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Clinical Impact of Preoperative Relief of Jaundice Following Endoscopic Retrograde Cholangiopancreatography on Determining Optimal Timing of Laparoscopic Cholecystectomy in Patients with Cholangitis. J Clin Med 2021; 10:jcm10194297. [PMID: 34640314 PMCID: PMC8509117 DOI: 10.3390/jcm10194297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/29/2021] [Accepted: 09/13/2021] [Indexed: 12/07/2022] Open
Abstract
Background: About 10% of patients with gallbladder (GB) stones also have concurrent common bile duct (CBD) stones. Laparoscopic cholecystectomy (LC) after removal of CBD stones using endoscopic retrograde cholangiopancreatography (ERCP) is the most widely used method for treating coexisting gallbladder and common bile duct stones. We evaluated the optimal timing of LC after ERCP according to clinical factors, focusing on preoperative relief of jaundice. Methods: A total of 281 patients who underwent elective LC after ERCP because of choledocholithiasis and cholecystolithiasis from January 2010 to April 2018 were retrospectively reviewed. We compared the hospital stay, perioperative morbidity, and rate of surgical conversion to open cholecystectomy according to the relief of jaundice before surgery. These enrolled patients were divided into two groups: relief of jaundice before surgery (group 1, n = 125) or not (group 2, n = 156). Results: The initial total bilirubin level was higher in group 1; however, there were no significant differences in the other baseline characteristics including age, sex, American Society of Anesthesiologists score, previous surgical history, white blood cell count, C-reactive protein, and operative time between the two groups. There was also no significant difference in postoperative hospital stay between the two groups (4.5 ± 3.3 vs. 5.5 ± 5.6 days, p = 0.087). However, after ERCP, the waiting time until LC was significantly longer in group 1 (5.0 ± 4.9 vs. 3.5 ± 2.4 days, p < 0.001). There were no statistical differences in the conversion rate (3.2% vs. 3.8%, p = 0.518) or perioperative morbidity (4.0% vs. 5.8%, p = 0.348), either. Conclusions: LC would not be delayed until the relief of jaundice after ERCP since there were no significant differences in perioperative morbidity or surgical conversion rate to open cholecystectomy. Early LC after ERCP may be feasible and safe in patients with cholangitis and cholecystolithiasis.
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Hoilat GJ, Hoilat JN, Abu-Zaid A, Raleig J, Tot J, Mandal A, Sostre V, Carvounis C, Sapkota B. Impact of early cholecystectomy on the readmission rate in patients with acute gallstone cholangitis: a retrospective single-centre study. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000705. [PMID: 34330787 PMCID: PMC8327811 DOI: 10.1136/bmjgast-2021-000705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 07/18/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND AND AIMS The pathogenesis of acute cholangitis (AC) occurs with biliary obstruction followed by bacterial growth in the bile duct. The leading cause of AC is obstructing gallstones. There have been conflicting theories about the optimal timing for cholecystectomy following AC. The aim of this study is to assess the impact of early cholecystectomy on the 30-day readmission rate, 30-day mortality, 90-day readmission rate and the length of hospital stay. METHODS This retrospective study was performed between January 2015 and January 2021 in a high-volume tertiary referral teaching hospital. Included patients were 18 years or older with a definitive diagnosis of acute gallstone cholangitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) with complete clearance of the bile duct as an index procedure. We divided the patients into two groups: patients who underwent ERCP alone and those who underwent ERCP with laparoscopic cholecystectomy (LC) on the same admission (ERCP+LC). Data were extracted from electronic medical records. The primary endpoint of the study was the 30-day readmission rate. RESULTS A total of 114 patients with AC met the inclusion criteria of the study. The ERCP+LC group had significantly lower rates of 30-day readmission (2.2% vs 42.6%, p<0.001), 90-day readmission (2.2% vs 30.9%, p<0.001) and 30-day mortality (2.2% vs 16.2%, p=0.017) when compared with the ERCP group. In a multivariate logistic regression analysis, patients in the ERCP+LC group had 90% lower odds of 30-day readmission compared with patients who did not undergo LC during admission (OR=0.1, 95% CI (0.032 to 0.313), p<0.001). CONCLUSION Performing LC on same day admission was associated with a decrease in 30-day and 90-day readmission rate as well as 30-day mortality.
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Affiliation(s)
- Gilles Jadd Hoilat
- Internal Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | | | - Ahmed Abu-Zaid
- Department of Pharmacology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Julia Raleig
- Department of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Joseph Tot
- Department of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Amrenda Mandal
- Gastroenterology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Vanessa Sostre
- Gastroenterology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Christos Carvounis
- Internal Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Bishnu Sapkota
- Gastroenterology, SUNY Upstate Medical University, Syracuse, New York, USA.,Gastroenterology, Syracuse VA Medical Center, Syracuse, New York, USA
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The Impact of Laparoscopic Cholecystectomy on 30-Day Readmission Rate for Acute Cholangitis Patients: A Single-Center Study. Dig Dis Sci 2021; 66:861-865. [PMID: 32248392 DOI: 10.1007/s10620-020-06240-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/25/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Laparoscopic cholecystectomy (LC) following acute gallstone cholangitis reduces the recurrence of biliary symptoms; however, the timing of LC has not been determined yet. The aim of our study was to evaluate the impact of performing LC during admission on the 30-day readmission rate. METHODS We conducted a retrospective cohort study of acute gallstone cholangitis patients who underwent endoscopic clearance (EC) of the bile duct through endoscopic retrograde cholangiopancreatography between April 2013 and May 2018. Patients were classified into two groups: EC only group and EC followed by LC during admission (EC + LC) group. The primary outcome was the 30-day readmission rate. RESULTS A total of 95 patients with acute cholangitis were included in the analysis. Of these patients, 35 patients (36.8%) underwent LC during admission. The 30-day readmission rate was significantly lower in the EC + LC group compared to the EC group (2.9% vs. 26.7%, P 0.003). In a multivariate regression analysis, patients who underwent LC during admission had 90% lower odds of readmission within 30 days compared to patients who did not (OR 0.1, 95% CI (0.01-0.9), P 0.04). CONCLUSIONS Performing laparoscopic cholecystectomy during admission for acute gallstone cholangitis patients following endoscopic clearance of the bile duct significantly reduced the 30-day readmission rate without affecting the length of stay.
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James PD, Kaplan GG, Myers RP, Hubbard J, Shaheen AA, Tinmouth J, Yong E, Love J, Heitman SJ. Decreasing mortality from acute biliary diseases that require endoscopic retrograde cholangiopancreatography: a nationwide cohort study. Clin Gastroenterol Hepatol 2014; 12:1151-1159.e6. [PMID: 24095977 DOI: 10.1016/j.cgh.2013.09.054] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 09/15/2013] [Accepted: 09/19/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The management of acute biliary diseases often involves endoscopic retrograde cholangiopancreatography (ERCP), but it is not clear whether this technique reduces mortality. We investigated whether mortality from acute biliary diseases that require ERCP has been reduced over time and explored factors associated with mortality. METHODS We conducted a cohort study using the Nationwide Inpatient Sample (1998-2008). We identified hospitalizations for choledocholithiasis, cholangitis, and acute pancreatitis that involved ERCP. Multivariate analyses were used to determine the effects of time period, patient factors, hospital characteristics, features of the ERCP procedure, and types of cholecystectomies on mortality, length of stay, and costs. RESULTS From 1998 to 2008 there were 166,438 admissions for acute biliary conditions that met the inclusion criteria, corresponding to more than 800,000 patients nationwide. During this interval, mortality decreased from 1.1% to 0.6% (adjusted odds ratio [aOR], 0.7; 95% confidence interval [CI], 0.6-0.8), diagnostic ERCPs decreased from 28.8% to 10.0%, hospitals performing fewer than 100 ERCPs per year decreased from 38.4% to 26.9%, open cholecystectomies decreased from 12.4% to 5.8%, and unsuccessful ERCPs decreased from 6.3% to 3.2% (P < .0001 for all trends). Unsuccessful ERCP (aOR, 1.7; 95% CI, 1.4-2.2), open cholecystectomy (aOR, 3.4; 95% CI 2.7-4.3), cholangitis (aOR, 1.9; 95% CI, 1.5-2.3), older age, having Medicare health insurance, and comorbidity were associated with increased mortality. CONCLUSIONS In-hospital mortality from acute biliary conditions requiring ERCP in the United States has decreased over time. Reductions in the rate of unsuccessful ERCPs and open cholecystectomies are associated with this trend.
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Affiliation(s)
- Paul D James
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Calgary Research and Education in Advanced Therapeutic Endoscopy, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Robert P Myers
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - James Hubbard
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Abdel Aziz Shaheen
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jill Tinmouth
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elaine Yong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Love
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Calgary Research and Education in Advanced Therapeutic Endoscopy, Calgary, Alberta, Canada
| | - Steven J Heitman
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Calgary Research and Education in Advanced Therapeutic Endoscopy, Calgary, Alberta, Canada.
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Abstract
Infection of the biliary tract, or cholangitis, is a potentially life-threatening condition. Bile duct stones are the most common cause of biliary obstruction predisposing to cholangitis. The key components in the pathogenesis of cholangitis are biliary obstruction and biliary infection. Several underlying mechanisms of bactibilia have been proposed. Characteristic clinical features of cholangitis include abdominal pain, fever, and jaundice. A combination of clinical features with laboratory tests and imaging studies are frequently used to diagnose cholangitis. Endoscopic retrograde cholangiopancreatography is the best diagnostic test. Less invasive imaging tests may be performed initially in clinically stable patients with uncertain diagnoses.
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Affiliation(s)
- Rajan Kochar
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94305, USA
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Sasaki K, Watanabe G, Matsuda M, Hashimoto M. Original single-incision laparoscopic cholecystectomy for acute inflammation of the gallbladder. World J Gastroenterol 2012; 18:944-51. [PMID: 22408354 PMCID: PMC3297054 DOI: 10.3748/wjg.v18.i9.944] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 08/18/2011] [Accepted: 08/27/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the safety and feasibility of our original single-incision laparoscopic cholecystectomy (SILC) for acute inflamed gallbladder (AIG).
METHODS: One hundred and ten consecutive patients underwent original SILC for gallbladder disease without any selection criteria and 15 and 11 of these were diagnosed with acute cholecystitis and acute gallstone cholangitis, respectively. A retrospective review was performed not only between SILC for AIG and non-AIG, but also between SILC for AIG and traditional laparoscopic cholecystectomy (TLC) for AIG in the same period.
RESULTS: Comparison between SILC for AIG and non-AIG revealed that the operative time was longer in SILC for AIG (97.5 min vs 85.0 min, P = 0.03). The open conversion rate (2/26 vs 2/84, P = 0.24) and complication rate (1/26 vs 3/84, P = 1.00) showed no differences, but a need for additional trocars was more frequent in SILC for AIG (5/24 vs 3/82, P = 0.01). Comparison between SILC for AIG and TLC for AIG revealed no differences based on statistical analysis.
CONCLUSION: Our original SILC technique was adequately safe and feasible for the treatment of acute cholecystitis and acute gallstone cholangitis.
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Judkins SE, Moore EE, Witt JE, Barnett CC, Biffl WL, Burlew CC, Johnson JL. Surgeons provide definitive care to patients with gallstone pancreatitis. Am J Surg 2011; 202:673-7; discussion 677-8. [DOI: 10.1016/j.amjsurg.2011.06.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Revised: 06/14/2011] [Accepted: 06/28/2011] [Indexed: 12/25/2022]
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Li VKM, Yum JLK, Yeung YP. Optimal timing of elective laparoscopic cholecystectomy after acute cholangitis and subsequent clearance of choledocholithiasis. Am J Surg 2010; 200:483-8. [DOI: 10.1016/j.amjsurg.2009.11.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 11/17/2009] [Accepted: 11/17/2009] [Indexed: 12/16/2022]
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Chandio A, Timmons S, Majeed A, Twomey A, Aftab F. Factors influencing the successful completion of laparoscopic cholecystectomy. JSLS 2010; 13:581-6. [PMID: 20202401 PMCID: PMC3030795 DOI: 10.4293/108680809x1258998404560] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
This study found that advanced age, presentation with acute cholecystitis, and choledocholithiasis are independent risk factors for conversion from laparoscopic to open cholecystectomy. Objective: To analyze the preoperative factors contributing to the decision to convert laparoscopic to open cholecystectomy. Methods: Retrospective identification of 324 consecutive patients undergoing laparoscopic cholecystectomy, with univariate and multivariate analysis of the following parameters: age, gender, obesity, previous abdominal surgery, presentation with acute cholecystitis, pancreatitis or obstructive jaundice, gallbladder wall thickening, gallbladder or common bile duct stones. Results: Thirty-nine patients (12%) underwent conversion to open cholecystectomy. Patients aged over 65 years were four times more likely to require conversion than patients under 50 years of age. Under 50 years of age, males had equal conversion rates to females, and above this age there was a non-significant increased conversion rate in males. Obese patients had higher conversion rates than non-obese patients (23% versus 9%, P < 0.003). Thirty-eight percent of patients with choledocholithiasis required conversion. Age, acute cholecystitis and choledocholithiasis independently predicted conversion. A patient aged less than fifty years with neither acute cholecystitis nor choledocholithiasis had a conversion rate of just 2%, while almost 60% of those over 65 years of age with acute cholecystitis or choledocholithiasis required conversion. Conclusion: The parameters of age, acute cholecystitis and choledocholithiasis must be considered in the clinical decision making process when planning laparoscopic cholecystectomy.
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Affiliation(s)
- Ashfaq Chandio
- Department of General & Laparoscopic Surgery, Mallow General Hospital, Mallow Co. Cork, Republic of Ireland.
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10
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Abstract
BACKGROUND A severity grading system is essential to reporting surgical complications. In 1992, we presented such a system (T92). Its use and that of systems derived from it have increased exponentially. Our purpose was to determine how well T92 and its modifications have functioned as a severity grading system and to develop an improved system for reporting complications. METHODS 129 articles were studied in detail. Twenty variables were searched for in each article with particular emphasis on type of study, substitution of qualitative terms for grades, grade compression, and cut-points if grade compression was used. We also determined relative distribution of complications and manner of presentation of complications. RESULTS T92 and derivative classifications have received wide use in surgical studies ranging from small studies with few complications to large studies of complex operations that describe many complications. There is a strong tendency to contract classifications and to substitute terms with self evident meaning for the numerical grades. Complications are presented in a large variety of tabular forms some of which are much easier to follow than others. CONCLUSIONS Current methods for reporting the severity of complications incompletely fulfill the needs of authors of surgical studies. A new system-the Accordion Severity Grading System-is presented. The Accordion system can be used more readily for small as well as large studies. It introduces standard definition of simple quantitative terms and presents a standard tabular reporting system. This system should bring the field closer to a common severity grading method for surgical complications.
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Schiphorst AHW, Besselink MGH, Boerma D, Timmer R, Wiezer MJ, van Erpecum KJ, Broeders IAMJ, van Ramshorst B. Timing of cholecystectomy after endoscopic sphincterotomy for common bile duct stones. Surg Endosc 2008; 22:2046-50. [PMID: 18270768 DOI: 10.1007/s00464-008-9764-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Revised: 10/10/2007] [Accepted: 10/31/2007] [Indexed: 12/19/2022]
Abstract
BACKGROUND According to the literature, the conversion rate for laparoscopic cholecystectomy (LC) after endoscopic sphincterotomy (ES) for cholecystodocholithiasis reaches 20%, at least when LC is performed 6 to 8 weeks afterward. It is hypothesized that early planned LC after ES prevents recurrent biliary complications and reduces operative morbidity and hospital stay. METHODS All consecutive patients who underwent LC after ES between 2001 and 2004 were retrospectively evaluated. Recurrent biliary complications during the waiting time for LC, conversion rate, postoperative complications, and hospital stay were documented. RESULTS This study analyzed 167 consecutive patients (59 men) with a median age of 54 years. The median interval between ES and LC was 7 weeks (range, 1-49 weeks). During the waiting time for LC, 33 patients (20%) had recurrent biliary complications including cholecystitis (n = 18, 11%), recurrent choledocholithiasis (n = 9, 5%), cholangitis (n = 4, 2%), and biliary pancreatitis (n = 2, 1%). Of these 33 patients, 15 underwent a second endoscopic retrograde cholangiography (ERC). The median time between ES and the development of recurrent complications was 22 days (range, 3-225 days). Most of the biliary complications (76%) occurred more than 1 week after ES. Conversion to open cholecystectomy occurred for 7 of 33 patients with recurrent complications during the waiting period, compared with 13 of 134 patients with an uncomplicated waiting period (p = 0.14). This concurred with doubled postoperative morbidity (24% vs 11%; p = 0.09) and a longer hospital stay (median, 4 vs 2 days; p < 0.001). CONCLUSION In this retrospective analysis, 20% of all patients had recurrent biliary complications during the waiting period for cholecystectomy after ES. These recurrent complications were associated with a significantly longer hospital stay. Cholecystectomy within 1 week after ES may prevent recurrent biliary complications in the majority of cases and reduce the postoperative hospital stay.
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Gholipour C, Shalchi RA, Abassi M. Efficacy and safety of early laparoscopic common bile duct exploration as primary procedure in acute cholangitis caused by common bile duct stones. J Laparoendosc Adv Surg Tech A 2008; 17:634-8. [PMID: 17907977 DOI: 10.1089/lap.2006.0199] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The elective laparoscopic management of common bile duct (CBD) stones is widely accepted; however, the urgent laparoscopic exploration of common bile duct (LCBDE) within the first 72 hours of acute cholangitis is not assessed extensively. Our aim was to study the safety and efficacy of urgent LCBDE in patients with acute cholangitis. MATERIALS AND METHODS In a single-center prospective study, 73 patients of a university hospital with acute gallstone cholangitis were operated on with laparoscopy or open surgery, based on a predetermined schedule concerning the presence of the skilled laparoscopic surgeon at the hospital. Patients with sever acute cholangitis (e.g., organ failure, shock, or peritonitis), pancreatitis, and suspected tumoral obstructions were excluded. The major outcomes, including mortality, complications of surgery, and the length of hospital and intensive care unit (ICU) stay, are reported in this paper. RESULTS In all 36 open surgery patients, a choledocotomy and T-tube placement procedure were performed. In laparoscopic patients, CBD clearance was approached by a transcystic and choledocotomy approach in 15 and 22 subjects, respectively. Eight (6 in the open and 2 in the laparoscopic group) choledocoduodenostomies were performed. Cholangitis was controlled sufficiently in all patients. Of 37 laparoscopies, 3 operations were converted into open surgeries. Operation time was longer in the laparoscopic group, compared to the open group (201 +/- 15 vs. 146 +/- 6.1 minutes; P < 0.01). The average ICU and hospital stay after an operation were significantly less than open surgery group. Total cost of treatment in laparoscopic group was less than 75% of that of the open surgery group. General complications were more common in the open surgery group. There was no mortality. One retained stone was discovered in the laparoscopic group. CONCLUSIONS Early one-stage LCBDE is an effective procedure as an initial and definite management of acute gallstone cholangitis, which prevents a second hospitalization and relapse problems.
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Affiliation(s)
- Changiz Gholipour
- Department of General Surgery, Sinaea Hospital, Tabriz University of Medical Sciences, Tabriz, Iran.
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Abstract
Acute ascending cholangitis is a potential life-threatening emergency characterized by infection and obstruction of the biliary tree. This article reviews the pathogenesis and clinical approach to patients with ascending cholangitis and examines the literature on this topic.
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Affiliation(s)
- Timothy P Kinney
- Department of Medicine--Section of Gastroenterology--G5, University of Minnesota/Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, USA.
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Abstract
OBJECTIVE Medical treatment is the first-line management in patients with acute cholangitis but those who fail to respond to antibiotic treatment need urgent biliary decompression. Early prediction of patients with acute cholangitis who require urgent biliary drainage is important because this group of patients has a higher morbidity and mortality from this pathology. This study was undertaken to identify early predictors for emergency biliary decompression in patients with acute cholangitis. METHODS This is a retrospective analysis of a prospective database of 171 consecutive patients with acute cholangitis managed in a regional hospital in Hong Kong. Emergency biliary drainage was performed when conservative treatment failed. Twenty-four variables that could be assessed upon admission were analyzed for the prediction of the need for emergency biliary decompression. RESULTS Thirty-one (18.1%) patients needed emergency biliary drainage. Older age (P=0.001), habit of chronic smoking (P=0.04), prolonged prothrombin time (P=0.025), higher blood glucose level (P=0.002), and dilated common bile duct diameter on ultrasonography (P=0.047) predicted the need for urgent biliary drainage. Patients aged older than 75 years had a significantly higher chance of failure of conservative treatment than those aged 75 years or less (26.5% versus 10.2%, P=0.005). CONCLUSIONS Biliary drainage should be considered early in cholangitic patients aged older than 75 years and/or chronic smoking because they are less likely to respond to conservative treatment. Further studies are required to confirm that the outcome of patients with acute cholangitis can be improved by this selective approach.
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Affiliation(s)
- Yeung Yuk Pang
- Department of Surgery, Kwong Wah Hospital, Kowloon, Hong Kong.
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Boerma D, Schwartz MP. Gallstone disease. Management of common bile-duct stones and associated gallbladder stones: Surgical aspects. Best Pract Res Clin Gastroenterol 2006; 20:1103-16. [PMID: 17127191 DOI: 10.1016/j.bpg.2006.04.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
For many years, open exploration of the common bile duct has been the treatment of choice for patients with common bile-duct stones. During recent decades endoscopic sphincterotomy has gained wide acceptance as an effective and less invasive alternative. After sphincterotomy, subsequent (laparoscopic) cholecystectomy is warranted in patients with gallbladder stones. This chapter will discuss whether sphincterotomy should be performed prior to, during or after cholecystectomy, and will also address the question of whether single-stage treatment by laparoscopic cholecystectomy and laparoscopic bile-duct exploration is in fact preferable. The rate of recurrent choledocholithiasis after endoscopic biliary sphincterotomy can reach more than 20%. This review focuses on the risk factors--delayed bile-duct clearance and bactobilia--that may lead to recurrent primary bile-duct stone formation. Underlying altered bile composition (relative phospholipid deficiency) should be recognised in a subgroup of patients. Identification of these risk factors may significantly affect treatment policy.
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Affiliation(s)
- Djamila Boerma
- Department of Surgery, St Antonius Hospital, Postbus 2500, 3430 EM Nieuwegein, The Netherlands.
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N/A, 杜 海, 许 冬. N/A. Shijie Huaren Xiaohua Zazhi 2005; 13:1628-1629. [DOI: 10.11569/wcjd.v13.i13.1628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
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Englesbe MJ, Dawes LG. Resistant pathogens in biliary obstruction: importance of cultures to guide antibiotic therapy. HPB (Oxford) 2005; 7:144-8. [PMID: 18333179 PMCID: PMC2023940 DOI: 10.1080/13651820510028792] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cholangitis, infection of the bile ducts, is a serious condition that necessitates prompt and efficacious treatment for a good clinical outcome. A single center retrospective study of cholangitis was conducted to better define the spectrum of responsible pathogens and their antibiotic sensitivities. METHODS We studied all patients at our hospital who had cholangitis from January 1998 to June 2004. Patients were identified by ICD-9 codes and the cause of the cholangitis, the treatment and culture data were noted by review of the medical record. RESULTS Thirty patients presented with cholangitis as noted by the clinical symptoms of jaundice, fever and abdominal pain. The cause of the biliary obstruction was gallstones in 18 patients, benign biliary strictures in 5 and malignant obstruction in 7. All the patients with malignant obstruction with cholangitis had stents; there were no cases of cholangitis in malignant obstruction unless prior instrumentation had been performed. The most common isolates were Enterococcus>E. coli>Enterobacter>Klebsiella. Sixty-four percent of blood cultures and all but one of the bile cultures grew organisms. Seventy-two percent of patients had positive blood cultures with at least one resistant organism present and 36% had organisms resistant to multiple antibiotics. Fifty percent of patients with benign biliary disease and positive blood cultures had multiple organisms growing in their blood. Three-quarters of the isolates were resistant to one or more antibiotics and one-quarter of isolates were resistant to three or more antibiotics. Resistant organisms were found regardless of the cause of the biliary obstruction. DISCUSSION For all causes of cholangitis, there is a high incidence of positive blood cultures and a high rate of antibiotic resistance. For optimal treatment, blood and/or bile cultures should be routinely performed to optimize antibiotic therapy.
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