Retained calculi in the cystic duct or gall bladder remnant can present as a post-cholecystectomy problem. Increased suspicion is necessary to diagnose this condition in a symptomatic post-cholecystectomy patient. Ultrasonography usually detects this condition, but magnetic resonance cholangiopancreatography is the test of choice for diagnosis as well as for surgical planning. Laparoscopic re-excision of the stump in most cases is feasible and safe. It is increasingly becoming the treatment of choice.

Key Clinical MessageCholedochoduodenal fistula (CDF) is an abnormal communication between the choledochus and the duodenum, accounts for 5–25% of all internal biliary fistulas. Here, we report a case of CDF secondary to chronic duodenal ulcer who presented with cholangitis. CDF is suspected in case of pneumobilia, and surgery is recommended for refractory cases.

Introduction: Most foreign bodies in the G.I tract are asymptomatic and probably pass spontaneously in stool. Few may cause complications and require interventions. Diagnosis can be a challenge in certain cases. We present a case in which the ingestion of a Neem Twig caused duodenal perforation mimicking Acalculous Cholecystitis. Case report: A 63-year-old lady visited emergency with acute abdominal pain of 2 day history. Computed tomography (CT) showed mildly thickened Gall bladder with loculated pericholecystic fluid collection which is extending into subcapsular region of segment III of liver. A Laparoscopic Cholecystectomy was planned in view of Acalculous cholecystitis. Intraoperative, an Omental phlegmon guarding a Neem (Azadirachta indica) twig which perforated out of duodenum was found. Laparoscopy was converted to an open midline Laparotomy and graham's Omental patch repair of duodenum perforation was done. Conclusion: The patient has been doing well since the operation. She gave history of swallowing the Neem Twig 6 Months prior to this surgery. Many a times open surgical approach would give a satisfactory search rather than Laparoscopy.

Background: Laparoscopic cholecystectomy is considered "gold standard" for the treatment of gallstone disease. In spite of the increasing number of laparoscopic cholecystectomies being performed as day care surgery in the West, the surgeons of developing countries are reluctant to adopt this trend probably due to the inadequate resources and infrastructure which they consider a hindrance for safe discharge. Our study aims to assess the feasibility of day care laparoscopic cholecystectomies. Materials and methods: This is a prospective observational study. All patients undergoing laparoscopic cholecystectomy were assessed postoperatively for dischargeability using post-anesthetic discharge scoring system (PADSS). We assessed the factors delaying the early discharge of laparoscopic cholecystectomy patients in terms of patient factors, intraoperative factors, postoperative factors, social factors, and logistic factors. Results: Of the total 88 patients, 57 (64.7%) were dischargeable at 6 hours and 78 (88.6%) were dischargeable at 24 hours. Factors found to affect dischargeability of patients at 6 hours were acute cholecystitis and increased duration of surgery. Difficulty of surgery and the use of drain had significant association with nondischargeability at 24 hours. Eighteen patients were fit for discharge by PADSS criteria but not discharged at 24 hours. Factors, which delayed the discharge of these patients, were continuation of intravenous antibiotics, delay in processing insurance, patients' unwillingness for early discharge, presence of drain, and surgeon's perceived fear of complications. Conclusion: Sixty-five percent of all laparoscopic cholecystectomies can be performed as day care procedure safely. Patients with acute cholecystitis and patients requiring an operative time more than 104 minutes should be observed for 24 hours.