Simultaneous cholecystectomy for asymptomatic gallstones during elective colorectal cancer surgery.

BACKGROUND: Asymptomatic gallstones are commonly detected using preoperative imaging in patients with colorectal cancer (CRC), but its management remains a topic of debate. METHODS: Clinicopathologic characteristics of patients who had asymptomatic gallstones presenting during the colorectal procedure were retrospectively reviewed. Medical records, including postoperative morbidity, mortality, and long-term gallstone-related diseases, were assessed. RESULTS: Of 134 patients with CRC having asymptomatic gallstones, 89 underwent elective colorectal surgery only (observation group), and 45 underwent elective colorectal surgery with simultaneous cholecystectomy (cholecystectomy group). After propensity score matching (PSM), the complications were similar in the 2 groups. During the follow-up period, biliary complications were noted in 11 patients (12.4%) in the observation group within 2 years after the initial CRC surgery, but no case was found in the cholecystectomy group. After PSM, the incidence of long-term biliary complications remained significantly higher in the observation group than in the cholecystectomy group (26.5% vs 0.0%; P < .01). Multivariable logistic regression analysis identified female gender, old age (≥65 years old), and small multiple gallstones as independent risk factors for the development of long-term gallstone-related diseases in patients from the observation group. CONCLUSION: Simultaneous prophylactic cholecystectomy during prepared, elective CRC surgery did not increase postoperative morbidity or mortality but decreased the risk of subsequent gallstone-related complications. Hence, simultaneous cholecystectomy might be a preferred therapeutic option for patients with CRC having asymptomatic gallstones in cases of elective surgery, especially for older patients (≥65 years old), female patients, and those with small multiple calculi.

Robotic management of primary cholecystoduodenal fistula: A case report and brief literature review.

BACKGROUND: Cholecystoduodenal fistula (CDF) arises from persistent biliary tree disorders, causing fusion between the gallbladder and duodenum. Initially, open resection was common until laparoscopic fistula closure gained popularity. However, complexities within the gallbladder fossa yielded inconsistent outcomes. Advanced imaging and robotic surgery now enhance precision and detection. METHOD: A 62-year-old woman with chronic cholangitis attributed to cholecystoduodenal fistula underwent successful robotic cholecystectomy and fistula closure. RESULTS: Postoperatively, the symptoms subsided with no complications during the robotic procedure. Existing studies report favourable outcomes for robotic cholecystectomy and fistula closure. CONCLUSIONS: Our case report showcases a rare instance of successful robotic cholecystectomy with CDF closure. This case, along with a review of previous cases, suggests the potential of robotic surgery as the preferred approach, especially for patients anticipated to face significant laparoscopic morbidity.

Textbook outcome in patients with biliary duct injury during cholecystectomy.

BACKGROUND: Iatrogenic bile duct injury (BDI) during cholecystectomy is associated with a complex and heterogeneous management owing to the burden of morbidity until their definitive treatment. This study aimed to define the textbook outcomes (TOs) after BDI with the purpose to indicate the ideal treatment and to improve it management. METHODS: We collected data from patients with an BDI between 1990 and 2022 from 27 hospitals. TO was defined as a successful conservative treatment of the iatrogenic BDI or only minor complications after BDI or patients in whom the first repair resolves the iatrogenic BDI without complications or with minor complications. RESULTS: We included 808 patients and a total of 394 patients (46.9%) achieved TO. Overall complications in TO and non-TO groups were 11.9% and 86%, respectively (P < .001). Major complications and mortality in the non-TO group were 57.4% and 9.2%, respectively. The use of end-to-end bile duct anastomosis repair was higher in the non-TO group (23.1 vs 7.8, P < .001). Factors associated with achieving a TO were injury in a specialized center (adjusted odds ratio [aOR], 4.01; 95% CI, 2.68-5.99; P < .001), transfer for a first repair (aOR, 5.72; 95% CI, 3.51-9.34; P < .001), conservative management (aOR, 5.00; 95% CI, 1.63-15.36; P = .005), or surgical management (aOR, 2.45; 95% CI, 1.50-4.00; P < .001). CONCLUSION: TO largely depends on where the BDI is managed and the type of injury. It allows hepatobiliary centers to identify domains of improvement of perioperative management of patients with BDI.

Risk factors for readmission after a cholecystectomy: a case-control study.

OBJECTIVE: The aim of this study was to assess the risk factors associated with 30-day hospital readmissions after a cholecystectomy. METHODS: We conducted a case-control study, with data obtained from UC-Christus from Santiago, Chile. All patients who underwent a cholecystectomy between January 2015 and December 2019 were included in the study. We identified all patients readmitted after a cholecystectomy and compared them with a randomized control group. Univariate and multivariate analyses were conducted to identify risk factors. RESULTS: Of the 4866 cholecystectomies performed between 2015 and 2019, 79 patients presented 30-day hospital readmission after the surgical procedure (1.6%). We identified as risk factors for readmission in the univariate analysis the presence of a solid tumor at the moment of cholecystectomy (OR = 7.58), high pre-operative direct bilirubin (OR = 2.52), high pre-operative alkaline phosphatase (OR = 3.25), emergency admission (OR = 2.04), choledocholithiasis on admission (OR = 4.34), additional surgical procedure during the cholecystectomy (OR = 4.12), and post-operative complications. In the multivariate analysis, the performance of an additional surgical procedure during cholecystectomy was statistically significant (OR = 4.24). CONCLUSION: Performing an additional surgical procedure during cholecystectomy was identified as a risk factor associated with 30-day hospital readmission.

OBJETIVO: El objetivo de este estudio fue evaluar los factores de riesgo asociados al reingreso hospitalario en los primeros 30 días post colecistectomía. MÉTODOS: Estudio de casos-controles con datos obtenidos del Hospital Clínico de la UC-Christus, Santiago, Chile. Se ­incluyeron las colecistectomías realizadas entre los años 2015-2019. Se consideraron como casos aquellos pacientes que reingresaron en los 30 primeros días posterior a una colecistectomía. Se realizó un análisis univariado y multivariado de diferentes posibles factores de riesgo. RESULTADOS: De un total de 4866 colecistectomías, 79 pacientes presentaron reingreso hospitalario. Los resultados estadísticamente significativos en el análisis univariado fueron; tumor sólido al momento de la colecistectomía (OR = 7.58) bilirrubina directa preoperatoria alterada (OR = 2.52), fosfatasa alcalina preoperatoria alterada (OR = 3.25), ingreso de urgencia (OR = 2.04), coledocolitiasis al ingreso (OR = 4.34) realización de otros procedimientos (OR = 4.12) y complicaciones postoperatorias. En el análisis multivariado sólo la realización de otro procedimiento durante la colecistectomía fue estadísticamente significativa (OR = 4.24). CONCLUSIÓN: La realización de otros procedimientos durante la colecistectomía es un factor de riesgo de reingreso hospitalario en los 30 días posteriores a la colecistectomía.

Percutaneous cholecystostomy in elderly patients with acute cholecystitis: a systematic review and meta-analysis.

Percutaneous cholecystostomy (PC) is often preferred over early cholecystectomy (EC) for elderly patients presenting with acute cholecystitis (AC). However, there is a lack of solid data on this issue. Following the PRISMA guidelines, we searched the Medline and Web of Science databases for reports published before December 2022. Studies that assessed elderly patients (aged 65 years and older) with AC treated using PC, in comparison with those treated with EC, were included. Outcomes analyzed were perioperative outcomes and readmissions. The literature search yielded 3279 records, from which 7 papers (1208 patients) met the inclusion criteria. No clinical trials were identified. Patients undergoing PC comprised a higher percentage of cases with ASA III or IV status (OR 3.49, 95%CI 1.59-7.69, p = 0.009) and individuals with moderate to severe AC (OR 1.78, 95%CI 1.00-3.16, p = 0.05). No significant differences were observed in terms of mortality and morbidity. However, patients in the PC groups exhibited a higher rate of readmissions (OR 3.77, 95%CI 2.35-6.05, p < 0.001) and a greater incidence of persistent or recurrent gallstone disease (OR 12.60, 95%CI 3.09-51.38, p < 0.001). Elderly patients selected for PC, displayed greater frailty and more severe AC, but did not exhibit increased post-interventional morbidity and mortality compared to those undergoing EC. Despite their inferior life expectancy, they still presented a greater likelihood of persistent or recurrent disease compared to the control group.

Endoscopic Gallbladder Stenting to Prevent Recurrent Cholecystitis in Deferred Cholecystectomy: A Randomized Trial.

BACKGROUND & AIMS: Endoscopic transpapillary gallbladder stenting (ETGS) has been proposed as one of the adjunctive treatments, apart from antibiotics, before surgery in patients with acute cholecystitis whose cholecystectomy could not be performed or was deferred. Currently, there are no comparative data on the outcomes of ETGS in those who receive and do not receive ETGS. We aimed to compare the rates of recurrent cholecystitis at 3 and 6 months in these 2 groups. METHODS: Between 2020 and 2023, eligible acute calculous cholecystitis patients with a high probability of common bile duct stone, who were surgical candidates but could not have an early cholecystectomy during COVID-19 surgical lockdown, were randomized into groups A (received ETGS) and B (did not receive ETGS). A definitive cholecystectomy was performed at 3 months or later in both groups. RESULTS: A total of 120 eligible patients were randomized into group A (n = 60) and group B (n = 60). In group A, technical and clinical success rates were 90% (54 of 60) and 100% (54 of 54), respectively. Based on intention-to-treat analysis, group A had a significantly lower rate of recurrence than group B at 3 months (0% [0 of 60] vs 18.3% [11 of 60]; P = .001). At 3-6 months, group A showed a nonsignificantly lower rate of recurrent cholecystitis compared to group B (0% [0 of 32] vs 10% [3 of 30]; P = .11). CONCLUSIONS: ETGS could prevent recurrent cholecystitis in acute cholecystitis patients with common bile duct stone whose cholecystectomy was deferred for 3 months. In those who did not receive ETGS, the majority of recurrences occurred within 3 months. (Thaiclinicaltrials.org, Number TCTR20200913001).

Associations of cholecystectomy with metabolic health changes and incident cardiovascular disease: a retrospective cohort study.

Although some studies conducted about the risk of cholecystectomy and cardiovascular disease, there was a limit to explaining the relationship. We investigated the short-term and long-term relationship between cholecystectomy and cardiovascular disease, and evidence using the elements of the metabolic index as an intermediate step. It was a retrospective cohort study and we used the National Health Insurance Service database of South Korea between 2002 and 2015. Finally, 5,210 patients who underwent cholecystectomy and 49,457 at 1:10 age and gender-matched controls of subjects were collected. The main results was estimated by Multivariate Cox proportional hazard regression to calculate the hazard ratio (HR) with 95% confidence interval (CI) for risk of cardiovascular disease after cholecystectomy. Regarding short-term effects of cholecystectomy, increased risk of cardiovascular disease (aHR 1.35, 95% CI 1.15-1.58) and coronary heart disease (aHR 1.77, 95% CI 1.44-2.16) were similarly seen within 2 years of surgery. When analyzing the change in metabolic risk factors, cholecystectomy was associated with a change in systolic blood pressure (adjusted mean [aMean]: 1.51, 95% CI: [- 1.50 to - 4.51]), total cholesterol (aMean - 14.14, [- 20.33 to 7.95]) and body mass index (aMean - 0.13, [- 0.37 to 0.11]). Cholecystectomy patients had elevated risk of cardiovascular disease in the short-term, possibly due to the characteristics of the patient before surgery. The association of cholecystectomy and cardiovascular disease has decreased after 2 years in patients who underwent cholecystectomy, suggesting that because of improvement of metabolic health, cholecystectomy-associated elevation of cardiovascular disease risk may be ameliorated 2 years after cholecystectomy.

Gallstone formation and subsequent cholecystectomy after oncological gastric and esophageal resection.

PURPOSE: Gallstone formation is increased after gastric (GR) or esophageal resection (ER); however, the exact pathophysiology is not fully understood yet. Symptomatic cholecystolithiasis and the need for subsequent cholecystectomy after upper gastrointestinal resection can alter the outcome in oncological patients. There is an ongoing discussion if these patients benefit from a simultaneous prophylactic cholecystectomy. This study aims to analyze the risk of gallstone formation after GR or ER and the perioperative course of a subsequent cholecystectomy. METHODS: In this study, all patients were included, who underwent an oncological gastric or esophageal resection at the Medical University of Innsbruck, Department of Visceral, Transplant and Thoracic Surgery in the years 2003-2021. RESULTS: A simultaneous cholecystectomy was performed in 29.8% with GR and in 2.1% with ER (p < 0.001). There was no significant difference in complications or length-of-stay between patients with simultaneous vs. no simultaneous cholecystectomy. Newly developed gallstones tended to be more common after GR (16% vs. 10% ER), after reconstruction without preservation of the duodenal passage (17% vs. 11% with) and after GR with lymph node dissection (19% vs. 5% without). After ER, subsequent cholecystectomy was significant less frequently (11.4% vs. 2.9% OR) (p = 0.005). The subsequent cholecystectomy was performed openly in 57.1% with major complications classified as Clavien-Dindo ≥ 3a in 14.3%. CONCLUSION: Based on the findings of our study, we do not recommend simultaneous cholecystectomy routinely in oncological gastric or esophageal resections. An individualized approach depending on risk factors like extensive lymphadenectomy or duodenal passage can be discussed.

Intrahepatic biloma after intraoperative cholangiography.

A woman in her 30s presented to the emergency department with a month-long history of postprandial epigastric pain radiating to her back. The diagnosis of cholecystolithiasis and suspected choledocholithiasis was made, and the patient underwent cholecystectomy with cholangiography using standard technique. The surgery was complicated by an intrahepatic bile duct injury attributed to high injection pressure during cholangiography. She developed an intrahepatic collection that was drained and confirmed the diagnosis of biloma. In this case report, we discuss a rare complication of intraoperative cholangiography during laparoscopic cholecystectomy and consider a way to prevent it.

Post-cholecystectomy bile duct injuries: a retrospective cohort study.

BACKGROUND: Bile duct injury (BDI) is still a major worrisome complication that is feared by all surgeons undergoing cholecystectomy. The overall incidence of biliary duct injuries falls between 0.2 and 1.3%. BDI classification remains an important method to define the type of injury conducted for investigation and management. Recently, a Consensus has been taken to define BDI using the ATOM classification. Early management brings better results than delayed management. The current perspective in biliary surgery is the laparoscopic role in diagnosing and managing BDI. Diagnostic laparoscopy has been conducted in various entities for diagnostic and therapeutic measures in minor and major BDIs. METHODS: 35 cases with iatrogenic BDI following cholecystectomy (after both open and laparoscopic approaches) both happened in or were referred to Alexandria Main University Hospital surgical department from January 2019 till May 2022 and were analyzed retrospectively. Patients were classified according to the ATOM classification. Management options undertaken were mentioned and compared to the timing of diagnosis, and the morbidity and mortality rates (using the Clavien-Dindo classification). RESULTS: 35 patients with BDI after both laparoscopic cholecystectomy (LC) (54.3%), and Open cholecystectomy (OC) (45.7%) (20% were converted and 25.7% were Open from the start) were classified according to ATOM classification. 45.7% were main bile duct injuries (MBDI), and 54.3% were non-main bile duct injuries (NMBDI), where only one case 2.9% was associated with vasculobiliary injury (VBI). 28% (n = 10) of the cases were diagnosed intraoperatively (Ei), 62.9% were diagnosed early postoperatively (Ep), and 8.6% were diagnosed in the late postoperative period (L). LC was associated with 84.2% of the NMBDI, and only 18.8% of the MBDI, compared to OC which was associated with 81.3% of the MBDI, and 15.8% of the NMBDI. By the Clavien-Dindo classification, 68.6% fell into Class IIIb, 20% into Class I, 5.7% into Class V (mortality rate), 2.9% into Class IIIa, and 2.9% into Class IV. The Clavien-Dindo classification and the patient's injury (type and time of detection) were compared to investigation and management options. CONCLUSION: Management options should be defined individually according to the mode of presentation, the timing of detection of injury, and the type of injury. Early detection and management are associated with lower morbidity and mortality. Diagnostic Laparoscopy was associated with lower morbidity and better outcomes. A proper Reporting checklist should be designed to help improve the identification of injury types.

Extrahepatic abscess and dropped gallstones: a case report and a narrative review of an unusual delayed complication of laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is the most common minimally invasive abdominal surgery procedure performed in Western countries; it offers several advantages over laparotomy but still carries some risks, such as intraoperative spillage of bile and gallstones. Diagnosis of dropped gallstones could be challenging, it is frequently delayed, and this can lead to further complications such as abscesses formation. METHODS: We report the history of a 51-year-old male with persistent dull abdominal pain in association to appetite loss, vomiting episodes and changes in regular bowel habits, a past medical history of laparoscopic cholecystectomy for biliary lithiasis (1.5 years earlier) and minimum elevation of inflammatory markers and gamma-GT values. RESULTS: Ultrasound examination showed perihepatic stones and magnetic resonance imaging revealed the presence of multiple perihepatic abscesses, findings compatible with fibrotic-inflammatory phenomena from 'dropped gallstones'. A re-laparoscopy was then performed with an abscess collection containing multiple gallstones; a liver wedge resection was also required due to strong adhesions. At follow up, the patient had improved both on clinical and biochemical perspective. CONCLUSION: Dropped gallstones are an underreported cause of morbidity and diagnostic dilemmas in subjects who underwent to laparoscopic cholecystectomy, in relation to infectious complications that can occur even several months or years after surgery. Imaging represents a valuable aid in the correct non-invasive diagnostic process, but proper awareness of this insidious condition is necessary. Surgeons and radiologists should always consider this eventuality in the differential diagnosis of a patient presenting with abdominal abscesses and history of cholecystectomy.

Evaluating Clinical Outcomes of Laparoscopic Subtotal and Total Cholecystectomy for Complicated Acute Cholecystitis: A Systematic Review and Meta-Analysis.

INTRODUCTION: This systematic review and meta-analysis aimed to compare clinical outcomes in patients with complicated acute cholecystitis undergoing laparoscopic total vs subtotal cholecystectomy. METHODS: This systematic review and meta-analysis was conducted according to PRISMA guidelines and queried PubMed, Embase, ProQuest, Google Scholar, and Cochrane databases from inception to May 2023. The primary outcome was complication rates including common bile duct injury, wound infection, reoperation, bile leak, retained stones, and subhepatic collection, whereas secondary outcomes were in-hospital mortality and hospital length of stay. RESULTS: A total of 7 studies with 135,233 cases were included for meta-analysis. Patients who underwent laparoscopic total cholecystectomy had a significantly lower risk of postoperative bile leaks (RR: .15; 95% CI: .03, .80) and subhepatic fluid collection (RR: 0.19; 95% CI: .06, .63) and were 2.94 times less likely to die compared to those who underwent subtotal cholecystectomy (RR .34; 95% CI: .15, .77). Patients who underwent subtotal cholecystectomy had significantly longer hospital length of stay (mean difference 1.0 days; 95% CI: .5 days, 1.4 days). CONCLUSIONS: In adult patients presenting with complicated cholecystitis, management with laparoscopic subtotal cholecystectomy presents a unique complication profile with increased risk of postoperative bile leak and subhepatic fluid collection, in-hospital mortality, and longer hospital length-of-stay when used as an alternative approach to laparoscopic total cholecystectomy. Further research into the most appropriate clinical scenarios and patient populations for the use of the subtotal cholecystectomy approach may prove useful in improving its associated outcomes.

A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation?

INTRODUCTION: Laparoscopic subtotal cholecystectomy (LSTC) is a bailout procedure that is undertaken when it is not safe to proceed with a laparoscopic total cholecystectomy owing to dense adhesions in Calot's triangle. The main aim of this review was to investigate the early (≤30 days) and late (>30 days) morbidity and mortality of LSTC. METHODS: A literature search of the PubMed® (MEDLINE®), Google Scholar™ and Embase® databases was conducted to identify all studies on LSTC published between 1985 and December 2020. A systematic review was then performed. RESULTS: Overall, 45 studies involving 2,166 subtotal cholecystectomy patients (51% female) were identified for inclusion in the review. The mean patient age was 55 years (standard deviation: 15 years). Just over half (53%) of the patients had an elective procedure. The conversion rate was 6.2% (n=135). The most common indication was acute cholecystitis (49%). Different techniques were used, with the majority having a closed cystic duct/gallbladder stump (71%). The most common closure technique was intracorporeal suturing (53%), followed by endoloop closure (15%). Four patients (0.18%) died within thirty days of surgery. Morbidity within 30 days included bile duct injury (0.23%), bile leak (18%) and intra-abdominal collection (4%). Reoperation was reported in 23 patients (1.2%), most commonly for unresolving intra-abdominal collections and failed endoscopic retrograde cholangiopancreatography to control bile leak. Long-term follow-up was reported in 30 studies, the median follow-up duration being 22 months. Late morbidity included incisional hernias (6%), symptomatic gallstones (4%) and common bile duct stones (2%), with 2% of cases requiring completion of cholecystectomy. CONCLUSIONS: LSTC is an acceptable alternative in patients with a "difficult" Calot's triangle.

Meta-analysis of fenestrating versus reconstituting subtotal cholecystectomy in the management of difficult gallbladder.

AIMS: To evaluate comparative outcomes of fenestrating and reconstituting subtotal cholecystectomy (STC) in patients with difficult gallbladder. METHODS: A systematic search of electronic data sources and bibliographic reference lists were conducted. All comparative studies reporting outcomes of laparoscopic fenestrating and reconstituting STC were included and their risk of bias were assessed using ROBINS-I tool. RESULTS: Seven comparative studies were included enrolling 590 patients undergoing laparoscopic STC using either fenestrating (n = 353) or reconstituting (n = 237) approaches. Although fenestrating STC was associated with a significantly higher rate of bile leak (OR: 2.47, p = 0.007) compared to reconstituting STC, both approaches were comparable in terms of resolution of bile leak without (RD: -0.02, p = 0.86) or with (OR: 1.84, p = 0.40) postoperative ERCP. Moreover, there was no significant difference in development of bile duct injury (RD: -0.02, p = 0.16), need for postoperative ERCP (OR: 1.36, p = 0.49), wound infection (RD: 0.03, p = 0.27), re-operation (OR: 0.95, p = 0.95), gallbladder remnant cholecystitis (OR: 0.21, p = 0.09) or need for completion cholecystectomy (RD: 0.01, p = 0.59) between two groups. CONCLUSIONS: Fenestrating STC is associated with a higher risk of bile leak than the reconstructing technique. This issue can be mitigated by routine use of drains, delayed drain removal, and in selected cases endoscopic therapy. We encourage the fenestrating approach considering trends in improved short- and long-term outcomes.

Cholecystectomy and ERCP in pregnancy: a nationwide register-based study.

OBJECTIVE: The objective was to examine the outcomes of cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy and compare these outcomes with those in nonpregnant women of fertile age. SUMMARY BACKGROUND DATA: Although both laparoscopic cholecystectomy and ERCP are considered safe and feasible in pregnant patients, there is still concern and uncertainty regarding gallstone intervention during pregnancy. This study aimed to investigate outcomes in pregnant patients compared to outcomes in nonpregnant patients. METHODS: Data on all female patients aged 18-45 years were retrieved from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography. The patients were divided into groups according to intervention: cholecystectomy, ERCP, or a combination thereof. Differences between pregnant and nonpregnant patients were analyzed. RESULTS: A total of 21 328 patients were included, with 291 cholecystectomy and 63 ERCP procedures performed in pregnant patients. At the 30-day follow-up, more complications after cholecystectomy were registered for pregnant patients. However, pregnancy was not a significant risk factor for adverse events when adjusting for previous complicated gallstone disease, intraoperative complications, emergency surgery, and common bile duct stones. There were no differences in outcomes when comparing cholecystectomy among the different trimesters. ERCP had no significant effect on outcomes at the 30-day follow-up. CONCLUSION: Cholecystectomy, ERCP, and combinations thereof are safe during pregnancy.