Elective laparoscopic cholecystectomy: recurrent biliary admissions predispose to difficult cholecystectomy

Introduction Patients undergoing elective laparoscopic cholecystectomy (ELLC) represent a heterogeneous group making it challenging to stratify risk. The aim of this paper is to identify pre-operative factors associated with adverse peri- and post-operative outcomes in patients undergoing ELLC. This knowledge will help stratify risk, guide surgical decision making and better inform the consent process. Methods All patients who underwent ELLC between January 2015 and December 2019 were included in the study. Pre-operative data and both peri- and post-operative outcomes were collected retrospectively from multiple databases using a deterministic records-linkage methodology. Patients were divided into groups based on clinical indication (i.e. biliary colic versus cholecystitis) and adverse outcomes were compared. Multivariate regression models were generated for each adverse outcome using pre-operative independent variables. Results Two-thousand one hundred and sixty-six ELLC were identified. Rates of peri- and post-operative adverse outcomes were significantly higher in the cholecystitis versus biliary colic group and increased with number of admissions of cholecystitis (p < 0.05). Rates of subtotal (29.5%), intra-operative complication (9.8%), post-operative complications (19.6%), prolonged post-operative stay (45.9%) and re-admission (16.4%) were significant in the group of patients with ≥ 2 admissions with cholecystitis. Conclusion Our data demonstrate that patients with repeated biliary admission (particularly cholecystitis) ultimately face an increased risk of a difficult ELLC with associated complications, prolonged post-operative stay and readmissions. These data provide robust evidence that individualised risk assessment and consent are necessary before ELLC. Strategies to minimise recurrent biliary admissions prior to LC should be implemented.

Comparison of Operative Outcomes Between Monopolar and Bipolar Coagulation in Hepatectomy: A Propensity Score-Matched Analysis in a Single Center

Background: Various hemostatic devices have been utilized to reduce blood loss during hepatectomy. Nonetheless, a comparison between monopolar and bipolar coagulation, particularly their usefulness or inferiority, has been poorly documented. The aim of this study is to reveal the characteristics of these hemostatic devices.Methods: A total of 264 patients who underwent open hepatectomy at our institution from January 2009 to December 2018 were included. Monopolar and bipolar hemostatic devices were used in 160 (monopolar group) and 104 (bipolar group) cases, respectively. Operative outcomes and thermal damage to the resected specimens were compared between these groups using propensity score matching according to background factors. Multivariate logistic regression analysis was performed to identify predictive factors for postoperative complications.Results: After propensity score matching, 73 patients per group were enrolled. The monopolar group had significantly lower total operative time (239 vs. 275 min; P=0.013) and intraoperative blood loss (487 vs. 790 mL; P<0.001). However, the incidence rates of ascites (27.4% vs. 8.2%; P=0.002) and grade ≥3 intra-abdominal infection (12.3% vs. 2.7%; P=0.028) were significantly higher in the monopolar group. Thermal damage to the resected specimens was significantly longer in the monopolar group (4.6 vs. 1.2 mm; P<0.001). Use of monopolar hemostatic device was an independent risk factor for ascites (odds ratio, 5.626, 95% confidence interval 1.881–16.827; P=0.002) and severe intra-abdominal infection (odds ratio, 5.905, 95% confidence interval 1.096–31.825; P=0.039).Conclusions: Although monopolar devices have an excellent hemostatic ability, they might damage the remnant liver. The use of monopolar devices can be one of the factors that increase the frequency of complications.

INSPIRATORY MUSCLES TRAINING: AN EFFECTIVE WAY TO IMPROVE POST-OPERATIVE OUTCOMES AFTER CORONARY ARTERY BYPASS GRAFTING

Cardiovascular diseases (CVD) are the leading cause of death worldwide. It is a multifactorial disease and has many risk factors including hypertension, diabetes mellitus, physical inactivity and smoking. Coronary artery disease (CAD) is one of the consequences of CVD.1 If we talk about CAD, it is a really common heart disease in our country, also known as ischemic heart disease and develops when coronary arteries or its sub-branches which are the blood supply of the heart become narrowed or blocked due to accumulation of plaque leading to an impaired supply of oxygen rich blood to the heart and thus cause retrosternal chest pain typically known as angina that is accompanied by dyspnea.2 Coronary artery bypass grafting (CABG) is generally the ideal treatment option for the individuals suffering from CAD. In this procedure, an auto-graft of vessel is taken and the commonly used vessels are left internal thoracic artery and great saphenous vein. The graft is sutured in such a way that the blocked coronary artery is bypassed and the blood supply to the heart is restored.3 Although medical sciences have advanced a lot, yet the prevalence of post-operative complications, specifically the respiratory ones pose an immediate threat to the survival and are the aiding factors to mortality and morbidity.4 Physical therapy after any surgery plays a pivotal role in improving the post-operative outcomes and helps the patient fight the effects of surgery. It makes a patient return to his or her normal life and helps in the early discharge of patients from hospitals thus preventing the chances of hospital acquired infections and reducing the financial load on masses.5 Respiratory rehabilitation, which is the specialty of physical therapy, have tremendous positive effects on the pulmonary compliance and function by preventing the post-operative pulmonary atelectasis.6 Moving further towards the components of respiratory rehabilitation, a group of breathing maneuvers conjointly known as inspiratory muscles training (IMT), if applied pre-operatively to the patients who are scheduled to undergo the coronary artery by-pass grafting displayed healthy post-operative outcomes.7 To conclude, it is the dire need of today to raise awareness among the health care professionals especially cardiologists and cardio-thoracic surgeons; and the general public regarding the pre-operative respiratory physical therapy for the patients planned to go through CABG. So, in the light of supported evidence, it is proved that respiratory physical therapy, particularly pre-operative IMT has positive outcomes in post-operative state. Moreover, the authors would also like to shed light on the facts about the healthcare policies and physical therapy services in Pakistan. Contrary to public sector hospitals, the rehabilitation departments in private sector hospitals are properly managed, substantially equipped and well established, leading to enhanced quality of physical therapy practices that result in better prognosis of the patients. The health department of our country should also emphasize on the public sector hospitals to make necessary arrangements for logistics of sufficient equipment and the hiring of physical therapists that are qualified and specialized in the field of cardiopulmonary physical therapy.

The role of choledochoscopy in transductal laparoscopic common bile duct exploration

Laparoscopic common bile duct exploration (LCBDE) performed by choledochoscope through the cystic duct or directly through the incision in the common bile duct (CBD) are well established methods for restoring biliary drainage function in patients with choledocholithiasis. Although it plays a crucial role in the transcystic approach, transductal approach can be achieved differently. However, it has restrictions in availability due to its expensiveness. Objective — to report efficacy of transductal LCBDE without laparoscopic choledochoscopy. Materials and methods. This is a prospective study of urgently admitted patients who underwent trans‑ductal LCBDE due to confirmed choledocholithiasis. During laparoscopy, clearance of the CBD was achieved in two ways: by choledochoscopy (group CS+, n = 43) and without it (group CS–, n = 34). The data of patient demographics, comorbidities, operative outcomes, morbidity, mortality and long‑term biliary complications were analysed and compared between the groups. Results. Out of a total of 154 patients with confirmed choledocholithiasis, the trans‑ductal approach of LCBDE was applied to 77 patients. In 43 patients, clearance was done with choledochoscope (group CS+) and in 34 patients without it (group CS–). Gallstone related complications and comorbidities did not differ between the groups. Surgery was done 4 days after admission in both groups. Median duration of the operation was significantly shorter in the group CS–, 93 vs 120 minutes (p = 0.036), without any difference in conversion and complication rates. Clearance rate was markedly high in both groups. Conclusions. Transductal laparoscopic common bile duct exploration without choledochoscopy is a time‑saving, safe and effective way for CBD clearance, without additional equipment.