Conservative treatment versus endoscopic sphincterotomy in the initial management of acute cholecystitis in elderly patients at high surgical risk

Cholecystectomy before, simultaneously, or after ERCP in patients with acute cholecystitis: A protocol for systematic review and/or meta analysis

INTRODUCTION

Cholecystectomy is the intervention of choice for treating acute cholecystitis; when conservative management does not work, it operates on the patient outside the critical condition. It can be performed together with or after endoscopic papillotomy through endoscopic retrograde cholangiopancreatography (ERCP) when it is concurrent with a situation of cholechodocolithiasis or when there is compression and consequent increase in pressure in the bile duct caused by a calculus jammed in the vesicular infundibulum (Mirizzi's syndrome), with or without jaundice, fever, and pain in the right hypochondrium (Charcot's Triad), which can progress to sepsis of biliary origin. This review aims to assess whether the timing of cholecystectomy (before or after ERCP) interferes with the postoperative period and clinical outcome in patients with acute cholecystitis.

METHODS AND ANALYSIS

By searching the MEDLINE/PubMed, Embase, Web of Science, ScienceDirect, ClinicalTrials.gov, CINAHAL, Latin American and Caribbean Literature in Health Sciences, Scopus and Cochrane Central databases, Controlled Trials Registry Randomized clinical trials will be searched to analyze whether ERCP performed before or after open or laparoscopic cholecystectomy (LC) in patients with acute cholecystitis is beneficial or not, through the analysis of postoperative complications. No language or publication period restrictions will be imposed. The primary outcome will be postoperative complications (postoperative morbidity and mortality). Four independent reviewers will select the studies and extract data from the original publications, with a fifth reviewer in case of disagreement regarding the inclusion or not of particular research in the present review. The risk of bias will be assessed using The Risk of Bias 2 (RoB 2.0) tool, and the certainty of evidence will be evaluated using the grading of recommendations assessment, development, and evaluation. Data synthesis will be performed using the Review Manager software (RevMan V.5.2.3). To assess heterogeneity, we will calculate the I2 statistics. Additionally, a quantitative synthesis will be performed if the included studies are sufficiently homogeneous.

ETHICS AND DISCLOSURE

Since the present study will review secondary data, previously published and scientifically validated, it will not be necessary to obtain ethical approval. The results of this systematic review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

International Prospective Registry of Systematic Reviews (PROSPERO) CRD42021290726.

Occult pancreaticobiliary reflux is a pathogenic factor of some benign biliary diseases and gallbladder cancer

BACKGROUND

Pancreaticobiliary maljunction (PBM) is a well-known high-risk factor for biliary malignant tumors because of constant pancreaticobiliary reflux (PBR). However, the impact of occult pancreaticobiliary reflux (OPR), which is characterized by high bile amylase levels in individuals with anatomically normal pancreaticobiliary junction, on biliary diseases remains unclear. The aim of this study was to assess the correlation between OPR and biliary diseases.

METHODS

We enrolled 94 consecutive patients with normal pancreaticobiliary junction and primary biliary diseases confirmed by magnetic resonance cholangiopancreatography. We prospectively collected patients' bile samples and measured bile amylase levels. We investigated the incidence of OPR and the difference in bile amylase levels among these patients and assessed the correlation between high bile amylase levels (HBAL) and benign or malignant biliary diseases, as well as the OPR risk factors.

RESULTS

The incidence of OPR was 36.6% in patients with benign biliary diseases, 26.7% in those with cholangiocarcinoma and 62.5% in those with gallbladder cancer. The median bile amylase level tended to be higher in patients with gallbladder cancer than in those with benign biliary diseases, but there was no significant difference (165.5 IU/L vs. 23.0 IU/L, P = 0.212). The prevalence of an HBAL with bile amylase levels of 1000-7500 IU/L was similar in patients with gallbladder cancer and benign biliary diseases. However, the incidence of HBAL with bile amylase levels greater than 7500 IU/L was significantly higher in patients with gallbladder cancer than in those with benign biliary diseases (37.5% vs. 4.2%, P = 0.012). Multivariate logistic regression analysis revealed that choledocholithiasis was an independent risk factor for OPR.

CONCLUSIONS

OPR can occur in benign and malignant biliary diseases, and it may be a pathogenic factor for some benign biliary diseases and a high-risk factor for gallbladder cancer. There is a correlation between choledocholithiasis and OPR.

Relationship between high bile juice amylase levels and chronic bacterial infections in patients with gallbladder cancer

Purpose

Pancreatic enzyme reflux into the biliary tract is associated with chronic inflammation and increased cellular proliferation in the biliary epithelium, leading to biliary carcinoma. We evaluated the relationship between high bile juice amylase levels and biliary microflora in patients with malignant gallbladder lesions.

Methods

In this retrospective study, 25 gallbladder specimens were obtained from patients with gallbladder cancer to evaluate amylase levels and perform bacterial culture. The samples were divided into high and low amylase groups and culture-positive and negative groups for analysis. Bile juice amylase 3 times higher than the normal serum amylase level (36–128 IU/L) was considered high.

Results

The number of positive cultures was higher in the high amylase group than in the low amylase group, but the difference was insignificant. There were no differences in other clinicopathological factors. Sixteen patients showed positive culture results; Escherichia coli and Klebsiella spp. were the most common gram-negative bacteria, whereas Enterococcus and Streptococcus spp. were the most common gram-positive bacteria. Age and bile juice amylase levels were significantly higher in the culture-positive group than in the culture-negative group. The incidence of bacterial resistance to cephalosporins was 6.25%–35.29%, and this incidence was particularly high for lower-generation cephalosporins.

Conclusion

Bacteria in gallbladder were identified more frequently when the amylase level was high. High amylase levels in the gallbladder can be associated with caused chronic bacterial infections with occult pancreaticobiliary reflux, potentially triggering gallbladder cancer.

Characteristics and outcome of elderly patients admitted for acute Cholecystitis to medical or surgical wards

BACKGROUND

Elderly patients admitted because of acute cholecystitis are usually not operated during their initial admission and receive conservative treatment. To help formulate a new admission policy regarding elderly patients with acute cholecystitis we compared the demographic and clinical characteristics and outcome of patients > 65 with acute cholecystitis admitted to medical or surgical wards.

METHODS

This retrospective study included all patients > 65 years admitted for acute cholecystitis between January, 2009 and September, 2016. Data were retrieved from the electronic health records.

RESULTS

A total of 187 patients were detected, 54 (29%) in medical departments and 133 (71%) in surgical wards. The mean age (±SD) was 80 ± 7.5 and was higher among those in medical than surgical wards (84 ± 7 versus 79 ± 7, p <  0.05). Patients hospitalized in medical departments had more comorbidity, disability and mental impairment. However, there was no difference in mortality between the two groups, 1 (2%) and 6 (4%) respectively. Independent predictors for hospitalization in medical departments were chronic obstructive pulmonary disease (OR = 9.8, 95% C. I 1.6-59) and the Norton Scale score (NSS)(OR = 0.7, 95% C. I 0.7-0.8). Impaired mental condition was the only predictor for hospitalization > 1 week. The strongest predictor for having cholecystostomy was admission to the surgical department (OR = 14.7, 95% C. I 3.9-56.7). Linear regression showed a negative correlation between NSS and length of hospitalization (LOH; Beta = - 0.5).

CONCLUSION

Elderly patients with acute cholecystitis who require conservative management, especially those with severe functional and mental impairment can be safely hospitalized in medical departments. Outcome was not inferior in terms of mortality and LOH. These results have practical policy implications for the placement of elderly patients with acute cholecystitis in medical rather than surgical departments.

Efficacy and Safety of Therapeutic ERCP in the Elderly: A Single Center Experience

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) has been an important therapeutic measure for the treatment of pancreatobiliary diseases in the elderly, but limited data on the use of ERCP in the super-aged elderly are available. This study aimed to evaluate the efficacy and safety of ERCP in patients 80 years of age or older.

METHODS

All therapeutic ERCPs performed from January 2012 to December 2015 at our endoscopy unit were retrospectively reviewed to evaluate the clinical outcomes and ERCP-related complications in patients 80 years of age or older (group A) and in patients younger than 65 years of age (group B).

RESULTS

A total of 141 patients (182 procedures) were 80 years of age or older (group A), and 513 patients (610 procedures) were 65 years old or younger (group B). Chronic concomitant diseases (73.05% vs. 31.19%, P<0.01) and the use of antithrombotic drugs (25.53% vs. 15.01%, P<0.01) were more frequent in group A than in group B. Common bile duct (CBD) stones were the most common indication for ERCP in both groups. The rate of a difficult cannulation was higher in group A than in group B (23.63% vs. 16.56%, P<0.01). The mean procedure time was longer, and second ERCPs were performed more frequently in group A than in group B. In addition, periampullary diverticulum was observed significantly more frequently in group A (30.22% vs. 20%, P<0.01) than in group B. The overall success rate (92.31% vs. 93.93%, P>0.05) and the complication rate (6.59% vs. 5.25%, P>0.05) were not significantly different between the 2 groups.

CONCLUSIONS

ERCP is a safe and effective intervention in patients 80 years of age or older, although elderly patients had a high rate of concomitant chronic diseases and used antithrombotic drugs more frequently.

Recurrent biliary acute pancreatitis is frequent in a real-world setting

BACKGROUND

Data about recurrent acute pancreatitis (RAP) are limited.

AIMS

To evaluate the rate of RAP and associated factors.

METHODS

Single-centre prospective study of consecutive patients at first episode of acute pancreatitis (AP) being followed-up.

RESULTS

Of 266 consecutive AP patients, (47% biliary, 15.4% alcoholic, 14.3% idiopathic) 66 (24.8%) had RAP in a mean follow-up of 42 months; 17.9% of recurrences occurred within 30 days from discharge. Age, gender, smoking and severity of first AP were not associated with RAP risk. The rate of biliary RAP was 31.3% in patients who did not receive any treatment, 18% in those treated with ERCP only, 16% in those who received cholecystectomy only, and 0% in those treated both with surgery and ERCP. Patients with biliary AP who received cholecystectomy had a significantly longer time of recurrence-free survival and reduced recurrence risk (HR = 0.45). In patients with alcoholic AP, the rate of recurrence was lower in those who quit drinking (5.8% vs 33%; p = 0.05). The alcoholic aetiology was associated with a higher risk of having >2 RAP episodes.

CONCLUSION

RAP occurs in about 25% of cases, and failure to treat biliary aetiology or quitting drinking is associated with increased recurrence risk.

Acute cholecystitis in elderly patients: A case for early cholecystectomy

BACKGROUND

Recent advances in laparoscopic techniques and perioperative care have changed the indications for surgery in elderly patients. Consequently, the willingness to offer early surgery for acute cholecystitis continues to increase. This study aims to assess the perioperative outcome of early cholecystectomy for acute calculous cholecystitis in elderly patients.

PATIENTS AND METHODS

All consecutive patients treated by early cholecystectomy for acute calculous cholecystitis in a major teaching hospital, between January 2002 and November 2016, were retrospectively analyzed. The outcome of elderly patients (≥75 years) was compared to that of all others. Conversion rate, 30 days morbidity, 30 days mortality and length of hospital stay were assessed.

RESULTS

Early cholecystectomy for acute calculous cholecystitis was performed in 703 patients: 121 (17%) aged ≥75 years and 582 (83%) aged <75 years. Significantly more elderly patients had an ASA score ≥3 (37% vs. 8%, P<0.001). Morbidity was higher in the elderly group (17% vs. 8%, P<0.004), mainly attributable to the high incidence of cystic stump leakage in this group; a complication that no longer occurred after changing the technique of ligation of the cystic stump. The cardiopulmonary complication rate (4% vs. 3%, P=0.35) as well as mortality did not significantly differ (3% vs. 1%, P=0.07). The conversion rate was higher in the elderly group (18% vs. 5%, P<0.001) and the median postoperative length of hospital stay was longer (5.0 vs. 3.0 days, P<0.001).

CONCLUSION

Early laparoscopic cholecystectomy is a treatment well suited to elderly patients with mild and moderate acute cholecystitis.

Conservative treatment of acute cholecystitis: a systematic review and pooled analysis

BACKGROUND

In medical practice, the tendency to remove an inflamed gallbladder is deeply rooted. Cholecystectomy, however, is associated with relatively high complication rates, and therefore the decision whether or not to perform surgery should be well considered. For some patients, the surgical risk-benefit profile may favour conservative treatment. The objective of this study was to examine the short- and long-term outcome of conservative treatment of patients with acute calculous cholecystitis.

METHODS

A systematic search of MEDLINE, Embase and Cochrane Library databases was performed. Prospective studies reporting on the success rate of conservative treatment (i.e. non-invasive treatment) of acute cholecystitis during index admission were included, as well as prospective and retrospective studies reporting on the recurrence rate of gallstone-related disease during long-term follow-up (i.e. ≥12 months) after initial non-surgical management. Study selection was undertaken independently by two reviewers using predefined criteria. The risk of bias was assessed. The pooled success and mortality rate during index admission and the pooled recurrence rate of gallstone-related disease during long-term follow-up were calculated using a random-effects model.

RESULTS

A total of 1841 patients were included in 10 randomized controlled trials and 14 non-randomized studies. Conservative treatment during index admission was successful in 87 % of patients with acute calculous cholecystitis and in 96 % of patients with mild disease. In the long term, 22 % of the patients developed recurrent gallstone-related disease. Pooled analysis showed a success rate of 86 % (95 % CI 0.8-0.9), a mortality rate of 0.5 % (95 % CI 0.001-0.009) and a recurrence rate of 20 % (95 % CI 0.1-0.3).

DISCUSSION

Conservative treatment of acute calculous cholecystitis during index admission seems feasible and safe, especially in patients with mild disease. During long-term follow-up, less than a quarter of the patients appear to develop recurrent gallstone-related disease, although this outcome is based on limited data.

Critically ill patients with acute cholecystitis are at increased risk for extensive gallbladder inflammation

Background

Acute cholecystitis is a common diagnosis and surgery is the standard of care for young and fit patients. However, due to high risk of postoperative morbidity and mortality, surgical management of critically ill patients remains a controversy. It is not clear, whether the increased risk of perioperative complications associated with the management of critically ill patients with acute cholecystitis is secondary to reduced physiologic reserve per se or to the severity of gallbladder inflammation.

Methods

A retrospective analysis of prospectively collected data of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a university hospital over a three-year-period was performed. The ASA scores at the time of presentation were used to categorize patients into two groups. The study group consisted of critically ill patients with ASA 3 and 4, while the control group was made up of fit patients with ASA 1 and 2. Both groups were compared with regard to perioperative data, postoperative outcome and extent of gallbladder inflammation on histopathology.

Results

Two hundred and seventeen cases of acute cholecystitis with complete charts were available for analysis. The study group included 67 critically ill patients with ASA 3 and 4, while the control group included 150 fit patients with ASA 1 and 2. Both groups were comparable with regard to perioperative data. Histopathology confirmed severe cholecystitis in a significant number of cases in the study group compared to the control group (37 % vs. 18 %, p = 0.03). Significantly higher rates of morbidity and mortality were recorded in the study group (p < 0.05). Equally, significantly more patients from the study group were managed in the ICU (40 % vs. 8 %, p = 0.001).

Conclusion

Critically ill patients presenting with acute cholecystitis are at increased risk for extensive gallbladder inflammation. The increased risk of morbidity and mortality seen in such patients might partly be secondary to severe acute cholecystitis.

Primary cholecystectomy is feasible in elderly patients with acute cholecystitis

BACKGROUND

While early cholecystectomy is generally accepted as the standard procedure for young and fit patients with acute cholecystitis, controversy exits on the management of elderly and severely sick patients. We postulated that primary cholecystectomy is feasible in this subgroup. The aim of this study was to compare the outcomes of young and fit patients to those of elderly patients undergoing surgery for acute cholecystitis.

METHODS

The outcomes of elderly patients (≥70 years) undergoing surgery for acute cholecystitis in a primary care center in Germany were retrospectively compared to those of younger patients (<70 years).

RESULTS

152 patients, 74 aged ≥ 70 years (study group) and 78 < 70 years (control) were included for analysis. The study group was significantly older at the time of surgery (78 vs. 68 years, p = 0.02). Severe cholecystitis was seen in a significant number of cases in the study group, p = 0.01. Equally, the mean WBC (19.5 vs. 17, p = 0.02), CRP (26 vs. 22, p = 0.04) and APACHE II score (17 vs. 8, p = 0.01) were significantly higher in the study group. There was no significant difference in the duration of anesthesia (123 vs. 133 min, p = 0.70) and surgery (72 vs. 81 min, p = 0.90) amongst both groups. There was no significant difference in rate of complication amongst both groups (24 vs. 14%, p = 0.11). Two cases of mortality were recorded (1.3%) in the study group.

CONCLUSION

The age of the patient cannot be the sole factor in deciding whether or not a patient with acute cholecystitis is fit for surgery.

Pancreaticobiliary reflux as a high-risk factor for biliary malignancy: Clinical features and diagnostic advancements

Pancreaticobiliary junction is composed of complex structure with which biliary duct and pancreatic duct assemble and go out into the ampulla of Vater during duodenum wall surrounding the sphincter of Oddi. Although the sphincter of Oddi functionally prevents the reflux of pancreatic juice, pancreaticobiliary reflux (PBR) occurs when function of the sphincter of Oddi halt. The anatomically abnormal junction is termed pancreaticobiliary maljunction (PBM) and is characterized by pancreatic and bile ducts joining outside of the duodenal wall. PBM is an important anatomical finding because many studies have revealed that biliary malignancies are related due to the carcinogenetic effect of the pancreatic back flow on the biliary mucosa. On the other hand, several studies have been published on the reflux of pancreatic juice into the bile duct without morphological PBM, and the correlation of such cases with biliary diseases, especially biliary malignancies, is drawing considerable attention. Although it has long been possible to diagnose PBM by various imaging modalities, PBR without PBM has remained difficult to assess. Therefore, the pathological features of PBR without PBM have not been yet fully elucidated. Lately, a new method of diagnosing PBR without PBM has appeared, and the features of PBR without PBM should soon be better understood.

Adverse events in older patients undergoing ERCP: a systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

Biliary and pancreatic diseases are common in the elderly; however, few studies have addressed the occurrence of adverse events in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Our objective was to determine the incidence rates of specific adverse events in this group and calculate incidence rate ratios (IRRs) for selected comparison groups.

PATIENTS AND METHODS

Bibliographical searches were conducted in Medline, EMBASE, and Cochrane library databases. The studies included documented the incidence of adverse events (perforation, pancreatitis, bleeding, cholangitis, cardiopulmonary adverse events, mortality) in patients aged ≥ 65 who underwent ERCP. Pooled incidence rates were calculated for each reported adverse event and IRRs were determined for available comparison groups. A parallel analysis was performed in patients aged ≥ 80 and ≥ 90.

RESULTS

Our literature search yielded 7429 articles, of which 69 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 ERCPs) in patients aged ≥ 65 were as follows: perforation 3.8 (95 %CI 1.8 - 7.0), pancreatitis 13.1 (95 %CI 11.0 - 15.5), bleeding 7.7 (95 %CI 5.7 - 10.1), cholangitis 16.1 (95 %CI 11.7 - 21.7), cardiopulmonary events 3.7 (95 %CI 1.5 - 7.6), and death 7.1 (95 %CI 5.2 - 9.4). Patients ≥ 65 had lower rates of pancreatitis (IRR 0.3, 95 %CI 0.3 - 0.4) compared with younger patients. Octogenarians had higher rates of death (IRR 2.4, 95 %CI 1.3 - 4.5) compared with younger patients, whereas nonagenarians had increased rates of bleeding (IRR 2.4, 95 %CI 1.1 - 5.2), cardiopulmonary events (IRR 3.7, 95 %CI 1.0 - 13.9), and death (IRR 3.8, 95 %CI 1.0 - 14.4). Conclusions ERCP appears to be safe in elderly patients, except in the very elderly who are at higher risk of some adverse events. These data on adverse event rates can help to inform clinical decision-making, the consent process, and comparative effectiveness analyses.

Long-term follow-up may be needed for pancreaticobiliary reflux in healthy adults

PURPOSE

The reflux of pancreatic enzymes into the biliary tract is associated with chronic inflammation and increases cellular proliferation of the biliary epithelium, leading to biliary carcinoma. The aim of this study is to detect the incidence of occult pancreaticobiliary reflux (OPBR) in patients who underwent elective cholecystectomy.

METHODS

Forty-seven patients with symptomatic gallstones who underwent cholecystectomy were recruited for this study. The gallbladder bile samples were obtained from the specimen of gallbladder and the amylase level was measured. The immunohistochemistry of p53, SMAD4 and Ki-67 were performed for the detection of metaplasia and dysplasia.

RESULTS

Biliary amylase was higher than the serum amylase in 10 patients (group A, 15,402.66 ± 33,592.43 IU/L; group B, 13.06 ± 18.12 IU/L). The mean age was 67.2 years in group A and 51.2 in group B (P < 0.01). The ratio of male to female was 1:2.3 and 1:1.8 in group A and B, respectively (P = 0.297). Eight patients in group A and thirteen patients in group B had inflammation (P = 0.014). The positive results of the Ki-67 test were exhibited in five cases in each group (P = 0.024).

CONCLUSION

Results from the study indicate that the age was older, degree of inflammation and positive rate of Ki-67 were higher when OPBR was suspected. In conclusion, the patients with OPBR would need long-term follow-up, because the OPBR can cause dysplasia and the reflux of pancreatic juice may be considered as a risk factor for extrahepatic bile duct carcinoma.

Current knowledge on pancreaticobiliary reflux in normal pancreaticobiliary junction

Knowledge on pancreaticobiliary reflux in normal pancreaticobiliary junction and their pathologic implications has experienced tremendous progress during the last few years. This article reviews the current knowledge on this condition and its pathological implications on gallbladder diseases. Many publications with different levels of evidence were found supporting biliary carcinogenesis associated with pancreaticobiliary reflux in normal and abnormal pancreaticobiliary junction. Also, there are many publications supporting the common occurrence of pancreaticobiliary reflux in normal pancreaticobiliary junction, and sphincter of Oddi dysfunction as the most plausible cause of this condition. Although an important body of research has been published regarding pancreaticobiliary reflux in normal pancreaticobiliary junction and their clinical significance, the current evidence does not fully support what has been suggested. The reflux of pancreatic enzymes into the bile tract and gallbladder is a fascinating subject of study which is open to active research. The final demonstration of the pathophysiology and consequences of PBR in NPBL and support by evidence level type I would constitute a major breakthrough in the understanding and eventually in the treatment of gallbladder diseases.

Pancreaticobiliary reflux in patients with a normal pancreaticobiliary junction: Pathologic implications

Knowledge on pancreaticobiliary reflux in normal pancreaticobiliary junction and its pathologic implications has experienced tremendous progress during the last few years. This editorial reviews the current knowledge on this condition and its pathological implications on gallbladder diseases. The following aspects were defined appropriate for discussion: (1) Evidence of carcinogenesis associated with pancreaticobiliary reflux; (2) Evidence of pancreaticobiliary reflux in normal pancreaticobiliary junction; and (3) Evidence of sphincter of Oddi (SO) dysfunction as a cause of pancreaticobiliary reflux in normal pancreaticobiliary junction. The articles reviewed were selected and classified according to five levels of evidence: LevelI, meta-analysis double-blind randomized clinical trials, Level II, cohort non-blinded studies and non-randomized clinical trials, Level III, good quality case-control studies and non-randomized cohort studies, Level IV, case series and poor quality case-control studies, and Level V, case report articles and experts’ opinion. Evidence levels II, III, IV and V were found to support biliary carcinogenesis associated with pancreaticobiliary reflux in normal and abnormal pancreaticobiliary junction. The same levels of evidence were found to support the common occurrence of pancreaticobiliary reflux in normal pancreaticobiliary junction, and SO dysfunction as the most plausible cause of this condition. Although an important body of research has been published regarding pancreaticobiliary reflux in normal pancreaticobiliary junction and its clinical significance, the current evidence does not fully support what has been suggested. Studies with evidence level I have not been undertaken. This is a fascinating subject of study, and if finally supported by evidence level I, the importance of this condition will constitute a major breakthrough in biliary pathology.

Progress in research of occult pancreatobiliary reflux

Increasing knowledge regarding pancreaticobiliary maljunction (PBM) has led researchers to find that pancreatobiliary reflux (flow of pancreatic juice into the biliary tract) occurs not only in PBM patients but also in individuals with a normal pancreaticobiliary junction (occult pancreatobiliary reflux, OPR). The functional disorders of the sphincter of Oddi have been proposed as a possible cause for OPR. Some studies have found that OPR is a high risk factor for gallbladder cancer. The incidence of choledochal stones is higher in patients with OPR than in those without OPR. In this article, we review the progress in research of OPR.

Endoscopy in the elderly: a review of the efficacy and safety of colonoscopy, esophagogastroduodenoscopy, and endoscopic retrograde cholangiopancreatography

Gastrointestinal endoscopy including colonoscopy, esophagogastroduodenoscopy, and endoscopic retrograde cholangiopancreatography (ERCP) are safe and efficacious in elderly patients. Screening colonoscopies have little efficacy in patients over 80 years. Colonoscopies performed for bleeding or iron-deficiency anemia have a higher yield in elderly patients. Colonic preparations were well tolerated and colonoscopic success rates are high in elderly patients. However, poor colonic preparation is more likely in these patients. Esophagogastroduodenoscopy is a high-yield procedure with no significant increase in adverse events in patients over 80 years with symptoms including dyspepsia and dysphagia. ERCP in the elderly carries a high degree of success with low complication rates. Elderly patients undergoing ERCP carry similar risks of bleeding and perforation and a lower risk of pancreatitis compared with younger patients. Advanced age should not be regarded as an absolute contraindication to any gastrointestinal endoscopy procedure.

CT findings of mild forms or early manifestations of acute cholecystitis

OBJECTIVE

The objective of this study was to determine the most predictive CT feature of the mild forms or early manifestations of acute cholecystitis.

MATERIALS AND METHODS

Two radiologists analyzed CT of 34 patients with mild or early acute cholecystitis and 34 control patients for pericholecystic increased attenuation on the arterial phase, indistinctness of the interface between the gallbladder (GB) and the liver, enhancement of the GB wall, and increased attenuation of the GB bile.

RESULTS

There were significant differences in the mean values for each CT feature but increased attenuation of the GB bile between patients and control group (P<.05). The most significant predictor of mild or early acute cholecystitis on CT was the presence of pericholecystic increased attenuation on the arterial phase (sensitivity, 82.4%), followed by indistinctness of the interface between the GB and liver (sensitivity, 38.0%), which were identified by both observers with good agreement (kappa=0.735 and kappa=0.687).

CONCLUSIONS

The pericholecystic increased attenuation on arterial phase CT was the most significant predictor of mild forms or early manifestations of acute cholecystitis.

Percutaneous cholecystostomy without interval cholecystectomy as definitive treatment of acute cholecystitis in elderly and critically ill patients

OBJECTIVE

The aim of this study was to evaluate the safety and effectiveness of percutaneous cholecystostomy without interval cholecystectomy as definitive treatment for acute cholecystitis in elderly or critically ill patients with various coexisting diseases who were unfit for surgery under general anesthesia.

DESIGN

Between July 2004 and June 2006, 24 consecutive elderly and critically ill patients unfit for surgery, suffering from acute cholecystitis, and in whom significant comorbid factors were present, underwent percutaneous cholecystostomy as an emergency procedure at Laiko General Hospital. The diagnosis and the severity of acute cholecystitis were based on the Tokyo Guidelines, whereas the American Society of Anesthesiologists' (ASA) physical status classification was used for the perioperative risk stratification for cholecystectomy.

RESULTS

There were 14 male and 10 female patients with a median age of 79 years. Acute cholecystitis was classified as grade 2 in 20 patients and as grade 3 in 4 patients; 17 patients were classified as ASA score III and 7 as ASA score IV, whereas a total of 52 comorbid factors were present. Gallstones were disclosed as the underlying etiology in 23 patients, whereas one patient was diagnosed as suffering from acalculous cholecystitis. Percutaneous cholecystostomy was technically feasible in all patients (100%). Clinical improvement was noticed in 14 patients within 24 hours and in all patients within 72 hours. Statistically significant reduction in the values of white blood cells, C-reactive protein, and axillary body temperature were observed within 72 hours. The procedure-related mortality was 4%, whereas within a median follow-up of 17.5 months, definitive and effective control of symptoms was achieved in 90.5% of the patients.

CONCLUSIONS

For the subgroup of extremely high-risk and unfit for surgery patients, percutaneous cholecystostomy might be considered as the definitive treatment since it controls the local symptoms and the systemic inflammatory response.

Occult pancreaticobiliary reflux in gallbladder cancer and benign gallbladder diseases

BACKGROUND AND OBJECTIVES

It was proposed that occult pancreaticobiliary reflux (OPBR) was associated with precancerous mucosal changes in the gallbladder, hence the importance of this disorder. There are no published reports investigating the incidence of OPBR in patients operated on for the entire spectrum of benign gallbladder diseases and gallbladder cancer. Our aim was to determine the incidence of OPBR and measure the levels of active pancreatic enzymes (amylase and lipase) in gallbladder bile of patients undergoing cholecystectomy for benign and malignant gallbladder diseases.

METHODS

One hundred eight patients with normal pancreaticobiliary junction evidenced by operative cholangiography were included in the study.

RESULTS

According to gallbladder bile amylase and lipase levels, 84.2% and 89% patients respectively had OPBR. OPBR was present in all gallbladder cancer patients; in these patients the biliary levels of amylase and lipase were significantly higher than the levels found in patients with benign gallbladder pathology (P < 0.0001).

CONCLUSIONS

OPBR could lead to inflammatory changes of the biliary epithelium and progress towards the development of precancerous mucosal changes and gallbladder cancer. The reason why such high levels of pancreatic enzymes are regurgitated into the biliary tree of patients with gallbladder cancer should be clarified.