Scheduled Laparoscopic Cholecystectomy Research Articles

Effectiveness of pre-operative routine MRCP in patients scheduled for laparoscopic cholecystectomy

Background: Cholelithiasis is one of the most common surgical diseases worldwide. Laparoscopic cholecystectomy is the gold standard treatment for cholelithiasis, and has become the most common performed gastro intestinal operation. The prevalence is higher in women (7.7%) than in men (3.3%). We aimed to investigate the effectiveness of pre-routine magnetic resonance cholangiopancreatography (MRCP) before performing scheduled Laparoscopic cholecystectomy. Methods: This was a prospective observational study conducted in the Department of General Surgery, Dhaka Central International Medical College, and selected single private Hospital from Dhaka, Bangladesh during the period from January 2021 to January 2023. In our study, we included 90 female patients presented with acute or chronic calculus cholecystitis. All patients were diagnosed with multiple gall stones diseases on USG abdomen after initial clinical evaluation were included in this study. Result: In our study, we found the mean age was 34.97±8.48 years. Among 90 patients USG showed multiple stones in 85(94.44%) patients whereas, MRCP showed stones only in 24 (26.67%) patients. Among patients with normal CBD, MRCP found 25.33 % and USG found 93.33% with stones. There were 3 patients with more than 5 mg/dl. bilirubin who was diagnosed with stones in both findings. Among the patients with 148-220 ALP levels, both USG and MRCP found 90.48% of patients with stones. We found 1 true negative case and 20 true positive cases of multiple stones (with a p value of 0.017). Conclusion: We found that MRCP helps increase the safety of perioperative management in some cases. Preoperative ultrasonography has a low diagnostic accuracy rate when it comes to patients who also have gallstones and CBD stones. So, individuals with gallstones are advised to undergo a normal preoperative MRCP examination.

Gallbladder sinistroposition (left-sided) finding in laparoscopic cholecystectomy, a case report

A left-sided gallbladder (LSGB), also known as sinistropostition, is a rare anatomical variant with a reported incidence of 0.2-1.1%. It is defined as a gallbladder located on the left side of the falciform ligament, embedded in the third hepatic lobe, without situs inversus viscerum. A 37-year-old Latino man with a history of bilateral inguinal repair underwent a scheduled laparoscopic cholecystectomy due to multiple gallbladder polyps. Preoperative ultrasound reported a gallbladder of 60x20 mm, wall thickness of 1 mm, with polyps of up to 10 mm. Standard laparoscopic cholecystectomy trocar placement was used. Upon revision of the right hepatic lobe, there was an absence of the GB in the visceral side of segments IV, V, or VI. It was identified to the left of the falciform ligament with adhesions to the anterior and superior portions of the pylorus and lesser curvature. The subxiphoid trocar was adjusted to the left of the falciform ligament, and Calot’s triangle dissection was performed to obtain a critical view of safety. No other anatomical variants were identified. The procedure was performed safely with a satisfactory view of critical cholecystectomy steps and anatomy identification. After the procedure, the surgeon complained of right-hand pain and numbness due to a medial position of the subxiphoid trocar for dissection. The surgical approach of a LSGB in laparoscopic surgery should be individualized for each patient. A minimally invasive approach may be realized successfully when critical thinking by the surgeon is applied and always prioritizing the safety of the patient.

Impact of Standard Versus Low Pneumoperitoneum Pressure on Peritoneal Environment in Laparoscopic Cholecystectomy. Randomized Clinical Trial.

High CO 2 pneumoperitoneum pressure during laparoscopy adversely affects the peritoneal environment. This study hypothesized that low pneumoperitoneum pressure may be linked to less peritoneal damage and possibly to better clinical outcomes. One hundred patients undergoing scheduled laparoscopic cholecystectomy were randomized 1:1 to low or to standard pneumoperitoneum pressure. Peritoneal biopsies were performed at baseline time and 1 hour after peritoneum insufflation in all patients. The primary outcome was peritoneal remodeling biomarkers and apoptotic index. Secondary outcomes included biomarker differences at the studied times and some clinical variables such as length of hospital stay, and quality and safety issues related to the procedure. Peritoneal IL6 after 1 hour of surgery was significantly higher in the standard than in the low-pressure group (4.26±1.34 vs. 3.24±1.21; P =0.001). On the contrary, levels of connective tissue growth factor and plasminogen activator inhibitor-I were higher in the low-pressure group (0.89±0.61 vs. 0.61±0.84; P =0.025, and 0.74±0.89 vs. 0.24±1.15; P =0.028, respectively). Regarding apoptotic index, similar levels were found in both groups and were 44.0±10.9 and 42.5±17.8 in low and standard pressure groups, respectively. None of the secondary outcomes showed differences between the 2 groups. Peritoneal inflammation after laparoscopic cholecystectomy is higher when surgery is performed under standard pressure. Adhesion formation seems to be less in this group. The majority of patients undergoing surgery under low pressure were operated under optimal workspace conditions, regardless of the surgeon's expertise.

Evaluation of the Analgesic Effect of Flurbiprofen Axetil in Combination with Fentanyl after Laparoscopic Cholecystectomy

To analyze the analgesic effect of flurbiprofen axetil in combination with fentanyl on the patients after laparoscopic cholecystectomy is the objective of the study. Between April 2020 and April 2021, a total of 120 patients who received the delayed or scheduled laparoscopic cholecystectomy were enrolled into this study and divided into the control group and observation according to their admission sequence, with 60 patients in each group. Patients in the control group received the fentanyl for postoperative analgesia, while those in the observation group received the flurbiprofen axetil in combination with fentanyl. The visual analogue scale scores of patients in the observation group at postoperative 3 h, 6 h, 12 h, 24 h and 48 h were (1.4±0.4) points, (1.8±0.3) points, (2.2±0.5) points, (1.8±0.5) points and (1.4±0.5) points, significantly lower than (2.3±0.6) points, (2.4±0.7) points, (3.0±0.6) points, (2.5±0.5) points and (1.9±0.5) points in the control group (t=6.618, 4.244, 5.489, 5.218 and 3.728, p<0.05). Following operation, the ratio of patients requiring more analgesics in the observation group was only 5.0 %, far lower than 28.3 % in the control group (χ2=7.467, p<0.05). Besides, the difference in the incidence rates of the adverse reactions between two groups showed no statistical significance (p>0.05). As for the hemodynamic indexes (mean arterial pressure, oxygen saturation and heart rate), differences were only found in comparison of heart rate (p<0.05), instead of mean arterial pressure or oxygen saturation (p>0.05) at postoperative 3 h, 6 h, 12 h, 24 h and 48 h between two groups. For patients undergoing the laparoscopic cholecystectomy, combination of flurbiprofen axetil and fentanyl for postoperative analgesia can mitigate the pains within 2 d and reduce the additional demand for analgesics.

Injection of methylene blue in the lungs during laparoscopic cholecystectomy

In a surgical setting, intraoperative methylene blue usage is a safe and effective technique in detecting gastric leak during laparoscopic abdominal surgery [1]. A Nasogastric (NG) tube is commonly used to empty the stomach and to monitor the occurrence of bowel occlusion after major abdominal surgery. The incidence of misplacement of NG tubes into the airways ranges between 0.3% and 15% [2] and is associated with significant morbidity and mortality [3]. A 68-year-old male patient presented to the operating room for scheduled laparoscopic cholecystectomy. After tracheal intubation and commencement of surgery, an 18 Fr. NG tube was inserted blindly through the nostril with no means of assessing its position. A solution of methylene blue was prepared and 240 ml were injected in the NG tube. Upon applying negative pressure suction on the NG, a noticeable change in airway pressure was noted and investigation through the use of fiber optic vision revealed the presence of bluish liquid in the bronchi. The NG tube was then re-inserted, the surgeon made the final confirmation of its proper placement within the stomach and the surgery continued uneventfully. Postoperative chest x-ray was suggestive of hypersensitivity pneumonitis and emphysema. Patient was first admitted to the intensive care unit where treatment was initiated, to be then transferred to the ward and later discharged on post-operative day three. Keywords: laparoscopic cholecystectomy; methylene blue; nasogastric tube; hypersensitivity pneumonitis; emphysema.

Impact of B-mode-ultrasound-guided transhepatic and transperitoneal cholecystostomy tube placement on laparoscopic cholecystectomy.

BACKGROUNDB-mode-ultrasound-guided percutaneous cholecystostomy (PC) may be performed by a transhepatic or transperitoneal approach, called percutaneous transhepatic gallbladder drainage (PHGD) and percutaneous transperitoneal gallbladder drainage (PPGD), respectively. We compared the impact of PC related to the route of catheter placement on subsequent laparoscopic cholecystectomy (LC).AIMTo compare the impact of PC related to the route of catheter placement on subsequent LC.METHODSWe retrospectively studied 103 patients with acute calculous cholecystitis who underwent scheduled LC after PC between January 2010 and January 2019. Group I included 58 patients who underwent scheduled LC after PHGD. Group II included 45 patients who underwent scheduled LC after PPGD. Clinical outcomes were analyzed according to each group.RESULTSBaseline demographic characteristics did not differ significantly between both groups (P > 0.05). Both PHGD and PPGD were able to quickly resolve cholecystitis sepsis. Group I showed significantly higher efficacy than group II in terms of lower pain score during puncture (3.1 vs 4.5; P = 0.001) and at 12 h follow-up (1.5 vs 2.2; P = 0.001), lower rate of fever within 24 h after PC (13.8% vs 42.2%; P = 0.001), shorted operation duration (118.3 vs 139.6 min; P = 0.001), lower amount of intraoperative bleeding (72.1 vs 109.4 mL; P = 0.001) and shorter length of hospital stay (14.3 d vs 18.0 d; P = 0.001). However, group II had significantly lower rate of local bleeding at the PC site (2.2% vs 20.7%; P = 0.005) and lower rate of severe adhesion (33.5% vs 55.2%; P = 0.048). No significant differences were noted between both groups regarding the conversion rate to laparotomy, rate of subtotal cholecystectomy, complications and pathology.CONCLUSIONB-mode-ultrasound-guided PHGD is superior to PPGD followed by LC for treatment of acute calculous cholecystitis, with shorter operating time, minimal amount of intraoperative bleeding and short length of hospital stay.

Gallbladder microbiota in patients with gallstone disease

The article presents the results of investigating 20 patients with cholelithiasis. The bile and a piece of the gallbladder were taken to analyze microbiota during a scheduled laparoscopic cholecystectomy. The study of microbiota was carried out with the cultural method and real-time PCR. Bifidobacterium spp., Bacteroides spp., Lactobacillus spp., E. coli prevailed in the taxonomic structure of isolated bacteria. Isolated Enterococcus spp. had a lot of genes encoding various factors of pathogenicity.

Surgical treatment of an intraductal papillary mucinous neoplasm of the biliary tract diagnosed by SpyGlass�

We present the case of a 76-year-old male with a history of acute cholecystitis who underwent a scheduled laparoscopic cholecystectomy. Chronic cholecystitis with a thickened cystic duct was observed intraoperatively. The anatomic pathology report found high-grade dysplasia that affected the distal edge of the cystic duct. In view of these findings, an endoscopic retrograde cholangiopancreatography (ERCP) was performed with SpyGlass® and an excrescent lesion suggestive of malignancy adjacent to the cystic-common bile duct junction was observed. A resection of the extrahepatic bile duct was performed with lymphadenectomy of the hepatic hilum and hepaticojejunostomy in a subsequent procedure. The definitive pathology report confirmed pancreaticobiliary intraductal papillary mucinous neoplasia with high-grade dysplasia and free margins.

Segment IV approach for difficult laparoscopic cholecystectomy.

Although achieving the critical view of safety (CVS) is useful for avoiding vasculobiliary injury during laparoscopic cholecystectomy (LC), the CVS cannot always be achieved in cases of severe cholecystitis because of technical difficulties. Herein, we focused on segment IV of the liver and its diagonal line (D‐line) as a feasible landmark for carrying out difficult LC. The D‐line connects the right dorsal and left ventral corners of segment IV and is used as the vectoral landmark, which is where the gallbladder is first dissected to achieve CVS without misidentification. Conversion to subtotal cholecystectomy along the D‐line is also feasible when gallbladder wall scarring is severe. We named this procedure the segment IV approach for LC. Sixty‐two consecutive difficult LC (including 27 scheduled LC after percutaneous transhepatic gallbladder drainage [PTGBD] and 35 conservatively treated cases of Tokyo Guidelines [TG] grade II cholecystitis) were managed by the segment IV approach. Successful gallbladder extraction along the D‐line was achieved in 44 (71%) cases; all of these cases also achieved CVS following total cholecystectomy. The other 18 (29%) cases were converted to subtotal cholecystectomy because gallbladder extraction along the D‐line failed as a result of severe cholecystitis with inflammatory adhesion with surrounding structures. Median operative time and intraoperative blood loss were 135 (range, 54‐290) min and 10 (range, 0‐100) mL, respectively. No intra‐ or postoperative complications were observed. The segment IV approach is feasible for achieving CVS and for considering subtotal cholecystectomy in difficult LC cases where scarring of the gallbladder wall is present.

Percutaneous Transhepatic Gallbladder Drainage Combined with Laparoscopic Cholecystectomy: A Meta-Analysis of Randomized Controlled Trials.

To investigate the clinical effect of the laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGD) in elder acute cholecystitis. The Cochrane Library, PubMed, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang Databases were searched for randomized controlled trials (RCTs) on LC after PTGD in elder acute cholecystitis published from 1970 to July 2017. Two researchers selected RCTs, extracted data, and evaluated methodological quality independently, and RevMan 5.3 software was used for the meta-analysis. The chi-square test was used for heterogeneity analysis of RCTs included, and the funnel plots were used to evaluate publication bias. A total of 9 RCTs with 1000 patients were included in this analysis. Compared with the direct LC Group, the PTGD Group has significant better effect in operative duration (minutes) [standard mean difference (SMD) = -1.37, 95% confidence interval (95% CI): -2.52 to -0.22, P = .02], the amount of intraoperative bleeding (mL) (SMD = -1.38, 95% CI: -2.11 to -0.65, P = .0002), conversion rate to laparotomy (%) [odds ratio (OR) = 0.16, 95% CI: 0.08 to 0.31, P < .00001], postoperative complication morbidity (%) (OR = 0.29, 95% CI: 0.17 to 0.51, P < .0001), and postoperative hospital stay (days) (SMD = -1.26, 95% CI: -1.94 to -0.59, P = .0003). The funnel plots were slightly asymmetric, which suggested the presence of publication bias. The PTGD before scheduled LC can effectively not only shorten operative duration, intraoperative bleeding less, and postoperative hospital stay but also decrease the rate to laparotomy and postoperative complication morbidity in elder acute cholecystitis, and it is recommended to be regarded as the preferred therapy of the elder patients.

A randomised controlled trial of propofol vs. thiopentone and desflurane for fatigue after laparoscopic cholecystectomy

Fatigue may delay functional recovery after day surgery and may be more common after propofol anaesthesia. We randomly allocated 123 participants scheduled for ambulatory laparoscopic cholecystectomy to induction and maintenance of general anaesthesia with propofol or thiopentone and desflurane. Postoperative fatigue was unaffected by the allocated anaesthetic. The combined mean (SD) Identity-Consequences Fatigue Scale of 34.3 (15.1) before surgery increased in the first postoperative week: to 60.4 (21.1) on day 1, p < 0.001; to 51.1 (17.2) on day 2, p < 0.001; and to 37.5 (16.3) on day 6, p = 0.028. The mean (SD) fatigue reduced at one postoperative month to 22.4 (12.6), 35% less than the combined pre-operative level, p < 0.001. Rates of nausea, vomiting and rescue antie-mesis during the first week after propofol, compared with thiopentone and desflurane, were: 23/63 vs. 32/60, p = 0.27; 8/63 vs. 9/60, p = 0.71; and 12/63 vs. 28/60, p = 0.001, respectively. There were no differences in postoperative pain. In conclusion, fatigue after scheduled laparoscopic cholecystectomy was unaffected by anaesthesia with propofol vs. thiopentone and desflurane.

Impact of scheduled laparoscopic cholecystectomy in patients with acute cholecystitis, following percutaneous transhepatic gallbladder drainage.

Backgrounds/AimsFrequently encountered in practice, the first-line treatment for acute cholecystitis is early or urgent cholecystectomy, with laparoscopic cholecystectomy (LC) being the preferred method. Percutaneous transhepatic gallbladder drainage (PTGBD) is considered as a safe alternative therapeutic option for resolving acute cholecystitis in surgically high-risk patients. We evaluated the surgical outcomes of acute cholecystitis, focusing on the differences between emergent LC without PTGBD, and scheduled LC following PTGBD.MethodsBetween March 2010 and December 2014, 294 patients with acute cholecystitis who had undergone LC, were retrospectively studied. Group I included 166 patients who underwent emergency LC without PTGBD. Group II included 128 patients who underwent scheduled LC after PTGBD. Clinical outcomes were analyzed according to each group.ResultsOn admission, Group II had a higher mean level of c-reactive protein than Group I. According to the classification of the American Society of Anesthesiologists (ASA), group II had a greater number of high-risk patients than group I. There was no significant difference on perioperative outcomes between the two groups, including open conversion rate and complications. Analysis as per the ASA classes revealed no statistically remarkable finding between the groups.ConclusionsThere are no significant differences in the surgical outcomes of emergency LC group without PTGBD, and scheduled LC group following PTGBD. Comparison between two groups according to ASA classification reflecting the comorbidity and severity of condition of the patients also revealed no significant differences. However, scheduled LC following PTGBD is important for patients having acute cholecystitis with concurrent comorbidity.

Effect of hepatic function on the EC50 of midazolam and the BIS50 at the time of loss of consciousness.

To explore the effect of hepatic function on loss of consciousness (LOC) and bispectral index (BIS) during sedation with midazolam (MDZ). Forty-five patients were assigned to three groups according to their liver function. Thirty of these patients with diagnoses of cholelithiasis were scheduled laparoscopic cholecystectomy, including 15 patients with normal liver function (normal group), and 15 patients with moderately abnormal liver function based on the results of ultrasonic diagnosis of a moderately fatty liver and elevated alanine transaminase levels of less than three times normal (moderate group). The other 15 patients with end-stage liver disease (severe group) underwent liver transplantation. Each patient was administered MDZ by way of target-controlled infusion to increase the concentration gradually. At the time of LOC, the BIS was recorded and a blood sample was withdrawn for measurement of the concentration of MDZ. The concentration of MDZ (EC50) and the BIS value (BIS50) at which 50% of patients lose consciousness were calculated using logistic regression. At the time of LOC, the EC50 of MDZ and the BIS50 were similar in the normal and moderate groups (P>0.05). LOC occurred at a lower EC50 of MDZ and at a higher BIS50 in the severe group, compared with the normal and moderate groups (P<0.01). Patients with end-stage liver disease were more sensitive to MDZ and this affected the prediction of their time of LOC following MDZ administration. There were no changes in response in patients with moderately abnormal hepatic function.

Su1735 Risk Factors Related to Open Converted Cholecystectomy in Patients With Cholelithiasis After Endoscopic Removal of Choledocholithiasis

Su1735 Risk Factors Related to Open Converted Cholecystectomy in Patients With Cholelithiasis After Endoscopic Removal of Choledocholithiasis Yong-Hwan Kwon*, Chang-MIN Cho, MIN Kyu Jung, Seongwoo Jeon Internal Medicine, Kyungpook National University medical center, Daegu, Republic of Korea Background and aims: Laparoscopic cholecystectomy (LC) has been established as the gold standard management for symptomatic patients with cholelithiasis. Sometimes, it is inevitable to convert to open cholecystectomy (OC) in patients who planned to LC. In patient with GB and CBD stones, endoscopic removal of CBD stone may cause inflammation that is associated with adhesion adjacent to gallbladder. It is related to open converted cholecystectomy (OCC). However, there are few studies about which factors related to endoscopic retrograde cholangiopancreatography (ERCP) may influence conversion to OC. The purpose of this study was to evaluate the risk factors related with OCC in patients who were planned to LC after endoscopic removal of choledocholithiasis (ERC). Patients and Methods: The data for all patients who underwent LC or OCC after endoscopic removal of bile duct stone at our institution between January 2001 and December 2010 were retrospectively reviewed. Factors predictive for conversion were analyzed. Results: Three hundred seven patients underwent endoscopic removal of choledocholithiasis followed by scheduled LC. Among them, 48 patients (15.6%) needed conversion to OC. The most common cause of conversion to OC was anatomical adhesion in operation field (37.5%). Cholecystitis (p!0.005), percutaneous transhepatic biliary drainage (PTBD) or percutaneous gallbladder drainage (PTGBD) (pZ0.005), mechanical lithotripsy (p!0.005), multiple stones (pZ0.011), and multiple endoscopic trials of stone removal (pZ0.006) were significantly related to conversion in univariate analysis. In multivariate analysis, cholecystitis (OR 2.844, 95%CI 1.301-6.214, pZ0.009), mechanical lithotripsy (OR 6.881, 95%CI 2.142-22.109, p!0.005), multiple stones (OR 2.308, 95%CI 1.1614.590, pZ0.017), and multiple trials of stone removal (OR 3.180, 95%CI 1.0209.916, pZ0.046) were associated with OCC. Analyzing the OCC-related risk factors according to the duration from ERC to LC, mechanical lithotripsy (OR 16.161, 95% CI 2.971-87.895, p!0.005), multiple stones (OR 3.400, 95%CI 1.095-10.556, pZ0.034), and multiple trials of ERC (OR 8.632, 95%CI 1.072-69.481, pZ0.043) were significantly related to OCC within 2 weeks. However, there was no significant risk factor for conversion to OC after 2 weeks. Conclusions: In patients who had combined choledocholithiasis and cholelithiasis, considering risk factors related to open conversion cholecystectomy will be helpful determining the timing of LC, and if the patients had these endoscopic related risk factors, it is better to delay LC after 2 weeks from ERCP. Table 1. The risk factors of LC and OC after ERC www.giejournal.org LC (N[259) OC (N[48) Univariate P value Multivariate P value Age (years old) 61.9 15.2 60.8 16.1 0.665 Gender 0.076 Male 151 (58.3%) 35 (72.9%) Female 108 (41.7%) 13 (27.1%)

Su1736 Is Spontaneous Pancreatic Stent (Ps) Migration a Predictor of Early Recurrent Symptoms in Patients With Suspected or Proven Sphincter of Oddi Dysfunction (SOD)?

Su1735 Risk Factors Related to Open Converted Cholecystectomy in Patients With Cholelithiasis After Endoscopic Removal of Choledocholithiasis Yong-Hwan Kwon*, Chang-MIN Cho, MIN Kyu Jung, Seongwoo Jeon Internal Medicine, Kyungpook National University medical center, Daegu, Republic of Korea Background and aims: Laparoscopic cholecystectomy (LC) has been established as the gold standard management for symptomatic patients with cholelithiasis. Sometimes, it is inevitable to convert to open cholecystectomy (OC) in patients who planned to LC. In patient with GB and CBD stones, endoscopic removal of CBD stone may cause inflammation that is associated with adhesion adjacent to gallbladder. It is related to open converted cholecystectomy (OCC). However, there are few studies about which factors related to endoscopic retrograde cholangiopancreatography (ERCP) may influence conversion to OC. The purpose of this study was to evaluate the risk factors related with OCC in patients who were planned to LC after endoscopic removal of choledocholithiasis (ERC). Patients and Methods: The data for all patients who underwent LC or OCC after endoscopic removal of bile duct stone at our institution between January 2001 and December 2010 were retrospectively reviewed. Factors predictive for conversion were analyzed. Results: Three hundred seven patients underwent endoscopic removal of choledocholithiasis followed by scheduled LC. Among them, 48 patients (15.6%) needed conversion to OC. The most common cause of conversion to OC was anatomical adhesion in operation field (37.5%). Cholecystitis (p!0.005), percutaneous transhepatic biliary drainage (PTBD) or percutaneous gallbladder drainage (PTGBD) (pZ0.005), mechanical lithotripsy (p!0.005), multiple stones (pZ0.011), and multiple endoscopic trials of stone removal (pZ0.006) were significantly related to conversion in univariate analysis. In multivariate analysis, cholecystitis (OR 2.844, 95%CI 1.301-6.214, pZ0.009), mechanical lithotripsy (OR 6.881, 95%CI 2.142-22.109, p!0.005), multiple stones (OR 2.308, 95%CI 1.1614.590, pZ0.017), and multiple trials of stone removal (OR 3.180, 95%CI 1.0209.916, pZ0.046) were associated with OCC. Analyzing the OCC-related risk factors according to the duration from ERC to LC, mechanical lithotripsy (OR 16.161, 95% CI 2.971-87.895, p!0.005), multiple stones (OR 3.400, 95%CI 1.095-10.556, pZ0.034), and multiple trials of ERC (OR 8.632, 95%CI 1.072-69.481, pZ0.043) were significantly related to OCC within 2 weeks. However, there was no significant risk factor for conversion to OC after 2 weeks. Conclusions: In patients who had combined choledocholithiasis and cholelithiasis, considering risk factors related to open conversion cholecystectomy will be helpful determining the timing of LC, and if the patients had these endoscopic related risk factors, it is better to delay LC after 2 weeks from ERCP. Table 1. The risk factors of LC and OC after ERC www.giejournal.org LC (N[259) OC (N[48) Univariate P value Multivariate P value Age (years old) 61.9 15.2 60.8 16.1 0.665 Gender 0.076 Male 151 (58.3%) 35 (72.9%)

Impact of Delayed Laparoscopic Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage for Patients With Complicated Acute Cholecystitis

Laparoscopic cholecystectomy (LC) for complicated acute cholecystitis is associated with high rates of complications and conversion to open cholecystectomy. Percutaneous transhepatic gallbladder drainage (PTGBD) is a safe and effective treatment for acute inflammation of the gallbladder. This study was a retrospective analysis of patients who underwent an LC with or without PTGBD for complicated acute cholecystitis at our hospital between January 2002 and January 2007. Patients were classified into 3 groups: group 1, patients who underwent an LC without preoperative PTGBD (n=60); group 2, patients who underwent an early scheduled LC within 7 days of PTGBD (n=35); and group 3, patients in whom the LC was delayed for a mean of 19.9 days (range, 14 to 39 d) after PTGBD (n=38). The conversion rate to open cholecystectomy and the postoperative complication rate were lower in group 3 than in group 1 (P<0.05). Elective delayed LC after PTGBD may lower the conversion and complication rates of patients with complicated acute cholecystitis.

Foramen of Winslow hernia

Foramen of Winslow hernia is a rare surgical condition that is notoriously difficult to diagnose and most patients are diagnosed only at the time of surgery. As such, a high index of suspicion is necessary to avoid potentially life‐threatening complications. The present paper describes two such cases. In the first case, a freely suspending gall bladder herniated into the lesser sac via the foramen of Winslow. This was diagnosed during a scheduled laparoscopic cholecystectomy. In the second case, the caecum herniated into the foramen of Winslow causing small bowel obstruction and ischaemic hepatitis. Diagnostic dilemma and treatment of the condition is also described.