Does early surgery imply a critical risk for patients with Grade III acute cholecystitis?

Kohga, Atsushi; Okumura, Toshikatsu; Yamashita, Kimihiro; Isogaki, Jun; Kawabe, Akihiro; Kimura, Taizo

doi:10.1111/ases.12799

Cited by 5 publications

(3 citation statements)

References 23 publications

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“…Stabilizing the patient medically, followed by early source control should be the preferred strategy nonetheless. A recent Japanese cohort of 35 patients showed that for severe cholecystitis, “early” CCE (≤ 7 days after admission) was safe and lead to less conversions and a shorter overall length of stay [ 17 ].…”

Section: Discussionmentioning

confidence: 99%

Primary admission to a surgical service facilitates early cholecystectomy in acute cholecystitis but does not influence patient outcome

Strohäker

Sabrow

Meier

et al. 2023

Langenbecks Arch Surg

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Purpose Early cholecystectomy is recommended for acute calculous cholecystitis to reduce complications and lower health care costs. However, not all patients admitted to emergency services due to acute calculous cholecystitis are considered for surgery immediately. Our intention was therefore to evaluate patient management and outcome parameters following cholecystectomy depending on the type of emergency service patients are primarily admitted to. Methods We performed a retrospective analysis of all patients that were treated for acute cholecystitis at our hospital between 2014 and 2021. Only patients that underwent surgical treatment for acute calculous cholecystitis were included. Patients with cholecystectomies that were performed due to other medical conditions were not incorporated. Primary outcomes were the perioperative length of stay and postoperative complications. Perioperative antimicrobial management and disease deterioration according to Tokyo Guidelines from 2018 due to inhouse organization were assessed as secondary outcome parameters. Results Of 512 patients included in our final analysis, 334 patients were primarily admitted to a surgical emergency service (SAG) whereas 178 were initially treated in a medical service (MAG). The latency between admission and cholecystectomy was significantly prolonged in the MAG with a median time to surgery of 2 days (Q25 1, Q75 3.25, IQR 2.25) compared to the SAG with a median time to surgery of 1 day (Q25 1, Q75 2, IQR 1) (p < 0.001). The duration of surgery was comparable between both groups. Necrotizing cholecystitis (27.2% vs. 38.8%, p = 0.007) and pericholecystic abscess or gallbladder perforation (7.5% vs. 14.6% p = 0.010) were less frequently described in the SAG. In the SAG, 85.7% of CCEs were performed laparoscopically, 6.0% were converted to open, and 10.4% were performed as open surgery upfront. In the MAG, 80.9% were completed laparoscopically, while 7.2% were converted and 11.2% were performed via primary laparotomy (p = 0.743). Histologically gangrenous cholecystitis was confirmed in 38.0% of the specimen in the SAG compared to 47.8% in the MAG (p = 0.033). While the prolonged preoperative stay led to prolonged overall length of stay, the postoperative length of stay was similar at a median of 3 days in both groups. Conclusions To our knowledge, we present the largest single center cohort of acute calculous cholecystitis evaluating the perioperative management and outcome of patients admitted to either medical or surgical service prior to undergoing cholecystectomy. In patients that were primarily admitted to medical emergency services, we found disproportionately more gallbladder necrosis, perforation, and gangrene. Despite prolonged time intervals between admission and cholecystectomy in the MAG and advanced cases of cholecystitis, we did not record a prolonged procedure duration, conversion to open surgery, or complication rate. However, patients with acute calculous cholecystitis should either be primarily admitted to a surgical emergency service or at least a surgeon should be consulted at the time of diagnosis in order to avoid disease progression and unnecessary health care costs.

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Section: Discussionmentioning

confidence: 99%

Primary admission to a surgical service facilitates early cholecystectomy in acute cholecystitis but does not influence patient outcome

Strohäker

Sabrow

Meier

et al. 2023

Langenbecks Arch Surg

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“…While this rate varies between 1 and 15% for elective operations, it is higher in acute cholecystitis. [2,12,15,16] Not being able to reveal the anatomy completely, adherences, bleeding and biliary tract injuries are reported to be among the causes. In the series we present, our rate of conversion to open surgery in laparoscopic cholecystectomy in the patients with acute cholecystitis is 9%.…”

Section: Discussionmentioning

confidence: 99%

Complications during laparoscopic cholecystectomy performed due to acute cholecystitis

Kutluer¹

2020

Laparosc Endosc Surg Sci

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Introduction: Today, laparoscopic cholecystectomy is essential in the treatment of acute cholecystitis, particularly in all patients who have applied in the early period and can tolerate surgery. Although the rates of complication and conversion to open surgery tend to decrease over time with the increasing experience, they are still among the important problems today. The most important complications of laparoscopic cholecystectomy in acute cholecystitis are biliary tract injuries and bleeding. In this article, we aimed to retrospectively present the complications that we encountered in laparoscopic cholecystectomy due to acute cholecystitis. Materials and Methods: The patients, who underwent laparoscopic cholecystectomy with the diagnosis of acute cholecystitis between March 2016 and December 2019, were retrospectively examined. The patients' age, gender, symptoms-examination findings, laboratory findings, ultrasonography findings and pathology findings were analyzed. Complications and the rate of conversion to open in surgical treatment were evaluated. Results: Of 70 the patients included in this study, 22 (31%) were male and 48 (69%) were female. The ages of the patients were between 25-70 and the mean age was 46.08±11.8. Open surgery was performed in six patients (9%). Perop-postop complications developed in three (4%) patients in total. Conversion to open was required in one of these patients. Biliary tract injury occurred in one patient, cystic duct stump leak occurred in one patient, and choledochal stenosis occurred in one patient. Conclusion: As a result, early laparoscopic cholecystectomy in acute cholecystitis is an acceptable treatment option with these complications and rates of conversion to open. It should be considered that complications may occur in the interim period and patients will be at a second risk due to the postponed operation. Minimal invasive methods should be preferred as much as possible with developing complications, and if necessary, support should be obtained from more experienced teams.

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“…Kohga et al reported that LC could be performed even in Grade III AC as safely as in Grade I and II. 24 As assessments of the intraoperative difficulty and surgical techniques in LC have progressed since the publication of the TG18, there might be some patients who benefitted from up-front cholecystectomy even though they had ASA-PS of ≥3 or age-adjusted CCI of ≥4 in the cases with Grade III AAC. 25 However, two deaths were actually recorded in the DT group and the DT group had significantly younger age, lower ASA-PS, and lower CRP levels than the CT group.…”

Section: Factorsmentioning

confidence: 99%

Current status and therapeutic strategy of acute acalculous cholecystitis: Japanese nationwide survey in the era of the Tokyo guidelines

Morikawa,

Akada,

Shimizu

et al. 2023

J Hepato Biliary Pancreat

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PurposeThis study aimed to clarify the incidence, therapeutic modality, and prognosis of acute acalculous cholecystitis and to reveal its optimal treatment strategy.MethodsAs a project study of the Japanese Society for Abdominal Emergency Medicine, we performed a questionnaire survey of demographic data and perioperative outcomes of acute acalculous cholecystitis treated between January 2018 and December 2020 from 42 institutions.ResultsIn this study, 432 patients of acute acalculous cholecystitis, which accounts for 7.04% of acute cholecystitis, were collected. According to the Tokyo guidelines severity grade, 167 (38.6%), 202 (46.8%), and 63 (14.6%) cases were classified as Grade I, II, and III, respectively. A total of 11 (2.5%) patients died and myocardial infarction/congestive heart failure was the only independent risk factor for in‐hospital death. Cholecystectomy, especially the laparoscopic approach, had more preferable outcomes compared to their counterparts. The Tokyo guidelines flow charts were useful for Grade I and II severity, but in the cases with Grade III, upfront cholecystectomy could be suitable in some patients.ConclusionsThe proportions of severity grade and mortality of acute acalculous cholecystitis were found to be similar to those of acute cholecystitis, and laparoscopic cholecystectomy is recommended as an effective treatment option. (UMIN000047631).

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Does early surgery imply a critical risk for patients with Grade III acute cholecystitis?

Cited by 5 publications

References 23 publications

Primary admission to a surgical service facilitates early cholecystectomy in acute cholecystitis but does not influence patient outcome

Primary admission to a surgical service facilitates early cholecystectomy in acute cholecystitis but does not influence patient outcome

Complications during laparoscopic cholecystectomy performed due to acute cholecystitis

Current status and therapeutic strategy of acute acalculous cholecystitis: Japanese nationwide survey in the era of the Tokyo guidelines

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