Critical considerations for the management of acute abdomen in transplant patients

The number of solid organ transplantations performed annually is increasing and are increasing in the following order:Kidney,liver,heart,lung,pancreas,small bowel,and uterine transplants.However,the outcomes of transplants are impro-ving(organ survival>90%after the 1st year).Therefore,there is a high probability that a general surgeon will be faced with the management of a transplant patient with acute abdomen.Surgical problems in immunocompromised patients may not only include graft-related problems but also nongraft-related problems.The perioperative regulation of immunosuppression,the treatment of accompanying problems of immunosuppression,the administration of cortisol and,above all,the realization of a rapidly deteriorating situation and the accurate evaluation and interpretation of clinical manifestations are particularly important in these patients.The perioperative assessment and preparation includes evaluation of the patient’s cardiovascular system and determining if the patient has hypertension or suppression of the hypothalamic-pituitary-adrenal axis,or if the patient has had any coagulation mechanism abnormalities or thromboembolic episodes.Immunosuppression in transplant patients is associated with the use of calci-neurin inhibitors,corticosteroids,and antiproliferation agents.Many times,the clinical picture is atypical,resulting in delays in diagnosis and treatment and leading to increased morbidity and mortality.Multidetector computed tomo-graphy is of utmost importance for early diagnosis and management.Transplant recipients are prone to infections,especially specific infections caused by cytomegalovirus and Clostridium difficile,and they are predisposed to intraop-erative or postoperative complications that require great care and vigilance.It is necessary to follow evidence-based therapeutic protocols.Thus,it is required that the clinician choose the correct therapeutic plan for the patient(conservative,emergency open surgery or minimally invasive surgery,including laparoscopic or even robotic surgery).

Evaluation of The Effectiveness of Abdominal and Vaginal B-Ultrasound in The Diagnosis of Acute Abdomen in Obstetrics and Gynecology

Objective: To explore the clinical effect of the combined application of abdominal and vaginal B-ultrasound in the diagnosis of acute abdomen in obstetrics and gynecology. Methods: Eighty patients admitted to our hospital from March 2023 to March 2024 were selected, all of whom were acute abdomen patients admitted to the Department of Obstetrics and Gynecology. In this study, the patients were divided into two groups. One group of 40 patients was given a simple abdominal B-ultrasound diagnosis (control group). The other group of 40 patients was given both abdominal and vaginal B-ultrasound examinations (experimental group). The diagnostic accuracy between the two groups was compared. Results: Patients in the experimental group had higher consistency rates with pathological diagnosis results in ectopic pregnancy rupture, embryonic arrest, acute pelvic inflammation, corpus luteum rupture, and intrauterine adhesions as compared to the control group. At the same time, the inspection accuracy rate of the experimental group (92.50%) was higher than that of the control group (70.00%) (P < 0.05). Conclusion: The combined application of abdominal and vaginal B-ultrasound in the diagnosis of acute abdomen was of great significance in improving the accuracy of clinical diagnosis and guiding doctors to provide effective treatment.

Acute abdomen caused by spontaneous rupture of degenerative hysteromyoma during pregnancy:A case report

BACKGROUND Hysteromyoma is not a rare tumor among pregnant women.During pregnancy,the symptoms caused by hysteromyoma can be improved through conservative treatment in most cases.However,in order to ensure the safety of mothers and children,surgeries are necessary in some special cases.CASE SUMMARY We report a case of pregnancy complicated with hysteromyoma red degeneration.The patient had peritonitis after sudden abdominal pain during the 20th week of pregnancy.Laparoscopic exploration suggested rupture and bleeding of hysteromyoma,which were improved after drainage and an anti-inflammatory treatment.A cesarean section was performed after full term.This case shows the complications of rupture after red degeneration of hysteromyoma during pregnancy.CONCLUSION We should be alert to rupture of hysteromyoma during pregnancy,and active laparoscopic exploration is essential to improve the prognosis of such patients.

Spontaneous gastric hematoma as a rare cause of acute abdomen:A case report

BACKGROUND Spontaneous gastric hematoma is an exceedingly rare condition characterized by the accumulation of blood within the gastric wall without any apparent iatrogenic or traumatic cause.Coagulopathies are the most frequent cause of gastric he-matomas.However,other causes include amyloidosis,pancreatitis,visceral vas-cular aneurysms,endoscopy complications and others.The pathophysiology of spontaneous gastric hematoma is not completely understood.However,it is postulated that it is caused by disruption of submucosal vessels that leads to dissection of the muscularis layer and formation of false lumen.The rarity of this condition increases the challenge of diagnosis,and there is no standard treatment protocol.CASE SUMMARY We present the case of a spontaneous gastric hematoma in a 22-year-old male.He presented to our emergency department complaining of pain in the left flank area lasting for 2 wk.There was no history of trauma,antico-agulant medications or endoscopy procedures.His hemoglobin and hematocrit levels were slightly lower than normal.Multi-slice computed tomography,ultrasound and endoscopy confirmed a gastric intramural hematoma.We recommended conservative treatment because there was no hemodynamic instability nor significant bleeding.The patient responded well,and there were no unexpected events.At the 3-mo follow-up,the ultrasound exa-mination revealed complete regression of the hematoma.CONCLUSION After reviewing the literature and our experience,we recommend that more of these cases should be treated conservatively.The tendency to treat these cases with potentially burdensome procedures such as total or subtotal gastrectomy should be significantly reduced.

Prevalence, Aetiology, and Clinical Profile of Acute Abdomen in Pregnancy in Southwest Cameroon: A 5-Year Retrospective Study

Background: Acute abdomen is one of the commonest reasons for presentation at the emergency department. The physiologic changes of pregnancy increase the chances of developing acute abdomen. The global incidence of acute abdomen in pregnancy range from 1 in 500 to 1 in 635 pregnant women. In 2018, a study in Azerbaijan reported a prevalence of 25%. However, to the best of our knowledge, very few studies have been carried out on this subject in Cameroon. Objectives: To determine the prevalence, assess the aetiologies, and review clinical profile of acute abdomen in pregnancy in the Southwest Cameroon. Methods: We conducted a 5-year retrospective study at the Obst/Gyn and Surgical units of Kumba, Buea, and Limbe Regional Hospitals. We included all files of pregnant women that were admitted for acute abdomen within the study period (1st Jan 2017 to 31st Dec 2021). Data was collected using a structured checklist adapted from previous studies. Descriptive statistics and statistical testing was done using SPSS version 25.0. Chi-square was used to compare categorical variables. p Results: Over 14,106 pregnant women were admitted to the aforementioned hospitals within the study period. 335 (2.4%) met our inclusion criteria. The patients’ age ranged from 17 to 43 years. The mean age was 27 years. Acute abdomen was more frequent (65%) in the first trimester. Ectopic pregnancy was the commonest obstetric aetiology while appendicitis was the commonest non obstetric surgical aetiology. Abdominal pain and tenderness were the most common presentation. Conclusion: The prevalence of acute abdomen in pregnancy in the Southwest Cameroon is 10 times higher than the global prevalence. Our study also confirmed the numerous aetiologies and varied clinical presentations of acute abdomen in pregnancy. Hence a wake-up call for primary care physicians.

A Qualitative Study of the Triage of Patients with Non-Traumatic Acute Abdomen

Objective: To explore the work experience of medical staff in the emergency department of a general hospital in the triage of patients with non-traumatic acute abdomen to formulate corresponding intervention measures and branch evaluation tools. Methods: With descriptive phenomenology as the research method, semi-structured interviews were conducted with the medical staff in a tertiary hospital in Nanjing from February 1st to 10th, 2023, and Colaizzi seven-step analysis was used to analyze the data. Results: A total of 17 emergency medical staff were interviewed in this study. Four themes were derived from the analysis of the data: the etiology of acute abdomen is complex, so it is difficult to categorize them: acute abdomen requires immediate treatment, but the treat will be delayed if the categorization is inaccurate;the high pressure of nurses and the accuracy in categorizing the patients are problems that should be addressed. Conclusion: The categorization of patients with non-traumatic acute abdomen is challenging. Therefore, it is necessary to carry out corresponding intervention and formulate appropriate departmental evaluation tools to improve the accuracy of categorization of patients with acute abdomen.

Pancreatic Pseudocyst Rupture: Cause of Acute Abdomen

Case report of a 23-year-old male patient with a pancreatic pseudocyst, initially was treated by the Interventional Radiology service by placing percutaneous drainage with poor evolution, abruptly presented abdominal pain, Systemic Inflammatory Response Syndrome and peritoneal irritation, so an urgent exploratory laparotomy was performed with a finding of rupture of the pancreatic pseudocyst into the abdominal cavity. He presented septic shock and died in the immediate postoperative period. Computerized Axial Tomography represents the ideal diagnostic method. Spontaneous rupture is extremely rare and requires urgent surgical intervention.

Dengue fever may mislead the surgeons when it presents as an acute abdomen

Objective: To review the management experience of a consecutive series of patients presenting as acute surgical abdomen whom were ultimately diagnosed to have DF(Dengue fever)/ DHF(Dengue heamorrhagic fever),Methods: Clinical data of all cases of apparent acute abdomen(AA) which were later confirmed as having DF/DHF reviewed by two surgical units from December 2012 to December 2013 were analyzed,Initially confirmed patients with DF/DHF who developed abdominal symptoms were not considered,Results: Out of the seventeen cases(7 males,age range 10-71 years) presented with fever and AA; appendicitis,cholecystitis,pancreatitis and non-specific peritonitis were suspected initially in 8,5,1 and 3 cases,respectively,Neutropenia or thrombocytopenia signifying DF/DHF occurred only in 11 patients at first evaluation thus six remained as surgical candidates beyond 24 h,One patient underwent appendicectomy with a prolonged hospital stay,DF was confirmed by serology in all patients,latest by fourth day of admission,One required blood product transfusion,4 needed critical care treatment and there was 1 death,Conclusions: DF/DHF misleads the clinicians when it presents as AA,Initial heamatological and ultrasonographic findings may be equivocal creating a diagnostic and management dilemma,Vigilant clinical suspicion and early dengue serological assessment is advisable in equivocal cases of AAs with fever in dengue endemic areas,to confirm/exclude the infection in order to avoid unnecessary surgical morbidity in the presence of DF.

Expression and Significance of Toll-like Receptor 2,4 of Peripheral Blood Mononuclear Cells in Acute Abdomen Patients Associated with Systemic Inflammatory Response Syndrome

The changes of Toll-like receptor （TLR） 2, 4 of peripheral blood mononuclear cells （PBMCs） in the acute abdomen patients associated with systemic inflammatory response syndrome （SIRS） and their potential significance were explored. A clinical study was performed on 103 acute abdomen patients in whom 65 were associated with SIRS. Forty healthy individuals served as normal controls. The mRNA expression of TLR2, 4 was detected by RT-PCR, and the expression of TNF-α and IL-6 by ELISA. The level of plasma endotoxin, hospital stay and mortality were measured. It was found that the endotoxin level was increased to varying degrees in all the acute abdomen patients, and the endotoxin level was and hospital stay longer in SIRS group than in non-SIRS group （P〈0.01）. TLR2 mRNA, TLR4 mRNA, IL-6 and TNF-ct could be detected with low value in normal controls, but they were up-regulated markedly on the 1 st day after admission. Then TLR4 mRNA, IL-6 and TNF-α were decreased gradually, but TLR2 mRNA maintained at a high level till the 5th day. These indexes above in SIRS group were higher than those in non-SIRS group （P〈0.01）. The results of correlation analysis revealed the expression of TLR2, 4 mRNA was positively correlated with the levels of TNF-α and IL-6, and the hospital stay, The results of Logistic regression demonstrated that overexpression of TLR2, 4 mRNA might result in higher risk of multiple organ dysfunction syndrome （MODS）. It was concluded that in the acute abdomen patients associated with SIRS, the expression of TLR2, 4 in PBMCs was increased markedly, suggesting that TLR might play an important role in the pathogenesis of acute abdomen associated with SIRS.

Spontaneous rupture of the giant gastric stromal tumor(> 35 cm) as a rare cause of acute abdomen: a case report

A case of spontaneous rupture of giant gastrointestinal stromal tumor(GIST) of stomach causing acute abdomen is described below. A male patient with abdominal mass presented with symptoms and signs of acute abdomen after admitting for 1 day. After preoperative management and evaluation, an exploratory laparotomy was performed, where rupture of a huge tumor in the stomach was found. A subtotal gastrectomy including the mass was performed and the final immunohistochemical examination verified that the neoplasm was a high risk GIST. The postoperative period was uneventful and the patient received treatment with imatinib mesylate, and regular follow-up without recurrence.

Hepatitis A virus-associated acute acalculous cholecystitis in an adult-onset Still’s disease patient:A case report and review of the literature

BACKGROUND Acute acalculous cholecystitis(AAC)is inflammation of the gallbladder without evidence of calculi.Although rarely reported,its etiologies include hepatitis virus infection(e.g.,hepatitis A virus,HAV)and adult-onset Still’s disease(AOSD).There are no reports of HAV-associated AAC in an AOSD patient.CASE SUMMARY Here we report a rare case of HAV infection-associated AAC in a 39-year-old woman who had a history of AOSD.The patient presented with an acute abdomen and hypotension.Elevated hepatobiliary enzymes and a thickened and distended gallbladder without gallstones on ultrasonography suggested AAC,but there were no signs of anemia nor thrombocytopenia.Serological screening revealed anti-HAV IgM antibodies.Steroid treatment did not alleviate her symptoms,and she was referred for laparoscopic cholecystectomy.The resected gallbladder was hydropic without perforation,and her clinical signs gradually improved after surgery.CONCLUSION AAC can be caused by HAV in AOSD patients.It is crucial to search for the underlying etiology for AAC,especially uncommon viral causes.

Management of infected acute necrotizing pancreatitis

Necrotizing or severe pancreatitis represents approximately 10%-20%of acute pancreatitis.30%-40%of patients with acute necrotizing pancreatitis(ANP)will develop debris infection through translocation of intestinal microbial flora.Infected ANP constitutes a serious clinical condition and is complicated by severe sepsis with high mortality rates of up to 40%despite progress in current intensive care.The timely detection of sepsis is crucial.The Quick Sequential Organ Failure Assessment score,procalcitonin levels>1.8 ng/mL and increased lactates>2 mmol/L(>18 mg/dL),indicate the need for urgent management.The escalated step-by-step management protocol starts with broad-spectrum antibiotics,percutaneous drainage or endoscopic management,and ends with surgical management if needed.The latter includes necrosectomy(either laparoscopic or traditional open surgery),peritoneal lavage and extensive drainage.This management protocol increases the chance of survival to approximately 60%in patients with otherwise fatal cases.Any treatment choice must be individualized,and the timing is critical.

Congestive heart failure masquerading as acute abdomen:A case report

Rationale:As an uncommon manifestation of congestive heart failure,congestive hepatopathy requires an early diagnosis in order to render appropriate care.Misdiagnosis as intraabdominal sepsis may lead to erroneous initial intervention,such as fluid boluses,that can potentially tip an already sick patient with poor reserves over into an extreme state.Patient’s Concern:A 65-year-old man was brought to the emergency department for excruciating abdominal pain,vomiting and jaundice.He also had lower limb pitting edema and was hypotensive en route.Diagnosis:Congestive hepatopathy.Interventions:Intravenous furosemide and fluid restriction.Outcomes:The patient declined admission to the cardiology ward and discharged himself against medical advice after his condition was improved in the emergency department.Lessons:It is important to pay attention to acute abdominal pain induced by extraabdominal pathologies.In this case of acute decompensated congestive heart failure,early recognition of the cause makes a difference to the management.

Presentation of the Diverticulum of the Caecum, Cause of the Acute Abdomen

Solitary caecal diverticulum is an uncommon entity and therefore it is difficult to diagnose except during surgery exploration. It is extremely difficult to differentiate it preoperatively from acute appendicitis. We report a case of an enlarged colon segment, presenting macroscopically as tumor diverticulum in a 27-year-old female patient, presenting with a 2 day history of a severe abdominal right lower quadrant pain with accompanying anorexia, nausea, vomiting and high body temperature. After clinical assessment, laboratory examination, X-ray, and CT are performed, the indication for surgical treatment is set.

Application of Student Standardized Patient in the Clinical Teaching of Acute Abdomen

Background:In recent years,with the gradual expansion of the scale of medical education,the shortage of medical teaching resources and the reluctance of patients to cooperate with teaching have become increasingly prominent.Objective:To explore the application effect of student standardized patient(SSP)in the clinical teaching of acute abdomen.Methods:Fifty-four fifth-year general medical students from class 1826 of the general department of The First Affiliated Hospital of Xi’an Medical University were selected as the research subjects and randomly divided into two groups,with 27 students in the experimental teaching group,and the remaining 27 students in the conventional teaching group.The experimental teaching group adopted the SSP teaching approach.The SSPs were generated from the training students of the hospital through the recruitment and training process of SSP.In this study,seven qualified SSPs were selected for the clinical teaching of acute abdomen.At the end of the course,a periodic assessment was held.The rank sum test was used to compare the excellent and good rates between the two groups,while t-test was used to compare the difference between the two groups.Results:The results showed that the excellent and good rate of the experimental teaching group was significantly higher than that of the conventional group,in which the difference between the two groups was statistically significant(p<0.05).In terms of the assessment results,the theoretical scores and skills scores of the experimental teaching group were better than those of the conventional teaching group,in which the differences between the two groups were statistically significant(p<0.05).Conclusion:Through the training of SSP for acute abdomen and its application in surgical teaching and examination,the superiority of SSP is emphasized.Although there are still some shortcomings in the application of SSP in clinical teaching,it is a relatively new and effective teaching method,and it will play an increasingly critical role in clinical skills training pertaining to the medical specialty.

Etiologies, Clinical Presentation and Outcome of Adult Patients Presenting with Bowel Obstruction on a Virgin Abdomen

Context: Generally in Africa, BO remains the leading cause of acute abdomen. We therefore sought to study the current etiological factors of intestinal obstruction on a virgin abdomen or unhealed abdomen at the central hospital of Yaoundé in order to better understand the main causes and to better anticipate and improve the diagnosis, management and the evolution of intestinal obstruction on a virgin abdomen. Method: The patients were prospectively included from June 2021 to May 2022, these patients were recruited from the digestive and emergency surgery units of the Yaoundé Central Hospital during the study period and who met the inclusion criteria, with suspicion of partial or total intestinal obstruction or those with an intraoperative confirmed diagnosis were enrolled. Results: We recruited 73 patients including 43 (60.3%) men and 29 (39.7%) women whose mean age was 42.5 years with extremes ranging from 16 to 70 years. Most of them consulted after 72 hours, i.e. 65.2% of cases due to self-medication or even prior consultations in the lower level center at the Central Hospital of Yaoundé. The patients retained for this work presented in majority the symptoms according to the abdominal pains, the stop of the materials and gases;meteorism and vomiting. Abdominal wall hernias with incarcerated intestinal loops were the most common cause of intestinal obstruction in an unscarred abdomen in adults at 38.4% of cases, followed by digestive tumors 23.3% and adhesions 17.8%. Exceptionally, a cluster of roundworms was found as the cause of intestinal obstruction in two of our patients. Complications occurred in 25 patients or 31.5% of cases and were dominated respectively by nausea and hematoma (36%), local infections (24%) and malaria (24%). Death occurred in 5 of our patients, or 6.8% of cases, and was mostly caused by hypovolemic shock (40%) and pulmonary embolism (40%). Conclusion: Intestinal obstructions on the abdomen without scarring remain the prerogative of young adults and are caused by strangulated hernias with incarcerated intestinal loops, tumors and adhesions. The rate of complications remains high and they are dominated by infectious pathology. Their mortality is clearly improving.

Management of obstructed colorectal carcinoma in an emergency setting:An update

Colorectal carcinoma is common,particularly on the left side.In 20%of patients,obstruction and ileus may be the first clinical manifestations of a carcinoma that has advanced(stage II,III or even IV).Diagnosis is based on clinical presentation,plain abdominal radiogram,computed tomography(CT),CT colonography and positron emission tomography/CT.The best management strategy in terms of short-term operative or interventional and long-term oncological outcomes re-mains unknown.For the most common left-sided obstruction,the first choice should be either emergency surgery or endoscopic decompression by self-expen-dable metal stents or tubes.The operative plan should be either one-stage or two-stage resection.One-stage resection with on-table bowel decompression and irrigation can be accompanied or not accompanied by proximal defunctioning stoma(colostomy or ileostomy).Primary anastomosis is more convenient but has increased risks of anastomotic leakage and morbidity.Two-stage resection(Hart-mann’s procedure)is safer and the most widely used despite temporally affecting quality of life.Damage control surgery in high-risk frail patients is less frequently performed since it can be successfully substituted with endoscopic stenting or tubing.For the less common right-sided obstruction,one-stage surgical resection is more beneficial than endoscopic decompression.The role of minimally invasive surgery(laparoscopic or robotic)is a subject of debate.Emergency laparoscopic-assisted management is advantageous to some extent but requires much expertise due to inherent difficulties in dissecting the distended colon and the risk of rup-ture and subsequent septic complications.The decompressing stent as a bridge to elective surgery more substantially decreases the risks of morbidity and mortality than emergency surgery for decompression and has equivalent medium-term overall survival and disease-free survival rates.Its combination with neoadjuvant chemotherapy or radiation may have a positive effect on long-term oncological outcomes.Management plans are crucial and must be individualized to better fit each case.Core Tip:Acute obstruction is common in patients with more advanced colorectal carcinoma and may be the first manifestation mainly of left-sided obstruction and in elderly individuals.Emergency decompression is mandatory.Emergency surgical resection and primary anastomosis accompanied or not accompanied by proximal defunctioning stoma must be the first treatment choice for fit patients under 70 years.Hartmann’s two-stage procedure,although more preferable,must be the second alternative choice.Emergency endoscopic self-expendable metal stents must be preferred in unfit patients as a bridge to surgery and for palliative treatment in all inoperable cases.However,these basic management principles constitute a general direction.Decision-making is important and should be individualized.

Stercoral perforation of the cecum:A case report

BACKGROUND With less than 90 reported cases to date,stercoral perforation of the colon is a rare occurrence.Stercoral ulceration is thought to occur due to ischemic pressure necrosis of the bowel wall,which is caused by the presence of a stercoraceous mass.To underscore this urgent surgical situation concerning clinical presentation,surgical treatment,and results,we present the case of a 66-year-old man with a stercoral perforation.CASE SUMMARY A 66-year-old man with a history of hypertension,hyperlipidemia,and gout presented at the emergency department with lower abdominal pain and a low-grade fever lasting for a few hours.Abdominal computed tomography indicated a suspected bezoar(approximately 7.6 cm)in the dilated cecum,accompanied by pericolic fat stranding,mild proximal dilatation of the ileum,pneumoperitoneum,and minimal ascites.Intraoperatively,feculent peritonitis with isolated cecal perforation were observed.Consequently,a right hemicolectomy with peritoneal lavage was performed.A histopathological examination supported the intraoperative findings.CONCLUSION In stercoral perforations,a diagnosis should be diligently pursued,especially in older adults,and prompt surgical intervention should be implemented.

Clinical significance of appendicoliths in elderly patients over eighty years old undergoing emergency appendectomy:A single-center retrospective study

BACKGROUND Acute appendicitis with an appendicolith is one of the most common abdominal emergencies in elderly patients and is more likely to progress to gangrene and perforation.AIM To analyze the clinical data of elderly patients undergoing emergency appende-ctomy for acute appendicitis,aiming to improve treatment strategies.METHODS The clinical data of 122 patients over 80 years old who underwent emergency appendectomy for acute appendicitis at the Department of Emergency Surgery of Zhongshan Hospital,Fudan University from January 2016 to March 2023 were retrospectively analyzed.The patients were divided into two groups based on the presence of an appendicolith or not,and clinicopathological and surgery-related features were compared between the two groups.RESULTS The duration of abdominal pain in all 122 patients ranged from 5 to 168 h.All patients underwent emergency appendectomy:6 had an open appendectomy,101 had a laparoscopic appendectomy,and 15 required conversion from laparoscopic to open surgery,resulting in a conversion rate of 12.9%(15/116).The patients were divided into two groups:Appendicolith group(n=46)and non-appendi-colith group(n=76).Comparisons of clinicopathological features revealed that patients with appendicoliths were more likely to develop appendiceal gangrene(84.8%vs 64.5%,P=0.010)and perforation(67.4%vs 48.7%,P=0.044),and had a lower surgical conversion rate(2.2%vs 19.7%,P=0.013).The median length of hospital stay was 5.0 d for both groups and there was no significant difference between them.All patients were successfully dis-charged.CONCLUSION Around 40%of patients over 80 years old with acute appendicitis have an appendicolith,increasing their risk of developing appendiceal gangrene and perforation,and therefore should receive timely surgical treatment.

Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis

BACKGROUND: In low-risk patients with acute cholecystitis who did not respond to nonoperative treatment, we prospectively compared treatment with emergency laparoscopic cholecystectomy or percutaneous transhepatic cholecystostomy followed by delayed cholecystectomy.METHODS: In 91 patients(American Society of Anesthesiologists class I or II) who had symptoms of acute cholecystitis ≥72 hours at hospital admission and who did not respond to nonoperative treatment(48 hours), 48 patients were treated with emergency laparoscopic cholecystectomy and 43 patients were treated with delayed cholecystectomy at ≥4 weeks after insertion of a percutaneous transhepatic cholecystostomy catheter. After initial treatment, the patients were followed up for 23 months on average(range 7-29).RESULT: Compared with the patients who had emergency laparoscopic cholecystectomy, the patients who were treated with percutaneous transhepatic cholecystostomy and delayed cholecystectomy had a lower frequency of conversion to open surgery [19(40%) vs 8(19%); P=0.029], a frequency of intraoperative bleeding ≥100 mL [16(33%) vs 4(9%); P=0.006],a mean postoperative hospital stay(5.3±3.3 vs 3.0±2.4 days;P=0.001), and a frequency of complications [17(35%) vs 4(9%);P=0.003].CONCLUSION: In patients with acute cholecystitis who presented to the hospital ≥72 hours after symptom onset and did not respond to nonoperative treatment for 48 hours, percutaneous transhepatic cholecystostomy with delayed laparoscopic cholecystectomy produced better outcomes and fewer complications than emergency laparoscopic cholecystectomy.