Surgical Management Of Acute Cholecystitis Research Articles

Impact of the COVID-19 pandemic on outcomes of cholecystectomy for acute cholecystitis: a national cohort study.

The COVID-19 pandemic was associated with significant disruptions to healthcare provision globally and in Aotearoa New Zealand. It remains unclear how this disruption affected the surgical management of acute cholecystitis and whether there are ongoing impacts. We conducted a secondary analysis of two multicentre cohort studies (CHOLECOVID and CHOLENZ) on patients who underwent cholecystectomy for acute cholecystitis. Participants were categorized into pre-pandemic (September-November 2019), pandemic (March-May 2020), and late-pandemic (August-October 2021) phases. Baseline demographics, clinical management, and 30-day postoperative complications were assessed between phases. Multivariable logistic regression was used to explore the impact of timing of operation on rates of hospital readmission and postoperative complications. 517 participants were included, of whom 85 (16%) were in the pre-pandemic-phase, 52 (10%) were in the pandemic phase, and 380 (73%) were in the late-pandemic phase. Pandemic and late-pandemic phase participants were more comorbid and had higher rates of obesity and deranged blood results than pre-pandemic. After multivariable adjustment, there were no differences in rates of hospital readmission or postoperative complications at 30-day follow-up across phases. The COVID-19 pandemic had minimal impacts on the provision of cholecystectomy for acute cholecystitis in Aotearoa New Zealand. However, patients managed during the COVID-19 pandemic were more comorbid and had higher rates of obesity and elevated inflammatory markers.

EP-602 The impact of COVD-19 on the surgical management of acute cholecystitis

AimThe Association of Upper Gastrointestinal Surgeons (AUGIS) recommends performing a laparoscopic cholecystectomy within 72 hours of admission for acute cholecystitis. COVID-19 has drastically affected the way healthcare is able to be delivered worldwide. This project was designed to audit the impact of COVID-19 on the surgical management of acute cholecystitis against AUGIS guidelines.MethodsAll general surgical admission from November 2020 were retrospectively analysed. Admission records were screened for those presenting with acute cholecystitis. Those identified had their records analysed for laparoscopic cholecystectomy. Patients who died before surgery, had an alternative procedure performed, or who were unfit for surgery, were excluded.ResultsDuring this time, 28 patients were admitted with acute cholecystitis. In total, 3 patients were excluded: 1 died before any possible intervention, 1 was unfit for surgery, and 1 received a cholecystostomy. Of the 25 included patients, only 11% (n=3) patients received a laparoscopic cholecystectomy within seven days from their hospital admission. The remaining 89% (n=22) of patients were managed conservatively with fluids, analgesia, and antibiotics.ConclusionIt can be concluded that COVID-19 has severely impacted the surgical management of acute cholecystitis as only 11% of those patients presenting were managed in accordance with AUGIS guidelines. Whether conservative management is an alternative long-term option for management remains to be seen as further long-term studies are needed.

Surgical trends in the management of acute cholecystitis during pregnancy.

Since 2007, clinical practice guidelines by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommend early surgical management with laparoscopic cholecystectomy for pregnant women with symptomatic gallbladder disease regardless of trimester. However, little is known about practice patterns in the management of pregnant patients with acute cholecystitis. This study aims to examine nationwide trends in the surgical management of acute cholecystitis, as well as their impact on clinical outcomes during pregnancy. The National Inpatient Sample was queried for all pregnant women diagnosed with acute cholecystitis between January 2003 and September 2015. After applying appropriate weights, multivariate regression analysis adjusted for patient- and hospital-level characteristics andquantified the impact of discharge year (2003-2007 versus 2008-2015) on cholecystectomy rates and timing of surgery. Multivariate regression analysis was also used to examine the impact of same admission cholecystectomy and its timing on maternal and fetal outcomes. A total of 23,939 pregnant women with acute cholecystitis satisfied our inclusion criteria. The median age was 26years (interquartile range: 22-30). During the study period, 36.3% were managed non-operatively while 59.6% and 4.1% underwent laparoscopic and open cholecystectomy, respectively. After adjusting for covariates, laparoscopic cholecystectomy was more commonly performed after 2007 (odds ratio [OR] 1.333, p < 0.001). Furthermore, time from admission to surgery was significantly shorter in the latter study period (regression coefficient -0.013, p < 0.001). Compared to non-operative management, laparoscopic cholecystectomy for acute cholecystitis was significantly associated with lower rates of preterm delivery, labor, or abortion (OR 0.410, p < 0.001). Each day that laparoscopic cholecystectomy was delayed significantly associated with an increased risk of fetal complications (OR 1.173, p < 0.001). This nationwide study exhibits significant trends favoring surgical management of acute cholecystitis during pregnancy. Although further studies are still warranted, early laparoscopic cholecystectomy should be considered in pregnant patients with acute cholecystitis.

Surgical management of acute cholecystitis in a nationwide Danish cohort.

In the Danish national guidelines from 2006 on the treatment of acute cholecystitis, early laparoscopic operation within 5days after the debut of symptoms was recommended. The aim of this study was to analyze the outcome in patients with acute cholecystitis subjected to cholecystectomy in Denmark in the five-year period hereafter. All patients undergoing cholecystectomy in the period 2006-2010 were registered in the Danish Cholecystectomy Database, from which outcome data were collected. The effect of potential risk factors such as age, gender, BMI, American Society of Anesthesiologists (ASA) score, previous pancreatitis, previous abdominal surgery, year of operation, surgical approach, and surgeon experience was analyzed. Of 33,853 patients registered with a cholecystectomy, 4667 (14%) were operated for acute cholecystitis. In 95% of the patients, laparoscopic cholecystectomy was intended and in 5% primary open access was chosen. The frequency of conversion from laparoscopic to open surgery was 18%. High age and ASA score, operation in the early years of the period, and open or converted procedure all increased the risk of hospital stay to > 3days or readmission. High age and ASA score, converted or open operation, and previous pancreatitis increased the risk of additional procedures. Postoperative mortality was 1.2%, and significant risk factors for postoperative death were age, low BMI, high ASA score, early year of operation, and open procedures. Acute cholecystectomy was safely managed laparoscopically in most patients after the introduction of national guidelines, with an increasing rate of laparoscopically completed procedures during the study period.

Advances in the management of acute cholecystitis.

The diagnosis and management of acute cholecystitis (AC) continues to evolve. Among the most common surgically treated conditions in the USA, appropriate diagnosis and management of AC require astute clinical judgment and operative skill. Useful diagnostic and grading systems have been developed, most notably the Tokyo guidelines, but some recent clinical validation studies have questioned their generalizability to the US population. The timing of surgical intervention is another area that requires further investigation. US surgeons traditionally pursue laparoscopic cholecystectomy (LC) for AC patients with symptoms onset <72 hours, but for patients with symptoms over 72 hours, surgeons often elect to treat the patients with antibiotics and delay LC for 4‐6 weeks to permit the inflammation to subside. This practice has recently been called into question, as there are data suggesting that LC even for AC patients with over 72 hours of symptoms confers decreased morbidity, shorter length of stay, and reduced overall healthcare costs. Finally, the role of percutaneous cholecystostomy (PC) needs to be better defined. Traditional role of PC is a temporizing measure for patients who are poor surgical candidates. However, there are data suggesting that in AC patients with organ failure, PC patients suffered higher mortality and readmission rates when compared with a propensity‐matched LC cohort. Beyond diagnosis, the surgical management of AC can be remarkably challenging. All surgeons need to be familiar with best‐practice surgical techniques, adjunct intra‐operative imaging, and bail‐out options when performing LC.

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

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

Trends in surgical management of acute cholecystitis: 10 years experience from a tertiary care hospital of developing country

Introduction: Treatment for acute cholecystitis includes cholecystectomy and in high risk patients, initial medical management, followed by cholecystectomy. Our aim was to look for trends in surgical management of acute cholecystitis at Aga Khan University Hospital over a period of 10 years. Methods: A retrospective study was performed by reviewing the medical records of patients who underwent cholecystectomy after a preoperative diagnosis of acute cholecystitis admitted to our hospital, from January 2001 to December 2010. Patients were divided into Group-I (2001–2005) and Group-II (2006–2010). Results: A total of 567 patients met inclusion criteria. Mean age was 50.4 years and 46% were male. Nearly 74% of patients had laparoscopic cholecystectomy. Conversion rate from laparoscopic to open cholecystectomy was 19.2%. Early cholecystectomy was performed in 72% of patients. Percutaneous cholecystostomy tube was used in 8.6% of patients. A total of 6.5% patients developed complication. Most common morbidity was wound infection (3.9%), followed by intra-abdominal abscess (1.6%). Bile duct injury was reported in 0.7% cases. Almost 60% of patients were discharged within 48 hours. On comparing Group-I (n = 170) and Group-II (n = 397), significant increase in early cholecystectomy (79.5% vs. 54%, p = 0.00) and decrease in conversion rates (15.9% vs. 27%, p = 0.02) were noticed in Group-II. Conclusion: This is the largest series from Pakistan in this regard. Over the years our experience of managing acute cholecystitis has changed dramatically. Now early laparoscopic cholecystectomy is being performed more frequently, with comparable morbidity rate, also frequency of conversion has fallen significantly in all grades of acute cholecystitis.

Surgical management of acute cholecystitis.

Acute cholecystitis occurs in approximately 1% of patients with known gallstones. It presents as a surgical emergency and usually requires hospitalisation for treatment. It is associated with significant morbidity and mortality, particularly in the elderly. Cholecystectomy is advocated for acute cholecystitis; however, the timing of cholecystectomy and the value of the additional treatments have been a matter of debate. This review examines the available evidence regarding the optimal surgical management of patients with acute cholecystitis. A literature search was performed on the MEDLINE, EMBASE and WHO International Clinical Trials Registry Platform, databases for English language publications. The MeSH headings 'cholecystitis', 'acute', 'gallbladder', 'inflammation', 'surgery', 'cholecystectomy', 'laparoscopic', 'robotic', 'telerobotic' and 'computer-assisted' were used. Data from eight randomised controlled trails and three population-based analyses show that early cholecystectomy for acute cholecystitis performed on the index admission is safe and not associated with increased conversion rates or morbidity in comparison to conservative treatment followed by elective cholecystectomy. Delaying cholecystectomy increases readmissions for gallstone-related events, complications, hospital stay and mortality in the elderly. Early cholecystectomy is also more cost-effective. Randomised trials addressing antibiotic use in acute cholecystitis suggest that antibiotics should be stopped on the day of cholecystectomy. Insufficient trials have been performed to address the optimal analgesia regime post cholecystectomy. Similarly, a lack of trials on intraoperative cholangiography and management of common bile duct stones in patients with acute cholecystitis means that treatment of concomitant bile duct stones should be based on institutional expertise and resource availability. As regards acute cholecystitis in elderly and high-risk patients, case series and retrospective studies would suggest that cholecystectomy is more effective and of lower mortality than percutaneous cholecystostomy. There is not enough evidence to support the routine use of robotic surgery, single-incision laparoscopic cholecystectomy or natural orifice transluminal endoscopic surgery (NOTES) in the treatment of acute cholecystitis. Trial evidence would favour a policy of early laparoscopic cholecystectomy following admission with acute cholecystitis. The optimal approach to support early cholecystectomy is suggested but requires evidence from further randomised trials.

Surgical management of acute cholecystitis complicated by hyperbilirubinemia

Surgical management of acute cholecystitis complicated by hyperbilirubinemia

Surgical management of acute cholecystitis complicated by hyperbilirubinemia

Surgical management of acute cholecystitis complicated by hyperbilirubinemia

Surgical Management of Acute Cholecystitis. Results of a Nation-Wide Survey Among Spanish Surgeons

There is a wide variability in the management of acute cholecystitis. A survey among the members of the Spanish Association of Surgeons (AEC) analyzed the preferences of Spanish surgeons for its surgical management. The majority of the 771 responders did not declare any subspecialty (41.6%), 21% were HPB surgeons, followed by colorectal and upper-GI specialities. Early cholecystectomy during the first admission is the preferred method of management of 92.3% of surgeons, but only 42.7% succeed in adopting this practice. The most frequent reasons for changing their preferred practice were: patients not fit for surgery (43.6%) and lack of availability of emergency operating room (35.2%). A total of 88.9% perform surgery laparoscopically. The majority of AEC surgeons advise index admission cholecystectomy for acute cholecystitis, although only half of them succeed in its actual implementation. There is room for improvement in the management of acute cholecystitis in Spanish hospitals.

Early versus Delayed Surgery for Acute Cholecystitis as an Applied Treatment Strategy When Assessed in a Population-Based Cohort

Background: The aims of this study were to describe the surgical management of acute cholecystitis (AC) in a well-defined population-based patient cohort, in particular adherence to and outcome of the early open/laparoscopic cholecystectomy (EC/ELC) strategy. Methods: The medical records of all patients residing in Stockholm County who were treated for AC during 2003 and 2008 were reviewed according to a standardized protocol. Results: In 2003, 799 patients were admitted 850 times for AC, and the respective figures for 2008 were 833 and 919. The number of patients who underwent EC/ELC increased from 42.9% in 2003 to 47.4% in 2008. In multivariate regression analysis adjusting for age, gender, severity of cholecystitis, maximal CRP and maximal WBC, EC/ELC was associated with shorter operation time but higher perioperative blood loss when compared to delayed open/laparoscopic cholecystectomy (DC/DLC). The odds ratio for completing the procedure laparoscopically was significantly higher in DC/DLC when adjusting for the same covariates. There were no significant differences in peri- or postoperative complications between the groups. Conclusion: Strategies should be implemented in order to secure a more evidence-based approach to the surgical treatment of AC.

Does a Role of Surgical Management of Acute Cholecystitis Develop?

Does a Role of Surgical Management of Acute Cholecystitis Develop?

Minimally Invasive Surgical Management of Acute Cholecystitis during Pregnancy: What are the Recommendations?

Minimally Invasive Surgical Management of Acute Cholecystitis during Pregnancy: What are the Recommendations?

TG13 surgical management of acute cholecystitis

Laparoscopic cholecystectomy is now accepted as a surgical procedure for acute cholecystitis when it is performed by an expert surgeon. There are several lines of strong evidence, such as randomized controlled trials (RCTs) and meta-analyses, supporting the introduction of laparoscopic cholecystectomy for patients with acute cholecystitis. The updated Tokyo Guidelines 2013 (TG13) describe the surgical treatment for acute cholecystitis according to the grade of severity, the timing, and the procedure used for cholecystitis in a question-and-answer format using the evidence concerning surgical management of acute cholecystitis. Forty-eight publications were selected for a careful examination of their full texts, and the types of surgical management of acute cholecystitis were investigated using this evidence. The items concerning the surgical management of acute cholecystitis were the optimal surgical treatment for acute cholecystitis according to the grade of severity, optimal timing for the cholecystectomy, surgical procedure used for cholecystectomy, optimal timing of the conversion of cholecystectomy from laparoscopic to open surgery, and the complications of laparoscopic cholecystectomy. There were eight RCTs and four meta-analyses concerning the optimal timing of the cholecystectomy. Consequently, it was found that cholecystectomy is preferable early after admission. There were three RCTs and two meta-analyses concerning the surgical procedure, which concluded that laparoscopic cholecystectomy is preferable to open procedures. Literature concerning the surgical treatment according to the grade of severity could not be quoted, because there have been no publications on this topic. Therefore, the treatment was determined based on the general opinions of professionals. Surgical management of acute cholecystitis in the updated TG13 is fundamentally the same as in the Tokyo Guidelines 2007 (TG07), and the concept of a critical view of safety and the existence of extreme vasculobiliary injury are added in the text to call the surgeon's attention to the need to reduce the incidence of bile duct injury. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

Surgical management of acute cholecystitis: results of a 2-year prospective multicenter survey in Belgium

Laparoscopic cholecystectomy is considered nowadays as the standard management of acute cholecystitis (AC). However, results from multicentric studies in the general surgical community are still lacking. A prospective multicenter survey of surgical management of AC patients was conducted over a 2-year period in Belgium. Operative features and patients' clinical outcome were recorded. The impact of independent predictive factors on the choice of surgical approach, the risk of conversion, and the occurrence of postoperative complications was studied by multivariate logistic regression analysis. Fifty-three surgeons consecutively and anonymously included 1,089 patients in this prospective study. A primary open approach was chosen in 74 patients (6.8%), whereas a laparoscopic approach was the first option in 1,015 patients (93.2%). Independent predictive factors for a primary open approach were previous history of upper abdominal surgery [odds ratio (OR) 4.13, p < 0.001], patient age greater than 70 years (OR 2.41, p < 0.05), surgeon with more than 10 years' experience (OR 2.08, p = 0.005), and gangrenous cholecystitis (OR 1.71, p < 0.05). In the laparoscopy group, 116 patients (11.4%) required conversion to laparotomy. Overall, 38 patients (3.5%) presented biliary complications and 49 had other local complications (4.5%). Incidence of bile duct injury was 1.2% in the whole series, 2.7% in the open group, and 1.1% in the laparoscopy group. Sixty patients had general complications (5.5%). The overall mortality rate was 0.8%. All patients who died were in poor general condition [American Society of Anesthesiologists (ASA) III or IV]. Although laparoscopic cholecystectomy is currently considered as the standard treatment for acute cholecystitis, an open approach is still a valid option in more advanced disease. However, overall mortality and incidence of bile duct injury remain high.

Surgical Management of Acute Cholecystitis at a Tertiary Care Center in the Modern Era

The advent of laparoscopy has changed the paradigm of surgical training and care delivery for the treatment of patients with acute cholecystitis (AC). Retrospective data collection and analysis. Hospital admissions with a primary diagnosis of AC at a tertiary care center from January 1, 2002, to January 1, 2007. During the study period, 923 patients were admitted with a primary diagnosis of AC. One hundred fourteen patients were excluded from the study because of missing data, medical management, incomplete operative notes or documents, or metastatic gastrointestinal cancer. Patient demographics, preoperative morbidity, procedures (medical and surgical), and postoperative outcomes were statistically analyzed using chi(2) test, t test, and analysis of variance. Eight hundred nine patients (87.6%) with a primary diagnosis of AC underwent surgery by 44 surgeons. Procedures included 663 laparoscopic cholecystectomies (LCs) (82.0%), 9 open cholecystectomies (1.1%), 51 conversions from LC to open cholecystectomy (6.3%), and 86 cholecystostomy tube placements (10.6%). During the study period, cholecystostomy tube placements increased, while open cholecystectomies and conversions from LC to open cholecystectomy decreased (P < .05). Laparoscopic cholecystectomy was associated with significantly better outcomes, including shorter postsurgical stay (2.2 vs 6.3 days for other modalities) and fewer complications (8.5% vs 17.0%). Based on 5-year results from a tertiary care center, LC was performed with a low conversion rate to open surgery and was associated with decreased morbidity and mortality compared with other surgical modalities to treat AC. Our data confirm the benefits and widespread use of LC in the modern era, reflecting changes in the training paradigm and learning curve for laparoscopy.

A survey of surgical management of acute cholecystitis in eastern Saudi Arabia

Background/Aim:It is now 60 years since early cholecystectomy was advocated for acute cholecystitis (AC). Yet, surgical opinion remains divided regarding its optimal timing. Furthermore, recent surveys have shown low utilization of early laparoscopic cholecystectomy (LC) for AC.Aim:This survey aimed to assess the current management of AC in Eastern Saudi Arabia.Materials and Methods:A postal survey was conducted by means of a questionnaire sent to 95 surgeons practicing LC. The questionnaire addressed the surgical management of AC in relation to the subspecialty of interest, duration of consultant status, number of cholecystectomies performed per year, and the percentage performed laparoscopically.Results:There were 87 responders (92%); two were excluded from the analysis for different reasons. Early LC was preferred by 71% of the responders. With regard to the timing of LC, there was no significant difference in relation to the surgeon's subspecialty of interest or duration of consultant status. However, increased number of cholecystectomies and percentage of cholecystectomies performed with a laparoscopic approach were significantly associated with early LC.Conclusion:Early LC for AC is practiced by the majority of surgeons in Eastern Saudi Arabia. This practice is significantly associated with increased number of cholecystectomies performed as well as with the percentage performed with a laparoscopic approach. According to the current literature, early LC for AC results in a shorter total hospital stay and reduced cost of treatment.

Current Status of Surgical Management of Acute Cholecystitis in the United States

We attempted to determine population-based outcomes of laparoscopic (LC) and open cholecystectomy (OC) for acute cholecystitis (AC). We used the National Hospital Discharge Surveys from 2000 through 2005. Annual medical and demographic data from a national sample of discharge records from nonfederal, short-stay hospitals were queried. We identified all patients who underwent LC or OC for AC. The main outcome measures were the rate of LC or OC and in-hospital morbidity and mortality. One million patients underwent cholecystectomy (859,747 LCs; 152,202 OCs) for AC during 2000-2005. Of the cases started laparoscopically, 9.5% were converted to OC. Compared to OC, patients who underwent LC were more likely to be discharged home (91% vs. 70%), carry private insurance (47% vs. 30%), suffer less morbidity (16% vs. 36%), and have a lower unadjusted mortality (0.4% vs. 3.0%). OC was associated with a 1.3-fold increase (95% confidence interval 1.1-1.4) in perioperative morbidity compared to LC after adjusting for patient and hospital factors. Most patients in the 21st century with AC undergo LC with a low conversion rate and low morbidity. In the general population with acute cholecystitis, LC results in lower morbidity and mortality rates than OC even in the setting of open conversion.

STUDIES ON THE SURGICAL SELECTION FOR ACUTE CHOLECYSTITIS WITH CLINICAL COURSE AND ULTRASONOGRAPHIC FINDINGS

It has been debated whether eraly or delayed operation should be selected for surgical management of acute cholecystitis, but there is no definite answer to this argument. Therefore, we studied our 84 acute cholecystitis cases with clinical signs and diagnostic images in order to establish the criteria for surgical selection. This study was to find out for which patients conservative treatment is not adequate. Ultrasonographic (US) study was done to examine (1) US findings during hospitalization (2) US findings of early surgical cases (3) US findings of cases on standby surgery. Early surgery was indicated for 23 patients (27%). Sixty-one patients (73%) could be treated by conservative treatment in the acute stage, and 51 patients underwent elective operations and 10 were discharged without surgery. Of clinical findings, not only pain, fever and local tenderness but also defence musclulare and jaundice were seen in early surgery cases. Severe complications such as liver and/or subphrenic abscess, severe cholangitis, panperitonitits, renal disturbance, toxic dermatitis and shock were found in early surgery cases. Of US findings, not onlyt local tenderness, enlarged gallbladder, thickened gallbladder wall, sonolucent layer and debris in the gallbladder but also bile duct dilatation, liver abscess and fluid collection were seen in early surgical cases.