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Ma Y, Yue P, Zhang J, Yuan J, Liu Z, Chen Z, Zhang H, Zhang C, Zhang Y, Dong C, Lin Y, Liu Y, Li S, Meng W. Early prediction of acute gallstone pancreatitis severity: a novel machine learning model based on CT features and open access online prediction platform. Ann Med 2024; 56:2357354. [PMID: 38813815 PMCID: PMC11141304 DOI: 10.1080/07853890.2024.2357354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 04/26/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Early diagnosis of acute gallstone pancreatitis severity (GSP) is challenging in clinical practice. We aimed to investigate the efficacy of CT features and radiomics for the early prediction of acute GSP severity. METHODS We retrospectively recruited GSP patients who underwent CT imaging within 48 h of admission from tertiary referral centre. Radiomics and CT features were extracted from CT scans. The clinical and CT features were selected by the random forest algorithm to develop the ML GSP model for the identification of severity of GSP (mild or severe), and its predictive efficacy was compared with radiomics model. The predictive performance was assessed by the area under operating characteristic curve. Calibration curve and decision curve analysis were performed to demonstrate the classification performance and clinical efficacy. Furthermore, we built a web-based open access GSP severity calculator. The study was registered with ClinicalTrials.gov (NCT05498961). RESULTS A total of 301 patients were enrolled. They were randomly assigned into the training (n = 210) and validation (n = 91) cohorts at a ratio of 7:3. The random forest algorithm identified the level of calcium ions, WBC count, urea level, combined cholecystitis, gallbladder wall thickening, gallstones, and hydrothorax as the seven predictive factors for severity of GSP. In the validation cohort, the areas under the curve for the radiomics model and ML GSP model were 0.841 (0.757-0.926) and 0.914 (0.851-0.978), respectively. The calibration plot shows that the ML GSP model has good consistency between the prediction probability and the observation probability. Decision curve analysis showed that the ML GSP model had high clinical utility. CONCLUSIONS We built the ML GSP model based on clinical and CT image features and distributed it as a free web-based calculator. Our results indicated that the ML GSP model is useful for predicting the severity of GSP.
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Affiliation(s)
- Yuhu Ma
- Department of Anesthesiology, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Ping Yue
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Jinduo Zhang
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Jinqiu Yuan
- Clinical Research Center, Big Data Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Zhaoqing Liu
- School of Medical Information and Engineering, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Zixian Chen
- Department of Radiology, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Hengwei Zhang
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Chao Zhang
- Department of Orthopedics, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Yong Zhang
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Chunlu Dong
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Yanyan Lin
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Yatao Liu
- Department of Anesthesiology, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Shuyan Li
- School of Medical Information and Engineering, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Wenbo Meng
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
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Bhaskaran P, Swaminathan C, Krasicka D, Gilbert JA, Bhaskaran IP, Khan M. A Systematic Review and Meta-Analysis of the Management of Gallstone Cholecystitis and Common Biliary Duct Stones to Reduce the Incidence of Complications in Elderly Patients. Cureus 2024; 16:e63115. [PMID: 38947136 PMCID: PMC11211966 DOI: 10.7759/cureus.63115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 07/02/2024] Open
Abstract
As the age increases particularly above the age of 50 years, there is a significantly higher risk of developing gallstone-related complications especially cholecystitis and common bile duct stones with its associated consequences. Complications that arise after surgical operations for cholecystitis have been reported to have negative impacts on senior patients. These effects include a higher rate of complications, a longer hospital stay, higher expenditures, and decreased patient satisfaction. Therefore, finding the most effective treatment for cholecystitis in older patients is still a challenge. The aim of the study was carried out in order to identify many approaches that can be taken in the treatment of cholecystitis and stones in the common bile duct in older patients. A search was conducted through Medline (PubMed), EMBASE, ProQuest, and Cochrane using relevant Medical Subject Heading (MeSH) terms and keywords (elderly, age over 50, cholecystitis, bile duct stones, cholecystectomy, ERCP, surgical, conservative management, and open). The searches were limited to studies on elderly individuals over 50 who had cholecystectomy and endoscopic retrograde cholangiopancreatography between January 2000 and December 2022. The meta-analysis used the Mantel-Haenszel odds ratio (MHOR) and 95% confidence interval (CI). Aries Systems Corporation's Editorial Manager® (Aries Systems Corporation, North Andover, USA) and ProduXion Manager® (Aries Systems Corporation, North Andover, USA) facilitated the study. Out of 102 citations, 39 studies were selected for further study. After that, 18 studies were eliminated, leaving 21 for meta-analysis. The study found a protective risk of cholecystitis in cholecystectomy patients (MHOR = 0.16; 95%, CI = 0.10 to 0.25; p 0.001). Developing cholecystitis was substantially lower in early cholecystectomy patients (MHOR = 0.16; 95%, CI = 0.10 to 0.25; p 0.001). There was no significant difference in cholecystitis risk between open and laparoscopic surgery (MHOR = 0.65; 95%, CI = 0.41 to 1.04; p 0.07). Cholecystectomy performed at an earlier stage protects elderly patients from developing recurrent cholecystitis. In contrast to late cholecystitis, in which the patient would experience several attacks of cholecystitis, early cholecystectomy protects against the recurrence of the condition.
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Affiliation(s)
- Premjithlal Bhaskaran
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College London, London, GBR
| | - Christie Swaminathan
- Department of Gastrointestinal Surgery, University Hospitals Sussex NHS Foundation Trust, Brighton, GBR
| | - Dominika Krasicka
- Department of Gastrointestinal Surgery, University Hospitals Sussex NHS Foundation Trust, Brighton, GBR
| | - James A Gilbert
- Department of Surgery, The New Foscote Hospital, Banbury, GBR
- Department of Digestive Disease and General Surgery, Royal Sussex County Hospital, Brighton, GBR
| | - India P Bhaskaran
- Department of Cardiovascular Surgery, Imperial College London, London, GBR
| | - Mansoor Khan
- Department of General Surgery, University Hospitals Sussex NHS Foundation Trust, Brighton, GBR
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Bergeron E, Doyon T, Manière T, Désilets É. Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event. Surg Endosc 2023; 37:9546-9555. [PMID: 37726412 PMCID: PMC10709473 DOI: 10.1007/s00464-023-10423-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/31/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Gallstone disease will affect 15% of the adult population with concomitant common bile duct stone (CBDS) occurring in up to 30%. Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for removal of CBDS, as cholecystectomy for the prevention of recurrent biliary event (RBE). RBE occurs in up to 47% if cholecystectomy is not done. The goal of this study was to evaluate the timing of occurrence of RBE after common bile duct clearance with ERCP and associated outcomes. METHODS The records of all patients who underwent ERCP for gallstone disease followed by cholecystectomy, in a single center from 2010 to 2022, were reviewed. All RBE were identified. Actuarial incidence of RBE was built. Patients with and without RBE were compared. RESULTS The study population is composed of 529 patients. Mean age was 58.0 (18-95). There were 221 RBE in 151 patients (28.5%), 39/151 (25.8%) having more than one episode. The most frequent RBE was acute cholecystitis (n = 104) followed by recurrent CBDS (n = 95). Median time for first RBE was 34 days. Actuarial incidence of RBE started from 2.5% at 7 days to reach 53.3% at 1 year. Incidence-rate of RBE was 2.9 per 100 person-months. Patients with RBE had significant longer hospitalisation time (11.7 vs 6.4 days; P < 0.0001), longer operative time (66 vs 48 min; P < 0.0001), longer postoperative stay (2.9 vs 0.9 days; P < 0.0001), higher open surgery rate (7.9% vs 1.3%; P < 0.0001), and more complicated pathology (23.8% vs 5.8%; P < 0.0001) and cholecystitis (64.2% vs 25.9%; P < 0.0001) as final diagnoses. CONCLUSIONS RBE occurred in 28.5% of the subjects at a median time of 34 days, with an incidence of 2.5% as early as 1 week. Cholecystectomy should be done preferably within 7 days after common bile duct clearance in order to prevent RBE and adverse outcomes.
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Affiliation(s)
- Eric Bergeron
- Department of Surgery, Charles-LeMoyne Hospital, 3120, Boulevard Taschereau, Greenfield Park, QC, J4V 2H1, Canada.
| | - Théo Doyon
- Department of Gastroenterology, Charles-LeMoyne Hospital, Greenfield Park, QC, Canada
| | - Thibaut Manière
- Department of Gastroenterology, Charles-LeMoyne Hospital, Greenfield Park, QC, Canada
| | - Étienne Désilets
- Department of Gastroenterology, Charles-LeMoyne Hospital, Greenfield Park, QC, Canada
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Koishibayeva L, Turgunov Y, Sandblom G, Koishibayev Z, Teleuov M. Quality-of-life After Cholecystectomy in Kazakhstan and Sweden: Comparative Study Based on the Gastrointestinal Quality-of-life Index Questionnaire. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.10020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: As severe morbidity rarely is the focus in gallstone surgery, health-related quality of life has evolved as the main outcome measure of the management of patients with gallstone disease (GSD). The lack of universally accepted guidelines on treatment of GSD has also resulted in regional differences in the preoperative evaluation and management of patients with GSD.
AIM: The aim of this study was to compare quality-of-life (QoL) following gallstone surgery in cohorts from Kazakhstan and Sweden.
METHODS: A comparative study on QoL after cholecystectomy (CE) in two cohorts from Sweden and Kazakhstan using the gastrointestinal QoL index (GIQLI) questionnaire. QoL measures of 259 patients in Kazakhstan and 448 patients in Sweden were compared taking into account surgical approach, mode of admission, and indication for surgery. Patients in both cohorts were requested to fill in the GIQLI questionnaire after surgery. Similar routines were applied to ensure high coverage in both countries.
RESULTS: The mean overall GIQLI score was higher for patients undergoing CE in Sweden than those in Kazakhstan (p < 0.01). The same was seen when stratifying for open or laparoscopic surgery (both p < 0.05), absence of presence of acute cholecystitis (both p < 0.05), and emergency admission (p < 0.05), but not in case of planned admission (p = 0.54).
CONCLUSIONS: There were large differences in QoL, especially in the group having undergone surgery for pain attacks or chronic cholecystitis. These differences in may be explained by differences in attitudes to health status and treatment expectations. Standardized routines for evaluating the outcome after surgery are needed.
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Quality of Care for Gallstone Pancreatitis-the Impact of the Acute Care Surgery Model and Hospital-Level Operative Resources. J Gastrointest Surg 2022; 26:849-860. [PMID: 34786665 DOI: 10.1007/s11605-021-05145-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/27/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Index cholecystectomy is the standard of care for gallstone pancreatitis. Hospital-level operative resources and implementation of an acute care surgery (ACS) model may impact the ability to perform index cholecystectomy. We aimed to determine the influence of structure and process measures related to operating room access on achieving index cholecystectomy for gallstone pancreatitis. METHODS In 2015, we surveyed 2811 US hospitals on ACS practices, including infrastructure for operative access. A total of 1690 hospitals (60%) responded. We anonymously linked survey data to 2015 State Inpatient Databases from 17 states using American Hospital Association identifiers. We identified patients ≥ 18 years who were admitted with gallstone pancreatitis. Patients transferred from another facility were excluded. Univariate and multivariable regression analyses, clustered by hospital and adjusted for patient factors, were performed to examine multiple structure and process variables related to achieving an index cholecystectomy rate of ≥ 75% (high performers). RESULTS Over the study period, 5656 patients were admitted with gallstone pancreatitis and 70% had an index cholecystectomy. High-performing hospitals achieved an index cholecystectomy rate of 84.1% compared to 58.5% at low-performing hospitals. On multivariable regression analysis, only teaching vs. non-teaching hospital (OR 2.91, 95% CI 1.11-7.70) and access to dedicated, daytime operative resources (i.e., block time) vs. no/little access (OR 1.93, 95% CI 1.11-3.37) were associated with high-performing hospitals. CONCLUSIONS Access to dedicated, daytime operative resources is associated with high quality of care for gallstone pancreatitis. Health systems should consider the addition of dedicated, daytime operative resources for acute care surgery service lines to improve patient care.
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Early Versus Delayed Cholecystectomy for Acute Biliary Pancreatitis: A Systematic Review and Meta-Analysis. World J Surg 2022; 46:1359-1375. [DOI: 10.1007/s00268-022-06501-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 12/15/2022]
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Index Admission Cholecystectomy and Recurrence of Pediatric Gallstone Pancreatitis: Multicenter Cohort Analysis. J Am Coll Surg 2022; 234:352-358. [PMID: 35213498 DOI: 10.1097/xcs.0000000000000062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND We aim to evaluate recurrence rates of gallstone pancreatitis in children undergoing early vs interval cholecystectomy. STUDY DESIGN A multicenter, retrospective review of pediatric patients admitted with gallstone pancreatitis from 2010 through 2017 was performed. Children were evaluated based on timing of cholecystectomy. Early cholecystectomy was defined as surgery during the index admission, whereas the delayed group was defined as no surgery or surgery after discharge. Outcomes, recurrence rates, and complications were evaluated. RESULTS Of 246 patients from 6 centers with gallstone pancreatitis, 178 (72%) were female, with mean age 13.5 ± 3.2 years and a mean body mass index of 28.9 ± 15.2. Most (90%) patients were admitted with mild pancreatitis (Atlanta Classification). Early cholecystectomy was performed in 167 (68%) patients with no difference in early cholecystectomy rates across institutions. Delayed group patients weighed less (61 kg vs. 72 kg, p = 0.003) and were younger (12 vs. 14 years, p = 0.001) than those who underwent early cholecystectomy. However, there were no differences in clinical, radiological, or laboratory characteristics between groups. There were 4 (2%) episodes of postoperative recurrent pancreatitis in the early group compared with 22% in the delayed group. More importantly, when cholecystectomy was delayed more than 6 weeks from index discharge, recurrence approached 60%. There were no biliary complications in any group. CONCLUSIONS Cholecystectomy during the index admission for children with gallstone pancreatitis reduces recurrent pancreatitis. Recurrence proportionally increases with time when patients are treated with a delayed approach.
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National Trends in Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography During Index Hospitalization for Mild Gallstone Pancreatitis. World J Surg 2021; 46:524-530. [PMID: 34817621 DOI: 10.1007/s00268-021-06389-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Guidelines call for cholecystectomy during the index hospitalization for patients with gallstone pancreatitis. Therefore, the study sought to determine the trends for cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (ERCP) for mild gallstone pancreatitis. METHODS A retrospective analysis of the 2010-2018 Nationwide Readmission Database (NRD) was performed to identify patients with mild gallstone pancreatitis. The primary aim was to identify the trends in the use of cholecystectomy in these patients, and the secondary aim was to assess if ERCP alone was protective against readmission. RESULTS A total of 510,470 patients with mild gallstone pancreatitis were identified. There has been an increasing trend in ERCP use (25% in 2018 vs. 22% in 2010; p-0.001) and a decline in cholecystectomy (37% in 2018 vs. 46% in 2010; p-0.001) prior to discharge. Multivariate analysis revealed higher 30-day readmission for patients who underwent ERCP without cholecystectomy (odds ratio1.3; 95% confidence interval, 1.1-3.5) during the index admission. CONCLUSIONS There has been a decline in the use of cholecystectomy during index hospitalization for mild gallstone pancreatitis. In addition, ERCP was not protective against 30-day readmission from mild gallstone pancreatitis.
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Shmelev A, Axentiev A, Hossain MB, Cunningham SC. Predictors of same-admission cholecystectomy in mild, acute, biliary pancreatitis. HPB (Oxford) 2021; 23:1674-1682. [PMID: 34099373 DOI: 10.1016/j.hpb.2021.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 12/24/2020] [Accepted: 04/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Failure to perform same-admission cholecystectomy (SA-CCY) for mild, acute, biliary pancreatitis (MABP) is a recognized risk factor for recurrence and readmission. However, rates of SA-CCY are low and factors associated with these low rates require elucidation. METHODS Primary MAPB admissions were pooled from NIS 2000-2014 (weighted n = 578 258). Patients with chronic pancreatitis, pancreatic masses, alcohol-related disorders, hypertriglyceridemia, acute cholecystitis and AP-related organ dysfunction or complications were excluded. Annual rates of SA-CCY were calculated. Regression model for prediction of SA-CCY was built on 2010-2011 subset (weighted n = 74 169), yielding 96.3% of complete observations. RESULTS Nationwide rate of SA-CCY in the U.S. was 40.8%. In multivariate analysis, SA-CCY was positively associated with BMI>30 (OR = 1.4, 95%CI 1.2-1.6), Asian ethnicity (vs. Black; OR = 1.2, 95%CI 1.0-1.5), private insurance (vs. Medicare; OR = 1.1, 95%CI 1.0-1.3), large (vs. small; OR = 1.3, 95%CI 1.2-1.4) urban hospitals (vs. rural; OR = 1.5 95%CI 1.3-1.7) of the South (vs. Northeast; OR = 1.5, 95%CI 1.3-1.7), as well as with chronic cholecystitis (OR = 17.0, 95%CI 15.4-18.7) and abdominal-wall hernias (OR = 5.2; 95%CI 3.0-8.9); the latter two predictors were not included in the final model. SA-CCY was negatively associated with age >40 (OR = 0.72; 95%CI 0.66-0.79), male gender (OR = 0.86, 95%CI 0.80-0.93), dementia (OR = 0.88, 95%CI 0.72-1.1), chronic comorbidities (OR = 0.64; 95%CI 0.54-0.77) and ostomies (OR = 0.51; 95%CI 0.31-0.86). CONCLUSION Adherence to SA-CCY guidelines for MABP remains inadequate. Independent geographic variation in SA-CCY rates may be related to reimbursement differences, ownership of AP patients, accessibility to surgical care, or cultural characteristics of the patient population.
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Affiliation(s)
- Artem Shmelev
- Department of Surgery, Saint Agnes Healthcare, Baltimore, MD, USA.
| | - Anna Axentiev
- Department of Surgery, Saint Agnes Healthcare, Baltimore, MD, USA
| | - Mian B Hossain
- School of Community Health and Policy, Morgan State University, Baltimore, MD, USA
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Yawar B, Marzouk A, Ali H, Asim A, Ghorab T, Bahli Z, Abousamra M, Fleville S. Acute Pancreatitis During COVID-19 Pandemic: An Overview of Patient Demographics, Disease Severity, Management and Outcomes in an Acute District Hospital in Northern Ireland. Cureus 2021; 13:e18520. [PMID: 34659920 PMCID: PMC8496563 DOI: 10.7759/cureus.18520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 01/08/2023] Open
Abstract
Background Acute pancreatitis (AP) is a common disease requiring admissions under surgical and critical care units. The two most common causes are alcohol and gallstones. Coronavirus disease 2019 (COVID-19) pandemic had a significant impact on service delivery and patient management throughout all surgical specialties. In this study, the primary aim was to ascertain the incidence of COVID-19 in acute pancreatitis patients. Secondary objectives were to study aetiology, demographics, severity, 30-day mortality, outcomes and management of acute pancreatitis patients from 1st March, 2020 till 31st August, 2020. Methods A retrospective observational review of all patients admitted under the General Surgical team was performed. Information regarding demographics, severity of AP (using Glasgow score, Atlanta classification and CT severity index score), ICU admission and organ support, treatment modalities and follow-up data for outcomes was collected based on data collection tool used by COVID-PAN study and results were compared to outcomes results of COVID-PAN study. Results Forty-three (43) patients were admitted with AP. Only one patient (2.3%) was diagnosed with COVID-19 at the time of pancreatitis. Gallstones were noted to be the most common cause of AP in our population. Mortality was 7% (3 patients). Five patients (11%) needed ITU admission due to organ dysfunction. Three patients (7%) developed ARDS. Conclusion The overall incidence of COVID-19 in pancreatitis in our population of the study was low. The incidence of COVID-19 during the first wave in Derry/Londonderry area was low and this may explain why the incidence was low in our study as well. Patients with AP in our target population were mostly elderly, one in five had moderate to severe or severe pancreatitis and in 16.3% the aetiology could not be identified. As observed in other centres globally, urgent cholecystectomy for gallstone pancreatitis faced significant delays with no patients being offered index cholecystectomy and only 4 out of 19 patients having undergone interval cholecystectomy within six months of index admission for gallstone pancreatitis in our centre.
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Affiliation(s)
- Bakhat Yawar
- General Surgery, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
| | - Ahmed Marzouk
- General Surgery, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
| | - Heba Ali
- Radiology, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
| | - Ayeisha Asim
- Geriatrics, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
| | - Tamer Ghorab
- General Surgery, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
| | - Zahid Bahli
- General Surgery, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
| | - Mohammad Abousamra
- General Surgery, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
| | - Samara Fleville
- General Surgery, The Western Trust Health & Social Care Jobs in Northern Ireland (HSCNI) (Altnagelvin Area Hospital), Derry/Londonderry, GBR
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Bagepally BS, Haridoss M, Sasidharan A, Jagadeesh KV, Oswal NK. Systematic review and meta-analysis of gallstone disease treatment outcomes in early cholecystectomy versus conservative management/delayed cholecystectomy. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000675. [PMID: 34261757 PMCID: PMC8280848 DOI: 10.1136/bmjgast-2021-000675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/04/2021] [Indexed: 01/07/2023] Open
Abstract
Background The effectiveness of early cholecystectomy for gallstone diseases treatment is uncertain compared with conservative management/delayed cholecystectomy. Aims To synthesise treatment outcomes of early cholecystectomy versus conservative management/delayed cholecystectomy in terms of its safety and effectiveness. Design We systematically searched randomised control trials investigating the effectiveness of early cholecystectomy compared with conservative management/delayed cholecystectomy. We pooled the risk ratios with a 95% CI, also estimated adjusted number needed to treat to harm. Results Of the 40 included studies for systematic review, 39 studies with 4483 patients are included in meta-analysis. Among the risk ratios of gallstone complications, pain (0.38, 0.20 to 0.74), cholangitis (0.52, 0.28 to 0.97) and total biliary complications (0.33, 0.20 to 0.55) are significantly lower with early cholecystectomy. Adjusted number needed to treat to harm of early cholecystectomy compared with conservative management/delayed cholecystectomy are, for pain 12.5 (8.3 to 33.3), biliary pancreatitis >1000 (50–100), common bile duct stones 100 (33.3 to 100), cholangitis (100 (25–100), total biliary complications 5.9 (4.3 to 9.1) and mortality >1000 (100 to100 000). Conclusions Early cholecystectomy may result in fewer biliary complications and a reduction in reported abdominal pain than conservative management. PROSPERO registration number 2020 CRD42020192612.
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Affiliation(s)
- Bhavani Shankara Bagepally
- ICMR-NIE Health Technology Assessment Resource Centre, ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India
| | - Madhumitha Haridoss
- ICMR-NIE Health Technology Assessment Resource Centre, ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India
| | - Akhil Sasidharan
- ICMR-NIE Health Technology Assessment Resource Centre, ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India
| | - Kayala Venkata Jagadeesh
- Health Technology Assessment in India (HTAIn) Secretariat, Department of Health Research, MoHFW, GOI, New Delhi, India
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Clout M, Blazeby J, Rogers C, Reeves B, Lazaroo M, Avery K, Blencowe NS, Vohra R, Jennings N, Hollingworth W, Thorn J, Jepson M, Collingwood J, Guthrie A, Booth E, Pathak S, Beckingham I, Culliford L, Griffiths EA, Albazaz R, Toogood G. Randomised controlled trial to establish the clinical and cost-effectiveness of expectant management versus preoperative imaging with magnetic resonance cholangiopancreatography in patients with symptomatic gallbladder disease undergoing laparoscopic cholecystectomy at low or moderate risk of common bile duct stones (The Sunflower Study): a study protocol. BMJ Open 2021; 11:e044281. [PMID: 34187817 PMCID: PMC8245448 DOI: 10.1136/bmjopen-2020-044281] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 03/20/2021] [Accepted: 03/28/2021] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Surgery to remove the gallbladder (laparoscopic cholecystectomy (LC)) is the standard treatment for symptomatic gallbladder disease. One potential complication of gallbladder disease is that gallstones can pass into the common bile duct (CBD) where they may remain dormant, pass spontaneously into the bowel or cause problems such as obstructive jaundice or pancreatitis. Patients requiring LC are assessed preoperatively for their risk of CBD stones using liver function tests and imaging. If the risk is high, guidelines recommend further investigation and treatment. Further investigation of patients at low or moderate risk of CBD stones is not standardised, and the practice of imaging the CBD using magnetic resonance cholangiopancreatography (MRCP) in these patients varies across the UK. The consequences of these decisions may lead to overtreatment or undertreatment of patients. METHODS AND ANALYSIS We are conducting a UK multicentre, pragmatic, open, randomised controlled trial with internal pilot phase to compare the effectiveness and cost-effectiveness of preoperative imaging with MRCP versus expectant management (ie, no preoperative imaging) in adult patients with symptomatic gallbladder disease undergoing urgent or elective LC who are at low or moderate risk of CBD stones. We aim to recruit 13 680 patients over 48 months. The primary outcome is any hospital admission within 18 months of randomisation for a complication of gallstones. This includes complications of endoscopic retrograde cholangiopancreatography for the treatment of gallstones and complications of LC. This will be determined using routine data sources, for example, National Health Service Digital Hospital Episode Statistics for participants in England. Secondary outcomes include cost-effectiveness and patient-reported quality of life, with participants followed up for a median of 18 months. ETHICS AND DISSEMINATION This study received approval from Yorkshire & The Humber - South Yorkshire Research Ethics Committee. Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ISRCTN10378861.
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Affiliation(s)
- Madeleine Clout
- Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Jane Blazeby
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Rogers
- Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Barnaby Reeves
- Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Michelle Lazaroo
- Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Kerry Avery
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Natalie S Blencowe
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Ravi Vohra
- Trent Oesophago-Gastric Unit, Nottingham City Hospital, Nottingham, UK
| | - Neil Jennings
- Bariatric Unit, Department of Surgery, Sunderland Royal Hospital, Sunderland, UK
| | | | - Joanna Thorn
- School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Marcus Jepson
- School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Jane Collingwood
- School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Ashley Guthrie
- Clinical Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Elizabeth Booth
- NHS Coventry and Rugby Clinical Commissioning Group, Coventry, UK
| | - Samir Pathak
- Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ian Beckingham
- Division of Gastrointestinal Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lucy Culliford
- Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Ewen A Griffiths
- Department of Upper GI Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Raneem Albazaz
- Clinical Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Giles Toogood
- Department of Hepatobiliary and Transplantation Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Gao MJ, Jiang ZL. Effects of the timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography on liver, bile, and inflammatory indices and cholecysto-choledocholithiasis patient prognoses. Clinics (Sao Paulo) 2021; 76:e2189. [PMID: 33852651 PMCID: PMC8009063 DOI: 10.6061/clinics/2021/e2189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/26/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES This study explored the effects of the timing of laparoscopic cholecystectomy (LC) after endoscopic retrograde cholangiopancreatography (ERCP) on liver function, bile biochemical indices, inflammatory reactions, and cholecysto-choledocholithiasis patient prognoses. METHODS A total of 103 cholecysto-choledocholithiasis patients were stratified into control (CG; n=51; LC at 4-7 d after ERCP) and observation groups (OG; n=52; LC at 1-3 d after ERCP) using a random number table. RESULTS The surgical time was shorter and intraoperative blood loss was less in OG than in CG, and the two groups were not statistically different in terms of time to the first passage of gas through anus, length of postoperative hospital stay, conversion rate to laparotomy, and stone-free rate. Four weeks after LC, alanine aminotransferase (ALT), total bilirubin (TBil), albumin (ALB), and glutamyl transpeptidase (GGT) levels declined in both groups, but the difference was not statistically significant. Three days after LC, total bile acid (TBA) levels increased, and cholesterol (CHO), unconjugated bilirubin (UCB), and TBiL levels were reduced in both groups, but were not statistically different (p>0.05). Three days after LC, interleukin (IL)-6, procalcitonin (PCT), and high-sensitivity C-reactive protein (hs-CRP) levels in the serum and bile increased in both groups and were lower in OG. The total incidence of perioperative complications was 1.92% in OG, which was lower than 15.69% in the CG. CONCLUSION For cholecysto-choledocholithiasis patients, LC at 1-3 d after ERCP can shorten surgical times, reduce intraoperative blood loss, improve liver function and bile biochemistry, relieve inflammatory reactions, reduce complications, and improve prognoses.
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Affiliation(s)
- Ming-Jun Gao
- Department of Gastroenterology, Taizhou People’s Hospital, Taizhou City, Jiangsu Province, China
| | - Zhi-Lan Jiang
- Department of Immunization Program, Center for Disease Control and Prevention of Hailing District, Taizhou City, Jiangsu Province, China
- *Corresponding author. E-mail:
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14
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Zheng Z, Ding YX, Qu YX, Cao F, Li F. A narrative review of acute pancreatitis and its diagnosis, pathogenetic mechanism, and management. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:69. [PMID: 33553362 PMCID: PMC7859757 DOI: 10.21037/atm-20-4802] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute pancreatitis (AP) is an inflammatory disease that can progress to severe acute pancreatitis (SAP), which increases the risk of death. AP is characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. Other contributing factors may include calcium (Ca2+) overload, mitochondrial dysfunction, impaired autophagy, and endoplasmic reticulum (ER) stress. In addition, exosomes are also associated with pathophysiological processes of many human diseases and may play a biological role in AP. However, the pathogenic mechanism has not been fully elucidated and needs to be further explored to inform treatment. Recently, the treatment guidelines have changed; minimally invasive therapy is advocated more as the core multidisciplinary participation and "step-up" approach. The surgical procedures have gradually changed from open surgery to minimally invasive surgery that primarily includes percutaneous catheter drainage (PCD), endoscopy, small incision surgery, and video-assisted surgery. The current guidelines for the management of AP have been updated and revised in many aspects. The type of fluid to be used, the timing, volume, and speed of administration for fluid resuscitation has been controversial. In addition, the timing and role of nutritional support and prophylactic antibiotic therapy, as well as the timing of the surgical or endoscopic intervention, and the management of complications still have many uncertainties that could negatively impact the prognosis and patients' quality of life. Consequently, to inform clinicians about optimal treatment, we aimed to review recent advances in the understanding of the pathogenesis of AP and its diagnosis and management.
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Affiliation(s)
- Zhi Zheng
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Yi-Xuan Ding
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Yuan-Xu Qu
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Feng Cao
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Fei Li
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
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15
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Maurer LR, Maatman TK, Luckhurst CM, Horvath KD, Zyromski NJ, Fagenholz PJ. Risk of gallstone-related complications in necrotizing pancreatitis patients treated with a step-up approach: The experience of two tertiary care centers. Surgery 2020; 169:1086-1092. [PMID: 33323200 DOI: 10.1016/j.surg.2020.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/15/2020] [Accepted: 11/01/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND A minimally invasive step-up approach to necrotizing biliary pancreatitis often requires multiple interventions, delaying cholecystectomy. The risk of gallstone-related complications during this time interval is unknown, as is the feasibility and safety of cholecystectomy after minimally invasive step-up treatment. In this paper, we analyzed both. METHODS Necrotizing pancreatitis patients treated with a minimally invasive step-up approach who underwent interval cholecystectomy at 2 tertiary care centers between 2014 and 2019 were included. Gallstone-related complications prior to cholecystectomy were examined, as were surgical approaches to cholecystectomy and complications. Necrotizing pancreatitis patients treated without mechanical intervention were also examined. RESULTS Seven of 31 patients developed gallstone-related complications between minimally invasive step-up treatment initiation and cholecystectomy. One patient developed biliary colic. Six patients developed acute cholecystitis. Two of these patients also developed choledocholithiasis, and 1 developed cholangitis, all requiring endoscopic retrograde cholangiopancreatography. Cholecystectomy was performed laparoscopically in 27 of 31 patients. One patient required open conversion, and 3 patients underwent planned cholecystectomy during another open operation. Four patients developed postoperative complications. Two of 14 necrotizing pancreatitis patients treated without mechanical intervention developed recurrent pancreatitis while awaiting cholecystectomy. CONCLUSION Over 20% of necrotizing pancreatitis patients treated by a minimally invasive step-up approach developed gallstone-related complications while awaiting cholecystectomy. Laparoscopic cholecystectomy is feasible and safe in the great majority of necrotizing pancreatitis patients treated by a minimally invasive step-up approach.
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Affiliation(s)
- Lydia R Maurer
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Thomas K Maatman
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | | | - Karen D Horvath
- Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Peter J Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA.
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16
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The safety, feasibility, and cost-effectiveness of early laparoscopic cholecystectomy for patients with mild acute biliary pancreatitis: A meta-analysis. Surgeon 2020; 19:287-296. [PMID: 32709425 DOI: 10.1016/j.surge.2020.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 05/31/2020] [Accepted: 06/13/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND It remains controversial on the optimal timing of cholecystectomy for patients with mild acute biliary pancreatitis. This study aimed at comparing the safety, feasibility, and cost-effectiveness of early laparoscopic cholecystectomy (ELC, within 72 h after admission) versus delayed laparoscopic cholecystectomy (DLC, beyond 72 h after admission) for patients with mild acute biliary pancreatitis. METHODS We performed a systematic search in the following databases: PubMed, Embase, Web of Science, and Cochrane library. We only included articles from RCTs which designed to evaluate the complications, conversion to open cholecystectomy, recurrence of acute pancreatitis, the length of hospital stay, and costs between patients undergoing ELC and those undergoing DLC. We schemed to analyze data using STATA 15.0 with both the random-effects and the fixed-effect models. We computed relative risk (RR) and weighted mean difference (WMD) with 95% confidence intervals (CI) based on the intention-to-treat (ITT) analysis. RESULTS A total of 4 studies involving 439 (215 vs 224) patients were included. The difference of complication rate [3.3% vs 3.2%; RR 1.03 (0.35, 3.01), P = 0.961] and rate of conversion to open cholecystectomy [3.8% vs 3.3%; RR 1.13 (0.37, 3.43), P = 0.830] are insignificant between patients who underwent ELC and ones who underwent DLC. The difference of rate of recurrence of acute pancreatitis is significant between ELC and DLC (2.17% vs 8.99%; RR 0.24 (0.08-0.70), P = 0.009). ELC does not shorten the length of hospital stay (random-effects model analysis: WMD -1.09 days (-2.67, 0.48), P = 0.173; fixed-effect model analysis: WMD -0.62 days (-1.00, -0.24), P = 0.001). CONCLUSION Compared to DLC, ELC is equally safe and feasible both in complication rate and rate of conversion to open procedure, and significantly reduces the recurrence rate of acute pancreatitis. PROSPERO REGISTRATION NUMBER CRD42018116239.
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17
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Bergeron E, Desilets E, Maniere T, Bensoussan M. Same-day endoscopic ultrasound, retrograde cholangiopancreatography and stone extraction, followed by cholecystectomy: A case report and literature review. Int J Surg Case Rep 2020; 70:115-118. [PMID: 32416480 PMCID: PMC7229231 DOI: 10.1016/j.ijscr.2020.04.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/06/2020] [Accepted: 04/21/2020] [Indexed: 12/07/2022] Open
Abstract
The risk of recurrence or complications is high after a common bile duct stone related event. Cholecystectomy should be carried out soon after extraction of a common bile duct stone. Same-day investigation, endoscopic stone extraction and cholecystectomy is feasible and safe.
Introduction Common bile duct stone-related events and their recurrence are frequent even after endoscopic retrograde cholangiopancreatography and stone extraction. Cholecystectomy should be carried out as soon as possible after the initial episode to prevent complications. Case presentation We present a case of a patient who underwent endoscopic ultrasound, cholangiopancreatography with stone extraction and cholecystectomy on the same day. Discussion After a common bile duct stone-related event, investigation, and stone extraction, cholecystectomy should be carried out as soon as possible to avoid high rates of recurrence and complications. Rise in health care costs nowadays mandate such an approach as a pre-emptive measure to prevent health complications while lowering health costs. Conclusion Diagnosis of common bile duct stone followed by extraction with endoscopic cholangiopancreatography and cholecystectomy on the same day is feasible, safe, and has many potential advantages.
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Affiliation(s)
- Eric Bergeron
- Departments of Surgery and Gastroenterology, Charles-LeMoyne Hospital, Greenfield Park, Canada.
| | - Etienne Desilets
- Departments of Surgery and Gastroenterology, Charles-LeMoyne Hospital, Greenfield Park, Canada
| | - Thibaut Maniere
- Departments of Surgery and Gastroenterology, Charles-LeMoyne Hospital, Greenfield Park, Canada
| | - Michael Bensoussan
- Departments of Surgery and Gastroenterology, Charles-LeMoyne Hospital, Greenfield Park, Canada
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18
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Giuffrida P, Biagiola D, Cristiano A, Ardiles V, de Santibañes M, Sanchez Clariá R, Pekolj J, de Santibañes E, Mazza O. Laparoscopic cholecystectomy in acute mild gallstone pancreatitis: how early is safe? Updates Surg 2020; 72:129-135. [PMID: 32009229 DOI: 10.1007/s13304-020-00714-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 01/22/2020] [Indexed: 02/07/2023]
Abstract
The surgical strategy to resolve the underlying biliary pathology in patients with acute gallstone pancreatitis (AGP) remains controversial. The aim of this study was to evaluate the safety and effectiveness of early laparoscopic cholecystectomy (ELC) in patients with mild AGP. A retrospective cohort of consecutive patients diagnosed with mild AGP according to the Atlanta Guidelines from January 2009 to July 2019 was selected. Patients were assigned to surgery on the first available surgical shift, 48 h after the symptoms onset. Univariate analysis was performed to determine the association between AGP and grades of Balthazar (A, B and C) with time to surgery, days of hospitalization and postoperative complications. From 239 patients evaluated, 238 (99.58%) were operated by laparoscopic approach. Intraoperative cholangiogram was performed routinely. Choledocholithiasis, if present, was successfully treated by laparoscopic common bile duct exploration in all cases. A significant association was found between Balthazar grades and time to surgery (median of 3 days, p = 0.003), with length hospitalization and from surgery to discharge, with median of 4 days (p = 0.0001) and 2 days (p = 0.003), respectively. Mild postoperative complications (CD I/II) were observed in 22/239 patients (9.2%). This represents 2% of patients with grade A of Balthazar, 9% of grade B and 14% of grade C (p = 0.016). We observed no severe complications or mortality. ELC with routine intraoperative cholangiogram, performed on the first available surgical shift 48 h after the symptoms of pancreatitis onset, is a viable, effective and safe strategy for the resolution of mild AGP and its underlying biliary pathology in a single procedure.
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Affiliation(s)
- Pablo Giuffrida
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - David Biagiola
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Agustín Cristiano
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Victoria Ardiles
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Martín de Santibañes
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Rodrigo Sanchez Clariá
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Juan Pekolj
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Oscar Mazza
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina.
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Riquelme F, Marinkovic B, Salazar M, Martínez W, Catan F, Uribe-Echevarría S, Puelma F, Muñoz J, Canals A, Astudillo C, Uribe M. Early laparoscopic cholecystectomy reduces hospital stay in mild gallstone pancreatitis. A randomized controlled trial. HPB (Oxford) 2020; 22:26-33. [PMID: 31235428 DOI: 10.1016/j.hpb.2019.05.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/21/2019] [Accepted: 05/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Two strategies for same-admission cholecystectomy in mild gallstone pancreatitis (MGP) exist: early surgery (within 48-72 h from admission) and delayed surgery until resolution of symptoms and normalization of pancreatic tests. METHODS This was a single-center, open-label RCT. Patients with MGP according to revised Atlanta classification-2012 and SIRS criteria were randomly assigned to early laparoscopic cholecystectomy (E-LC) within 72 h from admission or delayed laparoscopic cholecystectomy (D-LC). Laparoscopic-endoscopic rendezvous was performed when common bile duct stones were found at systematic intraoperative cholangiography. The primary outcome was length of stay (LOS), and the secondary outcomes were complications at 90 days, need for ERCP/choledocolithiasis, conversion, and re-admission. One year of follow-up was carried-on. RESULTS At interim analysis, 52 patients were randomized (26 E-LC, 26 D-LC). E-LC versus D-LC was associated with a significantly shorter LOS (median 58 versus 167 h; P = 0.001). There were no differences in ERCP necessity for choledocolithiasis between the two approaches (E-LC 26.9% versus D-LC 23.1%, P = 1.00). No differences in postoperative complications were found. CONCLUSIONS E-LC approach in patients with MGP significantly reduced LOS and was not associated with clinically relevant postoperative complications. TRIAL REGISTRATION clinicaltrials.gov (NCT02590978).
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Affiliation(s)
- Francisco Riquelme
- Department of Surgery, Hospital del Salvador, Santiago, Chile; University of Chile, Santiago, Chile.
| | - Boris Marinkovic
- Department of Surgery, Hospital del Salvador, Santiago, Chile; University of Chile, Santiago, Chile
| | - Marco Salazar
- Department of Surgery, Hospital del Salvador, Santiago, Chile
| | - Waldo Martínez
- Department of Surgery, Hospital del Salvador, Santiago, Chile
| | - Felipe Catan
- Department of Surgery, Hospital del Salvador, Santiago, Chile
| | | | - Felipe Puelma
- Department of Surgery, Hospital del Salvador, Santiago, Chile
| | - Jorge Muñoz
- Department of Surgery, Hospital del Salvador, Santiago, Chile
| | | | | | - Mario Uribe
- Department of Surgery, Hospital del Salvador, Santiago, Chile; University of Chile, Santiago, Chile
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20
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Jenkins A, Shapiro J. Clinical Guideline Highlights for the Hospitalist: Initial Management of Acute Pancreatitis in the Hospitalized Adult. J Hosp Med 2019; 14:764-765. [PMID: 31634105 DOI: 10.12788/jhm.3324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
2018 American Gastroenterological Association (AGA) Institute Guideline on Initial Management of Acute Pancreatitis RELEASE DATE: March 2018 PRIOR VERSION: Not applicable DEVELOPER: AGA Clinical Practice Guideline Committee FUNDING SOURCE: AGA Institute TARGET POPULATION: Patients within first 48-72 hours of admission with acute pancreatitis (AP).
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Affiliation(s)
- Ashley Jenkins
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jordan Shapiro
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
- Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey VA Medical Center, Houston, Texas
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21
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Zhong FP, Wang K, Tan XQ, Nie J, Huang WF, Wang XF. The optimal timing of laparoscopic cholecystectomy in patients with mild gallstone pancreatitis: A meta-analysis. Medicine (Baltimore) 2019; 98:e17429. [PMID: 31577759 PMCID: PMC6783238 DOI: 10.1097/md.0000000000017429] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/20/2019] [Accepted: 09/05/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The optimal timing of laparoscopic cholecystectomy (LC) in patients with mild acute gallstone pancreatitis (MAGP) is controversial. The aim of this study was to systematically evaluate and compare the safety and efficacy of early laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC) in patients with MAGP. METHODS A strict search was conducted of the electronic databases, including PubMed, MEDLINE Embase, the ISI Web of Science, and Cochrane Library for all relevant English literature and RevMan5.3 software for statistical analysis was used. RESULTS A total of 19 studies comprising 2639 patients were included. There was no significant difference in intraoperative complications [risk ratio (RR) = 1.46; 95% confidence interval (CI) = 0.88-2.41; P = .14)], postoperative complications (RR = 0.81; 95% CI = 0.58-1.14; P = .23), rate of conversion to open cholecystectomy (RR = 1.00; 95% CI = 0.75-1.33; P = .99), operative time (MD = 1.60; 95% CI = -1.36-4.56; P = .29), and rate of readmission (RR = 0.63; 95% CI = 0.19-2.10; P = .45) between the ELC and DLC groups. However, the ELC group was significantly correlated with lower length of hospital stay (MD = -2.01; 95% CI = -3.15 to -0.87; P = .0006), fewer gallstone-related events rates (RR = 0.17; 95% CI = 0.07-0.44; P = .0003), and lower endoscopic retrograde cholangiopancreatography (ERCP) usage (RR = 0.83; 95% CI = 0.71-0.97; P = .02) compared with the DLC group. CONCLUSION Early laparoscopic cholecystectomy is safe and effective for patients with MAGP, but the indications and contraindications must be strictly controlled.
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Affiliation(s)
- Fu-ping Zhong
- Department of Hepatobiliary Surgery, Pingxiang People's Hospital, Pingxiang
| | - Kai Wang
- Department of Hepatobiliary Surgery, Pingxiang People's Hospital, Pingxiang
- The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xue-qin Tan
- Department of Hepatobiliary Surgery, Pingxiang People's Hospital, Pingxiang
| | - Jian Nie
- Department of Hepatobiliary Surgery, Pingxiang People's Hospital, Pingxiang
| | - Wen-feng Huang
- Department of Hepatobiliary Surgery, Pingxiang People's Hospital, Pingxiang
| | - Xiao-fang Wang
- Department of Hepatobiliary Surgery, Pingxiang People's Hospital, Pingxiang
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Abstract
The incidence of acute pancreatitis continues to increase worldwide, and it is one of the most common gastrointestinal causes for hospital admission in the USA. In the past decade, substantial advancements have been made in our understanding of the pathophysiological mechanisms of acute pancreatitis. Studies have elucidated mechanisms of calcium-mediated acinar cell injury and death and the importance of store-operated calcium entry channels and mitochondrial permeability transition pores. The cytoprotective role of the unfolded protein response and autophagy in preventing sustained endoplasmic reticulum stress, apoptosis and necrosis has also been characterized, as has the central role of unsaturated fatty acids in causing pancreatic organ failure. Characterization of these pathways has led to the identification of potential molecular targets for future therapeutic trials. At the patient level, two classification systems have been developed to classify the severity of acute pancreatitis into prognostically meaningful groups, and several landmark clinical trials have informed management strategies in areas of nutritional support and interventions for infected pancreatic necrosis that have resulted in important changes to acute pancreatitis management paradigms. In this Review, we provide a summary of recent advances in acute pancreatitis with a special emphasis on pathophysiological mechanisms and clinical management of the disorder.
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Moody N, Adiamah A, Yanni F, Gomez D. Meta-analysis of randomized clinical trials of early versus delayed cholecystectomy for mild gallstone pancreatitis. Br J Surg 2019; 106:1442-1451. [PMID: 31268184 DOI: 10.1002/bjs.11221] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/14/2019] [Accepted: 04/03/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Gallstones account for 30-50 per cent of all presentations of acute pancreatitis. While the management of acute pancreatitis is usually supportive, definitive treatment of gallstone pancreatitis is cholecystectomy. Guidelines from the British Society of Gastroenterology suggest definitive treatment on index admission or within 2 weeks of discharge, whereas joint recommendations from the International Association of Pancreatology and the American Pancreatic Association recommend definitive treatment on index admission. Evidence suggests that uptake of these guidelines is low. METHODS Embase, MEDLINE and Cochrane databases were searched for RCTs investigating early versus delayed cholecystectomy in patients with a confirmed diagnosis of mild gallstone pancreatitis. The pooled synthesis was undertaken using a random-effects meta-analysis of the primary outcome of recurrent biliary complications causing hospital readmission. Secondary outcomes included intraoperative and postoperative complications, and total length of hospital stay (LOS). All analyses were performed using RevMan5 software. RESULTS Five RCTs were identified, which included 629 patients (318 in the early cholecystectomy (EC) group and 311 in the delayed cholecystectomy (DC) group). Recurrent biliary events that required readmission were reduced in patients undergoing EC compared with the number in patients having DC (odds ratio (OR) 0·17, 95 per cent c.i. 0·09 to 0·33). There was no difference in the rate of intraoperative (OR 0·58, 0·17 to 1·92) or postoperative (OR 0·78, 0·38 to 1·62) complications. CONCLUSION EC following mild gallstone pancreatitis does not increase the risk of intraoperative or postoperative complications, but reduces the readmission rate for recurrent biliary complications.
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Affiliation(s)
- N Moody
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - A Adiamah
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - F Yanni
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - D Gomez
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
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Lyu YX, Cheng YX, Jin HF, Jin X, Cheng B, Lu D. Same-admission versus delayed cholecystectomy for mild acute biliary pancreatitis: a systematic review and meta-analysis. BMC Surg 2018; 18:111. [PMID: 30486807 PMCID: PMC6263067 DOI: 10.1186/s12893-018-0445-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/08/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The timing of laparoscopic cholecystectomy (LC) performed after the mild acute biliary pancreatitis (MABP) is still controversial. We conducted a review to compare same-admission laparoscopic cholecystectomy (SA-LC) and delayed laparoscopic cholecystectomy (DLC) after mild acute biliary pancreatitis (MABP). METHODS We systematically searched several databases (PubMed, EMBASE, Web of Science, and the Cochrane Library) for relevant trials published from 1 January 1992 to 1 June 2018. Human prospective or retrospective studies that compared SA-LC and DLC after MABP were included. The measured outcomes were the rate of conversion to open cholecystectomy (COC), rate of postoperative complications, rate of biliary-related complications, operative time (OT), and length of stay (LOS). The meta-analysis was performed using Review Manager 5.3 software (The Cochrane Collaboration, Oxford, United Kingdom). RESULTS This meta-analysis involved 1833 patients from 4 randomized controlled trials and 7 retrospective studies. No significant differences were found in the rate of COC (risk ratio [RR] = 1.24; 95% confidence interval [CI], 0.78-1.97; p = 0.36), rate of postoperative complications (RR = 1.06; 95% CI, 0.67-1.69; p = 0.80), rate of biliary-related complications (RR = 1.28; 95% CI, 0.42-3.86; p = 0.66), or OT (RR = 1.57; 95% CI, - 1.58-4.72; p = 0.33) between the SA-LC and DLC groups. The LOS was significantly longer in the DLC group (RR = - 2.08; 95% CI, - 3.17 to - 0.99; p = 0.0002). Unexpectedly, the subgroup analysis showed no significant difference in LOS according to the Atlanta classification (RR = - 0.40; 95% CI, - 0.80-0.01; p = 0.05). The gallstone-related complications during the waiting time in the DLC group included gall colic, recurrent pancreatitis, acute cholecystitis, jaundice, and acute cholangitis (total, 25.39%). CONCLUSION This study confirms the safety of SA-LC, which could shorten the LOS. However, the study findings have a number of important implications for future practice.
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Affiliation(s)
- Yun-Xiao Lyu
- Department of Hepatobiliary Surgery, Dongyang People’s Hospital, 60 West Wuning Road, 322100, Dongyang, Zhejiang, China
| | - Yun-Xiao Cheng
- Department of Hepatobiliary Surgery, Dongyang People’s Hospital, 60 West Wuning Road, 322100, Dongyang, Zhejiang, China
| | - Hang-Fei Jin
- Department of Hepatobiliary Surgery, Dongyang People’s Hospital, 60 West Wuning Road, 322100, Dongyang, Zhejiang, China
| | - Xin Jin
- Department of Hepatobiliary Surgery, Dongyang People’s Hospital, 60 West Wuning Road, 322100, Dongyang, Zhejiang, China
| | - Bin Cheng
- Department of Hepatobiliary Surgery, Dongyang People’s Hospital, 60 West Wuning Road, 322100, Dongyang, Zhejiang, China
| | - Dian Lu
- Department of Hepatobiliary Surgery, Dongyang People’s Hospital, 60 West Wuning Road, 322100, Dongyang, Zhejiang, China
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