Gallstone, cholecystectomy and risk of gastric cancer

The Associations Between Gallstone Disease and Pan-Cancer Incidence Risk Based on Over 13 Million Participants

BACKGROUND

Increasing evidence connects gallstone disease (GSD) to all types of cancer incidence; however, the results were inconsistent. The present study aimed to evaluate whether and to what extent these associations exist comprehensively.

METHODS

We systematically searched published longitudinal studies indexed in PubMed and Embase database from dates of inception to March 31, 2020. We pooled the effect of GSD on all-cause cancer incidence. Moreover, we further employed stratified analysis concerning sex, geographic background, surgery status, and follow-up period. Trial sequential analysis (TSA) was applied to decide whether the included sample size was sufficient for evaluating these associations.

RESULTS

Fifty-one studies incorporating over 13 million participants were eligible for analysis in this study. GSD pose an increased risk of all-cause cancer risk (pooled RR = 1.43; 95% CI: 1.33-1.54) compared with the healthy controls, especially hematologic malignancy (pooled RR = 1.14; 95% CI: 1.05-1.25), gastrointestinal cancers (pooled RR = 1.28; 95% CI: 1.15-1.41), liver, pancreas, and biliary tract cancer (pooled RR = 1.84; 95% CI: 1.62-2.10), and kidney cancer (pooled RR = 1.19; 95% CI: 1.03-1.37). These associations are not markedly changed after stratification by different subgroups. Moreover, the TSA confirmed the sample size was sufficient to draw these conclusive conclusions.

CONCLUSIONS

The present meta-analysis with sufficient evidence indicates GSD increases the risk for all causes of cancer incidence. The evidence may warrant GSD patients to perform screening and prophylactic treatment for the prevention of these complications. The indication for cholecystectomy should be determined through a comprehensive evaluation of the patient's clinical presentation, with a thorough assessment of the potential therapeutic benefits and surgical risks.

Effect of smoking on the risk of gastrointestinal cancer after cholecystectomy: A national population-based cohort study

BACKGROUND

The role of smoking in the incidence of colorectal cancer (CRC) or gastric cancer (GC) in populations undergoing cholecystectomy has not been investigated.

AIM

To evaluate the effect of smoking on CRC or GC development in cholecystectomy patients.

METHODS

A total of 174874 patients who underwent cholecystectomy between January 1, 2010 and December 31, 2017 were identified using the Korean National Health Insurance Service claims database. These patients were matched 1:1 with members of a healthy population according to age and sex. CRC or GC risk after cholecystectomy and the association between smoking and CRC or GC risk in cholecystectomy patients were evaluated using adjusted hazard ratios (HRs) and 95%CIs.

RESULTS

The risks of CRC (adjusted HR: 1.15; 95%CI: 1.06-1.25; P = 0.0013) and GC (adjusted HR: 1.11; 95%CI: 1.01-1.22; P = 0.0027) were significantly higher in cholecystectomy patients. In the population who underwent cholecystectomy, both CRC and GC risk were higher in those who had smoked compared to those who had never smoked. For both cancers, the risk tended to increase in the order of non-smokers, ex-smokers, and current smokers. In addition, a positive correlation was observed between the amount of smoking and the risks of both CRC and GC.

CONCLUSION

Careful follow-up and screening should be performed, focusing on the increased risk of gastrointestinal cancer in the cholecystectomy group, particularly considering the individual smoking habits.

Gastric precancerous lesions:occurrence, development factors, and treatment

Patients with gastric precancerous lesions (GPL) have a higher risk of gastric cancer (GC). However, the transformation of GPL into GC is an ongoing process that takes several years. At present, several factors including H.Pylori (Hp), flora imbalance, inflammatory factors, genetic variations, Claudin-4, gastric stem cells, solute carrier family member 26 (SLC26A9), bile reflux, exosomes, and miR-30a plays a considerable role in the transformation of GPL into GC. Moreover, timely intervention in the event of GPL can reduce the risk of GC. In clinical practice, GPL is mainly treated with endoscopy, acid suppression therapy, Hp eradication, a cyclooxygenase-2 inhibitor, aspirin, and diet. Currently, the use of traditional Chinese medicine (TCM) or combination with western medication to remove Hp and the use of TCM to treat GPL are common in Asia, particularly China, and have also demonstrated excellent clinical efficacy. This review thoroughly discussed the combining of TCM and Western therapy for the treatment of precancerous lesions as conditions allow. Consequently, this review also focuses on the causes of the development and progression of GPL, as well as its current treatment. This may help us understand GPL and related treatment.

Association between history of cholecystectomy and risk of gastric cancer: a meta-analysis of epidemiological studies

PURPOSE

Evidence from previous studies on the association between cholecystectomy and risk of gastric cancer are still inconsistent. We aimed at conducting a meta-analysis of epidemiological studies to evaluate this association.

METHODS

Researchers searched three databases (PubMed, Embase and Web of Science) through January 2021 for eligible studies. Relative risks (RRs) and 95% CIs in each included studies were pooled by random-effects models. Patients and the public were not involved in our study.

RESULTS

Eight studies were identified. Four studies reported significantly positive association between history of cholecystectomy and risk of gastric cancer, and the remaining studies reported null association. The pooled RR of these eight studies showed that a history of cholecystectomy was associated with a 11% higher risk of gastric cancer (pooled RR=1.11, 95% CI: 1.03 to 1.20). Moderate heterogeneity across the studies was detected (p=0.117, I2=37.8%). The pooled RRs were 1.12 (95% CI: 1.01 to 1.24) for five cohort studies and 0.95 (95% CI: 0.66 to 1.38) for three case-control studies. Compared with the risk in Europe and the USA, the pooled RR was higher for two studies conducted in Asia. Six studies were assessed as high-quality studies with the pooled RR of 1.12 (95% CI: 1.02 to 1.23). The pooled results were robust by sensitivity analyses, and no indication of publication bias was detected.

CONCLUSION

This meta-analysis suggests that a history of cholecystectomy may be associated with an increased risk of gastric cancer.

Endoscopic ultrasound-guided gallbladder endoscopic mucosal resection: a pilot porcine study

INTRODUCTION

Endoscopic ultrasound (EUS)-guided natural orifice transluminal gallbladder polypectomy provides a minimally invasive alternative to cholecystectomy. The study aimed to investigate the feasibility and safety of protocol for gallbladder endoscopic mucosal resection (gEMR) under EUS guidance using a porcine model.

MATERIAL AND METHODS

Fifteen Bama mini pigs were randomly divided into the control (CG, n = 3) and experimental (EG, n = 12) groups. EUS-guided fine needle aspiration was performed in the CG and used to establish a gallbladder pathway for polyp resection under EUS guidance in the EG. Procedural safety was evaluated using routine blood and biochemical tests, microbial bile cultures, histopathological tests, and enzyme-linked immunosorbent assays for inflammatory adhesion factors.

RESULTS

EUS-guided metal stents were successfully deployed in all 12 pigs. Two cases of stent displacement occurred postoperatively, and one pig died of infectious peritonitis on the first day after stent implantation. In 11 surviving experimental animals, mature gallbladder paths were formed at 7-14 days after gastro-cholecystostomy, through which gEMR of gallbladder polyps was successfully performed. There were no significant changes in levels of inflammatory and adhesion factors during the postoperative process.

CONCLUSIONS

EUS-gEMR may be a safe and effective minimally invasive treatment approach for gallbladder polyps.

Risk factors in the development of gastric adenocarcinoma in the general population: A cross-sectional study of the Wuwei Cohort

Several risk factors have been identified for the development of gastric adenocarcinoma (GAC), where the control group was usually a healthy population. However, it is unclear at what stage known risk factor exert their influence toward the progression to cancer. Based on the Wuwei Cohort, we enrolled 1,739 patients with chronic non-atrophic gastritis (no-CAG), 3,409 patients with chronic atrophic gastritis (CAG), 1,757 patients with intestinal metaplasia (IM), 2,239 patients with low-grade dysplasia (LGD), and 182 patients with high-grade dysplasia (HGD) or GAC to assess the risk factors between each two consecutive stages from no-CAG to GAC/HGD using adjusted logistic regression. We found that different groups of risk factors were associated with different stages. Age, occupation of farmer, low annual family income, Helicobacter pylori (H. pylori) infection, drinking, eating hot food, histories of gastritis and peptic ulcer were associated with the development of CAG. Age, illiteracy, H. pylori infection, smoking, eating hot food, eating quickly, and histories of gastritis and gallbladder diseases were associated with the progression to IM from CAG. Male, occupation of farmer and history of peptic ulcer were associated with the development of LGD from IM. Age, male and polyp history appeared to be risk factors associated with the development of GAC/HGD from LGD. In conclusion, it seems that most risk factors function more as a set of switches that initiated the GAC carcinogenesis. H. Pylori eradication and control of other risk factors should be conducted before IM to decrease the incidence of GAC.

Bile Reflux Gastritis: Insights into Pathogenesis, Relevant Factors, Carcinomatous Risk, Diagnosis, and Management

Bile reflux gastritis (BRG), a kind of gastrointestinal disorder in clinical practice, is characterized by regurgitation and inflammation. However, lack of guidelines leads to simple cognition and even ignorance of this disease for clinicians. Primarily, making the pathogenesis of BRG clear contributes to a correct and general understanding of this disease for physicians. Next, although recently there has been an increasing awareness among researchers in terms of the relevant factors for BRG, further studies involving large samples are still required to certify the relationship between them explicitly. Besides, researches have established that BRG is closely associated with the development of precancerous lesions and gastric cancer. Till now, there is still no golden standard for diagnosis of BRG. Nevertheless, advances in techniques, especially extensive applications of endoscopy and chemical analysis of reflux contents, have improved our ability to identify the occurrence of this disease as well as distinguishing physiological reflux from pathological reflux. Finally, it is fortunate for patients that more and more importance has been attached to the treatment of BRG. From lifestyle modification to drug therapy to surgery, all of them with the view of realizing symptomatic relief are employed for patients with BRG. In this review, we briefly evaluate this disorder based on the best available evidence, offering an overview of its complicated pathogenesis, diverse relevant factors, potential carcinomatous risk, modern diagnostic investigations, and effective therapeutic plans.

Clinicopathological difference between gastric cancer in the lesser curvature and gastric cancer in the greater curvature

Gastric cancer (GC) is a heterogeneous disease; the tumor distribution and molecular subtype could affect the prognosis of patients with GC. However, the clinicopathological difference between GC in the lesser and that in the greater curvature remains unknown. In this study, we aimed to investigate the difference and provide new clues for the treatment of GC. Between January 2010 and August 2014, 1249 consecutive patients with GC in the lesser or greater curvature were treated in our surgery department; data related to the demographic characteristics, pathological type, tumor grade, tumor size, TNM stage, tumor markers, operative methods, complications, and follow-up were retrospectively analyzed using a univariate analysis and the Kaplan-Meier method. The tumor size in lesser curvature was larger than that in the greater curvature (4.95 ± 2.57 vs 4.43 ± 2.62 cm, P = .034); patients with GC in the lesser curvature had a higher incidence of total gastrectomy and a lower incidence of distal gastrectomy than those with GC in the greater curvature (60.2% vs 43.2%, and 34.8% vs 49.2%, P = .002). No significant differences were found in the 5-year survival rate between patients with GC in the greater curvature and those with GC in the lesser curvature (62.6% vs 66.1%, P = .496). The epidermal growth factor receptor (EGFR) expression rate of tumors in the lesser curvature was 40.55%, which was significantly higher than that of tumors in the greater curvature (25.92%, P = .024), while the 5-year survival rate of patients with EGFR-positive expression was 50.8%, which was significantly lower than that of patients with EGFR-negative expression (64.8%, P = .021). Significant differences were observed in the clinicopathological features between GC in the lesser curvature and that in the greater curvature. These differences contribute to the improvement in the treatment outcome.

Increased Risk of Cancer after Cholecystectomy: A Nationwide Cohort Study in Korea including 123,295 Patients

Background/Aims

Contradictory findings on the association between cholecystectomy and cancer have been reported. We aimed to investigate the risk of all types of cancers or site-specific cancers in patients who underwent cholecystectomy using a nationwide dataset.

Methods

Subjects who underwent cholecystectomy from January 1, 2007, to December 31, 2014, who were older than 20 years and who underwent an initial baseline health check-up within 2 years were enrolled. Those who were diagnosed with any type of cancer before the enrollment or within 1 year after enrollment were excluded. Ultimately, patients (n=123,295) who underwent cholecystectomy and age/sex matched population (n=123,295) were identified from the database of the Korean National Health Insurance Service. The hazard ratio (HR) and 95% confidence interval (CI) for cancer were estimated, and Cox regression analysis was performed.

Results

The incidence of cancer in the cholecystectomy group was 9.56 per 1,000 personyears and that in the control group was 7.95 per 1,000 person-years. Patients who underwent cholecystectomy showed an increased risk of total cancer (adjusted HR, 1.19; 95% CI, 1.15 to 1.24; p<0.001), particularly leukemia and malignancies of the colon, liver, pancreas, biliary tract, thyroid, pharynx, and oral cavity. In the subgroup analysis according to sex, the risk of developing cancers in the pancreas, biliary tract, thyroid, lungs and stomach was higher in men than in women.

Conclusions

Physicians should pay more attention to the possibility of the occurrence of secondary cancers among patients who undergo cholecystectomy.

Association Between Cholecystectomy and Gastric Cancer Risk: A Systematic Review and Meta-Analysis

Objectives

Although several epidemiological studies have attempted to evaluate the relationship between cholecystectomy and gastric cancer risk, the findings have been controversial. This study aimed to carry out a systematic review and meta-analysis following the reporting guidelines to comprehensively analyze and quantify the evidence of the aforementioned association.

Methods

Studies were identified by searching the Medline (PubMed), Embase, and Web of Science from inception to November 30, 2020, with only studies published in English being considered. Summary relative risks (RRs) and 95% confidence intervals (CIs) were calculated by random-effects models.

Results

Eight studies (five cohort studies and three case–control studies) with a total of 26,063 gastric cancer patients and 848,081 participants were included. The summarized RR of the relationship between cholecystectomy and gastric cancer risk was 1.11 (95%CI: 1.03–1.20), with low heterogeneity (P = 0.117, I² = 37.8%). These positive findings were consistent in most subgroup analyses like region in Asia, number of cases ≥200, cohort study design, sex in male, low risk of bias, exposure collection by database, and adjustments made for age, gender, calendar year. Of note, we also observed positive association between cholecystectomy and non-cardia of gastric cancer risk (RR = 1.17, 95%CI: 1.04–1.33). No publication bias was present.

Conclusions

The aforementioned evidence suggested that a history of cholecystectomy was associated with a slightly elevated risk of gastric cancer. Results of most subgroup analyses also supported the main findings. More prospective studies are warranted to further validate these findings.

Cholecystitis, Concealment of Hepatobiliary-Pancreatic Pathology: The Role of Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound

Cholecystitis is an inflammation of the gallbladder with classic symptoms of right upper quadrant abdominal pain and fever. The most common precipitating factor is cholelithiasis; however, it sometimes appears in conjunction with other hepatobiliary-pancreatic pathology. Management is generally done with antibiotics and supportive care with or without cholecystectomy. The surgical management in practice is often limited by surgery time and patient suitability considering their likely overall outcome. We have outlined two cases with different etiologies presenting as cholecystitis. The aim was to further understand the benefits of multidisciplinary team meetings to optimize patient care and emphasize the roles of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in hepatobiliary pathology.

Gallstones, Body Mass Index, C-Reactive Protein, and Gallbladder Cancer: Mendelian Randomization Analysis of Chilean and European Genotype Data

BACKGROUND AND AIMS

Gallbladder cancer (GBC) is a neglected disease with substantial geographical variability: Chile shows the highest incidence worldwide, while GBC is relatively rare in Europe. Here, we investigate the causal effects of risk factors considered in current GBC prevention programs as well as C-reactive protein (CRP) level as a marker of chronic inflammation.

APPROACH AND RESULTS

We applied two-sample Mendelian randomization (MR) using publicly available data and our own data from a retrospective Chilean and a prospective European study. Causality was assessed by inverse variance weighted (IVW), MR-Egger regression, and weighted median estimates complemented with sensitivity analyses on potential heterogeneity and pleiotropy, two-step MR, and mediation analysis. We found evidence for a causal effect of gallstone disease on GBC risk in Chileans (P = 9 × 10-5 ) and Europeans (P = 9 × 10-5 ). A genetically elevated body mass index (BMI) increased GBC risk in Chileans (P = 0.03), while higher CRP concentrations increased GBC risk in Europeans (P = 4.1 × 10-6 ). European results suggest causal effects of BMI on gallstone disease (P = 0.008); public Chilean data were not, however, available to enable assessment of the mediation effects among causal GBC risk factors.

CONCLUSIONS

Two risk factors considered in the current Chilean program for GBC prevention are causally linked to GBC risk: gallstones and BMI. For Europeans, BMI showed a causal effect on gallstone risk, which was itself causally linked to GBC risk.

De Novo Cancer Incidence after Cholecystectomy in Korean Population

Background: Cancer development after cholecystectomy remains debatable. We estimated the major cancer incidence rates after cholecystectomy stratified by age and sex. Methods: The records of 408,769 subjects aged >20 years were extracted from the National Health Insurance database from 2008 to 2016. The risks of major cancers were compared between the cholecystectomy and general populations using standardised incidence ratios (SIR). Results: The overall cancer incidence was comparable between cholecystectomy patients and the general population. However, patients aged <65 years who underwent cholecystectomy had a higher cancer risk than those aged ≥65 years and the general population (SIR 2.62; 95% confidence interval [CI] 2.15–3.08; SIR 1.36, 95% CI 1.32–1.40; and SIR 0.90, 95% CI 0.87–0.92 in men and SIR 1.91; 95% CI 1.71–2.10; SIR 1.07; 95% CI 1.03–1.10; and SIR 0.90; 95% CI 0.87–0.94 in women aged 20–34, 35–64, and ≥65 years at cholecystectomy). Colorectal and liver cancer incidences after cholecystectomy were higher than those in the general population regardless of age group and sex (SIR, 1.55 for colorectal cancer in men and women; SIR, 1.25 and 1.51 for liver cancer in men and women, respectively). However, for other major cancers, the risk was higher in patients who underwent cholecystectomy at a younger age than in those who underwent cholecystectomy at an age ≥65 years. Conclusion: Patients with cholecystectomy, especially those undergoing cholecystectomy at a younger age, need preventive strategies based on the cancer type.

Association of Cholecystectomy with the Risk of Prostate Cancer in Patients with Gallstones

Objectives: To assess the association of cholecystectomy with the risk of prostate cancer in patients with gallstones. Methods: This nationwide population-based cohort study was conducted by retrieving the Longitudinal Health Insurance Research Database (LHID2000) for inpatient claims in the Taiwan National Health Insurance (NHI) program. The study cohort consisted of 72,606 men aged ≥ 20 years with gallstones undergoing cholecystectomy between 2000 and 2010. The control cohort consisted of the men with gallstones, but without cholecystectomy, by 1:1 propensity score matching with the study cohort based on age, sex, urbanization, occupation, comorbidities, and the index date. We compared the hazard ratio of prostate cancer between both of the cohorts. Results: The incidence of prostate cancer was 0.76/1000 person-years for the non-cholecystectomy cohort and 1.28/1000 person-years for the cholecystectomy cohort [aHR (adjusted hazard ratio) = 1.67, 95% confidence interval (CI = 1.45–1.92), respectively (p < 0.001). When compared with the non-cholecystectomy cohort, the hazard ratio of prostate cancer for the cholecystectomy cohort was 1.49-fold greater (95% CI = 1.04–2.11) for follow-up ≤ 1 year, 1.52-fold greater (95% CI = 1.24–1.86) for follow-up 1–5 years, and 1.99-fold greater (95% CI = 1.56–2.53) for follow-up > 5 years, respectively. Conclusions: Cholecystectomy is associated with an increased hazard ratio of prostate cancer in gallstones patients, and the risk increases with an incremental period of follow-up. This observational study cannot ascertain the detrimental mechanisms of cholecystectomy for the development of prostate cancer, and cholecystectomy is not recommended for the prevention of prostate cancer based on our study.

[Diseases of biliary tract in the context of association with oncological diseases of the digestive system]

Cancers of the gastrointestinal tract are widespread among the population and cause significant damage to the health care system. In order to improve the strategy of preventive measures and the detection of oncological diseases at the early stages, it is necessary to provide timely impact on possible risk factors contributing to the onset and progression of malignant neoplasms. This review demonstrates the association between the pathology of the biliary tract and oncological diseases of the digestive system, discusses the possible mechanisms of the influence of cholelithiasis and cholecystectomy on the development of malignant neoplasms of various parts of the gastrointestinal tract.

Cholesterol cholelithiasis: part of a systemic metabolic disease, prone to primary prevention

Cholesterol gallstone disease have relationships with various conditions linked with insulin resistance, but also with heart disease, atherosclerosis, and cancer. These associations derive from mechanisms active at a local (i.e. gallbladder, bile) and a systemic level and are involved in inflammation, hormones, nuclear receptors, signaling molecules, epigenetic modulation of gene expression, and gut microbiota. Despite advanced knowledge of these pathways, the available therapeutic options for symptomatic gallstone patients remain limited. Therapy includes oral litholysis by the bile acid ursodeoxycholic acid (UDCA) in a small subgroup of patients at high risk of postdissolution recurrence, or laparoscopic cholecystectomy, which is the therapeutic radical gold standard treatment. Cholecystectomy, however, may not be a neutral event, and potentially generates health problems, including the metabolic syndrome. Areas covered: Several studies on risk factors and pathogenesis of cholesterol gallstone disease, acting at a systemic level have been reviewed through a PubMed search. Authors have focused on primary prevention and novel potential therapeutic strategies. Expert commentary: The ultimate goal appears to target the manageable systemic mechanisms responsible for gallstone occurrence, pointing to primary prevention measures. Changes must target lifestyles, as well as experimenting innovative pharmacological tools in subgroups of patients at high risk of developing gallstones.

Recent advances in understanding and managing cholesterol gallstones

The high prevalence of cholesterol gallstones, the availability of new information about pathogenesis, and the relevant health costs due to the management of cholelithiasis in both children and adults contribute to a growing interest in this disease. From an epidemiologic point of view, the risk of gallstones has been associated with higher risk of incident ischemic heart disease, total mortality, and disease-specific mortality (including cancer) independently from the presence of traditional risk factors such as body weight, lifestyle, diabetes, and dyslipidemia. This evidence points to the existence of complex pathogenic pathways linking the occurrence of gallstones to altered systemic homeostasis involving multiple organs and dynamics. In fact, the formation of gallstones is secondary to local factors strictly dependent on the gallbladder (that is, impaired smooth muscle function, wall inflammation, and intraluminal mucin accumulation) and bile (that is, supersaturation in cholesterol and precipitation of solid crystals) but also to "extra-gallbladder" features such as gene polymorphism, epigenetic factors, expression and activity of nuclear receptors, hormonal factors (in particular, insulin resistance), multi-level alterations in cholesterol metabolism, altered intestinal motility, and variations in gut microbiota. Of note, the majority of these factors are potentially manageable. Thus, cholelithiasis appears as the expression of systemic unbalances that, besides the classic therapeutic approaches to patients with clinical evidence of symptomatic disease or complications (surgery and, in a small subgroup of subjects, oral litholysis with bile acids), could be managed with tools oriented to primary prevention (changes in diet and lifestyle and pharmacologic prevention in subgroups at high risk), and there could be relevant implications in reducing both prevalence and health costs.

A restrictive dose of crystalloids in patients during laparoscopic cholecystectomy is safe and cost-effective: prospective, two-arm parallel, randomized controlled trial

Purpose

There are no evidence-based guidelines for volume replacement during surgical procedures such as laparoscopic cholecystectomy. However, the administration of a restrictive volume of crystalloids could be more cost-effective and safe. This trial aimed to determine the effectiveness and safety of a restrictive regimen of crystalloids in patients during laparoscopic cholecystectomy by analyzing its cost-effectiveness and 1-year morbidity rate.

Patients and methods

In this randomized, prospective study, patients were assigned to one of three groups based on the volume of fluid administered: the restrictive group received 1 mL/kg/hr, the low liberal group received 5 mL/kg/hr, and the high liberal group received 15 mL/kg/hr of Ringer’s solution intraoperatively. There were 40 patients in each group. Each patient’s hemodynamic parameters and laboratory values (arterial blood gas and lactate levels) were measured together with their consumption of crystalloids, volatile anesthetics, and analgesics.

Results

Analysis of the hemodynamic and laboratory parameters revealed no signs of global hypoperfusion in any of the groups analyzed. There was no significant difference in the duration of surgery and anesthesia, but the consumption of crystalloids, volatile anesthetics, and opioids was significantly lower in the restrictive group, compared with the low and high liberal groups. Although there was no significant difference in the 1-year morbidity among the groups, heart failure was observed in one patient in the high liberal group in the early postoperative period.

Conclusion

Restrictive fluid therapy during laparoscopic cholecystectomy is justified, safe, and more cost-effective than other options.