Complication Of Gallstone Disease Research Articles

The Metabolic Syndrome Is Associated with Complicated Gallstone Disease

Gallstone disease (GD) is a common condition worldwide. Several studies demonstrated that the presence of gallstones is strongly associated with cardiovascular disease. The metabolic syndrome is a highly prevalent cardiovascular condition. To examine the relationship between complicated GD (CGD) and the metabolic syndrome or its components. Two hundred seventeen patients with gallstones were examined. All patients underwent biliary ultrasonography after a complete medical history and laboratory examination. Data collection for the diagnosis of metabolic syndrome included measurements of waist circumference, blood pressure and lipids, and biochemical tests. Of the 217 patients examined, 115 patients (53%) had CGD and 102 patients (47%) had uncomplicated GD (UCGD). There was a significant difference between the number of patients with large gallstones in the CGD and UCGD groups (n=14 [12%] versus n=2 [2%], respectively; P=0.004). Metabolic syndrome, diabetes mellitus and large waist circumference were more prevalent in the CGD group than in the UCGD group. Homeostatic model assessment of insulin resistance scores were higher in the CGD group than in UCGD group (2.51 [95% CI 0.57 to 23.90] versus 2.20 [95% CI 0.09 to 8.87], respectively; P=0.032). Logistic regression analysis revealed that the presence of metabolic syndrome (OR 1.434; 95% CI 1.222 to 1.846, P=0.014), diabetes mellitus (OR 1.493; 95% CI 1.255 to 1.953; P=0.035) and large gallstones (OR 1.153; 95% CI 1.033 to 1.714; P=0.017) were independent predictors of CGD. Results of the present study demonstrated that metabolic syndrome, diabetes and gallstone size were associated with CGD. Further prospective studies are needed to understand the clinical importance of this association.

Health-related quality of life outcomes after cholecystectomy

Gallbladder diseases are very common in developed countries. Complicated gallstone disease represents the most frequent of biliary disorders for which surgery is regularly advocated. As regards, cholecystectomy represents a common abdominal surgical intervention; it can be performed as either an elective intervention or emergency surgery, in the case of gangrene, perforation, peritonitis or sepsis. Nowadays, the laparoscopic approach is preferred over open laparotomy. Globally, numerous cholecystectomies are performed daily; however, little evidence exists regarding assessment of post-surgical quality of life (QOL) following these interventions. To assess post-cholecystectomy QOL, in fact, documentation of high quality care has been subject to extended discussions, and the use of patient-reported outcome satisfaction for quality improvement has been advocated for several years. However, there has been little research published regarding QOL outcomes following cholecystectomy; in addition, much of the current literature lacks systematic data on patient-centered outcomes. Then, although several tools have been used to measure QOL after cholecystectomy, difficulty remains in selecting meaningful parameters in order to obtain reproducible data to reflect postoperative QOL. The aim of this study was to review the impact of surgery for gallbladder diseases on QOL. This review includes Medline searches of current literature on QOL following cholecystectomy. Most studies demonstrated that symptomatic patients profited more from surgery than patients receiving an elective intervention. Thus, the gain in QOL depends on the general conditions before surgery, and patients without symptoms profit less or may even have a reduction in QOL.

THE LEARNING CURVE OF FIRST ONE HUNDRED LAPAROSCOPIC CHOLECYSTECTOMY

Laparoscopic cholecyctectomy became gold standard for treatment of symptomatic gall stone disease. Analysis of the first hundred patients who underwent laparoscopic cholecystectomy to study the learning curve and complications. The highest number of patients underwent completed laparoscopic cholecystectomy 54 (90%) and the lowest conversion rate 10% (6/60) with high percentage 22% of patients with complicated gall stone disease during year of 2004. Biliary injury 2%, occurred mainly in the early years. Total conversion rate was 21%. These results were improved with~1

Laparoscopic Cholecystectomy in Patients Over 80 Years is Feasible and Safe: Analysis of 68 Consecutive Cases

Background: Wide variations are reported in morbidity, mortality and conversion rates for laparoscopic cholecystectomy in the octogenarian population. As a retrospective review, this paper reports the experience of a district general hospital unit in the management of gallstone disease in an elderly population. Methods: The case notes of all patients over 80 years of age undergoing laparoscopic cholecystectomy over a 7 years period were retrospectively analyzed. Primary outcome measures were conversion to an open procedure and complications of surgery. Results: Sixty-eight octogenarians (mean age of 84 years [range 8096 years], 37 female) undergoing laparoscopic cholecystectomy were identified. Five (7.3%) operations were converted to open surgery. The total number of patients having complications was 16 (24%), 8 (12%) being grade 1 and 8 (12%) grade 2. Forty-eight (71%) patients had complicated gallstone disease. Grade 2 complications were related to the presence of CBD stones (p = 0.0003). Conclusion: Octogenarians should be considered for laparoscopic cholecystectomy for symptomatic gallstones. Although the overall risk of complications remains higher in octogenarians, conversion rates can be low. Octogenarians with common bile duct stones may be best managed with ERCP as this group of patients appears to be at particular risk from surgical intervention.

Symptomatic gallstones after sleeve gastrectomy

Cholelithiasis is a common complication after bariatric surgery. Pure restrictive procedures such as sleeve gastrectomy and gastric banding theoretically should result in less gallstone formation because the food continues to follow the normal gastrointestinal transit, maintaining the enteric-endocrine reflex intact. To the authors' knowledge, the literature has no studies that analyze the incidence of gallstone formation after sleeve gastrectomy. This study aimed to compare the rates of symptomatic gallstones between laparoscopic Roux-en-Y gastric bypass (RYGBP) and sleeve gastrectomy (SG). A retrospective chart review of patients who underwent laparoscopic RYGBP and SG between 2004 and 2006 was performed. The patients with previous cholecystectomy, known gallstones with or without concomitant cholecystectomy, and previous weight-reduction operations were excluded from the analysis. The outcome measures were the numbers of patients who had experienced symptomatic and complicated gallstones. Using Cox regression analysis, comparisons was made between the patients with laparoscopic RYGBP (group A) and those with laparoscopic SG (group B). Groups A excluded 174 (26%) of 670 patients, and group B excluded 27 (34.2%) of 79 patients. The patients in group A had a significantly higher preoperative body mass index (BMI) than those in group B. Additionally, more group A than group B patients had a BMI exceeding 45 and more than a 25% loss of original weight. No significant difference in the development of symptomatic (8.7% vs. 3.8%; p = 0.296) or complicated (1.8% vs. 1.9%; p = 0.956) gallstones was noted between the two groups There was no significant difference in symptomatic or complicated gallstone disease between the patients treated with laparoscopic SG and those treated with laparoscopic RYGBP. Routine prophylactic cholecystectomy should not be recommended for weight reduction during laparoscopic SG.

Conversion after laparoscopic cholecystectomy in England

Laparoscopic cholecystectomy is the procedure of choice for the treatment of symptomatic gallstones. Conversion to open surgery is reported to be necessary in 5-10% of cases. This study aimed to define those factors associated in English hospitals with the need to convert a laparoscopic cholecystectomy to an open procedure. These included patient-related and particularly nonpatient-related factors. Using data derived from a national administrative database, Hospital Episode Statistics, patients undergoing cholecystectomy in acute National Health Service (NHS) hospitals in England during the financial years 2004-2006 were studied. The individual surgeon caseload and the hospital conversion rate were calculated using data from the first (baseline) year. Factors affecting the need for conversion were analyzed using data from the second (index) year. The study included 43,821 laparoscopic cholecystectomies undertaken from 2005 to 2006 in English hospitals. The overall conversion rate was 5.2%: 4.6% for elective procedures and 9.4% for emergency procedures. Patient-related factors that were good predictors of conversion included male sex, emergency admission, old age, and complicated gallstone disease (p < 0.001). Nonpatient-related factors that were good predictors of conversion included the laparoscopic cholecystectomy caseload of individual consultant surgeons and the overall hospital conversion rate in the previous year (all p < 0.001). Conversion after laparoscopic cholecystectomy is less common as consultant caseload increases. This suggests that operation should be undertaken only by surgeons with an adequate caseload. There is a wide variation in conversion rates among hospitals. This has important implications for training as well as for the organization and accreditation of cholecystectomy services on a national basis.

Is Complicated Gallstone Disease Preceded by Biliary Colic?

IntroductionCholecystectomy in cases of “warning” episodes of biliary colic may prevent biliary pancreatitis. We aimed to determine which proportion of patients with biliary pancreatitis, compared to other complicated and uncomplicated symptomatic gallstone disease, experienced “warning” episodes of colic and why these episodes did not lead to early cholecystectomy. Patients and methodsOne hundred seventy-five patients with complicated gallstone disease [pancreatitis (n = 53), symptomatic common bile duct (CBD) stones (n = 64), and acute cholecystitis (n = 58)] and 175 patients with symptomatic uncomplicated gallstones were interviewed at admission. ResultsFifty-seven percent (100 of 175) of patients with complicated disease (95% confidence interval = 50–65%) experienced “warning” episodes of biliary colic (pancreatitis 58%, CBD stones 67%, cholecystitis 45%) vs 96% (164 of 175) in uncomplicated disease. Eighty-seven percent of patients with “warning” episodes and complicated disease experienced patient’s and general practitioner’s delays. General practitioner’s delay was more frequent if pain was located in the epigastric region compared to the right upper quadrant (51% vs 38%, P = 0.03). ConclusionsHalf of patients with biliary pancreatitis experience “warning” episodes of biliary colic, similar to other gallstone complications. In symptomatic patients, complications are often not prevented because of significant delays in diagnosis and treatment.

Mirizzi With Pre-Bouveret’s Syndrome

d i d t s t d s s s I t s c t m d 35-year-old woman was admitted with a 3-week history of recurrent biliary colic, jaundice, nausea, and nonbilious emeis after meals. Her serum bilirubin was 18 mg/dL (normal, 0.2–1.3 g/dL), and her alkaline phosphatase was 1436 units/L (normal, 8–126 units/L). A right upper quadrant ultrasound showed comon bile duct dilatation with evidence of cholelithiasis and massike structure in the gallbladder fossa. Murphy’s sign was negative. computed tomography scan of the abdomen/pelvis showed ntrahepatic duct dilatation and common bile duct (CBD) dilataion up to 2.5 cm, just before the head of the pancreas (Figure A). here was a large hypodense lesion at this level with a hyperatenuating rim (Figure A, arrow), with abrupt duct narrowing therefter. There was no pancreatic head mass. On endoscopic retrorade cholangiopancreatography (ERCP), a 3to 4-cm filling efect was seen coming from the cystic duct and causing obstrucion within the CBD, ie, Mirizzi syndrome (Figure B). On endosopy, there was a large protruding bulge at the lateral wall in the rst portion of the duodenum (Figure C), corresponding to the arge gallstone seen on cholangiogram. On fluoroscopy, the tip of he endoscope was “touching” the gallstone when we placed tip of he endoscope on the duodenal bulge. The large gallstone moved ppropriately on gentle poking of the duodenal bulge with the tip f the endoscope. After biliary sphincterotomy, a 10F 9-cm iliary stent was placed with good drainage. During cholecystecomy, a 4-cm gallstone was removed from the CBD, and there was lmost complete obliteration of the cystic duct with formation of fistulous tract from the gallbladder to the CBD. Mirizzi syndrome is a rare cause of obstructive jaundice prouced by the impaction of a gallstone either in the cystic duct or n the gallbladder, resulting in stenosis of the extrahepatic bile uct.1,2 Although she had Mirrizi syndrome, the patient’s presenation was also concerning for Bouveret’s syndrome, which decribes gastric outlet obstruction caused by impacted gallstone in he pylorus or duodenum.3 A single gallstone of at least 2.5 cm in iameter is the most common underlying cause of Bouveret’s yndrome. The symptoms are epigastric pain, nausea, and emeis. Jaundice is an uncommon physical finding with Bouveret’s yndrome and is more commonly seen with Mirizzi syndrome. n patients with Mirizzi syndrome, a preoperative diagnosis and herapy by ERCP reduce the risk of biliary damage during urgery. Although enterotomy or gastrotomy with or without holecystectomy and fistula repair is the most common surgical herapy, there are reported cases of successful endoscopic treatent of Bouveret’s syndrome with intracorporeal electrohyraulic lithotripsy and mechanical lithotripsy.

QS272. Complicated Gallstone Disease in a Large Urban Public Hospital

Background: Laparoscopic Cholecystectomy is the gold standard for patients who are diagnosed with biliary colic (NIH, 1993). Figures in 2005 demonstrated that Houston has the highest percentage of uninsured individuals of any city in the United States at 27.8%. Harris County Hospital District provides care to many uninsured individuals, with 44% of the patient population more than 200% below the poverty level. This study was performed to assess the history of gallstone disease in individuals who are largely uninsured.

Laparoscopic Cholecystectomy in the Pediatric Population

The experience with laparoscopic cholecystectomy in children trails the adult numbers and remains underreported. Therefore, we reviewed our experience with this approach. A retrospective review of our most recent 6-year experience with laparoscopic cholecystectomy at Children's Mercy Hospital (Kansas City, MO) between September 5, 2000, and June 1, 2006, was performed. Data points reviewed included patient demographics, indication for operation, operative time, complications, and recovery. During the study period, 224 patients underwent a laparoscopic cholecystectomy. The mean age was 12.9 years (range, 0-21) with a mean weight of 58.3 kg (range, 3-121). Indications for laparoscopic cholecystectomy were symptomatic gallstones in 166 children, biliary dyskinesia in 35, gallstone pancreatitis in 7, gallstones and an indication for splenectomy in 6, calculous cholecystitis in 5, choledocholithiasis in 1, gallbladder polyps in 1, acalculous cholecystitis in 1, and congenital cystic duct obstruction in 1. The mean operative time (excluding patients with concomitant operations) was 77 minutes (range, 30-285). An intraoperative cholangiogram was performed in 38 patients. Common bile duct (CBD) stones were cleared intraoperatively in 5 patients. Two patients required a postoperative endoscopy to retrieve CBD stones. One sickle-cell patient developed a postoperative hemorrhage, requiring a laparotomy. There were no conversions, ductal injuries, bile leaks, or mortality. Biliary dyskinesia was diagnosed in 10% of the first 30 patients in this series and 40% of the most recent 30 patients. The mean ejection fraction in these patients was 21%. All experienced an improvement in their symptoms after the cholecystectomy. Laparoscopic cholecystectomy is safe and effective in children. Biliary dyskinesia is becoming more frequently diagnosed in children, and these patients respond favorably to cholecystectomy. As opposed to the adult population, the incidence of complicated gallstone disease appears less common in children, as most present with symptomatic cholelithiasis without active inflammation, accounting for the very low rate of ductal complications.

High rate of complicated idiopathic gallstone disease in pediatric patients of a North American tertiary care center

To assess spectrum and etiology of gallstones and biliary sludge in the pediatric population of a North American tertiary care centre. Retrospective review of abdominal ultrasounds recorded at Saint Justine Hospital over a period of 24 mo (8/2003 to 8/2005) in patients < 19 years of age. Patients < 2 years of age were analyzed separately. The presence of gallstones was noted in 127 patients. In 107 it was a new diagnosis, in 48/105 (45.7%) patients > 2 years of age idiopathic gallstone disease was found. These 48 patients represent 2.1% of the population who required ultrasound for abdominal pain. Complicated gallstone disease occurred in 28/48 with idiopathic disease, mainly adolescent girls. Patients with hemolytic disorders, cystic fibrosis, oncologic diseases or kidney transplantation and gallstones were asymptomatic and stones were detected during routine abdominal ultrasound. Twenty two patients < 2 years of age not consulting for abdominal pain had gallstone disease of diverse etiology. Biliary sludge was seen in 84 patients, 78.5% on total parenteral nutrition. In 4 patients, sludge progressed to gallstones. Idiopathic gallstone disease and its rate of complication are more frequent in our cohort than expected from previous studies. Adolescent girls with abdominal pain and idiopathic gallstones require special attention for complicated disease course.

Outcome measurement in laparoscopic cholecystectomy by using a prospective complication registry: results of an audit

The aim was to assess and discuss the utility of a complication registry for determining outcome and delivered care in surgery. All patients with Laparoscopic Cholecystectomy between 1998 and 2006 were analysed. Complications were prospectively documented and evaluated according to outcome measures mentioned in literature (bile duct injury, morbidity, mortality and conversion rate) for Laparoscopic Cholecystectomy. In addition, all patient files were evaluated for possible risk factors and non-registered complications. One thousand two hundred fifty four Laparoscopic Cholecystectomies were performed, with 207 complications in 152 (12%) patients. Eighteen (9%) events were additionally found after evaluating all medical files. Thirteen (1%) bile duct injuries occurred, 7% (n = 91) morbidity, no mortality and 18% (n = 226) conversion rate. The probability of complications was significantly higher in patients diagnosed with complicated gallstone disease, ASA 3/4, > 70 years, acute and converted procedures. Thirty % (n = 63) of all documented adverse events reflected issues other than traditionally mentioned outcome measures, categorised as hospital-provider errors or miscellaneous. Ninety % of all complications in laparoscopic cholecystectomy were documented in our registry. Factors associated with a high probability of complications were identified and 30% of all events reflected issues other than traditionally mentioned outcome measures for Laparoscopic Cholecystectomy. The registry can be used for outcome measurement, however differences in case mix and data collection methods should be taken into account.

Outcome Analysis of Laparoscopic Cholecystectomy in Patients Aged 80 Years and Older with Complicated Gallstone Disease

The aim of this study was to evaluate the outcome of laparoscopic cholecystectomy (LC) in octogenarians with complicated gallstone disease. This study was a retrospective analysis of prospectively collected data of 51 patients aged 80 years or older who underwent an LC for complicated gallstone disease between 2001 and 2006. This group was compared with 41 octogenarian patients with uncomplicated gallstone disease. There were 51 patients (26 men) with a median (range) age of 87 years (range, 80-93) who underwent an LC for complicated biliary disease, including acute cholecystitis in 29 (57%), gallstone pancreatitis in 14 (27%), cholangitis in 4 (7.8%), and obstructive jaundice in 4 (7.8%). Significantly more patients in the complicated disease group underwent preoperative endoscopic retrograde cholangiopancreatography (33.3% vs. 12.1%; P = 0.026) The median operative time was 110 minutes (range, 55-165) and this was significantly longer, compared to the uncomplicated disease group (P = 0.031). Postoperative morbidity was 27.3%, a significantly higher rate, compared to the uncomplicated group (27.4% vs. 7.3%; P = 0.015) with zero mortality. The conversion rate was 7.8% and this was not significantly different from the uncomplicated disease group. The median length of hospital stay was 6 days, which was significantly longer than the uncomplicated disease group (P = 0.021). The LC can be performed with acceptable morbidity in octogenarians with complicated gallstone disease. Early treatment of gallstone disease in this age group could further improve outcomes.

Microbiological assessment of bile during cholecystectomy: is all bile infected?

Aims. To determine the prevalence of bactibilia in patients undergoing cholecystectomy and to relate the presence or absence of organisms to the preoperative and postoperative course. Patients and methods. Patients undergoing cholecystectomy under the care of a single consultant surgeon during a continuous 5-year period were identified from a prospectively maintained departmental database. Symptoms, clinical signs, findings of investigations, details of treatment and postoperative care were noted. Risk factors for bactibilia (acute cholecystitis, common duct stones, emergency surgery, intraoperative findings and age > 70 years) were documented. Patients were divided according to the presence (B +) or absence (B–) of bacteria on culture of their bile. Results. In all, 128/180 (70%) of cholecystectomies had full data available for analysis. Bacteria were identified in the bile of 20 (15.6%) patients (B+ group). The B+ group was significantly older at 63.78±9.7 versus 61.62±13.9 (p<0.05) and contained significantly fewer females than the B– group (p<0.05). All 20 patients (100%) in the B+ group had ≥ 1 risk factor, while these factors were present in only 29/108 (30.3%) of patients in the B– group (p<0.05). The overall incidence of infective complications was 20% in the B+ group compared with 0.9% in the B– group (p<0.05) and the bile-related infections were higher in the B+ group (p<0.05). Conclusions. The study demonstrated that while patients with complicated gallstone disease frequently exhibit bactibilia, patients with uncomplicated cholelithiasis have aseptic bile. The findings would suggest that prophylactic antibiotics should be limited to patients with risk factors for bactibilia.

The Impact of Patient-Controlled Analgesia on Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy has revolutionised the management of symptomatic gallstones and is increasingly performed as a day-case procedure. The aim of this study was to assess the impact of opioid patient-controlled analgesia (PCA) on elective laparoscopic cholecystectomy. In a prospective, non-randomised, observational study, 76 consecutive patients who underwent elective in-patient laparoscopic cholecystectomy were reviewed. Six patients with complicated gall stone disease and four patients who converted from laparoscopic to an open operation were excluded. Of the 66 remaining in the study group, 25 patients received morphine-PCA and, of these, 9 were fit for discharge. In contrast, 41 patients did not receive PCA and, of these, 27 were fit for discharge (P < 0.05). Median Aldrete score in the PCA group was 16 and in the non-PCA group 18 (P < 0.05). Postoperative nausea and vomiting were more common in patients receiving a morphine-based PCA and with in those with higher anti-emetic requirement (10/25 in PCA and 7/41 non-PCA groups; P < 0.05). Routine postoperative opioid PCA prolongs the recovery and in-patient stay following elective laparoscopic cholecystectomy. Its role in postoperative pain management in routine laparoscopic cholecystectomy should be questioned.

Complications of gallstone disease in kidney transplantation patients

We studied the complications of gallstone disease in kidney transplantation patients and evaluated whether the screening and treatment of gallstones before acceptance to the kidney waiting list is relevant. Complications of gallstone disease were evaluated in 1608 kidney transplantation patients on cyclosporine and long-term steroid treatment with median age 45.5 years, transplanted between 1990 and 2000. To evaluate the prevalence of cholecystolithiasis after kidney transplantation an abdominal ultrasound examination was cross-sectionally performed to a subgroup of 304 patients and the results were correlated to their serum lipid values, changes in BMI and use of statins. Pre-transplant cholecystectomy due to cholecystolithiasis (prerequisite for acceptance to kidney waiting list) had been performed on 71 (4%) of the patients. Thirty (15%) patients with diagnosed post-transplant gallstones and four without gallstones developed biliary complications. There were 25 cases of cholecystitis of which three resulted in gallbladder perforations. Seventeen patients (50%) with biliary complications required urgent surgery and one (3%) patient died of post-operative complications. In the subgroup of ultrasound examination patients (median 7 years post-transplant follow-up) 81% of the patients had no gallstones and 9% of the patients had gallstones had developed after transplantation. Patients with pre-transplant gallstones were older (P < 0.01) and patients with post-transplant gallstones gained the most weight during the follow-up. No differences in lipid values were found. In transplantation patients, the complications of gallstone disease may be severe. Screening and treatment of pre- and post-transplantation gallstone disease are recommended.

Pain attacks in non-complicated and complicated gallstone disease have a characteristic pattern and are accompanied by dyspepsia in most patients: The results of a prospective study

Objective. The cardinal indication for surgical treatment of gallstones is pain attacks. However, following cholecystectomy, 20% of patients remain symptomatic. It is unclear to what extent post-cholecystectomy symptoms can be ascribed to persistence of preoperative symptoms or to new pathology. The pain and digestive pattern in gallstone patients has not been defined in a recent setting with ultrasonography as the diagnostic method. The aim of this study was to characterize a pain pattern that is typical for gallstone disease and to describe the extent of associated dyspepsia. Material and methods. A total of 220 patients with symptomatic gallstone disease including complicated disease (acute cholecystitis and common bile duct stones) were interviewed using detailed questionnaires to disclose pain patterns and symptoms of indigestion. Results. All patients had pain in the right upper quadrant (RUQ) including the upper midline epigastrium. The pain was localized to the right subcostal area in 20% and to the upper epigastrium in 14%, and in the rest (66%) it was more evenly distributed. An area of maximal pain could be defined in 90%. Maximal pain was located under the costal arch in 51% of patients and in the epigastrium in 41%, but in 3% behind the sternum and in 5% in the back. The pain was referred to the back in 63% of the patients. The mean visual analogue scale (VAS) score was very high: 90 mm on a 0–100 scale. A pattern of incipient or low-grade warning pain with a subsequent relatively steady state until subsiding in the same fashion was present in 90% of the patients. An urge to walk around was experienced by 71%. Pain attacks usually occurred in the late evening or at night (77%), with 85% of the attacks lasting for more than one hour and almost never less than half an hour. Sixty-six percent of the patients were intolerant to at least one kind of food, but only 48% to fatty foods. Symptoms of functional indigestion (gastroesophageal reflux, dyspepsia or irritable bowel symptoms) were seen in the vast majority in association with attacks. Conclusions. Gallstone-associated pain follows a certain pattern in the majority of patients. The pain is located in a defined area with a point of maximum intensity, is usually referred, and occurs mainly at night with duration of more than one hour. The majority of patients experience functional indigestion, mainly of the reflux type or dyspepsia.

Endoscopic Retrograde Cholangiopancreatography during Pregnancy

Physiologic changes of pregnancy leave women at increased risk for gallstone complications. Endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy was first reported in 1990 for the treatment of complicated gallstone disease. Since then, numerous reports have shown that if certain precautionary measures are taken, therapeutic ERCP can be safely performed during pregnancy. A multidisciplinary approach that involves obstetrics, surgery, and gastroenterology is necessary to help ensure maternal and fetal safety. This article addresses the physiologic changes that increase a women's risk for gallstone complications, the indications for ERCP, the safety of ERCP, and its use within the last 15 years.

Urgent Laparoscopic Cholecystectomy Is the Best Management for Biliary Colic

Background/Aim: Delay of laparoscopic cholecystectomy after the diagnosis of biliary colic may increase the probability of recurrent emergency admission while awaiting elective cholecystectomy. The aim of this study was to compare the possible advantages and safety of urgent laparoscopic cholecystectomy (ULC) with elective laparoscopic cholecystectomy (ELC) in patients with biliary colic. Patients and Methods: Between 2001 and 2003, 75 patients with biliary colic were included in this study. The patients were classified into following two groups: patients who had ULC in 24 h were in group I (n = 28) and patients who had ELC (mean interval 4.22 ± 1.42 months) were in group II (n = 35). Conversion to open cholecystectomy, operative time, postoperative hospital stay, costs, and complications were evaluated. Results: In group II, 9 patients made a total of 13 return visits to the emergency department with recurrent attacks of biliary colic or complications of gallstone disease. Mean operative time increased from 35.1 ± 6.74 min for urgent laparascopic cholecystectomy to 49.9 ± 6.12 min for ELC (p > 0.05) and hospital stay time increased from 1.06 ± 0.4 to 2.31 ± 2.36 days (p < 0.05). Conversion to open cholecystectomy increased from 0% in group I to 17.2% in group II (p < 0.05). Discussion: ULC for biliary colic may be the most medically efficacious and cost-effective treatment.

Long-Term Follow-up after Robotic Cholecystectomy

Most surgeons gain their first clinical experience with surgical robots when performing cholecystectomies. Although this procedure is rather easily applicable for the da Vinci surgical system, the long-term outcome after this operation has not yet been clarified. This study follows up our institutional first series of robotic cholecystectomies (June to November 2001). Patients were assessed on the basis of standardized management including a quality-of-life questionnaire, clinical examination, blood tests, and abdominal sonogram. The follow-up rate for 23 patients after robotic cholecystectomy was 100 per cent and the median follow-up time 33 (30-35) months. There was one (4%) recurrence of gallstone disease in a patient who suffered from solitary choledocholithiasis 29 months after robotic cholecystectomy. Abdominal sonogram, clinical examinations, and blood tests revealed no post-cholecystectomy-specific pathological findings. The main long-term symptoms were bloating (57%), heartburn (43%) and nausea (30%). Of the patients, 96 per cent (22 patients) felt that the operation had cured or significantly improved their specific preoperative symptoms. Long-term results after robotic laparoscopic cholecystectomy are excellent and comparable to those for the conventional laparoscopic procedure. The advanced vision control and instrument maneuverability of robotic surgery might open minimally invasive surgery also for complicated gallstone disease and bile duct surgery.