Intraoperative endoscopic sphincterotomy for common bile duct stones during laparoscopic cholecystectomy

INTRODUCTION The advent of laparoscopic cholecystectomy(LC)inthe late 1980s gained widespread acceptance withina short period of time and has become the preferredtreatment for symptomatic gallstones,but themanagement of coexisting gallbladder and commonbile duct(CBD)stones has remained controversialbecause the various strategies proposed have theirlimitations.In fact,choledocholithiasis

Non-image diagnosis of bile duct injury during laparoscopic cholecystectomy

Objective: To evaluate the role of simple non-imagetechnique in intraoperative diagnosis of bile duct in-jury (BDI).Methods: BDI was highly suspected at the original la-paroscopic cholecystectomy (LC) when the following 3abnormal findings were noted: the 'cystic duct' stump(the common bile duct stump actually) markedly re-tracted down to the duodenum; bile leakage from theporta hepatis; abnormal mucosal patch attached to the'cystic duct' stump of the removed gallbladder. Allcases of suspected BDI were converted to have laparo-tomy. Image techniques such as intraoperative cholan-giography or ultrasonography were not utilized forrecognition of BDI in all 9 patients.Results: BDI in 4 of the 9 patients was suspected ac-cording to 1-3 abnormal intraoperative findings de-scribed above. The four patients were subjected imme-diately to converted laparotomy. Abnormal findingswere not observed or misinterpreted in the other 5misdiagnosed patients.Conclusions: Timely recognizing whether BDI occursshould be considered as a routine procedure ofLC. Negligence of operators to the abnormalities of theoriginal LC, is the main cause of misdiagnosis forBDL. Simple non-image approaches such as close ob-servation of these abnormalities can make timely diag-nosis for most BDIs during the original LC.

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.

Bile leakage after loop closure vs clip closure of the cystic duct during laparoscopic cholecystectomy:A retrospective analysis of a prospective cohort

BACKGROUND Laparoscopic cholecystectomy(LC)is one of the most frequently performed surgical procedures.Cystic stump leakage is an underestimated,potentially life threatening complication that occurs in 1%-6%of the patients.With a secure cystic duct occlusion technique during LC,bile leakage becomes a preventable complication.AIM To investigate the effect of polydioxanone(PDS)loop closure of the cystic duct on bile leakage rate in LC patients.METHODS In this retrospective analysis of a prospective cohort,the effect of PDS loop closure of the cystic duct on bile leakage complication was compared to patients with conventional clip closure.Logistic regression analysis was used to develop a risk score to identify bile leakage risk.Leakage rate was assessed for categories of patients with increasing levels of bile leakage risk.RESULTS Of the 4359 patients who underwent LC,136(3%)underwent cystic duct closure by a PDS loop.Preoperatively,loop closure patients had significantly more complicated biliary disease compared to the clipped closure patients.In the loop closure cohort,zero(0%)bile leakage occurred compared to 59 of 4223(1.4%)clip closure patients.For patients at increased bile leakage risk(risk score≥1)rates were 1.6%and up to 13%(4/30)for clip closure patients with a risk score≥4.This risk increase paralleled a stepwise increase of actual bile leakage complication for clip closure patients,which was not observed for loop closure patients.CONCLUSION Cystic duct closure with a PDS loop during LC may reduce bile leakage in patients at increased risk for bile leakage.

Clinical observation of laparoscopic cholecystectomy combined with endoscopic retrograde cholangiopancreatography or common bile duct lithotripsy

BACKGROUND The incidence of common bile duct(CBD) stones accounts for approximately 10%–15% of all CBD diseases.Approximately 8%–20% of these patients also have gallstones with heterogenous signs and symptoms.AIM To investigate the clinical effects of laparoscopic cholecystectomy(LC) combined with endoscopic retrograde cholangiopancreatography(ERCP) and LC with CBD excision and stone extraction in one-stage suture(LBEPS) for the treatment of gallbladder and CBD stones.METHODS Ninety-four patients with gallbladder and CBD stones were selected from our hospital from January 2018 to June 2021.They were randomly divided into study and control groups with 47 patients each.The study group underwent LC with ERCP,and the control group underwent LC with LBEPS.Surgery,recovery time of gastrointestinal function,complication rates,liver function indexes,and stress response indexes were measured pre-and postoperatively in both the groups.RESULTS The durations of treatment and hospital stay were shorter in the study group than in the control group.There was no significant difference between the one-time stone removal rate between the study and control groups.The time to anal evacuation,resumption of oral feeding,time to bowel sound recovery,and time to defecation were shorter in the study group than in the control group.The preoperative serum direct bilirubin(DBIL),total bilirubin(TBIL),and alanine aminotransferase(ALT) levels were insignificantly higher in the study group than that in the control group.A day after surgery,the postoperative serum DBIL,TBIL,and ALT levels were lower than their preoperative levels in both groups,and of the two groups,the levels were lower in the study group.Although the preoperative serum adrenocorticotrophic(ACTH),cortisol(COR),epinephrine(A),and norepinephrine(NE) levels were higher in the study group than that in the control group,these differences were not significant(P > 0.05).The serum ACTH,COR,A,and NE levels in both groups decreased one day after surgery compared to the preoperative levels,but the inter-group difference was statistically insignificant.Similarly,(91.79 ±10.44) ng/mL,A,and NE levels were lower in the study group than in the control group.The incidence of complications was lower in the study group than in the control group.CONCLUSION LC combined with ERCP induces only a mild stress response;this procedure can decrease the risk of complications,improve liver function,and achieve and promote a faster recovery of gastrointestinal functions.

Factors influencing the results of treatment of bile duct injuries during laparoscopic cholecystectomy

BACKGROUND: The short-term results of repair of lapa- roscopic bile duct injuries have been well discussed, but the long-term results have been rarely reported. This study was undertaken to evaluate the factors influencing the outcome of repair of bile duct injuries caused by laparoscopic chole- cystectomy. METHODS: The outcomes of repair of bile duct injuries caused by laparoscopic cholecystectomy in 31 patients were reviewed retrospectively, and the effects of injury recogni- tion, cholangiography, repair modality and techniques on the long-term results were analyzed. RESULTS: Bile duct injuries were repaired successfully in 19 (95%) of 20 patients with injuries who had been recog- nized intraoperatively, and in 10 (90%) of 11 patients with injuries who had been recognized postoperatively. Repair was successful in 29 (93% ) of the 31 patients after complete cholangiography. Closure of partial division, laceration, or small perforation of the bile duct with or without T tube drainage was satisfactory in the 23 patients. End to end re- pair over T tube was successful in 2 transection patients, who were detected intraoperatively. Roux-en-Y hepatico- jejunostomy was used successfully to repair transection, ex- cision or stricture of the bile duct in 4 of 5 patients (80% ). CONCLUSION: Early detection of bile duct injuries caused by laparoscopy, complete evaluation of the biliary duct, and appropriate surgical modality and techniques are help- ful to improve the results of repair for laparoscopic bile duct injuries.

Management of bile duct injuries combined with accessory hepatic duct during laparoscopic cholecystectomy

Bile duct injuries(BDIs)are difficult to avoid absolutely when the biliary tract has a malformation,such as accessory hepatic duct.Here,we investigated the management strategies for BDI combined with accessory hepatic duct during laparoscopic cholecystectomy.

Selection criteria for preoperative endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy and endoscopic treatment of bile duct stones:Results of a retrospective,single center study between 1996-2002

AIM: The optimal treatment for bile duct stones (in terms of cost, complications and accuracy) is unclear. The aim of our study was to determine the predictive factors for preoperative endoscopic retrograde cholangiopancreatography (ERCP).METHODS: Patients undergoing preoperative ERCP (≤90 d before laparoscopic cholecystectomy) were evaluated in this retrospective study from the 1^st of January 1996 to the 31^st of December 2002. The indications for ERCP were elevated serum bilirubin, elevated liver function tests (LFT), dilated bile duct (≥8 mm) and/or stone at US examination, coexisting acute pancreatitis and/or acute pancreatitis or jaundice in patient's history. Suspected prognostic factors and the combination of factors were compared to the result of ERCRRESULTS: Two hundred and six preoperative ERCPs were performed during the observed period. The rate of successful cannulation for ERC was (97.1%). Bile duct stones were detected in 81 patients (39.3%), and successfully removed in 79 (97.5%). The number of prognostic factors correlated with the presence of bile duct stones. The positive predictive value for one prognostic factor was 1.2%, for two 43%,for three 72.5%, for four or more 91.4%.CONCLUSION: Based on our data preoperative ERCP is highly recommended in patients with three or more positive factors (high risk patients). In contrast, ERCP is not indicated in patients with zero or one factor (low risk patients).Preoperative ERCP should be offered to patients with two positive factors (moderate risk patients), however the practice should also be based on the local conditions (e.g.skill of the endoscopist, other diagnostic tools).

Timing of surgical repair of bile duct injuries after laparoscopic cholecystectomy: A systematic review

BACKGROUND The surgical management of bile duct injuries(BDIs)after laparoscopic cholecystectomy(LC)is challenging and the optimal timing of surgery remains unclear.The primary aim of this study was to systematically evaluate the evidence behind the timing of BDI repair after LC in the literature.AIM To assess timing of surgical repair of BDI and postoperative complications.METHODS The MEDLINE,EMBASE,and The Cochrane Library databases were systematically screened up to August 2021.Risk of bias was assessed via the Newcastle Ottawa scale.The primary outcomes of this review included the timing of BDI repair and postoperative complications.RESULTS A total of 439 abstracts were screened,and 24 studies were included with 15609 patients included in this review.Of the 5229 BDIs reported,4934(94%)were classified as major injury.Timing of bile duct repair was immediate(14%,n=705),early(28%,n=1367),delayed(28%,n=1367),or late(26%,n=1286).Standardization of definition for timing of repair was remarkably poor among studies.Definitions for immediate repair ranged from<24 h to 6 wk after LC while early repair ranged from<24 h to 12 wk.Likewise,delayed(>24 h to>12 wk after LC)and late repair(>6 wk after LC)showed a broad overlap.CONCLUSION The lack of standardization among studies precludes any conclusive recommendation on optimal timing of BDI repair after LC.This finding indicates an urgent need for a standardized reporting system of BDI repair.

Triple non-invasive diagnostic test for exclusion of common bile ducts stones before laparoscopic cholecystectomy

AIM: To evaluate the impact of a preoperative "triple non-invasive diagnostic test" for diagnosis and/or exclusion of common bile duct stones. METHODS: All patients with symptomatic gallstone disease, operated on by laparoscopic cholecystectomy from March 2004 to March 2006 were studied retrospectively. Two hundred patients were included and reviewed by using a triple diagnostic test including: patient's medical history, routine liver function tests and routine ultrasonography. All patients were followed up 2-24 mo after surgery to evaluate the impact of triple diagnostic test. RESULTS: Twenty-five patients were identified to have common bile duct stones. Lack of history of stones, negative laboratory tests and normal ultrasonography alone was proven to exclude common bile duct stones in some patients. However, a combination of these three components (triple diagnostic), was proven to be the most statistically significant test to exclude common bile duct stones in patients with gallstone disease. CONCLUSION: Using a combination of routinely used diagnostic components as triple diagnostic modality would increase the diagnostic accuracy of common bile duct stones preoperatively. This triple non-invasive test is recommended for excluding common bile duct stones and to identify patients in need for other investigations.

Iatrogenic Bile Duct Injuries after Cholecystectomy, Is the Laparoscopic Approach a Good Idea?

Objective: The treatment of iatrogenic bile duct injuries is still a challenge for hepatobiliary and general surgeons. Roux-en-Y hepaticojejunostomy, one of the most appropriate techniques for the treatment of circumferential lesions, either occurring less than 2 cm from the bifurcation or in the bifurcation of the common hepatic duct, requires experience in advanced laparoscopy and hepatobiliary surgery. This study aims to present the results of laparoscopic hepaticojejunostomy (LHJ) for the treatment of iatrogenic bile duct injuries (IBDI). Methods: A retrospective study analyzing the medical records of patients diagnosed with IBDI and treated using LHJ of patients at the Hospital S?o José do Avaí (HSJA). Sex, age, previous cholecystectomy technique, signs and symptoms, postoperative complications, length of stay, injury classification, and time elapsed from injury to diagnosis were analyzed. Magnetic resonance cholangiography (MRC), endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiography. Results: From March 2006 to December 2018, six patients underwent LHJ. In five cases (83.33%), the primary operation was a laparoscopic cholecystectomy (LC) and in one patient (13.66%) open cholecystectomy. The most frequent clinical sign was jaundice. The mean surgical time was 153.2 minutes (range: 115 to 206 minutes), and the hospital stay was 3 to 7 days (mean: 4.16 days). One patient had infection of the umbilical trocar incision and one patient presented with stenosis of the hepaticojejunal anastomosis and was treated with radioscopic pneumatic dilatation. Conclusion: LHJ for circumferential and total IBDI either diagnosed early (during surgery) or late, may be a safe and effective option, with similar results to the conventional technique, a low complication rate and all the known advantages of minimally invasive surgery.

Three-dimensional identification of the cystic infundibulum-cystic duct junction: a technique for identification of the cystic duct in laparoscopic cholecystectomy

OBJECTIVE: The main cause of bile duct injury (BDI) at laparoscopic cholecystectomy is misidentification of the common bile duct as the cystic duct (CD). The aim of this article is to introduce a modified technique, i. e., three-dimensional identification of the cystic infundibulum (CI)-CD junction, to prevent misidentification-induced BDI during laparoscopic cholecystectomy. METHODS: The Cl was extensively dissected to expose its anterior, interior-superior and inferior-dorsal aspects. With the CI nearly circularly dissected out, the CI and the appearance-indicated CI-CD junction might be three-dimensionally identified and the reality of the CI-CD junction as well as the reality of the CD could be precisely judged. RESULTS: Overall 10 BDIs were documented in this group. Since BDI occurred in 8 of 4382 patients receiving laparoscopic cholecyxtectomy, the technique for prevention of mixidentification-induced BDI was established. Among the late batch of 7618 patients, only two BDIs were noted. CONCLUSIONS: Three-dimensional identification of the CI-CD junction is a reliable, feasible and relatively low experience-dependent technique to prevent most of misidentification-induced BDI.

Iatrogenic extrahepatic bile duct injury in 182 patients: causes and management

Objective: To describe the causes and treatment ofiatrogenic bile duct injury caused by cholecystecto-my.Methods: 182 patients with iatrogenic extrahepaticbile duct injury from 4 university hospitals of Chinawere reviewed. Details of primary cholecystectomy,biliary reconstruction as well as postoperative ma-nagement were recorded. All patients were followedup for at least 6 months (6 months to 9 years, medi-an 3.5 years). The adequacy of repair was assessedby regular evaluation of the patients clinical statusand liver function variables. Hepatobiliary B-ultra-sonography was used routinely in the follow up of pa-tients, and magnetic resonance cholangiopancreatog-raphy was applied in the patients suggestive of abnor-mality.Results: In 152 patients, bile duct injury happenedduring open cholecystectomy, and in 30 patients dur-ing laparoscopic cholecystectomy. All the injuries de-veloped during anterograde cholecystectomy (at theCalot’s triangle). All the patients with these injuriesunderwent choledochocholedochostomy or Roux-en-Ycholedochojejunostomy with good results (161 pa-tients), recurrent stricture (11), and death (10).Conclusions: During cholecystectomy, the Calot’s tri-angle should be identified anatomically, but retro-grade cholecystectomy is the optimal choice. Bileduct injury should be discovered as soon as possibleand be managed timely. Different operative methodsare optional according to the degree of injury and thepostoperative period.

Hem-o-lok clip migration to the common bile duct after laparoscopic common bile duct exploration:A case report

BACKGROUND Laparoscopic cholecystectomy(LC)and laparoscopic common bile duct exploration(LCBDE)has been widely used for management of gallbladder and common bile duct(CBD)stones.Post-operative clip migration is a rare complication of laparoscopic biliary surgery,which can serve as a nidus for stone formation and cause recurrent cholangitis.CASE SUMMARY A 59-year-old female was admitted to hospital because of fever and acute right upper abdominal pain.She has a history of LC and had a LCBDE surgery 2 mo ago.Physical examination revealed tenderness in the upper quadrant of right abdomen.Computed tomography scan demonstrated a high-density shadow at the distal CBD,which was considered as migrated clips.The speculation was confirmed by endoscopic retrograde cholangiopancreatography examination,and two displaced Hem-o-lok clips were removed with a stone basket.No fever or abdominal pain presented after the operation.In addition to the case report,literature regarding surgical clip migration after laparoscopic biliary surgery was reviewed and discussed.CONCLUSION Incidence of postoperative clip migration may be reduced by using clips properly and correctly;however,new methods should be explored to occlude cystic duct and vessels.If a patient with a past history of LC or LCBDE presents with features of sepsis and recurrent upper quadrant pain,clip migration must be considered as one of the differential diagnosis.

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.

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.

Clinical efficacy of laparoscopic cholecystectomy combined with endoscopic papillary balloon dilation in treatment of gallbladder stones with common bile duct stones: A retrospective study

BACKGROUND The incidence of cholelithiasis has been on the rise in recent years,but the choice of procedure is controversial.AIM To investigate the efficacy of laparoscopic cholecystectomy(LC)combined with endoscopic papillary balloon dilation(EPBD)in patients with gallbladder stones(GS)with common bile duct stones(CBDS).METHODS The clinical data of 102 patients with GS combined with CBDS were selected for retrospective analysis and divided into either an LC+EPBD group(n=50)or an LC+endoscopic sphincterotomy(EST)group(n=52)according to surgical methods.Surgery-related indexes,postoperative recovery,postoperative complications,and expression levels of inflammatory response indexes were compared between the two groups.RESULTS Total surgical time,stone free rate,rate of conversion to laparotomy,and successful stone extraction rate did not differ significantly between the LC+EPBD group and LC+EST group.Intraoperative hemorrhage,time to ambulation,and length of hospitalization in the LC+EPBD group were lower than those of the LC+EST group(P<0.05).The rate of total complications of the two groups was 9.80%and 17.65%,respectively,and the difference was not statistically significant.No serious complications occurred in either group.At 48 h postoperatively,the expression levels of interleukin-6,tumor necrosis factor-α,high-sensitivity Creactive protein,and procalcitonin were lower in the LC+EPBD group than in the LC+EST group(P<0.05).At 3 d postoperatively,the expression levels of aspartate transaminase,alanine transaminase,and total bilirubin were lower in the LC+EPBD group than in the LC+EST group(P<0.05).CONCLUSION LC combined with EPBD and LC combined with EST are both effective procedures for the treatment of GS with CBDS,in which LC combined with EPBD is beneficial to shorten the patient’s hospitalization time,reduce the magnitude of elevated inflammatory response indexes,and promote postoperative recovery.

Role of laparoscopic subtotal cholecystectomy in the treatment of complicated cholecystitis

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the 'gold standard' in treating benign gallbladder diseases. Increasing laparoscopic experience and techniques have made laparoscopic subtotal cholecystectomy (LSC) a feasible option in more complex procedures. In recent years, few studies with a few cases of LSC have reported good results in patients with various types of cholecystitis. This study was designed to evaluate the feasibility, indications, characteristics and benefits of LSC in patients with complicated cholecystitis. METHODS: Altogether, 3485 patients were scheduled to receive LC during the past 4 years at our institute. Among them, 168 patients with various complicated forms of cholecystitis were treated by LSC. Meanwhile, the other 3317 patients who received standard LC were enrolled as the control group. Perioperative data from the two groups were collected and retrospectively analyzed. RESULTS: In the LSC group, 135 patients suffered from acute calculic cholecystitis, 18 from chronic calculic cholecystitis with cirrhotic portal hypertention, and 15 from chronic calculic atrophy cholecystitis with severe fibrosis. These patients constituted 4.8% of the total patients who underwent LC (168/3485) in the same period at our institute. In 122 patients, the cystic duct and artery were clipped before division. In another 46 patients, the gallbladder was initially incised at Hartmann's pouch. Five patients (3.0%) were converted to open subtotal cholecystectomy. The median operation time for LSC was 65.5±15.2 minutes, estimated operative blood loss was 71.5±15.5 ml, and the time to resume diet was 20.4±6.3 hours. Thirteen patients (7.7%) had local complications. The mean postoperative hospital stay was 4.2±2.6 days. In the LC group, 2887 had chronic calculic cholecystitis, 312had acute calculic cholecystitis, 47 had chronic calculic atrophy cholecystitis, and 71 had polypus. Seventeen patients (0.5%) were converted to open cholecystectomy. The median operation time was 32.6±10.2 minutes, the estimated operative blood loss was 24.5±8.5 ml, and the time to resume diet was 18.3±4.5 hours. Thirty- nine patients (1.2%) had local complications. Mean postoperative hospital stay was 3.8±1.4 days. There was no bile duct injury or mortality in either group. CONCLUSIONS: LSC for patients with complicated cholecystitis is difficult, with a longer operation time, more operative blood loss and higher conversion and complication rates than LC. However, it is feasible and relatively safe. LSC is advantageous over open surgery, but it remains a non-routine choice. It is important to know the technical characteristics of LSC, and pay attention to perioperative bleeding and bile leak.

Utility of fluorescent cholangiography during laparoscopic cholecystectomy: A systematic review

AIM: To verify the utility of fluorescent cholangiography for more rigorous identification of the extrahepatic biliary system.METHODS: MEDLINE and Pub Med searches were performed using the key words "fluorescent cholangiography", "fluorescent angiography", "intraoperative fluorescent imaging", and "laparoscopic cholecystectomy" in order to identify relevant articles published in English, French, German, and Italian during the years of 2009 to 2014. Reference lists from the articles were reviewed to identify additional pertinent articles. For studies published in languages other than those mentioned above, all available information was collected from their English abstracts. Retrieved manuscripts(case reports, reviews, and abstracts) concerning the application of fluorescent cholangiography were reviewed by the authors, and the data were extracted using a standardized collection tool. Data were subsequently analyzed with descriptive statistics. In contrast to classic meta-analyses, statistical analysis was performed where the outcome was calculated as the percentages of an event(without comparison) in pseudo-cohorts of observed patients.RESULTS: A total of 16 studies were found that involved fluorescent cholangiography during standard laparoscopic cholecystectomies(n = 11), singleincision robotic cholecystectomies(n = 3), multiport robotic cholecystectomy(n = 1), and single-incision laparoscopic cholecystectomy(n = 1). Overall, these preliminary studies indicated that this novel technique was highly sensitive for the detection of important biliary anatomy and could facilitate the prevention of bile duct injuries. The structures effectively identified before dissection of Calot's triangle included the cystic duct(CD), the common hepatic duct(CHD), the common bile duct(CBD), and the CD-CHD junction. A review of the literature revealed that the frequenciesof detection of the extrahepatic biliary system ranged from 71.4% to 100% for the CD, 33.3% to 100% for the CHD, 50% to 100% for the CBD, and 25% to 100% for the CD-CHD junction. However, the frequency of visualization of the CD and the CBD were reduced in patients with a body mass index > 35 kg/m2 relative to those with a body mass index < 35 kg/m2(91.0% and 64.0% vs 92.3% and 71.8%, respectively).CONCLUSION: Fluorescent cholangiography is a safe procedure enabling real-time visualization of bile duct anatomy and may become standard practice to prevent bile duct injury during laparoscopic cholecystectomy.

Two-stage vs single-stage management for concomitant gallstones and common bile duct stones

AIM:To evaluate the safety and effectiveness of twostage vs single-stage management for concomitant gallstones and common bile duct stones.METHODS:Four databases,including PubMed,Embase,the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011,were searched to identify all randomized controlled trials(RCTs).Data were extracted from the studies by two independent reviewers.The primary outcomes were stone clearance from the common bile duct,postoperative morbidity and mortality.The secondary outcomes were conversion to other procedures,number of procedures per patient,length of hospital stay,total operative time,hospitalization charges,patient acceptance and quality of life scores.RESULTS:Seven eligible RCTs [five trials(n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography(ERCP)/endoscopic sphincterotomy(EST) + laparoscopic cholecystectomy(LC) with LC + laparoscopic common bile duct exploration(LCBDE);two trials(n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE],composed of 787 patients in total,were included in the final analysis.The metaanalysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios(RR) =-0.10,95% confidence intervals(CI):-0.24 to 0.04,P = 0.17],postoperative morbidity(RR = 0.79,95% CI:0.58 to 1.10,P = 0.16),mortality(RR = 2.19,95% CI:0.33 to 14.67,P = 0.42),conversion to other procedures(RR = 1.21,95% CI:0.54 to 2.70,P = 0.39),length of hospital stay(MD = 0.99,95% CI:-1.59 to 3.57,P = 0.45),total operative time(MD = 12.14,95% CI:-1.83 to 26.10,P = 0.09).Two-stage(LC + ERCP/EST) management clearly required more procedures per patient than single-stage(LC + LCBDE) management.CONCLUSION:Single-stage management is equivalent to two-stage management but requires fewer procedures.However,patient's condition,operator's expertise and local resources should be taken into account in making treatment decisions.