A nationwide analysis of gallbladder surgery in England between 2000 and 2019.

BACKGROUND: There are no reports on nationwide trends in subtotal cholecystectomy (STC) and cholecystostomy in England. We hypothesized that, as in the United States, a substantial increase in the utilization of these surgical procedures, over time, may be observed. We aimed to generate a reliable report on 4 of the most common gallbladder surgical procedures in England to allow cross-procedure comparisons and highlight significant changes in the management of benign gallbladder disease over time. METHODS: We obtained data from NHS Digital and extracted population estimates from the Office of National Statistics. We examined the trends in the use of STC, cholecystostomy, cholecystolithotomy and total cholecystectomy (TC) between 2000 and 2019. RESULTS: Of the 1,234,319 gallbladder surgeries performed, TC accounted for 96.8% (n = 1,194,786) and the other 3 surgeries for 3.2% (n = 39,533). The total number of gallbladder surgeries performed annually increased by 80.4% from 2000 to 2019. We detected increases in the counts of cholecystostomies by 723.1% (n = 290 in 2000 vs n = 2,387 in 2019) and STCs by 716.6% (n = 217 in 2000 vs n = 1,772 in 2019). Consequently, there was a decrease in the ratio of TC to STC (180:1 in 2000 vs 38:1 in 2019). A similar decrease was observed in the ratio of cholecystectomy to cholecystostomy (135:1 in 2000 vs 29:1 in 2019). CONCLUSION: Increased utilization of STC and cholecystostomy was detected in England. These findings highlight the importance of regular monitoring of nationwide trends in gallbladder surgery and the associated clinical outcomes.

National trends and outcomes in timing of ERCP in patients with cholangitis.

INTRODUCTION: Guidelines recommend early endoscopic retrograde cholangiopancreatography for the management of acute cholangitis, but the definition of the term "early" remains debatable. This study analyzed national trends in the timing of endoscopic retrograde cholangiopancreatography and identified the ideal time to perform preoperative endoscopic retrograde cholangiopancreatography in patients with acute cholangitis. METHODS: The 2005 to 2016 National Inpatient Sample was used to identify patients undergoing cholecystectomy for acute cholangitis. Severity of cholangitis was defined using the 2013 Tokyo Grading Criteria, where Tokyo grade III patients were defined as having organ dysfunction and non-Tokyo grade III patients were defined as grades I and II. Multivariable regressions (accounting for patient and hospital characteristics) were used to identify the timing of preoperative endoscopic retrograde cholangiopancreatography associated with the least mortality risk. RESULTS: Of 91,051 patients undergoing cholecystectomy for cholangitis, 55% underwent preoperative endoscopic retrograde cholangiopancreatography: 24% of patients received endoscopic retrograde cholangiopancreatography on the day of admission, 41% on hospital day 2, and the use of endoscopic retrograde cholangiopancreatography decreased gradually thereafter. Mortality rates remained under 1% if endoscopic retrograde cholangiopancreatography was performed during the first 3 days and increased as endoscopic retrograde cholangiopancreatography was performed during days 4 to 7 (P < .001). On multivariable regression, endoscopic retrograde cholangiopancreatography performed >72 hours after admission was associated with increased mortality (adjusted odds ratio 1.80, P = .01). Receiving endoscopic retrograde cholangiopancreatography P > 72 hours increased risk of death among Tokyo grade III patients (adjusted odds ratio 1.88, P = .01). Overall, during the study period, the utilization of preoperative endoscopic retrograde cholangiopancreatography for all grades of acute cholangitis increased from 39% of patients in 2005 to 51% in 2016 (P < .001). CONCLUSION: There has been an increase in the use of endoscopic retrograde cholangiopancreatography for acute cholangitis. Although endoscopic retrograde cholangiopancreatography on the day of admission was not associated with a decrease in mortality in patients with Tokyo grade III disease, endoscopic retrograde cholangiopancreatography within 72 hours of hospitalization was associated with decreased in-hospital mortality.

DPP-4 as a Possible Biomarker of Inflammation Before Abdominal Surgery for Chronic Pathology: Our Experience with Elective Cholecystectomy.

Background and objectives: Dipeptidyl-Peptidase 4 (DPP-4) is a protein expressed in numerous cells and tissues. Recently it has shown its involvement as a catalyst in the inflammatory response in various pulmonary, autoimmune, intestinal and other pathologies. The objective of this study was to compare the preoperative serum levels of DPP-4 in patients with and without surgical finding of perivesicular inflammation. Materials and methods: a cross-sectional analytical study nested in a prospective cohort, including patients scheduled for elective cholecystectomy, without surgical complications, that were 18-70 years of age, with low cardiovascular risk, without a history of peritonitis, pancreatitis, or jaundice and underwent ERCP protocol, type 2 diabetes mellitus, acute inflammatory (Protein C Reactive < 3 mg/L, leucocytes < 10 1000/mm3), neoplastic, nephrologic or liver disease, the use of anti-inflammatory drugs, steroids and/or antibiotics, the use of pacemakers or metallic implants and without major amputations and whom agreed to participate by providing their informed consent. Ethical and Research register: 45-16. Prior to surgery we compiled anthropometric data and a blood sample to determine the serum levels of DPP-4. The presence of perivesicular inflammation was determined in the surgery. The data was analyzed using the statistical program Rstudio. Results: High BMI values were observed (27.8 ± 6.4); waist circumference (94.7 ± 15.1) and percentage of fat mass (34.7 ± 11.7), showing a cumulative frequency of 65.9% for overweight/obesity. In 27.3% of the interventions, intraoperative perivesicular inflammation findings were reported. The serum levels of DPP-4 were lower in the group of patients with perivesicular inflammation (3947.6 ± 1659.5 vs. 3053.2 ± 1469.6, LC95% of the difference: 160.4-1628.3), being statistically significant (P = 0.018). Conclusions: In the subacute or chronic phases of cholecystitis, there appears to be a constant consumption of DPP-4, which would modulate a better immune response that could be related to the reduction of postoperative complications, so the use of Serum levels of DPP-4 as an early biomarker could improve the diagnostic accuracy of this pathology and the surgical approach.

Gallbladder Disease in Children: A 20-year Single-center Experience.

OBJECTIVE: Aim of this study was to examine the changes in incidence of pediatric cholecystectomies. METHODS: Based on a review of hospital-records, children were divided into two groups regarding year of surgery (Group I: 1998-2007; Group II: 2008-2017) and their characteristics were compared. RESULTS: Number of cholecystecomies increased from 11 to 34. Median age increased from 11 to 15.5 years and mean BMI increased from 19.2 cm/m2 to 23.0 cm/m2. Hereditary spherocytosis decreased from 63.6% to 11.8% (P=0.001) of indications for cholecystectomy, while proportion of cholesterol stones increased from 27.3% to 70.6% (P=0.006). Frequency of laparoscopic cholecystectomy increased from 36.4% to 85.3% (P=0.001). Duration of hospital stay shortened from 8 to 4 days (P=0.008). CONCLUSIONS: Number of pediatric cholecystectomies has significantly increased in the last 20 years, as well as average BMI of the observed population This probably signifies a correlation between rising obesity rates and increase in frequency of symptomatic cholelithiasis in children.

Systematic review with meta-analysis: cholecystectomy for biliary dyskinesia-what can the gallbladder ejection fraction tell us?

BACKGROUND: Gallbladder dyskinesia (gallbladder spasm, biliary dyskinesia or chronic acalculous cholecystitis) is a poorly defined entity which presents as biliary-type pain without any identifiable organic pathology. Abnormal gallbladder ejection fraction (GBEF) is used by some to select those likely to benefit from cholecystectomy. The validity of this approach has been questioned. AIM: To systematically review the literature and summarise the evidence surrounding the practice of cholecystectomy based on GBEF for gallbladder dyskinesia. METHODS: We conducted a systematic search of PubMed/MEDLINE and SCOPUS from 1980 to 2016 to identify the relevant literature. RESULTS: Twenty-nine studies including 2891 patients were included in the final analysis. In comparing cholecystectomy with medical management, patients with a normal GBEF did not benefit from cholecystectomy; whereas those with low GBEF had a higher chance (RR, relative risk = 2.37) of symptomatic improvement following surgery. When those classified as "low" and "normal" GBEF were compared in terms of outcome following cholecystectomy, the rate of improvement following surgery was similar in the two groups (RR 1.09) which suggests a placebo effect of surgery. CONCLUSIONS: While a low GBEF may provide some guidance in identifying those with gallbladder dyskinesia who may benefit from cholecystectomy, the available data are inconsistent and based on studies of poor quality which are often subject to bias and the impact of confounding factors. For these reasons, we conclude that the role of scintigraphy and cholecystectomy in the definition and management of this disorder remain unclear pending definitive study.

Increased incidence of cholecystectomy related to gallbladder disease in France: Analysis of 807,307 cholecystectomy procedures over a period of seven years.

PURPOSE: Gallstones are one of the most common abdominal reasons for admission to hospital. The aim of this study was to analyze trends and outcomes in patients undergoing cholecystectomy with gallbladder related disease in France from 2008 to 2014. PATIENTS AND METHODS: We carried out a population-based, retrospective cohort study using data extracted from the French nationwide hospital discharge database (PMSI). We included all patients having a cholecystectomy related to gallbladder disease from January 2008 to December 2014. Patients' demographics, primary diagnosis, procedure type, length of stay (LOS), admission in an intensive care unit, discharge disposition, complications, and in-hospital mortality were analyzed. RESULTS: Overall, 807,307 cholecystectomies were performed in France over the study period, with an increase in the national incidence rate from 167.5 (95%CI [166.5; 168.5]) to 182.6 (95%CI [181.6; 183.6]) per 100,000 inhabitants. Females accounted for 66.5% of procedures (P<0.001). The mean age was lower for females than for males: 52.1 versus 60.2 (P<0.001). The ratio of laparoscopic cholecystectomy significantly increased from 90% in 2008 to 94% in 2014 (P<0.001). Average inpatient LOS decreased significantly from 6.5 days in 2008 to 4.7 days in 2014 (P<0.001). Most common complication type was intra-abdominal (23.1%) for laparoscopic procedure (95%CI [22.7; 23.5]), and in-hospital mortality significantly decreased over time from 0.45% in 2008 to 0.38% in 2014 (P<0.005). CONCLUSION: Our results showed that the national incidence rate of cholecystectomy related to gallbladder disease increased from 2008 to 2014.

Immunomodulatory effects of intraoperative dexmedetomidine on T helper 1, T helper 2, T helper 17 and regulatory T cells cytokine levels and their balance: a prospective, randomised, double-blind, dose-response clinical study.

BACKGROUND: The ratio of T helper 1 (Th1) to T helper 2 (Th2) as well as T helper 17 (Th17) to regulatory T cells (Treg) represents the state and direction of immune response. Recent studies demonstrated that dexmedetomidine reduced the secretion of inflammatory cytokines. We performed this study to investigate the effect of different doses of intraoperative dexmedetomidine on the expression of Th1, Th2, T17 and Treg cytokines and their ratios. METHODS: Seventy-five patients undergoing laparoscopic cholecystectomy were randomly separated into one of three groups: the full dose group (n = 25), in which dexmedetomidine was infused with a 1.0 µg/kg loading followed by an infusion of 0.5 µg/kg/min after anaesthetic induction, or the half dose group (n = 26), in which the dose was half of that of full dose group, or the saline group (n = 24) which was control. T cell cytokines were quantified by sandwich enzyme-linked immunoassay for blood samples taken after anaesthetic induction (T0), at the end of surgery (T1), and 60 min after surgery (T2). IFN-gamma/IL-4 and IL-17/IL-10, which represent the ratio of Th1/Th2 and Th17/Treg cytokines, respectively, were calculated as indices of immune cell levels based upon serum cytokines levels in place of direct measurements. C-reactive protein (CRP) concentrations were measured on the next day following surgery. RESULTS: The full dose group was associated with higher ratios of IFN-gamma/IL-4 than those of half dose group and control [10.1 vs. 1.9 at T1 (P = 0.041) compared with half dose group, and 10.1 vs. 0.2 at T1 (P = 0.031), 7.4 vs. 0.1 at T2 (P = 0.025) compared with control]. IL-17/IL-10 ratios were higher in the full dose group than those in control [4.2 vs. 0.6 at T1 (P = 0.013), 3.0 vs. 0.3 at T2 (P = 0.011)]. The CRP levels were lower in the dexmedetomidine-treated groups in a dose-dependent manner. CONCLUSIONS: Dexmedetomidine exhibits immunomodulatory effects, shifting the Th1/Th2 and T17/Treg cytokine balance toward Th1 and T17, respectively, in a dose-dependent pattern in patients with surgical and anaesthetic stress. TRIAL REGISTRATION: Clinical Research Information Service, Republic of Korea (CRIS); KCT0000503 ; Registration date: Aug 13, 2012.

Current practices and future prospects for the management of gallbladder polyps: A topical review.

A gallbladder polyp is an elevation of the gallbladder mucosa that protrudes into the gallbladder lumen. Gallbladder polyps have an estimated prevalence in adults of between 0.3%-12.3%. However, only 5% of polyps are considered to be "true" gallbladder polyps, meaning that they are malignant or have malignant potential. The main radiological modality used for diagnosing and surveilling gallbladder polyps is transabdominal ultrasonography. However, evidence shows that other modalities such as endoscopic ultrasound may improve diagnostic accuracy. These are discussed in turn during the course of this review. Current guidelines recommend cholecystectomy for gallbladder polyps sized 10 mm and greater, although this threshold is lowered when other risk factors are identified. The evidence behind this practice is relatively low quality. This review identifies current gaps in the available evidence and highlights the necessity for further research to enable better decision making regarding which patients should undergo cholecystectomy, and/or radiological follow-up.

Cholecystectomy in Emilia-Romagna region (Italy): A retrospective cohort study based on a large administrative database.

BACKGROUND: The aim of this study was to ascertain the variability and to identify a trend for the outcome of cholecystectomy surgery when used to treat cholelithiasis and acute cholecystitis. METHODS: This was a large retrospective cohort study following patients up to 11 years post surgery, based on administrative data collected from 2002 to 2012 in the Emilia-Romagna Region (Northern Italy) and comparing the effectiveness and efficiency of surgical activity (laparoscopic (LC) and open cholecystectomy (OC)). Analyses included patient characteristics, length of hospital stay, type of admission and mortality risk. Outcomes considered were death from all causes (during the index hospital admission or thereafter), hospital readmissions with cholecystitis or cholelithiasis as principal diagnosis and time to surgery. RESULTS: A total of 84,628 cholecystomies were performed from 2002 to 2012 out of 123,061 admissions with primary diagnostic category of cholecystitis or cholelitiasis. Laparoscopic procedure was used in 69,842 patients. Over time there was a rising linear statistically significant trend in the use of LC. Mortality rate at 1 year of OC treated patients showed a statistically significant difference compared to LC treated patients (using a cohorts match with propensity score). Only a small number of patients with acute cholecystitis was operated according guidelines within 72 hours. CONCLUSIONS: The analysis of aggregate administrative data is a powerful tool to support regional health management, improve the quality of medical care, and assess the appropriateness of therapeutic or diagnostic approaches. It is important to stress a short hospital stay for laparoscopic cholecystectomy patients (50% less than open surgery): this shorter hospital stay leads to a significant economic advantage. Moreover, mortality is significantly higher in open surgery for acute cholecystitis. Interestingly, the same finding was confirmed after 30 days and 1 year, probably due to comorbidities that are more evident in open surgery. KEY WORDS: Cholecystitis, Cholelithiasis, Delivery of health care, Disease management, Surgical.

Update in Natural Orifice Translumenal Endoscopic Surgery (NOTES).

PURPOSE OF REVIEW: The recent developments and clinical applications of natural orifice translumenal endoscopic surgery (NOTES)-procedures and technologies are going to be presented. RECENT FINDINGS: In experimental as well as clinical settings, NOTES-procedures are predominantly performed in hybrid technique. Current experimental studies focus on the implementation of new surgical approaches as well as on the training of procedures. One emphasis in the clinical application is transrectal and transanal interventions. Transanal total mesorectal excision is equivalent to laparoscopic procedures but with the benefit of an even less invasive access. Transvaginal cholecystectomy can achieve results that are comparable to surgeries that are performed with laparoscopic techniques alone. An analysis of the German NOTES-Register concerning appendectomies as well as the national performance of NOTES-interventions in Switzerland is presented. Apart from intraabdominal approaches, several centers proclaim transoral thyroidectomies and transoral mediastinoscopies. SUMMARY: NOTES-procedures are performed in animal experiments as well as in clinical setting although with less frequency. At this time, hybrid techniques using rigid instruments are mainly applied.

[Novelties in surgery in 2016]. / Quoi de neuf en chirurgie?

The year 2016 allowed further implementation of previous years innovations with the PIPAC treatment for peritoneal carcinomatosis, the development of new surgical technologies and procedures and challenging general principles in general and digestive surgery, including cholecystectomy and appendectomy. Prevention, improved general and perioperative care (ERAS program) become an integral part of our standard surgical activity.

L'année 2016 a permis le développement des innovations des années précédentes avec le traitement PIPAC pour la carcinose péritonéale, le déploiement de nouvelles technologies et procédures chirurgicales et la remise en cause de principes généraux en chirurgie générale et digestive, notamment pour la cholécystectomie et l'appendicectomie. La prévention, l'amélioration des soins et de la prise en charge périopératoire (programme ERAS) deviennent une part intégrante de notre activité chirurgicale.

Who Will Be Able to Perform Open Biliary Surgery in 2025?

BACKGROUND: Although laparoscopic cholecystectomy (LC) is the gold standard, some patients still require an open cholecystectomy (OC). This study evaluates the mean number of OCs performed by each graduating general surgery resident during each of 3 decades. STUDY DESIGN: Data were obtained from all patients undergoing a cholecystectomy during 3 decades: prelaparoscopic era (1981 to 1990), first decade of LC (1991 to 2001), and recent decade of LC (2004 to 2013). Data were prospectively collected and retrospectively reviewed and analyzed by chi-square or Fisher's exact test. RESULTS: Compared with the prelaparoscopic decade, the number of patients undergoing an OC decreased considerably, by 67%, during the first decade of LC, and by 92% during the most recent decade at the 2 core teaching hospitals. Mean number of OCs performed per graduating chief general surgery resident decreased significantly for both laparoscopic decades compared with the prelaparoscopic decade (70.4, 22.4, and 3.6, respectively). In the last decade at the core institutions, 683 (8.8%) patients also underwent an intraoperative cholangiogram (IOC) and 36 (0.5%) underwent common bile duct exploration (CBDE). When biliary cases done at affiliated institutions during the last decade were included, the mean number of OCs (from 3.6 to 10.2), IOCs (from 683 to 2,098), and CBDEs (from 36 to 116) all increased (p < 0.001) per graduating chief general surgery resident. CONCLUSIONS: There has been a considerable decline in the number of OCs, IOCs, and CBDEs available to our trainees during the past 30 years. New training paradigms should include renewed focus on performing an IOC and/or CBDE as clinically indicated during LC; high-quality simulation programs for OC, IOC, and CBDE; and the availability of an advanced video library depicting complicated open biliary procedures.

Can 4-port laparoscopic cholecystectomy remain the gold standard for gallbladder surgery?

UNLABELLED: Since the first laparoscopic cholecystectomy (LC), laparoscopic approach has been the focus of surgical authorities and continued its technical revolution. With increasing surgical experience, a trend toward even more minimally invasive approaches has led to laparoscopic surgery to new inovations. Current surgical procedures are: four ports (4PLC), still the gold standart technique, three ports (3PLC), two ports (2PLC) and single port laparoscopic cholecystectomy (SPLC). Robotic cholecystectomy (RC) and natural orifice translumenal endoscopic surgery (NOTES) are the other new techniques for performing cholecystectomy. This article aims to make an objective comparision between different types of laparoscopic cholecystectomies by using available medical literature. KEY WORDS: Cholecystectomy, Laparoscopic, Technique.

The increasing incidence of gallbladder disease in children: A 20year perspective.

OBJECTIVE: The incidence of cholecystectomy in the pediatric population has increased over the last 20years but has not been described in a Canadian population. We conducted the first province-wide study to describe the incidence of cholecystectomy in children in Ontario. STUDY DESIGN: A population-based, retrospective cohort using administrative databases in Ontario, Canada, was conducted. We included patients less than 18years of age who underwent cholecystectomy from 1993 to 2012. Trends in rates of cholecystectomy were assessed with the Cochrane-Armitage test. RESULTS: There were a total of 6040 pediatric cholecystectomies performed over the study period in Ontario. The mean age was 14.3years, and 79.6% of patients were females. The crude incidence per 100,000 person-years increased from 8.8 to 13.0 (p<0.001) from 1993 96-2009-12, respectively. The sex-specific incidence showed a larger increase in the female population from 14.7 to 21.1 per 100,000 person-years (p<0.001). The vast majority (82%) of surgeries were performed in 13-17year olds and were largely performed in the community (>75%). CONCLUSIONS: There has been a significant rise in the incidence of pediatric cholecystectomy in Ontario over the last 20years. The majority of surgeries are performed in the community, and pediatricians will likely see an increase of gallbladder disease in practice.

Childhood cholecystectomy in New Zealand: A multicenter national 10year perspective.

AIM: International studies show increasing incidence of cholelithiasis in childhood and an increasing caseload for the pediatric surgeon. We reviewed pediatric cholecystectomy in all four centers in New Zealand, examining changes in incidence and the demographics of the patient population. METHOD: Coding data were used to retrieve case notes and extract demographic data, diagnosis, comorbidities, length of stay, and complications for patients less than 16years old undergoing cholecystectomy from January 1st, 2004-December 31st, 2013. Patients with congenital biliary malformations were excluded. Statistical analysis was performed using SPSS. RESULTS: 170 children required cholecystectomy. On average, 15 procedures were performed annually (IQR 8-24). There was a slight upward trend, with a gradient of 0.34 (P=0.63). Median age was 14 (range 2-15)years, male:female 2:3. While 72% of children were Caucasian, Maori were significantly overrepresented (20%). Numbers of Pacific Islander increased significantly over time (P=0.05), in line with population increases. Of 114 patients with complete dataset, 31% were overweight or obese. Complication rates were 8.8% overall, but 27% of complications occurred in Maori children. 40% of those suffering a complication were obese. Three complications were major, requiring return to theater. Mean length of stay was 5days. CONCLUSIONS: New Zealand has not seen the rapid increase in pediatric cholecystectomy experienced elsewhere in the OECD. However, the problem of adolescent biliary disease is prevalent. The average recipient of a cholecystectomy is 14years old, overweight, and Caucasian; though Maori have a high relative risk of both biliary disease and complicated postoperative course. The reasons for this remain unclear and require further study.

Utilization and costs associated with robotic surgery in children.

BACKGROUND: To evaluate utilization and costs associated with robotic surgery in children. MATERIALS AND METHODS: We identified patients in the Pediatric Health Information System database who underwent robotic surgery between October 2008 and December 2013. After determining the six most frequently performed surgeries in this group, we identified patients who underwent equivalent nonrobotic surgeries at the same hospitals. Equivalent surgeries were defined as open procedures for urology and laparoscopic procedures for general surgery. We examined trends in the numbers of surgeries performed and compared hospitalization costs between patients undergoing elective robotic and nonrobotic surgery for each procedure. RESULTS: The number of robotic surgeries performed increased by 19.8% per year (P < 0.001). The most common robotic surgeries performed were pyeloplasty (n = 760), ureteral reimplantation (n = 351), nephrectomy (n = 145), partial nephrectomy (n = 56), gastrointestinal antireflux procedure (n = 61), and cholecystectomy (n = 46). Total increase over time was primarily driven by increases in urologic surgeries (17.4% per year, P < 0.001). Postoperative length of stay was shorter after robotic surgeries than equivalent open urologic surgeries but not equivalent laparoscopic general surgery procedures. Total hospitalization costs were higher for robotic surgeries than equivalent urologic or general surgery procedures. CONCLUSIONS: Use of robotic surgery in pediatrics is increasing especially in the management of urologic conditions. Costs of robotic surgery-associated hospitalizations were higher than nonrobotic surgery-associated hospitalizations.

Gallstone recurrence after minimally-invasive cholecystolithotomy with gallbladder reservation: a follow-up of 720 cases.

OBJECTIVE: To discuss the hazards of cholecystolithiasis recrudesce after cholecystolithotomy with gallbladder reservation; To provide a theoretical basis for reducing the recurrence rate of gallstone. PATIENTS AND METHODS: The patients who were followed up for at least one year after minimally-invasive operation with gallbladder reservation because of cholecystolithiasis were selected. In this population, the patients with recurrence after surgery were as the case group, those patients with no recurrence after surgery were as the control group. Through collection of general data of selected cases, relevant information of Ultrasound Examinations of gallbladder and history data of the patients questionnaires were completed. Relevant factors of gallstone recurrence of patients, were observed through statistic analysis. Main factors go as follows: gender, age, nation, career, BMI, whether or not the patient had the history of chronic superficial gastritis, and regulation of gallbladder emptying function, family history, etc. The information of selected cases is complete. RESULTS AND CONCLUSIONS: The main hazards of cholecystolithiasis recurrence were BMI, family history of gallstone disease, and emptying function of gallbladder.

[Natural orifice transluminal endoscopic surgery in Germany: Data from the German NOTES registry]. / "Natural orifice transluminal endoscopic surgery" in Deutschland : Daten aus dem deutschen NOTES-Register.

BACKGROUND: The German NOTES registry (GNR) was initiated by the German Society for General and Visceral Surgery (DGAV) as a treatment and outcome database for natural orifice transluminal endoscopic surgery (NOTES). AIM: The aim of this study was the descriptive analysis of all GNR data collected over a 5-year period since its start in 2008 with more than 3000 interventions. MATERIAL AND METHODS: The GNR is an online database with voluntary participation available to all German-speaking clinics. Demographic data, therapy details, complications and data on the postoperative course of patients are recorded. All cases in the GNR between March 2008 and November 2013 were included in the analysis. RESULTS: From a total of 3150 data sets 2992 (95 %) were valid and suited for the analysis. Hybrid transvaginal cholecystectomy was the most frequently used procedure (88.7 %), followed by hybrid transvaginal/transgastric appendectomy (6.1 %) and hybrid transvaginal/transrectal colon procedures (5.1 %). Intraoperative complications occurred in 1.6 %, postoperative complications in 3.7 % and conversions were reported in 1.5 %. Intraoperative bladder injuries and postoperative urinary tract infections were identified as method-specific complications of transvaginal procedures. Bowel injuries occurred as a rare (0.2 %) but potentially serious complication of transvaginal operations. CONCLUSION: The German surgical community ensures a safe and responsible introduction of the new NOTES operation techniques with its active participation in the GNR. Despite an overall low complication rate, the high number of procedures in the GNR permitted the identification of method-specific complications. This knowledge can be used to further increase the safety of NOTES in practice.

Innovation and the difficult gallbladder: tread lightly.

Innovation has advanced the treatment of biliary disease significantly, but further progress is needed to improve safety. An uncommonly used technique is described, which could potentially prevent serious complications for the difficult gallbladder.