Clinical Diagnosis Of Acute Cholecystitis Research Articles

ThP4.3 - How accurate is the clinical diagnosis of acute cholecystitis? A plea for specialisation in biliary emergencies!

Abstract Aim To evaluate the accuracy of preoperative diagnosis of acute cholecystitis (AC). Methods A prospective database of cholecystectomies and bile duct explorations spanning 30 years was analysed. Results 593/6140 patients (9.6%) had a preoperative diagnosis of AC (Group 1) 12.3% had no AC at surgery. 300/5547 patients (5.4%) had AC without preoperative criteria (Group 2).Group 1Group 2Emergency admission588 (99.1)203 (67.6)Presentation with Jaundice96 (16.2)110 (36.6)Previous acute cholecystitis76 (12.8)3 (1)USS:GB Thick wall or contraction389 (65.6)112 (37.3))Bile duct dilatation66 (11.1)179 (36.6)Preoperative imaging:MRCP23 (3.8)21 (7)CT76 (12.8)15 (5)ERCP8 (1.35)11 (3.6)Operative GB findingsAcute193 (32.5)140 (46.7)Empyema313 (52.8)160 (53.3)Difficulty Grading I&II20 (3.4)--III177 (29.8)117 (39.1)IV344 (58)168 (56.2)V52 (8.8)15 (4.7)Adhesions GB to:Duodenum503 (84.8)241 (80.3))Hepatic flexure410 (69.1)169 (56.3)Difficult cystic pedicle524 (88.3)273 (91)Fundus first dissection39 (6.6)19 (6.3)Bile Duct Exploration:106 (17.8)98 (32.6)Transcystic93 (15.6)72 (24)Choledochotomy13 (2.2)26 (8.7)Operative time (median, range)80 min (32-280)85 (35-350)Open conversion3 (0.5)3 (1)Morbidity40 (6.7)30 (10)Hospital stay (median, range)9.9 (1-62)13 (1-100)Mortality4 (0.67)1 (0.3)Resolved in one episode427 (72)189 (63) Conclusions 300/806 (37.2%) of AC or empyema encountered at operation do not have preoperative criteria. 25% of all AC require bile duct exploration. Emergency biliary admissions should be dealt with by specialist surgeons.

Does the postoperative diagnosis correlate with the final pathologic diagnosis in cholecystectomy?

Physicians diagnose cholecystitis using a variety of clinical signs and imaging modalities. Diagnoses are routinely confirmed with the gold-standard histopathological examination of the excised gallbladder. This study examines the correlation between the postoperative clinical diagnosis and postoperative pathology report findings. The clinical diagnosis of acute cholecystitis had a sensitivity of 58.8%, specificity of 75.2%, positive predictive value of 53.1%, and negative predictive value of 79.2% when compared to the final pathologic diagnosis. The clinical diagnosis of chronic cholecystitis agreed with the pathologic diagnosis of chronic cholecystitis in 45 of 54 cases (83.3%) but did not agree in 8 of 54 acute cases (14.8%); a clinical diagnosis of “symptomatic cholelithiasis” was associated with pathologic diagnosis of acute cholecystitis in 85 of 388 cases (21.9%). There was a statistically significant relationship between the clinical diagnosis and final pathologic diagnosis (chi-squared > 32.91, p-value <0.001). One incidental case of malignant neoplasm was found in a patient with gallstones. Surgeons made an accurate clinical diagnosis of acute cholecystitis in one third to one half of their surgical cases; they made an accurate clinical diagnosis of chronic cholecystitis 80% of the time and correctly diagnosed neoplasms in 3 out of 4 cases. These results suggest that the mismatch between the postoperative clinical diagnosis and postoperative pathology occurs frequently enough that pathologic assessment should occur routinely after cholecystectomy.

A prospective study to assess the use of preoperative neutrophil to lymphocyte ratio as a predictor of severe cholecystitis

Background: Cholecystitis can be divided into simple and severe cholecystitis. Untreated simple cholecystitis resolves within 7–10 days if it does not progress to more severe cholecystitis. Aims and objectives were to evaluate whether neutrophil-to-lymphocyte ratio can differentiate between simple cholecystitis and severe cholecystitis. To evaluate role of NLR as a prognostic indicator.Methods: The source of data for our study will be patients admitted in the department of general surgery diagnosed with acute cholecystitis in Konaseema Institute of medical sciences and research foundation, Amalapuram. All patients between 15 to 70 years of age with a clinical diagnosis of acute cholecystitis confirmed with histopathology study. Results: With an NLR value of 4.35, the sensitivity and specificity were 67% and 87%, respectively. Therefore, we considered 4.35 as the cutoff value, and divided the patient population into two groups: those with preoperative NLR values below 4.35 (n=50) and those with values equal to or greater than 4.35 (n=15). 53.33% of higher NLR group patients had severe cholecystitis compared to only 8 % of patients in lower NLR group (p<0.05). Conclusions: It was seen that the patients with cholecystitis can be divided into low risk (NLR<4.35) and high risk (NLR≥4.35) groups for severe cholecystitis as per the NLR value at admission.

Early versus delayed cholecystectomy in acute cholecystitis: a comparative study in a tertiary care hospital

Background: For patients with acute cholecystitis the timing of operative intervention has two broad approaches- early cholecystectomy and elective or delayed cholecystectomy. The main advantage of early cholecystectomy is that, it offers a definitive treatment during the same admission and avoids the problem of failed conservative treatment. The present study is an endeavour to discuss and to compare the outcome of management of acute cholecystitis with early and delayed cholecystectomy.Methods: 100 patients with clinical diagnosis of acute cholecystitis, admitted in the surgical wards of Gauhati Medical College and Hospital during the period of 1st July 2017 to 30th June 2018 were selected for the study. 40 patients underwent early cholecystectomy (within 7 days of onset of symptoms) and 60 patients underwent elective or late cholecystectomy (after a gap of 6-8 weeks from the acute attack).Results: In the present series the average duration of surgery was 90.37±11.96 minutes in the early group and 65.3±7.83 minutes for the elective group which is found to be statistically significant (p value<0.05). In the early surgery group 8.33% required conversion to open surgery. In the elective surgery group 3.63% required conversion. Wound infection, biliary leakage, bile duct injury, and respiratory tract infection was found to be statistically not significant between the two groups.Conclusions: Early cholecystectomy is feasible and safe for acute cholecystitis and is better method of treatment because of its shorter hospital stay, which is a major economic benefit to both the patient and health care system.

Emotional Support and its Medical and Healthcare Implications: A Mind and Body Approach

High complications and conversion rate associated with laparoscopic treatment for acute cholecystitis was a common sense by surgeons. The optimal time of laparoscopic cholecystectomy for acute cholecystitis remains controversial. Either early or interval elective to undergo laparoscopic cholecystectomy for acute cholecystitis could gain the best cost/beneficial ratio. A prospective randomized study was performed to make it clear. During a 29-month period, 97 patients with a clinical diagnosis of acute cholecystitis were randomly assigned to early laparoscopic cholecystectomy within 72 hours of admission (early group, n= 48) or delayed interval surgery after initial medical treatment (delayed group, n=49). Thirteen patients (five in the early group and eight in the delayed group) were excluded because of refusal of operation (n=5), misdiagnosis (n=5), contraindication for laparoscopic surgery (ca. of gallbladder), or loss of follow-up (n=2). Eight of 41 patients in the delayed group underwent urgent operation at a median of 63 hours (range, 32 to 140 hours) after admission because of spreading peritonitis (n=3) and persistent fever (n=5). Although the delayed group required less frequent modifications in operative technique and a shorter operative time, there was a tendency toward a higher conversion rate (23% vs.11%; p=0.174) and complication rate (29% vs.13%; p=0.07). For 38 patients with symptoms exceeding 72 hours before admission, the conversion rate remained high after delayed surgery (30% vs. 17%; p=0.454). In addition, delayed laparoscopic cholecystectomy prolonged the total hospital stay (11 days vs. 6 days; p＜0.001) and recuperation period (19 days vs.12 days; p＜0.001).We concluded that initial conservative treatment followed by interval surgery cannot reduce the morbidity and conversion rate of laparoscopic cholecystectomy for acute cholecystitis. Early laparoscopic or traditional cholecystectomy within 72 hours may be safer and has definite socioeconomic benefits.

Predicting operative difficulty of laparoscopic cholecystectomy in patients with acute biliary presentations.

BackgroundEarly laparoscopic cholecystectomy (LC) is advocated in patients with an acute biliary presentation but may require some precaution. We aimed to assess the intra‐operative difficulty of cholecystectomy in patients who underwent early intervention, and to establish a prediction model for a ‘complicated’ LC.MethodsRetrospective analysis of prospectively collected data from patients presenting to the emergency department with acute biliary symptoms, and who subsequently underwent early LC between 2015 and 2018. Operative difficulty was assessed by standardized grading of intra‐operative findings (grades 1–4). Pre‐operative predictors for a ‘complicated’ LC (grades 3/4) were assessed using univariable and multivariable logistic regression analysis. A prediction model was created using variable regression coefficients. Cut‐off and accuracy of the model were assessed using a receiver operating characteristic curve.ResultsA total of 185 patients were included and 59% presented with acute cholecystitis. In this cohort 113 (61%) patients underwent a ‘complicated’ LC. A prediction model for a ’complicated’ LC (0–4.5 points) included: clinical diagnosis of acute cholecystitis (2 points), C‐reactive protein >10.5 mg/L (1.5 points) and pericholecystic fluid on pre‐operative imaging (1 point). A score ≥2.5 had a sensitivity of 77.7%, specificity of 81.7% and positive and negative predictive values of 87.0% and 69.9%, respectively.ConclusionEarly LC may be ‘complicated’ in up to 60% of cases. The presented prediction model uses readily available information in the emergency department and is a simple but accurate way to predict a likely ‘complicated’ LC in patients with acute biliary presentations.

Acute Acalculous Cholecystitis: A Rare Presentation of Autoimmune Hepatitis and Primary Sclerosing Cholangitis Overlap Syndrome

Lymphoplasmacytic cholecystitis (LPC) is a unique form of chronic cholecystitis, and it has been reported in patients with medical conditions such as primary sclerosing cholangitis, inflammatory bowel disease, and autoimmune pancreatitis. We report a case of LPC in a 23-year-old male with a history of autoimmune hepatitis who presented to the hospital with 3-day duration of abdominal pain, nausea and vomiting. A clinical diagnosis of acute cholecystitis and sclerosing cholangitis was made, and the patient was treated with laparoscopic cholecystectomy. Histopathological examination of the gallbladder revealed marked diffuse mononuclear inflammatory infiltrate that was rich in IgG4-positive plasma cells and focal neutrophilic inflammation with erosion. These findings were consistent with active LPC. The patient’s post-operative endoscopic retrograde cholangiopancreatography performed 1 month after cholecystectomy revealed typical features of primary sclerosing cholangitis. This is the first report of acute acalculous cholecystitis as an initial presentation of autoimmune hepatitis and primary sclerosing cholangitis overlap syndrome. J Med Cases. 2018;9(10):332-337 doi: https://doi.org/10.14740/jmc3137w

Acute Acalculous Cholecystitis: A Rare Presentation of Autoimmune Hepatitis and Primary Sclerosing Cholangitis Overlap Syndrome

Lymphoplasmacytic cholecystitis (LPC) is a unique form of chronic cholecystitis, and it has been reported in patients with medical conditions such as primary sclerosing cholangitis, inflammatory bowel disease, and autoimmune pancreatitis. We report a case of LPC in a 23-year-old male with a history of autoimmune hepatitis who presented to the hospital with 3-day duration of abdominal pain, nausea and vomiting. A clinical diagnosis of acute cholecystitis and sclerosing cholangitis was made, and the patient was treated with laparoscopic cholecystectomy. Histopathological examination of the gallbladder revealed marked diffuse mononuclear inflammatory infiltrate that was rich in IgG4-positive plasma cells and focal neutrophilic inflammation with erosion. These findings were consistent with active LPC. The patient’s post-operative endoscopic retrograde cholangiopancreatography performed 1 month after cholecystectomy revealed typical features of primary sclerosing cholangitis. This is the first report of acute acalculous cholecystitis as an initial presentation of autoimmune hepatitis and primary sclerosing cholangitis overlap syndrome. J Med Cases. 2018;9(10):332-337 doi: https://doi.org/10.14740/jmc3137w

Clinicopathological Study of Eosinophilic Cholecystitis: Five Year Single Institution Experience.

Gallbladder diseases are very common in Northern India, most common of which is Chronic Cholecystitis. Rarely, histopathological diagnosis of Eosinophilic Cholecystitis (EC) is given when transmural cellular infiltrate consists of more than 90% eosinophils. To determine the prevalence and clinicopathological profile of eosinophilic cholecystitis at a tertiary care hospital of New Delhi. This was a retrospective clinicopathological study done on twenty two cases of eosinophilic cholecystitis over a period of five years from January 2011- December 2015. In cases diagnosed histopathologically as eosinophilic cholecystitis, clinical details were obtained from hospital records and slides were retrieved. Various histologic features, pattern of the inflammatory infiltrate and association of EC with other medical diseases, drugs and allergic states were evaluated. Out of a total of 1370 cholecystectomy specimens received during five year period, Eosinophilic cholecystitis was diagnosed in 22 (1.6%) of the specimens. Clinically, seven of these patients had a clinical diagnosis of acute cholecystitis. Patient's age ranged from 25-64 years and male to female ratio was 1:2.7. Most common symptom reported was abdominal pain. Most of the cases showed gallstones radiologically (90%) while only two cases showed peripheral eosinophilia (9%). Histologically, mucosal and muscular eosinophilic infiltrate was seen in 72.6% of the cases. No association with drug therapy, allergies or other pre-existing medical conditions was noted. EC is a relatively uncommon entity in which histopathology remains the main stay of diagnosis. Although the presentation may be similar to general cholecystitis, if a postoperative histopathological diagnosis of EC is made, then the patient must be investigated thoroughly to rule out other associated disease conditions, which may have a worse prognosis than cholecystitis itself.

Colonic lipoma causing colo-colic intussusception

A 32-year-old female patient is presenting with severe right upper quadrant abdominal pain and vomiting. On examination, she had tenderness in the epigastrium, apart from this there were no other positive findings on examination. The clinical diagnosis of acute cholecystitis was made. Her routine investigations were noncontributory. Ultrasound scan of the abdomen revealed thickening of the bowel wall in the region of the hepatic flexure. A contrast enhanced computed tomography of the abdomen was suggestive of ileo-colic intussusception with a lipoma as the lead point. Intraoperatively, she had a colo-colic intussusception involving the ascending colon and the right half of the transverse colon. A pedunculated polyp in the region of the hepatic flexure was the lead point and seen to be obstructing the lumen completely. She underwent a right hemi colectomy with an ileo-transverse anastomosis. Her postoperative recovery was uneventful, and she was discharged on the 5 th postoperative day. The histopathological examination confirmed the polyp to be of the submucouslipomatous variety.

Acute Adrenal Failure Associated with Primary Antiphospholipid Syndrome and Homozygosity for MTHFR C677T

A 47-year-old woman with a recent clinical diagnosis of acute cholecystitis developed acute adrenal failure. Initial computed tomograms of the abdomen showed bilateral adrenal swelling which evolved into bilateral adrenal hemorrhage on repeat examination a few days later. Laboratory investigations revealed a previously undiagnosed primary antiphospholipid syndrome and homozygosity for the MTHFR C677T mutation with hyperhomocysteinemia. This case highlights the protean clinical manifestations of adrenal vascular accidents and the need for a thorough search for underlying prothrombotic states in this setting.

Laparoscopic cholecystectomy in patients with empyematous cholecystitis: an outcome analysis

Laparoscopic cholecystectomy (LC), the procedure of choice for elective cholelithiasis, is now also used in the management of acute cholecystitis. Empyema of the gallbladder is unexpectedly encountered in a proportion of these patients. This paper describes our experience with LC in the treatment of patients with empyema of the gallbladder. From May 1992 to July 2007, 315 patients with a clinical diagnosis of acute cholecystitis underwent LC. Operative and histopathology reports were used to identify patients with empyema of the gallbladder, to which retrospective chart reviews were applied. Factors associated with conversion and complications were assessed to determine their predictive power. Being male and having high levels of aspartate transaminase (AST), alanine transaminase (ALT), and white blood cells significantly influenced the prediction of empyema. The conversion rate was significantly higher for empyema and acute cholecystitis, but the complication rate did not differ significantly between these conditions. Previous abdominal surgery was an independent risk factor for conversion and complications. Also, temperature >37.5°C, AST >60 IU/l, and ALT >60 IU/l were associated with higher conversion rates. The hospital stay was longer in patients with empyema, while the operation time did not differ between the two groups. Empyema of the gallbladder can be encountered in patients with presumed acute cholecystitis. Preoperatively differentiating between simple acute cholecystitis and empyema is difficult, if not impossible. The conversion rate is expected to be higher when empyema is approached laparoscopically than for simple acute cholecystitis or symptomatic cholelithiasis.

Leptospirosis Presenting as Acute Acalculous Cholecystitis and Pancreatitis

Acute cholecystitis in the absence of any detectable stones is known as acute acalculous cholecystitis (AAC) and has been often associated with severe illness or major surgeries in patients with significant co-morbid conditions. Acute pancreatitis is commonly due to gallstone diseases. Infectious disease presenting as AAC or pancreatitis is rare. We report a case of leptospirosis presenting with AAC and acute pancreatitis as the initial manifestations. A 41-year-old gentleman presented with a 3-day history of fever, intermittent right upper quadrant pain and vomiting. He did not have any significant past medical history except for previous excess alcohol ingestion and smoking (10 to 20 cigarettes/day). He worked as a cleaner. He had been well and denied any infectious diseases contacts or recent travel abroad. On examination, he was icteric, lethargic, had non-specific right upper quadrant tenderness and was in some respiratory distress, but did not require any respiratory support. Otherwise, he was haemodynamically stable. Admission electrocardiogram showed tachycardia with non-specific T waves changes. Chest radiography was unremarkable. Blood investigations showed leukocytosis (17 x 109/L), mild thrombocytopaenia (105 x 109/L), hyperbilirubin (171 μmol/L), coagulopathy (INR 2.03), hyperamylasaemia (328 U/L) and mild dehydration (serum urea 9.1 mmol/L and serum creatinine 130 μmol/L). The rest of parameters were unremarkable or showed only mild abnormalities. A clinical diagnosis of acute cholecystitis with cholangitis was made. An urgent ultrasound scan (USS) showed a thickened gallbladder wall (7 mm) and pericholecystic collection. There was no evidence of biliary dilatation, gallbladder stones or sludge. A computer tomography scan confirmed the USS findings and showed mild pancreatitis. In view of the clinical and radiological findings, he was treated as per AAC and acute pancreatitis. He was kept nil per orally and initiated on intravenous antibiotics (ceftriaxone 2 gm daily and metronidazole 500 mg t.i.d) and continuous somatostatin infusion. However, his condition deteriorated rapidly over the next 24 hours, leading to septic shock and respiratory failure requiring ventilation and ionotropic support. Postintubation radiography showed features of acute respiratory distress syndrome. Repeat serum amylase was elevated at 3049 U/L the following day. His renal function also rapidly deteriorated and required renal replacement therapy. Serum Leptospirosis Presenting as Acute Acalculous Cholecystitis and Pancreatitis

Role of Laparoscopic Cholecystectomy in the Management of Acute Cholecystitis

Objective: To evaluate the outcome of laparoscopic cholecystectomy in the management of acute cholecystitis in term of hospital stay, ease or difficulty of the procedure and to assess the incidence of complications. Design: An observational study. Place and duration of study: The study was conducted at department of surgery ward 2, Jinnah Postgraduate Medical Center Karachi from Jan 2004 to march 2006. Patients and methods : Case records of all patients who underwent laparoscopic cholecystectomy for acute cholecystitis with in the specified period were scrutinized. Patients with the clinical diagnosis of acute cholecystitis were admitted. All patients had ultrasound abdomen, CBC, LFTs and other laboratory work up as required. Fifty patients with diagnosis of acute cholecystitis were included into the study, who fulfilled the inclusion criteria. Patients with acute symptoms more than five days and ASA grade III &IV were excluded .Data on age, gender, ultra sound findings, operative findings, hospital stay and complications were recorded. Results : There were fifty patients 27 males and 23 females. Age ranged from 28 to 73 years, majority belonged to 5 th decade of life. Mean hospital stay was 2.58 days. There was no mortality and CBD injury. Excessive bleeding was encountered in two patients. Hemostasis was secured and blood transfusion was not required. Operative difficulties were experienced in 39 (78%) patients. These were mainly because of presence of adhesions 28 (56%). Difficult dissection in Callot's triangle was experienced due to obscured anatomy in 10 (20%) patients. Perforation of gall bladder occurred in 12 (24%) patients. One case was converted to open cholecystectomy and drain was placed in that case. In postoperative period shoulder tip pain was noticed by 11 (22%) patients and wound infection occurred in 5 (10%) patients. Conclusion: Laproscopic cholecystectomy is reliable and safe modality for the management of acute cholecystitis. Better clinical results, shorter hospital stay and few complications points to significant advantage of laproscopic cholecystectomy in the management of acute cholecystitis.

Prognostic parameters for the prediction of acute gangrenous cholecystitis

The aim of this study was to identify preoperative prognostic parameters for gangrenous cholecystitis to differentiate this subgroup of patients with acute cholecystitis in order to provide immediate surgical therapy. The medical records of patients who had an emergency cholecystectomy with the diagnosis of acute cholecystitis between January 2002 and June 2005 were reviewed retrospectively. Univariate and multivariate analysis were performed on the data. Out of 203 individuals with the clinical diagnosis of acute cholecystitis, 21 (10.3%) patients had a histological diagnosis of gangrenous cholecystitis. Multivariate analysis demonstrated an independent association of male sex, diabetes mellitus and white blood cell (WBC) count with the development of acute gangrenous cholecystitis. The risk for gangrenous cholecystitis is increased in male patients who have diabetes and a greater WBC count than 14 900/mm(3). Urgent surgical intervention should be considered for these patients because of the high morbidity and mortality rate of the condition.

Percutaneous cholecystostomy: a valuable technique in high-risk patients with presumed acute cholecystitis.

Percutaneous cholecystostomy offers a potentially important therapeutic modality for critically ill patients with acute cholecystitis who represent a high risk for general anaesthesia. The aim of the study was to assess experience with percutaneous cholecystostomy in resolving the acute episode of cholecystitis without operative intervention. Twenty-two consecutive patients with a clinical diagnosis of acute cholecystitis underwent the procedure. All were at high risk for general anaesthesia, and all but one developed cholecystitis while hospitalized for another co-morbid condition; 14 were in an intensive care unit. Twenty-one of the 22 patients proved to have acute cholecystitis (11 acalculous, ten cholelithiasis). There were no acute technical complications. Toxaemia resolved in 17 of the 21 patients with acute cholecystitis. Acute cholecystitis failed to resolve in three patients; all died within 48 h from overwhelming generalized sepsis. One patient required emergency cholecystectomy for bile peritonitis when the cholecystostomy catheter became dislodged 24 h after placement. The 60-day mortality rate for the acalculous and calculous patient groups was 55 and 20 per cent, respectively. Only three interval cholecystectomies have been performed at a mean follow-up of 19 months. In conclusion, percutaneous cholecystostomy may be the procedure of choice for the management of acute cholecystitis in the very high-risk critically ill patient. If symptoms fail to resolve quickly, ongoing sepsis, cholangitis or gallbladder necrosis should be suspected.

Acute cholecystitis.

One hundred and fifty-six successive patients have been admitted with the clinical diagnosis of acute cholecystitis and have been treated by operation on the next operating list. The diagnosis was correct in 154 and a diagnostic pathway has been determined. The clinical features, investigations, bacteriology and pathology are discussed. There is an increased need for choledochotomy in acute cholecystitis and this bile is more commonly infected than in the elective patient. It is suggested that those with infection can be identified prior to operation and should be treated with antibiotics on admission. The morbidity of operation on patients with uninfected bile is no greater than in those receiving elective surgery, and operative treatment is recommended for both groups of patients.

Outcome of laparoscopic cholecystectomy in acute cholecystitis.

To evaluate the outcome of laparoscopic cholecystectomy in acute cholecystitis and to determine various pre-operative risk factors predicting conversion to open cholecystectomy. Observational study. Department of Surgery, Riyadh Medical Complex, Riyadh, Saudi Arabia over 5 years period from June 1, 1997 to May 30, 2002. Consecutive patients admitted with clinical diagnosis of acute cholecystitis confirmed subsequently by abdominal ultrasonography and undergoing laparoscopic cholecystectomy during the same admission. Patients with symptoms of more than one week duration, or various uncontrolled co-morbid conditions requiring optimization before surgery were excluded. Parameters analyzed were morbidity, mortality, incidence and etiology of conversion. Various pre-operative risk factors predicting failure of laparoscopic procedure in acute cholecystitis were further analyzed. Statistical analyses were carried out employing Chi-square test, using IBM-compatible PC, utilizing SPSS 10.0 for Windows (SPSS Inc., Chicago). Three hundred and eleven patients qualified the inclusion criteria. Mean age was 43.7 years with female to male ratio of 4.5:1. Majority of the patients (91%) were operated within 72 hours of onset of symptoms. Laparoscopic cholecystectomy was successfully accomplished in 86.8 % cases. Out of the 41 converted cases, disturbed anatomy in the region of Calot's triangle was the most common cause of conversion observed in 41.5% patients. Male gender, age more than 65 years, very high leucocyte count, gallbladder wall thickness of more than 4 mm on ultrasonography and complicated disease were observed as most significant determinant for conversion to open procedure. Overall morbidity was 2.9% with no mortality. Laparoscopic cholecystectomy can be accomplished with minimal morbidity in acute cholecystitis. Knowledge of various factors predicting possible conversion helps in pre-operative selection and counseling for open procedure and early conversion to open technique, with further reduction in the overall morbidity of laparoscopic cholecystectomy.

Early decision for conversion of laparoscopic to open cholecystectomy for treatment of acute cholecystitis

Although recent reports suggest an initial laparoscopic approach to acute cholecystitis, the risk factors and consequences of the failure of an attempt remained unknown. A retrospective study of 557 laparoscopic cholecystectomies was undertaken to identify 70 patients (13%) with a clinical diagnosis of acute cholecystitis confirmed by ultrasonography. Patients who required conversion to laparotomy (conversion group) were compared to those with successful laparoscopic cholecystectomy (successful group). Eight of 70 patients (11%) required conversion. The conversion group had significantly more elderly (< or =65 years) patients (88% vs 37%; P = 0.02) and larger gallstones as shown on ultrasonography (25 mm vs 15.5 mm; P = 0.03). Other preoperative factors associated with severe inflammation were not predictive. Conversion was associated with the intraoperative finding of severe adhesions and not with those of empyema of gallbladder or gangrenous cholecystitis. Conversion was made after a median laparoscopic surgery time of 50 minutes. The conversion group required more operation time, more analgesics, a longer recovery time, and a longer hospital stay. In addition, the postoperative complication rate was significantly higher (63% vs 16%; P = 0.009). Patients who required conversion from laparoscopic to open cholecystectomy for acute cholecystitis are at risk for postoperative complications. In elderly patients with large gallstones, the surgeon should made an early decision to convert if severe adhesions are encountered.

Early Versus Delayed Laparoscopic Cholecystectomy for Treatment of Acute Cholecystitis

The current study compared the results of early versus delayed laparoscopic cholecystectomy for treatment of acute cholecystitis. Although recent reports have suggested the use of laparoscopic cholecystectomy for acute cholecystitis, the complication and conversion rates remain high. No data are available on whether initial medical treatment can improve the results. Among 497 patients who underwent laparoscopic cholecystectomy, 52 (10.5%) had a clinical diagnosis of acute cholecystitis confirmed by ultrasonography. Twenty-seven of these patients had early surgery, that is, within 120 hours of admission, and 25 had interval cholecystectomy after initial medical treatment. The early group required modifications in operative technique more frequently (p < 0.001). The conversion rate (7.4%) and minor complication rate (22%) were comparable. Successful early laparoscopic cholecystectomy required a longer operative time (137.2 minutes vs. 98.0 minutes; p < 0.05) and postoperative hospital stay (4.6 days vs. 2.5 days; p < 0.005) but reduced the total hospital stay (6.4 days vs. 12.4 days; p < 0.001). Early laparoscopic cholecystectomy for the treatment of acute cholecystitis has no adverse effect on complication and conversion rates. Although it is technically demanding and time consuming, this procedure provides the economic advantage of a markedly reduced total hospital stay.