Ten-year Audit of Safe Bail-Out Alternatives to the Critical View of Safety in Laparoscopic Cholecystectomy.

BACKGROUND: To prevent vasculobiliary injuries according to the Tokyo Guidelines, Critical View of Safety (CVS) is the recommended method for the identification of the cystic duct and cystic artery. Our aim was to audit laparoscopic cholecystectomies, in order to determine the rate of CVS feasibility and to explore safe bail-out alternatives, when CVS cannot be obtained. METHODS: Patients who underwent either elective or emergent laparoscopic cholecystectomy, between January 2009 and December 2018, in whom the CVS was attempted, were retrospectively identified from the institutional electronic database. Dissection technique was documented in the operative notes. Bile duct injuries (BDI) were classified by the Strasberg classification, and their management and outcome were reported in the patient files. RESULTS: In total, 1226 cases were included in the final analysis. CVS was feasible in 1128 cases (92.0%), whereas 65 patients (5.3%) were managed laparoscopically by a bail-out technique. Of those, 52 (4.3%) underwent a subtotal cholecystectomy, 12 (0.9%) a fundus-first cholecystectomy, and in one patient (0.1%) the operation was concluded by a tube cholecystostomy. Overall conversion rate was 2.7% (33/1226 cases). Male gender, older age, junior surgeons, and acute cholecystitis were significantly associated with higher conversion rates. Post-operatively, 10 patients (0.82%) developed a type A bile leakage. No major BDI (types B-E) were observed, either with CVS or the bail-out techniques. CONCLUSIONS: Our study showed that CVS and the bail-out alternatives complement each other in preventing major BDI and should belong to the armamentarium of every modern surgeon.

Review of management options for pancreatic pseudocysts.

Pancreatic pseudocysts (PPs) present a challenging problem for physicians dealing with pancreatic disorders. Their management demands the co-operation of surgeons, radiologists and gastroenterologists. Historically, they have been treated either conservatively or surgically, with acceptable rates of complications and recurrence. However, recent advances in radiology and endoscopy, have leaded physicians to implement percutaneous and endoscopic drainage (ED) into their treatment algorithms. Moreover, laparoscopic surgery, with its advantages, has become an attractive alternative choice when surgical drainage (SD) is required. The aim of this review is to summarize the main diagnostic and therapeutic tools in the management of pseudocysts and to present the main studies that compare the three different types of pseudocyst drainage.

Impact of biliary stenting on surgical outcome in patients undergoing pancreatectomy. A retrospective study in a single institution.

PURPOSE: There are conflicting views regarding preoperative biliary drainage in patients undergoing pancreatectomy. The aim of this study was to evaluate the effect of jaundice resolution on postoperative outcomes. METHODS: Patients who underwent pancreatectomy in a single institution since 2010 were retrospectively analyzed. They were divided into two groups, depending on the presence or not of preoperative biliary drainage. Postoperative morbidity and mortality were evaluated. RESULTS: Ninety-nine patients underwent biliary drainage by endoscopic retrograde cholangiopancreatography (ERCP) (PBD group), while 105 patients had no biliary drainage (non-PBD group). No significant difference between the two groups could be identified in terms of overall complications (p = 0.121) or mortality (p = 1). There was no significant difference regarding pancreatic fistula (p = 0.554), delayed gastric emptying (p = 0.127), hemorrhage (p = 0.426), number of reoperations (p = 1.000) or readmissions (p = 1.000). The only significant difference was found in the hospital stay, where patients who underwent preoperative biliary drainage had a prolonged length of stay of more 3 days (15.52 vs. 11.31) (p < 0.001). CONCLUSION: Preoperative biliary drainage in patients undergoing pancreatectomy does not increase the rates of postoperative morbidity or mortality, but has a negative effect on hospital stay.

Simultaneous Gastric and Duodenal Erosions due to Adjustable Gastric Banding for Morbid Obesity.

Erosion is an uncommon but feared late complication of adjustable gastric banding for morbid obesity. A high index of clinical suspicion is required, since symptoms are usually vague and nonspecific. Diagnosis is confirmed on upper gastrointestinal endoscopy and band removal is the mainstay of treatment, with band revision or conversion to other bariatric modalities at a later stage. Duodenal erosion is a much rarer complication, caused by the connection tubing of the band. We present our experience with a case of simultaneous gastric and duodenal erosions, managed by laparoscopic explantation of the band, primary suture repair of the duodenum, and omentopexy.

Transient femoral nerve palsy complicating "blind" transversus abdominis plane block.

We present two cases of patients who reported quadriceps femoris weakness and hypoesthesia over the anterior thigh after an inguinal hernia repair under transversus abdominis plane (TAP) block. Transient femoral nerve palsy is the result of local anesthetic incorrectly injected between transversus abdominis muscle and transversalis fascia and pooling around the femoral nerve. Although it is a minor and self-limiting complication, it requires overnight hospital stay and observation of the patients. Performing the block under ultrasound guidance and injecting the least volume of local anesthetic required are ways of minimizing its incidence.

Mesothelial cyst of the round ligament misdiagnosed as irreducible inguinal hernia.

We report the case of a 36-year-old woman who presented with signs and symptoms of an irreducible inguinal hernia. Surgical exploration revealed a mesothelial cyst of the round ligament of the uterus. Mesothelial cysts of the round ligament are rare lesions, frequently masquerading as inguinal hernias, and should be included in the differential diagnosis of any inguinal mass. Clinical findings are those of a groin mass, discomfort, and bulging. Ultrasound and CT scans often demonstrate an aperistaltic cystic mass. Definitive diagnosis is usually made intraoperatively and confirmed histopathologically.

Clinical significance of tumor-associated antigen RCAS1 expression in human pancreatic ductal adenocarcinoma.

Receptor-binding cancer antigen expressed on SiSo cells (RCAS1) is a human tumor-associated antigen that induces cell cycle arrest and/or apoptosis in RCAS1 receptor-expressing immune cells. The aim of the present study was to evaluate the clinical significance of RCAS1 expression in human pancreatic adenocarcinoma. Immunohistochemical analysis of RCAS1 expression was performed on paraffin-embedded tissue sections obtained from 76 pancreatic adenocarcinoma patients. RCAS1 positivity and overexpression and intensity of the staining were correlated with clinicopathological parameters, proliferative capacity and patient survival. Of the 76 adenocarcinoma patients, 65 (86%) tested positive for RCAS1; of these 65 RCAS1-positive cases, 36 (55%) showed RCAS1 overexpression. RCAS1 positivity was statistically significantly correlated with the histopathological grade of the tumor (P = 0.026), and it showed a trend to be correlated with tumor size (P = 0.071). RCAS1 intensity and overexpression of staining showed a trend to be correlated with the histopathological grade of the tumor (P = 0.061 and P = 0.089, respectively), whereas RCAS1 positivity and the overexpression and intensity of staining were not statistically significantly correlated with the proliferative capacity of the tumor or any other clinicopathological parameter examined nor with patients' survival. Our data provide evidence for the implication of RCAS1 in pancreatic neoplasia. However, the prediction of survival using RCAS1 expression as a marker seems uncertain for this type of cancer.

Day-case laparoscopic cholecystectomy: a prospective evaluation of a 6-year experience.

BACKGROUND/PURPOSE: Day-case laparoscopic cholecystectomy (LC) offers convenience to patients and cost saving to the healthcare institutes. This article reviews our prospectively recorded experience with day-case LC to determine its applicability and safety, as well as patient satisfaction. METHODS: Of 744 consecutive patients who underwent LC over a 6-year period, 140 (19%) were scheduled for day-case surgery. Selection criteria included American Society of Anesthesiologists (ASA) score of 1 or 2, absence of morbid obesity, low risk for common bile duct stones, domicile within 50 km of the hospital, age greater than 18 and less than 75, and the ability to admit the patient on the day of surgery for operation during the morning. Patient satisfaction with day-case surgery was assessed by questionnaire at 4-6 weeks after operation. RESULTS: Some 117 of the 140 patients (84%) were discharged home on the same day of the operation. Two patients were re-admitted with abdominal pain, 1 of whom underwent a negative re-laparoscopy. There were no major complications. The reasons for overnight hospital stay were anesthetic in 12 (52%), surgical in 7 (30%), and social or logistic in 4 (18%) patients. There were no conversions. The proportion of patients scheduled for day-case remained static (median, 18.5%; range, 16%-22%). Some 99 of 105 patients (94%) who completed the questionnaire were satisfied with day-case surgery. CONCLUSIONS: In carefully selected patients, day-case LC is achievable and safe, and provides good patient satisfaction.