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PubMed2003

Cholecysto-choledochostomy plus construction of subcutaneous cholecystic tunnel in treatment of choledocholith.

OBJECTIVE: To avoid the pitfalls of choledochotomy with T-tube drainage in the treatment of choledocholith. METHODS: A novel operation was designed as cholecysto-choledochostomy plus construction of subcutaneous cholecystic tunnel. After the common bile duct was cut open and stones were removed, the gallbladder was appropriately dissociated and the cholecystic ampulla was incised. Then, the incision of the cholecystic ampulla was anastomosed to the opened common bile duct, and the cholecystic fundus was fixed out of the abdominal muscular stratum. RESULTS: Twenty-one patients with choledocholith underwent this operation successfully and recovered well without postoperative complications. One of them was diagnosed as having recurrent stones in 2 years and 3 months after operation. Consequently, the subcutaneous cholecystic tunnel was opened under local anesthesia to remove successfully the stones with choledochoscope. CONCLUSION: This operation provides a convenient way to remove postoperative recurrent stones with choledochoscope and avoid receliotomy.

Adult↗

PubMed1959

Radiographic signs of acute suppurative cholecystitis.

In a recent series of 26 pathologically proven cases of acute cholecystitis, preoperative radiographic examination of the abdomen confirmed the presence of an inflammatory process in 17. The radiographic signs associated with acute suppurative cholecystitis are:1. Enlargement of the gallbladder, as indicated by separation or alteration in position of opaque calculi or indentation of adjacent bowel.2. Localized peritoneal irritation, manifested by (a) ileus of hepatic flexure of colon; (b) ileus of duodenal loop; (c) effacement of haustra of the hepatic flexure or valvulae conniventes of the duodenum; (d) obscuration of fat line marking inferior border of liver.3. Cholecystitis emphysematosa.4. Perforation of gallbladder, which if localized (retroperitoneal) is manifested by bubbles of gas in the gallbladder bed. If generalized (intraperitoneal) the signs are adynamic ileus of small and large bowel, increased intraperitoneal fluid, subdiaphragmatic abscess and plate atelectasis of right lung base. Visualization of the gallbladder and biliary tree after intravenous cholecystography rarely occurred in the presence of acute cholecystitis. Plain film examination of the abdomen aids in establishing the diagnosis of an acute cholecstitis and leads to the early recognition of complications such as perforation and peritonitis.

Abdomen↗

PubMed2005

Outcome of laparoscopic cholecystectomy in acute cholecystitis.

OBJECTIVE: To evaluate the outcome of laparoscopic cholecystectomy in acute cholecystitis and to determine various pre-operative risk factors predicting conversion to open cholecystectomy. DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Surgery, Riyadh Medical Complex, Riyadh, Saudi Arabia over 5 years period from June 1, 1997 to May 30, 2002. PATIENTS AND METHODS: Consecutive patients admitted with clinical diagnosis of acute cholecystitis confirmed subsequently by abdominal ultrasonography and undergoing laparoscopic cholecystectomy during the same admission. Patients with symptoms of more than one week duration, or various uncontrolled co-morbid conditions requiring optimization before surgery were excluded. Parameters analyzed were morbidity, mortality, incidence and etiology of conversion. Various pre-operative risk factors predicting failure of laparoscopic procedure in acute cholecystitis were further analyzed. Statistical analyses were carried out employing Chi-square test, using IBM-compatible PC, utilizing SPSS 10.0 for Windows (SPSS Inc., Chicago). RESULTS: Three hundred and eleven patients qualified the inclusion criteria. Mean age was 43.7 years with female to male ratio of 4.5:1. Majority of the patients (91%) were operated within 72 hours of onset of symptoms. Laparoscopic cholecystectomy was successfully accomplished in 86.8 % cases. Out of the 41 converted cases, disturbed anatomy in the region of Calot's triangle was the most common cause of conversion observed in 41.5% patients. Male gender, age more than 65 years, very high leucocyte count, gallbladder wall thickness of more than 4 mm on ultrasonography and complicated disease were observed as most significant determinant for conversion to open procedure. Overall morbidity was 2.9% with no mortality. CONCLUSION: Laparoscopic cholecystectomy can be accomplished with minimal morbidity in acute cholecystitis. Knowledge of various factors predicting possible conversion helps in pre-operative selection and counseling for open procedure and early conversion to open technique, with further reduction in the overall morbidity of laparoscopic cholecystectomy.

Acute Disease↗

PubMed2000

Variation in the use of laparoscopic cholecystectomy for elderly patients with acute cholecystitis.

HYPOTHESIS: There is regional variation in the use of laparoscopic cholecystectomy (LC) for acute cholecystitis in the New England (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut) Medicare population. DESIGN: Population-based, cross-sectional study. SETTING: Hospital service areas (HSAs), small geographic areas reflecting local hospital markets, in New England. PATIENTS: We identified from the claims database 21 570 Medicare patients undergoing cholecystectomy between 1995 and 1997. Patients with acute calculous cholecystitis but no bile duct stones (n = 6156) were then identified using International Classification of Diseases, Ninth Revision diagnostic codes. To reduce variation by chance, we excluded patients residing in HSAs with fewer than 26 cases, leaving 5014 patients in 77 HSAs. MAIN OUTCOME MEASURES: For each HSA, we assessed the rate of cholecystectomies performed laparoscopically, mortality, and hospital length of stay. RESULTS: Overall, 53.5% of patients with acute cholecystitis underwent LC. There was wide regional variation in the rate of patients undergoing laparoscopic surgery, from 30.3% in the Salem, Mass, HSA to 75.5% in the Hyannis, Mass, HSA. Seventeen HSAs had rates below 40%, while 9 had rates above 70%. The average length of stay (7.6 days) was approximately 1 day shorter in HSAs with high rates of patients undergoing LC than in other HSAs. There was no correlation between regional use of laparoscopic surgery and 30-day mortality (3.1% overall). CONCLUSIONS: The likelihood of elderly patients with acute cholecystitis receiving LC depends strongly on where they live. Efforts to reduce regional variation should focus on disseminating techniques for safe LC in this high-risk population.

Acute Disease↗

PubMed1976

Postoperative acute acalculous cholecystitis.

Two patients with acute acalculous cholecystitis after major surgical operations (cystectomy ad modum Bricker because of carcinoma of the urinary bladder, and proctocolectomy because of ulcerative colitis) are described. Various possible causes of acalculous cholecystitis after operation or after trauma are discussed. Postoperative acute acalculous cholecystitis has a more fulminant course than ordinary calculous cholecystitis. Treatment consists of immediate cholecystectomy.

Acute Disease↗

PubMed1983

Acute cholecystitis and common-duct calculi.

The detection of common-duct stones is important in the treatment of patients with acute cholecystitis. The records of 256 patients with histopathologically confirmed acute cholecystitis were reviewed retrospectively. Associated choledocholithiasis was found in 32 (12.5%). Preoperative serum bilirubin and alkaline phosphatase levels were inconsistent predictors of common-duct calculi. Gray-scale ultrasonography is useful in the diagnosis of acute cholecystitis, but its role in the detection of common-duct calculi is uncertain. Dilated bile ducts were found in only three of eight icteric patients examined with ultrasonography. Intraoperative cholangiograms were obtained in 24 of 32 patients with choledocholithiasis, and common-duct stones were successfully demonstrated in 23 of these. Intraoperative cholangiography is a reliable method of detecting common-duct calculi and should be routinely used in the surgical treatment of acute cholecystitis.

Adolescent↗

PubMedDate not supplied

Further observations on the usefulness of the sonographic Murphy sign in the evaluation of suspected acute cholecystitis.

A positive sonographic Murphy sign, the presence of maximal tenderness elicited over a sonographically localized gallbladder, has been reported to be a helpful adjunctive finding in patients with proven acute cholecystitis who are evaluated with ultrasonography. We evaluated 200 patients with right upper quadrant pain, thought to be acute cholecystitis. Results of ultrasound examinations and subsequent follow-up were tabulated. The sensitivity of the sonographic Murphy sign in acute cholecystitis was 86% with a specificity of 35%, positive predictive value of 43%, and negative predictive value of 82%. The sensitivity of the sonographic findings, including stones, gallbladder wall edema, and pericholecystic fluid collections, was 93%, a specificity of 53%. The combination of the Murphy sign accompanied by gallstones yielded a specificity of 77%. The large number of false positives, and only moderate improvement in specificity when accompanied by gallstones, makes this sign unreliable in separating acute from chronic cholecystitis.

Abdominal Pain↗

PubMed1982

Hepatobiliary scanning in cholecystitis.

To validate the use of 99mTc-PIPIDA in the diagnosis of biliary tract disease, 117 patients with clinical symptoms of acute cholecystitis were prospectively scanned as an initial screening test. The accuracy of the test was evaluated on the basis of surgical pathology in 59 patients. Three groups were defined: cystic duct obstruction, common duct obstruction, and normal scan. The diagnostic accuracy of the test for acute cholecystitis was 97%. Complete common duct obstruction was confirmed at surgery in 12 patients (100%). A normal scan helped to rule out acute cholecystitis. Jaundice did not influence the reliability of the method. Hepatobiliary scanning is an accurate, safe, and rapid diagnostic test for acute cholecystitis.

Acute Disease↗

PubMed1983

Immunohistochemical demonstration of lysozyme in pseudopyloric glands in chronic cholecystitis.

Gallbladders of 12 cases with chronic cholecystitis showing pseudopyloric glands (PPG) and of 18 cases with acute cholecystitis or chronic cholecystitis but without PPG were examined by the peroxidase - antiperoxidase (PAP) method using rabbit antibody against human lysozyme (LM). LM-immunoreactivity was detected in the cytoplasm of PPG and, to a lesser extent, in the pits of epithelial crypts that gave rise to PPG. No LM was found in normal gallbladders; in cases of cholecystitis without PPG, LM-immunoreactivity was restricted to infiltrating inflammatory cells. The presence of LM in PPG suggests that PPG represent functional metaplastic areas, involved in the non-specific defence mechanisms through participation of LM.

Cholecystitis↗

PubMed1982

Hepatobiliary scanning in hemobilia-induced acute cholecystitis.

Radionuclide scanning of the hepatobiliary tree is highly accurate for the detection of patients with acute cholecystitis. Hemobilia, a rare complication of percutaneous liver biopsy, may result in blood clots within the biliary canaliculi. Such clots, like gallstones, may occlude the ducts and produce a clinical syndrome indistinguishable from acute cholecystitis. A patient with acute cholecystitis resulting from hemobilia following percutaneous biopsy of the liver is described. The diagnosis of acute cholecystitis secondary to blood clots was made with technetium 99mTc Iprofenin (Pipida [Sn]) scintigraphy. The patient was treated conservatively, and follow-up Pipida scan 6 weeks later demonstrated normal hepatobiliary function.

Adult↗

PubMed1994

Emphysematous cholecystitis after ERCP.

Emphysematous cholecystitis is a rare variant of acute cholecystitis, most frequently seen in elderly, debilitated, or diabetic patients. This report documents the development of fulminant sepsis due to acalculous cholecystitis after endoscopic retrograde cholangiopancreatogram (ERCP) in an otherwise healthy patient with suspected malignant obstructive jaundice. Three other cases of acute cholecystitis have been reported in the literature after ERCP. Although not proven to prevent infectious complications during ERCP, strong consideration should be given to prophylactic antibiotics in patients with suspected malignant obstruction and/or coexistent medical illness, eg, diabetes. When attempts at decompression of the obstructed biliary system by endoscopy fail, decompression by percutaneous or surgical routes should be considered in a timely fashion.

Acute Disease↗

PubMed1994

Experimental study of the pathogenesis of acute acalculous cholecystitis: role of autonomic denervation.

This study was undertaken to elucidate the role of autonomic denervation in the pathogenesis of acute acalculous cholecystitis. In Experiment I, the gallbladder was denervated by performing either celiac neurotomy (sympathetic denervation) or truncal vagotomy (parasympathetic denervation), or both, in dogs. In Experiment II, 45-min ischemia and 90-min reperfusion of the gallbladder with or without autonomic denervation were performed by simultaneously occluding the middle hepatic artery and superior mesenteric vein. Celiac neurotomy, and truncal vagotomy, or both, did not cause cholecystitis. Sympathetic denervation, however, decreased the amount of mucin in the gallbladder mucosa and parasympathetic denervation caused reduction of the tissue blood flow, as well as the accumulation of lipid peroxide and xanthine oxidase in the gallbladder mucosa. These changes were most remarkable 1-2 weeks after denervation and were alleviated 4 weeks after denervation. Ischemia-reperfusion 2 weeks after denervation caused more severe cholecystitis than ischemia-reperfusion alone. The most severe inflammation developed in animals that received both celiac neurotomy and truncal vagotomy. These results suggest that autonomic denervation alone does not induce acute cholecystitis, but that it plays an important role in the progression of the inflammatory process in ischemia-reperfusion injury.

Acute Disease↗

PubMed1991

Experimental study on the pathogenesis of acute acalculous cholecystitis, with special reference to the roles of microcirculatory disturbances, free radicals and membrane-bound phospholipase A2.

To elucidate the pathogenesis of acute acalculous cholecystitis, the gallbladder was subjected to ischemia-reperfusion by simultaneously occluding the middle hepatic artery and the superior mesenteric vein in dogs, and the degree of inflammation and biochemical changes in the gallbladder mucosa were studied by varying the duration of ischemia or reperfusion. Ischemia alone did not induce cholecystitis either macroscopically and histologically, although it increased phospholipase A2 (PLA2) activity, content of lipid peroxide, and superoxide dismutase (SOD) activity in the mucosa with prolongation of the ischemic time. Cholecystitis was produced in all animals by 45-min ischemia followed by 90-min reperfusion as the shortest ischemia and reperfusion times. In this model, prolongation of the ischemic time increased the area of mucosal inflammation horizontally with increases of the PLA2 activity, content of lipid peroxide, and SOD activity, whereas by prolonging the reperfusion time the inflammation area spread deeper vertically toward the serosal side with significant increase in the mucosal PLA2 activity, content of lipid peroxide, and SOD activity. These results revealed that ischemia-reperfusion plays an important role in the pathogenesis of acute acalculous cholecystitis, causing the generation of free radicals and the activation of membrane-bound PLA2.

Acute Disease↗

PubMed1997

Emergency minilaparotomy cholecystectomy for acute cholecystitis: prospective randomized trial--implications for the laparoscopic era.

This prospective controlled trial evaluates the efficacy of minicholecystectomy (MC) in cases of acute cholecystitis compared to that of conventional cholecystectomy (CC) and discusses its implications in the laparoscopic era. Sixty consecutive patients with acute cholecystitis were prospectively randomized into two groups: MC group (30 cases) and CC group (30 cases). The two groups were well matched with regard to age, sex, weight/height index, previous upper abdominal surgery, and APACHE II scores. The mean length of incision was 5.5 cm (range 4.5-9.0 cm) in the MC group compared to 13.5 cm (range 12-16 cm) in the CC group. No significant differences were found between MC and CC with regard to operative time (69.1 +/- 17.0 and 68.1 +/- 15.4 minutes, respectively; p = 0.82), operative difficulty on a 1 to 10 scale (5.2 +/- 1.5 versus 4.6 +/- 1.6, respectively; p = 0.177), and complication rate (11% and 17%, respectively; p = 0.19). Significantly lower analgesia requirements were noted in the MC group: 27.5 +/- 14.6 mg of morphine sulfate compared to 44.5 +/- 13.2 mg in the CC group (p < 0.001). In addition, the duration of hospital stay was significantly shorter for MC patients (3.1 +/- 1.0 days) than in CC patients (4.7 +/- 1.2 days) (p < 0.001). Twenty-two patients (73.3%) in the MC group were reported to return to normal daily activities 2 weeks after the operation, compared to only 12 (40%) in the CC group (p = 0.0028). MC is safe and applicable as an emergency procedure for acute cholecystitis. It is superior to CC in terms of convalescence and cosmesis. The results of MC in the setting of acute cholecystitis compare favorably with the published results of laparoscopic cholecystectomy.

Acute Disease↗

PubMed2003

Laparoscopic subtotal cholecystectomy for severe cholecystitis.

BACKGROUND: In severe cholecystitis, laparoscopic cholecystectomy can be technically difficult, and is associated with an increased rate of procedure conversions and common bile duct lesions. METHODS: We investigated the safety and complications of laparoscopic subtotal cholecystectomy for severe cholecystitis in a medium- to long-term follow-up evaluation. Laparoscopic cholecystectomy was performed in 345 patients during a period of 64 months. In 46 of the patients (13.3%), a subtotal cholecystectomy was performed. The results were compared with data on laparoscopic cholecystectomy from 16,130 patients in 84 surgical institutes in Switzerland, collected prospectively by the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS). RESULTS: The median operating time was 93 min (range, 50-140) min. The overall rate of procedure conversions in acute cholecystitis was lowered significantly from 23.2% (SALTS) to 9.7%. There was no bile duct lesion, as compared with the rate of 0.8% in the SALTS data. In follow-up evaluations, fluid collections in 16 patients (35%) and residual gallstones in 6 patients (13%) were of no clinical relevance. CONCLUSIONS: Laparoscopic subtotal cholecystectomy for acute cholecystitis offers a simple and safe solution that prevents bile duct injuries and decreases the rate of conversion in anatomically difficult situations.

Adult↗

PubMed2005

Percutaneous cholecystostomy for high-risk patients with acute cholecystitis.

BACKGROUND: Cholecystectomy remains the best treatment for acute cholecystitis but may cause high morbidity and mortality in critically ill or elderly patients. METHODS: From October 1995 to March 2004, percutaneous cholecystostomy was performed in 65 patients with acute cholecystitis. The mean age was 78 years (range, 45-95). All patients were American Society of Anesthesiologists (ASA) class III (n = 51) or ASA IV (n = 14). RESULTS: Percutaneous cholecystostomy was technically successful in 63 patients (97%) with no attributable mortality or major complications. In two patients, bile drainage was inefficient, requiring emergency laparoscopic cholecystectomy. One patient developed necrotic cholecystitis and died. The 30-day mortality rate was 13.8% (n = 9); eight patients died of respiratory or cardiac complications related to comorbidities. Mean drainage time was 18 days (range, 9-60). Postoperative length of hospital stay was 15 days (range, 7-30). Early and delayed cholecystitis occurred in six and five patients, respectively. During follow-up (mean, 20.4 months), five patients died of their underlying medical condition at 5, 6, 8, 12, and 14 months, respectively. In this study, delayed elective cholecystectomy was performed in 10 patients (15.3%). CONCLUSIONS: Percutaneous cholecystostomy is a valuable and effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.

Acute Disease↗

PubMed2006

Urgent laparoscopic cholecystectomy in the management of acute cholecystitis: timing does not influence conversion rate.

BACKGROUND: The optimal treatment of acute cholecystitis is urgent laparoscopic cholecystectomy. Most reports suggest that a delay of 72 or 96 h from onset of symptoms leads to a higher conversion rate. This study assessed the conversion rate in relation to the timing of urgent laparoscopic cholecystectomy for acute cholecystitis. METHODS: During a 12 month period, 112 patients received laparoscopic cholecystectomy for acute cholecystitis at a tertiary care university hospital in central Taiwan. Data were collected prospectively. RESULTS: The overall conversion rate was 3.6% (4/112). Of 62 procedures performed within 72 h from onset of symptoms, 2 were converted, as compared with 2 of 50 procedures after 72 h. Of 76 procedures performed within 96 h from onset of symptoms, 3 were converted, as compared with 1 of 36 procedures after 96 h. There were no mortalities or common bile duct injuries. CONCLUSIONS: The conversion rate for urgent laparoscopic cholecystectomy among patients with acute cholecystitis can be as low as 3.6%. The timing of urgent laparoscopic cholecystectomy has no impact on the conversion rate.

Adult↗

PubMed2006

Is there an optimal time for laparoscopic cholecystectomy in acute cholecystitis?

BACKGROUND: Laparoscopic cholecystectomy (LC) is safe in acute cholecystitis, but the exact timing remains ill-defined. This study evaluated the effect of timing of LC in patients with acute cholecystitis. METHODS: Prospective data from the hospital registry were reviewed. All patients admitted with acute cholecystitis from June 1994 to January 2004 were included in the cohort. RESULTS: Laparoscopic cholecystectomy was attempted in 1,967 patients during the study period; 80% were women, mean patient age was 44 years (range, 20-73 years). Of the 1,967 LC procedures, 1,675 were successful, and 292 were converted to an open procedure (14%). Mean operating time for LC was 1 h 44 min (SD +/- 50 min), versus 3 h 5 min (SD +/- 79 min) when converted to an open procedure. Average postoperative length of stay was 1.89 days (+/- 2.47 days) for the laparoscopic group and 4.3 days (+/- 2.2 days) for the conversion group. No clinically relevant differences regarding conversion rates, operative times, or postoperative length of stay were found between patients who were operated on within 48 h compared to those patients who were operated on post-admission days 3-7. CONCLUSIONS: The timing of laparoscopic cholecystectomy in patients with acute cholecystitis has no clinically relevant effect on conversion rates, operative times, or length of stay.

Adult↗