Laparoscopic cholecystectomy for severe acute cholecystitis. A meta-analysis of results

Surgical Management of the Horrible Gallbladder

Laparoscopic cholecystectomy is one of the most frequently performed operations by general surgeons, with up to 1 million cholecystectomies performed annually in the United States alone. Despite familiarity, common bile duct injury occurs in no less than 0.2% of cholecystectomies, with significant associated morbidity. Understanding biliary anatomy, surgical techniques, pitfalls, and bailout maneuvers is critical to optimizing outcomes when encountering the horrible gallbladder. This article describes normal and aberrant biliary anatomy, complicated cholelithiasis, ways to recognize cholecystitis, and considerations of surgical approach.

Acute cholecystitis, obesity, and steatohepatitis constitute the lethal triad for bile duct injury (BDI) during laparoscopic cholecystectomy

OBJECTIVE

The most feared complication during laparoscopic cholecystectomy remains a bile duct injury (BDI). Accurately risk-stratifying patients for a BDI remains difficult and imprecise. This study evaluated if the lethal triad of acute cholecystitis, obesity, and steatohepatitis is a prognostic measure for BDI.

METHODS

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) registry was performed. All laparoscopic cholecystectomy cases within the main NSQIP database for 2012-2019 were queried. Two study cohorts were constructed. One with the lethal triad of acute cholecystitis, BMI ≥ 30, and steatohepatitis. The other cohort did not have the full triad present. Multivariate analysis was performed via logistic regression modeling with calculation of odds ratios (OR) to identify independent factors for BDI. An uncontrolled and controlled propensity score match analysis was performed.

RESULTS

A total of 387,501 cases were analyzed. 36,887 cases contained the lethal triad, the remaining 350,614 cases did not have the full triad. 860 BDIs were identified resulting in an overall incidence rate 0.22%. There were 541 BDIs within the lethal triad group with 319 BDIs in the other cohort and an incidence rate of 1.49% vs 0.09% (P < 0.001). Multivariate analysis identified the lethal triad as an independent risk factor for a BDI by over 15-fold (OR 16.35, 95%CI 14.28-18.78, P < 0.0001) on the uncontrolled analysis. For the controlled propensity score match there were 29,803 equivalent pairs identified between the cohorts. The BDI incidence rate remained significantly higher with lethal triad cases at 1.65% vs 0.04% (P < 0.001). The lethal triad was an even more significant independent risk factor for BDI on the controlled analysis (OR 40.13, 95%CI 7.05-356.59, P < 0.0001).

CONCLUSIONS

The lethal triad of acute cholecystitis, obesity, and steatohepatitis significantly increases the risk of a BDI. This prognostic measure can help better counsel patients and potentially alter management.

Effect of Early Versus Delayed Laparoscopic Cholecystectomy on Postoperative Morbidity and Difficult Cholecystectomy in Patients With Grade II Cholecystitis According to Tokyo 2018 Guidelines: A Prospective Study

BACKGROUND

The timing of the cholecystectomy in patients with acute cholecystitis is still controversial. In our study, we aimed to investigate the effect of early and delayed cholecystectomy on difficult cholecystectomy, morbidity and mortality in patients diagnosed with Grade II acute cholecystitis according to Tokyo 2018 guidelines.

METHODS

Patients who presented to the emergency department and diagnosed with Grade II acute cholecystitis between December 2019 and June 2021 were included in this study. Cholecystectomy was performed within 7 days and 6 weeks after symptom onset. The effect of early and delayed cholecystectomy was observed.

RESULTS

A total of 92 patients were included in the study. The timing of cholecystectomy was not a risk factor for mortality, morbidity and difficult cholecystectomy. The conversion rate was higher in delayed group (P = .007). The bleeding was significantly higher in early group (P = .033). Total hospital stay was higher in delayed group (P < .001). CRP was a predictive parameter for increased Parkland score in early group (P < .001).

CONCLUSIONS

Delayed cholecystectomy does not facilitate cholecystectomy in patients with Grade II acute cholecystitis. Early cholecystectomy can be performed safely and high CRP levels can be used to determine difficult cholecystectomy in early period.

Single-Port Cholecystectomy for Cholecystitis Versus Non-Cholecystitis

Background and Objectives:

To assess the safety and efficacy of single-port laparoscopic cholecystectomy (SPLC) for the treatment of symptomatic cholelithiasis in different gallbladder pathologic conditions.

Methods:

All patients who underwent SPLC in our department between October 1, 2017 and March 31, 2020 were registered consecutively in a prospective database. Patients’ charts were retrospectively divided according to histological diagnosis: normal gallbladder (NG) (n = 13), chronic cholecystitis (CC) (n =47), and acute cholecystitis (AC) (n = 10). The parameters for assessing the procedure outcome included operative time, blood loss, use of additional trocars, conversion to laparotomy, intraoperative and postoperative complications, and length of hospital stay. Patient groups were statistically compared.

Results:

Seventy patients underwent SPLC. Duration of surgery increased from NG (55 ± 22.7 min) to CC (70 ± 33.5 min), and to AC patients (110.5 ± 50.5 min), which is statistically significant (P = .001). Postoperative complication rates were 7.6% in NG patients, 17% in CC, and 30% in AC (P = .442). Length of hospitalization was shorter for NG patients (1.0 ± 0.6 days) versus CC (2.0 ± 1.1 days) and AC patients (2.0 ± 4.7 days), with statistical significance (P = .020). Multivariate analysis found that pathology type and the occurrence of postoperative complications were independent predictors for prolonged operative times and prolonged hospital stay, respectively.

Conclusion:

SPLC is feasible for acute and chronic cholecystitis with good procedural outcomes. Since SPLC technique itself can be sometimes challenging with the existing technology, its application, especially in cases of acute cholecystitis, should be done with caution. Only prospective randomized studies on this approach for acute and chronic gallbladder diseases will assess the complete reliability of this technique.

Short and long term outcomes of laparoscopic fenestrating or reconstituting subtotal cholecystectomy versus laparoscopic total cholecystectomy in the management of acute cholecystitis

BACKGROUND

Strasberg proposed classifying subtotal cholecystectomy techniques into fenestrating (fSC) and reconstituting (rSC) subtypes. The aim of this study is to compare our outcomes of laparoscopic subtotal cholecystectomies of both subtypes against laparoscopic total cholecystectomy (TC) in difficult emergency laparoscopic cholecystectomies.

METHODS

Patients undergoing emergency laparoscopic cholecystectomy were identified over 2 years and all Nassar scale 3 and 4 cholecystectomies were included for analysis.

RESULTS

108 fSC and 24 rSC were compared against 317 TC. Patients undergoing fSC and rSC were older and more likely to be male. fSC (128 min) and rSC (141 min) recorded longer median operative times than TC (109). Post-operative ERCP was more common after rSC (16.7%). Patients undergoing fSC (2 days) and rSC (3.5 days) had longer post-operative stays. Bile leaks were more likely in fSC (9.3%) and rSC (8.3%) compared to TC (1.9%), Long term morbidity was higher in the rSC group (12.5% vs 10%). And these were solely due to gallbladder remnant complications.

CONCLUSION

Laparoscopic fSC and rSC techniques are associated with a higher rate of bile leaks and rSC has more long term morbidty as compared to TC.

Laparoscopy in Emergency: Why Not? Advantages of Laparoscopy in Major Emergency: A Review

A laparoscopic approach is suggested with the highest grade of recommendation for acute cholecystitis, perforated gastroduodenal ulcers, acute appendicitis, gynaecological disorders, and non-specific abdominal pain (NSAP). To date, the main qualities of laparoscopy for these acute surgical scenarios are clearly stated: quicker surgery, faster recovery and shorter hospital stay. For the remaining surgical emergencies, as well as for abdominal trauma, the role of laparoscopy is still a matter of debate. Patients might benefit from a laparoscopic approach only if performed by experienced teams and surgeons which guarantee a high standard of care. More precisely, laparoscopy can limit damage to the tissue and could be effective for the reduction of the overall amount of cell debris, which is a result of the intensity with which the immune system reacts to the injury and the following symptomatology. In fact, these fragments act as damage-associated molecular patterns (DAMPs). DAMPs, as well as pathogen associated molecular patterns (PAMPs), are recognised by both surface and intracellular receptors of the immune cells and activate the cascade which, in critically ill surgical patients, is responsible for a deranged response. This may result in the development of progressive and multiple organ dysfunctions, manifesting with acute respiratory distress syndrome (ARDS), coagulopathy, liver dysfunction and renal failure. In conclusion, none of the emergency surgical scenarios preclude laparoscopy, provided that the surgical tactic could ensure sufficient cleaning of the abdomen in addition to resolving the initial tissue damage caused by the “trauma”.

Surgical outcome of percutaneous transhepatic gallbladder drainage in acute cholecystitis: Ten years' experience at a tertiary care centre

Background

Percutaneous transhepatic gallbladder drainage (PTGBD) plays an important role in the treatment of elderly patients and/or patients in poor health with acute cholecystitis (AC). The primary aim of this study is to determine how these factors influence the clinical outcome of PTGBD. Moreover, we assessed the timing and results of subsequent cholecystectomies.

Patients and Methods

We retrospectively examined the results of 162 patients undergoing PTGBD between 2010 and 2020 (male–female ratio: 51.23% vs. 48.77%; mean age: 71.43 ± 13.22 years). Patient’s performance status and intervention outcomes were assessed with clinical success rates (CSR) and in-hospital mortality. The conversion rate (CR) of possible urgent or delayed, elective laparoscopic cholecystectomies (LC) after PTGBD were analysed.

Results

PTGBD was the definitive treatment in 42.18% of patients, while it was a bridging therapy prior to cholecystectomy (CCY) for the other patients. CSR was 87.97%, it was only 64.29% in grade III AC. In 9.87% of the cases, urgent LC was necessary after PTGBD, and its conversion rate was approximately equal to that of elective LC (18.18 vs. 17.46%, respectively, p = 0.2217). Overall, the post-PTGBD in-hospital mortality was 11.72%, while the same figure was 0% for grade I AC, 7.41% for grade II and 40.91% for grade III. Based on logistic regression analyses, in-hospital mortality (OR 6.07; CI 1.79–20.56), clinical progression (OR 7.62; CI 2.64–22.05) and the need for emergency CCY (OR 14.75; CI 3.07–70.81) were mostly determined by AC severity grade.

Conclusion

PTGBD is an easy-to-perform intervention with promising clinical success rates in the treatment of acute cholecystitis. After PTGBD, the level of gallbladder inflammation played a decisive role in the course of AC. In a severe, grade III inflammation, we have to consider low CSR and high mortality.

Timing of early laparoscopic cholecystectomy for acute calculous cholecystitis: a meta-analysis of randomized clinical trials

Background

Early cholecystectomy for acute cholecystitis has proved to reduce hospital length of stay but with no benefit in morbidity when compared to delayed surgery. However, in the literature, early timing refers to cholecystectomy performed up to 96 h of admission or up to 1 week of the onset of symptoms. Considering the natural history of acute cholecystitis, the analysis based on such a range of early timings may have missed a potential advantage that could be hypothesized with an early timing of cholecystectomy limited to the initial phase of the disease. The review aimed to explore the hypothesis that adopting immediate cholecystectomy performed within 24 h of admission as early timing could reduce post-operative complications when compared to delayed cholecystectomy.

Methods

The literature search was conducted based on the Patient Intervention Comparison Outcome Study (PICOS) strategy. Randomized trials comparing post-operative complication rate after early and delayed cholecystectomy for acute cholecystitis were included. Studies were grouped based on the timing of cholecystectomy. The hypothesis that immediate cholecystectomy performed within 24 h of admission could reduce post-operative complications was explored by comparing early timing of cholecystectomy performed within and 24 h of admission and early timing of cholecystectomy performed over 24 h of admission both to delayed timing of cholecystectomy within a sub-group analysis. The literature finding allowed the performance of a second analysis in which early timing of cholecystectomy did not refer to admission but to the onset of symptoms.

Results

Immediate cholecystectomy performed within 24 h of admission did not prove to reduce post-operative complications with relative risk (RR) of 1.89 and its 95% confidence interval (CI) [0.76; 4.71]. When the timing was based on the onset of symptoms, cholecystectomy performed within 72 h of symptoms was found to significantly reduce post-operative complications compared to delayed cholecystectomy with RR = 0.60 [95% CI 0.39;0.92].

Conclusion

The present study failed to confirm the hypothesis that immediate cholecystectomy performed within 24 h of admission may reduce post- operative complications unless surgery could be performed within 72 h of the onset of symptoms.

Acute Cholecystitis Following Allogeneic Hematopoietic Stem Cell Transplantation: Clinical Features, Outcomes, Risk Factors, and Prediction Model

Acute cholecystitis (AC) is a potentially fatal complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT); however, only limited information is available on its clinical features, outcomes, and risk management strategies. This retrospective, nested, case-control study included 6701 patients undergoing allo-HSCT at our center from January 2004 to June 2019. In total, 72 patients (1.1%) were diagnosed with AC; among these, acute acalculous cholecystitis had a slightly higher prevalence (42 patients, 58.3%). Patients with moderate and severe AC exhibited remarkably worse overall survival (P = .001) and non-relapse mortality (P = .011) than others. Survival of haploidentical HSCT recipients with AC was comparable to that for patients with human leukocyte antigen (HLA)-identical donors. Age ≥ 18 years, antecedent stage II to IV acute graft-versus-host disease, and total parenteral nutrition were identified as potential risk factors for AC following allo-HSCT, while haploidentical transplantations were not more susceptible to AC than HLA-identical HSCT. Based on these criteria, a risk score model was developed and validated to estimate the probability of AC following allo-HSCT. The model separates all patients into low-, intermediate-, and high-risk groups and thereby provides a basis for early detection of this complication in the management of allo-HSCT.

2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis

BACKGROUND

Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC.

MATERIALS AND METHODS

The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached.

RESULTS

The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal.

CONCLUSIONS, KNOWLEDGE GAPS AND RESEARCH RECOMMENDATIONS

ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.

Accuracy of pre-operative parameters in predicting severe cholecystitis-A systematic review

INTRODUCTION

Severity of cholecystitis can be defined by the presence of histopathological changes such as gangrene, perforation, and empyema. Severe cholecystitis correlates with higher morbidity and longer hospital stay. The present review aimed to identify the predictors of severe cholecystitis.

METHODS

Electronic databases including PubMed, Scopus, and Cochrane library were searched in the period of January 1980 to March 2019. The main outcome of this review was to assess the predictability of pre-operative parameters such as Leukocytosis, fever, tachycardia, gallbladder wall edema, gallbladder distension, serum platelet count, and gallbladder mural striation. The role of patients' characteristics including age, gender, and diabetes mellitus in predicting severe cholecystitis was also assessed.

RESULTS

A total of 8823 patients were analysed. The mean age of patients was 67.14 ± 4.17. The parameters that had the highest Odds ratio in predicting severe cholecystitis were all findings on CT scanning and included attenuation of arterial phase, mural striation of the gallbladder, and decreased gallbladder wall enhancement.

CONCLUSION

We conclude that CT findings were the most significant predictors of severe cholecystitis. Patients with clinical and laboratory predictors of severe cholecystitis should be urgently evaluated with contrast CT scan to rule out any severe complications.

Robotic cholecystectomy for acute cholecystitis: Three case reports

INTRODUCTION

Nowadays laparoscopic cholecystectomy is considered as criterion standard for surgical treatment of acute calculous cholecystitis. During the last few years, there has been growing interest about the robotic approach. Several authors have reported the superiority of robotic cholecystectomy, associated with a lower percentage of conversion especially in patients with intraoperative diagnosis of acute or gangrenous cholecystitis. We report 3 case reports of moderate acute cholecystitis successfully treated by robotic cholecystectomy.

PATIENT CONCERNS

Three patients presented moderate acute calculous cholecystitis with leukocytosis, fever, nausea, vomiting, and pain.

DIAGNOSIS

Three patients of our study population had clinical and laboratory suspicion of moderate acute calculous cholecystitis verified by abdominal ultrasound examination, which found out cholelitiasis in all 3 cases. Final diagnosis was confirmed by intraoperative findings and histopathological examination, with two empyematous cholecystitis and one perforated cholecystitis.

INTERVENTIONS

All patients underwent robotic cholecystectomy with the da Vinci Robotic Surgical System. The entire procedure required a mean operation time of 128 minutes and the average blood loss was 60 mL, without any intraoperative complications.

OUTCOMES

In all 3 cases postoperative period was uneventfull. All the patients were discharged within 24 hours and no readmissions were reported during a 30 days' follow-up.

CONCLUSIONS

Robotic cholecystectomy for ACC is feasible and safe. Several studies have demonstrated that robotic approach reduces the risk of conversion to open surgery in case of acute or gangrenous cholecystitis. Our results are in line with current literature. In fact, we have successfully treated 2 patients with empyematous acute cholecystitis and 1 with gangrenous cholecystitis with a totally robotic approach, without any complications or need of conversion to open surgery. In conclusion, our results confirm that it is the time to include robotic surgery in the emergency setting.

Prophylactic drainage after laparoscopic cholecystectomy for acute cholecystitis: a systematic review and meta-analysis

In the literature, there is a large evidence against the use of drains in laparoscopic cholecystectomy (LC) in elective surgery. However, evidence is lacking in the setting of acute cholecystitis (AC). The present meta-analysis was performed to assess the role of drains to reduce complications and improve recovery in LC for AC. An electronic search of the MEDLINE, Science Citation Index Expanded, SpringerLink, Scopus, and Cochrane Library database from January 1990 to July 2018 was performed to identify randomized clinical trials (RCTs) that compare prophylactic drainage with no drainage in LC for AC. Odds ratio (OR) with confidence interval (CI) for qualitative variables and mean difference (MD) with CI for continuous variables were calculated. Three RCTs were included in the meta-analysis, involving 382 patients randomized to drain (188) versus no drain (194). Morbidity was similar in both the study groups (OR 1.23; 95% CI 0.55-2.76; p = 0.61) as well as wound infection rate (OR 1.98; 95% CI 0.53-7.40; p = 0.31) and abdominal abscess rate (OR 0.62; 95% CI 0.08-4.71; p = 0.31). Abdominal pain 24 h after surgery was less severe in the no drain group (MD 0.80; 95% CI 0.46-1.14; p < 0.000). A significant difference in favor of the no drain group was found in the postoperative hospital stay (MD 1.05; 95% CI 0.87-1.22; p < 0.000). No significant difference was present with respect to postoperative fluid collection in the subhepatic area and operative time. The present study shows that prophylactic drain placement is useless to reduce complications in LC performed to treat AC. Postoperative recovery is improved if drain is not present.

Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy

The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.

Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy

The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.

Association of circulating inflammation proteins and gallstone disease

BACKGROUND AND AIM

Inflammation plays a role in the development of both gallstones and gallbladder cancer; however, few studies have investigated the association of circulating inflammation proteins with risk of gallstones.

METHODS

This study measured 13 cytokines (including 10 interleukins [ILs]) that have been associated with cancer in serum samples collected from 150 gallstone patients and 149 population-based controls from Shanghai, China, in 1997-2001. This study estimated the associations of each cytokine, categorized into quartiles and coded as a trend, with risk of gallstones using logistic regression models adjusted for potential confounders.

RESULTS

Higher levels of IL-6, IL-10, IL-12 (p70), and IL-13 were associated with increased risk of gallstones (i.e. P_trend  < 0.003, Bonferroni corrected), with odds ratios (ORs) that ranged from OR_{highest quartile [Q4] versus lowest quartile [Q1]}  = 3.2 (95% confidence interval: 1.4, 7.5) for IL-13 to OR_{Q4 versus Q1}  = 5.7 (95% confidence interval: 2.5, 13.5) for IL-12 (p70). In a regression model including all four ILs, only IL-12 retained statistical significance (P < 0.05).

CONCLUSION

This study found four circulating ILs that were associated with gallstones. Future studies are needed to validate the findings and evaluate the common pathway or mechanism in the development of gallbladder diseases associated with these cytokine signatures.

Percutaneous Cholecystostomy for Severe Acute Cholecystitis: A Useful Procedure in High-Risk Patients for Surgery

BACKGROUND

Acute cholecystitis has the potential to cause sepsis and death, particularly in patients with poor physiological reserve. The gold standard treatment of acute cholecystitis (cholecystectomy) is often not safe in high-risk patients and recourse is made to percutaneous cholecystostomy as either definite treatment or temporizing measure. The aim of this study is to evaluate early and late outcomes following percutaneous cholecystostomy in patients with acute cholecystitis treated at our institution.

METHODS

All patients who underwent percutaneous cholecystostomy for acute cholecystitis (excluding patients with malignancy) between January 2005 and September 2014 were included in the study.

RESULTS

A total of 53 patients (22 female, median age, 74 years; range, 27-95 years) underwent percutaneous cholecystostomy during the study period. In total, 12 patients (22.6%) had acalculous cholecystitis. The main indications for percutaneous cholecystostomy were significant co-morbidities (n = 28, 52.8%) and patients too unstable for surgery (n = 21, 39.6%). The median time to percutaneous cholecystostomy from diagnosis of acute cholecystitis was 3.6 days (range, 0-45 days). The median length of hospital stay was 27 (range, 4-87) days. The overall 90-day mortality was 9.3% with two further deaths at 12-month follow up. The mortality was significantly higher in patients with American Society of Anesthesiology grade 4-5 (18% vs 0% in American Society of Anesthesiology grade 2-3, p = 0.026) and in patients with acalculous cholecystitis (25% vs 4.5%, p = 0.035). The overall readmission rate was 18%. A total of 24 (45.2%) patients had surgery: laparoscopic cholecystectomy, n = 11; laparoscopic converted to open, n = 5; open total cholecystectomy, n = 5; open cholecystectomy, n = 1; laparotomy and washout, n = 1; laparotomy partial cholecystectomy and closure of perforated small intestine and gastrostomy, n = 1.

CONCLUSION

Percutaneous cholecystostomy is a useful temporary or permanent procedure in patients with acute cholecystitis of both calculous and acalculous origin, who are unfit for surgery.

Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era

BACKGROUND

Laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure. It is superior in nearly every regard compared to open cholecystectomies. The one significant aspect where the laparoscopic approach is inferior regards the association with bile duct injuries (BDI). The BDI rate with laparoscopic cholecystectomy is approximately 0.5%; nearly triple the rate compared to the open approach. We propose that 0.5% BDI rate with the laparoscopic approach is no longer accurate.

METHODS

The National Surgical Quality Improvement Program (NSQIP) registry was retrospectively reviewed. All laparoscopic cholecystectomies performed between 2012 and 2016 were extracted. A total of 217,774 cases meeting inclusion criteria were analyzed. The primary data points were the overall BDI incidence rate and time of diagnosis. BDI were identified by ICD-9 and ICD-10 codes. Secondary data points were variables associated with BDI.

RESULTS

The BDI rate was 0.19%. 77% of cases were diagnosed after the index surgical admission. Intra-operative cholangiography (IOC) use was associated with a higher BDI rate and higher identification rate of a BDI intraoperatively (P value < 0.0001). Resident teaching cases were protective with a RR score of 0.56 (P value < 0.0001). The presence of cholecystitis increased the risk of a BDI with a RR score of 1.20 (P value < 0.0001). There was a low conversion rate of 0.04% however converted cases had a nearly hundredfold increase in BDI at 15% (P value < 0.0001).

CONCLUSIONS

The performance of laparoscopic cholecystectomies in North America is no longer associated with higher BDI rates compared to open. IOC use still is not protective against BDI, and cholecystitis continues to be a risk factor for BDI. When a cholecystectomy requires conversion from a laparoscopic to an open approach the BDI increases a hundredfold; which may raise the concern if this approach is still a safe bailout method for a difficult laparoscopic dissection.

Nondrainage after Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis Does Not Increase the Postoperative Morbidity

Background

It is now established that prophylactic drainage is not needed after laparoscopic cholecystectomy (LC) for chronic calculous cholecystitis. However, the benefit of drains versus their potential harm for acute calculous cholecystitis (ACC) following laparoscopic LC has been questioned. Therefore, we conducted a comparative study to assess the need for drainage.

Methods

Between January 2014 and October 2016, 212 patients with ACC undergoing LC undergo either drainage (n= 106) or no drainage (n= 106). The primary end points were the number of patients with postoperative drain-related complications, early and late Visual Analogue Scale (VAS) score, and hospital stay. Secondary end points included estimated blood loss, postoperative recovery, analgesia requirement, and cosmetic satisfaction result.

Results

There was no bile duct injury and mortality in both groups. The overall complication rate was 12.5% with no significant difference between those with or without drainage (P=0.16). Normal activity resumption was significantly faster and the postoperative hospital stay was slightly shorter in the nondrainage group (P =0.03 and P= 0.04, respectively). The early VAS score in the drainage group was significantly higher (p< 0.05). There were no significant differences between the two groups in postoperative hematology test, late VAS score, and patient satisfaction of cosmetic outcome.

Conclusion

Routine drainage for patients with ACC after LC may not be justified with similar drain-related complications compared with nondrainage group.

Hybrid procedure combining endoscopic gallbladder lavage and internal drainage with elective cholecystectomy for acute cholecystitis: A prospective pilot study (The BLADE study)

BACKGROUND AND AIM

Percutaneous transhepatic drainage is the most common method for non-operative gallbladder drainage, but the technique does have several disadvantages because of its invasive nature and requirement for continuous drainage. To overcome these disadvantages, we developed a novel procedure, endoscopic gallbladder lavage followed by stent placement, carried out in a single endoscopic session. Our aim was to prospectively evaluate the efficacy and safety of this procedure in patients with acute cholecystitis.

METHODS

Patients diagnosed with moderate cholecystitis at four tertiary care centers were enrolled in this study. We initially placed a 5-Fr tube to carry out gallbladder lavage. The tube was then cut to the optimal length and placed as a stent. Main outcomes were procedural and clinical success rates.

RESULTS

The procedure was attempted in 40 patients and was successful in 30 (75.0%). Minor adverse events occurred in two (5.0%) patients: perforation of the cystic duct by the guidewire in one patient and pancreatitis in the other. Among the 30 patients in whom the procedure was successfully done, clinical resolution was obtained in 29 (96.6%). Elective cholecystectomy was carried out in 37 patients (92.5%), with a median delay after drainage of 42 days (range, 12-138 days). There were no adverse events during the waiting period.

CONCLUSIONS

Gallbladder rinsing followed by internal drainage using a 5-Fr nasobiliary tube is considered an effective and safe alternative to other techniques, providing an acceptable success rate in patients with acute cholecystitis prior to elective surgery.

CLINICAL TRIAL INFORMATION

http://www.umin.ac.jp/ctr/index.htm (ID: UMIN-000009680).

Evaluating the Relevance of the 2013 Tokyo Guidelines for the Diagnosis and Management of Cholecystitis

BACKGROUND

The 2013 Tokyo Guidelines (TG13) are used to diagnose, grade severity, and guide management of acute cholecystitis (AC). The aim of our study was to verify the diagnostic criteria, severity assessment, and management protocols based on the TG13.

STUDY DESIGN

Our prospectively maintained emergency general surgery registry was used to review patients who had a surgical consultation for right upper quadrant pain (from 2013 to 2015). Diagnosis and severity were graded based on TG13 and compared with pathology reports. Our institutional management protocols were compared with TG13.

RESULTS

Nine hundred and fifty-two patients were analyzed, of which 857 had biliary diseases. Mean age was 42 ± 18 years and 67% were female. Seven hundred and seventy-nine had a cholecystectomy, 15 underwent cholecystostomy tube placement, and 63 patients were managed conservatively. Only 4% were febrile on presentation and 51% of patients had leukocytosis. Fifty-nine percent of patients did not have any signs of AC on ultrasonography. The TG13 criteria had a sensitivity of 53% for diagnosing AC (definitive 27%, suspected 26%, and undiagnosed 47%) when compared with the final pathology report; 92.5% of patients with grade I, 93% with grade II, and even 64% with grade III, underwent cholecystectomy safely at our institute. There were no differences in complication rates (3.7% vs 4.7%; p = 0.81), return to operating room rates (0.6% vs 0.7%; p = 0.95), or mortality rates (0.3% vs 0%; p = 0.96) between grade I and grade II patients who underwent early cholecystectomy.

CONCLUSIONS

The TG13 diagnostic criteria lack sensitivity and missed more than half of the patients with AC, as many patients lack clinical signs (fever and leukocytosis). The TG13 recommendations for conservative management and delayed cholecystectomy in grade II and grade III disease are not warranted.

Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos)

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Validation of the AAST EGS acute cholecystitis grade and comparison with the Tokyo guidelines

BACKGROUND

Acute cholecystitis presents with heterogeneous severity. The Tokyo Guidelines 2013 is a validated method to assess cholecystitis severity, but the variables are multifactorial. The American Association for the Surgery of Trauma (AAST) developed an anatomically based severity grading system for surgical diseases, including cholecystitis. Because the Tokyo Guidelines represent the gold standard to estimate acute cholecystitis severity, we wished to validate the AAST emergency general surgery scoring system and compare the performance of both systems for several patient outcomes.

METHODS

Adults (≥18 years) with acute cholecystitis during 2013-2016 were identified. Baseline demographic characteristics, comorbidity severity as defined by Charlson Comorbidity Index score, procedure types, and AAST and Tokyo Guidelines 2013 grades were abstracted. Outcomes included duration of stay, 30-day mortality, and complications. Comparison of the Tokyo Guidelines and AAST grading system was performed using receiver operating characteristic (AUROC) curve C statistics.

RESULTS

There were 443 patients, with a mean (±standard deviation) age of 64.8 (±18) years, 59% male. The median (interquartile ratio) Charlson Comorbidity score was 3 (0-6). Management included laparoscopic (n = 307, 69.3%), open (n = 26, 6%), laparoscopy converted to laparotomy (n = 53, 12%), and cholecystostomy (n = 57, 12.7%). Comparison of AAST with Tokyo Guidelines AUROC C statistics indicated (P < .05) mortality (0.86 vs 0.73), complication (0.76 vs 0.63), and cholecystostomy tube utilization (0.80 vs 0.68).

CONCLUSION

Emergency general surgery grading systems improve disease severity assessment, may improve documentation, and guide management. Discrimination of disease severity using the AAST grading system outperforms the Tokyo Guidelines for key clinical outcomes. The AAST grading system requires prospective validation and further comparison.

Risk factors for difficulty of laparoscopic cholecystectomy in grade II acute cholecystitis according to the Tokyo guidelines 2013

Background

The Tokyo Guidelines 2013 classifies acute cholecystitis (AC) into three grades and recommends appropriate therapy for each grade. For grade II AC, either early laparoscopic cholecystectomy (LC) or percutaneous transhepatic gallbladder drainage (PTGBD) should be performed. This study aimed to identify the risk factors for difficulty of LC for treating grade II AC.

Methods

Totally, 122 patients who underwent LC for grade II AC were enrolled and divided into difficult LC (DLC) and nondifficult LC (NDLC) groups. The DLC group included patients who experienced one of the following conditions: conversion from LC to open cholecystectomy, operating time ≥ 180 min, or blood loss ≥300 ml. Preoperative characteristics and postoperative outcomes were analyzed.

Results

In univariate analysis, risk factors included male sex, interval between symptom onset and admission, interval between symptom onset and LC, and anticoagulant therapy. The incidence of postoperative complications was higher in the DLC group than in the NDLC group (23.5% vs. 4.6%, p = 0.0016). According to receiver operating characteristic curves, the optimal cutoff value was calculated, and multivariate analysis showed that male sex [odds ratio (OR), 5.76; 95% confidence interval (CI), 1.979–19.51; p = 0.0009) and interval between symptom onset and LC of over 96 h (OR, 6.32; 95% CI, 2.126–20.15; p = 0.0009) were independent risk factors for difficulty of LC.

Conclusions

In patients with grade II AC, LC was technically difficult when performed over 96 h after symptom onset. Moreover, male sex was a risk factor. Therefore, PTGBD should be considered in these patients.

Electronic supplementary material

The online version of this article (10.1186/s12893-017-0319-6) contains supplementary material, which is available to authorized users.

Postoperative Complications of Laparoscopic Cholecystectomy for Acute Cholecystitis: A Comparison to the ACS-NSQIP Risk Calculator and the Tokyo Guidelines

BACKGROUND

We compared observed postoperative outcomes from laparoscopic cholecystectomy performed for acute cholecystitis (AC) to outcomes predicted by the ACS-NSQIP risk calculator.We also noted and compared any differences in observed outcomes across the different Tokyo Guidelines (TG) levels of AC severity.We hypothesized that ACS-NSQIP would accurately predict complications and length of stay (LOS) and that increased TG severity levels would correlate with more complications, increased conversion to open surgery, and longer LOS.

METHODS

A review of all patients who underwent laparoscopic cholecystectomy for acute cholecystitis over eighteen months was performed.

RESULTS

ACS-NSQIP predicted a complication rate of 4.6% (11% found) and LOS of 0.73 days (2.5 found), p < 0.05. Increased TG severity had LOS of 1.89, 2.75, and 5.33, respectively, p < 0.05. The complication numbers and conversion to open cholecystectomy were insignificant between the TG classes.

CONCLUSION

ACS-NSQIP did not accurately predict complications or LOS. TG classifications did not show a significant difference in complications or conversion to open surgery, but positively correlated with LOS. ACS-NSQIP may not accurately predict patient outcomes and the TG, originally created with the purpose of differentiating levels of inflammation and severity, may only be useful for predicting LOS.

Utility of Laparoscopic Subtotal Cholecystectomy with or without Cystic Duct Ligation for Severe Cholecystitis

We use open cholecystectomy (OC) to treat severe cholecystitis in cases in which we are worried that inflammation might cause anatomical changes in Calot's triangle. Furthermore, in cases of severe cholecystitis in which marked inflammation leads to fibrosis, we perform subtotal cholecystectomy (SC), i.e., incomplete gallbladder resection. Laparoscopic SC (LSC) without cystic duct dissection is considered to be effective at reducing the incidence of serious complications in patients with severe cholecystitis. The cases of 246 patients who underwent cholecystectomy for benign gallbladder disease between January 2011 and May 2015 were evaluated retrospectively. Of these patients, 14 were treated with LSC, and 19 underwent OC. Moreover, three patients in the LSC group underwent LSC without cystic duct ligation because it was considered that it would be difficult to dissect and ligate the cystic duct. The LSC group suffered significantly less intra-operative blood loss than the OC group. However, the operative times of the two groups were similar. Moreover, the duration of the postoperative hospitalization period was significantly shorter in the LSC group than in the OC group. Next, we compared the long-term outcomes of the SC and total cholecystectomy groups, regardless of the surgical method. No cases of cholecystitis or gallbladder cancer were encountered in either group. It is suggested that LSC is safe, effective, and helps to prevent serious complications in cases of severe cholecystitis that require conversion to OC, regardless of whether cystic duct ligation is performed.

Tokyo Guidelines 2013 may be too restrictive and patients with moderate and severe acute cholecystitis can be managed by early cholecystectomy too

OBJECTIVE

The aim of this study was to determine whether early laparoscopic cholecystectomy (LC) is safe and feasible for patients diagnosed with moderate (grade 2) and severe (grade 3) acute cholecystitis (AC) according to the Tokyo Guidelines 2013 (TG13).

BACKGROUND

Early cholecystectomy is the current accepted standard of care for patients with mild (grade 1) and selected grade 2 AC based on TG13. For selected grade 2 and grade 3 AC, early percutaneous cholecystostomy (PC) followed by delayed cholecystectomy is recommended.

METHODS

Patients diagnosed with AC over a 14-month period were identified and divided into three grades of AC based upon chart review using the grading and severity indicators according to TG13.

RESULTS

A total of 149 patients underwent emergency LC. Eighty-two (55 %) patients were male. Eighty-four (56.4 %) patients were classified as grade 1 AC, 49 (32.9 %) as grade 2, and 16 (10.7 %) as grade 3. Eighty-three (98.8 %) patients with grade 1 AC underwent emergency LC, and 1 patient (1.2 %) underwent PC followed by emergency LC. The median length of hospital stay for grade 1 AC patients was 2 (1-11) days. There were 2 (2.4 %) readmissions with fever and no additional complications. Among the 65 patients identified with grade 2 or 3 AC, 6 (9.2 %) underwent PC followed by emergency LC. Fifty-nine (90.8 %) patients underwent emergency cholecystectomy: 58 (98.3 %) LC and one (1.7 %) open cholecystectomy. Among the 58 patients with LC, 3 (5.2 %) patients had open conversion and 10 (17.2 %) patients required subtotal cholecystectomy. One patient was converted to open due to bile duct injury and had hepaticojejunostomy repair. Two other patients were converted due to dense adhesions and inability to safely dissect Calot's triangle. The median length of hospital stay was 4 (1-28) days. There was one readmission for ileus.

CONCLUSION

Severity grading of AC is not the sole determinant of early LC. Patient comorbidity also impacts clinical decision. Confirmation in a larger cohort is warranted.

Is Percutaneous Cholecystostomy a Good Alternative Treatment for Acute Cholecystitis in High-Risk Patients?

Cholecystectomy is the treatment of choice for acute cholecystitis but the management of high-risk surgical patients is a difficult dilemma. Percutaneous cholecystostomy (PC) could represent a safer and less invasive option. The aim of the study was to assess the outcomes of PC in high-risk patients. This is a retrospective single-center study; data were collected from our hospital electronic record system. From February 2009 to March 2014, there were 753 patients admitted with acute cholecystitis. Of these 39 were considered high risk for surgery and underwent PC during their hospital stay. The radiological approach was transperitoneal in 29 patients and transhepatic in 10 patients. Median follow-up was 19 months. There were 27 males (69.2%) and 12 females (30.8%) with a mean age of 72 years (range 41–90 years). Twenty-seven patients had PC as definitive treatment (group A) and 12 patients as a bridge to cholecystectomy (group B). There were no postprocedure complications. Five patients in group A were readmitted once with another episode of cholecystitis after PC (18.5%), one patient in group B was readmitted with cholecystitis after two years before proceeding to cholecystectomy, and two patients were readmitted after cholecystectomy (16.6%) for intra-abdominal collections treated with percutaneous radiological drainage. Seven patients died (17.9%) as a result of severe biliary sepsis during their index hospital admission. PC is a safe approach in high-risk patients with acute cholecystitis and can provide satisfactory long-term results when cholecystectomy is not a viable option.

Optimal timing of cholecystectomy after percutaneous gallbladder drainage for severe cholecystitis

Background

The Tokyo guideline for acute cholecystitis recommended percutaneous transhepatic gallbladder drainage followed by cholecystectomy for severe acute cholecystitis, but the optimal timing for the subsequent cholecystectomy remains controversial.

Methods

Sixty-seven patients who underwent either laparoscopic or open cholecystectomy after percutaneous transhepatic gallbladder drainage for severe acute cholecystitis were enrolled and divided into difficult cholecystectomy (group A) and non-difficult cholecystectomy (group B). Patients who had one of these conditions were placed in group A: 1) conversion from laparoscopic to open cholecystectomy; 2) subtotal cholecystectomy and/or mucoclasis; 3) necrotizing cholecystitis or pericholecystic abscess formation; 4) tight adhesions around the gallbladder neck; and 5) unsuccessfully treated using PTGBD. Preoperative characteristics and postoperative outcomes were analyzed.

Results

The interval between percutaneous transhepatic gallbladder drainage and cholecystectomy in Group B was longer than that in Group A (631 h vs. 325 h; p = 0.031). Postoperative complications occurred more frequently when the interval was less than 216 h compared to when it was more than 216 h (35.7 vs. 7.6%; p = 0.006).

Conclusions

Cholecystectomy for severe acute cholecystitis was technically difficult when performed within 216 h after percutaneous transhepatic gallbladder drainage.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-017-0631-8) contains supplementary material, which is available to authorized users.

A preoperative predictive scoring system to predict the ability to achieve the critical view of safety during laparoscopic cholecystectomy for acute cholecystitis

PURPOSE

The aim of this study was to develop a preoperative scoring system to predict the ability to achieve the critical view of safety (CVS) in patients undergoing emergency laparoscopic cholecystectomy (LC) for acute cholecystitis (AC).

METHODS

A retrospective review of patients who underwent LC for AC between 2012 and 2015 was performed. The achievement or failure of creating the CVS was judged by operative records, video recordings, and interviews of the surgeons. Independent preoperative variables associated with failure were determined by multivariate logistic regression analysis and a prediction scoring system created.

RESULTS

A C-reactive protein (CRP) >5.5 mg/dl, gallstone impaction, and symptom onset to operation >72 h were identified as independently correlated risk factors for the failure to achieve the CVS. A preoperative risk scoring system for the failure to create the CVS (0-5 points) was constructed using these 3 factors: CRP >5.5 mg/dl (2 points), gallstone impaction (1 points), and time from symptom onset to operation >72 h (2 points). When monitoring the frequency of patients who had a failure to create the CVS at each score, the incidence of failure increased as the score increased (P<0.001).

CONCLUSIONS

Using only three preoperative factors, the proposed scoring system provides an objective evaluation of the likelihood that CVS can be achieved in patients undergoing emergency LC for AC.

Cholecystectomy for Acute Cholecystitis After Renal Transplantation

BACKGROUND

The aim of our study was to evaluate the rate of surgical complications, patient outcomes, and impact on graft function in renal transplant recipients in whom cholecystectomy for acute cholecystitis was performed.

METHODS

We reviewed data on transplant patients from January 1, 2006, to December 31, 2013. The subgroup of patients who required subsequent cholecystectomy for acute cholecystitis was assessed, and their data were further analyzed.

RESULTS

Thirty-one patients who underwent cholecystectomy for acute cholecystitis after renal transplantation were included in the study. Clinical signs such as pain in the right upper quadrant, temperature >38°C, and elevation in bilirubin levels occurred in 20 (64.5%), 8 (25.8%), and 3 (9.7%) patients, respectively. Ultrasound signs of acute cholecystitis were present in 27 patients (87.1%). In terms of laboratory values, white blood cell counts >10 × 10(9)/L occurred in 17 patients (54.8%), and C-reactive protein levels >40 mg/L were reported in 21 patients (67.7%). The conversion rate to open surgery was 32.3% (10 patients). In 13 cases, acalculous cholecystitis was present (41.9%). The average serum creatinine level 1 year after cholecystectomy had no statistically significant differences. One patient required temporary dialysis during the postoperative period (with subsequent graft recovery), and 1 graft was lost.

CONCLUSIONS

Acute cholecystitis in kidney transplant recipients is a serious complication, with frequent difficulties related to evaluation and diagnosis. Because clinical signs could be very mild compared with severity of gallbladder affliction, there is little room if any for conservative treatment in these patients. We have not noticed adverse impact of acute cholecystitis on 1-year graft function.

Laparoscopic partial cholecystectomy: A way of getting out of trouble

Aims: Laparoscopic cholecystectomy (LC) is currently the standard treatment for symptomatic gallstones. In the presence of moderate to severe inflammation when dissection of the cholecystohepatic triangle cannot be safely achieved, laparoscopic partial cholecystectomy (LPC) has been proposed as an alternative to open conversion to prevent bile duct injuries. The aim of this study is to review our experience of the technique. Materials and Methods: A retrospective review of all patients who underwent laparoscopic cholecystectomy under the upper gastrointestinal surgical unit at Westmead Hospital was undertaken. The study included all emergency and elective cases during a period from February 2012 to February 2014. Demographic, clinical, operative and postoperative characteristics including operative technique, placement of a drain, complications, length of hospital stay and histopathology were collected. Results: A total of 404 patients underwent LC during the two year study period of which 23 were LPC's. Patients who underwent LPC tended to be older and more likely of the male gender. These patients were also more likely to be an emergency operation and have a higher ASA grade compared to the LC group. Length of stay and operative time tended to be longer. There were five (22%) bile leaks postoperatively and all were successfully managed with postoperative ERCP and stenting. The major complication rate was 35% (8/23) with no bile duct injury or perioperative mortality. Conclusion: This current case series adds further evidence to suggest that LPC is a viable alternative to conversion in cases of difficult LC.

2016 WSES guidelines on acute calculous cholecystitis

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Surgical management of empyematous cholecystitis: a register study of over 12,000 cases from a regional quality control database in Germany

BACKGROUND

Acute cholecystitis is a common indication for surgery. Surgical outcomes depend among other factors on the extent of gallbladder inflammation. Data on the outcomes of patients undergoing cholecystectomy due to acute empyematous cholecystitis are rare.

METHODS

Data from a prospectively maintained quality control database in Germany were analyzed. Cases with empyematous cholecystitis were compared to cases without gallbladder empyema with regard to baseline features, clinical parameters and surgical outcomes.

RESULTS

A total of 12,069 patients with empyematous cholecystitis (EC) were compared to 33,296 patients without empyema. The male gender, advanced age, ASA score >2, elevated white blood count and fever were confirmed as risk factors for EC. The EC group differed significantly from the control group with regard to fever (28.0 vs. 9.5 %), elevated WBC (82.5 vs. 62.3 %) and positive findings from ultrasound sonography (87.4 vs. 76.9 %), p < 0001. Surgery lasted significantly longer in the EC group (86.1 ± 38.5 vs. 72.2 ± 33.6, p < 0.001). The rates of conversion (15.2 vs. 5.8 %), bile duct injury (0.8 vs. 0.4 %), re-intervention (5.5 vs. 2.6 %) and mortality (2.8 vs. 1.2 %) were significantly higher in the EC group, p < 0.001. Similarly, the length of stay (11.9 ± 10.5 vs. 8.8 ± 8.3, p < 0.001) was significantly longer in the EC group.

CONCLUSION

Empyematous cholecystitis is a severe form of acute cholecystitis with high rates of morbidity and mortality. Even the experienced laparoscopic surgeon should expect dissection difficulties, therefore the threshold for conversion in order to prevent bile duct injury should be low.

Factor Analysis Influencing Postoperative Hospital Stay and Medical Costs for Patients with Definite, Suspected, or Unmatched Diagnosis of Acute Cholecystitis according to the Tokyo Guidelines 2013

Purpose. To identify significant independent preoperative factors influencing postoperative hospital stay (PHS) and medical costs (MC) in 171 patients who underwent cholecystectomy for benign gallbladder diseases and had definite, suspected, or unmatched acute cholecystitis (AC) diagnosis according to the Tokyo Guidelines 2013 (TG13). Methods. The 171 patients were classified according to the combination of diagnostic criteria including local signs of inflammation (A), systemic signs of inflammation (B), and imaging findings (C): A+ B+ C (definite diagnosis, n = 84), A+ B (suspected diagnosis, n = 25), (A or B) + C (n = 10), A (n = 41), and B (n = 11). Results. The A+ B + C and (A or B) + C groups had equivalent PHS and MC, suggesting that imaging findings were essential for AC diagnosis. PHS and MC were significantly increased in the order of severity grades based on TG13. Performance status (PS), white blood cell count, and severity grade were identified as preoperative factors influencing PHS by multivariate analysis, and significant independent preoperative factors influencing MC were age, PS, preoperative biliary drainage, hospital stay before surgery, albumin, and severity grade. Conclusion. PS and severity grade significantly influenced prolonged PHS and increased MC.

Endoscopic ultrasound-guided placement of the lumen-apposing self-expandable metallic stent for gallbladder drainage: a promising technique

Acute cholecystitis and other clinical problems requiring gallbladder removal or drainage have conventionally been treated with surgery, endoscopic retrograde cholangiopancreatography or percutaneous transhepatic drainage of the gallbladder and/or extrahepatic bile duct. Patients unable to undergo these procedures due to functional status or anatomical anomalies are candidates for endoscopic ultrasound (EUS)-guided gallbladder drainage with stent placement. The aim of this review was to evaluate the technical feasibility and efficacy of EUS-guided placement of the recently developed lumen-apposing self-expandable metallic stent (LASEMS). A literature review was performed to identify the studies describing this technique. In this review article we have summarized case series or reports describing EUS-guided LASEMS placement. The indications, techniques, limitations and complications reported are discussed. A total of 78 patients were included across all studies described thus far in the literature. Studies have reported near 100% technical and clinical success rates in selected cases. No major complications were reported. EUS-guided gallbladder drainage and LASEMS placement can be a safe and effective alternative approach in the management of selected patients.

Delayed jejunal perforation after laparoscopic cholecystectomy

Bowel perforation is a rare complication of laparoscopic cholecystectomy, which if left undiagnosed can have fatal consequences. In addition, isolated small bowel perforation is extremely rare and should be considered in patients presenting with sudden onset abdominal pain in the postoperative period. A 57-year-old male with symptomatic gallstones underwent urgent laparoscopic cholecystectomy and was discharged home on postoperative day (POD) 1 without complications. He presented to the emergency department on POD 11 complaining of sudden onset abdominal pain. A CT scan did not confirm a diagnosis and he was admitted for observation. On post admission day 2, he became significantly peritonitic and laparotomy revealed jejunal perforation. Bowel resection with hand-sewn anastomosis was completed and he was discharged on POD 10. Follow-up at 6 weeks revealed no further issues. We review the literature on small bowel perforation post laparoscopic cholecystectomy.

Admission after the gold interval in acute calculous cholecystitis: Should we really cool it off?

PURPOSE

The aim of this study was to compare early and delayed cholecystectomy for the treatment of acute calculous cholecystitis (ACC).

MATERIALS AND METHODS

The medical records of patients who were diagnosed to have ACC by combined clinical and radiological examination were evaluated retrospectively. The patients were divided into two non-randomized groups according to the duration between the onset of symptoms and cholecystectomy. Group 1 included the patients who underwent cholecystectomy within the first 72 h after the onset of symptoms and Group 2 those who underwent beyond the 72nd hour after the onset of symptoms.

RESULTS

We reviewed records for 203 patients. There were 109 patients in Group 1 and 74 patients in Group 2. Access-related complications occurred in four patients. One patient in Group 1 and two patients in Group 2 had trocar site bleeding. In one patient in Group 1, liver trauma occurred. Two patients had bile duct injury in Group 1 as Type D injury according to the Strasberg classification in one patient and E2 injury in other.

CONCLUSION

Early cholecystectomy in acute cholecystitis with biliary stones could be performed regardless of time with similar complication, mortality and conversion rates.

Critically ill patients with acute cholecystitis are at increased risk for extensive gallbladder inflammation

Background

Acute cholecystitis is a common diagnosis and surgery is the standard of care for young and fit patients. However, due to high risk of postoperative morbidity and mortality, surgical management of critically ill patients remains a controversy. It is not clear, whether the increased risk of perioperative complications associated with the management of critically ill patients with acute cholecystitis is secondary to reduced physiologic reserve per se or to the severity of gallbladder inflammation.

Methods

A retrospective analysis of prospectively collected data of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a university hospital over a three-year-period was performed. The ASA scores at the time of presentation were used to categorize patients into two groups. The study group consisted of critically ill patients with ASA 3 and 4, while the control group was made up of fit patients with ASA 1 and 2. Both groups were compared with regard to perioperative data, postoperative outcome and extent of gallbladder inflammation on histopathology.

Results

Two hundred and seventeen cases of acute cholecystitis with complete charts were available for analysis. The study group included 67 critically ill patients with ASA 3 and 4, while the control group included 150 fit patients with ASA 1 and 2. Both groups were comparable with regard to perioperative data. Histopathology confirmed severe cholecystitis in a significant number of cases in the study group compared to the control group (37 % vs. 18 %, p = 0.03). Significantly higher rates of morbidity and mortality were recorded in the study group (p < 0.05). Equally, significantly more patients from the study group were managed in the ICU (40 % vs. 8 %, p = 0.001).

Conclusion

Critically ill patients presenting with acute cholecystitis are at increased risk for extensive gallbladder inflammation. The increased risk of morbidity and mortality seen in such patients might partly be secondary to severe acute cholecystitis.

Percutaneous cholecystostomy is safe and effective option for acute calculous cholecystitis in select group of high-risk patients

PURPOSE

In high-risk patients with acute calculous cholecystitis (ACC), percutaneous cholecystostomy (PC) can serve as a bridging option to cholecystectomy [laparoscopic cholecystectomy (LC)] or as definitive treatment. The purpose of this study was to identify predictors of the need for permanent PC.

METHODS

Data from 257 PCs performed for ACC (mean age 67.3 ± 14) was collected for a 10-year period. Demographic and clinical characteristics at initial admission, co-morbidities were analyzed. Patients who underwent interval LC were defined as the surgery group (SG; n = 163, 63.4 %) and the remaining patients as the non-SG (NSG; n = 94, 36.6 %).

RESULTS

Patients in the SG were significantly younger and had a shorter length of hospital stay (p < 0.01). The rate of coronary artery disease (CAD; 63.2 vs. 20.2 %), chronic renal failure (14.9 vs. 6.1 %), and the mean number of co-morbidities (2.2 vs. 1.4) were significantly higher in the NSG. Sepsis at admission was more common in the NSG (19.1 vs. 4.9 %, p < 0.001). 56 patients (34.4 %) in the SG and 24 patients (25.5 %) in the NSG developed tube-related complications. In hospital mortality was similar between the groups. Multivariate analysis showed that age ≥75, increased alkaline phosphatase (ALK-P), history of CAD, were predictors of PC as a definite treatment in this high-risk group of patients with ACC.

CONCLUSIONS

High operative risk due to older age and CAD preclude LC in more than one-third of patients following PC especially presenting with sepsis and elevated ALK-P. This study suggests that PC could be a safe treatment option in this select group of high-risk patients.

Emergency laparoscopy: Role and implementation

Laparoscopic surgery has emerged over the past two decades as the surgical approach of choice in the treatment of many digestive disorders. Laparoscopy has its place in the management of abdominal surgical emergencies since it provides the same benefits: less postoperative pain and shorter length of hospital stay when compared to laparotomy. However, its role in the management of abdominal emergencies has not yet been fully clarified. In this review, we focus on what has been validated concerning the role of emergency laparoscopy in the management of abdominal diseases.

Does the Tokyo guidelines predict the extent of gallbladder inflammation in patients with acute cholecystitis? A single center retrospective analysis

Background

The Tokyo guidelines provide criteria for the diagnosis and classification of acute cholecystitis in three severity grades. However, no data exists on the predictive value of these guidelines. The aim of this study was to analyze the accuracy of the Tokyo guidelines as a predicting parameter for the severity of acute cholecystitis in patients undergoing laparoscopic cholecystectomy.

Methods

A retrospective analysis of the charts of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a primary care hospital within a five-year period was performed. The preoperative severity grades were compared with the histological extent of inflammation.

Results

One hundred thirty-eight patients; 79 with severity grade I, 33 with grade II and 26 with grade III were analyzed. The incidence of uncomplicated cholecystitis decreased with increasing severity grade, while the incidence of complicated cholecystitis increased with increasing severity. However, complicated cholecystitis was evident in an unexpectedly high number of cases with severity grade I. There was a significant correlation (χ²(1) = 10. 43, p = 0.01) between the preoperative severity grade and the extent of gallbladder inflammation on histopathology. Conversion to open surgery (14 vs. 5, p = 0.002) and complications (17 vs. 7, p = 0.001) were significantly higher in patients with preoperative severity grade II/III compared to patients with severity grade I.

Conclusion

Worsening clinical severity correlated significantly with worseing pathology, findings from blood test and clinical outcomes; rates of conversion and morbidity. However, the Tokyo guidelines may have a tendency to underestimate the extent of inflammation in male patients with severity grade I and over estimate the difficulty of dissection in severity grade II.

Laparoscopic management of intra-abdominal infections: Systematic review of the literature

AIM: To investigate the role of laparoscopy in diagnosis and treatment of intra abdominal infections.

METHODS: A systematic review of the literature was performed including studies where intra abdominal infections were treated laparoscopically.

RESULTS: Early laparoscopic approaches have become the standard surgical technique for treating acute cholecystitis. The laparoscopic appendectomy has been demonstrated to be superior to open surgery in acute appendicitis. In the event of diverticulitis, laparoscopic resections have proven to be safe and effective procedures for experienced laparoscopic surgeons and may be performed without adversely affecting morbidity and mortality rates. However laparoscopic resection has not been accepted by the medical community as the primary treatment of choice. In high-risk patients, laparoscopic approach may be used for exploration or peritoneal lavage and drainage. The successful laparoscopic repair of perforated peptic ulcers for experienced surgeons, is demonstrated to be safe and effective. Regarding small bowel perforations, comparative studies contrasting open and laparoscopic surgeries have not yet been conducted. Successful laparoscopic resections addressing iatrogenic colonic perforation have been reported despite a lack of literature-based evidence supporting such procedures. In post-operative infections, laparoscopic approaches may be useful in preventing diagnostic delay and controlling the source.

CONCLUSION: Laparoscopy has a good diagnostic accuracy and enables to better identify the causative pathology; laparoscopy may be recommended for the treatment of many intra-abdominal infections.