Significance of Hepatectomy in Patients Diagnosed With T2 Gallbladder Cancer.

BACKGROUND: A radical surgery is mandatory for advanced gallbladder cancer. However, the appropriate surgical procedure for T2 gallbladder cancer remains controversial because of the difficulty associated with accurate preoperative diagnosis. The aims of the study were to analyze the clinicopathologic features of patients diagnosed with T2 gallbladder cancer and to identify the survival benefit of hepatectomy for such cases. METHODS: Eighty-four patients, who were diagnosed with pT2 gallbladder cancer from January 1995 to December 2012, were included in this study. Patients were divided into nonhepatectomy and hepatectomy groups. RESULTS: Partial hepatectomies were performed in 36 of 84 patients (42.9%). A significant difference in age was observed between the nonhepatectomy and hepatectomy groups (P=0.027). However, no significant differences were observed in sex, tumor size, or pathologic outcome between the 2 groups. No significant difference in survival rate was observed between the 2 groups (5-year survival rate, 60.4% vs. 66.6%). Of the 23 patients who underwent cholecystectomy, 11 (47.8%) were treated with extended surgery as a second operation with curative intent. No remnant tumor was detected at the hepatectomy site in any patient. However, the second operation revealed lymph node metastasis in 2 patients (18.2%). In terms of recurrence, 8 patients (34.7%) had hepatic metastasis. However, the metastatic tumor was away from the resection margin. No significant difference in survival rate was found between the peritoneal and the hepatic side groups (5-year survival rate, 62.5% vs. 73.0%). CONCLUSIONS: Hepatectomy is not associated with a better survival rate after surgery for T2 gallbladder cancer. Moreover, no recurrence near the gallbladder fossa is observed. In case of T2 gallbladder cancer confirmed by first operation, however, a second operation should be recommended on the basis of accurate nodal staging and additional therapy.

Effect of clinical signs, endocrinopathies, timing of surgery, hyperlipidemia, and hyperbilirubinemia on outcome in dogs with gallbladder mucocele.

Gallbladder mucocele (GBM) is a common extra-hepatic biliary syndrome in dogs with death rates ranging from 7 to 45%. Therefore, the aim of this study was to identify the association of survival with variables that could be utilized to improve clinical decisions. A total of 1194 dogs with a gross and histopathological diagnosis of GBM were included from 41 veterinary referral hospitals in this retrospective study. Dogs with GBM that demonstrated abnormal clinical signs had significantly greater odds of death than subclinical dogs in a univariable analysis (OR, 4.2; 95% CI, 2.14-8.23; P<0.001). The multivariable model indicated that categorical variables including owner recognition of jaundice (OR, 2.12; 95% CI, 1.19-3.77; P=0.011), concurrent hyperadrenocorticism (OR 1.94; 95% CI, 1.08-3.47; P=0.026), and Pomeranian breed (OR, 2.46; 95% CI 1.10-5.50; P=0.029) were associated with increased odds of death, and vomiting was associated with decreased odds of death (OR, 0.48; 95% CI, 0.30-0.72; P=0.001). Continuous variables in the multivariable model, total serum/plasma bilirubin concentration (OR, 1.03; 95% CI, 1.01-1.04; P<0.001) and age (OR, 1.17; 95% CI, 1.08-1.26; P<0.001), were associated with increased odds of death. The clinical utility of total serum/plasma bilirubin concentration as a biomarker to predict death was poor with a sensitivity of 0.61 (95% CI, 0.54-0.69) and a specificity of 0.63 (95% CI, 0.59-0.66). This study identified several prognostic variables in dogs with GBM including total serum/plasma bilirubin concentration, age, clinical signs, concurrent hyperadrenocorticism, and the Pomeranian breed. The presence of hypothyroidism or diabetes mellitus did not impact outcome in this study.

Outcome of elective cholecystectomy for the treatment of gallbladder disease in dogs.

OBJECTIVE To determine mortality rates for dogs undergoing cholecystectomy and variables associated with failure to survive to hospital discharge. DESIGN Retrospective cohort study. ANIMALS 70 dogs that underwent cholecystectomy for biliary tract disease at a companion animal referral hospital from 2009 through 2015. PROCEDURES Medical records of dogs were reviewed and data collected; dogs with biliary diversion surgery were excluded. Included dogs were grouped by whether cholecystectomy had been elective (ie, dogs with no or mild clinical signs, with no indication of biliary obstruction, or that initially underwent surgery for a different procedure) or nonelective (ie, dogs with icterus and questionable patency of the biliary system). Mortality rates (proportions of dogs that failed to survive to hospital discharge) were compared between various groups. RESULTS 45 (64%) dogs were included in the elective group and 25 (36%) in the nonelective group. Group mortality rates were 2% (1/45) and 20% (5/25), respectively, and differed significantly. Overall mortality rate was 9% (6/70). Serum albumin concentration was significantly lower and serum alanine aminotransferase activity and total bilirubin concentration were significantly higher in nonsurviving versus surviving dogs. Dogs with vomiting, signs of lethargy or anorexia, icterus, or azotemia were less likely to survive than dogs without these signs. CONCLUSIONS AND CLINICAL RELEVANCE Dogs that underwent elective cholecystectomy had a considerably lower mortality rate than previously reported. Elective cholecystectomy may be an appropriate recommendation for dogs with early signs of biliary disease to avoid the greater mortality rate associated with more advanced disease and nonelective cholecystectomy.

Gallbladder Mucocele: Variables Associated with Outcome and the Utility of Ultrasonography to Identify Gallbladder Rupture in 219 Dogs (2007-2016).

BACKGROUND: Gallbladder mucocele (GBM) is an increasingly recognized extrahepatic biliary disease in dogs. OBJECTIVES: To investigate cases of GBM and identify variables associated with survival and the sensitivity and specificity of ultrasonography to identify gallbladder rupture. ANIMALS: Two hundred and nineteen client-owned dogs with GBM. METHODS: Multicenter, retrospective study of dogs with GBM, presented from January 2007 to November 2016 to 6 academic veterinary hospitals in the United States. Interrogation of hospital databases identified all cases with the inclusion criteria of a gross and histopathologic diagnosis of GBM after cholecystectomy and intraoperative bacteriologic cultures of at least 1 of the following: gallbladder wall, gallbladder contents, or abdominal effusion. RESULTS: Two hundred and nineteen dogs fulfilled the inclusion criteria. Dogs with GBM and gallbladder rupture with bile peritonitis at the time of surgery were 2.7 times more likely to die than dogs without gallbladder rupture and bile peritonitis (P = 0.001; 95% confidence interval [CI], 1.50-4.68; n = 41). No significant associations were identified between survival and positive bacteriologic cultures, antibiotic administration, or time (days) from ultrasonographic identification of GBM to the time of surgery. The sensitivity, specificity, positive, and negative likelihood ratios for ultrasonographic identification of gallbladder rupture were 56.1% (95% CI, 39.9-71.2), 91.7% (95% CI, 85.3-95.6), 6.74, and 0.44, respectively. CONCLUSION AND CLINICAL IMPORTANCE: Dogs in our study with GBM and intraoperative evidence of gallbladder rupture and bile peritonitis had a significantly higher risk of death. Additionally, abdominal ultrasonography had low sensitivity for identification of gallbladder rupture.

Subtotal cholecystectomy for the hostile gallbladder: failure to control the cystic duct results in significant morbidity.

BACKGROUND: Outcomes following the inability to control the cystic duct due to a hostile triangle of Calot during cholecystectomy remain unknown. The purpose of this study was to analyze the safety and efficacy of subtotal cholecystectomy, with attention to the necessity for secondary interventions. METHODS: Sixteen thousand five hundred ninety six cholecystectomies from January 2002 to August 2014 were reviewed, identifying patients managed with subtotal cholecystectomy, defined as the inability to isolate/transect the cystic duct. After propensity matching, we investigated surgical indications, perioperative outcomes, and the necessity for secondary ERCP, percutaneous drainage, and completion cholecystectomy. RESULTS: 65 (0.39%) patients underwent subtotal cholecystectomy; 54 (83.1%) began laparoscopically, of which 30 (55.6%) required conversion to laparotomy. Subtotal cholecystectomy, performed more frequently for acute cholecystitis (70.8% vs 34.6%), was associated with extended hospitalizations (4 d vs 2 d) and frequent surgical site infections (20% vs 4.6%). 25 (38.5%) subtotal cholecystectomy patients required ≥1 secondary intervention, and compared to standard cholecystectomy, underwent higher rates postoperative ERCP (30.8% vs 5.4%), percutaneous drainage (9.2% vs 1.5%), and completion cholecystectomy (6.2% vs 0%) [all P < 0.05]. DISCUSSION: Subtotal cholecystectomy fails to control the cystic duct, resulting in significant morbidity. Most do not require completion cholecystectomy; however, patients demand close observation and, frequently, secondary interventions.

Evaluating cumulative and annual surgeon volume in laparoscopic cholecystectomy.

BACKGROUND: Although there is a large body of published data demonstrating improved outcomes for complex operations when performed by high-volume surgeons at high-volume hospitals, the literature is mixed regarding whether this same relationship applies in less complex and more common surgeries such as laparoscopic cholecystectomy. METHODS: This study utilized the New York State Department of Health Statewide Planning and Research Cooperative System database to identify patients undergoing laparoscopic cholecystectomy for acute and chronic biliary pathology. Rates of perioperative outcomes were compared among 4 distinct categories of surgeons based on surgeon annual and cumulative volume: low cumulative/low annual, low cumulative/high annual, high cumulative/low annual, and high cumulative/high annual. RESULTS: A total of 150,938 patients undergoing operation by 3,306 surgeons at 250 hospitals across New York state were included for analysis from 2000-2014. There was no difference in adjusted 30-day in-hospital mortality, major events, procedural complications, bile duct injury, or reintervention rates between the 4 groups of surgeons. However, patients undergoing operation by high cumulative/high annual volume surgeons were less likely to experience 30-day readmission, prolonged duration of stay, and high charges when compared with low cumulative/low annual volume surgeons. CONCLUSION: In New York state, increased surgeon annual and cumulative volume predicts lower rates of 30-day readmission, prolonged duration of stay, and high charges in laparoscopic cholecystectomy, but has no effect on in-hospital mortality, major events, bile duct injury, procedural complications, or reintervention. There is no evidence to support regionalization of this procedure as operative outcomes are comparable even in less experienced hands.

Intraoperative baseline oxygen consumption as a prognostic factor in emergency open abdominal surgery.

BACKGROUND: A new anesthesia system, the E-CAIOVX (GE Healthcare) enables the continuous monitoring of oxygen consumption (VO2) and carbon dioxide elimination (VCO2) during the surgical operation. The aim of this study was to evaluate the prognostic role of intraoperative baseline VO2 and VCO2 in an emergency open abdominal operation. METHODS: A total of 103 patients who had an emergency open abdominal operation were enrolled in the study. VO2 and VCO2 were continuously measured from the induction of anesthesia to the end of the operation. RESULTS: There were significant correlations between intraoperative baseline VO2 and body surface area (BSA; P < .001, r = 0.68), VO2 and tidal volume (P < .001, r = 0.59), and VO2 and baseline body temperature (P < .0001, r = 0.49). Also, there were significant correlations between intraoperative baseline VCO2 and BSA (P < .001, r = 0.70), VCO2 and tidal volume (P < .001, r = 0.70), and VCO2 and body temperature (P < .001, r = 0.41). Fifteen (14.6%) of the 103 patients died within 4 months after the operation without having been discharged from hospital. Baseline VO2/BSA was higher in surviving patients (123.7 ± 23.6 mL/min ∙ m(2)) than the deceased (103.8 ± 15.6 mL/min ∙ m(2); P = .002). There was no significant difference in baseline VCO2/BSA levels between surviving (106.2 ± 20.1 mL/min ∙ m(2)) and deceased patients (99.4 ± 21.4 mL/min ∙ m(2)). In multivariate analysis, baseline body temperature lower than 36.2°C (P = .02), serum albumin less than 3.0 g/dL (P = .002), and baseline VO2/BSA less than 111.9 mL/min ∙ m(2) (P = .03) were independent factors. CONCLUSION: Baseline low VO2/BSA less than 111.9 mL/min ∙ m(2) was one of the poor predictors for the prognosis of an emergency open abdominal surgery.

Relationship of hepatic fibrosis, cirrhosis, and mortality with cholecystectomy in patients with hepatitis C virus infection.

OBJECTIVES: Studies have suggested that cholecystectomy is a risk factor for nonalcoholic fatty liver disease, but it is not known whether cholecystectomy is a risk factor for the progression of other chronic liver diseases such as hepatitis C virus (HCV) infection. The aim of this study was to assess whether cholecystectomy is associated with an increase in fibrosis, cirrhosis, and cirrhosis-related complications in patients with chronic HCV infection. METHODS: Among a total of 3989 HCV-positive patients at the VA North Texas Health Care System, we retrospectively reviewed the records of 88 patients who had undergone cholecystectomy between 1998 and 2013, followed up for a median of 4.9 years. We compared the outcomes of these patients with those of two age-matched, race-matched, and sex-matched cohorts: a cohort consisting of 129 HCV-positive patients without gallbladder disease (GBD) and a second cohort consisting of 178 HCV-positive patients with GBD who had not undergone cholecystectomy. Demographics, presence of metabolic syndrome, alcohol use, laboratory data, and clinical progression of liver disease were compared at study entry and 5 years later. RESULTS: Controlling for multiple factors associated with increase in liver fibrosis, analyses confirmed that a there was an increase in the proportion of patients who developed cirrhosis [odds ratio (OR)=3.24, 95% confidence interval (CI) 1.57-6.68, P=0.001] and ascites (OR=3.01, 95% CI 1.14-7.97, P=0.026) as well as in the incidence of death (OR=6.29, 95% CI 2.13-18.59, P=0.001) 5 years after cohort entry among HCV-positive patients with cholecystectomy compared with HCV-positive controls. The HCV-positive patient group with previous cholecystectomy showed an increased incidence of cirrhosis (OR=2.43, 95% CI 1.34-4.41, P=0.004), hepatocellular carcinoma (OR=2.85, 95% CI 1.11-7.36, P=0.030), and death (OR=3.31, 95% CI 1.50-7.28, P=0.003) 5 years after cohort entry compared with HCV-positive controls with GBD who had not undergone cholecystectomy. CONCLUSION: Cholecystectomy among HCV-positive patients is associated an increased incidence of fibrosis, cirrhosis, and its complications (ascites, hepatocellular carcinoma, and death) compared with HCV-positive controls and HCV-positive patients with GBD who have not undergone cholecystectomy.

Less Surgical Experience Has no Impact on Mortality and Morbidity After Laparoscopic Cholecystectomy: A Prospective Cohort Analysis.

BACKGROUND: The number of cholecystectomies required to be fully educated as a surgeon has not yet been established. The European Association for Endoscopic Surgery, however, claims that inadequate experience is a risk factor for bile duct injury. The objective was to investigate surgical experience as a risk factor after laparoscopic cholecystectomy. METHODS: A prospective cohort study using the Danish Cholecystectomy Database to generate a cohort including adults treated with laparoscopic cholecystectomy from 2006 to 2011. The relationship between surgeons' level of experience and outcomes were evaluated. RESULTS: Surgical inexperience was not a risk factor for mortality and morbidity. The risk of conversion was however higher when the patients were operated by more experienced surgeons with an odds ratio of 1.80 (95% confidence interval, 1.51-2.14). Surgical inexperience was not a risk factor for bile duct injury. CONCLUSION: We found that low surgical experience did not by itself increase the risk of mortality or morbidity.

Gallbladder tumor and pseudotumor: Diagnosis and management.

The most common gallbladder disease, by far, is cholecystolithiasis. Nevertheless, the discovery of abnormal thickening of the gallbladder wall or a tumorous lesion (with or without gallstones), is a frequent problem. The physician who confronts this finding must be aware of the various lesions to be considered in the differential diagnosis, whether neoplastic or pseudotumoral, epithelial or not, benign or malignant. Because of the particularly grim prognosis of gallbladder cancer, especially when discovered at a late stage, it is especially important to focus on the potential for malignant degeneration of any gallbladder lesion. Imaging plays an important role in distinguishing these lesions; ultrasound remains the key diagnostic tool for gallbladder disease, but other modalities including CT and MRI may help to characterize these lesions. The resulting treatment strategies vary widely depending on the risk of malignancy. A wide and extensive resection is recommended for malignant lesions; prophylactic cholecystectomy is recommended for lesions at risk for malignant degeneration while observation is indicated for purely benign lesions.

Does concomitant cholecystectomy at time of Roux-en-Y gastric bypass impact adverse operative outcomes?

BACKGROUND: We hypothesized that patients undergoing Roux-en-Y gastric bypass (RYGB) with concomitant cholecystectomy (RYGB + C) would be at greater risk for adverse events compared to patients undergoing RYGB alone. METHODS: Patients who underwent a RYGB were identified in the 2005-2009 American College of Surgeons National Surgical Quality Improvement Program Database. Multivariate logistic regression with adjustment for confounding variables was utilized to identify risk factors for mortality at 30 days, major adverse events, and prolonged length of stay (PLOS). RESULTS: We identified 32,946 patients who underwent RYGB; of these, 1,731 (5.2%) underwent RYGB + C. Overall, RYGB + C was a risk factor for predicting major adverse events following laparoscopic but not open procedures. Regardless of approach, PLOS was more common among RYGB + C patients following adjustment. Overall mortality at 30 days was low and did not vary with concomitant cholecystectomy following adjustment. CONCLUSIONS: The risk for major adverse events is significantly greater for RYGB + C patients following laparoscopic procedures, and the risk for PLOS is greater for RYGB + C patients following both open and laparoscopic procedures. The short-term risks identified in this study can assist in decision-making when considering concomitant cholecystectomy at the time of RYGB.

A population-based analysis of the morbidity and mortality of gallbladder surgery in the elderly.

BACKGROUND: Historically, emergency gallbladder surgery in elderly patients has been associated with high rates of morbidity and mortality. Recent studies have described much lower complication rates that may still overestimate morbidity. The purpose of this study was to determine the true population morbidity and mortality rates after gallbladder surgery in the elderly. METHODS: All elderly patients (defined as age 65 years or older) admitted to the hospital with a principle diagnosis related to benign gallbladder disease in the Province of Manitoba from January 1, 1995 to December 31, 2008 were identified by using administrative claims data. Outcomes after emergency gallbladder surgery, including complication rates and their predictors, were compared with outcomes after elective surgery and after nonoperative treatment for gallbladder-related hospital admissions. RESULTS: A total of 9,936 patients were included: 2,355 had emergency or urgent surgery and 4,901 had elective procedures, whereas 2,680 patients were treated without surgery. Emergency gallbladder surgery was associated with a mortality rate of 0.7 %, compared with 1.6 % for elective cases and 5.6 % for patients treated nonoperatively. Complication rates were 16.2, 17.7, and 25 % respectively. Independent predictors of 30-day mortality were age, male gender, increasing comorbidity, surgeon experience, and surgical treatment. CONCLUSIONS: Emergency gallbladder surgery in the elderly was not associated with higher mortality or complication rate compared with the elective setting. Elderly patients with gallbladder-related emergencies should be offered urgent surgery when feasible.

Surgery for acute gallbladder disease in Sweden 1989-2006--a register study.

OBJECTIVE: Since early 1970s, prospective randomized controlled trials have emphasized the advantages of early cholecystectomy in patients with acute cholecystitis, compared to elective delayed cholecystectomy. The aim of this investigation was to study surgery for acute gallbladder disease in Sweden during a 15-year period when open cholecystectomy was replaced by a laparoscopic procedure. MATERIAL AND METHODS: Data from the Swedish National Patient Register and the Cause of Death Register 1988-2006 comprising hospital stays with a primary diagnosis of gallbladder/gallstone disease in Sweden were retrieved. Patients were analyzed with reference to timing of cholecystectomy, length of hospital stay, and mortality. RESULTS: Emergency cholecystectomy at index (first) admission or at readmission within 2 years of index admission was performed in 32.2% and 6.1% of patients, respectively. Elective cholecystectomy within 2 years of index admission was performed in 20.3% patients, whereas 41.3% of all patients did not undergo cholecystectomy within 2 years. Standardized mortality ratio did not significantly change during the audit period. Total hospital stay (days at index stay and subsequent stay(s) for biliary diagnoses within 2 years) was shorter for patients who had emergency cholecystectomy at first admission compared to patients with later or no cholecystectomy within 2 years. CONCLUSIONS: Around 30% of patients with acute gallbladder disease were operated with cholecystectomy during the first admission with no time trend from 1990 through 2004. A total of 40% of patients with acute gallbladder disease were not cholecystectomized within 2 years. Analysis of outcome of long-term conservative treatment is warranted.

Laparoscopic cholecystectomy in the cirrhotic patient: predictors of outcome.

BACKGROUND: We sought to determine the outcome predictors of 94 cirrhotic patients undergoing laparoscopic cholecystectomy (LC). METHODS: We performed a single-center, retrospective review of cirrhotic patients undergoing LC for symptomatic gallbladder disease. Statistical analysis was completed using the Chi-square, Wilcoxon rank-sum, and Student t tests as appropriate. RESULTS: Ninety-four procedures were completed. The median Child-Turcotte-Pugh (CTP) score was 6 (range, 5-12), and the average Model for End-Stage Liver Disease (MELD) score was 11 ± 5. Hepatitis C was the most common etiology of liver disease (50%) followed by Laennec's cirrhosis (22%). The average length of stay was 2.6 ± 4.3 days; 21% were outpatient procedures. The conversion rate was 11%. Conversion risk factors were decreased serum albumin, increased MELD score, and blood loss. Morbidity occurred in 32 patients. Predictors of morbidity were decreases in serum albumin, increases in International Normalized Ratio (INR) and CTP score, and the number of intraoperative red blood cell transfusions. Mortality occurred in 4 patients. Increased INR, CTP score, CTP class, the number of intraoperative blood and platelet transfusions were predictors of mortality. CONCLUSION: LC can be safely performed in cirrhotic patients with appropriate patient selection. Liver synthetic function, operative blood loss, transfusion requirement, CTP, and MELD scores may be used to predict outcomes in these patients.

Laparoscopic cholecystectomy is the preferred approach in cirrhosis: a nationwide, population-based study.

BACKGROUND/AIM: To assess the impact of open versus laparoscopic surgery in cirrhotic patients undergoing a cholecystectomy using the Nationwide Inpatient Sample (NIS). METHODS: All patients with cirrhosis who underwent a cholecystectomy (open or laparoscopic) between 2003 and 2006 were queried from the NIS. Associated complications including infection, transfusion, reoperation, liver failure and mortality were determined. RESULTS: A total of 3240 patients with cirrhosis underwent a cholecystectomy: 383 patients underwent an open cholecystectomy (OC) whereas 2857 patients underwent a laparoscopic cholecystectomy (LC), which included 412 patients converted (LCC) from a LC to an OC. Post-operative infection was higher in OC as opposed to a laparoscopic cholecystectomy (TLC) or LCC (3.5% versus 0.7% versus 0.2%, P < 0.0001). The need for a blood transfusion was significantly higher in the OC and LCC groups as compared with the TLC group (19.2% versus 14.4% versus 6.2%, P < 0.0001). Reoperation was more frequent after OC or LCC versus TLC (1.5% versus 2.5% versus 0.8%, P = 0.007). In-hospital mortality was higher after OC as compared with TLC and LCC (8.3% versus 1.3% versus 1.4%, P < 0.0001). CONCLUSION: Patients with cirrhosis have increased in-hospital morbidity and mortality after an open as opposed to a laparoscopic or conversion to an open cholecystectomy. LC should be the preferred initial approach in cirrhotic patients.

Gallbladder perforation: case series and systematic review.

BACKGROUND: Gallbladder perforation is a serious complication of acute cholecystitis. Its management has evolved considerably since its classification by Niemeier in 1934. This review summarises the evidence surrounding the natural progression of this condition and potential problems with Niemeier's classification, and proposes a management algorithm for the more complex type II perforation. METHODS: Data from a retrospective case series and a systematic review were combined. The case series included all patients with gallbladder perforations from 2004 to 2008 at a British teaching hospital. The systematic review searched for gallbladder perforation using the MEDLINE, Embase, Web of Science and Cochrane Library (2011 Issue 4) databases, as well as recent conference abstracts. The outcome data were analysed using SPSS version 15. No adjustments were made for multiple testing. RESULTS: 198 patients (including 19 patients from the present series) with a mean age of 62.1+/-9.7 years and male gender proportion of 55.4% (range 33.3-76.7%) were included. The most common gallbladder perforations were type II (median 46.2%, range 7.4-83.3%), followed by type I (median 40.6%, range 16.7-70.0%) and type III (median 10.1%, range 0-48.1%). Perforation was associated with cholelithiasis in 86.6% (range 78.9-90.6%) of patients, and the overall median mortality rate was 10.8% (range 0-12.5%). Male gender was weakly associated with mortality (p = 0.089) but age (p = 0.877) and cholelithiasis (p = 0.425) were not. Mortality did not vary significantly with perforation type. CONCLUSIONS: Gallbladder perforation should be reported according to the original Neimeier's classification to avoid heterogeneity in data (e.g. varying rates of perforation types). The algorithm proposed in this study aims to guide the management of complex type II gallbladder perforations to minimise subsequent morbidity and mortality.

Cholecystectomy in the very elderly--is 90 the new 70?

BACKGROUND: Nonagenarians are the fastest growing sector of population across Western Europe. Although prevalence of gallstone disease is high, elective cholecystectomy is still controversial in this age group. METHODS: A retrospective chart review was conducted of cholecystectomies done in patients over 90 years of age at our institution between 2004 and December 2009. During this period, a total of 3,009 cholecystectomies were performed on patients of all ages. Data collected included demographics, patient comorbidities, indications for surgery, type of surgery performed, intraoperative findings, histology, perioperative morbidity and mortality. RESULTS: Twenty-two nonagenarians (18 females) underwent cholecystectomy during the study period. Of these patients, 19 patients (86%) had diabetes, 16 (73%) had hypertension, and 10 (45%) had coronary artery disease. Twenty patients (91%) underwent an emergency procedure. In two patients, cholecystectomy was indicated for non-resolving pain after attempted conservative therapy, only two patients were operated electively. Laparoscopic cholecystectomy was attempted in 13 patients (59%), 3 patients needed a conversion, and 9 patients (41%) considered unfit to undergo a laparoscopic approach had an open procedure. Mean operation time was 83 min. Histology showed gangrenous cholecystitis in six (27%) patients. The mean length of stay was 10 days (4-23 days). Two patients (8.3%) required intensive care following surgery. There were no common bile duct injuries, one patient had a cystic stump leak. One patient died in the postoperative period (4.6%). All patients with an emergency operation were classified as at least ASA III. Conversion rate, percentage of open procedures, percentage of advanced histology, ASA score, and hospital stay were significantly higher when compared to all patients. CONCLUSION: Our study demonstrates that in unselected nonagenarians,cholecystectomy is safe with acceptable perioperative morbidity and mortality even as an emergency procedure. However, our data also suggests that cholecystitis appears to be a neglected condition in this age group.

Expression of ezrin, HGF and c-met and its clinicopathological significance in the benign and malignant lesions of the gallbladder.

BACKGROUND/AIMS: To investigate the expression of ezrin, HGF and c-met in the benign and malignant lesions of the gallbladder. METHODOLOGY: Ezrin, HGF and c-met expression was detected by immunohistochemistry. RESULTS: The positive ezrin, HGF and c-met expression was significantly higher in gallbladder adenocarcinoma than in benign lesions. The benign lesions with positive ezrin, HGF and/or c-met expression showed moderately- or severely-atypical hyperplastic epithelium. The positive expression of ezrin, HGF and c-met was significantly associated with differentiation, tumor mass, lymph node metastasis and invasion of adenocarcinoma. Univariate Kaplan-Meier analysis showed that increased expression of ezrin, HGF and c-met was associated with decreased overall survival. Multivariate Cox regression analysis showed that increased expression of ezrin, HGF or c-met was an independent bad-prognostic predictor in gallbladder adenocarcinoma. CONCLUSIONS: The expression of ezrin, HGF and/or c-met might be closely related to the carcinogenesis, progression, clinical biological behaviors and prognosis of gallbladder adenocarcinoma.

Age matters: a study of clinical and economic outcomes following cholecystectomy in elderly Americans.

BACKGROUND: Gallstone disease increases with age. The aims of this study were to measure short-term outcomes from cholecystectomy in hospitalized elderly patients, assess the effect of age, and identify predictors of outcomes. METHODS: This was a cross-sectional analysis, using the Health Care Utilization Project Nationwide Inpatient Sample (1999-2006), of elderly patients (aged 65-79 and ≥80 years) and a comparison group (aged 50-64 years) hospitalized for cholecystectomy. Linear and logistic regression models were used to evaluate age and outcome relationships. Main outcomes were in-hospital mortality, complications, discharge disposition, mean length of stay, and cost. RESULTS: A total of 149,855 patients aged 65 to 79 years, 62,561 patients aged ≥ 80 years, and 145,675 subjects aged 50 to 64 years were included. Elderly patients had multiple biliary diagnoses and longer times to surgery from admission and underwent more open procedures. Patients aged 65 to 79 years and those aged ≥80 years had higher adjusted odds of mortality (odds ratios [ORs], 2.36 and 5.91, respectively), complications (ORs, 1.57 and 2.39), nonroutine discharge (ORs, 3.02 and 10.76), longer length of stay (ORs, 1.11 and 1.31), and higher cost (ORs, 1.09 and 1.22) than younger patients. CONCLUSIONS: Elderly patients undergoing inpatient cholecystectomy have complex disease, with worse outcomes. Longer time from admission to surgery predicts poor outcome.