Effectiveness of conservative management versus laparoscopic cholecystectomy in the prevention of recurrent symptoms and complications in adults with uncomplicated symptomatic gallstone disease (C-GALL trial): pragmatic, multicentre randomised controlled trial

Urgent Versus Elective Laparoscopic Cholecystectomy Following Percutaneous Transhepatic Gallbladder Drainage for Moderate Acute Cholecystitis: A Meta-Analysis

BACKGROUND

There is still controversy regarding the treatment strategy for moderate acute cholecystitis (AC). Percutaneous transhepatic gallbladder drainage (PTGBD) followed laparoscopic cholecystectomy (LC) has shown advantages compared to emergency LC (ELC). However, the results are controversial. Therefore, we conducted this updated meta-analysis to clarify this issue.

MATERIALS AND METHODS

A comprehensive literature search for relevant studies comparing the PTGBD + LC and ELC for moderate AC was performed. The statistical analysis was conducted using Stata.

RESULTS

A total of 14 studies were included. The pooled analysis revealed that PTGBD + LC group had a shorter operation time (SMD = -1.07, 95%CI = -1.19 to -0.95), lower amount of intraoperative bleeding (SMD = -0.93, 95%CI = -1.07 to -0.79), lower conversion rate (OR = 0.28, 95% CI = 0.17-0.44), lower postoperative complications (OR = 0.45, 95% CI = 0.23-0.88) shorter postoperative hospital stay (SMD = -1.20, 95%CI = -1.33 to -1.07), lower wound infection rate (OR = 0.41, 95%CI = 0.23-0.74) and higher hospitalization expenses (SMD = 1.13, 95%CI = 0.96 to 1.29) compared with ELC group. There was no significant difference in the incidence of bile leak, bile duct injury and total hospital stay.

CONCLUSION

This meta-analysis suggested that PTGBD + LC has significant advantages over ELC for moderate AC patients, including lower surgical difficulty, lower conversion rate, fewer postoperative complications, and shorter hospital stay.

Restrictive Strategy vs Usual Care for Cholecystectomy in Patients With Abdominal Pain and Gallstones: 5-Year Follow-Up of the SECURE Randomized Clinical Trial

Importance

The 1-year results of the SECURE trial, a randomized trial comparing a restrictive strategy vs usual care for select patients with symptomatic cholelithiasis for cholecystectomy, resulted in a significantly lower operation rate after restrictive strategy. However, a restrictive strategy did not result in more pain-free patients at 1 year.

Objective

To gauge pain level and determine the proportion of pain-free patients, operation rate, and biliary and surgical complications at the 5-year follow-up.

Design, Setting, and Participants

This randomized clinical trial was a multicenter, parallel-arm, noninferiority, prospective study. Between February 2014 and April 2017, patients from 24 hospitals with symptomatic, uncomplicated cholelithiasis were included. Uncomplicated cholelithiasis was defined as gallstone disease without signs of complicated cholelithiasis, ie, biliary pancreatitis, cholangitis, common bile duct stones, or cholecystitis. Follow-up data for this analysis were collected by telephone from July 11, 2019, to September 23, 2023.

Interventions

Patients were randomized (1:1) to receive usual care or a restrictive strategy with stepwise selection for cholecystectomy.

Main Outcomes and Measures

The primary, noninferiority end point was proportion of patients who were pain free as evaluated by Izbicki pain score at the 5-year follow-up. A 5% noninferiority margin was chosen. The secondary end points included cholecystectomy rates, biliary and surgical complications, and patient satisfaction.

Results

Among 1067 patients, the median (IQR) age was 49.0 years (38.0-59.0 years); 786 (73.7%) were female, and 281 (26.3%) were male. At the 5-year follow-up, 228 of 363 patients (62.8%) were pain free in the usual care group, compared with 216 of 353 patients (61.2%) in restrictive strategy group (difference, 1.6%; 1-sided 95% lower confidence limit, -7.6%; noninferiority P = .18). After cholecystectomy, 187 of 294 patients (63.6%) in the usual care group and 160 of 254 patients (63.0%) in the restrictive strategy group were pain free, respectively (P = .88). The restrictive care strategy was associated with 387 of 529 cholecystectomies (73.2%) compared with 437 of 536 in the usual care group (81.5%; 8.3% difference; P = .001). No differences between groups were observed in biliary and surgical complications or in patient satisfaction.

Conclusions and Relevance

In the long-term, a restrictive strategy results in a significant but small reduction in operation rate compared with usual care and is not associated with increased biliary and surgical complications. However, regardless of the strategy, only two-third of patients were pain free. Further criteria for selecting patients with uncomplicated cholelithiasis for cholecystectomy and rethinking laparoscopic cholecystectomy as treatment is needed to improve patient-reported outcomes.

Trial Registration

CCMO Identifier: NTR4022.

Worse cholecystectomy outcomes during the COVID-19 pandemic: were staff shortages or a change in patient case-mix the culprit?

BACKGROUND

The COVID-19 pandemic has profoundly impacted the field of surgery, mostly through infectious risks, staff shortages, reduced hospital capacities, and changed patient pathways. Prompted by an increase in wound complications, we performed an in-depth analysis of an example surgical procedure.

METHODS

A consecutive cohort of 195 patients undergoing laparoscopic cholecystectomy was studied retrospectively. Data of patients receiving cholecystectomy before, during, and after the peak of the pandemic were compared. The potential influence of patient characteristics, pandemic phase, and staffing level (surgeons and nurse assistants) was analyzed statistically. In the primary analyses, the composite measure of a 'textbook outcome' was examined, which was defined as no relevant complication, hospital stay < 5 days, and no readmission.

RESULTS

During the COVID-19 phase, acute biliary disease was more common than in the pre-COVID-19 phase (62% vs. 30%). In 35% of cases, no qualified operating room nurse was available. Intraoperative features and postoperative complication rates were increased (bile spillage in 46%, wound complications in 24%). A 59-year-old male admitted with acute cholecystitis during COVID-19 died of wound-related septic shock. Multivariate analysis confirmed the acuity of gallbladder inflammation (odds ratio 5.3) and old age (2.6) as risk factors for a non-textbook outcome. The absence of qualified nursing staff was clearly associated with a non-textbook outcome (odds ratio 3.3).

CONCLUSIONS

The fact that laparoscopic cholecystectomy outcomes were worse during COVID-19 can be partly attributed to a change in patient case-mix, but the shortage of qualified nursing staff in the operating room also had a strong negative influence.

Integration of bile proteomics and metabolomics analyses reveals novel insights into different types of gallstones in a high-altitude area

BACKGROUND

To explore the pathogenesis of different subtypes of gallstones in high-altitude populations from a molecular perspective.

METHODS

We collected bile samples from 20 cholesterol gallstone disease (CGD) patients and 20 pigment gallstone disease (PGD) patients. Proteomics analysis was performed by LC/MS DIA, while metabolomics analysis was performed by UPLC- Q-TOF/MS.

RESULTS

We identified 154 up-regulated and 196 down-regulated differentially expressed proteins, which were significantly enriched in neurodegenerative diseases, energy metabolism, amino acid metabolism etc. In metabolomics analysis, 20 up-regulated and 63 down-regulated differentially expressed metabolites were identified, and they were significantly enriched in vitamin B6 metabolism. Three pathways of integrated proteomics and metabolomics were significantly enriched: porphyrin and chlorophyll metabolism, riboflavin metabolism and aminoacyl-tRNA biosynthesis. Remarkably, 7 differentially expressed proteins and metabolites showed excellent predictive performance and were selected as potential biomarkers.

CONCLUSION

The findings of our metabolomics and proteomics analyses help to elucidate the underlying mechanisms of gallstone formation in high-altitude populations.

Symptomatic uncomplicated gallstone disease is associated with a high short-term risk of gallstone-related complications: a contemporary cohort study

BACKGROUND

The natural history of symptomatic uncomplicated gallstone disease is largely unknown. We examined the risk of progressing from symptomatic uncomplicated to complicated gallstone disease in a large regional cohort of patients, where disruptions in elective surgical capacities have led to the indefinite postponement of surgery for benign conditions, including cholecystectomies.

METHODS

Patients with radiologically diagnosed incident symptomatic and uncomplicated gallstone disease were identified from outpatient clinics and emergency departments on the Island of Funen, Denmark. The absolute risk of complications (cholecystitis, cholangitis, pancreatitis, acute cholecystectomy for unremitting pain) was calculated using death and elective cholecystectomies as competing risks using the Aalen-Johansen method. Cox proportional hazards regression analysis was used to estimate hazard ratios (HRs) of gallstone complications associated with patient and gallstone characteristics.

RESULTS

Two hundred eighty-six patients diagnosed with incident symptomatic, uncomplicated gallstone disease from 1 January 2020 to 1 July 2023 were identified. During 79,170 person-years of observation, 176 (61.5%) patients developed a gallstone-related complication. The 6-, 12- and 24-month risk of developing gallstone-related complications were 36%, 55% and 81%. The risk of developing complications related to common bile duct stones was lowest with larger stones (aHR per millimeter increase = 0.89 (0.82-0.97), p < 0.01), while no covariates were statistically significantly associated with the risk of cholecystitis. Eighty-five (30%) patients underwent elective laparoscopic cholecystectomy, with one patient (1.2%) developing a gallstone-related complication afterward.

CONCLUSIONS

The risk of developing complications to symptomatic gallstones in a general Scandinavian population is high, and prophylactic cholecystectomy should be considered.

Follow-up study of gallbladder stones in 44 children

BACKGROUND

Cholesterol stones affect a certain subpopulation of children. Concerns have been raised on the impact of gallbladder surgery on the growth of children and adolescents.

AIM

To study the population characteristics, clinical features, treatment, and prognosis of gallstones in children.

METHODS

The clinical data of 44 children with gallstones admitted to The First Affiliated Hospital of Naval Medical University from August 2009 to August 2021 were collected, the children were followed up by telephone to monitor their prognoses. The follow-up ended in August 2023. The shortest follow-up time was 2 years and 6 months, whereas the longest was 13 years and 11 months. The population characteristics, general clinical characteristics, and treatments were retrospectively analyzed. The children were divided according to whether they underwent surgical gallbladder removal into an operation group (n = 28) and a non-operation group (n = 16), The effects of surgical gallbladder resection on the growth and development of children were analyzed.

RESULTS

The male-female ratio in the population was 6:5 and 84.09% of the children had onset in adolescence. Furthermore, 29.55% of the children were overweight or obese. The study identified 26 cases with metabolic abnormalities, 9 with hemolytic anemia, and 4 with choledochal cyst. Of the population, 68.18% had recurrent symptomatic cholecystolithiasis. Surgical treatment accounted for 63.64%, with laparoscopic cholecystectomy accounting for 71.43% of surgical treatment. No significant differences were observed in symptoms and complications between the surgery and non-surgery groups. Furthermore, no significant differences were found between the two groups in the attainment of genetic height target and the rightward shift of height curve during follow-up.

CONCLUSION

The sex characteristics of gallstones in children were not observed. Most gallstones occurred in adolescents and rarely in young children. A considerable proportion of children have inborn causes, which are often concurrent with metabolic abnormalities and hemolytic anemia. Most children had recurrent symptomatic gallstones. Surgical treatment, especially laparoscopic cholecystectomy, is still the main treatment for gallstones in children. Surgical treatment did not affect the growth and development of children who underwent gallstone removal.