Predicting factors for the diagnosis of gangrene acute cholecystitis.

Background: Gangrenous cholecystitis (GC) must be promptly treated for its high morbimortality. The object of our study is to identify clinical, laboratory or ultrasound factors that might us diagnose GC. Method: A Retrospective cohort study is devised including all patients admitted to Hospital de Laredo (Cantabria, Spain) between 2015 and 2017 with the diagnose of acute cholecystitis and having been operated. Patients were classified in two groups according to pathology: GC and non-GC. We compared their demographics characteristics, comorbidities, laboratory parameters and ultrasound findings. Results: A total of 115 patients were operated, of whom 32 had CG and 83 CNG. Neutrophil-to-lymphocyte ratio and C-reactive protein (CRP) showed significantly increased levels in GC group (p = 0.042) and CRP (p < 0.0001). To CRP showed an area under the ROC curve of 0.872 (95% confidence interval: 0.797-0.946). Acalculous cholecystitis was significantly associated to GC (24.1 vs. 7%; p < 0.005). In the multivariate analysis only the CPR showed as a predictive factor. A cutting point of CRP at 15.25 mg/dl, that had high sensibility (90.6%) and high negative predictive value (95%). Conclusion: CRP helped identify patients with CG to indicate early surgical intervention.

Antecedentes: La colecistitis aguda gangrenosa (CG) debe tratarse precozmente por su alto riesgo de morbimortalidad. Objetivo: Identificar factores clínicos, analíticos o ecográficos que permitan diagnosticar CG preoperatoriamente. Método: Estudio de cohorte retrospectiva en el Hospital de Laredo (Cantabria, España), entre 2015 y 2017, de pacientes con diagnóstico de colecistitis aguda que hayan sido intervenidos. Se clasificó a los pacientes en dos grupos según el diagnóstico anatomopatológico: CG y colecistitis no gangrenosa (CNG). Se compararon las características demográficas, la comorbilidad, los datos analíticos y los datos ecográficos. Resultados: Fueron operados 115 pacientes, de los cuales 32 tenían CG y 83 tenían CNG. Los pacientes con CG muestran unos valores más altos de índice de neutrófilos/linfocitos (p = 0.042) y de proteína C reactiva (PCR) (p < 0.0001). La colecistitis alitiásica se asoció con mas frecuencia a la CG (24.1 vs. 7.0%; p < 0.005). En el estudio multivariable, solo la PCR se muestra significativa. La PCR mostró un área bajo la curva ROC de 0.872, (intervalo de confianza del 95%: 0.797-0.946). Un punto de corte de PCR de 15.25 mg/dl tuvo una alta sensibilidad (90.6%) y un alto valor predictivo negativo (95%). Conclusión: La PCR ayuda a identificar a los pacientes con CG para indicar una intervención quirúrgica precoz.

Risk factors for unplanned admission after ambulatory laparoscopic cholecystectomy.

INTRODUCTION: Laparoscopic cholecystectomy (LC) performed as day-case (DC) surgery has more unexpected admissions than most day-case procedures. We revised the literature about factors associated with unexpected admissions in LC as well as reconversion to open laparotomy and we investigate these factors in our series. METHODS: Retrospective cohort study, period 1999-2013 (511 cases). We study factors that in the literature have been associated with unpredicted admissions in DC or reconversion. RESULTS: In the period 1999-2013 511 patients were included (166 male/345 female), median age 53 years. Surgical indication was: Symptomatic cholelithiasis (386 cases), previous episode of cholecystitis (52 cases), biliary pancreatitis (47 cases) and ERCP for common duct stones (11 cases). 70% were discharged on the same day, 13% overnight and 17% stayed longer than 24 hours. Reconversion rate was 3.3%, readmission rate 2.8% and reoperation rate 1.2%. Bivariant study showed significant statistical association with age 65 or, ASA classification II or higher, previous admission for acute cholecystitis and logistic regression showed them to be significantly associated with readmission (sensibility: 10.6%, specificity: 98.6%, R2 coefficient: 0.046-0.066). CONCLUSIONS: The model's predictive capacity is null. We think that factors other than indications are responsible for the high proportion of failure showed by LC in DC.

[Intraabdominal septic complications in laparoscopic appendectomy: description of a possible new intraabdominal septic complication specific to laparoscopic appendectomy]. / Complicaciones sépticas intraabdominales tras apendicectomía laparoscópica: descripción de una posible nueva complicación específica de la apendicectomía laparoscópica.

BACKGROUND: Controversies about laparoscopic appendectomy (LA) focus mainly on the high intraabdominal infection rate. In 2005, Serour et al described a distinct complication specific to LA, termed "postlaparoscopic appendectomy complication" (PLAC). This complication is an intraabdominal infection, without abscess formation, which develops after laparoscopic appendectomy for non-complicated appendicitis (simple, phlegmonous, or normal appendix) and is observed in patients discharged after an uneventful postoperative period. We reviewed our case series to establish our intraabdominal infection rate in appendectomy and to identify cases similar to this newly described complication. MATERIAL AND METHOD: We retrospectively reviewed 651 clinical records of appendectomy performed by the laparoscopic (LA) or open approach (OA) over an 11-year period in our hospital. The criteria for a diagnosis of PLAC were as follows: a) clinical criteria: uneventful appendectomy (OA or LA), asymptomatic status on hospital discharge, and onset of right lower quadrant pain, fever, and elevated white blood cell count after discharge; b) pathologic criteria: non-complicated appendicitis (gangrenous or perforated appendicitis were excluded), and c) ultrasound scan showing characteristic features. RESULTS: A total of 432 LA and 219 OA were reviewed. The conversion rate was 11.1%. The main complications (intention-to-treat analysis) were wound infection (6.3% in LA versus 7.8% in OA) and intraabdominal infection (4.2% in LA versus 2.3% in OA). Four out of 18 cases of intraabdominal infection after LA fulfilled PLAC criteria, representing 1% of all LA and 22% of intraabdominal infections after LA. CONCLUSIONS: LA seems to be associated with an increased risk of intraabdominal infection. Our results suggest that a distinct form of intraabdominal infection specific to laparoscopic appendectomy may exist.