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Background: Acute cholecystitis is a common complication of gallstone disease. Although early laparoscopic cholecystectomy is recommended, some patients do not undergo early surgery and remain at risk of recurrent disease. This study investigated whether early cholecystectomy for recurrent cholecystitis is associated with higher complication rates versus first-time cholecystitis.

Methods: A retrospective population-based cohort study was conducted using data from the Swedish Registry of Gallstone Surgery. Patients undergoing early cholecystectomy for acute cholecystitis in Sweden between 1 January 2006, and 31 December 2020, were included. Patients with recurrent cholecystitis were compared to those with a first episode. The primary outcome was the total 30-day complication rate. Secondary outcomes included open surgery, prolonged surgery (≥ 120 minutes), bile duct injury, and specific complications such as intestinal injury, bleeding, reoperation, abscess, and 30-day mortality. Multivariable logistic regression was used to calculate odds ratios (OR), adjusting for age, sex, American Society of Anesthesiologists (ASA) grade, and time from admission to surgery as confounders.

Results: Among 34 925 patients, 3384 had recurrent cholecystitis and 31 541 had first-time cholecystitis. The recurrent cholecystitis group had a higher complication rate (20.2 versus 13.8%) and an increased risk of bile duct injury (OR 2.44; 95% confidence interval (c.i.) 1.67 to 3.56), intestinal perforation (OR 2.54; 95% c.i. 1.51 to 4.25), prolonged surgery (OR 1.64; 95% c.i. 1.53 to 1.67), and open surgery (OR 1.76; 95% c.i. 1.64 to 1.92). However, patients with recurrent cholecystitis were older and had a higher ASA grade.

Conclusion: Early cholecystectomy for recurrent cholecystitis is associated with increased complication rates compared with first-time cholecystitis. These findings support early surgical intervention during the first episode to reduce the risk of adverse outcomes associated with recurrent disease.

Background: The rate of retained common bile duct stones (CBDS) following cholecystectomy can only be estimated if CBDS managed conservatively as well as CBDS treated with endoscopic retrograde cholangiopancreatography (ERCP) are identified. The aim was to explore the rate of retained CBDS and evaluate performance of ERCP as proxy for retained CBDS in a population-based setting.

Methods: Data were collected from The Swedish Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography Register (GallRiks) on patients who underwent cholecystectomy 2015–2020 with suspected CBDS at South General Hospital, Stockholm, Sweden. Medical records were reviewed to identify rate of patients with events raising suspicion of passage of retained CBDS and compare this to the rate of ERCP for retained CBDS.

Results: A total of 182 of 386 patients (47.2%) had CBDS on intraoperative cholangiography (IOC). During follow-up, 33 of the 182 presented with retained CBDS according to medical records. Of these, 24 had an ERCP registered in GallRiks with retained CBDS reported, whereas 9 had retained CBDS according to medical records only.

Conclusion: Postoperative ERCP found valid as proxy for retained stones following surgery for CBDS and can be a quality measure for management of patients undergoing gallstone surgery with suspicion of CBDS.

Background: The optimal timing of surgery for acute cholecystitis has been a subject of debate, but the predominant view supports early cholecystectomy. This study investigated the safety of early cholecystectomy during weekends compared with delayed surgery until a weekday.

Methods: This was a population-based cohort study based on data from the Swedish National Register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). Data from 2006 to 2020 were analyzed, and patients with acute cholecystitis were included. Patients who underwent surgery during weekends were compared with patients in hospital during weekends and underwent surgery on any subsequent weekday. Statistical analyses were conducted using logistic regression analysis.

Results: 15,730 patients were included, and complications were registered in 2,246 patients (14.3%). The proportion of complications was equal in both groups (14.0% vs 14.5%, P = .365). The proportion of open surgery was higher in the weekend surgery group (29.1% vs 26.3%), with an odds ratio of 1.32 in multivariate logistic regression analysis (P < .001). Meanwhile, the duration of surgery exceeding 2 hours was less common when surgery was performed on the weekend (32.7% vs 46.8%, P < .001, odds ratio: 0.69).

Conclusion: In this study, procedures performed during weekends had outcomes that did not substantially differ from those performed during weekdays. The results of our study support performing early cholecystectomies during the weekend without increasing the patients’ risk of complications.

Background: To develop and psychometrically test a condition-specific, patient-reported outcomes instrument for patients undergoing gallstone surgery.

Methods: A mixed-methods design, including six gender-mixed patient focus-groups was used. Statements were thematically analysed and compared to PROMIS and the Gastrointestinal Quality of Life Index (GIQLI). A pilot questionnaire of 63 items and the full scale GIQLI was sent to preoperative and 30 items were sent to postoperative patients. Factor analysis identified structure and redundant items. Short versions were assessed to ensure internal reliability and validity. Unidimensionality was assessed via graded response model.

Results: 273 patients completed the questionnaires (preoperatively n = 104 and postoperatively n = 169). Factor and IRT analysis identified 13 domains with 45 questions. Internal reliability 0.75 to 0.93 in the preoperative and 0.73 to 0.90 in the postoperative questionnaire. A PROM questionnaire was developed with pre- and postoperative modules (24 questions, 8 domains and 21 questions, 5 domains).

Conclusion: This study has shown the validity of a disease specific Health Related Quality-of-Life (HRQoL) instrument in a population with gallstone disease and a post-operative module for follow-up. Further testing in a longitudinal cohort is recommended in order to establish responsiveness.

Background and aims: Whereas the value of endoscopic retrograde cholangiopancreatography (ERCP) training in clinical practice is well known, the impact on stress markers and performance in a virtual reality (VR) simulator is not. The primary aim of the study was to see how the number of clinical ERCPs performed during a 1-year period influenced VR-ERCP performance. A secondary aim was to compare differences in salivary stress marker levels, between the first and final simulator attempts.

Methods: Thirty-one endoscopists completed three VR-ERCP procedures of increasing difficulty. The times taken to complete the different steps of the procedures were recorded. Saliva chromogranin A, cortisol, and α-amylase were measured before and after each phase of the cystic leakage procedure. Participants then did 1 year of clinical ERCP training at their respective centers. The remaining cohort (26/31) was divided into two subgroups according to their level of clinical training. They then completed the same VR-ERCP procedures. Differences in time before and after each phase as well as stress marker levels during the cystic leakage procedure were assessed.

Results: Those with >100 ERCPs of clinical training improved times to completion of all 15 phases in the VR-ERCP procedures (p < 0.05) in contrast to the group with 20–50 ERCPs who only improved in 11/15. Differences in increases in salivary stress marker levels of chromogranin A before and after each phase of the cystic leakage procedure, adjusted for number of ERCPs, showed significant reductions in four of the five phases measured.

Conclusion: Clinical ERCP training enhances subsequent performance in terms of time to completion in a VR-ERCP simulator. Additional intended use of simulators could be used as a benchmark for clinical progress. Saliva markers may be feasible to use in measuring stress reactions in a training setting.

Background: Stress during the early ERCP learning curve may interfere with acquisition of skills during training. The purpose of this study was to compare stress biomarkers in the saliva of trainees before and after familiarisation with ERCP exercises on a virtual simulator.

Methods: Altogether 26 endoscopists under training, 14 women and 12 men, completed the three phases of this study: Phase 1. Three different ERCP procedures were performed on the simulator. Saliva for α-amylase (sAA), Chromogranin A (sCgA), and Cortisol (sC) were collected before (baseline), halfway through the exercise (ex.), and 10 min after completion of the exercise (comp.); Phase 2. A three-week familiarisation period where at least 30 different cases were performed on the virtual ERCP simulator; and Phase 3. Identical to Phase 1 where saliva samples were once again collected at baseline, during, and after the exercise. Percentage differences in biomarker levels between baseline and exercise (Diff_ex) and between baseline and completion (Diff_comp) during Phase 1 and Phase 3 were calculated for each stress marker.

Results: Mean % changes, Diff_ex and Diff_comp, were significantly positive (p < 0.05) for all markers in both Phase 1 and Phase 3. Diff_ex in Phase 1 was significantly greater than Diff_ex in Phase 3 (p < 0.05) for sAA and sCgA. Diff_comp for sAA in Phase 1 was significantly greater than Diff_comp in Phase 3 (p < 0.05). No significant differences were found in sC concentration between Phases 1 and 3.

Conclusion: This study shows that familiarisation with the ERCP simulator greatly reduced stress as measured by the three saliva stress biomarkers used with sAA being the best. It also suggests that familiarisation with an ERCP simulator might reduce stress in the clinical setting.

BACKGROUND: Laparoscopic cholecystectomy with ultrasonic dissection presents a compelling alternative to conventional electrocautery. The evidence for elective cholecystectomy supports the adoption of ultrasonic dissection, citing advantages such as reduced operating time, diminished bleeding, shorter hospital stays and decreased postoperative pain and nausea. However, the efficacy of this procedure in emergency surgery and patients diagnosed with acute cholecystitis remains uncertain. The aim of this study was to compare outcomes of electrocautery and ultrasonic dissection in patients with acute cholecystitis.

METHODS: A randomized, parallel, double-blinded, multicentre controlled trial was conducted across eight Swedish hospitals. Eligible participants were individuals aged ≥ 18 years with acute cholecystitis lasting ≤ 7 days. Laparoscopic cholecystectomy was performed in the emergency setting as soon as local circumstances permitted. Random allocation to electrocautery or ultrasonic dissection was performed in a 1:1 ratio. The primary endpoint was the total complication rate, analysed using an intention-to-treat approach. The primary outcome was analysed using logistic generalized estimated equations. Patients, postoperative caregivers, and follow-up personnel were blinded to group assignment.

RESULTS: From September 2019 to March 2023, 300 patients were enrolled and randomly assigned to electrocautery dissection (n = 148) and ultrasonic dissection (n = 152). No significant difference in complication rate was observed between the groups (risk difference [RD] 1.6%, 95% confidence interval [CI], - 7.2% to 10.4%, P = 0.720). No significant disparities in operating time, conversion rate, hospital stay or readmission rates between the groups were noted. Haemostatic agents were more frequently used in electrocautery dissection (RD 10.6%, 95% CI, 1.3% to 19.8%, P = 0.025).

CONCLUSIONS: Ultrasonic dissection and electrocautery dissection demonstrate comparable risks for complications in emergency surgery for patients with acute cholecystitis. Ultrasonic dissection is a viable alternative to electrocautery dissection or can be used as a complementary method in laparoscopic cholecystectomy for acute cholecystitis.

TRIAL REGISTRATION: The trial was registered prior to conducting the research on  http://clinical.trials.gov, NCT03014817.

Background and Aim: Primary sclerosing cholangitis (PSC) is characterized by multiple strictures of the biliary tree. Patients with PSC frequently require repeated endoscopic retrograde cholangiopancreatography (ERCP) procedures. These procedures are encumbered by an increased incidence of infectious adverse events such as cholangitis. Evidence regarding whether antibiotic prophylaxis (AP) should be administered is sparse; however, prophylaxis is recommended. We aimed to determine whether AP affects the rate of postprocedural infectious and overall adverse events.

Methods: We conducted a retrospective cohort study and extracted all ERCP procedures with indicated PSC performed between 1 January 2006 and 31 December 2019, which were registered in the Swedish Registry for Gallstone Surgery and ERCP (GallRiks). The exclusion criteria were incomplete 30-day follow-up, non-index procedures, or ongoing antibiotics. The main outcomes were postprocedural infectious adverse events and overall adverse events at the 30-day follow-up.

Results: A total of 2144 procedures with indication of PSC were eligible for inclusion. AP was administered in 1407 (66%) of these procedures. Patients receiving AP were slightly younger (44 vs 46 years, P = 0.005) and had more comorbidities (ASA ≥3, 19.8% vs 13.6%; P < 0.001). Procedures with AP demonstrated an infectious adverse event rate of 3.3% compared to 4.5% for non-AP procedures (P = 0.19). Postprocedural infectious adverse events (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.48–1.21) and overall adverse events (OR 0.79, 95% CI 0.60–1.04) did not differ between AP and non-AP.

Conclusion: Patients with PSC who undergo ERCP have the same frequency of adverse events regardless of whether AP was used.

Background and study aims: Single-operator peroral cholangioscopy (SOC) has gained increasing attention in modern biliary and pancreatic therapy and diagnosis. This procedure has shown higher rates of infectious complications than conventional endoscopic retrograde cholangiopancreatography (ERCP); therefore, many guidelines recommend antibiotic prophylaxis (AP). However, whether AP administration decreases infectious or overall adverse events (AEs) has been little studied. We aimed to study whether AP affects post-procedure infectious or overall AEs in ERCP with SOC.

Patients and methods: We collected data from the Swedish Registry for Gallstone Surgery and ERCP (GallRiks). Of the 124,921 extracted ERCP procedures performed between 2008 and 2021, 1,605 included SOC and represented the study population. Exclusion criteria were incomplete 30-day follow-up, ongoing antibiotic use, and procedures with unspecified indication. Type and dose of antibiotics were not reported. Post-procedure infectious complications and AEs at 30-day follow-up were the main outcomes.

Results: AP was administered to 1,307 patients (81.4%). In this group, 3.4% of the patients had infectious complications compared with 3.7% in the non-AP group. The overall AE rates in the AP and non-AP groups were 14.6% and 15.2%, respectively. The incidence of cholangitis was 3.1% in the AP group and 3.4% in the non-AP group. Using multivariable analysis, both infectious complications (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.54-1.57) and AEs (OR 0.87, 95% CI 0.65-1.16) remained unaffected by AP administration.

Conclusions: No reduction in infectious complication rates and AEs was seen with AP administration for SOC. The continued need for AP in SOC remains uncertain.

IMPORTANCE: Female surgeons are still in the minority worldwide, and highlighting gender differences in surgery is important in understanding and reducing inequities within the surgical specialty. Studies on different surgical procedures indicate equal results, or safer outcomes, for female surgeons, but it is still unclear whether surgical outcomes of gallstone surgery differ between female and male surgeons.

OBJECTIVE: To examine the association of the surgeon's gender with surgical outcomes and operating time in elective and acute care cholecystectomies.

DESIGN, SETTING, AND PARTICIPANTS: A population-based cohort study based on data from the Swedish Registry of Gallstone Surgery was performed from January 1, 2006, to December 31, 2019. The sample included all registered patients undergoing cholecystectomy in Sweden during the study period. The follow-up time was 30 days. Data analysis was performed from September 1 to September 7, 2022, and updated March 24, 2023.

EXPOSURE: The surgeon's gender.

MAIN OUTCOME(S) AND MEASURE(S): The association between the surgeon's gender and surgical outcomes for elective and acute care cholecystectomies was calculated with generalized estimating equations. Differences in operating time were calculated with mixed linear model analysis.

RESULTS: A total of 150 509 patients, with 97 755 (64.9%) undergoing elective cholecystectomies and 52 754 (35.1%) undergoing acute care cholecystectomies, were operated on by 2553 surgeons, including 849 (33.3%) female surgeons and 1704 (67.7%) male surgeons. Female surgeons performed fewer cholecystectomies per year and were somewhat better represented at universities and private clinics. Patients operated on by male surgeons had more surgical complications (odds ratio [OR], 1.29; 95% CI, 1.19-1.40) and total complications (OR, 1.12; 95% CI, 1.06-1.19). Male surgeons had more bile duct injuries in elective surgery (OR, 1.69; 95% CI, 1.22-2.34), but no significant difference was apparent in acute care operations. Female surgeons had significantly longer operation times. Male surgeons converted to open surgery more often than female surgeons in acute care surgery (OR, 1.22; 95% CI, 1.04-1.43), and their patients had longer hospital stays (OR, 1.21; 95% CI, 1.11-1.31). No significant difference in 30-day mortality could be demonstrated.

CONCLUSIONS AND RELEVANCE: The results of this cohort study indicate that female surgeons have more favorable outcomes and operate more slowly than male surgeons in elective and acute care cholecystectomies. These findings may contribute to an increased understanding of gender differences within this surgical specialty.