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Acute Cholecystitis andAcute Cholecystitis and
The Timing of Surgery:The Timing of Surgery:When is it time to heal with steel?When is it time to heal with steel?
Vincent C. Schooler, MDVincent C. Schooler, MD
Resident Grand RoundsResident Grand Rounds
June 6, 2003June 6, 2003
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Clinical CasesClinical Cases
Case 1
80 yo female
3 days of N/V/RUQ pain
PMH: Cholelithiasis, DM, CHF, HTN
WBC 17 (6% bands); Tbili 9, ALP 197, AST699, ALT 650, Amylase 103, Lipase 19
Abd CT Cholelithiasis with pericholecysticfluid and gallbladder distention
HIDA Scan Cystic duct obstruction
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Clinical CasesClinical Cases
Case 2
48 yo male
progressive RUQ pain for 2 weeks
PMH: DM, HTN, Obesity
WBC 6.8, Tbili 0.8, ALP 88, AST 34, ALT66
Abd U/S: Cholelithiasis in neck ofgallbladder, negative Murphys sign, NoCBD dilatation
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Clinical QuestionsClinical Questions
What is the optimal time for surgery in thesepatients?
What is the evidence that supports a
laparoscopic approach to patients with acutecholecystitis?
What evidence-based clinical factors exist topredict a successful laparoscopic surgicaloutcome?
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StatisticsStatistics
About 3 million adults in the U.S. havegallstones
Elderly, diabetics, obese patients, debilitatedpatients increased incidence of gallstones
90% of acute cholecystitis cases due togallstones
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BackgroundBackground
Aging is the most significant factor higher incidence of acute cholecystitis1
Acute Cholecystitis is the initialpresentation of symptomatic gallstonesin 15% - 20% of patients3
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Acute CholecystitisAcute Cholecystitis
RUQ Pain
Fever
Leukocytosis
Severe persistent pain
+/- Jaundice
Positive Murphys Sign
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Acute CholecystitisAcute Cholecystitis33
Persistent cystic duct obstruction
Pain lasts > 4 hours
Usually fatty food ingestion 1 hr before pain
Biliary Colic
3= Cleveland Clinic Journal of Med3= Cleveland Clinic Journal of Med
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Acute CholecystitisAcute Cholecystitis
Distention and inflammation of thegallbladder
Obstruction of cystic duct Chemicalirritants in the bile Lysolecithin
Prostaglandins
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UptoDate 2003UptoDate 2003
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Acute CholecystitisAcute Cholecystitis22
Thickened gallbladder wall or edema
Pericholecystic Fluid Sonographic Murphys Sign
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Acute CholecystitisAcute Cholecystitis
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Acute CholecystitisAcute Cholecystitis
Early stages Edema and hyperemia
Later stages Adhesions, fibrosis, and necrosis
Triangle of Calot visible in early stagesCourtesy of Netter
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Management of AcuteManagement of Acute
CholecystitisCholecystitis
Supportive care with IVFs, bowel rest, & Abx
Almost half of patients have positive bilecultures
E. Coli is most common organism
Antibiotic choice: Ampicillin + Aminoglycosideor 3rd generation cephalosporin
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Management cont.Management cont.
No evidence exists showing a definitebenefit with use of antibiotics
NSAIDs may improve course of acutecholecystitis6
SURGERY is the only definitive treatment
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Management cont.Management cont.
1st open cholecystectomy: 1886 by Justus Ohage
1st half of 20th Century: Supportive care delayedopen cholecystectomy
In 1970s mid-1980s: Open cholecystectomyearly in the treatment course
Golden 72 hours Rule
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Studies in early 1980s early surgery was betterthan delayed surgery (using standard openapproach)14
Laparoscopic surgery developed in late 1980s
Complications from LC dependent on laparoscopic
skill of surgeon (major bleeding, wound infection,bile leak, and biliary injury)
Was the benefit of early surgery by the open
approach true laparoscopically??
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Timing of SurgeryTiming of Surgery
Early surgery = Within 72 hours ofadmission or onset of symptoms
Delayed surgery = Supportive careonly followed by discharge andreadmission in 6-12 weeks for surgery
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Timing of SurgeryTiming of Surgery
Based on patients overall risk of surgery
American Society of Anesthesiologists (ASA)Scale7 is a guide for decisions on surgery
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Laparoscopic vs. Open CholecystectomyLaparoscopic vs. Open Cholecystectomy
Kiviluoto et al.8
63 pts. randomized to LC vs. OC; > 60 y.o. = 59% vs. 48% 1 endpt = hosp. mortality and morbidity, length of hosp. stay 16% of LC group needed conversion to open No deaths in either group; Hosp. stay average of 2 days shorter in LC
group (p=0.0063) 8Lancet 1998.
3
42
0
1020
30
40
50
Rate (%)
Lap Chole Open Chole
Morbidity
p=0.0048
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Timing of SurgeryTiming of Surgery
Chandler et al.10
Objective: Compare the safety and efficacy ofearly vs. delayed laparoscopic cholecystectomyfor treatment of acute cholecystitis
Study Design:
RCT of 43 pts. Early = LC within 72 hours of admission Delayed = LC after symptom resolution or after
5 days of treatment
IVFs, Piperacillin, bowel rest Delayed group also given indomethacin
10 Amer Surg 2000
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Chandler et al.
Inclusion: RUQ pain, WBC 10K, temp >38C, U/S evidenceInclusion: RUQ pain, WBC 10K, temp >38C, U/S evidence
Exclusion: Hx. of PUD, GB perforation, unclear diagnosisExclusion: Hx. of PUD, GB perforation, unclear diagnosisConclusions:Conclusions:
No statistically significant decrease in the complication rate in theNo statistically significant decrease in the complication rate in the
delayed groupdelayed group
Limitations: Small study group, average age < 40 years oldLimitations: Small study group, average age < 40 years old
0
5
1015
20
2530
35
40
%
Early Delayed
Early vs. Delayed LC
ComplicationConversion
Gangrenous
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Eldar et al.11
Objective: Determine the optimal timing of laparoscopiccholecystectomy for acute cholecystitis and to evaluatepreop. and operative factors associated with conversionfrom LC to OC
Study Design: 137 patients treated for acute cholecystitis
Prospective, non-randomized trial
7 patients excluded due to choledocholithiasis
LC done on all patients as soon as diagnosis established
Cephazolin given preop to all patients
11 World J Surg 1997
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Eldar et al.Eldar et al.
Results:
28% conversion rate overall (37/130 total patients)
Mean age 50 in LC group vs. 60 in converted group
Patients with lap chole >96 hours after symptom onsethigher conversion rate (47% vs. 23%, p=0.022)
Complication rate: 8.5% in LC vs. 27% in converted group
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Eldar et al.Eldar et al.
Conversion Complication
OddsRatio
Acutegangrenouscholecystitis
630.8
Nonpalpable
gallbladder
111.2
WBC > 13K 15.25
Hx. of biliarydisease
12.4
Age > 65 10.5
OddsRatio (* =
NS)
WBC > 13K 13.7
Bili. >0.8mg/dl 9.1
Gender 8.9*
Large bilestones
8.5
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Eldar et al.Eldar et al.
Conclusions:
3/5 independent factors associated with conversion fromLC can be determined preoperatively (WBC, age, hx ofbiliary disease)
2/4 independent factors associated with complicationsfrom LC can be determined preoperatively (WBC, Serumbili)
Limitations: Validation of these factors needed using RCT,small study
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Timing of SurgeryTiming of Surgery
Lai et al.12
Objective: Define the optimummanagement between early anddelayed laparoscopiccholecystectomy
Study Design: Average age in each group of 56
years old
Early group = LC within 24
hrs of randomization Delayed group = LC in 6-8
wks
12 Brit J Surg 1998
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Timing of SurgeryTiming of Surgery
Lai et al.
Results:
No major bile duct injuries in either group
21% (early) vs. 24% (delayed) conversion rate
No statistically significant difference in conversion rate, postop. pain or
complications 16% of delayed group had a recurrence and failed conservative Rx
Conclusions:
Early LC better than delayed LC due to lower conversion rate andpotentially lower risk of complications
Limitations: Selection bias (exclusion of patients with sxs > 1 week)
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Timing of SurgeryTiming of Surgery
Lo et al.13
Objective:Compare early withdelayed laparoscopic chole.(LC) for acute cholecystitis
Study design:
Early = LC within 72 hrs ofadmission
Delayed = LC 8-12 weeks
after resolution of acuteattack
13 Annals Surg 1998
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Lo et al.Lo et al.
Inclusion: RUQ tenderness, T > 37.5C, WBC > 10K, U/S
evidence 44% of patients in trial had symptoms for 3 days Median age of 60 years old
Results:
16% of patients in delayed group failed conservative Rx.urgent LC
1 13
2329
0
1020
30
Rate (%
Early Delayed
Comparison of Outcomes for Laparoscopic Cholecystec
Conversion
Complicatio
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Timing of SurgeryTiming of Surgery
Lo et al.
Conclusions:
Lower hosp. stay and recuperation period in early vs.delayed group (5 days vs. 7 days)
Key factor that is controllable in the timing of surgeryinvolves delay from admission to surgery
Delayed group more fibrotic adhesions on gallbladder increased conversion rate and morbidity
Optimal timing of LC is within 72 hours of admission
Limitations: Low number of obese patients, unclear howmany diabetics in trial
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Timing of SurgeryTiming of Surgery
Koo et al.4
Objective: Review the results of laparoscopiccholecystectomy (LC) in patients with acutecholecystitis with attention to cost and clinical outcome
Study Design:
Retrospective review of 60 patients who had LC foracute cholecystitis
Exclusion: Patients with histopathologic evidence of acutecholecystitis due to pancreatitis or carcinomatosis and
patients without definite signs and symptoms of acutecholecystitis4Arch Surg 1996
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Timing of SurgeryTiming of Surgery
Koo et al.
3 groups based on timing of surgery Group 1: LC within 72 hours of onset of symptoms
Group 2: LC between 4th and 7th day of symptom onset
Group 3: LC after 7 days of symptoms
Results:
13
32 28
0
10
20
30
40
Rate (%)
Group 1 Group 2 Group 3
Conversion
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Timing of SurgeryTiming of Surgery
Koo et al.Conclusions:
Group 1 (LC within 72 hrs of sxs) had lower conversion rate,shorter & less costly operations, and shorter convalescent rates
More severe inflammation in gallbladders from groups 2 and 3
NS relation: WBC, LFTs, or U/S findings and conversion rate Patients presenting within 72 hrs. from symptom onset LC
Patients presenting after 72 hrs. from sxs. onset considerelective LC in 6-8 weeks
Limitations: Selection bias, No description of patient
demographics of each group
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Clinical Predictive FactorsClinical Predictive Factors
Schafer et al.15
Objective: Define preop. criteria to predict both thesurgical strategy for managing acute cholecystitis andthe severity of inflammation
Study Design:
236 patients with acute cholecystitis had LC or OC within48 hours of admission
Non-randomized decision for LC vs. OC
Resected gallbladders classified into 3 subgroups
Type I (Mucosal inflammation); Type II (Phlegmonousinflammation); Type III (Gangrenous or necrotizing inflammation)
Inclusion: RUQ tenderness, fever, leukocytosis, elevatedCRP levels, U/S findings
15 Amer J Surg 2001
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Schafer et al.Schafer et al.
0
10
20
30
4050
60
70
80
90
%
LC Conv OC
ASA (I,II)
ASA(III,IV)
37
127 132
0
20
40
60
80
100
120
140
LC Conv OC
Mean Age
Mean WBC
MeanCRP(mg/ L)
(p
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Schafer et al.Schafer et al.
0
5
10
15
20
25
30
35
40
%
LC Conv OC
Gangrenous
(TypeIII)
PostopComplication
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Schafer et al.Schafer et al.
Type I
(n=109)
Type II
(n=63)
Type III
(n=64)
Mean Age 54.7 63.3 66.8
Preop SxsDuration
(days)
2.2 3.2 3.6
MeanWBC(X109/L)
11.5 12.9 14.1
Mean CRP(mg/L)
42.1 91.0 146.4
ConversionRate (%)
10 43 49
Com lication 14 24 40
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Schafer et al.Schafer et al.
Conclusions:
CRP levels, duration of symptoms, WBC countdetermined to be preoperative parameters thatpredict the severity of inflammation
5 independent parameters that determine the type ofsurgical approach (CRP levels, WBC count, ASA class,duration of symptoms, and age)
Increased CRP levels associated with advancedinflammation of gallbladder
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Schafer et al.Schafer et al.
As severity of inflammation increased complication
rate increased
CRP levels > 100 mg/L related to local tissue necrosis
Defined a set of preoperative conditions that may helpdetermine the safest method of surgery
Limitations: Elevation of CRP levels may be also due to bacterial
infection (Trial did not evaluate for it)
Selection bias
Validation of markers needed with RCT Timing of Surgery not evaluated
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Clinical Predictive FactorsClinical Predictive Factors
Rattner et al.Rattner et al.1616
Objective: Determine which preoperative data correlatesObjective: Determine which preoperative data correlates
with successful completion of a laparoscopicwith successful completion of a laparoscopic
cholecystectomy in patients with acute cholecystitischolecystectomy in patients with acute cholecystitis
Study Design:Study Design:
20 of 281 pts. with acute cholecystitis had LC between20 of 281 pts. with acute cholecystitis had LC between1990-92 at Mass General Hospital1990-92 at Mass General Hospital
Inclusion: Fever, leukocytosis, RUQ tenderness,Inclusion: Fever, leukocytosis, RUQ tenderness,
intraoperative findings of severe acute inflammation,intraoperative findings of severe acute inflammation,
pathologic evidence of ACpathologic evidence of ACExclusion: Intraoperative findings of AC but no clinicalExclusion: Intraoperative findings of AC but no clinical
signs, lab signs, or pathologic evidence of ACsigns, lab signs, or pathologic evidence of AC
1616 Annals Surg 1993Annals Surg 1993
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Rattner et al.Rattner et al.
Results: Degree of leukocystosis, ALP elevation, and
APACHE II scores were significantly associatedwith failure of laparoscopic surgery
Interval from admission to surgery: 0.6 days(successful group) vs. 5 days (failure group)
Failure of LC related to gangrenous changes ingallbladder
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Rattner et al.Rattner et al.
Conclusions:
Surgery within 48 hrs of admission successful LC
Optimal timing of surgery is as soon as possible afterdiagnosis of acute cholecystitis
Limitations: Retrospective, small study, recall bias(authors of study reviewed their own surgical cases),laparoscopic expertise unknown
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Clinical Cases Follow-upClinical Cases Follow-up
Case 1: 48 hrs after admission: LC converted to open chole
due to adhesions in RUQ and necrosis of hergallbladder
Diagnosis: Acute obstructive cholecystitis
Uneventful recovery
Case 2:
4 days after admission: LC converted to open choledue to necrosis of the gallbladder and cystic duct
junction
Diagnosis: Acute Necrotizing Cholecystitis
Uneventful recovery
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ConclusionsConclusions
LC compared with OC has decreased pain and disability withoutan increase in morbidity or mortality
LC is more cost-effective
Outcome of LC influenced by expertise of surgeon
ASA scale useful but difficult to classify all patients
Percutaneous cholecystostomy useful alternative in ASA IV, Vpatients BUT 50% still require surgery15
Conversion from laparoscopic to open cholecystectomy shouldnot be viewed as a complication
Conversion must occur if anatomy is obscured or excessive
bleeding occurs18
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ConclusionsConclusions
Most significant clinical factor for successfulMost significant clinical factor for successfulLC is the duration of symptomsLC is the duration of symptoms
Increased chance of gangrene of theIncreased chance of gangrene of thegallbladder after 72 hrsgallbladder after 72 hrs
Elderly, diabetics, obese patients, anddebilitated patients can safely undergolaparoscopic cholecystectomy for acutecholecystitis
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ConclusionsConclusions
Should be performed within 72 hrs of admission
If > 72 hours since admission, then evidencesupports attempted lap chole with a low threshold
for conversion to an open procedure
More data needed to determine role of CRP levelsMore data needed to determine role of CRP levels
in preoperative management of patients within preoperative management of patients with
acute cholecystitisacute cholecystitis