Urgent Laparoscopic Cholecystectomy Research Articles

Gallbladder volvulus: Putting a spin on acute cholecystitis

First reported in 1898, gallbladder volvulus is rare. It occurs when the gallbladder twists on its longitudinal axis greater than 180 degrees, resulting in occlusion of the cystic vessels and duct. Herein, we describe the case of a 73-year old woman who was diagnosed with acalculus gallbladder volvulus, with the aid of computerised tomography. This was managed by urgent laparoscopic cholecystectomy and the patient continues to do well 15 months postoperatively. Although rare, a high index of suspicion of the condition must remain and a low threshold for imaging is needed to prevent the complications of gallbladder necrosis, perforation and biliary peritonitis.

Outcome of specialist-led urgent laparoscopic cholecystectomy for gallstone disease at a London District General Hospital

Outcome of specialist-led urgent laparoscopic cholecystectomy for gallstone disease at a London District General Hospital

OGBN P27 Outcome of specialist-led urgent laparoscopic cholecystectomy for gallstone disease at a London District General Hospital

Abstract Background Laparoscopic cholecystectomy is the mainstay for treatment of symptomatic gallstones and its associated complications. Emergency cholecystectomy rates in the United Kingdom (UK) remain low despite NICE guidelines recommendations to offer surgery within 7 days for acute cholecystitis and index cholecystectomy for mild gallstone pancreatitis. We analysed our data over last 10 years to assess the safety and feasibility of providing an emergency cholecystectomy service in a London District general Hospital with a specialist Upper Gastrointestinal / hepatobiliary consultant workforce in line with NICE guidelines. Methods Data of 663 consecutive patients undergoing index admission emergency cholecystectomy during 2013-2023 from a prospectively maintained database was reviewed. Patient demographics, duration of hospital stay, complications, need for further interventions and re-admission rates were collected and analysed. Results Six hundred and sixty-three consecutive patients underwent emergency cholecystectomy gallstone disease and associated complications. The conversion rate was 5.2% (n=35). The median time from presentation to surgery was 2 days (Range 0-63), overall length of stay was 6 days (Range 1-91), and post-procedure stay was 2 days (Range 1-89). Overall complication rate was 7% (n=45), bile leak was observed in 8 patients (1.2%) with no evidence of major biliary injury. One patient had postoperative haemorrhage requiring laparotomy (No bleeder identified) (grade IVa) and 1 patient died within 90 days for reasons unrelated to the operation. The re-admission rate was 10.2%. Conclusions Index admission emergency laparoscopic cholecystectomy in district general hospitals is feasible and safe when performed by a specialist consultant workforce, leading to compliance to guidelines and a low rate of complications and readmissions to hospital.

849 Quality Improvement in the Service Delivery of Early Laparoscopic Cholecystectomy (LC) for Acute Cholecystitis (AC)

Abstract Aim Acute gallstone disease comprises 30-40% of emergency general surgery workload. Delayed cholecystectomy is related to increased readmissions, biliary complications, and costs. BSG, AUGIS and NICE guideline advocate early Laparoscopic Cholecystectomy (LC). The aim of this Quality Improvement (QI) project is to establish an early LC service in a tertiary hospital in central London, based on national QI Collaborative led by Royal College of Surgeons (RCS). The objectives are assessing existing management, developing strategies, and measuring outcome. Method The management was evaluated including surgeons’ preferences and operating barriers. Strategies were developed through process mapping and stakeholder engagements. Following the implementation, admissions including time to surgery, and reasons for non-compliance, were recorded. The intervention period was set in 4 phases between September 2019 and November 2020: Plan, Improve, Pause and Restart. The sustainability of change was monitored between January 2021 and October 2022. Results 282 AC cases were admitted during intervention period and 68% (194) were fit and consented for surgery. The rate of early LC within 8 days increased from 11% to 61%. During the “pause” phase, the intervention was stopped, and early LC rate dropped to zero, demonstrating the importance of continuous application of strategy. The sustainability was shown during the monitoring period; 343 cases were admitted, 140 (41%) fit for surgery, 62 had surgery within 8 days (43%), and 77 within 14 days (54%). Conclusions The QI study significantly improved the urgent LC rate and received the RCS prize. Sustainability was demonstrated with continual reviews and adaptations.

Near-infrared indocyanine green fluorescent cholangiography in urgent and emergency laparoscopic cholecystectomy: a preliminary study after propensity score-matched study

IntroductionBile duct injury is a major complication of laparoscopic cholecystectomy (LC). Indocyanine green near-infrared fluorescence cholangiography (ICG-NIFC) is a well-recognized technique who provides an intraoperative mapping of the biliary system.MethodsAll patients underwent urgent LC and randomly divided into two groups: in one group, only white light imaging was used and, in the ICG group, ICG was used. Due to the heterogeneity of our groups, a PSM was performed with a 1:1 PSM cohort.ResultsThe use of ICG clearly decreases the operation time (p value 0.002). The overall rate of intra- and post- operative complications was 4.17% and 15.8% respectively. Post-operative biliary duct injury trend decreases in ICG group and after the homogenization of the 2 cohorts, the intra- and post- operative complications (including vascular and biliary duct injury) results changed with a highest rate of complication in the cohort with no-ICG administration.The use of NIFC demonstrated a protective effect against intra- and post- operative complications and biliary duct injury (HR 0.037, p value 0.337 and HR 0.039, p value 0.647; HR 0.288; p value 0.05 and HR 0.635; p value 0.687, respectively).ConclusionsThe intra-operative use of NIFC showed a trend in the reduction of the rate of intra- and post-operative complications, the duration of surgery, and the length of hospital stay. ICG is a highly safe approach to urgent and emergency LC, as for elective LC, and could lead the surgeon to conduct the procedure more efficiently.

Intraoperative Fluorescent Cholangiography Using Indocyanine Green Fluorescence for Identification and Treatment of Bile Leaks After Urgent Laparoscopic Cholecystectomy

Introduction: Laparoscopic cholecystectomy (LC) is one of the most common surgical procedures performed worldwide.1 Postoperative bile leaks caused by bile duct injuries (BDIs) are serious complications after LC, resulting in a prolonged length of hospital stay, increased costs, morbidity, and mortality rates.2 Incidence of BDIs during LC is ~0.4%–1.5%.1 Intraoperative fluorescent cholangiography using indocyanine green fluorescence (ICG-C) is a safe method to observe the biliary tree and may be useful to prevent postoperative bile leaks after LC and hepatic surgery.1,2 However, detection of bile leaks using the ICG-C during LC has limited evidence in international literature.3–8 This video illustrates how to use ICG-C to identify and treat a bile leak after an urgent LC. Materials and Methods: A 54-year-old man with a history of hypertension, diabetes mellitus, cholelithiasis, and hepatic abscesses was admitted with right upper quadrant pain and fever. An urgent CT scan of the abdomen showed acute cholecystitis associated with a large pericholecystic abscess. A percutaneous cholecystostomy (PC) was placed and nonoperative management with intravenous antibiotic was started. On the seventh postprocedural day, the PC was accidentally removed, and a second CT scan of the abdomen showed a reduction of the pericholecystic abscess size, and a subhepatic fluid collection. An urgent LC was performed, and two surgical drains were placed (one subhepatic and one suprahepatic). On the first postoperative day, a low-flow biliary output (250 mL/day) from the subhepatic drainage was associated with a gradual deterioration of the patient's clinical condition. Considering the low flow rate of the biliary fistula, nonoperative management was carried out; on the second post-operative day the patient presented hypotension, oliguria, fever (temperature 38.2°C), and worsening right upper abdominal pain with signs of diffuse peritonitis. The hematologic investigations showed a WBC 17,560/mL, Hb 10.7 g/dL, C-Reactive Protein 17.66 mg/dL, normal liver function tests, and normal bilirubin levels. Owing to signs of septic shock and diffuse signs of peritonitis, an urgent surgical exploration was performed. After the induction of anesthesia, 2.5 mg of Indocyanine Green was intravenously injected. Eight minutes later, the ICG-C demonstrated exactly and in real-time the biliary leak on the liver surface, coming from a subvesical bile duct. Two laparoscopic Roeder's knots were placed to repair the injury. Two surgical drains were placed. Results: The postoperative period was uneventful, with a progressive improvement of the patient's performance status, vital parameters, and laboratory tests. The surgical drains were serosanguinous with low output and both were removed on postoperative day 9. The patient was discharged on day 10 in good clinical condition. Conclusions: One of the most common causes of LC-associated biliary leaks are injuries to the subvesical bile ducts. ICG-C clearly identifies these bile spots on the liver surface during surgery, allowing them to be repaired immediately and prevent biliary fistulas. ICG-C is a safe, easy, repeatable, and noninvasive method to identify bile leaks during surgery. ICG-C may be useful to prevent and treat bile leaks after LC, especially in complicated cholecystitis.5,6 Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No competing financial interests exist. Running time of video: 8 mins 27 secs

Outcome of Laparoscopic Cholecystectomy in Acute Gall Bladder Disease

Background: In order to remove the gall bladder, cholecystectomy, which may be performed laparoscopically, is one option. Before, acute cholecystitis was a barrier to laparoscopic treatment, but that limitation has been removed as the technique has evolved and become more refined. Objective: To see the outcome of laparoscopic cholecystectomy in acute gall bladder disease. Methods: This prospective observational research was undertaken from July 2021 to July 2022 at Rangpur Medical college Hospital. This research includes 52 acute cholecystitis patients. Age and gender didn't affect patient selection. Detailing routine and unusual clinical histories Blood, bilirubin Sugar, serum creatinine, CBC, SGPT, HBsAg, etc. Same surgical team performed all procedures. Post-op course and problems were noted. Everyone had four ports (Additional ports) Few individuals had 2-7-day cholecystectomy after acute attack. After attack conversion counseling, all patients had urgent Laparoscopic cholecystectomy. Results: Ultrasonographic findings (Table 2) showed that all the 52 patients had features of acute cholecystitis i.e. distended tense gallbladder with oedematous wall. In this series, 51patients had stones in the gall bladder and 1 patient had only features of acute cholecystitis. 27 patients had single stone. None of them had dilated biliary tree or stone in common bile duct. Most of the patients (41 patients, 78.85%) had leucocyte count (Table-3) between 11000- 13000/cmm, 4 (26.92%) had 13000-15000/cmm and rest seven patients had normal leucocyte count. Conclusion: Early surgery for acute calculous cholecystitis and acute biliary discomfort had a better prognosis than delayed treatment. Acute biliary pain patients benefit from early surgery to prevent read mission, however laparoscopic surgeries in the acute and elective context had a comparable conversion rate. Laparoscopic cholecystectomy is doable and useful provided the patient has the proper support and skill.

Abstract 11656: Preoperative Cardiac Risk Assessment for a Patient With an Intracardiac Shunt Undergoing Laparoscopic Surgical Intervention

Introduction: In this case, we discuss the intraoperative risk of air cardioembolic stroke in patients with intra-cardiac shunts undergoing laparoscopic surgery due to CO 2 insufflation of the abdomen in conjunction with provoked right-to-left shunting from anesthesia. Case Presentation: 27-year-old Female with Down Syndrome and asymptomatic VSD presented with abdominal pain. CT Abdomen performed revealed Acute Cholecystitis and patient was admitted for urgent laparoscopic cholecystectomy. Cardiology was consulted for preoperative risk assessment. Echocardiogram recommended and redemonstrated known VSD with predominant left-to-right shunting and occasional flow reversal (right-to-left) at baseline. Upon discussion with Anesthesia, the concern arose for anesthesia induced flow reversal of the shunt with a risk of possible paradoxical air embolism from CO 2 insufflation during laparoscopy. This concern was presented to the General Surgery team for consideration of conversion of procedure to open cholecystectomy. Open cholecystectomy was performed without complications. Discussion/Conclusion: Laparoscopic surgery requires CO 2 insufflation of the abdomen to cause pneumoperitoneum (Fig 1A), following which a gas embolism can result (Fig 1B). Consequently, in the absence of a pre-existing cardiac defect, patients can develop a pulmonary embolism (Fig 1C). However, individuals with right-to-left intracardiac shunting (Fig 1D), or Eisenmenger Syndrome, confer the additional risk of cardioembolic stroke (Fig 1E). In the preoperative assessment, right-to-left shunting is easily identified by TTE and managed accordingly. However, less intuitively, it can also occur transiently from the intraoperative use of certain anesthesia medications such as Propafol, which is known to decrease SVR. Therefore, if the evaluating clinician is unaware of this mitigated risk, it may go undetected, the result of which can be fatal.

Biliary Tract Microflora in Patients Undergoing Cholecystectomy for Acute Biliary Tract Disease: An Analysis of the Effect of Bile Spillage and Microbiology on Outcomes

INTRODUCTION: Bile spillage (BS) is common during laparoscopic cholecystectomy and has been shown to be associated with an increased risk of surgical site infection (SSI). We hypothesized that positive bile cultures (PBCs) increase the risk of postoperative complication including SSI. METHODS: A retrospective chart review was conducted of all patients older than 18 years undergoing urgent laparoscopic cholecystectomy at an academic hospital from January to September 2019. Charts were reviewed for the index admission and postoperative visits. We compared those who had PBCs with those who did not. Our primary endpoint was the rate of SSI. A univariate analysis, as well as a multivariate logistic regression, were used to identify predictors of SSI. RESULTS: A total of 272 patients underwent laparoscopic cholecystectomy. Indications for operation included acute cholecystitis (62.5%), symptomatic cholelithiasis (12.5%), and other indications (25%). Bile was spilled in 191 patients (70.2%). PBCs were obtained in 78 of 249 (31.3%) patients and were associated with preoperative endoscopic retrograde cholangiopancreatography (ERCP; 44% vs 26%, p = 0.014) and drain placement (50% vs 28.9%, p = 0.031). Eleven postoperative complications were noted, including 6 SSI (2.2%). Positive bile culture (3.8% vs 1.8%, p = 0.38), BS (3.1% vs 0%, p = 0.18), ERCP (1.4% vs 2.5%, p = 1.0), and drain placement (6.7% vs 1.7%, p = 0.13) were not associated with SSI. Multivariate analysis demonstrated that positive cultures were not predictive of complication or SSI (p = 0.13, p = 0.91, respectively). CONCLUSION: Positive bile cultures are not inherently associated with an increased risk of SSI and therefore should not lead to ongoing postoperative antibiotic therapy.

Optimal Timing of Cholecystectomy for Acute Cholecystitis: A Retrospective Cohort Study.

BackgroundLaparoscopic cholecystectomy performed less than 72 hours from hospital admission for acute cholecystitis has shown to decrease hospital cost without an increase in length of stay (LOS). Very few studies have examined clinical and cost outcomes of performing cholecystectomy less than 24 hours from hospital admission. The aim of this study was to examine the cost and LOS of laparoscopic cholecystectomy performed on an early (less than 24 hours from admission) and late (more than 24 hours from hospital admission) basis.MethodsWe performed a retrospective observational study of 569 patients at Baystate Medical Center, Springfield, USA, who underwent urgent laparoscopic cholecystectomy for acute cholecystitis between January 1, 2018 and February 28, 2020. We evaluated preoperative/postoperative LOS, operative duration, hospital cost, and patient complications.Results468 patients underwent urgent laparoscopic cholecystectomy for acute cholecystitis during our study period. Early cholecystectomy (less than 24 hours from admission) had an overall decreased LOS (43.6 hours versus 102.9 hours, p-value < 0.01) and decreased hospital cost ($23,736.70 versus $30,176.40, p-value < 0.01) compared to late cholecystectomy (more than 24 hours from admission). There was also a significantly higher rate of bile leak in patients who underwent surgery more than 24 hours from hospital admission compared to those who had surgery less than 24 hours from admission (5.9% versus 0.4%, p-value < 0.01). Additionally, those procedures performed greater than 24 hours from hospital admission were significantly more likely to be converted to an open procedure (6.9% versus 2.2%, p-value = 0.02). ConclusionUrgent laparoscopic cholecystectomy performed within 24 hours of hospital admission for acute cholecystitis decreased hospital cost, LOS, and operative complications in our institution's patient population. Our data suggests that performing laparoscopic cholecystectomy within 24 hours of hospital admission would be beneficial from a patient and hospital standpoint.

EP-277 Emphysematous cholecystitis: A diagnostic dilemma and treatment challenge

Abstract Background Emphysematous cholecystitis (EC) is a rare life-threatening variant of acute cholecystitis. It is commonly seen in elderly men who are immunocompromised, known diabetes mellitus or peripheral vascular disease. EC is caused by gas-forming organisms such as Escherichia coli, Clostridium perfringens and Bacteroides fragilis and has a reported mortality of up to 25%. Computed Tomography is the most sensitive diagnostic imaging study for the detection of intraluminal or intramural gallbladder gas. Methods We report a diagnostic dilemma and multidisciplinary management of a case of emphysematous cholecystitis with unusual presentation in a young, healthy patient with no risk factors. Results A 47-year-old male chef, otherwise fit and well, presented with a clinical picture of sepsis and abdominal pain. Initial investigations were normal apart from bilateral basal atelectasis, hence he was treated for pneumonia, although without clinical improvement. Due to persistent fever, patient underwent further investigations that established the diagnosis of emphysematous cholecystitis. His clinical condition improved dramatically after urgent laparoscopic cholecystectomy with patient being safely discharged home 6 days post-op, with an uneventful postoperative recovery. Conclusion A high index of clinical suspicion and multidisciplinary team management including surgery, radiology, and microbiology is crucial for early diagnosis of the rare life-threatening condition of EC. Our clinical case highlights that EC is not limited to elderly morbid patients and urgent laparoscopic cholecystectomy is the best treatment when feasible.

Urgent versus elective laparoscopic cholecystectomy following percutaneous transhepatic gallbladder drainage for high-risk grade II acute cholecystitis

BackgroundThe aim of this study was to evaluate the safety of urgent laparoscopic cholecystectomy (Lap-C) for grade II acute cholecystitis (AC) in high-risk patients who were defined by Tokyo Guideline 18 as having age-adjusted Charlson comorbidity index ≥6 or American Society of Anesthesiologists physical status classification (ASA-PS) ≥ 3, compared with elective Lap-C following percutaneous transhepatic gallbladder drainage (PTGBD). MethodsIn 73 grade II AC patients who underwent Lap-C from January 2012 to March 2021, 35 were identified as high-risk; 22 underwent urgent Lap-C (urgent group) and 13 PTGBD followed by elective Lap-C (elective group). Surgical and perioperative outcomes were analyzed. ResultsThere was no significant difference in operation time (median: 101 min vs 125 min; P = 0.371), blood loss (25 ml vs 7 ml; P = 0.853), morbidity rate (31.8% vs 38.5%; P = 0.726), or the incidence of total perioperative major complications (13.6% vs 15.4%; P = 1.000) between the two groups. The total duration of treatment was significantly shorter in the urgent group than the elective group (11 days vs 71 days; P < 0.001). Multivariate analysis revealed that blood loss ≥45 ml [odds ratio (OS): 12.14, 95% confidence interval (CI): 2.03–72.42, P = 0.006], and age ≥75 years with ASA-PS ≥ 3 (OS: 9.85, 95%CI: 1.26–77.26, P = 0.03) were the independent risk factors for total perioperative major complications. ConclusionIn well-selected high-risk patients with grade II AC, urgent Lap-C can be performed with comparable safety to elective Lap-C following PTGBD.

The Impact of COVID-19 Pandemic Upon Non-elective Admissions and Surgery at a Safety-Net Hospital: A Retrospective Cohort Study

IntroductionIn response to the COVID-19 pandemic, hospitals reported decreased admissions for acute surgical diagnoses, but scant data was available to quantify the decrease and its consequences. The objective of this study was to examine the incidence of acute care surgery encounters before and during the COVID-19 pandemic. Materials and MethodsA retrospective cohort study was performed at a single, urban, United States safety-net hospital. Emergency room encounters, admissions, non-elective surgical procedures, patient acuity, and surgical complications were compared before and after the start of the COVID-19 pandemic. The primary outcome of the study was the incidence rate (IR) and incidence rate ratios (IRR) for surgical admissions, laparoscopic appendectomy, and urgent laparoscopic cholecystectomy. ResultsDuring the COVID-19 (exposure) time period, the number of nonelective procedures was 143 (IR 4.76) which was significantly lower than the control periods (n = 431, IR 7.2), P < 0.001. During the COVID-19 exposure period, there were significantly fewer urgent cholecystectomies performed (1.37 per day versus 2.80-2.93 per day, P < 0.001). There was a trend toward fewer appendectomies performed, but not significant. There was little difference in patient acuity between the exposure and control periods. A higher proportion of patients that underwent urgent cholecystectomy during the COVID time period had been seen in the ED in the prior 30 d (22% versus 5.6%). ConclusionsSurgical volume significantly decreased during the COVID-19 pandemic. Management of acute cholecystitis may require re-evaluation as nonsurgical management appears to increase repeat presentations.

Intraoperative complexity and risk factors associated with conversion to open surgery during laparoscopic cholecystectomy in eight hospitals in Mexico City.

The conversion to open surgery (COS) during the Laparoscopic Cholecystectomy (LC) is reported to occur at a rate of 10-15%. Some preoperative risk factors (RF) have been postulated; however, few studies have evaluated these factors and the intraoperative complexity with the COS rate. The aim of the study was to evaluate the preoperative RF and intraoperative complexity using the Parkland grading scale (PGS) with the COS rate in LC. A retrospective study was done evaluating the demographic and surgical variables from the patients and LC videos from 8 different hospitals of Mexico City from December 2018 to January 2020. The evaluation of the PGS was done by 2 surgeons (one MI and one HPB surgeon); the PGS was also categorized as Non-Complex LC (nCLC, PGS1-2) and Complex LC (CLC, PGS 3-5). Logistic regression was used to evaluate the association of this factors with the COS rate. 430 LC were analyzed; 358 (78.61%) were women, 261 (60.7%) were elective and 169(39.3%) urgent LC, the mean age was 44.06 (SD ± 13.16) years. 21 (4.8%) LC were COS; the mean age of this group was 55 (SD ± 12.95), 3 (0.7%) were nCLC and 18 (4.19%) CLC, mean PGS of 3.76 (SD ± 1.09), the mean time to COS was 48.67 (SD ± 41.9), the estimated blood loss (EBL) was 258 (SD ± 260.22) and 6 (1.4%) intraoperative BDI were recognized on this group. Univariate analysis showed a significant association with the COS with male sex, older age, age > 45years, presence of comorbidities, a higher PGS, a CLC, higher EBL and possible BDI; multivariate analysis produced a model using male sex, age, presence of comorbidities and a CLC with a 0.809 area under the ROC curve. The recognition of the associated RF and a CLC can guide the surgeon to establish preoperative and bailout strategies during the procedure, recognizing a higher risk of COS and its higher morbidity.

55 Laparoscopic Cholecystectomy Consent Form Analysis Audit

Abstract Aim To assess consent forms in the new urgent laparoscopic cholecystectomy theatre (ESAC) list in the University Hospital of Wales. With procedure-specific consent forms becoming more regularly utilised, we assess the need for them in our Trust. Method We prospectively assessed the consent forms of the first 20 patients who were enrolled in ESAC. We measured the complications list against national standards to assess completeness, including any use of abbreviations and the overall legibility. To complete our assessment and for posterity, we called each patient and gave them an official questionnaire to ensure their understanding before, during and after surgery. Results We found that of the complications included in the ESAC consent forms, there was a high degree of variability. For example, 75% contained ‘bile leak’ and 55% ‘post-cholecystectomy syndrome’; both named examples in national guidelines. Additionally, while the vast majority were legible, 50% of the consent forms utilised abbreviations in their written sections. Lastly, patient understanding surrounding the details of the operation was sound, with the majority correctly identifying their surgery, what it entailed and what they were expected to do post-operatively. However, just over half were able to provide a moderately detailed list of the associated complications that may have occurred. Conclusions That the trust would benefit from a procedure-specific consent form (PSCF) to provide exhaustive information on procedure details, complications, and their rates, as well as mortality rates. Additionally, this would eliminate issues of legibility and usage of abbreviations. We anticipate that it will also improve patient understanding.

CIS-ATRACURIUM WITH MASSETER MUSCLE SPASM: AN UNANTICIPATED DIFFICULT ENDOTRACHEAL INTUBATION AND TEMPOROMANDIBULAR JOINT DISPLACEMENT: A CASE REPORT

Masseter muscle spasm and displacement of temporomandibular joint under anaesthesia could be life threatening if an anaesthesiologist is not prepared. We present a case of 23 years old young lady, who otherwise healthy, having symptoms of abdominal pain and vomiting. Initial baseline workup showed a solitary gallstone and was then planned for urgent laparoscopic cholecystectomy. The challenges faced in the perioperative period were the management of unanticipated masseter muscle spasm and difficult endotracheal intubation after administration of cisatracurium, and temporomandibular joint displacement.

Laparoscopic Cholecystectomy for Acute Cholecystitis: Indication, Risk, and Outcome

Background: A laparoscopic cholecystectomy is a fundamental approach to treating acute cholecystitis, and the timing of performing this given treatment is associated with clinical outcomes. It is unknown whether surgical indication, risk, and consequences of laparoscopic cholecystectomy for acute cholecystitis differ from those for the chronic form, making it questionable whether urgent laparoscopic cholecystectomy is the best approach even in severe acute cases. Objective: This study aimed to evaluate surgical indication, risk, and outcomes of laparoscopic cholecystectomy for acute cholecystitis. Methods: This prospective observational study was carried out at Bangladesh Medical College Hospital (Uttara Campus) from July 2006 to November 2008. A total of 103 acute cholecystitis patients were observed to evaluate the safety, risk, and outcomes (includes hospital stay, joining to routine daily works) of laparoscopic cholecystectomy. Result: Male and female ratio is 1:4, and the mean age in our series is 47 years. Acute calculas cholecystitis ultra-sonogram feature shows the highest percentage (85.4%) compare to the other four parts. The study also confirmations around 69% did not get any complications, and bleeding was the most frequently observed (16%) complication. The overall outcomes in this research were observed around 75% of total operated patients did not experience any difficulty and said they fit entirely. The other 19% who had some complications include Pain, RTI, Seroma, Jaundice, Cholangitis, Wound infection). Conclusion: Regarding bile duct injury and prolonged complications, laparoscopic surgery is not a very good treatment option for acute cholecystitis.

The Impact of a Dedicated "Hot List" on the In-Patient Management of Patients With Acute Gallstone-Related Disease.

Background: Index admission laparoscopic cholecystectomy is the standard of care for patients admitted to hospital with symptomatic acute cholecystitis. The same standard applies to patients suffering with mild acute biliary pancreatitis. Operating theatre capacity can be a significant constraint to same admission surgery. This study assesses the impact of dedicated theatre capacity provided by a specialist surgical team on rates of index admission cholecystectomy.Methods: This clinical cohort study compares the management of patients with symptomatic gallstone disease admitted to a tertiary care university teaching hospital over two equal but chronologically separate time periods. The periods were before and after service reconfiguration including a specialist HPB service with dedicated operating theatre time allocation.Results: There was a significant difference in the number of admissions over the two time periods with a greater proportion of patients having index admission surgery in the second time period with correspondingly fewer having more than one admission during this latter time period. In the second time period 43% of patients underwent index admission cholecystectomy compared to 23% in the first (P < 0.001). The duration of surgery was shorter for patients undergoing surgery during the second time period [135 (102–178) min in the first period and in the second period 106 (89–145) min] (P = 0.02).Discussion: This paper shows that the concentration of theatre resources and surgical expertise into regular theatre access for patients undergoing urgent laparoscopic cholecystectomy is an effective and safe model for dealing with acute biliary disease.

Comparative Analysis of Three-Versus Two-dimensional Imaging in Laparoscopic Cholecystectomy.

Three-dimensional (3D) imaging has been suggested to improve learning and performance of laparoscopy. We sought to investigate whether 3D imaging could improve the outcomes after laparoscopic cholecystectomy. Two-hundred and forty-one consecutive patients underwent elective or urgent laparoscopic cholecystectomy using 2D (n = 111) and 3D (n = 130) imaging equipments from March 2017 to March 2019 at the Kainuu Central Hospital, Finland. The main outcomes of this study were biliary tract injury, conversion to open procedure and procedure duration. In the overall series, there were 5 cases of biliary tract injury (2.1%). When compared to 3D imaging, 2D was associated with increased risk of biliary tract injury in the overall series (0% in 3D vs. 4.7% in 2D, p = 0.026) in addition to a subgroup of acute cholecystitis patients operated by senior surgeons (n = 92), 0% in 3D group (n = 60) vs. 10.0% in 2D group (n = 32), p = 0.037 in univariate analysis. The rates of conversion to open surgery did not differ between the groups in the overall series (5.3 vs 5.7%, p = 0.909) or any of the subgroups. Duration of surgery with 3D vs. 2D imaging were comparable in the elective (57.0 ± 16.3 vs. 54.1 ± 18.9min, p = 0.228) and urgent setting (66.9 ± 15.1 vs. 67.4 ± 16.6min, p = 0.805). Such differences were not significant in multivariate analysis. The present study suggests that the use of 3D imaging is significantly associated with a reduced risk of intraoperative biliary tract injury during laparoscopic cholecystectomy especially in acute cholecystitis.

Colecistitis hemorrágica, a propósito de un caso

Introducción: La colecistitis hemorrágica es una patología muy poco frecuente y de alta mortalidad. Sin embargo, puede o no estar asociada a cálculos biliares. La colecistitis hemorrágica es de difícil diagnóstico. Los cambios inflamatorios desencadenados por la hemorragia, causan ulceración de la mucosa y necrosis, acompañando a una inflamación sostenida donde interactúan citoquinas; provocando una dilatación exagerada de la vesícula biliar y finalmente su ruptura, causando hemoperitoneo e incluso la muerte.&#x0D; Objetivo: Describir un caso clínico de un paciente con colecistitis hemorrágica como complicación de colecistitis aguda.&#x0D; Material y métodos: Estudio descriptivo retrospectivo, presentación de caso clínico.&#x0D; Resultados: Se presenta el caso de un paciente sexo masculino de 39 años, que sufrió un episodio de dolor abdominal intenso acompañado de vómitos e ictericia en facies; por lo cual requirió evaluación médica con exámenes complementarios y procedimiento quirúrgico inmediato. Se realizó una colecistectomía laparoscópica urgente que reveló una vesícula biliar tensa y necrótica con múltiples litos en su interior y una mucosa aplanada, ulcerada focalmente mientras que el resto de la túnica muestra sangrado abundante.&#x0D; Conclusiones: La colecistitis hemorrágica, es una complicación importante y rara de la colecistitis aguda, muy difícil de diagnosticarla preoperatoriamente. Sin embargo, el cirujano debe conocerla y manejarla adecuadamente; puesto que, al correlacionar: la clínica, el laboratorio y los métodos de imagen, que estén a su alcance; brindará un tratamiento quirúrgico temprano y disminuirá significativamente la morbimortalidad del paciente.