Risk factors for complications in acute calculous cholecystitis. Deconstruction of the Tokyo Guidelines

OBJECTIVE

To challenge the risk factors described in Tokyo Guidelines in Acute Calculous Cholecystitis.

METHODS

Retrospective single center cohort study with 963 patients with Acute Cholecystitis during a period of 5 years. Some 725 patients with a "pure" Acute Calculous Cholecystitis were selected. The analysis included 166 variables encompassing all risk factors described in Tokyo Guidelines. The Propensity Score Matching method selected two subgroups of patients with equal comorbidities, to compare the severe complications rate according to the initial treatment (Surgical vs Non-Surgical). We analyzed the Failure-to-rescue as a quality indicator in the treatment of Acute Calculous Cholecystitis.

RESULTS

the median age was 69 years (IQR 53-80). 85.1% of the patients were ASA II or III. The grade of the Acute Calculous Cholecystitis was mild in a 21%, moderate in 39% and severe in 40% of the patients. Cholecystectomy was performed in 95% of the patients. The overall complications rate was 43% and the mortality was 3.6%. The Logistic Regression model isolated 3 risk factor for severe complication: ASA > II, cancer without metastases and moderate to severe renal disease. The Failure-to-Rescue (8%) was higher in patients with non-surgical treatment (32% vs. 7%; P = 0.002). After Propensity Score Matching, the number of severe complications was similar between Surgical and Non-Surgical treatment groups (48.5% vs 62.5%; P = 0.21).

CONCLUSIONS

the recommended treatment for Acute Calculous Cholecystitis is the Laparoscopic Cholecystectomy. Only three risk factors from the Tokyo Guidelines list appeared as independent predictors of severe complications. The failure-to-rescue is higher in non-surgically treated patients.

Is percutaneous cholecystostomy safe and effective in acute cholecystitis? Analysis of adverse effects associated with the technique

INTRODUCTION

The main objective of our study is to assess the safety and efficacy of percutaneous cholecystostomy for the treatment of acute cholecystitis, determining the incidence of adverse effects in patients undergoing this procedure.

MATERIAL AND METHOD

Observational study with consecutive inclusion of all patients diagnosed with acute cholecystitis for 10 years. The main variable studied was morbidity (adverse effects) collected prospectively. Minimum one-year follow-up of patients undergoing percutaneous cholecystostomy.

RESULTS

Of 1223 patients admitted for acute cholecystitis, 66 patients required percutaneous cholecystostomy. 21% of these have presented some adverse effect, with a total of 22 adverse effects. Only 5 of these effects, presented by 5 patients (7.6%), could have been attributed to the gallbladder drainage itself. The mortality associated with the technique is 1.5%. After cholecystostomy, one third of the patients (22 patients) have undergone cholecystectomy. Urgent surgery was performed due to failure of percutaneous treatment in 2 patients, and delayed in another 2 patients due to recurrence of the inflammatory process. The rest of the cholecystectomized patients underwent scheduled surgery, and the procedure could be performed laparoscopically in 16 patients (72.7%).

CONCLUSION

We consider percutaneous cholecystostomy as a safe and effective technique because it is associated with a low incidence of morbidity and mortality, and it should be considered as a bridge or definitive alternative in those patients who do not receive urgent cholecystectomy after failure of conservative antibiotic treatment.

Conversion from laparoscopic to open cholecystectomy: Risk factor analysis based on clinical, laboratory, and ultrasound parameters

INTRODUCTION AND AIMS

The standard of care for gallbladder disease is laparoscopic cholecystectomy. Difficult dissection of the hepatocytic triangle and bleeding can result in conversion to open cholecystectomy, which is associated with increased morbidity. Identifying risk factors for conversion in the context of acute cholecystitis will allow patient care to be individualized and improve outcomes.

MATERIALS AND METHODS

A retrospective case-control study included all patients diagnosed with acute cholecystitis, according to the 2018 Tokyo Guidelines, admitted to a tertiary care academic center, from January 1991 to January 2012. Using logistic regression, we analyzed variables to identify risk factors for conversion. Variables that were found to be significant predictors of conversion in the univariate analysis were included in a multivariate model. We then performed an exploratory analysis to identify the risk factor summation pathway with the highest sensitivity for conversion.

RESULTS

The study included 321 patients with acute cholecystitis. Their mean age was 49 years (±16.8 SD), 65% were females, and 35% were males. Thirty-nine cases (12.14%) were converted to open surgery. In the univariate analysis, older age, male sex, gallbladder wall thickness, and pericholecystic fluid were associated with a higher risk for conversion. In the multivariate analysis all of the variables, except pericholecystic fluid, were associated with conversion. Our risk factor summation model had a sensitivity of 84%.

CONCLUSIONS

Preoperative clinical data can be utilized to identify patients with a higher risk of conversion to open cholecystectomy. Being aware of such risk factors can help improve perioperative planning and preparedness in challenging cases.

How correct is the postponed cholecystectomy during the coronavirus disease-19 pandemic process? Gallstone ileus is not a myth anymore

Posponer cirugías electivas durante el proceso pandémico de Covid-19 aumentó el riesgo de complicaciones graves de enfermedades benignas. El íleo biliar es una de las raras complicaciones de la colelitiasis (0,3-0,5%). Los episodios recurrentes de colecistitis aguda están involucrados en la fisiopatología. La demostración de la tríada de Rigler en tomografía computarizada es diagnóstica. Para reducir la morbilidad se recomienda la cirugía dos etapas: extirpar el cálculo por enterotomía en la primera operación, cirugía biliar en la segunda operación. El íleo biliar debe estar en el diagnóstico diferencial de las obstrucciones intestinales mecánicas, especialmente en pacientes con antecedentes de ataques de colecistitis durante el proceso pandémico de Covid-19 porque las cirugías electivas se detuvieron.

Postponing elective surgeries during the coronavirus disease-19 (COVID-19) pandemic process increased the risk of severe complications of benign diseases. Gallstone ileus is one of the rare complications of cholelithiasis (0.3-0.5%). Recurrent episodes of acute cholecystitis are involved in pathophysiology. Demonstration of Rigler’s triad on computed tomography is diagnostic. To reduce morbidity stepped surgery is recommended: remove the stone by enterotomy at the first operation and biliary surgery at the second operation. Gallstone ileus should be in the differential diagnosis of mechanical intestinal obstructions, especially in patients with a history of cholecystitis attacks during the COVID-19 pandemic process because elective surgeries stopped.

Is percutaneous cholecystostomy safe and effective in acute cholecystitis? Analysis of adverse effects associated with the technique

INTRODUCTION

The main objective of our study is to assess the safety and efficacy of percutaneous cholecystostomy for the treatment of acute cholecystitis, determining the incidence of adverse effects in patients undergoing this procedure.

MATERIAL AND METHOD

Observational study with consecutive inclusion of all patients diagnosed with acute cholecystitis for 10 years. The main variable studied was morbidity (adverse effects) collected prospectively. Minimum one-year follow-up of patients undergoing percutaneous cholecystostomy.

RESULTS

Of 1223 patients admitted for acute cholecystitis, 66 patients required percutaneous cholecystostomy. 21% of these have presented some adverse effect, with a total of 22 adverse effects. Only 5 of these effects, presented by 5 patients (7.6%), could have been attributed to the gallbladder drainage itself. The mortality associated with the technique is 1.5%. After cholecystostomy, one third of the patients (22 patients) have undergone cholecystectomy. Urgent surgery was performed due to failure of percutaneous treatment in 2 patients, and delayed in another 2 patients due to recurrence of the inflammatory process. The rest of the cholecystectomized patients underwent scheduled surgery, and the procedure could be performed laparoscopically in 16 patients (72.7%).

CONCLUSION

We consider percutaneous cholecystostomy as a safe and effective technique because it is associated with a low incidence of morbidity and mortality, and it should be considered as a bridge or definitive alternative in those patients who do not receive urgent cholecystectomy after failure of conservative antibiotic treatment.

Safety of laparoscopic cholecystectomy in patients older than 90 years in a private hospital in Ecuador: A case series

ANTECEDENTES

La tasa de litiasis biliar y sus complicaciones son mayores en los ancianos. Algunos autores describen la edad como un factor principal que aumenta significativamente la morbilidad y la mortalidad de los pacientes sometidos a colecistectomía.

OBJETIVO

Describir la seguridad de la colecistectomía laparoscópica centrándose en su tasa de complicaciones y de conversión en pacientes mayores de 90 años, en un hospital privado de un país en desarrollo.

MÉTODO

Esta serie de casos incluyó pacientes mayores de 90 años diagnosticados de colecistitis aguda según los criterios Tokio 2013. Todos fueron sometidos a colecistectomía laparoscópica entre enero de 2010 y diciembre de 2016 en el Hospital Vozandes Quito (Ecuador). Se informaron las frecuencias y los porcentajes, y la media, para las variables categóricas y numéricas, respectivamente.

RESULTADOS

Se incluyeron 15 pacientes con edades comprendidas entre los 90 y 96 años. Hubo tres complicaciones posoperatorias, dos casos de shock hipovolémico secundario a sangrado que remitieron sin reoperación (13%) y uno de delirio (7%). Se realizó conversión quirúrgica en dos pacientes (13%) debido a la imposibilidad de visualizar las estructuras anatómicas y lograr una visión crítica adecuada de seguridad por flemón vesicular.

CONCLUSIÓN

La colecistectomía laparoscópica parece ser un enfoque seguro, con unas tasas de conversión y de complicaciones relativamente bajas, en los pacientes mayores de 90 años.

BACKGROUND

The rate of biliary lithiasis and its complications are higher in the elderly. Some authors describe age as the main factor that significantly increases the morbidity and mortality of patients undergoing cholecystectomy.

OBJECTIVE

The objective of this study was to describe the safety of laparoscopic cholecystectomy, focusing on complication and conversion rates in patients older than 90 years, in a private hospital of a developing country.

MATERIALS AND METHODS

This case-series enrolled patients older than 90 years diagnosed with acute cholecystitis using the Tokyo 2013 criteria. All included patients underwent laparoscopic cholecystectomy from January 2010 to December 2016 at Vozandes Hospital Quito-Ecuador. Frequencies and percentages and mean were reported for categorical and numerical variables, respectively.

RESULTS

We included 15 patients aged between 90 and 96 years. There were three post-operative complications, two cases of hypovolemic shock secondary to bleeding that stop without reoperation (13%) and 1 of delirium (7%). Conversion was performed in two patients (13%) due to the impossibility of visualizing the anatomical structures and obtain an adequate critical view of safety due to gallbladder phlegmon.

CONCLUSION

Laparoscopic cholecystectomy seems to be a safe approach, with relatively low complication and conversion rates in patients older than 90 years.

Hemoperitoneum secondary to haemocholecyst due to acute cholecystitis

The haemocholecyst is a rare disease with a low index of suspiction, which is even lower if the patient does not present risk factors. Likewise, the course of this pathology with a haemoperitoneum without vesicular perforation is equally infrequent. We present an unusual case in which the diagnosis of the patient was carried out intraoperatively. We consider that communicating these unusual cases in clinical practice helps to increase clinical suspiction and prompt diagnosis.

Conversion from laparoscopic to open cholecystectomy: Risk factor analysis based on clinical, laboratory, and ultrasound parameters

INTRODUCTION AND AIMS

The standard of care for gallbladder disease is laparoscopic cholecystectomy. Difficult dissection of the hepatocytic triangle and bleeding can result in conversion to open cholecystectomy, which is associated with increased morbidity. Identifying risk factors for conversion in the context of acute cholecystitis will allow patient care to be individualized and improve outcomes.

MATERIALS AND METHODS

A retrospective case-control study included all patients diagnosed with acute cholecystitis, according to the 2018 Tokyo Guidelines, admitted to a tertiary care academic center, from January 1991 to January 2012. Using logistic regression, we analyzed variables to identify risk factors for conversion. Variables that were found to be significant predictors of conversion in the univariate analysis were included in a multivariate model. We then performed an exploratory analysis to identify the risk factor summation pathway with the highest sensitivity for conversion.

RESULTS

The study included 321 patients with acute cholecystitis. Their mean age was 49 years (±16.8 SD), 65% were females, and 35% were males. Thirty-nine cases (12.14%) were converted to open surgery. In the univariate analysis, older age, male sex, gallbladder wall thickness, and pericholecystic fluid were associated with a higher risk for conversion. In the multivariate analysis all of the variables, except pericholecystic fluid, were associated with conversion. Our risk factor summation model had a sensitivity of 84%.

CONCLUSIONS

Preoperative clinical data can be utilized to identify patients with a higher risk of conversion to open cholecystectomy. Being aware of such risk factors can help improve perioperative planning and preparedness in challenging cases.

Litiasic acute cholecystitis: application of Tokyo Guidelines in severity grading

Background

Acute calculous cholecystitis (AC) is one of the most frequent surgical emergencies in our field. Laparoscopic cholecystectomy is considered the treatment of choice, although not sufficiently widespread.

Objective

To analyze the application of the Tokyo Guidelines in the management of AC and to determine the influence of the degree of severity on management and prognosis.

Method

Prospective, observational study of patients with a primary diagnosis of AC between 2010 and 2015.. Exclusion criteria: AC recurrence; AC as a secondary diagnosis; acalculous cholecystitis; concurrent biliary pathology. Severity was classified according Tokyo 2013 Guidelines.

Results

998 patients were included: 338 (33.9%) mild AC, 567 (56.8%) moderate AC, and 93 (9.3%) severe AC. A total of 582 (58.3%) patients were operated on. Postoperative complications Dindo-Clavien grade ≥ II 12.6%: mild AC 3.6%; moderate AC 12.2%; severe AC 49.0% (p < 0.001). Overall mortality 2%: mild AC 0%; moderate AC 0.5%; severe AC 18.0% (p < 0.001).

Conclusion

Urgent laparoscopic cholecystectomy remains the treatment of choice for mild and moderate AC. In patients with severe AC, the risks and benefits of surgery should be assessed, given the high degree of complications and associated mortality.

Enhanced Recovery After Emergency Surgery: Utopia or Reality?

Enhanced Recovery After Surgery (ERAS) constitutes the application of a series of perioperative measures based on the evidence, in order to achieve a better recovery of the patient and a decrease of the complications and the mortality. These ERAS programs initially proved their advantages in the field of colorectal surgery being progressively adopted by other surgical areas within the general surgery and other surgical specialties. The main excluding factor for the application of such programs has been the urgent clinical presentation, which has caused that despite the large volume of existing literature on ERAS in elective surgery, there are few studies that have investigated the effectiveness of these programs in surgical patients in emergencies. The aim of this article is to show ERAS measures currently available according to the existing evidence for emergency surgery.

Association of laboratory and radiologic parameters in the diagnosis of acute cholecystitis

INTRODUCTION AND OBJECTIVES

There is currently more evidence suggesting that early surgery should be the treatment of choice for acute calculous cholecystitis, although initial conservative treatment is also reported to be safe. Treatment decision depends on the conditions of the patient, surgical experience, and hospital infrastructure, given that early surgery cannot always be carried out. The aim of the present study was to correlate C-reactive protein values with other variables to determine those situations in which surgery cannot be delayed.

MATERIALS AND METHODS

A retrospective study was conducted on patients admitted to the hospital from the emergency service with the diagnosis of acute calculous cholecystitis. The patients were divided into 2groups: 1) patients that required urgent cholecystectomy and 2) patients that responded well to conservative medical treatment and later underwent deferred cholecystectomy.

RESULTS

A total of 238 patients (♂ 54.6%, ♀ 45.4%) were analyzed. Urgent surgery was performed on 158 patients, whereas the remaining 80 patients were released from the hospital following conservative treatment. The odds ratio of gangrenous cholecystitis presenting in acute cholecystitis for C-reactive protein was calculated in the logistic regression analysis, obtaining an OR of 1.088 and a 95% CI of 1.031-1.121.

CONCLUSION

In patients diagnosed with acute calculous cholecystitis, the combination of elevated values of C-reactive protein levels, gallbladder wall thickness, and number of leukocytes was correlated with less favorable clinical and gallbladder histologic states, resulting in a greater need for urgent surgical treatment.

Eosinophilic cholecystitis: a retrospective study spanning a fourteen-year period

INTRODUCTION AND AIMS

Eosinophilic cholecystitis is a rare entity that was first described in 1949 and is clinically indistinguishable from calculous cholecystitis. Histologically, there is transmural inflammatory infiltration of the gallbladder wall, more than 90% of which is composed of eosinophils. The aim of the present article was to review the prevalence of eosinophilic cholecystitis and analyze the clinical and surgical characteristics of patients diagnosed with the disease that were operated on at our hospital.

MATERIALS AND METHODS

A retrospective study was conducted on patients that underwent cholecystectomy and whose postoperative histopathologic diagnosis was eosinophilic cholecystitis, within the time frame of January 2000 and August 2014. The demographic, clinical, paraclinical, surgical, and histopathologic variables were described.

RESULTS

Over a period of 14 years, a total of 7,494 patients underwent cholecystectomy. Of those patients, 12 had a postoperative histologic diagnosis of eosinophilic cholecystitis. Mean patient age for disease presentation was 39 years (±11 years), and female sex was predominant, with 7 cases. All the patients had concomitant gallstones and 10 patients presented with acute cholecystitis that required urgent cholecystectomy. All the cases were considered idiopathic. We found a prevalence of 0.16%, corresponding to 1 case for every 625 cholecystectomies performed at our hospital.

CONCLUSION

We found a low prevalence of eosinophilic cholecystitis (0.16%) in our study population. The clinical manifestations were similar to those of calculous cholecystitis. Cholecystectomy is adequate treatment in patients with idiopathic disease.

Preoperative factors associated with technical difficulties of laparoscopic cholecystectomy in acute cholecystitis

OBJECTIVE

To identify preoperative factors associated with surgical time and conversion of the laparoscopic cholecystectomy (LC) to open surgery in subjects with acute cholecystitis (AC).

METHOD

We developed a cross-sectional study that included 99 subjects older than 17 years with definitive diagnosis of AC who had undergone to LC. Preoperative variables such as clinical data, laboratory markers and ultrasound findings as wall thickness, the size of the major calculus and the presence of: perivesicular fluid, multiple cholelithiasis, biliary mud or microlithiasis were registered. We consider indirect measures of technical difficulties of LC the total surgical time and the need for conversion to open surgery. We used the square chi and Mann-Whitney U test to stablish the correlation between preoperative variables and the technical difficulties of LC. We build ROC curves of the variables with significant statistical association (p ≤0.05 and 95% confidence interval [95%CI]) to determine the cut-off points of better sensitivity and specificity to predict conversion of LC to open surgery.

RESULTS

A gallbladder wall thickness ≥6mm detected by ultrasound has a sensitivity of 87.5% and a specificity of 62.6% with OR 11.71 (95%CI: 1.38-99; p = 0.008) for predict conversion to open surgery. There was no relationship between surgical time and the preoperative evaluated variables.

CONCLUSION

The gallbladder wall thickness detected by the ultrasound is associated with the need of conversion of LC to open surgery in subjects with AC, furthermore this finding could warn the surgeon on the complexity with a particular patient.

[Pylephlebitis: a rare but possible complication of intra-abdominal infections]

BACKGROUND

Pylephlebitis or septic thrombophlebitis of the portal venous system is a rare but serious complication of intra-abdominal infections which drain into the portal venous system. Its diagnosis is based on clinical suspicion and imaging tests, mainly a computed tomography scan, given the lack of specificity of the signs and symptoms. Spread of septic emboli is the major cause of morbidity and mortality. The aim of the study was to analyse patients diagnosed in our hospital.

MATERIAL AND METHODS

Retrospective descriptive study of patients diagnosed with pylephlebitis in our hospital.

CLINICAL CASES

Four patients were included, 3 men and one woman. In 3 cases it was acute cholecystitis that led to the diagnosis of pylephlebitis at the same time as the intra-abdominal infection. Emergency surgery was performed in one case, whilst the other 2 were treated conservatively. Blood cultures were performed in all cases, and empirical antibiotic treatment was used. In the only case of acute appendicitis, diagnosis of pylephlebitis was achieved during the study of postoperative fever, with empirical antibiotic treatment also being started. The haematologist was requested to start the required anticoagulation therapy in all cases.

CONCLUSIONS

Pylephlebitis is a rare complication of intra-abdominal infections that may make lead to a worse outcome. A high level of suspicion is required as well as imaging tests to make an early diagnosis and appropriate treatment.