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Khirurgiia 2020To improve the results of treatment of acute cholecystitis.
OBJECTIVE
To improve the results of treatment of acute cholecystitis.
MATERIAL AND METHODS
A historical cohort study (1965-2016) included 1248 patients with acute obstructive cholecystitis and 154 patients with acute obstructive cholecystitis combined with ductal complications and obstructive jaundice. Cholecystostomy was used in all patients. A systematic review of the evidence base on the use of cholecystostomy in high-risk patients was carried out.
RESULTS
Cholecystostomy through laparotomy was performed in 240 patients for the period 1965-1981. Overall mortality was 3.6%. Staged treatment strategy has been applied since 1982. Laparoscopic cholecystostomy followed by cholecystectomy through laparotomy was performed in 225 patients for the period from 1982 to 1992. Overall mortality rate was 3.2%. Laparoscopic cholecystostomy (=617) followed by staged laparoscopic cholecystectomy has been applied for the period from 1993 to 2007. Overall mortality decreased up to 1.1%. Indications for laparoscopic cholecystostomy and staged treatment have been limited since 2008 (=166). Overall mortality rate was 0.6%. The maximum postoperative mortality after cholecystostomy in some years reached 14.8%.
UNLABELLED
Simultaneous surgeries through laparotomy in patients with acute obstructive cholecystitis and ductal complications were followed by mortality rate 8%, staged laparoscopic cholecystostomy and other minimally invasive technologies (endoscopic papillosphincterotomy with lithoextraction and laparoscopic cholecystectomy) - 4.7%.
CONCLUSION
External drainage of the gallbladder is more effective as additional method within staged minimally invasive treatment of complicated cholecystitis rather separate operation. Further analysis of treatment of high-risk patients with acute cholecystitis (as most often selected for cholecystostomy) is required considering the absence of evidence base on this issue.
Topics: Cholecystectomy; Cholecystitis, Acute; Cholecystostomy; Humans; Laparoscopy; Retrospective Studies
PubMed: 32573531
DOI: 10.17116/hirurgia202006144 -
The Journal of Trauma and Acute Care... Sep 2020Acute care surgery (ACS) was initiated two decades ago to address timeliness and quality in emergency general surgery. We hypothesized that ACS has improved the... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Acute care surgery (ACS) was initiated two decades ago to address timeliness and quality in emergency general surgery. We hypothesized that ACS has improved the management of acute appendicitis and biliary disease.
METHODS
A comprehensive systematic review and meta-analysis of outcome studies for emergent appendectomy and cholecystectomy from 1966 to 2017, comparing studies prior to and following ACS implementation, were performed.
RESULTS
Of 1,704 studies, 27 were selected for analysis (appendicitis, 16; biliary pathology, 7; both, 4). Following ACS introduction, the complication rate was significantly reduced in both appendectomy and cholecystectomy (risk ratios, 0.70; 95% confidence interval [CI], 0.57-0.85; I = 9.2% and relative risk, 0.62; 95% CI, 0.41-0.94; I = 63.5%) respectively. There was a significant reduction in the time from arrival in emergency until admission and from admission to operation (-1.37 hours: 95% CI, -1.93 to -0.80; -2.51 hours: 95% CI, -4.44 to -0.58) in the appendectomy cohort. Time to operation was shorter in the cholecystectomy group (-6.46 hours; 95% CI, -9.54 to -3.4). Length of hospital stay was reduced in both groups (appendectomy, -0.9 day; cholecystectomy, -1.09 day). There was a reduction in overall cost in cholecystectomy group (-US $854.37; 95% CI, -1,554.1 to -154.05). No statistical significance was detected for wound infection, abscess, conversion of laparoscopy to open technique, rate of negative appendectomy, after hours, readmission, and cost.
CONCLUSION
The implementation of ACS models in general surgery emergency care has significantly improved system and patient outcomes for appendicitis and biliary pathology.
LEVEL OF EVIDENCE
Systematic review and meta-analysis of a retrospective study, level III.
Topics: Appendectomy; Appendicitis; Cholecystectomy; Cholecystitis, Acute; Emergency Service, Hospital; Emergency Treatment; Humans; Length of Stay; Models, Organizational; Postoperative Complications; Quality of Health Care; Surgery Department, Hospital
PubMed: 32544106
DOI: 10.1097/TA.0000000000002825 -
Surgical Endoscopy May 2020In patients with acute cholecystitis who are deemed high risk for cholecystectomy, percutaneous cholecystostomy (PC) was historically performed for gallbladder drainage... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In patients with acute cholecystitis who are deemed high risk for cholecystectomy, percutaneous cholecystostomy (PC) was historically performed for gallbladder drainage (GBD). There are several limitations associated with PC. Endoscopic GBD [Endoscopic transpapillary GBD (ET-GBD) and EUS-guided GBD (EUS-GBD)] is an alternative to PC. We performed a systematic review and meta-analysis to compare the effectiveness and safety of EUS-GBD versus ET-GBD.
METHODS
We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GBD versus ET-GBD in the management of acute cholecystitis in high-risk surgical patients. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GBD and ET-GBD groups were calculated.
RESULTS
Five studies with a total of 857 patients (EUS-GBD vs ET-GBD: 259 vs 598 patients) were included in the analysis. EUS-GBD was associated with higher technical [pooled OR 5.22 (95% CI 2.03-13.44; p = 0.0006; I = 20%)] and clinical success [pooled OR 4.16 (95% CI 2.00-8.66; p = 0.0001; I = 19%)] compared to ET-GBD. There was no statistically significant difference in the rate of overall adverse events [pooled OR 1.30 (95% CI 0.77-2.22; p = 0.33, I = 0%)]. EUS-GBD was associated with lower rate of recurrent cholecystitis [pooled OR 0.33 (95% CI 0.14-0.79; p = 0.01; I = 0%)]. There was low heterogeneity in the analyses.
CONCLUSION
EUS-GBD has higher rate of technical and clinical success compared to ET-GBD. While the rates of overall adverse events are statistically similar, EUS-GBD has lower rate of recurrent cholecystitis. Hence, EUS-GBD is preferable to ET-GBD for endoscopic management of acute cholecystitis in select high-risk surgical patients.
Topics: Aged; Cholecystitis; Cholecystitis, Acute; Endoscopy; Female; Gallbladder; Humans; Male; Retrospective Studies
PubMed: 32048019
DOI: 10.1007/s00464-020-07409-7 -
Clinical Endoscopy Mar 2020The bleeding complication risk of surgery or percutaneous transhepatic gallbladder drainage (PTGBD) may increase in patients with acute cholecystitis receiving... (Review)
Review
The bleeding complication risk of surgery or percutaneous transhepatic gallbladder drainage (PTGBD) may increase in patients with acute cholecystitis receiving antithrombotic therapy (ATT). Endoscopic gallbladder drainage (EGBD) may be recommended for such patients. English articles published between 1991 and 2018 in peer-reviewed journals that discuss cholecystectomy, PTGBD, and EGBD in patients with ATT or coagulopathy were reviewed to assess the safety of the procedures, especially in terms of the bleeding complication. There were 8 studies on cholecystectomy, 3 on PTGBD, and 1 on endoscopic transpapillary gallbladder drainage (ETGBD) in patients receiving ATT. With respect to EGBD, 28 studies on ETGBD (including 1 study already mentioned above) and 26 studies on endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) were also analyzed. The overall bleeding complication rate in patients with ATT who underwent cholecystectomy was significantly higher than that in patients without ATT (6.5% [23/354] vs. 1.2% [26/2,224], p<0.001). However, the bleeding risk of cholecystectomy and PTGBD in patients receiving ATT was controversial. The overall technical success, clinical success, and bleeding complication rates of ETGBD vs. EUS-GBD were 84% vs. 96% (p<0.001), 92% vs. 97% (p<0.001), and 0.65% vs. 2.1% (p=0.005), respectively. One patient treated with ETGBD experienced bleeding complication among 191 patients with bleeding tendency. ETGBD may be an ideal drainage procedure for patients receiving ATT from the viewpoint of bleeding, although EUS-GBD is also efficacious.
PubMed: 31914723
DOI: 10.5946/ce.2019.177 -
ANZ Journal of Surgery Sep 2020Acute cholecystitis (AC) is a surgical condition that is usually managed by emergency surgery. The presence of common bile duct stones (CBDS) in this setting mandates... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Acute cholecystitis (AC) is a surgical condition that is usually managed by emergency surgery. The presence of common bile duct stones (CBDS) in this setting mandates definitive treatment to avoid complications such as cholangitis. The incidence of CBDS in the setting of AC is poorly defined.
METHODS
A systematic English literature search was conducted in PubMed, MEDLINE and Embase to determine the incidence of CBDS in patients presenting with AC. Outlier studies identified by funnel plot analysis were excluded and the incidence of CBDS was identified. The mean CBD diameter and liver function test values of patients with AC and CBDS were calculated.
RESULTS
Data were extracted from 19 studies representing a total 4057 patients with AC. Routine biliary imaging was not performed in all studies. The pooled incidence of CBDS was 13.7% (95% confidence interval 11.8-15.9). The incidence of unsuspected retained CBDS was 1.1%. Histologically confirmed cases of AC had a similar rate of CBDS compared to those diagnosed clinically. The mean CBD diameter of patients with AC and CBDS was 7.2 mm compared to 5.8 mm without. Liver function test values in the presence of CBDS were more likely to be deranged, with gamma-glutamyltransferase the most sensitive and specific marker for CBDS in the setting of AC.
CONCLUSION
CBDS is present in a significant proportion of patients presenting with AC. Routine biliary imaging is advised in all patients presenting with AC where possible.
Topics: Cholangiopancreatography, Endoscopic Retrograde; Cholecystitis, Acute; Choledocholithiasis; Common Bile Duct; Humans; Incidence; Retrospective Studies
PubMed: 31743951
DOI: 10.1111/ans.15565 -
The Cochrane Database of Systematic... Nov 2019Sickle cell disease (SCD) is a group of inherited disorders of haemoglobin (Hb) structure in a person who has inherited two mutant globin genes (one from each parent),... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Sickle cell disease (SCD) is a group of inherited disorders of haemoglobin (Hb) structure in a person who has inherited two mutant globin genes (one from each parent), at least one of which is always the sickle mutation. It is estimated that between 5% and 7% of the world's population are carriers of the mutant Hb gene, and SCD is the most commonly inherited blood disorder. SCD is characterized by distorted sickle-shaped red blood cells. Manifestations of the disease are attributed to either haemolysis (premature red cell destruction) or vaso-occlusion (obstruction of blood flow, the most common manifestation). Shortened lifespans are attributable to serious comorbidities associated with the disease, including renal failure, acute cholecystitis, pulmonary hypertension, aplastic crisis, pulmonary embolus, stroke, acute chest syndrome, and sepsis. Vaso-occlusion can lead to an acute, painful crisis (sickle cell crisis, vaso-occlusive crisis (VOC) or vaso-occlusive episode). Pain is most often reported in the joints, extremities, back or chest, but it can occur anywhere and can last for several days or weeks. The bone and muscle pain experienced during a sickle cell crisis is both acute and recurrent. Key pharmacological treatments for VOC include opioid analgesics, non-opioid analgesics, and combinations of drugs. Non-pharmacological approaches, such as relaxation, hypnosis, heat, ice and acupuncture, have been used in conjunction to rehydrating the patient and reduce the sickling process.
OBJECTIVES
To assess the analgesic efficacy and adverse events of pharmacological interventions to treat acute painful sickle cell vaso-occlusive crises in adults, in any setting.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online, MEDLINE via Ovid, Embase via Ovid and LILACS, from inception to September 2019. We also searched the reference lists of retrieved studies and reviews, and searched online clinical trial registries.
SELECTION CRITERIA
Randomized, controlled, double-blind trials of pharmacological interventions, of any dose and by any route, compared to placebo or any active comparator, for the treatment (not prevention) of painful sickle cell VOC in adults.
DATA COLLECTION AND ANALYSIS
Three review authors independently assessed studies for eligibility. We planned to use dichotomous data to calculate risk ratio (RR) and number needed to treat for one additional event, using standard methods. Our primary outcomes were participant-reported pain relief of 50%, or 30%, or greater; Patient Global Impression of Change (PGIC) very much improved, or much or very much improved. Our secondary outcomes included adverse events, serious adverse events, and withdrawals due to adverse events. We assessed GRADE and created three 'Summary of findings' tables.
MAIN RESULTS
We included nine studies with data for 638 VOC events and 594 participants aged 17 to 42 years with SCD presenting to a hospital emergency department in a painful VOC. Three studies investigated a non-steroidal anti-inflammatory drug (NSAID) compared to placebo. One study compared an opioid with a placebo, two studies compared an opioid with an active comparator, two studies compared an anticoagulant with a placebo, and one study compared a combination of three drugs with a combination of four drugs. Risk of bias across the nine studies varied. Studies were primarily at an unclear risk of selection, performance, and detection bias. Studies were primarily at a high risk of bias for size with fewer than 50 participants per treatment arm; two studies had 50 to 199 participants per treatment arm (unclear risk). Non-steroidal anti-inflammatory drugs (NSAID) compared with placebo No data were reported regarding participant-reported pain relief of 50% or 30% or greater. The efficacy was uncertain regarding PGIC very much improved, and PGIC much or very much improved (no difference; 1 study, 21 participants; very low-quality evidence). Very low-quality, uncertain results suggested similar rates of adverse events across both the NSAIDs group (16/45 adverse events, 1/56 serious adverse events, and 1/56 withdrawal due to adverse events) and the placebo group (19/45 adverse events, 2/56 serious adverse events, and 1/56 withdrawal due to adverse events). Opioids compared with placebo No data were reported regarding participant-reported pain relief of 50% or 30%, PGIC, or adverse events (any adverse event, serious adverse events, and withdrawals due to adverse events). Opioids compared with active comparator No data were reported regarding participant-reported pain relief of 50% or 30% or greater. The results were uncertain regarding PGIC very much improved (33% of the opioids group versus 19% of the placebo group). No data were reported regarding PGIC much or very much improved. Very low-quality, uncertain results suggested similar rates of adverse events across both the opioids group (9/66 adverse events, and 0/66 serious adverse events) and the placebo group (7/64 adverse events, 0/66 serious adverse events). No data were reported regarding withdrawal due to adverse events. Quality of the evidence We downgraded the quality of the evidence by three levels to very low-quality because there are too few data to have confidence in results (e.g. too few participants per treatment arm). Where no data were reported for an outcome, we had no evidence to support or refute (quality of the evidence is unknown).
AUTHORS' CONCLUSIONS
This review identified only nine studies, with insufficient data for all pharmacological interventions for analysis. The available evidence is very uncertain regarding the efficacy or harm from pharmacological interventions used to treat pain related to sickle cell VOC in adults. This area could benefit most from more high quality, certain evidence, as well as the establishment of suitable registries which record interventions and outcomes for this group of people.
Topics: Acute Pain; Analgesics; Analgesics, Opioid; Anemia, Sickle Cell; Anti-Inflammatory Agents, Non-Steroidal; Humans; Pain Management; Pain Measurement; Peripheral Vascular Diseases; Randomized Controlled Trials as Topic
PubMed: 31742673
DOI: 10.1002/14651858.CD012187.pub2 -
Facts, Views & Vision in ObGyn Mar 2019Laparoscopy is widely utilised to diagnose and treat acute and chronic, gynaecological and general surgical conditions. It has only been in recent years that laparoscopy...
Evidence-Based Guideline on Laparoscopy in Pregnancy: Commissioned by the British Society for Gynaecological Endoscopy (BSGE) Endorsed by the Royal College of Obstetricians & Gynaecologists (RCOG).
Laparoscopy is widely utilised to diagnose and treat acute and chronic, gynaecological and general surgical conditions. It has only been in recent years that laparoscopy has become an acceptable surgical alternative to open surgery in pregnancy. To date there is little clinical guidance pertaining to laparoscopic surgery in pregnancy. This is why the BSGE commissioned this guideline. MEDLINE, EMBASE, CINAHL and the Cochrane library were searched up to February 2017 and evidence was collated and graded following the NICE-approved process. The conditions included in this guideline are laparoscopic management of acute appendicitis, acute gall bladder disease and symptomatic benign adnexal tumours in pregnancy. The intended audience for this guideline is obstetricians and gynaecologists in secondary and tertiary care, general surgeons and anaesthetists. However, only laparoscopists who have adequate laparoscopic skills and who perform complex laparoscopic surgery regularly should undertake laparoscopy in pregnant women, since much of the evidence stems from specialised centres.
PubMed: 31695854
DOI: No ID Found -
Endoscopy Feb 2020Endoscopic transpapillary gallbladder drainage (ETGBD) and endoscopic ultrasound-guided gallbladder drainage (EUSGBD) are alternatives to percutaneous gallbladder... (Meta-Analysis)
Meta-Analysis
Endoscopic ultrasound-guided gallbladder drainage, transpapillary drainage, or percutaneous drainage in high risk acute cholecystitis patients: a systematic review and comparative meta-analysis.
BACKGROUND
Endoscopic transpapillary gallbladder drainage (ETGBD) and endoscopic ultrasound-guided gallbladder drainage (EUSGBD) are alternatives to percutaneous gallbladder drainage (PCGBD) for patients with acute cholecystitis who are unfit for surgery. Data comparing these modalities are limited and have reported conflicting results.
METHODS
We searched multiple databases from inception to May 2019 to identify studies that reported on ETGBD, EUSGBD, and PCGBD in the management of acute cholecystitis in patients with a high surgical risk. Aims were to compare the pooled rates of technical success, clinical success, adverse events, and disease recurrence.
RESULTS
1223 patients (22 studies), 557 patients (14 studies), and 13 351 patients (46 studies) were treated by ETGBD, EUSGBD, and PCGBD, respectively. The pooled technical and clinical successes were: ETGBD 83 % (95 % confidence interval [CI] 80.1 - 85.5, = 29) and 88.1 % (95 %CI 83.6 - 91.4, = 50), respectively; EUSGBD 95.3 % (95 %CI 92.8 - 96.9, = 0) and 96.7 % (95 %CI 94.0 - 98.2, = 0), respectively; and PCGBD 98.7 % (95 %CI 98.0 - 99.1, = 0) and 89.3 % (95 %CI 86.6 - 91.5, = 84), respectively. Clinical success with EUSGBD was significantly superior to the other approaches. All complications were comparable between the groups. Pancreatitis occurred with ETGBD in 5.1 % (95 %CI 3.5 - 7.3), whereas bleeding and perforation occurred with EUSGBD in 4.3 % (95 %CI 2.7 - 6.8) and 3.7 % (95 %CI 2.3 - 6.0), respectively. Stent migration occurred with PCGBD in 7.4 % (95 %CI 5.5 - 10.0).
CONCLUSION
EUSGBD demonstrated better clinical success than ETGBD and PCGBD in the management of acute cholecystitis patients at high surgical risk.
Topics: Cholecystitis, Acute; Cholecystostomy; Drainage; Gallbladder; Humans; Ultrasonography, Interventional
PubMed: 31645067
DOI: 10.1055/a-1020-3932 -
Journal of Medical Microbiology Nov 2019is becoming a growing public health challenge, especially for its ability to cause infections in immunocompromised patients. This bacterium is a Gram+coccus,...
is becoming a growing public health challenge, especially for its ability to cause infections in immunocompromised patients. This bacterium is a Gram+coccus, catalase+, coagulase, and it is a common inhabitant of skin and oral mucosa. To investigate the spectrum of infections caused by . Between January-March 2018, we carried out a systematic search in PubMed utilizing the key search term ''. The selection criteria for studies were studies reporting cases of human infections due to , case-control and cohort studies and studies published in English or Spanish. The literature search yielded 48 publications: after title, abstract and full-text analysis, 20 papers were consistent with the selection criteria. These studies were carried out in the period 2001-2017 in the USA, Japan, Taiwan, Hong Kong, Ukraine, Egypt, Bahrain, Serbia, India, Italy, Spain, Turkey and Mexico. was involved in 17 cases of central venous catheter-related bacteremia, four infective endocarditis, three acute peritonitis, one abdominal abscess, umbilical sepsis, acute cholecystitis and urinary tract infection. Additionally, was found in 40 % of carious cavities, although it is not clear whether they are directly involved in the development of caries. Antibiotic susceptibility testing has sometimes revealed multi-drug resistance. The clinical spectrum of infections has recently widened. The increasing spread of this underestimated bacterium and its resistance to antibiotics represent a new challenge for public health, which requires specific actions to limit it.
Topics: Actinomycetales Infections; Adult; Aged; Anti-Bacterial Agents; Case-Control Studies; Catheter-Related Infections; Drug Resistance, Bacterial; Female; Humans; Immunocompromised Host; Male; Micrococcaceae; Middle Aged; Young Adult
PubMed: 31526454
DOI: 10.1099/jmm.0.001023 -
Endoscopy Aug 2019Recent evidence suggests that endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an effective and safe alternative to percutaneous drainage (PT-GBD). We... (Meta-Analysis)
Meta-Analysis
Endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for high risk surgical patients with acute cholecystitis: a systematic review and meta-analysis.
BACKGROUND
Recent evidence suggests that endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an effective and safe alternative to percutaneous drainage (PT-GBD). We conducted a systematic review and meta-analysis to compare these two procedures in high risk surgical patients with acute cholecystitis.
METHODS
A comprehensive electronic literature search was conducted for all articles published up to October 2017 to identify comparative studies between EUS-GBD and PT-GBD. A meta-analysis was performed on outcomes including technical success, clinical success, post-procedure adverse events, length of hospital stay, unplanned hospital readmission, need for reintervention, recurrent cholecystitis, and disease- or treatment-related mortality for these two procedures.
RESULTS
Five comparative studies (206 patients in the EUS-GBD group vs. 289 patients in the PT-GBD group), were included in the final analysis. There were no statistically significant differences in technical success (odds ratio [OR] 0.43, 95 % confidence interval [CI] 0.12 to 1.58; = 0.21; = 0 %) and clinical success (OR 1.07, 95 %CI 0.36 to 3.16; = 0.90; = 44 %) between the two procedures. EUS-GBD had fewer adverse events than PT-GBD (OR 0.43, 95 %CI 0.18 to 1.00; = 0.05; = 66 %). Moreover, patients undergoing EUS-GBD had shorter hospital stays, with pooled standard mean difference of - 2.53 (95 %CI - 4.28 to - 0.78; = 0.005; = 98 %), and required significantly fewer reinterventions (OR 0.16, 95 %CI 0.04 to 0.042; 0.001; = 32 %) resulting in significantly fewer unplanned readmissions (OR 0.16, 95 %CI 0.05 to 0.53; = 0.003; = 79 %).
CONCLUSIONS
EUS-GBD was associated with lower rates of post-procedure adverse events, shorter hospital stays, and fewer reinterventions and readmissions compared with PT-GBD in patients with acute cholecystitis who were unfit for surgery.
Topics: Cholecystitis, Acute; Cholecystostomy; Drainage; Endosonography; Humans; Length of Stay; Patient Readmission; Retreatment; Ultrasonography, Interventional
PubMed: 31238375
DOI: 10.1055/a-0929-6603