Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial

One-Stage Intraoperative ERCP combined with Laparoscopic Cholecystectomy Versus Two-Stage Preoperative ERCP Followed by Laparoscopic Cholecystectomy in the Management of Gallbladder with Common Bile Duct Stones: A Meta-analysis

INTRODUCTION

Concomitant gallbladder and common bile duct (CBD) stones, known as cholecystocholedocholithiasis, are clinically prevalent. There is currently no consensus on sequential versus simultaneous management approaches, and, if simultaneous, which approach to adopt. This meta-analysis evaluates the safety and efficacy of one-stage laparoscopic cholecystectomy (LC) with intraoperative endoscopic retrograde cholangiopancreatography (ERCP) versus two-stage ERCP followed by LC for treating concomitant gallbladder and CBD stones.

METHODS

A comprehensive literature search was conducted in five databases, PubMed, Embase, Web of Science, VIP, and Wanfang, for all randomized controlled trials (RCTs), cohort and retrospective studies published up to February 2024. Data extraction was performed independently by two reviewers. The primary outcomes were CBD stone clearance rate and postoperative complications morbidity. Secondary outcomes included conversion to other procedures and length of hospital stay. Statistical analyses were performed using R (v.4.3.2) with weighted mean differences and odds ratios (ORs) calculated for continuous and dichotomous variables, respectively, with 95% confidence intervals (CIs).

RESULTS

A total of 17 studies involving 2120 patients have been included, with 898 patients receiving single-stage and 1222 patients undergoing two-stage treatment. Of these studies, 9 were RCTs and 8 were retrospective cohort study. The one-stage group demonstrated superior outcomes in terms of CBD stone clearance (OR = 2.07, p = 0.0004), overall morbidity (OR = 0.35, p < 0.0001), post-operative pancreatitis (OR = 0.49, p = 0.006), conversion to other procedures (OR = 0.38, p = 0.0006), and length of hospital stay (MD = - 2.6456, 95% CI - 3.5776; - 1.7136, p < 0.0001). No significant differences were observed in post-operative cholangitis (OR = 0.44, p = 0.12), post-operative bleeding (OR = 0.76, p = 0.47), or bile leakage (OR = 1.28, p = 0.54).

CONCLUSION

For patients with concomitant gallbladder and CBD stones, the one-stage approach combining ERCP and LC appears safer and more effective, with advantages including higher stone clearance rates, reduced postoperative complications (particularly pancreatitis), shorter hospital stays, fewer residual stones, and decreased need for additional procedures. However, additional high-quality clinical trials are needed to establish the optimal treatment approach for various patient scenarios.

Gallstones: Prevention, Diagnosis, and Treatment

Gallstones are common and affect up to 20% of the general adult population and >20% of them will develop symptoms or complications of cholelithiasis. The high risk of gallbladder stone formation can be reduced by ursodeoxycholic acid in the case of significant weight reduction resulting from diet or bariatric surgery. Laparoscopic cholecystectomy is indicated for symptomatic gallstones, as the risk of recurrence or complications increases over the course of the disease. Biliary colic is treated with nonsteroidal anti-inflammatory drugs and spasmolytics; opioids can also be used in cases of severe acute pain. Acute cholecystitis represents a common complication of gallbladder stones and a cholecystectomy should be performed early electively, i.e., within 24 hours of admission to hospital. Symptomatic bile duct stones are primarily treated endoscopically. Immediate anti-infective therapy is mandatory in acute cholangitis. Although knowledge on the genetics and pathophysiology of gallstones has increased, current treatment algorithms remain predominantly invasive, based on interventional endoscopy and surgery. Future efforts should focus on novel strategies to prevent the development of gallstones.

Usefulness of Endoscopic Retrograde Cholangiopancreatography (ERCP)-Related Procedures for Gallstone Pancreatitis

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) are said to be useful procedures for gallstone pancreatitis. However, there have been few reports on a large number of patients to whom they were used. The clinical usefulness of ERCP and EST is herein examined retrospectively.

METHODS

ERCP and EST were performed to evaluate their clinical usefulness and safety in 108 patients who had gallbladder stones from December 1985 to October 2017 and were diagnosed as having gallstone pancreatitis. Of 108 patients, 83 were mild, and 25 were severe. Following the procedures, clinical courses were observed for three years in 108 patients who underwent the treatments.

RESULTS

Cholangiogram was successfully conducted in 108 patients. Bile duct stones were noted in 90 patients, and the stones were removed after EST. Of 18 patients who did not show bile duct stone in cholangiogram, 13 patients underwent EST, while five patients taking anticoagulants completed procedures only with cholangiogram. Accidental symptom was hemorrhage in three patients (2.7%; 3/108), but it was mild and conservatively resolving. During the three-year observation period, acute cholangitis was noted in three patients (2.7%; 3/108), but no relapsing pancreatitis was noted.

CONCLUSIONS

It was suggested that ERCP and EST could be useful therapies for gallstone pancreatitis.

Timely cholecystectomy: important factors to improve guideline adherence and patient treatment

OBJECTIVE

Cholecystectomy is one of the most frequently performed surgeries in Germany and is performed as a treatment of acute cholecystitis (guideline S3 IIIB.8) and after endoscopic retrograde cholangiopancreatography for choledocholithiasis with simultaneous cholecystolithiasis (guideline S3 IIIC.6). This article examines the effects of a guideline update from 2017, which recommends prompt cholecystectomy within 24 hours of admission due to cholecystitis or within 72 hours after bile duct repair. In addition, it aims to identify reasons (eg, financial disincentives) and potential for improvement for non-adherence to the guidelines.

DESIGN

Methodologically, a retrospective analysis based on routine billing data from 84 Helios Group hospitals from 2016 and 2022, with a total of 45 393 included cases, was applied. The guideline adherence rate is used as the main outcome measure.

RESULTS

Results show the guideline updates led to a statistically significant increase in the proportion of cholecystectomy performed in a timely manner (guideline S3 IIIB.8: increase from 43% to 49%, p<0.001; guideline S3 IIIC.6: increase from 7% to 20%, p<0.001). Medical, structural and financial reasons for non-adherence could be identified.

CONCLUSION

As possible reasons for non-adherence, medical factors such as advanced age, multimorbidity and frailty could be identified. Analyses of structural factors revealed that hospitals in very rural regions are less likely to perform timely cholecystectomies, presumably due to infrastructural and personnel-capacity bottlenecks. A similar picture emerges for maximum-care hospitals, which might be explained by more severe and complex cases on average. Further evaluation indicates that an increase in and better hospital-internal participation of gastroenterologists in remuneration could lead to even greater adherence to the S3 IIIC.6 guideline.

National analysis of outcomes in timing of cholecystectomy for acute cholangitis

BACKGROUND

The present study aimed to compare outcomes between cholecystectomy on index versus delayed admission for acute cholangitis.

METHODS

The 2011-2020 Nationwide Readmissions Database was used to identify adult patients admitted for acute cholangitis who underwent cholecystectomy. Study cohorts were defined based on timing of surgery. Multivariable regressions and Royston-Parmar time-adjusted analysis were used to evaluate the association of cholecystectomy timing and outcomes.

RESULTS

Of 65,753 patients, 82.0 ​% received surgery on Index and 18.0 ​% on Delayed admissions. Following adjustment, Delayed operation was associated with significantly increased odds of mortality (AOR 1.67 [95 ​% CI 1.10-2.54]), complications (1.25 [1.13-1.40]), repair of bile duct injury (1.66 [1.15-2.41]), conversion to open (1.69 [1.48-1.93]), and 30-day readmission (3.52 [3.21-3.86]). The Delayed cohort experienced a +$14,200 increment in hospitalization costs relative to Index.

CONCLUSIONS

Delayed cholecystectomy for acute cholangitis is significantly associated with adverse postoperative outcomes, suggesting that index cholecystectomy may be safe to perform.

Surgical strategies for challenging common bile duct stones in the endoscopic era: A comprehensive review of current evidence

While endoscopic retrograde cholangiopancreatography (ERCP) remains the primary treatment modality for common bile duct stones (CBDS) or choledocholithiasis due to advancements in instruments, surgical intervention, known as common bile duct exploration (CBDE), is still necessary in cases of difficult CBDS, failed endoscopic treatment, or altered anatomy. Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes. This review elucidates relevant clinical anatomy, selection indications, and outcomes to enhance surgical understanding. The selection between trans-cystic (TC) vs trans-choledochal (TD) approaches is described, along with stone removal techniques and ductal closure. Detailed surgical techniques and strategies for both the TC and TD approaches, including instrument selection, is also provided. Additionally, this review comprehensively addresses operation-specific complications such as bile leakage, stricture, and entrapment, and focuses on preventive measures and treatment strategies. This review aims to optimize the management of CBDS through laparoscopic CBDE, with the goal of improving patient outcomes and minimizing risks.

Recent Treatment Strategies for Acute Pancreatitis

Acute pancreatitis (AP) is a leading gastrointestinal disease that causes hospitalization. Initial management in the first 72 h after the diagnosis of AP is pivotal, which can influence the clinical outcomes of the disease. Initial management, including assessment of disease severity, fluid resuscitation, pain control, nutritional support, antibiotic use, and endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis, plays a fundamental role in AP treatment. Recent updates for fluid resuscitation, including treatment goals, the type, rate, volume, and duration, have triggered a paradigm shift from aggressive hydration with normal saline to goal-directed and non-aggressive hydration with lactated Ringer's solution. Evidence of the clinical benefit of early enteral feeding is becoming definitive. The routine use of prophylactic antibiotics is generally limited, and the procalcitonin-based algorithm of antibiotic use has recently been investigated to distinguish between inflammation and infection in patients with AP. Although urgent ERCP (within 24 h) should be performed for patients with gallstone pancreatitis and cholangitis, urgent ERCP is not indicated in patients without cholangitis. The management approach for patients with local complications of AP, particularly those with infected necrotizing pancreatitis, is discussed in detail, including indications, timing, anatomical considerations, and selection of intervention methods. Furthermore, convalescent treatment, including cholecystectomy in gallstone pancreatitis, lipid-lowering medications in hypertriglyceridemia-induced AP, and alcohol intervention in alcoholic pancreatitis, is also important for improving the prognosis and preventing recurrence in patients with AP. This review focuses on recent updates on the initial and convalescent management strategies for AP.

Laparoscopic cholecystectomy versus antibiotic therapy for acute cholecystitis in patients over 75 years: Randomized clinical trial and retrospective cohort study

BACKGROUND AND OBJECTIVE

The prevalence of acute cholecystitis among elderly patients is increasing. The aim of this study was to compare laparoscopic cholecystectomy (LC) to antibiotics in elderly patients with acute cholecystitis.

METHODS

A randomized multicenter clinical trial including patients over 75 years with acute calculous cholecystitis was conducted in four hospitals in Finland between January 2017 and December 2019. Patients were randomized to undergo LC or antibiotic therapy. Due to patient enrollment challenges, the trial was prematurely terminated in December 2019. To assess all eligible patients, we performed a retrospective cohort study including all patients over 75 years with acute cholecystitis during the study period. The primary outcome was morbidity. Predefined secondary outcomes included mortality, readmission rate, and length of hospital stay.

RESULTS

Among 42 randomized patients (LC n = 24, antibiotics n = 18, mean age 82 years, 43% women), the complication rate was 17% (n = 4/24) after cholecystectomy and 33% (n = 6/18, 5/6 patients underwent cholecystectomy due to antibiotic treatment failure) after antibiotics (p = 0.209). In the retrospective cohort (n = 630, mean age 83 years, 49% women), 37% (236/630) of the patients were treated with cholecystectomy and 63% (394/630) with antibiotics. Readmissions were less common after surgical treatment compared with antibiotics in both randomized and retrospective cohort patients (8% vs 44%, p < 0.001% and 11 vs 32%, p < 0.001, respectively). There was no 30-day mortality within the randomized trial. In the retrospective patient cohort, overall mortality was 6% (35/630).

CONCLUSIONS

LC may be superior to antibiotic therapy for acute cholecystitis in the selected group of elderly patients with acute cholecystitis.

Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event

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.

Prophylactic cholecystectomy offers best outcomes following ERCP clearance of common bile duct stones: a meta-analysis

BACKGROUND

Symptomatic calculus biliary disease is common with associated morbidity and occasional mortality, further confounded when there is concomitant common bile duct (CBD) stones. Choledocholithiasis and clearance of the duct reduces recurrent cholangitis, but the question is whether after clearance of the CBD if there is a need to perform a cholecystectomy. This meta-analysis evaluated outcomes in patients undergoing ERCP with or without sphincterotomy to determine if cholecystectomy post-ERCP clearance offers optimal outcomes over a wait-and-see approach.

METHODS

A Prospero registered meta-analysis of the literature using PRISMA guidelines incorporating articles related to ERCP, choledocholithiasis, cholangitis and cholecystectomy was undertaken for papers published between 1st January 1991 and 31st May 2021. Existing research that demonstrates outcomes of ERCP with no cholecystectomy versus ERCP and cholecystectomy was reviewed to determine the related key events, complications and mortality of leaving the gallbladder in situ and removing it. Odds ratios (OR) were calculated using Review Manager Version 5.4 and meta-analyses performed using OR using fixed-effect (or random-effect) models, depending on the heterogeneity of studies.

RESULTS

13 studies (n = 2598), published between 2002 and 2019, were included in this meta-analysis, 6 retrospective, 2 propensity score-matched retrospective studies, 3 prospective studies and 2 randomised control trials from a total of 11 countries. There were 1433 in the no cholecystectomy cohort (55.2%) and 1165 in the prophylactic cholecystectomy (44.8%) cohort. Cholecystectomy resulted in a decreased risk of cholecystitis (OR = 0.15; CI 0.07-0.36; p < 0.0001), cholangitis (OR = 0.51; CI 0.26-1.00; p = 0.05) and mortality (OR = 0.38; CI 0.16-0.9; p = 0.03). In addition, prophylactic cholecystectomy resulted in a significant reduction in biliary events, biliary pain and pancreatitis.

CONCLUSIONS

In patients undergoing CBD clearance, consideration should be given to performing prophylactic cholecystectomy to optimise outcomes.

Role of Biliary Stent in Recurrence of Biliary Stones and Complications After Stone Clearance in Patients Awaiting Cholecystectomy: A Randomized Trial

INTRODUCTION

The role of prophylactic biliary stenting after clearance of choledocholithiasis in patients awaiting cholecystectomy for concomitant cholelithiasis is controversial. We planned a randomized controlled trial to study the effect of prophylactic biliary stenting after achieving biliary clearance in reducing recurrence of choledocholithiasis and biliary complications in patients awaiting cholecystectomy.

METHODS

Patients with concomitant cholelithiasis and choledocholithiasis were included, and those who had evidence of clearance of choledocholithaisis (documented on occlusion cholangiogram during endoscopic retrograde cholangiography [ERC]) were randomized to prophylactic biliary stenting or no stenting. Choledocholithaisis recurrence rate (primary outcome), biliary complications and need for repeat/emergency ERC (secondary outcomes) were compared till 3 months after clearance.

RESULTS

Between September 2021 and July 2022, 70 patients were randomized into group A, stenting (n = 35), and group B, no stenting (n = 35). Sixty-six patients were included in the final analysis. Baseline characteristics were comparable between the 2 groups. Ten (15.2%) patients had recurrence of choledocholithiasis, and it was comparable between the 2 groups (7/34 [20.6%] and 3/34 [9.4%], P = 0.306). Five patients (2 cholecystitis and 3 post-ERC pancreatitis) from the stent group while none from the no stent group developed complications, and this difference was statistically significant ( P = 0.024). None of the patients in both the groups needed emergency ERC during the follow-up.

DISCUSSION

This randomized trial shows a higher complication rate with prophylactic stenting, while there is no benefit in preventing choledocholithiasis recurrence in patients waiting for cholecystectomy after biliary clearance (CTRI registration number: CTRI/2021/09/036538).

Early versus delayed laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography: A meta-analysis

PURPOSES

Patients with cholecysto- and choledocholithiasis usually undergo endoscopic retrograde cholangiopancreatography (ERCP)/-endoscopic sphincterotomy followed by laparoscopic cholecystectomy (LC). However, differences in the timing of LC after the ERCP may alter the post-operative outcomes. The aim of this study was to compare the effect of early (≤3 days) or delayed LC (>3 days) following ERCP on the post-operative outcomes.

METHODS

A comprehensive search of the 3 databases PubMed, EMBASE and the Cochrane Library was performed. Articles related to LC at different time-points after ERCP were retrieved. Dichotomous and continuous outcomes were analyzed by risk ratio (RR) and mean difference, and RevMan was used to analyze each group.

RESULTS

A total of 7 studies, including 5 randomized controlled studies and 2 retrospective studies, involved a total of 711 patients. There were 332 patients in early LC group and 379 in delayed LC group. The conversion rate was lower in the early LC group compared to the delayed LC group (RR 0.38, 95% confident interval 0.19 to 0.74, P = .005, I2 = 0%). Early LC resulted in a shorter operation time (RR -6.2, 95% CI -27.2 to -5.2, P = .004, I2 = 97%) and fewer complications (RR 0.48, 95% CI 0.29 to 0.79, P = .004, I2 = 17%). Subgroup analysis found that there were no significant differences in the conversion rate (RR 0.61, 95% CI 0.25 to 1.45, P = .26, I2 = 0%) or complications between the early LC group and the delayed group who underwent LC after 1 month.

CONCLUSION

Early LC after ERCP is the preferred treatment for patients with concurrent cholecysto- and choledocholithiasis due to improved clinical outcomes as compared to those who undergo delayed LC.

The role of cholecystectomy following endoscopic sphincterotomy and bile duct stone removal

INTRODUCTION

Choledocholithiasis is common, with patients usually treated with endoscopic retrograde cholangiopancreatography (ERCP) and subsequent cholecystectomy to remove the presumed source of common bile duct (CBD) stones. However, previous investigations into the management of patients following ERCP have focused on recurrent CBD stones, negating the risks of cholecystectomy. This article appraises the role of cholecystectomy following successful endoscopic clearance of bile duct stones.

METHODS

Patients undergoing ERCP and CBD clearance for choledocholithiasis at St James's University Hospital January 2015-December 2018 were included. Patients were divided into those who received cholecystectomy and those managed non-operatively. Readmissions, operative morbidity, mortality and treatment costs were investigated.

RESULTS

Eight hundred and forty-four patients received ERCP and CBD clearance with 3.9 years follow-up. Two hundred and nine patients underwent cholecystectomy with 15% requiring complex surgery. Three hundred and seventy-three patients were non-operatively managed. Unplanned readmissions occurred in 15% following ERCP, mostly within two years. There was no difference in readmissions between the two groups. Accounting for the entire patient pathway, non-operative management was less expensive.

CONCLUSIONS

The majority of patients do not require readmission following ERCP for CBD stones, and cholecystectomy did not reduce the risk of readmission. Few patients have recurrent CBD stones, but complex biliary surgery is frequently required. Routine cholecystectomy following ERCP needs to be re-evaluated and a more stratified approach to future risk developed.

Evidence-based clinical practice guidelines for cholelithiasis 2021

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

The Safety of Laparoscopic Cholecystectomy in Super-elderly Patients: A Propensity Score Matching Analysis

BACKGROUND

Although reports on the safety of laparoscopic cholecystectomy (LC) exist, few have included patients aged ≥ 85 years. Hence, our study aimed to evaluate surgical outcomes of LC in patients aged ≥ 85 years.

METHODS

After excluding patients who underwent other types of surgeries, 583 patients who underwent LC between 2015 and 2022 were included. Patients were classified into two groups based on age: < 85 years (control group, n = 551) and ≥ 85 years (super-elderly group, n = 32). Propensity score matching (PSM) was performed based on preoperative clinical parameters, and intraoperative and postoperative outcomes were compared.

RESULTS

After PSM, 28 patients were included in each group. Intraoperative blood loss (1 vs. 5 mL, respectively; P = .052) and frequency of serious postoperative complications (Clavien-Dindo class ≥ 2, 2/28 (7.1%) vs. 6/28 (21.4%), P = .252) were similar between the control and elderly groups. There was no significant difference in the length of postoperative stay (control group: 5 (4-24) days vs. super-elderly group: 7 (3-64) days, P = .236). Unfortunately, one case of pneumonia of unknown cause occurred postoperatively, resulting in the death of one patient in the super-elderly group.

CONCLUSIONS

There were no clinically significant differences in the short-term outcomes of LC between super-elderly patients aged ≥ 85 years and patients aged < 85 years. Hence, LC may be relatively safe even in patients aged ≥ 85 years. However, owing to many pre-existing diseases and deterioration of physiological function, careful management during the perioperative period is desirable.

Wait-and-see strategy is justified after ERCP and endoscopic sphincterotomy in elderly patients with common biliary duct stones

BACKGROUND

Older patients with simultaneous main bile duct and gallbladder stones, especially those with high-surgical risks, create a common clinical dilemma. After successful endoscopic removal of main bile duct stones, should these patients undergo laparoscopic cholecystectomy to reduce risk of recurrent biliary events? In this population-based cohort study, we report long-term outcomes of a wait-and-see strategy after successful endoscopic extraction of main bile duct stones.

METHODS

Consecutive patients 75 years or older undergoing endoscopic stone extraction without subsequent cholecystectomy in two tertiary academic centers between January 2010 and December 2018 were included. Primary outcome measure was recurrence of biliary events. Secondary outcome measures were operation-related morbidity and mortality.

RESULTS

A total of 450 patients (median age, 85 years; 61% female) were included, with a median follow-up time of 36 months (0-120 months). Recurrent biliary events occurred in 51 patients (11%), with a median time from index hospital admission to recurrence of 307 days (12-1993 days). The most common biliary event was acute cholecystitis (7.1%). Twelve patients had cholangitis (2.7%) and two biliary pancreatitis (0.4%). Only one patient (0.4%) underwent surgery due to later gallstone-related symptoms. Eighteen patients (4.0%) required endoscopic intervention and 16 (3.5%) underwent surgery. There were no operation-associated deaths or morbidity among those undergoing later surgical or endoscopic interventions.

CONCLUSION

In elderly patients, it is relatively safe to leave gallbladder in situ after successful sphincterotomy and endoscopic common bile duct stone removal. In elderly and frail patients, a wait-and-see strategy without routine cholecystectomy rarely leads to clinically significant consequences.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Revised Clinical Practice Guidelines of the Korean Pancreatobiliary Association for Acute Pancreatitis

Acute pancreatitis can range from a mild, self-limiting disease requiring no more than supportive care, to severe disease with life-threatening complications. With the goal of providing a recommendation framework for clinicians to manage acute pancreatitis, and to contribute to improvements in national health care, the Korean Pancreatobiliary Association (KPBA) established the Korean guidelines for acute pancreatitis management in 2013. However, many challenging issues exist which often lead to differences in clinical practices. In addition, with newly obtained evidence regarding acute pancreatitis, there have been great changes in recent knowledge and information regarding this disorder. Therefore, the KPBA committee underwent an extensive revision of the guidelines. The revised guidelines were developed using the Delphi method, and the main topics of the guidelines include the following: diagnosis, severity assessment, initial treatment, nutritional support, convalescent treatment, and the treatment of local complications and necrotizing pancreatitis. Specific recommendations are presented, along with the evidence levels and recommendation grades.

Is early laparoscopic cholecystectomy after clearance of common bile duct stones by endoscopic retrograde cholangiopancreatography superior?: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

With medical advancement, common bile duct stones were treated by endoscopic retrograde cholangiopancreatography (ERCP), considered the standard treatment. However, ERCP might induce complications including pancreatitis and cholecystitis that could affect a subsequent laparoscopic cholecystectomy (LC), leading to conversion to open cholecystectomy perioperative complications. It is not yet known whether or not the time interval between ERCP and LC plays a role in increasing conversion rate and complications. Bides, in the traditional sense, after ERCP, for avoiding edema performing LC was several weeks later. Even no one study could definite whether early laparoscopic cholecystectomy after ERCP affected the prognosis or not clearly.

OBJECTIVE

Comparing some different surgical timings of LC after ERCP.

METHOD

Searching databases consist of all kinds of searching tools, such as Medline, Cochrane Library, Embase, PubMed, etc. All the included studies should meet the demands of this meta-analysis. In all interest outcomes below, we took full advantage of RevMan5 and WinBUGS to assess; the main measure was odds ratio (OR) with 95% confidence. Moreover, considering the inconsistency of the specific time points in different studies, we set a subgroup to analyze the timing of LC after ERCP. For this part, Bayesian network meta-analysis was done with WinBUGS.

RESULT

In the pool of conversion rate, the result suggested that the early LC group was equal compared with late LC (OR = 0.68, I2 = 0%, P = .23). Besides, regarding morbidity, there was no significant difference between the 2 groups (OR = 0.74, I2 = 0%, P = .26). However, early LC, especially for laparoscopic-endoscopic rendezvous that belonged to performing LC within 24 hours could reduce the post-ERCP pancreatitis (OR = 0.16, I2 = 29%, P = .0003). Considering early LC included a wide time and was not precise enough, we set a subgroup by Bayesian network, and the result suggested that performing LC during 24 to 72 hours was the lowest conversion rate (rank 1: 0%).

CONCLUSION

In the present study, LC within 24 to 72 hours conferred advantages in terms of the conversion rate, with no recurrence of acute cholecystitis episodes.

Assessment of postoperative common bile duct stones after endoscopic extraction and subsequent cholecystectomy

BACKGROUND

Common bile duct stones (CBDSs) occasionally cause serious diseases, and endoscopic extraction is the standard procedure for CBDS. To prevent biliary complications, cholecystectomy is recommended for patients who present with gallbladder (GB) stones after endoscopic CBDS extraction. However, CBDS can occasionally recur. To date, the occurrence of CBDS after endoscopic CBDS extraction and subsequent cholecystectomy is not fully understood. Hence, the current study aimed to evaluate the incidence of postoperative CBDSs.

METHODS

This retrospective observational study included consecutive patients who underwent postoperative endoscopic retrograde cholangiography after endoscopic CBDS extraction and subsequent cholecystectomy between April 2012 and June 2021 at our institution. After endoscopic CBDS extraction, a biliary plastic stent was inserted to prevent obstructive cholangitis. Endoscopic retrograde cholangiography was performed to evaluate postoperative CBDSs after cholecystectomy until hospital discharge. The outcomes were the incidence of postoperative CBDSs and CBDSs/sludge. Moreover, the predictive factors for postoperative CBDSs were evaluated via univariate and multivariate analyses.

RESULTS

Of eligible 204 patients, 52 patients (25.5%) presented with postoperative CBDSs. The incidence rate of CBDS/sludge was 36.8% (n = 75). Based on the univariate analysis, the significant predictive factors for postoperative CBDSs were ≥ 6 CBDSs, presence of cystic duct stones, and ≥ 10 GB stones (P < 0.05). Moreover, male sex and < 60-mm minor axis in GB might be predictive factors (P < 0.10). Based on the multivariate analysis, ≥ 6 CBDSs (odds ratio = 6.65, P < 0.01), presence of cystic duct stones (odds ratio = 4.39, P < 0.01), and ≥ 10 GB stones (odds ratio = 2.55, P = 0.01) were independent predictive factors for postoperative CBDSs.

CONCLUSIONS

The incidence of postoperative CBDS was relatively high. Hence, patients with predictive factors for postoperative CBDS must undergo imaging tests or additional endoscopic procedure after cholecystectomy.

National clinical practice guidelines for the treatment of symptomatic gallstone disease: 2021 recommendations from the Danish Surgical Society

BACKGROUND AND OBJECTIVE

Gallstones are highly prevalent, and more than 9000 cholecystectomies are performed annually in Denmark. The aim of this guideline was to improve the clinical course of patients with gallstone disease including a subgroup of high-risk patients. Outcomes included reduction of complications, readmissions, and need for additional interventions in patients with uncomplicated gallstone disease, acute cholecystitis, and common bile duct stones (CBDS).

METHODS

An interdisciplinary group of clinicians developed the guideline according to the GRADE methodology. Randomized controlled trials (RCTs) were primarily included. Non-RCTs were included if RCTs could not answer the clinical questions. Recommendations were strong or weak depending on effect estimates, quality of evidence, and patient preferences.

RESULTS

For patients with acute cholecystitis, acute laparoscopic cholecystectomy is recommended (16 RCTs, strong recommendation). Gallbladder drainage may be used as an interval procedure before a delayed laparoscopic cholecystectomy in patients with temporary contraindications to surgery and severe acute cholecystitis (1 RCT and 1 non-RCT, weak recommendation). High-risk patients are suggested to undergo acute laparoscopic cholecystectomy instead of drainage (1 RCT and 1 non-RCT, weak recommendation). For patients with CBDS, a one-step procedure with simultaneous laparoscopic cholecystectomy and CBDS removal by laparoscopy or endoscopy is recommended (22 RCTs, strong recommendation). In high-risk patients with CBDS, laparoscopic cholecystectomy is suggested to be included in the treatment (6 RCTs, weak recommendation). For diagnosis of CBDS, the use of magnetic resonance imaging or endoscopic ultrasound prior to surgical treatment is recommended (8 RCTs, strong recommendation). For patients with uncomplicated symptomatic gallstone disease, observation is suggested as an alternative to laparoscopic cholecystectomy (2 RCTs, weak recommendation).

CONCLUSIONS

Seven recommendations, four weak and three strong, for treating patients with symptomatic gallstone disease were developed. Studies for treatment of high-risk patients are few and more are needed.

ENDORSEMENT

The Danish Surgical Society.

Management of choledocholithiasis in the elderly: Same-admission cholecystectomy remains the standard of care

BACKGROUND

Current guidelines recommend that patients with choledocholithiasis undergo same-admission cholecystectomy. The compliance with this guideline is poor in elderly patients. We hypothesized that elderly patients treated with endoscopic retrograde cholangiopancreatography (ERCP) alone would have higher complication and readmission rates than the patients treated with cholecystectomy.

METHODS

The Nationwide Readmissions Database was queried for all patients aged ≥65 years with admission for choledocholithiasis January to June 2016. The patients were divided based on index treatment received: (1) no intervention; (2) ERCP alone; or (3) cholecystectomy. Multivariate analyses identified predictors of cholecystectomy during index admission and of readmissions.

RESULTS

A total of 16,121 patients with choledocholithiasis were admitted; 38.4% underwent cholecystectomy, 37.6% endoscopic retrograde cholangiopancreatography alone, and 24.0% no intervention. The patients not receiving a cholecystectomy were more likely to be older, female, have a higher Elixhauser score, do-not-resuscitate status, and at a teaching hospital (all P < .001). Emergency readmissions for recurrent biliary disease were lowest in patients undoing a cholecystectomy (2.2% vs 9.2% endoscopic retrograde cholangiopancreatography and 12.4% no intervention, P < .001), as were readmissions for complications (3.6% vs 5.5% and 7.8%, P < .001). Cholecystectomy reduced rates of readmissions for recurrent disease (odds ratio 0.168, P < .001), for complications (odds ratio 0.540, P < .001), and death during readmission (odds ratio 0.503, P = .007); endoscopic retrograde cholangiopancreatography alone reduced only rates of readmissions. Age was not a predictor of readmission or death.

CONCLUSION

Index admission cholecystectomy is associated with a lower risk of readmission for biliary disease or complications, as well as death during readmission, in elderly patients. Age alone is not predictive of outcomes; surgical intervention should be guided by clinical condition, comorbidities, and patient preference.

Cholecystectomy after endoscopic sphincterotomy in elderly: A dilemma

Background/Aim: Although cholecystectomy is recommended by many guidelines after endoscopic retrograde cholangiopancreatography (ERCP) for gallstones, the necessity of cholecystectomy in geriatric patients is a matter of debate. Here we compare the outcomes of new biliary events in cholecystectomized and non-cholecystectomized patients of geriatric age after ERCP for suspected choledocholithiasis. Methods: Non-cholecystectomized patients who underwent ERCP for choledocholithiasis from 2015 to 2017 were included in this retrospective cohort study. Patients with other biliary pathologies, incomplete clearance of common bile duct stones, and those who could not be reached at follow-up were excluded from the study. Biliary events (cholecystitis, cholangitis, pancreatitis, re-ERCP) were evaluated by considering age groups in patients with and without cholecystectomy in their follow-up after sphincterotomy. Results: A total of 284 patients were followed for an average of 69.77 (0.2) months. The cumulative incidence of biliary events in cholecystectomized patients was lower (16% vs. 21.5%; P < 0.001), and cholecystectomized patients had a longer time to the occurrence of events (mean 74.49 [0.27] months vs. 73.50 [0.33] months; P = 0.03). There was no significant difference in the frequency of biliary events between elderly patients with and without cholecystectomy (P = 0.81), and the cumulative incidence of biliary events in the in situ group was significantly lower than that in the geriatric group (17.5% vs 32.6%; P = 0.03) Conclusion: Although cholecystectomy significantly reduces subsequent biliary complications in young patients, it does not provide a statistically significant benefit in geriatric patients. We believe that there may be no need for routine prophylactic cholecystectomy after endoscopic sphincterotomy in geriatric patients.

A retrospective cohort study on the optimal interval between endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy

Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) are the most important procedures for patients with choledocholithiasis and gallstones. Many studies recommend early LC after ERCP; however, there is still no consensus on the optimal interval between the two. The purpose of this study was to investigate the appropriate timing of LC after ERCP in patients with choledocholithiasis and cholecystolithiasis. We retrospectively reviewed all ERCPs in our institution from November 2014 to August 2021. All eligible 261 patients were divided into ERCP-LC1 (≤3 days), ERCP-LC2 (3-7 days), and ERCP-LC3 (>7 days). We also reviewed 90 patients with elective LC as the LC group. Procedures, treatment outcomes, and postoperative adverse events were evaluated. In a total of 1642 ERCPs, 261 eligible patients were divided into ERCP-LC1 (n = 102), ERCP-LC2 (n = 113), and ERCP-LC3 (n = 46). The ERCP-LC groups had no difference in operation time, postoperative adverse events, and open conversion rate with the LC group, but the total hospital stay and hospital stay after LC were longer than the LC group. There were no differences between the ERCP-LC groups in operation time, hospital stay after LC, open conversion rate, postoperative adverse events, and efficacy. However, LC within 7 days and even 3 days after ERCP had significant advantages in improvement in total length of stay and medical expenses. Furthermore, we also found an increased risk of gallbladder gangrene and perforation in LC >7 days after ERCP. LC within 7 days and even 3 days after ERCP is a safe, effective, and economical method for patients with choledocholithiasis and gallstones.

Endoscopic Management of Complex Biliary Stones

Complex biliary stones may be challenging to remove with standard endoscopic techniques. Factors contributing to complexity include large stone size (≥15 mm), multiple stones, high stone:distal duct ratio, stones above strictures and those in difficult anatomic position. In these cases, additional techniques may be needed, such as endoscopic papillary large balloon dilatation, mechanical lithotripsy, cholangioscopic visually directed lithotripsy, and extracorporeal shockwave lithotripsy. The choice of technique depends on local expertise and resources. Cases should be planned to identify the appropriate technique to avoid multiple procedures. This article describes the factors linked to difficulty and the steps to overcome them.

Optimal Timing of Cholecystectomy in Secondary Choledocholithiasis Patients Who Underwent Preoperative Endoscopic Retrograde Cholangiopancreatography

Secondary choledocholithiasis occurs when stones leave the gallbladder. After therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with stone removal, cholecystectomy should be performed to prevent recurrence. However, the optimal timing for cholecystectomy in secondary choledocholithiasis patients is unclear. The aim of this study was to determine the optimal timing for laparoscopic cholecystectomy in patients with secondary choledocholithiasis. In total, 22,996 patients in the Taiwan National Health Insurance Research Database (NHIRD) who underwent laparoscopic cholecystectomy for acute cholecystitis from 1998–2015 were divided into three groups according to whether they underwent surgery as an inpatient (early cholecystectomy (ELC)), within 2 months of admission (intermediate cholecystectomy (ILC)), or 2 months after admission (delayed cholecystectomy (DLC)). The primary outcomes included the recurrence, complication, and mortality rates. After adjusting for confounders, according to the 2013 Tokyo guidelines (cut-off at 2013), a subgroup analysis showed that, compared to the ELC group, the ILC group had lower recurrence, complication, and mortality rates, whereas the DLC group exhibited statistically significantly higher recurrence and mortality rates. In conclusion, the optimal timing of cholecystectomy in secondary choledocholithiasis patients after preoperative ERCP is within 2 months (ILC) after hospital admission. Moreover, ELC is associated with a measurable risk of complications.

Endoscopic Sphincterotomy for Cholecysto-Choledocholithiasis Complicates Subsequent Laparoscopic Cholecystectomy: A Retrospective Report From Sri Lanka

Objective: Published literature so far has supported the fact that patients who underwent endoscopic retrograde cholangio-pancreatography and sphincterotomy (ERCPS) had a difficult perioperative course after subsequent laparoscopic cholecystectomy. Through a retrospective study, this original report mentions statistics in a Southeast Asian population comparing the effect on conversion to open surgery in patients undergoing laparoscopic cholecystectomy after ERCPS in a university hospital in Sri Lanka.

Methods: The results of 205 patients who underwent laparoscopic cholecystectomy and 85 patients who were converted to open surgery between 2016 and 2018 were analyzed to find out whether ERCPS is a risk factor for conversion or subsequent perioperative morbidity.

Results: Demographics like age, gender and previous abdominal surgeries were comparable between the two groups. Cholecysto-choledocholithiasis and undergoing ERCPS for it were significant factors associated with conversion to open cholecystectomy.

Conclusion: Performing laparoscopic cholecystectomy after ERCPS for cholecysto-choledocholithiasis is a significant challenge and preferably should be often handled by a more experienced surgeon.

Optimal timing of laparoscopic cholecystectomy post-endoscopic retrograde cholangiography and common bile duct clearance: A prospective observational study

Background:

The treatment of patients with cholelithiasis with common bile duct (CBD) stones is CBD clearance with cholecystectomy. While traditional teachings advocate waiting for 4–6-week post-endoscopic retrograde cholangiography (ERCP) with CBD clearance, recent studies favour an early laparoscopic cholecystectomy (LC). Hence, this study was conducted to evaluate the optimal timing of LC post-ERCP.

Methods:

We conducted a prospective observational study between March 2017 and October 2018. Patients diagnosed with cholelithiasis and CBS stones on ultrasonography or computed tomography were included. They were assigned to one of two groups (<2 weeks and >2 weeks) based on the time interval between ERCP and subsequent LC. Chi-square test was used to analyse the intraoperative and post-operative outcomes between the two study groups,

Results:

One hundred and forty patients were included in the study of which 69 underwent an early LC (<2 weeks). There was a significant decrease in the blood loss and incidence of bowel injury in the early group. Calots triangle was better defined and critical view of safety was achieved more in the patients who underwent an early LC. This resulted in a significantly lower incidence of drain placement and length of hospital stay in those patients who underwent an early LC.

Conclusion:

A delay of 2 weeks after ERCP makes the LC more difficult and is associated with a longer hospital stay. We advocate LC within 2 weeks of ERCP whenever feasible.

Long-Term Outcomes of Elderly Patients Managed Without Early Cholecystectomy After Endoscopic Retrograde Cholangiopancreatography and Sphincterotomy for Choledocholithiasis

Background

Prophylactic cholecystectomy following endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP-S) remains the gold standard management of choledocholithiasis. Some clinicians propose ERCP-S alone as the definitive management in the elderly, given perioperative complication risks. This retrospective cohort study aimed to assess the long-term efficacy and safety of non-operative management of choledocholithiasis in adults aged ≥70.

Methodology

A total of 252 patients aged ≥70 underwent ERCP from 2004 to 2014 at a single institution. The rates of cholecystectomy, ERCP, complications, and mortality were gathered. Data were linked to a provincial health database to capture follow-up visits to alternate hospitals. Predictors of operation, recurrence, and mortality were analyzed using multivariable regression.

Results

Following ERCP, of the 252 patients, 33 (13.1%) underwent prophylactic cholecystectomy within three months, while 219 (86.9%) were initially managed conservatively. Of the 219 patients, 147 (67.1%) experienced no further choledocholithiasis after conservative management, while 23 (10.5%) patients underwent cholecystectomy. The mean follow-up was 2.9 years. Delayed operative patients were younger (mean age: 77.56 vs. 82.90; p < 0.001) and had lower Charlson Comorbidity Index (CCI) (1.04 vs. 1.84; p = 0.030). When adjusted for age, CCI score, and sex, cholecystectomy was associated with increased survival, with an odds ratio of 0.48 (95% confidence interval = 0.26-0.90; p = 0.021). Perioperative complications occurred in 7/56 (12.5%) patients.

Conclusions

Recurrent choledocholithiasis is common in elderly patients. Despite recurrent symptoms, these patients are unlikely to undergo cholecystectomy. Surgeons operate on patients with greater life expectancy and fewer comorbidities with high success despite advanced patient age. Future prospective studies should examine objective criteria for prophylactic cholecystectomy in this population, given purported safety and benefits.

Comparison of the efficacy and safety between palliative biliary stent placement and duct clearance among elderly patients with choledocholithiasis: a propensity score-matched analysis

Objectives

This study aimed to evaluate and compare the outcomes of palliative endoscopic biliary stenting (EBS) and complete stone removal among elderly patients with choledocholithiasis using propensity score matching.

Methods

From April 2012 to October 2017, 161 patients aged 75 years and older with choledocholithiasis underwent endoscopic retrograde cholangiopancreatography at our institution. Among them, 136 (84.5%) had complete stone removal, and 25 (15.5%) underwent palliative EBS without further intervention until symptom occurrence. The median age of the EBS group was significantly higher than that of the complete stone removal group. The proportion of patients with dementia, cerebral infarction, preserved gallbladder with gallstones, and surgically altered anatomy was higher in the EBS group than in the complete stone removal group. Propensity score matching was used to adjust for different factors. In total, 50 matched patients (n = 25 in each group) were analyzed.

Results

The median duration of cholangitis-free periods was significantly shorter in the EBS group (596 days) than in the complete stone removal group. About half of patients in the EBS group required retreatment and rehospitalization for cholangitis during the observation period. Cholangitis was mainly caused by stent migration. There was no significant difference in terms of mortality rate and procedure-related adverse events between the two groups. Death was commonly attributed to underlying diseases. However, one patient in the EBS group died due to severe cholangitis.

Conclusions

Palliative EBS should be indicated only to patients with choledocholithiasis who have a poor prognosis.

Clinical Impact of Preoperative Relief of Jaundice Following Endoscopic Retrograde Cholangiopancreatography on Determining Optimal Timing of Laparoscopic Cholecystectomy in Patients with Cholangitis

Background: About 10% of patients with gallbladder (GB) stones also have concurrent common bile duct (CBD) stones. Laparoscopic cholecystectomy (LC) after removal of CBD stones using endoscopic retrograde cholangiopancreatography (ERCP) is the most widely used method for treating coexisting gallbladder and common bile duct stones. We evaluated the optimal timing of LC after ERCP according to clinical factors, focusing on preoperative relief of jaundice. Methods: A total of 281 patients who underwent elective LC after ERCP because of choledocholithiasis and cholecystolithiasis from January 2010 to April 2018 were retrospectively reviewed. We compared the hospital stay, perioperative morbidity, and rate of surgical conversion to open cholecystectomy according to the relief of jaundice before surgery. These enrolled patients were divided into two groups: relief of jaundice before surgery (group 1, n = 125) or not (group 2, n = 156). Results: The initial total bilirubin level was higher in group 1; however, there were no significant differences in the other baseline characteristics including age, sex, American Society of Anesthesiologists score, previous surgical history, white blood cell count, C-reactive protein, and operative time between the two groups. There was also no significant difference in postoperative hospital stay between the two groups (4.5 ± 3.3 vs. 5.5 ± 5.6 days, p = 0.087). However, after ERCP, the waiting time until LC was significantly longer in group 1 (5.0 ± 4.9 vs. 3.5 ± 2.4 days, p < 0.001). There were no statistical differences in the conversion rate (3.2% vs. 3.8%, p = 0.518) or perioperative morbidity (4.0% vs. 5.8%, p = 0.348), either. Conclusions: LC would not be delayed until the relief of jaundice after ERCP since there were no significant differences in perioperative morbidity or surgical conversion rate to open cholecystectomy. Early LC after ERCP may be feasible and safe in patients with cholangitis and cholecystolithiasis.

Clinical Impact of Common Bile Duct Angulation on the Recurrence of Common Bile Duct Stone: A Meta-analysis and Review

Background/Aims

Local and systemic factors, such as diabetes, obesity, and hyperlipidemia, are considered risk factors for the recurrence of choledocholithiasis after successful endoscopic clearance. Local factors include the presence of bile sludge, common bile duct (CBD) diameter, and CBD angulation. Among them, it is unclear if acute CBD angulation is preferable to the recurrence of a CBD stone.

Methods

PubMed, EMBASE, CINAHL, the Cochrane Library databases, and google website were searched for randomized controlled trials reported in English and undertaken until August 2019. Meta-analysis was performed on all randomized controlled trials for the recurrence of CBD stones between the patients with acute CBD angulation.

Results

Eight randomized trials (1,776 patients) were identified, and the total recurrent rate of CBD stones was 18.8% (334/1,776). A CBD angle ≤145° was significantly associated with an increased risk of recurrent CBD stone (OR=2.65, p<0.01). In two prospective studies, acute CBD angulation was not proven to be associated with a recurrence (p=0.39).

Conclusions

Approximately 20% of patients with a CBD stone showed recurrence after the complete clearance of the CBD stone, and a CBD angle ≤145° could increase the risk of recurrence. Overall, a large-scale prospective study should be necessary.

Impact of early cholecystectomy on the readmission rate in patients with acute gallstone cholangitis: a retrospective single-centre study

BACKGROUND AND AIMS

The pathogenesis of acute cholangitis (AC) occurs with biliary obstruction followed by bacterial growth in the bile duct. The leading cause of AC is obstructing gallstones. There have been conflicting theories about the optimal timing for cholecystectomy following AC. The aim of this study is to assess the impact of early cholecystectomy on the 30-day readmission rate, 30-day mortality, 90-day readmission rate and the length of hospital stay.

METHODS

This retrospective study was performed between January 2015 and January 2021 in a high-volume tertiary referral teaching hospital. Included patients were 18 years or older with a definitive diagnosis of acute gallstone cholangitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) with complete clearance of the bile duct as an index procedure. We divided the patients into two groups: patients who underwent ERCP alone and those who underwent ERCP with laparoscopic cholecystectomy (LC) on the same admission (ERCP+LC). Data were extracted from electronic medical records. The primary endpoint of the study was the 30-day readmission rate.

RESULTS

A total of 114 patients with AC met the inclusion criteria of the study. The ERCP+LC group had significantly lower rates of 30-day readmission (2.2% vs 42.6%, p<0.001), 90-day readmission (2.2% vs 30.9%, p<0.001) and 30-day mortality (2.2% vs 16.2%, p=0.017) when compared with the ERCP group. In a multivariate logistic regression analysis, patients in the ERCP+LC group had 90% lower odds of 30-day readmission compared with patients who did not undergo LC during admission (OR=0.1, 95% CI (0.032 to 0.313), p<0.001).

CONCLUSION

Performing LC on same day admission was associated with a decrease in 30-day and 90-day readmission rate as well as 30-day mortality.

Systematic review and meta-analysis of gallstone disease treatment outcomes in early cholecystectomy versus conservative management/delayed cholecystectomy

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.

Delayed cholecystectomy following endoscopic retrograde cholangio-pancreatography is not associated with worse surgical outcomes

BACKGROUND

There is no universal consensus on the optimal timing of cholecystectomy following endoscopic retrograde cholangio-pancreatography (ERCP). This study aims to evaluate the effect of time delay and post-ERCP complications on cholecystectomy outcomes.

MATERIALS AND METHODS

All patients who underwent pre-op ERCP for concurrent cholelithiasis and choledocholithiasis between January 2009 and August 2019 at University Hospitals Plymouth, UK, were included. Patients who underwent single-stage cholecystectomy and common bile duct exploration were excluded from the study. Based on the delay to cholecystectomy, the patients were divided into early (within 2 weeks), intermediate (2-6 weeks) and late (> 6 weeks) groups. The operative outcomes between the three groups were compared.

RESULTS

We included 444 patients in the study, with 62 (14%), 90 (20%) and 292 (66%) patients in the early, intermediate and late groups, respectively. The median duration from ERCP to cholecystectomy was 75 days. There was no statistically significant difference in the conversion-to-open rate, bile leak rate or retained stones between the three groups. The median post-operative hospital stay (PHS) was 2, 2 and 1 day (P = 0.005) in the early, intermediate and late groups, respectively. The readmission rate was significantly more in the delayed group (3.2%, 11.1% and 13.7%; P = 0.05). Patients who suffered post-ERCP complications had a significantly longer PHS (4 vs 1 day, P = 0.001) and had higher conversion-to-open rate (16 vs 4.5%, P = 0.04).

CONCLUSION

Delayed cholecystectomy following ERCP is not associated with worse peri-operative outcomes and can facilitate more day-case surgery. However, early cholecystectomy can significantly reduce readmissions with gallstone-related symptoms and its associated hospital stay. Post-ERCP complications lead to a difficult cholecystectomy.

Outcomes of same admission cholecystectomy and endoscopic retrograde cholangiopancreatography for common bile duct stones: A post hoc analysis of an Eastern Association for the Surgery of Trauma multicenter study

BACKGROUND

The optimal timing for cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) stones is unknown. We hypothesized that a delay between procedures would correlate with more biliary complications and longer hospitalizations.

METHODS

We prospectively identified patients who underwent same admission cholecystectomy after ERCP for CBD stones from 2016 to 2019 at 12 US medical centers. The cohort was stratified by time between ERCP and cholecystectomy: ≤24 hours (immediate), >24 to ≤72 hours (early), and >72 hours (late). Primary outcomes included operative duration, postoperative length of stay, (LOS), and hospital LOS. Secondary outcomes included rates of open conversion, CBD explorations, biliary complications, and in-hospital complications.

RESULTS

For the 349 patients comprising the study cohort, 33.8% (n = 118) were categorized as immediate, 50.4% (n = 176) as early, and 15.8% (n = 55) as late. Rates of CBD explorations were lower in the immediate group compared with the late group (0.9% vs. 9.1%, p = 0.01). Rates of open conversion were lower in the immediate group compared with the early group (0.9% vs. 10.8%, p < 0.01) and in the immediate group compared with the late group (0.9% vs. 10.9%, p < 0.001). On a mixed-model regression analysis, an immediate cholecystectomy was associated with a significant reduction in postoperative LOS (β = 0.79; 95% confidence interval, 0.65-0.96; p = 0.02) and hospital LOS (β = 0.68; 95% confidence interval, 0.62-0.75; p < 0.0001).

CONCLUSION

An immediate cholecystectomy following ERCP correlates with a shorter postoperative LOS and hospital LOS. Rates of CBD explorations and conversion to open appear more common after 24 hours.

LEVEL OF EVIDENCE

Therapeutic, level III.

Role of Prophylactic Cholecystectomy After Endoscopic Sphincterotomy for Biliary Stone Disease: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this study was to perform a structured systematic review and meta-analysis to evaluate the effectiveness and complication rate of cholecystectomy deferral versus prophylactic cholecystectomy among patients post-endoscopic biliary sphincterotomy for common bile duct stones.

BACKGROUND

Although previous reports suggest a decreased risk of biliary complications with prophylactic cholecystectomy, biliary endoscopic cholangiopancreatography (ERCP) with sphincterotomy may provide a role for deferring cholecystectomy with the gallbladder left in situ.

METHODS

Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed through August 2019 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. Measured outcomes included: mortality, recurrent biliary pain or cholecystitis, pancreatitis, cholangitis, and eventual need for cholecystectomy. Random effects models were used to determine pooled effect size and corresponding 95% confidence intervals (CIs).

RESULTS

Nine studies (n = 1605) were included. A total of 53.8% (n = 864) patients had deferred cholecystectomy post-sphincterotomy. Deferral cholecystectomy as compared to prophylactic cholecystectomy resulted in a significant increased risk of mortality [odds raio (OR) 2.56 (95% confidence interval, CI 1.54-4.23); P < 0.0001; I2 = 18.49]. Patients who did not undergo prophylactic cholecystectomy developed more recurrent biliary pain or cholecystitis [OR 5.10 (95% CI 3.39-7.67); P < 0.0001; I2 = 0.00]. Rate of pancreatitis [OR 3.11 (95% CI 0.99-9.83); P = 0.053; I2 = 0.00] and cholangitis [OR 1.49 (95% CI 0.74-2.98); P = 0.264; I2 = 0.00] was unaffected. Overall, 26.00% (95% CI 14.00-40.00) of patients with deferred prophylactic cholecystectomy required eventual cholecystectomy.

CONCLUSIONS

Prophylactic cholecystectomy remains the preferred strategy compared to a deferral approach with gallbladder in situ post-sphincterotomy for patients with bile duct stones. Future studies may highlight a subset of patients (ie, those with large balloon biliary dilation) that may not require cholecystectomy.

Incidence and risk factors for postoperative common bile duct stones in patients undergoing endoscopic extraction and subsequent cholecystectomy

BACKGROUND AND AIMS

In patients who undergo cholecystectomy after endoscopic common bile duct (CBD) stone extraction, CBD stones found postoperatively could be problematic. This study aimed to investigate the incidence and risk factors of postoperative CBD stones after cholecystectomy.

METHODS

A total of 278 patients (mean age, 59.2 years; 71 men [51.1%]) who underwent endoscopic removal of CBD stones followed by cholecystectomy from January 2013 to December 2017 were included. An endoscopic nasobiliary drainage (ENBD) tube was placed immediately after endoscopic clearance of the CBD stones in all patients until cholecystectomy. An ENBD tubogram was obtained in all patients to determine the presence of postoperative CBD stones.

RESULTS

Postoperative CBD stones were detected in 20.1% (56/278). An ENBD tubogram was obtained after an average of 2.42 days postoperatively. Based on univariate analysis, the statistically significant risk factors for postoperative CBD stone were CBD stones >2, CBD stone size >10 mm, cholesterol stone, maximum diameter of CBD >15 mm, treatment with endoscopic sphincterotomy alone, and use of endoscopic mechanical lithotripsy (EML). In multivariate analysis, cholesterol stone, CBD stones >2, CBD stone size >10 mm, and EML were related to postoperative CBD stones after cholecystectomy.

CONCLUSIONS

Based on the relatively high rate of postoperative CBD stones after cholecystectomy, careful follow-up should be considered in patients with high-risk factors to detect CBD stones early.

The Impact of Laparoscopic Cholecystectomy on 30-Day Readmission Rate for Acute Cholangitis Patients: A Single-Center Study

OBJECTIVES

Laparoscopic cholecystectomy (LC) following acute gallstone cholangitis reduces the recurrence of biliary symptoms; however, the timing of LC has not been determined yet. The aim of our study was to evaluate the impact of performing LC during admission on the 30-day readmission rate.

METHODS

We conducted a retrospective cohort study of acute gallstone cholangitis patients who underwent endoscopic clearance (EC) of the bile duct through endoscopic retrograde cholangiopancreatography between April 2013 and May 2018. Patients were classified into two groups: EC only group and EC followed by LC during admission (EC + LC) group. The primary outcome was the 30-day readmission rate.

RESULTS

A total of 95 patients with acute cholangitis were included in the analysis. Of these patients, 35 patients (36.8%) underwent LC during admission. The 30-day readmission rate was significantly lower in the EC + LC group compared to the EC group (2.9% vs. 26.7%, P 0.003). In a multivariate regression analysis, patients who underwent LC during admission had 90% lower odds of readmission within 30 days compared to patients who did not (OR 0.1, 95% CI (0.01-0.9), P 0.04).

CONCLUSIONS

Performing laparoscopic cholecystectomy during admission for acute gallstone cholangitis patients following endoscopic clearance of the bile duct significantly reduced the 30-day readmission rate without affecting the length of stay.

Could cholecystectomy be abandoned after removal of bile duct stones by endoscopic retrograde cholangio-pancreaticography?

BACKGROUND/OBJECTIVE

The current treatment for choledocholithiasis is endoscopic common bile duct clearance followed by cholecystectomy. However, few studies have investigated whether cholecystectomy is necessary after the endoscopic removal of bile duct stones. This study aimed to determine the rate of patients without symptoms during the follow-up period after endoscopic retrograde cholangiopancreaticography (ERCP).

MATERIALS AND METHODS

We retrospectively analyzed data from patients with choledocholithiasis who underwent ERCP from a single centre.The patients were invited to the hospital for evaluation of symptoms during the follow-up period after ERCP. The primary outcome of this study was to determine the rate of patients with symptoms during the follow-up period after ERCP.

RESULTS

A total of 286 patients with a median age of 57 (18-95) years old were included in the study. Of these, 195patients (68%) remained asymptomatic during the follow-up period of 18 months (1-70) after endoscopic sphincterotomy without cholecystectomy. A total of 75(50%) out of 151 patients who underwent cholecystectomy reported having symptoms after ERCP. In contrast, 119 (88%) out of 135 patients did not undergo cholecystectomy after the ERCP, remained asymptomatic during a median follow-up period of 43 months (11-70). The estimated 5-year asymptomatic rates of the patients after ERCP were 51% for the whole cohort (n = 286) according to Kaplan-Meier analysis.

CONCLUSION

Majority of patients with choledocholithiasis who did not undergo cholecystectomy after ERCP were asymptomatic during the follow-up period. Thus, cholecystectomy may be unnecessary after endoscopic sphincterotomy for bile duct stones within a midterm period.

Challenging situations in cholecystectomy and strategies to overcome them

Background

Cholecystectomy may be difficult and hazardous, causing major morbidity and mortality. This review aims to identify situations increasing the probability of difficult gallbladders and present today’s best practice to overcome them.

Methods

Review of the literature and expert comment.

Results

One in six gallbladders is expected to be a difficult cholecystectomy. The majority can be predicted by patient history, clinical symptoms, and pre-existing comorbidities. Acute cholecystitis, mild biliary pancreatitis, prior endoscopic sphincterotomy, and liver cirrhosis are the predominant underlying diseases. Early or delayed cholecystectomy, percutaneous cholecystostomy, and pure conservative treatment are evidence-based options. Early laparoscopic cholecystectomy is of advantage in patients fit for surgery, with subtotal cholecystectomy or conversion to open surgery as bail-out strategies. The choice of the procedure depends on the experience of the surgeon.

Conclusion

Clinical decisions should follow a pathway based on patients’ risk, favoring laparoscopic cholecystectomy whenever possible. The implementation of an institutional pathway to deal with difficult gallbladders is recommended.

Bile Duct Stones Predict a Requirement for Cholecystectomy in Older Patients

BACKGROUND

The requirement for elective cholecystectomy in older patients is unclear. To determine predictors for requiring elective cholecystectomy in older patients, a prospective cohort study was performed.

METHODS

All patients with gallstone disease who presented to our department from 2006 to 2018 were included if they met the following criteria: (1) age 75 years or older, (2) presentation for elective cholecystectomy, and (3) preoperative diagnosis of cholecystolithiasis. Two therapeutic options, elective surgery and a wait-and-see approach, were offered at their initial visit. Enrolled patients were assigned to one arm of the study according to their choice of the therapeutic options. The primary endpoint was the incidence of gallstone-related complications. The endpoint was compared between patients who underwent cholecystectomy (CH group) and those who chose a wait-and-see approach (No-CH group).

RESULTS

During the study period, there were 344 patients in the CH group and 161 in the No-CH group. Among patients with a history of bile duct stones, the incidence of gallstone-related complications in the No-CH group was significantly higher (45% within 3 years, including two gallstone-related deaths) than that in the CH group (RR 2.66, 95% confidence interval 1.50-4.77, p = 0.0009). Among patients with no history of bile duct stones, the incidence of gallstone-related complications in the No-CH group reached only 10% over the 12 years.

CONCLUSION

Cholecystectomy is recommended for older patients with both histories of cholecystolithiasis and bile duct stones, whereas a wait-and-see approach is preferable for patients with no bile duct stone history. A history of bile duct stones is a good predictor for cholecystectomy in older patients.

Low-phospholipid-associated cholelithiasis syndrome: Prevalence, clinical features, and comorbidities

Background & Aims

Low-phospholipid-associated cholelithiasis (LPAC) syndrome, a rare genetic form of intrahepatic cholelithiasis in adults, is still poorly understood. We report the results of the largest-ever case-control study of patients with LPAC syndrome aiming to assess the prevalence, clinical features, and comorbidities of the disease.

Methods

We included all LPAC cases diagnosed between 2001 and 2016 in 11 French centres. Controls consisted of all patients who underwent a cholecystectomy for common gallstone disease in a single non-academic centre over 1 year. A logistic regression analysis was used to identify the clinical features associated with LPAC syndrome across several patient strata with increasing levels of diagnostic confidence. The ratio between the incident cases of LPAC syndrome and the total number of cholecystectomies for gallstones was used to assess the relative prevalence of the disease.

Results

In this study, 308 cases and 206 controls were included. LPAC syndrome accounted for 0.5–1.9% of all patients admitted with symptomatic gallstone disease. Age at first symptoms <40 years, absence of overweight, persistence of symptoms after cholecystectomy, intrahepatic micro- or macrolithiasis, common bile duct (CBD) lithiasis, and no history of cholecystitis were independently associated with LPAC diagnosis. ATP-binding cassette subfamily B member 4 (ABCB4) variants, present in 46% of cases, were associated with CBD lithiasis, chronic elevation of gamma-glutamyltransferase (GGT), and personal or family history of hepato-biliary cancer.

Conclusions

In this case-control study, LPAC syndrome accounted for approximately 1% of symptomatic cholelithiasis in adults. In addition to pre-established diagnostic criteria, normal weight, CBD lithiasis, and no history of cholecystitis were significantly associated with the syndrome. ABCB4 gene variations in patients with LPAC were associated with CBD lithiasis, chronic cholestasis, and a personal or family history of hepato-biliary cancer.

Lay summary

In the largest case-control study ever conducted in patients with LPAC syndrome, a rare genetic form of intrahepatic cholelithiasis in young adults, LPAC syndrome was found in approximately 1% of all patients admitted to the hospital for symptomatic gallstones and, in addition to the pre-established characteristics of the syndrome (age at first symptoms <40 years, recurrence of symptoms after cholecystectomy, and/or imaging evidence of intrahepatic microlithiasis), was associated with lower BMI, higher prevalence of common bile duct stones, and lower incidence of acute cholecystitis. ABCB4 gene variants, which were detected in about half of cases, were associated with common bile duct stones and a personal or family history of hepato-biliary cancer.

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Low-phospholipid-associated cholelithiasis (LPAC) syndrome affects approximately 1% of adults with symptomatic cholelithiasis.

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Normal weight, common bile duct stones, and lack of cholecystitis are clinical features significantly associated with this syndrome.

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ABCB4 variants in patients with LPAC may be associated with an increased personal or family risk of hepato-biliary cancer.

Early Versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis with Mild Pancreatitis

The safety and feasibility of early laparoscopic cholecystectomy (LC) for acute cholecystitis with mild pancreatitis were explored. A total of 973 patients with acute pancreatitis, including 651 mild cases and 322 moderate or severe cases were retrospectively studied from July 2014 to December 2018 in our department. And 426 mild pancreatitis cases with acute cholecystitis were enrolled in this study, of which 328 patients underwent LC during the same-admission (early LC group), and 98 patients underwent LC a period of time after conservative treatment (delayed LC group). Clinical characteristics, operative findings and complications were recorded and followed up. The two groups were comparable in age, gender, the grade of American Society of Anesthesiologist (ASA), biochemical findings and Balthazar computer tomography (CT) rating (P>0.05). The operation interval and hospital stay in early LC group were significantly shorter than in delayed LC group (5.83±1.62 vs. 41.36±8.44 days; 11.38±2.43 vs. 16.49±3.48 days, P<0.01). There was no significant difference in the average operation time between the two groups. No preoperative biliary related events recurred in early LC group but there were 21 cases of preoperative biliary related events in delayed LC group (P<0.01). There was no significant difference in conversion rate (3.85 vs. 5.10%, P=0.41) and surgical complication rate (3.95 vs. 4.08%, P=0.95) between early LC group and delayed LC group. During the postoperative follow-up period of 375 cases, biliary related events recurred in 4 cases in early LC group and 3 cases in delayed LC group (P=0.37). The effect of early LC during the same-admission is better than delayed LC for acute cholecystitis with mild pancreatitis.

The Efficiency of Laparoscopic Common Bile Duct Exploration in Endoscopic Retrograde-Cholangiopancreatography-Limited Setting in a Peripheral University Hospital

Background: The aim of this study is to evaluate complications and costs in patients treated with laparoscopic and open method for common bile duct (CBD) stones. Secondary aim is to compare the effectiveness, safety, and outcomes of these methods. In addition, it is aimed to review the feasibility of laparoscopic method in rural areas. Methods: Seventy-one patients were analyzed retrospectively. Patients were divided into two groups as open and laparoscopic surgical method. These groups were analyzed comparatively in terms of complications and costs. Subgroups were formed from patients who underwent T-tube drainage, primary closure, and biliary anastomosis as choledochotomy management. As a secondary outcome, these three subgroups were investigated in terms of complications and cost. Results: The cost was lower in open method compared to laparoscopic method (484$, 707$, P = .002). There was no significant difference in postoperative complications between groups (P = .257). While the mean hospital stay was longer in the open group, the operation time was shorter (P = .002, P = .03). The mean length of hospital stay in the T-tube group was significantly higher than the primary closure (P = .001). The cost in the T-tube group was significantly higher than the primary closure and biliary anastomosis groups. Conclusion: Laparoscopic CBD exploration by experienced surgeons in endoscopic retrograde-cholangiopancreatography-limited settings is an effective and safe method in the treatment of choledocholithiasis. This procedure should not be limited to reference centers and should be performed safely in rural areas by well-trained surgeons.

Comparison of early and delayed cholecystectomy for biliary pancreatitis: A meta-analysis

BACKGROUND

Biliary stones are the most common etiology of acute pancreatitis Cholecystectomy has been accepted as a popular treatment for acute biliary pancreatitis (ABP) to reduce the risk of recurrent complications. However, the precise time of intervention still remains controversial.

OBJECTIVE

The aim of this meta-analysis was to compare early and delayed cholecystectomy and determine the most precise timing of cholecystectomy following gallstone pancreatitis.

METHOD

Search the publications on comparison the efficacy of early cholecystectomy comparison with delayed cholecystectomy in treatment outcomes of ABP to October, 2018. After rigorous reviewing on quality, the data was extracted from eligible trials. All trials analyzed the summary hazard ratios (HRs) of the endpoints of interest, including survival data and individual postoperative complications.

RESULTS

A total of 9 trials were met our inclusion criteria. The pooled results indicate that postoperative complications、readmission rate、conversion to an open procedure and cholecystectomy-related morbidity/mortality did not have statistical significance (P > 0.05) between the early and delayed cholecystectomy. While, the length of hospital stay was shorter for the early cholecystectomy group than the delayed group in all included studies.

CONCLUSIONS

Although the efficacy of delayed intervention in terms of inflammation reduction is definite, their adverse events are often major limitations. In the present study, an early cholecystectomy may result in a significantly shortened hospital stays without increased complications or mortality.

Cholecystectomy outcomes after endoscopic sphincterotomy in patients with choledocholithiasis: a meta-analysis

Background

Endoscopic sphincterotomy (ES) is the standard treatment for common bile duct stones. The reported findings regarding complications, such as biliary pancreatitis and cholangitis, differ between cholecystectomy after ES. The purpose of this study is to compare cholecystectomy outcomes after endoscopic treatment of common bile duct stones whether or not the incidence of recurrent pancreatitis and cholangitis is reduced, especially in high-risk patients.

Methods

We analyzed 8 studies, including 7 randomized controlled trials retrieved from the PubMed (1990–2019), Embase (1990–2019), and Cochrane (1990–2019) databases for trials comparing the two strategies for treatment of gallstones after ES. A related study on gallbladder removal after ES was acquired, followed by analysis of each group using RevMan. Risk ratios (RRs) were calculated for categorical variables and differences in means were calculated for continuous variables.

Results

We retrieved a total of 8 studies, including seven randomized controlled trials and one retrospective study. A total of 12,717 patients were included in the study (4922 in the early cholecystectomy group and 7795 in the gallbladder in situ group). During the follow-up period, 41 patients had pancreatitis after ES in the cholecystectomy group and 177 patients in the wait-and-see group. The incidence of pancreatitis in the cholecystectomy group was significantly reduced (RR, 0.38; 95% CI, 0.27–0.53; P < 0.00001; I² = 0%). The incidence of cholangitis and jaundice in the cholecystectomy group was also less than the preserved gallbladder group (RR, 0.31; 95% CI, 0.26–0.38; P < 0.00001; I² = 0%). There was no significant difference in mortality between the two groups (RR, 0.73; 95% CI, 0.52–1.02; P = 0.07; I² = 14%). There was a significant difference in cholecystitis and biliary colic (RR, 0.28; 95% CI, 0.24–0.32; P < 0.00001; I² = 17%).

Conclusion

Early cholecystectomy after removal of common bile duct stones can effectively reduce biliary complications. This is still true for high-risk patients and has no significant effect on the mortality of patients. Laparoscopic cholecystectomy is recommended after ES.

Surgical outcomes of ERCP-guided transpapillary gallbladder drainage versus percutaneous cholecystostomy as bridging therapies for acute cholecystitis followed by interval cholecystectomy

BACKGROUND

Select patients with acute cholecystitis (AC) are not candidates for index cholecystectomy. We compared the influence of ERCP-guided transpapillary gallbladder drainage (ERGD) versus percutaneous cholecystostomy (PC) on delayed cholecystectomy outcomes.

METHODS

Consecutive patients undergoing ERGD or PC for AC from January 2007 to October 2018 were included. Primary outcome was the rate of conversion to open cholecystectomy and perioperative complications in groups.

RESULTS

The study included 52 patients with ERGD and 140 with PC prior to cholecystectomy (median 68 days [IQR: 47-105.5]). Technical success was higher in the PC group (100% vs 91%; P = 0.0004). There was a nonsignificant trend to lower postoperative complications with ERGD (30.7% vs 43.5%; P = 0.07). No difference in conversion to open cholecystectomy OR: 1.5 (95% CI: 0.68-3.65; P = 0.28) or severity of complications (Clavien-Dindo grade >2) OR: 0.60, (95% CI: 0.19-1.87; P = 0.38) was noted between the ERGD and PC groups. PC was associated with higher rates of unplanned repeat intervention (16.4% vs 7.7%; P = 0.02).

CONCLUSION

ERGD is suitable for patients with AC who is candidates for delayed cholecystectomy and should be considered for gallbladder drainage in patients with concomitant choledocholithiasis or cholangitis who require ERCP.

Long-term Outcomes of Endoscopic Papillary Large-balloon Dilation for Common Bile Duct Stones

Objective Endoscopic papillary large-balloon dilation (EPLBD) for common bile duct (CBD) stone removal has been confirmed to be safe and effective in the short term. The long-term outcomes of EPLBD, which have not been sufficiently evaluated, were therefore investigated in this study. Methods For patients who had undergone endoscopic CBD stone removal with EPLBD between October 2011 and December 2015, follow-up surveys were conducted using a postal survey, telephone interview, or medical record review in August 2017. The main outcome measurement was the recurrence rate of CBD stones after complete stone removal with EPLBD in patients who received follow-up for more than one year. Risk factors for such recurrence were secondarily analyzed. Results Of the 98 patients treated using EPLBD, 93 (95%) were followed up after complete stone removal and analyzed for the long-term outcomes. During the mean follow-up period of 33.7±16.6 months, CBD stones recurred in 16 patients (17%) with a mean interval of 12.7±12.7 months. Univariate analyses showed that a large stone size, multiple stones, a large distal CBD diameter, and a history of cholecystectomy were significant risk factors for stone recurrence (p=0.022, 0.013, 0.001 and 0.035, respectively). The large distal CBD diameter was the only significant risk factor for stone recurrence in a multivariate analysis (hazard ratio, 1.227; p=0.031). Conclusion The long-term outcomes of EPLBD for CBD stones, including the rate of stone recurrence, were found to be acceptable. A large distal CBD diameter was an independent risk factor for stone recurrence.

Laparoscopic cholecystectomy: which predicting factors of conversion? Two Italian center's studies

BACKGROUND

Laparoscopic cholecystectomy represents the gold standard technique for the treatment of lithiasic gallbladder disease. Although it has many advantages, laparoscopic cholecystectomy is not risk-free and in special situations there is a need for conversion into an open procedure, in order to minimize postoperative complications and to complete the procedure safely. The aim of this study was to identify factors that can predict the conversion to open cholecystectomy.

METHODS

We analyzed 1323 patients undergoing laparoscopic cholecystectomy over the last five years at St. Orsola University Hospital-Bologna and Umberto I University Hospital-Rome. Among these, 116 patients (8.7%) were converted into laparotomic cholecystectomy. Clinical, demographic, surgical and pathological data from these patients were included in a prospective database. A univariate analysis was performed followed by a multivariate logistic regression.

RESULTS

On univariate analysis, the factors significantly correlated with conversion to open were the ASA score higher than 3 and the comorbidity, specifically cardiovascular disease, diabetes and chronic renal failure (P<0.001). Patients with a higher mean age had a higher risk of conversion to open (61.9±17.1 vs. 54.1±15.2, P<0.001). Previous abdominal surgery and previous episodes of cholecystitis and/or pancreatitis were not statistically significant factors for conversion. There were four deaths in the group of converted patients and two in the laparoscopic group (P<0.001). Operative morbility was higher in the conversion group (22% versus 8%, P<0.001). Multivariate analysis showed that the factors significantly correlated to conversion were: age <65 years old (P=0.031 OR: 1.6), ASA score 3-4 (P=0.013, OR:1.8), history of ERCP (P=0.16 OR:1.7), emergency procedure (P=0.011, OR:1.7); CRP higher than 0,5 (P<0.001, OR:3.3), acute cholecystitis (P<0.001, OR:1.4). Further multivariate analysis of morbidity, postoperative mortality and home discharge showed that conversion had a significant influence on overall post-operative complications (P=0.011, OR:2.01), while mortality (P=0.143) and discharge at home were less statistically influenced.

CONCLUSIONS

Our results show that most of the independent risk factors for conversion cannot be modified by delaying surgery. Many factors reported in the literature did not significantly impact conversion rates in our results.