Changing indications for laparoscopic cholecystectomy. Stones without symptoms and symptoms without stones

Metabolic dysfunction-associated gallstone disease: expecting more from critical care manifestations

About 20% of adults worldwide have gallstones which are solid conglomerates in the biliary tree made of cholesterol monohydrate crystals, mucin, calcium bilirubinate, and protein aggregates. About 20% of gallstone patients will definitively develop gallstone disease, a condition which consists of gallstone-related symptoms and/or complications requiring medical therapy, endoscopic procedures, and/or cholecystectomy. Gallstones represent one of the most prevalent digestive disorders in Western countries and patients with gallstone disease are one of the largest categories admitted to European hospitals. About 80% of gallstones in Western countries are made of cholesterol due to disturbed cholesterol homeostasis which involves the liver, the gallbladder and the intestine on a genetic background. The incidence of cholesterol gallstones is dramatically increasing in parallel with the global epidemic of insulin resistance, type 2 diabetes, expansion of visceral adiposity, obesity, and metabolic syndrome. In this context, gallstones can be largely considered a metabolic dysfunction-associated gallstone disease, a condition prone to specific and systemic preventive measures. In this review we discuss the key pathogenic and clinical aspects of gallstones, as the main clinical consequences of metabolic dysfunction-associated disease.

Cholecystectomy for asymptomatic gallstones: Markov decision tree analysis

Gallstones are a common public health problem, especially in developed countries. There are an increasing number of patients who are diagnosed with gallstones due to increasing awareness and liberal use of imaging, with 22.6%-80% of gallstone patients being asymptomatic at the time of diagnosis. Despite being asymptomatic, this group of patients are still at life-long risk of developing symptoms and complications such as acute cholangitis and acute biliary pancreatitis. Hence, while early prophylactic cholecystectomy may have some benefits in selected groups of patients, the current standard practice is to recommend cholecystectomy only after symptoms or complications occur. After reviewing the current evidence about the natural course of asymptomatic gallstones, complications of cholecystectomy, quality of life outcomes, and economic outcomes, we recommend that the option of cholecystectomy should be discussed with all asymptomatic gallstone patients. Disclosure of material information is essential for patients to make an informed choice for prophylactic cholecystectomy. It is for the patient to decide on watchful waiting or prophylactic cholecystectomy, and not for the medical community to make a blanket policy of watchful waiting for asymptomatic gallstone patients. For patients with high-risk profiles, it is clinically justifiable to advocate cholecystectomy to minimize the likelihood of morbidity due to complications.

Is fundus first laparoscopic cholecystectomy a better option than conventional laparoscopic cholecystectomy for difficult cholecystectomy? A systematic review and meta-analysis

The gallstone disease prevalence is up to 27% in the general adult population. Though most of the patients are asymptomatic, about 1-4% of these patients became symptomatic every year and will require treatment. Fundus first laparoscopic cholecystectomy (FFLC) was first reported by Cooperman in 1990 when he utilized the approach to safely perform LC for patients with acute cholecystitis and dense adhesion around the calot's triangle which precluded safe dissection. Some surgeons reported that the FFLC may be quicker than the traditional dissection starting at the Calot's triangle, although no randomized trial has been undertaken to confirm that. We aim to perform this systematic review and meta-analysis to compare outcome of fundal first laparoscopic cholecystectomy with conventional laparoscopic cholecystectomy. Three reviewers independently searched the Pubmed, medline, google schoolar, Cochrane library and Embase databases for prospective or retrospective articles comparing outcomes of fundus first LC and conventional LC. The search terms were "retrograde cholecystectomy", "antegrade cholecystectomy", "fundus first cholecystectomy", "fundus down cholecystectomy", and "dome down cholecystectomy". Studies were selected based on predetermined criteria and data were extracted from the study for meta-analysis. Twelve studies were included for meta-analysis. Our analysis revealed that FFLC is associated with less conversion to open surgery, less time of surgery, less risk of bile duct injuries and shorter duration of hospital stay compared conventional cholecystectomy in patients with difficult cholecystectomy. In conclusion, fundus first laparoscopic cholecystectomy is a safer alternative to conventional laparoscopic cholecystectomy in patients with difficult cholecystectomy.

Gallbladder Disorders: A Comprehensive Review

Gallbladder disorders encompass a wide breadth of diseases that vary in severity. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of cholelithiasis-related disease, acute acalculous cholecystitis, functional gallbladder disorder, gallbladder polyps, gallbladder hydrops, porcelain gallbladder, and gallbladder cancer.

Cholecystectomy as a risk factor for non-alcoholic fatty liver disease development

BACKGROUND

Hepatic steatosis and gallstone disease are highly prevalent in the general population; the shared risk factors are age, ethnicity, obesity, insulin resistance, metabolic syndrome, atherosclerosis, risk of cardiovascular disease, and mortality. The presence of insulin resistance is the critical element in this association because it represents a crucial link between metabolic syndrome and non-alcoholic fatty liver disease, as well as a higher susceptibility to gallstone formation.

METHODS

An exhaustive search engine investigation of gallstone disease, cholecystectomy, and liver steatosis latest literature was made.

RESULTS

Clinical studies and systematic reviews suggest an association between gallstone disease, cholecystectomy, and hepatic steatosis.

CONCLUSION

The bidirectional relationship between liver steatosis and gallstone disease and cholecystectomy is summarized in the role of insulin resistance, lipid metabolism, bile acids signaling pathways regulated by transcription factors expression, and to the gallbladder physiological role; however, more epidemiological and experimental studies should be complemented.

Critical Care Aspects of Gallstone Disease

Approximately twenty per cent of adults have gallstones making it one of the most prevalent gastrointestinal diseases in Western countries. About twenty per cent of gallstone patients requires medical, endoscopic, or surgical therapies such as cholecystectomy due to the onset of gallstone-related symptoms or gallstone-related complications. Thus, patients with symptomatic, uncomplicated or complicated gallstones, regardless of the type of stones, represent one of the largest patient categories admitted to European hospitals. This review deals with the important critical care aspects associated with a gallstone-related disease.

Bidirectional Association between Nonalcoholic Fatty Liver Disease and Gallstone Disease: A Cohort Study

Nonalcoholic fatty liver disease (NAFLD) and gallstone disease (GD) are often found to coexist but the sequential relationship of NAFLD and GD to each other remains controversial. We prospectively evaluated the bidirectional relationship of NAFLD with GD. A cohort study was performed on Korean adults who underwent a health checkup and were followed annually or biennially for a mean of 6.0 years. Fatty liver and gallstones were diagnosed by ultrasound. NAFLD was defined as hepatic steatosis on ultrasonography in the absence of excessive alcohol use or other identifiable causes. The NAFLD severity was determined by non-invasive fibrosis markers. Among 283,446 participants without either gallstones or cholecystectomy at baseline, 6440 participants developed gallstones. Among 219,641 participants without NAFLD at baseline, 49,301 participants developed NAFLD. The multivariable-adjusted hazard ratio (95% confidence interval) for incident gallstone comparing the NAFLD group vs. the non-NAFLD group was 1.26 (1.17–1.35). Increased non-invasive fibrosis markers of NAFLD were positively associated with an increased incidence of gallstones in a graded and dose-responsive manner (p-trend < 0.01). The multivariable-adjusted hazard ratios (95% confidence intervals) for incident NAFLD comparing gallstone and cholecystectomy to no GD were 1.14 (1.07–1.22) and 1.17 (1.03–1.33), respectively. This large-scale cohort study of young and middle-aged individuals demonstrated a bidirectional association between NAFLD and GD. NAFLD and its severity were independently associated with an increased incidence of gallstones, while GD and cholecystectomy were also associated with incident NAFLD. Our findings indicate that the conditions may affect each other, requiring further studies to elucidate the potential mechanisms underlying this association.

Acute Acalculous Cholecystitis due to primary acute Epstein-Barr virus infection treated with laparoscopic cholecystectomy; a case report

Introduction

Epstein Barr virus (EBV) is a human herpes virus 4, transmitted through intimate contact between susceptible persons and asymptomatic EBV shedders. It usually presents with fever, pharyngitis and lymphadenopathy. Majority of individuals with primary EBV infection recover uneventfully. Acute Acalculous Cholecystitis (AAC) is usually seen in hospitalized and critically ill patients with major trauma, shock, severe sepsis, total parenteral nutrition and mechanical ventilation.

Case presentation

We report a 25-year- old woman presented with acute Epstein-Barr Virus (EBV)infection and hepatobiliary iminodiacetic acid (HIDA) scan confirmed presence of Acute Acalculous Cholecystitis (AAC). Conservative management was advised initially, but she had a laparoscopic cholecystectomy due to intolerable abdominal pain.

Conclusion

AAC is a rare complication of acute EBV infection and it is usually managed conservatively, although our patient had laparoscopic cholecystectomy due to intolerable abdominal pain.

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Acute Acalculous Cholecystitis (AAC) is a rare complication of acute EBV infection.

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AAC should be suspected in patient with acute EBV infection, presenting with abdominal pain.

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Management is usually conservative without surgical intervention.

Regional variations in cholecystectomy rates in Sweden: impact on complications of gallstone disease

OBJECTIVE

There are considerable variations in cholecystectomy rates between countries, but it remains unsettled whether high cholecystectomy rates prevent future gallstone complications by reducing the gallstone prevalence. The aims of this study were to investigate the regional differences in cholecystectomy rates and their relation to the incidence of gallstone complications.

MATERIAL AND METHODS

Nation-wide registry-based study of the total number of cholecystectomies in Sweden between 1998 and 2013. Data were obtained from the Swedish Inpatient Registry covering the entire population and subdivided for by the 21 different counties. Indications for the procedure were prospectively collected during the years 2006-2013 in the National Registry for Gallstone Surgery and ERCP. The detailed demography of the total number of patients undergoing cholecystectomy and its relation to the respective indications were analysed by linear regression.

RESULTS

The annual rates of cholecystectomy in the Swedish counties ranged from 100 to 207 per 100,000 inhabitants, with a mean of 157 (95% CI 145-169). The majority of cholecystectomies were done in females based on the indication biliary colic, with a peak incidence in younger ages. Cholecystectomies performed due to gallstone complications, pancreatitis and cholecystitis, were mainly carried out in the older age groups. No significant relationship could be demonstrated between cholecystectomy rates in the different regions and the respective incidences of gallstone complications.

CONCLUSIONS

There are wide regional variations in cholecystectomy rates in Sweden. The present study does not give support that frequent use of cholecystectomy in uncomplicated gallstone disease prevents future gallstone complications.

Gallbladder dysfunction: how much longer will it be controversial?

BACKGROUND

Motility disorders of the biliary tree [biliary dyskinesia, including both gallbladder dysfunction (GBD), and sphincter of Oddi dysfunction] are difficult to diagnose and to treat.

SUMMARY

There is controversy in the literature in particular regarding the criteria that should be used to select patients for cholecystectomy (CCY) in cases of suspected GBD. The current review covers the history, diagnosis, and treatment of GBD. Key Messages: Only >85% of patients with suspected GBD have relief following CCY, a much lower rate than the nearly 100% success rate following CCY for gallstone disease. Unfortunately, the literature is lacking, and there are no universally agreed-upon criteria for selecting which patients to refer for operation, although cholecystokinin (CCK)-enhanced hepatobiliary iminodiacetic acid scan is often used, with emphasis on an abnormally low gallbladder ejection fraction or pain reproduction at CCK administration. There is a clear need for large, well-designed, more definitive, prospective studies to better identify the indications for and efficacy of CCY in cases of GBD.

Addressing the appropriateness of elective colon resection for diverticulitis: a report from the SCOAP CERTAIN collaborative

OBJECTIVE

To assess the reported indications for elective colon resection for diverticulitis and concordance with professional guidelines.

BACKGROUND

Despite modern professional guidelines recommending delay in elective colon resection beyond 2 episodes of uncomplicated diverticulitis, the incidence of elective colectomy has increased dramatically in the last 2 decades. Whether surgeons have changed their threshold for recommending a surgical intervention is unknown. In 2010, Washington State's Surgical Care and Outcomes Assessment Program initiated a benchmarking and education initiative related to the indications for colon resection.

METHODS

Prospective cohort study evaluating indications from chronic complications (fistula, stricture, bleeding) or the number of previously treated diverticulitis episodes for patients undergoing elective colectomy at 1 of 49 participating hospitals (2010-2013).

RESULTS

Among 2724 patients (58.7 ± 13 years; 46% men), 29.4% had a chronic complication indication (15.6% fistula, 7.4% stricture, 3.0% bleeding, 5.8% other). For the 70.5% with an episode-based indication, 39.4% had 2 or fewer episodes, 56.5% had 3 to 10 episodes, and 4.1% had more than 10 episodes. Thirty-one percent of patients failed to meet indications for either a chronic complication or 3 or more episodes. Over the 4 years, the proportion of patients with an indication of 3 or more episodes increased from 36.6% to 52.7% (P < 0.001) whereas the proportion of those who failed to meet either clinical or episode-based indications decreased from 38.4% to 26.4% (P < 0.001). The annual rate of emergency resections did not increase significantly, varying from 5.6 to 5.9 per year (P = 0.81).

CONCLUSIONS

Adherence to a guideline based on 3 or more episodes for elective colectomy increased concurrently with a benchmarking and peer-to-peer messaging initiative. Improving adherence to professional guidelines related to appropriate care is critical and can be facilitated by quality improvement collaboratives.

Gangrenous cholecystitis: mortality and risk factors

As a serious complication of cholelithiasis, gangrenous cholecystitis presents greater mortality than noncomplicated cholecystitis. The aim of this study was to specify the risk factors on mortality. 107 consecutive patients who underwent surgery due to gangrenous cholecystitis between January 1997 and October 2011 were investigated retrospectively. The study included 60 (56.1%) females and 47 (43.9%) males, with a mean age of 60.7 ± 16.4 (21-88) years. Cardiovascular diseases were the most frequently accompanying medical issues (24.3%). Thirty-six complications (33.6%) developed in 29 patients, and surgical site infection was proven as the most common. Longer delay time prior to hospital admission, low white blood cell count, presence of diabetes mellitus, higher blood levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase and total bilirubin, pericholecystic fluid in abdominal ultrasonography, and conversion from laparoscopic surgery to open surgery were identified as risk factors affecting mortality (P < 0.001, P = 0.001, P = 0.044, P = 0.005, P = 0.049, P = 0.009, P = 0.022, P = 0.011, and P = 0.004, respectively). Longer delay time prior to hospital admission and low white blood cell count were determined as independent risk factors affecting mortality.

Acalculous gallbladder disease: the outcomes of treatment by laparoscopic cholecystectomy

INTRODUCTION

The treatment of symptomatic patients with the presence of gallstones is well established, with laparoscopic cholecystectomy being the treatment of choice for symptomatic cholelithiasis. The results of surgery in symptomatic patients without gallstones are highly variable. These patients are often referred to as having acalculous gallbladder disease and represent between 5% and 30% of laparoscopic cholecystectomies performed annually. We retrospectively reviewed the outcomes of patients who underwent laparoscopic cholecystectomy for acalculous gallbladder disease in our institution.

PATIENTS AND METHODS

We retrospectively analysed the period from February 2005 to January 2006 where 20 laparoscopic cholecystectomies had been performed specifically for a preoperative diagnosis of acalculous gallbladder disease. The histology of all laparoscopic cholecystectomies performed during this year was analysed and it was found that a further 46 patients had histological specimens that demonstrated the absence of gallstones in the presence of an intact gallbladder specimen. These patients were therefore included in the study group for acalculous gallbladder disease. All patients were sent a questionnaire comparing their state of health before and after surgery.

RESULTS

After laparoscopic cholecystectomy, 66% of patients were completely pain free. The remainder, however, experienced infrequent, moderate pain with occasional pain on eating. Following surgery, all patients were able to conduct their activities of daily living without any limitation.

CONCLUSIONS

We therefore conclude that laparoscopic surgery for patients with acalculous gallbladder disease is effective in symptom control and allowing patients to return to their normal lifestyle.

Gallbladder dyskinesia

The most appropriate means to diagnose and manage patients with suspected gallbladder dyskinesia remain contentious. A major problem relates to difficulties in clearly identifying the features that characterize biliary-like pain. Conflicting reports in the literature regarding whether symptoms alone are reliable predictors of pain relief after cholecystectomy in patients with suspected gallbladder dysfunction underscore the perceived need by clinicians for a reliable test to help confirm a clinical suspicion of gallbladder dysfunction before cholecystectomy. Most studies report use of cholecystokinin-cholescintigraphy (CCK-CS) with calculation of gallbladder ejection fraction in predicting symptom outcome after cholecystectomy in patients with suspected gallbladder dyskinesia. However, quality evidence is lacking, thereby precluding a definitive recommendation regarding its use. Nevertheless, CCK-CS may be useful when performed using a slow infusion of CCK in a well-selected patient population. Based on our clinical experience and interpretation of the literature, we currently suggest consideration of cholecystectomy to our patients based on high clinical suspicion. This is performed after adequate follow-up with trials of pharmacologic therapies and exclusion of other disease entities and counseling the patient on postoperative expectations. Clearly, a large, prospective, controlled study is needed with patients meeting the Rome definition of gallbladder dyskinesia, randomized to surgery or no surgery, and using standardized CCK-CS methods and outcome measures with long-term follow-up. This study would help us better understand the pathophysiology and optimal management of this clinically challenging condition.

Antibiotic prophylaxis for patients undergoing elective laparoscopic cholecystectomy

BACKGROUND

Cholecystectomy is a common surgical procedure. In the open cholecystectomy area, antibiotic prophylaxis showed beneficial effects, but it is not known if its benefits and harms are similar in laparoscopic cholecystectomy. Some clinical trials suggest that antibiotic prophylaxis may not be necessary in laparoscopic cholecystectomy.

OBJECTIVES

To assess the beneficial and harmful effects of antibiotic prophylaxis versus placebo or no prophylaxis for patients undergoing elective laparoscopic cholecystectomy.

SEARCH STRATEGY

We searched the The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 3, 2010), MEDLINE (1985 to August 2010), EMBASE (1985 to August 2010), SCI-EXPANDED (1985 to August 2010), LILACS (1988 to August 2010) as well as reference lists of relevant articles.

SELECTION CRITERIA

Randomised clinical trials comparing antibiotic prophylaxis versus placebo or no prophylaxis in patients undergoing elective laparoscopic cholecystectomy.

DATA COLLECTION AND ANALYSIS

Our outcome measures were all-cause mortality, surgical site infections, extra-abdominal infections, adverse events, and quality of life. All outcome measures were confined to within hospitalisation or 30 days after discharge. We summarised the outcome measures by reporting odds ratios and 95% confidence intervals (CI), using both the fixed-effect and the random-effects models.

MAIN RESULTS

We included eleven randomised clinical trials with 1664 participants who were mostly at low anaesthetic risk, low frequency of co-morbidities, low risk of conversion to open surgery, and low risk of infectious complications. None of the trials had low risk of bias. We found no statistically significant differences between antibiotic prophylaxis and no prophylaxis in the proportion of surgical site infections (odds ratio (OR) 0.87, 95% CI 0.49 to 1.54) or extra-abdominal infections (OR 0.77, 95% CI 0.41 to 1.46). Heterogeneity was not statistically significant.

AUTHORS' CONCLUSIONS

This systematic review shows that there is not sufficient evidence to support or refute the use of antibiotic prophylaxis to reduce surgical site infection and global infections in patients with low risk of anaesthetic complications, co-morbidities, conversion to open surgery, and infectious complications, and undergoing elective laparoscopic cholecystectomy. Larger randomised clinical trials with intention-to-treat analysis and patients also at high risk of conversion to open surgery are needed.

Functional gallbladder disorder: gallbladder dyskinesia

Functional gallbladder disorder, commonly referred to as gallbladder dyskinesia, is characterized by the occurrence of abdominal pain resembling gallbladder pain but in the absence of gallstones. The diagnosis and management of this condition can be confusing even for the most astute clinician. The aim of this article is to clarify the identification and management of patients with suspected functional gallbladder disorder.

Management of gallstones and gallbladder disease in patients undergoing gastric bypass

The appropriate management of gallstones and gallbladder disease in patients undergoing gastric bypass remains unknown. Several therapeutic modalities are used and include performing cholecystectomy on all patients at the time of gastric bypass, performing concomitant cholecystectomy only when patients have gallstones and performing cholecystectomy only in the presence of both symptoms and gallstones. Some groups administer ursodeoxycholic acid for gallstone prevention in the postoperative period. All treatment modalities are analyzed and their results and rationality are discussed.

Natural history of gallstone disease: Expectant management or active treatment? Results from a population-based cohort study

BACKGROUND AND AIMS

The knowledge of natural history is essential for disease management. We evaluated the natural history (e.g. frequency and characteristics of symptoms and clinical outcome) of gallstones (GS) in a population-based cohort study.

METHODS

A total of 11 229 subjects (6610 men, 4619 women, age-range: 29-69 years, mean age: 48 years) were studied. At ultrasonography, GS were present in 856 subjects (338 men, 455 women) (7.1%). GS were followed by means of a questionnaire inquiring about the characteristics of specific biliary symptoms.

RESULTS

At enrollment, 580 (73.1%) patients were asymptomatic, 94 (11.8%) had mild symptoms and 119 (15.1%) had severe symptoms. GS patients were followed up for a mean period of 8.7 years; 63 subjects (7.3%) were lost to follow up. At the end of the follow up, of the asymptomatic subjects, 453 (78.1%) remained asymptomatic; 61 (10.5%) developed mild symptoms and 66 (11.4%) developed severe symptoms. In subjects with mild symptoms, the symptoms disappeared in 55 (58.5%), became severe in 23 (24.5%), remained stable in 16 (17%); in subjects with severe symptoms, the symptoms disappeared in 62 (52.1%), became mild in 20 (16.8%) and remained stable in 37 (31.1%). A total of 189 cholecystectomies were performed: 41.3% on asymptomatic patients, 17.4% on patients with mild symptoms and 41.3% on patients with severe symptoms.

CONCLUSIONS

This study indicates that: (i) asymptomatic and symptomatic GS patients have a benign natural history; (ii) the majority of GS patients with severe or mild symptoms will no longer experience biliary pain; and (iii) a significant proportion of cholecystectomies are performed in asymptomatic patients. Expectant management still represents a valid therapeutic approach in the majority of patients.

Acute acalculous cholecystitis: a review

Although recognized for more than 150 years, acute acalculous cholecystitis (AAC) remains an elusive diagnosis. This is likely because of the complex clinical setting in which this entity develops, the lack of large prospective controlled trials that evaluate various diagnostic modalities, and thus dependence on a small data base for clinical decision making. AAC most often occurs in critically ill patients, especially related to trauma, surgery, shock, burns, sepsis, total parenteral nutrition, and/or prolonged fasting. Clinically, AAC is difficult to diagnose because the findings of right upper-quadrant pain, fever, leukocytosis, and abnormal liver tests are not specific. AAC is associated with a high mortality, but early diagnosis and intervention can change this. Early diagnosis is the crux of debate surrounding AAC, and it usually rests with imaging modalities. There are no specific criteria to diagnose AAC. Therefore, this review discusses the imaging methods most likely to arrive at an early and accurate diagnosis despite the complexities of the radiologic modalities. A pragmatic approach is vital. A timely diagnosis will depend on a high index of suspicion in the appropriate patient, and the combined results of clinical findings (admittedly nonspecific), plus properly interpreted imaging. Sonogram (often sequential) and hepatic iminodiacetic acid scans are the most reliable modalities for diagnosis. It is generally agreed that cholecystectomy is the definitive therapy for AAC. However, at times a diagnostic/therapeutic drainage via interventional radiology/surgery may be necessary and life-saving, and may be the only treatment needed.

Evaluation and management of functional biliary pain in patients with an intact gallbladder

The diagnosis and management of suspected functional biliary pain in patients with an intact gallbladder remains contentious. Major issues include the lack of a clear definition of what constitutes biliary pain, a poor understanding of its natural history and pathophysiology, and the all too common scenario of the patient who has persistent pain despite surgical removal of the gallbladder. As a consequence, symptoms alone have generally been considered to be unreliable in the diagnosis of gallbladder dysfunction, and this has led to a search for a reliable test to help confirm a clinical suspicion of gallbladder dysfunction prior to the definitive treatment, cholecystectomy. At present, cholecystokinin-cholescintigraphy with a calculation of the gallbladder ejection fraction is the most commonly used test; however, its utility in predicting symptom outcome after cholecystectomy has been questioned. The use of cholecystokinin-cholescintigraphy to determine the appropriateness for cholecystectomy appears to be most useful when performed using a slow infusion of cholecystokinin in a well-selected patient population. However, for reasons explained herein, consideration of cholecystectomy on the basis of high clinical suspicion after adequate follow-up with trials of pharmacological therapies and exclusion of other disease entities, together with counseling the patient on postoperative expectations, may be a reasonable alternative.

Estudo da incidência de coledocolitíase em pacientes com colecistite calculosa aguda e crônica submetidos à colecistectomia vídeolaparoscópica

OBJETIVO: Avaliar a incidência da coledocolitiase em pacientes submetidos à colecistectomia laparoscópica, portadores de colecistopatia calculosa aguda e crônica. O presente estudo, também, analisa se a era laparoscópica modificou a incidência e a história natural da litíase da via biliar quando compara os dados da literatura com os índices do Grupo estudado. MÉTODO: O estudo foi realizado em um Grupo de 946 pacientes, distribuídos em Grupo A de 214 pacientes de 1991-1995 e Grupo B de 732 pacientes de 1999-2007 colecistectomizados pelo método laparoscópico. O critério diagnóstico de coledocolitíase foi estabelecido por colangiofluoroscopia de rotina em todas as operações. RESULTADOS: A incidência total de coledocolitiase no Grupo A de 9,8% e no B de 5,8% não mostram diferença estatística significativa entre si e com a literatura mundial (p=0,08).Nos pacientes operados por colecistite aguda também não se observou diferença estatística entre o grupo A e B na incidência de litíase da via biliar( p=0,8). A análise dos dados nos pacientes operados por colecistite crônica revela uma taxa de coledocolitíase menor no Grupo B de 3,7% com significância estatística do que no A de 8,4% p=0,03. CONCLUSÃO: O presente estudo revela uma diminuição expressiva na incidência de coledocolitiase no Grupo B em relação ao A e a literatura mundial quando a indicação cirúrgica ocorre na fase não complicada da doença litiásica biliar. O estudo também demonstra um aumento significativo na indicação da colecistectomia laparoscópica eletiva mais precoce no Grupo B como já observado em diversas publicações da literatura médica.

Metabolic consequences of bariatric surgery

Obesity has gained prominence as a main cause of preventable illness and death in the developed world. Surgical therapy for obesity is extremely effective in terms of weight reduction and amelioration of comorbidities. Bariatric procedures are not simply cosmetic operations, however, and involve considerable manipulation of the gastrointestinal tract to induce weight loss. The metabolic consequences of these procedures can be severe if not preempted with relatively simple postoperative precautions on the part of the patient and surgeon. Modern bariatric procedures are much safer than their predecessors, but nutritional and metabolic changes must be anticipated and compensated to fully realize the benefits of surgery. The metabolic consequences of the now outdated jejunoileal bypass, and the more modern Roux-Y gastric bypass, gastroplasty, and biliopancreatic diversion, are presented here, along with specific considerations of patient populations.

Contribution of silent gallstones in gallbladder cancer

Silent (asymptomatic) gallstones are detected frequently with the widespread use of abdominal ultrasonography. The presence of gallstones is found strongly associated with gallbladder carcinoma. Studies on the natural history and most decision analysis studies do not favor prophylactic cholecystectomy for patients with silent gallstones. Gallbladder carcinoma is known to be highly aggressive and lethal disease with a poor outcome. It is rarely diagnosed early and only 10-30% patients are offered radical surgery on presentation. This has lead to a dilemma leading most surgeons to opt for an expectant management of silent gallstones. It thus raises the important question of the implications of leaving asymptomatic gallstones untouched. In this paper the author has reviewed the current understanding on silent gallstones and gallbladder carcinoma.

Twenty years after Erich Muhe: Persisting controversies with the gold standard of laparoscopic cholecystectomy

This review article is a tribute to the genius of Professor Erich Muhe, a man ahead of his times. We trace the development of laparoscopic cholecystectomy and detail the tribulations faced by Muhe. On the occasion of the twentieth anniversary of the first laparoscopic cholecystectomy, we take another look at some of the controversies surrounding this gold standard in the management of gallbladder disease.

Laparoscopic cholecystectomy for biliary dyskinesia: correlation of preoperative cholecystokinin cholescintigraphy results with postoperative outcome

BACKGROUND

A gallbladder ejection fraction (EF) on cholescintigraphy of less than 35% after cholecystokinin (CCK) has been considered to be pathophysiologic and an indication for laparoscopic cholecystectomy (LC).

METHODS

All patients undergoing LC for biliary dyskinesia between 1994 and 2001 were prospectively entered into a database. These patients were retrospectively evaluated with regard to demographics, the number of preoperative studies obtained, postoperative symptoms, and the number of postoperative studies obtained.

RESULTS

Sixty patients underwent LC for biliary dyskinesia. The mean gallbladder EF was 14%, and 75% of patients were asymptomatic postoperatively. Persistent symptoms prompted further investigation in 6% of patients with a gallbladder EF <14% and in 35% of patients with an EF between 14 and 35% (p = 0.05).

CONCLUSION

Laparoscopic cholecystectomy alleviated symptoms in 94% of patients with a gallbladder EF <14% after CCK injection. The diagnostic significance of a preoperative CCK cholescintigram (EF 14-35%) needs further investigation.

[Biliary lithiasis in childhood: therapeutic approaches]

Until recently, biliary lithiasis was considered infrequent in childhood. According to their composition, gallstones can be classified into cholesterol stones and pigment stones. The latter are mainly composed of calcium salts of unconjugated bilirubin and are divided into hard black and soft brown stones. In children, up to 75 % of gallstones are pigment stones. Their etiology is often unknown. Biliary lithiasis in children differs from that in adults and there is very little scientific evidence on the most suitable therapeutic procedures. Symptom-free stones usually have a benign course and do not require medical or surgical treatment. Symptoms are often nonspecific and include dyspepsia and chronic abdominal pain. These symptoms are an indication for ultrasonographic scan to rule out the presence of gallstones. Cholecystectomy is the definitive treatment for gallstones but is not always indicated. Medical treatment with ursodeoxycholic acid is indicated in oligosymptomatic and asymptomatic lithiasis with transparent, soft, cholesterol-rich stones and a functional bladder and in patients with a high surgical risk.

Diagnosis and management of cholecystitis and cholangitis

Cholelithiasis is a prevalent condition in Western populations. Most cases are asymptomatic but complications can occur. Acute cholangitis, cholecystitis, and gallstone pancreatitis are the most common biliary tract emergencies and are usually caused by biliary calculi. Whenever possible, acute cholecystitis should be treated with early LC. AAC is an uncommon condition usually affecting patients with significant comorbidities. Treatment is usually with percutaneous cholecystostomy, which often is also the only required therapy. Endoscopic drainage is the preferred form of biliary decompression in acute cholangitis and these patients should subsequently undergo elective LC unless unfit for surgery. Effective and optimal management of biliary tract emergencies relies on close cooperation between gastroenterologist, surgeon, and radiologist.

Surgical complications of selected gastrointestinal emergencies: pitfalls in management of the acute abdomen

Complaints referable to the abdomen are common emergency department presentations. Many of these conditions prove to be benign and self-limited, whereas others are potentially catastrophic. Because serious and benign intra-abdominal conditions share many relatively nonspecific symptoms, it is often difficult to identify patients who have life-threatening problems early in the course of their disease. Apart from relieving the patient's symptoms, the emergency physician's primary role is to detect and stabilize life-threatening conditions in a rapid and cost-effective manner.

Laparoscopic cholecystectomy for symptomatic gallstones in diabetic patients

PURPOSE

To find out whether diabetes mellitus is a risk factor in patients who undergo laparoscopic cholecystectomy because of symptomatic gallbladder stones.

PATIENTS AND METHODS

Eight hundred sixty-two patients with symptomatic gallbladder stones underwent laparoscopic cholecystectomy at our institution between January 1993 and July 2000. Age, sex, risk classification of the American Society of Anesthesiologists (ASA), laboratory tests, operative records, morbidity, and length of hospital stay for each patient were analyzed.

RESULTS

There were 184 (21%) diabetic and 678 (79%) nondiabetic patients. The ASA class I applied to 534 nondiabetic (control) patients (79%), and ASA class II to 161 diabetic (study) patients (88%). There was no significant difference between the diabetic and nondiabetic patients regarding leukocyte count, bilirubin, or amylase levels. Operative and postoperative complication rates were significantly higher in the diabetic patients. Conversion to open surgery was required in 19 of 678 patients in the control group (2.8%) and 13 of 184 in the study group (7.1%). The operative time and length of hospital stay were not significantly different in the two groups.

CONCLUSIONS

Although they had the same symptoms and laboratory findings, laparoscopic cholecystectomy in diabetic patients is associated with more morbidity and a higher conversion rate than in nondiabetic patients.

Laparoscopic cholecystectomy in the new millennium

BACKGROUND

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic cholelithiasis. Many authors-including investigators at our institution, who reported one of the initial experiences with laparoscopic cholecystectomy in July 1992-have documented a definite learning curve associated with this procedure. We present a follow-up study of our experience with laparoscopic cholecystectomy and compare these data to an earlier study of the initial experience with laparoscopic cholecystectomy at the Beth Israel Medical Center.

METHODS

We retrospectively reviewed 300 consecutive patients from March 1998 through March 1999. The patient population was epidemiologically similar to that of the original study with regard to age, sex, and American Society of Anesthesia (ASA) classification. However, whereas the initial population included only patients with chronic disease, in our study 13.7% of the patients had been admitted through the emergency room with acute stone disease of the biliary tract.

RESULTS

We found a 5.7% conversion rate, a 1% rate of major complication, and a 5.7% rate of minor complication rates, as compared to the initial study's rates of 12%, 4%, and 10%, respectively. Whereas none of the patients in the original study left the hospital on the day of surgery and only 49% were discharged within 1 day, in our group, 29 patients (10%) underwent ambulatory procedures and an additional 186 patients (62%) were discharged on the 1st post-operative day. The average duration of the operation was 90 min, which did not represent a statistical improvement over the time of 93 min reported in the earlier study.

CONCLUSIONS

Since 1992, both the conversion rate and length of stay have declined at our hospital, but operative time has remained essentially the same. These findings probably reflect a bimodal learning curve, the increase in the number of cholangiograms and additional intraoperative procedures now performed, the greater severity of gallbladder disease currently treated with laparoscopic cholecystectomy, and increases in the number of attending physicians as well as the level of residents who perform this procedure.

Comparison of quality and cost-effectiveness in the evaluation of symptomatic cholelithiasis with different approaches to ultrasound availability in the ED

Ultrasound is the imaging study of choice for the detection of gallstones, but ultrasound through medical imaging departments (MI Sono) is not readily available on an immediate basis in many emergency departments (EDs). Several studies have shown that emergency physicians can perform ultrasound themselves (ED Sono) to rule out gallstones with acceptable accuracy after relatively brief training periods, but there have been no studies to date specifically addressing the effect of ED Sono of the gallbladder on quality and cost-effectiveness in the ED. In this study, we investigated measures of quality and cost-effectiveness in evaluating patients with suspected symptomatic cholelithiasis during three different years with distinctly different approaches to ultrasound availability. The study retrospectively identified a total of 418 patients who were admitted for cholecystectomy or for a complication of cholelithiasis within 6 months of an ED visit for possible biliary colic. The percentage of patients who had gallstones documented at the first ED visit improved from 28% in 1993, when there was limited availability of ultrasound through the Medical Imaging Department (MI Sono), to 56% in 1995, when MI Sono was readily available, to 70% in 1997, when both MI Sono and ED Sono were readily available (P <.001). There were also significant differences over the 3 years in the mean number of days from the first ED visit to documentation of gallstones (19.7 in 1993, 10.7 in 1995, 7.4 in 1997, P <.001); the mean number of return visits for possible biliary colic before documentation of gallstones (1.67 in 1993, 1.24 in 1995, and 1.25 in 1997, P <.001); and the incidence of complications of cholelithiasis in the interval between the first ED visit for possible biliary colic and the date of documentation of cholelithiasis (6.8% in 1993, 5.9% in 1995, 1.5% in 1997, P =.049). The number of MI Sonos ordered by emergency physicians per case of symptomatic cholelithiasis identified increased from 1.7 in 1993 to 2.5 in 1995 and dropped back to 1.7 in 1997, when 4.2 ED Sonos per study case were also done. The cost of ED Sonos was more than offset by savings in avoiding calling in ultrasound technicians after regular Medical Imaging Department hours. The indeterminate rate for ED Sonos was 18%. Excluding indeterminates, the sensitivity of ED Sono for detection of gallstones was 88.6% (95% CI 83.1-92.8%), the specificity 98.2% (95% CI 96.0-99.3%), and the accuracy 94.8% (95% CI 92.5-96.5%). We conclude that greater availability of MI Sono in the ED was associated with improved quality in the evaluation of patients with suspected symptomatic cholelithiasis but also with increased ultrasound costs. The availability of ED Sono in addition to readily available MI Sono was associated with further improved quality and decreased costs. The indeterminate rate for ED Sono was relatively high, but excluding indeterminates, the accuracy of ED Sono was comparable with published reports of MI Sono.

[Cholelithiasis in heart transplant patients]

The incidence of cholelithiasis is increased in heart transplant recipients.

STUDY AIM

The aim of this retrospective study was to report a series of 27 heart transplant recipients operated for cholelithiasis and to assess the indications and safety of cholecystectomy in this population.

PATIENTS AND METHODS

Over a 9-year period, from January 1991 to December 1999, 27 heart transplant recipients (21 men and 6 women; mean age: 54.6 years, mainly transplanted for ischemic or dilated cardiomyopathy) underwent cholecystectomy. All patients received immunosuppressive therapy with a combination of corticosteroids and cyclosporin and 10 also received azathioprine. Five patients admitted urgently with calculous acute cholecystitis and one patient with previous gastrectomy underwent laparotomy, while the other 21 patients were operated by laparoscopy.

RESULTS

There were no postoperative deaths. In patients operated by laparoscopy, there was no conversion to laparotomy and oral immunosuppressive drugs were continued without interruption. There was one postoperative hemoperitoneum related to liver biopsy performed concomitantly. In patients operated by laparotomy, intravenous cyclosporin was necessary until return to bowel function and the only complication was a wound abscess. Mean length of hospital stay was 3.1 days after laparoscopy and 8.8 days after laparotomy.

CONCLUSION

Systematic ultrasound screening of cholelithiasis after heart transplantation is necessary because cholelithiasis carries a risk of septic complications in these patients. Laparoscopic cholecystectomy, associated with a low morbidity, is justified even in asymptomatic cases. In patients with acute cholecystitis, "open" cholecystectomy must be preferred in order to minimize the risk of biliary complications which would be very serious in these immunosuppressed patients.

Hepatobiliary surgery

The transformation of liver and biliary tract surgery into a full speciality began with the application of functional anatomy to segmental surgery in the 1950's, reinforced by ultrasound and new imaging techniques. The spectrum of gall-stone disease encountered by the hepatobiliary surgeon has changed with the laparoscopic approach to cholecystectomy. There is increased need for conservation techniques to repair the bile duct injuries that arise more often in the laparoscopic approach to cholecystectomy. These and other surgical interventions on the bile ducts should be selected as a function of risk versus benefit in relation to the patient's requirements and the institutional expertise. Bile duct cancers, including hilar cholangiocarcinoma, and gallbladder cancers have a dismal reputation, but evidence is accumulating for better survivals from aggressive approaches performed by specialist hepatobiliary surgeons. Hepatic surgery has increased in safety and effectiveness, largely due to the segmental approach, but also to experience with techniques for vascular control and exclusion used in liver transplantation. Techniques such as portal vein embolisation, which induces hypertrophy of the future remnant liver, percutaneous local tumour destruction using cryotherapy or radiofrequency tumour coagulation and more effective chemotherapy are beginning to increase the number of patients who can undergo curative resection. In liver transplantation, segmental surgery has been applied to graft reduction and to split liver grafts, and is opening new perspectives for living donor transplantation. Today the limitation to survival in primary and metastatic liver cancer lies not in the surgical technique but in the difficulty of dealing with microscopic and extrahepatic disease. Progress in these fields will enable the hepatobiliary surgeon to further extend the possibilities for proposing curative resections.

Gallstones

Gallstone disease is a common clinical problem that poses particular difficulties for our aging and increasingly obese population. Exciting new research suggests an infectious cause for most cholesterol stones. The keys to managing patients with gallstone disease are recognition of the wide spectrum of clinical disease resulting from gallstones and a flexible, multidisciplinary approach to diagnosis and treatment. The biliary tract has been a proving ground in the development of minimally invasive technology.

Nonsurgical management of gallstone disease

Cholelithiasis is a common disease in the United States associated with significant morbidity. Surgical treatment with cholecystectomy has been increasing with a significant cost to the health care system. Surgical management is not without risk. Cholecystectomy has also been associated with a significant morbidity and mortality in elderly patients. Cholecystectomies are often performed unnecessarily in gallstone patients for nonspecific symptoms. Many patients with nonspecific pain, which may have a psychogenic component, continue to experience similar pain after cholecystectomy. There are problems in determining the symptom status of patients. Patients who believe surgery will relieve symptoms may maximize their symptoms, whereas patients who are reluctant to undergo surgery may minimize their symptoms. Although cholecystectomy is the mainstay of gallstone treatment, bile acid therapy and, if available, ESWL and topical dissolution are nonsurgical treatment alternatives in selected patients. In selected cases, in particular in the elderly and in other patients at increased risk from surgery, nonsurgical management offers lower morbidity and mortality than does operative treatment. The decision for surgical versus nonsurgical management should be based on both objective selection criteria and patient choice.