Subtotal Cholecystectomy Research Articles

Subtotal Cholecystectomy Results in High Peri-operative Morbidity and Its Risk-Profile Should be Emphasised During Consent

BackgroundSubtotal cholecystectomy aims to reduce the likelihood of bile duct injury but risks a multitude of less severe, yet significant complications. The primary aim of the present study was to report peri-operative outcomes of subtotal laparoscopic cholecystectomy (SLC) relative to total laparoscopic cholecystectomy (TLC) to inform the consent process.MethodAll laparoscopic cholecystectomies between 2015 and 2020 in one health board were included. The peri-operative outcomes of SLC (n = 87) and TLC (n = 2650) were reported. Pre-operative variables were compared between the two groups to identify risk factors for SLC. The outcomes between the SLC and TLC were compared using univariate, multivariate and propensity analysis.ResultsRisk factors for SLC included higher age, male gender, cholecystitis, increased biliary admissions, ERCP, cholecystostomy and emergency cholecystectomy. Following SLC, rates of post-operative complication (45.9%), imaging (37.9%) intervention (28.7%) and readmission (29.9%) were significant. The risk profile was vastly heightened compared to that of TLC: intra-operative complications (RR 9.0; p < 0.001), post-operative complications [bile leak (RR 58.9; p < 0.001), collection (RR 12.2; p < 0.001), retained stones (RR 7.2; p < 0.001) and pneumonia (RR 5.4; p < 0.001)], post-operative imaging (RR 4.4; p < 0.001), post-operative intervention (RR 12.3; p < 0.001), prolonged PLOS (RR 11.3; p < 0.001) and readmission (RR 4.5; p < 0.001). The findings were consistent using multivariate logistic regression and propensity analysis.ConclusionThe relative morbidity associated with SLC is significant and high-risk patients should be counselled for the peri-operative morbidity of subtotal cholecystectomy.

S2885 Endoscopic Ultrasound-Guided Drainage of a Remnant Gallbladder

Introduction: Endoscopic Ultrasound (EUS) guided drainage of a remnant gallbladder (RGB) with lumen-apposing metal stents (LAMS) can be safely performed for suppurative cholecystitis and choledocholithiasis following subtotal cholecystectomy (STC). Case Description/Methods: A 68-year-old man presented with recurrent bacteremia secondary to symptomatic RGB after undergoing STC for severe necrotizing gallstone pancreatitis. His preceding course was complicated by infected walled-off pancreatic necrosis, recurrent choledocholithiasis with ascending cholangitis, liver abscess, and bacteremia. His treatments included EUS-guided necrosectomy, multiple endoscopic retrograde cholangiopancreatopgraphies (ERCPs) with unsuccessful attempts at transpapillary gallbladder drainage, and percutaneous cholecystostomy followed by laparoscopic STC. Given his life-threatening complications and poor surgical candidacy EUS-guided drainage of the RGB was pursued. Linear EUS identified the RGB measuring 19.4mm in diameter. Using a 19-gauge FNA needle, the RGB was instilled with 80cc of sterile saline to a diameter of 28.5mm (Figure a). EUS-guided cholecystogastrostomy was then performed using a 10 x 15 mm electrocautery-enabled access catheter-enhanced LAMS. The LAMS was dilated to 12mm sequentially using a controlled radial expansion balloon. Multiple large, pigmented stones passed with several remaining in the gallbladder (Figure b). A 10Fr by 5cm double pigtail stent was passed over a wire into the gallbladder to complete the procedure (Figure c). At one month follow-up ERCP, the LAMS was removed leaving a mature gastrocholecystic fistula. No recurrence of symptoms noted at 12-month follow-up. Discussion: Laparoscopic cholecystectomy after recovery of gallstone pancreatitis is recommended to reduce risk of recurrent pancreatitis. In some patients, difficult anatomy and inflammation necessitates STC to avoid injury to the extrahepatic bile ducts and surrounding blood vessels. STC is associated with significant morbidity. Completion cholecystectomy for symptomatic complications from RBG is recommended if possible. However, our patient was deemed a poor surgical candidate. Transpapillary drainage of the RBG was also precluded by difficult anatomy with sharp angulation at the confluence of the common hepatic and cystic ducts. This case describes the novel application of EUS-guided drainage of an RBG as a safe and effective alternative to completion cholecystectomy for patients who are poor operative candidates.Figure 1.: EUS used to measure dimensions of remnant gallbladder after injecting 80mL of sterile saline (A). Cholecystogastrostomy was performed using a 10 mm X 15 mm LAMS with cautery tip over a wire and dilated using a controlled radial expansion balloon (B). A double pigtail stent was placed through the lumen of the LAMS (C).

S372 Cystic Artery Pseudoaneurysm: A Rare Case of Upper Gastrointestinal Bleeding

Introduction: Cystic artery pseudoaneurysm (CAP) is a rare complication of acute cholecystitis and cholecystectomy. We present an unusual case of upper GI bleed due to CAP. Case Description/Methods: An elderly female presented with one month history of lethargy and unintentional weight loss. Clinical exam was unremarkable apart from pallor. Blood tests revealed severe iron deficiency anaemia and bland cholestasis. CT scan showed a common bile duct (CBD) mass and a gallbladder (GB) neck lesion with prominent regional lymph nodes, which was worrying for biliary malignancy. MRI scan showed a 3cm CBD stone with acute emphysematous cholecystitis and possible CAP at the GB neck. An urgent OGD and ERCP was done on the same day as she developed hematemesis and cholangitis. On endoscopy, there was active bleeding from possible enteric fistula at first part of duodenum (D1), this was treated with metal clips. During ERCP, haemobilia was noted on CBD cannulation. On cholangiogram, the endoclips were adjacent to distal CBD stone. A plastic stent was inserted into the CBD and she was referred to the surgeons. Cholecystectomy and CBD exploration was performed for definitive treatment. Intra-operatively, there was active bleeding into the GB from CAP. D1 was thinned out with adhesions to the GB. There was stale blood in the bile duct but no biliary-enteric fistula seen. CAP was sutured, adhesiolysis, subtotal cholecystectomy, omental patch repair of D1 and CBD stone was retrieved. Repeat OGD and ERCP with CBD stent removal done 2 months later showed healed D1 mucosa. Discussion: The clinical features of CAP include right upper quadrant pain, upper GI bleed due to haemobilia and abnormal liver enzymes. It is diagnosed on arterial phase of CT scan, angiography, MRI or during surgery. It is treated with surgery or angioembolization. This is a challenging case with delayed diagnosis of CAP as she lacks the typical presentation of CAP. A plain contrasted CT without arterial phase was done initially, which have mistaken the CAP as soft tissue lesion in GB. Endoscopic findings raises possibility of choledocho-duodenal fistula; this was excluded during surgery. The final diagnosis is acute calculous cholecystitis complicated by CAP with direct pressure on D1 leading to upper GI bleed. To our knowledge, this is the first case of CAP with such entity. In conclusion, CAP should be considered in patients with symptomatic gallstone disease and upper GI bleed in order to select appropriate imaging modality and guide therapy. Watch the video at https://tinyurl.com/ACGAbstractS372

S1767 Metastatic Solid Pseudopapillary Neoplasm of the Pancreas, Rare Presentation of an Uncommon Tumor

Introduction: Solid pseudopapillary neoplasms (SPN) make up less than 3% of all diagnosed pancreatic neoplasms. Abdominal CT or MRI are the imaging modalities most utilized, and biopsy is necessary to confirm the diagnosis. Resection of the mass is standard of care and the prognosis is quite good, with 5-year survival rates of over 95%. Both recurrence and metastasis of the tumor are exceedingly rare, occurring in only 1-4% of patients. Case Description/Methods: A 26-year-old female presented with several years of abdominal pain. CT scan revealed a 10cm mass in the neck and body of the pancreas and patient underwent a hybrid resection including subtotal pancreatectomy, splenectomy, and cholecystectomy. Pathology showed a neoplasm extending to the inked margins with positive beta-catenin and CD10 nuclear staining with no evidence of metastasis. At the age of 32, the patient presented again with abdominal pain. A CT and PET scan showed numerous LUQ, perirenal, pancreatic, and periadrenal soft tissue densities. Laparoscopic resection of a 3.5x3 cm soft tissue mass near the remnant pancreas was performed, showing fibrous stroma with angulated islands of epithelioid cells with cystic degeneration and positive staining for vimentin, CD56, and beta-catenin. Resection of multiple abdominal soft tissue tumors, in bulk measuring more than 10 cm, as well as complete omentectomy, left adrenalectomy, bilateral salpingo-oophorectomy, appendectomy, and hyperthermic intraperitoneal chemotherapy with cisplatin was performed. Pathology showed multiple metastatic tumors all consistent with SPN. The appendix, left adrenal gland, bilateral ovaries, and all lymph nodes were negative for any tumor. Two years later, MRI revealed 3.0 x 2.1 cm hyperintense lesion in the caudate lobe of the liver. EUS with biopsy was performed, revealing clusters of uniform, bland cells with ovoid nuclei and associated fibrillary stroma circumscribing vessels with a background of hemorrhagic debris (Figure). Immunohistochemistry showed cells positive for vimentin, LEF1, and beta-catenin, again consistent with SPN. Discussion: This is one of the few cases of multiple instances of both recurrence and metastasis of SPN documented in the literature. This case report shows that serial imaging studies and close follow-up are needed even years after resection and that, although rare, recurrence and metastasis can occur more than one time after the initial diagnosis.Figure 1.: Biopsy of the caudate liver lesion showing clusters of uniform, bland cells with ovoid nuclei and associated fibrillary stroma and hemorrhagic debris, consistent with SPN.

S2835 Gastro-Cholecysto-Colonic Fistula Following Endoscopic Ultrasound-Guided Gallbladder Drainage for Stump Cholecystitis: A Case Report

Introduction: Cholecystocolonic fistulas (CCF) usually occur as a complication of gallstones but cases due to malignancy, peptic ulcers, and Crohn’s disease have been reported. We present a case of a gastro-cholecysto-colonic fistula after endoscopic ultrasound guided-gallbladder drainage (EUS-GBD) for stump cholecystitis. Case Description/Methods: A 50 year old male presented with abdominal pain. CT scan noted acute cholecystitis. He underwent laparoscopic converted to open subtotal cholecystectomy due to significant inflammation around the gallbladder. He represented 3 weeks later for abdominal pain. CT showed stump cholecystitis. Gastroenterology was consulted for EUS-GBD given his poor surgical candidacy. Diagnostic EUS revealed choledocholithiasis. Endoscopic retrograde cholangiography (ERC) with cholangioscopy, electrohydraulic lithotripsy, and stone removal was completed. Transgastric EUS-GBD with a 10 x 10 mm electrocautery enhanced lumen apposing metal stent (LAMS) was then performed followed by double pigtail stent (DPT) placement within the LAMS. At a follow up visit, abdominal pain resolved but he developed debilitating diarrhea and was started on cholestyramine. Upper endoscopy 4 weeks after EUS-GBD revealed a gastro-cholecysto-colonic fistula with the proximal end of the DPT in the colon. Cholecystoscopy confirmed absence of gallstones so the LAMS and DPT were removed. Clips were used to close the cholecystogastric tract. Oral contrasted CT with delayed images showed tethering of the gallbladder to the hepatic flexure but no extravasation of contrast into the gallbladder from either the stomach or colon. Given this, clinical observation was pursued. Six weeks later, CT noted similar tethering without contrast leak. On colonoscopy, an area of inflamed mucosa at the hepatic flexure was seen without a patent fistula tract. Biopsies showed chronic colitis. Diarrhea subsequently resolved. (Figure) Discussion: CCFs are a rare complication of gallstone disease. If untreated, biliary sepsis can occur. Surgery is the standard treatment but endoscopic transpapillary gallbladder drainage with a DPT can promote fistula healing in non-surgical patients. We present a case of a gastro-cholecysto-colonic fistula in a poor surgical candidate after EUS-GBD for stump cholecystitis. This was managed with closure of the cholecystogastric tract. CCF closure occurred spontaneously. In cases of persistent CCF, transpapillary gallbladder drainage should be considered.Figure 1.: A. Double pigtail stent migrated into transverse colon with gastro-cholecysto-colonic fistula as viewed from the gallbladder lumen. B. CT scan showing tethering of hepatic flexure to remnant gallbladder (red arrow) without contrast extravasation into the gallbladder from the stomach or colon. C. Closed cholecystocolonic fistula (black arrow) viewed from the hepatic flexure.

IATROGENIC INJURIES OF SUBVESICAL BILE DUCT - CASE REPORT AND LITERATURE REVIEW

With the rise of laparoscopic cholecystectomy as the gold standard for treating gallbladder calculi andpolyps, subvesical bile ducts are gaining increased clinical importance. With the introduction of electrocautery insurgery, a large part of these tubular structures, although with interrupted continuity, do not show extravasation ofbile content postoperatively. Decreased bile production during general anesthesia and increased intraperitonealpressure also make diagnosis of injuries difficult. Surgeons who frequently operate in the right upper quadrant haveto understand the anatomy of the biliary tree and its tendency for structural variation. The work of laparoscopicsurgeons should be conceptualized around three main goals: to enable safe identification of key anatomicalstructures, usually by providing a critical point of safety (Critical View of Safety), to make a decision at the rightmoment not to proceed with laparoscopic surgery when working conditions become too dangerous and there is nopossibility of identification of structures and to end the laparoscopic surgery with subtotal cholecystectomy whenidentification of structures is impossible. Controversy among authors on the naming of the various subvesicalstructures causes confusion in their identification and description. In order to overcome these challenges, there was aneed to establish classification systems for post-cholecystectomy lesions of the biliary tract. But due to theindividual shortcomings of all these systems, in June 2011, during the 19th meeting of the European Association forEndoscopic Surgery in Turin, Italy, a conference was held to reach a consensus to establish a uniform classificationof iatrogenic bile duct injuries that will have two primary goals: first, to take into account changes in the type ofinjuries with the introduction of laparoscopic cholecystectomy, and second, to combine all existing classificationsystems and integrate them into one, universally accepted classification system. As part of the new inclusiveclassification system for iatrogenic injuries of the biliary ducts, the following systems are considered: Bismuth,Strasberg et al., McMahon et al., AMA, Neuhaus et al., Csendes et al., Steward et al., Hanover, Lau and Lai ,Siewert et al., Cannon et al., Kapoor., Sandha et al.. In the new system a total of fifteen classifications areincorporated using semantic connotations and grouped into three categories that will allow easy memorization bysurgeons. A (anatomy) for anatomy, To (time of) for time/moment of observation and M (mechanism) for themechanism of occurrence of the injury. By enabling a more precise classification of each of the injuries, the surgicalcommunity will have the opportunity to develop recommendations for prevention, treatment and prognosis for theiroutcome.

Evaluation of Textbook Outcome as a Composite Quality Measure of Elective Laparoscopic Cholecystectomy

A textbook outcome (TO) is a composite quality measure that incorporates multiple perioperative events to reflect the most desirable outcome. The use of TO increases the event rate, captures more outcomes to reflect patient experience, and can be used as a benchmark for quality improvement. To introduce the concept of TO to elective laparoscopic cholecystectomy (LC), propose the TO criteria, and identify characteristics associated with TO failure. This retrospective cohort study was performed at 3 surgical units in a single health board in the United Kingdom. Participants included all patients undergoing elective LC between January 1, 2015, and January 1, 2020. Data were analyzed from January 1, 2015, to January 1, 2020. The TO criteria were defined based on review of existing TO metrics in the literature for other surgical procedures. A TO was defined as an unremarkable elective LC without conversion to open cholecystectomy, subtotal cholecystectomy, intraoperative complication, postoperative complications (Clavien-Dindo classification ≥2), postoperative imaging, postoperative intervention, prolonged length of stay (>2 days), readmission within 100 days, or mortality. The rate of TOs was reported. Reasons for TO failure were reported, and preoperative characteristics were compared between TO and TO failure groups using both univariate analysis and multivariable logistic regressions. A total of 2166 patients underwent elective LC (median age, 54 [range, 13-92] years; 1579 [72.9%] female). One thousand eight hundred fifty-one patients (85.5%) achieved a TO with an unremarkable perioperative course. Reasons for TO failure (315 patients [14.5%]) included conversion to open procedure (25 [7.9%]), subtotal cholecystectomy (59 [18.7%]), intraoperative complications (40 [12.7%]), postoperative complications (Clavien-Dindo classification ≥2; 92 [29.2%]), postoperative imaging (182 [57.8%]), postoperative intervention (57 [18.1%]), prolonged length of stay (>2 days; 142 [45.1%]), readmission (130 [41.3%]), and mortality (1 [0.3%]). Variables associated with TO failure included increasing American Society of Anesthesiologists score (odds ratio [OR], 2.55 [95 CI, 1.69-3.85]; P < .001), increasing number of prior biliary-related admissions (OR, 2.68 [95% CI, 1.36-5.27]; P = .004), acute cholecystitis (OR, 1.42 [95% CI, 1.08-1.85]; P = .01), preoperative endoscopic retrograde cholangiopancreatography (OR, 2.07 [95% CI, 1.46-2.92]; P < .001), and preoperative cholecystostomy (OR, 3.22 [95% CI, 1.54-6.76]; P = .002). These findings suggest that applying the concept of TO to elective LC provides a benchmark to identify suboptimal patterns of care and enables institutions to identify strategies for quality improvement.

A DUSTED INDICATION FOR PROPHYLACTIC CHOLECYSTECTOMY AND YET FREQUENTLY CONSIDERED A SIGNIFICANT RISK FACTOR FOR DIFFICULT CHOLECYSTECTOMY: DM AND FATTY LIVER, SHOULD BE FOCUSED AGAIN AS AN INDICATION FOR PROPHYLACTIC CHOLECYSTECTOMY. A SHORT TERM FOLLOW UP STUDY OF LAPAROSCOPIC RECONSTITUTING SUBTOTAL CHOLECYSTECTOMY

Background: Laparoscopic subtotal cholecystectomy has vital benefit in preventing severe bile duct injuries and outweighs the morbidity associated with subtotal gall bladder removal in certain circumstances. We Methods: evaluated the 81 patients who underwent Laparoscopic Reconstituting Subtotal cholecystectomy during July 2019 to Jan 2022. Preoperative parameters (Age, Gender, DM, Smoking, Alcohol, Fatty Liver) and postoperative parameters (Duration of surgery, Hospital Stay, Postoperative Bile leak, Postoperative ERCP stenting, retained stone, Mortality) were compared. Aim of the study was to evaluate outcome of the surgery and to identify the risk factors of bile leak. Results: Bile leak occurred in 5 patients (6.2%). All patient who had bile leak had fatty liver (p = 0.019, chi square test). Four out of five patients were diabetic (p = 0.079, ฀2 test). Four of five patients who had leak were above 50 yrs. of age group (P= 0.517, chi square test). Mean duration of surgery was higher for both Diabetic patients and Fatty liver patients, but statistically significant results were seen for Diabetics only (T test p=0.008). Laparoscopic recon Conclusion: stituting Subtotal Cholecystectomy is safe approach for the difficult cholecystectomy and with minimal/no risk of retained stones. Diabetes mellites and fatty liver are the risk factors to predict difficult cholecystectomy and we suggest the need for reconsideration of the recommendation for prophylactic cholecystectomy in diabetic patients with Asymptomatic cholelithiasis.

Early Outcomes of Subtotal vs Total Cholecystectomy for Acute Cholecystitis

This cohort study compares outcomes including hospital length of stay and 30-day rates of complications after nonelective subtotal cholecystectomy vs total cholecystectomy among patients with cholecystitis.

Posterior First Infundibular Dissection: Another Safe Approach in Laparoscopic Cholecystectomy

Objective: To test the efficacy of posterior infundibular dissection during Laparoscopic cholecystectomy Place and duration of the study: Surgical ward of Bakhtawar Amin Trust Teaching Multan for 1 year Study design: A retrospective study Methodology: A total of 150 patients undergoing laparoscopic cholecystectomy were included in the study. Firstly, the bile duct, Calot's node and gallbladder neck were identified along with the lower third of the common duct. An incision was made in the peritoneum anterior to the Calot's node at infundibulum and extended laterally and posteriorly. By retracting the gallbladder cephalad and medially, dissection continued in avascular plane between posterior wall of gall bladder and posterior branch of cystic artery. Anteriorly, a plane is created above the calot’s node and inferior to cystic artery, which was facilitated by posterior dissection of infundibulum. Posterior clipping and division of the cystic artery and duct was done. The rest of the gallbladder was dissected from the liver. Results: 120 patients (80%) had an elective LC status and 30 patients (20%) underwent an emergency LC. 2 patients (1.3%) underwent subtotal cholecystectomy.26 patients (18%) underwent MRCP due to suspicion of stones. Out of these 26 patients, 3 patients (11.5%) underwent ERCP due to the presence of stones.No bile duct injury was recorded. Conclusion: Posterior first infundibular dissection reduces the risk of bile duct injury and ensures safe laparoscopic cholecystectomy. Keywords: Laparoscopic cholecystectomy, infundibular dissection, bile duct injury, cholecystectomy, safe calot’s dissection.

Indications and Outcomes of Completion Cholecystectomy: A 5-year Experience From a Rural Tertiary Center.

Completion cholecystectomy (CC) is performed for recurrent or persistent biliary symptoms following subtotal cholecystectomy (STC) or incomplete cholecystectomy (IC). Due to its complexity, cases are often referred to hepato-pancreato-biliary (HBP) surgeons. There is little published literature on indications or outcomes of CC. Completion cholecystectomy cases performed between 2016 and 2021 by the sole HPB surgeon covering a rural referral base of >250-mile radius in West Texas were included. Primary variables of interest include indications and outcomes of CC. Of the eleven patients included, 5 (45.5%) had laparoscopic STC, 3 patients (27.3%) had laparoscopic converted to open STC, and 2 (18.2%) had laparoscopic IC. Most STC cases (6/9, 66.6%) were reconstituting, while 3 STC cases were fenestrating (all had persistent bile leak). For reconstituting STC, indications were symptomatic cholelithiasis in 5 patients (45.5%), and choledocholithiasis in 3 patients (27.3%). The median (IQR) duration between index procedure and subsequent CC was 15 (1.4-92) months. The median (IQR) remnant gallbladder length was 4 (3-4.5) cm. Completion cholecystectomy was performed robotically in 8 cases (72.7%). Post-CC complications occurred in 3 patients (27.3%); these were 1 superficial surgical site infection, 1 hepatic abscess requiring percutaneous drainage, and lastly atrial fibrillation. All patients requiring CC had residual gallbladder remnant >2.5cm; this is longer than recommended for STC. Completion cholecystectomy is a complex operation that carries significant morbidity, even when performed using minimally invasive techniques. As bailout procedures become more common in severely inflamed cholecystitis, it is important to collate more data on the outcomes of requiring CC.

1022 Early Cholecystectomy in the Ageing Population

Abstract Background The age group of patients presenting acutely with biliary pathology is rising and gallstone disease can no longer be said to be a disease of the young. The World Health Organisation classifies those aged 65 and over as elderly. Early cholecystectomy is accepted as a safe and effective method of managing acute biliary pathology, reducing further admissions, and reducing in-hospital stays. Our unit does not use age as barrier but uses performance status and co-morbidity to identify potential candidates for cholecystectomy. Method Patients over the age of 65 who underwent acute cholecystectomy (AC) via the emergency cholecystectomy lists, were audited from 31st December 2019 to 31st June 2021. Patient demographics, co-morbidities and surgical factors were recorded. The primary outcome measures were in-hospital stay and re-admission, secondary outcomes were complications and perioperative mortality. Results 41 elderly patients underwent AC during the audit period, (Female 56%, Male 44%). 30 patients had acute cholecystitis (73%). The median inpatient stay following surgery was 2 days (range 2–5 days) and the median admission to surgery time was 6 days (range 5–12 days). Three patients had a subtotal cholecystectomy. There were 3 complications from surgery which were all between a Clavien-Dindo score of 2 and 3. There were 3 immediate post-operative readmissions, with one 30-day mortality from ERCP pancreatitis and not from the operation. Conclusion Early cholecystectomy appears to be a safe and effective treatment for this group of patients and based on this evidence we should continue to offer this treatment to patients irrespective of age.

Evidence-based surgery for laparoscopic cholecystectomy

BackgroundLaparoscopic cholecystectomy is frequently performed for acute cholecystitis and symptomatic cholelithiasis. Considerable variation in the execution of key steps of the operation remains. We conducted a systematic review of evidence regarding best practices for critical intraoperative steps for laparoscopic cholecystectomy. MethodsWe identified 5 main intraoperative decision points in laparoscopic cholecystectomy: (1) number and position of laparoscopic ports; (2) identification of cystic artery and duct; (3) division of cystic artery and duct; (4) indications for subtotal cholecystectomy; and (5) retrieval of the gallbladder. PubMed, EMBASE, and Web of Science were queried for relevant studies. Randomized controlled trials and systematic reviews were included for analysis, and evidence quality was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation framework. ResultsFifty-two articles were included. Although all port configurations were comparable from a safety standpoint, fewer ports sometimes resulted in improved cosmesis or decreased pain but longer operative times. The critical view of safety should be obtained for identification of the cystic duct and artery but may be obtained through fundus-first dissection and augmented with cholangiography or ultrasound. Insufficient evidence exists to compare harmonic-shear, clipless ligation against clip ligation of the cystic duct and artery. Stump closure during subtotal cholecystectomy may reduce rates of bile leak and reoperation. Use of retrieval bag for gallbladder extraction results in minimal benefit. Most studies were underpowered to detect differences in incidence of rare complications. ConclusionKey operative steps of laparoscopic cholecystectomy should be informed by both compiled data and surgeon preference/patient considerations.

WE2.12 Prognostic Factors and Predictive Models in Hot Gallbladder Surgery. Results of a High-Volume Tertiary Centre

Abstract Introduction Gallstone disease is a significant worldwide problem constituting almost one third of emergency general surgery admissions. This study aimed identify the prognostic factors and create statistical models to predict the outcomes of having an emergency laparoscopic cholecystectomy (LC) during the acute symptomatic phase. Methods A prospective, cohort study was conducted on all patients that underwent a LC for a hot gallbladder between January 2019 to August 2020. Patients were divided on prognostic variables such as: age, comorbidities and time to operation. The primary outcome measured was suboptimal treatment, defined by: abandoned procedure, conversion to open and subtotal cholecystectomy. Secondary outcomes measured were biliary leak, postoperative morbidity, readmission rate, and length of postoperative stay. Results A total of 466 patients were included. A multivariate analysis using a backward stepwise linear regression was used to conduct predictive models based on the significant prognostic factors from a univariant analysis. Approximately 10% of patients had suboptimal treatment predicted by age (p&amp;lt;0.0001) and low albumin (p=0.0034). 17.2% of patients had post-operative morbidity predicted by age (p=0.0201), admission day (p=0.0238), and male gender (p=0.0481). 20.8% of patients were re-admitted, predicted by an ASA &amp;gt;3 (p=0.0096), thin-walled gallbladder (p=0.0491) and greater admission to operation time (p=0.0351). Post-operative length of stay was predicted by age (p=0.0048), low albumin (p=0.0048) and greater admission to operation time (p=0.0169). Conclusion Several predictive prognostic factors were found to be related to poor emergency LC outcomes which can be used to inform patients of risks pre-operatively and select patients suitable for a delayed cholecystectomy.

Invited Commentary: Advancing the Safety of Laparoscopic Cholecystectomy-Collaboration between Radiologists and Surgeons.

Invited Commentary: Advancing the Safety of Laparoscopic Cholecystectomy-Collaboration between Radiologists and Surgeons.

Optimal drain management following complicated laparoscopic cholecystectomy for acute cholecystitis: a propensity-matched comparative study

PurposeThis study was performed to investigate the effect of drain placement on complicated laparoscopic cholecystectomy (cLC) for acute cholecystitis (AC).MethodsThis single-center retrospective study reviewed patients with AC who underwent cLC between January 2010 and December 2020. cLC was defined as open conversion, subtotal cholecystectomy, adjacent organ injury during surgery, operation time of ≥90 minutes, or estimated blood loss of ≥100 mL. One-to-one propensity score matching was performed to compare the surgical outcomes between patients with and without drain on cLC.ResultsA total of 216 patients (mean age, 65.8 years; 75 female patients [34.7%]) underwent cLC, and 126 (58.3%) underwent intraoperative abdominal drainage. In the propensity score-matched cohort (61 patients in each group), early drain removal (≤postoperative day 3) was performed in 42 patients (68.9%). The overall rate of surgical site infection (SSI) was 10.7%. Late drain removal demonstrated significantly worse surgical outcomes than no drain placement and early drain removal for overall complications (13.1% vs. 21.4% vs. 47.4%, p = 0.006), postoperative hospital stay (3.8 days vs. 4.4 days vs. 12.7 days, p < 0.001), and SSI (4.9% vs. 11.9% vs. 31.6%, p = 0.006). In the multivariate analysis, late drain removal was the most significant risk factor for organ space SSI.ConclusionThis study demonstrated that drain placement is not routinely recommended, even after cLC for AC. When placing a drain, early drain removal is recommended because late drain removal is associated with a higher risk of organ space SSI.

Promoting a Culture of Safety in Cholecystectomy (COSIC) over a decade at a Philippine public regional hospital after the SAGES International Proctoring Course in Laparoscopic Cholecystectomy Course.

The SAGES International Proctoring Course for Laparoscopic Cholecystecomy accepts applications from low to middle-income countries for SAGES faculty to train local surgeons. A regional public hospital in the 10th most populous city in the Philippines was one of the chosen sites for the 1-week course in 2010. Two SAGES surgeons and one nurse trained two local surgeons and four nurses identified by the hospital director. All patients seen in the out-patient clinic at the Zamboanga City Medical Center in the Philippines and scheduled for elective laparoscopic cholecystectomy from the first day of the course in August 2010 until December 2018 were entered into a prospectively collected database including demographics, pre-op diagnosis, operative findings, histopathologic diagnosis, conversion rates and 30-day complications including re-operations. 521 patients underwent laparoscopic cholecystectomy. Majority were female (63.7%) with a mean age of 45.9years. Most procedures were completed laparoscopically with an open conversion rate of 3.3%. Three patients underwent laparoscopic subtotal cholecystectomy. Reported complications requiring reoperation included one stump necrosis, two incisional hernias and one retained stone. One serosal injury and one surgical site infection were also reported for an overall morbidity rate of 4.6%. Pathology showed chronic calculous cholecystitis in 92.8% of specimens. No 30-day mortality was recorded. The SAGES International Proctoring Course for Laparoscopic Cholecystectomy has been shown to be a successful method for global surgery training. A focused 1-week direct proctoring model in the Philippines showed a sustained culture of safety in cholecystectomy with low 30-day morbidity, complication and conversion rates over a decade following participation in this program.

Efficacy of endoscopic gallbladder drainage in patients with acute cholecystitis

BackgroundEarly cholecystectomy is recommended for patients with acute cholecystitis. However, emergency surgery may not be indicated due to complications and disease severity. Patients requiring drainage are usually treated with percutaneous transhepatic gallbladder drainage (PTGBD), whereas patients with biliary duct stones undergo endoscopic stones removal followed by endoscopic gallbladder drainage (EGBD). Herein, we investigated the efficacy of EGBD in patients with acute cholecystitis.MethodsOverall, 101 patients receiving laparoscopic cholecystectomy between September 2019 and September 2020 in our department were retrospectively analyzed.ResultsThe patients (n = 101) were divided into three groups: control group that did not undergo drainage (n = 68), a group that underwent EGBD (n = 7), and a group that underwent PTGBD (n = 26). Median surgery time was 107, 166, and 143 min, respectively. Control group had a significantly shorter surgery time, whereas it did not significantly differ between EGBD and PTGBD groups. The median amount of bleeding was 5 g, 7 g, and 7.5 g, respectively, and control group had significantly less bleeding than the drainage group. We further divided patients into the following subgroups: patients requiring a 5 mm clip to ligate the cystic duct, patients requiring a 10 mm clip due to the thickness of the cystic duct, patients requiring an automatic suturing device, and patients undergoing subtotal cholecystectomy due to impossible cystic duct ligation. There was no significant difference between EGBD and PTGBD regarding the clip used or the need for an automatic suturing device and subtotal cholecystectomy.ConclusionsThere was no significant difference between EGBD and PTGBD groups regarding surgery time or bleeding amount when surgery was performed after gallbladder drainage for acute cholecystitis. Therefore, EGBD was considered a useful preoperative drainage method requiring no drainage bag.

Presence of cystic duct stone is a risk for postoperative retained stones in patients with acute cholecystitis

PurposeRetained stones (RS) in the common bile duct (CBD) are one of the major problems after laparoscopic cholecystectomy and usually require endoscopic treatment. However, few reports have investigated risk factors for the development of RS in the CBD. MethodsA total of 325 patients with acute cholecystitis underwent laparoscopic cholecystectomy at our hospital between January 2013 and Jury 2021. Patient characteristics, including radiographic factors and perioperative outcomes, were reviewed, and perioperative factors predicting RS in the CBD were investigated. ResultsRS in the CBD were developed in 34 patients. All 34 patients were treated endoscopically. ASA-PS class 3 or more (p = 0.029, odds ratio = 2.601), subtotal cholecystectomy performance (p = 0.004, odds ratio = 3.783) and the presence of cystic duct stones (p < 0.001, odds ratio = 11.759) were found by logistic regression analysis to be independent risk factors for developing RS in the CBD. Cystic duct stones were preoperatively detected in 60 patients. Of these, 21 cases were not detected on magnetic resonance cholangiopancreatography (MRCP) but on CT, while 15 cases were not detected on CT but on MRCP. ConclusionsThe presence of cystic duct stones on preoperative CT or MRCP is a crucial risk factor for developing RS in the CBD. Both CT and MRCP are useful to avoid overlooking cystic duct stones.

Laparoscopic subtotal cholecystectomy; change in practice over a 10-year period.

Laparoscopic subtotal cholecystectomy is a recognised safe, alternative strategy when a critical view of safety cannot be obtained. This study audits the change in practice at a District General Hospital following the adoption of subtotal cholecystectomy in 2013. Retrospective case series included consecutive cholecystectomies over a ten-year period in a single institution. Cases were divided into subgroups based on operation date. Primary outcome was the proportion of patients undergoing laparoscopic total cholecystectomy, laparoscopic subtotal and laparoscopic converted to open cholecystectomy. Secondary outcomes included incidence of bile leak, complication rate, return to theatre, and length of stay. There were 4217 cases: 1381 in Group A (pre-adoption of subtotal cholecystectomy 2009-2012), and 2836 in Group B (post-adoption of subtotal cholecystectomy 2013-2019). The rate of laparoscopic total cholecystectomy was higher in Group A than Group B (95.4% vs. 92.8%, p<0.001). In the subtotal group (n=114, 14 (12.3%) patients had bile leak, 6 (5.3%) underwent re-laparoscopy, and median length of stay was 2 days. Laparoscopic subtotal cholecystectomy appears to be an acceptable alternative technique at this centre, reducing the rate of open conversion and length of stay, with a low reintervention rate for bile leak.