Feasibility of laparoscopic cholecystectomy for symptomatic gallstone disease with portal cavernoma: Can prior portal vein decompression be avoided?

Backgrounds/Aims

Biliary surgery in patients with extrahepatic portal vein obstruction with portal cavernoma (PC) is technically challenging, and associated with the risk of bleeding. Therefore, prior portal vein decompression is usually recommended before definitive biliary surgery. Only a few studies have so far reported the safety of isolated laparoscopic cholecystectomy. We aimed to evaluate our experience of laparoscopic cholecystectomy in patients with PC without prior portal decompression.

Methods

Prospectively maintained data for patients with PC who underwent laparoscopic cholecystectomy for symptomatic gallstone disease without portal decompression were analyzed. Clinical features, imaging, intraoperative factors, conversion rate, complications of surgery, and long-term outcomes were assessed.

Results

Sixteen patients underwent cholecystectomy without portal decompression from 2012 to 2021, of which interventions 14 were laparoscopic cholecystectomies. One patient required conversion (7.1%) to open surgery. Jaundice was present in 5 patients (35.7%), and underwent endoscopic stone clearance before surgery. Median intraoperative blood loss, operative time, and hospital stay were 100 mL (20-400 mL), 105 min (60-220 min), and 2 days (1-7 days), respectively. Blood transfusion was required in two patients (14.2%). Prior endoscopic or percutaneous intervention was associated with significant blood loss and prolonged intraoperative time.

Conclusions

In centers with experience, prior portal decompression can be avoided in patients with PC requiring isolated cholecystectomy to treat gallstones or their complications. Laparoscopic surgery is safe and feasible for these patients, and gives excellent outcomes in the selected group.

A 'twist' in the tale of a 'simple' laparoscopic cholecystectomy: Duplication of the gall bladder

The duplication of the gall bladder (GB) is unusual biliary anatomy that can be encountered during cholecystectomy and can create intraoperative confusion if missed on pre-operative imaging. Here, we describe a case of duplication of GB in a young female, which was detected during laparoscopic cholecystectomy as an operative surprise. Laparoscopic cholecystectomy was done successfully with the removal of both the GBs. She was discharged uneventfully and remained symptom-free at a 6-month follow-up.

Portal vein fenestration: a case report of an unusual portal vein developmental anomaly

Portal vein anatomic variations are common in living donor liver transplantation. Portal vein fenestration, in which a segment of a vessel divides into at least two channels that reunite into a single distal lumen, has not yet been reported in the literature. Failure to identify this anomaly can lead to catastrophic events in donor liver hepatectomy. Herein, we report an unusual portal vein anomaly that was detected intraoperatively in a living liver donor.

An unusual cause of obstructive jaundice in childhood: Intra-choledochal malignant neuroendocrine tumour

The extrahepatic biliary apparatus is a rare site for neuroendocrine tumours. A 13-year-old child presented with cholestatic symptoms of jaundice and pruritus with soft hepatomegaly and mild ascites. Magnetic resonance imaging and endoscopic ultrasound revealed a mid-common bile duct mass, and dilated intrahepatic biliary system. An en-bloc resection of the extrahepatic biliary apparatus, showed malignant cells disposed in lobules in a desmoplastic stroma with intramural invasion, staining positive for cytokeratin, chromogranin, synaptophysin and negative for CD56. At 3 months post-resection, whole body positron emission tomography scan was normal with no recurrence at 24 months.

Sex disparities in completeness of revascularisation and outcomes in patients with ST-elevation myocardial infarction and multivessel coronary artery disease

Background

In patients with ST-elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD), complete revascularisation is associated with reduced mortality compared to culprit only revascularisation. However, there are limited data regarding the relationship between sex and revascularisation strategy in STEMI with multivessel CAD and outcomes.

Purpose

Our aim is to evaluate sex related differences in treatment strategies and outcomes in patients with STEMI and multi-vessel CAD.

Methods

We included all consecutive patients from a provincial registry presenting with STEMI and multivessel CAD treated with percutaneous coronary intervention (PCI) from 2008–2015. The study population consisted of 856 females and 3152 males who were treated with culprit vessel only PCI or complete revascularisation using staged-PCI. The outcomes were death, admission for acute coronary syndrome (ACS), and admission for heart failure (HF). Multivariate Cox proportional hazard models were used to examine the association between treatment strategy and outcomes. Backward stepwise logistic regression was used to identify predictors of patients undergoing staged-PCI versus culprit vessel only PCI.

Results

At 3 years, the incidence of death was higher in females than males (15.9% vs. 8.2%, p<0.001), as were HF admissions (10.3% vs. 5.0%, p<0.001). Females underwent less staged-PCI than males (10.4% vs. 14.8%; adjusted odds ratio 0.75; 95% CI 0.57–0.97). Younger age and increasing Duke jeopardy score were also associated with performing staged-PCI.

After adjusting for baseline characteristics, females had a higher risk of death (HR 1.35; 95% CI 1.07–1.71), ACS admission (HR 1.27; 95% CI 1.00–1.60), and HF admission (HR 1.38; 95% CI 1.03–1.85). Following additional adjustment for revascularisation strategy, only death and HF admission remained significant. Females undergoing staged-PCI had similar survival to males (figure), with no significant interaction between revascularisation strategy and sex (p for interaction = 0.19)

Conclusion

Females with STEMI and multivessel CAD were less likely to be treated with complete revascularisation by staged-PCI and had worse outcomes when compared to males. Survival in both males and females treated with staged-PCI was similar. Our study suggests that addressing the lack of complete revascularisation in females presenting with STEMI may improve outcomes.

Figure 1

Funding Acknowledgement

Type of funding source: None