Uncomplicated Acute Cholecystitis Research Articles

Management and patient outcomes following admission with acute cholecystitis in Ireland: A national registry-based study

IntroductionAcute cholecystitis is a common general surgical emergency, accounting for 3–10 % of all patients attending with acute abdominal pain. International guidelines suggest that emergency cholecystectomy is the treatment of choice for uncomplicated acute cholecystitis where feasible. There is a paucity of published data on the uptake of emergency cholecystectomy in Ireland. AimThe aim of this study was to evaluate the management of acute cholecystitis in Ireland and to establish the rate of emergency cholecystectomy performed. MethodsAll patients with acute cholecystitis presenting to public hospitals in Ireland between January 2017 and July 2023 were identified using the National Quality Assurance and Improvement System (NQAIS). Data were collected on patient demographics, co-morbidities, length of stay, operative intervention, endoscopic intervention, critical care admissions, in-patient mortality, and readmissions. Propensity score matched analysis and logistic regression were performed to account for selection bias in comparing patients managed with cholecystectomy and those managed conservatively. Results20,886 admission episodes were identified involving 17,958 patients. 3585 (20 %) patients underwent emergency cholecystectomy in total. 3436 (96 %) of these were performed laparoscopically, with 140 (4 %) requiring conversion to an open procedure, and common bile duct injuries occurring in 4 (0.1 %) of patients. In comparison to patients treated conservatively, patients who underwent cholecystectomy were younger (median 50 v 60 years, p < 0.001) and more likely to be female (64 % v 55 % p < 0.001). Following propensity score matched analysis, those who had an emergency cholecystectomy had reduced length of stay (LOS) (median 5 days (IQR 3–8) v 6 days (interquartile range (IQR) 3–10), p < 0.001) and fewer readmissions to hospital (282 (8 %) v 492 (14 %), p < 0.001). On logistic regression, age >65 (OR 1.526), CCI >3 (OR 2.281) and non-operative management (OR 1.136) were significant risk factors for adverse outcome. ConclusionUptake of emergency cholecystectomy in Ireland remains low, and is carried out on a younger, fitter cohort of patients. In those patients, however, it is associated with improved outcomes for cholecystitis compared to conservative management, including shorter LOS and reduced readmission rates for matched cohorts.

Early Cholecystectomy in Patients with Sickle Cell Disease with Uncomplicated Cholelithiasis Is Associated with Better Outcomes.

Up to 85% of patients with sickle cell disease (SCD) will develop gallstones by their third decade. Cholecystectomy is the most commonly performed procedure in these patients. Cholecystectomy is recommended for patients with SCD with symptomatic cholelithiasis and leads to lower morbidity. No contemporary large studies have evaluated this recommendation or associated clinical outcomes. This study evaluates clinical outcomes after cholecystectomy in patients with SCD and cholelithiasis with specific advanced clinical presentations. The Nationwide Inpatient Sample was queried for patients with SCD and gallbladder disease between 2006 and 2015. Patients were divided into groups based on their disease presentation, including uncomplicated cholelithiasis, acute and chronic cholecystitis, and gallstone pancreatitis. Clinical outcomes associated with disease presentation were analyzed. Statistical analysis was performed using the Student's t -test, chi-square test, ANOVA, and logistic regression. There were 6,662 patients with SCD who presented with cholelithiasis. Median age was 20 (interquartile range 16 to 34) years and 54% were female patients. Cholecystectomy was performed in 1,779 patients with SCD with the most common indication being chronic cholecystitis (44%), followed by uncomplicated cholelithiasis (27%), acute cholecystitis (21%), and choledocholithiasis or gallstone pancreatitis (8%). On multivariable regression, advanced clinical presentation was the strongest predictor of perioperative vaso-occlusive crisis, which was the most common complication. Patients undergoing cholecystectomy for uncomplicated cholelithiasis were at lower risk than those with acute cholecystitis (odds ratio [OR] 2.37; 95% CI 1.64 to 3.41), chronic cholecystitis (OR 1.74; 95% CI 1.26 to 2.4), and choledocholithiasis or gallstone pancreatitis (OR 2.24; 95% CI 1.41 to 3.57). Seventy-three percent of patients with SCD have advanced clinical presentation at the time of their cholecystectomy. After cholecystectomy, perioperative vaso-occlusive events were significantly increased in patients with advanced clinical presentation. These data support screening abdominal ultrasounds and early cholecystectomy for cholelithiasis in patients with SCD.

RISK FACTORS FOR THE DEVELOPMENT OF VENOUS THROMBOEMBOLISM IN PATIENTS WITH UNCOMPLICATED ACUTE CALCULOUS CHOLECYSTITIS

The aim is to identify and analyze risk factors for venous thromboembolism in patients diagnosed with uncomplicated acute calculous cholecystitis.&#x0D; Materials and Methods. A prospective analysis of clinical data of 71 patients diagnosed with uncomplicated acute calculous cholecystitis was conducted. Two clinical groups were formed: subgroup 1A (n=6) included patients diagnosed with venous thromboembolism, and subgroup 1B (n=65) included patients without venous thromboembolism.&#x0D; Results and Discussion. During the study, the coagulation potential of the patients was studied. The prothrombin index on the third day of the postoperative period and at the time of discharge was significantly higher in subgroup 1A patients (109.1% and 123.0%) compared to subgroup 1B patients (98.0% and 96.4%). The situation with total fibrinogen is similar: the mean level of this indicator during the entire observation period was significantly higher in patients of subgroup 1A (p&lt;0.05). The mean D-dimer level at the time of hospital discharge in subgroup 1A was 3.6 mg/ml higher compared to the level of this indicator on the first day after surgery, and in subgroup 1B it was only 0.5 mg/ml higher. The risk of venous thromboembolism according to the Caprini score in subgroup 1A was 7.5 [5.5; 9.0] points, compared to 6.0 [4.0; 8.0] points in subgroup 1B. Assessment of the risk of venous thromboembolism according to the Rogers scale showed similar results: 8.0 [6.3; 9.8] points for patients of subgroup 1A and 7.0 [6.0; 8.0] points for subgroup 1B. When assessing the interleukin 1 beta (IL1b) level, its increased value was detected in subgroup 1A - 14.0 [7.0; 33.7] pg/ml, as opposed to subgroup 1B, where it was 9.0 [3.5; 26.2] pg/ml. Similar results were found in the assessment of tumor necrosis factor TNF: the mean values of this cytokine level were also higher in subgroup 1A (13.9 [7.9; 15.8] pg/ml) than in subgroup 1B (8.8 [6.0; 13.1] pg/ml).&#x0D; Conclusions. According to the results of the study, the following factors for the development of venous thromboembolism in patients with uncomplicated acute calculous cholecystitis were determined: elevated levels of indicators of total fibrinogen, D-dimer, interleukin 1 beta (IL1b) and tumor necrosis factor (TNF) at the time of admission. The mean values of the total risk assessment points according to the Caprini score and Rogers scale were significantly higher (p&lt;0.05) in the subgroup of patients with uncomplicated acute calculous cholecystitis who later developed venous thromboembolism.

Infection or Inflammation: Are Uncomplicated Acute Appendicitis, Acute Cholecystitis, and Acute Diverticulitis Infectious Diseases?

Background: It is recognized increasingly that common surgical infections of the peritoneal cavity may be treated with antibiotic agents alone, or source control surgery with short-course antimicrobial therapy. By extension, testable hypotheses have emerged that such infections may not actually be infectious diseases, but rather represent inflammation that can be treated successfully with neither surgery nor antibiotic agents. The aim of this review is to examine extant data to determine which of uncomplicated acute appendicitis (uAA), uncomplicated acute calculous cholecystitis (uACC), or uncomplicated mild acute diverticulitis (umAD) might be amenable to management using supportive therapy alone, consistent with the principles of antimicrobial stewardship. Methods: Review of pertinent English-language literature and expert opinion. Results: Only two small trials have examined whether uAA can be managed with observation and supportive therapy alone, one of which is underpowered and was stopped prematurely because of challenging patient recruitment. Data are insufficient to determine the safety and efficacy of non-antibiotic therapy of uAA. Uncomplicated acute calculous cholecystitis is not primarily an infectious disease; infection is a secondary phenomenon. Even when bactibilia is present, there is no high-quality evidence to suggest that mild disease should be treated with antibiotic agents. There is evidence to indicate that antibiotic prophylaxis is indicated for urgent/emergency cholecystectomy for uACC, but not in the post-operative period. Uncomplicated mild acute diverticulitis, generally Hinchey 1a or 1b in current nomenclature, does not benefit from antimicrobial agents based on multiple clinical studies. The implication is that umAD is inflammatory and not an infectious disease. Non-antimicrobial management is reasonable. Conclusions: Among the considered disease entities, the evidence is strongest that umAD is not an infectious disease and can be treated without antibiotic agents, intermediate regarding uACC, and lacking for uAA. A plausible hypothesis is that these inflammatory conditions are related to disruption of the normal microbiome, resulting in dysbiosis, which is defined as an imbalance of the natural microflora, especially of the gut, that is believed to contribute to a range of conditions of ill health. As for restorative pre- or probiotic therapy to reconstitute the microbiome, no recommendation can be made in terms of treatment, but it is not recommended for prevention of primary or recurrent disease.

Necrotizing Fasciitis Secondary to Emphysematous Cholecystitis and Cholecystocutaneous Fistula: A Rare Case Report Presentation

Emphysematous cholecystitis is a rare subtype of acute cholecystitis characterized by the presence of gas in the gallbladder wall secondary to ischemia. Typically, this is a result of cystic artery vascular compromise with a concomitant infection from gas-forming organisms such as Clostridium species, Klebsiella species, or Escherichia coli. The mortality rate of acute emphysematous cholecystitis is 15% - 20% compared with 1.4% in uncomplicated acute cholecystitis. The subsequent development of a cholecystocutaneous fistula, an abnormal connection between the gallbladder and the skin, is also a rare complication of gallbladder disease. We describe a case of a 77-year-old male who presented with right flank necrotizing fasciitis which developed from a cholecystocutaneous fistula secondary to emphysematous cholecystitis. Once the necrotic tissues were adequately debrided, the large open wound was treated with negative pressure wound therapy with instillation (NPWT-i) utilizing hypochlorous acid (HOCL). The wound was closed with a split-thickness skin graft.

THROMBOEMBOLIC COMPLICATIONS IN PATIENTS WITH ACUTE CALCULOUS CHOLECYSTITIS

The aim is the analysis of clinical and anamnestic, biochemical and hemostasiological parameters in thromboembolic complications in patients with acute calculous cholecystitis (ACC).&#x0D; Materials and Methods. A retrospective analysis of clinical information was performed regarding 206 patients with a diagnosis of acute calculous cholecystitis, who were hospitalized in the Emergency Medical Care Hospital of Lviv (current name: St. Panteleimon Hospital of the First Territorial Medical Association of the City of Lviv) in the period from 2014 to 2018.&#x0D; Results and Discussion. It was established that 2.91% of patients with ACC had thromboembolic complications, which were manifested in the form of deep vein thrombosis and PE of small branches and were more often diagnosed in patients with significantly older age (on average, 72.67±11.13 years of age). Thromboembolic complications in patients with ACC developed reliably more often in people who had concomitant pathology (hypertensive disease, IHD, COPD, liver cirrhosis, stroke). Patients with a complicated thrombotic diagnosis were also diagnosed with final non-thrombotic complications: local and general peritonitis, perivesical abscess, perforation, abdominal sepsis and subhepatic abscess. The average duration of laparoscopic cholecystectomy (LCE) in patients without complications was 60.00 [45.0-70.0] minutes, in patients with non-thrombotic complications - 62.50 [38.5-85.0] minutes, and in patients with thrombotic complications it was significantly longer - 95.0 [95.0-95.0] minutes (p&lt;0.05).&#x0D; Conclusions. In patients with complicated acute cholecystitis, thromboembolic complications with local and general peritonitis, perivesical abscess were diagnosed more often (p&lt;0.05). Patients with complicated acute calculous cholecystitis underwent cholecystectomy (83.33% [46.48-99.96]) reliably more often than patients with uncomplicated acute cholecystitis, whereas LCE was performed only in 16.67% [0.04-53.52] of cases. Therefore, cholecystectomy lasted for more than 1 hour in 80% [38,45-99,94] of cases.

Influence of PTGS1 gene polymorphisms on efficiency and safety of post-operative Ketorolac treatment of uncomplicated acute calculus cholecystitis

Objective : The study aimed to evaluate the possible association of PTGS1 gene polymorphisms (rs10306135, rs12353214) with the clinical effi cacy and safety of ketorolac in relation to postoperative pain. Materials and methods : The study included 107 patients after video laparoscopic cholecystectomy, who received ketorolac 30 mg as postoperative pain relief 2.0 x 3 times a day. All patients were genotyped for PTGS1 (rs10306135, rs12353214). The pain syndrome was assessed using the Visual Analog scale (VAS), the McGill pain questionnaire. The profi le of adverse reactions was assessed by the dynamics of red blood counts, as a possible trigger for the development of gastrointestinal bleeding according to the method of global assessment of triggers (GTT). Results : According to the VAS and the McGill pain questionnaire, there were no statistically signifi cant diff erences in the intensity of pain between the two groups. There were also no statistically signifi cant diff erences in the dynamics of red blood counts. Conclusion : We did not fi nd an association between the carriage of the PTGS1 genotype (rs10306135, rs12353214) and the effectiveness of postoperative anesthesia with ketorolac, and we did not fi nd an association with the risk of developing adverse reactions after ketorolac anesthesia.

National clinical practice guidelines for the treatment of symptomatic gallstone disease: 2021 recommendations from the Danish Surgical Society.

Gallstones are highly prevalent, and more than 9000 cholecystectomies are performed annually in Denmark. The aim of this guideline was to improve the clinical course of patients with gallstone disease including a subgroup of high-risk patients. Outcomes included reduction of complications, readmissions, and need for additional interventions in patients with uncomplicated gallstone disease, acute cholecystitis, and common bile duct stones (CBDS). An interdisciplinary group of clinicians developed the guideline according to the GRADE methodology. Randomized controlled trials (RCTs) were primarily included. Non-RCTs were included if RCTs could not answer the clinical questions. Recommendations were strong or weak depending on effect estimates, quality of evidence, and patient preferences. For patients with acute cholecystitis, acute laparoscopic cholecystectomy is recommended (16 RCTs, strong recommendation). Gallbladder drainage may be used as an interval procedure before a delayed laparoscopic cholecystectomy in patients with temporary contraindications to surgery and severe acute cholecystitis (1 RCT and 1 non-RCT, weak recommendation). High-risk patients are suggested to undergo acute laparoscopic cholecystectomy instead of drainage (1 RCT and 1 non-RCT, weak recommendation). For patients with CBDS, a one-step procedure with simultaneous laparoscopic cholecystectomy and CBDS removal by laparoscopy or endoscopy is recommended (22 RCTs, strong recommendation). In high-risk patients with CBDS, laparoscopic cholecystectomy is suggested to be included in the treatment (6 RCTs, weak recommendation). For diagnosis of CBDS, the use of magnetic resonance imaging or endoscopic ultrasound prior to surgical treatment is recommended (8 RCTs, strong recommendation). For patients with uncomplicated symptomatic gallstone disease, observation is suggested as an alternative to laparoscopic cholecystectomy (2 RCTs, weak recommendation). Seven recommendations, four weak and three strong, for treating patients with symptomatic gallstone disease were developed. Studies for treatment of high-risk patients are few and more are needed. The Danish Surgical Society.

EP-617 Early vs delayed laparoscopic cholecystectomy for acute cholecystitis: A systemic review

Abstract Background Gallstones are present in approximately 10% to 15% of the adult western population with 1% to 4% of patients becoming symptomatic each year. Laparoscopic cholecystectomy for acute cholecystitis is usually performed after the acute cholecystitis episode settles because of the perceived fear of higher morbidity and of need for conversion from laparoscopic to open cholecystectomy. However, delaying surgery may expose the individual to gallstone-related complications. Aims &amp; objectives To compare early laparoscopic cholecystectomy, defined as less than seven days of clinical presentation with acute cholecystitis, versus delayed laparoscopic cholecystectomy more than six weeks after index admission and conservative treatment for acute cholecystitis. Search Criteria Clinical databases were searched for suitable studies. Randomised and non-randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy in participants with acute cholecystitis published after 1994 were included. Results 16 studies were identified for this review and the outcomes measured were operation time, conversion to open surgery, postoperative complication, post operative pain and analgesia use, length of hospital stay, and duration of antibiotic therapy. For all but one of the criteria it has been found that early and delayed laparoscopic surgery were equivalent for these end points. The endpoint antibiotic duration post-surgery still remains an area of contention. Conclusion Early and delayed cholecystectomy for the treatment of uncomplicated acute cholecystitis is both safe and feasible. Early laparoscopic cholecystectomy is preferred over delayed laparoscopic cholecystectomy mainly because of decreased length of hospital stay in the early laparoscopic cholecystectomy group. This is a clear advantage.

Emergency single-incision laparoscopic cholecystectomy for acute cholecystitis: A multi-center study.

Single-incision laparoscopy is accepted as a safe alternative to multiple port laparoscopy for elective cholecystectomy; however, there are limited data on its use in patients with acute cholecystitis. The present multi-center study evaluated the outcomes of emergency single-incision surgeries for acute cholecystitis in hospitals in Belgium, Jamaica, and Trinidad and Tobago over a 5-year period. Standardized definitions of uncomplicated and complicated acute cholecystitis were used and the data were compared using SPSS software. The results revealed that over the 5-year period, 108 patients with a mean age of 48±15 years and a mean body mass index of 27±4.2 kg/m2 underwent emergency single-incision cholecystectomies. The surgeries were successful in 92.1% of cases without supplemental trocars being used. The overall morbidity rates (9.3%) were also comparable to the historic controls with multiple port cholecystectomy. As was expected, the complicated cholecystitis group required a significantly longer operating time (86.11±30.16 vs. 66.79±16.8; P<0.00194), as well as supplemental trocars (7.9%) vs. 0; P=0.0413). On the whole, the present study demonstrates that emergency single-incision cholecystectomy is a technically feasible and safe procedure for patients with acute cholecystitis. These findings advocate a low threshold to place additional ports to assist with dissection and exposure.

PECULIARITIES OF CLINICAL COURSE OF ACUTE CALCULOUS CHOLECYSTITIS

Introduction. Rational approaches to the diagnosis and tactics of surgical treatment of acute cholecystitis have resulted in the cut down in postoperative mortality. Despite the frequent occurrence of acute cholecystitis in everyday practice, interest in the problem of its treatment does not fade. With such an extensive and comprehensive investigation of this issue, the availability of international and national recommendations, nevertheless, there are some unresolved issues, including, in particular, the problem of the treatment of acute calculous cholecystitis, the peculiarities of its diagnosis and clinical course. The aim of the study is to elucidate the peculiarities of the clinical course of acute calculous cholecystitis. Methods. We analyzed the findings of diagnostic procedures of 209 patients who received inpatient treatment for uncomplicated acute calculous cholecystitis at the surgical department of the Malovyskivska Central District Hospital, Kirovograd region, from 2016 to 2021. The age of all patients ranged from 18 to 89 years. Results. Ultrasound examination of the abdominal organs plays an important role in the diagnosis of acute and chronic cholecystitis in everyday practice. The patients indicated a history of attacks of hepatic colic, mechanical jaundice. Having analyzed the anamnesis data, we determined the duration of cholelithiasis and the duration of acute calculous cholecystitis in the participants. The most typical symptom of acute cholecystitis was constant or paroxysmal pain with localization in the right hypochondrium. Conclusions. The course of acute calculous cholecystitis in the patients is characterized by a polymorphic clinical picture, its severity is less pronounced due to the depth of pathomorphological changes in the gallbladder wall. Complications of acute calculous cholecystitis produce a significant impact on the course of the disease, moreover, the severity of the systemic inflammatory reaction and concomitant pathology of the patients ' condition is also predetermined by the presence of concomitant pathology.

EP.TH.917An Audit of Compliance with NICE guidelines for Acute Cholecystitis

Abstract Background Gallstone disease is common and affects approximately 10-15% of adults. Laparoscopic Cholecystectomy (LC) is the definitive management of cholecystitis. NICE and RCS guidance recommend that in patients diagnosed with acute cholecystitis a LC should be performed during the same admission or within 7 days. We audited our compliance against these national guidelines. Methods Retrospective audit of all patients admitted with uncomplicated acute cholecystitis over a 4 month period. Patient demographics, admission details, timing of cholecystectomy, complications, follow-up, and re-admission data were collected. Results 50 patients (60% female, 40% male; mean age: 60.7 years) with acute cholecystitis were included. Mean length of stay was 4.8 days. Only 10% had a cholecystectomy within 1 week of diagnosis. Of those discharged without a LC on the index admission, 14% were readmitted with further gallstone related complications (cholangitis, pancreatitis) within 48.6 days from initial discharge. The mean time to surgery after initial discharge was 125.8 days. Conclusion There is poor compliance with NICE guidelines to perform an early LC in our cohort of patients, primarily because of the lack of Trust based guidelines. This audit demonstrates the need to develop a robust ‘hot gallbladder’ pathway within our hospital to improve current practice.

A case of acute calculous cholecystitis with contained gall bladder perforation with pericholecystic collections extending to liver parenchyma

Gall bladder perforation is a serious complication of acute cholecystitis and represents an advanced stage of the disease. Its clinical presentation is varied and can range from non-specific symptoms to acute generalized peritonitis. In many cases, GB perforation in diagnosis during exploratory laparotomy for peritonitis and with no definite source identified. The presentation of gall bladder perforation can be indistinguishable from uncomplicated acute cholecystitis. A 60 yrs. old male with no known comorbidities presented to a tertiary care hospital with diffuse pain abdomen associated with vomiting and constipation of 04 days’ duration. Clinical evaluation revealed icterus and tenderness in right hypochondrium and generalized peritonitis. Lab investigations revealed conjugated type hyperbilirubinemia and elevated serum Lipase levels and normal Amylase levels. Initial USG revealed Acute acalculous cholecystitis with normal IHBR and normal CBD. Later NCCT abdomen and MRCP were done which revealed calculous cholecystitis with sealed off GB perforation IHBR, CBD, and normal pancreas. The patient was managed non-operatively and responded well. The inflammatory reaction of the peritoneum in bile peritonitis increases the absorption of the spilled conjugated bile from the peritoneal cavity. The conjugated type hyperbilirubinemia without dilatation of the bile duct on imaging examination was the sign of bile leakage into the peritoneal cavity.

902 Too Hot to Handle? Acute Cholecystitis (‘Hot Gallbladder’) Management and Compliance with NICE Guidelines in A District General Hospital

Abstract Introduction Current NICE guidelines recommend that patients with acute cholecystitis should be offered laparoscopic cholecystectomy within 1 week of diagnosis. However, the recommendation is often not met within our trust. We aim to investigate our compliance with these guidelines while outlining the complications and cost effects associated with delayed operation. Method A retrospective study identifying emergency patients presenting with image proven uncomplicated acute cholecystitis was performed. Hospital coding and finance departments were used to obtain this information. Results 166 patients were identified within a 3-month period. Of which, 85 patients were diagnosed with acute uncomplicated cholecystitis and fulfilled the inclusion criteria. On average, patients waited 108 days for their cholecystectomies (range 14-281). No patients received a cholecystectomy within 1 week of diagnosis. 33 patients re-presented to hospital at least once and the total number of repeated admissions was 51. The average length of stay during readmissions was 6 days (range 1-27). The total cost incurred for those readmissions was £117,118. Conclusion Delayed cholecystectomies for acute cholecystitis increase the likelihood of repeated hospital admissions and place significant strain on resources. Furthermore, it is associated with increased risk of complications. We recommend introducing a weekly ‘hot gallbladder list’ within our trust dedicated for acute cholecystitis.

Complicated Acute Cholecystitis: The Role of C-Reactive Protein and Neutrophil-Lymphocyte Ratio as Predictive Markers of Severity.

ObjectivesThe clinical diagnosis of complicated acute cholecystitis (CAC) remains difficult with several pathological or ultrasonography criteria used to differentiate it from uncomplicated acute cholecystitis (UAC). This study aims to evaluate the use of combined inflammatory markers C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR) as surrogate markers to differentiate between UAC and CAC.MethodsWe identified 600 consecutive patients admitted with biliary symptoms during an acute surgical take from our electronic prospectively maintained database over a period of 55 months. Only patients undergoing emergency cholecystectomy performed during the index admission were included. The primary outcome was the finding of CAC versus UAC.ResultsA total of 176 patients underwent emergency laparoscopic cholecystectomy (ELC) during the index admission, including 118 (67%) females with a median age of 51 years (range: 21-97 years). The proportion of UAC (130 [74%]) and CAC (46 [26%]) was determined along with demographic data. Multivariate regression analysis showed that patient’s age (OR=1.047; p=0.003), higher CRP (OR=1.005; p=0.012) and NLR (OR=1.094; p=0.047) were significant independent factors associated with severity of cholecystitis. Receiver operating characteristic (ROC) analysis for CRP showed an AUC (area under the curve) of 0.773 (95% CI: 0.698- 0.849). Using a cut-off value of 55 mg/L for CRP, the sensitivity of CAC was 73.9% and specificity was 73.1% in predicting CAC. The median post-operative length of stay was four days. The conversion rate from laparoscopic cholecystectomy to open surgery was 2% (4/176), and 5% (9/176) patients suffered post-operative complications with no mortality at 30 days.ConclusionCRP, NLR and age were independent factors associated with the severity of acute cholecystitis. NLR and CRP can be used as surrogate markers to predict patients at risk of CAC during emergency admission, which can inform future guidelines. Moreover, ELC for CAC can be safely performed under the supervision of dedicated upper GI surgeons.

Laparoscopic approach for coexisting cholecystogastric and cholecystocolonic fistula: a case report

Background: Cholecystoenteric fistula (CEF) is a rare intraoperative finding during video laparoscopic cholecystectomy. The presence of a double cholecystogastric (CGF) and cholecystocolonic fistula (CCF) is even more rare, and its management is not fully codified. Case Presentation: We present the case of a 26-year-old woman known for cholelithiasis and a previous episode of uncomplicated acute cholecystitis and subsequent indication to elective cholecystectomy. Routine pre-operative studies did not show signs of biliary abnormalities. Intraoperative findings consisted of a coexisting CGF and CCF, which were successfully treated laparoscopically. Conclusion: Laparoscopic approach can be safe and feasible in selected cases of double complete CEFs.

The Effect of Polymorphisms in the CYP2D6 and CYP2C9 Genes on the Clinical Efficacy of Tramadol and Ketorolac When Using the Accelerated Recovery Protocol in Patients With Uncomplicated Acute Calculous Cholecystitis Who Underwent Cholecystectomy

Relevance. One of the key components of the accelerated recovery protocols (ARP), in addition to minimizing the surgical approach, is an adequate postoperative analgesia. Despite this, applied postoperative analgesia combinations are not devoid of drawbacks, such as lack of effective postoperative analgesia and the presence of side effect. The use of a pharmacogenetic approach to analgesic therapy for the purpose of its personalization may increase the effectiveness and safety of the use of analgesics. In particular, the presence of an inactive CYP2D6*4 allele , in which the conversion of tramadol to its active metabolite is reduced, contributes to the insufficient efficacy of the drug. As for non-steroidal anti-inflammatory drugs, the presence of CYP2C9*2/*3 polymorphisms leads to a decrease in drug metabolism and a longer half-life, resulting in the increase of the clinical effect and the risk of adverse reactions. Thus, genotyping of patients with the determination of the presence of specific genetic factors can rationalize the postoperative analgesia.Aim of study. Evaluation of the possible association of polymorphisms of the CYP2D6 and CYP2C9 genes with the clinical efficacy of tramadol and ketorolac in relation to postoperative pain.Material and methods. This observational clinical study involved 107 patients with uncomplicated acute calculous cholecystitis who underwent videolaparoscopic cholecystectomy and perioperative treatment according to ARP. All patients underwent whole blood sampling followed by real-time polymerase chain reaction genotyping. Analgesic efficacy was assessed using a visual analog scale (VAS) and McGill Pain Questionnaire.Results. In CYP2D64* carriers pain was higher than that of wild-type carriers, according to VAS and McGill Pain Questionnaire in all investigated periods. In carriers of CYP2C9*2, the pain syndrome was lower than in carriers of the wild type at all intervals studied. In carriers of CYP2C9*3 pain was lower only after 2 and 6 hours, also according to McGill Pain Questionnaire.Conclusion. 1. The presence of the polymorphic marker CYP2D6*4 may reduce the efficacy of postoperative tramadol analgesia compared with wild type. 2. The presence of the polymorphic marker CYP2C9*2 and CYP2C9*3 may increase the efficacy of ketorolac pain relief compared to wild type.

AB161. 182. Emphysematous cholecystitis: case report on a rare, life threatening presentation

: A 78-year-old gentleman with type 2 diabetes mellitus, atrial fibrillation, chronic kidney disease and hypertension presented to the emergency department with sudden onset of severe right upper quadrant with associated vomiting. White cell count showed a leukocytosis of 24×10×9/L and a C-reactive protein of 57 mg/L. An ultrasound abdomen revealed no acute gallbladder or biliary pathology. Computed tomography of the abdomen revealed pericholecystic fat stranding, an air-liquid level within the gallbladder and gas dissecting along a significant portion of the gallbladder wall—findings consistent with emphysematous cholecystitis, grade 3 with associated perforation and small volume of portal venous gas. Our patient underwent an emergency laparotomy with cholecystectomy. Pathology examination revealed acute acalculous gangrenous cholecystitis. Our patient required a 5-day admission to intensive care unit post-operatively. Emphysematous cholecystitis was first described at autopsy in 1901 by Stolz, who characterized emphysematous cholecystitis by the presence of air within the gallbladder and/or the biliary tree in the absence of an abnormal communication between the biliary system and the gastrointestinal tract. Emphysematous cholecystitis is a potentially life-threatening anaerobic infection, is a variant of acute cholecystitis. The mortality rate for acute emphysematous cholecystitis however is 15–50%. Despite the high mortality associated with gangrene and gallbladder perforation, patients with emphysematous cholecystitis do not exhibit alarming clinical signs of sepsis, and the presenting symptoms are often nonspecific and initially indistinguishable from those of uncomplicated acute cholecystitis. Patients with diabetic neuropathy may not experience typical right upper quadrant pain and maybe present with a paucity of symptoms.

Surgical treatment of acute calculous cholecystitis followed by one-day discharge of patients

To develop rational tactics of surgical treatment of patients with acute calculous cholecystitis with their subsequent discharge within 1 day since admission. There were 283 patients with acute cholecystitis and 58 patients with chronic cholecystitis. All patients underwent laparoscopic cholecystectomy. Patients with acute cholecystitis were divided into 2 groups: main group - 136 patients were discharged within 1 day since admission, control group - 147 patients who were discharged later. Age, gender, duration of attack and ASA score were similar in both groups. Incidence of intraoperative complications was significantly higher in the control group compared with the main group (6.1% vs. 0.7%). There were no postoperative complications in the main group; postoperative morbidity in the control group was 6.1%. Criteria preventing discharge within 1 day since admission were developed. Uneventful early postoperative period after laparoscopic cholecystectomy allows us to discharge 48% of patients with uncomplicated acute calculous cholecystitis within 1 day since hospitalization. The developed algorithm of treatment is followed by reduced hospital-stay by 4 days. The developed algorithm of treatment of patients with acute calculous cholecystitis can reduce hospital-stay up to 1 day. Favorable early postoperative period and follow-up of patients after discharge are essential for safe treatment.

Early Versus Delayed Laparoscopic Cholecystectomy for Uncomplicated Acute Cholecystitis

Introduction: Acute cholecystitis is a relatively common complication of gallstones It can lead to significant morbidity and mortality from potentially life-threatening complications such as empyema, gallbladder gangrene and gallbladder perforation It presents as a surgical emergency and usually requires hospitalization for management Laparoscopic cholecystectomy is advocated for acute cholecystitis; however, the timing of cholecystectomy and the value of the additional treatments have been a matter of controversy Aim: To compare the outcome of early versus delayed laparoscopic cholecystectomy in cases of non-complicated acute cholecystitis, as its place remains controversial in the management of acute cholecystitis due to a high reported incidence of bile leaks and conversion rate Design: Prospective interventional comparative study Methods: 120 Patients admitted to Qena and Aswan universities’ hospitals with acute cholecystitis over two years period (2013-2015) were included in this study An early laparoscopic cholecystectomy (ELC), within 7 days from onset of symptoms, for 50 patients, and delayed Laparoscopic cholecystectomy (DLC) after 6 weeks of conservative treatment for 70 patients was performed Demographic details, operative findings, conversion to open surgery, operative time, complications, timing of endoscopic retrograde cholangiopancreatography (ERCP) and hospital stay for all those patients were recorded Statistical analysis was performed by SPSS version 18 Results: There was insignificant difference in the conversion rates (2 in ELC group versus 2 DLC group, p value: 0.555), post-operative hospital stay (2 days vs 1.5days, p value: 0.375) However, operative time was significantly more in the ELC group (85 minutes versus 70 minutes, p value: 0.023) Postoperative ERCP was required in 2 patients in ELC group and one patient in DLC group Pre-operative ERCP was required in 2 patients in delayed group 40% of patients (48) had previous admissions with similar symptoms Conclusion: ELC for uncomplicated acute cholecystitis is technically demanding surgery, but it is safe and do not have increased complication rate than DLC It decreases re-admission rate and overall hospital stay.