Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients: the Italian Society of Emergency Surgery and Trauma (SICUT) guidelines

Dealing with acute cholecystitis in high-risk, critically ill, and unfit-for-surgery patients is frequent during daily practice and requires complex management. Several procedures exist to postpone and/or prevent surgical intervention in those patients who temporarily or definitively cannot undergo surgery. After a systematic review of the literature, an expert panel from the Italian Society of Emergency Surgery and Trauma (SICUT) discussed the different issues and statements in subsequent rounds. The final version of the statements was discussed during the annual meeting in Rome (September 2022). The present paper presents the definitive conclusions of the discussion. Fifteen statements based on the literature evidence were provided. The statements gave precise indications regarding the decisional process and the management of patients who cannot temporarily or definitively undergo cholecystectomy for acute cholecystitis. Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients should be multidisciplinary. The different gallbladder drainage methods must be tailored according to each patient and based on the expertise of the hospital. Percutaneous gallbladder drainage is recommended as the first choice as a bridge to surgery or in severely physiologically deranged patients. Endoscopic gallbladder drainage (cholecystoduodenostomy and cholecystogastrostomy) is suggested as a second-line alternative especially as a definitive procedure for those patients not amenable to surgical management. Trans-papillary gallbladder drainage is the last option to be reserved only to those unfit for other techniques. Delayed laparoscopic cholecystectomy in patients with percutaneous gallbladder drainage is suggested in all those patients recovering from the conditions that previously discouraged surgical intervention after at least 6 weeks from the gallbladder drainage.

Complication analysis in acute appendicitis, results from an international multicenter study

PURPOSE

Acute appendicitis (AA) is frequent, its diagnosis is challenging, and the surgical intervention is not risk free. An accurate diagnosis will reduce unnecessary surgeries and associated risks. This study aimed to analyze the rate of appendectomies' postoperative complications.

METHODS

Multicenter, prospective, observational study conducted at three large hospitals (Pisa University Hospital, Italy; Henri Mondor University Hospital, Paris, France; and Valencia University Hospital, Spain).

RESULTS

A total of 3070 patients with a median age of 28 years (IQR 20-43) were enrolled. 1403 (45.7%) were females. Eight hundred ninety patients (29%) did not undergo preoperative imaging. Ultrasound and CT scans were performed in 1465 (47.7%) and 715 (23.3%) patients. Patients requiring CT scan were older [median 38 (IQR 26-53) vs. no imaging median 24 (IQR 16-35), Ultrasound median 28 (IQR 20-41); p < 0.0001]. Laparoscopic appendectomy was performed in 58.6%. Complications developed in 1279 (41.7%) patients: Clavien-Dindo grades I-II in 1126 (33.9%); Clavien-Dindo grades III-IV in 146 (5.2%). Overall mortality was 0.2%. Following resection of a normal appendix, 15% experienced major complications (Clavien-Dindo grades IIIb and above). Multivariable analysis revealed that age, Charlson comorbidity index, histopathology, and Alvarado score over 7 were associated with a higher risk of Clavien-Dindo complication grades IIIa and higher.

CONCLUSION

Appendectomy may be associated with serious postoperative complications. Complications were associated with older age, Charlson comorbidity index, histopathology, and high Alvarado scores. The definition of accurate diagnostic and therapeutic pathways may improve results. The association between clinical scores and radiology is recommended.

Non-operative management in blunt splenic trauma: A ten-years-experience at a Level 1 Trauma Center

Trauma; Spleen injuries are among the most frequent trauma-related injuries. The approach for diagnosis and management of Blunt Splenic Injury (BSI) has been considerably shifted towards Non- Operative Management (NOM) in the last few decades. NOM of blunt splenic injuries includes Splenic Angio-Embolization (SAE). Aim of this study was to analyze Pisa Level 1 trauma center (Italy) last 10-years-experience in the management of Blunt Splenic Trauma (BST), and more specifically to evaluate NOM rate and failure. Retrospective analysis of all patients admitted with blunt splenic trauma was done. They were divided into two groups according to the treatment: hemodynamically unstable patients treated operatively (OM group) and patients underwent a nonoperative management (NOM group). The CT scan performed in all NOM group patients. Univariate analysis was performed to identify differences between the two groups. Multivariate analysis adjusting for factors with a p value < 0.05 or with clinical relevance was used to identify possible risk factors for NOM failure. 193 consecutive patients with blunt splenic trauma were admitted. Emergency splenectomies were performed in 53 patients (OM group); 140 were managed non-operatively with or without SAE (NOM group). NOM rate in high grade injuries is 57%. Overall NOM failure rate is 9%, and success rate in high grade splenic injuries is 48%; multivariate analysis showed AAST score ≥3 as a risk factor for NOM failure. Non-operative management currently represents the gold standard management for hemodynamically stable patient with blunt splenic trauma even in high grade splenic injuries. AAST ≥3 spleen lesion is a failure risk factor but not a contraindication to for non-operative management.

Laparoscopic cholecystectomy for acute calculous cholecystitis in elderly. More complex but equally safe and effective

AIM

Acute calculous cholecystitis (ACC) is one of the most common pathologies in the elderly. Laparoscopy is the gold standard for ACC treatment, regardless of age. This study aimed to compare different classes of elderly patients affected by ACC and assess whether laparoscopy has the same safety and effectiveness as younger patients.

MATERIALS AND METHODS

Patients aging ≠ 70 y-o presenting with ACC treated with laparoscopic cholecystectomy were prospectively enrolled from 2010 to 2020. Three groups were identified: age 70-75 (Group 1); age 76-80 (Group 2); Age > 80 (Group 3). Major postoperative complications were considered as more than grade II according to the Clavien and Dindo classification. Demographic, intra-, and postoperative outcomes were compared. A multivariate analysis was also performed to identify predictive factors of morbidity.

RESULTS

We reviewed 832 patients: 302 (36.3%) were ≠ 70 y-o. Group 1 accounted for 124 patients (41.1%), group 2 for 74 (24.5%) and group 3 for 104 (34.3%). Male gender was significantly less represented with increasing ages (p<0.001). ASA score >2 (p=0.010), CACI score (p<0.001), and ERD score (p<0.001) were more frequent in group 3. No significant differences were found about AAST distribution and comorbidities. Conversion to open rate was significantly higher in group 1 (6.5%) and group 3 (8.7%) (p=0.019). Common bile duct stones rate was higher in group 3 (14.5% vs 13.5% vs 31.7%; p<0.001). Median postoperative hospital length of stay was increasingly longer (p<0.001). AAST grade ≠ 3 (OR 3.187; 95% CI 1.356-7.489; p=0.008), age ≠ 70 y-o (OR 3.358; p<0.001), and CBD stones (OR 2.912; 95% CI 1.456-5.824; p=0.003) were identified as predictive factors of morbidity between < and ≠ 70 ys. Among the three groups of elderly, age > 80 ys was associated with an increase of OR of postoperative complication by 2.94 (95% CI 1.099-7.912; p = 0.032).

CONCLUSIONS

Laparoscopy can be safely offered in elderly patients, although longer postoperative hospital stay. The presence of associated CBD stones may increase the risk of morbidity.

KEY WORDS

Acute calculous cholecystitis, Cholecystectomy, Common bile duct lithiasis, Elderly, Frailty, Laparoscopy.

Indocyanine Green (ICG) for the assessment of splenic perfusion during laparoscopic splenic artery aneurysmectomy. A case report

CASE REPORT

We describe the case of a 54-year-old man with a 20mm splenic aneurysm, who underwent laparoscopic aneurysmectomy, without splenic removal. The residual splenic blood supply was assessed by using indocyanine green i.v. administration.

CLINICAL FINDINGS

The patient presented at ED with abdominal pain, syncopal episode, and tachycardia. A CT scan with contrast showed hemoperitoneum with a 20mm splenic aneurysm, which was located at the bifurcation of the splenic and left gastroepiploic artery. Treatment and Outcome Laparoscopic surgery was then warranted. Abdominal exploration revealed a serohemorrhagic collection without active source of bleeding. After opening the gastro-colic ligament and obtaining vascular control of the splenic artery, the aneurysm was clipped and resected. No macroscopic modifications occurred to the spleen. This finding was confirmed by intravenous administration of indocyanine green. The operating time was 265 minutes. During the postoperative course, a grade A pancreatic fistula occurred. The patient was discharged on postoperative day seventh.

CLINICAL RELEVANCE

The management of true splenic artery aneurysms should be patient-tailored, considering the location of the aneurysm, operative risks and the patient's age, life expectancy and clinical status. The use of ICG in splenic surgery helps delineate the splenic parenchyma and evaluate residual splenic vascularization.

KEY WORDS

Indocyanine Green, Laparoscopy, Mini-invasive Surgery, Splenic Artery Aneurysm.

Early cholecystectomy for non-severe acute gallstone pancreatitis: easier said than done

BACKGROUND

Laparoscopic cholecystectomy (LC) carried out within 3 days after an attack of non-severe acute gallstone pancreatitis (NSAGP) is recommended to reduce hospital stay and overall costs. Aim of the study was to evaluate factors that may delay a timely surgical management of NSAGP and the consequences of this deviation.

METHODS

We reviewed the charts of patients admitted for NSAGP and managed by LC during the last 14 years. A total number of 316 patients entered the study, 98 of whom underwent early LC. A comparison of pre-operative and outcome data from the group of patients undergone early LC and those who received a delayed LC (>3 days since the admission) was made.

RESULTS

Only 31% of patients presenting with NSAGP were managed by early LC. Respect to these, patients who received a delayed LC were significantly older and had a greater occurrence of clinical signs suggesting common bile duct stones (CBDS). Stabilization of co-morbidities and need to investigate preoperatively the common duct were the main factors associated to the surgical delay. By comparing patients undergone early LC and those who received delayed LC, differences regarding conversion to open surgery (2% vs. 1.3%), need to explore the common bile duct (18.3% vs. 25.6%), CBDS clearance rates (94.4% vs. 94.6%), morbidity (8.1% vs. 8.7%), and postoperative hospital stay (3.9 vs. 3.2 days) were however statistically not significant.

CONCLUSIONS

Several reasons could delay the 3-day recommendation for surgery in NSAGP. These include the need to achieve before surgery the control of age-related co morbidities, and the workup to investigate for common duct stones. A fast track program aiming to early surgery would be advisable for patients presenting with NSAGP. Compared to delayed LC, early LC appears to shorten overall hospitalization but it does not seem to have any clinical impact on the course.

Pancreatoduodenectomy for groove pancreatitis Report of two cases

Groove pancreatitis is a rare condition with patients having clinical characteristics similar to those of chronic pancreatitis. Differentiating on clinical and radiological basis between groove pancreatitis and paraduodenal head cancer can be extremely challenging. Due to diagnostic uncertainty and to poor response to medical treatment surgery may offer these patients the best chance of cure. As the main localization of the inflammatory process is at the groove between the duodenum and the head of the pancreas, pancreato-duodenectomy is proposed as the most reliable surgical procedure. We report about two patients presenting with clinical and radiological features suggesting a groove pancreatitis in which control of symptoms was achieved by pancreatoduodenectomy.

KEY WORDS

Groove pancreatitis, Paraduodenal pancreatic cancer.

Laparoscopic repair of perforated peptic ulcer: single-center results

BACKGROUND

Perforated peptic ulcer (PPU), the most common indication for emergency gastric surgery, is associated with high morbidity and mortality rates. Outcomes might be improved by performing this procedure laparoscopically, but no consensus exists on whether the benefits of laparoscopic repair (LR) of PPU outweigh the disadvantages.

METHODS

From January 2002 to December 2012, 111 patients underwent surgery for perforated ulcer. A "laparoscopy-first" policy was attempted and then applied for 56 patients. The exclusion criteria for LR ruled out patients who had shock at admission, severe cardiorespiratory comorbidities, or a history of supramesocolic surgery. The aim of this study was a retrospective analysis of the 56 patients treated laparoscopically.

RESULTS

The patient distribution was 30 men and 26 women, who had a mean age of 59 years (range 19-95 years). The mean ulcer size was 10 mm, and the Mannheim peritonitis index (MPI) was 21. LR was performed for 39 (69.6%) of the 56 patients and included peritoneal lavage, suturing of the perforation, and omental patching. Conversion to laparotomy was necessary in 17 cases (30.4%). The "conversion group" showed significant differences in ulcer size (larger ulcers: 1.9 vs. 0.7 mm; p < 0.01), ulcer-site topography (higher incidence of posterior ulcers: 5 vs. 0; p < 0.01), and MPI score (higher score: 24 vs. 20; p < 0.05). The LR group had a mean operating time of 86 min (range 50-125 min), an in-hospital morbidity rate of 7.6 %, a mortality rate of 2.5%, and a mean hospital stay of 6.7 days (range 5-12 days). None of these patients required reintervention.

CONCLUSIONS

The results showed that LR for PPU is feasible with acceptable mortality and morbidity rates. Skill in laparoscopic abdominal emergencies is required. Perforations 1.5 cm or larger, posterior duodenal ulcers, and an MPI higher than 25 should be considered the main risk factors for conversion.