Colecistectomía con exploración de vías biliares laparoscópica en paciente con situs inversus totalis

Se presenta el caso de un paciente varón de 77 años con diagnóstico de colecistitis crónica calculosa y coledocolitiasis, con antecedente de situs inversus totalis. Se le realizó una colecistectomía con exploración de vías biliares laparoscópica, utilizando la "técnica francesa en espejo", con extracción de los cálculos. El paciente evolucionó favorablemente. El objetivo del presente trabajo es dar a conocer el caso clínico que es poco frecuente su reporte en la literatura mundial (solo 9 casos). Su importancia radica en que sería el primer reporte de caso clínico publicado de una colecistectomía y exploración de vías biliares laparoscópica con retiro del cálculo en colédoco en un paciente con situs inversus totalis, realizado en el Perú.

We present the case of a 77-year-old male patient with a diagnosis of chronic calculous cholecystitis and choledocholithiasis, with a history of situs inversus totalis. Therefore, a laparoscopic cholecystectomy with common bile duct exploration were performed, using the "french mirror technique", with stone extraction. Patient evolved favorably. The aim of this study is to present this clinical case that is rarely reported in the world literature (only 9 cases). Its importance lies in the fact that it would be the first published clinical case report of a laparoscopic cholecystectomy and bile duct exploration with removal of the common bile duct stones in a patient with situs inversus totalis, performed in Peru.

Colecistectomía laparoscópica ambulatoria, una realidad actual / Ambulatory laparoscopic cholecystectomy, a current reality / Colecistectomia Laparoscópica Ambulatorial, uma realidade atual

La cirugía ambulatoria ha ido evolucionando y abarcando cada día procedimientos quirúrgicos más complejos, incluso la colecistectomía laparoscópica, actualmente considerada como la cirugía de elección para el tratamiento de la patología biliar, se puede realizar de manera ambulatoria gracias a los avances en técnicas quirúrgicas y anestésicas que actuales. Objetivo. Determinar la viabilidad y aceptación del procedimiento dentro de la practica ambulatoria mediante una revisión de la literatura actual sobre los protocolos de colecistectomía laparoscópica ambulatoria existentes. Metodología. Se realizó una revisión sistemática de la literatura, basado en la declaración PRISMA para ajustar la información obtenida en las diferentes bases científicas disponibles utilizando los descriptores relacionados con colecistectomía laparoscópica ambulatoria y cirugía del día enfocándose en aquellos registros sobre el tema, su conceptualización y puesta en marcha. De esta manera se identificaron 118 registros en las diferentes bases de datos consultadas. Tras la aplicación de criterios de inclusión se separaron 56 artículos de los cuales finalmente se utilizaron 11 registros para la revisión. Conclusión. La colecistectomía laparoscópica es segura y eficaz, siempre y cuando se realice la estatificación correcta del paciente a beneficiarse. No hay diferencia significativa entre los diferentes anestésicos utilizados durante el procedimiento, el anestésico subdérmico no mejora el tiempo de recuperación por dolor postoperatorio. La valoración protocolizada del postquirúrgico es vital para el alta hospitalaria.

Ambulatory surgery has been evolving and encompassing more complex surgical procedures every day. Even laparoscopic cholecystectomy, currently considered the surgery of choice for the treatment of biliary pathology, can be performed on an ambulatory basis thanks to advances in surgical and anesthetic techniques. Objective. To determine the feasibility and acceptance of the procedure in outpatient practice by reviewing the current literature on existing outpatient laparoscopic cholecystectomy protocols. Methodology. A systematic review of the literature was carried out, based on the PRISMA statement to adjust the information obtained in the different scientific bases available using the descriptors related to ambulatory laparoscopic cholecystectomy and day surgery focusing on those records on the subject, its conceptualization and implementation. In this way, 118 records were identified in the different databases consulted. After the application of inclusion criteria, 56 articles were separated from which 11 records were finally used for the review. Conclusion. Laparoscopic cholecystectomy is safe and effective, as long as the correct staging of the patient to be benefited is performed. There is no significant difference between the different anesthetics used during the procedure, the subdermal anesthetic does not improve postoperative pain recovery time. Protocolized postoperative assessment is vital for hospital discharge.

A cirurgia ambulatorial tem evoluído e engloba procedimentos cirúrgicos mais complexos a cada dia. Mesmo a colecistectomia laparoscópica, atualmente considerada a cirurgia de escolha para o tratamento da patologia biliar, pode ser realizada em regime ambulatorial graças aos avanços nas técnicas cirúrgicas e anestésicas. Objetivo. Determinar a viabilidade e aceitabilidade do procedimento na prática ambulatorial através de uma revisão da literatura atual sobre os protocolos existentes de coleistectomia laparoscópica ambulatorial. Metodologia. Foi realizada uma revisão sistemática da literatura, baseada na declaração PRISMA para ajustar as informações obtidas nas diferentes bases científicas disponíveis usando os descritores relacionados à coleistectomia laparoscópica ambulatorial e à cirurgia diurna, focalizando aqueles registros sobre o assunto, sua conceitualização e implementação. Desta forma, 118 registros foram identificados nos diferentes bancos de dados consultados. Após a aplicação dos critérios de inclusão, 56 artigos foram separados dos quais 11 registros foram finalmente utilizados para a revisão. Conclusão. A coleistectomia laparoscópica é segura e eficaz, desde que o estadiamento correto do paciente a ser beneficiado seja realizado. Não há diferença significativa entre os diferentes anestésicos utilizados durante o procedimento, a anestesia subdérmica não melhora o tempo de recuperação da dor pós-operatória. A avaliação pós-operatória protocolizada é vital para a alta hospitalar.

Application of percutaneous transhepatic gallbladder drainage with delayed laparoscopic cholecystectomy in the treatment of acute cholecystitis / 国际外科学杂志

Objective:To compare the clinical efficacy of percutaneous transhepatic gallbladder drainage (PTGBD) combined with delayed laparoscopic cholecystectomy (LC) with direct LC in the treatment of acute cholecystitis.Methods:A single-center case-control retrospective study was used. Sixty-three patients with acute cholecystitis with onset time ≥ 72 hours during the period from August 1, 2021 to December 10, 2022 in the Department of Hepatobiliary Surgery of the 900TH Hospital of Joint Logistics Support Force were selected. There were 38 males and 25 females, aged (57.3±15.4) years, with an age range of 28-87 years. According to whether PTGBD treatment was performed before LC, they were divided into experimental group ( n=29) and control group ( n=34). Experimental group was treated with PTGBD combined with delayed LC and control group was treated with LC only.The differences in operative time, intra-operative bleeding, intra-operative transit open rate, post-operative hospital days, total hospital days, hospital costs, short-term post-operative complications of LC and post-operative time to exhaustion were compared and analysed between the two groups. Measurement data with normal distribution were expressed as mean±standard deviation ( ± s), and independent sample t-test was used for comparison between groups.Measurement data with skewed distribution were expressed as M( Q1, Q3), and rank sum test was used for comparison between groups; Chi-square test was used to compare the counting data groups. Results:Intraoperative bleeding, total hospital days, hospital costs and postoperative time to exhaustion were 0(0, 50) mL, 13(11, 18) d, 29 015.0 (22 791.6, 39 000.8) yuan and 1(1, 2) d in the experimental group and 50(0, 88) mL, 7(6, 11) d, 16 015.0 (15 832.1, 22 185.1) yuan, 2(1, 3) d, the difference was statistically significant between the two groups( P<0.05). In the experimental group, the operative time, the intraoperative transit open rate, the number of postoperative hospital days, and the incidence of short-term postoperative complications of LC were 80 (55, 115) min, 13.8%, 5 (3, 7) days, 34.5%, respectively, compared with 98(70, 125) min, 20.6%, 5(3, 6) days, 38.2% in the control group, the difference between the two groups was not statistically significant ( P>0.05). Conclusion:The clinical efficacy of PTGBD combined with delayed LC is better than direct line LC, and it is feasible and effective for patients with cholecystitis whose inflammatory indexes have returned to normal and who have high gallbladder tone.

Research progress of intraoperative cholangiography in laparoscopic cholecystectomy / 国际外科学杂志

With the widespread implementation of laparoscopic cholecystectomy in various levels of medical institutions, surgical complications have also increased. Among them, the incidence of bile duct injury remains high in complex laparoscopic cholecystectomy. The reason for this is that surgeons cannot effectively and accurately identify the relationship between the aberrant bile duct and the cystic duct and the common bile duct, resulting in the accidental injury of the bile duct, resulting in long hospital stays, increased medical costs, and decreased long-term quality of life for patients. Intraoperative cholangiography, as a real-time visual method of biliary presentation, can effectively reduce the incidence of iatrogenic bile duct injury. However, most surgeons do not fully understand the technology of intraoperative cholangiography during cholecystectomy. This article reviews the application of intraoperative cholangiography in laparoscopic cholecystectomy based on the clinical experience of the author′s team and the literature in recent years, with the aim of deepening the understanding of surgeons about intraoperative cholangiography, so as to better apply it to clinical practice and benefit patients.

Comparative evaluation of three laparoscopic cholecystectomy techniques in rabbit's model

Purpose: The aim of this randomized study was to compare the complications and perioperative outcome of three different techniques of laparoscopic cholecystectomy (LC). Changes in the liver function test after LC techniques were investigated. Also, we compared the degree of postoperative adhesions and histopathological changes of the liver bed. Methods: Thirty rabbits were divided into three groups: group A) Fundus-first technique by Hook dissecting instrument and Roeder Slipknot applied for cystic duct (CD) ligation; group B) conventional technique by Maryland dissecting forceps and electrothermal bipolar vessel sealing (EBVS) for CD seal; group C) conventional technique by EBVS for gallbladder (GB) dissection and CD seal. Results: Group A presented a longer GB dissection time than groups B and C. GB perforation and bleeding from tissues adjacent to GB were similar among tested groups. Gamma-glutamyl transferase and alkaline phosphatase levels increased (p ≤ 0.05) on day 3 postoperatively in group A. By the 15th postoperative day, the enzymes returned to the preoperative values. Transient elevation of hepatic transaminases occurred after LC in all groups. Group A had a higher adherence score than groups B and C and was associated with the least predictable technique. Conclusions: LC can be performed using different techniques, although the use of EBVS is highly recommended.

Gallbladder polyps: correlation and agreement between ultrasonographic and histopathological findings in a population with high incidence of gallbladder cancer / Pólipos da vesícula biliar: correlação e concordância entre achados ultrassonográficos e histopatológicos em uma população com alta incidência de câncer de vesícula biliar

ABSTRACT BACKGROUND: Gallbladder polyps are becoming a common finding in ultrasound. The management has to consider the potential risk of malignant lesions. AIMS: The aim of this study was to analyze the ultrasound findings in patients undergoing cholecystectomy due to gallbladder polyps and compare them for histopathological findings (HPs). METHODS: Patients with an ultrasonographic diagnosis of gallbladder polyp and who underwent cholecystectomy from 2007 to 2020 were included in the study. RESULTS: A total of 447 patients were included, of whom 58% were women. The mean age was 45±12 years. The mean size of polyps in US was 7.9±3.6 mm. Notably, 9% of polyps were greater than 10 mm, and single polyps were significantly larger than the multiple ones (p=0.003). Histopathological findings confirmed the presence of polyps in 88.4%, with a mean size of 4.8±3.4 mm. In all, 16 cases were neoplastic polyps (4.1%), 4 of them being malignancies, and all were single and larger than 10 mm. We found a significant correlation between ultrasound and histopathological findings polyp size determination (r=0.44; p<0.001). The Bland-Altman analysis obtained an overestimation of the US size of 3.26 mm. The receiver operating characteristic (ROC) curve analysis between both measures obtained an area under the receiver operating characteristic curve (AUC) of 0.77 (95%CI 0.74-0.81). Ultrasound polyps size larger than 10 mm had an odds ratio (OR) of 8.147 (95%CI 2.56-23.40) for the presence of adenoma and malignancy, with a likelihood ratio of 2.78. CONCLUSIONS: There is a positive correlation and appropriate diagnostic accuracy between ultrasound size of gallbladder polyps compared to histopathological records, with a trend to overestimate the size by about 3 mm. Neoplastic polyps are uncommon, and it correlates with size. Polyps larger than 10 mm were associated with adenoma and malignancy.

RESUMO RACIONAL: Os pólipos da vesícula biliar estão se tornando um achado comum na ultrassonografia (US). O manejo deve levar em consideração o risco de lesões malignas. OBJETIVOS: Analisar os achados da ultrassonografia em pacientes submetidos à colecistectomia por pólipos vesicais e compará-los com os achados histopatológicos. MÉTODOS: Foram revisados os prontuários médicos dos pacientes com diagnóstico ultrassonográfico de pólipo vesicular e submetidos à colecistectomia no período de 2007 a 2020. RESULTADOS: Foram incluídos no estudo 447 pacientes. A média de idade foi 45±12anos, sendo 58% mulheres. O tamanho médio dos pólipos na US foide 7,9±3,6mm. Nove por cento foram maiores que 10 mm, e os pólipos únicos encontrados foram maiores do que os múltiplos (p=0,003). A HP confirmou a presença de pólipos em 88,4%, tamanho médio 4,8±3,4mm. Dezesseis eram pólipos neoplásicos (4,1%) e quatro deles malignos, únicos e maiores que 10 mm. Foi encontrado correlação significativa entre a determinação do tamanho do pólipo ao ultrassonografia e histopatológicos (r=0,44; p<0,001). A análise de Bland-Altman obteve uma superestimação do tamanho do pólipo ao US em 3,26 mm. A análise da curva da característica de operação do receptor entre as duas medidas obteve uma área sob a curva curva da característica de operação do receptor (AUC) de 0,77 (IC95% 0,74-0,81). Pólipos ao ultrassonografia maiores que 10 mm apresentaram razão de chance (OR) de 8,147 (IC95% 2,56-23,40) para presença de adenoma e malignidade, com razão de verossimilhança de 2,78. CONCLUSÕES: Há uma correlação positiva e acurácia diagnóstica apropriada entre o tamanho dos pólipos da vesícula biliar por ultrassonografia em comparação com os achados histopatológicos, com uma tendência de superestimar o tamanho em cerca de 3 mm. Pólipos maiores que 10 mm foram associados a adenoma e malignidade.

Expert consensus on day-case laparoscopic cholecystectomy / 临床肝胆病杂志

‍The concept of day-case surgery was first proposed by British surgeon Nicoll， referring to the surgery or procedure in which a patient completes admission and discharge within one day （24 h）. In recent years， China has gradually implemented the day-case mode of laparoscopic cholecystectomy. Day-case laparoscopic cholecystectomy could significantly shorten hospital stay， reduce hospital infections， accelerate patient recovery， improve the efficiency of medical resource utilization， and reduce medical costs. In order to provide reference for exploring and developing standardized day-case laparoscopic cholecystectomy and promote the standardized application and promotion of day-case laparoscopic cholecystectomy， the Minimally Invasive Surgery Committee of the Chinese Research Hospital Association organized experts from surgery， anesthesia， and nursing to develop this expert consensus.

Application of transversus abdominis plane block combined with sevoflurane in laparoscopic cholecystectomy for patients with coronary heart disease / 中国医师杂志

Objective:To investigate the application value of ultrasound guided transversus abdominis plane block (TAP) combined with sevoflurane inhalation general anesthesia in patients with coronary heart disease undergoing laparoscopic cholecystectomy.Methods:A total of 90 patients with coronary heart disease who received laparoscopic cholecystectomy in the Third Hospital of Changsha from April 2021 to December 2021 were selected. The patients were randomly divided into observation group (47 cases) and control group (43 cases). The observation group was given ultrasound guided TAP combined with sevoflurane inhalation general anesthesia; The control group was given conventional general anesthesia. The heart rate (HR), mean arterial pressure (MAP) and pulse oxygen saturation (SpO 2) of the two groups were observed before anesthesia (T 1), at the time of skin resection (T 2), at the time of gallbladder separation (T 3) and at the time of skin suture (T 4). The recovery time, operation time, anesthesia time and postoperative Visual Analogue Scale(VAS) score at 2, 6, 12 and 24 h were recorded. The levels of serum creatine kinase (CK), creatine kinase isoenzyme (CK-MB), myocardial troponin (cTnI), superoxide dismutase (SOD) and malondialdehyde (MDA) before and after operation were detected, and the incidence of adverse cardiovascular events in the two groups were observed. Results:The MAP and HR in T 2, T 3 and T 4 were higher than those in T 1 in the control group (all P<0.05); The MAP and HR at T 2, T 3 and T 4 in the observation group were significantly lower than those in the control group (all P<0.05); There was no significant difference in operation time and anesthesia time between the observation group and the control group (all P>0.05); The recovery time of observation group was significantly earlier than that of control group ( P<0.05). The CK, CK-MB and cTnI in the observation group were significantly lower than those in the control group at 24 h after surgery (all P<0.05). There was no significant difference in SOD and MDA between the observation group and the control group at 24 h after surgery (all P<0.05). The VAS score of the observation group were lower than those of the control group at 2 h, 6h, 12 h and 24 h after surgery (all P<0.05). There was no significant difference in the incidence of postoperative adverse cardiovascular events between the two groups ( P>0.05). Conclusions:TAP combined with sevoflurane inhalation general anesthesia has good application value in laparoscopic cholecystectomy in elderly patients, which can improve the anesthesia effect and the quality of recovery, and significantly reduce the myocardial injury of patients.

Laparo-endoscopic Rendezvous in the Treatment of Cholecystocholedocholithiasis: A Single Center Initial Experience

Cholecystocholedocholithiasis is a common disease worldwide; however, there is still no consensus regarding a gold standard therapy for its management. Nowadays, the preferred method is a "two-step" process, starting with an endoscopic common bile duct (CBD) stone extraction (endoscopic retrograde cholangiopancreatography [ERCP]) followed by a laparoscopic cholecystectomy (LC). Nevertheless, this "two-step" approach has shown some difficulties over time (i.e., need for two hospital admissions, need of at least two anesthesia inductions, higher rate of post-procedural pancreatitis, longer hospitalizations and thus, increased costs). On the other hand, the laparo-endoscopic rendezvous (LER), which is a simultaneous combined procedure for removing the gallbladder laparoscopically and clearing the CBD endoscopically, is another valid treatment modality that involves a "single-step" resolution of cholecystocholedocholithiasis applying a multidisciplinary approach of the patient. The aim of this study was to present our initial outcomes. We retrospectively analyzed eleven patients who consecutively underwent LER at our institution from May 2017 to March 2022. The patients' mean age was 50.6 years old (range, 34 - 68) and most were male 54.5% (6/11). LER successfully achieved CBD stone clearance in 90.9% (10/11) of the cases. Post-LER pancreatitis was not recorded in any case. Post-operative complications included one reoperation (1/11; 9.1%) due to bleeding from one of the laparoscopic trocar sites. Our group concluded that LER can be effectively applied in Perú with good mid-term results and confirmed its effectiveness in accomplishing CBD stone clearance. Based on our results, we recommend the use of LER as a safe and valid therapeutic option for our patients.

La colecistocoledocolitiasis es una enfermedad común a nivel mundial; sin embargo, aún no hay ningún consenso sólido acerca de una sola "terapia ideal" para su manejo. Hoy en día, el método mas utilizado es un procedimiento que involucra "dos estadios", el cual comienza con la extracción endoscópica de cálculos del conducto biliar común (CBD) (colangiopancreatografía retrógrada endoscópica [CPRE]) seguida de una colecistectomía laparoscópica (CL). Sin embargo, este enfoque de "dos estadios" ha mostrado algunas desventajas con el tiempo (necesidad de dos ingresos hospitalarios, necesidad de al menos dos inducciones anestésicas, mayor tasa de pancreatitis post-procedimiento, hospitalizaciones más prolongadas y, por lo tanto, mayores costos). Por otra parte, el rendezvous laparo-endoscópico (RLE), es otra modalidad de tratamiento que implica la resolución en "un solo paso" de la colecistocoledocolitiasis, aplicando un enfoque multidisciplinario hacia el paciente. El RLE es un procedimiento en el cual simultáneamente se realizan la CL y la extracción de cálculos coledocianos por vía endoscópica. El objetivo de este estudio fue presentar nuestros resultados iniciales. Analizamos retrospectivamente once pacientes que fueron intervenidos quirúrgicamente mediante la técnica de RLE en nuestra institución desde mayo de 2017 hasta marzo de 2022. La edad media de los pacientes fue de 50,6 años (rango de edad, 34 - 68) y la mayoría fueron varones 54,.5% (6/11). RLE logró eliminar con éxito los cálculos de CBD en el 90,9 % (10/11) de los casos. En ningún caso se registró pancreatitis post-RLE. Las complicaciones postoperatorias incluyeron una reintervención (1/11; 9,1%) por sangrado de uno de los trócares laparoscópicos. Nuestro grupo concluyó que la técnica RLE se puede aplicar de manera efectiva en Perú con buenos resultados a mediano plazo y confirmó su efectividad para lograr la eliminación de cálculos de CBD. En base a nuestros resultados, recomendamos el uso de RLE como una opción terapéutica segura y válida para nuestros pacientes.

Costos de las diversas modalidades posoperatorias de la colecistectomía laparoscópica. Cooperativa Médica de Florida (COMEF), 2016-2021 / Cost effectivenes of the different postoperative management modalities in laparoscopic cholecystectomy Florida Medical Cooperative (COMEF) 2016-2021 / Custos das várias modalidades pós-operatórias do colecistectomia laparoscópica. Cooperativa Médica da Flórida (COMEF). 2016-2021

Introducción: la colecistectomía laparoscópica constituye el patrón oro en el tratamiento de la litiasis biliar. Bajo una estricta selección de pacientes, la modalidad ambulatoria ha demostrado ser factible y segura. En COMEF se realiza desde el año 2016. El posoperatorio transcurrió por diferentes etapas, internación en cuidados moderados, internación en sala de cirugía del día más internación domiciliaria, internación únicamente en sala de cirugía del día y finalmente alta domiciliaria desde block quirúrgico. El objetivo del trabajo es calcular los costos de cada una de las modalidades posoperatorias de la colecistectomía laparoscópica en el período 2016-2021. Materiales y método: se realizó un estudio de costos de cada una de las modalidades posoperatorias mediante la determinación del costo del día cama ocupada en cuidados moderados e internación domiciliaria, así como la retribución de un auxiliar de enfermería encargado de la sala de cirugía del día. Los datos fueron obtenidos de la Estructura de Costos de Atención a la Salud y la producción de cada servicio. Resultados: el costo del día cama ocupada en cuidados moderados es de $15.056, el de internación en sala de cirugía del día y luego internación domiciliaria $4.953,69, únicamente en sala de cirugía del día $807,69 y finalmente el alta domiciliaria desde block quirúrgico $33. Conclusiones: los costos del posoperatorio de la colecistectomía laparoscópica en modalidad ambulatoria son menores que los que requieren internación en cuidados moderados, y dichos costos se reducen progresivamente cuando se pasa de la internación domiciliaria al alta sin internación domiciliaria y sin recuperación en sala de cirugía del día.

Introduction: laparoscopic cholecystectomy constitutes the gold standard to treat gallstones. Ambulatory treatment has proved to be feasible and safe for carefully selected patients. At COMEF, laparoscopic cholecystectomies have been performed since 2016, and postoperative management has covered different stages: intermediate care during hospitalization, admission in day surgery units plus home care or home admissions, hospitalization in day surgery units and discharge directly after surgery, directly from the ER. The study aims to calculate the cost of each one of the different postoperative management modalities for laparoscopic cholecystectomies between 2016 and 2021. Method: a cost study was conducted for each one of the postoperative management modalities by calculating the cost of the hospital bed day in intermediate care and house care, as well as the salary of the nurses' staff at the day surgery unit. Data was obtained from the Healthcare Services Cost Structure and the production of each one of the services mentioned. Results: the daily bed day cost in intermediate care is $ 15,056, the daily cost of day surgery unit plus home care afterwards is $ 4,953.69, the cost of surgery admission in the day surgery unit is $ 807.69 and discharge directly from the OR is $ 33. Conclusions: the postoperative cost of ambulatory laparoscopic cholecystectomy is lower than that requiring interaction in intermediate care and these costs are progressively reduced when moving from home care with and without interaction upon discharge towards no recovery in the day surgery unit.

Introdução: a colecistectomia laparoscópica é o padrão ouro no tratamento da litíase biliar. Com uma rigorosa seleção de pacientes, a modalidade ambulatorial tem se mostrado viável e segura. Na COMEF é realizada desde 2016, com o pós-operatório passando por diferentes etapas: internação em cuidados moderados, internação na sala de cirurgia do dia mais internação domiciliar, internação apenas na sala de cirurgia no dia e finalmente alta domiciliar do bloco cirúrgico. Objetivo: calcular os custos de cada uma das modalidades pós-operatórias de colecistectomia laparoscópica no período 2016-2021. Materiais e método: foi realizado um estudo dos custos de cada uma das modalidades pós-operatórias determinando o custo do dia de leito ocupado em cuidados moderados e internação atendimento domiciliar, bem como a remuneração de um auxiliar de enfermagem responsável pela cirurgia do dia. Os dados foram obtidos da Estrutura de Custos de Assistência à Saúde e da produção de cada serviço. Resultados: o custo do leito de dia ocupado em cuidados moderados, em é de $ 15.056, a hospitalização na sala de cirurgia de dia e depois internação domiciliar $ 4.953,69, apenas na sala da cirurgia de dia $ 807,69 e finalmente alta domiciliar do bloco cirúrgico $ 33 (valores em pesos uruguaios). Conclusões: os custos pós-operatórios da colecistectomia laparoscópica na modalidade ambulatorial são menores do que aqueles que requerem interação em cuidados moderados e são progressivamente reduzidos quando passa da internação em casa à alta sem interação em casa e sem recuperação na sala de cirurgia no dia.

A propensity score matching study on safety and efficacy of laparoscopic cholecystectomy for T2a and lower stages of gallbladder carcinoma / 中华肝胆外科杂志

Objective:To study the safety and efficacy of laparoscopic cholecystectomy (LC) in treatment of T2a and lower stages of gallbladder carcinoma.Methods:A retrospective study was performed on patients who were diagnosed with gallbladder cancer and underwent surgical treatment from January 2016 to January 2021 at Hunan Provincial People's Hospital. These patients were divided into the simple treatment group and the radical treatment group based on the surgical methods used. The simple treatment group consisted of 64 patients who underwent LC for accidental gallbladder cancers. The radical treatment group consisted of 30 patients who underwent laparoscopic radical cholecystectomy (LRC). The baseline characteristic of the two groups of patients were matched in a 1∶1 ratio using propensity score matching. After matching, there were 26 patients in each of the 2 groups. There were 7 males and 19 females in the simple group, with mean ± s. d. age of (60.6±9.6) years. There were 8 males and 18 females, with mean ± s. d. age (60.9±9.1) years in the radical treatment group. Blood loss, operation time, postoperative hospital stay, biliary leakage, acute pulmonary embolism, and incisional infection were compared between the two groups.Results:In the simple group, the operative time was (78.7±62.9) min, intraoperative blood loss was (10.7±11.6) ml and postoperative hospital stay was (4.4±2.6) d. These results were significantly better than those in the radical group with operative time (298.7±101.3) min, intraoperative blood loss (161.9±96.7) ml and postoperative hospital stay (9.9±4.0) d (all P<0.05). There were no significant difference in the postoperative complications and disease free survival rates between the two groups (both P>0.05). Conclusion:LC was safe and effective for treatment of T2a and lower stages of gallbladder cancer, and it could achieve a similar disease-free survival rate as LRC.

A multicenter prospective randomized controlled study on the timing of laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for grade Ⅱ-Ⅲ acute cholecystitis / 中华肝胆外科杂志

Objective:To study the optimal timing of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD) for grade Ⅱ-Ⅲ acute cholecystitis.Methods:A multicenter, single blind and randomized controlled study was conducted at Shanghai Fifth People's Hospital Affiliated to Fudan University, Shanghai Pudong Hospital, and Shanghai Minhang District Central Hospital from October 2018 to September 2021. Patients who underwent LC after PTGBD were divided 1∶1 into the early group and the late group. LC was performed 4-6 weeks after PTGBD in the early group and 7-8 weeks after PTGBD in the late group. Gender, age, AC grade, complications after PTGBD, body mass index, complications before LC, operation time of LC, intraoperative bleeding, total treatment cost, conversion rate to open surgery and complications after LC were compared between the two groups. The 36-Item Short Form Health Survey (SF-36) before and after LC was also compared.Results:Of 248 patients who were eligible for the study, there were 52 males and 196 females, with ages ranging from 18 to 89 years, and mean ±s.d. of (52.5 ± 20.2) years. There were 126 patients in the early group and 122 patients in the late group. There were no significant differences in gender, age, AC grade, body mass index and complications before LC between the two groups (all P>0.05). The preoperative score of SF-36 in the early group was significantly better than that in late group, and the complications of PTGBD in the late group were significantly higher than the early group (both P<0.05). The operation time and total treatment cost of the early group were significantly less than those of the late group (37.2±12.8 min vs. 48.5±19.7 min, 20 856±2 136 yuan vs. 2 2207±2 049 yuan) (both P<0.05). The intraoperative bleeding volume of LC in the early group was [ M( Q1, Q3)] 40 (40, 60) ml and the late group was [ M( Q1, Q3)] 35 (25, 40) ml. The difference was also significant ( P<0.05). There was no significant differences in the conversion rates to open surgery, complications and SF-36 scores after LC between the two groups (all P>0.05). Conclusion:LC should be performed 4-6 weeks after PTGBD for grade Ⅱ-Ⅲ acute cholecystitis. Although the amount of intraoperative bleeding was higher, the operation time was shorter, the burden on patients was reduced and there was more rapid recovery.

Application of enhanced recovery after surgery using the LEER model in patients subjected to laparoscopic cholecystectomy in basic hospitals of Yi nationality area / 中国基层医药

Objective:To investigate the clinical application value of enhanced recovery after surgery using the LEER model in patients subjected to laparoscopic cholecystectomy in basic hospitals of Yi nationality area.Methods:Twenty-six patients who underwent laparoscopic cholecystectomy based on the concept of enhancing recovery after surgery using the LEER model in People's Hospital of Jinkouhe District of Leshan from January to October 2021 were included in the observation group. An additional 20 patients who concurrently underwent laparoscopic cholecystectomy and conventional intervention were included in the control group. Clinical efficacy, postoperative complications and postoperative pain were compared between the two groups.Results:Postoperative fasting time, length of hospital stay, and total hospital days in the observation group were 6 (6, 6) hours, 2 (2, 3) days and 4 (4, 6) days respectively, which were significantly shorter than 24 (24, 36) hours, 5 (5, 6) days, 7 (7, 9) days in the control group ( H = 351.00, 407.50, 458.00, all P < 0.05). Hospitalization cost in the observation group was 5 454.58 (5 014.11, 6 016.58) yuan, which was significantly lower than 6 611.91 (6 192.68, 7 841.73) yuan in the control group ( H = 420.00, P < 0.05). There were no significant differences in operative time and postoperative complications between the two groups (both P > 0.05). At postoperative 6 hours, Visual Analogue Scale score in the observation group was 3 (3, 4) points, and patients with mild pain accounted for 73.07% (19/26). At postoperative 24 hours, Visual Analogue Scale score in the observation group was 2 (2, 3) points, and patients with mild pain accounted for 92.31% (24/26). Overall pain was well controlled after surgery. Patient satisfaction rate in the observation was 96.15% (25/26). All patients recovered and were discharged. Conclusion:Application of enhanced recovery after surgery using the LEER model in patients subjected to laparoscopic cholecystectomy in basic hospitals of Yi nationality area can promote postoperative recovery, contribute to changing the theory of diagnosis and treatment, and improve overall medical quality. The enhanced recovery after surgery protocol using the LEER model has a good application value.

Effects of preoperative administration of parecoxib sodium on stress reaction and postoperative nausea and vomiting score in patients undergoing laparoscopic cholecystectomy / 中国基层医药

Objective:To investigate the effects of preoperative administration of parecoxib sodium on stress reaction and postoperative nausea and vomiting score in patients undergoing laparoscopic cholecystectomy.Methods:A total of 112 patients undergoing laparoscopic cholecystectomy in Lishui City People's Hospital from January 2020 to January 2021 were included in this study. They were randomly divided into observation group and control group, with 56 patients per group. The observation group was intravenously administered 40 mg parecoxib sodium 30 minutes before surgery, and the control group was identically administered equal amount of 0.9% sodium chloride injection. At 1, 6, 12 and 24 hours after surgery, Visual Analogue Scale (VAS) score, cortisol and adrenocorticotropic hormone levels and postoperative nausea and vomiting score were compared between the two groups.Results:At 1, 6 and 12 hours after surgery, VAS score in the observation group was (3.23 ± 0.85) points, (2.44 ± 0.76) points, (2.37 ± 0.69) points, respectively, which were significantly lower than (4.06 ± 1.12) points, (3.24 ± 0.95) points, (3.10 ± 1.07) points in the control group ( t = 4.41, 4.92, 4.29, all P < 0.001). At 1, 6, 12 and 24 hours after surgery, cortisol level in the observation group was (287.79 ± 35.46) ng/L, (303.55 ± 34.77) ng/L, (368.58 ± 31.22) ng/L, (397.16 ± 32.60) ng/L, respectively, which were significantly lower than (337.64 ± 39.52) ng/L, (364.18 ± 36.90) ng/L, (405.56 ± 37.29) ng/L, (455.51 ± 37.81) ng/L in the control group ( t = 7.02, 8.94, 5.69, 8.74, all P < 0.05). At 1, 6, 12 and 24 hours after surgery, adrenocorticotropic hormone level in the observation group was (59.25 ± 7.63) ng/L, (65.27 ± 8.23) ng/L, (72.29 ± 7.49) ng/L, (83.63 ± 8.57) ng/L, which were significantly lower than (64.48 ± 8.06) ng/L, (71.44 ± 8.59) ng/L, (79.79 ± 8.15) ng/L, (90.08 ± 8.26) ng/L in the control group ( t = 3.52, 3.88, 5.07, 4.05, all P < 0.05). Within 24 hours after surgery, the incidence of postoperative nausea and vomiting in the observation group was significantly lower than that in the control group [12.50% (7/56) vs. 28.57% (16/56), χ2 = 4.43, P < 0.05). Within 2 hours, 2-6 hours, and > 6-24 hours, postoperative nausea and vomiting score in the observation group was (1.31 ± 0.26) points, (1.43 ± 0.32) points, and (1.46 ± 0.41) points, respectively, which was significantly lower than (1.67 ± 0.41) points, (1.83 ± 0.39) points, (1.88 ± 0.44) points in the control group ( t = 2.12, 2.37, 2.14, all P < 0.05). Conclusion:Preoperative administration of parecoxib sodium exhibits a good postoperative analgesic effect in patients undergoing laparoscopic cholecystectomy. It can effectively reduce postoperative stress reactions, decrease the incidence of postoperative nausea and vomiting, and lower the severity of postoperative nausea and vomiting, and thereby can be widely used in clinical practice.

Evaluation of the efficacy of transgallbladder injection of indocyanine green in symptomatic gallbladder stones combined with liver cirrhosis surgery / 国际外科学杂志

Objective:To investigate the feasibility and efficacy of transcystic injection of indocyanine green during laparoscopic cholecystectomy (LC) surgery in the treatment of patients with gallbladder stones combined with liver cirrhosis.Methods:The clinical data of 96 patients with cirrhosis who underwent LC for gallbladder stones with cholecystitis attacks in the Department of Hepatobiliary and Pancreatic Surgery of the Second People′s Hospital of Changzhou City from January 2018 to May 2022 were retrospectively analyzed. All patients were diagnosed by clinical history and auxiliary examination before surgery and underwent cholecystectomy according to their groups, which were divided into fluorescence group ( n=49) and white light group ( n=47) according to whether ICG was used or not, where the fluorescence group underwent LC in fluorescence mode after direct intraoperative injection of ICG via gallbladder. The two groups were compared in terms of identification time of the three tubes, operation time, intraoperative bleeding, intraoperative injury, intraoperative open abdomen and blood transfusion, postoperative drainage time, postoperative hospitalization time, postoperative complications and changes in infection and liver function indexes before and after surgery. The measurement data obeying normal distribution were expressed as mean±standard deviation( ± s), and independent sample t-test was used for comparison between groups. The measurement data obeying the skewed distribution were expressed by M( Q1, Q3), and the Mann-Whitney U test was used for comparison between groups. Count data were expressed as rates (%), and the chi-square test or Fisher′s exact probability method was used for comparison between groups. Results:The procedure was successfully performed in both groups, and the identification of triple-tube time, operative time, intraoperative bleeding, postoperative drainage time, postoperative hospital stay, postoperative ALT, postoperative GGT, and postoperative TBIL in the fluorescent group were (14.96±1.49) min, (52.14±7.36) min, 5(5, 10) mL, (1.61±0.61) d, (2.37±0.49) d, 31.5(22.0, 44.8) U/L, 38.0(21.0, 91.5) U/L, 18.0(11.5, 22.8) μmol/L, and (29.87±3.37) min, (84.36±13.25) min, 10(10, 20) mL, (2.70±0.69) d, (3.15±0.42) d, 45.0(28.0, 64.8) U/L, 73.0(32.0, 132.0) U/L, 23.0(16.1, 29.3) μmol/L in the white light group and the differences were statistically significant compared with the two groups( P<0.05). In the fluorescence group, there was no intraoperative injury and no cases of intraoperative opening, and there were 2 cases of postoperative complications, while in the white light group, there were 2 cases of intraoperative injury, 1 case of intraoperative opening, and 5 cases of postoperative complications, and there were no cases of blood transfusion in both groups. There was no statistically significant difference between the fluorescence group and the white light group when comparing the preoperative laboratory indexes of both groups ( P>0.05). When comparing the first postoperative white blood cell count, C-reactive protein, aspartate aminotransferase, and alkaline phosphatase indexes in the fluorescence group and the white light group, there was no statistically significant difference between the two groups ( P>0.05). Conclusion:When LC is performed in patients with symptomatic gallbladder stones combined with cirrhosis, intraoperative injection of indocyanine green via the gallbladder to visualize the gallbladder and bile duct structures is simple and easy to perform, and the safe and efficient dissection of extrahepatic bile ducts and gallbladder bed speeds up the procedure while reducing postoperative trauma.

Cohort cholecystectomies in the Brazilian public system: is access to laparoscopy universal after three decades? / Colecistectomias em coorte no sistema público brasileiro: o acesso à laparoscopia é universal após três décadas?

ABSTRACT Objective: videosurgery in Brazil started in 1990 with the performance of laparoscopic cholecystectomy, being included by the public health system in 2008. We evaluated the current situation of the use of this technology in the Unified Health System (SUS - Sistema Único de Saúde). Methods: from 2013 to 2019, 1,406,654 patients registered at the SUS Informatics Department (DATASUS) were analyzed to calculate the rate of laparoscopic cholecystectomies (LC) in relation to open cholecystectomies (OC). Patient characteristics, disease presentation and postoperative mortality were evaluated. Results: the LC rate reached 41.5% (growth of 68%) with no decrease in the absolute number of OC. In University Hospitals (UH), the LC rate reached 91.96%. The open technique in emergencies was more associated with male patients, aged 60 years or older, with prolonged hospitalization and in the ICU. Those undergoing LC were less predisposed to postoperative death, both electively (OR 0.49; 95% CI 0.42 - 0.56; NNT=20) and urgently (OR 0.23; 95% CI 0.20 - 0.25; NNT ≅1), providing a protective effect. Conclusion: despite the increase in the indication of LC, the open technique during the years studied remained stable and the most used in the public health system in Brazil. The effectiveness of public health policies to shorten the complete implementation of videosurgery in SUS needs to be investigated in future epidemiological studies, as well as its impact on postoperative morbidity and mortality.

RESUMO Introdução: a videocirurgia no Brasil iniciou em 1990 com a realização da colecistectomia laparoscópica, sendo incluída pelo sistema público de saúde em 2008. Avaliamos a situação atual do emprego desta tecnologia no Sistema Único de Saúde (SUS). Métodos: de 2013 a 2019, 1.406.654 pacientes registrados no Departamento de Informática do SUS (DATASUS) foram analisados para calcular a taxa de colecistectomias laparoscópicas (CL) em relação a colecistectomias abertas (CA). Avaliaram-se características dos pacientes, apresentação da doença e mortalidade pós-operatória. Resultados: a taxa de CL atingiu 41,5%, com crescimento de 68%, sem ocorrer diminuição do número absoluto de CA. Já em Hospitais Universitários (HUs) a taxa de CL chegou a 91,96%. A técnica aberta em urgências esteve mais associada a pacientes masculinos, com 60 anos ou mais, à internação prolongada e em UTI. Aqueles submetidos à CL estiveram menos predispostos à morte pós-operatória, tanto em caráter eletivo (OR 0,49; IC 95% 0,42 - 0,56; NNT = 20) como na urgência (OR 0,23; IC 95% 0,20 - 0,25; NNT ≅ 1), conferindo efeito protetor. Conclusão: apesar do aumento da indicação da CL, a cirurgia aberta durante os anos estudados se manteve estável e a técnica mais utilizada no sistema público de saúde do Brasil. A efetividade de políticas de saúde pública para abreviar a completa implementação da videocirurgia no SUS necessita ser investigada em estudos epidemiológicos futuros, assim como seu impacto na morbimortalidade pós-operatória.

Application of indocyanine green cholangiography in accurate identification of the common bile duct in laparoscopic cholecystectomy / 临床肝胆病杂志

Objective To investigate the application of intraoperative indocyanine green (ICG) cholangiography in the accurate identification of the common bile duct since common bile duct injury is a common complication of laparoscopic cholecystectomy (LC), and to reduce the incidence rate of common bile duct injury during LC. Methods A total of 68 patients who underwent LC in Zhuhai People's Hospital from April 2021 to Jane 2021 were enrolled, among whom 56 patients underwent conventional LC and 12 patients underwent LC under the guidance of ICG cholangiography. The common bile duct, cystic duct, and gallbladder were examined by white light laparoscopy for the conventional LC group and near-infrared laparoscopy for the ICG cholangiography group. The propensity score matching method was used to balance the preoperative data between the two groups. The t -test and the chi-square test were used for comparison of intraoperative blood loss, time of operation, length of postoperative hospital stay, and incidence rate of common bile duct injury between the two groups. Results Compared with the conventional LC group, the ICG cholangiography group had significantly lower intraoperative blood loss 3.1±0.9 mL vs 10.8±2.3 mL, t =-22.709, P < 0.05), significantly shorter time of operation (20.2±1.6 min vs 48.3±5.1 min, t =-19.856, P < 0.05) and length of postoperative hospital stay (1.2±0.3 days vs 2.3±0.8 days, t =-19.507, P < 0.05), and a significantly lower incidence rate of complications (0 vs 8.3%, χ 2 =1.287, P < 0.05). Conclusion ICG cholangiography is an effective method to differentiate between the common bile duct and the cystic duct during LC and can prevent common bile duct injury. This method has great advantages in the treatment of patients with gallstones due to its high degree of identification of the biliary tract, long onset time, repeated application, convenient operation, and ability to be combined with intraoperative navigation device.

Analgesic modalities for ambulatory laparoscopic cholecystectomy / 中华普通外科杂志

Objective:To explore the analgesic methods in ambulatory laparoscopic cholecystectomy (LC) patients.Methods:Three hundred patients were randomly divided into six groups receiving different analgesic regimen. VAS scores, postoperative blood pressure, CRP, IL-6, and the occurrence of postoperative adverse effects were recorded at 2, 4, 8, and 12 h postoperatively.Results:The success rate of ambulatory LC in this study was 66.22%. The dynamic VAS scores of patients in each group gradually decreased with time elapsing, with groups B and C being significantly lower than group A at 2 h and 4 h postoperatively ( P<0.05). Groups D, E and F were significantly different from group A at all postoperative time points ( P<0.05). There was a statistically significant difference at 8 h and 12 h postoperatively in group B vs. group D and group C vs. group E (all P<0.05). There was significant difference at the 12 h postoperatively between groups (B and C) compared to group F ( P<0.05). There was a significant difference in CRP and IL-6 between the groups (all P<0.05). Postoperative dizziness, nausea and delayed discharge were significantly higher in patients using analgesic pumps ( P<0.05). Conclusion:Local infiltration of ropivacaine combined with postoperative parecoxib sodium drip is a recommended analgesic regimen.

Analysis of the risk factors related to prolonged drainage time in patients with selective abdominal drainage after laparoscopic cholecystectomy / 中华肝胆外科杂志

Objective:To determine the risk factors of drainage time longer than 1 day in patients with selective abdominal drainage after laparoscopic cholecystectomy.Methods:The clinical data related to patients with selective abdominal drainage undergoing laparoscopic cholecystectomy from November 2009 to November 2019 at Chinese PLA General Hospital were retrospectively analyzed. Of 233 patients enrolled into this study, there were 147 males and 86 females, with a median aged 59.0 (47.5, 65.5) years old. The patients were divided into drainage time 1 day group of 65 patients and longer than 1 day group of 168 patients according to postoperative drainage time. The baseline data and perioperative data were collected, the risk factors correlated with drainage time longer than 1 day were analyzed.Results:The drainage time was 1 in the 1 day group and 2~8 in another group. Among the 233 patients, there was one with biliary leakage and 14 patients had abdominal bleeding, all of them healed after 2~3 days. All of the 233 patients were recovered when discharged. Independent risk factors related to drainage time longer than 1 day include BMI≥28 kg/m 2 ( OR=3.443, 95% CI: 1.411-8.405, P=0.007), operation time ≥65 min ( OR=2.570, 95% CI: 1.310-5.045, P=0.006), thickness of gallbladder wall ≥0.5 cm ( OR=12.720, 95% CI: 1.350-5.478, P=0.005), postoperative stomachache ( OR=13.537, 95% CI: 1.685-108.748, P=0.014) and postoperative fever ( OR=8.156, 95% CI: 1.035-64.249, P=0.046). Conclusion:For patients undergoing selective abdominal drainage after laparoscopic cholecystectomy with BMI ≥28 kg/m 2, operation time ≥65 min, gallbladder wall thickness ≥0.5 cm, postoperative abdominal pain and fever, clinicians should appropriately prolong the drainage time to ensure medical safety.

Effect of local infiltration of ropivacaine in gallbladder triangle on agitation and postoperative pain in patients undergoing laparoscopic cholecystectomy / 中国医师杂志

Objective:To study the effect of local infiltration of ropivacaine in gallbladder triangle on agitation and postoperative pain in patients undergoing laparoscopic cholecystectomy (LC).Methods:108 patients with LC who met the requirements of this study treated in Yunnan Cancer Hospital from March 2018 to March 2021 were randomly divided into two groups, 54 cases in each group. Both groups received routine LC under general anesthesia. The observation group received ropivacaine for local infiltration in the gallbladder triangle, and the control group received the same amount of normal saline for local infiltration in the gallbladder triangle. The anesthesia indexes, agitation during awakening and postoperative pain were compared between the two groups.Results:There was no significant difference in extubation, anesthesia and recovery time between the observation group and the control group (all P>0.05); The scores of static and dynamic visual analogue scale (VAS) in the two groups reached the highest value at 6 h after operation, and then decreased gradually, with significant differences between the two groups ( F=15.28, 4.26, 11.06, 3.21, all P<0.05). The dynamic and static VAS scores of the observation group were lower than those of the control group at the time of awakening, 6 h, 12 h and 24 h after operation, with statistically significant difference (all P<0.05). Compared with the control group, the Riker sedation agitation score (SAS) and the incidence of agitation in the observation group were significantly lower (all P<0.05), and the effective times of analgesic pump pressing 24 hours after operation were significantly less ( P<0.05); There was no significant difference in SpO 2 level between the observation group and the control group ( P>0.05); The levels of heart rate (HR) and mean arterial pressure (MAP) in the two groups were significantly higher than those before anesthesia, and the rising degree in the observation group was significantly lower than that in the control group (all P<0.05); The levels of norepinephrine (NE), C-reactive protein (CRP) and cortisol in the two groups were significantly higher than those before anesthesia, and the rising degree in the observation group was significantly lower than that in the control group (all P<0.05). Conclusions:Local infiltration of gallbladder triangle with ropivacaine during LC can reduce the degree of postoperative pain, the use of PCIA pump and the occurrence of agitation during awakening, so as to maintain hemodynamic stability.