Primary cholecystectomy is feasible in elderly patients with acute cholecystitis.

BACKGROUND: While early cholecystectomy is generally accepted as the standard procedure for young and fit patients with acute cholecystitis, controversy exits on the management of elderly and severely sick patients. We postulated that primary cholecystectomy is feasible in this subgroup. The aim of this study was to compare the outcomes of young and fit patients to those of elderly patients undergoing surgery for acute cholecystitis. METHODS: The outcomes of elderly patients (≥70 years) undergoing surgery for acute cholecystitis in a primary care center in Germany were retrospectively compared to those of younger patients (<70 years). RESULTS: 152 patients, 74 aged ≥ 70 years (study group) and 78 < 70 years (control) were included for analysis. The study group was significantly older at the time of surgery (78 vs. 68 years, p = 0.02). Severe cholecystitis was seen in a significant number of cases in the study group, p = 0.01. Equally, the mean WBC (19.5 vs. 17, p = 0.02), CRP (26 vs. 22, p = 0.04) and APACHE II score (17 vs. 8, p = 0.01) were significantly higher in the study group. There was no significant difference in the duration of anesthesia (123 vs. 133 min, p = 0.70) and surgery (72 vs. 81 min, p = 0.90) amongst both groups. There was no significant difference in rate of complication amongst both groups (24 vs. 14%, p = 0.11). Two cases of mortality were recorded (1.3%) in the study group. CONCLUSION: The age of the patient cannot be the sole factor in deciding whether or not a patient with acute cholecystitis is fit for surgery.

Is gallbladder inflammation more severe in male patients presenting with acute cholecystitis?

BACKGROUND: The male gender is considered a risk factor for complications in patients undergoing laparoscopic cholecystectomy. The reasons for this gender associated risk are not clearly understood. The extent of gallbladder inflammation has been shown to influence surgical outcome. The aim of this study was to investigate whether or not gallbladder inflammation is more severe in male patients presenting with acute cholecystitis. METHODS: A retrospective gender dependent comparison of the data of patients undergoing laparoscopic cholecystectomy for acute cholecystitis in a primary care facility within a five-year period was performed. RESULTS: 138 patients, 69 males and 69 females were included for analysis. Severe gallbladder inflammation (gangrenous and necrotizing cholecystitis) was seen in a significant portion of the male population compared to the female population (p = 0.002). The male gender was confirmed in a multivariate analysis as an independent risk factor for severe cholecystits (p = 0.018). CONCLUSION: The male gender is a risk factor for severe gallbladder inflammation. An early surgical intervention may be needed to prevent complications.

The Treatment of Critically Ill Patients With Acute Cholecystitis.

BACKGROUND: Besides cholecystectomy (CC), percutaneous cholecystostomy (PC) has been recommended for the management of critically ill patients with acute cholecystitis. However, solid evidence on the benefit of PC in this subgroup of patients is lacking. METHODS: In accordance with the PRISMA guidelines for systematic reviews, we systematically searched the Cochrane Library, CINAHL, MEDLINE, Embase, and Scopus for relevant studies published between 2000 and 2014. Two investigators independently screened the studies included. RESULTS: Six studies with a total of 337 500 patients (PC 10 045, CC 327 455) were included for meta-analysis. Significant differences in favor of CC were recorded with regard to the rate of mortality (OR 4.28, [1.72 to 10.62], p = 0.0017), length of hospital stay (OR 1.41, [1.02 to 1.95], p = 0.04), and the rate of readmission for biliary complaints (OR 2.16, [1.72 to 2.73], p<0.0001). There was no statistically significant difference between both intervention arms with regard to complications (OR 0.74, [0.36 to 1.53], p = 0.42) and re-interventions (OR 7.69, [0.68 to 87.33], p = 0.10). CONCLUSION: The benefit of percutaneous cholecystostomy (PC) over cholecystectomy (CC) in the management of critically ill patients with acute cholecystitis could not be proven in this systematic review.

Cholecystectomy vs. percutaneous cholecystostomy for the management of critically ill patients with acute cholecystitis: a protocol for a systematic review.

BACKGROUND: Acute cholecystitis is a common diagnosis. However, the heterogeneity of presentation makes it difficult to standardize management. Although surgery is the mainstay of treatment, critically ill patients have been managed via percutaneous cholecystostomy. However, the role of percutaneous cholecystostomy in the management of such patients has not been clearly established. This systematic review will compare the outcomes of critically ill patients with acute cholecystitis managed with percutaneous cholecystostomy to those of similar patients managed with cholecystectomy. METHODS/DESIGN: Systematic searches will be conducted across relevant health databases including the Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, Embase, and Scopus using the following keywords: (acute cholecystitis OR severe cholecystitis OR cholecystitis) AND (cholecystectomy OR laparoscopic cholecystectomy OR open cholecystectomy) AND (Cholecystostomy OR percutaneous cholecystectomy OR gallbladder drain OR gallbladder tube OR transhepatic gallbladder drain OR transhepatic gallbladder tube OR cholecystostomy tube). The reference lists of eligible articles will be hand searched. Articles from 2000-2014 will be identified using the key terms "acute cholecystitis, cholecystectomy, and percutaneous cholecystostomy". Studies including both interventions will be included. Relevant data will be extracted from eligible studies using a specially designed data extraction sheet. The Newcastle-Ottawa scale will be used to assess the quality of non-randomized studies. Central tendencies will be reported in terms of means and standard deviations where necessary, and risk ratios will be calculated where possible. All calculations will be performed with a 95 % confidence interval. Furthermore, the Fisher's exact test will be used for the calculation of significance, which will be set at p < 0.05. Pooled estimates will be presented after consideration of both clinical and methodological heterogeneity of included studies. Both interventions would be compared with regard to in-hospital mortality, 30-day mortality, procedure-dependent complications, re-intervention, length of intensive care unit (ICU) stay, length of hospital stay, re-admission, and cost of treatment. The review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. DISCUSSION: This systematic review aims at identifying and evaluating the clinical value of percutaneous cholecystostomy in the management of critically ill patients with acute cholecystitis. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015016205.

Cholecystectomy for acute cholecystitis. How time-critical are the so called "golden 72 hours"? Or better "golden 24 hours" and "silver 25-72 hour"? A case control study.

INTRODUCTION: Early cholecystectomy within 72 hours has been shown to be superior to late or delayed cholecystectomy with regard to outcome and cost of treatment. Recently, immediate cholecystectomy within 24 hours of onset of symptom was proposed as standard procedure for the management of fit patients presenting with acute cholecystitis. We sort to find out if there are any differences in surgical outcomes between patients managed within 24 h and those managed 25-72 h following symptom begin for acute cholecystitis. PATIENTS AND METHODS: A retrospective analysis was performed. The outcomes of patients undergoing laparoscopic cholecystectomy within 24 h were compared to those of patients managed 25-72 h following symptom onset for acute cholecystitis. RESULTS: 35 patients managed 25-72 h following begin of symptoms were matched with 35 patients with similar baseline features, medical comorbidities and disease severity managed within 24 hours of symptom onset. There were no significant differences in the duration of surgery, postoperative complications, rate of conversion and length of hospital stay. CONCLUSION: Immediate laparoscopic cholecystectomy for acute cholecystitis within 24 hour of symptom onset is not superior to surgery 25-72 hour after symptoms begin. Laparoscopic cholecystectomy for acute cholecystitis therefore can be safely performed anytime within the golden 72 h.

Swallowed foreign bodies in adults.

BACKGROUND: Foreign-body ingestion is a common event most often seen in children from 6 months to 6 years of age. In adults, foreign bodies are usually ingested accidentally together with food. This happens more commonly in persons with certain pathological changes of the gastrointestinal tract. METHODS: We present a selective review of pertinent literature retrieved by a search in the PubMed database. RESULTS: The foreign bodies most commonly ingested by adults are fish bones and chicken bones. The clinical approach to the problem depends on the type of material ingested and on the patient's symptoms and physical findings. In about 80% of cases, the ingested material passes uneventfully through the gastrointestinal tract; endoscopy is performed in about 20% of cases, and surgery in less than 1%. Emergency esophagogastroduodenoscopy (EGD) is recommended when the esophagus is completely occluded (because of the risk of aspiration and/or pressure necrosis), when the ingested object has a sharp point or edge (because of the risk of perforation, with ensuing mediastinitis or peritonitis), and when a battery has been ingested (because of the risk of necrosis and fistula formation). For non-occluding esophageal foreign bodies, including magnets, an urgent but non-emergency EGD within 12 to 24 hours is recommended. CONCLUSION: Most patients can be treated conservatively by observation alone, but there should be a low threshold for deciding to proceed to endoscopic retrieval. Surgery is reserved for complicated cases.