Publications by authors named "Ahmad H M Nassar"

26 Publications

  • Page 1 of 1

Operative Difficulty, Morbidity and Mortality Are Unrelated to Obesity in Elective or Emergency Laparoscopic Cholecystectomy and Bile Duct Exploration.

J Gastrointest Surg 2022 May 31. Epub 2022 May 31.

Laparoscopic Upper GI and Biliary Service, University Hospital Monklands, Airdrie, Scotland, UK.

Objectives: The challenges posed by laparoscopic cholecystectomy (LC) in obese patients and the methods of overcoming them have been addressed by many studies. However, no objective tool of reporting operative difficulty was used to adjust the outcomes and compare studies. The aim of this study was to establish whether obesity adds to the difficulty of LC and laparoscopic common bile duct exploration (LCBDE) and affects their outcomes on a specialist biliary unit with a high emergency workload.

Methods: A prospectively maintained database of 4699 LCs and LCBDEs performed over 19 years was analysed. Data of patients with body mass index (BMI) ≥ 35, defined as grossly obese, was extracted and compared to a control group.

Results: A total of 683 patients (14.5%) had a mean BMI of 39.9 (35-63), of which 63.4% met the definition of morbidly obese. They had significantly more females and significantly higher ASA II classifications. They had equal proportions of emergency admissions, similar incidence of operative difficulty grades 4 or 5 and no open conversions and were less likely to undergo LCBDE than non-obese patients. There were no significant differences in median operative times, morbidity, readmission or mortality rates.

Conclusions: This study, the first to classify gall stone surgery in obese patients according to operative difficulty grading, showed no difference in complexity when compared to the non-obese. Refining access and closure techniques is key to avoiding difficulties. Index admission surgery for biliary emergencies prevents multiple admissions with potential complications and should not be denied due to obesity.
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http://dx.doi.org/10.1007/s11605-022-05344-7DOI Listing
May 2022

The incidence, operative difficulty and outcomes of staged versus index admission laparoscopic cholecystectomy and bile duct exploration for all comers: a review of 5750 patients.

Surg Endosc 2022 May 4. Epub 2022 May 4.

Laparoscopic Biliary Service, University Hospital Monklands, Monkscourt Avenue, Airdrie, Lanarkshire, ML6 0JS, Scotland, UK.

Background: The timing of laparoscopic cholecystectomy (LC) for emergency biliary admissions remains inconsistent with national and international guidelines. The perception that LC is difficult in acute cholecystitis and the popularity of the two-session approach to pancreatitis and suspected choledocholithiasis result in delayed management.

Methods: Analysis of prospectively maintained data in a unit adopting a policy of "intention to treat" during the index admission. The aim was to study the incidence of previous biliary admissions and compare the operative difficulty, complications and postoperative outcomes with patients who underwent index admission LC.

Results: Of the 5750 LC performed, 20.8% had previous biliary episodes resulting in one admission in 93% and two or more in 7%. Most presented with biliary colic (39.6%) and acute cholecystitis (27.6%). A previous biliary history was associated with increased operative difficulty (p < 0.001), longer operating times (86.9 vs. 68.1 min, p < 0.001), more postoperative complications (7.8% vs. 5.4%, p = 0.002) and longer hospital stay (8.1 vs. 5.5 days, p < 0.001) and presentation to resolution intervals. However, conversion and mortality rates showed no significant differences.

Conclusion: Index admission LC is superior to interval cholecystectomy and should be offered to all patients fit for general anaesthesia regardless of the presenting complaints. Subspecialisation should be encouraged as a major factor in optimising resource utilisation and postoperative outcomes of biliary emergencies.
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http://dx.doi.org/10.1007/s00464-022-09272-0DOI Listing
May 2022

Multi-institutional expert update on the use of laparoscopic bile duct exploration in the management of choledocholithiasis: Lesson learned from 3950 procedures.

J Hepatobiliary Pancreat Sci 2022 Feb 5. Epub 2022 Feb 5.

Department of Upper GI Surgery, London North West University Healthcare, London, UK.

Background: Recently there has been a growing interest in the laparoscopic management of common bile duct stones with gallbladder in situ (LBDE), which is favoring the expansion of this technique. Our study identified the standardization factors of LBDE and its implementation in the single-stage management of choledocholithiasis.

Methods: A retrospective multi-institutional study among 17 centers with proven experience in LBDE was performed. A cross-sectional survey consisting of a semi-structured pretested questionnaire was distributed covering the main aspects on the use of LBDE in the management of choledocholithiasis.

Results: A total of 3950 LBDEs were analyzed. The most frequent indication was jaundice (58.8%). LBDEs were performed after failed ERCP in 15.2%. The most common approach used was the transcystic (63.11%). The overall series failure rate of LBDE was 4% and the median rate for each center was 6% (IQR, 4.5-12.5). Median operative time ranged between 60-120 min (70.6%). Overall morbidity rate was 14.6%, with a postoperative bile leak and complications ≥3a rate of 4.5% and 2.5%, respectively. The operative time decreased with experience (P = .03) and length of hospital stay was longer in the presence of a biliary leak (P = .04). Current training of LBDE was defined as poor or very poor by 82.4%.

Conclusion: Based on this multicenter survey, LBDE is a safe and effective approach when performed by experienced teams. The generalization of LBDE will be based on developing training programs.
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http://dx.doi.org/10.1002/jhbp.1123DOI Listing
February 2022

Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5675 laparoscopic cholecystectomies.

Langenbecks Arch Surg 2022 Feb 26;407(1):213-223. Epub 2021 Aug 26.

NHS Greater Glasgow and Clyde, Glasgow, UK.

Purpose: The main sources of post-cholecystectomy bile leakage (PCBL) not involving major duct injuries are the cystic duct and subvesical/hepatocystic ducts. Of the many studies on the diagnosis and management of PCBL, few addressed measures to avoid this serious complication. The aim of this study was to examine the causes and mechanisms leading to PCBL and to evaluate the effects of specific preventative strategies.

Methods: A prospectively maintained database of 5675 consecutive laparoscopic cholecystectomies was analysed. Risk factors for post-cholecystectomy bile leakage were identified and documented and technical modifications and strategies were adopted to prevent this complication. The incidence, causes and management of patients who suffered bile leaks were studied and their preoperative characteristics, operative data and postoperative outcomes were compared with patients where potential risks were identified and PCBL avoided and with the rest of the series.

Results: Twenty-five patients (0.4%) had PCBL (7 expected and less than half requiring reintervention): 11 from cystic ducts (0.2%), 3 from subvesical ducts (0.05%) and 11 from unconfirmed sources (0.2%). The incidence of cystic duct leakage was significantly lower with ties (0.15%) than with clips (0.7%). Fifty-two percent had difficulty grades IV or V, 36% had empyema or acute cholecystitis and 16% had contracted gallbladders. Twelve patients required 17 reinterventions before PCBL resolved; 7 percutaneous drainage, 6 ERCP and 4 relaparoscopy. The median hospital stay was 17 days with no mortality. Hepatocystic ducts were encountered in 72 patients (1.3%) and were secured with loops (54.2%), ties (25%) or sutures (20.8%) with no PCBL. Eighteen sectoral ducts were identified and secured.

Conclusion: Ligation of the cystic duct reduces the incidence of PCBL resulting from dislodged endoclips. Careful blunt dissection in the proper anatomical planes avoiding direct or thermal injury to subvesical and sectoral ducts and a policy of actively searching for hepatocystic ducts during gallbladder separation to identify and secure them can reduce bile leakage from such ducts.
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http://dx.doi.org/10.1007/s00423-021-02264-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8847250PMC
February 2022

Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients.

Surg Endosc 2022 05 2;36(5):2809-2817. Epub 2021 Jun 2.

University Hospital Monklands, Airdrie, Scotland, ML6 0JS, UK.

Background: Complications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients' quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE.

Methods: A prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined.

Results: Reinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females (p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention (p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths.

Conclusion: This large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications.
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http://dx.doi.org/10.1007/s00464-021-08568-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9001563PMC
May 2022

Laparoscopic Cholecystectomy for Gallbladder Dysfunction and Polyps: Incidence and Follow up.

JSLS 2021 Apr-Jun;25(2)

University Hospital Hairmyres, Lanarkshire, Scotland, UK.

Aim: This study aims to evaluate the incidence, indications, management, and long term follow up of cholecystectomy in patients with no gallstones, other than acalculous acute cholecystitis.

Methods: Prospectively collected data of 5675 patients undergoing laparoscopic cholecystectomy (LC) over 28 years was extracted and analyzed. Patients with biliary symptoms, no stones on ultrasound scans and abnormal hepatobiliary iminodiacetic acid scans, and those with confirmed gallbladder polyps (GBP) were included.

Results: Two percent of cholecystectomies were performed in patients with acalculous pathology [1.3% functional gallbladder disorder (FGBD) and 0.7% GBP]. The 114 patients were younger, had lower American Society of Anesthesiologists classification, and had fewer previous biliary admissions than those with gallstones (5560). The clinical presentations of FGBD were chronic biliary symptoms (93.1%) and acute biliary pain (6.9%). GBP patients presented with chronic biliary symptoms. LC in 98.6% FGBD and 92.8% GBP were significantly easier than those for gall stones (P < 0.0001). They were significantly (P < 0.0001 FGBD and P < 0.001 GBP) less likely to have adhesions to the gallbladder. This ease was reflected in shorter operation times and lower utilization of abdominal drains. Polyp numbers ranged from 1 to 30 and sizes from 1 mm to 11 mm. No malignant polyps were encountered. In 95.8% FGBD and 95% GBP, patients had a good symptomatic response to LC.

Conclusions: FGBD and GBP are uncommon in patients undergoing LC. FGBD should be considered during evaluation of right upper quadrant pain with no gall stones. Laparoscopic cholecystectomy may be considered as it achieves long term symptomatic relief in most patients with FGBD and GBP.
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http://dx.doi.org/10.4293/JSLS.2021.00009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088335PMC
June 2021

Utilisation of Laparoscopic Choledochoscopy During Bile Duct Exploration and Evaluation of the Wiper Blade Manoeuvre for Transcystic Intrahepatic Access.

Ann Surg 2021 Apr 14. Epub 2021 Apr 14.

University Hospital Monklands, Lanarkshire, Scotland, UK NHS Greater Glasgow and Clyde, Glasgow, UK.

Objective: This study aims to examine the indications, techniques and outcomes of choledochoscopy during laparoscopic bile duct exploration and evaluate the results of the Wiper Blade Manoeuvre (WBM) for transcystic intrahepatic choledochoscopy.

Summary Background Data: Choledochoscopy has traditionally been integral to bile duct explorations. However, laparoscopic era studies have reported wide variations in choledochoscopy availability and use, particulary with the increasing role of transcystic exploration.

Methods: The indications, techniques and operative and postoperative data on choledeochoscopy collected prospectively during 1320 transcystic and choledochotomy explorations were analysed. The success rates of the WBM were evaluated for the 3 mm and 5 mm choledochocoscopes.

Results: Of 935 choledochoscopies, 4 were performed during laparoscopic cholecystectomies and 931 during bile duct explorations (70.5%); 486 transcystic choledochoscopies (52%) and 445 through choledochotomies (48%). Transcystic choledochoscopy was utilised more often than blind exploration (55.7%% vs 44.3%) in patients with emergency admissions, jaundice, dilated bile ducts on preoperative imaging, wide cystic ducts and large, numerous or impacted bile duct stones. Intrahepatic choledochoscopy was successful in 70% using the 3 mm scope and 81% with the 5 mm scope. Choledochoscopy was necessary in all 124 explorations for impacted stones. 20 retained stones (2.1%) were encountered but no choledochoscopy related complications.

Conclusions: Choledochoscopy should always be performed during a choledochotomy, particularly with multiple and intrahepatic stones, reducing the incidence of retained stones. Transcystic choledochoscopy was utilised in over 50% of explorations, increasing their rate of success. When attempted, the transcystic Wiper Blade Manoeuvre achieves intrahepatic access in 70-80%. It should be part of the training curriculum.
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http://dx.doi.org/10.1097/SLA.0000000000004912DOI Listing
April 2021

Cystic Lymph Node Identification Is More Reliable Than Critical View of Safety in Difficult Cholecystectomies.

Surg Laparosc Endosc Percutan Tech 2021 Jan 20;31(2):155-159. Epub 2021 Jan 20.

Central Hospital of Leiria, Leiria, Portugal.

Background: The cystic lymph node (CLN) represents an anatomic safety marker and a surrogate marker of technique during laparoscopic cholecystectomy (LC). We aim to demonstrate the value of CLN in comparison to the critical view of safety (CVS) and study the effects of increasing difficulty on the 2 approaches.

Methods: A prospective study of consecutive LC was conducted. Patient demographics, type of admission, clinical presentation, operative difficulty grade, visualization of CLN, identification of CVS, operative time, and complications were recorded and analyzed.

Results: Of 393 LCs, half of the admissions were emergencies. Thirty-four percent had obstructive jaundice or acute cholecystitis. The CLN was visually identified in 81.7% with a small difference between operative difficulty grades 1 to 3 versus 4 to 5. Although CVS was unachievable in 62 patients, 43 (69.4%) still had an identifiable CLN. The median operating time was 68 minutes with 1 mortality but no conversions or intraoperative complications.

Conclusions: Identifying the CLN during LC could compliment the CVS in avoiding major ductal injury. Dissecting lateral to the CLN to commence the process of displaying the cystic pedicle structures may be a strategy in safely achieving the CVS. During the more difficult LC where displaying the CVS is impossible, the CLN may be the key anatomic landmark.
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http://dx.doi.org/10.1097/SLE.0000000000000900DOI Listing
January 2021

Open conversion in laparoscopic cholecystectomy and bile duct exploration: subspecialisation safely reduces the conversion rates.

Surg Endosc 2022 01 2;36(1):550-558. Epub 2021 Feb 2.

Department of Surgery, NHS Greater Glasgow and Clyde, Glasgow, UK.

Background: Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time.

Methods: Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature.

Results: 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%.

Conclusion: Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.
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http://dx.doi.org/10.1007/s00464-021-08316-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8741693PMC
January 2022

Conventional Surgical Management of Bile Duct Stones: A Service Model and Outcomes of 1318 Laparoscopic Explorations.

Ann Surg 2020 Dec 18;Publish Ahead of Print. Epub 2020 Dec 18.

Laparoscopic biliary service, University Hospital Monklands Royal Alexandra Hospital, Paisley, Scotland Forth Valley Royal Hospital, Larbert, Scotland.

Objective: The primary aim of this study was to describe the service model of one session management, with a limited role for preoperative endoscopic clearance. The secondary aim was to review the outcomes and long term follow up in comparison to available studies on LCBDE.

Background: The laparoscopic era brought about a decline in the conventional surgical management of common bile duct stones (CBDS). Preoperative endoscopic removal became the primary method of managing choledocholithiasis. Although laparoscopic common bile duct exploration (LCBDE) deals with gallstones and ductal stones in one session, the limited availability of such an advanced procedure perpetuated the reliance on the endoscopic approach.

Methods: Prospective data was entered into a single surgeon's database containing 5739 laparoscopic cholecystectomy over 28 years and analysed.

Results: 1318 consecutive LCBDE were included (23% of the series). Intraoperative cholangiography (IOC) was performed in 1292 (98.0%). The median age was 60 years, male to female ratio 1:2 and 75% were emergency admissions. Most patients (43.4%) presented with jaundice. 66% had transcystic explorations and one third through a choledochotomy with 2.1% retained stones, 1.2% conversion, 18.7% morbidity and 0.2% mortality. Postoperative ERCPs were needed 3.1%. Recurrent stones occurred in 3%.

Conclusion: One stage LCBDE is a safe and cost effective treatment where the expertise and equipment are available. Endoscopic treatment has a role for specific indications but remains the first line treatment in most units. This study demonstrates that establishing specialist services through training and logistic support can optimise the outcomes of managing CBDS.
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http://dx.doi.org/10.1097/SLA.0000000000004680DOI Listing
December 2020

Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors of failure.

Surg Endosc 2021 11 16;35(11):6039-6047. Epub 2020 Oct 16.

Centro Hospitalar de Leiria, Leiria, Portugal.

Background: Bile duct injury rates for laparoscopic cholecystectomy (LC) remain higher than during open cholecystectomy. The "culture of safety" concept is based on demonstrating the critical view of safety (CVS) and/or correctly interpreting intraoperative cholangiography (IOC). However, the CVS may not always be achievable due to difficult anatomy or pathology. Safety may be enhanced if surgeons assess difficulties objectively, recognise instances where a CVS is unachievable and be familiar with recovery strategies.

Aims And Methods: A prospective study was conducted to evaluate the achievability of the CVS during all consecutive LC performed over four years. The primary aim was to study the association between the inability to obtain the CVS and an objective measure of operative difficulty. The secondary aim was to identify preoperative and operative predictors indicating the use of alternate strategies to complete the operation safely.

Results: The study included 1060 consecutive LC. The median age was 53 years, male to female ratio was 1:2.1 and 54.9% were emergency admissions. CVS was obtained in 84.2%, the majority being difficulty grade I or II (70.7%). Displaying the CVS failed in 167 LC (15.8%): including 55.6% of all difficulty grade IV LC and 92.3% of difficulty grade V. There were no biliary injuries or conversions.

Conclusion: All three components of the critical view of safety could not be demonstrated in one out of 6 consecutive laparoscopic cholecystectomies. Preoperative factors and operative difficulty grading can predict cases where the CVS may not be achievable. Adapting instrument selection and alternate dissection strategies would then need to be considered.
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http://dx.doi.org/10.1007/s00464-020-08093-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8523408PMC
November 2021

Optimising the outcomes of index admission laparoscopic cholecystectomy and bile duct exploration for biliary emergencies: a service model.

Surg Endosc 2021 08 28;35(8):4192-4199. Epub 2020 Aug 28.

Laparoscopic Biliary Service, University Hospital Monklands, Airdrie, Scotland, UK.

Aims: The rate of acute laparoscopic cholecystectomy remains low due to operational constraints. The purpose of this study is to evaluate a service model of index admission cholecystectomy with referral protocols, refined logistics and targeted job planning.

Methods: A prospectively maintained dataset was evaluated to determine the processes of care and outcomes of patients undergoing emergency biliary surgery. The lead author has maintained a 28 years prospective database capturing standard demographic data, intraoperative details including the difficulty of cholecystectomy as well as postoperative outcome parameters and follow up data.

Results: Over five thousand (5555) consecutive laparoscopic cholecystectomies were performed. Only patients undergoing emergency procedures (2399,43.2% of entire group) were analysed for this study. The median age was 52 years with 70% being female. The majority were admitted with biliary pain (34%), obstructive jaundice (26%) and acute cholecystitis (16%). 63% were referred by other surgeons. 80% underwent surgery within 5 days (40% within 24 h). Cholecystectomies were performed on scheduled lists (44%) or dedicated emergency lists (29%). Two thirds had suspected bile duct stones and 38.1% underwent bile duct exploration. The median operating time was 75 min, median hospital stay 7 days, conversion rate 0.8%, morbidity 8.9% and mortality rate 0.2%.

Conclusion: Index admission cholecystectomy for biliary emergencies can have low rates of morbidity and mortality. Timely referral and flexible theatre lists facilitate the service, optimising clinical results, number of biliary episodes, hospital stay and presentation to resolution intervals. Cost benefits and reduced interval readmissions need to be weighed against the length of hospital stay per episode.
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http://dx.doi.org/10.1007/s00464-020-07900-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263394PMC
August 2021

Hartmann's Pouch Stones and Laparoscopic Cholecystectomy: The Challenges and the Solutions.

JSLS 2020 Jul-Sep;24(3)

Department of General Surgery, University Hospital Monklands.

Background & Objective: Hartmann's pouch stones (HPS) encountered during laparoscopic cholecystectomy (LC) may hinder safe dissection of the cystic pedicle or be complicated by mucocele, empyema, or Mirizzi syndrome; distorting the anatomy and increasing the risk of bile duct injury. We studied the incidence, presentations, operative challenges, and outcomes of HPS.

Methods: A cohort study of a prospectively maintained database of LCs and bile duct explorations performed by a single surgeon. Patients were divided into two groups: those with HPS and those without. Patients' demographics, clinical presentation, intra-operative findings, and postoperative outcomes were compared.

Results: Of the 5136 patients, 612 (11.9%) had HPS. The HPS group were more likely to present with acute cholecystitis (27.9% vs 5.9%, = .000) and more patients underwent emergency LC (50.7% vs 41.5%, = .000). The HPS group had more difficult cholecystectomies, with 46.1% vs 11.8% in the non-HPS group being operative difficulty grade 4 and 5. Mucocele, empyema, and Mirizzi syndrome were more common in the HPS group (24.0% vs 3.7% = .000, 30.9% vs 3.7% = .000, 1.8% vs 0.9% = .000, respectively). There was no significant difference in the open conversion rate or complications.

Conclusion: HPS increase the difficulty of LC. Surgeons should be aware of their presence and should employ appropriate dissection strategies. Sharp or diathermy dissection should be avoided. Dislodging the stone into the gall bladder, stone removal, swab dissection, and cholangiography are useful measures to avoid ductal injury and reduce the conversion rate.
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http://dx.doi.org/10.4293/JSLS.2020.00043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7434399PMC
January 2021

One-session laparoscopic management of Mirizzi syndrome: feasible and safe in specialist units.

Surg Endosc 2021 07 6;35(7):3286-3295. Epub 2020 Jul 6.

Faculty of Medicine, Zagazig University, Zagazig, Egypt.

Background: To evaluate the laparoscopic management of Mirizzi syndrome, seldom diagnosed preoperatively causing difficulty when performing cholecystectomy and increasing complication risks.

Methods: Analysis of a prospective single-surgeon database of 5700 laparoscopic cholecystectomies found 58 Mirizzi syndrome cases. They were managed with an intention to treat during the index admission according to protocol of single-session management of bile duct stones.

Results: 38/58 patients were females (65.5%). The median age was 55 years. 53 cases were emergency admissions. 34 cases (58.6%) only had ultrasound scanning. Operative difficulty was Grade IV in 34 cases (58.6%) and Grade V in 20 (34.5%) (Nassar Scale). There were 33 Mirizzi Type IA, 7 Type IB, 16 Type II and one each of Type III and Type IV. Bile duct exploration was performed in 94.8% through choledochotomy/ transfistula in 58.6% or transcystic in 36.2%. Four cases required conversion to open. Postoperative morbidity occurred in 29%. Two 30-day mortalities occurred from pneumonia in two elderly patients who were late referrals.

Conclusion: Although the utilization of the laparoscopic approach in managing bile duct stones is not currently widely practiced it was safer in this series than in reported series of open surgery in Mirizzi Syndrome. The optimal approach to Mirizzi Type II is via cholecystocholedochal fistula to explore the bile duct then drain with T-tube through the fistula. It is unnecessary to perform bilioenteric bypass in majority of cases, reducing the morbidity and mortality.
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http://dx.doi.org/10.1007/s00464-020-07765-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8195921PMC
July 2021

Gall Bladder Empyema: Early Cholecystectomy during the Index Admission Improves Outcomes.

JSLS 2020 Apr-Jun;24(2)

Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom.

Objectives: We aim to evaluate our policy of index admission management of gall bladder empyema and the effect of the timing of surgery on the outcomes.

Methods: We analyzed a series of 5400 laparoscopic cholecystectomies. Data were collected prospectively over 26 y. Patients were divided into two groups: group 1, intervention within 72 h, and group 2, intervention after 72 h of admission. We had a policy of intention to treat during the index admission, but delays sometimes occurred because of late referral, a need to optimize patients, availability of theater time, or the biliary surgeon being on leave. The groups were then compared with regard to the duration of surgery, the difficulty grading, complications, hospital stay, and conversion rate.

Results: A total of 372 patients were included; 160 (43%) operated on within 72 h (group 1) and 212 (57%) after 72 h (group 2). There was no statistically significant difference between the two groups with regard to the operation time, conversion rate, and complications rate. The difference in total hospital stay was, however, statistically significant.

Conclusion: Surgical management of empyema should be offered as soon as possible after admission as with any acute cholecystitis. Surgery carried out after 72 h of admission is only associated with longer hospital stay but no statistically significant differences in other outcome parameters. In the presence of specialist expertise, fitness for surgery should be the determining factor of whether or not to offer surgery to these patients, regardless of the interval since their admission.
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http://dx.doi.org/10.4293/JSLS.2020.00015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7208918PMC
October 2020

Predicting the difficult laparoscopic cholecystectomy: development and validation of a pre-operative risk score using an objective operative difficulty grading system.

Surg Endosc 2020 10 15;34(10):4549-4561. Epub 2019 Nov 15.

Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.

Background: The prediction of a difficult cholecystectomy has traditionally been based on certain pre-operative clinical and imaging factors. Most of the previous literature reported small patient cohorts and have not used an objective measure of operative difficulty. The aim of this study was to develop a pre-operative score to predict difficult cholecystectomy, as defined by a validated intra-operative difficulty grading scale.

Method: Two cohorts from prospectively maintained databases of patients who underwent laparoscopic cholecystectomy were analysed: the CholeS Study (8755 patients) and a single surgeon series (4089 patients). Factors potentially predictive of difficulty were correlated to the Nassar intra-operative difficulty scale. A multivariable binary logistic regression analysis was then used to identify factors that were independently associated with difficult laparoscopic cholecystectomy, defined as operative difficulty grades 3 to 5. The resulting model was then converted to a risk score, and validated on both internal and external datasets.

Result: Increasing age and ASA classification, male gender, diagnosis of CBD stone or cholecystitis, thick-walled gallbladders, CBD dilation, use of pre-operative ERCP and non-elective operations were found to be significant independent predictors of difficult cases. A risk score based on these factors returned an area under the ROC curve of 0.789 (95% CI 0.773-0.806, p < 0.001) on external validation, with 11.0% versus 80.0% of patients classified as low versus high risk having difficult surgeries.

Conclusion: We have developed and validated a pre-operative scoring system that uses easily available pre-operative variables to predict difficult laparoscopic cholecystectomies. This scoring system should assist in patient selection for day case surgery, optimising pre-operative surgical planning (e.g. allocation of the procedure to a suitably trained surgeon) and counselling patients during the consent process. The score could also be used to risk adjust outcomes in future research.
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http://dx.doi.org/10.1007/s00464-019-07244-5DOI Listing
October 2020

Laparoscopic Training Opportunities in an Emergency Biliary Service.

JSLS 2019 Jul-Sep;23(3)

Department of General Surgery, University Hospital Monklands, Airdrie, Lanarkshire, United Kingdom.

Background And Objectives: Optimizing single-session management of biliary emergencies whilst maximizing laparoscopic training opportunities is challenging. We analyzed training opportunities available in an emergency biliary department and its impact on service provision and patient outcomes.

Methods: A single surgeon's practice of 2049 emergency laparoscopic cholecystectomies and common bile duct explorations was prospectively analyzed. Training involved a modular stepwise approach incorporating access, gallbladder bed dissection, pedicle dissection, intra- corporeal tying, and cholangiogram ± common bile duct exploration. Training cases were identified, trainee involvement ascertained, and parameters predictive of a training case were established.

Results: Thirty percent of laparoscopic cholecystectomies were performed in part or completely by trainees, with a training component in 30% of bile duct explorations. Trainee involvement increased mean operating time by approximately 10 minutes. There was no difference in minor (5% vs 5%, = .8) or major complications (1% vs 0.9%, = .7) on trainee versus consultant cases. Postoperative hospital stay was greater in consultant cases (2.87 vs 4.44 days, = .0025).Multivariate analysis identified predictors of trainee cases including lower age (OR, 1.3; 95% CI, 1.1-1.7), female sex (OR, 1.6; 95% CI, 1.3-2), normal-weight subjects (OR, 1.54; 95% CI, 1.3-1.9), lower difficulty grade (1-2) (OR, 1.8; 95% CI, 1.4-2.2), and American Society of Anesthesiologists score ≤ 2 (OR, 1.8; 95% CI, 1.4-2.4).

Conclusions: Surgical training is possible in a singlesession biliary emergency service without significantly impacting theatre utilization times or early patient outcomes. Further dedicated studies will allow individual learning curves to be determined.
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http://dx.doi.org/10.4293/JSLS.2019.00031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6708413PMC
January 2020

Correction to: Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy.

Surg Endosc 2019 Jan;33(1):122-125

Department of Surgery, University Hospital Monklands, Lanarkshire, Scotland, UK.

The list of the CholeS management group, Collaborators and Data Validators were omitted from the Acknowledgments.
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http://dx.doi.org/10.1007/s00464-018-6377-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6828446PMC
January 2019

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy.

Surg Endosc 2019 01 28;33(1):110-121. Epub 2018 Jun 28.

Department of Surgery, University Hospital Monklands, Lanarkshire, Scotland, UK.

Background: A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets.

Methods: Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall's tau for dichotomous variables, or Jonckheere-Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis.

Results: A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001).

Conclusion: We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty.
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http://dx.doi.org/10.1007/s00464-018-6281-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6336748PMC
January 2019

Basket-in-catheter access for transcystic laparoscopic bile duct exploration: technique and results.

Surg Endosc 2016 May 22;30(5):1958-64. Epub 2015 Jul 22.

Monklands Hospital, NHS Lanarkshire, Airdrie, ML6 0JS, Scotland, UK.

Background: When common bile duct (CBD) stones are detected during laparoscopic cholecystectomy, the insertion of baskets via the cystic duct (CD) can be difficult and may occasionally cause complications. We introduced a new technique 'basket in catheter' (BIC) for transcystic CBD exploration.

Methods: Although cannulating the CD using a cholangiography catheter is successful in most cases, it may occasionally be difficult. Cystic duct anatomy may prevent the usually stiffer sharper tip of the basket, from entering the CBD, resulting in failure, perforation or a false passage. In the majority of our cases, the cholangiography catheter (CC) is not withdrawn from the duct should the intraoperative cholangiography show CBD stones. The tip of a basket is inserted into the CC and advanced to a predetermined distance, allowing the tip of the basket to exit the end of the CC into the CBD. The basket is then opened, advanced to feel the lower end and manipulated to trap the stone. The common hepatic duct is compressed gently to prevent stones from slipping upwards. The catheter and basket are pulled back together to extract the stone.

Results: We have used this technique in 274 cases since 2010. The rate of transcystic versus choledochotomy stone extraction has increased, saving unnecessary choledochotomies. The percentage of transcystic exploration increased from 55 % for the period 2005-2009 to 70 % for the period 2010-2014. There were no conversions to open surgery and no retained stones. The morbidity rate was 4.0 % with no mortality.

Conclusions: We demonstrate a technique to facilitate the insertion of extraction baskets into the common bile duct using the cholangiography catheter as a guide. The 'basket-in-catheter' (BIC) technique for transcystic CBD exploration is easier and safer than inserting the basket alone.
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http://dx.doi.org/10.1007/s00464-015-4421-5DOI Listing
May 2016

Fluorocholangiography: reincarnation in the laparoscopic era-evaluation of intra-operative cholangiography in 3635 laparoscopic cholecystectomies.

Surg Endosc 2016 May 21;30(5):1804-11. Epub 2015 Jul 21.

Department of General Surgery, Monklands Hospital, NHS Lanarkshire, Airdrie, Lanarkshire, ML6 0JS, Scotland, UK.

Background: The introduction of laparoscopic cholecystectomy (LC) resulted in the decline of routine intra-operative cholangiography (IOC). Common bile duct stones are being diagnosed preoperatively using magnetic resonance cholangiopancreatography (MRCP). We aim to evaluate the use and benefits of IOC during laparoscopic biliary surgery at a high-volume biliary surgery unit.

Methods: Prospective data from 4088 patients undergoing LC over 22 years were analysed. Referral protocols allow one firm to receive the great majority of biliary emergencies and all suspected ductal stones. All patients with gall stones on ultrasound scanning, fit for surgery, will undergo LC during the index admission. MRCP and ERCP are not part of preoperative investigation. A four-port LC is performed with a size 5Fr ureteric catheter within an open cannula to obtain an IOC through right sub-costal port.

Results: Of 4088 patients, IOC was attempted in 3691 (90.2 %) and 3635 had a successful IOC (98.4 %). 75 % were females. The mean age was 59 years. Patients presented with one or more of the following: chronic biliary pain in 60 %, acute pain 26.7 %, acute cholecystitis 8.4 %, gallstone pancreatitis 7.8 % and jaundice with or without cholangitis in 19.2 %. A total of 1328 patients (36.5 %) had risk factors for CBD stones. The IOC was abnormal in 975 cases (26.8 %), recording 1599 abnormalities. IOC identified 774 patients with CBD stones (21.3 %), including previously unsuspected CBD stones in 4.7 %. IOC was false negative in 20 cases (0.5 %) found to have stones on basket exploration. A decision not to perform IOC in 453 cases (11 %) was made preoperatively in 74.2 % and intra-operatively in 12.3 %.

Conclusion: IOC can be safely and routinely performed in LC. It helps to identify CBD stones, even in patients with no known risk factors, delineate bile duct anatomy and facilitate single-stage management of CBD stones.
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http://dx.doi.org/10.1007/s00464-015-4449-6DOI Listing
May 2016

One-Session Laparoscopic Management of Combined Common Bile Duct and Gallbladder Stones Versus Sequential ERCP Followed by Laparoscopic Cholecystectomy.

J Laparoendosc Adv Surg Tech A 2015 Jun 7;25(6):482-5. Epub 2015 May 7.

2 General Surgery Department, Monklands Hospital , NHS Lanarkshire, Airdrie, Scotland, United Kingdom .

Aim: This study aimed to evaluate the efficacy and safety of laparoscopic management of common bile duct (CBD) stones in a single session in comparison with two-session procedures including endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC). The most popular approach to treat CBD stones that were detected before LC is with ERCP followed by LC. This two-session approach has some disadvantages, which include spontaneous passage of stones found on magnetic resonance cholangiopancreatography while awaiting ERCP, the risk for CBD stone passage between ERCP and LC or during LC due to excessive gallbladder handling, and the need for multiple anesthesia sessions and hospital admissions within a short interval.

Patients And Methods: A prospective outcome analysis was done for 150 patients with CBD stones treated either laparoscopically in a single session with either transcystic exploration (conducted in 23 cases) or CBD exploration (conducted in 46 cases) (Group I included 75 patients) or via two sessions using ERCP followed by cholecystectomy (Group II included 75 patients).

Results: The rate of CBD clearance in Group I was 94.7%, whereas it was 97% in Group II. Group I is superior to Group II with regard to the operative time. There were no significant differences between the two groups regarding conversion to the open procedure, hospital stay, or postoperative complications.

Conclusions: The single-session laparoscopic management of CBD stones is as safe and effective as the gold standard sequential ERCP followed by LC with nearly the same rate of success, hospital stay, and complications.
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http://dx.doi.org/10.1089/lap.2014.0582DOI Listing
June 2015

Intrahepatic choledochoscopy during trans-cystic common bile duct exploration; technique, feasibility and value.

Surg Endosc 2012 Nov 12;26(11):3190-4. Epub 2012 May 12.

Department of Surgery, Monklands Hospital, Airdrie, Lanarkshire, ML6 0JS, Scotland, UK.

Background: Transcystic laparoscopic common bile duct exploration (TC-LCBDE) is advantageous for exploring the bile duct. Choledochoscopy, however, may be quite challenging to perform transcystically because the cystic duct is usually narrow, duct anatomy may be unfavorable, and not all stones are amenable to transcystic extraction. Convention suggests that it is technically very difficult to visualize the intrahepatic bile ducts with transcystic choledochoscopy, due to the angle of insertion of the cystic into the common bile duct (CBD). However, we have performed intrahepatic choledochoscopy successfully, moving the choledochoscope from the CBD into the common hepatic duct by using what we have termed a "wiper blade maneuver". The purpose of this study was to confirm how often this was possible.

Methods: A search of a prospectively collected database of patients undergoing routine intraoperative cholangiography (IOC) and laparoscopic CBD exploration under the care of a single consultant surgeon was performed.

Results: A total of 592 LCBDEs were performed between September 1992 and January 2011; 325 were transcystic explorations. Of these, 72.5 % were female and 56 % were admitted acutely. Exploration and duct clearance was performed by blind Dormia basket trawling in 63 %. The choledochoscope was utilized in 120 cases (37 %). The 3-mm choledochoscope was used in 66 (55 %) and the 5-mm scope in 54 (45 %). Intrahepatic choledochoscopy was performed in 49 patients (40.8 %). Length of surgery was 40-350 min (median 90 min; standard deviation 49 min).

Conclusions: It is technically challenging to perform intrahepatic choledochoscopy with a 3-mm choledochoscope due to its narrow gauge. The more rigid 5-mm scope is thus preferred, but is limited in TCE because its effective use depends on the presence of a dilated cystic duct. Despite the technical limitations of both caliber scopes, we have demonstrated that intrahepatic choledochoscopy during TCE is possible, with each, in 40 % of cases.
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http://dx.doi.org/10.1007/s00464-012-2315-3DOI Listing
November 2012

Laparoscopic transcystic bile duct exploration: the treatment of first choice for common bile duct stones.

Surg Endosc 2010 Jul 1;24(7):1552-6. Epub 2010 Jan 1.

Monklands Hospital, NHS Lanarkshire, Airdrie, ML6 0JS, UK.

Background: This study was designed to explore the role of transcystic bile duct exploration (TCE) as a first line of treatment for patients with suspected or incidental common bile duct (CBD) stones.

Methods: A prospective, case-control study of clinically comparable groups of patients who underwent laparoscopic cholecystectomy (LC) alone (n = 1,854) and combined LC/TCE for CBD stones (n = 253) under the care of one surgeon was performed. Other than ultrasonography, no routine preoperative imaging was used; however, we performed routine intraoperative cholangiography on all patients.

Results: There was no difference in age (49 +/- 15 vs. 57 +/- 19, p = 0.7), sex (79% vs. 82% females, p = 0.6), and ASA grade (1.9 +/- 1 vs. 1.8 +/- 1, p = 0.7). A larger proportion of the TCE group presented as an emergency (TCE 45% vs. LC alone 27%, p = 0.03) and more often presented with acute biliary pain compared with LC alone (27% vs. 13%, p = 0.02). Although a majority of the patients in the TCE group had clinical or biochemical risk factors for CBD stones (86%), only 27% had suspected stones on preoperative ultrasound. The incidence of jaundice (6% vs. 20%, p = 0.01) was lower in the LC alone group compared with TCE patients. Previous abdominal surgery was noted in 34% patients who underwent LC alone and 30% in LC/TCE (p = 0.06). Significantly there was no difference in open conversion between the two groups (LC alone 0.5% vs. LC/TCE 0.6%, p = 0.07). Comparison of selected outcome parameters for LC versus TCE showed a postoperative hospital stay of 2 (1-14) vs. 2 (1-17) days (p = 0.07), presentation to resolution 1 (1-11) vs. 1 (1-11) weeks (p = 0.07), and morbidity 1.07% vs. 1.2% (p = 0.07).

Conclusions: The study advocates single-session laparoscopic cholecystectomy with transcystic CBD exploration as a feasible first choice treatment and the logical next step in the management of patients with CBD stones.
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http://dx.doi.org/10.1007/s00464-009-0809-4DOI Listing
July 2010

Optimising laparoscopic cholangiography time using a simple cannulation technique.

Surg Endosc 2009 Mar 4;23(3):513-7. Epub 2008 Apr 4.

Department of Surgery, Laparoscopic and Upper GI Unit, Monklands Hospital, Airdrie, Lanarkshire, Scotland, UK.

Background: Opponents of the routine use of intraoperative cholangiography (IOC) express concern over its technical difficulty and the length of time it takes.

Aim: To evaluate the impact of our cystic duct cannulation (CDC) technique, as implemented by one consultant and his trainees, on the IOC time.

Methods: IOC is done routinely in all the laparoscopic cholecystectomies (LCs) undertaken in our unit. We carried out a prospective audit over a period of 18 months, recording the IOC time in consecutive patients undergoing laparoscopic cholangiography (LC) with and without laparoscopic common bile duct exploration (LCBDE). The total IOC time was considered to consist of two components: cystic duct cannulation (CDC) time and fluoroscopy time. The IOC time was further analysed according to the difficulty of cannulation and the operator experience. Special consideration was given to the LCBDE cases. We also describe the detailed steps of our CDC technique.

Results: Over a period of 18 months 243 patients underwent LC. IOC was completed in 240 patients (98.8% success rate). Of those, 194 were females (81%). The mean age was 50 years (range 18-85 years). The mean total IOC time was 6 min, with a CDC time of 2 min, and fluoroscopy time of 4 min. On further analysis, CDC was considered easy in 86% of cases with a mean CDC time of 1.5 min and total IOC time of 4.3 min. When cannulation was difficult (14% of cases) a cholangiography clamp had to be used to prevent leakage of contrast. In difficult cases, the CDC and IOC mean times were 5 and 8.5 min, respectively. As would be expected, trainees spent more time performing cannulation and completing the IOC than the specialist surgeon (3.8 versus 1.8 min, and 7.2 versus 5.6 min, respectively). These differences were statistically but not clinically significant. Similarly, the IOC time was also significantly increased in LCBDE (13 min). This was mainly due to an increase in fluoroscopy time (10 min) rather than CDC time (3 min).

Conclusion: The IOC time could be optimised by using a simple and learnable cannulation technique to less than 5 min in most LCs. Surgeons should not, therefore, refrain from using this important investigation on selective or routine basis, subject to their policy for dealing with patients with suspected bile duct stones.
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March 2009
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