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Sun Y, Zhang Y, Wang Z, Liu Q, Mo J. Efficacy and safety of Chinese herbal medicine in treating postcholecystectomy diarrhea: A systematic review and meta-analysis. Medicine (Baltimore) 2024; 103:e38046. [PMID: 38701312 PMCID: PMC11062710 DOI: 10.1097/md.0000000000038046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 04/05/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Postcholecystectomy diarrhea (PCD) is among the most distressing and well-known clinical complications of cholecystectomy. Despite various available treatment options, clinical outcomes are greatly limited by unclear pathophysiological mechanisms. Chinese herbal medicine (CHM) is widely used as a complementary and alternative therapy for the treatment of functional diarrhea. Thus, we conducted a meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of CHM for the treatment of PCD. METHODS Electronic database searches were conducted using the Cochrane Library, PubMed, Web of Science, Embase, Wanfang Data, China National Knowledge Infrastructure, and the Chinese Scientific Journal Database. All RCTs on CHMs for managing patients with PCD were included. The meta-analysis was performed using RevMan 5.4 software. RESULTS The present meta-analysis included 14 RCTs published between 2009 and 2021 in China. The primary findings indicated that CHM had a higher total efficacy and cure rate as a monotherapy for PCD (P < .00001). Two trials reported the scores of the main symptoms with statistically significant differences in stool nature (P < .00001), defecation frequency (P = .002), and abdominal pain and bloating (P < .00001). In addition, CHM reduced CD3+ and CD4+ levels more effectively in terms of T lymphocyte subset determination (P < .00001). The main symptoms of PCD in traditional Chinese medicine (TCM) are splenic deficiency and liver stagnation. All treatments were used to strengthen the spleen and (or) soothing the liver. CONCLUSION CHM had a favorable effect on PCD. No adverse events were observed. Larger, high-quality RCTs are warranted to draw definitive conclusions and standardize treatment protocols.
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Affiliation(s)
- Yan Sun
- Guang’an Men Hospital, China Academy of Chinese Medical Sciences, Xicheng District, Beijing, P.R. China
| | - Yong Zhang
- Guang’an Men Hospital, China Academy of Chinese Medical Sciences, Xicheng District, Beijing, P.R. China
| | - Zheng Wang
- Guang’an Men Hospital, China Academy of Chinese Medical Sciences, Xicheng District, Beijing, P.R. China
| | - Quanda Liu
- Guang’an Men Hospital, China Academy of Chinese Medical Sciences, Xicheng District, Beijing, P.R. China
| | - Juefei Mo
- Guang’an Men Hospital, China Academy of Chinese Medical Sciences, Xicheng District, Beijing, P.R. China
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Thomas AS, Gleit Z, Younan S, Genkinger J, Kluger MD. High rate of stone-related complications after stapling the cystic duct during laparoscopic cholecystectomy-an underrecognized risk. Surg Endosc 2023:10.1007/s00464-023-09947-2. [PMID: 36890412 DOI: 10.1007/s00464-023-09947-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/12/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Laparoscopic staplers (LS) have been suggested as a safe alternative to metal clips in laparoscopic cholecystectomy when the cystic duct is too inflamed or wide for complete clip occlusion. We aimed to evaluate the perioperative outcomes of patients whose cystic ducts were controlled by LS and evaluate the risk factors for complications. METHODS Patients who underwent laparoscopic cholecystectomy with LS used to control the cystic duct from 2005 to 2019 were retrospectively identified from an institutional database. Patients were excluded for open cholecystectomy, partial cholecystectomy, or cancer. Potential risk factors for complications were assessed using logistic regression analysis. RESULTS Among 262 patients, 191 (72.9%) were stapled for size and 71 (27.1%) for inflammation. In total, 33 (16.3%) patients had Clavien-Dindo grade ≥ 3 complications, with no significant difference when surgeons chose to staple for duct size versus inflammation (p = 0.416). Seven patients had bile duct injury. A large proportion had Clavien-Dindo grade ≥ 3 postoperative complications specifically related to bile duct stones [n = 29 (11.07%)]. Intraoperative cholangiogram was protective against postoperative complications [odds ratio (OR) = 0.18 (p = 0.022)]. CONCLUSION Whether these high complication rates reflect a technical issue with stapling, more challenging anatomy, or worse disease, findings question whether the use of LS during laparoscopic cholecystectomy is truly a safe alternative to the already accepted methods of cystic duct ligation and transection. Based on these findings, an intraoperative cholangiogram should be performed when considering a linear stapler during laparoscopic cholecystectomy to: (1) ensure the biliary tree is free of stones; (2) prevent inadvertent transection of the infundibulum rather than the cystic duct; and, (3) allow opportunity for safe alternative strategies when an IOC is not able to confirm anatomy. Otherwise, surgeons employing LS devices should be aware that patients are at higher risk for complications.
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Affiliation(s)
- Alexander S Thomas
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA.
- Division of GI and Endocrine Surgery, Surgery Resident and Postdoctoral Research Fellow, New York Presbyterian Hospital, 8th Floor, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Zachary Gleit
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Stephanie Younan
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Jeanine Genkinger
- Department of Epidemiology, Herbert Irving Comprehensive Cancer Center, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Michael D Kluger
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Wu H, Guo S, Liu X, Li Y, Su Z, He Q, Liu X, Zhang Z, Yu L, Shi X, Gao S, Wang H, Pan Y, Ma C, Liu R, Dai M, Jin G, Liang Z. Noninvasive detection of pancreatic ductal adenocarcinoma using the methylation signature of circulating tumour DNA. BMC Med 2022; 20:458. [PMID: 36434648 PMCID: PMC9701032 DOI: 10.1186/s12916-022-02647-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/01/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) has the lowest overall survival rate primarily due to the late onset of symptoms and rapid progression. Reliable and accurate tests for early detection are lacking. We aimed to develop a noninvasive test for early PDAC detection by capturing the circulating tumour DNA (ctDNA) methylation signature in blood. METHODS Genome-wide methylation profiles were generated from PDAC and nonmalignant tissues and plasma. Methylation haplotype blocks (MHBs) were examined to discover de novo PDAC markers. They were combined with multiple cancer markers and screened for PDAC classification accuracy. The most accurate markers were used to develop PDACatch, a targeted methylation sequencing assay. PDACatch was applied to additional PDAC and healthy plasma cohorts to train, validate and independently test a PDAC-discriminating classifier. Finally, the classifier was compared and integrated with carbohydrate antigen 19-9 (CA19-9) to evaluate and maximize its accuracy and utility. RESULTS In total, 90 tissues and 546 plasma samples were collected from 232 PDAC patients, 25 chronic pancreatitis (CP) patients and 323 healthy controls. Among 223 PDAC cases with known stage information, 43/119/38/23 cases were of Stage I/II/III/IV. A total of 171 de novo PDAC-specific markers and 595 multicancer markers were screened for PDAC classification accuracy. The top 185 markers were included in PDACatch, from which a 56-marker classifier for PDAC plasma was trained, validated and independently tested. It achieved an area under the curve (AUC) of 0.91 in both the validation (31 PDAC, 26 healthy; sensitivity = 84%, specificity = 89%) and independent tests (74 PDAC, 65 healthy; sensitivity = 82%, specificity = 88%). Importantly, the PDACatch classifier detected CA19-9-negative PDAC plasma at sensitivities of 75 and 100% during the validation and independent tests, respectively. It was more sensitive than CA19-9 in detecting Stage I (sensitivity = 80 and 68%, respectively) and early-stage (Stage I-IIa) PDAC (sensitivity = 76 and 70%, respectively). A combinatorial classifier integrating PDACatch and CA19-9 outperformed (AUC=0.94) either PDACatch (0.91) or CA19-9 (0.89) alone (p < 0.001). CONCLUSIONS The PDACatch assay demonstrated high sensitivity for early PDAC plasma, providing potential utility for noninvasive detection of early PDAC and indicating the effectiveness of methylation haplotype analyses in discovering robust cancer markers.
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Affiliation(s)
- Huanwen Wu
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No.1, Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Shiwei Guo
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, Navy Medical, University (the Second Military Medical University), No.168, Changhai Road, Shanghai, 200433, China
| | - Xiaoding Liu
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No.1, Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Yatong Li
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No.1, Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Zhixi Su
- Singlera Genomics (Shanghai) Ltd., No. 500, Furonghua Road, Shanghai, 201203, China
| | - Qiye He
- Singlera Genomics (Shanghai) Ltd., No. 500, Furonghua Road, Shanghai, 201203, China
| | - Xiaoqian Liu
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No.1, Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Zhiwen Zhang
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No.1, Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Lianyuan Yu
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No.1, Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Xiaohan Shi
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, Navy Medical, University (the Second Military Medical University), No.168, Changhai Road, Shanghai, 200433, China
| | - Suizhi Gao
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, Navy Medical, University (the Second Military Medical University), No.168, Changhai Road, Shanghai, 200433, China
| | - Huan Wang
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, Navy Medical, University (the Second Military Medical University), No.168, Changhai Road, Shanghai, 200433, China
| | - Yaqi Pan
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, Navy Medical, University (the Second Military Medical University), No.168, Changhai Road, Shanghai, 200433, China
| | - Chengcheng Ma
- Singlera Genomics (Shanghai) Ltd., No. 500, Furonghua Road, Shanghai, 201203, China
| | - Rui Liu
- Singlera Genomics (Shanghai) Ltd., No. 500, Furonghua Road, Shanghai, 201203, China.
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No.1, Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China.
| | - Gang Jin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, Navy Medical, University (the Second Military Medical University), No.168, Changhai Road, Shanghai, 200433, China.
| | - Zhiyong Liang
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No.1, Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China.
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Thapar VB, Thapar PM, Goel R, Agarwalla R, Salvi PH, Nasta AM, Mahawar K, Karthik A, Lakshman A, Amit A, Rishabh A, Manas A, Anmol A, Varadaraj AK, Murtaza A, Temsula A, Reddy AD, Srinivas A, Rambabu B, Rajendra B, Sarfaraz B, Manish B, Lovenish B, Lal BB, Rajandeep B, Rajesh B, Sharath B, Somendra B, Akshay B, Sonali B, Bhavneet B, Jatin B, Siddhartha B, Rajesh B, Bisht SD, Arjun B, Pankaj B, Vijay B, Prashanta B, Chandra BR, Chitra C, Kanhaiyya C, Sakthivel C, Bitan C, Shamita C, Tamonas C, Madeswaran CVC, Shreya C, Aditya C, Sourav C, Supriya C, Pradeep C, H CA, Ashwani D, Usha D, Abhay D, Chitta D, Ram DG, kumar DJ, Arupabha D, Rupjyoti D, Kunal D, Ashish D, Sumanta D, Monika D, Nilesh D, Poornima DB, Sanjay D, Easwaramoorthy S, Nishith E, Reddy EV, Naima G, Amitabh G, Apoorv G, Deep G, Thakut G, Pankaj G, Achal G, Rajkumar G, Rahul G, Shalu G, Shardool G, Lokesh HM, Nisar H, Sarath H, Bhaskar H, Vikas H, Srikantaiah H, Hariharasaran I, Mohammad I, Chaidul I, Samsul I, Mohammed I, Amit J, Mohit J, Parakash J, Sumita J, Advait J, Nikita J, Samrat J, James J, Yashpaul J, Abhijit J, Praveen J, Rejana J, Pooja K, Prasad K, Anirudhan K, Vishakha K, Adityakalyan K, Manmohan K, Abhimanyu K, Mayank K, Rohan K, Jaspreet K, Hosni K, Archana K, Ajay K, Khandelwal RG, Subhash K, Shashi K, Elbert K, Rajesh K, Suhail K, Shashank K, Uttam K, Shyam K, Prakash KC, Jyotsna K, Anil K, Bhartendu K, Durgesh K, Jitendra K, Shashidhar K, Saurabh K, Kshitiz K, Puneet K, Ranjith K, Hampher K, Krishnaswamy L, Suchitra L, Kona L, Nishanth L, Pawan L, Samuel L, Alfred L, Manjusha L, Lancelot L, Sushil L, Temsutoshi L, MuniReddy M, Vijaykumar M, Sivakumar M, Deepak M, Singh MM, Prasad MBV, Kumar MN, Suman M, Parth M, Shresth M, Faiz M, Alok M, Noushif M, Sadananda M, Magan M, Diksha M, Senthil M, Prakash MG, Lalan M, Subhash M, Taher M, Tarun M, kushal M, Rajan M, Abhiram M, Erbaz M, Rajashekar M, Ramya M, Khalid M, Sheetal AM, Majid M, Dileep N, Nikhil N, Ramprasanna NN, Madhavi N, Anand N, Govind N, Kumar NB, Barun N, Darshan N, Manjunath N, Rohit N, Ashok NO, Prabha O, Aashutosh P, Niranjan P, Hirak P, Chirag P, Roy P, Rakeshkumar P, Danesh P, Deepak P, Tejas P, Tanmaye P, Soumen P, Pratik P, Anshuman P, Pankaj P, Anand P, Arun P, Pallawi P, Gaurav P, Puneet P, Durai R, Santhosh R, Prashant R, Mohsinur R, Mahesh R, Ramesh BS, Gordon R, Prashanth R, Arshad R, Sandip R, Udipta R, Sameer R, Shyam R, Rajendar R, Anand S, ArunKumar S, DineshKumar S, Viswanath S, Amit S, Sajeesh S, Vishal S, Anurag S, Sauradeep S, Ankush S, Snehasish S, Harsh S, Shrenik S, Anil S, Abadhesh S, Meenakshi S, Varsha S, Nikhil S, Harsh S, Pravin S, Vikram SS, Ankur S, Pranav S, Arvind S, Abhishek S, Abhiyutthan S, Chandrapal S, Charan S, Gurbhaij S, Gurbachan S, Saurav S, Harmanmeet S, Pal SS, Kumar SN, Aalok S, Vandana S, Sanjai S, Sushama S, Pravin S, Om T, Fahad T, Ashwin T, Anuroop T, Abhishek T, K TS, Pradeep T, Lohith U, Peeyush V, Ashish V, Ravindra V, Kumar VR, Arunima V, Soumil V, Ajaz W, Sachin W, Amit Y, Kumar YA, Raghu Y, Mohammed Y. Evaluation of 30-day morbidity and mortality of laparoscopic cholecystectomy: a multicenter prospective observational Indian Association of Gastrointestinal Endoscopic Surgeons (IAGES) Study. Surg Endosc 2022; 37:2611-2625. [PMID: 36357547 PMCID: PMC9648883 DOI: 10.1007/s00464-022-09659-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/18/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is the standard of care for benign gallstone disease. There are no robust Indian data on the 30-day morbidity and mortality of this procedure. A prospective multicentre observational study was conducted by the Indian Association of Gastro-Intestinal Endo Surgeons (IAGES) to assess the 30-day morbidity and mortality of LC in India. MATERIALS AND METHODS Participating surgeons were invited to submit data on all consecutive LCs for benign diseases performed between 09/12/2020 and 08/03/2021 in adults. Primary outcome measures were 30-day morbidity and mortality. Univariate and multivariate analyses were performed to identify variables significantly associated with primary outcomes. RESULTS A total of 293 surgeons from 125 centres submitted data on 6666 patients. Of these, 71.7% (n = 4780) were elective. A total LC was carried out in 95% (n = 6331). Laparoscopic subtotal cholecystectomy was performed in 1.9% (n = 126) and the procedure were converted to open in 1.4% of patients. Bile duct injury was seen in 0.3% (n = 20). Overall, 30-day morbidity and mortality were 11.1% (n = 743) and 0.2% (n = 14), respectively. Nature of practice, ischemic heart disease, emergency surgery, postoperative intensive care, and postoperative hospital stay were independently associated with 30-day mortality. Age, weight, body mass index, duration of symptoms, nature of the practice, history of Coronavirus Disease-2019, previous major abdominal surgery, acute cholecystitis, use of electrosurgical or ultrasonic or bipolar energy for cystic artery control; use of polymer clips for cystic duct control; conversion to open surgery, subtotal cholecystectomy, simultaneous common bile duct exploration, mucocele, gangrenous gall bladder, dense adhesions, intraoperative cholangiogram, and use of drain were independently associated with 30-day morbidity. CONCLUSION LC has 30-day morbidity of 11.1%, 30-day mortality of 0.2%, conversion to open rate of 1.4%, and bile duct injury rate of 0.3% in India.
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Arkle T, Lam S, Toogood G, Kumar B. How should we secure the cystic duct during laparoscopic cholecystectomy? A UK-wide survey of clinical practice and systematic review of the literature with meta-analysis. Ann R Coll Surg Engl 2022; 104:650-654. [PMID: 35196149 PMCID: PMC9685994 DOI: 10.1308/rcsann.2021.0264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 11/03/2023] Open
Abstract
INTRODUCTION It is currently unknown which method of cystic duct closure is most effective at reducing the risk of bile leak after laparoscopic cholecystectomy. The aims of this work were to determine the most common closure methods used in the UK and review available evidence on which method has the lowest risk of bile leak. METHODS We conducted an online survey through the Association of Upper Gastrointestinal Surgeons (AUGIS). We also undertook a systematic review using PubMed, EMBASE, MEDLINE and the Cochrane Library for studies that compared different methods for cystic duct occlusion and reported postoperative bile leak. FINDINGS There was significant variation in practice between consultant surgeons. For routine laparoscopic cholecystectomy metal clips were used most (64%) followed by locking polymer clips (33%) and suture ties (3%). In cases of a dilated cystic duct, preferences were locking polymer clips (60%), suture ties (30%) and metal clips (5%). We included six studies in our review with a total of 8,011 patients. Metal clips were associated with an increased odds of bile leak compared with locking polymer clips (OR 5.66, 95% CI 1.13-28.41, p=0.04) or suture ties (OR 4.17, 95% CI 0.72-24.31, p=0.12). Most studies were retrospective, unlikely to be adequately powered, and vulnerable to selection bias. CONCLUSIONS Limited available evidence suggests that metal clips have the highest risk of bile leak, but results are not strong enough to recommend a change in current clinical practice. A trial is now required to determine the best method of cystic duct closure.
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Affiliation(s)
| | | | - G Toogood
- Leeds Teaching Hospital NHS Trust, UK
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Fisher AT, Bessoff KE, Khan RI, Touponse GC, Yu MM, Patil AA, Choi J, Stave CD, Forrester JD. Evidence-based surgery for laparoscopic cholecystectomy. Surg Open Sci 2022; 10:116-134. [PMID: 36132940 PMCID: PMC9483801 DOI: 10.1016/j.sopen.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 08/15/2022] [Indexed: 11/30/2022] Open
Abstract
Background Laparoscopic cholecystectomy is frequently performed for acute cholecystitis and symptomatic cholelithiasis. Considerable variation in the execution of key steps of the operation remains. We conducted a systematic review of evidence regarding best practices for critical intraoperative steps for laparoscopic cholecystectomy. Methods We identified 5 main intraoperative decision points in laparoscopic cholecystectomy: (1) number and position of laparoscopic ports; (2) identification of cystic artery and duct; (3) division of cystic artery and duct; (4) indications for subtotal cholecystectomy; and (5) retrieval of the gallbladder. PubMed, EMBASE, and Web of Science were queried for relevant studies. Randomized controlled trials and systematic reviews were included for analysis, and evidence quality was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation framework. Results Fifty-two articles were included. Although all port configurations were comparable from a safety standpoint, fewer ports sometimes resulted in improved cosmesis or decreased pain but longer operative times. The critical view of safety should be obtained for identification of the cystic duct and artery but may be obtained through fundus-first dissection and augmented with cholangiography or ultrasound. Insufficient evidence exists to compare harmonic-shear, clipless ligation against clip ligation of the cystic duct and artery. Stump closure during subtotal cholecystectomy may reduce rates of bile leak and reoperation. Use of retrieval bag for gallbladder extraction results in minimal benefit. Most studies were underpowered to detect differences in incidence of rare complications. Conclusion Key operative steps of laparoscopic cholecystectomy should be informed by both compiled data and surgeon preference/patient considerations.
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Gustafsson A, Enochsson L, Tingstedt B, Olsson G. Bile leakage and the number of metal clips on the cystic duct during laparoscopic cholecystectomy. Scand J Surg 2022; 111:14574969221102284. [PMID: 35694737 DOI: 10.1177/14574969221102284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVE The most common way of closing the cystic duct in laparoscopic cholecystectomy is by using metal clips (>80%). Nevertheless, bile leakage occurs in 0.4%-2.0% of cases, and thus causes significant morbidity. However, the optimal number of clips needed to avoid bile leakage has not been determined. The primary aim of this study was to evaluate bile leakage and post-procedural adverse events after laparoscopic cholecystectomy concerning whether two or three clips were used to seal the cystic duct. METHODS Using a retrospective observational design, we gathered data from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (ERCP) (GallRiks). From 2006 until 2019, 124,818 patients were eligible for inclusion. These were nested to cohorts of 75,322 (60.3%) for uncomplicated gallstone disease and 49,496 (39.7%) with complicated gallstone disease. The cohorts were grouped by the number (i.e. two or three) of metal clips applied to the proximal cystic duct. The main outcome was 30-day bile leakage and post-procedural adverse events. RESULTS No significant differences surfaced in the rate of bile leakage (0.8% vs 0.8%; P = .87) or post-procedural adverse events (three clips, 5.7% vs two clips, 5.4%; P = .16) for uncomplicated gallstone disease. However, for complicated disease, bile leakage (1.4% vs 1.0%; P < .001) and post-procedural adverse events (10.2% vs 8.6%; P < .001) significantly increased when the cystic duct was sealed with three clips compared with two. CONCLUSIONS Because no differences in the rates of bile leakage or adverse events emerged in uncomplicated gallstone disease when a third clip was applied, a third clip for additional safety is not recommended in such cases. On the contrary, bile leakage and adverse events increased when a third clip was used in patients with complicated gallstone disease. This finding probably indicates a more difficult cholecystectomy rather than being caused by the third clip itself.
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Affiliation(s)
- Arvid Gustafsson
- Department of Surgery and Department of Research and Development, Central Hospital, Region Kronoberg, Växjö, Sweden.,Department of Clinical Sciences Lund, Lund University and Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Lars Enochsson
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå University Hospital, Umeå, Sweden
| | - Bobby Tingstedt
- Department of Clinical Sciences Lund, Lund University and Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Greger Olsson
- Department of Surgery and Department of Research and Development, Central Hospital, Region Kronoberg, Strandvägen 8, SE-35185 Växjö, Sweden
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Farrugia A, Attard JA, Khan S, Williams N, Arasaradnam R. Postcholecystectomy diarrhoea rate and predictive factors: a systematic review of the literature. BMJ Open 2022; 12:e046172. [PMID: 35177439 PMCID: PMC8860059 DOI: 10.1136/bmjopen-2020-046172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Cholecystectomy is one of the most common surgical procedures performed worldwide to treat gallstone-related disease. Postcholecystectomy diarrhoea (PCD) is a well-reported phenomenon, however, the actual rate, predictive factors and mechanism of action have not been well determined. A systematic review was undertaken to determine the rate and predictive factors associated with diarrhoea in the postcholecystectomy setting. METHODS The review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol. Databases searched included Medline, Embase, Pubmed, Cochrane and Google Scholar up to 29 September 2020. The inclusion criteria consisted of cohort studies or randomised trials which investigated the rate of PCD and predictive factors. Case reports, case series, conference abstracts and expert opinion pieces were excluded as were other systematic reviews as all the original articles from those reviews were included in this review. Papers that did not include PCD as a separate entity were excluded. Bias assessment was performed using the Newcastle-Ottawa Scale for cohort studies and the Cochrane risk of bias tool for randomised controlled trials as appropriate. Data were extracted by two authors (AF and JAA) and an overall rate of PCD was calculated. Predictive factors were also extracted and compared between studies. RESULTS 1204 papers were obtained and 21 were found to contain relevant information about PCD, including the number of patients developing diarrhoea, method of symptom assessment and time of onset postcholecystectomy. A pooled total of 3476 patients were included across the identified studies with 462 (13.3%) patients developing PCD. Possible predictive factors varied across all studies, with characteristics such as gender, age and weight of patients postulated as being predictive of PCD, with no agreement across studies. DISCUSSION PCD is therefore relatively common (13.3%). This has important implications for patient consent. Patients ought to be investigated early for bile acid diarrhoea in suspected PCD. More studies are required to determine the possible predictive factors for PCD. Limitations of the study included that most studies were not powered for calculation of PCD, and assessment methods between studies varied. PROSPERO REGISTRATION NUMBER CRD42019140444.
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Affiliation(s)
- Alexia Farrugia
- General Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Biomedical sciences, University of Warwick, Warwick Medical School, Coventry, UK
| | | | - Saboor Khan
- General Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Nigel Williams
- General Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Ramesh Arasaradnam
- Biomedical sciences, University of Warwick, Warwick Medical School, Coventry, UK
- Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Aboelela A, Abouheba M, Khairi A, Kotb M. Evaluation of the safety of using harmonic scalpel during laparoscopic cholecystectomy in children: A preliminary report. Front Pediatr 2022; 10:998106. [PMID: 36105859 PMCID: PMC9464866 DOI: 10.3389/fped.2022.998106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/05/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE In spite of being one of the most common surgical procedures performed in adults, laparoscopic cholecystectomy (LC) is relatively uncommon in the pediatric age group. Most surgeons prefer to dissect the cystic duct using a monopolar electrosurgical hook and occlude it with simple metal clips. Although the safety of using the ultrasonically-activated shears, e.g., harmonic scalpel for dissection of the gallbladder is confirmed in many studies, its efficacy in the closure of the cystic artery and duct in adults is still debatable. Furthermore, very few reports studied its safety in children during LC. The aim of our work is to study the safety and efficacy of ultrasonic shears in controlling the cystic duct and artery during LC in children. MATERIALS AND METHODS A prospective study was conducted from May 2017 to April 2020, where all children having symptomatic gallbladder stone disease were included in the study. HS was used as a sole instrument in gallbladder dissection as well as in controlling cystic duct and artery. No metal clips or sutures were used throughout the procedure. RESULTS A total of forty-two children having symptomatic gallstone disease were included in the study. The main indication for LC was hemolytic anemia. Their age ranged from 3 to 13 years with a mean of 8.4 ± 3.25 years. All operations were completed laparoscopically, i.e., no conversion to open surgery was needed. The mean operative time was 40 ± 10.42 min. There were no intraoperative complications apart from gall bladder perforation in two cases during dissection from the liver bed while the postoperative recovery was smooth in all patients. Patients started oral feeding after 11.30 ± 3.01 h. The mean time for discharge was 25.47 ± 7.49 h, ranging from 14 to 48 h. Postoperative ultrasound for all cases showed no evidence of minor or major bile leaks or CBD injuries. CONCLUSION This is the first report to evaluate the use of HS as a sole instrument during LC in the pediatric age group. HS is a safe and efficient instrument that can be used alone in gallbladder dissection as well as in controlling cystic duct and artery during LC in children.
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Affiliation(s)
- Ahmed Aboelela
- Pediatric Surgery Unit, Faculty of Medicine Alexandria University, Alexandria, Egypt
| | - Mohamed Abouheba
- Pediatric Surgery Unit, Faculty of Medicine Alexandria University, Alexandria, Egypt
| | - Ahmed Khairi
- Pediatric Surgery Unit, Faculty of Medicine Alexandria University, Alexandria, Egypt
| | - Mostafa Kotb
- Pediatric Surgery Unit, Faculty of Medicine Alexandria University, Alexandria, Egypt
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Nassar AHM, Ng HJ. Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5675 laparoscopic cholecystectomies. Langenbecks Arch Surg 2021; 407:213-223. [PMID: 34436660 PMCID: PMC8847250 DOI: 10.1007/s00423-021-02264-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 07/01/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE The main sources of post-cholecystectomy bile leakage (PCBL) not involving major duct injuries are the cystic duct and subvesical/hepatocystic ducts. Of the many studies on the diagnosis and management of PCBL, few addressed measures to avoid this serious complication. The aim of this study was to examine the causes and mechanisms leading to PCBL and to evaluate the effects of specific preventative strategies. METHODS A prospectively maintained database of 5675 consecutive laparoscopic cholecystectomies was analysed. Risk factors for post-cholecystectomy bile leakage were identified and documented and technical modifications and strategies were adopted to prevent this complication. The incidence, causes and management of patients who suffered bile leaks were studied and their preoperative characteristics, operative data and postoperative outcomes were compared with patients where potential risks were identified and PCBL avoided and with the rest of the series. RESULTS Twenty-five patients (0.4%) had PCBL (7 expected and less than half requiring reintervention): 11 from cystic ducts (0.2%), 3 from subvesical ducts (0.05%) and 11 from unconfirmed sources (0.2%). The incidence of cystic duct leakage was significantly lower with ties (0.15%) than with clips (0.7%). Fifty-two percent had difficulty grades IV or V, 36% had empyema or acute cholecystitis and 16% had contracted gallbladders. Twelve patients required 17 reinterventions before PCBL resolved; 7 percutaneous drainage, 6 ERCP and 4 relaparoscopy. The median hospital stay was 17 days with no mortality. Hepatocystic ducts were encountered in 72 patients (1.3%) and were secured with loops (54.2%), ties (25%) or sutures (20.8%) with no PCBL. Eighteen sectoral ducts were identified and secured. CONCLUSION Ligation of the cystic duct reduces the incidence of PCBL resulting from dislodged endoclips. Careful blunt dissection in the proper anatomical planes avoiding direct or thermal injury to subvesical and sectoral ducts and a policy of actively searching for hepatocystic ducts during gallbladder separation to identify and secure them can reduce bile leakage from such ducts.
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Affiliation(s)
- Ahmad H M Nassar
- Laparoscopic Biliary Surgery Service, University Hospital Monklands, Lanarkshire, Airdrie, Scotland, ML6 0JS, UK.
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11
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Aspart F, Bolmgren JL, Lavanchy JL, Beldi G, Woods MS, Padoy N, Hosgor E. ClipAssistNet: bringing real-time safety feedback to operating rooms. Int J Comput Assist Radiol Surg 2021; 17:5-13. [PMID: 34297269 PMCID: PMC8739308 DOI: 10.1007/s11548-021-02441-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/17/2021] [Indexed: 12/18/2022]
Abstract
Purpose Cholecystectomy is one of the most common laparoscopic procedures. A critical phase of laparoscopic cholecystectomy consists in clipping the cystic duct and artery before cutting them. Surgeons can improve the clipping safety by ensuring full visibility of the clipper, while enclosing the artery or the duct with the clip applier jaws. This can prevent unintentional interaction with neighboring tissues or clip misplacement. In this article, we present a novel real-time feedback to ensure safe visibility of the instrument during this critical phase. This feedback incites surgeons to keep the tip of their clip applier visible while operating. Methods We present a new dataset of 300 laparoscopic cholecystectomy videos with frame-wise annotation of clipper tip visibility. We further present ClipAssistNet, a neural network-based image classifier which detects the clipper tip visibility in single frames. ClipAssistNet ensembles predictions from 5 neural networks trained on different subsets of the dataset. Results Our model learns to classify the clipper tip visibility by detecting its presence in the image. Measured on a separate test set, ClipAssistNet classifies the clipper tip visibility with an AUROC of 0.9107, and 66.15% specificity at 95% sensitivity. Additionally, it can perform real-time inference (16 FPS) on an embedded computing board; this enables its deployment in operating room settings. Conclusion This work presents a new application of computer-assisted surgery for laparoscopic cholecystectomy, namely real-time feedback on adequate visibility of the clip applier. We believe this feedback can increase surgeons’ attentiveness when departing from safe visibility during the critical clipping of the cystic duct and artery. Supplementary Information The online version supplementary material available at 10.1007/s11548-021-02441-x.
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Affiliation(s)
- Florian Aspart
- Caresyntax GmbH, Komturstraße 18A, 12099, Berlin, Germany.
| | - Jon L Bolmgren
- Caresyntax GmbH, Komturstraße 18A, 12099, Berlin, Germany
| | - Joël L Lavanchy
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | | | - Nicolas Padoy
- ICube, University of Strasbourg, CNRS, IHU, Strasbourg, France
| | - Enes Hosgor
- Caresyntax GmbH, Komturstraße 18A, 12099, Berlin, Germany
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12
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Gupta V. Post-cholecystectomy bile leak is not always synonymous with acute bile duct injury: Need for reclassification. Hepatobiliary Pancreat Dis Int 2020; 19:492-494. [PMID: 32624373 DOI: 10.1016/j.hbpd.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/16/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Vishal Gupta
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, UP 226003, India.
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Mansueto G, Gatti FL, Boninsegna E, Conci S, Guglielmi A, Contro A. Biliary Leakage After Hepatobiliary and Pancreatic Surgery: A Classification System to Guide the Proper Percutaneous Treatment. Cardiovasc Intervent Radiol 2019; 43:302-310. [DOI: 10.1007/s00270-019-02374-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/05/2019] [Indexed: 12/18/2022]
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Nezami N, Jarmakani H, Arici M, Latich I, Mojibian H, Ayyagari RR, Pollak JS, Perez Lozada JCL. Selective Trans-Catheter Coil Embolization of Cystic Duct Stump in Post-Cholecystectomy Bile Leak. Dig Dis Sci 2019; 64:3314-3320. [PMID: 31123973 DOI: 10.1007/s10620-019-05677-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/16/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Percutaneous drainage is a first-line treatment for bilomas developed post-cholecystectomy in the setting of bile leak from the cystic duct stump. Percutaneous drainage is usually followed by surgical or endoscopic treatment to address the leak. AIMS This study aimed to evaluate outcome of selective coil embolization of the cystic duct stump via the percutaneously placed drainage catheters in patients with post-cholecystectomy bile leak. METHODS Seven patients with persistent bile leak after laparoscopic cholecystectomy who underwent percutaneous catheter placement for biloma/abscess formation in the region of the gallbladder fossa were followed. These patients underwent selective trans-catheter cystic duct stump coil embolization from Feb 2013 to Feb 2019. Procedural management, complications, and success rates were analyzed. RESULTS All patients underwent placement of a percutaneous catheter for drainage of biloma formation in the gallbladder fossa post-cholecystectomy. Selective coil embolization of the cystic duct was performed through the existing percutaneous tract on average 3.5 weeks after percutaneous catheter placement, resulting in resolution of the biloma. All bile leaks were immediately closed. None of the patients showed recurrent bile leak or further clinical symptoms. Coil migration to the common bile duct was diagnosed in a single case, after 2.5 years, with no bile leak reported. CONCLUSIONS Selective trans-catheter coil embolization of the cystic stump is a feasible and safe procedure, which successfully seals leaking cystic duct stumps and can circumvent the need for repeat surgical or endoscopic intervention in selected patient populations.
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Affiliation(s)
- Nariman Nezami
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Haddy Jarmakani
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Melih Arici
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Igor Latich
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Hamid Mojibian
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Rajasekhara R Ayyagari
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Jeffrey S Pollak
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Juan Carlos L Perez Lozada
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA.
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Abstract
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
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Affiliation(s)
- Vishal Gupta
- Department of Surgical Gastroenterology, Shatabdi Hospital Phase 1, King George's Medical University, Lucknow 226003, Uttar Pradesh, India.
| | - Gaurav Jain
- Transplant and HPB Surgery, the Iowa Clinic-Iowa Methodist Hospital, Des Moines, IA 50309, United States
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Gupta V, Jain G. Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy. World J Gastrointest Surg 2019; 11:62-84. [PMID: 30842813 PMCID: PMC6397793 DOI: 10.4240/wjgs.v11.i2.62] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/06/2019] [Accepted: 01/23/2019] [Indexed: 02/06/2023] Open
Abstract
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
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Affiliation(s)
- Vishal Gupta
- Department of Surgical Gastroenterology, Shatabdi Hospital Phase 1, King George’s Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Gaurav Jain
- Transplant and HPB Surgery, the Iowa Clinic-Iowa Methodist Hospital, Des Moines, IA 50309, United States
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Ai XM, Ho LC, Yang NY, Han LL, Lu JJ, Yue X. A comparative study of ultrasonic scalpel (US) versus conventional metal clips for closure of the cystic duct in laparoscopic cholecystectomy (LC): A meta-analysis. Medicine (Baltimore) 2018; 97:e13735. [PMID: 30572514 PMCID: PMC6320032 DOI: 10.1097/md.0000000000013735] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND laparoscopic cholecystectomy (LC) has become the gold standard surgery for benign gallbladder diseases. Metal clips are conventionally used to secure the cystic duct and artery, while monopolar electrocautery (ME) predominates during laparoscopic dissection. ultrasonic scalpel (US) has already been explored for sealing the cystic duct and artery as a sole instrument, which has been regarded as a reasonable alternative to clips. The aim of this study was to investigate the safety and effectiveness of US versus clips for securing the cystic duct during LC. METHODS We identified eligible studies in PubMed, Medline, Cochrane Library, Embase, and SpringerLink up to 1st May 2018, together with the reference lists of original studies. Meta-analysis was conducted using STATA 14.0. Q-based chi-square test and the I statistics were utilized to assess heterogeneity among the included studies. A P-value below .05 was set for statistical significance. Forest plots of combined Hazard ratios (HRs) with 95% confidence intervals (CIs) were also generated. RESULTS Eight studies met eligibility criteria in this meta-analysis eventually. A total of 1131 patients were included, of whom 529 were contained in the US group, compared to 602 in the clips group, which showed a significant difference (P = .025) without substantial statistical heterogeneity (I = 0.0%). No statistical significance was revealed regarding age (I = 0.0%, P = .957), and sex (I = 0.0%, P = .578) between both groups. The operative time and hospital stay in the US group were significantly shorter than that in the clips group, with I = 95.0%, P = .000 and I = 72.8%, P = .005, respectively. Concerning conversion (I = 48.6%, P = .084), perforation (I = 12.0%, P = .338), along with bile leakage (I = 0.0% P = .594), and overall morbidity (I = 19.1%, P = .289), comparison between both groups exhibited no statistical significance. CONCLUSIONS US enabled shorter operative time and hospital stay during LC, compared with clips. Additionally, US was comparable to clips regarding conversion, perforation, along with bile leakage and overall morbidity. Therefore, our meta-analysis concluded that US is clinically superior to the conventional clips in some aspects, or is at least as safe and effective as them, concerning closure of the cystic duct and artery.
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