Cholelithiasis and cholecystitis

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.     

The spectrum and cost of complicated gallstone disease in California

HYPOTHESIS: We hypothesized that complications of gallstone disease are more common than previously recognized and are related to treatment delay. DESIGN: Retrospective review. PATIENTS: Data for 248 consecutive patients from a university hospital in 1995-1996 and 40,571 patients identified through the 1996 California Office of Statewide Health Planning and Development database who underwent cholecystectomy for gallstone disease were reviewed. MAIN OUTCOME MEASURES: Diagnosis, length of hospital stay, hospital mortality, type of admission, type of surgical procedure, hospital cost, and interval of delay between onset of initial symptoms, ultrasound diagnosis, and cholecystectomy. RESULTS: The spectrum of gallstone disease included biliary colic in 56%, acute cholecystitis in 36%, acute pancreatitis in 4%, choledocholithiasis in 3%, gallbladder cancer in 0.3%, and cholangitis in 0.2%. Community hospitals, public or county hospitals, and academic health centers had a similar distribution of diagnoses. Patients undergoing cholecystectomy for biliary colic had a significantly shorter length of hospital stay, lower operative mortality rate, were more likely to have their operations completed laparoscopically, and had lower hospital charges than patients undergoing cholecystectomy for complications such as acute cholecystitis. Over half of the patients requiring cholecystectomy for complications of gallstones initially presented with biliary colic. Patients with gallstone complications had an average delay from ultrasound confirmation to surgery of 6 months. CONCLUSION: Complications of gallstone disease are (1) common, (2) costly, and (3) potentially preventable.     

Laparoscopic cholecystectomy. Treatment of choice for symptomatic cholelithiasis.

Our initial experience with laparoscopic cholecystectomy (LC) for symptomatic cholelithiasis has involved 152 patients. Patient age ranged from 17 to 83 years; most were female (78%). Their average weight was 170 pounds (range, 75 to 365 lbs.). Twenty-two per cent had a single gallstone, while 9% had two to three stones and 64% had more than three stones. Exclusion criteria initially included upper abdominal scarring, severe acute cholecystitis, choledocholithiasis, and inability to tolerate general anesthesia. The first two of these are now only relative contraindications with increased experience. Thirteen of the one hundred fifty-two procedures (8.5%) required conversion to an open operation. Average time of operation was 138 minutes. Intraoperative cholangiography was attempted in 78% of cases and was completed successfully in 66% of those attempted. There have been no deaths. The complication rate has been low: 4% major, 0% life-threatening, and 7.2% minor complications. Postoperative analgesic requirements are remarkably low: 36% of patients required no narcotics after leaving the recovery room. Eighty-seven per cent of patients successfully undergoing LC were discharged by the first postoperative day. Most patients resumed normal activities within 1 week after discharge. Laparoscopic cholecystectomy offers the majority of patients with symptomatic cholelithiasis an improved treatment option, resulting in significantly less postoperative pain, hospitalization, and recuperation time.     

Laparoscopic cholecystectomy in children: lessons learned from the first 100 patients.

BACKGROUND/PURPOSE: Laparoscopic cholecystectomy is a very common operation in adults but is relatively infrequently required in children. A retrospective review of 100 consecutive infants and children undergoing laparoscopic cholecystectomies from 1990 to 1998 was performed to see what lessons have been learned from this relatively large population of pediatric patients. RESULTS: The patients ranged in age from 25 to 230 months, with a mean of 105 months. Only 19 patients had hemolytic disease as the etiology for their cholelithiasis. Two patients had biliary dyskinesia. Seventy-eight patients underwent an elective operation. Twenty-two children required urgent hospitalization because of complications from their cholelithiasis: acute cholecystitis (n = 7), jaundice and pain (n = 6), gallstone pancreatitis (n = 5), acute biliary colic (n = 4). All 6 patients who presented with jaundice underwent endoscopic retrograde cholangiopancreatography (ERCP) before their laparoscopic cholecystectomy. Two patients required laparoscopic choledochal exploration. The operating time and postoperative hospitalization were significantly longer (P = .0005) in the complicated group when compared with the elective patients. No significant complications such as the need for reoperation, injury to the choledocuhus or to other viscera, bile leak, or retained choledocholithiasis occurred. CONCLUSIONS: Laparoscopic cholecystectomy is a safe, effective procedure in children for removal of the gallbladder. The exact role of routine cholangiography and ERCP remains unclear.     

Gallstones: best served hot.

BACKGROUND: Acute episodes of gallstone-related diseases have traditionally been managed conservatively. In the event of gallstones obstructing the common bile duct, patients had endoscopic extraction of calculi with interval cholecystectomy after 4 weeks to 6 weeks when acute inflammatory changes have subsided. This placed the patient at risk of recurrent cholecystitis, pancreatitis, or other complications of cholelithiasis. METHODS: Patients presenting with acute gallstone-related diseases were investigated and underwent laparoscopic cholecystectomy during the same admission according to a predetermined treatment protocol. RESULTS: All patients (119) treated according to the study protocol had good results, with no 30-day mortality and no biliary tract injuries. One patient had bleeding from the cystic artery, and 6 patients required conversion to open cholecystectomy. CONCLUSION: Growing expertise in laparoscopic cholecystectomy has made it possible for surgeons to perform safe cholecystectomy in the presence of acute gallstone-related disease. Our experience of managing gallstone disease with prompt cholecystectomy during the index admission shows that this approach provides better, safer, and more cost-effective patient care.     

Does gender affect laparoscopic cholecystectomy?

The relationship between sex and outcome after laparoscopic surgery for symptomatic cholelithiasis remains unclear. The purpose of this study was to determine the influence of sex on the clinical presentation of patients with symptomatic gallstone disease and the clinical outcomes of laparoscopic cholecystectomy. The rates of conversion to open cholecystectomy, complication rates, operative times, and lengths of hospital stay were compared between the sexes. Compared with female patients, males were significantly older and more likely to have coexisting cardiovascular disease, previous upper abdominal surgery, previous hospitalization for acute cholecystitis and pancreatitis, acute cholecystitis, and suppurative cholecystitis (such as empyema), conversions, and complications. The mortality rate was nil. Analyses revealed an independent effect of sex on the prevalence of complications, even when including all of the major confounding factors in the model. In contrast, the effect of sex on conversion to open cholecystectomy was not significant when controlling for patient age. Operative time and postoperative hospital stay were significantly longer in males than in females. The tendency of male patients to have cholecystitis of greater severity should remind surgeons of the need to inform patients about the higher conversion rate among male patients, to reduce the disappointment of a large laparotomy wound or prolonged recovery period. On the other hand, there may be an increased need for surgeons to strongly advice male patients with symptomatic cholelithiasis to undergo early intervention.     

Deaths from gallstones. Incidence and associated clinical factors.

The purpose of this study was to determine the incidence of death as the initial manifestation of cholelithiasis. Records of patients who died or underwent cholecystectomy for gallstone-related disease at Duke University Medical Center between 1976 and 1985 were reviewed. Thirty patients died, six of whom (20%) had previous episodes of biliary pain and stone documentation. Twenty-four (80%) were asymptomatic (three with previous incidental diagnosis of cholelithiasis). Reason for admission included acute cholecystitis (nine), pancreatitis (eight), biliary pain (six), cholangitis (four), jaundice (one), and endocarditis (one). Three patients died of gallstone complications without surgical intervention; one patient had renal failure and two had septicemia. Other causes of death were: sepsis (seven patients), cardiac failure (six), pulmonary complications (four), renal failure (three), cerebrovascular accident (three), liver failure (two), pancreatitis (one), and gastrointestinal bleeding (one). During this period, 1731 cholecystectomies were performed without mortality. In this group, the patients were younger (50 +/- 8 years vs. 64 +/- 13 years, p less than 0.001), and had a lower incidence of cirrhosis (p less than 0.001) and diabetes (p less than 0.002). The sex ratio was inverted (p less than 0.001). This study demonstrates that death from gallstones is uncommon (three cases per year), as is death from their initial clinical manifestation (1.2%). The risk of death is two- and ninefold higher in patients with acute cholecystitis or acute pancreatitis. Age, cirrhosis, and diabetes are important determinants of outcome.     

Safety and success of early laparoscopic cholecystectomy for acute cholecystitis

Although elective laparoscopic cholecystectomy is today's gold standard for the treatment of symptomatic cholelithiasis, its safety and effectiveness for acute cholecystitis remain controversial. The authors present a retrospective study comparing laparoscopic cholecystectomy in the acute versus the elective setting. A total of 605 patients were treated surgically for gallstone disease between August 1991 and January 1999. A total of 269 patients (44.5%) underwent surgery for acute cholecystitis as soon as possible after diagnosis, and elective cholecystectomy was performed on 336 patients (55.5%) for symptomatic gallstones. Initial open cholecystectomy was performed on 52 (19.3%) of the acute patients and 16 (4.8%) of the elective patients. Laparoscopic cholecystectomy was attempted on 217 of the acute patients (80.7%), with 11 cases (5.1%) converted to open cholecystectomy, and on 320 (95.2%) of the elective patients, with 6 cases (1.9%) converted to open cholecystectomy. The mean (+/-SD) operative time for the acute and elective patients was 105 (+/-38) and 85 (+/-21) minutes, respectively (P < 0.05). There was no perioperative mortality in either laparoscopic group. Surgical complications related to laparoscopic cholecystectomy in the acute and elective groups occurred in six (2.9%) and eight (2.5%) cases, respectively (P = NS). The current study shows that early laparoscopic cholecystectomy for acute cholecystitis is safe and efficient. Low conversion rates can be maintained with strict guidelines for appropriate patient selection, adequate experience, and proper laparoscopic technique.     

Quality of life and pain in patients with acute cholecystitis. Results of a randomized clinical trial.

BACKGROUND: Acute cholecystitis carries a higher risk of subsequent gallstone related events than symptomatic, non-complicated disease. However, it is largely unknown to what extent non-operative treatment will affect the patient's well-being as no trial has studied the possible consequences on pain and quality of life. Our aim was to study in a randomized trial how observational treatment (watchful waiting) compared to cholecystectomy. METHODS: Sixty-four patients with acute cholecystitis were randomized to observation or cholecystectomy. All gallstone related events were registered and patients answered questionnaires on quality of life (PGWB and NHP) and pain (Pain score and VAPS) at randomization and at 6, 12 and 60 months later. RESULTS: Patients were followed-up for a median of 67 months. Ten of 33 patients (30%, 95% CI 15%-46%) patients randomized to observation and 27 of 31 (87%, 95% CI 75 %- 99%) of patients randomized to operation had a cholecystectomy. Twelve of 33 (36%, 95% CI 20%-53%) patients in the observation group had a gallstone related event compared to 6 of 31 (19%, 95% CI 5%-33%) patients in the operation group, but the difference was not significant. When patients were grouped according to randomization or actual operative outcome (+/- cholecystectomy), we did not find any significant differences in pain or quality of life measurements. CONCLUSION: Although conservative treatment of AC carried a certain but not significantly increased risk of subsequent gallstone related events, this did not influence the symptomatic outcome as assessed by quality of life and pain measurements. Thus, we argue that conservative (non-operative) treatment and observation of AC is an acceptable option and should at least be considered in elderly and frail patients.     

Screening for cholelithiasis prior to aortic reconstruction

A study was undertaken to determine the value of preoperative oral cholecystography and the incidence and complications of cholelithiasis in patients undergoing aortic reconstruction. Over an 11-year period, 785 patients underwent aortic reconstruction. Forty-seven had a previous cholecystectomy; of the 738 remaining patients, 394 underwent preoperative operative oral cholecystography to screen for cholelithiasis. Seventy-three (18 percent) were found to have gallbladder disease. Thirteen had symptoms attributed to cholelithiasis and underwent cholecystectomy with aortic reconstruction. Three hundred eighty-one were left with the gallbladder after aortic reconstruction, 60 in whom disease was identified and 321 with normal oral cholecystography results. Three patients developed cholecystitis in the postoperative period, one in the diseased group and two with normal gallbladders. The incidence of postoperative cholecystitis was 0.8 percent (3 patients). Preoperative oral cholecystography is of little value as a screening tool. Cholecystectomy during aortic reconstruction is probably safe and the risk of postoperative cholecystitis in the asymptomatic patient is negligible.     

Gallbladder Findings after Cholecystectomy in Morbidly Obese Patients

Morbidly obese patients constitute a high risk group for the development of gallbladder disease. In our series 70 consecutive patients underwent vertical gastroplasty in an effort to manage morbid obesity. The mean age was 37 years (range 20-60), and the mean excess body weight was 92 kg (range 52-265). Six patients (8.5%) had undergone cholecystectomy before bariatric surgery because of symptomatic cholelithiasis. The remaining 64 patients underwent cholecystectomy at the time of vertical gastroplasty. Ninety-seven percent of the removed gallbladders had gross or histologic abnormalities, including cholelithiasis 18.5% (13 patients), and cholesterolosis 31% (22 patients). Histologically, chronic cholecystitis was present in all patients with cholelithiasis and cholesterolosis. Chronic cholecystitis alone was found in 27 patients (38.5%) and only two patients (3%) had normal findings. The mean excess body weight of the patients with cholesterolosis (96 kg) was not significantly greater than that of patients with cholelithiasis (89 kg) or chronic cholecystitis (88 kg). Our findings suggest that cholecystectomy should be performed in all morbidly obese patients concomitant with vertical gastroplasty.     

Reasons for conversion from laparoscopic to open cholecystectomy: A 10-year review

Laparoscopic cholecystectomy is now considered the "gold standard" operation for patients with gallstone disease. A number of patients require conversion to an open cholecystectomy for the safe completion of the procedure. This study investigates how the etiology and incidence of conversion from laparoscopic to open cholecystectomy has changed over time. All 5884 patients undergoing laparoscopic cholecystectomy between March 1991 and June 2001 were prospectively collected in a database. A total of 310 patients (5.2%) had had their cholecystectomies converted to an open procedure. The mortality rate for these patients was 0.7%. Causes for conversion were inability to correctly identify anatomy (50%), "other" indications (16%), bleeding (14%), suspected choledocholithiasis (11%), and suspected bile duct injury (8%). After an initial learning curve in thin patients with symptomatic cholelithiasis, inclusion of patients with acute cholecystitis, morbid obesity, or a prior celiotomy resulted in a peak conversion rate of 11% by 1994. From 1994 to the first half of 2001, the conversion rate has declined significantly for all patients (10% to 1%), as well as for patients with acute cholecystitis (26% to 1%). Although unclear anatomy secondary to inflammation remains the most common reason for conversion, the impact of acute cholecystitis on the operative outcome has decreased with time. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation). Supported by an unrestricted education grant from Ethicon Inc., Cincinnati, Ohio.     

Laparoscopic cholecystectomy for an abnormal hepato-iminodiacetic acid scan: a worthwhile procedure

Patients with symptoms similar to symptomatic cholelithiasis but with no sonographic evidence of gallstones can be difficult to manage. Cholecystokinin (CCK)-stimulated hepatobiliary scans can be helpful in determining whether the biliary tract is the potential source of the symptoms. We retrospectively reviewed the medical records of 69 patients at our institution who underwent CCK-stimulated hepatobiliary scans over a 2-year period. Twenty-nine of 69 patients had an abnormal gallbladder ejection fraction (defined as 35% or less). All 29 patients had no sonographic evidence of cholelithiasis. Seventeen of the 29 underwent cholecystectomy. There were no complications or deaths within the operative group. Fifteen of the pathologic specimens had evidence of chronic cholecystitis, one was cytomegalovirus cholecystitis, and one showed only cholesterolosis. There was no other intraperitoneal pathology to explain the abdominal symptoms. At an average follow-up of 11 months, eight patients (47%) in the operative group had complete resolution of their symptoms, six (35%) had significant improvement, two (12%) were unchanged, and one (6%) was worse. Twelve of 29 patients did not have a cholecystectomy. At an average follow-up of 11 months, four (33%) of these patients had improvement and eight (66%) reported no change or worsening of their symptoms. In the operative group, 53 per cent had reproduction of their symptoms with CCK stimulation, and in the nonoperative group, 33 per cent reported symptoms. Average gallbladder ejection fraction was 10 per cent (range, 0-32) in the operative group and 23 per cent (range, 0-35) in the nonoperative group. Liver function tests were similar in each group. CCK-stimulated hepatobiliary scans were helpful in defining biliary tract disease in patients without gallstones. These patients may benefit from cholecystectomy with minimal risk of morbidity and mortality.     

Single-incision laparoscopic cholecystectomy in a pediatric population: a preliminary report

Laparoscopic cholecystectomy has become a standard procedure for treatment of gallbladder diseases. The operation is performed through a four-trocar technique. Single-incision laparoscopy (SIL) has recently gained popularity. The purpose of our study was to review our cases of SIL cholecystectomy and to evaluate the safety and feasibility of this technique. After the approval of the Institutional Review Boards, we performed a retrospective chart review of our SIL cholecystectomy cases performed between January 2008 and August 2009. Pertinent clinical data were extracted. The outcomes were reported as operating room time, intraoperative and postoperative complications, length of stay, and intravenous narcotic use. We identified 24 patients (19 females and five males) with a mean age of 15 years. Most patients (67%) had a diagnosis of symptomatic cholelithiasis. Two patients had gallstone pancreatitis, three had acute cholecystitis, and one had a hydropic gallbladder. Two patients had an intraoperative cholangiogram performed. Average operating room time was 97.5 +/- 34.5 minutes (range, 65 to 145 minutes). There were no intraoperative complications. All patients had minimal (one to three doses) need for intravenous narcotics. All patients have had excellent cosmetic results on postoperative follow-up. SIL cholecystectomy in children is safe and feasible, even in the setting of acute cholecystitis and the need for cholangiogram.     

Gallstone disease in heart transplant recipients

OBJECTIVE: To review the outcome of cholecystectomy after heart transplant. SUMMARY BACKGROUND DATA: The optimal timing for gallbladder surgery in heart transplant patients is controversial. METHODS: Between April 1985 and October 2000, 518 cardiac transplants were performed at Ochsner Foundation Hospital. Data gathered included ultrasound reports, cholecystectomy operative reports, gallbladder pathologic reports, complications, and deaths. RESULTS: Charts were available for 509 patients (98%), 68 (13%) of whom underwent cholecystectomy before transplantation. Of the 509, 53 (10%) had serial ultrasound examinations and 29 of the 53 (55%) developed gallstones. After transplant, 47 (9%) underwent cholecystectomy. Five cholecystectomies were performed during the immediate postoperative course. Two patients who underwent cholecystectomy had acalculous cholecystitis; one was incidental. Four patients died (one with rejection and three with sepsis). After discharge, 42 cholecystectomies were performed: 16 for biliary colic (no deaths, three patients with complications), 19 for acute cholecystitis (one death, nine patients with complications), 5 for biliary pancreatitis (1 death, 1 patient with complications), and 2 others. CONCLUSIONS: The risk of morbidity and mortality from gallstone disease is high in cardiac transplant patients, particularly immediately posttransplant. Posttransplant patients require annual ultrasound examinations to detect the onset of gallstone disease, and this risk is higher than in the general population. Gallstones alone are an indication for cholecystectomy in the cardiac transplant patient. Pretransplant cholecystectomy should be considered in clinically stable patients with gallstones.     

Laparoscopic cholecystectomy in the pediatric population

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

Laparoscopic cholecystectomy: a report of 60 cases

From April to August 1990, 60 patients underwent laparoscopic cholecystectomy. Patients with biliary colic were included, but those who had florid acute cholecystitis, morbid obesity or scars in the upper portion of the abdomen were excluded. Three patients had acute cholecystitis, 56 had chronic cholecystitis and 1 had hydrops of the gallbladder. Nineteen patients had had previous lower abdominal surgery. Five patients did not require analgesia, but the remainder needed parenteral analgesia on an average of 1.7 occasions and enteral analgesia on an average of 1.8 occasions. There were no intraoperative complications, and no patient had the procedure completed by standard surgery. Postoperative hospital stay averaged 2.5 days. The mean follow-up was 39 days. Few postoperative complications were noted: two patients suffered from ileus; two patients had biliary colic postoperatively (one required endoscopic sphincterotomy with stone extraction, and in the other no common-duct stones were seen on retrograde cholangiography); one patient had an intra-abdominal abscess, which was drained percutaneously; and one patient complained of upper abdominal pain that was incisional in origin. Laparoscopic cholecystectomy should be considered the procedure of choice for elective treatment of uncomplicated symptomatic gallstone disease.     

Review of the Impact of Antineoplastic Therapies on the Risk for Cholelithiasis and Acute Cholecystitis

Background

Development of cholecystitis in patients with malignancies can potentially disrupt their treatment and alter prognosis. This review aims to identify antineoplastic interventions associated with increased risk of cholecystitis in cancer patients.

Methods

A comprehensive search strategy was developed to identify articles pertaining to risk factors and complications of cholecystitis in cancer patients. FDA-issued labels of novel antineoplastic drugs released after 2010 were hand-searched to identify more therapies associated with cholecystitis in nonpublished studies.

Results

Of an initial 2,932 articles, 124 were reviewed in the study. Postgastrectomy patients have a high (5–30 %) incidence of gallstone disease, and 1–7 % develop symptomatic disease. One randomized trial addressing the role of cholecystectomy concurrent with gastrectomy is currently underway. Among other risk groups, patients with neuroendocrine tumors treated with somatostatin analogs have a 15 % risk of cholelithiasis, and most are symptomatic. Hepatic artery based therapies carry a risk of cholecystitis (0.02–24 %), although the risk is reduced with selective catheterization. Myelosuppression related to chemotherapeutic agents (0.4 %), bone marrow transplantation, and treatment with novel multikinase inhibitors are associated with high risk of cholecystitis.

Conclusions

There are several risk factors for gallbladder-related surgical emergencies in patients with advanced malignancies. Incidental cholecystectomy at index operation should be considered in patients planned for gastrectomy, and candidates for regional therapies to the liver or somatostatin analogs. While prophylactic cholecystectomy is currently recommended for patients with cholelithiasis receiving myeloablative therapy, this strategy may have value in patients treated with multikinase inhibitors, immunotherapy, and oncolytic viral therapy based on evolving evidence.     

The role of magnetic resonance cholangiography in the management of patients with gallstone pancreatitis

OBJECTIVE: To examine the utility of magnetic resonance cholangiography (MRC) in the preoperative evaluation of patients with gallstone pancreatitis. SUMMARY BACKGROUND DATA: Gallstone pancreatitis is often associated with the presence of common bile duct (CBD) stones that may require endoscopic removal prior to planned laparoscopic cholecystectomy. No reliable clinical criteria exist, however, that can accurately predict CBD stones and the need for preoperative endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Sixty-four patients were identified with gallstone pancreatitis based on clinical presentation and imaging studies over a three-and-a-half-year period. All patients underwent MRC, and the images were evaluated for gallstones, CBD stones, cholecystitis, and pancreatitis RESULTS: Seventeen of the 64 patients (27%) with gallstone pancreatitis were found to have CBD stones confirmed by ERCP. MRC correctly predicted CBD stones in 16 of the 17 patients (sensitivity = 94%). In 1 additional patient, MRC demonstrated CBD stones not seen at ERCP, consistent with probable passage. By comparison, the sensitivities of other criteria for predicting CBD stones were (1) elevated bilirubin >or=2.0 mg/dL = 65%; (2) dilated duct on ultrasound = 55%; and (3) CBD stones on ultrasound = 27%. MRC was able to visualize gallbladder stones in 57 of 62 patients (94%) and correctly predicted acute cholecystitis in 6 of 8 patients. MRC also detected peripancreatic edema and inflammatory changes consistent with acute pancreatitis in 45 of 64 patients (70%). CONCLUSIONS: These results demonstrate that MRC can accurately identify CBD stones preoperatively in patients with gallstone pancreatitis and provide valuable information with respect to other biliary pathology, including cholelithiasis, acute cholecystitis, and pancreatitis. MRC is an effective noninvasive screening tool for CBD stones, appropriately selecting candidates for preoperative ERCP and sparing others the need for an endoscopic procedure with its associated complications.     

Randomized trial of needlescopic versus laparoscopic cholecystectomy

BACKGROUND: Several studies have reported the feasibility of using 'needlescopic' instruments with a diameter less than 3 mm in minimally invasive surgery. This study reports a comparison of needlescopic cholecystectomy and laparoscopic cholecystectomy. METHODS: Seventy-five patients with symptomatic chronic cholelithiasis were randomized to needlescopic (n = 37) or laparoscopic (n = 38) cholecystectomy. RESULTS: The duration of surgery in the two groups was similar. Patients in the needlescopic group had less pain (mean visual analogue score 2.2 versus 3.6; P < 0.003) and had smaller scars (median length 17.0 versus 25.0 mm; P < 0.001). In addition, patients in the needlescopic group tended to require fewer intramuscular pethidine injections (P = 0.05). However, oral analgesic requirements in the two groups were similar. There were no complications in either group. CONCLUSION: Needlescopic cholecystectomy resulted in less postoperative pain and a smaller surgical scar than laparoscopic cholecystectomy in patients with chronic cholecystitis.