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Background: Multiple scores have been created in order to predict difficult cholecystectomy, nonetheless there is not a consensuated standard on which to use. The importance of a predictive score to be able to establish a difficult cholecystectomy would be a relevant instrument in order to better inform the patient, properly call for help when needed, choose the correct staff, and schedule and plan the surgical procedure accordingly. Methods: A diagnostic trial study was performed. All different predictive scores for difficult cholecystectomy were calculated for each patient. The correlation between the preoperative score and cholecystectomies considered as "difficult" were measured estimating the preoperative score's predictive value using a receiver operating characteristics curve in order to predict findings for difficult cholecystectomy. Results: A total of 635 patients between 2014 and 2021 were selected. Selected patients had a mean age of 55.0 (interquartile range: 28.00) and were mostly female (64.25%). Surgical outcomes of patients with difficult cholecystectomy had statistically significant higher rates of subtotal cholecystectomies, drain usage, complications and reinterventions, prolonged surgical times, and longer hospital stay. When analyzing the predictive value on each of the different scores applied, score 4 had the highest performance for predicting difficult cholecystectomy with an area under the curve =0.783 (CI 95% 0.745-0.822). Conclusions: Difficult cholecystectomies are associated with worse surgical outcomes. The standardization and use of predictive scores for difficult cholecystectomy must be implemented in order to improve surgical outcomes as a result of more meticulous planning when scheduling the procedure. [ABSTRACT FROM AUTHOR]

Teaching Point: Recognize anatomical bile duct anomalies as a potential etiology of bile leakage post-cholecystectomy, and emphasize the importance of adequate radiological evaluation for correct management. [ABSTRACT FROM AUTHOR]

Background: Cystic artery pseudoaneurysms are rare. It usually occurs as a complication of laparoscopic cholecystectomy, but can arise uncommonly as a complication of acute cholecystitis. Ruptured cystic artery aneurysms present with haemobilia, intraperitoneal or upper gastrointestinal bleeding. We present an unusual case of cystic artery aneurysm presenting as a massive lower gastrointestinal bleed. Case presentation: A 47-year-old man was admitted with a thoracic abscess and was noted incidentally on CT to have acute cholecystitis. Subsequently the patient then presented with massive fresh PR bleeding. This was found on CT to be the result of a cystic artery pseudoaneurysm with associated gallbladder fistulation to the hepatic flexure, secondary to cholecystitis. The patient was treated with coil embolisation of the cystic artery made a full recovery and was discharged with a view to performing an elective cholecystectomy. Conclusion: Cystic artery pseudoaneurysm is a rare complication of cholecystitis which can present as massive lower gastrointestinal haemorrhage secondary to cholecystocolic fistula. Percutaneous embolization is a safe and effective treatment in the acute phase. [ABSTRACT FROM AUTHOR]

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Abstract Background Consistent measurement and reporting of outcomes, including adequately defined complications, is important for the evaluation of surgical care and the appraisal of new surgical techniques. The range of complications reported after LC has not been evaluated. This study aimed to identify the range of complications currently reported for laparoscopic cholecystectomy (LC), and the adequacy of their definitions. Methods MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for prospective studies reporting clinical outcomes of LC, between 2013 and 2016. Results In total 233 studies were included, reporting 967 complications, of which 204 (21%) were defined. One hundred and twenty-two studies (52%) did not provide definitions for any of the complications reported. Conversion to open cholecystectomy was the most commonly reported complication, reported in 135 (58%) studies, followed by bile leak in 89 (38%) and bile duct injury in 75 (32%). Mortality was reported in 89 studies (38%). Conclusion Considerable variation was identified between studies in the choice of measures used to evaluate the complications of LC, and in their definitions. A standardised set of core outcomes of LC should be developed for use in clinical trials and in evaluating the performance of surgical units. [ABSTRACT FROM AUTHOR]

The Erector Spinae Plane Block (ESP) is a novel regional technique for anesthesia or analgesia. Originally the ESP block was described in 2016 in a case report regarding analgesia intervention for a case of thoracic neuropathic pain. Since then, there has been growing interest and research adding experience about the ESP block as regional anesthetic and analgesic technique. Reviewing the literature about this novel technique in databases like PubMed using the key words "erector spinae plane block" returns approximately 56 publications. So far there is no available big series of cases or reviews regarding the ESP block. The literature is limited to case reports or case series. With the present case we are interested in exploring the efficacy of ESP block as a postoperative analgesic method for laparoscopic cholecystectomy. We describe the case of a 76-year-old female patient scheduled for laparoscopic cholecystectomy. Written informed consent was granted (for procedure and publication of photos). We applied a bilateral ultrasound-guided ESP block at T6 level while the patient was awake before general anesthesia induction. The anesthetic solution we used consisted of 12 mL Ropivacaine 0.375% plus 2 mg dexamethasone (on each side). After the successful administration of the block (observation of the solution spread between transverse process and the erector spinae muscles), general anesthesia was induced and the procedure was started. Procedure and recovery was uneventful with the patient experiencing very good analgesia (NRS pain score 0 up to 6 hours after block placement). The patient presented mild pain (NRS score of 2–3) after 6 hours and requested the "on demand" pain medication (1 g paracetamol IV) only 10 hours after the ESP block (NRS pain score of 4–5). The patient experienced no nausea or vomiting, was mobilized easily about 6 hours after the block and was discharged the next day. This relatively simple and safe block dramatically reduced the amount of IV pain medication we usually administer for the specific procedure. The overall result was increased satisfaction of the patient and avoidance of opioid use. [ABSTRACT FROM AUTHOR]

Background: Gallstones and biliary sludge accounted for 30-55% of acute pancreatitis in the West whereas in other countries the incidence of all cases of pancreatitis amounts up to 68.5%. The risk of subsequent attacks for patients recovering from the first attack of acute biliary pancreatitis is 30-fold higher than general population. Further attacks can be prevented by cholecystectomy. Both immediate and delayed cholecystectomies are used with different degree of success and complication rates. Objectives: To compare the frequencies of complications in early and late cholecystectomy in cases of mild acute biliary pancreatitis. Material & Methods:… Study Design: Randomized control trial. Setting: Surgical unit I Nishtar Medical College/ Hospital Multan. Duration of Study: 2 years from 1-1-2015 to 31-12-3016. Sample Size: Total 172 patients, 86 in each group. Sampling Technique: Nonprobability, consecutive sampling. Results: In this study there were total 172 cases out of which 89 (51.74%) were males and 83 (48.26%) females. The mean age was 42.02± 6.36 years and mean duration of symptoms was 4.08± 2.54 days. Mean duration of surgery was 53.30± 6.30 minutes. There were 47 males in the group undergoing early cholecystectomy and 39 in delayed with p= 0.44. Both groups had maximum cases in age group of 40-50 year with p= 0.39. There was no significant difference in terms of duration of symptoms (p=0.26) in both groups. There was significant difference in terms of prolonged duration of surgery where it was seen in 8 (9.30%) out of 86 cases with early as compared to 2 (2.33%) out of 86 cases with delayed cholecystectomy with p value of 0.05. Prolonged duration of hospital stay was also more seen in early cholecystectomy as compared to delayed one, seen in 10 (11.63) cases in early and 4 (4.65%) cases with delayed surgery in their respective groups with p= 0.09. There was significant difference (p= 0.008) in terms of per operative complication with early surgery where it affected the 18 (20.93%) cases as compared to delayed one with 6 (6.95%) cases. There was again significant difference shown in terms of recurrence of pancreatitis which was seen in 7 (8.14%) of cases with early as compared to 1 (1.16%) with delayed surgery with p= 0.03. Conclusion: Early and late cholecystectomies both are performed in tertiary care hospitals. The late cholecystectomy has shown significantly lower per operative complications, duration of surgery and chances of the recurrent pancreatitis. [ABSTRACT FROM AUTHOR]

Background: Despite being the most commonly performed operations, sometimes cholecystectomy fails to relieve symptoms; this is now a well-recognised clinical entity termed 'post-cholecystectomy syndrome' (PCS). Very few studies from India deal with PCS, and the present study was carried out to find the incidence and risk factors for PCS in patients undergoing elective laparoscopic cholecystectomy (LC). Materials and Methods: The records of 207 patients undergoing elective LC were prospectively maintained for 6 months after surgery. Persistence or appearance of new symptoms after surgery was documented and investigated only when they persisted beyond 30 days of surgery. Results: There were 185 (89.4%) female patients and 22 (10.6%) male patients with a mean age of 44.4 years (age range: 12-79 years). Conversion to open cholecystectomy was done in 18 patients (8.69%), mainly due to adhesions and unclear anatomy. The incidence of symptoms was found to be 13% at 6 months follow-up, showing a reducing trend from 58% in the 1st week after LC; the most common symptom in symptomatic patients was dyspepsia (55.56%). On investigation, a cause for symptoms could be detected in only 0.97%. Conclusion: Symptoms are common after LC, but they settle over time. Very few patients have a detectable cause for symptoms after LC, and it is difficult to predict which patients will become symptomatic after LC; in the present series, previous attacks of cholecystitis and presence of co-morbid conditions were the only consistent risk factors for symptoms after LC. [ABSTRACT FROM AUTHOR]

Premise and Objective: Elective laparoscopic cholecystectomy (LC) has low risk for post-operative infectious complications; still most clinicians use persistent post-operative prophylactic antibiotics out of habit, tradition, or simply as defensive practice due to evolving medicolegal implications of a large number of surgeries being showcased as daycare or next day discharge procedures. This randomised prospective trial was done to test the need for such prophylaxis in cases of elective LC in a rural/semi-urban setting. Materials and Methods: Two hundred and ten successive patients undergoing elective LC were randomised into groups receiving single dose of injection ceftriaxone at the time of induction of anaesthesia, (Group A = 112 cases) and those who in addition to above received injection ceftriaxone twice daily for 2 days postoperatively (Group B = 98 cases). Post-operative infectious complications between two groups were compared for variables such as age, sex, body mass index and bile/stone spillage. Results: There was no significant difference in surgical site infection rates between the groups for variables such as age, sex, body mass index, duration of symptoms, American Society of Anesthesiologists grade, duration of surgery and hospital stay. Intraoperative spillage of stones (9.8% [A]: 5.1% [B]) did not increase infectious complications even in the presence of positive bile culture (Group A, N = 7 vs. Group B, N = 3). An operative time of greater than 60 min was found to be associated with increased surgical site infection (P = 0. 0006). Conclusion: Single dose of ceftriaxone at the time of induction is adequate prophylaxis following elective LC even in the rural/semi-urban Indian setting and routine continued administration of antibiotic should be abandoned as it contributes to adverse reactions, drug resistance and unnecessary financial burden. [ABSTRACT FROM AUTHOR]

Background: Laparoscopy is an acceptable procedure for cholecystitis in pregnancy. Laparoscopic complications during pregnancy can be unique. Uterine perforation is a rare complication during laparoscopy of pregnant women. Acquaintance with this complication can help surgeons and gynecologist to manage these patients properly. We will report a case of uterine perforation during laparoscopy. Case presentation: Our patient was a 24-year pregnant woman with gestational age of 28 weeks. She had nausea and vomiting and right upper quadrant tenderness, she was admitted in surgery ward on January 2017 in an academic hospital in Mashhad and candidate for laparoscopic cholecystectomy with diagnosis of cholecystitis. Her fundal height was 28 centimeters. Laparoscopy was done with Hasson technique and three punctures. During abdominal trocar insertion uterine perforation occurred. Amniotic fluid leaked in the abdomen. Perforation repaired immediately and then cholecystectomy was done. Fetal heart rate was normal. After surgery according to stable vital signs and absence of bleeding and contraction, the patient was transferred to the midwifery department. The patient received one course of betamethasone for fetal lung maturation. Antibiotic therapy initiated. During the hospitalization, the patient was monitored daily for vital signs (fever and tachycardia), uterine contraction, vaginal bleeding and vaginal bleeding. Daily fetal heart monitoring was performed. After close prenatal care cesarean section was done in 38 weeks of pregnancy and a healthy baby was born with appropriate Apgar score. Conclusion: Laparoscopy in pregnant women is usually safe.Pregnancy-specific complications such as uterine injury are not common, but with a series of precautions before and during surgery. These complications can be reduced. Uterine perforation during laparoscopy if properly managed is usually not associated with significant risk. [ABSTRACT FROM AUTHOR]

Laparoscopic cholecystectomy (LC) is preferred in the treatment of symptomatic cholecystolithiasis. Gallstone spillage is not uncommon, and there have been reports of associated complications. We report a case of a free intraperitoneal gallstone, left inadvertently during LC, which developed an inflammatory phlegmon with abscess containing gallstone, causing extraluminal compression on the distal ileum, resulting in small bowel obstruction. This complication in particular is almost unheard of. The patient underwent laparoscopic drainage of abscess and retrieval of gallstone, which relieved the obstruction. Clinicians, therefore, need to keep an open mind in the workup for bowel obstruction. During LC, gallstone spillage should be prevented and retrieved whenever possible to minimize early and late complications associated with it. [ABSTRACT FROM AUTHOR]

Introduction and Background: Infection of the incised skin or soft tissue is a common but potentially avoidable complication of surgical procedures. Some bacterial contamination of surgical site infection is inevitable, from patients own flora or from the environment. Pre operative risk score based on presence of co-morbidities has been devised by American Society of Anaesthesiologists (ASA). Post operative wound infection has an enormous impact on patient's quality of life and contributes substantially to the financial cost of patient care. Objective: To find out the prevalence of wound infection, its correlation with ASA score, duration of procedure and positive bile culture and also to find out the type of organisms commonly found in the bile aspirated from gall bladder in patients subjected to cholecystectomy in a tertiary care hospital in Kashmir. Materials and Methods: After an institutional approval, the study was conducted by the Department of Pharmacology; Government Medical College Srinagar in collaboration with the Department of Surgery, SMHS Hospital (Associated hospital of Government Medical College, Srinagar). Patients with USG diagnosed cholelithiasis attending the surgical OPD of the SMHS hospital, planned for elective cholecystectomy were enlisted and those with no known drug allergy were eligible. Results: Out of 200 patients studied, the number of females was twice the number of males with the mean age of study population being 41.4± 9.4 years.66% of patients belonged to ASA score 1 and rest to ASA score 2.The prevalence of post operative wound infection amongst the study population was 18.5% with a higher rate amongst those belonging to ASA score 2 as compared to those belonging to score 1. Amongst the study population, 99% showed negative bile culture, in 0.5% aspiration was not done and only 9.5% of patients showed the growth of one or the other organisms that included Klebsiella and E. Coli (31.5% each), Pseudomonas and Non haemolytic streptococcus (10.5% each) and Citrobacter(16%). As such no co relation was found to exist between positive bile culture and duration of surgery with the subsequent development of post operative wound infection. Conclusion: The overall prevalence of wound infection amongst the study group was 18.5% with a higher rate amongst those belonging to ASA score 2 as compared to those belonging to score 1 with statistically no significant association between the positive bile culture and duration of surgery with the development of postoperative wound infection. [ABSTRACT FROM AUTHOR]

Introduction: Cholecystectomies are most common surgical specimens sent in pathology laboratories. Most common histologically identified lesion of gallbladder is chronic cholecystitis which on most occasions is associated with cholelithiasis. It is most common indication for cholecystectomy and also associated with gallbladder carcinomas. Aim: The aim of the present was to study the morphological spectrum of gallstone disease and correlation of cholelithiasis with benign and malignant lesions. Materials and Methods: A retrospective study was carried out from January 2012 to June 2016. A total of 1693 specimens were assessed for size of gallbladder, serosa, wall thickness, mucosa, presence/absence of stones, their number, and type along with any mass lesions. Microscopic features assessed included inflammation, cholesterolosis, granulomas, metaplasia, calcification, dysplasia, benign and malignant neoplasms. Results: Maximum numbers of cases were between 31 to 40 years with female preponderance. Chronic cholecystitis was the most common lesion seen in 1170 (69.1%) cases. Associated calculi was present in 1625 cases, mixed and cholesterol type accounting for 1050 (64.6%) and 382 (23.51%) respectively based on morphological appearance. Amongst 439 cases showing metaplasia, antral type metaplasia was most common followed by intestinal metaplasia. Most frequent stromal change was cholesterolosis. Dysplasia was seen in 15 (0.88%) cases and malignancy in 16 cases. Conclusion: Incidental detection of gallbladder malignancy on microscopic examination is the most significant information for the surgeon as well as for the patient and this fact emphasises the importance of subjecting each gallbladder specimen for histopathological examination. [ABSTRACT FROM AUTHOR]

Background and Aims: Sevoflurane is an excellent but expensive anesthetic agent for laparoscopic cholecystectomy. To decrease sevoflurane consumption during surgery adjuvants like dexmedetomidine may be used. Dexmedetomidine is a recently introduced drug which alleviates the stress response of surgery, produces sedation and analgesia. We aimed to evaluate sevoflurane sparing effect of dexmedetomidine in patients undergoing laparoscopic cholecystectomy under entropy-guided general anesthesia (GA). Material and Methods: In this prospective randomized control study, 100 American Society of Anesthesiologists physical status I-II adult surgical patients scheduled to undergo laparoscopic cholecystectomy were enrolled. Patients were randomly divided into two groups (n = 50). In dexmedetomidine group, patients received intravenous (IV) dexmedetomidine 0.5 μg/kg over 10 min before induction followed by 0.5 μg/kg/h infusion while in control group, patients received the same volume of normal saline. Results: Sevoflurane consumption was 41% lower in dexmedetomidine group as compared to control group (7.1 [1.6] vs. 12.1 [1.9] ml, P<0.001). A 40% reduction was observed in induction dose of propofol (83.0 [19.1] vs. 127.6 [24.8] mg, P <0.001). Mean Riker sedation-agitation score, visual analog score for pain and Aldrete's score were significantly lower in dexmedetomidine group as compared to control group. None of the patients experienced any significant side effects. Conclusion: A 41% reduction in sevoflurane consumption was observed in patients receiving IV dexmedetomidine as an adjuvant in patients undergoing laparoscopic cholecystectomy under GA. [ABSTRACT FROM AUTHOR]

Hemobilia is caused by the abnormal connection between a blood vessel and the bile duct, which is usually iatrogenic and caused by hepatobiliary procedures. The classic triad of hemobilia includes biliary colic, obstructive jaundice, and gastrointestinal bleeding. We present the case of an 80-year-old man who had laparoscopic cholecystectomy complicated by hemobilia. He had an unusual presentation of hemobilia in the form of transient vasovagal episodes in addition to abdominal pain and hematochezia. [ABSTRACT FROM AUTHOR]

Objective: To describe the experience of treating empyema gall bladder with laparoscopic cholecystectomy. Study Design: Descriptive observational study. Place and Duration of Study: The study was carried out at Combined Military Hospital (CMH) Peshawar, from Feb 2012 till May 2014 for a period of twenty eight months. Material and Methods: Twenty eight patients were enrolled in the study who fulfilled the criteria for empyema and were willing for laparoscopic cholecystectomy, chances of conversion to open cholecystectomy and risk of complications involved. We defined the operative difficulty levels according to the intra-operative findings. Level 1-adherent omentum, level 2--oedematous gall bladder wall, level 3--necrotic gall bladder wall, level 4--adherent gut and level 5 -- adherent Hartmann's pouch and oedematous Calot's triangle having no defined planes. The results were noted in terms of time taken for the operation and complications of the operative procedure. Results: Twenty eight patients of empyema gall bladder underwent laparoscopic cholecystectomy. Mean age was 46.2 ± 7.1 years. Average duration of symptoms was 4.1 ± 2.3 days. Two patients had level-I operative difficulty, 6 patients had level-II difficulty, 9 patients had level-3 difficulty, 2 patients had level-IV difficulty and 9 patients had level-V difficulty. In 21(75%) patients total cholecystectomy was performed, anterior partial cholecystectomy was done in 2 patients (7.1%) and 5 patients (17.9%) were converted to open cholecystectomy. One patient (3.5%) had Stresburgh Bismuth type D injury and was managed by open exploration and T-tube placement. No mortality was encountered in the study group. Conclusion: The technique of laparoscopic cholecystectomy can be used effectively for treating empyema gall bladder specifically in American Society of Anaesthesiologists (ASA) I & II patients. Further randomized controlled trials can elaborate its efficacy. This will not only prove to be cost effective but it will also add to the comfort of the patient. [ABSTRACT FROM AUTHOR]

Objective: To find out safety and feasibility of single incision laparoscopic cholecystectomy (SLIC) using conventional instruments. Methods: This study was conducted at surgical department of LUMHS Jamshoro Pakistan from Jan: 2014 to Dec: 2015. All cases of symptomatic cholelithiasis that consented for laparoscopic surgery were included. The exclusion criteria were acute cholecystitis, acute gall stone pancreatitis, common bile duct stones and patients with co-morbid. A midline 3cm incision made supraumbilically and 10mm port placed. Two 5mm ports placed on either side of umbilicus slightly superior and laterally in order to triangulate. A 2/0 prolene suture placed through the infundibulum of the gall bladder to achieve retraction. The rest of the procedure is like standard 4 ports laparoscopic cholecystectomy. Results: Total no of cases were 50. The age ranged from 30-59 years (mean 35.20 years ±4.886.) There were 43(86%) females and 07(14%) males. The mean operating time was 80 minutes (range 50-120±16.020). Four (8%) cases were converted to standard four ports laparoscopic cholecystectomy due to bleeding and difficult dissection in Calot's triangle. Minimal blood loss was observed during the procedure with no postoperative complications. The range of hospital stay was 1-2 days (mean 1.08±0.274). Conclusion: SILC is a safe and feasible procedure with conventional laparoscopic instruments without additional cost of single port and articulated instruments. The cosmetic results are excellent with minimal increase in the operating time. [ABSTRACT FROM AUTHOR]

Background. There are limited data on risk factors for surgical site infection (SSI) after open or laparoscopic cholecystectomy. Methods. A retrospective cohort of commercially insured persons aged 18-64 years was assembled using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure or Current Procedural Terminology, 4th edition codes for cholecystectomy from December 31, 2004 to December 31, 2010. Complex procedures and patients (eg, cancer, end-stage renal disease) and procedures with pre-existing infection were excluded. Surgical site infections within 90 days after cholecystectomy were identified by ICD-9-CM diagnosis codes. A Cox proportional hazards model was used to identify independent risk factors for SSI. Results. Surgical site infections were identified after 472 of 66 566 (0.71%) cholecystectomies; incidence was higher after open (n = 51, 4.93%) versus laparoscopic procedures (n = 421, 0.64%; P < .001). Independent risk factors for SSI included male gender, preoperative chronic anemia, diabetes, drug abuse, malnutrition/weight loss, obesity, smoking-related diseases, previous Staphylococcus aureus infection, laparoscopic approach with acute cholecystitis/obstruction (hazards ratio [HR], 1.58; 95% confidence interval [CI], 1.27-1.96), open approach with (HR, 4.29; 95% CI, 2.45-7.52) or without acute cholecystitis/obstruction (HR, 4.04; 95% CI, 1.96-8.34), conversion to open approach with (HR, 4.71; 95% CI, 2.74-8.10) or without acute cholecystitis/obstruction (HR, 7.11; 95% CI, 3.87-13.08), bile duct exploration, postoperative chronic anemia, and postoperative pneumonia or urinary tract infection. Conclusions. Acute cholecystitis or obstruction was associated with significantly increased risk of SSI with laparoscopic but not open cholecystectomy. The risk of SSI was similar for planned open and converted procedures. These findings suggest that stratification by operative factors is important when comparing SSI rates between facilities. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim of this study was to find a better prophylaxis against postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy. STUDY DESIGN: A randomized control study was carried out for comparison. SETTING & DURATION: This study was conducted at department of anaesthesia and intensive care, Madinah Teaching Hospital, Faisalabad from January 2015 to July 2015. SAMPLE SIZE: The study population consisted of 90 ASA I & II status patients undergoing laparoscopic cholecystectomy under general anaesthesia. METHODS: The patients were randomly divided into three groups A, B and C. Group A patients were to receive prophylactic Dexamethasone, group B patients were to receive both Ondansetron and Dexamethasone and group C patients were to receive Ondansetron preoperatively. Postoperative nausea and vomiting was recorded and compared between three groups in PACU (Post anaesthesia care unit) for one hour and surgical ward for 23 hours respectively. RESULTS: It was observed that group B (combined Dexamethasone and Ondansetron group) patients had significantly less postoperative nausea and vomiting as well as less requirement for rescue antiemetics postoperatively as compared to group A (Dexamethasone group) and C (Ondansetron group) patients. The frequency of nausea and vomiting was 0% and 3.3% in group B as compared to 30% and 30% in group A and 16.7% and 23.3% in group C respectively. Rescue antiemetics were used in 6.7% patients in group B as compared to 40% patients in group A and 23.3% patients in group C. CONCLUSION: It is concluded that combined Dexamethasone and Ondansetron offer effective prophylaxis against postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy as compared to Dexamethasone and Ondansetron alone. [ABSTRACT FROM AUTHOR]

A double gallbladder is a rare congenital malformation. The present study describes a case of double gallbladder with secondary common bile duct stones. By way of laparoscopic choledochoscopy, the exploration and removal of a common bile duct stone was performed through the cystic duct. The process involved a primary suture of the cystic duct and was performed without using a T-tube, and completed a surgical removal of the gallbladder. The present case was successfully treated by laparoscopic surgery. From a review of previous studies published in the English language, this study, to the best of our knowledge, is the first report of such a case. Therefore, laparoscopic dissection is safe for the removal of a double gallbladder and for exploration of the common duct by choledochoscopy. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy is commonly performed, and several factors increase the risk of open conversion, prolonging operating time and hospital stay. Preoperative stratification would improve consent, scheduling and identify appropriate training cases. The aim of this study was to develop a validated risk score for conversion for use in clinical practice. Patients and methods: Preoperative patient and disease-related variables were identified from a prospective cholecystectomy database (CholeS) of 8820 patients, divided into main and validation sets. Preoperative predictors of conversion were identified by multivariable binary logistic regression. A risk score was developed and validated using a forward stepwise approach. Results: Some 297 procedures (3.4%) were converted. The risk score was derived from six significant predictors: age (p = 0.005), sex (p < 0.001), indication for surgery (p < 0.001), ASA (p < 0.001), thickwalled gallbladder (p = 0.040) and CBD diameter (p = 0.004). Testing the score on the validation set yielded an AUROC = 0.766 (p < 0.001), and a score >6 identified patients at high risk of conversion (7.1% vs. 1.2%). Conclusion: This validated risk score allows preoperative identification of patients at six-fold increased risk of conversion to open cholecystectomy. [ABSTRACT FROM AUTHOR]

Background: Although intraoperative opioids provide more comfortable anesthesia and reduce the use of postoperative analgesics, it may cause opioid induced hyperalgesia (OIH). OIH is an increased pain response to opioids and it may be associated with N-methyl-D-aspartate (NMDA) receptor. This study aimed to determine whether intraoperative nefopam or ketamine, known being related on NMDA receptor, affects postoperative pain and OIH after continuous infusion of intraoperative remifentanil. Methods: Fifty-four patients undergoing laparoscopic cholecystectomy were randomized into three groups. In the nefopam group (N group), patients received nefopam 0.3 mg/kg at the induction of anesthesia followed by a continuous infusion of 0.065 mg/kg/h. In the ketamine group (K group), patients received ketamine 0.3 mg/kg at the induction of anesthesia followed by a continuous infusion of 3 μg/kg/min. The control group did not received any other agents except for the standard anesthetic regimen. Postoperative pain score, first time and number of demanding rescue analgesia, OIH and degrees of drowsiness/sedation scale were examined. Results: Co-administrated nefopam or ketamine significantly reduced the total amount of intraoperative remifentanil and postoperative supplemental morphine. Nefopam group showed superior property over control and ketamine group in the postoperative VAS score and recovery index (alertness and respiratory drive), respectively. Nefopam group showed lower morphine consumption than ketamine group, but not significant. Conclusions: Both nefopam and ketamine infusion may be useful in managing in postoperative pain control under concomitant infusion of remifentanil. However, nefopam may be preferred to ketamine in terms of sedation. [ABSTRACT FROM AUTHOR]

Background: Standard recommendations for patients recovering from an episode of biliary pancreatitis include cholecystectomy with intra operative cholangiogram or ERCP during the same hospital admission as it is believed that the instigating factor is the passage of stones through the common bile duct. As ERCP is not widely available and expensive, cholecystectomy with IOC is routinely performed to rule out choledocholithiasis. However detection of common bile duct stones is challenging. Whether these patients undergoing cholecystectomy require direct common bile duct evaluation is controversial. Objectives: To see the presence of common bile duct stones in patients with resolving acute mild biliary pancreatitis. Materials and Methods: Patients admitted in the surgical ward in Patan and Bir hospital with the diagnosis of mild acute biliary pancreatitis that underwent cholecystectomy with intra operative cholangiography from August 2010 to July 2011 were studied. The outcome of cholangiogram was analyzed together with findings of Common bile duct exploration. Result and Conclusion: A total of 52 patients with acute mild biliary pancreatitis were operated during this period. The Common bile duct stone was found in 1.9%. Out of four patients with abnormal cholangiogram, only one patient (25%) had stone on exploration, rest of the three cases (75%) had negative exploration. The presence of common bile duct stone in case of mild acute biliary pancreatitis undergoing cholecystectomy is very low (1.96%), and thus policy of selective IOC should be applied for cases with mild biliary pancreatitis. [ABSTRACT FROM AUTHOR]

Retained abdominal swabs remain a difficult problem. This review highlights the risk factors and index pathology, as well as markers that raise clinical suspicion, of a condition that may be elusive in presentation on account of its otherwise nonspecific signs and symptoms. A review of the English literature reporting retained abdominal swabs between 1992 and 2012 revealed 100 cases. Fifty-six percent of patients presented with pain, most commonly coupled with an abdominal mass or symptoms of bowel obstruction; 6% of patients presented with a fistula or a sinus; and 6% presented with extrusion of the swab; only 7% presented with signs indicative of sepsis. The most common initial surgery was obstetric and gynaecological (in 44% of cases); the second most common was general surgery (36%), most commonly following cholecystectomy. Plain abdominal X-ray was done in 45% of patients, followed by ultrasound, computed tomography (CT) scan or both. CT scan is the best preoperative diagnostic tool currently. The varying presentations exhibited by this postsurgical entity will continue to perplex the attendant practitioner. Clinical suspicion assisted by ultrasound and CT scan will improve definitive diagnosis. While there are many checkpoints to prevent this rare yet significant complication, human error and the unpredictability of surgery may make elimination impossible. The challenges presented with a retained swab, although rare, will persist, and with it the devastating consequences for both patient and clinician. Because of this, especially in the era of a litigious mindset, surgical vigilance and pre-emptive measures cannot be emphasised enough. [ABSTRACT FROM AUTHOR]

Background: Postcholecystectomy pain (PCP) is characterized by abdominal pain after cholecystectomy. However, prevention of PCP is not well known yet. The purpose of this study was to determine whether Rowachol might be useful in preventing PCP. Methods: Between May 2013 and January 2014, a total of 138 patients with gallbladder disease who were scheduled to undergo laparoscopic cholecystectomy were randomly assigned to orally receive 100 mg Rowachol or placebo three times daily for 3 months after surgery. Abdominal pain was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire. Results: Incidence of PCP in the placebo group (n = 9, 14.3%) was higher than that in the Rowachol group (n = 3, 4.7%) with statistically marginal significance (P = 0.08). Risk factor analysis implicated PCP with increased difficulty in performing LC, more frequent pathology with acute cholecystitis, and absence of postoperative Rowachol treatment. Multivariate analysis revealed that greater difficulty of laparoscopic cholecystectomy (HR = 5.78, 95% CI 1.36-24.40, P < 0.05), and absence of postoperative Rowachol treatment (HR = 2.54, 95% CI 1.10-10.39, P < 0.05) were independent risk factors for development of PCP. Conclusion: Rowachol might be beneficial for prevention of PCP after laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

Objectives: Intra-peritoneal bile leak and gallstones spillage is a common event, during laparoscopic cholecystectomy. Some time it is not possible to retrieve all spilt gallstones, these unretrieved intra-peritoneal gallstones, initially considered harmless, with time a number of complications have been reported. Our aim was to study, factors predisposing to gallbladder perforation during laparoscopic cholecystectomy, and the incidence and adverse consequences of intra-peritoneal spilt gallstone. Period: November 2008 to December 2011. Setting: Liaquat University Hospital were studied. Method: Patients who underwent successful laparoscopic cholecystectomy for biliary colic and cholelitiasis. Patients who had intraperitoneal bile and gallstones spillage during laparoscopic cholecystectomy were follow up for long period, and all patients studied for risk of perforation and complications. Results: 1038 patient underwent successful laparoscopic cholecystectomy, among them in 812(78.23%) patient intact gallbladder were removed, and in 226 (21.77%) patient gallbladder perforation occurred. Patients had gallbladder perforations in 129(12.43) patients only bile leak was noted, and in 97(9.34%) patients bile and gallstones spillage occurred. Conclusion: We concluded the outcome and incidence of serious complications after intra-operative spillage of gallstones and bile, during laparoscopic cholecystectomy, is low and avoidable. [ABSTRACT FROM AUTHOR]

Introduction: Cancer of the gallbladder is a serious diagnostic and therapeutic problem. According to the literature, 30% of cases are not confirmed before surgery. Other cases are detected incidentally by histopathology. Clinical trials and meta-analyses show that incidental gallbladder cancer (iGBC) occurs in 0.19%-2.8% of patients after cholecystectomy. The aim of this study was to analyze the incidence and severity of iGBC in cholecystectomy procedures performed in the surgical department at the 4th Military Teaching Hospital in Wroclaw during the years 1990-2014. Patients and methods: In the years 1990-2014, a total of 7,314 cholecystectomies were performed in the surgical department because of cholecystolithiasis: 6,145 were performed using the laparoscopic approach (84.02%), 867 were performed as open surgery (11.8%), and 302 cases required conversion (5.1%). In this group, 5,214 of the patients were females (71.3%) and 2,100 were males (28.7%), with an average age of 54.7 years. Results: We found 64 iGBC cases which were confirmed by histopathology. This represented 0.87% of all cases. In this group, 50 patients were females (78.1%) and 14 were males (21.8%), with an average age of 67.1 years. Of this group, 40 patients underwent a classic cholecystectomy, while 24 underwent laparoscopic procedures, out of which 13 cases ultimately required traditional surgery. The histopathology showed 15 carcinomas that were classified as G1 (23.4%), 28 were G2 (43.75%), and 21 were G3 (32.8%). Conclusion: iGBC detected after a cholecystectomy due to cholecystolithiasis is a rare disease. We found iGBC in 0.87% of cases, which is on a comparable scale to the world literature. In the case of cancer, we frequently found it necessary to convert to an open surgical procedure. This cancer is more common in females and in people over 60 years of age. [ABSTRACT FROM AUTHOR]

Background: Following surgery and anesthesia, post-operative nausea and vomiting (PONV) are two of the most common side effects. Dexamethasone has been reported to be effective in reducing the incidence of emesis in patients undergoing chemotherapy. Aim: The aim of the study was to compare the effectiveness of granisetron and dexamethasone in combination with ondansetron and dexamethasone in combination for prophylaxis after laparoscopic cholecystectomy. Materials and methods: This is a prospective study on patients undergoing laparoscopic cholecystectomy consisted of 200 patients. 164 patients completed the study. 82 patients in group 1 and 82 patients in group 2. Patients were randomised in two groups, namely group 1 received granisetron and dexamethasone while group 2 received ondansetron and dexamethasone. Results: Out of 200 patients who initially signed the informed consent form, 164 patients (82 in group 1 and 82 in group 2) completed the study. In this study, Granisetron + Dexamethasone was found to be as effective as when compared to ondansetron + Dexamethasone as at 0-1 hour, 100% of patients in group 1 had no vomiting and 97.56% of patients had no vomiting in group 2. Total response was present in 97.56% in group 1 and 95.12% in group 2. The percentage of patients who received metoclopramide was 8.53% in both the groups. At 1-7 hour, 97.56% of patients in group 1 had no vomiting and 100% of patients had no vomiting in group 2. Total response was present in 96.34% in group 1 and 93.90% in group 2. The percentage of patients who received metoclopramide was 4.87% in group 1 and 2.43% in group 2. At 7-24 hour, 97.56% of patients in group 1 had no vomiting and 100% of patients had no vomiting in group 2. Total response was present in 95.12% in group 1 and 95.12% in group 2. The percentage of patients who received metoclopramide was 2.43% in both the groups. 4 out of 82 patients complained of dizziness in group 1 and 4 out of 82 patients complained of dizziness in group 2. 6 out of 82 patients complained of headache in group 1 and 6 out of 82 patients complained of headache in group 2 in the post anaesthesia care unit. Pain scores in group 1 were at 0-1 hr was 6±2.4, at 1-7 hour was 5.4±0.7 and at 7-24 hour was 3.5±0.9. Pain scores in group 1 were at 0-1 hr was 7±2.3, at 1-7 hour was 5.9±2.7 and at 7-24 hour was 4.5±0.2. In between the two groups, there was no significant difference in the side effects and pain scores. Conclusion: The combination of dexamethasone with either granisetron or ondansetron after induction of anesthesia in patients undergoing laparoscopic surgery showed no statistically significant difference in antiemetic efficacy with minimal side effects and excellent patient satisfaction. [ABSTRACT FROM AUTHOR]

Background and Aims: Laparoscopic cholecystectomy is associated with a fairly high incidence of postoperative discomfort which is more of visceral origin than somatic. Studies have concluded that the instillation of local anesthetic with opioid around gall bladder bed provides more effective analgesia than either local anesthetic or opioid alone. Material and Methods: The study included 90 American Society of Anesthesiologists I-II patients of age 16-65 years scheduled for laparoscopic cholecystectomy under general anesthesia. The patients received the study drugs at the initiation of insufflation of CO2 in the intraperitoneal space by the operating surgeon under laparoscopic camera guidance over the gallbladder bed. Patients in Group T received tramadol 2 mg/kg in 30 ml normal saline, in Group B received bupivacaine 30 ml of 0.125% and in Group BT received tramadol 2 mg/kg in 30 ml of 0.125% bupivacaine intraperitoneally. Postoperative pain assessment was done at different time intervals in the first 24 h using Visual Analog Scale of 0-10 (0 = No pain, 10 = Worst pain imagined). Time to first dose of rescue analgesic and total analgesics required in the first 24 h postoperatively were also recorded. The incidence of side effects during the postoperative period was recorded. Results: Reduction in postoperative pain was elicited, at 4 and 8 h postoperatively when Group BT (bupivacaine-tramadol group) was compared with Group T (tramadol group) or Group B (bupivacaine group) (P < 0.01). There was a significantly lower requirement of analgesics during first 24 h postoperatively in Group BT compared to Group B or T but no significant difference in the intake of analgesics was noted between Groups B Group T. Time to first dose of rescue analgesic was also significantly prolonged in Group BT compared to Group B or T. The incidence of nausea and vomiting was comparable in all the study groups. Conclusions: Intraperitoneal application of bupivacaine with tramadol was a more effective method for postoperative pain control after laparoscopic cholecystectomy compared to intraperitoneal bupivacaine or tramadol alone. [ABSTRACT FROM AUTHOR]

Introduction: Gallstones are the hard deposits in the gallbladder, which is a sac - like organ lying on the inferior surface of liver in the right upper quadrant of abdomen. Cholecystectomy is the first line surgical procedure to manage symptomatic gallstone. Carcinoma gallbladder carries worst prognosis of all cancer mortality and seen in patients with chronic cholecystitis due to cholelithiasis. The purpose of conducting this study was to highlight the fact, that the histopathology of the gallbladder in Pakistan is only restricted to those specimens, which are associated with macroscopic abnormalities. Objective: The frequency of gallbladder carcinoma in routine histopathology after elective Cholecystectomy for gallstones who did not show any macroscopic findings peroperatively. Material and Methods: This cross sectional study of 250 patients of both gender aged between 18 - 60 years was conducted in surgical OPD/North Surgical Unit of Mayo Hospital, Lahore in one year duration from 01-01-2014 to 31-12-2014. The non-probability purposive sampling technique was used in this study. Informed consent was taken from all the patients. Their demographics like name, age, gender and address were noted. Open / laparoscopic cholecystectomy was performed depending upon patient's choice. All gallbladder specimens, those with no obvious gross abnormalities were sent for histopathology (Gross findings, histopathological diagnosis). All data was recorded on a pre-designed proforma and analyzed using SPSS version 20. Mean and standard deviation were used to express the continuous variables like age, stone size and duration of disease. All qualitative variables like gender, number of stones and gallbladder carcinoma were presented in the form of frequency and percentages. Stratification was done for duration of disease, number of stone, size of stone and gender to address effect modifiers. Post-stratification chi-square test was applied keeping P-value ≤ 0.05 as significant. Results: In this study the mean age of the patients was 39.52 ± 12.38 years. Among 250 patients, 75 (30%) were males and 175 (70%) females. The mean duration of disease was 5.61 ± 2.75 months. Gallbladder carcinoma on routine histopathology after elective Original Article Cholecystectomy was observed in 18 (7.2%) patients whereas 232 (92.8%) patients did not have gallbladder carcinoma. All of the 18 patients who had carcinoma were females which showed a highly significant difference (p < 0.05). Among 153 cases with < 7 mm stone size, carcinoma was observed in 11 patients and in 97 cases with ≥ 7 mm stone size, carcinoma was observed in 7 cases. Among 124 cases with < 5 months of duration of disease, carcinoma was observed in 9 patients and in 126 cases with ≥ 5 months of duration of disease, carcinoma was observed in 9 cases. Among 93 cases with < 2 stones, carcinoma was observed in 7 patients and in 157 cases with ≥ 2 stones, carcinoma was observed in 11 cases. Statistically insignificant difference was found between the duration of disease, number and size of stones and carcinoma of the patients (P > 0.05). Conclusion: Although the frequency of gallbladder carcinoma on histopathology is low, but not negligible, therefore histopathology of gallbladder specimen is necessary to rule out carcinoma. [ABSTRACT FROM AUTHOR]

Mirizzi syndrome has been defined in the literature as common bile duct obstruction resulting from calculi within Hartmann’s pouch or cystic duct. We present a case of a 78-year-old female, who developed postcholecystectomy Mirizzi syndrome from a remnant cystic duct stone. Diagnosis of postcholecystectomy Mirizzi syndrome was made on endoscopic retrograde cholangiography (ERCP) performed postoperatively. The patient was treated with a novel strategy by combining advanced endoscopic and laparoscopic techniques in three stages as follows: Stage 1 (initial presentation): endoscopic sphincterotomy with common bile duct stent placement; Stage 2 (6 weeks after Stage 1): laparoscopic ultrasonography to locate the remnant cystic duct calculi followed by laparoscopic retrieval of the calculi and intracorporeal closure of cystic duct stump; Stage 3 (6 weeks after Stage 2): endoscopic removal of common bile duct stent along with performance of completion endoscopic retrograde cholangiogram. In addition, we have performed an extensive review of the various endoscopic and laparoscopic management techniques described in the literature for the treatment of postcholecystectomy syndrome occurring from retained cystic duct stones. [ABSTRACT FROM AUTHOR]

Introduction: During single-incision laparoscopic cholecystectomy (SILC), the gallbladder is suspended with stitches, resulting in perforation risk and difficulty in exploration. Aim: We used the needle grasper in SILC to hang and manipulate the gallbladder. Material and methods: Sixty-five patients (43 female, 22 male) who underwent SILC between December 2013 and December 2014 were analyzed retrospectively for patient demographics, duration of operation, laparotomy or conventional laparoscopy necessity, drain use, complications, and hospital stay periods. To place the SILC port (Covidien, Inc.), the needle grasper was inserted at the right upper abdominal quadrant without an incision to hang and manipulate the gall-bladder. Results: The mean age was 47.9 ±13.068 years; the mean body mass index (BMI) was 26.94 ±3.913 kg/m². ASA scores were 1, 2, and 3. Two patients with high BMI with additional trocar use were excluded. The operations were completed without any additional trocar in 59 patients. The mean operation time was 89 ±22.41 min. Eighteen patients required a drain; all were discharged after drain removal. One patient needed re-hospitalization and percutaneous drainage and was discharged on the 9th day. Fifty-three patients were discharged on the 1st post-operative day. Eleven patients with drains were discharged on the 2nd day, and 1 was discharged on the 7th day. The mean hospital stay period was 1.26 ±0.815 days. Conclusions: The main difficulty of SILC is to manipulate hand tools because the triangulation principle of laparoscopy use is not possible in SILC. Inserting a needle grasper into the abdominal cavity at the right subcostal area to manipulate the gallbladder helps and does not leave a visible scar. [ABSTRACT FROM AUTHOR]

Background and Aims: Postoperative pain for day surgery laparoscopic cholecystectomy has traditionally been managed with the surgeon infiltrating the wound with local anesthetic (LA). However, transversus abdominis plane (TAP) block has recently been used, although its superiority over LA remains uncertain. The primary aim was to compare LA and TAP block pain scores and analgesia used. The secondary aim was to assess satisfaction score and cost. Material and Methods: This retrospective study was commenced after ethics committee approval and ANZ clinical trial registry (ACTRN: 12612000737831). The data were collected from the theatre database and medical records of patients presenting for day case laparoscopic cholecystectomy. The sample included patients who received either bilateral port site LA infiltration with 20 ml of 0.25% Bupivacaine or bilateral TAP block with 20 ml of 0.5% ropivacaine and fentanyl postoperative pain protocol. The patients with incomplete medical records were excluded as were those admitted to an inpatient ward. Demographics and clinical characteristics were obtained from the hospital record along with pain score and postsurgery analgesia use. Postoperative pain satisfaction scores were collected by telephonic interview 30-180 days postsurgery. Results: Of 51 patients analyzed, 19 were in TAP group 29 in LA group. There were no significant differences between the LA and TAP groups with respect to postoperative pain scores (P = 0.31) or patient satisfaction scores (1 and 2+) (P = 0.36). However, fentanyl consumption in the recovery room was significantly lower in TAP group (P = 0.0079.). The consumables cost were >3 times higher in the TAP when compared to LA group. Conclusion: The performance of the TAP block with respect to pain management was comparable to LA. However, LA remains more cost effective. [ABSTRACT FROM AUTHOR]

BACKGROUND: Incomplete gallbladder removal following open and laparoscopic techniques leads to residual gallbladder stones. The commonest presentation is abdominal pain, dyspepsia and jaundice. We reviewed the literature to report diagnostic modalities, management options and outcomes in patients with residual gallbladder stones after cholecystectomy. MATERIALS AND METHODS: Medline, Google and Cochrane library between 1993 and 2013 were reviewed using search terms residual gallstones, post-cholecystectomy syndrome, retained gallbladder stones, gallbladder remnant, cystic duct remnant and subtotal cholecystectomy. Bibliographical references from selected articles were also analyzed. The parameters that were assessed include demographics, time of detection, clinical presentation, mode of diagnosis, nature of intervention, site of stone, surgical findings, procedure performed, complete stone clearance, sequelae and follow-up. RESULTS: Out of 83 articles that were retrieved between 1993 and 2013, 22 met the inclusion criteria. In most series, primary diagnosis was established by ultrasound/computed tomography scan. Localization of calculi and delineation of biliary tract was performed using magnetic resonance imaging/magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. In few series, diagnosis was established by endoscopic ultrasound, intraoperative cholangiogram and percutaneous transhepatic cholangiography. Laparoscopic surgery, endoscopic techniques and open surgery were the most common treatment modalities. The most common sites of residual gallstones were gallbladder remnant, cystic duct remnant and common bile duct. CONCLUSION: Residual gallbladder stones following incomplete gallbladder removal is an important sequelae after cholecystectomy. Completion cholecystectomy (open or laparoscopic) is the most common treatment modality reported in the literature for the management of residual gallbladder stones. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic Cholecystectomy (LC) has become the gold standard treatment for gallstone disease ever since its widespread acceptance in the early 90s. LC is a safe procedure that is very commonly performed. Objective: To evaluate the standard care of LC in terms of morbidity, mortality, complication and length of hospital stay. Setting: Surgical Department, King Hamad University Hospital, Bahrain. Design: A Retrospective Study. Method: LC patients were reviewed from July 2012 to September 2014. The following data were documented: personal characteristics, hospital stay both pre and postoperative complications, conversion to open, biliary injury and wound infection. Result: Two hundred thirty-nine patients had LC; 185 (77.41%) were females and 54 (22.59%) were males. The mean age of patients was 38.71; the youngest patient was 17 years and the oldest was 71 years. The technique of 4-port standard LC was used on 232 (97.07%) patients and 7 (2.93%) patients had a single port LC. Seven (2.93%) LC were converted to open, 6 due to distorted anatomy and the other was due to vascular injury. Six (2.51%) patients had wound infection and 2 (0.83%) had biliary tract injury. The mean hospital stay was 3.23 days. There was no mortality recorded during the study. Conclusion: LC is a safe procedure. The standard of care of LC in this study is well within the accepted values in other studies. [ABSTRACT FROM AUTHOR]

Background: Major bleeding is rare but among the most serious complications of laparoscopic surgery. Still very little is known on bleeding complications and related blood component use in laparoscopic cholecystectomy (LC). The aim of this study is to compare bleeding complications, transfusion rates and related costs between LC and open cholecystectomy (OC). Methods: Data concerning LCs and OCs and related blood component use between 2002 and 2007 were collected from existing computerized medical records (Finnish Red Cross Register) of ten Finnish hospital districts. Results: Register data included 17175 LCs and 4942 OCs. In the LC group, 1.3 % of the patients received red blood cell (RBC) transfusion compared to 13 % of the patients in the OC group (p < 0.001). Similarly, the proportions of patients with platelet (0.1 % vs. 1.2 %, p < 0.001) and fresh frozen plasma (FFP) products (0.5 % vs. 5.8 %) transfusions were respectively higher in the OC group than in the LC group. The mean transfused dose of RBCs, PTLs and FFP product Octaplas® or the mean cost of the transfused blood components did not differ significantly between the LC and OC groups. Conclusions: Laparoscopic cholecystectomy was associated with lower transfusion rates of blood components compared to open surgery. The severity of bleeding complications may not differ substantially between LC and OC. [ABSTRACT FROM AUTHOR]

Transversus abdominis plane (TAP) block is now a commonly used regional anesthesia technique. It can provide unilateral analgesia to the skin and muscles of lower abdominal wall. Original TAP block was introduced as regional abdominal field infiltration technique using landmarks. Use of ultrasound for TAP blocks enabled to perform safe and reliable block procedure. The indication for this block has been extended especially for lower abdominal surgeries. There are two concepts for TAP blocks. By subcostal to lateral TAP blocks, spread of local anesthetic is on the transvers abdominis plane. By, posterior TAP blocks including quadratus lumborum block, the target of local anesthetic is paravertebral space. The efficiency of these two techniques should be evaluated by prospective studies. [ABSTRACT FROM AUTHOR]

Purpose: Cholecystectomy is rarely performed in the child and adolescent. However, it is associated with several conditions. This study was conducted to describe the characteristics of pediatric patient who underwent cholecystectomy unrelated to hematologic disorders, and then to suggest its clinical significance in management by comparing a simple and complicated gallbladder disease. Methods: We reviewed cases of cholecystectomy in pediatric patients (under 18 years old) at a single institution between January 2003 and October 2014. There were 143 cases during the study period and 24 were selected as the subject group. Results: There were 7 male (29.2%) and 17 female (70.8%) patients. The mean age was 13.1 years old, and 66.6% of patients were older than 12 years. Mean body weight was 52.7 kg, and body mass index was 21.7 kg/m², with 41.7% of patients being overweight or obese. We could identify a female predominance and high proportion of overweight or obesity in a complicated disease. There were also significantly increased levels of aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP) and bilirubin in this group. Most patients (87.5%) underwent laparoscopic cholecystectomy. Conclusion: Cholecystectomy for diseases unrelated to hematologic disorders is rarely performed in the child and adolescent. In general, female patients who are overweight or obese, and those older than 12 years old, require laparoscopic cholecystectomy owing to multiple gallstones. This condition has a tendency to show a complicated gallbladder disease and significantly increased levels of AST, ALT, ALP, and bilirubin. [ABSTRACT FROM AUTHOR]

Background: Prior studies indicate a possible association between depression and cholecystectomy, but no study has compared the risk of post-operative depressive disorders (DD) after cholecystectomy. This retrospective follow-up study aimed to examine the relationship between cholecystectomy and the risk of DD in patients with gallstones in a population-based database. Methods: Using ambulatory care data from the Longitudinal Health Insurance Database 2000, 6755 patients who received a first-time principal diagnosis of gallstones at the emergency room (ER) were identified. Among them, 1197 underwent cholecystectomy. Each patient was then individually followed-up for two years to identify those who were later diagnosed with DD. Cox proportional hazards regressions were performed to estimate the risk of developing DD between patients with gallstone who did and those who did not undergo cholecystectomy. Results: Of 6755 patients with gallstones, 173 (2.56%) were diagnosed with DD during the two-year follow-up. Among patients who did and those who did not undergo cholecystectomy, 3.51% and 2.36% later developed depressive disorder, respectively. After adjusting for the patient’s sex, age and geographic location, the hazard ratio (HR) of DD within two years of gallstone diagnosis was 1.43 (95% CI, 1.02–2.04) for patients who underwent cholecystectomy compared to those who did not. Females, but not males, had a higher the adjusted HR of DD (1.61; 95% CI, 1.08–2.41) for patients who underwent cholecystectomy compared to those who did not. Conclusions: There is an association between cholecystectomy and subsequent risk of DD among females, but not in males. [ABSTRACT FROM AUTHOR]

The document is based on consensus among the experts and best available evidence pertaining to Indian population and is meant for practice in India. All postcholecystectomy gallbladder specimens should be opened and examined carefully by the operating surgeon and be sent for histopathological examination. All "incidental" gall bladder cancers (GBCs) picked up on histopathological examination should have an expert opinion. Evaluation of a patient with early GBC should include essential tests: A computed tomography (CT) scan (multi-detector or helical) of the abdomen and pelvis for staging with a CT chest or chest X-ray, and complete blood counts, renal and liver function tests. magnetic resonance imaging/positron emission tomography (PET)-CT are not recommended for all patients. For early stage disease (up to Stage IVA), surgery is recommended. The need for adjuvant treatment would be guided by the histopathological analysis of the resected specimen. Patients with Stage IVB/metastatic disease must be assessed for palliative e.g. endoscopic or radiological intervention, chemotherapy versus best supportive care on an individual basis. These patients do not require extensive workup outside of a clinical trial setting. There is an urgent need for multicenter trials from India covering various aspects of epidemiology (viz., identification of population at high-risk, organized follow-up), clinical management (viz., bile spill during surgery, excision of all port sites, adjuvant/ neoadjuvant therapy) and basic research (viz., what causes GBC). [ABSTRACT FROM AUTHOR]

Background The trade-off between the benefits of surgery for gallstone disease for a large population and the risk of lethal outcome in a small minority requires knowledge of the overall mortality. Methods Between 2007 and 2010, 47 912 cholecystectomies for gallstone disease were registered in the Swedish Register for Cholecystectomy and endoscopic retrograde cholangiopancreatography ( ERCP) (GallRiks). By linkage to the Swedish Death Register, the 30-day mortality after surgery was determined. The age- and sex-standardized mortality ratio ( SMR) was estimated by dividing the observed mortality with the expected mortality rate in the Swedish general population 2007. The Charlson Comorbidity Index ( CCI) was estimated by International Classification of Diseases ( ICD) codes retrieved from the National Patient Register. Results Within 30 days after surgery, 72 (0.15%) patients died. The 30-day mortality was close [ SMR = 2.58; 95% confidence interval ( CI): 2.02-3.25] to that of the Swedish general population. In multivariable logistic regression analysis, predictors of 30-day mortality were age >70 years [odds ratio ( OR) 7.04, CI: 2.23-22.26], CCI > 2 ( OR 1.93, CI: 1.06-3.51), American Society of Anesthesiologists ( ASA) > 2 ( OR 13.28, CI: 4.64-38.02), acute surgery ( OR 10.05, CI:2.41-41.95), open surgical approach ( OR 2.20, CI: 1.55-4.69) and peri-operative complications ( OR 3.27, CI: 1.74-6.15). Discussion Mortality after cholecystectomy is low. Co-morbidity and peri-operative complications may, however, increase mortality substantially. The increased mortality risk associated with open cholecystectomy could be explained by confounding factors influencing the decision to perform open surgery. [ABSTRACT FROM AUTHOR]

Objectives: To analyze the complications of first 400 laparoscopic cholecystectomies (LC) for patients with symptomatic gall stone disease at a tertiary care hospital. Study Design: Quasi-experimental study. Place and Duration of Study: PNS Shifa Karachi and CMH Lahore, Pakistan from Nov 2009 to Jan 2013. Patients and Methods: A prospective analysis of complications occurring in first 400 consecutive laparoscopic cholecystectomies by a single consultant/unit at a tertiary care hospital was made. Out of total 421 patients presenting with symptomatic gall stone disease in a single unit, 21 cases that underwent open cholecystectomy were excluded from the study. Laparoscopic Cholecystectomies were performed using three port and four port technique and data including age, sex, diagnosis, number of trocar placements, conversion to open surgery and its reasons, operative time, post-operative hospital stay and complications was collected on personal computer and analyzed using Statistical package for social sciences (SPSS) version 13. Results: Total 400 patients were included in study with median age of 44years. Female to male ratio was 5.3: 1. Depending upon the preoperative diagnosis and laparoscopic findings, patients had diagnosis of Chronic cholecystitis / biliary colic 68.25%, acute cholecystitis 23.75%, empyema gall bladder 7.25%, gallstone pancreatitis 0.5% and mucocele gallbladder 0.25%. Median operating time was 30 min. Median hospital stay was 1days (range 1 - 20 days). Conversion rate was 1.25%. Postoperative complications included bleeding 0.5%, biliary peritonitis due to cystic duct leak 0.25%, biloma 0.25%, sub hepatic abscess 0.25%, subcutaneous fat necrosis right flank at drain site 0.25%, umbilical trocar site infection 2%, keloid at umbilical port site 0.25% and incisional hernia at umbilicus 0.25%. There was one hospital death due to myocardial infarction on 2nd post-operative day. Conclusion: Laparoscopic Cholecystectomy is associated with some serious complications which can be avoided with adequate training of surgeons as well as knowledge of mechanism of typical complications. [ABSTRACT FROM AUTHOR]

Background Laparoscopic cholecystectomy (LC) is generally safe and well-accepted. In rare cases, it is associated with complications (intra- e postoperative bleeding, visceral injury and surgical site infection). Splenic lesion has been reported only after direct trauma. We report an unusual case of splenic rupture presenting after "uncomplicated" LC. Case presentation A 77-year-old woman presented with distended abdomen, tenderness in the left upper quadrant and severe anemia 12 hours after LC. Clinical examination revealed hypovolemic shock. Abdominal computed tomography confirmed the diagnosis of splenic rupture, and the patient required an urgent splenectomy through midline incision. The post-operative course was uneventful and the patient was discharged on 7th postoperative day. Splenic injury rarely complicates LC. We postulate that congenital or post-traumatic adhesions of the parietal peritoneum to the spleen may have been stretched from the splenic capsule during pneumoperitoneum establishment, resulting in subcapsular hematoma and subsequent delayed rupture. Conclusions Splenic rupture is an unusual but life-threatening complication of LC. Direct visualization of the spleen at the end of LC might be a useful procedure to aid early recognition and management in such cases. [ABSTRACT FROM AUTHOR]

We report a case of cholelithiasis followed by gallstone ileus, documented with serial computed tomography (CT) scans, that responded to conservative therapy. An 80-year-old woman was admitted because of abdominal pain and vomiting. Six months previously, she had presented with abdominal pain and nausea of sudden onset. A CT scan showed thickening of the gallbladder wall and a gallbladder stone. She refused cholecystectomy, and the abdominal pain gradually improved in response to conservative treatment. On admission, plain abdominal radiographs showed obstruction of the proximal small bowel. A CT scan revealed disappearance of the gallbladder stone, fluid-filled bowel loops, and the presence in the small bowel of an impacted stone (major axis, 45 mm; minor axis, 23 mm). We diagnosed gallstone ileus. Because the gallstone was not large, we inserted a stomach tube and administered conservative treatment. One day after admission, CT showed that the impacted stone had migrated to the transverse colon. Four days after admission the impacted stone was not seen on plain abdominal radiography. Five days after admission, follow-up CT revealed pneumobilia but no impacted stone. Because the symptoms had improved the patient resumed oral intake of liquids The patient was discharged 14 days after admission and is doing well. [ABSTRACT FROM AUTHOR]

Background: The precise steps for the removal of gall bladder from the gall bladder bed are not well standardised. The dissection becomes more difficult near the fundus where the assistant's grasper holding the fundus creates a 'tug of war' like situation. Materials and Methods: This is a description of a simple technique that aids in accurate dissection of the gallbladder from liver bed. As the gallbladder dissection approaches fundus and more than two-third of gallbladder is dissected from liver bed, the medial and lateral peritoneal folds of gall bladder are further incised. The assistant is asked to leave the traction from the gallbladder fundus, while the surgeon holds the dissected surface of gall bladder around 2-3 cm away from its attachment with liver and flip it above the liver. Further dissection is carried out using a hook or a dissector till it is disconnected completely from the liver bed. Results: We have employed 'Flip technique' in around 645 consecutive cases of laparoscopic cholecystectomy operated in the past 3 years. Only one case of liver bed bleeding and two cases of injury to gall bladder wall were noted during this part of dissection in this study. Ease of dissection by surgeons was rated as 9.6 on a scale of 1-10. Conclusion: Gallbladder 'Flip technique' is a simple and easily reproducible technique employed for dissection of gall bladder from liver bed that reduces complications and makes dissection easier. [ABSTRACT FROM AUTHOR]

Gallbladder duplication is a rare congenital malformation that occurs in about 1:4000 cases. Congenital anomalies of the gallbladder and anatomical variations of their position are associated with an increased risk of complications during laparoscopic cholecystectomy. We report a case of gallbladder duplication with symptomatic cholelithiasis, who presented with recurrent episodes of biliary colic and subsequently underwent laparoscopic cholecystectomy with intraoperative cholangiography. We also discussed in brief about the available literature support in relation to incidence of this disorder, imaging modalities used, intraoperative strategies and recommended measures for safe outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Colorectal cancer is cancer of the large intestine, the lower part of digestive system which includes the sigmoid colon and rectum. Aim: To study the relation of incidence of colorectal cancer with previous gall bladder disease or post-cholecystectomy status, a relation between gall bladder disease and smoking in particular and the most common region of colon involved in colorectal cancer in gall bladder disease and non-gall bladder disease patients. Materials and Methods: A total of 256 patients with symptoms of rectal bleeding, change in bowel habit, unexplained tiredness, weight loss, pelvic pain, jaundice and abdominal distension were screened by using colonoscopy among whom 30 patients were diagnosed with colorectal cancer. Detailed history was taken with the help of a modified questionnaire and the patients were assessed, examined and the list of investigations such as faecal occult blood test, ultrasound of abdomen and pelvis, colonoscopy, sigmoidoscopy, barium enema, Computed Tomography (CT), Magnetic Resonance Imaging (MRI) of the abdomen and pelvis, tumour markers like Carcinoembryonic Antigen (CEA) and biopsy were collected. Patient pool was categorized into Gall Bladder Disease (GBD) and Non Gall Bladder Disease (NGBD). Proportions test and Fisher's-Exact test were used to calculate the p-values. Results: Ten patients had previous gall bladder disease (33%) which was significant with a p-value of 0.016 by proportions test. Two patients underwent cholecystectomy, two patients underwent Endoscopic Retrograde Cholangio Pancreatography (ERCP) and the remaining six patients did not take any treatment for their gall bladder disease. Five patients with previous gall bladder disease were found to be smokers with a p-value of 0.091. The average age was 47.2 years in males and 42.2 years in females. Males constituted 66.6% (20 males) of the diseased population whereas, females constituted 33.4% (10 females). Rectal bleeding and altered bowel habits were the commonest symptoms. Confirmation of the disease was proven using CT abdomen and biopsy. Right sided colorectal cancer was common in GBD patients. Left sided colon cancer was common in NGBD patients. Conclusion: This study established a statistically significant risk of colorectal cancer following cholelithiasis though no risk was apparent following cholecystectomy. [ABSTRACT FROM AUTHOR]

Mirizzi's syndrome (MS) caused by the retention of a stone in the cystic duct stump after cholecystectomy is rare. Most cases of MS are treated by surgical intervention. However, developments of endoscopic accessories and techniques have resulted in the recent introduction of endoscopic treatments for MS. Furthermore, in view of the postoperative morbidity caused by post-operative scarring, the endoscopic approach should be preferred to the surgical approach. In the described case, the authors were able to remove a remnant cystic duct stone endoscopically because the cystic duct stump was wide and non-tortuous. This case shows endoscopic retrograde cholangiopancreatography with mechanical lithotripsy can be utilized in suitable cases of type I MS development after cholecystectomy. [ABSTRACT FROM AUTHOR]

Background Gangrenous cholecystitis ( GC) is often challenging to treat. The objectives of this study were to determine the accuracy of pre-operative diagnosis, to assess the rate of post-cholecystectomy complications and to assess models to predict GC. Methods A retrospective single-institution review identified patients undergoing a cholecystectomy. Logistic regression models were used to examine the association of variables with GC and to build risk-assessment models. Results Of 5812 patients undergoing a cholecystectomy, 2219 had acute, 4837 chronic and 351 GC. Surgeons diagnosed GC pre-operatively in only 9% of cases. Patients with GC had more complications, including bile-duct injury, increased estimated blood loss ( EBL) and more frequent open cholecystectomies. In unadjusted analyses, variables significantly associated with GC included: age > 45 years, male gender, heart rate ( HR) > 90, white blood cell count ( WBC) > 13 000/mm3, gallbladder wall thickening ( GBWT) ≥ 4 mm, pericholecystic fluid ( PCCF) and American Society of Anesthesiology ( ASA) > 2. In adjusted analyses, age, WBC, GBWT and HR, but not gender, PCCF or ASA remained statistically significant. A 5-point scoring system was created: 0 points gave a 2% probability of GC and 5 points a 63% probability. Conclusion Using models can improve a diagnosis of GC pre-operatively. A prediction of GC pre-operatively may allow surgeons to be better prepared for a difficult operation. [ABSTRACT FROM AUTHOR]

Background:Associations between medical conditions and pancreatic cancer risk are controversial and are thus evaluated in a study conducted during 1994-1998 in Minnesota.Methods:Cases (n=215) were ascertained from hospitals in the metropolitan area of the Twin Cities and the Mayo Clinic. Controls (n=676) were randomly selected from the general population and frequency matched to cases by age and sex. The history of medical conditions was gathered with a questionnaire during in-person interviews. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated using unconditional logistic regression.Results:After adjustment for confounders, subjects who had cholecystectomy or gallstones experienced a significantly higher risk of pancreatic cancer than those who did not (OR (95% CI): 2.11 (1.32-3.35) for cholecystectomy and 1.97 (1.23-3.12) for gallstones), whereas opposite results were observed for tonsillectomy (0.67 (0.48-0.94)). Increased risk associated with cholecystectomy was the greatest when it occurred ⩽2 years before the cancer diagnosis (5.93 (2.36-15.7)) but remained statistically significant when that interval was ⩾20 years (2.27 (1.16-4.32)).Conclusions:Cholecystectomy, gallstones, and tonsillectomy were associated with an altered risk of pancreatic cancer. Our study suggests that cholecystectomy increased risk but reverse causality may partially account for high risk associated with recent cholecystectomy. [ABSTRACT FROM AUTHOR]