The impact of patient delay and physician delay on the outcome of laparoscopic cholecystectomy for acute cholecystitis

The Use of Systemic Inflammatory Response Syndrome (SIRS) and Elevated Liver Enzymes as Predictive Factors of Gangrenous Cholecystitis: A Case Report

Gangrenous cholecystitis is a severe complication of acute cholecystitis. It is often found incidentally during laparoscopic cholecystectomy or during conversion to open surgery and diagnosed with subsequent pathological analysis. While intraoperative diagnosis is typically through direct visualization of the gallbladder, specific diagnostic modalities may guide physicians toward an earlier diagnosis. Surgical intervention and a more aggressive approach are often needed to prevent the advancement of the disease and its catastrophic complications. This case report illustrates the distinct risk factors predisposing a patient to develop gangrenous cholecystitis. Comorbidities such as hypertension, coronary artery disease, age, the relevance of the SIRS criteria, and elevated liver enzymes are explored as predictive factors in a patient with gangrenous cholecystitis.

Effectiveness of a quality improvement collaborative in reducing time to surgery for patients requiring emergency cholecystectomy

Background

Acute gallstone disease is a high‐volume emergency general surgery presentation with wide variations in the quality of care provided across the UK. This controlled cohort evaluation assessed whether participation in a quality improvement collaborative approach reduced time to surgery for patients with acute gallstone disease to fewer than 8 days from presentation, in line with national guidance.

Methods

Patients admitted to hospital with acute biliary conditions in England and Wales between 1 April 2014 and 31 December 2017 were identified from Hospital Episode Statistics data. Time series of quarterly activity were produced for the Cholecystectomy Quality Improvement Collaborative (Chole‐QuIC) and all other acute National Health Service hospitals (control group). A negative binomial regression model was used to compare the proportion of patients having surgery within 8 days in the baseline and intervention periods.

Results

Of 13 sites invited to join Chole‐QuIC, 12 participated throughout the collaborative, which ran from October 2016 to January 2018. Of 7944 admissions, 1160 patients had a cholecystectomy within 8 days of admission, a significant improvement (P < 0·050) from baseline performance. This represented a relative change of 1·56 (95 per cent c.i. 1·38 to 1·75), compared with 1·08 for the control group. At the individual site level, eight of the 12 Chole‐QuIC sites showed a significant improvement (P < 0·050), with four sites increasing their 8‐day surgery rate to over 20 per cent of all emergency admissions, well above the mean of 15·3 per cent for control hospitals.

Conclusion

A surgeon‐led quality improvement collaborative approach improved care for patients requiring emergency cholecystectomy.

DOES MALE GENDER INCREASE THE RISK OF LAPAROSCOPIC CHOLECYSTECTOMY?

Background:

Laparoscopic cholecystectomy is the preferable treatment for chronic or acute cholecystitis. Some factors may increase the rate of laparoscopic conversion to open cholecystectomy and perioperative complications. The role of gender as a risk factor for laparoscopic cholecystectomy is controversial.

Aim:

To evaluate the role of the gender on the operative findings and outcome of laparoscopic cholecystectomy.

Method:

All patients who underwent laparoscopic cholecystectomy for chronic or acute cholecystitis were included. Demographic, clinical, laboratory, imaging exams, intraoperative and postoperative data were obtained and analyzed. The data was obtained retrospectively from electronic medical records and study protocols.

Results:

Of a total 1,645 patients who were subjected to laparoscopic cholecystectomy, 540 (32.8%) were men and 1,105 (67.2%) were women. Mean age was similar in both genders (p=0.817). Operative time has longer in the male (72.48±28.50) than in the female group (65.46±24.83, p<0.001). The rate of acute cholecystitis was higher in the male (14.3%) than in the female group (5.1%, p<0.001). There was no difference between the genders in regard to the rate of conversion (p=1.0), intraoperative complication (p=1.0), postoperative complication (p=0.571), and operative mortality (p=1.0).

Conclusion:

Male gender is not an independent risk factor for laparoscopic conversion and perioperative complications.

Emergency Cholecystectomy Versus Percutaneous Cholecystostomy for Treatment of Acute Cholecystitis in High-Risk Surgical Patients

Our aim is to present our experience with laparoscopic cholecystectomy (LC) and percutaneous cholecystostomy (PC) in high-risk patients with acute cholecystitis (AC). The guidelines for AC are still debatable for high-risk patients. We aimed to emphasize the role of LC as a primary treatment method in patients with severe AC instead of a treatment after PC according to the Tokyo Guidelines (TG). AC patients with high surgical risk [American Society of Anesthesiologists (ASA) III-IV] who were admitted to our department between March 2008 and November 2014 were retrospectively evaluated. Disease severity in all patients was assessed according to the 2007 TG for AC. Patients were either treated by emergency LC (group LC) or PC (group PC). Demographic data, ASA scores, treatment methods, rates of conversion to open surgery, duration of drainage, length of hospital stay, and morbidity and mortality rates were compared among groups. Age, ASA score, and TG07 severity scores in the PC group were significantly higher than that in the LC group (P &lt; 0.001, P &lt; 0.001, and P &lt; 0.001, respectively). Sex distribution (P = 0.33), follow-up periods (P = 0.33), and morbidity (P = 0.86) were similar. In the patients with early surgical intervention, mortality was significantly lower (P &lt; 0.001). Length of hospital stay was significantly shorter in the LC group compared with the PC group (P &lt; 0.001). In high-risk surgical patients, PC can serve as an alternative treatment method because of its efficiency in the prevention of sepsis-related complications due to AC. However, LC still should be an option for severe AC with comparable short-term results.

Atypical presentation of gangrenous cholecystitis: A case series

Gangrenous cholecystitis (GC) is a serious complication of acute cholecystitis that has been associated with increased morbidity. Patient with GC can present with a wide variety of non-specific clinical, laboratory, and imaging characteristics, making the diagnosis challenging. This disease requires emergent treatment, which is why a quick and reliable diagnosis is essential for the wellbeing of the patient. The authors herein present a case of GC in a patient whose initial complaint was intractable hiccups, and provide a thorough review of the literature of cases of GC with atypical presentations.

Is Single-incision Laparoscopic Cholecystectomy Feasible for Acute Cholecystitis? A Consecutive Study of 60 Cases

The feasibility of single-incision laparoscopic cholecystectomy (SIL-C) for patients with acute cholecystitis were evaluated based on the timing of operation after onset of symptoms. Sixty patients with acute cholecystitis who underwent SIL-C were divided into 2 groups according to the timing of operation: group E included 23 patients who underwent SIL-C within 72 hours, and group O included 37 patients who underwent SIL-C later. There were no statistical differences between group E and group O in clinicopathologic characteristics. Group E demonstrated significantly shorter operating time and less blood loss than group O. Although the incidences of additional port(s) requirements were not significantly different, 8 patients in group O required open conversion, indicating significantly higher rate. As group E demonstrated favorable surgical outcomes compared with group O, SIL-C for acute cholecystitis seems to be a feasible therapeutic procedure when performed within 72 hours as updated Tokyo Guidelines recommended.

Gangrenous cholecystitis: mortality and risk factors

As a serious complication of cholelithiasis, gangrenous cholecystitis presents greater mortality than noncomplicated cholecystitis. The aim of this study was to specify the risk factors on mortality. 107 consecutive patients who underwent surgery due to gangrenous cholecystitis between January 1997 and October 2011 were investigated retrospectively. The study included 60 (56.1%) females and 47 (43.9%) males, with a mean age of 60.7 ± 16.4 (21-88) years. Cardiovascular diseases were the most frequently accompanying medical issues (24.3%). Thirty-six complications (33.6%) developed in 29 patients, and surgical site infection was proven as the most common. Longer delay time prior to hospital admission, low white blood cell count, presence of diabetes mellitus, higher blood levels of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase and total bilirubin, pericholecystic fluid in abdominal ultrasonography, and conversion from laparoscopic surgery to open surgery were identified as risk factors affecting mortality (P < 0.001, P = 0.001, P = 0.044, P = 0.005, P = 0.049, P = 0.009, P = 0.022, P = 0.011, and P = 0.004, respectively). Longer delay time prior to hospital admission and low white blood cell count were determined as independent risk factors affecting mortality.

Risk factors of open converted cholecystectomy for cholelithiasis after endoscopic removal of choledocholithiasis

BACKGROUND

Open converted cholecystectomy could occur in patients who planned for laparoscopic cholecystectomy after endoscopic removal of choledocholithiasis.

AIM

To evaluate the risk factors associated with open converted cholecystectomy.

PATIENTS AND METHODS

The data for all patients who underwent cholecystectomy after endoscopic removal of choledocholithiasis were retrospectively reviewed. Factors predictive for conversion to open cholecystectomy were analyzed.

RESULTS

The rate of open converted cholecystectomy was 15.7 %. In multivariate analysis, cholecystitis (OR 1.908, 95 % CI 1.390-6.388, p = 0.005), mechanical lithotripsy (OR 6.129, 95 % CI 1.867-20.123, p < 0.005), and two or more choledocholithiases (OR 2.202, 95 % CI 1.097-4.420, p = 0.026) revealed significant risk factors for conversion to open cholecystectomy. Analyzing the risk factors for open converted cholecystectomy according to duration from endoscopic stone removal to cholecystectomy (within 2 weeks, between 2 and 6 weeks, and beyond 6 weeks), acute cholangitis (OR 3.374, 95 % CI 1.267-8.988, p = 0.015), cholecystitis (OR 3.127, 95 % CI 1.100-8.894, p = 0.033), and mechanical lithotripsy (OR 17.504, 95 % CI 3.548-86.355, p < 0.005) were related to open converted cholecystectomy in ≤2 weeks group.

CONCLUSIONS

For patients who need cholecystectomy after endoscopic removal of choledocholithiasis, endoscopic retrograde cholangiography-related factors predictive for open converted cholecystectomy are helpful in planning the appropriate timing of surgery.

Endoscopic ultrasonography-guided gallbladder drainage for acute cholecystitis: from evidence to practice

With the evolution of the linear echoendoscope and the improved ability to direct a needle within the field of interest, the therapeutic potential of endoscopic ultrasonography (EUS) has greatly expanded. Endoscopic ultrasonography-guided transmural gallbladder drainage (EUS-GBD) may be the next frontier for therapeutic EUS. Since EUS-GBD was first described in 2007, recent reports have suggested it as an alternative to external gallbladder drainage for acute cholecystitis. EUS-GBD includes EUS-guided transmural nasogallbladder drainage, EUS-guided gallbladder aspiration, and EUS-guided transmural gallbladder stenting. Indications for the EUS-GBD technique as currently practiced, including equipment, technical details, complications, and efficacy are herein reviewed.

Utility of point-of-care biliary ultrasound in the evaluation of emergency patients with isolated acute non-traumatic epigastric pain

To determine the utility of emergency physician-performed point-of-care biliary ultrasound in the evaluation of emergency department (ED) patients with isolated acute non-traumatic epigastric pain. This was a multi-center prospective observational study of adult patients presenting to the ED with isolated acute non-traumatic epigastric pain. Patients with abdominal tenderness at any site other than the epigastric region, or with a history of gall stones, cholecystectomy, gastrointestinal bleeding, chronic abdominal pain, trauma, or altered mental status were excluded. Emergency physician investigators performed point-of-care biliary ultrasound after clinical assessment. Demographic information, history, physical examination findings, laboratory results, additional diagnostic tests, and disposition data were collected. A total of 51 patients (39 women, 12 men) were enrolled. The mean age of the patients was 36.4 years ± 13.6 (SD). All subjects had isolated epigastric tenderness. Gallstones were found in 20/51 (39%, 95% CI 26-52%) on point-of-care biliary ultrasound. Of the 20 patients who had gallstones, eight had sonographic signs of chloecystitis. The treating emergency physicians' initial evaluation did not plan to include an ultrasound in 17/20 patients with gallstones. 19/20 patients were initially given a GI cocktail by the treating emergency physicians. Point-of-care biliary ultrasound detected gall stones in more than one-third of ED patients with isolated acute non-traumatic epigastric pain. All patients presenting to the ED with non-traumatic epigastric pain should be evaluated for biliary disease with an ultrasound imaging study. Bedside ultrasound can avoid misdiagnosis and expedite management in these patients.

The management of acute cholecystitis in chronic hemodialysis patients: percutaneous cholecystostomy versus cholecystectomy

INTRODUCTION

Treatment of acute cholecystitis in chronic hemodialysis (HD) patients still remains controversial. Because of underlying disease that can influence surgical results, less invasive alternative managements have been tried over the last decades. The goal of this study was to analyze the results of cholecystectomy versus percutaneous cholecystostomy for acute cholecystitis (AC) in chronic HD patients.

METHODS

All patients with end-stage renal disease who were treated for AC were identified retrospectively from our medical records. Between July 2007 and September 2011, 47 patients were treated for AC while they were on chronic HD. The records of these patients were reviewed for documented AC and its treatment.

RESULTS

Of the 47 HD patients, 26 (55.3 %) underwent cholecystectomy (CC), while 21 (44. 7 %) had a percutaneous cholecystostomy (PC) for AC as an initial treatment. The mean length of follow-up was 20.4 ± 16 months in PC and 18 ± 15 months in CC patients. The success rate was higher in CC patients compared to PC patients (92. 3 versus 66.7 %, p = 0.0698). Eleven (52. 4 %) patients who had PC subsequently underwent CC; six open CC and five delayed laparoscopic CC were performed. Of the 26 patients who underwent CC, 18 were performed emergently due to the persistence of AC-related symptoms and gangrenous and perforated gallbladders. Eight were initially treated conservatively and then underwent elective cholecystectomy at an interval of 32 ± 24 (range = 14-59) days following initial treatment. In emergent CC, 10 (55.6 %) were completed laparoscopically, three were open, and five (33.3 %) had conversions. In elective CC patients, two were conversions, but the remainder (75 %) had laparoscopic CC. Readmission rates were higher in the PC group (33.3 versus 12.5 %, p = 0.1732). Although AC-related mortality was higher in PC patients, there was no statistically significant difference in the patient survival rate between the two groups (Kaplan-Meier analysis, Fig. 1, 19 versus 7.7 %; p = 0.4035), and the overall mortality rate was higher in the PC group (33.7 versus 15.7 %, p = 0.2737).

CONCLUSION

This study confirms that the safety and effectiveness of CC has a higher success rate and lower morbidity and mortality rate compared with percutaneous cholecystostomy for acute cholecystitis in chronic HD patients.

Percutaneous cholecystostomy in high-risk elderly patients with acute cholecystitis: a lifesaving option

PURPOSE

To analyze the results of percutaneous cholecystostomy in in high-risk elderly patients with acute cholecystitis.

MATERIALS AND METHODS

Between June 2010 and May 2011, 11 patients aged over 60 who had at least 1 systemic disease and underwent percutaneous cholecystostomy were reviewed retrospectively.

RESULTS

The procedure was technically successful in 10 (90.9%) patients. Clinical improvement was achieved in 81.8% of patients within 72 hours. Two patients received emergency surgery while elective cholecystostomy was performed in 5 patients. Percutaneous cholecystostomy was performed singly in 4 (36.4%) patients. Early complication rate was 18.2%. Two (18.2%) patients died.

CONCLUSION

Percutaneous cholecystostomy can be performed with low mortality and morbidity. Cholecystectomy should be performed in all patients with suitable general conditions due to the high recurrence rates of percutaneous cholecystostomy.

Endoscopic ultrasound-guided transmural and percutaneous transhepatic gallbladder drainage are comparable for acute cholecystitis

BACKGROUND & AIMS

Endoscopic ultrasound-guided transmural gallbladder drainage (EUS-GBD) is an alternative to percutaneous transhepatic gallbladder drainage (PTGBD) for patients with acute, high-risk, or advanced-stage cholecystitis who do not respond to initial medical treatment and cannot undergo emergency cholecystectomy. However, the technical feasibility, efficacy, and safety of EUS-GBD and PTGBD have not been compared.

METHODS

Fifty-nine patients with acute cholecystitis, who did not respond to initial medical treatment and were unsuitable for an emergency cholecystectomy, were chosen randomly to undergo EUS-GBD (n = 30) or PTGBD (n = 29). The technical feasibility, efficacy, and safety of EUS-GBD and PTGBD were compared.

RESULTS

EUS-GBD and PTGBD showed similar technical (97% [29 of 30] vs 97% [28 of 29]; 95% 1-sided confidence interval lower limit, -7%; P = .001 for noninferiority margin of 15%) and clinical (100% [29 of 29] vs 96% [27 of 28]; 95% 1-sided confidence interval lower limit, -2%; P = .0001 for noninferiority margin of 15%) success rates, and similar rates of complications (7% [2 of 30] vs 3% [1 of 29]; P = .492 in the Fisher exact test) and conversions to open cholecystectomy (9% [2 of 23] vs 12% [3 of 26]; P = .999 in the Fisher exact test). The median post-procedure pain score was significantly lower after EUS-GBD than after PTGBD (1 vs 5; P < .001 in the Mann-Whitney U test).

CONCLUSIONS

EUS-GBD is comparable with PTGBD in terms of the technical feasibility and efficacy; there were no statistical differences in the safety. EUS-GBD is a good alternative for high-risk patients with acute cholecystitis who cannot undergo an emergency cholecystectomy.

Risk factors for conversion during laparoscopic cholecystectomy - experiences from a general teaching hospital

BACKGROUND AND AIMS

Laparoscopic cholecystectomy (LC) is the gold standard for treating symptomatic cholelithiasis. Conversion, however, is sometimes necessary. The aim of this study was to determine predictive factors of conversion in patients undergoing LC for various indications in elective and acute settings in a general teaching hospital.

MATERIAL AND METHODS

A retrospective analysis was performed on 972 consecutive patients who underwent a laparoscopic cholecystectomy in Máxima Medical Centre in Veldhoven, the Netherlands, from January 2000 till January 2006. Recorded data were sex, age, indication for LC, conversion to open cholecystectomy, reason for conversion, performing surgeon, co-morbidity, type of complication, length of hospital stay and 30-day mortality.

RESULTS

Conversion to open cholecystectomy was performed in 121 patients (12%). The most frequent reasons for conversion were infiltration/fibrosis of Calot's triangle (30%) and adhesions (27%). In the multivariate analyses male gender (OR 1.67, 95% CI 1.07-2.59), age >65 years (OR 2.10, 95% CI 1.32-3.34), acute cholecystitis (OR 11.8, 95% CI 6.98-20.1), recent acute cholecystitis (OR 4.71, 95% CI 2.42-9.18) and recent obstructive jaundice (OR 20.6, 95% CI 4.52-94.1) were independent predictive factors for conversion.

CONCLUSIONS

Male gender, age >65 years, (recent) acute cholecystitis and recent obstructive jaundice are independent predictive risk factors for conversion. By appreciating these risk factors for conversion, preoperative patient counselling can be improved.

Better treatment strategies for patients with acute cholecystitis and American Society of Anesthesiologists classification 3 or greater

PURPOSE

Laparoscopic cholecystectomy is the best treatment choice for acute cholecystitis. However, it still carries high conversion and mortality rates. The purpose of this study was to find out better treatment strategies for high surgical risk patients with acute cholecystitis.

MATERIALS AND METHODS

Between January 2002 and June 2008, we performed percutaneous cholecystostomy instead of emergency cholecystectomy in 44 patients with acute cholecystitis and American Society of Anesthesiologists (ASA) classification 3 or greater. This was performed in 31 patients as a bridge procedure before elective cholecystectomy (bridge group) and as a palliative procedure in 11 patients (palliation group).

RESULTS

The mean age of patients was 71.6 years (range 52-86 years). The mean ASA classifications before and after percutaneous cholecystostomy were 3.3 +/- 0.5 and 2.5 +/- 0.6, respectively, in the bridge group, and 3.6 +/- 0.7 and 3.1 +/- 1.0, in the palliation group, respectively. Percutaneous cholecystostomy was technically successful in all patients. There were two deaths after percutaneous cholecystostomy in the palliation group due to underlying ischemic heart disease and multiple organ failure. Resumption of oral intake was possible 2.9 +/- 1.8 days in the bridge group and 3.9 +/- 3.5 days in the palliation group after percutaneous cholecystostomy. We attempted 17 laparoscopic cholecystectomies and experienced one failure due to bile duct injury (success rate: 94.1%). The postoperative course of all cholecystectomy patients was uneventful.

CONCLUSION

Percutaneous cholecystostomy is an effective bridge procedure before cholecystectomy in patients with acute cholecystitis and ASA classification 3 or greater.

Risk Factors for Conversion to Open Surgery in Patients With Acute Cholecystitis Undergoing Interval Laparoscopic Cholecystectomy

Introduction: Laparoscopic cholecystectomy for acute cholecystitis is associated with higher rate of conversion to laparotomy. The value of several factors that might influence the rate of conversion is analysed. Materials and Methods: In a retrospective analysis of a prospective database, the medical records of patients who underwent laparoscopic cholecystectomy from May 1998 to June 2004 were reviewed. Patients who had acute cholecystitis and had undergone interval laparoscopic cholecystectomy were included in this study. Results: Out of 1000 laparoscopic cholecystectomies, 201 were operated on for acute cholecystitis. One hundred and forty-five patients (72.3%) underwent succesful laparoscopic cholecystectomy and 56 patients (27.7%) needed conversion to open cholecystectomy. Patient’s age (P = 0.031), total white cell count (P = 0.014), total bilirubin (P = 0.002), alkaline phosphatase (P = 0.003) and presence of common bile duct stone (P = 0.001) were found to be independently associated with conversion. Conclusion: Laparoscopic cholecystectomy can be performed safely for acute cholecystitis. Predictors of conversion will be helpful when planning the laparoscopic approach and for counselling patients preoperatively. Key words: Acute cholecystitis, Laparoscopic cholecystectomy, Risk factors

Is there an optimal time for laparoscopic cholecystectomy in acute cholecystitis?

BACKGROUND

Laparoscopic cholecystectomy (LC) is safe in acute cholecystitis, but the exact timing remains ill-defined. This study evaluated the effect of timing of LC in patients with acute cholecystitis.

METHODS

Prospective data from the hospital registry were reviewed. All patients admitted with acute cholecystitis from June 1994 to January 2004 were included in the cohort.

RESULTS

Laparoscopic cholecystectomy was attempted in 1,967 patients during the study period; 80% were women, mean patient age was 44 years (range, 20-73 years). Of the 1,967 LC procedures, 1,675 were successful, and 292 were converted to an open procedure (14%). Mean operating time for LC was 1 h 44 min (SD +/- 50 min), versus 3 h 5 min (SD +/- 79 min) when converted to an open procedure. Average postoperative length of stay was 1.89 days (+/- 2.47 days) for the laparoscopic group and 4.3 days (+/- 2.2 days) for the conversion group. No clinically relevant differences regarding conversion rates, operative times, or postoperative length of stay were found between patients who were operated on within 48 h compared to those patients who were operated on post-admission days 3-7.

CONCLUSIONS

The timing of laparoscopic cholecystectomy in patients with acute cholecystitis has no clinically relevant effect on conversion rates, operative times, or length of stay.

Videolaparoscopic cholecystectomy for acute cholecystitis: analyzing conversion risk factors

We examined a series of 176 consecutive patients scheduled for videolaparoscopic cholecystectomy for acute cholecystitis to identify the independent parameters most likely to lead to conversion to laparotomy. This prospective study was conducted from June 2001 to December 2003 on 176 consecutive patients who were scheduled for videolaparoscopic cholecystectomy for acute cholecystitis. Of the 176 patients, 119 (group A) underwent videolaparoscopic chlecystectomy, and 57 (32.3%) were converted to laparotomy (group B). Patients were assessed for gender, age, time between onset of symptoms and surgery, previous surgery, ASA (American Society of Anesthesia) risk, leukocytosis, echotomographic findings, average operating time, intra- and post-operative complications, and conversion rate. Our study found that the parameters of age, ASA risk, duration of symptoms, leukocytosis, and operative time are independent conversion risk factors.

Timing of laparoscopic cholecystectomy for acute cholecystitis: A prospective non randomized study

AIM: To study the timing of laparoscopic cholecy-stectomy for patients with acute cholecystitis.

METHODS: Between January 2002 and December 2005, all American Society of Anesthesiologists classification (ASA)I,IIand III patients with acute cholecystitis were treated laparoscopically during the urgent (index) admission. The patients were divided into three groups according to the timing of surgery: (1) within the first 3 d, (2) between 4 and 7 d and (3) beyond 7 d from the onset of symptoms. The impact of timing on the conversion rate, morbidity and postoperative hospital stay was studied.

RESULTS: One hundred and twenty-nine patients underwent laparoscopic cholecystectomy for acute cholecystitis during the index admission. Thirty six were assigned to group 1, 58 to group 2, and 35 to group 3. The conversion rate and morbidity for the whole cohort of patients were 4.6% and 10.8%, respectively. There was no significant difference in the conversion rate, morbidity and postoperative hospital stay between the three groups.

CONCLUSION: Laparoscopic cholecystectomy for acute cholecystitis during the index admission is safe, regardless of the time elapsed from the onset of symptoms. This policy can result in an overall shorter hospitalization.

Prognostic parameters for the prediction of acute gangrenous cholecystitis

BACKGROUND/PURPOSE

The aim of this study was to identify preoperative prognostic parameters for gangrenous cholecystitis to differentiate this subgroup of patients with acute cholecystitis in order to provide immediate surgical therapy.

METHODS

The medical records of patients who had an emergency cholecystectomy with the diagnosis of acute cholecystitis between January 2002 and June 2005 were reviewed retrospectively. Univariate and multivariate analysis were performed on the data.

RESULTS

Out of 203 individuals with the clinical diagnosis of acute cholecystitis, 21 (10.3%) patients had a histological diagnosis of gangrenous cholecystitis. Multivariate analysis demonstrated an independent association of male sex, diabetes mellitus and white blood cell (WBC) count with the development of acute gangrenous cholecystitis.

CONCLUSIONS

The risk for gangrenous cholecystitis is increased in male patients who have diabetes and a greater WBC count than 14 900/mm(3). Urgent surgical intervention should be considered for these patients because of the high morbidity and mortality rate of the condition.

Urgent laparoscopic cholecystectomy in the management of acute cholecystitis: timing does not influence conversion rate

BACKGROUND

The optimal treatment of acute cholecystitis is urgent laparoscopic cholecystectomy. Most reports suggest that a delay of 72 or 96 h from onset of symptoms leads to a higher conversion rate. This study assessed the conversion rate in relation to the timing of urgent laparoscopic cholecystectomy for acute cholecystitis.

METHODS

During a 12 month period, 112 patients received laparoscopic cholecystectomy for acute cholecystitis at a tertiary care university hospital in central Taiwan. Data were collected prospectively.

RESULTS

The overall conversion rate was 3.6% (4/112). Of 62 procedures performed within 72 h from onset of symptoms, 2 were converted, as compared with 2 of 50 procedures after 72 h. Of 76 procedures performed within 96 h from onset of symptoms, 3 were converted, as compared with 1 of 36 procedures after 96 h. There were no mortalities or common bile duct injuries.

CONCLUSIONS

The conversion rate for urgent laparoscopic cholecystectomy among patients with acute cholecystitis can be as low as 3.6%. The timing of urgent laparoscopic cholecystectomy has no impact on the conversion rate.

Acute gallstone cholecystitis in the elderly: treatment with emergency ultrasonographic percutaneous cholecystostomy and interval laparoscopic cholecystectomy

BACKGROUND

The treatment of acute cholecystitis in the elderly is still a subject of debate, particularly with reference to the timing of surgery and the role of laparoscopy.

PATIENTS

From January 1994 to June 2002 we observed 27 patients aged over 70 years with acute calcolous cholecystitis. The patients were submitted to ultrasonographic percutaneous cholecystostomy within 12 h of the acute attack. For two patients (7.4%) at high operative risk, we chose a conservative treatment. Twenty-five patients (92.6%) were submitted, in 15 cases (60%) within 5 days and in 10 patients (40%) within 8 days, to a laparoscopic cholecystectomy. Statistical significance was accepted when the value of p was less than 0.05.

RESULTS

Ultrasonographic percutaneous cholecystostomy was performed successfully in all patients, without major morbidity or mortality, and complete resolution of clinical symptoms was obtained within 48 h. The conversion rate of laparoscopy was 20% (13.3% in patients submitted to surgery within 5 days and 30% in the group submitted within 8 days--p > 0.05). The postoperative morbidity rate was 24%; it was higher (40% versus 15%) in patients converted to laparotomy (p > 0.05); mortality was 4%. The period of hospitalization was 11 days in patients operated laparoscopically and 21 days in those converted to open cholecystectomy (p < 0.001).

CONCLUSIONS

The more rational treatment of acute calcolous cholecystitis in elderly patients is represented by ultrasonographic percutaneous cholecystostomy followed, within 5 days, by laparoscopic cholecystectomy using an abdominal insufflation maximum to 12 mmHg and a limited 10-15 degrees head-up tilt.

Management of Acute Calculous Cholecystitis in High-Risk Patients

Emergency cholecystectomy for acute cholecystitis is associated with high morbidity and mortality rates in patients with significant comorbidities and high-risk surgery. The aim of this study was to evaluate the effectiveness, possible advantages, and complications of percutaneous cholecystostomy (PC) followed by an early laparoscopic cholecystectomy (LC) in relation to conservative treatment followed by a delayed LC in high-surgical risk patients. Between 2002 and 2004, patients were randomly classified into 2 groups: the first group consisted of patients who had PC followed by an early LC (PCLC group, n = 31) and the second group consisted of patients who had conservative treatment followed by a delayed LC (DLC group, n = 30). The groups were statistically compared regarding their demographic, comorbidity, hospital stay, conversion, and complication rates. PC was technically successful in 31 patients with no attributable mortality or major complications. No difference had been found in regarding demographic, comorbidity, and complication rates. In PCLC group, all the patients experienced symptom relief within 24 hours, and early LC was attempted in 31 patients once their clinical condition was sufficiently stable, this was successfully accomplished in 29 (93.5%). In the DLC group, delayed LC was attempted in 30 patients, and this was successfully accomplished in 26 (86.6%). The hospital stay was shorter and cost was in the PCLC group was lower than in the DLC group. PC allows resolution of sepsis in patients at high surgical risk. Early LC could be safely performed once sepsis and acute infection resolved in these patients.

Laparoscopy for abdominal emergencies

BACKGROUND

Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment.

METHODS

A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain.

RECOMMENDATIONS

Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen.

CONCLUSIONS

Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

Contemporary minimally invasive approaches to the management of acute cholecystitis: a review and appraisal

Acute cholecystitis is one of the most common emergency admissions in surgical practice. This review appraises the available evidence from the English-language literature regarding the minimally invasive approaches to the management of this condition. The following aspects of care are reviewed and appraised: (1) the diagnostic criteria for acute cholecystitis, (2) the optimal timing for cholecystectomy (early, delayed, or interval surgery), (3) the optimal approach to cholecystectomy (laparoscopic versus open), (4) the role of intraoperative cholangiography, and (5) the management of patients unfit for surgery.

Can gangrenous cholecystitis be prevented?: a plea against a "wait and see" attitude

BACKGROUND/AIMS

A delay in recognizing and treating an inflamed gallbladder may increase the risk of a necrotic evolution and represent a critical factor affecting the progression of the inflammatory process. Aim of the study is to assess the therapeutic attitude in patients with histologically proved gangrenous cholecystitis, to find out whether it could play a role in the progression of the inflammatory condition.

METHODOLOGY

Twenty-seven patients with gangrenous cholecystitis at histology were compared with a matched-control group with phlegmonous cholecystitis.

RESULTS

Age, gender, ASA score, and concomitant diseases did not differ significantly in both groups. WBC was significantly higher (P = 0.026) in patients with gangrene. Ultrasounds were unhelpful in identifying the severity of the disease. Patients with gangrenous gallbladder showed a significantly increased (P = 0.0006) admission delay compared with controls (104.3+/-15.3 hours vs. 59.7+/-7.7 hours). Surgeon's delay, morbidity and mortality were not different in both groups.

CONCLUSION

Patient's delay before hospitalization may represent a crucial factor in the progression toward a more severe disease in acute cholecystitis. The time between symptoms onset and hospital admission (and consequently surgery) was significantly longer in patients with gangrenous cholecystitis, further emphasizing the need for an early (if not urgent) surgical treatment in acute cholecystitis, even with mild symptoms.

An evaluation of laparoscopic cholecystectomy after selective percutaneous transhepatic gallbladder drainage for acute cholecystitis

BACKGROUND

The aim of this study was to evaluate the safety and usefulness of laparoscopic cholecystectomy after selective percutaneous transhepatic gallbladder drainage in patients with severe acute cholecystitis and patients with acute cholecystitis and severe comorbid disease.

METHODS

According to whether percutaneous transhepatic gallbladder drainage was performed before surgery, 133 patients with acute cholecystitis were divided into a percutaneous transhepatic gallbladder drainage group (n=60) and non-percutaneous-transhepatic-gallbladder-drainage group (n=73). Background factors, safety, and postoperative course were retrospectively evaluated and compared between these two groups.

RESULTS

Compared with the non-percutaneous-transhepatic-gallbladder-drainage group, the percutaneous transhepatic gallbladder drainage group was significantly older (p=0.0009), had a higher frequency of comorbid disease (p=0.0252), and a worse American Society of Anesthesiology classification (p=0.0021). In individual statistical tests, body temperature (p=0.0288), white blood cell count (p=0.0175), and C-reactive protein value (p=0.0022) were significantly elevated in the percutaneous transhepatic gallbladder drainage group; however, for frequency of comorbid disease, body temperature, and white blood cell count, significance was removed by correction for multiple testing of data. There was no significant difference in gender distribution, history of upper abdominal surgery, or body mass index between the two groups. The duration of surgery was marginally but significantly longer in the percutaneous transhepatic gallbladder drainage group (p=0.0414; in a single statistical test; however, that significance was removed by correction for the multiple testing of data). Between the two groups, there was no significant difference in blood loss at surgery, frequency of postoperative complications, rate of conversion to open laparotomy, interval until oral feeding was resumed, and length of postoperative hospital stay.

CONCLUSIONS

These data suggest that satisfactory outcomes can be achieved with selective pre-operative gallbladder drainage in older and sicker patients with acute cholecystitis.

Timing of cholecystectomy for acute calculous cholecystitis: a meta-analysis

OBJECTIVES

To compare early with delayed cholecystectomy for the treatment of acute lithiasic cholecystitis: a meta-analysis of prospective randomized trials.

METHODS

Pertinent studies were selected from the Medline, Embase, Cancerlit, HealthSTAR and Cochrane Library Databases, references from published articles, and reviews. Twelve prospective randomized trials (9 addressing open cholecystectomy and 3 laparoscopic cholecystectomy) were selected. Conventional meta-analysis according to the DerSimonian and Laird method was used for the pooling of the results. The rate difference (RD) (95% CI) and the number needed to treat (NNT) were used as a measure of the therapeutic effect.

RESULTS

Cumulative operative and perioperative mortality and morbidity were 0.9% and 17.8%, respectively, for open cholecystectomy and 0% and 13.1%, respectively, for laparoscopic cholecystectomy. The pooled RD for operative complications in early surgery was 1.37% (95% CI =-3.78% to 6.53%; p= 0.2) for open cholecystectomy and 3.11% (95% CI =-15.10% to 8.87%; p= 0.6) for laparoscopic cholecystectomy. In laparoscopic cholecystectomy the cumulative conversion rate to open cholecystectomy was 21.5%. The pooled RD for conversion rate in early laparoscopic cholecystectomy was -7.99% (95% CI =-18.46% to 2.47%; p= 0.1; NNT = 13). Total hospital stay (mean +/- SD) was significantly shorter in the early surgery group (9.6 +/- 2.5 days vs 17.8 +/- 5.8 days; p < 0.0001). More than 20% of patients referred to delayed surgery fail to respond to conservative management or suffer recurrent cholecystitis in the interval period.

CONCLUSIONS

Early operation (open or laparoscopic) does not carry a higher risk of mortality and morbidity compared to delayed operation and should be the preferred surgical approach for patients with acute lithiasic cholecystitis.

Prognostic factors for the development of gangrenous cholecystitis

BACKGROUND

The operative morbidity and mortality for patients with gangrenous cholecystitis (GC) remains high. Our objective was to identify preoperative prognostic factors for GC in order to distinguish this subset of patients with acute cholecystitis (AC).

METHODS

From 1/98 to 11/01 the medical records of patients who presented with the diagnosis of AC were reviewed. Univariate and multivariate analysis were performed on this retrospective data.

RESULTS

Of 113 patients with acute cholecystitis, 45 (39.8%) had histologically confirmed gangrenous cholecystitis. Nine variables were identified that were associated with GC by univariate analysis: age > or =51 years, African-American race, white blood cell count > or =15,000, diabetes, pericholecystic fluid, asparate aminotransferase, alanine aminotransferase, alkaline phosphatase, and lipase. Two variables were identified by multivariate analysis: diabetes, and white blood cell count.

CONCLUSIONS

Our data suggest that patients with a history of diabetes and white blood cell count >15,000 to be at an increased risk for having GC upon presentation and they should have urgent surgical intervention.

Changing trends in the management of gallstone disease

BACKGROUND

Day case cholecystectomy is increasingly becoming a management option for elective cases while "same admission" cholecystectomy is now considered a favorable option in the treatment of acute cholecystitis. To assess the advent of these changes in our surgical practice, a retrospective analysis of our experience is presented.

METHODS

All patients undergoing cholecystectomy between January 2000 and January 2001 were analyzed according to admission status, operation type, conversion rate, complications, and nonsurgical intervention.

RESULTS

156 patients underwent cholecystectomy and 152 charts were retrieved. Laparoscopic cholecystectomy was performed on 95% of patients with a conversion rate of 9%. Morbidity for the series was 12.5%, including one common bile duct injury (0.6%). Day case and acute cholecystectomy comprised 67% of our cholecystectomy practice.

CONCLUSIONS

Our findings suggest that there is an increasing trend toward shortening the hospital stay of patients undergoing laparoscopic cholecystectomy. This does not appear to have had a deleterious effect on outcome.

Empyema of the gall bladder: reappraisal in the laparoscopy era

BACKGROUND

In evaluations of laparoscopic cholecystectomy for acute cholecystitis, the role of this technique specifically for empyema of the gall bladder has not been separately addressed. Therefore, we describe the demographic characteristics, clinical and laboratory findings, management and outcome of patients presenting with empyema of the gall bladder who were treated with open cholecystectomy or laparoscopic cholecystectomy.

PATIENTS AND METHODS

Our retrospective evaluation included 1449 patients who underwent cholecystectomy over 88 months, including a 30-month period when open cholecystectomy was the standard operation and a 58-month period when laparoscopic cholecystectomy became the standard operation for acute and chronic cholecystitis.

RESULTS

Of the 1449 cholecystectomies, 29 cases proved to have empyema, an incidence of 2%. Males constituted 48.3% of the patients (vs. 22% for the whole cholecystectomy group, P < or = 0.005) and the average age was 54.6 years (vs. 43 years for the whole cholecystectomy group, P < or = 0.005). The clinical picture was indistinguishable from other forms of acute cholecystitis. Laparoscopic cholecystectomy was attempted for all the patients in the laparoscopy era with a conversion rate of 42%, significantly higher than other forms of gall bladder diseases (P=0.002).

CONCLUSION

Empyema of the gall bladder is more often encountered in males and the elderly. The clinical picture is indistinguishable from other forms of acute cholecystitis and a preoperative diagnosis is difficult. Early laparoscopic cholecystectomy is advisable for all patients with acute cholecystitis. A higher conversion rate is expected for patients with empyema.

Prospective evaluation of emergency versus delayed laparoscopic cholecystectomy for early cholecystitis

Treatment of acute cholecystitis is still under debate. The aim of this study was to evaluate the efficacy of early laparoscopic cholecystectomy (ELC) in comparison with conservative treatment followed by delayed laparoscopic cholecystectomy (DLC) in the management of acute cholecystitis. This prospective comparative study involved two groups of patients presenting with acute cholecystitis within 72 hours of the onset of symptoms. ELC was performed in 82 consecutive patients, whereas DLC was performed in 87 patients who previously underwent medical treatment. Surgical variables, hospital stay, and postoperative morbidity were evaluated in both groups. Time of surgery and conversion rate were lower in the ELC group. Postoperative morbidity was similar in both groups. Overall hospital stay was shorter in the ELC group. ELC within 72 hours of the onset of acute cholecystitis is a safe procedure with better results than DLC in terms of surgical timing, conversion rate, and hospital stay.

Does this patient have acute cholecystitis?

CONTEXT

Although few patients with acute abdominal pain will prove to have cholecystitis, ruling in or ruling out acute cholecystitis consumes substantial diagnostic resources.

OBJECTIVE

To determine if aspects of the history and physical examination or basic laboratory testing clearly identify patients who require diagnostic imaging tests to rule in or rule out the diagnosis of acute cholecystitis.

DATA SOURCES

Electronic search of the Science Citation Index, Cochrane Library, and English-language articles from January 1966 through November 2000 indexed in MEDLINE. We also hand-searched Index Medicus for 1950-1965, and scanned references in identified articles and bibliographies of prominent textbooks of physical examination, surgery, and gastroenterology. To identify relevant articles appearing since the comprehensive search, we repeated the MEDLINE search in July 2002.

STUDY SELECTION

Included studies evaluated the role of the history, physical examination, and/or laboratory tests in adults with abdominal pain or suspected acute cholecystitis. Studies had to report data from a control group found not to have acute cholecystitis. Acceptable definitions of cholecystitis included surgery, pathologic examination, hepatic iminodiacetic acid scan or right upper quadrant ultrasound, or clinical course consistent with acute cholecystitis and no evidence for an alternate diagnosis. Studies of acalculous cholecystitis were included. Seventeen of 195 identified studies met the inclusion criteria.

DATA EXTRACTION

Two authors independently abstracted data from the 17 included studies. Disagreements were resolved by discussion and consensus with a third author.

DATA SYNTHESIS

No clinical or laboratory finding had a sufficiently high positive likelihood ratio (LR) or low negative LR to rule in or rule out the diagnosis of acute cholecystitis. Possible exceptions were the Murphy sign (positive LR, 2.8; 95% CI, 0.8-8.6) and right upper quadrant tenderness (negative LR, 0.4; 95% CI, 0.2-1.1), though the 95% CIs for both included 1.0. Available data on diagnostic confirmation rates at laparotomy and test characteristics of relevant radiological investigations suggest that the diagnostic impression of acute cholecystitis has a positive LR of 25 to 30. Unfortunately, the available literature does not identify the specific combinations of clinical and laboratory findings that presumably account for this diagnostic success.

CONCLUSIONS

No single clinical finding or laboratory test carries sufficient weight to establish or exclude cholecystitis without further testing (eg, right upper quadrant ultrasound). Combinations of certain symptoms, signs, and laboratory results likely have more useful LRs, and presumably inform the diagnostic impressions of experienced clinicians. Pending further research characterizing the pretest probabilities associated with different clinical presentations, the evaluation of patients with abdominal pain suggestive of cholecystitis will continue to rely heavily on the clinical gestalt and diagnostic imaging.

Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial

BACKGROUND

Patients who undergo endoscopic sphincterotomy for common bile-duct stones, who have residual gallbladder stones, are referred for laparoscopic cholecystectomy. However, only 10% of patients who do not have this operation are reported to develop recurrent biliary symptoms. We aimed to assess whether a wait-and-see policy is justified.

METHODS

We did a prospective, randomised, multicentre trial in 120 patients (age 18-80 years) who underwent endoscopic sphincterotomy and stone extraction, with proven gallbladder stones. Patients were randomly allocated to wait and see (n=64) or laparoscopic cholecystectomy (56). Primary outcome was recurrence of at least one biliary event during 2-year follow-up, and secondary outcomes were complications of cholecystectomy and quality of life. Analysis was by intention to treat.

FINDINGS

12 patients were lost to follow-up immediately. Of 59 patients allocated to wait and see, 27 (47%) had recurrent biliary symptoms compared with one (2%) of 49 patients after laparoscopic cholecystectomy (relative risk 22.42, 95% CI 3.16-159.14, p<0.0001). 22 (81%) of 27 patients underwent cholecystectomy, mainly for biliary pain (n=13) or acute cholecystitis (7). Conversion rate to open surgery was 55% in patients allocated to wait and see who underwent cholecystectomy compared with 23% in those who were allocated laparoscopic cholecystectomy (p=0.0104). Morbidity was 32% versus 14% (p=0.1048), and median hospital stay was 9 versus 7 days. Quality of life returned to normal within 3 months after either treatment policy.

INTERPRETATION

A wait-and-see policy after endoscopic sphincterotomy in combined cholecystodocholithiasis cannot be recommended as standard treatment, since 47% of expectantly managed patients developed at least one recurrent biliary event and 37% needed cholecystectomy. No major biliary complications arose, but conversion rate was high.

How early is early laparoscopic treatment of acute cholecystitis?

BACKGROUND

Despite the well-accepted success of laparoscopic cholecystectomy in elective treatment of symptomatic cholelithiasis, the efficacy and timing of this technique has been subject to some debate in the setting of acute cholecystitis. This study was undertaken to evaluate our institution's experience with early cholecystectomy as a safe, effective treatment of acute cholecystitis.

METHODS

Charts of all patients who had undergone laparoscopic cholecystectomy for the diagnosis of acute cholecystitis were reviewed. Patients were divided into two groups based on the length of time from onset of symptoms to surgical intervention: less than 48 hours in the early group (n = 14) and more than 48 hours in the late group (n = 31).

RESULTS

Comparing the two groups, the conversion rate to an open procedure was significantly less (0 versus 29%, P <0.04) in the early treated patients. Furthermore, the operative time (73 versus 96 minutes, P <0.004), postoperative hospitalization (1.2 versus 3.9 days, P <0.001), and total hospital stay (2.1 versus 5.4 days, P <0.004) were significantly reduced in patients undergoing early laparoscopic cholecystectomy.

CONCLUSIONS

Laparoscopic cholecystectomy performed by experienced surgeons is a safe, effective technique for treatment of acute cholecystitis. Patients treated within 48 hours of onset of symptoms experience a lower conversion rate to an open procedure, shorter operative time and reduced hospitalization.

Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis

BACKGROUND

The ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography (CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced open cholecystostomy for the treatment of acute cholecystitis in critically ill patients.

METHODS

The aim of the present study was to evaluate the results of a 5-year protocol using PTHC followed by delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis in critically ill patients. We reviewed the charts of 55 patients who underwent PTHC at the Hadassah University Hospital Mount Scopus during the years 1994 to 1999.

RESULTS

The main indications for PTHC among this group of severely sick and high-risk patients was biliary sepsis and septic shock in 23 patients (42%); and severe comorbidities in 32 patients (58%). The median age was 74 (32 to 98) years, 33 were female and 22 male. Successful biliary drainage by PTHC was achieved in 54 of 55 (98%) of the patients. The majority of the patients (31 of 55) were drained transhepaticlly under CT guidance. The rest, (24 of 55) were drained using ultrasound guidance followed by cholecystography for verification. Complications included hepatic bleeding that required surgical intervention in 1 patient and dislodgment of the catheter in 9 patients that was reinserted in 2 patients. Three patients died of multisystem organ failure 12 to 50 days following the procedure. The remaining 52 patients recovered well with a mean hospital stay of 15.5 plus minus 11.4 days. Thirty-one patients were able to undergo delayed surgery: 28 underwent laparoscopic cholecystectomy of whom 4 (14%) were converted to open cholecystectomy. This was compared with a 1.9% conversion rate in 1,498 elective laparoscopic cholecystectomies performed at the same time period (P = 0.012). Another 3 patients underwent planned open cholecystectomy, 1 urgent and 2 combined with other abdominal procedures. There was no surgery associated mortality, severe morbidity, or bile duct injury.

CONCLUSIONS

The use of PTHC in critically ill patients with acute cholecystitis is both safe and effective.

Urinary retention after elective cholecystectomy

BACKGROUND

There are few reports about urinary retention rate after elective cholecystectomy. We designed a prospective study to assess the problem.

METHODS

A total of 121 female and 19 male patients were included in the study with a prospective study protocol. Laparoscopic cholecystectomy was performed in 107 patients and open cholecystectomy in 33 patients.

RESULTS

Neither gender nor age affected rate. Postoperative micturition difficulty developed in 10 patients. Of these patients, 9 could void with helping measures, and only 1 needed catheterization. Only 1 patient who underwent laparoscopic surgery required catheterization (0.7%). The open approach caused a higher incidence of postoperative micturition difficulty than did the laparoscopic approach (15.2% versus 4.7%; P = 0.04). Only large amounts of perioperative fluid administration and meperidine use had statistically significant effects on micturition problems.

CONCLUSIONS

Urinary retention is a rare complication after elective cholecystectomy. Helping measures are very effective and should be tried before inserting a urethral catheter.

Laparoscopic cholecystectomy in the new millennium

BACKGROUND

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic cholelithiasis. Many authors-including investigators at our institution, who reported one of the initial experiences with laparoscopic cholecystectomy in July 1992-have documented a definite learning curve associated with this procedure. We present a follow-up study of our experience with laparoscopic cholecystectomy and compare these data to an earlier study of the initial experience with laparoscopic cholecystectomy at the Beth Israel Medical Center.

METHODS

We retrospectively reviewed 300 consecutive patients from March 1998 through March 1999. The patient population was epidemiologically similar to that of the original study with regard to age, sex, and American Society of Anesthesia (ASA) classification. However, whereas the initial population included only patients with chronic disease, in our study 13.7% of the patients had been admitted through the emergency room with acute stone disease of the biliary tract.

RESULTS

We found a 5.7% conversion rate, a 1% rate of major complication, and a 5.7% rate of minor complication rates, as compared to the initial study's rates of 12%, 4%, and 10%, respectively. Whereas none of the patients in the original study left the hospital on the day of surgery and only 49% were discharged within 1 day, in our group, 29 patients (10%) underwent ambulatory procedures and an additional 186 patients (62%) were discharged on the 1st post-operative day. The average duration of the operation was 90 min, which did not represent a statistical improvement over the time of 93 min reported in the earlier study.

CONCLUSIONS

Since 1992, both the conversion rate and length of stay have declined at our hospital, but operative time has remained essentially the same. These findings probably reflect a bimodal learning curve, the increase in the number of cholangiograms and additional intraoperative procedures now performed, the greater severity of gallbladder disease currently treated with laparoscopic cholecystectomy, and increases in the number of attending physicians as well as the level of residents who perform this procedure.

Consequences of delay in surgical treatment of biliary disease

BACKGROUND

Delay of laparoscopic cholecystectomy after the diagnosis of uncomplicated biliary disease is common at our institution. This study assessed the effect of delay of operation for symptomatic biliary disease.

METHODS

A cohort of 251 patients was retrospectively reviewed at Parkland Memorial Hospital with follow-up available for 168 patients (67%) from January 1998 to July 1998. Data were analyzed using Student's t test and the chi-square test.

RESULTS

Of the 88 patients with the initial diagnosis of biliary colic, 69 (78%) underwent elective laparoscopic cholecystectomy. Thirty-six patients made a total of 44 return visits the emergency department with a recurrent attack of biliary colic or a complication of gallstone disease. Mean operative time increased from 94 minutes for elective operations to 122 minutes for nonelective operations and hospital stay increased from 0.6 days to 6.1 days. Conversion to open operation increased from 6% in the elective group to 26% in the nonelective group.

CONCLUSION

Delay of surgical therapy is associated with complications, increased operative times, higher conversion to open cholecystectomy, and prolonged hospitalization. We conclude that patients with symptomatic cholelithiasis should undergo early cholecystectomy.