Emergent laparoscopic cholecystectomy for acute acalculous cholecystitis revisited

Current status and therapeutic strategy of acute acalculous cholecystitis: Japanese nationwide survey in the era of the Tokyo guidelines

PURPOSE

This study aimed to clarify the incidence, therapeutic modality, and prognosis of acute acalculous cholecystitis and to reveal its optimal treatment strategy.

METHODS

As a project study of the Japanese Society for Abdominal Emergency Medicine, we performed a questionnaire survey of demographic data and perioperative outcomes of acute acalculous cholecystitis treated between January 2018 and December 2020 from 42 institutions.

RESULTS

In this study, 432 patients of acute acalculous cholecystitis, which accounts for 7.04% of acute cholecystitis, were collected. According to the Tokyo guidelines severity grade, 167 (38.6%), 202 (46.8%), and 63 (14.6%) cases were classified as Grade I, II, and III, respectively. A total of 11 (2.5%) patients died and myocardial infarction/congestive heart failure was the only independent risk factor for in-hospital death. Cholecystectomy, especially the laparoscopic approach, had more preferable outcomes compared to their counterparts. The Tokyo guidelines flow charts were useful for Grade I and II severity, but in the cases with Grade III, upfront cholecystectomy could be suitable in some patients.

CONCLUSIONS

The proportions of severity grade and mortality of acute acalculous cholecystitis were found to be similar to those of acute cholecystitis, and laparoscopic cholecystectomy is recommended as an effective treatment option. (UMIN000047631).

Acute Acalculous Cholecystitis in Hospitalized Patients With Hematologic Malignancies and Prognostic Importance of Gallbladder Ultrasound Findings

OBJECTIVES

Patients with hematologic malignancies, especially those with acute disease or those receiving intense chemotherapy, are known to develop acute acalculous cholecystitis (AAC). The aim of this study was to evaluate the diagnostic and prognostic value of the established ultrasound (US) diagnostic criteria for AAC in patients with acute hematologic malignancies who were clinically suspected to have AAC.

METHODS

We retrospectively studied the US findings of the gallbladder in patients with hematologic malignancies and correlated these findings with the duration of clinical symptoms, complications, and gallbladder-specific mortality. The major criteria were a 3.5-mm or thicker wall, pericholecystic fluid, intramural gas, and a sloughed mucosal membrane. The minor criteria were echogenic bile and hydrops (gallbladder distension > 4 cm). Ultrasound findings were considered positive if they included 2 major criteria or 1 major and 2 minor criteria.

RESULTS

Ninety-four (25.5%) of 368 patients with hematologic malignancies had clinical signs of AAC during their acute phase of illness or during intense chemotherapy. Forty-three (45.7%) of these 94 patients had AAC-positive test results based on US criteria. The mean duration of symptoms was significantly longer (7.8 days) in this group than among the patients with negative test results (3.9 days; P < .001). Patients with positive test results had a higher rate of complications or mortality (20.9%) than those with negative test results (0%; P < .001).

CONCLUSIONS

Symptomatic patients who meet the US criteria for the diagnosis of AAC have a poor prognosis. Other patients require a close follow-up US examination within 1 week to detect early progression.

Is cholecystectomy the treatment of choice for acute acalculous cholecystitis? A systematic review of the literature

BACKGROUND AND OBJECTIVES

There is currently no consensus with regard to the use of cholecystectomy or percutaneous cholecystostomy as the therapy of choice for acute acalculous cholecystitis. The goal of this study was to review the scientific evidence on the management of these patients according to clinical and radiographic findings.

METHODS

A systematic review of the literature from 2000 to 2016 was performed. The databases of PubMed, Índice Médico Español, Cochrane Library and Embase were searched according to the following inclusion criteria: publication language (English or Spanish), adult patients, acalculous etiology and appropriate study design.

RESULTS

A total of 1,013 articles were identified and ten articles were selected for review. These included five observational controlled studies and five case series which described the outcome of patients treated with percutaneous cholecystostomy and emergency cholecystectomy. No prospective or randomized studies were identified using the search criteria. The data from the literature and analysis of results suggested that percutaneous cholecystostomy may be a definitive therapy for acute acalculous cholecystitis with no need for subsequent elective cholecystectomy.

CONCLUSIONS

Percutaneous cholecystostomy may be the first treatment option for patients with acute acalculous cholecystitis except in cases with a perforation or gallbladder gangrene. Patients at low surgical risk may benefit from cholecystectomy but both treatment options may be effective. Percutaneous cholecystostomy in patients with acute acalculous cholecystitis may be a definitive therapy with no need for a subsequent elective cholecystectomy. However, the overall quality of studies is low and the final recommendations should be considered with caution.

[Acute acalculous gangrenous cholecystitis in postoperative period after orthopedic surgery: about a case]

La cholécystite gangreneuse alithiasique postopératoire est une complication grave et sévère, surtout chez les malades hospitalisés en réanimation. Elle survient le plus souvent au décours d'une chirurgie vasculaire ou digestive majeure, d'un polytraumatisme, dans un contexte septique ou dans un contexte de choc. Nous rapportons l'observation d'un homme âgé de 74 ans opéré d'une fracture du col du fémur, au sixième jour postopératoire il a développé un tableau clinique d'une cholécystite aigue dont les explorations radiologiques ont confirmé son caractère alithiasique. Après une cholécystectomie en urgence, l'étude anatomopathologique a conclu à une cholécystite gangreneuse alithiasique.

The impact of frailty syndrome and risk scores on emergency cholecystectomy patients

PURPOSE

Cholecystectomy, which is one of the most common surgical procedures, is also performed in the emergency setting. A number of risk scores have been introduced in recent studies; moreover, over the last few years literature has focused on surgical patients with frailty syndrome. The aim of the present study is to evaluate whether frailty syndrome and the risk scores are correlated with morbidity, post-operative hospital stay and the ICU admission rate following emergency cholecystectomy.

METHODS

Eighty-five consecutive patients of >65 years of age who underwent cholecystectomy were selected from 2306 emergency procedures for inclusion in the present study. The patients were assessed for frailty syndrome and their scores were calculated on the basis of chart review. Univariate analyses were performed to compare severe frailty patients to intermediate frailty and robust patients. ROC and logistic regression analyses were performed with the end-points of morbidity, hospital stay and ICU admission.

RESULTS

In addition to having worse ASA, inflammatory and risk values than robust patients, frailty syndrome patients also had higher rates of morbidity and ICU admission and longer hospitalization periods. A logistic regression analysis showed that the P-Possum was independently correlated with morbidity. Frailty and open surgery were independently correlated with longer hospitalization, whereas ICU admission was correlated with worse ASA and P-Possum values.

CONCLUSIONS

Frailty syndrome significantly impacts the length of hospitalization in patients undergoing emergency cholecystectomy. Although the ORs were limited, the P-Possum value was independently associated with the outcome.

Clinical value and pitfalls of fluorescent cholangiography during single-incision laparoscopic cholecystectomy

PURPOSE

To clarify the clinical value and pitfalls of fluorescent cholangiography (FC) during single-incision laparoscopic cholecystectomy (SILC).

METHODS

Our SILC procedure utilized the SILS-Port with additional 5-mm forceps through an umbilical incision. A laparoscopic fluorescent imaging system developed by Karl Storz Endoskope was utilized for fluorescent cholangiography.

RESULTS

We performed fluorescent cholangiography during SILC in 21 patients. All procedures were completed successfully without biliary injury. The detectability of the running course of the cystic duct, the confluence between the cystic duct and the common hepatic duct, and the common hepatic duct before the dissection in Calot's triangle was 47.6, 71.4, and 81.0 %, respectively. The detectability of biliary structures was worse in 9 obese patients (body mass index ≥ 25.0 kg/m²) than in 12 non-obese patients. The mean operative time for the patients in whom fluorescent cholangiography could identify the running course of the cystic duct before dissection in Calot's triangle (68 ± 16 min) was shorter than that for the other patients (91 ± 35 min; p = 0.037).

CONCLUSIONS

Fluorescent cholangiography can prevent biliary injury during SILC and facilitate SILC. Obesity is the most important factor that can prevent identification of biliary structures under fluorescent cholangiography.