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PubMed2000

[Percutaneous cholecystostomy for acute cholecystitis in high-risk patients].

AIM OF THE STUDY: The aim of this retrospective study was to report the results of percutaneous cholecystostomy in a selected group of high-risk patients with contraindications of general anesthesia. PATIENTS AND METHODS: From October 1995 to December 1999, a percutaneous cholecystostomy was performed in 29 patients with acute cholecystitis. There were 20 women and nine men with a mean age of 80.6 years (range: 59 to 95 years). All the patients were ASA III (N = 23) or ASA IV (N = 6). Ultrasound-guided percutaneous cholecystostomy was performed in 24 cases and computed tomography-guided cholecystostomy in five cases. RESULTS: Percutaneous cholecystostomy was easily performed in 28 cases; there was one failed procedure. The drainage was not efficient in three patients who were operated on with one postoperative death of a patient who had a necrotic cholecystitis. There was no mortality in relation with cholecystostomy. One patient died at day 15 from myocardia infarction. The morbidity rate was 3.4% (one case). Postoperative length of hospital stay was 13 days (range: 7-30 days). The duration of the entire procedure ranged from 9 to 60 days (mean: 20 days). The mean follow-up of patients was 17 months (range: 4-40 months). One patient had recurrent acute cholecystitis and another one had angiocholitis; two patients underwent delayed elective laparoscopic cholecystectomy; 20 patients remained asymptomatic and 16 were still alive at the time of this study (13 with biliary stones and three without). CONCLUSION: Percutaneous cholecystostomy is a valuable alternative procedure for high-risk patients with acute cholecystitis. It's a safe and usually effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.

Acute Disease↗

PubMed1980

Chronic cholecystitis and the oral cholecystogram.

Gallbladder image density at oral cholecystography has been compared with histological grading of the severity of chronic cholecystitis in resulting cholecystectomy specimens. (i) There was a linear relationship between gallbladder opacification and the grade of chronic cholecystitis. (ii) Removal of patients with either non-opacified gallbladders or abnormal liver function did not alter the linear trend. (iii) The occurrence of gallstones was independent of the degree of gallbladder opacification. (iv) The presence of gallstones did not correlate with the severity of chronic cholecystitis. A standardised oral cholecystographic technique with a grading system for gallbladder image density can be used as an index of the severity of chronic cholecystitis.

Cholecystitis↗

PubMed1987

Ultrasound changes of the gallbladder wall in cholecystitis: a sonographic-pathological correlation.

To assess the pathological basis of the changes seen on ultrasound examination of the gallbladder wall in cholecystitis, the appearances of the gallbladder wall were analysed in 17 patients with acute cholecystitis and 27 patients with chronic cholecystitis, and correlated with the pathological specimens removed at surgery. A thin echo reduced layer within the echogenic gallbladder wall corresponds to a complex of subserosal oedema, haemorrhage and inflammatory cell infiltration, or to muscular hypertrophy. Indistinctness or a low echogenicity rind along the inner margin represents mucosal sloughing or obliteration of the mucosal folds. Uniformly decreased echogenicity of the wall is caused by severe inflammatory change with sloughing of the mucosa or obliteration of the mucosal folds. These ultrasound signs are considered to be valuable signs of cholecystitis.

Acute Disease↗

PubMed2004

An evaluation of laparoscopic cholecystectomy after selective percutaneous transhepatic gallbladder drainage for acute cholecystitis.

BACKGROUND: The aim of this study was to evaluate the safety and usefulness of laparoscopic cholecystectomy after selective percutaneous transhepatic gallbladder drainage in patients with severe acute cholecystitis and patients with acute cholecystitis and severe comorbid disease. METHODS: According to whether percutaneous transhepatic gallbladder drainage was performed before surgery, 133 patients with acute cholecystitis were divided into a percutaneous transhepatic gallbladder drainage group (n=60) and non-percutaneous-transhepatic-gallbladder-drainage group (n=73). Background factors, safety, and postoperative course were retrospectively evaluated and compared between these two groups. RESULTS: Compared with the non-percutaneous-transhepatic-gallbladder-drainage group, the percutaneous transhepatic gallbladder drainage group was significantly older (p=0.0009), had a higher frequency of comorbid disease (p=0.0252), and a worse American Society of Anesthesiology classification (p=0.0021). In individual statistical tests, body temperature (p=0.0288), white blood cell count (p=0.0175), and C-reactive protein value (p=0.0022) were significantly elevated in the percutaneous transhepatic gallbladder drainage group; however, for frequency of comorbid disease, body temperature, and white blood cell count, significance was removed by correction for multiple testing of data. There was no significant difference in gender distribution, history of upper abdominal surgery, or body mass index between the two groups. The duration of surgery was marginally but significantly longer in the percutaneous transhepatic gallbladder drainage group (p=0.0414; in a single statistical test; however, that significance was removed by correction for the multiple testing of data). Between the two groups, there was no significant difference in blood loss at surgery, frequency of postoperative complications, rate of conversion to open laparotomy, interval until oral feeding was resumed, and length of postoperative hospital stay. CONCLUSIONS: These data suggest that satisfactory outcomes can be achieved with selective pre-operative gallbladder drainage in older and sicker patients with acute cholecystitis.

Acute Disease↗

PubMed1989

Gangrenous acalculous cholecystitis in a premature infant.

Acute acalculous cholecystitis is uncommon, although children are more likely to have this condition than adults. A 1,100-g premature baby girl with a gangrenous acalculous cholecystitis is reported. She presented with clinical and radiographic findings that were initially interpreted as necrotizing enterocolitis. An exploratory laparotomy demonstrated the presence of an acute gangrenous acalculous cholecystitis, and a cholecystectomy was performed. To our knowledge, this one of the smallest patients reported with this entity, and the first whose condition was initially diagnosed as necrotizing enterocolitis. It is important to recognize this entity and consider it in the differential diagnosis of premature infants, because in patients with necrotizing enterocolitis nonoperative management should be attempted initially, and patients with acute gangrenous cholecystitis most likely will require a laparotomy and cholecystectomy.

Acute Disease↗

PubMed1988

Acute cholecystitis.

Acute cholecystitis is a common cause of the acute abdomen. The diagnosis has been distinctly improved with the development of ultrasonography and hepatobiliary scanning over the past 20 years. The treatment is cholecystectomy, with early as opposed to delayed operation gaining increasing popularity nationwide. Acute acalculous cholecystitis and emphysematous cholecystitis are special features of acute cholecystitis occurring in more complicated cases and requiring diligence in diagnosis and great care in treatment.

Abdomen, Acute↗

PubMed1990

Surgery for acute and chronic cholecystitis.

Cholecystostomy and cholecystectomy remain appropriate and effective therapy for acute and chronic cholecystitis. Cholecystectomy is the gold standard against which all alternative methods of treatment of inflammatory biliary stone disease should be judged. The pathogenesis, diagnosis, and surgical treatment of acute and chronic cholecystitis have been described. Techniques of cholecystostomy, cholecystectomy, and intraoperative cholangiography used by the author have been given. Our results and those generally described in the literature indicate that the overall mortality rate for cholecystectomy, in all age groups, is approximately 0.5%. This rate increases slightly in patients with acute cholecystitis and in those over the age of 65 years. Cholecystectomy remains the most effective and the definitive treatment for acute and chronic cholecystitis.

Acute Disease↗

PubMed1998

Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis.

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the treatment of choice for elective cholecystectomy, but controversy persists over use of this approach in the treatment of acute cholecystitis. We undertook a randomised comparison of the safety and outcome of LC and open cholecystectomy (OC) in patients with acute cholecystitis. METHODS: 63 of 68 consecutive patients who met criteria for acute cholecystitis were randomly assigned OC (31 patients) or LC (32 patients). The primary endpoints were hospital mortality and morbidity, length of hospital stay, and length of sick leave from work. Analysis was by intention to treat. Suspected bile-duct stones were investigated by preoperative endoscopic retrograde cholangiography (LC group) or intraoperative cholangiography (OC group). FINDINGS: The two randomised groups were similar in demographic, physical, and clinical characteristics. 48% of the patients in the OC group and 59% in the LC group were older than 60 years. 13 patients in each group had gangrene or empyema, and one in each group had perforation of the gallbladder causing diffuse peritonitis. Five (16%) patients in the LC group required conversion to OC, in most because severe inflammation distorted the anatomy of Calot's triangle. There were no deaths or bile-duct lesions in either group, but the postoperative complication rate was significantly (p=0.0048) higher in the OC than in the LC group: seven (23%) patients had major and six (19%) minor complications after OC, whereas only one (3%) minor complication occurred after LC. The postoperative hospital stay was significantly shorter in the LC than the OC group (median 4 [IQR 2-5] vs 6 [5-8] days; p=0.0063). Mean length of sick leave was shorter in the LC group (13.9 vs 30.1 days; 95% CI for difference 10.9-21.7). INTERPRETATION: Even though LC for acute and gangrenous cholecystitis is technically demanding, in experienced hands it is safe and effective. It does not increase the mortality rate, and the morbidity rate seems to be even lower than that in OC. However, a moderately high conversion rate must be accepted.

Acute Disease↗

PubMed2001

Diagnosis of acute cholecystitis: sensitivity of sonography, cholescintigraphy, and combined sonography-cholescintigraphy.

BACKGROUND: Radiographic diagnosis of acute cholecystitis can be established using ultrasonography (US), cholecystoscintigraphy (HIDA), or both. Although both modalities have been effective in diagnosing acute cholecystitis (AC), physicians from the emergency department and admitting surgeons continue to request both tests in an attempt to increase the diagnostic accuracy of AC. This article reports the institutional experience of a large tertiary care health care facility, with respect to the sensitivity of US, HIDA, and combined US and HIDA. STUDY DESIGN: We conducted a retrospective review of 132 patients diagnosed with AC who underwent laparoscopic cholecystectomy during the same hospitalization. Patients were stratified into three groups: Group 1 (Gp1, n = 50) included patients who underwent US alone, group 2 (Gp2, n = 28) included patients who underwent HIDA scan alone, and group 3 (Gp3, n = 54) included patients who underwent both US and HIDA. RESULTS: The three groups did not differ with respect to age, liver chemistry, time to operation, and hospital length of stay. The sensitivity of US, HIDA, and combined US/HIDA as diagnostic modalities for acute cholecystitis was referenced to histopathologic confirmation. Sensitivity was 24 of 50 (48%), 24 of 28 (86%), and 49 of 54 (90%) for US, HIDA, and the combination of US/HIDA, respectively. CONCLUSIONS: HIDA scan is a more sensitive test than US in diagnosing patients with AC. Based on the results of this study, we recommend that HIDA scan should be used as the first diagnostic modality in patients with suspected acute cholecystitis; US should be used to confirm the presence of gallbladder stones rather than to diagnose AC.

Acute Disease↗

PubMed2000

Enhanced cell kinetics, p53 accumulation and high p21WAF1 expression in chronic cholecystitis: comparison with background mucosa of gallbladder carcinomas.

AIMS: Since neoplasia resulting from chronic inflammation has recently attracted increasing attention, we have investigated surgically removed gallbladders to examine the relationship between chronic cholecystitis and carcinogenesis. METHODS AND RESULTS: The mucosa of 108 cholecystectomy specimens without gallbladder cancer and 54 surgically resected gallbladder carcinomas were classified into three groups according to the degree of lymphocytic infiltration, and assessed immunohistochemically for Ki67, p53, p21WAF1 and apoptosis. In gallbladder mucosa without carcinoma, all four parameters tended to increase with the inflammation score (IS). Significantly positive correlations were revealed between Ki67 and p53, Ki67 and p21WAF1, and p53 and p21WAF1. However, in gallbladder carcinoma cases, values of p53 and p21WAF1 for background mucosa were elevated as compared to the mucosa of cholecystitis with low IS, but there was no correlation between their expression and IS, except for Ki67. CONCLUSIONS: Severe chronic cholecystitis is associated with acceleration of epithelial cell turnover, damaged cells being eliminated by apoptosis. The background mucosa of gallbladder carcinomas showed similar cell proliferative activity (Ki67) to that in cholecystitis, with no parallel changes of p53 and p21WAF1 expression, suggesting the possibility of unknown cofactors causing genomic damage.

Adenocarcinoma↗

PubMed2002

Immunohistochemical detection of 8-hydroxydeoxyguanosine, a marker of oxidative DNA damage, in human chronic cholecystitis.

AIMS: Recent studies suggest that oxidative DNA damage induced during chronic inflammation may play a role in carcinogenesis in some organs. Although gallbladder carcinomas are frequently observed with a background of chronic cholecystitis, little is known about oxidative DNA damage in chronic cholecystitis. The aims of this study were to investigate the expression of 8-hydroxydeoxyguanosine (8-OHdG), a biomarker of oxidative DNA damage, in normal and chronically inflamed human gallbladder mucosa and compare its expression with clinicopathological findings. METHODS AND RESULTS: 8-OHdG expression was immunohistochemically examined using a monoclonal antibody against 8-OHdG in human gallbladder specimens. In normal gallbladder (n=5), no 8-OHdG expression was observed. In contrast, nuclear expression of 8-OHdG was detected in 28 of 31cases (90.3%) in gallbladder epithelial cells with chronic cholecystitis. The positive cells were predominantly observed in the areas of active inflammation with prominent cell infiltration. Quantitative analysis revealed that the number of 8-OHdG+ cells (labelling index) significantly (rs=0.671, P < 0.05) correlated with the degree of the activity of mucosal inflammation, while gender, age, and the presence of gallstones did not influence the index. CONCLUSIONS: Oxidative DNA damage is common in chronic cholecystitis, suggesting a possible link between chronic inflammation and gallbladder carcinogenesis.

8-Hydroxy-2'-Deoxyguanosine↗

PubMed2004

Endogenous endothelin increases gallbladder tone and leads to acute cholecystitis in the Australian possum.

Endothelins are bioactive peptides produced by gallbladder epithelial cells. We aimed to determine the role of endothelins in acute cholecystitis. Escherichia coli lipopolysaccharide vs saline (sham) was instilled into the gallbladder lumen of Australian possums. Some animals received the non-selective endothelin antagonist, tezosentan. At 4 or 24 h, plasma and gallbladder endothelins and white blood cell count (WBCC) were determined. Acute cholecystitis was assessed using a histopathology score. In other animals gallbladder tone was determined. At 4h, a dose-dependent 60-fold increase in gallbladder endothelin level occurred (P = 0.001) but other parameters remained comparable with sham animals. Epithelial cells were endothelin-immunoreactive. At 24 h, the WBCC rose (P < 0.007), and severe cholecystitis developed. Gallbladder but not plasma endothelin levels remained elevated. Tezosentan pre-treatment resulted in a histologically normal gallbladder, but the WBCC and gallbladder endothelin levels were elevated. Lipopolysaccharide or saline instillation also caused a time-dependent increase in gallbladder tone over 4 h (P < 0.001), but not in control animals. This increase was reduced by tezosentan treatment. Gallbladder endothelin production is an early event in acute cholecystitis, increases gallbladder tone and plays a crucial role in the inflammatory process.

Animals↗

PubMed1999

The early operation for acute severe cholecystitis: the Riedel paper; an introduction and translation.

BACKGROUND: For acute cholecystitis in the latter 19th century and early 20th century, the diagnosis was difficult and the management not defined. METHODS AND RESULTS: Bernhard Riedel of Jena in Germany documented his patients, analysed his results, and described his method of cholecystectomy. CONCLUSIONS: Riedel advocated early operation for acute cholecystitis when the conditions were favourable, as for acute appendicitis. He stressed the importance of good lighting, an experienced surgeon and trained assistants. He advocated conservative treatment for minor cholecystitis (biliary colic) until the diagnosis was certain, followed by elective cholecystectomy to reduce the risk of subsequent acute cholecystitis or bile duct stones. Caution was advised when analysing previous statistics, to ensure appropriate patient comparison.

Acute Disease↗

PubMed1978

[Intravenous cholegraphy in acute cholecystitis (author's transl)].

In this prospective study iv-cholegraphy was performed before surgery on 152 patients by whom acute cholecystitis could not be excluded. The examination was diagnostic in 85% of the cases. Most of the patients (20/23) with nonvisualization of the biliary tract by iv-cholegraphy suffered from acute cholecystitis, the others (3/23) from acute pancreatitis. In three false negative examinations the opacification of the gallbladder was weak and in three false positive cases the cystic duct obstruction was caused by a chronic gallbladder disease. Because the preliminary clinical suspicion of acute cholecystitis even when using rigid criteria proved to be false in 30% of the cases, we consider a radiologic clarification to be indicated. Iv-cholegraphy is found to be an important examination in acute cholecystitis, practicable even at small radiologic departments with conventional equipment, and a reliable indicator of cystic duct obstruction.

Acute Disease↗

PubMed2006

Conservative treatment versus endoscopic sphincterotomy in the initial management of acute cholecystitis in elderly patients at high surgical risk.

BACKGROUND AND STUDY AIMS: Surgery in elderly patients with acute cholecystitis is quite a high-risk procedure. The recent finding that activated pancreatic enzyme is present in sterile bile from the acutely inflamed gallbladder suggests that obstruction at the level of the common channel is a possible precipitating factor. It was therefore hypothesized that an initial endoscopic sphincterotomy in patients with acute cholecystitis might improve the clinical course. PATIENTS AND METHODS: A prospective unselected series of 105 patients over 65 years of age (52 men, 53 women; mean age 78) suffering from acute cholecystitis were initially treated on a random basis with either conservative methods or endoscopic sphincterotomy. Within the first 72 h after the onset of symptoms, all 52 patients in the endoscopic sphincterotomy group were managed by endoscopic retrograde cholangiopancreatography (ERCP), combined with endoscopic sphincterotomy in 50 cases. The main study parameter was the need for emergency cholecystectomy within the first week after admission. RESULTS: Biliary sepsis requiring emergency surgery occurred in 15 patients in the conservatively treated group, in contrast with none of the 52 patients in the endoscopic sphincterotomy group ( P < 0.001). Iatrogenic complications after endoscopic sphincterotomy occurred in three patients, one of whom required surgery, while two were managed by conservative means. The clinical course improved, avoiding the need for emergency cholecystectomy and other interventions, in 48 patients in the endoscopic sphincterotomy group and in 36 patients in the conservatively treated group ( P < 0.01). CONCLUSIONS: The clinical course after endoscopic sphincterotomy improved in the majority of elderly patients suffering from acute cholecystitis, suggesting that early relief of obstruction at the level of the common channel reduces the risk of developing biliary sepsis. The majority of these patients can undergo surgery electively or can receive further conservative treatment.

Aged↗

PubMed1992

[Sonomorphology of stress cholecystitis].

Acute acalculous cholecystitis is a well-known complication in postoperative and particularly in severely traumatized unit patients. All that is known so far of "stress"-cholecystitis is based on episodic case reports and retrospective analyses. An incidence between 0.5 and 4.2%, a complicated clinical course and a lethality up to 75% have been reported. In intensive-care unit patients a clinical diagnosis of suspected acute cholecystitis is rarely reliable; greater reliance is placed on the ultrasound findings as seen in our prospective study. According to the literature, the established ultrasound criteria of cholecystitis include: hydrops, thickening of the gallbladder wall, sludge, subserosal oedema, pericholecystic fluid collection and fragmentation of the gallbladder wall. Other factors, however, may also lead to morphological changes of the gallbladder, and hence there is no agreement about the definitive sonomorphology of this entity. The variability of sonomorphological criteria is reviewed and compared to the results of a series of our own.

Acute Disease↗

PubMed1987

Ultrasound in acute and chronic cholecystitis.

Sonograms of 412 consecutive patients with operatively and histologically proven acute or chronic cholecystitis were reviewed retrospectively. 267 of them had been operated on in an acute phase of gallbladder disease and 145 had undergone an elective operation. 236 patients had an operative and/or histological diagnosis of acute cholecystitis and 176 both operatively and histologically confirmed chronic cholecystitis. A thickened gallbladder wall was seen in 80% of acute cases, wall sonolucency in 39%, dilated gallbladder in 60%, sludge in 26% and stones in 75%, the corresponding proportions of the chronic cases being 18%, 4%, 12%, 13% and 93%. A contracted gallbladder with stones was seen in 15% of the chronic and 1% of the acute cholecystitis cases. 90% of the acute cases had two or more sonographic abnormalities, whereas 70% of the chronic cases had only one abnormality, most frequently gallstones. Only one normal sonographic finding was recorded in each group.

Acute Disease↗

PubMed2000

Safety and usefulness of percutaneous transhepatic cholecystoscopy examination in high-risk surgical patients with acute cholecystitis.

BACKGROUND: The aim of the present study was to evaluate the diagnostic and therapeutic usefulness of percutaneous transhepatic cholecystoscopy in high-risk surgical patients with acute cholecystitis. METHODS: Between January 1992 and June 1998, there were 33 consecutive patients who underwent percutaneous transhepatic cholecystostomy and subsequent percutaneous transhepatic cholecystoscopy for the management of acute cholecystitis. RESULTS: Percutaneous transhepatic cholecystostomy and subsequent percutaneous transhepatic cholecystoscopy were successfully accomplished in all 33 patients. During percutaneous transhepatic cholecystoscopy, minor complications (2 episodes of minor bleeding during electrohydraulic lithotripsy, 2 of tube dislodgement, and 1 of bile leakage to peritoneum) occurred in 5 patients. Percutaneous transhepatic cholecystoscopy revealed gallstones in 26 cases, sludge ball in 3, gallbladder carcinoma in 3, and 1 case of clonorchiasis related with acute cholecystitis. The 3 gallbladder cancers which were not identified radiologically were found incidentally during percutaneous transhepatic cholecystoscopy. For the 26 patients with gallstones, percutaneous transhepatic cholecystoscopy and concomitant stone removal were successful in 1 to 4 consecutive sessions (mean 2.2 sessions). Gallstones recurred in 3 of 22 patients (14%) during the mean follow-up period of 27 months. All of them remain asymptomatic. CONCLUSION: Percutaneous transhepatic cholecystostomy may be justified in the management of acute cholecystitis in selected patients with high surgical risk.

Acute Disease↗