Organ system dysfunction following open cholecystectomy for acute acalculous cholecystitis in critically ill patients

Acute acalculous cholecystitis and cardiovascular disease, which came first? After two hundred years still the classic chicken and eggs debate: A review of literature

The existence of a close association between disease of the biliary tract and disease of the heart is known from the mists of time.

Acute acalculous cholecystitis (AAC) can be defined as an acute necro inflammatory disease of the gallbladder in the absence of cholelithiasis.

AAC is a challenging diagnosis. The atypical clinical onset associated to a paucity and similarity of symptoms and to laboratory data mimicking cardiovascular disease (CVD) often results in under and misdiagnosed cases. Moreover, AAC has commonly a fulminant course compared to calculous cholecystitis and it is often associated with gangrene, perforation and empyema as well as considerable morbidity and mortality (up 50%). Early diagnosis is crucial to a prompt treatment in order to avoid complications and to increase survivability.

Even today, although scientific evidence dating two hundred years has shown a close association between AAC and CVD, due to the lack of RCT, there is still a lot of confusion regarding the relationship and consequently the clinical management AAC and CVD.

In addition, emergency physicians are not always familiar with transient ECG changes with AAC.

The aim of this review was to provide evidence regarding epidemiology, pathophysiology, clinical presentation and treatment of the complex association between AAC and CVD.

Our main findings indicate that AAC should be suspected after each general disease leading to hypoperfusion such as cardiovascular diseases or cerebrovascular diseases or major heart or aortic surgery. ECG changes in absence of significant laboratory data for IMA (Acute myocardial infarction) could be related to a misdiagnosed AAC.

US – Ultrasonography-plays a key role in the early diagnosis and also in the follow up of AAC.

Cholecystostomy and cholecystectomy as unique or sequential represent the two prevailing treatment options for AAC.

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AAC should be suspected after each general disease leading to hypoperfusion such as cardiovascular diseases or cerebrovascular diseases or major heart or aortic surgery.

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ECG changes in absence of significant laboratory data for IMA could be related to a misdiagnosed AAC.

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Cholecystectomy is an only definitive treatment for AAC.

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The first report on this theme after 20 years.

Compared With a Nasointestinal Route, Pre-operative Enteral Nutrition via a Nasogastric Tube Reduced the Incidence of Acalculous Acute Cholecystitis After Definitive Surgery for Small Intestinal Fistula

Purpose: This study aimed to investigate the difference in the efficacy of pre-operative enteral nutrition (EN) via a nasogastric tube (NGT) and pre-operative EN via a nasointestinal tube (NIT) in reducing the incidence of post-operative acalculous acute cholecystitis (AAC) after definitive surgery (DS) for small intestinal fistulas.

Methods: Patients with a small intestinal fistula, who had a DS for the disease between January 2015 and March 2021, were enrolled in this study. They were divided into the NIT group and the NGT group based on the pre-operative routes of feeding they received. The clinical characteristics of the two groups were analyzed, and the incidences of post-operative AAC in the two groups were evaluated.

Results: A total of 200 patients were enrolled in the study, 85 in the NGT group and 115 in the NIT group. Thirty-one patients developed post-operative AAC (8 in the NGT group and 23 in the NIT group). The incidence of post-operative AAC was 15.5%. EN via the NGT route was associated with a reduction in the incidence of post-operative AAC (adjusted HR = 0.359; 95% CI: 0.139–0.931; P = 0.035).

Conclusion: Pre-operative EN via the NGT may reduce the incidence of post-operative AAC in patients who received a DS for small intestinal fistulas.

Clinical characteristics of patients with newly developed acute cholecystitis after admission to the intensive care unit

INTRODUCTION

Critical care patients have many risk factors for acute cholecystitis (AC). However, less data are available regarding newly developed AC in critically ill patients.

OBJECTIVES

To investigate the clinical features of AC occurring in critically ill patients after admission to an intensive care unit (ICU).

METHODS

We performed a retrospective cohort study from January 2006 to August 2016 at a tertiary care university hospital. We included patients diagnosed with AC with or without gallstones after ICU admission. All cases of AC were confirmed by gastroenterologists or general surgeons. We excluded patients with AC diagnosed before or at the time of ICU admission.

RESULTS

A total of 38 patients were diagnosed with AC after ICU admission between January 2006 and August 2016. Seventeen (44.7%) had acute acalculous cholecystitis, while 21 (55.3%) had acute calculous cholecystitis. The median age was 73 years (interquartile range = 63-81 years), and 22 (57.9%) patients were male. The most common reason for ICU admission was pneumonia or sepsis. The median interval from ICU admission to diagnosis of AC was 11 days (interquartile range = 4.8-22.8 days). Before AC diagnosis, almost 90% of patients used total parenteral nutrition, 68% used opioids, 76% were mechanically ventilated, and 42% received vasoactive drugs. More than half of patients underwent cholecystectomy, and all surgically resected gallbladders had pathology results for cholecystitis. Gangrenous cholecystitis was observed in five patients with acute calculous cholecystitis. The overall mortality was 42.1%, and 1/3 of these deaths were directly associated with AC. The average length of stay in the ICU and hospital was 26.5 and 44.5 days, respectively.

CONCLUSION

The development of AC in the ICU should be carefully monitored, especially in patients who have been infected and admitted to the ICU for more than 10 days. Proper diagnosis and treatment at a critical time could be lifesaving.

Cholecystostomy Treatment in an ICU Population: Complications and Risks

BACKGROUND

Percutaneous cholecystostomy tube placement has widely been used as an alternative treatment to cholecystectomy, especially in advanced disease or critically ill patients. Reported postprocedural complication rates have varied significantly over the last decade. The goal of this study is to evaluate the safety of percutaneous cholecystostomy tube treatment in critically ill patients.

STUDY DESIGN

We performed a retrospective chart analysis of 96 critically ill patients who underwent cholecystostomy tube placement during an intensive care unit (ICU) stay between 2005 and 2010 in a tertiary care center in central Massachusetts. Complications within 72 hours of cholecystostomy tube placement and any morbidity or mortality relating to presence of cholecystostomy tube were considered.

RESULTS

A total of 65 male and 31 female patients with a mean age of 67.4 years underwent percutaneous cholecystostomy tube placement during an ICU stay. Sixty-six patients experienced a total of 121 complications, resulting in an overall complication rate of 69%. Fifty-four of these complications resulted from the actual procedure or the presence of the cholecystostomy tube; the other 67 complications occurred within 72 hours of the cholecystostomy procedure. Ten patients died. Tube dislodgment was the most common complication with a total of 34 episodes.

CONCLUSIONS

Cholecystostomy tube placement is associated with frequent complications, the most common of which is tube dislodgment. Severe complications may contribute to serious morbidity and death in an ICU population. Complication rates may be underreported in the medical literature. The potential impact of cholecystostomy tube placement in critically ill patients should not be underestimated.

Acute acalculous cholecystitis in the critically ill: risk factors and surgical strategies

PURPOSE

Acute acalculous cholecystitis (AAC) is characterized by severe gallbladder inflammation without cystic duct obstruction. Critical illness and neurological deficits are often associated with AAC, and early radiologic imaging is necessary for the detection and timely treatment of AAC. In critically ill patients, effective surgical management is difficult. This review examines the three common surgical treatments for AAC (open cholecystectomy (OC), laparoscopic cholecystectomy (LC), or percutaneous cholecystostomy (PC)), their prevalence in current literature, and the perioperative outcomes of these different approaches using a large retrospective database.

MATERIALS AND METHODS

This review examined literature gathered from PubMed and Google Scholar to select more than 50 sources with data pertinent to AAC; of which 20 are described in a summary table. Outcomes from our previous research and several updated results were obtained from the University HealthSystem Consortium (UHC) database.

RESULTS

LC has proven effective in treating AAC when the risks of general anesthesia and the chance for conversion to OC are low. In critically ill patients with multiple comorbidities, PC or OC may be the only available options. Data in the literature and an examination of outcomes within a national database indicate that for severely ill patients, PC may be safer and met with better outcomes than OC for the healthier set of AAC patients.

CONCLUSIONS

We suggest a three-pronged approach to surgical resolution of AAC. Patients that are healthy enough to tolerate LC should undergo LC early in the course of the disease. In critically ill patients, patients with multiple comorbidities, a high conversion risk, or who are poor surgical candidates, PC may be the safest and most successful intervention.

TG13 miscellaneous etiology of cholangitis and cholecystitis

This paper describes typical diseases and morbidities classified in the category of miscellaneous etiology of cholangitis and cholecystitis. The paper also comments on the evidence presented in the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG 07) published in 2007 and the evidence reported subsequently, as well as miscellaneous etiology that has not so far been touched on. (1) Oriental cholangitis is the type of cholangitis that occurs following intrahepatic stones and is frequently referred to as an endemic disease in Southeast Asian regions. The characteristics and diagnosis of oriental cholangitis are also commented on. (2) TG 07 recommended percutaneous transhepatic biliary drainage in patients with cholestasis (many of the patients have obstructive jaundice or acute cholangitis and present clinical signs due to hilar biliary stenosis or obstruction). However, the usefulness of endoscopic naso-biliary drainage has increased along with the spread of endoscopic biliary drainage procedures. (3) As for biliary tract infections in patients who underwent biliary tract surgery, the incidence rate of cholangitis after reconstruction of the biliary tract and liver transplantation is presented. (4) As for primary sclerosing cholangitis, the frequency, age of predilection and the rate of combination of inflammatory enteropathy and biliary tract cancer are presented. (5) In the case of acalculous cholecystitis, the frequency of occurrence, causative factors and complications as well as the frequency of gangrenous cholecystitis, gallbladder perforation and diagnostic accuracy are included in the updated Tokyo Guidelines 2013 (TG13). Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

Impact of preoperative organ failures on survival in intensive care unit patients with colectomy

BACKGROUND

The present study aimed to evaluate the prognostic value of preoperative changes in sequential organ failure assessment (SOFA) score, daily norepinephrine (NE) dose, lactate, C-reactive protein, and white blood cell count among patients with colectomy in the intensive care unit (ICU).

METHODS

We performed a retrospective analysis of 77 colectomized patients (30 female, 47 male) who were treated in a single tertiary-level mixed ICU during 2000-2009.

RESULTS

The underlying conditions leading to colectomy included sepsis (31 patients), cardiovascular operations (21 patients), and fulminant Clostridium difficile colitis (25 patients). The 28-day mortality was 53.3 % (41/77). Nonsurvivors had significantly higher median values than survivors (p < 0.05) for the following parameters: admission SOFA [10.0 (25th-75th percentile 8.0-13.0) vs. 9.0 (6.5-10.0)], highest SOFA [14.0 (12.0-16.0) vs. 12.5 (9.5-14.5)], operative day lactate level (6.3 vs. 2.2 mmol/L), and NE dose (16.8 vs. 9.3 total mg/day). During the last three preoperative days, significant increases were observed in total SOFA score (p < 0.001) and in cardiovascular (p < 0.001), coagulation (p = 0.017), renal (p < 0.01), and respiratory (p < 0.001) SOFA subscores, without statistically significant differences between nonsurvivors and survivors. Increasing Glasgow Coma Scale score, preoperative lactate level, and NE dose were significantly associated with mortality.

CONCLUSIONS

It should be prospectively studied whether preoperatively increasing lactate level and NE dose are surrogate markers for early laparotomy among ICU patents with colitis.

Diagnostic accuracy of computed tomography imaging of surgically treated acute acalculous cholecystitis in critically ill patients

BACKGROUND

Acute acalculous cholecystitis (AAC) is a potentially fatal condition mainly affecting critically ill patients. Current experience from computed tomography (CT) findings in AAC is contradictory.

METHODS

CT images of 127 mixed medical-surgical intensive care unit patients were retrospectively reviewed for the following findings: bile density, thickness and enhancement of the gallbladder (GB) wall, subserosal edema, greatest perpendicular diameters of the GB, width of extrahepatic bile ducts, gas within the GB, ascites, peritoneal fat edema, and diffuse tissue edema. Forty-three of these patients underwent open cholecystectomy, and 8 patients revealed a normal GB, 26 an edematous GB, and 9 a necrotic AAC.

RESULTS

Abnormal CT findings were present in 96% of all the intensive care unit patients. Higher bile density in the GB body and subserosal edema was associated with an edematous GB (specificity, 93.6%; sensitivity, 23.1%). The most specific findings predicting necrotic AAC were gas in the GB wall or lumen, lack of GB wall enhancement, and edema around the GB (specificity, 99.2%, 94.9%, and 92.4%, respectively; and sensitivity, 11.1%, 37.5%, and 22.2%, respectively).

CONCLUSIONS

The frequency of nonspecific abnormal findings in the GB of critically ill patients limits the diagnostic value of CT scanning in detecting AAC. However, in the case of totally normal GB findings in CT, the probability of necrotic AAC is low.

Acute acalculous cholecystitis: a review

Although recognized for more than 150 years, acute acalculous cholecystitis (AAC) remains an elusive diagnosis. This is likely because of the complex clinical setting in which this entity develops, the lack of large prospective controlled trials that evaluate various diagnostic modalities, and thus dependence on a small data base for clinical decision making. AAC most often occurs in critically ill patients, especially related to trauma, surgery, shock, burns, sepsis, total parenteral nutrition, and/or prolonged fasting. Clinically, AAC is difficult to diagnose because the findings of right upper-quadrant pain, fever, leukocytosis, and abnormal liver tests are not specific. AAC is associated with a high mortality, but early diagnosis and intervention can change this. Early diagnosis is the crux of debate surrounding AAC, and it usually rests with imaging modalities. There are no specific criteria to diagnose AAC. Therefore, this review discusses the imaging methods most likely to arrive at an early and accurate diagnosis despite the complexities of the radiologic modalities. A pragmatic approach is vital. A timely diagnosis will depend on a high index of suspicion in the appropriate patient, and the combined results of clinical findings (admittedly nonspecific), plus properly interpreted imaging. Sonogram (often sequential) and hepatic iminodiacetic acid scans are the most reliable modalities for diagnosis. It is generally agreed that cholecystectomy is the definitive therapy for AAC. However, at times a diagnostic/therapeutic drainage via interventional radiology/surgery may be necessary and life-saving, and may be the only treatment needed.

Effect of intraoperative magnesium sulphate infusion on pain relief after laparoscopic cholecystectomy

INTRODUCTION

The aim of the study is to evaluate the analgesic efficiency of perioperative magnesium sulphate infusion in patients undergoing laparoscopic cholecystectomy (LC).

METHODS

In a randomized, double-blind trial study, 83 patients were divided into two groups. Group MT received 50 mg/kg i.v. magnesium sulphate in 100 ml of 0.9% normal saline and Group T received the same volume of isotonic saline during the intraoperative period. The cumulative post-operative tramadol consumption was measured to assess the analgesic effect using a patient-controlled analgesia device. Pain intensities at rest and while coughing were evaluated at 0, 2, 4, 8, 12, and 24 h post-operatively.

RESULTS

The pain scores in Group MT were significantly lower than Group T at 0, 4, and 12 h post-operatively. The average of visual analogue scale at rest and during cough during 24 h post-operatively was found to be statistically significant between groups. The total dose of tramadol the 24-h period in Group MT and Group T was found to be 281.34 +/- 90.82 and 317.46 +/- 129.59, respectively.

CONCLUSION

Per-operative 50 mg/kg magnesium sulphate infusion is effective in reducing post-operative pain in patients undergoing LC.

Effects of NO/L-arginine pathway on gallbladder contractility in bile duct ligated guinea pigs

BACKGROUND

Common bile duct ligation (CBDL) produces gallbladder distension and acute inflammation similar to that seen in human acute acalculous cholecystitis. CBDL in the guinea pig affects smooth muscle contractility. The aim of this study was to determine whether the nitric oxide-L-arginine pathway plays a role in the inflammatory process and abnormal gallbladder contractility that occur after CBDL.

MATERIALS AND METHODS

Contractility of gallbladder muscle from CBDL and sham-operated guinea pigs was studied in vitro. Animals were treated with saline, aminoguanidine (AG), or an aminoguanidine + L-arginine combination (AG + L-Arg) in vivo. Potassium chloride, carbachol, and electric field stimulation (EFS) were used for contracting the gallbladder muscle strips or activating intrinsic nerves. Hematoxylin and eosin-stained slides of muscle strips were scored for inflammation.

RESULTS

Contraction responses to carbachol and EFS were decreased significantly in CBDL guinea pigs compared with those in the sham-operated group. AG partly reversed the smooth muscle contractile response to carbachol and EFS, but did not reduce the inflammation score. Treatment with AG + L-arg did not reverse either the contraction response or the inflammation score.

CONCLUSIONS

These findings suggest that AG and AG + L-Arg treatments have no beneficial effect on inflammation in guinea pigs after CBDL, although AG significantly reversed the effect on muscle contractility (P < 0.05). This improvement was independent of inflammation and may be due to a decreased level of NO and its diminished relaxant effect.

Cellular turnover and expression of hypoxic-inducible factor in acute acalculous and calculous cholecystitis

INTRODUCTION

Epithelial corrective and destructive mechanisms have not been studied in inflammatory gallbladder disease.

METHODS

Epithelial apoptosis, cell proliferation and expression of hypoxia-inducible factor (HIF)-1alpha were compared in gallbladders from patients with acute acalculous cholecystitis (AAC; n = 30) and acute calculous cholecystitis (ACC; n = 21), and from patients undergoing surgery for other reasons (normal gallbladders; n = 9), which were removed during open cholecystectomy. The immunohistochemical stains included antibodies to Ki-67 (proliferation), M30 (apoptosis) and HIF-1alpha. Proliferation and apoptosis were expressed as percentages of positive cells. HIF-1alpha expression was expressed as absent, weak, or strong.

RESULTS

Apoptosis (median [25th to 75th percentile]) was significantly increased in AAC (1.31% [0.75% to 1.8%], P < 0.001) and ACC (1.10% [0.63% to 1.64%], P = 0.001), compared with control samples (0.20% [0.07% to 0.45%]. The proliferation rate was significantly increased in AAC (8.0% [4.0% to 17.0%], P < 0.001) and ACC (14% [7.5% to 26.5%], P = 0.001) compared with control samples (1.0% [1.0% to 3.0%]). Strong HIF-1alpha staining was observed in 57% of AAC, in 100% of ACC and in 44% of control specimens (P < 0.001). Intense HIF-1alpha expression was associated with increased cell proliferation (P = 0.002).

CONCLUSION

Cell proliferation and apoptosis were increased in AAC and ACC, as compared with normal gallbladders. Expression of HIF-1alpha was lower in AAC than in ACC.

Severity scoring in the ICU: a review

BACKGROUND

Patients in the intensive care unit (ICU) require huge resources because of the dysfunction of several of their vital organs. The heterogeneity and complexity of the ICU patient have generated interest in systems able to measure severity of illness as a method of predicting outcome, comparing quality-of-care and stratification for clinical trials.

METHODS

By searching Medline and EMBASE for publications describing scoring systems in the ICU, the most frequently used systems, defined as resulting in more than 50 references, are included in this review. Scoring systems belong to one of four classes prognostic, single-organ failure, trauma scores and organ dysfunction (OD). The different systems are described and discussed.

RESULTS

Three different prognostic scoring systems, including several versions, four single OD scores and three OD scores, were included in this review.

CONCLUSION

Different forms of scoring systems are frequently used in the ICU. They have become a necessary tool to describe ICU populations and to explain differences in mortality. As there are several pitfalls related to the interpretation of the numbers supplied by the systems, they should not be used without knowledge on the science of severity scoring.