Urgent and early cholecystectomy for acute gallbladder disease

A retrospective study of 645 cholecystectomies performed in a surgical unit over a 10-year period is presented, of which 236 were carried out during an acute admission. Of these 236 cholecystectomies, 195 were performed for acute cholecystitis and 41 for acute gallstone pancreatitis. In the acute cholecystitis group the proportion of patients over 70 years of age was significantly higher (35 per cent) than the corresponding elective group (10.3 per cent). Of those patients presenting with complications (empyema, gangrene, perforation, and biliary peritonitis) 51 per cent were over the age of 70 years. The most valuable investigation in the diagnosis of acute cholecystitis was ultrasound carried out within the first 48 h, with positive results in 83 per cent of those examined. The mortality for elective cholecystectomy was 0.5 per cent rising to 4.7 per cent in the urgent/early cholecystectomy group. The mean age of the 11 patients who died was 76 years, 8 of these patients being over the age of 70 years. The mortality in the subgroup of patients over 70 years was 10 per cent rising to 20 per cent in the over-80 age group. There were no deaths in the acute gallstone pancreatitis group. We conclude that emergency or early cholecystectomy is a safe procedure in patients under 70 years of age. However, patients over 70 years present with more serious complications of acute gallbladder disease which necessitate urgent surgery. We therefore recommend early cholecystectomy in patients over 70 years despite the high attendant mortality.     

The management of acute cholecystitis in elderly patients

Acute cholecystitis is a common cause of emergency room admissions in elderly patients, and may have an atypical course with serious complications and high mortality. The authors present 131 elderly patients (aged 70 and older) who were treated for acute cholecystitis. The most common complaint was right upper abdominal pain (73%), followed by fever (55%), vomiting (48%), palpable mass (22%) and jaundice (13%). Twelve per cent of the patients were in septic shock on admission. Most patients (74%) had severe concomitant disease, increasing their operative risk significantly. Patients were prepared for surgery by hydration, nasogastric drainage, and antibiotics, while imaging was performed. They were all operated on within 48 hours. The operation of choice was cholecystectomy, which was performed in 86 patients. In 45 older and high risk patients, cholecystostomy was performed. The decision to perform cholecystostomy was taken prior to the operation, and was based on the estimated operative risk. Five patients (3.8%) died postoperatively. The major cause of death was cardiovascular disorders. Major complications occurred in 14.5 per cent and minor in 23 per cent of the patients. The complication rate correlated with severe concomitant diseases and older age groups. Patients with fever and leukocytosis had a better outcome, possibly reflecting a better immunologic status. The authors conclude that aggressive preoperative preparation and judicious use of cholecystostomy as a life-saving drainage procedure can lower the mortality from acute cholecystitis in the elderly population.     

Acute pancreatitis in the aged

Forty-seven patients aged more than 75 years with acute pancreatitis were studied. The most common cause of acute pancreatitis was biliary tract stones. The clinical presentation and severity of the disease as judged by the number of poor prognostic factors were not different from the group of patients aged less than 75 years. The mortality rate in the older group was thrice that of the younger group (21.3% versus 7.24%). The higher mortality rate was explained by a higher incidence of deaths related to complications of biliary stones and coincidental diseases. Significantly more aged patients with mild disease died, indicating the limitation of predictive ability of the scoring system in acute pancreatitis of the aged.     

Prognosis of colorectal cancer in the elderly

The prognosis of colorectal cancer in the elderly was examined in a study of 306 consecutive patients. The patients were divided into two groups: Group 1 included 171 patients of average age 77 years (range 70-97); Group 2 comprised 135 patients of average age 59 years (range 22-69). There was no significant difference between the two groups with regard to the mode of presentation, the location and Duke's classification of the tumours, the incidence of palliative operations, and the perioperative mortality. The surgical mortality rates in Group 1 were 6 per cent overall, 4 per cent after elective operations, and 16 per cent after emergency surgery; the corresponding mortality rates for Group 2 were 3 per cent, 1 per cent, and 20 per cent. Emergency surgery was associated with a significantly higher incidence of perioperative death at any age (P less than 0.001) and most deaths resulted from complications of coexisting medical disorders or thrombo-embolic complications. Crude actuarial 5-year survival curves showed an increased death rate in Group 1 after 18 months and a significantly lower 5-year survival (P less than 0.05) but the age-corrected survival curves for the two groups were not significantly different, and it was concluded that the prognosis for colorectal cancer in the elderly is not significantly different from that of younger patients.     

Abdominal pain: a surgical audit of 1190 emergency admissions

In an audit of 1190 emergency admissions with abdominal pain (1166 patients) in a general surgical unit, the diagnosis was non-specific abdominal pain (NSAP) in 415 (35 per cent), acute appendicitis in 200 (17 per cent) and intestinal obstruction in 176 (15 per cent). The largest number of admissions occurred in the age groups 10-29 years (31 per cent) and 60-79 years (29 per cent). Surgical operations were performed in 551 patients (47 per cent) and there was a 16 per cent incidence of unnecessary appendicectomy (22 per cent in the age group 20-29 years). Fifty-one deaths resulted in a 30-day hospital mortality rate of 4.4 per cent and a perioperative mortality rate of 8 per cent. The mortality rate increased significantly in patients aged greater than or equal to 60 years, and patients aged 80-89 years had a perioperative mortality rate of 20 per cent. The causes of perioperative death included laparotomy for inoperable disease (28 per cent), ruptured abdominal aortic aneurysm (23 per cent), perforated peptic ulcer (16 per cent) and colonic resections (14 per cent). The perioperative mortality rates for ruptured aneurysm and perforated ulcer were 71 and 23 per cent respectively. The duration of inpatient stay increased significantly with the age of the patients, including those with NSAP. The results of the study indicate a need to review the methods of management of ruptured aortic aneurysm and perforated peptic ulcer, the methods of diagnosis of appendicitis, particularly in young females, and the factors that determine the duration of stay of patients suffering from NSAP.     

High early mortality rate from acute pancreatitis in Scotland, 1984-1995.

BACKGROUND: Death from acute pancreatitis within the first week after admission is usually a consequence of multiple organ dysfunction. Reports from specialist centres suggest that, with improvements in resuscitation and supportive care, such deaths are becoming uncommon but it is unclear if this is reflected in a decrease in early mortality rate from acute pancreatitis in the general population. METHODS: Data concerning patients discharged with a diagnosis of acute pancreatitis (International Classification of Disease-9 code 577.0) between 1984 and 1995 were obtained from the Information and Statistics Division, National Health Service in Scotland, and analysed on a computer database. RESULTS: The incidence of acute pancreatitis in Scotland continues to increase in both sexes. The in-hospital mortality rate (death from all causes) was 7.5 per cent and showed a slight but significant downward trend over the period of study. Death within 7 days of hospital admission accounted for 53.7 per cent of all deaths and the proportion of early deaths did not decline over the study interval. CONCLUSION: These results suggest that scope remains for considerable improvement in the early management of acute pancreatitis. There is an urgent need to improve the early recognition of severe pancreatitis coupled to a willingness on behalf of clinicians to transfer these patients at an early stage to a centre with high-dependency and intensive care facilities supervised by a multidisciplinary team with expertise in the endoscopic, radiological and surgical management of these patients.     

Management of symptomatic gallstones in the elderly

In a study of 544 patients with symptomatic gallstones 158 subjects were aged greater than 70 years. Elderly patients had a significantly higher incidence of emergency presentation, jaundice, cholangitis, ductal stones, biliary drainage procedures, and acute complications requiring urgent or emergency surgery (P less than 0.001); they had more than twice the incidence of postoperative complications in comparison with patients aged less than 70 years. There was an increased perioperative mortality in the elderly (1.3 per cent after cholecystectomy and 2.9 per cent after bile duct exploration, P = 0.039). Conservative treatment in 11 per cent of elderly patients resulted in no mortality due to gallstones, but 3 of 17 patients had recurrent biliary symptoms. It was estimated that 38 per cent of the bile duct explorations in the elderly might have been avoided by referral for endoscopic sphincterotomy, but surgical treatment of gallstones in the district general hospital is relatively safe and specialist referral should be considered only in the relatively small number of 'high risk' cases.     

A policy of early excision and grafting in elderly burn patients shortens the hospital stay and improves survival

Early excision and grafting of the burn wound appears to shorten the hospital stay and decrease mortality in children and adults. However, whether an early surgical approach is safe in elderly burn patients has not been resolved. To answer this question we carried out a prospective study of early surgery in 114 consecutive patients over the age of 50 years. Patients were generally operated on between post-burn days 2 and 5. The mean age of the patients was 68 years, with a burn size of 22 per cent, of which 13 per cent was full thickness skin loss. The mean hospital stay of the surviving patients was reduced by 40 per cent compared to national averages (P less than 0.001). The mortality rate for the entire group of patients was 17 per cent, with 2 deaths in the 65 patients with burns less than 20 per cent total body surface area (TBSA). Although the mortality rate for patients with burns greater than 20 per cent TBSA was 35 per cent, this was less than predicted (P less than 0.05). The improvement in survival appeared to be due to a decrease in the incidence of lethal burn wound infections.     

Cholecystectomy in the elderly: a prospective study

The mortality and morbidity of 151 elderly patients (greater than 64 years of age) undergoing biliary surgery for benign disease were prospectively studied. The overall mortality was 3.3 per cent. This comprised a 0.77 per cent mortality in the elective group and a 19 per cent mortality in the emergency group. In spite of 77 per cent of the emergency group having a gangrenous gallbladder, a complication difficult to predict preoperatively, the majority of deaths were from cardiovascular disease. The overall incidence of common bile duct exploration was 36 per cent, which was similar in the elective and emergency groups. A comparison between the old (65-74 years) and the aged (over 74 years of age) revealed twice the number of emergency cases in the aged. Considering elective biliary surgery, there was no difference between the mortality, morbidity, or common bile duct exploration rate comparing the old with the aged. This suggests that elective biliary surgery is safe even in the aged.     

Resection in chronic pancreatitis

In the absence of ductal ectasia there is no adequate alternative to pancreatectomy for severe chronic pancreatitis. A personal series of 30 such patients operated upon between 1977 and 1984 included 16 with distal pancreatectomy, 6 with proximal pancreatectomy and 12 with total pancreatectomy; 4 patients progressed from distal to total resection after an interval of 15-28 months. The mean age was 39 years with a male preponderance of 77 per cent. The main aetiological agents were chronic alcoholism (63 per cent) and previous acute pancreatitis (23 per cent). One patient died after total pancreatectomy, giving a 30-day mortality rate for all resections of 3 per cent. Postoperative complications necessitated reoperation in 10 per cent, and there have been 5 late deaths (17 per cent). Among 27 patients followed for a median of 4.5 years, pain relief has been good in 16, fair in 8 and poor in 3 (11 per cent). Proximal pancreatectomy has proved superior to distal pancreatectomy with regard to analgesia and the avoidance of diabetes. Although technically demanding, total pancreatectomy has improved symptoms substantially in 9 of 10 patients surviving for a minimum of 18 months.     

Role of cholecystostomy in the management of critically ill patients suffering from acute cholecystitis

Between the years 1976 and 1985, 60 patients underwent cholecystostomy for acute cholecystitis in the surgical department of the Rokach hospital in Tel Aviv. The patients' average age was 73 years; 78 per cent were 70 years or older at the time of operation. The decision to perform cholecystostomy was taken before the operation which was performed as an emergency procedure for patients considered to be at high risk for cholecystectomy. Forty-six patients (77 per cent) had severe concomitant diseases, and 42 per cent of them had two or more associated diseases simultaneously. The cardiac risk index was high in most patients (90 per cent). Fifty-two patients recovered promptly after surgery. Five patients (8 per cent) developed significant postoperative complications. Three other patients (5 per cent) died of cardiovascular complications. Forty-two patients (70 per cent) underwent an elective cholecystectomy 6-8 weeks later with no further morbidity or mortality. Eleven patients who were at high risk had no further surgery. No residual stones were found in these patients and no relapse of the disease was recorded in the long term follow-up. Four patients were lost to follow-up. We conclude that cholecystostomy may still be used as an initial life saving procedure for critically ill patients with acute cholecystitis, and serves as a definitive procedure for patients considered to be at very high operative risk and who have no residual stones.     

Mortality and perforated peptic ulcer: a case for risk stratification in elderly patients

In a consecutive series of 284 patients with a perforated peptic ulcer (229 pyloroduodenal, 55 gastric) there was a 26 per cent hospital mortality rate, and patients aged greater than or equal to 70 years (n = 176) had a significantly higher mortality rate (34 per cent) than patients aged less than 70 years (14 per cent, P less than 0.001). Multiple clinical variables were significantly more common in the elderly group of patients (65 per cent), in those having non-steroidal anti-inflammatory drugs or steroid therapy (56 per cent), in patients where there is an absence of a previous dyspeptic history (69 per cent), and when risk factors such as delayed presentation (33 per cent) and the presence of shock on admission to hospital (27 per cent) are present. Definitive operations (vagotomy or gastrectomy) had an increased mortality rate in the elderly (P = 0.018). Risk scores based upon the presence of shock, delayed presentation or concurrent medical illness could have predicted 87 per cent of postoperative deaths in elderly subjects, and it is suggested that risk stratification and greater caution in the use of definitive operations for perforated ulcer may result in a reduction in the high mortality rate in elderly subjects.     

Acute pancreatitis in Hong Kong.

A series of 311 Chinese patients with acute pancreatitis admitted to Queen Mary Hospital, Hong Kong, over a 10-year period is reviewed. Biliary tract disease was associated with pancreatitis in 52.4 per cent of patients and 77.9 per cent of them had stones, mud or parasites in the common bile duct. Fever and jaundice were present in 55 per cent and 41.2 per cent of patients respectively. Because of the prevalence of recurrent pyogenic cholangitis among the indigenous population, emergency operation, with the aim of common duct decompression, was conducted in 54.3 per cent of patients during the acute episode, with a mortality rate of 14.8 per cent. Five of 142 patients (3.5 per cent) died whilst on conservative treatment and all 5 had haemorrhagic pancreatitis. The overall mortality rate was 9.6 per cent. Exploration of the common bile duct, which was carried out in 57.4 per cent of patients in the acute phase, was not associated with a higher mortality than when laparotomy alone was performed, and 19 patients had sphincteroplasty without any death. Subtotal pancreatectomy was performed in 2 patients with haemorrhagic pancreatitis with 1 death.     

Role of emergency laparotomy in acute pancreatitis.

Two hundred and thirty-seven cases of acute pancreatitis were reviewed and the etiology and prognostic features were analyzed. The following were found to adversely affect prognosis: female sex, old age and low blood pressure, jaundice or disorientation on admission. The results also indicate that if a patient survives the first attack of acute pancreatitis, he is unlikely to have an overwhelming fatal attack later on. One hundred and ninety-four patients were treated conservatively, with a mortality rate of 8.8 per cent and morbidity rate of 20 per cent. Thirteen patients were semi-electively operated on for biliary tract disease with no mortality. The remaining 30 patients underwent emergency laparotomy. The mortality in this latter group was 23 per cent and the morbidity rate was 77 per cent. These results suggest that emergency laparotomy should only be advised for specific indications. In addition, our data suggest that if laparotomy is performed for acute pancreatitis, the peripancreatic area should not be drained unless an abscess or pancreatic necrosis is present.     

急性胆管炎合并胆总管结石高龄患者行急诊ERCP治疗的安全性及有效性

目的探讨急性胆管炎高龄患者行急诊ERCP治疗的安全性及有效性。方法回顾性分析上海中医药大学附属普陀医院2011年1月至2015年12月因急性胆管炎合并胆总管结石行急诊ERCP的患者186例病例资料。其中,年龄≥80岁者96例,作为观察组;年龄65岁者90例,作为对照组。分析两组的一般资料、合并症、治疗结果及是否存在并发症等信息。结果观察组中合并症的发生率明显高于对照组(87.50%vs51.11%,P0.05)。两组病例中,ERCP插管成功率无统计学差异(94.79%vs 95.56%,P0.05)。对照组无终止操作病例,观察组有2例患者因心肺功能抑制而终止操作。两组病例中ERCP术后相关并发症发生率的比较无统计学差异(7.29%vs 5.56%,P0.05),胰腺炎、出血、穿孔及感染发生率的比较组间差异均无统计学意义(P均0.05)。所有并发症均未进行外科手术干预。两组病例中无ERCP相关死亡病例的发生。结论急诊ERCP可安全有效地用于急性胆管炎合并胆总管结石的高龄患者,但需密切关注合并症,并及早发现可能引起的不良事件。高龄患者如发生并发症往往较严重,应加强围手术期的管理。     

The characteristics of coronary artery revascularization in aged patients

This study was undertaken in order to clarify the clinical characteristic features and surgical results of coronary artery bypass grafting (CABG) in patients over 65 years of age (group III, n = 43). These patients were compared with 2 other groups of patients, one aged between 50 and 59 years (group I, n = 88) and another aged between 60 and 64 years (group II, n = 54), with respect to mortality, morbidity and late survival. CABG was performed with the saphenous vein under cold K-Mg-cardioplegia with systemic hypothermia. The hospital mortality was 2.3, 3.7, and 4.7 per cent in groups I, II and III, respectively, although no operative mortality was noted in any group. The number of coronary artery lesions increased with age, however, the left ventricular ejection fraction was relatively better preserved in the aged patients than in the younger ones. The 5-year survival rates were 93.4, 95.1 and 96.9 per cent in groups I, II and III, respectively, with most of the late deaths occurring within a year after CABG in each group. In the aged patients, postoperative functional recovery was delayed in the liver and kidney, and postoperative psychosis was not infrequent. The results of this study, indicating a low operative mortality and satisfactory late survival rate, thus strongly support CABG for the aged. Nevertheless, the prevention of postoperative complications is also extremely important for reducing hospital mortality.     

Late mortality in patients with severe acute pancreatitis.

BACKGROUND: Mortality due to severe or necrotizing acute pancreatitis most often results from multiorgan dysfunction syndrome (MODS) occurring either early (within the first 14 days) or 2 weeks or more after the onset of symptoms due to septic complications. The aim of this study was to analyse the course of the disease in patients who died from severe acute pancreatitis. METHODS: Between January 1994 and August 2000 details of 263 consecutive patients with acute pancreatitis were entered prospectively into a database. All patients were treated in an intermediate or intensive care unit. RESULTS: The overall mortality rate was 4 per cent (ten of 263 patients). The mortality rate was 9 per cent (ten of 106) in patients with necrotizing disease. No patient died within the first 2 weeks of disease onset. The median day of death was 91 (range 15-209). Six patients died from septic MODS. Ranson score, Acute Physiology and Chronic Health Evaluation (APACHE) II score during the first week of disease, pre-existing co-morbidity, body mass index, infection and extent of necrosis were significantly associated with death (P < 0.01 for all parameters). However, only infection of the necrotic pancreas was an independent risk factor in the multivariate analysis. CONCLUSION: Early deaths in patients with severe acute pancreatitis are rare, mainly as a result of modern intensive care treatment. Nine of the ten deaths occurred more than 3 weeks after disease onset. Infection of pancreatic necrosis was the main risk factor for death.     

The characteristics of coronary artery revascularization in aged patients

This study was undertaken in order to clarify the clinical characteristic features and surgical results of coronary artery bypass grafting (CABG) in patients over 65 years of age (group III, n=43). These patients were compared with 2 other groups of patients, one aged between 50 and 59 years (group I, n=88) and another aged between 60 and 64 years (group II, n=54), with respect to mortality, morbidity and late survival. CABG was performed with the saphenous vein under cold K-Mg-cardioplegia with systemic hypothermia. The hospital mortality was 2.3, 3.7, and 4.7 per cent in groups I, II and III, respectively, although no operative mortality was noted in any group. The number of coronary artery lesions increased with age, however, the left ventricular ejection fraction was relatively better preserved in the aged patient than in the younger ones. The 5-year survival rates were 93.4, 95.1 and 96.9 per cent in groups I, II and III, respectively, with most of the late deaths occurring within a year after CABG in each group. In the aged patients, postoperative functional recovery was delayed in the liver and kidney, and postoperative psychosis was not infrequent. The results of this study, indicating a low operative mortality and satisfactory late survival rate, thus strongly support CABG for the aged. Nevertheless, the prevention of postoperative complications is also extremely important for reducing hospital mortality.     

Surgical treatment of acute necrotizing pancreatitis

Between January 1980 and June 1986, 21 patients required surgery for acute necrotizing pancreatitis. Four patients had been transferred from other hospitals; the remaining 17 patients had been treated from the outset at Glasgow Royal Infirmary, representing 3.7 per cent of the 456 patients treated for acute pancreatitis during this time. Necrosectomy was performed on 14 patients and 7 patients were treated by pancreatic resection, with 4 deaths in each group; thus 8 patients (38 per cent) died at a median time of 22 days from onset of their attack. Three of the four patients transferred to our care died, giving a mortality in our own patients of 29 per cent. Of the survivors, all but three had a prolonged and complicated hospital course. Our data confirm that acute necrotizing pancreatitis is still associated with a considerable mortality and morbidity. Early multi-organ failure, advanced age, underlying medical illness and the presence of infected necrosis were associated with a poor outcome. Necrosectomy delayed until the second or subsequent week appeared to be a suitable procedure for the majority of our patients, but shortcomings were apparent with the traditional methods of closed drainage of the pancreatic bed postoperatively. The many demands imposed by this small group of patients suggests that their management is best undertaken in centres in which there is special expertise and this should contribute to a further reduction in the mortality from this condition.