Safety profile and outcomes of intraoperative ultrasound-guided remnant cholecystectomy

INTRODUCTION

Subtotal cholecystectomy (STC) is a safe approach in difficult cholecystectomies to prevent bile duct and vascular injury. However, the gallbladder remnant can become symptomatic, necessitating further surgical intervention. This study evaluates the safety profile and perioperative outcomes of remnant cholecystectomy (RC) performed under intraoperative ultrasound guidance.

METHODS

We retrospectively reviewed the records of all patients that underwent RC under intraoperative ultrasound guidance in 2009 and 2019. Pre-, intra- and postoperative details of patients who underwent RC were obtained from patients' electronic and paper copy records.

RESULTS

Ninety-seven patients underwent STC during the study period. Of this cohort, 16 patients (16.5%) presented with symptomatic gallbladder remnant over a median follow-up period of 14 months (interquartile range [IQR] 2-26). The median age was 64 years (IQR 54-69) with an equal male-to-female distribution. The median body mass index was 31kg/m2 (IQR 28-33). Twelve of 16 patients (75%) then proceeded to elective RC. Intraoperative ultrasound was used in all cases to identify the location of the remnant gallbladder and biliary anatomy. The median operative time was 88min (IQR 80-96), with 67% completed laparoscopically. No patients suffered bile duct injury. The median hospital stay was 3 days (IQR 1-5). During the follow-up period, eight patients (67%) reported symptom resolution.

CONCLUSIONS

RC is a safe operation that can be performed laparoscopically even after previous open subtotal cholecystectomy. We recommend the routine use of intraoperative ultrasound as an adjunct for identifying remnant gallbladder and biliary anatomy in all patients.

Subtotal cholecystectomy: is it a safe option for difficult gall bladders?

INTRODUCTION

Subtotal cholecystectomy (STC) is an alternative to total cholecystectomy (TC) in patients with severe inflammation/adhesions around the hepatocystic triangle. This study aimed to evaluate the safety profile of STC.

METHODS

We retrospectively reviewed all patients who had STC at our unit between February 2009 and August 2019. STC was divided into two types, reconstituting (R-STC) and fenestrating (F-STC), depending on whether the gall bladder remnant was closed or left open. Patients who had cholecystectomy for gall bladder malignancy or as part of another operation were excluded from the study.

RESULTS

A total of 5,664 patients underwent cholecystectomy during the study period. Of these, 97 (1.7%) underwent STC. The laparoscopic to open conversion rate was high at 48.8% (47 cases), as was the overall postoperative complication rate (45.4%, 44 cases). No patient suffered iatrogenic bile duct injury. Nineteen patients (19.6%) suffered postoperative bile leak. This was significantly higher in patients who had STC in the acute setting (41% vs 13% for elective STC cases; p=0.04). There was no significant difference in rate of bile leak or other complications between R-STC and F-STC types. The 90-day readmission rate was 8.2% (8 cases). No mortalities were recorded within 90 days post STC.

CONCLUSIONS

STC seems to be an effective technique to avoid bile duct injury in difficult cholecystectomy cases. However, the perioperative morbidity associated with STC is relatively high. Surgeons should be aware of the risks of STC and take appropriate steps to minimise them.

Contemporary surgical treatment of primary hyperparathyroidism without intraoperative parathyroid hormone measurement

INTRODUCTION

Primary hyperparathyroidism (pHPT) is usually the result of a single adenoma that can often be accurately located preoperatively and excised by a focused operation. Intraoperative parathyroid hormone (IOPTH) measurement is used occasionally to detect additional abnormal glands. However, it remains controversial as to whether IOPTH monitoring is necessary. This study presents the results of a large series of focused parathyroidectomy without IOPTH measurement.

METHODS

Data from 2003 to 2014 were collected on 180 consecutive patients who underwent surgical treatment for pHPT by a single surgeon. Preoperative ultrasonography and sestamibi imaging was performed routinely, with computed tomography (CT) and/or selective venous sampling in selected cases. The preferred procedure for single gland disease was a focused lateral approach guided by on-table surgeon performed ultrasonography. Frozen section was used selectively and surgical cure was defined as normocalcaemia at the six-month follow-up appointment.

RESULTS

Focused surgery was undertaken in 146 patients (81%) and 97% of these cases had concordant results with two imaging modalities. In all cases, an abnormal gland was discovered at the predetermined site. Of the 146 patients, 132 underwent a focused lateral approach (11 of which were converted to a collar incision), 10 required a collar incision and 4 underwent a mini-sternotomy. At 6 months following surgery, 142 patients were normocalcaemic (97% primary cure rate). Three of the four treatment failures had subsequent surgery and are now biochemically cured. There were no complications or cases of persistent hypocalcaemia.

CONCLUSIONS

This study provides further evidence that in the presence of concordant preoperative imaging, IOPTH measurement can be safely omitted when performing focused parathyroidectomy for most cases of pHPT.

The impact of virtual crossmatching in the shortening of cold ischaemic times in renal transplantation

Affiliated to the Association of Surgeons in Training and the British Transplantation Society, the Carrel Club is the transplant trainee surgical society. The Carrel Club held a joint meeting with the Chapter of Transplant Surgeons, a subsidiary organisation of the British Transplantation Society, at the Manchester Hilton Hotel on 31 January and 1 February 2013. As part of the meeting, ten abstracts were presented. A selection is printed below. The winner of the Best Presentation award was Mr Mownah.

A new technique for assessing renal transplant perfusion preoperatively using contrast-enhanced ultrasound (CEUS) and three-dimensional ultrasound (3DUS)--a porcine model pilot study

PURPOSE

This pilot study aims to assess the viability of using contrast-enhanced ultrasound (CEUS) in renal grafts while they are on hypothermic perfusion machines prior to transplantation. We assessed the vascularity and renal perfusion of machine-perfused porcine kidneys (Maastricht category II) using CEUS.

MATERIALS AND METHODS

Five kidneys were placed on hypothermic machine perfusion for up to 24 hours after retrieval. The kidneys were then scanned with a low MI contrast-specific preset and a bolus of 0.5 ml of Sonovue contrast agent was administered. Contrast-specific ultrasound images of the kidney were acquired in 2D and 3D.

RESULTS

The five kidneys demonstrated variable flow rates on the perfusion machine (10 - 37 ml/min at 30 mmHg). The CEUS technique demonstrated good perfusion and flow patterns, similar to those seen in vivo, in four kidneys. One kidney had patent arteries up to the interlobar region but no contrast filling in the cortex or medulla. Small perfusion defects were seen in two of the perfused kidneys.

CONCLUSION

CEUS appears to be a viable technique for assessing global perfusion and small defects within kidneys prior to transplantation. The flow patterns seen in vitro appear to correspond to those seen in vivo. Further work is required to evaluate the relevance of the flow dynamics measured.