急性胆囊炎的腹腔镜胆囊切除术

胆囊疾病是最常见的消化系统疾病之一。⒇胆囊切除术仍是目前该病最有效的治疗方法。腹腔镜胆囊切除术（ｌａｐａｒｏｓｃｏｐｉｃｃｈｏｌｅｃｙｓｔｅｃｔｏｍｙ，ＬＣ）有着与传统开腹胆囊切除术相同的治疗效果，同时具有住院时间短、术后疼痛轻、恢复快及保持腹部美观...

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

AIM： To study the timing of laparoscopic cholecystectomy for patients with acute cholecystitis. METHODS： Between January 2002 and December 2005, all American Society of Anesthesiologists classification （ASA） Ⅰ ,Ⅱ and Ⅲ patients with acute cholecystitis were treated laparoscopically during the urgent （index） admission. The patients were divided into three groups according to the timing of surgery： （1） within the first 3 d, （2） between 4 and 7 d and （3） beyond 7 d from the onset of symptoms. The impact of timing on the conversion rate, morbidity and postoperative hospital stay was studied. RESULTS： One hundred and twenty-nine patients underwent laparoscopic cholecystectomy for acute cholecystitis during the index admission. Thirty six were assigned to group 1, 58 to group 2, and 35 to group 3. The conversion rate and morbidity for the whole cohort of patients were 4.6% and 10.8%, respectively. There was no significant difference in the conversion rate, morbidity and postoperative hospital stay between the three groups.CONCLUSION： Laparoscopic cholecystectomy for acute cholecystitis during the index admission is safe, regardless of the time elapsed from the onset of symptoms. This policy can result in an overall shorter hospitalization.

Acute transient hepatocellular injury in cholelithiasis and cholecystitis without evidence of choledocholithiasis

AIM： To investigate acute transient hepatocellular injury in patients with cholelithiasis and cholecystitis but no evidence of choledocholithiasis.METHODS： The medical records of patients with cholelithiasis who underwent cholecystectomy between July 2003 and June 2007 were retrospectively reviewed. Imaging studies to detect common bile duct （CBD） stones were performed in 186 patients, who constituted the study population. Biochemical liver tests before and after surgery, and with the presence or absence of CBD stones were analyzed.RESULTS： In 96 patients with cholelithiasis and cholecystitis without evidence of CBD stones, 49 （51.0%） had an alanine aminotransferase level elevated to 2-3 times the upper limit of normal, and 40 （41.2%） had an elevated aspartate aminotransferase level. Similar manifestations of hepatocellular injury were, as would be expected, even more obvious in the 90 patients with CBD stones. These markers of hepatocellular injury resolved almost completely within 2 wk to 1 mo after cholecystectomy. Compared to 59 patients with histologically less severe cholecystitisin the group undergoing urgent surgery （total 74 patients）, the 15 patients with a gangrenous gallbladder had a higher mean level of total bilirubin （2.14 ± 1.27 mg/dL vs 2.66 ± 2.97 mg/dL, P 〈 0.001） and white cell count （9480 ± 4681/μL vs 12840 ± 5273/μL, P = 0.018）.CONCLUSION： Acute hepatocellular injury in cholelithiasis and cholecystitis without choledocholithiasis is mild and transient. Hyperbilirubinemia and leukocytosis may predict severe inflammatory changes in the gallbladder.

Risk factors of acute cholecystitis after endoscopic common bile duct stone removal

AIM： To evaluate the risk factors of acute cholecystitis after endoscopic common bile duct （CBD） stone removal. METHODS： A total 100 of patients who underwent endoscopic CBD stone removal with gallbladder （GB） in situ without subsequent cholecystectomy from January 2000 to July 2004 were evaluated retrospectively. The following factors were considered while evaluating risk factors for the development of acute cholecystitis： age, gender, serum bUirubin level, GB wall thickening, cystic duct patency, presence of a GB stone, CBD diameter, residual stone, lithotripsy, juxtapapillary diverticulum, presence of liver cirrhosis or diabetes mellitus, a presenting illness of cholangitis or pancreatitis, and procedure-related complications. RESULTS： During a mean 18-mo follow-up, 28 （28%） patients developed biliary symptoms; 17 （17%） acute cholecystitis and 13 （13%） CBD stone recurrence. Of patients with acute cholecystitis, 15 （88.2%） received laparoscopic cholecystectomy and 2 （11.8%） open cholecystectomy. All recurrent CBD stones were successfully removed endoscopically. The mean time elapse to acute cholecystitis was 10.2 mo （1-37 mo） and that to recurrent CBD stone was 18.4 mo. Of the 17 patients who received cholecystectomy, 2 （11.8%） developed recurrent CBD stones after cholecystectomy. By multivariate analysis, a serum total bUirubin level of 〈1.3 mg/dL and a CBD diameter of 〈11 mm at the time of stone removal were found to predict the development of acute cholecystitis. CONCLUSION： After CBD stone removal, there is no need for routine prophylactic cholecystectomy. However, patients without a dilated bile duct （〈11 mm） and jaundice （〈1.3 mg/dL） at the time of CBD stone removal have a higher risk of acute cholecystitis and are possible candidates for prophylactic cholecystectomy.

Factors associated with time to laparoscopic cholecystectomy for acute cholecystitis

AIM: To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. METHODS: A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service (medical or surgical). Patients not undergoing cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery.RESULTS: Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean ± SD time to surgery was 39.3 ± 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography (ERCP, P = 0.01) as well with admission to medical service without adjustment for ERCP (P < 0.05). Patients undergoing both magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier (30.4 ± 34.9 vs 82.7 ± 55.1 h, P < 0.01), had less post-operative complications (12% vs 58%, P < 0.01), and shorter length of stay (4.3 ± 3.4 vs 8.1 ± 5.2 d, P < 0.01).CONCLUSION: Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed up time to surgery should be considered.

Percutaneous liver biopsy complicated by hemobilia-associated acute cholecystitis

Liver biopsy is generally considered a safe and highly useful procedure. It is frequently performed in an outpatient setting for diagnosis and follow-up in numerous liver disorders. Since its introduction at the end of the 19th century, broad experience, new imaging techniques and special needles have significantly reduced the rate of complications associated with liver biopsy. Known complications of percutaneous biopsy of the liver include hemoperitoneum, subcapsular hematoma, hypotension, pneumothorax and sepsis. Other intra-abdominal complications are less common. Hemobilia due to arterio-biliary duct fistula has been described, which has only rarely been clinically expressed as cholecystitis or pancreatitis. We report a case of a fifteen year-old boy who developed severe acute cholecystitis twelve days after a percutaneous liver biopsy performed in an outpatient setting. The etiology was clearly demonstrated to be hemobilia-associated, and the clinical course required the performance of a laparoscopic cholecystectomy. The post operative course was uneventful and the patient was discharged home. Percutaneous liver biopsy is a safe and commonly performed procedure. However, severe complications can occasionally occur. Both medical and surgical options should be evaluated while dealing with these rare incidents.

Metastatic melanoma of the gallbladder: An unusual clinical presentation of acute cholecystitis

Metastatic disease from cutaneous melanoma can af-fect all organs of the body, and varies in its biological behavior and clinical presentation. We present the case of a 58-year-old man who arrived at our clinic with acute abdominal pain, which, after investigation, was diagnosed as acute cholecystitis. The patient under-went laparotomy and cholecystectomy. Two years ago, he underwent surgical removal of a primary cutaneous melanoma on his right upper back. Pathological exami-nation revealed the presence of malignant melanoma with a metastatic lesion of the gallbladder.

Tc-99m ciprofloxacin imaging in acute cholecystitis

AIM: To evaluate the eff icacy of a new nuclear imaging Infecton (Tc-99m ciprofloxacin) for the diagnosis of acute cholecystitis. METHODS: Sixteen patients thought to have acute cholecystitis were included in this study. The diagnosis of acute cholecystitis was made based on clinical symptoms and ultrasonographic and pathologic f indings. RESULTS: The 16 patients were composed of 12 acute and 4 chronic cholecystitis patients. Twelve patients with acute cholecystitis were image-positive, including one false-positive. Four patients with chronic cholecystitis were image-negative, of whom three were true-negative. This nuclear imaging had a sensitivity of 91.7%, a specificity of 75%, a positive-predictive value of 91.7%, and a negative-predictive value of 75%. CONCLUSION: Tc-99m ciprofloxacin imaging is easy to perform and applicable for the diagnosis of acute cholecystitis.

α-Lipoic acid protects against cholecystokinin-induced acute pancreatitis in rats

AIM: α-Lipoic acid (ALA) has been used as an antioxidant.The aim of this study was to investigate the effect of α-lipoic acid on cholecystokinin (CCK)-octapeptide induced acute pancreatitis in rats.METHODS: ALA at 1 mg/kg was intra-peritoneally injected, followed by 75 μg/kg CCK-octapeptide injected thrice subcutaneously after 1, 3, and 5 h. This whole procedure was repeated for 5 d. We checked the pancreatic weight/body weight ratio, the secretion of pro-inflammatory cytokines and the levels of lipase,amylase of serum. Repeated CCK octapeptide treatment resulted in typical laboratory and morphological changes of experimentally induced pancreatitis.RESULTS: ALA significantly decreased the pancreatic weight/body weight ratio and serum amylase and lipase in CCK octapeptide-induced acute pancreatitis. However,the secretion of IL-1β, IL-6, and TNF-α were comparable in CCK octapeptide-induced acute pancreatitis.CONCLUSION: ALA may have a protective effect against CCK octapeptide-induced acute pancreatitis.

Original single-incision laparoscopic cholecystectomy for acute inflammation of the gallbladder

AIM： To investigate the safety and feasibility of our original single-incision laparoscopic cholecystectomy （SII_C） for acute inflamed gallbladder （AIG）.

Effect of electroacupuncture at Lower He-Sea points including Yanglingquan(GB 34)on nuclear factor-κB and interleukin-1βin guinea pigs with acute cholecystitis

Objective:To observe the effect of electroacupuncture(EA)at Lower He-Sea points on the expression levels of interleukin-1β(IL-1β)in the serum and gallbladder tissues,and nuclear factor-κB(NF-κB)in gallbladder tissues of the guinea pigs with acute cholecystitis(AC),and to explore whether Yanglingquan(GB 34),the Lower He-Sea point pertaining to Dan Fu(gallbladder),is relatively specific for the Dan Fu(gallbladder)disorders.Methods:Eighty-two healthy guinea pigs were randomly divided into 6 groups according to the random number table method,a blank group,a model group,a Yanglingquan(GB 34)group,a Zusanli(ST 36)group,a Shangjuxu(ST 37)group,and a Xiajuxu(ST 39)group,with 12 guinea pigs in the blank group while 14 in the other groups,respectively,half males and half females in each group.Except for the blank group,guinea pigs in the other groups were injected with E.coli into the gallbladder to establish AC models.Guinea pigs in the blank group were fed routinely without special treatment;those in the model group were daily tied up for 30 min without EA treatment;those in the 4 groups receiving EA treatment were acupunctured at the corresponding Lower He-Sea points after daily binding and stimulated with the SDZ-V EA instrument.After successful modeling and treatment for 5 d,blood was collected from the abdominal aorta of the guinea pigs,and the gallbladder tissues in each group were isolated for hematoxylin-eosin(HE)staining to observe the morphological changes.Enzyme-linked immunosorbent assay(ELISA)was used to detect the serum IL-1βlevel,and immunohistochemistry(IHC)was used to detect the expression levels of NF-κB and IL-1βin gallbladder.Results:On the 3rd day after modeling,the guinea pigs in the five groups with modeling were mentally depressed with decreased appetite,significantly reduced activities,slouch,lassitude,slack and matted fur,and loose stools;two guinea pigs were selected from each group(one male and one female,not included in the final statistics)to isolate the gallbladder after sacrifice;macroscopic observation showed that the gallbladder wall was differently thickened;the bile color was dark green and opaque with particles suspended or accumulated;light microscope observation showed that the submucosal blood vessels of the gallbladder were congested,along with mucosal edema,ulceration,necrosis,shedding,and a large number of inflammatory cells infiltrating in the lamina propria,indicating that the AC model was successfully prepared.Compared with the model group,the gallbladder tissue injuries of the four groups receiving EA treatment were all differently repaired,the serum IL-1βlevels were reduced(P<0.01 or P<0.05),and the IL-1βlevels in the gallbladder tissues were reduced(P<0.01 or P<0.05).Compared with the model group,the NF-κB expression level in the Yanglingquan(GB 34)group was significantly reduced(P<0.01),but was not statistical different in the Zusanli(ST 36)group,Shangjuxu(ST 37)group and Xiajuxu(ST 39)group(all P>0.05).Compared with the Yanglingquan(GB 34)group,the gallbladder tissues of the Zusanli(ST 36)group,Shangjuxu(ST 37)group and Xiajuxu(ST 39)group were more severely damaged,and the expression levels of serum IL-1β,the NF-κB and IL-1βin the gallbladder tissues were increased(P<0.01 or P<0.05).Intervention effect of Yanglingquan(GB 34)on AC guinea pigs was superior to that of Zusanli(ST 36),Shangjuxu(ST 37)and Xiajuxu(ST 39).Conclusion:EA at the Lower He-Sea points of the stomach,large intestine,small intestine and gallbladder can produce curative effects on AC guinea pigs and reduced the inflammatory symptoms.Intervention effect of Yanglingquan(GB 34)on AC guinea pigs is superior to that of Zusanli(ST 36),Shangjuxu(ST 37)and Xiajuxu(ST 39).The mechanism of EA at Yanglingquan(GB 34)in treating AC may be regulating IL-1βand NF-κB to control the inflammatory response and improve the gallbladder tissue damage.

Nationwide trends of hospital admissions for acute cholecystitis in the United States

Background and aims:Acute cholecystitis is a fairly common inpatient diagnosis among the gastrointestinal disorders.The aim of this study was to use a national database of US hospitals to evaluate the incidence and costs of hospital admissions associated with acute cholecystitis.Method:We analyzed the National Inpatient Sample Database(NIS)for all patients in which acute cholecystitis(ICD-9 codes:574.00,574.01,574.30,574.31,574.60,574.61 or 575.0)was the principal discharge diagnosis from 1997 to 2012.The NIS is the largest all-payer inpatient database in the United States and contains data from approximately 8 million hospital stays each year.The statistical significance of the difference in the number of hospital discharges,lengths of stay and associated hospital costs over the study period was determined by using the Chi-square test for trends.Results:In 1997,there were 149661 hospital admissions with a principal discharge diagnosis of acute cholecystitis,which increased to 215995 in 2012(P<0.001).The mean length of stay for acute cholecystitis decreased by 17% between 1997 and 2012(i.e.from 4.7 days to 3.9 days);(P<0.05).During the same time period,however,mean hospital charges have increased by 195.4% from US$14608 per patient in 1997 to US$43152 per patient in 2012(P<0.001).Conclusion:The number of inpatient discharges related to acute cholecystitis has increased significantly in the United States over the last 16 years,along with a great increase in the associated hospital charges.However,there has been a gradual decline in the mean length of stay.Inpatient costs associated with acute cholecystitis contribute significantly to the total healthcare bill.Further research on cost-effective evaluation and management of acute cholecystitis is required.