Early versus delayed laparoscopic cholecystectomy for acute cholecystitis

Timely cholecystectomy: important factors to improve guideline adherence and patient treatment

OBJECTIVE

Cholecystectomy is one of the most frequently performed surgeries in Germany and is performed as a treatment of acute cholecystitis (guideline S3 IIIB.8) and after endoscopic retrograde cholangiopancreatography for choledocholithiasis with simultaneous cholecystolithiasis (guideline S3 IIIC.6). This article examines the effects of a guideline update from 2017, which recommends prompt cholecystectomy within 24 hours of admission due to cholecystitis or within 72 hours after bile duct repair. In addition, it aims to identify reasons (eg, financial disincentives) and potential for improvement for non-adherence to the guidelines.

DESIGN

Methodologically, a retrospective analysis based on routine billing data from 84 Helios Group hospitals from 2016 and 2022, with a total of 45 393 included cases, was applied. The guideline adherence rate is used as the main outcome measure.

RESULTS

Results show the guideline updates led to a statistically significant increase in the proportion of cholecystectomy performed in a timely manner (guideline S3 IIIB.8: increase from 43% to 49%, p<0.001; guideline S3 IIIC.6: increase from 7% to 20%, p<0.001). Medical, structural and financial reasons for non-adherence could be identified.

CONCLUSION

As possible reasons for non-adherence, medical factors such as advanced age, multimorbidity and frailty could be identified. Analyses of structural factors revealed that hospitals in very rural regions are less likely to perform timely cholecystectomies, presumably due to infrastructural and personnel-capacity bottlenecks. A similar picture emerges for maximum-care hospitals, which might be explained by more severe and complex cases on average. Further evaluation indicates that an increase in and better hospital-internal participation of gastroenterologists in remuneration could lead to even greater adherence to the S3 IIIC.6 guideline.

What is the ideal timing of cholecystectomy after percutaneous cholecystostomy for acute cholecystitis?

BACKGROUND

Acute cholecystitis (AC) is one of the most prevalent diseases in clinical practice. Poor surgical candidates may benefit from early percutaneous cholecystostomy (PC) drainage followed by interval cholecystectomy (IC), which is the definitive treatment. The optimal timing between the PC drainage and the IC has not been identified. This study aimed to investigate how the duration between PC and IC affects perioperative outcomes and identify the optimal IC timing to minimize complications.

METHODS

This retrospective cohort study included all adult patients diagnosed with AC who underwent PC followed by IC at a single institution center between 2014 and 2022. Patients with a history of hepatobiliary surgery, stones in the common bile duct, cirrhosis, active malignancy, or prolonged immunosuppression were excluded. The analysis did not include cases with major concurrent procedures during cholecystectomy, previously aborted cholecystectomies, or failure of the PC drain to control the inflammation. Linear and logistic regression models were used to analyze the impact of the interval between PC and IC on intra- and perioperative outcomes.

RESULTS

One hundred thirty-two patients (62.1% male) with a mean age of 64.4 ± 15 (mean ± SD) years were diagnosed with AC (25% mild, 47.7% moderate, 27.3% severe). All patients underwent PC followed by IC after a median of 64 [48-91] days. Longer ICU stay was associated with longer time intervals between PC and IC (Coef 105.98, p < 0.001). No significant variations were detected in the intraoperative and perioperative outcomes between patients undergoing IC within versus after 8 weeks from PC placement. However, a higher percentage of patients with delayed IC (after 8 weeks) were discharged home (96.4% vs. 83.7%; p = 0.019).

CONCLUSIONS

Patients may benefit from undergoing IC after the 8-week cutoff after PC. However, very long periods between PC and IC procedures may increase the risk of longer ICU stay.

Pancreatitis aguda: puntos clave. Revisión argumentativa de la literatura

Introducción. La pancreatitis aguda es una condición gastrointestinal común que se asocia a una importante morbimortalidad. Se estima que su incidencia es de 34 por cada 100.000 habitantes, afecta principalmente a adultos a partir de la sexta década de la vida y en nuestra región es debida en la mayoría de los casos a cálculos biliares. Métodos. Se hizo una revisión de los aspectos fundamentales de esta patología, común y potencialmente mortal. Resultados. El diagnóstico requiere del hallazgo de manifestaciones clínicas, aumento de las enzimas pancreáticas en suero y, en ocasiones, el uso de imágenes diagnósticas. Se puede clasificar en leve, moderada y severa, lo cual es fundamental para determinar la necesidad de tratamiento y vigilancia en una unidad de cuidados intensivos. Conclusión. En la actualidad los pilares de manejo de la pancreatitis aguda son la terapia temprana con líquidos, tratamiento del dolor, inicio precoz de la vía oral y resolución del factor etiológico desencadenante. En presencia de complicaciones o un curso severo de enfermedad, pueden requerirse manejo antibiótico e intervenciones invasivas.

Focusing in on gallbladder disease. Do current imaging modalities accurately depict the severity of final pathology?

BACKGROUND

Accuracy of imaging modalities for gallbladder disease(GBD) remains questionable. We hypothesize ultrasonography(US), computed tomography(CT), and magnetic resonance imaging(MRI) poorly correlate with final pathologic analysis.

METHODS

This was a retrospective review of all patients who underwent cholecystectomy at our institution. Primary outcome was agreement between US, CT, and MRI, and final pathology report of the gallbladder. Cohen's Kappa statistic was used to describe the level of agreement (0 = agreement equivalent to chance, 0.1-0.2 = slight agreement, 0.21-0.40 = minimal/fair agreement, 0.41-0.60 = moderate agreement, 0.61-0.80 = substantial agreement, 0.81-0.99 = near perfect agreement, 1 = perfect agreement). Significance was set at p < 0.05.

RESULTS

1107 patients were enrolled. Average age was 48.6(±17.6); 64.2% were female. There was minimal agreement between the three imaging modalities and final pathology (US = 0.363; CT = 0.223; MRI = 0.351;p < 0.001).

CONCLUSION

Poor agreement exists between imaging modalities and final pathology report for GBD. Urgent surgical intervention for patients presenting with symptoms of GBD should be considered, despite imaging results.

A Rare Case of Acute Calculous Cholecystitis With Gallbladder Hydrops

Gallbladder hydrops or mucocele is usually due to the obstruction of the gallbladder by a gallstone. It is usually characterized by an increase in gallbladder volume, which remains clinically silent and is often incidentally diagnosed during exploratory laparotomy or laparoscopy. We report a rare case of acute calculous cholecystitis with gallbladder hydrops (measuring 17 cm in maximum dimension) due to the obstruction of the cystic duct by a gallstone in a 67-year-old female. We highlight the importance of early magnetic resonance imaging (MRI) in patients with right upper quadrant (RUQ) pain to rule out gallbladder hydrops especially in those with a history of gallstones.

Comparison of Postoperative Port-Site Pain After Gallbladder Retrieval From Epigastric Versus Umbilical Port in Patients of Laparoscopic Cholecystectomy for Symptomatic Cholelithiasis: A Randomized Controlled Trial

Introduction Gallbladder (GB) retrieval is an important cause of postoperative pain (POP) after laparoscopic cholecystectomy (LC). Retrieval is through the epigastric or umbilical port based on the surgeon's preference. There is limited evidence to support the superiority of one port over the other in terms of POP. This study was done to compare POP between epigastric and umbilical ports after GB retrieval in LC for symptomatic cholelithiasis.  Material and methods All patients who underwent elective LC for symptomatic cholelithiasis were randomized for GB retrieval either through the umbilical (n = 15) or epigastric (n = 15) port. Postoperatively, the retrieval difficulty score by the operating surgeon, visual analog scale (VAS) scores for pain, and surgical site infection (SSI) by postoperative day (POD) 10 and 30 were assessed. Results The mean visual analog scores at the umbilical port at 1, 6, 12, 24, and 36 hours postoperatively were 5.20 ± 0.86, 4.60 ± 0.74, 4.00 ± 0.53, 3.40 ± 0.08, and 2.73 ± 0.82, which were significantly less than the visual analog scores at the epigastric port at the same time intervals, measuring 6.06 ± 1.34, 5.87 ± 1.30, 5.27 ± 1.16, 4.73 ± 1.10, and 3.93 ± 1.03, respectively. The difference was statistically significant between the two arms (p-value < 0.05). The mean retrieval difficulty score was significantly less for the umbilical port (4.40 ± 0.74) when compared with the epigastric port (5.13 ± 0.55). The overall SSI rate in the present study was 10%, and three (20%) patients in the epigastric port group developed SSI by POD 10, while none in the umbilical port group developed SSI. Conclusion GB retrieval from the umbilical port is associated with less POP, SSI, and retrieval difficulty when compared with GB retrieval from the epigastric port after elective LC for symptomatic cholelithiasis. Titration of analgesic use can also be done appropriately, reducing the dose of analgesics after 12-24 hours.

Laparoscopic Training Opportunities in an Emergency Biliary Service

Background and Objectives:

Optimizing single-session management of biliary emergencies whilst maximizing laparoscopic training opportunities is challenging. We analyzed training opportunities available in an emergency biliary department and its impact on service provision and patient outcomes.

Methods:

A single surgeon's practice of 2049 emergency laparoscopic cholecystectomies and common bile duct explorations was prospectively analyzed. Training involved a modular stepwise approach incorporating access, gallbladder bed dissection, pedicle dissection, intra- corporeal tying, and cholangiogram ± common bile duct exploration. Training cases were identified, trainee involvement ascertained, and parameters predictive of a training case were established.

Results:

Thirty percent of laparoscopic cholecystectomies were performed in part or completely by trainees, with a training component in 30% of bile duct explorations. Trainee involvement increased mean operating time by approximately 10 minutes. There was no difference in minor (5% vs 5%, P = .8) or major complications (1% vs 0.9%, P = .7) on trainee versus consultant cases. Postoperative hospital stay was greater in consultant cases (2.87 vs 4.44 days, P = .0025).

Multivariate analysis identified predictors of trainee cases including lower age (OR, 1.3; 95% CI, 1.1-1.7), female sex (OR, 1.6; 95% CI, 1.3-2), normal-weight subjects (OR, 1.54; 95% CI, 1.3-1.9), lower difficulty grade (1-2) (OR, 1.8; 95% CI, 1.4-2.2), and American Society of Anesthesiologists score ≤ 2 (OR, 1.8; 95% CI, 1.4-2.4).

Conclusions:

Surgical training is possible in a singlesession biliary emergency service without significantly impacting theatre utilization times or early patient outcomes. Further dedicated studies will allow individual learning curves to be determined.

A predictive grading scale for acute cholecystitis

Background

Acute cholecystitis presents in a spectrum of severity, where acute disease may be complicated by severe inflammation, gangrene, and perforation. The goal of this study is to outline an evidence-based grading scale that predicts patient outcomes after laparoscopic cholecystectomy (LC).

Methods

A retrospective review of all patients with a preoperative diagnosis of acute cholecystitis who underwent LC from August 2011 until June 2015 at a tertiary-level hospital was performed. Patients who underwent elective cholecystectomy, incidental cholecystectomy, a planned open cholecystectomy, had gallstone pancreatitis or choledocholithiasis, and those admitted to a non-surgical service were excluded. Severity of disease was obtained from operative and pathology reports, and patients were classified according to the following grading scale:

Grade I: symptomatic cholelithiasis.

Grade II: acute/chronic cholecystitis.

Grade III: gangrenous/necrotizing cholecystitis.

Grade IV: gallbladder perforation or abscess.

The groups were compared on age, gender, body mass index, severity of gallbladder disease, presence of preoperative systemic inflammatory response syndrome, hospital length of stay, length of operation, complications within 30 days, conversion to open rate, and cost of hospitalization.

Results

During the study period, 1252 patients who underwent laparoscopic cholecystectomy were analyzed; 677 met inclusion criteria. The most common grade was grade 2, which was present in 80% of patients, followed by grade 3, which was found in 16% of patients. Grade 4 cholecystitis occurred in 1.2% of patients and grade 1 occurred in 3.2% of patients. There were statistically significant increases in age, presence of preoperative systemic inflammatory response syndrome, hospital length of stay, conversion to open rate, cost of hospitalization, and length of operation with increased cholecystitis grade.

Conclusions

The proposed grading scale is an accurate predictor of duration of operation, conversion to open rate, hospital length of stay, and cost of hospitalization.

Level of evidence

III

Study type

Prognostic

Role of Cholecystectomy in Choledocholithiasis Patients Underwent Endoscopic Retrograde Cholangiopancreatography

There are no clinical guidelines for the timing of cholecystectomy (CCY) after performing therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. We tried to analyze the clinical practice patterns, medical expenses, and subsequent outcomes between the early CCY, delayed CCY, and no CCY groups of patients. 1827 choledocholithiasis patients who underwent therapeutic ERCP were selected from the nationwide population databases of two million random samples. These patients were further divided into early CCY, delayed CCY, and no CCY performed. In our analysis, 1440 (78.8%) of the 1827 patients did not undergo CCY within 60 days of therapeutic ERCP, and only 239 (13.1%) patients underwent CCY during their index admission. The proportion of laparoscopic CCY increased from 37.2% to 73.6% in the delayed CCY group. There were no significant differences (p = 0.934) between recurrent biliary event (RBE) rates with or without early CCY within 60 days of ERCP. RBE event-free survival rates were significantly different in the early CCY (85.04%), delayed CCY (89.54%), and no CCY (64.45%) groups within 360 days of ERCP. The method of delayed CCY can reduce subsequent RBEs and increase the proportion of laparoscopic CCY with similar medical expenses to early CCY in Taiwan’s general practice environment.

Literature review and case series of haemorrhagic cholecystitis

A diagnosis of haemorrhagic cholecystitis is difficult to make as it is rare and mimics other common disorders. We present three patients who presented with haemorrhagic cholecystitis, two of whom were on anti-coagulation at presentation. All 3 patients were treated conservatively, 2 with percutaneous cholecystostomy drainage and 1 patient with intravenous antibiotics. There are few guidelines on the management of such a condition.

Financial implications of laparoscopic hot gallbladder service in a nontertiary District General Hospital

INTRODUCTION

The service of providing index admission laparoscopic cholecystectomy (IALC), as recommended by NIC guidelines, often falls short in nontertiary centres because of a combination of limited resources and financial constraints.

METHODS

This retrospective study in a single-centre District General Hospital included 50 patients, eligible to undergo IALC, and calculated potential savings from performing IALC on the day of admission by considering admission tariffs, bed, and operating costs.

RESULTS

The IALC was provided in 19 patients (38%), with a mean delay from admission to operation of (median) 3 days. Mean surplus tariff was £1421 and £1571 in IALC and non-IALC groups, respectively. Performing immediate IALC (on the day of admission) for acute cholecystitis (AC) is predicted to increase mean surplus tariff to £2132 per patient, raising total predicted annual surplus by £53 000. Immediate IALC is also predicted to reduce waiting time for day-case LC by freeing up 53 day-case slots, attracting additional £95 600 annually, along with freeing up many inpatient bed days.

CONCLUSIONS

This study demonstrates that reduction of preoperative stay in AC by expediting operations in every eligible patient promises significant surplus revenue. Additional advantages include reducing inpatient bed days and freeing up operating lists that are otherwise taken up by patients for interval cholecystectomy.

Current practices and future prospects for the management of gallbladder polyps: A topical review

A gallbladder polyp is an elevation of the gallbladder mucosa that protrudes into the gallbladder lumen. Gallbladder polyps have an estimated prevalence in adults of between 0.3%-12.3%. However, only 5% of polyps are considered to be "true" gallbladder polyps, meaning that they are malignant or have malignant potential. The main radiological modality used for diagnosing and surveilling gallbladder polyps is transabdominal ultrasonography. However, evidence shows that other modalities such as endoscopic ultrasound may improve diagnostic accuracy. These are discussed in turn during the course of this review. Current guidelines recommend cholecystectomy for gallbladder polyps sized 10 mm and greater, although this threshold is lowered when other risk factors are identified. The evidence behind this practice is relatively low quality. This review identifies current gaps in the available evidence and highlights the necessity for further research to enable better decision making regarding which patients should undergo cholecystectomy, and/or radiological follow-up.

Efficacy of preoperative percutaneous cholecystostomy in the management of acute cholecystitis according to severity grades

BACKGROUND/AIMS

The aim of this retrospective study was to assess the efficacy of percutaneous cholecystostomy (PC) for patients with acute cholecystitis (AC) according to severity.

METHODS

A total of 325 patients who underwent cholecystectomy between January 2008 and October 2010 were enrolled. Patients were classified into three groups based on severity grade according to the Tokyo guidelines for AC: grade I (mild), grade II (moderate), and grade III (severe). These groups were further classified into two subgroups based on whether or not they underwent preoperative PC.

RESULTS

A total of 184 patients were classified into the grade I group (57%), 135 patients were classified into the grade II group (42%), and five patients were classified into the grade III group (1%). In the grade I and II groups, the mean length of hospital stay was significantly shorter in the patients who did not undergo PC than in those who received PC (10.7 ± 4.4 vs. 13.7 ± 5.8, p < 0.001; 11.8 ± 6.5 vs. 16.9 ± 12.5, p = 0.003, respectively). The mean length of preoperative hospital stay was significantly shorter in the patients without PC than in those with PC in the grade I and II groups (5.8 ± 3.3 vs. 8.2 ± 4.6, p = 0.001; 6.0 ± 4.4 vs. 8.8 ± 5.2, p = 0.002). In addition, the operative time was shorter in patients without PC, especially in the grade I group (94.6 ± 36.4 vs. 107.3 ± 33.5, p = 0.034).

CONCLUSIONS

Preoperative PC should be reserved for only selected patients with mild or moderate AC. No significant benefit of preoperative PC was identified with respect to clinical outcome or complications.

Early laparoscopic cholecystectomy is more cost-effective than delayed laparoscopic cholecystectomy in the treatment of acute cholecystitis

Background

This economic evaluation quantifies the cost-effectiveness of early laparoscopic cholecystectomy (ELC) versus delayed laparoscopic cholecystectomy (DLC) in the management of acute cholecystitis. The two interventions were assessed in terms of outcome measures, including utilities, to derive quality-adjusted life years (QALYs) as a unit of effectiveness. This study hypothesizes that ELC is more cost-effective than DLC.

Materials and methods

In this economic evaluation, existing literature was compiled and analyzed to estimate the incremental cost-effectiveness of ELC versus DLC. Six randomized controlled trials were used to schematically represent the probabilities of each decision tree branch. To calculate health outcomes, quality of life scores were sourced from three articles and multiplied by the expected length of life postintervention to give QALYs. From an National Health Service (NHS) perspective, one QALY may be sacrificed if the incremental cost-effectiveness ratio is above £20,000–£30,0000 in cost savings.

Results

This economic evaluation calculated the average net present values of ELC to be £3920 and DLC to be £4565, demonstrating that ELC is the less-expensive intervention, with potential cost savings of £645 per operation. When scaling these savings up to a population approximately comparable to the size of the UK, full-scale implementation of ELC rather than DLC will potentially save the NHS £30,000,000 per annum.

Conclusion

ELCs are cost-effective from the perspective of the NHS. As such, policy should review existing guidelines and consider the merits of ELC versus DLC, improving resource allocation. The findings of this article advocate that ELC should become a standard practice.

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.

Gallbladder Hydrops Associated with an Episode of Acute Liver Toxicity in the Adult: May It Be Considered a Surgical Emergency or Not?

Introduction: Gallbladder hydrops is an increase in the volume of the gallbladder without any inflammatory sign, bacterial infection or the presence of any abnormalities of the biliary ducts or of the gallbladder.

Case presentation: A 52-year-old man presented at the Department of Internal Medicine complaining of moderate intensity pain in the right upper quadrant, low fever, fatigue, general weakness, symptoms stemming from an excessive intake of food (a meal abundant in animal proteins, fats, and alcohol) which appeared following a 6-week period of food restriction. On examination, the patient presented a globular abdomen, sensitive to deep palpation in the right upper quadrant, the liver and spleen being impalpable. Blood tests performed on admission showed liver-specific pathological changes. Abdominal ultrasound revealed hepatomegaly with homogeneous echostructure, slightly increased echogenicity with rear attenuation, with no focal images, intrahepatic biliary duct dilatation, or dilated suprahepatic veins. The gallbladder looked dropsical, with slender walls, with images of hyperechoic infundibular calculi with a posterior shadow cone, the largest having 14 mm. The portal vein and bile duct were normal in appearance.

Conclusions: Gallbladder hydrops is a disorder commonly seen in children. Its occurrence in adults is uncommon, moreover since it occurs simultaneously with an episode of acute toxic hepatitis. Surgery for this patient was possible only after normalization of liver function tests, on admission there being no subjective complaints of marked intensity that required immediate surgery.

Evaluation of Early Cholecystectomy versus Delayed Cholecystectomy in the Treatment of Acute Cholecystitis

Objective. To evaluate if early cholecystectomy (EC) is the most appropriate treatment for acute cholecystitis compared to delayed cholecystectomy (DC). Patients and Methods. A retrospective cohort study of 1043 patients was carried out, with a group of 531 EC cases and a group of 512 DC patients. The following parameters were recorded: (1) postoperative hospital morbidity, (2) hospital mortality, (3) days of hospital stay, (4) readmissions, (5) admission to the Intensive Care Unit (ICU), (6) type of surgery, (7) operating time, and (8) reoperations. In addition, we estimated the direct cost savings of implementing an EC program. Results. The overall morbidity of the EC group (29.9%) was significantly lower than the DC group (38.7%). EC demonstrated significantly better results than DC in days of hospital stay (8.9 versus 15.8 days), readmission percentage (6.8% versus 21.9%), and percentage of ICU admission (2.3% versus 7.8%), which can result in reducing the direct costs. The patients who benefited most from an EC were those with a Charlson index > 3. Conclusions. EC is safe in patients with acute cholecystitis and could lead to a reduction in the direct costs of treatment.

Gallstones: new insights into an old story

Gallstones, particularly cholesterol gallstones, are common in Western populations and may cause symptoms such as biliary colic or complications such as acute cholecystitis or gallstone pancreatitis. Recent studies have allowed for a better understanding of the risk of symptoms or complications in patients with gallstones. In addition, newer data suggest an association of gallstones with overall mortality, cardiovascular disease, gastrointestinal cancers, and non-alcoholic fatty liver disease. Knowledge of appropriate indications and timing of cholecystectomy, particularly for mild biliary pancreatitis, has gradually accumulated. Lastly, there are exciting possibilities for novel agents to treat or prevent cholesterol stone disease. This review covers new advances in our understanding of the natural history, clinical associations, and management of gallstone disease.

A case report: Clinical application of celiac plexus block in bile duct interventional procedures

Although percutaneous transhepatic biliary drainage (PTBD) and tract dilatation (TD) are very painful procedures, almost all of those procedures have been conducted under local anesthesia and opioid injection due to the lack of manpower and time. Celiac plexus block (CPB) is an interventional technique used for diagnostic and therapeutic purposes in the treatment of abdominovisceral pain. CPB decreases the side effects of opioid medications and enhances analgesia from medications. We present the case of a patient who underwent PTBD and TD under CPB in order to reduce procedure-related abdominal pain.CPB can be a useful alternative technique for pain management during and after biliary interventional procedures, although CPB-induced complications must always be kept in mind.

Timing of percutaneous cholecystostomy affects conversion rate of delayed laparoscopic cholecystectomy for severe acute cholecystitis

BACKGROUND

Percutaneous cholecystostomy is reserved for very high-operative-risk patients suffering from severe acute cholecystitis, who do not respond to conservative treatment. It is associated with high conversion rate to open surgery, when cholecystectomy is held later on. Our objective was to assess whether early timing of percutaneous cholecystostomy decreases conversion rate of delayed laparoscopic cholecystectomy to open surgery.

METHODS

The study population included 59 patients who underwent percutaneous cholecystostomy for severe cholecystitis and then proceeded to delayed interval laparoscopic cholecystectomy. The study consisted of a retrospective survey of medical files, based on a prospective enrollment of the data. We assessed conversion rate between two groups based on the time period from onset of symptoms and from admission to hospital until performance of cholecystostomy.

RESULTS

Regarding the time from onset of pain to drainage, early cholecystostomy (within 2 days, group I) was associated with 8.3% conversion rate, in contrast to 33.3% in group II (3-6 days from onset of symptoms). Regarding the day of admission to hospital, early drainage revealed 16% conversion rate in contrast to 40.7% in later drainage (p = 0.047, Chi-square test). We found correlation between time interval of symptoms and admission to conversion rate, according to Spearman's correlation coefficient.

CONCLUSIONS

Early percutaneous cholecystostomy does decrease conversion rate of delayed laparoscopic cholecystectomy, possibly by halting the propagation of the inflammatory process and its consequences. When decision regarding the necessity to perform drainage of the severely inflamed gallbladder is established, it is suggested to be done as soon as possible.

Open versus laparoscopic cholecystectomy in acute cholecystitis. Systematic review and meta-analysis

INTRODUCTION

Laparoscopic cholecystectomy (LC) has become a popular alternative to open cholecystectomy (OC) in the treatment of acute cholecystitis (AC). Laparoscopic cholecystectomy (LC) is now considered the gold standard of therapy for symptomatic cholelithiasis and chronic cholecystitis. However no definitive data on its use in AC has been published. CIAO and CIAOW studies demonstrated 48.7% of AC were still operated with the open technique. The aim of the present meta-analysis is to compare OC and LC in AC.

MATERIAL AND METHODS

A systematic-review with meta-analysis and meta-regression of trials comparing open vs. laparoscopic cholecystectomy in patients with AC was performed. Electronic searches were performed using Medline, Embase, PubMed, Cochrane Central Register of Controlled Trials (CCTR), Cochrane Database of Systematic Reviews (CDSR) and CINAHL.

RESULTS

Ten trials have been included with a total of 1248 patients: 677 in the LC and 697 into the OC groups. The post-operative morbidity rate was half with LC (OR = 0.46). The post-operative wound infection and pneumonia rates were reduced by LC (OR 0.54 and 0.51 respectively). The post-operative mortality rate was reduced by LC (OR = 0.2). The mean postoperative hospital stay was significantly shortened in the LC group (MD = -4.74 days). There were no significant differences in the bile leakage rate, intraoperative blood loss and operative times.

CONCLUSIONS

In acute cholecystitis, post-operative morbidity, mortality and hospital stay were reduced by laparoscopic cholecystectomy. Moreover pneumonia and wound infection rate were reduced by LC. Severe hemorrhage and bile leakage rates were not influenced by the technique. Cholecystectomy in acute cholecystitis should be attempted laparoscopically first.

Should Delayed Cholecystectomy Following Acute Calculous Cholecystitis Be Discouraged in a Resource-restricted Setting?

BACKGROUND

Early cholecystectomy for acute calculous cholecystitis (ACC) reduces hospital stay and complications during the waiting period. The purpose of this study is to establish the patterns of management of ACC at the University Hospital of the West Indies (UHWI) and to evaluate the advantages of early versus delayed cholecystectomy.

METHODS

This was a retrospective chart review of patients admitted with a diagnosis of ACC. Data collection included demographics, management strategy, timing to cholecystectomy, significant events while awaiting cholecystectomy and duration of hospital stay. Mann-Whitney U and Chi-squared tests were used for analysis. P-value of < 0.05 was considered significant.

RESULTS

A total of 102 patient charts were extracted, 59 of which were managed conservatively and 43 managed with early cholecystectomy. The mean time to surgery after conservative management was 173 days. About 30% of persons managed conservatively had significant attacks while awaiting surgery, which included need for re-admission and earlier intervention. There was a trend toward longer mean total hospital stay in the conservative group (xsx = 5.03, xCons = 6.12; p = 0.054).

CONCLUSION

Conservative management of ACC results in significant delays in definitive management and risks of complications during the waiting period. Early cholecystectomy should be encouraged even in a resource-restricted setting.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

Analysis of actual healthcare costs of early versus interval cholecystectomy in acute cholecystitis

BACKGROUND

Healthcare cost modeling have favored early (ELC) over interval laparoscopic cholecystectomy (ILC) for acute cholecystitis (AC). However, actual costs of treatment have never been studied. The aim of the present study was to compare actual hospital costs involved in ELC and ILC in patients with AC.

METHODS

Retrospective study of patients who underwent laparoscopic cholecystectomy for AC was conducted. Demographic, clinical, operative data and costs were extracted and analyzed.

RESULTS

Between 2011 and 2013, 201 had laparoscopic surgery for AC at Tan Tock Seng Hospital, Singapore. One hundred and thirty-four (67%) patients underwent ELC (≤7 days of presentation, within index admission). Median total length of stay (LOS) was 4.6 and 6.8 days for ELC and ILC groups, respectively (P = 0.006). Patients who had ELC also had significantly lesser total number of admissions (P < 0.001). The median (IQR) total inpatient costs were €4.4 × 10(3) (3.6-5.6) and €5.5 × 10(3) (4.0-7.5) for ELC and ILC patients, respectively (P < 0.007). Costs associated with investigations were significantly higher in the ILC group (P = 0.039), of which serological costs made most difference (P < 0.005). The ward costs were also significantly higher in the ILC group.

CONCLUSION

The cost differences reflect the significantly increased total LOS, and repeat presentations associated with ILC. Therefore, ELC should be the preferred management strategy for AC.

Osteoporosis increases subsequent risk of gallstone: a nationwide population-based cohort study in Taiwan

BACKGROUND

Osteopontin (OPN) is a pro-inflammatory cytokine which is expressed in various tissues. It participates in the bone remodeling process and stimulates bone resorption by osteoclasts. It is also a core protein of cholesterol gallstones. We hypothesized osteoporotic patients might have higher risk in developing gallstones and conducted a population-based study to examine the risk of developing gallstone in osteoporotic patients in Taiwan.

METHODS

A total of 1,638 patients diagnosed with osteoporosis between 2003 and 2005 were identified in the National Health Insurance Research Database. A comparison cohort without osteoporosis (n =6,552) was randomly matched to each osteoporosis patient at a ratio of 4: 1 based on age and sex. A Cox proportional-hazards regression analysis was performed to evaluate the 5-year gallstone-free survival rates for the 2 cohorts.

RESULTS

During the 5-year follow-up period, 114 and 311 cases of gallstone occurred in the osteoporosis and comparison cohorts, respectively. After adjusting for the confounders, the Cox regression analysis of the risk of gallstone in the osteoporosis and comparison cohorts yielded a hazard ratio of 1.35 (95% confidence interval: 1.07 - 1.69; p < 0 .01).

CONCLUSION

Patients with osteoporosis in Taiwan have a higher risk of developing gallstone than the general population.

The HAC trial (harmonic for acute cholecystitis): a randomized, double-blind, controlled trial comparing the use of harmonic scalpel to monopolar diathermy for laparoscopic cholecystectomy in cases of acute cholecystitis

BACKGROUND

The HARMONIC SCALPEL (H) is an advanced ultrasonic cutting and coagulating surgical device with important clinical advantages, such as: reduced ligature demand; greater precision due to minimal lateral thermal tissue damage; minimal smoke production; absence of electric corrents running through the patient. However, there are no prospective RCTs demonstrating the advantages of H compared to the conventional monopolar diathermy (MD) during laparoscopic cholecystectomy (LC) in cases of acute cholecystitis (AC).

METHODS

This study was a prospective, single-center, randomized trial (Trial Registration Number: NCT00746850) designed to investigate whether the use of H can reduce the incidence of intra-operative conversion during LC in cases of AC, compared to the use of MD. Patients were divided into two groups: both groups underwent early LC, within 72 hours of diagnosis, using H and MD respectively (H = experimental/study group, MD = control group). The study was designed and conducted in accordance with the regulations of Good Clinical Practice.

RESULTS

42 patients were randomly assigned the use of H (21 patients) or MD (21 patients) during LC. The two groups were comparable in terms of basic patient characteristics. Mean operating time in the H group was 101.3 minutes compared to 106.4 minutes in the control group (p=ns); overall blood loss was significantly lower in the H group. Conversion rate was 4.7% for the H group, which was significantly lower than the 33% conversion rate for the control group (p<0.05). Post-operative morbidity rates differed slightly: 19% and 23% in the H and control groups, respectively (p=ns). Average post-operative hospitalization lasted 5.2 days in the H group compared to 5.4 days in the control group (p=ns).

CONCLUSIONS

The use of H appears to correlate with reduced rates of laparoscopic-open conversion. Given this evidence, H may be more suitable than MD for technically demanding cases of AC.

Early versus delayed surgery for acute cholecystitis as an applied treatment strategy when assessed in a population-based cohort

BACKGROUND

The aims of this study were to describe the surgical management of acute cholecystitis (AC) in a well-defined population-based patient cohort, in particular adherence to and outcome of the early open/laparoscopic cholecystectomy (EC/ELC) strategy.

METHODS

The medical records of all patients residing in Stockholm County who were treated for AC during 2003 and 2008 were reviewed according to a standardized protocol.

RESULTS

In 2003, 799 patients were admitted 850 times for AC, and the respective figures for 2008 were 833 and 919. The number of patients who underwent EC/ELC increased from 42.9% in 2003 to 47.4% in 2008. In multivariate regression analysis adjusting for age, gender, severity of cholecystitis, maximal CRP and maximal WBC, EC/ELC was associated with shorter operation time but higher perioperative blood loss when compared to delayed open/laparoscopic cholecystectomy (DC/DLC). The odds ratio for completing the procedure laparoscopically was significantly higher in DC/DLC when adjusting for the same covariates. There were no significant differences in peri- or postoperative complications between the groups.

CONCLUSION

Strategies should be implemented in order to secure a more evidence-based approach to the surgical treatment of AC.

Complicated intra-abdominal infections worldwide: the definitive data of the CIAOW Study

The CIAOW study (Complicated intra-abdominal infections worldwide observational study) is a multicenter observational study underwent in 68 medical institutions worldwide during a six-month study period (October 2012-March 2013). The study included patients older than 18 years undergoing surgery or interventional drainage to address complicated intra-abdominal infections (IAIs).

1898 patients with a mean age of 51.6 years (range 18-99) were enrolled in the study. 777 patients (41%) were women and 1,121 (59%) were men. Among these patients, 1,645 (86.7%) were affected by community-acquired IAIs while the remaining 253 (13.3%) suffered from healthcare-associated infections. Intraperitoneal specimens were collected from 1,190 (62.7%) of the enrolled patients.

827 patients (43.6%) were affected by generalized peritonitis while 1071 (56.4%) suffered from localized peritonitis or abscesses.

The overall mortality rate was 10.5% (199/1898).

According to stepwise multivariate analysis (PR = 0.005 and PE = 0.001), several criteria were found to be independent variables predictive of mortality, including patient age (OR = 1.1; 95%CI = 1.0-1.1; p < 0.0001), the presence of small bowel perforation (OR = 2.8; 95%CI = 1.5-5.3; p < 0.0001), a delayed initial intervention (a delay exceeding 24 hours) (OR = 1.8; 95%CI = 1.5-3.7; p < 0.0001), ICU admission (OR = 5.9; 95%CI = 3.6-9.5; p < 0.0001) and patient immunosuppression (OR = 3.8; 95%CI = 2.1-6.7; p < 0.0001).

How long is antibiotic therapy necessary after urgent cholecystectomy for acute cholecystitis?

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.

[The intensive care gallbladder as shock organ: symptoms and therapy]

Acute acalculous cholecystitis (AAC) represents a severe disease in critically ill patients. The pathogenesis of acute necroinflammatory gallbladder disease is multifactorial and intensive care unit (ICU) patients show multiple risk factors. In addition AAC is difficult to diagnose because of the vague physical and non-specific technical findings. Only the combination of clinical and technical findings including the challenging physical examination of critically ill patients, laboratory results and ultrasound or computed tomography (CT) scan, will lead to the diagnosis. The condition of AAC has a rapid progress to gallbladder necrosis, gangrene and perforation and these complications are reflected in the high morbidity and mortality rates, therefore, therapy should be promptly initiated. If there are no clinical contraindications for an operative approach cholecystectomy is the definitive treatment and both open and laparoscopic procedures have been used. In unstable, critically ill patients percutaneous cholecystostomy should be immediately performed. In addition, transpapillary endoscopic drainage is also possible if there are contraindications for percutaneous cholecystostomy. Patients who fail to improve or deteriorate following interventional drainage should be reconsidered for cholecystectomy. Due to the fact that more than 90 % of patients treated with percutaneous cholecystostomy showed no recurrence of symptoms during a period of more than 1 year, it is still unclear if percutaneous cholecystostomy is the definitive treatment of AAC for unstable patients or if delayed cholecystectomy is still necessary.

Percutaneous cholecystostomy for high-risk surgical patients with acute calculous cholecystitis

BACKGROUND

The management of people at high risk of perioperative death due to their general condition (high-risk surgical patients) with acute calculous cholecystitis is controversial, with no clear guidelines. In particular, the role of percutaneous cholecystostomy in these patients has not been defined.

OBJECTIVES

To compare the benefits (temporary or permanent relief of symptoms) and harms (recurrence of symptoms, procedure-related morbidity) of percutaneous cholecystostomy in the management of high-risk individuals with symptomatic gallstones.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded to December 2012 to identify the randomised clinical trials. We also handsearched the references lists of identified trials.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or publication status) addressing this issue.

DATA COLLECTION AND ANALYSIS

Two review authors collected data independently. For each outcome, we calculated the P values using Fisher's exact test or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included two trials with 156 participants for this review. The comparisons included in these two trials were percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy (1 trial; 70 participants) and percutaneous cholecystostomy versus conservative treatment (1 trial; 86 participants). Both trials had high risk of bias. Percutaneous cholecystostomy with early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy: There was no significant difference in mortality between the two intervention groups (0/37 versus 1/33; Fisher's exact test: P value = 0.47). There was no significant difference in overall morbidity between the two intervention groups (1/31 versus 2/30; Fisher's exact test: P value = 0.61). This trial did not report on quality of life. There was no significant difference in the proportion of participants requiring conversion to open cholecystectomy between the two intervention groups (2/31 percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus 4/30 delayed laparoscopic cholecystectomy; Fisher's exact test: P value = 0.43). The mean total hospital stay was significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group (1 trial; 61 participants; MD -9.90 days; 95% CI -12.31 to -7.49). The mean total costs were significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group (1 trial; 61 participants; MD -1123.00 USD; 95% CI -1336.60 to -909.40). Percutaneous cholecystostomy versus conservative treatment: Nine of the 44 participants underwent delayed cholecystectomy in the percutaneous cholecystostomy group. Seven of the 42 participants underwent delayed cholecystectomy in the conservative treatment group. There was no significant difference in mortality between the two intervention groups (6/44 versus 7/42; Fisher's exact test: P value = 0.77). There was no significant difference in overall morbidity between the two intervention groups (6/44 versus 3/42; Fisher's exact test: P value = 0.49). The number of participants who underwent laparoscopic cholecystectomy was not reported in this trial. Therefore, we were unable to calculate the proportion of participants who underwent conversion to open cholecystectomy. The other outcomes, total hospital stay, quality of life, and total costs, were not reported in this trial.

AUTHORS' CONCLUSIONS

Based on the current available evidence from randomised clinical trials, we are unable to determine the role of percutaneous cholecystostomy in the clinical management of high-risk surgical patients with acute cholecystitis. There is a need for adequately powered randomised clinical trials of low risk of bias on this issue.

Early versus delayed laparoscopic cholecystectomy for uncomplicated biliary colic

BACKGROUND

Uncomplicated biliary colic is one of the commonest indications for laparoscopic cholecystectomy. Laparoscopic cholecystectomy involves several months of waiting if performed electively. However, people can develop life-threatening complications during this waiting period.

OBJECTIVES

To assess the benefits and harms of early versus delayed laparoscopic cholecystectomy for people with uncomplicated biliary colic due to gallstones.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2013.

SELECTION CRITERIA

We included only randomised clinical trials, irrespective of language and publication status.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data. We sought to include data on short-term mortality (30-day mortality or in-hospital mortality), bile duct injury, other serious adverse events, quality of life, conversion to open cholecystectomy, length of hospital stay, operating time, and return to work. We planned to calculate the risk ratio with 95% confidence interval (CI) for dichotomous outcomes and mean difference (MD) with 95% CI for continuous outcomes using RevMan and based on intention-to-treat analysis when data were available. Since only one trial contributed data to this review, Fisher's exact test was used for binary outcomes. A P value of < 0.05 was considered statistically significant.

MAIN RESULTS

Only one trial including 75 participants (average age: 43 years; females: 65% of participants), randomised to early laparoscopic cholecystectomy (less than 24 hours after diagnosis) (n = 35) or delayed laparoscopic cholecystectomy (mean waiting period of 4.2 months) (n = 40), contributed information to this review. The trial had a high risk of bias. Information on the outcome mortality was available for the 75 participants. Information on serious adverse events was available for 68 participants (28 people in the early group and 40 people in the delayed group). The other outcomes were available for 28 participants in the early laparoscopic cholecystectomy group and 35 participants in the delayed laparoscopic cholecystectomy group. There were no deaths in the early group (0/35) (0%) versus 1/40 (2.5%) in the delayed laparoscopic cholecystectomy group (P > 0.9999). There was no bile duct injury in either group. There were no serious adverse events related to the surgery in either group. During the waiting period, complications developed in the delayed laparoscopic cholecystectomy group. The complications that the participants suffered included pancreatitis (n = 1), empyema of the gallbladder (n = 1), gallbladder perforation (n = 1), acute cholecystitis (n = 2), cholangitis (n = 2), obstructive jaundice (n = 2), and recurrent biliary colic (requiring hospital visits) (n = 5). In total, 14 participants required hospital admissions for the above symptoms. All of these admissions occurred in the delayed group as all the participants were operated on within 24 hours in the early group. The proportion of people who developed serious adverse events was 0/28 (0%) in the early group, which was significantly lower than in the delayed laparoscopic cholecystectomy group 9/40 (22.5%) (P = 0.0082). This trial did not report quality of life or return to work. There was no significant difference in the proportion of people who required conversion to open cholecystectomy in the early group 0/28 (0%) compared with the delayed group (6/35 or 17.1%) (P = 0.0743). There was a statistically significant shorter hospital stay in the early group than in the delayed group (MD -1.25 days, 95% CI -2.05 to -0.45). There was a statistically significant shorter operating time in the early group than the delayed group (MD -14.80 minutes, 95% CI -18.02 to -11.58).

AUTHORS' CONCLUSIONS

Based on evidence from only one high-bias risk trial, it appears that early laparoscopic cholecystectomy (less than 24 hours after diagnosis of biliary colic) decreases the morbidity during the waiting period for elective laparoscopic cholecystectomy (mean waiting time 4.2 months), the hospital stay, and operating time. Further randomised clinical trials are necessary to confirm or refute these findings, and to determine if early laparoscopic cholecystectomy is better than the delayed laparoscopic cholecystectomy if the waiting time is shortened further.

Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis

BACKGROUND

Gallstones are present in about 10% to 15% of the adult western population. Between 1% and 4% of these adults become symptomatic in a year (the majority due to biliary colic but a significant proportion due to acute cholecystitis). Laparoscopic cholecystectomy for acute cholecystitis is mainly performed after the acute cholecystitis episode settles because of the fear of higher morbidity and of need for conversion from laparoscopic to open cholecystectomy. However, delaying surgery exposes the people to gallstone-related complications.

OBJECTIVES

The aim of this systematic review was to compare early laparoscopic cholecystectomy (less than seven days of clinical presentation with acute cholecystitis) versus delayed laparoscopic cholecystectomy (more than six weeks after index admission with acute cholecystitis) with regards to benefits and harms.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and World Health Organization International Clinical Trials Registry Platform until July 2012.

SELECTION CRITERIA

We included all randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy in participants with acute cholecystitis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We identified seven trials that met the inclusion criteria. Out of these, six trials provided data for the meta-analyses. A total of 488 participants with acute cholecystitis and fit to undergo laparoscopic cholecystectomy were randomised to early laparoscopic cholecystectomy (ELC) (244 people) and delayed laparoscopic cholecystectomy (DLC) (244 people) in the six trials. Blinding was not performed in any of the trials and so all the trials were at high risk of bias. Other than blinding, three of the six trials were at low risk of bias in the other domains such as sequence generation, allocation concealment, incomplete outcome data, and selective outcome reporting. The proportion of females ranged between 43.3% and 80% in the trials that provided this information. The average age of participants ranged between 40 years and 60 years. There was no mortality in any of the participants in five trials that reported mortality. There was no significant difference in the proportion of people who developed bile duct injury in the two groups (ELC 1/219 (adjusted proportion 0.4%) versus DLC 2/219 (0.9%); Peto OR 0.49; 95% CI 0.05 to 4.72 (5 trials)). There was no significant difference between the two groups (ELC 14/219 (adjusted proportion 6.5%) versus DLC 11/219 (5.0%); RR 1.29; 95% CI 0.61 to 2.72 (5 trials)) in terms of other serious complications. None of the trials reported quality of life from the time of randomisation. There was no significant difference between the two groups in the proportion of people who required conversion to open cholecystectomy (ELC 49/244 (adjusted proportion 19.7%) versus DLC 54/244 (22.1%); RR 0.89; 95% CI 0.63 to 1.25 (6 trials)). The total hospital stay was shorter in the early group than the delayed group by four days (MD -4.12 days; 95% CI -5.22 to -3.03 (4 trials; 373 people)). There was no significant difference in the operating time between the two groups (MD -1.22 minutes; 95% CI -3.07 to 0.64 (6 trials; 488 people)). Only one trial reported return to work. The people belonging to the ELC group returned to work earlier than the DLC group (MD -11.00 days; 95% CI -19.61 to -2.39 (1 trial; 36 people)). Four trials did not report any gallstone-related morbidity during the waiting period. One trial reported five gallstone-related morbidities (cholangitis: two; biliary colic not requiring urgent operation: one; acute cholecystitis not requiring urgent operation: two). There were no reports of pancreatitis during the waiting time. Gallstone-related morbidity was not reported in the remaining trials. Forty (18.3%) of the people belonging to the delayed group had either non-resolution of symptoms or recurrence of symptoms before their planned operation and had to undergo emergency laparoscopic cholecystectomy in five trials. The proportion with conversion to open cholecystectomy was 45% (18/40) in this group of people.

AUTHORS' CONCLUSIONS

We found no significant difference between early and late laparoscopic cholecystectomy on our primary outcomes. However, trials with high risk of bias indicate that early laparoscopic cholecystectomy during acute cholecystitis seems safe and may shorten the total hospital stay. The majority of the important outcomes occurred rarely, and hence the confidence intervals are wide. It is unlikely that future randomised clinical trials will be powered to measure differences in bile duct injury and other serious complications since this might involve performing a trial of more than 50,000 people, but several smaller randomised trials may answer the questions through meta-analyses.

A population-based analysis of the morbidity and mortality of gallbladder surgery in the elderly

BACKGROUND

Historically, emergency gallbladder surgery in elderly patients has been associated with high rates of morbidity and mortality. Recent studies have described much lower complication rates that may still overestimate morbidity. The purpose of this study was to determine the true population morbidity and mortality rates after gallbladder surgery in the elderly.

METHODS

All elderly patients (defined as age 65 years or older) admitted to the hospital with a principle diagnosis related to benign gallbladder disease in the Province of Manitoba from January 1, 1995 to December 31, 2008 were identified by using administrative claims data. Outcomes after emergency gallbladder surgery, including complication rates and their predictors, were compared with outcomes after elective surgery and after nonoperative treatment for gallbladder-related hospital admissions.

RESULTS

A total of 9,936 patients were included: 2,355 had emergency or urgent surgery and 4,901 had elective procedures, whereas 2,680 patients were treated without surgery. Emergency gallbladder surgery was associated with a mortality rate of 0.7 %, compared with 1.6 % for elective cases and 5.6 % for patients treated nonoperatively. Complication rates were 16.2, 17.7, and 25 % respectively. Independent predictors of 30-day mortality were age, male gender, increasing comorbidity, surgeon experience, and surgical treatment.

CONCLUSIONS

Emergency gallbladder surgery in the elderly was not associated with higher mortality or complication rate compared with the elective setting. Elderly patients with gallbladder-related emergencies should be offered urgent surgery when feasible.

Advantages of early cholecystectomy in clinical practice of a terciary care center

BACKGROUND

Despite a number of studies show the superiority of early over delayed cholecystectomy in the treatment of acute cholecystitis, there is still controversy over the time for intervention. This study aimed to assess the use of early versus delayed cholecystectomy for the treatment of acute cholecystitis in terms of complications, conversion to open surgery and mean hospital stay.

METHOD

We collected patients with acute cholecystitis treated at a referral center for a year, and retrospectively analyzed the chosen therapeutic approach, the percentage of conversion of early cholecystectomy to open surgery, appearance of surgical complications, and mean hospital stay.

RESULTS

The study included 117 patients, 44 women and 73 men, who had a mean age of 67.36+/-15.74 years. Early cholecystectomy was chosen in 31 (26.5%) and delayed cholecystectomy in 74 patients (63.2%). Of the 74 patients, 28 (37.8%) required emergency performance of delayed cholecystectomy, and 19 (25.7%) had not undergone surgery by the end of the study. While no differences were observed between early and delayed cholecystectomy in terms of surgical complications and conversion to open surgery, mean hospital stay was nevertheless significantly shorter in the early versus the delayed cholecystectomy group (8.32+/-4.98 vs 15.96+/-8.89 days).

CONCLUSION

Under the routine working conditions of a hospital that is neither specially dedicated to the surgical treatment of acute cholecystitis nor provided with specific management guidelines, early cholecystectomy can reduce the hospital stay without increase of the conversion rate or complications.

Role of antibiotic therapy in mild acute calculus cholecystitis: a prospective randomized controlled trial

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.

Evidence-based current surgical practice: calculous gallbladder disease

BACKGROUND

Gallbladder disease is common and, if managed incorrectly, can lead to high rates of morbidity, mortality, and extraneous costs. The most common complications of gallstones include biliary colic, acute cholecystitis, common bile duct stones, and gallstone pancreatitis. Ultrasound is the initial imaging modality of choice. Additional diagnostic and therapeutic studies including computed tomography, magnetic resonance imaging, magnetic resonance cholangiopancreatography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography are not routinely required but may play a role in specific situations.

DISCUSSION

Biliary colic and acute cholecystitis are best treated with early laparoscopic cholecystectomy. Patients with common bile duct stones should be managed with cholecystectomy, either after or concurrent with endoscopic or surgical relief of obstruction and clearance of stones from the bile duct. Mild gallstone pancreatitis should be treated with cholecystectomy during the initial hospitalization to prevent recurrence. Emerging techniques for cholecystectomy include single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery. Early results in highly selected patients demonstrate the safety of these techniques. The management of complications of the gallbladder should be timely and evidence-based, and choice of procedures, particularly for common bile duct stones, is largely influenced by facility and surgeon factors.

Outcome after percutaneous cholecystostomy for acute cholecystitis: a single-center experience

BACKGROUND

Percutaneous cholecystostomy is an alternative treatment for acute cholecystitis patients with high surgical risk.

METHODS

One hundred and sixty-six patients consecutively treated by percutaneous cholecystostomy for acute cholecystitis in a single medical center were retrospectively reviewed.

RESULTS

The cohort included 121 males and 45 females with mean age of 75.9 years. The overall inhospital mortality rate was 15.1 % (n = 25). Elevated serum creatinine level at diagnosis [odds ratio (OR) 1.497; p = 0.020], septic shock (OR 11.755; p = 0.001), and development of cholecystitis during admission (OR 7.256; p = 0.007) were predictive of inhospital mortality. Of 126 patients who recovered from calculous cholecystitis, 11 experienced recurrent cholecystitis within 2 months. Serum C-reactive protein (CRP) level >15 mg dl(-1) at diagnosis [hazard ratio (HR) 10.141; p = 0.027] and drainage duration of cholecystostomy longer than 2 weeks (HR 3.638; p = 0.039) were independent risk factors of early recurrence. The 53 patients who underwent cholecystectomy had an 18.9 % perioperative complication rate and no operation-related mortality.

CONCLUSIONS

In-patients or those with septic shock or renal insufficiency have worse outcome. Prolonged drainage duration and high CRP level predict early recurrence. Removal of the drainage tube is recommended after resolution of the acute illness.

Cost utility of early versus delayed laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Early laparoscopic cholecystectomy for acute cholecystitis is safe and effective. However, the potential cost savings of this management strategy have not been well studied in a North American context. This study aimed to estimate the cost effectiveness of early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy in Canada.

METHODS

A decision analytic model estimating and comparing costs from a Canadian providing institution after either early or delayed laparoscopic cholecystectomy was used. The health care resources consumed were calculated using local hospital data, and outcomes were measured in quality-adjusted life years (QALYs) gained during 1 year. Uncertainty was investigated with one-way sensitivity analyses, varying the probabilities of the events and utilities.

RESULTS

Early laparoscopic cholecystectomy was estimated to cost approximately $2,000 (Canadian dollars) less than delayed laparoscopic cholecystectomy per patient, with an incremental gain of approximately 0.03 QALYs. Sensitivity analysis showed that only extreme values of bile duct injury or bile leak altered the direction of incremental gain.

CONCLUSIONS

Adoption of a policy in favor of early laparoscopic cholecystectomy will result in better patient quality of life and substantial savings to the Canadian health care system.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Treatment of cholecystitis with Chinese herbal medicines: A systematic review of the literature

AIM: To analyze the literature on the use of Chinese herbal medicines for the treatment of cholecystitis.

METHODS: The literature on treatment of cholecystitis with traditional Chinese medicines (TCM) was analyzed based on the principles and methods described by evidence-based medicine (EBM). Eight databases including MEDLINE, EMbase, Cochrane Central (CCTR), four Chinese databases (China Biological Medicine Database, Chinese National Knowledge Infrastructure Database, Database of Chinese Science and Technology Periodicals, Database of Chinese Ministry of Science and Technology) and Chinese Clinical Registry Center, were searched. Full text articles or abstracts concerning TCM treatment of cholecystitis were selected, categorized according to study design, the strength of evidence, the first author’s hospital type, and analyzed statistically.

RESULTS: A search of the literature published from 1977 through 2009 yielded 1468 articles in Chinese and 9 in other languages; and 93.92% of the articles focused on clinical studies. No article was of level I evidence, and 9.26% were of level II evidence. The literature cited by Science Citation Index (SCI), MEDLINE and core Chinese medical journals accounted for 0.41%, 0.68% and 7.29%, respectively. Typically, the articles featured in case reports of illness, examined from the perspective of EBM, were weak in both quality and evidence level, which inconsistently conflicted with the fact that most of the papers were by authors from Level-3 hospitals, the highest possible level evaluated based on their comprehensive quality and academic authenticity in China.

CONCLUSION: The published literature on TCM treatment of cholecystitis is of low quality and based on low evidence, and cognitive medicine may functions as a useful supplementary framework for the evaluation.

Therapy of gallstone disease: What it was, what it is, what it will be

Cholesterol gallstone disease is a common clinical condition influenced by genetic factors, increasing age, female gender, and metabolic factors. Although laparoscopic cholecystectomy is currently considered the gold standard in treating patients with symptomatic gallstones, new perspectives regarding medical therapy of cholelithiasis are currently under discussion, also taking into account the pathogenesis of gallstones, the natural history of the disease and the analysis of the overall costs of therapy. A careful selection of patients may lead to successful non-surgical therapy in symptomatic subjects with a functioning gallbladder harboring small radiolucent stones. The classical oral litholysis by ursodeoxycholic acid has been recently paralleled by new experimental observations, suggesting that cholesterol-lowering agents which inhibit cholesterol synthesis (statins) or intestinal cholesterol absorption (ezetimibe), or drugs acting on specific nuclear receptors involved in cholesterol and bile acid homeostasis, might be proposed as additional approaches for treating cholesterol gallstones. In this review we discuss old, recent and future perspectives on medical treatment of cholesterol cholelithiasis.

Outcome of laparoscopic cholecystectomy conversion: is the surgeon's selection needed?

BACKGROUND

Risk factors for conversion in cholecystectomy may be of clinical value. This study aimed to investigate whether a set of risk factors, including the surgeon's specialization, can be used for the development of a preoperative strategy to optimize conversion outcome.

METHODS

The data for all patients who underwent laparoscopic cholecystectomy at a single institution between January 2004 and December 2008 were retrospectively reviewed. Factors predictive for conversion were identified, and a preoperative strategy model was deduced.

RESULTS

Of the 1,126 patients analyzed, 106 (9%) underwent laparoscopic cholecystectomy in an emergency setting. Delayed surgery was performed for 63 (46%) of 138 patients (12%) with acute cholecystitis. Preoperative endoscopic retrograde cholangiography was achieved for 161 of the patients (14%). Risk factors predictive of conversion (for 65 patients) were male gender [odds ratio (OR), 2.3; 95% confidence interval (CI), 1.3-3.9; p = 0.004], age older than 65 years (OR, 2.6; 95% CI, 1.4-4.8; p = 0.002), body mass index (BMI) exceeding 25 kg/m(2) (OR, 3.4; 95% CI, 1.7-7.1; p < 0.001), history of complicated biliary disease (HCBD) (OR, 5.6; 95% CI, 3.2-9.8; p = < 0.001), and surgery by a non-gastrointestinal (non-GI) surgeon (OR, 4.9; 95% CI, 2.2-10.6; p < 0.001). The conversion rate for patients with a history of no complications who had two or more risk factors (gender, age, BMI > 25) and for patients with a HCBD who had one or more risk factors was significantly higher if the surgery was performed by non-GI rather than GI surgeons.

CONCLUSION

Male gender, age older than 65 years, BMI exceeding 25 kg/m(2), HCBD, and surgery by a non-GI surgeon are predictive for conversion. A preoperative triage for surgeon selection based on risk factors and a HCBD is proposed to optimize conversion outcome.

Original single-incision laparoscopic cholecystectomy for acute inflammation of the gallbladder

AIM: To investigate the safety and feasibility of our original single-incision laparoscopic cholecystectomy (SILC) for acute inflamed gallbladder (AIG).

METHODS: One hundred and ten consecutive patients underwent original SILC for gallbladder disease without any selection criteria and 15 and 11 of these were diagnosed with acute cholecystitis and acute gallstone cholangitis, respectively. A retrospective review was performed not only between SILC for AIG and non-AIG, but also between SILC for AIG and traditional laparoscopic cholecystectomy (TLC) for AIG in the same period.

RESULTS: Comparison between SILC for AIG and non-AIG revealed that the operative time was longer in SILC for AIG (97.5 min vs 85.0 min, P = 0.03). The open conversion rate (2/26 vs 2/84, P = 0.24) and complication rate (1/26 vs 3/84, P = 1.00) showed no differences, but a need for additional trocars was more frequent in SILC for AIG (5/24 vs 3/82, P = 0.01). Comparison between SILC for AIG and TLC for AIG revealed no differences based on statistical analysis.

CONCLUSION: Our original SILC technique was adequately safe and feasible for the treatment of acute cholecystitis and acute gallstone cholangitis.