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.

Acalculous Cholecystitis: Is an Elective Interval Cholecystectomy Necessary.

BACKGROUND: Acute acalculous cholecystitis (AAC) accounts for 5-10% of cases of acute cholecystitis. The advantage of interval cholecystectomy for patients with AAC is unclear. Therefore, a retrospective analysis of patients diagnosed with AAC at our institution was performed over a 5-year period. METHODS: Patients were identified via hospital coding using the keywords "acalculous cholecystitis, cholecystostomy and gall bladder perforation." Follow-up data was obtained by performing a retrospective review of the patients' hospital records. RESULTS: A total of 33 patients with AAC were identified and followed for a median period of 18 months. The median age at presentation was 70 (10-96) and American Society of Anesthesiologists (ASA) grade was 3 (1-5). Twenty-three patients (70%) were treated with antibiotics alone, 7 patients (21%) with percutaneous cholecystostomy and 3 patients (9%) with laparoscopic cholecystectomy. The 90-day mortality rate was 30% with significant correlation to comorbid status, as all deaths occurred in ASA grade 3-5 individuals (p = 0.020). Two patients (6%) developed recurrent AAC and were managed non-operatively. CONCLUSION: Antibiotics and cholecystostomy were the mainstay of AAC management, and comorbid status influenced related mortality. Our results suggest that it appears safe to avoid interval cholecystectomy in patients who recover from AAC, as they are typically high-risk surgical candidates.

Risk factors for poor outcomes of children with acute acalculous cholecystitis.

BACKGROUND: Acute acalculous cholecystitis (AAC) is generally considered to be a mild disease in children; however, if left untreated or treated without caution, AAC can lead to severe outcomes, such as death. The objectives of this study were to present the clinical features and identify the predictors of mortality in pediatric AAC. METHODS: Patients diagnosed with AAC between 2005 and 2012 were enrolled. AAC was defined by the presence of fever and an echo-proven thickened gallbladder wall exceeding 4 mm. A poor health outcome was defined as death. Further information related to the demographics, clinical manifestations, laboratory results, ultrasound findings, and pathogens present in the AAC patients was also collected. Predictors of mortality were identified by association analyses and confirmed by multivariate logistic regression. RESULTS: A total of 147 pediatric AAC patients (male/female = 1.01, mean age = 5.2 years) were included in this retrospective study. The most common clinical presentation was an elevated C-reactive protein level (84%) followed by hepatomegaly (80%) and anorexia (78%). AAC in children was associated with various diseases, including infectious diseases (70%), systemic diseases (13%), and malignancy (11%). Fourteen of the 147 (9.25%) patients died during the study period. The presences of thrombocytopenia, anemia, gallbladder sludge, hepatitis, and/or sepsis plus hepatitis were found to be the important predictors of AAC mortality. CONCLUSIONS: The factors associated with AAC mortality were anemia, thrombocytopenia, gallbladder sludge, hepatitis, and sepsis plus hepatitis. These predictors are likely to help clinicians identify patients who are at a high risk of poor prognoses and make appropriate clinical decisions.

Epidemiology of acute cholecystitis and its treatment in Bergamo District, Northern Italy.

BACKGROUND: Acute calcolous cholecystitis (ACC) is a very common pathology in western countries. The aim of our work was to assess the epidemiology of ACC and its treatment in Bergamo, a northern Italy province, during the last seventeen years. METHODS: A restrospective analysis, covering 1997 to 2013, was performed based on the administrative register of the province Health System. Only patients admitted for ACC were selected. From 1997 to 2013 were collected 8959 cases of ACC, mean age was 61.28, 51.5% were male. RESULTS: The incidence of ACC was 48/100.000 per year; the operation rate was 66%. Overall mortality was 0.7%, mean hospitalization time was 9.7 days. The treatment of ACC in Bergamo Province seemed to be acceptable and comparable to literature results. Over the last years, laparoscopy has become the standard treatment. CONCLUSIONS: This study outlined some criticisms on the selection's methodology sourcing data from administrative registers, raising questions about truthfulness of results and usefulness for health policy issues.

Percutaneous cholecystostomy is an effective definitive treatment option for acute acalculous cholecystitis.

AIMS: Acute acalculous cholecystitis can be treated with percutaneous cholecystostomy in critically ill patients unfit for surgery. However, the evidence on the outcome is sparse. We conducted a retrospective analysis of acute acalculous cholecystitis patients treated with percutaneous cholecystostomy during a 10-year study period. METHODS: An observational study of 56 consecutive patients treated with percutaneous cholecystostomy for acute acalculous cholecystitis was conducted in the period from 1 June 2002 to 31 May 2012. All data were obtained by review of medical records. RESULTS: A total of 56 consecutive patients were treated with percutaneous cholecystostomy for acute acalculous cholecystitis. Six patients (10.7%) died within 30 days after the procedure. Percutaneous cholecystostomy could serve as a definitive treatment option in 45 patients (80.4%), whereas 1 patient (1.8%) required cholecystectomy due to recurrence of cholecystitis. Four patients (7.1%) were treated with percutaneous cholecystostomy as a bridging procedure to subsequent elective laparoscopic cholecystectomy within a median of 8.8 months (range: 7.7-33.4 months). There was no significant difference in the risk of cholecystitis recurrence between patients with (6/37) and without (2/3) contrast passage to the duodenum on cholangiography (p = 0.096). CONCLUSION: Percutaneous cholecystostomy is successful as a definitive treatment option in the majority of patients with acute acalculous cholecystitis. It is associated with a low rate of mortality and subsequent cholecystectomy.

Cholecystostomy offers no survival benefit in patients with acute acalculous cholecystitis and severe sepsis and shock.

BACKGROUND: Acute acalculous cholecystitis is often managed with cholecystectomy or cholecystostomy, but data guiding surgical practice are lacking. MATERIALS AND METHODS: Longitudinal analysis of the California Office of Statewide Health Planning and Development Patient Discharge Data was performed from 1995-2009. Patients with acute acalculous cholecystitis were identified by International Classification of Diseases 9 code. Cox proportional hazard analysis found predictors of time to death, adjusting for patient demographics, sepsis, shock, frailty, Charlson comorbidity index, length of stay, insurance status, teaching hospital status, and year. RESULTS: Of 43,341 patients, 63.5% received a cholecystectomy, 2.8% received a cholecystostomy, and 1.2% received both. Overall, 30.4% of patients died, with higher mortality among patients with cholecystostomy (61.7%) or no procedure (42.0%) than cholecystectomy (23.0%). In patients with severe sepsis and shock, there was no difference in survival of patients with cholecystostomy versus no intervention (hazard ratio [HR] 1.13, P = 0.256), although patients with cholecystectomy (with or without prior cholecystostomy) had improved survival (HR 0.29, P < 0.001; HR 0.56, P < 0.001). Results were similar among patients on the ventilator >96 h. CONCLUSIONS: Although cholecystostomy offered no survival benefit for patients with severe sepsis and shock, cholecystectomy offered improved survival compared with patients without surgical management. Cholecystostomy may not benefit the sickest patients in whom cholecystectomy may never be considered.

[Acute acalculous cholecystitis--difficulties of diagnosis and treatment]. / Colecistita acuta alitiazica--dificultati de diagnostic si tratament.

Acute acalculous cholecystitis is defined by ultrasonographic, intraoperative and pathologic findings of acute cholecystitis, without evidence of gallstones. It is associated to recent operations, trauma, burns, multisystem organ failure and parenteral nutrition. It can also occur as the first episode, in patients with pathological conditions which generate local ischemia: diabetes mellitus, malignant disease, abdominal vasculitis, congestive heart failure. The authors present a series of 20 patients, operated in the Surgical Department of the Clinical Hospital "Dr. I. Cantacuzino", between 2004 and 2010. There are analysed the significant risk factors, the diagnostic methods and the surgical procedures--laparoscopic or classical cholecystectomies. Among the 20 patients, 14 had a favorable postoperative evolution, 4 had wound infections and in 1 patient a cerebral vascular stroke occurred in the 2nd day after the operation. Another patient died 3 days after the operation, due to an extended myocardial infarction. The medical literature referring to this subject is also reviewed.

Acute acalculous cholecystitis: a review.

Although recognized for more than 150 years, acute acalculous cholecystitis (AAC) remains an elusive diagnosis. This is likely because of the complex clinical setting in which this entity develops, the lack of large prospective controlled trials that evaluate various diagnostic modalities, and thus dependence on a small data base for clinical decision making. AAC most often occurs in critically ill patients, especially related to trauma, surgery, shock, burns, sepsis, total parenteral nutrition, and/or prolonged fasting. Clinically, AAC is difficult to diagnose because the findings of right upper-quadrant pain, fever, leukocytosis, and abnormal liver tests are not specific. AAC is associated with a high mortality, but early diagnosis and intervention can change this. Early diagnosis is the crux of debate surrounding AAC, and it usually rests with imaging modalities. There are no specific criteria to diagnose AAC. Therefore, this review discusses the imaging methods most likely to arrive at an early and accurate diagnosis despite the complexities of the radiologic modalities. A pragmatic approach is vital. A timely diagnosis will depend on a high index of suspicion in the appropriate patient, and the combined results of clinical findings (admittedly nonspecific), plus properly interpreted imaging. Sonogram (often sequential) and hepatic iminodiacetic acid scans are the most reliable modalities for diagnosis. It is generally agreed that cholecystectomy is the definitive therapy for AAC. However, at times a diagnostic/therapeutic drainage via interventional radiology/surgery may be necessary and life-saving, and may be the only treatment needed.