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Background: Cholecystectomy often disrupts autonomic balance, impacting recovery. Remote ischemic preconditioning (RIPC) may enhance ANS function and protect organs, but its role in cholecystectomy is unclear. Methods: In this randomized controlled trial, 80 patients aged 45 to 65 years, scheduled for elective laparoscopic cholecystectomy, were randomly assigned to either the RIPC group or the control group. The primary outcomes were mean arterial pressure (MAP), heart rate variability (HRV), and the low-frequency to high-frequency ratio (LF/HF) measured at various time points during the perioperative period. Secondary outcomes included liver and kidney function markers, postoperative hospital stay, and 30-day mortality rates. Results: RIPC group significantly improved HRV compared to the control group at 5 minutes post-anesthesia induction (42.5 ± 9.8 ms vs. 36.4 ± 10.1 ms, P = 0.02) and at the end of surgery (44.8 ± 10.5 ms vs. 37.1 ± 9.3 ms, P = 0.01). The LF/HF ratio was significantly lower in the RIPC group at 30 minutes into surgery (1.25 ± 0.35 vs. 1.67 ± 0.42, P = 0.04) and at the end of surgery (1.19 ± 0.31 vs. 1.71 ± 0.39, P = 0.03), indicating improved autonomic balance. There were no significant differences in MAP, liver function markers (ALT), or kidney function (SCr) between groups at any time point. Conclusions: RIPC may improve ANS function and MAP stability during cholecystectomy, as shown by better HRV and lower LF/HF ratios. Though the impact on recovery was not significant. [ABSTRACT FROM AUTHOR]

Background: Transgender individuals frequently undergo gender-affirming hormone therapy (GAHT) during their gender transition which plays a vital role in gender identity affirmation. Cholelithiasis, a common condition affecting 10-15% of the US population, has been linked to estrogen therapy in cisgender women. Despite the fact that hormonal profiles achieved after GAHT are not always identical to cisgender individuals, the effects of GAHT on gallbladder disease (GBD) risk have not been evaluated in transgender populations. This research aims to address this gap utilizing a large nationwide database. Methods: The study analyzed medical records data from the TrinetX database from 52,847 trans men and 38,114 trans women. Four cohorts were created: trans women and men either receiving either hormone therapy or no intervention. Descriptive statistics were calculated before matching to estimate disease burden. The groups were then propensity score matched on known risk factors (age, race, BMI, etc.) and rates of GBD were compared. Results: Before matching, trans women on hormone therapy (TWHT) had a significantly higher 10-year GBD probability than those naïve to therapy (TWNI) (4.69% vs 1.88%). For trans men, there was no significant difference in 10-year rates between those on therapy (TMHT) and those not (TMNI) (3.15% vs 3.87%). Cholecystectomy rates were significantly higher for TWHT than TWNI (1.10% vs. 0.57%), but similar between TMHT and TMNI (0.95% vs. 1.10%). After accounting for risk factors, TWHT had increased GBD risk (HR 1.832), while TMHT showed no significant change. Discussion: This study suggests a link between estrogen GAHT and increased GBD risk in transgender women. Notably, testosterone GAHT did not offer protection against GBD in transgender men, contrary to expectations. This study is, to our knowledge, the first to describe the burden of GBD in the transgender population and to investigate the effects of GAHT on GBD risk. [ABSTRACT FROM AUTHOR]

The incidence of cholelithiasis is higher among individuals who have undergone gastric surgery. The benefits of concomitant gallbladder removal in asymptomatic gallstone patients remain uncertain. The aim was to investigate the necessity and safety of simultaneous cholecystectomy in this particular patient population. We performed a systematic review and meta-analysis to assess the incidence of asymptomatic cholelithiasis converting to symptomatic after gastric surgery and the complication rate associated with simultaneous cholecystectomy. PubMed, Embase, and the Cochrane Library were searched for relevant articles published until 10 March 202210 March 2022. Patients with asymptomatic cholelithiasis after gastric surgery were at a higher risk of developing symptomatic cholelithiasis compared to those without cholelithiasis (relative risk [RR] 2.28, 95% confidence interval [CI] 1.23–4.25) and those with unknown gallbladder conditions (RR 2.70, 95% CI 1.54–4.73). Additionally, patients who underwent simultaneous cholecystectomy did not face a higher risk of complications compared to those who only underwent gastric surgery (RR 0.86, 95% CI 0.48–1.53). Simultaneous cholecystectomy is both necessary and safe for patients with asymptomatic cholelithiasis undergoing gastric surgery. It is crucial to assess the gallbladder's condition before gastric surgery, and if the gallbladder status is unknown, simultaneous cholecystectomy should be avoided. [ABSTRACT FROM AUTHOR]

Laparoscopic cholecystectomy (LC) is the standard surgical treatment for patients with gallstone disease, ranging from symptomatic cholelithiasis to severe cholecystitis. As there is high variability in operative findings during LC, it is important to assess the surgical difficulty objectively. This is critical for further developing and using future artificial intelligence algorithms in LC surgery, as it allows more reliable benchmarking between surgeons and can help in surgical OR planning. In this study, deep learning models were trained to assess the level of difficulty in the first phase of the procedure. 93 LC videos recorded at the Meander Medical Center were included. A modified Nassar scale was used to annotate gallbladder difficulty (grade 1–3) and adhesion presence (grade 1–3). Various models, were trained on different label combinations;binary and multi-label. On the multi-label test set, the best model reached accuracies of 66% and 40% for the classification of the gallbladder and adhesions, respectively. The best binary models classifies gallbladder difficulty grade 3 vs 1,2 with an accuracy of 88%, and gives an accuracy of 82% for grade 1 vs 2,3. This work shows the potential of difficulty understanding in surgical scenery based on early phase endoscopic video. [ABSTRACT FROM AUTHOR]

Global rating scales (GRSs) such as the Objective Structured Assessment of Technical Skills (OSATS) and Global Operative Assessment of Laparoscopic Surgery (GOALS) are assessment methods for surgical procedures. The aim of this study was to establish construct validity of Procedure-Based Assessment (PBA) and to compare PBA with GRSs for laparoscopic cholecystectomy. OSATS and GOALS GRSs were compared with PBA in their ability to discriminate between levels of performance between trainees who can perform the procedure independently and those who cannot. Three groups were formed based on the number of procedures performed by the trainee: novice (1–10), intermediate (11–20) and experienced (>20). Differences between groups were assessed using the Kruskal–Wallis and Mann–Whitney U tests. Increasing experience correlated significantly with higher GRSs and PBA scores (all p <.001). Scores of novice and intermediate groups overlapped substantially on the OSATS (p =.1) and GOALS (p =.1), while the PBA discriminated between these groups (p =.03). The median score in the experienced group was higher with less dispersion for PBA (97.2[85.3–100]) compared to OSATS (82.1[60.7–100]) and GOALS (80[60–100]). For assessing skill level or the capability of performing a laparoscopic cholecystectomy independently, PBA has a higher discriminative ability compared to the GRSs. [ABSTRACT FROM AUTHOR]

Laparoscopic cholecystectomy causes moderate to severe pain despite its minimally invasive nature. This study was performed to compare the efficacy of the bilateral erector spinae plane block (ESPB) and the subcostal transversus abdominis plane block (STAPB) under ultrasound guidance. 64 patients were included in this prospective, randomized study. The patients were allocated into two groups as those receiving ESPB (n = 32) and those receiving STAPB (n = 32). Pain scores at rest and during movement, fentanyl requirement, postoperative walking time, and duration of hospital stay were compared. The complications which related to block were also recorded. In the ESPB group, the Numeric Rating Scale (NRS) scores at rest were lower at hour 0 [at the time of post-anesthetic care unit (PACU) admission] and postoperative hours 2, 4, 6, and 12 (p < 0.05). In the same group, the NRS scores at movement were lower at hours 0, 2, 4, 6, 12, and 24 (p < 0.05). In the ESPB group, the time to first analgesic need was longer (p < 0.05), intraoperative and postoperative Fentanyl requirement (p < 0.0001 for both) and PACU rescue analgesic requirement were lower (p < 0.05), the lengths of PACU and hospital stay were shorter (p < 0.0001), and unassisted walking time was shorter (p < 0.0001). There were no complications related to the block in either group. Bilateral ultrasound-guided ESPB provides superior analgesia after laparoscopic cholecystectomy surgery compared to STAPB and further reduces unaided walking time and hospital stay. [ABSTRACT FROM AUTHOR]

To provide optimal health care for patients with acute cholecystitis in need of acute cholecystectomy, resource allocation has to be optimized. The aim of this study was to assess possible regional inequity regarding the treatment of acute cholecystitis and explore regional differences in the management of acute cholecystitis. Data were retrieved from the Swedish National Register for Gallstone Surgery and Endoscopic Retrograde CholangioPancreatography. Between January 2010 and December 2019, 22,985 patients who underwent cholecystectomy for acute cholecystitis and without prior history of acute cholecystitis were included in the study. The ratio of cholecystectomies with acute cholecystitis performed within two days of admission to hospital compared to population density was studied. Furthermore, the proportion of acute performed cholecystectomies within two days of admission in regions, with or without tertiary care centers, was also examined. No correlation between population density and proportion of acute performed cholecystectomies was found. Regions without tertiary care centers had a higher proportion of acute cholecystectomies performed within two days (5–10%). The difference in the ratio of acute cholecystectomies within two days of admission was significant for all years investigated except 2010. The presence of a tertiary referral center within the region had a greater influence than the population density on the chance of undergoing acute cholecystectomy for patients with acute cholecystitis. There are several potential explanations for this, one being an interference of the needs of patients requiring tertiary referral center care with the needs of patients in need of acute care surgery. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the effect of cholecystectomy on the subsequent risk of acute myocardial infarction (AMI) in patients with gallbladder stones (GBS). Methods: We used the Taiwan National Health Insurance Research Database (NHIRD) for hospitalization to conduct a retrospective nationwide population-based cohort study. The study cohort consisted of a total of 122,421 patients aged ≥20 years with cholecystectomy for GBS between 2000 and 2010. The control cohort consisted of the GBS patients without cholecystectomy and they were randomly selected by propensity score matching with the study cohort at a 1:1 ratio according to age, sex, occupation category, urbanization level, comorbidities, and year of the index date for cholecystectomy. We measured the incidence of AMI for both cohorts. Results: The cumulative incidence of AMI was lower in GB patients with cholecystectomy than that in those without cholecystectomy (2.26 vs 3.28 per 1000 person-years, adjusted hazard ratio [aHR] = 0.65, 95% confidence interval [CI] = 0.61–0.69). Compared to those without cholecystectomy, the risk of developing AMI after cholecystectomy was 0.69 (95% CI = 0.63–0.76) for the first year, 0.69 (95% CI = 0.63–0.77) for 2–5 years, and 0.59 (95% CI = 0.53–0.66) for ≥5 years, respectively. Conclusions: Our findings indicate cholecystectomy ameliorates the risk of AMI in patients with GBS, and the protective effect tends to increase with incremental duration of follow-up. However, it needs more studies to ascertain the protective mechanisms of cholecystectomy against AMI. [ABSTRACT FROM AUTHOR]

Objectives: Two-stage treatment of common bile duct stones by Endoscopic Retrograde Cholangio-Pancreatography and subsequent laparoscopic cholecystectomy is well established. In many cases multiple procedures are needed before clearance of the common bile duct is obtained. This study aimed to describe the clinical course from common bile duct stone diagnosis to successful clearance. Materials and Methods: A prospective observational study from 2011 to 2014 of consecutive patients diagnosed with common bile duct stones undergoing Endoscopic Retrograde Cholangio-Pancreatography at a public university hospital. Results: In this study 297 patients with common bile duct stones were identified. More than one Endoscopic Retrograde Cholangio-Pancreatography was performed in 174 (59%) patients and more than two in 51(17%) before clearance. A sphincterotomy was performed in 269 (91%) patients and 189 (64%) had a stent inserted. Bleeding occurred in 17 (6%) requiring injection treatment and post procedure complications occurred in 38 (13%). Subsequent laparoscopic cholecystectomy was performed in 180 (61%) patients. Overall, the patients were hospitalized for 11 (8.5) days and the length of treatment from diagnose to stone clearance was 49 (84.5) days. Overweight, pancreatitis at admission, universal anesthesia, and expert level endoscopist inversely determined common bile duct clearance failure. Conclusions: Common bile duct clearance by Endoscopic Retrograde Cholangio-Pancreatography requires multiple procedures and complications are frequent leading to prolonged treatment and hospitalization suggesting a limited efficacy. [ABSTRACT FROM AUTHOR]

Introduction: There is alarming evidence about the involvement of general anaesthesia in the development of postoperative cognitive dysfunction. Aim: To clarify the impact of general anaesthesia on cognitive function and to study the possible effect of general anaesthesia on serum S100B, the marker of neuronal degeneration. Methods: This is a prospective randomised controlled study carried out on 50 patients undergoing elective laparoscopic cholecystectomy under conventional general anaesthesia. Cognitive assessment for selected patients was done preoperative and 1 week postoperative using Paired Associate Learning test (PALT) for assessment of verbal memory and Benton Visual Retention test (BVRT) for assessment of visual memory. Quantitative determination of serum S100B was done for all patients in the basal sample and postoperative sample by applying an enzyme- linked immunoabsorbent assay technique on am automated ELISA platform. Results: Regarding cognitive tests, there was a statistically significant difference between the mean value of preoperative PALT and postoperative PALT (p-value =.012). There was also a statistically significant difference between the mean value of preoperative BVRT and postoperative BVRT (p-value =.011). Regarding S100B, there was a statistically significant difference between preoperative and postoperative serum level (p-value =.002). There was also a statistically significant negative correlation between postoperative S100B serum level and the postoperative scores of both PALT and BVRT. Conclusion: General anaesthesia is incriminated in the development of postoperative verbal and visual memory impairment and in the postoperative increase in serum S100B, the markers of neuronal degeneration. [ABSTRACT FROM AUTHOR]

Introduction: Cholesterol gallstone disease have relationships with various conditions linked with insulin resistance, but also with heart disease, atherosclerosis, and cancer. These associations derive from mechanisms active at a local (i.e. gallbladder, bile) and a systemic level and are involved in inflammation, hormones, nuclear receptors, signaling molecules, epigenetic modulation of gene expression, and gut microbiota. Despite advanced knowledge of these pathways, the available therapeutic options for symptomatic gallstone patients remain limited. Therapy includes oral litholysis by the bile acid ursodeoxycholic acid (UDCA) in a small subgroup of patients at high risk of postdissolution recurrence, or laparoscopic cholecystectomy, which is the therapeutic radical gold standard treatment. Cholecystectomy, however, may not be a neutral event, and potentially generates health problems, including the metabolic syndrome. Areas covered: Several studies on risk factors and pathogenesis of cholesterol gallstone disease, acting at a systemic level have been reviewed through a PubMed search. Authors have focused on primary prevention and novel potential therapeutic strategies. Expert commentary: The ultimate goal appears to target the manageable systemic mechanisms responsible for gallstone occurrence, pointing to primary prevention measures. Changes must target lifestyles, as well as experimenting innovative pharmacological tools in subgroups of patients at high risk of developing gallstones. [ABSTRACT FROM AUTHOR]

Objective: To study the outcome of acute pancreatitis and risk factors for recurrent and chronic pancreatitis in a population based cohort of patients with first-time acute pancreatitis. Methods: All patients with first-time acute pancreatitis from 2006-2015 in Iceland were retrospectively evaluated. Medical records were scrutinized and relevant data extracted. Results: 1102 cases of first-time acute pancreatitis were identified: mean age 56yr, 46% female, 41% biliary, 21% alcohol, 26% idiopathic, 13% other causes, mean follow-up 4yr. 21% had ≥1 recurrent acute pancreatitis which was independently related to alcoholic (vs. biliary hazard ratio (HR) 2.29, 95% confidence interval (CI) 1.51-3.46), male gender (HR 1.48, 95%CI 1.08-2.04), and smoking (HR 1.62, 95%CI 1.15-2.28). 3.7% developed chronic pancreatitis. Independent predictors were recurrent acute pancreatitis (HR 8.79, 95%CI 3.94-19.62), alcoholic (vs. biliary HR 9.16, 95%CI 2.71-30.9), local complications (HR 4.77, 95%CI 1.93-11.79), and organ-failure (HR 2.86, 95%CI 1.10-7.42). Conclusions: Recurrent acute pancreatitis occurred in one-fifth of patients. Development of chronic pancreatitis was infrequent. Both recurrent acute pancreatitis and chronic pancreatitis were related to alcoholic acute pancreatitis, while recurrent acute pancreatitis was associated with smoking and male gender, and chronic pancreatitis to recurrent acute pancreatitis, organ-failure, and local complications. [ABSTRACT FROM AUTHOR]

In the context of the flat-rate reimbursements in healthcare, we reviewed physicians' behavior towards laboratory test ordering. We demonstrated how it could be improved when a specific stage of the patient management is considered. We took a multi-step approach to analyze the laboratory test orders in the context of planned laparoscopic cholecystectomy in a general teaching hospital. A reference order set was defined through a collaborative analysis between clinicians and laboratory physicians. The clinical and financial impacts were then evaluated over a period of 24 months. After the introduction of the reference order set, the number of laboratory tests per order decreased significantly for patients with cholecystitis of low severity. Above the monitoring of repeated orderings during a single stay, the major impacts were achieved by a drastic reduction of inappropriate orders, particularly in the field of bacteriology. The main effects of the order set were maintained throughout a follow-up period of 24 months. Our study demonstrated that, when considering laboratory test ordering optimization, reference order sets could achieve high levels of efficiency. To ensure high compliance to reference order sets, extensive collaboration between clinicians and laboratory physician is mandatory even if very sophisticated information systems are available. [ABSTRACT FROM AUTHOR]

Purpose/Aim of the study: We investigated the effects of different positive end-expiratory pressure (PEEP) levels on postoperative respiration parameters in patients undergoing laparoscopic cholecystectomy. Materials and Methods: One hundred and five consecutive patients were randomly divided to three groups (n = 35, for each group). Group I did not receive PEEP whereas group II received PEEP as 5 cmH2O and group III received PEEP as 8 cm H2O. Measurements with spirometer were taken 1 hour before the operation (T1) and, 1 (T2), 6 (T3), and 24 hours (T4) after extubation by an anesthetist. Forced expiratory volume (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF) were recorded. Results: Group I had higher FVC values measured at T2 time point compared with other groups (p < 0.05, for both groups). There was a statistically significant difference between group I and group III in terms of the FVC values measured at T3 and T4 time points (p = 0.05 and p < 0.05, retrospectively). A statistical difference was found between group I and group II in terms of FEV1 measured at T2 time point (p < 0.05). Group I had higher FEV1 values measured at T3 and T4 time points compared to group III (p = 0.05, P<0.05; respectively). Group III had lower PEF values measured at T4 time point compared to group I and II (p < 0.05). Conclusions: We concluded that PEEP with 5 or 8 cmH2O has negative effects on lung function tests measured with spirometer during postoperative 1st, 6th, and 24th hours in patients underwent elective laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

Objectives: Recurrence of primary common bile duct (CBD) stone commonly occurs after complete removal of CBD stones in patients with cholecystectomy. This study aimed to investigate potential risk factors for the recurrence of primary CBD stones after endoscopic treatment. Materials and methods: Between January 2005 and December 2015, the endoscopic retrograde cholangiopancreatography (ERCP) database of our medical center was retrospectively reviewed; information regarding eligible patients who had recurrent CBD stones with a history of previous cholecystectomy was collected. The characteristics of the patients, CBD stone, CBD and ERCP-related factors were analyzed. Results: The recurrence rate of CBD stone was 18.5% (115/622) after endoscopic treatment in patients with cholecystectomy. In univariate analysis, the number of CBD stones (≥2), CBD stone diameter (≥10 mm), stone composition, stone consistency, CBD diameter (≥15 mm), bile duct dilatation pattern, sharp bile duct angulation (<145°), balloon dilatation, large balloon (>12 mm) dilatation, endoscopic mechanical lithotripsy, endoscopic sphincterotomy, and endoscopic papillary balloon dilatation alone method were significant between the non-recurrence and recurrence groups. However, in multivariate analysis (based on the binary logistic regression method), the number of CBD stones (≥2) (adjusted odds ratio [AOR] 3.232; 95% confidence interval [CI] 1.344-7.773; p = .009), cholesterol stone (AOR 2.824; 95% CI 1.175-6.786; p =.02) and sharp bile duct angulation (<145°) (AOR 2.462; 95% CI 1.062-5.711; p = .036) were independent risk factors of CBD stone recurrence after cholecystectomy. Conclusions: CBD stone number (≥2), cholesterol stone and sharp bile duct angulation (<145°) are associated with recurrent common bile duct stones after cholecystectomy. [ABSTRACT FROM AUTHOR]

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 (allp < .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. [ABSTRACT FROM AUTHOR]

Introduction: Gallbladder polypoid-lesions (GPs) are found in 5–10% of the general population. Although the majority of GPs are asymptomatic and benign in nature, some of them can develop into cancer, which carries a poor prognosis. Currently, the risk factors, natural history and classification of GPs remain unclear, differentiation of benign from malignant or premalignant GPs based on available diagnostic modalities and/or features of patients and GPs remain difficult, and there are still no evidence-based guidelines to dictate when and how GPs of varying sizes and subtypes should be managed. All of these facts have left GPs in uncertainty. Areas covered: A literature search was performed using the terms ‘gallbladder polyps’ AND ‘polypoid lesion of gallbladder’ in the PubMed database from January 2000 to September 2016. Original and review articles on almost all aspects of GPs in humans, especially diagnosis, treatment and surveillance, were reviewed and analyzed. Reference lists of reviews and original articles were also examined for relevant publications. Expert commentary: The present article summarizes almost all aspects of GPs, analyzes the controversies, and outlines our data and comments. It is the authors’ purpose that this article be beneficial for scientific, accurate and appropriate management of GPs. [ABSTRACT FROM PUBLISHER]

Objectives:Gallstone-related disease is the second most common non-obstetric cause, following appendicitis, for acute abdomen in pregnancy. This study aimed to investigate treatment strategies, changes over time and outcome. Materials and methods:All consecutive patients with symptomatic gallstone-related disease during pregnancy admitted to Skane University hospital in Lund and Malmö 2001–2015 were analysed retrospectively. Information regarding the patient, pregnancy and fetus/child was recorded. The material was analysed by dividing it into two equal time periods and by comparing conservative management and surgical intervention. Results:We included 96 patients with 97 pregnancies. The age was 30 (26–34) years and BMI 28 (24–31). Median length of pregnancy at first admission was 23 (13–31) weeks. The three most common diagnoses were biliary colic (n = 63), cholecystitis (n = 22) and acute pancreatitis (n = 16). Conservative treatment was practiced in 62 (64%) patients and intervention in 35 (36%). Conservatively treated patients were admitted later during pregnancy (week 26 (20–33) versus 17 (10–22),p < .001). Surgically treated patients had a longer total length of stay (all admissions) than conservatively treated patients (p = .001), less readmissions (p = .001) and equal birth outcome. Surgical intervention was more common in the later time period (48% versus 22%,p = .011). Of the conservatively treated patients, 56% were subjected to surgical intervention within 2 years after delivery. Conclusions:We found that intervention was more common in the later time period, with good results concerning safety, and less readmissions. A majority of the conservatively treated patients had surgical intervention within two years after delivery. Our results support surgical intervention in pregnancy. [ABSTRACT FROM AUTHOR]

Aim of the study: The guidelines recommend that patients with mild gallstones pancreatitis should undergo a definitive management for gallstones during the same admission or within the next two weeks. The aim of this study was to estimate the financial cost resulting from a delay in surgical management following mild gallstones pancreatitis. This includes the costs of readmissions with biliary events and the subsequent investigations required during these admissions.Materials and methods: A retrospective analysis included patients with gallstone pancreatitis who were admitted to a district general hospital in the United Kingdom over one year. Patients with severe pancreatitis and those unfit for surgery were excluded.Results: Forty patients were included in the study, 27 females (67%) and 13 males (33%). Mean age was 50.2 years. Twenty-two patients of the total presented with a single admission with gallstone pancreatitis prior to an elective surgery; however, 18 patients (45%) required recurrent admissions. The duration between the first admission and surgery ranged from 14 to 389 days (median of 99 days). Only one patient (2.5%) had cholecystectomy within two weeks of admission as per guidelines. Twenty-two ultrasound scans, four computed tomography scans, 15 magnetic resonance cholangiopancreatography, and two endoscopic retrograde cholangiopancreatography were the total of the extra-investigations required during readmissions. Estimated costs of extra admissions and extra investigations exceeded £33,000.Conclusions: The delay in cholecystectomy for patients admitted with mild gallstone pancreatitis and fit for surgery has resulted in high readmission rate with biliary events, and subsequently high extrax costs. [ABSTRACT FROM PUBLISHER]

Objective:To evaluate existing evidence regarding surgical treatments for gallbladder cancer in a Health Technology Assessment. A specific aim was to evaluate whether extended surgery regarding liver, lymph nodes, bile duct, and adjacent organs compared with cholecystectomy alone in the adult patient with gallbladder cancer in early and late stages implies improved survival. Methods:In April 2015 and updated in June 2016, a systematic literature search was conducted in PubMed, Embase, and the Cochrane Library. Two authors independently screened titles, abstracts, and full-text articles. The certainty of evidence was evaluated according to GRADE. Main results:Forty-four observational studies (non-randomised, controlled studies) and seven case series were included. Radical resection, including liver and lymph node resection, compared with cholecystectomy alone showed significantly better survival for patients with stages T1b and above. All studies had serious study limitations and the certainty of evidence was very low (GRADE ⊕○○○). A survival benefit seen in patients with stage T1b or higher with lymph node resection, was most evident in stage T2, but the certainty of evidence was low (GRADE ⊕⊕○○). It is uncertain whether routine bile duct resections improve overall survival in patients with gallbladder cancer stage T2–T4 (GRADE ⊕○○○). Conclusion:Data indicate that prognosis can be improved if liver resection and lymph node resection is performed in patients with tumour stage T1b or higher. There is no evidence supporting resection of the bile duct or adjacent organs if it is not necessary in order to achieve radicality. [ABSTRACT FROM PUBLISHER]

Background: We aimed to compare laparoscopic cholecystectomy (LC) and simultaneous laparoscopic transcystic common bile duct exploration (LTCBDE) using an ultrathin choledochoscope with LC followed by endoscopic retrograde cholangiopancreatography (ERC) and endoscopic sphincterotomy (ES) when indicated. Methods: We retrospectively reviewed the records of patients seen between 2004 and 2014 and treated with LC+LTCBDE or LC for gallstones and suspected choledocholithiasis. Postoperative complications and surgical outcomes were compared using t-test, Mann-Whitney U test, or chi-square test. Results: 115 patients underwent successful LC+LTCBDE and 112 LC; follow-up data was available for 103 and 106 patients, respectively. Seventeen patients (16.5%) in the LC+LTCBDE group and 10 (28.6%) in the LC+ERC+ES group developed complications (P = 0.114). The LC+LTCBDE group had a significantly higher rate of satisfactory biliary function outcomes than the LC+ERC+ES group (98.1% vs. 85.7%, respectively) (P = 0.017). Conclusions: Single-step LC+LTCBDE using an ultrathin choledochoscope may provide better outcomes in patients with gallstones and suspected choledocholithiasis. [ABSTRACT FROM PUBLISHER]

Introduction: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. [ABSTRACT FROM PUBLISHER]

Introduction:In Bouveret’s syndrome, a biliary stone obstructs the duodenum. Surgical treatment is plagued by high morbidity and mortality. Therefore, endoscopic treatment has become a first-line approach. Areas covered:A literature search of Medline and Google Scholar databases was performed using the terms endoscopic treatment, non-operative treatment, Bouveret’s syndrome, and gallstone ileus. Sixty-one cases of successful endoscopic treatment were found over the period 1978–2016 and are summarized herein. Therapeutic modalities used in 52 patients with complete success included mechanical lithotripsy (40% of cases), electrohydraulic lithotripsy (21% of cases), extraction of the intact stone and laser lithotripsy (15% of cases each), extracorporeal shockwave lithotripsy and duodenal stenting (4% of cases each). In the remaining 9 patients, stone fragments migrated distally and required surgical removal. Cholecystectomy was performed in five (8.2%) of 61 patients and gallbladder cancer was detected in three (4.9%) patients. Expert commentary:Meticulous preparation, including that of instruments, personnel, patient anesthesia, and X-ray availability, is key to success in this unusual situation. Partial success (stone fragmentation and mobilization to another location) may render surgery easier as these patients present with dense adherences in the right upper quadrant. Cholecystectomy is reserved for highly selected patients (e.g. relapsing ileus, gallbladder cancer). [ABSTRACT FROM PUBLISHER]

ObjectiveEndoscopic transpapillary gallbladder drainage using a nasocystic tube or plastic stent has been attempted as an alternative to percutaneous drainage for patients with acute cholecystitis who are not candidates for urgent cholecystectomy. We aimed to assess the efficacy of single-step endoscopic drainage of the common bile duct and gallbladder, and to evaluate which endoscopic transpapillary gallbladder drainage method is ideal as a bridge before elective cholecystectomy.Materials and methodsFrom July 2011 to December 2014, 35 patients with acute moderate-to-severe cholecystitis and a suspicion of choledocholithiasis were randomly assigned to the endoscopic naso-gallbladder drainage (ENGBD) (n = 17) or endoscopic gallbladder stenting (EGBS) (n = 18) group.ResultsBile duct clearance was performed successfully in all cases. No significant differences were found between the ENGBD and EGBS groups in the technical success rates [82.4% (14/17) vs. 88.9% (16/18),p = 0.658] and clinical success rates [by intention-to-treat analysis: 70.6% (12/17) vs. 83.3% (15/18),p = 0.443; by per protocol analysis of technically feasible cases: 85.7% (12/14) vs. 93.8% (15/16),p = 0.586]. Three ENGBD patients and two EGBS patients experienced adverse events (p = 0.658). No significant differences were found in operation time or rate of conversion to open cholecystectomy.ConclusionsSingle-step endoscopic transpapillary drainage of the common bile duct and gallbladder seems to be an acceptable therapeutic modality in patients with acute cholecystitis and a suspicion of choledocholithiasis. There were no significant differences in the technical and clinical outcomes between ENGBD and EGBS as a bridge before cholecystectomy. [ABSTRACT FROM PUBLISHER]

The majority of gallstone patients remain asymptomatic; however, interest toward the gallstone disease is continuing because of the high worldwide prevalence and management costs and the development of gallstone symptoms and complications. For cholesterol gallstone disease, moreover, a strong link exists between this disease and highly prevalent metabolic disorders such as obesity, dyslipidemia, type 2 diabetes, hyperinsulinemia, hypertriglyceridemia and the metabolic syndrome. Information on the natural history as well as the diagnostic, surgical (mainly laparoscopic cholecystectomy) and medical tools available to facilitate adequate management of cholelithiasis and its complications are, therefore, crucial to prevent the negative outcomes of gallstone disease. Moreover, some risk factors for gallstone disease are modifiable and some preventive strategies have become necessary to reduce the onset and the severity of complications. [ABSTRACT FROM PUBLISHER]

The medical treatment of acute pancreatitis continues to focus on supportive care, including fluid therapy, nutrition, and antibiotics, all of which will be critically reviewed. Pharmacologic agents that were previously studied were found to be ineffective likely due to a combination of their targets and flaws in trial design. Potential future pharmacologic agents, particularly those that target intracellular calcium signaling, as well as considerations for trial design will be discussed. As the incidence of acute pancreatitis continues to increase, greater efforts will be needed to prevent hospitalization, readmission and excessive imaging in order to reduce overall healthcare costs. Primary prevention continues to focus on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and secondary prevention on cholecystectomy for biliary pancreatitis as well as alcohol and smoking abstinence. [ABSTRACT FROM AUTHOR]