Assessment of a Scoring System to Predict Difficult Laparoscopic Cholecystectomy

Introduction Laparoscopic cholecystectomy (LC) has become the procedure of choice for management of symptomatic gallstone disease. It would be useful to have some reliable predictive factors for conversion in LC. Our aim is to predict difficult laparoscopic cholecystectomy preoperatively by using a scoring system. MethodsA total of 136 patients were included. The parameters considered for this study were old age, male sex, history of hospitalization, obesity, abdominal surgery scar, palpable gall bladder, gall bladder wall thickness, pericholecystic collection and impacted stone. ResultsAmong 136 cases, 70.6% were easy, 24.3% were difficult and 5.1% were very difficult intraoperatively. The factors like age >50 years, history of hospitalization for acute cholecystitis, previous abdominal surgery, palpable gall bladder, wall thickness >4mm and impacted stone were found statistically significant in predicting difficult LC. The preoperative scoring is statistically and clinically a good test for predicting the difficult LC (area under the curve = 0.824) with sensitivity of the test being 82.3% and specificity 72.7%. Conversion rate was 3.67%. ConclusionThe factors like age >50 years, history of hospitalization for acute cholecystitis, previous abdominal surgery, palpable gall bladder, wall thickness >4 mm and impacted stone are the preoperative predictors of difficult LC.

Failure of endoscopic management of ureteral strictures is due to ureteroscopic lithotripsy as a cause and longer length of stricture

Background Ureteroscopic lithotripsy is a common treatment for middle and lower ureteral stones. Although effective and minimally invasive, this technique might cause significant complications, including postoperative ureteral strictures, which occur in 1–4% of patients after ordinary ureteroscopic lithotripsy and in 7.8–24% when lithotripsy is performed for impacted stones. The main purpose of the management of ureteral strictures is to improve hydronephrosis and protect renal function. However, factors that influence the success rate of the endoscopic management of US (e.g., the cause and length of stricture, the duration of hydronephrosis, surgical management technique, and the number of placed ureteral stents) are controversial. The aim of this study was to investigate factors determining the outcomes of endoscopic management for stone-related ureteral stricture. Methods This multi-center case series study was performed at one of the highest-volume centers and the affiliated institutions in Japan. Data of patients who underwent endoscopic surgery for ureteral stricture from January 2016 to March 2019 were retrospectively analyzed. Laser incision and/or balloon dilation were performed for management; single or double stents were placed at the end of the surgery. Treatment success was defined as improvement in hydronephrosis status. Results Nineteen patients were treated for stone-related ureteral stricture. Hydronephrosis successfully improved in 12 patients (63.2%). All seven patients with failed endoscopic management had ureteroscopic lithotripsy-related stricture, whereas 3/12 (25.0%) and 7/12 (58.3%) patients with ureteroscopic lithotripsy-related stricture and impacted stone-related stricture, respectively, underwent successful endoscopic treatment (P = 0.004). Stricture length > 15 mm was observed in five patients (71.4%) with failed management, two patients (16.6%) with successful management (P = 0.046), 7/10 patients (70.0%) with ureteroscopic lithotripsy-related stricture, and 1/7 patients (14.3%) with impacted stone-related stricture (P = 0.049). Among patients with ureteroscopic lithotripsy-related stricture and impacted stone-related stricture, both laser incision and balloon dilation were performed in 5/10 (50.0%) and 2/7 (28.6%) patients (P = 0.874) while double stents were placed in 5/10 (50.0%) and 5/7 (57.1%) patients (P = 0.874), respectively. Conclusions Ureteroscopic lithotripsy as a cause and stricture length > 15 mm could strongly affect the success rate of endoscopic management of ureteral stricture. In such cases, reconstructive management should be considered in the early stages.

A Rare Case of Large Impacted Stone in Jejunum Causing Obstruction in a Patient of Gallstone Ileus

Gallstone ileus is a rare complication of cholelithiasis that occurs as a result of occlusion of the intestinal lumen by a large sized gallstone accounting for 1-4% cases of small bowel obstruction. The aim of this work is to introduce a case report that emphasize the diagnostic and therapeutic management of gallstone ileus with an enterolith impacted in jejunum (an uncommon site).

Can difficulties in laparoscopic cholecystectomy be anticipated preoperatively: evaluation of a scoring system

Background: Laparoscopic cholecystectomy is often associated with intra operative difficulties leading to increased intra and post-operative morbidity. Accurate prediction of a difficult laparoscopic cholecystectomy can reduce the complication rate, rate of conversion and overall medical cost. This study was an attempt to validate a scoring system developed to predict difficult laparoscopic cholecystectomy.Methods: 100 patients undergoing laparoscopic cholecystectomy were included. Details such as age, sex, BMI, previous surgical history, history of hospitalisation for biliary disease, sonographical wall thickness, pericholecystic collection and presence of impacted stone were noted. With these, pre-operative score was calculated using the scoring system. Intra operative details and complications were noted and were classified as easy, difficult and very difficult. Student t test and chi square test was used to test the difference of significance (p<0.05).Results: Male sex, higher BMI, a history of previous surgery, a history of prior hospitalisation for biliary disease, a palpable gall bladder, a thickened gall bladder wall, impacted stone and pericholecystic collection all had a statistically significant accurate prediction of the difficulty in laparoscopic cholecystectomy. The mean duration of surgery was 62.7±33.15 minutes. The scoring system developed by Randhawa et al predicted difficult laparoscopic cholecystectomy with a sensitivity of 77.8%, specificity of 78.1%, positive predictive value of 66.7% and a negative predictive value of 86.2%.Conclusions: The proposed scoring system predicted difficult laparoscopic cholecystectomy with a sensitivity of 77.8%, specificity of 78.1%, positive predictive value of 66.7% and a negative predictive value of 86.2%.