Recent advances in understanding and managing cholesterol gallstones.

The high prevalence of cholesterol gallstones, the availability of new information about pathogenesis, and the relevant health costs due to the management of cholelithiasis in both children and adults contribute to a growing interest in this disease. From an epidemiologic point of view, the risk of gallstones has been associated with higher risk of incident ischemic heart disease, total mortality, and disease-specific mortality (including cancer) independently from the presence of traditional risk factors such as body weight, lifestyle, diabetes, and dyslipidemia. This evidence points to the existence of complex pathogenic pathways linking the occurrence of gallstones to altered systemic homeostasis involving multiple organs and dynamics. In fact, the formation of gallstones is secondary to local factors strictly dependent on the gallbladder (that is, impaired smooth muscle function, wall inflammation, and intraluminal mucin accumulation) and bile (that is, supersaturation in cholesterol and precipitation of solid crystals) but also to "extra-gallbladder" features such as gene polymorphism, epigenetic factors, expression and activity of nuclear receptors, hormonal factors (in particular, insulin resistance), multi-level alterations in cholesterol metabolism, altered intestinal motility, and variations in gut microbiota. Of note, the majority of these factors are potentially manageable. Thus, cholelithiasis appears as the expression of systemic unbalances that, besides the classic therapeutic approaches to patients with clinical evidence of symptomatic disease or complications (surgery and, in a small subgroup of subjects, oral litholysis with bile acids), could be managed with tools oriented to primary prevention (changes in diet and lifestyle and pharmacologic prevention in subgroups at high risk), and there could be relevant implications in reducing both prevalence and health costs.

Cost analysis and risk factors for interval cholecystectomy after bariatric surgery: a national study.

BACKGROUND: Besides rate and extent of weight loss, little is known regarding demographic factors predicting interval cholecystectomy (IC) after bariatric surgery and its incremental costs. OBJECTIVES: We aim to identify risk factors predicting IC after bariatric surgery and quantify its associated costs. SETTING: Nationally representative sampling of acute care hospitals across the United States. METHODS: A retrospective cohort study was performed using the National Readmission Database 2010 to 2014. Cox proportional hazard analyses were used to identify risk factors for IC. Linear regression models were constructed to examine associations between cholecystectomy timing and cumulative hospitalization costs. RESULTS: An estimated national total of 553,658 patients received bariatric surgery during the study period. Of these, 3.3% received concomitant cholecystectomy (CC). After adjusting for bariatric procedure type, age, sex, complication, and length of stay, CC was independently associated with a US$1589 increase in hospitalization cost (95% confidence interval US$1021-2158, P<.01). Of patients that received no CC, only .6% underwent IC during the up to 1-year follow-up. Age<35 (P<.01), female sex (P<.01), and high preoperative body mass index (P = .03) were all risk factors for IC. IC was independently associated with a US$1499 higher cumulative hospitalization cost than CC (P<.01, 95% confidence interval US$844-2154). CONCLUSIONS: Despite the higher absolute cost of IC, its low incidence does not financially justify a routine prophylactic CC approach. In addition, no significant reduction in cholecystectomy-related complications was achieved by performing CC. An individualized approach taking identified risk factors for IC into consideration is recommended when deciding whether to perform prophylactic CC.

Routine mini-laparoscopic cholecystectomy: Outcome in 200 patients.

INTRODUCTION: In order to improve the outcome of classical laparoscopic cholecystectomy (CLC), surgeons have attempted to minimize tissue trauma. The aim of this study is to describe the technique of mini-laparoscopic cholecystectomy (MLC) and to report the outcome of this approach when used as a routine procedure. METHODS: Since January 2012, all consecutive patients undergoing MLC were included in this study. Operative and perioperative data were prospectively collected. Additionally, cost analysis was performed. RESULTS: From 2012 to 2015, 200 MLC were performed (F/M: 132/68, mean age 45±16 years). Mean operative duration was 97±32min for the first 50 patients and 75±25min for the subsequent 150 patients (P<0.0001). Modifications in the number or size of trocars were necessary in nine of the first 50 procedures and in seven of the subsequent 150 procedures (P=0.003). Perioperative morbidity included gallbladder perforation (n=28) or moderate (<50mL) bleeding (n=6). Postoperative morbidity was 4%. The mean global cost for a MLC procedure was 1757±1855 euros. This cost decreased from 2946±3115 euros in the first 50 patients to 1390±1278 euros in the subsequent 150 patients (P=0.001). CONCLUSION: Mini-laparoscopy can be used for routine elective cholecystectomy. This approach is associated with low morbidity and good cosmetic results.

[Cholecystectomy as a simultant abdominal intervention in bariatric surgery].

Necessity and validity of simultant interventions while doing restrictive bariatric operations were considered. There were analyzed the results of perioperative examination of 41 patients, in whom laparoscopic bariatric operation was performed, and 23--after simultant operations. There was established necessity for obligatory performance of simultant operations while presence of indices and according qualification of surgeons.

Cost-effectiveness of elective laparoscopic cholecystectomy versus observation in older patients presenting with mild biliary disease.

Our objective was to determine the probability threshold for recurrent symptoms at which elective cholecystectomy compared to observation in older patients with symptomatic cholelithiasis is the more effective and cost-effective option. We built a decision model of elective cholecystectomy versus observation in patients >65 presenting with initial episodes of symptomatic cholelithiasis that did not require initial hospitalization or cholecystectomy. Probabilities for subsequent hospitalization, emergency cholecystectomy, and perioperative complications were based on previously published probabilities from a 5 % national sample of Medicare patients. Costs were estimated from Medicare reimbursements and from the Healthcare Cost and Utilization Project. Utilities (quality-adjusted life years, QALYs) were obtained from established literature estimates. Elective cholecystectomy compared to observation in all patients was associated with lower effectiveness (-0.10 QALYs) and had an increased cost of $3,422.83 per patient at 2-year follow-up. Elective cholecystectomy became the more effective option when the likelihood for continued symptoms exceeded 45.3 %. Elective cholecystectomy was both more effective and less costly when the probability for continued symptoms exceeded 82.7 %. An individualized shared decision-making strategy based on these data can increase elective cholecystectomy rates in patients at high risk for recurrent symptoms and minimize unnecessary cholecystectomy for patients unlikely to benefit.

Assessment of characteristics of patients with cholelithiasis from economically deprived rural Karachi, Pakistan.

BACKGROUND: Gallstones have been regarded as one of the most expensive diseases in Gastroenterology, posing a great economic burden on developing nations. The majority of Pakistani people live in rural areas where healthcare facilities are not available or are very primitive. We aim to assess the characteristics among cholelithiasis patients from rural Karachi so that a prevention campaign can be launched in rural underprivileged settings to reduce the economic burden of this preventable disease. METHOD: A total of 410 patients were included in the study after giving verbal consent as well as written consent. Variables such as age, weight, height, body mass index (BMI), blood pressure, waist circumference, number of children, monthly family income, number of siblings, and number of family members, were considered in this questionnaire. All data was analysed by SPSS ver. 16.0. Mean and standard deviation (SD) were calculated for continuous variables. Frequency and percentages were calculated for categorical variables. RESULTS: Nearly 85.4% of the participants were female. The mean ± S.D. for age was 43.8 ± 9.59. Nearly 61% of the patients were illiterate. All of our patients were from low socioeconomic status and their mean salary ± S.D. was 6915 ± 1992 PKR (1 US $ = 90.37PKR). 75% of them were smokers with mean consumption ± S.D. of 7.5 ± 10 cigarettes per day. Fibre in diet was not used by 83.65% of patients. 40.2% were living in combined families. 61% were living in purchased homes. A positive history of diabetes mellitus was given by 45.1%, family history of cholelithiasis by 61% and history of hypertension by 31.7% of subjects. Soft drink consumption was given by 45.1% of patients; while only 8.5% used snacked daily. Tea was consumed by 95.1% of the subjects. Daily physical activity for 30 minutes was reported by only 13.4% of participants. CONCLUSION: In conclusion, rural dwellers from low socioeconomic strata are neglected patients and illiteracy further adds fuel to the fire by decreasing the contact with the health professionals. Assessment of the characteristics are very important because considering the great socio-economic burden, an intervention strategy in the form of mass media campaign as well as small group discussions in such rural areas can be formulated and applied to high risk populations to reduce the burden and complications of gallstone disease.

Cost-effective treatment of patients with symptomatic cholelithiasis and possible common bile duct stones.

BACKGROUND: Clinicians must choose a treatment strategy for patients with symptomatic cholelithiasis without knowing whether common bile duct (CBD) stones are present. The purpose of this study was to determine the most cost-effective treatment strategy for patients with symptomatic cholelithiasis and possible CBD stones. STUDY DESIGN: Our decision model included 5 treatment strategies: laparoscopic cholecystectomy (LC) alone followed by expectant management; preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC; LC with intraoperative cholangiography (IOC) ± common bile duct exploration (CBDE); LC followed by postoperative ERCP; and LC with IOC ± postoperative ERCP. The rates of successful completion of diagnostic testing and therapeutic intervention, test characteristics (sensitivity and specificity), morbidity, and mortality for all procedures are from current literature. Hospitalization costs and lengths of stay are from the 2006 National Centers for Medicare and Medicaid Services data. The probability of CBD stones was varied from 0% to 100% and the most cost-effective strategy was determined at each probability. RESULTS: Across the CBD stone probability range of 4% to 100%, LC with IOC ± ERCP was the most cost-effective. If the probability was 0%, LC alone was the most cost-effective. Our model was sensitive to 1 health input: specificity of IOC, and 3 costs: cost of hospitalization for LC with CBDE, cost of hospitalization for LC without CBDE, and cost of LC with IOC. CONCLUSIONS: The most cost-effective treatment strategy for the majority of patients with symptomatic cholelithiasis is LC with routine IOC. If stones are detected, CBDE should be forgone and the patient referred for ERCP.

Costs and utilization of intraoperative cholangiography.

BACKGROUND: Routine intraoperative cholangiography (IOC) has been advocated as a viable strategy to reduce common bile duct injury (CDI) during cholecystectomy. This is predicated, in part, on the low cost of IOC, making it a cost-effective preventive strategy. Using billed hospital charges as a proxy for costs, we sought to estimate costs associated with the performance of IOC. METHODS: The 2001 National Inpatient Survey (NIS) database was assessed for IOC utilization and associated charges. Average charges for hospital admission where the primary procedure was laparoscopic cholecystectomy were compared for those associated with and without the performance of IOC. RESULTS: Eighteen percent of cholecystectomies were performed in facilities that never perform IOC. Routine IOC (defined as >75% of cholecystectomies performed in any one hospital having a concomitant IOC) was performed in only 11% of hospitals. In the remaining 71% of hospitals, selective IOC was performed. IOCs were associated with US $706-739 in additional hospital charges when performed in conjunction with laparoscopic cholecystectomy. We project a cost of US $371,356 to prevent a single bile duct injury by using routine cholangiography. CONCLUSION: We conclude that only a minority of hospitals performs cholecystectomies with routine IOC. Because of the significant amount of hospital charges attributable to IOC, routine IOC is not cost-effective as a preventative measure against bile duct injury during cholecystectomy.

Proyecto Nacional para la Gestión Clínica de Procesos Asistenciales. Tratamiento quirúrgico de la colelitiasis. Desarrollo de la vía clínica / National Project for the Clinical Management of Healthcare Processes. The surgical treatment of gallstones.Development of a clinical pathway

Introducción. La alta prevalencia del tratamiento quirúrgico de la colelitiasis ofrece un gran interés para la realización de un estudio a escala nacional dirigido a conocer los indicadores más importantes y desarrollar una vía clínica. Objetivos. Analizar los resultados obtenidos durante la etapa hospitalaria del proceso. Definir los indicadores clave del proceso. Elaborar una vía clínica para la colecistectomía laparoscópica. Pacientes y métodos. Estudio multicéntrico, prospectivo, transversal y descriptivo, de pacientes intervenidos quirúrgicamente de forma consecutiva por presentar colelitiasis durante el año 2002. El tamaño muestral calculado con los datos suministrados por el Instituto Nacional de Estadística fue de 304 pacientes, que se incrementó en un 45% para compensar posibles pérdidas. Los criterios de inclusión fueron: colecistectomía programada por colelitiasis, sin sospecha preoperatoria fundamentada de litiasis de la vía biliar principal. Se diseñó una base de datos (Microsoft Access 2000®) con 76 variables analizadas en cada paciente. Resultados. Se obtuvieron los cuestionarios de 37 hospitales con 426 pacientes. La edad media fue de 55,69 años, con predominio del sexo femenino (68,3%). La sintomatología más frecuente fue el cólico biliar (23%), con un 20,3% de pacientes con antecedentes de colecistitis y un 18% con pancreatitis leve. Al diagnóstico se llegó con la ecografía en un 93,2% de los casos. El consentimiento informado se completó en un 93,2%. En un 96,1% de los pacientes la intervención se realizó en régimen hospitalario y en el resto, de forma ambulatoria. Se realizó tratamiento antibiótico en el 78,9% y antitrombótico en el 75,1% de los casos. La intervención se realizó de forma laparoscópica en el 84,6%, con un porcentaje de reconversión del 4,9%. En un 17,8% de los pacientes se realizaron colangiografías peroperatorias, y se encontró coledocolitiasis en 7 pacientes. La complicación más frecuente fue la infección de la herida quirúrgica (1,1%). La posible lesión accidental de la vía biliar se produjo en un 0,7% de los casos, descrita como fístula biliar. Hubo 4 reintervenciones: fístula biliar (1), hemoperitoneo (2) y no se informó causa (1). La duración media de la intervención fue de 73,17 min, con una mediana de 60 min. La estancia postoperatoria de los pacientes intervenidos por laparotomía fue de 4,75 días, y 2,67 días la de los pacientes intervenidos por vía laparoscópica. El 99% de los pacientes se mostró satisfecho o muy satisfecho con la atención hospitalaria. Conclusiones. Con el análisis del proceso y la revisión de la literatura médica se ha identificado una serie de indicadores de mejora recogidos en la vía clínica que se desarrolla: porcentaje de pacientes con uso de tratamiento antibiótico y antitrombótico correctamente indicada, porcentaje de pacientes con consentimiento informado y pruebas preoperatorias adecuadas, porcentaje de pacientes con colangiografía peroperatoria correctamente adecuada y porcentaje de pacientes intervenidos con una estancia global de 3 días (AU)

Objectives. To analyze the results obtained during the hospital phase of the process. To define the key indicators of the process. To design a clinical pathway for laparoscopic cholecystectomy. Patients and methods. A multicenter, prospective, cross-sectional, descriptive study was performed of patients who consecutively underwent surgery for gallstones in 2002. The sample size calculated with data provided by the National Institute of Statistics was 304 patients, which was increased by 45% to compensate for possible losses. Inclusion criteria consisted of elective cholecystectomy for gallstones, without preoperative findings suggestive of common duct stones. A database was designed (Microsoft Access 2000®) with 76 variables analyzed in each patient. Results. Completed questionnaires were obtained from 37 hospitals with 426 patients. The mean age was 55.69 years, with a predominance of women (68.3%). The most frequent symptom was biliary colic (23%). A total of 20.3% of the patient had prior episodes of cholecystitis and 18% had a history of mild pancreatitis. Diagnosis was given by ultrasonography in 93.2% of the patients. Informed consent was provided by 93.2%. The intervention was performed on an inpatient basis in 96.1% and in the ambulatory setting in the remainder. Antibiotic and antithrombotic prophylaxis was administered in 78.9% and 75.1% of the patients respectively. The laparoscopic approach was used in 84.6%, with a conversion rate of 4.9%. Intraoperative cholangiography was performed in 17.8% of the patients and common duct stones were found in 7 patients. The most frequent complication was surgical wound infection (1.1%). Possible accidental lesion of the biliary tract occurred in 0.7% of the patients and was described as biliary fistula. There were four reinterventions: biliary fistula (1), hemoperitoneum (2) and cause unknown (1). The mean surgical time was 73.17 minutes, with a median of 60 minutes. Postoperative length of stay was 4.75 days in open surgery and 2.67 days in laparoscopic surgery. Ninety-nine percent of the patients were satisfied or highly satisfied with the healthcare received. Conclusions. Analysis of the process and review of the literature identified a series of areas requiring improvement, which were gathered in the clinical pathway developed. These areas consisted of increasing the number of patients with correctly indicated antibiotic and antithrombotic prophylaxis, increasing the percentage of patients providing informed consent and undergoing adequate preoperative tests, limiting intraoperative cholangiography to selected patients, and reducing the number of patients with an overall stay of 3 days (AU)

[Cost-effect evaluation of different variants of cholecystectomies].

Short-term results of treatment and cost-effect rates were analyzed in three groups of patients undergone traditional cholecystectomy, laparoscopic cholecystectomy and cholecystectomy through minilaparotomy. It was demonstrated that frequency of complications was less after operations through laparoscopy and minilaparotomy. Traditional approach had the most costs due to more number of postoperative complications, hospital stay after surgery and more number of analgesics. Cholecystectomy through minilaparotomy is most cost-effective due to high clinical effectiveness, short hospital stay and rare complications. This procedure does not require expensive devices and can be performed with regional anesthesia only. It is concluded that minimally invasive methods of cholecystectomy must be used more widely.

[Gallstones--surgical aspects]. / Gallensteinleiden--chirurgische Aspekte.

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

Economic burden of obesity in youths aged 6 to 17 years: 1979-1999.

OBJECTIVE: To examine the trend of obesity-associated diseases in youths and related economic costs. METHODS: Using a multiyear data file of the National Hospital Discharge Survey, 1979-1999, we analyzed the changes in obesity-associated diseases and economic costs in youths (6-17 years of age) over time. Diabetes, obesity, sleep apnea, and gallbladder disease were examined to explore the trend of the disease burden. Other obesity-associated diseases for which obesity was listed as a secondary diagnosis were also analyzed. Obesity-associated hospital costs were estimated from the discharges with obesity listed as a principal or secondary diagnosis. RESULTS: From 1979-1981 to 1997-1999, the percentage of discharges with obesity-associated diseases increased. The discharges of diabetes nearly doubled (from 1.43% to 2.36%), obesity and gallbladder diseases tripled (0.36% to 1.07% and 0.18% to 0.59%, respectively), and sleep apnea increased fivefold (0.14% to 0.75%). Ninety-six percent of discharges with a diagnosis of obesity listed obesity as a secondary diagnosis. Asthma and some mental disorders were the most common principal diagnoses when obesity was listed as a secondary diagnosis. Obesity-associated annual hospital costs (based on 2001 constant US dollar value) increased more than threefold; from $35 million (0.43% of total hospital costs) during 1979-1981 to $127 million (1.70% of total hospital costs) during 1997-1999. CONCLUSIONS: Among all hospital discharges, the proportion of discharges with obesity-associated diseases has increased dramatically in the past 20 years. This increase has led to a significant growth in economic costs. These findings may reflect the impact of increasing prevalence and severity of obesity. Diet and physical activity interventions should be developed for weight loss and prevention of weight gain in youths.

Selective use of endoscopic retrograde cholangiopancreatography to facilitate laparoscopic cholecystectomy without cholangiography. A review of 1139 consecutive cases.

BACKGROUND: The aim of this study was to show that laparoscopic cholecystectomy can be performed safely without routine intraoperative cholangiography. METHODS: We performed a retrospective analysis of 1139 consecutive patients (376 men and 763 women with an average age of 51.4 years) who underwent laparoscopic cholecystectomy between 1991 and 1999. In all, 227 patients (20%) were selected to undergo preoperative endoscopic retrograde cholangiopancreatography (ERCP) on the basis of four criteria for risk of stones. RESULTS: ERCP allowed us to make a diagnosis of biliary stones in 53.3% of the selected patients. Extraction of the stones was successful in 97% of the cases. In 14% of cases, ERCP was normal; in 32.7%, some useful diagnostic information was obtained. There were three complications (pancreatitis) following endoscopy (complication rate, 1.3%). Laparoscopic cholecystectomy was successful in 92% of patients. The postoperative morbidity rate was 3.2% (major complications, 0.5%). There were no deaths. During a follow-up period ranging from 3 to 97 months, six patients (0.6%) were found to have residual biliary stones. CONCLUSION: This study confirms the hypothesis that laparoscopic cholecystectomy can be performed safely without routine intraoperative cholangiography.

Economics of surgery.

The time has come to subject surgery to the same rigours of economic assessment that other health-care sectors are already receiving--namely, the comparative assessment of costs and benefits. The surgical management of gallstones provides a good example of the role of economics in surgery. Gallstone disease is common and patients are usually referred to a surgeon, but the threshold for intervention is not agreed and varies widely, with considerable implications for resources. Gallstone removal has been subject to much innovation over the past 10 years, yet economic assessment of laparoscopic and "mini" cholecystectomy and of gallstone lithotripsy is rare, despite the fact that operation rates have increased by up to 50% in some countries. For surgery to compete with other interventions, economic assessment of new surgical techniques will be increasingly important. This assessment should be based on well-conducted clinical trials in which interventions are provided in a routine service setting, and in which benefits are assessed among other things on the basis of the patient's perceived quality of life. Economic assessment often needs data beyond those collected in a clinical trial, however pragmatic the trial design, so modelling will often be required, incorporating a range of sources of evidence. Finally, evidence alone will not be enough to promote cost-effective practices. The take-up of surgical techniques will always be affected by the way hospitals and surgeons are remunerated. Affecting practice requires a realistic system of reimbursement that reflects evidence on cost effectiveness.

Preinsertion local anesthesia at the trocar site improves perioperative pain and decreases costs of laparoscopic cholecystectomy.

BACKGROUND: Local anesthesia at the trocar site in laparoscopic cholecystectomy is expected to decrease postoperative pain and hence expedite recovery. The aims of this prospective randomized study were to investigate the effect of local anesthesia and to discover whether it is cost effective. METHODS: For this study, 100 patients undergoing laparoscopic cholecystectomy were randomized into two groups. The 43 study patients were injected with 0.5% bupivacaine hydrochloride at the trocar site before the trocars were inserted. They then were compared with 41 control patients who received no local anesthesia. The remaining 16 patients were excluded from the study. The postoperative pain was evaluated at the standard four trocar sites at 4 h and 24 h after surgery on a scale 1 (the mildest pain the patient had ever experienced) to 10 (the most severe pain the patient had ever experienced). Postoperative pain medications and their cost were evaluated. RESULTS: There was no difference between the two groups with regard to gender, age, weight, operative time, estimated operative blood loss, and bile culture. The patients who received bupivacaine at the trocar site clinically had less pain (p < 0.001 for all four sites) both at 4 and 24 h after surgery. The treatment group patients used less mepiridine and promethzine than the control group (p = 0.001 and 0.002, respectively) postoperatively. Overall, the patients who had local anesthesia used less postoperative pain and antiemetic medication than the control patients (p = 0.02). This afforded a significant decrease in the costs and charges of these medications (p = 0.004 and 0.005, respectively). Three patients in the study group were discharged from the hospital the day of surgery. CONCLUSION: Preinsertion of local anesthesia at the trocar site in laparoscopic cholecystectomy significantly reduces postoperative pain and decreases medication usage costs.

[Surgical pathology costs more in emergencies: a bias in the clinical scoring index]. / La pathologie chirurgicale coûte plus cher en urgence: un biais des points ISA.

A retrospective study of all records of patients operated on for biliary lithiasis during the years 1995, 1996 and 1997 was performed in a general hospital setting to compare the costs of management according to presentation. This study shows that acute and chronic cholecystitis have statistically significantly different costs. The reimbursement plans, base on diagnostic related groups do not take this into account. This system disadvantages those centers which preferentially treat acute pathologies.

[Day surgery for cholecyst lithiasis].

Since 1997, laparoscopic cholecystectomy has been performed as one-day surgery (LC/DS) at our institution. Among the 122 patients enrolled in this program, 97 (80%) were successfully discharged within 24 hours after admission. Discharge was delayed for the other 25 patients, although 12 (48%) of them were discharged on postoperative day (POD) 2 or 3. This study not only verified the efficacy of LC/DS in shortening convalescence and allowing an early resumption of work but also confirmed the safety of LC/DS except in one patient with hemophilia A who required laparotomy for intraabdominal bleeding on POD 13. LC/DS is now the first choice of treatment for cholelithiasis regardless of symptoms. Discharge can be expected within 24 hours after admission in most cases, although the preference of patients should be considered when determining the timing of discharge.

The spectrum and cost of complicated gallstone disease in California.

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

Routine vs "on demand" postoperative ERCP for small bile duct calculi detected at intraoperative cholangiography. Clinical evaluation and cost analysis.

BACKGROUND: The detection of small and often asymptomatic gallbladder calculi within the bile duct at intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) frequently poses a management dilemma. Therefore, we set out to compare the outcomes and costs of two management strategies for small stones that remain in the bile duct after LC-routine postoperative endoscopic retrograde cholangiopancreatography (ERCP) vs observation alone with "on-demand" ERCP. METHODS: We studied 70 patients with bile duct stones among 922 consecutive patients who underwent LC between 1990 and 1997. Data were collected prospectively. Bile duct calculi were detected in 70 of 705 patients (9.9%) with successful IOC. Of these, 44 patients had large calculi (> or =5 mm in diameter) and were subjected to a laparoscopic common bile duct exploration. The remaining 26 patients had small calculi (<5 mm in diameter); four of them had undergone preoperative endoscopic sphincterotomy and duct clearance and were therefore excluded from analysis. Patients with small duct calculi were assigned, according to individual surgeon policy, to either routine postoperative ERCP (group A, n = 8) or observation (group B, n = 14). ERCP was reserved for those who become symptomatic. The two groups were comparable for age and sex distribution. RESULTS: No complications developed during the follow-up period in patients assigned to observation, although four became symptomatic and underwent ERCP. In group A, ERCP demonstrated a clear biliary tree in four patients and bile duct calculi in three patients; it failed in one patient. In group B, ERCP demonstrated a clear bile duct in one patient and bile duct calculi in two patients; it also failed in one patient. Endoscopic sphincterotomy and duct clearance were achieved in all patients with demonstrable bile duct calculi at ERCP. There was no morbidity or mortality associated with ERCP. The overall hospital stay was significantly longer in group A than in group B (median 5 vs 1.5 days; p = 0.011); however, the number of outpatient clinic visits was significantly greater in group b (median 3 vs 5.5, p = 0.011). The mean hospital costs, including the costs of hospital stay, readmissions, ERCP, and follow-up, were significantly greater in group A than in group B (mean pound2669 vs pound1508, p = 0.008). CONCLUSION: A "wait and see" policy of observation alone for patients with small bile duct calculi detected at IOC during LC appears to be safe, and it is more cost-effective than routine postoperative ERCP. ERCP should be reserved for post-LC patients who become symptomatic.