Prediction of extensive necrotic change in acute gangrenous cholecystitis.

PURPOSE: Gangrenous cholecystitis (GC) is a severe type of acute cholecystitis that implies higher mortality and morbidity rates than uncomplicated cholecystitis. The characteristics of GC are various for each case. However, preoperative predictors of GC with extensive necrotic change have not been investigated well. METHODS: A total of 239 patients who were pathologically diagnosed with GC underwent laparoscopic cholecystectomy at our hospital between January 2013 and December 2021. Of these, 135 patients were included in this study and were subdivided into the extensive necrosis group (patients with necrotic change extending to the neck of the gallbladder, n = 18) and the control group (patients with necrotic change limited to the fundus or body, not extending to the neck, n = 117) according to each operation video. Patient characteristics and perioperative factors predicting extensive necrotic change were investigated. RESULTS: Pericholecystic fat stranding (83.3 vs. 53.8%, p = 0.018) and absence of wall enhancement on preoperative CT images (50.0 vs. 24.7%, p = 0.026) were significantly associated with extensive necrosis. Seven of 18 patients in the extensive necrosis group showed necrotic changes beyond the infundibulum. The absence of wall enhancement on preoperative CT images (71.4 vs. 28.8%, p = 0.018) was significantly associated with necrotic changes beyond the infundibulum. CONCLUSIONS: Pericholecystic fat stranding and absence of wall enhancement on preoperative enhanced CT are predictors of extensive necrotic change in patients with GC. In addition, the absence of wall enhancement also predicts the presence of necrotic changes beyond the infundibulum.

Does preoperative MRCP imaging predict risk for conversion to subtotal cholecystectomy in patients with acute cholecystitis?

BACKGROUND: Subtotal cholecystectomy (SC) is a useful procedure for avoiding bile duct injury in patients with difficult gallbladder. However, risk factors for conversion to SC, especially preoperative magnetic resonance cholangiopancreatography (MRCP) findings that predict conversion to SC, have not been investigated in detail. METHODS: A total of 290 patients with acute cholecystitis who underwent laparoscopic cholecystectomy at our hospital between November 2011 and March 2020 were included. Patient characteristics and perioperative outcomes were reviewed, and preoperative clinical factors predicting conversion to SC were investigated. RESULTS: Forty-three patients underwent SC, whereas the remaining 247 patients underwent total cholecystectomy. An American Society of Anesthesiologists (ASA) score of 3 or greater (p = 0.011), surgery on or after 9 days from symptom onset (p < 0.001), obscuration of the gallbladder wall around the neck on MRCP images (p = 0.010) and disruption of the common hepatic duct on MRCP images (p < 0.001) were significantly associated with conversion to SC. Logistic regression analyses revealed that an ASA score of 3 or greater (odds ratio = 2.667, p = 0.020), surgery on or after 9 days from symptom onset (odds ratio = 4.229, p < 0.001) and disruption of the common hepatic duct on MRCP images (odds ratio = 4.478, p = 0.002) were independent predictors for conversion to SC. CONCLUSIONS: Early surgery yielded a lower risk for conversion to SC. Disruption of the common hepatic duct on preoperative MRCP images is associated with a risk for conversion to SC.

Does the presence of an appendicolith or abscess predict failure of nonoperative management of patients with acute appendicitis?

PURPOSE: Nonoperative management (NOM) has been widely accepted as one of the standard treatments for patients with acute appendicitis. However, predictive factors for the failure of NOM have not been thoroughly investigated. METHODS: A total of 196 patients with acute appendicitis underwent NOM between April 2014 and December 2020. Of these 196 patients, 24 patients failed NOM and required emergency surgery (failure group: n = 24), while the other 172 patients were successfully treated with NOM (success group: n = 172). These two groups were compared, and the predictive factors for the failure of NOM were investigated. RESULTS: The number of patients who had a previous history of stroke was significantly increased in the failure group (12.5% vs. 2.9%, p = 0.026). Incarceration of an appendicolith on CT images was significantly associated with the failure group (20.8% vs. 1.7%, p < 0.001), while neither the presence of an appendicolith nor abscess was associated. The presence of periappendiceal fluid was significantly associated with the failure group (50.0% vs. 26.7%, p = 0.019). The incarceration of an appendicolith (p < 0.001, odds ratio = 19.85) and periappendiceal fluid (p = 0.009, odds ratio = 3.62) were found to be independent risk factors for failure of NOM. Neither the presence of an appendicolith nor abscess was associated with the recurrence of appendicitis. CONCLUSIONS: The presence of an appendicolith or abscess was not a crucial factor for surgery. Incarceration of an appendicolith and periappendiceal fluid on CT images was predictive factors for the failure of NOM.

Risk factors for postoperative bile leak in patients who underwent subtotal cholecystectomy.

BACKGROUND: Subtotal cholecystectomy (SC) is a procedure for avoiding the risk of bile duct injury, especially in patients with difficult gallbladders. However, recent meta-analyses have demonstrated that SC is associated with a relatively high incidence of postoperative bile leak. To our knowledge, there have been no reports that have investigated risk factors for postoperative bile leak. METHODS: A total of 76 patients underwent reconstituting SC at our hospital between January 2005 and July 2019. Patient characteristics and perioperative outcomes were reviewed, and risk factors for postoperative bile leak were investigated. In addition, in patients with acute cholecystitis (AC) (n = 60), subgroup analyses were performed. RESULTS: Bile leak developed in 11 patients with AC (18.3%), while no patients with chronic cholecystitis developed bile leak (p = 0.064). Patients with AC who underwent surgery 10 days or later from onset developed postoperative bile leak significantly more frequently than those who underwent surgery within 10 days (38.0 vs 7.6%, p = 0.003). Patients with AC who underwent gallbladder stump closure with suturing developed postoperative bile leak significantly more frequently than those who underwent ligation (37.5 vs 11.3%, p = 0.020). In the patients with AC, surgery after 10 days from onset (p = 0.022, odds ratio = 5.85) was found by logistic regression analysis to be an independent risk factor for developing postoperative bile leak. CONCLUSION: Early surgery yielded a lower incidence of postoperative bile leak in patients who underwent SC. Surgery during the subacute phase was considered to imply a higher risk for developing bile leak than surgery during the acute and chronic phases.

Carbon sources that enable enrichment of 1,4-dioxane-degrading bacteria in landfill leachate.

1,4-Dioxane (DX) is a recalcitrant cyclic ether that has gained attention as an emerging pollutant in the aquatic environment. Enrichment of indigenous DX-degrading bacteria, which are considered to be minor populations even in DX-impacted environments, is the key for efficient biological DX removal. Therefore, this study aimed to explore carbon sources applicable for the enrichment of DX-degrading bacteria present in landfill leachate, which is a potential source of DX pollution. Microorganisms collected from landfill leachate were cultivated on six different carbon sources (DX, tetrahydrofuran (THF), 1,3,5-trioxane (TX), ethylene glycol (EG), diethylene glycol (DEG), and 1,4-butanediol (BD)) in a sequential batch mode. Consequently, enrichment cultures cultivated on THF in addition to DX improved the DX degradation ability compared to that of the original leachate sample, while those on the other test carbon sources did not. The results indicated that THF can be an alternative carbon source to enrich DX-degrading bacteria, and that TX, EG, DEG and BD are not applicable to concentrate DX-degrading bacteria in complex microbial consortia. In addition, sequencing analyses of 16S rRNA and soluble di-iron monooxygenase (SDIMO) genes revealed notable dominance of thm/dxm genes involved in group 5 SDIMO both in DX- and THF-enrichment cultures. The analysis also showed a predominance of Pseudonocardia in THF-enrichment culture, suggesting that Pseudonocardia harboring thm/dxm genes contributes to enhanced DX degradation in THF-enrichment culture.

A Case of Isolated Cecal Necrosis Preoperatively Diagnosed with Perforation of Cecum.

Isolated cecal necrosis (ICN) is a rare condition which is developed under decreased mesenteric perfusion. Only a few dozen cases of ICN have been reported previously. The patient was a 59-year-old male with a previous history of atrial fibrillation. He presented to our emergency room with the chief complaint of lower abdominal pain. Computed tomography imaging revealed a dilated cecum and presence of free air. With a preoperative diagnosis of perforation of the cecum; an urgent surgery was conducted. Intraoperative findings revealed an ischemic change of the cecum and a laparoscopic-assisted ileocecal resection was performed. The pathological findings showed transmural ischemic change on the anti-mesenteric side of the cecum, and the diagnosis of ICN was achieved. Preoperative diagnosis of ICN is difficult because of its non-specific radiological features. In patients with right lower abdominal pain, ICN should be considered as a differential diagnosis especially if the patient has a comorbidity causing hypotension attack.

Are Preoperative CT Findings Useful for Predicting Postoperative Intraabdominal Abscess in the Patients with Acute Appendicitis?

Background and objective: In patients with acute appendicitis (AA), preoperative computed tomography (CT) findings suggesting development of intraabdominal abscess (IAA) had not been widely used. The aim of this study was to investigate the preoperative clinical and radiological factors that predict the development of a postoperative IAA in patients with AA who were treated by laparoscopic appendectomy (LA). Methods: Two hundred and sixteen patients with pathologically proven AA underwent LA between January 2013 and March 2018 in our department. Medical records and preoperative CT images of these 216 patients were retrospectively reviewed and the predictive factors of postoperative IAA were investigated. In addition, patients were divided into complicated appendicitis (CA) and simple appendicitis (SA) and perioperative factors of two groups were compared. Results: One hundred and forty-seven patients were diagnosed with CA, while the other 69 patients were diagnosed with SA. Sixteen patients developed postoperative IAA in the CA group, while no patients in the SA group did. The univariate analysis revealed that time from onset to surgery more than 3 days (p = 0.011), the preoperative CT finding of periappendiceal fluid (p = 0.003), abscess (p < 0.001), and free air (p < 0.001), operation time more than 120 min (p = 0.023) and placement of a drainage tube (p < 0.001) were significantly associated with the development of IAA. Multivariate analysis revealed that the preoperative CT finding of free air was independently associated with the development of IAA (p = 0.007, odds ratio = 5.427, 95% CI: 1.586⁻18.57). Conclusions: IAA developed predominantly in patients with CA. Preoperative CT findings of free air was found to be an independent predictor for the development of IAA. Surgeons should be meticulous in managing the postoperative course of patients with this finding.

Calculus left in remnant gallbladder cause long-term complications in patients undergoing subtotal cholecystectomy.

BACKGROUND: There have been only a few reports that describe the long-term outcomes of Subtotal cholecystectomy (SC). METHODS: A total of 59 patients underwent "reconstituting" SC at our hospital between January 2005 and July 2017. In the 59 patients, risk factors for long-term complications were analyzed. In addition, in the patients with acute cholecystitis (AC), perioperative and long-term clinical factors were compared for patients who underwent SC (n = 48) and those who underwent total cholecystectomy (n = 378). RESULTS: In the 59 patients who underwent SC, long-term complication developed in 14 (23.7%), including residual calculus in the common bile duct (n = 12), remnant cholecystitis (n = 1), and persistent severe inflammatory response (n = 1). Postoperative magnetic resonance image was performed in 35/59 patients (59.3%) who underwent SC. In these 35 patients, the size of the remnant gallbladder calculated by magnetic resonance cholangiopancreatography was significantly associated with the occurrence of long-term complications (p = 0.009). In the patients with AC, regarding long-term complications, the incidence of residual calculus in the common bile duct (16.6 versus 0.7%) was significantly higher in the SC group. CONCLUSIONS: SC was associated with a relatively high incidence of long-term complications associated with remnant calculus.

[A Patient with Lung Cancer Experiencing Abdominal Aortic Aneurysm Rupture during Bevacizumab Treatment-Case Report].

CASE: Right pleural effusion was detected on chest X-ray performed prior to surgery for a right inguinal hernia in a 63-yearold man. Adenocarcinoma was diagnosed based on pleural effusion cytology results. A CT scan revealed mediastinal lymphadenopathy and pleural dissemination, but no obvious lung tumor; other examinations also did not reveal a primary tumor. We, therefore, diagnosed primary lung cancer(c-TxN2M1a, Stage ⅣA, according to the General Rules for Clinical and Pathological Record of Lung Cancer, 8th edition). An abdominal aortic aneurysm was also observed on CT. Since he was diagnosed with EGFR-negative lung cancer with malignant pleural effusion, we selected chemotherapy with cisplatin, pemetrexed, and bevacizumab(CDDP/PEM/Bev)and administered 2 courses without problems. He experienced no adverse events during the 3rd course and was discharged on day 8. However, he was transported to our emergency room at 20: 45 on treatment day 10 when he developed abdominal pain and nearly fainted. An abdominal aortic rupture was diagnosed by CT, and he was transported to another hospital because he could not be treated at our hospital. Information that this patient had been treated with Bev was not provided to the doctor on duty, and abdominal aortic graft replacement was immediately performed. The patient had a good postoperative course without anastomotic leakage and was discharged on day 7 after surgery. Bev is a monoclonal antibody for vascular endothelial growth factor. CONCLUSION: We report that this drug, bevacizumab, may be associated with abdominal aortic rupture.

[A Case of Advanced Squamous Cell Lung Cancer with Hemodialysis Treated with Carboplatin and Paclitaxel].

We herein describe a patient on hemodialysis with advanced squamous cell lung cancer who was treated with chemotherapy that consisted of carboplatin(CBDCA)and paclitaxel(PTX). A 54-year-old man who was undergoing a routine hemodialysis for chronic renal failure presented with cold symptoms and was prescribed antibiotics.As no symptomatic improvement was achieved, he was referred to the Department of Internal Medicine in our hospital, where computed tomographic scan findings raised the suspicion of lung cancer.He was then referred to the Department of Surgery.A bronchoscopy detected a tumor, which obstructed the right upper lobe bronchus, and the patient was diagnosed with squamous cell carcinoma.Based on the mediastinal lymph node enlargement that extended into the contralateral hilar region, the stage was determined to be III B(c-T3N3M0), and we initiated chemotherapy.The regimen was CBDCA plus PTX.The carboplatin dose area under the curve(AUC)was 4(100 mg at a glomerular filtration rate of 0)for the first course, AUC 5 for the second course, and AUC 6 for the third to sixth courses, and the PTX dose was 200mg/m2.Only mild adverse events were noted, and the patient achieved a partial response after 6 treatment courses.Only a few reports have described chemotherapies administered to patients with lung cancer on hemodialysis, and as such, evidence of useful drugs is not yet available.This makes it difficult to select the most appropriate treatment for such patients.We report our experience with this patient, with a relevant literature review.

A Case of Low-Grade Appendiceal Mucinous Neoplasm That Led to Surgery After 12 Years of No Treatment.

Low-grade appendiceal mucinous neoplasm (LAMN) is a relatively rare, non-invasive appendiceal tumor. We experienced a case of LAMN that led to surgery after 12 years of no treatment. Until now, LAMN has been reported to progress more slowly than other tumors, but there have been no reports of long-term follow-up of appendiceal tumors without treatment. Although the tumor had grown over the course of 12 years, there was no mixing or migration of other histological types, and it did not lead to pseudomyxoma peritonei. As this course is considered to be relatively rare, we report it along with a literature review.

Presence of cystic duct stone is a risk for postoperative retained stones in patients with acute cholecystitis.

PURPOSE: Retained stones (RS) in the common bile duct (CBD) are one of the major problems after laparoscopic cholecystectomy and usually require endoscopic treatment. However, few reports have investigated risk factors for the development of RS in the CBD. METHODS: A total of 325 patients with acute cholecystitis underwent laparoscopic cholecystectomy at our hospital between January 2013 and Jury 2021. Patient characteristics, including radiographic factors and perioperative outcomes, were reviewed, and perioperative factors predicting RS in the CBD were investigated. RESULTS: RS in the CBD were developed in 34 patients. All 34 patients were treated endoscopically. ASA-PS class 3 or more (p = 0.029, odds ratio = 2.601), subtotal cholecystectomy performance (p = 0.004, odds ratio = 3.783) and the presence of cystic duct stones (p < 0.001, odds ratio = 11.759) were found by logistic regression analysis to be independent risk factors for developing RS in the CBD. Cystic duct stones were preoperatively detected in 60 patients. Of these, 21 cases were not detected on magnetic resonance cholangiopancreatography (MRCP) but on CT, while 15 cases were not detected on CT but on MRCP. CONCLUSIONS: The presence of cystic duct stones on preoperative CT or MRCP is a crucial risk factor for developing RS in the CBD. Both CT and MRCP are useful to avoid overlooking cystic duct stones.

Safety and Feasibility of Laparoscopic Transabdominal Preperitoneal Hernia Repair for Octo- and Nonagenarians.

Background: The feasibility of laparoscopic hernia repair in octo- and nonagenarians has not been investigated in detail. The aim of this retrospective study was to evaluate the safety and feasibility of laparoscopic hernia repair in octo- and nonagenarians. Methods: This study included 607 patients who underwent transabdominal preperitoneal laparoscopic hernia repair at our hospital between April 2014 and October 2020. Patients were divided into an over 80 group (112 patients aged 80 years and older) and a control group (495 patients younger than 80 years). The clinical outcomes were compared between the groups. In addition, among patients aged 80 years and older, those who underwent elective laparoscopic hernia repair (laparoscopic group: 111 patients) were compared with patients who underwent elective open hernia repair during the same study period (open group: 79 patients). Results: The number of patients who underwent bilateral hernia repair was significantly larger in the over 80 group (26.7% versus 11.7%, P < .001). The incidence of postoperative complications was not significantly different between the over 80 group and the control group. Compared with open group, the number of patients who underwent bilateral hernia repair was significantly larger in the laparoscopic group (27.0% versus 2.5%, P < .001). The incidence of postoperative complications (2.7% versus 10.1%) and the incidence of readmission (0.9% versus 6.3%) were significantly greater in the open group. Conclusions: Laparoscopic hernia repair in octo- and nonagenarian patients yields safe and noninferior outcomes. Laparoscopic hernia repair in octo- and nonagenarian patients is considered more suitable for detecting and repairing contralateral hernias simultaneously.

Treatment of 1,4-dioxane-containing water using carriers immobilized with indigenous microorganisms in landfill leachate treatment sludge: A laboratory-scale reactor study.

1,4-Dioxane (DX) is a contaminant of emerging concern in aquatic environments, and is frequently found in landfill leachate. As a biological method applicable to landfill leachate treatment facilities, the feasibility of DX treatment using carriers immobilized with microorganisms indigenous to landfill leachate treatment sludge was explored through laboratory-scale reactor experiments by introducing carriers prepared via microorganism immobilization in the aeration tank of a leachate treatment facility. Three different carrier materials were used to immobilize microorganisms, and a model DX-containing water (10 mg/L) was treated under continuous feeding. Biological DX removal to < 0.5 mg/L was achieved using all carrier types, thereby adhering to the effluent standard for landfill leachate in Japan, which confirms the usefulness of the proposed method. However, weaker aeration and enhanced DX loading drastically impaired the DX removal performance depending on the carrier materials. This suggests the importance of carrier selection and control of the operational variables to ensure stable and effective DX removal. Microbial community analyses revealed that Pseudonocardia with thm genes may largely contribute to the initial oxidation of DX, irrespective of the carrier type, suggesting the importance of this population for the continuous treatment of low DX concentrations with mixed microbial consortia.

A case of indirect inguinal bladder hernia treated by laparoscopic hernia repair.

Inguinal bladder hernia is a rare clinical condition, and only a small number of reported cases have been treated by laparoscopic surgery. In the present case, the patient was a 78-year-old man who presented to our emergency department with a chief complaint of right inguinal bulge and pain. CT imaging revealed an incarcerated right inguinal hernia containing the small intestine and a portion of the urinary bladder. We performed manual reduction of the incarcerated intestine, and he was admitted to the surgical ward for follow-up. On the 19th day after discharge, recurrence of incarceration developed, and he was readmitted after manual reduction. A laparoscopic transabdominal preperitoneal repair was performed. After careful reduction of the protruding bladder from the hernial orifice, we repaired the right inguinal hernia with a mesh prosthesis. We experienced a rare case of right indirect inguinal bladder hernia that was treated successfully with laparoscopic repair.

Does early surgery imply a critical risk for patients with Grade III acute cholecystitis?

BACKGROUND: For patients with Grade III acute cholecystitis (AC), several factors have been proposed in the 2018 Tokyo guidelines as caution signs in performing early surgery. However, these factors have not been externally validated in detail. METHODS: This retrospective study examined 35 patients who had been diagnosed with Grade III AC and treated with laparoscopic cholecystectomy between January 2008 and July 2019. The patients were allocated into an early group (patients who underwent surgery within 7 days of admission, n = 28) and a delayed group (patients who underwent surgery at least 8 days after admission, n = 7). Comparisons were made between these groups. RESULTS: No patients died. Significantly more patients required a conversion to open surgery (0% vs 28.5%, P = .003) or conversion to subtotal cholecystectomy (25.0% vs 71.4%, P = .020) in the delayed group than in the early group, and the total length of postoperative stay was significantly longer in the delayed group (11.4 vs 27.2 days, P = .001). The presence of negative predictive factors or risk factors listed in the 2018 Tokyo guidelines was not associated with death or postoperative complications. CONCLUSIONS: Early surgery was considered appropriate and feasible for select patients who had Grade III AC and preoperative risk factors.

Emergency surgery versus elective surgery after reduction for patients with incarcerated groin hernias.

BACKGROUND: The feasibility and potential advantages of elective surgery after manual reduction of incarcerated hernia (IH) have not been investigated in detail. Therefore, the aim of this retrospective study was to compare perioperative outcomes of emergency surgery to those of elective surgery after reduction of IH. METHODS: A total of 112 patients were preoperatively diagnosed with IH between January 2010 and April 2019. Patients were divided into an emergency group (76 patients underwent emergency surgery: 21 patients received intestinal resection and 55 patients did not) and a reduction group (36 patients underwent elective surgery after reduction and none required intestinal resection). The outcomes between the groups were compared. A subgroup analysis was also performed on the patients who did not require intestinal resection. RESULTS: In patients who did not undergo intestinal resection, the post-operative length of stay was significantly shorter in the reduction group than in the emergency group (8.0 versus 4.3 days, P < 0.001). The percentage of mesh prosthesis cases was significantly higher in the reduction group (74.4% versus 100%, P = 0.001). The incidence of post-operative complications was significantly lower in the reduction group (45.4% versus 13.8%, P < 0.001). In all 112 patients, femoral hernia (P = 0.013, odds ratio = 4.76) and emergency surgery (P = 0.008, odds ratio = 4.49) were found to be independent risk factors for developing post-operative complications. CONCLUSIONS: Elective surgery after reduction showed more favourable outcomes in selected patients. Moreover, emergency surgery was an independent predictor for post-operative complications.

Laparoscopic vs open surgery for patients with strangulated small bowel obstruction.

BACKGROUND: Recent reports revealed that laparoscopic adhesiolysis is a feasible procedure for patients with adhesive small bowel obstruction (SBO). However, the feasibility of laparoscopic surgery for strangulated SBO has not been investigated in detail. METHODS: Ninety-six patients who underwent surgery for strangulated SBO between April 2008 and September 2019 were included. Of these, 49 patients were intended to undergo laparoscopic surgery, while the other 47 underwent open surgery from the first. Comparisons were made between the patients who underwent laparoscopic and open surgery in the patients with intestinal resection and without resection, respectively. RESULTS: In the resection group, eight patients (50.0%) who underwent laparoscopic surgery required conversion to open surgery. Perioperative outcomes were not statistically different between laparoscopic and open surgery except for postoperative use of continuous infusion of an analgesic agent or epidural anesthesia (P = .008). In the non-resection group, five patients (15.1%) who underwent laparoscopic surgery required conversion. Time from surgery to ingestion (P = .025) and postoperative use of continuous infusion of an analgesic agent or epidural anesthesia (P < .001) were significantly favorable in the laparoscopic group. In the patients who underwent laparoscopic surgery, white blood cell count was >12 000/µL (P = .024, odds ratio = 7.569) and intestinal resection (P = .026, odds ratio = 5.19) were found by logistic regression analysis to be independent risk factors for conversion to open. CONCLUSIONS: Laparoscopic surgery yields superior outcomes in patients without a requirement of intestinal resection. Laparoscopic surgery was considered as a first-choice strategy in selected patients with strangulated SBO.

Outcomes of early versus delayed laparoscopic cholecystectomy for acute cholecystitis performed at a single institution.

INTRODUCTION: Debate continues regarding the clinical outcomes of early laparoscopic cholecystectomy (ELC) versus delayed laparoscopic cholecystectomy (DLC) for acute cholecystitis (AC). The aim of this retrospective study was to compare clinical outcomes of ELC and DLC. METHODS: This study consisted of 465 patients who had undergone laparoscopic cholecystectomy for AC between January 2000 and February 2017. Patients were divided between an ELC group (patients who underwent laparoscopic cholecystectomy within 6 days of symptom onset, n = 288) and a DLC group (patients who underwent laparoscopic cholecystectomy at least 7 days from symptom onset, n = 177), and clinical outcomes were compared. RESULTS: Operation time (105 vs 124 min), length of postoperative hospital stay (4 vs 4 days), conversion rate (1.3% vs 10.7%), bile leak (0.3% vs 3.3%), residual calculus (2.4% vs 6.7%), and readmission (1.0% vs 6.7%) were significantly better in the ELC group. A history of upper abdominal surgery, grade II or grade III AC, preoperative percutaneous transhepatic gallbladder drainage, and time between symptom onset and surgery of more than 7 days were independent risk factors for conversion. CONCLUSIONS: ELC for AC yields more favorable clinical outcomes than DLC.

Is postponed laparoscopic cholecystectomy justified for acute cholecystitis appearing early after onset?

INTRODUCTION: Early laparoscopic cholecystectomy (ELC) is considered the standard treatment for acute cholecystitis for patients who can tolerate surgery. The ideal time for performing ELC is reported to be 72 h from onset. However, many patients undergo surgery on or after the fourth day from onset, even if they presented early after onset. A few reports have investigated the feasibility and disadvantages of this so-called "postponed laparoscopic cholecystectomy" (PLC). METHODS: This study consisted of 215 patients who had undergone laparoscopic cholecystectomy for acute cholecystitis within 6 days of onset between July 2006 and December 2017. Patients were divided into an ELC group (patients who underwent LC within 3 days of symptom onset, n = 172) and a PLC group (patients who underwent LC 4-6 days from symptom onset and on or after 3 days from admission, n = 43). Comparisons were made between these groups. RESULTS: Perioperative outcomes between the PLC and ELC groups were not significantly different, except for the requirement of subtotal cholecystectomy (SC) (16.2% vs 5.2%, P = 0.013). In the PLC group, persistent fever after admission was significantly associated with the need for SC (P = 0.036). CONCLUSIONS: PLC for acute cholecystitis performed within 6 days of onset gave acceptable perioperative outcomes, except for an increased requirement for SC. Surgeons should keep in mind that PLC may increase the need for SC. A persistent fever after admission may be a risk factor for SC in the PLC group.