Epidemiología de las enfermedades biliares y su manejo laparoscópico en un hospital básico.

Gallstones are highly prevalent, and more than 9000 cholecystectomies are performed annually in Denmark. The aim of this guideline was to improve the clinical course of patients with gallstone disease including a subgroup of high-risk patients. Outcomes included reduction of complications, readmissions, and need for additional interventions in patients with uncomplicated gallstone disease, acute cholecystitis, and common bile duct stones (CBDS). An interdisciplinary group of clinicians developed the guideline according to the GRADE methodology. Randomized controlled trials (RCTs) were primarily included. Non-RCTs were included if RCTs could not answer the clinical questions. Recommendations were strong or weak depending on effect estimates, quality of evidence, and patient preferences. For patients with acute cholecystitis, acute laparoscopic cholecystectomy is recommended (16 RCTs, strong recommendation). Gallbladder drainage may be used as an interval procedure before a delayed laparoscopic cholecystectomy in patients with temporary contraindications to surgery and severe acute cholecystitis (1 RCT and 1 non-RCT, weak recommendation). High-risk patients are suggested to undergo acute laparoscopic cholecystectomy instead of drainage (1 RCT and 1 non-RCT, weak recommendation). For patients with CBDS, a one-step procedure with simultaneous laparoscopic cholecystectomy and CBDS removal by laparoscopy or endoscopy is recommended (22 RCTs, strong recommendation). In high-risk patients with CBDS, laparoscopic cholecystectomy is suggested to be included in the treatment (6 RCTs, weak recommendation). For diagnosis of CBDS, the use of magnetic resonance imaging or endoscopic ultrasound prior to surgical treatment is recommended (8 RCTs, strong recommendation). For patients with uncomplicated symptomatic gallstone disease, observation is suggested as an alternative to laparoscopic cholecystectomy (2 RCTs, weak recommendation). Seven recommendations, four weak and three strong, for treating patients with symptomatic gallstone disease were developed. Studies for treatment of high-risk patients are few and more are needed. The Danish Surgical Society.

ICG fluorescence (ICGF) guidance during laparoscopic cholecystectomy (LC) is gaining wider acceptance. While the accruing data largely addresses ICGF guidance during LC in patients with uncomplicated gallstone disease (UGS) and acute cholecystitis, there is a paucity of data related for complicated gall stone disease (CGS) such as choledocholithiasis, bilio-enteric fistula, remnant gall bladder, etc. The purpose of this study was to evaluate the role of ICGF during LC in the spectrum of CGS with state of the art 4 chip camera system. Retrospective review from a prospectively maintained database of all patients who underwent ICGF guided LC during the period June 1st, 2019 till December 30th, 2021 formed part of the study. Clinical profile and findings on ICGF during LC for CGS were studied. The data was studied to evaluate the potential roles of ICGF during LC for CGS. Of 68 patients, there were 29 males and 39 females. Among them were 32 and 36 in the uncomplicated and complicated gallstone disease groups, respectively. ICGF showed CBD visualization in 67(98.5%) and cystic duct in 62(91%). ICGF guidance helped in management of CGS, prior to, during and after completion of LC. It had novel application in patients undergoing CBD exploration. In our small series of patients with CGS, ICGF guidance enabled a LC and laparoscopic subtotal cholecystectomy in 94% and 6% of patients respectively. The study highlights potential roles and advantages with ICGF guided laparoscopic management for CBD stones, bilioenteric fistula, completion cholecystectomy and cystic duct stones. Large scale multicenter prospective studies are required to clarify the role of ICGF in the wide spectrum of CGS.

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. 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. 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. Secondary care elective settings. Adults with symptomatic uncomplicated gallstone disease referred to a secondary care setting were considered for inclusion. Participants were randomised 1: 1 at clinic to receive either laparoscopic cholecystectomy or observation/conservative management. 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. 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. 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. This trial is registered as ISRCTN55215960. 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.

The standard treatment for patients with symptomatic gallstones is laparoscopic cholecystectomy (LC). In patients undergoing LC the prevalence of common bile duct (CBD) stones ranges between 8% and 15% and it increases with advancing age, reaching up to 60% in elderly patients. Every patient who is candidate for LC should be evaluated for the presence of CBD stones and these should be treated if the diagnosis is confirmed. In the literature, the procedure of choice for CBD stones treatment is still debated. In many centers, pre- or postoperative endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) and LC (two-stage endo-laparoscopic management) is considered standard practice instead of open choledocholithotomy and cholecystectomy. Laparoscopic single-stage management of gallstones and CBD stones has demonstrated equivalent outcomes to the two-stage endo-laparoscopic approach in randomized controlled trials but with shorter hospital stay and fewer interventions. Moreover, the two-stage endo-laparoscopic management of CBD stones and gallstones may be associated with a higher additional procedures rate, and possibly increased costs, as compared to single-stage laparoscopic management. Another option is single-stage endo-laparoscopic management of gallstones and CBD stones, performing ERCP/ES during the same LC anesthesia (so called, “Rendez-Vous” procedure). Excluding patients with cholangitis, who should be managed by emergency ERCP with ES and stones removal, in the elective setting the ultimate choice for one procedure or the other largely depends on the local resources and expertise that are available in the individual center, notwithstanding the scientific evidence in favour of single-stage laparoscopic management. The authors report the surgical techniques that they follow during LC for CBD exploration and stones’ removal by laparoscopic trans-cystic or choledochotomy approach.

Laparoscopic cholecystectomy: Applicability in the geriatric population: [formula omitted] Dept. of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD

The objective of this report was to study the sensitivity of indicators used for predicting bile duct stones and their endoscopic removal before laparoscopic cholecystectomy. A retrospective study was conducted on 104 patients who successfully underwent endoscopic retrograde cholangiopancreatogram (ERCP) before laparoscopic cholecystectomy at Riyadh Medical Complex between 1992 and 1994 (1412H-1414H). Six indicatorsâjaundice, biliary pancreatitis, stones in bile duct on sonography, dilated bile duct (>7 mm) on ultrasonography, dilated bile duct with deranged liver function test, and deranged liver function test without jaundiceâwere used for suspecting choledocholithiasis and endoscopic removal before laparoscopic cholecystectomy. Ultrasound correctly predicted bile duct stone in 75%, followed by dilated bile duct with deranged liver function test (46%). Clinical jaundice and biliary pancreatitis were equally sensitive indicators (42% each). Sensitivity of only dilated bile duct on ultrasonography in predicting duct stone was 36%. Deranged liver function without jaundice was the least sensitive (22%) of the predictors. Overall, these indicators correctly diagnosed bile duct stones in 34% of patients. Until laparoscopic exploration of bile duct or a noninvasive technique, such as magnetic resonance cholangiopancreatogram (MRCP), is widely available, these predictors will help in selecting patients with bile duct stones for preoperative removal. Other workers have suggested combining these indicators to improve the predictive value.

Gallbladder disease is one of the most prevalent digestive disorders affecting the health and quality of life of millions of people around the world. Laparoscopic cholecystectomy is the procedure of choice in managing symptomatic cholelithiasis. This study was conducted to report on the postoperative complications after laparoscopic and open cholecystectomy in a Palestinian government hospital. The study also investigated associations between sociodem-ographic and surgical variables of the study patients and postoperative complications, dura-tion of hospital stay, and duration of the surgical procedure. A retrospective observational design was used in the present study in which patient files (n = 101) were included in the fi-nal analysis. The study site was one of the main hospitals in Hebron District, Palestine. Of the patients included, the majority (75.2%) were female in gender, more than half (53.5%) were between 40 and 60 years of age, the majority (88.1%) had laparoscopic cholecystectomy, the duration of the surgical procedure ranged from 40 minutes to 3 hours, and the duration of hospital stay ranged from 1 to 14 days. Postoperative complications were reported in 14 pa-tients (13.9% of the cases). Postoperative complications were significantly associated with open cholecystectomy (χ2/Fisher's exact test = 8.73, p value = 0.011, Spearman’s rho = 0.30, p value = 0.003). Patients who have had postoperative complications stayed significantly longer duration in the hospital (χ2/Fisher's exact test = 61.86, p value &lt; 0.001; Spearman’s rho = 0.79, p value &lt; 0.001). Older patients have had significantly more open cholecystectomy compared to younger patients (χ2/Fisher's exact test = 12.50, p value = 0.003; Spearman’s rho = 0.34, p value = 0.001) and the length of the surgical procedure was significantly higher (χ2/Fisher's exact test = 7.30, p value = 0.043; Spearman’s rho = 0.21, p value = 0.036). Lapa-roscopic cholecystectomies are the standard of practice in managing gallstone disease in Pal-estine. Laparoscopic cholecystectomies were associated with reduced postoperative compli-cations, surgical operation time, and hospital stay similar to those reported previously. More studies are still needed to analyze and compare pain and speed of recovery after laparoscopic cholecystectomies in Palestine.

Common bile duct (CBD) stone is a relatively frequent disorder with a prevalence of 10-20% in patients with gallstones. This is also associated with serious complications, including obstructive jaundice, acute suppurative cholangitis, and acute pancreatitis. Early diagnosis and prompt treatment is the most important for managing CBD stones. According to a recent meta-analysis, endoscopic ultrasonography and magnetic resonance cholangiopancreatography have high sensitivity, specificity, and accuracy for the diagnosis of CBD stones. Endoscopic ultrasonography, in particular, has been reported to have higher sensitivity between them. A suggested management algorithm for patients with symptomatic gallstones is based on whether they are at low, intermediate, or high probability of CBD stones. Single-stage laparoscopic CBD exploration and cholecystectomy is superior to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy with respect to technical success and shorter hospital stay in high risk patients with gallstones and CBD stones, where expertise, operative time, and instruments are available. ERCP plus laparoscopic cholecystectomy is usually performed to treat patients with CBD stones and gallstones in many institutions. Patients at intermediate probability of CBD stones after initial evaluation benefit from additional biliary imaging. Patients with a low probability of CBD stones should undergo cholecystectomy without further evaluation. Endoscopic sphincterotomy and endoscopic papillary balloon dilation in ERCP are the primary methods for dilating the papilla of Vater for endoscopic removal of CBD stones. Endoscopic papillary large balloon dilation is now increasingly performed due to the usefulness in the management of giant or difficult CBD stones. Scheduled repeated ERCP may be considered in patients with high risk of recurrent CBD stones.

Single Stage Biliary Stone Treatment by Laparoscopic Cholecystectomy and Intraoperative Endoscopic Sphincterotomy Experience with 204 Patients

Background Laparoscopic cholecystectomy (LC) has emerged as the gold standard for the treatment of symptomatic cholelithiasis, however, things are not quite so clear when it comes to managing cholelithiasis with suspected common bile duct (CBD) stones and debate continues among surgeons about the optimal pathway of management. The current recommendation is that patients with symptomatic cholelithiasis should be investigated for CBD stones. There is controversy because investigating for suspected choledocholithiasis by means of Magnetic resonance cholangiopancreatography (MRCP)/ pre-operative or post-operative Endoscopic retrograde cholangiopancreatography (ERCP)/ laparoscopic cholecystectomy with on-table cholangiography (OTC) may lead to subsequent over or under treatment with significant morbidity, readmissions, decline in Health Related Quality of Life (HRQoL) and costs to the health service. We conducted a retrospective clinical audit to compare our care provision for symptomatic gall stone disease with suspected choledocholithiasis against the guidelines laid down by Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) in 2016, NICE (2014) and European Society of Gastrointestinal Endoscopy (ESGE). This also highlights the importance of a single stage approach (LC with OTC) for management of gall stones with suspected CBD stones. Methods A retrospective audit was conducted for 18 months at a referral centre for hepato-pancreato-biliary (HPB) diseases, with available expertise for management of CBD stones, endoscopically and surgically. All patients admitted to general surgery facility with a diagnosis of gallstone disease with deranged liver function tests (LFTs), and suspicious of having or diagnosed to have common bile duct stones were included in the study. Patients aged 18 years and above with symptomatic gall stones suspected to have or diagnosed with choledocholithiasis were included, while patients with cholelithiasis but no evidence of stones in CBD on initial investigations were excluded. A total of 95 patients who met the inclusion and exclusion criteria were included in the study. We used the guidelines put forth by AUGIS (2016), NICE guidelines (2014), British Society of Gastroenterology (BSG) in 2017 and European Society of Gastrointestinal Endoscopy (ESGE) 2019 to compare management of symptomatic gallstone disease. Data with regards to length of hospital stay, comorbidities, investigations done, diagnosis, management, readmissions before undergoing further investigations or having a surgery (laparoscopic cholecystectomy) with or without on-table cholangiogram (OTC) were analysed. Data analysis for this set of data was done using numbers, percentages and descriptive statistics, using SPSS 25.0. Results Out of 95 patients, 90 had deranged LFTs at presentation (3 presented with cholangitis) and 5 had suspicious findings on initial imaging. The diagnosis included Mirizzi syndrome, pancreatitis, Choledocholithiasis, Biliary colic, Acute cholecystitis and benign CBD stricture. Out of 95 patients, 76 of them had Ultrasound abdomen as their initial investigation, mostly on the day of admission. 41 patients had MRCP, 73% of them during their index admission. Amongst the 95, 59% underwent ERCP, 76.8% of them during the index admission. The median time from admission to MRCP and ERCP was 5 and 8 days, respectively. Out of 56 patients who underwent ERCP, 9 of them had it done within 72 hours of admission. Overall, 22 patients underwent LC with OTC. Out of 95 patients, 51 patients underwent LC. Out of 79 patients who were fit for surgery, 28 of them were still awaiting surgery. Amongst 18 patients who had Pancreatitis at presentation, 14 of them underwent ERCP. Out of which 3 of them had LC during index admission. The maximum length of stay observed amongst 95 patients was 36. Amongst the 95 patients, the study also records that 13 patients had readmissions before they underwent ERCP or LC. Conclusions We found 16% compliance with the guidelines in regards to the timing of biliary decompression with ERCP. Our results show 66.66% compliance with guidelines, with regards to timing of biliary decompression in Cholangitis. The study reflects a significant non-adherence to the guidelines as 68.40% of patients could not have definitive management within the recommended time frame. Looking into the finer details, we found that 35.40% of the patients did not have their surgery at the time of the audit. 22% of patients had LC performed in accordance with the recommendations, while the timing of surgery in 78% of patients showed no compliance with the guidelines. Guidelines for management of patients with gallstone disease associated with CBD stones was not met for majority of patients. A significant number of patients were readmitted to the hospital because of delay in receiving further investigations or definitive surgery. There may be a role for multidisciplinary team meetings to identify patients requiring expedited ERCP, which in turn may translate into early definitive surgical management. Laparoscopic cholecystectomy with OTC, with or without laparoscopic CBD exploration or post-operative ERCP can be incorporated as an alternative to pre-operative ERCP to reduce patient morbidity and length of hospital stay.

Background: Perforation of the gallbladder during laparoscopic cholecystectomy (LC) results in spill of bile or gallstones in the abdominal cavity. The aim of this study was to assess whether antibiotic agents after spill have an effect on post-operative and infectious complications. Patients and Methods: Operative reports and clinical data of patients undergoing LC between 2012 and 2016 in three hospitals were screened retrospectively for spill of bile and spill of gallstones. Included patients were divided into two groups: Patients who were treated with antibiotic agents (either prophylactic or a single administration during or directly post-operatively because of spill) and patients who did not receive any antibiotic agents. Patients were also categorized as to uncomplicated or complicated gallstone disease. Multi-variable logistic regression was used to assess risk factors for overall and infectious complications after spill. Results: Spill was reported in 14.7% (481 of 3,262). The infectious complication rate was 8.7% (42/481). Of 481 patients, 295 (61.3%) had uncomplicated gallstone disease and 239 (49.7%) received antibiotic treatment. Rates of infectious complications were comparable among patients receiving antibiotic agents or no antibiotic agents (8% vs. 9%, respectively; p = 0.779); also when analysis only included patients with complicated gallstone disease (11% vs. 10% respectively, p = 0.861). Spill of stones was the only independent risk factor associated with post-operative complications (odds ratio 2.55, 95% confidence interval 1.23-5.29, p = 0.012). Conclusion: Antibiotic agents (prophylaxis or intra-operative) after spill of bile and spill of gallstones do not reduce the risk of overall and infectious complications. Spill of stones is associated independently with post-operative complications. The present study sample may leave small differences in complication rates undetected.

Symptomatic gallstone disease is considered an indication for cholecystectomy. A considerable proportion of patients may experience persistent symptoms after surgery. The purpose of the present study was to find out the rate of symptom persistence after elective laparoscopic cholecystectomy (LC) performed for symptomatic uncomplicated gallstone disease and, in particular, to clarify whether the recurrence rate differs according to the severity of preoperative symptoms. During a 10-year period (1992-2001), 1,101 patients underwent elective LC at Turku City Hospital for Surgery. A questionnaire concerning the intensity of preoperative symptoms, persistence of symptoms postoperatively, and overall satisfaction with the outcome of the procedure was sent to patients. A total of 677 patients [mean age (range) 59 (21-94) years; 554 (83.1%) females] with uncomplicated gallstone disease returned the completed form. Overall, 380 (57%) patients reported attacks of intense upper abdominal pain, and 287 (43%) reported episodic mild abdominal symptoms as the prevailing preoperative symptom. Two hundred and forty-eight (37%) patients continued to have abdominal symptoms after the operation. Among those with predominantly mild abdominal symptoms preoperatively, 119 (41%) reported the persistence of symptoms after the operation, while in the group with mainly severe upper abdominal pain attacks, 129 (33%) patients had recurrences (p = 0.052). According to our data, more than one-third of patients with symptomatic uncomplicated gallstone disease experienced persistent symptoms after elective LC. Patients with mild preoperative symptoms seemed to have more recurrences than those with severe symptoms, although the difference was not statistically significant.

BackgroundInternational consensus on the ideal outcome for treatment of uncomplicated symptomatic gallstone disease is absent. This mixed-method study defined a Textbook Outcome (TO) for this large group of patients. MethodsFirst, expert meetings were organised with stakeholders to design the survey and identify possible outcomes. To reach consensus, results from expert meetings were converted in a survey for clinicians and for patients. During the final expert meeting, clinicians and patients discussed survey outcomes and a definitive TO was formulated. Subsequently, TO-rate and hospital variation were analysed in Dutch hospital data from patients with uncomplicated gallstone disease. ResultsFirst expert meetings returned 32 outcomes. Outcomes were distributed in a survey among 830 clinicians from 81 countries and 645 Dutch patients. Consensus-based TO was defined as no more biliary colic, no biliary and surgical complications, and the absence or reduction of abdominal pain. Analysis of individual patient data showed that TO was achieved in 64.2% (1002/1561). Adjusted-TO rates showed modest variation between hospitals (56.6-74.9%). ConclusionTO for treatment of uncomplicated gallstone disease was defined as no more biliary colic, no biliary and surgical complications, and absence or reduction of abdominal pain.TO may optimise consistent outcome reporting in care and guidelines for treating uncomplicated gallstone disease.

BackgroundMany completed trials of interventions for uncomplicated gallstone disease are not as helpful as they could be due to lack of standardisation across studies, outcome definition, collection and reporting. This...

PurposeThis study was performed to compare the safety and efficacy of one-stage laparoscopic common bile duct exploration (LCBDE) plus laparoscopic cholecystectomy (LC) with those of endoscopic sphincterotomy (EST) plus LC for concomitant gallbladder (GB) and common bile duct (CBD) stones in elderly patients.MethodsThis single-center retrospective study reviewed the medical records of patients aged >80 years who were diagnosed with concomitant GB and CBD stones between January 2010 and December 2020.ResultsOf the 137 patients included in this study, 46 underwent one-stage LCBDE + LC and 91 underwent two-stage EST + LC. The frequency of previous gastrectomy (23.9% vs. 5.5%, p = 0.002) and multiple stones (76.1% vs. 49.5%, p = 0.003) was higher in the LCBDE + LC group than in the EST + LC group. Further, patients in LCBDE + LC group had larger CBD stones (11.9 mm vs. 6.0 mm, p < 0.001). There were no significant differences in the clearance (91.3% vs. 95.6%, p = 0.311) and recurrence (4.3% vs. 8.8%, p = 0.345) rates between the groups. The incidence of posttreatment overall complications (17.4% vs. 22.0%, p = 0.530) and total hospital stay (12.7 days vs. 11.7 days, p = 0.339) were similar in the two groups.ConclusionOne-stage LCBDE + LC is a safe and effective treatment for concomitant GB and CBD stones, even in elderly patients, and may be considered as the first treatment option in elderly patients with previous gastrectomy, multiple large (≥ 15 mm) CBD stones, or inability to cooperate with endoscopic procedures.