Article 1
A little goes a long way: A comparison of enterolithotomy versus single-stage cholecystectomy in the management of gallstone ileus. Khurshid MH, Hejazi O, Spencer AL, Nelson A, Stewart C, Colosimo C, Ditillo M, Matthews MR, Magnotti LJ, Joseph B. J Trauma Acute Care Surg. 2025 Apr 1;98(4):649-654.
Management of gallstone ileus includes the option of enterolithotomy alone (EL), 1 stage enterolithotomy with concomitant cholecystectomy (EL-CCY) and 2 stage EL-CCY. Classic teaching has focused on initial treatment with EL alone followed by selective progression to cholecystectomy as a second stage.
This paper set out to further evaluate the optimal treatment strategy for gallstone ileus by evaluating the Nationwide Readmissions Database from 2011-2017. 1,960 patients were included in the study based on gallstone ileus being diagnosed on their index admission; these were stratified by EL vs EL-CCY. Primary outcomes were in-hospital complications and mortality. Secondary outcomes were hospital LOS, hospital costs and readmissions.
Of the 1,960 patients, 289 (14.7%) underwent EL-CCY while 1,671 (85.3%) underwent EL alone. Overall, 4.2% of patients died prior to discharge and 22.1% had complications. The most common complications during index admission were sepsis (11.2%), postprocedural intestinal obstruction (8.0%) and surgical site infections (5.5%). 4.8% of patients were readmitted, most commonly for intestinal obstruction. For EL alone patients, 1.9% required readmission for cholelithiasis.
In comparing the two groups, there were no statistically significant differences in complications. The mortality rate for EL-CCY was 6.2% which was higher than the 3.9% for EL alone but this was not statistically significant. Additionally, the rate of readmission in the EL group for gallstone ileus was similar in both groups (0.7% in EL-CCY vs 0.8% in EL alone, p =0.98) and the rate of readmission for cholelithiasis was low in the EL alone group (1.9%) with the majority of patients undergoing elective cholecystectomy,not urgent/emergent. Of note, the study did find that hospital LOS and hospital costs were higher in the EL-CCY group.
The limitations of this study include its retrospective database nature as well as the lack of information regarding why either treatment strategy was pursued.
The study appears to validate EL alone as an effective management strategy for gallstone ileus which lowers hospital LOS as well as hospital costs. This conclusion would benefit from further study to demonstrate whether the long-term risk of recurrent biliary complications (such as recurrent gallstone ileus, symptomatic cholelithiasis, acute cholecystitis and choledocholithiasis) are low enough to suggest that forgoing cholecystectomy is a reasonable treatment strategy. Additionally, further study of the risk of procedure-specific complications such as bile duct injury, bile leak and duodenal leak would also be beneficial as these are not specifically addressed by the current study.
Article 2
Percutaneous and endoscopic transpapillary cholecystoduodenal stenting in acute cholecystitis-A viable long-term option in high-risk patients? Argandykov D, El Moheb M, Nzenwa IC, Kalva SP, Iqbal S, Smolinski-Zhao S, Krishnan K, Velhamos GC, Paranjape C. J Trauma Acute Care Surg. 2025 Feb 1;98(2):319-326.
Percutaneous cholecystostomy tube (PCT) placement is a viable alternative for patients with short-term modifiable risk factors precluding them from the gold-standard treatment of cholecystectomy for cholecystitis. However, PCT is a less-satisfying treatment strategy for patients who may never make it to surgery given the risk of drain dislodgement/obstruction, skin infection and erosion, need for repeated tube exchanges, and overall patient dissatisfaction. This paper explores the alternative of transpapillary cholecystoduodenal stenting (TCDS) placed either endoscopically or percutaneously. The study is a prospective cohort study at two partner academic hospitals that explores the outcomes of patients who underwent management following a multidisciplinary protocol for high-risk patients with acute cholecystitis. The study took place between 2018-2022 and included patients with acute cholecystitis who were evaluated by a surgeon and felt to have surgical risk beyond 6 weeks. If the patient had a need for ERCP they would undergo endoscopic TCDS. If the patient did not have need for ERCP they would undergo initial PCT with conversion to percutaneous TCDS at 4-6 weeks if risks prohibiting surgery remained.
Overall, 80 patients met inclusion criteria for the study and 73 patients made it to TCDS. 50 had percutaneous TCDS and 23 had endoscopic TCDS. TCDS was successful in 67 patients (92%). There were no adverse events during TCDS procedures. However, 22% experienced postprocedural adverse events, including stent blockage (9%), pancreatitis (7%) and stent migration (5%). All but one of the patients who experienced post-procedural adverse events were managed without surgery. This single patient suffered stent migration with gallbladder perforation necessitating open subtotal cholecystectomy. All of those with stent blockage needed either repeat percutaneous or endoscopic intervention. All-cause mortality in the median follow-up period of 17 months was 26% with no deaths being associated with gallbladder disease.
Limitations of this paper were that determination of whether a patient was high-risk was left up to the surgeon with no pre-defined criteria, this protocol was not directly compared to the standard practice of PCT and there may be lack of generalizability due to the study been conducted at two partnering hospitals with considerable experience in these procedures.
Overall, the article does show that TCDS appears to be a safe and viable alternative to PCT for high-risk acute cholecystitis patients but would benefit from further study directly comparing the two treatment options.
Article 3
LASER Focus on Long-Term Outcomes for Diverticular Disease. Myers S, Davids JS. JAMA Surg. 2025 Jun 1;160(6):622-623.
The LASER randomized clinical trial, conducted across six Finnish hospitals, compared two treatment strategies for patients with recurring, persistent painful, or complicated diverticulitis: elective laparoscopic sigmoid resection (surgery group) and conservative treatment involving dietary advice and symptom management without surgery (conservative group). Ninety patients were randomized equally between these groups and followed for four years. The primary aim was to evaluate long-term quality of life (QOL), recurrence of diverticulitis, and complications. Results showed no statistically significant difference in overall QOL between the groups at four years, although surgery was notably effective in preventing recurrent diverticulitis (only 10% recurrence in the surgery group versus 92% in the conservative group). Approximately one-third of those initially assigned to conservative treatment eventually required surgery, primarily due to persistently low QOL—characterized by chronic lower abdominal pain, disrupted bowel habits, and reduced daily functioning. These patients had significantly lower baseline Gastrointestinal Quality of Life Index (GIQLI) scores and experienced meaningful improvements after undergoing surgery.
Despite the higher recurrence rate of diverticulitis in the conservative group, overall rates of serious complications were similar between the two treatment groups over four years. However, patients who initially received conservative treatment but later required surgery experienced significantly more major complications than those who had surgery from the outset (36% vs 10%). These findings suggest that delaying surgery may increase the risk of adverse outcomes. Additionally, rates of stoma formation and incisional hernia were higher in the conservative group. While early surgery did not significantly improve QOL in the overall cohort, it was more beneficial for patients with low baseline QOL—those suffering from persistent pain, recurring infections, and poor gastrointestinal function. Conversely, patients with relatively normal QOL at baseline were often satisfied with conservative management, even if recurrent episodes occurred. The results support a personalized treatment approach, weighing the risks and benefits based on symptom severity and patient preferences.
Article 4
Management of adhesive small bowel obstruction during pregnancy in the United States. Ashbrook MJ, Cheng V, Longo E, Kohrman N, Matsuo K, Martin MJ, Inaba K, Matsushima K. J Trauma Acute Care Surg. 2025 Jun 1;98(6):915-920.
The study analyzed data from the National Inpatient Sample between 2003 and 2015, identifying 4,266 pregnant patients diagnosed with adhesive small bowel obstruction (ASBO). Patients were grouped into three management strategies: nonoperative management (NOM), immediate operation (within 24 hours of admission), and delayed operation (after 24 hours). The study found that nonoperative management and immediate surgery were associated with similar rates of maternal and fetal complications, including preterm labor, delivery, abortion, and maternal septic shock. In contrast, delayed surgery was linked to significantly higher risks of these complications. Each additional day of delay in surgical intervention increased the odds of preterm labor, delivery, or abortion by 14%.
The authors concluded that early surgical intervention, when indicated, is associated with better maternal and fetal outcomes in cases of ASBO during pregnancy. Surgical intervention is recommended in cases where nonoperative management fails, or when there are signs of bowel ischemia, peritonitis, or clinical deterioration. They emphasized the importance of prompt diagnosis and early surgical consultation to minimize delays in treatment. The study advocates for a proactive approach in managing ASBO during pregnancy to reduce the risk of adverse outcomes.
