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HPB : the Official Journal of the... Oct 2022Compare outcomes of early laparoscopic cholecystectomy (ELC) and percutaneous trans-hepatic drainage of gallbladder (PTGBD) as an initial intervention for AC and to... (Meta-Analysis)
Meta-Analysis Review
Outcome of early cholecystectomy compared to percutaneous drainage of gallbladder and delayed cholecystectomy for patients with acute cholecystitis: systematic review and meta-analysis.
BACKGROUND
Compare outcomes of early laparoscopic cholecystectomy (ELC) and percutaneous trans-hepatic drainage of gallbladder (PTGBD) as an initial intervention for AC and to compare operative outcomes of ELC and delayed laparoscopic cholecystectomy (DLC).
METHODS
English-language studies published until December 2020 were searched. Randomised controlled trials (RCTs) and observational studies compared EC and PTGBD with delayed cholecystectomy for patients presented with acute cholecystitis were considered. Main outcomes were mortality, conversion to open, complications and length of hospital stay.
RESULTS
Out of 1347 records, 14 studies were included. 205,361 (94.7%) patients had EC and 11,565 (5.3%) patients had PTGBD as an initial intervention for AC. Mortality was higher in PTGBD; HR, 95% CI: [3.68 (2.13, 6.38)]. In contrast, complication rate was significantly higher in EC group (47%) vs PTGBD group (8.7%) in patients admitted to ICU; P-value = 0.011. Patients who had ELC were at higher risk of post-operative complications compared to DLC; RR [95% CI]: 2.88 [1.78, 4.65]. Risk of bile duct injury was six folds more in ELC; RR [95% CI]: 6.07 [1.67, 21.99].
CONCLUSION
ELC may be a preferred treatment option over PTGBD in AC. However, patient and disease specific factors should be considered to avoid unfavourable outcomes with ELC.
Topics: Humans; Gallbladder; Time Factors; Cholecystitis, Acute; Cholecystectomy; Cholecystectomy, Laparoscopic; Drainage; Treatment Outcome; Retrospective Studies
PubMed: 35597717
DOI: 10.1016/j.hpb.2022.04.010 -
Frontiers in Surgery 2022Since the beginning of the COVID-19 pandemic, many patients with clinically acute presentations have been approached differently. The fear of viral transmission along...
INTRODUCTION
Since the beginning of the COVID-19 pandemic, many patients with clinically acute presentations have been approached differently. The fear of viral transmission along with the short period of study made patients delay their hospital visits and doctors reassess the approach of certain acute situations. This study aimed to assess the changes in the management of patients with acute cholecystitis before and during COVID-19.
METHODS
A systematic review of the literature using PubMed (MEDLINE), Scopus, and ScienceDirect databases was performed until 01 September 2021. Totally, two kinds of studies were included, those assessing the management of acute cholecystitis during COVID-19 and those comparing the periods before and during the pandemic. The outcomes recorded include management approaches, complications, and mean length of stay.
RESULTS
A number of 15 eligible articles were included in the study. During the pandemic, six studies revealed a shift toward conservative management of acute cholecystitis and five of them reported that conservative management was opted in 73% of the patients. On the contrary, data from all studies revealed that the surgical approach was preferred in only 29.2% of patients. Furthermore, when comparing the periods before vs. during COVID-19, the conservative approach was reported in 36.3 and 43.2% before vs. during COVID-19, respectively, whereas surgical intervention was performed in 62.5% of patients before COVID-19 and 55.3% during the pandemic. The length of stay was delayed when a non-surgical approach was selected in most studies. Complications, mainly classified by the Clavien-Dindo scale, were higher in the pandemic period.
CONCLUSION
A tendency toward more conservative approaches was observed in most studies, reversing the previously used surgical approach in most cases of acute cholecystitis. In most of the examined cases during the COVID-19 pandemic, antibiotic treatment and percutaneous cholecystostomy were much more considered and even preferred.
PubMed: 35495756
DOI: 10.3389/fsurg.2022.871685 -
HPB : the Official Journal of the... Sep 2022High risk surgical patients with acute cholecystitis are commonly treated with percutaneous cholecystostomy (PTC) drainage. The optimal timing of subsequent interval... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
High risk surgical patients with acute cholecystitis are commonly treated with percutaneous cholecystostomy (PTC) drainage. The optimal timing of subsequent interval laparoscopic cholecystectomy (LC) remains unclear.
METHODS
Medline, EMBASE, and Scopus were searched to identify studies published between 01/01/2000 and 31/12/2020, reporting on interval LC outcomes in patients initially treated by PTC. Early and late interval LC were defined as <30 and ≥ 30 days respectively. The Methodological Index for Nonrandomized Studies was used for quality assessment. Meta-analysis of proportions was conducted using a random-effects model.
RESULTS
A total of 512 studies were screened, 41 met the inclusion criteria. There were 22 studies in both early and late interval LC groups, with 3 included studies reporting both early and late groups. Following quality assessment, 29 studies were included in the meta-analysis. There were no significant differences between early and late interval LC in terms of conversion rates (7.2% vs 8.3%, p = 0.854), 90-day morbidity (12.8% vs 15.9%, p = 0.496), and 90-day mortality (0.25% vs 0.32%, p = 0.704). Heterogeneity was significant (I>50%) in all groups.
CONCLUSION
Current evidence of interval LC within or beyond 30 days demonstrates no significant impact on outcomes. Patient factors, clinical experience, and hospital facilities may prove more important predictors.
Topics: Cholecystectomy, Laparoscopic; Cholecystitis, Acute; Cholecystostomy; Humans; Morbidity; Retrospective Studies; Treatment Outcome
PubMed: 35469743
DOI: 10.1016/j.hpb.2022.03.016 -
Journal of Neurological Surgery. Part... Jan 2023Lower back pain is a frequent cause of emergency department visits and one of the leading causes of the disease burden worldwide. The purpose of this case report and...
BACKGROUND
Lower back pain is a frequent cause of emergency department visits and one of the leading causes of the disease burden worldwide. The purpose of this case report and literature review was to discuss atypical abdominal entities mimicking spinal diseases typically presenting with lower back pain.
METHODS
A 79-year-old man presented with lower back pain and urinary incontinence after receiving a non-image-guided lumbar infiltration treatment 4 weeks prior to admission. The magnetic resonance imaging (MRI) highlighted multisegmental hyperintensities in the intervertebral disk spaces of the lumbar spine indicative for spondylodiscitis. Antibiotic treatment over a week did not lead to significant clinical improvement. Blood cultures, cardiologic, otorhinolaryngologic, and dental examinations turned out negative for a focus of infection. A computed tomography (CT) guided biopsy was indicated after discontinuation of antibiotic treatment for less than 24 hours. Rapid clinical deterioration with concomitant onset of abdominal pain resulted in the diagnosis of cholecystitis, which required cholecystectomy. We performed a systematic literature review using the Pubmed database for the keywords "spondylodiscitis," "spine," "abdominal," and "cholecystitis," to identify abdominal diseases that mimic spine pathologies and spinal diseases that mimic abdominal pathologies.
RESULTS
No other report in English literature of cholecystitis associated with initial onset of lower back pain was identified. Eighteen reports referred to abdominal conditions that mimic spinal diseases, among them a patient with cyclic lumbar back pain who received a lumbar spinal fusion who, after persisting symptoms led to further diagnostic procedures, was ultimately diagnosed with endometriosis. Spinal symptoms included paraplegia and urinary incontinence as results of acute aortic pathologies. Eleven reports presented spinal pain mimicking abdominal conditions including abdominal pain and diarrhea as well as have had surgical procedures such as an appendectomy before the spinal condition was discovered.
CONCLUSION
Clinical symptoms of the spine such as lower back pain can be unspecific and lead to false conclusions in the presence of concomitant pathologies in MRI. Only clinical deterioration in our case patient prompted correction of the diagnosis on day 7. Initial workup for alternative common infectious foci such as lung and urinary tract was performed, but further abdominal workup despite the absence of abdominal symptoms may have led to an earlier diagnosis. Our literature review found several cases of misdiagnosed spinal and abdominal conditions. Some had undergone unnecessary surgical procedures before the right diagnosis was made. Because of the high incidence of symptoms such as lumbar back pain and abdominal pain, considering optimal patient care as well as economic aspects, it would be essential to conduct an interdisciplinary clinical management to avoid errors in the early stage of diagnostics.
Topics: Male; Female; Humans; Aged; Discitis; Low Back Pain; Clinical Deterioration; Lumbar Vertebrae; Cholecystitis; Abdominal Pain; Anti-Bacterial Agents; Magnetic Resonance Imaging
PubMed: 35354214
DOI: 10.1055/a-1811-7393 -
Expert Review of Gastroenterology &... Jan 2022The accurate characterization of gallbladder wall thickening (GWT) into benign or malignant on ultrasound (US) is a significant challenge. (Meta-Analysis)
Meta-Analysis
BACKGROUND
The accurate characterization of gallbladder wall thickening (GWT) into benign or malignant on ultrasound (US) is a significant challenge.
METHODS
We searched the MEDLINE and EMBASE databases for studies reporting two-dimensional grayscale US in benign and malignant GWT. The pooled prevalence was calculated using a generalized linear mixed method with a random-effects model. The pooled sensitivity and specificity were calculated using a bivariate random-effects model.
RESULTS
Of the 7309 studies screened by titles, 73 studies with 18,008 patients were included. The most common findings in xanthogranulomatous cholecystitis (XGC) were lack of wall disruption and intramural hypoechoic nodules while adenomyomatosis (ADM) was frequently associated with intramural cysts and intramural echogenic foci. Echogenic foci, lack of gallbladder wall disruption, and hypoechoic nodules had a sensitivity of 89%, 77%, and 66% and specificity of 86%, 51%, and 80%, respectively for the diagnosis of benign GWT. Focal thickening and indistinct liver interface had a sensitivity of 75% and 55% and specificity of 64% and 69%, respectively for the diagnosis of malignant GWT.
CONCLUSION
intramural features (echogenic foci, hypoechoic nodules), gallbladder wall disruption, and liver interface are useful US features for the characterization of GWT.
Topics: Gallbladder Diseases; Humans; Sensitivity and Specificity; Ultrasonography
PubMed: 34826262
DOI: 10.1080/17474124.2021.2011210 -
Langenbeck's Archives of Surgery May 2022The aim of this review was to examine whether neutrophil-to-lymphocyte ratio (NLR) can predict the presence of cholecystitis and distinguish between simple and severe... (Meta-Analysis)
Meta-Analysis
PURPOSE
The aim of this review was to examine whether neutrophil-to-lymphocyte ratio (NLR) can predict the presence of cholecystitis and distinguish between simple and severe cholecystitis.
METHODS
A systematic literature search was performed. Risk of bias was assessed using the Newcastle-Ottawa Scale. Random effects model was used to calculate mean difference (MD) in two situations: (a) no cholecystitis versus cholecystitis and (b) simple versus severe cholecystitis. Receiver operating characteristic (ROC) curve analysis was performed to determine cut-off values of NLR for the above situations.
RESULTS
Ten retrospective studies comprising of 2827 patients were included. Three hundred twenty-seven had no cholecystitis, 2100 had simple cholecystitis and the remaining 400 had severe cholecystitis. NLR was significantly higher in acute cholecystitis compared to "no cholecystitis" (MD = 8.05 (95% CI 7.71-8.38), p < 0.01) and in severe cholecystitis when compared with simple cholecystitis (MD = 3.14 (95% CI 1.26-5.02), p < 0.01). For patients with cholecystitis compared to those without cholecystitis, an NLR cut-off value of 2.98 was identified (AUC = 0.90). Logistic regression analysis confirmed an NLR > 2.9 was an independent predictor of cholecystitis (OR 36.0, p = 0.006). In simple versus severe cholecystitis, an NLR cut-off value of 8.5 was identified (AUC = 0.73). Binary logistic regression analysis suggested an NLR > 8.5 was not an independent predictor of severe cholecystitis (OR 6.5 p = 0.090).
CONCLUSION
NLR is significantly higher in patients with cholecystitis of any severity compared to patients without cholecystitis. Moreover, NLR can predict acute cholecystitis. However, NLR cannot predict the severity of disease due to inadequately powered studies. Future research is required.
Topics: Cholecystitis; Cholecystitis, Acute; Humans; Lymphocytes; Neutrophils; Prognosis; ROC Curve; Retrospective Studies
PubMed: 34746977
DOI: 10.1007/s00423-021-02350-2 -
Outcomes of percutaneous cholecystostomy in elderly patients: a systematic review and meta-analysis.Przeglad Gastroenterologiczny 2021Percutaneous cholecystostomy (PC) represents a management option to control sepsis in patients with acute cholecystitis, who are unable to tolerate surgery. (Review)
Review
INTRODUCTION
Percutaneous cholecystostomy (PC) represents a management option to control sepsis in patients with acute cholecystitis, who are unable to tolerate surgery.
AIM
This review aimed to evaluate the outcomes of elderly patients treated with PC and compare it with emergent cholecystectomy.
MATERIAL AND METHODS
An electronic search of the Embase, Medline Web of Science, and Cochrane databases was performed. Percutaneous cholecystostomy was used as the reference group, and weighted mean differences (WMD) were calculated for the effect of PC on continuous variables, and pooled odds ratios (POR) were calculated for discrete variables.
RESULTS
There were 20 trials included in this review. Utilisation of PC was associated with significantly increased mortality (POR = 4.85; 95% CI: 1.02-7.30; = 0.0001) and increased re-admission rates (POR = 2.95; 95% CI: 2.21-3.87; < 0.0001).
CONCLUSIONS
This pooled analysis established that patients treated with PC appear to have increased mortality and readmission rates relative to those managed with cholecystectomy.
PubMed: 34584579
DOI: 10.5114/pg.2020.100658 -
International Journal of Surgery... Oct 2021To systematically review comparative studies on the acute surgical unit (ASU) model. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To systematically review comparative studies on the acute surgical unit (ASU) model.
METHODS
Searches were performed of Cochrane, Embase, Medline and grey literature. Eligible articles were comparative studies of the Acute Surgical Unit (ASU) model published 01/01/2000-12/03/2020. Amongst patients with any diagnosis, primary outcomes were length of stay, after-hours operating, complications and cost. Secondary outcomes were time to surgical review, time to theatre, mortality and re-admission for patients with any diagnosis, and cholecystectomy during index admission for patients with biliary disease. Additional analyses were planned for specific cohorts, such as patients with appendicitis or cholecystitis.
RESULTS
Searches returned 9,677 results from which 77 eligible publications were identified, representing 150,981 unique patients. Cohorts were adequately homogenous for meta-analysis of all outcomes except cost. For patients with any diagnosis, compared with the Traditional model, the introduction of an ASU model was associated with reduced length of stay (mean difference [MD] 0.68 days; 95% confidence interval [CI] 0.38-0.98), after-hours operating rates (odds ratio [OR] 0.56; 95% CI 0.46-0.69) and complications (OR 0.48, 95% CI 0.33-0.70). Regarding cost, two studies reported savings following ASU introduction, while one found no difference. Amongst secondary outcomes, for patients with any diagnosis, ASU commencement was associated with reduced time to surgical review, time to theatre and mortality. Re-admissions were unchanged. For patients with biliary disease, ASU establishment was associated with superior rates of index cholecystectomy.
CONCLUSION
Compared to the Traditional structure, the ASU model is superior for most metrics. ASU introduction should be promoted in policy for widespread benefit.
Topics: Appendicitis; Cholecystectomy; Humans; Odds Ratio; Retrospective Studies; Surgery Department, Hospital
PubMed: 34536599
DOI: 10.1016/j.ijsu.2021.106109 -
World Journal of Emergency Surgery :... Sep 2021Aim of this study was to clarify the best laparoscopic subtotal cholecystectomy (LSTC) technique for finalizing a difficult cholecystectomy.
BACKGROUND
Aim of this study was to clarify the best laparoscopic subtotal cholecystectomy (LSTC) technique for finalizing a difficult cholecystectomy.
PATIENTS AND METHODS
A review was performed (1987-2021) searching "difficulty cholecystectomy" AND/OR "subtotal cholecystectomy". The LSTC techniques considered were as follows: type A, leaving posterior wall attached to the liver and the remainder of the gallbladder stump open; type B, like type A but with the stump closed; type C, resection of both the anterior and posterior gallbladder walls and the stump closed; type D, like type C but with the stump open. Morbidity (including mortality) was analysed with Dindo-Clavien classification.
RESULTS
Nineteen articles were included. Of the 13,340 patients screened, 678 (8.2%) had cholecystectomy finalized by LSTC: 346 patients (51.0%) had type A LSTC, 134 patients (19.8%) had type B LSTC, 198 patients (29.2%) had type C LSTC, and 198 patients (0%) had type D LSTC. Bile leakage was found in 83 patients (12.2%), and recorded in 58 patients (69.9%) treated by type A. Twenty-three patients (3.4%) developed a subhepatic collection, 19 of whom (82.6%) were treated by type A. Other complications were reported in 72 patients (10.6%). The Dindo-Clavien classification was four for grade I, 27 for grade II, 126 for grade IIIa, 18 for grade IIIb, zero for grade IV and three for grade V.
CONCLUSION
In the case of LSTC, closure of the gallbladder stump represents the best method to avoid complications. Careful exploration of the gallbladder stump is mandatory, washing the abdominal cavity and leaving drainage.
Topics: Cholecystectomy; Cholecystectomy, Laparoscopic; Cholecystitis, Acute; Humans
PubMed: 34496916
DOI: 10.1186/s13017-021-00392-x -
HPB : the Official Journal of the... Nov 2021The optimal management of localized gallbladder perforation (Neimeier type II) has yet to be defined. The aim of this systematic review was to identify factors... (Review)
Review
BACKGROUND
The optimal management of localized gallbladder perforation (Neimeier type II) has yet to be defined. The aim of this systematic review was to identify factors associated with improved patient outcomes.
METHODS
Systematic review of studies that described the management of Neimeier type II perforation, reported complications of the first intervention, necessity of added interventions, resolution of the pathology, and days of hospital stay were included. The search strategy was conducted in EMBASE, Mayo Journals, MEDLINE, SCOPUS, and Web of Science (December 2020) RESULTS: A total of 122 patients (53% male) from case reports, series, and cohorts were included for analysis. In total 56 (46%) and 44 (36%)patients were treated with open and laparoscopic cholecystectomy respectively. Overall risk of bias was moderate. The need for another intervention was higher in the laparoscopic group (5 vs 17, p=<0.001) as well as prevalence of complications (4 vs 16, p=<0.001), but lower for days of hospital stay (median days 5. vs 15, p = 0.008) against open cholecystectomy. Preoperative percutaneous catheter drainage did not influence outcome.
CONCLUSION
Open cholecystectomy has a lower need for further surgical procedures and postoperative complications, but a longer hospital stay. These outcomes did not vary with preoperative percutaneous drainage. The effect of timing of cholecystectomy did not influence the outcomes.
Topics: Cholecystectomy; Cholecystectomy, Laparoscopic; Cholecystitis, Acute; Drainage; Female; Gallbladder; Gallbladder Diseases; Humans; Male; Prognosis; Treatment Outcome
PubMed: 34246546
DOI: 10.1016/j.hpb.2021.06.003