Low skeletal muscle mass and high visceral adiposity are associated with recurrence of acute cholecystitis after conservative management:A propensity score-matched cohort study

Background:Recurrent acute cholecystitis(RAC)can occur after non-surgical treatment for acute cholecystitis(AC),and can be more severe in comparison to the first episode of AC.Low skeletal muscle mass or adiposity have various effects in several diseases.We aimed to clarify the relationship between RAC and body parameters.Methods:Patients with AC who were treated at our hospital between January 2011 and March 2022 were enrolled.The psoas muscle mass and adipose tissue area at the third lumbar level were measured using computed tomography at the first episode of AC.The areas were divided by height to obtain the psoas muscle mass index(PMI)and subcutaneous/visceral adipose tissue index(SATI/VATI).According to median VATI,SATI and PMI values by sex,patients were divided into the high and low PMI groups.We performed propensity score matching to eliminate the baseline differences between the high PMI and low PMI groups and analyzed the cumulative incidence and predictors of RAC.Results:The entire cohort was divided into the high PMI(n=81)and low PMI(n=80)groups.In the propensity score-matched cohort there were 57 patients in each group.In Kaplan-Meier analysis,the low PMI group and the high VATI group had a significantly higher cumulative incidence of RAC than their counterparts(log-rank P=0.001 and 0.015,respectively).In a multivariate Cox regression analysis,the hazard ratios of low PMI and low VATI for RAC were 5.250(95%confidence interval 1.083-25.450,P=0.039)and 0.158(95%confidence interval:0.026-0.937,P=0.042),respectively.Conclusions:Low skeletal muscle mass and high visceral adiposity were independent risk factors for RAC.

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.

Impact of interstitial cells of Cajal on slow wave and gallbladder contractility in a guinea pig model of acute cholecystitis

BACKGROUND Impaired interstitial cells of Cajal(ICCs)are central to the pathophysiology of acute cholecystitis(AC).Common bile duct ligation is a common model of AC,producing acute inflammatory changes and decrease in gallbladder contractility.AIM To investigate the origin of slow wave(SW)in the gallbladder and the effect of ICCs on gallbladder contractions during the process of AC.METHODS Methylene blue(MB)with light was used to establish selective impaired ICCs gallbladder tissue.Gallbladder motility was assessed using the frequency of SW and gallbladder muscle contractility in vitro in normal control(NC),AC12h,AC24h,and AC48h groups of guinea pigs.Hematoxylin and eosin and Massonstained gallbladder tissues were scored for inflammatory changes.ICCs pathological changes alterations were estimated using immunohistochemistry and transmission electron microscopy.The alterations of c-Kit,α-SMA,cholecystokinin A receptor(CCKAR),and connexin 43(CX43)were assessed using Western blot.RESULTS Impaired ICCs muscle strips resulted in the decrease in gallbladder SW frequency and contractility.The frequency of SW and gallbladder contractility were significantly lower in the AC12h group.Compared with the NC group,the density and ultrastructure of ICCs were remarkably impaired in the AC groups,especially in the AC12h group.The protein expression levels of c-Kit were significantly decreased in the AC12h group,while CCKAR and CX43 protein expression levels were significantly decreased in the AC48h group.CONCLUSION Loss ICCs could lead to a decrease in gallbladder SW frequency and contractility.The density and ultrastructure of ICCs were clearly impaired in the early stage of AC,while CCKAR and CX43 were significantly reduced at end stage.

Acute Alithiasis Cholecystitis in Children: Diagnostic and Therapeutic Approach in the Pediatric Surgery Department of the CHU of Conakry

Acute alithiasic cholecystitis (AAC) is the inflammatory disease of the gallbladder in the absence of gallstones. It is a rare pathology in children. The aim was to describe the clinical, diagnostic and therapeutic characteristics of this disease. Materials and Method: This was a 3-year retrospective study (January 2008 to December 2010) including 66 patient records collected for CAA. Results: The frequency of AAC was 3.57%, the mean age of the patients was 8 ± 3.52 years, and there were 36 boys and 30 girls. The main clinical features were right hypochondrial pain (66 cases), positive Murphy’s (66 cases), fever (53 cases) and jaundice or sub-jaundice (51 cases). The main ultrasound signs were thickened vesicular wall 50 cas (75.76%), vesicular distension 50cas (75.76%) and positive ultrasound Murphy 47 cas (71.21%). Medical treatment was exclusive in 64 patients (96.97%) and surgical treatment in 2 patients (3.03%). Conclusion: Acute alithiasic cholecystitis is a rare pathology in children, the clinical picture is not very specific and abdominal ultrasound is the key to early diagnosis. Conservative treatment is the first choice in the absence of any complications.

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.

Single-incision vs three-incision laparoscopic cholecystectomy for complicated and uncomplicated acute cholecystitis

AIM:To compare the clinical outcome of single-incision laparoscopic cholecystectomy(SILC)and three-incision laparoscopic cholecystectomy(3ILC)for acute cholecystitis.METHODS:From July 2009 to September 2012,136patients underwent SILC or 3ILC for acute cholecystitis at a tertiary referral hospital.One experienced surgeon performed every procedure using 5 or 10 mm 30-degree laparoscopes,straight instruments,and conventional ports.Five patients with perforated gallbladder and diffuse peritonitis and 23 patients with mild acute cholecystitis were excluded.The remaining 108 patients were divided into complicated and uncomplicated groups according to pathologic findings.Patient demography,clinical data,operative results and complications were recorded and analyzed.RESULTS:Fifty patients with gangrenous cholecystitis,gallbladder empyema,or hydrops were classified as the complicated group,and 58 patients with acute cholecystitis were classified as the uncomplicated group.Twenty-three(46.0%)of the patients in the complicated group(n=50)and 39(67.2%)of the patients in the uncomplicated group(n=58)underwent SILC;all others underwent 3ILC.The postoperative length of hospital stay(PLOS)was significantly shorter in the SILC subgroups than the 3ILC subgroups(3.5±1.1 d vs 4.6±1.3 d,P<0.01 in the complicated group;2.9±1.1 d vs 3.7±1.4 d,P<0.05 in the uncomplicated group).The maximum body temperature recorded at day 1 and at day 2 following the procedure was lower in the SILC subgroups,but the difference reached statistical significance only in the uncomplicated group(37.41±0.56℃vs 37.80±0.72℃,P<0.05 on postoperative day 1;37.10±0.43℃vs 37.57±0.54℃,P<0.01 on postoperative day 2).The operative time,estimated blood loss,postoperative narcotic use,total length of hospital stay,conversion rates,and complication rates were similar in both SILC and 3ILC subgroups.The complicated group had longer operative time(122.2±35.0 min vs 106.6±43.6 min,P<0.05),longer PLOS(4.1±1.3 d vs 3.2±1.2 d,P<0.001),and higher conversion rates(36.0%vs 19.0%,P<0.05)compared with the uncomplicated group.CONCLUSION:SILC is safe and efficacious for patients with acute cholecystitis.The main benefit is a faster recovery than that achieved with 3ILC.

Acute acalculous cholecystitis immediately after gastric operation:Case report and literatures review

Acute acalculous cholecystitis(AAC)is a rare complication of gastric surgery.The most commonly accepted concepts regarding its pathogenesis are bile stasis,sepsis and ischemia,but it has not been well described how to identify and manage this disease in the early stage.We report three cases of AAC in elderly patients immediately after gastric surgery,which were treated with three different strategies.One patient died 42 d after emergency cholecystectomy,and the other two finally recovered through timely cholecystostomy and percutaneous transhepatic gallbladder drainage,respectively.These cases informed us of the value of early diagnosis and proper treatment for perioperative AAC after gastric surgery.We further reviewed reported cases of AAC immediately after gastric operation,which may expand our knowledge of this disease.

Clinical features and outcomes of patients with severe acute pancreatitis complicated with gangrenous cholecystitis

BACKGROUND: The effects of gangrenous cholecystitis (GC) and consequent surgical interventions on the clinical outcomes and prognosis of patients with severe acute pancreatitis are not clear. The present study was to characterize the clinical outcomes of patients with severe acute pancreatitis complicated with GC. METHODS: We retrospectively analyzed 253 consecutive patients hospitalized for acute pancreatitis in intensive care unit. Among them, 68 were diagnosed as having severe acute pancreatitis; 10 out of the 68 patients had GC. We compared these 10 patients with GC and 58 patients without GC. The indices analyzed included sepsis/septic shock, pancreatic encephalopathy, acute respiratory distress syndrome, acute renal failure, multiple organ dysfunction syndrome, and death. RESULTS: Specific CT images of GC in patients with severe acute pancreatitis included enlarged and high-tensioned gallbladder, wall thickening, lumenal emphysema, discontinuous and/or irregular enhancement of mucosa, and pericholecystic effusion. The rates of severe sepsis/septic shock (70.0% vs 24.1%, P【0.01), pancreatic encephalopathy (50.0% vs 17.2%, P【0.05), acute respiratory distress syndrome (90.0% vs 41.4%, P【0.01), multiple organ dysfunction syndrome (70.0% vs 24.1%, P【0.01), acute renal failure (40.0% vs 27.6%, P【0.05), and death (40.0% vs 13.8%, P【0.05) were significantly higher in patients with GC than in those without GC.CONCLUSION: CT scans can help to identify early GC in patients with severe acute pancreatitis; early diagnosis and intervention for patients with GC can reduce morbidity and mortality.

Operative complications and economic outcomes of cholecystectomy for acute cholecystitis

BACKGROUND Recent management of acute cholecystitis favors same admission(SA)or emergent cholecystectomy based on overall shorter hospital stay and therefore cost savings.We adopted the practice of SA cholecystectomy for the treatment of acute cholecystitis at our tertiary care center and wanted to evaluate the economic benefit of this practice.We hypothesized that the existence of complications,particularly among patients with a higher degree of disease severity,during SA cholecystectomy could negate the cost savings.AIM To compare complication rates and hospital costs between SA vs delayed cholecystectomy among patients admitted emergently for acute cholecystitis.METHODS Under an IRB-approved protocol,complications and charges for were obtained for SA,later after conservative management(Delayed),or elective cholecystectomies over an 8.5-year period.Patients were identified using the acute care surgery registry and billing database.Data was retrieved via EMR,operative logs,and Revenue Cycle Operations.The severity of acute cholecystitis was graded according to the Tokyo Guidelines.TG18 categorizes acute cholecystitis by Grades 1,2,and 3 representing mild,moderate,and severe,respectively.Comparisons were analyzed withχ2,Fisher’s exact test,ANOVA,ttests,and logistic regression;significance was set at P<0.05.RESULTS Four hundred eighty-six(87.7%)underwent a SA while 68 patients(12.3%)received Delayed cholecystectomy.Complication rates were increased after SA compared to Delayed cholecystectomy(18.5%vs 4.4%,P=0.004).The complication rates of patients undergoing delayed cholecystectomy was similar to the rate for elective cholecystectomy(7.4%,P=0.35).Mortality rates were 0.6%vs 0%for SA vs Delayed.Patients with moderate disease(Tokyo 2)suffered more complications among SA while none who were delayed experienced a complication(16.1%vs 0.0%,P<0.001).Total hospital charges for SA cholecystectomy were increased compared to a Delayed approach($44500±$59000 vs$35300±$16700,P=0.019).The relative risk of developing a complication was 4.2x[95%confidence interval(CI):1.4-12.9]in the SA vs Delayed groups.Among eight patients(95%CI:5.0-12.3)with acute cholecystitis undergoing SA cholecystectomy,one patient will suffer a complication.CONCLUSION Patients with Tokyo Grade 2 acute cholecystitis had more complications and increased hospital charges when undergoing SA cholecystectomy.This data supports a selective approach to SA cholecystectomy for acute cholecystitis.

Single-port versus multi-port cholecystectomy for patients with acute cholecystitis: a retrospective comparative analysis

BACKGROUND: Trans-umbilical single-port laparoscopic cholecystectomy for chronic gallbladder disease is becoming increasingly accepted worldwide. But so far, no reports exist about the challenging single-port surgery for acute cholecystitis. The objective of this study was to describe our experience with single-port cholecystectomy in comparison to the conventional laparoscopic technique. METHODS: Between August 2008 and March 2010, 73 patients with symptomatic gallbladder disease and histopathological signs of acute cholecystitis underwent laparoscopic cholecystec- tomy at our institution. Thirty-six patients were operated on with the single-port technique (SP group) and the data were compared with a control group of 37 patients who were treated with the multi-port technique (MP group). RESULTS: The mean age in the SP group was 61.5 (range 21-81) years and in the MP group was 60 (range 21-94) (P=0.712). Gender, ASA status and BMI were not significantly different. The number of white blood cells was different before [SP: 9.2 (range 2.8-78.4); MP: 13.2 (range 4.4-28.6); P=0.001] and after the operation [SP: 7.8 (range 3.5-184.8); MP: 11.1 (range 5-20.8); P=0.002]. Mean operating time was 88 (range 34-174) minutes in the SP group vs 94 (range 39-209) minutes in the MP group (P=0.147). Four patients (5%) required conversion to an open procedure (SP: 1; MP: 3; P=0.320). During the follow- up period of 332 (range 29-570) days in the SP group and 428 (range 111-619) days in the MP group (P=0.044), eleven (15%) patients developed postoperative complications (P=0.745) and two patients in the SP group required reoperation (P=0.154). CONCLUSIONS: Trans-umbilical single-port cholecystectomy for beginning acute cholecystitis is feasible and the complicationrate is comparable with the standard multi-port operation. In spite of our good results, these operations are difficult to perform and should only be done in high-volume centers for laparoscopic surgery with experience in single-port surgery.

Feasibility of single-incision laparoscopic cholecystectomy for acute cholecystitis

AIM: To assess the safety of single-incision laparoscopic cholecystectomy(SILC) for acute cholecystitis.METHODS: All patients who underwent SILC at Sano Hospital(Kobe, Japan) between January 2010 and December 2014 were included in this retrospective study. Clinical data related to patient characteristics and surgical outcomes were collected from medical records. The parameters for assessing the safety of the procedure included operative time, volume of blood loss, achievement of the critical view of safety, use of additional trocars, conversion to laparotomy, intraoperative and postoperative complications, and duration of postoperative hospital stay. Patient backgrounds were statistically compared between those with and without conversion to laparotomy.RESULTS: A total of 100 patients underwent SILC for acute cholecystitis during the period. Preoperative endoscopic treatment was performed for suspected choledocholithiasis in 41 patients(41%). The mean time from onset of acute cholecystitis was 7.7 d. According to the Updated Tokyo Guidelines(TG13) for the severity of cholecystitis, 86 and 14 patients had grade Ⅰ and grade Ⅱ acute cholecystitis, respectively. The mean operative time was 87.4 min. The mean estimated blood loss was 80.6 mL. The critical view of safety was obtained in 89 patients(89%). Conversion laparotomy was performed in 12 patients(12%). Postoperative complications of Clavien-Dindo grade Ⅲ or greater were observed in 4 patients(4%). The mean duration of postoperative hospital stay was 5.7 d. Patients converted from SILC to laparotomy tended to have higher days after onset.CONCLUSION: SILC is feasible for acute cholecystitis; in addition, early surgical intervention may reduce the risk of laparotomy conversion.

Drainage vs. non-drainage after cholecystectomy for acute cholecystitis:a retrospective study

Many surgeons practice prophylactic drainage after cholecystectomy without reliable evidence,this study was conducted to answer the question whether to drain or not to drain after cholecystectomy for acute calculous cholecystitis.A retrospective review of all patients who had cholecystectomy for acute cholecystitis in Aseer Central Hospital,Abha,Saudi Arabia,was conducted from April 2010 to April 2012.Data were extracted from hospital case files.Preoperative data included clinical presentation,routine investigations and liver function tests.Operative data included excessive adhesions,bleeding,bile leak,and drain insertion.Complicated cases such as pericholecystic collections,mucocele and empyema were also reported.Patients who needed therapeutic drainage were excluded.Postoperative data included hospital stay,volume of drained fluid,time of drain removal,and drain site problems.The study included 103 patients allocated into two groups;group A（n = 38） for patients with operative drain insertion and group B（n = 65） for patients without drain insertion.The number of patients with preoperative diagnosis of acute non-complicated cholecystitis was significantly greater in group B（80%） than group A（36.8%）（P 〈 0.001）.Operative time was significantly longer in group A.All patients who were converted from laparoscopic to open cholecystectomy were in group A.Multivariate analysis revealed that hospital stay was significantly（P 〈 0.001） longer in patients with preoperative complications.There was no added benefit for prophylactic drain insertion after cholecystectomy for acute calculous cholecystitis in non-complicated or in complicated cases.

Histological examination of frozen sections for patients with acute cholecystitis during cholecystectomy

BACKGROUND： Unexpected gallbladder cancer may present with acute cholecystitis-like manifestat/ons. Some authors rec- ommended that frozen section analysis should be performed during laparoscopic cholecystectomy for all cases of acute cholecystitis. Others advocate selective use of frozen section analysis based on gross examination of the specimen by the surgeon. The aim of the present study was to evaluate whether surgeons could effectively identify suspected gallbladder with macroscopic examination alone. If not, is routine frozen sec- tion analysis worth advocating？

Early Versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis with Mild Pancreatitis

The safety and feasibility of early laparoscopic cholecystectomy(LC)for acute cholecystitis with mild pancreatitis were explored.A total of 973 patients with acute pancreatitis,including 651 mild cases and 322 moderate or severe cases were retrospectively studied from July 2014 to December 2018 in our department.And 426 mild pancreatitis cases with acute cholecystitis were enrolled in this study,of which 328 patients underwent LC during the same-admission(early LC group),and 98 patients underwent LC a period of time after conservative treatment(delayed LC group).Clinical characteristics,operative findings and complications were recorded and followed up.The two groups were comparable in age,gender,the grade of American Society of Anesthesiologist(ASA),biochemical findings and Balthazar computer tomography(CT)rating(P>0.05).The operation interval and hospital stay in early LC group were significantly shorter than in delayed LC group(5.83+1.62 vs.41.3618.44 days;11.38+2.43 vs.16.49+3.48 days,P<0.01).There was no significant difference in the average operation time between the two groups.No preoperative biliary related events recurred in early LC group but there were 21 cases of preoperative biliary related events in delayed LC group(P<0.01).There was no significant difference in conversion rate(3.85 vs.5.10%,P=0.41)and surgical complication rate(3.95 vs.4.08%,P-0.95)between early LC group and delayed LC group.During the postoperative follow-up period of 375 cases,biliary related events recurred in 4 cases in early LC group and 3 cases in delayed LC group(P=0.37).The effect of early LC during the same-admission is better than delayed LC for acute cholecystitis with mild pancreatitis.

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

瞄准：在内视镜的胆总管(CBD ) 投掷移动以后，评估尖锐胆汁的风险因素。方法：经历了内视镜的 CBD 的 A 总数 100 病人与胆囊(GB ) 投掷移动没有到 2004 年 7 月的从 2000 年 1 月的随后的胆囊炎的原位回顾地被评估。当为尖锐胆汁的发展评估风险因素时，下列因素被考虑：年龄，性，浆液胆红素水平， GB 围变厚的、膀胱的管明显，一块 GB 石头的存在， CBD 直径，剩余石头，碎石术， juxtapapillary 憩室，肝肝硬化或糖尿病的存在，胆管炎或胰腺炎的现在病，和过程相关的复杂并发症。结果：在吝啬的 18 瞬间后续期间， 28 (28%) 病人们开发了胆汁的症状；17 (17%) 尖锐胆汁并且 13 (13%) CBD 投掷复发。有尖锐胆汁的病人，(88.2%) 15 收到了 laparoscopic 胆囊炎并且(11.8%) 2 开胆囊炎。所有周期性的 CBD 石头是成功地移开的内视镜的联盟者。吝啬的时间过去到尖锐胆汁是 10.2 瞬间(1-37 瞬间) ，那是 18.4 瞬间到周期性的 CBD 石头。收到了胆囊炎的 17 个病人，(11.8%) 2 在胆囊炎以后开发了周期性的 CBD 石头。由多，变量分析， 【1.3 mg/dL 的浆液总数胆红素水平和在石头移动的时候的 【11 公里的一条 CBD 直径被发现预言尖锐胆汁的发展。结论：在 CBD 石头移动以后，对平淡的预防胆囊炎没有需要。然而，没有扩大胆汁管(【11 公里) 的病人和黄疸(【1.3 mg/dL ) 在 CBD 石头移动的时候有尖锐胆汁的更高的风险并且是预防胆囊炎的可能的候选人。

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

AIM: To study the timing of laparoscopic cholecy- stectomy for patients with acute cholecystitis.METHODS: Between January 2002 and December 2005, all American Society of Anesthesiologists classification (ASA)—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.

Training vs practice: A tale of opposition in acute cholecystitis

Acute cholecystitis is one of the most common surgical diagnoses encountered by general surgeons.Despite its high incidence there remains a range of treatment of approaches.Current practices in biliary surgery vary as to timing,intraoperative utilization of biliaryimaging,and management of bile duct stones despite growing evidence in the literature defining best practice.Management of patients with acute cholecystitis with early laparoscopic cholecystectomy(LC)results in better patient outcomes when compared with delayed surgical management techniques including antibiotic therapy or percutaneous cholecystostomy.Regardless of this data,many surgeons still prefer to utilize antibiotic therapy and complete an interval LC to manage acute cholecystitis.The use of intraoperative biliary imaging by cholangiogram or laparoscopic ultrasound has been demonstrated to facilitate the safe completion of cholecystectomy,minimizing the risk for inadvertent injury to surrounding structures,and lowering conversion rates,however it is rarely utilized.Choledocholithiasis used to be a diagnosis managed exclusively by surgeons but current practice favors referral to gastroenterologists for performance of preoperative endoscopic removal.Yet,there is evidence that intraoperative laparoscopic stone extraction is safe,feasible and may have added advantages.This review aims to highlight the differences between existing management of acute cholecystitis and evidence supported in the literature regarding best practice with the goal to change surgical practice to adopt these current recommendations.

Efficacy and safety of endoscopic transpapillary gallbladder drainage in acute cholecystitis:An updated meta-analysis

BACKGROUND Percutaneous transhepatic gallbladder drainage has been the most frequently performed treatment for acute cholecystitis for patients who are not candidates for surgery.Endoscopic transpapillary gallbladder drainage(ETGBD)has evolved into an alternative treatment.There have been numerous retrospective and prospective studies evaluating ETGBD for acute cholecystitis,though results have been variable.AIM To evaluate the efficacy and safety of ETGBD in the treatment of inoperable patients with acute cholecystitis.METHODS We performed a systematic review of major literature databases including PubMed,OVID,Science Direct,Google Scholar(from inception to March 2021)to identify studies reporting technical and clinical success,and post procedure adverse events in ETGBD.Weighted pooled rates were then calculated using fixed effects models for technical and clinical success,and post procedure adverse events,including recurrent cholecystitis.RESULTS We found 21 relevant articles that were then included in the study.In all 1307 patients were identified.The pooled technical success rate was 82.62%[95%confidence interval(CI):80.63-84.52].The pooled clinical success rate was found to be 94.87%(95%CI:93.54-96.05).The pooled overall complication rate was 8.83%(95%CI:7.42-10.34).Pooled rates of post procedure adverse events were bleeding 1.03%(95%CI:0.58-1.62),perforation 0.78%(95%CI:0.39-1.29),peritonitis/bile leak 0.45%(95%CI:0.17-0.87),and pancreatitis 1.98%(95%CI:1.33-2.76).The pooled rates of stent occlusion and migration were 0.39%(95%CI:0.13-0.78)and 1.3%(95%CI:0.75-1.99)respectively.The pooled rate of cholecystitis recurrence following ETGBD was 1.48%(95%CI:0.92-2.16).CONCLUSION Our meta-analysis suggests that ETGBD is a feasible and efficacious treatment for inoperable patients with acute cholecystitis.

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 cholecystitis in the group undergoing urgent surgery (total 74 patients), the 15 patients with a gangrenous gallbladder had a higher mean level of total bilirubin (1.14 ± 1.27 mg/dL vs 2.66 ± 1.97 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.

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.