Background: The advancement in medical care has led to an increase in patients with acute cholecystitis (AC) and cardiopulmonary comorbidities referred for surgery. Grade II AC, according to Tokyo Guidelines in 2018 (TG18), is characterized by severe local inflammation with no systemic affection. The optimal treatment for patients with high-risk grade II AC has not yet been clearly established, which is still a dilemma. For these patients, laparoscopic cholecystectomy (LC), despite being the only definitive treatment, is still a challenge. The introduction of percutaneous cholecystostomy as a temporary minimally invasive alternative technique allows an immediate gallbladder decompression with a rapid clinical improvement. However, the next step after percutaneous transhepatic gall bladder drainage (PTGBD) in these high-risk patients is still a debate, with no definitive consensus about the ideal treatment of choice as well as its optimal timing. In our study, we followed a treatment algorithm for high-risk patients that involved early gallbladder decompression by PTGBD, followed by LC at different intervals once the patient is considered fit for surgery. Method: A retrospective study of 58 patients with high-risk grade II AC with cardiopulmonary comorbidity from our medical records was included. They were managed initially with PTGBD, an LC was then performed either within 7 days after drain insertion (early group, 26 patients), while an LC was performed later for the remaining patients within 6-8 weeks after PTGBD (late group, 32 patients). The results of the two groups were analyzed. Result: Procalcitonin and C-reactive protein were significantly higher in the late group. No significant difference was found between both groups with regard to operative time, PTGBD-related complications, and major perioperative complications. Timing after PTGBD did not affect the incidence of operative complications. Total hospital stay was significantly shorter in the early group. Conclusion: PTGBD is a safe initial intervention for high-risk patients with AC with a low morbidity and high success rate. Urgent LC after PTGBD can be performed safely for well-selected high-risk patients with the timing of surgery is personalized according to each patient's clinical situation. Early LC (after PTGBD) has the advantage of shorter hospital stay, low cost, as well as avoiding the risk of biliary complications and mortality if waiting a delayed surgery with no significant difference in morbidity compared with late LC.
Background: Total extraperitoneal (TEP) approach is one of the commonly used minimally invasive method in inguinal hernia repair. There are limited data that compares the results of the telescopic dissection and balloon trocar for preperitoneal dissection. In our study, we aimed to retrospectively evaluate the TEP cases performed at our center and compare the results of these two techniques. Methods: TEP cases performed between 2020 and 2024 were evaluated. Strangulated and recurrent hernia cases were excluded. Telescopic dissection and balloon trocar techniques were compared in terms of conversion, postoperative pain, complications, and recurrence. Results: A total of 177 patients were included. Telescopic method was used in 122 cases, while a balloon trocar was used in 55 cases. The median age was 50 years (range: 20-86), and 163 patients (92%) were male. Bilateral inguinal hernia was present in 61 patients (35%). The median operative time was 100 minutes (IQR: 80-120 minutes). Conversion was required in a total of 3 cases (1.5%); specifically, the transabdominal preperitoneal method was employed in 2 cases, and Lichtenstein-style anterior approach hernia repair was performed in one case. Between the telescopic dissection and balloon trocar groups, no significant differences were observed in operation time (P = .407), conversion rates (P = .228), postoperative pain scores (P = .505, P = .264, P = .681, P = .743), complication rates (P = .205), or recurrence rates (P = .311). Conclusions: The results of using a balloon trocar and telescopic dissection in inguinal hernia repair with TEP are similar, and telescopic dissection could be a cost-effective alternative to the balloon trocar.
Introduction: For patients with choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) is more cost effective than endoscopic retrograde cholangiopancreatography (ERCP) and results in shorter hospital length of stay. As LCBDE can be technically challenging to perform, utilizing a disposable single-use cholangioscope (DSUC) for LCBDE through a cystic ductotomy has several advantages, such as potentially avoiding a choledochotomy and expanding access to cholangioscopes as a DSUC is disposable and does not require infrastructure for cleaning or maintenance. Methods: An IRB-approved, retrospective chart review from 2021 to 2023 was conducted for patients who underwent concurrent laparoscopic cholecystectomy (LC) and LCBDE with a DSUC (SpyGlass™ Discover, Boston Scientific, Natick, MA) for the management of choledocholithiasis diagnosed either preoperatively or during intraoperative cholangiogram (IOC). Primary endpoint was successful clearance of biliary duct stones. Results: Twelve patients with a mean age of 55.3 years (SD ±13.9) and mean body mass index of 33.8 (SD ±10.8) were found to have filling defects on IOC for LC and underwent LCBDE with DSUC. Of these, 10 patients had stones. Complete stone clearance was achieved in all 10 patients with various stone extraction maneuvers. The mean operative time was 189 minutes (SD ±63.6) and mean hospital length of stay postoperatively was 1 day (SD ±.8). Mean length of follow-up postoperatively was 26.9 (SD ±16.0) days. There were no intraoperative complications, no need for repeat procedures, and only one postoperative complication involving a superficial surgical site infection requiring oral antibiotics. Conclusions: LCBDE with a DSUC is safe and efficacious for clearing stones and identifying pathology of the CBD. Familiarity with this device is especially useful for surgeons who want to simultaneously manage choledocholithiasis at the same time as cholecystectomy to reduce hospital stay and overall cost.
Background: Laparoscopic common bile duct exploration (LCBDE) proves a safe and effective treatment for choledochal stones. After LCBDE, preferred choledochal closure is favored for short- and long-term outcomes compared with t-tube drainage. However, there are no relevant studies on the technique of layered closure of the common bile duct with double-needle bidirectional barbed suture at home and abroad. Materials and Methods: A retrospective study of 37 patients who underwent laparoscopic choledochotomy from January 2021 to October 2023 in our hospital was performed. A continuous layered one-stage suture using two-needle bidirectional barb wire. The primary outcomes were stone clearance, operative time, blood loss, and complications. Secondary outcomes were complications, length of hospitalization, and time to drain removal. Results: During the study period, laparoscopic surgery was successful in all cases, and the initial stones were removed without complications. Conclusion: The treatment of choledocholithiasis with continuous layered one-stage suture with double-needle bidirectional barbed wire after LCBDE is a new convenient and effective treatment in selected patients.
Purpose: We aimed to assess the perioperative, oncological, and functional outcomes of patients aged 70 years or older following retroperitoneal laparoscopic partial nephrectomy (LPN) and compare their results with younger patients. Materials and Methods: A retrospective review of our prospectively maintained database identified 329 patients who underwent retroperitoneal LPN from January 2013 to October 2022. The patients divided into 2 groups defined by age ≥70 or <70 years at the time of surgery. A propensity score matching analysis was conducted to obtain two balanced groups. The groups were compared for safety (perioperative outcomes) and efficacy (oncological and functional outcomes). Results: After matching, all variables were well balanced with no differences between the two cohorts. No significant differences were found in perioperative outcomes, including operative time, warm ischemia time, blood loss, hospital stay, and complications (P values >.05). Concerning functional outcomes, postoperative glomerular filtration rate and decrease in glomerular filtration rate were significantly better in the younger group compared with the elderly groups (P = .003 and P = .001, respectively). Although margin, ischemia, complications rates were similar between the cohorts (P = .068), Pentafecta rates were lower in the elderly patients (P = .029). In terms of oncological outcomes, recurrence-free survival and cancer-specific survival were comparable between the groups. Conclusion: Retroperitoneal LPN can be performed safely and with adequate oncological efficacy in elderly patients.
Background: Despite single-incision laparoscopic surgery (SILS) being a standard procedure, its main shortcomings include narrow operating space and instrument collisions. Although the proposal of single-incision plus one-port laparoscopic surgery (SILS + 1) reduces the operational difficulty, laparoscopic pancreaticoduodenectomy (LPD) involves complex digestive tract resection and anastomosis. To reduce the number of incisions while ensuring the quality of LPD, we propose a single-incision plus two ports LPD (SILPD + 2) procedure wherein a surgeon uses two trocars with a traditional layout while the assistant and scope assistant conduct subumbilical incision. Methods: Retrospective analysis was performed of the perioperative data of 64 patients who underwent total LPD at our department from January to June 2023, including their age, gender, surgical operation time, estimated bleeding loss, and postoperative complications. Based on the number of inserted trocars, the patients were assigned to the conventional LPD (CLPD) group (n = 55) with five incisions and the new SILPD + 2 group (n = 9). Results: A total of 64 patients were included in this study, including 55 in the CLPD group and 9 in the SILPD + 2 group. The SILPD + 2 group patients had lower age and body mass index when compared to the CLPD group patients, albeit there was no statistical significance. In both groups of patients, laparoscopic surgery was completed. Regarding the operation time, estimated blood loss, and intraoperative blood transfusion, the SILPD + 2 group showed no significant disadvantage. Conclusion: When compared to CLPD, SILPD + 2 reduced the surgical difficulty by reducing incisions, and there was no significant difference in the short-term prognosis outcomes.
Background: Laparoscopic sleeve gastrectomy (SG) is a commonly performed bariatric procedure. At our institution, two vessel sealing devices, Thunderbeat® (Olympus) and Maryland LigaSure™ (Covidien) are utilized for intraoperative dissection. Methods: A retrospective review of all patients who underwent primary SG from July 2013 through August 2022 was performed to evaluate postoperative bleeding (POB) rates between the two devices. The primary outcome measured was POB as defined by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), with secondary outcomes including reoperation, source of bleed, and overall safety. Results: A total of 8157 underwent SG. Average BMI and age were 43.2 kg/m2 and 37.1 years, respectively. A total of 6600 (80.9%) were female. Thunderbeat® was utilized in 5143 (63%) cases and Maryland LigaSure™ was used in 3014 (37%) cases. There was no significant difference in overall bleeding between the Thunderbeat® (18/5143, .35%) and the Maryland LigaSure™ (19/3014, .63%; P = .0689). However, there was a difference noted when comparing reoperation for bleeding between Thunderbeat® (9/5143, .17%) and Maryland LigaSure™ (13/3014, .43%; P = .0291). Furthermore, the location of bleeding in the reoperations was more common from the cut edge of the mesentery compared to the staple line with the Maryland LigaSure™ versus the Thunderbeat® (P = .038). Conclusions: The Thunderbeat® device is comparatively more hemostatic than the Maryland LigaSure™ for SG. The location of postoperative bleed may be related to vessel sealing devices used.
Aim: To review the indications for rectal mucosal/submucosal biopsy (RMSBx) used for diagnosing Hirschsprung's disease (HD) in pediatric patients. Methods: The medical records of all children between 1 and 15 years old assessed for chronic constipation between 2012 and 2022 were reviewed. Until the end of 2018, enema usage (E+) was a major indication for RMSBx. In 2019, laxative use for 3 months irrespective of enema use was added as an indication (L+). To determine the relevance of enema usage, L+ was subdivided by enema usage into (L+E+) and (L+E-) groups. The effect of changing the indications for RMSBx on the incidence of HD was investigated. Results: Of 562 eligible subjects, E+ = 410, L+ = 152; demographics are similar. RMSBx rate in E+ (E+RMSBx) was 36/410 (8.8%) and in L+ (L+RMSBx) was 42/152 (27.6%;) (P < .05). For L+RMSBx, 15/42 were L+E+ and 27/42 were L+E-. HD incidence in E+RMSBx was 8/36 (22.2%; E+HD) and in L+RMSBx was 13/42 (31.0%; L+HD) (p = ns). In L+RMSBx, HD incidence in L+E+ was 5/15 (33.3%; L+E+HD) and in L+E- was 8/27 (29.6%; L+E-HD) (P = ns). Differences in daily bowel motion frequency 6 months postoperatively were not statistically significant; E+HD (1.75/d) versus L+HD (2.03/d) and L+E+HD (1.60/day) versus L+E-HD (2.31/day). Unassisted voluntary defecation was confirmed 12 months postoperatively in 7/8 (87.5%) E+HD, 11/13 (84.6%) L+HD, 4/5 (80.0%) L+E+HD, and 7/8 (87.5%) L-E-HD; differences were not significant. Laxatives were still required in 2/8 (25.0%) E+HD, 3/13 (23.1%) L+HD, in 1/5 (20.0%) in L+E+HD, and 2/8 (25.0%) L+E-HD; differences were not significant. Conclusion: Incidence of HD was higher in L+HD, but not significantly different suggesting that indications for RMSBx have potential to influence incidence of HD and hint that the incidence of HD could actually be higher. Further assessment of additional indications is warranted to diagnose HD with greater accuracy.
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