Surgical treatment of gallstones

The difficult laparoscopic cholecystectomy: a narrative review

BACKGROUND/PURPOSE

Laparoscopic cholecystectomy is one of the most commonly performed general surgical procedures. Difficult laparoscopic cholecystectomy is associated with increased operative time, hospital stay, complication rates, open conversion, treatment costs, and mortality. This study aimed to provide a comprehensive literature review on difficult laparoscopic cholecystectomy.

METHODS

A literature search was conducted for articles published in English up to June 2024 using common databases including PubMed/MIDLINE, Web of Science, Google Scholar, and ScienceDirect. Keywords included "safe laparoscopic cholecystectomy", "difficult laparoscopic cholecystectomy", "acute cholecystitis", "prevention of bile duct injuries", "intraoperative cholangiography," "bailout procedure," and "subtotal cholecystectomy". Only clinical trials, systematic reviews/meta-analyses, and review articles were included. Studies involving children, robotic cholecystectomy, single incision laparoscopic cholecystectomy, open cholecystectomy, and cholecystectomy for indications other than gallstone disease were excluded.

RESULTS/DISCUSSION

Emergency laparoscopic cholecystectomy for acute cholecystitis is ideally performed within 72 h of symptom onset, with a maximum window of 7-10 days. Intraoperative cholangiography can help clarify unclear biliary anatomy and detect bile duct injuries. In the "impossible gallbladder", laparoscopic cholecystostomy or gallbladder aspiration may be considered. When dissection of Calot's triangle is deemed hazardous or impossible, the fundus-first approach allows for completion of the procedure with either total cholecystectomy or subtotal cholecystectomy. Subtotal cholecystectomy is effective in preventing bile duct injuries, can be performed laparoscopically, and is currently the best available bailout approach for difficult laparoscopic cholecystectomy.

CONCLUSION

Difficult laparoscopic cholecystectomy is a common clinical scenario that requires a judicious approach by experienced surgeons in appropriate settings. When difficult laparoscopic cholecystectomy is encountered, various bailout strategies are available. Currently, subtotal cholecystectomy is likely the most effective bailout approach.

The Effects of Pranayama and Deep Breathing Exercises on Pain and Sleep Quality After Laparoscopic Cholecystectomy

The purpose of the present research is to determine the effects of pranayama and deep breathing exercises applied to patients after laparoscopic cholecystectomy on shoulder pain and sleep quality. The research was conducted at the General Surgery Clinics of the University of Health Sciences, Van Training and Research Hospital between March 2023 and June 2024. The study was carried out using a pretest-posttest control group randomized controlled experimental trial design. A total of 66 patients (22 in the pranayama group, 22 in the deep breathing group, and 22 in the control group) were included in the study. The research data were collected using the "Patient Descriptive Form," "Visual Analog Scale," and "Richard-Campbell Sleep Scale." The three groups had similar mean preoperative pain and sleep scores (p > 0.05). Mean pain scores were lower in the pranayama and deep breathing groups than in the control group after the exercise at the 6th, 12th, and 24th postoperative hours and discharge (p < 0.05). Deep breathing exercises were revealed to decrease postoperative pain more effectively than pranayama breathing exercises. Considering sleep scores, the pranayama and deep breathing groups had higher mean sleep scores in comparison with the control group (p < 0.05). Trail Registration: This study was registered in the ClinicalTrials.gov database as (NCT06495411) Protocol Registration and Result System. This study was conducted as a master thesis.

Cracking the silent gallstone code: Wait or operate?

The widespread availability of abdominal ultrasound has revealed the common occurrence of asymptomatic gallstones. While the treatment for symptomatic gallstones is clear, the benefits of minimally invasive laparoscopic cholecystectomy have sparked debate about the best approach to managing silent gallstones. The potential for asymptomatic gallstones to become symptomatic or lead to complications complicates the decision-making process regarding surgical intervention, as it's uncertain when or which patients might develop complications. Consequently, risk stratification appears to play a critical role in guiding decisions about silent gallstones. However, there is no definitive evidence to direct management, and a consensus-based on high-quality evidence is yet to be established.

THYROID FUNCTION ABNORMALITIES IN PATIENTS WITH CHOLELITHIASIS: A HOSPITAL-BASED CROSS-SECTIONAL STUDY

Objective: The objective of the study is to analyze the association between thyroid function abnormalities and cholelithiasis, focusing on the prevalence and types of thyroid dysfunctions in patients with gallstone disease compared to a healthy control group. Methods: A comparative, hospital-based cross-sectional study was conducted in the department of general surgery at a tertiary care medical college. The study included 60 patients diagnosed with cholelithiasis (Group A) and 60 age-matched healthy individuals (Group B). Detailed history, physical examinations, ultrasound imaging, and thyroid function tests (TFTs) were performed. TFTs included measurements of free triiodothyronine (FT3), free thyroxine (FT4), and thyroid-stimulating hormone. Patients were categorized based on thyroid status into euthyroid, subclinical and clinical hypothyroidism, and hyperthyroidism. Statistical analysis was performed using SPSS version 21.0, with significance set at p<0.05. Results: The study revealed a female preponderance in cholelithiasis cases (76.67% in Group A vs. 65.00% in Group B). The mean age and BMI were comparable between the groups. Thyroid function abnormalities were more prevalent in the cholelithiasis group (p=0.0251), with a higher incidence of hypothyroidism compared to the control group. Subclinical hypothyroidism was the most common thyroid dysfunction in cholelithiasis patients. Common complaints in the cholelithiasis group included anemia, menstrual irregularities, skin changes, and weakness. Conclusion: The study demonstrates a significant association between cholelithiasis and thyroid function abnormalities, particularly hypothyroidism. The findings suggest the need for routine thyroid function evaluation in patients with cholelithiasis, which could influence management strategies and improve patient outcomes.

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

Transgastric versus transrectal: Which access route is the best for NOTES gallbladder-preserving gallstone therapy?

OBJECTIVES

To compare the effectiveness and safety of transgastric and transrectal pure natural orifice transluminal endoscopic surgery (NOTES) for cholecystolithotomy.

METHODS

This was a single-center retrospective comparative study of consecutive patients who underwent pure NOTES for either transrectal or transgastric gallbladder-preserving cholecystolithotomy between September 2017 and April 2020. Patients with symptomatic cholelithiasis were assigned for transrectal or transgastric NOTES based on the patients' choice. Treatment success, postoperative pain, peritonitis, time to resume normal diet, and duration of hospitalization were compared.

RESULTS

The technical success rate was 100%. Forty-eight patients underwent successful NOTES cholecystolithotomy via the transrectal (n = 26) or transgastric route (n = 22). One (3.8%) patient in the transrectal NOTES group experienced postoperative abdominal pain compared to 6 (27.3%) in the transgastric NOTES group (P = 0.04). Fever and bile peritonitis developed in one (3.8%) patient in the transrectal NOTES group versus 8 (36.4%) in the transgastric NOTES group (P = 0.005). A postoperative fluid diet was commenced at 6 h with the transrectal approach versus on day 3 for the transgastric NOTES group. The mean postoperative hospitalization for transrectal and transgastric NOTES groups was 4.5 days versus 7 days (P = 0.001). Three patients in the transgastric NOTES group developed postoperative gastric fistula.

CONCLUSIONS

Transrectal NOTES has advantages over transgastric NOTES, including preserved spatial orientation, relatively easier removal of specimens, early food intake, shorter hospitalization, fewer postoperative complications and less pain. Multicenter clinical trials with long-term follow-up are needed to confirm the safety and efficacy of both approaches.

The Effects of Breathing Exercises on Patients Having Laparoscopic Cholecystectomy Surgery

The aim of the study is to determine the effect of breathing exercises on patients who underwent laparoscopic cholecystectomy in terms of their level of anxiety, sleep, and recovery of quality after surgery. A randomized, controlled experimental research model was used in this work. This study was conducted in surgery clinic of a university hospital between December 2020 and May 2021. The research was completed with 58 patients in the experimental group and 57 patients in the control group. The mean Visual Analog Sleep Scale and state anxiety score of the patients in the control group was higher in the morning of the operation and on the 1st, 15th, and 30th days after the operation than that of the experimental group patients, and the difference was statistically significant (p < .05). The correlations between recovery quality, state anxiety, and sleep quality on the first postoperative day were significant at (p < .05) in the opposite direction.

The effects of acupressure on postoperative nausea and vomiting among patients undergoing laparoscopic surgery: A meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

Laparoscopic surgery is one of the most commonly performed surgeries in general surgery, with fewer side effects and rapid recovery. Postoperative nausea and vomiting (PONV) remains the main challenge that confronts the prognosis of this minimally invasive surgery. We aimed to evaluate the effect of acupressure, a nonpharmacological non-invasive method, on the incidence of nausea and vomiting following laparoscopic surgery within the early phase (first six hours postoperatively) and the extended phase (for at least 24 h postoperatively).

METHODS

We searched PubMed, Cochran, Scopus, Web of Science, Google scholar, and Wiley for randomized controlled trials that evaluated the effect of acupressure on PONV in patients undergoing laparoscopy. Data were extracted and analyzed in a random model, and pooled risk ratios (RRs) with their respective 95% confidence intervals (CIs) were calculated.

RESULTS

Eleven trials were included in the meta-analysis, comprising 941 patients. Most of the included patients were females undergoing gynecological laparoscopy or laparoscopic cholecystectomy. Acupressure significantly lowered the incidence of nausea and vomiting, within the early phase (RR = 0.62, 95% CI [0.44 to 0.88]; p = 0.008), (RR = 0.5, 95% CI [0.30 to 0.84]; p = 0.008), and the extended phase (RR = 0.65, 95% CI [0.52 to 0.83]; p = 0.0003), (RR = 0.44, 95% CI [0.32 to 0.61]; p < 0.00001), respectively. Moreover, acupressure significantly reduced the need for rescue antiemetic drugs in both phases (p < 0.05).

CONCLUSION

Acupressure is an effective procedure for reducing nausea, vomiting, and the need for antiemetic drugs after laparoscopic surgery.

Which octogenarian patients are at higher risk after cholecystectomy for symptomatic gallstone disease? A single center cohort study

BACKGROUND

Incidence of gallstones in those aged ≥ 80 years is as high as 38%-53%. The decision-making process to select those oldest old patients who could benefit from cholecystectomy is challenging.

AIM

To assess the risk of morbidity of the “oldest-old” patients treated with cholecystectomy in order to provide useful data that could help surgeons in the decision-making process leading to surgery in this population.

METHODS

A retrospective study was conducted between 2010 and 2019. Perioperative variables were collected and compared between patients who had postoperative complications. A model was created and tested to predict severe postoperative morbidity.

RESULTS

The 269 patients were included in the study (193 complicated). The 9.7% of complications were grade 3 or 4 according to the Clavien-Dindo classification. Bilirubin levels were lower in patients who did not have any postoperative complications. American Society of Anesthesiologists scale 4 patients, performing a choledocholithotomy and bilirubin levels were associated with Clavien-Dindo > 2 complications (P < 0.001). The decision curve analysis showed that the proposed model had a higher net benefit than the treating all/none options between threshold probabilities of 11% and 32% of developing a severe complication.

CONCLUSION

Patients with American Society of Anesthesiologists scale 4, higher level of bilirubin and need of choledocholithotomy are at the highest risk of a severely complicated postoperative course. Alternative endoscopic or percutaneous treatments should be considered in this subgroup of octogenarians.

Biliary stents are forgotten more frequently in elderly patients

Background/aim

Plastic biliary stents that remain in situ for more than 12 months, called forgotten biliary stents (FBSs), can cause complications such as cholangitis, stent migration, stent occlusion, and perforation.

Materials and methods

The medical records of patients who underwent ERCP procedures from December 2016 to December 2020 were analysed retrospectively. Data on patient characteristics, indications for ERCP and stenting, stent types, stenting duration, complications, and causes of FBSs were obtained from the hospital’s database.

Results

A total of 48 cases with FBSs were analysed. The mean age (SD) of the patients was 71.23 years (±12.165), the male-to-female ratio was 23/25 (0.92), and the mean stenting duration was 27.12 months (range: 12–84 months). The most common indication for biliary stenting was irretrievable choledochal stones (40/48). Stone formation (79%) and proximal stent migration (26.4%) were the most frequent complications. The patients in the FBS group were significantly older than those from whom stents were removed in a timely manner (71.23 vs. 62.43 years, p < 0.001). Endoscopic treatment was possible in all cases; surgery was not required in any case. The most common cause of FBSs cited by patients was not having been informed about the need for long-term management of their stents (n = 14, 29.2%)

Conclusion

FBSs are potentially problematic particularly in elderly patients. Communication with the patient to remind them of the need for stent management is important for preventing FBSs.

Open Cholecystostomy Under Local Anesthesia for Acute Cholecystitis in the Elderly and High-Risk Surgical Patients

BACKGROUND

The morbidity and mortality rates associated with cholecystectomy for acute cholecystitis are higher in the critically ill elderly population. As an alternative to cholecystectomy, we report the results of treatment of acute cholecystitis in the elderly after open cholecystolithotomy with cholecystostomy tube placement under local anesthesia.

METHODS

A case series was performed on 5 patients from August 2007 to April 2010 who presented with acute cholecystitis and underwent an open cholecystolithotomy and tube placement. Thirty-day mortality, intra- and immediate-postoperative complications, clinical improvement after drainage, additional biliary procedures needed, and outcome after cholecystostomy tube removal were recorded.

RESULTS

Open cholecystolithotomy and tube placement were performed successfully in all patients and permitted resolution of the acute attack in all after a mean period of 3.75 days. Thirty-day mortality was 0%. Patients did not experience any intraoperative complications. We observed 100% rate of successful short-term outcomes in our patients including resolution pain, and objectively, normalization of leukocytosis, and defervescence. None of the patients required emergency cholecystectomy. All patients had their cholecystostomy tubes removed at a mean postoperative day 27. There were no cases of biliary leakage or tube dislodgement. There were no recurrences of acute cholecystitis within the mean follow-up of 20.75 months.

DISCUSSION

Emergency open cholecystolithotomy and cholecystostomy tube placement represent an effective, safe, and definitive alternative treatment strategy for acute gallstone cholecystitis in selected elderly patients with a mortality rate of 0% in the authors' experience.

Endoscopic Ultrasound-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography for Removal of Cystic Duct Coils: A Novel Application of an Emerging Technique

The altered anatomy of patients after Roux-en-Y gastric bypass (RYGB) surgery creates technical challenges for endoscopic and surgical treatment of gallstones. We present a unique case of a post-RYGB patient with complicated gallbladder surgery requiring coiling and embolization of the cystic duct for bile leak. The cystic duct coils migrated out into the bile duct forming a nidus for infection and biliary obstruction, which was resolved using the novel endoscopic ultrasound–directed transgastric routine endoscopic retrograde cholangiopancreatography technique, with successful transpapillary removal of cystic duct coils in RYGB anatomy.

The effect on gastrointestinal system functions, pain and anxiety of acupressure applied following laparoscopic cholecystectomy operation: A randomised, placebo-controlled study

The aim of this randomised, placebo-controlled, 3-way blinded study was to determine the effect on GIS symptoms, pain and anxiety of acupressure applied for a total of 12 min, as 3 min at each of the ST25, CV12, TH6, and HT7 acupuncture points, at 0, 4 and 8 h after laparoscopic cholecystectomy operation. The research data were collected using a patient data collection form, the Numeric Pain Intensity Scale and the State-Trait Anxiety Inventory. The patients were evaluated in respect of the time to first flatus and defecation, pain and the State-Trait Anxiety points at 0, 4, and 8 h postoperatively. The application of acupressure was determined to have signficantly reduced acute postoperative pain and shortened the time to defecation (p < 0.05). The application of acupressure can be recommended in the nursing interventions following laparoscopic cholecystectomy to reduce acute pain and shorten the time to defecation.

Clinical practice guidelines for the management of biliary tract cancers 2019: The 3rd English edition

BACKGROUND

The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014.

METHODS

In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence-based approach. Recommendations were graded as Grade 1 (strong) or Grade 2 (weak) according to the concepts of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

The 31 CQs covered the six topics: (a) prophylactic treatment, (b) diagnosis, (c) biliary drainage, (d) surgical treatment, (e) chemotherapy, and (f) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded.

CONCLUSIONS

This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence.

Association of gallbladder hyperkinesia with acalculous chronic cholecystitis: A case-control study

BACKGROUND

This is the first case-control study investigating an association between gallbladder hyperkinesia and symptomatic acalculous chronic cholecystitis.

METHODS

This retrospective study in a single academic center compared resolution of biliary pain in adults with gallbladder hyperkinesia, defined as a hepatobiliary iminodiacetic acid scan ejection fraction ≥80%, undergoing cholecystectomy (study group) with those treated medically without cholecystectomy (control group). Of 1,477 hepatobiliary iminodiacetic acid scans done between 2013 and 2018, a total of 296 adults without gallstones had an ejection fraction ≥80%, of whom 46 patients met predetermined eligibility criteria. Demographic data, hepatobiliary iminodiacetic acid scan ejection fraction, chronicity of pain, and resolution of pain were compared between groups.

RESULTS

Demographics (mean ± standard deviation) in the control group (n = 25) and in the study group (n = 21) were, respectively, age 40 y ± 16 y and 39 y ± 14 y, body mass index 28.9 ± 5.2 and 29.1 ± 7.1 kg/m², with 15 (60%) and 18 (86%) females in each. Resolution of pain after cholecystectomy occurred in 18 of 21 patients (86%); however, pain persisted in 20 of 25 patients (80%) treated medically after mean follow-up of 36 ± 28 months (range 10-120 months) (P < .01). Pain resolution with cholecystectomy was independent of demographic variables, hepatobiliary iminodiacetic acid scan ejection fraction, and chronicity of pain. The odds of pain resolution was 19.7 times greater with cholecystectomy than without (odds ratio, 19.7; 95% confidence interval, 4.34, 89.43; P < .01), and remained robust even with the odds adjusted for each covariate. Gallbladder histopathology confirmed chronic cholecystitis in all 21 cholecystectomy specimens.

CONCLUSION

Symptomatic gallbladder hyperkinesia could be a new indication for cholecystectomy in adults.

Contemporary Experience with Cholecystectomy: Establishing ‘Benchmarks’ Two Decades after the Introduction of Laparoscopic Cholecystectomy

With quality and public reporting of increasing importance, benchmarks are anticipated to grow in relevance. We studied cholecystectomy in a practice in an urban tertiary care hospital. A total of 1083 cholecystectomies were performed in 2008 and 2009. Laparoscopic cholecystectomy was performed in 97.8 per cent of patients with a 2.2 per cent conversion rate. A planned open procedure was performed in only 2.2 per cent of patients. Approximately half of procedures were urgent and performed during an acute hospitalization. Most patients (74%) were female and most patients were overweight or obese (64.8%). Ages into the tenth decade of life were represented. Comorbidities included hypertension, 28.7 per cent; coronary disease, 15.6 per cent; diabetes mellitus, 13.4 per cent; gastroesophageal reflux disease, 10.7 per cent; and asthma, 5.5 per cent. Of female patients, 98 (12.2%) were postpartum and five (0.6%) were pregnant. Of 137 patients without gallstones, 59.1 per cent had biliary dyskinesia and 27 per cent had acalculous cholecystitis. Preoperative magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) were performed in most patients with suspected choledocholithiasis. Intraoperative cholangiograms were performed in 6.9 per cent of patients, 3.3 per cent for abnormal liver function studies. Postoperative ERCP was used in most patients with positive intraoperative cholangiograms. All-cause mortality was 0.8 per cent and attributable mortality was 0.2 per cent. Complications occurred in 7.5 per cent of patients, including retained common bile duct stones in 1.1 per cent, bile duct leak in 0.3 per cent, and common bile duct injury in 0.1 per cent.

Selective Trans-Catheter Coil Embolization of Cystic Duct Stump in Post-Cholecystectomy Bile Leak

BACKGROUND

Percutaneous drainage is a first-line treatment for bilomas developed post-cholecystectomy in the setting of bile leak from the cystic duct stump. Percutaneous drainage is usually followed by surgical or endoscopic treatment to address the leak.

AIMS

This study aimed to evaluate outcome of selective coil embolization of the cystic duct stump via the percutaneously placed drainage catheters in patients with post-cholecystectomy bile leak.

METHODS

Seven patients with persistent bile leak after laparoscopic cholecystectomy who underwent percutaneous catheter placement for biloma/abscess formation in the region of the gallbladder fossa were followed. These patients underwent selective trans-catheter cystic duct stump coil embolization from Feb 2013 to Feb 2019. Procedural management, complications, and success rates were analyzed.

RESULTS

All patients underwent placement of a percutaneous catheter for drainage of biloma formation in the gallbladder fossa post-cholecystectomy. Selective coil embolization of the cystic duct was performed through the existing percutaneous tract on average 3.5 weeks after percutaneous catheter placement, resulting in resolution of the biloma. All bile leaks were immediately closed. None of the patients showed recurrent bile leak or further clinical symptoms. Coil migration to the common bile duct was diagnosed in a single case, after 2.5 years, with no bile leak reported.

CONCLUSIONS

Selective trans-catheter coil embolization of the cystic stump is a feasible and safe procedure, which successfully seals leaking cystic duct stumps and can circumvent the need for repeat surgical or endoscopic intervention in selected patient populations.

A comparative study on the prophylactic effects of paracetamol and dexmedetomidine for controlling hemodynamics during surgery and postoperative pain in patients with laparoscopic cholecystectomy

BACKGROUND

Today, the ever-expanding technology is inevitably shadowing on all aspects of human life. This study was aimed to compare the prophylactic effects of paracetamol and dexmedetomidine for controlling hemodynamics during surgery and postoperative pain.

METHODS

The study population consisted of 132 patients aged 18 to 70 years and from both genders, who were candidates for emergency cholecystectomy or elective surgery. Group A consisted of 66 patients who received dexmedetomidine, and Group B included 66 patients with paracetamol administration. The amount of postoperative pain was measured on the basis of visual analog scale, arterial blood pressure, as well as heart rate at recovery and 4, 12, and 24 hours after surgery.

RESULTS

The mean age in the 2 groups was similar and almost equal to 52 years; there was no difference in the sex ratios in both groups (P > .05). Pain score in the paracetamol group was significantly lower than that in the dexmedetomidine group (P = .04); nevertheless, there were no group differences in the mean scores of pain during these hours (P > .05). The median opioid use in 24 hours after operation in the paracetamol group was lower when compared with that in the dexmedetomidine group, and the mean duration of analgesia in the paracetamol group was higher when comparing with dexmedetomidine group. Furthermore, in both groups, mean arterial pressure and preoperative PR interval were similar at various times.

CONCLUSION

The findings demonstrated that both regimens of drugs can control the hemodynamic status of patients during laparoscopic cholecystectomy, which provides effective postoperative analgesia for pain management.

Inpatient Choledocholithiasis Requiring ERCP and Cholecystectomy: Outcomes of a Combined Single Inpatient Procedure Versus Separate-Session Procedures

OBJECTIVES

Separate-session endoscopic retrograde cholangiography (ERCP) and laparoscopic cholecystectomy (LC) is the usual method for management of inpatient choledocholithiasis. Our goal was to compare single operative-session LC and ERCP to a multi-session approach for both the same hospitalization and within 30 days after; there is limited data comparing the three groups.

METHODS

A retrospective review on inpatients with choledocholithiasis that underwent ERCP and LC was performed. Single operative-session ERCP + LC (SOS group) and separate hospitalization ERCP + LC (DH group) were compared against the control cohort: separate-session ERCP + LC performed during the same hospitalization (SH group).

RESULTS

Among the 214 cases, 37 (17%) had LC + ERCP performed under a single operative session (SOS), 130 (60.7%) cases had LC + ERCP performed in separate operative sessions during the same hospitalization (SH), and 47 (22%) cases had LC + ERCP performed in different hospitalizations, within 30 days (DH). There was no statistically significant difference in efficacy or adverse events. The SOS group had a statistically significant mean shorter length of hospital stay as compared to the SH and DH groups (5.46 vs 7.15 vs 9.38; p = 0.05 and 0.02). There was a statistically significant reduction in the total cost of care in the SOS group versus the SH group ($59,221 vs $75, 808; p = 0.007).

CONCLUSION

The SOS approach is safe, efficacious, and cost-efficient when compared to separate operative sessions. This approach can be considered in situations where it is preferable for the patient to undergo a single session of anesthesia, without compromising technical success and safety.

Making the invisible visible: improving conspicuity of noncalcified gallstones using dual-energy CT

PURPOSE

To determine whether virtual monochromatic imaging (VMI) increases detectability of noncalcified gallstones on dual-energy CT (DECT) compared with conventional CT imaging.

MATERIALS AND METHODS

This retrospective IRB-approved, HIPAA-compliant study included consecutive patients who underwent DECT of the abdomen in the Emergency Department during a 30-month period (July 1, 2013-December 31, 2015), with a comparison US or MR within 1-year. 51 patients (36F, 15M; mean age 52 years) fulfilled the inclusion criteria. All DECT were acquired on a dual-source 128 × 2 slice scanner using either 80/Sn140 or 100/Sn140 kVp pairs. Source images at high and low kVp were used for DE post-processing with VMI. Within 3 mm reconstructed images, regions of interest of 0.5 cm² were placed on noncalcified gallstones and bile to record hounsfield units (HU) at VMI energy levels ranging between 40 and 190 keV.

RESULTS

Noncalcified gallstones uniformly demonstrated lowest HU at 40 keV and increase at higher keV; the HU of bile varied at higher keV. Few of the noncalcified stones are visible at 70 keV (simulating a conventional 120 kVp scan), with measured contrast (bile-stone HU difference) <10 HU in 78%, 10-20 HU in 20%, and >20 HU in 2%. Contrast was maximal at 40 keV, where 100% demonstrated >20 HU difference from surrounding bile, 75% >44 HU difference, and 50% >60 HU difference. A paired t test demonstrated a significant difference (p < 0.0001) between this stone-bile contrast at 40 vs. 70 keV and 70 vs. 190 keV.

CONCLUSION

Low keV virtual monochromatic imaging increased conspicuity of noncalcified gallstones, improving their detectability.

New insights into the role of Lith genes in the formation of cholesterol-supersaturated bile

Cholesterol gallstone formation represents a failure of biliary cholesterol homeostasis in which the physical-chemical balance of cholesterol solubility in bile is disturbed. Lithogenic bile is mainly caused by persistent hepatic hypersecretion of biliary cholesterol and sustained cholesterol-supersaturated bile is an essential prerequisite for the precipitation of solid cholesterol monohydrate crystals and the formation of cholesterol gallstones. The metabolic determinants of the supply of hepatic cholesterol molecules that are recruited for biliary secretion are dependent upon the input-output balance of cholesterol and its catabolism in the liver. The sources of cholesterol for hepatic secretion into bile have been extensively investigated; however, to what extent each cholesterol source contributes to hepatic secretion is still unclear both under normal physiological conditions and in the lithogenic state. Although it has been long known that biliary lithogenicity is initiated by hepatic cholesterol hypersecretion, the genetic mechanisms that cause supersaturated bile have not been defined yet. Identification of the Lith genes that determine hepatic cholesterol hypersecretion should provide novel insights into the primary genetic and pathophysiological defects for gallstone formation. In this review article, we focus mainly on the pathogenesis of the formation of supersaturated bile and gallstones from the viewpoint of genetics and pathophysiology. A better understanding of the molecular genetics and pathophysiology of the formation of cholesterol-supersaturated bile will undoubtedly facilitate the development of novel, effective, and noninvasive therapies for patients with gallstones, which would reduce the morbidity, mortality, and costs of health care associated with gallstones, a very prevalent liver disease worldwide.

Synchronous Open Heart Surgery and Laparoscopic Cholecystectomy: An Observational Case Study with 28 Patients

Acute cholecystitis (AC) may be a severe problem and may increase the mortality rate and hospital stay in patients who undergo open heart surgery (OHS), due to its aggressive course; therefore, AC should be treated as soon as possible. We aimed to present data on our synchronous cardiac and laparoscopic cholecystectomy (LC) operations performed for AC complicating patients with cardiac disease and who were waiting to undergo OHS. Between January 2008 and September 2014, we performed 2773 OHSs in Medical Park Gaziantep Hospital. Among these, 28 (1%) patients underwent concomitant LC in the same session by the same experienced surgeon. The mean age of the patients was 61.4 ± 9.1 years, and the proportion of males was 71.4 per cent. Acalculous cholecystitis was found in 42.9 per cent of the patients. Patients stayed in the intensive care unit for 3.1 ± 1.4 days and were discharged from the hospital after 16.5 ± 6.3 days. Postoperative 2-year follow-up was completed in all patients with a mean follow-up period of 3.4 ± 2.0 years. The overall complication rate was 28.6 per cent. LC-related complications were seen in four patients. No inhospital mortality was observed. Only one patient who underwent mitral valve replacement and tricuspid valve repair died in the second year after the operation due to congestive heart failure. Three patients died due to noncardiac reasons in the follow-up period. By increasing the experiences of surgeons in laparoscopic surgery in critically ill patients, LC can be safely performed concurrently in patients scheduled for OHS.

Evidence-based clinical practice guidelines for cholelithiasis 2016

Cholelithiasis is one of the commonest diseases in gastroenterology. Remarkable improvements in therapeutic modalities for cholelithiasis and its complications are evident. The Japanese Society of Gastroenterology has revised the evidence-based clinical practice guidelines for cholelithiasis. Forty-three clinical questions, for four categories-epidemiology and pathogenesis, diagnosis, treatments, and prognosis and complications-were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This article preferentially describes the clinical management of cholelithiasis and its complications. Following description of the diagnosis performed stepwise through imaging modalities, treatments of cholecystolithiasis, choledocholithiasis, and hepatolithiasis are introduced along with a flowchart. Since there have been remarkable improvements in endoscopic treatments and surgical techniques, the guidelines ensure flexibility in choices according to the actual clinical environment. The revised clinical practice guidelines are appropriate for use by clinicians in their daily practice.

Cholecystectomy and the risk of colorectal cancer by tumor mismatch repair deficiency status

PURPOSE

Gallbladder diseases and cholecystectomy may play a role in the development of colorectal cancer (CRC). Our aim was to investigate the association between cholecystectomy and CRC risk overall and by sex, family history, anatomical location, and tumor mismatch repair (MMR) status.

METHODS

This study comprised 5847 incident CRC cases recruited from population cancer registries in Australia, Canada, and the USA into the Colon Cancer Family Registry between 1997 and 2012 and 4970 controls with no personal history of CRC who were either randomly selected from the general population or were spouses of the cases. The association between cholecystectomy and CRC was estimated using logistic regression, after adjusting for confounding factors.

RESULTS

Overall, there was no evidence for an association between cholecystectomy and CRC (odds ratio [OR] = 0.88, 95 % confidence interval 0.73, 1.08). In the stratified analyses, there was no evidence for a difference in the association between women and men (P = 0.54), between individuals with and without family history of CRC in first-degree relative (P = 0.64), between tumor anatomical locations (P = 0.45), or between MMR-proficient and MMR-deficient cases (P = 0.54).

CONCLUSION

Cholecystectomy is not a substantial risk factor for CRC, regardless of sex, family history, anatomical location, or tumor MMR status.

Single-Incision Laparoscopic Cholecystectomy: our experience and review of literature

AIM

After the revolution in the surgery of gallbladder stones represented by the laparoscopic cholecystectomy, we tried a new technique that further maximize the aesthetic results and that at the same time is of easy learning for young surgeons.

PATIENTS AND METHODS

From January 2011 to December 2012 we performed at our department 320 cholecystectomy: 27 in laparotomy and 293 in laparoscopy. Of these, 88 underwent to Single Incision Laparoscopic Surgery (SILS), namely the Single Incision Laparoscopic Cholecystectomy (SILC), in recruited patients aged between 19-65 years; 56 patients were females and 32 were males.

RESULTS

The laparoscopic cholecystectomy with the SILS methodology is a safe technique. Respect to multi-port Laparoscopic Cholecystectomy (LC), we have cosmetic advances. The pain is less in extraumbilical sites, and the major umbilical pain can be prevented by local anaesthesia. The times are slightly longer, especially at the beginning of training, but after a few of operations it is reduced to about one hour. We didn't found any other difference in vantage and advantage between the two technics, only a case of postoperative umbilical hernia in SILS.

CONCLUSION

We found the SILS a safe and effective technique for the cholecystectomy.

PREOP-Gallstones: A Prognostic Nomogram for the Management of Symptomatic Cholelithiasis in Older Patients

OBJECTIVE AND BACKGROUND

The decision regarding elective cholecystectomy in older patients with symptomatic cholelithiasis is complicated. We developed and validated a prognostic nomogram to guide shared decision making for these patients.

METHODS

We used Medicare claims (1996-2005) to identify the first episode of symptomatic cholelithiasis in patients older than 65 years who did not undergo hospitalization or elective cholecystectomy within 2.5 months of the episode. We described current patterns of care and modeled their risk of emergent gallstone-related hospitalization or cholecystectomy at 2 years. Model discrimination and calibration were assessed using a random split sample of patients.

RESULTS

We identified 92,436 patients who presented to the emergency department (8.3%) or physician's office (91.7%) and who were not immediately admitted. The diagnosis for the initial episode was biliary colic/dyskinesia (65.3%), acute cholecystitis (26.6%), choledocholithiasis (5.7%), or gallstone pancreatitis (2.4%). The 2-year emergent gallstone-related hospitalization rate was 11.1%, with associated in-hospital morbidity and mortality rates of 56.5% and 6.5%. Factors associated with gallstone-related acute hospitalization included male sex, increased age, fewer comorbid conditions, complicated biliary disease on initial presentation, and initial presentation to the emergency department. Our model was well calibrated and identified 51% of patients with a risk less than 10% for 2-year complications and 5.4% with a risk more than 40% (C statistic, 0.69; 95% confidence interval, 0.63-0.75).

CONCLUSIONS

Surgeons can use this prognostic nomogram to accurately provide patients with their 2-year risk of developing gallstone-related complications, allowing patients and physicians to make informed decisions in the context of their symptom severity and its impact on their quality of life.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones

BACKGROUND

Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are tests used in the diagnosis of common bile duct stones in patients suspected of having common bile duct stones prior to undergoing invasive treatment. There has been no systematic review of the accuracy of EUS and MRCP in the diagnosis of common bile duct stones using appropriate reference standards.

OBJECTIVES

To determine and compare the accuracy of EUS and MRCP for the diagnosis of common bile duct stones.

SEARCH METHODS

We searched MEDLINE, EMBASE, Science Citation Index Expanded, BIOSIS, and Clinicaltrials.gov until September 2012. We searched the references of included studies to identify further studies and of systematic reviews identified from various databases (Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA), Medion, and ARIF (Aggressive Research Intelligence Facility)). We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively.

SELECTION CRITERIA

We included studies that provided the number of true positives, false positives, false negatives, and true negatives for EUS or MRCP. We only accepted studies that confirmed the presence of common bile duct stones by extraction of the stones (irrespective of whether this was done by surgical or endoscopic methods) for a positive test, and absence of common bile duct stones by surgical or endoscopic negative exploration of the common bile duct or symptom free follow-up for at least six months for a negative test, as the reference standard in people suspected of having common bile duct stones. We included participants with or without prior diagnosis of cholelithiasis; with or without symptoms and complications of common bile duct stones, with or without prior treatment for common bile duct stones; and before or after cholecystectomy. At least two authors independently screened abstracts and selected studies for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently collected the data from each study. We used the bivariate model to obtain pooled estimates of sensitivity and specificity.

MAIN RESULTS

We included a total of 18 studies involving 2366 participants (976 participants with common bile duct stones and 1390 participants without common bile duct stones). Eleven studies evaluated EUS alone, and five studies evaluated MRCP alone. Two studies evaluated both tests. Most studies included patients who were suspected of having common bile duct stones based on abnormal liver function tests; abnormal transabdominal ultrasound; symptoms such as obstructive jaundice, cholangitis, or pancreatitis; or a combination of the above. The proportion of participants who had undergone cholecystectomy varied across studies. Not one of the studies was of high methodological quality. For EUS, the sensitivities ranged between 0.75 and 1.00 and the specificities ranged between 0.85 and 1.00. The summary sensitivity (95% confidence interval (CI)) and specificity (95% CI) of the 13 studies that evaluated EUS (1537 participants; 686 cases and 851 participants without common bile duct stones) were 0.95 (95% CI 0.91 to 0.97) and 0.97 (95% CI 0.94 to 0.99). For MRCP, the sensitivities ranged between 0.77 and 1.00 and the specificities ranged between 0.73 and 0.99. The summary sensitivity and specificity of the seven studies that evaluated MRCP (996 participants; 361 cases and 635 participants without common bile duct stones) were 0.93 (95% CI 0.87 to 0.96) and 0.96 (95% CI 0.90 to 0.98). There was no evidence of a difference in sensitivity or specificity between EUS and MRCP (P value = 0.5). From the included studies, at the median pre-test probability of common bile duct stones of 41% the post-test probabilities (with 95% CI) associated with positive and negative EUS test results were 0.96 (95% CI 0.92 to 0.98) and 0.03 (95% CI 0.02 to 0.06). At the same pre-test probability, the post-test probabilities associated with positive and negative MRCP test results were 0.94 (95% CI 0.87 to 0.97) and 0.05 (95% CI 0.03 to 0.09).

AUTHORS' CONCLUSIONS

Both EUS and MRCP have high diagnostic accuracy for detection of common bile duct stones. People with positive EUS or MRCP should undergo endoscopic or surgical extraction of common bile duct stones and those with negative EUS or MRCP do not need further invasive tests. However, if the symptoms persist, further investigations will be indicated. The two tests are similar in terms of diagnostic accuracy and the choice of which test to use will be informed by availability and contra-indications to each test. However, it should be noted that the results are based on studies of poor methodological quality and so the results should be interpreted with caution. Further studies that are of high methodological quality are necessary to determine the diagnostic accuracy of EUS and MRCP for the diagnosis of common bile duct stones.

Ultrasound versus liver function tests for diagnosis of common bile duct stones

BACKGROUND

Ultrasound and liver function tests (serum bilirubin and serum alkaline phosphatase) are used as screening tests for the diagnosis of common bile duct stones in people suspected of having common bile duct stones. There has been no systematic review of the diagnostic accuracy of ultrasound and liver function tests.

OBJECTIVES

To determine and compare the accuracy of ultrasound versus liver function tests for the diagnosis of common bile duct stones.

SEARCH METHODS

We searched MEDLINE, EMBASE, Science Citation Index Expanded, BIOSIS, and Clinicaltrials.gov to September 2012. We searched the references of included studies to identify further studies and systematic reviews identified from various databases (Database of Abstracts of Reviews of Effects, Health Technology Assessment, Medion, and ARIF (Aggressive Research Intelligence Facility)). We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively.

SELECTION CRITERIA

We included studies that provided the number of true positives, false positives, false negatives, and true negatives for ultrasound, serum bilirubin, or serum alkaline phosphatase. We only accepted studies that confirmed the presence of common bile duct stones by extraction of the stones (irrespective of whether this was done by surgical or endoscopic methods) for a positive test result, and absence of common bile duct stones by surgical or endoscopic negative exploration of the common bile duct, or symptom-free follow-up for at least six months for a negative test result as the reference standard in people suspected of having common bile duct stones. We included participants with or without prior diagnosis of cholelithiasis; with or without symptoms and complications of common bile duct stones, with or without prior treatment for common bile duct stones; and before or after cholecystectomy. At least two authors screened abstracts and selected studies for inclusion independently.

DATA COLLECTION AND ANALYSIS

Two authors independently collected data from each study. Where meta-analysis was possible, we used the bivariate model to summarise sensitivity and specificity.

MAIN RESULTS

Five studies including 523 participants reported the diagnostic accuracy of ultrasound. One studies (262 participants) compared the accuracy of ultrasound, serum bilirubin and serum alkaline phosphatase in the same participants. All the studies included people with symptoms. One study included only participants without previous cholecystectomy but this information was not available from the remaining studies. All the studies were of poor methodological quality. The sensitivities for ultrasound ranged from 0.32 to 1.00, and the specificities ranged from 0.77 to 0.97. The summary sensitivity was 0.73 (95% CI 0.44 to 0.90) and the specificity was 0.91 (95% CI 0.84 to 0.95). At the median pre-test probability of common bile duct stones of 0.408, the post-test probability (95% CI) associated with positive ultrasound tests was 0.85 (95% CI 0.75 to 0.91), and negative ultrasound tests was 0.17 (95% CI 0.08 to 0.33).The single study of liver function tests reported diagnostic accuracy at two cut-offs for bilirubin (greater than 22.23 μmol/L and greater than twice the normal limit) and two cut-offs for alkaline phosphatase (greater than 125 IU/L and greater than twice the normal limit). This study also assessed ultrasound and reported higher sensitivities for bilirubin and alkaline phosphatase at both cut-offs but the specificities of the markers were higher at only the greater than twice the normal limit cut-off. The sensitivity for ultrasound was 0.32 (95% CI 0.15 to 0.54), bilirubin (cut-off greater than 22.23 μmol/L) was 0.84 (95% CI 0.64 to 0.95), and alkaline phosphatase (cut-off greater than 125 IU/L) was 0.92 (95% CI 0.74 to 0.99). The specificity for ultrasound was 0.95 (95% CI 0.91 to 0.97), bilirubin (cut-off greater than 22.23 μmol/L) was 0.91 (95% CI 0.86 to 0.94), and alkaline phosphatase (cut-off greater than 125 IU/L) was 0.79 (95% CI 0.74 to 0.84). No study reported the diagnostic accuracy of a combination of bilirubin and alkaline phosphatase, or combinations with ultrasound.

AUTHORS' CONCLUSIONS

Many people may have common bile duct stones in spite of having a negative ultrasound or liver function test. Such people may have to be re-tested with other modalities if the clinical suspicion of common bile duct stones is very high because of their symptoms. False-positive results are also possible and further non-invasive testing is recommended to confirm common bile duct stones to avoid the risks of invasive testing.It should be noted that these results were based on few studies of poor methodological quality and the results for ultrasound varied considerably between studies. Therefore, the results should be interpreted with caution. Further studies of high methodological quality are necessary to determine the diagnostic accuracy of ultrasound and liver function tests.

Endoscopic retrograde cholangiopancreatography versus intraoperative cholangiography for diagnosis of common bile duct stones

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative cholangiography (IOC) are tests used in the diagnosis of common bile duct stones in people suspected of having common bile duct stones. There has been no systematic review of the diagnostic accuracy of ERCP and IOC.

OBJECTIVES

To determine and compare the accuracy of ERCP and IOC for the diagnosis of common bile duct stones.

SEARCH METHODS

We searched MEDLINE, EMBASE, Science Citation Index Expanded, BIOSIS, and Clinicaltrials.gov to September 2012. To identify additional studies, we searched the references of included studies and systematic reviews identified from various databases (Database of Abstracts of Reviews of Effects (DARE)), Health Technology Assessment (HTA), Medion, and ARIF (Aggressive Research Intelligence Facility)). We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively.

SELECTION CRITERIA

We included studies that provided the number of true positives, false positives, false negatives, and true negatives for ERCP or IOC. We only accepted studies that confirmed the presence of common bile duct stones by extraction of the stones (irrespective of whether this was done by surgical or endoscopic methods) for a positive test, and absence of common bile duct stones by surgical or endoscopic negative exploration of the common bile duct, or symptom-free follow-up for at least six months for a negative test as the reference standard in people suspected of having common bile duct stones. We included participants with or without prior diagnosis of cholelithiasis; with or without symptoms and complications of common bile duct stones; with or without prior treatment for common bile duct stones; and before or after cholecystectomy. At least two authors screened abstracts and selected studies for inclusion independently.

DATA COLLECTION AND ANALYSIS

Two authors independently collected data from each study. We used the bivariate model to summarise the sensitivity and specificity of the tests.

MAIN RESULTS

We identified five studies including 318 participants (180 participants with and 138 participants without common bile duct stones) that reported the diagnostic accuracy of ERCP and five studies including 654 participants (125 participants with and 529 participants without common bile duct stones) that reported the diagnostic accuracy of IOC. Most studies included people with symptoms (participants with jaundice or pancreatitis) suspected of having common bile duct stones based on blood tests, ultrasound, or both, prior to the performance of ERCP or IOC. Most studies included participants who had not previously undergone removal of the gallbladder (cholecystectomy). None of the included studies was of high methodological quality as evaluated by the QUADAS-2 tool (quality assessment tool for diagnostic accuracy studies). The sensitivities of ERCP ranged between 0.67 and 0.94 and the specificities ranged between 0.92 and 1.00. For ERCP, the summary sensitivity was 0.83 (95% confidence interval (CI) 0.72 to 0.90) and specificity was 0.99 (95% CI 0.94 to 1.00). The sensitivities of IOC ranged between 0.75 and 1.00 and the specificities ranged between 0.96 and 1.00. For IOC, the summary sensitivity was 0.99 (95% CI 0.83 to 1.00) and specificity was 0.99 (95% CI 0.95 to 1.00). For ERCP, at the median pre-test probability of common bile duct stones of 0.35 estimated from the included studies (i.e., 35% of people suspected of having common bile duct stones were confirmed to have gallstones by the reference standard), the post-test probabilities associated with positive test results was 0.97 (95% CI 0.88 to 0.99) and negative test results was 0.09 (95% CI 0.05 to 0.14). For IOC, at the median pre-test probability of common bile duct stones of 0.35, the post-test probabilities associated with positive test results was 0.98 (95% CI 0.85 to 1.00) and negative test results was 0.01 (95% CI 0.00 to 0.10). There was weak evidence of a difference in sensitivity (P value = 0.05) with IOC showing higher sensitivity than ERCP. There was no evidence of a difference in specificity (P value = 0.7) with both tests having similar specificity.

AUTHORS' CONCLUSIONS

Although the sensitivity of IOC appeared to be better than that of ERCP, this finding may be unreliable because none of the studies compared both tests in the same study populations and most of the studies were methodologically flawed. It appears that both tests were fairly accurate in guiding further invasive treatment as most people diagnosed with common bile duct stones by these tests had common bile duct stones. Some people may have common bile duct stones in spite of having a negative ERCP or IOC result. Such people may have to be re-tested if the clinical suspicion of common bile duct stones is very high because of their symptoms or persistently abnormal liver function tests. However, the results should be interpreted with caution given the limited quantity and quality of the evidence.

[Mini-laparoscopic cholecystectomy as an innovative method in minimally invasive abdominal surgery]

INTRODUCTION

In our study, we applied a mini-laparosopic approach during laparoscopic cholecystectomy (LC) (using the minimum size of trocars with the simultaneous intention to reduce their number). The advantages and disadvantages of the mini-LC approach were compared with those of traditional LC.

PATIENTS AND METHODS

During mini-LC procedures, we used 3 ports (11 mm, 5 mm, 3.5 mm). Mini-LC was performed in 10 patients, and the results were compared with those of 10 cases of traditional LCs. The two groups were homogenous in terms of gender, age, BMI and ASA classification. Comparison criteria included operative time, the need to use an extra port, conversion rate, oral analgesic requirement, early/late complications and cosmetic results.

RESULTS

There were no significant differences in terms of operative time, blood loss, hospital stay and complications. Cumulative size of incisions was 19.5 mm with mini-LC- and 41 mm in the LC group, respectively, and the tissue injury was 124.2 mm(2) and 448.2 mm(2). Cosmetic results of mini-LC were highly improved by these values. Increased oral analgetic requirements were detected in LC group.

CONCLUSION

Mini-LC is a safe procedure with outstanding cosmetic results accompanied by less oral analgetic requirements. In selected patients, it can be recommended as an alternative method of traditional LC.

Effect of statin use on outcome of symptomatic cholelithiasis: a case-control study

Background

Statins can modify bile cholesterol and, thus, the formation of gallstones. We examined whether statin use also modifies the severity of symptomatic gallstone disease and its treatment.

Methods

A total of 1,140 consecutive patients with symptomatic gallstone disease were recruited during 2008-2010 at Kuopio university hospital, Finland. Case-control analysis matched the patients using (n = 272) or not using (n = 272) statins by age and sex. The baseline characteristics of the patients, need and type of surgical treatment, duration of operation, perioperative bleeding, postoperative complications and overall mortality rate were compared statistically between the study groups.

Results

Morbidity and subsequent polypharmacy occurred more frequently among the patients with statins compared to the patients without statins. There were no significant differences between the statin users and non-users regarding surgical treatment (open vs. laparoscopic cholecystectomy). The mean operation time for laparoscopic cholecystectomy was 10% shorter for the patients with statin use than for the patients without. In addition, there was a non-significant tendency for statin users to bleed less during laparoscopic operations than the non-users. There were no differences in other procedure-related parameters (e.g., operation urgency, conversions, choledochotomies, complications and mortality) in patients with or without statins.

Conclusions

Compared to no treatment, statin treatment was associated with a shorter operation time for laparoscopy cholecystectomy. Other surgical outcome parameters were similar in patients with or without statins, although statin users had more polypharmacy and circulatory illnesses than non-users.

Acute inflammatory surgical disease

Infectious and inflammatory diseases comprise some of the most common gastrointestinal disorders resulting in hospitalization in the United States. Accordingly, they occupy a significant proportion of the workload of the acute care surgeon. This article discusses the diagnosis, management, and treatment of appendicitis, acute cholecystitis/cholangitis, acute pancreatitis, diverticulitis, and Clostridium difficile colitis.

Increased rate of cholecystectomies performed with doubtful or no indications after laparoscopy introduction: a single center experience

Background

During recent years laparoscopic cholecystectomy has dramatically increased, sometimes resulting in overtreatment. Aim of this work was to retrospectively analyze all laparoscopic cholecystectomies performed in a single center in order to find the percentage of patients whose surgical treatment may be explained with this general trend, and to speculate about the possible causes.

Methods

831 patients who underwent a laparoscopic cholecystectomy from 1999 to 2008 were retrospectively analyzed.

Results

At discharge, 43.08% of patients were operated on because of at least one previous episode of biliary colic before the one at admission; 14.08% of patients presented with acute lithiasic cholecystitis; 14.68% were operated on because of an increase in bilirubin level; 1.56% were operated on because of a previous episode of jaundice with normal bilirubin at admission; 0.72% had gallbladder adenomas, 0.72% had cholangitis, 0.36% had biliodigestive fistula and one patient (0.12%) had acalculous cholecystitis. By excluding all these patients, 21.18% were operated on without indications.

Conclusions

The broadening of indications for laparoscopic cholecystectomy is undisputed and can be considered a consequence of new technologies that have been introduced, increased demand from patients, and the need for practice by inexperienced surgeons. If not prevented, this trend could continue indefinitely.

Risk of hepato-biliary cancer after cholecystectomy: a nationwide cohort study

BACKGROUND

Epidemiologic studies have identified cholecystectomy as a possible risk factor for cancers in Western countries. The aim of this study was to estimate the risk of hepato-biliary cancer after cholecystectomy in Taiwan.

METHODS

Based on the Taiwan National Health Insurance Research Database, 2,590 cholecystectomized patients without prior cancers in the period 1996-2008 were identified from a cohort dataset of 1,000,000 randomly sampled individuals. The standard incidence ratio (SIR) of each cancer was calculated.

RESULTS

After a median follow-up of 4.82 years, 67 liver cancer and 17 biliary tract cancer patients were diagnosed. Patients who received cholecystectomy had higher risks of liver cancer (SIR, 3.29) and biliary tract cancer (SIR, 8.50). Cholecystectomized patients aged ≤60 years had higher risks of liver cancer (SIR, 11.14) and biliary tract cancer (SIR, 55.86) compared to those aged >60 years (SIR, 2.31 and 5.67). Female cholecystectomized patients had higher risks of liver cancer (SIR, 4.18) and biliary tract cancer (SIR, 10.56) than males (SIR, 2.96 and 7.26). Cholecystectomized patients with cirrhosis had higher SIR of liver cancer than patients without cirrhosis (SIR, 33.84 vs. 1.41).

CONCLUSIONS

Cholecystectomy may be associated with an increased risk of hepato-biliary cancer. Further and regular surveillance should be performed on such patients.

Evidence-based current surgical practice: calculous gallbladder disease

BACKGROUND

Gallbladder disease is common and, if managed incorrectly, can lead to high rates of morbidity, mortality, and extraneous costs. The most common complications of gallstones include biliary colic, acute cholecystitis, common bile duct stones, and gallstone pancreatitis. Ultrasound is the initial imaging modality of choice. Additional diagnostic and therapeutic studies including computed tomography, magnetic resonance imaging, magnetic resonance cholangiopancreatography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography are not routinely required but may play a role in specific situations.

DISCUSSION

Biliary colic and acute cholecystitis are best treated with early laparoscopic cholecystectomy. Patients with common bile duct stones should be managed with cholecystectomy, either after or concurrent with endoscopic or surgical relief of obstruction and clearance of stones from the bile duct. Mild gallstone pancreatitis should be treated with cholecystectomy during the initial hospitalization to prevent recurrence. Emerging techniques for cholecystectomy include single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery. Early results in highly selected patients demonstrate the safety of these techniques. The management of complications of the gallbladder should be timely and evidence-based, and choice of procedures, particularly for common bile duct stones, is largely influenced by facility and surgeon factors.

The effects of different insufflation pressures on liver functions assessed with LiMON on patients undergoing laparoscopic cholecystectomy

Purpose. Laparoscopic cholecystectomy has been accepted as an alternative to laparotomy, but there is still controversy regarding the effects of pneumoperitoneum on splanchnic and hepatic perfusion. We assessed the effects of different insufflation pressures on liver functions by using indocyanine green elimination tests (ICG-PDR). Methods. We analyzed 43 patients who were scheduled for laparoscopic cholecystectomy. The patients were randomly allocated to two groups. In Group I, the operation was performed using 10 mmHg pressure pneumoperitoneum. In Group II, 14 mmHg pressure pneumoperitoneum was used. The ICG-PDR measurements were made after induction (ICG-PDR 1) and after the end of the operation (ICG-PDR 2). Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin levels were all recorded preoperatively, 1 hour, and postoperative 24 hours after surgery. Results. The ICG-PDR 1 values for Groups I and II were as follows: 26.78 ± 4.2% per min versus 26.01 ± 2.4% per min (P > 0.05). ICG-PDR 2 values were found to be 25.63 ± 2.1% per min in Group I versus 19.06 ± 2.2% per min in Group II (P < 0.05). There was a statistically significant decrease between baseline and postoperative ICG-PDR values in Group II compared to Group I (P < 0.05). Statistically, there was an increase between baseline and postoperative 1st-hour serum AST and ALT level in Group II (P < 0.05) compared to Group I. No statistical differences were detected on postoperative 24st-hour serum AST and ALT levels and all the time bilirubin between groups (P > 0.05). Conclusion. In conclusion, the results show that 14 mmHg pressure pneumoperitoneum decreased the blood flow to the liver and increased postoperative 1st-hour serum AST and ALT levels. We think that 10 mmHg pressure pneumoperitoneum is superior to 14 mmHg pressure pneumoperitoneum in laparoscopic cholecystectomy.