Abstract
Objective. For unsafe (seriously ill or debilitated) and severe cholecystitis patients, percutaneous cholecystostomy with scheduled interval cholecystectomy (IC) has been advocated; however, because of lacking an inflammation grading system none of the published data comparing changes of inflammation status is available. Background. Using a self-designed gallbladder (GB) inflammation grading system, the author tried to predict outcomes of IC and reappraise whether delayed IC is justified. Methods. The intraoperative inflammation of 260 consecutive laparoscopic cholecystectomy (LC) patients with symptomatic GB stone diseases was graded (I–VI). Based on grading criteria, predicted outcomes were categorized as “improve”, “unpredictable”, “no change”, and “worsen”. Results. Predictive results of these four categories for Grades I–III (inflammation limited to GB) were 23.7, 2.5, 73.0, and 1.4%; 14.3, 57.1, 14.3, and 14.3%; 7.7, 53.8, 7.7, and 30.8% respectively. For Grade IV (mild to moderate inflammation of Calot’s triangle) they were 11.5, 9.6, 30.8, and 50.0%. For Grades V (severe inflammation of Calot’s triangle) and VI (severe inflammation involving the hepatoduodenal ligament) they were 0, 0, 0, and 100%. All 3 common bile duct injuries were in the “worsen” category. Conclusion. Our findings do not favor IC. For simple GB (Grades I–IV), immediate LC can be done safely and IC is unnecessary. For difficult GB (Grade V–VI), IC brings no improvement. Interval waiting to downgrade the inflammation seems impractical, especially for difficult GB. Our inflammation grading system can provide actual inflammation data during cholecystostomy and IC for judging the justification of the delayed IC policy.
Highlights
Because of better surgical outcomes of laparoscopic cholecystectomy (LC), the debate about early versus delayed interval LC for symptomatic gallbladder (GB) inflammation is becoming much clearer in retrospective [1] and prospective studies [2,3,4] and in meta-analyses [5, 6], which suggest that the safety and efficacy of early and delayed-interval LC for acute cholecystitis are comparable
Interval LC is still a common strategy as a subsequent procedure for acute cholecystitis after initial treatment with antibiotics to cool down the inflammation [1,2,3,4, 7, 8], or after percutaneous transhepatic gallbladder drainage (PTGBD) when antibiotic “cool down” treatment fails [1, 7], no matter whether the patient is fit or unfit for the immediate surgery
Operation difficulty was encountered in lapse group 5 (15–21 days), and one common bile duct (CBD) injury occurred each d on lapse days 15, 21, and 107
Summary
Because of better surgical outcomes of laparoscopic cholecystectomy (LC), the debate about early versus delayed interval LC for symptomatic gallbladder (GB) inflammation is becoming much clearer in retrospective [1] and prospective studies [2,3,4] and in meta-analyses [5, 6], which suggest that the safety and efficacy of early and delayed-interval LC for acute cholecystitis are comparable. Interval LC is still a common strategy as a subsequent procedure for acute cholecystitis after initial treatment with antibiotics to cool down the inflammation [1,2,3,4, 7, 8], or after percutaneous transhepatic gallbladder drainage (PTGBD) when antibiotic “cool down” treatment fails [1, 7], no matter whether the patient is fit or unfit for the immediate surgery. (): Number of conversions to open cholecystectomy; HDL: hepatoduodenal ligament; PTGBD: percutaneous transhepatic gallbladder drainage. Прочие изменения расценивали как “положительный эффект”, “без изменений” и “непредсказуемый результат” соответственно
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