Panamerican Journal of Trauma, Critical Care & Emergency Surgery

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2022 | September-December | Volume 11 | Issue 3

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Marc A de Moya

Biliary Disease for the Acute Care Surgeon

[Year:2022] [Month:September-December] [Volume:11] [Number:3] [Pages:1] [Pages No:113 - 113]

   DOI: 10.5005/jp-journals-10030-1404  |  Open Access |  How to cite  | 



Rao R Ivatury

Our Surgical Heritage: The Eponymous Titans of the Biliary Tract in Health and Disease

[Year:2022] [Month:September-December] [Volume:11] [Number:3] [Pages:9] [Pages No:114 - 122]

Keywords: Biliary disorders, Biliary tract anatomy, Biliary tract eponyms, Historical review

   DOI: 10.5005/jp-journals-10030-1396  |  Open Access |  How to cite  | 


Aim: To review the eponyms associated with biliary tract and its diseases. Background: A review of the existing literature. Results: Well-known eponyms related to selected famous innovators in the field of biliary tract anatomy, pathology, and surgery are presented with highlights from their lives. Conclusion: The eponymous greats had a personality matching their discoveries in complexity. Their lives were often tainted by tragedy but lived with valor and resilience.



Chance Nichols, Joshua Dilday, Matthew Martin

Tips and Tricks to Avoiding Iatrogenic Bile Duct Injuries during Cholecystectomy

[Year:2022] [Month:September-December] [Volume:11] [Number:3] [Pages:11] [Pages No:123 - 133]

Keywords: Bailout procedures, Bile duct injury, Cholangiography, Cholecystitis, Critical view of safety, Subtotal cholecystectomy

   DOI: 10.5005/jp-journals-10030-1406  |  Open Access |  How to cite  | 


Aim: The aim of this article was to assess the currently available literature and provide a review of strategies and techniques for surgeons performing laparoscopic cholecystectomy (LC) to minimize the risk of bile duct injury (BDI). Background: Laparoscopic cholecystectomy (LC) is one of the most common general surgical procedures performed worldwide, with BDI being the most dreaded complication. Recently, the concept of a universal culture of safety for performing LC has introduced strategies to mitigate the risk and enhance the prevention of BDI. Review results: The first concept to performing safe LC and minimizing the risk of BDI is the recognition of high-risk patient factors. These include significant patient comorbidities, especially obesity and liver cirrhosis. Other disease-specific factors are related to the duration and severity of cholecystitis which may cause anatomic distortion in the field of dissection. The surgeon's ability to adequately identify normal hepatocystic (HC) triangle anatomy and recognition of anomalous anatomy are other important surgeon factors involved in preventing BDI. The critical view of safety (CVS) is the best anatomic identification method, with other methods leading to error traps, but it does have some limitations, particularly in the setting of severe inflammation prohibiting safe dissection from obtaining a CVS. Visual heuristics resulting in the anatomic misperception of bile duct location and anatomy and, to a lesser degree, surgeon inexperiences are the most frequent causes of BDI. One important surgical technique includes the consistent use of anatomic landmarks. An example is the Rouviere's sulcus (RS)→segment 4→umbilical fissure (R4U) line which establishes a safe zone of dissection and three-dimensional planar considerations to avoid BDI. Another surgical technique involves the liberal use of intraoperative biliary imaging in cases of uncertain anatomy. In cases in which dissection of the HC triangle is extremely difficult or prohibitive, the surgeon should resort to a bailout procedure such as subtotal cholecystectomy (STC) or conversion to open cholecystectomy (OC). Conclusion: Surgeons should understand and adhere to these tenets of safe LC to decrease the incidence of BDI. Clinical significance: The strategies discussed in this review will allow for a more standardized approach to LC and mitigate the risk of BDI.



Dennis Kim, John M Ruddy

Tips and Tricks for the Acute Care Surgeon to Perform Laparoscopic Transcystic Common Bile Duct Exploration

[Year:2022] [Month:September-December] [Volume:11] [Number:3] [Pages:5] [Pages No:134 - 138]

Keywords: Acute care surgery, Biliary, Choledocholithiasis, Laparoscopic cholecystectomy, Laparoscopic common bile duct exploration

   DOI: 10.5005/jp-journals-10030-1405  |  Open Access |  How to cite  | 


Management of emergency general surgery (EGS) patients who present with common bile duct (CBD) stones continues to evolve. Although a two-step approach involving duct clearance via pre- or postoperative endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) has long been the accepted treatment strategy, recent advances in laparo-endoscopic techniques have made single-stage operative management of CBD stones a reality in a select group of EGS patients presenting with choledocholithiasis. In this review article, we outline several key tips and tricks, as well as pitfalls, for acute care surgeons to consider prior to or during the development and implementation of an institutional laparoscopic common bile duct exploration (LCBDE) program.



Michael W Cripps, Nell T Weber

Classification Schemes for Acute Cholecystitis

[Year:2022] [Month:September-December] [Volume:11] [Number:3] [Pages:6] [Pages No:139 - 144]

Keywords: American Association for Surgery of Trauma grade, Cholecystitis, Cholecystitis grading scale, Emergency surgery, Parkland grading scale, Tokyo Guidelines

   DOI: 10.5005/jp-journals-10030-1394  |  Open Access |  How to cite  | 


The impact of the increasing burden of emergency general surgery (EGS) cannot be understated. Each year, millions of patients will present to the hospital with a condition that will require an emergency operation. Over the past 2 decades, there has been a steady increase in this patient volume. Both calculous and acalculous cholecystitis account for 12% of the entire EGS population, making laparoscopic cholecystectomy one of the most commonly performed operations. With increased scrutiny of operating room utilization and postoperative complications, it has become imperative to be able to qualify disease severity and risk-adjust patients in order to accurately compare outcomes. We recognize that not all cholecystitis is created equal, with the spectrum running from minimal to no inflammation in symptomatic cholelithiasis to perforated gangrenous cholecystitis adhered to the duodenum. Such high variance calls for a reliable cholecystitis scoring system to allow the surgical team to properly educate the patient on their risks for complications, prepare for operative time, and appropriately analyze outcomes. This article will review the three predominant scoring systems for acute cholecystitis—the Tokyo grading scale, the American Association for Surgery of Trauma (AAST) grading scale, and the Parkland grading scale (PGS) for cholecystitis to review their development, strengths, and weaknesses.



Erik J Teicher, Paula A Ferrada

The use of Percutaneous Tubes for Management of Acute Cholecystitis

[Year:2022] [Month:September-December] [Volume:11] [Number:3] [Pages:6] [Pages No:145 - 150]

Keywords: Acalculous, Calculous, Cholecystectomy, Cholecystitis, Cholecystostomy, Gallbladder, Gallstones

   DOI: 10.5005/jp-journals-10030-1397  |  Open Access |  How to cite  | 


Percutaneous cholecystostomy (PC) tubes have been used in the management of acute cholecystitis (AC) as an alternative to cholecystectomy for decades. We place the management of AC into a structure based on the Tokyo guidelines. We then generally review the PC tubes and their appropriateness in the treatment of AC. Finally, we provide an algorithm when approaching patients with AC. This is an important topic as it is one of the common problems encountered in acute care surgery. Standardization of the care we provide to these patients can only lead to improved outcomes.



Andrew J Kamien

Laparoscopic-assisted Endoscopic Retrograde Cholangiopancreatogram (ERCP)

[Year:2022] [Month:September-December] [Volume:11] [Number:3] [Pages:5] [Pages No:151 - 155]

Keywords: Altered anatomy, LA-ERCP, Y de Roux.

   DOI: 10.5005/jp-journals-10030-1400  |  Open Access |  How to cite  | 


Objectives: Describe the indications, technique, and success rates for Laparoscopic-assisted Endoscopic Retrograde Cholangiopancreatogram (ERCP). Methods: A review of the literature was performed to describe the common indications for imaging of the biliary system in surgically-altered anatomy. A majority of the data is drawn from experiences in patients with choledocholithiasis following bariatric surgery. Results: Laparoscopic-assisted endoscopic retrograde cholangiopancreatogram (ERCP) has a high technical and therapeutic success rate (98.5–100% and 97.5–99%, respectively). It requires the coordination of both the surgical and endoscopy teams and is associated with long procedural time (134–180 minutes). Complication rate ranges from 0–30% but most of them minor and self-limiting. Conclusion: Laparoscopic-assisted Endoscopic Retrograde Cholangiopancreatogram (ERCP) can be technically and logistically challenging but has a high technical success rate. Complications occur but are seldom of significant clinical consequence.



Elise A Biesboer, Patrick B Murphy

Laparoscopic Common Bile Duct Exploration for the Acute Care Surgeon

[Year:2022] [Month:September-December] [Volume:11] [Number:3] [Pages:7] [Pages No:156 - 162]

Keywords: Choledocholithiasis, Laparoscopic common bile duct exploration, Review article, Transcystic

   DOI: 10.5005/jp-journals-10030-1395  |  Open Access |  How to cite  | 


Aim: To provide the acute care surgeon with an overview, technical description, and discussion of the benefits of laparoscopic common bile duct exploration to promote surgically focused care of gallstone disease. Background: Gallstone disease is one of the most common surgical conditions worldwide. Choledocholithiasis imparts specific management concerns and challenges. Currently, most suspected choledocholithiasis is managed via a two-stage approach by clearing the biliary tree preoperatively, followed by laparoscopic cholecystectomy (LC). Laparoscopic common bile duct exploration (LCBDE) is an attractive, one-stage surgical approach to manage choledocholithiasis; however, it has become a lost skill for modern surgeons. Transcystic (TC) LCBDE has been shown to be as successful as alternative methods and offers a low complication rate and short length of hospital stay. Clinical significance: Although most surgeons do not currently perform LCBDE, surgically focused care of choledocholithiasis promotes improved patient care through a single anesthetic and low complication rate. Surgeons and hospital systems also benefit from increased surgical expertise, shorter length of hospital stay, and potentially decreased costs. Conclusion: Surgeons and systems should focus on shifting the balance toward surgically based care for the management of suspected and confirmed choledocholithiasis. The review focuses on strategies to promote a surgery-first approach to choledocholithiasis.



Riham A Affan, Ahmed W Noureldin, Marcelo AF Ribeiro Jr

Classification and Management of Acute Cholangitis

[Year:2022] [Month:September-December] [Volume:11] [Number:3] [Pages:6] [Pages No:163 - 168]

Keywords: Acute cholangitis, Ascending cholangitis, Biliary drainage

   DOI: 10.5005/jp-journals-10030-1401  |  Open Access |  How to cite  | 


Acute cholangitis (AC) is an urgent medical condition characterized by inflammation of the biliary system due to ascending bacterial infection that carries a high mortality rate. Obstruction precedes infection and is caused by both nonmalignant and malignant etiologies, but most are attributed to biliary stone obstruction or choledocholithiasis. AC is a clinical diagnosis based on patient presentation, laboratory values, and imaging criteria and is further stratified by severity. Treatment involves fluid resuscitation, antibiotics, and biliary drainage following the severity of the presentation. This review article describes the latest updates in the diagnosis, classification, and management of AC, as well as the outcomes of different treatment modalities.



Bryce B Patin, Jacob M Welsch, Christopher S Davis

Evidence-based Guidelines for the Management of Acute Cholecystitis

[Year:2022] [Month:September-December] [Volume:11] [Number:3] [Pages:7] [Pages No:169 - 175]

Keywords: Acute cholecystitis, Cholecystectomy, Evidence-based management, Literature review

   DOI: 10.5005/jp-journals-10030-1398  |  Open Access |  How to cite  | 


Aim: This review aims to highlight the current evidence-based guidelines for acute cholecystitis. Background: Laparoscopic cholecystectomy is the procedure of choice for acute cholecystitis. The severity of cholecystitis and the patient's clinical status is heterogeneous. Many guidelines have been established to guide the preoperative and intraoperative management of acute cholecystitis. We provide an up-to-date appraisal of these guidelines and expert consensus recommendations. Review results: Many preoperative considerations exist, including patient health status/risk stratification, the severity of cholecystitis, choice of antibiotics, etiology of cholecystitis, considerations for gravid mothers, and utilization of cholecystostomy tubes. Intraoperative considerations are similarly paramount, including the surgical approach, adjuncts, and grading of the severity of cholecystitis once in the operating room. Clinical significance: The management of acute cholecystitis should never be viewed as routine, particularly regarding the heterogeneity of the patient's clinical status and severity of the disease process. Adherence to up-to-date, evidence-based, and expert consensus practice is critical to optimal outcomes for these patients.



Mary Bokenkamp, Pedro Teixeira

Use of Transmural Cholecystic Stents for Management of Acute Cholecystitis

[Year:2022] [Month:September-December] [Volume:11] [Number:3] [Pages:5] [Pages No:176 - 180]

Keywords: Acute cholecystitis, Biliary drainage, Stenting.

   DOI: 10.5005/jp-journals-10030-1403  |  Open Access |  How to cite  | 


The management of acute cholecystitis in high-risk surgical patients requires the use of alternative procedures for gallbladder drainage. This has historically been accomplished via percutaneous transhepatic gallbladder drainage (PTGBD). Over the past 20 years, advancements in endoscopy have produced alternative techniques for endoscopic ultrasound-guided gallbladder drainage (EUS-GBD). These drainage options have evolved from endoscopic transpapillary gallbladder drainage (ETPGBD) with an externalized nasocholecystic drain, to transmural gallbladder drainage with internalized stents. The aim of this article is to present a focused review of the current literature on transmural EUS-GBD with cholecystic stent placement for the treatment of acute cholecystitis.



Rao R Ivatury

Beyond Bogota Bag

[Year:2022] [Month:September-December] [Volume:11] [Number:3] [Pages:3] [Pages No:181 - 183]

Keywords: Bogota bag, Damage control surgery, Temporary abdominal closure, Vacuum pack

   DOI: 10.5005/jp-journals-10030-1399  |  Open Access |  How to cite  | 



Diana M Sánchez Parra, Angelica Clavijo, Juan P Ávila, Diana Urrego, Lincoln E Pérez, Andres M Rubiano

Fundamentos Para La Elaboración De Artículos Científicos En Trauma Y Cuidado Agudo De Emergencias (Parte 5-b): Metodología Avanzada Para Análisis Estadístico E Interpretación De Resultados

[Year:2022] [Month:September-December] [Volume:11] [Number:3] [Pages:9] [Pages No:184 - 192]

Keywords: Descriptive statistics, Epidemiology, Statistical analysis, Statistical methods

   DOI: 10.5005/jp-journals-10030-1393  |  Open Access |  How to cite  | 


Introduction: There are gaps in the application of evidence-based medicine in the field of trauma and acute emergency care due to the lack of understanding of the basic and advanced concepts of statistical methodology. This second delivery aims to provide tools to expand the analysis and interpretation of research results in projects related to trauma and emergency systems. Materials and methods: A narrative review was conducted based on a nonsystematic literature search in different databases, including PubMed, Scielo, Scopus, Embase, Web of Science, and Google Scholar. Additional sources of gray literature, such as statistical texts, were also reviewed. Results: As a result of the nonsystematic review of the literature related to the subject, 14 topics of relevance for the analysis and interpretation of results were defined. This second installment includes topics such as linear regression analysis, survival analysis, parameter estimation, meta-analysis statistical methods, software for automated analysis, and critical evaluation of scientific article methodology. Conclusion: Statistics concepts, including linear regression analysis, survival analysis, parameter estimation, statistical methods for meta-analysis, statistical software for automated analysis, and critical analysis of scientific article methodology, are essential for the correct analysis of data in clinical research and evaluating the quality of published articles in trauma surgery and emergency acute care. This knowledge is essential for the interaction between students and mentors during the development of scientific manuscripts in this clinical subspecialty.


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