Liver pucker sign: predictor of difficult laparoscopic cholecystectomy: a case series.

Introduction: Pucker sign is the depression of the liver in the region of the gallbladder due to a high degree of chronic contractive inflammation of the gallbladder. It usually develops in patients who have a delayed cholecystectomy after acute cholecystitis due to a high degree of chronic contractive inflammation of the gallbladder and contraction of the cystic plate. It is an essential finding either preoperatively or intraoperatively as it can act as a stopping rule during cholecystectomy (act as a guide that cholecystectomy will be difficult). Case series: The authors here report three cases of pucker sign that were incidentally discovered during laparoscopy. Discussion: Chronic cholecystitis is a prolonged, subacute condition caused by inflammation of the gallbladder, which mostly occurs in the setting of cholelithiasis. Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis. Hence, it would be beneficial to be aware of reliable signs that predict difficult Laparoscopic cholecystectomy. Pucker sign usually predicts increased operative difficulty as there is an operative danger of biliary or vascular injury. Conclusion: The pucker sign is a novel indicator of significant persistent inflammation and heightened difficulty during surgery. It might establish a halting rule that modifies the procedure's management and raises its level of safety.

Feasibility of Telementoring as an Intraoperative Time-out Tool during Laparoscopic Cholecystectomy for Prevention of Biliovascular Injuries.

Laparoscopic cholecystectomy is commonly performed procedure for gallbladder diseases. Biliovascular injuries are well known complications and various standard and safe strategies have been developed for safe cholecystectomy. Intraoperative time out is one of the strategies where two or more surgeons stop during surgery before dividing any structure in Calot's triangle. COVID-19 pandemic has expanded the horizon of telesurgery, teleconsultation, use of artificial intelligence and robotics in surgical training and execution. Easily available mobile applications like Facebook messenger, WhatsApp and Viber can be used for intraoperative time-out during difficult cholecystectomy with expert surgeon outside the vicinity of theatre. Such tools are cost effective and definitely boost the confidence of surgeons during surgery in case of any complexity, or help in stopping the procedure and in timely referral. Keywords: Cholecystectomy; laparoscopy; telementoring.

Diagnostic Dilemma in Groove Pancreatitis: A Case Report.

Groove pancreatitis is uncommon form of chronic pancreatitis common in patients with history of smoking and alcohol abuse. High index of suspicion is required as it may masquerade pancreatic ductal adenocarcinoma and both of these conditions are difficult to differentiate preoperatively. Pancreaticoduodenectomy has good outcome in patient with Groove pancreatitis.  Hence, we are reporting a case report of Groove pancreatitis in 40 years gentleman, who was being managed by multiple endoscopic dilatations, later underwent pancreaticoduodenectomy for persistent symptoms.  He had no perioperative morbidity and doing well in 24 months follow up.

Prospective Validation of a Decision Tree Model for Prediction of Severity in Acute Pancreatitis.

BACKGROUND: Early identification of severe acute pancreatitis is important for early stratification, goal directed fluid therapy, rationalizing level of care to improve outcome. Various clinical, laboratory and imaging scoring system has been used to identify severe acute pancreatitis with variable results. Recently a decision tree model was proposed using serum creatinine, serum lactate dehydrogenase and oxygenation index to predict severe acute pancreatitis. This system is easy and usable at our centre. Hence, we conducted the study to validate the decision tree model prospectively. METHODS: Patients admitted with a diagnosis of acute pancreatitis were included in the study. Decision tree model was used to identify patients at high and low risk for severe acute pancreatitis. Sensitivity and specificity were calculated for prediction of the decision tree model. RESULTS: Fifty-three patients were included in the study. Fourty-one (77.4 %) patients with mild acute pancreatitis, five (9.4 %) patients had moderately severe pancreatitis and seven (13.2 %) patients had severe acute pancreatitis. Sensitivity and specificity of decision tree model to predict severity of pancreatitis was 97.83%(95 % CI - 88.47% to 99.94%) and 71.43 % % (95 % CI - 29.04% to 96.33%) respectively with positive and negative predictable value of 95.74 % % (95 % CI - 87.45% to 98.64%) and 83.33 % % (95 % CI - 40.49% to 97.35%) respectively. CONCLUSIONS: Decision tree model with serum creatinine, lactate dehydrogenase, and oxygenation index is an easy and useful tool to predict patients at high risk of developing severe acute pancreatitis.

Appropriateness of Indications of Upper Gastrointestinal Endoscopy and its Association With Positive Finding.

INTRODUCTION: Upper Gastrointestinal Endoscopy is a frequently advised investigation for upper abdominal symptoms. Studies have questioned the appropriateness of indications for upper gastrointestinal endoscopy and have shown that inappropriate indications range from 5% to 49%. The unnecessary upper gastrointestinal endoscopy expose patients to the risk. The number of upper gastrointestinal endoscopy is rising in our region and we assume so is the number of unnecessary upper gastrointestinal endoscopy. With an aim to find out the appropriateness of the indications of upper gastrointestinal endoscopy and compare its association with positive findings, we conducted a cross-sectional descriptive study. METHODS: All patients undergoing diagnostic upper gastrointestinal endoscopy during study period were included in the study. Appropriateness of indications for upper gastrointestinal endoscopy was defined as per American Society for Gastrointestinal Endoscopy criteria as "appropriate" and "inappropriate". Upper gastrointestinal endoscopy findings were classified as "significant" and "insignificant" based on endoscopy findings. The extent of this association between appropriateness of indications and upper gastrointestinal endoscopy findings was expressed as the odds ratio of finding a relevant diagnosis in patients with an ''appropriate'' indication compared with those with an 'inappropriate'' indication. RESULTS: Seventy-nine patients were included in the study. Fifty- two (65.8%) of the indications were considered appropriate as per American Society for Gastrointestinal Endoscopy guidelines. Thirty-three (63.5%) of the appropriate indications has clinically significant finding as compared to seven (25.9%) of inappropriate indication with an odds ratio of 4.962 (95% CI:1.773 - 13.890, P=0.002) which is statistically significant. CONCLUSIONS: Appropriate indications have significantly higher rates of clinically significant findings. Use of guidelines may decrease the number of unnecessary procedures.