Three-arm robotic cholecystectomy: a novel, cost-effective method of delivering and learning robotic surgery in upper GI surgery

Cholecystectomy is one of the commonest performed surgeries worldwide. With the introduction of robotic surgery, the numbers of robot-assisted cholecystectomies has risen over the past decade. Despite the proven use of this procedure as a training operation for those surgeons adopting robotics, the consumable cost of routine robotic cholecystectomy can be difficult to justify in the absence of evidence favouring or disputing this approach. Here, we describe a novel method for performing a robot-assisted cholecystectomy using a "three-arm" technique on the newer, 4th generation, da Vinci system. Whilst maintaining the ability to perform precision dissection, this method reduces the consumable cost by 46%. The initial series of 109 procedures proves this procedure to be safe, feasible, trainable and time efficient.

Laparoscopic subtotal cholecystectomy for the difficult gallbladder: Evolution of technique at a single teaching hospital

BACKGROUND

We have developed an algorithmic approach to laparoscopic cholecystectomy, including subtotal cholecystectomy, as a bailout strategy when the Critical View of Safety cannot be safely achieved due to significant inflammation and fibrosis of the hepatocystic triangle.

METHODS

This is a retrospective cohort study comparing postoperative outcomes in patients with severe cholecystitis who underwent laparoscopic cholecystectomy or laparoscopic subtotal cholecystectomy at St. Joseph's Health Centre from May 2016 to July 2021, as well as against a historical cohort. We further stratified laparoscopic subtotal cholecystectomy cases based on fenestrating or reconstituting subtype.

RESULTS

The cohort included a total of 105 patients who underwent laparoscopic cholecystectomy and 31 patients who underwent laparoscopic subtotal cholecystectomy. Bile leaks (25.8% vs 1.0%, relative risk 3.5, 95% confidence interval 3.5-208.4) were more common in the laparoscopic subtotal cholecystectomy group. Postoperative endoscopic retrograde cholangiopancreatography (22.6% vs 3.8%, relative risk 5.9, 95% confidence interval 1.9-18.9) and biliary stent insertion (19.4% vs 1.0%, relative risk 20.3, 95% confidence interval 2.5-162.5) were also more common in the laparoscopic subtotal cholecystectomy group. Bile leaks in laparoscopic subtotal cholecystectomy were only documented in the fenestration subtype, most of which were successfully managed with endoscopic retrograde cholangiopancreatography and biliary stenting. Compared to our previous study of laparoscopic cholecystectomy and subtotal cholecystectomy for severe cholecystitis between 2010 and 2016, there has been a decrease in postoperative laparoscopic cholecystectomy complications, subtotal cholecystectomy cases, and no bile duct injuries.

CONCLUSION

Following our algorithmic approach to safe laparoscopic cholecystectomy has helped to prevent bile duct injury. Laparoscopic cholecystectomy remains the gold standard for the management of severe cholecystitis; however, in extreme cases, laparoscopic subtotal cholecystectomy is a safe bailout strategy with manageable morbidity.

[Can laparoscopic surgery be the preferred strategy for gallbladder cancer?]

Gallbladder cancer, notoriously known for its high malignancy, predominantly requires radical surgery as the treatment of choice. Although laparoscopic techniques have become increasingly prevalent in abdominal surgeries in recent years, the progress of laparoscopic techniques in gallbladder cancer is relatively slow. Due to the anatomical complexity, technical difficulty, and biological features of gallbladder cancer that is prone to metastasis and dissemination, traditional open surgery is still the main surgical approach. This study aims to reappraisal the current state of laparoscopic surgery for gallbladder cancer by appraising clinical practice and research evidence. Laparoscopic surgery for various stages of gallbladder cancer, including early, advanced, incidental, and unresectable gallbladder cancer were discussed. The promise and limitations of laparoscopic techniques are systematically explored.

Application of 3-Step Laparoscopic Cholecystectomy in Acute Difficult Cholecystitis

BACKGROUND

With the aging of the global population, the incidence rate of acute cholecystitis is increasing. Laparoscopic cholecystectomy is considered as the first choice to treat acute cholecystitis. How to effectively avoid serious intraoperative complications such as bile duct and blood vessel injury is still a difficult problem that puzzles surgeons. This paper introduces the application of laparoscopic cholecystectomy, a new surgical concept, in acute difficult cholecystitis.

METHODS

This retrospective analysis was carried out from January 2019 to January 2021. A total of 36 patients with acute difficult cholecystitis underwent 3-step laparoscopic cholecystectomy. The general information, clinical features, surgical methods, surgical results, and postoperative complications of the patients were analyzed.

RESULTS

All patients successfully completed the surgery, one of them was converted to laparotomy, and the other 35 cases were treated with 3-step laparoscopic cholecystectomy. Postoperative bile leakage occurred in 2 cases (5.56%), secondary choledocholithiasis in 1 case (2.78%), and hepatic effusion in 1 case (2.78%). No postoperative bleeding, septal infection, and other complications occurred, and no postoperative colon injury, gastroduodenal injury, liver injury, bile duct injury, vascular injury, and other surgery-related complications occurred. All 36 patients were discharged from hospital after successful recovery. No one died 30 days after surgery, and there was no abnormality in outpatient follow-up for 3 months after surgery.

CONCLUSIONS

Three-step laparoscopic cholecystectomy seems to be safer and more feasible for acute difficult cholecystitis patients. Compared with traditional laparoscopic cholecystectomy or partial cholecystectomy, 3-step laparoscopic cholecystectomy has the advantages of safe surgery and less complications, which is worth trying by clinicians.

Elective Cholecystectomy After Endoscopic Gallbladder Stenting for Acute Cholecystitis: A Propensity Score Matching Analysis

OBJECTIVE

To investigate the influence of endoscopic gallbladder stenting (EGBS) on subsequent cholecystectomy. We retrospectively compared the surgical outcomes of EGBS, followed by elective cholecystectomy with those of immediate cholecystectomy (IC).

PATIENTS AND METHODS

A total of 503 patients were included in this study. Patients who underwent EGBS as initial treatment for acute cholecystitis, followed by elective cholecystectomy, were included in the EGBS group and patients who underwent IC during hospitalization were included in the IC group. Propensity score matching analysis was used to compare the surgical outcomes. In addition, the factors that increased the amount of bleeding were examined by multivariate analysis after matching.

RESULTS

Fifty-seven matched pairs were obtained after propensity matching the EGBS group and the IC group. The rate of laparoscopic cholecystectomy in the EGBS versus IC groups was 91.2% versus 49.1% ( P < 0.001). The amount of bleeding was 5 mL in the EGBS versus 188 mL in the IC group ( P < 0.001). In the EGBS and IC groups, multivariate analysis of factors associated with more blood loss revealed IC (odds ratio: 4.76, 95% CI: 1.25-20.76, P = 0.022) as an independent risk factor.

CONCLUSION

EGBS as the initial treatment for acute cholecystitis and subsequent elective cholecystectomy after the inflammation has disappeared can be performed in minimally invasive procedures and safely.

Operative efficiency: a comparative analysis of Versius and da Vinci robotic systems in abdominal surgery

Robotic-assisted surgery has gained momentum in the pursuit of improved minimally invasive procedures. The adoption of new robotic platforms, such as the Versius, raises concerns about safety, efficacy, and learning curves. This study compares the Versius to the well-established da Vinci in terms of operative time and patient population. Retrospective data collection was conducted on patient data from inguinal hernia surgery, ventral hernia surgery, and cholecystectomies performed between February 2022 and March 2023 at the American Hospital of Dubai. Only experienced cases were included, ensuring proficiency with robotic technology. Versius had longer procedure times in inguinal and ventral hernia surgeries but not in cholecystectomy. No intraoperative complications were observed in either system. This study demonstrates that Versius can provide comparable outcomes to the da Vinci in abdominal surgery, with no observed intraoperative complications.

BILE DUCT INJURY REPAIR IN A PATIENT WITH SITUS INVERSUS TOTALIS

BACKGROUND

Bile duct injury (BDI) causes significant sequelae for the patient in terms of morbidity, mortality, and long-term quality of life, and should be managed in centers with expertise. Anatomical variants may contribute to a higher risk of BDI during cholecystectomy.

AIMS

To report a case of bile duct injury in a patient with situs inversus totalis.

METHODS

A 42-year-old female patient with a previous history of situs inversus totalis and a BDI was initially operated on simultaneously to the lesion ten years ago by a non-specialized surgeon. She was referred to a specialized center due to recurrent episodes of cholangitis and a cholestatic laboratory pattern. Cholangioresonance revealed a severe anastomotic stricture. Due to her young age and recurrent cholangitis, she was submitted to a redo hepaticojejunostomy with the Hepp-Couinaud technique. To the best of our knowledge, this is the first report of BDI repair in a patient with situs inversus totalis.

RESULTS

The previous hepaticojejunostomy was undone and remade with the Hepp-Couinaud technique high in the hilar plate with a wide opening in the hepatic confluence of the bile ducts towards the left hepatic duct. The previous Roux limb was maintained. Postoperative recovery was uneventful, the drain was removed on the seventh post-operative day, and the patient is now asymptomatic, with normal bilirubin and canalicular enzymes, and no further episodes of cholestasis or cholangitis.

CONCLUSIONS

Anatomical variants may increase the difficulty of both cholecystectomy and BDI repair. BDI repair should be performed in a specialized center by formal hepato-pancreato-biliary surgeons to assure a safe perioperative management and a good long-term outcome.

Subtotal vs total cholecystectomy for difficult gallbladders: A systematic review and meta-analysis

INTRODUCTION

With severely inflamed gallbladders, laparoscopic cholecystectomy can be difficult and may require procedures like subtotal cholecystectomy (SC). Few studies exist comparing SC and total cholecystectomy (TC) in the setting of severe biliary inflammation. This meta-analysis aims to compare SC and TC for difficult gallbladders.

METHODS

Medline-OVID, Embase-OVID, and Cinahl were searched including only studies comparing SC to TC for difficult gallbladders. Primary outcome was CBD injury. Secondary outcomes included bile leak, duodenal injury, retained stone, bleeding, intraabdominal collection, wound infection, reoperation, and mortality.

RESULTS

Ten studies were included. Compared to TC, SC significantly lowered the risk for CBD injury (0 ​% vs. 1.6 ​%, RR 0.30, 95%CI 0.10-0.87) but increased risk of bile leaks (RR 3.5, 95%CI 1.79-6.84), postoperative ERCP (RR 2.86, 95%CI 1.53-5.35), intraabdominal collections (RR 2.55, 95%CI 1.32-4.93), and reoperation (RR 2.92, 95%CI 1.14-7.47).

CONCLUSION

SC is a reasonable alternative to difficult gallbladders that may decrease the risk of CBD injuries. Knowing both approaches is crucial to manage the difficult gallbladder while minimizing harm. Further studies are needed to understand the value of SC for difficult cholecystectomy.

[Expert consensus on the laparoscopic radical resection of gallbladder cancer(2023)]

The incidence of gallbladder cancer has been increasing. Radial resection is still the most promising curable treatment for patients with gallbladder cancer. Although the techniques required for laparoscopic radical resection of gallbladder cancer have matured, the number of reports is also on the rise, and laparoscopic radical resection of gallbladder cancer is still controversial. To standardize laparoscopic radical resection of gallbladder cancer, the Biliary Surgery Branch, Chinese Society of Surgery, Chinese Medical Association, together with the Chinese Medical Doctor Association in Chinese Committee of Biliary Surgeons, gathered experts to formulate recommendations and consensus on laparoscopic radical resection of gallbladder cancer. This consensus includes several parts: safety, preoperative evaluation, indications, surgical team, positioning of patient and trocars, intraoperative frozen examination, lymph node dissection, liver resection,bile duct resection, etc. Furthermore, suggestions on the principle of treatment, surgical procedures, and precautions were also provided for patients with delayed diagnoses of gallbladder cancer undergoing resection. This consensus aims to offer valuable suggestions for the standardization of laparoscopic radical resection of gallbladder cancer.

Full robotic cholecystectomy: first worldwide experiences with HUGO RAS surgical platform

BACKGROUND

The Hugo RAS™ system (Medtronic, Minneapolis, MN, USA), approved for gynaecological and urological procedures, has been recently certified for the use in few general surgeries. Only bariatric and colorectal procedures have been described so far.

METHODS

Here, we report the first worldwide experience with three cases of full-robotic cholecystectomies with the Hugo RAS™ system.

RESULTS

A description of the operative room setup, of the docking angles and details of the procedures is reported. Docking time was 12, 10, and 6 min, respectively. The total operative time was 105 min in the first case, 100 min in the second and 88 in the third case. Intra- and post-operative courses were uneventful.

CONCLUSIONS

With this pre-defined set up, the innovative conformation of Hugo RAS™ system can safely allow performing full robotic cholecystectomy avoiding the need for additional ports.

A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation?

INTRODUCTION

Laparoscopic subtotal cholecystectomy (LSTC) is a bailout procedure that is undertaken when it is not safe to proceed with a laparoscopic total cholecystectomy owing to dense adhesions in Calot's triangle. The main aim of this review was to investigate the early (≤30 days) and late (>30 days) morbidity and mortality of LSTC.

METHODS

A literature search of the PubMed® (MEDLINE®), Google Scholar™ and Embase® databases was conducted to identify all studies on LSTC published between 1985 and December 2020. A systematic review was then performed.

RESULTS

Overall, 45 studies involving 2,166 subtotal cholecystectomy patients (51% female) were identified for inclusion in the review. The mean patient age was 55 years (standard deviation: 15 years). Just over half (53%) of the patients had an elective procedure. The conversion rate was 6.2% (n=135). The most common indication was acute cholecystitis (49%). Different techniques were used, with the majority having a closed cystic duct/gallbladder stump (71%). The most common closure technique was intracorporeal suturing (53%), followed by endoloop closure (15%). Four patients (0.18%) died within thirty days of surgery. Morbidity within 30 days included bile duct injury (0.23%), bile leak (18%) and intra-abdominal collection (4%). Reoperation was reported in 23 patients (1.2%), most commonly for unresolving intra-abdominal collections and failed endoscopic retrograde cholangiopancreatography to control bile leak. Long-term follow-up was reported in 30 studies, the median follow-up duration being 22 months. Late morbidity included incisional hernias (6%), symptomatic gallstones (4%) and common bile duct stones (2%), with 2% of cases requiring completion of cholecystectomy.

CONCLUSIONS

LSTC is an acceptable alternative in patients with a "difficult" Calot's triangle.

Acute cholecystitis: how to avoid subtotal cholecystectomy-preliminary results

BACKGROUND

The aim of this manuscript is to illustrate a new method permitting safe cholecystectomy in terms of complications with respect to the common bile duct (CBD).

METHODS

The core of this new technique is identification of the continuity of the cystic duct with the infundibulum. The cystic duct can be identified between the inner gallbladder wall and inflamed outer wall.

RESULTS

In the last 2 years, from January 2019 until December 2021, 3 patients have been treated with the reported technique without complications.

CONCLUSIONS

Among the various cholecystectomy procedures, this is a new approach that ensures the safety of the structures of Calot's triangle while providing the advantages gained from total removal of the gallbladder.

Retrospective multi-center study of robotic-assisted cholecystectomy: after-hours surgery and business-hours surgery outcomes

The effect of robotic-assisted cholecystectomy (RAC), when performed after hours, on perioperative outcomes has not been evaluated against outcomes achieved during normal business hours. Subjects 18-80 years old who underwent da Vinci robotic-assisted cholecystectomy from August 2018 to February 2021 were included. Baseline and 30-day perioperative outcomes were retrospectively and consecutively collected and analyzed. Inverse probability treatment weighting (IPTW) was performed to balance patient characteristics between groups. A weighted comparative analysis was followed. Outcomes from 505 patients (after hours, n = 169; business hours, n = 336) undergoing RAC across 5 U.S. medical institutions were analyzed. The higher rates of acute cholecystitis and gallbladder inflammation, gangrene, and intraoperative abnormalities in the after-hours group were associated with higher rates of urgent cases and longer operative times-but not increased complication rates-compared to the business-hours group. There were no significant differences in rates of intraoperative or postoperative complications, readmissions, or reoperations. Integrated da Vinci Firefly fluorescence imaging system was used extensively, and the critical view of safety was achieved in > 96% of cases in both groups. No conversions occurred in the after-hours group compared to four conversions in the business-hours group (p = 0.0266). After-hours patients had shorter outpatient lengths of stay. No mortalities were reported for either group (p = 0.0139). After-hours RAC with integrated da Vinci Firefly imaging performed by surgeons experienced in RAC is associated with similar or improved outcomes than the same procedures during business hours in terms of complications, conversions, readmissions, reoperations, and length of stay. ClinicalTrials.gov identifier: NCT04551820; August 5, 2020.

Laparoscopic-Assisted Transvaginal Cholecystectomy - the US Military Experience With Long-Term Follow Up

Objectives

We present our initial clinical experience applying Natural Orifice Transluminal Endoscopic Surgical (NOTES) technique to perform cholecystectomy in ten patients at a military institution.

Methods

A posterior colpotomy was created to accommodate a single site working port used to facilitate dissection and gallbladder mobilization under direct visualization via an infraumbilical port. The specimen was retrieved through the vagina and the colpotomy was closed with absorbable suture under direct visualization. Long-term follow up was performed over the phone to assess quality of life with 2 widely used health-related quality of life (HRQoL) surveys including RAND-36 Health Item Survey (Version 1.0),1 and the Female Sexual Function Index (FSFI).2.

Results

Ten women underwent a laparoscopic-assisted transvaginal cholecystectomy (TVC) with 7 available for long-term follow-up. The average age was 28.9 years (20-37) and the indications for surgery included symptomatic cholelithiasis (9) and biliary dyskinesia (1). The mean operative time was 129 mins (95-180), and median blood loss was 34 ml (5-400). There were no conversions and the average length of stay was 9.98 hours (2.4-28.8). Pain (analogue scale 1-10) on postoperative day three was minimal (mean 2.3) and was limited to the infraumbilical incision. On average patients returned to work by postoperative day six and resumed normal daily activities at seven days. Immediate postoperative complications included one incident of postoperative urinary retention requiring bladder catheterization. One intra-operative cholangiogram was successfully performed due to elevated preoperative liver enzymes without significant findings. Long-term complications included one asymptomatic incisional hernia repair at the infraumbilical port site. The RAND-36 survey demonstrated an average physical and mental health summary score of 82.2 and 63.7 with an average general health score of 63.6. The average FSFI total score was 21.8.

Conclusion

TVC is safe and effective. Implementation may improve operational readiness by returning service members to normal activities more expeditiously than conventional laparoscopy.

Meta-analysis of fenestrating versus reconstituting subtotal cholecystectomy in the management of difficult gallbladder

AIMS

To evaluate comparative outcomes of fenestrating and reconstituting subtotal cholecystectomy (STC) in patients with difficult gallbladder.

METHODS

A systematic search of electronic data sources and bibliographic reference lists were conducted. All comparative studies reporting outcomes of laparoscopic fenestrating and reconstituting STC were included and their risk of bias were assessed using ROBINS-I tool.

RESULTS

Seven comparative studies were included enrolling 590 patients undergoing laparoscopic STC using either fenestrating (n = 353) or reconstituting (n = 237) approaches. Although fenestrating STC was associated with a significantly higher rate of bile leak (OR: 2.47, p = 0.007) compared to reconstituting STC, both approaches were comparable in terms of resolution of bile leak without (RD: -0.02, p = 0.86) or with (OR: 1.84, p = 0.40) postoperative ERCP. Moreover, there was no significant difference in development of bile duct injury (RD: -0.02, p = 0.16), need for postoperative ERCP (OR: 1.36, p = 0.49), wound infection (RD: 0.03, p = 0.27), re-operation (OR: 0.95, p = 0.95), gallbladder remnant cholecystitis (OR: 0.21, p = 0.09) or need for completion cholecystectomy (RD: 0.01, p = 0.59) between two groups.

CONCLUSIONS

Fenestrating STC is associated with a higher risk of bile leak than the reconstructing technique. This issue can be mitigated by routine use of drains, delayed drain removal, and in selected cases endoscopic therapy. We encourage the fenestrating approach considering trends in improved short- and long-term outcomes.

Double cholecystectomy of duplex gallbladder associated with chronic cholecystitis in a cat

A 6-year-old female neutered Persian cat presented with hyporexia and gradual weight loss over 6 months. Physical examination revealed cranial abdominal pain. Haematology and serum biochemistry were within normal limits. Abdominal ultrasonography and a computed tomography scan suggested a non-neoplastic mass compressing the gallbladder. During an exploratory laparotomy, a duplex gallbladder with two separate cystic ducts was diagnosed intraoperatively. The mass identified using the imaging techniques was an abnormal right gallbladder which was distended with immobile mucoid bile and a thickened wall. The left gallbladder and cystic duct were grossly normal. A cholecystectomy of both gallbladders was performed. Histopathology of the right gallbladder identified chronic cholecystitis. The cat made a good recovery from surgery and reported complete resolution of its hyporexia and a return to normal body weight. This is the first report of a successful cholecystectomy of a duplex gallbladder with chronic cholecystitis of a single gallbladder.

Posterior Calot's Triangle Approach First Would Be a Better Choice for Chronic Atrophic Cholecystitis: A Retrospective Controlled Study

Objective: Compare the clinical efficacy of anterior and posterior Calot's triangle approach in laparoscopic cholecystectomy (LC) for chronic atrophic cholecystitis, to find out which approach is much safer and more reliable. Patients and Methods: From June 2020 to June 2022, 102 patients with chronic atrophic cholecystitis underwent LC in our hospital. They were divided into anterior Calot's triangle approach group and posterior Calot's triangle approach group. In addition, their clinical data, intraoperative conditions, surgical results, and postoperative recovery were analyzed. Results: LC was performed in 41 females and 28 males by the anterior Calot's triangle approach, and in 20 females and 13 males by the posterior Calot's triangle approach. There were no differences in age, gender, and body mass index between the two groups (P > .05). The probability of rupture of cystic artery between both groups was not significantly different (P = .549), and the intraoperative blood loss was more in the anterior group (P = .014). The operative time of the posterior approach appeared to be shorter (P = .013). Bile duct injury and conversion to open cholecystectomy revealed no significant difference (P > .05). The recovery time of gastrointestinal function, wound infection, white blood cell count, liver function, and postoperative hospital stay time were found to be not significantly different (P > .05). Conclusion: By the posterior Calot's triangle approach, LC is a convenient and feasible surgical procedure for chronic atrophic cholecystitis with less blood loss and can become easier without increasing the risk of surgery.

Oncologic safety of robotic extended cholecystectomy for gallbladder cancer

BACKGROUND

Although laparoscopic cholecystectomy is applicable for the treatment of early gallbladder cancer (GBC), minimally invasive surgery is not widely used for advanced GBC. This is because advanced GBCs necessitate complicated surgical techniques, including lymph node dissection and liver resection. Robotic extended cholecystectomy (REC) is thought to overcome the limitations of laparoscopic surgery, but oncological safety studies are lacking. Therefore, in this study, we aimed to evaluate the oncologic outcomes of REC compared with those of open extended cholecystectomy (OEC).

METHODS

A total of 125 patients, who underwent extended cholecystectomy for GBC with tentative T2 or higher stage between 2018 and 2021, were included and stratified by surgical methods. To minimize the confounding factors, 1:1 propensity-score matching was performed between the patients who underwent REC and those who underwent OEC.

RESULTS

Regarding short-term outcomes, the REC group showed significantly lower estimated blood loss (382.7 vs. 717.2 mL, P = 0.020) and shorter hospital stay (6.9 vs. 8.5 days, P = 0.042) than the OEC group. In addition, the REC group had significantly lower subjective pain scores than the OEC group from the day of surgery through the 5th postoperative day (P = 0.006). Regarding long-term outcomes, there were no significant differences in the 3-year [5-year] overall survival (OS) and disease-free survival (DFS) rates between the REC group [OS, 92.3% (92.3%); DFS, 84.6% (72.5%)] and the OEC group [OS, 96.8% (96.8%); DFS, 78.2% (78.2%)] (P = 0.807 for OS and 0.991 for DFS).

CONCLUSIONS

In this study, REC showed superior short-term outcomes to OEC and no difference in long-term survival outcomes. Additionally, REC was superior to OEC in terms of postoperative pain. Therefore, REC may be a feasible option with early recovery compared with OEC for patients with advanced GBC.

Patient outcomes and cost in robotic emergency general surgery

The use of robotic technology in general surgery continues to increase, though its utility for emergency general surgery remains under-studied. This study explores the current trends in patient outcomes and cost of robotic emergency general surgery (REGS). The Florida Agency for Healthcare Administration database (2018-2020) was queried for adult patients undergoing intra-abdominal emergency general surgery within 24 h of admission and linked to CMS Cost Reports/Hospital Compare, American Hospital Association, and Rand Corporation Hospital datasets. Patients from the four most common REGS procedures were propensity matched to laparoscopic equivalents for hospital cost analysis. A telephone survey was performed with the top 10 REGS hospitals to identify key qualities for successful REGS programs. 181 hospitals (119 REGS, 62 non-REGS) performed 60,733 emergency surgeries. Six-percent were REGS. The most common REGS were cholecystectomy, appendectomy, inguinal and ventral hernia repairs. Before and after propensity matching, total cost for these four procedures were significantly higher than their laparoscopic equivalents, which was due to higher surgical cost as the non-operative costs did not differ. There were no differences in mortality, individual complications, or length of stay for most of the four procedures. REGS volume significantly increased each year. The survey found that 8/10 hospitals have robotic-trained staff available 24/7. Although REGS volume is increasing in Florida, cost remains significantly higher than laparoscopy. Given higher costs and lack of significantly improved outcomes, further study should be undertaken to better inform which specific patient populations would benefit from REGS.

Prognostic Effect of Liver Resection in Extended Cholecystectomy for T2 Gallbladder Cancer Revisited: A Retrospective Cohort Study With Propensity Score-matched Analysis

OBJECTIVE

This study aimed to evaluate the effect of liver resection on the prognosis of T2 gallbladder cancer (GBC).

BACKGROUND

Although extended cholecystectomy [lymph node dissection (LND) + liver resection] is recommended for T2 GBC, recent studies have shown that liver resection does not improve survival outcomes relative to LND alone.

METHODS

Patients with pT2 GBC who underwent extended cholecystectomy as an initial procedure and did not reoperation after cholecystectomy at 3 tertiary referral hospitals between January 2010 and December 2020 were analyzed. Extended cholecystectomy was defined as either LND with liver resection (LND+L group) or LND only (LND group). We conducted 2:1 propensity score matching to compare the survival outcomes of the groups.

RESULTS

Of the 197 patients enrolled, 100 patients from the LND+L group and 50 from the LND group were successfully matched. The LND+L group experienced greater estimated blood loss ( P <0.001) and a longer postoperative hospital stay ( P =0.047). There was no significant difference in the 5-year disease-free survival (DFS) of the 2 groups (82.7% vs 77.9%, respectively, P =0.376). A subgroup analysis showed that the 5-year DFS was similar in the 2 groups in both T substages (T2a: 77.8% vs 81.8%, respectively, P =0.988; T2b: 88.1% vs 71.5%, respectively, P =0.196). In a multivariable analysis, lymph node metastasis [hazard ratio (HR) 4.80, P =0.006] and perineural invasion (HR 2.61, P =0.047) were independent risk factors for DFS; liver resection was not a prognostic factor (HR 0.68, P =0.381).

CONCLUSIONS

Extended cholecystectomy including LND without liver resection may be a reasonable treatment option for selected T2 GBC patients.

Use of artificial intelligence for decision-support to avoid high-risk behaviors during laparoscopic cholecystectomy

INTRODUCTION

Bile duct injuries (BDIs) are a significant source of morbidity among patients undergoing laparoscopic cholecystectomy (LC). GoNoGoNet is an artificial intelligence (AI) algorithm that has been developed and validated to identify safe ("Go") and dangerous ("No-Go") zones of dissection during LC, with the potential to prevent BDIs through real-time intraoperative decision-support. This study evaluates GoNoGoNet's ability to predict Go/No-Go zones during LCs with BDIs.

METHODS AND PROCEDURES

Eleven LC videos with BDI (BDI group) were annotated by GoNoGoNet. All tool-tissue interactions, including the one that caused the BDI, were characterized in relation to the algorithm's predicted location of Go/No-Go zones. These were compared to another 11 LC videos with cholecystitis (control group) deemed to represent "safe cholecystectomy" by experts. The probability threshold of GoNoGoNet annotations were then modulated to determine its relationship to Go/No-Go predictions. Data is shown as % difference [99% confidence interval].

RESULTS

Compared to control, the BDI group showed significantly greater proportion of sharp dissection (+ 23.5% [20.0-27.0]), blunt dissection (+ 32.1% [27.2-37.0]), and total interactions (+ 33.6% [31.0-36.2]) outside of the Go zone. Among injury-causing interactions, 4 (36%) were in the No-Go zone, 2 (18%) were in the Go zone, and 5 (45%) were outside both zones, after maximizing the probability threshold of the Go algorithm.

CONCLUSION

AI has potential to detect unsafe dissection and prevent BDIs through real-time intraoperative decision-support. More work is needed to determine how to optimize integration of this technology into the operating room workflow and adoption by end-users.

There Is No Such Thing as Too Soon: Long-Term Outcomes of Early Cholecystectomy for Frail Geriatric Patients with Acute Biliary Pancreatitis

BACKGROUND

Early cholecystectomy (CCY) for acute biliary pancreatitis (ABP) is recommended but there is a paucity of data assessing this approach in frail geriatric patients. This study compares outcomes of frail geriatric ABP patients undergoing index admission CCY vs nonoperative management (NOM) with endoscopic retrograde cholangiopancreatography (ERCP).

STUDY DESIGN

Retrospective analysis of the Nationwide Readmissions Database (2017). All frail geriatric (65 years or older) patients with ABP were included. Patients were grouped by treatment at index admission: CCY vs NOM with endoscopic retrograde cholangiopancreatography. Propensity score matching was performed in a 1:2 ratio. Primary outcomes were 6-month readmissions, mortality, and length of stay. Secondary outcomes were 6-month failure of NOM defined as readmission for recurrent ABP, unplanned pancreas-related procedures, or unplanned CCY. Subanalysis was performed to compare outcomes of unplanned CCY vs early CCY.

RESULTS

A total of 29,130 frail geriatric patients with ABP were identified and 7,941 were matched (CCY 5,294; NOM 2,647). Patients in the CCY group had lower 6-month rates of readmission for pancreas-related complications, unplanned readmissions for pancreas-related procedures, overall readmissions, and mortality, as well as fewer hospitalized days (p < 0.05). NOM failed in 12% of patients and 7% of NOM patients were readmitted within 6 months to undergo CCY, of which 56% were unplanned. Patients who underwent unplanned CCY had higher complication rates and hospital costs, longer hospital lengths of stay, and increased mortality compared with early CCY (p < 0.05).

CONCLUSIONS

For frail geriatric patients with ABP, early CCY was associated with lower 6-month rates of complications, readmissions, mortality, and fewer hospitalized days. NOM was unsuccessful in nearly 1 of 7 within 6 months; of these, one-third required unplanned CCY. Early CCY should be prioritized for frail geriatric ABP patients when feasible.

Indications and Outcomes of Completion Cholecystectomy: A 5-year Experience From a Rural Tertiary Center

BACKGROUND

Completion cholecystectomy (CC) is performed for recurrent or persistent biliary symptoms following subtotal cholecystectomy (STC) or incomplete cholecystectomy (IC). Due to its complexity, cases are often referred to hepato-pancreato-biliary (HBP) surgeons. There is little published literature on indications or outcomes of CC.

METHODS

Completion cholecystectomy cases performed between 2016 and 2021 by the sole HPB surgeon covering a rural referral base of >250-mile radius in West Texas were included. Primary variables of interest include indications and outcomes of CC.

RESULTS

Of the eleven patients included, 5 (45.5%) had laparoscopic STC, 3 patients (27.3%) had laparoscopic converted to open STC, and 2 (18.2%) had laparoscopic IC. Most STC cases (6/9, 66.6%) were reconstituting, while 3 STC cases were fenestrating (all had persistent bile leak). For reconstituting STC, indications were symptomatic cholelithiasis in 5 patients (45.5%), and choledocholithiasis in 3 patients (27.3%). The median (IQR) duration between index procedure and subsequent CC was 15 (1.4-92) months. The median (IQR) remnant gallbladder length was 4 (3-4.5) cm. Completion cholecystectomy was performed robotically in 8 cases (72.7%). Post-CC complications occurred in 3 patients (27.3%); these were 1 superficial surgical site infection, 1 hepatic abscess requiring percutaneous drainage, and lastly atrial fibrillation.

CONCLUSIONS

All patients requiring CC had residual gallbladder remnant >2.5 cm; this is longer than recommended for STC. Completion cholecystectomy is a complex operation that carries significant morbidity, even when performed using minimally invasive techniques. As bailout procedures become more common in severely inflamed cholecystitis, it is important to collate more data on the outcomes of requiring CC.

Defining Biliary Hyperkinesia and the Role of Cholecystectomy

BACKGROUND

Functional gallbladder disorder is most commonly defined by biliary colic and low ejection fraction (EF) on cholescintigraphy. Biliary hyperkinesia is a controversial type of functional gallbladder disorder, and its definition and the role of cholecystectomy in treating functional gallbladder disorder remains unclear.

STUDY DESIGN

We conducted a retrospective review of patients who underwent cholecystokinin-stimulated cholescintigraphy and cholecystectomy at 3 Mayo Clinic sites between 2007 and 2020. Eligible patients were 18 years or older, presented with symptoms of biliary disease, had an EF greater than 50%, underwent cholecystectomy, and had no evidence of acute cholecystitis or cholelithiasis on imaging. We used receiver operating characteristics curve analysis to identify the optimal cutoff value that predicted symptom resolution within 30 days of cholecystectomy.

RESULTS

A total of 2,929 cholecystokinin-stimulated cholescintigraphy scans were performed during the study period; the average EF was 67.5% and the median EF was 77%. Analyzing those with EFs greater than or equal to 50% yielded 1,596 patients with 141 (8.8%) going on to have cholecystectomy. No significant differences were found in age, sex, BMI, final pathology between patients with and without pain resolution. Using a cutoff EF of 81% was significantly associated with pain resolution after cholecystectomy (78.2% for EF greater than or equal to 81% vs 60.0% for EF less than 81%, p = 0.03). Chronic cholecystitis was found in 61.7% of the patients on final pathology.

CONCLUSIONS

We determined that an EF cutoff of 81% is a reasonable upper limit of normal gallbladder EF. Patients with biliary symptoms and an EF greater than 81% but no evidence of biliary disease on ultrasound or scintigraphy can be classified as having biliary hyperkinesia. Based on our findings, we recommend cholecystectomy for this patient population.

Differences in Cholecystectomy Outcomes and Operating Time Between Male and Female Surgeons in Sweden

Importance

Female surgeons are still in the minority worldwide, and highlighting gender differences in surgery is important in understanding and reducing inequities within the surgical specialty. Studies on different surgical procedures indicate equal results, or safer outcomes, for female surgeons, but it is still unclear whether surgical outcomes of gallstone surgery differ between female and male surgeons.

Objective

To examine the association of the surgeon's gender with surgical outcomes and operating time in elective and acute care cholecystectomies.

Design, Setting, and Participants

A population-based cohort study based on data from the Swedish Registry of Gallstone Surgery was performed from January 1, 2006, to December 31, 2019. The sample included all registered patients undergoing cholecystectomy in Sweden during the study period. The follow-up time was 30 days. Data analysis was performed from September 1 to September 7, 2022, and updated March 24, 2023.

Exposure

The surgeon's gender.

Main Outcome(s) and Measure(s)

The association between the surgeon's gender and surgical outcomes for elective and acute care cholecystectomies was calculated with generalized estimating equations. Differences in operating time were calculated with mixed linear model analysis.

Results

A total of 150 509 patients, with 97 755 (64.9%) undergoing elective cholecystectomies and 52 754 (35.1%) undergoing acute care cholecystectomies, were operated on by 2553 surgeons, including 849 (33.3%) female surgeons and 1704 (67.7%) male surgeons. Female surgeons performed fewer cholecystectomies per year and were somewhat better represented at universities and private clinics. Patients operated on by male surgeons had more surgical complications (odds ratio [OR], 1.29; 95% CI, 1.19-1.40) and total complications (OR, 1.12; 95% CI, 1.06-1.19). Male surgeons had more bile duct injuries in elective surgery (OR, 1.69; 95% CI, 1.22-2.34), but no significant difference was apparent in acute care operations. Female surgeons had significantly longer operation times. Male surgeons converted to open surgery more often than female surgeons in acute care surgery (OR, 1.22; 95% CI, 1.04-1.43), and their patients had longer hospital stays (OR, 1.21; 95% CI, 1.11-1.31). No significant difference in 30-day mortality could be demonstrated.

Conclusions and Relevance

The results of this cohort study indicate that female surgeons have more favorable outcomes and operate more slowly than male surgeons in elective and acute care cholecystectomies. These findings may contribute to an increased understanding of gender differences within this surgical specialty.

The clinical impact of early recurrence and its recurrence patterns in patients with gallbladder carcinoma after radical resection

BACKGROUND

It is common for patients with gallbladder carcinoma (GBC) to develop recurrence shortly after radical resection. We aimed to investigate the risk factors of early recurrence (ER) and its recurrence patterns and further analyze the effect of adjuvant chemotherapy (ACT) on ER and non-ER patients for decision-making in clinical practice.

METHODS

A total of 276 patients who underwent radical resection for GBC were retrospectively analyzed. Factors associated with overall survival (OS) and recurrence free survival (RFS) were identified using the Cox proportional hazard regression model, whereas ER was investigated using univariate and multivariable logistic regression models.

RESULTS

The results indicated that 23.2% (64/276) of GBC patients developed ER after radical resection. ER was determined to be an independent risk factor for OS in patients with GBC after resection (P < 0.05). CA125, liver invasion, T stage, and N stage were independently associated with ER (P < 0.05). N1/N2 stage disease was an independent risk factor for OS, RFS and ER, and had a better predictive value in identifying ER than the other three variables associated with ER (P < 0.05). The liver and lymph nodes were the main first recurrence sites, and ER patients had a higher proportion of multisite recurrence. The prognosis of GBC patients with ER after radical resection differed significantly depending on whether ACT was provided, with ACT demonstrated to improve their prognosis (P < 0.05).

CONCLUSIONS

Early recurrence after radical resection indicates a very poor prognosis in GBC and can be used to identify those who will benefit from ACT.

Retrospective analysis of operative time and time to discharge for laparoscopic vs robotic approaches to appendectomy and cholecystectomy

Robotic-assisted appendectomies and cholecystectomies are believed to increase cost compared to the gold standard laparoscopic approach. Two equally qualified surgeons performed both approaches over 2 years to evaluate intraoperative duration, time to discharge, conversion to open procedure, and readmission within 30 days. 110 laparoscopic, 81 robotic-assisted appendectomies; and 105 laparoscopic and 165 robotic-assisted cholecystectomies were performed. Intraoperative time; laparoscopic appendectomy was 1.402 vs 1.3615 h for robotic-assisted (P value = 0.304); laparoscopic cholecystectomy was 1.692 vs 1.634 h for robotic-assisted (P value = 0.196). Time to discharge, was 38.26 for laparoscopic vs 28.349 h for robotic-assisted appendectomy (P value = 0.010), and 35.95 for laparoscopic vs 28.46 h for robotic-assisted cholecystectomy (P value = 0.002). Intraoperative conversion to open; only laparoscopic procedures were converted, one appendectomy and nine cholecystectomies. None in the robotic-assisted procedures. Readmissions, none in the appendectomy group and three in the cholecystectomy group. One laparoscopic and two robotic-assisted cholecystectomy patients were readmitted. Intraoperative times for robotic appendectomy and cholecystectomy were not longer than laparoscopic approach. Robotic approach shortened the time to discharge and the likelihood for conversion to open procedure.

Comparison of Postoperative Outcomes, Costs, and Readmission Between Total and Subtotal Cholecystectomy

BACKGROUND

An increasing body of literature supports subtotal cholecystectomy (STC) in the management of patients with difficult gallbladder anatomy; however, large-scale studies examining outcomes of total cholecystectomy and STC are lacking.

METHODS

All adults undergoing total cholecystectomy or STC were tabulated from the 2016-2019 Nationwide Readmissions Database. Entropy balancing was performed to adjust for patient differences based on extent of resection. Subsequent multivariable regression models were used to assess the association of STC with major adverse events, postoperative length of stay (pLOS), hospitalization costs, and 30-day non-elective readmission rates.

RESULTS

Of an estimated 854 357 patients, 7089 (.8%) underwent STC. Compared to total, STC patients were significantly older, less commonly female, and had a higher Elixhauser Index (all P < .001). Both cohorts had similar rates of postoperative ERCP (1.7% vs 1.5%, P = .33); however, the STC cohort had significantly higher utilization of subsequent drainage procedures (1.8% vs .5%, P < .001). After entropy balancing and multivariable risk-adjustment, STC was not associated with greater odds of MAE (AOR 1.11, 95% CI .99-1.23, P = .06). Notably, relative to total, STC was associated with longer pLOS (β .14, 95% CI .11-.17, P < .001) and greater hospitalization costs (β + $1,900, 95% CI 1300-2,500, P < .001). However, the extent of resection was not associated with the likelihood of 30-day non-elective readmission (AOR 1.01, 95% CI .91-1.13, P = .86).

DISCUSSION

Our findings suggest that STC is a viable, yet resource intensive, option in the management of complex cholecystitis.

Time to interval cholecystectomy and associated outcomes in a population aged 50 and above with mild gallstone pancreatitis

BACKGROUND

Cholecystectomy on index admission for mild gallstone pancreatitis (GSP) is recommended, although not always feasible. This study examined rates and outcomes of people aged ≥ 50 years who underwent interval (delayed) cholecystectomy at increasing time points.

METHODS

Hospitalisation and death data were linked for individuals aged ≥ 50 years admitted to hospital in New South Wales, Australia with mild GSP between 2008-2018. Primary outcome was interval cholecystectomy timing. Secondary outcomes included mortality, emergency readmission for gallstone-related disease (GSRD) (28 and 180-day), and length of stay (LOS) (index admission and total six-month GSRD).

RESULTS

3,003 patients underwent interval cholecystectomy: 861 (28.6%) at 1-30, 1,221 (40.7%) at 31-90 and 921 (30.7%) at 91-365 days from index admission. There was no difference in 365-day mortality between groups. Longer delay to cholecystectomy was associated with increased 180-day emergency GSRD readmission (17.5% vs 15.8% vs 19.9%, p < 0.001) and total six-month LOS (5.9 vs 8.4 vs 8.3, p < 0.001). Endoscopic retrograde cholangiopancreatography (ERCP) was increasingly required with cholecystectomy delay (14.5% vs 16.9% vs 20.4%, p < 0.001), as were open cholecystectomy procedures (4.8% vs 7.6% vs 11.3%, p < 0.001). Extended delay was associated with patients of lower socioeconomic status, regional/rural backgrounds or who presented to a low volume or non-tertiary hospital (p < 0.001).

CONCLUSION

Delay to interval cholecystectomy results in increased rates of emergency readmission, overall LOS, risks of conversion to open surgery and need for ERCP. Index admission cholecystectomy is still recommended, however when not possible, interval cholecystectomy should be performed within 30 days to minimise patient risk and healthcare burden.

Preliminary experience with robotic cholecystectomy illustrates feasibility in a canine cadaver model

OBJECTIVE

To evaluate the feasibility and describe the relevant differences between robotic cholecystectomy (RC) and laparoscopic cholecystectomy in a canine model.

SAMPLE

Canine cadavers (n = 4) weighing between 30 and 42 kg.

METHODS

Dogs were positioned in dorsal recumbency. A surgical robot was used to perform the RC and was placed at the cranial aspect of the surgical table. One 12-mm and 3 8-mm robotic ports and 1 5-mm laparoscopic port were placed as needed to perform the RC. The specific steps of the procedure were described and timed. Perceived differences between psychomotor skills between robotics and laparoscopy were noted.

RESULTS

RC was successful in all dogs, but minor intraoperative complications did occur during the manipulation of the gallbladder in 1 dog. The median length of time for ports to be appropriately docked was 19.5 minutes, and the median procedure time was 119.5 minutes. Psychomotor skills specific to robotics can be learned during this procedure.

CLINICAL RELEVANCE

Robotic cholecystectomy is feasible. RC allowed for experience with the different psychomotor skills utilized with robotic instrumentation and may be an appropriate training procedure for veterinary surgeons wishing to gain basic experience with robotic instrumentation.

Examining the Impact of Cholecystectomy on Tumor Recurrence in Breast Cancer Patients

Previous studies have found that bile acids influence the growth of breast cancer cells in vitro, suggesting that naturally occurring bile acids may also influence the growth of human breast cancer cells. Cholecystectomy alters modulation of bile acid metabolites, and therefore postcholecystectomy women could be at an increased risk of cancer development and recurrence. This study examined the breast cancer outcome in women who underwent cholecystectomy as compared to those with intact gallbladder. Ninety-three patients diagnosed with Stage I-III invasive mammary carcinoma in 2014 were retrospectively identified and patient demographics, treatment, and outcomes were collected and statistically analyzed. Results revealed 36% of patients who underwent cholecystectomy had recurrence compared to 25% recurrence in patients with intact gallbladders (p = .30). Forty-six percent of cholecystectomy patients were deceased, and 23% of those with intact gallbladder were deceased (p = .024). The effect of cholecystectomy on bile acid modulation and breast cancer recurrence requires further investigation.

Surgical and Oncological Outcomes of Wedge Resection Versus Segment 4b + 5 Resection for T2 and T3 Gallbladder Cancer: a Meta-Analysis

BACKGROUND

Liver resection is the standard operative procedure for patients with T2 and T3 gallbladder cancers (GBC). However, the optimal extent of hepatectomy remains unclear.

METHODS

We conducted a systematic literature search and meta-analysis to assess the safety and long-term outcomes of wedge resection (WR) vs. segment 4b + 5 resection (SR) in patients with T2 and T3 GBC. We reviewed surgical outcomes (i.e., postoperative complications and bile leak) and oncological outcomes (i.e., liver metastasis, disease-free survival (DFS), and overall survival (OS)).

RESULTS

The initial search yielded 1178 records. Seven studies reported assessments of the above-mentioned outcomes in 1795 patients. WR had significantly fewer postoperative complications than SR, with an odds ratio of 0.40 (95% confidence interval, 0.26 - 0.60; p < 0.001), although there were no significant differences in bile leak between WR and SR. There were no significant differences in oncological outcomes such as liver metastases, 5-year DFS, and OS.

CONCLUSIONS

For patients with both T2 and T3 GBC, WR was superior to SR in terms of surgical outcome and comparable to SR in terms of oncological outcomes. WR that achieves margin-negative resection may be a suitable procedure for patients with both T2 and T3 GBC.

Short-term outcomes and costs analysis of robotic-assisted versus laparoscopic cholecystectomy-a retrospective single-center analysis

PURPOSE

Robotic-assisted surgery is an alternative technique for patients undergoing minimal invasive cholecystectomy (CHE). The aim of this study is to compare the outcomes and costs of laparoscopic versus robotic CHE, previously described as the major disadvantage of the robotic system, in a single Austrian tertiary center.

METHODS

A retrospective single-center analysis was carried out of all patients who underwent an elective minimally invasive cholecystectomy between January 2010 and August 2020 at our tertiary referral institution. Patients were divided into two groups: robotic-assisted CHE (RC) and laparoscopic CHE (LC) and compared according to demographic data, short-term postoperative outcomes and costs.

RESULTS

In the study period, 2088 elective minimal invasive cholecystectomies were performed. Of these, 220 patients met the inclusion criteria and were analyzed. One hundred ten (50%) patients underwent LC, and 110 patients RC. There was no significant difference in the mean operation time between both groups (RC: 60.2 min vs LC: 62.0 min; p = 0.58). Postoperative length of stay was the same in both groups (RC: 2.65 days vs LC: 2.65 days, p = 1). Overall hospital costs were slightly higher in the robotic group with a total of €2088 for RC versus €1726 for LC.

CONCLUSIONS

Robotic-assisted cholecystectomy is a safe and feasible alternative to laparoscopic cholecystectomy. Since there are no significant clinical and cost differences between the two procedures, RC is a justified operation for training the whole operation team in handling the system as a first step procedure. Prospective randomized trials are necessary to confirm these conclusions.

A practical port-sharing approach for concomitant cholecystectomy with laparoscopic sleeve gastrectomy: single-center experience

Gallbladder disease is very common in obese patients. Concomitant cholecystectomy with laparoscopic sleeve gastrectomy (CC-LSG) may be necessary in such cases, and it has been proven safe when indicated. Herein, we presented an experience of our practical four-port-sharing technique for CC-LSG that can substitute the conventional trocar placement. A cohort study was conducted between January 2017 and March 2022 using a prospective database. Out of 238 patients with obesity who underwent bariatric surgery, 45 patients with gallbladder disease received CC-LSG using our four-port-sharing technique. The patients' demographic characteristics, intraoperative outcomes, and postoperative outcomes were examined. Of 45 obese patients with gallbladder disease undergoing CC-LSG, 18 patients with symptomatic cholelithiasis, 25 patients with asymptomatic cholelithiasis, and 2 patients with gallbladder polyps were identified. The mean age of these 45 patients (26 men and 19 women) was 38.3 years, and the mean body mass index was 41.8 kg/m2. There was no case of conversion to laparotomy. The mean operative time of LC and following LSG, the volume of blood loss, and hospital stay were 52.7 minutes and 95.2 minutes, 13.3 mL, and 3.8 days, respectively. No postoperative complications, including hemorrhage, bile leakage, staple leakage, pulmonary embolism, incisional hernia, and wound infection were noted. In CC-LSG, the application of our four-port-sharing technique is safe and feasible for obese patients with gallbladder diseases.

Short- and long-term outcomes of laparoscopic radical gallbladder resection for gallbladder carcinoma: A multi-institutional retrospective study in Japan

BACKGROUND/PURPOSE

Laparoscopic resection of gallbladder carcinomas remains controversial. This study aimed to evaluate the surgical and oncological outcomes of laparoscopic procedures for suspected gallbladder carcinoma (GBC).

METHODS

In this retrospective study, data regarding suspected GBC treated with laparoscopic radical cholecystectomy before 2020 in Japan, was included. Patient characteristics, surgical procedure details, surgical outcomes, and long-term outcomes were analyzed.

RESULTS

Data of 129 patients with suspected GBC who underwent laparoscopic radical cholecystectomy were retrospectively collected from 11 institutions in Japan. Among them, 82 patients with pathological GBC were included in the study. Laparoscopic gallbladder bed resection was performed in 114 patients and laparoscopic resection of segments IVb and V was performed in 15 patients. The median operation time was 269 min (range: 83-725 min), and the median intraoperative blood loss was 30 mL (range: 0-950 mL). The conversion and postoperative complication rates were 8% and 2%, respectively. During the follow-up period, the 5-year overall survival rate was 79% and the 5-year disease-free survival rate was 87%. Recurrence was detected in the liver, lymph nodes, and other local tissues.

CONCLUSION

Laparoscopic radical cholecystectomy is a treatment option with potential favorable outcomes in selected patients with suspected GBC.

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.

Learning Curve of Single-site Robotic Cholecystectomy: A Cumulative Sum Analysis

BACKGROUND

Minimally invasive surgery has significantly improved cosmesis and clinical outcomes after either laparoscopic or robotic cholecystectomy. In an effort to minimize the number of incisions in multiport procedures, single-site approaches have been developed. However, single-site robotic cholecystectomy (SSRC) can be technically challenging for novice surgeons. The goal of this study is to establish the learning curve (LC) of SSRC through an assessment of operative times and clinical outcomes.

MATERIALS AND METHODS

A retrospective analysis of patients undergoing SSRC over a period of 5 years was performed. Consecutive cholecystectomy cases were assessed based on the procedure setting (elective vs. emergent). Cumulative sum analysis were used to establish the LC through an evaluation of the skin-to-skin (STS) time and postoperative complications rate. Afterward, a direct comparison was performed between the established phases.

RESULTS

This study included a total of 259 SSRCs with an overall mean STS time of 41.1 minutes. Elective cases took on average of 38.8 minutes, whereas emergent cases spanned over 60.5 minutes ( P= 0.005). The cumulative sum-LC was obtained by summing the differences between each procedure's STS time, revealing a quadratic best-fit line maximum and an inflection point between the early and late phases at case 91. A significant difference between STS time was seen between the early and late phases (53.8 vs. 30.0 min, P< 0.0001). There were no significant differences in terms of postoperative complications between the 2 phases. Incisional hernia rates were comparable between the 2 phases (early: 4.4% vs. late: 2.5%, P< 0.461).

CONCLUSIONS

This is the largest study to assess the LC of SSRC through operative time and clinical outcomes. A steady decrease in STS time was observed during the completion of the first 91 consecutive cases.

3D reconstruction of a gallbladder duplication to guide LC: A case report and literature review

RATIONALE

Gallbladder duplication is a congenital aberration of the biliary tree, which is rarely encountered in the abdomen. It is a challenge that can be encountered by surgeons and is associated with an increased risk of complications after cholecystectomy. More than 50% of gallbladder duplication cases were undetected on preoperative traditional imaging. In this study, a case of gallbladder duplication in a patient with mild abdominal pain detected using preoperative 3-dimensional (3D) reconstruction of the gallbladder was described for the first time.

PATIENT CONCERNS AND DIAGNOSIS

We present a case of gallbladder duplication in a 32-year-old man who was referred to our hospital for recurrent right upper quadrant abdominal pain without any other significant history.

INTERVENTIONS AND OUTCOMES

He underwent a 3D reconstruction technique as a supplement for gallbladder duplication that could not be diagnosed using magnetic resonance cholangiopancreatography or other traditional tools. Compared with other diagnostic tools, 3D reconstruction is more visual and accurate for diagnosing gallbladder duplication and guiding laparoscopic cholecystectomy without ductal injuries or other complications.

CONCLUSION

Gallbladder duplication is an extremely rare biliary anatomical anomaly; failure to recognize it perioperatively exposes the patient to an increased risk of bile duct injuries. We review 28 cases of missed gallbladder duplication and conclude that less 50% of gallbladder duplication cases were detected via preoperative traditional imaging. We present a case and find that the 3D reconstruction technique can be used as a supplement for gallbladder duplication that could not be diagnosed by using magnetic resonance cholangiopancreatography or other tools. The value of using 3D reconstruction of gallbladder duplication is feasible and innovative, and facilitates guiding to laparoscopic cholecystectomy.

A rare case of urothelial carcinoma metastasizing to the gallbladder wall with manifestations as acute cholecystitis

BACKGROUND

Metastasis to the gallbladder is very rare. This case report highlights a rare cause of acute cholecystitis, which should be considered by the surgeon and other treating physicians in the differential diagnosis of patients with urothelial carcinoma.

CASE

We report the case of a 73 year-old man with follow-up oncology care. He was diagnosed with infiltrating urothelial carcinoma in 2019, received neoadjuvant chemotherapy, and subsequently underwent radical cystectomy with ureteroileostomy in April 2020. Histology confirmed complete regression of bladder cancer, the lymphonodes were also free of tumour infiltration. In July 2021, the patient was examined for intermittent abdominal pain, predominantly of the right upper quadrant. On clinical examination, the gallbladder hydrops was palpable and a positive Murphy's sign was present. Due to the signs of acute cholecystitis, the patient was indicated for acute cholecystectomy. Gallbladder histology revealed metastatic involvement of the gallbladder wall by urothelial carcinoma.

CONCLUSION

If patients with bladder cancer present with intermittent right subcostal pain or signs of acute cholecystitis and diagnostic imaging shows a thickened gallbladder wall, clinicians and radiologists should consider the possibility of metastatic origin of lesion.

[The COVID-19 pandemic had significant impact on duration of surgery and hospitalization time for patients after cholecystectomy]

BACKGROUND

The COVID-19 pandemic made substantial changes in medical care necessary. The aims of this study were to find out what influence the pandemic had on the perioperative course in patients with cholecystectomy (CHE) and to highlight possible residual consequences.

METHOD

From 1 July 2018 to 31 December 2021 a total of 735 patients with CHE were analyzed. Up to 21 March 2020 patients were assigned to the regular patient group (Reg, n = 430), patients after this date (first lockdown 22 March 2020) to the Cov19 patient group (Cov19, n = 305) and the 2 groups were compared.

RESULTS

The average age of all patients was 59 years and 63% were women. The average length of hospitalization (KrVD, time period between surgery and discharge) was 4.4 days. The patient groups Reg and Cov19 did not differ with respect to age, gender or KrVD. The total number of CHEs carried out was reduced by 21.4% in the Cov19 group. This affected elective and emergency CHE to the same extent. The length of surgery significantly increased in the Cov19 group from 64 min (SD 34 min) to 71 min (SD 38 min). The number of short and long hospital stays (KrVD 2 or >4 days) significantly increased in the Cov19 group from 4 % to 20 % (short stay, p < 0.01) and from 23 % to 27 % (long stay, p < 0.01). This was particularly observed for patients >70 years old with an increase in long stays from 43 % to 56 % in the Cov19 group.

CONCLUSION

The COVID-19 pandemic led to a clear reduction in CHE both for elective and emergency interventions. Furthermore, a significant lengthening of the surgery and hospitalization times could be observed for older patients. The residual consequences of the pandemic could be shortened hospitalization times after uncomplicated CHE and more interventional treatment procedures in complex cases.

An Early Prospective Clinical Study to Evaluate the Safety and Performance of the Versius Surgical System in Robot-Assisted Cholecystectomy

OBJECTIVE

The aim of this study was to demonstrate the ability of the Versius Surgical System to successfully and safely complete cholecystectomy.

BACKGROUND

The system has been developed in-line with surgeon feedback to overcome limitations of conventional laparoscopy to enhance surgeon experience and patient outcomes. Here we present results from the cholecystectomy cohort from a completed early clinical trial, which was designed to broadly align with Stage 2b of the Idea, Development, Exploration, Assessment, Long-term follow-up framework for surgical innovation.

METHODS

Procedures were performed between March 2019 and September 2020 by surgical teams consisting of a lead surgeon and operating room (OR) assistants. Male or female patients aged 18 years and over and requiring cholecystectomy were enrolled. The primary endpoint was the rate of unplanned conversion from robot-assisted surgery to conventional laparoscopic or open surgery. Adverse events (AEs) and serious AEs were adjudicated by video review of the surgery and patient study reports by an independent Clinical Expert Committee.

RESULTS

Overall, 134/143 (93.7%) cholecystectomies were successfully completed using the device. Of the 9 (6.3%) conversions to another surgical modality, 7 were deemed to be related to the device. A total of 6 serious AEs and 3 AEs occurred in 8 patients (5.6%), resulting in 4 (2.8%) readmissions to hospital within 30 days of surgery and 1 death.

CONCLUSIONS

This study demonstrates cholecystectomy performed using the device is as safe and effective as conventional laparoscopy and supports the implementation of the device on a wider scale, pending instrument modifications, in alignment with Idea, Development, Exploration, Assessment, Long-term follow-up Stage 3 (Assessment).

The utility of the CADISS® system in laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

The CADISS® system combines the use of a topical formulation of mesna (sodium 2-Mercaptoethane sulfonate) to facilitate selective dissection of pathological and fibrotic tissues with a non-cutting instrument for a safer dissection. A prospective, multi-site, clinical trial was performed to explore the use of the CADISS® system in laparoscopic cholecystectomy for acute cholecystitis.

METHODS

A total of 15 patients were enrolled at different severity stages of pathology according to Tokyo classification. They were operated on prior to, or after 72 h of, the onset of symptoms. The primary measure was the number of critical dissection steps successfully achieved using the CADISS® system without cutting instruments.

RESULTS

Five patients were operated on before 72 h of symptom onset and ten after. All the dissections were successfully achieved using the CADISS® method. No mortality was recorded. No conversion to open surgery was performed. No bile duct injury was observed. Other endpoints (facilitation of dissection of critical structures, identification of cleavage planes and reduction of risk) had scores of above nine on our Likert scale. Four postoperative serious adverse events including cholangitis, fever, pulmonary embolism and right hepatic artery pseudoaneurysm were reported. However, they seemed to be more related to cholecystitis or local conditions rather than the use of the CADISS® method.

CONCLUSION

This is the first study to investigate the use of the CADISS® System in cholecystectomy. The CADISS® system seemed to facilitate dissection in acute cholecystitis. Encouraging results are reported independently of the severity grade of cholecystitis and the delay in performing the surgery. Even now, laparoscopic cholecystectomy for acute cholecystitis remains a surgical challenge. Techniques that could facilitate this operation and reduce surgical complications may be helpful. Further studies should be conducted to confirm our preliminary results. Trial registration Clinical trials.gov NCT05041686.

Update on the natural orifice transluminal endoscopic surgery for gallbladder preserving gallstones therapy: A review

Cholecystectomy remains the "gold standard" for the management of symptomatic gallstones. Minimally invasive laparoscopic cholecystectomy has been the treatment of choice for the past 3 decades. However, the technique of natural orifice transluminal endoscopic surgery cholecystolithotomy is evolving, with some experts advocating gallbladder stone removal without gallbladder excision in order to preserve gallbladder function and eliminate post-cholecystectomy syndromes, including complications of the surgical incision, bile duct injury, functional gastrointestinal, and psychological conditions, and possibly an increase in colon cancer. In addition, transluminal endoscopic cholecystolithotomy is an option for elderly patients who are not suitable candidates for open surgery and those who desire scar-free minimally invasive surgery with organ preservation. This article summarizes the established pure natural orifice transluminal endoscopic surgery gallbladder preserving gallstone removal techniques and highlights the pros and cons of different popular available endoscopic approaches to gallstone therapy and how flexible endoscopic surgery via the natural orifice is compared to the well-established cholecystectomy.

Simple cholecystectomy is an adequate treatment for grade I T1bN0M0 gallbladder carcinoma: Evidence from 528 patients

BACKGROUND

T1b gallbladder carcinoma (GBC) is defined as a tumor that invades the perimuscular connective tissue without extension beyond the serosa or into the liver. However, controversy still exists over whether patients with T1b GBC should undergo cholecystectomy alone or radical GBC resection.

AIM

To explore the optimal surgical approach in patients with T1b gallbladder cancer of different pathological grades.

METHODS

Patients with T1bN0M0 GBC who underwent surgical treatment between 2000 and 2017 were included in the Surveillance, Epidemiology, and End Results database. The Kaplan-Meier method and log-rank test were used to analyze the overall survival (OS) and disease-specific survival (DSS) of patients with T1b GBC of different pathological grades. Cox regression analysis was used to identify independent predictors of mortality and explore the selection of surgical methods in patients with T1b GBC of different pathological grades and their relationship with prognosis.

RESULTS

Of the 528 patients diagnosed with T1bN0M0 GBC, 346 underwent simple cholecystectomy (SC) (65.5%), 131 underwent SC with lymph node resection (SC + LN) (24.8%), and 51 underwent radical cholecystectomy (RC) (9.7%). Without considering the pathological grade, both the OS (P < 0.001) and DSS (P = 0.003) of T1b GBC patients who underwent SC (10-year OS: 27.8%, 10-year DSS: 55.1%) alone were significantly lower than those of patients who underwent SC + LN (10-year OS: 35.5%, 10-year DSS: 66.3%) or RC (10-year OS: 50.3%, 10-year DSS: 75.9%). Analysis of T1b GBC according to pathological classification revealed no significant difference in OS and DSS between different types of procedures in patients with grade I T1b GBC. In patients with grade II T1b GBC, obvious survival improvement was observed in the OS (P = 0.002) and DSS (P = 0.039) of those who underwent SC + LN (10-year OS: 34.6%, 10-year DSS: 61.3%) or RC (10-year OS: 50.5%, 10-year DSS: 78.8%) compared with those who received SC (10-year OS: 28.1%, 10-year DSS: 58.3%). Among patients with grade III or IV T1b GBC, SC + LN (10-year OS: 48.5%, 10-year DSS: 72.2%), and RC (10-year OS: 80%, 10-year DSS: 80%) benefited OS (P = 0.005) and DSS (P = 0.009) far more than SC (10-year OS: 20.1%, 10-year DSS: 38.1%) alone.

CONCLUSION

Simple cholecystectomy may be an adequate treatment for grade I T1b GBC, whereas more extensive surgery is optimal for grades II-IV T1b GBC.

Reaching a consensus on the definition of "difficult" cholecystectomy among Spanish experts. A Delphi project. A qualitative study

BACKGROUND

Being able to predict preoperatively the difficulty of a cholecystectomy can increase safety and improve results. However, there is a need to reach a consensus on the definition of a cholecystectomy as "difficult". The aim of this study is to achieve a national expert consensus on this issue.

METHODS

A two-round Delphi study was performed. Based on the previous literature, history of biliary pathology, preoperative clinical, analytical, and radiological data, and intraoperative findings were selected as variables of interest and rated on a Likert scale. Inter-rater agreement was defined as "unanimous" when 100% of the participants gave an item the same rating on the Likert scale; as "consensus" when ≥80% agreed; as "majority" when the agreement was ≥70%. The delta of change between the two rounds was calculated.

RESULTS

After the two rounds, the criteria that reached "consensus" were bile duct injury (96.77%), non-evident anatomy (93.55%), Mirizzi syndrome (93.55%), severe inflammation of Calot's triangle (90.32%), conversion to laparotomy (87.10%), time since last acute cholecystitis (83.87%), scleroatrophic gallbladder (80.65%) and pericholecystic abscess (80.65%).

CONCLUSION

The ability to predict difficulty in cholecystectomy offers important advantages in terms of surgical safety. As a preliminary step, the items that define a surgical procedure as difficult should be established. Standardization of the criteria can provide scores to predict difficulty both preoperatively and intraoperatively, and thus allow the comparison of groups of similar difficulty.

Open Cholecystectomy among Patients undergoing Laparoscopic Cholecystectomy in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction:

In the current era, laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstone disease. The aim of this study is to find out the prevalence of open cholecystectomy among patients undergoing laparoscopic cholecystectomy in a tertiary care centre.

Methods:

It is a descriptive cross-sectional study done among 345 patients at the Department of Surgery of a tertiary care centre from June, 2020 to May, 2021 after receiving ethical clearance from the Institutional Review Committee (Reference number: 0770798-271). Convenience sampling was done. Successive patients who underwent elective laparoscopic cholecystectomy during the study period were included. Standard 4 port laparoscopic technique was used for the laparoscopic cholecystectomy and sub-costal Kocher incision was used for the open cholecystectomy respectively. After data collection, entry and analysis were done in Microsoft Excel 2016. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.

Results:

Out of 345 patients, the prevalence of open cholecystectomy among patients undergoing laparoscopic cholecystectomy was 6 (1.73%) (0.35-3.11 at 95% Confidence Interval).

Conclusions:

This study showed that the prevalence of open cholecystectomy among patients undergoing laparoscopic cholecystectomy was lower when compared to similar studies conducted in similar settings.

Timing of cholecystectomy in recurrent attacks of acute cholecystitis

BACKGROUND

Although laparoscopic cholecystectomy (LC) is the standard treatment for acute cholecystitis, its optimal timing is still controversial. In this study, our aim is to determine the appropriate cholecystectomy time by comparing the results of emergency and elective cholecystectomy in patients presenting with recurrent acute cholecystitis.

METHODS

Between January 2019 and January 2022, the data of 434 patients who were scheduled for late cholecystectomy and were admitted to our hospital with recurrent cholecystitis attacks during the waiting period were retrospectively evaluated. Demo-graphic data of patients, stage according to Tokyo Guidelines 2018, duration of hospital stay before and after surgery, surgery dura-tion, open surgery rate, drain use, hollow organ injury, biliary tract injury, bleeding, wound infection, post-operative collection, and mortality rates were analyzed.

RESULTS

Emergency LC (group 1) was performed in 176 (40.5%) of 434 patients presenting with recurrent cholecystitis, and elec-tive LC (group 2) was performed in 258 (59.5%) patients. Pre-operative hospital stay was significantly longer in group 2, and mean surgery duration was significantly longer in group 1 (p=0.001 and p=0.035, respectively). Gastric or intestinal injury, biliary tract injury, wound infection, and mortality were not detected in either group. There was no significant difference between the groups in the rate of open surgery and postoperative collection rates (p>0.05).

CONCLUSION

In centers experienced in hepatobiliary surgery, LC can be safely performed in recurrent acute cholecystitis attacks, regardless of symptom duration and the number of attacks.

Acute Cholecystitis: A Review

IMPORTANCE

Gallbladder disease affects approximately 20 million people in the US. Acute cholecystitis is diagnosed in approximately 200 000 people in the US each year.

OBSERVATIONS

Gallstone-associated cystic duct obstruction is responsible for 90% to 95% of the cases of acute cholecystitis. Approximately 5% to 10% of patients with acute cholecystitis have acalculous cholecystitis, defined as acute inflammation of the gallbladder without gallstones, typically in the setting of severe critical illness. The typical presentation of acute cholecystitis consists of acute right upper quadrant pain, fever, and nausea that may be associated with eating and physical examination findings of right upper quadrant tenderness. Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis. When an ultrasound result does not provide a definitive diagnosis, hepatobiliary scintigraphy (a nuclear medicine study that includes the intravenous injection of a radiotracer excreted in the bile) is the gold standard diagnostic test. Following diagnosis, early (performed within 1-3 days) vs late (performed after 3 days) laparoscopic cholecystectomy is associated with improved patient outcomes, including fewer composite postoperative complications (11.8% for early vs 34.4% for late), a shorter length of hospital stay (5.4 days vs 10.0 days), and lower hospital costs. During pregnancy, early laparoscopic cholecystectomy, compared with delayed operative management, is associated with a lower risk of maternal-fetal complications (1.6% for early vs 18.4% for delayed) and is recommended during all trimesters. In people older than 65 years of age, laparoscopic cholecystectomy is associated with lower mortality at 2-year follow-up (15.2%) compared with nonoperative management (29.3%). A percutaneous cholecystostomy tube, in which a drainage catheter is placed in the gallbladder lumen under image guidance, is an effective therapy for patients with an exceptionally high perioperative risk. However, percutaneous cholecystostomy tube placement in a randomized trial was associated with higher rates of postprocedural complications (65%) compared with laparoscopic cholecystectomy (12%). For patients with acalculous acute cholecystitis, percutaneous cholecystostomy tube should be reserved for patients who are severely ill at the time of diagnosis; all others should undergo a laparoscopic cholecystectomy.

CONCLUSIONS AND RELEVANCE

Acute cholecystitis, typically due to gallstone obstruction of the cystic duct, affects approximately 200 000 people in the US annually. In most patient populations, laparoscopic cholecystectomy, performed within 3 days of diagnosis, is the first-line therapy for acute cholecystitis.

[Clinical value of alternative technologies to standard laparoscopic cholecystectomy - single port, reduced port, robotics, NOTES]

Surgical interventions should ideally treat an existing disease curatively and achieve this with a low complication rate and minimal trauma. In this sense, laparoscopic cholecystectomy has become established as the recognized standard for the treatment of cholecystolithiasis. Newer procedures, such as single-port surgery or natural orifice transluminal endoscopic surgery (NOTES) have recently emerged to reduce the already low interventional trauma even further and to provide a better cosmetic outcome. With all new methods the main aim is the reduction of the transabdominal access points. Based on published results and diagnosis-related groups (DRG) data, this article examines whether this goal has been achieved, also with respect to the overall quality of treatment and the complication rates. In this context and in addition to the already mentioned approaches, robotic cholecystectomy and the reduced port approach are also considered.

Gallstone Ileus. What therapeutic options are there?

Gallstone ileus is a rare disorder in emergency surgical practice with diagnosis usually difficult and only achieved at surgery. The current approaches are: enterolithotomy, cholecystectomy and fistula repair (one-stage surgery), enterolithotomy with cholecystectomy performed later (two-stage surgery) and only enterolithotomy (most reported surgical procedure).

METHODS

The clinical, operative and follow-up data on 14 consecutive patients treated in our clinic for gallstone ileus was retrospectively reviewed.

RESULTS

Gallstone ileus was recorded in 0.06% of all operations for biliary lithiasis and 1% of all enteric occlusions. There were 11 women and one men, with a mean age of 77.3 (range 67-100) years. There was a mean delay of 3.16 days for onset of symptoms to admission. Urgent laparotomy confirmed gallstone obstruction and a cholecysto-duodenal fistula (13 cases) or cholecysto-colonic fistula (1 case). We performed one stage surgery in 4 cases, enterolithotomy alone in 8 cases (one case operated initially in another surgical service), Hartman procedure, cholecystectomy and fistula repair in one case and a spontaneous evacuation of the gallstone with cholecystectomy and fistula repair later in another case. We recorded 2 deaths in patients with multiple comorbidities in which only enterolithotomy was performed and with 1 and 2 reinterventions, respectively. Postoperative stay was 9.4 days for cases with simple enterolithotomy and 18.6 days for cases with radical treatment. We did not record any recurrence.

CONCLUSIONS

Although rarely encountered in surgical practice, gallstones ileus should be noted in the differential diagnosis of intestinal obstruction in patients with a past history of biliary disease, occlusive syndrome, pneumobilia and possibly ectopic gallstone. The one-stage procedure should be the offered to stabilized patients, but in cases with associated comorbidities, only enterolithotomy represent a best option.

KEY WORDS

Gallstone ileus, Cholecystoduodenal fistula, Intestinal Obstruction.