Evaluation of inflammatory biomarkers affecting mortality in acute cholecystitis in the emergency department.

OBJECTIVES: The aim of this study was to investigate the effectiveness of pan-immune inflammation value (PIV), systemic immune-inflammatory index (SII), and systemic inflammation response index (SIRI) in predicting mortality in acute cholecystitis (AC). BACKGROUND: Abdominal pain is one of the most frequent complaints encountered by physicians at emergency department (ED). METHODS: This clinical study is a cross-sectional study among patients admitted to the emergency department of a tertiary hospital and diagnosed with AC. Total survival curves were estimated by the Kaplan‒Meier method. Differences according to risk groups were determined by the log-rank test. RESULTS: A total of 789 patients (survival: 737, non-survival: 52) diagnosed with AC were enrolled in the study. NLR and SII had an excellent diagnostic power in predicting 30-day mortality in the receiver operating characteristic (ROC) analysis, while the diagnostic power of SIRI and PIV was acceptable. It was observed that the probability of survival period decreased in the presence of NLR (>11.07), SII (>2315.18), SIRI (>6.55), and PIV (>1581.13) above the cut-off levels. The HRs of NLR, SII, SIRI, and PIV were 10.52, 7.44, 6.34, and 5.6, respectively. CONCLUSION: NLR, SII, SIRI, and PIV may be useful markers in predicting 30-day mortality in patients with AC (Tab. 3, Fig. 5, Ref. 25).

Outcomes Following an Index Emergency Admission With Cholecystitis: A National Cohort Study.

OBJECTIVE: The objective of this study was to evaluate the differences between patients who undergo cholecystectomy following index admission for cholecystitis, and those who are managed nonoperatively. SUMMARY BACKGROUND DATA: Index emergency cholecystectomy following acute cholecystitis is widely recommended by national guidelines, but its effect on clinical outcomes remains uncertain. METHODS: Data collected routinely from the Hospital Episode Statistics database (all admissions to National Health Service organizations in England and Wales) were extracted between April 1, 2002 and March 31, 2015. Analyses were limited to patients aged over 18 years with a primary diagnosis of cholecystitis. Exclusions included records with missing or invalid datasets, patients who had previously undergone a cholecystectomy, patients who had died without a cholecystectomy, and those undergoing cholecystectomy for malignancy, pancreatitis, or choledocholithiasis. Patients were grouped as either "no cholecystectomy" where they had never undergone a cholecystectomy following discharge, or "cholecystectomy." The latter group was then subdivided as "emergency cholecystectomy" when cholecystectomy was performed during their index emergency admission, or "interval cholecystectomy" when a cholecystectomy was performed within 12 months following a subsequent (emergency or elective) admission. Propensity Score Matching was used to match emergency and interval cholecystectomy groups. Main outcome measures included 1) One-year total length of hospital stay due to biliary causes following an index emergency admission with cholecystitis. 2) One-year mortality; defined as death occurring within 1 year following the index emergency admission with acute cholecystitis. RESULTS: Of the 99,139 patients admitted as an emergency with acute cholecystitis, 51.1% (47,626) did not undergo a cholecystectomy within 1 year of index admission. These patients were older, with more comorbidities (Charlson Comorbidity Score ≥ 5 in 23.5% vs. 8.1%, P < 0.001) when compared to patients who did have a cholecystectomy. While all-cause 1-year mortality was higher in the nonoperated versus the operated group (12.2% vs. 2.0%, P < 0.001), gallbladder-related deaths were significantly lower than all other causes of death in the non-operated group (3.3% vs. 8.9%, P < 0.001). Following matching, 1-year total hospital admission time was significantly higher following emergency compared with interval cholecystectomy (17.7 d vs. 13 d, P < 0.001). CONCLUSIONS: Over 50% of patients in England did not undergo cholecystectomy following index admission for acute cholecystitis. Mortality was higher in the nonoperated group, which was mostly due to non-gallbladder pathologies but total hospital admission time for biliary causes was lower over 12 months. Increasing the numbers of emergency cholecystectomy may risk over-treating patients with acute cholecystitis and increasing their time spent admitted to hospital.

Comparison of laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy in aged acute calculous cholecystitis: a cohort study.

BACKGROUND: In elderly patients with calculous acute cholecystitis, the risk of emergency surgery is high, and percutaneous cholecystostomy tube drainage (PC) combined with delayed laparoscopic cholecystectomy (DLC) may be a good choice. We retrospectively compared laparoscopic cholecystectomy (LC) to DLC after PC to determine which is the better treatment strategy. METHOD: We performed a retrospective cohort analysis of 752 patients with acute calculous cholecystitis. Patients with the following conditions were included: (1) age > 65 years old; (2) patients with a grade 2 or 3 severity of cholecystitis according to the 2013 Tokyo Guidelines (TG13); (3) the surgeons who performed the LC were professors or associate professors and (4) the DLC was performed in our hospital after PC. Patients who missed their 30-day follow-up; were diagnosed with bile duct stones, cholangitis or gallstone pancreatitis or were pregnant were excluded from the study. A total of 51 of 314 patients who underwent LC and 73 of 438 patients who underwent PC + DLC were assessed. PC + DLC and LC patients were matched by cholecystitis severity grade according to the TG13, and the National Surgical Quality Improvement Program (NSQIP) calculator was used to predict mortality (n = 21/group). Preoperative characteristics and postoperative outcomes were analysed. RESULTS: Compared to the matched LC group, the DLC group had less intraoperative bleeding (42.2 vs 75.3 mL, p = 0.014), shorter hospital stays (4.9 vs 7.4 days, p = 0.010) and lower rates of type A bile duct injury (4.8% vs 14.3%, p = 0.035) and type D (0 vs 9.5%, p = 0.002) according to Strasberg classification, residual stones (4.8 vs 14.3%, p = 0.035) and gastrointestinal organ injury (0 vs 3.6%, p < 0.001). Patients in the DLC group had lower incidences of ICU admission and death and a significantly lower incidence of repeat surgery. CONCLUSION: In elderly patients treated for acute calculous cholecystitis, the 30-day mortality and complication rates were lower for PC + DLC than for LC. However, the total hospitalisation time was significantly prolonged and the costs were significantly higher for PC + DLC.

Surgical management of acute cholecystitis in a nationwide Danish cohort.

PURPOSE: In the Danish national guidelines from 2006 on the treatment of acute cholecystitis, early laparoscopic operation within 5 days after the debut of symptoms was recommended. The aim of this study was to analyze the outcome in patients with acute cholecystitis subjected to cholecystectomy in Denmark in the five-year period hereafter. METHODS: All patients undergoing cholecystectomy in the period 2006-2010 were registered in the Danish Cholecystectomy Database, from which outcome data were collected. The effect of potential risk factors such as age, gender, BMI, American Society of Anesthesiologists (ASA) score, previous pancreatitis, previous abdominal surgery, year of operation, surgical approach, and surgeon experience was analyzed. RESULTS: Of 33,853 patients registered with a cholecystectomy, 4667 (14%) were operated for acute cholecystitis. In 95% of the patients, laparoscopic cholecystectomy was intended and in 5% primary open access was chosen. The frequency of conversion from laparoscopic to open surgery was 18%. High age and ASA score, operation in the early years of the period, and open or converted procedure all increased the risk of hospital stay to > 3 days or readmission. High age and ASA score, converted or open operation, and previous pancreatitis increased the risk of additional procedures. Postoperative mortality was 1.2%, and significant risk factors for postoperative death were age, low BMI, high ASA score, early year of operation, and open procedures. CONCLUSIONS: Acute cholecystectomy was safely managed laparoscopically in most patients after the introduction of national guidelines, with an increasing rate of laparoscopically completed procedures during the study period.

Acute Cholecystitis in Elderly Patients after Hip Fracture: a Nationwide Cohort Study.

BACKGROUND: Because acute cholecystitis in elderly hip fracture is not easily distinguishable from other gastrointestinal symptoms and involves atypical clinical behaviors, it may not be diagnosed in the early stage. However, the exact incidences could not be reported. We utilized data from a nationwide claims database and attempted to assess the incidence of acute cholecystitis in elderly hip fracture patients and how cholecystitis affects mortality rates after hip fracture. METHODS: Study subjects were from the Korean National Health Insurance Service-Senior cohort. From a population of approximately 5.5 million Korean enrollees > 60 years of age in 2002, a total of 588,147 participants were randomly selected using 10% simple random sampling. The subjects included in this study were those who were over 65 years old and underwent surgery for hip fractures. RESULTS: A total of 15,210 patients were enrolled in the cohort as hip fracture patients. There were 7,888 cases (51.9%) of femoral neck fracture and 7,443 (48.9%) cases of hemiarthroplasty. Thirty-six patients developed acute cholecystitis within 30 days after the index date (30-day cumulative incidence, 0.24%). Four of the 36 acute cholecystitis patients (11.1%) died within 30 days versus 2.92% of patients without acute cholecystitis. In the multivariate-adjusted Poisson regression model, hip fracture patients with incident acute cholecystitis were 4.35 (adjusted risk ratio 4.35; 95% confidence interval, 1.66-11.37; P = 0.003) times more likely to die within 30 days than those without acute cholecystitis. CONCLUSION: Incidence of acute cholecystitis in elderly patients after hip fracture within 30 days after the index date was 0.24%. Acute cholecystitis in elderly hip fracture patients dramatically increases the 30-day mortality rate by 4.35-fold. Therefore, early disease detection and management are crucial for patients.

Early percutaneous cholecystostomy versus antibiotic treatment for mild and moderate acute cholecystitis: A retrospective cohort study.

BACKGROUND: Percutaneous cholecystostomy (PC) is an effective treatment for severe acute cholecystitis (AC). Guidelines recommend PC as rescue therapy for patients with mild or moderate AC who do not receive emergent cholecystectomy. This study aims to investigate whether PC could be a first-line treatment for these patients. METHODS: Adult patients admitted through the emergency department between October 2004 and December 2013 were retrospectively reviewed. Patients with mild or moderate AC who did not undergo emergent cholecystectomy were included. Early PC was defined as a PC tube inserted within 24 h of diagnosis. The outcomes were compared between patients who received antibiotics plus early PC (early PC group) and those who received antibiotic treatment alone (antibiotic group). RESULTS: A total of 698 patients were included. The mean age was 63.4 years. There were 171 patients in the early PC group and 527 patients in the antibiotic group. Multivariable logistic regression analyses indicated that early PC was significantly associated with a decreased rate of prolonged fever (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.16-0.57; p < 0.001). Early PC also correlated with both increased short-term (OR, 15.95; 95% CI, 5.73-44.38; p < 0.001) and long-term treatment success (OR, 4.27; 95% CI, 2.55-7.15; p < 0.001). CONCLUSION: For patients with mild/moderate AC without emergent cholecystectomy, early PC might expedite sepsis resolution and improve the treatment success rate compared with antibiotic treatment alone. This result should be deemed as hypothesis-generating and should be examined in a randomized controlled trial.

The impact of delayed source control and antimicrobial therapy in 196 patients with cholecystitis-associated septic shock: a cohort analysis

Background: Cholecystitis-associated septic shock carries a significant mortality. Our aim was to determine whether timing of source control affects survival in cholecystitis patients with septic shock. Methods: We conducted a nested cohort study of all patients with cholecystitis-associated septic shock from an international, multicentre database (1996­2015). Multivariable logistic regression was performed to determine associations between clinical factors and in-hospital mortality. The results were used to inform a classification and regression tree (CART) analysis that modelled the association between disease severity (APACHE II), time to source control and survival. Results: Among 196 patients with cholecystitis-associated septic shock, overall mortality was 37%. Compared with nonsurvivors (n = 72), survivors (n = 124) had lower mean admission APACHE II scores (21 v. 27, p < 0.001) and lower median admission serum lactate (2.4 v. 6.8 µmol/L, p < 0.001). Survivors were more likely to receive appropriate antimicrobial therapy earlier (median 2.8 v. 6.1 h from shock, p = 0.012). Survivors were also more likely to undergo successful source control earlier (median 9.8 v. 24.7 h from shock, p < 0.001). Adjusting for covariates, APACHE II (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.06­1.21 per increment) and delayed source control > 16 h (OR 4.45, 95% CI 1.88­10.70) were independently associated with increased mortality (all p < 0.001). The CART analysis showed that patients with APACHE II scores of 15­26 benefitted most from source control within 16 h (p < 0.0001). Conclusion: In patients with cholecystitis-associated septic shock, admission APACHE II score and delay in source control (cholecystectomy or percutaneous cholecystostomy drainage) significantly affected hospital outcomes.

Contexte: Le choc septique associé à une cholécystite s'accompagne d'une mortalité significative. Notre but était de déterminer si le moment du contrôle de la source affecte la survie chez les patients atteints de cholécystite qui se trouvent en choc septique. Méthodes: Nous avons procédé à une étude de cohorte nichée regroupant tous les patients ayant présenté un choc septique associé à une cholécystite à partir d'une base de données multicentrique internationale (1996­2015). La régression logistique multivariée a été utilisée pour déterminer les liens entre les facteurs cliniques et la mortalité perhospitalière. Les résultats ont été utilisés pour éclairer une analyse par arbre de classification (CART) qui modélisait le lien entre la gravité de la maladie (APACHE II), le temps nécessaire au contrôle de la source et la survie. Résultats: Parmi 196 patients souffrant d'un choc septique associé à une cholécystite, la mortalité globale a été de 37 %. Comparativement aux patients décédés (n = 72), les survivants (n = 124) présentaient à l'admission des scores APACHE II moyens plus bas (21 c. 27, p < 0,001) et un taux de lactate sérique médian plus bas (2,4 c. 6,8 µmol/L, p < 0,001). Les survivants étaient plus susceptibles de recevoir une antibiothérapie adéquate plus hâtive (médiane 2,8 c. 6,1 h suivant le choc, p = 0,012). Les survivants étaient aussi plus susceptibles de bénéficier plus hâtivement d'un contrôle réussi de la source (médiane 9,8 c. 24,7 h suivant le choc, p < 0,001). L'ajustement pour tenir compte des covariables du score APACHE II (rapport des cotes [RC] 1,13, intervalle de confiance [IC] de 95 % 1,06­1,21 par palier) et le retard du contrôle de la source > 16 h (RC 4,45, IC de 95 % 1,88­10,70) ont été associés indépendamment à une mortalité plus élevée (tous deux p < 0,001). L'analyse CART a révélé que les patients ayant des scores APACHE II de 15­26 ont le plus bénéficié d'un contrôle de la source dans les 16 h (p < 0,0001). Conclusion: Chez les patients présentant un choc septique associé à une cholécystite, le score APACHE II à l'admission et le retard de contrôle de la source (cholécystectomie ou drainage par cholécystotomie percutanée) ont significativement influé sur les résultats hospitaliers.

[A retrospective analysis of clinical characteristics and mortality risks in elderly patients with acute cholecystitis and cholangitis].

Objective: To analyze the clinical characteristics and explore the risk predictors on mortality in elderly patients with acute cholecystitis and cholangitis. Methods: We conducted a retrospective analysis of elderly patients hospitalized in the Second Medical Center of General Liberation Army Hospital for acute cholecystitis and cholangitis during 2000 to 2018. Clinical data and risk predictors on mortality were assessed. The patients were stratified into three groups based on age:Ⅰ (65-74 years old),Ⅱ (75-84 years old), and Ⅲ (≥85 years old). Logistic regression analysis was used to identify the predictors of mortality. Results: A total of 574 patients were finally enrolled with the mean age 87.6 years including 191 in group Ⅰ, 167 in group Ⅱ, and 216 in group Ⅲ. The main cause of acute cholecystitis and cholangitis was gallstone (76.3%),and the main symptom was abdominal pain (62.9%),followed by chills(62.5%),fever(59.8%),jaundice (47.2%) and septic shock(26.3%). Cholecystitis was the most common diagnosis in groups Ⅰ and Ⅱ,whereas it was cholangitis in group Ⅲ. Percutaneous transhepatic biliary/gallbladder drainage (PTBD/PTGD) and endoscopic retrograde cholangiopancreatography (ERCP) were administrated more frequently in groups Ⅲ. A total of 35 patients (6.1%) died during follow-up. Senior in age (OR=11.1),the Charlson comorbidity index (OR=19.5),cancers (OR=9.6),blood stream infections (OR=7.4),severity of cholecystitis and cholangitis (OR=4.2) were risk factors associated with mortality. Conclusions: Even in the elderly patients with acute cholecystitis and cholangitis,comorbidity is one of the main factors affecting clinical outcomes. Due to the poor performance, this group of population presents more severe disease and undergoes conservative treatment strategies.

Percutaneous Cholecystostomy in Acute Cholecystitis-Predictors of Recurrence and Interval Cholecystectomy.

BACKGROUND: Percutaneous cholecystostomy (PC) tube is a preferred option in acute cholecystitis for patients who are high risk for cholecystectomy (CCY). There are no evidence-based guidelines for patient care after PC. We identified the predictors of disease recurrence and successful interval CCY. METHODS: A retrospective review of 145 PC patients between 2008 and 2016 at a tertiary hospital was performed. Primary outcomes included mortality, readmissions, hospital and intensive care unit length of stay (LOS), disease recurrence, and interval CCY. RESULTS: There were 96 (67%) calculous and 47 (33%) acalculous cholecystitis cases. Seventy-two (49%) had chronic and 73 (51%) had acute prohibitive risks as an indication for PC. There were 54 (37%) periprocedural complications, which most commonly were dislodgements. Twenty-six (18%) patients had a recurrence at a median time of 65 days. Calculous cholecystitis (odds ratio [OR] 3.44, P = 0.038) and purulence in the gallbladder (OR 3.77, P = 0.009) were predictors for recurrence. Forty-one (28%) patients underwent interval CCY. Patients with acute illness were likely to undergo interval CCY (OR 6.67, P = 0.0002). Patients with acalculous cholecystitis had longer hospital LOS (16 versus 8 days) and intensive care unit LOS (2 versus 0 days), and higher readmission rates (OR 2.42, P = 0.02). Thirty-day mortality after PC placement was 9%. Patients receiving interval CCY were noted to have increased survival compared to PC alone. However, this should not be attributed to interval CCY alone in absence of randomization in this study. CONCLUSIONS: Calculous cholecystitis and purulence in the gallbladder are independent predictors of acute cholecystitis recurrence. Acute illness is a strong predictor of successful interval CCY. The association of interval CCY and prolonged survival in patients with PC as noted in this study should be further assessed in future prospective randomized trials.

Visceral adiposity but not subcutaneous fat associated with improved outcome of patients with acute cholecystitis.

BACKGROUND: The aim of this study to study the effect of visceral and subcutaneous fat tissue mass on short- and long-term prognosis of patients with acute calculus cholecystitis (ACC). METHODS: Retrospective analysis of medical records. Included were all patients admitted because of ACC. Computed tomography images at the level of L3 were analyzed for body composition using designated software (Slice-O-matic; TomoVision, Montreal, Quebec, Canada). General linear model was used to analyze the effect of body composition on length of hospital stay, and Cox regression analysis was used to ascertain the effect of the different parameters on 1-y survival. RESULTS: Included were 159 patients (mean age: 71.7 ± 15.8 y, 54.7% males). Fat was the most abundant tissue (401 ± 175 cm2 of the computed tomography slices surface area), and visceral fat was 45.8 ± 14.1% of the fat area measured. Using the general linear model, we found that American Society of Anesthesiologists score, disease severity index, and age were positively associated with higher length of stay, whereas high visceral fat was associated with lower length of stay (estimated marginal means at 7.4 ± 1.4 d compared to 12.7 ± 1.4 d among patients with lower visceral fat surface area, P = 0.010). The Cox regression model showed that 1-y survival risk was significantly reduced by age, the Charlson Comorbidity Index and high muscle mass. High visceral adiposity was associated with improved survival (odds ratio: 0.216, 95% confidence interval: 0.064-0.724, P = 0.013). Subcutaneous adiposity did not affect prognosis. CONCLUSIONS: Visceral adiposity is associated with shorter length of stay and improved 1-y survival among patients hospitalized with ACC.

Evolution in the management of acute cholecystitis in the elderly: population-based cohort study.

BACKGROUND: Acute cholecystitis is a life-threatening emergency in elderly patients. This population-based cohort study aimed to evaluate the commonly used management strategies for elderly patients with acute cholecystitis as well as resulting mortality and re-admission rates. METHODS: Data from all consecutive elderly patients (≥ 80 years) admitted with acute cholecystitis in England from 1997 to 2012 were captured from the Hospital Episode Statistics database. Influence of management strategies upon mortality was analyzed with adjustment for patient demographics and treatment year. RESULTS: 47,500 elderly patients were admitted as an emergency with acute cholecystitis. On the index emergency admission the majority of patients (n = 42,620, 89.7%) received conservative treatment, 3539 (7.5%) had cholecystectomy, and 1341 (2.8%) underwent cholecystostomy. In the short term, 30-day mortality was increased in the emergency cholecystectomy group (11.6%) compared to those managed conservatively (9.9%) (p < 0.001). This was offset by the long-term benefits of cholecystectomy with a reduced 1-year mortality [20.8 vs. 27.1% for those managed conservatively (p < 0.001)]. Management with percutaneous cholecystostomy had increased 30-day and 1-year mortality (13.4 and 35.0%, respectively). The annual proportion of cholecystectomies performed laparoscopically increased from 27% in 2006 to 59% in 2012. Within the cholecystectomy group, laparoscopic approach was an independent predictor of reduced 30-day mortality (OR 0.16, 95% CI 0.10-0.25). Following conservative management, there were 16,088 admissions with further cholecystitis. Only 11% of patients initially managed conservatively or with cholecystostomy received subsequent cholecystectomy. CONCLUSION: Acute cholecystitis is associated with significant mortality in elderly patients. Potential benefits of emergency cholecystectomy in selected elderly patients include reduced rate of readmissions and 1-year mortality. Laparoscopic approach for emergency cholecystectomy was associated with an 84% relative risk reduction in 30-day mortality compared to open surgery.

Acalculous Cholecystitis: Is an Elective Interval Cholecystectomy Necessary.

BACKGROUND: Acute acalculous cholecystitis (AAC) accounts for 5-10% of cases of acute cholecystitis. The advantage of interval cholecystectomy for patients with AAC is unclear. Therefore, a retrospective analysis of patients diagnosed with AAC at our institution was performed over a 5-year period. METHODS: Patients were identified via hospital coding using the keywords "acalculous cholecystitis, cholecystostomy and gall bladder perforation." Follow-up data was obtained by performing a retrospective review of the patients' hospital records. RESULTS: A total of 33 patients with AAC were identified and followed for a median period of 18 months. The median age at presentation was 70 (10-96) and American Society of Anesthesiologists (ASA) grade was 3 (1-5). Twenty-three patients (70%) were treated with antibiotics alone, 7 patients (21%) with percutaneous cholecystostomy and 3 patients (9%) with laparoscopic cholecystectomy. The 90-day mortality rate was 30% with significant correlation to comorbid status, as all deaths occurred in ASA grade 3-5 individuals (p = 0.020). Two patients (6%) developed recurrent AAC and were managed non-operatively. CONCLUSION: Antibiotics and cholecystostomy were the mainstay of AAC management, and comorbid status influenced related mortality. Our results suggest that it appears safe to avoid interval cholecystectomy in patients who recover from AAC, as they are typically high-risk surgical candidates.

Conservative treatment of acute cholecystitis: a systematic review and pooled analysis.

BACKGROUND: In medical practice, the tendency to remove an inflamed gallbladder is deeply rooted. Cholecystectomy, however, is associated with relatively high complication rates, and therefore the decision whether or not to perform surgery should be well considered. For some patients, the surgical risk-benefit profile may favour conservative treatment. The objective of this study was to examine the short- and long-term outcome of conservative treatment of patients with acute calculous cholecystitis. METHODS: A systematic search of MEDLINE, Embase and Cochrane Library databases was performed. Prospective studies reporting on the success rate of conservative treatment (i.e. non-invasive treatment) of acute cholecystitis during index admission were included, as well as prospective and retrospective studies reporting on the recurrence rate of gallstone-related disease during long-term follow-up (i.e. ≥12 months) after initial non-surgical management. Study selection was undertaken independently by two reviewers using predefined criteria. The risk of bias was assessed. The pooled success and mortality rate during index admission and the pooled recurrence rate of gallstone-related disease during long-term follow-up were calculated using a random-effects model. RESULTS: A total of 1841 patients were included in 10 randomized controlled trials and 14 non-randomized studies. Conservative treatment during index admission was successful in 87 % of patients with acute calculous cholecystitis and in 96 % of patients with mild disease. In the long term, 22 % of the patients developed recurrent gallstone-related disease. Pooled analysis showed a success rate of 86 % (95 % CI 0.8-0.9), a mortality rate of 0.5 % (95 % CI 0.001-0.009) and a recurrence rate of 20 % (95 % CI 0.1-0.3). DISCUSSION: Conservative treatment of acute calculous cholecystitis during index admission seems feasible and safe, especially in patients with mild disease. During long-term follow-up, less than a quarter of the patients appear to develop recurrent gallstone-related disease, although this outcome is based on limited data.

The optimal treatment of patients with mild and moderate acute cholecystitis: time for a revision of the Tokyo Guidelines.

INTRODUCTION: According to the Tokyo Guidelines, severity of acute cholecystitis is divided into three grades based on the degree of inflammation and the presence of organ dysfunction. These guidelines recommend grade I (mild) acute cholecystitis to be treated with early laparoscopic cholecystectomy and grade II (moderate) acute cholecystitis with delayed cholecystectomy. Yet, several studies have shown that, for acute cholecystitis in general, early cholecystectomy is superior to delayed cholecystectomy in terms of complication rate, duration of hospital stay and costs. The aim of this study was to determine the clinical outcomes of emergency cholecystectomy in patients with grade II acute cholecystitis. Based on our findings, we propose a revision of the Tokyo Guidelines. METHODS: We performed a retrospective observational cohort study of 589 consecutive patients undergoing emergency cholecystectomy for acute calculous cholecystitis in a large teaching hospital between January 2002 and January 2015. Patients were classified according to the severity assessment criteria of the Tokyo Guidelines. Patients with grade I and grade II acute cholecystitis were compared for perioperative outcomes. RESULTS: Emergency cholecystectomy was performed in 270 patients with grade I acute cholecystitis and 187 patients with grade II acute cholecystitis. There was no difference in conversion rate (6 vs. 6%, p = 0.985) and operating time (60 min [25-255] vs. 70 min [30-255], p = 0.421). Also the perioperative complication rate (7 vs. 9%, p = 0.517), 30-day mortality (1 vs. 1%, p = 0.648) and length of hospital stay (4 days [1-42] vs. 4 days [1-62], p = 0.327) were similar between grade I and grade II acute cholecystitis. CONCLUSION: The clinical outcomes of emergency cholecystectomy did not differ between patients with grade I and grade II acute cholecystitis. The findings support a revision of the Tokyo Guidelines with respect to the recommendation of performing emergency cholecystectomy in both grade I and grade II acute cholecystitis.

Risk-adjusted treatment selection and outcome of patients with acute cholecystitis.

PURPOSE: Age and comorbidities increase the surgical risk for patients with acute cholecystitis and impact on the initial treatment selection. The aim of this article is the implementation of objective risk criteria that may be used to select the most appropriate treatment. METHODS: We carried out a prospective cohort study of all patients who were admitted to the hospital with a diagnosis of acute cholecystitis during 2014. They were initially allocated to three different treatment groups according to cholecystitis grade, number of days from clinical onset, and surgical risk scores as follows: immediate surgery by sepsis (EmergS), early surgery (EarlyS), or medical treatment group (MedT). Differences in the outcomes between the treatment groups were evaluated using bivariate and logistic regression analyses. RESULTS: A total of 149 patients were admitted; 44 % were >80 years old and 40 % were American Society of Anesthesiologists (ASA) > II. The mortality rate of the series was 0 % in EarlyS, 17 % in MedT, and 19 % in EmergS. The mortality rate was significantly associated with a higher degree of cholecystitis, age, and worse score values in risk scales and Charlson index. Logistic regression identified that the only independent predictors of death at the time of admission were the degree of cholecystitis (OR 2.87, p = 0.018) and the Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) score (OR 1.14, p = 0.001). CONCLUSION: The evaluation for the initial treatment in acute cholecystitis should include a systematic determination of the degree of cholecystitis and a surgical risk assessment. Tokyo guideline recommendations should be reviewed.

Impact of medical or surgical admission on outcomes of patients with acute cholecystitis.

BACKGROUND: Although acute cholecystitis (AC) is a surgical disease, patients with the condition may be admitted to medical-related services (MS). This may lead to delayed cholecystectomy thereby affecting outcomes and quality of care. METHODS: Between July 2010 and March 2013, 329 patients under 70 years old presented to a community-based tertiary care hospital with AC and underwent same admission cholecystectomy. Outcomes were compared between patients admitted to MS and surgical services (SS). RESULTS: Two hundred fifteen patients (65.3%) were admitted to a MS. Patients under the MS had longer LOS (3.0 days vs. 2.0 days, p < 0.001), waiting time to surgical consultation (7.3 h vs. 5.0 h, p < 0.001) and to cholecystectomy (1.0, 0-2 days vs. 1.0, 0-1 day, p < 0.001), and increased hospital costs ($3685 vs. $4,688, p < 0.001) compared to the SS. Readmission and mortality rates were not significantly different between groups. CONCLUSION: Patients under 70 years old with AC undergoing cholecystectomy admitted to MS had increased LOS, delay to the operation, and hospital costs compared to those admitted to a SS. Admission of patients with AC to a SS needs to be emphasized to reduce costs and improve quality of care.

Outcomes of Percutaneous Cholecystostomy in the Presence of Ascites.

PURPOSE: To evaluate whether the presence of ascites increases complications following placement of percutaneous cholecystostomy tubes (PCTs). MATERIALS AND METHODS: Retrospective review of all transhepatic PCTs placed between January 2005 and June 2014 was performed: 255 patients were included (median age of 65 y; range, 20-95 y). Of these patients, 97 had ascites and 158 had no ascites or only pelvic fluid. In all, 115 patients had calculous cholecystitis (45%), 127 had acalculous cholecystitis (50%), and 13 had common bile duct obstruction (5%). The primary outcome of interest was all complications, including bile peritonitis, pericatheter leakage requiring PCT change, pericholecystic abscess formation, drain dislodgment, or death from biliary sepsis within 14 days of initial PCT insertion. RESULTS: The overall complication rate was 11% among patients with ascites (n = 11), compared with 10% in those without (n = 16; P = .834). No difference was found between the two groups in any one complication. The overall outcome of PCT drainage differed between groups, with significantly shorter survival times in patients with ascites. Patients with ascites underwent cholecystectomy less often than patients without ascites (21% vs 39%; P = .002). Likewise, patients with ascites were more likely than those without ascites to die with the PCT in place (49% vs 25%; P = .001). CONCLUSIONS: Frequencies of complications following PCT insertion were similar in patients with and without ascites. Additionally, the overall complication rate was low and not significantly different between the two groups. These observations support the use of PCT placement in patients with ascites.

[APPROACH TO ESTABLISHMENT OF INDICATIONS FOR PROGRAMMED SANATION OF ABDOMINAL CAVITY IN DIFFUSE PERITONITIS].

The results of treatment of 33 patients, suffering diffuse peritonitis, with postoperatively applied tactics of the programmed surgical sanation of abdominal cavity were analyzed. Indications for relaparotomy were established, based on the estimation scale for the enteral insufficiency severity. The patients death and the complications causes were analyzed, depending on terms and rates of relaparotomy conduction.

Percutaneous cholecystostomy is an effective treatment option for acute calculous cholecystitis: a 10-year experience.

BACKGROUND: Percutaneous cholecystostomy (PC) can be used to treat patients with acute calculous cholecystitis (ACC) who are considered to be unfit for surgery. However, this procedure has been insufficiently investigated. This paper presents the results of a 10-year experience with this treatment modality. METHODS: A retrospective observational study of all consecutive patients treated with PC for ACC in the period from 1 May 2002 to 30 April 2012 was conducted. All data were collected from patients' medical records. RESULTS: A total of 278 patients were treated with PC for ACC. Of these, 13 (4.7%) died within 30 days, 28 (10.1%) underwent early laparoscopic cholecystectomy and three (1.1%) patients were lost from follow-up. Of the remaining 234 patients, 55 (23.5%) were readmitted for the recurrence of cholecystitis. In 128 (54.7%) patients, PC was the definitive treatment (median follow-up time: 5 years), whereas 51 (21.8%) patients were treated with elective laparoscopic cholecystectomy. The frequency of recurrence of cholecystitis in patients with contrast passage to the duodenum on cholangiography was lower than that in patients without contrast passage (21.1% versus 36.7%; P = 0.037). CONCLUSIONS: The present study, which is the largest ever conducted in this treatment area, supports the hypothesis that PC is an effective treatment modality for critically ill patients with ACC unfit for surgery and results in a low rate of 30-day mortality.

[The nature of postoperative complications in patients with peritonitis].

We studied the postoperative period in patients with peritonitis. The structure of the most important factors that slow down the healing process and lead to mortality. Among the factors that affect the healing process is the most important character of fluid, and the prevalence of peritonitis (causative factor), which causes complications on the part of the internal organs and wounds.