Acute cholecystitis: Delayed cholecystectomy has lesser perioperative morbidity compared to emergency cholecystectomy

Outcomes after cholecystectomy in patients aged ≥80 years: A National Surgical Quality Improvement Program analysis evaluating safety and risk factors for elderly patients

BACKGROUND

Geriatric patients may be at an increased risk of complications after cholecystectomy; however, quantification of this risk is not defined. We aimed to evaluate outcomes after cholecystectomy in octogenarians and factors independently associated with complications in these patients.

METHODS

This is a retrospective study of 2017 to 2021 National Surgical Quality Improvement Program data evaluating patients undergoing cholecystectomy, comparing patients aged ≥80 years with those aged <80 years. We compared demographics and outcomes with multivariable logistic regression modeling to evaluate factors independently associated with serious complications and mortality or serious complications.

RESULTS

Overall, 288,705 patients were included with 4.9% being octogenarian. Octogenarians were more likely to have comorbidities, functional dependence, and lower body mass index. Octogenarians were more likely to receive open cholecystectomies (7.2% vs 2.8%; P <.001), and they had longer operative time (76.6 vs 70.2 min; P <.001) and hospital stay (4.1 vs 1.6 days; P <.001). They were also more likely to undergo reoperation (1.7% vs 0.9%; P <.001) or have serious complications (9.7% vs 2.9%; P <.001). Multivariable logistic regression demonstrated that being an octogenarian was an independent factor of increased risk of mortality (odds ratio [OR], 3.29; P <.001) and serious complications (OR, 1.54; P <.001). Specific to octogenarians, minimally invasive surgical approach was significantly protective against serious complications (OR, 0.30; P <.001) and mortality (OR, 0.29; P <.001), whereas functional dependence increased likelihood of morbidity (OR, 4.42; P <.001) and serious complications (OR, 2.08; P =.002).

CONCLUSION

Octogenarians have an increased risk of morbidity after cholecystectomy. Minimally invasive surgery seems protective for these patients. Assessment of the octogenarians' functional dependence would provide insight preoperatively into their markedly increased perioperative risk.

Global burden of gallbladder and biliary diseases (1990-2021) with healthcare workforce analysis and projections to 2035

BACKGROUND

Gallbladder and biliary tract diseases pose a significant global health burden, yet comprehensive analyses of their long-term epidemiological trends and future projections remain limited. This study aims to examine the temporal and spatial patterns of these diseases globally from 1990 to 2021, analyze healthcare workforce distribution relative to disease burden, and project the disease burden to 2035.

METHODS

Using data from the Global Burden of Disease Study 2021, we analyzed incidence, prevalence, disability-adjusted life years (DALYs), and mortality for gallbladder and biliary tract diseases. We employed the Estimated Annual Percentage Change (EAPC) to assess trends, decomposition analysis to identify drivers of change, health inequality analysis to evaluate distributional disparities, and the Bayesian Age-Period-Cohort (BAPC) model for projections to 2035. Additionally, we examined correlations between healthcare workforce density and disease burden across countries.

RESULTS

The global age-standardized incidence rate decreased by 12.84% from 1990 to 865.4 per 100,000 population in 2021, while the absolute number of cases increased by 60.11%. Age-standardized prevalence decreased by 13.31%, DALYs by 20.98%, and mortality by 28%. Decomposition analysis revealed that population aging contributed 95.37% and population growth 73.96% to the increase in global deaths, while epidemiological improvements offset 69.33% of this increase. High SDI regions had significantly higher disease burden, with Western Europe showing the highest prevalence (4,009.85 per 100,000). Our healthcare workforce analysis revealed substantial disparities; high-burden Honduras had only 48.3 health workers per 10,000 population (8.4 physicians), while Austria had 385.5 (45.6 physicians), despite similar disease prevalence. Health inequality increased between 1990 and 2021, with the concentration index for mortality rising from 0.24 to 0.31. By 2035, despite decreasing age-standardized rates, the absolute number of cases is projected to increase by 20.3%, DALYs by 26.1%, and deaths by 36.9%, primarily driven by demographic changes.

CONCLUSION

The increasing absolute burden of gallbladder and biliary diseases despite improvements in age-standardized rates necessitates targeted interventions. Health systems should implement enhanced screening programs for high-risk populations, expand surgical workforce capacity in underserved regions, develop region-specific clinical guidelines for early intervention, and adopt policies addressing modifiable risk factors such as obesity and diet. Strategic healthcare workforce planning is crucial, as our analysis revealed significant imbalances in both the density and composition of healthcare personnel relative to disease burden.

Predictors of failure of conservative management of cholecystitis: a systematic review of the literature

OBJECTIVES

While emergency cholecystectomy is the preferred treatment for acute cholecystitis, conservative management can be used as a bridge to definitive surgical management in situations where emergency surgical services are limited. The objective of this systematic review is to identify factors associated with conservative management failure as defined as either failed resolution of symptoms on initial presentation, or the recurrence of symptoms whilst awaiting an elective cholecystectomy. This study aims to allow clinicians to make evidence-based recommendations for conservative versus operative management.

METHODS

A systematic review of the Medline database was conducted in May 2022 to identify studies analysing the success of non-operative management of acute cholecystitis. Two independent reviewers selected studies based on predefined criteria, and the risk of bias was evaluated. Out of the initial 1344 studies retrieved, 12 studies met the inclusion criteria.

RESULTS

Factors significantly associated with persistence of symptoms in at least one study on multivariable analysis included diabetes mellitus, age >70, tachycardia, elevated temperature, elevated white cell count >15 000/uL and a distended gallbladder >5 cm. Factors significantly associated with recurrence of symptoms included Age <40 or >80, male sex, acute cholecystitis grade 2 or 3, elevated creatinine, serum albumin <4 g/dL, thickened gallbladder wall >5 mm.

CONCLUSION

Several factors have been identified which may facilitate future evidence-based recommendations for tailored management strategies for patients with acute cholecystitis.

Sarcomatoid Hepatocellular Carcinoma: A Case Report and Review of Literature

Sarcomatoid hepatocellular carcinoma (SHC), which contains variable proportions of sarcomatous and carcinomatous components, is a rare variant of hepatocellular carcinoma and is a special variant of hepatocellular carcinoma. It is highly malignant, progresses rapidly, and has an extremely poor prognosis. However, the molecular pathogenesis of SHC remains unknown. We report a case of a 35-year-old male, previously healthy with no liver disease history, who presented with intermittent fever. Imaging examination during hospitalization revealed focal liver lesions. Without obvious surgical contraindications, right hemihepatectomy, cholecystectomy, and regional lymph node dissection were performed. Postoperative pathology and immunohistochemistry confirmed the diagnosis of SHC. However, due to the financial burden of the disease, the patient and his family chose traditional Chinese medicine as postoperative supplementary treatment rather than targeted drug combined with immunotherapy or other adjuvant therapies. Unfortunately, the patient passed away due to tumor recurrence 8 months after surgery.

Preoperative Waiting Time Affects the Length of Stay of Patients Treated via Laparoscopic Cholecystectomy in an Acute Care Surgical Setting

Background/Objectives: Acute cholecystitis (AC) presents a significant burden in emergency surgical settings. Early laparoscopic cholecystectomy (ELC) is the standard of care for AC, yet its implementation varies. This study aims to assess the impact of preoperative waiting time (WT) on postoperative length of stay (LOS) in patients undergoing urgent cholecystectomy. Methods: From June 2021 to September 2022, data on patients undergoing urgent cholecystectomy for AC or pancreatitis were collected from two university hospitals. Patients were categorized into early (ELC) or delayed (DLC) cholecystectomy groups based on WT. The primary outcome was the assessment of the variables influencing LOS via univariate and multivariate analyses. Results: This study included 170 patients, predominantly female, with a median age of 64.50 years. ELC was performed in 58.2% of cases, with a median WT of 0 days, while DLC was performed in 41.8%, with a median WT of 3 days. Postoperative complications occurred in 21.8% of cases, with LOS being significantly shorter in the ELC group (median 5 days vs. 9 days; p = 0.001). Multivariate analysis confirmed that WT (OR 8.08 (1.65-77.18; p = 0.033)) was the most important predictor of LOS. Conclusions: ELC is associated with a shorter LOS and with DLC, aligning with the WSES recommendations. Earlier surgery reduces the risk of complications and overall hospital costs. An extended WT contributes to a prolonged LOS, underscoring the importance of timely access to operating theaters for acute biliary pathologies.

A critical view: Examining disparities regarding timely cholecystectomy

BACKGROUND

Implicit bias may prevent patients with abdominal pain from receiving optimal workup and treatment. We hypothesized that patients from socially disadvantaged backgrounds would be more likely to experience delays in receiving operative treatment for cholecystitis. To study this question, we examined factors related to having a prior emergency department presentation for abdominal pain (prior emergency department visit) within 3 months of urgent cholecystectomy.

METHODS

We performed a retrospective analysis of consecutive patients who received an urgent cholecystectomy at an urban safety net public hospital between July 2019 and December 2022. The main outcome of interest was prior emergency department visit within 3 months of index cholecystectomy. We examined patient age, sex, race, ethnicity, preferred language, insurance, and employment status. Bivariate comparisons and logistic regression were used to determine the relationship between patient factors and prior emergency department visit.

RESULTS

Of 508 cholecystectomy patients, 138 (27.2%) had a prior emergency department visit in the 3 months preceding their surgery. In bivariate analysis, younger age, Black race, Hispanic ethnicity, non-English preferred language, and type of insurance (P < .05) were associated with prior emergency department visit. In regression, younger age, Black race, Hispanic ethnicity, and having Medicare or being uninsured were associated with higher odds of having a prior emergency department visit.

CONCLUSION

More than 1 in 4 patients had an evaluation for abdominal pain within 3 months of having an urgent cholecystectomy, and these patients were more likely to be from socially disadvantaged backgrounds. Standardized evaluation pathways for abdominal pain are needed to reduce disparities from institutional or implicit bias.

Elective Cholecystectomy After Endoscopic Gallbladder Stenting for Acute Cholecystitis: A Propensity Score Matching Analysis

OBJECTIVE

To investigate the influence of endoscopic gallbladder stenting (EGBS) on subsequent cholecystectomy. We retrospectively compared the surgical outcomes of EGBS, followed by elective cholecystectomy with those of immediate cholecystectomy (IC).

PATIENTS AND METHODS

A total of 503 patients were included in this study. Patients who underwent EGBS as initial treatment for acute cholecystitis, followed by elective cholecystectomy, were included in the EGBS group and patients who underwent IC during hospitalization were included in the IC group. Propensity score matching analysis was used to compare the surgical outcomes. In addition, the factors that increased the amount of bleeding were examined by multivariate analysis after matching.

RESULTS

Fifty-seven matched pairs were obtained after propensity matching the EGBS group and the IC group. The rate of laparoscopic cholecystectomy in the EGBS versus IC groups was 91.2% versus 49.1% ( P < 0.001). The amount of bleeding was 5 mL in the EGBS versus 188 mL in the IC group ( P < 0.001). In the EGBS and IC groups, multivariate analysis of factors associated with more blood loss revealed IC (odds ratio: 4.76, 95% CI: 1.25-20.76, P = 0.022) as an independent risk factor.

CONCLUSION

EGBS as the initial treatment for acute cholecystitis and subsequent elective cholecystectomy after the inflammation has disappeared can be performed in minimally invasive procedures and safely.

The Significance of Preoperative Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), and Systemic Inflammatory Index (SII) in Predicting Severity and Adverse Outcomes in Acute Calculous Cholecystitis

The prediction of severity in acute calculous cholecystitis (AC) is important in therapeutic management to ensure an early recovery and prevent adverse postoperative events. We analyzed the value of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic inflammatory index (SII) to predict advanced inflammation, the risk for conversion, and postoperative complications in AC. Advanced AC was considered the cases with empyema, gangrene, perforation of the gallbladder, abscesses, or difficulties in achieving the critical view of safety. A 3-year retrospective was performed on 235 patients admitted in emergency care for AC. The NLR was superior to the PLR and SII in predicting advanced inflammation and risk for conversion. The best predictive value was found to be at an NLR "cut-off" value of >4.19, with a sensitivity of 85.5% and a specificity of 66.9% (AUC = 0.824). The NLR, SII, and TG 13/18 correlate well with postoperative complications of Clavien-Dindo grade IV (p < 0.001 for all variables) and sepsis. For predicting early postoperative sepsis, TG 13/18 grading >2 and NLR > 8.54 show the best predicting power (AUC = 0.931; AUC = 0.888, respectively), although not significantly higher than that of the PLR and SII. The NLR is a useful biomarker in assessing the severity of inflammation in AC. The SII and PLR may be useful in the prediction of systemic inflammatory response.