Clinical efficacy of laparoscopic cholecystectomy plus cholangioscopy for the treatment of cholecystolithiasis combined with choledocholithiasis.

BACKGROUND: Currently, endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (LC) is the main treatment for cholecystolithiasis combined with choledocholithiasis. However, the treatment is unsatisfactory, and the development of better therapies is needed. AIM: To determine the clinical efficacy of LC plus cholangioscopy for cholecystolithiasis combined with choledocholithiasis. METHODS: Patients (n = 243) with cholecystolithiasis and choledocholithiasis admitted to The Affiliated Haixia Hospital of Huaqiao University (910th Hospital of Joint Logistic Support Force) between January 2019 and December 2023 were included in the study; 111 patients (control group) underwent ERCP + LC and 132 patients (observation group) underwent LC + laparoscopic common bile duct exploration (LCBDE). Surgical success rates, residual stone rates, complications (pancreatitis, hyperamylasemia, biliary tract infection, and bile leakage), surgical indicators [intraoperative blood loss (IBL) and operation time (OT)], recovery indices (postoperative exhaust/defecation time and hospital stay), and serum inflammatory markers [C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) were compared. RESULTS: No significant differences in surgical success rates and residual stone rates were detected between the observation and control groups. However, the complication rate, IBL, OT, postoperative exhaust/defecation time, and hospital stays were significantly reduced in the observation group compared with the control group. Furthermore, CRP, TNF-α, and IL-6 Levels after treatment were reduced in the observation group compared with the levels in the control group. CONCLUSION: These results indicate that LC + LCBDE is safer than ERCP + LC for the treatment of cholecystolithiasis combined with choledocholithiasis. The surgical risks and postoperative complications were lower in the observation group compared with the control group. Thus, patients may recover quickly with less inflammation after LCBDE.

Comparative efficacy of laparoscopic choledocholithotomy with T-tube insertion vs. primary suture in the management of cholecystolithiasis complicated by choledocholithiasis.

OBJECTIVE: To evaluate the efficacy of laparoscopic choledocholithotomy with either an indwelling T-tube or primary suture in treating cholecystolithiasis complicated by choledocholithiasis. METHODS: We conducted a retrospective analysis of 133 patients with cholecystolithiasis complicated by choledocholithiasis treated at Inner Mongolia Aerospace Medical Baogang Hospital from March 2020 to March 2023. Patients were divided into a control group (laparoscopic choledocholithotomy with T-tube placement) and an observation group (laparoscopic choledocholithotomy with primary suture). We compared general and surgery-related data between groups. Factors correlated with favorable postoperative outcomes were identified using univariate and multivariate logistic regression analyses. RESULTS: The observation group exhibited significantly shorter surgical times, faster intestinal function recovery, reduced postoperative hospital stays, and lower total hospitalization costs compared to the control group (all P < 0.05). No significant differences were observed in postoperative total bilirubin (TBIL), aspartate aminotransferase (AST), or alanine aminotransferase (ALT) levels between the groups (all P > 0.05). Both primary suture technique and the absence of postoperative complications were independent predictors of favorable outcomes. CONCLUSION: Laparoscopic choledocholithotomy with primary suture is associated with shorter operation times, reduced medical costs, decreased hospitalization duration, and quicker gastrointestinal recovery compared to the traditional T-tube approach. This method is safe and feasible, provided clinicians are well-versed in its indications.

Ceftriaxone-induced symptomatic cholelithiasis in a child: case report and literature review.

Ceftriaxone is a third-generation cephalosporin. Due to its wide range of activity and acceptable safety profile, it is frequently prescribed to paediatric patients. However, there are several documented cases of reports of uncommon adverse events, such as cholecystitis, linked to the use of ceftriaxone. This study discusses the case of an 8-year-old female patient who developed cholecystitis, an inflammation of the gallbladder, after being treated with ceftriaxone. The patient presented with right upper quadrant pain, associated with nausea. Imaging studies showed the presence of stones and shadowing sludge, leading to acute inflammation of the gallbladder. Prompt cessation of ceftriaxone and supportive treatment led to the resolution of cholecystitis and the complete disappearance of the sludge and stones. The study highlights that early identification and withdrawal of the antibiotic can lead to successful therapy and the avoidance of unnecessary surgical procedures.

Ceftriaxone-induced severe hemolytic anemia, renal calculi, and cholecystolithiasis in a 3-year-old child: a case report and literature review.

Ceftriaxone is widely used in pediatric outpatient care for its efficacy against respiratory and digestive system infections, yet its increasing association with severe immune hemolytic reactions requires heightened vigilance from pediatricians. This report details a rare and severe case of ceftriaxone-induced severe immune hemolytic anemia (IHA), hemolytic crisis, myocardial injury, liver injury, renal calculi, and cholecystolithiasis in a previously healthy 3-year-old child. The child, treated for bronchitis, experienced sudden pallor, limb stiffness, and altered consciousness following the fifth day of ceftriaxone infusion, with hemoglobin (Hb) levels precipitously dropping to 21 g/L. Immediate cessation of ceftriaxone and the administration of oxygen therapy, blood transfusion, intravenous immunoglobulin (IVIG), and corticosteroids led to a gradual recovery. Despite initial improvements, the patient's condition necessitated extensive hospital care due to complications including myocardial injury, liver injury, renal calculi, and cholecystolithiasis. After a 12-day hospital stay and a 3-month follow-up, the child showed complete normalization of Hb and liver function and resolution of calculi. In children, ceftriaxone infusion may trigger severe, potentially fatal, hemolytic reactions. Pediatricians must promptly recognize symptoms such as pallor, limb stiffness, and unresponsiveness, indicative of ceftriaxone-induced severe IHA, and immediately discontinue the drug. Effective management includes timely blood transfusion, respiratory support, IVIG administration, and corticosteroids when necessary, along with rigorous vital signs monitoring. Continued vigilance is imperative, even after cessation of ceftriaxone, to promptly address any residual adverse effects.

Efficacy and safety of double endoscopy combined with exploration in the treatment of elderly patients with cholecystolithiasis complicated with choledocholithiasis.

OBJECTIVE: To investigate the efficacy and safety of laparoscopy combined with choledochoscopy in the treatment of elderly patients with cholecystolithiasis complicated with choledocholithiasis. METHODS: A retrospective analysis of 114 patients admitted to our hospital from January 2020 to January 2023 was conducted. These patients underwent laparoscopic cholecystectomy combined with choledocholithiasis and were divided into an elderly group (≥ 60 years old) of 63 cases and a young and middle-aged group (< 60 years old) of 51 cases according to age. The efficacy and safety indicators of the two groups of patients were observed, and complications were followed up by telephone within 6 months after surgery. The follow-up deadline was June 2023. RESULTS: Among the eligible patients (53 men, 61 women, average age 57 years), all were successfully operated, and 1 case was converted to laparotomy. The elderly and young and middle-aged groups were compared concerning hospitalisation time, bowel sound recovery time, and total postoperative complications, and the differences were statistically significant (P-values were 0.009, 0.006, and 0.039). However, there was no statistically significant difference between the two groups of patients in terms of hospitalisation costs, intraoperative blood loss, operation time, drainage tube removal time, conversion to laparotomy rate, and stone clearance rate (P-values > 0 0.05). CONCLUSION: Strict adherence to surgical standards and enhanced postoperative care resulted in similar efficacy and safety results for double endoscopy combined with the exploration of treatment for elderly and young patients with cholecystolithiasis and choledocholithiasis.

The Management of Biliary Disease in Patients with Severe Obesity Undergoing Metabolic and Bariatric Surgery-An International Expert Survey.

OBJECTIVE: This study aimed to survey international experts in metabolic and bariatric surgery (MBS) to improve and consolidate the management of biliary disease in patients with severe obesity undergoing MBS. BACKGROUND: Obesity and rapid weight loss after MBS are risk factors for the development of gallstones. Complications, such as cholecystitis, acute cholangitis, and biliary pancreatitis, are potentially life-threatening, and no guidelines for the proper management of gallstone disease exist. METHODS: An international scientific team designed an online confidential questionnaire with 26 multiple-choice questions. The survey was answered by 86 invited experts (from 38 different countries), who participated from August 1, 2023, to September 9, 2023. RESULTS: Two-thirds of experts (67.4%) perform concomitant cholecystectomy in symptomatic gallstones during MBS. Half of experts (50%) would wait 6-12 weeks between both surgeries with an interval approach. Approximately 57% of the experts prescribe ursodeoxycholic acid (UDCA) prophylactically after MBS, and most recommend a 6-month course. More than the half of the experts (59.3%/53.5%) preferred laparoscopic assisted transgastric ERCP as the approach for treating CBD stones in patients who previously had RYGB/OAGB. CONCLUSION: Concomitant cholecystectomy is preferred by the experts, although evidence in the literature reports an increased complication rate. Prophylactic UDCA should be recommended to every MBS patient, even though the current survey demonstrated that not all experts are recommending it. The preferred approach for treating common bile duct stones is a laparoscopic assisted transgastric ERCP after gastric bypass. The conflicting responses will need more scientific work and clarity in the future.

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.

Clinical study on the necessity and feasibility of routine MRCP in patients with cholecystolithiasis before LC.

BACKGROUND: In the past quite a long time, intraoperative cholangiography(IOC)was necessary during laparoscopic cholecystectomy (LC). Now magnetic resonance cholangiopancreatography (MRCP) is the main method for diagnosing common bile duct stones (CBDS). Whether MRCP can replace IOC as routine examination before LC is still inconclusive. The aim of this study was to analyze the clinical data of patients undergoing LC for cholecystolithiasis, and to explore the necessity and feasibility of preoperative routine MRCP in patients with cholecystolithiasis. METHODS: According to whether MRCP was performed before operation, 184 patients undergoing LC for cholecystolithiasis in the Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University from January 1, 2017 to December 31, 2018 were divided into non-MRCP group and MRCP group for this retrospective study. The results of preoperative laboratory test, abdominal ultrasound and MRCP, biliary related comorbidities, surgical complications, hospital stay and hospitalization expenses were compared between the two groups. RESULTS: Among the 184 patients, there were 83 patients in non-MRCP group and 101 patients in MRCP group. In MRCP group, the detection rates of cholecystolithiasis combined with CBDS and common bile duct dilatation by MRCP were higher than those by abdominal ultrasound (P < 0.05). The incidence of postoperative complications in non-MRCP group (8.43%) was significantly higher (P < 0.05) than that in MRCP group (0%). There was no significant difference in hospital stay (P > 0.05), but there was significant difference in hospitalization expenses (P < 0.05) between the two groups. According to the stratification of gallbladder stone patients with CBDS, hospital stay and hospitalization expenses were compared, and there was no significant difference between the two groups (P > 0.05). CONCLUSIONS: The preoperative MRCP can detect CBDS, cystic duct stones and anatomical variants of biliary tract that cannot be diagnosed by abdominal ultrasound, which is helpful to plan the surgical methods and reduce the surgical complications. From the perspective of health economics, routine MRCP in patients with cholecystolithiasis before LC does not increase hospitalization costs, and is necessary and feasible.

Associations of fatty acids with the risk of biliary tract calculus and inflammation: a Mendelian randomization study.

BACKGROUND: The presence of gallstones in both the gallbladder and bile ducts is referred to as cholelithiasis. The prevalence of cholecystolithiasis and bile duct stones differs. Observational and Mendelian randomization (MR) studies have elucidated the significant contributing role of numerous fatty acids (FAs) in the development of cholelithiasis. Despite numerous studies about cholelithiasis, evidence on the relationship between serum FA levels and cholecystolithiasis, as well as bile duct stones with or without inflammation, remains insufficient. METHODS: A two-sample MR study was designed to clarify the impact of serum FA levels on various bile duct inflammatory diseases. The summary statistics of single nucleotide polymorphisms (SNPs) associated with fatty acids were obtained from the UK Biobank (UKB) and included data from 114,999 participants. The researchers obtained GWAS summary statistics for cholecystolithiasis and bile duct stones in 463,010 and 361,194 European participants, including cases with and without inflammation. No sample overlap between the exposure and outcome was verified through the "mr-lap" package. The SNPs were screened to identify instrumental variables (IVs). Cochran's Q test was applied for heterogeneity assessment. Inverse variance weighting (IVW) (fixed effects or random effects), MR-Egger regression and weighted median methods were used for MR. Multivariable MR was applied to determine the direct effect of each exposure on the outcome. A false discovery rate (FDR) was applied to adjust for multiple testing correction based on the Benjamini-Hochberg method. Finally, the FinnGen Consortium was used to validate some results. RESULTS: The overall concentration of polyunsaturated fatty acids (PUFAs) in the serum was negatively associated with the risk of calculus of the gallbladder with acute cholecystitis (IVW, OR = 0.996, P = 0.038, CI 0.992-0.999; weighted median, OR = 0.995, P = 0.025, CI 0.991-0.999). The percentage of PUFAs to total monounsaturated fatty acids(MUFAs) (IVW, OR = 0.998, P = 0.045, CI 0.997-0.999) and the percentage of PUFAs to total FAs (IVW, OR = 0.997, P = 0.025, CI 0.995-0.999) had a protective role against cholecystitis. The percentage of PUFAs to total FAs had a protective role against calculus of the gallbladder without cholecystitis (IVW, OR = 0.995, P = 0.026, CI 0.990-0.999; MR Egger, OR = 0.99, P = 0.03, CI 0.982-0.998; weighted median, OR = 0.991, P = 5.41e-06, CI 0.988-0.995). Conversely, the percentage of MUFAs to total FAs increased the risk for cholecystitis (IVW, OR = 1.001, P = 0.034, CI 1.0001-1.002). However, there were no causal effects of the above exposures on the outcomes through multivariable MR and multiple testing correction. Finally, the causal effects of the above exposures on cholecystitis were validated in the FinnGen Consortium, which suggested that the percentage of PUFAs to total FAs (IVW, OR = 0.744, P = 0.021, CI 0.579-0.957) had a protective role against cholecystitis. CONCLUSION: These Mendelian randomization findings suggested that more attention should be focused on people who have low serum PUFA levels, which may have a potential role in the occurrence of calculus of the gallbladder or cholecystitis rather than calculus of the bile duct without cholangitis or cholecystitis.

Features of Metabolite Changes in Disease Evolution in Cholecystolithiasis.

BACKGROUND: Cholecystolithiasis is defined as a disease caused by complex and changeable factors. Advanced age, female sex, and a hypercaloric diet rich in carbohydrates and poor in fiber, together with obesity and genetic factors, are the main factors that may predispose people to choledocholithiasis. However, serum biomarkers for the rapid diagnosis of choledocholithiasis remain unclear. AIMS: This study was designed to explore the pathogenesis of cholecystolithiasis and identify the possible metabolic and lipidomic biomarkers for the diagnosis of the disease. METHODS: Using UHPLC-MS/MS and GC-MS, we detected the serum of 28 cholecystolithiasis patients and 19 controls. Statistical analysis of multiple variables included Principal Component Analysis (PCA). Visualization of differential metabolites was performed using volcano plots. The screened differential metabolites were further analyzed using clustering heatmaps. The quality of the model was assessed using random forests. RESULTS: In this study, dramatically altered lipid homeostasis was detected in cholecystolithiasis group. In addition, the levels of short-chain fatty acids and amino acids were noticeably changed in patients with cholecystolithiasis. They detected higher levels of FFA.18.1, FFA.20.1, LPC16.0, and LPC20.1, but lower levels of 1-Methyl-L-histidine and 4-Hydroxyproline. In addition, glycine and L-Tyrosine were higher in choledocholithiasis group. Analyses of metabolic serum in affected patients have the potential to develop an integrated metabolite-based biomarker model that can facilitate the early diagnosis and treatment of the disease. CONCLUSION: Our results highlight the value of integrating lipid, amino acid, and short-chain fatty acid to explore the pathophysiology of cholecystolithiasis disease, and consequently, improve clinical decision-making.

Comparative analysis of LC+ LCBDE and LC+ ERCP/EST for acute biliary pancreatitis / 中华肝胆外科杂志

Objective:To juxtapose laparoscopic cholecystectomy combined with common bile duct exploration and stone extraction (LC+ LCBDE) against endoscopic retrograde cholangiopancreatography/sphincterotomy with laparoscopic cholecystectomy (LC+ ERCP/EST) in the therapeutic context of acute biliary pancreatitis.Methods:The clinical data of patients with acute biliary pancreatitis in Department of Hepatobiliary Surgery, Datong Third People's Hospital from January 2017 to January 2021 were retrospectively analyzed. A total of 44 patients were inrolled, including 23 males and 21 females, with the age of (60.6±11.7) years. Based on different treatment approaches, the patients were divided into the LC+ LCBDE group ( n=33) and the LC+ ERCP group ( n=11, LC+ ERCP/EST). Total bilirubin, direct bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), blood amylase, operation time, postoperative hospitalization stays, total hospitalization cost, postoperative anal exhaust time, and postoperative complications (bile leakage, fever, bleeding) were compared between the two groups. Results:There were no significant differences in preoperative total bilirubin, direct bilirubin, ALT, AST, and blood amylase between LC+ ERCP group and LC+ LCBDE groups (all P>0.05). In LC+ LCBDE group, operation time was 110.0 (96.3, 147.5) min, postoperative hospitalization time was 9.0 (7.5, 11.0) d, postoperative exhaust time was 2.0 (1.0, 2.0) d, and in LC+ LCBDE group, operation time was 60.0 (32.0, 65.0) min, postoperative hospitalization time was 7.0 (4.0, 8.0) d, postoperative exhaust time was 1.0 (1.0, 1.0) d. Comparisons with LC+ LCBDE group, LC+ ERCP group had shorter postoperative hospitalization stay and earlier postoperative exhaust time, the total hospitalization cost of LC+ LCBDE group was 23 829.3 (21 779.6, 27 221.9) yuan, which was higher than 36 894.8 (31 963.5, 41 172.2) yuan in LC+ ERCP group, and the differences were statistically significant (all P<0.05). Comparison of postoperative total bilirubin, direct bilirubin, ALT and AST between LC+ ERCP group and LC+ LCBDE group, with no significant difference(all P>0.05). No postoperative complications such as bile leakage, residual stones, fever and bleeding occurred in both groups. Conclusion:Compared with LC+ ERCP/EST, LC+ LCBDE in the treatment of acute biliary pancreatitis, although the operation time and hospital stay are longer, but the total hospitalization cost is less, there is no need for multiple operations, and it can be used as the first choice for acute biliary pancreatitis.

Comparison of the effects of ampulla-guided realignment and conventional gallbladder triangle anatomy in difficult laparoscopic cholecystectomy.

OBJECTIVE: To compare the effects of ampulla-guided realignment and conventional gallbladder triangle anatomy in difficult laparoscopic cholecystectomy (DLC). METHODS: From June 2021 to August 2022, data from 100 patients undergoing DLC at Nanjing Hospital of Traditional Chinese Medicine were analyzed retrospectively. Patients were divided into two groups: the experimental group (LC with the ampulla-guided realignment) and the control group (conventional LC with triangular gallbladder anatomy), with 50 patients per group. The intraoperative blood loss, operation time, postoperative drainage tube indwelling time, hospitalization time, bile duct injury rate, operation conversion rate, and incidence of postoperative complications were recorded and compared between the two groups. The pain response and daily activities of the patients in the two groups were evaluated 48 h after the operation. RESULTS: The amount of intraoperative blood loss, postoperative drainage tube indwelling time, hospital stay, operation conversion rate, pain degree at 24 and 48 h after operation, bile duct injury incidence, and total postoperative complication rate were shorter or lower in the experimental group than those in the control group (p < 0.05). The Barthel index scores of both groups were higher 48 h after the operation than before the operation, and the experimental group was higher than the control group (p < 0.05). CONCLUSION: The ampulla-guided alignment in DLC surgery was more beneficial in promoting postoperative recovery, reducing postoperative pain response, reducing the incidence of postoperative complications, and reducing bile duct injury.

The value of preoperative neutrophil/lymphocyte ratio in predicting the severity of cholecystolithiasis with cholecystitis in elderly patients.

BACKGROUND: This study aims to assess the effectiveness of neutrophil/lymphocyte ratio (NLR) and C-reactive protein (CRP) in diagnosing cholecystolithiasis with cholecystitis in elderly patients. Additionally, the study seeks to determine the predictive value of preoperative NLR in determining the severity of the condition in this population. METHODS: This study is a retrospective cohort study, including 160 elderly patients with cholecystolithiasis with cholecystitis (45 cases of simple cholecystitis, 58 cases of suppurative cholecystitis, 57 cases of gangrenous cholecystitis) and 60 cases of normal gallbladder histology. The study collected clinical data of the patients detected the preoperative CRP content, neutrophil, and lymphocyte levels through blood routine tests, and calculated the NLR value. The diagnostic value of NLR and CRP was determined by using the Receiver Operating Characteristic Curve (ROC), and the optimal value of preoperative NLR related to the severity of elderly patients with cholecystolithiasis with cholecystitis was identified. RESULTS: This study found that for elderly patients with cholecystolithiasis with cholecystitis, preoperative NLR and CRP levels can be used to distinguish the condition. The critical value for NLR was found to be 2.995 (95% CI, 0.9465-0.9853; P < 0.001) with an area under the ROC curve of 0.9659, while the critical value for CRP was 13.05 (95% CI, 0.9284-0.9830; P < 0.001) with an area under the ROC curve of 0.9557. Both NLR and CRP were found to have equivalent diagnostic abilities. Additionally, the study found that there were significant differences in neutrophil and lymphocyte levels in elderly patients with different severity levels, with NLR increasing as severity increased (P < 0.001). The study identified cut-off values for preoperative NLR that could distinguish Simple cholecystitis and Purulent cholecystitis, as well as Purulent cholecystitis and Gangrenous cholecystitis in elderly patients with cholecystolithiasis, with respective AUCs of 0.8441 (95% CI: 0.7642-0.9239; P < 0.001) and 0.7886(95% CI: 0.7050-0.8721, P < 0.001), sensitivities of 91.38% and 87.72%, and specificities of 73.33% and 63.79%. CONCLUSIONS: Preoperative NLR and CRP values can serve as indicators to detect cholecystolithiasis with cholecystitis in elderly patients. Additionally, NLR has been recognized as a potential tool to differentiate the severity of cholecystolithiasis with cholecystitis in the elderly population.

Patients with Clinically Suspected Gallstone Disease: A More Selective Ultrasound May Improve Treatment Related Outcomes.

This study aimed to quantify the confirmation of gallstones on ultrasound (US) in patients with suspicion of gallstone disease. To aid general practitioners (GPs) in diagnostic workup, a model to predict gallstones was developed. A prospective cohort study was conducted in two Dutch general hospitals. Patients (≥18 years) were eligible for inclusion when referred by GPs for US with suspicion of gallstones. The primary outcome was the confirmation of gallstones on US. A multivariable regression model was developed to predict the presence of gallstones. In total, 177 patients were referred with a clinical suspicion of gallstones. Gallstones were found in 64 of 177 patients (36.2%). Patients with gallstones reported higher pain scores (VAS 8.0 vs. 6.0, p < 0.001), less frequent pain (21.9% vs. 54.9%, p < 0.001), and more often met criteria for biliary colic (62.5% vs. 44.2%, p = 0.023). Predictors for the presence of gallstones were a higher pain score, frequency of pain less than weekly, biliary colic, and an absence of heartburn. The model showed good discrimination between patients with and without gallstones (C-statistic 0.73, range: 0.68-0.76). Clinical diagnosis of symptomatic gallstone disease is challenging. The model developed in this study may aid in the selection of patients for referral and improve treatment related outcomes.

Risk Factors for Ceftriaxone-Associated Pseudolithiasis in Adults.

INTRODUCTION: Ceftriaxone (CTRX) is known to occasionally cause pseudolithiasis. This condition is often observed in children; however, few studies have reported the incidence and risk factors for CTRX-associated pseudolithiasis. METHODS: In this single-center retrospective study, we investigated the incidence of and risk factors for CTRX-associated pseudolithiasis in adults. All patients underwent computed tomography to confirm pseudolithiasis before and after CTRX administration. RESULTS: The study included 523 patients. Pseudolithiasis was detected in 89 patients (17%). Data analysis showed that abdominal area-related biliary diseases at the site of infection (odds ratio [OR] 0.19, 95% confidence interval [CI] 0.064-0.53, p = 0.0017), CTRX administration for >3 days (OR 5.0, 95% CI: 2.5-9.9, p < 0.0001), CTRX dose of 2 mg (OR 5.2, 95% CI: 2.8-9.6, p < 0.0001), fasting period >2 days (OR 3.2, 95% CI: 1.6-6.4, p = 0.0010), and estimated glomerular filtration rate <30 mL/min/1.73 m2 (OR 3.4, 95% CI: 1.6-7.5, p = 0.0022) were independent factors for pseudolithiasis. CONCLUSIONS: CTRX-associated pseudolithiasis may occur in adults and should be considered in the differential diagnosis in patients who develop abdominal pain or liver enzyme elevation after CTRX administration, particularly in patients with chronic kidney disease, in those who are fasting, in and those who receive high-dose CTRX therapy.

The Symptomatic Outcomes of Cholecystectomy for Gallstones.

Cholecystectomy is the definite treatment for symptomatic gallstones, and rates are rapidly rising. Symptomatic complicated gallstones are generally treated with cholecystectomy, but there is no consensus on the clinical selection of patients with symptomatic uncomplicated gallstones for cholecystectomy. The aim of this review is to describe symptomatic outcomes before versus after cholecystectomy in patients with symptomatic gallstones as reported in prospective clinical studies and to discuss patient selection for cholecystectomy. Following cholecystectomy, resolution of biliary pain is high and reported for 66-100%. Dyspepsia has an intermediate resolution of 41-91% and may co-exist with biliary pain but may also develop following cholecystectomy with an increase of 150%. Diarrhea has a high increase and debuts in 14-17%. Persisting symptoms are mainly determined by preoperative dyspepsia, functional disorders, atypical pain locations, longer duration of symptoms, and poor psychological or physical health. Patient satisfaction following cholecystectomy is high and may reflect symptom alleviation or a change in symptoms. Comparison of symptomatic outcomes in available prospective clinical studies is limited by variations in preoperative symptoms, clinical presentations, and clinical management of post-cholecystectomy symptoms. When selecting patients with biliary pain only in a randomized controlled trial, 30-40% still have persisting pain. Strategies for the selection of patients with symptomatic uncomplicated gallstones based on symptoms alone are exhausted. For the development of a selection strategy, future studies should explore the impact of objective determinants for symptomatic gallstones on pain relief following cholecystectomy.

Acute recurrent pancreatitis during 3rd trimester of pregnancy.

OBJECTIVE: We present an unusual case report of a pregnant patient with recurrent attacks of acute pancreatitis due to cholecystolithiasis. CONCLUSION: Acute pancreatitis in pregnancy is a rare disease. Unlike the non-pregnant population, it is characterized by a high recurrence rate. Acute pancreatitis during pregnancy has a negative effect on both the mother and the fetus. The treatment is modified depending on the trimester of pregnancy.

Efficacy and safety of laparoscopic common bile duct exploration with primary closure and intraoperative endoscopic nasobiliary drainage for choledocholithiasis combined with cholecystolithiasis.

BACKGROUND: The need for intraoperative endoscopic nasobiliary drainage during laparoscopic cholecystectomy and laparoscopic common bile duct exploration with primary closure is controversial in the treatment of cholecystolithiasis combined with choledocholithiasis. The aim of this study was to evaluate the safety and efficacy of laparoscopic cholecystectomy + laparoscopic common bile duct exploration + intraoperative endoscopic nasobiliary drainage + primary closure (LC + LCBDE + IO-ENBD + PC). The safety of different intubation methods in IO-ENBD was also evaluated. METHOD: From January 2018 to January 2022, 168 consecutive patients with cholecystolithiasis combined with choledocholithiasis underwent surgical treatment in our institution. Patients were divided into two groups: group A (n = 96) underwent LC + LCBDE + IO-ENBD + PC and group B (n = 72) underwent LC + LCBDE + PC. Patient characteristics, perioperative indicators, complications, stone residual, and recurrence rates were analyzed. Group A was divided into two subgroups. In group A1, the nasobiliary drainage tube was placed in an anterograde way, and in group A2, nasobiliary drainage tube was placed in an anterograde-retrograde way. Perioperative indicators and complications were analyzed between subgroups. RESULTS: No mortality in the two groups. The operation success rates in groups A and B were 97.9% (94/96) and 100% (72/72), respectively. In group A, two patients were converted to T-tube drainage. The stone clearance rates of group A and group B were 100% (96/96) and 98.6% (71/72), respectively. Common bile duct diameter was smaller in group A [10 vs. 12 mm, P < 0.001] in baseline data. In perioperative indicators, group A had a longer operation time [165 vs.135 min, P < 0.001], but group A had a shorter hospitalization time [10 vs.13 days, P = 0.002]. The overall complications were 7.3% (7/96) in group A and 12.5% (9/72) in group B. Postoperative bile leakage was less in group A [0% (0/96) vs. 5.6% (4/72), P = 0.032)]. There were no residual and recurrent stones in group A. And there were one residual stone and one recurrent stone in group B (all 1.4%). The median follow-up time was 12 months in group A and 6 months in group B. During the follow-up period, 2 (2.8%) patients in group B had a mild biliary stricture. At subgroup analysis, group A1 had shorter operation time [150 vs. 182.5 min, P < 0.001], shorter hospitalization time [9 vs. 10 days, P = 0.002], and fewer patients with postoperative elevated pancreatic enzymes [32.6% (15/46) vs. 68% (34/50), P = 0.001]. CONCLUSION: LC + LCBDE + IO-ENBD + PC is safer and more effective than LC + LCBDE + PC because it reduces hospitalization time and avoids postoperative bile leakage. In the IO-ENBD procedure, the antegrade placement of the nasobiliary drainage tube is more feasible and effective because it reduces the operation time and hospitalization time, and also reduces injury to the duodenal papilla.

Laparoscopic cholecystectomy combined with normal-sized common bile duct exploration for cholecystolithiasis and choledocholithiasis / 中华普通外科杂志

Objective:To evaluate laparoscopic choledocholithotomy in patients with cholecystolithiasis and normal sized common bile duct(CBD) with choledocholithiasis.Methods:The clinical data of 393 patients with cholecystolithiasis and choledocholithiasis treated by LC combined with LCBDE at the Department of General Surgery of Hefei Second People's Hospital from Mar 2014 to Jul 2021 were retrospectively analyzed.Results:There were 280 CBD calculi cases in which CBD diameter >8 mm which was included into CBD dilated group, and 113 cases of CBD calculi with normal diameter (5 mm≤CBD diameter ≤8 mm). There was no difference in operative time and postoperative complications in the small diameter group. During the follow-up period, 1 case in the dilated group experienced biliary tract stenosis and treated by stenting. There was no statistical significance in biliary tract stenosis in both groups ( P>0.05).Stone recurrence occurred in 3 cases (2.7%) in the normal diameter group, all of which were removed by ERCP lithotomy. Stone recurrence occurred in 8 cases (2.9%) in the CBD dilated group, 7 were removed by ERCP stone extraction and 1 refused further treatment. Conclusion:It is safe and feasible to perform LC+LCBDE in patients with cholecystolithiasis complicating normal sized CBD stones.

The effect of polyene phosphatidylcholine combined with Shudan decoction on the recovery of gallbladder function after fallbladder-preserving cholecystolithotomy / 中国医师进修杂志

Objective:To investigate the effect of polyene phosphatidylcholine combined with Shudan decoction on the recovery of gallbladder function after gallbladder-preserving cholecystolithotomy.Methods:Sixty patients with gallbladder stone admitted to Shenzhen Hospital (Longgang), Beijing University of Chinese Medicine from June 2018 to July 2021 were selected. All patients were received gallbladder-preserving cholecystolithotomy, and they were divided in two groups by random number table, each group with 30 patients. The control group was treated with polyene phosphatidylcholine capsule after the operation, while the observation group was treated with Shudan decoction on the basis of the control group. After 30 d of continuous treatment, the traditional Chinese medicine symptoms score, gallbladder contraction function and the levels of serum alkaline phosphatase (ALP), gamma-glutamine transferase (GGT), incidence of adverse reactions, clinical efficacy were compared between the two groups.Results:After treatment, the scores of abdominal distension, abdominal pain and anorexia in the observation group were lower than those in the control group ( P<0.05). After treatment, the thickness of the gallbladder wall in the observation group was lower than that in the control group and the the gallbladder contraction rate was higher than that in the control group: (2.62 ± 0.29) mm vs. (3.21 ± 0.32) mm, (74.17 ± 6.49)% vs. (62.03 ± 6.05)%, there were statistical differences ( P<0.05). After treatment, the levels of GGT and ALP in the observation group were lower than those in the control group: (132.32 ± 30.09) U/L vs. (150.27 ± 30.33)U/L, (56.12 ± 14.89) U/L vs. (75.07 ± 16.22) U/L, there were statistical differences ( P<0.05). The total effective rate in the observation group was higher than that in the control group: 96.67%(29/30) vs. 80.00%(24/30), there was statistical difference ( χ2 = 4.04, P<0.05). The adverse reactions in the two groups had no significant differences ( P>0.05). Conclusions:Polyene phosphatidylcholine combined with Shudan decoction has a definite efficacy for patients with cholecystolithiasis after gallbladder-preserving cholecystolithotomy, and can effectively promote the recovery of their gallbladder function and with good safety.