Gallstone Research: 2002-2006
     
Surg Endosc. 2006 Nov 16; [Epub ahead of print]
Thirteen years' experience with laparoscopic transcystic common bile duct exploration for stones : Effectiveness and long-term results.
Paganini AM, Guerrieri M, Sarnari J, De Sanctis A, D'Ambrosio G, Lezoche G, Perretta S, Lezoche E.
Clinica di Chirurgia Generale e Metodologia Chirurgica, Universita Politecnica delle Marche, Azienda Ospedaliera Umberto I, Via Conca, 60020, Ancona, Italy, silvanaucsf@yahoo.com.

BACKGROUND: The aim of the present study was to evaluate the effectiveness and long-term results of laparoscopic transcystic common bile duct exploration (TC-CBDE). METHODS: Ductal stones were present in 344 of 3212 patients (10.7%) who underwent laparoscopic cholecystectomy (LC). The procedure was completed laparoscopically in 329 patients (95.6%), with TC-CBDE performed in 191 patients (58.1%) who are the object of this study, or with a transverse choledochotomy in 138 cases (41.9%). RESULTS: Biliary drainage was employed in 71 of 191 cases (37.2%). Major complications occurred in 10 patients (5.1%), including retained stones in 6 (3.1%). Mortality was nil. No patients were lost to follow-up (median: 118.0 months; range: 17.6-168 months). No signs of bile stasis, no recurrent ductal stones and no biliary stricture were observed. At present 182 patients are alive with no biliary symptoms; 9 have died from unrelated causes. CONCLUSIONS: Long-term follow-up after laparoscopic TC-CBDE proved its effectiveness and safety for single-stage management of gallstones and common bile duct stones.

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Wien Med Wochenschr. 2006 Oct;156(19-20):527-533.
Gender and Gallstone Disease.
Novacek G.
Department of Internal Medicine IV, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria, gottfried.novacek@meduniwien.ac.at.

Gallstone disease is a common disorder all over the world. In the Western societies about 80 % of the gallstones are composed primarily of cholesterol. Several risk factors for gallstone formation have been identified. One of the most important risk factors is female gender. Rates of gallstones are two to three times higher among women than men. But this is primarily a phenomenon of the childbearing age. Pregnancy is also a major risk factor for gallstone formation. The risk is related to the number of pregnancies. Sex hormones are most likely to be responsible for the increased risk. Estrogen increases biliary cholesterol secretion causing cholesterol supersaturation of bile. Thus, hormone replacement therapy in postmenopausal women and oral contraceptives have also been described to be associated with an increased risk for gallstone disease. However, the effect of estrogen is dose-dependent and new oral contraceptives with a low estrogen dose do not seem to increase the rate of gallstone formation. The present article focuses on the mentioned risk factors associated with female sex hormones.

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Cochrane Database Syst Rev. 2006 Oct 18;(4):CD006231.
Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis.
Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ.
Diakonessenhuis, Surgery, Bosboomstraat 1, Utrecht, Netherlands. erickeus@hotmail.com

BACKGROUND: Cholecystectomy is one of the most frequently performed operations. Open cholecystectomy has been the gold standard for over 100 years. Laparoscopic cholecystectomy was introduced in the 1980s. OBJECTIVES: To compare the beneficial and harmful effects of laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. SEARCH STRATEGY: We searched TheCochrane Hepato-Biliary Group Controlled Trials Register (April 2004), The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), Web of Science (1988 to January 2004), and CINAHL (1982 to January 2004) for randomised trials. SELECTION CRITERIA: All published and unpublished randomised trials in patients with symptomatic cholecystolithiasis comparing any kind of laparoscopic cholecystectomy versus any kind of open cholecystectomy. No language limitations were applied. DATA COLLECTION AND ANALYSIS: Two authors independently performed selection of trials and data extraction. The methodological quality of the generation of the allocation sequence, allocation concealment, blinding, and follow-up was evaluated to assess bias risk. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed when appropriate. MAIN RESULTS: Thirty-eight trials randomised 2338 patients. Most of the trials had high bias risk. There was no significant difference regarding mortality (risk difference 0,00, 95% confidence interval (CI) -0.01 to 0.01). Meta-analysis of all trials suggests less overall complications in the laparoscopic group, but the high-quality trials show no significant difference ('allocation concealment' high-quality trials risk difference, random effects -0.01, 95% CI -0.05 to 0.02). Laparoscopic cholecystectomy patients have a shorter hospital stay (weighted mean difference (WMD), random effects -3 days, 95% CI -3.9 to -2.3) and convalescence (WMD, random effects -22.5 days, 95% CI -36.9 to -8.1) compared to open cholecystectomy. AUTHORS' CONCLUSIONS: No significant differences were observed in mortality, complications and operative time between laparoscopic and open cholecystectomy. Laparoscopic cholecystectomy is associated with a significantly shorter hospital stay and a quicker convalescence compared with the classical open cholecystectomy. These results confirm the existing preference for the laparoscopic cholecystectomy over open cholecystectomy.

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Cochrane Database Syst Rev. 2006 Oct 18;(4):CD006229.
Laparoscopic versus small-incision cholecystectomy for patients with symptomatic cholecystolithiasis.
Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ.
Diakonessenhuis, Surgery, Bosboomstraat 1, Utrecht, Netherlands. erickeus@hotmail.com

BACKGROUND: Cholecystectomy is one of the most frequently performed operations. Open cholecystectomy has been the gold standard for over 100 years. Small-incision cholecystectomy is a less frequently used alternative. Laparoscopic cholecystectomy was introduced in the 1980s. OBJECTIVES: To compare the beneficial and harmful effects of laparoscopic versus small-incision cholecystectomy for patients with symptomatic cholecystolithiasis. SEARCH STRATEGY: We searched TheCochrane Hepato-Biliary Group Controlled Trials Register (6 April 2004), The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), Web of Science (1988 to January 2004), and CINAHL (1982 to January 2004) for randomised trials. SELECTION CRITERIA: All published and unpublished randomised trials in patients with symptomatic cholecystolithiasis comparing any kind of laparoscopic cholecystectomy versus small-incision or other kind of minimal incision open cholecystectomy. No language limitations were applied. DATA COLLECTION AND ANALYSIS: Two authors independently performed selection of trials and data extraction. The methodological quality of the generation of the allocation sequence, allocation concealment, blinding, and follow-up was evaluated to assess bias risk. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate. MAIN RESULTS: Thirteen trials randomised 2337 patients. Methodological quality was relatively high considering the four quality criteria. Total complications of laparoscopic and small-incision cholecystectomy are high: 26.6% versus 22.9%. Total complications (risk difference, random-effects -0.01, 95% confidence interval (CI) -0.07 to 0.05), hospital stay (weighted mean difference (WMD), random-effects -0.72 days, 95% CI -1.48 to 0.04), and convalescence were not significantly different. High-quality trials show a quicker operative time for small-incision cholecystectomy (WMD, high-quality trials 'blinding', random-effects 16.4 minutes, 95% CI 8.9 to 23.8) while low-quality trials show no significant difference. AUTHORS' CONCLUSIONS: Laparoscopic and small-incision cholecystectomy seem to be equivalent. No differences could be observed in mortality, complications, and postoperative recovery. Small-incision cholecystectomy has a significantly shorter operative time. Complications in elective cholecystectomy are prevalent.

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Hepatogastroenterology. 2006 Sep-Oct;53(71):655-9.
Cholecystectomy improves long-term success after endoscopic treatment of CBD stones.
Hoem D, Viste A, Horn A, Gislason H, Sondenaa K.
Department of Surgery, Haukeland University Hospital, Bergen, Norway. dhoe@haukeland.no

BACKGROUND/AIMS: The aim was to study prospectively primary endoscopic treatment of CBD stones and further the long-term need for renewed gallstone disease interventions, defined as short- and long-term outcome. METHODOLOGY: Seven years prospective follow-up of 101 consecutive patients with CBD stones who underwent endoscopic treatment with the intent of primarily achieving duct clearance. RESULTS: Many patients underwent several endoscopy sessions before stone clearance was completed in 83%. Eleven patients were treated surgically, 2 patients received a permanent stent, and the remaining 3 became stone free with other means. Complications occurred in 47 patients. During follow-up, 31 patients were readmitted for gallstone disease and 15 of these had recurrent CBD stones. Ten percent (8/78) of patients with the gallbladder in situ had acute cholecystitis during follow-up and late cholecystectomy was carried out in 22%. Risk factors for new gallstone disease were an in situ gallbladder containing stones and previous episodes of CBD stones. CONCLUSIONS: A goal of complete CBD stone clearance with ERC and ES proved to be relatively resource consuming. Subsequent cholecystectomy after duct clearance for CBD should be advised when the gallbladder lodges gallstones, especially in younger patients. Recurrent CBD stones were not influenced by cholecystectomy.

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Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005440.
Early versus delayed laparoscopic cholecystectomy for acute cholecystitis.
Gurusamy KS, Samraj K.
Royal Free Hospital, Surgery, 291 Greenhaven Drive, Thamesmead, London, UK. kurinchi2k@hotmail.com

BACKGROUND: Gallstones are present in about 10% to 15% of the adult western population. Between 1% and 4% become symptomatic in a year. Cholecystectomy for symptomatic gallstones is mainly performed after the acute cholecystitis episode settles because of the fear of higher morbidity and conversion from laparoscopic cholecystectomy to open cholecystectomy during acute cholecystitis. OBJECTIVES: The aim was to compare the early laparoscopic cholecystectomy (less than seven days of onset of symptoms) versus delayed laparoscopic cholecystectomy (more than six weeks after index admission) with regards to benefits and harms. 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 IndexExpanded until November 2005. SELECTION CRITERIA: We considered for inclusion all randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis. DATA COLLECTION AND ANALYSIS: We collected the data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, conversion rate, operating time, and hospital stay from each trial. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome we calculated the odds ratio (OR) with 95% confidence intervals (CI) based on intention-to-treat analysis. MAIN RESULTS: We included five trials with 451 patients randomised: 223 to the early group and 228 to the delayed group. Surgery was performed on 222 patients in the early group and on 216 patients in the delayed group. There was no mortality in any of the trials. Four of the five trials were of high methodological quality. There was no statistically significant difference between the two groups for any of the outcomes including bile duct injury (OR 0.63, 95% CI 0.15 to 2.70) and conversion to open cholecystectomy (OR 0.84, 95% CI 0.53 to 1.34). Various other analyses including 'available case analysis', risk difference, statistical methods to overcome the 'zero-event trials' showed no statistically significant difference between the two groups in any of the outcomes measured. A total of 40 patients (17.5%) from the delayed group had to undergo emergency laparoscopic cholecystectomy due to non-resolving or recurrent cholecystitis; 18 (45%) of these had to undergo conversion to open procedure. The total hospital stay was about three days shorter in the early group compared with the delayed group. AUTHORS' CONCLUSIONS: Early laparoscopic cholecystectomy during acute cholecystitis seems safe and shortens the total hospital stay. The majority of the outcomes occurred rarely; hence, the confidence intervals are wide. Therefore, further randomised trials on the issue are needed.

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Cochrane Database Syst Rev. 2006 Oct 18;(4):CD004788.
Small-incision versus open cholecystectomy for patients with symptomatic cholecystolithiasis.
Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ.
Diakonessenhuis, Surgery, Bosboomstraat 1, Utrecht, Netherlands. erickeus@hotmail.com

BACKGROUND: Cholecystectomy is one of the most frequently performed operations. Open cholecystectomy has been the gold standard for over 100 years. Small-incision cholecystectomy is a less frequently used alternative. OBJECTIVES: To compare the beneficial and harmful effects of small-incision versus open cholecystectomy for patients with symptomatic cholecystolithiasis. SEARCH STRATEGY: We searched TheCochrane Hepato-Biliary Group Controlled Trials Register (6 April 2004), The Cochrane Library (Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), Web of Science (1988 to January 2004), and CINAHL (1982 to January 2004) for randomised trials. SELECTION CRITERIA: All published and unpublished randomised trials in patients with symptomatic cholecystolithiasis comparing any kind of small-incision or other kind of minimal incision cholecystectomy versus any kind of open cholecystectomy. No language limitations were applied. DATA COLLECTION AND ANALYSIS: Two authors independently performed selection of trials and data extraction. The methodological quality of the generation of the allocation sequence, allocation concealment, blinding, and follow-up was evaluated to assess bias risk. Analyses were based on the intention-to-treat principle. Authors were requested additional information in case of missing data. Sensitivity and subgroup analyses were performed if appropriate. MAIN RESULTS: Seven trials randomised 571 patients. Bias risk was high in the included trials. No mortality was reported. The total complication proportions are respectively 9.9% and 9.3% in the small-incision and open group, which is not significantly different (risk difference all trials, random-effects 0.00, 95% confidence interval (CI) -0.06 to 0.07). There are also no significant differences considering severe complications and bile duct injuries. However, small-incision cholecystectomy has a shorter hospital stay (weighted mean difference, random-effects -2.8 days (95% CI -4.9 to -0.6)) compared to open cholecystectomy. AUTHORS' CONCLUSIONS: Small-incision and open cholecystectomy seem to be equivalent regarding risks of complications, but the latter method is associated with a significantly longer hospital stay. The quicker recovery of small-incision cholecystectomy compared with open cholecystectomy confirms the existing preference of this technique over open cholecystectomy.

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Langenbecks Arch Surg. 2006 Sep;391(5):467-71. Epub 2006 Aug 15.
Laparoscopic management of appendicitis and symptomatic cholelithiasis during pregnancy.
Halkic N, Tempia-Caliera AA, Ksontini R, Suter M, Delaloye JF, Vuilleumier H.
Service de Chirurgie, CHUV, University of Lausanne, Lausanne, 1011, Switzerland, Nermin.Halkic@chuv.hospvd.ch.

BACKGROUND: Laparoscopic surgery during pregnancy is a challenging procedure that most surgeons are reluctant to perform. The objective of this study was to evaluate whether laparoscopic appendectomy and cholecystectomy is safe in pregnant women. The management of these situations remains controversial. We report a single center study describing the successful management of 16 patients during pregnancy. METHODS: More than 3,356 laparoscopic procedures were performed in our institutions between May 1990 and June 2005. Sixteen of these patients were operated on in the second and third trimester between 22 and 32 weeks of estimated gestational age. We performed 11 laparoscopic appendectomies and 5 laparoscopic cholecystectomies. We also reviewed the management and operative technique used in these patients. RESULTS: In this study, the laparoscopic appendectomy or cholecystectomy was performed successfully in all patients. Three patients were in their second trimester, weeks 22, 23, and 25, and 13 were in the third trimester, weeks 27 (three patients), 28 (five patients), 31 (three patients), and 32 (two patients). No maternal or fetal morbidity occurred. Open laparoscopy was performed safely in all patients and all patients delivered healthy babies. CONCLUSION: From our experience laparoscopic management of appendicitis and biliary colic during pregnancy is safe, however the second trimester is preferable for laparoscopic cholecystectomy. Pregnancy is not a contraindication to the laparoscopic approach to appendicitis or symptomatic cholelithiasis. We believe that laparoscopic operations, when performed by experienced surgeons, are safe and even preferable for the mother and the fetus.

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Am J Surg. 2006 Aug;192(2):196-202.
Improvement in gastrointestinal symptoms and quality of life after cholecystectomy.
Finan KR, Leeth RR, Whitley BM, Klapow JC, Hawn MT.
Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 35294, USA.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the accepted treatment for symptomatic cholelithiasis but has been criticized as an overused procedure. This study assesses the effectiveness of LC on reduction in gastrointestinal (GI) symptoms and the impact on quality of life (QOL). METHODS: A prospective cohort of subjects evaluated for gallstone disease between August 2001 and July 2004 completed preoperative and postoperative GI gallbladder symptom surveys (GISS) and SF36 QOL surveys. The GISS was developed to quantify the magnitude, severity, and distressfulness of 16 GI symptoms. Surveys were scored and evaluated using paired t tests. RESULTS: Fifty-five subjects were included in the final analysis. The GISS revealed significant improvement in biliary type symptoms but not reflux or irritable bowel symptoms after LC (P > .05). Significant improvement was seen in QOL (P < .01). CONCLUSION: This study supports the utility of LC by showing not only a significant reduction of GI symptoms but also marked improvement in patients' general QOL.

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World J Surg. 2006 Jul;30(7):1204-10.
Laparoscopic cholecystectomy in patients aged 80 years and over.
Kwon AH, Matsui Y.
Department of Surgery, Kansai Medical University, 10-15 Fumizono, Moriguchi, Osaka, 570-8507, Japan. kon@takii.kmu.ac.jp

INTRODUCTION: The aging population has led to a significant rise in the number of patients undergoing operations such as cholecystectomy. We have evaluated and compared the results of laparoscopic cholecystectomy (LC) in patients aged 80 years and over with those of patients aged between 65 and 79 years. METHODS: A total of 471 patients aged 65 to 79 years (group 1) and 45 patients aged>or=80 years (group 2) underwent LC. All patients underwent preoperative spiral computed tomography after intravenous infusion cholangiography and intraoperative cholangiography. RESULTS: There was a higher incidence of choledocholithiasis and gallbladder cancer in the patients>or=80 years of age. In addition, group 2 patients had a higher incidence of cardiopulmonary disease and higher American Association of Anesthesiology scores than did those in group 1. With respect to the conversion rate to open surgery, morbidity, mortality, and length of hospital stay, there were no significant differences between the two groups. There was a significantly higher incidence of positive bile cultures and gram-negative rods in group 2 patients than in those in group 1. CONCLUSIONS: Octogenarians tolerated LC well. Therefore, early elective LC should be encouraged to minimize morbidity and mortality in these elderly patients who have symptomatic cholelithiasis.

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Rev Med Suisse. 2006 Jun 14;2(70):1586-92.
[When should cholecystectomy be practiced? Not always an easy decision]
[Article in French]
Gonzalez M, Toso C, Zufferey G, Roiron T, Majno P, Mentha G, Morel P.
Clinique de chirurgie viscerale, Departement de chirurgie, HUG, Geneve.

Gallstone disease is a frequent medical problem. Cholelithiasis affects 10% of the population and 30% of patients with gallstones will undergo surgery. The treatment of choice for symptomatic gallstones remains cholecystectomy. A prophylactic cholecystectomy is indicated for asymptomatic patients in the presence of polyps, porcelain gallbladder or during bariatric surgery. The management of the complications of gallstone disease is discussed. At present, common bile duct stones, even if discovered preoperatively, should be managed by a multidisciplinary team including surgeons trained in laparoscopic techniques and gastroenterologists. This review is complemented by the information from a prospective database generated by a program called "DODIG" on 1099 cholecystectomies performed in our institution.

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J Surg Oncol. 2006 Jun 15;93(8):629-32.
Contribution of silent gallstones in gallbladder cancer.
Tewari M.
Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India. mallika_vns@satyam.net.in

Silent (asymptomatic) gallstones are detected frequently with the widespread use of abdominal ultrasonography. The presence of gallstones is found strongly associated with gallbladder carcinoma. Studies on the natural history and most decision analysis studies do not favor prophylactic cholecystectomy for patients with silent gallstones. Gallbladder carcinoma is known to be highly aggressive and lethal disease with a poor outcome. It is rarely diagnosed early and only 10-30% patients are offered radical surgery on presentation. This has lead to a dilemma leading most surgeons to opt for an expectant management of silent gallstones. It thus raises the important question of the implications of leaving asymptomatic gallstones untouched. In this paper the author has reviewed the current understanding on silent gallstones and gallbladder carcinoma. Copyright 2006 Wiley-Liss, Inc.

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World J Gastroenterol. 2006 May 28;12(20):3162-7.
Choledocholithiasis: evolving standards for diagnosis and management.
Freitas ML, Bell RL, Duffy AJ.
Department of Surgery, Yale University School of Medicine, 40 Temple Street, Suite 3A, New Haven, CT 06510, USA.
Free full text at: http://www.wjgnet.com/1007-9327/12/3162.asp

Cholelithiasis, one of the most common medical conditions leading to surgical intervention, affects approximately 10 % of the adult population in the United States. Choledocholithiasis develops in about 10%-20% of patients with gallbladder stones and the literature suggests that at least 3%-10% of patients undergoing cholecystectomy will have common bile duct (CBD) stones. CBD stones may be discovered preoperatively, intraoperatively or postoperatively Multiple modalities are available for assessing patients for choledocholithiasis including laboratory tests, ultrasound, computed tomography scans (CT), and magnetic resonance cholangiopancreatography (MRCP). Intraoperative cholangiography during cholecystectomy can be used routinely or selectively to diagnose CBD stones. The most common intervention for CBD stones is ERCP. Other commonly used interventions include intraoperative bile duct exploration, either laparoscopic or open. Percutaneous, transhepatic stone removal other novel techniques of biliary clearance have been devised. The availability of equipment and skilled practitioners who are facile with these techniques varies among institutions. The timing of the intervention is often dictated by the clinical situation.

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J Heart Lung Transplant. 2006 May;25(5):539-43. Epub 2006 Mar 30.
Expectant management is safe for cholelithiasis after heart transplant.
Takeyama H, Sinanan MN, Fishbein DP, Aldea GS, Verrier ED, Salerno CT.
Department of Cardiothoracic Surgery, University of Tokyo, Tokyo, Japan. csalerno@u.washington.edu

BACKGROUND: The optimal management of cholelithiasis after heart transplant remains unclear. We use expectant management based on symptoms, without screening studies or prophylactic treatment. We hypothesized that expectant management for cholelithiasis after heart transplant does not result in significant mortality or morbidity from gallstone-associated disease. METHODS: Between November 1985 and August 2004, 409 heart transplants were performed in 402 recipients at the University of Washington. This is a non-concurrent cohort study of these recipients. RESULTS: Among recipients, 24 underwent cholecystectomy before heart transplant. After transplant, in the remaining 378 patients, 34 were found to have gallstones during the observation period. There was no mortality from gallstone-associated disease. Thirty patients developed morbidity from gallstones, including 25 cases of biliary colic, 3 of acute cholecystitis and 2 of pancreatitis, and there was 1 abnormal liver function test. Acute cholecystitis and pancreatitis were treated with conservative management followed by cholecystectomy. Cholecystectomy was performed in 32 patients after transplant. Indications included symptomatic cholelithiasis in 31, and prophylactic cholecystectomy prior to kidney transplant in 1. The laparoscopic approach was performed in 25 of these 32 patients. There was no mortality from cholecystectomy, but there were 4 complications: surgical site infections (n = 2); wound dehiscence (n = 1); and bile duct injury (n = 1). Median hospital stay was 1 day. CONCLUSIONS: Our expectant management for cholelithiasis after heart transplant resulted in no mortality or significant morbidity related to delay in treatment. Symptomatic cholelithiasis was successfully treated with cholecystectomy, mostly with the laparoscopic approach. We believe expectant management is safe for patients after heart transplant.

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Cochrane Database Syst Rev. 2006 Apr 19;(2):CD003327.
Surgical versus endoscopic treatment of bile duct stones.
Martin DJ, Vernon DR, Toouli J.
Copenhagen Trial Unit, Dept 71 02, Cochrane Hepato-Biliary Group, Blegdamsvej 9, Copenhagen O, DK-2100, DENMARK. davidmartin72@hotmail.com

BACKGROUND: 10% to 18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment options for these stones include pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP) or open or laparoscopic surgery. OBJECTIVES: To systematically review the management of CBD stones by four approaches: (1) ERCP versus open surgical bile duct clearance. (2) Pre-operative ERCP versus laparoscopic bile duct clearance. (3) Post-operative ERCP versus laparoscopic bile duct clearance. (4) ERCP versus laparoscopic bile duct clearance in patients with previous cholecystectomy. SEARCH STRATEGY: We systematically searched key relevant electronic databases, bibliographies of relevant papers, and abstracts of relevant subspecialty meetings until November 2005. SELECTION CRITERIA: The quality of included trials was assessed by adequacy of allocation sequence generation, allocation concealment, blinding, and follow-up. DATA COLLECTION AND ANALYSIS: Published and unpublished data relevant to 12 predefined outcome measures were used to conduct fixed- and random-effects models meta-analyses, with exploration of heterogeneity and use of sensitivity and subgroup analysis where required. MAIN RESULTS: Thirteen trials randomised 1351 patients. Eight trials (n = 760) compared ERCP with open surgical clearance, three (n = 425) compared pre-operative ERCP with laparoscopic clearance, and two (n = 166) compared post-operative ERCP with laparoscopic clearance. There were no trials of ERCP versus laparoscopic clearance in patients without an intact gallbladder. Methodology was considered adequate in at least two of three assessable fields in ten trials. A significantly increased number of total procedures (including for complications) per patient was seen in the ERCP arms in all three comparisons with weighted mean differences of 0.62 (95% CI 0.15 to 1.09), 0.96 (95% CI 0.96 to 0.96), and 1.09 (95% CI 0.93 to 1.24), respectively. ERCP was less successful than open surgery in CBD stone clearance (Peto OR 2.89, 95% CI 1.81 to 4.61) with a tendency towards higher mortality (risk difference 1%, 95% CI -1% to 4%). Laparoscopic CBD stone clearance was as efficient as pre- (Peto OR 1.00, CI 0.53 to 1.80) and post-operative ERCP (OR 2.27, 95% CI 0.37 to 13.9) and with no significant difference in morbidity and mortality. Laparoscopic trials universally reported shorter hospital stays in surgical arms. Insufficient data were reported for cost analysis. AUTHORS' CONCLUSIONS: In the era of open cholecystectomy, open bile duct surgery was superior to ERCP in achieving CBD stone clearance. In the laparoscopic era, data are close to excluding a significant difference between laparoscopic and ERCP clearance of CBD stones. The use of ERCP necessitates increased number of procedures per patient.

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Chirurg. 2006 Apr;77(4):307-314.
[Therapeutic splitting as standard treatment for cholelithiasis.]
[Article in German]
Hopt UT, Adam U.
Abteilung Allgemein- und Viszeralchirurgie, Chirurgische Universitatsklinik Freiburg, Hugstetterstrasse 55, 79106 , Freiburg, ulrich.hopt@uniklinik-freiburg.de.

At the moment, therapeutic splitting is still regarded by the vast majority of surgeons as the gold standard for stones in the common bile duct. Endoscopic clearance of the duct certainly is much less invasive than open exploration. However, this does not apply when compared with laparoscopic stone removal. Both are equivalent in respect to stone clearance rates, but the laparoscopic techniques protect patients from the long-term sequelae of endoscopic papillotomy. This can be important particularly for younger patients. Laparoscopic bile duct exploration is cost-effective and safe. Special experience in laparoscopic surgical techniques, however, is mandatory. Thus, surgeons should intensify their training in laparoscopic bile duct exploration in order to increase the acceptance of these techniques.

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Curr Treat Options Gastroenterol. 2006 Apr;9(2):133-44.
Endoscopic treatment of biliary tract disease prior to orthotopic liver transplantation.
Shrestha R, Grunkemeier DM.
Piedmont Liver Transplant Program, Piedmont Hospital, 1968 Peachtree Road N.W., Fifth Floor, 77 Building, Atlanta, GA 30309, USA. roshan.shrestha@piedmont.org.

Endoscopic therapy for biliary tract disease in patients with end-stage liver disease (ESLD) before liver transplantation is safe and effective. Reported results in patients with choledocholithiasis, primary sclerosing cholangitis (PSC), and symptomatic gallbladder diseases are encouraging. Prompt recognition and appropriate treatment of symptomatic gallbladder and bile duct disease are important in reducing morbidity and mortality in these high-risk patients while they await liver transplantation. Confirmation of tissue diagnosis of cholangiocarcinoma in patients with sclerosing cholangitis is still difficult. Better screening tools and diagnostic methods are necessary for early detection. Because liver transplantation is the only definitive therapy for patients with advanced cirrhosis, maintenance of their candidacy with either endoscopic or radiologic therapeutic interventions is warranted until transplantation. Endoscopic therapy is the preferred method when feasible. If necessary, percutaneous transhepatic biliary drainage (PTBD) is a viable alternative because both avoid the attendant risks of surgery in a high-risk population with advanced liver disease.

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Am J Gastroenterol. 2006 Feb;101(2):278-83.
Endoscopic gallbladder stent placement for treatment of symptomatic cholelithiasis in patients with end-stage liver disease.
Schlenker C, Trotter JF, Shah RJ, Everson G, Chen YK, Antillon D, Antillon MR.
Division of Gastroenterology/Hepatology, University of Colorado Health Sciences Center, Denver, Colorado 80262, USA.

OBJECTIVES: Symptomatic cholelithiasis is a common disease in the general population with an increased prevalence in patients with cirrhosis. While cholecystectomy is the procedure of choice for the treatment of symptomatic cholelithiasis, cirrhotics have an increased risk of complications associated with this therapy. We have found that placement of an endoscopic gallbladder stent is an alternative, less invasive treatment for cirrhotic patients with symptomatic gallbladder disease and describe our experience here. METHODS: A retrospective medical record review of 23 patients with cirrhosis who underwent endoscopic retrograde cholangiography with gallbladder stent placement for symptomatic gallbladder disease from July 1994 to August 2004. RESULTS: Indications for stent placement included recurrent biliary colic (56.5%), acute calculous cholecystitis (39%), acalculous cholecystitis (8.6%), and gallstone pancreatitis (8.6%). All patients experienced resolution of their symptoms following stent placement. Twenty patients (87%) were asymptomatic from 5 days to 3 years post-procedure until transplantation, death, or end of study period. Nine patients (39%) underwent liver transplantation, 5 days to 34 months after the procedure. Eleven patients are well, with ten patients awaiting liver transplantation. Three patients developed late complications and were treated successfully with antibiotics. CONCLUSION: Endoscopic stenting of the gallbladder may be a potential treatment for symptomatic gallbladder disease in patients with cirrhosis awaiting liver transplantation, considered to be high-risk for cholecystectomy.

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J Gastrointest Surg. 2006 Feb;10(2):292-296.
Outcomes of Cholecystectomy After Endoscopic Sphincterotomy for Choledocholithiasis.
Allen NL, Leeth RR, Finan KR, Tishler DS, Vickers SM, Wilcox CM, Hawn MT.
>From the Departments of Surgery (N.L.A., R.R.L., K.R.F., D.S.T., S.M.V.) and Gastroenterology (C.M.W.), University of Alabama at Birmingham, Birmingham, Alabama; and Deep South Center for Effectiveness, Birmingham Veterans Affairs Medical Center (M.T.H.), Birmingham, Alabama.

Laparoscopic cholecystectomy (LC) for treatment of symptomatic common bile duct stones (CBDS) after endoscopic sphincterotomy (ES) is associated with increased conversion and complications compared with other indications. We examined factors associated with conversion and complications of LC after ES. A retrospective study of 32 patients undergoing ES for CBDS followed by cholecystectomy was undertaken. Surgical outcomes for this group were compared with a control population of 499 LCs for all other indications. Factors associated with open cholecystectomy and complications in the ES group were analyzed. Patients undergoing LC preceded by ES had a significantly higher complication (odds ratio [OR] = 7.97; 95% CI, 2.84-22.5) and conversion rate (OR = 3.45; 95% CI, 1.56-7.66) compared with LC for all other indications. Pre-ES serum bilirubin greater than 5 mg/dL was predictive of conversion (positive predictive value = 63%, P < 0.005). Patients with symptomatic CBDS that undergo LC after ES have higher complication and conversion rates than patients undergoing LC without ES. Pre-ES serum bilirubin is useful in identifying patients who may not have a successful laparoscopic approach at cholecystectomy.

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Rev Esp Enferm Dig. 2006 Jan;98(1):42-8.
Laparoscopic cholecystectomy in patients over 70 years of age: review of 176 cases.
[Article in English, Spanish]
Perez Lara FJ, de Luna Diaz R, Moreno Ruiz J, Suescun Garcia R, del Rey Moreno A, Hernandez Carmona J, Oliva Munoz H.
Service of Digestive Surgery, Hospital de Antequera, Malaga, Spain. javi-newyork@hotmail.com

INTRODUCTION: We assessed the results of laparoscopic cholecystectomy in 176 patients over the age of 70 years. PATIENTS AND METHODS: The study included all patients older than 70 years of age who underwent laparoscopic surgery cholelithiasis during the previous ten years. Variables studied included age, sex, type of operation (programmed/emergency), comorbidity, anesthetic risk, intraoperative cholangiography, conversion to open surgery, number of trocars, reoperation, residual choledocholithiasis, postoperative hospital stay, morbidity and mortality. RESULTS: The study included 176 patients (23.29% men and 76.71% women). The mean age was 74.86 years. The mean hospital stay was 1.27 days, with 16.98% morbidity and 0.56% mortality. CONCLUSIONS: Laparoscopic cholecystectomy is a safe procedure in older patients. It results in faster recovery, a shorter postoperative stay and lower rates of morbidity and mortality than open bile duct surgery.

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Surg Endosc. 2006 Jan 4; [Epub ahead of print]
Comparison of laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy and laparoscopic exploration of the common bile duct for cholecystocholedocholithiasis.
Hong DF, Xin Y, Chen DW.
Department of General Surgery, Sir Run Run Shaw Hospital, Medical College of Zhejiang University, Hangzhou Qin Chun Road 3#, Zhejiang Province, 310016, China, xinying20012001@163.com.

BACKGROUND: Laparoscopic cholecystectomy (LC) combined with intraoperative endoscopic sphincterotomy (IOEST) was compared with laparoscopic exploration of the common bile duct (LCBDE) for cholecystocholedocholithiasis in an attempt tried to find the best mini-invasive treatment for the cholelithiasis and choledocholithiasis. METHODS: For this study, 234 patients with cholelithiasis and choledocholithiasis diagnosed by preoperative B-ultrasonography and intraoperative cholangiogram were divided at random into an LC-LCBDE group (141cases) and an LC-IOEST group (93 cases). The surgical times, surgical success rates, number of stone extractions, postoperative complications, retained common bile duct stones, postoperative lengths of stay, and hospital charges were compared prospectively. RESULTS: There were no differences between the two groups in terms of surgical time, surgical success rate, number of stone extractions, postoperative complications, retained common bile duct stones, postoperative length of stay, and hospital charge. CONCLUSION: Both LC-IOEST and LC-LCBDE were shown to be safe, effective, minimally invasive treatments for cholecystocholedocholithiasis.

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Surg Endosc. 2005 Dec 28; [Epub ahead of print]
Laparoscopic cholecystectomy in children with chronic hemolytic anemia Is the outcome related to the timing of the procedure?
Curro G, Iapichino G, Lorenzini C, Palmeri R, Cucinotta E.
Department of Human Pathology, University of Messina, Via Nina da Messina, 2, 98121, Messina, Italy, ecucinot@unime.it.

BACKGROUND: The aim of this study was to evaluate whether the outcome in children with chronic hemolytic anemia (CHA) and cholelithiasis undergoing laparoscopic cholecystectomy (LC) is related to the operation timing. METHODS: From June 1995 to December 2004, 46 children with CHA were referred to our division of surgery for cholelithiasis. All 46 children were asymptomatic at the time of the first visit, and an elective LC was proposed to all of them before the onset of symptoms. The operation was accepted in the period of study by 24 children and refused by 22. The patients were divided into three groups (group A, asymptomatic; group B, symptomatic; and group C, emergency admitted) 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. In children who refused surgery (groups B and C), we observed four sickle cell crises, four acute cholecystitis, and two choledocholithiasis, and all these complications were related to waiting. Two sickle cell crises occurred in symptomatic children waiting for surgery during biliary colic. The risk of emergency admission in children with cholelithiasis and CHA awaiting surgery was found to be high: 28% of the children admitted in emergency after a mean of 32 months (range, 22-36). Morbidity rate and postoperative stay increased when children with hemoglobinopathies underwent emergency LC. CONCLUSIONS: Elective LC should be the gold standard in children with CHA and asymptomatic cholelithiasis in order to prevent the potential complications of cholecystitis and choledocholithiasis, which lead to major risks, discomfort, and longer hospital stay.

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JSLS. 2005 Oct-Dec;9(4):419-21.
A "one-stage" laparoscopic procedure for treating choledocholithiasis.
Lacitignola S, Minardi M, Palmieri R, Nigri A, Caliandro L, Rosellini A.
Martina Franca Hospital, General Surgery Department, Taranto, Italy. lacitignola@libero.it

OBJECTIVES: A minimally invasive approach is considered the treatment of choice for gallbladder stones. We report our experience with the treatment of choledocholithiasis. METHODS: From January 1993 to December 2002, 3118 patients underwent minimally invasive surgery for symptomatic gallstones, 2681 for gallbladder stones and 437 (14%) for cholecysto-choledocholithiasis. RESULTS: We performed endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy in 71 patients (18.7%) with high operative risks, transcystic clearance and transcystic drainage in 96 cases (26.2%) and transcholedochal clearance with a T-tube in 270 cases (73.8%). In 2 patients, residual stones were removed with endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy. Postoperative stay ranged from 4 days to 12 days. No morbidity or mortality occurred. CONCLUSION: In our experience, "one-stage" laparoscopic procedure for cholecystocholedocholithiasis is safe and effective in skilled hands.

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Dig Dis. 2005;23(2):119-26.
Current status of laparoscopic therapy of cholecystolithiasis and common bile duct stones.
Shamiyeh A, Wayand W.
Ludwig Boltzmann Institute for Operative Laparoscopy and Second Surgical Department, Academic Teaching Hospital, Linz, Austria. andreas.shamiyeh@akh.linz.at

BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard operation for gallstone disease. The aim of this review was to scrutinize the advantages and benefits of this minimal invasive technique compared to the conventional operation according to the available literature. Regarding the evidence-based medicine criteria, the current status of laparoscopy in the treatment of cholecystolithiasis, cholecystitis and common bile duct stones has been worked out. METHODS: A Medline, PubMed, Cochrane search. RESULTS: Ten randomized controlled trials (RCTs) are available comparing laparoscopic versus open cholecystectomy. The superiority of LC in less postoperative pain, shorter recovery and hospital stay is stated. Operation time was longer in the first years of LC. 3 RCTs deal with acute cholecystitis: one paper could not find any significant advantage of LC over conventional cholecystectomy, the other two found benefits in recovery, hospital stay and postoperative pain. The range of conversion is between 5 and 7% in elective cases and increases up to 27% for acute cholecystitis. With a rate of more than 90% in Europe, the standard procedure for common bile duct stones is 'therapeutic splitting' with endoscopy and retrograde cholangiopancreatography preoperatively followed by LC. Laparoscopic bile duct clearance is effective and safe in experienced hands, however, the only proven benefit is a slightly shorter hospital stay. CONCLUSION: The laparoscopic approach is preferred in elective cholecystectomy and acute cholecystitis. The minimal invasive technique has proven to be effective, gentle and safe. The main benefits are evident within the first postoperative days. Copyright 2005 S. Karger AG, Basel.

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Am J Gastroenterol. 2005 Nov;100(11):2540-50.
Small gallstones are associated with increased risk of acute pancreatitis: potential benefits of prophylactic cholecystectomy?
Venneman NG, Buskens E, Besselink MG, Stads S, Go PM, Bosscha K, van Berge-Henegouwen GP, van Erpecum KJ.
Gastrointestinal Research Unit, Department of Gastroenterology, University Medical Center, Utrecht, The Netherlands.

OBJECTIVES: Pancreatitis is a severe complication of gallstone disease with considerable mortality. Small gallstones may increase the risk of pancreatitis. Our aims were to evaluate potential association of small stones with pancreatitis and potential beneficial effects of prophylactic cholecystectomy. METHODS: Stone characteristics were determined in patients with biliary pancreatitis (115), obstructive jaundice due to gallstones (103), acute cholecystitis (79), or uncomplicated gallstone disease (231). Sizes and numbers of gallbladder and bile duct stones were determined by ultrasonography and endoscopic retrograde cholangiopancreatography, respectively. Effects of prophylactic cholecystectomy were assessed by decision analyses with a Markov model and Monte Carlo simulations. RESULTS: Patients with pancreatitis or obstructive jaundice had more and smaller gallbladder stones than those with acute cholecystitis or uncomplicated disease (diameters of smallest stones: 3 +/- 1, 4 +/- 1, 8 +/- 1, and 9 +/- 1 mm, respectively, p < 0.01). Bile duct stones were smaller in case of pancreatitis than in obstructive jaundice (diameters of smallest stones: 4 +/- 1 vs 8 +/- 1, p < 0.01). Multivariate analysis identified old age and small stones as independent risk factors for pancreatitis. Decision analysis in a representative group of patients with small (<or=5 mm) gallstones (5,000 patients, 67% females, 45 yr old, 10-yr follow-up) indicates that life-years may be gained or lost by cholecystectomy, depending on incidence and mortality of pancreatitis. CONCLUSIONS: Small gallstones are associated with pancreatitis. Prophylactic cholecystectomy may lead to gain or loss of life-years in patients with small stones, depending on incidence and mortality of pancreatitis.

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Klin Med (Mosk). 2005;83(9):38-40.
[Immediate and long-term effects of endoscopic papillosphincterotomy in patients with cholelithiasis]
[Article in Russian]
Saidmuradova A, Mansurova FKh.

The subjects of the study were 164 patients, divided into two groups. Group I included 76 patients at the physicochemical stage of cholelithiasis, and 38 patients after cholecystectomy, who underwent endoscopic papillosphincterotomy (EPST). Group II (control) included 30 patients at the physicochemical stage of cholelithiasis, and 20 patients after cholecystectomy, who did not undergo EPST. Endoscopic retrograde pancreatocholangiography revealed type II Oddi's sphincter dysfunction in all the patients. Evaluation of the chemical composition of bile in Group I, performed 6, 12, 18, and 24 months after EPST, revealed its graduate stabilization. In Group II the dynamics of bile composition was negative--in 8 patients bile became more lithogenic. Long-term observations showed that 6 years after EPST bile was lithogenic only in 4 Group I patients, while at the same moment in 25 Group I patients bile lithogenicity did not disappear, but even worsened. Biliferous tract ultrasonography, performed long after EPST, found biliary sludge in 4 Group I patients. 6-year observation of Group Il patients, including ultrasonography, demonstrated that during the 4th year of observation biliary sludge occurred in as many as 28 patients, in 15 of whom small concrements on the bottom of the gall bladder were found during the 5-6th year of observation, and in 3 of whom a solitary concrement of 4 to 5 mm in diameter was found in the choledoch. The results demonstrate that it is appropriate to perform EPST as early as at the physicochemical stage of cholelithiasis, because this procedure results in stabilization of biliary colloid balance and thus prevents biliary sludge and forming of gall bladder concrements. At the same time, 36% of patients with cholelithiasis at various stages who did not undergo EPST, formed gall bladder concrements. EPST is also appropriate in some patients after cholecystectomy, in order to prevent repeating gall bladder concrement formation.

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J Gastrointest Surg. 2005 September - October;9(7):965-972.
Prophylactic Cholecystectomy in Transplant Patients: A Decision Analysis.
Kao LS, Flowers C, Flum DR.
>From the Department of Surgery (L.S.K.), LBJ General Hospital, University of Texas Health Science Center at Houston, Houston, Texas; and the Departments of Internal Medicine (C.F.) and Surgery (D.R.F.), University of Washington Medical Center, Seattle, Washington.

Prophylactic laparoscopic cholecystectomy should be performed in solid organ transplant patients with asymptomatic cholelithiasis. Modeled, decision analytic techniques were used to evaluate the different management strategies for asymptomatic cholelithiasis in cardiac and pancreas/renal transplant recipients. The clinical outcomes of expectant management, pretransplantation prophylactic cholecystectomy, and posttransplantation prophylactic cholecystectomy were analyzed for each population. The probabilities and outcomes were derived form a pooled analysis of published studies. One- and two-way sensitivity and cost analyses were performed. Prophylactic posttransplantation cholecystectomy is favored for cardiac transplant recipients with asymptomatic cholelithiasis, resulting in 5:1000 deaths versus 80:1000 for pretransplantation cholecystectomy and 44:1000 for expectant management. In distinction, expectant management for asymptomatic cholelithiasis is favored in pancreas/renal transplant patients, resulting in 2:1000 deaths compared with 5:1000 for prophylactic cholecystectomy. After heart transplantation, a strategy of routine, prophylactic cholecystectomy is anticipated to result in a cost savings of $17,779 per quality-adjusted life-year. Prophylactic posttransplantation cholecystectomy is the preferred management strategy for cardiac transplant patients with incidental gallstones, resulting in decreased mortality and significant cost savings per quality-adjusted life-year. Expectant management is the preferred strategy for pancreas and/or kidney transplant recipients with asymptomatic cholelithiasis.

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Surg Innov. 2005 Sep;12(3):187-94.
Cholecystectomy after endoscopic sphincterotomy for common bile duct stones: is surgery necessary?
Harris HW, Davis BR, Vitale GC.
Division of General Surgery, University of California, San Francisco, San Francisco, CA.

It has been more than 30 years since the introduction of endoscopic sphincterotomy for the management of choledocholithiasis. Once introduced, this endoscopic intervention subsequently enabled clinicians to witness the natural history of leaving the gallbladder in situ once the common duct calculi were removed. Because many people were free of symptoms once the common bile duct was cleared of stones, patients and physicians alike soon questioned whether it was necessary to remove the gallbladder at all. Despite more than two decades of clinical research and numerous published reports, the answer to this question remains elusive. Similarly, the management algorithm for choledocholithiasis in patients with an intact gallbladder remains controversial. We review the available key data regarding this question. Importantly, there are only three prospective, randomized trials that have examined the need for cholecystectomy after endoscopic sphincterotomy, with case studies constituting most of the published reports. Consequently, the literature on this topic remains inconclusive, weakened by its retrospective approach, considerable variability between the patients studied, inconsistent inclusion and exclusion criteria, and frequently poor patient follow-up. Nonetheless, the preponderance of data favor removing the gallbladder after endoscopically clearing the common bile duct of gallstones because an estimated 25% of patients will experience recurrent symptoms within a 2-year follow up period. Recognizing the existence of various mitigating clinical factors, we advocate adopting a selective wait-and-see approach for high-risk patients, especially those with a life expectancy of less than 2 years or severely debilitating comorbidities.

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J Pediatr Surg. 2005 Sep;40(9):1459-63.
Laparoscopic approach as primary treatment of common bile duct stones in children.
Bonnard A, Seguier-Lipszyc E, Liguory C, Benkerrou M, Garel C, Malbezin S, Aigrain Y, de Lagausie P.
Department of Pediatric Surgery, Hopital Robert Debre, AP-HP, Paris, 75019, France. arnaud.bonnard@rdb.aphp.fr

BACKGROUND: Preoperative endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy (ES) are an effective strategy for choledocholithiasis, but complications such as pancreatitis and outcome in children are unknown. The laparoscopic cholecystectomy became the new gold standard in children for cholelithiasis. For the choledocholithiasis in children, the attitude is more controversial. We analyzed our series of laparoscopic approach for the management of choledocholithiasis in children to determine if it is an effective procedure. PATIENTS AND METHOD: Between 1996 and 2001, 126 children were treated for cholelithiasis in our institution; 13 children (10.3%) were managed for a choledocholithiasis. We reviewed age at symptom onset results of paraclinical examinations, the type of laparoscopic management, and postoperative outcome. RESULTS: The mean age at clinical signs was 9.9 years (range, 3 months-15.5 years). One child was excluded because he had a preoperative ES. Twelve children had a laparoscopic cholecystectomy and cholangiogram at the same time. A choledocholithiasis was found in 10 cases. A flush of the common bile duct (CBD) was performed in all cases with a 3F or 5F ureteral catheter; the stone was pushed into the duodenum in 3 cases and successfully extracted in 3 with a 4F Dormia or Fogarty catheter. One child needed a conversion to open surgery. Three times, an ES was necessary in postoperative course in each case for clinical and biologic signs of CBD obstruction or pancreatitis (30%). All children are symptom-free with an average follow-up of 28 months. CONCLUSION: Laparoscopic CBD exploration for choledocholithiasis can be performed safely in children at the time of cholecystectomy and can clear all of the stones in the CBD in two thirds of cases. If there is residual obstruction, a postoperative ES can be performed. We suggest primary treatment of choledocholithiasis by laparoscopic approach in children.

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Am Surg. 2005 Aug;71(8):682-6.
Early versus delayed single-stage laparoscopic eradication for both gallstones and common bile duct stones in mild acute biliary pancreatitis.
Griniatsos J, Karvounis E, Isla A.
Upper GI and Laparoscopic Unit, Ealing Hospital, Southall-Middlesex, London, United Kingdom.

Several studies addressed that preoperative endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) clearance, followed by interval laparoscopic cholecystectomy (two-stage approach), constitutes the most common practice in cases of uncomplicated mild acute biliary pancreatitis. Between June 1998 and December 2002, 44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were treated in our unit. All patients were electively submitted to surgery after subsidence of the acute symptoms, and for definitive treatment we favored the single-stage laparoscopic management, avoiding preoperative ERCP. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. Twenty patients were operated upon within 2 weeks since the attack of the acute symptoms and constitute the early group (n=20), whereas 24 patients underwent an operation later on and constitute the delay group (n=24). We retrospectively compare the safety, effectiveness, and outcome after the single-stage laparoscopic management between the two groups of patients. Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients, while an additional LCBDE was performed in the remaining 6 patients (14%), and all operations were achieved laparoscopically. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay. During the follow-up, none of the patients experienced recurrent pancreatitis. In uncomplicated mild acute biliary pancreatitis cases, a single-stage definitive laparoscopic management, avoiding preoperative ERCP, can be safely performed during the same admission, after the improvement of symptoms and local inflammation. Postoperative ERCP should be selectively used in patients in whom the single-stage method failed to resolve the problem.

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Am Fam Physician. 2005 Aug 15;72(4):637-42.
Management of gallstones.
Bellows CF, Berger DH, Crass RA.
Baylor College of Medicine, Houston, Texas, USA.

Many patients with gallstones can be managed expectantly. Generally, only persons with symptoms related to the presence of gallstones (e.g., steady, nonparoxysmal pain lasting four to six hours located in the upper abdomen) or complications (such as acute cholecystitis or gallstone pancreatitis) warrant surgical intervention. Biliary pain is alleviated by cholecystectomy in the majority of cases. Laparoscopic cholecystectomy is considered the most cost-effective management strategy in the treatment of symptomatic gallstones. Medical management strategies are mostly palliative and are not widely supported. Patients with longer-lasting biliary pain, in combination with abdominal tenderness, fever, and/or leukocytosis, require an ultrasound evaluation to help establish a diagnosis of acute cholecystitis. Once a patient is diagnosed, having cholecystectomy early in the course of the disease can significantly reduce the hospital stay.

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Proc (Bayl Univ Med Cent). 2005 Jul;18(3):211-3.
Usefulness of endoscopic ultrasound in patients at high risk of choledocholithiasis.
Dittrick G, Lamont JP, Kuhn JA, Mallat D.
Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) has been considered the nonsurgical gold standard for the diagnosis and treatment of choledocholithiasis (CDL). Complications include a 0.1% to 1.3% mortality rate and a 5% to 19% morbidity rate, including a reported 1.8% to 6.7% incidence of postprocedure pancreatitis. Twenty-seven percent to 67% of ERCPs done for suspected choledocholithiasis ultimately have negative results. Endoscopic ultrasound (EUS) has been proposed as an alternate means of diagnosing choledocholithiasis that may eliminate the need for ERCP and its associated morbidities in certain patients. METHODS: Retrospective chart review identified 30 patients who underwent EUS with or without ERCP for suspected choledocholithiasis. Reports of all procedures performed were obtained and data were collected on all biliary abnormalities identified on both EUS and ERCP. RESULTS: Pancreaticobiliary abnormalities were identified in 27 of 30 patients (90%) at EUS. Most common diagnoses included CDL (n = 9, 30%), biliary sludge (n = 11, 37%), pancreatitis (n = 8, 27%), and cholelithiasis (n = 7, 23%). Subsequent ERCP was performed in 14 patients (47%). Indications included a diagnosis of CDL by EUS (n = 9) and abnormal liver function tests (n = 5). CDL was identified in 5 of 14 patients (36%), and microlithiasis/biliary sludge was identified in an additional 5 patients (36%). In 4 patients, CDL was identified by EUS but not by ERCP. ERCP did not identify any new cases of CDL after EUS: of 21 patients without evidence of CDL on EUS, none were subsequently shown to have CDL or to develop any complications related to common duct stones. CONCLUSIONS: EUS is an effective method of diagnosing CDL. It demonstrates both a high sensitivity and specificity for identifying common bile duct stones. Its use as a screening modality in patients suspected of having CDL may allow more selective use of ERCP.

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J Long Term Eff Med Implants. 2005;15(3):329-38.
Cholelithiasis and cholecystitis.
Schirmer BD, Winters KL, Edlich RF.
Department of Surgery, University of Virginia Health System Charlottesville VA 22908, USA. bs@virginia.edu

Gallstone disease remains one of the most common medical problems leading to surgical intervention. Every year, approximately 500,000 cholecystectomies are performed in the US. Cholelithiasis affects approximately 10% of the adult population in the United States. It has been well demonstrated that the presence of gallstones increases with age. An estimated 20% of adults over 40 years of age and 30% of those over age 70 have biliary calculi. During the reproductive years, the female-to-male ratio is about 4:1, with the sex discrepancy narrowing in the older population to near equality. The risk factors predisposing to gallstone formation include obesity, diabetes mellitus, estrogen and pregnancy, hemolytic diseases, and cirrhosis. A study of the natural history of cholelithiasis demonstrates that approximately 35% of patients initially diagnosed with having, but not treated for, gallstones later developed complications or recurrent symptoms leading to cholecystectomy. During the last two decades, the general principles of gallstone management have not notably changed. However, methods of treatment have been dramatically altered. Today, laparoscopic cholecystectomy, laparoscopic common bile duct exploration, and endoscopic retrograde management of common bile duct (CBD) stones play important roles in the treatment of gallstones. These technological advances in the management of biliary tract disease are not infrequently accomplished by a multidisciplinary team of physicians, including surgeons trained in laparoscopic techniques, interventional gastroenterologists, and interventional radiologists. With the evolution of laparoscopic cholecystectomy, there has been a global reeducation and retraining program of surgeons. However, the treatment of choice for gallstones remains cholecystectomy. In recognition of the revolutionary advances in the treatment of cholelithiasis, it is the purpose of this collective review to describe recent information on the following topics: types of gallstones, asymptomatic gallstones, symptomatic gallstones, chronic cholecystitis, acute cholecystitis, and other complications of gallstones. Gross and compositional analysis of gallstones allows them to be classified as cholesterol, mixed, and pigment gallstones. When asymptomatic gallstones are detected during the evaluation of a patient, a prophylactic cholecystectomy is normally not indicated because of several factors. Only about 30% of patients with asymptomatic cholelithiasis will warrant surgery during their lifetime, suggesting that cholelithiasis can be a relatively benign condition in some people. However, there are certain factors that predict a more serious course in patients with asymptomatic gallstones and warrant a prophylactic cholecystectomy when they are present. These factors include patients with large (>2.5 cm) gallstones, patients with congenital hemolytic anemia or nonfunctioning gallbladders, or during bariatric surgery or colectomy. Epigastric and right upper quadrant pain occurring 30-60 minutes after meals is frequently associated with gallstone disease. The diagnosis of chronic cholecystitis is made by the presence of biliary colic with evidence of gallstones on an imaging study. Ultrasonography is the diagnostic test of choice, being 90-95% sensitive. The surgical literature suggests that 3-10% of patients undergoing cholecystectomy will have CBD stones. Intraoperative laparoscopic ultrasonography has recently replaced cholangiography as the method of choice for detecting CBD stones. Ultrasonography and radionuclide cholescintigraphy (HIDA scan) are useful in establishing a diagnosis of acute cholecystitis. Laparoscopic cholecystectomy should also be used in the treatment of acute cholecystitis. Laparoscopic cholecystectomy is more likely to be successful when performed within 3 days of the onset of symptoms. It is important to remember that gallstones can lead to a variety of other complications including choledocholithiasis, gallstone ileus, and acute gallstone pancreatitis.

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Ugeskr Laeger. 2005 Jun 13;167(24):2644-8.
[Outpatient laparoscopic cholecystectomy--two years of experience]
[Article in Danish]
Bardram L, Klarskov B, Rosenberg J, Lund CM, Kehlet H.
Kirurgisk Sektion, Gastroenheden, H:S Hvidovre Hospital, DK-2650 Hvidovre.

INTRODUCTION: By careful selection of both patients and surgeon, outpatient laparoscopic cholecystectomy can be performed in up to 90% of elective patients. The rate of same-day discharge in an unselected group scheduled for elective operation is, however, not clarified. MATERIALS AND METHODS: A clinical pathway for outpatient laparoscopic cholecystectomy was introduced as the standard procedure for all patients undergoing elective operation. The set-up allowed easy access to an overnight stay if needed. Hospital stay, complications, reasons for admittance, the need for medical advice after discharge, convalescence and patients" satisfaction were analysed. Prospective registrations were undertaken in a standard care plan, and a questionnaire was sent out after four weeks. RESULTS: During two years of the study, 535 patients had a cholecystectomy done. Of these, 403 were scheduled for elective laparoscopic operation and entered the clinical pathway. In 62% of the patients, the outpatient course was successfully completed, and 94% of the patients were discharged within 24 hours. In 2%, complications resulted in hospital stays longer than three days, and 2.7% of the operations were converted. About one third of the patients needed additional medical advice after discharge, and 4.3% of these were readmitted. Pain was among the most frequent complaints. The patients" satisfaction with the procedure was approximately 90%. DISCUSSION: In an unselected group of patients scheduled for elective laparoscopic cholecystectomy, about two thirds can be treated as outpatients with a high degree of safety and patients" satisfaction. Further development, especially in the multimodal treatment of pain, is still the most important area to focus on in order to reduce postoperative complaints and improve the course of convalescence.

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Endoscopy. 2005 Jun;37(6):542-7.
Single-operator duodenoscope-assisted cholangioscopy is an effective alternative in the management of choledocholithiasis not removed by conventional methods, including mechanical lithotripsy.
Farrell JJ, Bounds BC, Al-Shalabi S, Jacobson BC, Brugge WR, Schapiro RH, Kelsey PB.
Division of Digestive Diseases, UCLA School of Medicine, University of California at Los Angeles Center for the Health Sciences, Los Angeles, California 90095, USA. jfarrell@mednet.ucla.edu

BACKGROUND AND STUDY AIMS: The widespread use of cholangioscopy in the management of difficult choledocholithiasis has been limited by the need for two expert operators. This report describes the use of a technique of single-operator duodenoscope-assisted cholangioscopy (SODAC) in the successful management of 75 patients with choledocholithiasis. PATIENTS AND METHODS: The single-operator technique, allowing simultaneous control of both the duodenoscope and cholangioscope, was prospectively studied between June 1999 and June 2001 in the diagnosis and treatment of choledocholithiasis. RESULTS: A total of 109 SODAC procedures were conducted in 75 patients to manage choledocholithiasis. The indications were: firstly, SODAC-guided electrohydraulic lithotripsy (EHL) of stones in which conventional methods, including mechanical lithotripsy, had not been successful (52 SODAC procedures in 26 patients); and secondly, direct visualization of the biliary tree after cholangiography to assess the presence of stones (57 SODAC procedures in 49 patients). The locations and numbers of the stones, but not their size, were predictive of the number of SODAC-guided lithotripsy sessions required. All of the patients were free of stones at the end of the study period, and no complications were recorded. CONCLUSIONS: Single-operator SODAC-guided electrohydraulic lithotripsy was effective in the treatment of difficult cases of choledocholithiasis in which conventional methods had previously failed. The technique may allow increased use of cholangioscopy in the management of choledocholithiasis.

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Transplant Proc. 2005 Jun;37(5):2129-30.
The role of cholecystectomy in renal transplantation.
Sianesi M, Capocasale E, Ferreri G, Mazzoni MP, Dalla Valle R, Busi N.
Department of Surgery, Institute of General Surgery and Organ Transplantation, University of Parma, Enzi Capocasale, Via Bizzozero 7, 43100 Parma, Italy. chirtrap@unipr.it

INTRODUCTION: We reviewed our clinical experience to assess the role of cholecystectomy transplant candidates pre- and posttransplantation. METHODS: Between April 1986 and December 2003, 57 (6.8%) candidates among 839 kidney transplants were found during routine pretransplant screening to show gallstones. RESULTS: Thirty nine (68.4%) symptomatic patients underwent cholecystectomy before transplantation. Among 18 (31.6%) asymptomatic patients monitored after transplantation, the 7 (39%) who developed biliary tract symptoms underwent laparoscopy or minilaparocholecystectomy without postoperative morbidity, mortality, or graft loss. CONCLUSIONS: Symptomatic gallstones have to be treated using the laparoscopic cholecystectomy or minilaparotomy technique. In asymptomatic cholelithiasis prophylactic cholecystectomy is only reserved for patients with biliary "intrinsic" risk factors. An early diagnosis and prompt surgical treatment yields good results.

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J Gastrointest Surg. 2005 May-Jun;9(5):739-46.
Gallstones in chronic liver disease.
Silva MA, Wong T.
Liver Surgical Secretaries, The Liver Unit, Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Edgbaston, Birmingham, United Kingdom. M.A.Silva@bham.ac.uk

Gallstones occur more commonly in patients with cirrhosis. The incidence increases with severity of liver disease, and the majority remain asymptomatic. When symptoms do occur, morbidity and mortality are much higher than in noncirrhotic patients. Asymptomatic gallstones in cirrhotic patients are best managed conservatively with close follow-up and surgery if symptoms occur. The management of asymptomatic gallstones found incidentally at abdominal surgery for another indication is controversial. Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis in patients with well-compensated liver disease, whereas patients with choledocholithiasis are best managed endoscopically. Symptomatic cholelithiasis in the decompensated patient remains a challenge, and these patients are best managed in specialized hepatobiliary centers. This review examines the evidence currently available on gallstones in chronic liver disease and the factors that influence its management.

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J Hepatobiliary Pancreat Surg. 2005;12(2):163-6.
Telerobotic-assisted laparoscopic cholecystectomy: our experience on 29 patients.
Caratozzolo E, Recordare A, Massani M, Bonariol L, Jelmoni A, Antoniutti M, Bassi N.
Fourth Unit of Surgery, Regional Reference Center of Hepato-Biliary-Pancreatic Surgery, Regional Hospital Ca Foncello Piazza Ospedale, 31100, Treviso, Italy.

BACKGROUND/PURPOSE: The role of computer-assisted surgery (CAS) is still debated and not clearly defined. METHODS: The authors report their initial experience with CAS, comparing 29 patients submitted to cholecystectomy, using a Zeus remote-controlled robot and an Aesop remote voice-activated endoscope robot, with 29 patients submitted to standard laparoscopic cholecystectomy (LC). The surgical field and the arms of the robot were under the direct and real-time control of the surgeon, who stayed at the workstation and maneuvered the Zeus, using joysticks. The workstation was in the same room as the patient. RESULTS: Twenty-nine patients underwent telerobotic-assisted cholecystectomy (TLAC); 1 procedure was converted to standard LC and 1 to open cholecystectomy. The conversions were due to choledocholithiasis and cholecystitis. During TLAC, the mean operating time and transition time (from the induction of anesthesia to incision of the skin) were, respectively, 75 min (range, 60-170 min) and 45 min (range, 25-60 min). We did not observe any complications related to TLAC. The limitations of TLAC were the lack of tactile feedback, the increase in surgical time, and the expensive cost of the procedure to reach the same result as that of LC. CONCLUSIONS: After this initial experience, we believe that TLAC could be considered only for training in CAS, but that it is without advantages in terms of its higher cost compared with LC.

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Am Surg. 2005 Apr;71(4):281-5.
Long-term follow-up after robotic cholecystectomy.
Bodner J, Hoeller E, Wykypiel H, Klingler P, Schmid T.
Department of General and Transplant Surgery, Innsbruck Medical University, Innsbruck, Austria.

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

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Eur J Gastroenterol Hepatol. 2005 May;17(5):525-7.
Extracorporeal shock wave lithotripsy of gallstones: 20th anniversary of the first treatment.
Paumgartner G, Sauter GH.
Department of Medicine II, University Hospital Munich-Grosshadern, Germany.

Twenty years ago, in January 1985, extracorporeal shock wave lithotripsy (ESWL) was first applied successfully in a patient with gallbladder stones. In the following years, the conditions which influence the success rate of ESWL have been extensively investigated. It was shown that the characteristics of the stones, gallbladder emptying and the degree of stone fragmentation are the most important factors which determine the clearance of all fragments from the gallbladder after ESWL. Severe side effects, such as biliary pancreatitis and liver haematoma, were found to be rare and no deaths related to the procedure have been reported. One or more episodes of biliary pain were observed in about one third of patients within the first 3-4 months after ESWL. Follow-up studies after successful treatment, however, have shown that stone recurrence is considerable, limiting the use of ESWL as a non-invasive therapeutic option. Stone recurrence varies between different subgroups of patients indicating that gallbladder motor function and other less well defined factors may be of importance. The recurrence of stones after ESWL is one of the reasons why laparoscopic cholecystectomy has become the standard treatment of symptomatic gallbladder stones today. ESWL has kept its role only in the treatment of bile duct stones resistant to endoscopic extraction. Unless stone recurrence can be decreased by better patient selection and/or other measures to prevent gallstone recurrence, ESWL of gallbladder stones has little chance of surviving.

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World J Gastroenterol. 2005 May 7;11(17):2678-80.
Endoscopic sphincterotomy in the treatment of cholangiopancreatic diseases.
Li ZH, Chen M, Liu JK, Ding J, Dong JH.
Institute of Hepatobiliary Surgery of PLA, Southwest Hospital, Third Military Medical University, Chongqing 400038, China. jhdong@hbsky.com.cn.

AIM: To investigate the therapeutic effect of endoscopic sphincterotomy (EST) in the treatment of choledocholithiasis and stenosing papillitis. METHODS: A total of 1 026 patients undergoing EST during July 1983 to May 2003 at the institute were retrospectively analyzed. Chronic pancreatitis was diagnosed in 63 (6.1%), cholecystolithiasis and choledocholithiasis in 549 (53.5%), stones in residual biliary duct in 249 (24.3%), stenosing papillitis in 228 (22.2%). In patients with simple stenosing papillitis, most incisions were within 0.5-1 cm in length. As for patients with chronic pancreatitis simultaneously, selective pancreatic sphincterotomy was performed, and incision was within 0.5-0.8 cm in length. For stones less than 1 cm, incision was from 1 to 1.5 cm, and for those larger than 1 cm, incision ranged from 1.5 to 3 cm. For stones more than 2 cm in diameter, detritus basket rather than simple incision was chosen. RESULTS: Of the 798 patients with choledocholithiasis, 764 (93.5%) had successful stone clearance, 215 (94.3%) out of 228 cases of stenosing papillitis were cured totally, while 63 had chronic pancreatitis developed from stenosing papillitis, 57 (90.1%) had sound remission of symptoms, though membranous stenosis emerged in 13 of 57 which was treated with balloon dilatation. After the operation, only 21 cases (2.1%) had complications such as severe pancreatitis and incision bleeding. None of the patients died. CONCLUSION: EST is an ideal surgical management with mini-invasion in the treatment of choledocholithiasis and stenosing papillitis.

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Arch Surg. 2005 Apr;140(4):359-61.
Is there a role for routine preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in children?
Vrochides DV, Sorrells DL Jr, Kurkchubasche AG, Wesselhoeft CW Jr, Tracy TF Jr, Luks FI.
Division of Pediatric Surgery, Hasbro Children's Hospital, Providence, RI 02905, USA.

HYPOTHESIS: Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used preoperatively in adult patients with suspected choledocholithiasis. Cholelithiasis occurs much less often in children, and the indications for ERCP are not established. We hypothesized that the natural history of choledocholithiasis in children is spontaneous passage of stones through the papilla and that these children can be managed without routine preoperative ERCP. DESIGN: Retrospective analysis of patients treated over a 10-year period. SETTING: Tertiary care children's hospital. PATIENTS: All patients with cholecystectomy for biliary disease. INTERVENTIONS: Cholecystectomy; intraoperative cholangiography for suspected choledocholithiasis: hyperbilirubinemia, gallstone pancreatitis, and ultrasonographic evidence of common bile duct dilation or common bile duct stones; and postoperative ERCP for symptomatic choledocholithiasis: pain and jaundice. MAIN OUTCOME MEASURES: Incidence and complications of choledocholithiasis and frequency of ERCP. RESULTS: One hundred patients (63 females) were studied. Indications included acute cholecystitis (10%), chronic cholecystitis (59%), gallstone pancreatitis (26%), and choledocholithiasis (5%). An intraoperative cholangiography was performed in 45 patients, and common bile duct stones were identified in 13. Expectant management of asymptomatic common bile duct stones was associated with sonographic resolution within 1 week. One patient with intraoperative cholangiography-proven choledocholithiasis required ERCP for symptoms 24 hours after operation. One additional patient, who did not undergo intraoperative cholangiography, developed symptomatic choledocholithiasis and required ERCP. There were no choledocholithiasis- or ERCP-related complications. CONCLUSIONS: This study suggests that choledocholithiasis occurs frequently in children and that spontaneous passage of common bile duct stones is common. This could explain the relatively high incidence of gallstone pancreatitis. Conservative management of choledocholithiasis is successful in the majority of patients. Routine preoperative or postoperative ERCP is usually not indicated.

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Obes Surg. 2005 Feb;15(2):243-6.
Laparoscopic cholecystectomy in obese patients.
Simopoulos C, Polychronidis A, Botaitis S, Perente S, Pitiakoudis M.
Second Department of Surgery, Democritus University of Thrace, Alexandroupolis, Greece.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the treatment of choice for gallstones. Obesity was initially considered a contraindication to this approach. The aim of this report is to review our experience with LC, to evaluate the role of BMI in the outcome. METHODS: The records of 1,804 patients who underwent LC for symptomatic cholelithiasis from May 1992 to January 2004 were analyzed retrospectively. Patients were divided into 5 groups according to their BMI: < or =24.9, 25.0-29.9, 30.0-34.9, 35.0-39.9 and > or =40 kg/m2. RESULTS: Of the 1,804 patients [1,379 females (76.4%) and 425 males (23.6%)] who underwent LC, 431(23.9%), 924 (51.2%), 355 (19.7%), 68 (3.8%) and 26 (1.4%) had BMI values of < or =24.9, 25.0-29.9, 30.0-34.9, 35.0-39.9 and > or =40 kg/m2, respectively. Conversion to open cholecystectomy was required in 94 patients (5.2%), and complications occurred in 39 patients (2.2%). There was no correlation between BMI and the conversion rate (P=0.593) and complication rate (P=0.944), while the hospital stay was similar between the groups with successful LC. The only significant difference was the longer operating time in the two obesity groups (P<0.001). CONCLUSIONS: LC is effective and safe in patients with morbid obesity. As it carried low risks of conversion and perioperative complications, we suggest that LC is the select approach for these patients. Moreover, the rapid mobilization and hospital discharge following LC may provide extra benefit to these patients.

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Ann Emerg Med. 2005 Feb;45(2):172-6.
Treatment of suspected symptomatic cholelithiasis with glycopyrrolate: a prospective, randomized clinical trial.
Antevil JL, Buckley RG, Johnson AS, Woolf AM, Thoman DS, Riffenburgh RH.
Department of General Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA.

STUDY OBJECTIVE: Glycopyrrolate is advocated for the treatment of acute pain from suspected symptomatic cholelithiasis. However, there is no clinical evidence to substantiate its use. This study is designed to evaluate the efficacy of glycopyrrolate in relieving acute abdominal pain of suspected biliary tract origin. METHODS: Between July 2002 and April 2003, a convenience sample of patients presenting to the emergency department with upper abdominal pain of suspected biliary tract origin was randomized to receive either intravenous glycopyrrolate or placebo (normal saline solution). Pain level was assessed at baseline using a visual analog scale, with a repeat assessment 20 minutes after intervention. Patients and clinicians were blinded to the study drug. RESULTS: Because of difficulty with patient enrollment, the trial was terminated before achievement of the initial goal of 54 patients. On analysis of the 38 patients completing the study protocol, glycopyrrolate and placebo groups had similar demographic and baseline characteristics. There was no significant difference in pain relief between patients receiving glycopyrrolate and those receiving placebo (median decrease in visual analog pain scale pain 3 mm [95% confidence interval -2 to 17 mm] versus 8 mm [95% confidence interval -2 to 20 mm], respectively). CONCLUSION: Although limited by small size and convenience sampling, these results fail to demonstrate any improvement in pain of suspected biliary tract origin with the administration of glycopyrrolate. Further study is needed to determine whether intravenous glycopyrrolate has any significant analgesic effect for patients with this condition.

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Chir Ital. 2005 Jan-Feb;57(1):35-45.
[Therapy of asymptomatic gallstones: indications and limits]
[Article in Italian]
Picci R, Perri SG, Dalla Torre A, Pietrasanta D, Castaldo P, Nicita A, Del Prete M, Meli M, Moraldi A.
Scuola di Specializzazione in Chirurgia Generale, Universita degli Studi di Roma Tor Vergata.

Gallstone disease is one of the most common health problems world-wide. It is also one of the main causes of medical expenditure in Western countries. Asymptomatic gallstones are defined as stones that have not given rise to biliary cholic or other biliary symptoms. A number of epidemiological cross-sectional screening studies have shown that as many as 66 to 77% of patients with gallstones are asymptomatic. Opinion regarding the development of the disease in the asymptomatic patients has changed in the course of time. In 1992 Friedman, in his review of literature, established that only 1-2% of asymptomatic patients developed severe symptoms or complications early, with fewer complications developing in later years than in the years soon after discovery of the gallstones. Recent prospective epidemiological studies have established that no particular factor has any effect on the natural course of the disease. Laparoscopic cholecystectomy is the gold standard for symptomatic gallstones, but the management of patients with asymptomatic stones remains controversial. This problem is related to the incidence of biliary lesions which has remained substantially unchanged over the past few years. It has recently been demonstrated that the risk of iatrogenic lesions is not entirely dependent upon the surgeon's experience. There is a substantial consensus of agreement that surgical treatment has an unfavourable cost:benefit ratio in asymptomatic patients. The Authors conclude that, because of the condition's benign natural history, a wait-and-see policy is to be recommended in all asymptomatic patients, except for only a few selected cases.

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World J Gastroenterol. 2005 Jan 28;11(4):593-6.
Outcome of simple use of mechanical lithotripsy of difficult common bile duct stones.
Chang WH, Chu CH, Wang TE, Chen MJ, Lin CC.
Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Mackay Medicine, Nursing and Management College, Taipei, Taiwan. d220533864@yahoo.com.tw

AIM: The usual bile duct stone may be removed by means of Dormia basket or balloon catheter, and results are quite good. However, the degree of difficulty is increased when stones are larger. Studies on the subject reported many cases where mechanical lithotripsy is combined with a second technique, e.g. electrohydraulic lithotripsy (EHL), where stones are crushed using baby-mother scope electric shock. The extracorporeal shock-wave lithotripsy (ESWL) or laser lithotripsy also yields an excellent success rate of greater than 90%. However, the equipment for these techniques are very expensive; hence we opted for the simple mechanical lithotripsy and evaluated its performance. METHODS: During the period from August 1996 to December 2002, Mackay Memorial Hospital treated 304 patients suffering from difficult bile duct stones (stone >1.5 cm or stones that could not be removed by the ordinary Dormia basket or balloon catheter). These patients underwent endoscopic papillotomy (EPT) procedure, and stones were removed by means of the Olympus BML-4Q lithotripsy. A follow-up was conducted on the post-treatment conditions and complications of the patients. RESULTS: Out of the 304 patients, bile duct stones were successfully removed from 272 patients, a success rate of about 90%. The procedure failed in 32 patients, for whom surgery was needed. Out of the 272 successfully treated patients, 8 developed cholangitis, 21 developed pancreatitis, and 10 patients had delayed bleeding, and no patient died. Among these 272 successful removal cases, successful bile duct stone removal was achieved after the first lithotripsy in 211 patients, whereas 61 patients underwent multiple sessions of lithotripsy. As for the 61 patients that underwent multiple sessions of mechanical lithotripsy, 6 (9.8%) had post-procedure cholangitis, 12 (19.6%) had pancreatitis, and 9 patients (14.7%) had delayed bleeding. Compared with the 211 patients undergoing a single session of mechanical lithotripsy, 3 (1.4%) had cholangitis, 1 (0.4%) had delayed bleeding, and 7 patients (3.3%) had pancreatitis. Statistical deviation was present in post-procedure cholangitis, delayed bleeding, and pancreatitis of both groups. CONCLUSION: Mechanical bile stone lithotripsy on difficult bile duct stones could produce around 90% successful rate. Moreover, complications are minimal. This finding further confirms the significance of mechanical lithotripsy in the treatment of patients with difficult bile duct stones.

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Surg Endosc. 2005 Jan 10; [Epub ahead of print]
Expectant treatment or cholecystectomy after endoscopic retrograde cholangiopancreatography for choledocholithiasis in patients over 80 years old?
Pring CM, Skelding-Millar L, Goodall RJ.
Department of Surgery, Calderdale Royal Hospital, Salterhebble, Halifax HX3 OPW, UK, c_pring@yahoo.com.

BACKGROUND: It is recommended that most patients between 18-80 years old, who have had an endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis, should be offered cholecystecytomy. However, we were uncertain whether this was the correct advice for patients over 80. METHOD: A retrospective case note analysis was performed on 81 patients over 80, who had had an ERCP for choledocholithiasis. The primary end points were further biliary symptoms, cholecystectomy, death from biliary independent causes, and those still alive without further biliary symptoms. RESULTS: The records of 81 patients (median age 87; range, 80-96 years) were analyzed. Of the patients, 11% experienced further biliary symptoms at a median time of 4.5 months [interquartile range (IQR), 2.25-8.5 months] from the ERCP; 6% received cholecystectomy; 61% were still alive with no further biliary symptoms at a median time of 17 months (IQR, 12.25-23.75 months) after ERCP; and 22% had died from biliary independent causes at a median time of 9 months after ERCP (IQR, 3-12 months). CONCLUSION: Expectant treatment can be recommended in this group of patients. Those who do present with further biliary symptoms do so soon after ERCP. Therefore, we recommend follow-up for 12 months after ERCP, prior to discharge.

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Am J Surg. 2004 Dec;188(6):755-9.
Medical versus surgical management of biliary tract disease in pregnancy.
Lu EJ, Curet MJ, El-Sayed YY, Kirkwood KS.
Department of Surgery, University of California-San Francisco, 533 Parnassus Avenue, Room U-372, San Francisco, CA 94143-0790, USA.

BACKGROUND: The management of symptomatic cholelithiasis during pregnancy remains controversial. We compared outcomes after medical versus surgical management of biliary tract disease in pregnant patients. METHODS: We reviewed the clinical course of patients with symptomatic cholelithiasis during pregnancy from 1992 to 2002 at two university hospitals. RESULTS: Seventy-six women with 78 pregnancies were admitted with biliary tract disease. Of the 63 women who presented with symptomatic cholelithiasis, 10 underwent surgery while pregnant. There were no deaths, preterm deliveries, or intensive care unit admissions. Fifty-three patients were treated medically. Their clinical courses were complicated by symptomatic relapse in 20 patients (38%), by labor induction to control biliary colic (8 patients), and by premature delivery in 2 patients. Each relapse in the medically managed group accounted for an additional five days in hospital. CONCLUSION: Surgical management of symptomatic cholelithiasis in pregnancy is safe, decreases days in hospital, and reduces the rate of labor induction and preterm deliveries.

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Gut. 2004 Dec;53(12):1856-9.
Endoscopic retreatment of recurrent choledocholithiasis after sphincterotomy.
Sugiyama M, Suzuki Y, Abe N, Masaki T, Mori T, Atomi Y.
Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan. sgym@kyorin-u.ac.jp

BACKGROUND: Endoscopic sphincterotomy (ES) carries a substantial risk of recurrent choledocholithiasis but retreatment with endoscopic retrograde cholangiopancreatography (ERCP) is safe and feasible. However, long term results of repeat ERCP and risk factors for late complications are largely unknown. AIMS: To investigate the long term outcome of repeat ERCP for recurrent bile duct stones after ES and to identify risk factors predicting late choledochal complications. METHODS: Eighty four patients underwent repeat ERCP, combined with ES in 69, for post-ES recurrent choledocholithiasis. Long term outcomes of repeat ERCP were retrospectively investigated and factors predicting late complications were assessed by multivariate analysis. RESULTS: Complete stone clearance was achieved in all patients. Forty nine patients had no visible evidence of prior sphincterotomy. Two patients experienced early complications. During a follow up period of 2.2-26.0 years (median 10.9 years), 31 patients (37%) developed late complications, including stone recurrence (n = 26), acute acalculous cholangitis(n = 4), and acute cholecystitis (n = 1). There were neither biliary malignancies nor deaths attributable to biliary disease. Multivariate analysis identified three independent risk factors for choledochal complications: interval between initial ES and repeat ERCP < or =5 years, bile duct diameter > or =15 mm, and periampullary diverticulum. Choledochal complications were successfully treated with repeat ERCP in 29 patients. CONCLUSIONS: Choledochal complications after repeat ERCP are relatively frequent but are endoscopically manageable. Careful follow up is necessary, particularly for patients with a dilated bile duct, periampullary diverticulum, or early recurrence. Repeat ERCP is a reasonable treatment even for recurrent choledocholithiasis after ES.

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Am J Gastroenterol. 2004 Dec;99(12):2330-4.
Electrohydraulic lithotripsy in 111 patients: a safe and effective therapy for difficult bile duct stones.
Arya N, Nelles SE, Haber GB, Kim YI, Kortan PK.
Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.

BACKGROUND: Choledocholithiasis and intrahepatic bile duct stones pose a significant health hazard, especially in the elderly. The large stone not removable with conventional endoscopic techniques, can be effectively and safely managed with electrohydraulic lithotripsy (EHL). METHODS: This study is a retrospective review of consecutive patients at the Wellesley Central Hospital and St. Michael's Hospital, who underwent peroral endoscopic fragmentation of bile duct stones with EHL under direct cholangioscopic control using a "mother-baby" endoscopic system between October 1990 and March 2002. RESULTS: To date, 111 patients have been analyzed. Of the 111 patients reviewed, 94 patients have had complete records and were included in this study. Mean follow-up was 26.2 months (range 0-80). Prior to EHL, 93 of 94 patients (99%) had endoscopic retrograde cholangiopancreatography (ERCP) and failed standard stone extraction techniques (mean 1.9 ERCPs/patient, range 0-5). Indications for EHL were large stones (81 patients) or a narrow caliber bile duct below a stone of average size (13 patients). Successful fragmentation (61 complete, 28 partial) was achieved in 89 of 93 patients (96%) (1 patient was excluded from analysis due to a broken endoscope). Fragmentation failures were due to targeting problems (2 patients) and hard stones (2 patients). Seventy-six percent of patients required 1 EHL session, 14% required 2 sessions, and 10% required 3 or more. All patients with successful stone fragmentation required post-EHL balloon or basket extraction of fragments. Complications included: cholangitis and/or jaundice (13 patients); mild hemobilia (1 patient); mild post-ERCP pancreatitis (1 patient); biliary leak (1 patient); and bradycardia (1 patient). There were no deaths related to EHL. Final stone clearance was achieved in 85 of 94 patients (90%). CONCLUSIONS: EHL via peroral endoscopic choledochoscopy is a highly successful and safe technique for use in the management of difficult choledocholithiasis and intrahepatic stones. This study has shown a stone fragmentation rate of 96% (89 of 93 patients), and a final stone clearance rate of 90% (85 of 94 patients).

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Dig Dis Sci. 2004 Nov-Dec;49(11-12):1803-7.
Long-term effects of endoscopic papillary balloon dilation on gallbladder motility.
Sugiyama M, Atomi Y.
First Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan. sgym@kyorin-u.ac.jp

We prospectively studied long-term (5 years) effects of endoscopic papillary balloon dilation (EPBD) on gallbladder motility. Thirteen patients with intact gallbladders (six with and seven without gallbladder stones) who had undergone EPBD for choledocholithiasis were enrolled in this study. Gallbladder volumes, while fasting and after dried egg yolk ingestion, were determined by ultrasonography, before and at 7 days, 1 month, and 1, 2, and 5 years after EPBD. Before EPBD, the gallbladder had a larger fasting volume and lower yolk-stimulated maximum contraction than in normal controls. Seven days after EPBD, fasting volume was decreased and maximum contraction was increased, regardless of whether the patient had gallbladder stones, showing significant differences from the pre-EPBD values. At 1 month to 5 years after EPBD, these changes were far less evident and gallbladder function did not differ significantly from baseline. EPBD does not adversely affect gallbladder motility in the long-term (5 years).

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J Gastroenterol Hepatol. 2004 Oct;19(10):1206-1211.
Biliary microlithiasis in patients with idiopathic acute pancreatitis and unexplained biliary pain: Response to therapy.
Saraswat VA, Sharma BC, Agarwal DK, Kumar R, Negi TS, Tandon RK.
Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Abstract Background and Aims: Microlithiasis has been suspected to cause acute pancreatitis and biliary pain. We studied the frequency of microlithiasis and response to treatment in recurrent idiopathic acute pancreatitis (RIAP) and unexplained biliary pain. Methods: Gallbladder bile was examined microscopically for cholesterol monohydrate crystals (CMC) and calcium bilirubinate granules (CBG) in patients with RAIP (n = 24; mean age 36 years, range 18-56 years; 14 men), unexplained biliary pain (n = 12; mean age 32 years, range 22-55 years; six men), gallstones (n = 22; mean age 40 years, range 30-58 years; 12 men) and patients without clinical or imaging evidence of gallstone disease (n = 12; mean age 32 years, range 14-54 years; six men). The presence of a single CMC or >25 CBG/slide was considered abnormal. Results: Bile microscopy was abnormal in 75% patients with RAIP (18/24; CMC in 10, CBG in six, CMC and CBG in two), 83.3% patients with unexplained biliary pain (10/12; CMC in seven, CBG in one, CMC and CBG in two) and 95.4% patients with gallstones (21/22; CMC in 12, CBG in one, CMC and CBG in eight). None of the controls without gallstone disease had CMC while three patients had low counts of CBG. Twenty-eight patients with RAIP and biliary pain having microlithiasis agreed to be treated with cholecystectomy (n = 2), endoscopic sphincterotomy (n = 21) or ursodeoxycholic acid (UDCA; n = 5). The 23 patients treated with cholecystectomy or sphincterotomy remained asymptomatic during follow up (mean 23 months, range 6-48 months). Four of five patients treated with UDCA remained asymptomatic for a follow-up period of 9, 10, 11 and 18 months, respectively. One patient who had refused cholecystectomy or sphincterotomy continued to experience pain at the same frequency as before during a follow-up period of 12 months. One patient, who was asymptomatic on UDCA for 9 months, agreed to undergo sphincterotomy and remained asymptomatic over a follow-up period of 14 months. Conclusions: Microlithiasis is a common cause for idiopathic acute pancreatitis and unexplained biliary pain. Lasting relief is obtained in most patients after treatment with UDCA, cholecystectomy or sphincterotomy.

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Hepatogastroenterology. 2004 Sep-Oct;51(59):1263-6.
Early removal of bile duct stones in patients with acute biliary pancreatitis by endoscopic papillary balloon dilatation.
Toda N, Saito K, Wada R, Komatsu Y, Tada M, Kawabe T, Mitsushima T, Shiratori Y, Omata M.
Department of Gastroenterology, University of Tokyo, Japan toda-2im@h.u-tokyo.ac.jp

BACKGROUND/AIMS: Endoscopic papillary balloon dilatation has been accepted as a novel alternative to endoscopic sphincterotomy for the management of bile duct stones. Hence, little or no attempt was made to retrieve stones in cases with acute biliary pancreatitis by endoscopic papillary balloon dilatation. METHODOLOGY: The present study was conducted in ten patients with acute biliary pancreatitis associated with cholestasis or biliary infection. Two patients came with disseminated intravascular coagulopathy, one Child C liver cirrhosis, and another with prolonged prothrombin time of unknown etiology. After the papilla was dilated with a balloon-tipped catheter, the stones were removed with either a retrieval basket catheter, a retrieval balloon, or both. RESULTS: Clearance of the common bile duct was achieved in all ten patients without any serious complications such as pancreatitis aggravation or hemorrhage. Clinical signs and laboratory findings were strikingly improved in all patients. CONCLUSIONS: The results suggest that bile duct stones can be effectively and safely removed by means of endoscopic papillary balloon dilatation even in patients with acute pancreatitis.

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Am J Gastroenterol. 2004 Aug;99(8):1461-3.
To cut or stretch?
Gerke H, Baillie J.

Endoscopic papillary balloon dilation (EPBD) offers an alternative to endoscopic sphincterotomy (EST), which preserves the barrier function of the biliary sphincter. However, reports of increased complications, especially pancreatitis, have stalled the widespread adoption of this technique. A metaanalysis of randomized trials of EPBD versus EST found similar overall complication rates (10.5% vs 10.3%). However, while postprocedure bleeding was reduced with EPBD compared to EST (0% vs 2.0%), the rate of postprocedure pancreatitis was higher (7.4% vs 4.3%). In addition, 20% of EPBD cases required "rescue" EST. EPBD should probably be reserved for special indications, such as uncorrected or anticipated coagulopathy, and unfavorable endoscopic anatomy for EST. Copyright 2004 American College of Gastroenterology

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Am J Gastroenterol. 2004 Aug;99(8):1455-60.
Endoscopic balloon dilation of the biliary sphincter compared to endoscopic biliary sphincterotomy for removal of common bile duct stones during ERCP: a metaanalysis of randomized, controlled trials.
Baron TH, Harewood GC.
Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Medical Center, Rochester, Minnesota, USA.

OBJECTIVES: To compare the effect of endoscopic balloon dilation (EPBD) of the papilla with that of endoscopic biliary sphincterotomy (EST) in the treatment of patients with common bile duct stones. METHODS: Searches of computerized bibliographic and scientific citations, and review of citations in relevant primary articles. Eight fully published prospective, randomized trials in English that compared EPBD with EST for the removal of common bile duct stones were subjected to metaanalysis. RESULTS: EPBD compared with EST resulted in similar outcomes with regards to overall successful stone removal (94.3% vs 96.5%) and overall complications (10.5% vs 10.3%). Bleeding occurred less frequently with EPBD (0% vs 2.0%, p = 0.001). Post-ERCP pancreatitis occurred more commonly in the EPBD group (7.4% vs 4.3%, p = 0.05). No significant differences were seen in the rates of perforation or infection. Patients undergoing EPBD were more likely to require mechanical lithotripsy for stone extraction (20.9% vs 14.8%, p = 0.014). CONCLUSIONS: On the basis of lower rates of bleeding, EPBD should be the preferred strategy over EST for endoscopic removal of common bile duct stones in patients with coagulopathy. Although EPBD is theoretically attractive for use in young patients for biliary sphincter preservation, the rate of pancreatitis is higher with EPBD and cannot be routinely recommended at this time. Copyright 2004 American College of Gastroenterology

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Surg Endosc. 2004 Aug;18(8):1216-23. Epub 2004 Jun 23.
The AESOP robot system in laparoscopic surgery: Increased risk or advantage for surgeon and patient?
Kraft BM, Jager C, Kraft K, Leibl BJ, Bittner R.
Department of General and Visceral Surgery, Marienhospital Stuttgart, Boheimstrasse 37, D-70199, Stuttgart, Germany, barbarakraft@vinzenz.de

BACKGROUND. The aim of this study was to examine the advantages and risks of the Automated Endoscopic System for Optical Positioning (AESOP) 3000 robot system during uncomplicated laparoscopic cholecystectomies or laparoscopic hernioplasty.METHODS. In a randomized study, we examined two groups of 120 patients each with the diagnosis cholecystolithiasis respectively the unilateral inguinal hernia. We worked with the AESOP 3000, a robotic arm system that is voice-controlled by the surgeon. The subjective and objective comfort of the surgeon as well as the course and length of the operation were measured.RESULTS. The robot-assisted operations required significantly longer preparation and operation times. With regard to the necessary commands and manual camera corrections, the assistant group was favored. The same was true for the subjective evaluation of the surgical course by the surgeon.CONCLUSIONS. Our study showed that the use of AESOP during laparoscopic cholecystectomy and hernioplasty is possible in 94% of all cases. The surgeon must accept a definite loss of comfort as well as a certain loss of time against the advantage of saving on personnel.

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Trop Gastroenterol. 2004 Apr-Jun;25(2):65-8.
Silent gallstones: a therapeutic dilemma.
Gupta SK, Shukla VK.
Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India.

Asymptomatic gall stones are defined as stones that have not caused biliary colic or other biliary symptoms. Nearly two-third of patients with gall stones are asymptomatic. Studies of the natural history of asymptomatic gall stones suggest that the cumulative probability of developing biliary colic after 10 years ranges from 15% to 25%. The incidence of other complications is much less. The operative mortality of elective cholecystectomy is <0.5% but increased mortality is seen in elderly persons (>60 year of age), particularly in those with complications such as acute cholecystitis. Most decision analysis studies do not favour prophylactic cholecystectomy for asymptomatic cholelithiasis. Nonetheless, many studies have listed certain criteria for carrying out elective cholecystectomy in asymptomatic patients. The authors, from their own experience and after reviewing the literature, propose the following criteria for cholecystectomy: life expectancy >20 years, calculi >3 cm in diameter, particularly in individuals in geographical regions with a high prevalence of gall bladder cancer or calculi <3 mm, chronically obliterated cystic duct, non-functioning gallbladder and calcified (porcelain) gallbladder. The widespread use of diagnostic abdominal ultrasonography has led to the increasing detection of clinically unsuspected gall stones. This, in turn, has given rise to a great deal of controversy regarding the optimal management of asymptomatic or 'silent' gall stones. While cholecystectomy is the undisputed gold standard treatment for symptomatic gall stones, the natural history of silent gall stones is not known well enough to recommend a definitive therapeutic strategy for such patients. The treatment options for asymptomatic or silent gall stones range from no treatment to selective cholecystectomy in at-risk group to elective cholecystectomy in all patients. There are a large number of proponents for each of these options so that each merits careful consideration. In this article, the authors examine the evidence for and against treating silent gall stones with the aim of providing more specific guidelines for the management of patients found to have asymptomatic gall stones.

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Dtsch Med Wochenschr. 2004 Jul 9;129(28-29):1548-50.
Evidence based prevention of cholecystolithiasis.
Lammert F, Matern S.
Medizinische Klinik III, Universitatsklinikum Aachen, RWTH Aachen, Aachen.

Evidence based prevention of cholecystolithiasis. Cholesterol cholelithiasis is one of the most common and expensive gastroenterological diseases. Beside common exogenous risk factors, recent molecular genetic studies have identified genetic risk factors for both cholesterol and pigment stone formation. Examples are low phospholipid-associated cholelithiasis due to mutations of the gene encoding the hepatocanalicular phosphatidylcholine transporter, and pigment stones in association with mutations of the ileal bile salt transporter gene. Evidence-based options for primary prevention of cholecystolithiasis include physical activity, slow weight reduction, regular vitamin C supplementation, and moderate coffee consumption. The ongoing genome projects provide the basis for future epidemiological studies of human gallstone (LITH) genes, which might offer new prospects for individual risk assessment and prevention of gallstones.

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Indian J Gastroenterol. 2004 May-Jun;23(3):102-6.
The management of bile duct stones.
Roberts-Thomson IC.
Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, Australia. ian.roberts-thomson@nwahs.sa.gov.au

Bile duct stones are almost always associated with gallbladder stones and coexist with gallbladder stones in approximately 10% of patients. The frequency of coexisting bile duct stones increases with advancing age. In patients with stones in both the gallbladder and bile duct, therapeutic options for the latter include laparoscopic or open exploration of the bile duct, and pre-operative and post-operative endoscopic sphincterotomy and stone extraction. Endoscopic sphincterotomy remains the treatment of choice for bile duct stones after cholecystectomy. However, management algorithms in individual institutions will be influenced by surgical and endoscopic expertise and by other factors such as overall costs. After surgical or endoscopic removal of bile duct stones, estimates of the lifetime risk of recurrent stones range from 5%-20%. Increased life expectancy and the apparent absence of simple preventative measures indicate that the burden of bile duct stones on health expenditure is likely to increase in many countries.

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Am J Surg. 2004 Jun;187(6):747-50.
Laparoscopic cholecystectomy in geriatric patients.
Majeski J.
drmajeski@aol.com

BACKGROUND: The results and advantages of laparoscopic cholecystectomy in the geriatric population have received minimal attention. Several early reports related high conversion rates complications and mortality. This case series review is focused on the results of laparoscopic cholecystectomy in the geriatric population in a private practice environment. METHODS: The records of all patients undergoing cholecystectomy by the author over the past 12 years were reviewed. The entire series consists of 248 patients in whom 239 procedures were completed laparoscopically, with 9 patients converted to an open cholecystectomy. This report identifies 82 patients who were aged 65 years or older at the time of the laparoscopic cholecystectomy. The results of this series are reported in three progressive geriatric age groups: 65 to 74, 75 to 84, and 85 to 95 years. RESULTS: All 82 geriatric patients reported from this series were symptomatic from their gallbladder disease. A majority of all patients in all age groups were female. Gallstones were present in 77 patients, and 5 patients had a gallbladder ejection fraction of less than 35%. In this series of laparoscopic cholecystectomy, 26.8% had an emergent procedure for acute cholecystitis and the remainder had an elective or semielective procedure for symptomatic cholecystitis. The majority of patients between the ages of 65 and 84 years had elective procedures whereas the majority of patients over age 85 had an emergent procedure. There were 2 deaths. The first death (age 86 years) was from extensive metastatic cancer from the gallbladder, and the second patient (age 91 years) died of sepsis and multiple system organ failure. Each patient in this entire series had an attempt at laparoscopic removal of the gallbladder. The conversion rate was 3.6% in the entire series of 248 patients and also 3.6% in the geriatric series. Ninety-one percent of the patients in this geriatric series were discharged home after only 24 to 48 hours of postoperative observation. CONCLUSIONS: Laparoscopic cholecystectomy is a safe procedure in the geriatric population. The procedure should be recommended for all geriatric patients who have symptomatic cholecystitis before the development of acute cholecystitis or severe fibrosis with dense adhesions from chronic cholecystitis.

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Hepatogastroenterology. 2004 May-Jun;51(57):652-7.
Endoscopic papillary balloon dilation for treatment of common bile duct stones.
Watanabe H, Hiraishi H, Koitabashi A, Sasai T, Kanke K, Oinuma T, Otsuka Y, Watanabe Y, Suzuki Y, Terano A.
Department of Gastroenterology, Dokkyo University School of Medicine, Shimotsuga, Tochigi, Japan. hidetaka@dokkyomed.ac.jp

BACKGROUND/AIMS: Use of endoscopic papillary balloon dilation (EPBD) for the treatment of common bile duct stones has increased in recent years, owing to its simplicity and its advantage of preserving sphincter function. It has been reported that EPBD is associated with a lower risk of bleeding, but a higher risk of pancreatitis than endoscopic sphincterotomy. However, there have been few reports on studies of post-EPBD pancreatitis. This report concerns the use of EPBD at our department for the treatment of common bile duct stones and early postoperative complications, with a focus on pancreatitis. METHODOLOGY: The study was conducted in 63 patients with choledocholithiasis, including 4 patients with cirrhosis and 21 patients with periampullary diverticula. The stones were extracted after EPBD conducted with an 8-mm dilatation balloon. RESULTS: Complete removal of stones was achieved in 53 out of 63 patients (84.1%). Pancreatitis meeting the criteria of Cotton et al. occurred in 7 of the 63 patients (11.1%), while 12 patients (19.5%) were affected when milder cases of pancreatitis were included. Severe pancreatitis occurred in 1 patient only. Cholangitis occurred in 3 patients (4.8%) and basket impaction occurred in 1 patient (1.6%), but no serious complications such as bleeding or perforation were encountered. CONCLUSIONS: These results suggest that EPBD is an effective procedure for the treatment of common bile duct stones, with a low risk of serious complications.

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Hepatobiliary Pancreat Dis Int. 2004 May;3(2):284-7.
Combined laparoscopic and endoscopic treatment for bile duct diseases.
Qin MF, Xu HB.
Department of Endoscopic Surgery, Nankai Hospital, Tianjin 300100, China. qins@public.tpt.tj.cn

BACKGROUND: Clinical application of laparoscopy, duodenoscopy and choledochoscopy has been accepted as a mini-invasive surgical therapy for bile duct diseases; but either endoscopic or laparoscopic therapy alone is disadvantageous in its narrow indications and in failure to give full play to the individual superiority. The present study was to evaluate the procedures and therapeutic results of combined laparoscopic and endoscopic treatment for bile duct diseases. METHODS: Clinical data of 1990 patients with bile duct diseases treated by combination of laparoscopy, duodenoscopy and choledochoscopy in two hospitals were reviewed and analyzed. RESULTS: Patients with cholecystolithiasis and choledocholithiasis were treated with combined laparoscopy and duodenoscopy (n=1350) in a single operation with a cure rate of 93.6%. Those with choledocholithiasis (n=332) were treated with combined laparoscopy and choledochoscopy with a cure rate of 100%. Combined laparoscopy, duodenoscopy and choledochoscopy was used in 258 patients with choledocholithiasis (29 of them complicated with pancreatitis) and 24 patients with Mirizzi's syndrome, with a cure rate of 100%. Laparoscopic choledochoenterostomy and preoperative endoscopic nasobiliary drainage were done in 26 patients with a cure rate of 100%. There were no serious operative complications. A follow-up study of 1051 patients for 3 months to 12 years (mean 7.8 years) showed that 10 patients had recurrence of stones but no stenosis of the bile duct. CONCLUSION: Combined laparoscopic and endoscopic procedures are mini-invasive and cause less pain and minimal operative complications.

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Surg Endosc. 2004 May;18(5):762-5. Epub 2004 Feb 02.
Laparoscopic management of common bile duct stones.
Ebner S, Rechner J, Beller S, Erhart K, Riegler FM, Szinicz G.
Department of General Surgery, General Hospital Bregenz, C.-Pedenz-Str. 2, 6900 Bregenz, Austria. stefan.ebner@lkhb.at

BACKGROUND: While laparoscopic cholecystectomy is widely accepted for therapy of cholecystolithiasis, controversy still exists concerning the management of common bile duct stones. Besides preoperative endoscopic papillotomy followed by laparoscopic cholecystectomy and open common bile duct surgery, management of common bile duct stones can be conducted by laparoscopy, if respective experience is available. METHOD: During laparoscopic cholecystectomy a cholangiography via the cystic duct is routinely performed. If bile duct stones are detected they are retrieved via the cystic duct or via incision of the common bile duct by insertion of a Fogarty catheter or Dormia basket. Exclusion criteria against simultaneous laparoscopic management include suspicion of malignancy, severe pancreatitis, or cholangitis. RESULTS: From November 1991 to March 2002, 200 patients primarily underwent laparoscopic therapy of bile duct stones. Retrieval was performed via cystic duct and common bile duct incision in 115 and 85 cases, respectively. Complete removal was achieved in 91%; complication rate and mortality was 7% and 0.5%, respectively. During the same period primary endoscopic papillotomy was necessary in 40 patients because of the above contraindications. CONCLUSIONS: When correct indications and surgical expertise are observed, simultaneous laparoscopic management of common bile duct stones represents a safe and minimally invasive alternative to a two-procedure approach.

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Dig Surg. 2004;21(1):60-4; discussion 65. Epub 2003 Dec 30.
Endoscopic management of common bile duct stones leaving the gallbladder in situ. A cohort study with long-term follow-up.
Schreurs WH, Vles WJ, Stuifbergen WH, Oostvogel HJ.
St. Elisabeth Hospital, Tilburg, The Netherlands. Bartels.schreurs@wxs.nl

BACKGROUND: Obstructive jaundice caused by stones is a common disorder, mostly managed by endoscopic sphincterotomy followed by cholecystectomy. The aim of this study was to evaluate whether or not clearance of the common bile duct alone is sufficient as treatment for patients with choledocholithiasis. METHODS: A cohort with 447 patients with symptomatic cholecystocholedocholithiasis, undergoing endoscopic retrograde cholangiography (ERC) and if necessary sphincterotomy (ES). In 164 patients common bile duct stones were proven and treated endoscopically, without performing a subsequent cholecystectomy. All 164 patients were free of symptoms after the endoscopic intervention. This group of patients was compared with 78 patients who underwent cholecystectomy after endoscopic treatment of common bile duct stones. Patients were followed for 1-13 years after ERC and sphincterotomy results and complications were registered. RESULTS: The ages of the 164 patients in the in situ group were significantly higher than in the cholecystectomy group and the ASA classification (American Society of Anesthesiologists) was significantly higher in the in situ patients. Mean follow-up was 70.9 months. Of the in situ patients 27 (16%) returned with biliary symptoms; 12 with common bile duct stones, three with cholangitis, and one with stenosis of Vater's papilla. Eight patients returned with cholecystitis and 3 with symptomatic cholecystolithiasis. Thirteen patients underwent cholecystectomy and 11 were managed (also) endoscopically. Minor complications were 2 wound infections and 1 bleeding after cholecystectomy. Two patients (1%) died of abdominal sepsis due to cholecystitis. Of the patients who underwent cholecystectomy, 6 (7.6%) returned during follow-up. Three patients had common bile duct stones, 2 had cholangitis and 1 patient presented with papillostenosis. Three patients needed surgical common bile duct exploration and the other 3 were treated endoscopically. After reintervention, cardiopulmonary complications were observed in 1 patient. There was no related death. CONCLUSION: When common bile duct stones are treated successfully by endoscopic sphincterotomy and patients are free of symptoms, there is no need for routine prophylactic cholecystectomy. Copyright 2004 S. Karger AG, Basel

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Gastrointest Endosc. 2004 May;59(6):614-8.
Endoscopic papillary balloon dilation and endoscopic sphincterotomy for bile duct stones: long-term outcomes in a prospective randomized controlled trial.
Tanaka S, Sawayama T, Yoshioka T.
Department of Gastroenterology, Iwakuni National Hospital, Iwakuni, Japan.

BACKGROUND: Little is known about the long-term outcome of endoscopic papillary balloon dilation for removal of bile duct stones. A randomized trial that compared long-term outcomes after endoscopic papillary balloon dilation and endoscopic sphincterotomy was conducted. METHODS: Thirty-two patients with bile duct stones were randomized to endoscopic papillary balloon dilation or endoscopic sphincterotomy, with 16 patients in each group. Endoscopic papillary balloon dilation was performed by using an 8-mm-diameter balloon; endoscopic sphincterotomy was performed in the standard manner. The success rates for stone removal, as well as the frequency and types of early (<15 days), mid-term (<1 year), and long-term (1-6 years) post-procedure complications were evaluated. RESULTS: The success rates for stone removal and early complication rates were similar for both groups. The frequency of stone recurrence was approximately 4-fold higher in the endoscopic papillary balloon dilation group (25%) vs. the endoscopic sphincterotomy group (6.3%) at mid-term evaluation. However, over the long term, Kaplan-Meier estimated probability of stone recurrence tended to be higher in the endoscopic sphincterotomy group vs. the endoscopic papillary balloon dilation group; recurrent stones were found in, respectively, 26.7% vs. 6.3%. Complications occurred in 7 patients in each group. CONCLUSIONS: Long-term outcome of endoscopic papillary balloon dilation for bile duct stone removal is satisfactory, provided that consideration is given to recurrence of stones by early follow-up evaluation.

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J Gastrointest Surg. 2004 Feb;8(2):191-9.
Management of complex biliary tract calculi with a holmium laser.
Shamamian P, Grasso M.
Department of Surgery, New York University School of Medicine , New York, New York 10016, USA. peter.shamamian@med.nyu.edu

The difficulty in managing complex biliary tract calculi is exemplified in patients with primary intrahepatic calculi. Standard surgical and endoscopic approaches often fail to clear calculi in these patients who have recurrent episodes of cholangitis. The success of the holmium laser for urologic calculi led us to adapt treatment strategies for primary and secondary biliary tract calculi where standard treatments had been unsuccessful. Our goals were to remove all calculi, prevent recurrent sepsis, and preserve hepatic parenchyma. Thirty-six patients with complex biliary calculi were treated. After sepsis was controlled and the extent of calculi was evaluated, appropriate access to and drainage of the biliary tract was achieved. Holmium laser lithotripsy was performed under video guidance using flexible choledochoscopes and a 200 micro laser fiber generating 0.6 to 1.0 joules at frequencies of 6 to 10 Hz. Lithotripsy procedures were repeated until cholangiography and cholangioscopy confirmed the clearance of calculi. Twenty-two patients of Asian descent with primary intrahepatic calculi and 14 patients with secondary intrahepatic calculi were treated. Access to the biliary tract could be accomplished through percutaneous catheter tracts, T-tube tracts, or the cystic duct during laparoscopic cholecystectomy. Biliary drainage was by biliary enteric anastomosis or endoscopic sphincterotomy. Complete stone clearance required an average of 3.9 procedures (range 1 to 15) for patients with primary intrahepatic calculi and 2.6 procedures (range 1 to 10) for patients with secondary intrahepatic calculi regardless of stone composition. No patient required hepatic resection and no complications or deaths were attributed to the holmium laser. Clearance of calculi can reliably and safely be achieved with a holmium laser regardless of stone composition or location while preserving hepatic parenchyma and preventing recurrent sepsis.

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Internist (Berl). 2004 Jan;45(1):8-15.
[Gallbladder calculi--always an indication for surgery?]
[Article in German]
Bittner R, Ulrich M.
Klinik fur Allgemein- und Viszeralchirurgie, Marienhospital Stuttgart. reinhardbittner@vinzenz.de

There is consensus that symptomatic cholecystolithiasis presents an indication for cholecystectomy. Today the surgical method of choice is the laparoscopic technique, which has proven its superiority in numerous randomized studies. Epidemiologic studies showed that 10-15% of all gallstone patients develop complications so that a prophylactic cholecystectomy is repeatedly being discussed. A few older studies based on conventional cholecystectomies, however, showed no decisive advantage for a prophylactic cholecystectomy, but rather clearly higher costs. Therefore a wait-and-see policy is generally recommended for asymptomatic gallstones. The analysis of our large group of patients showed that acute cholecystitis as well as common bile duct stones occur significantly more often with increasing duration of the gallstone disease. The older the patient, the longer the operation time, the more frequent a conversion, and the higher the morbidity of the procedure. Considering the minor impairment of daily activities with the laparoscopic technique, the present concept of treatment for asymptomatic and mildly symptomatic cholecystolithiasis needs to be scrutinized.

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Surg Endosc. 2004 Jan 12 [Epub ahead of print]
Laparoscopic treatment of choledocholithiasis using modified biliary stents.
Kim EK, Lee SK.
Department of Surgery, College of Medicine, The Catholic University of Korea, #62 Youido-dong, Youngdeungpo-ku, Seoul, 150-713, Korea.

Background: When common bile duct (CBD) stones are present, the laparoscopic approach is widely used. For postoperative biliary decompression, T-tube insertion is the most traditional method. Antegrade biliary stenting is another method that could eventually replace the T-tube. Methods: This study involved 86 patients with CBD stones who underwent laparoscopic CBD exploration. A simple modification was made to the biliary stent by eliminating the proximal flap, and we adopted this as a routine biliary decompression device. This modified biliary stent (MBS) was inserted in 50 patients (MBS group), and the T-tube was used for 36 patients (T-tube group). Results: The mean operative time and the overall complication rate were similar between the two groups. There was no mortality. The mean hospital stay was significantly shorter for the MBS group. Biliary stents were eliminated spontaneously via the gastrointestinal tract among 36 (81.8%) patients, and for 8 patients, the stents had to be removed endoscopically. Six patients were lost to follow-up evaluation. The mean time that elapsed until spontaneous stent elimination was 11.5 +/- 9.5 days. Conclusions: Among the different methods of biliary decompression, MBS renders the patients free of an uncomfortable T-tube. Morbidity and even mortality associated with T-tubes are eliminated, and the hospital stay may be shortened. Therefore, for selected patients, the modified biliary stent may be a better option than the traditional T-tube.

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Ther Umsch. 2003 Feb;60(2):113-8.
[Gallstones—surgical aspects]
[Article in German]
Gock M, Krahenbuhl L.
Klinik fur Viszeral- und Transplantationschirurgie, Universitatsspital, Zurich.

Between 10% to 15% of the adult population develop gallstones. Therefore, cholecystectomy is among the most common operations in general surgery. The diagnosis of cholelithiasis depends on the patient's history, clinical findings, laboratory tests and ultrasound examination. Once diagnosis of symptomatic gallbladder disease has been confirmed, laparoscopic cholecystectomy is the treatment of choice. Its advantages in comparison with open surgery are decreased morbidity, costs and hospital stay. Open cholecystectomy is still the treatment of choice for complicated gallstone disease (i.e. cancer, Mirizzi's syndrome, severe inflammation) and in high-risk patients. In case of acute cholecystitis, early laparoscopic cholecystectomy is a safe procedure and is associated with the same benefits as for symptomatic disease.

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Ther Umsch. 2003 Feb;60(2):109-12.
[Gallstones—natural history and conservative management]
[Article in German]
Reichen J.
Institut fur Klinische Pharmakologie, Universitat Bern. reichen@ikp.unibe.ch

Gallstones have a very high prevalence affecting 9.5 and 19.5% of men and women, respectively. The pathophysiology and risk factors for cholesterol gallstones are considered. Modern imaging techniques, in particular ultrasound, are very sensitive to detect cholecystolithiasis, while ERCP remains the gold standard to detect choledocholithiasis. ERCP could be supplanted soon by endosonography and MRCP. Biliary scintigraphy is useful to detect a 'vesicule exclue' and to document gallbladder/sphincter Oddi dysfunction. The different conservative management strategies including litholytic treatment with ursodeoxycholate and lithotripsy have been largely abandoned in favor of laparoscopic cholecystectomy. Litholytic treatment has still a role to play in the prevention of gallstone formation in patients with rapid weight loss and in the newly detected MDR3 defect associated with sludge formation. Biliary colic is treated with non-steroidal analgesic drugs, analgesics and/or spasmolytic agents.

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Am Surg. 2003 Jul;69(7):555-60; discussion 560-1.
Current management of common bile duct stones in a teaching community hospital.
Patel AP, Lokey JS, Harris JB, Sticca RP, McGill ES, Arrillaga A, Miller RS, Kopelman TR.
Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina 29605, USA.

The advent of laparoscopic cholecystectomy (LC) has complicated management of common bile duct (CBD) stones. While LC is routine, laparoscopic CBD exploration (LCBDE) is not, and an algorithm to manage suspected choledocholithiasis has not been uniformly accepted. We evaluated current management of choledocholithiasis. Patients suspected of having CBD stones over a 2-year period were evaluated, and 42 studies in the literature were reviewed. Thirty-two patients were identified. Fourteen patients (44%) had LC with intraoperative cholangiogram (IOC) with no preoperative studies. IOC revealed CBD stones in nine (64%). Seven had CBD exploration (CBDE) at cholecystectomy, and two had postoperative endoscopic retrograde cholangiopancreatography (ERCP). CBDE was successful in five cases, and ERCP was successful in one. Eighteen patients (56%) underwent preoperative ERCP. Five (28%) had no CBD stones. ERCP removed stones in nine patients, and four had open CBDE after failed ERCP. Current literature supports LC with IOC without any preoperative studies. Laparoscopic CBDE is highly successful but depends on surgeon experience. Removing CBD stones with ERCP is also very successful but is associated with increased cost, hospital stay, and complications. We conclude that LC with IOC should be performed without preoperative ERCP when choledocholithiasis is suspected. If found, stones should be removed laparoscopically if possible.

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Eksp Klin Gastroenterol. 2003;(1):46-50, 182.
[Efficacy of ursodeoxycholic acid in gallbladder cholesterosis accompanied by cholecystolithiasis]
[Article in Russian]
Il'chenko AA, Orlova IuN.
Central Scientific Research Institute of Gastroenterology, Moscow.

23 patients with gall-bladder cholesterosis associated with cholesterol gallstones were treated with ursodeoxycholic acid preparations. A regression of cholesterol polyps was recorded in 56.5% against the background of treatment, and complete or partial dissolution of gallstones was observed in 87%. The efficiency of dissolution of cholesterol polyps and stones in the gall-bladder went up along with the extension of the therapy terms, reaching its maximum by 7-9 months of treatment. The dissolution rates were higher for gallstones than for cholesterol polyps. The volume of bile being secreted increased, and the gall-bladder contractile function improved in the course of treatment.

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Ann R Coll Surg Engl. 2003 Mar;85(2):91-6.
Management of gallstone disease in the elderly.
Arthur JD, Edwards PR, Chagla LS.
Department of Surgery, Whiston Hospital, Prescot, Merseyside, UK.

AIM: To determine the outcome of management of symptomatic gallstone disease (GSD) in patients aged 80 years or more. PATIENTS AND METHODS: A retrospective review of the outcome of 79 patients admitted to 2 district general hospitals with symptomatic GSD over a 1-year period was undertaken. Patients were grouped according to method of management: non-operative, ERCP, and cholecystectomy. POSSUM scores for the ERCP and cholecystectomy groups were calculated and observed, and predicted outcome compared. RESULTS: Obstructive jaundice and biliary colic were the most common presenting symptoms. Each patient had been admitted at least once before the study period (median, 2; range, 1-3). Outcomes are detailed in Table 1. Non-operative management failed in 18 of 23 patients, with 17.4% mortality. ERCP was successful in 40 of 47 patients with 3 complications (0.24 of predicted) and no mortality. In all, 11 laparoscopic and 12 open cholecystectomies were performed with 6 complications and 1 mortality (0.95 and 0.83 of predicted, respectively): 4 complications and the only death occurring after emergency cholecystectomy. Table 1 Outcomes Management Number Mortality Morbidity Outcome Non-operative 23 4 9 5 OK, 13 re-admitted, 4 still symptomatic ERCP 47 0 3 1 PTC, 6 operated Operative 23 1 6 Conclusions: This study suggests that recurrent GSD in elderly patients managed non-operatively may have fatal outcome. Elective cholecystectomy has acceptable morbidity and mortality in this age group and there is often ample opportunity to avoid emergency surgery, but a prospective randomised study is required to improve clinical algorithms.

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Ned Tijdschr Geneeskd. 2003 Jan 25;147(4):146-50.
[The treatment of gallstone disease in the elderly]
[Article in Dutch]
van Assen S, Nagengast FM, van Goor H, Cools BM.
Afd. Algemene Interne Geneeskunde, Universitair Medisch Centrum St Radboud, Postbus 9101, 6500 HB Nijmegen.

Gallstone diseases (asymptomatic, symptomatic and complicated) are frequently seen in the elderly; the prevalence increases proportionally with age. At higher ages (> 60 years) the presentation of symptomatic or complicated gallstone disease is frequently atypical. Complicated gallstone disease (especially cholecystitis and cholangitis) in the elderly is associated with high morbidity and mortality rates. The introduction of laparoscopic cholecystectomy has decreased the morbidity and mortality rates of symptomatic and complicated gallstone disease in the elderly; for elective procedures in particular, the risks hardly differ from those for younger patients. Percutaneous cholecystostomy is an effective and safe alternative for (laparoscopic) cholecystectomy in high-risk patients with an acute cholecystitis. Endoscopic retrograde cholangiopancreaticography (ERCP) with sphincterotomy is also the treatment of choice for common bile duct stones in the elderly. After removal of common bile duct stones (whether or not accompanied by cholangitis or pancreatitis) a laparoscopic cholecystectomy should be performed, unless contraindications are present.

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Dtsch Med Wochenschr. 2003 Mar 7;128(10):481-4.
[Cholangioscopy after successful treatment of complicated choledocholithiasis. Is stone free
really stone free?]
[Article in German]
Weickert U, Jakobs R, Hahne M, Eickhoff A, Schilling D, Riemann JF.
Medizinische Klinik C, Klinikum der Stadt Ludwigshafen gGmbH. MedCLu@t-online.de

BACKGROUND AND OBJECTIVE: After successful percutaneous or endoscopic therapy of complicated choledocholithiasis (requiring more than one therapeutic intervention or lithotripsy), radiological visualization of the bile duct is the standard to determine if any stone fragments are left. It is unknown how often stone fragments, which might be the cause for another period of symptomatic choledocholithiasis, are missed. PATIENTS AND METHODS: We performed cholangioscopy in 31 consecutive patients (age 42 - 85; 14 male, 17 female) with complicated choledocholithiasis after successful therapy when there were no stone fragments left radiographically. RESULTS: Cholangioscopy revealed retained stone fragments in four female patients. Two of these had a benign stricture of the common bile duct. CONCLUSIONS: Cholangioscopy after successful endoscopic or percutaneous therapy of complicated choledocholithiasis seems to be useful, because in bile ducts radiographically free of stones, cholangioscopy detects stone fragments in some patients. Further studies are needed to demonstrate if cholangioscopy can reduce the rate of symptomatic relapse after treatment of complicated choledocholithiasis.

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Gastrointest Endosc. 2003 Feb;57(2):156-9.
Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract.
Ersoz G, Tekesin O, Ozutemiz AO, Gunsar F.
Ege University School of Medicine, Department of Gastroenterology, Izmir, Turkey.

BACKGROUND: Bile duct stones are still present in 10% to 15% of patients after the application of conventional endoscopic extraction techniques and require additional procedures for duct clearance. In the vast majority of these cases, there are 2 main problems: large stone size (>15 mm) and tapering of distal bile duct. METHODS: Fifty-eight patients in whom endoscopic sphincterotomy and standard basket/balloon extraction were unsuccessful in the removal of bile duct stones underwent dilation with a 10- to 20-mm diameter (esophageal/pyloric type) balloon at the same session. In 18 patients with tapered distal bile ducts (Group 1), 12- to 18-mm diameter balloon catheters were used to enlarge the orifice. In 40 patients with square, barrel shaped and/or large (>15mm) stones (Group 2), the sphincterotomy orifice was enlarged with 15- to 20-mm diameter balloon catheters. After dilatation, standard basket/balloon extraction techniques were used to remove the stone(s). RESULTS: Stone clearance was successful in 16 patients (89%) in Group 1 and 35 (95%) in Group 2. Complications occurred in 9 (15.5%) patients. CONCLUSION: Dilation with a large-diameter balloon after endoscopic sphincterotomy is a useful alternative technique in patients with bile duct stones that are difficult to remove with standard methods.

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Gastrointest Endosc. 2003 Feb;57(2):151-5.
Endoscopic sphincterotomy and endoscopic papillary balloon dilatation for bile duct stones: A prospective randomized controlled multicenter trial.
Fujita N, Maguchi H, Komatsu Y, Yasuda I, Hasebe O, Igarashi Y, Murakami A, Mukai H, Fujii T, Yamao K, Maeshiro K; JESED Study Group.
Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan.

BACKGROUND: Endoscopic papillary balloon dilatation may be an alternative to endoscopic sphincterotomy in the treatment of bile duct stones. However, there is a controversy as to the effectiveness and safety of endoscopic papillary balloon dilatation. METHODS: Two hundred eighty-two patients with bile duct stones were enrolled and randomized to an endoscopic sphincterotomy or endoscopic papillary balloon dilatation group. The success rate for duct clearance as well as the frequency and types of complications were evaluated prospectively. Endoscopic sphincterotomy was performed in a standard manner. Endoscopic papillary balloon dilatation was carried out with gradual inflation of a 4-, 6-, or 8-mm diameter balloon. RESULTS: Complete duct clearance was achieved in 100% in the endoscopic sphincterotomy group and 99.3% in the endoscopic papillary balloon dilatation group (not significant). Complications occurred in 11.8% of patients in the endoscopic sphincterotomy group and 14.5% of those in the endoscopic papillary balloon dilatation group (not significant). No complication was severe; there was no mortality. The frequency of acute pancreatitis was higher in the endoscopic papillary balloon dilatation group than the endoscopic sphincterotomy group (respectively, 10.9% vs. 2.8%; p < 0.045). Hemorrhage occurred only in the endoscopic sphincterotomy group. CONCLUSIONS: Endoscopic sphincterotomy and endoscopic papillary balloon dilatation were approximately equal in terms of successful clearance of bile duct stones. They were also similar with respect to overall complications. Endoscopic papillary balloon dilatation is an alternative to endoscopic sphincterotomy as a treatment of bile duct stones.

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Aliment Pharmacol Ther. 2003 Jan;17(2):289-96.
Retained common bile duct stones: a comparison between biliary stenting and complete clearance of stones by electrohydraulic lithotripsy.
Hui CK, Lai KC, Ng M, Wong WM, Yuen MF, Lam SK, Lai CL, Wong BC.
Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong, China.

BACKGROUND: There is some uncertainty as to whether high-risk patients with difficult common bile duct stones should be subjected to a further endoscopic procedure for the complete removal of stones by electrohydraulic lithotripsy or whether permanent biliary stenting should be performed. AIM: To compare the outcome of permanent biliary stenting with electrohydraulic lithotripsy in this group of patients. METHODS: In a prospective study, 36 patients with difficult common bile duct stones were investigated: 19 underwent double pigtail insertion (stent group), whereas 17 underwent complete clearance of stones (electrohydraulic lithotripsy). RESULTS: In the electrohydraulic lithotripsy group, successful stone clearance was achieved in 76.5%, whereas, in the stent group, the success of stenting was 94.7%. A significant difference was detected in the actuarial incidence of recurrent acute cholangitis when the electrohydraulic lithotripsy group was compared with the stent group [one patient (7.7%) vs. 12 patients (63.2%), respectively; P = 0.002, log rank test]. A significant difference was detected in the actuarial frequency of mortality between the electrohydraulic lithotripsy and stent groups [seven patients (41.2%) vs. 14 patients (73.7%), respectively; P = 0.01, log rank test]. CONCLUSIONS: The removal of difficult common bile duct stones by electrohydraulic lithotripsy and further endoscopic retrograde cholangiopancreatography has a high success rate and a low complication rate even in the elderly.

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Med Hypotheses. 2003 Jan;60(1):143-7.
Alternative treatment of gallbladder disease.
Moga MM.
Terre Haute Center for Medical Education, Indiana University School of Medicine, Terre Haute, IN 47809, USA. mmoga@medicine.indstate.edu

Major risk factors for gallbladder disease include a sedentary lifestyle and a diet rich in refined sugars. In genetically prone individuals, these two factors lead to an abnormal bile composition, altered gut microflora, and hyperinsulinemia, with resulting gallstone formation. As a large percentage of gallbladder patients have continued digestive complaints following cholecystectomy, the author examines complementary and alternative medicine (CAM) treatments to counteract gallstone formation. Herbal medicine such as turmeric, oregon grape, bupleurum, and coin grass may reduce gallbladder inflammation and relieve liver congestion. Elimination of offending foods, not necessarily 'fatty' foods, is often successful and recommended by many holistic physicians. Regular aerobic exercise has a beneficial effect on hyperinsulinemia, which is often associated with gallbladder disease. Dietary changes that lower plasma insulin levels, such as a change in dietary fats and substitution of unrefined carbohydrates for refined carbohydrates, may also be helpful.

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Arch Surg. 2003 May;138(5):531-5; discussion 535-6.
Laparoscopic cholecystectomy for elderly patients: gold standard for golden years?
Bingener J, Richards ML, Schwesinger WH, Strodel WE, Sirinek KR.
Department of Surgery, University of Texas Health Science Center at San Antonio, 78229, USA.

HYPOTHESIS: Laparoscopic cholecystectomy (LC) has known physiological benefits and positive socioeconomic effects over the open procedure. Although recent studies have questioned the technique's efficacy in elderly patients (>65 years), we hypothesize that LC is safe and efficacious in that patient group. METHODS: Five thousand eight hundred eighty-four consecutive patients (mean age, 40 years; 26% male) underwent an attempted LC (conversion rate, 5.2%) from 1991 to 2001 at a teaching institution. Of these, 395 patients (6.7%) were older than 65 years. Analysis included patient age, sex, American Society of Anesthesiologists classification, conversion rate, morbidity, mortality, and assessment of results over time. RESULTS: Elderly patients were predominantly male (64%). Septuagenarians had a 40% incidence of complicated gallstone disease, such as acute cholecystitis, choledocholithiasis, or biliary pancreatitis, and octogenarians had a 55% incidence. Overall mortality was 1.4%. The conversion rate was 17% for the first 5 years of the study period and 7% for the second half. The conversion rate was 22% for patients with complicated disease and 2.5% for patients with chronic cholecystitis. Average hospital stay decreased from 10.2 days to 4.6 days during the first and second half of the study period, respectively. CONCLUSIONS: The results of LC in patients aged 65 to 69 years are comparable with those previously reported in younger patients. Patients older than 70 years had a 2-fold increase in complicated biliary tract disease and conversion rates, but a low mortality rate (2%) compared with results of other authors (12%), despite an increase in American Society of Anesthesiologists classification. Increased technical experience with LC favorably affected outcomes over time. Early diagnosis and treatment prior to onset of complications are necessary for further improvement in the outcomes of elderly patients undergoing LC.

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Chirurgia (Bucur). 2002 Sep-Oct;97(5):497-504.
[Combined laparoscopic and endoscopic treatment of gallbladder and bile duct stones]
[Article in Romanian]
Turcu F.
Clinica de Chirurgie Generala, Spitalul Clinic de Urgenta Sf. Ioan-Bucuresti. florin.turcu@net4u.ro

In the present study we have tried to find what is the best time for endoscopy in the treatment of gallstones associated with common bile duct stones. METHOD: We have selected on the intention to treat 89 patients suspected of cholecysto-choledocholithiasis. There have been 38 cases with preoperative endoscopy (Group A), 35 cases with postoperative endoscopy (Group B) and 16 cases with perioperative endoscopy (Group C). RESULTS: In group C it has been a significant higher proportion of successfully treated cases (94%) and a lower hospital stay (8.6 +/- 3.7 days). CONCLUSIONS: Combining the endoscopy and laparoscopy in the same operation ("rendez-vous" technique) is the best approach for treating cholecysto-choledocholithiasis.

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Kongressbd Dtsch Ges Chir Kongr. 2002;119:322-7.
[Laparoscopic cholecystectomy--surgical standard in cholelithiasis]
[Article in German]
Kraas E, Farke S.
Chirurgische Klinik, DRK Kliniken Westend, Spandauer Damm 130, 14050 Berlin.

Laparoscopic surgery showed a dramatic development in the last years of the 20th century. From the beginning laparoscopic cholecystectomy (LCCE) has been the pacemaker of this development. Today laparoscopic cholecystectomy is the first choice for treatment of cholecystolithiasis in nearly all surgical clinics. Therefore laparoscopic cholecystectomy is the most common part of minimal invasive technique. LCCE is the golden standard in therapy of gallstones, more than 90% of cholecystectomies in specialized clinics are done laparoscopically. It is an established, evidence based operation today. Open cholecystectomy is left for special indications only. A problem of LCCE is the occult carcinoma of the gallbladder. In histological proven carcinoma of the gallbladder LCCE is the adequate operation only for Tis and T1 carcinoma. In T2 and T3 carcinoma a radical oncologic resection with lymph node dissection should be performed. Due to the poor prognosis T4 tumors should be left with laparoscopic biopsy only.

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Tidsskr Nor Laegeforen. 2002 Nov 30;122(29):2772-3.
[Laparoscopic cholecystectomy]
[Article in Norwegian]
Trondsen E.
Gastrokirurgisk avdeling Ulleval universitetssykehus 0407 Oslo. erik.trondsen@ulleval.no

Gallbladder stones are common, but most persons with stones are asymptomatic. The symptoms of gallbladder stones are usually characteristic. They are often associated with other types of abdominal symptoms, which are not affected by cholecystectomy. Day surgery laparoscopic cholecystectomy is increasingly popular. The operation may be associated with serious complications, but the risk is low. 85-90% of patients operated with cholecystectomy are asymptomatic after the operation.

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J R Coll Surg Edinb. 2002 Dec;47(6):742-8.
Asymptomatic gallstones in the laparoscopic era.
Meshikhes AW.
Department of Surgery, Dammam Central Hospital, Dammam, Eastern Province, Saudi Arabia.

Recent introduction of new treatment options has significantly altered the approach towards gallstone management. There is now general agreement that cholecystectomy is the treatment of choice for symptomatic gallstones. Controversy, however, exists as to the management of asymptomatic gallstones. The ready availability of abdominal ultrasonography for the investigation of a wide range of abdominal symptoms has resulted in the increased diagnosis of asymptomatic gallstones. Management of such accidentally discovered gallstones poses a dilemma as conclusive evidence of the benefits of cholecystectomy is lacking. This is further complicated by the fact that the majority of asymptomatic gallstones remain so and patients rarely experience symptoms or complications. Furthermore, cholecystectomy is associated with a low but recognised morbidity. Recent introduction of laparoscopic cholecystectomy as the treatment of choice of symptomatic gallstones has further complicated the issue of asymptomatic gallstone management. This article reviews the current management of asymptomatic gallstones in the era of laparoscopic cholecystectomy

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Khirurgiia (Mosk). 2002;(11):38-41.
[Surgical treatment of cholelithiasis in elderly and aged patients]
[Article in Russian]
Borodach VA, Borodach AV.

Surgical treatment of cholelithiasis in 485 elderly and aged patients operated from 1991 to 2000 are analyzed. Patients with acute inflammation in the biliary tract underwent surgery after standard conservative therapy during 12-48 hours after hospitalization. Methods of completion of surgery on the biliary tract are proposed: treatment of the bile cyst bed after cholecystectomy associated with lesion of hepatic tissue; methods of external and internal drainage of the major bile ducts and drainage of infrahepatic space through loin. Epidural blocking was used as the main component of combined anesthesia. These methods of surgical treatment in elderly and aged patients reduce number of postoperative complications and shorten hospital stay.

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Gastroenterol Hepatol. 2002 Dec;25(10):585-8.
[Endoscopic treatment combined with extracorporeal shock wave lithotripsy of difficult bile duct stones]
[Article in Spanish]
Mora J, Aguilera V, Sala T, Martinez F, Bastida G, Palau A, Arguello L, Pons V, Pertejo V, Berenguer J, Alapont JM.
Unidad de Endoscopias. Servicios de Medicina Digestiva. Hospital La Fe. Valencia. Espana. iuliusmora@hotmail.com

OBJECTIVES: The aim of this study was to determine the safety and effectiveness of extracorporeal shock wave lithotripsy (ESWL) in difficult bile duct stones resistant to endoscopic extraction. PATIENTS AND METHOD: From January 1997 to February 2002, combined treatment with endoscopy and ESWL was used in 19 patients who had undergone unsuccessful endoscopic bile duct stone extraction after sphincterotomy. The procedure was carried out using analgesic and sedative drugs or deep sedation, prophylactic antibiotic therapy, and monitoring of vital signs. Bile duct stone localization was performed by contrast injection through nasobiliary drainage and fluoroscopy. After each ESWL session, lavage was performed through drainage and stone fragments were extracted endoscopically. RESULTS: The 19 patients presented high surgical risk due to advanced aged and/or concomitant diseases. All presented jaundice and pain and nine (47.3%) presented associated cholangitis. Thirty ESWL sessions were performed (1.57 sessions per patient), with a mean of 2,120 shock waves per session. In 16 of the 19 patients (84.2%), combined treatment with ESWL and subsequent instrumental endoscopic extraction achieved complete clearance of the biliary tract. The treatment failed in 3 patients who were referred for surgical treatment. No early or late complications were observed, except in one patient who presented a self-limiting febrile syndrome. CONCLUSIONS: Therapeutic endoscopy combined with ESWL is safe and effective in patients with difficult bile duct stones. It represents a therapeutic alternative in patients at high surgical risk.

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Nippon Geka Gakkai Zasshi. 2002 Oct;103(10):737-41.
[Laparoscopic biliary surgery]
[Article in Japanese]
Tokumura H, Rikiyama T, Harada N, Kakyo M, Yamamoto K.
Department of Surgery, Tohoku Rosai Hospital, Sendai, Japan.

Laparoscopic cholecystectomy has become the standard treatment for patients with symptomatic gallbladder disease. However, there is a substantial proportion of patients in whom laparoscopic cholecystectomy cannot be successfully performed, and conversion to open surgery is required because of technical difficulties or complications. The incidence of bile duct injury has increased in laparoscopic cholecystectomy. Meticulous dissection and intraoperative cholangiography could significantly reduce the rate of that injury. Laparoscopic cholecystectomy for acute cholecystitis is still controversial because of surgical difficulty. In our experience, early laparoscopic cholecystectomy is a beneficial option for patients with acute cholecystitis, and it may even be safe in the acute stage. A better alternative for high-risk early operation and septic cases is percutaneous transhepatic gallbladder drainage. The coexistence of gallbladder cancer should be ruled out and preoperative diagnosis should be done carefully. Laparoscopic management of common bile duct (CBD) stones has many advantages. However it has been reported to be demanding and time-consuming to perform, which limits its widespread adoption. In our experience with 258 patients, laparoscopic CBD exploration was feasible for almost all CBD stones. The technical difficulties associated with laparoscopic CBD exploration could be overcome with the development of suitable equipment and increased expertise.

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Scand J Gastroenterol Suppl. 2002;(236):87-90.
New strategies for the treatment of gallstone disease.
Keulemans YC, Venneman NG, Gouma DJ, van Berge Henegouwen GP.
Dept. of Gastroenterology, University Medical Center, Utrecht, The Netherlands. yolande_keulemans@hotmail.com

BACKGROUND: Symptomatic gallstones are generally accepted as being the indication for cholecystectomy. Generally, severe abdominal pain in epigastrium and in the right upper abdominal quadrant, and lasting for more than 15 min, is thought to be caused by gallstones. However, many patients with other abdominal complaints undergo cholecystectomy and are satisfied with the outcome of surgery. Possible ways to improve the results of cholecystectomy are discussed. METHODS: Review of previous work by the authors. RESULTS: The introduction of laparoscopic cholecystectomy has even led to an increase in cholecystectomies; in a higher complication rate; and in increased costs of the treatment of gallstone disease. Because of faster recovery, 70% of symptomatic gallstone patients are able and willing to undergo laparoscopic cholecystectomy in day care. Cholecystectomy after sphincterotomy and stone extraction in patients who have stones in the gallbladder was demonstrated to prevent gallstone-related symptoms in at least 40% of patients. If the gallbladder had to be removed later for symptomatic disease, however, this did not result in a higher rate of conversions and complications. Because of shortage in operation capacity in The Netherlands, there is a considerable delay between the diagnosis of symptomatic stones and cholecystectomy. Better selection of patients for cholecystectomy will not only improve the results of cholecystectomy, it will also reduce the number of cholecystectomies and patients on waiting lists. Delay of cholecystectomy is associated with more complications, longer operative times, higher conversion rates to open cholecystectomy and prolonged hospitalization. The efficacy of the bile salt ursodeoxycholic acid in preventing gallstone-related pain attacks and complications in patients with contraindications for operation or waiting to undergo cholecystectomy should be investigated further, since two retrospective studies have demonstrated favourable outcomes for this strategy. CONCLUSION: The results of cholecystectomy are likely to be improved by better selection of patients, prevention of delay of the procedure and possibly treatment with ursodeoxycholic acid.

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Minerva Chir. 2002 Oct;57(5):657-62.
[The use of surgical endo-prosthesis in the treatment of choledocolithiasis in the elderly.
Personal experience]
[Article in Italian]
Burattini MF, Covarelli P, Cristofani R, Moriconi E, Servoli A, Cavazzoni E, Ricci E, Bartoli A.
Policlinico Monteluce, Dipartimento di Scienze Chirurgiche, Sezione di Chirurgia Generale e Oncologica, Universita degli Studi di Perugia, Perugia, Italy. bsensi@unipg.it

BACKGROUND: The usefulness of biliary endoprostheses in some selected elderly patients affected by hepato-choledocolithiasis is described. METHODS: In the Department of Surgery, University of Perugia, 119 elderly patients were surgically treated for choledocholithiasis from January 1999 to December 2000. In 44 selected cases#151;oldest patients with thinner hypovascularized ectasic choledochal wall#151; a permanent transpapillary polyurethane prosthesis was placed, after choledocolithotomy with or without sphinterotomy; sometimes prosthesis was placed under the duodenal mucosa. RESULTS: Endoprosthesis had a long duration and gave good results in canalization and periprosthetic flow, in absence of biliary stasis and/or angiocholitis. Only one patient had prostheses displacement. CONCLUSIONS: On the basis of personal experience and considering physiopathology and pathogenesis of biliary stones in the elderly, the authors underline, in selected cases, the need of stenting the hepatocholedochal lumen with the aim of avoiding collapse.

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Eur J Radiol. 2002 Sep;43(3):237-45.
Percutaneous management of bile duct stones.
Ilgit ET, Gurel K, Onal B.
Department of Radiology, School of Medicine, Gazi University, Besevler 06510, Ankara, Turkey. erhanti@med.gazi.edu.tr

This article presents a review of the interventional radiological procedures in the percutaneous management of the bile duct stones through T-tube or transhepatic tracts. Interventional stone removal techniques mainly include extraction through the T-tube tract with baskets or forceps and expulsion into the duodenum by means of baskets or balloon catheters with the dilatation of the sphincter of Oddi. Fragmentation or size reduction of the stone, dilatation of the strictures and cholangioscopic assistance can facilitate the procedures.

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Scand J Gastroenterol. 2002 Jul;37(7):834-9.
Symptomatic, non-complicated gallbladder stone disease. Operation or observation?
A randomized clinical study.
Vetrhus M, Soreide O, Solhaug JH, Nesvik I, Sondenaa K.
Rogaland Central Hospital, Stavanger, Norway. mvetrhus@chello.no

BACKGROUND: Cholecystectomy has been recognized as the treatment of choice for symptomatic gallbladder stone disease. Not all patients are cured by an operation and the reason for having the gallbladder removed may rest on common practice rather than evidence-based medicine. The aim was to compare cholecystectomy with observation (watchful waiting) in patients with uncomplicated symptomatic GBS disease. Three-hundred-and-thirty-eight patients were considered for participation in the study; 45 patients were excluded according to predefined criteria and 156 did not join for other reasons. The remaining 137 were randomized to cholecystectomy (n = 68) or non-operative, expectant treatment (n = 69). METHODS: Randomized patients were contacted regularly and followed for a median of 67 months. All gallstone-related hospital contacts were registered in both randomized and excluded patients. RESULTS: Eight of the patients randomized to cholecystectomy did not undergo operation, while 35 of the patients randomized to observation later had their gallbladders removed. The cumulative risk of having a cholecystectomy seemed to level off after 4 years. Gallstone-related complications occurred in 3 patients in the observation group, 1 in the operation group and 5 of 201 excluded patients. After cholecystectomy, 16 of 222 patients had a major complication and 10 a minor. CONCLUSIONS: We found that non-operative expectant treatment carries a low risk of complications. Patients should be informed that watchful waiting is a safe option.

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Eur J Gastroenterol Hepatol. 2002 Jul;14(7):741-4.
Quality of life after cholecystectomy and after successful lithotripsy for gallbladder stones: a matched-pairs comparison.
Carrilho-Ribeiro L, Serra D, Pinto-Correia A, Velosa J, De Moura MC.
Centre of Gastroenterology, Lithotripsy Unit, University Hospital of Santa Maria, Rua Garcia de Orta, 73-1, 1200-678 Lisbon, Portugal. lcarrilho@netc.pt

BACKGROUND : There are few data on the quality of life of patients after successful extra-corporeal shock-wave lithotripsy of gallbladder stones and how it compares with the quality of life of patients who underwent cholecystectomy. DESIGN : Prospective case-control study. PATIENTS AND METHODS : Eighteen consecutive patients who had been rendered stone free in 1992 in our unit and who have not shown recurrence until now were selected. For comparison, 18 individually matched (sex, age, body mass index and number of gallbladder stones) controls were selected among the patients who underwent unsuccessful extra-corporeal shock-wave lithotripsy at the same time, eventually undergoing cholecystectomy. Between January and April 2000, all 36 patients answered a validated questionnaire on quality of life focusing on digestive complaints: the Gastro Intestinal Quality of Life Index (GIQLI). RESULTS : The overall GIQLI scores for both groups were good: a median of 128 points (out of a maximum of 144 points) for the extra-corporeal shock-wave lithotripsy group versus a median of 124 points for the cholecystectomy group. The slight advantage of the extra-corporeal shock-wave lithotripsy group was not significant (P = 0.33, paired sign-test). However, the extra-corporeal shock-wave lithotripsy group scored significantly better in the eight questions regarding dyspeptic complaints (P = 0.01, paired sign-test), mainly in the items regarding nausea and need for dietary restriction. There were no significant differences in the questions regarding symptoms of gastro-oesophageal reflux disease, bowel complaints or general well-being. CONCLUSIONS : The quality of life after either cholecystectomy or extra-corporeal shock-wave lithotripsy is good overall, but cholecystectomy might be associated with a higher rate of dyspeptic complaints than a gallbladder preserving treatment like extra-corporeal shock-wave lithotripsy.

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Gastrointest Endosc. 2002 Aug;56(2):233-8.
Transnasal extraction of residual biliary stones by Seldinger technique and nasobiliary drain.
Mutignani M, Shah SK, Foschia F, Pandolfi M, Perri V, Costamagna G.
Digestive Endoscopy Unit, Universita Cattolica del Sacro Cuore, A. Gemelli University Hospital, Rome, Italy.

BACKGROUND: Complete endoscopic clearance of bile duct stones is unsuccessful in up to 30% of patients at the first attempt, necessitating further endoscopic procedures. A novel transnasal approach for extraction of these residual stones using Seldinger technique and a nasobiliary drain was evaluated. METHODS: Twenty-one patients with residual biliary stones after ERCP underwent transnasal extraction under fluoroscopy without sedation. A 0.035-inch guidewire was inserted though the previously placed nasobiliary drain into the intrahepatic ducts. The nasobiliary drain was removed, leaving the guidewire in place. A double-lumen extraction balloon was inserted over the guidewire. Multiple withdrawal maneuvers of the inflated balloon were performed to clear the bile duct. RESULTS: Residual stones were present in the extrahepatic and intrahepatic ducts in, respectively, 18 and 3 patients. The mean largest stone diameter was 5.9 mm (range, 3-12 mm). Seventeen patients had a single stone. Complete duct clearance was achieved in 17 patients (81%). The procedure was unsuccessful because of guidewire dislodgement in 3 patients and inability to pass the guidewire through the nasobiliary drain in 1 patient. There was no procedure-related complication. CONCLUSIONS: Transnasal extraction of residual biliary stones after ERCP with the Seldinger technique is safe and feasible with reasonable success and can avoid the inconvenience and cost of a repeat ERCP.

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