Randomised controlled trial of laparoscopic versus mini cholecystectomy. The McGill Gallstone Treatment Group

Diagnostic utility of ultrasonography in the management of postoperative fluid collections and abdominal indwelling catheters following pancreaticoduodenectomy: retrospective cohort study

INTRODUCTION

The management of postoperative fluid collections, which refers to the accumulation of fluid in the peritoneal cavity following pancreaticoduodenectomy, presents significant challenges. However, ultrasonography has emerged as a promising tool for diagnosing and guiding interventions for this condition. Ultrasonography offers several advantages, including accessibility, cost-effectiveness, and real-time imaging capabilities. It plays a crucial role in identifying ascitic fluid collections, characterizing their contents, and evaluating the severity of fluid collections. Moreover, ultrasound guidance enhances the safety and effectiveness of placing abdominal catheters. The aim of this study is to assess the diagnostic utility of ultrasonography in postoperative fluid collections following pancreaticoduodenectomy and evaluate the clinical efficacy of ultrasound-guided abdominal catheter placement.

METHODS

A total of 309 hospitalized patients underwent postoperative pancreaticoduodenectomy, with 171 patients undergoing laparoscopic pancreaticoduodenectomy (LPD) and 138 patients undergoing open pancreaticoduodenectomy (OPD), as assessed by ultrasonography. We examined the abdominal cavity for the presence of postoperative fluid collections and evaluated the site of postoperative fluid collections and the necessity for tube drainage. In cases where an abdominal indwelling catheter was required, we observed the location of postoperative fluid collections, performed echocardiography, and analyzed the characteristics of drainage fluid. We conducted a comparative analysis of short-term postoperative outcomes between LPD and OPD, encompassing hospitalization duration, fever duration, presence or localization of postoperative fluid collections, number of abdominal indwelling catheters used, location of abdominal drainage fluid collection, and time until postoperative catheter removal.

RESULTS

The LPD group demonstrated a significantly lower incidence of postoperative fluid collections compared to the OPD group, as determined by ultrasonography (39.2% vs. 59.3%, p = 0.001). Additionally, the LPD group had shorter hospital stays (16 [13, 21] vs. 21 [17, 28] days; p < 0.001), reduced duration of fever (1 [0, 3] vs. 3 [1, 5] days; p < 0.001), faster time to postoperative catheterization (7 [5, 10] vs. 8 [6, 13] days; p < 0.001), fewer required tubes (0 [0, 1] vs. 1 [0, 1]; p < 0.001), and shorter extubation time (7 [5, 9] vs. 9 [5, 12] h; p < 0.001) compared to the OPD group. There were correlations observed between the two groups regarding postoperative fluid collections, ultrasound sound transmission, separation of postoperative fluid collections, and traits of drainage fluid. However, there were no significant differences between the two groups in terms of postoperative fluid collections location (dissociative or restrictive), ultrasound sound transmission (excellent or poor), and separation of postoperative fluid collections (no separation, less separation, and more separation).

CONCLUSIONS

Postoperative fluid collections is a commonly encountered concurrent condition following pancreaticoduodenectomy. Ultrasonography allows for the observation of diverse characteristics related to postoperative fluid collections, including its precise localization, sound transmission properties, and the presence of internal separations. Moreover, it enables timely guidance for precise placement of drainage tubes.

Is a giant incisional hernia a contraindication for laparoscopic cholecystectomy?

Laparoscopic cholecystectomy (LC) is one of the most commonly performed surgical procedures worldwide. A previous abdominal operation is not considered a significant risk factor for conversion to open cholecystectomy. We describe the case of an 80-year-old woman with a surgical history of a giant uncomplicated incisional midline hernia presenting at our department with choledocholithiasis and acute cholangitis. After an ERCP with extraction of common bile duct stones, a LC was planned. The first trocar was inserted in the right midclavicular line, using an open technique and a careful inspection of the abdominal cavity and the hernia sac content. An uncomplicated cholecystectomy was performed and the postoperative course was uneventful.

Current status of laparoscopic surgery usage in Türkiye: A middle-income country

Objectives

This study aimed to determine the usage status of laparoscopic procedures in general surgical practice in Türkiye, which is a sample of middle-income countries.

Material and Methods

The questionnaire was sent to general surgeons, gastrointestinal surgeons, and surgical oncologists who have completed their residency training and are actively working in university, public or private hospitals. Demographic data, laparoscopy training and the period of education, the rate of laparoscopy use, the type and volume of laparoscopic surgical procedures, their views on the advantages and disadvantages of laparoscopic surgery, and the reasons for preferring laparoscopy were determined with a 30-item questionnaire.

Results

Two hundred and forty-four questionnaires from 55 different cities of Türkiye were evaluated. The responders were mainly males, younger surgeons (F/M= 11.1/88.9 % and 30-39 y/o), and graduated from the university hospital residence program (56.6%). Laparoscopic training was frequently taken during residency (77.5%) in the younger age group, while the elderly participants mostly received additional training after specialization (91.7%). Laparoscopic surgery was mostly not available in public hospitals for advanced procedures (p <0.0001) but was available for cholecystectomy and appendectomy operations (p= NS). However, participants working in university hospitals mostly stated that the laparoscopic approach was the first choice for advanced procedures.

Conclusion

The results of this study showed that the surgeons working in MICs spent strong effort to use laparoscopy in daily practice, especially in university and high-volume hospitals. However, inappropriate education, cost of laparoscopic equipment, healthcare policies, and some cultural and social barriers might have negatively impacted the widespread use of laparoscopic surgery and its usage in daily practice in MICs such as Türkiye.

Laparoscopic cholecystectomy using the subserosal layer dissection technique in dogs: 34 cases (2015‐2021)

OBJECTIVES

To describe a standardised subserosal layer dissection technique and evaluate its outcomes in canine laparoscopic cholecystectomy.

MATERIALS AND METHODS

Medical records of dogs undergoing laparoscopic cholecystectomy using the standardised subserosal layer dissection technique for the treatment of cholecystolithiasis, cholecystitis, and gall bladder mucocele at a single veterinary hospital from January 2015 to September 2021 were extracted. Operative time, subserosal layer dissection achievement rate, open conversion rate, and complication rate were evaluated.

RESULTS

Thirty-four dogs were included. The most common preoperative diagnosis was cholecystolithiasis (n=29). Operative time was 190 minutes (range: 110 to 330 minutes). Subserosal layer dissection of more than 90% of the gall bladder bed was achieved in 27 (79%) dogs. Conversion to open surgery was required in three (8.8%) dogs. There were no cases of intraoperative bleeding, bile duct injury, or reoperation.

CLINICAL SIGNIFICANCE

This study showed that laparoscopic cholecystectomy using the standardised subserosal layer dissection technique could be performed successfully in dogs. Future prospective clinical studies are needed to determine safety and effectiveness of this technique compared to standard techniques.

Recruitment Maneuver to Reduce Postoperative Pulmonary Complications after Laparoscopic Abdominal Surgery: A Systematic Review and Meta-Analysis

Background: Lung-protective ventilation strategies are recommended for patients undergoing mechanical ventilation. However, there are currently no guidelines to follow regarding recruitment maneuvers (RMs). We attempted to identify the effects of RMs on patients undergoing laparoscopic abdominal surgery. Methods: We searched for randomized controlled trials (RCTs) in PubMed, the Cochrane Library databases, Embase, Web of Science and the ClinicalTrials.gov registry for trials published up to December 2021. The primary outcome was postoperative pulmonary complications (PPCs). The secondary outcomes consisted of the static lung compliance, driving pressure (DP), intraoperative oxygenation index (OI), OI in the post-anesthesia care unit (PACU), mean arterial pressure (MAP) and heart rate (HR). Seventeen RCTs with a total of 3480 patients were examined. Results: Patients who received RMs showed a considerable reduction in PPCs (risk ratio (RR) = 0.70; 95% confidence interval (CI): 0.62 to 0.79; p < 0.01), lower DP (weighted mean difference (WMD) = −3.96; 95% CI: −5.97 to −1.95; p < 0.01), elevated static lung compliance (WMD = 10.42; 95% CI: 6.13 to 14.71; p < 0.01) and improved OI (intraoperative: WMD = 53.54; 95% CI: 21.77 to 85.31; p < 0.01; PACU: WMD = 59.40; 95% CI: 39.10 to 79.69; p < 0.01) without substantial changes in MAP (WMD = −0.16; 95% CI −1.35 to 1.03; p > 0.05) and HR (WMD = −1.10; 95% CI: −2.29 to 0.10; p > 0.05). Conclusions: Recruitment maneuvers reduce postoperative pulmonary complications and improve respiratory mechanics and oxygenation in patients undergoing laparoscopic abdominal surgery. More data are needed to elucidate the effect of recruitment maneuver on the circulatory system.

Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery

BACKGROUND

Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort.

METHODS

Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups.

RESULTS

The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status.

CONCLUSION

The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.

Robotic Kidney Transplant: The Modern Era Technical Revolution

Since the mid 20th century, transplantation has been a fast-developing field of contemporary medicine. The technical aspects of transplant operations were developed in the 1950s, with little significant change for >50 y. Those techniques allowed completion of various organ transplants and successful patient outcomes, but they also carried the inherent disadvantages of open surgery, such as postoperative pain, wound complications and infections, and prolonged length of hospital stay. The introduction and adoption of minimally invasive surgical techniques in the early 1990s to various surgical specialties including general, gynecologic, and urologic surgery led to significant improvements in postoperative patient care and outcomes. Organ transplantation, with its precision demanding vascular anastomoses, initially had been considered infeasible to accomplish with conventional laparoscopic devices. The institution of robotic surgical technology in the late 1990s and its subsequent wide utilization in fields of surgery changed its accessibility and acceptance. With the steady camera, 3D views, and multidirectional wrist motions, surgical robotics opened new horizons for technically demanding surgeries such as transplantation to be completed in a minimally invasive fashion. Furthermore, the hope was this technique could find a niche to treat patients who otherwise are not deemed surgical candidates in many fields including transplantation. Here in, robotics in kidney transplantation and its ability to help provide equity through access to transplantation will be discussed.

[Evidence-based medicine of gallstone disease regarding development of national clinical guidelines]

OBJECTIVE

To study the Cochrane evidence base of systematic reviews and meta-analyses regarding development of national guidelines for surgical treatment of gallstone disease and its complications.

MATERIAL AND METHODS

We analyzed the original database involving 35 systematic reviews and meta-analyses of Cochrane Library devoted to gallstone disease and its complications. Methodology of electronic and manual searching of trials was used for identification and screening of information for the period until October 2021.

RESULTS

There were 430 randomized controlled trials from different countries estimated in 35 systematic reviews of Cochrane Library. At the same time, Russian-language researches are not included in the world's evidence database of biliary tract surgery. Expert groups couldn't perform meta-analysis and limited to systematic-review in 6 (17%) publications because of insufficient statistical power or primary researches. Need for further research of this issue was determined after assessment of 26 (74%) meta-analyses.

CONCLUSION

We have to convey foreign experience as subbase of national clinical guidelines taking into account deficiency of scientific trials with high level of evidence in our country. Need for further evidence trials, considering the peculiarities of surgical care in the Russian Federation, is determined by unsolved issues of treatment of gallstone disease and its complications.

Innovation and Tribulation in the History of Randomized Controlled Trials in Surgery

Despite persistent critiques of the rigor of surgical research, surgeons have actually pursued careful empirical studies for centuries. Their work has enriched not only surgical science but also the development of evidencebased medicine. From conducting landmark controlled trials, to using statistics, alternate patient allocation, randomization, and sham controls, surgeons have long embraced innovative trial approaches and played important roles in the development of key methods of RCTs. However, historical contexts unique to surgery have shaped the implementation of RCTs in this field. Unlike the history of pharmaceuticals, in which substantial research funding has been devoted to testing new drugs before their approval, surgical trials have followed a different trajectory. New operations have repeatedly come into wide use in the absence of RCTs. On many occasions, when established procedures have become controversial, surgeons have then marshaled the resources to conduct RCTs reassessing the operations. Such trials have triggered powerful debates in which proponents of surgical RCTs battled against ingrained practices and preferences. In such cases, RCTs often were not decisive factors in determining the fate of surgical practices but supporting tools that followed and reflected changes in surgical judgment already underway. Surgical trialists also have encountered specific, recurring challenges, especially with the methodological and ethical complexity of blinded and sham-controlled trials. The history of surgical trials thus reveals major contributions from surgeons to the advancement of evidence-based medicine, as well as ongoing challenges. Strengthened and systematic trial support could advance the future of surgical RCTs.

Comparative outcomes of needlescopic, single-incision laparoscopic, standard laparoscopic, mini-laparotomy, and open cholecystectomy: A systematic review and network meta-analysis of 96 randomized controlled trials with 11,083 patients

BACKGROUND

Most randomized trials on minimally invasive cholecystectomy have been conducted with standard (3/4-port) laparoscopic or open cholecystectomy serving as the control group. However, there exists a dearth of head-to-head trials that directly compare different minimally invasive techniques for cholecystectomy (eg, single-incision laparoscopic cholecystectomy versus needlescopic cholecystectomy). Hence, it remains largely unknown how the different minimally invasive cholecystectomy techniques fare up against one another.

METHODS

To minimize selection and confounding biases, only randomized controlled trials were considered for inclusion. Perioperative outcomes were compared using frequentist network meta-analyses. The interpretation of the results was driven by treatment effects and surface under the cumulative ranking curve values. A sensitivity analysis was also undertaken focusing on a subgroup of randomized controlled trials, which recruited patients with only uncomplicated cholecystitis.

RESULTS

Ninety-six eligible randomized controlled trials comprising 11,083 patients were identified. Risk of intra-abdominal infection or abscess, bile duct injury, bile leak, and open conversion did not differ significantly between minimally invasive techniques. Needlescopic cholecystectomy was associated with the lowest rates of wound infection (surface under the cumulative ranking curve value = 0.977) with an odds ratio of 0.095 (95% confidence interval: 0.023-0.39), 0.32 (95% confidence interval: 0.11-0.98), 0.33 (95% confidence interval: 0.11-0.99), 0.36 (95% confidence interval: 0.14-0.98) compared to open cholecystectomy, single-incision laparoscopic cholecystectomy, mini-laparotomy, and standard laparoscopic cholecystectomy, respectively. Mini-laparotomy was associated with the shortest operative time (surface under the cumulative ranking curve value = 0.981) by a mean difference of 22.20 (95% confidence interval: 13.79-30.62), 12.17 (95% confidence interval: 1.80-22.54), 9.07 (95% confidence interval: 1.59-16.54), and 8.36 (95% confidence interval: -1.79 to 18.52) minutes when compared to single-incision laparoscopic cholecystectomy, needlescopic cholecystectomy, standard laparoscopic cholecystectomy, and open cholecystectomy, respectively. Needlescopic cholecystectomy appeared to be associated with the shortest hospitalization (surface under the cumulative ranking curve value = 0.717) and lowest postoperative pain (surface under the cumulative ranking curve value = 0.928).

CONCLUSION

Perioperative outcomes differed across minimally invasive techniques and, in some instances, afforded superior outcomes compared to standard laparoscopic cholecystectomy. These findings suggest that there may be equipoise for exploring further the utility of novel minimally invasive techniques and potentially incorporating them into the general surgery training curriculum.

Minimising in minimally invasive surgery through the use of a novel and flexible super elastic titanium needle suitable for a 3.5- and 5-mm trocar

The use of smaller ports in surgery is the next step in the evolution of minimally invasive procedures. We present findings, using a novel flexible needle made from a super elastic titanium alloy, which demonstrate that it is possible for a 26- and 30-mm needle to pass through a 3.5- and 5-mm trocar. This new approach results in less trauma and improved cosmetic effect in comparison to the classical 10-mm port. Traditional steps such as handling of the needle holders, loading the needle and placing it at the correct angle and direction, inserting the needle into the tissue and finally safely tying a knot remain the same as with the standard procedure. We propose that this improved type of needle creates a refinement opportunity to replace the classic ones during both laparoscopic and robotic surgeries.

Postcholecystectomy biliary injuries: frequency, and role of early versus late endoscopic retrograde cholangiopancreatography

BACKGROUND AND STUDY AIM

Bile duct injuries are not infrequently seen during hepatobiliary surgery, particularly after liver transplantation and cholecystectomy. The current study aims to figure out the frequency of postcholecystectomy biliary injuries (PCBI) and the role of early versus late endoscopic retrograde cholangiopancreatography (ERCP) in their management.

PATIENTS AND METHODS

Totally 960 cases operated by both laparoscopic and open cholecystectomy were evaluated in the current study. In total, 942 cases were operated in our institutes, by both laparoscopic (n = 925) and open (n = 17) cholecystectomy, and the frequency of PCBI among patients operated in our institutes was (9/942) 0.95%. Additional 18 cases of PCBI referred to our centers were included in the study. One patient was treated by repair during the surgery, in the remaining 26 patients, ERCP management was attempted. The full details of the 26 patients regarding ERCP management were discussed.

RESULTS

The overall success rate of ERCP management was 88.46% (23/26), whereas 11.54% of cases were treated surgically by choledochal-jejunal anastomosis due to complete common bile duct ligation. There were no differences between patients treated by early (first week) versus late (after the first week) ERCP regarding the needed interventions, type of PCBI, type and diameter of the inserted stents, and the overall success. There were no adverse events associated with ERCP management.

CONCLUSIONS

ERCP was valuable in the treatment of 88.46% of injured cases. There were no differences between early and late ERCP in the treatment of PCBI. Furthermore, ERCP management was not associated with adverse events.

[Randomized trials and progress in surgery]

It is very difficult to find certain surgical field in which surgeon's decision is absolutely evidence-based. The objective of evidence-based medicine (and surgery) is offering the best treatment for each patient that should encourage conducting the randomized trials (RT) as the highest level of evidence. The results of RTs often contradict the existing clinical experience, and experience per se does not always confirm the significance of the results obtained. One cannot make any conclusions based on RT data. Treatment strategy for a particular patient remains unclear. The authors have analyzed the results of large-scale RTs devoted to laparoscopic cholecystectomy, rectal surgery, lung cancer surgery, postoperative care, treatment of pulmonary emphysema. It was shown that RT data as the highest level of evidence are not always true for surgery. In most clinical situations, the decision is not based on RT results. The desire of surgeons to master a new technique is often more significant than patient care, while clinical experience and the laws of the market are more important than science. There is no doubt that knowledge of RT results are essential in training period, but this means quite a bit for a particular patient. The best decision can be made during discussion and conversation with colleagues, where an experience of each specialist will have the same value as the best evidence.

Mini-cholecystectomy versus laparoscopic cholecystectomy: a retrospective multicentric study among patients operated in some Eastern Libyan hospitals

Objectives

This study was conducted to analyze the difference between Mini-Cholecystectomy (MC) and Laparoscopic Cholecystectomy (LC) in terms of feasibility and postoperative outcomes to determine if MC could be accepted as a good alternative procedure to LC.

Material and Methods

A retrospective comparative study of 206 consecutively operated patients of chronic cholecystitis (138 LC and 68 MC), in Al-Jalaa, Ajdabiya and Almrg Teaching hospitals between January 2014 and December 2015 was performed. All cases within the two groups were balanced for age, sex, co-morbidities, ultrasound and intraoperative findings. Exclusion criteria were acute cholecystitis, preoperative jaundice, liver cirrhosis, suspicion of malignancy, previous upper abdominal surgery and pregnancy.

Results

Mean age of the patients in the study was around 37 years. Female patients represented 88.84%. Intraoperative complications occurred in about 2% of the patients with bleeding in three cases (one in MC, two in LC) and injury to the bile ducts occurred in one case who underwent LC. Operative duration was longer in LC (mean values 64 minutes for LC and 45 minutes for MC). Rate of conversion to classical cholecystectomy in LC was 5% while it was 0% in MC. Only one case of wound infection was registered in the LC group. Postoperative hospital stay was insignificantly longer for LC versus MC (1.97 days for MC and 2.63 days for LC).

Conclusion

Mini-cholecystectomy is a feasible technique, which can be considered as a good alternative method for gallbladder removal for surgeons who have no experience with laparoscopic techniques and in peripheral hospitals where LC is not available.

Who should record surgical complications? Results from a third-party assessment of complications after radical cystectomy

Objective: In Sweden complications after radical cystectomy have been reported to the nationwide population-based Swedish Cystectomy Registry since 2011. Here, validation of the reporting was assessed in two healthcare regions.Materials and methods: Complications were ascertained from patient records by a third party not involved in the care delivered to 429 randomly selected patients from 949 who had undergone radical cystectomy since 2011 in four hospitals. Without knowledge of the outcome in the primary registration, post-operative complications within 90 days post-operatively were assessed by an independent review of patient charts, and the results were compared with the primary reports in the Swedish Cystectomy Registry.Results: The third-party assessment identified post-operative complications in 310 patients (72%). Low-grade complications (Clavien-Dindo I-II) were noted in 110 (26%) of the patients in the primary registration, but increased to 182 (42%) in the validation (p < 0.00001). High-grade complications (Clavien-Dindo III-V) were reported in 113 (26%) patients in the primary registration, but in 128 (30%) of the patients in the validation (p = 0.02). According to the third-party assessment, 18 patients (4%) had Clavien-Dindo grade IV complications and 12 (3%) died within 90 days of surgery (Clavien-Dindo grade V); corresponding values in the primary registration were 15 (3%) and 9 (2%), respectively. The readmission rate within 90 days increased from 27 to 32% in the validation (p < 0.00001).Conclusions: Compared with registry data, third-party assessment revealed more complications and readmissions after radical cystectomy. Hence such evaluation may improve the validity of reported complication data.

A systematic review of patient reported outcome measures (PROMs) and quality of life reporting in patients undergoing laparoscopic cholecystectomy

Patient reported outcome measures (PROMs) provide a valuable means of measuring outcomes subjectively from a patient's perspective, facilitating the assessment of service quality across healthcare providers, and assisting patients and clinicians in shared decision making. The primary aim of this systematic review was to critically appraise all historic studies evaluating patient reported quality of life, in adult patients undergoing laparoscopic cholecystectomy for symptomatic gallstones. The secondary aim was to perform a quality assessment of cholecystectomy-specific PROM-validation studies. A literature review was performed in PubMed, Google ScholarTM, the Cochrane Library, Medline, CINAHL, EMBASE and PsychINFO databases up to September 2017. Study characteristics, PROM-specific details and a bias assessment were summarised for non-validation studies. A COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) analysis was performed to assess the methodological quality of identified PROM-validation studies. Fifty one studies were found to evaluate health-related quality of life (HRQoL) after laparoscopic cholecystectomy. Although 94.1% of these studies included PROMs as a primary outcome measure, <20% provided level 1 evidence through randomised controlled trials (RCTs). There was significant variation in the selection and reporting of PROMs, with no studies declaring patient involvement in PROM selection, and 88.2% of studies failing to document the management of missing data points, or non-returned surveys (33.3%). In the 6 PROM-validation studies identified, only 5 psychometric properties were evaluated, the findings of which were limited due to the small number of studies. This systematic review identifies a lack in consistency of study design and PRO reporting in clinical trials. Whilst an increasing number of studies are being performed to evaluate PROs, a lack of adherence to existing PRO administration and reporting guidelines is continuing to negatively affect study quality. We recommend that future clinical trials utilizing PROs should adhere to established comprehensive guidelines as described.

Assessment of the difficulties in laparoscopic cholecystectomy among patients at Baghdad province

Background

Laparoscopic surgery for gallbladder cholecystectomy has become the typical procedure for symptomatic gallbladder stone diseases treatment as a type of minimal invasiveness surgery associated with less pain and early recovery as there is minimal trauma of access without shrinking the exposure of operative field. The current study aimed to assess factors associated with difficult LC.

Methodology

A cross sectional study was conducted at medical city complex (Baghdad Teaching Hospital) from October 2015 to October 2016, in which all patients that were admitted for LC were examined preoperatively, underwent LC and followed postoperatively to study factors associated with difficult LC. All LC were operated by qualified senior surgeons and supervised by well-trained resident doctors. A pre-operative score system parameters were obtained from history, clinical examination and investigation findings.

Results

Laparoscopic cholecystectomy was performed for 100 patients, 78% were females and 49% were among 40–59 years of age. The preoperative scoring revealed that in 58% of the patients the score indicate difficulty, and very difficult in only 7% of the patients. Difficult and very difficult operations were significantly associated with high difficult scoring preoperatively, gender, BMI and cause of admission.

Conclusion

High difficult scoring preoperatively, gender, BMI and cause of admission can be used as predictors for difficult LC.

•

The current study aimed to assess factors associated with difficult LC.

•

Very difficult operations were associated with high difficult scoring preoperatively, gender, BMI and cause of admission.

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Laparoscopic surgery for gallbladder cholecystectomy has become the typical procedure for symptomatic cholelithiasis treatment.

DISCHARGE AFTER ELECTIVE UNCOMPLICATED LAPAROSCOPIC CHOLECYSTECTOMY: CAN THE POSTOPERATIVE STAY BE REDUCED?

- The aim of the study was to reevaluate the safety and feasibility of discharge 24 h after elective uncomplicated laparoscopic cholecystectomy. Since the introduction of laparoscopic cholecystectomy in our hospital, the minimum postoperative stay was considered to be two days based on surgeons' experience. The study included 337 operations performed by 21 surgeons during 2016 in the Sestre milosrdnice University Hospital Centre. Conversion to open technique and cases of acute cholecystitis were excluded, while 15 patients had insufficient postoperative data. The mean length of stay was 2.38 (range 1 to 6) postoperative days, median two postoperative days. Serious complications involving suspected drain bile leakage and postoperative hemorrhage occurred in two (0.59%) patients, both in the first 24 h following surgery. One patient required emergency laparotomy on the first postoperative day. Readmission rate was 1.2%. The postoperative minor complication rate was 42 of 337 (12.46%); these included wound infections, urinary tract infections, symptoms included in postcholecystectomy syndrome, etc. The onset of these complications was mostly after postoperative day 3. The data obtained suggest that discharge on the first postoperative day after elective uncomplicated laparoscopic cholecystectomy should be considered safe and can be practiced in our hospital.

Short-term outcome of laparoscopic cholecystectomy for benign gall bladder diseases in 76 dogs

Laparoscopic cholecystectomy (LC) is widely accepted as the standard treatment for benign gall bladder diseases in humans because it has proven to be less invasive and safer than are traditional methods. However, the efficacy of LC in dogs remains unclear. The present study aimed to examine the short-term outcome of LC for benign gall bladder diseases in dogs. We enrolled 76 consecutive dogs that underwent LC for benign gall bladder diseases at our hospital between April 2008 and October 2016. Dogs with jaundice, gall bladder ruptures, abdominal effusion, or extrahepatic biliary obstruction were not excluded from the indication. Factors including age, body weight, sex, clinical sign, disease, operative time, conversion to open surgery, perioperative complications, and postoperative hospital stay were investigated. The median age of the dogs was 11 years, and the median body weight was 5.4 kg. Fifty percent of the dogs exhibited no symptoms at the initial visit. Preoperative elevation of total bilirubin levels was observed in 16 dogs (21%). LC was successfully completed in 71 dogs (93%); the median operative time was 124 min. Although gall bladder ruptures were observed in 2 (2.6%) dogs, the operations were completed successfully. Three dogs (4.1%) had to be converted to open cholecystectomy and 2 (2.6%) underwent reoperation. Two dogs (2.6%) died intraoperatively and 2 (2.6%) died postoperatively. LC was a feasible, safe, and appropriate procedure considering the current operative indications for benign gall bladder diseases in dogs.

Evaluation of the impact of preoperative education in ambulatory laparoscopic cholecystectomy. A prospective, double-blind randomized trial

INTRODUCTION

Outpatient laparoscopic cholecystectomy is a safe procedure and provides a better use of health resources and perceived satisfaction without affecting quality of care. Preoperative education has shown less postoperative stress, pain and nausea in some interventions. The principal objective of this study is to assess the impact of preoperative education on postoperative pain in patients undergoing ambulatory laparoscopic cholecystectomy. Secondary objectives were: to evaluate presence of nausea, morbidity, hospital admissions, readmissions rate, quality of life and satisfaction.

METHODS

Prospective, randomized, and double blind study. Between April 2014 and May 2016, 62 patients underwent outpatient laparoscopic cholecystectomy.

INCLUSION CRITERIA

ASA I-II, age 18-75, outpatient surgery criteria, abdominal ultrasonography with cholelithiasis. Patient randomization in two groups, group A: intensified preoperative education and group B: control.

RESULTS

Sixty-two patients included, 44 women (71%), 18 men (29%), mean age 46,8 years (20-69). Mean BMI 27,5. Outpatient rate 92%. Five cases required admission, two due to nausea. Pain scores obtained using a VAS was at 24-hour, 2,9 in group A and 2,7 in group B. There were no severe complications or readmissions. Results of satisfaction and quality of life scores were similar for both groups.

CONCLUSIONS

We did not find differences due to intensive preoperative education. However, we think that a correct information protocol should be integrated into the patient's preoperative preparation. Registered in ISRCTN number ISRCTN83787412.

Comparison Between Outcomes of Laparoscopic Cholecystectomy in Patients With Liver Cirrhosis or With Normal Liver Function

Objective and Background:

The safety of laparoscopic cholecystectomy in patients with Child–Pugh A and B cirrhosis is well-established, but perioperative complications are frequently observed in patients with cirrhosis. Technical challenges of this operation in cirrhotic patients remain in need of resolution.

Methods:

Twenty-one patients preoperatively diagnosed as having cirrhosis underwent laparoscopic cholecystectomy mainly using the French approach and were retrospectively reviewed. Their clinicopathologic characteristics were compared with 74 continuous patients with gallstone but no cirrhosis who underwent laparoscopic cholecystectomy using the American approach.

Results:

Most cirrhotic patients (19/21, 90.5%) had a chronic liver disease such as hepatitis B/C, alcoholic hepatitis, or primary biliary cholangitis. On imaging, the Chilaiditi sign and gallbladder bed pocket score, previously proposed to be informative in these patients, were significantly higher in the cirrhosis group than in the no cirrhosis group. Although the Child–Pugh score was higher in patients with cirrhosis, the model for end-stage liver disease (MELD) score was similar for the 2 groups. There were no differences in the operation time or the amount of intraoperative blood transfused. Postoperative hospital stay and postoperative morbidity rates were significantly greater in the cirrhosis group, although severe complications with a Clavien–Dindo score ≥ IIIa occurred in only 1 patient in each group.

Conclusions:

The safety of laparoscopic cholecystectomy in cirrhotic patients was confirmed. Because the gallbladder is completely covered in patients with cirrhosis, the French style approach, which enables surgeons to more easily access the gallbladder pocket, is assumed to be one of the operative options.

Totally laparoscopic or robot-assisted pancreaticoduodenectomy versus open surgery for periampullary neoplasms: separate systematic reviews and meta-analyses

OBJECTIVE

To compare perioperative and oncologic outcomes of pure (totally) laparoscopic pancreaticoduodenectomy (TLPD) or robot-assisted pancreaticoduodenectomy (RAPD) with those of conventional open pancreaticoduodenectomy (OPD).

METHODS

A systematic literature search was performed using PubMed, EMBASE, and Cochrane library databases. Studies comparing TLPD with OPD and RAPD with OPD were included; only original studies reporting more than 10 cases for each technique were included. Studies were combined using a random-effects model to report heterogeneous data, or a fixed-effects model was applied.

RESULTS

TLPD involved longer operative time (weighted mean difference [WMD]: 116.85 min; 95% confidence interval [CI] 54.53-179.17) and significantly shorter postoperative hospital stay (WMD: -3.68 days; 95% CI -4.65 to -2.71). Overall morbidity and postoperative pancreatic fistula were not significantly different between TLPD and OPD. RAPD was associated with a longer operative time, less intraoperative blood loss, and shorter hospital stay. Oncologic outcomes were not significantly different among the procedure types.

CONCLUSIONS

Compared to OPD, TLPD and RAPD were feasible and oncologically safe procedures. However, there are no prospective studies, and the majority of the studies on TLPD and RAPD have remained in the early training phase. In addition to randomized controlled trials or prospective studies, new data from the late training phase of learning experiences should also be analyzed.

Consequences of Lost Gallstones During Laparoscopic Cholecystectomy: A Review Article

BACKGROUND

Laparoscopic cholecystectomy (LC) has become a popular and widespread procedure for the treatment of gallstone disease. There is still an increasing concern about specific complications of LC due to gallbladder perforation and spillage of bile and stones. Although unretrieved intraperitoneal gallstones rarely become symptomatic, their infective complications may cause serious morbidities even after a long interval from LC.

METHODS

We performed a review of the literature on the diagnosis, prevention, consequences, and management of lost gallstones. All studies with a focus on lost gallstones or perforated gallbladder were analyzed to evaluate the postoperative complications.

RESULTS

Between 1991 and 2015, >250 cases of postoperative complications of spilled gallstones were reviewed in the surgical literature. The most common complications are intraperitoneal abscesses and fistulas. Confusing clinical pictures due to gallstones spreading in different locations makes diagnosis challenging. Even asymptomatic dropped gallstones may masquerade intraperitoneal neoplastic lesions.

CONCLUSIONS

Every effort should be made to prevent gallbladder perforation; otherwise, they should be retrieved immediately during laparoscopy. In cases with multiple large spilled stones or infected bile, conversion to open surgery can be considered. Documentation in operative notes and awareness of patients about lost gallstones are mandatory to early recognition and treatment of any complications.

Evidence-based clinical practice guidelines for cholelithiasis 2016

Cholelithiasis is one of the commonest diseases in gastroenterology. Remarkable improvements in therapeutic modalities for cholelithiasis and its complications are evident. The Japanese Society of Gastroenterology has revised the evidence-based clinical practice guidelines for cholelithiasis. Forty-three clinical questions, for four categories-epidemiology and pathogenesis, diagnosis, treatments, and prognosis and complications-were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This article preferentially describes the clinical management of cholelithiasis and its complications. Following description of the diagnosis performed stepwise through imaging modalities, treatments of cholecystolithiasis, choledocholithiasis, and hepatolithiasis are introduced along with a flowchart. Since there have been remarkable improvements in endoscopic treatments and surgical techniques, the guidelines ensure flexibility in choices according to the actual clinical environment. The revised clinical practice guidelines are appropriate for use by clinicians in their daily practice.

Laparoscopic versus open cholecystectomy in pregnancy: a systematic review and meta-analysis

BACKGROUND

The operative management of symptomatic cholelithiasis during pregnancy is either laparoscopic cholecystectomy (LC) or open cholecystectomy (OC). The aim of this systematic review and meta-analysis is to compare the outcomes of the laparoscopic and open approach for cholecystectomy during pregnancy.

METHOD

A literature search was conducted using MEDLINE, PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL and Current Contents Connect using appropriate search terms. All comparative studies reporting maternal, fetal, and/or surgical complications were included.

RESULTS

Eleven comparative studies, with a total of 10,632 patients, were included. The laparoscopic approach was performed at mean 18-week gestation and the open approach at mean 24-week gestation. LC was associated with decreased risks for fetal (OR 0.42; 95 % CI 0.28-0.63; p < 0.001), maternal (OR 0.42; 95 % CI 0.33-0.53; p < 0.001) and surgical (OR 0.45; 95 % CI 0.25-0.82, p = 0.01) complications. The average length of hospital stay (LOS) was: LC 3.2 days and OC 6.0 days (p = 0.02). The conversion rate from LC to OC was 3.8 %.

CONCLUSION

The results of this first meta-analysis suggest that LC is associated with fewer maternal and fetal complications than OC during pregnancy. However, 91 % of included patients were in the first or second trimester at the time of surgery. These findings do not account for gestational age during pregnancy, which may be a significant confounding factor. The results support intervention for symptomatic gallstones in the first and second trimester with a laparoscopic approach.

Inflammatory response to surgical trauma in patients with minilaparotomy cholecystectomy versus laparoscopic cholecystectomy: a randomised multicentre study

OBJECTIVE

The aim of the study was to evaluate the inflammatory response to surgical trauma in minilaparotomy cholecystectomy (MC) compared to laparoscopic cholecystectomy (LC). Assessment of inflammatory response to surgical trauma in MC has not been addressed properly. Therefore, we investigated five interleukins (IL) and C-reactive protein (CRP) in MC versus LC group in a prospective randomised trial.

METHODS

Initially, 106 patients with non-complicated symptomatic gallstone disease were randomised into MC (n = 56) or LC (n = 50) groups. Plasma levels of five interleukins (IL-1β, IL-1ra, IL-6, IL-8, IL-10) and hs-CRP were measured at three time points; before operation (PRE), immediately after operation (POP1) and six hours after operation (POP2). The primary end-point of the study was to compare the plasma levels of five interleukins and CRP in LC versus MC group.

RESULTS

The demographic variables and the surgical data were similar in the study groups. The patients in the MC group had higher elevation of the CRP mean values post-operatively (p = 0.01). However, the patients in the MC group had higher elevation of the IL-1ra mean values post-operatively, the mean pre-/post-operative IL-1ra values being 299/614 pg/ml in the MC group versus 379/439 pg/ml in the LC group (p = 0.003). There was no statistical significance in IL-6 mean values between the MC and LC groups pre- and post-operatively (POP1). However, the patients in the MC group had higher IL-6 mean values six hours post-operatively (POP2), the mean IL-6 values being 27.6 pg/ml in the MC group versus 14.8 pg/ml in the LC group (p = 0.037). In addition, the patients in the MC group had higher elevation of the IL-6 mean values post-operatively, the mean pre-/post-operative IL-6 values being 4.1/27.6 pg/ml in the MC group versus 3.8/14.8 pg/ml in the LC group (p = 0.04). There was no statistical significance in IL-8, IL-10, and IL-1β mean values between the MC and LC groups pre- and post-operatively.

CONCLUSION

Our results suggest that the inflammatory response in MC versus LC groups was similar based on the IL-8, IL-10, and IL-1β values. A new finding with possible clinical relevance in the present work is higher relative elevation of the IL-1ra and IL-6 mean values post-operatively in the MC group.

Appraisal of Laparoscopic Distal Pancreatectomy for Left-Sided Pancreatic Cancer: A Large Volume Cohort Study of 152 Consecutive Patients

BACKGROUND

The aim of this study was to appraise the value of laparoscopic distal pancreatectomy (LDP) for left-sided pancreatic cancer based on a large volume cohort study.

METHODS

We reviewed data for all consecutive patients undergoing LDP for left-sided pancreatic cancer at Asan Medical Center (Seoul, Korea) between December 2006 and December 2014.

RESULTS

A total of 91 male and 61 female patients, with a median age of 62.7 years were included in this study. The median operative duration was 234 minutes. Pathological reports revealed the following: a median tumor size of 3.0 cm (range, 0.4-10.0), T stages (T1 in 7.9%, T2 in 5.3%, T3 in 86.8%, and no T4), the tumor differentiation (well differentiated in 16.4%, moderately differentiated in 75.4%, and poorly differentiated in 8.2%), and R0 resection in 126 patients (82.9%). After pancreatectomy, 96 patients (63.2%) received adjuvant chemotherapy, and the median time to chemotherapy was 30 days. The median length of hospital stay was 8 days (range, 5-31), and the median time to diet resumption was 1 day. Grade B or C postoperative pancreatic fistula occurred in 14 patients (9.2%) and grade II or III complications occurred in 27 (17.7%). The median overall survival was 43.0 months. A Cox proportional hazards model showed that tumor size, N1 stage, combined resection, and incompleteness of planned adjuvant chemotherapy affect patient survival.

CONCLUSIONS

LDP for left-sided pancreatic cancer is reasonable within selected indications. An international consensus on laparoscopic surgery for pancreatic cancer would be desirable and timely.

Physiopathology and clinical considerations of laparoscopic surgery in the elderly

OBJECTIVE

The marked improvements in medical technology and healthcare, lead an increasing number of elderly patients to take advantage of even complex surgical. Recently, laparoscopic surgery has been accepted as a minimally invasive treatment to reduce the morbidity after conventional surgery, and a number of studies have demonstrated the feasibility of laparoscopy with significant advantages also in the elderly. On the other side, the laparoscopic procedure has some drawbacks, including prolonged operation time and impact of carbon dioxide pneumoperitoneum on circulatory and respiratory dynamics. This paper will review the physiopathological implications of laparoscopy, as well as the current literature concerning the most common laparoscopic procedures that are increasingly performed in elderly patients.

MATERIALS AND METHODS

A systematic review of the current literature was performed using the search engines EMBASE and PubMed to identify all studies reporting the physiopathological implications of laparoscopy in the elderly. The MeSH search terms used were "laparoscopy in the elderly", "physiopathology of laparoscopy", and "pneumoperitoneum". Multiple combinations of the keywords and MeSH terms were used with particular reference to elderly patients.

RESULTS

Although laparoscopy is minimally invasive in its dissection techniques, the increased physiologic demands present particular challenges among elderly patients.

CONCLUSIONS

Laparoscopy and its safety in the elderly patients remains a challenge and the evaluation of this approach is therefore mandatory. Although many studies have demonstrated the applicability and advantages of the laparoscopy also in the geriatric population, with low rates of morbidity and mortality, in elderly patients undergoing general surgical procedures the physiologic demands of laparoscopy should be carefully considered.

Laparoscopic transhiatal esophagectomy improves hospital outcomes and reduces cost: a single-institution analysis of laparoscopic-assisted and open techniques

BACKGROUND

Several case series have demonstrated that laparoscopic transhiatal esophagectomy (LTHE) is associated with favorable perioperative outcomes compared to historical data for open transhiatal esophagectomy (OTHE). Contemporaneous evaluation of open and laparoscopic THE is rare, limiting meaningful comparison of techniques.

METHODS

All patients who underwent OTHE (n = 32) and LTHE (n = 41) during the introduction of the latter procedure at our institution (1/2012-4/2014) were identified, and patient charts were retrospectively reviewed.

RESULTS

Indications for operation included 69 patients with esophageal malignancy (adenocarcinoma: 64; squamous cell carcinoma: 4; melanoma: 1) and 4 patients with benign disease. There were no significant differences in clinicopathologic variables between OTHE and LTHE cohorts, except for an increased rate of cardiovascular disease in the LTHE cohort (p = 0.04). There was no significant difference in median operative time or operative complications, yet LTHE was associated with a lower incidence of intraoperative blood transfusion (p < 0.01). There were no 30-day mortalities. LTHE was associated with a reduced time to reach 24-h tube feeding goals (p = 0.02), shorter length of hospital stay (p = 0.01), and 6 % reduced median direct cost (p = 0.04). There were no significant differences in rates of major perioperative morbidities. Patients were followed for a median of 11.0 months during which there were no significant differences between cohorts in disease-free survival or overall survival.

CONCLUSION

When compared to OTHE, LTHE improves surgical outcomes and decreases hospital costs; short-term oncologic outcomes are similar. LTHE is preferable to OTHE in patients requiring transhiatal esophagectomy.

Emerging Techniques in Minimally Invasive Surgery. Pros and Cons

New trends have emerged regarding the best minimally invasive access approaches to perform gastrointestinal surgery. However, these newer approaches are seen critically by those who demand a more strict assessment of outcomes and safety. An international panel of expert gathered at the 2014 American College of Surgeons Meeting with the goal of providing an evidence-based understanding of the real value of these approaches in gastrointestinal surgery. The panel has compared the efficacy and safety of most established approaches to gastrointestinal diseases to those of new treatment modalities: peroral esophageal myotomy vs. laparoscopic myotomy for achalasia, transgastric vs. transvaginal approach, and single-incision vs. multi-port access minimally invasive surgery. The panel found that (1) the outcome of these new approaches was not superior to that of established surgical procedures; (2) the new approaches are generally performed in few highly specialized centers; and (3) transgastric and transvaginal approaches might be safe and feasible in very experienced hands, but cost, training, operative time, and tools seem to limit their application for the treatment of common procedures such as cholecystectomy and appendectomy. Because the expected advantages of new approaches have yet to be proven in controlled trials, new approaches should be considered for adoption into practice only after thorough analyses of their efficacy and effectiveness and appropriate training.

Laparoscopic cholecystectomy versus minilaparotomy in cholelithiasis: systematic review and meta-analysis

Introduction

A introdução da técnica laparoscópica em 1985 foi um fator importante na colecistectomia por representar técnica menos invasiva, resultado estético melhor e menor risco cirúrgico comparado ao procedimento laparotômico.

Aim

To compare laparoscopic and minilaparotomy cholecystectomy in the treatment of cholelithiasis.

Methods

A systematic review of randomized clinical trials, which included studies from four databases (Medline, Embase, Cochrane and Lilacs) was performed. The keywords used were "Cholecystectomy", "Cholecystectomy, Laparoscopic" and "Laparotomy". The methodological quality of primary studies was assessed by the Grade system.

Results

Ten randomized controlled trials were included, totaling 2043 patients, 1020 in Laparoscopy group and 1023 in Minilaparotomy group. Laparoscopic cholecystectomy dispensed shorter length of hospital stay (p<0.00001) and return to work activities (p<0.00001) compared to minilaparotomy, and the minilaparotomy shorter operative time (p<0.00001) compared to laparoscopy. Laparoscopy decrease the risk of postoperative pain (NNT=7) and infectious complications (NNT=50). There was no statistical difference between the two groups regarding conversion (p=0,06) and surgical reinterventions (p=0,27), gall bladder's perforation (p=0,98), incidence of common bile duct injury (p=1.00), surgical site infection (p=0,52) and paralytic ileus (p=0,22).

Conclusion

In cholelithiasis, laparoscopic cholecystectomy is associated with a lower incidence of postoperative pain and infectious complications, as well as shorter length of hospital stay and time to return to work activities compared to minilaparotomy cholecystectomy.

Transvaginal/transumbilical hybrid--NOTES--versus 3-trocar needlescopic cholecystectomy: short-term results of a randomized clinical trial

In a randomized clinical trial, needlescopic 3-trocar cholecystectomy was compared with transvaginal/transumbilical hybrid—NOTES—technique for symptomatic cholecystolithiasis. We found significantly less pain despite less analgesics, increased satisfaction with the aesthetic result, and improved postoperative quality of life in the NOTES group. Furthermore, both techniques were equal in terms of safety.

Objective:

For cholecystectomy, both the needlescopic cholecystectomy (NC) 3-trocar technique using 2 to 3 mm trocars and the umbilical-assisted transvaginal cholecystectomy (TVC) technique have found their way into clinical routine. This study compares these 2 techniques in female patients who are in need of an elective cholecystectomy.

Background:

Natural orifice transluminal endoscopic surgery (NOTES) is a surgical concept permitting scarless intra-abdominal operations through natural orifices, such as the vagina. Because of the lack of an adequately powered trial, we designed this first randomized controlled study for the comparison of TVC and NC.

Methods:

This prospective, randomized, nonblinded, single-center trial evaluates the safety and effectiveness of TVC (intervention), compared with NC (control) in female patients with symptomatic cholecystolithiasis. The primary endpoint was intensity of pain until the morning of postoperative day (POD) 2. Secondary outcomes were among others intra- and postoperative complications, procedural time, amount of analgesics used, pain intensity until POD 10, duration of hospital stay, satisfaction with the aesthetic result, and quality of life on POD 10 as quantified with the Eypasch Gastrointestinal Quality of Life Index (GIQLI).

Results:

Between February 2010 and June 2012, 40 patients were randomly assigned to the interventional or control group. All patients completed follow-up. Procedural time, length of postoperative hospital stay, and the rate of intra- and postoperative complications were similar in the 2 groups. However, significant advantages were found for the transvaginal access regarding pain until POD 2, but also until POD 10 (P = 0.043 vs P = 0.010) despite significantly less use of peripheral analgesics (P = 0.019). In the TVC group, patients were significantly more satisfied with the aesthetic result (P < 0.001) and had a significantly better GIQLI (P = 0.028).

Conclusions:

Although comparable in terms of safety, TVC caused less pain, increased satisfaction with the aesthetic result, and improved postoperative quality of life in the short term.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

A comparative study of laparoscopic vs. open distal pancreatectomy for left-sided ductal adenocarcinoma: a propensity score-matched analysis

BACKGROUND

Although laparoscopic surgery has many advantages, its application in pancreatic ductal adenocarcinoma has not been sufficiently studied. The objective of this study was to compare the surgical outcomes of laparoscopic distal pancreatectomy (LDP) to those of open distal pancreatectomy (ODP) for left-sided ductal adenocarcinoma.

STUDY DESIGN

Among 167 consecutive patients between December 2006 and August 2013, 150 patients were included. Unmatched and propensity score-matched analyses were performed to compare the primary (oncologic adequacy) and secondary outcomes (hospital course and complications) between ODP and LDP groups.

RESULTS

In unmatched patients, LDP was associated with an earlier return to diet and a shorter hospital stay compared with ODP. The 5-year survival rates were 27.6% in unmatched ODP (n = 80) and 32.5% in unmatched LDP (n = 70). Fifty-one patients from each group were selected by propensity score matching. In this matched patient comparison, LDP was again associated significantly with a shorter median postoperative time to restarting diet and a shorter hospital stay. The 2 groups did not differ significantly in terms of primary outcomes of operative time, number of harvested lymph nodes, resection margin status, and secondary outcomes of frequency of pancreatic fistula and complications. The 2 groups also had comparable patient survival (p = 0.91).

CONCLUSIONS

This large single-center study of laparoscopic surgery for left-sided pancreatic ductal adenocarcinoma indicated that LDP was safe and more efficacious than OPD after propensity score adjustment for presurgical variables of return to diet and length of stay.

A prospective, randomized multicenter study comparing conventional laparoscopic cholecystectomy versus minilaparotomy cholecystectomy with ultrasonic dissection as day surgery procedure--1-year outcome

OBJECTIVE

The long-term outcome between laparoscopic cholecystectomy (LC) and minilaparotomy cholecystectomy (MC) with ultrasonic dissection (UsD) technique has not been compared in randomized trials. Therefore, we investigated the outcome after conventional LC and MC with UsD in 78 patients (ClinicalTrials.gov Identifier: NCT0172340).

MATERIAL AND METHODS

Initially 88 patients with non-complicated symptomatic gallstone disease were randomized into MC (n = 44) or LC (n = 44) over a period of 2 years (2010-2012) and 78 of them (89%) were reached for a follow-up interview at 12 months after the surgery.

RESULTS

Baseline parameters were similar in the two groups, and 1/44 MCs and 2/44 LCs were converted to open laparotomy. The prevalence of chronic post-surgical pain (CPSP) one year after the procedure was quite similar in the two groups: 3/36 (8%) in the MC group and 2/42 (5%) in the LC group (p = 0.502). Residual abdominal symptoms were common, but the proportion was similar in both groups (28% in MC and 33% in LC group, p = 0.665). Both groups were very satisfied with the cosmetic outcome (numeric rating scale, p = 0.470). The Quality of life (QoL) improved 34/36 (94%) in the MC group and 33/42 (79%) in the LC group (p = 0.046) and all patients in both groups were satisfied with the operation overall.

CONCLUSION

Day-case MC and LC patients have a quite similar one-year outcome with no significant difference regarding residual abdominal symptoms, cosmetic satisfaction, QoL or CPSP.

Is gynaecological laparoscopic surgery safe for elderly women? A comparison study

The aim of this study was to evaluate the efficacy and safety of gynaecological laparoscopic surgery in an elderly group, by comparing the operative outcomes of the elderly group with those of the younger group. We analysed retrospective data of 121 women who underwent laparoscopic surgery for benign gynaecological disease. Women aged > 60 years were compared with women aged between 30 and 50 years who had the same operation. We evaluated body mass index, comorbidities, number of previous abdominal surgeries, operating time, haemoglobin change, postoperative complications, hospital stay and return of bowel activity. There were no significant differences between the elderly and a matched younger group in number of previous abdominal surgeries, operating time, ASA score distribution, changes in haemoglobin level, hospital stay and postoperative complications (p > 0.05). Laparoscopic surgery can be safely performed in elderly patients with benign gynaecological disease, and surgeons should not hesitate to perform laparoscopic surgery in elderly patients.

Evaluation of the health-related quality of life for patients following laparoscopic cholecystectomy

PURPOSE

Laparoscopic cholecystectomy (LC) has become the standard procedure, and contributes to a shorter hospital stay. However, there have been no reports regarding when the patients can be discharged in terms of their health-related quality of life (HRQOL).

METHODS

The HRQOL was evaluated by using the SF-8 health survey (SF-8) 24-hour version in 127 consecutive patients treated from May 2007 to December 2008. The HRQOL and a visual analogue scale (VAS) score were assessed on the day before surgery and on postoperative day (POD) 1, POD2 and POD7.

RESULTS

All scores of the eight domains on POD1 were significantly decreased compared to the preoperative score (P < 0.05), and seven scores were still decreased on POD2, with the mental health (MH) domain showing an improvement. On POD7, the general health score improved to the preoperative level. The physical component summary 8 (PCS-8) was suppressed for all 7 days after LC. The mental health component summary 8 (MCS-8) was improved to the preoperative level on POD2, despite the significant suppression observed on POD1 (P < 0.05). The VAS score was higher in the low PCS-8 (PCS-8 < 42.4) and low MCS-8 (MCS-8 < 40.6) patients than in the high PCS-8 and high MCS-8 patients.

CONCLUSION

The HRQOL score demonstrated the improvement of the MCS-8 on POD2, which might suggest that a discharge of LC patients is appropriate on POD2 in terms of the patients' point of view.