The Role of Series Cholecystectomy in High Risk Acute Cholecystitis Patients Who Underwent Gallbladder Drainage
Chi‐Chih WangMing‐Hseng TsengSheng‐Wen WuTzu‐Wei YangWen‐Wei SungYao‐Tung WangHsiang‐Lin LeeBei‐Hao ShiuChun‐Che LinMing‐Chang Tsai
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Background: Cholecystectomy (CCY) is the only definitive therapy for acute cholecystitis. We conducted this study to evaluate which patients may not benefit from further CCY after percutaneous transhepatic gallbladder drainage (PTGBD) has been performed in acute cholecystitis patients. Methods: Acute cholecystitis patients with PTGBD treatment were selected from one million random samples from the National Health Insurance Research Database obtained between January 2004 and December 2010. Recurrent biliary events (RBEs), RBE-related medical costs, RBE-related mortality rate and an RBE-free survival curve were compared in patients who accepted CCY within 2 months and patients without CCY within 2 months after the index admission. Results: Three hundred and sixty-five acute cholecystitis patients underwent PTGBD at the index admission. A total of 190 patients underwent further CCY within 2 months after the index admission. The other 175 patients did not accept further CCY within 2 months after the index admission. RBE-free survival was significantly better in the CCY within 2 months group (60 vs. 42%, p < 0.001). The RBE-free survival of the CCY within 2 months group was similar to that of the no CCY within 2 months group in patients ≥ 80 years old and patients with a Charlson Comorbidity Index (CCI) score ≥ 9. Conclusions: We confirmed CCY after PTGBD reduced RBEs, RBE-related medical expenses, and the RBE-related mortality rate in patients with acute cholecystitis. In patients who accepted PTGBD, the RBE and survival benefits of subsequent CCY within 2 months became insignificant in patients ≥ 80 years old or with a CCI score ≥ 9.Objective. To improve quality of diagnosis of paravesical complications in patients, suffering an acute cholecystitis, using demonstration of interrelationship of changes in the gallbladder wall histostructure and its echogram data.
Materials and methods. Comparative analysis of the gallbladder wall echogram and results of the gallbladder wall morphological investigation was conducted in 520 patients with an acute cholecystitis to determine the kind of paravesical complications.
Results. Morphological investigation of the gallbladder wall have shown that the gallbladder dimensions and the wall thickness enhancement are not universal characteristic features for an acute cholecystitis. To determine the kind of its inflammation (phlegmonous, gangrenous or catarral) is also impossible. In accordance to ultrasonographic criteria an acute cholecystitis diagnosis is established, аnd patho-morphologist determines the inflammation form. Sclerotic processes with overgrowth of dense connective tissue were revealed in the gallbladder wall while presence of a long-term inflammatory process. That's why in the patients, suffering an acute cholecystitis, the gallbladder wall echograms may show excessively white signal with delineated contours, but at the same time the gallbladder volume may be not changed or even reduced. This data may impact the choice of operative procedure. Ultrasonographic signs of presence of paravesical infiltrate and abscess were established as well.
Conclusion. Echographic changes of the gallbladder wall indicates its inflammation, but do not give possibility to find which form it has. The gallbladder volume may be reduced in an acute cholecystitis, if inflammation occurs on background of recurrent process. The gallbladder wall demonstrates excessively white positive echographic signal, if in its structure connective tissue and collagen fibers prevail.
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Chronic cholecystitis, with cholelithiasis and choledocholithiasis, and acute cholecystitis occur more frequently in elderly persons than in younger ones. Because of the serious and often fatal complications which these conditions cause, cholecystectomy should be advised for chronic cholecystitis with stones whenever the condition exists. Elderly patients for whom operation is not strongly contraindicated tolerate simple cholecystectomy well.Acute cholecystitis usually is best managed by early surgical treatment.The most common condition requiring abdominal surgical treatment in the aged is disease of the biliary tract.
Chronic cholecystitis
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Calcification of the gallbladder wall (porcelain gallbladder) is an intense structure and uncommon manifestation seen in chronic cholecystitis and resulting from chronic inflammation of the gallbladder wall. Patients with porcelain gallbladder are usually considered not at risk of acute cholecystitis. However, sporadic cases of cholecystitis on porcelain gallbladder have been described in literature. Gallbladder perforation is a rare entity and may complicate on acute or chronic cholecystitis in a non-calcified gallbladder. We report an unusual case of acute cholecystitis with perforation in a porcelain gallbladder.
Perforation
Chronic cholecystitis
Gallbladder disease
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Objective:Monitoring the gallbladder contrctility by ultrasound after puncturing the points,to evaluate the contribution in diagnosing cholecystitis.Methods: Fifty-one cholecystitis cases were examined by ultrasound.The gallbladders were monitored by ultrasound at 10min,20min,30min after acupuncture separately.Calculating the volume of gallbladder by utilizing gallbladder volume calculation formula in different time was performed,then comment the gallbladder contrctility.The cholecystitis series and the normal series were compared by T test.Results: The gallbladder contrctility of cholecystitis series was obviously lower than normal series(t0.01).Conclusion: Ultrasound with acupunrcture can be used to evaluate the the gallbladder contrctility in order to diagnose the cholecystitis.It has many merits,such as no risk,little suffering,easily receiving,easily repetition,etc.And it is a useful method of the integrated traditional and western medicine.
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Objective: The objective of this study was to evaluate the differences between patients who undergo cholecystectomy following index admission for cholecystitis, and those who are managed nonoperatively. Summary Background Data: Index emergency cholecystectomy following acute cholecystitis is widely recommended by national guidelines, but its effect on clinical outcomes remains uncertain. Methods: Data collected routinely from the Hospital Episode Statistics database (all admissions to National Health Service organizations in England and Wales) were extracted between April 1, 2002 and March 31, 2015. Analyses were limited to patients aged over 18 years with a primary diagnosis of cholecystitis. Exclusions included records with missing or invalid datasets, patients who had previously undergone a cholecystectomy, patients who had died without a cholecystectomy, and those undergoing cholecystectomy for malignancy, pancreatitis, or choledocholithiasis. Patients were grouped as either “no cholecystectomy” where they had never undergone a cholecystectomy following discharge, or “cholecystectomy.” The latter group was then subdivided as “emergency cholecystectomy” when cholecystectomy was performed during their index emergency admission, or “interval cholecystectomy” when a cholecystectomy was performed within 12 months following a subsequent (emergency or elective) admission. Propensity Score Matching was used to match emergency and interval cholecystectomy groups. Main outcome measures included 1) One-year total length of hospital stay due to biliary causes following an index emergency admission with cholecystitis. 2) One-year mortality; defined as death occurring within 1 year following the index emergency admission with acute cholecystitis. Results: Of the 99,139 patients admitted as an emergency with acute cholecystitis, 51.1% (47,626) did not undergo a cholecystectomy within 1 year of index admission. These patients were older, with more comorbidities (Charlson Comorbidity Score ≥ 5 in 23.5% vs. 8.1%, P < 0.001) when compared to patients who did have a cholecystectomy. While all-cause 1-year mortality was higher in the nonoperated versus the operated group (12.2% vs. 2.0%, P < 0.001), gallbladder-related deaths were significantly lower than all other causes of death in the non-operated group (3.3% vs. 8.9%, P < 0.001). Following matching, 1-year total hospital admission time was significantly higher following emergency compared with interval cholecystectomy (17.7 d vs. 13 d, P < 0.001). Conclusions: Over 50% of patients in England did not undergo cholecystectomy following index admission for acute cholecystitis. Mortality was higher in the nonoperated group, which was mostly due to non-gallbladder pathologies but total hospital admission time for biliary causes was lower over 12 months. Increasing the numbers of emergency cholecystectomy may risk over-treating patients with acute cholecystitis and increasing their time spent admitted to hospital.
Biliary disease
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We collected data from 2070 patients who had undergone cholecystectomy for acute cholecystitis, investigating the circumstance of preoperative antimicrobial therapy. The duration of preoperative antimicrobial therapy was significantly longer in delayed cholecystectomy than early cholecystectomy (p<0.001). The number of types of antimicrobial drugs was also significantly greater in delayed cholecystectomy patients. The length of preoperative hospital stay in accordance with the number of antimicrobial drugs used in delayed cholecystectomy (p<0.001). This study suggests the importance of early cholecystectomy and the appropriate use of preoperative antimicrobial drugs for acute cholecystitis.
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Objective To study the pathologic changes of the gallbladder in rabbits with calculous cholecystitis and the causes of gallstone recurrence after choleystolithotomy. Methods Twenty- four rabbits were randomly divided into four groups:(1) normal control group (n=5);(2) operative control group(n=5);(3) stone-implanted(S-I) group (n=6),and (4)stone- removed(S-R) group(n=8).The human cholesterol gallstones were implanted into the rabbit gallbladder in stone-implanted and stone- removed rabbits,The pathologic change of the gallbladder was observed by light microscopy 3 months before and after cholecystolithotomy. Results (1)The wet weight of gallbladder in the S-R group [ (1.1±0.06)g] was significant higher than that in S-I group [(0.515±0.1)g] (P0.05). (2)The thickness of gallbladder in S-R group [(1.956±0.23)mm] was no significant different from that in the S-I group [(1.248±0.85)mm] (P0.05);(3)Sever chronic cholecystitis was 33.3% in S-I group 87.5% and in S-R group(P0.05);(4)Both mucous cell and collagen fibre cell in the gallbladder of stone-removed group were proliferous. Conclusions The structure of diseased gallbladder unable to restore to the normal after cholecystolithotomy is likely a cause of gallstone recurrence.
Chronic cholecystitis
Gallbladder Stone
Gallbladder disease
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Background: The gallbladder is surgically removed in a cholecystectomy. The prevalence of gallbladder carcinoma is determined by examining cholecystectomy specimens. Gallbladder carcinoma is an extremely unusual condition that affects more women than men. The goal of this study is to find out how common gallbladder cancer is in medical centers over five years. Objective: To determine the frequency and prevalence of Gallbladder cancer (GBC) in tertiary care hospitals over five years Methods: We analyzed the record of 1835 patients who underwent cholecystectomy at our tertiary care center, Mayo Hospital Lahore. Results: Adenocarcinoma was found in only 7 cases (0.4%) out of 1835 cholecystectomy specimens. Gallbladder cancer is more common in females (6, 85.71%) than in males (1 case, 14.78%). Chronic cholecystitis accounted for the majority of the cases (1703, or 92.8%), followed by acute cholecystitis (66, or 3.6%), Xanthogranulomatous, cholecystitis (30, or 1.6%), gangrenous cholecystitis (6, or 0.34%), follicular cholecystitis (3, or 0.016%) and one case (0.05%) each of cholesterolosis, foci of chronic inflammation, hemorrhagic infarction and empyema gallbladder. 13 cases (0.79%) was partially or fully autolyzed. Conclusion: Chronic cholecystitis is the most common disease in cholecystectomy specimens followed by acute cholecystitis, Xanthogranulomatous cholecystitis, gangrenous cholecystitis, follicular cholecystitis, and empyema gallbladder. Gallbladder carcinoma is very rare and more common in females than males.
Gallbladder Cancer
Gallbladder disease
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Chronic inflammation is a risk factor for gallbladder carcinoma. The molecular mechanisms linking inflammation and gallbladder carcinogenesis are incompletely understood. Toll-like receptors are involved in inflammatory response and play an important role in the innate immune system by initiating and directing immune response to pathogens. We tested the hypothesis that TLR4 participated in the development of gallbladder carcinoma through investigating the expression of TLR4 in chronic cholecystitis, gallbladder carcinoma and normal gallbladder.The expression of TLR4 in 30 specimens of chronic calculous cholecystitis, 13 specimens of gallbladder adenocarcinoma and 10 specimens of normal gallbladder tissue was determined by immunohistochemistry, western blotting analysis and quantitative RT-PCR.We showed that TLR4 was mostly localized to the glandular and luminal epithelium of gallbladder. TLR4 expression was lower in gallbladder carcinoma tissue than in chronic cholecystitis and normal gallbladder tissue, whereas the difference between chronic cholecystitis tissue and normal gallbladder tissue was not statistically significant.The expression of TLR4 may be closely associated with the course of gallbladder carcinoma.
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Three patients with cholelithiasis were found to possess a duplicate gallbladder. A 48-year-old woman continued to have symptoms one year after cholecystectomy, a 69-year-old woman had symptoms even though her gallbladder had been removed 40 years before, and in a 29-year-old woman a second gallbladder was found during cholecystectomy. In all three patients, the second gallbladder was removed as well, after which they recovered. The differential diagnosis of persistent symptoms following cholecystectomy should also consider the possible presence of an accessory gallbladder.
Gallbladder disease
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