A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation?

INTRODUCTION

Laparoscopic subtotal cholecystectomy (LSTC) is a bailout procedure that is undertaken when it is not safe to proceed with a laparoscopic total cholecystectomy owing to dense adhesions in Calot's triangle. The main aim of this review was to investigate the early (≤30 days) and late (>30 days) morbidity and mortality of LSTC.

METHODS

A literature search of the PubMed® (MEDLINE®), Google Scholar™ and Embase® databases was conducted to identify all studies on LSTC published between 1985 and December 2020. A systematic review was then performed.

RESULTS

Overall, 45 studies involving 2,166 subtotal cholecystectomy patients (51% female) were identified for inclusion in the review. The mean patient age was 55 years (standard deviation: 15 years). Just over half (53%) of the patients had an elective procedure. The conversion rate was 6.2% (n=135). The most common indication was acute cholecystitis (49%). Different techniques were used, with the majority having a closed cystic duct/gallbladder stump (71%). The most common closure technique was intracorporeal suturing (53%), followed by endoloop closure (15%). Four patients (0.18%) died within thirty days of surgery. Morbidity within 30 days included bile duct injury (0.23%), bile leak (18%) and intra-abdominal collection (4%). Reoperation was reported in 23 patients (1.2%), most commonly for unresolving intra-abdominal collections and failed endoscopic retrograde cholangiopancreatography to control bile leak. Long-term follow-up was reported in 30 studies, the median follow-up duration being 22 months. Late morbidity included incisional hernias (6%), symptomatic gallstones (4%) and common bile duct stones (2%), with 2% of cases requiring completion of cholecystectomy.

CONCLUSIONS

LSTC is an acceptable alternative in patients with a "difficult" Calot's triangle.

886 Healing Hands and Thrifty Plans! A Prospective, Cost-Effective Trial in Abscess Management

Aim

Cutaneous abscesses are ubiquitous presentations requiring surgical drainage in most cases. There is a wide variation across the UK in the surgical practice dealing with such common problem. The aim of this study was to reduce the costs incurred in surgical drainage of acute skin and soft tissue abscess.

Method

This was a prospective, cost-effective study of the expenses incurred in surgical drainage of acute cutaneous and subcutaneous abscesses treated under the general surgeons' care over one year.

Results

A consequential saving of £13,962 was achieved during the study period. Between October 2019 and October 2020, 322 patients with soft tissue abscesses were treated by incision and drainage in general surgery. We calculated a total cost of £55.26 per patient for this routine operation. These expenses were based on basic surgical drapes pack, standard surgical gowns, sterile gloves and obtaining and processing the microbiology specimens. We have designed and implemented a new theatre protocol specifically for this procedure, resulting in a substantial reduction of the costs to £11.90 per patient. The total savings of £13,962 do not include savings caused by abscess drainage under local anaesthesia and does not calculate the savings that occurred due to shorter inpatient stay. These extra savings will be calculated and added later.

Conclusions

Considering the increasing financial burden on the NHS, we could make significant savings of nearly 80% of the operative costs of surgical drainage of a cutaneous abscess. We could achieve that by implementing simple modifications in the current surgical pathways without compromising patients' safety.

Systematic evaluation of radiological findings in the assessment of resectability of peri-ampullary cancer by CT using different contrast phase protocols

AIMS

To determine the relative significance of radiological signs in determining the resectability of peri-ampullary cancer (PC) and to assess the value of multi-phase imaging in detecting these findings.

MATERIALS AND METHODS

Blinded, double re-reporting of preoperative imaging from five hospitals was undertaken of 411 patients undergoing surgery for PC over an 8-year period, of whom 119 patients were found to be inoperable at the time of surgery.

RESULTS

The median tumour size was 26.7 mm and the proportion of patients reported to have regional lymphadenopathy (RL), venous (VI) and arterial involvement (AI) was 24.7%, 11.5%, and 3.9%, respectively and was similar regardless of the number of contrast phases undertaken. Significant associations were, however, noted between individual risk factors: VI was closely associated with tumour size (p=0.002) and AI (p<0.0001). In multivariate analysis AI, VI, and RL were independently associated with resectability (relative risk of resection=0.05, 0.31, and 0.51, respectively). Tumour size, however, was not associated with resectability when VI was included in the multivariate model.

CONCLUSIONS

The use of multiple vascular contrast phases has no measureable impact on the rate of determination of tumour resectability of PC. In preoperative staging, AI is the most significant adverse finding for resectability. Large tumour diameter is not an adverse finding in isolation from other risk factors.

Management and outcomes of appendicular neuroendocrine tumours: Retrospective review with 5-year follow-up

BACKGROUND

Neuroendocrine (NEN) tumours are the commonest type of tumours affecting the appendix. The majority of cases are diagnosed incidentally on post-operative histopathological examination of the resected appendicectomy specimen. Preoperative diagnosis remains a challenge, unless the patient presents with obvious features of carcinoid syndrome or signs of metastatic disease. Hence, the authors present our five-year experience in diagnosing and managing NEN tumours of the appendix.

METHODS

Retrospective review of all patients underwent an emergency appendicectomy with intention to treat clinically suspected appendicitis at Derriford Hospital (Plymouth, Devon, UK) was undertaken. Patients with diagnoses other than NEN of the appendix were excluded. For patients with appendicular NEN, demographic data, pre-operative inflammatory markers, post-operative histology results as well as follow-up investigations were obtained using patients' electronic records. Case notes were reviewed for clinical presentation, operative details and follow-up information.

RESULTS

2724 patients underwent emergency appendicectomy between January 2009 and May 2014. Carcinoid tumours were identified in 17 histologically examined appendicectomy specimens. Clinically, all patients presented with acute appendicitis with raised inflammatory markers in 58.5% of patients. Median tumour size was 5 (1-20) mm. Median postoperative follow up was 2.9 (0.92-5.8) years. All patients remained tumour free with no evidence of metastasis or recurrence during the entire study period.

CONCLUSION

Appendicular NEN are rare and usually diagnosed incidentally; hence precise examination of routine appendicectomy specimens is fundamental in the diagnosis. Simple appendicectomy is sufficient for tumours less than 1 cm for adequate clearance, whilst right hemi-colectomy is recommended for larger tumours.