Asociación de parámetros analíticos y radiológicos en el diagnóstico de la colecistitis aguda

Introduction and objectivesThere is currently more evidence suggesting that early surgery should be the treatment of choice for acute calculous cholecystitis, although initial conservative treatment is also reported to be safe. Treatment decision depends on the conditions of the patient, surgical experience, and hospital infrastructure, given that early surgery cannot always be carried out. The aim of the present study was to correlate C-reactive protein values with other variables to determine those situations in which surgery cannot be delayed.Materials and methodsA retrospective study was conducted on patients admitted to the hospital from the emergency service with the diagnosis of acute calculous cholecystitis. The patients were divided into 2 groups: 1) patients that required urgent cholecystectomy and 2) patients that responded well to conservative medical treatment and later underwent deferred cholecystectomy.ResultsA total of 238 patients (♂ 54.6%, ♀ 45.4%) were analyzed. Urgent surgery was performed on 158 patients, whereas the remaining 80 patients were released from the hospital following conservative treatment. The odds ratio of gangrenous cholecystitis presenting in acute cholecystitis for C-reactive protein was calculated in the logistic regression analysis, obtaining an OR of 1.088 and a 95% CI of 1.031-1.121.ConclusionIn patients diagnosed with acute calculous cholecystitis, the combination of elevated values of C-reactive protein levels, gallbladder wall thickness, and number of leukocytes was correlated with less favorable clinical and gallbladder histologic states, resulting in a greater need for urgent surgical treatment.     

Safety and feasibility of cholecystectomy in octogenarians. Analysis of a single center series of 316 patients

IntroductionCholecystectomy is the treatment of choice for symptomatic cholelithiasis. However, outcomes for patients over 80years of age are not well studied. The primary aim of this study was to describe the safety and feasibility of cholecystectomy, including in the acute setting, in a cohort of patients≥80 years of age.Material and methodsA retrospective study of patients aged≥80 years submitted to cholecystectomy at a single institution from January 2013 to January 2018 was performed. Severity of acute cholecystitis was graded according to the updated Tokyo Guidelines 18. Early cholecystectomy was defined as being performed within the first 48h after admission and delayed when performed beyond 48h of the admission.ResultsIn total 316 patients underwent cholecystectomy. The indication was acute cholecystitis in 113 (36%) patients. Of the 316 patients 289 (92%) were attempted laparoscopically and 30 (10%) were converted to open. Major complications occurred in 44 patients (14%) and mortality rate was 4%. No bile duct injuries were observed. For those patients with mild or moderate acute cholecystitis (n = 103), there was no differences in outcomes when comparing early vs delayed surgery.ConclusionCholecystectomy in patients≥80 years of age is safe and feasible. Outcomes did not differ between early and delayed surgery for mild/moderate acute cholecystitis.     

Timing of cholecystectomy for acute calculous cholecystitis: a meta-analysis

OBJECTIVES: To compare early with delayed cholecystectomy for the treatment of acute lithiasic cholecystitis: a meta-analysis of prospective randomized trials. METHODS: Pertinent studies were selected from the Medline, Embase, Cancerlit, HealthSTAR and Cochrane Library Databases, references from published articles, and reviews. Twelve prospective randomized trials (9 addressing open cholecystectomy and 3 laparoscopic cholecystectomy) were selected. Conventional meta-analysis according to the DerSimonian and Laird method was used for the pooling of the results. The rate difference (RD) (95% CI) and the number needed to treat (NNT) were used as a measure of the therapeutic effect. RESULTS: Cumulative operative and perioperative mortality and morbidity were 0.9% and 17.8%, respectively, for open cholecystectomy and 0% and 13.1%, respectively, for laparoscopic cholecystectomy. The pooled RD for operative complications in early surgery was 1.37% (95% CI =-3.78% to 6.53%; p= 0.2) for open cholecystectomy and 3.11% (95% CI =-15.10% to 8.87%; p= 0.6) for laparoscopic cholecystectomy. In laparoscopic cholecystectomy the cumulative conversion rate to open cholecystectomy was 21.5%. The pooled RD for conversion rate in early laparoscopic cholecystectomy was -7.99% (95% CI =-18.46% to 2.47%; p= 0.1; NNT = 13). Total hospital stay (mean +/- SD) was significantly shorter in the early surgery group (9.6 +/- 2.5 days vs 17.8 +/- 5.8 days; p < 0.0001). More than 20% of patients referred to delayed surgery fail to respond to conservative management or suffer recurrent cholecystitis in the interval period. CONCLUSIONS: Early operation (open or laparoscopic) does not carry a higher risk of mortality and morbidity compared to delayed operation and should be the preferred surgical approach for patients with acute lithiasic cholecystitis.     

Surgical outcomes of ERCP-guided transpapillary gallbladder drainage versus percutaneous cholecystostomy as bridging therapies for acute cholecystitis followed by interval cholecystectomy

BackgroundSelect patients with acute cholecystitis (AC) are not candidates for index cholecystectomy. We compared the influence of ERCP-guided transpapillary gallbladder drainage (ERGD) versus percutaneous cholecystostomy (PC) on delayed cholecystectomy outcomes.MethodsConsecutive patients undergoing ERGD or PC for AC from January 2007 to October 2018 were included. Primary outcome was the rate of conversion to open cholecystectomy and perioperative complications in groups.ResultsThe study included 52 patients with ERGD and 140 with PC prior to cholecystectomy (median 68 days [IQR: 47–105.5]). Technical success was higher in the PC group (100% vs 91%; P = 0.0004). There was a nonsignificant trend to lower postoperative complications with ERGD (30.7% vs 43.5%; P = 0.07). No difference in conversion to open cholecystectomy OR: 1.5 (95% CI: 0.68–3.65; P = 0.28) or severity of complications (Clavien-Dindo grade >2) OR: 0.60, (95% CI: 0.19–1.87; P = 0.38) was noted between the ERGD and PC groups. PC was associated with higher rates of unplanned repeat intervention (16.4% vs 7.7%; P = 0.02).ConclusionERGD is suitable for patients with AC who is candidates for delayed cholecystectomy and should be considered for gallbladder drainage in patients with concomitant choledocholithiasis or cholangitis who require ERCP.     

Gallstone pancreatitis: does discharge and readmission for cholecystectomy affect outcome?

BackgroundConventional surgical wisdom is that a patient with gallstone pancreatitis should have the gallbladder removed during their initial hospitalization. However, patients are now often discharged to await operating room availability.MethodsA retrospective review of all cases of gallstone pancreatitis at the Foothills Hospital between 1992 and 1996 was undertaken. Patients with a first attack of mild gallstone pancreatitis were studied.ResultsIn all, 164 patients were identified: 90 patients were discharged for readmission cholecystectomy (discharged group), and 74 patients had the cholecystectomy before discharge (in-hospital group). Over the 5-year time period the proportion of patients discharged for readmission cholecystectomy increased from 27% to 67% (p<0.01). The total number of days waited for operation was greater in the discharged group versus in-hospital group: 40±69 days versus 8±10 days respectively (mean±SD). There was a trend towards an increased total number of days in hospital in the in-hospital group, 15.5±17 days versus 10.7±16 days. In the discharged group 20% (18 of 90) of patients experienced an adverse event requiring readmission while awaiting operation. Three had documented recurrent pancreatitis, 10 experienced recurrent pain, and 5 developed acute cholecystitis. There were no deaths in either group.DiscussionTwenty percent of patients with gallstone pancreatitis who are discharged to await operating room time (average wait 40 days) will require readmission for biliary symptoms.     

Outcome of early cholecystectomy compared to percutaneous drainage of gallbladder and delayed cholecystectomy for patients with acute cholecystitis: systematic review and meta-analysis

BackgroundCompare outcomes of early laparoscopic cholecystectomy (ELC) and percutaneous trans-hepatic drainage of gallbladder (PTGBD) as an initial intervention for AC and to compare operative outcomes of ELC and delayed laparoscopic cholecystectomy (DLC).MethodsEnglish-language studies published until December 2020 were searched. Randomised controlled trials (RCTs) and observational studies compared EC and PTGBD with delayed cholecystectomy for patients presented with acute cholecystitis were considered. Main outcomes were mortality, conversion to open, complications and length of hospital stay.ResultsOut of 1347 records, 14 studies were included. 205,361 (94.7%) patients had EC and 11,565 (5.3%) patients had PTGBD as an initial intervention for AC. Mortality was higher in PTGBD; HR, 95% CI: [3.68 (2.13, 6.38)]. In contrast, complication rate was significantly higher in EC group (47%) vs PTGBD group (8.7%) in patients admitted to ICU; P-value = 0.011. Patients who had ELC were at higher risk of post-operative complications compared to DLC; RR [95% CI]: 2.88 [1.78, 4.65]. Risk of bile duct injury was six folds more in ELC; RR [95% CI]: 6.07 [1.67, 21.99].ConclusionELC may be a preferred treatment option over PTGBD in AC. However, patient and disease specific factors should be considered to avoid unfavourable outcomes with ELC.     

Protector effect of α-thalassaemia on cholecystitis and cholecystectomy in sickle cell disease

Objectives: Cholecystitis is one of the complications of symptomatic cholelithiasis responsible for high levels of morbidity of sickle cell disease (SCD) patients. Here, we investigated the possible protective role of single gene deletions of α-thalassaemia in the occurrence of cholelithiasis and cholecystitis in SCD patients, as well as the cholecystectomy requirements.

Methods: The α-globin genotype was determined in 83 SCD patients using the multiplex-polymerase chain reaction and compared with clinical events.

Results: Overall, in 23% of patients, -α^3.7 deletion was found. α-Thalassaemia concomitant to SCD was an independent protective factor to cholecystitis (OR?=?0.07; 95% CI: 0.01–0.66; p?=?0.020) and cholecystectomy requirement (OR?=?0.14; 95% CI: 0.03–0.60; p?=?0.008). The risk of cholelithiasis was not affected by the α-thalassaemia concomitance.

Conclusions: To the best our knowledge, our study is the first to show the protective effect of α-thalassaemia on cholecystitis and cholecystectomy requirements in SCD, which may be due to an improved splenic function.     

Cholecystitis and risk of pancreatic,liver, and biliary tract cancer in patients undergoing cholecystectomy

BackgroundCholecystitis before cholecystectomy may increase risk of cancers in the hepato-pancreato-biliary area.MethodsA population-based cohort study of all patients undergoing cholecystectomy in Denmark during 1996–2015, using nationwide healthcare registries. We retrieved information on cholecystitis within two years before the date of surgery and information on pancreatic cancer, hepatocellular carcinoma (HCC), and biliary tract cancer. We examined cancer risk using a Cox model to calculate the hazard ratios (HRs). We also computed cumulative incidence functions with 95% CIs, comparing patients with and without cholecystitis before cholecystectomy.ResultsWe included 132,794 patients, of which 73.0% were women. In the first five years of follow-up, we observed an increased risk of biliary tract cancer, but not pancreatic cancer or HCC, in patients with prior cholecystitis. After more than five years of follow-up, patients with prior cholecystitis had an increased risk of pancreatic cancer (adjusted HR: 1.26; 95% CI: 0.98–1.63) and possibly biliary tract cancer (adjusted HR: 1.33; 95% CI: 0.64–2.77). Long-term risk of HCC was decreased in patients with prior cholecystitis. For all cancers, the 20-year absolute risks were less than 1%.ConclusionIn patients undergoing cholecystectomy, prior cholecystitis was associated with increased risk of pancreatic and possibly biliary tract cancer.     

Gallbladder perforation: A single-center experience in north India and a step-up approach for management

Background: Spontaneous gallbladder perforation(GBP) is an uncommon diagnosis. This study presented the experience of managing spontaneous GBP over nine years at a large, tertiary care university hospital in north India and investigated the outcomes and treatment strategies. Methods: A retrospective review of prospectively maintained digital database of consecutive patients was performed. All patients received medical and/or surgical treatment for spontaneous GBP in our department between Januar...     

Timing of laparoscopic cholecystectomy for acute cholecystitis： A prospective non randomized study

INTRODUCTION Laparoscopic cholecystectomy (LC) has been established as the treatment of choice for the management of acute cholecystitis (AC), despite initial reservations, regarding the impact of this policy on the conversion rate and morbid- ity[1]. Sev…     

Systematic review of cholecystostomy as a treatment option in acute cholecystitis

ObjectivesPercutaneous cholecystostomy (PC) is an established low-mortality treatment option for elderly and critically ill patients with acute cholecystitis. The primary aim of this review is to find out if there is any evidence in the literature to recommend PC rather than cholecystectomy for acute cholecystitis in the elderly population.MethodsIn April 2007, a systematic electronic database search was performed on the subject of PC and cholecystectomy in the elderly population. After exclusions, 53 studies remained, comprising 1918 patients. Three papers described randomized controlled trials (RCTs), but none compared the outcomes of PC and cholecystectomy. A total of 19 papers on mortality after cholecystectomy in patients aged >65 years were identified.ResultsSuccessful intervention was seen in 85.6% of patients with acute cholecystitis. A total of 40% of patients treated with PC were later cholecystectomized, with a mortality rate of 1.96%. Procedure mortality was 0.36%, but 30-day mortality rates were 15.4 % in patients treated with PC and 4.5% in those treated with acute cholecystectomy (P < 0.001).ConclusionsThere are no controlled studies evaluating the outcome of PC vs. cholecystectomy and the papers reviewed are of evidence grade C. It is not possible to make definitive recommendations regarding treatment by PC or cholecystectomy in elderly or critically ill patients with acute cholecystitis. Low mortality rates after cholecystectomy in elderly patients with acute cholecystitis have been reported in recent years and therefore we believe it is time to launch an RCT to address this issue.     

Surgical treatment of acute cholecystitis. Results of an early intervention protocol

A prospective study of 425 patients operated for gallstones was undertaken in order to assess the applicability of a protocol including early surgery in acute cholecystitis. Acute cholecystitis (AC) was present in 119 patients who had 123 episodes of AC (28%). Of 114 patients diagnosed as having AC, 103 were operated on before 72 h and the remaining before 7 days. There were no significant differences between the AC series and that of 306 patients who underwent an elective operation, in regard to morbidity, mortality or length of hospitalization. Early cholecystectomy can be recommended for the treatment of AC as its results are comparable to those of elective surgery.     

Timing of cholecystectomy after percutaneous transhepatic gallbladder drainage for acute cholecystitis: a nationwide inpatient database study

BackgroundOptimal interval from percutaneous transhepatic gallbladder drainage (PTGBD) to cholecystectomy for acute cholecystitis remains unclear.MethodsWe analyzed patients undergoing cholecystectomy following PTGBD for acute cholecystitis, using a national database. We performed restricted cubic spline (RCS) analyses to investigate the association of interval from PTGBD to cholecystectomy with outcomes (mortality/morbidity, blood transfusion, duration of anesthesia, and postoperative hospital stay).ResultsAmong 9,256 patients, RCS analyses showed reverse J-shaped associations of the interval with mortality/morbidity and blood transfusion, and J-shaped associations of the interval with both duration of anesthesia and postoperative hospital stay. Each interval was compared with the bottom of the spline curve. Patients with intervals ≤6 days or ≥27 days had higher mortality/morbidity than those with a 10-day interval. Patients with intervals ≤8 days had higher proportions of blood transfusion than those with a 10-day interval. Patients with intervals ≥17 days had longer duration of anesthesia than those with a 5-day interval. Postoperative hospital stay was longer among those with intervals ≤10 days or ≥19 days than those with a 15-day interval.ConclusionsBased on the mortality/morbidity data, the optimum time to perform cholecystectomy is between 7 and 26 days after PTGBD.     

Predictors of 90-Day Readmission and in-Hospital Mortality in Takotsubo Cardiomyopathy: An Analysis of 28,079 Index Admissions

BackgroundTakotsubo cardiomyopathy (TC) is diagnosed in 1% to 2% of patients presenting with suspected acute coronary syndromes. Readmission patterns after TC have been less studied. Thus, we sought to perform a study to evaluate the etiologies, trends, and predictors of 90-day readmission in TC.MethodsThe Nationwide Readmissions Database (NRD), 2014, was used to select the study cohort. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code 429.83 was used to identify TC. Admissions within 90 days of index admission were considered early readmissions. Readmission etiologies were identified by an ICD-9-CM code. Hierarchical multivariate models were used to evaluate predictors of early readmission.ResultsA total of 28,079 patients were identified during the study period, of whom 24.3% (n = 6841) were readmitted within 90 days of discharge. In-hospital mortality during index admissions was 5.69%. The most common etiologies for readmission were cardiac (18.56%), respiratory (17.20%), and infections (13.12%). Among cardiac complications, acute heart failure was the most common etiology (7.48%). The highest number of readmissions happened on the first day after discharge (n = 125). On multivariate analysis, the age of 50–64 years, diabetes, heart failure, chronic pulmonary disease, peripheral vascular disease, anemia, and malignancy were shown to be significant predictors of readmission. Patients of female gender are less likely to be readmitted and have lower in-hospital mortality.ConclusionsPatients with TC are highly likely to be readmitted within the first month after discharge, most likely with secondary to cardiac or respiratory complications. These findings warrant close post-discharge transition to reduce morbidity and improve healthcare outcomes.SummaryThis analysis from the Nationwide Readmission Database outlines a detailed analysis on etiologies, trends, and predictors of 90-day readmission for patients presenting with takotsubo cardiomyopathy.     

Pre-surgery age-adjusted Charlson Comorbidity Index is associated with worse outcomes in acute cholecystitis

BackgroundBeneficial effects of cholecystectomy in acute cholecystitis (AC) might be weakened by complications. The age-adjusted Charlson Comorbidity Index (CCI) assesses disease relevance in the prediction of one-year mortality.AimsTo evaluate whether age-adjusted CCI predicted complications (including surgical complications, intensive care unit [ICU] admission, and in-hospital death) among patients undergoing cholecystectomy for AC. Associations between age-adjusted CCI and the length of hospital stay have been also evaluated.Methods271 patients were enrolled at Ospedale Policlinico San Martino (Genoa, Italy) between 2005 and 2013. Clinical data and blood samples were collected.ResultsPatients’ median age was 67 years. They underwent more frequently video-laparoscopic cholecystectomy with a limited rate of conversion to open cholecystectomy. Surgical complications occurred in 23 patients (8.5%). 6 patients (2.2%) needed ICU admission, while death occurred in 4 patients (1.5%). According to the cut-off point identified by ROC curve, an age-adjusted CCI cut-off value of 5 was found predictive for in-hospital complications also when confounders were considered (OR 1.35, 95% CI 1.02–1.79, p = 0.035). No association between adjusted CCI and the length of hospital stay was found.ConclusionsIn patients surgically treated for AC, age-adjusted CCI could represent an additional tool, along with available risk scores, to help surgeons in choosing the best therapeutic option.     

Long-term follow-up of a randomized controlled trial of observation versus surgery for acute cholecystitis: Non-operative management is an option in some patients

Abstract

Background. Cholecystectomy is routinely recommended to prevent recurrent disease after an initial episode of acute cholecystitis. Therefore, randomized controlled trials have mainly focused on the timing of surgery, but many patients scheduled for cholecystectomy have deferred surgery with long periods of symptom-free intervals. Our present aim is to examine the long-term feasibility and safety of observation compared with surgery. Methods. Trial of 64 patients with acute cholecystitis previously randomized to observation or cholecystectomy, which examined outcome in terms of completed randomized treatment and appearance of further symptoms and the need for surgical treatment. Thirty-three patients were randomized to observation and 31 patients to cholecystectomy. Median follow-up was 14 years. Results. Of the 33 patients randomized to observation, 11 (33%) experienced a new event of gallstone-related disease (eight (24.2%) had acute cholecystitis) and 11 (33%) were operated. No significant difference (p = 0.565) was found between the two randomized groups with regard to recurrent disease or complications. Virtually no surgery took place after 5 years of follow-up. The difference in completed randomized treatment between the groups was not significant (p = 0.077). Long-term mortality was equal in those operated and in those observed. Conclusions. Twenty-four percent of the patients experienced recurrent cholecystitis, but escalation of disease severity or increased mortality was not observed. Long-term observation after acute cholecystitis was feasible in two-thirds of the patients as the risk for recurrent disease was negligible after 5 years.     

Influence of splenorenal shunt on long-term outcomes in cirrhosis

Objective. Cholecystectomy is the standard treatment for acute cholecystitis, but in high-risk patients with serious comorbidity and in patients of advanced age there is substantial morbidity and mortality associated with the intervention. In these selected patients, percutaneous cholecystostomy (PCS) is an alternative mode of management. The aim of the present study was to evaluate the outcome of PCS in selected patients with acute cholecystitis. Material and methods. Thirty-five patients, representing 0.6% of all acute cholecystitis patients managed during the period 1994–2003, were subjected to PCS. Patients’ charts were reviewed retrospectively for age, gender, comorbidity, hospital stay, procedure, complications and final outcome, including requirement of additional interventions. Results. PCS was considered successful in 34/35 patients, 26 of whom responded within 3 days. Two patients required additional cholecystectomy 3 days and 20 months, respectively, after the PCS procedure. Two patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and one patient underwent rotation lithotripsy. Four patients suffered recurrent biliary complaints after the acute episode of cholecystitis, while the only serious procedure-related complication was bile leakage from the gallbladder in one patient, which necessitated cholecystectomy. Conclusions. PCS is a comparatively safe and efficient procedure in the treatment of acute cholecystitis in high-risk patients with serious comorbidity and in elderly patients, contraindicating the general anaesthesia required for laparoscopic or open cholecystectomy.     

Surgery for acute cholecystitis in Denmark

Objective. Despite laparoscopic cholecystectomy being the preferred treatment for elective cholecystectomy, surgery for acute cholecystitis is often performed using the open method. The aim of the study was to assess the incidence of cholecystectomy for acute cholecystitis and to determine the proportion of laparoscopically completed procedures compared with all cholecystectomies for acute cholecystitis. Material and methods. Data from the Danish National Patient Registry were analysed. The annual numbers of all cholecystectomies and of cholecystectomies performed for acute cholecystitis from 1996 to 2004 were registered. Separate data for open and laparoscopic operations were obtained. Results. An increase in the number of cholecystectomies for acute cholecystitis from 13.6 in 1996 to 17.2/100,000 in 2004 was observed (p<0.05). In 1996, 41% of cholecystectomies performed for acute cholecystitis were completed laparoscopically as compared with 64% in 2004 (p<0.05). For laparoscopic cholecystectomies performed for reasons other than acute cholecystitis, the corresponding rates were 78% and 87%, respectively (p<0.05). Conclusions. The total number of patients having cholecystectomy for acute cholecystitis has increased as has the rate of laparoscopically completed procedures. It is not known whether it is possible to obtain a further reduction in the number of open cholecystectomies.