Early Laparoscopic Cholecystectomy Research Articles

Laparoscopic Cholecystectomy in Acute Cholecystitis: An Updated Review

Laparoscopic cholecystectomy is the gold standard for the management of gallstone disease, but it has recently been incorporated into the treatment of acute cholecystitis. It is divided into early and delayed laparoscopic cholecystectomy. Early laparoscopic cholecystectomy is done within 72 hours of the onset of symptoms, and delayed laparoscopic cholecystectomy is done after eight weeks. As there is no consensus on the timing of early laparoscopic cholecystectomy in adults and elderly patients, we have conducted this review article to examine the timing of early laparoscopic cholecystectomy, the risk factors for conversion to open cholecystectomy, and the role of laparoscopic subtotal cholecystectomy in the management of acute cholecystitis.

The Diagnosis and Treatment of Acute Cholecystitis: A Comprehensive Narrative Review for a Practical Approach.

Acute cholecystitis (AC), generally associated with the presence of gallstones, is a relatively frequent disease that can lead to serious complications. For these reasons, AC warrants prompt clinical diagnosis and management. There is general agreement in terms of considering early laparoscopic cholecystectomy (ELC) to be the best treatment for AC. The optimal timeframe to perform ELC is within 72 h from diagnosis, with a possible extension of up to 7-10 days from symptom onset. In the first hours or days after hospital admission, before an ELC procedure, the patient's medical management comprises fasting, intravenous fluid infusion, antimicrobial therapy, and possible administration of analgesics. Additionally, concomitant conditions such as choledocholithiasis, cholangitis, biliary pancreatitis, or systemic complications must be recognized and adequately treated. The importance of ELC is related to the frequent recurrence of symptoms and complications of gallstone disease in the interval period between the onset of AC and surgical intervention. In patients who are not eligible for ELC, it is suggested to delay surgery at least 6 weeks after the clinical presentation. Critically ill patients, who are unfit for surgery, may require rescue treatments, such as percutaneous or endoscopic gallbladder drainage (GBD). A particular treatment approach should be applied to special populations such as pregnant women, cirrhotic, and elderly patients. In this review, we provide a practical diagnostic and therapeutic approach to AC, even in specific clinical situations, based on evidence from the literature.

The Difficult Cholecystectomy: What You Need to Know.

This review discusses the grading of cholecystitis, the optimal timing of cholecystectomy, adopting a culture of safe cholecystectomy, understanding the common error traps that can lead to intraoperative complications and how to avoid them. The Tokyo Guidelines, AAST, Nassar and Parkland scoring systems are discussed. The patient factors, physiologic status and operative findings that predict a difficult cholecystectomy or conversion from laparoscopic to open cholecystectomy are reviewed. With laparoscopic expertise and patient conditions that are not prohibitive, early laparoscopic cholecystectomy is recommended. This is ideally within 72 hours of admission but supported up to the seventh hospital day. The majority of bile duct injuries (BDI) are due to misidentification of normal anatomy. Strasberg's four error traps and the zones of danger to avoid during a cholecystectomy are described. The review emphasizes the importance of a true critical view of safety (CVS) for identification of the anatomy. In up to 15% of operations for acute cholecystitis, a CVS cannot be achieved safely. Recognizing these conditions and changing your operative strategy are mandatory to avoid harm. The principles to follow for a safe cholecystectomy are discussed in detail. The cardinal message of this review is "under challenging conditions, BDI can be minimized via either a subtotal cholecystectomy or top-down cholecystectomy if dissection in the hepatocystic triangle is avoided." (28) The most severe biliary/vascular injuries usually occur after conversion from laparoscopic cholecystectomy. Indications and techniques for bailout procedures including the fenestrating and reconstituting subtotal cholecystectomy are presented. Seven to ten percent of cholecystectomies for acute cholecystitis currently result in subtotal cholecystectomy.

Microbiological etiology and current resistance patterns in acute calculous cholecystitis

IntroductionThe current treatment for acute calculous cholecystitis (ACC) is early laparoscopic cholecystectomy, in association with appropriate empiric antibiotic therapy. In our country, the evolution of the prevalence of the germs involved and their resistance patterns have been scarcely described. The aim of the study was to analyze the bacterial etiology and the antibiotic resistance patterns in ACC. MethodsWe conducted a single-center, retrospective, observational study of consecutive patients diagnosed with ACC between 01/2012 and 09/2019. Patients with a concomitant diagnosis of pancreatitis, cholangitis, postoperative cholecystitis, histology of chronic cholecystitis or carcinoma were excluded. Demographic, clinical, therapeutic and microbiological variables were collected, including preoperative blood cultures, bile and peritoneal fluid cultures. ResultsA total of 1104 ACC were identified, and samples were taken from 830 patients: bile in 89%, peritoneal fluid and/or blood cultures in 25%. Half of the bile cultures and less than one-third of the blood and/or peritoneum samples were positive. Escherichia coli (36%), Enterococcus spp (25%), Klebsiella spp (21%), Streptococcus spp (17%), Enterobacter spp (14%) and Citrobacter spp (7%) were isolated. Anaerobes were identified in 7% of patients and Candida spp in 1%. Nearly 37% of patients received inadequate empirical antibiotic therapy. Resistance patterns were scrutinized for each bacterial species. The main causes of inappropriateness were extended-spectrum beta-lactamase–producing bacteria (34%) and Enterococcus spp (45%), especially in patients older than 80 years. ConclusionsUpdated knowledge of microbiology and resistance patterns in our setting is essential to readjust empirical antibiotic therapy and ACC treatment protocols.

Evaluation of the Validity of Endoscopic Transpapillary Gallbladder Drainage for Acute Cholecystitis Based on the Tokyo Guidelines 2018.

We evaluated the validity of endoscopic transpapillary gallbladder drainage (ETGBD) as a bridging therapy prior to elective Lap-C for the patients with acute cholecystitis (AC). The Tokyo Guidelines 2018 recommend early laparoscopic cholecystectomy (Lap-C) for patients with AC, however, some patients require the preoperative drainage because of inadequate for early Lap-C du to background and comorbidities. We performed a retrospective cohort analysis using data from our hospital records from 2018-2021. In total, 71 cases of 61 patients with AC underwent ETGBD. The technical success rate was 85.9%. Patients in the failure group had more complicated branching of the cystic duct. The length of time until feeding was started and until WBC levels normalized, and the length of hospital stay were significantly shorter in the success group. The median waiting period for surgery was 39 days in the ETGBD success cases. The median operating time, amount of bleeding, and length of postoperative hospital stay were 134 min, 83.2g, and 4 days, respectively. In patients who underwent Lap-C, the waiting period for surgery and the operating time were similar between the ETGBD success and failure groups. However, the temporary discharge period after drainage and the length of postoperative hospital stay were significantly longer in the patients with ETGBD failure. Our study revealed that ETGBD has equivalent efficacy prior to elective Lap-C despite some challenges that lower its success rate. Preoperativ ETGBD can improve patient quality of life by eliminating the need for a drainage tube.

Preoperative difficulty factors in delayed laparoscopic cholecystectomy: Tokyo Guidelines 2018 surgical difficulty score analysis.

Tokyo Guidelines 2018 (TG18) recommend early laparoscopic cholecystectomy (LC) for low-risk acute cholecystitis (AC); however, some patients undergo delayed LC (DLC) after conservative treatment. DLC, influenced by chronic inflammation, is a difficult procedure. Previous studies on LC difficulty lacked objective measures. Recently, TG18 introduced a novel 25 findings difficulty score, which objectively assesses intraoperative factors. The purpose of this study was to use the difficulty score proposed in TG18 to identify and investigate the predictors of preoperative high-difficulty cases of DLC for AC. We retrospectively reviewed 100 patients with DLC after conservative AC treatment. The surgical difficulty of DLC was evaluated using a difficulty score. Based on previous studies, the highest scores in each category were categorized as grades A-C. The severity of AC was mild in 51 patients and moderate in 49. Surgical outcomes revealed a distribution of difficulty scores, with grade C indicating high difficulty, showing significant differences in operative time, blood loss, achieving a critical view of safety, bailout procedures, and postoperative hospital stay compared with grades A and B. Regarding the preoperative risk factors, multivariate analysis identified age >61 years (p = .008), body mass index >27.0 kg/m2 (p = .007), and gallbladder wall thickness >6.2 mm (p = .001) as independent risk factors for grade C in DLC. The difficulty score proposed in TG18 provides an objective framework for evaluating surgical difficulty, allowing for more accurate risk assessments and improved preoperative planning in DLC for AC.

Intraoperative transcystic laparoscopic common bile duct stone clearance with SpyGlass™ discover during emergency and elective cholecystectomy: a single-center case series

Background and study aimThe development of a new cholangioscope, the SpyGlass™ Discover (Boston Scientific), has allowed the laparoscopic transcystic common bile duct exploration and stone clearance. The possibility of simultaneous treatment of choledocholithiasis during early laparoscopic cholecystectomy offers the opportunity to enormously reduce the time between acute cholecystitis diagnosis and the execution of cholecystectomy with better outcomes for patients. Furthermore, an altered anatomy of the gastrointestinal tract is not an obstacle to this technique. The aim of the study was to determine whether this new procedure is feasible, safe, and effective.Patients and methodsThe investigation employs a retrospective case series study including all consecutive patients with a diagnosis of common bile duct stones undergoing cholecystectomy and intraoperative laparoscopic common bile duct clearance using SpyGlass™ Discover at IRCCS Policlinico San Matteo in Pavia (Italy). Eighteen patients were included from May 2022 to May 2023.ResultsA complete clearance of the common bile duct was obtained in 88.9% of patients. The mean postoperative length of stay was 3 days. No major complications occurred. After a median follow-up of 8 months, no recurrence of biliary events or readmissions occurred.ConclusionThis procedure has proven to be feasible, safe, and effective.

The effect of previous endoscopic retrograde cholangiopancreatography on subsequent laparoscopic cholecystectomy: The retrospective analysis of 1500 patients.

Laparoscopic cholecystectomy (LC) is the gold standard for patients with acute cholecystitis at early period. However, 15%-20% of patients with acute cholecystitis develop obstructive jaundice, cholangitis and bile duct stones ultimately requiring endoscopic retrograde cholangiopancreatography (ERCP). In such cases, a two-session approach is usually recommended, first ERCP followed by LC thereafter. However, the effect of prior ERCP on the difficulty of subsequent LC is unknown. Hence, the aim of the present study is to determine the effects of previous ERCP on the results of LC. In this study, the files of 1500 patients who underwent LC were reviewed retrospectively. The patients were divided into three groups (500 patients for each group). The patients undergoing LC for asymptomatic cholelithiasis were assigned to the L-e group. The patients who underwent LC for acute cholecystitis were assigned to the L-c group. The patients with acute cholecystitis who underwent ERCP first and then LC were assigned to the L-ercp group. The rates of conversion to open cholecystectomy, operation times, complication rates and hospital stays of the three groups were compared. The results of LC performed after ERCP are similar to the results of LC for cholecystitis without ERCP in terms of operation time, hospital stay, conversion and complications. Previous ERCP does not affect the safety and effectiveness of early LC in patients with acute cholecystitis.

Early laparoscopic cholecystectomy in severely comorbid patients with acute cholecystitis: results of a monocentric study

Aim: The aim is to evaluate laparoscopic cholecystectomy safety based on American Society of Anesthesiologists score for acute cholecystitis in patients with comorbidities. Patients & methods: This is retrospective study of patients who underwent laparoscopic cholecystectomy for acute cholecystitis between 2003 and 2021. According to their respective ASA-score, patients were divided into group 1: ASA1-2 and group 2: ASA3-4. Results: We collected 578 patients. Even though the gangrenous forms were more frequent and the operative time was longer in group 2, laparoscopic cholecystectomy seems safe and effective. We didn't observe any differences in terms of intraoperative incidents, open conversion rate, or postoperative complications compared with other patients. Conclusion: ASA3-4 patients with acute cholecystitis don't face elevated risks of complications or mortality during laparoscopic cholecystectomy.

Bedside Ultrasound-Guided Percutaneous Cholecystostomy in Critically Ill Patients—Outcomes in 51 Patients

Abstract Purpose The aim of this study was to report technical and clinical success of bedside ultrasound-guided percutaneous cholecystostomy (PC) tube placement in intensive care unit (ICU). Materials and Methods This is a retrospective study of 51 patients (36 males:15 females, mean age: 67 years) who underwent ultrasound-guided PC from May 2015 to January 2020. The indication for cholecystostomy tube placement, comorbidities, imaging finding, technical success, clinical success, timing of surgery post-cholecystostomy tube placement, indwelling catheter time, complications, and follow-up were recorded. Results Indications for cholecystostomy tube placement were acute calculous cholecystitis (n = 43; 84.3%), perforated cholecystitis (n = 5; 9.8%), and emphysematous cholecystitis (n = 3; 5.9%). Most of the patients had multiple comorbidities; these were diabetes mellitus, hypertension, cardiovascular disease, chronic renal disease, underlying malignancy, and multisystem disease with sepsis. All patients had undergone PC through transhepatic approach under ultrasound guidance in ICU. Technical success rate of the procedure was 100%. Clinical success rate was 92.1% (47/51) and among these 44/51 (86.2%) patients underwent definitive elective cholecystectomy, 3/51 (5.9%) patients had elective tube removal. Three of fifty-one (5.9%) patients did not improve; among these two underwent emergency surgery, while there was 1/51 (1.9%) mortality due to ongoing sepsis and multiorgan dysfunction. There were no procedure-related mortalities or procedure-related major complications. One patient had bile leak due to multiple attempts for cholecystostomy placement. Mean tube indwelling time was 13 days (range: 3–45 days). Conclusion Ultrasound-guided PC can be safely performed in ICU in critically ill patients unfit for surgery with high technical and clinical success rates. Early laparoscopic cholecystectomy should be preferred after stabilization of clinical condition following cholecystostomy.

Combining preoperative C-reactive protein values with the Tokyo Guidelines 2018 grading criteria can enhance the prediction of surgical difficulty in early laparoscopic cholecystectomy for acute cholecystitis

BackgroundEarly laparoscopic cholecystectomy (ELC) is the standard treatment for acute cholecystitis (AC). However, predicting the difficulty of this procedure remains challenging. The present study aimed to develop an improved prediction model for surgical difficulty during ELC, surpassing the current Tokyo Guidelines 2018 (TG18) grading system. MethodsWe analyzed data from 201 consecutive patients who underwent ELC for AC between 2019 and 2021. Surgical difficulty was defined as the failure to achieve the critical view of safety (non-CVS). We developed a scoring system by conducting multivariate analysis on demographics, symptoms, laboratory data, and radiographic findings. The predictive accuracy of our scoring system was compared to that of the TG18 grading system (Grade I vs. Grade II/III). ResultsThrough multivariate logistic regression analysis, a novel scoring system was formulated. This system incorporated preoperative C-reactive protein (CRP) values (≥5: 1 pt, ≥10: 2 pts, ≥15: 3 pts) and TG18 grading score (duration >72 h: 1 pt, image criteria for Grade II AC: 1 pt). Our model, a cutoff score of ≥3, exhibited a significantly elevated area under the curve (AUC) of 0.721 compared to the TG18 grading system alone (AUC 0.609) (p = 0.001). ConclusionCombining preoperative CRP values with TG18 grading criteria can enhance the accuracy of predicting intraoperative difficulty in ELC for AC.

HPB P15 Diagnosis of Choledocholithiasis in Risk-Stratified patients: the benefits of Magnetic Resonance Cholangiopancreatography. - A single centre retrospective cohort study

Abstract Background Association of Upper Gastrointestinal Surgeons (AUGIS) guidelines recommend that magnetic resonance cholangiopancreatography (MRCP) should be performed in patients with suspected gallstone disease who have deranged liver function tests (LFTs) and dilated bile ducts on ultrasound scan (USS). Early laparoscopic cholecystectomy (LC) is recommended to reduce complications of gallstone disease. Confirmation of choledocholithiasis helps guide acute management as well as operative planning. The aim of this study was to determine the probability of choledocholithiasis on MRCP of risk stratified patients. Methods A retrospective cohort study of adult patients who underwent MRCP in a single centre was conducted from September 2020 to September 2022. Patients being investigated for non-biliary indications (e.g. hepato-pancreato-biliary malignancies) were excluded. Patient demographics, pre-MRCP peak LFTs, clinical indications and all radiology imaging results were analysed. Patients were risk-stratified based on modified AUGIS guidelines using hyperbilirubinemia and the presence of biliary duct dilation on USS and CT-scans as risk factors. Patients with MRCP proven choledocholithiasis were compared to those without. P value was calculated using chi-square testing. This study was registered with Clinical Quality Project (LanQIP: 14737). Results 1,107 MRCP were identified; 97 were excluded. Median age was 65 years (IQR 50.3-75) and 625 (61.9%) were female. 677 (67%) were inpatient scans and 432 (42. 8%) were urgent. Median time for inpatient scans was 1.1 days (IQR 0.8-2.1). 739 (73.2%) patients had known gallstones. 157 (15.5%) were post-cholecystectomy. 596 (59%) had hyperbilirubinemia and 726 (71.9%) had elevated alkaline phosphatase (ALP). 38.5% of USS and 48.2% of CT scans showed dilated ducts. Overall, 276 (27.3%) MRCPs showed choledocholithiasis. Raised ALP, hyperbilirubinemia, and dilated ducts on preceding imaging were strongly predictive for choledocholithiasis on MRCP (p<0.001). Conclusions Our result are consistent with previously published data. We suggest that AUGIS guidelines should be used to risk stratify patients to maximise the utility of MRCP. If early LC cannot be performed, careful assessment of patient risk factors can guide the need for MRCP to determine the need for interval endoscopic retrograde cholangiopancreatography and aid pre-operative surgical planning. In centres where expertise is available, intra-operative cholangiogram can replace the need for MRCP in low-risk group.

Symptom Duration and Surgeon Volume: Impact on Early Laparoscopic Cholecystectomy for Acute Cholecystitis.

The 'golden 72 hours' rule from the onset of symptoms still applies in laparoscopic cholecystectomy for acute cholecystitis. This rule has been discussed with increasing experience in laparoscopic surgery in recent years. This study aims to determine the optimal symptom duration based on the surgeon's volume when deciding on early laparoscopic cholecystectomy for acute cholecystitis. The patients were categorized into two groups: Group 1 (≤3 days) and Group 2 (>3 days) based on the symptom duration, andhigh-volume surgeons (performing >100 laparoscopic cholecystectomies in a year) and low-volume surgeons (performing <100 laparoscopic cholecystectomies in a year) based on the surgeon volume. All surgeons had received advanced training in laparoscopic surgery. There was no statisticaldifference in postoperative outcomes between groups, except for a few data (p>0.05). The operative time was longer in Group 2, the postoperative hospital stay was longer for low-volume surgeons than for high-volume surgeons after three days, and operative time was longer after three days than the first three days in low-volume surgeons (p<0.05). Early laparoscopic cholecystectomy may be recommended for acute cholecystitis with symptom duration of more than three days, regardless of the surgeon volume, as long as they are competent in laparoscopic surgeries.

Operative management of acute cholecystitis in pregnancy: Case report

Introduction: Acute cholecystitis is the second most common non-obstetric surgical disease during pregnancy. There have been several trials comparing operative and non-operative management in the past. Purpose: To present a clinical case from our practice and to compare clinical management with worldwide standards. Materials and methods: A 42-year-old patient in the 20th gestational week presented to our department with complaints of pain in the epigastrium and RUQ, as well as a single incidence of vomiting, during the last two days. Results: We operated 15 h after admission and did a standard laparoscopy. The patient was discharged on the 4th postoperative day. Conclusion: A review of the available literature shows the prevalence of early laparoscopic cholecystectomy, while non-operative management has proven to have higher complication rates. Laparoscopic surgery in pregnancy has proven to be safe for both mother and fetus. In our case, the patient was operated on within the first 24 hours of admission. We did not observe any complications during her stay and follow-up.

Early versus delayed laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography: A meta-analysis.

Patients with cholecysto- and choledocholithiasis usually undergo endoscopic retrograde cholangiopancreatography (ERCP)/-endoscopic sphincterotomy followed by laparoscopic cholecystectomy (LC). However, differences in the timing of LC after the ERCP may alter the post-operative outcomes. The aim of this study was to compare the effect of early (≤3 days) or delayed LC (>3 days) following ERCP on the post-operative outcomes. A comprehensive search of the 3 databases PubMed, EMBASE and the Cochrane Library was performed. Articles related to LC at different time-points after ERCP were retrieved. Dichotomous and continuous outcomes were analyzed by risk ratio (RR) and mean difference, and RevMan was used to analyze each group. A total of 7 studies, including 5 randomized controlled studies and 2 retrospective studies, involved a total of 711 patients. There were 332 patients in early LC group and 379 in delayed LC group. The conversion rate was lower in the early LC group compared to the delayed LC group (RR 0.38, 95% confident interval 0.19 to 0.74, P = .005, I2 = 0%). Early LC resulted in a shorter operation time (RR -6.2, 95% CI -27.2 to -5.2, P = .004, I2 = 97%) and fewer complications (RR 0.48, 95% CI 0.29 to 0.79, P = .004, I2 = 17%). Subgroup analysis found that there were no significant differences in the conversion rate (RR 0.61, 95% CI 0.25 to 1.45, P = .26, I2 = 0%) or complications between the early LC group and the delayed group who underwent LC after 1 month. Early LC after ERCP is the preferred treatment for patients with concurrent cholecysto- and choledocholithiasis due to improved clinical outcomes as compared to those who undergo delayed LC.

849 Quality Improvement in the Service Delivery of Early Laparoscopic Cholecystectomy (LC) for Acute Cholecystitis (AC)

Abstract Aim Acute gallstone disease comprises 30-40% of emergency general surgery workload. Delayed cholecystectomy is related to increased readmissions, biliary complications, and costs. BSG, AUGIS and NICE guideline advocate early Laparoscopic Cholecystectomy (LC). The aim of this Quality Improvement (QI) project is to establish an early LC service in a tertiary hospital in central London, based on national QI Collaborative led by Royal College of Surgeons (RCS). The objectives are assessing existing management, developing strategies, and measuring outcome. Method The management was evaluated including surgeons’ preferences and operating barriers. Strategies were developed through process mapping and stakeholder engagements. Following the implementation, admissions including time to surgery, and reasons for non-compliance, were recorded. The intervention period was set in 4 phases between September 2019 and November 2020: Plan, Improve, Pause and Restart. The sustainability of change was monitored between January 2021 and October 2022. Results 282 AC cases were admitted during intervention period and 68% (194) were fit and consented for surgery. The rate of early LC within 8 days increased from 11% to 61%. During the “pause” phase, the intervention was stopped, and early LC rate dropped to zero, demonstrating the importance of continuous application of strategy. The sustainability was shown during the monitoring period; 343 cases were admitted, 140 (41%) fit for surgery, 62 had surgery within 8 days (43%), and 77 within 14 days (54%). Conclusions The QI study significantly improved the urgent LC rate and received the RCS prize. Sustainability was demonstrated with continual reviews and adaptations.

1285 Management of Acute Cholecystitis – Evaluating the Timing of Laparoscopic Cholecystectomy

Abstract Aim Current National Institute for Health and Care Excellence Quality Standards (NICE QS104) recommend adults with Acute Cholecystitis (AC) have Early Laparoscopic Cholecystectomy (ELC) within 1 week of diagnosis. If this is not achievable, a Delayed Laparoscopic Cholecystectomy (DLC) should be performed more than 4 weeks after the initial episode. This study evaluated current practice in a tertiary hospital General Surgical department. Method All patients presenting with their first presentation with AC between November 2021 and March 2022 were identified from prospectively maintained surgical handovers. Patients admitted with acalculous cholecystitis, under different specialities, residing out of the area, and who self-discharged were excluded. Data was collected from electronic patient records retrospectively. Results 81 patients were included in the study, 29 males and 52 females. The mean age of included patients was 64. 61 patients were fit for surgical intervention. 14.8% (9) of patients had an ELC within 1 week of diagnosis. 85.5% (52) of patients were planned for DLC after discharge. 13.5% (7) of DLCs were performed within 3 months of discharge and a further 50.0% (26) of DLCs were performed within 6 months of discharge. 21.2% (11) of patients were readmitted to hospital with gallstone-related presentations within 6 months of their discharge whilst awaiting DLC. Conclusions This study shows that national standards are currently not being achieved. This is likely due to multifactorial causes, including increasing pressures due to the pandemic. We plan to expand our data and utilise these findings to produce a business case for a regular dedicated ELC list.

Early laparoscopic cholecystectomy for acute cholecystitis: Does age matter?

Advances in laparoscopic surgery and perioperative care have improved the prognosis of operated patients, especially the oldest among them. This study aimed to assess the outcomes of early laparoscopic cholecystectomy for acute calculous cholecystitis in older adult patients. A retrospective analysis was carried out of 567 patients who underwent early laparoscopic cholecystectomy for acute calculous cholecystitis between January 2003 and July 2021. The outcomes of older adult patients (≥ 75 years) were compared with those of younger patients. The older adult group had significantly more patients with an American Society of Anesthesiologists score ≥3 (37.5% vs 8.3%; P < 0.001) and more severe acute calculous cholecystitis (grade II; 82.8% vs 67%; P = 0.01). There were no significant differences regarding operative time (90 vs 80 min; P = 0.064), conversion rate (20.3% vs 13.5%; P = 0.144), and both intra- and postoperative morbidity, principally bile duct injuries (1.6% vs 0%; P = 0.113) and bile leakage (0% vs 1.2%; P = 1). Early laparoscopic cholecystectomy could be proposed safely for older adult patients with mild and moderate acute cholecystitis. Geriatr Gerontol Int 2023; 23: 671-675.

The 2023 MANCTRA Acute Biliary Pancreatitis Care Bundle: A Joint Effort Between Human Knowledge and Artificial Intelligence (ChatGPT) to Optimize the Care of Patients With Acute Biliary Pancreatitis in Western Countries.

To generate an up-to-date bundle to manage acute biliary pancreatitis using an evidence-based, artificial intelligence (AI)-assisted GRADE method. A care bundle is a set of core elements of care that are distilled from the most solid evidence-based practice guidelines and recommendations. The research questions were addressed in this bundle following the PICO criteria. The working group summarized the effects of interventions with the strength of recommendation and quality of evidence applying the GRADE methodology. ChatGPT AI system was used to independently assess the quality of evidence of each element in the bundle, together with the strength of the recommendations. The 7 elements of the bundle discourage antibiotic prophylaxis in patients with acute biliary pancreatitis, support the use of a full-solid diet in patients with mild to moderately severe acute biliary pancreatitis, and recommend early enteral nutrition in patients unable to feed by mouth. The bundle states that endoscopic retrograde cholangiopancreatography should be performed within the first 48 to 72 hours of hospital admission in patients with cholangitis. Early laparoscopic cholecystectomy should be performed in patients with mild acute biliary pancreatitis. When operative intervention is needed for necrotizing pancreatitis, this should start with the endoscopic step-up approach. We have developed a new care bundle with 7 key elements for managing patients with acute biliary pancreatitis. This new bundle, whose scientific strength has been increased thanks to the alliance between human knowledge and AI from the new ChatGPT software, should be introduced to emergency departments, wards, and intensive care units.

Efficacy of early laparoscopic cholecystectomy compared with percutaneous transhepatic gallbladder drainage in treating acute calculous cholecystitis in elderly patients

Background Acute calculous cholecystitis is a common acute disease in elderly patients. This study aimed to evaluate the efficacy of early laparoscopic cholecystectomy (ELC) compared to percutaneous transhepatic gallbladder drainage (PTGD) for treating acute calculous cholecystitis in elderly patients. Methods This retrospective study compared the clinical outcomes of two groups of elderly patients treated with ELC (group A) and PTGD (group B) from January 2018 to December 2021. Preoperative clinical characteristics and postoperative treatment outcomes were analyzed for both groups. Results There were no statistically significant differences in preoperative clinical characteristics between the ELC and PTGD groups. ELC took longer to perform (69.8 ± 15.9 min vs. 29.6 ± 5.3 min, p < 0.001) but resulted in a significantly shorter duration of pain (1.9 ± 0.9 days vs. 3.9 ± 1.0 days, p < 0.001) and hospital stay (6.3 ± 2.5 days vs. 9.9 ± 3.6 days, p < 0.001), and a lower rate of sepsis (3.4% vs. 16.9%, p < 0.019). Time to soft diet was faster in the ELC group (1.5 ± 0.9 days vs. 3.0 ± 1.6 days, p < 0.001). Fewer patients in the ELC group experienced surgical reintervention than in the PTGD group (0% vs. 5.6%, p = 0.043). The incidence of postoperative complications and readmission rates in the ELC group were significantly lower than those in the PTGD group (ELC, 3.6%; PTGD, 25.4%, p = 0.001). Conclusions ELC is an effective treatment option for acute calculous cholecystitis in elderly patients, and has the added benefits of low postoperative complication rates, rapid recovery, shorter duration of pain, and excellent curative effects as compared to PTGD.