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Annals of Surgery Sep 2019Early cholecystectomy shortly after admission for mild gallstone pancreatitis has been proposed based on observational data. We hypothesized that cholecystectomy within... (Comparative Study)
Comparative Study Randomized Controlled Trial
INTRODUCTION
Early cholecystectomy shortly after admission for mild gallstone pancreatitis has been proposed based on observational data. We hypothesized that cholecystectomy within 24 hours of admission versus after clinical resolution of gallstone pancreatitis that is predicted to be mild results in decreased length-of-stay (LOS) without an increase in complications.
METHODS
Adults with predicted mild gallstone pancreatitis were randomized to cholecystectomy with cholangiogram within 24 hours of presentation (early group) versus after clinical resolution (control) based on abdominal exam and normalized laboratory values. Primary outcome was 30-day LOS including readmissions. Secondary outcomes were time to surgery, endoscopic retrograde cholangiopancreatography (ERCP) rates, and postoperative complications. Frequentist and Bayesian intention-to-treat analyses were performed.
RESULTS
Baseline characteristics were similar in the early (n = 49) and control (n = 48) groups. Early group had fewer ERCPs (15% vs 29%, P = 0.038), faster time to surgery (16 h vs 43 h, P < 0.005), and shorter 30-day LOS (50 h vs 77 h, RR 0.68 95% CI 0.65 - 0.71, P < 0.005). Complication rates were 6% in early group versus 2% in controls (P = 0.613), which included recurrence/progression of pancreatitis (2 early, 1 control) and a cystic duct stump leak (early). On Bayesian analysis, early cholecystectomy has a 99% probability of reducing 30-day LOS, 93% probability of decreasing ERCP use, and 72% probability of increasing complications.
CONCLUSION
In patients with predicted mild gallstone pancreatitis, cholecystectomy within 24 hours of admission reduced rate of ERCPs, time to surgery, and 30-day length-of-stay. Minor complications may be increased with early cholecystectomy. Identification of patients with predicted mild gallstone pancreatitis in whom early cholecystectomy is safe warrants further investigation.
Topics: Adult; Age Factors; Bayes Theorem; Cholangiography; Cholangiopancreatography, Endoscopic Retrograde; Cholecystectomy, Laparoscopic; Female; Gallstones; Humans; Intraoperative Care; Length of Stay; Male; Middle Aged; Pancreatitis; Patient Admission; Prognosis; Reference Values; Risk Assessment; Severity of Illness Index; Sex Factors; Time-to-Treatment; Treatment Outcome
PubMed: 31415304
DOI: 10.1097/SLA.0000000000003424 -
World Journal of Gastroenterology Sep 2016Portal biliopathy refers to cholangiographic abnormalities which occur in patients with portal cavernoma. These changes occur as a result of pressure on bile ducts from... (Review)
Review
Portal biliopathy refers to cholangiographic abnormalities which occur in patients with portal cavernoma. These changes occur as a result of pressure on bile ducts from bridging tortuous paracholedochal, epicholedochal and cholecystic veins. Bile duct ischemia may occur due prolonged venous pressure effect or result from insufficient blood supply. In addition, encasement of ducts may occur due fibrotic cavernoma. Majority of patients are asymptomatic. Portal biliopathy is a progressive disease and patients who have long standing disease and more severe bile duct abnormalities present with recurrent episodes of biliary pain, cholangitis and cholestasis. Serum chemistry, ultrasound with color Doppler imaging, magnetic resonance imaging with magnetic resonance cholangiopancreatography and magnetic resonance portovenography are modalities of choice for evaluation of portal biliopathy. Endoscopic retrograde cholangiography being an invasive procedure is indicated for endotherapy only. Management of portal biliopathy is done in a stepwise manner. First, endotherapy is done for dilation of biliary strictures, placement of biliary stents to facilitate drainage and removal of bile duct calculi. Next portal venous pressure is reduced by formation of surgical porto-systemic shunt or transjugular intrahepatic portosystemic shunt. This causes significant resolution of biliary changes. Patients who persist with biliary symptoms and bile duct changes may benefit from surgical biliary drainage procedures (hepaticojejunostomy or choledechoduodenostomy).
Topics: Bile Ducts; Biliary Tract; Cholangiography; Cholangiopancreatography, Endoscopic Retrograde; Cholangitis; Cholestasis; Gallbladder Diseases; Humans; Hypertension, Portal; Ischemia; Liver; Portal Pressure; Portal Vein; Portasystemic Shunt, Surgical; Stents
PubMed: 27672292
DOI: 10.3748/wjg.v22.i35.7973 -
The Western Journal of Medicine Apr 1976Cholesterol saturation of bile has a primary role in the pathogenesis of gallstone formation. Predisposing factors should be considered. The characteristic features of... (Review)
Review
Cholesterol saturation of bile has a primary role in the pathogenesis of gallstone formation. Predisposing factors should be considered. The characteristic features of biliary colic are important to keep in mind, as well as the fact that a history of fatty food intolerance is not of value in the diagnosis of gallstones. The technique of endoscopic retrograde cholangiography is useful for the diagnosis of bile duct stones in jaundiced patients and in patients with a strong clinical history, but in whom findings on oral and intravenous cholangiograms are within normal limits. Improved techniques of operative cholangiography to diminish the incidence of retained gallstones have been developed. Also, choledochoscopy provides a remarkable technique for diagnosis and choledocholithotomy. The dissolution of gallstones with chenodeoxycholic acid is an experimental procedure. This bile acid is thought to act by increasing the chenodeoxycholic acid pool size and decreasing cholesterol synthesis and secretion, thereby reversing the defects responsible for gallstone formation.
Topics: Bile Acids and Salts; Child; Cholangiography; Cholelithiasis; Cholesterol; Female; Humans
PubMed: 772986
DOI: No ID Found -
Canadian Medical Association Journal Jun 1964Percutaneous transhepatic cholangiography is a method of visualizing the biliary tree by the injection of radio-opaque medium through the abdominal wall and liver into...
Percutaneous transhepatic cholangiography is a method of visualizing the biliary tree by the injection of radio-opaque medium through the abdominal wall and liver into an intrahepatic bile duct. The procedure is indicated in the immediate preoperative evaluation of patients with obstructive jaundice of unknown etiology and is usually diagnostic in these cases. It may also be of value in avoiding operation in poor-risk patients with obstructive jaundice. Biliary leak resulting in chemical peritonitis is a complication in about 5% of these procedures. Intraperitoneal hemorrhage is a complication in less than 1%. Death results from the procedure in less than 0.5% of cases. Transhepatic cholangiography during surgical operation is of value in demonstrating obstructive lesions of the bile ducts. However, preoperative percutaneous transhepatic cholangiography is preferred, since it makes possible adequate preparation for technically difficult repairs and resections.
Topics: Bile Duct Neoplasms; Bile Ducts, Intrahepatic; Cholangiography; Gallbladder Neoplasms; Gallstones; Geriatrics; Humans; Jaundice, Obstructive; Liver; Pancreatic Neoplasms; Technology, Radiologic
PubMed: 14158553
DOI: No ID Found -
Gut Apr 1977
Review
Topics: Carcinoma, Papillary; Catheterization; Cholangiography; Diagnosis, Differential; Endoscopes; Endoscopy; Humans; Jaundice; Pancreas; Pancreatic Juice; Pancreatic Neoplasms; Pancreatitis; Sphincter of Oddi
PubMed: 324875
DOI: 10.1136/gut.18.4.316 -
The British Journal of Radiology Jul 2012Recent developments in imaging technology have enabled CT and MR cholangiopancreatography (MRCP) to provide minimally invasive alternatives to endoscopic retrograde... (Comparative Study)
Comparative Study Review
Recent developments in imaging technology have enabled CT and MR cholangiopancreatography (MRCP) to provide minimally invasive alternatives to endoscopic retrograde cholangiopancreatography for the pre- and post-operative assessment of biliary disease. This article describes anatomical variants of the biliary tree with surgical significance, followed by comparison of CT and MR cholangiographies. Drip infusion cholangiography with CT (DIC-CT) enables high-resolution three-dimensional anatomical representation of very small bile ducts (e.g. aberrant branches, the caudate branch and the cystic duct), which are potential causes of surgical complications. The disadvantages of DIC-CT include the possibility of adverse reactions to biliary contrast media and insufficient depiction of bile ducts caused by liver dysfunction or obstructive jaundice. Conventional MRCP is a standard, non-invasive method for evaluating the biliary tree. MRCP provides useful information, especially regarding the extrahepatic bile ducts and dilated intrahepatic bile ducts. Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced MRCP may facilitate the evaluation of biliary structure and excretory function. Understanding the characteristics of each type of cholangiography is important to ensure sufficient perioperative evaluation of the biliary system.
Topics: Adult; Aged; Biliary Tract; Biliary Tract Diseases; Biliary Tract Neoplasms; Cholangiography; Cholangiopancreatography, Magnetic Resonance; Contrast Media; Female; Gadolinium DTPA; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Perioperative Care; Radiographic Image Enhancement; Risk Assessment; Sensitivity and Specificity; Tomography, X-Ray Computed
PubMed: 22422383
DOI: 10.1259/bjr/21209407 -
Annals of the Royal College of Surgeons... Sep 1979Clinical, operative, and conventional radiological criteria may provide insufficient indications for exploration of the common bile duct. The technique of contact...
Clinical, operative, and conventional radiological criteria may provide insufficient indications for exploration of the common bile duct. The technique of contact cholangiography improves the radiographic definition, especially in the obese, and has resulted in more positive choledochotomies and in fewer negative explorations.
Topics: Cholangiography; Common Bile Duct; Humans; Methods
PubMed: 496230
DOI: No ID Found -
International Surgery 2014Duplication of the gallbladder is a rare congenital anomaly of the biliary system with the incidence of 1 in 3800. A 38-year-old woman visited our patient clinic for...
Duplication of the gallbladder is a rare congenital anomaly of the biliary system with the incidence of 1 in 3800. A 38-year-old woman visited our patient clinic for evaluation of wall thickening of the gallbladder, detected by abdominal ultrasonography during a regular medical checkup. Drip infusion cholecystocholangiography-computed tomography revealed Y-shaped duplicated gallbladders.
Topics: Adult; Cholangiography; Female; Gallbladder; Humans; Tomography, X-Ray Computed; Ultrasonography
PubMed: 24444274
DOI: 10.9738/INTSURG-D-13-00036.1 -
Surgery May 2022Early experience with indocyanine green-based fluorescent cholangiography during laparoscopic cholecystectomy suggests the potential to improve outcomes. However, the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Early experience with indocyanine green-based fluorescent cholangiography during laparoscopic cholecystectomy suggests the potential to improve outcomes. However, the cost-effectiveness of routine use has not been studied. Our objective was to evaluate the cost-effectiveness of fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy for noncancerous gallbladder disease.
METHODS
A Markov model decision analysis was performed comparing fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy alone. Probabilities of outcomes, survival, toxicities, quality-adjusted life-years, and associated costs were determined from literature review and pooled analysis of currently available studies on fluorescent cholangiography (n = 37). Uncertainty in the model parameters was evaluated with 1-way and probabilistic sensitivity analyses, varying parameters up to 40% of their means. Cost-effectiveness was measured with an incremental cost-effectiveness ratio expressed as the dollar amount per quality-adjusted life-year.
RESULTS
The model predicted that fluorescent cholangiography reduces lifetime costs by $1,235 per patient and improves effectiveness by 0.09 quality-adjusted life-years compared to standard bright light laparoscopic cholecystectomy. Reduced costs were due to a decreased operative duration (21.20 minutes, P < .0001) and rate of conversion to open (1.62% vs 6.70%, P < .0001) associated with fluorescent cholangiography. The model was not influenced by the rate of bile duct injury. Probabilistic sensitivity analysis found that fluorescent cholangiography was both more effective and less costly in 98.83% of model iterations at a willingness-to-pay threshold of $100,000/quality-adjusted life year.
CONCLUSION
The current evidence favors routine use of fluorescent cholangiography during laparoscopic cholecystectomy as a cost-effective surgical strategy. Our model predicts that fluorescent cholangiography reduces costs while improving health outcomes, suggesting fluorescence imaging may be considered standard surgical management for noncancerous gallbladder disease. Further study with prospective trials should be considered to verify findings of this predictive model.
Topics: Cholangiography; Cholecystectomy, Laparoscopic; Coloring Agents; Cost-Benefit Analysis; Gallbladder Diseases; Humans; Prospective Studies
PubMed: 34952715
DOI: 10.1016/j.surg.2021.09.027 -
Deutsches Arzteblatt International Oct 2014Cholangiocarcinoma (CCA) is the second most common primary hepatic tumor in Germany, with about 3500 new cases per year. In recent years, its prognosis has improved... (Review)
Review
BACKGROUND
Cholangiocarcinoma (CCA) is the second most common primary hepatic tumor in Germany, with about 3500 new cases per year. In recent years, its prognosis has improved because of wider resections and the establishment of local treatment and chemotherapy in the palliative situation.
METHODS
This review is based on pertinent articles that were retrieved by a selective literature search in the PubMed database with the keywords "cholangiocarcinoma AND diagnostic OR therapy." Articles in English or German published up to January 2014 were considered.
RESULTS
The sole curative treatment for CCA is surgery, but 40-85% of all patients have recurrent disease even after radical excision. Because of this high recurrence rate, adjuvant treatments are now under intense discussion. For unresectable CCA without distant metastases, small case series have shown that liver transplantation can yield promising survival rates of over 50% at 5 years. For many patients with CCA, however, only palliative treatments can be offered, including endoscopic clearing of the biliary pathways. Because of the low prevalence of the disease, there have been only a few phase 3 studies of palliative chemotherapy for CCA. On the basis of one positive phase 3 study, chemotherapy with gemcitabine and cisplatin is considered the standard and now plays an established role in palliative care.
CONCLUSION
CCA presents a special challenge in gastroenterology, oncology, and visceral surgery because of the difficulty in establishing the diagnosis, local complications in the biliary pathways, and a high recurrence rate after resection. Future studies should address not only the role of adjuvant chemotherapy, but also the efficacy of combined local and systemic treatment.
Topics: Bile Duct Neoplasms; Bile Ducts, Intrahepatic; Chemotherapy, Adjuvant; Cholangiocarcinoma; Cholangiography; Endoscopy, Digestive System; Humans; Liver Transplantation
PubMed: 25412632
DOI: 10.3238/arztebl.2014.0748