Emergency Cholecystectomy For Acute Cholecystitis Research Articles

TH2.2 Optimum Timing of Emergency Cholecystectomy for Acute Cholecystitis - A Single Sited Retrospective Cohort Study

Abstract Aim To evaluate timing of emergency cholecystectomy performed at one of the hospital in West Midlands. Methods This is a retrospective single centre study conducted from September 2019 to August 2020. The patients were divided into two groups with those operated within 1 week as emergency group (EG) and those operated after a week but within 6 weeks as delayed group(DG). The outcome is to evaluate post-operative complications, conversion to open, re-admissions, hospital stay, intra-operative blood loss, surgery duration and level of surgeons. Results Among 176 patients, only 88 patients underwent LC. Only 40.9% (36) underwent LC within 1 week of index admission and 12.5% (11) underwent LC after 1 week but within 6 weeks of admission. The remaining 46.5% (41) underwent delayed LC after 6 weeks. 10.6% (5) developed post op complications. Among which only one developed complication in EG and 8.5% (4) developed in DG. Total number of readmissions after LC in both group was 5.5% (5) and 10.2% (9) respectively. Median Length of hospital stay in days (4.03 versus 8.72 days respectively), Duration of surgery was 81(23–153) mins versus 69 (28–122) mins respectively), Intra operative blood loss (64 ml versus 166 ml respectively). Level of surgeon by consultant and Registrar in both groups were 21:6 and 15:5 respectively. None of the patients were converted to open surgery in both group. Conclusion Early LC within 1 week can be performed safely in most patients with AC to minimise the intra-operative blood loss, total hospital stay, post-op complication and readmissions rate.

Surgery for acute cholecystitis in severely comorbid patients: a population-based study on acute cholecystitis

BackgroundInternational guidelines recommend emergency cholecystectomy for acute cholecystitis in patients who are healthy or have mild systemic disease (ASA1-2). Surgery is also an option for patients with severe systemic disease (ASA3) in clinical practice. The study aimed to investigate the risk of complications in ASA3 patients after surgery for acute cholecystitis.Method1 634 patients treated for acute cholecystitis at three Swedish centres between 2017 and 2020 were included in the study. Data was gathered from electronic patient records and the Swedish registry for gallstone surgery, Gallriks. Logistic regression was used to assess the risk of complications adjusted for confounding factors: sex, age, BMI, Charlson comorbidity index, cholecystitis grade, smoking and time to surgery.Results725 patients had emergency surgery for acute cholecystitis, 195 were ASA1, 375 ASA2, and 152 ASA3. Complications occurred in 9% of ASA1, 13% of ASA2, and 24% of ASA3 patients. There was no difference in 30-day mortality. ASA3 patients stayed on average 2 days longer after surgery. After adjusting for other factors, the risk of complications was 2.5 times higher in ASA3 patients than in ASA1 patients. The risk of complications after elective surgery was 5% for ASA1, 13% for ASA2 and 14% for ASA3 patients. Regardless of ASA 18% of patients treated non-operatively had a second gallstone complication within 3 months.ConclusionPatients with severe systemic disease have an increased risk of complications but not death after emergency surgery. The risk is lower for elective procedures, but a substantial proportion will have new gallstone complications before elective surgery.Trial registration: Not applicable.

The impact of obesity on outcomes in patients undergoing emergency cholecystectomy for acute cholecystitis.

BackgroundObesity is a perceived risk factor for poorer surgical outcomes, including increased complication rates and mortality. As obesity rates rise annually, evaluating surgical outcomes in the obese population has become increasingly important. This study examines the impact of obesity on outcomes following emergency laparoscopic cholecystectomy (LC) for acute cholecystitis.MethodsA retrospective review of patients who underwent emergency LC for acute cholecystitis between March 2018 and March 2021 was performed. A total of 326 patients were included and stratified by body mass index (BMI) into two groups: obese (BMI ≥30 kg/m2, n = 156) and non‐obese (BMI <30 kg/m2, n = 170). Primary outcomes included length of stay, time to definitive surgery, and postoperative complications. Secondary outcomes included total operative time and intraoperative findings.ResultsObese patients were younger than non‐obese patients (median, 45 [34.3–56.8] and 48.5 [34.0–66.3] years; p < 0.001) and had a higher prevalence of diabetes (13.5% versus 6.5%; p = 0.034). Higher American Society of Anesthesiologists (ASA) classification (p < 0.001) and operative grading scores were observed in the obese group (76.3% versus 40.6%, p < 0.001), who were more likely to have a distended gallbladder (19.9% versus 11.2%, p = 0.030) and gallstone impaction (23.1% versus 11.8%, p = 0.007) in comparison to the non‐obese group. Length of hospital stay, time to definitive surgery, and postoperative complication rates were similar between groups.ConclusionAlthough obesity is associated with greater technical difficulty during surgery than non‐obese patients, similar postoperative outcomes were achieved. Obesity should not be a contraindication for LC and can be safely performed in the emergency setting.

Comparative Analysis of Models of Care and Its Impact on Emergency Cholecystectomy Outcomes.

Background: The implementation of the acute surgical unit (ASU) model has been demonstrated to improve care outcomes for the emergency general surgery patient in comparison to the traditional "on call" model. Currently, only few studies have evaluated surgical outcomes of the ASU model in patients with acute biliary pathologies. This is the first comparative study of two different emergency surgery structures in the acute management of patients with acute cholecystitis and biliary colic. Methods: A retrospective review of patients who underwent emergency cholecystectomy for acute cholecystitis and biliary colic at two tertiary hospitals between April 2018 and March 2019 was conducted. Primary outcomes included length of hospital stay, time from admission to definitive surgery, and postoperative complications. Secondary outcomes include proportion of cases performed during daylight hours, length of operating time, rate of conversion to open cholecystectomy, and consultant surgeon involvement. Results: A total of 339 patients presented with acute biliary symptoms and were managed operatively. Univariate analysis identified a shorter mean time to surgery in the traditional group compared to the ASU group (29.2 hours versus 43.1 hours; P < .001). There was no difference in mean length of stay, operation duration between models, and postoperative complication rates between groups, with the majority of surgeries performed during daylight hours. The ASU group had a greater proportion of consultant-led cases (48.2% versus 2.5%, P < .001) compared to the traditional group. Conclusion: Patients with acute biliary pathology requiring laparoscopic cholecystectomy achieve equivalent surgical outcomes irrespective of the model of acute surgical care.

Clinical and therapeutic features of acute cholecystitis in diabetic patients.

The present study aimed to compare the clinical, paraclinical, intraoperative findings, and postoperative complications in acute cholecystitis in diabetic patients vs. non-diabetic patients. A 2-year retrospective study was performed on the patients who underwent emergency cholecystectomy for acute cholecystitis between 2017 and 2019 at the 4th Department of Surgery, Emergency University Hospital Bucharest. The diabetic subgroup numbered 46 eligible patients and the non-diabetic one 287 patients. Demographics, the severity of the clinical forms, biological variables (including white cell count, urea, creatinine, coagulation and liver function tests) comorbidity status, surgical approach, postoperative complications, and hospital stay were analyzed. Statistical analyses were performed to assess comparative results between the aforementioned data (SPSS V 13.0). The CCI and ASA risk classes were increased in the diabetic group, with 34.78% of patients having 3 or more associated comorbidities. No statistically significant associations were demonstrated between diabetes and the severity of the cholecystitis and risk for conversion. Postoperatively both minor complications such as surgical site infections and major cardiovascular events were more common in the diabetic subgroup (P=0.0254), well associated with the preoperative status and baseline cardiovascular comorbidities. Laparoscopic cholecystectomy is a safe procedure for diabetic patients, which can provide the best outcomes, by decreasing the risks of surgical wounds. Attentive perioperative care and good glycemic control must be provided to minimize the risk of complications.

Effect of antithrombotic therapy on postoperative outcome of 538 consecutive emergency laparoscopic cholecystectomies for acute cholecystitis: two Italian center's study.

The risk of developing hemorrhagic complications during or after emergency cholecystectomy (EC) for acute cholecystitis (AC) in patients with antithrombotic therapy (ATT) remains uncertain. In this double-center study, we evaluated post-operative outcomes in patients with ATT undergoing EC. We retrospectively evaluated 538 patients who underwent laparoscopic EC for AC between May 2015 and December 2019 at two referral centers. 89 of them (17%) were on ATT. We defined postoperative complication rates, including bleeding, as our primary outcome. Mortality was higher in the ATT group. Morbidity was higher in the ATT group as well; however, the difference was not statistically significant. 12 patients (2%) experienced intraoperative blood loss over 500ml and ten (2%) had postoperative bleeding complications. Two patients (< 1%) experienced both intraoperative and postoperative bleeding. On multivariate analysis, ATT was not significantly associated with worse postoperative outcomes. Antithrombotic therapy is not an independently associated factor of severe postoperative complications (including bleeding) or mortality. However, these patients still represent a challenging group and must be carefully managed to avoid postoperative bleeding complications.

Acute Cholecystitis as a Diagnosis of Mucinous Cystic Neoplasia of the Gallbladder. A Literature Review

Purpose: Mucinous cystic neoplasms (MCNs) of the gallbladder are extremely rare, benign, unilocular or multilocular cystic tumors that contain septations. We present a case diagnosed incidentally after emergency cholecystectomy for acute cholecystitis. Method: 69-year-old woman with epigastric pain of 24 hours of evolution associated with nausea and fever. No jaundice. 14,000 leukocytes, CRP: 33. Normal bilirubin, gamma-GT, and alkaline phosphatase. Positive Murphy's sign. Abdominal ultrasound: acute cholecystitis. Surgical treatment: laparoscopic cholecystectomy, showing acute edematous cholecystitis. No complications in the postoperative period. AP: mucinous cystic neoplasm (MCN) with low-grade dysplasia. Results and conclusions: MCNs of the gallbladder are rare, and no established guidelines for appropriate management have been developed. It´s benign cystic proliferations of the hepatobiliary epithelium. Lesions originate in the liver in 85% of cases and affect women more frequently, with a mean age at presentation of 45 years. Its origin remains unclear. Previous studies have hypothesized that originate from ectopic remnants of embryonal gallbladder tissue and aberrant hamartomatous bile ducts. Discrepancies across the literature exist regarding the malignant potential. Some authors believe that approximately 13% of cystadenomas have dysplastic changes that can progress to a malignant form. If suspected, ultrasound or CT-guided fine needle aspiration for biopsy is generally not recommended as it increases the chances of tumor spread in the peritoneal cavity. The only consistent consensus across the literature is that all suspected MCNs originating in the gallbladder should be imaged, surgically removed, and evaluated under the microscope to determine the nature of the disease.

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.

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.

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.

Effect of antithrombic therapy on bleeding complications in patients receiving emergency cholecystectomy for acute cholecystitis.

The risk of developing hemorrhagic complications during or after emergency cholecystectomy in patients with antithrombic therapy (ATT) remains uncertain. In this study, we evaluate outcomes in patients with ATT undergoing emergency cholecystectomy and assess the relevance between ATT and perioperative complications including bleeding complications. We retrospectively evaluated 296 patients who were diagnosed as acute cholecystitis and underwent emergency cholecystectomy between 2005 and 2017. One hundred and thirty-three of them (45%) were on ATT. The primary outcome measures were intraoperative blood loss over 500ml and postoperative complications including bleeding complications. This study was approved by our institutional review board (#13072904). There were 23 patients (8%) who experienced intraoperative blood loss over 500ml and nine postoperative bleeding complications (3%). Multivariable analyses showed that male sex (P = 0.027), Performance Status 2-4 (P = 0.031) and grade II or III acute cholecystitis (P = 0.033) were independent risk factors for intraoperative bleeding over 500ml, whereas not single antiplatelet therapy (APT) use but multiple APT (P = 0.034) and anticoagulation therapy (ACT) (P = 0.032) were independently associated with postoperative bleeding complications. Additionally, laparoscopic surgery, but not ATT, was a significant prognostic factor for severe postoperative complications. Single APT was not remained as an independently associated factor of intraoperative excessive bleeding or severe postoperative complications including bleeding complications. However, patients treated with multiple APT or ACT still represent a challenging group and must be carefully managed to avoid postoperative bleeding complications.

Differentiation between gallbladder cancer with acute cholecystitis: Considerations for surgeons during emergency cholecystectomy, a cohort study

PurposeGallbladder cancer (GBCA) is an uncommon malignancy with vague and non-specific symptoms. GBCA is sometimes diagnosed after emergency cholecystectomy for acute cholecystitis. We investigated the differential diagnosis between GBCA with acute cholecystitis. Materials and methodsThirteen patients were diagnosed with GBCA after emergency cholecystectomy carried out for acute cholecystitis. A radiologist who was blinded to the final diagnoses retrospectively reviewed the computed tomography (CT) scans of the patients with GBCA and 25 patients with acute cholecystitis. We retrospectively reviewed the medical records of these patients and compared the clinical characteristics and CT findings between patients with GBCA and those with acute cholecystitis. We also investigated the prognostic factors in patients with GBCA who underwent emergency cholecystectomy. ResultsGallbladder (GB) stones were found more often in patients with acute cholecystitis (n = 17, 68%) than in patients with GBCA (n = 7, 53.8%) (p = 0.486). Patients with GBCA showed typical GB masses or focal enhanced wall thickening when compared to diffuse wall thickening in patients with acute cholecystitis. Some GBCA patients showed irregular mural thickening and GB enhancement. Differentiating carcinoma from acute cholecystitis might sometimes not possible, but the latter group of patients had significantly lower C-reactive protein (CRP) levels (p = 0.033) and less regional fat stranding (p = 0.047). Survival was significantly affected by aggressive tumor characteristics (lymphatic invasion [p = 0.025], depth of tumor invasion [p = 0.004]) or R0 resection (p = 0.013) rather than bile spillage (p = 0.112). ConclusionsSurgeons deciding on emergency cholecystectomy for elderly patients with acute cholecystitis must suspect GBCA in patients with a low CRP level, irregular mural thickening or enhancement of GB without regional fat stranding.

Emergency Cholecystectomy for Patients on Antiplatelet Therapy

The use of antiplatelet therapy (APT) and/or anticoagulant therapy (ACT) continues to increase due to the aging population. Because the management of patients with acute cholecystitis receiving APT/ACT is still unclear, surgeons are sometimes faced with the difficult decision to delay surgery. We aimed to analyze characteristics and surgical risks of patients who underwent emergency cholecystectomy for acute cholecystitis without discontinuing APT. We conducted a retrospective review of 113 patients between 2006 and 2014. Treatment outcomes among 13 patients who underwent cholecystectomy without discontinuing APT (the cAPT group), 11 patients who discontinued APT and ACT (the D group), and 89 patients who did not receive preoperative APT and/or ACT (the No APT group) were compared. There were no significant differences in intraoperative blood loss, conversion to open surgery, and bleeding-related complications. However, the incidence of intraoperative blood transfusion was higher in the cAPT group (P = 0.04). They presented with severe local inflammation; thus, it was difficult to stop bleeding from the gallbladder bed. Hemostatic tools for liver surgery were used to control bleeding. Emergency cholecystectomy was tolerable for patients with acute cholecystitis while continuing APT. However, in case of severe local inflammation, there is a greater risk for massive hemorrhage.

Percutaneous cholecystostomy for acute cholecystitis in high-risk elderly patients

Emergency cholecystectomy for acute cholecystitis (AC) is associated with high morbidity and mortality rates in elderly patients with significant comorbidities. The aim of this study was to evaluate percutaneous cholecystostomy for AC in elderly patients with various coexisting diseases. We retrospectively reviewed the records of 4311 patients with AC treated in Mackay Memorial Hospital between the years 2000 and 2015. The clinical course of AC was compared between nonelderly (age ≤70 years) and elderly patients (age>70 years). In total, 67 elderly patients and 32 nonelderly patients received percutaneous cholecystostomy. The rate of percutaneous cholecystostomy increased between the years 2011 and 2015 (from 2.5% to 12.2%) and this procedure was more common in the elderly group (p=0.009). In addition, the comorbidities of ischemic heart disease and chronic kidney disease were higher in elderly than in nonelderly patients (p=0.014 and p=0.015, respectively). The American Society of Anesthesiologists' classification was higher in the elderly patients (p=0.001). The overall survival-free rate of recurrent cholecystitis in patients who did not receive cholecystectomy was not significantly different in the two groups. When compared with emergent cholecystectomy in high-risk elderly patients, percutaneous cholecystostomy resulted in reduced hospital stay and morbidity (p=0.002 and p=0.013, respectively). Our results demonstrate that percutaneous cholecystostomy has become a common and early treatment for AC in high-risk elderly patients with ischemic heart disease or chronic kidney disease. Identifying such patients will possibly improve clinical outcomes, reduce hospital stay and morbidity, and facilitate delayed laparoscopic cholecystectomy.

Use of dynamic CT attenuation value for diagnosis of acute gangrenous cholecystitis

ObjectiveTo determine if the increase in transient focal enhancement of the liver adjacent to the gallbladder seen on dynamic computed tomography (CT) is greater in gangrenous cholecystitis than in nongangrenous cholecystitis by determining the CT attenuation value. MethodsWe retrospectively reviewed the medical records of 57 patients who underwent emergency cholecystectomy for acute cholecystitis and preoperative dynamic CT scans between March 2011 and April 2016. Based on the pathology findings, patients were assigned to a gangrenous group or a nongangrenous group. The CT attenuation ratio (AR) was defined as the ratio of the maximum CT attenuation value in the region of interest in segment 5 (liver parenchyma adjacent to the gallbladder) and that in the control region of interest in segment 8. The patient characteristics and CT findings were compared between the groups. The appropriate AR of the arterial phase (ARAP) cutoff value for a diagnosis of gangrenous cholecystitis was determined using receiver operating characteristic curve analysis. ResultsThe ARAP was significantly higher in the gangrenous group than in the nongangrenous group (P < .001); the area under the receiver operating characteristic curve was 0.849. The ARAP cutoff value of 1.46 had a sensitivity and specificity of 84.6% and 83.9%, respectively (odds ratio, 21.17; 95% confidence interval, 4.90-118.91), and ARAP ≥1.46 was significantly correlated with a diagnosis of gangrenous cholecystitis (P < .001). ConclusionsThe increase in transient focal enhancement of the liver adjacent to the gallbladder during the arterial phase of dynamic CT was greater in gangrenous cholecystitis than in nongangrenous cholecystitis.

Effect of Diabetes on Outcomes in Patients Undergoing Emergency Cholecystectomy for Acute Cholecystitis

In this study, one of the most prevalent diseases meets one of the most frequently performed operations. This topic is becoming more and more important because of the increasing age of the surgical population, paralleling the increasing incidence of diabetes. Karamanos et al. [1] analyzed data collected between 2004 and 2010 in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, focusing on 5,460 patients who underwent emergency inpatient cholecystectomy for acute cholecystitis. The main aim of the study was to identify the prevalence of diabetes in this patient group and explore its effect on surgical outcomes. Multivariate analysis revealed significantly more adverse events in patients with diabetes than in nondiabetics, particularly regarding mortality, preoperative gallbladder perforation, and infectious complications. In light of the large database and robust multivariate analysis, the authors provide relevant support for their hypothesis. Of interest is the strong impact of diabetes mellitus on the presentation of cholecystitis, with a significantly increased incidence of preoperative gallbladder perforation. Potential causal interactions between the incidence of acute cholecystitis and diabetes will hopefully be addressed in future studies. Another interesting finding is the impact of insulin use on local and systemic infections compared to its effect on diabetic patients given oral medication and patients without diabetes mellitus. The elevated incidence of infections is unlikely to be explained by the higher incidence of perforations and longer hospital stays. Potentially complex interactions between diabetes and other aspects of the metabolic syndrome—obesity, fatty liver disease, consequences of arteriosclerosis—may influence the incidence of these outcome parameters. The impact of diabetes on some clinical outcome parameters may be explained in part by differences between the populations because despite being extensive multivariate analysis might not entirely correct for all factors that may have a causal effect on the observed events. The data of this study pave the way for new studies that address therapeutic aspects in patients with diabetes undergoing laparoscopic cholecystectomy. Optimal blood glucose levels and the intensity of the insulin treatment are of particular clinical interest in this population. With our current knowledge, it is unclear if local and systemic complications are altered by different approaches of intraoperative and postoperative glucose control, including tight glycemic control or standard care [2]. The present article addresses a frequent and highly relevant clinical scenario. In future, surgeons need to investigate further the relevance of the metabolic syndrome and associated diseases to the pathogenesis, outcomes, and clinical management of their patient population.

PTU-088 The microflora of bile after intraoperative aspiration of the gallbladder during cholecystectomy for acute cholecystitis

IntroductionEmergency cholecystectomy for the management of acute cholecystitis is now common. In order to facilitate this procedure it can be helpful to decompress the gallbladder by aspirating its contents. The...

Acute acalculous cholecystitis and gall bladder perforation induced by &lt;i&gt;Salmonella enterica&lt;/i&gt; serovar typhi

Salmonella Typhi is a causative agent of enteric fever, which is an ongoing public health problem in urban areas of the Kathmandu valley in Nepal. It is estimated that approximately 5 % of people in an endemic enteric fever area may asymptomatically carry Salmonella Typhi in the gall bladder. Here we describe a rare clinical manifestation of chronic Salmonella carriage. A 40 year old male resident of Kathmandu underwent an emergency cholecystectomy for acute cholecystitis and gall bladder perforation. No stone was identified but Salmonella Typhi was cultured from the gall bladder. Key Words: Acalculous cholecystitis, perforation, Salmonella Typhi. DOI: 10.3126/joim.v31i3.3002 Journal of Institute of Medicine, December, 2009; 31(3)63-65

Laparoscopic Cholecystostomy Is A Safe And Effective Alternative in Critically Ill Patients with Acute Cholecystitis: Two Cases

Emergency cholecystectomy for acute cholecystitis in critically ill patients with organ failure and sepsis carries a high risk of morbidity and mortality. Temporizing interventions such as laparoscopic cholecystostomy can help the patient to recover from the critical illness by deferring the definitive procedure to a later, safer period. We describe our experience of laparoscopic cholecystostomy performed in two critically ill patients. In the first case, a 56-year-old man with hypertension, diabetes, and ischemic heart disease, was admitted for evaluation of malena. During the course of his stay, he developed acute calculous cholecystitis, acute renal failure, and right pleural effusion. In the second case, a 68-year-old man presented with diabetes, hypertension, diabetic nephropathy, acute chronic renal failure, and acute calculous cholecystitis. Both patients failed to improve with conservative measures and underwent laparoscopic cholecystostomy under local anesthesia and sedation in view of severe comorbidities and sepsis. Both patients recovered from sepsis. Laparoscopic cholecystectomy was performed uneventfully after six and eight weeks, respectively, and both patients were doing well at one-year follow-up.

Routine laparoscopic cholecystectomy after endoscopic sphincterotomy for choledocholithiasis in octogenarians: is it worth the risk?

No unanimous consensus has been reached as to the need for routine laparoscopic cholecystectomy (LC) after endoscopic sphincterotomy (ES) for choledocholithiasis in very elderly patients, who are considered as high-risk subjects for surgery. From 1991 through 1997, 170 patients were referred to undergo preoperative ES and routine LC for common bile duct (CBD) stones. The results for 27 patients (age 80 years or older) were compared with those achieved for younger patients. Successively, in a retrospective case-control study, the results for the selected patients were compared with those for 27 very elderly patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), but did not receive LC. The mean follow-up period was 126 months. Octogenarians showed longer surgery time (79 vs 51 min) and postoperative hospital stay (2.8 vs 1.2 days), as well as more early low-grade complications (15% vs 3%), whereas there were no differences in conversion rate or serious complications. Recurrent symptoms or complications developed in 48% of octogenarians not undergoing routine LC, and 30% finally needed surgery. One patient in the control group died after emergency cholecystectomy for acute cholecystitis. The results of surgery were significantly poorer for the control group. Although a "wait-and-see" policy allowed two-thirds of LCs to be avoided in octogenarians, biliary-related events developed for every second patient, often requiring delayed surgery, with poorer results. Sequential treatment (ES followed by elective LC) is a safe procedure for octogenarians, and should be considered as a standard, definitive treatment for cholecystocholedocholithiasis even after the age of 80 years.