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Therapeutic Advances in... 2023Acute calculous cholecystitis (ACC) represents about one-third of all surgical emergencies. The gold standard management of ACC is laparoscopic cholecystectomy. Although...
BACKGROUND AND AIMS
Acute calculous cholecystitis (ACC) represents about one-third of all surgical emergencies. The gold standard management of ACC is laparoscopic cholecystectomy. Although cholecystectomy is a safe procedure, it may be dangerous and contraindicated in patients with complex comorbidities. Endoscopic transpapillary gallbladder stenting (ETGBS) and drainage had been widely used to manage patients suffering from ACC with comorbidities.
METHODS
We searched PubMed, SCOPUS, Web of Science, and Cochrane Library for relevant studies assessing the use of ETGBS in patients suffering from ACC with various comorbidities. Risk of bias assessment was performed using the National Institues of Health (NIH) tool. We included the following outcomes: clinical success, technical success, late complications, and pancreatitis.
RESULTS
We included seven studies that met our inclusion criteria. We found that the pooled proportion of clinical success, technical success, late complications, and pancreatitis was [91.3%, 95% confidence interval (CI) (86.8%, 95.9%)], [92.8%, 95% CI (89%, 96.5%)], [5.4%, 95% CI (2.9%, 7.9%)], and [3.5%, 95% CI (1.2%, 5.8%)], respectively.
CONCLUSION
We found that an ETGBS was an effective and well-tolerated method for the treatment of cholecystitis, especially in high-risk individuals.
PubMed: 37664530
DOI: 10.1177/26317745231192177 -
Cureus Oct 2023Cholecystectomy is a widespread surgical procedure for gallbladder diseases. Evolving techniques and technologies, such as intraoperative cholangiography (IOC), enhance... (Review)
Review
Cholecystectomy is a widespread surgical procedure for gallbladder diseases. Evolving techniques and technologies, such as intraoperative cholangiography (IOC), enhance safety and outcomes by providing real-time biliary system visualization during surgery. This systematic review explored available data on using IOC during cholecystectomy, highlighting its effectiveness, safety, and cost-effectiveness. To perform this systematic review, a thorough literature search was conducted using relevant keywords in electronic databases, such as PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Library, Web of Science, and Google Scholar. We included studies published during the last 10 years exploring the use of IOC during cholecystectomy. The findings showed success rates of up to 90% with a median time of 21.9 minutes without complications. Most (90%) patients with acute gallstone pancreatitis underwent cholecystectomy with IOC, with unclear IOC results in 10.7% and failure in 14.7%. IOC failure factors included age, body mass index (BMI), male sex, concurrent acute cholecystitis, common bile duct (CBD) stone evidence on imaging, CBD diameter of >6 mm, total bilirubin of >4 mg/dL, abnormal liver tests, and gallstone pancreatitis. The detection of choledocholithiasis by IOC prompted trans-cystic duct exploration and endoscopic retrograde cholangiopancreatography (ERCP). Biliary abnormalities and stone identification were observed using IOC, and routine use increased bile duct stone detection while decreasing bile duct injury and readmission rates. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of IOC for common bile duct stone detection were reported at 77%, 98%, 97.2%, 63%, and 99%, respectively. Routine IOC was projected to provide substantial quality-adjusted life years (QALY) and cost-effectiveness gains compared to selective IOC. Regarding safety, IOC was generally associated with reduced complication and open surgery conversion risks, with similar rates of CBD injury and bile leaks. These findings indicate that IOC enhances cholecystectomy outcomes through precision and decreasing complications.
PubMed: 37899894
DOI: 10.7759/cureus.47646 -
Translational Gastroenterology and... 2023Laparoscopic cholecystectomy (LC) in patients admitted with acute cholecystitis is considered the preferred, feasible and safe mode of managing gallstone disease. The...
BACKGROUND
Laparoscopic cholecystectomy (LC) in patients admitted with acute cholecystitis is considered the preferred, feasible and safe mode of managing gallstone disease. The objective of this study is to evaluate the role of single-dose pre-operative prophylactic antibiotics in patients undergoing emergency LC for mild to moderate acute cholecystitis.
METHODS
All randomized control trials (RCTs) reporting the use of single-dose pre-operative prophylactic antibiotics in patients undergoing acute cholecystectomy were retrieved from the search of standard medical electronic databases and analysis was conducted by using the principles of meta-analysis on the statistical software RevMan version 5.
RESULTS
Standard medical databases search produced only 3 RCTs on 781 patients undergoing acute cholecystectomy. There were 384 patients in single dose pre-operative antibiotics group whereas 397 patients were recruited in the no-antibiotics group. In the random effects model analysis, the use of single-dose preoperative prophylactic antibiotics in patients undergoing acute cholecystectomy for mild to moderate cholecystitis failed to demonstrate any extra advantage of reducing the risk of [risk ratio (RR) =0.69; 95% confidence interval (CI): 0.46-1.03; Z=1.80; P=0.07] infective complications. There was no heterogeneity [Tau =0; Chi =1.74, df =2 (P=0.42; I=0%)] among included studies.
CONCLUSIONS
A preoperative single dose of prophylactic antibiotics in patients undergoing acute LC for mild to moderate acute cholecystitis does not offer extra benefits to reduce infective complications.
PubMed: 38021359
DOI: 10.21037/tgh-23-48 -
Journal of Robotic Surgery Apr 2023Robotically assisted operations are the state of the art in laparoscopic general surgery. They are established predominantly for elective operations. Since laparoscopy... (Review)
Review
Robotically assisted operations are the state of the art in laparoscopic general surgery. They are established predominantly for elective operations. Since laparoscopy is widely used in urgent general surgery, the significance of robotic assistance in urgent operations is of interest. Currently, there are few data on robotic-assisted operations in urgent surgery. The aim of this study was to collect and classify the existing studies. A two-stage, PRISMA-compliant literature search of PubMed and the Cochrane Library was conducted. We analyzed all articles on robotic surgery associated with urgent general surgery resp. acute surgical diseases of the abdomen. Gynecological and urological diseases so as vascular surgery, except mesenterial ischemia, were excluded. Studies and case reports/series published between 1980 and 2021 were eligible for inclusion. In addition to a descriptive synopsis, various outcome parameters were systematically recorded. Fifty-two studies of operations for acute appendicitis and cholecystitis, hernias and acute conditions of the gastrointestinal tract were included. The level of evidence is low. Surgical robots in the narrow sense and robotic camera mounts were used. All narrow-sense robots are nonautonomous systems; in 82%, the Da Vinci system was used. The most frequently published emergency operations were urgent cholecystectomies (30 studies, 703 patients) followed by incarcerated hernias (9 studies, 199 patients). Feasibility of robotic operations was demonstrated for all indications. Neither robotic-specific problems nor extensive complication rates were reported. Various urgent operations in general surgery can be performed robotically without increased risk. The available data do not allow a final evidence-based assessment.
Topics: Humans; Robotic Surgical Procedures; Robotics; Laparoscopy; Cholecystectomy; Hernia
PubMed: 35727485
DOI: 10.1007/s11701-022-01425-6 -
Academic Emergency Medicine : Official... Mar 2017Acute cholecystitis (AC) is a common differential for patients presenting to the emergency department (ED) with abdominal pain. The diagnostic accuracy of history,... (Review)
Review
BACKGROUND
Acute cholecystitis (AC) is a common differential for patients presenting to the emergency department (ED) with abdominal pain. The diagnostic accuracy of history, physical examination, and bedside laboratory tests for AC have not been quantitatively described.
OBJECTIVES
We performed a systematic review to determine the utility of history and physical examination (H&P), laboratory studies, and ultrasonography (US) in diagnosing AC in the ED.
METHODS
We searched medical literature from January 1965 to March 2016 in PubMed, Embase, and SCOPUS using a strategy derived from the following formulation of our clinical question: patients-ED patients suspected of AC; interventions-H&P, laboratory studies, and US findings commonly used to diagnose AC; comparator-surgical pathology or definitive diagnostic radiologic study confirming AC; and outcome-the operating characteristics of the investigations in diagnosing AC were calculated. Sensitivity, specificity, and likelihood ratios (LRs) were calculated using Meta-DiSc with a random-effects model (95% CI). Study quality and risks for bias were assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies.
RESULTS
Separate PubMed, Embase, and SCOPUS searches retrieved studies for H&P (n = 734), laboratory findings (n = 74), and US (n = 492). Three H&P studies met inclusion/exclusion criteria with AC prevalence of 7%-64%. Fever had sensitivity ranging from 31% to 62% and specificity from 37% to 74%; positive LR [LR+] was 0.71-1.24, and negative LR [LR-] was 0.76-1.49. Jaundice sensitivity ranged from 11% to 14%, and specificity from 86% to 99%; LR+ was 0.80-13.81, and LR- was 0.87-1.03. Murphy's sign sensitivity was 62% (range = 53%-71%), and specificity was 96% (range = 95%-97%); LR+ was 15.64 (range = 11.48-21.31), and LR- was 0.40 (range = 0.32-0.50). Right upper quadrant pain had sensitivity ranging from 56% to 93% and specificity of 0% to 96%; LR+ ranged from 0.92 to 14.02, and LR- from 0.46 to 7.86. One laboratory study met criteria with a 26% prevalence of AC. Elevated bilirubin had a sensitivity of 40% (range = 12%-74%) and specificity of 93% (range = 77%-99%); LR+ was 5.80 (range = 1.25-26.99), and LR- was 0.64 (range = 0.39-1.08). Five US studies with a prevalence of AC of between 10% and 46%. US sensitivity was 86% (range = 78%-94%) and specificity was 71% (range = 66%-76%); LR+ was 3.23 (range = 1.74-6.00), and LR- was 0.18 (range = 0.10-0.33).
CONCLUSION
Variable disease prevalence, coupled with limited sample sizes, increases the risk of selection bias. Individually, none of these investigations reliably rule out AC. Development of a clinical decision rule to include evaluation of H&P, laboratory data, and US are more likely to achieve a correct diagnosis of AC.
Topics: Abdominal Pain; Cholecystitis, Acute; Diagnostic Tests, Routine; Emergency Service, Hospital; Female; Humans; Male; Observational Studies as Topic; Physical Examination; Sensitivity and Specificity
PubMed: 27862628
DOI: 10.1111/acem.13132 -
BMC Surgery Nov 2018The timing of laparoscopic cholecystectomy (LC) performed after the mild acute biliary pancreatitis (MABP) is still controversial. We conducted a review to compare... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The timing of laparoscopic cholecystectomy (LC) performed after the mild acute biliary pancreatitis (MABP) is still controversial. We conducted a review to compare same-admission laparoscopic cholecystectomy (SA-LC) and delayed laparoscopic cholecystectomy (DLC) after mild acute biliary pancreatitis (MABP).
METHODS
We systematically searched several databases (PubMed, EMBASE, Web of Science, and the Cochrane Library) for relevant trials published from 1 January 1992 to 1 June 2018. Human prospective or retrospective studies that compared SA-LC and DLC after MABP were included. The measured outcomes were the rate of conversion to open cholecystectomy (COC), rate of postoperative complications, rate of biliary-related complications, operative time (OT), and length of stay (LOS). The meta-analysis was performed using Review Manager 5.3 software (The Cochrane Collaboration, Oxford, United Kingdom).
RESULTS
This meta-analysis involved 1833 patients from 4 randomized controlled trials and 7 retrospective studies. No significant differences were found in the rate of COC (risk ratio [RR] = 1.24; 95% confidence interval [CI], 0.78-1.97; p = 0.36), rate of postoperative complications (RR = 1.06; 95% CI, 0.67-1.69; p = 0.80), rate of biliary-related complications (RR = 1.28; 95% CI, 0.42-3.86; p = 0.66), or OT (RR = 1.57; 95% CI, - 1.58-4.72; p = 0.33) between the SA-LC and DLC groups. The LOS was significantly longer in the DLC group (RR = - 2.08; 95% CI, - 3.17 to - 0.99; p = 0.0002). Unexpectedly, the subgroup analysis showed no significant difference in LOS according to the Atlanta classification (RR = - 0.40; 95% CI, - 0.80-0.01; p = 0.05). The gallstone-related complications during the waiting time in the DLC group included gall colic, recurrent pancreatitis, acute cholecystitis, jaundice, and acute cholangitis (total, 25.39%).
CONCLUSION
This study confirms the safety of SA-LC, which could shorten the LOS. However, the study findings have a number of important implications for future practice.
Topics: Acute Disease; Cholecystectomy, Laparoscopic; Gallstones; Humans; Pancreatitis; Time Factors
PubMed: 30486807
DOI: 10.1186/s12893-018-0445-9 -
HPB : the Official Journal of the... Sep 2022High risk surgical patients with acute cholecystitis are commonly treated with percutaneous cholecystostomy (PTC) drainage. The optimal timing of subsequent interval... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
High risk surgical patients with acute cholecystitis are commonly treated with percutaneous cholecystostomy (PTC) drainage. The optimal timing of subsequent interval laparoscopic cholecystectomy (LC) remains unclear.
METHODS
Medline, EMBASE, and Scopus were searched to identify studies published between 01/01/2000 and 31/12/2020, reporting on interval LC outcomes in patients initially treated by PTC. Early and late interval LC were defined as <30 and ≥ 30 days respectively. The Methodological Index for Nonrandomized Studies was used for quality assessment. Meta-analysis of proportions was conducted using a random-effects model.
RESULTS
A total of 512 studies were screened, 41 met the inclusion criteria. There were 22 studies in both early and late interval LC groups, with 3 included studies reporting both early and late groups. Following quality assessment, 29 studies were included in the meta-analysis. There were no significant differences between early and late interval LC in terms of conversion rates (7.2% vs 8.3%, p = 0.854), 90-day morbidity (12.8% vs 15.9%, p = 0.496), and 90-day mortality (0.25% vs 0.32%, p = 0.704). Heterogeneity was significant (I>50%) in all groups.
CONCLUSION
Current evidence of interval LC within or beyond 30 days demonstrates no significant impact on outcomes. Patient factors, clinical experience, and hospital facilities may prove more important predictors.
Topics: Cholecystectomy, Laparoscopic; Cholecystitis, Acute; Cholecystostomy; Humans; Morbidity; Retrospective Studies; Treatment Outcome
PubMed: 35469743
DOI: 10.1016/j.hpb.2022.03.016 -
International Journal of Surgery... 2012Gallbladder perforation is a serious complication of acute cholecystitis. Its management has evolved considerably since its classification by Niemeier in 1934. This... (Review)
Review
BACKGROUND
Gallbladder perforation is a serious complication of acute cholecystitis. Its management has evolved considerably since its classification by Niemeier in 1934. This review summarises the evidence surrounding the natural progression of this condition and potential problems with Niemeier's classification, and proposes a management algorithm for the more complex type II perforation.
METHODS
Data from a retrospective case series and a systematic review were combined. The case series included all patients with gallbladder perforations from 2004 to 2008 at a British teaching hospital. The systematic review searched for gallbladder perforation using the MEDLINE, Embase, Web of Science and Cochrane Library (2011 Issue 4) databases, as well as recent conference abstracts. The outcome data were analysed using SPSS version 15. No adjustments were made for multiple testing.
RESULTS
198 patients (including 19 patients from the present series) with a mean age of 62.1+/-9.7 years and male gender proportion of 55.4% (range 33.3-76.7%) were included. The most common gallbladder perforations were type II (median 46.2%, range 7.4-83.3%), followed by type I (median 40.6%, range 16.7-70.0%) and type III (median 10.1%, range 0-48.1%). Perforation was associated with cholelithiasis in 86.6% (range 78.9-90.6%) of patients, and the overall median mortality rate was 10.8% (range 0-12.5%). Male gender was weakly associated with mortality (p = 0.089) but age (p = 0.877) and cholelithiasis (p = 0.425) were not. Mortality did not vary significantly with perforation type.
CONCLUSIONS
Gallbladder perforation should be reported according to the original Neimeier's classification to avoid heterogeneity in data (e.g. varying rates of perforation types). The algorithm proposed in this study aims to guide the management of complex type II gallbladder perforations to minimise subsequent morbidity and mortality.
Topics: Adult; Aged; Aged, 80 and over; Algorithms; Cholangiopancreatography, Endoscopic Retrograde; Cholecystectomy; Cholecystitis, Acute; Decision Support Techniques; Female; Gallbladder Diseases; Humans; Male; Middle Aged; Retrospective Studies; Rupture, Spontaneous
PubMed: 22210542
DOI: 10.1016/j.ijsu.2011.12.004 -
Health Technology Assessment... Aug 2014Approximately 10-15% of the adult population suffer from gallstone disease, cholelithiasis, with more women than men being affected. Cholecystectomy is the treatment of... (Comparative Study)
Comparative Study Review
Clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones or cholecystitis: a systematic review and economic evaluation.
BACKGROUND
Approximately 10-15% of the adult population suffer from gallstone disease, cholelithiasis, with more women than men being affected. Cholecystectomy is the treatment of choice for people who present with biliary pain or acute cholecystitis and evidence of gallstones. However, some people do not experience a recurrence after an initial episode of biliary pain or cholecystitis. As most of the current research focuses on the surgical management of the disease, less attention has been dedicated to the consequences of conservative management.
OBJECTIVES
To determine the clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management in people presenting with uncomplicated symptomatic gallstones (biliary pain) or cholecystitis.
DATA SOURCES
We searched all major electronic databases (e.g. MEDLINE, EMBASE, Science Citation Index, Bioscience Information Service, Cochrane Central Register of Controlled Trials) from 1980 to September 2012 and we contacted experts in the field.
REVIEW METHODS
Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies that enrolled people with symptomatic gallstone disease (pain attacks only and/or acute cholecystitis). Two reviewers independently extracted data and assessed the risk of bias of included studies. Standard meta-analysis techniques were used to combine results from included studies. A de novo Markov model was developed to assess the cost-effectiveness of the interventions.
RESULTS
Two Norwegian RCTs involving 201 participants were included. Eighty-eight per cent of people randomised to surgery and 45% of people randomised to observation underwent cholecystectomy during the 14-year follow-up period. Participants randomised to observation were significantly more likely to experience gallstone-related complications [risk ratio = 6.69; 95% confidence interval (CI) 1.57 to 28.51; p = 0.01], in particular acute cholecystitis (risk ratio = 9.55; 95% CI 1.25 to 73.27; p = 0.03), and less likely to undergo surgery (risk ratio = 0.50; 95% CI 0.34 to 0.73; p = 0.0004), experience surgery-related complications (risk ratio = 0.36; 95% CI 0.16 to 0.81; p = 0.01) or, more specifically, minor surgery-related complications (risk ratio = 0.11; 95% CI 0.02 to 0.56; p = 0.008) than those randomised to surgery. Fifty-five per cent of people randomised to observation did not require an operation during the 14-year follow-up period and 12% of people randomised to cholecystectomy did not undergo the scheduled operation. The results of the economic evaluation suggest that, on average, the surgery strategy costs £1236 more per patient than the conservative management strategy but was, on average, more effective. An increase in the number of people requiring surgery while treated conservatively corresponded to a reduction in the cost-effectiveness of the conservative strategy. There was uncertainty around some of the parameters used in the economic model.
CONCLUSIONS
The results of this assessment indicate that cholecystectomy is still the treatment of choice for many symptomatic people. However, approximately half of the people in the observation group did not require surgery or suffer complications in the long term indicating that a conservative therapeutic approach may represent a valid alternative to surgery in this group of people. Owing to the dearth of current evidence in the UK setting a large, well-designed, multicentre trial is needed.
STUDY REGISTRATION
The study was registered as PROSPERO CRD42012002817.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: Adult; Cholecystectomy; Cholecystitis; Cost-Benefit Analysis; Female; Gallstones; Humans; Male; Recurrence; Treatment Outcome; Watchful Waiting
PubMed: 25164349
DOI: 10.3310/hta18550 -
Cancers May 2023Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is a rescue technique for patients with malignant biliary obstruction who fail conventional treatment with... (Review)
Review
BACKGROUND
Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is a rescue technique for patients with malignant biliary obstruction who fail conventional treatment with ERCP or EUS-guided biliary drainage. The technique has been successfully employed in the management of acute cholecystitis in patients not fit for surgery. However, the evidence for its use in malignant obstruction is less robust. This review article aims to evaluate the data available at present to better understand the safety and efficacy of EUS-guided gallbladder drainage.
METHODS
A detailed literature review was conducted and several databases were searched for any studies relating to EUS-GBD in malignant biliary obstruction. Pooled rates with 95% confidence intervals were calculated for clinical success and adverse events.
RESULTS
Our search identified 298 studies related to EUS-GBD. The final analysis included 7 studies with 136 patients. The pooled rate of clinical success (95% CI) was 85% (78-90%, I: 0%). The pooled rate of adverse events (95% CI) was 13% (7-19%, I: 0%). Adverse events included: peritonitis, bleeding, bile leakage, stent migration, and stent occlusion. No deaths directly related to the procedure were reported; however, in some of the studies, deaths occurred due to disease progression.
CONCLUSION
This review supports the use of EUS-guided gallbladder drainage as a rescue option for patients who have failed conventional measures.
PubMed: 37296955
DOI: 10.3390/cancers15112988