Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
Bile duct and vascular injuries that occur during laparoscopic cholecystectomy are the most feared complications of this procedure, and early recognition of difficult anatomy is essential to avoid this morbidity. Once the decision is made to discontinue dissection, laparoscopic subtotal cholecystectomy (LSC) can be substituted as a means to reduce the amount of inflamed tissue and remove gallstones from the gallbladder lumen so that patient symptoms improve.
LSC has typically been described in two forms: reconstituting and fenestrating. The reconstituting procedure consists of resection of the upper portion of the gallbladder (if the fundus area can be safely dissected). After removal of all stones from the remaining gallbladder, the remnant is closed, creating a new, smaller gallbladder. If the fundus cannot be safely dissected from the liver surface, the dorsal portion of the gallbladder wall is left in place. The fenestrated approach leaves the dorsal segment of the gallbladder wall in place and the remnant open; the cystic duct is clipped, ligated, or closed with a suture after removal of all residual gallstones.
The authors emphasized that complications of LSC procedures (biliary fistula, retained stones) usually resolve spontaneously or can be managed with postoperative endoscopic techniques. This article supplies clear descriptions and excellent illustrations of the technical features of all types of LSC. These can be used to increase understanding and improve skills for this important set of procedures.
Pancreatogenic Diabetes after Partial Pancreatectomy
New-onset diabetes mellitus is a well-known complication of partial pancreatectomy. The objective of the study reported in this article was to determine the long-term incidence of this complication, as well as its clinical implications for patients undergoing partial pancreatectomy. The authors used data from a national Medicare database and identified 4,255 patients who had undergone distal pancreatectomy or pancreaticoduodenectomy. Follow-up data were available at a median interval of 10.8 months.
The data analysis showed that new-onset diabetes occurred in 20.3% of patients; the first evidence of diabetes was observed at a median of 3.6 months following the index surgical procedure. Risk factors for new-onset diabetes included male gender, distal pancreatectomy, family history of diabetes, a preoperative diagnosis of pre-diabetes, and pancreatectomy for malignant disease. Rates of hospital readmission and higher healthcare costs were observed in patients who developed postoperative diabetes. The authors recommended that patients be screened for risk factors and educated regarding early diagnosis and effective management of this complication.
In the editorial that accompanied this article, the editorialists noted that postoperative diabetes is included as a subgroup of type 3 diabetes. Other conditions included in this group are diseases of the exocrine pancreas including pancreatitis, pancreatic trauma, and cystic fibrosis. The editorialists emphasized the value of preoperative and postoperative screening as well as patient education. They noted that postoperative diabetes can occur up to 10 years after pancreatectomy, making long-term monitoring an important component of postoperative care for this patient group.
The authors used information from a national database to examine their hypothesis that elderly (age ≥65 years) patients with symptomatic choledocholithiasis who undergo same-admission cholecystectomy would have better outcomes compared with patients treated with endoscopic interventions or no intervention. The patient cohort consisted of 16,121 patients of whom 38.4% underwent same-admission cholecystectomy; endoscopic interventions were used in 37.6% of patients and 24% of patients had no intervention. Comorbidities were assessed and recorded using a standard comorbidity rating scale.
The data analysis showed that hospital readmissions (emergency and planned) and mortality risk were higher in patients treated with endoscopic interventions or no intervention compared with same-admission cholecystectomy. The authors emphasized that the main reason for choosing an endoscopic or nonoperative approach was the perception of high operative risk. Patients who were chosen for same-admission cholecystectomy were, therefore, perceived to be lower-risk patients. The improved outcomes in this patient group may be due in part to the fact that these were healthier patients. Nonetheless, the data suggest that same-admission cholecystectomy is beneficial for elderly patients with choledocholithiasis.
