Background: s/Aims: Assessing surgical difficulty in laparoscopic cholecystectomy (LC) is challenging due to variations in surgeon proficiency and institutional protocols. This study evaluates surgeons’ perspectives on procedural difficulty and examines how intraoperative findings and preoperative imaging contribute to refining difficulty assessment criteria. Methods: A cross-sectional survey was conducted among 50 laparoscopic surgeons in India, providing insights into tolerances for surgical duration and blood loss, reasons for conversion, and predictors of complexity. Responses were analyzed using SPSS, with statistical significance set at p < 0.05. Results: Among surveyed surgeons, 82.0% were male, and 78.0% worked in private institutions and 52.0% had performed over 1,000 LCs. Conversion to open surgery was primarily influenced by significant blood loss (68.0%) and biliary injury (94.0%). While 38.0% preferred surgeries under 60 minutes, 26.0% imposed no time constraints. Key intraoperative challenges included dense adhesions, cholecysto-enteric fistulas, and fibrosis. Less experienced surgeons reported greater challenges with scarring adhesions and anatomical variations, but no significant differences were found for other factors like edematous or necrotic changes. Preoperative imaging was considered essential by most surgeons. Conclusions This study underscores the limited reliability of traditional parameters for assessing difficulty in LC. Surgeons highlighted the importance of objective intraoperative findings and preoperative imaging in predicting surgical challenges. Factors such as adhesions, fibrosis, and anatomical variations significantly impact LC difficulty, with decisions regarding conversion to open surgery largely driven by individual judgment rather than experience. Standardized grading systems incorporating these factors could improve surgical planning, reduce complications, and enhance patient outcomes.

Incidental gallbladder cancer (iGBC) diagnosed post-histopathological examination of gallbladders removed assuming benign gallstone disease constitutes a significant proportion of GBC patients. Most iGBC patients present with early-stage disease. The standard care for localized (non-metastatic) iGBC includes a reoperation for complete extended (radical) cholecystectomy involving liver resection and lymphadenectomy, followed by postoperative adjuvant systemic therapy. However, a major drawback of this approach is the high recurrence rate within six months post-radical surgery, which undermines the benefits of the extensive procedure; notably, most recurrences are distant, highlighting the efficacy of systemic therapy. Similar to other gastrointestinal cancers, there appears to be a potential for neoadjuvant systemic therapy (chemotherapy) before reoperative surgery in iGBC cases. The premise that neoadjuvant systemic therapy aids in selecting diseases with more favorable biological characteristics and addresses micro-metastatic disease appears applicable to iGBC as well. This systematic review examines the current evidence supporting or refuting neoadjuvant therapy and discusses criteria for selecting patients who would derive significant benefit, along with proposing an optimal chemotherapy regimen for iGBC patients. Improved outcomes have been reported in patients undergoing reoperation after 4 to 14 weeks following the initial cholecystectomy compared to immediate reoperation. Limited, yet promising, evidence supports the use of 3 to 4 cycles of gemcitabine-based neoadjuvant chemotherapy prior to reoperative surgery in select high-risk iGBC cases.

Background: s/Aims: Assessing surgical difficulty in laparoscopic cholecystectomy (LC) is challenging due to variations in surgeon proficiency and institutional protocols. This study evaluates surgeons’ perspectives on procedural difficulty and examines how intraoperative findings and preoperative imaging contribute to refining difficulty assessment criteria. Methods: A cross-sectional survey was conducted among 50 laparoscopic surgeons in India, providing insights into tolerances for surgical duration and blood loss, reasons for conversion, and predictors of complexity. Responses were analyzed using SPSS, with statistical significance set at p < 0.05. Results: Among surveyed surgeons, 82.0% were male, and 78.0% worked in private institutions and 52.0% had performed over 1,000 LCs. Conversion to open surgery was primarily influenced by significant blood loss (68.0%) and biliary injury (94.0%). While 38.0% preferred surgeries under 60 minutes, 26.0% imposed no time constraints. Key intraoperative challenges included dense adhesions, cholecysto-enteric fistulas, and fibrosis. Less experienced surgeons reported greater challenges with scarring adhesions and anatomical variations, but no significant differences were found for other factors like edematous or necrotic changes. Preoperative imaging was considered essential by most surgeons. Conclusions This study underscores the limited reliability of traditional parameters for assessing difficulty in LC. Surgeons highlighted the importance of objective intraoperative findings and preoperative imaging in predicting surgical challenges. Factors such as adhesions, fibrosis, and anatomical variations significantly impact LC difficulty, with decisions regarding conversion to open surgery largely driven by individual judgment rather than experience. Standardized grading systems incorporating these factors could improve surgical planning, reduce complications, and enhance patient outcomes.

Incidental gallbladder cancer (iGBC) diagnosed post-histopathological examination of gallbladders removed assuming benign gallstone disease constitutes a significant proportion of GBC patients. Most iGBC patients present with early-stage disease. The standard care for localized (non-metastatic) iGBC includes a reoperation for complete extended (radical) cholecystectomy involving liver resection and lymphadenectomy, followed by postoperative adjuvant systemic therapy. However, a major drawback of this approach is the high recurrence rate within six months post-radical surgery, which undermines the benefits of the extensive procedure; notably, most recurrences are distant, highlighting the efficacy of systemic therapy. Similar to other gastrointestinal cancers, there appears to be a potential for neoadjuvant systemic therapy (chemotherapy) before reoperative surgery in iGBC cases. The premise that neoadjuvant systemic therapy aids in selecting diseases with more favorable biological characteristics and addresses micro-metastatic disease appears applicable to iGBC as well. This systematic review examines the current evidence supporting or refuting neoadjuvant therapy and discusses criteria for selecting patients who would derive significant benefit, along with proposing an optimal chemotherapy regimen for iGBC patients. Improved outcomes have been reported in patients undergoing reoperation after 4 to 14 weeks following the initial cholecystectomy compared to immediate reoperation. Limited, yet promising, evidence supports the use of 3 to 4 cycles of gemcitabine-based neoadjuvant chemotherapy prior to reoperative surgery in select high-risk iGBC cases.

Background: s/Aims: Assessing surgical difficulty in laparoscopic cholecystectomy (LC) is challenging due to variations in surgeon proficiency and institutional protocols. This study evaluates surgeons’ perspectives on procedural difficulty and examines how intraoperative findings and preoperative imaging contribute to refining difficulty assessment criteria. Methods: A cross-sectional survey was conducted among 50 laparoscopic surgeons in India, providing insights into tolerances for surgical duration and blood loss, reasons for conversion, and predictors of complexity. Responses were analyzed using SPSS, with statistical significance set at p < 0.05. Results: Among surveyed surgeons, 82.0% were male, and 78.0% worked in private institutions and 52.0% had performed over 1,000 LCs. Conversion to open surgery was primarily influenced by significant blood loss (68.0%) and biliary injury (94.0%). While 38.0% preferred surgeries under 60 minutes, 26.0% imposed no time constraints. Key intraoperative challenges included dense adhesions, cholecysto-enteric fistulas, and fibrosis. Less experienced surgeons reported greater challenges with scarring adhesions and anatomical variations, but no significant differences were found for other factors like edematous or necrotic changes. Preoperative imaging was considered essential by most surgeons. Conclusions This study underscores the limited reliability of traditional parameters for assessing difficulty in LC. Surgeons highlighted the importance of objective intraoperative findings and preoperative imaging in predicting surgical challenges. Factors such as adhesions, fibrosis, and anatomical variations significantly impact LC difficulty, with decisions regarding conversion to open surgery largely driven by individual judgment rather than experience. Standardized grading systems incorporating these factors could improve surgical planning, reduce complications, and enhance patient outcomes.

Incidental gallbladder cancer (iGBC) diagnosed post-histopathological examination of gallbladders removed assuming benign gallstone disease constitutes a significant proportion of GBC patients. Most iGBC patients present with early-stage disease. The standard care for localized (non-metastatic) iGBC includes a reoperation for complete extended (radical) cholecystectomy involving liver resection and lymphadenectomy, followed by postoperative adjuvant systemic therapy. However, a major drawback of this approach is the high recurrence rate within six months post-radical surgery, which undermines the benefits of the extensive procedure; notably, most recurrences are distant, highlighting the efficacy of systemic therapy. Similar to other gastrointestinal cancers, there appears to be a potential for neoadjuvant systemic therapy (chemotherapy) before reoperative surgery in iGBC cases. The premise that neoadjuvant systemic therapy aids in selecting diseases with more favorable biological characteristics and addresses micro-metastatic disease appears applicable to iGBC as well. This systematic review examines the current evidence supporting or refuting neoadjuvant therapy and discusses criteria for selecting patients who would derive significant benefit, along with proposing an optimal chemotherapy regimen for iGBC patients. Improved outcomes have been reported in patients undergoing reoperation after 4 to 14 weeks following the initial cholecystectomy compared to immediate reoperation. Limited, yet promising, evidence supports the use of 3 to 4 cycles of gemcitabine-based neoadjuvant chemotherapy prior to reoperative surgery in select high-risk iGBC cases.

Introduction: Orthopaedic theatre lists are an important tool which must convey essential information to all staff to run an effective and safe theatre list. However, there are no set standards or guidelines on the components of an Orthopaedic theatre list. The objective of this study is to formulate guidelines for elective Orthopaedic theatre lists which improve efficiency and reduce errors. Materials and methods: We looked at 326 elective Orthopaedic theatre lists from October to November 2018. Various factors such as: theatre and patient demographics, surgical team, type of anaesthesia, Surgery, acronyms and finally extra information such as allergies. Additionally, a survey was distributed to a variety of theatre staff to understand their requirements from a theatre list. Thereafter, we created a proforma for waiting list coordinators. Subsequently, we re-audited six more weeks of theatre lists (255) from November to December 2019. Results: The orthopaedic consultant in charge was noted for 100% of patients compared to 85% previously. There was an improvement in documenting the required anaesthesia such as noting 14.5% required spinal compared to 0.3% previously. Prosthesis/equipment was mentioned for 34% of patients compared to 23%. Fluoroscopy was noted as being required for 25% of patients compared to 11%. Conclusion: We believe standards should be in place in order for us to follow to ensure we carry out safe and efficient Orthopaedic theatre lists, and these standards should entail the parameters we have audited. The ‘William Harvey theatre list standard’ should be used as a gold standard for all elective Orthopaedic theatre lists.

A 13-year-old boy presented with an 8-year history of repeated episodes of anemia. Laboratory investigations confirmed iron deficiency anemia due to occult blood loss from the gastrointestinal tract. Despite undergoing esophagogastroduodenoscopy, colonoscopy, and push enteroscopy, no abnormalities were detected. Subsequent computed tomography enterography also yielded normal results. However, a capsule endoscopy revealed multiple superficial ulcers in the jejunum and proximal ileum. Initially, the patient was treated for Crohn’s disease using various therapeutic approaches, all of which were unsuccessful. Further investigation led to a positive diagnosis for a rare condition known as chronic enteropathy associated with SLCO2A1 mutation (CEAS), marking the first reported case in India.

Bronchobiliary fistula is a very rare entity that presents with bilioptysis. We present a noteworthy case involving a patient with portal cavernoma cholangiopathy complicated by cholangitis and bronchobiliary fistula. The diagnosis was established through high-resolution computed tomography of the thorax and bronchoscopic evaluation. Subsequently, the patient underwent endoscopic retrograde cholangiopancreatography with stenting of the common bile duct. Remarkably, the bronchobiliary fistula resolved 1 month after the procedure.

A 21-year-old man presented with acute onset of jaundice, abdominal pain, ascites, and hepatomegaly, along with a history of Budd-Chiari syndrome previously treated with vena cava angioplasty. Investigations revealed rapidly worsening jaundice, coagulopathy, elevated creatinine levels, reactive hepatitis B serology, and positive antiphospholipid antibodies, with scores indicating a poor prognosis for liver transplant-free survival.Abdominal computed tomography demonstrated a narrowed intrahepatic vena cava and new thrombosis in the right and middle hepatic veins. Renal biopsy, prompted by nephritic range proteinuria, indicated mesangioproliferative glomerulonephritis (MPGN) with immune complex deposition. The described case involves acute-on-chronic liver failure with acute insults from new onset hepatic vein thrombosis and hepatitis B reactivation, in a patient at a non-transplant center, who also had underlying antiphospholipid antibody syndrome, and MPGN. The patient was successfully treated with antiviral, anticoagulation, and antiplatelet agents, along with a sodium-glucose cotransporter 2 inhibitor and a direct intrahepatic portosystemic shunt, despite having a Model for End-Stage Liver Disease score of 35.