Near-infrared cholangiography with intragallbladder indocyanine green injection in minimally invasive cholecystectomy

Laparoscopic cholecystectomy(LC)remains one of the most commonly performed procedures in adult and paediatric populations.Despite the advances made in intraoperative biliary anatomy recognition,iatrogenic bile duct injuries during LC represent a fatal complication and consist an economic burden for healthcare systems.A series of methods have been proposed to prevent bile duct injury,among them the use of indocyanine green(ICG)fluorescence.The most commonly reported method of ICG injection is the intravenous administration,while literature is lacking studies investigating the direct intragallbladder ICG injection.This narrative mini-review aims to assess the potential applications,usefulness,and limitations of intragallbladder ICG fluorescence in LC.Authors screened the available international literature to identify the reports of intragallbladder ICG fluorescence imaging in minimally invasive cholecystectomy,as well as special issues regarding its use.Literature search retrieved four prospective cohort studies,three case-control studies,and one case report.In the three case-control studies selected,intragallbladder near-infrared cholangiography(NIRC)was compared with standard LC under white light,with intravenous administration of ICG for NIRC and with standard intraoperative cholangiography(IOC).In total,133 patients reported in the literature have been administered intragallbladder ICG administration for biliary mapping during LC.Literature includes several reports of intragallbladder ICG administration,but a standardized technique has not been established yet.Published data suggest that NIRC with intragallbladder ICG injection is a promising method to achieve biliary mapping,overwhelming limitations of IOC including intervention and radiation exposure,as well as the high hepatic parenchyma signal and time interval needed in intravenous ICG fluorescence.Evidence-based guidelines on the role of intragallbladder ICG fluorescence in LC require the assessment of further studies and multicenter data collection into large registries.

Research on the prognostic value of adjusting intraperitoneal threedimensional quality evaluation mode in laparoscopic cholecystectomy patients

BACKGROUND Benign gallbladder diseases have become a high-prevalence condition not only in China but also worldwide.The main types of benign gallbladder diseases include gallbladder polyps,acute and chronic cholecystitis,and gallstones,with gallstones being the most common,accounting for over 70%of cases.Although the mortality rate of benign gallbladder diseases is low,they carry obvious potential risks.Studies have shown that an increased incidence of benign gallbladder diseases can increase the risk of cardiovascular diseases and gallbladder cancer,resulting in a substantial disease burden on patients and their families.AIM To assess the medical utility of the Configuration-Procedure-Consequence(CPC)three-dimensional quality evaluation model in modulating the prognosis of laparoscopic cholecystectomy patients.METHODS A total of 98 patients who underwent laparoscopic cholecystectomy in our hospital from February 2020 to January 2022 were selected as the subjects.According to the random number table method,they were divided into a study group and a control group,with 49 patients in each group.The control group received routine perioperative care,while the study group had the addition of the CPC three-dimensional quality evaluation.The postoperative recovery-related indicators(time to first flatus,time to oral intake,time to ambulation,hospital stay),stress indicators(cortisol and adrenaline levels),distinctions in anxiety and RESULTS The time to first flatus,time to oral intake,time to ambulation,and hospital stay of the study group patients were obviously lower than those of the control group patients,with statistical significance(P<0.05).On the 1st day after admission,there were no obvious distinctions in cortisol and adrenaline levels in blood samples,as well as in the Self-Rating Anxiety Scale(SAS)and Self-Rating Depression Scale(SDS)scores between the study group and the control group(P>0.05).However,on the 3rd day after surgery,the cortisol and adrenaline levels,as well as SAS and SDS scores of the study group patients,were obviously lower than those of the control group patients(P<0.05).The study group had 2 cases of incisional infection and 1 case of pulmonary infection,with a total incidence of complications of 6.12%(3/49),which was obviously lower than the 20.41%(10/49)in the control group(P<0.05).CONCLUSION Implementing the CPC three-dimensional quality evaluation model for patients undergoing laparoscopic cholecystectomy can help accelerate their perioperative recovery process,alleviate perioperative stress symptoms,mitigate anxiety,depression,and other adverse emotions,and to some extent,reduce the incidence of perioperative complications.

Evaluating effectiveness and safety of combined percutaneous transhepatic gallbladder drainage and laparoscopic cholecystectomy in acute cholecystitis patients:Meta-analysis

BACKGROUND Acute cholecystitis(AC)is a common disease in general surgery.Laparoscopic cholecystectomy(LC)is widely recognized as the"gold standard"surgical procedure for treating AC.For low-risk patients without complications,LC is the recommended treatment plan,but there is still controversy regarding the treatment strategy for moderate AC patients,which relies more on the surgeon's experience and the medical platform of the visiting unit.Percutaneous transhepatic gallbladder puncture drainage(PTGBD)can effectively alleviate gallbladder inflammation,reduce gallbladder wall edema and adhesion around the gallbladder,and create a"time window"for elective surgery.AIM To compare the clinical efficacy and safety of LC or PTGBD combined with LC for treating AC patients,providing a theoretical basis for choosing reasonable surgical methods for AC patients.METHODS In this study,we conducted a clinical investigation regarding the combined use of PTGBD tubes for the treatment of gastric cancer patients with AC.We performed searches in the following databases:PubMed,Web of Science,EMBASE,Cochrane Library,China National Knowledge Infrastructure,and Wanfang Database.The search encompassed literature published from the inception of these databases to the present.Subsequently,relevant data were extracted,and a meta-analysis was conducted using RevMan 5.3 software.RESULTS A comprehensive analysis was conducted,encompassing 24 studies involving a total of 2564 patients.These patients were categorized into two groups:1371 in the LC group and 1193 in the PTGBD+LC group.The outcomes of the meta-analysis revealed noteworthy disparities between the PTGBD+LC group and the LC group in multiple dimensions:(1)Operative time:Mean difference(MD)=17.51,95%CI:9.53-25.49,P<0.01;(2)Conversion to open surgery rate:Odds ratio(OR)=2.95,95%CI:1.90-4.58,P<0.01;(3)Intraoperative bleeding loss:MD=32.27,95%CI:23.03-41.50,P<0.01;(4)Postoperative hospital stay:MD=1.44,95%CI:0.14-2.73,P=0.03;(5)Overall postoperative compli-cation rate:OR=1.88,95%CI:1.45-2.43,P<0.01;(6)Bile duct injury:OR=2.17,95%CI:1.30-3.64,P=0.003;(7)Intra-abdominal hemorrhage:OR=2.45,95%CI:1.06-5.64,P=0.004;and(8)Wound infection:OR=0.These find-ings consistently favored the PTGBD+LC group over the LC group.There were no significant differences in the total duration of hospitalization[MD=-1.85,95%CI:-4.86-1.16,P=0.23]or bile leakage[OR=1.33,95%CI:0.81-2.18,P=0.26]between the two groups.CONCLUSION The combination of PTGBD tubes with LC for AC treatment demonstrated superior clinical efficacy and enhanced safety,suggesting its broader application value in clinical practice.

Hem-o-lok clip migration to duodenal bulb post-cholecystectomy:A case report

BACKGROUND Hem-o-lok clips are typically used to control the cystic duct and vessels during laparoscopic cholecystectomy(LC)and common bile duct exploration for stones in the bile duct and gallbladder.Here,we report a unique example of Hem-o-lok clip movement towards the duodenal bulb after LC,appearing as a submucosal tumor(SMT).Additionally,we provide initial evidence of gradual and evolving endoscopic manifestations of Hem-o-lok clip migration to the duodenal bulb wall and review the available literature.CASE SUMMARY A 72-year-old man underwent LC for gallstones,and Hem-o-lok clips were used to ligate both the cystic duct and cystic artery.Esophagogastroduodenoscopy(EGD)2 years later revealed an SMT-like lesion in the duodenal bulb.Due to the symptomatology,the clinical examination did not reveal any major abnormalities,and the patient was followed up as an outpatient.A repeat EGD performed 5 months later revealed an SMT-like lesion in the duodenal bulb with raised edges and a central depression.A third EGD was conducted,during which a Hem-o-lok clip was discovered connected to the front side of the duodenum.The clip was extracted easily using biopsy forceps,and no complications occurred.Two months after the fourth EGD,the scar was surrounded by normal mucosa.CONCLUSION Clinicians should be aware of potential post-LC complications.Hem-o-lok clips should be removed if symptomatic.

Research on the Application and Effectiveness of the DRG Model on Perioperative Medical Management of Cholecystectomy

Objective:This study aimed to explore the application and effectiveness of the DRG model in the perioperative management of cholecystectomy.By comparing the DRG model with traditional management methods,this study focused on evaluating the potential impact of the DRG model in improving surgical efficiency and reducing complication rates and medical costs.Methods:The random envelope method was used to divide patients scheduled for cholecystectomy from January 2021 to October 2023 into two groups:one group underwent surgery under the DRG model(experimental group),and the other group underwent the traditional management model(control group).Data including basic information,surgery-related data,length of stay,complication records,and medical expenses were collected.Data analysis was carried out using a t-test and chi-square(χ2)test.Results:Results showed that the DRG model shortened the average length of stay,decreased the incidence of complications,reduced medical expenses,and increased patient satisfaction.These results demonstrate the effectiveness of the DRG model in the perioperative management of cholecystectomy,especially in improving surgical efficiency,reducing medical costs,and improving patient satisfaction.Conclusion:The DRG model in the perioperative management of cholecystectomy can significantly improve medical service quality and efficiency and enhance patient satisfaction as compared to traditional treatment methods.

Early versus delayed laparoscopic cholecystectomy in uncomplicated biliary colic: An observational study

Objective:Biliary colic is a condition treated with laparoscopic cholecystectomy.However,the outcomes of surgery depend on early or delayed time points.Few research findings reported no benefits of early over delayed,on contra,other reported benefits.This study aims to compare the benefits associated with early and delayed laparoscopic cholecystectomy among uncomplicated biliary colic patients.Methods:This observational study included patients with right upper abdominal pain and abdominal ultrasound showing cholelithiasis.Patients who were admitted at the first and second visits(within 6 weeks of the first visit)were assigned to the early and delayed groups,respectively.All participants were followed up for one-week postsurgery.The diagnosis of the patient,postoperative hospital stay,duration of surgery and complications were noted and compared primarily.Results:A total of 80 patients were included,40 each in the early group and delayed group.The patients in the two groups had comparable mean ages(40.55±13.12 y vs.40.45±12.06 y,p=0.972).The early group had more female patients(72.5%vs.45.0%,p=0.012).The duration of hospital stay(2.18±0.38 d vs.2.68±1.04 d,p=0.009)and duration of surgery(61.63±3.64 min vs.71.13±16.19 min,p=0.001)were found to be significantly different between the early and delayed groups.Only 1(2.5%)patient in both groups was converted to open cholecystectomy.Recurrent biliary colic requiring hospital admission was seen in 1(2.5%)patient and 6(15.0%)patients,acute cholecystitis in 2(5.0%)and 6(15.0%),biliary pancreatitis in 1(2.5%)and 2(5.0%),and obstructive jaundice in 1(2.5%)and 1(2.5%)in the early and delayed groups,respectively,with insignificant differences(p>0.05).Conclusion:Early laparoscopic cholecystectomy decreases the operating time and duration of hospital stay.In terms of postoperative complications,our study did not find any significant difference between the groups.

Awake laparoscopic cholecystectomy:A case report and review of literature

BACKGROUND Laparoscopic cholecystectomy(LC)is one of the most widely practiced surgical procedures in abdominal surgery.Patients undergo LC during general anaesthesia;however,in recent years,several studies have suggested the ability to perform LC in patients who are awake.We report a case of awake LC and a literature review.CASE SUMMARY A 69-year-old patient with severe pulmonary disease affected by cholelithiasis was scheduled for LC under regional anaesthesia.We first performed peridural anaesthesia at the T8-T9 level and then spinal anaesthesia at the T12-L1 level.The procedure was managed in total comfort for both the patient and the surgeon.The intra-abdominal pressure was 8 mmHg.The patient remained stable throughout the procedure,and the postoperative course was uneventful.CONCLUSION Evidence has warranted the safe use of spinal and epidural anaesthesia,with minimal side effects easily managed with medications.Regional anaesthesia in selected patients may provide some advantages over general anaesthesia,such as no airway manipulation,maintenance of spontaneous breathing,effective postoperative analgesia,less nausea and vomiting,and early recovery.However,this technique for LC is not widely used in Europe;this is the first case reported in Italy in the literature.Regional anaesthesia is feasible and safe in performing some types of laparoscopic procedures.Further studies should be carried out to introduce this type of anaesthesia in routine clinical practice.

Initial management of suspected biliary injury after laparoscopic cholecystectomy

Although rare,iatrogenic bile duct injury(BDI)after laparoscopic cholecystectomy may be devastating to the patient.The cornerstones for the initial management of BDI are early recognition,followed by modern imaging and evaluation of injury severity.Tertiary hepato-biliary centre care with a multidisciplinary approach is crucial.The diagnostics of BDI commences with a multiphase abdominal computed tomography scan,and when the biloma is drained or a surgical drain is put in place,the diagnosis is set with the help of bile drain output.To visualize the leak site and biliary anatomy,the diagnostics is supplemented with contrast enhanced magnetic resonance imaging.The location and severity of the bile duct lesion and concomitant injuries to the hepatic vascular system are evaluated.Most often,a combination of percutaneous and endoscopic methods is used for control of contamination and bile leak.Generally,the next step is endoscopic retrograde cholangiography(ERC)for downstream control of the bile leak.ERC with insertion of a stent is the treatment of choice in most mild bile leaks.The surgical option of re-operation and its timing should be discussed in cases where an endoscopic and percutaneous approach is not sufficient.The patient's failure to recover properly in the first days after laparoscopic cholecystectomy should immediately raise suspicion of BDI and this merits immediate investigation.Early consultation and referral to a dedicated hepatobiliary unit are essential for the best outcome.

Explore the clinical nursing path of daytime laparoscopic cholecystectomy under the guidance of enhanced recovery after surgery

Objective:To explore the safety and effectiveness nursing of 12 h discharged daytime laparoscopic cholecystectomy guided by enhanced recovery after surgery(ERAS)concept.Methods:Included 180 cases from the 12 h discharged daytime laparoscopic cholecystectomy patients which assessmended and guided by ERAS,with the 180 case of routine cholecystectomy patients as control group at the same time.To quantitatively analyze the related indexes of perioperative period and ERAS concept,and evaluate the clinical safety,and effectiveness.Results:It displayed no significant differences in average age,gender distribution,duration of gallbladder related disease and distribution of clinical symptoms between the two groups(P>0.05).There were also no significant differences in preoperative smoking history,hypertension history,cardio-cerebrovascular history,abdominal operation history and disease composition ratio between the two groups(P>0.05).None of the patients had conversion to laparotomy.Compared with the conventional surgery group,there were no significant differences in the average amount of intraoperative blood loss,operation time and muscle strength before returning to the ward in patients with ERAS guided day surgery(P>0.05).When compared with the conventional surgery group,ERAS guided day surgery group had no significant difference in muscle strength between the two groups when going under the ground(t=1.64,P=0.082).Also,the level of peripheral white blood cells in patients with ERAS guided day surgery group was not significantly increased at 6 h after surgery.Meanwhile,liver function related indexes,transaminase,total bilirubin,indirect bilirubin were not significantly abnormal(P>0.05).Conclusion:12 h daytime laparoscopic cholecystectomy guided by ERAS concept can improve the clinical efficacy of patients with cholecystolithiasis,which is safe and feasible.

The effect of cholecystectomy on the risk of colorectal cancer:A systematic review and meta-analysis

Objective:Some studies have found that cholecystectomy may increase the risk of colorectal cancer(CRC),while others have reached inconsistent conclusions.We thus performed a systematic review and meta-analysis to assess the incidence rate of CRC after cholecystectomy for patients with gallstones or gallbladder diseases,and whether the geographical location of the patients affected the results.Methods:We systematically searched PubMed,Embase,and Cochrane for studies reporting changes in the incidence rate of CRC after cholecystectomy published before January 12,2023.Our main endpoint wasthe occurrence of CRC Data were extracted and pooled,and the relative risk(RR)and 95%confidence interval(CI)were calculated.We assessed pooled data using a random-effects model.Results:In total,477 articles were identifled,and 6 articles were eligible,including 7 studies thatincluded 797,917 participants.Overall,the summarized research results showed that the risk of CRC was reduced in patients with gallbladder diseases who underwent cholecystectomy(RR:0.80,95%C:0.65 to0.99,p=0.040;I^(2)=85.0%).In the subgroup analysis based on different geographical locations,chole-cystectomy was not associated with the nisk of CRC in the Western population(RR:0.90,95%C:0.65 to 1.25.p=0.522;I^(2)=86.5%),but there was a negative corelation between cholecystectomy and the risk of CRC(RR:0,66,95%Cl:0.60 to 0,73,p=0.000)in the Chinese population Conclusions:Our findings support that for patients with gallstones or gallbladder diseases,the incidence of CRC after cholecystectomy is lower than that of patients who do not undergo cholecystectomy.

Minimally invasive surgery for post cholecystectomy biliary stricture:current evidence and future perspectives

Postcholecystectomy bile duct injury(BDI)remains a devastating iatrogenic complication that adversely impacts the quality of life with high healthcare costs.Despite a decrease in the incidence of laparoscopic cholecystectomy-related BDI,the absolute number remains high as cholecystectomy is a commonly performed surgical procedure.Open Roux-en-Y hepaticojejunostomy with meticulous surgical technique remains the gold standard surgical procedure with excellent longterm results in most patients.As with many hepatobiliary disorders,a minimally invasive approach has been recently explored to minimize access-related complications and improve postoperative recovery.Since patients with gallstone disease are often admitted for a minimally invasive cholecystectomy,laparoscopic and robotic approaches for repairing postcholecystectomy biliary stricture are attractive.While recent series have shown the feasibility and safety of minimally invasive post-cholecystectomy biliary stricture management,most are retrospective analyses with small sample sizes.Also,long-term follow-up is avail-able only in a limited number of studies.The principles and technique of minimally invasive repair resemble open repair except for the extent of adhesiolysis and the suturing technique with continuous sutures commonly used in minimally invasive approaches.The robotic approach overcomes key limitations of laparoscopic surgery and has the potential to become the preferred minimally invasive approach for the repair of postcholecystectomy biliary stricture.Despite increasing use,lack of prospective studies and selection bias with available evidence precludes definitive conclusions regarding minimally invasive surgery for managing postcholecystectomy biliary stricture.High-volume prospective studies are required to confirm the initial promising outcomes with minimally invasive surgery.

Vascular injury during laparoscopic cholecystectomy:An oftenoverlooked complication

Laparoscopic cholecystectomy is one of the most frequently performed procedures in gastrointestinal surgery worldwide.Bleeding complications due to vascular injuries represent an important cause of morbidity and mortality,especially when facing major bleeding during laparoscopy,where bleeding control can be technically challenging in inexperienced hands.Interestingly,the reported incidence rate of conversion to open surgery due to vascular lesions is approximately 0%-1.9%,with a mortality rate of approximately 0.02%.The primary aim of this article was to perform an up-to-date overview regarding the incidence and surgical management of vascular injuries during laparoscopic cholecystectomy according to the available scientific evidence.

Post-cholecystectomy iatrogenic bile duct injuries:Emerging role for endoscopic management

Post-cholecystectomy iatrogenic bile duct injuries(IBDIs),are not uncommon and although the frequency of IBDIs vary across the literature,the rates following the procedure of laparoscopic cholecystectomy are much higher than open cholecystectomy.These injuries caries a great burden on the patients,physicians and the health care systems and sometime are life-threatening.IBDIs are associated with different manifestations that are not limited to abdominal pain,bile leaks from the surgical drains,peritonitis with fever and sometimes jaundice.Such injuries if not witnessed during the surgery,can be diagnosed by combining clinical manifestations,biochemical tests and imaging techniques.Among such techniques abdominal US is usually the first choice while Magnetic Resonance Cholangio-Pancreatography seems the most appropriate.Surgical approach was the ideal approach for such cases,however the introduction of Endoscopic Retrograde Cholangio-Pancreatography(ERCP)was a paradigm shift in the management of such injuries due to accepted success rates,lower cost and lower rates of associated morbidity and mortality.However,the literature lacks consensus for the optimal timing of ERCP intervention in the management of IBDIs.ERCP management of IBDIs can be tailored according to the nature of the underlying injury.For the subgroup of patients with complete bile duct ligation and lost ductal continuity,transfer to surgery is indicated without delay.Those patients will not benefit from endoscopy and hence should not do unnecessary ERCP.For low–flow leaks e.g.gallbladder bed leaks,conservative management for 1-2 wk prior to ERCP is advised,in contrary to high-flow leaks e.g.cystic duct leaks and stricture lesions in whom early ERCP is encouraged.Sphincterotomy plus stenting is the ideal management line for cases of IBDIs.Interventional radiologic techniques are promising options especially for cases of failed endoscopic repair and also for cases with altered anatomy.Future studies will solve many unsolved issues in the management of IBDIs.

Biloma Post-Cholecystectomy: A Prudent “Wait-and-See” Approach

Bile duct injury (BDI) is a well-known complication of cholecystectomy and can lead to the formation of a variety of complications, including biloma. Once diagnosed, the appropriate treatment depends on the severity of the condition and can range from minimally invasive procedures to more invasive procedures. We report the case of a 31-year-old woman who exhibited postoperative bile leakage after a cholecystectomy and a CT scan revealed a left hepatic subcapsular biloma. The patient was managed conservatively with close monitoring. The biloma resolved on its own without any intervention. Bilomas are rare complication of cholecystectomy that can be managed conservatively with a wait and see approach, especially in asymptomatic patients. Close monitoring with imaging and laboratory parameters is crucial in the management of these patients.

Our initial single port robotic cholecystectomy experience:A feasible and safe option for benign gallbladder diseases

BACKGROUND Although single-port laparoscopic cholecystectomy has been performed for over 25 years, it is still not popular. The narrow working space used in this surgery limits the movement of instruments and causes ergonomic challenges. Robotic surgery not only resolves the ergonomic challenges of single-port laparoscopic surgery but is also considered a good option with its additional technical advantages, like a three-dimensional display and not being affected by tremors.However, the extent to which these technical and ergonomic advantages positively affect the surgical outcomes and how safe the single-port robotic surgeries need to be assessed for each particular surgery.AIM To evaluate the feasibility and safety of single-port robotic cholecystectomy for patients with cholelithiasis.METHODS The electronic records of the first 40 consecutive patients with gallbladder lithiasis who underwent single-port robotic cholecystectomy from 2013 to 2021 were analyzed retrospectively. In addition to the demographic characteristics of the patients, we analyzed American Society of Anesthesiologists(ASA) scores and body mass index. The presence of an accompanying umbilical hernia was also noted. The amount of blood loss during the operation, the necessity to place a drain in the subhepatic area, and the need to use grafts during the closure of the fascia of the port site were determined. Hospital stay, readmission rates, perioperative and postoperative complications, the Clavien-Dindo complication scores and postoperative analgesia requirements were also evaluated.RESULTS The mean age of the 40 patients included in the study was 49.5 ± 11.6 years, and 26 were female(65.0%). The umbilical hernia was present in 24(60.0%) patients,with a body mass index median of 29.3 kg/m^(2) and a mean of 29.7 ± 5.2 kg/m^(2). Fifteen(37.5%) of the patients were evaluated as ASA Ⅰ, 18(45.0%) as ASA Ⅱ, and 7(17.5%) as ASA Ⅲ. The mean bleeding amount during the operation was 58.4 ± 55.8 mL, and drain placement was required in 12patients(30.0%). After port removal, graft reinforcement during fascia closure was preferred in 14patients(35.0%). The median operation time was 93.5 min and the mean was 101.2 ± 27.0 min. The mean hospital stay was 1.4 ± 0.6 d, and 1 patient was readmitted to the hospital due to pain(2.5%).Clavien-Dindo I complications were seen in 14 patients(35.0%), and five(12.5%) complications were wound site problems.CONCLUSION In addition to the technological and ergonomic advantages robotic surgery provides surgeons, our study strongly supports that single-port robotic cholecystectomy is a feasible and safe option for treating patients with gallstones.

Early vs late cholecystectomy in mild gall stone pancreatitis: Anupdated meta-analysis and review of literature

BACKGROUND Gallstone pancreatitis is one of the most common causes of acute pancreatitis.Cholecystectomy remains the definitive treatment of choice to prevent recurrence.The rate of early cholecystectomies during index admission remains low due toperceived increased risk of complications.AIMTo compare outcomes including length of stay, duration of surgery, biliarycomplications, conversion to open cholecystectomy, intra-operative, and postoperativecomplications between patients who undergo cholecystectomy duringindex admission as compared to those who undergo cholecystectomy thereafter.METHODSStatistical Method: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (randomeffects model).RESULTSInitial search identified 163 reference articles, of which 45 were selected andreviewed. Eighteen studies (n = 2651) that met the inclusion criteria were includedin this analysis. Median age of patients in the late group was 43.8 years while thatin the early group was 43.6. Pooled analysis showed late laparoscopiccholecystectomy group was associated with an increased length of stay by 88.96 h(95%CI: 86.31 to 91.62) as compared to early cholecystectomy group. Pooled riskdifference for biliary complications was higher by 10.76% (95%CI: 8.51 to 13.01) in the late cholecystectomy group as compared to the early cholecystectomy group.Pooled analysis showed no risk difference in intraoperative complications [riskdifference: 0.41%, (95%CI: -1.58 to 0.75)], postoperative complications [riskdifference: 0.60%, (95%CI: -2.21 to 1.00)], or conversion to open cholecystectomy[risk difference: 1.42%, (95%CI: -0.35 to 3.21)] between early and latecholecystectomy groups. Pooled analysis showed the duration of surgery to beprolonged by 39.11 min (95%CI: 37.44 to 40.77) in the late cholecystectomy groupas compared to the early group.CONCLUSIONIn patients with mild gallstone pancreatitis early cholecystectomy leads to shorterhospital stay, shorter duration of surgery, while decreasing the risk of biliarycomplications. Rate of intraoperative, post-operative complications and chances ofconversion to open cholecystectomy do not significantly differ whethercholecystectomy was performed early or late.

Single-incision laparoscopic cholecystectomy:Single institution experience and literature review

Single-incision laparoscopic surgery is a rapidly evolving field as a bridge between traditional laparoscopic surgery and natural orifice transluminal endoscopic surgery.We report one of the initial clinical experiences in Japan with this new technique.Four cases of gallbladder diseases were selected for this new technique.A single curved intra-umbilical 25-mm incision was made by pulling out the umbilicus.A 12-mm trocar was placed through an open approach,and the abdominal cavity was explored with a 10-mm semiflexible laparoscope.Two 5-mm ports were inserted laterally from the laparoscope port.A 2-mm mini-loop retractor was inserted to retract the fundus of the gallbladder.Dissection was performed using an electric cautery hook and an Endograsper roticulator.There were two women and two men with a mean age of 50.5 years(range:40-61 years).All procedures were completed successfully without any perioperative complications.In all cases,there was no need to extend the skin incision.Average operative time was 88.8 min.Postoperative follow-up didnot reveal any umbili-cal wound complication.Single-incision laparoscopic cholecystectomy is feasible and a promising alternative method as scarless abdominal surgery for the treatment of some patients with gallbladder disease.

Changes in gut microbiota composition and diversity associated with post-cholecystectomy diarrhea

BACKGROUND Post-cholecystectomy diarrhea(PCD)frequently occurs in patients following gallbladder removal.PCD is part of the post-cholecystectomy(PC)syndrome,and is difficult to treat.After cholecystectomy,bile enters the duodenum directly,independent of the timing of meals.The interaction between the bile acids and the intestinal microbes is changed.Therefore,the occurrence of PCD may be related to the change in microbiota.However,little is known about the relationship between the gut microbiota and PCD.AIM To better understand the role of the gut microbiota in PCD patients.METHODS Fecal DNA was isolated.The diversity and profiles of the gut microbiota were analyzed by performing high-throughput 16S rRNA gene sequencing.The gut microbiota were characterized in a healthy control(HC)group and a PC group.Subsequently,the PC group was further divided into a PCD group and a postcholecystectomy non-diarrhea group(PCND)according to the patients’clinical symptoms.The composition,diversity and richness of microbial communities were determined and compared.RESULTS In the PC and HC groups,720 operational taxonomic units(OTUs)were identified.The PC group had fewer OTUs than the HC group.β-diversity was decreased in the PC group.This indicated decreased microbial diversity in the PC group.Fifteen taxa with differential abundance between the HC and PC groups were identified.In the PCD group compared to the PCND group,significant decreases in microbial diversity,Firmicutes/Bacteroidetes ratio,and richness of probiotic microbiota(Bifidobacterium and Lactococcus),and an increase in detrimental microbiota(Prevotella and Sutterella)were observed.Moreover,a negative correlation was found between Prevotella and Bifidobacterium.Using a Kyoto Encyclopedia of Genes and Genomes functional analysis,it was found that the abundances of gut microbiota involved in lipid metabolism pathways were markedly lower in the PCD group compared to the PCND group.CONCLUSION This study demonstrated that gut dysbiosis may play a critical role in PCD,which provides new insights into therapeutic options for PCD patients.

Operative complications and economic outcomes of cholecystectomy for acute cholecystitis

BACKGROUND Recent management of acute cholecystitis favors same admission(SA)or emergent cholecystectomy based on overall shorter hospital stay and therefore cost savings.We adopted the practice of SA cholecystectomy for the treatment of acute cholecystitis at our tertiary care center and wanted to evaluate the economic benefit of this practice.We hypothesized that the existence of complications,particularly among patients with a higher degree of disease severity,during SA cholecystectomy could negate the cost savings.AIM To compare complication rates and hospital costs between SA vs delayed cholecystectomy among patients admitted emergently for acute cholecystitis.METHODS Under an IRB-approved protocol,complications and charges for were obtained for SA,later after conservative management(Delayed),or elective cholecystectomies over an 8.5-year period.Patients were identified using the acute care surgery registry and billing database.Data was retrieved via EMR,operative logs,and Revenue Cycle Operations.The severity of acute cholecystitis was graded according to the Tokyo Guidelines.TG18 categorizes acute cholecystitis by Grades 1,2,and 3 representing mild,moderate,and severe,respectively.Comparisons were analyzed withχ2,Fisher’s exact test,ANOVA,ttests,and logistic regression;significance was set at P<0.05.RESULTS Four hundred eighty-six(87.7%)underwent a SA while 68 patients(12.3%)received Delayed cholecystectomy.Complication rates were increased after SA compared to Delayed cholecystectomy(18.5%vs 4.4%,P=0.004).The complication rates of patients undergoing delayed cholecystectomy was similar to the rate for elective cholecystectomy(7.4%,P=0.35).Mortality rates were 0.6%vs 0%for SA vs Delayed.Patients with moderate disease(Tokyo 2)suffered more complications among SA while none who were delayed experienced a complication(16.1%vs 0.0%,P<0.001).Total hospital charges for SA cholecystectomy were increased compared to a Delayed approach($44500±$59000 vs$35300±$16700,P=0.019).The relative risk of developing a complication was 4.2x[95%confidence interval(CI):1.4-12.9]in the SA vs Delayed groups.Among eight patients(95%CI:5.0-12.3)with acute cholecystitis undergoing SA cholecystectomy,one patient will suffer a complication.CONCLUSION Patients with Tokyo Grade 2 acute cholecystitis had more complications and increased hospital charges when undergoing SA cholecystectomy.This data supports a selective approach to SA cholecystectomy for acute cholecystitis.

Prevention of common bile duct injury during laparoscopic cholecystectomy

BACKGROUND: Since the widespread adoption of laparoscopic cholecystectomy (LC) in the late 1980s, a rise in common bile duct (CBD) injury has been reported. We analyzed the factors contributing to a record of zero CBD injuries in 10 000 consecutive LCs. METHODS: The retrospective investigation included 10 000 patients who underwent LC from July 1992 to June 2007. LC was performed by 4 teams of surgeons. The chief main surgeon of each team has had over 10 years of experience in hepatobiliary surgery. Calot's triangle was carefully dissected, and the relationship of the cystic duct to the CBD and common hepatic duct was clearly identified. A clip was applied to the cystic duct at the neck of the gallbladder and the duct was incised with scissors proximal to the clip. The cystic artery was dissected by the same method. Then, the gallbladder was dissected from its liver bed. A drain was routinely left at the gallbladder bed for 1-2 days postoperatively. RESULTS: No CBD injuries occurred in 10 000 consecutive LCs, and there were 16 duct leaks (0.16%). Among these there were 10 Luschka duct leaks (0.1%) and 6 cystic duct leaks (0.06%). Four hundred thirty cases were converted to open cholecystectomy (OC), giving a conversion rate of 4.3%. After a mean follow-up of 17.5 months (range 6-24 months), no postoperative death due to LC occurred, and good results were observed in 95% of the patients. CONCLUSIONS: In our 10 000 LCs with zero CBD injuries, the techniques used and practices at our department have been successful. Surgeon's expertise in biliary surgery, preoperative imaging, precise operative procedures, and conversion from LC to OC when needed are important measures to prevent CBD injuries.