Symptomatic Cholelithiasis Research Articles

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

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

Patients with symptomatic cholelithiasis at a safety net hospital: Early surgeon involvement matters.

Gallstones are a common diagnosis in the United States; though many patients remain asymptomatic, others develop symptoms. Standard of care for symptomatic cholelithiasis is cholecystectomy, but many do not undergo surgery. The purpose of this study is to identify factors that influence receipt of cholecystectomy for symptomatic cholelithiasis at a safety net hospital. This is a retrospective study performed at a large, academic, tertiary care and safety net state hospital. Patients who presented with symptomatic cholelithiasis were included. Same admission cholecystectomy and elective outpatient cholecystectomy were considered success/standard of care, and readmission cholecystectomy or no cholecystectomy were considered failures/not standard of care. Of 376 patients, a substantial minority were Spanish speaking, and almost half had public insurance. 23.7% were successfully treated, and 76.3% had failure in management. A larger number of patients in the group that had successful treatment had surgery consultation, 67.4%. Only 28.5% of patients saw a surgeon as an outpatient within 30days of their visit. On multivariable analysis, patients who were provided a surgery consultation were more likely to receive standard of care. Age, sex, language, smoking status, lack of insurance, and alcohol use were not associated. Surgery consultation during presentation for symptomatic cholelithiasis was associated with receipt of same admission, or outpatient elective cholecystectomy, or successful management. There should be a low threshold to involve a surgeon for symptomatic cholelithiasis.

Lower Socioeconomic Status Predicts Greater Obstacles to Care: Using Outpatient Cholecystectomy as a Model Cohort.

Patients with low socioeconomic status (SES) are disadvantaged in terms of access to health care. A novel metric for SES is the Distressed Communities Index (DCI). This study evaluates the effect of DCI on hospital choice and distance traveled for surgery. A Florida database was queried for patients with symptomatic cholelithiasis or chronic cholecystitis who underwent an outpatient cholecystectomy between 2016 and 2019. Patients' DCI was compared with hospital ratings, comorbidities, Charlson Comorbidity Index, and distance traveled for surgery. Stepwise logistic regression was used to determine which factors most influenced distance traveled for surgery. There were 54,649 cases-81 open, 52,488 laparoscopic, and 2,080 robotic. There was no difference between surgical approach and patient's DCI group (p = 0.12). Rural patients traveled the farthest for surgery (avg 21.29 miles); urban patients traveled the least (avg 5.84 miles). Patients from distressed areas more often had surgery at one- or two-star hospitals than prosperous patients (61% vs 36.3%). Regression indicated distressed or at-risk areas predicted further travel for rural/small-town patients, while higher hospital ratings predicted further travel for suburban/urban patients. Compared to prosperous areas, patients from distressed areas have surgery at lower-rated hospitals, travel further if they live in rural/small-town areas, but travel less if they live in suburban areas. We postulate that farther travel in rural areas may be explained by a lack of health care resources in poor, rural areas, while traveling less in suburban areas may be explained by personal lack of resources for patients with low SES.

CLINICAL ADVANTAGES OF LAPAROSCOPIC CHOLECYSTECTOMY: EFFECTS ON RECOVERY AND PATIENT SATISFACTION OVER THE OPEN APPROACH

Cholecystectomy is a surgical procedure aimed at removing the gallbladder, and is commonly used in the treatment of conditions such as symptomatic cholelithiasis and various gallbladder-related diseases. With advances in surgical techniques, laparoscopic cholecystectomy has become the preferred approach in many cases, replacing the conventional open technique. The objective of this integrative review is to analyze the advantages of laparoscopic cholecystectomy compared to conventional surgery, focusing on aspects such as recovery time, postoperative pain, complications, costs, and aesthetic results. The methodology included searches in databases such as PubMed, Scopus, and SciELO, covering studies published in the last 20 years. Inclusion criteria included systematic reviews, clinical trials, and observational studies that compared both surgical approaches. The results indicate that laparoscopic cholecystectomy offers significantly shorter recovery times, allowing patients to quickly return to daily activities. Additionally, this technique is associated with reduced levels of postoperative pain and a lower rate of complications, such as infections and hernias. The aesthetic results are also superior, with less visible scars. Although the initial costs of laparoscopy may be higher, the cost-effectiveness analysis suggests that in the long run, it may be more cost-effective due to the reduction in length of hospital stay and postoperative care. This review provides a comprehensive overview of the benefits of laparoscopic cholecystectomy and its implications for clinical practice and public health.

Is the trocar through which the gallbladder is removed during cholecystectomy important for potential complications?

Objective: Laparoscopic cholecystectomy is considered the gold standard for the treatment of gallstone disease and complications can develop at trocar sites following laparoscopic cholecystectomy. This study aims to evaluate the impact of extracting the gallbladder through either the umbilical or epigastric ports during laparoscopic cholecystectomy on the complications observed after gallbladder extraction. Methods: Symptomatic cholelithiasis patients who had four port laparoscopic cholecystectomy included to the study. Individuals were divided into two groups based on gallbladder removal site: umbilical or epigastric. Medical records were reviewed for post-surgical complications within 30 days and incisional hernias within one year. The age, gender, operation duration, BMI and the largest stone dimentions of the patients were also noted. Results: A total of 112 patients were included in the study, with 45 patients in the umbilical group and 67 patients in the epigastric group. No significant differences were observed in age, gender, body mass index and stone dimentions between groups. Port site hernia and port site infection developed more frequently but not significantly in umblical group. When examined the stone dimention and BMI based on the presence of a port site hernia and port site infection, BMI and stone dimention were significantly higher in port site infection and hernia patients. Conclusion: Using umbilical port for removing gallbladder, carried a higher risk of infection and hernia development. Additionally, regardless of which trocar is used, patients with a high BMI and large stone dimensions have a higher risk of port site infection and hernia. Patients should be informed about these risks during the preoperative period.

FREQUENCY OF EASY AND DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY FOR CHOLELITHIASIS

The prevalence of gallstone disease is influenced by factors such as age, gender, and marital status. Ultrasonography is important for screening. Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic cholelithiasis, but some cases may require conversion to open surgery (OC). Preoperative ultrasound assessments, particularly the common bile duct (CBD) diameter, may help predict the difficulty of LC and prepare for potential complications. Objective: The objectives of this study are to assess the frequency of easy and difficult laparoscopic cholecystectomy in patients with cholelithiasis and to compare the mean diameter of the common bile duct between cases of easy and difficult laparoscopic cholecystectomy. Methods: This sctional study was conducted from February 10, 2023, to August 10, 2023, and included 170 patients (ages 18-60 years) undergoing laparoscopic cholecystectomy for cholelithiasis. Both genders were included. Variables such as age, gender, diabetes, hypertension, and cholecystectomy status were recorded. The mean and standard deviation (SD) were calculated for age and CBD diameter. An independent t-test was used to compare CBD diameters between easy and difficult LC cases. Chi-square tests were applied to control for effect modifiers. Results: The mean age of the patients was 52.32 ± 4.89 years. Other patient characteristics included an average height of 162.90 ± 9.25 cm, weight of 75.95 ± 12.32 kg, and BMI of 27.47 ± 4.72. The common bile duct diameter was 4.55 ± 1.42 mm. Gender distribution showed 54.7% male and 45.3% female patients. Of the 170 patients, 84 (49.4%) were classified as easy LC cases, while 86 (50.6%) were classified as difficult. The mean CBD diameter was significantly different between the two groups, measuring 3.54 ± 1.03 mm in easy cases and 5.52 ± 1.02 mm in difficult cases (p = 0.001). Conclusion: This study highlights the importance of preoperative assessment of common bile duct diameter in predicting the difficulty of laparoscopic cholecystectomy. Patients with a larger CBD diameter are more likely to experience a difficult LC, emphasizing the need for personalized surgical planning. These findings underscore the value of preoperative ultrasonography in optimizing patient outcomes and reducing the risk of conversion to open surgery.

Telemedicine and Access to Elective Cholecystectomy for Socially Vulnerable Adults

Socially vulnerable patients with symptomatic cholelithiasis are more likely to face barriers to accessing surgical care. This barrier to access can lead to delays in treatment, the need for emergent cholecystectomy, and worse outcomes. To determine the effectiveness of telemedicine vs in-person surgical consultation on access to elective cholecystectomy in socially vulnerable populations and to evaluate the association of scheduling navigation with access to elective cholecystectomy in these populations. This pilot randomized clinical trial conducted in a single academic center enrolled 60 adults from February 1, 2023, to February 21, 2024, with 3-month follow-up of clinical outcomes. Data were also collected retrospectively on a comparison group of 32 patients referred from June 30 to December 29, 2022. Adults with social vulnerability, such as being non-White or Hispanic or having nonprivate insurance or low income, with a diagnosis of symptomatic cholelithiasis and referral for outpatient surgical consultation were included. All trial participants were randomized to the telemedicine or in-person surgical consultation group, and received professional scheduling navigation. The latter intervention was compared with a historical cohort without navigation assistance. The primary outcome was completion of outpatient surgical consultation. Secondary outcomes included receipt of treatment and operative urgency. The trial enrolled 60 participants (30 per arm). Their mean (SD) age was 48.2 (18.2) years, 50 (83.3%) were female, 2 (3.3%) were Asian, 39 (65.0%) were Black, 8 (13.3%) were Hispanic, 11 (18.3%) were White, and 41 (68.3%) had no private insurance. The historical patient cohort included 32 participants (mean [SD] age, 45.9 [3.2] years; 27 [84.4%] female; 3 [9.4%] Asian, 15 [46.9%] Black, 10 [31.3%] Hispanic, and 6 [18.8%] White; and 18 [56.3%] without private insurance). In total, 18 trial participants assigned to telemedicine (60.0%) completed surgical consultations compared with 23 trial participants assigned to in-person visits (76.7%; P = .17). For telemedicine participants who underwent cholecystectomy, 3 of 7 (42.9%) underwent emergent cholecystectomy compared with 0 of 14 (0%) participants with in-person consultations (P = .03). Of 30 trial participants who received scheduling navigation, 23 (76.7%) completed surgical consultations compared with 15 of 32 patients in the historical cohort who did not receive scheduling navigation (46.9%; P = .02). Of 14 trial participants who received scheduling navigation and cholecystectomy, no participants underwent emergent cholecystectomy compared with 4 of 16 (25.0%) participants in the historical cohort without scheduling navigation (P = .04). In this pilot randomized clinical trial of socially vulnerable adults with symptomatic cholelithiasis, telemedicine consultation compared with in-person visits did not improve access to elective outpatient surgical care. However, scheduling navigation services may improve access to elective outpatient surgical care. Future large-scale studies are needed to identify possible barriers to virtual health care and mechanisms to address inequities. ClincialTrials.gov Identifier: NCT05745077.

Ideal Local Anesthetic for Intraperitoneal Gallbladder Bed Infiltration Following Laparoscopic Cholecystectomy: A Randomized Controlled Trial.

Background Laparoscopic cholecystectomy is the gold standard operation for symptomatic cholelithiasis; however, pain remains a major factor in increasing morbidity and length of hospital stay. Infiltration of the gallbladder bed with a local anesthetic has been shown to improve postoperative pain after laparoscopic cholecystectomy, although it is unclear which local anesthetic provides superior pain relief. Objective The aim of this study was to compare the efficacy of various local anesthetics on postoperative pain when instilled intraperitoneally in the gallbladder bed following laparoscopic cholecystectomy. Methods Patients undergoing laparoscopic cholecystectomies were randomized into three groups of 30 patients each, depending on the local anesthetic instilled in the gallbladder bed: lignocaine (Group A), bupivacaine (Group B), or a combination of lignocaine and bupivacaine (Group C). Pain was measured using the Visual Analogue Scale (VAS) at two, six, 12, and 24 hours following surgery. Secondary outcomes included vitals, rescue analgesic use, return of bowel function, time to ambulation, and presence of nausea. Results Group C showed the lowest pain scores at all time points compared to the other groups (p < 0.05). Mean arterial pressures and heart rates were lower in Group C than in Group A at two and 24 hours. Return of bowel function and time to ambulation was earlier in Group C than in Group B. No significant complications were noted in any of the groups. Conclusion We conclude that a combination of lignocaine and bupivacaine instillation in the gallbladder bed provides the most effective pain relief following laparoscopic cholecystectomy, without significant complications at the doses used.

A Comparative Study of Postoperative Outcomes: Open Cholecystectomy versus Laparoscopic Cholecystectomy

Background: Surgery is usually necessary to treat gallstones, or cholelithiasis. Because laparoscopic cholecystectomy is less intrusive than open cholecystectomy, it is now the treatment of choice. Objectives: To evaluate and compare the postoperative results of open and laparoscopic cholecystectomies with regard to duration of hospital stay, complication rates, and amount of discomfort experienced during the procedure. Methods: A prospective comparative study was conducted on one hundred patients with symptomatic cholelithiasis who were to undergo elective cholecystectomy. Patients were randomized into two groups: Among the patients, 50 patients were operated for Laparoscopic Cholecystectomy and 50 for Open Cholecystectomy. The data on the postoperative results of the operation, including the time spent during the operation, as well as the time spent on pain, the length of stay in the hospital, and complications were collected and compared using statistical methods with the chosen level of significance equals to p ≤0.05. Results: The mean operative time of Laparoscopic Cholecystectomy was less than Open Cholecystectomy (48. 5 ± 12. 4 vs. 68. 5 ± 15. 3 minutes; p≤0.05). The overall postoperative pain was less in patients who undertook Laparoscopic Cholecystectomy with the mean pain period of (18. 3 ± 5.2) hours compared with 30. 7 ± 7. For Open Cholecystectomy patients the time taken was 1 hours. The length of the hospital stay was also lesser in Laparoscopic Cholecystectomy group which was (1.8 ± 1.2) days compared to Open Cholecystectomy group of (4.8 ± 1.5) days. Also, the Laparoscopic Cholecystectomy group had less complication rate at 12% compared to the Open Cholecystectomy at 38% with p ≤0.05 Conclusion: Laparoscopic Cholecystectomy is shown to be more beneficial in terms of postoperative results than Open Cholecystectomy in terms of the operating time, pain, hospital stay, and complications. Thus, these results shows Laparoscopic Cholecystectomy as the most appropriate surgical management for patients with symptomatic cholelithiasis; however, Open Cholecystectomy will still be required for cases that are not suitable for Laparoscopic Cholecystectomy.

Is conversion the only itinerary to peace with "hostile" laparoscopic cholecystectomy?

Laparoscopic cholecystectomy (LC) remains the most common surgical procedure worldwide. With these unequivocal benefits, it is today the optimal standard of care for symptomatic cholelithiasis. However, this routine operation can also represent one of the most "hostile" situations. In scenarios of uncertain Critical View of Safety display, total cholecystectomy and laparoscopic approach incur a risk of serious complications such as iatrogenic bile duct injury (IBDI). In such situations, it is necessary to improvise an approach different from the traditional concepts used for elective cases and provide a rescue plan that promotes safety. Although the balance between maintaining LC and moving to an exit procedure is resolved, it remains a challenge for providers to navigate the best alternative strategy. The truth in this debate of seeking optimal results is that surgeons are inclined to resort to conversion, as the most usual itinerary. However, it is inconsistent to consider that the simple fact of switching to an open procedure necessarily protects against IBDI, as well as to approve the conversion as a single manifest alternative to cope without knowing the other saviors procedures and their profiles. Therefore, we found it very useful to compile research data regarding "hostile" CL bailout methods to optimize their use in our practice and to answer the question which strategy to choose? And why?

Restrictive Strategy vs Usual Care for Cholecystectomy in Patients With Abdominal Pain and Gallstones

The 1-year results of the SECURE trial, a randomized trial comparing a restrictive strategy vs usual care for select patients with symptomatic cholelithiasis for cholecystectomy, resulted in a significantly lower operation rate after restrictive strategy. However, a restrictive strategy did not result in more pain-free patients at 1 year. To gauge pain level and determine the proportion of pain-free patients, operation rate, and biliary and surgical complications at the 5-year follow-up. This randomized clinical trial was a multicenter, parallel-arm, noninferiority, prospective study. Between February 2014 and April 2017, patients from 24 hospitals with symptomatic, uncomplicated cholelithiasis were included. Uncomplicated cholelithiasis was defined as gallstone disease without signs of complicated cholelithiasis, ie, biliary pancreatitis, cholangitis, common bile duct stones, or cholecystitis. Follow-up data for this analysis were collected by telephone from July 11, 2019, to September 23, 2023. Patients were randomized (1:1) to receive usual care or a restrictive strategy with stepwise selection for cholecystectomy. The primary, noninferiority end point was proportion of patients who were pain free as evaluated by Izbicki pain score at the 5-year follow-up. A 5% noninferiority margin was chosen. The secondary end points included cholecystectomy rates, biliary and surgical complications, and patient satisfaction. Among 1067 patients, the median (IQR) age was 49.0 years (38.0-59.0 years); 786 (73.7%) were female, and 281 (26.3%) were male. At the 5-year follow-up, 228 of 363 patients (62.8%) were pain free in the usual care group, compared with 216 of 353 patients (61.2%) in restrictive strategy group (difference, 1.6%; 1-sided 95% lower confidence limit, -7.6%; noninferiority P = .18). After cholecystectomy, 187 of 294 patients (63.6%) in the usual care group and 160 of 254 patients (63.0%) in the restrictive strategy group were pain free, respectively (P = .88). The restrictive care strategy was associated with 387 of 529 cholecystectomies (73.2%) compared with 437 of 536 in the usual care group (81.5%; 8.3% difference; P = .001). No differences between groups were observed in biliary and surgical complications or in patient satisfaction. In the long-term, a restrictive strategy results in a significant but small reduction in operation rate compared with usual care and is not associated with increased biliary and surgical complications. However, regardless of the strategy, only two-third of patients were pain free. Further criteria for selecting patients with uncomplicated cholelithiasis for cholecystectomy and rethinking laparoscopic cholecystectomy as treatment is needed to improve patient-reported outcomes. CCMO Identifier: NTR4022.

Safety and Effectiveness of Large-Bore Percutaneous Cholangioscopy–Assisted Gallstone Retrieval for Inoperable Calculous Cholecystitis: A Multi-Institutional Retrospective Study

PurposeTo evaluate the safety and effectiveness of large-bore percutaneous biliary access techniques for cholangioscopy-assisted gallstone extraction in patients with a history of acute calculous cholecystitis who are poor surgical candidates. Materials and MethodsA retrospective analysis was conducted on patients who underwent percutaneous cholangioscopy for gallstone extraction using large-bore access (24 or 30 F) at 2 large academic centers from September 2020 and August 2022. Technical success, procedure duration, fluoroscopy time, immediate postprocedural symptom reduction, 3-month symptom-free outcomes, and adverse events (AEs) were assessed. ResultsThirty consecutive patients were included. Gallstone removal in a single cholangioscopy session was successful in 93.3% of cases. Large-bore access facilitated the removal of gallstones ranging from 0.5 to 4 cm in diameter, with mean procedure and fluoroscopy times of 105.4 minutes and 21.7 minutes, respectively. All patients who presented for 3-month follow-up remained symptom-free without gallstone recurrence on imaging. The overall AE rate was 6.7%, one Grade 2 and one Grade 3 based on the Society of Interventional Radiology (SIR) AE grading system, both managed successfully, leading to patient discharge home. ConclusionsLarge-bore percutaneous biliary access for cholangioscopy-assisted gallstone extraction is a safe and effective technique for managing symptomatic cholelithiasis in poor surgical candidates.

Morphological variants of Rouviere's sulcus and its significance in a patient undergoing laparoscopic cholecystectomy: An emerging paradigm.

Laparoscopic cholecystectomy (LC) is the gold-standard treatment for symptomatic cholelithiasis. To prevent bile duct injuries, various practices are recommended, one of which is the identification of Rouviere's sulcus (RS) and starting dissection above its level. So far, no uniform anatomical description of RS is available in the literature. After prospective observation of 302 patients, we have proposed a new classification based solely on gross morphology. The purpose of this study is to make surgeons well acquainted with its different anatomical variations and its significance for the prevention of complications. We performed a prospective analysis of 302 patients during LC, and various morphological variants of RS and its relationship with hepatobiliary anatomy were recorded. We have used the nomenclature as described by previous authors and added a few. A total of 330 patients were included in our study. We could not visualise the sulcus due to dense adhesion in 28 patients. RS was absent in 24.1% of cases and was present in various forms in 75.8% of cases. Amongst these, the open type was found in 28.8% of cases, fused type was found in 4.8% of cases, groove type was found in 24.8% of cases, pit type was found in 8.2% of cases, close type was found in 14.4% of cases, slit type was found in 8.7% of cases and scar type was found in 10% of cases. Using RS as a landmark, we could perform surgery safely in all cases. The RS can be described as closed, slit, open, fused, groove, pit or scar type.

Gall stones in children with sickle cell disease, management and outcomes

Background: It is rare to encounter a gall bladder stones in the paediatric age group. In Saudi Arabia, sickle cell disease (SCD) is common with incidence reach to 19.7%in some provinces. Cholecystitis is responsible for significant morbidity in SCD patients. Laparoscopic cholecystectomy (LC) is now considered as the procedure of choice for treating such cases. Over a period of 3 years, a total of 21 children with sickle cell anemia (SCA) had cholecystectomy. We exclude 3 patients who had splenectomy and cholecystectomy in the same time, the remaining 18 patients (6 males and 12 females) had LC only. Their age ranged from 4 years to 13 years (mean of 7.45±1.94 years). Methods: LC was the standard procedure performed in all the children in our study group. The mean duration of operation was 92.17±27.31 minutes (range from 62-167 minutes). Results: The mean post-operative stay after operation was 2.167±0.5 days (range from 1-3 days). One patient required conversion to open cholecystectomy (OC) because of severe adhesions, there were no immediate postoperative complications in the other 17 patients of our study group. Conclusions: In conclusion, elective LC in well prepared patients, is feasible and safe in children with SCA and should be the treatment of choice for both symptomatic and asymptomatic cholelithiasis. ERCP is a valuable diagnostic and therapeutic investigation both preoperatively and postoperatively.

Converting From Laparoscopic Cholecystectomy to Open Cholecystectomy: A Systematic Review of Its Advantages and Reasoning.

Cholecystectomy is the standard treatment for symptomatic cholelithiasis and asymptomatic impending biliary obstruction, which is typically carried out laparoscopically. However, difficult gallbladders, due to distorted anatomy or increased risk of bleeding, can necessitate conversion to open surgery. This systematic review evaluates the advantages, disadvantages, complications, and outcomes of laparoscopic versus converted open cholecystectomy. We screened articles published from 2011 to 2024 by utilizing advanced filters of PubMed, Cochrane, and Scholar databases. Exclusion criteria included non-English language articles, duplicates, and animal studies. After analyzing relevant articles, 31 articles were included in this study. The total number of participants who underwent laparoscopic procedures was 28,054, of which 5,847 were converted from laparoscopic to open procedures. Conversions were primarily due to bleeding, adhesions, and obscured anatomy, with bile leakage being the most common short-term complication. Converted cases showed higher rates of long-term complications, increased hospital stays, and higher morbidity and mortality. Laparoscopic cholecystectomy remains safe and effective, but identifying high-risk patients for conversion is important. Preoperative identification of high-risk patients and recognizing predictive factors for conversion can enhance surgical outcomes and cost-effectiveness. While laparoscopic cholecystectomy is generally preferred, timely conversion to open surgery is essential for patient safety.

The use of propofol to induce anesthesia can mitigate the oxidative stress created by laparoscopic cholecystectomy, but not thiopental

Aim: Laparoscopic cholecystectomy is one of the treatment methods in symptomatic cholelithiasis cases, and pneumoperitoneum has been shown to increase oxidative stress. Our aim is to compare propofol and thiopental in terms of their effects on oxidative stress parameters in laparoscopic cholecystectomy cases. Materials and Methods: After obtaining Ethics Committee permission, patients who underwent laparoscopic cholecystectomy were divided into thiopental and propofol groups according to the agent used for anesthesia induction in the randomized and prospective study. Serum serum oxidative stress parameters levels were measured in all patients two times, before induction of general anesthesia and at the 30th minute postoperatively. Results: When comparing the preoperative period with the postoperative period, TAS levels increased statistically significantly in the propofol group (preoperatively 1.21±0.21 mmolH2O2/L, postoperatively 1.31±0.18 mmolH2O2/L, p

Barriers to elective cholecystectomy following emergency department discharge for symptomatic cholelithiasis

BackgroundPatients with symptomatic cholelithiasis are often discharged from the Emergency Department (ED) and asked to follow-up for elective cholecystectomy. We aimed to identify the social determinants of health (SDOH) that serve as barriers to elective cholecystectomy and to assess the associated impact on patient outcomes. MethodsWe conducted a multi-institutional, retrospective cohort study of patients discharged from the ED with symptomatic cholelithiasis. Univariable logistic regression was used to assess for variables associated with re-presenting to the ED rather than for elective cholecystectomy. P values ​< ​0.05 identified significance. ResultsUnivariate analysis identified lack of a primary care physician, Black race, self-pay, language other than English as the primary language, and unemployed status to be independently associated with re-presentation to the ED for biliary disease. ConclusionsSocially disadvantaged populations would benefit from surgery at the time of presentation to the ED versus being sent home for elective follow-up.

UNVEILING THE ENIGMA: PORT SITE METASTASIS IN LAPAROSCOPIC CHOLECYSTECTOMY - A CASE REPORT WITH CRYPTIC PRIMARY TUMOR

The phenomenon of Port site metastasis post lap cholecystectomy with incidental carcinoma is common, but reporting of PSM with unknown primary is rare. Our literature search yielded only 4 such cases. We here report the case of a 70-year-old lady with symptomatic cholelithiasis who underwent LC at our institute, 6 months after which she developed a discharging mass at 2 of the previous laparoscopic port sites. The postoperative histopathology of the gall bladder was benign and even after a review of slides yielded no evidence of malignancy. A whole-body PET-CT scan was done for the patient but it revealed no primary tumor. The mass was ultimately resected after the necessary investigations and the defect closed primarily. Postoperative pathology was suggestive of adenocarcinoma with suspected pancreaticobiliary origin.

Hyperkinetic Biliary Dyskinesia: An Underrecognized Problem With Good Surgical Outcomes After Cholecystectomy.

Introduction While surgical indications for symptomatic cholelithiasis and biliary hypokinesia are clear, hyperkinetic biliary dyskinesia (HBD) is an underrecognized condition with poorly defined symptomology and management guidelines. HBD is typically defined as a gallbladder ejection fraction (EF) ≥ 80% on a hepatobiliary iminodiacetic acid (HIDA) scan. We aimed to identify the prevalence and radiographic reporting of HBD, physician referral patterns, and clinical outcomes following cholecystectomy. Methods A retrospective cohort study of patients with HIDA scans completed over 21 years at our tertiary care hospital was performed. Demographics, symptomatology, referral patterns, and operative data were collected. HBD was defined as HIDA EF ≥80%. Patients with HBD who underwent cholecystectomy were analyzed. ANOVA and chi-square tests were used to compare variables among patients with or without symptom improvement using Statistical Product and Service Solutions (SPSS;IBM SPSS Statistics for Windows, Armonk, NY). Results Of 1,997 patients (73% female, mean age 51.7 years) who had HIDA scans with reported EF, 730 (36.6%) had an EF≥80%. Only 13.7% of HIDA scans with EF≥80% were reported as hyperkinetic, and the rest are "normal". Cholecystectomy was performed in 57 (7.8%) patients with EF≥80%, most being elective (89.5%) and all minimally invasive. Primary care physicians (PCPs) referred most elective cases to surgery (61.4%). The median time from HIDA to cholecystectomy was 146 days. Chronic cholecystitis was common in pathology (82.5%), while 38.6% had cholelithiasis. Overall, 53 patients (93.0%) reported symptom improvement at a median follow-up of 17.0 days. Patients without improvement had a higher prevalence of chronic gastrointestinal conditions (p<0.05), but not significantly more cholelithiasis, cholecystitis, time to surgery, or elective surgery status. Conclusions HBD is common but often underdiagnosed and thus likely underrecognized by treating physicians. Most HBD patients benefit from cholecystectomy, regardless of cholelithiasis. Patients with persistent symptoms after cholecystectomy may have confounding gastrointestinal diagnoses. Increased awareness among radiologists, referring PCPs, gastroenterologists, and surgeons about HBD and postoperative outcomes is needed to ensure that HBD is adequately treated.

Prevalence of Salmonella Typhi in Bile of the Patients Undergoing Cholecystectomy at a Tertiary Care Hospital Karachi

Objective: To estimate the prevalence of salmonella typhi in bile specimens collected from patients undergoing cholecystectomy at a tertiary care Hospital Karachi. Methodology: The descriptive cross-sectional study, was conducted at Department of Surgical Unit 21, Jinnah Postgraduate Medical Center, Karachi, from January 2021 to June 2021. Patients with symptomatic Cholelithiasis like sudden pain in the upper right portion of your abdomen which radiate towards right shoulder, nausea, vomiting, undergo cholecystectomy of either gender male or female with age 14 to 60 years were included. After open cholecystectomy, bile was aspirated from the gallbladder at fundus in five ml syringe and long spinal needles was used in case of laparoscopic cholecystectomy to collect bile under vision of telescope. Specimens were sent to laboratory according to protocol for culture sensitivity. Results: A total of 171 patients who met the inclusion and exclusion criteria were included. Mean age of the patients was 49.39±8.78 years. 83 (48.5%) were male and 88 (51.5%) were female. Prevalence of salmonella typhi in bile specimens collected from patients undergoing cholecystectomy, was found 17.54%. Furthermore, the frequency of salmonella isolate was statically insignificant according to the patient’s gender, diabetes and obesity (p=&gt;0.05), while it was statically significant according to age up to 40 years and residence in rural areas (p-&lt;0.05. Conclusion: A significant proportion of patients were found to have Salmonella in bile from patients undergoing cholecystectomy. Therefore, close monitoring of patients must be done in all patients with regular follow-up.