Episode Of Cholecystitis Research Articles

Multiple cystic artery pseudoaneurysms in a COVID-19 patient

Cystic artery pseudoaneurysm are very rare and less than one hundred cases have been reported around the world. Usually, they are consequences of laparoscopic cholecystectomy or can be found after an episode of cholecystitis. The most common clinical presentation is with right upper quadrant pain and haemobilia or other signs of upper gastrointestinal bleeding. The treatment usually involves urgent angioembolization followed by cholecystectomy. We presented the case of an 81-year-old male who, during the recovery in our hospital for COVID-19 disease, showed a septic state with fever and right upper quadrant pain. The patient underwent an abdomen CT scan that showed a 16 mm pseudoaneurysm of cystic artery. The angioembolization was performed with the finding of multiple pseudoaneurysms of hepatic and cystic artery. The aim of our case report was to show this rare pathological condition and to clarify the best management possible, especially in patients with multiple comorbidities.

OGBN P17 Preoperative scoring system in predicting difficulty in laparoscopic cholecystectomy

Abstract Background For a long time now, laparoscopic cholecystectomy (LC) has been the gold standard treatment for gallstone disease. Having said that, approximately 2–15% of attempted LCs have to be converted to an open procedure due to various difficulties faced while performing the procedure. This study has been structured and planned taking into account the various difficult situations a laparoscopic surgeon faces during laparoscopic cholecystectomy and assigns an objective outlook to the difficulty in the form of a difficulty score. The main objective of the study is to evaluate a scoring system in predicting difficulty in laparoscopic cholecystectomy. Methods Patients with symptomatic gallstone disease that were admitted in SU-1 of Holy family hospital during the above period were included in the study. For collection of data, a pre-tested questionnaire was used after taking informed oral consent. On admission, one day before the surgery, preoperative points were allotted on basis of patient's history, examination, hematological (CBC), biochemical (LFTs) and ultrasound results. Preoperative scores up to 5 was summed up as easy, scores 6–10 as difficult, 11–16 as very difficult. Calculated sample size was 229. SPSS version 22 and WHO Anthro calculator version 3.2.2 were used for data entry and analysis Results Among 230 patients that were included in the study, 188 were female and 42 were male. Various risk factors were found to have significant positive correlation with intraoperative difficulty during cholecystectomy. These are: Previous episodes of cholecystitis and pancreatitis (p=0.00), ERCP (p=0.00), tenderness in right hypochondrium (p=0.002), hepatitis serology (p=0.02), and Total Leukocyte Count (p=0.006). Whereas the following factors had insignificant relation with intraoperative difficult cholecystectomy: ALT and ALP (p>0.05, p=0.06 and 0.26 respectively) and hepatitis serology (p=0.406). A significant correlation was found between preoperative and intraoperative scores of the patients (p=0.003) indicating that preoperative assessment of various risk factors can predict the level of difficulty of cholecystectomy and its conversion to open cholecystectomy. Conclusions We may conclude that the scoring system evaluated in our study is a sturdy, reliable and useful benchmark to predict difficult cases. Preoperative prediction of the risk factors of conversion or difficulty of operation is an important point for operative planning and the high-risk patients may be informed accordingly.

Conversion from laparoscopic cholecystectomy to open surgery reasons and possible risks: A single center experience

Laparoscopic cholecystectomy has grown in popularity since its introduction and has become the gold standard surgical method for treating cholelithiasis. It has several advantages over open surgery, including less postoperative pain, a shorter hospital stay, a faster return to normal activities, and better cosmetic results. Converting from laparoscopic to open surgery may be necessary in some cases, either to prevent or treat difficulties. The current conversion rate from laparoscopic to open surgery is between 2 and 15%. Open surgery may be required due to advanced age, male gender, acute cholecystitis, anatomical alterations of the gallbladder or biliary system, obesity, bleeding, adhesions, and biliary tract injuries. Our study aimed to determine the risk factors that influence the conversion to open surgery. Between January 2018 and December 2021, we analyzed 921 cholecystectomy cases retrospectively at the Recep Tayyip Erdogan University Training and Research Hospital. We excluded twenty-three of these patients from the study once it was revealed that they had undergone direct open surgery or an open cholecystectomy while undergoing another operation. Twenty-eight patients had a laparoscopic cholecystectomy but had to convert to open surgery due to difficulties. We obtained the demographic and clinical information about the patients from hospital records. We analyzed whether these characteristics had a significant impact on the conversion from laparoscopic to open surgery by comparing the data of an equal number of randomly selected laparoscopic completed patients. The most common reason for conversion from laparoscopic to open cholecystectomy was adhesion due to inflammation, which accounted for 3.04 percent of conversions. In our study, cholecystitis symptoms, including multiple calculi on ultrasonography and increased wall thickness, and raised GGT and ALP levels, all affected the decision to convert to open surgery. We discovered no significant associations between gender, pancreatitis, cholangitis, stone size, and ASA score. The duration of hospitalization was considerably longer in the group that converted to open surgery. Increased rates of conversion to open surgery are associated with advanced age, obesity, previous episodes of cholecystitis, and adhesions due to previous abdominal incisions, presence of cholecystitis findings such as multiple calculi on ultrasonography, increased wall thickness and high GGT and ALP values. The most influential factor in converting to open surgery appears to have previously had cholecystitis. A preoperative patient examination can aid in predicting the risk of exposure.

Bowel obstruction secondary to gallstone ileus within a strangulated inguinal hernia: Report of a rare diagnosis.

IntroductionGallstone ileus is rare and inguinal hernias are common causes of intestinal obstruction but combination of them is a very rare cause of intestinal obstruction. It is accepted that in patients with severe comorbidities surgeons can manage inguinal hernias and gallstone conservatively. In this article we report a patient with gallstone and inguinal hernia that managed with conservatively management because of heart failure but admitted with complication of gallstone and hernia and treated successfully.Case presentationAn 80-year-old woman with a history of heart failure and two bouts of acute cholecystitis, who presented with pain and swelling in the inguinal region and obstructive symptoms. And due to the urgent nature of the condition, she underwent surgery.ConclusionOne of the rare complications of gallstones is cholecystoduodenal fistulas, especially in patients whose episodes of cholecystitis are treated medically. Early diagnosis and appropriate surgical management in these circumstances reduce the mortality and morbidity.

Preoperative scoring system in predicting difficulty in laparoscopic cholecystectomy.

Objective: To evaluate a scoring system in predicting difficulty in laparoscopic cholecystectomy. Study Design: Non-Randomized Prospective study. Setting: Surgical Unit-1 of Holy Family Hospital, Rawalpindi. Period: January 2018 to September 2018. Material & Methods: Patients with symptomatic gallstone disease that were admitted in SU-1 of Holy family hospital during the above period were included in the study. For collection of data, a pre-tested questionnaire was used after taking informed oral consent. On admission, one day before the surgery, preoperative points were allotted on basis of patient’s history, examination, hematological (CBC), biochemical (LFTs) and ultrasound results. Preoperative scores up to 5 was summed up as easy, scores 6 – 10 as difficult, 11 – 16 as very difficult. Calculated sample size was 229. SPSS version 22 and WHO Anthro calculator version 3.2.2 were used for data entry and analysis. Results: Among 230 patients that were included in the study, 188 were female and 42 were male. Various risk factors were found to have significant positive correlation with intraoperative difficulty during cholecystectomy. These are: Previous episodes of cholecystitis and pancreatitis (p=0.00), ERCP (p=0.00), tenderness in right hypochondrium (p=0.002), hepatitis serology (p=0.02), and Total Leukocyte Count (p=0.006). Whereas the following factors had insignificant relation with intraoperative difficult cholecystectomy: ALT and ALP (p>0.05, p=0.06 and 0.26 respectively) and hepatits serology (p=0.406). A significant correlation was found between preoperative and intraoperative scores of the patients (p=0.003) indicating that preoperative assessment of various risk factors can predict the level of difficulty of cholecystectomy and its conversion to open cholecystectomy. Conclusion: We may conclude that the scoring system evaluated in our study is a sturdy, reliable and useful benchmark to predict difficult cases. Preoperative prediction of the risk factors of conversion or difficulty of operation is an important point for operative planning and the high-risk patients may be informed accordingly.

Gall stone ileus: An uncommon cause of small bowel obstruction at an unusual age: A Case report

Gallstone ileus is a rare complication of cholelithiasis. It is an uncommon cause of a mechanical small bowel obstruction. Repeated episodes of cholecystitis results adhesion of the gallbladder to the small bowel (usually duodenum) with eventual formation of cholecystoenteric fistula via which gallbladder stone enters the small bowel. It is most commonly seen in elderly females hence linked with high morbidity & mortality. Computed tomography (CT) imaging have made it easier to diagnose gallstone ileus effectively. Surgical intervention results in prompt relief of obstructive symptoms by removing stone & repairing fistula. Here is a case of gall stone ileus in a 27-year-young gentleman who presented to us with history of acute abdomen & without any comorbidities or biliary manifestation.

106 Laparoscopic Cholecystectomy Following an Episode of Cholecystitis: Are We Meeting the NICE Guidance?

Abstract Aim On average, acute cholecystitis is responsible for 3% of admissions to emergency general surgery wards. NICE Guideline [QS104] states that adult patients admitted with acute cholecystitis should be offered a laparoscopic cholecystectomy within one week of diagnosis. This study aims to assess adherence to this guideline in a medium size district general hospital. Method Data was gathered retrospectively from contemporaneous electronic-based patient record system. Patients with a first case of cholecystitis within a 486-days’ time period were included; incorrect coding or repeat admissions within our time period were excluded. Data was gathered on admission length, aetiology, investigations undergone and procedure type (open vs laparoscopic). Additionally, for those that underwent a cholecystectomy, the length of time between diagnosis and operation was calculated. Results 72 adults were admitted with acute cholecystitis in the 486-day study period. The median length of stay was 3 days. The commonest aetiology was either gallstones or unknown (47.2% of cases each), followed by bacterial infection (5.6%). 9 patients (12.5%) underwent laparoscopic cholecystectomy, and 10 (13.9%) were placed on a waiting list. The remaining 53 (73.6%) had no mention of being listed for surgery in their notes. Of those undergoing laparoscopic cholecystectomy (n = 9), none were within the recommended one-week period from time of diagnosis. Conclusions Over 486 days, no patients diagnosed with acute cholecystitis in our unit were being treated according to NICE guidance. We therefore recommend reinstating the hot gallbladder list at this hospital, which will enable surgeons to deliver the biliary emergency service advocated by the national guidelines.

Gallbladder Cryoablation: Clinical and Technical Considerations

AbstractAs many as 500,000 cholecystectomies are performed per year in the United States. Frail patients are at higher risk from cholecystectomy, with reported postoperative complication and mortality rates as high as 31 and 5% in patients older than 75 years. Percutaneous cholecystostomy drainage is commonly employed in high-risk patients with cholecystitis, with over 12,000 cases performed annually. Cholecystostomy, however, is not a definitive treatment, with up to 30% of patients having a recurrent episode of cholecystitis within 4 months after tube removal. Gallbladder cryoablation has emerged as a minimally invasive procedure that achieves transmural gallbladder wall necrosis in a single session resulting in gallbladder fibrosis and involution. Early clinical data have been promising, with reported technical success of 86% and clinical success of 100% at up to 500 days of follow-up. Several challenges and unknowns remain, however, including optimal patient selection and procedural technique, the potential need for adjunct procedures to occlude the cystic duct, the implications of the immunostimulatory effects of cryoablation, and the impact of the presence of gallstones on outcomes. This article reviews the rationale behind gallbladder cryoablation, updates early clinical outcomes, and discusses the challenges that remain for the adoption of the technique for the treatment of benign gallbladder disease.

Recurrent anaphylaxis owing to chronic cholecystitis

Anaphylaxis is a severe, life-threatening systemic hypersensitivity reaction, triggered by variable allergic and nonallergic exposures.1 Here, we report a case of recurrent anaphylaxis coinciding with flares of chronic cholecystitis. We hypothesize that in rare cases, inflammatory mediators released during episodes of cholecystitis can trigger anaphylaxis.

S1560 An Unusual Case of Gallstone Ileus 6 Years Post-Cholecystectomy

Introduction: Gallstone ileus is a rare condition associated with high mortality that is generally caused by the passage of a stone through a cholecystoenteric fistula and subsequently causes an intestinal obstruction. It is very rare for patients to have gallstone ileus many years post-cholecystectomy. We present a case of gallstone ileus that is interesting for a couple reasons: (1) patient developed the ileus 6 years post-cholecystectomy and (2) there is no objective evidence of a cholecystoenteric fistula. Case Description/Methods: 80-year-old woman with a history of cholecystitis (requiring cholecystectomy 6 years ago) presented with nausea, vomiting and decreased appetite for 6 days. Exam revealed tenderness on palpation in the right upper quadrant. Labs revealed mild leukocytosis. An x-ray revealed a lamellated density within the right lower quadrant measuring 4.8 x 2.0 cm and multiple dilated loops of small bowel in the visualized abdomen measuring up to 6.7 cm. A CT scan of the abd/pelvis with contrast revealed a lamellated density within the mid to distal ileum with distally collapsed loops of small bowel and proximately dilated loops of bowel measuring up to 5.7 cm. Gallbladder was absent and no pneumobilia was noted. The patient underwent exploratory laparotomy. Small bowel resection was performed with removal of the foreign body. The foreign body was a green, smooth ovoid calculus that was 6.5 x 3.0 x 2.5 cm in size and confirmed as a gallstone via microscopic examination. The patient did well post-operatively and was discharged on day 9. Discussion: In patients presenting with small bowel obstruction, about 0.5% of these cases are due to a gallstone ileus. The entry of the gallstone into the small intestine is typically through a biliary enteric fistula which occurs in about 2-3% of all cases of cholecystitis. We postulate that the patient developed a cholecystoenteric fistula after her episode of cholecystitis 6 years ago. She may have passed the large gallstone immediately afterwards, but may have been lodged within a diverticulum until prior to the onset of her symptoms when it dislodged and caused an obstruction. Although our patient did not exhibit evidence of pneumobilia, it has been reported that it is present in only 30% of cases so this should not exclude the presence of a fistula. It is important to recognize that patients may develop gallstone ileus years after a cholecystectomy and to not delay diagnosis or treatment in patients who present with symptoms of gallstone ileus.Figure 1.: Figure A. X-ray demonstrating lamellated density in right lower quadrant, identified by red arrows. Figure B. Computed tomography scan demonstrating lamellated density in mid to distal ileum, identified by red arrow.

Safety and efficacy of bexarotene in patients with relapsing-remitting multiple sclerosis (CCMR One): a randomised, double-blind, placebo-controlled, parallel-group, phase 2a study

Progressive disability in multiple sclerosis occurs because CNS axons degenerate as a late consequence of demyelination. In animals, retinoic acid receptor RXR-gamma agonists promote remyelination. We aimed to assess the safety and efficacy of a non-selective retinoid X receptor agonist in promoting remyelination in people with multiple sclerosis. This randomised, double-blind, placebo-controlled, parallel-group, phase 2a trial (CCMR One) recruited patients with relapsing-remitting multiple sclerosis from two centres in the UK. Eligible participants were aged 18-50 years and had been receiving dimethyl fumarate for at least 6 months. Via a web-based system run by an independent statistician, participants were randomly assigned (1:1), by probability-weighted minimisation using four binary factors, to receive 300 mg/m2 of body surface area per day of oral bexarotene or oral placebo for 6 months. Participants, investigators, and outcome assessors were masked to treatment allocation. MRI scans were done at baseline and at 6 months. The primary safety outcome was the number of adverse events and withdrawals attributable to bexarotene. The primary efficacy outcome was the patient-level change in mean lesional magnetisation transfer ratio between baseline and month 6 for lesions that had a baseline magnetisation transfer ratio less than the within-patient median. We analysed the primary safety outcome in the safety population, which comprised participants who received at least one dose of their allocated treatment. We analysed the primary efficacy outcome in the intention-to-treat population, which comprised all patients who completed the study. This study is registered in the ISRCTN Registry, 14265371, and has been completed. Between Jan 17, 2017, and May 17, 2019, 52 participants were randomly assigned to receive either bexarotene (n=26) or placebo (n=26). Participants who received bexarotene had a higher mean number of adverse events (6·12 [SD 3·09]; 159 events in total) than did participants who received placebo (1·63 [SD 1·50]; 39 events in total). All bexarotene-treated participants had at least one adverse event, which included central hypothyroidism (n=26 vs none on placebo), hypertriglyceridaemia (n=24 vs none on placebo), rash (n=13 vs one on placebo), and neutropenia (n=10 vs none on placebo). Five (19%) participants on bexarotene and two (8%) on placebo discontinued the study drug due to adverse events. One episode of cholecystitis in a placebo-treated participant was the only serious adverse event. The change in mean lesional magnetisation transfer ratio was not different between the bexarotene group (0·25 percentage units [pu; SD 0·98]) and the placebo group (0·09 pu [0·84]; adjusted bexarotene-placebo difference 0·16 pu, 95% CI -0·39 to 0·71; p=0·55). We do not recommend the use of bexarotene to treat patients with multiple sclerosis because of its poor tolerability and negative primary efficacy outcome. However, statistically significant effects were seen in some exploratory MRI and electrophysiological analyses, suggesting that other retinoid X receptor agonists might have small biological effects that could be investigated in further studies. Multiple Sclerosis Society of the United Kingdom.

Gallstone ileus associated with cholecystogastric fistula: Case report, diagnosis and surgical treatment.

IntroductionGallstone Ileus is a rare complication of cholelithiasis, associated with multiple episodes of cholecystitis, with the formation of adhesions and fistulas between the gallbladder and adjacent organs. Its diagnosis is difficult, requiring complementary imaging tests such as computed tomography or radiography.Presentation of caseFemale patient, with intestinal obstruction for 7 days, associated with abdominal pain and previous episodes of pain in the right hypochondrium for 3 months. Abdominal CT scan identified aerobilia, gallstone impacted in the ileocecal valve and small loop dilatation, in addition to a probable cholecystogastric fistula. Opted for exploratory laparotomy, enterolithotomy and fistula correction in one surgical time.DiscussionGallstone ileus is rare among the complications of cholelithiasis, in addition to the fact that cholecystogastric fistula is associated with gastric pylorus obstruction and not impaction on the ileocecal valve. Imaging tests are useful to complement the diagnosis, and if Rigler's triad is present, the suspicion of gallstone ileus is increased. The presence of fistula between the gallbladder and stomach presents a frequency between 0 and 13.3%. There is no gold standard treatment for gallstone ileus, but surgery options for each type of patient and severity level.ConclusionThere is no definitive protocol for optimal surgical treatment for biliary ileus, but the possibility of enterolithotomy associated with cholecystectomy and fistula correction can be evaluated in selected patients.

Gallbladder, Gallstones, and Diseases of the Gallbladder in Children.

1. Deborah A. Goldman, MD* 1. *Pediatric Institute, Cleveland Clinic Foundation, Cleveland, OH Pediatric providers should have a heightened awareness of gallbladder diseases in children, which have increased in incidence during the past few decades. After completing this review, readers should be able to: 1. Understand gallbladder issues in children. 2. Understand what pediatric population is at increased risk for cholelithiasis. 3. Be able to recognize the signs and symptoms associated with gallstone disease in children. 4. Know what treatments are available and when to refer for surgery. 5. Understand the concepts associated with other diseases of the gallbladder. There is an increased incidence of gallstones in the pediatric population, most likely due to the rise of childhood obesity. There needs to be increased awareness of gallstones in this population and of other risk factors associated with gallstone formation in children. Diseases of the gallbladder have been known to occur since antiquity, with models of the gallbladder and biliary tree dating back thousands of years. In fact, gallstones have been found in mummies from ancient Egypt. Some historians have even postulated that Alexander the Great died of an acute episode of cholecystitis. Although this organ has been described for centuries in historical medical accounts, it has only been in the past 100 years that the function and diseases of the gallbladder have been better recognized. The incidence of these disorders is relatively uncommon in children compared with adults. However, during the past several decades there has been increased recognition of diseases of the gallbladder, including gallstones, in the pediatric population. This may stem from the abrupt rise in childhood obesity, which carries an increased risk of gallstone formation. Therefore, there needs to be awareness among pediatric providers about gallbladder disease …

ASSESSMENT OF SURGICAL OUTCOME FROM LAPAROSCOPIC VERSUS OPEN CHOLECYSTECTOMY DURING 1ST WEEK OF ACUTE CHOLECYSTITIS

Background: Acute Calcular Cholecystitis (A.C) is inflammation of the gallbladder and is the most common complication of gallstones, requiring hospital admission and prompt intervention. Its Symptoms include right upper abdominal pain, nausea, vomiting, and occasionally fever. Often gallbladder attacks (biliary colic) precede acute cholecystitis without appropriate treatment, recurrent episodes of cholecystitis are common. Complications of acute cholecystitis include gallstone pancreatitis, common bile duct stones, and inflammation of the common bile duct.Aim of The Work: To assess surgical outcome from laparscopic and open cholecystectomy in acute calcular cholecystitis by assessment and differentiate between both of them in these parameters as regards: 1-Hospital stay, 2-Wound infection, 3-Bilary fistula, 4-Missed stone, 5-intestinal injury.Patients and Methods: Type of Study: prospective clinical trial. Study Setting: This study will be carried out, at Ain Shams hospitals. Study Period: This study will be carried out during the period between October2018 and October 2019. Study Population: This study will include 30 patients with diagnosis of acute calcularcholycystitis.Results: The present study was a prospective, clinical, trial that included30 patients diagnosed with acute calcular cholecystitis attended to surgery theatre at Ain Shams hospital. The patients were divided into two groups: Group I including 15 patients underwent laparoscopic cholecystectomy during the first week of their presentation. Group II including 15 patients underwent open cholecystectomy during the first week of their presentation.Conclusion: Cholecystectomy during 1st week of acute cholecystitis should be attempted by laparoscopy at first in condition that there are no complications as gangerenous gall bladder. as, post-operative morbidity and hospital stay are reduced by laparoscopic cholecystectomy. Moreover, intestinal injury and wound infection rate are reduced by laparoscopy. A positive trend exists in operating time favoring laparoscopy, however more studies are necessary. Severe hemorrhage and bile leakage rate are not influenced by the technique.

Is subtotal cholecystectomy safe and feasible? Short- and long-term results.

Cholecystectomy is one of the most commonly performed surgical procedures. However, it may result in some unpleasant conditions such as bile duct injury (BDI), bile leak, and vessel injury. Subtotal cholecystectomy (SC), which has been introduced as an alternative method for reducing the complication rates, has been reported to have lower risk of BDI when compared to total cholecystectomy. This study aimed to evaluate the indications for SC, its early and late complications and their management, and the risk factors affecting the bile leak. Fifty-seven patients who underwent SC were included in the study, and their medical records were retrospectively reviewed. Thirty-three patients were male (57.9%) and the mean age was 64.84 ± 11.35 (range: 29-86). All patients had at least one episode of cholecystitis. Forty-seven (82.5%) patients underwent surgery under emergency conditions. Postoperative bile leak/fistula, surgical site infection, and fluid collection were developed in 12 (21.1%), eight (14%), and six (10.5%) patients, respectively. Leaving the remnant tissue pouch open, presence of comorbidity and emergency operative condition were found to increase the risk of leak development (P < .001). During the average follow-up of 49 months (range: 13-98), symptomatic choledocholithiasis, symptomatic gallstones in the remnant tissue, and incisional hernia were detected within the first year of surgery in three (5.3%), four (7%), and seven (12.3%) patients, respectively. Although SC is not an equivalent to total cholecystectomy, its vital benefit of lowering the risk of BDI should be considered in difficult cases.

Experience With Teduglutide in Pediatric Short Bowel Syndrome: First Real-life Data.

The aim of the study was to describe the experience with teduglutide of several Spanish hospitals in pediatric patients with SBS (SBS). Seventeen pediatric patients with intestinal failure associated with SBS were treated with teduglutide. Patients received 0.05 mg · kg · day of subcutaneous teduglutide. Patients' demographics and changes in parenteral nutrition (PN) needs, fecal losses, and citrulline level initially and at 3, 6, and 12 months were collected, as well as any adverse events. Patients were receiving 55 ml · kg · day and 33 kcal · kg · day of parenteral supplementation on average at baseline (2 patients received only hydroelectrolytic solution). A total of 12/17 patients achieved parenteral independence: 3 patients after 3 months of treatment, 4 patients at 6 months, and 5 after 12 months. One patient discontinued treatment 1 year after the beginning as no changes in parenteral support or fecal losses were obtained. All others decreased their intravenous requirements by 50%. One patient suffered an episode of cholecystitis, and another one with a pre-existing cardiac disease, developed a cardiac decompensation. Teduglutide seems to be a safe and effective treatment in the pediatric SBS population with better results than in the pivotal study as well as in the adult population.

Laparoscopic cholecystectomy: which predicting factors of conversion? Two Italian center's studies.

Laparoscopic cholecystectomy represents the gold standard technique for the treatment of lithiasic gallbladder disease. Although it has many advantages, laparoscopic cholecystectomy is not risk-free and in special situations there is a need for conversion into an open procedure, in order to minimize postoperative complications and to complete the procedure safely. The aim of this study was to identify factors that can predict the conversion to open cholecystectomy. We analyzed 1323 patients undergoing laparoscopic cholecystectomy over the last five years at St. Orsola University Hospital-Bologna and Umberto I University Hospital-Rome. Among these, 116 patients (8.7%) were converted into laparotomic cholecystectomy. Clinical, demographic, surgical and pathological data from these patients were included in a prospective database. A univariate analysis was performed followed by a multivariate logistic regression. On univariate analysis, the factors significantly correlated with conversion to open were the ASA score higher than 3 and the comorbidity, specifically cardiovascular disease, diabetes and chronic renal failure (P<0.001). Patients with a higher mean age had a higher risk of conversion to open (61.9±17.1 vs. 54.1±15.2, P<0.001). Previous abdominal surgery and previous episodes of cholecystitis and/or pancreatitis were not statistically significant factors for conversion. There were four deaths in the group of converted patients and two in the laparoscopic group (P<0.001). Operative morbility was higher in the conversion group (22% versus 8%, P<0.001). Multivariate analysis showed that the factors significantly correlated to conversion were: age <65 years old (P=0.031 OR: 1.6), ASA score 3-4 (P=0.013, OR:1.8), history of ERCP (P=0.16 OR:1.7), emergency procedure (P=0.011, OR:1.7); CRP higher than 0,5 (P<0.001, OR:3.3), acute cholecystitis (P<0.001, OR:1.4). Further multivariate analysis of morbidity, postoperative mortality and home discharge showed that conversion had a significant influence on overall post-operative complications (P=0.011, OR:2.01), while mortality (P=0.143) and discharge at home were less statistically influenced. Our results show that most of the independent risk factors for conversion cannot be modified by delaying surgery. Many factors reported in the literature did not significantly impact conversion rates in our results.

Venetoclax Added to Ibrutinib in High-Risk CLL Achieves a High Rate of Undetectable Minimal Residual Disease. [RTS1

Venetoclax Added to Ibrutinib in High-Risk CLL Achieves a High Rate of Undetectable Minimal Residual Disease. [RTS1

Trends in 30-Day Readmission Rate in Patients With Acute Cholecystitis and Factors Associated With Readmissions

Introduction: Acute cholecystitis is a frequent cause of hospitalization in the US. However, the overall burden of readmissions and factors associated with readmissions after having an episode of cholecystitis is unclear. Methods: We interrogated the National Readmissions Database to identify index admissions with primary diagnosis of acute cholecystitis (ICD-9-CM: 575.0) between 2010-2014. Demographic characteristics, hospital factors, comorbidities, and procedural details were obtained. Trends in readmission rates were graphed. Differences in readmission rates based on aforementioned characteristics were computed. Chi-square test was used to assess significance of these differences. Multivariate survey logistic regression analysis was performed to identify factors associated with readmission within 30-days. Results: N=948,804 index hospitalizations had a primary diagnosis of acute cholecystitis. Of these, 8.7% were readmitted with 30 days. A slight but decreasing trend in readmission rate was noted going from 9.2% in 2010 to 8.5% in 2014 (Figure 1). Baseline characteristics and differences these characteristics based on occurrence of 30-day readmission event were computed (Table 1). Being middle aged (45-64 age group), having an admission during a weekend, increasing comorbidity index, and biliary obstruction were all associated with increased odds of readmission within 30 days on the multivariate model. Patients using private insurance/self-pay/other means to pay for their hospital stay, discharge to home without needing home health, and having either cholecystectomy or ERCP were associated with reduced odds of readmissions (Table 2).87_A Figure 1. 30-day Readmission rate After Index Admission for Acute CholecystitisConclusion: Although a fewer portion of patients hospitalized with acute cholecystitis are readmitted within 30 days compared to other causes (14%) the magnitude of readmissions is substantial and represents an opportunity for significant cost savings. Previous analysis demonstrated the benefit of same-admission cholecystectomy with regards to mortality and morbidity. Here, we demonstrate that same-admission ERCP and cholecystectomy are associated with significant reduction in readmission rates also. Additional factors associated with readmissions can inform healthcare policy to help reduce readmission risks.87_B Figure 2. Baseline characteristics & differences in readmission based on patient characteristics87_C Figure 3. Multivariate analysis of factors associated with early readmission

Is Percutaneous Cholecystostomy a Good Alternative Treatment for Acute Cholecystitis in High-Risk Patients?

Cholecystectomy is the treatment of choice for acute cholecystitis but the management of high-risk surgical patients is a difficult dilemma. Percutaneous cholecystostomy (PC) could represent a safer and less invasive option. The aim of the study was to assess the outcomes of PC in high-risk patients. This is a retrospective single-center study; data were collected from our hospital electronic record system. From February 2009 to March 2014, there were 753 patients admitted with acute cholecystitis. Of these 39 were considered high risk for surgery and underwent PC during their hospital stay. The radiological approach was transperitoneal in 29 patients and transhepatic in 10 patients. Median follow-up was 19 months. There were 27 males (69.2%) and 12 females (30.8%) with a mean age of 72 years (range 41-90 years). Twenty-seven patients had PC as definitive treatment (group A) and 12 patients as a bridge to cholecystectomy (group B). There were no postprocedure complications. Five patients in group A were readmitted once with another episode of cholecystitis after PC (18.5%), one patient in group B was readmitted with cholecystitis after two years before proceeding to cholecystectomy, and two patients were readmitted after cholecystectomy (16.6%) for intra-abdominal collections treated with percutaneous radiological drainage. Seven patients died (17.9%) as a result of severe biliary sepsis during their index hospital admission. PC is a safe approach in high-risk patients with acute cholecystitis and can provide satisfactory long-term results when cholecystectomy is not a viable option.