Early versus delayed laparoscopic cholecystectomy in uncomplicated biliary colic: An observational study

Objective:Biliary colic is a condition treated with laparoscopic cholecystectomy.However,the outcomes of surgery depend on early or delayed time points.Few research findings reported no benefits of early over delayed,on contra,other reported benefits.This study aims to compare the benefits associated with early and delayed laparoscopic cholecystectomy among uncomplicated biliary colic patients.Methods:This observational study included patients with right upper abdominal pain and abdominal ultrasound showing cholelithiasis.Patients who were admitted at the first and second visits(within 6 weeks of the first visit)were assigned to the early and delayed groups,respectively.All participants were followed up for one-week postsurgery.The diagnosis of the patient,postoperative hospital stay,duration of surgery and complications were noted and compared primarily.Results:A total of 80 patients were included,40 each in the early group and delayed group.The patients in the two groups had comparable mean ages(40.55±13.12 y vs.40.45±12.06 y,p=0.972).The early group had more female patients(72.5%vs.45.0%,p=0.012).The duration of hospital stay(2.18±0.38 d vs.2.68±1.04 d,p=0.009)and duration of surgery(61.63±3.64 min vs.71.13±16.19 min,p=0.001)were found to be significantly different between the early and delayed groups.Only 1(2.5%)patient in both groups was converted to open cholecystectomy.Recurrent biliary colic requiring hospital admission was seen in 1(2.5%)patient and 6(15.0%)patients,acute cholecystitis in 2(5.0%)and 6(15.0%),biliary pancreatitis in 1(2.5%)and 2(5.0%),and obstructive jaundice in 1(2.5%)and 1(2.5%)in the early and delayed groups,respectively,with insignificant differences(p>0.05).Conclusion:Early laparoscopic cholecystectomy decreases the operating time and duration of hospital stay.In terms of postoperative complications,our study did not find any significant difference between the groups.

Analgesic effect of paracetamol combined with low- dose morphine versus morphine alone on patients with biliary colic： a double blind, randomized controlled trial

BACKGROUND:Numerous drugs have been proposed to alleviate pain in patients with biliary colic,especially opioids,but still there is a tendency to use less narcotics because of their side effects and the unwillingness of some patients.The present study aimed to compare the analgesic effect of paracetamol combined with low-dose morphine versus morphine alone in patients with biliary colic.METHODS:A randomized double-blind controlled trial was performed in 98 patients with biliary colic,recruited from two emergency departments from August 2012 to August 2013.Eleven patients were excluded and the remaining were randomized into two groups:group A received 0.05mg/kg morphine+1 000 mg paracetamol in 100 m L normal saline and group B received 0.1 mg/kg morphine+normal saline(100 m L)as placebo.Pain scores were recorded using visual analogue scale(VAS)at baseline and 15 and 30 minutes after drug administration.Adverse effects and the need for rescue medication(0.75 g/kg intravenous fentanyl)were also reported within 60 minutes of drug administration.RESULTS:Before the infusion,the mean±SD VAS scores were 8.73±1.57 in group A and8.53±1.99 in group B.At 15 minutes after drug administration,the mean±SD VAS scores were2.16±1.90 in group A vs.2.51±1.86 in group B;mean difference was–0.35,and 95%CI–1.15 to 0.45(P=0.38).At 30 minutes the mean±SD VAS scores were 1.66±1.59 in group A vs.2.14±1.79 in group B;mean difference was–0.48,and 95%CI–1.20 to 0.24(P=0.19).The mean pain scores in the two groups at 15 and 30 minutes demonstrated no significant difference.CONCLUSION:Paracetamol combined with low-dose morphine may be effective for pain management in patients with biliary colic.

Endoscopic management of biliary ascariasis: A case report

BACKGROUND Biliary ascariasis is rare but remains the most common parasitic infection in remote areas and in people with poor medical conditions.Here,we reported a case of biliary ascariasis in order to raise awareness of possible parasitic infections.CASE SUMMARY A 68-year-old female was admitted to the emergency room of the Affiliated Hospital of Guizhou Medical University on 28 September 2017,with chief complaint of pain in the right upper abdomen.Ultrasonography of the abdomen showed that the upper segment of the common bile duct was slightly dilated with parallel tubular structures,indicative of biliary ascariasis.Endoscopic retrograde cholangiopancreatography was performed under general anesthesia on 29 September 2017,and an adult Ascaris lumbricoides worm was observed.After the worm was removed from the bile duct,the patient’s pain immediately subsided.The patient was successfully cured,without any complications.CONCLUSION This report emphasizes the need for physicians to consider biliary ascariasis as a possible cause when treating cases of biliary colic.

Early vs late cholecystectomy in mild gall stone pancreatitis: Anupdated meta-analysis and review of literature

BACKGROUND Gallstone pancreatitis is one of the most common causes of acute pancreatitis.Cholecystectomy remains the definitive treatment of choice to prevent recurrence.The rate of early cholecystectomies during index admission remains low due toperceived increased risk of complications.AIMTo compare outcomes including length of stay, duration of surgery, biliarycomplications, conversion to open cholecystectomy, intra-operative, and postoperativecomplications between patients who undergo cholecystectomy duringindex admission as compared to those who undergo cholecystectomy thereafter.METHODSStatistical Method: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (randomeffects model).RESULTSInitial search identified 163 reference articles, of which 45 were selected andreviewed. Eighteen studies (n = 2651) that met the inclusion criteria were includedin this analysis. Median age of patients in the late group was 43.8 years while thatin the early group was 43.6. Pooled analysis showed late laparoscopiccholecystectomy group was associated with an increased length of stay by 88.96 h(95%CI: 86.31 to 91.62) as compared to early cholecystectomy group. Pooled riskdifference for biliary complications was higher by 10.76% (95%CI: 8.51 to 13.01) in the late cholecystectomy group as compared to the early cholecystectomy group.Pooled analysis showed no risk difference in intraoperative complications [riskdifference: 0.41%, (95%CI: -1.58 to 0.75)], postoperative complications [riskdifference: 0.60%, (95%CI: -2.21 to 1.00)], or conversion to open cholecystectomy[risk difference: 1.42%, (95%CI: -0.35 to 3.21)] between early and latecholecystectomy groups. Pooled analysis showed the duration of surgery to beprolonged by 39.11 min (95%CI: 37.44 to 40.77) in the late cholecystectomy groupas compared to the early group.CONCLUSIONIn patients with mild gallstone pancreatitis early cholecystectomy leads to shorterhospital stay, shorter duration of surgery, while decreasing the risk of biliarycomplications. Rate of intraoperative, post-operative complications and chances ofconversion to open cholecystectomy do not significantly differ whethercholecystectomy was performed early or late.

Impact of COVID-19 on presentation,management,and outcomes of acute care surgery for gallbladder disease and acute appendicitis

BACKGROUND The ongoing coronavirus disease 2019(COVID-19)pandemic has significantly disrupted both elective and acute medical care.Data from the early months suggest that acute care patient populations deferred presenting to the emergency department(ED),portending more severe disease at the time of presentation.Additionally,care for this patient population trended towards initial non-operative management.AIM To examine the presentation,management,and outcomes of patients who developed gallbladder disease or appendicitis during the pandemic.METHODS A retrospective chart review of patients diagnosed with acute cholecystitis,symptomatic cholelithiasis,or appendicitis in two EDs affiliated with a single tertiary academic medical center in Northern California between March and June,2020 and in the same months of 2019.Patients were selected through a research repository using international classification of diseases(ICD)-9 and ICD-10 codes.Across both years,313 patients were identified with either type of gallbladder disease,while 361 patients were identified with acute appendicitis.The primary outcome was overall incidence of disease.Secondary outcomes included presentation,management,complications,and 30-d re-presentation rates.Relationships between different variables were explored using Pearson’s r correlation coefficient.Variables were compared using the Welch’s t-Test,Chi-squared tests,and Fisher’s exact test as appropriate.RESULTS Patients with gallbladder disease and appendicitis both had more severe presentations in 2020.With respect to gallbladder disease,more patients in the COVID-19 cohort presented with acute cholecystitis compared to the control cohort[50%(80)vs 35%(53);P=0.01].Patients also presented with more severe cholecystitis in 2020 as indicated by higher mean Tokyo Criteria Scores[mean(SD)1.39(0.56)vs 1.16(0.44);P=0.02].With respect to appendicitis,more patients were diagnosed with a perforated appendix at presentation in 2020[20%(36)vs 16%(29);P=0.02]and a greater percentage were classified as emergent cases using the emergency severity index[63%(112)vs 13%(23);P<0.001].While a greater percentage of patients were admitted to the hospital for gallbladder disease in 2020[65%(104)vs 50%(76);P=0.02],no significant differences were observed in hospital admissions for patients with appendicitis.No significant differences were observed in length of hospital stay or operative rate for either group.However,for patients with appendicitis,30-d re-presentation rates were significantly higher in 2020[13%(23)vs 4%(8);P=0.01].CONCLUSION During the COVID-19 pandemic,patients presented with more severe gallbladder disease and appendicitis.These findings suggest that the pandemic has affected patients with acute surgical conditions.

Similarities and differences between biliary sludge and microlithiasis: Their clinical and pathophysiological significances

The terms biliary sludge and cholesterol microlithiasis(hereafter referred to as microlithiasis)were originated from different diagnostic techniques and may represent different stages of cholesterol gall-stone disease.Although the pathogenesis of biliary sludge and microlithiasis may be similar,micro-lithiasis could be preceded by biliary sludge,followed by persistent precipitation and aggregation of solid cholesterol crystals,and eventually,gallstone formation.Many clinical conditions are clearly associated with the formation of biliary sludge and microlithiasis,including total parenteral nutrition,rapid weight loss,pregnancy,organ transplantation,administration of certain medications,and a variety of acute and chronic illnesses.Numerous studies have demonstrated complete resolution of biliary sludge in approximately 40%of patients,a cyclic pattern of disappearing and reappearing in about 40%,and progression to gallstones in nearly 20%.Although only a minority of patients with ultrasonographic demonstration of biliary sludge develop gallstones,it is still a matter of controversy whether micro-lithiasis could eventually evolve to cholesterol gallstones.Biliary sludge and microlithiasis are asymp-tomatic in the vast majority of patients;however,they can cause biliary colic,acute cholecystitis,and acute pancreatitis.Biliary sludge and microlithiasis are most often diagnosed ultrasonographically and bile microscopy is considered the gold standard for their diagnosis.Specific measures to prevent the development of biliary sludge are not practical or cost-effective in the general population.Laparoscopic cholecystectomy offers the most definitive therapy on biliary sludge.Endoscopic sphincterotomy or surgical intervention is effective for microlithiasis-induced pancreatitis.Ursodeoxycholic acid can effectively prevent the recurrence of solid cholesterol crystals and significantly reduce the risk of recurrent pancreatitis.