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Knapen LM, van Dalem J, Keulemans YC, van Erp NP, Bazelier MT, De Bruin ML, Leufkens HGM, Croes S, Neef C, de Vries F, Driessen JHM. Use of incretin agents and risk of pancreatic cancer: a population-based cohort study. Diabetes Obes Metab 2016; 18:258-65. [PMID: 26537555 DOI: 10.1111/dom.12605] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Revised: 10/21/2015] [Accepted: 11/02/2015] [Indexed: 01/14/2023]
Abstract
AIM To investigate the association between the use of incretin agents and the risk of pancreatic cancer. METHODS A retrospective population-based cohort study, using data from the Clinical Practice Research Datalink, 2007-2012, was conducted. Patients (n = 182 428) with at least one non-insulin antidiabetic drug (NIAD) prescription and aged ≥18 years during data collection, were matched one-to-one to control patients without diabetes. Multivariable Cox proportional hazards models and a new user design were used to estimate the hazard ratio (HR) of pancreatic cancer in incretin users (n = 28 370) compared with control subjects without diabetes and other NIAD-treated patients. Time-dependent adjustments were made for age, sex, lifestyle, comorbidities and drug use. RESULTS The mean duration of follow-up was 4.1 years for incretin users. Current NIAD use was associated with a fourfold increased risk of pancreatic cancer [HR 4.28, 95% confidence interval (CI) 3.49-5.24]. This risk was almost doubled among current incretin users as compared with control subjects. Incretin use was not associated with pancreatic cancer when compared with control subjects with diabetes (HR 1.36, 95% CI 0.94-1.96); however, the 'new user' design did show an association between incretin use and pancreatic cancer when compared with control subjects with diabetes. In both cohorts with prevalent and incident users of antidiabetic drugs, the risk of pancreatic cancer almost doubled in those who had recently initiated incretin therapy (up to seven prescriptions), whereas this elevated risk dropped to baseline levels with prolonged use. CONCLUSIONS We found that incretin use was not associated with pancreatic cancer after adjustment for the severity of the underlying Type 2 Diabetes Mellitus (T2DM). The elevated risk of pancreatic cancer in those recently initiating incretin agents is likely to be caused by protopathic bias or other types of unknown distortion. The presence of considerable confounding by disease severity and the lack of a duration-of-use relationship do not support a causal explanation for the association between incretin agents and pancreatic cancer.
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Affiliation(s)
- L M Knapen
- Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J van Dalem
- Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Y C Keulemans
- Department of Gastroenterology, Zuyderland, Heerlen, Netherlands
| | - N P van Erp
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M T Bazelier
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - M L De Bruin
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - H G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - S Croes
- Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - C Neef
- Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
| | - F de Vries
- Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
| | - J H M Driessen
- Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
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Hermans MAW, Leffers P, Jansen LM, Keulemans YC, Stassen PM. The value of the Mortality in Emergency Department Sepsis (MEDS) score, C reactive protein and lactate in predicting 28-day mortality of sepsis in a Dutch emergency department. Emerg Med J 2011; 29:295-300. [DOI: 10.1136/emj.2010.109090] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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van Ooteghem NA, Keulemans YC. [Unexplained vague abdominal complaints in adults: indication for CT in case of suspected intussusception]. Ned Tijdschr Geneeskd 2003; 147:1293; author reply 1293-4. [PMID: 12861674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
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Boerma D, Rauws EA, Keulemans YC, Bergman JJ, Obertop H, Huibregtse K, Gouma DJ. Impaired quality of life 5 years after bile duct injury during laparoscopic cholecystectomy: a prospective analysis. Ann Surg 2001; 234:750-7. [PMID: 11729381 PMCID: PMC1422134 DOI: 10.1097/00000658-200112000-00006] [Citation(s) in RCA: 148] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess the impact of bile duct injury (BDI) sustained during laparoscopic cholecystectomy on physical and mental quality of life (QOL). SUMMARY BACKGROUND DATA The incidence of BDI during laparoscopic cholecystectomy has decreased but remains as high as 1.4%. Data on the long-term outcome of treatment in these patients are scarce, and QOL after BDI is unknown. METHODS One hundred six consecutive patients (75 women, median age 44 +/- 14 years) were referred between 1990 and 1996 for treatment of BDI sustained during laparoscopic cholecystectomy. Outcome was evaluated according to the type of treatment used (endoscopic or surgical) and the type of injury. Objective outcome (interventions, hospital admissions, laboratory data) was evaluated, a questionnaire was filled out, and a QOL survey was performed (using the SF-36). Risk factors for a worse outcome were calculated. RESULTS Median follow-up time was 70 months (range 37-110). The objective outcome of endoscopic treatment (n = 69) was excellent (94%). The result of surgical treatment (n = 31) depended on the timing of reconstruction (overall success 84%; in case of delayed hepaticojejunostomy 94%). Five patients underwent interventional radiology with a good outcome. Despite this excellent objective outcome, QOL appeared to be both physically and mentally reduced compared with controls (P <.05) and was not dependent on the type of treatment used or the severity of the injury. The duration of the treatment was independently prognostic for a worse mental QOL. CONCLUSIONS Despite the excellent functional outcome after repair, the occurrence of a BDI has a great impact on the patient's physical and mental QOL, even at long-term follow-up.
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Affiliation(s)
- D Boerma
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Keulemans YC, Mok KS, Slors JF, Brink MA, Gouma DJ, Tytgat GN, Groen AK. Concanavalin A-binding cholesterol crystallization inhibiting and promoting activity in bile from patients with Crohn's disease compared to patients with ulcerative colitis. J Hepatol 1999; 31:685-91. [PMID: 10551393 DOI: 10.1016/s0168-8278(99)80349-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND/AIMS Crohn's disease is a risk factor for gallstone formation. In contrast, patients with ulcerative colitis have an incidence of gallstone formation comparable to the general population. The reason for this difference is not known. The aim of this study was to elucidate the factors controlling cholesterol crystallization in gallbladder bile of Crohn's disease and ulcerative colitis patients. METHODS Gallbladder bile was obtained by aspiration during bowel resections (26 Crohn's disease patients, 20 ulcerative colitis patients). Biliary lipid composition, crystal detection time and the effect of extraction of the concanavalin A-binding fraction on crystal formation were determined. RESULTS Cholesterol crystals were present in seven of the 26 bile samples of Crohn's disease-patients and one of the 20 ulcerative colitis patients. Four of the bile samples of Crohn's disease patients were fast nucleating. None of the 20 ulcerative colitis patients had fast nucleating bile. Lipid composition, total lipid concentration and CSI were not significantly different between the two groups. In Crohn's disease patients extraction of concanavalin A-binding fraction decreased crystallization in 10 bile samples but accelerated crystallization in one bile sample. In eight bile samples from ulcerative colitis patients crystallization increased after concanavalin A-binding fraction extraction. CONCLUSIONS Compared to ulcerative colitis patients, gallbladder bile of Crohn's disease patients showed increased cholesterol crystallization despite comparable lipid composition and cholesterol saturation index. This difference is caused by increased cholesterol crystallization-promoting activity. Bile from ulcerative colitis patients contains a Con A-binding factor which inhibits cholesterol crystallization.
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Affiliation(s)
- Y C Keulemans
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Brink MA, Slors JF, Keulemans YC, Mok KS, De Waart DR, Carey MC, Groen AK, Tytgat GN. Enterohepatic cycling of bilirubin: a putative mechanism for pigment gallstone formation in ileal Crohn's disease. Gastroenterology 1999; 116:1420-7. [PMID: 10348826 DOI: 10.1016/s0016-5085(99)70507-x] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Patients with ileal disease, bypass, or resection are at increased risk for developing gallstones. In ileectomized rats, bilirubin secretion rates into bile are elevated, most likely caused by increased colonic bile salt levels, which solubilize unconjugated bilirubin, prevent calcium complexing, and promote its absorption and enterohepatic cycling. The hypothesis that ileal disease or resection engenders the same pathophysiology in humans was tested. METHODS Sterile gallbladder bile samples were obtained intraoperatively from 29 patients with Crohn's disease and 19 patients with ulcerative colitis. Bilirubin, total calcium, biliary lipids, beta-glucuronidase activities, and cholesterol saturation indices in bile were measured, and markers of hemolysis and ineffective erythropoiesis in blood were assessed. RESULTS Bilirubin conjugates, unconjugated bilirubin, and total calcium levels were increased 3-10-fold in bile of patients with ileal disease and/or resection compared with patients with Crohn's colitis or ulcerative colitis. Biliary bilirubin concentrations correlated positively with the anatomic length and duration of ileal disease. Endogenous biliary beta-glucuronidase activities were comparable in all groups, and both the hemogram and serum vitamin B12 levels were normal. CONCLUSIONS This study establishes that increased bilirubin levels in bile of patients with Crohn's disease are caused by lack of functional ileum, supporting the hypothesis that enterohepatic cycling of bilirubin occurs.
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Affiliation(s)
- M A Brink
- Department of Gastrointestinal and Liver Diseases, Academic Medical Center, Amsterdam, The Netherlands.
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Gouma DJ, Rauws EA, Keulemans YC, Bergman JJ, Huibregtse K, Obertop H. [Bile duct injuries after a laparoscopic cholecystectomy]. Ned Tijdschr Geneeskd 1999; 143:606-11. [PMID: 10321286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Eight years after the introduction of laparoscopic cholecystectomy a decrease of the incidence of bile duct injuries is reported in the literature. The incidence of a bile duct injury after laparoscopic cholecystectomy is now slightly higher than after open cholecystectomy. A minority of these injuries are detected during surgery. Most patients have a delayed identification of the bile duct injury, even after discharge from the hospital. An early diagnostic work-up with ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) is mandatory in every patient with persisting symptoms (more than 48 hours) after laparoscopic cholecystectomy. Still, one-third of the patients are subjected to a 'diagnostic' exploratory laparotomy without preoperative visualization of the biliary tract by ERCP or percutaneous transhepatic cholangiography. Minor lesions are mostly treated successfully by endoscopy with a stent. After transection of the bile duct surgical reconstruction by a hepaticojejunostomy has to be performed. A delayed elective reconstruction was associated with fewer complications than acute repair under suboptimal circumstances such as local inflammatory changes and bile leakage.
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Affiliation(s)
- D J Gouma
- Academisch Medisch Centrum/Universiteit van Amsterdam
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Abstract
BACKGROUND Previous studies have suggested that improvements in diagnostic workup and treatment of bile duct injuries (BDI) sustained during laparoscopic cholecystectomy can be expected as experience increases with the laparoscopic procedure. Many published articles reported that early diagnosis, proper classification, and optimal timing of treatment of BDI increase the likelihood of successful treatment. This study determined whether diagnosis and management of BDI have improved over the years. STUDY DESIGN Between June 1990 and November 1996, 106 patients were diagnosed and treated in the Amsterdam Academic Medical Center for BDI sustained during laparoscopic cholecystectomy. Detailed information was obtained about peroperative findings, time interval from laparoscopic cholecystectomy to symptoms, and interval from symptoms to diagnosis. Bile duct injuries were classified into four types. Two patient groups were compared: BDI patients diagnosed from 1990 until 1994 ("learning phase") and patients diagnosed from 1995 until 1996. RESULTS Bile duct injuries combined with bile leakage were diagnosed significantly earlier in the second period after the learning phase. The percentages of injuries diagnosed peroperatively, "blind laparotomies," and suboptimal timed hepaticojejunostomies were not different between the groups. CONCLUSIONS Except for earlier diagnosis of BDI in the later period than in previous years, there appeared to be no significant improvement in diagnostic workup and management during the past 2 years.
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Affiliation(s)
- Y C Keulemans
- Department of Surgery, Amsterdam Academic Medical Center, The Netherlands
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Keulemans YC, Mok KS, de Wit LT, Gouma DJ, Groen AK. Hepatic bile versus gallbladder bile: a comparison of protein and lipid concentration and composition in cholesterol gallstone patients. Hepatology 1998; 28:11-6. [PMID: 9657090 DOI: 10.1002/hep.510280103] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Many studies have demonstrated that gallbladder bile (but not hepatic bile) of animals or patients with cholesterol gallstones contains higher protein concentrations than does gallbladder bile of control patients without stones or with pigment stones. The underlying defect has not been elucidated. To establish whether there is net production or net absorption/degradation of protein by gallbladder epithelium for different classes of protein, paired samples of hepatic and gallbladder bile were obtained from fourteen patients with cholesterol gallstones during elective cholecystectomy. In these paired samples, lipid and protein composition were determined. To obtain the concentration ratio (CR) of protein and lipid, its concentration in the gallbladder was divided by the concentration determined in the paired hepatic bile sample. The CR of bile salts was used as a parameter for water absorption in the gallbladder. Of the biliary proteins that were determined only mucin, albumin, immunoglobulin (Ig) G, and aminopeptidase N appeared to increase in the gallbladder from another cause than water absorption. A strong correlation was found between mucin, albumin, and IgG. Haptoglobin, alpha1-acid glycoprotein, IgM, and IgA appeared to be absorbed by gallbladder epithelium in the majority of patients. In cholesterol gallstone patients, total protein concentration in gallbladder bile of cholesterol gallstone patients is increased when compared with hepatic bile. The increase in protein concentration cannot be explained for all bile samples solely by water absorption. In this study we show that the defect is largely caused by a selective increase in albumin, mucin, and IgG. All other proteins which were investigated are taken up by the gallbladder.
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Affiliation(s)
- Y C Keulemans
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Abstract
BACKGROUND Traditionally, a cholecystectomy is performed after successful endoscopic sphincterotomy and removal of common bile duct (CBD) stones, except in patients of advanced age or with substantial comorbidity. In practice, however, the gallbladder is left in situ more frequently now in patients without contraindications for surgery. The criteria by which patients are selected for an elective cholecystectomy are unclear. The aim of the present study was to establish the proportion of patients for whom a "wait-and-see" strategy was advised and to determine which, if any, patient characteristics had influenced this decision. METHODS This study included 71 patients, all younger than 80 years of age, with both CBD stones and a gallbladder containing stones in whom endoscopic clearance of bile duct stones was achieved. RESULTS Three patients underwent a cholecystectomy within 1 week because of acute cholecystitis. Among the remaining 68 patients, cholecystectomy was recommended for 42 patients and a wait-and-see strategy was advised for 26 patients. Patient characteristics were identical in both groups except for the American Society of Anesthesiologists Physical Status (ASA) score. The ASA score was higher in the wait-and-see group, but 69% of the patients in this group had an ASA score of I or II. Six patients in the wait-and-see group had symptoms; five patients underwent cholecystectomy. The outcome of surgery was no worse in this group than in the cholecystectomy group. CONCLUSIONS Selection of patients for either elective cholecystectomy or wait-and-see was not based on established criteria but mainly dependent on preference of the specialist. The outcome of surgery, indicated in 23% of the patients in the wait-and-see group was comparable with elective cholecystectomy. A controlled trial comparing both treatment options in patients younger than 80 years of age should be performed.
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Affiliation(s)
- Y C Keulemans
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Abstract
BACKGROUND/AIMS Many Concanavalin A-binding glycoproteins have been proposed to influence cholesterol crystallization in human bile. This has been studied mainly by addition of the Concanavalin A-binding fraction to model bile. The physiological relevance of the proteins in native bile is not yet known. The aim of this study was to establish the role of the Concanavalin A-binding fraction in cholesterol crystallization in native human gallbladder bile. METHODS To determine the effects of the removal of Concanavalin A-binding fraction, fresh human gallbladder bile was incubated with either Concanavalin A-Sepharose or Sepharose alone. Beads were sedimented and crystallization was studied in the supernatant. RESULTS Extraction of Concanavalin A-binding fraction decreased crystallization in fast-nucleating biles (Crystal Detection Time < or =4 days). Slow-nucleating biles were not affected. The effect could not be related to the content of known pronucleating proteins (IgA, IgM, haptoglobin, aminopeptidase N and alpha1-acid glycoprotein), since the slow-nucleating biles contained similar amounts of these proteins. CONCLUSIONS Although Concanavalin A-binding fraction always accelerated crystallization when added to model bile, removal of the same fraction from native bile often had no effect. We conclude that slow-nucleating biles in particular contain undetermined factors which regulate the activity of pronucleators.
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Affiliation(s)
- Y C Keulemans
- Department of Surgery, AMC, Amsterdam, The Netherlands
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Keulemans YC, Gouma DJ. Is 24-hour observation after laparoscopic cholecystectomy important for the identification of major vascular injury? Eur J Surg 1997; 163:475-6. [PMID: 9231862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Keulemans YC, Eshuis JH, Leeuwenberg A, de Wit LT, Gouma DJ. [Experiences with outpatient laparoscopic cholecystectomy]. Ned Tijdschr Geneeskd 1997; 141:686-9. [PMID: 9198771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To determine the feasibility and desirability of laparoscopic cholecystectomy in day care. DESIGN Prospective, pilot study. SETTING Academic Medical Centre, Amsterdam, the Netherlands. METHOD Fifteen patients (ASA I/II according to the American Society of Anesthesiologists) with symptomatic gallstones underwent laparoscopic cholecystectomy with the intention to discharge them the same day. Data were collected about: pain (visual analogue scale); pain medication before and after discharge; (rc)admissions; consultations of general practitioner or day care centre; complications; satisfaction of the patients about this treatment modality. RESULTS Fourteen patients could be discharged after 6.2 hour (standard deviation 1.2) of observation. The pain scores and medication use were low. Readmissions did not take place and there were no consultations of general practitioners or the day care centre. These patients had no complications. Thirteen of them preferred day care over admission in hospital. One patient was admitted because of colicky pains and a common bile duct stone was diagnosed, which was removed endoscopically. CONCLUSION Laparoscopic cholecystectomy in day care appears feasible in patients with symptomatic gallstones and no functional incapacities if day care facilities are present.
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Affiliation(s)
- Y C Keulemans
- Afd. Chirurgie, Academisch Medisch Centrum, Amsterdam
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