Emergency Cholecystectomy Research Articles

Prognostic Factors Associated with Hospital Stay in Patients Undergoing Emergency Cholecystectomy: Retrospective Cohort Study

Pinillos Navarro, Pilar C. MD; Martínez Martínez, Jorge A. MD; Junca, Edgar G. MD; Patiño, Andrés F. MD; Moyano, Juan S. MD; Bernal, Ginna M. MD; Paneso, Juan E. MD; Castro, Camilo A. MD; Baquero, Romar MD; Buitrago, Giancarlo MD Author Information

2336 Multiple Uncommon Complications After TACE

INTRODUCTION: TransarteriaL chemoembolization (TACE) is a widely-used treatment for unresectable hepatocellular cancer (HCC). Although TACE is minimally invasive, major complications occur in 5% of cases. These include acute cholecystitis, which is self-limiting and rarely requires surgical intervention. Liver abscess is a rare complication but can increase length-of-stay and morbidity. Our case focuses on multiple uncommon complications of TACE occurring in conjunction; gangrenous cholecystitis requiring emergent cholecystectomy, liver abscess and portal vein thrombosis. CASE DESCRIPTION/METHODS: A 67-year-old male with history of hepatitis C, cirrhosis and HCC status-post recent successful TACE who presented to the ER with right upper quadrant pain associated with fever. Physical examination with right upper quadrant tenderness and positive murphy’s sign. Laboratories showed leukocytosis and elevated alkaline phosphatase. Normal bilirubin, liver and pancreatic enzymes. Abdominopelvic CT with hydropic gallbladder with enhancing walls and pericholecystic inflammatory changes, new ill-defined hypodensities suggestive of abscess and extensive thrombus in the right portal vein. The patient received antibiotics and underwent an uneventful cholecystectomy. Post-operation findings consistent with a gangrenous gallbladder with severe adherent hepatic flexure and omentum to the gallbladder fundus. The patient was discharged on antibiotics and anticoagulation. Follow up MRI showed resolution of fluid filled lesions with almost complete resolution of the portal vein thrombosis. DISCUSSION: Cholecystitis is a complication of TACE due to reflux of the embolic material into the cystic artery. In most cases, management can be conservative. Our case is rare given that the patient developed gangrenous cholecystitis which is a serious complication that requires immediate surgical intervention. Liver abscess occurs infrequently unless there is a history of prior biliary reconstruction unlike our patient. Management includes antibiotics and percutaneous drainage for larger abscesses. In our case, our patient responded well to antibiotics. Because symptoms are non-specific, these complications may be mistaken for post embolization syndrome, which is usually self-limiting and abates by one week. Normal post-TACE CT findings can also confound the diagnosis of hepatic abscess formation. This case highlights the importance of being aware of complications of TACE as failure to recognize these may confer a higher mortality risk.

Outcomes Following an Index Emergency Admission With Cholecystitis: A National Cohort Study.

The objective of this study was to evaluate the differences between patients who undergo cholecystectomy following index admission for cholecystitis, and those who are managed nonoperatively. Index emergency cholecystectomy following acute cholecystitis is widely recommended by national guidelines, but its effect on clinical outcomes remains uncertain. Data collected routinely from the Hospital Episode Statistics database (all admissions to National Health Service organizations in England and Wales) were extracted between April 1, 2002 and March 31, 2015. Analyses were limited to patients aged over 18 years with a primary diagnosis of cholecystitis. Exclusions included records with missing or invalid datasets, patients who had previously undergone a cholecystectomy, patients who had died without a cholecystectomy, and those undergoing cholecystectomy for malignancy, pancreatitis, or choledocholithiasis. Patients were grouped as either "no cholecystectomy" where they had never undergone a cholecystectomy following discharge, or "cholecystectomy." The latter group was then subdivided as "emergency cholecystectomy" when cholecystectomy was performed during their index emergency admission, or "interval cholecystectomy" when a cholecystectomy was performed within 12 months following a subsequent (emergency or elective) admission. Propensity Score Matching was used to match emergency and interval cholecystectomy groups. Main outcome measures included 1) One-year total length of hospital stay due to biliary causes following an index emergency admission with cholecystitis. 2) One-year mortality; defined as death occurring within 1 year following the index emergency admission with acute cholecystitis. Of the 99,139 patients admitted as an emergency with acute cholecystitis, 51.1% (47,626) did not undergo a cholecystectomy within 1 year of index admission. These patients were older, with more comorbidities (Charlson Comorbidity Score ≥ 5 in 23.5% vs. 8.1%, P < 0.001) when compared to patients who did have a cholecystectomy. While all-cause 1-year mortality was higher in the nonoperated versus the operated group (12.2% vs. 2.0%, P < 0.001), gallbladder-related deaths were significantly lower than all other causes of death in the non-operated group (3.3% vs. 8.9%, P < 0.001). Following matching, 1-year total hospital admission time was significantly higher following emergency compared with interval cholecystectomy (17.7 d vs. 13 d, P < 0.001). Over 50% of patients in England did not undergo cholecystectomy following index admission for acute cholecystitis. Mortality was higher in the nonoperated group, which was mostly due to non-gallbladder pathologies but total hospital admission time for biliary causes was lower over 12 months. Increasing the numbers of emergency cholecystectomy may risk over-treating patients with acute cholecystitis and increasing their time spent admitted to hospital.

Laparoscopic trans-gastric endoscopic retrograde cholangiopancreatography during emergent cholecystectomy after Roux-en-Y gastric bypass: novel techniques for choledocholithiasis.

Laparoscopic trans-gastric endoscopic retrograde cholangiopancreatography during emergent cholecystectomy after Roux-en-Y gastric bypass: novel techniques for choledocholithiasis.

Opioid stewardship after emergency laparoscopic general surgery

BackgroundOpioid administration in postoperative patients has contributed to the opioid crisis by increasing the load of opioids available in the community. Implementation of evidence-based practices is key to optimizing the...

Understanding the influences on successful quality improvement in emergency general surgery: learning from the RCS Chole-QuIC project

BackgroundAcute gallstone disease is the highest volume Emergency General Surgical presentation in the UK. Recent data indicate wide variations in the quality of care provided across the country, with national guidance for care delivery not implemented in most UK hospitals. Against this backdrop, the Royal College of Surgeons of England set up a 13-hospital quality improvement collaborative (Chole-QuIC) to support clinical teams to reduce time to surgery for patients with acute gallstone disease requiring emergency cholecystectomy.MethodsProspective, mixed-methods process evaluation to answer the following: (1) how was the collaborative delivered by the faculty and received, understood and enacted by the participants; (2) what influenced teams’ ability to improve care for patients requiring emergency cholecystectomy? We collected and analysed a range of data including field notes, ethnographic observations of meetings, and project documentation. Analysis was based on the framework approach, informed by Normalisation Process Theory, and involved the creation of comparative case studies based on hospital performance during the project.ResultsChole-QuIC was delivered as planned and was well received and understood by participants. Four hospitals were identified as highly successful, based upon a substantial increase in the number of patients having surgery in line with national guidance. Conversely, four hospitals were identified as challenged, achieving no significant improvement. The comparative analysis indicate that six inter-related influences appeared most associated with improvement: (1) achieving clarity of purpose amongst site leads and key stakeholders; (2) capacity to lead and effective project support; (3) ideas to action; (4) learning from own and others’ experience; (5) creating additional capacity to do emergency cholecystectomies; and (6) coordinating/managing the patient pathway.ConclusionCollaborative-based quality improvement is a viable strategy for emergency surgery but success requires the deployment of effective clinical strategies in conjunction with improvement strategies. In particular, achieving clarity of purpose about proposed changes amongst key stakeholders was a vital precursor to improvement, enabling the creation of additional surgical capacity and new pathways to be implemented effectively. Protected time, testing ideas, and the ability to learn quickly from data and experience were associated with greater impact within this cohort.

Correlation between the Severity and Outcome of Acute Calculous Cholecystits According to Tokyo Guidelines

Introduction: Acute Calculous Cholecystitis is a condition in which the gallbladder becomes inflamed due to cholelithiasis. Early diagnosis, severity grading and appropriate intervention reduce both morbidity and mortality. The aim of this prospective study is to correlate the severity with the outcome of acute calculous cholecystitis according to Tokyo Guidelines.&#x0D; Methods: This was a hospital based prospective study conducted in the Department of Surgery, Nepalgunj Medical College Teaching Hospital for a period of two years from April 2017 to March 2019. The patients were classified into three groups according to the severity grading in the Tokyo guidelines (TG18/ TG13). Clinical characteristics among these patients were analyzed for comparison.&#x0D; Results: Among all diagnostic criteria, right upper quarter (RUQ)h abdominal pain (94%) Murphy's sign (94%) and thickened gallbladder wall (80%) had the highest sensitivity rates (p&lt;0.032), whereas elevated white cell count (32%) and RUQ abdominal mass (32%) had the lowest sensitivity rates (p&lt;0.035). Higher sensitivity rates of diagnostic criteria were related to severe cholecystitis, except for Fever (46%) and elevated white blood cell (WBC) count (32%). All the 28 patients in grade I and selected patients 3 out of 6in grade II underwent early laparoscopic cholecystectomy (LC) without any conversion and increased morbidity and mortality. Out of16 patients in grade III there was 2 mortalities due to ARDS, 1 needed Ultrasonography (USG) guided cholecystostomy, 1 underwent emergency cholecystectomy. 16 patients, 3 in grade II and 13 in grade III underwent interval laparoscopic cholecystectomy safely. There were no major postoperative morbidities except for superficial surgical site infection (SSI) in 1 patient in grade III who underwent emergency cholecystectomy Higher grade of severity was associated with increased morbidity and mortality (p&lt;0.03).&#x0D; Conclusion: A combination of diagnostic criteria with different path physiologic findings, as noted in the Tokyo guidelines, can help clinicians make the correct diagnosis for patients with acute cholecystitis and there was strong correlation between the severity and outcomes of acute cholecystitis.

An Acute General Surgical Unit (AGSU) Negates the Impact of the Tokyo Guidelines 2018 (TG18) Diagnostic Criteria for the Treatment of Acute Cholecystitis.

The Tokyo Guidelines 2018 (TG18) were developed to aid diagnosis and treatment for acute cholecystitis. The benefits of being treated in an acute general surgical unit (AGSU) include earlier diagnosis and treatment. This study aims to define the usefulness of TG18 before and after the introduction of AGSU. Patients who underwent cholecystectomy at Northern Health were audited retrospectively and assessed for TG18 diagnostic criteria and outcomes between 1 February 2012 and 1 February 2014 (one-year pre- and post-AGSU). Five hundred and eighty-seven patients underwent emergency cholecystectomy with 203 (34.6%) patients having a suspected diagnosis, and 234 (39.9%) patients with a definitive diagnosis of acute cholecystitis using TG18 diagnostic criteria. After the introduction of AGSU, time from imaging to operation improved from 2.5 to 1.7days (p = 0.012). There were more operations occurring during in-hours following AGSU implementation (75.8% vs. 62.7%, p < 0.001). Maximum pre-operative CRP of >26.6mg/L had a higher likelihood of Clavien-Dindo complication grade 3 or 4 (OR 3.86, 95%CI 1.18-12.63, p = 0.027) compared with TG18 definitive diagnosis criteria (OR 1.50, 95%CI 0.46-4.91, p = 0.501). Surprisingly, there was a trend towards higher complications and readmissions for patients operated within 24h, although this trend was not significant. Patients with suspected acute cholecystitis should be stratified clinically and with CRP in an AGSU with TG18 adding little value in a busy metropolitan unit.

Percutaneous Cholecystostomy as an Alternative to Cholecystectomy in High-Risk Patients with Acute Cholecystitis

Background: Cholecystectomy is the standard treatment for patients with acute cholecystitis. On the other hand, percutaneous cholecystostomy (PC) is an alternative for patients at high-risk for surgery. The aim of this study was to evaluate the clinical outcomes of PC.&#x0D; Methods: Surgically high-risk patients with acute cholecystits having undergone PC at our institution between January 2014 – January 2017 were evaluated. Data including the indications for PC, route of insertion, technical success, clinical improvement, length of hospital stay, mortality rates, procedure related complications, subsequent admissions and performance of interval cholecystectomy were recorded and analyzed.&#x0D; Results: The study group consisted of 30 patients with a mean age of 75.3 ( range: 49–99) years. The indications for PC were acute calculous cholecystitis in 28 (93.3%) and acalculous cholecystitis in 2 (6.7%) patients. All procedures were performed via the transhepatic route. Twenty-five PCs (84.4%) resulted in clinical improvement within five days. A repeated PC was performed in two (6.7%) patients. Seven (23.3%) patients underwent a subsequent cholecystectomy after 6 weeks. An emergent cholecystectomy was performed in one (3.3%) patient. Five (16.7%) patients died from underlying comorbid diseases, unrelated to the biliary system, during the follow-up.&#x0D; Conclusions: Patients with acute cholecystitis were promptly relieved from their symptoms following PC. There were only minor complications following the procedure and an interval cholecystectomy was necessary in only 23.3% of the patients. PC is a safe alternative to choecystectomy in high-risk patients with acute cholecystitis with satisfactory results.

Ten-year Audit of Safe Bail-Out Alternatives to the Critical View of Safety in Laparoscopic Cholecystectomy.

To prevent vasculobiliary injuries according to the Tokyo Guidelines, Critical View of Safety (CVS) is the recommended method for the identification of the cystic duct and cystic artery. Our aim was to audit laparoscopic cholecystectomies, in order to determine the rate of CVS feasibility and to explore safe bail-out alternatives, when CVS cannot be obtained. Patients who underwent either elective or emergent laparoscopic cholecystectomy, between January 2009 and December 2018, in whom the CVS was attempted, were retrospectively identified from the institutional electronic database. Dissection technique was documented in the operative notes. Bile duct injuries (BDI) were classified by the Strasberg classification, and their management and outcome were reported in the patient files. In total, 1226 cases were included in the final analysis. CVS was feasible in 1128 cases (92.0%), whereas 65 patients (5.3%) were managed laparoscopically by a bail-out technique. Of those, 52 (4.3%) underwent a subtotal cholecystectomy, 12 (0.9%) a fundus-first cholecystectomy, and in one patient (0.1%) the operation was concluded by a tube cholecystostomy. Overall conversion rate was 2.7% (33/1226 cases). Male gender, older age, junior surgeons, and acute cholecystitis were significantly associated with higher conversion rates. Post-operatively, 10 patients (0.82%) developed a type A bile leakage. No major BDI (types B-E) were observed, either with CVS or the bail-out techniques. Our study showed that CVS and the bail-out alternatives complement each other in preventing major BDI and should belong to the armamentarium of every modern surgeon.

Optimizing Perioperative Antimicrobial Therapy for Acute Cholecystitis Using Bile Gram Stain Results

ObjectiveWe aimed to evaluate whether Gram stain results from smear preparations of bile are useful in determining the optimal perioperative antimicrobial agents.Summary of background dataSurgical site infections (SSIs) are common complications in emergency cholecystectomy.MethodsA total of 185 patients who underwent emergency cholecystectomy for acute cholecystitis were enrolled (Bell Land General Hospital Ethic Board approval number 2017-0003). Bile was collected from 121 patients. The Gram stain results from bile smear and culture preparations were evaluated. Furthermore, the antimicrobial resistance was evaluated according to bile Gram stain results.ResultsBile bacteria were detected in 82 patients (67.8%) with the culture preparation and in 72 patients (59.5%) with the smear preparation. The average rate of correspondence in the Gram stain results between smear and culture preparations was 86.3% among patients with bile bacteria in the smear preparation. Cefepime and meropenem had a low antimicrobial resistance rate for all Gram stain results (&amp;lt;10%). However, the resistance rate of other antimicrobial agents differed according to the Gram stain results.ConclusionsThe Gram stain results from the smear preparation appear to be useful in choosing optimal perioperative antimicrobial agents.

The Correlation between Specific Biochemical Parameters, Radiological data and clinical sings for practicing laparoscopic cholecystectomy in the first 24 hours for acute cholecystitis. How safe it is?

The best timing of cholecystectomy on patients with acute gallbladder pathology is still unclearly defined. Some studies have reported that cholecystectomy during the index acute admission presents an increased morbidity rate, extended duration of stay and increased costs. The study below is aiming at finding the most accurate moment to practice the surgery when acute cholecystitis is confirmed. Consequently, 368 patients admitted to hospital from January 2013 to December 2015 with the diagnosis of acute cholecystitis (AC) who underwent cholecystectomy in the 2nd Department of Surgery, Emergency County Hospital, Timi�oara, Romania constituted the two lots. The cases were retrospectively identified, introduced into the database and the data were subsequently analyzed according to various parameters. The study results reveal that laparoscopic cholecystectomy (LC) in the first 24 hours is safe procedure on the majority of the cases. Also, our findings sustain that emergency cholecystectomy can reduce the length of hospital stay, having similar rates of conversion to open surgery, complications and outcome compared with a delayed operation.

Routine histopathological examination of gallbladder specimens after cholecystectomy: Is it time to change the current practice?

Routine histopathological examination of all gallbladder specimens, regardless of the clinical characteristics of the patient or macroscopic aspect of the gallbladder, is the current approach to detect the presence of gallbladder carcinoma. The aim of the present study was to assess whether or not it would be safe to adopt a policy of processing only gallbladder specimens with preoperative or intraoperative suspicion for malignancy without compromising patient safety. From January 2009 to June 2017, all histopathology reports of 3423 consecutive gallbladder specimens after elective and emergency cholecystectomies were retrospectively analyzed in two university hospitals. A total of 3423 gallbladder specimens submitted for histopathological examination during the study period were included into the study. The results of histopathological examination of these gallbladder specimens showed that chronic cholecystitis was found in 2792 (81.6%), acute cholecystitis in 237 (6.9%), and cholesterolosis in 223 (6.5%) patients. Dysplasia was found in 5 (0.14%) patients, and gallbladder carcinoma was detected in 4 (0.11%) patients. All patients with gallbladder carcinoma were diagnosed either preoperatively or intraoperatively, and none of the patients with gallbladder carcinoma were diagnosed from the histopathological examination. A strategy of selective approach for histopathological examination of gallbladder specimens may be safe in areas with very low incidence of gallbladder carcinoma. Such selective strategy is more cost-effective, reduces the workload of pathologists, and does not appear to compromise patient outcome.

Using the Social Vulnerability Index to Examine Local Disparities in Emergent and Elective Cholecystectomy

BackgroundThe Social Vulnerability Index (SVI) is a composite scale formulated by the Centers for Disease Control and is geocoded as a percentile ranking at the census tract level. SVI is potentially applicable to assess risk and target populations that are likely to present emergently for disease that could have been treated electively and target local disparities. We applied the SVI to compare cholecystectomy patients presenting emergently versus electively. MethodsWe identified patients who had undergone cholecystectomy at our academic medical center over a 6-month period. We abstracted patient demographics, chronic symptom duration, and diagnosis from the medical record. Patient addresses were geocoded to identify their census tract of residence and estimated SVI. ResultsTwo hundred and fifty five patients met inclusion criteria. Most patients (n = 185, 72.5%) had surgery in the emergent setting. Emergent patients lived in areas of greater social vulnerability compared with elective patients (median SVI 75th versus 64th percentile, P < 0.001). On multivariable analysis adjusting for chronicity of symptoms and patient proximity to the hospital, having high SVI (>70th percentile) was associated with higher odds of undergoing an emergent versus an elective procedure (OR 2.05, P = 0.04). ConclusionsThe SVI has potential utility for examining health care disparities, performing comparably with a more complex model including individual risk factors. Because it is a composite measure geocoded at the census tract level for all communities in the United States, it has potential for targeting relatively discrete geographic areas for intervention. Being a geocoded measure also offers opportunity for linking with other data sets using geographic information systems.

C-reactive Protein is an Independent Predictor of Difficult Emergency Cholecystectomy.

PurposeThe objective of this study was to identify variables that predict a difficult laparoscopic cholecystectomy performed in an emergency setting. The secondary aim was to devise a pathway for patients admitted acutely that required a cholecystectomy.MethodsPatients admitted to the Emergency General Surgery Department at Nottingham, the United Kingdom that had an emergency cholecystectomy performed during the one-year period from May 2016 to June 2017 were identified. Collected data included patient demographics, clinical presentation, biochemical analysis, radiological findings, subsequent interventions, surgical data, and clinical outcome. A difficult cholecystectomy was defined as operative time >60 minutes, conversion to an open procedure, or sub-total cholecystectomy performed. ResultsA total of 149 patients were included. Cholecystitis was the most common diagnosis (n = 86, 57.7%), followed by acute pancreatitis (n = 36, 24.1%). Fifty-five (36.9%) patients had an elevated C-reactive protein (CRP) >100 mg/dL. One hundred and twenty-one (81.2%) patients who had an emergency cholecystectomy were defined as “difficult”. The overall morbidity rate was 15.4% (n = 23), and there was no post-operative in-hospital mortality. Univariate analysis showed that age >60 years (p = 0.012), underlying diagnosis (p = 0.010), presence of heart rate >90 (p = 0.027), and an elevated pre-surgery CRP >100 (p < 0.001) was associated with a difficult emergency cholecystectomy. Multi-variate analysis demonstrated that an elevated pre-surgery CRP >100 was an independent predictor of a difficult emergency cholecystectomy (p = 0.041).ConclusionsAn elevated pre-operative CRP is an independent predictor of a technically more difficult cholecystectomy in the emergency setting.

Optimum timing of emergency cholecystectomy for acute cholecystitis in England: population-based cohort study

BackgroundCholecystectomy on index admission for acute cholecystitis is associated with improved patient outcomes. The timing of intervention is mainly driven by service provision. This population-based cohort study aimed to evaluate timing of emergency cholecystectomy in England.MethodsData from all consecutive patients undergoing surgery for acute cholecystitis on index admission in England from 1997 to 2012 were captured from the Hospital Episodes Statistics database. Data were analysed based on whether patients underwent surgery 0–3 days, 4–7 days or ≥ 8 days from admission. Outcome measures were rate of post-operative biliary complications, conversion to open and length of stay.ResultsForty-three thousand eight hundred and seventy patients underwent emergency cholecystectomy. 64.6% of patients underwent surgery between days 0 and 3 of admission, 24.3% between days 4–7 and 11.0% had surgery after day 8. Patients undergoing early surgery had significantly reduced rates of intra-operative laparoscopic conversion to open (0–3 days: 3.6%; 4–7 days: 4.0%; ≥ 8 days 4.7%, p = 0.001), post-operative ERCP (0–3 days: 1.1%; 4–7 days: 1.5%; ≥ 8 days 1.9%, p < 0.001) and bile duct injury (0–3 days: 0.6%; 4–7 days: 1.0%; ≥ 8 days 1.8%, p < 0.001). Early cholecystectomy was also associated with a shorter post-operative length of stay (LOS) [0–3 days group: median post-operative LOS 3 days (IQR: 1–6); 4–7 days group: 3 days (IQR 2–6); ≥ 8 days group: 4 days (IQR 2–9) (p < 0.001)]. High-volume centres undertook a significantly greater proportion of cholecystectomies within 3 days of presentation (high-volume: 67.3%; medium-volume: 64.8%; low-volume: 61.2%). In multivariate analysis greater time to surgery was independently associated with increased risk of post-operative ERCP and bile duct injury.ConclusionsEarly cholecystectomy within 3 days of admission reduces intra-operative conversion, post-operative biliary complications and length of stay. Centres undertaking the greatest numbers of emergency cholecystectomies perform a larger proportion within 3 days of admission.

Index Admission Emergency Laparoscopic Cholecystectomy and Common Bile Duct Exploration: Results From a Specialist Center in the United Kingdom.

The incidence of common bile duct (CBD) stones is between 10% to 18% in people undergoing cholecystectomy for gallstones. Laparoscopic exploration of the CBD is now becoming routine practice in the elective setting, however its safety and efficacy in emergencies is poorly understood. We analyzed our results for index emergency admission laparoscopic cholecystectomy within a specialist center in the United Kingdom. Data from all emergency cholecystectomies in our unit, between 2011 to 2016 were collected and analyzed retrospectively. In total, 494 patients underwent emergency laparoscopic cholecystectomy; 53 (10.7%) patients underwent common bile duct exploration (CBDE), with 1 conversion and 1 bile leak. Indications for CBDE were based on preoperative imaging (41 cases, 81%) or intra-operative cholangiogram (44 cases, 83%) findings. Index admission laparoscopic cholecystectomy and concomitant CBDE is safe and should be the gold standard treatment for patients presenting with acute biliary complications, reducing readmissions and the need for a 2-stage procedure.

Extended Postoperative Antibiotics Versus No Postoperative Antibiotics in Patients Undergoing Emergency Cholecystectomy for Acute Calculous Cholecystitis: A Systematic Review and Meta-Analysis.

Objectives. To compare the outcomes of extended postoperative antibiotics versus no postoperative antibiotics in patients with acute calculous cholecystitis undergoing emergency cholecystectomy. Methods. We performed a systematic review and conducted a search of electronic information sources to identify all randomized controlled trials comparing outcomes of extended postoperative antibiotics versus no postoperative antibiotics in patients with acute calculous cholecystitis undergoing emergency cholecystectomy. Postoperative infectious complications and surgical site infections were primary outcome measures. The secondary outcome measures included postoperative morbidity, postoperative noninfectious complications, urinary tract infections, pneumonia, length of hospital stay, postoperative mortality, and need for readmission. Random or fixed effects modeling was applied to calculate pooled outcome data. Results. Four randomized controlled trials enrolling 953 patients were identified. The included populations in the extended antibiotic group and no antibiotic group were comparable in terms of baseline characteristics. There was no difference between the 2 groups in terms of postoperative infectious complications (odds ratio [OR] =0.94, P = .79), surgical site infections (OR = 1.13, P = .72), postoperative morbidity (OR = 0.93, P = .70), postoperative noninfectious complications (OR = 0.85, P = .57), urinary tract infections (OR = 0.69, P = .55), pneumonia (OR = 0.33, P = .14), length of hospital stay (mean difference = 0.78, P = .25), postoperative mortality (risk difference = -0.00, P = .65), and need for readmission (OR = 0.87, P = .70). Conclusions. Our results suggest that extended postoperative antibiotic therapy does not improve postoperative infectious or noninfectious outcomes in patients with mild or moderate acute calculous cholecystitis undergoing emergency cholecystectomy. Postoperative antibiotics should not be routinely used and should be preserved only for selected cases.

Should Percutaneous Transhepatic Gallbladder Drainage be removed before elective cholecystectomy?

Introduction: Percutaneous transhepatic gallbladder drainage (PTGBD) is an alternative treatment for acute cholecystitis (AC). Definitive treatment of elective cholecystectomy is usually indicated later. We retrospectively compared the outcomes of patients with their PTGBD removed before elective surgery or retained till elective surgery. Method: From 2012 to 2016, there were 329 patients were treated PTGBD for initial treatment and intended elective cholecystectomy was arranged later. Only 230 of 329 patients were enrolled for analysis due to complete radiological studies available. We compared surgical outcomes between patients with and without PTGBD. The outcomes included emergent cholecystectomy before scheduled elective surgery, postoperative complication, and conversion from laparoscopic procedure to laparotomy. Result: The postoperative complication, related to infection, occurred more frequently in the group without PTGBD tube removal before surgery (p=0.012). For patients with PTGBD removed, emergent cholecystectomy was indicated more often. (OR=3.21, 95%CI 1.05-8.10, p=0.021). Conclusion: PTGBD tubes may be removed before definitive surgery due to the significantly decrease of surgical complications related to infection even with an increased likelihood of emergent cholecystectomy. Adequate education about the recurrence of symptom is important to patients in order to prompt management of relapse AC.

Impact of antiplatelet therapy on increased blood loss and bleeding complication in patients undergoing urgent cholecystectomy for acute cholecystitis

Background: The impact of antiplatelet therapy (APT) on surgical blood loss (SBL) and postoperative bleeding complications (PBCs) in patients receiving emergency cholecystectomy for acute cholecystitis (AC) still remains unknown. Methods: A total of 243 consecutive AC patients undergoing emergency cholecystectomy were reviewed. In patients receiving APT (APT group, n=89), surgery was performed without preoperative reversal of the APT effect. Perioperative and outcome variables of the APT group were compared with those of patients without APT (non-APT group, n=154). Results: In this cohort, 106 laparoscopic and 137 open operations were included. There were 18 patients with increased SBL (>=500mL, 7.4%) and 7 PBCs (2.9%). Patients with APT showed higher occurrence of Grade 3 acute cholecystitis (46% vs 28%, p=0.005) and less frequently received laparoscopic surgery (34% vs 49%, p=0.022) compared to those in the non-APT group. Multivariate analyses showed that Grade 3 acute cholecystitis (HR=2.76, p=0.046) and male gender (HR=12.99, p=0.017), but not APT use or laparoscopic surgery, were independent prognostic factors for increased SBL. However, increased PBCs were significantly associated with use of multiple APT (HR=14.85, p=0.044) and anticoagulation (HR=47.18, p=0.002). Conclusion: Single APT does not pose a risk for either SBL or PBCs after emergency cholecystectomy for acute cholecystitis, whereas patients with multiple APT or anticoagulation still represent a challenging group and need to be rigorously managed.