[Perforated cholecystitis. Classification and atypical clinical forms]. / Perforativnyi kholetsistit. Klassifikatsiia i atipichnye klinicheskie formy.

AIM: To obtain new data for diagnosis and treatment of patients with perforated cholecystitis. MATERIAL AND METHODS: It was analyzed the variants of original classification of perforated cholecystitis by Fedorov S.P. - Neimeier O.W. (1934). Moreover, we have assessed treatment of 292 patients with gallbladder perforation (own material of Faculty Surgery Clinic). RESULTS: According to continuous 20-year follow-up perforated cholecystitis was observed in 2.9% of patients with various forms of gallbladder inflammation (n=292 out of 10 215). The frequency of atypical clinical forms of gallbladder perforation including multiple and combined perforation, perforation with acute intestinal obstruction and intraabdominal bleeding was 10% (n=29 of 292). Overall mortality in atypical clinical forms related to whole cohort with perforated cholecystitis was 2% (n=6 of 292). CONCLUSION: Atypical clinical forms of gallbladder perforation require specific treatment strategy due to the need for emergency surgical interventions. At the same time, the possibilities of video-assisted surgery are somewhat limited compared with other forms of gallbladder inflammation and can be used only in a third of patients.

Preoperative evaluation to predict technical difficulties of laparoscopic cholecystectomy on the basis of histological inflammation findings on resected gallbladder.

BACKGROUND: No papers have heretofore documented histological studies of cases involving the inflammation of resected gallbladder or examined surgical difficulties on the basis of pathological findings. METHODS: On the basis of the histological inflammation findings on the resected gallbladders of 437 patients who underwent laparoscopic cholecystectomy (LC), the factors affecting the technical difficulty of the operation were examined through preoperative clinical findings (13 items), diagnostic imaging (22 items), and blood test findings (6 items), using multivariate analysis. RESULTS: In accordance with the four-stage classification of inflammation findings for the resected gallbladder, the inflammation findings on the resected gallbladder indicated a higher correlation with the time required for gallbladder dissection (30.2 +/- 16.3 minutes) than with the operation time (77.6 +/- 32.7 minutes). Thus, the technical difficulty of the operation was judged according to the time required for gallbladder dissection. For the preoperative findings on 418 patients who underwent successful LC, the most influential factors on the time required for gallbladder dissection were the presence of abnormal findings on computed tomography, the degree of fever, obesity index, nonvisualized gallbladder cholangiography, and cystic duct length. According to the multiple regression equation of these five factors, the gallbladder dissection for the 19 patients who underwent conversion to open cholecystectomy (OC) due to extreme inflammation was calculated to require 61.9 +/- 12.3 minutes, and the patients who showed a gallbladder dissection time longer than 49.6 minutes were judged to have high technical difficulty predicted from the preoperative evaluation. In the preoperative evaluation, sensitivity was 79.6%, specificity was 97.6%, accuracy was 95.0%, positive predictive value was 85.0%, and negative predictive value was 96.6%. Next, each finding was scored on the basis of a multiple regression equation of five factors, and the technical difficulty of the operation was quantified using these scores. The score of the patients who underwent conversion to OC was 8.0 +/- 2.0, and the patients who showed a score higher than 6 were judged to have high technical difficulty. Almost the same results as in the aforementioned preoperative evaluation were obtained using these scores. CONCLUSION: The judgment using the scores was satisfactory in terms of the simplicity of evaluating the technical difficulties associated with each patient and the ease of obtaining information for each factor. The quantification of technical difficulty using the scores is useful for preoperative prediction of which patients will have difficulties in gallbladder dissection and the conversion to OC in LC. Our results suggest that the consideration of technical difficulties is important for conducting safe operations with avoiding intraoperative complications.

Laparoscopic cholecystectomy in the elderly: a prospective study.

BACKGROUND: The aim of this prospective study was to determine the feasibility and the complications or benefits of laparoscopic cholecystectomy (LC) in the patients older than 75 years. METHODS: From January 1992 to July 1998, a total of 863 patients underwent LC, of these patients, 102 patients older than 75 years (group 1) were compared with 761 younger patients (group 2). RESULTS: In the elderly, 35.3% were at high surgical risk (American Society of Anesthesiology [ASA] III and ASA IV). The conversion rate to open cholecystectomy (OC) was 21.6%. The mean length of hospital stay was 6.9 days for both laparoscopy and conversion. Morbidity and mortality rates were 13.7% and 1%, respectively. No patient suffered intraoperative cardiopulmonary complication, and there was no reoperation in the elderly. CONCLUSIONS: Elderly patients experience more complications and longer duration of hospital stay than younger patients. However, our results compare favorably with other OC studies in elderly patients.

Xanthogranulomatous cholecystitis. Histopathological study and classification.

Xanthogranulomatous cholecystitis (XC) is a chronic inflammatory lesion of the gallbladder histologically characterized by the presence of varying amounts of foamy histiocytes in the inflammatory infiltrate. In this study a review of 63 cases selected from 1207 surgically removed gallbladder is presented; the percentage found (5.2%) is slightly higher than that of previous reports showing that XC is less uncommon than generally believed. A detailed microscopic study is performed: the authors observed according to the histological features particularly the different patterns of distribution of the inflammatory infiltrate and postulate the existence of three subtypes of XC: multinodular, focal and diffuse XC. Finally, the main etiopathogenetic hypotheses are briefly discussed.

A new classification of Mirizzi syndrome from diagnostic and therapeutic viewpoints.

BACKGROUND/AIMS: A new classification of Mirizzi syndrome was developed based on our experience with 30 cases. MATERIAL AND METHODS: Using diagnostic and therapeutic criteria, four distinct entities were identified. Type I characterized by stenosis of the common hepatic duct due to a stone impacted in the cystic duct or the neck of the gallbladder. Type II is characterized by fistulization of the common hepatic duct as a result of a stone embedded in the cystic duct or the neck of the gallbladder. Type III is defined by hepatic duct stenosis due to a stone of the confluence, and Type IV by hepatic duct stenosis as a complication of cholecystitis in the absence of calculi impacted in the cystic duct or the neck of the gallbladder. RESULTS: Of the 30 patients there were 14 Type I, 2 Type II, 6 Type III, and 8 Type IV patients. Distinctive cholangiographic features were identified. CONCLUSION: The therapeutic approach differs from each of the four distinct pathologic entities.

[100 cases of laparoscopic cholecystectomy]. / 100 casos de colecistectomías laparoscópicas.

The first one-hundred cases of laparoscopic cholecystectomy performed in this department are reviewed. The patients are grouped according to the classification of McSherry: type I: 5%; type II: 50%; type III; 27%; and type IV: 18%. Our technique, which is similar to the one of Troidl, except for entry of the number 4 port, is described. The results are analyzed according the classification of Troidl and 83% of the cases had no complications. There were technical incidents which had no repercussion for the patient in 7% of the cases. In 3% of the patients there were minor complications. There was no mortality.

Acute acalculous cholecystitis--a clinical-pathological disease spectrum.

OBJECTIVE: To assess the influence of disease setting on clinical and pathological features of acute acalculous cholecystitis (AAC). DESIGN: Analysis of prospectively accumulated clinical data. Blinded histopathological review. LOCATION OF STUDY: Tygerberg Hospital, Western Cape. PATIENTS: Fifty-seven consecutive patients with AAC treated over a 9-year period. MAIN OUTCOME MEASURES: Clinical, ancillary and pathological features of AAC in each of 3 arbitrarily designated types. Type I (N = 24) occurred in patients hospitalised for trauma or critical illness. Patients with type II disease (N = 20) presented primarily with symptoms of acute cholecystitis. Type III AAC (N = 13) was associated with non-calculous gallbladder outflow obstruction. RESULTS: Type I AAC was associated with the highest mortality rate (45.8%), occurred predominantly in males (75%) and was diagnosed pre-operatively in 50% of patients. Acute ischaemic cholecystitis was the most frequent histological diagnosis (66.7%). Only 1 death (5%) was associated with type II AAC despite patients being older, and all but 2 patients (10%) having chronic underlying disease. Acute cholecystitis was diagnosed pre-operatively in 90% of patients. Thirteen patients (65%) were males. Acute-on-chronic cholecystitis was the most frequent histological diagnosis (50%), followed by acute ischaemic cholecystitis in 30%. Type III was associated with an intermediate mortality rate (23.1%) and was the type most seldom diagnosed pre-operatively (15.4%). Histological findings reflected the nature and duration of underlying obstructive pathology. CONCLUSION: The circumstances in which AAC occurs appear to be associated with distinct clinical-pathological variants of the disease. Their recognition could serve to enhance understanding of this challenging condition.

[Acute acalculous cholecystitis as a surgical problem]. / Ostryi beskamennyi kholetsistit kak khirurgicheskaia problema.

Experience in operative treatment of 228 patients for acute acalculous cholecystitis is analysed. This disease differs from acute calculous cholecystitis essentially in the main clinical and morphological signs. Four types of acute acalculous cholecystitis were distinguished according to origin: vascular, enzymatic, enzymatic-vascular, and obturative. The clinical forms are shown: primary vascular, emphysematous, posttraumatic, gallbladder torsion, enzymatic, obturative. It is pointed out that acute acalculous cholecystitis is characterized by rapid destruction of the cystic wall and frequent and severe involvement of the liver and bile ducts, in view of which the tactics of early operations is justified in this pathological condition.

[Clinico-morphological characteristics of acute cholecystitis]. / Kliniko-morfologicheskaia kharakteristika ostrogo kholetsistita.

The clinical picture and morphological changes of the bile cyst were compared in 120 patients operated for acute cholecystitis. In 9% of cases no agreement was observed between the clinical picture of the disease and morphological changes of the bile cyst wall.

[Characteristics of the classification of acute cholecystitis in the elderly]. / Osobennosti klassifikatsii ostrogo kholetsistita u bol'nykh pozhilogo vozrasta.

On the grounds of the analysis of 1300 case records and own observations with the use of angioscopy and angiography the authors have come to the conclusion that acute cholecystitis in elderly individuals results from the blood supply disorder in the gallbladder wall, caused by the thrombosis of the vascular branches of the cystic artery. They have suggested the classification of acute cholecystitis, mirroring the stage character of the disease and the nature of pathological changes in the gallbladder.

[The clinico-anatomical characteristics of different forms of chronic calculous cholecystitis]. / Kliniko-anatomicheskie osobennosti razlichnykh form khronicheskogo kal'kuleznogo kholetsistita.

Three types of the disease course were marked out--hyperplastic (in 26% of observations), hypoplastic (in 40%) and normoplastic (in 34%)--according to the results obtained in clinico-morphological investigation of the excised gallbladder in 177 patients with calculous cholecystitis. For hyperplastic and normoplastic cholecystitis types the cholecystectomy conduction is indicated, and for normoplastic one in elderly patients the organ-preserving operation cholecystolithotomy conduction is possible.