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Background The optimal timing of cholecystectomy for patients admitted with acute gallbladder pathology is unclear. Some studies have shown that emergency cholecystectomy during the index admission can reduce length of hospital stay with similar rates of conversion to open surgery, complications and mortality compared with a 'delayed' operation following discharge. Others have reported that cholecystectomy during the index acute admission results in higher morbidity, extended length of stay and increased costs. This study examined the cost-effectiveness of emergency versus delayed cholecystectomy for acute benign gallbladder disease. Methods Using data from a prospective population-based cohort study examining the outcomes of cholecystectomy in the UK and Ireland, a model-based cost-utility analysis was conducted from the perspective of the UK National Health Service, with a 1-year time horizon for costs and outcomes. Probabilistic sensitivity analysis was used to investigate the impact of parameter uncertainty on the results obtained from the model. Results Emergency cholecystectomy was found to be less costly (£4570 versus £4720; €5484 versus €5664) and more effective (0·8868 versus 0·8662 QALYs) than delayed cholecystectomy. Probabilistic sensitivity analysis showed that the emergency strategy is more than 60 per cent likely to be cost-effective across willingness-to-pay values for the QALY from £0 to £100 000 (€0-120 000). Conclusion Emergency cholecystectomy is less costly and more effective than delayed cholecystectomy. This approach is likely to be beneficial to patients in terms of improved health outcomes and to the healthcare provider owing to the reduced costs. [ABSTRACT FROM AUTHOR]

Background The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals. Methods Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals. Conclusion Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care. [ABSTRACT FROM AUTHOR]

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all-cause 30-day readmissions and complications in a prospective population-based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all-cause 30-day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics. [ABSTRACT FROM AUTHOR]

B Correction: World J Surg (2019) 43:1928-1934 b https://doi.org/10.1007/s00268-019-04981-5 Since the publication of this work, S. Kanavati has changed their name from O. Kanavati. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. [Extracted from the article]

Background and Objectives: The COVID-19 pandemic has led to a tremendous backlog in elective surgical activity. Our hospital trust adopted an innovative approach to dealing with elective waiting times for cholecystectomy during the recovery phase from COVID-19. This study aimed to evaluate trends in overall cholecystectomy activity and the effect on waiting times. Materials and Methods: A prospective observational study was undertaken, investigating patients who received a cholecystectomy at a large United Kingdom hospital trust between February 2021 and February 2022. There were multiple phased strategies to tackle a 533-patient waiting list: private sector, multiple sites including emergency operating, mobile theatre, and seven-day working. The correlation of determination (R2) and Kruskal–Wallis analysis were used to evaluate trends in waiting times across the study period. Results: A total of 657 patients underwent a cholecystectomy. The median age was 49 years, 602 (91.6%) patients had an ASA of 1-2, and 494 (75.2%) were female. A total of 30 (4.6%) patients were listed due to gallstone pancreatitis, 380 (57.8%) for symptomatic cholelithiasis, and 228 (34.7%) for calculous cholecystitis. Median waiting times were reduced from 428 days (IQR 373–508) to 49 days (IQR 34–96), R2 = 0.654, p < 0.001. For pancreatitis specifically, waiting times had decreased from a median of 218 days (IQR 139–239) to 28 (IQR 24–40), R2 = 0.613, p < 0.001. Conclusions: This study demonstrates the methodology utilised to safely and effectively tackle the cholecystectomy waiting list locally. The approach utilised here has potential to be adapted to other units or similar operation types in order to reduce elective waiting times. [ABSTRACT FROM AUTHOR]

Background: Nonagenarian patients are an age group in progressive growth. In this age group, indications for surgical procedures, including cholecystectomy, will be increasingly frequent, as biliary pathology and its complications are frequent in this population group. The main objective of this study was to analyze the safety and outcomes of laparoscopic cholecystectomy in patients older than 90 years. Methods: A retrospective observational cohort study was designed. This study involved 600 patients that were classified in 4 age groups for analysis (under 50 years, 50–69 years, 70–89 years, and over 90 years). Demographic, clinical, paraclinics, surgical, and outcome variables were compared according to age group. A multivariate analysis, which included variables considered clinically relevant, was performed to identify factors associated with mortality and complications classified with the Clavien–Dindo scale. Results: The patients evaluated had a median age of 65.0 (IQR 34.0) years and there was a female predominance (61.8%). A higher complication rate, conversion rate, subtotal cholecystectomy rate, and prolonged hospital stay were found in nonagenarians. The overall mortality rate was 1.6%. Mortality in the age group over 90 years was 6.8%. Regression models showed that age over 90 years (RR 4.6 CI95% 1.07–20.13), presence of cholecystitis (RR 8.2 CI95% 1.29–51.81), and time from admission to cholecystectomy (RR 1.2 CI95% 1.10–1.40) were the variables that presented statistically significant differences as risk factors for mortality. Conclusion: Cholecystectomy in nonagenarian patients has a higher rate of complications, conversion rate, subtotal cholecystectomy rate, and mortality. Therefore, an adequate perioperative assessment is necessary to optimize comorbidities and improve outcomes. Also, it is important to know the greatest risk for informed consent and choose the surgical equipment and schedule of the procedure. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic cholecystectomy is the standard surgical procedure for gallstone disease. Difficulties could face the surgeons regarding the identification of the Critical View of Safety. Many techniques that are called salvage or bail-out techniques had been developed to deal with such conditions. We investigated a combination of three techniques namely laparoscopic fundus first lumen guided sub-total reconstituting cholecystectomy as another option. Methodology: A prospectively collected data from 1783 laparoscopic exploration of gallstone disease. Data on patient demographics, (Nassar) operative difficulty grade, operative time, perioperative complications, and mortality were recorded. Results: One hundred twenty-six patients were found to have Nasser difficulty grade above 3 and were involved in this study of whom 39 were males and 87 were females with average age of 49.9 years. The difficulties were dense adhesions at Calot's, Hartman's pouch stones, short wide cystic duct, and small contracted and gangrenous gall bladder respectively. There is one incidence each of conversion surgery, CBD stone, biliary fistula, paralytic ileus, and port site infection and we report two cases of sub-hepatic collection. Conversion to open cholecystectomy was done in one patient in whom difficulties still even with such measures. The mean duration of our surgical procedure was 70.1±18 minutes; a result that is statistically significant more than the classical procedure where the critical view of safety was visualized and less than that when each technique was performed separately. The sub-hepatic drain was put routinely in all salvage techniques to minimize post-operative Sub hepatic collections. triple techniques significantly decreased the incidence of bile duct injuries and hence open conversion when compared with conventional procedures in difficult cholecystectomy but not in simple ones. Mortality is a very rare complication. In all techniques. only a few cases have been reported but for a cause unrelated to the procedure. For the same reason; the triple technique is associated with a statistically significant reduction in post-operative hospital stay when compared with classical techniques related to the dramatic reduction in the associated complications. Conclusion: A combination of three salvage techniques namely, laparoscopic fundus first subtotal reconstituting cholecystectomy will help to minimize but not eliminate the complications associated with operation to difficult gall bladder and will assist the surgeon in managing difficult operative conditions. [ABSTRACT FROM AUTHOR]

Laparoscopic cholecystectomy (LC) is the standard surgical treatment for patients with gallstone disease, ranging from symptomatic cholelithiasis to severe cholecystitis. As there is high variability in operative findings during LC, it is important to assess the surgical difficulty objectively. This is critical for further developing and using future artificial intelligence algorithms in LC surgery, as it allows more reliable benchmarking between surgeons and can help in surgical OR planning. In this study, deep learning models were trained to assess the level of difficulty in the first phase of the procedure. 93 LC videos recorded at the Meander Medical Center were included. A modified Nassar scale was used to annotate gallbladder difficulty (grade 1–3) and adhesion presence (grade 1–3). Various models, were trained on different label combinations;binary and multi-label. On the multi-label test set, the best model reached accuracies of 66% and 40% for the classification of the gallbladder and adhesions, respectively. The best binary models classifies gallbladder difficulty grade 3 vs 1,2 with an accuracy of 88%, and gives an accuracy of 82% for grade 1 vs 2,3. This work shows the potential of difficulty understanding in surgical scenery based on early phase endoscopic video. [ABSTRACT FROM AUTHOR]

Background: Most of the scoring systems to predict difficult laparoscopic cholecystectomy are based on pre-operative clinical and radiological findings. Recently the Parkland Grading Scale system was introduced as a simple intra-operative grading scale. This study aims to utilize the Parkland Grading Scale system to assess the intraoperative challenges during laparoscopic cholecystectomy. Method: This was a prospective, cross-sectional study done at Chitwan Medical College and Teaching Hospital, Chitwan, Nepal. All the patients underwent laparoscopic cholecystectomy from April 2020 to March 2021. Based on the initial intra-operative finding, Parkland Grading Scale was noted and at the end of the surgery, the level of difficulty was given by the operating surgeon. All the pre-operative, intra-operative, and post-operative findings were compared with the scale. Results: Out of 206 patients, there were 176 (85.4%) females, and 30 (14.6%) males. The median age was 41 years (Range 19–75). The median body mass index was 23.67 kg/m2. There were 35(17%) patients with a history of previous surgery. The rate of conversion to open surgery was 5.8%. According to Parkland Grading Scale, 67(32.5%), 75(36.4%), 42(20.4%), 15(7.3%), and 7(3.4%) were graded as grade 1, 2, 3, 4, and 5 respectively. There was a difference in the Parkland grading scale in patients with a history of acute cholecystitis, gallbladder wall thickness, pericholecystic collection, stone size, and body mass index (p < 0.05). The total operative time, level of difficulty in surgery, rate of help needed from colleagues or replacement as the main surgeon, bile spillage, drain placement, gallbladder decompression, and conversion rate all increased with an increase in scale (p < 0.05). There was a significant increase in the development of post-operative fever, and post-operative hospital stay as the scale increased (p < 0.05). The Tukey-Kramer test for all pair-wise comparisons revealed that each grade was significantly different from each other (p < 0.05) on the difficulty of surgery except for grade 4 from 5. Conclusion: Parkland Grading Scale system is a reliable intra-operative grading system to assess the difficulty in laparoscopic cholecystectomy and helps the surgeon to change the strategy of surgery. An increase in scale is associated with an increased difficulty level of the surgery. [ABSTRACT FROM AUTHOR]

Biliary lithiasis is a global disorder affecting nearly 20% of the world's population, although most cases occur without symptoms. Gallbladder stones could move into the common bile duct after gallbladder contraction, causing acute cholecystitis. The progression of the acute disease can take different forms, from mild inflammation, treatable with oral antibiotics, to the most severe forms with septic shock or biliary peritonitis, requiring specific treatment. Liver function tests and abdominal ultrasound are generally sufficient for diagnostic purposes. The most commonly used antibiotic is penicillin, with piperacillin achieving the best results; alternatively, fluoroquinolones could also be used, although there is no univocal consensus and surgery remains the only definitive treatment. A prolonged antibiotic therapy after cholecystectomy seems inadvisable, except in severe cases and/or in the immuno-compromised patient, where it should be periodically evaluated to avoid antibiotic resistance and unnecessary use. This review presents an evidence-based analysis to describe the advantages and disadvantages of the available options for the treatment of biliary lithiasis and cholecystitis, from the pathophysiological mechanisms behind lithiasis formation and also covering the main diagnostic findings for biliary stones, recommending an approach tailored to the patient's characteristics and to the team's expertise. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy (LC) is the standard of care for acute calculous cholecystitis; however, in patients at high risk for surgery, particularly in the elderly, insertion of a percutaneous catheter drainage (PCD) at gallbladder is recommended. Current evidence suggests that PCD may have less favorable outcomes than LC, but also that LC-associated complications increase in direct relation to patient age. There is no recommendation supported by robust evidence to decide between one or the other procedure in super elderly patients. Methods: A retrospective observational cohort study was designed to analyze the surgical outcomes of super elderly patients with cholecystitis who underwent LC versus PCD for treatment. The surgical outcomes of a subgroup of high-risk patients were also analyzed. Results: A total of 96 patients who met the inclusion criteria between 2014 and 2021 were included. The median age of patients were 92 years (IQR: 4.00) with a female predominance (58.33%). The overall morbidity rate in the series was 36.45% and mortality rate was 7.29%. There was no statistically significant difference when compared to the associated morbidity and mortality among patients who underwent LC versus those who underwent PCD, neither in the analysis of the complete series or in the subgroup of high-risk patients. Conclusions: The morbidity and mortality associated with the two most frequently recommended therapeutic options for operating super elderly patients with acute cholecystitis are high. We found no evidence of superiority in outcomes for either of the two procedures in this age group. [ABSTRACT FROM AUTHOR]

Background: Upon encountering a difficult cholecystectomy in which, after a reasonable trial of dissection, anatomical identification has not been attained due to severe inflammation, and the risk of additional dissection is deemed to be hazardous, "bail-out" strategies are encouraged safety valves. One strategy is to abort the cholecystectomy and refer the patient to a HPB center for further management. Methods: A retrospective review was conducted of cholecystectomies performed by HPB surgeons at our center between 2005 and 2019. We identified 63 patients who had an aborted cholecystectomy because of acute or chronic cholecystitis and were referred for additional care. Of these, operative notes and other clinical records were available for 43 patients who were included in this study. Results: 42 cholecystectomies (98%) were started laparoscopically. 25 patients (58%) had chronic cholecystitis, and 18 (42%) had acute cholecystitis. 40 cases (93%) fell into the highest level of difficulty on the Nassar scale (Grade 4). Procedures were aborted at the following stages of dissection: in 10 patients (23%), none of the gallbladder was identified; in another 11 (26%), only the dome of gallbladder was identified; the body of the gallbladder was exposed in 13 (30%); and dissection of the hepatocystic triangle was attempted unsuccessfully in 9 (21%). Following referral to our center, 30 patients (70%) were managed with total cholecystectomy while in 13 cases (30%), subtotal cholecystectomy was performed. Conclusion: Aborting cholecystectomy and referring the patient to an HPB center is rarely needed but is an effective bail-out strategy for general surgeons encountering highly difficult operative conditions due to inflammation. [ABSTRACT FROM AUTHOR]

Background: Operative courses of laparoscopic cholecystectomies vary widely due to differing pathologies. Efforts to assess intra-operative difficulty include the Parkland grading scale (PGS), which scores inflammation from the initial view of the gallbladder on a 1-5 scale. We investigated the impact of PGS on intra-operative outcomes, including laparoscopic duration, attainment of the critical view of safety (CVS), and gallbladder injury. We additionally trained an artificial intelligence (AI) model to identify PGS.Methods: One surgeon labeled surgical phases, PGS, CVS attainment, and gallbladder injury in 200 cholecystectomy videos. We used multilevel Bayesian regression models to analyze the PGS's effect on intra-operative outcomes. We trained AI models to identify PGS from an initial view of the gallbladder and compared model performance to annotations by a second surgeon.Results: Slightly inflamed gallbladders (PGS-2) minimally increased duration, adding 2.7 [95% compatibility interval (CI) 0.3-7.0] minutes to an operation. This contrasted with maximally inflamed gallbladders (PGS-5), where on average 16.9 (95% CI 4.4-33.9) minutes were added, with 31.3 (95% CI 8.0-67.5) minutes added for the most affected surgeon. Inadvertent gallbladder injury occurred in 25% of cases, with a minimal increase in gallbladder injury observed with added inflammation. However, up to a 28% (95% CI - 2, 63) increase in probability of a gallbladder hole during PGS-5 cases was observed for some surgeons. Inflammation had no substantial effect on whether or not a surgeon attained the CVS. An AI model could reliably (Krippendorff's α = 0.71, 95% CI 0.65-0.77) quantify inflammation when compared to a second surgeon (α = 0.82, 95% CI 0.75-0.87).Conclusions: An AI model can identify the degree of gallbladder inflammation, which is predictive of cholecystectomy intra-operative course. This automated assessment could be useful for operating room workflow optimization and for targeted per-surgeon and per-resident feedback to accelerate acquisition of operative skills. [ABSTRACT FROM AUTHOR]

Knowing the surgical anatomy and related variations, revealing the factors that indicate difficult cholecystectomy, knowing and applying various safe surgical cholecystectomy techniques and guidelines recommended to prevent injuries can prevent complications. This study, it is aimed to evaluate the preoperative factors that will predict difficult elective cholecystectomy. We retrospectively analyzed the data of patients treated for cholelithiasis by an experienced hepatobiliary surgeon or under his supervision between March 2018 and March 2020. Clinical, laboratory, and imaging data obtained from patients' files were evaluated. According to the Modified Nassar Scale (MNS), 140 (79.5%) patients were considered grade 1-2 (easy) and 36 (20.5%) grade 3-5 (difficult) patients within the framework of intraoperative findings. Critical View of Safety was successfully performed in 170 (96.6%) of the patients. Converting laparoscopic cholecystectomy to open was performed in two (1.1%) patients who had an MNS of 4 and 5. The most common comorbidity was hypertension. Male gender, previous cholecystitis and ERCP, and increased gall bladder wall thickness from preoperative USG findings are independent risk factors for difficult cholecystectomy in patients scheduled for laparoscopic cholecystectomy. In addition, it should be kept in mind that LC can be difficult in patients with hypertension and coronary artery disease. [ABSTRACT FROM AUTHOR]

Laparoscopic cholecystectomy (LC) is one of the most commonly performed surgeries and is considered the standard treatment for cholelithiasis. However, it is associated with a risk of bile duct or hepatic artery injuries. This study evaluated the safety of LCs and the conversion rate (CR) by achieving a critical view of safety (CVS) and identification of Rouviere's sulcus (RS). This was a single-group cohort study that included consecutive patients undergoing LC at Smart Health Tower (Sulaimani, Iraq) from January 2021 to January 2023. The data were prospectively collected from patients' profiles or surgical notes within the hospital's database. A total of 419 patients underwent LC, of which females were the predominant gender (78.5%). The mean and median ages of the cases were 46.3±15.8 and 45 years, with a range of 2-90 years, respectively. The most common indications for surgery were biliary colic (69.5%), followed by acute cholecystitis (23.9%). The duration of the operations was significantly shorter for cases in which the CVS (45.6±17.9 min) or identification of RS (45.6±18.6 min) was achieved compared to those where the CVS (63.7±27.7 min) or RS (50.7±21.7 min) was not observed. Surgeries for patients with both CVS achievement and RS identification were also significantly less time-consuming (44.3±17.6) than counterparts (53.3±22.6). Among the cases without CVS achievement or RS identification (n=97, 23%), eight (8.2%) had adhesions, 12 (12.4%) had a distended gallbladder (GB) and 10 (10.3%) had thick GB walls. In addition, four (4.1%) experienced GB perforation, two (2.1%) had bleeding and one (1%) had stone spillage. There was no conversion. The achievement of CVS and identification of RS are practical landmarks in performing safe LC and decreasing the CR. [ABSTRACT FROM AUTHOR]

Objective: To determine the ability of C-reactive protein as a useful predictor of difficult laparoscopic cholecystectomy. Study Design: Cross sectional study. Place and Duration of Study: General Surgery unit of Combined Military Hospital, Rawalpindi Pakistan, from Nov 2021-Nov 2022. Methodology: Fifty-six patients who underwent emergency or early laparoscopic cholecystectomy were made part of this study. After an informed consent age, gender, Body Mass Index and C-Reactive Protein levels were documented. Patients then underwent surgery and operative time along with "Nassar Difficulty Grade" was documented to define difficult cholecystectomy. Results: A total of 56 patients who were scheduled to undergo laparoscopic cholecystectomy were included with mean age of 44.32±5.37 years. 23(41.10%) were male patients while 33(58.90%) were female patients. Mean CRP levels were 20.00±8.81 mg/L. Frequency of "difficult laparoscopic cholecystectomy" in patients who had high preoperative CRP was 15/22(68.18%) while in patients who had low preoperative CRP it was 13/34(38.23%). Additionally, bivariate analysis of CRP levels and mean operative time showed that Pearson correlation coefficient (r) value was 0.355 showing a significant positive correlation (p=0.007). Conclusion: C-reactive protein levels in patients undergoing laparoscopic cholecystectomy for gallstones or any of its related problems are helpful in predicting whether or not the patient will have a challenging laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

The introduction and rationalization of the terms ' I Critical View of Safety i ' (CVS) in 1995-2000 [[1]] and ' I Culture of Safety in Cholecystectomy i ' (COSIC) in 2014-2020 [[2]] constitute the most remarkable advancement in cholecystectomy theory and practice since the first laparoscopic removal of the gallbladder in the Böblingen county hospital on 12 September 1985 [[3]]. Transabdominal single incision laparoscopic surgery, robot-assisted surgery, natural orifice transluminal endoscopic surgery, gasless cholecystectomy, and hybrid procedures are part of this. To emphasize, a high intra-operative difficulty grade is one of the reasons for conversion from total cholecystectomy to subtotal cholecystectomy to mitigate BDI risk during gallbladder surgery. However, it is crucial to predict the cholecystectomy course in advance, especially when a second opinion regarding laparoscopic or open subtotal cholecystectomy, cholecystolithotomy, or abandoned cholecystectomy may be required. [Extracted from the article]

It is important to establish the difficulty of a cholecystectomy preoperatively to improve the outcomes. There are multiple risk factors for a difficult cholecystectomy that may depend on the patient, the disease, or extrinsic factors. The aim of this study is to evaluate the predictive capacity of a difficult cholecystectomy with a preoperative scale. A diagnostic trial study was designed to evaluate the performance of a scale to predict the difficulty of laparoscopic cholecystectomy, considering as a reference standard the intraoperative findings evaluated according to an intraoperative difficulty scale. A ROC curve was performed and used to estimate predictive value of the preoperative score to predict the difficulty of a cholecystectomy preoperatively. The ROC curve shows an area of 0.88 under the curve. The calculated ideal cutoff was 8, with a sensitivity, specificity, positive predictive value and negative predictive value of 75.15%, 88.31%, 87.32 and 76.83%, respectively. It was demonstrated that, as the difficulty predicted by the preoperative scale increases, the rate of conversion to open procedure, the rate of subtotal cholecystectomies, the rate of complication and the rate of a critical view of safety failed increase. We suggest implementing the preoperative scale in all patients who are planning laparoscopic cholecystectomy, considering it a simple and easy tool to perform. This to inform the patient, organize the surgery schedule, select personnel, request support and have adequate pre-operative planning. [ABSTRACT FROM AUTHOR]

Background This study provides a global overview of the management of patients with acute cholecystitis during the initial phase of the COVID-19 pandemic. Methods CHOLECOVID is an international, multicentre, observational comparative study of patients admitted to hospital with acute cholecystitis during the COVID-19 pandemic. Data on management were collected for a 2-month study interval coincident with the WHO declaration of the SARS-CoV-2 pandemic and compared with an equivalent pre-pandemic time interval. Mediation analysis examined the influence of SARS-COV-2 infection on 30-day mortality. Results This study collected data on 9783 patients with acute cholecystitis admitted to 247 hospitals across the world. The pandemic was associated with reduced availability of surgical workforce and operating facilities globally, a significant shift to worse severity of disease, and increased use of conservative management. There was a reduction (both absolute and proportionate) in the number of patients undergoing cholecystectomy from 3095 patients (56.2 per cent) pre-pandemic to 1998 patients (46.2 per cent) during the pandemic but there was no difference in 30-day all-cause mortality after cholecystectomy comparing the pre-pandemic interval with the pandemic (13 patients (0.4 per cent) pre-pandemic to 13 patients (0.6 per cent) pandemic; P  = 0.355). In mediation analysis, an admission with acute cholecystitis during the pandemic was associated with a non-significant increased risk of death (OR 1.29, 95 per cent c.i. 0.93 to 1.79, P  = 0.121). Conclusion CHOLECOVID provides a unique overview of the treatment of patients with cholecystitis across the globe during the first months of the SARS-CoV-2 pandemic. The study highlights the need for system resilience in retention of elective surgical activity. Cholecystectomy was associated with a low risk of mortality and deferral of treatment results in an increase in avoidable morbidity that represents the non-COVID cost of this pandemic. [ABSTRACT FROM AUTHOR]

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Background: Laparoscopic cholecystectomy in situs inversus totalis (SIT) is a technically and physically demanding procedure for surgeons and there is still a lack of consensus regarding the best technical approach in such cases. We conducted a systematic review and meta-analysis to evaluate port placement, the dominant hand of the surgeon, preoperative imaging, morbidity, and mortality. Methods: We searched MEDLINE, SCOPUS, Web of Science, and the Cochrane Library for studies of patients with SIT that underwent laparoscopic cholecystectomy. Of 387 identified records, 101 met our inclusion criteria, all of them case reports or case series of maximum of 6 patients. Results: Out of the 121 patients included in the analysis, 94 were operated on using a "mirrored American" technique, 12 using the "Mirrored French", 9 employed single-port techniques, and 6 described novel port placements. Even though most surgeries were conducted by a right-handed surgeon (93 cases), surgeries performed by the seven left-handed surgeons yielded shorter intervention times (p = 0.024). Preoperative imaging (CT, MRI, MRCP, ERCP) also correlated with a lower duration of surgery (p = 0.038. Length of stay was associated with the type of disease, but not with other studied endpoints. Morbidity was less than 1%, and conversion rates and mortality were nil. Conclusions: Cholecystectomy in SIT is a safe but challenging procedure and surgeons should prepare in advance for the unfamiliar aspects of completing such a task. While preoperative imaging and a left-handed surgeon are beneficial in terms of surgery length, when these are not available surgeons should focus on achieving the most comfortable setting based on their experience and tailor their approach to the patient at hand. Further studies are needed in order to properly describe and evaluate intraoperative findings as well as surgeon-dependent factors that could improve future recommendations. [ABSTRACT FROM AUTHOR]

Background: Complications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients' quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE. Methods: A prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined. Results: Reinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females (p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention (p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths. Conclusion: This large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications. [ABSTRACT FROM AUTHOR]

Background: Despite the call to enhance accuracy and value of operation records few international recommended minimal standards for operative notes documentation have been described. This study undertook a systematic review of existing operative reporting systems for laparoscopic cholecystectomy (LC) to fashion a comprehensive, synoptic operative reporting template for the future. Methods: A search for all relevant articles was conducted using PubMed version of Medline, Scopus and Web of Science databases in June 2021, for publications from January 1st 2011 to October 25th 2021, using the keywords: laparoscopic cholecystectomy AND operation notes OR operative notes OR proforma OR documentation OR report OR narrative OR audio-visual OR synoptic OR digital. Two reviewers (NOC, GMC) independently assessed each published study using a MINORS score of ≥ 16 for comparative and ≥ 10 for non-comparative for inclusion. This systematic review followed PRISMA guidelines and was registered with PROSPERO. Synoptic operative templates from published data were assimilated into one "ideal" laparoscopic operative report template following international input from the World Society of Emergency Surgery board. Results: A total of 3567 articles were reviewed. Following MINORS grading 25 studies were selected spanning 14 countries and 4 continents. Twenty-two studies were prospective. A holistic overview of the operative procedure documentation was reported in 6/25 studies and a further 19 papers dealt with selective surgical aspects of LC. A unique synoptic LC operative reporting template was developed and translated into Chinese/Mandarin, French and Arabic. Conclusion: This systematic review identified a paucity of publications dealing with operative reporting of LC. The proposed new template may be integrated digitally with hospitals' medical systems and include additional narrative text and audio-visual data. The template may help define new OR (operating room) recording standards and impact on care for patients undergoing LC. [ABSTRACT FROM AUTHOR]

Purpose: The main sources of post-cholecystectomy bile leakage (PCBL) not involving major duct injuries are the cystic duct and subvesical/hepatocystic ducts. Of the many studies on the diagnosis and management of PCBL, few addressed measures to avoid this serious complication. The aim of this study was to examine the causes and mechanisms leading to PCBL and to evaluate the effects of specific preventative strategies. Methods: A prospectively maintained database of 5675 consecutive laparoscopic cholecystectomies was analysed. Risk factors for post-cholecystectomy bile leakage were identified and documented and technical modifications and strategies were adopted to prevent this complication. The incidence, causes and management of patients who suffered bile leaks were studied and their preoperative characteristics, operative data and postoperative outcomes were compared with patients where potential risks were identified and PCBL avoided and with the rest of the series. Results: Twenty-five patients (0.4%) had PCBL (7 expected and less than half requiring reintervention): 11 from cystic ducts (0.2%), 3 from subvesical ducts (0.05%) and 11 from unconfirmed sources (0.2%). The incidence of cystic duct leakage was significantly lower with ties (0.15%) than with clips (0.7%). Fifty-two percent had difficulty grades IV or V, 36% had empyema or acute cholecystitis and 16% had contracted gallbladders. Twelve patients required 17 reinterventions before PCBL resolved; 7 percutaneous drainage, 6 ERCP and 4 relaparoscopy. The median hospital stay was 17 days with no mortality. Hepatocystic ducts were encountered in 72 patients (1.3%) and were secured with loops (54.2%), ties (25%) or sutures (20.8%) with no PCBL. Eighteen sectoral ducts were identified and secured. Conclusion: Ligation of the cystic duct reduces the incidence of PCBL resulting from dislodged endoclips. Careful blunt dissection in the proper anatomical planes avoiding direct or thermal injury to subvesical and sectoral ducts and a policy of actively searching for hepatocystic ducts during gallbladder separation to identify and secure them can reduce bile leakage from such ducts. [ABSTRACT FROM AUTHOR]

Background: In patients with severe biliary pancreatitis, delayed cholecystectomy associated with a high risk of recurrence is recommended. The current study aimed to evaluate the effect of common bile duct (CBD) stenting on reducing gallstones migration and recurrence of symptoms in patients with pancreatitis and delayed cholecystectomy candidates. Methods: To this purpose, the randomized, controlled clinical trial was performed on 40 patients with biliary pancreatitis who were candidates for delayed cholecystectomy. Patients were randomly divided into two groups of A and B that underwent CBD stenting after ERCP and received endoscopic treatment without stenting, respectively. A checklist recorded demographics and complications. Group A was followed up after four weeks to remove the stent and record the complications. Group B underwent MRCP to examine the migration of new gallstones as well as the complications. Results: Of the 40 patients, 20 subjects (11 males and 9 females) were allocated to each group, matched for demographic variables. In the one-month follow-up, only one subject in group A manifested symptoms of gallstone migration and recurrence, while in group B, recurrence was observed in 6 patients (P = 0.037). There was no significant difference in the success rate of ERCP and the incidence of complications between the two groups. Conclusion: CBD stenting in patients with biliary pancreatitis and gallstone could reduce the risk of recurrence and remigration of gallstones in delayed cholecystectomy cases. [ABSTRACT FROM AUTHOR]

Background: Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time. Methods: Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature. Results: 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%. Conclusion: Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies. [ABSTRACT FROM AUTHOR]

Background: Bile duct injury rates for laparoscopic cholecystectomy (LC) remain higher than during open cholecystectomy. The "culture of safety" concept is based on demonstrating the critical view of safety (CVS) and/or correctly interpreting intraoperative cholangiography (IOC). However, the CVS may not always be achievable due to difficult anatomy or pathology. Safety may be enhanced if surgeons assess difficulties objectively, recognise instances where a CVS is unachievable and be familiar with recovery strategies.Aims and Methods: A prospective study was conducted to evaluate the achievability of the CVS during all consecutive LC performed over four years. The primary aim was to study the association between the inability to obtain the CVS and an objective measure of operative difficulty. The secondary aim was to identify preoperative and operative predictors indicating the use of alternate strategies to complete the operation safely.Results: The study included 1060 consecutive LC. The median age was 53 years, male to female ratio was 1:2.1 and 54.9% were emergency admissions. CVS was obtained in 84.2%, the majority being difficulty grade I or II (70.7%). Displaying the CVS failed in 167 LC (15.8%): including 55.6% of all difficulty grade IV LC and 92.3% of difficulty grade V. There were no biliary injuries or conversions.Conclusion: All three components of the critical view of safety could not be demonstrated in one out of 6 consecutive laparoscopic cholecystectomies. Preoperative factors and operative difficulty grading can predict cases where the CVS may not be achievable. Adapting instrument selection and alternate dissection strategies would then need to be considered. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy is the gold standard treatment for gallstones. Because of the numerous advantages of open surgery, such as limited incisions, short hospital stay, no drainage tube and stomach tube use, fewer analgesic and fewer complications. Aims: This study aimed at determine the effectiveness of an educational program on nurses knowledge toward pre and post-operative nursing intervention for patient with laparoscopic cholecystectomy; and identify the relationship between study findings and selected variables (age, level of education, and years of experience). Methods: A pre-experimental design one group (pre-post test) is conducted for the periods of December 26th 2020 to Jun 1st 2021. The study is carried out at the at AL-Imam AL-Hussein Teaching Hospital in AL-Nasiriya city. By non-probability purposive sample is selected from nurses who in surgical wards before and after implementing educational program, data were collected and analyzed through the application of descriptive and inferential statistics. Results: Findings indicate that nurses age at mean 24.2, (54%) females, (52%), nursing diploma graduated (46.0%) have 1-5 years of experience and no participated in training sessions. Knowledge statistically significance differences between pre and post -test for study group at (P < 0.05). There were statistically significances differences between (level of educational, years of experience and number of years of work in surgical wards) and effectiveness of educational program among the two period (Pre and Post-Test). Conclusion: More years of experience in training the staff nursing in surgical wards by local officials help raising professionals' nurses. Provide the health resources and exploiting young energies of nurses which indeed helps to develop their knowledge. [ABSTRACT FROM AUTHOR]

Aims: The rate of acute laparoscopic cholecystectomy remains low due to operational constraints. The purpose of this study is to evaluate a service model of index admission cholecystectomy with referral protocols, refined logistics and targeted job planning. Methods: A prospectively maintained dataset was evaluated to determine the processes of care and outcomes of patients undergoing emergency biliary surgery. The lead author has maintained a 28 years prospective database capturing standard demographic data, intraoperative details including the difficulty of cholecystectomy as well as postoperative outcome parameters and follow up data. Results: Over five thousand (5555) consecutive laparoscopic cholecystectomies were performed. Only patients undergoing emergency procedures (2399,43.2% of entire group) were analysed for this study. The median age was 52 years with 70% being female. The majority were admitted with biliary pain (34%), obstructive jaundice (26%) and acute cholecystitis (16%). 63% were referred by other surgeons. 80% underwent surgery within 5 days (40% within 24 h). Cholecystectomies were performed on scheduled lists (44%) or dedicated emergency lists (29%). Two thirds had suspected bile duct stones and 38.1% underwent bile duct exploration. The median operating time was 75 min, median hospital stay 7 days, conversion rate 0.8%, morbidity 8.9% and mortality rate 0.2%. Conclusion: Index admission cholecystectomy for biliary emergencies can have low rates of morbidity and mortality. Timely referral and flexible theatre lists facilitate the service, optimising clinical results, number of biliary episodes, hospital stay and presentation to resolution intervals. Cost benefits and reduced interval readmissions need to be weighed against the length of hospital stay per episode. [ABSTRACT FROM AUTHOR]

Introduction: Subtotal cholecystectomy (SC) is a technique to manage the difficult gallbladder and avoid hazardous dissection and biliary injury. Until recently it was used infrequently. However, because of reduced exposure to open total cholecystectomy in resident training, we recently adopted subtotal cholecystectomy as the bail-out procedure of choice for resident teaching. This study reports our experience and outcomes with subtotal cholecystectomy in the years immediately preceding adoption and since adoption.Methods: A retrospective analysis was conducted of patients undergoing SC from July 2010 to June 2019. Outcomes, including bile leak, reoperation and need for additional procedures, were analyzed. Complications were graded by the Modified Accordion Grading Scale (MAGS).Results: 1571 cholecystectomies were performed of which 71 were SC. Subtotal cholecystectomy patients had several indicators of difficulty including prior attempted cholecystectomy and previous cholecystostomy tube insertion. The most common indication for SC was marked inflammation in the hepatocystic triangle (51%). As our experience increased, fewer patients required open conversion to accomplish SC and SC was completed laparoscopically, usually subtotal fenestrating cholecystectomy (SFC). Most patients (85%) had a drain placed and 28% were discharged with a drain. The highest MAGS complication observed was grade 3 (11 patients, 15%). Six patients had a bile leak from the cystic duct resolved by ERCP. At mean follow-up of about 1 year no patient returned with recurrent symptoms.Conclusions: Subtotal fenestrating cholecystectomy is a useful technique to avoid biliary injury in the difficult gallbladder and can be performed with very satisfactory rates of bile fistula, ERCP, and reoperation. [ABSTRACT FROM AUTHOR]

Background: To evaluate the laparoscopic management of Mirizzi syndrome, seldom diagnosed preoperatively causing difficulty when performing cholecystectomy and increasing complication risks.Methods: Analysis of a prospective single-surgeon database of 5700 laparoscopic cholecystectomies found 58 Mirizzi syndrome cases. They were managed with an intention to treat during the index admission according to protocol of single-session management of bile duct stones.Results: 38/58 patients were females (65.5%). The median age was 55 years. 53 cases were emergency admissions. 34 cases (58.6%) only had ultrasound scanning. Operative difficulty was Grade IV in 34 cases (58.6%) and Grade V in 20 (34.5%) (Nassar Scale). There were 33 Mirizzi Type IA, 7 Type IB, 16 Type II and one each of Type III and Type IV. Bile duct exploration was performed in 94.8% through choledochotomy/ transfistula in 58.6% or transcystic in 36.2%. Four cases required conversion to open. Postoperative morbidity occurred in 29%. Two 30-day mortalities occurred from pneumonia in two elderly patients who were late referrals.Conclusion: Although the utilization of the laparoscopic approach in managing bile duct stones is not currently widely practiced it was safer in this series than in reported series of open surgery in Mirizzi Syndrome. The optimal approach to Mirizzi Type II is via cholecystocholedochal fistula to explore the bile duct then drain with T-tube through the fistula. It is unnecessary to perform bilioenteric bypass in majority of cases, reducing the morbidity and mortality. [ABSTRACT FROM AUTHOR]

Purpose: Laparoscopic cholecystectomy (LC) is performed widely for acute cholecystitis (AC). This study was conducted to identify the predictors for conversion cholecystectomy (CC) for AC. Methods: The subjects of this study were 395 patients who underwent emergency surgery for AC between 2011 and 2019. Univariate and multivariate analyses were performed to establish the significance of the risk factors for CC in patients with grades II and III AC. Results: There were 162 TG18 GII and GIII patients in the LC group and 31 in the CC group. Univariate analysis revealed significant differences in performance status (p = 0.039), C-reactive protein levels (p = 0.016), albumin levels (p = 0.002), gallbladder (GB) wall thickness (p = 0.045), poor contrast of the GB wall (p = 0.035), severe inflammation around the GB (p < 0.001), enhancement of the liver bed (p = 0.048), and duodenal edema (p < 0.001) between the groups. Multivariate analysis identified hypoalbuminemia (p = 0.043) and duodenal edema (p = 0.014) as independent risk factors for CC. Conclusions: Most patients with grade I AC underwent LC and had better surgical outcomes than those with grades II and III AC. The most appropriate surgical procedure should be selected based on preoperative imaging of the GB and the neighboring organs and by the presence of hypoalbuminemia. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy is increasingly performed in an ever ageing population; however, the risks are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of cholecystectomy in the elderly population compared to younger patients. Method: A systematic literature search of PubMed, EMBASE and the Cochrane Library databases were conducted including studies reporting laparoscopic cholecystectomy in the elderly population. A meta-analysis was reported in accordance with the recommendations of the Cochrane Library and PRISMA guidelines. Primary outcome was overall complications and secondary outcomes were conversion to open surgery, bile leaks, postoperative mortality and length of stay. Results: This review identified 99 studies incorporating 326,517 patients. Increasing age was significantly associated with increased rates of overall complications (OR 2.37, CI95% 2.00–2.78), major complication (OR 1.79, CI95% 1.45–2.20), risk of conversion to open cholecystectomy (OR 2.17, CI95% 1.84–2.55), risk of bile leaks (OR 1.50, CI95% 1.07–2.10), risk of postoperative mortality (OR 7.20, CI95% 4.41–11.73) and was significantly associated with increased length of stay (MD 2.21 days, CI95% 1.24–3.18). Conclusion: Postoperative outcomes such as overall and major complications appear to be significantly higher in all age cut-offs in this meta-analysis. This study demonstrated there is a sevenfold increase in perioperative mortality which increases by tenfold in patients > 80 years old. This study appears to confirm preconceived suspicions of higher risks in elderly patients undergoing cholecystectomy and may aid treatment planning and informed consent. [ABSTRACT FROM AUTHOR]

Background: Gallstone pancreatitis (GSP) has evidence‐based guidelines regarding management. Both the International Association of Pancreatology/American Pancreatology Association and American College of Gastroenterology recommend index admission cholecystectomy (IAC) in patients presenting with mild GSP. The aim of this study was to examine guideline adherence and GSP recurrence rate when IAC was not performed. A comparison between admitting specialty was also performed to examine the difference in compliance rates. Methods: A retrospective chart review was conducted on all patients who presented to the Sunshine Coast Hospital and Health Service with GSP from December 2013 to December 2016. Patient demographics, timing of surgery, admitting specialty, laboratory and imaging results were recorded. Results: A total of 95 patients were identified with a first presentation of mild GSP during the study period. Of whom, 66 (69.5%) underwent IAC and 29 (30.5%) were discharged prior to cholecystectomy with 10 of those patients receiving index admission endoscopic sphincterotomy. Five patients (17%) who did not receive IAC were readmitted with gallstone‐related complications with the mean time to re‐presentation of 12.8 days (range 7–21 days). Patients were more likely to receive IAC when admitted under surgery compared with gastroenterology (76% versus 20%, P < 0.001). Conclusion: Two out of three patients presenting with mild GSP underwent IAC in accordance with evidence‐based management guidelines. Patients should be admitted under a surgical service to prevent delay in definitive management. [ABSTRACT FROM AUTHOR]

Background: The prediction of a difficult cholecystectomy has traditionally been based on certain pre-operative clinical and imaging factors. Most of the previous literature reported small patient cohorts and have not used an objective measure of operative difficulty. The aim of this study was to develop a pre-operative score to predict difficult cholecystectomy, as defined by a validated intra-operative difficulty grading scale.Method: Two cohorts from prospectively maintained databases of patients who underwent laparoscopic cholecystectomy were analysed: the CholeS Study (8755 patients) and a single surgeon series (4089 patients). Factors potentially predictive of difficulty were correlated to the Nassar intra-operative difficulty scale. A multivariable binary logistic regression analysis was then used to identify factors that were independently associated with difficult laparoscopic cholecystectomy, defined as operative difficulty grades 3 to 5. The resulting model was then converted to a risk score, and validated on both internal and external datasets.Result: Increasing age and ASA classification, male gender, diagnosis of CBD stone or cholecystitis, thick-walled gallbladders, CBD dilation, use of pre-operative ERCP and non-elective operations were found to be significant independent predictors of difficult cases. A risk score based on these factors returned an area under the ROC curve of 0.789 (95% CI 0.773-0.806, p < 0.001) on external validation, with 11.0% versus 80.0% of patients classified as low versus high risk having difficult surgeries.Conclusion: We have developed and validated a pre-operative scoring system that uses easily available pre-operative variables to predict difficult laparoscopic cholecystectomies. This scoring system should assist in patient selection for day case surgery, optimising pre-operative surgical planning (e.g. allocation of the procedure to a suitably trained surgeon) and counselling patients during the consent process. The score could also be used to risk adjust outcomes in future research. [ABSTRACT FROM AUTHOR]

Background: Contemporary 3D platforms have overcome past deficiencies. Available trainee and laboratory studies suggest stereoscopic imaging improves performance but there is little clinical data or studies assessing specialists. We aimed to determine whether stereoscopic (3D) laparoscopic systems reduce operative time and number of intraoperative errors during specialist-performed laparoscopic cholecystectomy (LC).Methods: A parallel arm (1:1) randomised controlled trial comparing 2D and 3D passive-polarised laparoscopic systems in day-case LC using was performed. Eleven consultant surgeons that had each performed > 200 LC (including > 10 3D LC) participated. Cases were video recorded and a four-point difficulty grade applied. The primary outcome was overall operative time. Subtask time and the number of intraoperative consequential errors as identified by two blinded assessors using a hierarchical task analysis and the observational clinical human reliability analysis technique formed secondary endpoints.Results: 112 patients were randomised. There was no difference in operative time between 2D and 3D LC (23:14 min (± 10:52) vs. 20:17 (± 9:10), absolute difference - 14.6%, p = 0.148) although 3D surgery was significantly quicker in difficulty grade 3 and 4 cases (30:23 min (± 9:24), vs. 18:02 (± 7:56), p < 0.001). No differences in overall error count was seen (total 47, median 1, range 0-4 vs. 45, 1, 0-3, p = 0.62) although there were significantly fewer 3D gallbladder perforations (15 vs. 6, p = 0.034).Conclusion: 3D laparoscopy did not reduce overall operative time or error frequency in laparoscopic cholecystectomies performed by specialist surgeons. 3D reduced Calot's dissection time and operative time in complex cases as well as the incidence of iatrogenic gallbladder perforation (NCT01930344). [ABSTRACT FROM AUTHOR]

Objective We are aiming to identify the safety and feasibility of early laparoscopic cholecystectomy (LC) directly after the improvement of manifestations of an attack of mild acute biliary pancreatitis (MABP). Patients and methods This study included 150 patients of MABP. Patients were allocated into two groups: group same admission-laparoscopic cholecystectomy (SA-LC) (n=80) who underwent LC in the same hospital admission of MABP after improving the indicator of the acute inflammation, and group delayed laparoscopic cholecystectomy (D-LC) (n=70) who underwent LC 4–6 weeks after recovery of acute biliary pancreatitis. Patients' data were collected during and after surgery; thereafter, the gathered data were statistically analyzed. Results No significant differences between both groups about the mean operative time (P=0.162) were observed; however, the mean operative time was higher in the delayed elective group (SA-LC=48.12±10.44 and D-LC=50.56±11.43). The incidence of bile leakage was 1/80 and 1/70 in SA-LC and D-LC, respectively. Moreover, there was no significant difference between both groups with regard to the conversion rate, length of ICU admission, and the postoperative hospital stay days. Conclusion Undergoing LC during the same hospital admission after an attack of MABP is a feasible and safe operation. Furthermore, it stops the event of readmission due to gallstone-related complications. [ABSTRACT FROM AUTHOR]

Background: Day-case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day-case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables. Methods: Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set. Results: Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same-day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15–0.23), higher ASA scores (OR 0.19, 95% CI 0.15–0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58–0.74), previous acute gallstone-related admissions (OR 0.54, 95% CI 0.48–0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34–0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001). Conclusions: The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same-day discharges following cholecystectomy. [ABSTRACT FROM AUTHOR]

Background: A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets.Methods: Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall's tau for dichotomous variables, or Jonckheere-Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis.Results: A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001).Conclusion: We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty. [ABSTRACT FROM AUTHOR]

Objective: To correlate the operative findings of patients undergoing laparoscopic cholecystectomy, either acute or elective, with surgical complications and conversion to open cholecystectomy. Study Design: Comparative cross-sectional study. Place and Duration of Study: Combined Military Hospital and Pak-Emirates Military Hospital, Rawalpindi Pakistan, from Jul 2021 to Mar 2022. Methodology: Data from patients who underwent laparoscopic cholecystectomy was collected after gaining consent. Patients were evaluated for the correlation of operative findings of acute and nonacute gallbladder cases with the development of complications and conversion to open cholecystectomy. Results: Out of 250 patients, 205 were non-acute cases, whereas 45 were acute. The most common intraoperative complication was iatrogenic perforation of gallbladder 73(29.2%); more common in elective cases 49(19.6%) than in acute cases 24(9.6%). Post-operative complications included sub-hepatic collections 3(1.2%) and port site infections 2(0.8%). There were six overall conversions (2.4%), of which 3(1.2%) occurred in acute gallbladder cases and 3 in elective gallbladder. Acute cases were significantly more likely to be converted to open operations (p=0.039). They were found to have a significant association with gallstone spillage (p<0.001), iatrogenic perforation of the gallbladder (p<0.001), bile leakage (p=0.018), and subhepatic collection (p=0.024). Conclusion: The likelihood of surgical complications and conversion to open procedure can be accurately predicted by the acute gallbladder status pre-operatively. It is thus important to consider these outcomes when commencing post-operative care. [ABSTRACT FROM AUTHOR]

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations.Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves.Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45-85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p < 0.001), with the proportions of operations lasting > 90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score.Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care. [ABSTRACT FROM AUTHOR]

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Purpose: Robotic LaparoEndoscopic Single-Site Surgery Cholecystectomy has been performed for 5 years using a dedicated platform (da Vinci® Single-Site®) with the da Vinci® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). While short-term feasibility has been described, long-term assessment of this method is currently outstanding. The aim of this study was to assess long-term parietal complications of this technique.Methods: In this retrospective study, patients operated between 2011 and 2013 were evaluated. Parietal incision was assessed with ultrasonography and patients screened for residual pain from scar tissue. Demographic and perioperative data were also collected.Results: We evaluated 48 patients [38 female, 79.2%; median age 49 years (range: 24-81 years)]; mean BMI 25.9 kg/m2 [±SD 4.1 kg/m2]. After a median follow-up of 39 months (range: 25-46 months), six incisional hernias (two patients had a positive echography but a negative clinical examination) were found (12.5%, 95% CI 7.5-30.2), and two patients had a surgical repair. The overall rate of incisional hernia was 16.7% (95% CI 7.5-30.2). Residual pain was observed in 5 of 48 patients.Conclusion: This preliminary study suggests that a clinically significant rate of incisional hernias can occur after R-LESS-C. Larger studies comparing R-LESS-C to alternative methods with long-term follow-up are necessary. [ABSTRACT FROM AUTHOR]

Aim of the study: The guidelines recommend that patients with mild gallstones pancreatitis should undergo a definitive management for gallstones during the same admission or within the next two weeks. The aim of this study was to estimate the financial cost resulting from a delay in surgical management following mild gallstones pancreatitis. This includes the costs of readmissions with biliary events and the subsequent investigations required during these admissions.Materials and methods: A retrospective analysis included patients with gallstone pancreatitis who were admitted to a district general hospital in the United Kingdom over one year. Patients with severe pancreatitis and those unfit for surgery were excluded.Results: Forty patients were included in the study, 27 females (67%) and 13 males (33%). Mean age was 50.2 years. Twenty-two patients of the total presented with a single admission with gallstone pancreatitis prior to an elective surgery; however, 18 patients (45%) required recurrent admissions. The duration between the first admission and surgery ranged from 14 to 389 days (median of 99 days). Only one patient (2.5%) had cholecystectomy within two weeks of admission as per guidelines. Twenty-two ultrasound scans, four computed tomography scans, 15 magnetic resonance cholangiopancreatography, and two endoscopic retrograde cholangiopancreatography were the total of the extra-investigations required during readmissions. Estimated costs of extra admissions and extra investigations exceeded £33,000.Conclusions: The delay in cholecystectomy for patients admitted with mild gallstone pancreatitis and fit for surgery has resulted in high readmission rate with biliary events, and subsequently high extrax costs. [ABSTRACT FROM PUBLISHER]

Background:International guidelines recommend cholecystectomy within 2–4 weeks after mild to moderate acute biliary pancreatitis (ABP) to prevent recurrence. We aimed to investigate the compliance to guidelines concerning early cholecystectomy and the associated costs. Methods:Admissions for ABP 2011–2013 were retrospectively reviewed. Classification was made according to the revised Atlanta classification. Treatment, time to surgery and recurrence, as well as cost analysis for both in-hospital costs and loss of production (LOP) were performed. Results:In total, 254 patients were included. Some 202 of the ABP patients (80%) underwent definitive treatment during their first attack of ABP (68% cholecystectomy, 17% endoscopic retrograde cholangiopancreatography (ERCP), 15% both interventions) and 186 (73%) were treated within 1 month of discharge. Patients with ERCP alone were significantly older than cholecystectomy cases (p < .001), but no significant difference was observed between those who underwent ERCP or no treatment (p = .071). Mild ABP had intervention earlier (p < .001). In all, 52 patients (20%) had no intervention, out of which 15 were readmitted due to pancreatitis, compared to 3 patients of those treated at the initial admission (p < .001). The mean cost for hospital care and LOP in mild ABP was €6882 ± 3010 and €9580 ± 7047 for moderate ABP (p = .001). The cost for a recurrent episode was €16,412 ± 22,367. Conclusion:By improved compliance to current guidelines concerning the management of ABP, recurrence rate and associated costs can potentially be reduced. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to audit the current management of patients suffering with gallstone pancreatitis ( GSP) at a university teaching hospital for compliance with the British Society of Gastroenterology ( BSG) guidelines regarding cholecystectomy post- GSP. Methods Data were collected on all patients identified via the hospital coding department that presented with GSP between January 2011 and November 2013. Patients with alcoholic pancreatitis were excluded. The primary outcome was the length of time in days from diagnosis of GSP to cholecystectomy. Secondary outcomes included readmission with gallstone-related disease prior to definitive management and admitting speciality. Results One hundred and fifty-eight patients were identified with a presentation of GSP during the study period. Thirty-nine patients were treated conservatively. One hundred and six patients underwent laparoscopic cholecystectomy a median (interquartile range) interval of 33.5 days (64 days) post-admission. Patients with a severe attack as classified by the Glasgow severity score ( n = 16) waited a median of 79.5 days (71.5) for cholecystectomy. Only 32% ( n = 34) of patients with mild disease underwent cholecystectomy during the index admission or within 2 weeks. When grouped by admitting speciality, patients admitted initially under hepatobiliary surgery waited significantly fewer days for definitive treatment compared with other specialities ( P < 0.0001). Twenty-one patients (19.8%) re-presented with gallstone-related pathology prior to undergoing cholecystectomy. Conclusions Only 32.1% were treated as per BSG guidelines. About 19.8% ( n = 21) of the patients suffered further morbidity as a result of a delayed operation and there is a clear difference between admitting speciality and the median time to operation. [ABSTRACT FROM AUTHOR]

Background Same-admission cholecystectomy is indicated after gallstone pancreatitis to reduce the risk of recurrent disease or other gallstone-related complications, but its impact on overall costs is unclear. This study analysed the cost-effectiveness of same-admission versus interval cholecystectomy after mild gallstone pancreatitis. Methods In a multicentre RCT (Pancreatitis of biliary Origin: optimal timiNg of CHOlecystectomy; PONCHO) patients with mild gallstone pancreatitis were randomized before discharge to either cholecystectomy within 72 h (same-admission cholecystectomy) or cholecystectomy after 25-30 days (interval cholecystectomy). Healthcare use of all patients was recorded prospectively using clinical report forms. Unit costs of resources used were determined, and patients completed multiple Health and Labour Questionnaires to record pancreatitis-related absence from work. Cost-effectiveness analyses were performed from societal and healthcare perspectives, with the costs per readmission prevented as primary outcome with a time horizon of 6 months. Results All 264 trial participants were included in the present analysis, 128 randomized to same-admission cholecystectomy and 136 to interval cholecystectomy. Same-admission cholecystectomy reduced the risk of acute readmission for recurrent gallstone-related complications from 16·9 to 4·7 per cent ( P = 0·002). Mean total costs from a societal perspective were €234 (95 per cent c.i. -1249 to 738) less per patient in the same-admission cholecystectomy group. Same-admission cholecystectomy was superior to interval cholecystectomy, with a societal incremental cost-effectiveness ratio of -€1918 to prevent one readmission for gallstone-related complications. Conclusion In mild biliary pancreatitis, same-admission cholecystectomy was more effective and less costly than interval cholecystectomy. [ABSTRACT FROM AUTHOR]