title: Laparoscopic Cholecystectomy for Acute Cholecystitis: Is It Really Safe? Bile duct leaks after laparoscopic cholecystectomy: value of contrast-enhanced MRCP Prospective audit of the introduction of laparoscopic cholecystectomy in the west of Scotland. West of Scotland Laparoscopic Cholecystectomy Audit Group. Ultrasonographic screening for gallstone disease in middle-aged women. Detection rate, symptoms, and biochemical features. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a prospective randomized trial Complications of ERCP: a prospective study. Laparoscopic Cholecystectomy for Acute Cholecystitis: Prospective Trial Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Prevalence of gallstones in a Danish population. Management of acute cholecystitis in the laparoscopic era: Results of a prospective, randomized clinical trial Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: An audit of 5913 cases Methods for combining randomized clinical trials: strengths and limitations. Postcholecystectomy biliary leaks in the laparoscopic era: risk factors, presentation, and management. McGill Gallstone Treatment Group. Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones Impact of Choice of Therapeutic Strategy for Acute Cholecystitis on Patient’s Health-Related Quality of Life Acute cholecystitis: delayed surgery or observation. A randomized clinical trial. Postoperative ERCP Versus Laparoscopic Choledochotomy for Clearance of Selected Bile Duct Calculi: A Randomized Trial A survey of the timing and approach to the surgical management of cholelithiasis in patients with acute biliary pancreatitis and acute cholecystitis in the UK. Prospective Evaluation of Emergency Versus Delayed Laparoscopic Cholecystectomy for Early Cholecystitis Randomized trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis Urgent Laparoscopic Cholecystectomy Is the Best Management for Biliary Colic Surgical Management of Bile Duct Injuries Sustained During Laparoscopic Cholecystectomy: Perioperative Results in 200 Patients
abstract: Abstract . The prospect ively collected data from 530 cholecystectomies performed in a university clinic from October 1989 to March 1991 were analyzed after 1 to 3 years of follow-up . The aim of this study was to compare the results of laparoscopic cholecystectomy ( LC ) for acute cholecystitis with that for routine symptomatic gallbladders . The preoperative , intraoperative , and postoperative parameters of 424 routine ( noninflamed ) LCs and 54 LCs for acutely inflamed gallbladders were compared under the “ intention to treat ” principle . Operating time was longer in the inflamed group ( median 97 minutes versus 75 minutes;p < 0.0001 ) . Significantly more adhesions ( 20 % versus 8 % ) , more blood loss ( 48 % versus 19 % ) , a higher incidence of bile spillage ( 28 % versus 12 % ) , and lost stones ( 19 % versus 8 % ) were encountered in patients with acute cholecystitis . Common bile duct ( CBD ) injuries were also more frequent in that group ( 5.5 % versus 0.2%;p = 0.005 ) . The rate of conversion to open surgery was higher than with routine LCs ( 13 % versus 4 % ) . There were two deaths in the routine LC group and none in the acutely inflamed group . There was no difference in postoperative pain intensity or postoperative fatigue according to visual analog scale measurements . Patients with acute cholecystitis stayed only 1 day longer ( median 4 days versus 3 days ) in hospital . The quality of life scores indicate return to almost normal values by the 14th postoperative day . Long-term follow-up ( 1–3 years ) did not reveal any delayed clinical adverse effects . In summary , LC for inflamed gallbladders has a higher conversion rate than LC for routine symptomatic gallbladders . If successfully performed , it has definite benefit for the patient in terms of better postoperative recovery . The trade-off is that the risk of CBD injury is significantly higher Background We assessed the role of mangafodipir-enhanced magnetic resonance ( MR ) cholangiography in the detection and location of bile duct leaks after laparoscopic cholecystectomy . Methods In a prospect i ve study , 34 patients with clinical suspicion of bile duct leak after laparoscopic cholecystectomy underwent MR imaging .  Our protocol included conventional heavily T2-weighted MR cholangiography and three-dimensional T1-weighted MR cholangiography after an intravenous bolus injection of mangafodipir trisodium . All studies were performed on a 1.5-T or 1-T scanner . Contrast-enhanced MR cholangiograms were evaluated for the presence and location of bile duct leaks . Correlation was obtained in all cases with surgery ( n = 15 ) , endoscopic retro grade cholangiography ( n = 5 ) , percutaneous drainage ( n = 5 ) , and clinical follow-up ( n = 9 ) . Results In 20 of 34 patients , bile duct leakage was proved by surgery , endoscopic retro grade cholangiography , or drainage . Contrast enhancement displayed the leakage in 19 of 20 patients and ruled out leaks in the other 14 patients ( 95 % sensitivity , 100 % specificity ) . The leak site was depicted in 14 patients and contrast-enhanced MR cholangiography successfully located the origin of the leak in 11 patients . Conclusions Contrast-enhanced MR cholangiography with intravenous mangafodipir trisodium can accurately diagnose the presence and location of bile duct leaks in patients who have undergone laparoscopic cholecystectomy Although laparoscopic cholecystectomy has rapidly developed in the treatment of gall bladder disease in the absence of controlled clinical trial data its outcome parameters compared with open cholecystectomy remain unclear . A prospect i ve audit of the introduction of laparoscopic cholecystectomy in the west of Scotl and over a two year period was carried out to attempt to assess this new procedure . A total of 45 surgeons in 19 hospitals performing laparoscopic cholecystectomy su bmi tted prospect i ve data from September 1990 - 1992 . A total of 2285 cholecystectomies were audited ( a completed data collection rate of 99 % ) . Laparoscopic cholecystectomy was attempted in 1683 ( 74 % ) patients and completed in 1448 patients ( median conversion rate to the open procedure 17 % ) . The median operation time in the completed laparoscopic cholecystectomy patients was 100 minutes ( range 30 - 330 ) and overall hospital stay three days ( 1 - 33 ) . There were nine deaths ( 0.5 % ) after laparoscopic cholecystectomy although only two were directly attributable to the laparoscopic procedure . In the laparoscopic cholecystectomy group there were 99 complications ( 5.9 % ) , 53 ( 3 % ) of these were major requiring further invasive intervention . Forty patients ( 2.4 % ) required early or delayed laparotomy for major complications such as bleeding or bile duct injuries . There were 11 ( 0.7 % ) bile duct injuries in the laparoscopic cholecystectomy series , five were noted during the initial procedure and six were recognised later result ing from jaundice or bile leaks . Ductal injuries occurred after a median of 20 laparoscopic cholecystectomies . In conclusion laparoscopic cholecystectomy has rapidly replaced open cholecystectomy in the treatment of gall bladder disease . Although the overall death and complication rate associated with laparoscopic cholecystectomy is similar to open cholecystectomy , the bile duct injury rate is higher Five hundred and forty-seven middle-aged women , selected at r and om from the population of Malmö , Sweden , were invited to a screening survey for gallstone disease ; 424 participated ( 77.5 % ) . Forty-one had previously been operated on for gallbladder disease . The prevalence of gallstone disease , on the basis of a positive finding at ultrasonography and cholecystography , was 11 % . The predictive value of a positive finding at ultrasonography was 86 % . Six out of 10 women with gallstone were classified as asymptomatic . Body weight , blood pressure , liver enzymes , fasting blood glucose , and blood lipids , including apolipoprotein-A , did not differ significantly in women with and without gallstone disease . At least 9 out of 10 gallstones appeared to be cholesterol stones . Approximately half were of a size that would make them accessible for dissolution therapy Background : The role of laparoscopic cholecystectomy for acute cholecystitis is not yet clearly established . The aim of this prospect i ve r and omized study was to evaluate the safety and feasibility of laparoscopic cholecystectomy for acute cholecystitis and to compare the results with delayed cholecystectomy . Methods : Between January 2001 and November 2002 , 40 patients with a diagnosis of acute cholecystitis were assigned r and omly to early laparoscopic cholecystectomy within 24 h of admission ( early group , n = 20 ) or to initial conservative treatment followed by delayed laparoscopic cholecystectomy , 6 to 12 weeks later ( delayed group , n = 20 ) . Results : There was no significant difference in the conversion rates ( early , 25 % vs delayed , 25 % ) , operating times ( early , 104 min vs delayed , 93 min ) , postoperative analgesia requirements ( early , 5.3 days vs delayed , 4.8 days ) , or postoperative complications ( early , 15 % vs delayed , 20 % ) . However , the early group had significantly more blood loss ( 228 vs 114 ml ) and shorter hospital stay ( 4.1 vs 10.1 days ) . Conclusions : Early laparoscopic cholecystectomy for acute cholecystitis is safe and feasible , offering the additional benefit of a shorter hospital stay . It should be offered to patients with acute cholecystitis , provided the surgery is performed within 72 to 96 h of the onset of symptoms BACKGROUND Studies of ERCP-related morbidity seldom include a sufficient patient follow-up . The aim of this study was to characterize and to evaluate the frequency of complications , cardiopulmonary untoward events in particular . METHODS All patients undergoing ERCP during a 2-year period were included in this prospect i ve study . Complications were assessed at the time of ERCP and by postal/telephone contact at 30-days after the procedure . RESULTS A total of 1177 ERCPs  were included in the analysis , of which 56.2 % were therapeutic . The 30-day complication rate was 15.9 % ; the procedure-related mortality rate was 1.0 % . Post-ERCP pancreatitis occurred in 3.8 % of patients ( 3 deaths ) . Hemorrhage or perforation occurred with 0.9 % and 1.1 % , respectively , of the procedures ( 3 deaths ) . One perforation that result ed in the death of the patient occurred after placement of an endoprosthesis . Cholangitis occurred in relation to 5 % of the ERCP procedures ( 3 deaths ) . Cardiorespiratory complications occurred in 2.3 % ( 2 deaths ) . Dilated bile duct ( p = 0.0001 ) , placement of stent ( p = 0.001 ) , and use of more than 40 mg of hyoscine-N-butyl bromide ( p < 0.05 ) were risk factors for complications by multivariate analysis . Risk of pancreatitis was increased with age under 40 years ( p = 0.0078 ) , placement of stent ( p = 0.031 ) , and a dilated bile duct ( p = 0.036 ) . CONCLUSIONS This prospect i ve study confirms that the complication rate of ERCP including therapeutic procedures is high . Cardiopulmonary complications were not as common as expected , despite being the special focus of the study Abstract . This prospect i ve study determines the indications for and the optimal timing of laparoscopic cholecystectomy ( LC ) following the onset of acute cholecystitis . It also evaluates preoperative and operative factors associated with conversion from laparoscopic cholecystectomy to open cholecystectomy in the presence of acute cholecystitis . Having been established as the procedure of choice for elective cholelithiasis , LC is now also used for management of acute cholecystitis . Under these circumstances the procedure may be difficult and challenging . Certain favorable and unfavorable conditions may be present that influence the conversion and complication rates . Information about these conditions may be helpful for elucidating the optimal circumstances for LC or when the procedure is best avoided . We performed LC on an emergency basis as soon as the diagnosis was made on all patients presenting with acute cholecystitis from January 1994 to December 1995 . All preoperative , operative , and postoperative data were collected on st and ardized forms . Of the 137 patients registered , 130 were eligible for the audit . Seven patients found by laparoscopic intraoperative cholangiography to have choledocholithiasis were converted for common bile duct exploration and were excluded from the study . Altogether 93 patients ( 72 % ) underwent successful LC and 37 ( 28 % ) needed conversion to open cholecystectomy . The conversion rate of acute gangrenous cholecystitis ( 49 % ) was significantly higher than that for uncomplicated acute cholecystitis ( 4.5 % ) ( p < 0.00001 ) and for hydrops ( 28.5 % ) and empyema of the gallbladder ( 28.5 % ) ( p= 0.004 ) . The difference in conversion between the group with acute necrotizing ( gangrenous ) cholecystitis and the two groups with hydrops and empyema of the gallbladder was not statistically significant ( p= 0.07 ) . The complication rates of acute cholecystitis , hydrops , empyema of the gallbladder , and gangrenous cholecystitis were 9.0 % , 9.5 % , 14.0 % , and 20.0 % , respectively ( p= NS ) . Patients with an operative delay of 96 hours or less from the onset of acute cholecystitis had a conversion rate of 23 % , whereas a delay of more than 96 hours was associated with a conversion rate of 47 % ( p= 0.022 ) . The complication rate was 8.5 % in the laparoscopic group and 27 % in the converted group ( p= 0.013 ) . Patients over 65 years of age , with a history of biliary disease , a nonpalpable gallbladder , WBC count over 13,000/cc , and acute gangrenous cholecystitis were independently associated with a high LC conversion rate ; male patients , finding large bile stones , serum bilirubin over 0.8 mg/dl , and WBC count over 13,000/cc were independently associated with a high complication rate following laparoscopic surgery with or without conversion . Generally , LC can be performed safely for acute cholecystitis , with acceptably low conversion and complication rates . Different forms of cholecystitis carry various conversion and complication rates in selected cases . LC for acute cholecystitis should be performed within 96 hours of the onset of disease . Predictors of conversion and complications may be helpful when planning the laparoscopic approach to acute cholecystitis OBJECTIVE A prospect i ve r and omized study was undertaken to compare early with delayed laparoscopic cholecystectomy for acute cholecystitis . SUMMARY BACKGROUND DATA Laparoscopic cholecystectomy for acute cholecystitis is associated with high complication and conversion rates . It is not known whether there is a role for initial conservative treatment followed by interval elective operation . METHOD During a 26-month period , 99 patients with a clinical diagnosis of acute cholecystitis were r and omly assigned to  early laparoscopic cholecystectomy within 72 hours of admission  ( early group , n = 49 ) or delayed interval surgery after initial medical treatment ( delayed group , n = 50 ) . Thirteen patients ( four in the early group and nine in the delayed group ) were excluded because of refusal of operation ( n = 6 ) , misdiagnosis ( n = 5 ) , contraindication for surgery ( n = 1 ) , or loss to follow-up ( n = 1 ) . RESULTS Eight of 41 patients in the delayed group underwent urgent operation at a median of 63 hours ( range , 32 to 140 hours ) after admission because of spreading peritonitis ( n = 3 ) and persistent fever ( n = 5 ) . Although the delayed group required less frequent modifications in operative technique and a shorter operative time , there was a tendency toward a higher conversion rate ( 23 % vs. 11 % ; p = 0.174 ) and complication rate ( 29 % vs. 13 % ; p = 0.07 ) . For 38 patients with symptoms exceeding 72 hours before admission , the conversion rate remained high after delayed surgery ( 30 % vs. 17 % ; p = 0.454 ) . In addition , delayed laparoscopic cholecystectomy prolonged the total hospital stay ( 11 days vs. 6 days ; p < 0.001 ) and recuperation period ( 19 days vs. 12 days ; p < 0.001 ) . CONCLUSIONS Initial conservative treatment followed by delayed interval surgery can not reduce the morbidity and conversion rate of laparoscopic cholecystectomy for acute cholecystitis . Early operation within 72 hours of admission has both medical and socioeconomic benefits and is the preferred approach for patients managed by surgeons with adequate experience in laparoscopic cholecystectomy A r and om sample of 4,807 men and women , aged 30 , 40 , 50 , and 60 years , who lived in the western part of Copenhagen County , was drawn from the National Central Person Registry . A total of 226 subjects who were not of Danish origin were omitted . The response rate was 78.8 % ( 3,608/4,581 ) . Each person had his or her gallbladder examined by ultrasonography . The examinations took place between November 1982 and February 1984 . The overall prevalence of gallstone disease ( cases with stones and cholecystectomized cases ) in males aged 30 , 40 , 50 , and 60 years was 1.8 % , 1.5 % , 6.7 % , and 12.9 % , respectively . The corresponding prevalence in females was 4.8 % , 6.1 % , 14.4 % , and 22.4 % , respectively . Differences according to sex were significant in all age groups . Differences between the 40- and 50-year and 50- and 60-year age groups were significant in both sexes . Among subjects with gallstone disease , the disease was unknown to the prob and in the majority of males and in the 30-year-old females , but only in half of the women aged 40 , 50 , and 60 years . The prevalence of clinical ly diagnosed gallstones was not significantly different between respondents and nonrespondents The aim of this prospect i ve , r and omized study was to determine whether laparoscopic cholecystectomy should be performed as an early or a delayed operation in patients with acute cholecystitis . After diagnostic workup , patients were r and omized to one of two groups : ( 1 ) early laparoscopic cholecystectomy  ( i.e. , within 7 days after onset of symptoms ) or ( 2 ) initial conservative treatment followed by delayed laparoscopic cholecystectomy 6 to 8 weeks later .  Seventy-four patients were placed in the early-operation group , and 71 patients were assigned to the delayed-operation strategy . There was no significant difference in conversion rates ( early 31 % vs. delayed 29 % ) , operating times ( early 98 [ range 30 to 355 ] minutes vs. delayed 100 [ 45 to 280 ] minutes ) , or complications . Failure with the conservative treatment strategy was noted in 26 % of these patients . The total hospital stay was significantly shorter in the early group ( 5 [ range 3 to 63 ] days ) vs. the delayed group ( 8 [ range 4 to 50 ] days ; P < 0.05 ) . Despite a high conversion rate , early laparoscopic cholecystectomy offered significant advantages in the management of acute cholecystitis compared to a conservative strategy . The greatest advantage was a reduced total hospital stay The rapid introduction of laparoscopic cholecystectomy has been associated with an apparently increased incidence of bile duct injury which has provoked worldwide concern . The true incidence and mechanism of iatrogenic ductal injury during the development of this procedure remain unclear . To assess this , the introduction of laparoscopic cholecystectomy in the West of Scotl and has been audited prospect ively over a 5‐year period . All cases of biliary ductal injury have been independently review ed . Some 48 surgeons undertaking laparoscopic cholecystectomy in 19 hospitals su bmi tted prospect i ve data between September 1990 and September 1995 . A total of 5913 laparoscopic cholecystectomies were attempted with 98·3 per cent completion of data collection . During this period 37 laparoscopic bile duct injuries occurred . The annual incidence peaked at 0·8 per cent and has fallen to 0·4 per cent in the final year of audit . Injuries occurred after a median personal experience of 51 ( range 3–247 )  laparoscopic chole cystectomies  in 22 surgeons . Major bile duct injuries occurred in 20 of 37 patients , giving an incidence of 0·3 per cent . Five mechanisms for laparoscopic ductal injury were identified , including tenting , confluence and diathermy injuries as well as the classical and variant classical types . Ductal injuries were discovered at operation in 18 patients with consequent repair giving a good clinical outcome in 17 . Contributory factors ( severe inflammation , aberrant anatomy and poor visualization ) were present in only 13 of 37 cases . This audit suggests that , at least in the introductory period , laparoscopic cholecystectomy is associated with an overall bile duct injury rate higher than that reported previously after open cholecystectomy , although the incidence of major ductal injury is similar . The late downward trend in bile duct injury , however , suggests there may be a prolonged learning curve for this procedure . Improved underst and ing of the mechanism of injury may lead to yet further reductions in this complication Methods for combining data from several studies exist and appear to be quite useful . None satisfactorily addresses the question of what studies should be combined . This issue is the most serious method ological limitation . Even studies with statistically significant interaction might still be combined if the effect were in the same direction . Thus , substantial scientific input is required as to what criteria must be met by each potential study . Much can be learned from combining or pooling data but it must be done cautiously . Pooling exercises do not replace well design ed prospect i ve clinical trials . Efforts for establishing basic design criteria to allow for multicentre and multicountry trials to be more easily combined might be useful . BACKGROUND The management of  bile leaks  has evolved in the laparoscopic era . This study characterizes risk factors for their developmental and their clinical course and management . METHODS Data on a cohort of patients who developed bile leaks after cholecystectomy in the laparoscopic era  were gathered prospect ively and retrospectively from an ongoing surgical data base and following a review of hospital charts . RESULTS Sixty-four patients ( mean age 56 + /- 17.1 years , 72 % women ) were included over a 5-year study period . The incidence of leaks was 1.1 % among patients entered in a  laparoscopic cholecystectomy data base . Intraoperative complications were encountered in 36 % . Rates of intraoperative complication and conversion to open surgery were greater among patients who developed leaks ( 5.2 % vs 0.6 % and 33 % vs 6.3 % , respectively , p < 0.00001 ) . Patients presented 5.3 + /- 4.2 days following surgery with abdominal pain ( 89 % ) , fever ( 74 % ) , and tenderness ( 81 % ) . Ultrasound diagnosed a suspected leak in 73 % , which ERCP showed as originating from the cystic duct stump in 77 % . Biliary obstruction was noted in 20 ( 31 % ) patients ( 14 with stones ) . Treatments included percutaneous ( 13 % ) , endoscopic ( 28 % ) , primary or secondary operative procedures ( 14 % ) , or a combination thereof ( 45 % ) . CONCLUSION A complication at laparoscopic cholecystectomy increases the likelihood of a subsequent bile leak . Most patients present early with a patent cystic duct stump in the absence of biliary obstruction . Endoscopic therapy is successful in the majority of cases , but otherwise percutaneous or operative procedures may be needed BACKGROUND The management of  stones in the common bile duct in the laparoscopic era is controversial . The three major options are preoperative endoscopic retro grade cholangiography ( ERCP ) , laparoscopic exploration of the common bile duct ( LECBD ) , or postoperative ERCP . METHODS Between August , 1995 , and August , 1997 , 471 laparoscopic cholecystectomies were done in our department . In 427 ( 91 % ) , satisfactory peroperative cholangiography was obtained . In 80 ( 17 % ) of these cases there were stones in the common bile duct , 40 patients were r and omised to LECBD and 40 to postoperative ERCP .  If LECBD failed , patients had either open exploration of the common bile duct or postoperative ERCP . If one postoperative ERCP failed , the procedure was repeated until the common bile duct was cleared of stones or an endoprosthesis was placed to prevent stone impaction . The primary endpoints were duct-clearance rates , morbidity , operating time , and hospital stay . Analyses were by intention to treat . FINDINGS Age and sex distribution of patients was similar in the r and omised groups . Duct clearance after the first intervention was 75 % in both groups . By the end of treatment , duct clearance was 100 % in the laparoscopic group compared with 93 % in the ERCP group . Duration of treatment was a median of 90 min ( range 25 - 310 ) in the laparoscopic group ( including ERCPs for failed LECBD ) compared with 105 min ( range 60 - 255 ) in the postoperative ERCP group ( p = 0.1 , 95 % CI for difference -5 to 40 ) . Hospital stay was a median of 1 day ( range 1 - 26 ) in the laparoscopic group compared with 3.5 days ( range 1 - 11 ) in the ERCP group ( p = 0.0001 , 95 % CI 1 - 2 ) . INTERPRETATION LECBD is as effective as ERCP in clearing the common bile duct of stones . There is a non-significant trend to shorter time in the operating theatre and a significantly shorter hospital stay in patients treated by LECBD Background : The aim of this prospect i ve , r and omized study was to determine if health related quality of life is affected by the choice of surgical strategy in the management of acute cholecystitis . Material and Methods : After diagnostic workup , patients were r and omized to one of two groups : ( 1 ) early laparoscopic cholecystectomy  ( i.e. within 7 days after onset of symptoms ) or ( 2 ) initial conservative treatment followed by delayed laparoscopic cholecystectomy .  Seventy-four patients entered the early operation group and 71 patients were assigned to the delayed  operation  strategy . Assessment s of quality of life were made at 1 , 3 and 6 months after surgery , and in the delayed operation group also one month after the initial conservative treatment . Results : The gastrointestinal symptom scores were significantly better in three dimensions ( diarrhea , indigestion , abdominal pain ) one month after surgery for the acute operation group ( p < 0.01 ) . Three and 6 months after the operation we were unable to detect any significant differences between the groups . The patients in the delayed operation group did not appear to suffer from more symptoms in the period of time waiting for their elective operation . Psychological general well-being showed no major differences between the groups . Conclusion : Cholecystectomy in the acute phase of acute cholecystitis offers a significant reduction of gastrointestinal symptoms during the first postoperative month and to that associated improved quality of life in this group of patients BACKGROUND The aim of the present study was to compare the risk of observation versus that of cholecystectomy in acute cholecystitis in patients r and omly allocated to delayed operation or conservative treatment . METHODS One-hundred- and -eighty patients were considered for participation in the study ; 71 were excluded according to predefined criteria and 45 did not join for other reasons . The remaining 64 patients were r and omized to cholecystectomy ( n = 31 ) or observation ( n = 33 ) . R and omized patients were contacted regularly and followed up for a median of 67 months . All gallstone-related hospital contacts were registered in both r and omized and excluded patients . RESULTS Gallstone-related complications or emergency admissions for pain occurred in six patients in the operation group ( 19 % ; 95 % CI 5%-33 % ) and in 12 patients ( 36 % ; 9 % CI 20%-53 % ) in the observation group . Twenty-seven of 31 patients r and omized to cholecystectomy had a  cholecystectomy  at a median of 3.6 months after r and omization , and , of these , 3 ( 11 % ; 95 % CI 0%-23 % ) suffered a major and 7 ( 26 % ; 95 % CI 9%-42 % ) a minor complication . Ten patients r and omized to observation later had their gallbladders removed , 1 ( 10 % ; 95 % CI 0%-29 % ) patient had a major and 1 ( 10 % ; 95 % CI 0%-29 % ) a minor complication . We found no mortality after cholecystectomy . CONCLUSIONS We found a certain risk of subsequent gallstone-related events following conservative treatment of acute cholecystitis , but the data also show that cholecystectomy should not necessarily be compulsory after acute cholecystitis Objective : Prospect ively evaluate whether for patients having laparoscopic cholecystectomy with failed trans-cystic duct clearance of bile duct ( BD ) stones they should have  laparoscopic choledochotomy or postoperative endoscopic retro grade cholangiography ( ERCP ) . Summary Background Data : Clinical management of BD stones found at laparoscopic cholecystectomy in the last decade has focused on pre-cholecystectomy detection with ERCP clearance in those with suspected stones . This clinical algorithm successfully clears the stones in most patients , but no stones are found in 20 % to 60 % of patients and rare unpredictably severe ERCP morbidity can result in this group . Our initial experience of 300 consecutive patients with fluoroscopic cholangiography and intraoperative clearance  demonstrated that , for the pattern of stone disease we see , 66 % of patients ’ BD stones can be cleared via the cystic duct with dramatic reduction in morbidity compared to the 33 % requiring choledochotomy or ERCP . Given the limitations of the preoperative approach to BD stone clearance , this trial was design ed to explore the limitations , for patients failing laparoscopic trans-cystic clearance  , of laparoscopic choledochotomy or postoperative ERCP . Methods : Across 7 metropolitan hospitals after failed trans-cystic duct clearance , patients were intraoperatively r and omized to have either laparoscopic choledochotomy or postoperative ERCP . Exclusion criteria were : ERCP prior to referral for cholecystectomy , severe cholangitis or pancreatitis requiring immediate ERCP drainage , common BD diameter of less than 7 mm diameter , or if bilio-enteric drainage was required in addition to stone clearance . Drain decompression of the cleared BD was used in the presence of cholangitis , an edematous ampulla due to instrumentation or stone impaction and technical difficulties from local inflammation and fibrosis . The ERCP occurred prior to discharge from hospital . Mechanical and extracorporeal shockwave lithotripsy was available . Sphincter balloon dilation as an alternative to sphincterotomy to allow stone extraction was not used . Major endpoints for the trial were operative time , morbidity , retained stone rate , reoperation rate , and hospital stay . Results : From June 1998 to February 2003 , 372 patients with BD stones had successful trans-cystic duct clearance of stones in 286 , leaving 86 patients r and omized into the trial . Total operative time was 10.9 minutes longer in the choledochotomy group ( 158.8 minutes ) , with slightly shorter hospital stay 6.4 days versus 7.7 days . Bile leak occurred in 14.6 % of those having choledochotomy with similar rates of pancreatitis ( 7.3 % versus 8.8 % ) , retained stones ( 2.4 % versus 4.4 % ) , reoperation ( 7.3 % versus 6.6 % ) , and overall morbidity ( 17 % versus 13 % ) . Conclusions : These data suggest that the majority of secondary BD stones can be diagnosed at the time of cholecystectomy and cleared trans-cystically , with those failing having either choledochotomy or postoperative ERCP . However , because of the small trial size , a significant chance exists that small differences in outcome may exist . We would avoid choledochotomy in ducts less than 7 mm measured at the time of operative cholangiogram and severely inflamed friable tissues leading to a difficult dissection . We would advocate choledochotomy as a good choice for patients after Billroth 11 gastrectomy , failed ERCP access , or where long delays would occur for patient transfer to other locations for the ERCP BACKGROUND Recent management guidelines and r and omised clinical trials have provided evidence -based guidance to the management of acute  biliary pancreatitis and acute cholecystitis . METHODS A question naire was sent to the 1086 members of the Association of Surgeons of Great Britain and Irel and . There were 583 responders ( 54 % ) . RESULTS A policy of cholecystectomy during the index admission or within 4 weeks in fit patients recovering from mild acute biliary pancreatitis was adopted by 58 % of surgeons , and was significantly associated with an upper gastrointestinal and hepato-pancreato-biliary subspecialty interest and a volume of more than 50 cholecystectomies per annum ( OR , 0.43 ; 95 % CI , 0.26 - 0.72 ; P = 0.001 : and OR , 0.46 ; 95 % CI , 0.29 - 0.74 ; P = 0.001 , respectively ) . A policy of urgent cholecystectomy for acute cholecystitis was adopted by 20 % of surgeons , and was significantly associated with an upper gastrointestinal/hepato-pancreato-biliary subspecialty interest and the ' routine ' adoption of laparoscopic approach to  cholecystectomy  ( OR , 0.34 ; 95 % CI , 0.19 - 0.60 ; P < 0.001 : and OR , 0.51 ; 95 % CI , 0.3 - 0.86 ; P = 0.01 , respectively ) . CONCLUSIONS The management of cholelithiasis in patients with acute biliary pancreatitis in the UK remains suboptimal . Moreover , only a minority of surgeons offer patients presenting with acute cholecystitis the benefits of early laparoscopic cholecystectomy . The management of acute biliary disease may be improved if these cases were concentrated in the h and s of surgeons with upper gastrointestinal/hepato-pancreato-biliary interest and those who perform laparoscopic cholecystectomy regularly Treatment of acute cholecystitis is still under debate . The aim of this study was to evaluate the efficacy of early laparoscopic cholecystectomy ( ELC ) in comparison with conservative treatment followed by delayed laparoscopic cholecystectomy ( DLC ) in the management of acute cholecystitis . This prospect i ve comparative study involved two groups of patients presenting with acute cholecystitis within 72 hours of the onset of symptoms . ELC was performed in 82 consecutive patients , whereas DLC was performed in 87 patients who previously underwent medical treatment .  Surgical variables , hospital stay , and postoperative morbidity were evaluated in both groups . Time of surgery and conversion rate were lower in the ELC group . Postoperative morbidity was similar in both groups . Overall hospital stay was shorter in the ELC group . ELC within 72 hours of the onset of acute cholecystitis is a safe procedure with better results than DLC in terms of surgical timing , conversion rate , and hospital stay The aim of this prospect i ve r and omized study was to define the optimum management between early and delayed laparoscopic cholecystectomy for patients with acute cholecystitis Background / Aim : Delay of laparoscopic cholecystectomy after the diagnosis of biliary colic may increase the probability of recurrent emergency admission while awaiting elective cholecystectomy . The aim of this study was to compare the possible advantages and safety of urgent laparoscopic cholecystectomy ( ULC ) with elective laparoscopic cholecystectomy ( ELC ) in patients with biliary colic . Patients and Methods : Between 2001 and 2003 , 75 patients with biliary colic were included in this study . The patients were classified into following two groups : patients who had ULC in 24 h were in group I ( n = 28 ) and patients who had ELC ( mean interval 4.22 ± 1.42 months ) were in group II ( n = 35 ) . Conversion to open cholecystectomy , operative time , postoperative hospital stay , costs , and complications were evaluated . Results : In group II , 9 patients made a total of 13 return visits to the emergency department with recurrent attacks of biliary colic or complications of gallstone disease . Mean operative time increased from 35.1 ± 6.74 min for urgent laparascopic cholecystectomy to 49.9 ± 6.12 min for ELC ( p > 0.05 ) and hospital stay time increased from 1.06 ± 0.4 to 2.31 ± 2.36 days ( p < 0.05 ) . Conversion to open cholecystectomy increased from 0 % in group I to 17.2 % in group II ( p < 0.05 ) . Discussion : ULC for biliary colic may be the most medically efficacious and cost-effective treatment Objective : A single institution retrospective analysis of 200 patients with major bile duct injuries was completed . Three patients died without surgery due to uncontrolled sepsis . One hundred seventy-five patients underwent surgical repair , with a 1.7 % postoperative mortality and a complication rate of 42.9 % . Summary Background Data : The widespread application of laparoscopic cholecystectomy ( LC ) has led to a rise in the incidence of major bile duct injuries ( BDI ) . Despite the frequency of these injuries and their complex management , the published literature contains few substantial reports regarding the perioperative management of BDI . Methods : From January 1990 to April 2003 , a prospect i ve data base of all patients with a BDI following LC  was maintained . Patients ’ charts were retrospectively review ed to analyze perioperative surgical management . Results : Over 13 years , 200 patients were treated for a major BDI following LC . Patient demographics were notable for 150 women ( 75 % ) with a mean age of 45.5 years ( median 44 years ) . One hundred eighty-eight sustained their BDI at an outside hospital . The mean interval from the time of BDI to referral was 29.1 weeks ( median 3 weeks ) . One hundred nine patients ( 58 % ) were referred within 1 month of their injury for acute complications including bile leak , biloma , or jaundice . Twenty-five patients did not undergo a surgical repair at our institution . Three patients ( 1.5 % ) died after delayed referral before an attempt at repair due to uncontrolled sepsis . Twenty-two patients , having intact biliary-enteric continuity , underwent successful balloon dilatation of an anastomotic stricture . A total of 175 patients underwent definitive biliary reconstruction , including 172 hepaticojejunostomies ( 98 % ) and 3 end-to-end repairs . There were 3 deaths in the postoperative period ( 1.7 % ) . Seventy-five patients ( 42.9 % ) sustained at least 1 postoperative complication . The most common complications were wound infection ( 8 % ) , cholangitis ( 5.7 % ) , and intraabdominal abscess/biloma ( 2.9 % ) . Minor biliary stent complications occurred in 5.7 % of patients . Early postoperative cholangiography revealed an anastomotic leak in 4.6 % of patients and extravasation at the liver dome-stent exit site in 10.3 % of patients . Postoperative interventions included percutaneous abscess drainage in 9 patients ( 5.1 % ) and new percutaneous transhepatic cholangiography and stent placement in 4 patients ( 2.3 % ) . No patient required reoperation in the postoperative period . The mean postoperative length of stay was 9.5 days ( median 9 days ) . The timing of operation ( early , intermediate , delayed ) , presenting symptoms , and history of prior repair did not affect the incidence of the most common perioperative complications or length of postoperative hospital stay . Conclusions : This series represents the largest single institution experience reporting the perioperative management of BDI following LC . Although perioperative complications are frequent , nearly all can be managed nonoperatively . Early referral to a tertiary care center with experienced hepatobiliary surgeons and skilled interventional radiologists would appear to be necessary to assure optimal results
target: Early laparoscopic cholecystectomy during acute cholecystitis seems safe and shortens the total hospital stay .
background: BACKGROUND Gallstones are present in about 10 % to 15 % of the adult western population .
  Between 1 % and 4 % become symptomatic in a year .
  Cholecystectomy for symptomatic gallstones is mainly performed after the acute cholecystitis episode settles because of the fear of higher morbidity and conversion from laparoscopic cholecystectomy to open cholecystectomy during acute cholecystitis .
  OBJECTIVES The aim was to compare the early laparoscopic cholecystectomy ( less than seven days of onset of symptoms ) versus delayed laparoscopic cholecystectomy ( more than six weeks after index admission ) with regards to benefits and harms .