Effect of Timing of Surgery, Type of Inflammation, and Sex on Outcome of Laparoscopic Cholecystectomy for Acute Cholecystitis

Department of General Surgery, Princess Basma Teaching Hospital, University of Science and Technology, Irbid, Jordan.
Journal of Laparoendoscopic & Advanced Surgical Techniques (Impact Factor: 1.34). 07/2002; 12(3):193-8. DOI: 10.1089/10926420260188092
Source: PubMed


Studies have shown the safety and effectiveness of laparoscopic cholecystectomy (LC) for acute cholecystitis (AC). Our aim was to establish the outcome of LC in patients with AC on the basis of duration of the attack before surgery took place, the type of gallbladder inflammation, and patient sex.
All 204 patients at Princess Basma Teaching Hospital who underwent LC for AC by the authors between September 1994 and June 1999, were retrospectively reviewed. They were categorized into Group I, where surgery took place within 72 hours of the acute attack (N = 78; 54 women and 24 men), and Group II, if later than that (N = 126; 70 women and 56 men). Gallbladder pathology was classified as gangrenous, empyema, edematous, mucocele, or AC along with contracted fibrosed gallbladder.
Conversion to open cholecystectomy was needed in 12% of the total series. In Group I, 3.8% of the patients needed conversion compared with 16.7% in Group II patients (P = 0.01). Also, 4% of the female patients needed conversion compared with 24% of the male patients (P = 0.000). There was an association between the pathological type of AC and the likelihood of conversion (P = 0.002), conversion being least common in those with mucocele and most common in those with empyema and gangrene. The median operation time was 75 +/- 36 minutes, but the operation time for Group II patients was significantly longer (P = 0.001) than in Group I patients. Operation time in the male patients was significantly longer than in the female patients (P = 0.000). There was no statistically significant difference in the duration of hospital stay in the two groups or in men and women. There were no deaths or main bile duct injuries in the series. In successful LC, missed stones occurred in 3.3% of the patients. Bile collection, which was treated by open surgery, developed in one female patient.
Laparoscopic cholecystectomy is a reliable and safe modality for the management of AC. It was not associated with an increased incidence of bile duct injury in this series. It should be the first choice before resorting to open surgery. Factors associated with increased conversion include delay in surgery of more than 3 days from the acute attack and certain pathology, with conversion being more likely in empyema. Conversion also was more likely in male patients.

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Available from: Kamal Bani-Hani, Apr 11, 2015
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    • "Conversely, scarring and dense fibrotic adhesions render performing dissection more difficult in the delayed phase, increasing the conversion rate. Many reports thus recommend performing surgery early, within 3–4 days after symptom onset [12–15]. However, many patients are actually referred to the department of surgery after this early period and, therefore undergo elective surgery. "
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    ABSTRACT: Purpose Cholecystectomy can become hazardous when inflammation develops, leading to anatomical changes in Calot’s triangle. We attempted to study the safety and efficacy of laparoscopic subtotal cholecystectomy (LSC) to decrease the incidence of complications and the rate of conversion to open surgery. Methods Patients who underwent LSC between January 2005 and December 2008 were evaluated retrospectively. The operations were performed laparoscopically irrespective of the grade of inflammation estimated preoperatively. However, patients with severe inflammation of the gallbladder underwent LSC involving resection of the anterior wall of the gallbladder, removal of all stones and placement of an infrahepatic drainage tube. To prevent intraoperative complications, including bile duct injury, intraoperative cholangiography was performed. Results LSC was performed in 26 elective procedures among 26 patients (eight females, 18 males). The median patient age was 69 years (range 43–82 years). The median operative time was 125 min (range 60–215 min) and the median postoperative inpatient stay was 6 days (range 3–21 days). Cholangiography was performed during surgery in 24 patients. One patient underwent postoperative endoscopic sphincterotomy for a retained common bile duct stone that was found on cholangiography during surgery. Neither complications nor conversion to open surgery were encountered in this study. Conclusions LSC with the aid of intraoperative cholangiography is a safe and effective treatment for severe cholecystitis.
    Full-text · Article · Jun 2013 · Surgery Today
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    • "The mortality in patients with acute cholecystitis is 0–10%75–81 (Table 8), whereas the mortality in patients with postoperative cholecystitis and acalculous cholecystitis is as high as 23%–40%.82–84 The mortality of elderly patients (75 years and older) tends to be higher than that of younger patients,85,86 and a comorbidity such as diabetes may increase the risk of death.75 "
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    ABSTRACT: This article discusses the definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis. Acute cholangitis and cholecystitis mostly originate from stones in the bile ducts and gallbladder. Acute cholecystitis also has other causes, such as ischemia; chemicals that enter biliary secretions; motility disorders associated with drugs; infections with microorganisms, protozoa, and parasites; collagen disease; and allergic reactions. Acute acalculous cholecystitis is associated with a recent operation, trauma, burns, multisystem organ failure, and parenteral nutrition. Factors associated with the onset of cholelithiasis include obesity, age, and drugs such as oral contraceptives. The reported mortality of less than 10% for acute cholecystitis gives an impression that it is not a fatal disease, except for the elderly and/or patients with acalculous disease. However, there are reports of high mortality for cholangitis, although the mortality differs greatly depending on the year of the report and the severity of the disease. Even reports published in and after the 1980s indicate high mortality, ranging from 10% to 30% in the patients, with multiorgan failure as a major cause of death. Because many of the reports on acute cholecystitis and cholangitis use different standards, comparisons are difficult. Variations in treatment and risk factors influencing the mortality rates indicate the necessity for standardized diagnostic, treatment, and severity assessment criteria.
    Full-text · Article · Feb 2007 · Journal of Hepato-Biliary-Pancreatic Surgery
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    • "Connective tissue and autoimmune diseases like scleroderma, lupus erythematosus,17 and rheumatoid arthritis are more prevalent in females of reproductive age than in postmenopausal females or in men. These diseases decrease in severity when estrogen levels are high.5,18–21 It is also interesting that estrogen receptors are expressed by macrophages, monocytes, lymphocytes, and mast cells, and it is accepted that estrogen directly affects their function and suppresses their cytokine production.8,9,18,22,23 "
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    ABSTRACT: Although laparoscopic cholecystectomy has become the standard treatment for symptomatic gallbladder diseases, conversion to open surgery is required in a substantial proportion of patients. In this study, we attempted to clarify whether male sex carries an increased risk for conversion to open surgery during laparoscopic cholecystectomy. This study comprised 80 patients (41 females, 39 males) with symptomatic gallbladder stones. Average age was 39.2 years, and all female patients were of reproductive age. Patients were excluded from the study if they had acute cholecystitis, previous abdominal surgery, systemic or connective tissue diseases, or were using tobacco, alcohol, or medications that affect wound healing or inflammation. Tissue samples were obtained from the same sites in each gallbladder wall and pericholecystic tissue for the measurement of tissue hydroxyproline (HP) and collagen. Samples were examined under light microscopy for histopathology. Findings in male and female patients were compared by using the Student t test. All patients except 3 males received laparoscopic cholecystectomy. Conversion to open cholecystectomy was necessary in those 3 because of intense pericholecystic fibrosis. In male patient samples, macrophages were twice as numerous as in female samples, whereas mast cells in the men were 4 times more numerous, and eosinophils were 6 times more numerous (P<0.01). In men, HP levels in the gallbladder wall and pericholecystic tissue were 23.4+/-14.9 microg/mg dry tissue and 25.2+/-13.1 microg/mg dry tissue, respectively. The corresponding values in women were 13.1+/-9.4 microg/mg dry tissue and 14.5+/-8.1 microg/mg dry tissue. This higher level of tissue HP in men was statistically significant (P<0.015). Tissue collagen levels both in the submucosal area of the gallbladder wall and in pericholecystic tissue were significantly higher in men than in women (P<0.05). Our data suggest that in the context of symptomatic gallbladder stones, inflammation and fibrosis are more extensive in men than in women. These findings may help explain why the rate of conversion to open surgery is higher in men than in women.
    Full-text · Article · Mar 2006 · JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons
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