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A young adult male presented with biliary colic and intermittent jaundice for 1 year. Abdomen findings were unremarkable. Routine investigations revealed a raised total bilirubin. On abdominal ultrasonography, common bile duct (CBD) dilatation with multiple stones was noted. On further imaging with magnetic resonance cholangiopancreatography, type I choledochal cyst (CDC) was suspected. A laparoscopic approach was planned. Intraoperatively, dilatation of cystic duct was noted which constitute type VI CDC. Partial malrotation of the gut and accessory right hepatic artery were also noted as incidental finding. Laparoscopic cholecystectomy with CBD exploration and removal of stones, biliary stent placement, cystic duct cyst excision and primary repair of CBD was done. Postoperatively, the patient improved symptomatically with a fall in bilirubin to normal range. We are describing the laparoscopic management of a rare case of type IV CDC which was diagnosed intraoperatively.

We present a case of laparoscopic cholecystectomy with subarachnoid block (SAB) in an opioid-tolerant patient with chronic obstructive pulmonary disease (COPD). A 64-year-old woman presented to the emergency department with acute abdominal pain of biliary colic. Surgery was delayed in favour of conservative management given that she was considered high risk for general anaesthesia. Due to refractory pain, she successfully proceeded to have laparoscopic cholecystectomy with SAB. This case is a timely reminder that SAB is feasible and safe in patients with severe COPD, with the added benefit of increased analgesic effects, fewer postoperative pulmonary complications and quick recovery time.

Common bile duct (CBD) stones are prevalent in 11% to 21% of patients with gallstones and can cause various clinical manifestations, from biliary colic to biliary sepsis. The treatment of choice is endoscopic retrograde cholangiopancreatography, but approximately 5% to 10% of CBD stones are difficult to remove using these conventional endoscopic methods. Although percutaneous transhepatic cholangioscopy and lithotripsy can be used as an alternative, it can be technically demanding and risky if the intrahepatic duct is not dilated. We report a case of a large CBD stone that was successfully removed using percutaneous transcholecystic cholangioscopy.

Background Single-session endoscopic stone extraction (ESE) and laparoscopic cholecystectomy (LC) has the best outcome in managing concomitant cholelithiasis (gallstone disease [GSD]) and choledocholithiasis (common bile duct stone [CBDS]). Traditional rendezvous technique with an intraoperative cholangiogram is associated with various technical (bowel distention, frozen Calot's triangle, limitation of intraoperative cholangiogram and so on) and logistical difficulties (lack of trained personnel and equipment for ESE in the operating room). We modified our approach of ESE-LC (tandem ESE-LC) to study the safety of the approach and overcome these disadvantages of the traditional rendezvous approach. Methods A prospective study of patients with GSD and suspected CBDS from January 2017 to December 2019 was conducted. Tandem ESE-LC involves ESE and LC under the same general anaesthesia in a single day, while ESE is performed in the endoscopic suite using carbon dioxide insufflation, a balloon/basket was used for achieving bile duct clearance and the same was confirmed with an occlusion cholangiogram. Patients were then shifted to the operating room for LC. The primary outcome included bile duct clearance and safety of the procedure. Results Of 56 patients assessed for eligibility, 42 were included in the study (median age: 53 years, 25 [60%] women). Biliary colic was the most common presenting symptom (n = 24, 57%), followed by acute cholecystitis (n = 11, 26%). The median number of stones and stone size was 1 (1–6) and 4 mm (3–10), respectively. All patients had successful bile duct clearance. Stenting was performed in 5 (12%) patients. Intraoperatively, Calot's dissection was difficult and frozen in 10 and 11 patients respectively. The cystic duct was short and wide in 13 (31%) patients. Subtotal cholecystectomy was performed in 6 (14%) patients. The median duration of postprocedural hospital stay was 1 (0–13) day. Three patients had tandem ESE-LC on a day-care basis. One patient had post–endoscopic retrograde cholangiopancretography pancreatitis, and another required percutaneous drainage for gall bladder fossa collection. No patient had retained CBDS at a median follow-up of 18 (3–28) months. Conclusion Tandem ESE-LC is safe and effective method in managing concomitant GSD and CBDS.

BACKGROUNDS The impact of the SARS-CoV-2 virus (COVID-19) upon the delivery of surgical services in Australia has not been well characterized, other than restrictions to elective surgery due to government directive-related cancellations. Using emergency cholecystectomy as a representative operation, this study aimed to investigate the impact of COVID-19 on emergency general surgery in Australia in relation to in-hours versus after-hours operating. METHODS A retrospective analysis was conducted of medical records for patients admitted with cholecystitis or biliary colic between 1 March 2019 and 28 February 2021 at Frankston Hospital, Australia. Patient demographics, admission data, imaging findings, operative and post-operative data were compared between pre-COVID-19 and COVID-19 periods. Variables were compared using the Wilcoxon-Mann-Whitney, Chi Squared or Fishers exact test. RESULTS During the COVID-19 period, emergency cholecystectomy was performed for a greater proportion of patients presenting with cholecystitis or biliary colic (93.5% versus 77.7%, p

Zusammenfassung. Akute Oberbauchschmerzen sind ein häufiges Thema in der Notfallmedizin. In der Differenzierung spielt neben der Anamnese und Laborbefunden die Sonografie eine führende Rolle. Neben der direkten Darstellung der jeweiligen Pathologien (Gallensteine, Gangerweiterungen, Tumoren) ist auch die klinisch-sonografische Untersuchung, die sogenannte Palpation unter Ultraschall-Sicht, wichtig. In diesem Beitrag möchten wir die Wege der Differenzialdiagnose bei akuten Oberbauchschmerzen aufzeigen.

BACKGROUND The ongoing coronavirus disease 2019 (COVID-19) pandemic has significantly disrupted both elective and acute medical care. Data from the early months suggest that acute care patient populations deferred presenting to the emergency department (ED), portending more severe disease at the time of presentation. Additionally, care for this patient population trended towards initial non-operative management. AIM To examine the presentation, management, and outcomes of patients who developed gallbladder disease or appendicitis during the pandemic. METHODS A retrospective chart review of patients diagnosed with acute cholecystitis, symptomatic cholelithiasis, or appendicitis in two EDs affiliated with a single tertiary academic medical center in Northern California between March and June, 2020 and in the same months of 2019. Patients were selected through a research repository using international classification of diseases (ICD)-9 and ICD-10 codes. Across both years, 313 patients were identified with either type of gallbladder disease, while 361 patients were identified with acute appendicitis. The primary outcome was overall incidence of disease. Secondary outcomes included presentation, management, complications, and 30-d re-presentation rates. Relationships between different variables were explored using Pearson’s r correlation coefficient. Variables were compared using the Welch’s t-Test, Chi-squared tests, and Fisher’s exact test as appropriate. RESULTS Patients with gallbladder disease and appendicitis both had more severe presentations in 2020. With respect to gallbladder disease, more patients in the COVID-19 cohort presented with acute cholecystitis compared to the control cohort [50% (80) vs 35% (53); P = 0.01]. Patients also presented with more severe cholecystitis in 2020 as indicated by higher mean Tokyo Criteria Scores [mean (SD) 1.39 (0.56) vs 1.16 (0.44); P = 0.02]. With respect to appendicitis, more patients were diagnosed with a perforated appendix at presentation in 2020 [20% (36) vs 16% (29); P = 0.02] and a greater percentage were classified as emergent cases using the emergency severity index [63% (112) vs 13% (23); P < 0.001]. While a greater percentage of patients were admitted to the hospital for gallbladder disease in 2020 [65% (104) vs 50% (76); P = 0.02], no significant differences were observed in hospital admissions for patients with appendicitis. No significant differences were observed in length of hospital stay or operative rate for either group. However, for patients with appendicitis, 30-d re-presentation rates were significantly higher in 2020 [13% (23) vs 4% (8); P = 0.01]. CONCLUSION During the COVID-19 pandemic, patients presented with more severe gallbladder disease and appendicitis. These findings suggest that the pandemic has affected patients with acute surgical conditions.

Background Biliary ascariasis is rare but remains the most common parasitic infection in remote areas and in people with poor medical conditions. Here, we reported a case of biliary ascariasis in order to raise awareness of possible parasitic infections. Case summary A 68-year-old female was admitted to the emergency room of the Affiliated Hospital of Guizhou Medical University on 28 September 2017, with chief complaint of pain in the right upper abdomen. Ultrasonography of the abdomen showed that the upper segment of the common bile duct was slightly dilated with parallel tubular structures, indicative of biliary ascariasis. Endoscopic retrograde cholangiopancreatography was performed under general anesthesia on 29 September 2017, and an adult Ascaris lumbricoides worm was observed. After the worm was removed from the bile duct, the patient's pain immediately subsided. The patient was successfully cured, without any complications. Conclusion This report emphasizes the need for physicians to consider biliary ascariasis as a possible cause when treating cases of biliary colic.

Biliary hyperkinesia is typically diagnosed in patients with biliary-like pain and no evidence of gall stones on imaging modalities but who have had biliary scintigraphy scan (HIDA) that shows ejection fraction ≥ 80%. This study aims to identify whether the removal of the gall bladder can alleviate the symptoms associated with biliary hyperkinesia. Systematic search following PRISMA guidelines was done from inception to January 2020 using PubMed/Medline, OVID, Embase, Cochrane database of systemic reviews, Cochrane central register of controlled trials, The Database of Abstracts of Reviews of Effects (DARE) and Cochrane library databases. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardized MD (SMD) for continuous outcomes. A meta-analysis was done using random-effect model in RevMan 5.4® software. Thirteen studies met the inclusion criteria and were included in the review. A total of 332 patients diagnosed with biliary hyperkinesia underwent cholecystectomy, of whom 303 (91.3%) reported symptomatic improvement RR 8.67 (95% CI 4.95, 15.16) P = 0.01. Six studies described abnormal histological features in 163/181 (90.05%) with high GB EF. RR 7.88 (95% CI 3.94, 15.75) P = 0.08. Chronic cholecystitis n = 155 (95%), cholesterolosis n = 7 (4.3%), and one showed features of acute cholecystitis. Patients with typical biliary colic symptoms without gallstones and markedly high ejection fraction might benefit from having cholecystectomy to alleviate their symptoms.

Choledocholithiasis is a commonly encountered disease that is associated with various clinical presentations ranging from mild form of biliary colic to severe life-threatening acute cholangitis. Recently, peri-ampullary diverticulum (PAD) has been linked to the development of biliary diseases; however, data regarding its association with the development of acute cholangitis in the setting of choledocholithiasis are scarce. We aimed to identify predictors, specifically PAD, for the development of acute cholangitis in patients with choledocholithiasis. We performed a retrospective cross-sectional study of all patients admitted to Galilee Medical Center from 1 January 2010 to 31 December 2019 with different clinical presentations of documented choledocholithiasis including cholangitis, biliary pancreatitis, and biliary colic with abnormal liver enzymes. Overall, 651 patients were included in the final analysis. Among them, 88 patients (13.5%) had choledocholithiasis associated with acute cholangitis (group A), as compared to 563 patients (86.5%) without acute cholangitis (group B). The average ages in groups A and B were 77.8 ± 13.6 and 62.4 ± 20.4 years, respectively (P

In modern medicine, one of the most common situations requiring emergency care is biliary or renal colic as a manifestation of abdominal pain syndrome. In both cases, smooth muscle spasm plays an important role in the pathogenesis of visceral pain syndrome. Taking into account the fact that, regardless of the chosen treatment tactics, at the first stage it is necessary to stop pain, the question arises about the choice of a drug strategy for the relief of these conditions. It used to be thought that the more intense the pain, the more indications for the prescription of narcotic drugs, which were considered reference analgesics. In recent years, the world has become embroiled in an «opioid crisis». This prompted clinicians to consider the use of drugs from other groups, namely, non-steroidal anti-inflammatory drugs and antispasmodics alone or in combination, which turned out to be no less effective and, often, safer in comparison with narcotic analgesics. New opportunities for effective treatment of visceral pain are opened by the drug Neospastil® (PJSC «Pharmaceutical Company «Darnitsa»), which combines the benefits of nonsteroidal anti-inflammatory drugs (ketorolac tromethamine) with antispasmodic effect of cholinolytics, ganglioblockers and phenytoin phenytoin. The drug increases the effectiveness of analgesia, as well as the control of muscle spasm.

COVID-19 pandemic has impacted health care globally with restructuring and prioritization of health care services. We prospectively analyzed 104 patients who underwent laparoscopic cholecystectomy during the peak of COVID-19 in 2020 and compared with 217 patients from the same period in 2019. Emergency admissions constituted majority of cases with no statistical difference between both groups (p = 0.49). Most cholecystectomies were for biliary colic (41.3 vs. 35.5%) and cholecystitis (37.5 vs. 43.8%) without any statistically difference (p = 0.31 and p = 0.29, respectively). This study demonstrates that laparoscopic cholecystectomy was feasible and safe in patients with symptomatic gall bladder disease during the peak period for COVID-19.

Biliary dyskinesia (BD) is a well-established gallbladder pathology in adult patients and rates of cholecystectomy for BD continue to rise in the United States. Many pediatric patients with vague abdominal pain of variable duration are evaluated for biliary dyskinesia. It remains unknown which cohort of pediatric patients diagnosed with BD are most likely to have sustained improvement in symptoms following laparoscopic cholecystectomy. We aimed to determine whether cholecystectomy resulted in symptom relief and led to a reduction in the number of medical visits related to gastrointestinal (GI) symptoms after surgery. We performed a multi-institution retrospective review of all children

Hemobilia, or hemorrhage within the biliary system, is an uncommon form of upper gastrointestinal (GI) bleeding that presents unique diagnostic and therapeutic challenges. Most cases are the result of iatrogenic trauma, although accidental trauma and a variety of inflammatory, infectious, and neoplastic processes have also been implicated. Timely diagnosis can often be difficult, as the classic triad of upper GI hemorrhage, biliary colic, and jaundice is present in a minority of cases, and there may be considerable delay in the onset of bleeding after the initial injury. Therefore, the radiologist must maintain a high index of suspicion for this condition and be attuned to its imaging characteristics across a variety of modalities. CT is the first-line diagnostic modality in evaluation of hemobilia, while catheter angiography and endoscopy play vital and complementary roles in both diagnosis and treatment. The authors review the clinical manifestations and multimodality imaging features of hemobilia, describe the wide variety of underlying causes, and highlight key management considerations.©RSNA, 2021.

Background A minimally invasive step-up approach to necrotizing biliary pancreatitis often requires multiple interventions, delaying cholecystectomy. The risk of gallstone-related complications during this time interval is unknown, as is the feasibility and safety of cholecystectomy after minimally invasive step-up treatment. In this paper, we analyzed both. Methods Necrotizing pancreatitis patients treated with a minimally invasive step-up approach who underwent interval cholecystectomy at 2 tertiary care centers between 2014 and 2019 were included. Gallstone-related complications prior to cholecystectomy were examined, as were surgical approaches to cholecystectomy and complications. Necrotizing pancreatitis patients treated without mechanical intervention were also examined. Results Seven of 31 patients developed gallstone-related complications between minimally invasive step-up treatment initiation and cholecystectomy. One patient developed biliary colic. Six patients developed acute cholecystitis. Two of these patients also developed choledocholithiasis, and 1 developed cholangitis, all requiring endoscopic retrograde cholangiopancreatography. Cholecystectomy was performed laparoscopically in 27 of 31 patients. One patient required open conversion, and 3 patients underwent planned cholecystectomy during another open operation. Four patients developed postoperative complications. Two of 14 necrotizing pancreatitis patients treated without mechanical intervention developed recurrent pancreatitis while awaiting cholecystectomy. Conclusion Over 20% of necrotizing pancreatitis patients treated by a minimally invasive step-up approach developed gallstone-related complications while awaiting cholecystectomy. Laparoscopic cholecystectomy is feasible and safe in the great majority of necrotizing pancreatitis patients treated by a minimally invasive step-up approach.

BACKGROUND Gallstone pancreatitis is one of the most common causes of acute pancreatitis. Cholecystectomy remains the definitive treatment of choice to prevent recurrence. The rate of early cholecystectomies during index admission remains low due to perceived increased risk of complications. AIM To compare outcomes including length of stay, duration of surgery, biliary complications, conversion to open cholecystectomy, intra-operative, and post-operative complications between patients who undergo cholecystectomy during index admission as compared to those who undergo cholecystectomy thereafter. METHODS Statistical Method: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). RESULTS Initial search identified 163 reference articles, of which 45 were selected and reviewed. Eighteen studies (n = 2651) that met the inclusion criteria were included in this analysis. Median age of patients in the late group was 43.8 years while that in the early group was 43.6. Pooled analysis showed late laparoscopic cholecystectomy group was associated with an increased length of stay by 88.96 h (95%CI: 86.31 to 91.62) as compared to early cholecystectomy group. Pooled risk difference for biliary complications was higher by 10.76% (95%CI: 8.51 to 13.01) in the late cholecystectomy group as compared to the early cholecystectomy group. Pooled analysis showed no risk difference in intraoperative complications [risk difference: 0.41%, (95%CI: -1.58 to 0.75)], postoperative complications [risk difference: 0.60%, (95%CI: -2.21 to 1.00)], or conversion to open cholecystectomy [risk difference: 1.42%, (95%CI: -0.35 to 3.21)] between early and late cholecystectomy groups. Pooled analysis showed the duration of surgery to be prolonged by 39.11 min (95%CI: 37.44 to 40.77) in the late cholecystectomy group as compared to the early group. CONCLUSION In patients with mild gallstone pancreatitis early cholecystectomy leads to shorter hospital stay, shorter duration of surgery, while decreasing the risk of biliary complications. Rate of intraoperative, post-operative complications and chances of conversion to open cholecystectomy do not significantly differ whether cholecystectomy was performed early or late.

Individuals with cystic fibrosis (CF) have an increased risk for gallbladder abnormalities and biliary tract disease, but the reported incidence of these manifestations of CF varies widely in the literature. With the approval of elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA), increasing numbers of CF patients have been initiated on highly effective cystic fibrosis transmembrane regulator (CFTR) modulator therapy. While elevations in hepatic panel are known potential side effects of CFTR modulators, there have been no published cases of biliary disease or acute cholecystitis attributed to these medications. In this case series, we describe seven patients at two adult CF centers with biliary colic shortly after initiation with ELX/TEZ/IVA, six of whom required cholecystectomy.

La disfunción del esfínter de Oddi es un síndrome clínico causado por una enfermedad funcional (discinesia) o estructural (estenosis). La prevalencia estimada de disfunción del esfínter de Oddi en la población en general es del 1 %; aumentando a 20 % para pacientes con dolor persistente posterior a colecistectomía y a 70 % en pacientes con pancreatitis aguda recurrente idiopática. Se caracteriza clínicamente por la presencia de dolor abdominal, similar al cólico biliar o dolor tipo pancreático en ausencia de patología biliar orgánica; así como en pacientes con pancreatitis recurrente idiopática asociada con elevación de enzimas pancreáticas o hepáticas, y dilatación del conducto biliar o pancreático. El tratamiento para la disfunción del esfínter de Oddi tipo I se basa en la realización de esfinterotomía endoscópica, pero existe controversia en el manejo de la disfunción del esfínter de Oddi tipo II y III. En este artículo se presenta el caso clínico de una paciente de 67 años con antecedente de colecistectomía por laparotomía. Después del procedimiento quirúrgico refirió un dolor abdominal de predominio en el hipocondrio derecho tipo cólico asociado con emesis de características biliares. En el reporte de colangiorresonancia se encontró una ligera dilatación de la vía biliar intrahepática y gammagrafía con ácido iminodiacético hepatobiliar (HIDA) diagnóstica de disfunción del esfínter de Oddi. Se realizó una esfinterotomía endoscópica. En el seguimiento, dos años después, la paciente se encontraba asintomática con la disfunción del esfínter de Oddi resuelta.

Background MDCT cholangiography can be utilized to identify variant biliary anatomy to guide preoperative planning of biliary surgery, and determine the cause and level of biliary obstruction. Early tumor detection and staging of biliary cancer are key factors for a possible cure by surgical resection. Between December 2019 and October 2020, 69 patients with clinically suspected biliary obstruction were enrolled in the study, subjected to clinical assessment (full history taking and clinical examination) and imaging assessment by MDCT cholangiography. Our findings were correlated to standard reference examinations including operative/ERCP/biopsy and histopathology findings. Results The most affected age was between 60 and 70 years old, and males were more affected. The commonest clinical presentation was yellowish discoloration of the skin and sclera followed by biliary colic. Right hypochondrial tenderness was the main clinical finding on clinical examination. Our patients were categorized according to the etiology of biliary obstruction into 7 groups: malignant stricture 52.2% (36 patients), calcular 24.6% (17 patients), iatrogenic 5.8% (4 patients), portahepatis lesions 5.8% (4 patients), benign stricture 4.3% (3 patients), inflammatory 4.3% (3 patients), and congenital 1.4% (1 patient). The malignant group shows dominant mass, moderate biliary obstruction, and arterial and venous enhancement. The overall sensitivity was 94% for malignancy. Conclusion MDCT cholangiography is non-invasive, fast, and highly sensitive and specific in the diagnosis of different causes and levels of biliary obstruction and is useful in the characterization of the lesion in cases of malignant obstruction and differentiating it from benign stricture. It can be used as an effective alternative to ERCP or PTC.

Cholelithiasis is a common gastrointestinal pathology with a prevalence of over 6% in the USA. Symptomatic patients can develop cholangitis, biliary colic, pancreatitis and cholecystitis. Surgical management involves laparoscopic or open cholecystectomy. Stones within the common bile duct can be treated with endoscopic retrograde cholangiopancreatography (ERCP). Well-known ERCP complications include pancreatitis, perforation, bleeding and cholangitis. Hepatic hematomas as a complication of ERCP are extremely rare, with fewer than 50 reported cases in the literature. Approximately 22% have required operative management. We present an extremely rare case of ERCP-associated subcapsular hepatic hematoma in a 43-year-old lady that was initially non-operatively managed. She did not improve with antibiotics alone and underwent attempted interventional radiology drainage. Despite this, due to on-going sepsis, the patient underwent laparoscopic necrosectomy and drain placement with continued post-operative irrigation. After a long course of antibiotics and drain irrigation, the patient was discharged with repeated computed tomography imaging showing almost total resolution of the infected collection. This case highlights the extreme rarity of surgical management for post-ERCP subcapsular hepatic hematoma and its successful outcome. J Med Cases. 2021;12(5):186-189 doi: https://doi.org/10.14740/jmc3672

Background:Gallstone ileus, which is called Type Vb Mirizzi Syndrome, is a rare case of mechanical intestinal obstruction observed in older patients with history of cholelithiasis or cholecystitis. Diagnostic Imaging plays an important role in the management of patients with suspected gallstone ileus. X-Ray and Abdominal Computed Tomography (CT) are the preferred modality. Case presentation:The patient was diagnosed with gallstone ileus at the age of 45. The case had 10 years history of biliary colic disease. The patient who is suffered from intestinal obstruction. CT demonstrated pneumobilia involving the gallbladder, a 5, 5 cm calcified stone in the ileum and small bowel dilatation. He underwent enterolithotomy and a huge stone was removed. When gallbladder area was checked, the gallbladder was highly adherent (to colon and stomach) and was inflamed. We suspected malignancy so multipl biopsy was taken. Two-stage treatment model was planned. After the surgery, any emerging complications were closely monitored. Conclusions:Abdominal CT are the preferred modality for diagnosis. The main treatment for gallstone intestinal obstruction is surgery. First step enterotomy, later intented for the gallbladder. There are two type of surgical approach for gallbladder: one-stage treatment or two-stage treatment according the inflammation of gallbladder

Aim: The study aimed to compare the effect of intravenous administration of the NSAID (Non-steroidal anti-inflammatory drugs) ketorolac to that of intravenous administration of the opioid pethidine in the suppression of pain in patients with biliary colic. Methodology: The present study is a trial study. Among all the biliary colic patients in Mashhad Referral Hospital Emergency in Iran, 58 patients with inclusion criteria were selected using convenience sampling. They were randomly divided into two groups of 29 patients. In the first group, 1 mg/kg IV pethidine, and in the second group, 30 mg IV ketorolac was injected. The pain severity was assessed prior to the treatment and 15, 30, and 60 minutes after the onset of the treatment using the Visual Analogue Scale (VAS). The data were analyzed using SPSS 20 and Chi-square tests. Findings: The patients' mean age was 45±15 years old (age ranged from 30 to 60 years old). The results showed no significant relationship between pain suppression and medicine type after 15 minutes (P=0.5), 30 minutes (P=0.6), and 1 hour (P=0.7). It means that pethidine and ketorolac have an equal effect on pain suppression in patients with biliary colic. Also, the more time passes from the injection, the more the medicines suppress pain. Conclusion: the results of this study show that the efficacy of NSAIDs in the suppression of moderate to severe pain; therefore, a plan to use NSAIDs instead of narcotics for this purpose is essential.

Background The use of indocyanine green during laparoscopic cholecystectomy has been postulated to help to define anatomy. Studies have not specifically evaluated patients with acute cholecystitis. We sought to assess whether use of indocyanine green can decrease the rate of bail-out operation (subtotal cholecystectomy or conversion to an open operation) in an acute care surgery population where acute cholecystitis is more frequent. Methods Using a retrospective cohort design, we examined all inpatient cholecystectomies performed by the acute care surgery service under urgent or semiurgent (biliary colic as the presentation in the emergency room) conditions at a single institution from 7/1/18 to 6/30/19 during which indocyanine green was available for use at the surgeon’s discretion. Results A total of 198 patients were included in the analysis. Demographic variables were similar in groups receiving indocyanine green versus not. Pathology confirmed acute cholecystitis was present in 96 of 198 (48.5%) patients; of those, 55 (57.2%) received indocyanine green. Indocyanine green did not change the rate of bail-out operation between patients who received indocyanine green and those who did not (6.7% vs 4.3%, P = .468). No significant differences in complications were observed. Bail-out operation was more likely in cases of acute cholecystitis (9.4%) versus nonacute cholecystitis (2.0%) (odds ratio = 5.172, P = .039). In patients with acute cholecystitis, indocyanine green did not change the rate of bail-out operation (indocyanine green: 12.7% vs no indocyanine green: 4.9%, P = .293). Conclusion This is the first series looking at the use of indocyanine green specifically in an acute care surgery population. Indocyanine green did not decrease operative time or need for a bail-out operation in acute cholecystitis. Further study is needed to determine whether indocyanine green use is justified in this population.

The robotic platform for cholecystectomy has been extensively studied in comparison to its laparoscopic counterpart with acceptable outcomes. However, wide acceptance of a robotic approach to cholecystectomy has been limited by increased operative room (OR) times and substantially higher cost. This is a single-institution retrospective review of Veteran patients presenting for elective laparoscopic (LC) and robotic (RC) cholecystectomies for benign biliary disease at the Dallas VA Medical Center. The primary goal was to interrogate 30-day morbidity as well as operative room times, estimated blood loss (EBL), hospital length of stay (LOS), and conversion rates. The entire cohort included 612 patients (age = 55.1 ± 12.9 years, men = 77.9%, BMI = 31.2 ± 6.3 kg/m2) undergoing elective cholecystectomy (LC = 441 and RC = 171) for benign biliary disease (biliary colic = 78.8%, history of biliary pancreatitis = 7.8%, history of cholecystitis = 5.7%). Univariate analysis comparing LC and RC showed the two groups to be of similar age (55.4 ± 12.4 vs. 54.4 ± 14.2 years; p = 0.4), male gender (79.4% vs. 74.3%, p = 0.2), and BMI (31.1 ± 6.4 vs. 31.5 ± 6.3 kg/m2; p = 0.5). Except for dyslipidemia (LC = 48.3% vs. RC = 36.8%; p = 0.01), both groups had the same rate of co-morbid conditions. ASA level III and IV (LC = 60.1 vs. RC = 69.0%, p = 0.04) was higher in the RC group. Both groups underwent surgical intervention for similar indications (biliary colic LC = 80.5% vs. RC = 74.3; p = 0.1). Hospital LOS (1.7 ± 3.2 vs. 0.3 ± 0.9 days, p

Introduction Laparoscopic cholecystectomy is a common surgery with a varying difficulty level. Difficult laparoscopic cholecystectomy may be experienced by many surgeons. If difficult procedures are predicted preoperatively, surgeons may be able to plan the surgical approach and treatment accordingly. Studies have reported using blood and clinical imaging data to predict difficult cholecystectomy. However, to our knowledge, no studies have reported using MRI. The purpose of this study was to evaluate the usefulness of MRI as a predictor of difficult laparoscopic cholecystectomy. Methods We retrospectively evaluated 25 patients with cholecystitis or biliary colic who had undergone diffusion-weighted whole-body imaging before laparoscopic cholecystectomy. The apparent diffusion coefficient value of the cystic duct was measured and its relationship with operative time and blood loss was examined to assess the capacity of diffuse-weighted whole-body imaging to predict difficult cholecystectomy. Further, we collected blood data and compared its usefulness as a predictor. Results The apparent diffusion coefficient value of the cystic duct was significantly lower in patients with difficult laparoscopic cholecystectomy than in those with non-difficult procedures (P = .00007). White blood cell count and serum C-reactive protein level were significantly higher in patients with difficult cholecystectomy than in those with non-difficult procedures (P = .035, .030). In the receiver operating characteristic analysis, the apparent diffusion coefficient value was the best predictor. Conclusion Our results suggest that the apparent diffusion coefficient value of the cystic duct is a predictor of difficult laparoscopic cholecystectomy. In the future, it may be useful to study changes in coefficient values over time to determine optimal surgical timing.

Objective: To compare the long-term results of the treatment of mild acute biliary pancreatitis in patients with gallbladder in situ, without stones in the bile duct, treated by cholecystectomy, and endoscopic sphincterotomy (ES) versus simple cholecystectomy in the prevention of recurrence of this pathology. Material and Methods: Between May 2008 and December 2012, 110 consecutive patients with a mild acute biliary pancreatitis (ABP) were prospectively studied. None had undergone cholecystectomy, and choledocholithiasis was ruled out by ERCP. Two groups of patients were created and randomized: Group I (n = 55) who underwent ERCP plus ES and Group II (n = 55) only had diagnostic ERCP. Patients were then referred for cholecystectomy. Follow up was completed in 101 patients. Group I was made up of 53 patients and Group II had 48 similar characteristics. Patients were followed for an average of 105 months. At the end of the follow-up, 12 (22.6%) from Group I and 6 (12.5%) from Group II (p = 0.143) remained with the gallbladder in situ. Results: There were 53 patients in Group I (100%). Only 42 (87.5%) of those in Group II evolved without biliopancreatic complications (p = 0.0096). In the latter, 6 (12.5%) were complicated, and 5 had not had cholecystectomy. In Group I patients, there was no recurrence of acute biliary pancreatitis, but this was seen in 4 cases (8.4%) in Group II (p = 0.0476). Group I also had 2 cases of biliary colic (4.2%) and 2 cases of obstructive jaundice (4.2%). Conclusions : The risk of recurrence is significant in patients with mild acute biliary pancreatitis, without bile duct stones, and in whom cholecystectomy is not performed; thus, an ES is recommended.

Highlights • Acute cholecystitis with empyema and Mirizzi Syndrome mimics both XGC and malignancy. • Subtotal fenestrating cholecystectomy is both safe and effective in these cases. • PTC can be considered over ERCP for first-line pre-operative biliary drainage., Introduction Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome (MS) is a complex surgical problem both diagnostically and in terms of management as it mimics both xanthogranulomatous cholecystitis (XGC) and gallbladder carcinoma. Presentation of case A 48-year-old gentleman was referred to us with biliary colic and weight loss with ultrasound findings of gallstones. At subsequent follow-up he became deeply jaundiced with deranged liver function and a CT showing a gallbladder mass and dilated biliary tree. Follow-up MRCP suggested XGC and concomitant MS, but a malignant process could not be excluded. Pre-operative fine needle aspiration cytology (FNAC) at the time of percutaneous biliary drainage for his jaundice demonstrated XGC with no evidence of malignancy. Given the dense inflammation and a tense empyema at laparoscopy, he underwent a subtotal fenestrating cholecystectomy. The final histopathological diagnosis was acute cholecystitis. Discussion Our patient likely had unrecognised acute cholecystitis which progressed to a complex mass with empyema and type I Mirizzi Syndrome, ultimately resulting in severe obstructive jaundice mimicking gallbladder carcinoma. Given that a laparoscopic total cholecystectomy is dangerous in these cases of severe inflammation, a laparoscopic subtotal cholecystectomy has been shown to be a safe alternative to more invasive strategies and was successfully utilised in our patient. Conclusion Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome is a rare manifestation that requires adequate pre-operative work-up to exclude malignancy. Subtotal fenestrating cholecystectomy is a safe and effective alternative to open surgery in these cases of complex inflammation.

Background: Acute Calcular Cholecystitis (A.C) is inflammation of the gallbladder and is the most common complication of gallstones, requiring hospital admission and prompt intervention. Its Symptoms include right upper abdominal pain, nausea, vomiting, and occasionally fever. Often gallbladder attacks (biliary colic) precede acute cholecystitis without appropriate treatment, recurrent episodes of cholecystitis are common. Complications of acute cholecystitis include gallstone pancreatitis, common bile duct stones, and inflammation of the common bile duct.Aim of The Work: To assess surgical outcome from laparscopic and open cholecystectomy in acute calcular cholecystitis by assessment and differentiate between both of them in these parameters as regards: 1-Hospital stay, 2-Wound infection, 3-Bilary fistula, 4-Missed stone, 5-intestinal injury.Patients and Methods: Type of Study: prospective clinical trial. Study Setting: This study will be carried out, at Ain Shams hospitals. Study Period: This study will be carried out during the period between October2018 and October 2019. Study Population: This study will include 30 patients with diagnosis of acute calcularcholycystitis.Results: The present study was a prospective, clinical, trial that included30 patients diagnosed with acute calcular cholecystitis attended to surgery theatre at Ain Shams hospital. The patients were divided into two groups: Group I including 15 patients underwent laparoscopic cholecystectomy during the first week of their presentation. Group II including 15 patients underwent open cholecystectomy during the first week of their presentation.Conclusion: Cholecystectomy during 1st week of acute cholecystitis should be attempted by laparoscopy at first in condition that there are no complications as gangerenous gall bladder. as, post-operative morbidity and hospital stay are reduced by laparoscopic cholecystectomy. Moreover, intestinal injury and wound infection rate are reduced by laparoscopy. A positive trend exists in operating time favoring laparoscopy, however more studies are necessary. Severe hemorrhage and bile leakage rate are not influenced by the technique.

Background Student-run free clinics (SRFCs) provide medical care to uninsured, and surgical issues are often outside the normal scope of care of these clinics. The Shade Tree Clinic (STC) is an SRFC serving 300 patients with complex medical conditions. This study describes the implementation and efficacy of a General Surgery Specialty Clinic in this setting. Methods This descriptive study examines the demographics and referral patterns of patients seen in two pilot Specialty Clinics and other patients evaluated for general surgical issues from December 2017 to January 2020. Providers were surveyed regarding their experience in clinic. Results Twenty patients were evaluated by six general surgeons during 22 separate encounters (n = 20). Nine patients were seen in two pilot Specialty Clinics for biliary colic, hernia, hemorrhoids, anal mass, toenail lesion, surgical weight loss, and venous insufficiency. Referrals from these clinics to affiliated Vanderbilt University Medical Center included six ultrasounds; referrals to vascular surgery and podiatry clinics; and referrals for laparoscopic cholecystectomy and anal mass excision. STC also directly referred eight patients for colonoscopies and five patients for major operations through primary care clinic. Hundred percent of care was cost-free to patients. Providers reported a median satisfaction score of five with the Specialty Clinics (Very Satisfied; [4, 5]). Hundred percent of providers felt that the concerns of patients were addressed. Conclusions A surgery specialty clinic in the setting of an SRFC is an effective way to provide surgical care to underserved populations with the potential to reduce unplanned hospital utilization.

Highlights • Very few cases of preop diagnosis of absent gallbladder are described in literature. • Preop diagnosis for Agenesis of Gall Bladder helps to avoid unnecessary surgery. • Article shares experience of 2 cases diagnosed pre op and surgery was thus avoided. • To confirm Inconclusive USG should be combined with MR Cholangiogram(MRCP). • In case of suspicion present norm is to quit laparoscopy and resort to MRCP., Introduction & Background Agenesis of gall bladder is a rare congenital anomaly and incidence is 0.007–0.0027%. Even though gall bladder is absent, clinical presentation of 50% cases, mimic biliary colic. This combined with inconclusive radiological findings leads to wrong preoperative diagnosis and patients are subjected to unnecessary surgery causing complications like injury to biliary tract. Except for few cases where a preoperative diagnosis of absent gall bladder was made in majority of cases, agenesis of the gallbladder is described as an incidental finding during surgery. The work has been reported in line with the SCARE criteria (Agha et al., 2018). Case Presentation This article will share our experience about two cases who presented with complains of pain in right upper quadrant and USG examination revealed inconclusive reports as cholelethiasis with contracted or shrunken gall bladder in first case and in second case as cholelethiasis with non-visualisation of gall bladder. On further imaging with MR cholangiogram diagnosis of agenesis of gall bladder was made and unnecessary surgery was avoided. Discussion Ultrasound is the imaging technique of choice to assess the gallbladder; but difficulty arises when gallbladder is either contracted or atrophic. Magnetic cholangioresonance is a non-invasive modality which can describe anatomy of biliary apparatus. So Magnetic cholangiogram should be combined with inconclusive USG studies for gall bladder agenesis. Conclusion With better imaging modalities, it has been possible to diagnose gallbladder agenesis before surgery. And so inconclusive US reports of gall bladder should be combined with MR imaging. In Perioperative scenario on suspicion of gall bladder agenesis present norm is to quit laparoscopy and resort to MR cholangiogram to reduce exploration complications.

Introduction Multiple gallbladders represent a rare congenital disorder, and coexistence with carcinoma is extremely rare, leading to a high possibility of misdiagnosis and surgical complications. In this study, a case was reported and the literature was reviewed. Case presentation An 80-year-old woman was diagnosed with acute cholecystitis via ultrasonography and was successfully treated with antibiotics. After the patient’s biliary colic relapsed, she was referred to our hospital. Multiple imaging modalities revealed duplication of her gallbladder (H-type) and suggested coexistence with carcinoma. According to preoperative evaluations, we assumed the patient had stage IIIA disease, and cholecystectomy, cholangiography using a near-infrared ray vision system, and sectionectomy of segments 4a and 5 were performed. Contrary to the high standardized uptake values obtained by 18F-fluoro-2-deoxy-D-glucose positron emission tomography, gallbladder carcinoma was pathologically diagnosed as stage 0 mucosal cancer. Seven days after the operation, portal thrombosis of the posterior branch was revealed, and conservative therapy was indicated; satisfactory results were achieved. The patient was discharged 65 days after surgery. No recurrence was observed for 1 year after surgery. Conclusions An extremely rare case of malignancy in a duplicated gallbladder was reported, and the literature was reviewed. Accurate estimations are feasible for diagnoses of multiple gallbladders, where correct evaluations are vital, especially in malignant cases. Because of the possibility of malignancy, resected accessory gallbladders should be scrutinized pathologically.

Background/purpose The aim of the present study was to investigate the relationship between hepatobiliary scintigraphy findings and histopathological results in patients with recurrent biliary colic. Methods We retrospectively enrolled 107 patients who underwent hepatobiliary scintigraphy for recurrent biliary colic and subsequent cholecystectomy. According to the hepatobiliary scintigraphy findings, patients were categorized into a nonvisualization of gallbladder activity (nonvisualized GB) group, low gallbladder ejection fraction (GBEF) group, and normal GBEF group. Differences in histopathologic factors between the three groups were evaluated and multivariate logistic regression analyses were performed to identify histopathological predictors for hepatobiliary scintigraphy findings. Results The nonvisualized group had a higher frequency of patients with empyema and severe infiltration by neutrophils, lymphoplasma cells, and eosinophils. The low GBEF group had a higher muscle-to-total wall thickness ratio and muscle-to-fibrosis thickness ratio of the gallbladder wall than those in the normal GBEF group. On multivariate logistic regression analyses, severe degrees of lymphoplasma cell infiltration and eosinophil infiltration were independent predictors for nonvisualization of gallbladder activity, and a higher muscle-to-fibrosis thickness ratio was an independent predictor for low GBEF. Conclusions In patients with recurrent biliary colic, nonvisualization of gallbladder activity on hepatobiliary scintigraphy was related to the degree of inflammation in the gallbladder, while low GBEF was related to muscular hypertrophy of the gallbladder.

Background With improved laparoscopic techniques, experience, and availability of newer tools and instruments like ultrasonic shears; laparoscopic cholecystectomy (LC) became a feasible option in cirrhotic patients, the aim of this study was to analyze the outcome of LC in cirrhotic patients. Methods: We retrospectively analyzed 213 cirrhotic patients underwent LC, in the period from 2011 to 2019; the overall male/female ratio was 114/99. Results: The most frequent Child-Turcotte-Pugh (CTP) score was A, The most frequent cause of cirrhosis was hepatitis C virus (HCV), while biliary colic was the most frequent presentation. The harmonic device was used in 39.9% of patients, with a significant correlation between it and lower operative bleeding, lower blood and plasma transfusion rates, higher operative adhesions rates, lower conversion to open surgery and 30-day complication rates, shorter operative time and post-operative hospital stays where operative adhesions and times were independently correlated. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities. Conclusion: LC can be safely performed in cirrhotic patients. However, higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous peri-operative care and by using Harmonic scalpel shears., Highlights • LC can be safely performed in cirrhotic patients. • Outcome is affected by higher CTP and MELD scores. • Lower platelets count, and higher INR values affect outcome. • Proper patient selection and peri-operative care improve outcome. • Harmonic scalpel shears have positive effect on outcome.

Background and Aims Right aberrant hepatic ducts are an anatomic variant with clinical relevance because of the risk of injury during cholecystectomy. Treatment options for aberrant hepatic duct injuries are not standardized. This study aims to analyze the long-term results of endoscopic treatment of aberrant hepatic duct lesions. Methods Patients who underwent ERCP for aberrant hepatic duct lesions were retrospectively identified. Demographic data, type of aberrant duct lesion according to the Strasberg classification, type of treatment (number of plastic stents inserted, treatment duration, and number of ERCPs), and adverse events were recorded. Follow-up was obtained by telephone contact or medical examinations. Results Between January 1996 and March 2019, 32 patients (78% women, mean age 51.7 years) with aberrant hepatic duct injuries underwent ERCP at our Endoscopy Unit. Six patients had Strasberg type B lesions, 11 patients had type C, and 8 patients had type E5, and 7 patients had a stenosis of the aberrant duct. A mean of 3.7 biliary plastic stents per patient were used; mean treatment duration was 6.3 months. All patients with isolated aberrant duct stenosis and 1 of 6 patients (17%) with type B Strasberg lesions achieved patency. Ten of 11 patients (91%) with type C Strasberg lesions achieved duct recanalization. After a mean follow-up of 109.3 ± 61.2 months, 29 of 32 patients (91%) were asymptomatic; 1 underwent surgery for recurrent cholangitis, 1 received a new endoscopic procedure because of cholangitis, and 1 reported episodic biliary colic without an increase in liver function test values and was successfully managed with a low-fat diet. Conclusions An endoscopic approach to aberrant hepatic duct lesions after cholecystectomy can be considered an effective first-line therapy.

Summary Multiple studies confirm that point of care ultrasound (PoCUS) has a high sensitivity and specificity for cholelithiasis and cholecystitis. However, there is poor perceived reliability of biliary PoCUS by surgeons. This survey was performed to assess surgeons’ opinions on using PoCUS in gallstone disease and barriers that exist for its institution. The majority (60.3%) of respondents reported a total lack of confidence in PoCUS for the diagnosis of biliary disease. Most felt the sensitivity of PoCUS was poor and had concerns about the user-dependent nature of the test and the lack of imaging details provided. If offered ideal clinical/laboratory findings with PoCUS results, only 4.7% of surgeons would definitely operate for unremitting biliary colic and 5.4% for cholecystitis. The ability to replicate findings independently increased confidence in clinical decision-making. Our findings suggest there is substantial distrust in biliary PoCUS but that specific ultrasound training for the surgical workforce may prove tremendously beneficial for its utilization.

Highlights • Diaphragmatic agenesis is a rare condition. • In adults with partial diaphragmatic agenesis, laparoscopic cholecystectomy can be performed successfully. • A conservative management only with gallstones dissolution therapy can be used if laparoscopy cannot be done., Introduction The importance of unilateral diaphragmatic agenesis (DA) in adults for performing a laparoscopic cholecystectomy has not been well described in literature. Presentation of case A 60-year-old female patient entered our ward in March 2019 for laparoscopic cholecystectomy after 6 months history of epigastric pain and multiple episodes of biliary colic treated conservatively. She never complained of pulmonary symptoms. Preoperative chest Computed tomography (CT) was negative for diaphragmatic or pulmonary pathologies. Laparoscopic cholecystectomy was performed in 60 min with intraoperative detection of a thoracoabdominal communication with partial right hemidiaphragm agenesis. A chest CT and x-ray were performed in the postoperative period with progressive reduction of an asymptomatic small pneumothorax. The patient was discharged at home without complications on the fifth postoperative day. Thoracopulmonary surgery examination was performed without indications for diaphragmatic repair. Discussion DA is a rare condition and usually occurs in early neonatal period. The congenital form occurs in 1 out of 2200–12500 live births and is traditionally divided into anterior (Morgagni’s: 10%) and posterolateral (Bochdalek’s: 90%) hernias. Chest and abdomen CT with coronal and sagittal reconstructions is the most effective and useful imaging technique for the diagnosis of diaphragmatic hernia. In literature there are former two case reports of asymptomatic DA in cholelithiasis in which laparoscopic cholecystectomy was performed effectively. Conclusion In adults with partial DA, laparoscopic cholecystectomy can be performed successfully. A conservative management only with gallstones dissolution therapy can be used if laparoscopy cannot be done. Further studies with a higher level of evidence are needed.

Gallbladder stone with symptom is an indication of cholecystectomy according to the current guideline. However, about 80% of gallstone patients are asymptomatic. The identification of gallbladder stone patients likely to develop symptomatic complications would be of benefit in clinical practice. The aim of this study was to investigate the risk factors for asymptomatic gallstone diseases developing into a gallstone-related biliary event. This retrospective study evaluated 1284 patients with gallstones and received laparoscopic cholecystectomy (LC) in Peking Union Medical College Hospital. The age-gender-matched patients were divided into the acute cholecystitis group (group A), biliary colic group (group B), and asymptomatic gallstone group (group C). Baseline clinical characteristics and serum biochemical indexes were recorded and analyzed among the groups. Univariate logistic regression and multivariate Cox proportional hazard regression analysis were performed to determine the risk factors. The incidence of diabetes, hypertension, and sludge was higher in group A than in group B and in group C. The concentrations of plasma HDL in group A were lower than those in group B and group C (P

Cholelithiasis can present from a milder form of biliary colic to a more severe and complicated one like empyema gallbladder and a lesser-known variant of gangrenous gallbladder called marbleization of the gallbladder. The clinical signs and symptoms are similar to acute cholecystitis. Diabetes mellitus could have a role in the process of marbleization. Diagnosing marbleization of the gall bladder is not easy preoperatively. Computerized tomography is a better diagnostic modality when compared to laboratory investigations. Urgent cholecystectomy is the only option, and there is no role of conservative treatment. We report a case of a 36-year-old man with newly diagnosed Diabetes Mellitus diagnosed initially as acute cholecystitis and managed conservatively. He did not respond to treatment and hence underwent cholecystectomy and intraoperatively was found to have marbleization of the gall bladder.

Gallbladder agenesis is a rare anatomic congenital abnormality caused by the cystic bud failing to develop into the gallbladder. Gallbladder agenesis has a variable presentation, with 50% of patients presenting with symptoms mimicking biliary colic and 35% being incidentally discovered during surgery or autopsy, while another 15% can present with fatal fetal anomalies. In this article, we present a case of gallbladder agenesis in a young woman who presented with biliary-colic-like symptoms suggesting cholecystitis. The gallbladder was not well visualized on ultrasonography, simulating chronic cholecystitis due to shrunken or contracted bladder. Further imaging with computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) helped in the successful diagnosis of gallbladder agenesis and helped prevent unnecessary surgical intervention. Due to the lack of clinical suspicion diagnosing gallbladder agenesis preoperatively is still rare. Persistent symptoms are often associated with biliary colic pain leading to surgery. Conservative management consists of using antispasmodic medications. MRCP may be required to rule out gallbladder agenesis and avoid unnecessary surgery. Gallbladder agenesis can present with symptoms similar to cholecystitis. If the gallbladder is not visualized well on the ultrasound, an additional radiological examination is required. Clinicians' understanding of the condition helps to accurately diagnose the condition preoperatively using the appropriate investigations, thereby minimizing the operative risk to the patient.

Patient: Male, 47-year-old Final Diagnosis: Ectopic liver Symptoms: Right upper quadrant pain Medication:— Clinical Procedure: — Specialty: Surgery Objective: Congenital defects/diseases Background: Ectopic liver (EL) is liver tissue that is not attached to the mother liver, and is also known as choristoma and hepar succenturiatum. According to Watanabe’s 1060-patient series, it has an incidence rate of less than 1% (0.47%). The absence of an anatomical attachment to the hepatic proper is a rare congenital departure from the norm, known as EL. EL is thought to be caused by abnormal hepatic tissue growth from the foregut diver-ticulum, particularly at cystic structures. Case Report: We report the successful management of a 47-year-old male patient, not known to have any medical illness, who was referred to the surgical team with a clinical picture of biliary colic. An ultrasound (US) abdomen was performed, and cholecystitis was confirmed. During a laparoscopic cholecystectomy, ET was identified by chance. He tolerated the operation well. Gallbladder histological examination revealed significant mucosal and wall ulcers, chronic inflammation, many black stones, no dysplasia or malignancy, and connected liver tissue measuring 12×5 mm. As a result, chronic calcular cholecystitis was confirmed, as was normal EL architecture and no evidence of malignancy. Conclusions: We conclude that EL is a rare condition, but there have been cases reported in the literature. Imaging modalities such as US and computed tomography scans are recommended to rule out other underlying diagnoses and should be tailored to each individual when necessary. Because the presence of EL attached to the vesicle is a rare occurrence in the literature, a histological examination is required due to the elevated risk of hepatocellular carcinoma. Keeping such an abnormality in mind can help surgeons demarcate the embryological plane of dissection during cholecystitis to avoid tumor cell spillages if present.

Angiodysplasia is a common type of lesion characterized by malformed submucosal and mucosal blood vessels. Angiodysplasia of the gallbladder is extremely rare, usually an incidental finding, with only two cases reported. Laparoscopic cholecystectomy is a curative treatment for angiodysplasia of the gallbladder. Our report describes a case of angiodysplasia of the gallbladder in a patient who underwent elective laparoscopic cholecystectomy for biliary colic because of gallstones, and a systematic literature review. We surmise that angiodysplasia of the gallbladder could be a risk factor for gallstones in younger female patients.

Biliary sludge is seen on ultrasound as an amorphous echogenic material, which slowly moves to the dependent part. Endoscopic ultrasound has a sensitivity of 96% to detect biliary sludge, and the appearance is similar to that seen on transabdominal ultrasound. Other entities which can have a similar appearance include blood, pus, necrotic debris, and multiple small stones. This case represents a unique finding on endoscopic ultrasound of an echogenic image in CBD, mimicking biliary sludge.

Highlights • Laparoscopic cholecystectomy in a patient with situs inversus totalis after videolaparoscopic sleeve - Case Report. • A unique case of a surgery at a situs inversus totalis patient. • A new laparoscopic procedure at a patient submitted to a preview lap gastroplasty. • A complex surgery made in a latin american university hospital., Introduction Situs inversus totalis is the technical term used when there is a complete transposition of all organs to the opposite side referring to classical embryogenic orientation. Laparoscopic cholecystectomy is one of the most performed surgeries in the world. Presentation of case We report the case of a 61-year-old female patient who had previously undergone videolaparoscopic gastroplasty 7 months ago, who developed refractary biliary colic and underwent videolaparoscopic cholecystectomy. Discussion The surgical technique is challenging in these cases, specially because of the mirror findings in relation to the original technique. An additional challenge in this case was the fact that the patient had a previous laparoscopy due to gastroplasty performed. The presence of adhesions related to the surgery hardly interfered with the Calot triangle dissection, but the way they presented themselves required the attention of the entire surgical team. Conclusion Although uncommon, laparoscopic cholecystectomy can be performed in a situs inversus patient with ease, even in the presence of a previous surgical approach.

La cirugía laparoscópica por puerto único (LESS), ofrece ciertas ventajas, como la disminución del trauma quirúrgico, menor dolor postoperatorio, menor necesidad de analgésicos y excelentes resultados estéticos. El empleo de un único puerto quirúrgico otorga la oportunidad de combinar procedimientos en una sola sesión. Presentamos el caso de una paciente de 59 años con antecedente de cólico renal izquierdo e infecciones de vías urinarias de repetición, así como cuadros de cólico biliar de larga evolución, ambos tratados de forma sintomática. El estudio tomográfico demuestra la presencia de riñón izquierdo atrófico, sin captación de medio de contraste, así como patología biliar concomitante. Es sometida a Nefrectomía y Colecistectomía laparoscópica con técnica LESS, con adecuados resultados quirúrgicos y estéticos. La técnica LESS, es una opción viable en el manejo mínimamente invasivo de diferentes patologías. Realizar procedimientos quirúrgicos simultáneos por un mismo abordaje, podría evitar la necesidad de otra hospitalización y otra cirugía; hacerlo por un único puerto proporciona adecuados resultados estéticos, así como, permitir el abordaje de sitios anatómicos distantes entre sí a través de una sola incisión.

Portal hypertensive cholangiopathy is a rare complication of extrahepatic portal vein obstruction and portal cavernoma. It is usually asymptomatic but may be associated with jaundice, biliary colic, and fever. Abdominal sonography and Doppler are ideal initial diagnostic modalities, followed by magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography. These imaging modalities are important if an intervention is planned for the management of portal hypertension and for relieving biliary obstruction. If computed tomography (CT) is performed in isolation, it may be challenging to distinguish this entity from acute on chronic portal vein thrombosis. The diagnostic results should be interpreted cautiously. This case report of an abdomen CT performed on a patient with a history of portal vein thrombosis masqueraded as an acute on chronic portal vein thrombosis with cavernous collaterals. Doppler confirmed the diagnosis of portal hypertensive cholangiopathy. Correlation with clinical symptoms and Doppler may be necessary to distinguish portal hypertensive cholangiopathy from acute portal vein thrombus.

Objective: Hepatitis E virus (HEV) genotype 3 is endemic in Northern Europe and despite a high seroprevalence of anti-HEV IgG antibodies among blood donors (≈17%), few clinical cases are notified in Sweden. Low awareness of hepatitis E and its possible symptoms may contribute to this discrepancy. The aim of this study was to investigate the prevalence of acute HEV infection among hospital admitted patients with abdominal pain and elevated liver enzymes.Materials and methods: During 2016-2017, 148 adult patients with serum alanine aminotransferase (ALT) or aspartate aminotransferase (AST) > twice normal levels were prospectively enrolled at surgical wards at three Swedish hospitals. Serum samples were analyzed for HEV RNA as well as anti-HEV IgM and IgG, and medical records were reviewed.Results: Six (6/148, 4.1%) patients were HEV infected confirmed by detectable HEV RNA, but only one of these patients had detectable anti-HEV antibodies. Four of the HEV infected patients were diagnosed with gallstone-related disease: three with biliary pancreatitis and one with biliary colic. The remaining two were diagnosed with bowel obstruction and pancreatic malignancy. Four HEV strains were typed by sequencing to genotype 3.Conclusions: This study identified acute HEV3 infection in 4% of the patients with elevated liver enzymes admitted to a surgical ward. HEV infection was not the solitary disease leading to hospitalization, instead it was found to be associated with other surgical conditions such as gallstone-related disease including biliary pancreatitis. Additionally, HEV RNA might be the preferential diagnostic tool for detecting ongoing HEV infection.

Laparoscopic adrenalectomy (LA) is the treatment of choice for aldosteronomas and other adrenal tumors. Despite evidence that surgical cure of aldosteronomas is superior to medical treatment, reluctance remains to refer patients for LA. Here we compared the safety profile of LA to laparoscopic cholecystectomy (LC), a commonly performed laparoscopic procedure.Patients undergoing LA or LC from 2012 to 2015 were selected from the National Surgical Quality Improvement Program. Patients who had an LA for an adrenal adenoma or aldosteronoma were compared to those who had LC for biliary colic or cholelithiasis. Multivariable logistic regressions were used to analyze postoperative outcomes between the two groups, controlling for patient factors.A total of 19,315 patients met inclusion criteria (n = 1458 LA, n = 17,857 LC). Patients undergoing an LA were older (median 53 versus 46 y old, P 0.001), with a higher rate of American Society of Anesthesiologists score ≥3 (65.6% versus 25.0%, P 0.001) and modified frailty index score ≥ 1 (78.5% versus 33.6%, P 0.001). Overall mortality was 0.1% with no difference between the two cohorts (P = 0.426). Incidence of at least one postoperative complication was higher in the LA cohort (3.6% versus 2.2%, P 0.001). However, when adjusting for demographics, comorbidities, and operative time, adrenalectomy was not associated with an increased risk of postoperative complications (OR 0.83 (0.6-1.2), P = 0.268).After comparing postoperative outcomes between patients undergoing LA and LC, operation type was not independently associated with an increased incidence of complications. Therefore, physicians should consider LA as having a similar overall risk profile to LC when deciding whether to refer patients to surgery.