Cases Of Acute Cholecystitis Research Articles

Comprehensive Diagnosis of 103 Cases of Acute Cholecystitis and Cholangitis using a Metagenomic Analysis

Comprehensive Diagnosis of 103 Cases of Acute Cholecystitis and Cholangitis using a Metagenomic Analysis

CHANGING TRENDS IN SURGICAL MANAGEMENT FOR ACUTE CHOLECYSTITIS, IN LIGHT OF TOKYO GUIDELINES - 14 YEAR EXPERIENCE

To look for trends in surgical management of acute cholecystitis and compare the outcomes of patients with severe condition. The retrospective study was conducted at Aga Khan University Hospital, Karachi, from January to December 2016, and comprised data of adult patients who underwent cholecystectomy for acute cholecystitis from January 1, 2001, to December 31, 2014. Record of patients from 2001 to 2007 was designated in Group-1 while Group-II covered period between 2008 and 2014. Severe cases of acute cholecystitis were divided into similar period-based Group-A and Group-B. Data was analysed using SPSS 20. Of the 1153 patients, 521(45.2%) were males. The overall mean age was 49.3+14 years. There were 309(36.2%) patents in Group-I and 844(73.2%) in Group-II. Early laparoscopic-cholecystectomy was performed in 907(78%) patients. Postoperative morbidity was observed in 73(6.3%) patients. In Group-II, there was significant increase in early cholecystectomy, decrease in conversion rates and use of percutaneous cholecystostomy tube placement (p<0.05 each). In patients with severe acute cholecystitis, higher rate of early cholecystectomy was found in Group-A but it was not significant, and the same was the case in terms of conversion rate, postoperative morbidity and hospital stay (p>0.05 each). Over the years, the institutional experience of managing acute cholecystitis has changed dramatically which has helped improve the level of care for the patients.

EARLY CHOLECYSTECTOMY

Background: This study was conducted to evaluate results of earlycholecystectomy in acute cholecystitis in terms of procedural safety. Methods: In this study 50consecutive cases of acute cholecystitis who underwent early laparoscopic cholecystectomy(within 03 days of attack) were included. Patients with symptoms of more than 03 days durationor those with associated diseases were excluded. Evaluation of results was done by analyzingthe data in SPSS V-17. Results: Out of 50 patients operated 46 (92%) were female and 4 (8%)were male. Most of the patients were received within 24 hours after the onset of symptoms. Theage of patients ranged from 30-70 years with the median age of 45 years. Ultrasound revealedoedematous gall bladder with pericholecystic fluid in 38 (76%) patients. In 8 (16%) patients, gallbladder was small, shrunken and thick walled, there was empyema in 2 (4%) patients &amp;mucocele with stone impacted at hartmann’s pouch in 2 (4%) patients. Average operation timewas 40 minutes. All patients were operated within 72 hours of onset of symptoms. Per operativelysevere inflammation was noted in 32 (64%) patients, adhesions with colon/stomach/omentum in10 (20%) patients, adhesions with CBD in 3 (6%) patients, distorted anatomy at Calot’s triangle in5 (10%) patients. 6 (12%) patients had bleeding from liver bed, but controlled with diathermy. In46 (92%) patients laparoscopic cholecystectomy was completed successfully. In 4 (8%) patients,laparoscopic procedure was converted to open cholecystectomy. Reasons of conversion wereacute cholecystitis with severe adhesions which caused bleeding in 2 (4%) patients, obscureanatomy of Calot's triangle in 2 (4%) patients. Post operatively, there was bile leak in 1 (2%)patient which was due to minor injury of CBD, which required re-exploration &amp; suturing of defect.No patient developed post operative jaundice. There was no major bleed post operatively. 3 (6%)patients developed wound infection. Conclusions: Laparoscopic cholecystectomy is aneffective and safe technique of treating symptomatic gallstones even in cases of acutecholecystitis because of accelerated recovery couple with less postoperative pain and shorthospital stay.

Acute acalculous cholecystitis in children.

Acute acalculous cholecystitis (AAC) is the inflammatory disease of the gallbladder in the absence of gallstones. AAC is estimated to represent at least 50% to 70% of all cases of acute cholecystitis during childhood. Although this pathology was originally described in critically ill or post-surgical patients, most pediatric cases have been observed during several infectious diseases. In addition to cases caused by bacterial and parasitic infections, most pediatric reports after 2000 described children developing AAC during viral illnesses (such as Epstein-Barr virus and hepatitis A virus infections). Moreover, some pediatric cases have been associated with several underlying chronic diseases and, in particular, with immune-mediated disorders. Here, we review the epidemiological aspects of pediatric AAC, and we discuss etiology, pathophysiology and clinical management, according to the cases reported in the medical literature.

Acalculous Cholecystitis Presenting as Small Bowel Obstruction

Acalculous cholecystitis (AAC) is an inflammatory disease of the gallbladder which occurs in the absence of gallstones or biliary obstruction. Though the etiology of AAC remains unclear, multiple factors are responsible for its pathogenesis including biliary stasis, sepsis and ischemia. AAC is seen in 0.2% - 0.4% of hospitalized and critically ill patients and represents about 10% of all cases of acute cholecystitis. ACC is associated with a morbidity and mortality rate of 10% - 50%. Herein, we report a 78 year old male with a history of hypertension, hyperlipidemia, diabetes mellitus, and chronic obstructive pulmonary disease who was admitted for an infected left foot ulcer complicated by acute osteomyelitis. During his hospital stay he developed abdominal distention with bilious emesis. A nasogastric tube was placed and drained 2 liters of bilious fluid. Computer tomography (CT) scan of the abdomen and pelvis with contrast showed marked dilatation of the distal esophagus and stomach without evidence of gastric outlet, small or large bowel obstructions. The gallbladder was noted to be massively distended (figure 1) with no evidence of cholelithiasis. Abdominal ultrasound was also negative for cholelithiasis. A hepatobiliary iminodiacetic acid (HIDA) scan was unable to visualize the gallbladder. Liver chemistries remained normal during this time. Successful percutaneous transhepatic biliary drainage (PTBD) was performed for gallbladder decompression. The patient was no longer symptomatic. On subsequent imaging, normalization of the dilated stomach, esophagus and gallbladder was appreciated. An esophagogastroduodenoscopy (EGD) was performed noting a patent pylorus and no signs of obstruction. AAC may be complicated by perforation, gangrene, extra biliary abscess formation, and emphysematous cholecystitis [3]. Our case describes small bowel obstruction secondary to extrinsic compression from a massively distended gallbladder as a rare complication of AAC. A review of the literature shows that our report is the first to highlight this unusual finding. In conclusion, clinicians should bear the differential diagnosis of small bowel obstruction as a corollary to acalculous cholecystitis in the appropriate clinical context.2533 Figure 1. Computed tomography (CT) scan showing distended gallbladder.

Relationship between serum Pentraxin 3 and pro-adrenomedullin levels with acute cholecystitis

ObjectivesThe perforation of the gallbladder (GP) is one of the most significant complications of acute cholecystitis. A biochemical marker indicating the GP has not been determined fully to date. Pentraxin 3 and pro-adrenomedullin (Pro-ADM) proteins are novel acute phase reactants. We aimed to investigate the relationship between serum Pentraxin 3 and Pro-ADM and the GP in patients with acute cholecystitis. Methods: This prospective cross-sectional study was conducted on patients with acute cholecystitis in a tertiary care emergency department during the six-month period. The acute cholecystitis patients were divided into two groups as with GP, and without GP. Additionally, patients with GP were evaluated according to pericholecystic fluid and gallbladder wall thickness. Serum levels of pro-ADM and pentraxin 3, WBC, CRP and sedimentation rate were measured in all patients. ResultsA total of 60 patients with acute cholecystitis were included in the study. Pro-ADM and pentraxin 3 levels were significantly higher in patients with GP and the with pericholecystic free fluid (p < 0.0001). There was no significant relationship between serum pentraxin 3 and pro-ADM with gallbladder wall thickness (p > 0.05) According to the ROC analysis, serum Pentraxin 3 levels of ≥4.9 ng/mL could predict GP with a sensitivity of 75% and a specificity of 85% and serum pro-ADM levels of ≥97 nmol/L with sensitivity and specificity of 100% and 95%. ConclusionOur study results reveal that serum Pentraxin 3 and pro-ADM may be novel biochemical parameters in the detection of GP in acute cholecystitis cases.

Laparoscopic cholecystectomy difficulties, challenges and surprises

Introduction: Laparoscopic cholecystectomy is considered since long time as gold standard treatment for cholecystolithiasis. Preoperatively surgeon can anticipate difficulty of the procedure and prepare a plan how to deal with it. Sometimes the surgeon can be faced with a surprise intra-operatively. Methods: We collected retrospectively a series of cases subjected to laparoscopic cholecystectomy in Alexandria university from 2014 to 2017, in which there were technical or anatomical difficulties, intra-operative surprises, and how was the procedure completed safely. From 350 cases of laparoscopic cholecystectomy, 23 cases considered difficult or with intra-operative challenge. we had one case of acute cholecystitis in a child with situs invertus totalis, one case of left sided gall bladder, one case of gall stones after left donor hepatectomy, one case of heamangioma adherent to the gall bladder, one case diagnosed a huge liver cyst, one case child 4 years with acute cholecystitis and pancreatitis, five cases with previous big abdominal surgeries, one case with multiple whitish spots all over the liver, one case of accessory bile duct, three cases of caterpiller hump, two cases of stump cholecystectomy, and 4 cases of laparoscopic cholecystectomy after failed open cholecystectomy. Conclusion: Laparoscopic cholecystectomy is a frequently performed surgery with expected difficulties and challenges to the surgeons.

Successful Laparoscopic Cholecystectomy in Moderate to Severe Acute Cholecystitis: Visual Explanation with Video File

Case seriesPatient: —Final Diagnosis: Acute cholecystitisSymptoms: Abdominal painMedication: —Clinical Procedure: Laparoscopic cholecystectomySpecialty: SurgeryObjective:Management of emergency careBackground:Experience alone is insufficient to ensure successful laparoscopic cholecystectomy (LC), although LC has become widespread worldwide. Iatrogenic biliary injuries occur beyond the learning curve.Case Report:Biliary injury during laparoscopic cholecystectomy results from anatomical misidentification. The use of a critical view of safety has been established, to identify the cystic artery and the cystic duct, as the cystic duct can be hidden by inflammation (infundibular cystic duct). Seven patients who underwent emergency laparoscopic cholecystectomy due to acute cholecystitis are presented who underwent a critical view of safety protocol during surgery. Five men and two women (mean age, 63.0±13.0 years) included five cases of acute severe cholecystitis and two cases of acute moderate cholecystitis. The mean operative time to complete the critical view of safety exposure was 54.0±17.4 minutes. No cases underwent conversion to open surgery. The mean postoperative duration to ambulation and normal diet was 0.7±0.5 days and 1.0±0.6 days, respectively. The mean time to postoperative patient discharge was 3.9±0.9 days. In all seven cases, the postoperative course was uneventful. The protocol for this surgical procedure is presented, with schematic figures and videos.Conclusions:A case series of seven patients who presented with moderate-to-severe acute cholecystitis and who underwent laparoscopic cholecystectomy, showed good postoperative outcome without surgical complications, using a using a critical view of safety protocol.

Predictors of hyperamylasemia in patients with cholecystolithiasis after laparoscopic cholecystolithotomy with intraoperative dosed endoscopic papillotomy

The purpose of the work is to improve the early and long-term results of patients with cholecystolithiasis treatment by supplementing cholecystolithotomy with one-stage intraoperative dosed endoscopic papillosphincterotomy (EPST) and predictors of increased risk of transient hyperamylasemia after EPST identification. Material and methods. 33 patients with cholecytholithiasis were involved in the study, the average age was 46.82 ± 13.02 years, women 27 (82 %), body mass index 28.56 ± 5.85 kg/m 2 . We studied intraoperative, early postoperative complications and long-term results. The follow-up period of patients with cholecystolithiasis after cholecystolithotomy with intraoperative dosed endoscopic papillotomy was 1424 days (3.9 years), median follow-up – 467 days. The odds ratio was calculated using logistic regression analysis. Results . Intraoperative and early postoperative complications were not observed. During the endoscopic papillotomy and in the early postoperative period no serious complications (duodenal perforations, bleeding, pancreatitis (pancreatic necrosis)) were observed. Transient hyperamylasemia occurred in 4 (12.12 %) out of the 33 patients with choledocholithiasis who were performed laparoscopic cholecystolithotomy with intraoperative papillotomy in the first day after surgery. According to the logistic regression, the choledochus ascending diameter increase more than4.2 mm (HS = 2.31; 95% CI 1.02–6.11; P = 0.0483) is associated with transient amylasemia. One case of acute non-calculous cholecystitis requiring the surgical intervention (laparoscopic cholecystectomy) was registered during 3.9 years of follow-up. Recurrence of cholecystocholedocholithiasis and major duodenal papilla stenosis occurred in no case. Conclusions. Laparoscopic cholecystolithotomy supplemented with one-stage intraoperative dosed endoscopic papillotomy performed according to absolute indications, are safe and highly effective surgical intervention, which allows preserving the gall bladder, restoring its motor-evacuator and concentration functions, and preventing recurrence of cholecystocholedocholithiasis by restoring bile outflow to the duodenum. Transient hyperamylasemia occurred in the first day after operation in 12.12 % (4/33) patients with cholecystolithiasis, who were performed laparoscopic cholecystolithotomy with intraoperative endoscopic papillotomy. The predictor of transient hyperamylasemia after cholecystolithotomy with intraoperative dosed endoscopic papillotomy in patients with cholecystolithiasis is the ascending choledochus diameter increase more than4.2 mm (VS = 2.31; 95 % CI 1.02–6.11; P = 0.0483).

A clinical study on diagnostic, clinicopathological correlation of acute cholecystitis

Background: Acute cholecystitis (AC) one of the common surgical emergency. Thorough understanding of the profile of clinical presentation may help in clinical decision making in resource poor settings. Hence the present study is conducted with the objectives to study the clinico pathological profile of acute cholecystitis cases presenting to a tertiary care teaching hospital and to describe the management and complications.Methods: A prospective observational study was conducted in the department of emergency and general surgery of Dhanalakshmi Srinivas medical college and hospital. The study included 50 clinically confirmed cases of acute cholestasis presented between June 2017 to December 2017.Results: A total of 50 subjects were included in the final analysis. The highest proportion of subjects were in 46 to 50 years (28%) or 51 and above (26%) age groups. Females (56%) outnumbered males (44%). Right hypo chondral tenderness (100%) was the most common clinical presentation. The proportion of calculous and acalculous cholecystitis was 84% and 14% respectively, remaining 2% of cases were malignancies. The proportion of emergency and elective surgeries were 12% and 88% respectively. The most common organism cultured was E. coli in 24%, Staph, aureus in 14%, salmonella in 2% of the population. Post-operative wound infection was more commonly seen in culture positive cases.Conclusions: Health care practitioners at various levels need to have a good understanding of varied clinical presentation of acute cholecystitis and different management options, their advantages, and disadvantages to be able to treat the condition effectively.

Clinical characteristics of patients with newly developed acute cholecystitis after admission to the intensive care unit

IntroductionCritical care patients have many risk factors for acute cholecystitis (AC). However, less data are available regarding newly developed AC in critically ill patients. ObjectivesTo investigate the clinical features of AC occurring in critically ill patients after admission to an intensive care unit (ICU). MethodsWe performed a retrospective cohort study from January 2006 to August 2016 at a tertiary care university hospital. We included patients diagnosed with AC with or without gallstones after ICU admission. All cases of AC were confirmed by gastroenterologists or general surgeons. We excluded patients with AC diagnosed before or at the time of ICU admission. ResultsA total of 38 patients were diagnosed with AC after ICU admission between January 2006 and August 2016. Seventeen (44.7%) had acute acalculous cholecystitis, while 21 (55.3%) had acute calculous cholecystitis. The median age was 73 years (interquartile range = 63–81 years), and 22 (57.9%) patients were male. The most common reason for ICU admission was pneumonia or sepsis. The median interval from ICU admission to diagnosis of AC was 11 days (interquartile range = 4.8–22.8 days). Before AC diagnosis, almost 90% of patients used total parenteral nutrition, 68% used opioids, 76% were mechanically ventilated, and 42% received vasoactive drugs. More than half of patients underwent cholecystectomy, and all surgically resected gallbladders had pathology results for cholecystitis. Gangrenous cholecystitis was observed in five patients with acute calculous cholecystitis. The overall mortality was 42.1%, and 1/3 of these deaths were directly associated with AC. The average length of stay in the ICU and hospital was 26.5 and 44.5 days, respectively. ConclusionThe development of AC in the ICU should be carefully monitored, especially in patients who have been infected and admitted to the ICU for more than 10 days. Proper diagnosis and treatment at a critical time could be lifesaving.

An MRSA Infection in a Diabetic Patient Following Laparoscopic Cholecystectomy

Gall bladder empyema secondary to Methicillin-resistant Staphylococcus aureus (MRSA) infection is a very rare occurrence that was scarcely reported. Methicillin-resistant Staphylococcus aureus is a bacterium that causes infections in different parts of the body. It's tougher to treat than most strains of staphylococcus aureus, or staph, because it is resistant to some commonly used antibiotics. Garden-variety staph are common bacteria that can live on our bodies. Plenty of healthy people carry staph without being infected by it. In fact, 25-30% of us have staph bacteria in our noses.&#x0D; However, staph can be a problem if it manages to get into the body, often through a skin compromise. MRSA has become a major problem worldwide and is associated with significant morbidity and mortality (D.Q.A. Nguyen and N.I Ramus). Teranishi et al reported a case of acute cholecystitis caused by MRSA in the Japanese literature. No prior such cases were reported.

DISCHARGE AFTER ELECTIVE UNCOMPLICATED LAPAROSCOPIC CHOLECYSTECTOMY: CAN THE POSTOPERATIVE STAY BE REDUCED?

SUMMARY – The aim of the study was to reevaluate the safety and feasibility of discharge 24 h after elective uncomplicated laparoscopic cholecystectomy. Since the introduction of laparoscopic cholecystectomy in our hospital, the minimum postoperative stay was considered to be two days based on surgeons’ experience. The study included 337 operations performed by 21 surgeons during 2016 in the Sestre milosrdnice University Hospital Centre. Conversion to open technique and cases of acute cholecystitis were excluded, while 15 patients had insufficient postoperative data. The mean length of stay was 2.38 (range 1 to 6) postoperative days, median two postoperative days. Serious complications involving suspected drain bile leakage and postoperative hemorrhage occurred in two (0.59%) patients, both in the first 24 h following surgery. One patient required emergency laparotomy on the first postoperative day. Readmission rate was 1.2%. The postoperative minor complication rate was 42 of 337 (12.46%); these included wound infections, urinary tract infections, symptoms included in postcholecystectomy syndrome, etc. The onset of these complications was mostly after postoperative day 3. The data obtained suggest that discharge on the first postoperative day after elective uncomplicated laparoscopic cholecystectomy should be considered safe and can be practiced in our hospital.

A Case of Acute Cholecystitis

A Case of Acute Cholecystitis

A Case of Acute Hemorrhagic Cholecystitis with Intraperitoneal Bleeding during Antithrombotic Therapy

A Case of Acute Hemorrhagic Cholecystitis with Intraperitoneal Bleeding during Antithrombotic Therapy

Pancreatic tuberculosis causing biliary obstruction and mimicking pancreatic malignancy

Tuberculosis (TB) is a bacterial infection which can affect any part of the body from head to toe and has various presentations depending on the site of the infection. Pancreatic TB is very rare and usually happens as a part of disseminated or miliary TB, whereas isolated pancreatic TB is even rarer. Here, we present a case of pancreatic TB at a TB endemic zone which presented with obstructive jaundice and pancreatic lesions mimicking pancreatic malignancy. A 46-year-old Saudi female patient presented with right upper quadrant abdominal pain associated with dark coloured urine and pale stool. The patient had been admitted to the surgical ward as a case of acute cholecystitis for further evaluation. On abdominal ultrasound (US), findings demonstrated dilated common bile duct (CBD), but the distal part was difficult to be visualised; hence, further evaluation by magnetic resonance cholangiopancreatography (MRCP) was recommended to look for CBD stones. The MRCP showed two focal pancreatic lesions causing the distal CBD obstruction with no stones at CBD. Based on these findings, malignancy was considered and computed tomography-guided fine-needle aspiration biopsy from the pancreatic neck lesion was performed. This demonstrated multiple granulomas and lymphocytes with no malignant cell which indicated pancreatic TB. The patient became well after a course of anti-TB medications. pancreatic TB should be included in the differential diagnosis of pancreatic masses, especially in those patients who live in an endemic area of TB. A biopsy is necessary to establish the diagnosis and start the appropriate treatment for this curable disease as soon as possible.

Outcomes of Consistent Conservative Management for Acute Cholecystitis Followed by Delayed Cholecystectomy.

This study's objective was to assess outcomes of a totally conservative strategy for acute cholecystitis (AC) followed by delayed elective cholecystectomy. Consecutive patients who underwent cholecystectomy for AC were divided into the Emergent and Elective cholecystectomy groups. Patients in the elective cholecystectomy group were divided into early, medium, and late groups according to time from symptoms onset. The success rate for conservative management reached 97.2%. Increased blood loss and a higher conversion rate were significantly associated with the emergent group. Patients in the late group had significantly lower operative time and tended to have lower blood loss and less frequent conversion to open surgery than those in the early and medium groups. Most AC cases could be managed conservatively, and elective cholecystectomy was performed safely regardless of the time. Elective cholecystectomy carried out in late phase was likely to be associated with decreased surgical difficulty.

Acalculous Gangrenous Cholecystitis in Absence of Typical Risk Factors

Acute acalculous cholecystitis (AAC) is typically seen as a complication in severely ill, hospitalized patients. We report a case of acute gangrenous acalculous cholecystitis in an outpatient. 47-year-old African-American male presented with acute onset of epigastric abdominal discomfort and multiple episodes of vomiting persisting over one day. He denied having any fever or chills, change in bowel habits, dysphagia, weight loss, change in appetite, blood in stools, recent travel history or NSAID/alcohol use. He had a history of hypertension and hyperlipidemia. On exam, he was afebrile, BP 100/60 mmhg, HR 110 /min. He had tenderness in the epigastrium and right upper quadrant of his abdomen. Murphy's sign was positive. The initial blood tests including liver function tests and lipase were normal except for an elevated white cell count. An US of RUQ was obtained revealed, gall bladder wall thickening along with edema and pericholecystitc fluid collection. No gall stones were seen. Blood cultures were obtained, and the patient was started on antibiotics empirically. A HIDA scan revealed no uptake of contrast in the gall bladder one hour after contrast admission, confirming the diagnosis of AAC. Surgery was consulted and cholecystectomy was performed. Removed gall bladder appeared inflamed with early signs of gangrene. Acute acalculous cholecystitis (AAC) is defined as inflammation of the gall bladder without presence of gallstones. It is typically seen in severely medically or surgically ill, hospitalized patients. Altthough not common, cases of AAC in out patients with no significant risk factors have been reported. Physical examination and laboratory data are often unreliable in diagnosis of AAC, and diagnosis mainly rests on imaging studies. AAC has an extremely fulminant course leading to gall bladder gangrene in 50% of patients and perforation in 10 % of patients. Even with treatment, the mortality rate is about 30%. Hence, early diagnosis and treatment are warranted. In very few patients, atherosclerosis-causing changes in microcirculation of gall bladder, atherosclerotic changes can leading to ischemia at cellular level, thereby causing inflammation have been postulated to be causing AAC. Our patient presented in the outpatient setting and was diagnosed to have acute gangrenous acalculous cholecystitis. Given the high mortality rates AAC should be kept in dfferentials even in the outpatient settings.

Acalculous Cholecystitis: Is an Elective Interval Cholecystectomy Necessary

Background: Acute acalculous cholecystitis (AAC) accounts for 5-10% of cases of acute cholecystitis. The advantage of interval cholecystectomy for patients with AAC is unclear. Therefore, a retrospective analysis of patients diagnosed with AAC at our institution was performed over a 5-year period. Methods: Patients were identified via hospital coding using the keywords “acalculous cholecystitis, cholecystostomy and gall bladder perforation.” Follow-up data was obtained by performing a retrospective review of the patients' hospital records. Results: A total of 33 patients with AAC were identified and followed for a median period of 18 months. The median age at presentation was 70 (10-96) and American Society of Anesthesiologists (ASA) grade was 3 (1-5). Twenty-three patients (70%) were treated with antibiotics alone, 7 patients (21%) with percutaneous cholecystostomy and 3 patients (9%) with laparoscopic cholecystectomy. The 90-day mortality rate was 30% with significant correlation to comorbid status, as all deaths occurred in ASA grade 3-5 individuals (p = 0.020). Two patients (6%) developed recurrent AAC and were managed non-operatively. Conclusion: Antibiotics and cholecystostomy were the mainstay of AAC management, and comorbid status influenced related mortality. Our results suggest that it appears safe to avoid interval cholecystectomy in patients who recover from AAC, as they are typically high-risk surgical candidates.

Left Approach for Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis

Objectives: Laparoscopic cholecystectomy (LC) in acute cholecystitis is challenging especially in the presence of dense inflammatory adhesions and pericholecystic collection. The objective of this study was to evaluate the use of left approach in cases of difficult LC due to acute cholecystitis. Patients and methods: This was a prospective study done in Badr hospital – Helwan University and in Dar El Shefa hospital – Ministry of Health in Egypt between January 2014 and March 2016 which included 24 patients with difficult LC due to acute cholecystitis. We started the procedure with conventional four ports technique and if failed, we shifted to left approach instead of converting to open surgery. Outcome measures were operative time, rate of conversion to open and intra and post-operative complications. Results: The mean operative time was 135 minutes and in 1 patient (4%) the procedure was converted to open surgery due to unclear biliary anatomy. There were no intra-operative complications. Two patients (8.3%) in this study had port site infection and 1 patient (4%) had chest infection on the 3rd postoperative day. Postoperative bile leak was not detected in any of our patients. Conclusion: The use of left approach technique in LC for difficult cases of acute cholecystitis is effective and safe and further studies should be done to include larger number of patients with different types of difficulties.