when is it time to heal with

8/14/2019 When is It Time to Heal With

1/48

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


2/48

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


3/48

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


4/48

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?


5/48

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


6/48

BackgroundBackground

Aging is the most significant factor higher incidence of acute cholecystitis1

Acute Cholecystitis is the initialpresentation of symptomatic gallstonesin 15% - 20% of patients3


7/48

Acute CholecystitisAcute Cholecystitis

RUQ Pain

Fever

Leukocytosis

Severe persistent pain

+/- Jaundice

Positive Murphys Sign


8/48

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


9/48


Distention and inflammation of thegallbladder

Obstruction of cystic duct Chemicalirritants in the bile Lysolecithin

Prostaglandins


10/48

UptoDate 2003UptoDate 2003


11/48

Acute CholecystitisAcute Cholecystitis22

Thickened gallbladder wall or edema

Pericholecystic Fluid Sonographic Murphys Sign


12/48



13/48


Early stages Edema and hyperemia

Later stages Adhesions, fibrosis, and necrosis

Triangle of Calot visible in early stagesCourtesy of Netter


14/48

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


15/48

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


16/48

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


17/48

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??


18/48

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


19/48


Based on patients overall risk of surgery

American Society of Anesthesiologists (ASA)Scale7 is a guide for decisions on surgery


20/48

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


21/48


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


22/48

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


23/48

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


24/48

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


25/48


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


26/48


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


27/48


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


28/48


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)


29/48


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


30/48

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


31/48


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


32/48


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


33/48


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


34/48


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


35/48


36/48

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


37/48

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


38/48


0

5

10

15

20

25

30

35

40

%

LC Conv OC

Gangrenous

(TypeIII)

PostopComplication


39/48


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


40/48


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


41/48


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


42/48

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


43/48

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


44/48

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


45/48

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


46/48

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


47/48


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


48/48


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

when is it time to heal with

Documents