Symptom Duration and Surgeon Volume: Impact on Early Laparoscopic Cholecystectomy for Acute Cholecystitis.

BACKGROUND: The 'golden 72 hours' rule from the onset of symptoms still applies in laparoscopic cholecystectomy for acute cholecystitis. This rule has been discussed with increasing experience in laparoscopic surgery in recent years. OBJECTIVE: This study aims to determine the optimal symptom duration based on the surgeon's volume when deciding on early laparoscopic cholecystectomy for acute cholecystitis. MATERIALS AND METHODS:  The patients were categorized into two groups: Group 1 (≤3 days) and Group 2 (>3 days) based on the symptom duration, and high-volume surgeons (performing >100 laparoscopic cholecystectomies in a year) and low-volume surgeons (performing <100 laparoscopic cholecystectomies in a year) based on the surgeon volume. All surgeons had received advanced training in laparoscopic surgery. RESULTS: There was no statistical difference in postoperative outcomes between groups, except for a few data (p>0.05). The operative time was longer in Group 2, the postoperative hospital stay was longer for low-volume surgeons than for high-volume surgeons after three days, and operative time was longer after three days than the first three days in low-volume surgeons (p<0.05). CONCLUSIONS: Early laparoscopic cholecystectomy may be recommended for acute cholecystitis with symptom duration of more than three days, regardless of the surgeon volume, as long as they are competent in laparoscopic surgeries.

The Optimal Timing of Laparoscopic Cholecystectomy in Acute Cholecystitis: A Single-Center Study.

Introduction Early laparoscopic cholecystectomy (ELC) is a treatment option for acute cholecystitis (AC). However, the timing of ELC is controversial. Delayed laparoscopic cholecystectomy (DLC) continues to be a common practice. This study aims to determine the optimal timing of ELC in AC. Materials and methods Patients who underwent surgery for AC between 2014 and 2020 were divided into three groups: immediate laparoscopic cholecystectomy (ILC), prolonged ELC (pELC), and DLC. The demographic, laboratory, radiological findings, and postoperative results of all patients were retrospectively reviewed. Results The study included 178 patients, with 63 in the ILC group, 27 in the pELC group, and 88 in the DLC group. Postoperative outcomes, excluding hospital stay, were similar between the groups. The total hospital stay was significantly longer in the pELC and DLC groups (p<0.05). In addition, postoperative hospital stay was longer in the pELC group (p<0.05), and 17.7% of the patients who waited for delayed surgery experienced recurrent attacks during the interval period. Conclusion ILC is recommended in AC to minimize hospital stays.

Insulinoma Misdiagnosed as Post-bariatric Hypoglycemia: A Case Report and Review of the Literature.

Hypoglycemia is seen with increasing frequency after bariatric surgery. After the diagnosis of hypoglycemia has been clarified, malnutrition, drugs, hormone deficiencies, insulinoma, extra-islet tumors, post-bariatric hypoglycemia (PBH), early or late dumping syndrome, and nesidioblastosis should be considered in the differential diagnosis. A few case reports of insulinomas presenting after bariatric surgery have been reported in the literature. The coexistence of insulinoma and type 2 diabetes mellitus (T2D) is very rare. We herein report a clinical case of insulinoma presenting with severe hypoglycemia in a patient with a history of gastric transit bipartition. A patient with type 2 diabetes mellitus underwent gastric transit bipartition surgery due to the inability of medical therapy to provide adequate hyperglycemia control. After the operation, hypoglycemic symptoms appeared, and a reversal operation was performed, considering the diagnosis as PBH. After the reverse operation, the patient's hypoglycemia symptoms did not regress. The patient was admitted to our endocrinology clinic due to the persistence of hypoglycemia and symptoms such as fatigue, palpitation, and syncope. The patient's detailed anamnesis was examined, additional tests were performed, and the patient was diagnosed with insulinoma. The symptoms of hypoglycemia and the need for treatment for diabetes mellitus disappeared after the Whipple operation. This is the first case of insulinoma after gastric transit bipartition and subsequent reversal operations. In addition, the patient's diagnosis of diabetes mellitus makes this case unique. Although this is a very rare case, clinicians must be aware of it, especially if the patient has hypoglycemic symptoms during the fasting state.

Ultrasound-guided subcostal-posterior transversus abdominis plane block for pain control following laparoscopic sleeve gastrectomy.

OBJECTIVES: To investigate the analgesic effect of a subcostal-posterior transversus abdominis plane (TAP) block combination following laparoscopic sleeve gastrectomy. Methods: This study was conducted at Fatih Sultan Mehmet Educational and Research Hospital, Istanbul, Turkey, between March 2014 and June 2015. A total of 40 patients with a body mass index of 40-60 kg/m2 scheduled for laparoscopic sleeve gastrectomy were randomly allocated into 2 groups. Patients in Group I (n=20) received a bilateral subcostal TAP block, and patients in Group II (n=20) received a bilateral subcostal and posterior TAP block. Pain intensity was assessed at rest and during coughing using the visual analog scale (VAS) prior to and at various time points after TAP block (0 min, 30 min, 2 hours, 4 hours, 6 hours, 12 hours, and 24 hours). Morphine consumption over 24 hours and time to first morphine requirement were recorded.  Results: There was no difference in VAS scores between groups. Morphine consumption was 6.78±5.95 mg in Group I, and 7.28±5.95 mg in Group II (p=0.795). Time to first morphine requirement was 267.22±303.84 min for Group I, and 207.80±209.81 min for Group II (p=0.154).  Conclusions: Subcostal-posterior TAP block provided equivalent analgesia to subcostal TAP block alone following laparoscopic sleeve gastrectomy.

Ductoscopy in the evaluation and management of nipple discharge.

BACKGROUND: Nipple discharge is a relatively common complaint among patients visiting specialized outpatient clinics for disease of the breast. With advancing technology, it became possible to diagnose and manage nipple discharge using minimally invasive procedures. The aim of this study is to report our experience with ductoscopic evaluation of patients with nipple discharge. MATERIALS AND METHODS: Between September 2005 and February 2009, 236 patients with complaint of nipple discharge were admitted prospectively into the study. All patients were evaluated with ductoscopy. Data concerning age, ductoscopic and postsurgical diagnosis, duration, and complications with the procedure were statistically analyzed. RESULTS: For 236 patients evaluated, there were 249 ductoscopic investigations. Of these, 39 patients were found to have intraductal solitary papilloma of which 24 were excised ductoscopically. Of the 24 ductoscopically excised solitary papillomas, it was possible to remove 17 completely, but 7 papillomas could be removed partially. For 13 patients with solitary papillomas large enough or unfavorably localized so that they could not be snare-excised and for 14 patients with multiple papillomas, we offered surgical removal of the lesions by limited excision of the ducts with the help of ductoscopic localization and marking. There were 35 patients who had debris within the canalicular system, and the debris was washed out. Ductoscopy revealed atypical ductal hyperplasia in 3 patients, ductal carcinoma in situ in 6 patients, and invasive carcinoma in 3 patients; all patients underwent surgery. CONCLUSIONS: We believe that, as the technology quickly improves, ductoscopy will become more widely accepted and applied for breast disorders, not only as a diagnostic tool but also as a privileged therapeutic option for certain pathologies.