Post-cholecystectomy syndrome: spectrum of biliary findings at magnetic resonance cholangiopancreatography

Laparoscopic cholecystectomy versus conservative management for adults with uncomplicated symptomatic gallstones: the C-GALL RCT

Background

Gallstone disease is a common gastrointestinal disorder in industrialised societies. The prevalence of gallstones in the adult population is estimated to be approximately 10-15%, and around 80% remain asymptomatic. At present, cholecystectomy is the default option for people with symptomatic gallstone disease.

Objectives

To assess the clinical and cost-effectiveness of observation/conservative management compared with laparoscopic cholecystectomy for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones in secondary care.

Design

Parallel group, multicentre patient randomised superiority pragmatic trial with up to 24 months follow-up and embedded qualitative research. Within-trial cost-utility and 10-year Markov model analyses. Development of a core outcome set for uncomplicated symptomatic gallstone disease.

Setting

Secondary care elective settings.

Participants

Adults with symptomatic uncomplicated gallstone disease referred to a secondary care setting were considered for inclusion.

Interventions

Participants were randomised 1: 1 at clinic to receive either laparoscopic cholecystectomy or observation/conservative management.

Main outcome measures

The primary outcome was quality of life measured by area under the curve over 18 months using the Short Form-36 bodily pain domain. Secondary outcomes included the Otago gallstones' condition-specific questionnaire, Short Form-36 domains (excluding bodily pain), area under the curve over 24 months for Short Form-36 bodily pain domain, persistent symptoms, complications and need for further treatment. No outcomes were blinded to allocation.

Results

Between August 2016 and November 2019, 434 participants were randomised (217 in each group) from 20 United Kingdom centres. By 24 months, 64 (29.5%) in the observation/conservative management group and 153 (70.5%) in the laparoscopic cholecystectomy group had received surgery, median time to surgery of 9.0 months (interquartile range, 5.6-15.0) and 4.7 months (interquartile range 2.6-7.9), respectively. At 18 months, the mean Short Form-36 norm-based bodily pain score was 49.4 (standard deviation 11.7) in the observation/conservative management group and 50.4 (standard deviation 11.6) in the laparoscopic cholecystectomy group. The mean area under the curve over 18 months was 46.8 for both groups with no difference: mean difference -0.0, 95% confidence interval (-1.7 to 1.7); p-value 0.996; n = 203 observation/conservative, n = 205 cholecystectomy. There was no evidence of differences in quality of life, complications or need for further treatment at up to 24 months follow-up. Condition-specific quality of life at 24 months favoured cholecystectomy: mean difference 9.0, 95% confidence interval (4.1 to 14.0), p < 0.001 with a similar pattern for the persistent symptoms score. Within-trial cost-utility analysis found observation/conservative management over 24 months was less costly than cholecystectomy (mean difference -£1033). A non-significant quality-adjusted life-year difference of -0.019 favouring cholecystectomy resulted in an incremental cost-effectiveness ratio of £55,235. The Markov model continued to favour observation/conservative management, but some scenarios reversed the findings due to uncertainties in longer-term quality of life. The core outcome set included 11 critically important outcomes from both patients and healthcare professionals.

Conclusions

The results suggested that in the short term (up to 24 months) observation/conservative management may be a cost-effective use of National Health Service resources in selected patients, but subsequent surgeries in the randomised groups and differences in quality of life beyond 24 months could reverse this finding. Future research should focus on longer-term follow-up data and identification of the cohort of patients that should be routinely offered surgery.

Trial registration

This trial is registered as ISRCTN55215960.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/192/71) and is published in full in Health Technology Assessment; Vol. 28, No. 26. See the NIHR Funding and Awards website for further award information.

Biliary Duct Dilatation: AJR Expert Panel Narrative Review

Biliary duct dilatation is a common incidental finding in practice, but it is unlikely to indicate biliary obstruction in the absence of clinical symptoms or elevated levels on liver function tests (LFTs). However, the clinical presentation may be nonspecific, and LFTs may either be unavailable or difficult to interpret. The goal of this AJR Expert Panel Narrative Review is to highlight a series of topics fundamental to the management of biliary duct dilatation, providing consensus recommendations in a question-and-answer format. We start by covering a basic approach to interpreting LFT results, the strengths and weaknesses of the biliary imaging modalities, and how and where to measure the extrahepatic bile duct. Next, we define the criteria for biliary duct dilatation, including patients with prior cholecystectomy and advanced age, and discuss when and whether biliary duct dilatation can be attributed to papillary stenosis or sphincter of Oddi dysfunction. Subsequently, we discuss two conditions in which the duct is pathologically dilated but not obstructed: congenital cystic dilatation (i.e., choledochal cyst) and intraductal papillary neoplasm of the bile duct. Finally, we provide guidance regarding when to recommend obtaining additional imaging or testing, such as endoscopic ultrasound or ERCP, and include a discussion of future directions in biliary imaging.

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

OBJECTIVE

To assess the clinical and cost effectiveness of conservative management compared with laparoscopic cholecystectomy for the prevention of symptoms and complications in adults with uncomplicated symptomatic gallstone disease.

DESIGN

Parallel group, pragmatic randomised, superiority trial.

SETTING

20 secondary care centres in the UK.

PARTICIPANTS

434 adults (>18 years) with uncomplicated symptomatic gallstone disease referred to secondary care, assessed for eligibility between August 2016 and November 2019, and randomly assigned (1:1) to receive conservative management or laparoscopic cholecystectomy.

INTERVENTIONS

Conservative management or surgical removal of the gallbladder.

MAIN OUTCOME MEASURES

The primary patient outcome was quality of life, measured by area under the curve, over 18 months using the short form 36 (SF-36) bodily pain domain, with higher scores (range 0-100) indicating better quality of life. Other outcomes included costs to the NHS, quality adjusted life years (QALYs), and incremental cost effectiveness ratio.

RESULTS

Of 2667 patients assessed for eligibility, 434 were randomised: 217 to the conservative management group and 217 to the laparoscopic cholecystectomy group. By 18 months, 54 (25%) participants in the conservative management arm and 146 (67%) in the cholecystectomy arm had received surgery. The mean SF-36 norm based bodily pain score was 49.4 (standard deviation 11.7) in the conservative management arm and 50.4 (11.6) in the cholecystectomy arm. The SF-36 bodily pain area under the curve up to 18 months did not differ (mean difference 0.0, 95% confidence interval -1.7 to 1.7; P=1.00). Conservative management was less costly (mean difference -£1033, (-$1334; -€1205), 95% credible interval -£1413 to -£632) and QALYs did not differ (mean difference -0.019, 95% credible interval -0.06 to 0.02).

CONCLUSIONS

In the short term (≤18 months), laparoscopic surgery is no more effective than conservative management for adults with uncomplicated symptomatic gallstone disease, and as such conservative management should be considered as an alternative to surgery. From an NHS perspective, conservative management may be cost effective for uncomplicated symptomatic gallstone disease. As costs, complications, and benefits will continue to be incurred in both groups beyond 18 months, future research should focus on longer term follow-up to establish effectiveness and lifetime cost effectiveness and to identify the cohort of patients who should be routinely offered surgery.

TRIAL REGISTRATION

ISRCTN registry ISRCTN55215960.

Do not get stumped: multimodality imaging findings of early and late post-cholecystectomy complications

Cholecystectomy is the most performed intra-abdominal surgical procedure in the US, with 1.2 million performed annually, and is predominantly performed laparoscopically. Although largely safe, laparoscopic cholecystectomy results in higher rates of abdominal symptoms consisting of abdominal pain and dyspepsia, which may persist or recur, collectively known as post-cholecystectomy syndrome. This article aims to (1) provide an overview of post-cholecystectomy syndrome with an emphasis on biliary complications and emergent imaging findings, (2) illustrate the spectrum of imaging findings of early and late post-cholecystectomy complications, (3) enumerate the role of various imaging modalities in evaluating post-cholecystectomy complications and address the role of selective trans-catheter coil embolization in managing bile leaks, and (4) discuss pearls and pitfalls in imaging following cholecystectomy. While common first-line imaging modalities for post-cholecystectomy complications include CT and sonography, ERCP and MRCP can delineate the biliary tree with greater detail. Scintigraphy has a higher sensitivity and specificity than CT or sonography for diagnosing bile leak and may preclude the need for ERCP. Post-operative complications include biliary duct injury or leak, biliary obstruction, remnant gallbladder/cystic duct stones and inflammation, biliary dyskinesia, papillary stenosis, and vascular injury. Subtle cases resulting in lethal outcomes, such as hemorrhage from the gallbladder bed without major vessel injury, have also been described. Cases presented will include biliary complications such as post-cholecystectomy stump cholecystitis, nonbiliary complications such as subcapsular hematoma, and normal post-surgical findings such as oxidized regenerated cellulose. Post-operative biliary complications can cause significant morbidity and mortality, and thus familiarity with the expected post-surgical appearance of the gallbladder fossa and biliary tract, as well as understanding the spectrum of complications and associated multimodality imaging findings, are essential for emergency radiologists and those practicing in the acute care setting to direct appropriate patient management. Furthermore, many of the postoperative complications can be managed by noninvasive percutaneous interventional procedures, from drain placement to cystic artery and cystic duct stump embolization.

Surgical management of cystic duct stump calculi causing post-cholecystectomy syndrome: A prospective study

Aim

Remnant cystic duct stump calculi are an uncommon but important cause of 'post-cholecystectomy syndrome'. High index of suspicion is needed to diagnose this condition in a symptomatic post-cholecystectomy patient. We present our experience with the surgical management of this condition.

Patients and Methods

This prospective study included 19 patients with residual gallstone disease who underwent completion cholecystectomy between August 2016 and October 2021. Investigations included abdominal ultrasound and magnetic resonance cholangiopancreatography. The demographic, clinical, surgical and early post-operative variables of these patients were prospectively maintained and analysed.

Results

The study included 14 women and 5 men. The mean age was 42.1 years (range, 14-80 years). The median duration between index surgery and completion cholecystectomy was 36 months (range, 2-178 months) (interquartile range, 105 months). The follow-up duration was 2 months. The initial surgery was open cholecystectomy in 17 and laparoscopic cholecystectomy in 2 patients. All patients with residual stump stone presented with pain, while 10 out of 19 patients complained of dyspepsia. Completion cholecystectomy could be performed laparoscopically in 16 cases, whereas 3 patients underwent open surgery. The mean operative time was 80 min (range, 55-140 min), and the mean blood loss was 100 ml (range, 50-160 ml). The mean hospital stay was 3 days (range, 2-10 days). No post-operative mortality or major morbidity was recorded in any of our patients.

Conclusion

Laparoscopic excision of the cystic duct stump is feasible and safe even after previous open cholecystectomy. It is increasingly becoming the treatment of choice where expertise is available.

The clinical effect of a strategy called transcystic gallbladder-preserving cholecystolithotomy based on endoscopic retrograde cholangiopancreatography for cholecystolithiasis: A retrospective study from a single center

Background

Choledocholithiasis complicated with cholecystolithiasis is a common disease. This study explores a novel strategy, called ERCP-based transcystic gallbladder-preserving cholecystolithotomy, for the simultaneous removal of common bile duct stones and gallbladder stones.

Methods

From December 2018 to June 2021, all patients with cholecystolithiasis and common bile duct stones who met the criteria for gallbladder preservation in our hospital were included in the study and prospectively followed up.

Results

We included 48 patients, including 20 patients with acute biliary pancreatitis. All patients successfully underwent ERCP to remove common bile duct stones. One patient had gallbladder perforation during gallbladder-preserving cholecystolithotomy. The guide wire successfully entered the gallbladder, and the transpapillary gallbladder metal-covered stent was successfully placed in 44 patients. The technical success rate was 91.67% (44/48). All stones were removed in 34 patients, for a clinical success rate of 77.27% (34/44). The total postoperative complication rate was 6.25% (3/48), with 2 cases of pancreatitis (4.17%) and 1 case of cholangitis (2.08%). Three patients were lost to follow-up. Among the 31 patients who were followed up for a mean of 27 months (6-40), 5 patients (16.13%) experienced gallstone recurrence. The recurrence rates at 12 months, 18 months, 24 months, 30 months and 36 months were 0%, 3.23%, 6.45%, 12.9%, and 16.13%, respectively.

Conclusion

For patients with cholecystolithiasis and common bile duct stones, ERCP-based transcystic gallbladder-preserving cholecystolithotomy without gallbladder incision can preserve gallbladder structure, and this procedure is safe and feasible for the protection of gallbladder function.Clinical trial registration: The study was registered in the Chinese Clinical Trial Registry, and the registry number is ChiCTR1900028006.

Prevalence and Factors Associated With Post-Cholecystectomy Syndrome in Saudi Arabia

OBJECTIVES

Post-cholecystectomy syndrome (PCS) refers to the continuation or recurrence of biliary colic and any other gastrointestinal symptoms present prior to cholecystectomy. Given that PCS is rare and underestimated in Saudi Arabia, this study aimed to determine the prevalence of PCS among Saudis.

METHODS

This cross-sectional study included randomly gathered subjects who self-administered the validated European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire from September 6 to October 7, 2022.

RESULTS

A total of 518 participants who underwent cholecystectomies were included; most were female (73.6%), 153 (29.5%) were 19 to 25 years old, and the vast majority were Saudi Arabian (91.1%). The average preoperative weight was 71 ± 20.7 kg (range 20 to 258), and the mean current weight was 69 ± 19.4 kg (range 30 to 257). About 137 (26.4%) had a chronic disease, most frequently hypertension (37.2%). In the past week, most participants experienced some trouble doing strenuous activities (42.9%), slight pain (37.6%), fatigue (32.2%), insomnia (37.5%), and weakness (38.2%). There were no significant associations between age, nationality, or residence with the QLQ-C30 score (P-value = 0.152, 0.262, 0.071, respectively). A significant association was observed between gender and QLQ-C30 score (P-value < 0.001), with females scoring higher than their male counterparts. Females also reported having a higher quality of life than males.

CONCLUSIONS

The prevalence of PCS was higher than reported elsewhere.

Cholecystectomy for asymptomatic gallstones: Markov decision tree analysis

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

Role of 99mTc-Mebrofenin Hepatobiliary Scintigraphy in the Diagnosis of Post Cholecystectomy Syndrome

Background  Huge variation in the prevalence of post cholecystectomy syndrome (PCS) is because PCS can include a wide variety of disorders that can be both related and unrelated to cholecystectomy. Hepatobiliary scintigraphy (HBS) is a noninvasive nuclear medicine scan that can evaluate a delay in the transit of bile from the hepatic hilum to the duodenum using a radiotracer ^99m Tc-Mebrofenin that can be associated with a functional ampullary obstruction. The aim of this study was to assess the role of ^99m Tc-Mebrofenin HBS in the detection of the cause of PCS among the patients undergoing cholecystectomy.

Methods  Twenty-one patients who presented with PCS from September 2018 to February 2020 were included in the study. These patients were characterized based on history, examination, liver function test, and abdominal ultrasound. Sphincter of Oddi dysfunction (SOD) was diagnosed using the Rome 3 criteria and the Milwaukee classification. Magnetic resonance cholangiopancreatography (MRCP) and upper gastrointestinal endoscopy and biopsy were done when indicated, to establish the diagnosis. These patients were further subjected to ^99m Tc-Mebrofenin HBS, and the findings were analyzed.

Results  The most common symptom in PCS was biliary pain occurring in 85.7% of the patients. The average time of presentation since surgery was 1.9 years. The most common cause of PCS was SOD, occurring in 52.3% of the patients, followed by benign biliary stricture occurring in 23.8% of the patients. The mean bile duct (common bile duct) visualization time in patients with PCS was 25.2 minutes, the mean duodenal visualization time was 38.2 minutes, and the mean jejunal visualization time was 60.5 minutes. The mean bile duct to duodenum transit time was 12.7 minutes, while the mean bile duct to jejunum transit time was 30.1 minutes. HBS showed consistent findings with the final diagnosis made by other diagnostic modalities (clinical criteria/MRCP/intraoperative findings) in 80.9% of the patients.

Conclusion   ^99m Tc-Mebrofenin HBS has a significant role in the evaluation of PCS.

Diagnosis, monitoring, and management of pyruvate kinase deficiency in children

Pyruvate kinase (PK) deficiency is a rare, congenital red blood cell disorder caused by a single gene defect. The spectrum of genotypes, variants, and phenotypes are broad, commonly requiring a multimodal approach including enzyme and genetic testing for accurate and reliable diagnosis. Similarly, management of primary and secondary sequelae of PK deficiency varies, mainly including supportive care with transfusions and surgical interventions to improve symptoms and quality of life. Given the risk of acute and long-term complications of PK deficiency and its treatment, regular monitoring and management of iron burden and organ dysfunction is critical. Therefore, all children and adolescents with PK deficiency should receive regular hematology care with visits at least every 6 months regardless of transfusion status. We continue to learn more about the spectrum of symptoms and complications of PK deficiency and best practice for monitoring and management through registry efforts (NCT03481738). The treatment of PK deficiency has made strides over the last few years with newer disease-modifying therapies being developed and studied, with the potential to change the course of disease in childhood and beyond.

Laparoscopic Common Bile Duct Exploration with Gallbladder Preservation: An Innovative Technique for Primary Common Bile Duct Stones

Background: Primary common bile duct (CBD) stones can be treated with laparoscopic CBD exploration (LCBDE), during which cholecystectomy is routinely performed. For patients without gallstones, we have developed a new procedure, LCBDE with gallbladder preservation. The purpose of this study was to evaluate the management of LCBDE with gallbladder preservation at our institution. Methods: Retrospective analysis the clinical data of 105 patients with primary CBD stones. Demographic data, clinical characteristics, preoperative risk factors, and postoperative complications were evaluated. Results: All patients were divided into two groups depending on the presence of gallstones: the primary CBD stone coexistence gallstones group (Group A, n = 15) and the primary CBD stones absence gallstones group (Group B, n = 90). Complete stones clearance was achieved in all patients. There were no significant differences in postoperative complications rates and mortality between the two groups. The mean postoperative hospital stay was 3.2 days for Group A and 4.1 days for Group B (P = .03). Conclusion: This study found that LCBDE with gallbladder preservation can effectively and safely treat primary CBD stones without gallbladder stones.

Management of Postcholecystectomy Complications

Cholecystectomy is one of the most common general surgery procedures performed worldwide. Complications include bile duct injury, strictures, bleeding, infection/abscess, retained gallstones, hernias, and postcholecystectomy syndrome. Obtaining a critical view of safety and following the other tenets of the Safe Cholecystectomy Task Force will aid in the prevention of bile duct injury and other morbidity associated with cholecystectomy.

Review of imaging in post-laparoscopy cholecystectomy complications

Laparoscopic cholecystectomy is now considered the procedure of choice for uncomplicated symptomatic gallstone disease worldwide. Various biliary, vascular, gastrointestinal, neurological and local complications may be seen on imaging post surgery. Knowledge of these entities and imaging appearances is indispensable for the radiologist in today's era. We emphasize on the list of potential complications and imaging appearances of this surgical procedure.

MRI evaluation of bile duct injuries and other post-cholecystectomy complications

Laparoscopic cholecystectomy is one of the most common procedures performed each year and can be associated with various post-operative complications. Imaging is integral to diagnosis and management of patients with suspected cholecystectomy complications, and a thorough understanding of normal and abnormal biliary anatomy, risk factors for biliary injury, and the spectrum of adverse events is crucial for interpretation of imaging studies. Magnetic resonance cholangiography (MRC) enhanced with hepatobiliary contrast agent is useful in delineating biliary anatomy and pathology following cholecystectomy. In this article, we provide a protocol for contrast-enhanced MR imaging of the biliary tree. We also review the classification and imaging manifestations of post-cholecystectomy bile duct injuries in addition to other complications such as bilomas, retained/dropped gallstones, and vascular injuries.

Spontaneous Pneumobilia: Not So Benign

Pneumobilia is defined as air within the biliary system. It is usually caused by an abnormal connection between the biliary gastrointestinal tracts. Persistent asymptomatic pneumobilia is a rare occurrence and is generally considered a benign finding on imaging. Herein, we present a case of an 87-year-old male with long-standing pneumobilia of no identifiable cause who eventually developed Klebsiella cholangitis and bacteremia. In our report, we attempt to elucidate the causes of spontaneous pneumobilia and discuss its significance in the context of increased intraabdominal pressure.

Protocol for a randomised controlled trial comparing laparoscopic cholecystectomy with observation/conservative management for preventing recurrent symptoms and complications in adults with uncomplicated symptomatic gallstones (C-Gall trial)

BACKGROUND

Gallstone disease (cholelithiasis) is common. In most people it is asymptomatic and does not require treatment, but in about 20% it can become symptomatic, causing pain and other complications requiring medical attention and/or surgery. A proportion of symptomatic people with uncomplicated gallstone disease do not experience further episodes of pain and, therefore, could be treated conservatively. Moreover, surgery carries risks of perioperative and postoperative complications.

METHODS AND ANALYSIS

C-Gall is a pragmatic, multicentre, randomised controlled trial and economic evaluation to assess whether cholecystectomy is cost-effective compared with observation/ conservative management (here after referred to as medical management) at 18 months post-randomisation (with internal pilot).

PRIMARY OUTCOME MEASURE

Patient-reported quality of life (QoL) (36-Item Short Form Survey (SF-36) bodily pain domain) up to 18 months after randomisation.The primary economic outcome is incremental cost per quality-adjusted life year gained at 18 months.

SECONDARY OUTCOME MEASURES

Secondary outcome measures include condition-specific QoL, SF-36 domains, complications, further treatment, persistent symptoms, healthcare resource use, and costs assessed at 18 and 24 months after randomisation. The bodily pain domain of the SF-36 will also be assessed at 24 months after randomisation.A sample size of 430 participants was calculated. Computer-generated 1:1 randomisation was used.The C-Gall Study is currently in follow-up in 20 UK research centres. The first patient was randomised on 1 August 2016, with follow-up to be completed by 30 November 2021.

STATISTICAL ANALYSIS

Statistical analysis of the primary outcome will be intention-to-treat and a per-protocol analysis. The primary outcome, area under the curve (AUC) for the SF-36 bodily pain up to 18 months, will be generated using the Trapezium rule and analysed using linear regression with adjustment for the minimisation variables (recruitment site, sex and age). For the secondary outcome, SF-36 bodily pain, AUC up to 24 months will be analysed in a similar way. Other secondary outcomes will be analysed using generalised linear models with adjustment for minimisation and baseline variables, as appropriate. Statistical significance will be at the two-sided 5% level with corresponding CIs.

ETHICS AND DISSEMINATION

The North of Scotland Research Ethics Committee approved this study (16/NS/0053). The dissemination plans include Health Technology Assessment monograph, international scientific meetings and publications in high-impact, open-access journals.

TRIAL REGISTRATION NUMBER

ISRCTN55215960; pre-results.

A Study on Efficacy of UGI Scopy in Cholelithiasis Patients before Laparoscopic Cholecystectomy

Objectives

Upper abdominal symptoms are common in both gallstone disease and inflammatory disorders of gastroduodenum. To differentiate the causes of upper gastrointestinal symptoms due to gallstone and gastroduodenal disorders, upper gastrointestinal (UGI) scopy is a useful diagnostic tool. Our aim of study is to determine the efficacy of the preoperative UGI scopy and concurrent treatment of associated esophageal and gastric pathologies with symptomatic cholelithiasis in view of postoperative symptom reduction.

Materials and Methods

This is a prospective study comprising 400 symptomatic cholelithiasis patients admitted in our institution. All patients underwent upper GI endoscopy (1–4 days) prior to cholecystectomy, and the findings were noted. Then, based on findings in UGI scopy, patients were grouped as group A (endoscopy normal) and group B (endoscopy with some findings). Group B patients were treated with medication, and both groups were operated with laparoscopic cholecystectomy. Pain and other symptoms in the preoperative period and postoperative period were measured and compared in both groups.

Results

After excluding 7 patients with significant endoscopy findings, we have included 400 patients who underwent laparoscopy cholecystectomy. In a total of 400 patients, median age of presentation was 47.3 and female to male ratio was 2.2 : 1. Endoscopy showed some pathological findings in 75.5% patients, and the commonest endoscopy finding was gastritis. On comparison of pain score in preoperative patients, pain score was high in group B patients (p < 0.05). Pain reduction was significant in postoperative 1st, 4^th, and 6th weeks in both groups (p < 0.0005). In the same way, other symptoms other than pain were compared which shows postoperative symptom reduction is highly significant in group B patients.

Conclusion

Clinical presentation of cholelithiasis and other upper GI diseases resemble each other. It is difficult to discriminate between upper GI symptoms due to cholelithiasis or any other upper GI conditions. Although UGI scopy is not recommended for all patients with cholelithiasis, it may be beneficial to do UGI scopy in certain cholelithiasis patients with atypical presentation to prevent atypical symptoms after surgery.

Thermal Processes in Bile Ducts During Laparoscopic Cholecystectomy with Monopolar Instruments. Experimental Study Using Real-Time Intraluminal and Surface Thermography

Introduction. A significant rate of complications during laparoscopic cholecystectomy (LC) occurs due to thermal injury caused by monopolar electrosurgery (MES) equipment. Most of them manifest weeks and months after surgery with the common bile duct (CBD) and large duodenal papilla strictures, some in the early postoperative period with bile leaks. Objective. To study thermal processes occurring in the lumen and on the surface of the bile ducts during monopolar coagulation in a porcine model of LC. Methods. The temperature of the bile ducts was measured using instrumentation consisted of biliary stent with temperature sensors, which was inserted in the porcine CBD, signal amplifier, and current sense transformer. Surface temperature was measured with a scientific grade thermal camera. Cholecystectomy was performed using a standard "critical view of safety" (CVS) approach with 5 mm monopolar laparoscopic instruments. Results. Application of MES caused significant tissue heating. Lateral thermal spread and the rate of tissue heating depended on the duration of energy application and the initial tissue temperature. In 5 out of 6 experiments, the intraluminal temperature rose up to the critical threshold, and the exposure time ranged from 54 to 560 seconds. A sensor positioned at the papilla site was heated in all the experiments but still below the cell damage inducing threshold. The analysis of thermographic charts revealed the presence of the "current channeling" effect and the pedicle effect. Conclusion. There is a possibility of a direct and delayed thermal injury to the bile ducts during LC.

Direct access surgery for cholecystectomy - can we speed up the process?

BACKGROUND

In appropriate patients, direct referral from general practitioners to surgery without pre-operative clinic assessment can streamlining the process and allow more efficient use of clinical time. This study aimed to look at the feasibility of a direct access cholecystectomy pathway in patients with symptomatic gallstones and their satisfaction of it.

METHODS

In 2012, Bay of Plenty general practitioners (GP) were invited to refer fit patients (ASA 1 or 2, BMI <35 and <60 years old) with symptomatic cholelithiasis directly to a surgical list. One surgeon oversaw each referral and the process. The patients GP provided written and visual information and pre-operative health preoperative health questionnaire. Patients presented on the day of surgery, were seen, consented and underwent day stay cholecystectomy. Post-operative follow up was GP lead.

RESULTS

41 patients were referred via the Direct Access Surgery pathway. 37 patients were deemed appropriate with 35 proceeded to surgery. Waiting time from referral to operation was reduced from 120 (standard pathway) to 59.3 days. 30 patients (86%) had day stay procedures. Three patients (8%) re-presented with ongoing right upper quadrant pain within one year requiring further investigation. A written voluntary questionnaire was sent to all patients who underwent DAS with an 80% response rate. Overall the majority of patients (24/28; 85%) agreed or strongly agreed that they felt fully informed regarding the operation and were happy with the process.

CONCLUSION

Direct Access Surgery is an effective way to streamline healthy patients' access to operative intervention.

Pyogenic hepatic abscesses secondary to choledocholithiasis eight years post-cholecystectomy: A case report

Cholecystectomy is the gold standard surgical treatment for acute calculous cholecystitis. Only approximately 0.4 % of these patients subsequently develop choledocholithiasis. The incidence of hepatic abscesses in these patients is unknown, but is likely low, considering there are approximately 2–15 cases of hepatic abscesses per 100,000 people in the US. The authors report the case of a 62-year-old man whose CT scan revealed hepatic abscesses secondary to choledocholithiasis, eight years after a cholecystectomy.

Adverse outcomes and short-term cost implications of bile duct injury during cholecystectomy

BACKGROUND

Bile duct injury (BDI) is an uncommon but major complication of cholecystectomy that has a poorly defined magnitude of effect on hospital costs. This study sought to calculate the healthcare costs, length of stay, and discharge status associated with bile duct injury in patients undergoing cholecystectomy in the United States.

METHODS

The Premier Healthcare Database, which comprises hospital-billing records from over 700 hospitals in the United States, was queried for all patients undergoing cholecystectomy between January 2010 and March 2018. BDI was defined by ICD-9-CM and ICD-10-CM codes. Patient demographics, clinical characteristics, and operative information were extracted. Hospital costs, length of stay, and discharge status were compared between BDI and non-BDI patients. Propensity score matching was used to minimize confounding factors. Multivariable regression models were used to estimate the association between BDI and the outcomes variables.

RESULTS

A total of 1,168,288 cholecystectomies were identified. BDI occurred in 878 patients (0.08%). Laparoscopy was the most common approach (> 95%). The majority of BDI occurred during inpatient admissions (71.0%). BDI patients had higher index admission hospital costs ($18,771 vs. $12,345, p < 0.0001), increased rate of discharge to an institutional post-acute care facility (odds ratio 3.89, 95% CI 2.92-5.19, p < 0.0001), and increased risk of readmission within 30 days after discharge (odds ratio 1.86, 95% CI 1.52-2.28, p < 0.0001), compared to patients without BDI. Among inpatient cholecystectomies, BDI was associated with increased length of stay (8.6 days vs. 4.8 days, p < 0.0001).

CONCLUSION

BDI is associated with significantly increased hospital costs, length of stay, 30-day readmission, and discharge to an institutional post-acute care facility.

Hospitalization Burden of Biliary Strictures and Cholangitis After Pancreaticoduodenectomy

BACKGROUND

Postsurgical biliary disease in Roux-en-y and cholecystectomies has been investigated, but less literature exists regarding biliary complications after Whipple procedure (pancreaticoduodenectomy [PD]). Moreover, the hospital burden incurred after this complication has not been previously examined. The aim of this study is to assess the trends in hospitalization for biliary strictures and cholangitis after PD.

MATERIALS AND METHODS

The National Inpatient Sample identified all cases with a PD and a primary diagnosis of biliary complication in 2014. Cases were identified using the International Classification of Diseases, Clinical Modification codes. Primary outcomes were association of biliary complications with mortality, cost of admission, and length of stay.

RESULTS

A total of 10,145 patients in 2014 were documented with a previous PD. Mortality was 50-fold greater without biliary complications (2.7% versus 0.05%), but a 95% increased length of stay (25.8 d versus 13.2 d, P = 0.014) and 70% increased cost of admission ($293,894 versus $165,862, P = 0.092) occurred with biliary complications. Regression analysis revealed increased length of stay in all cohorts (adjusted odds ratio: 14.3, P = 0.007) and increased cost of admission with cholangitis (adjusted odds: 458283, P = 0.00). Finally, there was increased biliary strictures, cost of hospitalization, and length of stay from 2011 to 2014.

CONCLUSIONS

Biliary disease due to the PD appears to longitudinally increase length of stay and cost of hospitalization. Compared with gastrointestinal bleed and delayed gastric emptying, biliary strictures and cholangitis are still very high acuity, requiring more extensive medical resources. Minimally invasive surgeries and robotics could play a vital role in minimizing biliary complications and the ensuing hospitalization burden.

The hepatoduodenal ligament revisited: cross-sectional imaging spectrum of non-neoplastic conditions

INTRODUCTION

The hepatoduodenal ligament is frequently involved by conditions affecting the portal triad and surrounding structures, including a vast array of non-neoplastic conditions. Due its unique location between the retroperitoneum and the peritoneal space, the hepatoduodenal ligament is also targeted by inflammatory conditions involving the retroperitoneum and the liver. Finally, the presence of lymphatics and of the biliary tracts makes the hepatoduodenal ligament a route of spread for a variety of infections. The purpose of this pictorial essay is twofold: to review the cross-sectional radiological anatomy and variants of the structures within the hepatoduodenal ligament, and to illustrate the non-neoplastic conditions that may arise within the hepatoduodenal ligament.

CONCLUSION

Familiarity with these specific entities and their cross-sectional imaging findings is fundamental for a more accurate diagnosis.

Closure of the cystic duct orifice in laparoscopic subtotal cholecystectomy for severe cholecystitis

INTRODUCTION

Laparoscopic subtotal cholecystectomy (LSC) has been recognized as an alternative to conversion to laparotomy for severe cholecystitis. However, it may be associated with an increased risk of recurrent stones in the gallbladder remnant. The objective of this study was to evaluate the safety and feasibility of the complete removal of the gallbladder cavity in LSC for severe cholecystitis using the cystic duct orifice suturing (CDOS) technique.

METHODS

In a consecutive series of 412 laparoscopic cholecystectomies that were performed from January 2015 to June 2017, 12 patients who underwent LSC with CDOS were enrolled in this retrospective study. In this procedure, Hartmann's pouch was carefully identified, and the infundibulum-cystic duct junction was transected while the posterior wall adherent to Calot's triangle was left behind. The clinical records, including the operative records and outcomes, were analyzed.

RESULTS

The median operating time and blood loss were 158 min and 20 mL, respectively. In all cases, LSC with CDOS was completed without conversion to open surgery. No injuries to the bile duct or vessels were experienced. The median postoperative hospital stay was 6 days. Postoperative complications occurred in two patients (bile leakage, n = 1: common bile duct stones, n = 1) and were successfully treated by endoscopic management. A gallbladder remnant was not delineated by postoperative imaging in any of the cases.

CONCLUSION

These results suggest that LSC with CDOS is a promising approach that can avoid dissection of Calot's triangle and achieve the complete removal of the gallbladder cavity in patients with severe cholecystitis.

Surgical Management of Cystic Duct Stump Stone or Gall Bladder Remnant Stone

Retained calculi in the cystic duct or gall bladder remnant can present as a post-cholecystectomy problem. Increased suspicion is necessary to diagnose this condition in a symptomatic post-cholecystectomy patient. Ultrasonography usually detects this condition, but magnetic resonance cholangiopancreatography is the test of choice for diagnosis as well as for surgical planning. Laparoscopic re-excision of the stump in most cases is feasible and safe. It is increasingly becoming the treatment of choice.

Clinical patterns of postcholecystectomy syndrome

Backgrounds/Aims

Postcholecystectomy syndrome represents a heterogeneous group of symptoms and findings in patients who have previously undergone cholecystectomy. It is rare and under-reported in Saudi Arabia. It can be attributed to many complications such as bile duct injury, biliary leak, retained common bile duct stones, recurrent bile duct stones, and bile duct strictures. In this study, we aimed to analyze the causes and evaluate the approach to postcholecystectomy syndrome in our local Saudi Arabian community because of the vast number of cases encountered in our hospital for gallbladder clinical conditions and its related complications.

Methods

A prospective cohort database analysis of 272 patients who were diagnosed and treated for postcholecystectomy syndrome between January 2000 and December 2013 were reviewed.

Results

The incidence rate of postcholecystectomy syndrome was 19.8%. The male to female ratio was 1:1.45. The mean age was 37.41±7.12 years. The most common causes were as follows: No obvious cause in 50 (18.4%) patients, Helicobacter pylori infection in 43 (15.8%), pancreatitis in 42 (15.4%), peptic ulcer disease in 41 (15.1%), recurrent common bile duct (CBD) stone in 26 (9.6%), retained CBD stone in 22 (8.1%), bile leakage in 19 (7%), stenosis of the sphincter of Oddi in 12 (4.4%), cystic duct stump syndrome in 11 (4%), and CBD Stricture in 5 (1.8%). The mortality rate was 0%.

Conclusions

Any clinical presentation of postcholecystectomy should not be underestimated and be thoroughly investigated. Multidisciplinary collaboration is crucial for the best outcome and a safe approach for all the patients.

Post-cholecystectomy syndrome: A new look at an old problem

Background

Despite being the most commonly performed operations, sometimes cholecystectomy fails to relieve symptoms; this is now a well-recognised clinical entity termed 'post-cholecystectomy syndrome' (PCS). Very few studies from India deal with PCS, and the present study was carried out to find the incidence and risk factors for PCS in patients undergoing elective laparoscopic cholecystectomy (LC).

Materials and Methods

The records of 207 patients undergoing elective LC were prospectively maintained for 6 months after surgery. Persistence or appearance of new symptoms after surgery was documented and investigated only when they persisted beyond 30 days of surgery.

Results

There were 185 (89.4%) female patients and 22 (10.6%) male patients with a mean age of 44.4 years (age range: 12-79 years). Conversion to open cholecystectomy was done in 18 patients (8.69%), mainly due to adhesions and unclear anatomy. The incidence of symptoms was found to be 13% at 6 months follow-up, showing a reducing trend from 58% in the 1^st week after LC; the most common symptom in symptomatic patients was dyspepsia (55.56%). On investigation, a cause for symptoms could be detected in only 0.97%.

Conclusion

Symptoms are common after LC, but they settle over time. Very few patients have a detectable cause for symptoms after LC, and it is difficult to predict which patients will become symptomatic after LC; in the present series, previous attacks of cholecystitis and presence of co-morbid conditions were the only consistent risk factors for symptoms after LC.

The impact of pain frequency, pain localization and perceived cause of pain on quality of life after cholecystectomy

OBJECTIVE

Further research is needed to understand how pain frequency, localization of pain and the patient's conviction of the cause of pain effects long-term outcome after gallstone surgery.

MATERIALS AND METHODS

A cohort study was conducted based on patients evaluated with SF-36 along with three single-items focusing on gallstone specific symptoms. The physical component summary (PCS) and bodily pain (BP) of SF-36 were used as main outcome measures. To assess the improvement from the procedure, the differences between the preoperative and postoperative ratings were tested with univariate and multivariate logistic regression analysis. The ratings on the single-items regarding pain frequency, pain localization and patient's conviction of the cause of pain were used as predictors. In the multivariate analysis, adjustment was made for age, gender and approach. The study was approved by the Swedish Ethics Committee, Dnr 2015/115.

RESULTS

The study group was based on 4021 patients who responded to the questionnaire SF-36 and the three gallstone specific items preoperatively. A total of 2216 (55.1%) patients also responded postoperatively. In multivariate logistic regression analysis the frequency of the pain attacks and the patient's conviction of the origin of pain significantly predicted postoperative pain as well as PCS of SF-36 (all p < .05).

CONCLUSIONS

The preoperative frequency of pain attacks and the patient's conviction of the cause of pain can predict the outcome regarding PCS and the subscale BP of SF-36 with significantly better ratings in patients with a pain frequency exceeding once per month and in patients convinced of having pain related to gallstones.

Cystic duct remnant: a rare cause for post-cholecystectomy syndrome

Post-cholecystectomy syndrome is a group of disorders resulting from complications of laparoscopic cholecystectomy. Here we report a case of a 59-year-old female patient with history of cholecystectomy who presented with right hypochondrium pain and bloating. Ultrasound and magnetic resonance cholangiopancreatogram revealed a tubular cystic lesion with calculus in situ in the gallbladder fossa in keeping with cystic duct remnant.

Factors relevant to persistent upper abdominal pain after cholecystectomy

BACKGROUND

Cholecystectomy is a routine procedure for treatment of upper abdominal pain (UAP) and other atypical symptoms associated with gallstones. UAP, however, persists in some cases postoperatively. The present study was to identify the risk factors relevant to persistent UAP after cholecystectomy.

METHODS

1714 symptomatic patients undergoing cholecystectomy for gallstones were enrolled. All the patients were asked to complete a biliary symptom questionnaire. The risk factors for persistent postcholecystectomy UAP and features related to sustained relief of postcholecystectomy UAP were evaluated.

RESULTS

172 (10%) patients complained UAP after cholecystectomy. In multivariate analysis, female gender, preoperative UAP occurring >24h before admission, and each episode of UAP >30min were independently associated with persistent postoperative UAP (all p < 0.05). 132 (76.7%) patients reported sustained relief of postcholecystectomy UAP, the causes of which remained unknown but were attributed to functional postcholecystectomy syndrome. Shorter duration of preoperative UAP (occurring within 24 h before admission), less frequency of postoperative UAP (≤1 episode per day) and administration of choleretic medications were independently associated with postoperative UAP relief (all p < 0.05).

CONCLUSION

Females with longer historical and more frequent preoperative UAP are more likely to develop postcholecystectomy UAP. Choleretic medications are effective in relieving postoperative UAP.

Contrast-Enhanced Magnetic Resonance Cholangiography: Practical Tips and Clinical Indications for Biliary Disease Management

Since its introduction, MRCP has been improved over the years due to the introduction of several technical advances and innovations. It consists of a noninvasive method for biliary tree representation, based on heavily T2-weighted images. Conventionally, its protocol includes two-dimensional single-shot fast spin-echo images, acquired with thin sections or with multiple thick slabs. In recent years, three-dimensional T2-weighted fast-recovery fast spin-echo images have been added to the conventional protocol, increasing the possibility of biliary anatomy demonstration and leading to a significant benefit over conventional 2D imaging. A significant innovation has been reached with the introduction of hepatobiliary contrasts, represented by gadoxetic acid and gadobenate dimeglumine: they are excreted into the bile canaliculi, allowing the opacification of the biliary tree. Recently, 3D interpolated T1-weighted spoiled gradient echo images have been proposed for the evaluation of the biliary tree, obtaining images after hepatobiliary contrast agent administration. Thus, the acquisition of these excretory phases improves the diagnostic capability of conventional MRCP—based on T2 acquisitions. In this paper, technical features of contrast-enhanced magnetic resonance cholangiography are briefly discussed; main diagnostic tips of hepatobiliary phase are showed, emphasizing the benefit of enhanced cholangiography in comparison with conventional MRCP.

Post-cholecystectomy syndrome and sphincter of Oddi dysfunction: past, present and future

Post-cholecystectomy syndrome and the concept of a causal relationship to sphincter of Oddi dysfunction, despite the controversy, has presented a clinically relevant conflict for decades. Historically surgeons, and now gastroenterologists have expended tremendous efforts towards trying to better understand the dilemma that is confounded by unique patient phenotypes. Areas covered: This review encompasses the literature from a century of experience on the topic of post-cholecystectomy syndrome. Relevant historical and anecdotal experiences are examined in the setting of insights from evaluation of recently available controlled data. Expert commentary: Historical observations and recent data suggest that patients with post-cholecystectomy syndrome can be categorized as follows. Patients with sphincter of Oddi stenosis will most often benefit from treatment with sphincterotomy. Patients with classic biliary pain and some objective evidence of biliary obstruction may have a sphincter of Oddi disorder and should be considered for endoscopic evaluation and therapy. Patients with atypical post-cholecystectomy pain, without any evidence consistent with biliary obstruction, and/or with evidence for another diagnosis or dysfunction should not undergo ERCP.

Sphincter of Oddi Dysfunction: A Perplexing Presentation

Sphincter of Oddi dysfunction is caused by stenosis or dyskinesia of the sphincter of Oddi, leading to blockage of bile drainage from the common bile duct. We present the case of a 16-year-old female with chronic abdominal pain who underwent laparoscopic cholecystectomy for cholelithiasis but continued to experience abdominal pain, nausea, and vomiting along with persistently elevated ALT and AST levels. Postoperative abdominal ultrasound was nondiagnostic. Esophagogastroduodenoscopy showed mild reflux esophagitis and mild chronic Helicobacter pylori-negative gastritis. Omeprazole was started, but it did not decrease the frequency and severity of the abdominal symptoms. Magnetic resonance cholangiopancreatography did not reveal any pathology. Endoscopic retrograde cholangiopancreatography with manometry confirmed an elevated biliary sphincter pressure. Biliary sphincterotomy was performed, and the symptoms improved.

The Laparoscopic Re-Exploration in the Management of the Gallbladder Remnant and the Cystic Duct Stump Calculi

INTRODUCTION

The gallbladder remnant and the cystic duct stump calculi are uncommon causes of post-cholecystectomy syndrome. Re-exploration is usually needed in the cases where symptom persists. Very few case series and reports are available regarding laparoscopic re-exploration.

AIM

To assess the safety and feasibility of Laparoscopic re-exploration in the cases of gallbladder remnant and cystic duct stump calculi leading to post cholecystectomy syndromes.

MATERIALS AND METHODS

In this study, laparoscopic re-explorations was done in 22 patients in which 17 patients had gallbladder remnant calculi and 5 had cystic duct stump calculi. The study considered parameters like the operative time, conversion rate, post-operative complications, post-operative hospital stay and mortality in these patients. The duration of study was 15 years and the data was retrospectively reviewed.

RESULTS

The median operating time was 83 minutes (range 51 to 134 minutes). Only one patient had conversion to open surgery. In postoperative period two patients had bile leak. They were managed conservatively and leak subsided in 8 and 11 days respectively. One patient had postoperative bleeding not requiring blood transfusion. There was no major complication requiring further intervention and no mortality. Patients were discharged on median day 4 (range 2-11) after the surgery. Patients were followed up every 3 months for one year. However, out of these three patients did not turn up for follow-up.

CONCLUSION

In expert hands laparoscopic re-exploration of the gallbladder remnant/cystic duct stump calculi can be performed within a reasonable operating time. The conversion to conventional re-exploration rate was very low with minimal post-operative complications and shorter hospital stay.

Effects of Rowachol on prevention of postcholecystectomy pain after laparoscopic cholecystectomy: prospective multicenter randomized controlled trial

BACKGROUND

Postcholecystectomy pain (PCP) is characterized by abdominal pain after cholecystectomy. However, prevention of PCP is not well known yet. The purpose of this study was to determine whether Rowachol might be useful in preventing PCP.

METHODS

Between May 2013 and January 2014, a total of 138 patients with gallbladder disease who were scheduled to undergo laparoscopic cholecystectomy were randomly assigned to orally receive 100 mg Rowachol or placebo three times daily for 3 months after surgery. Abdominal pain was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire.

RESULTS

Incidence of PCP in the placebo group (n = 9, 14.3%) was higher than that in the Rowachol group (n = 3, 4.7%) with statistically marginal significance (P = 0.08). Risk factor analysis implicated PCP with increased difficulty in performing LC, more frequent pathology with acute cholecystitis, and absence of postoperative Rowachol treatment. Multivariate analysis revealed that greater difficulty of laparoscopic cholecystectomy (HR = 5.78, 95% CI 1.36-24.40, P < 0.05), and absence of postoperative Rowachol treatment (HR = 2.54, 95% CI 1.10-10.39, P < 0.05) were independent risk factors for development of PCP.

CONCLUSION

Rowachol might be beneficial for prevention of PCP after laparoscopic cholecystectomy.

Comparative analysis of iatrogenic injury of biliary tract in laparotomic and laparoscopic cholecystectomy

Background

Iatrogenic injury to the bile ducts is the most feared complication of cholecystectomy and several are the possibilities to occur.

Aim

To compare the cases of iatrogenic lesions of the biliary tract occurring in conventional and laparoscopic cholecystectomy, assessing the likely causal factors, complications and postoperative follow-up.

Methods

Retrospective cohort study with analysis of records of patients undergoing conventional and laparoscopic cholecystectomy. All the patients were analyzed in two years. The only criterion for inclusion was to be operative bile duct injury, regardless of location or time of diagnosis. There were no exclusion criteria. Epidemiological data of patients, time of diagnosis of the lesion and its location were analyzed.

Results

Total of 515 patients with gallstones was operated, 320 (62.1 %) by laparotomy cholecystectomy and 195 by laparoscopic approach. The age of patients with bile duct injury ranged from 29-70 years. Among those who underwent laparotomy cholecystectomy, four cases were diagnosed (1.25 %) with lesions, corresponding to 0.77 % of the total patients. No patient had iatrogenic interventions with laparoscopic surgery.

Conclusion

Laparoscopic cholecystectomy compared to laparotomy, had a lower rate of bile duct injury.

Clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones or cholecystitis: a systematic review and economic evaluation

BACKGROUND

Approximately 10-15% of the adult population suffer from gallstone disease, cholelithiasis, with more women than men being affected. Cholecystectomy is the treatment of choice for people who present with biliary pain or acute cholecystitis and evidence of gallstones. However, some people do not experience a recurrence after an initial episode of biliary pain or cholecystitis. As most of the current research focuses on the surgical management of the disease, less attention has been dedicated to the consequences of conservative management.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management in people presenting with uncomplicated symptomatic gallstones (biliary pain) or cholecystitis.

DATA SOURCES

We searched all major electronic databases (e.g. MEDLINE, EMBASE, Science Citation Index, Bioscience Information Service, Cochrane Central Register of Controlled Trials) from 1980 to September 2012 and we contacted experts in the field.

REVIEW METHODS

Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies that enrolled people with symptomatic gallstone disease (pain attacks only and/or acute cholecystitis). Two reviewers independently extracted data and assessed the risk of bias of included studies. Standard meta-analysis techniques were used to combine results from included studies. A de novo Markov model was developed to assess the cost-effectiveness of the interventions.

RESULTS

Two Norwegian RCTs involving 201 participants were included. Eighty-eight per cent of people randomised to surgery and 45% of people randomised to observation underwent cholecystectomy during the 14-year follow-up period. Participants randomised to observation were significantly more likely to experience gallstone-related complications [risk ratio = 6.69; 95% confidence interval (CI) 1.57 to 28.51; p = 0.01], in particular acute cholecystitis (risk ratio = 9.55; 95% CI 1.25 to 73.27; p = 0.03), and less likely to undergo surgery (risk ratio = 0.50; 95% CI 0.34 to 0.73; p = 0.0004), experience surgery-related complications (risk ratio = 0.36; 95% CI 0.16 to 0.81; p = 0.01) or, more specifically, minor surgery-related complications (risk ratio = 0.11; 95% CI 0.02 to 0.56; p = 0.008) than those randomised to surgery. Fifty-five per cent of people randomised to observation did not require an operation during the 14-year follow-up period and 12% of people randomised to cholecystectomy did not undergo the scheduled operation. The results of the economic evaluation suggest that, on average, the surgery strategy costs £1236 more per patient than the conservative management strategy but was, on average, more effective. An increase in the number of people requiring surgery while treated conservatively corresponded to a reduction in the cost-effectiveness of the conservative strategy. There was uncertainty around some of the parameters used in the economic model.

CONCLUSIONS

The results of this assessment indicate that cholecystectomy is still the treatment of choice for many symptomatic people. However, approximately half of the people in the observation group did not require surgery or suffer complications in the long term indicating that a conservative therapeutic approach may represent a valid alternative to surgery in this group of people. Owing to the dearth of current evidence in the UK setting a large, well-designed, multicentre trial is needed.

STUDY REGISTRATION

The study was registered as PROSPERO CRD42012002817.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Increased Risk of Depressive Disorder following Cholecystectomy for Gallstones

Background

Prior studies indicate a possible association between depression and cholecystectomy, but no study has compared the risk of post-operative depressive disorders (DD) after cholecystectomy. This retrospective follow-up study aimed to examine the relationship between cholecystectomy and the risk of DD in patients with gallstones in a population-based database.

Methods

Using ambulatory care data from the Longitudinal Health Insurance Database 2000, 6755 patients who received a first-time principal diagnosis of gallstones at the emergency room (ER) were identified. Among them, 1197 underwent cholecystectomy. Each patient was then individually followed-up for two years to identify those who were later diagnosed with DD. Cox proportional hazards regressions were performed to estimate the risk of developing DD between patients with gallstone who did and those who did not undergo cholecystectomy.

Results

Of 6755 patients with gallstones, 173 (2.56%) were diagnosed with DD during the two-year follow-up. Among patients who did and those who did not undergo cholecystectomy, 3.51% and 2.36% later developed depressive disorder, respectively. After adjusting for the patient’s sex, age and geographic location, the hazard ratio (HR) of DD within two years of gallstone diagnosis was 1.43 (95% CI, 1.02–2.04) for patients who underwent cholecystectomy compared to those who did not. Females, but not males, had a higher the adjusted HR of DD (1.61; 95% CI, 1.08–2.41) for patients who underwent cholecystectomy compared to those who did not.

Conclusions

There is an association between cholecystectomy and subsequent risk of DD among females, but not in males.

+Gz-induced post-cholecystectomy syndrome in rabbit model by using a telemetric method

Aviation-related mechanism may exist in the post-cholecystectomy syndrome (PCS) of aircrew patients. The aim of this study was to test this hypothesis on vivo rabbit model and to explore the mechanism by using a novel telemetric method. We constructed a bile duct-to-intestinal bridge bypass on 30 rabbits, with a telemetry implant attached to the Oddi's sphincter. Then a telemetric recording system was used to record the biliary pressure fluctuation through the subcutaneous bridge and the changes of electromyography of the Oddi's sphincter under different +Gz acceleration. Self-control comparison was made before and after cholecystectomy. The fully implantable device was very well accepted by rabbits and the data could reflect the real experimental environment simultaneously. Biliary pressure in common bile duct increased accordingly with +Gz acceleration increased, but bile secretion didn't change. Although +Gz acceleration could increase the frequency of burst of spike potentials in the Oddi's sphincter, the frequency didn't change with the +Gz acceleration increased, and the spike activity didn't change obviously before cholecystectomy. After cholecystectomy, the biliary pressure in common bile duct remained high in 12 rabbits (40%) under +Gz exposure, and the pressure value didn't change as the +Gz acceleration increased. The long-time changes in electromyography of the Oddi's sphincter were observed in the same 12 rabbits, with symptoms of PCS developed in 9 of them. +Gz exposure is an important external factor leading to the biliary physiology disorder, and it may induce PCS in some aircrew patients with individual susceptibility, which means gallbladder maybe a dominant factor in regulating the biliary physiology in theses aircrew patients.

Adult bile duct strictures: role of MR imaging and MR cholangiopancreatography in characterization

Bile duct strictures in adults are secondary to a wide spectrum of benign and malignant pathologic conditions. Benign causes of bile duct strictures include iatrogenic causes, acute or chronic pancreatitis, choledocholithiasis, primary sclerosing cholangitis, IgG4-related sclerosing cholangitis, liver transplantation, recurrent pyogenic cholangitis, Mirizzi syndrome, acquired immunodeficiency syndrome cholangiopathy, and sphincter of Oddi dysfunction. Malignant causes include cholangiocarcinoma, pancreatic adenocarcinoma, and periampullary carcinomas. Rare causes include biliary inflammatory pseudotumor, gallbladder carcinoma, hepatocellular carcinoma, metastases to bile ducts, and extrinsic bile duct compression secondary to periportal or peripancreatic lymphadenopathy. Contrast material-enhanced magnetic resonance (MR) imaging with MR cholangiopancreatography is extremely helpful in the noninvasive evaluation of patients with obstructive jaundice, an obstructive pattern of liver function, or incidentally detected biliary duct dilatation. Some of these conditions may show characteristic findings at MR imaging-MR cholangiopancreatography that help in making a definitive diagnosis. Although endoscopic retrograde cholangiopancreatography with tissue biopsy or surgery is needed for the definitive diagnosis of many of these strictures, certain MR imaging characteristics of the narrowed segment (eg, thickened wall, long-segment involvement, asymmetry, indistinct outer margin, luminal irregularity, hyperenhancement relative to the liver parenchyma) may favor a malignant cause. Awareness of the various causes of bile duct strictures in adults and familiarity with their appearances at MR imaging-MR cholangiopancreatography are important for accurate diagnosis and optimal patient management.

Effects of cholecystectomy on the changes of motility of Beagle dogs' sphincter of Oddi

PURPOSE

To observe the effect of cholecystectomy on the changes of motion pattern of Beagle dogs' sphincter of Oddi (SO), and investigate the modulatory role of nitric oxide (NO) and cholecystokinin (CCK) in the regulation of SO.

METHODS

Pressure of common bile duct, SO motility, response to bolus injections of cholecystokinin (CCK, 20 ng/kg and 100 ng/kg), basal pressure (BP) and phasic contraction amplitude (PCA) were measured respectively by manometry in six Beagle dogs before and after cholecystectomy.

RESULTS

After cholecystectomy, the pressure and diameter of common bile ducts (CBD) was significantly increased (p<0.01); BP and phasic contraction frequency (PCF) were also increased, however, no significant differences were found between the two groups; the SO motilities was not significantly changed. The relaxation responded to physiological dose of CCK (20ng/kg) was decreased, while bolus-dose of CCK (100ng/kg) induced rapid contractions and decreased PCA after cholecystectomy. The regulation pattern of SO pressure modulated by NO and its inhibitor had changed after cholecystectomy.

CONCLUSION

After cholecystectomy in Beagle dogs, no obviously change of motion pattern of SO was observed through self-compensation, but these compensations may lead to some changes of regulation pattern of CCK and NO on SO.

Clonorcis sinensis eggs are associated with calcium carbonate gallbladder stones

Calcium carbonate gallbladder stones were easily neglected because they were previously reported as a rare stone type in adults. The aim of this study was to investigate the relationship between calcium carbonate stones and Clonorchis sinensis infection. A total of 598 gallbladder stones were studied. The stone types were identified by FTIR spectroscopy. The C. sinensis eggs and DNA were detected by microscopic examination and real-time fluorescent PCR respectively. And then, some egg-positive stones were randomly selected for further SEM examination. Corresponding clinical characteristics of patients with different types of stones were also statistically analyzed. The detection rate of C. sinensis eggs in calcium carbonate stone, pigment stone, mixed stone and cholesterol stone types, as well as other stone types was 60%, 44%, 36%, 6% and 30%, respectively, which was highest in calcium carbonate stone yet lowest in cholesterol stone. A total of 182 stones were egg-positive, 67 (37%) of which were calcium carbonate stones. The C. sinensis eggs were found adherent to calcium carbonate crystals by both light microscopy and scanning electron microscopy. Patients with calcium carbonate stones were mainly male between the ages of 30 and 60, the CO2 combining power of patients with calcium carbonate stones were higher than those with cholesterol stones. Calcium carbonate gallbladder stones are not rare, the formation of which may be associated with C. sinensis infection.