Should acute cholecystitis be operated in the 24 h following symptom onset? A retrospective cohort study

Evaluation of early versus delayed laparoscopic cholecystectomy in acute calculous cholecystitis: a prospective, randomized study

Purpose

Uncertainty exists about whether early laparoscopic cholecystectomy (LC) is an appropriate surgical treatment for acute calculous cholecystitis. This study aimed to compare early vs. late LC for acute calculous cholecystitis regarding intraoperative difficulty and postoperative outcomes.

Methods

This was a prospective randomized study carried out between December 2015 and June 2017; 60 patients with acute calculous cholecystitis were divided into two groups (early and delayed groups), each comprising 30 patients. Thirty patients treated with LC within 3 to 5 days of arrival at the hospital were assigned to the early group. The other 30 patients were placed in the delayed group, first treated conservatively, and followed by LC 3 to 6 weeks later.

Results

The conversion rates in both groups were 6.7% and 0%, respectively (p = 0.143). The operating time was 56.67 ± 11.70 minutes in the early group and 75.67 ± 20.52 minutes in the delayed group (p = 0.001), and both groups observed equal levels of postoperative complications. Early LC patients, on the other hand, required much fewer postoperative hospital stay (3.40 ± 1.99 vs. 6.27 ± 2.90 days, p = 0.006).

Conclusion

Considering shorter operative time and hospital stay without significant increase of open conversion rates, early LC might have benefits over late LC.

Acute Gangrenous Cholecystitis: Proposal of a Score and Comparison with Previous Published Scores

BACKGROUND

Gangrenous cholecystitis (GC) is a particularly severe form of acute cholecystitis (AC) and is associated with an increased risk of postoperative morbidity and mortality. Recent reports show that surgeons are remarkably unsuccessful in diagnosing GC.

METHODS

We conducted a retrospective study involving 587 patients with AC. Logistic regression analysis was used to identify independent predictive factors of GC. We assigned points for the score according to the regression coefficient. The area under the curve (AUC) was determined using receiver operating characteristic (ROC) curves. The scoring system was then prospectively validated on a second population. We validated 2 previously published scoring models.

RESULTS

Six independent predictive factors of GC were identified: [3-]4 ASA score, temperature, duration of symptoms, WBC, male gender, and pericholecystic fluid. A predictive score of GC was established based on these independent predictive factors. Sensitivity was 81.4%; specificity was 70%. The AUC of this clinicoradiological score was 0.83. The AUC of our score was higher than that of the first published score (the AUC was 0.75 in the original report and 0.78 in the validation model using our dataset) and that of the second published score (the AUC was 0.77 in the original report and 0.72 in the validation model using our dataset).

CONCLUSIONS

The AUC of our score exceeded 0.80, indicating that this score can help in diagnosing patients with GC, and thus in prioritizing these patients for surgery or choosing the adapted technique of drainage in critically ill patients.

C-reactive Protein Is the Best Biomarker to Predict Advanced Acute Cholecystitis and Conversion to Open Surgery. A Prospective Cohort Study of 556 Cases

BACKGROUND

White blood cell levels (WBC) is the only biologic determinant criterion of the severity assessment of acute cholecystitis (AC) in the revised Tokyo Guidelines 2018 (TG18). The aims of this study were to evaluate the discriminative powers of common inflammatory markers (neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP)) compared with WBC for the severity of AC, and the risk for conversion to open surgery and to determine their diagnostic cutoff levels.

METHODS

This was a prospective cohort study. Over 3 years, 556 patients underwent laparoscopic cholecystectomy for AC. Patients were classified into two groups: 139 cases of advanced acute cholecystitis (AAC) (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis), and 417 cases of non-advanced acute cholecystitis (NAAC). Multiple logistic regression and receiver-operating characteristic curve analysis were employed to explore which variables (WBC, CRP, and neutrophil-to-lymphocyte ratio (NLR)) were statistically significant in predicting AAC and conversion to open surgery.

RESULTS

On multivariable logistic regression analysis, male gender (OR = 0.4; p = 0.05), diabetes mellitus (OR = 7.8; p = 0.005), 3-4 ASA score (OR = 5.34; p = 0.037), body temperature (OR = 2.65; p = 0.014), and CRP (OR = 1.01; p = 0.0001) were associated independently with AAC. The value of the area under the curve (AUC) of the CRP (0.75) was higher than that of WBC (0.67) and NLR (0.62) for diagnosing AAC. CRP was the only predictive factor of conversion in multivariate analysis (OR = 1.008 [1.003-1.013]. Comparing areas under the receiver operating characteristic curves, it was the CRP that had the highest discriminative power in terms of conversion.

CONCLUSION

CRP is the best inflammatory marker predictive of AAC and of conversion to open surgery. We think that our results would support a multicenter-international study to confirm the findings, and if supported, CRP should be considered as a severity criterion of acute cholecystitis in the next revised version of the Guidelines of Tokyo.

Early vs. Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis - Single Center Experience

Introduction:

Laparoscopic cholecystectomy is now considered the procedure of choice that achieves a shorter recovery period after the surgery and reduction in the cost of treatment. Aim: The aim of the study is to prove which method: early or delayed laparoscopic cholecystectomy is the method of choice in the treatment of acute cholecystitis by examining: duration of hospitalization, conversion rate, duration of surgery, postoperative complications, and total cost.

Methods:

The study was conducted at the University Clinical Center of Republika Srpska as a retrospective-prospective study from May 1^st 2013 until December 31^st 2019. Patients diagnosed with acute cholecystitis were divided into two groups: Patients designated for early laparoscopic cholecystectomy within 72 hours of admission (group A–42 patients), Patients designated for initial conservative treatment followed by a delayed interval of 6-12 weeks until surgery (group B-42 patients).

Results:

In both groups, there were statistically significantly more female respondents. The results showed that the average cost of treatment in the early treated group was statistically significantly lower than the cost of treatment in the delayed treatment group. The patients in the early group had shorter hospitalization times (an average of 2.8 days and 5.6 days in the delayed group of patients), a smaller percentage of conversions (4.8% in the early and 16.7 in the delayed group of patients), the total cost of in the early group it was 1300.83 KM, while in the delayed group it was 1645.43 KM.

Conclusion:

Early laparoscopic cholecystectomy is a method to be preferred in surgical treatment.

Acute cholecystitis or simple biliary colic after an emergency presentation: why it matters

BACKGROUND

Laparoscopic cholecystectomy (LC) is often performed during the index admission after emergency presentation for acute biliary pain. Many patients have acute cholecystitis (AC) that may increase operative difficulty and complications. Our primary aim was to assess the validity of Tokyo Guidelines (TG18) for diagnosing AC by comparison with the admitting team diagnosis, operative findings and histopathology. The secondary aim was to assess outcomes after same-admission or delayed LC.

METHODS

Retrospective analysis of patients who underwent LC after presenting to a tertiary hospital emergency department over a 12-month period was conducted.

RESULTS

A total of 139 patients underwent LC with no mortality or bile duct injury. A diagnosis of AC made by the admitting surgical team had sensitivity of 84% and specificity of 57%. The TG18 diagnosis had sensitivity of 84% and specificity of 53%. A diagnosis of AC by the admitting surgical team correlated well with TG18 criteria diagnosis. There was poor correlation between clinical and histopathological diagnoses. Nine percent of patients had complications and 4% required conversion to open procedure. Patients with a clinical diagnosis of AC had longer post-operative length of stay and more complications compared with those who had non-AC diagnosis. There was no difference in outcomes between same-admission LC or delayed LC.

CONCLUSION

TG18 diagnosis of AC does not improve accuracy of diagnosis or predictability of a poor outcome over the admitting surgical team diagnosis. Same-admission LC for patients with AC is associated with similar outcomes compared to those who undergo delayed LC.

The severity grading of acute cholecystitis following the Tokyo Guidelines is the most powerful predictive factor for conversion from laparoscopic cholecystectomy to open cholecystectomy

BACKGROUND

The relationship between the severity assessment of acute cholecystitis based on the Tokyo Guidelines and the risk for conversion from laparoscopic surgery to open surgery has been assessed in few previous reports, with conflicting results.

METHODS

A retrospective review of patients with acute cholecystitis within a single system from 2010 to 2013 was performed. The diagnosis and severity of acute cholecystitis were assigned by the Tokyo Guidelines 2013 (TG13). The primary outcome measure was conversion to open cholecystectomy.

RESULTS

During the period of study, 493 patients were operated by laparoscopy for acute cholecystitis. Laparoscopic cholecystectomy was intraoperatively converted to open surgery in 56 cases (11.4%). The multivariate analysis showed that the risk factors for conversion to open surgery included male gender (OR: 2.15; IC_95% [1.18-3.9]), diabetes (OR: 2.22; IC_95% [1.13-4.33]), total bilirubin levels (OR: 1.02; IC_95% [1-1.05]), and the TG13 severity classification (OR: 4.44; IC_95% [2.25-8.75]).

CONCLUSIONS

The independent risk factors for conversion to open surgery included male sex, diabetes mellitus, total bilirubin level, and TG13 grade. TG13 grade was found to be the most powerful predictive factor for conversion as it had the highest OR.

Propensity score-matching analysis of the efficacy of late cholecystectomy for acute cholecystitis

BACKGROUND

Urgent cholecystectomy within 72 h from symptom onset is recommended. We assessed the feasibility of performing late cholecystectomy (4-7 days from symptom onset) for acute cholecystitis.

METHODS

One hundred sixty-four patients with grades 1 and 2 cholecystitis, who underwent urgent cholecystectomy within 7 days from symptom onset between June 2011 and June 2015 were enrolled. One hundred thirteen patients underwent operation within 72 h from symptom onset (early operation group), and 51 underwent operation between 4 and 7 days (late operation group). Surgical outcomes and postoperative complications were analyzed using propensity score-matching analysis.

RESULTS

The rate of conversion, intraoperative bleeding, and complications were comparable between the groups. After a one-to-two propensity score-matched analysis was performed, outcomes of the late operation group were not inferior to those of the early operation group.

CONCLUSION

Late cholecystectomy was acceptable for treating grades 1 and 2 acute cholecystitis.