Purpose
Bile duct injury (BDI) is a catastrophic complication of cholecystectomy, and misidentification of the cystic anatomy is considered to be the main cause. Although several techniques have been developed to prevent BDI, such as the “critical view of safety”, the infundibular technique, the rates remain higher during laparoscopic cholecystectomy (LC) than during open surgery. We, here, propose a practical new strategy for ductal identification, that can help to prevent laparoscopic bile duct injury.
Methods
A retrospective study of 5539 patients who underwent LC from March 2007 to February 2019 at a single institution was conducted. The gallbladder infundibulum was classified by its position located on an imaginary clock with the gallbladder neck as the center point of the dial, 3-o’clock position as cranial, 6-o’clock as dorsal, 9-o’clock as caudal, and 12-o’clock as ventral, as well as the axial position. Patient demographics, pathologic variables and infundibulum classification were evaluated. Detailed analysis of ductal identification based on gallbladder infundibulum position was performed in this study. All infundibulum positions were recorded by intraoperative laparoscopic video or photographic images.
Results
All the patients successfully underwent LC during the study period. No conversion or serious complications such as biliary injury occurred. Gallbladders with infundibulum of 3-o’clock position, 6-o’clock position, 9-o’clock position, 12-o’clock position, axial position were 12.3%, 23.4%, 28.0%, 4.2%, and 32.1%, respectively. The 3-o’clock and 12-o’clock position were pitfalls that might cause biliary injury.
Conclusion
The gallbladder infundibulum as a navigator is useful for ductal identification to reduce BDI and improve the safety of LC.
Gallbladder carcinoma (GBC) is a rare biliary tract cancer with a high recurrence rate and a poor prognosis. Albumin-alkaline phosphatase ratio (AAPR) has been demonstrated to be a prognostic predictor for several cancers, but its predictive value for GBC patients remains unknown. The aim of this study was to investigate the predictive role of AAPR in GBC patients and to develop a novel nomogram prediction model for GBC patients. We retrospectively collected data from 80 patients who underwent surgery at the Hospital of 81st Group Army PLA as a training cohort. Data were collected from 70 patients with the same diagnosis who underwent surgery at the First Affiliated Hospital of Hebei North University as an external verification cohort. The optimal cut-off value of AAPR was determined using X-tile software. A nomogram for the overall survival (OS) based on multivariate Cox regression analysis was developed and validated using calibration curves, Harrell’s concordance index, the receiver operating characteristic curves, and decisive curve analyses. The optimal cut-off value of AAPR was .20. Univariate and multivariate Cox regression analyses demonstrated that BMI (p = .043), R0 resection (p = .001), TNM stage (p = .005), and AAPR (p = .017) were independent risk factors for GBC patients. In terms of consistency, discrimination, and net benefit, the nomogram incorporating these four independent risk factors performed admirably. AAPR is an independent predictor of GBC patients undergoing surgery, and a novel nomogram prediction model based on AAPR showed superior predictive ability.
Abdominal lymphangiomas are extremely rare in the adult population. We report an unusual case of a cystic lymphangiomas arising from the hepatoduodenal ligament. A 45-year-old man was admitted to our hospital with discontinuous upper abdominal pain. The preoperative CT diagnosis was neurinoma. Exploratory laparotomy revealed a cystic mass originating from the hepatoduodenal ligament and then it was resected successfully. The pathological sections proved it to be lymphangioma. The patient remains well with no evidence of recurrence two years post resection.
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