Updates on Antibiotic Regimens in Acute Cholecystitis.

Acute cholecystitis is one of the most common surgical diseases, which may progress from mild to severe cases. When combined with bacteremia, the mortality rate of acute cholecystitis reaches up to 10-20%. The standard of care in patients with acute cholecystitis is early laparoscopic cholecystectomy. Percutaneous cholecystostomy or endoscopic procedures are alternative treatments in selective cases. Nevertheless, antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis. Patients with acute cholecystitis have a bile bacterial colonization rate of 35-60%. The most frequently isolated microorganisms are Escherichia coli, Klebsiella spp., Streptococcus spp., Enterococcus spp., and Clostridium spp. Early empirical antimicrobial therapy along with source control of infection is the cornerstone for a successful treatment. In these cases, the choice of antibiotic must be made considering some factors (e.g., the severity of the clinical manifestations, the onset of the infection if acquired in hospital or in the community, the penetration of the drug into the bile, and any drug resistance). Furthermore, therapy must be modified based on bile cultures in cases of severe cholecystitis. Antibiotic stewardship is the key to the correct management of bile-related infections. It is necessary to be aware of the appropriate therapeutic scheme and its precise duration. The appropriate use of antibiotic agents is crucial and should be integrated into good clinical practice and standards of care.

Diagnosis and Treatment of a 64-Year-Old Man with Chyle Leak Following Laparoscopic Cholecystectomy: A Case Report.

BACKGROUND Chyle leakage with chylous ascites is a rare complication of abdominal surgery, and few cases have been reported following cholecystectomy. This report is of a 64-year-old man with chyle leak following laparoscopic cholecystectomy and describes the diagnosis and approach to treatment. Immediate diagnosis, although challenging, remains imperative. Frequently, patients manifest nonspecific symptoms, such as abdominal discomfort or nausea. They can also exhibit milky discharge from drains and wounds. Abdominal fluid analysis is fundamental for diagnosis. The existence of elevated triglyceride levels in peritoneal fluid is indicative of chyle leakage. CASE REPORT We present a case report of a 64-year-old man with chyle leakage after laparoscopic cholecystectomy for acute cholecystitis, on postoperative day 2. A milky-white fluid was drained, and diagnosis was confirmed with elevated triglycerides upon fluid analysis. Chyle leakage decreased gradually until complete resolution at postoperative day 7, after dietary modifications and the closed-suction silicone drain was removed. The patient was symptom-free at a 2-month follow-up. CONCLUSIONS Although chyle leakage is a rare postoperative complication of laparoscopic cholecystectomy, early diagnosis and rapid multidisciplinary management are required. It is vital to consider this diagnosis even if the course of laparoscopic cholecystectomy was uncomplicated and with no anatomical variation. Thus, a closed-suction silicone drain and close monitoring of output is essential for early diagnosis. The dietary modification constitutes a cornerstone in the management of chyle leakage, and a surgical approach should be preserved for patients for whom the conservative approach fails or who have large volumes of chyle.

Portal vein thrombosis associated with acute cholecystitis.

ABSTRACT: Portal venous thrombosis (PVT) is an uncommon clinical problem and is rare following cholecystectomy. This article describes a patient who developed PVT after an initially uneventful laparoscopic cholecystectomy. The patient was successfully treated with IV antibiotics and anticoagulation.

[Potentially preventable causes of mortality in acute calculous cholecystitis: a population-based study]. / Potentsial'no predotvratimye prichiny letal'nosti pri ostrom kal'kuleznom kholetsistite: populyatsionnoe issledovanie.

OBJECTIVE: To analyze potentially preventable causes of mortality from acute calculous cholecystitis (ACC) at the population level. MATERIAL AND METHODS: A retrospective study of causes of ACC-related mortality was conducted. We used online survey of state hospitals and estimated fatal outcomes following ACC considering appropriate annual e-database. RESULTS: There were 1.500 deaths among 142.975 patients aged ≥18 years with acute cholecystitis. We received responses to the proposed questionnaire about 1154 deaths (76.9%). Analysis included 648 cases of ACC (K80.0). Mean age of patients was 76.0 years (31-100). There were 256 (39.5%) men and 392 (60.5%) women. ACC severity was assessed according to the Tokyo guidelines (2018). Mild (I) degree was noted in 24 (3.7%) cases, moderate (II) - 270 (41.7%), severe (III) - 354 (54.6%) patients. Cardiovascular diseases and complications caused death in mild ACC regardless of treatment method in 16 (66.7%) cases, in moderate ACC - 106 (39.3%), in severe ACC - 97 (27.4%) cases. ACC caused death in 3 (12.5%) patients with mild disease, 111 (41.1%) with moderate disease and 200 (56.5%) ones with severe disease. Postoperative complications caused death in 4 (16.7%) patients with mild disease, 29 (10.7%) ones with moderate disease and 30 (8.5%) patients with severe disease. Other causes comprised 4.1% (n=1), 8.9% (n=24) and 7.6% (n=27), respectively. Potentially preventable causes of death were identified in 33.0% of cases. CONCLUSION: ACC-related mortality is mainly associated with comorbidity in elderly and senile patients, late presentation and complicated course of disease. Delayed surgical treatment due to diagnostic and tactical problems, as well as technical intraoperative errors is potentially preventable causes of death.

Timely cholecystectomy: important factors to improve guideline adherence and patient treatment.

OBJECTIVE: Cholecystectomy is one of the most frequently performed surgeries in Germany and is performed as a treatment of acute cholecystitis (guideline S3 IIIB.8) and after endoscopic retrograde cholangiopancreatography for choledocholithiasis with simultaneous cholecystolithiasis (guideline S3 IIIC.6). This article examines the effects of a guideline update from 2017, which recommends prompt cholecystectomy within 24 hours of admission due to cholecystitis or within 72 hours after bile duct repair. In addition, it aims to identify reasons (eg, financial disincentives) and potential for improvement for non-adherence to the guidelines. DESIGN: Methodologically, a retrospective analysis based on routine billing data from 84 Helios Group hospitals from 2016 and 2022, with a total of 45 393 included cases, was applied. The guideline adherence rate is used as the main outcome measure. RESULTS: Results show the guideline updates led to a statistically significant increase in the proportion of cholecystectomy performed in a timely manner (guideline S3 IIIB.8: increase from 43% to 49%, p<0.001; guideline S3 IIIC.6: increase from 7% to 20%, p<0.001). Medical, structural and financial reasons for non-adherence could be identified. CONCLUSION: As possible reasons for non-adherence, medical factors such as advanced age, multimorbidity and frailty could be identified. Analyses of structural factors revealed that hospitals in very rural regions are less likely to perform timely cholecystectomies, presumably due to infrastructural and personnel-capacity bottlenecks. A similar picture emerges for maximum-care hospitals, which might be explained by more severe and complex cases on average. Further evaluation indicates that an increase in and better hospital-internal participation of gastroenterologists in remuneration could lead to even greater adherence to the S3 IIIC.6 guideline.

Remote ischaemic preconditioning on gene expression and circulating proteins after subacute laparoscopic cholecystectomy: randomized clinical trial.

BACKGROUND: Surgical stress may lead to postsurgical hypercoagulability, endothelial dysfunction and systemic inflammation, which can impact on patient recovery. Remote ischaemic preconditioning is a procedure that activates the body's endogenous defences against ischaemia and reperfusion injury. Studies have suggested that remote ischaemic preconditioning has antithrombotic, antioxidative and anti-inflammatory effects. The hypothesis was that remote ischaemic preconditioning reduces surgery-induced systemic stress response. METHOD: During a 24-month period (2019-2021), adult patients undergoing subacute laparoscopic cholecystectomy due to acute cholecystitis were randomized to remote ischaemic preconditioning or control. Remote ischaemic preconditioning was performed less than 4 h before surgery on the upper arm. It consisted of four cycles of 5 min ischaemia and 5 min reperfusion. The gene expression of 750 genes involved in inflammatory processes, oxidative stress and endothelial function was investigated preoperatively and 2-4 h after surgery in both groups. In addition, changes in 20 inflammation- and vascular trauma-associated proteins were assessed preoperatively, 2-4 h after surgery and 24 h after surgery. RESULTS: A total of 60 patients were randomized. There were no statistically significant differences in gene expression 2-4 h after surgery between the groups (P > 0.05). Remote ischaemic preconditioning did not affect concentrations of circulating proteins up to 24 h after surgery (P > 0.05). CONCLUSION: The study did not demonstrate any effect of remote ischaemic preconditioning on expression levels of the chosen genes or in circulating immunological cytokines and vascular trauma-associated proteins up to 24 h after subacute laparoscopic cholecystectomy in patients with acute cholecystitis.

Revolutionizing outcomes: endoscopic ultrasound-guided gallbladder drainage using innovative electrocautery enhanced-lumen apposing metal stents for high-risk surgical patients.

This study retrospectively evaluated the outcomes of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using novel electrocautery-enhanced lumen-apposing metal stents (LAMS) in high-risk patients with acute cholecystitis (AC). Between January 1, 2021, and November 30, 2022, 58 high-risk surgical patients with AC underwent EUS-GBD with the novel electrocautery-enhanced LAMS. The technical success rate was 94.8% (55/58), with one case of duodenal perforation requiring surgery with complete stent migration and two of partial stent migration into the gallbladder. However, the clinical success rate was 100% (55/55). Recurrent AC occurred in 3.6% of the cases (2/55), managed with double pigtail plastic stents through the LAMS. Early AEs observed in 1.8% (1/55) due to stent obstruction. Late AEs occurred in 5.4% (3/55), including two cases of cholangitis and one of stent obstruction. For 33 patients followed over 6 months, LAMS maintenance was sustained in 30 cases. Two patients underwent double-pigtail plastic stent replacement after LAMS removal, and one underwent LAMS removal during surgery following tumor stage regression after chemotherapy for cholangiocarcinoma. The novel electrocautery-enhanced LAMS demonstrated high technical and clinical success rates in high-risk surgical patients with AC, maintaining effective gallbladder drainage with minimal AEs during long-term follow-up, thus highlighting its efficacy and safety in challenging patients.

Interhospital variation in the nonoperative management of acute cholecystitis.

BACKGROUND: Cholecystectomy remains the standard management for acute cholecystitis. Given that rates of nonoperative management have increased, we hypothesize the existence of significant hospital-level variability in operative rates. Thus, we characterized patients who were managed nonoperatively at normal and lower operative hospitals (>90th percentile). METHODS: All adult admissions for acute cholecystitis were queried using the 2016-2019 Nationwide Readmissions Database. Centers were ranked by nonoperative rate using multi-level, mixed effects modeling. Hospitals in the top decile of nonoperative rate (>9.4%) were classified as Low Operative Hospitals (LOH; others:nLOH). Separate regression models were created to determine factors associated with nonoperative management at LOH and nLOH. RESULTS: Of an estimated 418,545 patients, 9.9% were managed at 880 LOH. Multilevel modeling demonstrated that 20.6% of the variability was due to hospital factors alone. After adjustment, older age (Adjusted Odds Ratio [AOR] 1.02/year, 95% Confidence Interval [CI] 1.01-1.02) and public insurance (Medicare AOR 1.31, CI 1.21-1.43 and Medicaid AOR 1.43, CI 1.31-1.57; reference: Private Insurance) were associated with nonoperative management at LOH. These were similar at nLOH. At LOH, SNH status (AOR 1.17, CI 1.07-1.28) and small institution size (AOR 1.20, CI 1.09-1.34) were associated with increased odds of nonoperative management. CONCLUSION: We noted a significant variability in the interhospital variation of the nonoperative management of acute cholecystitis. Nevertheless, comparable clinical and socioeconomic factors contribute to nonoperative management at both LOH and non-LOH. Directed strategies to address persistent non-clinical disparities are necessary to minimize deviation from standard protocol and ensure equitable care.

Blunt dissection method using HiQ+ soft coagulation system for laparoscopic cholecystectomy in acute cholecystitis.

INTRODUCTION: During laparoscopic cholecystectomy for acute cholecystitis, it is often difficult to keep the surgical view dry because of inflammation-related tissue fragility and susceptibility to bleeding. The resulting inadequate surgical view can lead to bile duct or vascular injury. Soft coagulation systems are used to achieve hemostasis during various surgeries; however, the usefulness of soft coagulation during laparoscopic cholecystectomy for acute cholecystitis is unclear. We here demonstrate the usefulness and feasibility of blunt dissection and soft coagulation during this procedure. MATERIALS AND SURGICAL TECHNIQUE: We used blunt dissection and soft coagulation when performing laparoscopic cholecystectomy on two patients with acute cholecystitis. As with conventional laparoscopic cholecystectomy, four ports were inserted. After cutting the serosa by electrocautery, blunt dissection using soft coagulation was performed, exposing the inner subserosa. Maintaining this layer using blunt dissection with soft coagulation achieved a sufficiently clear view for safety. After resecting the cystic artery and duct, the gallbladder bed was also dissected by blunt dissection with soft coagulation. Blood loss was <20 mL in both patients. DISCUSSION: Blunt dissection with soft coagulation may be a useful and feasible means of keeping the surgical view dry and minimizing blood loss during laparoscopic cholecystectomy for acute cholecystitis.

Endoscopic Ultrasonography-Guided Gallbladder Drainage.

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has emerged as a popular alternative to percutaneous cholecystostomy and endoscopic transpapillary gallbladder drainage for patients suffering from acute calculous cholecystitis who are at high risk for surgery. Multiple cohorts, meta-analyses, and a randomized controlled trial have shown that EUS-GBD has lower rates of recurrent cholecystitis and unplanned reinterventions, while achieving similar technical and clinical success rates than transpapillary cystic duct stenting. The essential steps, precautions in performing EUS-GBD and long-term management will be discussed in this article.

Immunohistochemical inflammation in histologically normal gallbladders containing gallstones.

BACKGROUND: The aim of this study was to establish features of inflammation in histologically normal gallbladders with gallstones and compare the expression of inflammatory markers in acutely and chronically inflamed gallbladders. METHODS: Immunohistochemistry was performed on formalin-fixed paraffin-embedded gallbladders for tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-2R, and substance p in three groups: Group I (n = 60) chronic cholecystitis, Group II (n = 57) acute cholecystitis and Group III (n = 45) histologically normal gallbladders with gallstones. Expression was quantified using the H-scoring system. RESULTS: Median, interquartile range expression of mucosal IL-2R in Groups I (2.65, 0.87-7.97) and II (12.30, 6.15-25.55) was significantly increased compared with group III (0.40, 0.10-1.35, p < 0.05). Submucosal IL-2R expression in Groups I (2.0, 1.12-4.95) and II (10.0, 5.95-14.30) was also significantly increased compared with Group III (0.50, 0.15-1.05, p < 0.05). There was no difference in the lymphoid cell IL-6 expression between Groups I (5.95, 1.60-18.15), II (6.10, 1.1-36.15) and III (8.30, 2.60-26.35, p > 0.05). Epithelial IL-6 expression of Group III (8.3, 2.6-26.3) was significantly increased compared with group I (0.5, 0-10.2, p < 0.05) as was epithelial TNF-α expression in Group III (85.0, 70.50-92.0) compared with Groups I (72.50, 45.25.0-85.50, p < 0.05) and II (61.0, 30.0-92.0, p < 0.05). Lymphoid cell Substance P expression in Groups I (1.90, 1.32-2.65) and II (5.62, 2.50-20.8) was significantly increased compared with Group III (1.0,1.0-1.30, p < 0.05). Epithelial cell expression of Substance P in Group III (121.7, 94.6-167.8) was significantly increased compared with Groups I (75.7, 50.6-105.3, p < 0.05) and II (78.9, 43.5-118.5, p < 0.05). CONCLUSION: Histologically normal gallbladders with gallstones exhibited features of inflammation on immunohistochemistry.

The importance of leucine-rich α-2 glycoprotein-1 in acute calculus cholecystitis.

OBJECTIVE: The aim of this prospective, single-center cohort study was to analyze serum leucine-rich α-2-glycoprotein-1 (LRG1) expression in patients with acute cholecystitis (AC) and to investigate its variation depending on symptom duration. PATIENTS AND METHODS: Participants were divided into patients with AC and a healthy control group. At the time of diagnosis, blood samples were collected, and symptom onset times were questioned. Collected serum LRG1 levels were measured. RESULTS: 30 patients and 30 healthy volunteers were included in the study. LRG1 (p=0.008), white blood cells (WBC) (p<0.001), platelet (p=0.003), neutrophil (p<0.001), lymphocyte (p=0.001), and CRP (p=0.014) were significantly different in AC patients vs. the control group. When the correlations of serum laboratory values with the time of onset of symptoms were compared, LRG1 (p<0.001) was significantly correlated, while no significant correlation was observed in C-reactive protein (CRP) (p=0.572), WBC (p=0.155), and neutrophil (p=0.155). CONCLUSIONS: LRG1 expression increases after 24 hours in AC patients. Due to its correlation with symptom duration, we believe it can be helpful for timing cholecystectomy.

Expanded analysis for patients with acute cholecystitis indicates outcomes vary based on COVID-19 status and treatment modality.

BACKGROUND: The impact of different phases of COVID-19 infection on outcomes from acute calculous cholecystitis (ACC) is not well understood. Therefore, we examined outcomes of acute cholecystitis during the COVID-19 pandemic, comparing the effect of different treatment modalities and COVID-19 infection status. We hypothesized that patients with acute COVID-19 would have worse outcomes than COVID-negative patients, but there would be no difference between COVID-negative and COVID-recovered patients. METHODS: We used 2020-2023 National COVID Cohort Collaborative data to identify adults with ACC. Treatment (antibiotics-only, cholecystostomy tube, or cholecystectomy) and COVID-19 status (negative, active, or recovered) were collected. Treatment failure of nonoperative managements was noted. Adjusted analysis using a series of generalized linear models controlled for confounders (age, sex, body mass index, Charlson comorbidity index, severity at presentation, and year) to better assess differences in outcomes among treatment groups, as well as between COVID-19 groups. RESULTS: In total, 32,433 patients (skewed count) were included: 29,749 COVID-negative, 2112 COVID-active, and 572 (skewed count) COVID-recovered. COVID-active had higher rates of sepsis at presentation. COVID-negative more often underwent cholecystectomy. Unadjusted, COVID-active had higher 30-day mortality, 30-day complication, and longer length of stay than COVID-negative and COVID-recovered. Adjusted analysis revealed cholecystectomy carried lower odds of mortality for COVID-active and COVID-negative patients than antibiotics or cholecystostomy. COVID-recovered patients' mortality was unaffected by treatment modality. Treatment failure from antibiotics was more common for COVID-negative patients. CONCLUSION: Acute cholecystitis outcomes are affected by phase of COVID-19 infection and treatment modality. Cholecystectomy does not lead to worse outcomes for COVID-active and COVID-recovered patients than nonoperative treatments; thus, these patients can be considered for cholecystectomy if their physiology is not prohibitive.

Dual-energy CT in acute cholecystitis- features predicting culture-positive bile and outcome.

PURPOSE: Low mono-energetic CT has been shown to improve visualization of acute abdominal inflammatory processes. We aimed to determine its utility in patients with acute cholecystitis and potential added value in clinical decision making. METHODS: Sixty-seven consecutive patients with radiological signs of cholecystitis on contrast-enhanced dual-layer CT imaging were retrospectively identified over a four-year period (2/17-8/21). A ranked Likert scale was created for imaging findings present in acute cholecystitis, including gallbladder mucosal integrity and enhancement and pericholecystic liver parenchymal enhancement. These rankings were correlated with laboratory data, followed by sensitivity, specificity, and odds-ratios calculations. RESULTS: Mucosal integrity and pericholecystic liver enhancement were better seen on low-energetic images by unanimous consensus. Presence of pericholecystic liver enhancement and poorer mucosal wall integrity correlated with positive bile cultures (sensitivity: 93.8 % and 96.9 %, specificity: 37.5 and 50.0 %; odds-ratio: 9.0[1.1-68.1 95 %CI] and 31.0 [2.7-350.7 95 %CI], p = 0.017 and p ≤ 0.001) in patients undergoing cholecystostomy (n = 40/67). Moreover, binary regression modeling showed that the strongest predictor variable for bile culture positivity was the score for pericholecystic liver enhancement (Exp(B) = 0.6, P = 0.022). By contrast, other laboratory markers and other imaging findings (such as GB wall thickness) showed lower sensitivities (76-82 %), specificities (16-21 %) and odds ratios (0.2-4.4) for the prediction of infected bile. CONCLUSIONS: Pericholecystic liver enhancement and gallbladder wall integrity are better visualized on low-DECT images. These findings also potentially predict bile culture positivity in patients with cholecystitis, which may influence clinical management including the need for intervention.

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).

Association of biliary distention with a diagnosis of acute cholecystitis.

BACKGROUND: Gallbladder distention has been described in radiology literature but its value on point-of-care ultrasound (PoCUS) performed by emergency physicians is unclear. We sought to determine the test characteristics of gallbladder distention on PoCUS for cholecystitis (acute or chronic), and secondarily whether distention was associated with an obstructing stone-in-neck (SIN), acute cholecystitis on subsequent pathology report, and longer cholecystectomy operative times. METHODS: This was a dual-site retrospective cohort study of all Emergency Department (ED) patients that underwent diagnostic biliary PoCUS and were subsequently admitted from 11/1/2020 to 10/31/2022. Patients with pregnancy, liver failure, ascites, hepatobiliary cancer, prior cholecystectomy, or known cholecystitis were excluded. Gallbladder distention was defined as a width ≥4 cm or a length ≥10 cm. Saved ultrasound images were reviewed by three independent reviewers who obtained measurements during the review. Test characteristics, Cohen's kappa (κ), and strength of association between distention and our variables (acute cholecystitis on pathology report and SIN on PoCUS) were calculated using a Chi Square analysis, where intervention (cholecystectomy, percutaneous cholecystostomy, or intravenous antibiotics) was used as the reference standard for AC. A one-tail two sample t-test was calculated for mean operative times. RESULTS: Of 280 admitted patients who underwent ED biliary PoCUS, 53 were excluded, and 227 were analyzed. Of the 227 patients, 113 (49.8%) had cholecystitis according to our reference standard, and 68 (30.0%) had distention on PoCUS: 32 distended by both width and length, 16 distended by width alone, and 20 distended by length alone. Agreement between investigators was substantial for width (κ 0.630) and length (κ 0.676). Distention was 85.09% (95% CI 77.20-91.07%) specific and 45.1% (95% CI 35.8-54.8%) sensitive for cholecystitis. There was an association between distention and SIN; odds ratio (OR) 2.76 (95% CI 1.54-4.97). Distention of both length and width was associated with acute over chronic cholecystitis; OR 4.32 (95% CI 1.42-13.14). Among patients with acute cholecystitis, mean operative times were 114 min in patients with distention and 89 min in patients without distention (p = 0.03). CONCLUSION: Gallbladder distention on PoCUS was specific for cholecystitis (acute or chronic), and associated with SIN, acute cholecystitis on subsequent pathology report, and longer cholecystectomy operative times. Measurement of gallbladder dimensions as part of the assessment of cholecystitis may be advantageous.

Acute Cholecystitis Due to Lactococcus lactis and Single-Center Experience With Infections Due to Lactococcus spp.

Background: Lactococcus species are used to ferment milk to yogurt, cheese, and other products. The gram-positive coccus causes diseases in amphibia and fish and is a rare human pathogen. Patients and Methods: A 51-year-old male underwent laparoscopic cholecystectomy for acute and chronic calculous cholecystitis. Lactococcus lactis was isolated from pus from his gallbladder empyema. Results: Our institutional database was searched for other cases of Lactococcus spp. infections and four patients (2 males, 2 females; aged 51, 64, 78, and 80 years) were identified during a four-year period. The three other patients had positive blood cultures associated with pneumonia, toxic megacolon, and severe gastroenteritis. All isolates were monocultures with Lactococcus lactis (2), Lactococcus garvieae (1) and Lactococcus raffinolactis (1). Two patients died related to their sepsis. We report the second case of cholecystitis involving Lactococcus. Conclusions: Lactococcus is a very rare pathogen mainly causing blood stream infections but needs to be considered to cause serious surgical infections in humans.

Acute cholecystitis with double gall bladder diaphragm.

Gall bladder diaphragm is a rare congenital malformation of the gall bladder, entailing its segmentation in several chambers. Functioning as a non-return valve, it interferes with drainage, leading to gallstone formation and cholecystitis. We are reporting a rare case of acute cholecystitis with a double vesicular diaphragm.

Percutaneous cholecystostomy in acute complicated versus uncomplicated cholecystitis; is there a difference in outcomes? A single-center experience.

BACKGROUND: Percutaneous cholecystostomy (PC) is a therapeutic intervention for acute cholecystitis. The benefits of cholecystostomy have been demonstrated in the medical literature, with up to 90% of acute cholecystitis cases shown to resolve postoperatively, and only 40% of patients subsequently undergoing an interval cholecystectomy. PURPOSE: To compare the survival outcomes between acute complicated and uncomplicated cholecystitis in patients undergoing PC as an initial intervention, as there is a paucity of evidence in the literature on this perspective. MATERIAL AND METHODS: A retrospective search was conducted of all patients who underwent PC for acute cholecystitis between August 2016 and December 2020 at a tertiary institution. A total of 100 patients were included in this study. RESULTS: The outcome, in the form of 30-day mortality, 90-day mortality, being alive after six months, and reintervention, was compared between complicated and uncomplicated cases using the chi-square test or Fisher's exact test. There was no statistically significant difference in any of the compared outcomes. The only variable that showed a statistically significant association with the risk of mortality was acute kidney injury (AKI) at admission. Patients who had stage 1, 2, or 3 AKI had a higher hazard for mortality as compared to patients with no kidney disease. CONCLUSION: Our results demonstrate that PC is a safe and effective procedure. Mortality is not affected by the presence of complications. The results have, however, highlighted the importance of recognizing and treating AKI, an independent risk factor affecting mortality.