Sequential histologic evolution of gallbladder inflammation in acute cholecystitis over the first 10 days after onset of symptoms.

BACKGROUND: The timing of cholecystectomy during acute cholecystitis (AC) is controversial, especially whether it is advisable to perform in patients with duration of symptoms between 3 and 10 days. The purpose of this study is to define clearly the sequential evolution of histological changes following symptoms onset to guide recommendations regarding timing of cholecystectomy. METHODS: We identified patients with AC (2005-2018) who had cholecystectomy within 10 days of symptom onset of a first attack of AC. Histologic features of gallbladder injury including cellular and exudative inflammatory response to injury were determined on blinded pathologic slides. RESULTS: One hundred and forty-nine patients were divided into three groups; early-who underwent cholecystectomy 1-3 days after symptom-onset, intermediate-4-6 days, and late-7-10 days. Key features of injury were necrosis and hemorrhage. A subgroup of patients in the early phase developed severe necrosis and hemorrhage of an extent associated with difficult cholecystectomy. Large spikes in extent of necrosis and hemorrhage occurred at 7-10 days. Major inflammatory responses to injury were eosinophilic and lymphocytic infiltration and early fibrosis. CONCLUSIONS: Severe necrosis may develop rapidly and be present in the early period after symptom onset of AC. Cholecystectomy may be reasonable in some patients but by day 7-10, severe necrosis and hemorrhage may be expected to be present in most patients.

Sonographic Assessment of Acute Versus Chronic Cholecystitis: An Ultrasound Probability Stratification Model.

OBJECTIVES: What sonographic variables are most predictive for acute cholecystitis? What variables differentiate acute and chronic cholecystitis? METHODS: The surgical pathology database was reviewed to identify adult patients who underwent cholecystectomy for cholecystitis and had a preceding ultrasound of the right upper quadrant within 7 days. A total of 236 patients were included in the study. A comprehensive imaging review was performed to assess for gallstones, gallbladder wall thickening, gallbladder distension, pericholecystic fluid, gallstone mobility, the sonographic Murphy's sign, mural hyperemia, and the common hepatic artery peak systolic velocity. RESULTS: Of 236 patients with a cholecystectomy, 119 had acute cholecystitis and 117 had chronic cholecystitis on surgical pathology. Statistical models were created for prediction. The simple model consists of three sonographic variables and has a sensitivity of 60% and specificity of 83% in predicting acute versus chronic cholecystitis. The most predictive variables for acute cholecystitis were elevated common hepatic artery peak systolic velocity, gallbladder distension, and gallbladder mural abnormalities. If a patient had all three of these findings on their preoperative ultrasound, the patient had a 96% chance of having acute cholecystitis. Two of these variables gave a 73-93% chance of having acute cholecystitis. One of the three variables gave a 40-76% chance of having acute cholecystitis. If the patient had 0 of 3 of the predictor variables, there was a 29% chance of having acute cholecystitis. CONCLUSIONS: Gallbladder distension, gallbladder mural abnormalities, and elevated common hepatic artery peak systolic velocity are the most important sonographic variables in predicting acute versus chronic cholecystitis.

The Value of Ultrasonography in Predicting Acute Gangrenous Cholecystitis.

Acute cholecystitis is a common clinical inflammatory lesion of the gallbladder. With the aggravation of inflammation, ischemic, necrosis, and even acute gangrenous cholecystitis occur in the gallbladder. At the same time, a variety of complications appear, seriously affecting the prognosis of patients. It is recommended that ultrasound can be utilized as the first choice for the diagnosis of acute cholecystitis, due to its fastness, convenience, non-radiation, and low cost. Here, we summarize the latest progress that can predict acute gangrenous cholecystitis in ultrasound, thus assisting us in identifying patients with high risk of gangrene in early stage, and treating these patients in time.

Aggressive Laparoscopic Cholecystectomy in Accordance with the Tokyo Guideline 2018.

OBJECTIVES: The Tokyo Guidelines 2018 have been widely adopted since their publication. However, the few reports on clinical outcomes following laparoscopic cholecystectomy have not taken into account the severity of the acute cholecystitis and the patient's general condition, as estimated by the Charlson comorbidity index. This study aimed to assess the relationships between severity, Charlson comorbidity index, and clinical outcomes subsequent to laparoscopic cholecystectomy. METHODS: We extracted the retrospective data for 370 Japanese patients who underwent emergency or scheduled early laparoscopic cholecystectomy within 72 hours from onset between February 2015 and August 2018. We compared postoperative factors in relationship to severity (grade I versus grade II/III). Then, we made a similar comparison between those with low (< 4) and high Charlson comorbidity index (≥ 4). RESULTS: According to the Tokyo guideline 2018 levels of severity, there were 282 (76.2%), 61 (16.5%), and 27 (7.3%) patients in grades I, II, and III, respectively. With regards to surgical outcomes, the mean operating time was 62.3 minutes and the mean blood loss was 24.4 mL. The mean hospital stay was 3.6 days, with no mortalities. Blood loss was the only factor affected by severity (20.9 mL versus 60.1 mL, P = 0.0164), and operating time was the only factor affected by high Charlson comorbidity index (53.4 versus 67.8 minutes, P = 0.0153). CONCLUSION: Our aggressive strategy is acceptable, and severity and Charlson comorbidity index are not critical factors suggesting the disqualification of early laparoscopic cholecystectomy in patients with any grade acute cholecystitis.

Risk Prediction in Acute Calculous Cholecystitis: A Systematic Review and Meta-Analysis of Prognostic Factors and Predictive Models.

Background: Laparoscopic cholecystectomy is the main treatment of acute cholecystitis. Although considered relatively safe, it carries 6%-9% risk of major complications and 0.1%-1% risk of mortality. There is no consensus regarding the evaluation of the preoperative risks, and the management of patients with acute cholecystitis is usually guided by surgeon's personal preferences. We assessed the best method to identify patients with acute cholecystitis who are at high risk of complications and mortality. Methods: We performed a systematic review of studies that reported the preoperative prediction of outcomes in people with acute cholecystitis. We searched the Cochrane Library, MEDLINE, EMBASE, WHO ICTRP, ClinicalTrials.gov, and Science Citation Index Expanded until April 27, 2019. We performed a meta-analysis when possible. Results: Six thousand eight hundred twenty-seven people were included in one or more analyses in 12 studies. Tokyo guidelines 2013 (TG13) predicted mortality (two studies; Grade 3 versus Grade 1: odds ratio [OR] 5.08, 95% confidence interval [CI] 2.79-9.26). Gender predicted conversion to open cholecystectomy (two studies; OR 1.59, 95% CI 1.06-2.39). None of the factors reported in at least two studies had significant predictive ability of major or minor complications. Conclusion: There is significant uncertainty in the ability of prognostic factors and risk prediction models in predicting outcomes in people with acute calculous cholecystitis. Based on studies of high risk of bias, TG13 Grade 3 severity may be associated with greater mortality than Grade 1. Early referral of such patients to high-volume specialist centers should be considered. Further well-designed prospective studies are necessary.

Multicenter validation of the American Association for the Surgery of Trauma grading scale for acute cholecystitis.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) patient assessment committee has created grading systems for emergency general surgery diseases to assist with clinical decision making and risk adjustment during research. Single-institution studies have validated the cholecystitis grading system as associated with patient outcomes. Our aim was to validate the grading system in a multi-institutional fashion and compare it with the Parkland grade and Tokyo Guidelines for acute cholecystitis. METHODS: Patients presenting with acute cholecystitis to 1 of 8 institutions were enrolled. Discrete data to assign the AAST grade were collected. The Parkland grade was collected prospectively from the operative surgeon from four institutions. Parkland grade, Tokyo Guidelines, AAST grade, and the AAST preoperative grade (clinical and imaging subscales) were compared using linear and logistic regression to the need for surgical "bailout" (subtotal or fenestrated cholecystectomy, or cholecystostomy), conversion to open, surgical complications (bile leak, surgical site infection, bile duct injury), all complications, and operative time. RESULTS: Of 861 patients, 781 underwent cholecystectomy. Mean (SD) age was 51.1 (18.6), and 62.7% were female. There were six deaths. Median AAST grade was 2 (interquartile range [IQR], 1-2), and median Parkland grade was 3 (interquartile range [IQR], 2-4). Median AAST clinical and imaging grades were 2 (IQR, 2-2) and 1 (IQR, 0-1), respectively. Higher grades were associated with longer operative times, and worse outcomes although few were significant. The Parkland grade outperformed the AAST grade based on area under the receiver operating characteristic curve. CONCLUSION: The AAST cholecystitis grading schema has modest discriminatory power similar to the Tokyo Guidelines, but generally lower than the Parkland grade, and should be modified before widespread use. LEVEL OF EVIDENCE: Diagnostic study, level IV.

Intussusceptive Angiogenesis and Peg-Socket Junctions between Endothelial Cells and Smooth Muscle Cells in Early Arterial Intimal Thickening.

Angiogenesis in arterial intimal thickening (AIT) has been considered mainly in late AIT stages and only refers to sprouting angiogenesis. We assess angiogenesis during early AIT development and the occurrence of the intussusceptive type. For this purpose, we studied AIT development in (a) human arteries with vasculitis in gallbladders with acute cholecystitis and urgent (n = 25) or delayed (n = 20) cholecystectomy, using immunohistochemical techniques and (b) experimentally occluded arterial segments (n = 56), using semithin and ultrathin sections and electron microscopy. The results showed transitory angiogenic phenomena, with formation of an important microvasculature, followed by vessel regression. In addition to the sequential description of angiogenic and regressive findings, we mainly contribute (a) formation of intravascular pillars (hallmarks of intussusception) during angiogenesis and vessel regression and (b) morphological interrelation between endothelial cells (ECs) in the arterial wall and vascular smooth muscle cells (VSMCs), which adopt a pericytic arrangement and establish peg-and-socket junctions with ECs. In conclusion, angiogenesis and vessel regression play an important role in AIT development in the conditions studied, with participation of intussusceptive angiogenesis during the formation and regression of a provisional microvasculature and with morphologic interrelation between ECs and VSMCs.

Early Versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis with Mild Pancreatitis.

The safety and feasibility of early laparoscopic cholecystectomy (LC) for acute cholecystitis with mild pancreatitis were explored. A total of 973 patients with acute pancreatitis, including 651 mild cases and 322 moderate or severe cases were retrospectively studied from July 2014 to December 2018 in our department. And 426 mild pancreatitis cases with acute cholecystitis were enrolled in this study, of which 328 patients underwent LC during the same-admission (early LC group), and 98 patients underwent LC a period of time after conservative treatment (delayed LC group). Clinical characteristics, operative findings and complications were recorded and followed up. The two groups were comparable in age, gender, the grade of American Society of Anesthesiologist (ASA), biochemical findings and Balthazar computer tomography (CT) rating (P>0.05). The operation interval and hospital stay in early LC group were significantly shorter than in delayed LC group (5.83±1.62 vs. 41.36±8.44 days; 11.38±2.43 vs. 16.49±3.48 days, P<0.01). There was no significant difference in the average operation time between the two groups. No preoperative biliary related events recurred in early LC group but there were 21 cases of preoperative biliary related events in delayed LC group (P<0.01). There was no significant difference in conversion rate (3.85 vs. 5.10%, P=0.41) and surgical complication rate (3.95 vs. 4.08%, P=0.95) between early LC group and delayed LC group. During the postoperative follow-up period of 375 cases, biliary related events recurred in 4 cases in early LC group and 3 cases in delayed LC group (P=0.37). The effect of early LC during the same-admission is better than delayed LC for acute cholecystitis with mild pancreatitis.

Preoperative diagnoses and identification rates of unexpected gallbladder cancer.

BACKGROUND: Unexpected gallbladder cancer (UGBC) is sometimes found in the resected gallbladder of patients during or after surgery. Some reports have indicated UGBC identification rates for all gallbladder surgeries, but scarce data are available for the UGBC identification rates for specific gallbladder diseases. The present study was performed to clarify UGBC rates and the factors suspicious for UGBC categorized according to preoperative diagnoses, in patients undergoing laparoscopic cholecystectomy (LSC). METHODS: We recorded data for all LSC surgeries performed in the Department of Surgery, Sada Hospital, Japan since 1991, and analyzed the 28-year data. We used the chi-square test and Kaplan-Meier analysis for this retrospective case-control study. RESULTS: The UGBC identification rate was 0.69% (63/9186 patients). The UGBC identification rates categorized according to the preoperative diagnoses were 1.3% (13/969) for acute cholecystitis, 2.4% (16/655) for benign tumor, 2.0% (28/1383) for chronic cholecystitis or cholecystitis, and 0.054% (3/5585) for cholecystolithiasis. The percentage of older patients (≥ 60 years) was significantly higher in UGBCs compared with cases finally diagnosed as benign in each group categorized according to the preoperative diagnoses (p≤0.0014), except for cholecystolithiasis. In cases pre-diagnosed as benign tumor, UGBCs were associated with higher rates of thickened gallbladder wall compared with benign tumor (69.2% vs. 27.9%, respectively; p = 0.0011). UGBCs pre-diagnosed as acute cholecystitis had higher T2-T4 rates (100% vs. 64.3%, respectively; p<0.05) and lower survival rates (p = 0.0149) than UGBCs pre-diagnosed with chronic cholecystitis. CONCLUSIONS: UGBC identification rates depend on the preoperative diagnosis and range from 0.054% to 2.4%. Older age (≥ 60 years) could be related to UGBC, and a pre-diagnosis of acute cholecystitis might indicate more advanced cancer compared with a pre-diagnosis of chronic cholecystitis.

Clinical presentation and outcomes of cholecystectomy for acute cholecystitis in patients with diabetes - A matched pair analysis. A pilot study.

PURPOSE: The primary aim of this study is to compare the clinical course and laboratory parameters of acute cholecystitis in patients with diabetes vs. patients without diabetes. MATERIALS AND METHODS: The study involved patients who underwent emergency cholecystectomy in the Department of General, Endocrine and Transplant Surgery of University Clinical Center in Gdansk (Poland) between 2007 and 2017. There were 267 patients included in the study. The control group of 197 patients was age and sex matched at a 3:1 ratio. The following was compared between the groups: symptoms at admission, course of surgery, postoperative course, length of hospitalization, total costs of hospitalization and antibiotic therapy, other than routine perioperative prophylaxis. RESULTS: There was no significant difference between the patients with and without diabetes regarding symptoms at admission. Operative and postoperative complication rates were significantly higher in the patients with diabetes. The operative time and length of hospitalization were significantly longer in the study group. The conversion rate was not higher in the study group, but classic surgery was performed significantly more often. The patients without diabetes had less pronounced symptoms with more locally advanced disease. CONCLUSIONS: Our study demonstrates that patients with diabetes have a significantly more eventful course of acute cholecystitis than patients without diabetes. Patients with diabetes should therefore be qualified for cholecystectomy early in the course of acute cholecystitis.

Is There a Role for Color Doppler Ultrasonography in Acute Cholecystitis?

OBJECTIVE: The aim of this study was to evaluate the utility of the Pulsatility Index (PI) of the right hepatic artery, measured by color Doppler sonography, in the diagnosis of acute cholecystitis. METHODS: Seventy-five subjects were included in this study and divided into three groups, each consisting of 25 subjects: the cholecystitis group, the asymptomatic cholelithiasis group, and normal controls. Patients with acute cholecystitis fulfilled all the diagnostic criteria as stated in the latest Tokyo Guidelines. In all patients, the right hepatic artery was detected by color Doppler ultrasound and the PI was measured. RESULTS: Patients with acute cholecystitis were found to have significantly higher PI values compared to both normal controls and cholelithiasis patients. Regression analysis revealed a significant positive correlation between the PI and the cholecystitis outcome. CONCLUSION: Measurement of PI by color Doppler ultrasound represents a useful aid in the diagnostic process of acute cholecystitis. More studies are needed before this method is incorporated in the relevant guidelines.

Identification of risk factors for open conversion from laparoscopic cholecystectomy for acute cholecystitis based on computed tomography findings.

PURPOSE: Laparoscopic cholecystectomy (LC) is performed widely for acute cholecystitis (AC). This study was conducted to identify the predictors for conversion cholecystectomy (CC) for AC. METHODS: The subjects of this study were 395 patients who underwent emergency surgery for AC between 2011 and 2019. Univariate and multivariate analyses were performed to establish the significance of the risk factors for CC in patients with grades II and III AC. RESULTS: There were 162 TG18 GII and GIII patients in the LC group and 31 in the CC group. Univariate analysis revealed significant differences in performance status (p = 0.039), C-reactive protein levels (p = 0.016), albumin levels (p = 0.002), gallbladder (GB) wall thickness (p = 0.045), poor contrast of the GB wall (p = 0.035), severe inflammation around the GB (p < 0.001), enhancement of the liver bed (p = 0.048), and duodenal edema (p < 0.001) between the groups. Multivariate analysis identified hypoalbuminemia (p = 0.043) and duodenal edema (p = 0.014) as independent risk factors for CC. CONCLUSIONS: Most patients with grade I AC underwent LC and had better surgical outcomes than those with grades II and III AC. The most appropriate surgical procedure should be selected based on preoperative imaging of the GB and the neighboring organs and by the presence of hypoalbuminemia.

Comparison of endoscopic naso-gallbladder drainage and percutaneous transhepatic gallbladder drainage in acute suppurative cholecystitis: Study Protocol Clinical Trial (SPIRIT Compliant).

INTRODUCTION: Transitional drainage, which is followed by cholecystectomy plays a key role in the management of acute cholecystitis, especially in high-risk surgical patients. Endoscopic naso-gallbladder drainage (ENGBD) is an alternative to percutaneous transhepatic gallbladder drainage (PTGBD) for patients who need temporary drainage. There is a lack of prospective comparison on the relevant outcomes of the two drainage methods during the period of drainage, especially the subsequent cholecystectomy. METHODS: This is a randomized controlled two-arm non-blind single center trial. Patients with acute cholecystitis undergo emergent or early cholecystectomy and need drainage will be randomly assigned to group PTGBD or ENGBD. Pain score is defined as the primary endpoint, whereas several secondary endpoints, such as the rates of technical success, clinical remission, open conversion of cholecystectomy will be determined to elucidate more detailed differences between two groups. The general feasibility, safety, and quality checks required for high-quality evidence will be adhered to. DISCUSSION: This study would provide the first type A evidence concerning the comparison of ENGBD versus PTGBD in surgically high-risk patients with acute cholecystitis, it will be the first trial designed to determine the impact of two drainage methods on not only peri-drainage but also peri-LC. TRIAL REGISTRATION: NCT03701464. Registered on October 10, 2018.

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

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

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.

Impact of transient hepatic attenuation differences on computed tomography scans in the diagnosis of acute gangrenous cholecystitis.

BACKGROUND: We examined the utility of transient hepatic attenuation differences (THADs) detected in the arterial phase of computed tomography for the diagnosis of acute gangrenous cholecystitis (AGC). METHODS: We examined 83 consecutive patients who underwent cholecystectomy within 72 h of undergoing three-phase dynamic computed tomography scans for acute cholecystitis between 2009 and 2018 (histopathological examination later confirmed 42 with AGC, 41 without). The THAD volume (cm3 ) was calculated by multiplying the total area of the enhancing lesions (traced on axial images) by the thickness of the scan (0.5-cm slices). We evaluated the sensitivity and specificity of the THAD volume and other computed tomography findings of AGC. RESULTS: The THAD volume was significantly larger in the AGC group than in the non-gangrenous acute cholecystitis group (P < 0.0001). The cutoff value of 78 cm3 , determined using a receiver operating characteristics curve, yielded a sensitivity of 88.1% and specificity of 75.6% for detecting AGC. Multivariate analysis revealed a THAD volume of >78 cm3 to be an independent predictor of AGC. CONCLUSIONS: Acute gangrenous cholecystitis can be diagnosed using THAD volume, resulting in improved treatment and fewer serious complications.

Place for elective cholecystectomy for patients with severe thalassaemia: a retrospective case control study.

OBJECTIVE: At present, cholecystectomy is carried out for thalassaemia patients with gall stone disease only if they develop symptoms of cholecystitis, except in the rare instance where an un-inflammed gall bladder is removed simultaneously with splenectomy. We carried out this retrospective analysis of case records to examine if patients with thalassaemia have a higher rate of peri operative complications compared to non-thalassaemics with gall stone disease, warranting a change of policy to justify elective cholecystectomy. RESULTS: Case records of 540 patients with thalassaemia were retrospectively analysed of which 98 were found to have gallstones. Records of 62 patients without thalassaemia with gall stone disease too were used for comparison. 19 of patients with thalassaemia and 52 of non-thalassaemic who had gallstones had undergone cholecystectomy. In all but 5 patients with thalassaemia cholecystectomy was done following attacks of acute cholecystitis as was the case in the non-thalassaemic controls. A significantly higher proportion of early and late complications had occurred in thalassaemia patients compared to non-thalassaemic patients post operatively. Six deaths related to sepsis following acute cholecystitis in the peri operative period were reported among 19 thalassaemia patients whereas no deaths were reported among 55 non-thalassaemic patients who underwent cholecystectomy for gallstones.