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Previous Gallstone Research: 2002-2006   
The Gallstones File also contains summaries of past research that has shown promise and may still be standard practice among many physicians. To download earlier research findings on Gallstones, click HERE.
  

Latest Research on Gallstones
     
Ann R Coll Surg Engl. 2008 Jul;90(5):394-7.
Removing symptomatic gallstones at their first emergency presentation.
Anwar HA, Ahmed QA, Bradpiece HA.
Department of General and Laparoscopic Surgery, Princess Alexandra Hospital, Harlow, UK. hannyanwar@yahoo.co.uk

INTRODUCTION: Early operations for symptomatic gallstones are gaining favour as the complication rate is thought to be lower and it reduces the overall morbidity. This study was performed to clarify how frequently early operations were being performed and what benefits resulted. PATIENTS AND METHODS: Case notes of 171 patients who underwent laparoscopic cholecystectomy at Princess Alexandra Hospital Harlow were retrospectively reviewed. They were grouped according to their initial diagnosis (cholelithiasis, acute cholecystitis) and the delay to surgery (early, interval). Forty-one cases were excluded as they either had incomplete notes or the initial diagnosis was a different manifestation of gallstones such as pancreatitis. Those receiving interval operations were then grouped according to the mode of their initial presentation. A total of 130 case notes were analysed. RESULTS: The delay for an interval operation was 3-6 months compared with less than 2 weeks for early operations. Of patients with acute cholecystitis, 43% had early operations but only 12% of patients with cholelithiasis. Waiting for interval operations was associated with multiple re-admissions equivalent to an average of one extra presentation to accident and emergency per patient. This was particularly marked if the initial presentation was to accident and emergency rather than outpatients (P = 0.003). Complication rates were also higher in the interval group. CONCLUSIONS: Early cholecystectomy on the next available list is likely to reduce morbidity and the long-term in-patient burden so should be recommended for all patients presenting as an emergency with symptomatic gallstones.

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ANZ J Surg. 2008 Jul;78(7):579-82.
Endoscopic management of recurrent primary bile duct stones.
Kohn GP, Hassen AS, Banting SW, Mackay S, Cade RJ.
Hepatobiliary/Upper Gastrointestinal Surgical Unit, Box Hill Hospital, Melbourne, Victoria, Australia. Geoffrey_Kohn@med.unc.edu

BACKGROUND: The management of recurrent choledocholithiasis today remains as challenging as in the pre-endoscopic era. Between 2 and 7% of affected patients have historically required surgical intervention for the treatment of recurrent or retained choledocholithiasis and of these, as many as 24% develop biliary complications. To avoid surgery, repeated endoscopic management of the problem has been suggested. In this study, we evaluate our policy of repeated endoscopic management of recurrent primary bile duct stones. METHODS: This study examined a cohort of nine patients identified from a prospective database with recurrent choledocholithiasis. Demographic, clinical and investigative details were recorded and data were analysed. Complications were determined from a review of the patient's file. RESULTS: There were nine patients and 66 procedures were carried out. Mean age at time of first endoscopy was 70.1 years (36-91 years). Three patients were of male sex (33.3%). The mean number of endoscopies carried out per patient was 7.3 (3-13). Failure to completely clear the duct occurred in 36.4% of all endoscopies. There were no periprocedural complications. CONCLUSION: Repeated endoscopic stone extraction by endoscopic retrograde cholangiopancreatography when required is a safe policy. However, this technique will only provide temporary relief from primary duct stones and repeated endoscopic treatment, again safe, will be required.

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Tidsskr Nor Laegeforen. 2008 Jun 12;128(12):1384-7.
[Surgery for gallstone disease in two time periods]
[Article in Norwegian]
Naess F, Oerleke A, Tjomsland O.
Sykehuset Asker og Baerum Postboks 83 1309 Rud. frode.naess@sabhf.no

BACKGROUND: Laparoscopic cholecystectomy was introduced at our institution in October 1990. The perioperative results from 1.1.1991 to 31.12.1995 (first period) are compared with those from 1.1.2001 to 31.12.2005 (second period). MATERIAL AND METHODS: All patients who had undergone surgical treatment for gallstone disease at Asker and Baerum Hospital in the first or second period were included. Data retrieval was partly prospective and partly retrospective in both periods. RESULTS: Significantly more patients underwent cholecystectomy in the second than in the first period (843 vs. 342), but the proportion of patients that were operated on an acute indication was lower in the second (91 of 843) than in the first (79 of 342) period, p < 0.001. This coincided with a decline in the number of cholecystectomy patients with complications to gallstone disease (pancreatitis, cholangitis or acute cholecystitis) and a significant reduction of operating time and duration of hospital stay after the operation, whereas the number of per- and postoperative complications remained unchanged. INTERPRETATION: The number of patients operated for gallstone disease during the first 15 years of laparoscopic surgery has increased significantly. Fewer patients with acute cholecystitis are treated surgically, and the proportion of patients suffering from pancreatitis, cholangitis or acute cholecystitis before surgery appears to have declined.

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Harefuah. 2008 Apr;147(4):344-9, 373, 372.
[Innovations in the medical treatment of gallstones and fatty liver: FABACs (Fatty Acid Bile Acid Conjugates)]
[Article in Hebrew]
Keizman D, Goldiner I, Leikin-Frenkel A, Konikoff FM.
Department of Gastroenterology, the Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Gallstones and fatty liver are common disorders in the Western world, largely due to dietary and life style factors. Currently, laparoscopic cholecystectomy is the main treatment option for gallbladder stones. Surgery is, however, expensive and may cause morbidity and even mortality. An effective medical treatment would be desirable, especially in patients with mild to moderate symptoms or high surgical risk. Currently, the bile acid UDCA (Ursodeoxycholic acid) is used for oral dissolution treatment and for the prevention of cholelithiasis in selected cases. However, the major limitations of this treatment are its low efficacy, slow action and stone recurrence. Recently, phospholipids rather than bile salts were realized to be the major natural cholesterol solubilizers in bile. They also possess anti-crystallizing activity. The sn-2 fatty acid of the phospholipids molecule was found to be particularly important. This was the background for the development of FABACs (Fatty Acid and Bile Acid Conjugates), which are novel synthetic lipid molecules. These molecules are composed of fatty acids (with chain lengths from C-14 to C-22), that are linked to cholic acid, by an amide bond at position 3. In vitro and in vivo studies (in mice) have shown that FABACs can prevent the formation of cholesterol crystals and dissolve existing ones. C20-FABAC, when given orally, is absorbed and secreted into bile. It was also found to have a series of beneficial effects on cholesterol metabolism. The main treatment for patients with fatty liver consists of lifestyle and diet modifications, which are associated with low compliance. Currently there is no effective medical treatment for this disease. In the FABAC studies on the prevention and dissolution of gallstones in laboratory animals, it was observed that this treatment also prevents the formation of diet induced fatty liver. Further prospective studies found that FABACs indeed prevent/decrease the formation of fatty liver induced by high fat diet. This influence was observed in all the fatty liver parameters (histology as well as chemical analysis), and in different animal strains. Based on these findings, FABACs seem to be good candidates for the medical treatment of hepatobiliary disorders, in particular gallstones and fatty liver disease.

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Surg Endosc. 2008 Feb 13 [Epub ahead of print]
Timing of cholecystectomy after endoscopic sphincterotomy for common bile duct stones.
Schiphorst AH, Besselink MG, Boerma D, Timmer R, Wiezer MJ, van Erpecum KJ, Broeders IA, van Ramshorst B.
Department of Surgery, St. Antonius Hospital, P.O. Box 2500, 3430 EM, Nieuwegein, The Netherlands, A.Schiphorst@umcutrecht.nl.

BACKGROUND: According to the literature, the conversion rate for laparoscopic cholecystectomy (LC) after endoscopic sphincterotomy (ES) for cholecystodocholithiasis reaches 20%, at least when LC is performed 6 to 8 weeks afterward. It is hypothesized that early planned LC after ES prevents recurrent biliary complications and reduces operative morbidity and hospital stay. METHODS: All consecutive patients who underwent LC after ES between 2001 and 2004 were retrospectively evaluated. Recurrent biliary complications during the waiting time for LC, conversion rate, postoperative complications, and hospital stay were documented. RESULTS: This study analyzed 167 consecutive patients (59 men) with a median age of 54 years. The median interval between ES and LC was 7 weeks (range, 1-49 weeks). During the waiting time for LC, 33 patients (20%) had recurrent biliary complications including cholecystitis (n = 18, 11%), recurrent choledocholithiasis (n = 9, 5%), cholangitis (n = 4, 2%),
and biliary pancreatitis (n = 2, 1%). Of these 33 patients, 15 underwent a second endoscopic retrograde cholangiography (ERC). The median time between ES and the development of recurrent complications was 22 days (range, 3-225 days). Most of the biliary complications (76%) occurred more than 1 week after ES. Conversion to open cholecystectomy occurred for 7 of 33 patients with recurrent complications during the waiting period, compared with 13 of 134 patients with an uncomplicated waiting period (p = 0.14). This concurred with doubled postoperative morbidity (24% vs 11%; p = 0.09) and a longer hospital stay (median, 4 vs 2 days; p < 0.001). CONCLUSION: In this retrospective analysis, 20% of all patients had recurrent biliary complications during the waiting period for cholecystectomy after ES. These recurrent complications were associated with a significantly longer hospital stay. Cholecystectomy within 1 week after ES may prevent recurrent biliary complications in the majority of cases and reduce the postoperative hospital stay.

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J Laparoendosc Adv Surg Tech A. 2008 Feb;18(1):127-30.
Laparoscopic cholecystectomy in the pediatric population.
St Peter SD, Keckler SJ, Nair A, Andrews WS, Sharp RJ, Snyder CL, Ostlie DJ, Holcomb GW.
Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA.

BACKGROUND: The experience with laparoscopic cholecystectomy in children trails the adult numbers and remains underreported. Therefore, we reviewed our experience with this approach. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

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Gastrointest Endosc. 2008 Feb;67(2):364-8.
Commitment, confirmation, and clearance: new techniques for nonradiation ERCP during pregnancy (with videos).
Shelton J, Linder JD, Rivera-Alsina ME, Tarnasky PR.
Digestive Health Associates of Texas, Methodist Dallas Medical Center, Dallas, Texas, USA.

BACKGROUND: Symptomatic choledocholithiasis during pregnancy can be treated with ERCP (endoscopic retrograde cholangiopancreatography) , but fluoroscopy may pose a risk to the fetus. Nonradiation ERCP may be a safer form of treatment, but its performance has not been optimized. OBJECTIVES: The purpose of this study was to evaluate new methods of nonradiation ERCP during pregnancy, including wire-guided cannulation techniques to achieve bile-duct access without the use of fluoroscopy, and the use of peroral choledochoscopy to confirm ductal clearance. STUDY DESIGN: A retrospective review of consecutive ERCPs performed on pregnant women. SETTING: Urban referral hospital. PATIENTS: Pregnant women with symptomatic choledocholithiasis. INTERVENTIONS: All patients underwent therapeutic ERCP without any use of fluoroscopy. Endoscopist-controlled wire-guided cannulation was performed to achieve biliary access. MAIN OUTCOME MEASUREMENTS: The rate of successful biliary cannulation and short-term outcomes. LIMITATIONS: ERCP procedures were performed by a single endoscopist. RESULTS: Successful bile-duct cannulation with sphincterotomy and the removal of biliary stones or sludge was performed without fluoroscopy in 21 pregnant women. There was one case of mild post-ERCP pancreatitis. Choledochoscopy confirmed ductal clearance in 5 cases. CONCLUSIONS: Nonradiation ERCP is a safe and effective treatment for symptomatic choledocholithiasis during pregnancy. Wire-guided biliary cannulation and choledochoscopy may enhance the performance of ERCP in this setting.

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Rev Prat. 2007 Dec 15;57(19):2123-8.
[Current management of uncomplicated gallstones and choledocolithiasis]
[Article in French]
Mabrut JY, Ducerf C, Baulieux J.
Service de chirurgie générale digestive et de la transplantation hépatique, hôpital de la Croix-Rousse, 69317 Lyon Cedex 04. jean-yves.mabrut@chu-lyon.fr

In case of clinical suspicion of symptomatic bile duct stones, percutaneous ultrasonography and liver function tests should be performed as a primary evaluation. In the absence of predictive factors of common bile duct stones, laparoscopic cholecystectomy represents the treatment of choice for symptomatic gallstones. In case of clinical, radiological or biochemical suspicion of common bile duct stones, endoultrasonography or magnetic resonance cholangiography are efficient to confirm choledocolithiasis. In this instance, surgical approach permits simultaneous treatment of both choledocolithiasis and cholecystolithiasis while endoscopic sphincterotomy has to be followed by secondary cholecystectomy in a 2-stage procedure. Laparoscopic common bile duct exploration should be preferred to endoscopic clearance of the common bile duct but requires specific equipment and surgical experience.

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Endoscopy. 2007 Dec;39(12):1076-81.
Prospective multicenter quality assessment of endotherapy of biliary stones: does center volume matter?
Masci E, Minoli G, Rossi M, Terruzzi V, Comin U, Ravelli P, Buffoli F, Lomazzi A, Dinelli M, Prada A, Zambelli A, Fesce E, Lella F, Fasoli R, Perego EM, Colombo E, Bianchi G, Testoni PA.
Gastroenterology and Endoscopic Unit, S. Raffaele Hospital, Milan, Italy. masci.enzo@hsr.it

BACKGROUND AND STUDY AIMS: To study the effectiveness of endoscopic treatment for biliary stones in a large case list of patients treated in units with different experience and different workloads in a region of northern Italy. PATIENTS AND METHODS: We prospectively studied 700 patients undergoing endoscopic retrograde cholangiopancreatography or sphincterotomy, in 14 units (> or < 200 examinations/year), for their first treatment of biliary stones. The difficulty of the examinations, the results in terms of clearance of the stones, and the late outcomes (24 months) were recorded. A questionnaire (GHAA-9modified) was administered 24 hours and 30 days after the procedure to measure patient satisfaction. RESULTS: There were six units with a heavy workload and eight with a light schedule. There were 176 (25.1 %) difficult examinations (Schutz grades 3, 4, and 5). Stones were found in 580 (82.9 %) and were cleared in 504 of these patients (86.9 %). No differences were observed in the clearance of stones for the different groups of difficulty and high- and low-volume centers. Over the 24-month follow-up period, 96 patients (13.7 %) complained of recurrent symptoms and 44 (6.3 %) had proof of stones. In all, 603 questionnaires were evaluable and more than 80 % of patients expressed satisfaction. CONCLUSIONS: Our findings confirm the effectiveness of endoscopic treatment of biliary stones. However, the number of patients with symptoms (13.7) after 24 months, with or without persistence of stones, was not insignificant. It is feasible to record patient satisfaction, and in this series patients stated they were satisfied. Criticism mostly concerned pain control and explanations provided before the examination.

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HPB (Oxford). 2007;9(2):125-30.
Selective MRCP in the management of suspected common bile duct stones.
Mercer S, Singh S, Paterson I.
Queen Alexandra Hospital Portsmouth UK.

Background. It is controversial whether selective endoscopic sphincterotomy or routine laparoscopic bile duct exploration is the optimal treatment for choledocholithiasis. Magnetic resonance cholangio-pancreatography (MRCP) is a safe and accurate imaging modality; this study evaluated its use in a clinical algorithm for the management of suspected choledocholithiasis. Patients and methods. Consecutive patients presenting with suspected common bile duct (CBD) stones were managed according to an algorithm involving the selective use of MRCP to identify patients who required endoscopic sphincterotomy and bile duct clearance. Following radiological demonstration of a clear CBD, all patients were considered for cholecystectomy. Results. From 157 consecutive patients, 68 proceeded straight to endoscopic sphincterotomy, which was therapeutic in 59. Of 89 who underwent MRCP, choledocholithiasis was demonstrated in 29; subsequent endoscopic sphincterotomy was therapeutic in 22. MRCP demonstrated a clear CBD in the remaining 60 patients. Seventy-four patients subsequently underwent cholecystectomy, with a conversion rate of 9% and a median postoperative stay of 1 day. There were no instances of post-sphincterotomy pancreatitis or haemorrhage requiring transfusion. Conclusion. An algorithm involving selective MRCP with endoscopic sphincterotomy is a safe, effective means of managing suspected choledocholithiasis, particularly where the expertise, equipment or theatre time for laparoscopic bile duct exploration is not routinely available.

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Acta Anaesthesiol Scand. 2007 Dec 10 [Epub ahead of print]
Laparoscopic vs. small incision cholecystectomy: Implications for pulmonary function and pain. A randomized clinical trial.
Keus F, Ahmed Ali U, Noordergraaf GJ, Roukema JA, Gooszen HG, van Laarhoven CJ.
Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands.

Background: Upper abdominal surgery, including laparoscopic cholecystectomy (LC), is associated with post-operative pulmonary dysfunction. LC has, by consensus, become the treatment of choice for symptomatic cholecystolithiasis. The small-incision cholecystectomy (SIC), a procedure which does not require a pneumoperitoneum threatens to be lost to clinical practice even though there is evidence of equality. We hypothesized that the SIC technique should be equal and might even be superior to the LC when considering post-operative pulmonary function due to the short incision length. Methods: A single-centre, randomized clinical trial was performed including patients scheduled for elective cholecystectomy. Pulmonary flow-volume curves were measured pre-operatively, post-operatively, and at follow up. Blood gas analyses were measured pre-operative, in the recovery phase and on post-operative day 1. Anaesthesia, analgesics, and peri-operative care were standardized by protocol. Post-operatively, patients and caregivers were blinded to the procedure. Results: A total of 257 patients were analysed. There was one pulmonary complication (pneumonia) in the LC group. In both groups, similar reductions of approximately 20% in pulmonary function parameters occurred, with complete recovery to pre-operative values. Patients in the SIC group consumed more analgesia when compared with the LC group without impact on blood gas analysis. Patients converted to a conventional open technique showed significant differences in six of the eight parameters in pulmonary function tests. Conclusion: When evaluated with strict methodology and standardization of care, no clinically relevant differences were found between SIC and LC regarding pulmonary function. Our results suggest that the popularity of the laparoscopic technique cannot be attributed to pulmonary preservation.

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Surg Endosc. 2007 Dec 11 [Epub ahead of print]
Laparoscopic versus small-incision cholecystectomy: Health status in a blind randomised trial.
Keus F, de Vries J, Gooszen HG, van Laarhoven CJ.
Department of Surgery, Diakonessenhuis, Bosboomstraat 1, 3582, KE, Utrecht, The Netherlands, erickeus@hotmail.com.

BACKGROUND: Gallstones are a major cause of morbidity, and cholecystectomy is a commonly performed procedure. Minimal invasive procedures, laparoscopic cholecystectomy (LC) and small-incision cholecystectomy (SIC), have replaced the classical open cholecystectomy. No differences have been found in primary outcome measures between LC and SIC, therefore secondary outcome measures have to be considered to determine preferences. The aim of our study was to examine health status applying evidence-based guidelines in LC and SIC in a randomised trial. METHODS: Patients with symptomatic cholecystolithiasis were included in a blind randomised trial. Operative procedures, anaesthesia, analgesics and postoperative care were standardised in order to limit bias. Questionnaires were filled in preoperatively, the first day postoperatively, and at outpatients follow-up at 2, 6 and 12 weeks. In accordance with evidence-based guidelines, the generic short form (SF-36) and the disease-specific gastrointestinal quality-of-life index (GIQLI) questionnaires were used in addition to the body image questionnaire (BIQ). RESULTS: A total of 257 patients were randomised between LC (120) and SIC (137). Analyses were performed according to intention-to-treat (converted procedures included) and also distinguishing converted from minimal invasive (nonconverted) procedures. Questionnaires were obtained with a response rate varying from 87.5% preoperatively to 77.4% three months postoperatively. Except for two time-specific measurements in one SF-36 subscale, there were no differences between LC and SIC. There were significant differences in several subscales in all three questionnaires comparing minimal invasive versus converted procedures. CONCLUSIONS: Applying adequate methodological quality and evidence-based guidelines (by using SF-36 and GIQLI), there are no significant differences in health status between LC and SIC.

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Surg Endosc. 2007 Dec 11 [Epub ahead of print]
The use of laparoscopic subtotal cholecystectomy for complicated cholelithiasis.
Philips JA, Lawes DA, Cook AJ, Arulampalam TH, Zaborsky A, Menzies D, Motson RW.
ICENI Centre, Colchester General Hospital, Colchester, CO4 5JL, UK, bissue@genie.co.uk.

BACKGROUND: The risk of damage to the bile duct and structures in the hilum of the liver is significant when Calot's triangle cannot be safely dissected during laparoscopic cholecystectomy, and conversion to an open procedure often is performed. This is more common during emergency surgery, but may not render the procedure any easier. Traditionally, open subtotal cholecystectomy was performed, but with the advent of laparoscopic surgery, this has fallen from favor. The authors report their experience using laparoscopic subtotal cholecystectomy to avoid bile duct injury and conversion in difficult cases. METHODS: Laparoscopic subtotal cholecystectomy, performed when the cystic duct cannot be identified safely, consists of resecting the anterior wall of the gallbladder, removing all stones, and placing a large drain into Hartmann's pouch. The notes for all patients who underwent a laparoscopic subtotal cholecystectomy between 1 September 2001 and 31 December 2004 were retrospectively analyzed. RESULTS: Subtotal cholecystectomy was performed in 26 cases including 13 emergency and 13 elective procedures. The median age of the patients (15 women and 11 men) was 68 years (range, 36-86 years). The indications were severe fibrosis in 16 cases, inflammatory mass or empyema in 8 cases, and gangrenous gallbladder or perforation in 2 cases. The median postoperative inpatient stay was 5 days (range, 2-26 days). Five patients underwent postoperative endoscopic retrograde cholangiopancreatography: four for persistent biliary leak and one for a retained common bile duct stone. One patient required laparotomy for subphrenic abscess, and one patient (American Society of Anesthesiology [ASA] grade 4, presenting with biliary peritonitis) died 2 days postoperatively. One patient required a subsequent completion laparoscopic cholecystectomy for a retained gallstone. One patient had a chest infection, and two patients experienced port-site hernias. CONCLUSIONS: Laparoscopic subtotal cholecystectomy is a viable procedure during cholecystectomy in which Calot's triangle cannot be dissected. It averts the need for a laparotomy.

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J Am Coll Surg. 2007 Dec;205(6):762-6. Epub 2007 Sep 17.
Early cholecystectomy for mild to moderate gallstone pancreatitis shortens hospital stay.
Rosing DK, de Virgilio C, Yaghoubian A, Putnam BA, El Masry M, Kaji A, Stabile BE.
Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA 90509, USA.

BACKGROUND: The timing of cholecystectomy in gallstone pancreatitis remains controversial. We hypothesized that in patients with mild to moderate gallstone pancreatitis (three or fewer Ranson's criteria), performing early cholecystectomy before resolution of laboratory or physical examination abnormalities would result in shorter hospitalization, without adversely affecting outcomes. STUDY DESIGN: An observational study consisting of a retrospective and a prospective group was conducted. For the prospective group, a deliberate policy of early cholecystectomy (less than 48 hours from admission) was used. The primary end point was total length of hospital stay. Secondary endpoints were time from admission to definitive operation, need for endoscopic retrograde cholangiography, and major complications (organ failure and death). RESULTS: Group I consisted of 177 patients retrospectively reviewed, and Group II was composed of 43 patients prospectively followed. There were no differences between the two groups with respect to demographics. With respect to admission laboratory values, there was a significant difference in median serum amylase, but there were no differences in median serum levels of lipase, total bilirubin, albumin, white blood cell count, or Ranson's score. The median length of hospital stay was 7 days in Group I versus 4 days in Group II (p=or< 0.001). Median time from admission to cholecystectomy was 5 days in Group I versus 2 days in Group II (p=or< 0.0001). Complication rates were similar and there were no deaths in either group. CONCLUSIONS: In patients with mild to moderate gallstone pancreatitis, a policy of early cholecystectomy resulted in a significantly reduced length of hospital stay with no increase in complications or mortality.

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Surg Endosc. 2007 Dec;21(12):2317-21. Epub 2007 Oct 18.
Laparoscopic common bile duct stone clearance with flexible choledochoscopy.
Topal B, Aerts R, Penninckx F.
Department of Abdominal Surgery, University Hospital Leuven, Herestraat 49, 3000, Leuven, Belgium. baki.topal@med.kuleuven.be

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is as safe and efficient as endoscopic retrograde cholangiopancreatography (ERCP) in achieving bile duct clearance from stones. No clear guidelines are available on LCBDE with respect to indications for trans-cystic approach versus choledochotomy, or regarding when to use either flexible choledochoscopy (FCD) or intraoperative cholangiography (IOC) guidance. METHODS: From January 2001 until November 2006, 113 consecutive patients with common bile duct stones (CBDS) and gallbladder in situ were enrolled in a prospective non-randomized study to undergo laparoscopic cholecystectomy with LCBDE on an intention-to-treat basis. Twenty-three patients were aged 80 years or older with severe comorbidity. Preoperative ERCP with attempted stone clearance was performed in 24 patients. Laparoscopic common bile duct exploration was attempted for CBDS in the presence of acute cholecystitis in 24 patients. Laparoscopic common bile duct exploration was performed via the trans-cystic approach in 83 patients and via choledochotomy in 30 patients. Flexible choledochoscopy was used in 79 patients and IOC guidance in 34 patients. RESULTS: No mortality occurred. Postoperative complications were encountered in nine patients. Laparoscopic stone clearance of the bile duct was successful in 91.8% of the patients. Median length of hospital stay (LOS) was two days (range, 0 to 24 days) after trans-cystic LCBDE and six days (range, 2 to 34 days) after stone clearance via choledochotomy (p < 0.0001). Choledochotomy was performed for CBDS measuring an average of 11.5 mm (range, 5 to 30 mm) in diameter while trans-cystic LCBDE was successful for stones measuring an average of 5 mm (range, 2 to 14 mm) (p < 0.0001). Mean duration of surgery was 75 minutes (range, 30 to 180 minutes) when FCD was used, and 107 minutes (range, 45 to 240 minutes) in patients undergoing LCBDE under IOC guidance (p < 0.0001). CONCLUSION: Laparoscopic cholecystectomy and LCBDE with stone extraction can be performed with high efficiency, minimal morbidity and without mortality. A trans-cystic approach is feasible in most patients, whereas choledochotomy should be restricted to large bile duct stones that cannot be extracted through the cystic duct. The use of flexible choledochoscopy is preferable to IOC guidance.

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J Pediatr Surg. 2007 Aug;42(8):1333-6.
Is there a safe advantage in performing outpatient laparoscopic cholecystectomy in children?
Mendez K, Sabater R, Chinea E, Lugo-Vicente H.
U.P.R. School of Medicine, San Juan, Puerto Rico.

BACKGROUND: Laparoscopic cholecystectomy, the standard procedure for removing the sick gallbladder of children, is generally performed leaving the child overnight in the hospital. PURPOSE: This study aimed to determine if there is a safe advantage in performing laparoscopic cholecystectomy as an outpatient procedure while setting the clinical parameters for those who will benefit from in-hospital stay. METHODS: Thirty-five patients were selected for the study and were divided into group A, if the outpatient procedure was done, and group B, if the child was left overnight in the hospital. Retrospective review of medical charts was performed. Statistical significance was defined as P < .05. RESULTS: Group A consisted of 13 patients and group B of 22 patients. All patients in group A left the hospital the same day of surgery. Distribution by age and sex in the groups was not statistically different. Preoperative symptoms of vomiting were statistically significantly higher in group B. Presence of an associated medical condition was higher in the in-hospital patients. Concomitant procedures, blood loss estimates, and duration of surgery showed no statistical difference. No child was readmitted after release from the hospital. Pre-, intra-, and postoperative pain management were the same in all patients. Mean postoperative stay and medical charges were statistically significant between the groups. CONCLUSIONS: Laparoscopic cholecystectomy can safely be done as an outpatient procedure. Children with a complicated gallbladder disease process or associated medical condition benefit from an overnight stay. Perioperative pain management is crucial in all cases. Reduced hospital stay and medical charges are significant advantages in performing laparoscopic cholecystectomy as an outpatient procedure.

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Int J Surg. 2007 Aug;5(4):255-9. Epub 2006 Dec 28.
Day case laparoscopic cholecystectomy is safe and feasible: a case controlled study.
Rathore MA, Andrabi SI, Mansha M, Brown MG.
Department of Surgery, Causeway Hospital, Newbridge Road, Coleraine BT52 1HS, Northern Ireland, UK. munirrathore@doctors.org.uk <munirrathore@doctors.org.uk>

BACKGROUND: Day case laparoscopic cholecystectomy (DC-LC) is being practised in the USA and at sporadic centres in the UK including our department. The aim was to evaluate the admission rate after DC-LC. PATIENTS AND METHODS: Prospectively collected data was analysed retrospectively. The case notes of all patients were retrieved from the medical records and reviewed individually. Inclusion criteria for DC-LC were cholelithiasis, non-acute cholecystitis, ASA I-III and informed consent. Standard laparoscopic cholecystectomy was performed. All patients had anti-DVT prophylaxis (pneumatic compression and enoxaparin), per-operative antibiotic, oro-gastric tube, paracetamol suppository and local anaesthetic to all wounds. They were discharged the same day. The end point was 6-week follow-up (86% overall). RESULTS: Over a 32-month period, 164 consecutive patients with symptomatic cholelithiasis and ASA score of III or less were included. M:F was 1:5 and median age 45y. There were two conversions. The direct admission rate (DAR) was 26/164 (14%). The indication for direct admission included observation alone (7/26), wound pain (6/26), nausea (3/26), suction drain (2/26) and operation in the afternoon (2/26). Six (3.6%) required re-admission. One had a cystic artery pseudo-aneurysm presenting with colonic bleeding and another with an injury to CBD. One had post-operative mild pancreatitis and three had wound pain and bruising. Fourteen out of 41 were admitted in the >55y age group compared to 12/123 from <55y age group (p=0.00054). CONCLUSION: DC-LC is safe and feasible in non-acute patients with symptomatic cholelithiasis. Over-55y age group had a higher chance of admission, mainly due to caution.

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Obes Surg. 2007 Jun;17(6):747-51.
Is routine cholecystectomy indicated for asymptomatic cholelithiasis in patients undergoing gastric bypass?
Fuller W, Rasmussen JJ, Ghosh J, Ali MR.
Department of Surgery, University of California, Davis, Sacramento, CA 95817, USA.

BACKGROUND: The purpose of this study was to evaluate the natural history of patients undergoing Roux-en-Y gastric bypass (RYGBP) with known asymptomatic cholelithiasis in whom prophylactic cholecystectomy was not performed at the time of surgery. METHODS: The records of 144 consecutive patients from a single year experience in RYGBP surgery at the University of California, Davis Medical Center were reviewed. Patients undergoing RYGBP were routinely screened for cholelithiasis by ultrasound. Patients who did not have cholecystectomy were managed with ursodiol for 6 months postoperatively. RESULTS: 13 males (9.0%) and 131 females (91%) underwent RYGBP. The mean age was 43 years (SD 8.55), and mean BMI was 46 kg/m2 (SD 6.5). The comorbidities of our patient population included diabetes (14%), hypertension (48%), gastroesophageal reflux disease (50%), dyslipidemia (35%), obstructive sleep apnea (31%), and musculoskeletal complaints (69%). 22 patients were diagnosed with cholelithiasis by ultrasonography preoperatively. 9 of these patients (41%) were symptomatic and underwent concurrent cholecystectomy and RYGBP. The remaining 13 patients (59%) had asymptomatic cholelithiasis preoperatively but did not undergo cholecystectomy at the time of surgery. Only one of these asymptomatic patients eventually developed symptoms necessitating cholecystectomy at up to 1 year follow-up. CONCLUSIONS: Our data suggest that it may not be absolutely indicated to perform prophylactic cholecystectomy at the time of RYGBP surgery for asymptomatic cholelithiasis. We believe that this phenomenon needs to be further studied in a randomized trial.

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Pancreatology. 2007;7(2-3):131-41. Epub 2007 Jun 21.
When is pancreatitis considered to be of biliary origin and what are the implications for management?
Alexakis N, Lombard M, Raraty M, Ghaneh P, Smart HL, Gilmore I, Evans J, Hughes M, Garvey C, Sutton R, Neoptolemos JP.
Division of Surgery and Oncology, University of Liverpool, Royal Liverpool University Hospital, Liverpool, UK.

Acute pancreatitis is a disease caused by gallstones in 40-60% of patients. Identification of these patients is extremely important, since there are specific therapeutic interventions by endoscopic sphincterotomy and/or cholecystectomy. The combination of trans-abdominal ultrasound (stones in the gallbladder and/or main bile duct) and elevated serum alanine transaminase (circa >60 IU/l within 48 h of presentation) indicates gallstones as the cause in the majority of patients with acute pancreatitis. In the presence of a severe attack this is a strong indication for intervention by endoscopic sphincterotomy. The presence of a significant main bile duct dilatation is also strongly indicative of gallstones and should prompt the use of endoluminal ultrasonography: >8 mm diameter with gallbladder in situ, or >10 mm following cholecystectomy if aged <70 years and >12 mm, respectively, if > or = 70 years. In mild pancreatitis surgically fit patients should be treated by cholecystectomy, and intra-operative cholangiography, as pre-operative biliary imaging is not efficient in this setting. Patients who are not fit for cholecystectomy should undergo prophylactic endoscopic sphincterotomy to prevent further attacks. In the post-acute-phase, pancreatitis patients in whom the aetiology is uncertain should undergo endoluminal ultrasonography. Thisis the most sensitive method for the detection of cholelithiasis and choledocholithiasis and may reveal alternative aetiological factors such as a small ampullary or pancreatic cancer. A number of recent studies have shown that bile crystal analysis, a marker for microlithiasis, increases the yield of positive results over and above endoluminal ultrasonography, and should be considered as part of the modern investigative algorithm. (c) 2007 S. Karger AG, Basel and IAP.

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Surg Endosc. 2007 Jun 26; [Epub ahead of print]
Paediatric cholecystectomy: Shifting goalposts in the laparoscopic era.
Chan S, Currie J, Malik AI, Mahomed AA.
Department of Paediatric Surgery, Royal Alexandra Children’s Hospital, Dyke Road, Brighton, BN1 3JN, United Kingdom, anies.mahomed@bsuh.nhs.uk.

BACKGROUND: Laparoscopic cholecystectomy is the treatment of choice in symptomatic paediatric cholelithiasis. However, controversy exists about its role in asymptomatic cholelithiasis and biliary dyskinesia. We have reviewed the experiences of two UK paediatric centres with laparoscopic cholecystectomy over an 8.5 year period and critically evaluated the indications and outcomes of surgery. METHODS: Patients who underwent laparoscopic cholecystectomy by a single surgeon at the Royal Aberdeen and Royal Alexandra Hospitals between May 1996 to August 2003 and September 2003 to December 2005, respectively, were studied. Information was extracted from prospectively held databases and analysed. RESULTS: A total of 27 cholecystectomies were performed during the period of study. The mean age of patients was 11.7 years with a female preponderance. Symptomatic idiopathic cholelithiasis was the main indication for surgery (14). Cholecystectomy was also performed for haemolytic disease (3), acute recurrent pancreatitis of unknown cause (2), gallbladder trauma (1), and for asymptomatic calcific non-resolving stones (7). All patients were investigated with ultrasound scans with four patients undergoing magnetic resonance cholangiopancreatography (MRCP) for suspected common bile duct (CBD) stones. A standard four-port approach was used with the gallbladder extracted through the umbilical port. The mean operative time in the latter 13 cases was 105 minutes with a median postoperative stay of one day for the whole series. Histology revealed chronic cholecystitis in all but three cases. All patients were discharged after a six-month follow-up period. CONCLUSIONS: The advent of laparoscopy has resulted in an expansion of the traditional indications for cholecystectomy. MRCP is a useful investigation in selected children to exclude choledocholithiasis and avoid intraoperative cholangiography. There appears to be no clear correlation between histology and presenting symptoms. The natural history of asymptomatic gallstones in children is not known although a consensus is emerging to support cholecystectomy for all calcific non-resolving gallstones.

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Transplant Proc. 2007 Jun;39(5):1471-3.
Laparoscopic cholecystectomy in patients with mild cirrhosis and symptomatic cholelithiasis.
Curro G, Baccarani U, Adani G, Cucinotta E.
Department of Human Pathology, University of Messina, Strada Panoramica 30/A, Messina 98168, Italy. j.se.c@tiscali.it

BACKGROUND: Our goal was to support the emerging opinion that laparoscopic cholecystectomy is safe and well tolerated in selected cirrhotic patients with indications for surgery. We present our experience with 50 laparoscopic cholecystectomies performed on patients with mild cirrhosis. METHODS: We retrospectively reviewed and analyzed the outcomes of 50 laparoscopic cholecystectomies performed between January 1995 and May 2006 in patients with Child-Pugh A and B cirrhosis. RESULTS: Laparoscopic cholecystectomy was uneventful for 35 cirrhotic patients. Conversion to an open procedure was necessary in two Child-Pugh B patients with chronic cholelcystitis. One Child-Pugh B cirrhotic patient required blood transfusion. Postoperative complications occurred in 12 patients, including hemorrhage, wound infection, intra-abdominal collection, and cardiopulmonary complications. The mean postoperative stay was 5 days (range, 3 to 13). No deaths occurred. CONCLUSIONS: Laparoscopic cholecystectomy is a safe procedure in well-selected Child-Pugh A and B cirrhotic patients and should be the gold standard for patients with mild cirrhosis and symptomatic cholelithiasis.

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ANZ J Surg. 2007 Jun;77(6):440-5.
Laparoscopic bile duct exploration: results of 160 consecutive cases with 2-year follow up.
Taylor CJ, Kong J, Ghusn M, White S, Crampton N, Layani L.
Department of General Surgery, The Tweed Hospital, Northern Rivers, New South Wales, Australia. taylor_c@mac.com

BACKGROUND: Despite numerous reports showing the advantages of laparoscopic common bile duct exploration (LCBDE), many general surgeons, particularly those working outside of nonspecialist units, continue to rely heavily on endoscopic retrograde cholangiography with sphincterotomy (ERCP) to manage bile duct stones (BDS). This article investigates the performance of LCBDE when adopted as the preferred first-line management of both suspected and incidental BDS by general surgeons in a regional setting. METHODS: A retrospective review was conducted of all patients in whom LCBDE was attempted by a regional general surgical unit. The unit policy was to preferentially treat all incidental and suspected BDS (except in ascending cholangitis or severe pancreatitis) by LCBDE, with ERCP used only if unsuccessful. In addition to chart review, formal prospective follow up by telephone interview was carried out. RESULTS: A total of 160 consecutive patients with BDS (mean age 66.9 years, 65% suspected and 35% incidental) underwent attempted LCBDE between January 2000 and July 2005. Successful clearance was achieved in 84.3% according to chart review. However, four additional cases of retained choledocholithiasis shown by late telephone interview (median interval 2.5 years) yielded a more accurate clearance rate of 81.8%. Major morbidity occurred in 13.8%, including biliary leak in 7.5% and one late biliary stricture (0.6%). Median length of hospital stay was 4.8 days. In-hospital mortality was 0.6%. CONCLUSION: Laparoscopic common bile duct exploration remains an effective, efficient and safe first-line treatment of BDS even when carried out in regional nonspecialist units. In spite of the wide availability of ERCP, general surgeons should be encouraged to continue performing LCBDE in order to optimise patient care and maintain important surgical skills.

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World J Surg. 2007 Jun;31(6):1292-7. Epub 2007 Apr 15.
Gallstone ileus: diagnosis and management.
Ayantunde AA, Agrawal A.
Professorial Unit of Surgery, Nottingham City Hospital, Nottingham, United Kingdom. biodunayantunde@yahoo.co.uk

BACKGROUND: Gallstone ileus is a rare complication of cholelithiasis, mostly in the elderly. It accounts for 1%-4% of mechanical bowel obstruction and is associated with high morbidity and mortality. We present our experience of gallstone ileus and discuss current opinion as reported in the literature. PATIENTS AND METHODS: A retrospective review was performed of medical records of patients in our institution coded for gallstone ileus by the International Classification of Diseases (ICD K-563) coding system between January 1998 and December 2005. RESULTS: There were 22 patients with mean age of 77 (58-92) years and a female to male ratio of 4.5:1. Most patients presented with abdominal pain and vomiting, with a median duration of symptoms of 3 (1-28) days. Preoperative diagnosis was made in 77% from a combination of plain x-ray, ultrasonography, and computed tomography (CT) scans; 86.4% of the patients belonged to ASA class of 3 or 4. Twenty patients underwent enterolithotomy alone, and two had one-stage procedure. The mean size of impacted stones was 3.6 (2.5-4.5) cm, with location in the terminal ileum in 17 and jejunum in 5 patients. There were 5 perioperative deaths and an episode of cholangitis occurring in one patient 18 months after enterolithotomy alone. CONCLUSIONS: Gallstone ileus is a difficult clinical entity to diagnose. Unreserved use of imaging techniques can improve diagnostic accuracy and speed of therapeutic decision making. Management of gallstone ileus must be individualized. The one-stage procedure should be offered only to highly selected patients with good cardiorespiratory reserve and with absolute indications for biliary surgery at the time of presentation.

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Dig Dis Sci. 2007 May;52(5):1313-25. Epub 2007 Mar 28.
Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy.
Sakorafas GH, Milingos D, Peros G.
4th Department of Surgery, Athens University, Medical School, ATTIKON University Hospital, Arkadias 19-21, GR-115 26, Athens, Greece. georgesakorafas@yahoo.com

Asymptomatic cholelithiasis is increasingly diagnosed today, mainly as a result of the widespread use of abdominal ultrasonography for the evaluation of patients for unrelated or vague abdominal complaints. About 10-20% of people in most western countries have gallstones, and among them 50-70% are asymptomatic at the time of diagnosis. Asymptomatic gallstone disease has a benign natural course; the progression of asymptomatic to symptomatic disease is relatively low, ranging from 10-25%. The majority of patients rarely develop gallstone-related complications without first having at least one episode of biliary pain ("colic"). In the prelaparoscopy era, (open) cholecystectomy was generally performed for symptomatic disease. The minimally invasive laparoscopic cholecystectomy refueled the discussion about the optimal management of asymptomatic cholelithiasis. Despite some controversy, most authors agree that the vast majority of subjects should be managed by observation alone (expectant management). Selective cholecystectomy is indicated in defined subgroups of subjects, with an increased risk for the development of gallstone-related symptoms and complications. Concomitant cholecystectomy is a reasonable option for good-risk patients with asymptomatic cholelithiasis undergoing abdominal surgery for unrelated conditions. Routine cholecystectomy for all subjects with silent gallstones is a too aggressive management option, not indicated for most subjects with asymptomatic cholelithiasis. An in-depth knowledge of the natural history of gallstone disease is required to select the optimal management option for the individual subject with silent gallstones. Management options should be extensively discussed with the patient; he or she should be actively involved in the process of therapeutic decision making.

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J Laparoendosc Adv Surg Tech A. 2007 Apr;17(2):167-71.
Rendezvous technique versus endoscopic retrograde cholangiopancreatography to treat bile duct stones reduces endoscopic time and pancreatic damage.
La Greca G, Barbagallo F, Di Blasi M, Di Stefano M, Castello G, Gagliardo S, Latteri S, Russello D.
Department of Surgical Sciences, Transplantation, and Advanced Technologies, Cannizzaro Hospital, University of Catania, Catania, Italy. glagreca@unict.it

BACKGROUND: Endoscopic procedures on Vater's papilla are related to pancreatic damage with or without pathologic increase of pancreatic enzymes. Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy is a standard treatment for common bile duct stones, performed sequentially before or after laparoscopic cholecystectomy. The "rendezvous" (RV) procedure combines laparoscopic cholecystectomy, intra-operative cholangiography, and endoscopic bile duct clearance and is an alternative to the sequential treatment. We tried to analyze relevant differences between the two options concerning the main parameters of pancreatic damage. METHODS: Thirty-eight patients treated for biliary stones were divided into two groups of 19 patients depending on the type of treatment (RV vs. ERCP) and were compared for post-procedural amylase and lipase levels; the duration of the endoscopic procedures, effectiveness, and complications were also recorded. RESULTS: A pathologic increase of serum amylase occurred in 15.7% of the RV group and 47.3% of the ERCP group with significant differences regarding amylase levels in the 6- and 66-hour samples (p < 0.003; p < 0.006). The mean duration of endoscopic procedure was significantly shorter in the RV group (17 vs. 26 minutes, p < 0.0001). RV was effective in common bile duct clearance in 100% of cases, while ERCP was effective in only 89.5%. Minor morbidity affected one patient in each group. CONCLUSIONS: This is the first report comparing combined laparoendoscopic RV versus ERCP for potential pancreatic damage and showing that RV reduces the number of patients with an iatrogenic pathologic increase of amylase when compared to ERCP, and also significantly reduces the duration of endoscopic procedure.

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Isr Med Assoc J. 2007 Mar;9(3):147-8.
Comparison of the quality of life after minilaparotomy cholecystectomy versus laparoscopic cholecystectomy: a prospective randomized study.
Harju J, Pääkkönen M, Eskelinen M.
Kuusankoski District Hospital, Kuusankoski, Finland. jukka.harju@fimnet.fi

BACKGROUND: Earlier studies comparing minilaparotomy cholecystectomy with laparoscopic cholecystectomy did not find significant differences between the MC and the LC groups in operating times and patients' recovery. OBJECTIVES: To compare the postoperative quality of life between the MC and LC groups. METHODS: The 157 patients with uncomplicated symptomatic gallstones, confirmed by ultrasound, were randomized to two groups: 85 for MC and 72 for LC. The study was prospective and randomized but not blinded or consecutive. The study groups were similar in patients' age, gender, body mass index, American Association of Anesthesiology physical fitness classification, and the operating surgeon. Patients were reevaluated 4 weeks after operation using the RAND-36 quality of life questionnaire. RESULTS: The RAND-36 questionnaire did not identify statistically significant differences between the study groups in general health perceptions, physical functioning, emotional well-being, social functioning, energy, bodily pain, and role functioning/emotional score. Only the role functioning/physical score was slightly higher in the LC group (P= 0.038). CONCLUSIONS: The results of this study showed that the MC procedure is a good alternative to the LC procedure, when postoperative quality of life is measured.

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Cochrane Database Syst Rev. 2007 Jan 24;(1):CD006230.
Cholecystectomy versus no cholecystectomy in patients with silent gallstones.
Gurusamy K, Samraj K.

BACKGROUND: Cholecystectomy is currently advised only for patients with symptomatic gallstones. However, about 4% of patients with asymptomatic gallstones develop symptoms including cholecystitis, obstructive jaundice, pancreatitis, and gallbladder cancer. OBJECTIVES: To assess the benefits and harms of surgical removal of the gallbladder for patients with asymptomatic gallstones. SEARCH STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until 2006 for identifying the randomised trials using The Cochrane Hepato-Biliary Group search strategy. SELECTION CRITERIA: Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing cholecystectomy and no cholecystectomy were considered for the review. DATA COLLECTION AND ANALYSIS: We were unable to identify any randomised clinical trials comparing cholecystectomy versus no cholecystectomy. MAIN RESULTS: We were unable to identify any randomised clinical trial comparing cholecystectomy versus no cholecystectomy. AUTHORS' CONCLUSIONS: There are no randomised trials comparing cholecystectomy versus no cholecystectomy in patients with silent gallstones. Further evaluation of observational studies, which measure outcomes such as obstructive jaundice, gallstone-associated pancreatitis, and/or gall-bladder cancer for sufficient duration of follow-up is necessary before randomised trials are designed in order to evaluate whether cholecystectomy or no cholecystectomy is better for asymptomatic gallstones.

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Ann Surg. 2007 Jan;245(1):126-9.
Asymptomatic cholelithiasis in children with sickle cell disease: early or delayed cholecystectomy?
Curro G, Meo A, Ippolito D, Pusiol A, Cucinotta E.
Department of Human Pathology, University of Messina, Messina, Italy.

SUMMARY BACKGROUND DATA: Our study aimed to evaluate the role of elective laparoscopic cholecystectomy (LC) in children with sickle cell disease (SCD) and asymptomatic cholelithiasis and, furthermore, to determine whether the outcome is related to the operation timing. METHODS: The records of 30 children with SCD diagnosed with cholelithiasis from June 1995 to September 2005 were retraspectively reviewed. All 30 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them. The operation was accepted in the period of study by 16 children and refused by 14. During medical observation, 10 of the 14 children who refused surgery were admitted for severe biliary colics. Acute cholecystitis was diagnosed by abdominal ultrasound in 3 cases and in 1 case choledocholithiasis, ultrasonographically suspected, was confirmed by magnetic resonance cholangiopancreatography (MRCP) and treated during endoscopic retrograde cholangiopancreatography (ERCP). All children, emergency admitted, underwent LC after the onset of symptoms. The patients were divided up into 2 groups (A: asymptomatic; B: symptomatic) depending on clinical presentation and operation timing and the respective outcomes were compared. RESULTS: Elective LC in asymptomatic children (group A) is safe with no major complications reported. During medical observation in children who refused elective surgery (group B), 6 biliary colics, 3 acute cholecystitis, and 1 choledocholithiasis were observed. Three sickle cell crises occurred in symptomatic children during biliary colics. The correlation between cholecystectomy performed in asymptomatic children (group A) and cholecystectomy performed in symptomatic children (group B) showed significant differences in the outcome. Morbidity rate and postoperative stay increased when children with SCD underwent emergency LC. CONCLUSIONS: Elective LC should be the gold standard in children with SCD and asymptomatic cholelithiasis to prevent the potential complications of biliary colics, acute cholecystitis, and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.

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Chir Ital. 2006 Nov-Dec;58(6):709-16.
[Simultaneous laparoscopic treatment for common bile duct stones associated with acute cholecystitis. Results of a prospective study]
[Article in Italian]
Chiarugi M, Galatioto C, Lippolis PV, Puglisi A, Battini A, Scassa F, Zocco G, Seccia M.
UO Univ. Chirurgia Generale e Urgenza, Dipartimento di Chirurgia, Universita degli Studi di Pisa, Via Roma, 67 - 56100 Pisa.

Laparoscopy for the management of acute cholecystitis has gained wide acceptance. Although it is well known that acute cholecystitis may be complicated by common bile duct stones in up to 15% of cases, to date there are no published studies addressing the management of common bile duct stones detected during laparoscopy for acute cholecystitis. We postulated that, when found, common bile duct stones associated with acute cholecystitis could be effectively and safety managed during the same laparoscopic procedure. We report on a five-year prospective study (2001-2005) involving 313 unselected patients who presented with a clinical diagnosis of acute cholecystitis (confirmed by specimen examination) and without any contraindication to laparoscopy. At surgery, transcystic cholangiograms were obtained in 289 (92%); the other 24 were excluded from the study. With an established diagnosis of common bile duct stones, attempts were made to clear the common bile duct by transcystic basket retrieval, ERCP or choledochotomy. Prevalence of common bile duct stones in acute cholecystitis, success of laparoscopic common duct clearance, conversion rate, operative time, morbidity, and postoperative hospital stay were the main outcome measures. Common bile duct stones were found in 63 pts (21.7%) presenting with acute cholecystitis. At laparoscopy, 12 patients (19%) required conversion to open surgery, 3 of these being due to failure to achieve common bile duct clearance. Common bile duct stones were cleared entirely laparoscopically in 51 patients (81%) by means of transcystic stone retrieval (38 pts, 75%), ERCP (12 pts, 23%) or choledocotomy (1 pt, 2%). At intention to treat analysis, patients undergoing cholecystectomy plus common bile duct clearance compared to those undergoing cholecystectomy alone, spent significantly more time in the operating theatre (mean 192 min vs 118 min, p < 0.001), needed open conversion more frequently (19% vs 6.1%, p = 0.0045), and had a higher overall morbidity rate (17.4% vs 4.4%, p = 0.015). The simultaneous procedure also adversely affected the postoperative hospital stay (mean 4.8 vs 3.4 days, p = 0.0164). Mortality was nil in both groups. The prevalence of common bile duct stones in patients presenting with acute cholecystitis should not be neglected. When common bile duct stones are found, clearance may be obtained laparoscopically in a substantial number of cases without any need for open surgery. The simultaneous laparoscopic approach for acute cholecystitis and common bile duct stones remains, however, a highly skilled and technically demanding procedure. Although a moderate incidence of drawbacks is observed, the results should be interpreted from the point of view of an all-in-one procedure that allows the patients to be cured without needing any further sequential interventions.

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Adv Surg. 2006;40:265-84.
Management of gallstone pancreatitis.
Larson SD, Nealon WH, Evers BM.
Department of Surgery, The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0536, USA.

Gallstones are the most common cause of acute pancreatitis in the western world. Most patients with ABP suffer a mild attack and are expected to make a full recovery. They can be managed supportively and undergo laparoscopic cholecystectomy with IOC during their initial hospitalization to prevent recurrence. If necessary, laparoscopic common bile duct exploration can be performed. Otherwise, postoperative ERCP can be performed to remove common bile duct stones. Patients with severe ABP require ICU admission, close clinical monitoring, and aggressive fluid resuscitation. There is a bimodal mortality in severe ABP with most late deaths caused by septic complications. Antibiotics should be used judiciously and are usually warranted only in the presence of infection or sepsis. ERCP, +/- ES, should be performed when signs of cholangitis are present. Early ERCP should be considered in patients with severe ABP who do not improve clinically. CT scanning should be performed to assess for necrosis or peripancreatic fluid collections. Patients with no fluid collections can undergo cholecystectomy once their clinical condition improves. Patients with peripancreatic fluid collections should be followed with serial CT scans. Laparoscopic cholecystectomy should be performed once resolution of the fluid collection is documented. If fluid collections do not resolve after 6 weeks, patients should undergo concurrent cholecystectomy and fluid drainage procedures. Sterile necrosis can be closely monitored and does not require necrosectomy unless the patient's clinical status deteriorates. Patients with infected necrosis should undergo necrosectomy when they are clinically stable. After recovery from an attack of severe ABP, patients require close follow-up because late complications are common. Currently, no single test can establish the diagnosis or predict the severity of ABP. A prompt diagnosis requires a high degree of suspicion and clinical acumen. Recognizing patients with severe pancreatitis is an important priority because it affects the type and timing of intervention. The management of these patients requires close clinical observation and a multidisciplinary approach between the surgeon, radiologist, gastroenterologist, and intensivist.

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Best Pract Res Clin Gastroenterol. 2006;20(6):1103-16.
Gallstone disease. Management of common bile-duct stones and associated gallbladder stones: Surgical aspects.
Boerma D, Schwartz MP.
Department of Surgery, St Antonius Hospital, Postbus 2500, 3430 EM Nieuwegein, The Netherlands. djamilaboerma@hotmail.com

For many years, open exploration of the common bile duct has been the treatment of choice for patients with common bile-duct stones. During recent decades endoscopic sphincterotomy has gained wide acceptance as an effective and less invasive alternative. After sphincterotomy, subsequent (laparoscopic) cholecystectomy is warranted in patients with gallbladder stones. This chapter will discuss whether sphincterotomy should be performed prior to, during or after cholecystectomy, and will also address the question of whether single-stage treatment by laparoscopic cholecystectomy and laparoscopic bile-duct exploration is in fact preferable. The rate of recurrent choledocholithiasis after endoscopic biliary sphincterotomy can reach more than 20%. This review focuses on the risk factors--delayed bile-duct clearance and bactobilia--that may lead to recurrent primary bile-duct stone formation. Underlying altered bile composition (relative phospholipid deficiency) should be recognised in a subgroup of patients. Identification of these risk factors may significantly affect treatment policy.

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Best Pract Res Clin Gastroenterol. 2006;20(6):1085-101.
Gallstone disease: Symptoms, diagnosis and endoscopic management of common bile duct stones.
Caddy GR, Tham TC.
Department of Gastroenterology, Ulster Hospital, Dundonald, Belfast, Northern Ireland, UK. grant.caddy@ucht.n-i.nhs.uk

Bile duct stones (BDS) are often suspected on history and clinical examination alone but symptoms may be variable ranging from asymptomatic to complications such as biliary colic, pancreatitis, jaundice or cholangitis. The majority of BDS can be diagnosed by transabdominal ultrasound, computed tomography, endoscopic ultrasound or magnetic resonance cholangiography prior to endoscopic or laparoscopic removal. Approximately 90% of BDS can be removed following endoscopic retrograde cholangiography (ERC)+sphincterotomy. Most of the remaining stones can be removed using mechanical lithotripsy. Patients with uncorrected coagulopathies may be treated with ERC+pneumatic dilatation of the sphincter of Oddi. Shockwave lithotripsy (intraductal and extracorporeal) and laser lithotripsy have also been used to fragment large bile duct stones prior to endoscopic removal. The role of medical therapy in treatment of BDS is currently uncertain. This review focuses on the clinical presentation, investigation and current management of BDS.

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Best Pract Res Clin Gastroenterol. 2006;20(6):1063-73.
Gallstone disease: Primary and secondary prevention.
Venneman NG, van Erpecum KJ.
Gastrointestinal Research Unit, Department of Gastroenterology, University Medical Center Utrecht, The Netherlands. nielsvenneman@hotmail.com

Several risk factors for cholesterol gallstone formation in the general population have been identified. There is a strongly increased risk of gallstone disease during prolonged fasting, rapid weight loss, total parenteral nutrition, and somatostatin(-analogue) treatment. The annual risk of biliary colic and gallstone complications in asymptomatic gallstone carriers has been investigated sparsely. In asymptomatic and symptomatic gallstone carriers, treatment with the hydrophilic bile salt ursodeoxycholic acid (UDCA) has been claimed to reduce the risk of biliary colic and gallstone complications such as acute cholecystitis and acute pancreatitis. Also, prophylactic cholecystectomy could be beneficial in certain subgroups of asymptomatic gallstone carriers. However, randomized, double-blind, placebo-controlled trials are lacking. In this review, strategies for the prevention of gallstone formation in the general population and in high-risk conditions are dealt with. Also, strategies for the prevention of biliary colic and gallstone complications in asymptomatic and symptomatic gallstone carriers are discussed.

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Best Pract Res Clin Gastroenterol. 2006;20(6):1031-51.
Gallstone disease: Surgical aspects of symptomatic cholecystolithiasis and acute cholecystitis.
Keus F, Broeders IA, van Laarhoven CJ.
Diakonessenhuis, Bosboomstraat 1, 3582 KE Utrecht, The Netherlands. erickeus@hotmail.com

Indications for cholecystectomy are limited to clearly symptomatic gallstones. Relatively high failure rates of pain relief are probably caused by incorrect selection of patients for the operation. Contraindications for (laparoscopic) cholecystectomy are related to anaesthesiological considerations. Laparoscopic cholecystectomy was accepted by consensus as the gold standard within 5 years of its introduction. Nevertheless, both the classical open and small-incision cholecystectomies are safe alternatives, and superiority of any one of the three techniques over the others has not been proven. Primary outcome measures (mortality, complications, and symptom relief) seem to be equal for the three techniques. Acute cholecystitis is a complication of gallstones. Generally it is recommended that early cholecystectomy be performed, as delayed cholecystectomy is associated with longer total hospital stay and convalescence due to recurrent cholecystitis episodes. Cholecystostomy is an alternative technique for patients unfit for general anaesthesia. Reported complication and conversion rates in cholecystectomy for acute cholecystitis vary, but are higher than for symptomatic cholecystolithiasis. New developments--such as robot-assisted surgery--are expected to have a significant impact in the near future.
  
Previous Gallstone Research: 2002-2006   
The Gallstones File also contains summaries of past research that has shown promise and may still be standard practice among many physicians. To download earlier research findings on Gallstones, click HERE.
  

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©Copyright 1992-date by The Center for Current Research. The Gallstones File is a proprietary compilation of the Center for Current Research. The information in the File is solely for your use, and the use of your family, friends, and doctors. The information is the property of the individual researchers and institutions that produced it. It is an infringement of copyright law to attempt to "resell" the information as it is presented here.