Gangrenous Cholecystitis with Atypical Presentation in an Elderly Diabetic Woman

In elderly patients, numerous factors subsidize the diagnostic challenge and high incidence of complications in this specific population, taking gangrenous cholecystitis as a critical example. The aim of this work is to report an unusual case of gangrenous choleystitis in an elderly diabetic women and its atypical clinical presentation. A 79-year-old female patient came to our observation;her medical history showed nausea and vomiting of about 2 hours which rapidly ended with symptomatic therapy, without recurrence, and a 3-week history of intermittent fever associated with productive cough. No abdominal discomfort was declared. Physical examination of the abdomen was negative. Laboratory analysis revealed leukocytosis with the remaining criteria within the normal range. After 2 days, she started with a mildabdominal pain in the epigastric region that rapidly progressed to the right upper quadrant, right flank and right iliac fossa, without nausea, vomiting or fever. Abdominal computer tomography findings revealed thickness of the gall-bladder and important densification of the vascular bed. Acute cholecystitis was diagnosed. The patient was then submitted to a laparoscopic cholecystectomy under general anaesthesia with findings suggestive of gangrenous acute cholecystitis confirmed by histologic examination of the specimen. Delays in diagnosing acute cholecystitis in specific populations, such as elderly diabetics, result in a higher prevalence of morbidity and mortality due to potentially serious complications as gangrenous cholecystitis. Consequently, the diagnosis should be measured and investigated promptly in order to prevent poor outcomes.

Outcome of laparoscopic cholecystectomy is not influenced by chronological age in the elderly

AIM:To evaluate the outcome of laparoscopic cholecystectomy(LC)in patients aged 80 years and older. METHODS:A total of 353 patients aged 65 to 79 years(group 1)and 35 patients aged 80 years and older(group 2)underwent LC.Patients were further classified into two other groups:those with uncomplicated gallbladder disease(group A)or those with complicated gallbladder disease(group B). RESULTS:There were no significant differences between the age groups(groups 1 and 2)with respect to clinical characteristics such as age,gender,comorbid disease,or disease presentation.Mean operative time,conversion rate,and the incidence of major postoperative complications were similar in groups 1 and 2.However,the percentage of high-risk patients was significantly higher in group 2 than in group 1 (20.0%vs 5.7%,P<0.01).Group A comprised 322 patients with a mean age of 71.0±5.3 years,and group B comprised 51 patients with a mean age of 69.9±4.8 years.In group B,mean operative time (78.4±49.3 min vs 58.3±35.8 min,P<0.01),mean postoperative hospital stay(7.9±6.5 d vs 5.0±3.7 d, P<0.01),and the incidence of major postoperative complications(9.8%vs 3.1%,P<0.05)were significantly greater than in group A.The conversion rate tended to be higher in group B,but this difference was not significant. CONCLUSION:Perioperative outcomes in elderly patients who underwent LC seem to be influenced by the severity of gallbladder disease,and not by chronologic age.In octogenarians,LC should be performed at an earlier,uncomplicated stage of the disease whenever possible to improve perioperative outcomes.

Ultrasound guided percutaneous cholecystostomy in high-risk patients for surgical intervention

AIM: To assess the efficacy and safety of ultrasound guided percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis in a well-defined high risk patients under general anesthesia. METHODS: The data of 27 consecutive patients who underwent percutaneous transhepatic cholecystostomy for the management of acute cholecystitis from January 1999 to June 2003 was retrospectively evaluated. All of the patients had both clinical and sonographic signs of acute cholecystitis and had comorbid diseases. RESULTS: Ultrasound revealed gallbladder stones in 25 patients and acalculous cholecystitis in two patients. Cholecystostomy catheters were removed 14-32 d (mean 23 d) after the procedure in cases where complete regression of all symptoms was achieved. There were statistically significant reductions in leukocytosis, (13.7 × 103 ± 1.3 × 103 μg/L vs 13 × 103 ± 1 × 103 μg/L, P < 0.05 for 24 h after PC; 13.7 × 103 ± 1.3 × 103 μg/L vs 8.3 × 103 ± 1.2 × 103 μg/L, P < 0.0001 for 72 h after PC), C -reactive protein (51.2 ± 18.5 mg/L vs 27.3 ± 10.4 mg/L, P < 0.05 for 24 h after PC; 51.2 ± 18.5 mg/L vs 5.4 ± 1.5 mg/L, P < 0.0001 for 72 h after PC), and fever (38 ± 0.35℃ vs 37.3 ± 0.32℃, P < 0.05 for 24 h after PC; 38 ± 0.35℃ vs 36.9 ± 0.15℃, P < 0.0001 for 72 h after PC). Sphincterotomy and stone extraction was performed successfully with endoscopic retrograde cholangio-pancreatography (ERCP) in three patients. After cholecystostomy, 5 (18%) patients underwent delayed cholecystectomy without any complications. Three out of 22 patients were admitted with recurrent acute cholecystitis during the follow-up and recoveredwith medical treatment. Catheter dislodgement occurred in three patients spontaneously, and two of them were managed by reinsertion of the catheter. CONCLUSION: As an alternative to surgery, percutan- eous cholecystostomy seems to be a safe method in critically ill patients with acute cholecystitis and can be performed with low mortality and morbidity. Delayed cholecystectomy and ERCP, if needed, can be performed after the acute period has been resolved by percutaneous cholecystostomy.

Therapeutic experience of an 89-year-old high-risk patient with incarcerated cholecystolithiasis:A case report and literature review

BACKGROUND The global pandemic of coronavirus disease 2019 pneumonia poses a particular challenge to the emergency surgical treatment of elderly patients with high-risk acute abdominal diseases.Elderly patients are a high-risk group for surgical treatment.If the incarceration of gallstones cannot be relieved,emergency surgery is unavoidable.CASE SUMMARY We report an 89-year-old male patient with acute gangrenous cholecystitis and septic shock induced by incarcerated cholecystolithiasis.He had several coexisting,high-risk underlying diseases,had a history of radical gastrectomy for gastric cancer,and was taking aspirin before the operation.Nevertheless,he underwent emergency laparoscopic cholecystectomy,with maintenance of postoperative heart and lung function,successfully recovered,and was discharged on day 8 after the operation.CONCLUSION Emergency surgery for elderly patients with acute abdominal disease is safe and feasible during the coronavirus disease 2019 pandemic,the key is to abide strictly by the hospital's epidemic prevention regulations,fully implement the epidemic prevention procedure for emergency surgery,fully prepare before the operation,accurately perform the operation,and carefully manage the patient postoperatively.

Laparoscopic cholecystectomy for gangrenous cholecystitis in around nineties: Two case reports

BACKGROUND Gangrenous cholecystitis is a form of acute cholecystitis which involves gangrenous alterations in the gallbladder wall and it often follows an acute and serious course.We herein report on two cases of very elderly people diagnosed early with gangrenous cholecystitis,who safely underwent laparoscopic cholecystectomy(LC)and both demonstrated a good outcome.CASE SUMMARY Case 1:An 89-year-old female.She underwent abdominal contrast-enhanced computed tomography(CECT)due to abdominal pain and diarrhea.Her gallbladder wall indicated the absence of contrast enhancement,thus leading to diagnosis of gangrenous cholecystitis and she therefore underwent LC.Although her gallbladder demonstrated diffuse necrosis and it was also partly perforated,she was able to be discharged without any serious complications.Case 2:A 91-year-old female.She made an emergency visit with a chief complaint of abdominal pain.Abdominal CECT revealed swelling of the gallbladder and an ambiguous continuity of the gallbladder wall.She was diagnosed with gangrenous cholecystitis and underwent LC.Her gallbladder had swelling and diffuse necrosis.Although her preoperative blood culture was positive,she showed a good outcome following surgery.CONCLUSION Although a definite diagnosis of gangrenous cholecystitis is difficult to make prior to surgery,if an early diagnosis can be made and appropriate treatment can be carried out,then even very elderly individuals may be discharged without major complications.

Advances and controversies in the management of acute cholecystitis in high-risk, critically ill, and unfit-for-surgery patients: the Italian Society of Emergency Surgery and Trauma guidelines

There is an ongoing debate about the therapeutic strategies for acute cholecystitis in high-risk,critically ill patients,and finding the optimal management option is a work in progress.In the recent study“Acute cholecystitis management in high-risk,critically ill,and unfit-for-surgery patients:the Italian Society of Emergency Surgery and Trauma(SICUT)guidelines”,Prof.Coccolini et al.summarize current knowledge on treating acute cholecystitis in high risk,critically ill,and unfit for surgery patients(1).The article encompasses topics such as patient stratification,risk factors,and outcomes of non-operative gallbladder drainage and advances the knowledge of the field by proposing specific management recommendations for these patient groups.

Which octogenarian patients are at higher risk after cholecystectomy for symptomatic gallstone disease? A single center cohort study

BACKGROUND Incidence of gallstones in those aged≥80 years is as high as 38%-53%.The decision-making process to select those oldest old patients who could benefit from cholecystectomy is challenging.AIM To assess the risk of morbidity of the“oldest-old”patients treated with cholecystectomy in order to provide useful data that could help surgeons in the decision-making process leading to surgery in this population.METHODS A retrospective study was conducted between 2010 and 2019.Perioperative variables were collected and compared between patients who had postoperative complications.A model was created and tested to predict severe postoperative morbidity.RESULTS The 269 patients were included in the study(193 complicated).The 9.7%of complications were grade 3 or 4 according to the Clavien-Dindo classification.Bilirubin levels were lower in patients who did not have any postoperative complications.American Society of Anesthesiologists scale 4 patients,performing a choledocholithotomy and bilirubin levels were associated with Clavien-Dindo>2 complications(P<0.001).The decision curve analysis showed that the proposed model had a higher net benefit than the treating all/none options between threshold probabilities of 11%and 32%of developing a severe complication.CONCLUSION Patients with American Society of Anesthesiologists scale 4,higher level of bilirubin and need of choledocholithotomy are at the highest risk of a severely complicated postoperative course.Alternative endoscopic or percutaneous treatments should be considered in this subgroup of octogenarians.

高龄高危高难度腹腔镜胆囊切除术

目的探讨高龄高危高难度腹腔镜胆囊切除(LC)主要并存病、并发症、手术时机、适应证及方法。方法回顾性分析1994年￣2004年12月实施503例LC的高龄高危高难度手术患者主要并存病、并发症、手术难度、围手术期处理等对其预后的影响。结果该组伴有糖尿病83例(16.50%),肺心病79例(15.71%),肝硬化69例(13.72%),冠心病206例(40.95%)。该组严重并发症发生率2.98%(15/503),死亡率0.80%(4/503),中转开腹率1.39%(7/503),治愈率99.20%。结论高龄高危胆囊炎患者并存病、并发症发生率高,尤其是急性胆囊炎发生率更高,并存病、并发症、手术难度大是引起死亡的高危因素。完善的围手术期处理,积极治疗并存病、并发症,严格把握手术时机、适应证,熟练的操作技能,恰当的手术方式是治疗成功的关键。

老年患者急性结石性胆囊炎的临床特点及相关处理对策的研究(附126例报道)

目的:研究老年急性结石性胆囊炎患者的临床特点,探讨相关治疗措施。方法:回顾性对照分析13年间338例急性结石性胆囊炎的临床资料,病例分为老年组(≥60岁,A组,126例)和年轻组(<60岁,B组,212例)。结果:老年组患者就诊时间比年轻组患者晚36.2小时;腹痛普遍较轻,而体征较重;WBC、胆囊壁厚度、胆囊积液的病例数老年患者显著性高于年轻组(P<0.01);93.7%的老年患者伴合并症;老年组患者多采用保守治疗+手术切除方式(68.3%),而年轻组大多采用急诊手术治疗,两组均无手术死亡;老年组胆囊病理改变明显重于年轻组;老年组误诊率(16.7%)显著高于年轻组(P<0.01)。结论:老年患者具有就诊晚、症状轻而体征重、病情重、合并症多以及误诊率高的特点;治疗上采用个体化原则,情况良好行急诊手术,对于重症患者宜采用先保守后手术的方针,手术时间在2周内实施是安全有效的。同时对重症患者行PTGD治疗可有效缓解病情,改变患者全身情况,为进一步施行胆囊切除创造条件。

老年急性胆囊穿孔38例临床分析

目的探讨老年急性胆囊穿孔的外科治疗方法。方法回顾性分析2008年1月—2012年6月我院收治的38例老年胆囊穿孔的临床资料。结果全组均有不同程度腹痛,部分患者伴发热、腹膜刺激征、黄疸,术前均行B超检查,13例误诊,误诊率34.2%。误诊为胆囊结石并胆囊炎6例,消化性溃疡穿孔3例,急性胰腺炎、急性肠梗阻各2例。38例均经手术治疗证实胆囊穿孔。术后发生并发症16例,其中肺部感染5例,切口感染3例,膈下脓肿2例,多器官功能衰竭、肝脓肿、中毒性休克、心力衰竭、急性肺栓塞及下肢深静脉血栓形成各1例。死亡4例,病死率10.5%。结论老年急性胆囊穿孔临床表现不典型,易误诊,B超检查有助于诊断。一旦确诊,应尽早进行手术。术后并发症与并存疾病关系密切,需高度重视。

超声在老年急性非结石性胆囊炎诊断中的应用

目的 探讨超声在老年急性非结石性胆囊炎诊断中的价值。 方法回顾性总结和分析29例老年人急性非结石性胆囊炎。结果超声对急性非结石性胆囊炎的显示率和诊断符合率均为100％。急性非结石性胆囊炎的胆囊长径、宽径明显大于对照组(P<0.01),其胆囊壁较对照组增厚(P<0.01)。 结论 超声对急性非结石性胆囊炎具有重要的诊断价值。

老年急性胆囊炎患者早期行腹腔镜胆囊切除术围术期处理分析

目的探讨老年急性胆囊炎患者早期行腹腔镜胆囊切除术(LC)围术期处理的方法。方法以60岁以上老年急性胆囊炎患者76例为治疗组,以同期收治的60岁以上老年非急性胆囊炎患者42例为对照组,均给予LC术,比较2组疗效。结果治疗组手术时间较对照组长,差异具有统计学意义(P<0.05);2组术后肛门排气时间、术后住院时间差异无统计学意义(P>0.05)。2组术后并发症发生率,差异无统计学意义(P>0.05)。结论只要充分围术期处理,掌握手术适应证,老年人早期行腹镜胆囊切除术是安全可行的。

82例老年结石性急性胆囊炎临床分析

目的探讨老年结石性急性胆囊炎的临床特点、手术时机与方式。方法对我院2001-2006年经手术治疗的82例〉65岁老年人结石性急性胆囊炎的临床资料进行回顾性分析。结果68.3％的患者存在有不同类型的并存病，12.2％的患者胆囊坏疽，手术并发症发生率14.6％，发病〉72h，手术并发症发生率明显高于72h以内手术，治愈81例（98.8％），死亡1例。结论老年人对急诊胆囊手术大多都能耐受，早期手术，加强围手术期的处理，合理选用手术方式是关键。

76例老年结石性急性胆囊炎外科治疗分析

目的 探讨老年结石性急性胆囊炎的临床特点、手术时机与方式。方法 对我院 1998～ 2 0 0 1年经手术治疗的76例 6 5岁以上老年人结石性急性胆囊炎的临床资料进行回顾性分析。结果 5 3.9%的病人存在有不同类型的并存病 ,19.7%的病人胆囊坏疽 ,手术并发症发生率 15 .8% ,发病 72 h以上手术并发症发生率明显高于 72 h以内手术 ,治愈 75例 (98.7% )死亡 1例。结论 老年人对急诊胆囊手术一般都能耐受 ,早期手术 ,加强围手术期的处理 ,合理选用手术方式是关键。

老年结石性急性胆囊炎外科治疗体会

目的:探讨老年结石性急性胆囊炎的临床特点、手术时机及方式。方法:回顾分析我院66例60岁以上手术治疗的老年人急性结石性胆囊炎病例的临床资料。结果:51.5%的病人存在不同类型的并存病,13.6%的病人胆囊坏疽,手术并发症发生率19.7%,发病72h以上手术并发症发生率明显高于72h以内手术,治愈64例(97%),死亡2例。结论:老年人对急诊胆囊手术一般都能耐受,早期手术,加强围手术期的处理,合理选用手术方式是关键。

中老年胃癌根治术后发生胆囊炎的危险因素分析

目的分析中老年胃癌患者外科手术治疗后发生胆囊炎的危险因素,为其防治提供参考依据。方法收集沛县人民医院2012年1月至2016年6月收治并行胃癌根治术的478例≥50岁的胃癌患者的临床资料,通过单因素和多因素回归模型分析术后发生胆囊炎的危险因素。结果 478例患者中154例(32%)发生胆囊炎。多因素回归分析结果显示,患者体重指数、第8组、第12组淋巴结清扫是手术后发生胆囊炎的独立危险因素(P<0.05)。结论中老年胃癌根治术后发生胆囊炎的风险因素包括第8、12组淋巴结清扫及体重指数,术中清扫淋巴结时需精细操作,注意保留迷走神经肝胆支。

老年急性结石胆囊炎患者210例外科治疗策略探讨

目的总结老年急性结石性胆囊炎的临床特点及治疗方案,分析手术时机和方式对患者预后的影响。方法回顾性分析2000年1月至2016年6月我院收治的210例年龄为60~87岁的老年急性结石性胆囊炎患者的临床资料,分析其病情特点、治疗方法和并发症发生情况。结果 210例中,合并高血压97例(46.2%),冠心病178例(84.8%),糖尿病36例(17.1%),陈旧性心肌梗塞15例(7.1%),支气管炎肺气肿32例(15.2%),脑梗塞19例(9.0%),同时合并两种以上疾病52例(24.8%)。保守治疗14例,死亡3例;行腹腔镜胆囊切除术56例(中转开腹3例),开腹胆囊切除术140例,其中,胆囊大部切除术2例,胆囊切除加胆道探查术28例,193例治愈,死亡3例,伤口感染13例,肺部感染9例,平均住院时间为10~19d。结论老年胆囊炎并结石发病急,症状重,并发症多,临床容易误诊,手术风险较大,因此应仔细分析病情,选择合理的个性化治疗方案和手术时机,积极进行术前准备,是降低并发症和死亡率的关键。

开腹胆囊切除术与小切口胆囊切除术治疗高龄胆囊结石患者疗效分析

目的:探讨开腹胆囊切除术与小切口胆囊切除术治疗高龄胆囊结石患者的疗效,选择最佳术式。方法:将40例高龄胆囊结石患者随机分成两组,传统开腹胆囊切除术(OC)组20例和小切口胆囊切除术(MC)组20例,比较观察两组病例手术时间、术中出血量、疼痛指数、肠功能恢复时间、并发症和住院时间等。结果:发现术中出血量及肠功能恢复时间和术后疼痛指数MC组较OC组明显减小(P<0.05),MC组手术时间较OC组延长(P<O.05),MC组术后并发症高,住院时间延长(P<0.05)。结论:常规的胆囊切除术在治疗高龄胆囊结石患者优于小切口胆囊切除术。

老年人胆囊炎胆石症(附228例临床分析)

本文回顾了228例胆囊炎和胆石症的老年患者,主要临床表现是右上腹或剑突下疼痛(97.7％),并伴随有心血管系统和肺部疾病。126例(55.2％)作了手术。急诊手术死亡率为12％,择期手术死亡率为3.5％。本文认为,有症状并确诊为胆囊炎、胆石症的老年患者应选择积极的手术治疗。

超声引导下经皮经肝胆囊穿刺引流术在急性胆囊炎老年高危患者中的应用

目的通过分组对比的方式,观察经皮经肝胆囊穿刺引流术(percutaneous transhepatic gallbladder drainage,PTGD)的治疗效果,及其对择期手术的影响,分析并评价PTGD在急性胆囊炎老年高危患者中的应用价值。方法回顾性分析扬州大学附属医院普外科2016年3月至2018年3月收治的急性胆囊炎患者189例,选取符合本次试验病例纳入标准的患者78例。其中根据急性期治疗方式不同,将其分为2组,一组接受PTGD治疗,另外一组接受常规抗感染等保守治疗。每组随机选取30例,分别为试验组和对照组。分别对比2组患者首次入院时,从接受治疗开始,腹痛持续时间,体温恢复正常所用时间,抗生素的使用时间。入院治疗48～72 h抽血检测的血液中白细胞计数、转氨酶、总胆红素指标。并对择期腹腔镜胆囊切除术的手术时间,术中出血量,2次治疗总费用,术后并发症发生率进行比较。结果试验组患者腹痛持续时间(21. 10±3. 99) h明显低于对照组患者(32. 50±6. 52) h,试验组患者体温恢复至正常(36. 5≤T≤37. 2℃)所用时间(13. 37±3. 78) h较对照组患者(28. 70±9. 27) h明显缩短。入院后48h白细胞计数试验组(8. 34±1. 80)×109/L低于对照组(11. 78±2. 09)×10~9/L,试验组谷丙转氨酶(87. 50±30. 72) U/L、谷草转氨酶指标(90. 57±30. 84) U/L低于对照组(110. 33±25. 81、119. 93±29. 67) U/L,总胆红素指标试验组(15. 24±4. 43) mmol/L低于对照组(19. 45±5. 17) mmol/L。试验组患者抗生素使用时间(3. 82±0. 83) d少于对照组患者(6. 88±1. 24) d。差异均具有统计学意义(P <0. 05)。患者出院1～3个月至我院行腹腔镜胆囊切除术,试验组手术时间(58. 17±10. 92) min、术中出血量(25. 67±6. 02) ml与对照组(58. 00±11. 73) min、(24. 67±5. 62) ml相比,差异无统计学意义。治疗总费方面无明显差异。结论对急性胆囊炎老年高危患者,采取PTGD治疗可以迅速降低胆囊内压力,控制炎症发展,有效地缓解腹痛、发热等感染所带来的临床症状,降低胆囊穿孔和感染性休克等严重并发症发生的风险,加快转氨酶下降速度,保护肝功能,为择期手术创造一定的条件。