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PubMed2000

Treatment of acute cholecystitis. A comparison of open vs laparoscopic cholecystectomy.

BACKGROUND: In this study, the clinical results and cost-effectiveness of open vs laparoscopic cholecystectomy in the treatment of acute cholecystitis were compared. METHODS: Over a 5-year period (1994-98), 894 cholecystectomies were performed, 545 (60.96%) of them laparoscopically and 349 (39.04%) by the open method. The study included 209 patients with a clinical diagnosis of acute cholecystitis; 115 (55.02%) of them were operated on by the open method and 94 (44.98%) by the laparoscopic method. RESULTS: A comparison analysis revealed that the mean postoperative treatment period was 8.40 days after open and 4.38 days after laparoscopic cholecystectomy. In the group operated on by the open method, 106 patients received an antibiotic, a mean of 5.09 ampules and 3.2 tablets or suppositories of an analgesic, and 2.91 dressings per patient; whereas in the group submitted to the laparoscopic method, the comparable figures were 43, 3.13, 2.1, and 1.47, respectively. In 31 (26.96%) employed patients operated on by the open method, the mean absenteeism from work was 42 days; whereas in 31 (32.98%) of those operated on by the laparoscopic method, it was 17 days. The mean operating times for the procedures were 89 and 115 min for the open and laparoscopic methods, respectively. Two patients submitted to open cholecystectomy died within 30 days postoperatively. Wound infection was recorded in 10 (8.7%), prolonged biliary secretion in two, and cicatricial hernia in five (4.35%) patients. In the group submitted to laparoscopic cholecystectomy, there were no deaths; nine (9.57%) conversions were required; four patients had to be reoperated on, two of them for bile lobe hemorrhage and two for massive biliary secretion from the open cystic duct; herniation at the site of supraumbilical incision developed in three patients, and infection developed at the same site in two (2.13%) patients. The hospital cost was significantly higher in laparoscopic patients ($1181 vs $873) USD), as was the total cost of treatment for acute cholecystitis ($1430 vs $1316). However, the cost for sick leave and rehabilitation was significantly lower in laparoscopically treated patients ($486 vs $1199). CONCLUSIONS: Our comparison analysis of the results and cost-effectiveness of the surgical treatment of acute cholecystitis clearly pointed to the advantages of laparoscopic over open cholecystectomy-i.e., better clinical outcome and a more rapid resumption of daily activities. Hospital and total costs of treatment were on average higher in laparoscopic patients, except for the employed ones, where the lower sick leave cost translated into a significant reduction in total costs.

Acute Disease↗

PubMed1996

Laparoscopic management of acute cholecystitis. Prognostic factors for success.

BACKGROUND: Laparoscopic cholecystectomy for acute cholecystitis is considered feasible and safe, but it is associated with a higher rate of conversion to laparotomy than elective cholecystectomy because of technical reasons and anatomical changes related to the inflammatory process. The value of several factors that might influence its successful completion has not been studied completely yet, including the role of residents in operating such cases under attending-surgeon surveillance. METHODS: In a retrospective nonrandomized study, the medical charts of 182 patients that were operated for acute cholecystitis (94 of whom via the laparoscopic approach) were studied. The study was also conducted to study the effect of residents as operators. RESULTS: Male sex, duration of right upper abdominal pain, and the severity of the inflammatory process have all been significantly and independently correlated with increased conversion rate to laparotomy. Operation time was not longer than that of the open approach, and hospital stay and complication rate were lower. Operations performed by residents were associated with twofold conversion rate to laparotomy, without increased complication rate (p < 0.012). CONCLUSIONS: Laparoscopic management of acute cholecystitis is feasible and safe. Considering the factors discussed above, lowering the threshold for conversion is necessary in selected cases to maintain low morbidity rate. Integrating laparoscopic cholecystectomy for acute cholecystitis into surgical residency should be studied.

Acute Disease↗

PubMed2006

Timing of laparoscopic cholecystectomy for subacute calculous cholecystitis: early or interval--a prospective study.

BACKGROUND/PURPOSE: The aim of this prospective study was to evaluate the safety and feasibility of early laparoscopic cholecystectomy for subacute cholecystitis and to compare it with interval laparoscopic cholecystectomy. METHODS: The study was performed in 74 patients who had been diagnosed with subacute cholecystitis between January 2000 and June 2005. The patients were divided into two groups. The early laparoscopic cholecystectomy group was composed of 31 patients who underwent laparoscopic cholecystectomy 24 h after admission to the hospital. The interval laparoscopic cholecystectomy group was composed of 43 patients who underwent laparoscopic cholecystectomy 8-12 weeks after medical treatment. RESULTS: There was no significant difference between the conversion rate, intraoperative bleeding, need for intraoperative cholangiography, minor bile duct injury, and postoperative complications in the two groups. Eleven patients in the interval group underwent urgent laparoscopic cholecystectomy or additional procedures because of recurrent cholecystitis, choledocholithiasis, or biliary pancreatitis. The early group had a significantly shorter total hospital stay (P = 0.031), lower cost of treatment (P = 0.042), and less difficulty with Calot's triangle dissection (P = 0.008). CONCLUSIONS: Early laparoscopic cholecystectomy can be done without hesitation in patients with subacute cholecystitis, in the light of obstacles observed in the interval group, such as dissection difficulty, lack of success in "cooling down", and additional problems such as choledocholithiasis and biliary pancreatitis.

Adult↗

PubMed2002

Urgent versus interval laparoscopic cholecystectomy for acute cholecystitis: a comparative study.

BACKGROUND/PURPOSE: The surgical management of patients presenting with acute cholecystitis remains controversial. The aim of this study was to evaluate the safety and feasibility of urgent laparoscopic cholecystectomy (LC) during the "index" (acute) admission with acute cholecystitis, and to compare that with a policy of interval LC. METHODS: Between October 2000 and October 2001, 50 patients who had suffered with acute cholecystitis underwent LC. Thirty-three patients underwent surgery during the index admission (group I), of whom 11 patients had surgery within 96 h of admission. Seventeen patients were referred by colleagues to outpatients for, and underwent, an interval LC (group II). RESULTS: All operations were completed laparoscopically. There was no difference between the groups in the operating time (median [interquartile range]: 78 [61-124] versus 93 [53-128] min) or postoperative hospital stay (median, 1 day). The delay in performing an urgent LC beyond 96 h did not affect the operating time or postoperative stay but significantly increased the total hospital stay (median [interquartile range]: 5 (5-8) versus 13 [8-17] days; P = 0.001). CONCLUSIONS: Laparoscopic cholecystectomy during the index admission with acute cholecystitis can be performed safely and successfully. Earlier surgery has a beneficial impact for patients and the National Health Service.

Acute Disease↗

PubMed1999

Laparoscopic cholecystectomy in gallstone patients with acute cholecystitis.

It remains controversial whether patients with gallstones with acute cholecystitis should be operated on early, or whether surgery should be delayed until the acute phase subsides. To help resolve this question, we retrospectively studied 109 patients with acute cholecystitis, 56 of whom underwent laparoscopic cholecystectomy after acute cholecystitis had subsided (delayed group) and 53 of whom underwent early laparoscopic cholecystectomy--within 7 days after admission (early group). On admission, the inflammatory findings in the two groups were very similar; however, at operation, the inflammatory findings were alleviated in the delayed group, while they remained unchanged in the early group. The mean operative time for the two groups was very similar. As for intraoperative complications, there was no conversion to laparotomy in either group, and there were no major complications in either group. The total hospital stay was 37.7 +/- 14.4 days for the delayed group and 12.7 +/- 2.0 days for the early group, showing a highly significant difference (P < 0.001). Early laparoscopic cholecystectomy seems to be better than delayed treatment for patients with gallstones with acute cholecystitis.

Acute Disease↗

PubMed2005

Early versus delayed cholecystectomy for acute cholecystitis: a meta-analysis of randomized controlled trials.

PURPOSE: We performed a meta-analysis of randomized controlled trials to determine the optimal timing of laparoscopic cholecystectomy and open cholecystectomy for acute cholecystitis. METHODS: We retrieved randomized controlled trials (RCTs) that compared early with delayed cholecystectomy for acute cholecystitis by systematically searching Medline and the Cochrane Library for studies published between 1966 and 2003. The outcomes of primary interest were mortality and morbidity. RESULTS: The ten trials we analyzed comprised 1 014 subjects; 534 were assigned to the early group and 480 assigned to the delayed group. The combined risk difference of mortality appeared to favor open cholecystectomy in the early period (risk difference, -0.02; 95% confidence interval, -0.44 to -0.00), but no differences were found among laparoscopic procedures or among all procedures. The combined risk difference of morbidity showed no differences between the open and laparoscopic procedures. The combined risk difference of the rate of conversion to open surgery showed no differences in the included laparoscopic studies; however, the combined total hospital stay was significantly shorter in the early group than in the delayed group. CONCLUSIONS: There is no advantage to delaying cholecystectomy for acute cholecystitis on the basis of outcomes in mortality, morbidity, rate of conversion to open surgery, and mean hospital stay. Thus, early cholecystectomy should be performed for patients with acute cholecystitis.

Cholecystectomy↗

PubMed1980

Intraluminal gallbladder pressure measurements in patients with chronic or acute cholecystitis.

Gallbladder intraluminal pressures were determined during operation in 22 patients with chronic unobstructed cholecystitis and 25 patients with acute unobstructed cholecystitis by means of a glass manometer connected to a needle. Patients with chronic cholecystitis had a mean resting value of 9.9 +/- 0.9 cm H2O, and patients with acute cholecystitis had a mean fasting value of 36.0 +/- 1.8 cm H2O (p less than 0.001). The importance of these findings is discussed.

Acute Disease↗

PubMed1981

Acute acalculous cholecystitis. Ultrasonic diagnosis.

Ultrasonography is an effective and accurate diagnostic test for acalculous cholecystitis. Until recently, however, little attention was focused on the gallbladder wall as an indicator of disease. By accurately visualizing and measuring the gallbladder wall, ultrasonography can be used to screen patients in whom acute acalculous cholecystitis is suspected. If the gallbladder wall measures 3.5 mm or greater, in the absence of ascites, a diagnosis of acalculous cholecystitis can be made safely with a specificity greater than 98 percent. Four of our five patients with acute acalculous cholecystitis had ultrasonically measured gallbladder walls 3.5 mm or greater in width. We have found ultrasonography useful in any clinical situation, even in the face of ileus, jaundice or pancreatitis. In addition, with the use of the portable real-time ultrasound machine, postoperative, traumatized and other critically ill patients can be examined at the bedside.

Adult↗

PubMed1981

Diagnosis of acute cholecystitis using hepatobiliary scan with technetium-99m PIPIDA.

Sixty patients were evaluated for acute abdominal pain using technetium-99m PIPIDA hepatobiliary imaging. The sensitivity of the test was 90.6 percent in all patients and the accuracy was 93.3 percent. In the evaluation of acutely ill patients with right upper quadrant pain, fever, nausea and vomiting, hepatobiliary imaging with PIPIDA is the preferred test for diagnosing acute cholecystitis. If the test is positive, disease of the gallbladder and probably acute cholecystitis are present. Early operation can proceed if desirable. If the test is negative and the bilirubin level is less than 5.0 mg/dl, acute cholecystitis is not present. In such cases conservative treatment is appropriate, and follow-up tests should be performed to evaluate the possibility of chronic cholecystitis. When the bilirubin level exceeds 5.0 mg/dl, the test is often indeterminate.

Abdomen, Acute↗

PubMed1983

Acute acalculous cholecystitis in the critically ill patient.

Nine cases of acute acalculous cholecystitis were diagnosed in the surgical intensive care unit at Hartford Hospital during a 2 year period after abdominal, cardiovascular, and traumatic surgery. A tender mass in the right upper quadrant was suggestive but not diagnostic of the condition. Hyperamylasemia was seen in all patients. Ultrasonography is the most useful diagnostic tool; serial studies reveal progressive gallbladder dilatation and edema. Tube cholecystostomy was used in five patients and cholecystectomy in four. Cholecystostomy led to resolution of the inflammatory process in all five patients. Cholecystectomy should be reserved for those patients with extensive gallbladder necrosis. Six of the nine patients in the series died, all from multiple systems failure with concomitant sepsis. Hypotension is probably central to the development of acute acalculous cholecystitis. In the face of elevated intraluminal gallbladder pressure caused by ampullary edema and increased bile viscosity, hypotension may result in mucosal ischemia and necrosis with subsequent bacterial colonization. Acute acalculous cholecystitis represents another organ failure in critically ill patients who are experiencing progressive failure of multiple organ systems. An aggressive approach to the manifestations of organ failure, including acalculous cholecystitis, must be employed.

Acute Disease↗

PubMed1988

Common bile duct ligation in rabbit: a new model of acute cholecystitis description of histology and bile analysis.

The early stages of acute cholecystitis have been difficult to investigate due to the animal models developed and utilized over the past 60 years. A new model of animal acute cholecystitis induced by common bile duct ligation in the rabbit for 1 to 4 days produces histologic changes which are nearly identical to acute human cholecystitis. These changes include subserosal edema, hemorrhage, white cell infiltration, and dilatation of lymphatics. An inflammation scoring system is described with a range from 0 (not present) to 11 (the most severe). The inflammation score was 2 +/- 0.7 in control rising to 6.3 +/- 1.2 at 1 day of ligation and increasing further with time of duct ligation (P less than 0.01 all groups compared to control). Analysis of bile lithogenic index and concentrations of cholesterol, bile acids, and phospholipids showed no differences among control and experimental groups. Our findings show that the model of rabbit common bile duct ligation produces a histologic picture identical to human cholecystitis without chemical or physical manipulation of the gallbladder or significant changes in the bile lithogenic index.

Acute Disease↗

PubMed1991

Acute cholecystitis: radiological management.

Acute cholecystitis is a common condition which may be difficult to diagnose with confidence on clinical grounds alone. A large number of techniques are now available for imaging the gall bladder but, in practice, ultrasonography and cholescintigraphy are of greatest value. The former is cheap, readily available and features such as the presence of gall stones, gall bladder wall inflammation and a positive sonographic Murphy sign strongly suggest the diagnosis of acute cholecystitis. In addition to its diagnostic uses, ultrasonographically guided percutaneous cholecystostomy provides an alternative and sometimes life-saving form of treatment in those patients who are unfit for surgery. Cholescintigraphy is a highly accurate, non-invasive method for assessing patency of the cystic duct but is not always available in the emergency situation and takes longer to perform than an ultrasound examination. Acute cholecystitis, however, has many manifestations and may be calculous or acalculous, be associated with a patent or obstructed cystic duct, and may be complicated or uncomplicated. Imagining modalities other than those mentioned above may be useful in certain circumstances and this chapter aims to present the advantages and disadvantages of each technique in order to provide guidance for the clinician caring for a patient with suspected acute cholecystitis.

Acute Disease↗

PubMed2003

Prognostic factors for the development of gangrenous cholecystitis.

BACKGROUND: The operative morbidity and mortality for patients with gangrenous cholecystitis (GC) remains high. Our objective was to identify preoperative prognostic factors for GC in order to distinguish this subset of patients with acute cholecystitis (AC). METHODS: From 1/98 to 11/01 the medical records of patients who presented with the diagnosis of AC were reviewed. Univariate and multivariate analysis were performed on this retrospective data. RESULTS: Of 113 patients with acute cholecystitis, 45 (39.8%) had histologically confirmed gangrenous cholecystitis. Nine variables were identified that were associated with GC by univariate analysis: age > or =51 years, African-American race, white blood cell count > or =15,000, diabetes, pericholecystic fluid, asparate aminotransferase, alanine aminotransferase, alkaline phosphatase, and lipase. Two variables were identified by multivariate analysis: diabetes, and white blood cell count. CONCLUSIONS: Our data suggest that patients with a history of diabetes and white blood cell count >15,000 to be at an increased risk for having GC upon presentation and they should have urgent surgical intervention.

Acute Disease↗

PubMed2006

Cholecystitis in neutropenic patients: retrospective study and systematic review.

Abdominal infections are life-threatening complications in neutropenic patients. Among these, neutropenic cholecystitis is relatively rare. Nevertheless, its actual relevance is only investigated by anecdotal reports. We present a consecutive retrospective series of nine patients over a 12-year period. We calculated a frequency of 0.4% among all neutropenic episodes in patients with acute leukemia or aggressive lymphoma undergoing myelosuppressive chemotherapy. Only three of these patients had gallstones. Four patients died during the course of cholecystitis but in none of them cholecystitis was the primary cause of death. Systematic review of the literature revealed 45 patients with neutropenic cholecystitis of whom 26.7% died.

Acute Disease↗

PubMed1999

[Laparoscopy or laparotomy in acute cholecystitis (200 cases). Comparison of the results and factors predictive of conversion].

STUDY AIM: The aim of this prospective study was to compare the results of cholecystectomy for acute cholecystitis through laparoscopic and open approach and to assess factors responsible for conversion into laparotomy. PATIENTS AND METHODS: From January 1991 to October 1997, 200 patients with calculous acute cholecystitis were operated on in the same center, 100 through laparoscopy and 100 through laparotomy. Choice between these two procedures was only dependent on the disresponsibility of videolaparoscopic material. Comparison between laparoscopy and laparotomy groups concerned postoperative mortality and morbidity rates, hospital stay duration and late results. Intraoperative conversion into laparotomy occurred in 24 patients and factors responsible for conversion were assessed with univaried and multivaried analysis. RESULTS: Both groups were comparable with regard to sex ratio, age, ASA score but associated diseases incidence, plastron, fever above 38 degrees C and leucocytosis were significantly more frequent in the laparotomy group and delay between diagnosis and surgery was significantly longer in the laparoscopic group. There were two postoperative deaths in the laparotomy group, 0 in the laparoscopic group (NS). Morbidity rate was higher (32% versus 10%) (p = 0.0002) and hospital stay longer (12 +/- 10 days, versus 5 +/- 3) in the laparotomy group (p = 0.00005). Late results were similar in both groups. Conversion rate into laparotomy was 24%. Factors predisposing significantly to conversion were in univaried analysis: plastron, fever above 38 degrees C, leucocytosis, delay between diagnosis and surgery above 4 days, presence on ultrasonography of pericholecystic liquid and gallbladder wall edema, presence of "Klebsiella" in gallbladder bile. With multivaried analysis, leucocytosis and delay between diagnosis and surgery were the only independent factors. CONCLUSION: Videolaparoscopic cholecystectomy is a safe and efficient technique in the treatment of acute cholecystitis, with a lower postoperative morbidity rate and a shorter hospital stay. Conversion rate into laparotomy is significantly dependent on leucocytosis and delay between diagnosis and surgery. Laparoscopic cholecystectomy should be performed as soon as possible in acute cholecystitis.

Acute Disease↗

PubMed2002

How early is early laparoscopic treatment of acute cholecystitis?

BACKGROUND: Despite the well-accepted success of laparoscopic cholecystectomy in elective treatment of symptomatic cholelithiasis, the efficacy and timing of this technique has been subject to some debate in the setting of acute cholecystitis. This study was undertaken to evaluate our institution's experience with early cholecystectomy as a safe, effective treatment of acute cholecystitis. METHODS: Charts of all patients who had undergone laparoscopic cholecystectomy for the diagnosis of acute cholecystitis were reviewed. Patients were divided into two groups based on the length of time from onset of symptoms to surgical intervention: less than 48 hours in the early group (n = 14) and more than 48 hours in the late group (n = 31). RESULTS: Comparing the two groups, the conversion rate to an open procedure was significantly less (0 versus 29%, P <0.04) in the early treated patients. Furthermore, the operative time (73 versus 96 minutes, P <0.004), postoperative hospitalization (1.2 versus 3.9 days, P <0.001), and total hospital stay (2.1 versus 5.4 days, P <0.004) were significantly reduced in patients undergoing early laparoscopic cholecystectomy. CONCLUSIONS: Laparoscopic cholecystectomy performed by experienced surgeons is a safe, effective technique for treatment of acute cholecystitis. Patients treated within 48 hours of onset of symptoms experience a lower conversion rate to an open procedure, shorter operative time and reduced hospitalization.

Acute Disease↗

PubMed2002

Increased laparoscopic experience does not lead to improved results with acute cholecystitis.

BACKGROUND: As laparoscopic experience increases, ever more challenging cases are attempted. Enlarged surgeon experience, along with better technology, has been lauded as improving outcomes. The purpose of this study is to see if this applies to the management of acute cholecystitis. METHODS: We reviewed our experience over a 7 and a half year period. Information was obtained from a prospectively maintained computer database containing patient presentation, demographics, workup, laboratory values, and outcomes. Diagnosis of gangrene was based on pathologic examination of the specimen. RESULTS: There were 305 patients admitted to our institution with acute cholecystitis. Group I (n = 111) was admitted during the first half of the study and group II (n = 194) during the second half. Demographics were similar in the two groups. While slightly more patients were attempted laparoscopically in group II (90% versus 82%), conversion rates were virtually identical (27.1% versus 27.5%). There was a trend toward improved results with group II versus group I in mortality (3% versus 4%) and morbidity (14% versus 21%; P = not significant). Deaths were divided between sepsis and cardiac events. Gangrenous cholecystitis was less frequent in group II patients (29% versus 40%; P = 0.06). Analysis of gangrene versus non-gangrene patients within each group showed that conversion rates remained twice as high (40% versus 20%; P < 0.05) in those with gangrene. Interestingly, gangrene had no effect on morbidity or mortality. CONCLUSIONS: Morbidity and mortality for acute cholecystitis remain relatively high. These seem to be determined by the degree of acute and chronic illness present at the time of diagnosis. As conversion rates remain unchanged, increased surgeon experience and further advances in laparoscopic technology are unlikely to dramatically affect results. Efforts to improve outcomes for this common disease should therefore focus on better and earlier identification of patients for operation.

Acute Disease↗

PubMed1997

Early decision for conversion of laparoscopic to open cholecystectomy for treatment of acute cholecystitis.

BACKGROUND: Although recent reports suggest an initial laparoscopic approach to acute cholecystitis, the risk factors and consequences of the failure of an attempt remained unknown. METHODS: A retrospective study of 557 laparoscopic cholecystectomies was undertaken to identify 70 patients (13%) with a clinical diagnosis of acute cholecystitis confirmed by ultrasonography. Patients who required conversion to laparotomy (conversion group) were compared to those with successful laparoscopic cholecystectomy (successful group). RESULTS: Eight of 70 patients (11%) required conversion. The conversion group had significantly more elderly (< or =65 years) patients (88% vs 37%; P = 0.02) and larger gallstones as shown on ultrasonography (25 mm vs 15.5 mm; P = 0.03). Other preoperative factors associated with severe inflammation were not predictive. Conversion was associated with the intraoperative finding of severe adhesions and not with those of empyema of gallbladder or gangrenous cholecystitis. Conversion was made after a median laparoscopic surgery time of 50 minutes. The conversion group required more operation time, more analgesics, a longer recovery time, and a longer hospital stay. In addition, the postoperative complication rate was significantly higher (63% vs 16%; P = 0.009). CONCLUSIONS: Patients who required conversion from laparoscopic to open cholecystectomy for acute cholecystitis are at risk for postoperative complications. In elderly patients with large gallstones, the surgeon should made an early decision to convert if severe adhesions are encountered.

Acute Disease↗