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Dong CT, Liveris A, Lewis ER, Mascharak S, Chao E, Reddy SH, Teperman SH, McNelis J, Stone ME. Do surgical emergencies stay at home? Observations from the first United States Coronavirus epicenter. J Trauma Acute Care Surg 2021; 91:241-246. [PMID: 34144567 PMCID: PMC8218982 DOI: 10.1097/ta.0000000000003202] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/06/2021] [Accepted: 02/24/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND During the coronavirus disease 2019 pandemic, New York instituted a statewide stay-at-home mandate to lower viral transmission. While public health guidelines advised continued provision of timely care for patients, disruption of safety-net health care and public fear have been proposed to be related to indirect deaths because of delays in presentation. We hypothesized that admissions for emergency general surgery (EGS) diagnoses would decrease during the pandemic and that mortality for these patients would increase. METHODS A multicenter observational study comparing EGS admissions from January to May 2020 to 2018 and 2019 across 11 NYC hospitals in the largest public health care system in the United States was performed. Emergency general surgery diagnoses were defined using International Classification Diseases, Tenth Revision, codes and grouped into seven common diagnosis categories: appendicitis, cholecystitis, small/large bowel, peptic ulcer disease, groin hernia, ventral hernia, and necrotizing soft tissue infection. Baseline demographics were compared including age, race/ethnicity, and payor status. Outcomes included coronavirus disease (COVID) status and mortality. RESULTS A total of 1,376 patients were admitted for EGS diagnoses from January to May 2020, a decrease compared with both 2018 (1,789) and 2019 (1,668) (p < 0.0001). This drop was most notable after the stay-at-home mandate (March 22, 2020; week 12). From March to May 2020, 3.3%, 19.2%, and 6.0% of EGS admissions were incidentally COVID positive, respectively. Mortality increased in March to May 2020 compared with 2019 (2.2% vs. 0.7%); this difference was statistically significant between April 2020 and April 2019 (4.1% vs. 0.9%, p = 0.045). CONCLUSION Supporting our hypothesis, the coronavirus disease 2019 pandemic and subsequent stay-at-home mandate resulted in decreased EGS admissions between March and May 2020 compared with prior years. During this time, there was also a statistically significant increase in mortality, which peaked at the height of COVID infection rates in our population. LEVEL OF EVIDENCE Epidemiological, level IV.
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Jo IH, Kim YJ, Chung WC, Kim J, Kim S, Lim ES, Ahn H, Ryu SY. Microbiology and risk factors for gram-positive Cocci bacteremia in biliary infections. Hepatobiliary Pancreat Dis Int 2020; 19:461-466. [PMID: 32535063 DOI: 10.1016/j.hbpd.2020.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The rapid antibiotics treatment targeted to a specific pathogen can improve clinical outcomes of septicemia. We aimed to evaluate the clinical characteristics and outcomes of biliary septicemia caused by cholangitis or cholecystitis according to causative organisms. METHODS We performed a retrospective cohort study in 151 patients diagnosed with cholangitis or cholecystitis with bacterial septicemia from January 2013 to December 2015. All patients showed clinical evidence of biliary tract infection and had blood isolates that demonstrated septicemia. RESULTS Gram-negative, gram-positive, and both types of bacteria caused 84.1% (127/151), 13.2% (20/151), and 2.6% (4/151) episodes of septicemia, respectively. The most common infecting organisms were Escherichia coli among gram-negative bacteria and Enterococcus species (Enterococcus casseliflavus and Enterococcus faecalis) among gram-positive bacteria. There were no differences in mortality, re-admission rate, and need for emergency decompression procedures between the gram-positive and gram-negative septicemia groups. In univariate analysis, previous gastrectomy history was associated with gram-positive bacteremia. Multivariate analysis also showed that previous gastrectomy history was strongly associated with gram-positive septicemia (Odds ratio = 5.47, 95% CI: 1.19-25.23; P = 0.029). CONCLUSIONS Previous gastrectomy history was related to biliary septicemia induced by gram-positive organisms. This information would aid the choice of empirical antibiotics.
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Affiliation(s)
- Ik Hyun Jo
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
| | - Yeon-Ji Kim
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea.
| | - Woo Chul Chung
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
| | - Jaeyoung Kim
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
| | - Seonhoo Kim
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
| | - Eun Sun Lim
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
| | - Honggeun Ahn
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
| | - Seong Yul Ryu
- Division of Gastroenterology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea
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Xiao B, Geng X, Huang J, Zhuang S, Fu J. Decreased survival of advanced colorectal cancer among patients with chronic cholecystitis: results from two clinical centers. J BUON 2020; 25:890-898. [PMID: 32521883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE Chronic cholecystitis is a common inflammatory disease of the gallbladder. It is related with various gastrointestinal tumors, although its pathogenesis is not clear. This study was designed to investigate the association between chronic cholecystitis and the survival of patients with advanced colorectal cancer (CRC). METHODS We conducted a population-based large-scale retrospective case-control study involving 1094 patients with advanced CRC, 286 patients with cholecystitis, and 808 without. The patients were admitted in two hospitals in China. Data were obtained from a patient survey by professional interviewers in addition to medical records. The statistical significance was estimated by Kaplan-Mayer analysis and Cox proportional hazard regression. RESULTS The chronic cholecystitis group had a shorter survival time than non- cholecystitis group (HR for Nanfang hospital patients 0.638, 95%CI 0.457-0.890, p=0.008; HR for Changzhou No.2 hospital patients 0.583, 95%CI 0.433-0.787, p<0.001). Surgery and chemotherapy could prolong the survival of patients CRC and reduce their mortality (surgery: HR for Nanfang hospital patients 1.638, 95%CI 1.087-2.469, p=0.018; HR for Changzhou No.2 hospital patients 2.137, 95%CI 1.399-3.265, p<0.001; chemotherapy: HR for Nanfang hospital patients 1.766, 95%CI 1.238-2.518, p=0.002; HR for Changzhou No.2 hospital patients 2.616, 95%CI 1.816-3.768. p<0.001). The higher the TNM staging, the shorter the survival time (TNM staging: HR for Nanfang hospital patients 3.912, 95%CI 3.201-4.781, p<0.001; HR for Changzhou No.2 hospital patients 3.907, 95%CI 3.05-5.005, p<0.001). CONCLUSION Cholecystitis was strongly associated with a poor long-term prognosis for patients with CRC. The results suggest that special attention to gallbladder inflammation might be needed during the treatment of CRC.
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Affiliation(s)
- Bing Xiao
- Guangdong Provincial key laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou Province, China
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Loozen CS, van Santvoort HC, van Duijvendijk P, Besselink MG, Gouma DJ, Nieuwenhuijzen GA, Kelder JC, Donkervoort SC, van Geloven AA, Kruyt PM, Roos D, Kortram K, Kornmann VN, Pronk A, van der Peet DL, Crolla RM, van Ramshorst B, Bollen TL, Boerma D. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial. BMJ 2018; 363:k3965. [PMID: 30297544 PMCID: PMC6174331 DOI: 10.1136/bmj.k3965] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
OBJECTIVE To assess whether laparoscopic cholecystectomy is superior to percutaneous catheter drainage in high risk patients with acute calculous cholecystitis. DESIGN Multicentre, randomised controlled, superiority trial. SETTING 11 hospitals in the Netherlands, February 2011 to January 2016. PARTICIPANTS 142 high risk patients with acute calculous cholecystitis were randomly allocated to laparoscopic cholecystectomy (n=66) or to percutaneous catheter drainage (n=68). High risk was defined as an acute physiological assessment and chronic health evaluation II (APACHE II) score of 7 or more. MAIN OUTCOME MEASURES The primary endpoints were death within one year and the occurrence of major complications, defined as infectious and cardiopulmonary complications within one month, need for reintervention (surgical, radiological, or endoscopic that had to be related to acute cholecystitis) within one year, or recurrent biliary disease within one year. RESULTS The trial was concluded early after a planned interim analysis. The rate of death did not differ between the laparoscopic cholecystectomy and percutaneous catheter drainage group (3% v 9%, P=0.27), but major complications occurred in eight of 66 patients (12%) assigned to cholecystectomy and in 44 of 68 patients (65%) assigned to percutaneous drainage (risk ratio 0.19, 95% confidence interval 0.10 to 0.37; P<0.001). In the drainage group 45 patients (66%) required a reintervention compared with eight patients (12%) in the cholecystectomy group (P<0.001). Recurrent biliary disease occurred more often in the percutaneous drainage group (53% v 5%, P<0.001), and the median length of hospital stay was longer (9 days v 5 days, P<0.001). CONCLUSION Laparoscopic cholecystectomy compared with percutaneous catheter drainage reduced the rate of major complications in high risk patients with acute cholecystitis. TRIAL REGISTRATION Dutch Trial Register NTR2666.
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Affiliation(s)
- Charlotte S Loozen
- Department of Surgery, St Antonius Hospital, 3435CM, PO box 2500, Nieuwegein, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, 3435CM, PO box 2500, Nieuwegein, Netherlands
- Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Marc Gh Besselink
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | | | - Johannes C Kelder
- Department of Clinical Epidemiology, St Antonius Hospital, Nieuwegein, Netherlands
| | | | | | - Philip M Kruyt
- Department of Surgery, Gelderse Vallei Hospital, Amsterdam, Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaff Hospital, Delft, Netherlands
| | - Kirsten Kortram
- Department of Surgery, St Antonius Hospital, 3435CM, PO box 2500, Nieuwegein, Netherlands
| | - Verena Nn Kornmann
- Department of Surgery, St Antonius Hospital, 3435CM, PO box 2500, Nieuwegein, Netherlands
| | - Apollo Pronk
- Department of Surgery, Diakonessenhuis, Utrecht, Netherlands
| | | | | | - Bert van Ramshorst
- Department of Surgery, St Antonius Hospital, 3435CM, PO box 2500, Nieuwegein, Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Djamila Boerma
- Department of Surgery, St Antonius Hospital, 3435CM, PO box 2500, Nieuwegein, Netherlands
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Beburishvili AG, Panin SI, Zyubina EN. [Perforated cholecystitis. Classification and atypical clinical forms]. Khirurgiia (Mosk) 2018:10-13. [PMID: 29376951 DOI: 10.17116/hirurgia2018110-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
AIM To obtain new data for diagnosis and treatment of patients with perforated cholecystitis. MATERIAL AND METHODS It was analyzed the variants of original classification of perforated cholecystitis by Fedorov S.P. - Neimeier O.W. (1934). Moreover, we have assessed treatment of 292 patients with gallbladder perforation (own material of Faculty Surgery Clinic). RESULTS According to continuous 20-year follow-up perforated cholecystitis was observed in 2.9% of patients with various forms of gallbladder inflammation (n=292 out of 10 215). The frequency of atypical clinical forms of gallbladder perforation including multiple and combined perforation, perforation with acute intestinal obstruction and intraabdominal bleeding was 10% (n=29 of 292). Overall mortality in atypical clinical forms related to whole cohort with perforated cholecystitis was 2% (n=6 of 292). CONCLUSION Atypical clinical forms of gallbladder perforation require specific treatment strategy due to the need for emergency surgical interventions. At the same time, the possibilities of video-assisted surgery are somewhat limited compared with other forms of gallbladder inflammation and can be used only in a third of patients.
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Affiliation(s)
- A G Beburishvili
- Volgograd State Medical University, Faculty Surgery Department, Surgical Hepatology Center, Volgograd, Russia
| | - S I Panin
- Volgograd State Medical University, Faculty Surgery Department, Surgical Hepatology Center, Volgograd, Russia
| | - E N Zyubina
- Volgograd State Medical University, Faculty Surgery Department, Surgical Hepatology Center, Volgograd, Russia
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Abstract
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.
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Affiliation(s)
- Akın Önder
- Department of General Surgery, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
| | - Murat Kapan
- Department of General Surgery, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
| | - Burak Veli Ülger
- Department of General Surgery, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
| | - Abdullah Oğuz
- Department of General Surgery, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
| | - Ahmet Türkoğlu
- Department of General Surgery, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
| | - Ömer Uslukaya
- Department of General Surgery, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
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Chen Y, Chen C, Ma C, Sun S, Zhang J, Sun Y. Expression of heat-shock protein gp96 in gallbladder cancer and its prognostic clinical significance. Int J Clin Exp Pathol 2015; 8:1946-53. [PMID: 25973087 PMCID: PMC4396202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 01/28/2015] [Indexed: 06/04/2023]
Abstract
PURPOSE To detect the expression and prognostic clinical significance of heat-shock protein gp96 (HSP gp96) in gallbladder cancer. METHODS Immunohistochemistry was used to detect and compare the rate of HSP gp96 expression in 107 samples of gallbladder cancer, 70 of gallbladder adenoma and 67 of chronic cholecystitis. The association of clinicopathological factors and patients' survival were calculated by univariate and multivariate (Cox proportional hazard regression method) analysis. RESULTS The expression positive rate of HSP gp96 was 90.7% (97/107) in gallbladder cancer, 71.4% (50/70) in gallbladder adenoma and 47.76% (32/67) in chronic cholecystitis respectively. The positive rate of HSP gp96 in gallbladder cancer tissues was significantly higher than that in gallbladder adenoma and chronic cholecystitis tissues (P < 0.01). Multivariate and Cox regression analysis showed that positive of HSP gp96 (P = 0.026) expression was an independent poor prognostic predictor in gallbladder cancer. CONCLUSIONS HSP gp96-positive expression is closely correlated with poor survival in gallbladder cancer.
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Affiliation(s)
- Yongli Chen
- Department of General Surgery, Second Affiliated Hospital of Xingtai Medical CollegeHarbin, China
- Department of General Surgery, Second Affiliated Hospital of Harbin Medical UniversityHarbin, China
| | - Chuanqi Chen
- Department of General Surgery, Second Affiliated Hospital of Harbin Medical UniversityHarbin, China
| | - Chengzhi Ma
- Department of General Surgery, Second Affiliated Hospital of Harbin Medical UniversityHarbin, China
| | - Shibo Sun
- Department of General Surgery, Second Affiliated Hospital of Harbin Medical UniversityHarbin, China
| | - Jing Zhang
- Department of General Surgery, Second Affiliated Hospital of Harbin Medical UniversityHarbin, China
| | - Yan Sun
- Department of General Surgery, Second Affiliated Hospital of Harbin Medical UniversityHarbin, China
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Eachempati SR, Cocanour CS, Dultz LA, Phatak UR, Albarado R, Rob Todd S. Acute cholecystitis in the sick patient. Curr Probl Surg 2014; 51:441-66. [PMID: 25497405 DOI: 10.1067/j.cpsurg.2014.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 10/30/2014] [Indexed: 12/24/2022]
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Ozkan E, Fersahoğlu MM, Dulundu E, Ozel Y, Yıldız MK, Topaloğlu U. Factors affecting mortality and morbidity in emergency abdominal surgery in geriatric patients. ULUS TRAVMA ACIL CER 2010; 16:439-444. [PMID: 21038122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND The purpose of the present study was to determine the factors affecting morbidity and mortality in geriatric patients undergoing abdominal surgery. METHODS Ninety-two patients who had undergone acute abdominal surgery at >65 years of age were evaluated in terms of surgical indications, morbidity and mortality rates and the factors affecting morbidity and mortality. Forty-eight patients (52.2%) were males and 44 (47.8%) were females. The mean age was 73.32±6.37 (65-92) years. RESULTS The most common surgical indication was acute cholecystitis (26.09%). Morbidity was established as 21 (22.82%) and mortality as 14 (15.21%), and the most common cause of mortality was mesenteric vascular occlusion. American Society of Anesthesiology (ASA) IV was noted in 90.05% of the patients admitted to intensive care, and 92.85% of the patients had mortal progression. The mean hospitalization duration was 7.94±7.13 days (median, 7 days). While older age and high ASA scores were significantly correlated with morbidity, mortality and duration of hospitalization, gender was not (p>0.05). CONCLUSION In order to decrease the postoperative mortality rate in geriatric patients, precaution should be taken beforehand to avoid surgical complications. By carrying out elective surgery in geriatric patients, the likelihood of common causes of acute abdomen, such as acute cholecystitis and incarcerated hernia, can be reduced.
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Affiliation(s)
- Erkan Ozkan
- 5th Department of General Surgery, Haydarpaşa Numune Training and Research Hospital, İstanbul, Turkey.
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Choi HJ, Yun SS, Kim HJ, Choi JH. Expression of p16 protein in gallbladder carcinoma and its precancerous conditions. Hepatogastroenterology 2010; 57:18-21. [PMID: 20422865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND/AIMS Adenocarcinoma of the gallbladder is a highly malignant neoplasm. p16 is a tumor suppressor gene protein, which is a cyclin-dependent kinase inhibitor that regulates the G1-S phase of the cell cycle. The purpose of the present study was to investigate the expression of p16 in gallbladder carcinoma and its precancerous conditions and to examine the relationship between p16 expression and clinicopathological parameters. METHODOLOGY Formalin-fixed, paraffin-embedded tissue sections from 20 cases of normal gallbladder, 20 cases of chronic cholecystitis, 20 cases of gallbladder adenoma, 20 cases of dysplasia, and 58 cases of adenocarcinoma were examined. The expression of p16 was evaluated by immunohistochemical analysis. RESULTS In normal gallbladder, no expression of p16 was found. In chronic cholecystitis, expression of p16 was not found. In gallbladder adenomas, expression of p16 was found in 20% (4/20). In low grade dyspalsias, expression of p16 was not found. In high grade dysplasias, p16 expression was present in 45.0% (9/20). In gallbladder adenocarcinomas, p16 expression was found in 27.6% (16/58). Expression of p16 correlated significantly with histologic grade (p < 0.05). No correlation was found between p16 expression and age, gender, tumor size, gross type, location, vascular invasion, lymph node metastasis, and TNM stage, respectively. CONCLUSIONS P16 protein overexpression is an early and relatively common event in carcinogenesis of gallbladder carcinoma. Expression of p16 protein is absent in normal or chronic cholecystitis. Expression of p16 may be an ancillary diagnostic marker of gallbladder carcinoma and its precancerous conditions.
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Affiliation(s)
- Hye-Jeong Choi
- Department of Pathology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Korea
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Abstract
Acute cholecystitis and acute cholangitis are the most frequent surgical infections of the biliary tree. Early laparoscopic cholecystectomy is the treatment of choice in acute cholecystitis. Laparoscopic operation results in a shorter length of stay and less morbidity. Conversion rate is low in early laparoscopic cholecystectomy. Endoscopic or transhepatic decompression of the bile ducts is the treatment of choice in severe acute cholangitis. While the removal of stones is the causal therapy in choledocholithiasis, further diagnosis and consecutive therapy has to follow after decompression of bile duct stenosis.
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Affiliation(s)
- R Függer
- Chirurgische Abteilung, A ö Krankenhaus der Elisabethinen Linz, Akademisches Lehrkrankenhaus der Medizinischen Universitäten Wien und Innsbruck, Linz, Austria.
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Bjerkeset T. [Atypical cholecystitis--a diagnostic challenge]. Tidsskr Nor Laegeforen 2007; 127:738. [PMID: 17393586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
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Abstract
INTRODUCTION Gangrenous cholecystitis is a serious complication of acute cholecystitis. Male gender, older age, leukocytosis, cardio-vascular diseases and diabetes were reported as factors that increase the risk of gangrenous cholecystitis. The aim our study was to determine variables affecting morbidity and mortality as well as to define the independent risk factors in Gangrenous Cholecystitis. METHODS Fifty three patients who had been treated for Gangrenous Cholecystitis were reviewed. The variables are defined as follows: age, gender, systemic diseases, Mannheim Peritonitis index, aspartate aminotransferase, alanine aminotransferase, white blood cell count and type of surgery. In order to determine the independent risk factors that might affect morbidity and mortality in Gangrenous Cholecystitis, we made use of multivariate logistic regression analysis. RESULTS The independent risk factors affecting on morbidity were age (P = 0.037), existing systemic disease (P = 0.047) and > or = 29 Mannheim Peritonitis index (P = 0.008), and the independent risk factors affecting on mortality were age (P = 0.046), white blood cell count (P = 0.035). Pre-operative and post-operative third day aspartate amino-transferase and alanine aminotransferase average values were compared, there was a significant difference (P < 0.0001, P < 0.0001 respectively). CONCLUSIONS We found that older age, > or = 29 Mannheim Peritonitis index and existence of systemic diseases were independent risk factors affecting morbidity. Older age and lower of white blood cell count were independent risk factors affecting mortality. We believe that further comprehensive studies, involving prospective, multi-center and a large number of patients, are needed.
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Affiliation(s)
- S Girgin
- Department of General Surgery, School of Medicine, University of Dicle, Diyarbakir/Turkey.
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Roa JC, Roa I, Correa P, Vo Q, Araya JC, Villaseca M, Guzmán P, Schneider BG. Microsatellite instability in preneoplastic and neoplastic lesions of the gallbladder. J Gastroenterol 2005; 40:79-86. [PMID: 15692793 DOI: 10.1007/s00535-004-1497-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2003] [Accepted: 06/28/2004] [Indexed: 02/04/2023]
Abstract
BACKGROUND Gallbladder cancer is very common in Chile and is the leading cause of cancer deaths in women aged over 40 years. However, there is limited information about the molecular changes involved in its pathogenesis. Microsatellite analysis was performed using polymerase chain reaction (PCR)-based assays to identify genetic loci that were altered in neoplastic and preneoplastic conditions of early and advanced gallbladder cancer. Our findings were then correlated with clinicopathological variables and survival time. METHODS We selected 59 surgical specimens of gallbladder adenocarcinomas (29 early cancers and 30 advanced cancers) and 22 surgical specimens from patients with chronic cholecystitis from a high-risk area for gallbladder cancer (Temuco, Chile). Laser capture microdissection (LCM) was used to harvest tumor cells and preneoplastic lesions. Microsatellite analysis was performed using 13 different markers. The tumors and preneoplastic lesions were also examined with immunohistochemistry for hMLH1, hMSH2, and hMSH6. RESULTS We found that 10% (6/59) of gallbladder cancers showed high-frequency microsatellite instability (MSI-H), with identical proportions in both early and advanced cancers. In premalignant lesions adjacent to the six MSI-H tumors, we detected instability in two of six examples of intestinal metaplasia (33%) and five of six examples of dysplasia (83%). All MSI-H cases showed an altered pattern with the antibodies studied. MSI status was not associated with survival or other clinicopathological features. No MSI or immunohistochemical alterations were found in the chronic cholecystitis group. CONCLUSIONS Microsatellite instability was observed in equal proportions in early and late cancers, and it was also found in premalignant lesions, indicating that inactivation of mismatch repair genes occurs early in gallbladder carcinogenesis.
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Affiliation(s)
- Juan Carlos Roa
- Department of Pathology, Universidad de la Frontera, Faculty of Medicine, Manuel Montt 112, Temuco, Chile
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da Rocha AO, Coutinho LMB, Scholl JG, Leboutte LD. The value of p53 protein expression in gallbladder carcinoma: analysis of 60 cases. Hepatogastroenterology 2004; 51:1310-4. [PMID: 15362740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
BACKGROUND/AIMS Few studies, with small samples and diverging results, have been performed to evaluate the p53 protein expression in gallbladder carcinoma and its relationship to different clinicopathological parameters. Based on these facts, we performed a study for the purpose of assessing p53 expression in this disease and its association to prognostic factors. METHODOLOGY Samples of 141 gallbladders, with 60 cases of carcinoma, 62 cholelithiasis and 19 without gallstones were assessed using an immunohistochemical technique for the expression of p53 protein, and analyzed for prognosis, survival and other clinicopathological parameters. RESULTS p53 expression was positive in 58.3% of carcinomas of the gallbladder, 9.7% of the chronic cholecystitis and 10.5% of the gallbladders not associated to stones. In cases of carcinoma of the gallbladder there was no statistically significant association between the expression of this protein, the prognostic factors, histological type or grade, presence of gallstones and survival. CONCLUSIONS The mutation of gene p53 is involved in the pathogenesis of carcinoma of the gallbladder, and the intense chronic inflammatory process associated or not with cholelithiasis, appears to be one of the factors involved in the genesis of this process. Our data do not show an association between p53 protein expression and patient's survival prognosis.
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Affiliation(s)
- Andréa Oxley da Rocha
- Pathology Department, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Porto Alegre, Brazil.
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Blagovestnov DA, Khvatov VB, Upyrev AV, Grishin GP, Novosel SN. [Combined treatment of acute pancreatitis and its complications]. Khirurgiia (Mosk) 2004:68-75. [PMID: 15159764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Results of combined treatment of 314 patients with acute pancreatitis, including 58 (15.1%) with pancreonecrosis were analyzed. Etiologic factors of acute pancreatitis were alcohol (59% patients), diseases of the bile ducts (31.5%), surgery (2.5%). Up-to-date diagnostic criteria of severe pancreatitis are presented, character of complications is analyzed. Treatment policy in acute edematous pancreatitis was conservative. In calculous cholecystitis cholecystectomy was performed after regress of acute pancreatitis. Fermentative ascitis-peritonitis was the indication for laparoscopy in aseptic phase of pancreonecrosis. US- and CT-guided puncture and drainage were often used. Surgeries were performed only for complications of pancreonecrosis, more often through mini-approaches. General lethality in acute pancreatitis was 1.9%, in pancreonecrosis - 10.7%, postoperative lethality in pancreonecrosis was 16.6%.
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17
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Nedev PI, Uchikov AP, Novakov IP, Murdjev KA, Uchikov PA, Iliev YT, Todorov BE. Surgical treatment of necrotizing pancreatitis and complicated forms of cholecystopancreatitis. Folia Med (Plovdiv) 2003; 45:5-8. [PMID: 12943049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
The authors present a retrospective clinical analysis of 25 operated patients with necrotizing pancreatitis and severe cholecystopancreatitis. The severity of the disease was evaluated by the Ranson scale. Diagnosis was made using all available contemporary diagnostic methods. Eleven of the patients were operated in the first 2-5 days after admission because of severe form of acute pancreatitis resisting medical therapy (Ranson > 3) and 8 patients with infected necrotizing pancreatitis underwent surgery within 2-3 weeks after the disease onset. Five of the patients died (26.32%). Only one patient died (16.66%) out of the patients of the second group including patients with acute complicated cholecystopancreatitis (n = 6). The authors think that treatment of acute pancreatitis at its onset should be mainly conservative. Laparotomy should be resorted to only in cases of uncertain diagnosis. Surgery or percutaneous drainage should be used in infected necrotizing pancreatitis and the most favorable term of operation is 2-3 weeks after the disease onset. Severe pancreatitis associated with gallstone disease and its complications require emergency surgery.
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Affiliation(s)
- Petko I Nedev
- Clinic of Thoracic and Abdominal Surgery, University Hospital St. George, Plovdiv, Bulgaria
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18
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Ammori BJ, Davides D, Vezakis A, Larvin M, McMahon MJ. Laparoscopic cholecystectomy: are patients with biliary pancreatitis at increased operative risk? Surg Endosc 2003; 17:777-80. [PMID: 11984675 DOI: 10.1007/s00464-002-0002-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2002] [Accepted: 01/24/2002] [Indexed: 10/26/2022]
Abstract
BACKGROUND Previous reports of laparoscopic cholecystectomy (LC) in patients with biliary pancreatitis suggested increased operative difficulty, high rates of conversion, and greater morbidity and mortality. METHODS Between 1990 and 1997, LC was performed for biliary pancreatitis in 63 patients (Group I) and for other causes in 829 patients (Group II). RESULTS Patients with biliary pancreatitis were significantly older (median age 57 vs 50 years, p = 0.009), with greater co-morbidity (ASA III/IV 24% vs 11%, p = 0.008). The groups were comparable with respect to the frequency of previous abdominal operations, acute inflammation of the gallbladder, and the frequency of bile duct calculi detected by intraoperative cholangiography. Moderate to severe adhesions involving the gallbladder were significantly more frequent in patients with biliary pancreatitis (46% vs 29%, p = 0.004). No significant differences were observed between the two groups with respect to intraoperative (1.5% Group I vs 6.0% Group II, p = 0.109) or postoperative complications (10% vs 8%, p = 0.426), conversion rate (0 vs 2.7%, p = 0.181), or duration of operation (median 92 vs 85 min, p = 0.33). CONCLUSION Despite increased age and co-morbidity and more frequent adhesions, our data showed no evidence that intraoperative or postoperative complications were more frequent in patients with biliary pancreatitis than in other patients undergoing LC.
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Affiliation(s)
- B J Ammori
- Division of Surgery, University of Leeds, United Kingdom
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Hadas-Halpern I, Patlas M, Knizhnik M, Zaghal I, Fisher D. Percutaneous cholecystostomy in the management of acute cholecystitis. Isr Med Assoc J 2003; 5:170-1. [PMID: 12725134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND The mainstay of therapy for acute cholecystitis is cholecystectomy, which has a mortality of 14-30% in high risk patients. An alternative approach in patients suffering from acute cholecystitis with contraindications to emergency surgery is percutaneous cholecystostomy. OBJECTIVE To evaluate the efficacy and safety of percutaneous cholecystostomy as the initial treatment of acute cholecystitis in high risk patients. METHODS Eighty consecutive patients (42 men, 38 women) underwent ultrasound-guided percutaneous cholecystostomy over a 5 year period. Sixty-five patients suffered from acute calculous cholecystitis, 4 patients had acalculous cholecystitis, and 11 patients had sepsis of unknown origin. RESULTS Sixty-eight patients improved after the percutaneous gallbladder drainage, 10 patients died from co-morbid disease and 2 patients died from biliary peritonitis. During a 1 year follow-up, 32 of the patients underwent interval cholecystectomy, 4 additional patients died from a co-morbid disease, 18 patients did not suffer from any gallbladder symptoms, and 14 were lost to follow-up. CONCLUSIONS Percutaneous cholecystostomy is an effective contribution to the treatment of acute cholecystitis in high risk patients.
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Bender JS, Duncan MD, Freeswick PD, Harmon JW, Magnuson TH. Increased laparoscopic experience does not lead to improved results with acute cholecystitis. Am J Surg 2002; 184:591-4; discussion 594-5. [PMID: 12488180 DOI: 10.1016/s0002-9610(02)01089-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND As laparoscopic experience increases, ever more challenging cases are attempted. Enlarged surgeon experience, along with better technology, has been lauded as improving outcomes. The purpose of this study is to see if this applies to the management of acute cholecystitis. METHODS We reviewed our experience over a 7 and a half year period. Information was obtained from a prospectively maintained computer database containing patient presentation, demographics, workup, laboratory values, and outcomes. Diagnosis of gangrene was based on pathologic examination of the specimen. RESULTS There were 305 patients admitted to our institution with acute cholecystitis. Group I (n = 111) was admitted during the first half of the study and group II (n = 194) during the second half. Demographics were similar in the two groups. While slightly more patients were attempted laparoscopically in group II (90% versus 82%), conversion rates were virtually identical (27.1% versus 27.5%). There was a trend toward improved results with group II versus group I in mortality (3% versus 4%) and morbidity (14% versus 21%; P = not significant). Deaths were divided between sepsis and cardiac events. Gangrenous cholecystitis was less frequent in group II patients (29% versus 40%; P = 0.06). Analysis of gangrene versus non-gangrene patients within each group showed that conversion rates remained twice as high (40% versus 20%; P < 0.05) in those with gangrene. Interestingly, gangrene had no effect on morbidity or mortality. CONCLUSIONS Morbidity and mortality for acute cholecystitis remain relatively high. These seem to be determined by the degree of acute and chronic illness present at the time of diagnosis. As conversion rates remain unchanged, increased surgeon experience and further advances in laparoscopic technology are unlikely to dramatically affect results. Efforts to improve outcomes for this common disease should therefore focus on better and earlier identification of patients for operation.
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Affiliation(s)
- Jeffrey S Bender
- Department of Surgery, Johns Hopkins Bayview Medical Center and The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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21
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Abstract
Laparoscopic cholecystectomy is now considered the "gold standard" operation for patients with gallstone disease. A number of patients require conversion to an open cholecystectomy for the safe completion of the procedure. This study investigates how the etiology and incidence of conversion from laparoscopic to open cholecystectomy has changed over time. All 5884 patients undergoing laparoscopic cholecystectomy between March 1991 and June 2001 were prospectively collected in a database. A total of 310 patients (5.2%) had had their cholecystectomies converted to an open procedure. The mortality rate for these patients was 0.7%. Causes for conversion were inability to correctly identify anatomy (50%), "other" indications (16%), bleeding (14%), suspected choledocholithiasis (11%), and suspected bile duct injury (8%). After an initial learning curve in thin patients with symptomatic cholelithiasis, inclusion of patients with acute cholecystitis, morbid obesity, or a prior celiotomy resulted in a peak conversion rate of 11% by 1994. From 1994 to the first half of 2001, the conversion rate has declined significantly for all patients (10% to 1%), as well as for patients with acute cholecystitis (26% to 1%). Although unclear anatomy secondary to inflammation remains the most common reason for conversion, the impact of acute cholecystitis on the operative outcome has decreased with time.
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Affiliation(s)
- Juliane Bingener-Casey
- Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA
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22
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Jitea N, Burcoş T, Voiculescu S, Cristian D, Dimitriu C, Bărbulescu M, Bordea A, Dragomir S, Stănilescu S, Angelescu N. [Analysis of 3100 laparoscopic cholecystectomies]. Chirurgia (Bucur) 2001; 96:553-7. [PMID: 12731232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
AIM To evaluate the results of laparoscopic cholecystectomy (LC) in the 8 years period. PATIENTS AND METHODS First LC in Coltea Hospital was performed in September 1993 and introduced for treatment of patients with gallbladder disease. From September 1993 to February 2001 LC was performed in 3100 patients. Mean age 51.2 years (ranged from 8 to 87 years) among 2512 women and 588 men. 232 (7.48%) of the cases were patients with acute cholecystitis. Intraoperative cholangiography was performed in 112 cases (3.6%). RESULTS Conversion to open cholecystectomy (OC) was necessary in 111 patients (3.58%). Operative complications occurred in 16 (0.5%) patients: CBD lesions in 4 (0.12%) patients, bleeding from cystic artery--12 (0.38%) patients. In one patient CBD injuries was recognized at the time of operation and after conversion to OC primary ductal repair was performed. Postoperative complications occurred in 44 (1.41%) patients: a) local infection--in 15 (0.48%) patients (subhepatic abcess-3, wound infection-9. b) bile leakage--in 21 (0.67%) patients. c) haemoperitoneum because of the bleeding: from the abdominal wall at the trocar insertion site--in 2 patients, from a. cystica-one patient. d) obstructive jaundice due to stone in CBD--in 5 patients (endoscopic papillosphincterotomy and stone extraction was performed). There 21 reoperations due to complications: 13 laparatomies and 8 relaparascopies. Two patients (52 and 64 years old) died after LC-mortality 0.06 per cent. Mean hospitalisation day was 3.8. CONCLUSIONS To prevent iatrogenic CBD injuries correct preparation with a clear identification of the anatomic structures is essential. Relaparascopy and endoscopic retrograde cholangyopancreatography can be successfully used in the treatment of complications after LC.
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Affiliation(s)
- N Jitea
- Clinica de Chirurgie Colţea Bucureşti
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23
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Abstract
BACKGROUND Whereas early cholecystectomy is accepted as the optimal timing for surgery, the best treatment modality for acute cholecystitis (AC) is still under debate. In this series, we aimed to assess the current treatment of AC in a single institution. In addition, preoperative criteria were defined predicting the severity of inflammation. METHODS From January 1995 to June 1999, 236 patients undergoing cholecystectomy for AC were prospectively evaluated. Outcome measures were the treatment modality, the severity of inflammation, white blood cell (WBC) count, C-reactive protein (CRP), morbidity, and hospital stay. RESULTS There were 115 laparoscopic cholecystectomies (LC), 77 primary open cholecystectomies (OC), and 44 conversions (CON) to OC. Patients with LC were significantly younger, in better condition, with a shorter duration of symptoms and lower CRP levels and WBC counts compared with OC and CON (P <0.001). Postoperative complications, reinterventions, and mean hospital stay were significantly increased after OC and CON (P <0.001). Overall mortality was 2.5%. Advanced AC was predominantly found in OC and CON (P <0.001). Patients with advanced AC were significantly older, predominantly male, and had a prolonged duration of symptoms as well as increased CRP levels and WBC counts (P <0.001). The conversion rate increased from 10% for mild AC up to 48% for necrotizing AC. CONCLUSIONS Based on laboratory (CRP, WBC), demographic (age, sex), and individual (American Society of Anesthesiologists classification, duration of symptoms) findings, it is possible to reliably predict the severity of inflammation. Therefore, an individualized surgical approach can be used for each patient and type of AC.
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Affiliation(s)
- M Schäfer
- Department of Visceral and Transplantation Surgery, Inselspital, University of Bern, Freiburgstrasse, CH-3010, Bern, Switzerland.
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24
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Budarin VN. [Laparoscopic cholecystectomy]. Khirurgiia (Mosk) 2001:20-2. [PMID: 11195670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
The results of more than 1000 laparoscopic cholecystectomies are analyzed. Significant improvement of main parameters (mean hospital stay, postoperative lethality, postoperative complications rate) is demonstrated, including cases of acute destructive cholecystitis. The conception of emergency laparoscopic cholecystectomy is proposed. It is shown that the percentage of severe complications and lethality are significantly lower in laparoscopic operations than in the open operations. The widespread opinion of frequent damage of extrahepatic bile ducts is not confirmed. The development of laparoscopic surgery justifies more active policy in acute cholecystitis.
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Pessaux P, Lebigot J, Tuech JJ, Regenet N, Aube C, Ridereau C, Arnaud JP. [Percutaneous cholecystostomy for acute cholecystitis in high-risk patients]. Ann Chir 2000; 125:738-43. [PMID: 11105345 DOI: 10.1016/s0003-3944(00)00273-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
AIM OF THE STUDY The aim of this retrospective study was to report the results of percutaneous cholecystostomy in a selected group of high-risk patients with contraindications of general anesthesia. PATIENTS AND METHODS From October 1995 to December 1999, a percutaneous cholecystostomy was performed in 29 patients with acute cholecystitis. There were 20 women and nine men with a mean age of 80.6 years (range: 59 to 95 years). All the patients were ASA III (N = 23) or ASA IV (N = 6). Ultrasound-guided percutaneous cholecystostomy was performed in 24 cases and computed tomography-guided cholecystostomy in five cases. RESULTS Percutaneous cholecystostomy was easily performed in 28 cases; there was one failed procedure. The drainage was not efficient in three patients who were operated on with one postoperative death of a patient who had a necrotic cholecystitis. There was no mortality in relation with cholecystostomy. One patient died at day 15 from myocardia infarction. The morbidity rate was 3.4% (one case). Postoperative length of hospital stay was 13 days (range: 7-30 days). The duration of the entire procedure ranged from 9 to 60 days (mean: 20 days). The mean follow-up of patients was 17 months (range: 4-40 months). One patient had recurrent acute cholecystitis and another one had angiocholitis; two patients underwent delayed elective laparoscopic cholecystectomy; 20 patients remained asymptomatic and 16 were still alive at the time of this study (13 with biliary stones and three without). CONCLUSION Percutaneous cholecystostomy is a valuable alternative procedure for high-risk patients with acute cholecystitis. It's a safe and usually effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.
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Affiliation(s)
- P Pessaux
- Service de chirurgie viscérale, CHU, Angers, France
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26
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Abstract
BACKGROUND Preexisting gallstones and pharmacologic alterations in both bile lithogenicity and immune function may predispose organ transplant recipients to the complications of biliary calculi. METHODS Records of all 178 patients undergoing heart, lung, or heart-lung transplantation at our institution between 1980 and 1998 were reviewed. Patients with biliary tract disease were grouped as follows: group I, pretransplantation diagnosis and treatment; group II, pretransplantation diagnosis and posttransplantation treatment; group III, normal pretransplantation biliary tree with posttransplantation diagnosis and treatment; group IV, unknown pretransplantation biliary status with posttransplantation diagnosis and treatment. Comparison among groups was made with regard to ultrasound findings, presentation, indication for operation, procedure, and outcome. RESULTS Of the 141 patients undergoing pretransplantation and/or posttransplantation ultrasound surveillance, the prevalence of abnormal ultrasonography was 36%. All patients in group I (n = 11) underwent elective intervention without complication. Of the 14 patients (groups II through IV) undergoing posttransplantation operation, intervention was mandated by acute complications of biliary tract disease in 7. The mortality rate in these 7 patients was 29%. CONCLUSIONS Cholecystectomy in the posttransplantation period is often required emergently and has a high mortality. Posttransplantation surveillance of the biliary tree is crucial because of the high rate of de novo stone formation. All biliary calculi should be eradicated electively in stable patients before transplantation and on diagnosis after transplantation.
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Affiliation(s)
- D Gupta
- Department of Surgery and Health Sciences Research, Mayo Clinic, Rochester, Minn. 55905, USA
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Abstract
BACKGROUND Surgical cholecystostomy has been shown to carry a significantly higher mortality rate at Veterans Administration (VA) hospitals than at non-federal hospitals in the past. METHODS A retrospective outcomes study was undertaken at a large VA medical center with a policy favoring radiologic over surgical cholecystostomy over the past 9 years. Records of 24 consecutive patients with acute cholecystitis were reviewed to evaluate the effectiveness of the procedure. RESULTS Cholecystostomy was performed radiologically in 22 patients and surgically in 2 patients. Most (78%) of patients improved within 48 hours. The periprocedural mortality was 25%. The majority of these patients died from unrelated illnesses. Four patients developed complications, none of which required operative intervention. CONCLUSIONS Comorbidities are the most important mortality factor for cholecystostomies in VA patients. Radiologic tube placement is effective and uncomplicated in most cases.
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Affiliation(s)
- L Chang
- Surgical Service, Veterans Administration Puget Sound Health Care System, Department of Surgery, University of Washington, Seattle, Washington 98108, USA
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28
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Abstract
BACKGROUND Although endoscopic papillotomy is now considered established treatment for choledocholithiasis, therapeutic results of endoscopic papillotomy alone without subsequent cholecystectomy in patients with cholecystolithiasis have not been well evaluated. The aim of this study was to assess the long-term outcome of endoscopic papillotomy for these patients. METHODS Patients admitted with choledocholithiasis and cholecystolithiasis from 1976 to 1993 were studied retrospectively. Of 385 patients in whom the bile duct was cleared by endoscopic papillotomy and endoscopic stone extraction, 371 patients (195 men and 176 women; mean age 65.4 years) were followed. Predisposing risk factors for late complications were analyzed. RESULTS The mean duration of follow-up was 7.7 years. Cholecystitis and recurrence of choledocholithiasis as late complications occurred in 22 cases (5.9%) and 36 cases (9.7%), respectively. Cholecystitis, including 1 severe case, resolved with conservative treatment. Recurrent choledocholithiasis was successfully treated endoscopically except in 1 case. No significant risk factors were identified for cholecystitis. The presence of pneumobilia (p = 0.0016) and the need for lithotripsy (p = 0.0342) were found to be significant risk factors for the recurrence of choledocholithiasis. CONCLUSIONS Long-term outcome of endoscopic papillotomy in patients with choledocholithiasis and cholecystolithiasis was found to be relatively favorable. Cholecystectomy after endoscopic papillotomy is not always necessary in the management of cholecystolithiasis.
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Affiliation(s)
- M Saito
- First Department of Medicine, Chiba University School of Medicine, Chiba, Japan
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Warren BL, Carstens CA, Falck VG. Acute acalculous cholecystitis--a clinical-pathological disease spectrum. S AFR J SURG 1999; 37:99-104. [PMID: 10701340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
OBJECTIVE To assess the influence of disease setting on clinical and pathological features of acute acalculous cholecystitis (AAC). DESIGN Analysis of prospectively accumulated clinical data. Blinded histopathological review. LOCATION OF STUDY: Tygerberg Hospital, Western Cape. PATIENTS Fifty-seven consecutive patients with AAC treated over a 9-year period. MAIN OUTCOME MEASURES Clinical, ancillary and pathological features of AAC in each of 3 arbitrarily designated types. Type I (N = 24) occurred in patients hospitalised for trauma or critical illness. Patients with type II disease (N = 20) presented primarily with symptoms of acute cholecystitis. Type III AAC (N = 13) was associated with non-calculous gallbladder outflow obstruction. RESULTS Type I AAC was associated with the highest mortality rate (45.8%), occurred predominantly in males (75%) and was diagnosed pre-operatively in 50% of patients. Acute ischaemic cholecystitis was the most frequent histological diagnosis (66.7%). Only 1 death (5%) was associated with type II AAC despite patients being older, and all but 2 patients (10%) having chronic underlying disease. Acute cholecystitis was diagnosed pre-operatively in 90% of patients. Thirteen patients (65%) were males. Acute-on-chronic cholecystitis was the most frequent histological diagnosis (50%), followed by acute ischaemic cholecystitis in 30%. Type III was associated with an intermediate mortality rate (23.1%) and was the type most seldom diagnosed pre-operatively (15.4%). Histological findings reflected the nature and duration of underlying obstructive pathology. CONCLUSION The circumstances in which AAC occurs appear to be associated with distinct clinical-pathological variants of the disease. Their recognition could serve to enhance understanding of this challenging condition.
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Affiliation(s)
- B L Warren
- Department of Surgery, Tygerberg Hospital, W. Cape
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Arvieux-Barthelemy C, Mestrallet JP, Bouchard F, Delannoy P, Radmanesh O, Zattara A, Naud G, Faucheron JL, Eymard P, Dupré A, Létoublon C. [Surgical treatment of acute cholecystitis. A retrospective study of a series of 192 patients operated on over a period of 3 years]. Ann Chir 1999; 53:472-81. [PMID: 10427838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Emergency conditions make laparoscopic treatment of acute cholecystitis challenging. The aim of this study is to retrospectively analyse our experience of cholecystectomy for acute cholecystitis performed between January 1995 and December 1997. In order to be included, patients had to present (i) symptoms of acute cholecystitis correlated with laboratory blood tests and ultrasonographic studies (ii) evidence of acute inflammation during the operation and (iii) histological confirmation of acute or subacute inflammation of the excised gallbladder. 192 patients were treated: 62 were totally managed laparoscopically (group CCN), 33 managed laparoscopically but required conversion to open cholecystectomy (group CCC) and 97 were managed conventionally by laparotomy (group CL). Mean age was significantly different between the three groups, (CCN: 55.6 +/- 15 years, CCC: 64.2 +/- 13 years, CL: 66.5 +/- 17 years), as was ASA score (CCN: ASA 3 and ASA 4: 16%, CCC: ASA 3 and ASA 4: 48%, CL: ASA 3 and ASA 4: 46%), and initial infectious signs (temp. > or = 38 degrees C: CCN: 35%, CCC: 39%, CL: 63%). Mean operative delay was significantly higher in the converted group [8.7 +/- 13 days (CCC) vs 4.5 +/- 8 days (CCN) and 5.4 +/- 8 days (CL)]. There were two (1%) bile duct injuries, one in the CCC group, the other in the CL group. Operative mortality was 2% (CCC: 0%, CCN: 0%, CL: 4%) and operative morbidity was 40% (CCN: 21%, CCC: 24%, CL: 57%). The mean postoperative hospital stay was shorter in the CCN group (6.5 +/- 3.5 days) and CCC group (9.6 +/- 4.4 days) vs the mean stay in the CL group (14.7 +/- 11.6 days). Appears to be beneficial for selected patients with low surgical risk to conclude laparoscopic cholecystectomy. It has yet to be shown whether this benefit can be extended to patients with a high surgical risk.
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Affiliation(s)
- C Arvieux-Barthelemy
- Service de Chirurgie Générale et Digestive, Centre Hospitalier Universitaire A.-Michallon, Grenoble.
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31
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Garcia-Sancho Tellez L, Rodriguez-Montes JA, Fernandez de Lis S, Garcia-Sancho Martin L. Acute emphysematous cholecystitis. Report of twenty cases. Hepatogastroenterology 1999; 46:2144-8. [PMID: 10521957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
BACKGROUND/AIMS Our aim is to present our experience with acute emphysematous cholecystitis (AEC), a severe variety of acute cholecystitis characterized by early gangrene and perforation of the gallbladder. METHODOLOGY We reviewed the clinical records of 20 patients with AEC, analyzing age, sex, past medical history, symptoms, laboratory tests, X-rays, ultrasounds, operative and microbiological findings, morbidity and mortality. RESULTS Our study included 13 men and 7 women (mean age 59 years). Associated factors were diabetes mellitus (11 cases) and gallstones (6 cases, 3 of them with common bile duct stones). Clinical symptom presentation included: right hypochondrial pain and fever in all cases, vomiting in 9, septic shock in 3, jaundice in 7, and peritonitis in 8. Hyperbilirubinemia was present in 7 cases. Plain abdominal X-rays or ultrasounds led to diagnosis in 95% of the cases. Surgical findings were AEC in all cases, pericholecystic abscess in 8, gallbladder necrosis in 7 and bile peritonitis in 3. C perfringens, E coli and B fragilis were the most frequent pathogens. Mortality rate was 25%, and morbidity 50%. CONCLUSIONS AEC predominantly affects elderly diabetic men. Abdominal X-rays or ultrasounds are good diagnostic techniques, and emergency surgery is needed due to the high incidence of gangrene and perforation Despite all the efforts made, morbidity and mortality are still high.
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Affiliation(s)
- L Garcia-Sancho Tellez
- Department of Surgery, La Paz University Hospital, Universidad Autonoma de Madrid, Spain.
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Davis CA, Landercasper J, Gundersen LH, Lambert PJ. Effective use of percutaneous cholecystostomy in high-risk surgical patients: techniques, tube management, and results. Arch Surg 1999; 134:727-31; discussion 731-2. [PMID: 10401823 DOI: 10.1001/archsurg.134.7.727] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
HYPOTHESIS Percutaneous cholecystostomy (PC) is an effective, safe treatment in patients with suspected acute cholecystitis and severe concomitant comorbidity. DESIGN Retrospective medical record review from March 1989 to March 1998. SETTING Referral community teaching hospital (450 beds) in rural Wisconsin. PATIENTS Twenty-two consecutive patients underwent PC tube placement over a 10-year period. Twenty procedures were for acute cholecystitis (14 calculous, 6 acalculous) and 2 were for diagnostic dilemmas. Nineteen (86%) of 22 patients were American Society of Anesthesiologists class 4; 3 (14%) were class 3. INTERVENTIONS Pigtail catheters (8F-10F) placed by means of ultrasound or computed tomographic localization, with or without fluoroscopic adjunct. MAIN OUTCOME MEASURES Thirty-day mortality, complications, clinical improvement as determined by fever and pain resolution, normalization of leukocytosis, further biliary procedures required, and outcome after drain removal. RESULTS Twenty-two patients underwent PC for presumed acute cholecystitis based on ultrasound and clinical findings. All patients received antibiotics prior to PC for 24 or more hours. Thirty-day mortality was 36% (8 patients), reflecting severity of concomitant disease. Minor complications occurred in 3 of 22 patients. Clinical improvement occurred in 18 (82%) of 22 patients-15 (68%) within 48 hours. Follow-up of fourteen 30-day survivors is as follows: 7 (50%) had drains removed because the gallbladder was stone free, 4 (29%) had drains remaining due to persistent stones, 2 (14%) underwent cholecystectomy, and 1 (7%) awaits scheduled surgery. Only 1 (12.5%) of 8 patients developed biliary complications after drain removal, requiring endoscopic retrograde cholangiopancreatography 9 months after drain removal. One patient required urgent cholecystectomy after failure to respond to PC. This patient died of a perioperative myocardial infarction. CONCLUSIONS Percutaneous cholecystostomy is an effective, safe treatment in patients with suspected acute cholecystitis and severe concomitant comorbidity. Laparoscopic cholecystectomy is recommended as definitive treatment for patients whose risk for general anesthesia improves in follow-up. Drains can be safely removed once all gallstones are cleared. In patients with severe concomitant disease, drains can be left with a low incidence of complications if stones remain.
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Affiliation(s)
- C A Davis
- Department of Surgery, Gundersen Lutheran Medical Center, La Crosse, Wis. 54601, USA
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Abstract
In a 20-year period (1974-1993), 4230 patients underwent surgery of the gallbladder. Acute cholecystitis was the indication for emergency laparotomy in 869 patients (20.5%). Retrospective analysis demonstrated that after adjustment for age, sex, and mode of surgery--elective versus emergency--advanced age is not a risk factor contributing to mortality in uncomplicated cases of emergency surgery. Cases of acute cholecystitis complicated by perforation, peritonitis, and/or the presence of concrements in the biliary duct are associated with an increased mortality, however. We were able to demonstrate that advanced age is a risk factor in complicated cases and contributes to increased postsurgical mortality.
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Affiliation(s)
- G Banzhaf
- Klinik für Allgemein- und Thoraxchirurgie, Akademischen Lehrkrankenhauses Herford
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Abstract
BACKGROUND Several anecdotal papers suggest that laparoscopic cholecystectomy can be done safely in pregnant patients, but few patients are reported and other patients such as those who underwent laparoscopic appendectomy are often included. A larger series would help clarify the situation. METHODS The Connecticut Laparoscopic Cholecystectomy Registry and data from the Connecticut Hospital Association (CHA) were combined to search for all cholecystectomies performed in pregnant patients from 1992 through 1996. Information on outcomes for both mother and infant was obtained through the cooperation of most of the CHA hospitals. RESULTS Complete data were available for 46 patients, 20 laparoscopic and 26 open cases. The groups were comparable in all demographic respects except for the timing of cholecystectomy, which was performed at a mean of 18.4 +/- 6.7 weeks (range 9 to 32) of gestation for the laparoscopic and 24.8 +/- 4.7 weeks (range 14 to 35) for the open patients (P = 0.01). A maternal-fetal mortality due to intra-abdominal hemorrhage occurred in the laparoscopic group 2 weeks postoperatively. In the open group, a fetal demise occurred at 21 weeks gestation, 5 weeks postcholecystectomy. The open patients experienced 8 episodes of premature contractions compared with one one such event in the laparoscopic group (P = 0.057). CONCLUSIONS This represents the largest reported series of laparoscopic cholecystectomy in pregnant patients. Laparoscopic cholecystectomy does not lead to increased numbers of fetal complications. Premature uterine contractions tend to occur more frequently after open cholecystectomy and when the procedure is performed later in gestation.
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Affiliation(s)
- J E Barone
- Department of Surgery, Stamford Hospital and Columbia University College of Physicians and Surgeons, Connecticut 06902, USA
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Privalov VA, Shramchenko VA, Gubnitskiĭ AE, Privalov AV. [Surgical management of acute cholecystitis in elderly and old age patients]. Khirurgiia (Mosk) 1998:28-30. [PMID: 9791967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Results of treatment of 233 old and elderly patients with acute cholecystitis were analysed. In 206 from them percutaneous transhepatic drainage of the gallbladder (PTDGB) was carried out under US control with creation of temporary microcholecystostoma for elimination of acute attack of cholecystitis by decompression of the biliary system, in 2 patients laparoscopic cholecystostomy was performed, and in 27 patients with choledocholithiasis and jaundice early endoscopic papillosphincterotomy was carried out. Elimination of acute attack of cholecystitis in early terms contributed much to improvement of the patients condition, to carrying out further examination and correction of concomitant diseases. After adequate premedication 189 patients were operated on early after admission (on day 2-4). The operation of choice was cholecystectomy, in 49 patients being combined with various interventions on the choledochus. Postoperative mortality rate made up 4.2%. 44 patients were not operated because of elimination of the attack by PTDGB (17) and endoscopic papillosphincterotomy (27).
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Chao TC, Jeng LB, Jan YY, Hwang TL, Wang CS, Chen MF. Concurrent primary carcinoma of the gallbladder and acute cholecystitis. Hepatogastroenterology 1998; 45:921-6. [PMID: 9755981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND/AIMS Primary carcinoma of the gallbladder is rare and associated with a late diagnosis and poor prognosis. Concurrent acute cholecystitis frequently obscures the presence of carcinoma. The information regarding gallbladder carcinoma with acute cholecystitis is limited. In order to better understand the presentation of gallbladder carcinoma with acute cholecystitis, we retrospectively reviewed the data of patients with primary carcinoma of the gallbladder. METHODOLOGY The data of 86 patients with primary carcinoma of the gallbladder treated between 1979 and 1994 were compiled and reviewed. The patients were divided into 2 groups: Group 1 (with acute cholecystitis, 21 patients) and Group 2 (without cholecystitis, 65 patients). Clinicopathological comparisons were made and evaluated between these two groups RESULTS The average age of Group 1 patients was older than that of Group 2 patients (75+/-2 years vs. 63+/-2 years; p<0.05). Three Group 1 patients presented with sepsis. The interval between the onset of symptoms and hospital admission in Group 2 patients was significantly (p<0.05) longer than that in Group 1 patients (243+/-95 days vs. 20+/-11 days). Leukocytosis (>11,000/mm3) was more common in Group 1 patients than in Group 2 patients (47.6% vs. 15.4%). Jaundice was more common in Group 2, and fever was common in Group 1. The majority of Group 2 gallbladder cancers were stage V (75.4%). In contrast, 52.4% of Group 1 gallbladder cancers were stage III and 38.1% were stage V. The 30-day postoperative mortality rate in Group 1 and Group 2 patients was 9.5% and 7.7%, respectively. The cumulative survival of Group 1 patients was not different from that of Group 2 patients (log-rank test, p>0.05). CONCLUSIONS Age, the interval of symptoms prior to admission, the location of abdominal pain, fever, leukocytosis, and the absence of jaundice suggested the presence of acute cholecystitis in gallbladder carcinoma. A high index of suspicion of the disease, intraoperative examination of gallbladder specimens, and more aggressive surgical treatment may improve patient survival.
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Affiliation(s)
- T C Chao
- Department of Surgery, Chang Gung Medical College, and Chang Gung Memorial Hospital, Taipei, Taiwan
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Aliev SA. [Peculiarities of clinical features and surgical treatment policy in old patients with acute cholecystitis]. Khirurgiia (Mosk) 1998:25-9. [PMID: 9613059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The results of treatment of 138 patients with acute cholecystitis aged from 75 to 89 years are analyzed. Calculous cholecystitis was revealed in 126 patients, acalculous cholecystitis--in 12 patients. Cholelythiasis was revealed in 63 (45.6%), stricture of the large duodenal papilla (LDP)--in 13 (9.4%), combination of choledocholithiasis and stricture of LDP--in 16 (11.6%). Mechanical jaundice was revealed in 54 (39.1%) patients, purulent cholangitis--in 18 (13%). From 138 patients 113 (81.8%) underwent surgery. Urgent operations were carried out in 35 (30.9%), early operations--in 54 (47.8%), delayed operation--in 24 (21.2%) patients. Cholecystectomy was performed in 99 patients, it was supplemented with choledocholithotomy and various types of external drainage of the duct (n = 28), choledochoduodenostomy (in 40), transduodenal papillosphincterotomy (n = 6) and endoscopic papillosphincterotomy (n = 7). Cholecystostomy was carried out in 14 patients (including laparoscopic cholecystostomy, n = 5). Repeated operations were performed in 29 patients. Postoperative complications appeared in 28 (24.7%) patients. 16 patients (14.1%) died after the operation. The causes of death were hepatic functional deficiency (6), peritonitis (2), pancreatic necrosis (1), acute cardio-vascular failure (4), pulmonary artery thrombo-embolism (2), acute cerebro-vascular failure (1).
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Abstract
The laparoscopic approach to acute cholecystitis is not only feasible, but it is also a cost-effective, safe, and beneficial treatment option in selected patients. Patients undergoing laparoscopic surgery for acute cholecystitis seem to enjoy the same benefits of diminished pain and shorter hospitalization as those patients undergoing an elective laparoscopic cholecystectomy. The complication rates are also comparable with those for an open cholecystectomy. An early laparoscopic cholecystectomy within 4 days of the onset of symptoms has been shown to reduce the number of major complications and conversion rate, thus resulting in a decreased hospital stay. A low threshold for conversion to laparotomy also seems to be an important factor in maintaining a low incidence of operative complications. The conversion to laparotomy is therefore considered to be a good surgical option for experienced surgeons. Patients who are in the high-risk category or who have severe disease are best managed initially by gallbladder drainage unless they have perforated disease, which thus requires an emergency laparotomy.
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Affiliation(s)
- M Hashizume
- Department of Surgery, Kyushu University, Fukuoka, TX, 812-8582, Japan
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Asperger W, Reinhardt H. [Quality assurance in inpatient surgical care in the Saxony-Anhalt area. Results of 3 years]. Z Arztl Fortbild Qualitatssich 1998; 92:241-8. [PMID: 9675826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Quality assurance in surgery has a long tradition. In the last twenty years, especially externe quality assurance was very important. Pioneers of this development were Schega and Scheibe and the East German working group for quality assurance in surgery. After preparations of Scheibe in some federal countries, global measures could be started. In 1993, also in Sachsen-Anhalt we started externe quality assurance in surgery with the diagnosis gallstone disease and cholecystitis. The experiences and results of a 3-year period will be shown.
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Affiliation(s)
- W Asperger
- St. Elisabeth-Krankenhaus, Klinik für Allgemein- und Visceralchirurgie, Halle
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Verbanck J, Ghillebert G, Rutgeerts L, Baert F, Goethals C, Schepkens H, Geldhof K, Surmont I. Ultrasound-guided puncture of the gallbladder for acute cholecystitis. Acta Gastroenterol Belg 1998; 61:151-2. [PMID: 9658597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We performed a US-guided aspiration of the gallbladder in 27 patients with an acute cholecystitis and severe concurrent disease, not responding to IV antibiotics and supportive therapy. Twenty six of the 27 patients improved after the procedure. One patient died 7 days after the procedure due to multi organ failure; in the others immediate surgery could be avoided. Three patients experienced local pain after the procedure; no other puncture related complications were encountered. Long-term results (mean follow up 18 months; range 2-36 months) were excellent in 20/26 survivors with no biliary complications or need for elective cholecystectomy. Six of the 26 patients needed subsequent cholecystectomy for relapse or incomplete cure.
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Affiliation(s)
- J Verbanck
- Department of Internal Medicine, H. Hartziekenhuis, Roeselare
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Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) has become the treatment of choice for elective cholecystectomy, but controversy persists over use of this approach in the treatment of acute cholecystitis. We undertook a randomised comparison of the safety and outcome of LC and open cholecystectomy (OC) in patients with acute cholecystitis. METHODS 63 of 68 consecutive patients who met criteria for acute cholecystitis were randomly assigned OC (31 patients) or LC (32 patients). The primary endpoints were hospital mortality and morbidity, length of hospital stay, and length of sick leave from work. Analysis was by intention to treat. Suspected bile-duct stones were investigated by preoperative endoscopic retrograde cholangiography (LC group) or intraoperative cholangiography (OC group). FINDINGS The two randomised groups were similar in demographic, physical, and clinical characteristics. 48% of the patients in the OC group and 59% in the LC group were older than 60 years. 13 patients in each group had gangrene or empyema, and one in each group had perforation of the gallbladder causing diffuse peritonitis. Five (16%) patients in the LC group required conversion to OC, in most because severe inflammation distorted the anatomy of Calot's triangle. There were no deaths or bile-duct lesions in either group, but the postoperative complication rate was significantly (p=0.0048) higher in the OC than in the LC group: seven (23%) patients had major and six (19%) minor complications after OC, whereas only one (3%) minor complication occurred after LC. The postoperative hospital stay was significantly shorter in the LC than the OC group (median 4 [IQR 2-5] vs 6 [5-8] days; p=0.0063). Mean length of sick leave was shorter in the LC group (13.9 vs 30.1 days; 95% CI for difference 10.9-21.7). INTERPRETATION Even though LC for acute and gangrenous cholecystitis is technically demanding, in experienced hands it is safe and effective. It does not increase the mortality rate, and the morbidity rate seems to be even lower than that in OC. However, a moderately high conversion rate must be accepted.
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Affiliation(s)
- T Kiviluoto
- Second Department of Surgery, Helsinki University Central Hospital, Finland
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Bittner R, Leibl B, Kraft K, Butters M, Nick G, Ulrich M. [Laparoscopic cholecystectomy in therapy of acute cholecystitis: immediate versus interval operation]. Chirurg 1997; 68:237-43. [PMID: 9198565 DOI: 10.1007/s001040050180] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
From January 1991 to May 1996 a total of 3,010 cholecystectomies was performed for cholelithiasis. Pathohistologically an acute cholecystitis was found in 483 patients (16%). The overall proportion of laparoscopic operations has increased from 12.5% in 1991 to 96.6% at present. In patients with acute cholecystitis the proportion of laparoscopic operations has increased from initially only 1.87% up to 83.3%. The duration of surgery (81 min versus 54 min), rate of conversion (12% versus 1.07%) and rate of complications (7.76% versus 2.2%) were all significantly higher in cases of acute cholecystitis than in those without inflammation. There was no mortality in either group. Furthermore no significant difference was found between patients with histopathologically proven acute inflammation and patients with an acute episode of chronic cholecystitis. The duration of complaints, however, had a significant influence on surgical results. In patients that were either operated on within 48 h after the onset of disease or more than 10 days later, the length of the operation was shorter and the rates of conversion and complications were lower. Our results prove that laparoscopic cholecystectomy is also very successful in cases of acute cholecystitis, though a long learning curve has to be expected. Taking efficiency and economy into consideration, surgery within a few days of the onset of disease must be recommended.
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Affiliation(s)
- R Bittner
- Abteilung für Allgemein- und Visceralchirurgie, Marienhospital Stuttgart
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Catania G, Petralia GA, Salanitri T, Puleo C, Fimognari D, Cardì F. [Biliary surgery in the aged]. Ann Ital Chir 1997; 68:73-8; discussion 79. [PMID: 9235868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Between 1980 and 1995 in the Section of General and Oncological Surgery of the Department of Surgery of the University of Catania, on a total of 1715 biliary surgical procedures, 926 were performed on the elderly patients, 287 of which in emergency. Cholelithiasis (469 cases) morbidity 4.5%, mortality 0.4%; acute colecystitis, (247 cases) morbidity 21%, mortality 12%. Choledocholithiasis (122 cases) surgical treatment (51 cases) morbidity 21.6%, mortality 3.9%; endoscopic treatment (71 cases) morbidity 9.4%, mortality 0%. Neoplasms of the biliary tract (48 cases) diagnostic laparotomises 9, surgery (27 cases) morbidity 37%, mortality 11%; endoscopy (12 cases) morbidity 33%, mortality 0%. Acute obstructive cholangitis (34 cases), surgical drainage (9 cases) morbidity 55%, mortality 33%; endoscopic drainage (22 cases) morbidity 14%, mortality 4.8%; transhepatic drainage (3 cases) morbidity 66%, mortality 33%. Acute biliary pancreatitis (6 cases) surgery (2 cases) morbidity 100%, mortality 50%; endoscopy (4 cases) morbidity 25%, mortality 0%. This experience confirms that in elderly patients the treatment of choice for cholelithiasis is cholecystectomy and for acute colecystitis is early cholecistectomy. The preferred treatment of choledocholithiasis and severe acute biliary pancreatitis is endoscopic sphincterectomy. Endoscopic or radiologic drainages are the choice for acute biliary pancreatitis. In conclusion elderly patients with surgical biliary problems should be treated by a surgical, endoscopic and radiological team, taking in account all the available procedures.
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Affiliation(s)
- G Catania
- Dipartimento di Chirurgia, Università degli Studi di Catania
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Schwarz NT, Walgenbach KJ, Brünagel G, Hirner A. [Acute cholecystitis--a rare complication in intensive care patients?]. Langenbecks Arch Chir Suppl Kongressbd 1996; 113:364-6. [PMID: 9101877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
From 1989 to 1995, 25 ICU-patients underwent cholecystectomy for acute acalculous cholecystitis (AAC). Preoperative diagnosis remains difficult and ultrasound imaging proved to be the most valid instrument for early diagnosis. Predisposing factors like duration of respiratory failure, extent of surgery, amount of blood loss and mode of analgesia were analyzed. Undelayed surgical treatment was important to avoid further complications such as gangrene or perforation of the gall bladder.
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Affiliation(s)
- N T Schwarz
- Klinik und Poliklinik für Chirurgie, Rheinische Friedrich-Wilhelms-Universität Bonn
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Melin MM, Sarr MG, Bender CE, van Heerden JA. Percutaneous cholecystostomy: a valuable technique in high-risk patients with presumed acute cholecystitis. Br J Surg 1995; 82:1274-7. [PMID: 7552017 DOI: 10.1002/bjs.1800820939] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Percutaneous cholecystostomy offers a potentially important therapeutic modality for critically ill patients with acute cholecystitis who represent a high risk for general anaesthesia. The aim of the study was to assess experience with percutaneous cholecystostomy in resolving the acute episode of cholecystitis without operative intervention. Twenty-two consecutive patients with a clinical diagnosis of acute cholecystitis underwent the procedure. All were at high risk for general anaesthesia, and all but one developed cholecystitis while hospitalized for another co-morbid condition; 14 were in an intensive care unit. Twenty-one of the 22 patients proved to have acute cholecystitis (11 acalculous, ten cholelithiasis). There were no acute technical complications. Toxaemia resolved in 17 of the 21 patients with acute cholecystitis. Acute cholecystitis failed to resolve in three patients; all died within 48 h from overwhelming generalized sepsis. One patient required emergency cholecystectomy for bile peritonitis when the cholecystostomy catheter became dislodged 24 h after placement. The 60-day mortality rate for the acalculous and calculous patient groups was 55 and 20 per cent, respectively. Only three interval cholecystectomies have been performed at a mean follow-up of 19 months. In conclusion, percutaneous cholecystostomy may be the procedure of choice for the management of acute cholecystitis in the very high-risk critically ill patient. If symptoms fail to resolve quickly, ongoing sepsis, cholangitis or gallbladder necrosis should be suspected.
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Affiliation(s)
- M M Melin
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Mandak JS, Pollack B, Fishman NO, Furth EE, Kochman ML, Acker MA, Lichtenstein GR. Acalculous candidal cholecystitis: a previously unrecognized complication after cardiac transplantation. Am J Gastroenterol 1995; 90:1333-7. [PMID: 7639242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acalculous cholecystitis is a life-threatening complication in critically ill surgical patients. Whereas Candida albicans and Torulopsis glabrata have been reported as the primary pathogens in 14 previous cases of acalculous cholecystitis, we report the first case of Candida parapsilosis as a biliary pathogen in a patient after cardiac transplantation. Although cardiac transplant recipients often have many of the risk factors for acalculous candidal cholecystitis, including major surgery, immunosuppression, antibiotic therapy, parenteral nutrition, and prolonged intensive care unit stay, this entity has not been previously reported in the cardiac transplant population. Although rare, acalculous candidal cholecystitis is associated with very high morbidity and a mortality rate of 40%. Early diagnosis necessitates an aggressive approach to the critically ill patient with abdominal complaints. Prompt drainage or cholecystectomy, if possible, represent the mainstays of therapy and offer the greatest chance for survival.
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Affiliation(s)
- J S Mandak
- Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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47
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Kuzin NM, Kuznetsov NA. [Problems in the surgical treatment of calculous cholecystitis]. Khirurgiia (Mosk) 1995:18-23. [PMID: 7745929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The article analyses experience of the N. N. Burdenko clinic in surgical treatment of cholelithiasis. A total of 4,733 operations for cholecystectomy were performed. 96.7% of them were of a planned order, 14.3% of patients who underwent operation 65 years of age and older. Cholecystectomy was expanded to choledocholithotomy in 2.7, papillosphincterotomy in 1.7, separation of biliodigestive fistules in 0.6% of cases. Various combined operations were carried out on 558 patients. Intraoperative complications developed in 0.96% of cases: damage to the hepaticocholedochus (0.14%) and to the hepatic artery proper (0.02%) and its right branch (0.02%). Relaparotomy was performed in 0.86% of cases: for bile leakage (0.54%) and for bleeding (0.15%). Suppuration occurred in 3.9% of patients who were operated on. Total mortality was 0.25% (0.09% after planned and 5.7% after emergency operations). Fatal complications were encountered in 0.1% of patients under 65 years of age and in 1.18% of older patients. Fatal outcomes occurred in 1.1% of 558 combined operations, one of which was cholecystectomy; in none of the cases could the fatal complication be connected with expansion of the intervention. As it can be seen from the above-discussed material, there are definite prospects for improving the results of cholecystectomy: an obligatory condition is conduction of the operation in a planned order and under 65 years of age. Careful assessment of the operative risk factors for each patients on the basis of modern mathematical methods will help in solving the problem of the possibility of surgical treatment.(ABSTRACT TRUNCATED AT 250 WORDS)
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Miroshnikov BI, Svetlovidov VV, Tibilov VE. [An analysis of mortality in acute cholecystitis]. Vestn Khir Im I I Grek 1994; 153:14-7. [PMID: 7625017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Kocher T, Herzog U, Schuppisser JP, Tondelli P. [Laparoscopic and open cholecystectomy in 954 patients. A prospective evaluation]. Helv Chir Acta 1994; 60:761-5. [PMID: 7960904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
In 2 1/2 years we performed at the St. Clara Hospital in Basel 954 cholecystectomies; 661 were done laparoscopically. In the laparoscopic group we observed a morbidity of 2.3%, a reoperation rate of 0.6% and a mortality of 0.15%. In the group with open cholecystectomy the morbidity was 9.9% and the mortality 1.3%. In all 954 patients who had a cholecystectomy the morbidity was 4.6%, reoperation rate 0.4% and mortality 0.5%. Because of negative patient selection a comparison with the open cholecystectomy in our series is not possible. In summary we can say that the laparoscopic procedure has a low morbidity and low mortality. With the lesser operative trauma it allows a shorter hospital stay. We believe that laparoscopic cholecystectomy with good indication will replace open cholecystectomy as the gold standard therapy of symptomatic gallstone disease.
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Affiliation(s)
- T Kocher
- Chirurgische Abteilung, St. Claraspital, Basel
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50
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Kunin N, Letoquart JP, La Gamma A, Chaperon J, Mambrini A. [Acute cholecystitis in the elderly]. J Chir (Paris) 1994; 131:257-260. [PMID: 7989414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
We retrospectively studied 150 patients aged over 65 years who had been operated for acute cholecystitis in order to define the surgical results and evaluate this treatment as a function of age. The patients were divided into two groups. Group I included patients between the age of 65 and 79 years, n = 99 (53 males and 46 females). Group II included patients aged 80 years and over, n = 51 (14 males and 37 females). The data were compared with the chi 2 test and the Kruskall and Wallis test. Associated affections were observed in 69 patients in group I and in 36 patients in group II (NS). The clinical picture was similar in the 2 groups with manifestations of pain in the right hypochondral region (group I, n = 97; group II, n = 50), fever (group I, n = 73; group 2, n = 38) and abdominal defence (group I, n = 62; group II, n = 35). Echography revealed the diagnosis in almost all cases in both groups. There was no statistical difference between the two groups in terms of mean operative delay and length of hospital stay. Age increased significantly the risk of exploration of the main bile duct (group I, n = 14; group II, n = 15, p < 0.05). Nevertheless, this exploration did not affect post-operative follow-up. Mortality was 6.7% with 4 deaths in group I and 6% in group II (NS). Post-operative complications were observed in 36 patients in group I and 28 in group II (p < 0.05) (43% overall including deaths).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- N Kunin
- Service de Chirurgie Générale A, Hôpital Sud, C.H.R. de Rennes
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