Knowledge of the cystic artery and its variations is essential to perform safe cholecystectomies. The cystic artery originates from the right hepatic artery, passing posterior to the common hepatic duct, anterior to the cystic duct, and branching into two branches at the neck of the gallbladder. However, variations in position, size, and relationship with adjacent structures are common.
This article presents a literature review regarding cystic artery variations and their frequency during cholecystectomies.
The articles selected for this review were chosen from the PubMed and SciELO databases. The standardized descriptors used were anatomic variation and cholecystectomy. These were chosen using the “Medical Subject Headings” and combined with the Boolean operator AND and the non-standard descriptor cystic artery.
It was found in 54.5% of the studies that the anatomical pattern of the cystic artery was the most frequent type. A different origin from the standard was cited in 63.6% of the articles. Double irrigation of the gallbladder was found in 59.1%. In 36.4%, the cystic artery was anterior to the common hepatic duct or the cystic duct. Cystic arteries outside Calot’s triangle were found in 36.4%. Short cystic arteries were found in 13.6%. The absence or non-identification of the artery was reported in 9.1%.
Variations of the cystic artery are common and are frequently reported. One aspect of a safe cholecystectomy is anatomical knowledge and its possible variations. Thus, surgeons must be familiar with this point in order to reduce vascular and biliary injuries.
Laparoscopic cholecystectomy is considered safe; however, it is not free from complications, such as bile duct injuries, bleeding, and infection of the surgical site.
The aim of this study was to determine the effectiveness of two prediction tools, the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) calculator and the surgical Apgar, in predicting post-cholecystectomy complications.
A cross-sectional, analytical, and comparative study was conducted on patients over 18 years old diagnosed with acute cholecystitis who underwent open or laparoscopic cholecystectomy at the Regional Teaching Hospital of Trujillo between 2015 and 2019. A chi-square test was used for bivariate analysis, and the receiver operating characteristic (ROC) curve analysis was employed to determine the discriminative capacity of the ACS-NSQIP and surgical Apgar calculators in predicting severe complications.
A total of 227 patients were included in the study. The analysis revealed that the mean age of patients who experienced severe complications was 75.32±4.58 years. Additionally, 52.6% of these patients were male. Regarding the prediction analysis based on the ROC curve, the ACS-NSQIP calculator showed an area under the curve of 0.895 (95%CI 0.819–0.971; p=0.01), whereas the surgical Apgar calculator showed an area under the curve of 0.611 (95%CI 0.488–0.735; p=0.11).
The obtained results indicate that the ACS-NSQIP calculator is effective in predicting severe complications in patients undergoing cholecystectomy due to acute cholecystitis. These findings may have important implications for clinical practice and medical decision-making, focusing on the appropriate use of prediction tools to improve outcomes in this type of surgical procedure.
The incidence of biliary duct injuries remains higher in laparoscopic cholecystectomy (LC) in comparison to open surgery. The Critical View of Safety (CVS) was introduced by Strasberg as a strategy for reducing this catastrophic complication. AIM: The aim of this study was to evaluate how often an adequate CVS is achieved during LC, the determining factors for its success, and the associated surgical outcomes.
This is a prospective study. CVS photographs of all patients who underwent LC by the same surgeon between 2020 and 2023 were taken. Success in achieving CVS was analyzed by the surgeon herself and posteriorly by hepatobiliary specialists. Patients were classified into two groups: CVS achieved and CVS not achieved. Finally, multivariable logistic regression was used to examine the association between preoperatory factors and surgical complications.
Three hundred and nine consecutive patients were submitted to LC. There were 73.5% elective CL and 26.5% acute cholecystitis. The age ranged from 14 to 87 years, and 76.8% were female. The median body mass index was 26.7. Previous abdominal surgeries were present in 64%, and 26% were obese. The CVS was achieved in 79.9% of the patients, and there were no surgical complications in this group. The factors associated with nonachievement were acute cholecystitis (p=0.007), male sex (p=0.014), and previous surgeries (p=0.021). Three patients needed a subtotal cholecystectomy due to severe inflammation. There was no statistical correlation between the identification of CVS and surgical complications.
The CVS is achieved in most patients. Acute cholecystitis, male sex, and previous abdominal operations are associated with difficulties in obtaining CVS.
The recommended treatment for cholecystocholedocholithiasis is cholecystectomy (CCT) associated with endoscopic retrograde cholangiopancreatography (ERCP). CCT with intraoperative ERCP is associated with higher success rates and lower hospital stays and hospital costs. However, some case series do not describe the exact methodology used: whether ERCP or CCT was performed first.
Verify if there is a difference, in terms of outcomes and complications, when intraoperative ERCP is performed immediately before or after CCT.
This is a retrospective case-control study analyzing all patients who underwent CCT with intraoperative ERCP between January 2021 and June 2022, in a tertiary hospital in southern Brazil, for the treatment of cholecystocholedocholithiasis.
Out of 37 patients analyzed, 16 (43.2%) underwent ERCP first, immediately followed by CCT. The overall success rate for the cannulation of the bile duct was 91.9%, and bile duct clearance was achieved in 75.7% of cases. The post-ERCP pancreatitis rate was 10.8%. When comparing the "ERCP First" and "CCT First" groups, there was no difference in technical difficulty for performing CCT. The "CCT First" group had a higher rate of success in bile duct cannulation (p=0.020, p<0.05). Younger ages, presence of stones in the distal common bile duct and shorter duration of the procedure were factors statistically associated with the success of the bile duct clearance. Lymphopenia and cholecystitis as an initial presentation, in turn, were associated with failure to clear the bile duct.
There was no significant difference in terms of complications and success in clearing the bile ducts among patients undergoing CCT and ERCP in the same surgical/anesthetic procedure, regardless of which procedure was performed first. Lymphopenia and cholecystitis have been associated with failure to clear the bile duct.
Bile duct injury (BDI) causes significant sequelae for the patient in terms of morbidity, mortality, and long-term quality of life, and should be managed in centers with expertise. Anatomical variants may contribute to a higher risk of BDI during cholecystectomy.
To report a case of bile duct injury in a patient with situs inversus totalis.
A 42-year-old female patient with a previous history of situs inversus totalis and a BDI was initially operated on simultaneously to the lesion ten years ago by a non-specialized surgeon. She was referred to a specialized center due to recurrent episodes of cholangitis and a cholestatic laboratory pattern. Cholangioresonance revealed a severe anastomotic stricture. Due to her young age and recurrent cholangitis, she was submitted to a redo hepaticojejunostomy with the Hepp-Couinaud technique. To the best of our knowledge, this is the first report of BDI repair in a patient with situs inversus totalis.
The previous hepaticojejunostomy was undone and remade with the Hepp-Couinaud technique high in the hilar plate with a wide opening in the hepatic confluence of the bile ducts towards the left hepatic duct. The previous Roux limb was maintained. Postoperative recovery was uneventful, the drain was removed on the seventh post-operative day, and the patient is now asymptomatic, with normal bilirubin and canalicular enzymes, and no further episodes of cholestasis or cholangitis.
Anatomical variants may increase the difficulty of both cholecystectomy and BDI repair. BDI repair should be performed in a specialized center by formal hepato-pancreato-biliary surgeons to assure a safe perioperative management and a good long-term outcome.
Iatrogenic injury to the bile ducts is the most feared complication of cholecystectomy and several are the possibilities to occur.
To compare the cases of iatrogenic lesions of the biliary tract occurring in conventional and laparoscopic cholecystectomy, assessing the likely causal factors, complications and postoperative follow-up.
Retrospective cohort study with analysis of records of patients undergoing conventional and laparoscopic cholecystectomy. All the patients were analyzed in two years. The only criterion for inclusion was to be operative bile duct injury, regardless of location or time of diagnosis. There were no exclusion criteria. Epidemiological data of patients, time of diagnosis of the lesion and its location were analyzed.
Total of 515 patients with gallstones was operated, 320 (62.1 %) by laparotomy cholecystectomy and 195 by laparoscopic approach. The age of patients with bile duct injury ranged from 29-70 years. Among those who underwent laparotomy cholecystectomy, four cases were diagnosed (1.25 %) with lesions, corresponding to 0.77 % of the total patients. No patient had iatrogenic interventions with laparoscopic surgery.
Laparoscopic cholecystectomy compared to laparotomy, had a lower rate of bile duct injury.
Cholecystocolic fistula is a rare complication of gallbladder disease. Its clinical presentation is variable and nonspecific, and the diagnosis is made, mostly, incidentally during intraoperative maneuver. Cholecystectomy with closure of the fistula is considered the treatment of choice for the condition, with an increasingly reproducible tendency to the use of laparoscopy.
To describe the laparoscopic approach for cholecystocolic fistula and ratify its feasibility even with the unavailability of more specific instruments.
After dissection of the communication and section of the gallbladder fundus, the fistula is externalized by an appropriate trocar and sutured manually. Colonic segment is reintroduced into the cavity and cholecystectomy is performed avoiding the conversion procedure to open surgery.
Laparoscopy for resolution of cholecystocolic fistula isn't only feasible, but also offers a shorter stay at hospital and a milder postoperative period when compared to laparotomy.
Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as
empyema, gangrene, perforation of the gallbladder, and sepsis. The gold standard treatment for AC is laparoscopic cholecystectomy. However, for a small group
of AC patients, the risk of laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these critically ill patients,
percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to cholecystectomy. The
objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons,
endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure
are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological,
and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on
clinical conditions and available expertise; c) Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous
or endoscopic gallbladder drainage is not available; d) Percutaneous cholecystostomy and endoscopic gallbladder drainage should be performed only in wellequipped
hospitals with experienced interventional radiologist and/or endoscopist; e) Cholecystostomy catheter should be removed after resolution of AC.
However, in patients who have no clinical condition to undergo cholecystectomy, the catheter may be maintained for a prolonged period or even definitively; f)
If the cholecystostomy catheter is maintained for a long period of time several complications may occur, such as bleeding, bile leakage, obstruction, pain at the
insertion site, accidental removal of the catheter, and recurrent AC; g) The ideal waiting time between cholecystostomy and cholecystectomy has not yet been
established and ranges from immediately after clinical improvement to months. h) Long waiting periods between cholecystostomy and cholecystectomy may
be associated with new episodes of acute cholecystitis, multiple hospital readmissions, and increased costs. Finally, when selecting the best treatment option
other aspects should also be considered, such as costs, procedures available at the medical center, and the patient’s desire. The patient and his family should
be fully informed about all treatment options, so they can help making the final decision.
Asymptomatic cholelithiasis is a highly prevalent disease, and became more evident after the currently greater access to imaging tests. Therefore, it is increasingly necessary to analyse the risks and benefits of performing a prophylactic cholecystectomy.
To seek the best evidence in order to indicate prophylactic cholecystectomy or conservative treatment (clinical follow-up) in patients with asymptomatic cholelithiasis.
A systematic review was performed using the PubMed/Medline database, according to PRISMA protocol guidelines. The review was based on studies published between April 26, 2001 and January 07, 2022, related to individuals older than 18 years., The following terms/operators were used for search standardization: (asymptomatic OR silent) AND (gallstones OR cholelithiasis).
We selected 18 studies eligible for inference production after applying the inclusion and exclusion criteria. Also, the Tokyo Guideline (2018) was included for better clarification of some topics less or not addressed in these studies.
Most evidence point to the safety and feasibility of conservative treatment (clinical follow-up) of asymptomatic cholelithiasis. However, in post-cardiac transplant patients and those with biliary microlithiasis with low preoperative surgical risk, a prophylactic cholecystectomy is recommended. To establish these recommendations, more studies with better levels of evidence must be conducted.
Gallbladder polyps are becoming a common finding in ultrasound. The management has to consider the potential risk of malignant lesions.
The aim of this study was to analyze the ultrasound findings in patients undergoing cholecystectomy due to gallbladder polyps and compare them for histopathological findings (HPs).
Patients with an ultrasonographic diagnosis of gallbladder polyp and who underwent cholecystectomy from 2007 to 2020 were included in the study.
A total of 447 patients were included, of whom 58% were women. The mean age was 45±12 years. The mean size of polyps in US was 7.9±3.6 mm. Notably, 9% of polyps were greater than 10 mm, and single polyps were significantly larger than the multiple ones (p=0.003). Histopathological findings confirmed the presence of polyps in 88.4%, with a mean size of 4.8±3.4 mm. In all, 16 cases were neoplastic polyps (4.1%), 4 of them being malignancies, and all were single and larger than 10 mm. We found a significant correlation between ultrasound and histopathological findings polyp size determination (r=0.44; p<0.001). The Bland-Altman analysis obtained an overestimation of the US size of 3.26 mm. The receiver operating characteristic (ROC) curve analysis between both measures obtained an area under the receiver operating characteristic curve (AUC) of 0.77 (95%CI 0.74–0.81). Ultrasound polyps size larger than 10 mm had an odds ratio (OR) of 8.147 (95%CI 2.56–23.40) for the presence of adenoma and malignancy, with a likelihood ratio of 2.78.
There is a positive correlation and appropriate diagnostic accuracy between ultrasound size of gallbladder polyps compared to histopathological records, with a trend to overestimate the size by about 3 mm. Neoplastic polyps are uncommon, and it correlates with size. Polyps larger than 10 mm were associated with adenoma and malignancy.
Desenvolvido por Surya MKT