The prognostic role of procalcitonin in predicting mortality after early cholecystectomy in patients with acute calculous cholecystitis

While literature widely supports early cholecystectomy for mild gallstone pancreatitis (GSP), this has not been reflected in clinical practice. Early cholecystectomy for GSP with end organ dysfunction remains controversial. This study aims to evaluate the rate and outcomes of early cholecystectomy (<3days from admission) in mild GSP patients with end organ dysfunction (+EOD) and without (-EOD). Patients with GSP without necrosis were identified from 2017 to 2019 NSQIP database and categorized into GSP±EOD. Coarsened Exact Matching was used to match patients based on preoperative risk factors in each group, and outcomes were compared. There was a total of 3104 patients -EOD and 917 +EOD in the aggregate cohort. Early cholecystectomy was performed in 1520 (49.0%) of GSP-EOD and in 407 (44.4%) of GSP+EOD. In the matched cohorts, there were no significant differences in 30-day mortality, morbidity, or reoperation for early cholecystectomy in either group. In GSP-EOD, early cholecystectomy was associated with shorter LOS (2.9 ± 1.5 vs. 5.6 ± 3.0days, P < .001), shorter operative time (69.7 ± 34.4 vs. 73.3 ± 36.6min, P = .045), and more concurrent biliary procedures (52.1% vs. 35.4%, P < .001). Similarly, early cholecystectomy in GSP+EOD was associated with shorter LOS (3.3 ± 1.8 vs. 6.9 ± 6.6days, P < .001), shorter operative time (65.9 ± 32.1 vs. 76.0 ± 40.7, P < .001), and more concurrent biliary procedure (46.0% vs. 34.9%, P = .002). This study supports early cholecystectomy in patients with mild GSP. Even with end organ dysfunction, early cholecystectomy appears to be safe given there is no difference in morbidity and mortality, and the potential benefit of reduced LOS.

Background; Laparoscopic cholecystectomy is one of the commonly performed surgical procedure these days which is associated with significant reduction of morbidities and mortality. This study was conducted to ascertain port site infection after laparoscopic cholecystectomy without using gloves. Objective; To determine frequency of port site infection (PSI) in patients undergoing laparoscopic cholecystectomy when gallbladder is removed without using gloves. Material and Methods; A total of 254 patients undergoing laparoscpic cholecystectomy were enrolled in our study. The laparoscopic cholecystectomy was performed and after removal of gall bladder without endogloves the laparoscope was moved to the epigastric port, and a large-tooth grasping forceps were inserted through the umbilical port to grasp the gallbladder at the area of the cystic duct and were followed for wound infection. Results; Of these 254 study cases, 98 (36.6 %) were male patients while 156 (61.4 %) were female patients. Mean age of our study cases was 49.58 ± 6.32 years. Of these 254 study cases, 89 (35.0 %) belonged to rural areas and 165 (65.0 %) belonged to urban areas. Diabetes was present in 68 (26.8 %) of our study cases. Hypertension was present in 126 (49.6 %) of our study cases. Mean duration of surgery was 55.28 ± 15.23 minutes and 185 (72.8 %) had duration of procedure up to 1 hour. Mean hospital stay was 5.22 ± 2.18 days and 204 (80.3%) had hospital stay up to 6 days. Umblical port site infection (PSI) was noted in 20 (7.9%). Conclusion; High frequency of umblical port site infection was noted in our study among patients undergoing laparoscopic cholecystectomy without using gloves, so use of gloves is safe, cost effective and reduces related morbidities. Port site infection was significantly associated with increasing, gender, diabetes, residential status, prolonged duration of surgery and duration of hospitalization. Keywords; Umblical Port site infection, gloves, Laparoscopic cholecystectomy DOI : 10.7176/JMPB/54-13 Publication date : April 30 th 2019

Background: Cholecystectomy is a widely performed procedure all over world though popularized late in India. Today, Laparoscopic cholecystectomy is the method of choice to remove gall bladder. A concern exists in the minds of surgeons when it comes to immediate removal of an acutely inflammed gall bladder, laparoscopically. To analyze this hesitation, statistically, this study has been carried out.Methods: A prospective and randomized study was conducted among 66 patients from March 2013 to February 2016. Thirty three patients presenting with acute calculous cholecystitis were subjected to delayed laparoscopic cholecystectomy (Group A) after an initial conservative treatment and gap of 6-8 weeks. Another group of 33 patients presenting with acute calculous cholecystitis were taken up for laparoscopic cholecystectomy within 72 hours of onset of symptoms (Group B). Results obtained, in both the groups, under different headings were compared and analyzed.Results: Time taken for early laparoscopic cholecystectomy was significantly higher than that for delayed laparoscopic cholecystectomy. Cost of treatment and total hospital stay in delayed group was significantly high as compared to early group. No significant difference was found in incidence of conversion rate, common bile duct (CBD) and gastrointestinal tract (GIT) injury, requirement of drain, postoperative pain and analgesia requirement and port related complications.Conclusions: Early cholecystectomy in acute cholecystitis is feasible, safe, cheaper and requires shorter hospital stay, if, performed within 72 hours of onset of symptoms.

Clinical update on acute cholecystitis and biliary pancreatitis: between certainties and grey areas

Laparoscopic cholecystectomy (LC) is the treatment of choice for mild and moderate acute cholecystitis. The aim of this study was to analyze the utility of C-reactive protein (CRP) as a predictor of difficult laparoscopic cholecystectomy (DLC) in patients with acute cholecystitis. We conducted a prospective study. All patients included were treated with emergency LC. Patients were analyzed as DLC and nondifficult laparoscopic cholecystectomy (NDLC). Multiple logistic regression and receiver-operating characteristic curve analysis were employed to explore which variables were statistically significant in predicting a DLC. Two different models were analyzed. A total of 66 patients were included (37.9% DLC versus 62.1% NDLC). Ideal cutoff point for CRP was calculated as 11 mg/dL, with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for predicting DLC being 92% (95% CI 75-97.8), 82.9% (95% CI 68.7-91.5), 76.7%, and 94.4%, respectively. In the first model multivariate analysis, age >45 years, male sex, gallbladder wall thickness ≥5 mm, and pericholecystic fluid collection were significant predictors of DLC, with an area under the curve (AUC) of 0.89. In the second model multivariate analysis, only CRP ≥11 (odds ratio, OR = 17.9, P = .013) was significant predictor of presenting DLC, with an AUC of 0.96. Preoperative CRP with values ≥11 mg/dL was associated with the highest odds (OR = 17.9) of presenting DLC in our study. This value possesses good sensitivity, specificity, PPV, and NPV for predicting DLC in our population with acute calculous cholecystitis.

Acute calculous cholecystitis (ACC) is one of the most common emergencies in general surgery. In the past, acute cholecystitis was a contraindication of laparoscopic cholecystectomy, and patients with acute cholecystitis were managed conservatively and readmitted for elective laparoscopic cholecystectomy (LC) after 6-8 weeks. With the increased experience in laparoscopy, surgeons started to attempt early laparoscopic cholecystectomy for acute cholecystitis. This work aims to compare intraoperative and postoperative outcomes of early versus interval cholecystectomy in Acute cholecystitis. Our study was conducted on 100 patients divided into two groups of 50 each to compare the results of early surgery with delayed surgery. The correlation between the two groups showed that there is a statistically significant difference in favour of group (A) denoting that surgery in the early group is more economical because of less hospital stay. Total hospital stays in group (A) ranged from 3.5 to 6 days with a mean of 4.8 ± 0.91 days. While total hospital stays in the group (B) (including the number of days spent till the resolution of the acute attack of cholecystitis along with the number of days spent after readmission for laparoscopic cholecystectomy) ranged from 7 to 12 days with a mean of 9.2 ± 1.61 days. The conversion rate from laparoscopic cholecystectomy to open cholecystectomy between the two groups is not significantly different and the overall post-operative complication rate. However, operative time in group (A) ranged from 55 to 140 minutes, with a mean operative time of 100.3 ± 14.75 minutes. For the cases which were converted to open cholecystectomy the operative time ranged from 112 to 140 minutes with a mean of 125.6 minutes. While operative time in group (B) ranged from 45 to 106 minutes and the mean operative time was 80.3 ± 12.4 minutes. For the cases which were converted to open cholecystectomy the operative time ranged from 95 to 106 minutes with a mean of 101.75 minutes. The correlation between the two groups showed that there is statistically significant difference in favor of group (B) and this is due to difficult dissection at Calot’s triangle in early lap. cholecystectomy. From our study, we can conclude that the laparoscopic cholecystectomy in early cholecystectomy up to 96 hr from the starting of acute symptoms was found to be more economical with less total hospital stay and less total cost of the therapy than interval cholecystectomy in acute cholecystitis.

Early cholecystectomy for patients with acute cholecystitis is safe, cost effective, and leads to less time off work compared with delayed surgery. This study was designed to assess current practice...

Despite the fact that there is evidence advocating early laparoscopic cholecystectomy for acute cholecystitis (AC), the practice of this treatment has not been investigated sufficiently. This study was designed to assess the current practice of laparoscopic cholecystectomy for AC among Japanese general surgeons. A postal questionnaire was sent to the 291 councillors of the Japanese Society of Abdominal Emergency Medicine in order to ascertain their current management of patients with AC. The response rate was 72.5%. A policy of early cholecystectomy for AC was adopted by 41.7% of the responding surgeons. However, almost the same percentage of surgeons routinely managed their patients conservatively, and opted for delayed cholecystectomy at a later date. The adoption of laparoscopic cholecystectomy was made by 79.1% of surgeons. Laparoscopic cholecystectomy for patients with AC who had percutaneous transhepatic gallbladder drainage (PTGBD) was adopted by 73.9% of the surgeons. Of the surgeons opting for laparoscopic cholecystectomy, 37.3% performed intraoperative cholangiography laparoscopically for all patients with AC. Although early cholecystectomy for patients with AC was not adopted by the majority of the surgeons who responded, laparoscopic cholecystectomy was a common procedure for early and delayed cholecystectomy. Despite evidence that strongly supports the use of early cholecystectomy, the use of this treatment remains suboptimal in Japan.

Background: The treatment of acute cholecystitis has been controversially discussed in the literature as there are no high-evidence-level data yet for determining the optimal point in time for surgical intervention. So far, the laparoscopic removal of the gallbladder within 72 h has been the most preferred approach in acute cholecystitis. Methods: We conducted a systematic review by including randomized trials of early laparoscopic cholecystectomy for acute cholecystitis. Results: Based on a few prospective studies and two meta-analyses, there was consent to prefer an early laparoscopic cholecystectomy for patients suffering from acute calculous cholecystitis while the term ‘early' has not been consistently defined yet. So far, there is new level 1b evidence brought forth by the so-called ‘ACDC' study which has convincingly shown in a prospective randomized setting that immediate laparoscopic cholecystectomy - within a time frame of 24 h after hospital admission - is the smartest approach in ASA I-III patients suffering from acute calculous cholecystitis compared to a more conservative approach with a delayed laparoscopic cholecystectomy after an initial antibiotic treatment in terms of morbidity, length of hospital stay, and overall treatment costs. Concerning critically ill patients suffering from acute calculous or acalculous cholecystitis, there is no consensus in treatment due to missing data in the literature. Conclusion: Laparoscopic cholecystectomy for acute cholecystitis within 24 h after hospital admission is a safe procedure and should be the preferred treatment for ASA I-III patients. In critically ill patients, the intervention should be determined by a narrow interdisciplinary consent based on the patient's individual comorbidities.

Introduction: Cholecystectomy for acute cholecystitis is mainly performed after the acute cholecystitis episode settles because of the fear of higher morbidity. However, delaying surgery exposes the people to gallstone -related complications. Aims and Objectives: To clinically evaluate the surgical outcome of early cholecystectomy in patients presenting with acute cholecystitis and evaluate its various operative outcomes to assess its safety and feasibility. Methods: This study was carried out in Department of Surgery at Silchar Medical College (Assam, India) from 1st May 2019 to 30th April 2020.50 patients diagnosed to have acute cholecystitis after clinical, laboratory and ultrasonography assessment underwent cholecystectomy within 72 hours of onset of symptoms. They were evaluated in terms of primary outcomes like mortality, bile duct injury, major operative complications and secondary outcomes like duration of surgery, hospital stay etc. and then compared with available literature on delayed cholecystectomy. Results: Majority of the patients were of 41 -60 years with M: F ratio of 2: 3. The mean operating time was 65 mins. Intraoperatively, one patient each had bile duct and bowel injury, 10% patients had bleeding while 8% had stone spillage. Postoperatively, 6% patients had bile leak, 8% had jaundice, cholangitis developed in 4 patients while one patient went into septicemia. No mortality was noted. The mean postoperative indoor stay was 2.5 days. Conclusion: Primary outcomes and operative duration were comparable between early and delayed cholecystectomy. Early cholecystectomy reduced the hospital stays, overall costs and the risk of complications arising in waiting period and is hence safe, feasible and advisable for patients with acute cholecystitis.

Background The benefit of early or “hot” cholecystectomy in acute cholecystitis and pancreatitis is now widely recognised and recommended by NICE guidelines. However, in reality, surgery within the index admission is not always universally practised. We aim to report our experience of barriers to performing emergency cholecystectomy in the context of a district general London hospital. Method Data from patients admitted within a 1 month period with acute calculous cholecystitis, gallstone pancreatitis or recurrent biliary colic were retrospectively collected. Data points included patient demographics, reasons for not having emergency surgery and time to subsequent elective surgery. Any patients who underwent early emergency cholecystectomy were excluded from analysis. Results Twenty six (76.5%) out of 34 admissions did not receive emergency cholecystectomy. Eight (30.8%) were male and mean age was 69. Most common presentation was acute calculous cholecystitis (13, 50%). Reasons for not having surgery included frailty (7, 26.9%), waitlisted for endoscopic investigation (5, 19.2%), lack of emergency theatre capacity (4, 15.4%), unknown (3, 11.5%), severe disease (2, 7.7%), patient refusal (3, 11.5%) and acute medical contraindication (2, 7.7%). Four (15.4%) patients had repeat acute admission. To date, 4 patients subsequently underwent elective cholecystectomy with one procedure within 3 months. Conclusion Early cholecystectomy rates in district general hospitals can be affected by availability of local resources. By identifying the key factors for not proceeding to surgery, we can increase efforts to improve access to emergency theatre space, high-risk anaesthetic input and acute endoscopy services.

BackgroundLess invasive alternatives than early cholecystectomy (EC) for acute calculous cholecystitis (ACC) treatment have been spreading in recent years. We still lack a reliable tool to select high-risk patients who could benefit from these alternatives. Our study aimed to prospectively validate the Chole-risk score in predicting postoperative complications in patients undergoing EC for ACC compared with other preoperative risk prediction models.MethodThe S.P.Ri.M.A.C.C. study is a World Society of Emergency Surgery prospective multicenter observational study. From 1st September 2021 to 1st September 2022, 1253 consecutive patients admitted in 79 centers were included. The inclusion criteria were a diagnosis of ACC and to be a candidate for EC. A Cochran-Armitage test of the trend was run to determine whether a linear correlation existed between the Chole-risk score and a complicated postoperative course. To assess the accuracy of the analyzed prediction models—POSSUM Physiological Score (PS), modified Frailty Index, Charlson Comorbidity Index, American Society of Anesthesiologist score (ASA), APACHE II score, and ACC severity grade—receiver operating characteristic (ROC) curves were generated. The area under the ROC curve (AUC) was used to compare the diagnostic abilities.ResultsA 30-day major morbidity of 6.6% and 30-day mortality of 1.1% were found. Chole-risk was validated, but POSSUM PS was the best risk prediction model for a complicated course after EC for ACC (in-hospital mortality: AUC 0.94, p < 0.001; 30-day mortality: AUC 0.94, p < 0.001; in-hospital major morbidity: AUC 0.73, p < 0.001; 30-day major morbidity: AUC 0.70, p < 0.001). POSSUM PS with a cutoff of 25 (defined in our study as a ‘Chole-POSSUM’ score) was then validated in a separate cohort of patients. It showed a 100% sensitivity and a 100% negative predictive value for mortality and a 96–97% negative predictive value for major complications.ConclusionsThe Chole-risk score was externally validated, but the CHOLE-POSSUM stands as a more accurate prediction model. CHOLE-POSSUM is a reliable tool to stratify patients with ACC into a low-risk group that may represent a safe EC candidate, and a high-risk group, where new minimally invasive endoscopic techniques may find the most useful field of action.Trial Registration: ClinicalTrial.gov NCT04995380.

Difficult laparoscopic cholecystectomy (DLC) is difficult to precisely predict before operation. This observational cohort study aimed to evaluate the predictive value of procalcitonin (PCT) for DLC in patients with acute cholecystitis (AC). A total of 115 patients were included in the study from January 2017 to April 2018. Multiple logistic regression and receiver-operating characteristic (ROC) were performed to evaluate the predictive value of PCT levels in DLC. Patients with DLC had significantly higher Tokyo Guidelines 2018 (TG18) grade (P = 0.002) and levels of C-reactive protein (CRP) (P = 0.007) and PCT (P < 0.001). The cut-off value of PCT for predicting DLC was 1.50 ng/ml. The sensitivity and specificity were 91.3% (95% CI 78.3–97.1) and 76.8% (95% CI 64.8–85.8), respectively. The area under ROC curve was 92.7% (95% CI 88.2–97.3, P < 0.001). Our results suggested that PCT was a good predictor for DLC in the AC patients, but further research is necessary. Monitoring of PCT trends in AC patients may be useful for preoperative risk assessment.

While evidence supports early compared to delayed cholecystectomy as optimal management of acute calculous cholecystitis (ACC), significant variability in practice remains. The purpose of this study was to identify variables associated with early cholecystectomy, to target opportunities to improve adherence to best practices. Adult patients admitted to surgical units with ACC at two hospitals in a university hospital network between June 2010 and January 2015 were reviewed. Patients with concurrent pancreatitis, cholangitis or severe ACC (with organ system failure) were excluded. Early cholecystectomy was defined as surgery performed during same admission and within 7 days of presentation. Non-operative management was defined as admission for ACC treated conservatively, with or without eventual delayed cholecystectomy. The primary outcome was early cholecystectomy versus initial non-operative management; secondary outcomes included time to cholecystectomy, complications, and total hospital length of stay (LOS). A total of 374 patients were included. Two hundred and forty six patients (66%) underwent early cholecystectomy, 60 (16%) were treated non-operatively and had delayed cholecystectomy, and 68 (18%) were only treated non-operatively. Median time to OR from initial presentation was 38h [22-63] for early cholecystectomy patients and 69 days [29-116] for the non-operative patients who had delayed cholecystectomy. When comparing both groups, early cholecystectomy patients were younger and were treated more often at site 1. There were no differences in complications during hospitalization, but early cholecystectomy patients had a lower median total LOS (3 [2-5] vs. 5 [4-9], p < 0.001), and they had fewer gallstone-related events after discharge (1 vs. 18%, p < 0.001). On multiple logistic regression analysis, lower age, hospital site and lower risk of concurrent choledocholithiasis were all significantly associated with early cholecystectomy (p < 0.05). Our data supports early cholecystectomy as best practice in management of ACC with no differences in complications during hospitalization, shorter median LOS and fewer gallstone-related events compared to non-operative management. We identified patient and institutional factors associated with early cholecystectomy. This suggests that multiple strategies will be necessary to promote adherence to best practices in the management of ACC within our institution.

Objective. To determine the optimal timing of laparoscopic cholecystectomy in acute calculous cholecystitis with peripancreatic infiltrate. Materials and methods. We analyzed the results of treatment of 80 patients with acute calculous cholecystitis with peripancreatic infiltration in the clinic in the period from 2022 to 2025. The patients' age ranged from 21 to 72 years. There were 50 men (62.5%) and 30 women (37.5%). The duration of the disease was up to 24 hours in 20 (25%), from 25 to 72 hours in 20 (25%), and over 72 hours in 40 (50%) patients. All patients were divided into 2 groups. Group 1 (control) included 50 (62.5%) patients who had been operated on in district hospitals and private city clinics for acute calculous cholecystitis with peripancreatic infiltration before hospitalization in the clinic, Group 2 (main) included 30 (37.5%) patients with acute calculous cholecystitis who were initially hospitalized in the clinic, of whom 20 (66.7%) had peripancreatic infiltration, 10 (33.3%) had mild pancreatitis. Results. Emergency laparoscopic cholecystectomy was performed in 10 (33.3%) patients with acute calculous cholecystitis in the setting of mild pancreatitis. The postoperative period was uneventful. Patients were discharged on the 2nd – 3rd day after surgery. The condition of 20 (66.7%) patients with acute calculous cholecystitis against the background of peripancreatic infiltration was assessed as severe during hospitalization. Despite intensive care, pain remained in 12 (60%) patients. These patients underwent early laparoscopic cholecystectomy. In 8 patients with acute calculous cholecystitis against the background of peripancreatic infiltrate, preoperative intensive conservative therapy was performed. On the 20th – 25th day, the improvement of the patients' condition made it possible to perform a planned laparoscopic cholecystectomy. Conclusions. Comparative analysis of the results of laparoscopic cholecystectomy in acute calculous cholecystitis with peripancreatic infiltration and mild pancreatitis shows that delayed laparoscopic cholecystectomy, when the average time of conservative treatment is 20–25 days from the onset of acute calculous cholecystitis, is preferable to early cholecystectomy.