Timing of Cholecystectomy in Acute Cholecystitis

Timing is everything: outcomes of 30,259 delayed cholecystectomies in New York State

BACKGROUND

The timing of cholecystectomy in relation to outcomes has been debated. To our knowledge, there are no large population-based studies looking at outcomes and complications of delayed cholecystectomy [DC] (> 72 h after presentation). This study utilizes a statewide database to determine whether there are differences in patient outcomes for DC performed at 3-4 days, 5-6 days, and ≥ 7 days after presentation.

METHODS

The New York SPARCS database was used to identify adult patients presenting with a diagnosis of acute cholecystitis from 2005 to 2017. Patients aged < 18, those with missing identifier or procedure-date information, those who underwent early cholecystectomy < 72 h or upon readmission, were excluded. Patients undergoing DC at 3-4 days, 5-6 days, and ≥ 7 days were compared in terms of overall complications, hospital length of stay (LOS), 30-day readmissions/emergency department (ED) visits, and 30-day mortality.

RESULTS

30,259 patients were identified. DCs were performed within 3-4 days (n = 19,845, 65.6%), 5-6 days (n = 6432, 21.3%), and ≥ 7 days (n = 3982, 13.2%). There was a stepwise deterioration in outcomes with increased delay to surgery (Fig. 1). When comparing 3-4 and ≥ 7 days, overall complications (OR = 0.418, 95% CI: 0.387-0.452), 30-day readmissions (OR = 0.609, 95% CI: 0.549-0.674), 30-day ED visits (OR = 0.697, 95% CI: 0.637-0.763), 30-day mortality (OR = 0.601, 95% CI: 0.400-0.904), and LOS (OR = 0.729, 95% CI: 0.710-0.748) were lower in the 3-4 day cohort.

CONCLUSIONS

DC within 3-4 days is associated with fewer complications, readmissions and ED visits, and reduced LOS compared to DC at 5-6 or ≥ 7 days after presentation. In addition, 30-day mortality was also significantly different comparing 3-4 with ≥ 7-day cohorts. These data are important for guiding patients in the consent process and may point to choosing an earlier interval cholecystectomy for high-risk patients.

Analysis of the Effect of Laparoscopic Cholecystectomy for Acute Cholecystitis after Percutaneous Transhepatic Gallbladder Puncture and Drainage

Objective

To assess the effect of laparoscopic cholecystectomy for acute cholecystitis after percutaneous transhepatic gallbladder drainage (PTGBD).

Methods

A total of 70 patients with acute cholecystitis diagnosed and treated in our hospital between April 2020 and November 2021 were recruited and assigned to receive either conventional treatment (conventional group) or PTGBD plus laparoscopic cholecystectomy (experimental group) according to the order of admission (with January 2021 as the cut-off time point), with 35 cases in each group. Outcome measures included treatment outcomes, surgical indices, and postoperative recovery.

Results

Patients in the experimental group showed significantly less intraoperative hemorrhage volume and shorter operative time, time-lapse before passing gas, and hospital stay (83.15 ± 31.17, 32.54 ± 12.61, 23.02 ± 4.61, 7.98 ± 3.24) versus those in the conventional group (120.56 ± 30.55, 61.01 ± 15.54, 28.15 ± 5.91, 11.95 ± 4.15) (P < 0.05). The incidence of conversion to open surgery and postoperative drainage in the experimental group was significantly lower (2.86%, 5.71%) than that of the conventional group (25.71%, 45.71%) (P < 0.05). The differences in the postoperative body temperature of the two groups did not come up to statistical standard (P > 0.05). The experimental group had faster body temperature recovery and leukocyte recovery and better leukocyte levels (1.25 ± 0.56, 2.36 ± 0.48, 7.92 ± 1.36) than the conventional group (3.11 ± 1.05, 5.41 ± 0.63, 10.52 ± 2.78) (P < 0.05). There was 1 (2.86%) case of pneumothorax and 1 (2.86%) case of intestinal bleeding in the experimental group, and there were 2 (5.71%) cases of biliary leakage, 3 (8.57%) cases of pneumothorax, 4 (11.43%) cases of intestinal bleeding, 5.71% cases of incisional infection, 1 (2.86%) case of respiratory failure, and 1 (2.86%) case of liver damage in the conventional group. The experimental group showed a significantly lower incidence of complications (5.71%) versus the conventional group (37.14%) (P < 0.05).

Conclusion

PTGBD plus laparoscopic cholecystectomy for acute cholecystitis effectively improves surgical safety, promotes patients' postoperative recovery, and reduces the incidence of conversion to open surgery and postoperative complications with a high safety profile. Further trials are, however, required prior to clinical promotion.

Percutaneous Transhepatic Gallbladder Drainage Combined with Laparoscopic Cholecystectomy Versus Emergency Laparoscopic Cholecystectomy for the Treatment of Moderate Acute Cholecystitis: A Meta-Analysis

Background: We compared the clinical outcomes of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD) with those of emergency LC (ELC) in patients with moderate acute cholecystitis (AC) as per the Tokyo Guidelines. Methods: A meta-analysis of clinical comparative studies investigating the efficacy of PTGBD combined with LC (PTGBD + LC) versus ELC for moderate AC patients was performed. Results: The PTGBD + LC group had a shorter operative time (mean difference [MD] = -25.02 minutes; 95% confidence interval [95% CI] -35.50 to -14.54; P < .00001), less intraoperative bleeding (MD = -33.38 mL; 95% CI -45.43 to -21.33; P < .00001), shorter postoperative hospital stay (MD = -2.37 days; 95% CI -3.30 to -1.44; P < .00001), lower conversion rate (odds ratio [OR] 0.23; 95% CI 0.11-0.48; P < .0001), and lower total postoperative morbidity (OR 0.26; 95% CI, 0.10-0.67; P = .005) compared with the ELC group. There was no significant difference in total hospital stay (MD = 1.71 days; 95% CI -0.17 to 3.60; P = .08) and the incidence of bile leak (OR 0.30; 95% CI 0.07-1.29; P = .11). Conclusions: Compared with ELC, LC after PTGBD can effectively reduce the difficulty of operation, total postoperative morbidity, and conversion rate, and shorten the postoperative hospital stay and operative duration in patients with moderate AC as per the Tokyo Guidelines. In clinical practice, it is necessary to formulate individualized treatment plans based on the condition and willingness of the patients.

Lightweight deep neural networks for cholelithiasis and cholecystitis detection by point-of-care ultrasound

BACKGROUND AND OBJECTIVE

Emergency physicians (EPs) frequently deal with abdominal pain, including that is caused by either gallstones or acute cholecystitis. Easy access and low cost justify point-of-care ultrasound (POCUS) use as a first-line test to detect these diseases; yet, the detection performance of POCUS by EPs is unreliable, causing misdiagnoses with serious impacts. This study aimed to develop a machine learning system to detect and localize gallstones and to detect acute cholecystitis by ultrasound (US) still images taken by physicians or technicians for preliminary diagnoses.

METHODS

Abdominal US images (> 89,000) were collected from 2386 patients in a hospital database. We constructed training sets for gallstones with or without cholecystitis (N = 10,971) and cholecystitis with or without gallstones (N = 7348) as positives. Validation sets were also constructed for gallstones (N = 2664) and cholecystitis (N = 1919). We applied a single-shot multibox detector (SSD) and a feature pyramid network (FPN) to classify and localize objects using image features extracted by ResNet-50 for gallstones, and MobileNet V2 to classify cholecystitis. The deep learning models were pretrained using the COCO-2017 and ILSVRC-2012 datasets.

RESULTS

Using the validation sets, the SSD-FPN-ResNet-50 and MobileNet V2 achieved areas under the receiver operating characteristics curve of 0.92 and 0.94, respectively. The inference speeds were 21 (47.6 frames per second, fps) and 7 ms (142.9 fps).

CONCLUSIONS

A machine learning system was developed to detect and localize gallstones, and to detect cholecystitis, with acceptable discrimination and speed. This is the first study to develop this system for either gallstone or cholecystitis detection with absence or presence of each one. After clinical trials, this system may be used to assist EPs, including those in remote areas, for detecting these diseases.

Nighttime Cholecystectomies are Safe When Controlled for Individual Patient Risk Factors-A Nationwide Case-Control Analysis

Background

The aim of this study was to evaluate if the time of day a cholecystectomy was performed affects in-hospital complication rates and mortality.

Methods

A national quality measurement database was retrospectively studied. Study period was 2010 to 2017. The inclusion criteria were operatively treated cholecystitis or another benign disease of the gallbladder. Further, the time of day the operation was performed must have been documented. We defined nighttime as all interventions performed between 7PM until 6AM. A total of 11′459 patients were included. Development of any complication during hospitalization and in-hospital mortality was the main outcomes. The first part of the study was solely descriptive. In the second part, we applied a 1:1 case–control-matching. A matched group of 274 pairs were further investigated.

Results

Only 8.4% of the procedures were performed during nighttime. Complications occurred in 6.7% of all patients. We found twice as many complications in the nighttime group compared to the daytime group. Mortality was 0.56% during daytime and 0.52% during nighttime. In a matched-pair analysis, however, we found no significant differences in the overall mortality rate nor in the occurrence of complications when comparing day- vs. nighttime operations.

Conclusions

We found twice as many complications in the nighttime group (12%) compared to the daytime group (6.1%), mainly related to patient risk factors. In contrast to common apprehension, however, nighttime cholecystectomies were not associated with higher mortality rates.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-021-06021-7.

A Retrospective Study Comparing Radiological to Histopathological Diagnosis After Laparoscopic Cholecystectomy for Suspected Cholecystitis

Introduction Acute calculus cholecystitis is one of the most common causes of acute abdominal pain in patients presenting to the emergency department, representing a third of all surgical emergency hospital admissions. Laparoscopic surgery is typically performed within 24 to 48 hours of hospital admission. Due to similarities in presentation, it is often difficult to differentiate between biliary colic and acute cholecystitis. Currently, it is not clear how the clinical and radiological diagnosis of acute calculus cholecystitis correlates with the histopathological diagnosis.  Methods We performed a retrospective analysis of 350 patients who underwent laparoscopic cholecystectomy in our community hospital for acute calculus cholecystitis. The aim was to compare pre-operative radiological diagnoses of acute calculous cholecystitis to post-operative histopathological diagnosis. Four radiographic modalities were used for diagnosis of acute calculous cholecystitis: ultrasound, computerized tomography, MRI, and hepatobiliary scintigraphy (HIDA scan). A correlation was found between both the clinical pain of biliary origin and radiological diagnosis with subsequent histopathological diagnosis after laparoscopic surgery. Results When the four commonly used imaging modalities were compared, HIDA scan had the highest sensitivity and ultrasound had the highest specificity in successfully diagnosing acute calculus cholecystitis that had been confirmed with histopathological analysis. Conclusion No absolute correlation was found between any of the imaging modalities when compared to the pathological diagnosis. The ultrasound had maximum specificity, while the HIDA scan had maximum sensitivity when radiological imaging was compared to histopathology.

Impact of B-mode-ultrasound-guided transhepatic and transperitoneal cholecystostomy tube placement on laparoscopic cholecystectomy

BACKGROUND

B-mode-ultrasound-guided percutaneous cholecystostomy (PC) may be performed by a transhepatic or transperitoneal approach, called percutaneous transhepatic gallbladder drainage (PHGD) and percutaneous transperitoneal gallbladder drainage (PPGD), respectively. We compared the impact of PC related to the route of catheter placement on subsequent laparoscopic cholecystectomy (LC).

AIM

To compare the impact of PC related to the route of catheter placement on subsequent LC.

METHODS

We retrospectively studied 103 patients with acute calculous cholecystitis who underwent scheduled LC after PC between January 2010 and January 2019. Group I included 58 patients who underwent scheduled LC after PHGD. Group II included 45 patients who underwent scheduled LC after PPGD. Clinical outcomes were analyzed according to each group.

RESULTS

Baseline demographic characteristics did not differ significantly between both groups (P > 0.05). Both PHGD and PPGD were able to quickly resolve cholecystitis sepsis. Group I showed significantly higher efficacy than group II in terms of lower pain score during puncture (3.1 vs 4.5; P = 0.001) and at 12 h follow-up (1.5 vs 2.2; P = 0.001), lower rate of fever within 24 h after PC (13.8% vs 42.2%; P = 0.001), shorted operation duration (118.3 vs 139.6 min; P = 0.001), lower amount of intraoperative bleeding (72.1 vs 109.4 mL; P = 0.001) and shorter length of hospital stay (14.3 d vs 18.0 d; P = 0.001). However, group II had significantly lower rate of local bleeding at the PC site (2.2% vs 20.7%; P = 0.005) and lower rate of severe adhesion (33.5% vs 55.2%; P = 0.048). No significant differences were noted between both groups regarding the conversion rate to laparotomy, rate of subtotal cholecystectomy, complications and pathology.

CONCLUSION

B-mode-ultrasound-guided PHGD is superior to PPGD followed by LC for treatment of acute calculous cholecystitis, with shorter operating time, minimal amount of intraoperative bleeding and short length of hospital stay.

Risk of primary liver cancer associated with gallstones and cholecystectomy: A competing risks analysis

Previous research has revealed a positive relationship between GSD, cholecystectomy and primary liver cancer (PLC). However, previous studies had several limitations including the retrospective design, narrow assessment of potential confounders and lack of competing risk models in time-to-event analyses. We conducted a large prospective cohort study to explore the relationship between GSD, cholecystectomy and PLC. A total of 95,021 participants who had not been diagnosed with PLC previously were enrolled from the Kailuan Cohort study. Demographic characteristics and biochemical parameters were recorded at baseline for all participants. We used Cox regression models and competing risk regression models to evaluate the association of GSD and cholecystectomy with the risk PLC. A total of 306 incidental PLC cases were identified during a median follow-up of 9.05 (8.75-9.22) years per participant. Compared with the normal group, the multivariable HRs (95%CI) for the association of GSD and cholecystectomy with PLC were 1.77 (1.05-2.94), 5.25 (1.95-14.17). In the CS model, the multivariable HRs (95%CI) was 1.76 (1.05-2.94) for the association of GSD and cholecystectomy with PLC and 5.25 (1.95-14.17) for GSD and cholecystectomy. Similar results were also obtained in the SD model with corresponding multivariate HRs (95%CI) of 1.75 (1.01-3.00), 5.22 (1.90-14.07) in the GSD group and cholecystectomy group, respectively. GSD and cholecystectomy were associated with an elevated risk of PLC.Registration number: ChiCTR-TNRC-11001489.

Surgical treatment of acute calculous cholecystitis complicated with hepatic dysfunction

To evaluate the timing, feasibility, and necessity of early laparoscopic cholecystectomy (LC) in the management of patients with acute calculous cholecystitis complicated with hepatic dysfunction.The clinical data of 60 patients with acute calculous cholecystitis complicated with hepatic dysfunction treated from January 2016 to January 2018 were analyzed retrospectively. A total of 32 patients underwent LC within 72 hours of the cholecystitis attack, 28 patients after 72 hours. The results were compared with those from 28 patients with delayed LC.All the patients were operated by experienced surgeons, and no LC transfer to open operation. No significant differences were detected in the operation time, postoperative complications, intraoperative blood loss, white TBIL, ALT, GGT before and after the operation between the 2 groups (P > .05). Patients who underwent early LC had a short hospital stay and fewer hospital costs (P < .05). All the patients were cured.It is safe, feasible, and necessary to perform LC within 72 hours in patients with acute calculous cholecystitis complicated with hepatic dysfunction. Such patients show a high positive correlation between the inflammation of acute calculous cholecystitis and the damage of hepatic function.

Relationship between clinical and histopathological features of patients undergoing cholecystectomy

INTRODUCTION

Cholelithiasis is most common disease of the gallbladder and cholecystectomy is the one of the most performed surgical procedure worldwide.

AIM

To assess the relationship between the demographic, biochemical, and histopathological variables of patients who underwent cholecystectomy.

MATERIAL AND METHODS

Demographic, biochemical, and histopathological data of 5077 patients undergoing cholecystectomy were compared in terms of two different aspects: open cholecystectomy (OC group; n = 2090) versus laparoscopic cholecystectomy (LC group; n = 2987), and an elective group (n = 4814) versus an emergency group (n = 263).

RESULTS

A total of 5077 patients aged between 13 and 97 years were included in the study. Aspartate aminotransferase (AST) levels, alanine aminotransferase (ALT) levels, mean platelet volume, and prevalence of acute/chronic cholecystitis were significantly higher in the LC group than in the OC group. On the other hand, age, direct bilirubin level, thrombocyte count, and prevalence of gallbladder cancer/gangrenous cholecystitis were significantly higher in the OC group than in the LC group. Levels of AST, ALT, white blood cells, neutrophils, and some prevalence of acute/chronic active cholecystitis were higher in the emergency group than in the elective group. On the other hand, the lymphocyte count and prevalence of chronic cholecystitis/hyperplastic polyps were higher in the elective group than in the emergency group. Histopathological analysis identified 32 patients with malignant gallbladder cancer as follows: adenocarcinoma (n = 21), mucinous adenocarcinoma (n = 3), papillary adenocarcinoma (n = 3), adenosquamous carcinoma (n = 1), clear cell adenocarcinoma (n = 2), squamous carcinoma (n = 1), and hepatocellular carcinoma metastasis (n = 1).

CONCLUSIONS

Even when the appearance of gallbladder specimens is normal, histopathological assessment allows for early diagnosis of many unusual findings such as gallbladder cancer.

Controversias en el manejo de la colecistitis aguda tardía

La colecistitis aguda es la inflamación de la vesícula biliar, en la mayoría de los casos, explicada por la presencia de cálculos mixtos o de colesterol que producen obstrucción y desencadenan factores inflamatorios diversos. La colecistectomía por vía laparoscópica se ha convertido en su tratamiento estándar y definitivo. El procedimiento quirúrgico debe realizarse idealmente en las primeras 72 horas después de iniciados los síntomas, lo que habitualmente se denomina como cuadro agudo. Existe controversia sobre cuál es el manejo más adecuado cuando han pasado más de 72 horas del inicio de los síntomas, condición denominada ‘colecistitis aguda tardía’, cuando se considera que el proceso inflamatorio es mayor y, el procedimiento, técnicamente más complejo y peligroso. Para esta condición, se han establecido dos estrategias iniciales de manejo: la cirugía temprana –durante la hospitalización inicial– o el tratamiento conservador con antibióticos para la supuesta resolución completa de la inflamación, es decir, ‘enfriar el proceso’; varias semanas después, se practica una colecistectomía laparoscópica tardía –diferida o electiva–. Existen muchas publicaciones sobre ambas estrategias, en las que se exponen los beneficios y probables complicaciones de cada una; en la actualidad, se sigue debatiendo sobre el momento óptimo para practicar la intervención quirúrgica. Los trabajos más recientes y con mayor peso epidemiológico, resaltan los beneficios de la cirugía temprana pues, aunque las complicaciones intraoperatorias ocurren en las mismas proporciones, la cirugía en la hospitalización inicial reduce los costos, los reingresos y los tiempos hospitalarios. Después de revisar la literatura disponible a favor y en contra, este artículo pretende recomendar el procedimiento temprano, inclusive cuando hayan pasado más de tres días de iniciados los síntomas y, solo en casos muy seleccionados, diferir la cirugía.