Feasibility and Impact of Traction Band-Assisted Cannulation for Difficult Biliary Cannulation in Patients With Periampullary Diverticulum: A Propensity Score-Matched Analysis.

Abdominal ultrasound should be performed in a patient with a recent history of biliary pain (high quality evidence; strong recommendation); in case of strong clinical suspicion of gallbladder stones and negative abdominal ultrasound, EUS (or magnetic resonance imaging) may be performed (low quality; weak). Cholecystectomy is the preferred treatment for symptomatic gallbladder stones (moderate quality; strong recommendation), and laparoscopic cholecystectomy is the standard method, including for acute calculous cholecystitis (high quality; strong), although mini-laparotomy cholecystectomy (laparotomy <8 cm) is an equally acceptable alternative (high quality; strong). For uncomplicated biliary colic, cholecystectomy should be performed as early as possible (low quality; weak recommendation); EASL qualifies that cholecystectomy may not be necessary if biliary colic has not occurred within the last 5 years or after just one episode of colic (~50% chance of another colic within 1 year). For acute cholecystitis, early laparoscopic cholecystectomy preferably within 72 h of admission should be performed by surgeons with adequate expertise (high quality; strong recommendation). Antibiotics are NOT recommended at all times in mild acute cholecystitis, i.e. without cholangitis, bacteremia/sepsis, abscess or perforation (very low quality; weak recommendation). Biliary colic should be treated with NSAIDs, e.g. diclofenac 50-75 mg IM, ketoprofen 200 mg IV, or indomethacin 50 mg IV / 2 × 75 mg suppositories (moderate quality; weak), with spasmolytics and, for severe symptoms, opioids such as buprenorphine (low quality; strong). In severe acute cholecystitis or difficult biliary anatomy, subtotal cholecystectomy (laparoscopic or open) or percutaneous cholecystostomy followed by later cholecystectomy are options; percutaneous cholecystostomy is a treatment alternative in high-risk patients, but whether definitive cholecystectomy is still needed afterwards is explicitly unsolved (no RCTs) and cholecystectomy should be considered, since patients who improve after cholecystostomy may worsen during follow-up. In the elderly and those with high anaesthetic risk, cholecystectomy should be performed for gallstone complications (acute cholecystitis, gallstone pancreatitis, obstructive jaundice) as soon as general status allows (low quality; weak), and laparoscopic cholecystectomy should not be withheld on the basis of chronological age alone (very low quality; weak). Routine treatment is NOT recommended for asymptomatic gallbladder stones (very low quality; weak recommendation). Oral bile-acid litholysis, alone or with ESWL, is not recommended (moderate quality; strong). In patients with simultaneous gallbladder and bile duct stones, early laparoscopic cholecystectomy should be performed within 72 h after preoperative ERCP for choledocholithiasis (moderate quality; strong); same-day but separate ERCP and cholecystectomy are not recommended. Before elective cholecystectomy, abdominal ultrasound confirming stones is required (moderate quality; strong) and no other routine tests are necessary; liver biochemical tests in individually selected cases (very low quality; weak). Routine intraoperative cholangiography is not supported by current evidence.