Unanticipated Admission Following Outpatient Laparoscopic Cholecystectomy: Identifying Opportunities for Improvement

Background Unanticipated admissions are a burden to the health care system. Over 400 000 outpatient laparoscopic cholecystectomies (LCs) are performed annually in the United States. The aim of this study is to identify causes of unanticipated admissions and modifiable risk factors. Methods Patients undergoing elective outpatient LCs were identified from the 2013-2015 American College of Surgeons National Surgical Quality Improvement Program database. Results A total of 69 376 patients underwent outpatient LC or LC+ intraoperative cholangiogram (IOC); 2027 (2.9%) were admitted after a median of 5 days (interquartile range 3-8). Admission rates varied by preoperative indications: pancreatitis (4.9%), gallstones with obstruction (3.9%), cholecystitis (3.0%), and gallstones without obstruction (2.6%) ( P = .003). The most frequent causes were infection, retained stones, and other GI complications. Patients admitted for infection or cardiopulmonary complications were older with higher American Society of Anesthesiologists (ASA) ( P < .01), while patients with pain and retained stones were younger with lower ASA ( P < .01). Patients who underwent LC+IOC had a lower admission rate due to retained stones (.17% vs. .31% LC, P = .006). Conclusions Unanticipated admissions following outpatient LC occur infrequently for diverse reasons usually within the first week after surgery. Associated factors are patient and disease related and not at all modifiable. In selected patients, increased IOC use may decrease admissions from retained stones.

Analysis of the management of choledocholithiasis and it’s outcome with the role of preoperative endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography

Background: Choledocholithiasis implies stones in the common bile duct (CBD). Most of the common bile duct stones are those that have passed into the bile duct from the gall bladder. About 20 to 25% of patients above the age of 60 with symptomatic gall stones are likely to have stones in the CBD. To analyse the role of ERCP and MRCP in the management of choledocholithiasis.Methods: About 60 patients who are attending the General Surgery OPD of Rajiv Gandhi Government General Hospital, Madras Medical College, Chennai, Tamil Nadu, India from the October 2017-March 2018 were included in the study with confirmed common bile duct stones with or without gall stones were chosen. patients were categorized into group A- who has undergone a successful ERCP followed by laparoscopic cholecystectomy and group B- who underwent open cholecystectomy with CBD exploration.Results: Ultrasonography was done in 57 patients, of which 41 patients showed CBD stones (71.93%), 12 patients showed dilated CBD in the presence of cholelithiasis (21.05%) and in the remaining 4 patients (7.01%) this investigation showed only cholelithiasis. Since clinical condition warranted, authors proceeded with further hepatobiliary imaging, which revealed choledocholithiasis.Conclusions: Magnetic resonance cholangio pancreatography can also be used for follow up of the patients with choledocholithiasis after therapy, to look for the presence of retained stones, since it can detect stones even in the size as small as 2 mm. Selective use of intraoperative choledochoscopy in suspected cases helps in reducing the incidence of retained stones.

Migration of Surgical Clips into the Common Bile Duct after Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC) is currently the treatment of choice for symptomatic gallstones. Associated complications include bile duct injury, retained common bile duct (CBD) stones, and migration of surgical clips. Clip migration into the CBD can present with recurrent cholangitis over a period of time. Retained CBD stones can be another cause of recurrent cholangitis. A case of two surgical clips migrating into the common bile duct with few retained stones following LC is reported here. The patient had repeated episodes of fever, pain at epigastrium, jaundice, and pruritus 3 months after LC. Liver function tests revealed features of obstructive jaundice. Ultrasonography of the abdomen showed dilated CBD with few stones. In view of acute cholangitis, an urgent endoscopic retrograde cholangiopancreatography was done, which demonstrated few filling defects and 2 linear metallic densities in the CBD. A few retained stones along with 2 surgical clips were removed successfully from the CBD by endoscopic retrograde cholangiopancreatography after papillotomy using a Dormia basket. The patient improved dramatically following the procedure.

Long-Term Results of Hepatic Resection for Hepatolithiasis

Long-term results of hepatic resection for hepatolithiasis in 34 patients having intrahepatic biliary strictures were studied. The left lateral and the right posterior segmental ducts were commonly and often simultaneously involved. Fourteen patients had multiple segmental involvement. Hepatic resection included left sided resection (n=27), right sided resection (n=6), and repeated bilateral resection (n=1). Seven patients had biliary tumors: 3 cholangiocarcinomas, 2 gall bladder cancers, cystadenocarcinoma, and dysplasia of intrahepatic ducts. Nineteen patients received bilioenteric anastomosis. Retained stones and recurrent stones developed in 3 and 4 patients, respectively. Twenty-six patients had no remaining symptoms; 2 died of operative complication or cholangiocarcinoma; 6 presented symptoms caused by retained stones (n=2), recurrent stones (n=2), bile stasis (n=1), or neuralgia (n=1). In 4 of the 6 patients, unrelieved posterior duct strictures caused the symptoms. With a mean follow-up period of 4.5 years, 30 patients are symptoms free, and 27 are stone free. In patients with right lobar or bilobar type, intra- and extrahepatic type, and confluence strictures, bilioenteric anastomosis is required. Hepatic resection is a rational treatment for hepatolithiasis, however, meticulous management of biliary tract abnormalities, particularly the posterior duct stricture, is mandatory.