Analysis of actual healthcare costs of early versus interval cholecystectomy in acute cholecystitis

10.1002/jhbp.196Journal of Hepato-Biliary-Pancreatic Sciences223237-24

Isolated gallbladder tuberculosis mimicking acute cholecystitis : a case report

Background: Isolated tuberculosis of the gallbladder is extremely rare due to its intrinsic resistance to tuberculous infections. There are reports of gallbladder tuberculosis mimicking cholecystitis or malignancy. However, these presentations were chronic. The diagnosis of gallbladder tuberculosis warrants the need for investigation of additional sites of inoculation and contact tracing of all tuberculosis contacts. Gallbladder tuberculosis is a rare entity but should be suspected in patients from endemic regions with risk factors such as underlying immunosuppression or history of tuberculosis. Case Summary: We present a case of gallbladder tuberculosis presenting as acute cholecystitis. A44-year-old Filipino lady presented with a 11-d history of right hypochondrium and epigastric pain which worsened after meals with no significant past medical history. She underwent laparoscopic cholecystectomy on the presumptive diagnosis of acute cholecystitis and diagnosed as gallbladder tuberculosis after histopathological examination. The patient did not have features of pulmonary or systemic tuberculosis nor was she immunocompromised. She recovered uneventfully. She was subsequently discharged and followed-up at a hospital in her home country due to financial and social reasons. Conclusion: Clinicians should have a high index of suspicion for patients in endemic regions presenting with cholecystitis.Published versio

Sustaining a Multidisciplinary, Single-Institution, Postoperative Mobilization Clinical Practice Improvement Program Following Hepatopancreatobiliary Surgery During the COVID-19 Pandemic: Prospective Cohort Study

BackgroundThe Enhanced Recovery After Surgery (ERAS) protocol has been recently extended to hepatopancreatobiliary (HPB) surgery, with excellent outcomes reported. Early mobilization is an essential facet of the ERAS protocol, but compliance has been reported to be poor. We recently reported our success in a 6-month clinical practice improvement program (CPIP) for early postoperative mobilization. During the COVID-19 pandemic, we experienced reduced staffing and resource availability, which can make CPIP sustainability difficult. ObjectiveWe report outcomes at 1 year following the implementation of our CPIP to improve postoperative mobilization in patients undergoing major HPB surgery during the COVID-19 pandemic. MethodsWe divided our study into 4 phases—phase 1: before CPIP implementation (January to April 2019); phase 2: CPIP implementation (May to September 2019); phase 3: post–CPIP implementation but prior to the COVID-19 pandemic (October 2019 to March 2020); and phase 4: post–CPIP implementation and during the pandemic (April 2020 to September 2020). Major HPB surgery was defined as any surgery on the liver, pancreas, and biliary system with a duration of >2 hours and with an anticipated blood loss of ≥500 ml. Study variables included length of hospital stay, distance ambulated on postoperative day (POD) 2, morbidity, balance measures (incidence of fall and accidental dislodgement of drains), and reasons for failure to achieve targets. Successful mobilization was defined as the ability to sit out of bed for >6 hours on POD 1 and ambulate ≥30 m on POD 2. The target mobilization rate was ≥75%. ResultsA total of 114 patients underwent major HPB surgery from phases 2 to 4 of our study, with 33 (29.0%), 45 (39.5%), and 36 (31.6%) patients in phases 2, 3, and 4, respectively. No baseline patient demographic data were collected for phase 1 (pre–CPIP implementation). The majority of the patients were male (n=79, 69.3%) and underwent hepatic surgery (n=92, 80.7%). A total of 76 (66.7%) patients underwent ON-Q PainBuster insertion intraoperatively. The median mobilization rate was 22% for phase 1, 78% for phases 2 and 3 combined, and 79% for phase 4. The mean pain score was 2.7 (SD 1.0) on POD 1 and 1.8 (SD 1.5) on POD 2. The median length of hospitalization was 6 days (IQR 5-11.8). There were no falls or accidental dislodgement of drains. Six patients (5.3%) had pneumonia, and 21 (18.4%) patients failed to ambulate ≥30 m on POD 2 from phases 2 to 4. The most common reason for failure to achieve the ambulation target was pain (6/21, 28.6%) and lethargy or giddiness (5/21, 23.8%). ConclusionsThis follow-up study demonstrates the sustainability of our CPIP in improving early postoperative mobilization rates following major HPB surgery 1 year after implementation, even during the COVID-19 pandemic. Further large-scale, multi-institutional prospective studies should be conducted to assess compliance and determine its sustainability

Effect of remote ischemic preconditioning on hepatic microcirculation and function in a rat model of hepatic ischemia reperfusion injury

AbstractBackgroundLiver transplantation involves a period of ischemia and reperfusion to the graft which leads to primary non-function and dysfunction of the liver in 5–10% of cases. Remote ischemic preconditioning (RIPC) has been shown to reduce ischemia reperfusion injury (IRI) injury to the liver and increase hepatic blood flow. We hypothesized that RIPC may directly modulate hepatic microcirculation and have investigated this using intravital microscopy.MethodsA rat model of liver IRI was used with 45min of partial hepatic ischemia (70%) followed by 3h of reperfusion. Four groups of animals (Sham, IRI, RIPC+IRI, RIPC+Sham) were studied (n= 6, each group). Intravital microscopy was used to measure red blood cell (RBC) velocity, sinusoidal perfusion, sinusoidal flow and sinusoidal diameter. Neutrophil adhesion was assessed by rhodamine labeling of neutrophils and cell death using propidium iodide.ResultsRIPC reduced the effects of IRI by significantly increasing red blood cell velocity, sinusoidal flow and sinusoidal perfusion along with decreased neutrophil adhesion and cell death.ConclusionsUsing intravital microscopy, this study demonstrates that RIPC modulates hepatic microcirculation to reduce the effects of IRI. HO-1 may have a key role in the modulation of hepatic microcirculation and endothelial function

Bucillamine improves hepatic microcirculation and reduces hepatocellular injury after liver warm ischaemia-reperfusion injury

AbstractBackgroundLiver transplantation and resection surgery involve a period of ischaemia and reperfusion to the liver which initiates an inflammatory cascade resulting in liver and remote organ injury. Bucillamine is a low-molecular-weight thiol antioxidant that is capable of rapidly entering cells.MethodsThe effect of bucillamine was studied in a rat model of liver ischaemia–reperfusion injury with 45min of partial (70%) liver ischaemia and at 3 and 24h of reperfusion. Controls included ischaemia-reperfusion (I/R) only, sham and bucillamine alone (without ischaemia reperfusion). Liver injury was assessed by serum transaminases (AST and ALT). Sinusoidal blood flow and hepatocyte apoptosis were measured using intravital microscopy (IVM).ResultsThe hepatocellular injury of I/R produced a markedly elevated serum AST which was reduced with bucillamine (2072.5 ± 511.79 vs. 932 ± 200.8, P < 0.05) at 3h reperfusion. Bucillamine treatment with I/R also increased parenchymal blood flow [red blood cell (RBC) velocity 242.66 ± 16.86 vs. 181.11 ± 17.59, at the end of 3h of reperfusion) and reduced hepatocyte necrosis/apoptosis at 3h as well as 24h (P > 0.001).ConclusionBucillamine reduces the hepatocellular injury of liver ischaemia reperfusion and improves parenchymal perfusion