BACKGROUND: Cholelithiasis is a common disease of the biliary tract. Chinese medicinal herbs are being used widely as an alternative treatment in people with cholelithiasis, but their beneficial or harmful effects have not been assessed systematically. OBJECTIVES: To assess the beneficial and harmful effects of Chinese medicinal herbs in people with cholelithiasis. SEARCH METHODS: We conducted searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, Chinese Medicine Conference Disc, and Chinese Bio-Medicine Disc to January 2013. We handsearched four Chinese journals. No language or year of publication restrictions were applied. SELECTION CRITERIA: Randomised clinical trials studying Chinese medicinal herbs for treatment of cholelithiasis. DATA COLLECTION AND ANALYSIS: Two review authors (SJ, TG) independently extracted data. For dichotomous data, we estimated the risk ratio (RR), and for continuous data, we calculated the mean difference. We also calculated 95% confidence intervals (CI). MAIN RESULTS: Eleven randomised trials with 1205 participants with asymptomatic or mild-to-moderate cholelithiasis were included. None of the randomised clinical trials compared a single Chinese medicinal herb with a Western medicine or with surgery. No placebo-controlled trials were identified. In the trials comparing one Chinese herbal medicine (Gandanxiaoshi tablet) versus another (Aihuodantong tablet), there was no significant difference in the improvement of upper abdominal pain after the end of treatment (RR 1.21; 95% CI 0.71 to 2.05), and the heterogeneity among trials was not substantial. No other outcomes could be assessed. The remaining trials of Chinese medicinal herbs (Qingdan capsule, Danshu capsule, Paishi capsule, Rongdanpaishi capsule), did not offer specific data on symptoms, signs, or change in gallstones that would permit assessment of significant differences in curative effects between the treatment and control groups. No serious adverse events were reported. AUTHORS' CONCLUSIONS: This review reveals no strong evidence that the analysed Chinese medicinal herbs have any beneficial effects on asymptomatic or mild-to-moderate cholelithiasis. Definitive conclusions will require much better designed randomised trials to reduce risk of bias and allow detailed assessment of clinical outcomes.

AIM: To review the evidence for the use of different non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of biliary colic. METHODS: The strategies employed included an extensive literature review for articles and studies related to biliary colic from electronic databases including PubMed, Science Direct, Wiley Inter Science, Medline and Cochrane from last 15 years. Keywords: "Biliary colic", "management of biliary colic", "non-steroidal anti-inflammatory drugs", "cholelithiasis" and "biliary colic management". Six randomized control trials, 1 non-randomized trial and 1 meta-analysis were included in this review. The outcomes of these studies and their significance have been reviewed in this paper. RESULTS: Current evidence suggests there are no set protocols for biliary colic pain management. NSAIDs are potent in the management of biliary colic, not only in terms of symptom control but in disease progression as well. Apart from the studies on diclofenac and ketorolac, there are studies which have shown that intravenous tenoxicam and injectable flurbiprofen are equally effective in managing biliary colic. The efficacy of NSAIDs is superior in terms of lower number of doses and longer duration of action in comparison to other analgesic agents. CONCLUSION: This literature review has found that NSAIDs are safe and effective for pain control in biliary colic, and reduce the likelihood of further complications.

To assess the natural history of cholelithiasis in patients with cirrhosis, 32 charts coded for both diseases were retrospectively reviewed. Cholecystectomy was performed in 22 patients. Only two patients met criteria for acute cholecystitis and two patients had suspected choledocholithiasis. Despite the high incidence of preoperative jaundice (32%), no common duct stones were documented. There was no operative mortality. The complication rate was 45%. In 10 patients not operated upon, two patients died of liver failure and the remaining eight patients are alive 8 months to 13 years after diagnosis (mean: 46 months) with no active biliary disease. It is concluded that: jaundice in this subpopulation most often reflects hepatocellular injury and rarely biliary tract obstruction, there appears to be a much lower incidence of acute cholecystitis and choledocholithiasis in cirrhotic patients with cholelithiasis than in the normal population, and patients with cirrhosis and asymptomatic cholelithiasis can be safely managed without operation.

BACKGROUND: Incidental gallbladder cancer is found in upto 1% of cholecystectomy specimens for gallstone disease. Currently, in our institution, all gallbladder specimens are sent for routine histopathology, to rule out incidental gallbladder carcinoma. This study was aimed at assessing the need for routine histopathology of gallbladder specimens after cholecystectomy for gallstone disease. METHODS: Hospital records of all patients undergoing cholecystectomy for gallstone disease over a ten-year period, between 1998 and 2007, in a single surgical unit were reviewed. RESULTS: A total of 1312 patients underwent cholecystectomy for gallstone disease. Gallbladder carcinoma was detected in 13 patients. Macroscopic abnormalities of the gallbladder were found in all the 13 patients. In patients with a macroscopically normal gallbladder, there were no cases of gallbladder carcinoma. CONCLUSION: Gallbladder carcinoma is associated with macroscopic abnormalities in all cases. Therefore histopathology should be restricted to only those specimens which reveal a macroscopic abnormality. This would identify all cases of incidental gallbladder carcinoma, at the same time decreasing cost and pathological work load.

Available evidence of the relationship between cholelithiasis, cholecystectomy, and risk of liver cancer and hence we conducted a meta-analysis to investigate the relationships. PubMed, EMBASE, and ISI Web of Knowledge were searched to identify all published cohort studies and case-control studies that evaluated the relationships of cholelithiasis, cholecystectomy and risk of liver cancer and single-cohort studies which evaluated the incidence of liver cancer among patients who understood cholecystectomy (up to February 2013). Comprehensive meta-analysis software was used for meta-analysis. A total of 11 observational studies (six cohort studies and five case-control studies) were included in this meta-analysis. The result from meta-analysis showed that cholecystectomy (risk ratio [RR]: 1.59, 95% confidence interval [CI]: 1.01-2.51, I2=72%) and cholecystolithiasis (RR: 5.40, 95% CI: 3.69-7.89, I2=93%) was associated with more liver cancer, especially for intrahepatic cholangiocarcinoma (ICC) (cholecystectomy: RR: 3.51, 95% CI: 1.84-6.71, I2=26%; cholecystolithiasis: RR: 11.06, 95% CI: 6.99-17.52, I2=0%). The pooled standardized incidence rates (SIR) of liver cancer in patients who understood cholecystectomy showed cholecystectomy might increase the incidence of liver cancer (SIR: 1.57, 95% CI: 1.13-2.20, I2=15%). Based on the results of the meta-analysis, cholecystectomy and cholecystolithiasis seemed to be involved in the development of liver cancer, especially for ICC. However, most available studies were case-control studies and short-term cohort studies, so the future studies should more long-term cohort studies should be well-conducted to evaluate the long-term relationship.

BACKGROUND: While gallstones are associated with cancers of the gallbladder, the actual nature of their relationship needs to be clarified. This would aid the recommendations on the need for prophylactic cholecystectomy. METHODS: A systematic search of the scientific literature was carried out using the Medline, the Embase, and the Cochrane Central Register of Controlled Trials for the years 1891-2009 to obtain access to all publications involving gallstones in gallbladder cancer. RESULTS: While some epidemiological evidence supports a causal relationship for gallstones in gallbladder cancer, other studies have demonstrated a relatively low incidence of gallbladder cancer in countries reporting a high incidence of gallstones as a whole. In those studies where gallstones appear to have a causative role for cancer, the risk increases with increasing size, volume and weight, and number of the stones. The impact of duration of the stone or its composition is not clear. Experimental evidence from studies examining the impact of artificially introducing gallstones in the gallbladder has failed to lead to carcinogenesis. CONCLUSIONS: The evidence at the current time indicates that gallstones are a cofactor in the causation of gallbladder cancer. Absolute proof of their role as a cause for gallbladder cancer is lacking. The recommendation for prophylactic cholecystectomy in countries reporting a high incidence of gallbladder cancer and associated gallstones needs to be tailored to the epidemiological profile of the place.

The current evidence in favor of the laparoendoscopic rendezvous is promising and demonstrates the main advantages of this technique in regard to shorter hospital stay and selective cannulation of the common bile duct (CBD), avoiding thus the inadvertent cannulation of the pancreatic duct. In addition, in the rendezvous technique the contrast medium is not injected retrogradely as during the traditional endoscopic retrograde cholangiopancreatography (ERCP), when the medium accidentally could be injected under pressure into the pancreatic duct. The RV technique minimizes that risk. Both these main advantages of the RV technique over the classic ERCP, are related with a significant lower incidence of hyperamylasemia and post-ERCP pancreatitis, compared with the traditional two stage procedure. Choledocholithiasis is present in 10% to 15% of patients undergoing cholecystectomy. To date, the ideal management of CBD stones remains controversial. Prospective randomized trials have shown that laparoscopic management of the CBD stones, as a single stage procedure, is the most efficient and cost effective method of treatment. Laparoendoscopic rendezvous has been proposed as an alternative single stage approach. Several studies have shown the effective use of this technique in the treatment of CBD stones by improving patient compliance and clinical results including shorter hospital stay, higher success rate and less cost. The current evidence about the use of this technique presented in this review article is promising and demonstrates the main advantages of the procedure.

BACKGROUND: The etiological factor for intrahepatic cholangiocarcinoma (ICC) is not clear. Although it has been widely accepted that intrahepatic biliary tree stone is associated with increased risk of ICC, the role of extrahepatic biliary tree stone in the incidence of ICC is controversial. In the present study we aim to evaluate the association between pre-existing choledocholithiasis and cholecystolithiasis and the risk of ICC. METHODS: PubMed, Embase, and Web of Science were searched to identify cohort and case-control studies on the association between choledocholithiasis or cholecystolithiasis and the risk of ICC. Studies that met the inclusion criteria were subjected to a meta-analysis performed with Stata statistical software. Either a fixed or random effect model was used, depending on the heterogeneity within the studies. Egger's test was performed to assess publication bias. RESULTS: Seven case-control studies met our inclusion criteria. Of the 123,771 participants, 4763 (3.85 %) were patients with ICC, and 119,008 were tumor-free controls. The presence of pre-existing bile duct stones (choledocholithiasis alone or choledocholithiasis accompanied by hepatolithiasis) was associated with the risk of ICC (odds ratio [OR] 17.64, 95 % confidence interval [CI] 11.14-27.95). Even the presence of choledocholithiasis alone (in the absence of hepatolithiasis) was associated with a high risk of ICC (OR 11.79, 95 % CI 4.17-33.35). Cholecystolithiasis may possibly contributed to the incidence of ICC (OR 2.00, 95 % CI 1.16-3.42), with large heterogeneity within studies (I (2) = 78.5 %). CONCLUSIONS: Bile duct stones including choledocholithiasis are important risk factors for ICC. Careful surveillance of patients with extrahepatic biliary tree stone should be considered.

BACKGROUND: This study examined symptomatology and quality of life following elective cholecystectomy for symptomatic gallstone disease with defined indications for surgery. METHODS: In this prospective study of 200 consecutive patients (161 women; median age 46.5 (range 24-79) years), strict indications for elective cholecystectomy were stipulated. Digestive symptoms and quality of life were recorded with a self-administered questionnaire before and at 3 and 12 months after surgery. RESULTS: Of 149 patients who experienced abdominal pain with typical location before surgery, 136 (91.3 per cent) reported total remission or reduced frequency of that type of pain 12 months later. Of 35 patients who reported atypical or multiple pain location before operation, 27 (77 per cent) experienced reduced frequency or disappearance of that type of pain. Frequency of pain episodes, atypical or multiple pain location, specific food intolerance and frequency of disturbing abdominal gas at baseline correlated positively with the frequency of abdominal pain episodes at 12 months after surgery. There was a tendency towards an inverse relation to age. CONCLUSION: The frequency of persistent abdominal pain after elective cholecystectomy was low among patients with typical pain location before surgery. Atypical pain location, and frequent pain episodes before operation significantly reduced the chance of becoming pain-free.

Introducción: La laparoscopia es el estándar de referencia en el tratamiento de la colecistolitiasis. No obstante su efectividad es todavía poco conocida. El objetivo de este estudio es evaluar la evidencia disponible sobre la efectividad de la cirugía laparoscópica en el tratamiento de la colecistolitiasis y de la litiasis de la vía principal (LVBP). Material y Métodos: Se realizó una búsqueda en las bases de datos MEDLINE, EMBASE y la biblioteca Cochrane. Se consideraron todo tipo de estudios publicados entre 1988 y 2006. Se llevó a cabo la evaluación de la validez interna de la evidencia así como su calidad global. Resultados: Se seleccionaron 80 estudios (9 revisiones sistemáticas, 19 ensayos clínicos, 4 guías de práctica clínica, 15 estudios de cohortes, 1 de casos y controles y 32 series de casos). La colecistectomía laparoscópica (CL), respecto de la colecistectomía, se asocia a mayor tiempo operatorio, menor estancia hospitalaria y mejor calidad de vida, siendo un procedimiento relativamente seguro (calidad alta). El uso de profilaxis antibiótica no ofrece ningún beneficio en términos de disminución de la tasa de infecciones en pacientes de bajo riesgo [calidad alta]. Se han descrito multiplicidad de variantes tecnológicas para la realización de una CL, no obstante, la efectividad de las mismas es escasa y no concluyente. En el tratamiento de la LVBP, la cirugía en dos etapas es la estrategia más apropiada en pacientes de alto riesgo (calidad alta). La mortalidad es similar a la de la cirugía abierta y la efectividad es similar al tratamiento endoscópico (calidad alta). Conclusiones: La evidencia disponible es escasa y de baja calidad metodológica, situación que dificulta la formulación de recomendaciones. Son necesarios estudios de mejor calidad que evalúen de manera adecuada éstas técnicas.