Management of Acute Cholecystitis: Prevalence of Percutaneous Cholecystostomy and Delayed Cholecystectomy in the Elderly

Background

Published guidelines recommend early cholecystectomy for acute cholecystitis in the elderly. Alternatively, percutaneous cholecystostomy can be used in compromised patients.

Methods

We reviewed 806 elderly patients diagnosed with biliary disease retrospectively identified through billing and diagnosis codes. Two hundred sixty-five patients with histologically documented acute cholecystitis were selected.

Results

Initially, 75 patients had percutaneous cholecystostomy (Group 1), 64 (24 % underwent interval cholecystectomy, 74 (28 %) early (Group 2), and 127 (48 %) delayed cholecystectomy (Group 3). Group 1 was more likely to have American Society of Anesthesiologists (ASA) scores of 4 when compared to those in Groups 2 and 3 (p?=?0.04). No difference existed among the groups when patients with an ASA of 4 were excluded: conversion rates (11 %), biliary leak, bowel injury, need for reoperation, or 30 days mortality. Patients in Group 1 and in Group 3 were five times (p?=?0.04) and four times (p?=?0.06) more likely, respectively, than those in Group 2 to have recurrent episodes of pancreatitis, cholecystitis, and cholangitis.

Conclusion

Patients were more likely to have delayed cholecystectomy after initial antibiotic therapy or cholecystostomy without the benefit of a lower conversion rate when compared to the early group, but they had higher recurrent episodes of cholecystitis/pancreatitis or cholangitis.     

Development of lactobacilli therapy to prevent recurrent urinary tract infections in females

Urinary tract infections remain a common urogynecological problem. Although antibiotic therapy invariably eradicates bacteria from the bladder, it can also disrupt the genital flora and lead to emergence of drug-resistant uropathogens. A new therapeutic agent has been developed to prevent recurrence of uncomplicated, lower urinary tract infections in adult females. This unique product contains Lactobacillus casei var rhamnosus GR-1 and L. fermentum B-54, selected for their ability to adhere to uroepithelial cells in vitro and produce inhibitory substances against uropathogens, particularly Escherichia coli and Enterococcus species. In addition, unlike the majority of lactobacillus isolates, the strains GR-1 and B-54 resist the action of spermicide. The bacteria are freeze-dried in gelatin suppositories and instilled intravaginally. Weekly therapy in 8 patients has led to a 78.7% reduction in infection rate, without any major side effects. The results illustrate the potential effectiveness of this therapy in patients with recurrent urinary tract infections.     

Reassessment of simple cholecystostomy.

Cholecystostomy was performed on 22 patients with acute cholecystitis after partial (13) or complete (9) removal of gallbladder stones. One patient had complementary common-duct drainage. Early mortality occurred in two patients. Three patients with associated cholangitis but intraoperative reflux of cysticduct bile were all treated by cholecystostomy alone and survived. For the poor-risk patient with cholecystitis, cholecystostomy is effective. When there is associated cholangitis and documented cystic-duct patency, cholecystostomy is also sufficient. When accompanying cholangitis is associated with cystic-duct occlusion, choledochotomy and T tube drainage should be added.     

¿Es segura y eficaz la colecistostomía percutánea en la colecistitis aguda? Análisis de los efectos adversos asociados a la técnica

IntroductionThe main objective of our study is to assess the safety and efficacy of percutaneous cholecystostomy for the treatment of acute cholecystitis, determining the incidence of adverse effects in patients undergoing this procedure.Material and methodObservational study with consecutive inclusion of all patients diagnosed with acute cholecystitis for 10 years. The main variable studied was morbidity (adverse effects) collected prospectively. Minimum one-year follow-up of patients undergoing percutaneous cholecystostomy.ResultsOf 1223 patients admitted for acute cholecystitis, 66 patients required percutaneous cholecystostomy. 21% of these have presented some adverse effect, with a total of 22 adverse effects. Only 5 of these effects, presented by 5 patients (7.6%), could have been attributed to the gallbladder drainage itself. The mortality associated with the technique is 1.5%. After cholecystostomy, one third of the patients (22 patients) have undergone cholecystectomy. Urgent surgery was performed due to failure of percutaneous treatment in 2 patients, and delayed in another 2 patients due to recurrence of the inflammatory process. The rest of the cholecystectomized patients underwent scheduled surgery, and the procedure could be performed laparoscopically in 16 patients (72.7%).ConclusionWe consider percutaneous cholecystostomy as a safe and effective technique because it is associated with a low incidence of morbidity and mortality, and it should be considered as a bridge or definitive alternative in those patients who do not receive urgent cholecystectomy after failure of conservative antibiotic treatment.     

Percutaneous cholecystostomy and endoscopic cholecystolithotripsy in the management of acute cholecystitis

Background: Percutaneous cholecystostomy is a valuable alternative temporary measure for acute cholecystitis in elderly patients with severe underlying cardiopulmonary disease, but the subsequent management of gallbladder calculi is still controversial. Methods: Eleven patients treated with percutaneous endoscopic cholecystolithotripsy after percutaneous cholecystostomy were evaluated retrospectively. Results: All patients showed clinical improvement after percutaneous cholecystostomy. Tract dilation succeeded in 9 patients. Complete stone clearance was achieved in seven patients over one to four sessions (average, two sessions). Stone extraction could not be completed in two patients because gallbladder access was lost in one patient, and the other refused further procedure. There were three complications, with two biliary fistulas and one major bile leakage leading to emergency cholecystectomy. The duration of the entire procedure ranged from 30 to 126 days (mean, 58 days). During the follow-up (mean 17.2 months), one patient had recurrent cholangitis and the others remained asymptomatic. Conclusions: Percutaneous cholecystolithotripsy after percutaneous cholecystostomy is a safe alternative in the management of high-risk elderly patients with acute cholecystitis. Received: 26 February 1998/Accepted: 17 July 1998     

Upper gastrointestinal bleeding: A rare complication of acute cholecystitis

INTRODUCTIONHaemobilia is a rare complication of acute cholecystitis and may present as upper gastrointestinal bleeding.PRESENTATION OF CASEWe describe two patients with acute cholecystitis presenting with upper gastrointestinal bleeding due to haemobilia. Bleeding from the duodenal papilla was seen at endoscopy in one case but none in the other. CT demonstrated acute cholecystitis with a pseudoaneurysm of the cystic artery in both cases. Definitive control of intracholecystic bleeding was achieved in both cases by embolisation of the cystic artery. Both patients remain symptom free. One had subsequent laparoscopic cholecystostomy and the other no surgery.DISCUSSIONPseudoaneurysms of the cystic artery are uncommon in the setting of acute cholecystitis. OGD and CT angiography play a key role in diagnosis. Transarterial embolisation (TAE) is effective in controlling bleeding. TAE followed by interval cholecystectomy remains the treatment of choice in surgically fit patients.CONCLUSIONWe highlight an unusual cause of upper GI haemorrhage. Surgeons need to be aware of this rare complication of acute cholecystitis. Immediate non-surgical management in these cases proved to be safe and effective.     

A nationwide examination of outcomes of percutaneous cholecystostomy compared with cholecystectomy for acute cholecystitis, 1998–2010

Background

Improvements in percutaneous drainage techniques combined with the recognized advantages of avoiding surgery in critically ill patients have rendered cholecystostomy an attractive treatment option, particularly in those patients with acute acalculus cholecystitis. However, robust data to guide surgeons in choosing cholecystostomy versus cholecystectomy have been lacking.

Methods

Retrospective analysis of the Nationwide Inpatient Sample (NIS) database from 1998–2010 was performed. Patients identified as having acute cholecystitis (calculus and acalculus) were identified by ICD-9 diagnosis codes and further classified as having undergone cholecystostomy or cholecystectomy. Patients with both procedures were included in the cholecystectomy group. Patients with neither procedure and those younger than age 18 years were excluded. Multivariate analyses examined mortality, length of stay, total charges, gallbladder/gastrointestinal complications, or any complication. Results were adjusted for age, race, gender, Charlson comorbidity index, and teaching-hospital status. Subset analyses were performed among patients who survived and patients who died.

Results

A total of 248,229 calculus and 58,518 acalculus acute cholecystitis patients were analyzed. On unadjusted analysis, mortality, length of stay, and total charges were higher, but complication rates were lower, in patients with a cholecystostomy. Adjusted analysis showed lower odds of complications [calculus: odds ratio (OR) 0.3, p < 0.001; acalculus: OR 0.4, p < 0.001] but higher odds of mortality, total charges, and LOS (calculus: mortality OR 5.2, p < 0.001, $29,113, p < 0.001, +5.1 days, p < 0.001; acalculus: mortality OR 3.7, p < 0.001; $43,771, p < 0.001, +6.2 days, p < 0.001) among patients who received cholecystostomy. Results were similar in subset analyses.

Conclusions

Patients receiving cholecystostomy were more likely to be older and have more comorbidities. Among patients with calculus or acalculus cholecystitis, patients with cholecystostomy had decreased complication rates compared with patients with cholecystectomy. However, patients who received cholecystostomy had increased odds of death, longer length of stay, and higher total charges.     

Outcome After Percutaneous Cholecystostomy for Acute Cholecystitis: a Single-Center Experience

Background

Percutaneous cholecystostomy is an alternative treatment for acute cholecystitis patients with high surgical risk.

Methods

One hundred and sixty-six patients consecutively treated by percutaneous cholecystostomy for acute cholecystitis in a single medical center were retrospectively reviewed.

Results

The cohort included 121 males and 45 females with mean age of 75.9?years. The overall inhospital mortality rate was 15.1?% (n?=?25). Elevated serum creatinine level at diagnosis [odds ratio (OR) 1.497; p?=?0.020], septic shock (OR 11.755; p?=?0.001), and development of cholecystitis during admission (OR 7.256; p?=?0.007) were predictive of inhospital mortality. Of 126 patients who recovered from calculous cholecystitis, 11 experienced recurrent cholecystitis within 2?months. Serum C-reactive protein (CRP) level >15?mg?dl^?1 at diagnosis [hazard ratio (HR) 10.141; p?=?0.027] and drainage duration of cholecystostomy longer than 2?weeks (HR 3.638; p?=?0.039) were independent risk factors of early recurrence. The 53 patients who underwent cholecystectomy had an 18.9?% perioperative complication rate and no operation-related mortality.

Conclusions

In-patients or those with septic shock or renal insufficiency have worse outcome. Prolonged drainage duration and high CRP level predict early recurrence. Removal of the drainage tube is recommended after resolution of the acute illness.     

Laparoscopic cholecystostomy with delayed cholecystectomy as an alternative to conversion to open procedure

Background: Acute cholecystitis carries the highest incidence of conversion from planned laparoscopic cholecystectomy to open surgery due to unclear anatomy, excessive bleeding, complications, or other technical reasons. Methods: Laparoscopic tube cholecystostomy was performed instead of immediate conversion to laparotomy in 9 patients with acute cholecystitis after unsuccessful attempts at laparoscopic dissection. Elective laparoscopic cholecystectomy was done 3 months later. Results: Following this approach eight patients were treated successfully. After 3 months the acute process had subsided sufficiently to allow a safe laparoscopic cholecystectomy. One additional patient died of acute leukemia 6 weeks after cholecystostomy. Before adopting this technique we subjected 171 patients with acute calculous cholecystitis to laparoscopic cholecystectomy; there was an 11% (19 cases) rate of conversion. Since cholecystostomy has begun to be offered as an alternative to conversion, 121 patients with acute cholecystitis have had laparoscopic cholecystectomy and only 2 cases (1.5%) have been converted to immediate open cholecystectomy. Conclusions: We recommend the alternative of performing a cholecystostomy with delayed laparoscopic cholecystectomy instead of conversion to open procedure when facing a case of acute cholecystitis not amenable to laparoscopic cholecystectomy.     

An alternative approach to acute cholecystitis

Background: The mainstay of therapy for acute cholecystitis is cholecystectomy, which has a mortality of 5–30% in high-risk patients such as the elderly or critically ill. An alternative treatment option in patients suffering from acute cholecystitis with contraindications to emergency surgery is percutaneous cholecystostomy (PC) followed by interval laparoscopic cholecystectomy. Percutaneous cholecystostomy yields 10–12% mortality in high-risk patients and is therefore a safe temporizing measure, allowing delayed, elective cholecystectomy when the patient is in better condition for surgery. Methods: Hospital charts and radiology films were reviewed for all 50 patients who underwent PC for acute cholecystitis between January 1990 and September 1993. Most patients were high risk for emergency cholecystectomy by virtue of their critical illness or underlying medical condition. Twenty-five patients went on to have interval cholecystectomies. We recorded whether they underwent laparoscopic or open cholecystectomy, as elective or emergency procedures, and we recorded direct complications, mortality, and postoperative length of hospital stay. Results: Relief of symptoms occurred within 48 h of PC in 90% of patients, and two patients had complications of PC. Laparoscopic cholecystectomy was attempted in 13 patients and competed in nine. Four patients (31%) required conversion from laparoscopic to open cholecystectomies due to extensive adhesions (3) or bleeding (1). Three patients had direct complications of laparoscopic cholecystectomy. There was no mortality or major bile duct injury. Conclusion: Percutaneous cholecystostomy followed by interval laparoscopic cholecystectomy is a safe, minimally invasive approach which can be employed safely in the critically ill patient when contraindications to emergency surgery exist.     

Predictive factors for developing acute cholangitis and/or cholecystitis in patients undergoing delayed cholecystectomy: A retrospective study

Background/Objective: We evaluated the risk of acute cholangitis and/or cholecystitis while waiting for cholecystectomy for gallstones.MethodsWe retrospectively enrolled 168 patients who underwent cholecystectomy for gallstones after conservative therapy. We compared clinical data of 20 patients who developed acute cholangitis and/or cholecystitis while waiting for cholecystectomy (group A) with 148 patients who did not develop (group B). We investigated surgical outcomes and risk factors for developing acute cholangitis and/or cholecystitis.ResultsPreoperatively, significant numbers of patients with previous history of acute grade II or III cholecystitis (55.0% vs 10.8%; p < 0.001) and biliary drainage (20.0% vs 2.0%; p = 0.004) were observed between groups A and B. White blood cell counts (13500/μL vs 8155/μL; p < 0.001) and C-reactive protein levels (12.6 vs 5.1 mg/dL; p < 0.001) were significantly higher in group A than in group B; albumin levels (3.2 vs 4.0 g/dL; p < 0.001) were significantly lower in group A. Gallbladder wall thickening (≥5 mm) (45.0% vs 18.9%; p = 0.018), incarcerated gallbladder neck stones (55.0% vs 22.3%; p = 0.005), and peri-gallbladder abscess (20.0% vs 1.4%; p = 0.002) were significantly more frequent in group A than in group B. A higher conversion rate to open surgery (20.0% vs 2.0%; p = 0.004), longer operation time (137 vs 102 min; p < 0.001), and higher incidence of intraoperative complications (10.0% vs 0%; p = 0.014) were observed in group A, compared with group B.ConclusionA history of severe cholecystitis may be a risk factor for acute cholangitis and/or cholecystitis in patients waiting for surgery; it may also contribute to increased surgical difficulty.     

Cholecystostomy offers no survival benefit in patients with acute acalculous cholecystitis and severe sepsis and shock

Background

Acute acalculous cholecystitis is often managed with cholecystectomy or cholecystostomy, but data guiding surgical practice are lacking.

Materials and methods

Longitudinal analysis of the California Office of Statewide Health Planning and Development Patient Discharge Data was performed from 1995–2009. Patients with acute acalculous cholecystitis were identified by International Classification of Diseases 9 code. Cox proportional hazard analysis found predictors of time to death, adjusting for patient demographics, sepsis, shock, frailty, Charlson comorbidity index, length of stay, insurance status, teaching hospital status, and year.

Results

Of 43,341 patients, 63.5% received a cholecystectomy, 2.8% received a cholecystostomy, and 1.2% received both. Overall, 30.4% of patients died, with higher mortality among patients with cholecystostomy (61.7%) or no procedure (42.0%) than cholecystectomy (23.0%). In patients with severe sepsis and shock, there was no difference in survival of patients with cholecystostomy versus no intervention (hazard ratio [HR] 1.13, P = 0.256), although patients with cholecystectomy (with or without prior cholecystostomy) had improved survival (HR 0.29, P < 0.001; HR 0.56, P < 0.001). Results were similar among patients on the ventilator >96 h.

Conclusions

Although cholecystostomy offered no survival benefit for patients with severe sepsis and shock, cholecystectomy offered improved survival compared with patients without surgical management. Cholecystostomy may not benefit the sickest patients in whom cholecystectomy may never be considered.     

ACUTE SUPPURATIVE CHOLESYSTITIS: A RETROSPECTIVE STUDY OF 173 CASES

Over a 14-year period we treated 2,290 cases of non-malignant biliary tract conditions, and among them were 173 cases of acute suppurative cholecystitis, an incidence of 7.6%. A correct preoperative diagnosis of acute suppurative cholecystitis was made in only about half the cases because features of recurrent pyogenic cholangitis dominated the clinical picture on many occasions. The diagnosis was confirmed in all cases at operation. Cholecystectomy (88%) was performed whenever this was found to be safe, and cholecystostomy (12%) was carried out only in poor-risk patients or when operative difficulties were encountered. The overall mortality of operation was 5.8%. Old age, preoperative shock, delay of operation and the presence of free perforation affected the prognosis adversely.     

Tube Cholecystostomy Before Cholecystectomy for the Treatment of Acute Cholecystitis

Methods:This study was a retrospective chart review of patients who underwent tube cholecystostomy from July 1, 2005, to July 1, 2012.Results:During the study period, 82 patients underwent 125 cholecystostomy tube placements. Four patients (5%) died during the year after tube placement. The mean hospital length of stay for survivors was 8.8 days (range, 1–59 days). Twenty-eight patients (34%) required at least 1 additional percutaneous procedure (range, 1–6) for gallbladder drainage. Twenty-nine patients (34%) ultimately underwent cholecystectomy. Surgery was performed a mean of 7 weeks after cholecystostomy tube placement. Laparoscopic cholecystectomy was attempted in 25 operative patients but required conversion to an open approach in 8 cases (32%). In another 4 cases, planned open cholecystectomy was performed. Major postoperative complications were limited to 2 patients with postoperative common bile duct obstruction requiring endoscopic retrograde cholangiopancreatography, 1 patient requiring a return to the operating room for hemoperitoneum, and 2 patients with bile leak from the cystic duct stump.Conclusions:In high-risk patients receiving cholecystostomy tubes for acute cholecystitis, only about one third will undergo surgical cholecystectomy. Laparoscopic cholecystectomy performed in this circumstance has a higher rate of conversion to open surgery and higher hepatobiliary morbidity rate.     

Pyogenic discitis due to Abiotrophia adiacens

INTRODUCTIONAbiotrophia species have been referred to as nutritionally variant streptococci because of their fastidious nutritional requirements for growth. Abiotrophia species are difficult to identify with conventional solid culture.PRESENTATION OF CASEA 48-year-old woman was admitted to our hospital with severe low back pain and body temperature of 38.2 °C. Magnetic resonance imaging revealed edema and contrast enhancement of the L4 and L5 vertebral bodies with high signal intensity in the L3-4 and L4-5 intervertebral discs on the T2-weighted images. The patient underwent needle biopsy of the L3-4 disk. Cultures of disk biopsy samples and blood yielded gram positive cocci in short chains with scanty growth on chocolate agar. Further subculture with supplemented medium and subsequent 16S ribosomal RNA gene sequencing identified the pathogen as Abiotrhophia adiacens. The patient was treated with intravenous ampicillin. At 6-month follow-up, the patient was free of symptoms.DISCUSSIONCausative microorganisms remain unidentified in 25–40% of spinal infection cases. Abiotrophia species grow poorly on conventional solid media, and require pyridoxal or thiol group supplementation. Use of Brucella HK agar or GAM agar plate is helpful for detection of Abiotrophia species. We first confirmed the diagnosis by direct identification of Abiotrophia adiacens from infected disk. Abiotrophia species are one of the major pathogens of infective endocarditis accounting for 5% of cases. Considering their fastidious nature, it is likely that most cases of Abiotrophia discitis are falsely classified as culture-negative discitis; therefore, their role in pyogenic discitis may be underestimated.CONCLUSIONSubculture using nutritionally supplemented media is crucial for their identification.     

Old man gallbladder syndrome: Gangrenous cholecystitis in the unsuspected patient population

IntroductionAcute cholecystitis is a common surgical condition, but not many are aware of the serious complication of gangrenous cholecystitis (GC). Presence of GC increases patients’ postoperative complications, morbidity and mortality. Predictive factors for GC include age >45, male gender, white blood cell count >13,000/mm3 and ultrasound findings of a negative Murphy’s sign.Case presentation(1) GW, 83 male with dull right upper quadrant pain and a negative Murphy’s sign with further imaging showing a thickened septated gallbladder suggestive of GC. Patient’s surgery was difficult and he received a cholecystostomy tube for drainage. (2) PH, 75 male with minimal right upper quadrant pain, equivocal ultrasound with a negative Murphy’s sign and computer tomography (CT) showing acute cholecystitis. Patient was taken to the operating room for cholecystectomy, with pathology consistent with gangrenous cholecystitis.DiscussionMultiple laboratory findings and imaging patterns have been found to be highly predictive of GC. Along with age and WBC, thickened gallbladder wall and lack of mucosal enhancement have been predictive of GC. On physical examination, lack of Murphy’s sign secondary to denervation from gangrenous changes also increases the index of suspicion for GC.ConclusionGC is a serious complication of acute cholecystitis with increased morbidity and mortality. There should be a high index of suspicion for GC if the above unique physical and laboratory findings are present.     

Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines

Diagnostic and therapeutic strategies for acute biliary inflammation/infection (acute cholangitis and acute cholecystitis), according to severity grade, have not yet been established in the world. Therefore we formulated flowcharts for the management of acute biliary inflammation/infection in accordance with severity grade. For mild (grade I) acute cholangitis, medical treatment may be sufficient/appropriate. For moderate (grade II) acute cholangitis, early biliary drainage should be performed. For severe (grade III) acute cholangitis, appropriate organ support such as ventilatory/circulatory management is required. After hemodynamic stabilization is achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. For patients with acute cholangitis of any grade of severity, treatment for the underlying etiology, including endoscopic, percutaneous, or surgical treatment should be performed after the patient's general condition has improved. For patients with mild (grade I) cholecystitis, early laparoscopic cholecystectomy is the preferred treatment. For patients with moderate (grade II) acute cholecystitis, early laparoscopic or open cholecystectomy is preferred. In patients with extensive local inflammation, elective cholecystectomy is recommended after initial management with percutaneous gallbladder drainage and/or cholecystostomy. For the patient with severe (grade III) acute cholecystitis, multiorgan support is a critical part of management. Biliary peritonitis due to perforation of the gallbladder is an indication for urgent cholecystectomy and/or drainage. Delayed elective cholecystectomy may be performed after initial treatment with gallbladder drainage and improvement of the patient's general medical condition.     

Laparoscopy in the critically ill

Background: Laparoscopy was evaluated in critically ill patients with suspected acute cholecystitis, mesenteric ischemia, or gastrointestinal perforation. We studied laparoscopy to assess its utility, accuracy, and effect on cardiopulmonary stability. Methods: Twenty-six surgical ICU patients with possible abdominal sepsis underwent laparoscopy. Nineteen were post cardiac surgery; the remainder had other diagnoses. Video laparoscopy was performed with hemodynamic monitoring and inotropic support as needed. Eight patients had bedside laparoscopy. Results: Fifteen patients had suspected acute cholecystitis. Laparoscopy was positive in 10; four had open cholecystectomy, four laparoscopic cholecystectomy, and two tube cholecystostomy. Nine patients had suspected mesenteric ischemia; laparoscopy was positive in five, revealing cirrhosis in two and ischemic bowel in three. Two patients had suspected perforated viscus with colonic perforation in one and one false negative. There were no adverse hemodynamic events. Conclusions: Laparoscopy can be performed safely in critically ill patients. It is useful in patients with acute cholecystitis and in patients who are post cardiac surgery with refractory lactic acidosis in whom a diagnosis of mesenteric ischemia is considered.     

Acute cholecystitis in high surgical risk patients: percutaneous cholecystostomy or emergency cholecystectomy?

BackgroundPercutaneous cholecystostomy (PC) is an alternative treatment in acute cholecystitis (AC) in high-risk or elderly patients although its advantage over emergency cholecystectomy has not yet been established.Study DesignAC prospective database analysis in high-risk patients treated by PC (group 1, 29 patients) or emergency cholecystectomy (group 2, 32 patients). Surgical risk was estimated by physiological POSSUM, Charlson, Apache II, and American Society of Anesthesiologists (ASA) scores.ResultsThe groups showed homogeneity concerning age and surgical risk. PC allowed AC resolution in 19 patients (70.4%), but 8 (29.6%) needed emergency cholecystectomy. Morbidity and mortality rates were 31% and 17.2%, respectively. Mortality was significantly associated with ASA IV (P = .01). In group 2, the morbidity rate was 28.1% without mortality. There was no statistical difference in morbidity (P = .6) although mortality was significantly higher in group 1 (P = .02).ConclusionsPC seems of little benefit and ought to be left for those very old patients with surgical contraindication.     

Validation of the AAST EGS acute cholecystitis grade and comparison with the Tokyo guidelines

Background

Acute cholecystitis presents with heterogeneous severity. The Tokyo Guidelines 2013 is a validated method to assess cholecystitis severity, but the variables are multifactorial. The American Association for the Surgery of Trauma (AAST) developed an anatomically based severity grading system for surgical diseases, including cholecystitis. Because the Tokyo Guidelines represent the gold standard to estimate acute cholecystitis severity, we wished to validate the AAST emergency general surgery scoring system and compare the performance of both systems for several patient outcomes.