cute cholecystitis is an acute inflammatory disease of the gallbladder that is caused by gallstone obstruction of the cystic duct in approximately 90% to 95% of people diagnosed with this condition. 1 Less commonly, acalculous cholecystitis, in which acute inflammation of the gallbladder develops without gallstones, is present in approximately 5% to 10% of people diagnosed with acute cholecystitis.Gallbladder disease affects approximately 20 million individuals in the US and results in estimated direct annual costs of more than $6.3 billion, with more than 200 000 people diagnosed with acute cholecystitis each year. [2][3][4] Of the 10% to 15% of adults in the US general population with cholelithiasis, approximately 80% are asymptomatic. 5 Twenty percent of patients with gallstones will eventually develop gallstone-related complications at an incidence rate of 1% to 4% annually, with calculous acute cholecystitis as the first clinical presentation in 10% to 15% of all patients with gallstones. 6 In contrast, the etiology of acalculous acute cholecystitis, defined as an acute inflammatory disease of the gallbladder in the absence of cholelithiasis, is multifactorial. Factors associated with acalculous acute cholecystitis include critical illness, diabetes, HIV infection, atherosclerosis, and total parenteral nutrition. 7,8 Acalculous acute cholecystitis is present in approximately 5% to 10% of patients presenting with acute cholecystitis. Acalculous IMPORTANCE Gallbladder disease affects approximately 20 million people in the US. Acute cholecystitis is diagnosed in approximately 200 000 people in the US each year.OBSERVATIONS Gallstone-associated cystic duct obstruction is responsible for 90% to 95% of the cases of acute cholecystitis. Approximately 5% to 10% of patients with acute cholecystitis have acalculous cholecystitis, defined as acute inflammation of the gallbladder without gallstones, typically in the setting of severe critical illness. The typical presentation of acute cholecystitis consists of acute right upper quadrant pain, fever, and nausea that may be associated with eating and physical examination findings of right upper quadrant tenderness. Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis. When an ultrasound result does not provide a definitive diagnosis, hepatobiliary scintigraphy (a nuclear medicine study that includes the intravenous injection of a radiotracer excreted in the bile) is the gold standard diagnostic test. Following diagnosis, early (performed within 1-3 days) vs late (performed after 3 days) laparoscopic cholecystectomy is associated with improved patient outcomes, including fewer composite postoperative complications (11.8% for early vs 34.4% for late), a shorter length of hospital stay (5.4 days vs 10.0 days), and lower hospital costs. During pregnancy, early laparoscopic cholecystectomy, compared with delayed operative management, is associated with a lower risk of ...

BackgroundThe staged laparotomy in the operative management of emergency general surgery (EGS) patients is an extension of trauma surgeons operating on this population. Indications for its application, however, are not well defined, and are currently based on the lethal triad used in physiologically-decompensated trauma patients. This study sought to determine the acute indications for the staged, rapid source control laparotomy (RSCL) in EGS patients.MethodsAll EGS patients undergoing emergent staged RSCL and non-RSCL over 3 years were studied. Demographics, physiologic parameters, perioperative variables, outcomes, and survival were compared. Logistic regression models determined the influence of physiologic parameters on mortality and postoperative complications. EGS-RSCL indications were defined.Results215 EGS patients underwent emergent laparotomy; 53 (25 %) were staged RSCL. In the 53 patients who underwent a staged RSCL based on the lethal triad, adjusted multivariable regression analysis shows that when used alone, no component of the lethal triad independently improved survival. Staged RSCL may decrease mortality in patients with preoperative severe sepsis / septic shock, and an elevated lactate (≥3); acidosis (pH ≤ 7.25); elderly (≥70); male gender; and multiple comorbidities (≥3). Of the 162 non-RSCL emergent laparotomies, 27 (17 %) required unplanned re-explorations; of these, 17 (63 %) had sepsis preoperatively and 9 (33 %) died.ConclusionsThe acute physiologic indicators that help guide operative decisions in trauma may not confer a similar survival advantage in EGS. To replace the lethal triad, criteria for application of the staged RSCL in EGS need to be defined. Based on these results, the indications should include severe sepsis / septic shock, lactate, acidosis, gender, age, and pre-existing comorbidities. When correctly applied, the staged RSCL may help to improve survival in decompensated EGS patients.

BACKGROUND Transfusion with uncrossmatched cold-stored low-titer group O-positive or -negative whole blood (WB) in civilian trauma has been investigated as an alternative to component therapy but only in limited volumes. To our knowledge, this is the first analysis of the safety and efficacy of large volume transfusion of patients with trauma with WB. METHODS This is a retrospective cohort analysis comparing trauma patients resuscitated with component therapy (COMP) versus component therapy plus WB. The COMP group was comprised of patients who presented from January 2017 through June 2018 and the WB group from patients who presented from July 2018 through January 2019 after WB became available. We included patients if they received 1 unit of WB or red blood cells (RBCs) within 24 hours of admission and had massive transfusion protocol activated. We used bivariate analysis to compare groups. For analysis, one unit of WB equaled 1 unit of RBCs, 1 unit of plasma, and 1/6 of a unit of platelets. RESULTS Forty-two patients received WB and 83 patients received COMP with similar baseline characteristics. Patients had a median age of 41 years (interquartile range [IQR], 28–61 years) and 73% were male. Thirty percent had penetrating injuries with a median Injury Severity Score of 29 (IQR, 17–38). The WB group received a median of 6.5 units (IQR, 3–11). The WB group received significantly more component-equivalent units but with a plasma/RBC ratio of 0.94:1 compared with 0.8:1 (p < 0.001). There were no differences in 24-hour mortality (COMP, 27% vs. WB, 29%, p = 0.8) or 30-day mortality (COMP, 46% vs. WB, 58% p = 0.2). There were no transfusion reactions. CONCLUSION Transfusion utilizing primarily WB in civilian trauma is feasible, even in large volumes. It appears to be a safe and effective addition to component therapy and may lead to a more balanced resuscitation but with more overall product used. LEVEL OF EVIDENCE Therapeutic study, Level IV.