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The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?World Journal of Emergency Surgery :... Dec 2022The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study... (Observational Study)
Observational Study
BACKGROUND
The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not.
METHODS
Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not.
RESULTS
A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001].
CONCLUSIONS
The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands.
Topics: Male; Humans; Middle Aged; Female; Pandemics; SARS-CoV-2; COVID-19; Cholecystitis; Cholecystitis, Acute; Postoperative Complications; Sepsis
PubMed: 36527038
DOI: 10.1186/s13017-022-00466-4 -
HPB : the Official Journal of the... Mar 2022The incidence of acute cholecystitis has a seasonal peak in summer. However, the reason for such seasonality remains unclear. This retrospective cohort study was...
BACKGROUND
The incidence of acute cholecystitis has a seasonal peak in summer. However, the reason for such seasonality remains unclear. This retrospective cohort study was performed to examine the association between ambient temperature and acute cholecystitis.
METHODS
We identified admissions for acute cholecystitis from January 2011 to December 2017 from a nationwide inpatient database in Japan. We performed a Poisson regression analysis to investigate the association between ambient temperature and admission for acute cholecystitis with adjustment for relative humidity, national holidays, day of the week, and year. We accounted for clustering of the outcome within prefectures using a generalized estimating equation.
RESULTS
We analyzed 601 665 admissions for acute cholecystitis. With an ambient temperature of 5.0 °C-9.9 °C as a reference, Poisson regression showed that the number of admissions increased significantly with increasing temperature (highest above 30 °C; relative risk, 1.35; 95% confidence interval, 1.34-1.37). An ambient temperature of <5.0 °C was also associated with higher admission for acute cholecystitis than an ambient temperature of 5.0 °C-9.9 °C (relative risk, 1.23; 95% confidence interval, 1.21-1.25).
CONCLUSION
The present nationwide Japanese inpatient database study showed that high temperature (≥10.0 °C) and low temperature (<5.0 °C) were associated with increased admission for acute cholecystitis.
Topics: Cholecystitis, Acute; Hospitals; Humans; Inpatients; Japan; Retrospective Studies; Temperature
PubMed: 34284962
DOI: 10.1016/j.hpb.2021.06.431 -
Surgical Endoscopy May 2022The use of cholecystostomy (c-tube) in acute cholecystitis (AC) has increased yet there is limited evidence to guide surgical decision-making after placement. As a...
BACKGROUND
The use of cholecystostomy (c-tube) in acute cholecystitis (AC) has increased yet there is limited evidence to guide surgical decision-making after placement. As a result, there is variability in the use and timing of cholecystectomy after c-tube. We aimed to describe patient characteristics, outcomes, and biliary-related utilization in those who did and did not have cholecystectomy after c-tube.
METHODS
This is a retrospective cohort study (2007-2017) using the MarketScan® claims database of patients (18-63 years) with at least 3 months of follow-up (or death). ICD-9/10 and CPT codes were used to identify AC, c-tube placement, cholecystectomy and determine Elixhauser comorbidity index.
RESULTS
A total of 2386 patients (47.5% female, mean age 52.5 [SD 9.9] years) with AC underwent c-tube with an 11.2% 90-day mortality. Among survivors, by three months 57% underwent cholecystectomy (mean 34.8 days [95% CI: 33.3-36.3]). Cholecystectomy after c-tube was more common in those with fewer comorbid conditions (mean 2.41 [95% CI: 2.26-2.56] vs 4.56 [95%CI: 4.36-4.76]). Biliary episodes prior to cholecystectomy occurred in 12.5% and were associated with eventual cholecystectomy (HR 1.49 [1.32-1.68]). Biliary-specific hospital and ICU days were similar between groups. Biliary-specific ED visits were more common among patients with cholecystectomy (mean 1.39 [95% CI: 1.29-1.48] vs 0.94 [95% CI: 0.85-1.03]).
CONCLUSION
More than half of patients treated with c-tube underwent cholecystectomy by three months-most within five weeks of AC diagnosis. The high frequency of use and short time to cholecystectomy after c-tube raises questions about potential overuse of c-tube in the initial period. Future work should aim to understand how patient experience and indication for c-tube influence the likelihood and timing of subsequent cholecystectomy.
Topics: Cholecystectomy; Cholecystitis, Acute; Cholecystostomy; Female; Humans; Male; Middle Aged; Retrospective Studies; Treatment Outcome
PubMed: 34076767
DOI: 10.1007/s00464-021-08562-3 -
Journal of Visceral Surgery Dec 2015The performance of emergency abdominal surgery in an outpatient setting is increasingly the order of the day in France. This review evaluates the feasibility and... (Review)
Review
INTRODUCTION
The performance of emergency abdominal surgery in an outpatient setting is increasingly the order of the day in France. This review evaluates the feasibility and reliability of ambulatory surgical treatment of the most common abdominal emergencies: appendectomy for acute appendicitis and cholecystectomy for acute complications of gallstone disease (acute cholecystitis and gallstone pancreatitis).
METHODS
This study evaluates surgical procedures performed on an ambulatory basis according to the international definition (admission in the morning, discharge in the evening with a hospital stay of less than 12 hours). Just as for elective surgery, eligibility of patients for an ambulatory approach depends on the capacities of the surgical and anesthesia team: to manage the risks, particularly the risk of deferring surgery until the morning); to prevent or treat post-operative symptoms like pain, nausea, vomiting, re-ambulation in order to permit rapid post-operative discharge.
RESULTS
Recent studies have shown that appendectomy for non-complicated acute appendicitis can be deferred for up to 12 hours without any increase in danger. Many other studies have shown that early discharge after appendectomy for acute non-complicated appendicitis is feasible and safe. Nonetheless, there is only one published series of truly ambulatory appendectomies. The results were excellent. Patients who presented in the afternoon were brought back for operation the following morning. The appropriate timing for performance of cholecystectomy in patients with acute calculous cholecystitis or gallstone pancreatitis has not been well defined, but is always somewhat delayed relative to the onset of symptoms. To minimize operative complications, cholecystectomy for acute calculous cholecystitis should probably be performed between 24 and 72 hours after diagnosis. Cholecystectomy for gallstone pancreatitis should probably not be delayed longer than a week; the need to keep the patient hospitalized during the interval has not been demonstrated. Early discharge after cholecystectomy was usually possible, even in series where acute cholecystitis was diagnosed intra-operatively. Cholecystectomy for acute cholecystitis and gallstone pancreatitis seems to be feasible but no reports specifically support this approach.
CONCLUSIONS
Emergency abdominal surgery seems to be feasible on an ambulatory setting for non-complicated acute appendicitis, acute calculous cholecystitis and gallstone pancreatitis. Only a single French series on ambulatory appendectomy for acute appendicitis has been reported.
Topics: Acute Disease; Ambulatory Surgical Procedures; Appendectomy; Appendicitis; Cholecystectomy; Cholecystitis, Acute; Emergencies; Feasibility Studies; France; Gallstones; Humans; Pancreatitis; Reproducibility of Results; Treatment Outcome
PubMed: 26522504
DOI: 10.1016/j.jviscsurg.2015.09.015 -
Annals of the Royal College of Surgeons... Nov 2022Ultrasound has long been the radiological investigation of choice for right upper quadrant pain in the detection of gallstones and cholecystitis. However, previously...
INTRODUCTION
Ultrasound has long been the radiological investigation of choice for right upper quadrant pain in the detection of gallstones and cholecystitis. However, previously reported sensitivity, specificity and other diagnostic metrics have varied widely and the underlying patient numbers have been small. We present robust and exhaustive diagnostic metrics based on a large series of 795 patients.
METHODS
All laparoscopic cholecystectomies at Portsmouth Hospitals University were prospectively logged between 2017 and 2020. Ultrasound findings, Nassar operative difficulty and histopathological findings were all collected in addition to patient biometrics.
RESULTS
In our large patient series, the sensitivity of ultrasound for cholecystitis was lower than previously reported at 75.7% for acute cholecystitis, 34.6% for chronic cholecystitis and 42.7% overall. Moreover, we show that sensitivity degrades with the time between ultrasound and cholecystectomy, falling below 50% at 140 days. Finally, we show that ultrasound strongly predicts the Nassar difficulty grade of cholecystectomy and that its ability to do so is greatest when the interval between ultrasound and cholecystectomy is less than 27 days.
CONCLUSIONS
We present robust diagnostic metrics for ultrasound in the diagnosis of cholecystitis. These should caution the clinician that ultrasound may miss a quarter of cases of acute cholecystitis and over half of all cases of cholecystitis. Conversely, the finding of a thickened gallbladder wall on ultrasound can predict a 'difficult cholecystectomy' and highlight the need for appropriate expertise and resources. Both this prediction and the diagnostic sensitivity are best if the ultrasound is done less than 27 days before cholecystectomy.
Topics: Humans; Cholecystitis; Cholecystectomy; Cholecystitis, Acute; Cholecystectomy, Laparoscopic; Gallstones; Retrospective Studies
PubMed: 35175883
DOI: 10.1308/rcsann.2021.0322 -
BMC Gastroenterology Aug 2022International guidelines recommend emergency cholecystectomy for acute cholecystitis in patients who are healthy or have mild systemic disease (ASA1-2). Surgery is also...
BACKGROUND
International guidelines recommend emergency cholecystectomy for acute cholecystitis in patients who are healthy or have mild systemic disease (ASA1-2). Surgery is also an option for patients with severe systemic disease (ASA3) in clinical practice. The study aimed to investigate the risk of complications in ASA3 patients after surgery for acute cholecystitis.
METHOD
1 634 patients treated for acute cholecystitis at three Swedish centres between 2017 and 2020 were included in the study. Data was gathered from electronic patient records and the Swedish registry for gallstone surgery, Gallriks. Logistic regression was used to assess the risk of complications adjusted for confounding factors: sex, age, BMI, Charlson comorbidity index, cholecystitis grade, smoking and time to surgery.
RESULTS
725 patients had emergency surgery for acute cholecystitis, 195 were ASA1, 375 ASA2, and 152 ASA3. Complications occurred in 9% of ASA1, 13% of ASA2, and 24% of ASA3 patients. There was no difference in 30-day mortality. ASA3 patients stayed on average 2 days longer after surgery. After adjusting for other factors, the risk of complications was 2.5 times higher in ASA3 patients than in ASA1 patients. The risk of complications after elective surgery was 5% for ASA1, 13% for ASA2 and 14% for ASA3 patients. Regardless of ASA 18% of patients treated non-operatively had a second gallstone complication within 3 months.
CONCLUSION
Patients with severe systemic disease have an increased risk of complications but not death after emergency surgery. The risk is lower for elective procedures, but a substantial proportion will have new gallstone complications before elective surgery.
TRIAL REGISTRATION
Not applicable.
Topics: Cholecystectomy; Cholecystectomy, Laparoscopic; Cholecystitis; Cholecystitis, Acute; Comorbidity; Gallstones; Humans; Retrospective Studies
PubMed: 35927715
DOI: 10.1186/s12876-022-02453-0 -
Acta Radiologica (Stockholm, Sweden :... Apr 2023Cancellations of surgeries for elective cases and late admissions of symptomatic cases during the pandemic period might have increased the number of cases of acute...
BACKGROUND
Cancellations of surgeries for elective cases and late admissions of symptomatic cases during the pandemic period might have increased the number of cases of acute cholecystitis and its complications.
PURPOSE
To compare the severity of acute cholecystitis and complication rates during the pandemic and pre-pandemic periods.
MATERIAL AND METHODS
We evaluated the computed tomography (CT) findings observed for the diagnosis of complications for both acute simple and acute complicated cholecystitis during both the pandemic and pre-pandemic periods. Patients admitted to the hospital between March 2020 and December 2020 made up the study group and the corresponding appropriate patients from one year earlier were studied as the control group. In addition to the CT findings, clinical and laboratory findings, co-morbidities such as diabetes, as well as the admission time to hospital from the onset of the initial symptoms to hospital admission were also evaluated.
RESULTS
A total of 88 patients were evaluated (54 in the study group, 34 in the control group; mean age = 64.3 ± 16.3 years). The male-to-female ratio was 51/37. The number of patients diagnosed with complicated cholecystitis were significantly higher in the study group ( = 0.03). Murphy finding and diabetes status were similar between the two groups ( = 0.086 and = 0.308, respectively). Admission time to the hospital was significantly different for study and control groups in simple cholecystitis patients ( = 0.045); with no significant difference in cases of complicated cholecystitis ( = 0.499).
CONCLUSION
Our study reveals the course of acute cholecystitis during the pandemic period was much more serious with higher complications.
Topics: Humans; Male; Female; Middle Aged; Aged; Aged, 80 and over; Pandemics; Cholecystitis, Acute; Cholecystitis; Comorbidity; Diabetes Mellitus
PubMed: 36412110
DOI: 10.1177/02841851221137048 -
Clinical Gastroenterology and... May 2023Endoscopic gallbladder drainage is a feasible and efficacious alternative to percutaneous drainage in the management of acute cholecystitis for high-risk surgical... (Review)
Review
DESCRIPTION
Endoscopic gallbladder drainage is a feasible and efficacious alternative to percutaneous drainage in the management of acute cholecystitis for high-risk surgical candidates. Endoscopic ultrasound-guided gallbladder drainage and per-oral cholecystoscopy is facilitated by the use of lumen-apposing metal stents. Endoscopic ultrasound-guided gallbladder drainage should be performed by those expert in advanced therapeutic endoscopic ultrasound. Multidisciplinary collaboration between interventional radiology and surgery is paramount in the care of these patients. Choosing the optimal drainage method is dependent on individual patient characteristics.
METHODS
This commentary was drawn from a review of the literature to provide practical advice. Because this was not a systematic review, we did not perform any formal rating of the quality of evidence or strength of the presented considerations. This expert commentary was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer-review by the Clinical Practice Updates Committee and external peer-review through standard procedures of Clinical Gastroenterology and Hepatology.
Topics: Humans; Gallbladder; Cholecystitis, Acute; Endosonography; Drainage; Endoscopy; Stents; Treatment Outcome
PubMed: 36967319
DOI: 10.1016/j.cgh.2022.12.039 -
World Journal of Gastroenterology Dec 2019Recent management of acute cholecystitis favors same admission (SA) or emergent cholecystectomy based on overall shorter hospital stay and therefore cost savings. We...
BACKGROUND
Recent management of acute cholecystitis favors same admission (SA) or emergent cholecystectomy based on overall shorter hospital stay and therefore cost savings. We adopted the practice of SA cholecystectomy for the treatment of acute cholecystitis at our tertiary care center and wanted to evaluate the economic benefit of this practice. We hypothesized that the existence of complications, particularly among patients with a higher degree of disease severity, during SA cholecystectomy could negate the cost savings.
AIM
To compare complication rates and hospital costs between SA delayed cholecystectomy among patients admitted emergently for acute cholecystitis.
METHODS
Under an IRB-approved protocol, complications and charges for were obtained for SA, later after conservative management (Delayed), or elective cholecystectomies over an 8.5-year period. Patients were identified using the acute care surgery registry and billing database. Data was retrieved EMR, operative logs, and Revenue Cycle Operations. The severity of acute cholecystitis was graded according to the Tokyo Guidelines. TG18 categorizes acute cholecystitis by Grades 1, 2, and 3 representing mild, moderate, and severe, respectively. Comparisons were analyzed with , Fisher's exact test, ANOVA, -tests, and logistic regression; significance was set at < 0.05.
RESULTS
Four hundred eighty-six (87.7%) underwent a SA while 68 patients (12.3%) received Delayed cholecystectomy. Complication rates were increased after SA compared to Delayed cholecystectomy (18.5% 4.4%, = 0.004). The complication rates of patients undergoing delayed cholecystectomy was similar to the rate for elective cholecystectomy (7.4%, = 0.35). Mortality rates were 0.6% 0% for SA Delayed. Patients with moderate disease (Tokyo 2) suffered more complications among SA while none who were delayed experienced a complication (16.1% 0.0%, < 0.001). Total hospital charges for SA cholecystectomy were increased compared to a Delayed approach ($44500 ± $59000 $35300 ± $16700, = 0.019). The relative risk of developing a complication was 4.2x [95% confidence interval (CI): 1.4-12.9] in the SA Delayed groups. Among eight patients (95%CI: 5.0-12.3) with acute cholecystitis undergoing SA cholecystectomy, one patient will suffer a complication.
CONCLUSION
Patients with Tokyo Grade 2 acute cholecystitis had more complications and increased hospital charges when undergoing SA cholecystectomy. This data supports a selective approach to SA cholecystectomy for acute cholecystitis.
Topics: Adult; Cholecystectomy; Cholecystitis, Acute; Clinical Decision-Making; Cost Savings; Female; Hospital Costs; Humans; Length of Stay; Male; Middle Aged; Patient Selection; Postoperative Complications; Retrospective Studies; Severity of Illness Index; Tertiary Care Centers; Time Factors; Time-to-Treatment; Treatment Outcome
PubMed: 31908395
DOI: 10.3748/wjg.v25.i48.6916 -
Annals of Surgery Sep 2023To evaluate the safety and efficacy of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS).
OBJECTIVE
To evaluate the safety and efficacy of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS).
BACKGROUND
For patients with acute cholecystitis who are poor surgical candidates, EUS-GBD using a LAMS is an important treatment alternative to percutaneous gallbladder drainage.
METHODS
We conducted a regulatory-compliant, prospective multicenter trial at 7 tertiary referral centers in the United States of America and Belgium. Thirty consecutive patients with mild or moderate acute cholecystitis who were not candidates for cholecystectomy were enrolled between September 2019 and August 2021. Eligible patients had a LAMS placed transmurally with 30 to 60-day indwell if removal was clinically indicated, and 30-day follow-up post-LAMS removal. Endpoints included days until acute cholecystitis resolution, reintervention rate, acute cholecystitis recurrence rate, and procedure-related adverse events (AEs).
RESULTS
Technical success was 93.3% (28/30) for LAMS placement and 100% for LAMS removal in 19 patients for whom removal was attempted. Five (16.7%) patients required reintervention. Mean time to acute cholecystitis resolution was 1.6±1.5 days. Acute cholecystitis symptoms recurred in 10.0% (3/30) after LAMS removal. Five (16.7%) patients died from unrelated causes. Procedure-related AEs were reported to the FDA in 30.0% (9/30) of patients, including one fatal event 21 days after LAMS removal; however, no AEs were causally related to the LAMS.
CONCLUSIONS
For selected patients with acute cholecystitis who are at elevated surgical risk, EUS-GBD with LAMS is an alternative to percutaneous gallbladder drainage. It has high technical and clinical success, with low recurrence and an acceptable AE rate. Clinicaltrials.gov, Number: NCT03767881.
Topics: Humans; Gallbladder; Prospective Studies; Treatment Outcome; Cholecystitis, Acute; Endosonography; Drainage; Stents; Ultrasonography, Interventional
PubMed: 36537290
DOI: 10.1097/SLA.0000000000005784