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.

Laparoscopic management of remnant gall bladder with stones: Lessons from a tertiary care centre's experience

Objective:Laparoscopic cholecystectomy is currently the gold standard for treating symptomatic gallstone disease.Despite its success,approximately 10%of patients may experience persistent biliary symptoms,leading to the post-cholecystectomy syndrome.A remnant gallbladder with cystic duct or bile duct stones is one of the causes of this syndrome.The objective of this study was to shed light on the clinical manifestations,evaluation,therapeutic strategies,and outcomes associated with laparoscopic management of symptomatic remnant gallbladders.Methods:This was a retrospective study,conducted over a five-year period(January 2017 to December 2022)at Apollo Hospitals in South India.All patients who underwent laparoscopic completion cholecystectomy for a remnant gall bladder were included.The following data were collected:patient demographics,symptoms,preoperative investigations,intraoperative details and post operative outcomes.Results:In total,36 patients were included and analysed.The majority of patients were male(25,69.4%),with a mean age of 50.7±12.1 years.The most common presentation was pain in the upper abdomen or right upper quadrant region(24,66.7%).The laparoscopic approach was attempted in all patients,with a success rate of 94.4%.Two patients required conversion to open surgery.Cholecystoenteric fistula to the colon was observed in one patient.Choledocholithiasis was observed in 7 patients(19.4%),and stone clearance was successfully achieved using endoscopic retrograde cholangiopancreatography in all patients preoperatively.Conclusion:Incomplete gall bladder removal either intentionally or unintentionally leaves a remnant gall bladder that is at risk for stone formation and infection.Patients who have this clinical entity with symptoms require a redo or complete cholecystectomy,a complex procedure associated with certain risks.This study highlights the feasibility and safety of laparoscopic completion cholecystectomy for the management of remnant gallbladder with cystic duct or bile duct stones.

乌梅丸联合四逆散加减辅助治疗急性结石性胆囊炎术后临床观察

目的 观察乌梅丸联合四逆散加减辅助治疗急性结石性胆囊炎术后临床疗效。方法 采用前瞻性随机对照研究将94例急性结石性胆囊炎患者随机分为观察组与对照组各47例,两组患者均行腹腔镜胆囊切除手术,观察组在术后12 h加用乌梅丸联合四逆散加减治疗。观察两组患者临床疗效,治疗前后中医证候评分,炎症反应指标(血清淀粉样蛋白、超敏C反应蛋白及降钙素原),肝功能指标(谷草转氨酶、谷丙转氨酶及总胆红素),术后康复情况及术后并发症情况。结果 治疗后两组炎症反应指标、肝功能指标、中医证候评分均较治疗前降低,且观察组低于对照组(P<0.05),治疗后观察组肛门首次排气时间、疼痛缓解时间、腹腔引流时间、住院时间均短于对照组(P<0.05);观察组总有效率为95.74%,高于对照组89.36%(P<0.05),观察组术后并发症的发生率为4.26%,低于对照组的19.15%(P<0.05)。结论 乌梅丸联合四逆散加减辅助治疗急性结石性胆囊炎术后患者临床疗效显著。

Single-incision vs three-incision laparoscopic cholecystectomy for complicated and uncomplicated acute cholecystitis

AIM:To compare the clinical outcome of single-incision laparoscopic cholecystectomy(SILC)and three-incision laparoscopic cholecystectomy(3ILC)for acute cholecystitis.METHODS:From July 2009 to September 2012,136patients underwent SILC or 3ILC for acute cholecystitis at a tertiary referral hospital.One experienced surgeon performed every procedure using 5 or 10 mm 30-degree laparoscopes,straight instruments,and conventional ports.Five patients with perforated gallbladder and diffuse peritonitis and 23 patients with mild acute cholecystitis were excluded.The remaining 108 patients were divided into complicated and uncomplicated groups according to pathologic findings.Patient demography,clinical data,operative results and complications were recorded and analyzed.RESULTS:Fifty patients with gangrenous cholecystitis,gallbladder empyema,or hydrops were classified as the complicated group,and 58 patients with acute cholecystitis were classified as the uncomplicated group.Twenty-three(46.0%)of the patients in the complicated group(n=50)and 39(67.2%)of the patients in the uncomplicated group(n=58)underwent SILC;all others underwent 3ILC.The postoperative length of hospital stay(PLOS)was significantly shorter in the SILC subgroups than the 3ILC subgroups(3.5±1.1 d vs 4.6±1.3 d,P<0.01 in the complicated group;2.9±1.1 d vs 3.7±1.4 d,P<0.05 in the uncomplicated group).The maximum body temperature recorded at day 1 and at day 2 following the procedure was lower in the SILC subgroups,but the difference reached statistical significance only in the uncomplicated group(37.41±0.56℃vs 37.80±0.72℃,P<0.05 on postoperative day 1;37.10±0.43℃vs 37.57±0.54℃,P<0.01 on postoperative day 2).The operative time,estimated blood loss,postoperative narcotic use,total length of hospital stay,conversion rates,and complication rates were similar in both SILC and 3ILC subgroups.The complicated group had longer operative time(122.2±35.0 min vs 106.6±43.6 min,P<0.05),longer PLOS(4.1±1.3 d vs 3.2±1.2 d,P<0.001),and higher conversion rates(36.0%vs 19.0%,P<0.05)compared with the uncomplicated group.CONCLUSION:SILC is safe and efficacious for patients with acute cholecystitis.The main benefit is a faster recovery than that achieved with 3ILC.

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.

Feasibility of single-incision laparoscopic cholecystectomy for acute cholecystitis

AIM: To assess the safety of single-incision laparoscopic cholecystectomy(SILC) for acute cholecystitis.METHODS: All patients who underwent SILC at Sano Hospital(Kobe, Japan) between January 2010 and December 2014 were included in this retrospective study. Clinical data related to patient characteristics and surgical outcomes were collected from medical records. The parameters for assessing the safety of the procedure included operative time, volume of blood loss, achievement of the critical view of safety, use of additional trocars, conversion to laparotomy, intraoperative and postoperative complications, and duration of postoperative hospital stay. Patient backgrounds were statistically compared between those with and without conversion to laparotomy.RESULTS: A total of 100 patients underwent SILC for acute cholecystitis during the period. Preoperative endoscopic treatment was performed for suspected choledocholithiasis in 41 patients(41%). The mean time from onset of acute cholecystitis was 7.7 d. According to the Updated Tokyo Guidelines(TG13) for the severity of cholecystitis, 86 and 14 patients had grade Ⅰ and grade Ⅱ acute cholecystitis, respectively. The mean operative time was 87.4 min. The mean estimated blood loss was 80.6 mL. The critical view of safety was obtained in 89 patients(89%). Conversion laparotomy was performed in 12 patients(12%). Postoperative complications of Clavien-Dindo grade Ⅲ or greater were observed in 4 patients(4%). The mean duration of postoperative hospital stay was 5.7 d. Patients converted from SILC to laparotomy tended to have higher days after onset.CONCLUSION: SILC is feasible for acute cholecystitis; in addition, early surgical intervention may reduce the risk of laparotomy conversion.

Factors associated with time to laparoscopic cholecystectomy for acute cholecystitis

AIM: To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. METHODS: A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service (medical or surgical). Patients not undergoing cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery.RESULTS: Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean ± SD time to surgery was 39.3 ± 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography (ERCP, P = 0.01) as well with admission to medical service without adjustment for ERCP (P < 0.05). Patients undergoing both magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier (30.4 ± 34.9 vs 82.7 ± 55.1 h, P < 0.01), had less post-operative complications (12% vs 58%, P < 0.01), and shorter length of stay (4.3 ± 3.4 vs 8.1 ± 5.2 d, P < 0.01).CONCLUSION: Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed up time to surgery should be considered.

Outcome of laparoscopic cholecystectomy is not influenced by chronological age in the elderly

AIM:To evaluate the outcome of laparoscopic cholecystectomy(LC)in patients aged 80 years and older. METHODS:A total of 353 patients aged 65 to 79 years(group 1)and 35 patients aged 80 years and older(group 2)underwent LC.Patients were further classified into two other groups:those with uncomplicated gallbladder disease(group A)or those with complicated gallbladder disease(group B). RESULTS:There were no significant differences between the age groups(groups 1 and 2)with respect to clinical characteristics such as age,gender,comorbid disease,or disease presentation.Mean operative time,conversion rate,and the incidence of major postoperative complications were similar in groups 1 and 2.However,the percentage of high-risk patients was significantly higher in group 2 than in group 1 (20.0%vs 5.7%,P<0.01).Group A comprised 322 patients with a mean age of 71.0±5.3 years,and group B comprised 51 patients with a mean age of 69.9±4.8 years.In group B,mean operative time (78.4±49.3 min vs 58.3±35.8 min,P<0.01),mean postoperative hospital stay(7.9±6.5 d vs 5.0±3.7 d, P<0.01),and the incidence of major postoperative complications(9.8%vs 3.1%,P<0.05)were significantly greater than in group A.The conversion rate tended to be higher in group B,but this difference was not significant. CONCLUSION:Perioperative outcomes in elderly patients who underwent LC seem to be influenced by the severity of gallbladder disease,and not by chronologic age.In octogenarians,LC should be performed at an earlier,uncomplicated stage of the disease whenever possible to improve perioperative outcomes.

Original single-incision laparoscopic cholecystectomy for acute inflammation of the gallbladder

AIM： To investigate the safety and feasibility of our original single-incision laparoscopic cholecystectomy （SII_C） for acute inflamed gallbladder （AIG）.

Impact of B-mode-ultrasound-guided transhepatic and transperitoneal cholecystostomy tube placement on laparoscopic cholecystectomy

BACKGROUND B-mode-ultrasound-guided percutaneous cholecystostomy(PC)may be performed by a transhepatic or transperitoneal approach,called percutaneous transhepatic gallbladder drainage(PHGD)and percutaneous transperitoneal gallbladder drainage(PPGD),respectively.We compared the impact of PC related to the route of catheter placement on subsequent laparoscopic cholecystectomy(LC).AIM To compare the impact of PC related to the route of catheter placement on subsequent LC.METHODS We retrospectively studied 103 patients with acute calculous cholecystitis who underwent scheduled LC after PC between January 2010 and January 2019.Group I included 58 patients who underwent scheduled LC after PHGD.Group II included 45 patients who underwent scheduled LC after PPGD.Clinical outcomes were analyzed according to each group.RESULTS Baseline demographic characteristics did not differ significantly between both groups(P>0.05).Both PHGD and PPGD were able to quickly resolve cholecystitis sepsis.Group I showed significantly higher efficacy than group II in terms of lower pain score during puncture(3.1 vs 4.5;P=0.001)and at 12 h follow-up(1.5 vs 2.2;P=0.001),lower rate of fever within 24 h after PC(13.8%vs 42.2%;P=0.001),shorted operation duration(118.3 vs 139.6 min;P=0.001),lower amount of intraoperative bleeding(72.1 vs 109.4 mL;P=0.001)and shorter length of hospital stay(14.3 d vs 18.0 d;P=0.001).However,group II had significantly lower rate of local bleeding at the PC site(2.2%vs 20.7%;P=0.005)and lower rate of severe adhesion(33.5%vs 55.2%;P=0.048).No significant differences were noted between both groups regarding the conversion rate to laparotomy,rate of subtotal cholecystectomy,complications and pathology.CONCLUSION B-mode-ultrasound-guided PHGD is superior to PPGD followed by LC for treatment of acute calculous cholecystitis,with shorter operating time,minimal amount of intraoperative bleeding and short length of hospital stay.

Instrumental detection of cystic duct stones during laparoscopic cholecystectomy

Residual cystic duct stones (CDSs) after cholecystectomy have been recognized as a cause of post cholecystectomy pain. This study was undertaken to determine the incidence of CDSs during laparoscopic cholecystectomy(LC). A cohort of 330 consecutive patients (80 males and 250females) undergoing LC between November 2006 and May2010 was studied. Their age ranged between 16 and 88 years(median 50, IQR: 36.62). The data were prospectively collected of preoperative liver function tests, imaging, the presence of intraoperative CDSs, and common bile duct stones at on-table cholangiogram. CDSs were detected intraoperatively in 64 of the 330 patients (19%). Ultrasound failed to detect CDSs in any of these cases. Deranged liver function tests were noted in 73% of the patients with CDSs and in 57% without CDSs Common bile duct stones were detected in 9% (29) of the 330patients. CDSs occur commonly at routine cholecystectomy, and preoperative investigations are not helpful in their diagnosis As CDSs may lead to postoperative morbidity, they should be actively sought out during surgery if present.

Early Versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis with Mild Pancreatitis

The safety and feasibility of early laparoscopic cholecystectomy(LC)for acute cholecystitis with mild pancreatitis were explored.A total of 973 patients with acute pancreatitis,including 651 mild cases and 322 moderate or severe cases were retrospectively studied from July 2014 to December 2018 in our department.And 426 mild pancreatitis cases with acute cholecystitis were enrolled in this study,of which 328 patients underwent LC during the same-admission(early LC group),and 98 patients underwent LC a period of time after conservative treatment(delayed LC group).Clinical characteristics,operative findings and complications were recorded and followed up.The two groups were comparable in age,gender,the grade of American Society of Anesthesiologist(ASA),biochemical findings and Balthazar computer tomography(CT)rating(P>0.05).The operation interval and hospital stay in early LC group were significantly shorter than in delayed LC group(5.83+1.62 vs.41.3618.44 days;11.38+2.43 vs.16.49+3.48 days,P<0.01).There was no significant difference in the average operation time between the two groups.No preoperative biliary related events recurred in early LC group but there were 21 cases of preoperative biliary related events in delayed LC group(P<0.01).There was no significant difference in conversion rate(3.85 vs.5.10%,P=0.41)and surgical complication rate(3.95 vs.4.08%,P-0.95)between early LC group and delayed LC group.During the postoperative follow-up period of 375 cases,biliary related events recurred in 4 cases in early LC group and 3 cases in delayed LC group(P=0.37).The effect of early LC during the same-admission is better than delayed LC for acute cholecystitis with mild pancreatitis.

Diagnosis and treatment of binary injury caused by laparoscopic cholecystectomy

Objective: To summarize experience of the diagnosis and treatment of binary injury caused bylaparoscopic cholecystectomy. Methods: Twenty-three patients with binary injury of various types caused bylaparoscopic cholecystectomy were diagnosed and treated in our department in 6 years. The biliary injury wasdivided into 5 types from A to E. According to these types, the patients were treated with different methods.Results: Type A (3 cases) presenting binary leakage were recognized with Bus or CT scanning and treatedwith local drainage. Type B (1 case ) presenting dilated right anterior hepatlc duct was observed. Types C (3cases ) and D (3 cases ) presenting generalized peritonitis were detected with ERCP or fistulagram andmanaged by ligation of aberrant hepatic duct or T tube drainage or endoscopic nasobiliary drainage. Type E(14 case ) presenting jaundice, cholangitis or binary peritonitis were diagnosed with ERCP or PTC and treatedby enteric anastomosis. Conclusion: Patients with different types of bile duct injury present different clinicalcharacteristics and its diagnosis, treatment and outcome are also different.

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.

Outcomes of Laparoscopic Cholecystectomy in Patients with End-Stage Renal Disease

Purpose: In this study, we aimed to discuss the laparoscopic cholecystectomy in patients with end stage renal disease compared to the general population. Materials and Methods: We retrospectively evaluated a group of patients with (n = 45) and without (n = 90) end-stage renal disease undergoing laparoscopic cholecystectomy. The groups were compared in terms of length of surgery;duration of hospitalization after surgery;use of blood derivatives;mortality rates;and perioperative, postoperative, and postdischarge complications. Results: Patients with end-stage renal disease exhibited a higher frequency of associated diseases;lower hemoglobin levels;and elevated alkaline phosphatase, blood urea nitrogen, and creatinine values. Statistically significant differences were found between the two groups regarding length of surgery (83.6 ± 14.88 vs. 71.7 ± 11.42 minutes;p p p = 0.011), postoperative (p p = 0.011) rates. Among all patients with end-stage renal disease, 12 (26.7%) were converted to an open procedure (p < 0.001). Conclusion: Despite higher complication rates of laparoscopic cholecystectomy in end-stage renal disease patients, laparoscopic cholecystectomy could be performed safely in patients with end-stage renal disease with low levels of complications and no associated mortality.

Laparoscopic cholecystectomy for gangrenous cholecystitis in around nineties: Two case reports

BACKGROUND Gangrenous cholecystitis is a form of acute cholecystitis which involves gangrenous alterations in the gallbladder wall and it often follows an acute and serious course.We herein report on two cases of very elderly people diagnosed early with gangrenous cholecystitis,who safely underwent laparoscopic cholecystectomy(LC)and both demonstrated a good outcome.CASE SUMMARY Case 1:An 89-year-old female.She underwent abdominal contrast-enhanced computed tomography(CECT)due to abdominal pain and diarrhea.Her gallbladder wall indicated the absence of contrast enhancement,thus leading to diagnosis of gangrenous cholecystitis and she therefore underwent LC.Although her gallbladder demonstrated diffuse necrosis and it was also partly perforated,she was able to be discharged without any serious complications.Case 2:A 91-year-old female.She made an emergency visit with a chief complaint of abdominal pain.Abdominal CECT revealed swelling of the gallbladder and an ambiguous continuity of the gallbladder wall.She was diagnosed with gangrenous cholecystitis and underwent LC.Her gallbladder had swelling and diffuse necrosis.Although her preoperative blood culture was positive,she showed a good outcome following surgery.CONCLUSION Although a definite diagnosis of gangrenous cholecystitis is difficult to make prior to surgery,if an early diagnosis can be made and appropriate treatment can be carried out,then even very elderly individuals may be discharged without major complications.

Single-Incision Laparoscopic Cholecystectomy with Conventional Instruments: A Surgeon’s Initial Experience

Purpose: Since the early 1990s, laparoscopic cholecystectomy has become the gold standard for cholecystectomy. Single-incision laparoscopic surgery (SILS) is a rapidly evolving field as a bridge between traditional laparoscopic surgery and natural orifice transluminal endoscopic. The results are presented here of a single surgeon’s initial experience with single-incision laparoscopic cholecystectomy with conventional laparoscopic instruments through his first 11 cases. Materials and Methods: 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 laparoscope. One 10-mm and one 5-mm port were inserted laterally from the laparoscope port. Dissection was performed using a dissector, which was not articulated. The gallbladder was investigated with an Endograsper, which was not articulated either. The hilum was dissected, and the cystic duct and artery were clipped and divided. Results: The patients are comprised of 9 females and 2 males with a mean age of 43.3 years and mean body mass index (BMI) of 27.6 kg/m2. Open cholecystectomy was not required. The mean operative time was 69.9 min. Length of stay was only one day. All procedures were completed successfully without any perioperative or postoperative complications. In all cases, there was no need to extend the skin incision. Postoperative follow-up did not reveal any umbilical wound complications. The cosmetic results were scored as excellent by all patients. Conclusion: These results suggest that single-incision laparoscopic cholecystectomy is feasible, safe and effective and a promising alternative method to four-port and SILS-port laparoscopic cholecystectomy and as scarless abdominal surgery for the treatment of some patients with gallbladder disease with standard laparoscopic instruments.

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.

LAPAROSCOPIC TREATMENT OF ACUTE CHOLECYSTITIS

Objctive: To assess the current treatment of AC in a single institution in the series, which the best treatment modality for acute cholecystitis (AC) is still under debate, whereas early cholecystectomy is accepted as the optimal timing for surgery.Methods: From December 1996 to December 2001, 138 (102 women and 36 men) patients underwent laparoscopic cholecystectomy for acute cholecystitis confirmed by histopathological examination. The patients ranged in age from 21 to 85 years of age ( mean age: 45 3 years). Patients were divided into 2 groups (similar in age and ASA classification): group 1 (98 patients) underwent LC within 3 days after the onset of symptoms of acute cholecystitis and group 2 (40 patients) underwent LC after 3 days. Results: Approximately one half of the cases were uncomplicated, 26% were empyema, 13% had gangrenous changes and 7% had hydrops of the gallbladder. Conversion to open cholecystectomy was required in 21 (15 2%) cases. The principal reason for conversion was anatomic uncertainty (14 cases), uncontrolled bleeding (7 cases). The conversion rates in patients who underwent surgery before and after the onset of symptoms were respectively 6∶15. There was no significant difference in operative time (122 0 min in 1 group versus 124 0 min in 2 group) and postoperative stay ( 5 1 days in group 1 vs 6 8 days in group 2). The hepatorenal space was drained in 78 (56 5 %), and the drain is removed in 3rd postoperative days. Twenty six patients (18 8%) had undergone previous abdominal surgery. Thirty seven patients (26 8%) had spillage of bile and/or stones during the procedure. There were no deaths and major complications. Conclusions: LC for acute cholecystitis should be done immediately after the diagnosis is established because delaying surgery allows inflammation to become more intense, thus increasing the technical difficulty of LC. Intraoperative spillage of bile and stones does not lead to an increase in early complications. LC is safe and effective for acute cholecystitis even when complicated previous surgery, inflammatory adhesions and gangrene. LC has significantly fewer operative complications and provides shorter hospital stay which are medical and economic benefits. LC is safe and effective for acute cholecystitis.

Timing and Clinical Efficacy of Laparoscopic Cholecystectomy for Acute Cholecystitis at Different Stages

Objective:To investigate timing and clinical efficacy of laparoscopic cholecystectomy for acute cholecystitis at different stages.Methods:Clinical data of 100 acute cholecystitis patients admitted to our hospital from March 2018 to March 2019 were retrospectively analyzed.Clinical data of 48 patients who had surgery within 72 hours of symptom onset were classified as group A,and clinical data of 52 patients who had surgery at≥72 hours of symptom onset were classified as group B.Clinical indicators,rate of conversion to open surgery,and complication were compared between the two groups.Results:Length of hospital stay,operation time,exhaust time and intraoperative blood loss in group A were lower than those in group B,and the differences were statistically significant(P<0.05).Comparison of rate of conversion to open surgery between group A(2.08%,1/48)and group B(7.69%,4/52)showed no statistically significant difference(P>0.05).Incidence of postoperative complication was 8.33%(4/48)in group A and 11.54%(6/52)in group B,the difference was not statistically significance(P>0.05).Conclusions:Laparoscopic cholecystectomy within 72 hours of symptom onset has better efficacy than after 72 hours for patients with acute cholecystitis.It could effectively reduce surgical trauma and promote recovery.