The clinical management and results of surgery for acute cholecystitis

Efficacy and feasibility of laparoscopic subtotal cholecystectomy for acute cholecystitis

Backgrounds/Aims

For patients with acute cholecystitis, conversion from laparoscopic cholecystectomy to open surgery is not uncommon due to possibilities of serious hemorrhage at the liver bed and bile duct injury. Recent studies reported successful laparoscopic subtotal cholecystectomy for acute cholecystitis. The purpose of this study was to determine the efficacy and feasibility of such an operation based on the experience of surgeons at our facility.

Methods

In this study, we enrolled 144 patients who had received either laparoscopic subtotal cholecystectomy (LSC), laparoscopic cholecystectomy (LC), or open cholecystectomy (OC) for acute cholecystitis from January 2004 to December 2009 at the Department of Surgery of our hospital. Their symptoms, signs, operative findings, pathologic results and postoperative results were compared and analyzed.

Results

There were 26 patients in the LSC group 80 in the LC group and 38 in the OC group. There were no differences in mean age, sex, and symptoms of acute cholecystitis. The LSC group showed higher CRP levels (p<0.001) and a higher grade according to the Tokyo criteria (p=0.001). The mean operative time was 115.6 minutes and mean blood loss was 158.9 ml without intra-operative or postoperative transfusion. There weren't any bile duct injuries during the operation. No group suffered bile leakage. Drains were removed 3.3 days after the operation in the LC group, the shortest time compared to the other groups (p<0.001). LC and LSC groups demonstrated shorter postoperative hospital days and time to diet resumption than the OC group (p<0.001).

Conclusions

LSC appears to be a safe and effective treatment in cases of severe acute cholecystitis that require consideration of conversion to open surgery.

Laparoscopic subtotal cholecystectomy as an alternative procedure designed to prevent bile duct injury: experience of a hospital in northern China

PURPOSE

Experience and advances in laparoscopic techniques have made laparoscopic subtotal cholecystectomy (LSTC) a feasible option even in complex procedures. We report our experience of performing LSTC in the management of complicated cholecystitis.

METHODS

Among 1558 patients scheduled to undergo laparoscopic cholecystectomy (LC) in our institute between July 2004 and December 2007, 48 underwent LSTC for complicated cholecystitis. We describe our tailored approach and the techniques we used to accomplish this.

RESULTS

All 48 patients underwent retrograde cholecystectomy. Twenty (41.6%) required an additional port (the fourth port) to obtain adequate exposure of the hilum, 39 (81.3%) required suturing of the gallbladder infundibular remnant, and 4 (8.33%) experienced local complications. The mean operative time of LSTC was 61.7 +/- 17.5 min, the estimated operative blood loss was 72.0 +/- 32.8 ml, the time to resume oral intake was 27.8 +/- 14.9 h, and the mean postoperative hospital stay was 4.5 +/- 1.3 days. There was no bile duct injury or mortality in this series.

CONCLUSION

Laparoscopic subtotal cholecystectomy is a safe and feasible alternative to conversion to open surgery during difficult laparoscopic cholecystectomy for patients with complicated cholecystitis. However, we emphasize that only experienced laparoscopic surgeons should perform this procedure when complete removal of the gallbladder is not possible.

Laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

The aim of this study is to present our experience and results with performing laparoscopic cholecystectomy for acute cholecystitis evaluating the effect of timing of surgery and the influence of the various types of gallbladder inflammation on patient outcome.

MATERIALS AND METHODS

The patients were separated in three groups according to the time between the onset of symptoms and the operation: the "early" group was defined as laparoscopic cholecystectomy completed in the first 72 h after the onset of the symptoms, the "intermediate" group from 4 to 7 days, and the "delayed" group with symptoms lasting more than 8 days.

RESULTS

Two hundred twenty-five patients underwent laparoscopic cholecystectomy. There were 115 patients who underwent "early" surgery; 70 patients underwent "intermediate" surgery, and 70 patients underwent "delay" surgery. The total number of converted cases was 32 (12.5%). There were 124 cases of acute cholecystitis, 53 cases of gangrenous cholecystitis, 27 cases of hydrops, and 51 cases of empyema. There was no significant difference in complication rate, mortality, and postoperative hospital stay.

CONCLUSIONS

Laparoscopic cholecystectomy can be accomplished safely in most patients with acute cholecystitis. The timing of surgery has no clinical relevant effect on conversion rates, operative times, morbidity, and postoperative hospital stay.

Laparoscopic cholecystectomy for acute cholecystitis: can the need for conversion and the probability of complications be predicted? A prospective study

BACKGROUND

Laparoscopic cholecystectomy (LC) in acute cholecystitis is associated with a relatively high rate of conversion to an open procedure as well as a high rate of complications. The aim of this study was to analyze prospectively whether the need to convert and the probability of complications is predictable.

METHODS

A total of 215 patients undergoing LC for acute cholecystitis were studied prospectively by analyzing the data accumulated in the process of investigation and treatment. Factors associated with conversion and complications were assessed to determine their predictive power.

RESULTS

Conversion was indicated in 44 patients (20.5%), and complications occurred in 36 patients (17%). Male gender and age >60 years were associated with conversion, but these factors had no sensitivity and no positive predictive value. The same factors, together with a disease duration of >96 h, a nonpalpable gallbladder, a white blood count (WBC) of >18,000/cc(3), and advanced cholecystitis, predicted conversion with a sensitivity of 74%, a specificity of 86%, a positive predictive value of approximately 40%, and a negative predictive value of 96%. However, these data became available only when LC was underway. Male gender and a temperature of >38 degrees C were associated with complications, but these factors had no sensitivity and no positive predictive value. Progression along the stages of admission and therapy did not add predictive factors or improve the predictive characteristics. Male gender, abdominal scar, bilirubin >1 mg%, advanced cholecystitis, and conversion to open cholecystectomy were associated with infectious complications. Their sensitivity and positive predictive value remained 0 despite progression along the stages of admission and therapy.

CONCLUSION

Although certain preoperative factors are associated with the need to convert a LC for acute cholecystitis, they have limited predictive power. Factors with higher predictive power are obtained only during LC. The need to convert can only be established during an attempt at LC. Preoperative and operative factors associated with total and infectious complications have no predictive power.