Backgrounds/Aims Thoracic epidural analgesia (TEA) is an established analgesic method in open Kausch-Whipple pancreaticoduodenectomy (KWPD). Although, it can cause hemodynamic instability and neurological complications. Inter pleural analgesia (IPA) is an alternative option. We aim to evaluate the effectiveness of IPA versus TEA after KWPD. Methods We retrospectively studied the efficacy of IPA against TEA in patients, operated by a single surgeon. The primary outcome was the analgesic efficacy and secondary outcomes were analgesia-related complications, inotrope use, and duration. Results Forty patients (TEA, 22; IPA, 18) were included. Both groups were well matched for patient characteristics, type, and duration of surgery. TEA was associated with higher analgesia-related complications (n = 8, 36.4% vs. n = 1, 5.6%; p = 0.027). TEA complications included analgesia not working (n = 4), leakage (n = 2), refractory hemodynamic instability (n = 1), and lower limb anaesthesia (n = 1). One patient in the IPA group encountered leakage. TEA was associated with longer inotrope requirement (35 vs. 18 hours; p = 0.047). There was no significant difference in intensive care unit (ITU) admission rate (81.8% vs. 77.8%; p > 0.999), median ITU stay (3 vs. 2 days, p = 0.385), or hospital stay (11 days in both groups). Conclusions In open KWPD, IPA is not inferior to TEA in its efficacy of pain control. IPA was associated with less analgesia-related complications and shorter inotrope requirements. However, this was a small retrospective study. Larger randomized controlled trials are needed to study the effectiveness of IPA.
Introduction Subtotal cholecystectomy (STC) is a safe approach in difficult cholecystectomies to prevent bile duct and vascular injury. However, the gallbladder remnant can become symptomatic, necessitating further surgical intervention. This study evaluates the safety profile and perioperative outcomes of remnant cholecystectomy (RC) performed under intraoperative ultrasound guidance. Methods We retrospectively reviewed the records of all patients that underwent RC under intraoperative ultrasound guidance in 2009 and 2019. Pre-, intra- and postoperative details of patients who underwent RC were obtained from patients’ electronic and paper copy records. Results Ninety-seven patients underwent STC during the study period. Of this cohort, 16 patients (16.5%) presented with symptomatic gallbladder remnant over a median follow-up period of 14 months (interquartile range [IQR] 2–26). The median age was 64 years (IQR 54–69) with an equal male-to-female distribution. The median body mass index was 31kg/m2 (IQR 28–33). Twelve of 16 patients (75%) then proceeded to elective RC. Intraoperative ultrasound was used in all cases to identify the location of the remnant gallbladder and biliary anatomy. The median operative time was 88min (IQR 80–96), with 67% completed laparoscopically. No patients suffered bile duct injury. The median hospital stay was 3 days (IQR 1–5). During the follow-up period, eight patients (67%) reported symptom resolution. Conclusions RC is a safe operation that can be performed laparoscopically even after previous open subtotal cholecystectomy. We recommend the routine use of intraoperative ultrasound as an adjunct for identifying remnant gallbladder and biliary anatomy in all patients.
Background Subtotal cholecystectomy (STC) is perceived as a safe approach in difficult cholecystectomies to prevent bile duct and vascular injury. However, the gallbladder remnant can become symptomatic, necessitating further surgical intervention. This study aims to evaluate the safety profile and peri-operative outcomes of remnant cholecystectomy (RC) Methods We retrospectively reviewed the records of all patients that underwent STC from 2009 to 2019. Patients that underwent RC were included in the study. Results We identified 97 STC patients during the study period. Of this cohort, 16 patients (16.5%) presented with symptoms attributed to remnant gallbladder. The median age of this group was 64 years [Inter quartile range (IQR) 54–69] with equal male to female distribution. The median body mass index: 31kg/m2 (IQR 28–33). Twelve patients then proceeded to RC. All cases were performed by a consultant Hepatobiliary surgeon in an elective setting. The median operative time was 88 minutes (IQR 80–96) with 67% completed laparoscopically. No patients suffered bile duct injury. Median hospital was 3 days (IQR 1–5). Readmission rate was zero. One patient suffered with post-op hypotension requiring inotropic support. Overall mortality is zero. At the end of the follow up period [median of 14 months (IQR 2–26)], 8 patients (67%) reported symptoms resolution. Conclusions Remnant cholecystectomy is a safe operation that can be performed laparoscopically. It has a low complications rate and relatively short hospital stay when performed by an experienced surgeon. However, symptomatic resolution is not achievable in all cases.
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