Background:Recurrent acute cholecystitis(RAC)can occur after non-surgical treatment for acute cholecystitis(AC),and can be more severe in comparison to the first episode of AC.Low skeletal muscle mass or adiposity hav...Background:Recurrent acute cholecystitis(RAC)can occur after non-surgical treatment for acute cholecystitis(AC),and can be more severe in comparison to the first episode of AC.Low skeletal muscle mass or adiposity have various effects in several diseases.We aimed to clarify the relationship between RAC and body parameters.Methods:Patients with AC who were treated at our hospital between January 2011 and March 2022 were enrolled.The psoas muscle mass and adipose tissue area at the third lumbar level were measured using computed tomography at the first episode of AC.The areas were divided by height to obtain the psoas muscle mass index(PMI)and subcutaneous/visceral adipose tissue index(SATI/VATI).According to median VATI,SATI and PMI values by sex,patients were divided into the high and low PMI groups.We performed propensity score matching to eliminate the baseline differences between the high PMI and low PMI groups and analyzed the cumulative incidence and predictors of RAC.Results:The entire cohort was divided into the high PMI(n=81)and low PMI(n=80)groups.In the propensity score-matched cohort there were 57 patients in each group.In Kaplan-Meier analysis,the low PMI group and the high VATI group had a significantly higher cumulative incidence of RAC than their counterparts(log-rank P=0.001 and 0.015,respectively).In a multivariate Cox regression analysis,the hazard ratios of low PMI and low VATI for RAC were 5.250(95%confidence interval 1.083-25.450,P=0.039)and 0.158(95%confidence interval:0.026-0.937,P=0.042),respectively.Conclusions:Low skeletal muscle mass and high visceral adiposity were independent risk factors for RAC.展开更多
Anomalies in the gallbladder can lead to misidentifying anatomical structures,heightening the risk of complications in laparoscopic and open cholecystectomy procedures.Failure to recognize these variations increases t...Anomalies in the gallbladder can lead to misidentifying anatomical structures,heightening the risk of complications in laparoscopic and open cholecystectomy procedures.Failure to recognize these variations increases the chances of iatrogenic bile duct injuries and other complications.展开更多
Objective:To investigate the effectiveness of the systemic immune-inflammatory(SII)index and other inflammatory parameters in predicting mortality among patients with acute cholecystitis(AC).Methods:279 Patients prese...Objective:To investigate the effectiveness of the systemic immune-inflammatory(SII)index and other inflammatory parameters in predicting mortality among patients with acute cholecystitis(AC).Methods:279 Patients presented to the emergency department with abdominal pain and diagnosis of AC between September 2021 and September 2023 were included in the study.Demographic data,laboratory parameters,clinical follow-ups,and outcomes of the patients were recorded.Results:The mean age of the patients was(55.0±16.3)years and 36.6%were male.63.8%Had gallbladder/choledochal stones and 49.5%underwent surgery.The mortality rate was 6.1%.Advanced age(P=0.170)and prolonged hospitalization(P=0.011)were statistically significant risk factors for mortality.Decreased lymphocyte count(P=0.020)and increased C-reactive protein(CRP)levels(P=0.033)were found to be risk factors for mortality.According to the mortality predictor ROC analysis results,the cut-off for SII index was 3138(AUC=0.817,sensitivity=70.5%,specificity=84.7%),the cut-off for neutrophil count was 15.28×10^(3)/mm^(3)(AUC=0.761,sensitivity=52.9%,specificity=95.0%),the cut-off for leukocyte count was 19.0×10^(3)/mm^(3)(AUC=0.714,sensitivity=52.9%,specificity=98.0%),cut-off for CRP was 74.55(AUC=0.758,sensitivity=70.5%,specificity=79.0%),cut-off for aspartate transaminase(AST)was 33.0 IU/L(AUC=0.658,sensitivity=82.3%,specificity=50.3%).Conclusions:The SII index may be a good predictor of mortality with high sensitivity and specificity.Elevated levels of neutrophils,leukocytes,CRP,and AST are other inflammatory parameters that can be used to predict mortality associated with AC.展开更多
BACKGROUND Acute cholecystitis(AC)is a common disease in general surgery.Laparoscopic cholecystectomy(LC)is widely recognized as the"gold standard"surgical procedure for treating AC.For low-risk patients wit...BACKGROUND Acute cholecystitis(AC)is a common disease in general surgery.Laparoscopic cholecystectomy(LC)is widely recognized as the"gold standard"surgical procedure for treating AC.For low-risk patients without complications,LC is the recommended treatment plan,but there is still controversy regarding the treatment strategy for moderate AC patients,which relies more on the surgeon's experience and the medical platform of the visiting unit.Percutaneous transhepatic gallbladder puncture drainage(PTGBD)can effectively alleviate gallbladder inflammation,reduce gallbladder wall edema and adhesion around the gallbladder,and create a"time window"for elective surgery.AIM To compare the clinical efficacy and safety of LC or PTGBD combined with LC for treating AC patients,providing a theoretical basis for choosing reasonable surgical methods for AC patients.METHODS In this study,we conducted a clinical investigation regarding the combined use of PTGBD tubes for the treatment of gastric cancer patients with AC.We performed searches in the following databases:PubMed,Web of Science,EMBASE,Cochrane Library,China National Knowledge Infrastructure,and Wanfang Database.The search encompassed literature published from the inception of these databases to the present.Subsequently,relevant data were extracted,and a meta-analysis was conducted using RevMan 5.3 software.RESULTS A comprehensive analysis was conducted,encompassing 24 studies involving a total of 2564 patients.These patients were categorized into two groups:1371 in the LC group and 1193 in the PTGBD+LC group.The outcomes of the meta-analysis revealed noteworthy disparities between the PTGBD+LC group and the LC group in multiple dimensions:(1)Operative time:Mean difference(MD)=17.51,95%CI:9.53-25.49,P<0.01;(2)Conversion to open surgery rate:Odds ratio(OR)=2.95,95%CI:1.90-4.58,P<0.01;(3)Intraoperative bleeding loss:MD=32.27,95%CI:23.03-41.50,P<0.01;(4)Postoperative hospital stay:MD=1.44,95%CI:0.14-2.73,P=0.03;(5)Overall postoperative compli-cation rate:OR=1.88,95%CI:1.45-2.43,P<0.01;(6)Bile duct injury:OR=2.17,95%CI:1.30-3.64,P=0.003;(7)Intra-abdominal hemorrhage:OR=2.45,95%CI:1.06-5.64,P=0.004;and(8)Wound infection:OR=0.These find-ings consistently favored the PTGBD+LC group over the LC group.There were no significant differences in the total duration of hospitalization[MD=-1.85,95%CI:-4.86-1.16,P=0.23]or bile leakage[OR=1.33,95%CI:0.81-2.18,P=0.26]between the two groups.CONCLUSION The combination of PTGBD tubes with LC for AC treatment demonstrated superior clinical efficacy and enhanced safety,suggesting its broader application value in clinical practice.展开更多
BACKGROUND To date,the optimal timing for percutaneous transhepatic gallbladder drainage(PTGBD),particularly for patients who have missed the optimal window for emergency laparoscopic cholecystectomy(LC)(within 72 hou...BACKGROUND To date,the optimal timing for percutaneous transhepatic gallbladder drainage(PTGBD),particularly for patients who have missed the optimal window for emergency laparoscopic cholecystectomy(LC)(within 72 hours of symptom onset)has not been determined.AIM To study the effects of LC timing on outcomes of grade II/III acute cholecystitis(AC)in patients with delayed PTGBD.METHODS Data of patients diagnosed with Tokyo Guidelines 2018 grade II or III AC who underwent delayed PTGBD followed by LC at a single hospital between 2018 and 2022 were retrospectively studied.According to the interval between gallbladder drainage and cholecystectomy,the patients were divided into early and delayed LC groups.Outcomes including surgery time,postoperative complications and hospital stay,and patient satisfaction were analyzed and compared between the two groups using t-andχ^(2) tests.RESULTS There were no significant differences between the two groups in intraoperative blood loss,postoperative abdominal drainage tube placement time,pain index,or total disease duration(all P>0.05).Compared with those of the early LC group,the delayed group showed significant decreases in the length of procedure(surgery time),conversion rate to open surgery,degree of adhesions,surgical complications,postoperative hospital stay,and total treatment costs,and increased patient satisfaction despite a longer interval before PTGBD(all P<0.05).CONCLUSION For patients with grade II/III AC with delayed PTGBD,LC should be performed 2 weeks after PTGBD to decrease postoperative complications and hospital stays and improve patient satisfaction.展开更多
Emphysematous cholecystitis is a rare subtype of acute cholecystitis characterized by the presence of gas in the gallbladder wall secondary to ischemia. Typically, this is a result of cystic artery vascular compromise...Emphysematous cholecystitis is a rare subtype of acute cholecystitis characterized by the presence of gas in the gallbladder wall secondary to ischemia. Typically, this is a result of cystic artery vascular compromise with a concomitant infection from gas-forming organisms such as Clostridium species, Klebsiella species, or Escherichia coli. The mortality rate of acute emphysematous cholecystitis is 15% - 20% compared with 1.4% in uncomplicated acute cholecystitis. The subsequent development of a cholecystocutaneous fistula, an abnormal connection between the gallbladder and the skin, is also a rare complication of gallbladder disease. We describe a case of a 77-year-old male who presented with right flank necrotizing fasciitis which developed from a cholecystocutaneous fistula secondary to emphysematous cholecystitis. Once the necrotic tissues were adequately debrided, the large open wound was treated with negative pressure wound therapy with instillation (NPWT-i) utilizing hypochlorous acid (HOCL). The wound was closed with a split-thickness skin graft.展开更多
BACKGROUND Acute acalculous cholecystitis(AAC)is inflammation of the gallbladder without evidence of calculi.Although rarely reported,its etiologies include hepatitis virus infection(e.g.,hepatitis A virus,HAV)and adu...BACKGROUND Acute acalculous cholecystitis(AAC)is inflammation of the gallbladder without evidence of calculi.Although rarely reported,its etiologies include hepatitis virus infection(e.g.,hepatitis A virus,HAV)and adult-onset Still’s disease(AOSD).There are no reports of HAV-associated AAC in an AOSD patient.CASE SUMMARY Here we report a rare case of HAV infection-associated AAC in a 39-year-old woman who had a history of AOSD.The patient presented with an acute abdomen and hypotension.Elevated hepatobiliary enzymes and a thickened and distended gallbladder without gallstones on ultrasonography suggested AAC,but there were no signs of anemia nor thrombocytopenia.Serological screening revealed anti-HAV IgM antibodies.Steroid treatment did not alleviate her symptoms,and she was referred for laparoscopic cholecystectomy.The resected gallbladder was hydropic without perforation,and her clinical signs gradually improved after surgery.CONCLUSION AAC can be caused by HAV in AOSD patients.It is crucial to search for the underlying etiology for AAC,especially uncommon viral causes.展开更多
BACKGROUND Impaired interstitial cells of Cajal(ICCs)are central to the pathophysiology of acute cholecystitis(AC).Common bile duct ligation is a common model of AC,producing acute inflammatory changes and decrease in...BACKGROUND Impaired interstitial cells of Cajal(ICCs)are central to the pathophysiology of acute cholecystitis(AC).Common bile duct ligation is a common model of AC,producing acute inflammatory changes and decrease in gallbladder contractility.AIM To investigate the origin of slow wave(SW)in the gallbladder and the effect of ICCs on gallbladder contractions during the process of AC.METHODS Methylene blue(MB)with light was used to establish selective impaired ICCs gallbladder tissue.Gallbladder motility was assessed using the frequency of SW and gallbladder muscle contractility in vitro in normal control(NC),AC12h,AC24h,and AC48h groups of guinea pigs.Hematoxylin and eosin and Massonstained gallbladder tissues were scored for inflammatory changes.ICCs pathological changes alterations were estimated using immunohistochemistry and transmission electron microscopy.The alterations of c-Kit,α-SMA,cholecystokinin A receptor(CCKAR),and connexin 43(CX43)were assessed using Western blot.RESULTS Impaired ICCs muscle strips resulted in the decrease in gallbladder SW frequency and contractility.The frequency of SW and gallbladder contractility were significantly lower in the AC12h group.Compared with the NC group,the density and ultrastructure of ICCs were remarkably impaired in the AC groups,especially in the AC12h group.The protein expression levels of c-Kit were significantly decreased in the AC12h group,while CCKAR and CX43 protein expression levels were significantly decreased in the AC48h group.CONCLUSION Loss ICCs could lead to a decrease in gallbladder SW frequency and contractility.The density and ultrastructure of ICCs were clearly impaired in the early stage of AC,while CCKAR and CX43 were significantly reduced at end stage.展开更多
To the Editor: Xanthogranulomatous cholecystitis(XGC) is an uncommon inflammatory disease of the gallbladder, and its incidence is reported to be 1.3%-5.2% [1]. XGC is diagnosed by histopathological examination, chara...To the Editor: Xanthogranulomatous cholecystitis(XGC) is an uncommon inflammatory disease of the gallbladder, and its incidence is reported to be 1.3%-5.2% [1]. XGC is diagnosed by histopathological examination, characterized by severe inflammatory destruction followed by a granulomatous reaction, marked proliferative fibrosis, and infiltration of inflammatory cells [2].展开更多
Acute alithiasic cholecystitis (AAC) is the inflammatory disease of the gallbladder in the absence of gallstones. It is a rare pathology in children. The aim was to describe the clinical, diagnostic and therapeutic ch...Acute alithiasic cholecystitis (AAC) is the inflammatory disease of the gallbladder in the absence of gallstones. It is a rare pathology in children. The aim was to describe the clinical, diagnostic and therapeutic characteristics of this disease. Materials and Method: This was a 3-year retrospective study (January 2008 to December 2010) including 66 patient records collected for CAA. Results: The frequency of AAC was 3.57%, the mean age of the patients was 8 ± 3.52 years, and there were 36 boys and 30 girls. The main clinical features were right hypochondrial pain (66 cases), positive Murphy’s (66 cases), fever (53 cases) and jaundice or sub-jaundice (51 cases). The main ultrasound signs were thickened vesicular wall 50 cas (75.76%), vesicular distension 50cas (75.76%) and positive ultrasound Murphy 47 cas (71.21%). Medical treatment was exclusive in 64 patients (96.97%) and surgical treatment in 2 patients (3.03%). Conclusion: Acute alithiasic cholecystitis is a rare pathology in children, the clinical picture is not very specific and abdominal ultrasound is the key to early diagnosis. Conservative treatment is the first choice in the absence of any complications.展开更多
Objective:To assess the clinical effects of combining laparoscopic surgery with Modified Xiaoyan Lidan Decoction in patients diagnosed with cholecystitis and cholelithiasis.Methods:Following the guidelines of the doub...Objective:To assess the clinical effects of combining laparoscopic surgery with Modified Xiaoyan Lidan Decoction in patients diagnosed with cholecystitis and cholelithiasis.Methods:Following the guidelines of the double-blind method,86 cases of cholecystitis with cholelithiasis were randomly divided into two groups,each comprising 43 cases.Both groups underwent laparoscopic surgery,with the observation group additionally receiving Modified Xiaoyan Lidan Decoction.A comparative analysis was conducted on clinical treatment effectiveness,general observation indicators,Traditional Chinese Medicine(TCM)syndrome scores,and the occurrence of adverse reactions between the two groups.Results:The observation group demonstrated a significantly higher overall clinical treatment effectiveness compared to the control group(P<0.05).The clinical symptom improvement time and hospitalization time were shorter in the observation group,and the pain score and TCM syndrome score after treatment were lower than those in the control group(P<0.05).No statistically significant difference was observed in the total reaction values(P>0.05).Conclusion:The combined application of laparoscopic surgery and Modified Xiaoyan Lidan Decoction can enhance clinical treatment efficiency for patients with cholecystitis and cholelithiasis.It facilitates a quicker improvement in clinical symptoms without causing serious adverse reactions,suggesting its potential for widespread adoption.展开更多
AIM:To study relationship of injury induced by nitric oxide, oxidation, peroxidation,lipoperoxidation with chronic cholecystitis.METHODS:The values of plasma nitric oxide (P-NO), plasma vitamin C (P-VC), plasma vitami...AIM:To study relationship of injury induced by nitric oxide, oxidation, peroxidation,lipoperoxidation with chronic cholecystitis.METHODS:The values of plasma nitric oxide (P-NO), plasma vitamin C (P-VC), plasma vitamin E (P-VE), plasma beta-carotene (P-beta-CAR), plasma lipoperoxides (P-LPO), erythrocyte superoxide dismutase (E-SOD), erythrocyte catalase (E-CAT), erythrocyte glutathione peroxidase (E-GSH-Px) activities and erythrocyte lipoperoxides (E-LPO) level in 77 patients with chronic cholecystitis and 80 healthy control subjects were determined, differences of the above average values between the patient group and the control group and differences of the average values between preoperative and postoperative patients were analyzed and compared, linear regression and correlation of the disease course with the above determination values as well as the stepwise regression and correlation of the course with the values were analyzed.RESULTS:Compared with the control group, the average values of P-NO, P-LPO, E-LPO were significantly increased (P【0.01), and of P-VC, P-VE, P-beta-CAR, E-SOD, E-CAT and E-GSH-Px decreased (P 【0.01) in the patient group. The analysis of the linear regression and correlation showed that with prolonging of the course, the values of P-NO, P-LPO and E-LPO in the patients were gradually ascended and the values of P-VC,P-VE, P-beta-CAR, E-SOD, E-CAT and E-GSH-Px descended (P【0.01). The analysis of the stepwise regression and correlation indicated that the correlation of the course with P-NO, P-VE and P-beta-CAR values was the closest. Compared with the preoperative patients, the average values of P-NO, P-LPO and E-LPO were significantly decreased (P 【0.01) and the average values of P-VC, E-SOD, E-CAT and E-GSH-Px in postoperative patients increased (P 【0.01) in postoperative patients. But there was no significant difference in the average values of P-VE, P-beta-CAR preoperative and postoperative patients.CONCLUSION:Chronic cholecystitis could induce the increase of nitric oxide, oxidation, peroxidation and lipoperoxidation.展开更多
BACKGROUND: In low-risk patients with acute cholecystitis who did not respond to nonoperative treatment, we prospectively compared treatment with emergency laparoscopic cholecystectomy or percutaneous transhepatic cho...BACKGROUND: In low-risk patients with acute cholecystitis who did not respond to nonoperative treatment, we prospectively compared treatment with emergency laparoscopic cholecystectomy or percutaneous transhepatic cholecystostomy followed by delayed cholecystectomy.METHODS: In 91 patients(American Society of Anesthesiologists class I or II) who had symptoms of acute cholecystitis ≥72 hours at hospital admission and who did not respond to nonoperative treatment(48 hours), 48 patients were treated with emergency laparoscopic cholecystectomy and 43 patients were treated with delayed cholecystectomy at ≥4 weeks after insertion of a percutaneous transhepatic cholecystostomy catheter. After initial treatment, the patients were followed up for 23 months on average(range 7-29).RESULT: Compared with the patients who had emergency laparoscopic cholecystectomy, the patients who were treated with percutaneous transhepatic cholecystostomy and delayed cholecystectomy had a lower frequency of conversion to open surgery [19(40%) vs 8(19%); P=0.029], a frequency of intraoperative bleeding ≥100 mL [16(33%) vs 4(9%); P=0.006],a mean postoperative hospital stay(5.3±3.3 vs 3.0±2.4 days;P=0.001), and a frequency of complications [17(35%) vs 4(9%);P=0.003].CONCLUSION: In patients with acute cholecystitis who presented to the hospital ≥72 hours after symptom onset and did not respond to nonoperative treatment for 48 hours, percutaneous transhepatic cholecystostomy with delayed laparoscopic cholecystectomy produced better outcomes and fewer complications than emergency laparoscopic cholecystectomy.展开更多
Xanthogranulomatous cholecystitis(XGC) is an uncommon variant of chronic cholecystitis characterized by xanthogranulomatous inflammation of the gallbladder. Intramural accumulation of lipid-laden macrophages and acute...Xanthogranulomatous cholecystitis(XGC) is an uncommon variant of chronic cholecystitis characterized by xanthogranulomatous inflammation of the gallbladder. Intramural accumulation of lipid-laden macrophages and acute and chronic inflammatory cells is the hallmark of the disease. The xanthogranulomatous inflammation of the gallbladder can be very severe and can spill over to the neighbouring structures like liver, bowel and stomach resulting in dense adhesions, perforation, abscess formation, fistulous communication with adjacent bowel. Striking gallbladder wall thickening and dense local adhesions can be easily mistaken for carcinoma of the gallbladder, both intraoperatively as well as on preoperative imaging. Besides, cases of concomitant gallbladder carcinoma complicating XGC have also been reported in literature. So, we have done a review of the imaging features of XGC in order to better understand the entity as well as to increase the diagnostic yield of the disease summarizing the characteristic imaging findings and associations of XGC. Among other findings, presence of intramural hypodense nodules is considered diagnostic of this entity. However, in some cases, an imaging diagnosis of XGC is virtually impossible. Fine needle aspiration cytology might be handy in such patients. A preoperative counselling should include possibility of differential diagnosis of gallbladder cancer in not so characteristic cases.展开更多
Xanthogranulomatous cholecystitis(XGC) is an uncommon variant of chronic cholecystitis. The perioperative findings in aggressive cases may be indistinguishable from those of gallbladder or biliary tract carcinomas. Th...Xanthogranulomatous cholecystitis(XGC) is an uncommon variant of chronic cholecystitis. The perioperative findings in aggressive cases may be indistinguishable from those of gallbladder or biliary tract carcinomas. Three patients presented mass lesions that infiltrated the hepatic hilum,provoked biliary dilatation and jaundice,and were indicative of malignancy. Surgical excision was performed following oncological principles and included extirpation of the gallbladder,extrahepatic bile duct,and hilar lymph nodes,as well as partial hepatectomy. Postoperative morbidity was minimal. Surgical pathology demonstrated XGC and absence of malignancy in all three cases. All three patients are alive and well after years of follow-up. XGC may have such an aggressive presentation that carcinoma may only be ruled out on surgical pathology. In such cases,the best option may be radical resection following oncological principles performed by expert surgeons,in order that postoperative complications may be minimized if not avoided altogether.展开更多
AIM: To compare cases of xanthogranulomatous cholecystitis(XGC) and advanced gallbladder cancer and discuss the differential diagnoses and surgical options.METHODS: From April 2000 to December 2013, 6 XGC patients rec...AIM: To compare cases of xanthogranulomatous cholecystitis(XGC) and advanced gallbladder cancer and discuss the differential diagnoses and surgical options.METHODS: From April 2000 to December 2013, 6 XGC patients received extended surgical resections. During the same period, 16 patients were proven to have gallbladder(GB) cancer, according to extended surgical resection. Subjects chosen for analysis in this study were restricted to cases of XGC with indistinct borders with the liver as it is often difficult to distinguish these patients from those with advanced GB cancer. We compared the clinical features and computed tomography findings between XGC and advanced GB cancer. The following clinical features were retrospectively assessed: age, gender, symptoms, and tumor markers. As albumin and the neutrophil/lymphocyte ratio(NLR) are prognostic in several cancers, we compared serum albumin levels and the NLR between the two groups. The computerized tomography findings were used to compare the two diseases, determine the coexistence of gallstones, the pattern of GB thickening(focal or diffuse), the presence of a hypoattenuated intramural nodule, and continuity of the mucosal line.RESULTS: Based on the preoperative image findings, we suspected GB carcinoma in all cases includingXGC in this series. In addition, by pathological examination, we found that the group of patients with XGC developed inflammatory disease after surgery. Patients with XGC tended to have abdominal pain(4/6, 67%). However, there was no significant difference in clinical symptoms, including fever, between the two groups. Serum albumin and NLR were also similar in the two groups. Serum tumor markers, such as carcinoembryonic antigen(CEA) and carbohydrate antigen 19-9(CA19-9), tended to increase in patients with GB cancer. However, no significant differences in tumor markers were identified. On the other hand, gallstones were more frequently observed in patients with XGC(5/6, 83%) than in patients with GB cancer(4/16, 33%)(P = 0.0116). A hypoattenuated intramural nodule was found in 3 patients with XGC(3/6, 50%), but in only 1 patient with GB cancer(1/16, 6%)(P = 0.0024). The GB thickness, continuous mucosal line, and bile duct dilatation showed no significant differences between XGC and GB cancer.CONCLUSION: Although XGC is often difficult to differentiate from GB carcinoma, it is possible to obtain an accurate diagnosis by careful intraoperative gross observation, and several intraoperative frozen sections.展开更多
Acute calculous cholecystitis(ACC) is the most frequent complication of cholelithiasis and represents one-third of all surgical emergency hospital admissions, many aspects of the disease are still a matter of debate. ...Acute calculous cholecystitis(ACC) is the most frequent complication of cholelithiasis and represents one-third of all surgical emergency hospital admissions, many aspects of the disease are still a matter of debate. Knowledge of the current evidence may allow the surgical team to develop practical bedside decision-making strategies, aiming at a less demanding procedure and lower frequency of complications. In this regard, recommendations on the diagnosis supported by specific criteria and severity scores are being implemented, to prioritize patients eligible for urgency surgery. Laparoscopic cholecystectomy is the best treatment for ACC and the procedure should ideally be performed within 72h. Early surgery is associated with better results in comparison to delayed surgery. In addition, when to suspect associated common bile duct stones and how to treat them when found are still debated. The antimicrobial agents are indicated for high-risk patients and especially in the presence of gallbladder necrosis. The use of broad-spectrum antibiotics and in some cases with antifungal agents is related to better prognosis. Moreover, an emerging strategy of not converting to open, a difficult laparoscopic cholecystectomy and performing a subtotal cholecystectomy is recommended by adept surgical teams. Some authors support the use of percutaneous cholecystostomy as an alternative emergency treatment for acute Cholecystitis for patients with severe comorbidities.展开更多
AIM:To compare the clinical outcome of single-incision laparoscopic cholecystectomy(SILC)and three-incision laparoscopic cholecystectomy(3ILC)for acute cholecystitis.METHODS:From July 2009 to September 2012,136patient...AIM:To compare the clinical outcome of single-incision laparoscopic cholecystectomy(SILC)and three-incision laparoscopic cholecystectomy(3ILC)for acute cholecystitis.METHODS:From July 2009 to September 2012,136patients underwent SILC or 3ILC for acute cholecystitis at a tertiary referral hospital.One experienced surgeon performed every procedure using 5 or 10 mm 30-degree laparoscopes,straight instruments,and conventional ports.Five patients with perforated gallbladder and diffuse peritonitis and 23 patients with mild acute cholecystitis were excluded.The remaining 108 patients were divided into complicated and uncomplicated groups according to pathologic findings.Patient demography,clinical data,operative results and complications were recorded and analyzed.RESULTS:Fifty patients with gangrenous cholecystitis,gallbladder empyema,or hydrops were classified as the complicated group,and 58 patients with acute cholecystitis were classified as the uncomplicated group.Twenty-three(46.0%)of the patients in the complicated group(n=50)and 39(67.2%)of the patients in the uncomplicated group(n=58)underwent SILC;all others underwent 3ILC.The postoperative length of hospital stay(PLOS)was significantly shorter in the SILC subgroups than the 3ILC subgroups(3.5±1.1 d vs 4.6±1.3 d,P<0.01 in the complicated group;2.9±1.1 d vs 3.7±1.4 d,P<0.05 in the uncomplicated group).The maximum body temperature recorded at day 1 and at day 2 following the procedure was lower in the SILC subgroups,but the difference reached statistical significance only in the uncomplicated group(37.41±0.56℃vs 37.80±0.72℃,P<0.05 on postoperative day 1;37.10±0.43℃vs 37.57±0.54℃,P<0.01 on postoperative day 2).The operative time,estimated blood loss,postoperative narcotic use,total length of hospital stay,conversion rates,and complication rates were similar in both SILC and 3ILC subgroups.The complicated group had longer operative time(122.2±35.0 min vs 106.6±43.6 min,P<0.05),longer PLOS(4.1±1.3 d vs 3.2±1.2 d,P<0.001),and higher conversion rates(36.0%vs 19.0%,P<0.05)compared with the uncomplicated group.CONCLUSION:SILC is safe and efficacious for patients with acute cholecystitis.The main benefit is a faster recovery than that achieved with 3ILC.展开更多
AIM: To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. METHODS: A retrospective medical record review of 88 consecutive patien...AIM: To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. METHODS: A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service (medical or surgical). Patients not undergoing cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery.RESULTS: Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean ± SD time to surgery was 39.3 ± 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography (ERCP, P = 0.01) as well with admission to medical service without adjustment for ERCP (P < 0.05). Patients undergoing both magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier (30.4 ± 34.9 vs 82.7 ± 55.1 h, P < 0.01), had less post-operative complications (12% vs 58%, P < 0.01), and shorter length of stay (4.3 ± 3.4 vs 8.1 ± 5.2 d, P < 0.01).CONCLUSION: Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed up time to surgery should be considered.展开更多
AIM: To review and evaluate the diagnostic dilemma of xanthogranulomatous cholecystitis(XGC) clinically.METHODS: From July 2008 to June 2014, a total of 142 cases of pathologically diagnosed XGC were reviewed at our h...AIM: To review and evaluate the diagnostic dilemma of xanthogranulomatous cholecystitis(XGC) clinically.METHODS: From July 2008 to June 2014, a total of 142 cases of pathologically diagnosed XGC were reviewed at our hospital, among which 42 were misdiagnosed as gallbladder carcinoma(GBC) based on preoperative radiographs and/or intra-operative findings. The clinical characteristics, preoperative imaging, intra-operative findings, frozen section(FS) analysis and surgical procedure data of these patients were collected and analyzed.RESULTS: The most common clinical syndrome in these 42 patients was chronic cholecystitis, followed by acute cholecystitis. Seven(17%) cases presented with mild jaundice without choledocholithiasis. Thirtyfive(83%) cases presented with heterogeneous enhancement within thickened gallbladder walls on imaging, and 29(69%) cases presented with abnormal enhancement in hepatic parenchyma neighboring the gallbladder, which indicated hepatic infiltration. Intra-operatively, adhesions to adjacent organs were observed in 40(95.2%) cases, including the duodenum, colon and stomach. Thirty cases underwent FS analysis and the remainder did not. The accuracy rate of FS was 93%, and that of surgeon's macroscopic diagnosis was 50%. Six cases were misidentified as GBC by surgeon's macroscopic examination and underwent aggressive surgical treatment. No statistical difference was encountered in the incidence of postoperative complications between total cholecystectomy and subtotal cholecystectomy groups(21% vs 20%, P > 0.05).CONCLUSION: Neither clinical manifestations and laboratory tests nor radiological methods provide apractical and effective standard in the differential diagnosis between XGC and GBC.展开更多
基金This study was approved by the Ethics Committee of Kyushu Rosai Hospital Moji Medical Center(No:04-01,date of approval:June 2,2022).This study was conducted in compliance with the principles of the Declaration of Helsinki.
文摘Background:Recurrent acute cholecystitis(RAC)can occur after non-surgical treatment for acute cholecystitis(AC),and can be more severe in comparison to the first episode of AC.Low skeletal muscle mass or adiposity have various effects in several diseases.We aimed to clarify the relationship between RAC and body parameters.Methods:Patients with AC who were treated at our hospital between January 2011 and March 2022 were enrolled.The psoas muscle mass and adipose tissue area at the third lumbar level were measured using computed tomography at the first episode of AC.The areas were divided by height to obtain the psoas muscle mass index(PMI)and subcutaneous/visceral adipose tissue index(SATI/VATI).According to median VATI,SATI and PMI values by sex,patients were divided into the high and low PMI groups.We performed propensity score matching to eliminate the baseline differences between the high PMI and low PMI groups and analyzed the cumulative incidence and predictors of RAC.Results:The entire cohort was divided into the high PMI(n=81)and low PMI(n=80)groups.In the propensity score-matched cohort there were 57 patients in each group.In Kaplan-Meier analysis,the low PMI group and the high VATI group had a significantly higher cumulative incidence of RAC than their counterparts(log-rank P=0.001 and 0.015,respectively).In a multivariate Cox regression analysis,the hazard ratios of low PMI and low VATI for RAC were 5.250(95%confidence interval 1.083-25.450,P=0.039)and 0.158(95%confidence interval:0.026-0.937,P=0.042),respectively.Conclusions:Low skeletal muscle mass and high visceral adiposity were independent risk factors for RAC.
文摘Anomalies in the gallbladder can lead to misidentifying anatomical structures,heightening the risk of complications in laparoscopic and open cholecystectomy procedures.Failure to recognize these variations increases the chances of iatrogenic bile duct injuries and other complications.
文摘Objective:To investigate the effectiveness of the systemic immune-inflammatory(SII)index and other inflammatory parameters in predicting mortality among patients with acute cholecystitis(AC).Methods:279 Patients presented to the emergency department with abdominal pain and diagnosis of AC between September 2021 and September 2023 were included in the study.Demographic data,laboratory parameters,clinical follow-ups,and outcomes of the patients were recorded.Results:The mean age of the patients was(55.0±16.3)years and 36.6%were male.63.8%Had gallbladder/choledochal stones and 49.5%underwent surgery.The mortality rate was 6.1%.Advanced age(P=0.170)and prolonged hospitalization(P=0.011)were statistically significant risk factors for mortality.Decreased lymphocyte count(P=0.020)and increased C-reactive protein(CRP)levels(P=0.033)were found to be risk factors for mortality.According to the mortality predictor ROC analysis results,the cut-off for SII index was 3138(AUC=0.817,sensitivity=70.5%,specificity=84.7%),the cut-off for neutrophil count was 15.28×10^(3)/mm^(3)(AUC=0.761,sensitivity=52.9%,specificity=95.0%),the cut-off for leukocyte count was 19.0×10^(3)/mm^(3)(AUC=0.714,sensitivity=52.9%,specificity=98.0%),cut-off for CRP was 74.55(AUC=0.758,sensitivity=70.5%,specificity=79.0%),cut-off for aspartate transaminase(AST)was 33.0 IU/L(AUC=0.658,sensitivity=82.3%,specificity=50.3%).Conclusions:The SII index may be a good predictor of mortality with high sensitivity and specificity.Elevated levels of neutrophils,leukocytes,CRP,and AST are other inflammatory parameters that can be used to predict mortality associated with AC.
文摘BACKGROUND Acute cholecystitis(AC)is a common disease in general surgery.Laparoscopic cholecystectomy(LC)is widely recognized as the"gold standard"surgical procedure for treating AC.For low-risk patients without complications,LC is the recommended treatment plan,but there is still controversy regarding the treatment strategy for moderate AC patients,which relies more on the surgeon's experience and the medical platform of the visiting unit.Percutaneous transhepatic gallbladder puncture drainage(PTGBD)can effectively alleviate gallbladder inflammation,reduce gallbladder wall edema and adhesion around the gallbladder,and create a"time window"for elective surgery.AIM To compare the clinical efficacy and safety of LC or PTGBD combined with LC for treating AC patients,providing a theoretical basis for choosing reasonable surgical methods for AC patients.METHODS In this study,we conducted a clinical investigation regarding the combined use of PTGBD tubes for the treatment of gastric cancer patients with AC.We performed searches in the following databases:PubMed,Web of Science,EMBASE,Cochrane Library,China National Knowledge Infrastructure,and Wanfang Database.The search encompassed literature published from the inception of these databases to the present.Subsequently,relevant data were extracted,and a meta-analysis was conducted using RevMan 5.3 software.RESULTS A comprehensive analysis was conducted,encompassing 24 studies involving a total of 2564 patients.These patients were categorized into two groups:1371 in the LC group and 1193 in the PTGBD+LC group.The outcomes of the meta-analysis revealed noteworthy disparities between the PTGBD+LC group and the LC group in multiple dimensions:(1)Operative time:Mean difference(MD)=17.51,95%CI:9.53-25.49,P<0.01;(2)Conversion to open surgery rate:Odds ratio(OR)=2.95,95%CI:1.90-4.58,P<0.01;(3)Intraoperative bleeding loss:MD=32.27,95%CI:23.03-41.50,P<0.01;(4)Postoperative hospital stay:MD=1.44,95%CI:0.14-2.73,P=0.03;(5)Overall postoperative compli-cation rate:OR=1.88,95%CI:1.45-2.43,P<0.01;(6)Bile duct injury:OR=2.17,95%CI:1.30-3.64,P=0.003;(7)Intra-abdominal hemorrhage:OR=2.45,95%CI:1.06-5.64,P=0.004;and(8)Wound infection:OR=0.These find-ings consistently favored the PTGBD+LC group over the LC group.There were no significant differences in the total duration of hospitalization[MD=-1.85,95%CI:-4.86-1.16,P=0.23]or bile leakage[OR=1.33,95%CI:0.81-2.18,P=0.26]between the two groups.CONCLUSION The combination of PTGBD tubes with LC for AC treatment demonstrated superior clinical efficacy and enhanced safety,suggesting its broader application value in clinical practice.
文摘BACKGROUND To date,the optimal timing for percutaneous transhepatic gallbladder drainage(PTGBD),particularly for patients who have missed the optimal window for emergency laparoscopic cholecystectomy(LC)(within 72 hours of symptom onset)has not been determined.AIM To study the effects of LC timing on outcomes of grade II/III acute cholecystitis(AC)in patients with delayed PTGBD.METHODS Data of patients diagnosed with Tokyo Guidelines 2018 grade II or III AC who underwent delayed PTGBD followed by LC at a single hospital between 2018 and 2022 were retrospectively studied.According to the interval between gallbladder drainage and cholecystectomy,the patients were divided into early and delayed LC groups.Outcomes including surgery time,postoperative complications and hospital stay,and patient satisfaction were analyzed and compared between the two groups using t-andχ^(2) tests.RESULTS There were no significant differences between the two groups in intraoperative blood loss,postoperative abdominal drainage tube placement time,pain index,or total disease duration(all P>0.05).Compared with those of the early LC group,the delayed group showed significant decreases in the length of procedure(surgery time),conversion rate to open surgery,degree of adhesions,surgical complications,postoperative hospital stay,and total treatment costs,and increased patient satisfaction despite a longer interval before PTGBD(all P<0.05).CONCLUSION For patients with grade II/III AC with delayed PTGBD,LC should be performed 2 weeks after PTGBD to decrease postoperative complications and hospital stays and improve patient satisfaction.
文摘Emphysematous cholecystitis is a rare subtype of acute cholecystitis characterized by the presence of gas in the gallbladder wall secondary to ischemia. Typically, this is a result of cystic artery vascular compromise with a concomitant infection from gas-forming organisms such as Clostridium species, Klebsiella species, or Escherichia coli. The mortality rate of acute emphysematous cholecystitis is 15% - 20% compared with 1.4% in uncomplicated acute cholecystitis. The subsequent development of a cholecystocutaneous fistula, an abnormal connection between the gallbladder and the skin, is also a rare complication of gallbladder disease. We describe a case of a 77-year-old male who presented with right flank necrotizing fasciitis which developed from a cholecystocutaneous fistula secondary to emphysematous cholecystitis. Once the necrotic tissues were adequately debrided, the large open wound was treated with negative pressure wound therapy with instillation (NPWT-i) utilizing hypochlorous acid (HOCL). The wound was closed with a split-thickness skin graft.
基金Supported by the National High Level Hospital Clinical Research Funding,No.2022-PUMCH-A-017 and No.2022-PUMCH-B-045CAMS Innovation Fund for Medical Sciences from Chinese Academy of Medical Sciences,No.2021-I2M-1-062.
文摘BACKGROUND Acute acalculous cholecystitis(AAC)is inflammation of the gallbladder without evidence of calculi.Although rarely reported,its etiologies include hepatitis virus infection(e.g.,hepatitis A virus,HAV)and adult-onset Still’s disease(AOSD).There are no reports of HAV-associated AAC in an AOSD patient.CASE SUMMARY Here we report a rare case of HAV infection-associated AAC in a 39-year-old woman who had a history of AOSD.The patient presented with an acute abdomen and hypotension.Elevated hepatobiliary enzymes and a thickened and distended gallbladder without gallstones on ultrasonography suggested AAC,but there were no signs of anemia nor thrombocytopenia.Serological screening revealed anti-HAV IgM antibodies.Steroid treatment did not alleviate her symptoms,and she was referred for laparoscopic cholecystectomy.The resected gallbladder was hydropic without perforation,and her clinical signs gradually improved after surgery.CONCLUSION AAC can be caused by HAV in AOSD patients.It is crucial to search for the underlying etiology for AAC,especially uncommon viral causes.
基金Supported by the Pudong New Area Clinical Traditional Chinese Medicine of Top Discipline Project,No.PDZY-2018-0603 and the Featured Clinical Discipline Project of Shanghai Pudong,No.PWYts2021-06.
文摘BACKGROUND Impaired interstitial cells of Cajal(ICCs)are central to the pathophysiology of acute cholecystitis(AC).Common bile duct ligation is a common model of AC,producing acute inflammatory changes and decrease in gallbladder contractility.AIM To investigate the origin of slow wave(SW)in the gallbladder and the effect of ICCs on gallbladder contractions during the process of AC.METHODS Methylene blue(MB)with light was used to establish selective impaired ICCs gallbladder tissue.Gallbladder motility was assessed using the frequency of SW and gallbladder muscle contractility in vitro in normal control(NC),AC12h,AC24h,and AC48h groups of guinea pigs.Hematoxylin and eosin and Massonstained gallbladder tissues were scored for inflammatory changes.ICCs pathological changes alterations were estimated using immunohistochemistry and transmission electron microscopy.The alterations of c-Kit,α-SMA,cholecystokinin A receptor(CCKAR),and connexin 43(CX43)were assessed using Western blot.RESULTS Impaired ICCs muscle strips resulted in the decrease in gallbladder SW frequency and contractility.The frequency of SW and gallbladder contractility were significantly lower in the AC12h group.Compared with the NC group,the density and ultrastructure of ICCs were remarkably impaired in the AC groups,especially in the AC12h group.The protein expression levels of c-Kit were significantly decreased in the AC12h group,while CCKAR and CX43 protein expression levels were significantly decreased in the AC48h group.CONCLUSION Loss ICCs could lead to a decrease in gallbladder SW frequency and contractility.The density and ultrastructure of ICCs were clearly impaired in the early stage of AC,while CCKAR and CX43 were significantly reduced at end stage.
文摘To the Editor: Xanthogranulomatous cholecystitis(XGC) is an uncommon inflammatory disease of the gallbladder, and its incidence is reported to be 1.3%-5.2% [1]. XGC is diagnosed by histopathological examination, characterized by severe inflammatory destruction followed by a granulomatous reaction, marked proliferative fibrosis, and infiltration of inflammatory cells [2].
文摘Acute alithiasic cholecystitis (AAC) is the inflammatory disease of the gallbladder in the absence of gallstones. It is a rare pathology in children. The aim was to describe the clinical, diagnostic and therapeutic characteristics of this disease. Materials and Method: This was a 3-year retrospective study (January 2008 to December 2010) including 66 patient records collected for CAA. Results: The frequency of AAC was 3.57%, the mean age of the patients was 8 ± 3.52 years, and there were 36 boys and 30 girls. The main clinical features were right hypochondrial pain (66 cases), positive Murphy’s (66 cases), fever (53 cases) and jaundice or sub-jaundice (51 cases). The main ultrasound signs were thickened vesicular wall 50 cas (75.76%), vesicular distension 50cas (75.76%) and positive ultrasound Murphy 47 cas (71.21%). Medical treatment was exclusive in 64 patients (96.97%) and surgical treatment in 2 patients (3.03%). Conclusion: Acute alithiasic cholecystitis is a rare pathology in children, the clinical picture is not very specific and abdominal ultrasound is the key to early diagnosis. Conservative treatment is the first choice in the absence of any complications.
文摘Objective:To assess the clinical effects of combining laparoscopic surgery with Modified Xiaoyan Lidan Decoction in patients diagnosed with cholecystitis and cholelithiasis.Methods:Following the guidelines of the double-blind method,86 cases of cholecystitis with cholelithiasis were randomly divided into two groups,each comprising 43 cases.Both groups underwent laparoscopic surgery,with the observation group additionally receiving Modified Xiaoyan Lidan Decoction.A comparative analysis was conducted on clinical treatment effectiveness,general observation indicators,Traditional Chinese Medicine(TCM)syndrome scores,and the occurrence of adverse reactions between the two groups.Results:The observation group demonstrated a significantly higher overall clinical treatment effectiveness compared to the control group(P<0.05).The clinical symptom improvement time and hospitalization time were shorter in the observation group,and the pain score and TCM syndrome score after treatment were lower than those in the control group(P<0.05).No statistically significant difference was observed in the total reaction values(P>0.05).Conclusion:The combined application of laparoscopic surgery and Modified Xiaoyan Lidan Decoction can enhance clinical treatment efficiency for patients with cholecystitis and cholelithiasis.It facilitates a quicker improvement in clinical symptoms without causing serious adverse reactions,suggesting its potential for widespread adoption.
基金The item of scieace and technology research plans of Zhejiang Province (No 1999-2-121)
文摘AIM:To study relationship of injury induced by nitric oxide, oxidation, peroxidation,lipoperoxidation with chronic cholecystitis.METHODS:The values of plasma nitric oxide (P-NO), plasma vitamin C (P-VC), plasma vitamin E (P-VE), plasma beta-carotene (P-beta-CAR), plasma lipoperoxides (P-LPO), erythrocyte superoxide dismutase (E-SOD), erythrocyte catalase (E-CAT), erythrocyte glutathione peroxidase (E-GSH-Px) activities and erythrocyte lipoperoxides (E-LPO) level in 77 patients with chronic cholecystitis and 80 healthy control subjects were determined, differences of the above average values between the patient group and the control group and differences of the average values between preoperative and postoperative patients were analyzed and compared, linear regression and correlation of the disease course with the above determination values as well as the stepwise regression and correlation of the course with the values were analyzed.RESULTS:Compared with the control group, the average values of P-NO, P-LPO, E-LPO were significantly increased (P【0.01), and of P-VC, P-VE, P-beta-CAR, E-SOD, E-CAT and E-GSH-Px decreased (P 【0.01) in the patient group. The analysis of the linear regression and correlation showed that with prolonging of the course, the values of P-NO, P-LPO and E-LPO in the patients were gradually ascended and the values of P-VC,P-VE, P-beta-CAR, E-SOD, E-CAT and E-GSH-Px descended (P【0.01). The analysis of the stepwise regression and correlation indicated that the correlation of the course with P-NO, P-VE and P-beta-CAR values was the closest. Compared with the preoperative patients, the average values of P-NO, P-LPO and E-LPO were significantly decreased (P 【0.01) and the average values of P-VC, E-SOD, E-CAT and E-GSH-Px in postoperative patients increased (P 【0.01) in postoperative patients. But there was no significant difference in the average values of P-VE, P-beta-CAR preoperative and postoperative patients.CONCLUSION:Chronic cholecystitis could induce the increase of nitric oxide, oxidation, peroxidation and lipoperoxidation.
文摘BACKGROUND: In low-risk patients with acute cholecystitis who did not respond to nonoperative treatment, we prospectively compared treatment with emergency laparoscopic cholecystectomy or percutaneous transhepatic cholecystostomy followed by delayed cholecystectomy.METHODS: In 91 patients(American Society of Anesthesiologists class I or II) who had symptoms of acute cholecystitis ≥72 hours at hospital admission and who did not respond to nonoperative treatment(48 hours), 48 patients were treated with emergency laparoscopic cholecystectomy and 43 patients were treated with delayed cholecystectomy at ≥4 weeks after insertion of a percutaneous transhepatic cholecystostomy catheter. After initial treatment, the patients were followed up for 23 months on average(range 7-29).RESULT: Compared with the patients who had emergency laparoscopic cholecystectomy, the patients who were treated with percutaneous transhepatic cholecystostomy and delayed cholecystectomy had a lower frequency of conversion to open surgery [19(40%) vs 8(19%); P=0.029], a frequency of intraoperative bleeding ≥100 mL [16(33%) vs 4(9%); P=0.006],a mean postoperative hospital stay(5.3±3.3 vs 3.0±2.4 days;P=0.001), and a frequency of complications [17(35%) vs 4(9%);P=0.003].CONCLUSION: In patients with acute cholecystitis who presented to the hospital ≥72 hours after symptom onset and did not respond to nonoperative treatment for 48 hours, percutaneous transhepatic cholecystostomy with delayed laparoscopic cholecystectomy produced better outcomes and fewer complications than emergency laparoscopic cholecystectomy.
文摘Xanthogranulomatous cholecystitis(XGC) is an uncommon variant of chronic cholecystitis characterized by xanthogranulomatous inflammation of the gallbladder. Intramural accumulation of lipid-laden macrophages and acute and chronic inflammatory cells is the hallmark of the disease. The xanthogranulomatous inflammation of the gallbladder can be very severe and can spill over to the neighbouring structures like liver, bowel and stomach resulting in dense adhesions, perforation, abscess formation, fistulous communication with adjacent bowel. Striking gallbladder wall thickening and dense local adhesions can be easily mistaken for carcinoma of the gallbladder, both intraoperatively as well as on preoperative imaging. Besides, cases of concomitant gallbladder carcinoma complicating XGC have also been reported in literature. So, we have done a review of the imaging features of XGC in order to better understand the entity as well as to increase the diagnostic yield of the disease summarizing the characteristic imaging findings and associations of XGC. Among other findings, presence of intramural hypodense nodules is considered diagnostic of this entity. However, in some cases, an imaging diagnosis of XGC is virtually impossible. Fine needle aspiration cytology might be handy in such patients. A preoperative counselling should include possibility of differential diagnosis of gallbladder cancer in not so characteristic cases.
基金Supported by Nacif LS was supported by an International Travel Scholar Award from the International Liver Transplantation Society(ILTS)
文摘Xanthogranulomatous cholecystitis(XGC) is an uncommon variant of chronic cholecystitis. The perioperative findings in aggressive cases may be indistinguishable from those of gallbladder or biliary tract carcinomas. Three patients presented mass lesions that infiltrated the hepatic hilum,provoked biliary dilatation and jaundice,and were indicative of malignancy. Surgical excision was performed following oncological principles and included extirpation of the gallbladder,extrahepatic bile duct,and hilar lymph nodes,as well as partial hepatectomy. Postoperative morbidity was minimal. Surgical pathology demonstrated XGC and absence of malignancy in all three cases. All three patients are alive and well after years of follow-up. XGC may have such an aggressive presentation that carcinoma may only be ruled out on surgical pathology. In such cases,the best option may be radical resection following oncological principles performed by expert surgeons,in order that postoperative complications may be minimized if not avoided altogether.
文摘AIM: To compare cases of xanthogranulomatous cholecystitis(XGC) and advanced gallbladder cancer and discuss the differential diagnoses and surgical options.METHODS: From April 2000 to December 2013, 6 XGC patients received extended surgical resections. During the same period, 16 patients were proven to have gallbladder(GB) cancer, according to extended surgical resection. Subjects chosen for analysis in this study were restricted to cases of XGC with indistinct borders with the liver as it is often difficult to distinguish these patients from those with advanced GB cancer. We compared the clinical features and computed tomography findings between XGC and advanced GB cancer. The following clinical features were retrospectively assessed: age, gender, symptoms, and tumor markers. As albumin and the neutrophil/lymphocyte ratio(NLR) are prognostic in several cancers, we compared serum albumin levels and the NLR between the two groups. The computerized tomography findings were used to compare the two diseases, determine the coexistence of gallstones, the pattern of GB thickening(focal or diffuse), the presence of a hypoattenuated intramural nodule, and continuity of the mucosal line.RESULTS: Based on the preoperative image findings, we suspected GB carcinoma in all cases includingXGC in this series. In addition, by pathological examination, we found that the group of patients with XGC developed inflammatory disease after surgery. Patients with XGC tended to have abdominal pain(4/6, 67%). However, there was no significant difference in clinical symptoms, including fever, between the two groups. Serum albumin and NLR were also similar in the two groups. Serum tumor markers, such as carcinoembryonic antigen(CEA) and carbohydrate antigen 19-9(CA19-9), tended to increase in patients with GB cancer. However, no significant differences in tumor markers were identified. On the other hand, gallstones were more frequently observed in patients with XGC(5/6, 83%) than in patients with GB cancer(4/16, 33%)(P = 0.0116). A hypoattenuated intramural nodule was found in 3 patients with XGC(3/6, 50%), but in only 1 patient with GB cancer(1/16, 6%)(P = 0.0024). The GB thickness, continuous mucosal line, and bile duct dilatation showed no significant differences between XGC and GB cancer.CONCLUSION: Although XGC is often difficult to differentiate from GB carcinoma, it is possible to obtain an accurate diagnosis by careful intraoperative gross observation, and several intraoperative frozen sections.
文摘Acute calculous cholecystitis(ACC) is the most frequent complication of cholelithiasis and represents one-third of all surgical emergency hospital admissions, many aspects of the disease are still a matter of debate. Knowledge of the current evidence may allow the surgical team to develop practical bedside decision-making strategies, aiming at a less demanding procedure and lower frequency of complications. In this regard, recommendations on the diagnosis supported by specific criteria and severity scores are being implemented, to prioritize patients eligible for urgency surgery. Laparoscopic cholecystectomy is the best treatment for ACC and the procedure should ideally be performed within 72h. Early surgery is associated with better results in comparison to delayed surgery. In addition, when to suspect associated common bile duct stones and how to treat them when found are still debated. The antimicrobial agents are indicated for high-risk patients and especially in the presence of gallbladder necrosis. The use of broad-spectrum antibiotics and in some cases with antifungal agents is related to better prognosis. Moreover, an emerging strategy of not converting to open, a difficult laparoscopic cholecystectomy and performing a subtotal cholecystectomy is recommended by adept surgical teams. Some authors support the use of percutaneous cholecystostomy as an alternative emergency treatment for acute Cholecystitis for patients with severe comorbidities.
文摘AIM:To compare the clinical outcome of single-incision laparoscopic cholecystectomy(SILC)and three-incision laparoscopic cholecystectomy(3ILC)for acute cholecystitis.METHODS:From July 2009 to September 2012,136patients underwent SILC or 3ILC for acute cholecystitis at a tertiary referral hospital.One experienced surgeon performed every procedure using 5 or 10 mm 30-degree laparoscopes,straight instruments,and conventional ports.Five patients with perforated gallbladder and diffuse peritonitis and 23 patients with mild acute cholecystitis were excluded.The remaining 108 patients were divided into complicated and uncomplicated groups according to pathologic findings.Patient demography,clinical data,operative results and complications were recorded and analyzed.RESULTS:Fifty patients with gangrenous cholecystitis,gallbladder empyema,or hydrops were classified as the complicated group,and 58 patients with acute cholecystitis were classified as the uncomplicated group.Twenty-three(46.0%)of the patients in the complicated group(n=50)and 39(67.2%)of the patients in the uncomplicated group(n=58)underwent SILC;all others underwent 3ILC.The postoperative length of hospital stay(PLOS)was significantly shorter in the SILC subgroups than the 3ILC subgroups(3.5±1.1 d vs 4.6±1.3 d,P<0.01 in the complicated group;2.9±1.1 d vs 3.7±1.4 d,P<0.05 in the uncomplicated group).The maximum body temperature recorded at day 1 and at day 2 following the procedure was lower in the SILC subgroups,but the difference reached statistical significance only in the uncomplicated group(37.41±0.56℃vs 37.80±0.72℃,P<0.05 on postoperative day 1;37.10±0.43℃vs 37.57±0.54℃,P<0.01 on postoperative day 2).The operative time,estimated blood loss,postoperative narcotic use,total length of hospital stay,conversion rates,and complication rates were similar in both SILC and 3ILC subgroups.The complicated group had longer operative time(122.2±35.0 min vs 106.6±43.6 min,P<0.05),longer PLOS(4.1±1.3 d vs 3.2±1.2 d,P<0.001),and higher conversion rates(36.0%vs 19.0%,P<0.05)compared with the uncomplicated group.CONCLUSION:SILC is safe and efficacious for patients with acute cholecystitis.The main benefit is a faster recovery than that achieved with 3ILC.
文摘AIM: To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. METHODS: A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service (medical or surgical). Patients not undergoing cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery.RESULTS: Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean ± SD time to surgery was 39.3 ± 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography (ERCP, P = 0.01) as well with admission to medical service without adjustment for ERCP (P < 0.05). Patients undergoing both magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier (30.4 ± 34.9 vs 82.7 ± 55.1 h, P < 0.01), had less post-operative complications (12% vs 58%, P < 0.01), and shorter length of stay (4.3 ± 3.4 vs 8.1 ± 5.2 d, P < 0.01).CONCLUSION: Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed up time to surgery should be considered.
基金Supported by The Science and Technology Support Project of Sichuan Province,No.2014SZ0002-10
文摘AIM: To review and evaluate the diagnostic dilemma of xanthogranulomatous cholecystitis(XGC) clinically.METHODS: From July 2008 to June 2014, a total of 142 cases of pathologically diagnosed XGC were reviewed at our hospital, among which 42 were misdiagnosed as gallbladder carcinoma(GBC) based on preoperative radiographs and/or intra-operative findings. The clinical characteristics, preoperative imaging, intra-operative findings, frozen section(FS) analysis and surgical procedure data of these patients were collected and analyzed.RESULTS: The most common clinical syndrome in these 42 patients was chronic cholecystitis, followed by acute cholecystitis. Seven(17%) cases presented with mild jaundice without choledocholithiasis. Thirtyfive(83%) cases presented with heterogeneous enhancement within thickened gallbladder walls on imaging, and 29(69%) cases presented with abnormal enhancement in hepatic parenchyma neighboring the gallbladder, which indicated hepatic infiltration. Intra-operatively, adhesions to adjacent organs were observed in 40(95.2%) cases, including the duodenum, colon and stomach. Thirty cases underwent FS analysis and the remainder did not. The accuracy rate of FS was 93%, and that of surgeon's macroscopic diagnosis was 50%. Six cases were misidentified as GBC by surgeon's macroscopic examination and underwent aggressive surgical treatment. No statistical difference was encountered in the incidence of postoperative complications between total cholecystectomy and subtotal cholecystectomy groups(21% vs 20%, P > 0.05).CONCLUSION: Neither clinical manifestations and laboratory tests nor radiological methods provide apractical and effective standard in the differential diagnosis between XGC and GBC.
