Reclaiming the management of common duct stones in acute care surgery.

BACKGROUND: Acute care surgery (ACS) is well positioned to manage choledocholithiasis at the time of laparoscopic cholecystectomy, but barriers to laparoscopic common bile duct exploration (LCBDE) include experience and the perceived need for specialized equipment. The technical complexity of this pathway is generally seen as challenging. As such, LCBDE is historically relegated to the "enthusiast." However, a simplified, effective LCBDE technique as part of a "surgery first" strategy could drive wider adoption in the specialty most often managing these patients. To determine efficacy and safety, we sought to compare our initial ACS-driven experience with a simple, fluoroscopy-guided, catheter-based LCBDE approach during laparoscopic cholecystectomy (LC) to LC with endoscopic retrograde cholangiopancreatography (ERCP). METHODS: We reviewed ACS patients who underwent LCBDE or LC + ERCP (pre-/postoperative) at a tertiary care center in the 4 years since starting this surgery first approach. Demographics, outcomes, and length of stay (LOS) were compared on an intention to treat basis. Laparoscopic common bile duct exploration was performed via using wire/catheter Seldinger techniques under fluoroscopic guidance with flushing or balloon dilation of the sphincter as needed. Our primary outcomes were LOS and successful duct clearance. RESULTS: One hundred eighty patients were treated for choledocholithiasis with 71 undergoing LCBDE. The success rate of catheter-based LCBDE was 70.4%. Length of stay was significantly reduced for the LCBDE group compared with the LC + ERCP group (48.8 vs. 84.3 hours, p < 0.01). Of note, there were no intraoperative or postoperative complications in the LCBDE group. CONCLUSION: A simplified catheter-based approach to LCBDE is safe and associated with decreased LOS when compared with LC + ERCP. This simplified step-up approach may help facilitate wider LCBDE utilization by ACS providers who are well positioned for a timely surgery first approach in the management of uncomplicated choledocholithiasis. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

SAGES safe cholecystectomy modules improve practicing surgeons' judgment: results of a randomized, controlled trial.

BACKGROUND: Despite the advantages of laparoscopic cholecystectomy, major bile duct injury (BDI) rates during this operation remain unacceptably high. In October 2018, SAGES released the Safe Cholecystectomy modules, which define specific strategies to minimize the risk of BDI. This study aims to investigate whether this curriculum can change the knowledge and behaviors of surgeons in practice. METHODS: Practicing surgeons were recruited from the membership of SAGES and the American College of Surgeons Advisory Council for Rural Surgery. All participants completed a baseline assessment (pre-test) that involved interpreting cholangiograms, troubleshooting difficult cases, and managing BDI. Participants' dissection strategies during cholecystectomy were also compared to the strategies of a panel of 15 experts based on accuracy scores using the Think Like a Surgeon validated web-based platform. Participants were then randomized to complete the Safe Cholecystectomy modules (Safe Chole module group) or participate in usually scheduled CME activities (control group). Both groups completed repeat assessments (post-tests) one month after randomization. RESULTS: Overall, 41 participants were eligible for analysis, including 18 Safe Chole module participants and 23 controls. The two groups had no significant differences in pre-test scores. However, at post-test, Safe Chole module participants made significantly fewer errors managing BDI and interpreting cholangiograms. Safe Chole module participants were less likely to convert to an open operation on the post-test than controls when facing challenging dissections. However, Safe Chole module participants displayed a similar incidence of errors when evaluating adequate critical views of safety. CONCLUSIONS: In this randomized-controlled trial, the SAGES Safe Cholecystectomy modules improved surgeons' abilities to interpret cholangiograms and safely manage BDI. Additionally, surgeons who studied the modules were less likely to convert to open during difficult dissections. These data show the power of the Safe Cholecystectomy modules to affect practicing surgeons' behaviors in a measurable and meaningful way.

Outcomes following balloon sphincteroplasty as an adjunct to laparoscopic common bile duct exploration.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy is an efficient pathway for management of choledocholithiasis. Performing this safely under one anesthetic offers advantages over a two-step process with cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP). Despite the proven efficacy of LCBDE, endoscopy continues to be predominantly utilized. Simplifying the intervention may drive LCBDE adoption. To this end, we refined a stepwise intraoperative pathway that utilizes over the wire balloon catheters to dilate the Sphincter of Oddi to facilitate stone passage into the duodenum. To determine the efficacy during the initial adoption phase on a general surgery service, we reviewed our experience with LCBDE balloon sphincteroplasty as part of this pathway. METHODS: We retrospectively reviewed the records of patients who underwent LCBDE with balloon sphincteroplasty at a single tertiary care center over a three-year period. Preoperative demographics, imaging/laboratory results, intra and postoperative outcomes were reviewed. RESULTS: Choledocholithiasis was managed with transcystic balloon sphincteroplasty during LCBDE in 28 cases over a three-year period. The cohort included 16 women and 12 men with a mean age of 47 years (range = 19-89). Operative indications included cholecystitis (n = 11, 39%), choledocholithiasis (n = 13, 47%), cholelithiasis (n = 2, 7%), and gallstone pancreatitis (n = 2, 7%). The stones were successfully cleared by the balloon sphincteroplasty technique in 75% of the cases. The average fluoroscopy time during LCBDE was 338 s (± 214). The average operating room time was 173 min (± 35). Mean length of stay was 58 h (± 46). There were no intra- or postoperative complications. CONCLUSION: Wire ready cholangiography followed by balloon sphincteroplasty with saline/contrast flush is a simple and safe way to clear the common bile duct. This technique is a gateway for further expansion and adoption of LCBDE.

Outcomes After Laparoscopic Cholecystectomy in Hyperkinetic Biliary Dyskinesia.

BACKGROUND: Biliary dyskinesia (BD) is a poorly understood functional gallbladder disorder. Diagnosis is made with abdominal pain and an intact gallbladder without signs of anatomical obstruction on imaging or pathology. Our aim was to assess whether laparoscopic cholecystectomy (LC) resolves hyperkinetic BD symptoms. METHODS: Records of patients ≥18 years of age, who underwent LC by four surgeons at a tertiary care center between 2012 and 2020, were retrospectively reviewed. Patients were excluded if they had a documented gallbladder ejection fraction (GBEF) <80% or had biliary stones or sludge on pathology or imaging. Demographic information, HIDA results, preoperative testing, operative details, gallbladder pathology, and symptom status at follow-up were collected from electronic medical records. Improvement in BD symptoms was assessed using McNemar's test. Risk differences with standard errors were employed to estimate percent reduction in symptoms. RESULTS: Ninety-eight patients met inclusion criteria. Of those who presented for follow-up (n = 91), 92.3% (n = 84) reported partial or complete resolution of symptoms. Preoperative symptoms, including back pain (16.7%, 95% CI: [7.9%, 25.5%]; P < .0001), epigastric pain (31.1% [21.3%, 41.3%]; P < .0001), nausea (56.7% [45.0%, 65.8%]; P < .0001), RUQ pain (57.8% [46.1%, 66.9%]; P < .0001), and vomiting (27.8% [18.4%, 37.7%]; P < .0001) showed significant improvement after LC. Chronic cholecystitis and/or cholesterolosis were present on pathology in 79.8% of gallbladders. DISCUSSION: Our study currently represents the largest cohort of patients with hyperkinetic BD. Laparoscopic cholecystectomy appears to result in resolution of symptoms for this clinical entity.

Live Quality Assurance: Using a Multimedia Messaging Service Group Chat to Instantly Grade Intraoperative Images.

BACKGROUND: The technique for attaining photographic evidence of the critical view of safety (CVS) in laparoscopic cholecystectomy (LC) has previously been defined; however, the consistency, accuracy, and feasibility of CVS in practice is unknown. The aim of this study was to use an already established image sharing and grading system to determine the feasibility of timely feedback after sharing intraoperative images of the CVS and to evaluate if and how cholecystitis affects the ability to attain a CVS. STUDY DESIGN: We studied 193 laparoscopic cholecystectomies performed by 14 surgeons between August 2017 and January 2019. Anterior and posterior intraoperative CVS images were shared using a standard multimedia messaging system (MMS). Images were graded remotely by members of the group using an established scoring system, and their times to response and scores were recorded. Response data were analyzed for the ability to attain timely and consistent CVS scores. RESULTS: There were 74 urgent laparoscopic cholecystectomies for acute cholecystitis and 119 nonurgent cholecystectomies performed during the study period. Scoring of shared images occurred in less than 5 minutes, and peer review (mean 3 responses) showed agreement that was not significantly different. In patients with acute cholecystitis, a small but significant difference was observed between anterior and posterior image scoring agreement. CONCLUSIONS: An established image sharing and grading system for CVS can be used for real-time intraoperative feedback without increasing operative time or compromising private health information. The CVS is almost always attainable; however, decreases in CVS quality and grading agreement are observed in patients with acute cholecystitis.

Myotomy-First Approach to Epiphrenic Esophageal Diverticula.

Introduction: Epiphrenic esophageal diverticula are typically treated with concurrent cardiomyotomy and diverticulectomy. However, resection of these diverticula can be technically difficult and associated with significant morbidity with a staple line leak rate ranging up to 27%. For this reason, and because the diverticulum is secondary to a primary esophageal motility disorder such as achalasia, we decided to adopt a laparoscopic myotomy-first strategy, reserving the diverticulectomy for patients with persistent or recurrent symptoms. Methods: From 2004 to 2018, 22 patients with epiphrenic diverticula were treated by laparoscopic Heller myotomy and partial fundoplication alone, with the plan to add the diverticulectomy as a second stage if needed. There were 13 women and 9 women, with a mean age of 68 years. Results: Patients had been symptomatic for an average of 36 months. The most common presenting symptom was dysphagia (91%), followed by regurgitation (77%). More than half of the diverticula were solitary and on the right side. Esogphagoscopy ruled out cancer. Esophageal manometry (18 patients) showed achalasia in 14 patients, nutcracker esophagus in 3 patients, and nonspecific motility disorder in 1 patient. There were no perioperative complications, and average length of stay was 2.5 days. At a mean follow-up of 68 months, dysphagia resolved in 77% and regurgitation in 86% of patients. Three patients had persistent symptoms: 2 patients underwent a transthoracic diverticulectomy (1 patient with resolution of symptoms and 1 patient with no improvement). Another patient had per oral endoscopic myotomy, but his dysphagia persisted. Conclusions: The laparoscopic myotomy-first approach reduces risk and unnecessary surgery. A laparoscopic Heller myotomy and partial fundoplication provide excellent resolution of symptoms for most, whereasonly a few will need a staged resection of the diverticulum.

Fundoplication for laryngopharyngeal reflux disease.

BACKGROUND: Laryngopharyngeal reflux (LPR) disease arises from the effects of refluxed gastric contents on the proximal aerodigestive tract. LPR patients are often lumped into the category of "atypical" reflux. LPR symptoms are hoarseness, globus, cough, and pharyngitis. Severe disease is associated with subglottic stenosis and laryngeal cancer. Treatment includes lifestyle modifications and medications. The role of fundoplication for LPR has yet to be defined. STUDY DESIGN: Forty-one patients underwent fundoplication for LPR. They were prospectively followed with three outcomes measures: The Reflux Symptom Index, a laryngoscopic grading scale (Reflux Finding Score), and a reflux-based specific quality-of-life scale. RESULTS: Average early followup was at 4 months and late followup was at 14 months. The Reflux Symptom Index improved by 5.4 early (p < 0.05) and 6.5 late (p < 0.05). Improvement between early and late periods approached significance (p < 0.09). Reflux Finding Score improved 3.8 (p < 0.05) early and 4.4 (p < 0.05) late. The Quality of Life Index improved 0.6 early and 2.3 (p < 0.05) late. By Reflux Symptom Index criteria, 26 patients were improved early versus 35 late (p < 0.05). Factors associated with poor outcomes were structural laryngeal changes in five patients (p < 0.05) and no response to proton pump inhibitors in six patients (p < 0.05). CONCLUSIONS: Fundoplication augments treatment of LPR. Improvement of symptoms continues past the first 4 months. Laryngoscopy is critical in patient selection because selected findings are associated with outcomes, diagnosis, and management.