How Would You Treat This Patient With Gallstone Pancreatitis?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Enhancing patient outcomes through nursing care in laparoscopic common bile duct exploration; a randomized control trail

BACKGROUND

When compared to open surgery, laparoscopic common bile duct exploration (LCBDE) is known to cause less discomfort and a faster recovery. This study examines the effect of the Enhanced Recovery After Surgery (ERAS) strategy on LCBDE outcomes.

METHODS

In March 2021 to May 2024, 400 patients with LCBDE participated in randomized research. The six patient groups were: Multimodal Pain Management (n = 50), Standard Pain Management (n = 50), ERAS (n = 50), Preoperative Assessment (n = 100), Standard Preoperative Assessment (n = 100), and Standard Care (n = 50). The patient's satisfaction, long-term recovery, pain, anxiety, and complication rates were among the outcomes that were measured.

RESULTS

After the intervention, the mean anxiety level of the ERAS group was significantly lower (P < 0.05), and their rates of complications were also decreased. Reduced postoperative pain scores, which were 5 on day 1 and decreased to 3 by day 3, were the consequence of the multimodal pain management strategy inside ERAS. A 90% satisfaction rating and an average recovery period of five days were reported by the ERAS group. Long-term results in ERAS showed that the average time to return to work was only 25 days, and there was a decreased incidence of chronic pain.

CONCLUSION

The ERAS protocol enhances the short- and long-term course of recovery for patients with LCBDE, leading to increased satisfaction and better clinical outcomes. These results suggest that the ERAS method should be used as the gold standard for postoperative care for patients with LCBDE.

The link between serum cotinine levels and gallstones prevalence in adults: a cross-sectional analysis using NHANES data (2017-2020)

Background

Gallstones represent a prevalent health issue globally, resulting in significant annual healthcare costs. While tobacco exposure is recognized for its association with numerous diseases, its correlation with gallstones remains contentious. Serum cotinine, a metabolite of nicotine, serves as a widely utilized indicator for assessing tobacco exposure. Crucially, no research has yet examined the association between serum cotinine levels and the gallstones.

Methods

This study is designed as a cross-sectional analysis, utilizing data from the NHANES public database. The relationship between serum cotinine levels and gallstones was analyzed using multinomial logistic regression models and smooth curve fitting. Subgroup analyses and interaction tests were performed to examine the potential contributions of different populations and covariates to the findings.

Results

A total of 5,856 participants were included in this study. After adjusting for relevant covariates, the multiple logistic regression model results indicated that for each unit increase in serum cotinine concentration above 0.29 ng/mL, there was a 29% increase in the prevalence of gallstones. Furthermore, smooth curve fitting analysis revealed a positive correlation between these variables. These findings underscore the impact of tobacco exposure on gallstone prevalence.

Conclusion

This study demonstrates a positive correlation between tobacco exposure, as measured by serum cotinine levels, and the prevalence of gallstones, thus adding to the body of existing research on this relationship.

Current Gallstone Treatment Methods, State of the Art

This study aims to provide valuable references for clinicians in selecting appropriate surgical methods for biliary tract stones based on patient conditions. In this paper, the advantages and disadvantages of various minimally invasive cholelithiasis surgical techniques are systematically summarized and innovative surgical approaches and intelligent stone removal technologies are introduced. The goal is to evaluate and predict future research priorities and development trends in the field of gallstone surgery. In recent years, the incidence of gallstone-related diseases, including cholecystolithiasis and choledocholithiasis, has significantly increased. This surge in cases has prompted the development of several innovative methods for gallstone extraction, with minimally invasive procedures gaining the most popularity. Among these techniques, PTCS, ERCP, and LCBDE have garnered considerable attention, leading to new surgical techniques; however, it must be acknowledged that each surgical method has its unique indications and potential complications. The primary challenge for clinicians is selecting a surgical approach that minimizes patient trauma while reducing the incidence of complications such as pancreatitis and gallbladder cancer and preventing the recurrence of gallstones. The integration of artificial intelligence with stone extraction surgeries offers new opportunities to address this issue. Regarding the need for preoperative preparation for PTCS surgery, we recommend a combined approach of PTBD and PTOBF. For ERCP-based stone extraction, we recommend a small incision of the Oddi sphincter followed by 30 s of balloon dilation as the optimal procedure. If conditions permit, a biliary stent can be placed post-extraction. For the surgical approach of LCBDE, we recommend the transduodenal (TD) approach. Artificial intelligence is involved throughout the entire process of gallstone detection, treatment, and prognosis, and more AI-integrated medical technologies are expected to be applied in the future.

Gallstone pancreatitis: general clinical approach and the role of endoscopic retrograde cholangiopancreatography

Gallstones account for majority of acute pancreatitis in the Western world. Increase in number and smaller size of the stones increases the risk for biliary pancreatitis. In addition to features of acute pancreatitis, these patients also have cholestatic clinical picture. Fluid therapy and enteral nutrition are vital components in management of any case of acute pancreatitis. During initial evaluation, a right upper quadrant ultrasonogram is particularly important. On a case-bycase basis, further advanced imaging studies such as magnetic resonance cholangiopancreatography or endoscopic ultrasound may be warranted. Acute management also involves monitoring for local and systemic complications. Patients are triaged based on predictors of ongoing biliary obstruction in order to identify who would need endoscopic retrograde cholangiopancreatography. Index cholecystectomy is safe and recommended, with exception of cases with significant local and systemic complications where delayed cholecystectomy may be safer.