The acute cholecystitis: the operative timing for the laparoscopic approach

The aim of this study is to evaluate the results of early cholecystectomy in patients with acute cholecystitis. In the past, acute cholecystitis was a contraindication to laparoscopic cholecystectomy because of the greater risk of injury to the biliary duct, but acute gallbladder inflammation was a contraindication to open cholecystectomy, too. With greater experience and new technology, laparoscopic cholecystectomy is today the gold standard in the treatment of acute cholecystitis, in empyema and gangrenous cholecystitis. In recent years, attention has turned to surgical timing, rather than surgical management--open versus laparoscopy--because there is no advantage in delaying cholecystectomy for acute cholecystitis. In our experience, we always choose laparoscopic technique in all the patients without general contraindications to mini-invasive surgery and operate as soon as possible in a patient with unfavourable conditions. We believe that the patient must be quickly stabilized with preoperative medical procedures, and surgical treatment must be performed within 72-96 hours after the onset of symptoms. During this period, laparoscopic approach allows a reduction of operative time, operative risk and the conversion rate with medical and economic advantages.     

Laparoscopic biliary surgery

Laparoscopic cholecystectomy has become the standard treatment for patients with symptomatic gallbladder disease. However, there is a substantial proportion of patients in whom laparoscopic cholecystectomy cannot be successfully performed, and conversion to open surgery is required because of technical difficulties or complications. The incidence of bile duct injury has increased in laparoscopic cholecystectomy. Meticulous dissection and intraoperative cholangiography could significantly reduce the rate of that injury. Laparoscopic cholecystectomy for acute cholecystitis is still controversial because of surgical difficulty. In our experience, early laparoscopic cholecystectomy is a beneficial option for patients with acute cholecystitis, and it may even be safe in the acute stage. A better alternative for high-risk early operation and septic cases is percutaneous transhepatic gallbladder drainage. The coexistence of gallbladder cancer should be ruled out and preoperative diagnosis should be done carefully. Laparoscopic management of common bile duct (CBD) stones has many advantages. However it has been reported to be demanding and time-consuming to perform, which limits its widespread adoption. In our experience with 258 patients, laparoscopic CBD exploration was feasible for almost all CBD stones. The technical difficulties associated with laparoscopic CBD exploration could be overcome with the development of suitable equipment and increased expertise.     

Laparoscopic cholecystectomy for severe acute cholecystitis. A meta-analysis of results

Objective The aim of this review was to evaluate surgical outcomes of laparoscopic cholecystectomy for gangrenous and empyematous acute cholecystitis defined as severe acute cholecystitis. Background It is not known to what extent surgical outcomes of laparoscopic cholecystectomy for severe acute cholecystitis differ from those for the nonsevere acute form, making it questionable whether urgent laparoscopic cholecystectomy is the best approach even in severe acute cases. Methods Literature searches were conducted to identify: (1) comparative studies which reported laparoscopic surgical outcomes separately for severe acute and nonsevere acute cholecystitis; (2) studies comparing such an approach with open cholecystectomy, subtotal laparoscopic cholecystectomy or cholecystostomy in severe acute cholecystitis. Results were pooled by standard meta-analytic techniques. Results Seven studies with a total of 1,408 patients undergoing laparoscopic cholecystectomy were found. The risks of conversion (RR 3.2, 95% CI 2.5 to 4.2) and overall postoperative complications (RR 1.6, 95% CI 1.2–2.2) were significantly higher in severe acute cholecystitis with respect to the nonsevere acute forms. However, no difference was detected as regards to local postoperative complications. No studies comparing open cholecystectomy or cholecystostomy with urgent laparoscopy were found. Conclusion A lower feasibility of laparoscopic cholecystectomy has been found for severe cholecystitis. A lower threshold of conversion is recommended since this may allow to reduce local postoperative complications. Literature data lack valuable comparative studies with other treatment modalities, which therefore need to be investigated.     

Laparoscopic cholecystectomy for acute cholecystitis

Summary Because laparoscopic cholecystectomy reduces hospitalization time and postoperative disability, it is being offered to an increasing number of patients with symptomatic gallstones. Nevertheless, acute cholecystitis is still considered by many surgeons to be a relative contraindication. Our standard approach has been to perform laparoscopy on all patients considered candidates for cholecystectomy. From June 1990 to October 1991, the authors personally performed laparoscopic cholecystectomy on 110 patients, 29 (26%) of whom had pathologically confirmed acute cholecystitis. Of these, nine had evidence of gangrene, perforation, or abscess formation. It was necessary to convert to open cholecystectomy in four (14%) patients. In each, inflammation or dense adhesions precluded the performance of a safe operation. The hepatorenal space was drained in 12 (41%) and cystic dust cholangiograms were performed selectively. The mean operating time was 108 min. There were no intraoperative complications. One patient developed a prolonged postoperative paralytic ileus and two patients were noted to have postoperative common duct stones. There were no deaths. The average postoperative stay for laparoscopic cholecystectomy was 2.6 days. We conclude that the advantages of laparoscopic cholecystectomy can be safely and effectively extended to the majority of patients with acute cholecystitis.     

The efficacy of laparoscopy in acute cholecystitis.

OBJECTIVE: To evaluate the role of laparoscopic cholecystectomy in acute cholecystitis and establish the outcomes of this treatment modality at North Oakland Medical Centers. METHODS: This was a retrospective analysis over a three-year period (January 1, 1994 to December 31, 1996), performed at a University-affiliated urban teaching hospital, North Oakland Medical Centers, Pontiac, Michigan. Five hundred and fifty-seven patients underwent surgical treatment for gallbladder disease; 88 patients had acute cholecystitis, and 469 patients had chronic cholecystitis. Acute cholecystitis patients underwent surgery within 72 hours of the onset of symptoms; the patient's selection for laparoscopic cholecystectomy or open cholecystectomy depended on severity of disease, co-morbid factors and surgeon's preference. The parameters of age, gender, operating (OR) time, length of stay, complications, conversion rates from laparoscopic cholecystectomy to open cholecystectomy, and cost were compared in patients who underwent laparoscopic cholecystectomy and/or open cholecystectomy. RESULTS: Patients chosen to undergo laparoscopic cholecystectomy for acute cholecystitis tended to be younger females. Patients treated with laparoscopic cholecystectomy for acute cholecystitis had shorter OR times and LOS compared to patients treated with open cholecystectomy for acute cholecystitis. Conversion rates (CR) were 22% in acute cholecystitis and 5.5% in chronic cholecystitis during the study period; CR diminished considerably between the first and third year. Complications were also lower in patients who underwent laparoscopic cholecystectomy vs. open cholecystectomy. CONCLUSIONS: Laparoscopic cholecystectomy appears to be a reliable, safe, and cost-effective treatment modality for acute cholecystitis; however, the surgical approach should be cautionary because of the spectrum of potential technical hazards. CR is improving as surgeons gain experience.     

腹腔镜胆囊切除术治疗急性胆囊炎：附272例报告

目的 目的探讨急性胆囊炎腹腔镜胆囊切除术(LC)的术式、术中处理,并发症的防治.方法 回顾性分析2003年3月-2007年4月间272例急性胆囊炎患者临床资料,采用腹腔镜完整胆囊切除术260例,胆囊大部切除术加残余胆囊黏膜电灼破坏术12例.结果 无中转开腹者,无死亡、胆道损伤、大出血等严重并发症.结论 急性胆囊炎行腹腔镜胆囊切除术(LC)是安全、有效的.其出血少、创伤小、恢复快.     

Laparoscopic management of acute and chronic cholecystitis.

Contrary to earlier predictions, it appears that acute cholecystitis should be considered a relative rather than an absolute contraindication to laparoscopic surgery. The most important parameter in determining the feasibility of attempting laparoscopic cholecystectomy in the setting of acute inflammation appears to be the experience of the surgeon. This also appears to be true when encountering individuals with elements of long-standing chronic cholecystitis. Although laparoscopic intervention in such patients is associated with a greater likelihood of conversion to open laparotomy, the incidence of major biliary and nonbiliary complications appears to be low. In addition, these patients enjoy the same benefits of laparoscopic surgery as those undergoing elective surgery.     

Operative timing of laparoscopic cholecystectomy for acute cholecystitis in a Japanese institute

Background and Objectives:

In patients with acute cholecystitis who cannot undergo early laparoscopic cholecystectomy (within 72 hours), 6 weeks to 12 weeks after onset is widely considered the optimal timing for delayed laparoscopic cholecystectomy. However, there has been no clear consensus about it. We aimed to determine optimal timing for delayed laparoscopic cholecystectomy for acute cholecystitis.

Methods:

Medical records of 100 patients who underwent standard laparoscopic cholecystectomy were reviewed retrospectively. Patients were divided into group 1, patients undergoing laparoscopic cholecystectomy within 72 hours of onset; group 2, between 4 days to 14 days; group 3, between 3 weeks to 6 weeks; group 4, >6 weeks.

Results:

No significant differences existed between groups in conversion rate to open surgery, operation time, blood loss, or postoperative morbidity, and hospital stay. However, total hospital stay in groups 1 and 2 was significantly shorter than that in groups 3 and 4 (P<.01). In addition, the total hospital stay in group 3 was also significantly shorter than that in group 4 (P<.01).

Conclusions:

Best timing of laparoscopic cholecystectomy for acute cholecystitis may be within 72 hours, and the delayed timing of laparoscopic cholecystectomy in patients who cannot undergo early laparoscopic cholecystectomy is probably as soon as possible after they can tolerate laparoscopic cholecystectomy.     

老年人急性胆囊炎的腹腔镜手术治疗

目的:探讨腹腔镜手术治疗方法在老年人急性胆囊炎的临床疗效和安全性。方法:将2006年1月—2012年5月138例急性胆囊炎老年患者随机分成两组,分别行腹腔镜胆囊切除术(腔镜组,70例)和剖腹胆囊切除术(开腹组,68例),对比两组患者手术时间、肠功能恢复时间、住院时间、术后并发症。结果:腔镜组手术时间、肠功能恢复时间以及住院时间均短于开腹组(均P<0.05),两组术中出血量差异无统计学意义(P>0.05),腔镜组术后并发症明显少于开腹组(P<0.05)。结论:腹腔镜手术治疗方法在老年人急性胆囊炎中具有理想疗效,手术时机的选择与操作的熟练程度是治疗成功的关键。     

Cholelithiasis and cholecystitis

Gallstone disease remains one of the most common medical problems leading to surgical intervention. Every year, approximately 500,000 cholecystectomies are performed in the US. Cholelithiasis affects approximately 10% of the adult population in the United States. It has been well demonstrated that the presence of gallstones increases with age. An estimated 20% of adults over 40 years of age and 30% of those over age 70 have biliary calculi. During the reproductive years, the female-to-male ratio is about 4:1, with the sex discrepancy narrowing in the older population to near equality. The risk factors predisposing to gallstone formation include obesity, diabetes mellitus, estrogen and pregnancy, hemolytic diseases, and cirrhosis. A study of the natural history of cholelithiasis demonstrates that approximately 35% of patients initially diagnosed with having, but not treated for, gallstones later developed complications or recurrent symptoms leading to cholecystectomy. During the last two decades, the general principles of gallstone management have not notably changed. However, methods of treatment have been dramatically altered. Today, laparoscopic cholecystectomy, laparoscopic common bile duct exploration, and endoscopic retrograde management of common bile duct (CBD) stones play important roles in the treatment of gallstones. These technological advances in the management of biliary tract disease are not infrequently accomplished by a multidisciplinary team of physicians, including surgeons trained in laparoscopic techniques, interventional gastroenterologists, and interventional radiologists. With the evolution of laparoscopic cholecystectomy, there has been a global reeducation and retraining program of surgeons. However, the treatment of choice for gallstones remains cholecystectomy. In recognition of the revolutionary advances in the treatment of cholelithiasis, it is the purpose of this collective review to describe recent information on the following topics: types of gallstones, asymptomatic gallstones, symptomatic gallstones, chronic cholecystitis, acute cholecystitis, and other complications of gallstones. Gross and compositional analysis of gallstones allows them to be classified as cholesterol, mixed, and pigment gallstones. When asymptomatic gallstones are detected during the evaluation of a patient, a prophylactic cholecystectomy is normally not indicated because of several factors. Only about 30% of patients with asymptomatic cholelithiasis will warrant surgery during their lifetime, suggesting that cholelithiasis can be a relatively benign condition in some people. However, there are certain factors that predict a more serious course in patients with asymptomatic gallstones and warrant a prophylactic cholecystectomy when they are present. These factors include patients with large (>2.5 cm) gallstones, patients with congenital hemolytic anemia or nonfunctioning gallbladders, or during bariatric surgery or colectomy. Epigastric and right upper quadrant pain occurring 30-60 minutes after meals is frequently associated with gallstone disease. The diagnosis of chronic cholecystitis is made by the presence of biliary colic with evidence of gallstones on an imaging study. Ultrasonography is the diagnostic test of choice, being 90-95% sensitive. The surgical literature suggests that 3-10% of patients undergoing cholecystectomy will have CBD stones. Intraoperative laparoscopic ultrasonography has recently replaced cholangiography as the method of choice for detecting CBD stones. Ultrasonography and radionuclide cholescintigraphy (HIDA scan) are useful in establishing a diagnosis of acute cholecystitis. Laparoscopic cholecystectomy should also be used in the treatment of acute cholecystitis. Laparoscopic cholecystectomy is more likely to be successful when performed within 3 days of the onset of symptoms. It is important to remember that gallstones can lead to a variety of other complications including choledocholithiasis, gallstone ileus, and acute gallstone pancreatitis.