Uncomplicated Cholecystolithiasis Research Articles

Tailoring diagnosis and treatment in symptomatic gallstone disease.

There is a lack of consensus in selecting patients who do or do not benefit from surgery when patients present with abdominal pain and gallbladder stones are present. This review aimed to give an overview of results from recent trials and available literature to improve treatment decisions in patients with uncomplicated cholecystolithiasis. First, an overview of different symptom criteria for laparoscopic cholecystectomy in patients with uncomplicated cholecystolithiasis is given, based on national and international guidelines. Second, treatment outcomes (absence of biliary colic, pain-free state, biliary and surgical complications) are summarized, with data from three clinical trials. Finally, personal advice for treatment decisions in patients with uncomplicated cholecystolithiasis is provided, based on recent trials, the available literature, and expert opinion. This review describes different guidelines and criteria sets for uncomplicated cholecystolithiasis, provides an overview of outcomes after cholecystectomy, and advises on treatment decisions in patients with abdominal pain and gallbladder stones. After cholecystectomy, biliary colic is resolved in 95 per cent of patients. However, non-specific abdominal pain persists in 40 per cent. Irritable bowel syndrome and functional dyspepsia significantly increase the risk of persistent pain. Age, previous abdominal surgery, baseline pain score on a visual analogue scale, pain characteristics, nausea, and heartburn are part of the SUCCESS criteria, and are associated with clinically relevant pain reduction after gallbladder removal. The surgical community can now give more personalized advice on surgery to improve care for patients with abdominal pain and uncomplicated cholecystolithiasis.

Comparison of the ROME-III Criteria and a New Multivariable Prediction Model for the Selection of Patients with Symptomatic Cholecystolithiasis for Cholecystectomy

Introduction: Currently, selection for cholecystectomy in patients with uncomplicated cholecystolithiasis is based on the Rome-III criteria; severe pain attacks, in the right upper quadrant, and lasting 15-30 minutes or longer. This study evaluates these Rome-criteria and a new prediction model based on pre-operative variables for outcome after cholecystectomy. Methods: In two multicenter, prospective trials, the SECURE and SUCCESS, patients from 25 Dutch hospitals with symptomatic, uncomplicated cholecystolithiasis were included between April’14-June’19. We evaluated the Rome-criteria to predict a pain-free state or clinically relevant pain reduction after surgery. Furthermore, we developed and validated a multivariable model to predict both outcomes after surgery. Model performance was evaluated using calibration and discrimination. Results: We included 1,561 patients, of which 494 patients in the SUCCESS cohort. In the SUCCESS cohort, 80% underwent cholecystectomy. After, 57% was pain-free and 80% reported a clinically relevant pain reduction. A prediction model based on the Rome-criteria poorly predicted a pain-free state or clinically relevant pain reduction (c-statistic 0.56 (95%CI 0.50-0.61) and 0.59 (95%CI 0.50-0.67), respectively). A multivariable model showed that increased age, no history of abdominal surgery, increased baseline VAS pain-score, pain-radiation to the back, pain-reduction with simple analgesics, nausea, and no heartburn are independent predictors of clinically relevant post-operative pain reduction. After validation, good discrimination between patients with and without clinically relevant pain reduction was found (c-statistic 0.80 (95%CI 0.74-0.84). Conclusion: A comprehensive model with the SUCCESS-criteria better predicts outcome in patients after a cholecystectomy compared with a prediction model based on current Rome-III criteria.

Laparoscopic Cholecystectomy after Endoscopic Retrograde Cholangiopancreatography

Abstract Background Laparoscopic cholecystectomy (LC) post Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy(ES) is generally accepted as the treatment of choice for patient with choledococystolithiasis. Previous studies have shown that LC after ERCP is associated with a high conversion rate. The aim of the present study was to assess the complexity of LC after ERCP compared with standard LC for symptomatic uncomplicated cholecystolithiasis. Objective s: So the aim of this study is to assess the complexity of LC post ERCP comparted to elective LC without previous ERCP. Method The study is a prospective cohort study of two groups of patients: patients who had undergone a previous ERCP for choledocolithiasis (PES) and patients with cholecystolithiasis who had no previous intervention prior to LC (NPES). Results The PES group consists of 25 patients and the NPES group consists of 25 consecutive patients, patients in the PES group had a higher risks for longer (more than 35 min) duration of operation, the conversion rate in the PES group and the NPES group (12% versus 0%, respectively) were not significantly different, duration of post-operative hospital stay in the PES group was longer than NPES group, there was more difficulty in achieving the critical view of safety in the PES group (easily achieved in 48%) than NPES group(easily achieved in 92%). Conclusion A laparoscopic cholecystectomy after ES is longer and more difficult than in uncomplicated cholelithiasis and should therefore be performed by an experienced surgeon.

The Prevalence of Functional Gastrointestinal Disorders in Patients with Uncomplicated Cholecystolithiasis (PERFECT): a Prospective, Multicenter Observational Study

Background: Symptomatic gallstones, functional dyspepsia(FD), and irritable bowel syndrome(IBS) have similar symptom pattern. This study determined the prevalence of FD/IBS in patients with gallstones and assessed the outcome of a cholecystectomy in terms of resolution of biliary colics and abdominal pain. Methods: A multicentre, prospective observational study was conducted. Adult patients with abdominal pain and ultrasonically confirmed gallstones were included. The presence of FD/IBS was assessed with the validated ROME-IV questionnaire. A biliary colic was defined by the ROME-III criteria. Pain-free was defined as an Izbicki Pain Score ≤10. Patients with and without FD/IBS at baseline were compared. Results: Between January 2018-April 2019, 401 patients (51.7 years, 76.3% females) were included. In total, 34.9% (140/401) of the patients with gallstones fulfilled the ROME-IV criteria for FD/IBS, and 64.1% (257/401) fulfilled the ROME-III criteria for biliary colic. Cholecystectomy rate was similar between the groups (73.8% in FD/IBS-group vs. 75.5% in patients without FD/IBS, p=0.720). After follow-up of 24 weeks the biliary colic was resolved in 93.9% of patients with surgery (91.4% in FD/IBS-group vs. 95.1% in patients without FD/IBS, p=0.220). Pain-free after surgery was achieved in 56.8% of patients (40.7% in FD/IBS-group vs. 64.4% in patients without FD/IBS, p< 0.001). Conclusion: One-third of the patients with gallstones fulfil criteria for FD and/or IBS. Cholecystectomy resolves biliary colics in 94% of patients, with similar outcome between patients with and without FD/IBS. However, pain-free after surgery is significantly less in patients with FD/IBS. This study partially explains the poor pain reduction after cholecystectomy.

Challenges of Post ERCP Laparoscopic Cholecystectomy versus Elective Cholecystectomy

Background: Laparoscopic cholecystectomy (LC) post Endoscopic retrograde cholangio-pancreatography (ERCP) with endoscopic sphincterotomy (ES) is accepted as treatment of choice for choledocho-cholecystolithiasis. Studies have demonstrated that LC after ES is associated with difficulties, complications and higher conversion rate. Our study was to assess the challenges and complexities of LC after ERCP compared with standard elective LC for symptomatic uncomplicated cholecystolithiasis and assess the stenting effect when inserted on the following cholecystectomy and detect other factors that may cause post ERCP cholecystectomy challenges and complexities. Patients and methods: Prospective controlled clinical trial was conducted over 50 patients : (Group A 25 patients) who had undergone a previous ERCP for choledocholithiasis (PES) and (Group B 25 patients) with cholecystolithiasis with no previous intervention before LC (NPES). Results: Patients in PES group had higher risks for longer operative time (mean 36 min) which is statistically highly significant, the conversion rate in the PES group and the NPES group (12% versus 0%), were not statistically significant, duration of post-operative hospital stay in the PES group was longer than NPES group (statistically highly significant), there was more difficulty in achieving the critical view of safety in the PES group (easily achieved in 52%) than NPES group (easily achieved in 92%) (Statistically different), the amount of post-operative drain was higher in the PES group (30-300 ml sero-sanginous fluid) than the NPES group (15-30 ml serosanginous fluid) (statistically highly significant). Conclusion: Laparoscopic cholecystectomy post ERCP especially when delayed or stent was inserted is a challenge for any surgeon with higher complexity and longer operative time and more conversions to open cholecystectomies with more difficulty to achieve critical view of safety. So, it has to be done by an experienced surgeon and rendezvous ERCP with laparoscopic cholecystectomy in same setting is advised with further prospective studies is needed with proper timing of interventions.

Prevalence of dyspepsia in patients with cholecystolithiasis: a systematic review and meta-analysis.

Cholecystolithiasis and functional gastrointestinal disorders are both highly prevalent in the industrialized world and may exist concomitantly. The presence of both conditions impedes identification of the source of symptoms, leading to a risk of ineffective cholecystectomies with lack of symptom resolution. We carried out a systematic review and meta-analysis to determine the prevalence of dyspepsia in patients with uncomplicated cholecystolithiasis. The electronic databases Medline, Embase, and Web of Science were searched for articles reporting the prevalence of dyspepsia in adults (≥18 years) with uncomplicated cholecystolithiasis. Pooled prevalence and 95% confidence interval were calculated. I statistics were used to determine heterogeneity and the Methodological Evaluation of Observational Research criteria were applied for quality assessment. The study was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Of the 1696 studies evaluated, 13 reported the prevalence of dyspepsia in a total of 1227 cholecystolithiasis patients seeking medical care. The pooled prevalence of dyspepsia in patients with cholecystolithiasis was 65.7% (95% confidence interval: 51-79%). However, heterogeneity was large across studies. Overall, three studies used validated diagnostic criteria. Variation in diagnostic measures significantly influenced the prevalence of dyspepsia. In conclusion, symptoms similar to those of functional gastrointestinal disorders are common in patients with cholecystolithiasis, obscuring the source of abdominal complaints. Tools to select patients who will benefit from cholecystectomy are paramount to prevent ineffective surgery.

Feasibility of Single-Port Cholecystectomy With Wound Retractor and a Glove in a Rural Hospital in Mexico

Laparoscopic surgery has been established as the standard therapy for symptomatic cholecystolithiasis. Now, single-port cholecystectomy is a surgical option. Due to the need of special laparoscopic instruments and devices, the cost of the surgery is significantly increased, limiting its popularity in most medical centers in developing countries, especially in rural areas. This paper's objective was to show the safety, reproducibility, and feasibility of single-port laparoscopic cholecystectomy using conventional laparoscopic equipment, a wound retractor, and a sterile glove in a rural hospital in Mexico. A prospective study was carried out from July to October 2014. Patients diagnosed with uncomplicated cholecystolithiasis who agreed to participate were operated with this technique. Complications, operative time, bleeding, evolution, and length of hospital stay were recorded. A total of 24 women went onto surgery under this approach. A mean follow-up of 71 days was completed. No incisional hernias, bile duct injuries, wound infection, nor death was presented. Surgical time and cost were not significantly increased compared to conventional laparoscopic approach. Most patient discharge was done the same day of the surgery. Single-port laparoscopic cholecystectomy is a cost-effective procedure, which can be performed in all hospitals where an Alexis retractor and conventional laparoscopic equipment is available. There was no increase of surgical morbidity. The single-port cholecystectomy is a technically feasible and safe surgical option in selected patients and can be easily performed in rural hospitals at a low cost, providing the benefits of the single incision.

Significance of ultrasonography in selecting methods for the treatment of acute cholecystitis.

Surgical removal of the gallbladder is indicated in nearly all cases of complicated acute cholecystitis. In the 1990s, laparoscopic cholecystectomy became the method of choice in the treatment of cholecystolithiasis. Due to a large inflammatory reaction in the course of acute inflammation, a laparoscopic procedure is conducted in technically difficult conditions and entails the risk of complications.The aim of this paperThe aim of this paper was: 1) to analyze ultrasound images in acute cholecystitis; 2) to specify the most common causes of conversion from the laparoscopic method to open laparotomy; 3) to determine the degree to which the necessity for such a conversion may be predicted with the help of ultrasound examinations.Material and methodsIn 1993–2011, in the Second Department and Clinic of General, Gastroenterological and Oncological Surgery of the Medical University in Lublin, 5,596 cholecystectomies were performed including 4,105 laparoscopic procedures that constituted 73.4% of all cholecystectomies. Five hundred and forty-two patients (13.2%) were qualified for laparoscopic procedure despite manifesting typical symptoms of acute cholecystitis in ultrasound examination, which comprise: thickening of the gallbladder wall of > 3 mm, inflammatory infiltration in the Calot's triangle region, gallbladder filled with stagnated or purulent contents and mural or intramural effusion.ResultsIn the group of operated patients, the conversion was necessary in 130 patients, i.e. in 24% of cases in comparison with 3.8% of patients with uncomplicated cholecystolithiasis (without the signs of inflammation). The conversion most frequently occurred when the assessment of the anatomical structures of the Calot's triangle was rendered more difficult due to local inflammatory process, mural effusion and thickening of the gallbladder wall of >5 mm. The remaining changes occurred more rarely.ConclusionsBased on imaging scans, the most common causes of conversion included inflammatory infiltration in the Calot's triangle region, mural effusion and wall thickening to > 5 mm. The classical cholecystectomy in acute cholecystitis should be performed in patients with three major local complications detected on ultrasound examination and in those, who manifest acute clinical symptoms.

Laparoscopic cholecystectomy is more difficult after a previous endoscopic retrograde cholangiography

BackgroundEndoscopic retrograde cholangiography (ERCP) with endoscopic sphincterotomy (ES) followed by a laparoscopic cholecystectomy (LC) is generally accepted as the treatment of choice for patients with choledochocystolithiasis who are eligible for surgery. Previous studies have shown that LC after ES is associated with a high conversion rate. The aim of the present study was to assess the complexity of LC after ES compared with standard LC for symptomatic uncomplicated cholecystolithiasis. MethodsThe study population consisted of two patient cohorts: patients who had undergone a previous ERCP with ES for choledocholithiasis (PES) and patients with cholecystolithiasis who had no previous intervention prior to LC (NPES). ResultsThe PES group consisted of 93 patients and the NPES group consisted of 83 consecutive patients. Patients in the PES group had higher risks for longer [more than 65 min, odds ratio (OR) = 4.21 (95% confidence interval (CI) 1.79–9.91)] and more complex [higher than 6 points, on a 0–10 scale, OR 3.12 (95% CI 1.43–6.81)] surgery. The conversion rate in the PES and NPES group (6.5% versus 2.4%, respectively) and the complication rate (12.9% versus 9.6%, respectively) were not significantly different. DiscussionA laparoscopic cholecystectomy after ES is lengthier and more difficult than in uncomplicated cholelithiasis and should therefore be performed by an experienced surgeon.

Transcylindrical gas-free cholecystectomy for the treatment of cholelithiasis, cholecystitis, and choledocholithiasis

Laparoscopic cholecystectomy (LC) has become the standard for treatment of uncomplicated cholecystolithiasis. However, in cases of cholecystitis or cholecysto-choledocholithiasis, technical and skill requirements may make questionable the convenience of laparoscopy. Transcylindrical cholecystectomy (TC) is a modified minilaparotomy, performed gas-free through a single cylinder 3.8 cm in diameter and 10.0 cm in length. Our study objective has been to assess the efficacy and potential advantages of TC in the treatment of cholelithiasis, cholecystitis, and cholecholithiasis through an efficacy, prospective, and longitudinal study. TC was carried out in 364 consecutive patients including 78 acute cholecystitis, 37 acute biliary pancreatitis, and 48 suspected choledocholithiasis. Transcystic cholangiography was selectively attempted in 74 patients (20.3%) and successfully obtained in all but one patient. Twenty-six patients (7.1%) underwent transcylindrical common duct exploration (and calculi removal) through a choledochotomy. Operation was converted into subcostal laparotomy in other 23 patients (5.9%). In our series, there were no injuries to the main bile ducts or hemorrhagic accidents. Operating times in minutes (SD) were (i) "simple cholecystectomy" without cholangiography n = 237: 43.5 (13.3), with cholangiography n = 30: 64.2 (20.7), (ii) "cholecystitis" n = 78: 66.2 (28.7), and (iii) "choledocholithiasis" n = 26: 117.0 (24.6). Postoperative complications for the respective patients in groups i, ii, and iii were (a) wound infection: 5 (1.9%), 0 and 0; (b) bile leaks: 2 (0.75%; one causing death), 2 (0.75%) and 0; (c) reoperation for bleeding: 1 (0.4%), 0 and 1 (3.8%); and (d) residual stones in the main bile ducts: 0, 0 and 1 (3.8%). TC has been proved to be applicable, efficient, and safe for the treatment of cholelithiasis and its complications.

Arterial cholesterol and DNA contents in relation to serum lipids and apolipoproteins: Studies on cystic artery biopsies

Though various relationships between serum lipoprotein levels and risk for atherosclerotic disease have been shown there are only a few studies on the relationships between serum lipoprotein levels and the lipid contents of the arterial wall. This study presents cholesterol and DNA contents of arterial tissue from biopsies of the cystic artery in 23 patients with uncomplicated cholecystolithiasis. Serum levels of cholesterol, triglycerides, alphalipoprotein cholesterol, apoA-I, A-II and B were determined, and the relationships between artery and serum variables were calculated. There was a positive correlation between serum apoB and the arterial cholesterol, normalized to the DNA contents (r = 0.43, P < 0.05). There was a tendency towards an inverse correlation between the α-lipoprotein cholesterol levels and the arterial cholesterol (r = −0.39, P < 0.10). There were no significant correlations between serum apoA-I or A-II and the arterial cholesterol contents. These data indicate that deposition of cholesterol in the arterial wall is related to the serum level of apoB, with higher levels of arterial cholesterol at higher serum levels of apoB. Earlier observations of an inverse correlation between alphalipoprotein cholesterol and arterial cholesterol could, however, not be conclusively confirmed.