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Harry ML, Colling KP, Dindinger-Hill K, Salama PS, Woehrle TA, Brenholdt M, Moran SE. Increased Morbidity and One-Year Post-Discharge Mortality in Patients with Bacteremia Undergoing Emergent Cholecystectomy: An Exploratory Retrospective Observational Study. Surg Infect (Larchmt) 2024. [PMID: 39320332 DOI: 10.1089/sur.2024.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2024] Open
Abstract
Background: Gallbladder disease, one of the most common diseases in the United States, ranges from symptomatic gallstones to severe systemic infections from cholangitis. Little research is available on how often patients undergoing emergent cholecystectomy also have bacteremia. We hypothesized that blood cultures would be performed rarely in patients undergoing emergent cholecystectomy, and that positive cultures would be associated with worse outcomes. Methods: Exploratory retrospective observational cohort study of patients admitted to a single institution from January 17, 2011, to December 31, 2018, and undergoing emergent cholecystectomy by acute care surgeons within ∼72 hours, or three days, of admission. Analyses included descriptive and by-variable statistics, binary logistic regression, and negative binomial regression. Results: Of 892 patients undergoing emergent cholecystectomy, 145 (16.2%) had blood cultures obtained three days before or on the day of surgery, of whom 33 (22.8%) had at least one positive blood culture. Male and older patients had significantly higher rates of blood cultures being obtained. One-year post-discharge mortality and complication rates were significantly higher in those with blood cultures. Versus patients with negative blood cultures, those with positive cultures were significantly older and had higher rates of sepsis and septicemia, longer hospital stays, lower rates of being discharged home, and higher one-year post-discharge mortality rates (18.2% vs. 6.3%). Cholangitis, accounting for 29% of positive blood cultures, was diagnosed in 4.5% of emergent cholecystectomies performed. Gram-negative Escherichia coli were the most common bacteria isolates. Conclusions: Positive blood cultures were associated with significantly worse patient outcomes. Surgeons performing emergent cholecystectomies could consider implementing blood culture protocols to better identify patients at risk for greater hospital morbidity and post-discharge mortality.
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Affiliation(s)
- Melissa L Harry
- Essentia Institute of Rural Health, Essentia Health, Duluth, Minnesota, USA
| | | | | | - Peter S Salama
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Theo A Woehrle
- Essentia Institute of Rural Health, Essentia Health, Duluth, Minnesota, USA
| | - Morgan Brenholdt
- Essentia Institute of Rural Health, Essentia Health, Duluth, Minnesota, USA
| | - Sharon E Moran
- Essentia Health-St. Mary's Medical Center, Duluth, Minnesota, USA
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Fico V, La Greca A, Tropeano G, Di Grezia M, Chiarello MM, Brisinda G, Sganga G. Updates on Antibiotic Regimens in Acute Cholecystitis. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1040. [PMID: 39064469 PMCID: PMC11279103 DOI: 10.3390/medicina60071040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/18/2024] [Accepted: 06/24/2024] [Indexed: 07/28/2024]
Abstract
Acute cholecystitis is one of the most common surgical diseases, which may progress from mild to severe cases. When combined with bacteremia, the mortality rate of acute cholecystitis reaches up to 10-20%. The standard of care in patients with acute cholecystitis is early laparoscopic cholecystectomy. Percutaneous cholecystostomy or endoscopic procedures are alternative treatments in selective cases. Nevertheless, antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis. Patients with acute cholecystitis have a bile bacterial colonization rate of 35-60%. The most frequently isolated microorganisms are Escherichia coli, Klebsiella spp., Streptococcus spp., Enterococcus spp., and Clostridium spp. Early empirical antimicrobial therapy along with source control of infection is the cornerstone for a successful treatment. In these cases, the choice of antibiotic must be made considering some factors (e.g., the severity of the clinical manifestations, the onset of the infection if acquired in hospital or in the community, the penetration of the drug into the bile, and any drug resistance). Furthermore, therapy must be modified based on bile cultures in cases of severe cholecystitis. Antibiotic stewardship is the key to the correct management of bile-related infections. It is necessary to be aware of the appropriate therapeutic scheme and its precise duration. The appropriate use of antibiotic agents is crucial and should be integrated into good clinical practice and standards of care.
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Affiliation(s)
- Valeria Fico
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Istituto di Ricerca e Cura a Carattere Scientifico, Fondazione Policlinico Universitario Agostino Gemelli, 00168 Rome, Italy; (V.F.); (A.L.G.); (G.T.); (M.D.G.); (G.S.)
| | - Antonio La Greca
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Istituto di Ricerca e Cura a Carattere Scientifico, Fondazione Policlinico Universitario Agostino Gemelli, 00168 Rome, Italy; (V.F.); (A.L.G.); (G.T.); (M.D.G.); (G.S.)
- Catholic School of Medicine “Agostino Gemelli”, 00168 Rome, Italy
| | - Giuseppe Tropeano
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Istituto di Ricerca e Cura a Carattere Scientifico, Fondazione Policlinico Universitario Agostino Gemelli, 00168 Rome, Italy; (V.F.); (A.L.G.); (G.T.); (M.D.G.); (G.S.)
| | - Marta Di Grezia
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Istituto di Ricerca e Cura a Carattere Scientifico, Fondazione Policlinico Universitario Agostino Gemelli, 00168 Rome, Italy; (V.F.); (A.L.G.); (G.T.); (M.D.G.); (G.S.)
| | - Maria Michela Chiarello
- General Surgery Operative Unit, Department of Surgery, Azienda Sanitaria Provinciale Cosenza, 87100 Cosenza, Italy;
| | - Giuseppe Brisinda
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Istituto di Ricerca e Cura a Carattere Scientifico, Fondazione Policlinico Universitario Agostino Gemelli, 00168 Rome, Italy; (V.F.); (A.L.G.); (G.T.); (M.D.G.); (G.S.)
- Catholic School of Medicine “Agostino Gemelli”, 00168 Rome, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Istituto di Ricerca e Cura a Carattere Scientifico, Fondazione Policlinico Universitario Agostino Gemelli, 00168 Rome, Italy; (V.F.); (A.L.G.); (G.T.); (M.D.G.); (G.S.)
- Catholic School of Medicine “Agostino Gemelli”, 00168 Rome, Italy
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Hirata BHN, Sasagawa S, Navarini A, Mateus HC, Pacheco Junior AM, Salles MJC. Comparison of bacterial profile of gallbladder with gallstones from patients undergoing cholecystectomy due to complicated and uncomplicated cholelithiasis: changes in the epidemiological scenario. Rev Col Bras Cir 2023; 50:e20233474. [PMID: 37162041 PMCID: PMC10508671 DOI: 10.1590/0100-6991e-20233474-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 02/07/2023] [Indexed: 05/11/2023] Open
Abstract
INTRODUCTION cholelithiasis is a highly prevalent disease of the digestive system in the world. In Brazil, it is a routine condition, whose studies suggest a prevalence of around 10% of adults. Colonization of bile and gallstone pathogens can occur when there is bacterial stasis and proliferation. This proliferation is facilitated by the adhesion and biofilm formation capacity of some bacteria. There are also lithogenic processes that involve bacterial participation. Studies have shown changes in the microbiota of the gallbladder of patients undergoing cholecystectomy, which may impact empirical treatment with antibiotics. METHODOLOGY microbiological analyzes of the sonication fluid of the gallstones and of two samples with bile were performed. Identification and antimicrobial susceptibility testing were performed according to a standard routine. RESULTS of the 34 patients, 76.4% were female. The age group was 48 years +/- 16.61. Acute cholecystitis occurred in 50% of cases. Bactobilia was evidenced in 32.1% of the cases. Klebisiella pneumoniae was noted as the most prevalent pathogen in acute cholecystitis; and Enterobacter sp, in cases of uncomplicated cholelithiasis. Greater sensitivity was obtained in the search for microorganisms in the sonication fluid samples of the stones in relation to the bile samples (p=0.0058). CONCLUSION there was a higher prevalence of bactobilia in patients with acute cholecystitis compared to those with uncomplicated cholelithiasis. The use of sonication in bacterial investigation proved to be superior to the conventional method and can be considered.
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Affiliation(s)
| | - Suzethe Sasagawa
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Microbiologia - São Paulo - SP - Brasil
| | - Alessandra Navarini
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Microbiologia - São Paulo - SP - Brasil
| | - Henrique Cunha Mateus
- - Hospital de Misericórdia da Santa Casa de São Paulo, Cirurgia - São Paulo - SP - Brasil
| | | | - Mauro José Costa Salles
- - Hospital de Misericórdia da Santa Casa de São Paulo, Infectologia - São Paulo - SP - Brasil
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Moon DK, Kang JS, Byun Y, Choi YJ, Lee HW, Jang JY, Lim CS. Incidence of bactibilia and related factors in patients who undergo cholecystectomy. Ann Surg Treat Res 2023; 104:10-17. [PMID: 36685772 PMCID: PMC9830044 DOI: 10.4174/astr.2023.104.1.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/13/2022] [Accepted: 10/25/2022] [Indexed: 01/04/2023] Open
Abstract
Purpose In general, bile is normally sterile. However, there are reports bactibilia may occur in certain instances, though the causal factors are unclear. We analyzed possible preoperative predictors of bactibilia upon cholecystectomy. Methods Bile samples were collected during cholecystectomies from November 2018 to November 2019. A total of 428 open or laparoscopic cholecystectomies were performed. Preoperative, intraoperative, and postoperative variables were compared between the culture-positive and culture-negative groups. Results One hundred fifty-seven patients (36.7%) were culture-positive. Gram-negative bacteria (95 [61.0%]) were more common. Escherichia coli (38 [40.0%]) and Enterobacter (22 [23.2%]) were the most common species. In univariate analysis, age of ≥70 years (P < 0.001), male sex (P < 0.001), high American Society of Anesthesiologists physical status grades (P = 0.001), diabetes mellitus (P = 0.002), jaundice (P = 0.007), high Tokyo Guideline grades (P = 0.008), percutaneous transhepatic gallbladder drainage (PTGBD; P < 0.001), endoscopic retrograde cholangiopancreatography (ERCP; P < 0.001) were identified as a risk factors for bactibilia. In multivariate analysis, age of ≥70 years (hazard ratio [HR], 2.874; 95% confidence interval [CI], 1.769-4.670; P = 0.001), ERCP (HR, 9.001; 95% CI, 4.833-16.75; P < 0.001), and PTGBD (HR, 2.866; 95% CI, 1.440-4.901; P = 0.002) were independent risk factors for bactibilia. Conclusion Among patients who underwent cholecystectomy, those who were elderly, symptomatic, and underwent preoperative drainage were more likely to have bactibilia. In such cases, surgeons should take care to prevent bile leakage during surgery and consider administering appropriate antibiotics.
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Affiliation(s)
- Do Kyoon Moon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Korea University Medical College, Seoul, Korea
| | - Yoonhyeong Byun
- Department of Surgery, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Korea
| | - Yoo Jin Choi
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Korea University Medical College, Seoul, Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Chang-Sup Lim
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
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5
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Clinical implication of bactibilia in moderate to severe acute cholecystitis undergone cholecystostomy following cholecystectomy. Sci Rep 2021; 11:11864. [PMID: 34088947 PMCID: PMC8178313 DOI: 10.1038/s41598-021-91261-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/20/2021] [Indexed: 12/07/2022] Open
Abstract
There is little evidence of clinical outcome in using antibiotics during the perioperative phase of acute cholecystitis with bactibilia. The aim of current study is to examine the effect of bactibilia on patients with acute cholecystitis and their perioperative clinical outcome. We performed a retrospective cohort analysis of 128 patients who underwent cholecystectomy for acute cholecystitis with moderate and severe grade. Patients who were positive for bactibilia were compared to bactibilia-negative group in following categories: morbidity, duration of antimicrobial agent use, in-hospital course, and readmission rate. There was no difference in morbidity when patients with bactibilia (n = 70) were compared to those without (n = 58) after cholecystectomy. The duration of antibiotics use and clinical course were also similar in both groups. In severe grade AC group (n = 18), patients used antibiotics and were hospitalized for a significantly longer period of time than those in the moderate grade AC group. The morbidity including surgical site infection, and readmission rates were not significantly different in moderate and severe grade AC groups. In moderate and severe AC groups, bactibilia itself did not predict more complication and worse clinical course. Antibiotics may be safely discontinued within few days after cholecystectomy irrespective of bactibilia when cholecystectomy is successful.
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Kaplan U, Handler C, Chazan B, Weiner N, Hatoum OA, Yanovskay A, Kopelman D. The Bacteriology of Acute Cholecystitis: Comparison of Bile Cultures and Clinical Outcomes in Diabetic and Non-Diabetic Patients. World J Surg 2021; 45:2426-2431. [PMID: 33860354 DOI: 10.1007/s00268-021-06107-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND Acute cholecystitis is one of the most common acute surgical diseases. Diabetic patients have been shown to have an increased risk for gallbladder disease, but the correlation between the severity of gallstone disease and diabetes is still debated. The aim of this study is to examine the possible difference in the disease process between patients with diabetes mellitus (DM) and those without. PATIENTS AND METHODS A retrospective study was conducted of all patients who underwent percutaneous cholecystostomy between 2005 and 2015 at Emek Medical Center, Afula, Israel. Demographic and medical history including data on bile and blood culture results, antimicrobial susceptibility, and clinical outcomes were retrieved from patient files. RESULTS The cohort included 272 patients. Mean age was 68 years old, 50.74% were male and 43.75% had diabetes mellitus. Bile cultures were obtained from 252 (92.64%) patients and were positive in 134 (53.2%) patients. In 11 patients (4%) two pathogens were isolated. Blood cultures obtained from 231 patients and were positive in 35 (15.2%). Escherichia coli was the most common isolate, and was seen in 22.3% of positive bile cultures and 40% of blood cultures. Although diabetic patients had significantly more positive bile cultures, the severity of the disease, according to the Tokyo guidelines, was not higher. CONCLUSIONS Acute cholecystitis was neither more severe nor had significant difference in bacteriological properties when comparing diabetic patients to non-diabetic ones.
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Affiliation(s)
- Uri Kaplan
- Department of General Surgery B, Emek Medical Center, Yitzhak Rabin Boulevard 21, 1834111, Afula, Israel.
| | - Chovav Handler
- Department of General Surgery B, Emek Medical Center, Yitzhak Rabin Boulevard 21, 1834111, Afula, Israel
| | - Bibiana Chazan
- Infectious Disease Unit, Emek Medical Center, Yitzhak Rabin Boulevard 21, 1834111, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology,, Efron st. 1, Bat Galim,, 3525433, Haifa, Israel
| | - Noam Weiner
- Department of General Surgery B, Emek Medical Center, Yitzhak Rabin Boulevard 21, 1834111, Afula, Israel
| | - Ossama A Hatoum
- Department of General Surgery B, Emek Medical Center, Yitzhak Rabin Boulevard 21, 1834111, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology,, Efron st. 1, Bat Galim,, 3525433, Haifa, Israel
| | - Anna Yanovskay
- Infectious Disease Unit, Emek Medical Center, Yitzhak Rabin Boulevard 21, 1834111, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology,, Efron st. 1, Bat Galim,, 3525433, Haifa, Israel
| | - Doron Kopelman
- Department of General Surgery B, Emek Medical Center, Yitzhak Rabin Boulevard 21, 1834111, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology,, Efron st. 1, Bat Galim,, 3525433, Haifa, Israel
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7
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Loftus TJ, Brakenridge SC, Dessaigne CG, Sarosi GA, Zingarelli WJ, Moore FA, Jordan JR, Croft CA, Smith RS, Efron PA, Mohr AM. Antibiotics May be Safely Discontinued Within One Week of Percutaneous Cholecystostomy. World J Surg 2017; 41:1239-1245. [PMID: 28050668 DOI: 10.1007/s00268-016-3861-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND For patients with acute cholecystitis managed with percutaneous cholecystostomy (PC), the optimal duration of post-procedural antibiotic therapy is unknown. Our objective was to compare short versus long courses of antibiotics with the hypothesis that patients with persistent signs of systemic inflammation 72 h following PC would receive prolonged antibiotic therapy and that antibiotic duration would not affect outcomes. METHODS We performed a retrospective cohort analysis of 81 patients who underwent PC for acute cholecystitis at two hospitals during a 41-month period ending November 2014. Patients who received short (≤7 day) courses of post-procedural antibiotics were compared to patients who received long (>7 day) courses. Treatment response to PC was evaluated by systemic inflammatory response syndrome (SIRS) criteria. Logistic and linear regressions were used to evaluate associations between antibiotic duration and outcomes. RESULTS Patients who received short (n = 30) and long courses (n = 51) of antibiotics had similar age, comorbidities, severity of cholecystitis, pre-procedural vital signs, treatment response, and culture results. There were no differences in recurrent cholecystitis (13 vs. 12%), requirement for open/converted to open cholecystectomy (23 vs. 22%), or 1-year mortality (20 vs. 18%). On logistic and linear regressions, antibiotic duration as a continuous variable was not predictive of any salient outcomes. CONCLUSIONS Patients who received short and long courses of post-PC antibiotics had similar baseline characteristics and outcomes. Antibiotic duration did not predict recurrent cholecystitis, interval open cholecystectomy, or mortality. These findings suggest that antibiotics may be safely discontinued within one week of uncomplicated PC.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
| | - Scott C Brakenridge
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
- University of Florida Sepsis and Critical Illness Research Center, Gainesville, FL, USA
| | - Camille G Dessaigne
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
| | - George A Sarosi
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
- Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, USA
| | - William J Zingarelli
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
- Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, USA
| | - Frederick A Moore
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
- University of Florida Sepsis and Critical Illness Research Center, Gainesville, FL, USA
| | - Janeen R Jordan
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
| | - Chasen A Croft
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
| | - R Stephen Smith
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
| | - Phillip A Efron
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA
- University of Florida Sepsis and Critical Illness Research Center, Gainesville, FL, USA
| | - Alicia M Mohr
- Department of Surgery, University of Florida, 1600 SW Archer Road, PO Box 100108, Gainesville, FL, 32610, USA.
- University of Florida Sepsis and Critical Illness Research Center, Gainesville, FL, USA.
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Cueto-Ramos R, Hernández-Guedea M, Pérez-Rodríguez E, Reyna-Sepúlveda F, Muñoz-Maldonado G. [Incidence of bacteria from cultures of bile and gallbladder wall of laparoscopic cholecystectomy patients in the University Hospital "Dr. José Eleuterio González"]. CIR CIR 2017; 85:515-521. [PMID: 28104282 DOI: 10.1016/j.circir.2016.10.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 10/17/2016] [Indexed: 12/07/2022]
Abstract
BACKGROUND Through experience it has been accepted that bile in normal conditions remains sterile. Bactibilia is a common finding in individuals at high risk or with complicated cholecystolithiasis, however few data prevails about the prevalence of bactibilia in patients operated on for uncomplicated laparoscopic cholecystectomy. There is s common usage of preoperative and postoperative antibiotics in the different patients without the existence of any actual bacteriologic and epidemiologic evidence. MATERIAL AND METHODS 183 patients with diagnosis of cholecystolithiasis postoperated of laparoscopic cholecystectomy had their bile sent to bacteriology. RESULTS Bactibilia was identified in 31.95% of the cultures of mild cholecystitis and in 35.71% for moderate (p<.0001). A total of 125 negative cultures were obtained (68.3) and 58 positive (31.69%) with a prevalence of enterobacteria group (43.10%) and Enterococcus (27.58). CONCLUSIONS Comparing the groups according to severity there is a significant difference with regard to the presence of bactibilia, in addition to the bacterial groups cultivated. Fluoroquinolones and metronidazole is an option for the treatment of patients with the suspicion of bactibilia. The use of antibiotics is not justified in patients at low risk.
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Affiliation(s)
- Rubén Cueto-Ramos
- Servicio de Cirugía General, Hospital Universitario «Dr. José Eleuterio González», Monterrey, México
| | - Marco Hernández-Guedea
- Servicio de Cirugía General, Hospital Universitario «Dr. José Eleuterio González», Monterrey, México.
| | - Edelmiro Pérez-Rodríguez
- Servicio de Cirugía General, Hospital Universitario «Dr. José Eleuterio González», Monterrey, México
| | - Francisco Reyna-Sepúlveda
- Servicio de Cirugía General, Hospital Universitario «Dr. José Eleuterio González», Monterrey, México
| | - Gerardo Muñoz-Maldonado
- Servicio de Cirugía General, Hospital Universitario «Dr. José Eleuterio González», Monterrey, México
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Reducing Morbidity in Urgent Gastroenterologic Surgery; Propensity Score Analysis Using Triclosan-Coated Polydioxanone Sutures. Int Surg 2017. [DOI: 10.9738/intsurg-d-17-00047.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Superficial surgical site infections (S-SSIs), which prolonged hospital stay and increased costs, are a critical problem. The aim of the present study was to clarify the risk factors for S-SSIs after urgent gastroenterologic surgery and what surgeons can do to reduce their incidence and to shorten the hospital stay. A total of 275 patients who underwent urgent gastroenterologic surgery were enrolled in the present study. The correlations between the incidence of S-SSIs and clinicopathologic factors were retrospectively analyzed using propensity score matching. Of 275 cases, 43 (15.6%) patients had an S-SSI. On univariate analysis, the following factors were associated with a significantly higher incidence of S-SSI: American Society of Anesthesiologists score (P = 0.043); wound classification (P = 0.0005); peritonitis (P = 0.019); prolonged operation time (P = 0.0001); increased blood loss (P = 0.019); transfusion (P = 0.0047); and abdominal closure without triclosan-coated polydioxanone sutures (P = 0.042). However, a propensity score–matching analysis showed that abdominal closure using triclosan-coated polydioxanone sutures did not reduce the incidence of S-SSIs in patients who underwent urgent gastroenterologic surgery (P = 0.20), but it tended to be associated with a shorter hospital stay (P = 0.082). To reduce morbidity after urgent gastroenterologic surgery, surgeons should shorten the operation time and decrease the blood loss. In addition, abdominal closure using triclosan-coated polydioxanone sutures alone could not reduce the incidence of S-SSIs but might shorten the hospital stay after urgent gastroenterologic surgery by inhibiting bacterial activity and preventing prolongation of the infections.
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10
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Pasquali S, Boal M, Griffiths EA, Alderson D, Vohra RS. Meta-analysis of perioperative antibiotics in patients undergoing laparoscopic cholecystectomy. Br J Surg 2015; 103:27-34; discussion 34. [DOI: 10.1002/bjs.9904] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/21/2015] [Accepted: 06/23/2015] [Indexed: 01/05/2023]
Abstract
Abstract
Background
The effectiveness of perioperative antibiotics in reducing surgical-site infection (SSI) and overall nosocomial infections in patients undergoing laparoscopic cholecystectomy for biliary colic and low- and moderate-risk cholecystitis (Tokyo classification) is unclear. A systematic review and meta-analysis was performed to assess this.
Methods
Searches were conducted of the MEDLINE, Embase and Cochrane databases. Only randomized clinical trials (RCTs) were included. The analysis was performed using the random-effects method, and the risk ratio (RR) with 95 per cent c.i. was employed.
Results
Nineteen RCTs, published between 1997 and 2015, with a total of 5259 participants, of whom 2709 (51·5 per cent) were treated with antibiotics, were included. SSI and overall nosocomial infections were detected in 2·4 and 4·2 per cent respectively of patients given perioperative antibiotics, and in 3·2 and 7·2 per cent of those who received no antibiotics. Antibiotics did not significantly reduce the risk of SSI (RR 0·81, 95 per cent c.i. 0·58 to 1·13; P = 0·21) or overall nosocomial infections (RR 0·64, 0·36 to 1·14; P = 0·13). There was no significant between-study heterogeneity for SSI, but significant between-study heterogeneity in the eight studies that reported nosocomial infections. Analysis of studies considered to be high quality, grouped according to the timing of antibiotics (preoperative only or perioperative) and reporting intention-to-treat analyses, again failed to show a significant reduction in SSI.
Conclusion
Antibiotics should not be administered before laparoscopic cholecystectomy in patients with biliary colic and/or low- and moderate-risk cholecystitis.
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Affiliation(s)
- S Pasquali
- Department of Upper Gastro-Intestinal Surgery, Queen Elizabeth Hospital, Birmingham, UK
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, Birmingham, UK
| | - M Boal
- Department of Upper Gastro-Intestinal Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - E A Griffiths
- Department of Upper Gastro-Intestinal Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - D Alderson
- Department of Upper Gastro-Intestinal Surgery, Queen Elizabeth Hospital, Birmingham, UK
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - R S Vohra
- Department of Upper Gastro-Intestinal Surgery, Queen Elizabeth Hospital, Birmingham, UK
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
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Coccolini F, Sartelli M, Catena F, Montori G, Di Saverio S, Sugrue M, Ceresoli M, Manfredi R, Ansaloni L. Antibiotic resistance pattern and clinical outcomes in acute cholecystitis: 567 consecutive worldwide patients in a prospective cohort study. Int J Surg 2015; 21:32-7. [DOI: 10.1016/j.ijsu.2015.07.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 06/12/2015] [Accepted: 07/02/2015] [Indexed: 12/29/2022]
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12
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Rodríguez-Sanjuán JC, Casella G, Antolín F, Castillo F, Fernández-Santiago R, Riaño M, Herrera LA, Gómez-Fleitas M. How long is antibiotic therapy necessary after urgent cholecystectomy for acute cholecystitis? J Gastrointest Surg 2013; 17:1947-52. [PMID: 23975031 DOI: 10.1007/s11605-013-2321-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 08/11/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The objective of the study was to analyze surgical site infection (SSI) frequency with different duration antibiotic courses to establish the minimum necessary duration. METHODS This is an observational study of prospective surveillance of 287 consecutive patients (mean age 67.8 years) operated on for acute cholecystitis of grade II severity in the first 72 h. Postoperative antibiotics had been withdrawn before diagnosis of any infection as an inclusion criterion. Patients were classified into three groups, according to therapy duration: group 1 (0-4 days, n = 45, 15.7 %); group 2 (5-7 days, n = 75, 26.1 %); and group 3 (>7 days, n = 167, 58.2 %). A multivariable analysis of risk infection was performed. RESULTS Overall SSI frequency in groups 1, 2, and 3 was 2.2, 10.7, and 9 %, respectively. Risk analysis showed an increase in both crude and adjusted relative risks of overall infection in group 2 (crude relative risk (RR): 4.80 (0.62-37.13); adjusted RR, 2.03 (0.20-20.91)) and in group 3 (crude RR, 4.04 (0.55-29.79); adjusted RR, 2.35 (0.28-20.05)) by comparison with group 1, although without statistical significance. As a result, treatment lasting 4 days or less was not associated with overall surgical site infection incidence higher than longer treatment. CONCLUSION Antibiotic treatment over 4 days after early cholecystectomy provides no advantage in decreasing surgical site infection incidence.
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Affiliation(s)
- Juan C Rodríguez-Sanjuán
- Department of General Surgery, University Hospital "Marqués de Valdecilla", University of Cantabria, Avda Valdecilla S/N, 39008, Santander, Spain,
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13
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Yanni F, Mekhail P, Morris-Stiff G. A selective antibiotic prophylaxis policy for laparoscopic cholecystectomy is effective in minimising infective complications. Ann R Coll Surg Engl 2013; 95:345-8. [PMID: 23838497 PMCID: PMC4165137 DOI: 10.1308/003588413x13629960045959] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2013] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION It has been demonstrated previously that the identification of bactibilia during cholecystectomy is associated with the presence of one or more risk factors: acute cholecystitis, common duct stones, emergency surgery, intraoperative findings and age >70 years. Current evidence-based guidance on antibiotic prophylaxis during laparoscopic cholecystectomy (LC) is based on elective procedures and does not take into account these factors. The aim of this study was to assess the effectiveness of a selective antibiotic prophylaxis policy limited to high risk patients undergoing LC with the development of port site infections as the primary endpoint. METHODS One hundred consecutive patients undergoing LC under the care of a single consultant surgeon during a one-year period were studied prospectively. Data collected included patient demographics (age, sex) as well as details of the history of gallstone disease to determine those with complex disease and risk factors for bactibilia. A single dose of antibiotics (second generation cephalosporin and metronidazole) was administered on induction to patients with a risk factor present. Information relating to all radiologically or microbiologically confirmed infections was documented. RESULTS Eighty-four of the patients were female and the mean age was 47.7 ±16.0 years. Nineteen LCs were performed as emergencies and the remainder were elective procedures. A risk factor for bactibilia was present in 35 patients. A wound infection was identified in four cases, two of which were Staphylococcus aureus (one methicillin resistant), one was a coagulase negative Staphylococcus and one wound cultured a mixed anaerobic growth. Three of the infections occurred in patients receiving prophylaxis (2 staphylococcal and 1 anaerobic) at intervals of 7, 14 and 19 days respectively. One patient with a body mass index of 32kg/m² in the 'no prophylaxis' group developed a coagulase negative staphylococcal infection at 10 days. No intra or extra-abdominal abdominal infections were identified. CONCLUSIONS This study has demonstrated that restricting antibiotic prophylaxis to high risk patients has no detrimental effects in terms of increasing the rate of infections in those with no risk factors. Furthermore, the act of not prescribing to low risk patients will limit costs and the risk of adverse events. It will also reduce the risk of resistance and clostridial infections in this cohort.
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Abstract
Acute calculous cholecystitis may progress in a variety of ways from mild cases treatable with (or even without) oral antibiotics to severe cases complicated by bile peritonitis that require emergency surgical or radiological intervention. A sample of bile should always be sent for microbial cultures to identify aerobic and anaerobic bacterial organisms. Empirically selected broad spectrum antibiotic therapy (with a defined duration, dosage and administration route) should be prescribed according to the severity of the cholecystitis, an associated history of recent antibiotic therapy, and local bacterial susceptibility patterns. As soon as causative organisms have been identified, antibiotic therapy should be adjusted to a narrower spectrum antimicrobial agent based on the specific micro-organism(s) and the results of sensitivity testing.
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Affiliation(s)
- D Fuks
- Service de chirurgie viscérale et digestive, université de Picardie, CHU Nord Amiens, place Victor-Pauchet, 80054 Amiens cedex 01, France.
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Mazeh H, Mizrahi I, Dior U, Simanovsky N, Shapiro M, Freund HR, Eid A. Role of antibiotic therapy in mild acute calculus cholecystitis: a prospective randomized controlled trial. World J Surg 2012; 36:1750-9. [PMID: 22456803 DOI: 10.1007/s00268-012-1572-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Current recommendations for treating acute calculus cholecystitis include the use of intravenous antibiotics, although these recommendations were never tested scientifically. The aim of this study was to evaluate the role of intravenous antibiotic therapy in patients with mild acute calculus cholecystitis. METHODS In this prospective, randomized controlled trial, 84 patients with a diagnosis of mild acute calculus cholecystitis were randomly assigned to supportive treatment only or supportive treatment with intravenous antibiotic treatment (42 patients in each arm). Patients were followed through their index admission and until delayed laparoscopic cholecystectomy was performed. RESULTS The two study groups did not differ in their demographic data or in the clinical presentation and disease severity. Analysis was conducted on the intent-to-treat basis. Patients in the intravenous antibiotics arm resumed a liquid diet earlier (1.7 vs. 2.2 days, p = 0.02) but did not significantly differ in resumption of regular diet (2.8 vs. 3.2 days, p = 0.16) or hospital length of stay (LOS) (3.9 vs. 3.8 days, p = 0.89). Patients in the intravenous antibiotics arm had rates of percutaneous cholecystostomy tube placement (12 vs. 5 %, p = 0.43), readmissions (19 vs. 13 %, p = 0.73), and perioperative course similar to those not receiving antibiotics. The overall hospital LOS, including initial hospitalization and subsequent cholecystectomy, was similar for both groups (5.6 vs. 5.1 days, p = 0.29). Eight (19 %) patients in the supportive arm were crossed over to the intravenous antibiotic arm during the index admission. CONCLUSIONS Intravenous antibiotic treatment does not improve the hospital course or early outcome in most of the patients with mild acute calculus cholecystitis.
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Affiliation(s)
- Haggi Mazeh
- Department of Surgery, Hadassah-Hebrew University Medical Center, Mount Scopus, P.O.B. 24035, 91240, Jerusalem, Israel.
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16
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Bacteriological analysis of bile in acute cholecystitis according to the Tokyo guidelines. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 19:476-86. [DOI: 10.1007/s00534-011-0463-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Abstract
Biliary tract disease is a relatively uncommon, heterogenous disease in pregnancy. Specifically, acute cholecystitis can be especially difficult to recognize in pregnancy. However, once diagnosed, the initial management plan should be conservative and include antibiotic therapy. Subsequent management depends on the gestational age at diagnosis. Surgical therapy, when indicated, should not be delayed and a planned intervention during the second trimester appears to offer a better outcome than surgery performed under emergent conditions.
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Kook P, Schellenberg S, Grest P, Reusch C, Corboz L, Glaus T. Microbiologic Evaluation of Gallbladder Bile of Healthy Dogs and Dogs with Iatrogenic Hypercortisolism: A Pilot Study. J Vet Intern Med 2010; 24:224-8. [DOI: 10.1111/j.1939-1676.2009.0413.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Predicting the success of endoscopic transpapillary gallbladder drainage for patients with acute cholecystitis during pretreatment evaluation. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2008; 22:681-5. [PMID: 18701945 DOI: 10.1155/2008/702516] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
INTRODUCTION Although endoscopic transpapillary gallbladder drainage (ETGBD) has been reported to be an effective treatment for acute cholecystitis, technical difficulties have precluded more widespread use of this technique. Case evaluations that can predict the occurrence of such difficulties should increase the acceptance of ETGBD for acute cholecystitis treatment. OBJECTIVE To establish a pretreatment evaluation protocol for patients with acute cholecystitis. METHODS Eleven patients with acute cholecystitis who received ETGBD in 2003 or 2004 were enrolled in the present retrospective study. The frequency of success, complications and overall effectiveness of ETGBD for treatment of cholecystitis were measured. Factors that could affect ETGBD success, including clinical and laboratory parameters, and gallbladder ultrasonograms, were also evaluated. RESULTS ETGBD was successful in seven of 11 patients (success rate 63.6%). All seven patients who underwent ETGBD successfully were afebrile and asymptomatic within a few days. No clinical or laboratory variables were significantly associated with the success of ETGBD. In contrast, ultrasonographic measures of gallbladder minor-axis length and wall thickness in successful cases were significantly shorter (27.4 mm versus 38.0 mm; P=0.008) and thinner (4.2 mm versus 9.0 mm; P=0.041) relative to unsuccessful cases. CONCLUSIONS Ultrasonographic measures of gallbladder minor-axis length and wall thickness can serve as important predictors of ETGBD technical difficulties during pretreatment evaluation of patients with acute cholecystitis.
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The effect of bactibilia on the course and outcome of laparoscopic cholecystectomy. Eur J Clin Microbiol Infect Dis 2008; 27:797-803. [PMID: 18369670 DOI: 10.1007/s10096-008-0504-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Accepted: 03/03/2008] [Indexed: 02/07/2023]
Abstract
Although bactibilia is an important condition of acute cholecystitis, its effect on the course and outcome of the infectious gallbladder disease has rarely been studied, particularly in relation to the laparoscopic procedure. The current study attempts to learn more about the inter-relationship between bactibilia and laparoscopic cholecystectomy during acute cholecystitis. Demographic, preoperative, operative, and postoperative data were prospectively collected in every patient with acute cholecystitis treated in the department of surgery at the Bnai Zion Medical Center, Israel. Intraoperative biliary samples were collected under aseptic conditions at the time of operation for bacteriologic examination and were routinely cultured in aerobic and anaerobic media for 3 days. The study population was divided into culture-positive and culture-negative groups, and the collected parameters were compared between the groups. Age over 60 years, a palpable gallbladder, temperature over 37.5 degrees C, a white blood cell (WBC) count of more than 12,000/cc(3), and serum alkaline phosphatase higher than 100 U/dL were all found to be factors capable of predicting bactibilia. Bactibilia was a significant factor associated with total, as well as infectious, operative complications. Bactibilia is considered to indicate an advanced stage of acute cholecystitis. In cases of laparoscopic cholecystectomy for infectious gallbladder disease, bactibilia is strongly associated with total, as well as local, infectious complications. Preoperative conditions such as older age, elevated temperature, a palpable gallbladder, elevated WBC count, and elevated serum levels of alkaline phosphatase can serve as predictors of bactibilia and its consequent complications. Although the sensitivity and specificity of the predictive factors for bactibilia are limited to 63% and 67%, respectively, in their presence during acute cholecystitis, conservative wide-spectrum antibiotics as the first-line therapy is appropriate, and, upon regimen failure, laparoscopic surgery by an experienced surgeon is indicated as the adjusted therapy.
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Limongelli P, Pai M, Bansi D, Thiallinagram A, Tait P, Jackson J, Habib NA, Williamson RCN, Jiao LR. Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery. Surgery 2007; 142:313-8. [PMID: 17723881 DOI: 10.1016/j.surg.2007.04.022] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2006] [Revised: 04/12/2007] [Accepted: 04/15/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although previously examined, the potential relationship between preoperative biliary drainage (PBD), intraoperative bile culture (IBC), and postoperative morbidity and mortality rate for pancreatic surgery remains unclear. METHODS Two hundred twenty patients underwent operation for either benign pancreatic disease or malignant periampullary and pancreatic neoplasms, consisting of pylorus-preserving proximal pancreatoduodenectomy (n = 180), biliary bypass (n = 31), and total pancreatectomy (n = 9). An intraoperative bile specimen was prospectively collected immediately after division of the bile duct and sent for bacteriologic evaluation for both aerobic and anaerobic microorganisms. Morbidity and mortality rates were evaluated. RESULTS Of 220 patients evaluated, 113 patients (51.4%) had a positive IBC. Factors associated with a positive IBC were age >70 years (odds ratio [OR], 5.9;95% confidence interval, [CI]: 1.6-22.1; P = .007), history of coronary artery disease (OR, 0.08; 95% CI, 0.01-0.5; P = .007), diagnosis of neoplasia (OR, 0.3; 95% CI, 0.1-0.9; P =. 03), and PBD (OR, 0.1; 95% CI, 0.06-0.2; P = .0001). Infectious complications (OR, 1.8; 95% CI, 1-3; P = .03), and wound infection (OR, 2.8; 95% CI,1.4-5.3; P = .002) were greater in patients with positive IBC. CONCLUSIONS PBD predisposes to a positive IBC. Patients with a positive IBC have a clinically important increased risk of developing both infectious complications and wound infection after pancreatic surgery.
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Affiliation(s)
- Paolo Limongelli
- HPB unit, Hammersmith Campus, Hammersmith Hospital, London, England
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22
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Kim J, Ihm C. Usefulness of Bile Cultures and Predictive Factors for Bacteriobilia in Percutaneous Cholecystostomy in Patients with Acute Cholecystitis. Ann Lab Med 2007; 27:281-5. [DOI: 10.3343/kjlm.2007.27.4.281] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Jimyung Kim
- Department of Laboratory Medicine, Eulji University Hospital, Daejeon, Korea
| | - Chunhwa Ihm
- Department of Laboratory Medicine, Eulji University Hospital, Daejeon, Korea
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Morris-Stiff G, O'Donohue P, Ogunbiyi S, Sheridan W. Microbiological assessment of bile during cholecystectomy: is all bile infected? HPB (Oxford) 2007; 9:225-8. [PMID: 18333227 PMCID: PMC2063606 DOI: 10.1080/13651820701275105] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Indexed: 12/12/2022]
Abstract
AIMS To determine the prevalence of bactibilia in patients undergoing cholecystectomy and to relate the presence or absence of organisms to the preoperative and postoperative course. PATIENTS AND METHODS Patients undergoing cholecystectomy under the care of a single consultant surgeon during a continuous 5-year period were identified from a prospectively maintained departmental database. Symptoms, clinical signs, findings of investigations, details of treatment and postoperative care were noted. Risk factors for bactibilia (acute cholecystitis, common duct stones, emergency surgery, intraoperative findings and age > 70 years) were documented. Patients were divided according to the presence (B + ) or absence (B-) of bacteria on culture of their bile. RESULTS In all, 128/180 (70%) of cholecystectomies had full data available for analysis. Bacteria were identified in the bile of 20 (15.6%) patients (B+ group). The B+ group was significantly older at 63.78+/-9.7 versus 61.62+/-13.9 (p<0.05) and contained significantly fewer females than the B- group (p<0.05). All 20 patients (100%) in the B+ group had > or = 1 risk factor, while these factors were present in only 29/108 (30.3%) of patients in the B- group (p<0.05). The overall incidence of infective complications was 20% in the B+ group compared with 0.9% in the B- group (p<0.05) and the bile-related infections were higher in the B+ group (p<0.05). CONCLUSIONS The study demonstrated that while patients with complicated gallstone disease frequently exhibit bactibilia, patients with uncomplicated cholelithiasis have aseptic bile. The findings would suggest that prophylactic antibiotics should be limited to patients with risk factors for bactibilia.
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Affiliation(s)
| | - P. O'Donohue
- Department of Surgery, West Wales General HospitalCarmarthenUK
| | - S. Ogunbiyi
- Department of Surgery, West Wales General HospitalCarmarthenUK
| | - W.G. Sheridan
- Department of Surgery, West Wales General HospitalCarmarthenUK
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Reimann FM, Friess H. [Diagnostics for diseases of the gallbladder and biliary tract from the viewpoint of the internist and surgeon. Demands made on radiological diagnostics]. Radiologe 2005; 45:968, 970-5. [PMID: 16270208 DOI: 10.1007/s00117-005-1286-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Jaundice and colic pain of the right upper quadrant are the main symptoms of biliary diseases. Gallstone-related diseases often lead to hospital admission. The evaluation of a patient with biliary symptoms requires a combination of history taking, physical examination, laboratory analysis, and imaging modalities. A high-quality magnetic resonance imaging (MRI) or computed tomography (CT) scan is usually sufficient to evaluate a patient with painless jaundice. Ultrasonography is helpful as an initial screening test to guide the diagnostic work-up. Invasive methods (e.g., ERCP) are mainly used for palliation of patients with incurable disease.
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Laurila JJ, Ala-Kokko TI, Laurila PA, Saarnio J, Koivukangas V, Syrjälä H, Karttunen TJ. Histopathology of acute acalculous cholecystitis in critically ill patients. Histopathology 2005; 47:485-92. [PMID: 16241996 DOI: 10.1111/j.1365-2559.2005.02238.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIMS To illustrate the histopathological features of acute acalculous cholecystitis (AAC) of critically ill patients and to compare them with those of acute calculous cholecystitis (ACC) and normal gallbladders. METHODS AND RESULTS We studied 34 gallbladders with AAC and compared them with 28 cases of ACC and 14 normal gallbladders. Histological features were systematically evaluated. Typical features in AAC were bile infiltration, leucocyte margination of blood vessels and lymphatic dilation. Bile infiltration in the gallbladder wall was more common and extended wider and deeper into the muscle layer in AAC compared with ACC. Epithelial degeneration and defects and widespread occurrence of inflammatory cells were typical features in ACC. Necrosis in the muscle layer was also more common and extended wider and deeper in ACC. There were no differences in the occurrence of capillary thromboses, lymphatic follicles or Rokitansky-Aschoff sinuses between the AAC and ACC samples. CONCLUSIONS There are characteristic differences in histopathology between AAC and ACC, although due to overlap, none appeared to be specific as such for either condition. These results suggest that AAC is largely a manifestation of systemic critical illness, whereas ACC is a local disease of the gallbladder.
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Affiliation(s)
- J J Laurila
- Department of Anaesthesiology, Division of Intensiv Care, Oulu University Hospital, Finland.
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Beardsley SL, Shlansky-Goldberg RD, Patel A, Freiman DB, Soulen MC, Stavropoulos SW, Clark TWI. Predicting Infected Bile Among Patients Undergoing Percutaneous Cholecystostomy. Cardiovasc Intervent Radiol 2005; 28:319-25. [PMID: 15886948 DOI: 10.1007/s00270-003-0260-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE Patients may not achieve a clinical benefit after percutaneous cholecystostomy due to the inherent difficulty in identifying patients who truly have infected gallbladders. We attempted to identify imaging and biochemical parameters which would help to predict which patients have infected gallbladders. METHODS A retrospective review was performed of 52 patients undergoing percutaneous cholecystostomy for clinical suspicion of acute cholecystitis in whom bile culture results were available. Multiple imaging and biochemical variables were examined alone and in combination as predictors of infected bile, using logistic regression. RESULTS Of the 52 patients, 25 (48%) had infected bile. Organisms cultured included Enterococcus, Enterobacter, Klebsiella, Pseudomonas, E. coli, Citrobacter and Candida. No biochemical parameters were significantly predictive of infected bile; white blood cell count >15,000 was weakly associated with greater odds of infected bile (odds ratio 2.0, p = NS). The presence of gallstones, sludge, gallbladder wall thickening and pericholecystic fluid by ultrasound or CT were not predictive of infected bile, alone or in combination, although a trend was observed among patients with CT findings of acute cholecystitis toward a higher 30-day mortality. Radionuclide scans were performed in 31% of patients; all were positive and 66% of these patients had infected bile. Since no patient who underwent a radionuclide scan had a negative study, this variable could not be entered into the regression model due to collinearity. CONCLUSION No single CT or ultrasound imaging variable was predictive of infected bile, and only a weak association of white blood cell count with infected bile was seen. No other biochemical parameters had any association with infected bile. The ability of radionuclide scanning to predict infected bile was higher than that of ultrasound or CT. This study illustrates the continued challenge to identify bacterial cholecystitis among patients referred for percutaneous cholecystostomy.
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Affiliation(s)
- Shannon L Beardsley
- Section of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Laurila J, Syrjälä H, Laurila PA, Saarnio J, Ala-Kokko TI. Acute acalculous cholecystitis in critically ill patients. Acta Anaesthesiol Scand 2004; 48:986-91. [PMID: 15315616 DOI: 10.1111/j.0001-5172.2004.00426.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Acute acalculous cholecystitis (AAC) is a serious complication of critical illness. We evaluated the underlying diseases, clinical and diagnostic features, severity of associated organ failures, and outcome of operatively treated AAC in a mixed ICU patient population. METHODS The data of all ICU patients who had operatively confirmed AAC during their ICU stay between 1 January 2000 and 31 December 2001 were collected from the hospital records and the intensive care unit's data management system for predetermined variables. RESULTS Thirty-nine (1%) out of 3984 patients underwent open cholecystectomy for AAC during the two-year period. Infection was the most common admission diagnosis, followed by cardiovascular surgery. The mean APACHE II score on admission was 25, and 64% of the patients had three or more failing organs on the day of cholecystectomy. The mean length of ICU stay before cholecystectomy was 8 days, and the mean total length of ICU stay was 19 days. Most patients (85%) received norepinephrine infusion, and 90% suffered respiratory failure before cholecystectomy. Hospital mortality was 44%. The non-survivors had higher Sequential Organ Failure Assessment (SOFA) scores on the day of cholecystectomy compared to the survivors (12.9 vs. 9.5, P = 0.007). CONCLUSION Acute acalculous cholecystitis was associated with severe illness, infection, long ICU stay, and multiple organ failure. Mortality was related to the degree of organ failure. Prompt diagnosis and active treatment of AAC can be life-saving in these patients.
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Affiliation(s)
- J Laurila
- Division of Intensive Care, Department of Anesthesiology, Oulu University Hospital, Finland.
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De Waele B, Van Nieuwenhove Y, Lauwers S, Delvaux G. Biliary Tract Infection in Patients with Acute Biliary Pancreatitis. Surg Infect (Larchmt) 2003; 4:241-6. [PMID: 14588158 DOI: 10.1089/109629603322419571] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The presence of infective microorganisms in the bilio-pancreatic tract is believed to be important in both the onset and outcome of acute biliary pancreatitis. In this study, the characteristics of bile colonization or infection in human pancreatitis were investigated in order to optimize prophylactic antibiotic therapy. METHODS In 174 patients, 22 clinical and biological factors were recorded prospectively on admission and compared with the bacteriological findings at the time of surgery. RESULTS There was a significant difference between patients with negative or positive bile cultures in six parameters: Age (57.7 +/- 1.7 vs. 68.5 +/- 1.5 years, p < 0.001), serum concentrations of glucose (132 +/- 4 vs. 149 +/- 6 mg/dL, p < 0.02) and alanine aminotransferase (ALT) (304 +/- 28 vs. 226 +/- 25 IU/L, p < 0.05) and hematocrit (43.4 +/- 0.4% vs. 41.7 +/- 0.5%, p < 0.05), Glasgow pancreatitis score (1.58 +/- 0.11 vs. 1.97 +/- 0.10, p < 0.01) and APACHE II score (6.20 +/- 0.38 vs. 7.82 +/- 0.35, p < 0.005). The prediction of the presence of bacteria in bile by each of these individual parameters, however, was of variable accuracy. From 82 patients with positive bile cultures, a total of 150 microorganisms were isolated, including 66 gram-positive aerobes, 66 gram-negative facultative anaerobes, 15 obligate anaerobes, and three fungi. The most common organisms were Escherichia coli (20.6%), followed by enterococci (18%) and streptococci (15.3%). CONCLUSION Patients with acute biliary pancreatitis who manifest abnormalities of one or more of the above-mentioned risk factors are more likely to have positive bile cultures. Whether such patients might benefit from early antibiotic therapy directed against both gram-negative bacilli and gram-positive cocci needs to be determined.
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Takamiya R, Murakami M, Kajimura M, Goda N, Makino N, Takamiya Y, Yamaguchi T, Ishimura Y, Hozumi N, Suematsu M. Stabilization of mast cells by heme oxygenase-1: an anti-inflammatory role. Am J Physiol Heart Circ Physiol 2002; 283:H861-70. [PMID: 12181112 DOI: 10.1152/ajpheart.00740.2001] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This study examined the role of bilirubin in heme oxygenase (HO)-1-mediated amelioration of mast cell (MC)-elicited inflammatory responses. Pretreatment of rats with an intraperitoneal injection of hemin, an inducer of HO-1, evolved a marked induction of the enzyme in MCs. Intravital videomicroscopy revealed that hemin pretreatment attenuated compound 48/80-elicited degranulation of MCs and resultant leukocyte adhesion in venules. Superfusion with biliverdin or bilirubin, but not with carbon monoxide (CO), another product of the HO reaction, mimicked suppressive actions of the HO-1 induction on both the cell degranulation and leukocyte adhesion elicited by the stimulus, suggesting a requirement of the enzyme reaction to generate bilirubin in the inhibitory mechanisms. Such MC-desensitizing actions of bilirubin were observed in primary-cultured MCs and reproduced irrespective of the choice of stimuli, such as compound 48/80, calcium ionophore, and anti-IgE serum. Furthermore, MC-stabilizing effects of HO-1 were reproduced by the gene transfection of the enzyme into mastocytoma cell line RBL2H3. These results suggest that bilirubin generated through HO-1 serves as an anti-inflammatory substance that desensitizes MCs and ameliorates leukocyte recruitment.
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Affiliation(s)
- Rina Takamiya
- Department of Biotechnology, Research Institute for Biological Sciences, Science University of Tokyo, Chiba 278-0022, Japan
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Klein MD, Rabbani AB, Rood KD, Durham T, Rosenberg NM, Bahr MJ, Thomas RL, Langenburg SE, Kuhns LR. Three quantitative approaches to the diagnosis of abdominal pain in children: practical applications of decision theory. J Pediatr Surg 2001; 36:1375-80. [PMID: 11528609 DOI: 10.1053/jpsu.2001.26374] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE The authors compared 3 quantitative methods for assisting clinicians in the differential diagnosis of abdominal pain in children, where the most common important endpoint is whether the patient has appendicitis. Pretest probability in different age and sex groups were determined to perform Bayesian analysis, binary logistic regression was used to determine which variables were statistically significantly likely to contribute to a diagnosis, and recursive partitioning was used to build decision trees with quantitative endpoints. METHODS The records of all children (1,208) seen at a large urban emergency department (ED) with a chief complaint of abdominal pain were immediately reviewed retrospectively (24 to 72 hours after the encounter). Attempts were made to contact all the patients' families to determine an accurate final diagnosis. A total of 1,008 (83%) families were contacted. Data were analyzed by calculation of the posttest probability, recursive partitioning, and binary logistic regression. RESULTS In all groups the most common diagnosis was abdominal pain (ICD-9 Code 789). After this, however, the order of the most common final diagnoses for abdominal pain varied significantly. The entire group had a pretest probability of appendicitis of 0.06. This varied with age and sex from 0.02 in boys 2 to 5 years old to 0.16 in boys older than 12 years. In boys age 5 to 12, recursive partitioning and binary logistic regression agreed on guarding and anorexia as important variables. Guarding and tenderness were important in girls age 5 to 12. In boys age greater than 12, both agreed on guarding and anorexia. Using sensitivities and specificities from the literature, computed tomography improved the posttest probability for the group from.06 to.33; ultrasound improved it from.06 to.48; and barium enema improved it from.06 to.58. CONCLUSIONS Knowing the pretest probabilities in a specific population allows the physician to evaluate the likely diagnoses first. Other quantitative methods can help judge how much importance a certain criterion should have in the decision making and how much a particular test is likely to influence the probability of a correct diagnosis. It now should be possible to make these sophisticated quantitative methods readily available to clinicians via the computer.
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Affiliation(s)
- M D Klein
- Department of Surgery, Wayne State University School of Medicine and the Children's Hospital of Michigan, Detroit, MI 48201, USA
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Abstract
Initial therapy of acute cholecystitis and cholangitis is directed towards general support of the patient, including fluid and electrolyte replacement, correction of metabolic imbalances and antibacterial therapy. Factors affecting the efficacy of antibacterial therapy include the activity of the agent against the common biliary tract pathogens and pharmacokinetic properties such as tissue distribution and the ratio of concentration in both bile and serum to the minimum inhibitory concentration for the expected micro-organism. Antimicrobial therapy is usually empirical. Initial therapy should cover the Enterobacteriaceae, in particular Escherichia coli. Activity against enterococci is not required since their pathogenicity in biliary tract infections remains unclear. Coverage of anaerobes, in particular Bacteroides spp., is warranted in patients with previous bile duct-bowel anastomosis, in the elderly and in patients in serious clinical condition. In patients with acute cholecystitis or cholangitis of moderate clinical severity, monotherapy with a ureidopenicillin--mezlocillin or piperacillin--is at least as effective as the combination of ampicillin plus aminoglycoside. In severely ill patients with septicaemia, an antibacterial combination is preferable. Therapy with aminoglycosides, mostly for Pseudomonas aeruginosa-related infections, should not exceed a few days because the risk of nephrotoxicity seems to be increased during cholestasis. Relief of biliary obstruction is mandatory, even if there is clinical improvement with conservative therapy, because cholangitis is most likely to recur with continued obstruction. Emergency invasive therapy is reserved for patients who fail to show a clinical response to antibacterial therapy within the first 36 to 48 hours or for those who deteriorate after an initial clinical improvement. Immediate surgery is indicated for gangrenous cholecystitis and perforation with peritonitis. Long-term administration of antibacterials is required for recurrent cholangitis, as seen in bile duct-bowel anastomosis. Oral cotrimoxazole (trimethoprim/sulfamethoxazole) is the preferred agent. Wound infection rates after biliary tract surgery can be significantly reduced by preoperative administration of prophylactic antibacterials. Newer generation beta-lactams have not proven to be of greater benefit than older agents such as cefuroxime or cefazolin. Antibacterial prophylaxis before endoscopic retrograde cholangiopancreatography (ERCP) should be reserved for patients with obstructive jaundice, since the risk of infectious complications seems to be strongly associated with this clinical condition. Failure to achieve full biliary drainage is the most important factor in predicting septicaemia, and prophylaxis should be prolonged until the bile duct is unobstructed. Piperacillin, cefazolin, cefuroxime, cefotaxime and ciprofloxacin are effective for this indication.
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Affiliation(s)
- J F Westphal
- Department of Internal Medicine, Medical B Clinic, University Hospital of Strasbourg, France
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Abstract
BACKGROUND Bacteremia occurs frequently in cholangitis, but the incidence of bacteremia in acute cholecystitis has not previously been examined. METHODS Seventy-eight cases (46 men and 32 women; mean age, 63 +/- 10 years) of acute cholecystitis with positive blood cultures were analyzed for clinical manifestation, bacteriology, and what consequences ensued. Seventy-eight non-bacteremic cholecystitis patients, matched for age and sex, served as the control group. RESULTS The prevalence of bacteremia in acute cholecystitis was 7.65% (78 of 1020). A single microorganism was isolated from the blood and bile in 87.2% and 27.3%, respectively. The commonest organisms were Escherichia coli and Klebsiella pneumoniae. The source of bacteremia could be identified from the infected bile in 80% of cases. Compared with the non-bacteremia group, significant increases in liver biochemical test results (aspartate and alanine aminotransferases and bilirubin, and so forth), more complications (acute renal failure and septic shock), and higher mortality (9.0%) were found in the bacteremic group. CONCLUSION Acute cholecystitis is not often complicated by bacteremia, but when bacteremia is present, morbidity and death more consistently ensue.
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Affiliation(s)
- C H Kuo
- Division of Gastroenterology, Chang Gung Memorial Hospital, Kaohsiung Hsien, Taiwan
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Kadakia SC. Biliary tract emergencies. Acute cholecystitis, acute cholangitis, and acute pancreatitis. Med Clin North Am 1993; 77:1015-36. [PMID: 8371614 DOI: 10.1016/s0025-7125(16)30208-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute cholecystitis, acute cholangitis, and acute pancreatitis represent the most common biliary tract emergencies. Most are due to gallstones in the gallbladder and bile ducts. Acute cholecystitis is treated by surgery in most cases. Laparoscopic cholecystectomy combined with endoscopic sphincterotomy may become more common in the future for treatment of acute cholecystitis as well as in cases of acute cholangitis and pancreatitis if the bile ducts are cleared of gallstones. Although the role of either surgery or endoscopic treatment may be more clearly defined in some biliary tract emergencies, in other situations either modality may be appropriate or they may compliment each other. Most biliary emergencies should be managed by gastroenterologists, surgeons, and radiologists working together in a harmonious fashion.
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Affiliation(s)
- S C Kadakia
- Gastroenterology Service, Brooke Army Medical Center, San Antonio, Texas
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Sakurai S, Shinagawa N, Fukui T, Yura J. Bacterial adherence to human gallbladder epithelium. Surg Today 1992; 22:504-7. [PMID: 1472789 DOI: 10.1007/bf00308894] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The adherence of Escherichia coli and Pseudomonas aeruginosa to the epithelium of the gallbladders obtained from 32 patients with negative bile culture was quantified by a scanning electron microscope. Of the gallbladders, 5 were histologically normal (group A), 21 had chronic calculus cholecystitis (group B), and 6 had acute calculus cholecystitis (group C). The data were expressed as the mean +/- S.D. of the numbers of adherent bacteria to 1,000 microns2 of the gallbladder epithelium. The number of adherent E. coli were 0.1 +/- 0.2 in group A, 4.2 +/- 2.8 in group B, and 9.2 +/- 3.3 in group C. A similar result was also observed with P. aeruginosa. The number of adherent bacteria, both of E. coli and P. aeruginosa were significantly higher in group C than in groups A and B, and were also significantly higher in group B compared to group A. The amount of bacterial adherence paralleled that of the degree of epithelial damage, and the normal epithelium proved to have an inhibiting ability. Thus, a secondary bacterial infection is more likely to happen in patients with contaminated bile, and therefore, the treatment for acute cholecystitis should be based either on the results of a bile culture or according to predictive factors for bactibilia.
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Affiliation(s)
- S Sakurai
- First Department of Surgery, Nagoya City University Medical School, Japan
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Sen M, Williamson RC. Acute cholecystitis: surgical management. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1991; 5:817-40. [PMID: 1837241 DOI: 10.1016/0950-3528(91)90022-s] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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