defined as having organ dysfunction and non-Tokyo grade III patients were defined as grades I and II. Multivariable regressions (accounting for patient and hospital characteristics) were used to identify the timing of preoperative endoscopic retrograde cholangiopancreatography associated with the least mortality risk. ResultsOf 91,051 patients undergoing cholecystectomy for cholangitis, 55% underwent preoperative endoscopic retrograde cholangiopancreatography: 24% of patients received endoscopic retrograde cholangiopancreatography on the day of admission, 41% on hospital day 2, and the use of endoscopic retrograde cholangiopancreatography decreased gradually thereafter. Mortality rates remained under 1% if endoscopic retrograde cholangiopancreatography was performed during the first 3 days and increased as endoscopic retrograde cholangiopancreatography was performed during days 4 to 7 (P < .001). On multivariable regression, endoscopic retrograde cholangiopancreatography performed >72 hours after admission was associated with increased mortality (adjusted odds ratio 1.80, P = .01). Receiving endoscopic retrograde cholangiopancreatography P > 72 hours increased risk of death among Tokyo grade III patients (adjusted odds ratio 1.88, P = .01). Overall, during the study period, the utilization of preoperative endoscopic retrograde cholangiopancreatography for all grades of acute cholangitis increased from 39% of patients in 2005 to 51% in 2016 (P < .001). ConclusionThere has been an increase in the use of endoscopic retrograde cholangiopancreatography for acute cholangitis. Although endoscopic retrograde cholangiopancreatography on the day of admission was not associated with a decrease in mortality in patients with Tokyo grade III disease, endoscopic retrograde cholangiopancreatography within 72 hours of hospitalization was associated with decreased in-hospital mortality.

Impact of Endoscopic Retrograde Cholangiopancreatography on Laparoscopic Cholecystectomy

Background: For Common Bile Duct (CBD) stones an Endoscopic Retrograde Cholangiopancreatography (ERCP) is done prior to cholecystectomy. However, the ideal timing of cholecystectomy following ERCP is still a matter of debate. The aim of the present study was to observe the possible impact of ERCP on subsequent laparoscopic cholecystectomy.Material and Methods: This case control study was carried out in the Department of Surgery Unit 1, Holy Family hospital, Rawalpindi, from January 2018 to March 2019. A total number of 300 patients of symptomatic gallstones presenting to outpatient department were enrolled. Two groups, A (control group) and B (case group) were made on the basis of absence or presence of CBD stones, respectively. Group A underwent laparoscopic cholecystectomy within three working days of admission. In group B, ERCP was performed prior to cholecystectomy. Primary operating surgeon filled structured questionnaires for each patient immediately after surgery to compare operative differences between both groups. The baseline demographic details, clinical characteristics, laboratory investigations and peri-operative findings of both groups were recorded. Means and percentages were calculated with P value &lt;0.05 regarded as statistically significant.Results: Majority of patients in this study were females (81%) of middle age group (42.5+15 years). Biliary colic was most common presenting complaint in both groups (33%). Dissection in triangle of Calot (P=0.00) and removal of gallbladder from liver bed (P=0.00) was significantly more difficult in group B than A. Intra-abdominal lavage was also done more often in post ERCP group (P=0.00). However procedural time did not vary between the two groups (P=0.19).Conclusions: Preoperative ERCP increases difficulty in laparoscopic cholecystectomy but does not prolong procedural time.Key words: Choledocholithiasis, Endoscopic retrograde cholangiopancreatography, Laparoscopic cholecystectomy

Assessment of Laparoscopic Intraoperative Cholangiogram in Controlling Postoperative Outcomes and Its Implication on the Quality of Life

Background: Intraoperative cholangiography (IOC) is one of the surgical advances that aim to reduce the risk of bile duct injuries. Aim: To assess the role of IOC in controlling the postoperative outcomes and its implication on patient quality of life. Patients and Methods: This prospective randomized study conducted at the Department of Surgery, Faculty of Medicine, Suez Canal University from May 2017 to February 2019 on 56 patients with symptomatic gall stones who met our inclusion criteria. The exclusion criteria were having former upper abdominal surgery, chronic liver disease, impaired kidney function, bleeding tendency, and Common bile duct (CBD) stones indicated for preoperative ERCP. Our protocol was approved by the institutional review board at Suez Canal University. Results: Our sample comprised of 56 patients. The mean age was 42 ± 10 years, and most patients were females (68%). Most patients had no interventions like CBD explorations (82%). The success rate was 96%. Two patients had failed CBD exploration and referred to postoperative Endoscopic Retrograde Cholangiopancreatography (ERCP). Of notice, there were no reported cases of bile duct injury, and the mortality rate was 0%. Conclusion: IOC during laparoscopic cholecystectomy (LC) is associated with a low morbidity rate and no mortalities. This confirms the effectiveness of IOC in reducing the postoperative complications of LC which improve patent’s quality of life.

Usefulness of pre-operative endoscopic retrograde cholangiopancreatography in diagnosis and management of forme fruste choledochal cyst in children.

Forme fruste choledochal cyst (FFCC), characterized by a minimally dilated common bile duct (CBD) and associated pancreaticobiliary maljunction (PBM), is difficult to diagnose in a timely manner in clinical practice. However, endoscopic retrograde cholangiopancreatography (ERCP) can clearly delineate CBD and PBM. Hence, we evaluated the value of ERCP in the diagnosis and management of FFCC. The medical records of patients diagnosed with FFCC were retrospectively reviewed. From January 2003 to December 2010, patients underwent surgery without ERCP (non-ERCP group); from January 2011, all patients underwent pre-operative ERCP (ERCP group). Demographics, laboratory results, perioperative data and post-operative complications were compared between the two groups. There were 24 patients in the ERCP group and 11 in the non-ERCP group. Laboratory data improved to a greater extent after ERCP. ERCP was superior to both magnetic resonance cholangiopancreatography and ultrasonography in delineating CBD and PBM. In the ERCP group, 20 of the 24 patients were noted to have filling defects in the biliary tract and underwent pre-operative endoscopic sphincterotomy. Intra-operative blood loss was lower and transfusion less frequent in the ERCP group (P < 0.05). There were no ERCP-related complications. ERCP can accurately delineate the minimal CBD dilatation, associated pancreaticobiliary tract abnormalities and PBM of FFCC. ERCP can improve the perioperative and post-operative results of paediatric patients with FFCC.

Role of intraoperative cholangiogram (IOC) in diagnosing residual stones and variable anatomy in laparoscopic cholecystectomy (LC)

Background: Incidence of common bile duct (CBD) stones on Intra-operative Cholangiogram (IOC) ranges from 8-15% and it causes complications in 15% of these patients. IOC has high sensitivity (97%) and specificity (99%) but routine use causes increasing costs and operating time. Studies have indicated that IOC is not indicated if preoperative liver enzymes are normal. We evaluated efficacy of IOC in diagnosing stones and abnormal anatomy. Materials and Methods: A retrospectively analysis was performed of patients undergoing LC from January 2018-June 2018. We investigated pre-operative liver function tests (LFTs), if patients underwent pre-operative endoscopic retrograde cholangiopancreatography (ERCP), Endoscopic ultrasound (EUS) or Magnetic resonance cholangiopancreatography (MRCP), IOC findings, post-op complications and need of post-operative interventions (ERCP). Results: This study included 55 females, 28 males. The median age was 52yrs. 5 patients had markedly raised serum bilirubin (>80μmol/L). They underwent MRCP or EUS followed by pre-operative ERCP. 6 Patients had borderline raised bilirubin (>25μmol/L) and 7 had raised ALP (>147 IU/L). None of these patients showed stones on IOC. The incidence of stone and abnormal anatomy (abnormal insertion of cystic duct) on IOC was 6.4% and 3.6% respectively. All patients with stones had normal LFTs. The Sensitivity of IOC for stone was 100%, Specificity was 88%, Positive Predictive Value was 50% and Negative Predictive Value was 100%. False positive rate was 6.4%. There were no complications from IOC or missed retained stones. Conclusion: IOC is often only performed in patients with mild deranged pre-operative LFTs. In our HPB department we routinely perform IOC in LC. Our incidence rate (6.4%) of stones in such patients indicates IOC has role in detecting coincidental stones. Performing post-operative ERCP during same admission potentially prevents complications. In addition, recognizing abnormal anatomy on IOC is useful for cautious dissection.

Laparoscopic transcystic common bile duct exploration (LTCBDE): a safer method to treat common bile duct stones than laparoscopic choledochotomy.

We read the article published in the Spanish Journal of Gastroenterology and its accompanying editorial about the laparoscopic treatment of both cholecystolithiasis and choledocholithiasis in a single stage procedure. We would like to make some comments. Common bile duct (CBD) stones can lead to serious complications such as cholangitis and pancreatitis. So far, there is no standard surgical treatment for choledocholithiasis. Although, there are some ways to deal with CBD stones. Each method has its own advantages and disadvantages. In the era of advancements in minimally invasive technology, the treatment of CBD stones still remains controversial with regard to endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic common bile duct exploration (LCBDE). Preoperative ERCP followed by laparoscopic cholecystectomy (LC) is frequently performed.

Preoperative and Operative Risk Factors for Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy in Pakistan.

IntroductionThe currently available literature suggests a wide range of conversion (4.9-20%) from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) despite the increase in surgical expertise. Open cholecystectomy is important as the last resort for safe surgical practice in complicated cases. Increased number of pre-operative and perioperative risk factors need to be identified to pre-empt conversion. However, there has been a significant decrease in conversion rates over the past few decades. This study was conducted to determine conversion rates in our population and to identify any significant risks for conversion.MethodsThis prospective study was conducted at the Shifa International Hospital, Islamabad, Pakistan, including 1081 cholecystectomies, performed over a two-year period from January 2017 to January 2019. Comparison of risk factors between the two groups; laparoscopic cholecystectomy (LC) group and conversion to open cholecystectomy (OC) group was done. Statistical analysis was done using SPSS 24.0.1. P<0.05 were considered significant.ResultsIn our study, the overall conversion rate was 7.78%. Factors of conversion to open cholecystectomy (OC) included age ≥65, morbid obesity, diabetes mellitus, and previous abdominal surgery. Deranged alkaline phosphatase (ALP), increased total bilirubin, increased common bile duct (CBD) diameter, and multiple stones in ultrasonography showed a statistically significant association with the conversion. Per-operative findings of increased adhesions >50%, empyema gallbladder (GB), perforated GB, and scleroatrophic GB showed a higher risk of conversion too (p <0.05). However, there was no statistical association with preoperative endoscopic retrograde cholangiopancreatography (ERCP) to OC in our population.ConclusionAn open cholecystectomy is a safe approach for patients with complicated gallbladder disease. No doubt laparoscopic cholecystectomy is the gold standard having its outstanding benefits. This study identifies predictors of choice for OC in addition to the decision to convert to OC. In view of the raised morbidity and mortality associated with open cholecystectomy, distinguishing these predictors will serve to decrease the rate of OC and to address these factors preoperatively.

Analysis of the management of choledocholithiasis and it’s outcome with the role of preoperative endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography

Background: Choledocholithiasis implies stones in the common bile duct (CBD). Most of the common bile duct stones are those that have passed into the bile duct from the gall bladder. About 20 to 25% of patients above the age of 60 with symptomatic gall stones are likely to have stones in the CBD. To analyse the role of ERCP and MRCP in the management of choledocholithiasis.Methods: About 60 patients who are attending the General Surgery OPD of Rajiv Gandhi Government General Hospital, Madras Medical College, Chennai, Tamil Nadu, India from the October 2017-March 2018 were included in the study with confirmed common bile duct stones with or without gall stones were chosen. patients were categorized into group A- who has undergone a successful ERCP followed by laparoscopic cholecystectomy and group B- who underwent open cholecystectomy with CBD exploration.Results: Ultrasonography was done in 57 patients, of which 41 patients showed CBD stones (71.93%), 12 patients showed dilated CBD in the presence of cholelithiasis (21.05%) and in the remaining 4 patients (7.01%) this investigation showed only cholelithiasis. Since clinical condition warranted, authors proceeded with further hepatobiliary imaging, which revealed choledocholithiasis.Conclusions: Magnetic resonance cholangio pancreatography can also be used for follow up of the patients with choledocholithiasis after therapy, to look for the presence of retained stones, since it can detect stones even in the size as small as 2 mm. Selective use of intraoperative choledochoscopy in suspected cases helps in reducing the incidence of retained stones.

Preoperative and postoperative risk factors in laparoscopic cholecystectomy converted to open surgery.

Laparoscopic cholecystectomy (LC) is nowadays the gold standard in the surgical treatment of cholelithiasis and gallbladder diseases. But sometimes it may be inevitable to convert it to open surgery to safely end the procedure. In this study, we aimed to investigate the risk factors for conversion to open surgery from LC. The records of patients that underwent LC in Malatya State Hospital (Malatya, Turkey) between January 2013 and May 2014 were prospectively examined. One hundred and forty-five patients were involved in this study. The patients were divided into 2 groups: LC patients and patients converted to open surgery. For the patients in both groups, the preoperative age, gender, body mass index (BMI), disease history, previous abdominal operations, and preoperative laboratory findings were recorded, as well as the fact if the abdominal ultrasonography (US) and endoscopic retrograde cholangiopancreatography (ERCP) were performed. Of 145 patients involved in this study, 127 (87.5%) were female and 18 (12.5%) were male; their mean age was 46.54 years. Nineteen of the patients were operated on after ERCP due to acute cholecystitis and 6 patients were operated on after ERCP due to choledocholithiasis. In 134 of the patients (92.4%), the operations were completed laparoscopically, while the process was converted to open surgery in 11 cases (7.6%). Male gender, chronic disease history, normal BMI level, increased thickness of the gallbladder wall, increased preoperative blood glucose level, leukocytosis, preoperative ERCP history, grade 3 or 4 (Blauer scoring system) adhesions determined during the operation, and multiple stone presence in the bladder were found to be statistically significant risk factors for conversion to open surgery. Patients in the risk group should be informed by experienced laparoscopic surgeons about the potential conversion to open surgery and decision on such conversion should be made when necessary.

Endoscopic Retrograde Cholangiopancreatography for Ampullary Carcinomas: Friend or Foe?

The role of preoperative endoscopic retrograde cholangiopancreatography (ERCP) in ampullary carcinomas is under debate due to potential associated complications. We report the case of a 59-year-old male diagnosed with ampullary cancer, who had undergone ERCP that was followed by bleeding and perforation. We conclude that interventions before surgical resection, including ERCP, may compromise patient outcome.

Influence of Preoperative Endoscopic Retrograde Cholangiopancreatography (ERCP) on Bacterial Colonization of Biliary Tract in Patients Surgically Treated for Obstructive Jaundice.

Introduction:Cancelling elective procedures on the day of surgery presents a constant problem in all higher-level medical facilities, and the research of causes, consequences and possible solutions is the duty of every facility in order to enhance the quality of healthcare services.Methods:This prospective study included all patients that were scheduled for surgery from March 2016 to November 2018 in the operating rooms at our Department of Surgery, including both performed and cancelled cases. Cases by different surgical departments (general surgery, gynecology, orthopedics, urology, plastic surgery, ophthalmology and otorhinolaryngology) were all included.Results:Out of 8201 planned elective procedures from March 2016 to November 2018 at the General Hospital “Abdulah Nakas”, 7825 cases were performed and 376 cases (4.58%) were cancelled on the day of surgery. The most common reasons for cancelling a surgical procedure on the day of surgery were: lack of time to perform surgery, (33.51%), surgery cancelled due to medical/anesthetic reasons, (31.38%), surgical procedure cancelled by the surgeon on the day of surgery, (11.97%).Conclusion:This study has shown that the percentage of elective cases cancelled on the day of surgery at our institution stands at an acceptable 4.58%. The most common reasons for case cancellation on the day of surgery were identified. The majority of reasons for cancellation were avoidable, which means that appropriate steps could contribute to lowering the percentage of cancelled elective cases and an improved quality of healthcare services.