Complicated Gallstone Research Articles

Statins Reduce the Development of Complications in Patients With Asymptomatic Gallstone Disease: A Propensity Matched Analysis

Introduction: In a time to event analysis, we previously demonstrated an association between statin use and a decreased frequency of gallstone-related complications in patients with asymptomatic gallstone disease. The aim of this study is to use propensity matching, a more robust form of analysis, to evaluate the efficacy of statins in reducing specific gallstone associated complications. Methods: Patients with asymptomatic gallstones diagnosed on CT or ultrasound reports between 1996 - 2016 were identified using a validated natural language algorithm. Patients with at least one completed prescription for statin were propensity matched (one-to-one with non-replacement) to patients not on statins based on 30 variables: demographic information, comorbidities, features of gallstones at the time of initial imaging, other medication use, and years to event or last follow up. Quality of propensity matching was assessed using t-test. Occurrence of gallstone complications of chronic cholecystitis (includes right upper quadrant pain), acute cholecystitis, gallstone pancreatitis, choledocholithiasis or cholangitis, gallbladder cancer or cholangiocarcinoma, and procedural interventions for these complications were compared in patients with and without statin use. Results: N=22,800 patients were propensity matched to 7,493 patients each in the statin and non-statin groups (Figure 1). T-test analysis yielded no significant differences between the groups based on any matched variables. As noted on Table 1, patients on statins had significantly reduced rates of any complication (No statins, 16.1% versus statin, 11.3%; P= versus 6.1%; P versus 2.5%; P=0.003), and gallstone pancreatitis (2.6% versus 1.8%; P=0.001). No significant differences were noted based on statin use for choledocholithiasis or cholangitis (2.5% versus 2.3%; P=0.368), gallbladder cancer or cholangiocarcinoma (0.5% versus 0.4%; P=0.377), surgery or percutaneous drainage for above indications (3.6% versus 3.1%; P=0.069).86_A Figure 1. One-to-one propensity matching was performed to match patients using statins to patients without statin use based on 30 variables. This figure shows propensity scores of the two matched groups along those excluded from the analysis.Conclusion: In this well-matched propensity analysis of a large cohort, statin use was associated with a 30% reduced incidence of subsequent cholecystitis (acute or chronic) and gallstone pancreatitis in patients diagnosed with asymptomatic cholelithiasis. Given the relative safety of statin medications, use of these medications may be considered in patients with asymptomatic gallstone disease at high risk for the development of symptomatic gallstone disease. A randomized control trial is needed to confirm these findings.86_B Figure 2. Differences in occurrence of gallstone complications in patients with and without statins.

Laparoscopic management of gallstone complications

Abstract Introduction: Common bile ducts stones are very common diseases in Vietnam and Southeast Aisa. The pathogenesis of the stone is associated with biliary tract infection and intestinal parasiti. The aim of study is to evaluate the results of treatment of gallstone complications by laparoscopis cholecystomy, open the bile duct for gravel, Kehr drainage. Material and Methods: Prospective study patients with complicated choledocholithiasis were treated with emergency laparoscopic choledocotomy in the first 24 hours. From May 2013 to May 2018. Results: 83patients, no cases have been converted to open choledocotomy. The mean operation time was 90,75 minutes. There was no intraoperative complication. Postoperative complication consisde of 1 mild infection of umbilical port and 1 mild subhepatic fluid collection. Three cases were treated medically. There was no mortality. The mean hospital stay were 8.72 days. Conclusion: Laparoscopis cholecystomy, open the bile duct for gravel, Kehr drainage to treat gallstone complications was safe procedure with short hospital lenght stay.

Removal of percutaneous cholecystostomy (PTC) catheter after resolution of acute calculous cholecystitis in high-surgical-risk patients

Introduction: Percutaneous cholecystostomy (PTC) was an established treatment for acute calculous cholecystitis in patients with high surgical risk. Removal of PTC catheters may result in recurrent acute cholecystitis while keeping PTC catheters is associated with morbidities. This study to review outcomes of patients after PTC catheter removal. Method: This is a retrospective analysis of patients who underwent percutaneous cholecystostomy for acute calculous cholecystitis. Patients underwent interval cholecystectomy were excluded. Outcomes including recurrent acute cholecystitis and re-admissions for PTC catheter-related and gallstone complications were compared between patients with early removal of PTC catheters (< 4 months) and those who had catheters removed beyond 4 months. Results: From Jan 2011 to Oct 2012, 39 high-surgical-risk patients (mean age: 82.4) underwent percutaneous cholecystostomy for acute calculous cholecystitis. Clinical resolution was observed in 36 patients (92.3%) whereas 3 patients were diseased. PTC catheters were removed in 35 patients (Dislodgement, n = 21; catheter malfunction, n = 3; planned removal, n = 11). With a median follow-up duration of 61 months, recurrent acute cholecystitis was observed in 9 patients (25.7%), which were successfully treated with antibiotics alone (n = 2) and PTC insertion (n = 7). Re-admission rate is significantly lower in patients with early PTC catheter removal, 3.1 vs 1.2, p = 0.016, whereas risk of recurrent acute cholecystitis is similar between both groups, 26.3% vs 20%, p = 0.75. Conclusion: Early removal of PTC catheter after resolution of acute calculous cholecystitis is safe and may reduce re-admissions for PTC catheter-related and gallstone complications.

A rare case of spontaneous common bile duct perforation

Spontaneous perforation of the common bile duct (CBD) in adults is an extremely rare complication of gallstones. It is challenging to establish the diagnosis pre-operatively however with increasing utility of computer tomography, there may be subtle features visualized. We describe a case of a 35 year old Indian male who presented with an acute abdomen and was found to have biliary peritonitis secondary to a spontaneous CBD perforation. Mr JJ presented with sudden onset of abdominal pain associated with vomiting and diarrhea. He had generalized abdominal peritonitis. Initial erect chest x-ray was unremarkable for free air under the diaphragm, hence a CT was performed which revealed moderate amounts of free fluid around the 2nd part of the duodenum extending along the anterior para-renal space into the pelvis, with a 4mm distal CBD stone resulting in mild upstream dilatation. The gallbladder was decompressed and the CBD wall was not well visualized in the mid-portion, raising the possibility of perforation. An exploratory laparotomy revealed generalized biliary peritonitis secondary to a 2 cm CBD perforation just distal to the cystic duct junction. Choledochoscopy confirmed the small 4mm distal CBD stone which was advanced successfully through the ampulla into the duodenum. He underwent abdominal lavage, cholecystectomy, choledochectomy and a roux-en-Y hepatico-jejunostomy reconstruction. His recovery was uneventful. Histology confirmed focal transmural necrosis of the bile duct with fibrosis and micro-abscess formation. Clinicians should be aware that whilst spontaneous extrahepatic bile duct perforations are rare, it is important as timely diagnosis can be life-saving.

Roux en Y jejunal patch choledochoplasty for Mirizzi syndrome type-3: unique surgical approach

Introduction: Mirizzi syndrome is a rare complication of gallstones with an incidence of less than 1% per year. Obstructive jaundice, due to extrinsic compression of the common bile duct by gallstone impacted at Hartman's and formation of cholecysto-choledochal fistula due to pressure necrosis caused by compression of large gallstone in Hartman's are major presentations. If the fistula involves upto 2/3rd circumference of CBD, entity is labeled as type 3 Mirizzi syndrome. We hereby present a case managed with unique surgical approach for Mirizzi syndrome type 3- ROUX EN Y JEJUNAL PATCH CHOLEDOCHOPLASTY. Case report: 86 yr male presented with obstructive jaundice, underwent ERCP+CBD STENTING, submitted for cholecystectomy. Intraoperative cholecysto-choledochal fistula involving 2/3rd circumference of CBD was noted for which Roux-en-Y jejunal serosal patch choledochoplasty was done. Post operative minor bile leak was noted which was managed conservatively. Discussion: Diagnosis and surgical approach for Mirizzi syndrome are still a challenge. Surgical approaches for it differs depending on its type. For type 3 Mirizzi syndrome - Cholecystectomy with Roux-en-Y Hepaticojejunostomy has been described in the literature. But in our case, in view of non dilated duct not amenable for Hepaticojejunostomy, Roux-en-Y jejunal serosal patch choledochoplasty was done. Conclusion: Mirizzi syndrome type 3 presents a unique challenge to manage in non dilated ducts. Roux-en-Y jejunal serosal patch choledochoplasty can be a safe and viable approach in such a scenario. It presents an alternative to hepaticojejunostomy in non dilated ducts.

Galactose protects against cell damage in mouse models of acute pancreatitis.

Acute pancreatitis (AP), a human disease in which the pancreas digests itself, has substantial mortality with no specific therapy. The major causes of AP are alcohol abuse and gallstone complications, but it also occurs as an important side effect of the standard asparaginase-based therapy for childhood acute lymphoblastic leukemia. Previous investigations into the mechanisms underlying pancreatic acinar cell death induced by alcohol metabolites, bile acids, or asparaginase indicated that loss of intracellular ATP generation is an important factor. We now report that, in isolated mouse pancreatic acinar cells or cell clusters, removal of extracellular glucose had little effect on this ATP loss, suggesting that glucose metabolism was severely inhibited under these conditions. Surprisingly, we show that replacing glucose with galactose prevented or markedly reduced the loss of ATP and any subsequent necrosis. Addition of pyruvate had a similar protective effect. We also studied the effect of galactose in vivo in mouse models of AP induced either by a combination of fatty acids and ethanol or asparaginase. In both cases, galactose markedly reduced acinar necrosis and inflammation. Based on these data, we suggest that galactose feeding may be used to protect against AP.

CURRENT APPROACHES TO DIAGNOSIS AND SURGICAL TREATMENT OF MIRIZZI SYNDROME (OWN CLINICAL OBSERVATIONS WITH LITERATURE REVIEW)

The article presents the review of the literature and own clinical observations on the diagnosis and surgical treatment of Mirizzi syndrome – a rare complication of gallstones. The clinical features of the disease has no specific symptoms. The main clinical signs of MS are periodic jaundice (84%), pain in the right hypochondrium (75%) and cholangitis (56%), the phenomenon of acute cholecystitis and pancreatitis. The most informative method of preoperative diagnosis is magnetic resonance imaging, which, unfortunately, not readily available for public use. The diagnostic sensitivity of MRI with MS is 97,6%, intraoperative cholangiography – 94%, ERCP – 86%, PTC – 5%, fibrocholangioscopy – 77%, ultrasound – 46%. The most common type of MS (10,5-51%), less often type II (15-41%), even more rare types III (3-44%), IV (7,4%) and V (2,9% ). The leading role in the treatment of syndrome belongs to open surgery. Laparoscopic cholecystectomy can only be shown to individual MS and type I patients. Conversion with this occurs in 31-100%, complications – 60%, damage to common bile duct – 22%. Open cholecystectomy remains the standard. For Type II and III types of MS, they perform cholecystectomy while retaining part of the Hartmann pocket with the subsequent plastics of CBD at the Kehr drainage. At type IV of the MS it is shown a hepaticojejunostomy. Reorder phases of operation including cholangiography before cholecystectomy made it possible to diagnose and set the type of Mirizzi syndrome, to determine the optimal surgery approach and to prevent intra– and postoperative complications.

Complicated Gallstone Disease and Birth Outcomes: A Large-Scale Population-Based Study [20L

INTRODUCTION: Complicated gallstone disease (CGD) is a leading cause of surgery in pregnancy. Studies on the management and outcomes of CGD in pregnancy are limited by small sample size. We evaluated the association between CGD, surgical interventions, and birth outcomes in a large population-based dataset. METHODS: Pregnant patients with gallstones were identified in the California Office of Statewide Health Planning and Development 2007–2014 discharge dataset. CGD (acute cholecystitis, cholangitis, gallstone pancreatitis) was compared with uncomplicated gallstone disease (UGD). Adverse (miscarriage, spontaneous abortion, stillborn delivery) or normal (live birth) birth outcomes were identified, as were surgical interventions (cholecystectomy, cholecystotomy, endoscopic retrograde cholangiopancreatography). Preterm delivery, among live births, was a secondary outcome. RESULTS: We identified 5,116 eligible pregnancies: 10.6% CGD and 89.4% UGD. CGD patients had longer hospital stays (5.6 days versus 3.2 days), a higher incidence of surgical interventions (83.9% versus 6.7%), and an increased incidence of adverse birth outcomes (16.8% versus 2.6%; OR 3.23, 95% CI 2.13–4.92). CGD patients undergoing surgery had a markedly higher incidence of adverse birth outcomes compared with non-operative management (44.3% versus 7.4%; OR 5.42, 95% CI 3.24–9.08). Among live births, CGD was more frequently associated with preterm delivery when compared with UGD (26.2% versus 11.5%; OR 1.87, 95% CI 1.40–2.51). CONCLUSION: There is an increased risk of adverse birth outcomes and preterm delivery in women with CGD. Surgical intervention is also associated with higher risk of adverse outcomes. These findings may assist clinicians in managing and counseling patients and providing informed consent.

Bile duct mapping: Achilles heel for a safe laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) is one of the most frequent surgical procedures worldwide and is accepted as the gold standard for the management of symptomatic or complicated gallstone disease. Significant postoperative advantages have been described with this approach.

Evaluation of plasma microRNA-122, high-mobility group box 1 and keratin-18 concentrations to stratify acute gallstone disease: a pilot observational cohort study in an emergency general surgery unit

ObjectiveTo obtain pilot data to evaluate the discriminatory power of biomarkers microRNA-122 (miR-122), high-mobility group box 1 (HMGB1), full-length keratin-18 (flk-18) and caspase-cleaved keratin-18 (cck-18) in plasma to identify potential...

Home hospitalization for the surgical and conservative treatment of acute calculous cholecystitis

AimAcute calculous cholecystitis is a frequent complication of gallstones that can manifest in up to 10–15 per cent of previously asymptomatic patients. Current guidelines recommend laparoscopic cholecystectomy as the gold standard treatment; however, the presence of surgery risk factors might compel physicians to opt for conservative treatment, which is often associated with longer hospital stay. Home hospitalization could be an alternative to inpatient stay for these patients.Patients and MethodsThe present study was a retrospective analysis of data from a prospective patient single‐centre registry. Data from 915 patients with mild or moderate acute calculous cholecystitis, who presented in the Department of General Surgery of our hospital between 2010 and 2015, were analysed. The variables included grade of acute cholecystitis, type of treatment, use of antibiotics, inpatient stay, stay in hospital‐at‐home, complications, mortality, readmissions and relapse.ResultsA total of 147 (16 per cent) patients were referred to hospital‐at‐home, while the rest completed their treatment in the hospital ward. There were no significant differences between the home hospitalization and conventional hospitalization groups in the rates of complications, mortality, readmissions, relapse and length of antibiotherapy. Home hospitalization was associated with shorter inpatient stay, but longer total hospitalization, likely due to a prolonged follow up by the home care unit.ConclusionsHome hospitalization is an effective and safe alternative to conventional hospitalization, as it provides hospital‐level care and reduces the number of admissions and length of inpatient stay. The timely referral of patients to other levels of assistance, such as primary care, is needed to ensure economic benefits of home hospitalization programmes.

Incidence of gallstone disease and complications.

The purpose of this review was to describe the epidemiology of gallstone disease in the era of ultrasound screening and laparoscopic cholecystectomy. Recent general population cohorts, including ultrasound screenings, have contributed to our understanding of formation and clinical course of gallstone disease. Cohorts of symptomatic gallstone disease have been informative about symptom recurrence and need of treatment. Preventive targets for gallstone formation may include obesity and the associated metabolic changes. The presence of gallstone disease is best described as a continuum from asymptomatic to symptomatic disease, with the latter including both pain attacks and complicated disease. Symptomatic disease causes a persistent high risk of symptom recurrence and need of cholecystectomy. The majority of gallstone carriers will remain asymptomatic and about one in five will develop symptoms. Determinants of disease progression from asymptomatic to symptomatic disease include sex, age, body mass index, and gallstone ultrasound characteristics. Because of the absence of effective gallstone formation prevention, targets against the metabolic changes in obesity should be further explored in randomized controlled trials. To optimize patient selection for cholecystectomy, treatment algorithms including identified determinants of symptomatic disease in gallstone carriers should be explored in prospective clinical trials.

Akutno vnetje žolčnika – zgodnja operacija ali poskus konzervativnega zdravljenja?

Acute cholecystitis is a common disease, which ofen requires admission to hospital and surgical treatment. Acute cholecystitis is defined as inflammation of the gallbladder and usually occurs due to cystic duct obstruction from stones or sludge. It is a relatively common complication of gallstones, but it can also occur without gallstones. A combination of relevant clinical symptoms and ultrasound evidence is required to make a diagnosis of acute cholecystitis. Early surgery is recommended for all patients that are in good physical condition. There is still a debate how to treat high-risk and critically ill patients. Laparoscopic cholecystectomy is the method of choice for treatment of patients with acute cholecystitis. Early laparoscopic cholecystectomy should be done within 72 hours from the onset of symptoms.This article presents current guidelines according to the Tokyo guidelines and the World Society of Emergency Surgery guidelines, and at the end, experiences of some clinical trials.

“PANCREATITIS SCREENING INDEX”, A NOVEL INDEX FOR IDENTIFYING GALL STONE PATIENTS AT RISK OF ACUTE PANCREATITIS? : AN OUTCOME OF A CASE CONTROL STUDY

Background: Acute pancreatitis is an inflammatory disease of pancreas that is associated with little or no fibrosis of the gland. Biliary tract disease account for 30-60% cases. Approximately 85% of patients with symptomatic gallstone mainly report biliary colicky pain whereas other patients may present with complications such as acute cholecystitis, acute pancreatitis, cholangitis etc. However, factors predisposing to pancreatitis over other complications of gall stones are not well known. We aim to identify potential factors which can predict the occurrence of pancreatitis in gall stone patients. Material and Method: A single centre prospective Case Control study. 75 patients each of biliary pancreatitis (Group A) and of acute cholecystitis (group B) were enrolled in study. 6 weeks after acute attack they were assessed for gall bladder motility and taken up for cholecystectomy. Results: Gallbladder motility was stronger in pancreatitis patients than in patients with acute cholecystitis (residual volume 12.85±1.18 vs 18.13±1.5, p = 0.000 and Ejection Fraction 57.5%%±2.17 vs 44.5%%±3.3, p = 0.000)). Pancreatitis patients more often had sludge (52% vs. 28%; p = 0.0027) and smaller (4.07±0.9mm vs 9.77± 1mm, p = 0.0000.) and more gallstones (32±8 vs 13±6, p = 0.008). Mean Pancreatitis Screening Index(PSI) [Ejection Fraction/ Size of Smallest Calculi] score for Group A was 0.24±0.1 whereas mean score for Group B was 0.063±0.01 (p value is 0.000). At PSI value ≥ 0.132, patients of AP were reliably distinguished from patients with acute cholecystitis (sensitivity=80%, specificity=94.5%). Conclusion: Acute pancreatitis is more common in patients with smaller multiple stones with preserved gallbladder motility. Pancreatitis Screening Index can be a novel index to identify patients of gall stones at risk of acute pancreatitis. However, the potential benefit and usefulness of the index is yet to be elucidated.

Management of Acute Cholecystitis

Acute cholecystitis is a common serious complication of gallstones. The reported mortality of acute cholecystitis is approximately 3%, but the rate increases with age or comorbidity of the patient. If appropriate treatment is delayed, complications can develop as a consequence with a grave prognosis. The current standard of care in acute cholecystitis is an early laparoscopic cholecystectomy with the appropriate administration of fluid, electrolyte, and antibiotics. On the other hand, the severity of the disease and patient's operational risk must be considered. In those with high operational risks, gall bladder drainage can be performed as an alternative. Currently percutaneous and endoscopic drainage are available and show clinical success in most cases. After recovering from acute cholecystitis, the patients who have undergone drainage should be considered for cholecystectomy as a definitive treatment. However, in elderly patients or patients with significant comorbidity, operational risks may still be high, making cholecystectomy inappropriate. In these patients, gallstone removal using the percutaneous tract or endoscopy may be considered.

Role of preoperative magnetic resonance cholangio-pancreatography in avoiding complicated gall stone surgery

Role of preoperative magnetic resonance cholangio-pancreatography in avoiding complicated gall stone surgery

Features of Upper Abdominal Pain that Predict Symptoms Relief after Cholecystectomy in Patients with Uncomplicated Gallstones Disease

Introduction: Gallbladder disease is common and results in high health care costs. Indeed, estimates of the lifetime risk of gallstone formation are as high as 10% to 20% of the general population. The natural history of symptomatic gallstone disease is such that approximately 70% of patients will continue to have episodic symptoms or experience a complication of gallstones within 2 years of initial diagnosis. Adding to this potential confusion is the occurrence of abdominal pain thought to resemble gallbladder pain but without gallstones present. Laparoscopic cholecystectomy remains the gold standard for treatment of symptomatic cholelithiasis. However, persistent symptoms after cholecystectomy occur in 10 to 33% of patients. Although a variety of clinical characteristics have been evaluated as preoperative factors associated with outcome after cholecystectomy, preoperative symptoms are generally used as a reference point for diagnosis and determination of need of cholecystectomy. Characterizing and identifying symptoms that predict relief from upper abdominal pain after cholecystectomy could better guide physicians to recommend cholecystectomy so as to reduce morbidity, mortality and cost and minimize unnecessary surgery. Aim: The objective of this study is to identify symptoms predicting complete relief of upper abdominal pain (UAP) after cholecystectomy to help better selection of patients who might benefit from surgery. Subjects and methods: This study is a prospective analysis involving 950 adult patients undergoing cholecystectomy for symptomatic cholelithiasis. The study included 721 females (75.89%) and 229 males (24.11%). The patients were asked to complete a previously-validated biliary symptoms questionnaire (BSQ) before operation and 3 months postoperatively as well. At the end of the last questionnaire, each patient was required to define whether (as overall) his symptoms were relieved or not. Our patients were divided into two groups according to pain relief after surgery; Group (I) included patients who had pain relief after surgery (713 patients-75.05%) and group (2) included patients who did not have pain relief after surgery (237 patients-24.95%). Results: Our study shows that the likelihood of having pain relief is greater in patients who have UAP onset one year or less preoperatively, UAP of short duration, UAP occurring most frequently in the evening or at night time and whose pain awakens them by night, patients who do not have lower abdominal pain, patients who have normal bowel habit pattern, patients who have infrequent nausea attacks, patients who do not often have excessive gas bloat or burps and patients who do not suffer concomitant GERD or IBS. Conclusion: Laparoscopic cholecystectomy is an effective management option for symptomatic cholelithiasis, with a cure rate of 75.05% in our study. Better rates of pain relief can be achieved by better selection of patients, as sub analysis of symptoms showed better cure rates in the subgroups. The followings were found as good predictors of outcome: older age, female patients, short onset of the disease (≤ 1 year), infrequent attacks of pain once or less per week, short duration of attacks less than 30 minutes, attacks occurring by night or awakening the patient by night, attacks of moderate to severe intensity, patient with normal bowel habits, absence of lower abdominal symptoms, absence of gas bloating, and absence of GERD or IBS. Our study shows that pain relief progressively increases with increasing the number of positive predictive symptoms, being the best at the level of 4 positive predictive symptoms. Further larger studies are still needed to further define reliable prognostic symptoms to assure better selection of patients.

Technical aspects of diagnosis and treatment of complicated gallstone disease in patients with periampullary diverticulum

Technical aspects of diagnosis and treatment of complicated gallstone disease in patients with periampullary diverticulum

An evaluation of mini-laparotomy cholecystectomy in the laparoscopic era: a rural experience

Laparoscopic cholecystectomy (LC) is the gold standard for the management of symptomatic cholelithiasis and complications of gallstone disease. Mini laparotomy cholecystectomy (MOC) may be a more appropriate option in the resource constrained rural setting due to its widespread applicability and comparable outcome with LC. The study aimed to provide an epidemiological analysis of gallstone disease in the rural population and to evaluate the outcome of MOC in a rural hospital. A retrospective chart analysis of 248 patients undergoing cholecystectomy in a rural regional referral hospital in KwaZulu-Natal from January 2009 to December 2013 was undertaken. Of the 248 patients, the majority were females (n = 211, [85%]). The most frequent indications for cholecystectomy included: biliary colic (n = 115, [46.3%]); acute cholecystitis (n = 80, [32.3%]); gallstone pancreatitis (n = 27, [10.8%]). Forty cases (16.1%) were converted to open cholecystectomy (OC). The median operative time was 40 minutes (range18-57). Twenty-three morbidities (9.3%) occurred including: bile leaks (n = 6, [2.4%]); bleeding from drain site (n = 1, [0.4%]), incisional hernia (n = 8 [3.2%]) and wound sepsis (n = 8 [3.2%]). The median length of hospital stay in patients who underwent MOC was 48 hours (range: 24-72 hours) and the median time to return to work was 10 days (range: 4-14 days). There was one mortality in the entire cohort. MOC is a safe and feasible operation for symptomatic cholelithiasis when cholecystectomy is indicated. The low operative morbidity and mortality in the context of a high risk patient profile and complicated gallstone disease makes this procedure an alternative to LC where LC is inaccessible.

Cholecystoduodenal fistula, an infrequent complication of cholelithiasis: Our experience in its surgical management.

Bilioenteric fistulas are the abnormal communication between the bile duct system and the gastrointestinal tract that occurs spontaneously and is a rare complication of an untreated gallstone in the majority of cases. These fistulas can cause diverse clinical consequences and in some cases be life-threatening to the patient. To identify the incidence of bilioenteric fistula in patients with gallstones, its clinical presentation, diagnosis through imaging study, surgical management, postoperative complications, and follow-up. A retrospective study was conducted to search for bilioenteric fistula in patients that underwent cholecystectomy at our hospital center due to cholelithiasis, cholecystitis, or cholangitis, within a 3-year time frame. Four patients, 2 men and 2 women, were identified with cholecystoduodenal fistula. Their mean age was 81.5 years. Two of the patients presented with acute cholangitis and 2 presented with bowel obstruction due to gallstone ileus. All the patients underwent surgical treatment and the diagnostic and therapeutic management of each of them was analyzed. The incidence of cholecystoduodenal fistula was similar to that reported in the medical literature. It is a rare complication of gallstones and its diagnosis is difficult due to its nonspecific symptomatology. It should be contemplated in elderly patients that have a contracted gallbladder with numerous adhesions.