Discussion
Management of gallstone disease is performed at a number of Norwegian hospitals. Nevertheless, until now there has been no comprehensive overview of practices across institutions. An analysis of data from the Norwegian Patient Registry showed that laparoscopic access for cholecystectomy was already established as the standard treatment method during the period 1990–2000 (3) . The Norwegian Directorate of Health's guideline for the management of cholecystitis addresses the use of antibiotics. There are no national recommendations for the surgical management of gallstone disease, and hospitals have developed local protocols (4) . For the management of cholecystitis, cholangitis and biliary pancreatitis, the Tokyo Guidelines are frequently cited in studies and reports (2) . The survey suggests that routines at Norwegian hospitals only partially follow these international recommendations for the management of gallstone disease.
International studies recommend that cholecystectomy should be performed during the initial hospital stay in cases of isolated, mild biliary pancreatitis (2) . Cholecystectomy within 48 hours of admission for acute biliary pancreatitis is supported by several randomised clinical trials (5) . However, surgery should be postponed in cases of moderate or severe biliary pancreatitis due to an increased risk of complications (5) . Acute biliary pancreatitis was an indication for acute cholecystectomy at only 40 % of hospitals in Norway. The optimal timing of cholecystectomy after biliary pancreatitis remains unclear (5) . Consequently, there is no general consensus for routine cholecystectomy in biliary pancreatitis, particularly in relation to older patients presenting with a first episode of acute biliary pancreatitis.
Most Norwegian hospitals perform acute cholecystectomy for cholecystitis in accordance with international recommendations, such as the Tokyo Guidelines (2) . However, five hospitals did not use cholecystectomy as standard treatment for acute cholecystitis, with several citing limited capacity as the reason. This factor is known to impact on patient care, both in terms of timing and indications for surgery (6) . Studies have shown that 10 % of patients with acute cholecystitis who are not operated on experience a relapse within six weeks, which can be more severe than the first episode (7) .
Research indicates that high volume and surgical expertise can improve outcomes in cholecystectomy, particularly in complicated cases (8, 9) , and that low-volume hospitals can achieve good results with a structured approach (10, 11) . Definitions of high, medium and low-volume hospitals vary, and multiple factors beyond volume are crucial for treatment quality. A robust specialist team is an important determinant of the quality of surgical care (12, 13) . In our study, we found no major differences in patient care between low, medium and high-volume hospitals. Variations may reflect local traditions and differences in round-the-clock access to supporting services such as ERCP.
In our survey, acute cholecystectomy for cholecystitis was generally performed within five days of symptom onset. Previously, a three-day symptom duration was considered a 'limit', based on studies showing poorer outcomes with longer symptom duration (2, 14) . More recent studies suggest that cholecystectomy can be beneficial when performed up to seven days after symptom onset (2, 15) . However, there is no general consensus on an upper limit of symptom duration for cholecystectomy in acute cholecystitis (16) . Extending the interval between symptom onset and surgery would allow more patients to be treated during a single hospital stay (2) . The Tokyo Guidelines take into account the severity of cholecystitis, associated comorbidities, anaesthetic risk and surgical expertise when determining the indication for acute cholecystectomy.
The survey showed that open cholecystectomy is no longer performed for elective management of gallstone disease in Norway. For acute cholecystectomy, only three of 40 hospitals reported using open surgery to some extent.
In cases of challenging dissection or uncertain anatomy, subtotal cholecystectomy is considered an alternative approach. Half of the hospitals in the survey performed this procedure, usually leaving the gallbladder remnant open (fenestration). None reported routinely using the 'fundus-first' technique in complex cases, which is consistent with the Tokyo Guidelines (2) .
Over recent decades, a dissection method with a critical view of safety has been widely accepted as the preferred technique for laparoscopic cholecystectomy. This approach ensures that only two tubular structures enter the gallbladder from the liver hilum before the cystic artery and duct are divided (17) . Free-text comments from the survey, however, indicate that this method is not standard practice in several Norwegian hospitals, despite its inclusion in the Tokyo Guidelines as a recommended technique for safe laparoscopic cholecystectomy (2) .
One-fifth of hospital departments routinely performed IOC during cholecystectomy. Its benefit remains debated, and selective use is recommended by several authors (18) . Globally, there is a trend towards reduced use of IOC, possibly due to new non-interventional pre- and intraoperative imaging methods (19) . Nevertheless, proficiency in cholangiography as an intraoperative tool is considered important, particularly in cases of unclear anatomy and as a basis for intraoperative bile duct clearance (20) .
Percutaneous drainage of the gallbladder in acute cholecystitis carries a higher risk of complications and a lower therapeutic success rate compared with cholecystectomy. This approach is only recommended for patients with moderate to severe acute cholecystitis (grade II or III according to the Tokyo Guidelines) who are not candidates for surgery (2) .
The survey shows that a broad range of methods was used to manage common bile duct stones in patients indicated for cholecystectomy. In Norway, preoperative ERCP with stone clearance was the most common approach in both acute and elective settings. This is in line with international recommendations, which allow for several alternative strategies (2) . A small number of hospitals used intraoperative transcystic stone clearance for the management of common bile duct stones. This technique is increasingly used internationally. It is less costly than ERCP and may be particularly useful in patients with altered anatomy, such as after gastrectomy or bariatric surgery, where the bile ducts are not accessible via conventional ERCP (21, 22) . However, further studies are needed to establish the value of this method in routine practice. No hospital reported routine use of choledochotomy.
International recommendations advise against routine use of antibiotic prophylaxis for elective cholecystectomy (2) . Only one hospital in the survey reported routinely using antibiotic prophylaxis for elective cholecystectomy. However, it was common practice to continue antibiotics for up to five days after acute cholecystectomy. This practice is controversial, and the Tokyo Guidelines advise against postoperative antibiotics for mild or moderate acute cholecystitis (Tokyo grades I and II). For Tokyo grade III acute cholecystitis, antibiotics are recommended for 4–7 days postoperatively (2) , which aligns with the practice observed in Norwegian hospitals according to the survey. A meta-analysis found no benefit of extended antibiotic therapy for mild or moderate acute cholecystitis (23) . Although the Tokyo Guidelines suggest perioperative antibiotic prophylaxis for acute cholecystitis of all grades (2) , a recent meta-analysis of randomised trials found no benefit of such treatment in Tokyo grades I and II acute cholecystitis (24) .
Our survey has limitations. The questionnaire sent to Norwegian hospitals had not been validated. Variations between individual surgeons within hospitals were not considered, and the survey was not based on prospective registration of treatment. The survey did not account for the severity of cholecystitis, comorbidities, anaesthetic risk or surgical expertise. Consequently, it was not possible to draw direct conclusions regarding adherence to the Tokyo Guidelines in practice at Norwegian hospitals. The option to select multiple responses for some questions may also have complicated interpretation of the feedback.
Nevertheless, the high response rate: 40 of 41 hospitals identified as relevant, provides a good overview of current practices at Norwegian hospitals.
Summary
Summary
Management of gallstone disease in Norwegian hospitals varies in terms of indications for acute cholecystectomy, management of common bile duct stones and the use of intraoperative cholangiography and antibiotic prophylaxis.