Caracterización clínico quirúrgica de la colecistitis aguda en pacientes tratados en el Servicio de Cirugía General. Cienfuegos, 2017- 2019

Fundamento la colecistitis aguda es una enfermedad inflamatoria, caracterizada por alteraciones agudas de la pared vesicular que pueden ir desde el edema y la congestión hasta la gangrena y perforación. Es una enfermedad con alta incidencia en urgencia quirúrgica. Objetivo: caracterizar clínica y quirúrgicamente la colecistitis aguda en pacientes del Servicio de Cirugía General. Métodos: se realizó un estudio descriptivo y prospectivo de pacientes atendidos por colecistitis aguda en el Servicio de Cirugía durante el período del primero de enero de 2017 al treinta y uno de diciembre de 2019. Los datos se obtuvieron de las historias clínicas y los informes operatorios, utilizando un modelo de recolección de datos. Se analizaron las variables edad, sexo, enfermedades asociadas, manifestaciones clínicas, confirmación diagnóstica, tipo de tratamiento, modalidad de tratamiento quirúrgico, evolución, complicaciones, uso de antibiótico, lugar de ingreso y estadía hospitalaria Resultados: predominaron los pacientes de 60 años y más del sexo femenino; el dolor abdominal prevaleció en la mayoría de los pacientes, acompañado de vómitos y taquicardia; el diagnóstico se confirmó mediante la clínica; predominó el tratamiento quirúrgico, la colecistectomía convencional abierta fue la técnica de elección; la mayoría evolucionó de forma satisfactoria. La sepsis de la herida quirúrgica fue la complicación más frecuente. Conclusiones: la colecistitis aguda es más frecuente en ancianos, el diagnóstico precoz y tratamiento oportuno pueden disminuir el porcentaje de complicaciones; el tratamiento quirúrgico es el de elección, combinado con antibióticoterapia.

Background: acute cholecystitis is an inflammatory disease, characterized by acute changes in the gallbladder wall that can range from edema and congestion to gangrene and perforation. It is a disease with a high incidence in surgical urgency. Objective: to clinically and surgically characterize acute cholecystitis in patients of the General Surgery Service. Methods: a descriptive and prospective study of patients treated for acute cholecystitis in the Surgery Service was carried out from January the 1st, 2017 to December the 31st, 2019. Data were obtained from medical records and operative reports, using a data collection model. The variables age, sex, associated diseases, clinical manifestations, diagnostic confirmation, type of treatment, modality of surgical treatment, evolution, complications, use of antibiotics, place of admission and hospital stay were analyzed. Results: female patients aged 60 years and over predominated; abdominal pain prevailed in most of the patients, accompanied by vomiting and tachycardia; the diagnosis was confirmed through the clinic; surgical treatment predominated, conventional open cholecystectomy was the technique of choice; most progress satisfactorily. Surgical wound sepsis was the most frequent complication. Conclusions: acute cholecystitis is more frequent in the elderly, early diagnosis and timely treatment can reduce the percentage of complications; surgical treatment is the treatment of choice, combined with antibiotic therapy.

Application of percutaneous transhepatic gallbladder drainage with delayed laparoscopic cholecystectomy in the treatment of acute cholecystitis / 国际外科学杂志

Objective:To compare the clinical efficacy of percutaneous transhepatic gallbladder drainage (PTGBD) combined with delayed laparoscopic cholecystectomy (LC) with direct LC in the treatment of acute cholecystitis.Methods:A single-center case-control retrospective study was used. Sixty-three patients with acute cholecystitis with onset time ≥ 72 hours during the period from August 1, 2021 to December 10, 2022 in the Department of Hepatobiliary Surgery of the 900TH Hospital of Joint Logistics Support Force were selected. There were 38 males and 25 females, aged (57.3±15.4) years, with an age range of 28-87 years. According to whether PTGBD treatment was performed before LC, they were divided into experimental group ( n=29) and control group ( n=34). Experimental group was treated with PTGBD combined with delayed LC and control group was treated with LC only.The differences in operative time, intra-operative bleeding, intra-operative transit open rate, post-operative hospital days, total hospital days, hospital costs, short-term post-operative complications of LC and post-operative time to exhaustion were compared and analysed between the two groups. Measurement data with normal distribution were expressed as mean±standard deviation ( ± s), and independent sample t-test was used for comparison between groups.Measurement data with skewed distribution were expressed as M( Q1, Q3), and rank sum test was used for comparison between groups; Chi-square test was used to compare the counting data groups. Results:Intraoperative bleeding, total hospital days, hospital costs and postoperative time to exhaustion were 0(0, 50) mL, 13(11, 18) d, 29 015.0 (22 791.6, 39 000.8) yuan and 1(1, 2) d in the experimental group and 50(0, 88) mL, 7(6, 11) d, 16 015.0 (15 832.1, 22 185.1) yuan, 2(1, 3) d, the difference was statistically significant between the two groups( P<0.05). In the experimental group, the operative time, the intraoperative transit open rate, the number of postoperative hospital days, and the incidence of short-term postoperative complications of LC were 80 (55, 115) min, 13.8%, 5 (3, 7) days, 34.5%, respectively, compared with 98(70, 125) min, 20.6%, 5(3, 6) days, 38.2% in the control group, the difference between the two groups was not statistically significant ( P>0.05). Conclusion:The clinical efficacy of PTGBD combined with delayed LC is better than direct line LC, and it is feasible and effective for patients with cholecystitis whose inflammatory indexes have returned to normal and who have high gallbladder tone.

Comparison of bacterial profile of gallbladder with gallstones from patients undergoing cholecystectomy due to complicated and uncomplicated cholelithiasis: changes in the epidemiological scenario / Perfil bacteriano da vesícula biliar e dos cálculos biliares de pacientes submetidos à colecistectomia por colelitíase complicada e não complicada: mudanças no cenário epidemiológico

ABSTRACT Introduction: cholelithiasis is a highly prevalent disease of the digestive system in the world. In Brazil, it is a routine condition, whose studies suggest a prevalence of around 10% of adults. Colonization of bile and gallstone pathogens can occur when there is bacterial stasis and proliferation. This proliferation is facilitated by the adhesion and biofilm formation capacity of some bacteria. There are also lithogenic processes that involve bacterial participation. Studies have shown changes in the microbiota of the gallbladder of patients undergoing cholecystectomy, which may impact empirical treatment with antibiotics. Methodology: microbiological analyzes of the sonication fluid of the gallstones and of two samples with bile were performed. Identification and antimicrobial susceptibility testing were performed according to a standard routine. Results: of the 34 patients, 76.4% were female. The age group was 48 years +/- 16.61. Acute cholecystitis occurred in 50% of cases. Bactobilia was evidenced in 32.1% of the cases. Klebisiella pneumoniae was noted as the most prevalent pathogen in acute cholecystitis; and Enterobacter sp, in cases of uncomplicated cholelithiasis. Greater sensitivity was obtained in the search for microorganisms in the sonication fluid samples of the stones in relation to the bile samples (p=0.0058). Conclusion: there was a higher prevalence of bactobilia in patients with acute cholecystitis compared to those with uncomplicated cholelithiasis. The use of sonication in bacterial investigation proved to be superior to the conventional method and can be considered.

RESUMO Introdução: a colelitíase é uma doença do sistema digestivo de alta prevalência no mundo. No Brasil, trata-se de uma condição rotineira, cujos estudos sugerem uma prevalência em torno de 10% dos adultos. A colonização de patógenos da bile e do cálculo biliar pode ocorrer quando há estase e proliferação bacteriana. Esta proliferação é facilitada pela capacidade de adesão e de formação de biofilme de algumas bactérias. Também há processos litogênicos que envolvem a participação bacteriana. Estudos evidenciaram mudanças na microbiota da vesícula biliar de pacientes submetidos à colecistectomia, o que pode impactar no tratamento empírico com antibióticos. Metodologia: Realizou-se análises microbiológicas do fluido de sonicação dos cálculos biliares e de duas amostras com bile. A identificação e o teste de sensibilidade aos antimicrobianos foram realizados de acordo com uma rotina padrão. Resultados: Nos 34 pacientes, 76,4% deles foram do sexo feminino. A faixa etária foi de 48 anos +/- 16,61. A colecistite aguda ocorreu em 50% dos casos. A bactobilia foi evidenciada em 32,1% dos casos. Notou-se Klebisiella pneumoniae como o patógeno mais prevalente em quadros de colecistite aguda; e Enterobacter sp, nos casos de colelitíase não complicada. Obteve-se maior sensibilidade na pesquisa de microrganismos nas amostras de fluido de sonicação dos cálculos em relação às de bile (p=0,0058). Conclusão: Houve maior prevalência de bactobilia nos pacientes com colecistite aguda em relação àqueles com colelitíase não complicada. A utilização da sonicação na investigação bacteriana se mostrou superior ao método convencional e pode ser considerada.

Opciones terapéuticas para la colecistitis aguda: de las guías de Tokio 2018 a la práctica clínica / Therapeutic options for acute cholecystitis: from the Tokyo guidelines 2018 to clinical practice / Opções terapêuticas para colecistite aguda: das diretrizes de Tóquio 2018 à prática clínica

Resumen: Introducción: el tratamiento "gold standard" de la colecistitis aguda es la colecistectomía laparoscópica temprana. En pacientes añosos de alto riesgo anestésico-quirúrgico, con cuadros de evolución subaguda y/o con repercusión sistémica, es alternativa el tratamiento médico exclusivo o asociado al drenaje vesicular percutáneo. Objetivo: analizar y comparar las recomendaciones internacionales con las conductas terapéuticas en dos centros asistenciales de tercer nivel para pacientes con colecistitis aguda. Método: trabajo descriptivo, prospectivo de 161 pacientes con colecistitis aguda litiásica asistidos en los departamentos de emergencia del Hospital de Clínicas y el Hospital Español entre mayo de 2018 y mayo de 2019. Resultados: la colecistectomía laparoscópica temprana fue indicada en el 88% de los pacientes, con 3% de conversión y 9% de morbilidad. 12% recibieron manejo no operatorio, asociándose en el 65% colecistostomía percutánea. La edad avanzada, comorbilidades, discrasias y la severidad del cuadro presentaron asociación significativa con la modalidad terapéutica (p <0,05). El 40% de los pacientes en los que se realizó manejo no operatorio presentó recurrencias sintomáticas. A todos se les realizó la colecistectomía en diferido. Conclusiones: la colecistectomía laparoscópica temprana es la conducta terapéutica más frecuente. Las principales indicaciones de manejo no operatorio en nuestro medio son las características sistémicas desfavorables. El mismo presenta altas tasas de éxito y escasa morbilidad con una recurrencia sintomática del 40%.

Abstract: Introduction: early laparoscopic cholecystectomy is the gold standard treatment for acute cholecystitis. However, exclusive medical treatment (EMC) or medical treatment associated with percutaneous gallbladder drainage is the treatment of choice in elderly patients given their high surgical and anesthetic risk and upon the subacute course of the condition and/or its systemic repercussions. Objective: to analyze and compare international guidelines to the therapeutic behavior for patients with acute cholecystectomy in two third-level hospitals. Methodology: descriptive, prospective study of 161 patients with litiasic acute cholecystitis treated in the ER of Hospital de Clínicas and Hospital Español between May 2018 and May 2019. Results: early laparoscopic cholecystectomy was indicated in 88% of patients, conversion being 3% and morbidity 9%. Twelve percent of patients received non-surgical treatment, 65% of which evidenced percutaneous cholecystostomy. Old age, comorbidities, dyscrasias, and severity of the condition were closely related to the therapeutic modality (p < 0.05). Forty percent of patients who received non-surgical treatment presented symptomatic repercussions. They all underwent delayed cholecystectomy. Conclusions: early laparoscopic cholecystectomy is the most frequent treatment of choice. Unfavorable systemic characteristics are the main indications for non-surgical management in our country. This surgical treatment evidences high success rates and scarce morbidity with 40% of systemic repercussions.

Resumo: Introdução: o tratamento padrão ouro da colecistite aguda é a colecistectomia laparoscópica precoce. Em pacientes idosos com alto risco anestésico-cirúrgico, com evolução subaguda e/ou repercussão sistêmica, o tratamento clínico isolado ou associado à drenagem percutânea da vesícula biliar é uma alternativa. Objetivo: analisar e comparar recomendações internacionais com condutas terapêuticas em dois centros terciários para pacientes com colecistite aguda. Método: estudo descritivo e prospectivo de 161 pacientes com colecistite aguda de cálculos atendidos nos serviços de emergência do Hospital de Clínicas e Hospital Español no período maio de 2018 - maio de 2019. Resultados: a colecistectomia laparoscópica precoce foi indicada em 88% dos pacientes, com 3% de conversão e 9% de morbidade. 12% receberam tratamento não operatório, associado a 65% colecistostomia percutânea. Idade avançada, comorbidades, discrasias e gravidade do quadro apresentaram associação significativa com a modalidade terapêutica (p < 0,05). 40% dos pacientes nos quais o manejo não operatório foi realizado apresentaram recidivas sintomáticas. Todos foram submetidos à colecistectomia diferida. Conclusões: a colecistectomia laparoscópica precoce é a abordagem terapêutica mais frequente. As principais indicações para o manejo não operatório em nosso meio são as características sistêmicas desfavoráveis. Apresentando altas taxas de sucesso e baixa morbidade com recorrência sintomática de 40%.

Gangrena vesicular por colecistitis hemorrágica en paciente sin factores de riesgo: reporte de un caso

La colecistitis hemorrágica es una complicación rara de la colecistitis aguda, pero con alta mortalidad. Clínicamente es idéntica a la colecistitis aguda, y no suele presentarse con hemorragia gastrointestinal. Presentamos el caso de un varón 57 años, sin antecedentes, ni uso de anticoagulantes, referido a nuestro hospital por una "tumoración vesicular", tras los estudios tomográficos y de colangioresonancia, asociado a la caída de hemoglobina sérica, se define su sospecha. Ingresa a sala de operaciones y se evidencia una vesícula gangrenada, conteniendo coágulos y cálculos. Confirmando su diagnóstico con el estudio histopatológico. Debido a su similitud clínica, debe considerarse en pacientes con antecedentes de terapia anticoagulante, trauma, malignidad, o hallazgos compatibles con colecistitis alitiásica. Pero puede presentarse en pacientes sin antecedentes y estar asociado a colelitiasis. El diagnóstico temprano de esta complicación potencialmente fatal es importante para facilitar el manejo quirúrgico urgente, siendo el apoyo imagenológico, necesario para su sospecha.

Hemorrhagic cholecystitis is a rare complication of acute cholecystitis, but with high mortality. Clinically it is identical to acute cholecystitis, and it does not usually present with gastrointestinal bleeding. We present the case of a 57-year-old man, with no history or use of anticoagulants, referred to our hospital for a "gallbladder tumor", after tomographic and cholangioresonance studies, associated with a drop in serum hemoglobin, suspicion of him is defined. He enters the operating room and a gangrenous gallbladder is evident, containing clots and stones. Confirming his diagnosis with histopathological study. Due to its clinical similarity, it should be considered in patients with a history of anticoagulant therapy, trauma, malignancy, or findings consistent with acalculous cholecystitis. But it can occur in patients with no history and be associated with cholelithiasis. Early diagnosis of this potentially fatal complication is important to facilitate urgent surgical management, imaging support being necessary for its suspicion.

Guía de práctica clínica para el diagnóstico y manejo de la colelitiasis, colecistitis aguda y coledocolitiasis en el Seguro Social del Perú (EsSalud) / Clinical practice guideline for Diagnosis and management of cholelithiasis, cholecystitis and choledocholithiasis for the Peruvian Social Security (EsSalud)

RESUMEN Introducción: El presente artículo resume la guía de práctica clínica (GPC) para el diagnóstico y manejo de los pacientes con colelitiasis, colecistitis aguda y coledocolitiasis en el Seguro Social del Perú (EsSalud). Objetivo: Proveer recomendaciones clínicas basadas en evidencia para la evaluación y el manejo de pacientes con colelitiasis, colecistitis aguda y coledocolitiasis en EsSalud. Métodos: Se conformó un grupo elaborador de la guía (GEG) que incluyó médicos especialistas en gastroenterología, cirujanos generales y metodólogos. El GEG formuló 10 preguntas clínicas a ser respondidas por la presente GPC. En septiembre del 2017 se realizaron búsquedas de revisiones sistemáticas y -cuando fue considerado pertinente- estudios primarios en PubMed. Se seleccionó la evidencia para responder 10 preguntas clínicas. La certeza de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). En reuniones de trabajo periódicas, el GEG usó la metodología GRADE para revisar la evidencia y formular las recomendaciones, los puntos de buenas prácticas clínicas y el flujograma de evaluación y manejo. Finalmente, la GPC fue aprobada con Resolución N° 021-IETSIESSALUD-2018. Resultados: La presente GPC abordó 10 preguntas clínicas sobre el diagnóstico y manejo de colelitiasis, colecistitis aguda y coledocolitiasis. En base a dichas preguntas se formularon 6 recomendaciones (5 recomendaciones condicionales y 1 recomendación fuerte), 17 puntos de buena práctica clínica y 3 flujogramas. Conclusión: El presente artículo resume la metodología y las conclusiones de la GPC basadas en evidencias para el diagnóstico y tratamiento de la colelitiasis, colecistitis aguda y coledocolitiasis de EsSalud.

ABSTRACT Introduction: This article summarizes the clinical practice guide (CPG) for the diagnosis and management of cholelithiasis, acute cholecystitis and choledocholithiasis in the Peruvian Social Security (EsSalud). Objective: To provide clinical recommendations based on evidence for the management of patients with cholelithiasis, acute cholecystitis and choledocholithiasis in EsSalud. Methods: a guideline task force (GTF) was formed with internists, general surgeons, gastroenterologists, and methodologists. The group proposed 10 clinical questions to be answered in this Clinical practice guideline (CPG). Systematic searches of preview reviews were performed and when it was necessary, primary studies from PubMed and CENTRAL during 2017 were reviewed. The evidence was selected aiming to answer each proposed question. Certainty of evidence was evaluated using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodical work sessions, the group used GRADE methodology for reviewing the evidence and formulating recommendations, good clinical practice items and three flowcharts for diagnosis and treatment. Finally, the CPG was approved by Resolution Nº 046-IETSI-ESSALUD-2017. Results: This CPG approached 10 clinical questions divided into two topics: diagnosis and management. Based on these questions; one strong recommendation, five weak recommendations, and 17 good clinical practice items and three flowcharts were formulated. Conclusion: This paper abstracts the methodology and evidence-based conclusions of the CPG for diagnosis and management of cholelithiasis, acute cholecystitis and choledocholithiasis in EsSalud.

A multicenter prospective randomized controlled study on the timing of laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for grade Ⅱ-Ⅲ acute cholecystitis / 中华肝胆外科杂志

Objective:To study the optimal timing of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD) for grade Ⅱ-Ⅲ acute cholecystitis.Methods:A multicenter, single blind and randomized controlled study was conducted at Shanghai Fifth People's Hospital Affiliated to Fudan University, Shanghai Pudong Hospital, and Shanghai Minhang District Central Hospital from October 2018 to September 2021. Patients who underwent LC after PTGBD were divided 1∶1 into the early group and the late group. LC was performed 4-6 weeks after PTGBD in the early group and 7-8 weeks after PTGBD in the late group. Gender, age, AC grade, complications after PTGBD, body mass index, complications before LC, operation time of LC, intraoperative bleeding, total treatment cost, conversion rate to open surgery and complications after LC were compared between the two groups. The 36-Item Short Form Health Survey (SF-36) before and after LC was also compared.Results:Of 248 patients who were eligible for the study, there were 52 males and 196 females, with ages ranging from 18 to 89 years, and mean ±s.d. of (52.5 ± 20.2) years. There were 126 patients in the early group and 122 patients in the late group. There were no significant differences in gender, age, AC grade, body mass index and complications before LC between the two groups (all P>0.05). The preoperative score of SF-36 in the early group was significantly better than that in late group, and the complications of PTGBD in the late group were significantly higher than the early group (both P<0.05). The operation time and total treatment cost of the early group were significantly less than those of the late group (37.2±12.8 min vs. 48.5±19.7 min, 20 856±2 136 yuan vs. 2 2207±2 049 yuan) (both P<0.05). The intraoperative bleeding volume of LC in the early group was [ M( Q1, Q3)] 40 (40, 60) ml and the late group was [ M( Q1, Q3)] 35 (25, 40) ml. The difference was also significant ( P<0.05). There was no significant differences in the conversion rates to open surgery, complications and SF-36 scores after LC between the two groups (all P>0.05). Conclusion:LC should be performed 4-6 weeks after PTGBD for grade Ⅱ-Ⅲ acute cholecystitis. Although the amount of intraoperative bleeding was higher, the operation time was shorter, the burden on patients was reduced and there was more rapid recovery.

Research progress in surgical diagnosis and treatment of gallstones and acute calculous cholecystitis in the elderly / 国际外科学杂志

Gallstones and acute calculous cholecystitis are common diseases in surgery. China has entered an aging society. Elderly patients are a high incidence group of gallstones and acute calculous cholecystitis. Their surgical diagnosis and treatment strategies need to be formulated individually, and reasonable diagnosis and treatment methods should be comprehensively selected according to the patient′s condition and the medical level of the medical institution. For those who are in good physical condition and can tolerate the operation, it is recommended to give priority to surgical treatment, and the minimally invasive surgery mainly suitable for laparoscopic cholecystectomy (LC) is preferred. Open surgery is more appropriate for complicated conditions or patients whose general conditions are not suitable for laparoscopic surgery. Other minimally invasive treatment measures can be applied at the same time. For patients who can not tolerate surgical treatment, puncture, endoscopy, intervention and other means can be selected, combined with drugs for conservative treatment, so as to obtain the opportunity of surgical treatment or improve the prognosis. In this paper, the latest research literature at home and abroad has been collected to review and summarize the latest research progress in the physiology and aging characteristics of the biliary tract in the elderly, the diagnosis and treatment of gallstones and acute calculous cholecystitis. It is hoped that this paper can provide reference for the clinical diagnosis and treatment of such diseases, and think and prospect the future research.

Advances in diagnosis and treatment of acute suppurative cholecystitis in the elderly / 国际外科学杂志

Acute suppurative cholecystitis is a complex acute abdomen in general surgery, which usually occurs in middle-aged and elderly people. With the improvement of living standards and the aging of the population, the incidence of the disease is increasing year by year. Elderly patients have certain clinical particularities, and they are often combined with other underlying diseases such as cardiovascular and cerebrovascular diseases. Therefore, specific programs should be implemented for different situations during patient treatment, and a more complete risk assessment should be carried out. The preferred treatment for acute suppurative cholecystitis is surgery, but for patients with poor general conditions or intolerable surgery, percutaneous transhepatic gallbladder drainage may be a good alternative. This article reviews the clinical characteristics, diagnosis and treatment of acute suppurative cholecystitis in the elderly.

Efficacy of endoscopic retrograde cholangiopancreatography combined with SpyGlass system in treatment of acute cholecystitis secondary to choledocholithiasis / 临床肝胆病杂志

Objective To investigate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP)+SpyGlass system versus percutaneous transhepatic gallbladder drainage (PTGD)+ERCP in the treatment of acute cholecystitis secondary to choledocholithiasis. Methods A retrospective analysis was performed for the clinical data of the patients with acute cholecystitis secondary to choledocholithiasis who were treated in Department of Gastroenterology, Jilin City People's Hospital, from December 2019 to September 2021, among whom there were 23 patients in the ERCP+SpyGlass group and 19 patients in the PTGD+ERCP group. The two groups were compared in terms of the indicators such as surgical technical success, surgical operation time, surgical clinical success, postoperative recovery, length of hospital stay, and complications. The two-independent-samples t test was used for comparison of normally distributed continuous data between groups, and the Wilcoxon rank-sum test was used for comparison of non-normally distributed continuous data between groups; the chi- square test or the Fisher's exact test was used for comparison of categorical data between groups. Results Compared with the PTGD+ERCP group, the ERCP+SpyGlass group had a significant reduction in C-reactive protein after surgery ( Z =2.999, P =0.003). There were no significant differences between the two groups in technical success rate ( χ 2 =1.735, P =0.188), clinical success rate ( χ 2 =0.846, P =0.358), total time of operation ( t =1.667, P = 0.113), white blood cell count on day 1 after surgery ( t =1.075, P = 0.289), length of postoperative hospital stay ( t =1.560, P =0.127), and incidence rate of complications (all P > 0.05). Conclusion In the treatment of acute cholecystitis secondary to choledocholithiasis, the ERCP+SpyGlass system has a comparable clinical effect to PTGD+ERCP and is safe and effective, without increasing surgery-related adverse events and risks, and it can also solve the problems of the biliary tract and the gallbladder at one time through natural orifices, with no scars on body surface and convenient postoperative nursing. Therefore, it holds promise for clinical application.

Research advances in endoscopic interventional treatment of acute cholecystitis / 临床肝胆病杂志

Acute cholecystitis is a common acute abdominal disease, and it can be classified into grade Ⅰ (mild), grade Ⅱ (moderate), and grade Ⅲ (severe) based on severity. Gallbladder drainage is an important treatment method for patients with severe disease conditions and a high surgical risk. Percutaneous transhepatic gallbladder drainage is commonly used in clinical practice and has a clinical success rate of more than 65%. With the development of endoscopic technology, some centers in China and globally have begun to apply endoscopic gallbladder drainage to the management of acute cholecystitis. This article introduces the methods of gallbladder drainage commonly used in clinical practice, such as percutaneous hepatic gallbladder drainage, endoscopic ultrasound-guided gallbladder drainage, endoscopic transpapillary gallbladder drainage, as well as the progress in endoscopic interventional treatment of acute cholecystitis in recent years.

Retrospective analysis of early surgical treatment of acute calculous cholecystitis with elevated liver enzymes / 国际外科学杂志

Objective:To investigate the safety and feasibility of early operation for acute calculous cholecystitis with elevated liver enzymes.Methods:The clinical data concerned about 39 patients with acute calculous cholecystitis complicated with elevated liver enzymes in The First Department of General Surgery, The First Affiliated Hospital of Anhui University of Science and Technology between January 2018 to December 2018 were analyzed retrospectively.There were 14 males and 25 females, the age was(57.59±15.30) years(range 29 to 84 years). All patients were given hepatoprotective therapy and antibiotic therapy, A total of 18 patients received early surgical treatment within 7 days (surgical group), 21 patients who received only hepatoprotective therapy and antibiotic therapy(control group). Observation indicators: (1)Total bilirubin, white blood cells and pancreatin in both groups at admission; (2)Data of liver enzyme indexes (ALT, AST, GGT) of the two groups at admission and 3 days after admission; (3)The length of hospital stay in the two groups, and gallstone-related events after discharge(the incidence of gallstone-related emergency, the rehospitalization rate). Normally distributed measurement data were expressed as mean±standard deviation( ± s), and comparison between groups were analyzed using t test; Non-normal distribution measurement data were represented by M( Q1, Q3), and comparison between groups were analyzed using Mann-Whitney U test. Comparison between groups were analyzed using chi-square test or Fisher method of count data. Results:There was no statistical difference between the two groups in terms of total bilirubin, white blood cells and pancreatin( P>0.05). There was no significant difference in liver enzyme indexes (ALT, AST, GGT) between the two groups when they were admitted to the hospital ( P>0.05) and 3 days later ( P>0.05). Before treatment, ALT、AST、GGT in surgical group were 161.00(83.75, 237.75) U/L, 63.50(49.50, 257.75) U/L, 245.50(66.75, 549.75) μmol/L, ALT, AST, GGT in control group were 187.00(64.00, 335.50) U/L, 104.00(53.50, 355.00) U/L, 299.00(136.50, 455.00) μmol/L, after 3 days antibiotic therapy and hepatoprotective therapy, ALT, AST, GGT in surgical group were 77.50(52.00, 111.00) U/L, 41.50(33.00, 53.75) U/L, 190.50(65.00, 372.00) μmol/L, ALT, AST, GGT in control group were 67.00(23.50, 129.50) U/L, 37.00(26.00, 61.50) U/L, 187.00(90.50, 337.00) μmol/L, levels of the two groups decreased significantly( P<0.05). There was no statistically significant difference in the length of hospital stay between the surgical group and the control group[(12.89±3.41) d vs (11.05±4.57) d, P>0.05]. After 12 months of follow-up, Gallstone-related events after discharge, the incidence of gallstone-related emergency in the surgical group was lower than that in the control group (5.6% vs 33.3%), the rehospitalization rate in the surgical group was significantly lower than that in the control group (5.6% vs 42.9%), there was statistically significant difference between the two groups ( P<0.05). Conclusion:Hepatoprotective therapy and antibiotic therapy and can effectively reduce the liver enzyme indexes of such patients in a short period of time, early surgical treatment after liver enzymes has decreased is a complete and safe option.

Acute hemorrhagic cholecystitis with gallbladder rupture and massive intra-abdominal hemorrhage

Acute hemorrhagic cholecystitis is a rare, life-threatening condition that can be further complicated by perforation of the gallbladder. We describe a patient with clinical and radiologic findings of acute cholecystitis with a gallbladder rupture and massive intra-abdominal bleeding. Our patient is a 67-year-old male who presented with an ischemic stroke and was treated with early tissue plasminogen activator. His hospital course was complicated by a fall requiring posterior spinal fusion surgery. He recovered well, but several days later developed subxiphoid and right upper quadrant pain and an episode of hemobilia and melena. A computed tomography scan revealed an inflamed, distended gallbladder with indistinct margins and a large hematoma in the gallbladder fossa extending to the right paracolic gutter. The patient also developed hemodynamic instability concerning for hemorrhagic shock. He underwent an emergent laparoscopic converted to open subtotal fenestrating cholecystectomy with abdominal washout for management of his acute hemorrhagic cholecystitis with massive intra-abdominal hemorrhage. Prompt recognition of this lethal condition in high-risk patients is crucial for optimizing patient care.

Comparison and progress of the Tokyo guidelines and the European World Association of Emergency Surgery guidelines for acute cholecystitis / 中华肝胆外科杂志

The Tokyo guidelines (TG) for acute cholecystitis, published in 2007, have been updated to the third edition of TG18, and the European World Association of Emergency Surgeons (WSES) Guidelines, published in 2016, has also been updated to the 2020 edition. Different guidelines have certain consensus and differences in diagnosis and treatment ideas. Better understanding the updated content in the guidelines and master the consensus among different guidelines can make the clinical diagnosis and treatment more standardized, safer and scientific. In this paper, the changes in the updating process of each version of the two guidelines and the consensus differences between the guidelines are summarized in order to provide a clear idea for clinical workers in the diagnosis and treatment of acute cholecystitis.

Discussion on the timing of sequential LC for acute cholecystitis after percutaneous transhepatic gallbladder puncture and drainage / 中华肝胆外科杂志

Objective:To study the optimal surgical timing of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD) for acute cholecystitis.Methods:A retrospective analysis of the clinical data of patients with acute cholecystitis who were treated at Zhengzhou Central Hospital Affiliated to Zhengzhou University from April 2016 to October 2020 with initial PTGBD followed by LC. These patients were divided into three groups according to the time intervals between LC with PTGBD. Patients who underwent LC 3~4 weeks after PTGBD were in the short interval group ( n=67); patients who underwent LC 5~8 weeks after PTGBD were in the intermediate interval group ( n=78); and patients who underwent LC>8 weeks after PTGBD were in the long interval group ( n=73). The baseline and perioperative data of the three groups were compared. Results:In 218 patients, 97 were males and 121 were females, aged (72.1±8.4) years. Before LC, the gallbladder wall in the short interval group (4.77±0.62) mm was significantly thicker than that in the intermediate interval group (3.85±0.34) mm and the long interval group (3.81±0.25) mm (all P<0.05). Intraoperative blood loss in the intermediate interval group was significantly less than that in the short interval group ( P<0.05). The operation time, conversion to laparotomy, placement of drainage tube, postoperative hospital stay and total hospitalization expenses in the intermediate interval group were significantly better than those in the other two groups (all P<0.05). The incidence of complications in the intermediate interval group was significantly lower than that in the short interval group [2.56% (2/78) vs. 14.93% (10/67)], and the long interval group [2.56% (2/78) vs. 12.33% (9/73), all P<0.05]. Conclusion:The best timing for sequential LC after PTGBD in acute cholecystitis was shown in this study to be 5 to 8 weeks after PTGBD.

To study the use of different assessment methods in predicting perioperative outcomes in patients with acute cholecystitis and decompensated cirrhosis / 中华肝胆外科杂志

Objective:To study the use of different assessment methods in predicting perioperative outcomes in patients with acute cholecystitis and decompensated cirrhosis.Methods:A retrospective study was performed on 28 patients with acute cholecystitis and decompensated cirrhosis (MELD ≥ 15) who underwent laparoscopic surgical intervention from January 2016 to August 2020 at the Third People Hospital of Xinjiang Uygur Autonomous Region. These patients were divided into 2 groups according to the severity of acute cholecystitis grading in the Tokyo Guidelines 2018 (TG18): TG18 grade Ⅰ for the mild cholecystitis group ( n=15) and TG18 grade Ⅱ and grade Ⅲ for the moderate and severe cholecystitis group ( n=13). 16 patients with a MELD score ranging from 5 to 15 and with TG18 grade Ⅰ were used as the control group. The operation-related conditions, surgical injuries and surgical complications were compared among the three groups. Results:Of 44 patients with acute cholecystitis and decompensated cirrhosis included in this study, there were 28 males and 16 females, aged (57.3±5.9) years. Significantly more patients in the moderate and severe cholecystitis group (13/13) suffered from cholecystitis due to stone impaction than the control group (11/16) and the mild cholecystitis group (10/15) ( P<0.05). When compared to the control group, patients in the mild cholecystitis group and the moderate and severe cholecystitis group had significant increases in operative time, intraoperative bleeding, amount of abdominal drainage, abdominal drainage time, delayed feeding time and hospital stay ( P<0.05). These perioperative outcomes were further and significantly increased in the moderate and severe cholecystitis group when compared to the mild cholecystitis group ( P<0.05). The blood bilirubin levels, blood creatinine levels and MELD scores after surgery were significantly better in both the mild cholecystitis group and the moderate and severe cholecystitis group on postoperative day 3 when compared to those before treatment ( P<0.05). The Child score was significantly better in the control group after surgery than that before surgery ( P<0.05). The grade Ⅰ-Ⅱ surgical complication rate was significantly higher in the moderate and severe cholecystitis group (11/13) than the mild cholecystitis group (5/15, χ 2=7.479), and the control group (4/16, χ 2=10.208) ( P<0.05). There were no significant differences in the grade Ⅲ-Ⅴ surgical complication rates among the three groups (all P>0.05). The overall surgical complication rate was significantly higher in the moderate and severe cholecystitis group (12/13) than the mild cholecystitis group (7/15, χ 2=7.385), and the control group (5/16, χ 2=11.023), (all P<0.05). Conclusions:The MELD score when combined with the severity grading for acute cholecystitis of the TG18 was effective to evaluate the perioperative risks of patients with acute cholecystitis and decompensated cirrhosis. Patients with a MELD score ≥ 15 and TG18 Ⅱ or Ⅲ had significantly higher risks after minimally invasive surgery.

Efficacy of early versus delayed laparoscopic cholecystectomy in the treatment of acute calculous cholecystitis combined with abnormal liver function / 中国基层医药

Objective:To investigate the efficacy of early versus delayed laparoscopic cholecystectomy (LC) in the treatment of acute calculous cholecystitis complicated by abnormal liver function. Methods:A total of 106 patients with acute calculous cholecystitis complicated by abnormal liver function who received LC in Nanjing Drum Tower Hospital, Nanjing University Medical School, China between February 2018 and February 2020 were included in this study. They were assigned to receive laparoscopic cholecystectomy either within 72 hours after disease onset (early group, n = 51) or 72 hours after disease onset (delayed group, n = 51). Perioperative indexes, complications, immune function and liver function were compared between the two groups. Results:Intraoperative blood loss in the early group was less than that in the delayed group [(63.11 ± 8.18) mL vs. (92.39 ± 7.23) mL, t = 19.558, P < 0.001]. Operative time, time to anal exhaust and length of hospital stay in the early group were (49.53 ± 6.33) minutes, (23.24 ± 4.65) hours and (6.38 ± 1.23) days in the early group were significantly shorter than those in the delayed group [(63.24 ± 5.42) minutes, (32.88 ± 5.78) hours, (8.34 ± 1.54) days, t = 12.004, 9.415, 7.204, all P < 0.001]. There was no significant difference in the rate of conversion to open cholecystectomy during LC between the two groups ( χ2 = 0.877, P > 0.05). There was no significant difference in the incidence of complications between early and delayed groups [11.76% (6/51) vs. 7.27% (4/55), χ2 = 0.625, P > 0.05]. On day 3 after surgery, the proportion of CD 3+ cells and the ratio of CD 4+/CD 8+ cells in the early group were (37.81 ± 4.29) % and (1.32 ± 0.29), respectively, which were significantly higher than those in the delayed group [(32.56 ± 5.26) %, 1.21 ± 0.23, t = 5.605, 6.379, both P < 0.001]. Total bilirubin, alanine aminotransferase and alkaline phosphatase levels in the early group were (21.05 ± 5.16) μmol/L, (71.58 ± 9.36) U/L and (175.73 ± 19.64) U/L, respectively, which were significantly lower than those in the delayed group [(27.81 ± 5.14) μmol/L, (82.54 ± 12.35) U/L, (214.62 ± 20.58) U/L, t = 6.921, 7.893, 9.865, all P < 0.001]. On day 5 after surgery, total bilirubin, alanine aminotransferase and alkaline phosphatase levels in the early group were (14.63 ± 4.58) μmol/L, (42.13 ± 8.24) U/L, (137.72 ± 17.62) U/L, respectively, which were significantly lower than those in the delayed group [(18.67 ± 6.45) μmol/L, (59.64 ± 11.29) U/L, (162.76 ± 18.39) U/L, t = 3.692, 8.265, 7.462, all P < 0.001]. Conclusion:Early LC for treatment of acute calculous cholecystitis complicated by abnormal liver function can effectively promote the recovery of liver function, mitigate immune injury, improve perioperative indicators, and dose not increase the incidence of complications.

Effect of electroacupuncture at Lower He-Sea points including Yanglingquan (GB 34) on nuclear factor-κB and interleukin-1β in guinea pigs with acute cholecystitis / 针灸推拿医学（英文版）

Objective: To observe the effect of electroacupuncture (EA) at Lower He-Sea points on the expression levels of interleukin-1β (IL-1β) in the serum and gallbladder tissues, and nuclear factor-κB (NF-κB) in gallbladder tissues of the guinea pigs with acute cholecystitis (AC), and to explore whether Yanglingquan (GB 34), the Lower He-Sea point pertaining to Dan Fu (gallbladder), is relatively specific for the Dan Fu (gallbladder) disorders. Methods: Eighty-two healthy guinea pigs were randomly divided into 6 groups according to the random number table method, a blank group, a model group, a Yanglingquan (GB 34) group, a Zusanli (ST 36) group, a Shangjuxu (ST 37) group, and a Xiajuxu (ST 39) group, with 12 guinea pigs in the blank group while 14 in the other groups, respectively, half males and half females in each group. Except for the blank group, guinea pigs in the other groups were injected with E. coli into the gallbladder to establish AC models. Guinea pigs in the blank group were fed routinely without special treatment; those in the model group were daily tied up for 30 min without EA treatment; those in the 4 groups receiving EA treatment were acupunctured at the corresponding Lower He-Sea points after daily binding and stimulated with the SDZ-V EA instrument. After successful modeling and treatment for 5 d, blood was collected from the abdominal aorta of the guinea pigs, and the gallbladder tissues in each group were isolated for hematoxylin-eosin (HE) staining to observe the morphological changes. Enzyme-linked immunosorbent assay (ELISA) was used to detect the serum IL-1β level, and immunohistochemistry (IHC) was used to detect the expression levels of NF-κB and IL-1β in gallbladder. Results: On the 3rd day after modeling, the guinea pigs in the five groups with modeling were mentally depressed with decreased appetite, significantly reduced activities, slouch, lassitude, slack and matted fur, and loose stools; two guinea pigs were selected from each group (one male and one female, not included in the final statistics) to isolate the gallbladder after sacrifice; macroscopic observation showed that the gallbladder wall was differently thickened; the bile color was dark green and opaque with particles suspended or accumulated; light microscope observation showed that the submucosal blood vessels of the gallbladder were congested, along with mucosal edema, ulceration, necrosis, shedding, and a large number of inflammatory cells infiltrating in the lamina propria, indicating that the AC model was successfully prepared. Compared with the model group, the gallbladder tissue injuries of the four groups receiving EA treatment were all differently repaired, the serum IL-1β levels were reduced (P<0.01 or P<0.05), and the IL-1β levels in the gallbladder tissues were reduced (P<0.01 or P<0.05). Compared with the model group, the NF-κB expression level in the Yanglingquan (GB 34) group was significantly reduced (P<0.01), but was not statistical different in the Zusanli (ST 36) group, Shangjuxu (ST 37) group and Xiajuxu (ST 39) group (all P>0.05). Compared with the Yanglingquan (GB 34) group, the gallbladder tissues of the Zusanli (ST 36) group, Shangjuxu (ST 37) group and Xiajuxu (ST 39) group were more severely damaged, and the expression levels of serum IL-1β, the NF-κB and IL-1β in the gallbladder tissues were increased (P<0.01 or P<0.05). Intervention effect of Yanglingquan (GB 34) on AC guinea pigs was superior to that of Zusanli (ST 36), Shangjuxu (ST 37) and Xiajuxu (ST 39). Conclusion: EA at the Lower He-Sea points of the stomach, large intestine, small intestine and gallbladder can produce curative effects on AC guinea pigs and reduced the inflammatory symptoms. Intervention effect of Yanglingquan (GB 34) on AC guinea pigs is superior to that of Zusanli (ST 36), Shangjuxu (ST 37) and Xiajuxu (ST 39). The mechanism of EA at Yanglingquan (GB 34) in treating AC may be regulating IL-1β and NF-κB to control the inflammatory response and improve the gallbladder tissue damage.

Management of patients with gallstones and acute cholecystitis during the epidemic of coronavirus disease 2019 / 临床肝胆病杂志

At present, the epidemic of coronavirus disease 2019 is still serious, and the prevention and control of this epidemic is taken seriously throughout the country. As one of the most common acute abdominal diseases in hepatobiliary surgery, gallstones with acute cholecystitis has sudden onset and rapid progression and thus requires early diagnosis and timely and effective treatment. During the prevention and control of the epidemic, patients should be admitted properly to reduce nosocomial infection. Gallstones with acute cholecystitis is often accompanied by pyrexia, and therefore, the presence or absence of severe acute respiratory syndrome coronavirus 2 infection should be clarified. Treatment regimen should be selected appropriately and individualized treatment measures should be developed. While ensuring that patients receive timely and effective diagnosis and treatment, hospitals should adopt prevention and control measures for patients and their caregivers to reduce nosocomial infection. The personal protection of medical personnel should also be taken seriously, and scientific measures should be implemented to guarantee their safety.

Current status of the research on laparoscopic cholecystectomy / 临床肝胆病杂志

Laparoscopic cholecystectomy is considered the gold standard for the treatment of symptomatic cholecystolithiasis and has become one of the typical representatives of minimally invasive surgery. This article briefly introduces the contraindication and indication for laparoscopic cholecystectomy, commonly used surgical procedures, and possible complications and related treatment methods, emphasizes the improvement of surgical procedure and the development of new equipment for cholecystectomy, and points out the current status, problems, and development trend of laparoscopic cholecystectomy, in order to provide a reference for better application of laparoscopic cholecystectomy in clinical practice.