[Perforated cholecystitis. Classification and atypical clinical forms]. / Perforativnyi kholetsistit. Klassifikatsiia i atipichnye klinicheskie formy.

AIM: To obtain new data for diagnosis and treatment of patients with perforated cholecystitis. MATERIAL AND METHODS: It was analyzed the variants of original classification of perforated cholecystitis by Fedorov S.P. - Neimeier O.W. (1934). Moreover, we have assessed treatment of 292 patients with gallbladder perforation (own material of Faculty Surgery Clinic). RESULTS: According to continuous 20-year follow-up perforated cholecystitis was observed in 2.9% of patients with various forms of gallbladder inflammation (n=292 out of 10 215). The frequency of atypical clinical forms of gallbladder perforation including multiple and combined perforation, perforation with acute intestinal obstruction and intraabdominal bleeding was 10% (n=29 of 292). Overall mortality in atypical clinical forms related to whole cohort with perforated cholecystitis was 2% (n=6 of 292). CONCLUSION: Atypical clinical forms of gallbladder perforation require specific treatment strategy due to the need for emergency surgical interventions. At the same time, the possibilities of video-assisted surgery are somewhat limited compared with other forms of gallbladder inflammation and can be used only in a third of patients.

Correlación ecográfica-laparoscópica en colecistitis crónica y aguda: validación 10 años después / Ultrasonographic and laparoscopic correlation in acute and chronic cholecystitis: 10 years later validation

Introduction: Abdominal ultrasound is the initial diagnosis tool for gallbladder disease and laparoscopic surgery is the gold standard approach. The aim of this study was to validate 10 years after, the ultrasonographic and laparoscopic findings previously proposed by our team to forecast laparoscopic cholecystectomy in terms of difficulties and perioperative complications. Materials and Methods: We evaluated 336 patients operated by laparoscopy between June and ¡December 2007 in our center. Ultrasound findings were classified according to the classification proposed in 1997 based on the thickness of the gallbladder wall, lumen and the presence of gallstones or sonic shadow. Results: Type I and IIA cholecystitis had a lower percentage of intraoperative difficulties (14.9 and 32.8 percent respectively) and conversion to open surgery (1.1 vs 1.7 percent respectively), whereas type LIB and III were associated greater presence of difficulties (51.3 percent and 71.4 percent respectively) and conversion rate (9.2 percent and 23.8 percent respectively). Conclusions: this classification is a useful tool in de correlation of ultrasonographic and laparoscopic findings in acute and chronic cholecystitis, helping the surgeon in predicting surgical problems, complications and risk of conversion to open surgery and supports the results previously published.

Introducción: La ecografia abdominal constituye el examen inicial en la patología vesicular; la cirugía laparoscópica es la vía de abordaje de elección. El objetivo de este estudio fue validar, 10 años después, la clasificación ecográfica y su correlación con los hallazgos laparoscópicos, propuesta previamente por nuestro equipo de trabajo para pronóstico de la colecistectomía laparoscópica en cuanto a dificultades y complicaciones peri operatorias. Materiales y Métodos: Se evaluaron 336 pacientes operados por vía laparoscópica entre junio y diciembre de 2007 en nuestro centro. Los hallazgos ecográficos se clasificaron de acuerdo a la clasificación propuesta en 1997, basada en el grosor de la pared vesicular, la presencia de lumen y de cálculos o sombra sónica. Programa Stata 9.1. Se realizó prueba de comparación de proporciones con p < 0,05. Resultados: Las colecistitis tipo I y IIA tuvieron menor porcentaje de dificultades intraoperatorias (14,9 y 32,8 por ciento) y de conversión a cirugía abierta (1,1 y 1,7 por ciento), mientras que las tipo IIB y III se asociaron a una mayor presencia de dificultades (51,3 por ciento y 71,4 por ciento respectivamente) y porcentaje de conversión (9,2 y 23,8 por ciento respectivamente). Conclusiones: esta clasificación constituye una herramienta útil en la correlación de hallazgos ecográficos y laparoscópicos en colecistitis crónica y aguda, ayudando al cirujano en la predicción de problemas quirúrgicos, complicaciones y riesgo de conversión a cirugía abierta, apoyando los resultados previamente publicados.

Histologic analysis of chronic inflammatory patterns in the gallbladder: diagnostic criteria for reporting cholecystitis.

Cholecystectomy is one of the most common surgical procedures. Inflammatory disease is by far the most common pathology of the gallbladder. Terms for describing cholecystitis are numerous, thus there is no uniform terminology. One hundred cholecystectomies and 10 gallbladders from autopsies were reviewed and inflammatory changes were analyzed. Chronic cholecystitis was seen in 75% of cases with epithelial metaplasia and 73% with regenerative epithelium, the latter being associated with erosion but not with the presence of lithiasis. Muscular thickening and adipose deposits were mostly mild. Inflammation was mild in 28%, moderatein 57%, and severe in 15%. Activity was found in 29% of cases. Fibrosis was present in all cases: 26% mild, 62% moderate, and 12% severe. Autopsy cases did not show significant changes. A simple and reproducible scoring system of inflammation and fibrosis of the gallbladder is proposed. Three numbers refer to mild, moderate, or severe degrees of chronic inflammation and activity, with a final score that results from adding both values. The fibrosis is classified in three different stages. The final report uses both values to classify the chronic cholecystitis. A scoring system for chronic cholecystopathy to replace descriptive terms would give an exact transduction of the observed changes in an objective fashion that could not be misinterpreted by physicians or other pathologists.

Laparoscopic cholecystectomy for acute cholecystitis: can the need for conversion and the probability of complications be predicted? A prospective study.

BACKGROUND: Laparoscopic cholecystectomy (LC) in acute cholecystitis is associated with a relatively high rate of conversion to an open procedure as well as a high rate of complications. The aim of this study was to analyze prospectively whether the need to convert and the probability of complications is predictable. METHODS: A total of 215 patients undergoing LC for acute cholecystitis were studied prospectively by analyzing the data accumulated in the process of investigation and treatment. Factors associated with conversion and complications were assessed to determine their predictive power. RESULTS: Conversion was indicated in 44 patients (20.5%), and complications occurred in 36 patients (17%). Male gender and age >60 years were associated with conversion, but these factors had no sensitivity and no positive predictive value. The same factors, together with a disease duration of >96 h, a nonpalpable gallbladder, a white blood count (WBC) of >18,000/cc(3), and advanced cholecystitis, predicted conversion with a sensitivity of 74%, a specificity of 86%, a positive predictive value of approximately 40%, and a negative predictive value of 96%. However, these data became available only when LC was underway. Male gender and a temperature of >38 degrees C were associated with complications, but these factors had no sensitivity and no positive predictive value. Progression along the stages of admission and therapy did not add predictive factors or improve the predictive characteristics. Male gender, abdominal scar, bilirubin >1 mg%, advanced cholecystitis, and conversion to open cholecystectomy were associated with infectious complications. Their sensitivity and positive predictive value remained 0 despite progression along the stages of admission and therapy. CONCLUSION: Although certain preoperative factors are associated with the need to convert a LC for acute cholecystitis, they have limited predictive power. Factors with higher predictive power are obtained only during LC. The need to convert can only be established during an attempt at LC. Preoperative and operative factors associated with total and infectious complications have no predictive power.

Preoperative evaluation to predict technical difficulties of laparoscopic cholecystectomy on the basis of histological inflammation findings on resected gallbladder.

BACKGROUND: No papers have heretofore documented histological studies of cases involving the inflammation of resected gallbladder or examined surgical difficulties on the basis of pathological findings. METHODS: On the basis of the histological inflammation findings on the resected gallbladders of 437 patients who underwent laparoscopic cholecystectomy (LC), the factors affecting the technical difficulty of the operation were examined through preoperative clinical findings (13 items), diagnostic imaging (22 items), and blood test findings (6 items), using multivariate analysis. RESULTS: In accordance with the four-stage classification of inflammation findings for the resected gallbladder, the inflammation findings on the resected gallbladder indicated a higher correlation with the time required for gallbladder dissection (30.2 +/- 16.3 minutes) than with the operation time (77.6 +/- 32.7 minutes). Thus, the technical difficulty of the operation was judged according to the time required for gallbladder dissection. For the preoperative findings on 418 patients who underwent successful LC, the most influential factors on the time required for gallbladder dissection were the presence of abnormal findings on computed tomography, the degree of fever, obesity index, nonvisualized gallbladder cholangiography, and cystic duct length. According to the multiple regression equation of these five factors, the gallbladder dissection for the 19 patients who underwent conversion to open cholecystectomy (OC) due to extreme inflammation was calculated to require 61.9 +/- 12.3 minutes, and the patients who showed a gallbladder dissection time longer than 49.6 minutes were judged to have high technical difficulty predicted from the preoperative evaluation. In the preoperative evaluation, sensitivity was 79.6%, specificity was 97.6%, accuracy was 95.0%, positive predictive value was 85.0%, and negative predictive value was 96.6%. Next, each finding was scored on the basis of a multiple regression equation of five factors, and the technical difficulty of the operation was quantified using these scores. The score of the patients who underwent conversion to OC was 8.0 +/- 2.0, and the patients who showed a score higher than 6 were judged to have high technical difficulty. Almost the same results as in the aforementioned preoperative evaluation were obtained using these scores. CONCLUSION: The judgment using the scores was satisfactory in terms of the simplicity of evaluating the technical difficulties associated with each patient and the ease of obtaining information for each factor. The quantification of technical difficulty using the scores is useful for preoperative prediction of which patients will have difficulties in gallbladder dissection and the conversion to OC in LC. Our results suggest that the consideration of technical difficulties is important for conducting safe operations with avoiding intraoperative complications.

Laparoscopic cholecystectomy in the elderly: a prospective study.

BACKGROUND: The aim of this prospective study was to determine the feasibility and the complications or benefits of laparoscopic cholecystectomy (LC) in the patients older than 75 years. METHODS: From January 1992 to July 1998, a total of 863 patients underwent LC, of these patients, 102 patients older than 75 years (group 1) were compared with 761 younger patients (group 2). RESULTS: In the elderly, 35.3% were at high surgical risk (American Society of Anesthesiology [ASA] III and ASA IV). The conversion rate to open cholecystectomy (OC) was 21.6%. The mean length of hospital stay was 6.9 days for both laparoscopy and conversion. Morbidity and mortality rates were 13.7% and 1%, respectively. No patient suffered intraoperative cardiopulmonary complication, and there was no reoperation in the elderly. CONCLUSIONS: Elderly patients experience more complications and longer duration of hospital stay than younger patients. However, our results compare favorably with other OC studies in elderly patients.

Acute acalculous cholecystitis--a clinical-pathological disease spectrum.

OBJECTIVE: To assess the influence of disease setting on clinical and pathological features of acute acalculous cholecystitis (AAC). DESIGN: Analysis of prospectively accumulated clinical data. Blinded histopathological review. LOCATION OF STUDY: Tygerberg Hospital, Western Cape. PATIENTS: Fifty-seven consecutive patients with AAC treated over a 9-year period. MAIN OUTCOME MEASURES: Clinical, ancillary and pathological features of AAC in each of 3 arbitrarily designated types. Type I (N = 24) occurred in patients hospitalised for trauma or critical illness. Patients with type II disease (N = 20) presented primarily with symptoms of acute cholecystitis. Type III AAC (N = 13) was associated with non-calculous gallbladder outflow obstruction. RESULTS: Type I AAC was associated with the highest mortality rate (45.8%), occurred predominantly in males (75%) and was diagnosed pre-operatively in 50% of patients. Acute ischaemic cholecystitis was the most frequent histological diagnosis (66.7%). Only 1 death (5%) was associated with type II AAC despite patients being older, and all but 2 patients (10%) having chronic underlying disease. Acute cholecystitis was diagnosed pre-operatively in 90% of patients. Thirteen patients (65%) were males. Acute-on-chronic cholecystitis was the most frequent histological diagnosis (50%), followed by acute ischaemic cholecystitis in 30%. Type III was associated with an intermediate mortality rate (23.1%) and was the type most seldom diagnosed pre-operatively (15.4%). Histological findings reflected the nature and duration of underlying obstructive pathology. CONCLUSION: The circumstances in which AAC occurs appear to be associated with distinct clinical-pathological variants of the disease. Their recognition could serve to enhance understanding of this challenging condition.

Laparoscopic cholecystectomy for the various types of gallbladder inflammation: a prospective trial.

Laparoscopic cholecystectomy (LC), the procedure of choice for elective cholelithiasis, is now also used in the management of acute cholecystitis. In the various types of gallbladder disease, favorable and unfavorable conditions may influence the conversion and complication rates. Information about these conditions may help elucidate the optimal circumstances for LC or indicate when the procedure is best avoided. We attempted to perform emergency LC on 215 patients with acute cholecystitis. The procedure was successful in 171 patients (79.5%), and conversion to open cholecystectomy (OC) was needed in 44 (20.5%). Complications occurred in 37 patients (17%). Uncomplicated acute cholecystitis was associated with age <50 years, duration of complaint <48 h, temperature <38.5 degrees C, a nonpalpable gallbladder, and an alkaline phosphatase >100 U/L. Acute gangrenous cholecystitis was associated with a negative gallbladder history, other associated diseases, temperature >38.5 degrees C, a palpable gallbladder, and serum bilirubin levels <1 mg/dl. Hydrops was associated with a temperature <38 degrees C and a leukocyte count of >12,000/cc3, and empyema of the gallbladder was associated with duration of complaint >48 h and a palpable gallbladder. The conversion rate of acute gangrenous cholecystitis (40%) was significantly higher than that of uncomplicated acute cholecystitis (8%) (p < 0.00001, odds ratio=7.7), as well as that of empyema of the gallbladder (12.5%) (p=0.005, odds ratio=4.7). The conversion from LC to OC in uncomplicated acute cholecystitis was associated with male sex and with duration of complaint >24 h, and in gangrenous cholecystitis with age >60 years, a nonpalpable gallbladder, and a leukocyte count of >15,000/cc3. The complication rates of acute cholecystitis, hydrops, empyema of the gallbladder, and gangrenous cholecystitis were 16%, 7%, 22%, and 21%, respectively (p = NS). The total complication rate in acute cholecystitis tended to be associated with a duration of complaint >48 h and in gangrenous cholecystitis with male sex, age >60 years, other associated disease, larger bile stones, and elevated serum bilirubin levels. Generally, LC is safe in all forms of cholecystitis, with acceptably low conversion and complication rates, excluding gangrenous cholecystitis. In gangrenous cholecystitis, a conversion rate of approximately 40% is expected. Predictors of conversion and complications may be particularly helpful in planning the laparoscopic approach to acute gangrenous cholecystitis. Patients >60 years of age, with a nonpalpable gallbladder and with a leukocyte count >15,000/cc3, frequently need conversion. In men >60 years old, with other associated disease, with larger bile stones, and with elevated serum bilirubin levels, complications are frequently expected. Under these conditions, laparoscopic approach should be undertaken by especially experienced teams, or OC should be considered.

[The clinico-anatomical characteristics of different forms of chronic calculous cholecystitis]. / Kliniko-anatomicheskie osobennosti razlichnykh form khronicheskogo kal'kuleznogo kholetsistita.

Three types of the disease course were marked out--hyperplastic (in 26% of observations), hypoplastic (in 40%) and normoplastic (in 34%)--according to the results obtained in clinico-morphological investigation of the excised gallbladder in 177 patients with calculous cholecystitis. For hyperplastic and normoplastic cholecystitis types the cholecystectomy conduction is indicated, and for normoplastic one in elderly patients the organ-preserving operation cholecystolithotomy conduction is possible.

Colecistectomia minitraumática por minilaparotomía / Minitraumatic cholecystectomy by minilaparatomy

Desde hace más de doce (12) años, un grupo de cirujanos se dedicaron a la tarea de modificar las laparotomías clásicas para colecistectomías, buscando reducir el disconfort de postoperatorio y la estancia hospitalaria (9), con llevando a una reducción de los costos de hospitalización. Por estas razones iniciamos un estudio prospectivo desde junio de 1993 hasta octubre de 1995, practicando Colecistectomías Minitraumáticas por Minilaparotomías en 62 (91 por ciento) de 68 pacientes en forma consecutiva. La edad media fue de 35.4 años. La circunferencia abdominal osciló entre 70 y 94 cm., con una media de 78 cm. La longitud media de la incisión fue de 4,5 cm., con rangos de 3,2 a 6,5 cm. La disección vesicular más empleada fue la mixta, en 51 casos (82,25 por ciento). El tiempo quirúrgico medio fue de 47 minutos con rangos de 30 a 85 minutos. En 11 casos (17,74 por ciento) la técnica se realizó debido a Colecistitis aguda. La estancia hospitalaria media fue de 27,9 horas. con rangos de 12 a 72 horas. La media de dosis de Ketoprofeno fue de 1,5 dosis, con rangos entre 1 y 3 dosis, no siendo requerido por 4 pacientes (6,45 por ciento). La incorporación postoperatoria a las actividades habituales se produjo entre el sexto y veintiunavo día, con una media de 12 días. 55 casos (88,7 por ciento) fueron practicados por cirujanos en formación. La única complicación reportada fue de un descenso de las cifras de hemoglobina en 3 gramos por ciento, en una paciente intervenida por Piocolecisto. Concluimos que la técnica resulta factible y sumamente segura

A new classification of Mirizzi syndrome from diagnostic and therapeutic viewpoints.

BACKGROUND/AIMS: A new classification of Mirizzi syndrome was developed based on our experience with 30 cases. MATERIAL AND METHODS: Using diagnostic and therapeutic criteria, four distinct entities were identified. Type I characterized by stenosis of the common hepatic duct due to a stone impacted in the cystic duct or the neck of the gallbladder. Type II is characterized by fistulization of the common hepatic duct as a result of a stone embedded in the cystic duct or the neck of the gallbladder. Type III is defined by hepatic duct stenosis due to a stone of the confluence, and Type IV by hepatic duct stenosis as a complication of cholecystitis in the absence of calculi impacted in the cystic duct or the neck of the gallbladder. RESULTS: Of the 30 patients there were 14 Type I, 2 Type II, 6 Type III, and 8 Type IV patients. Distinctive cholangiographic features were identified. CONCLUSION: The therapeutic approach differs from each of the four distinct pathologic entities.

Resultado de la colecistectomía laparoscópica según el grado de complejidad anatomoquirúrgica y la experiencia / Result of laparoscopic cholecystectomy based in anatomosurgical findings

949 pacientes sometidos a colecistectomía laparoscópica entre junio de 1991 y junio de 1994, fueron agrupados para su análisis según la clasificación A, B, C, D basada en los hallazgos anatomoquirúrgicos propuesta por los autores. Para determinar la influencia de la experiencia, se evaluaron por separado un período que abarcó de junio de 1991 a junio de 1992 y otrode junio de 1992 a junio de 1994. En ambos períodos las patologías vesiculares grado A y B no presentaron complicaciones intra ni postoperatorias ni conversiones. En cambio, en el primer período hubo un 18,42 por ciento de conversiones en las grado C, que disminuyó a 5,1 por ciento en el segundo período (p <0,023). Esto demuestra la importancia de la experiencia en los resultados cuando se operan colecistectomías laparoscópicas complejas. En le primera serie hubo 3 reoperaciones y ninguna en la segunda. Por definición todas las grado D fueron convertidas. Se enfatiza en la necesidad de homogeneizar las múltiples situaciones anatomoquirúrgicas de la patología del área vesicular para que los resultados sean comparables

Resultado de la colecistectomía laparoscópica según el grado de complejidad anatomoquirúrgica y la experiencia / Result of laparoscopic cholecystectomy based in anatomosurgical findings

949 pacientes sometidos a colecistectomía laparoscópica entre junio de 1991 y junio de 1994, fueron agrupados para su análisis según la clasificación A, B, C, D basada en los hallazgos anatomoquirúrgicos propuesta por los autores. Para determinar la influencia de la experiencia, se evaluaron por separado un período que abarcó de junio de 1991 a junio de 1992 y otrode junio de 1992 a junio de 1994. En ambos períodos las patologías vesiculares grado A y B no presentaron complicaciones intra ni postoperatorias ni conversiones. En cambio, en el primer período hubo un 18,42 por ciento de conversiones en las grado C, que disminuyó a 5,1 por ciento en el segundo período (p <0,023). Esto demuestra la importancia de la experiencia en los resultados cuando se operan colecistectomías laparoscópicas complejas. En le primera serie hubo 3 reoperaciones y ninguna en la segunda. Por definición todas las grado D fueron convertidas. Se enfatiza en la necesidad de homogeneizar las múltiples situaciones anatomoquirúrgicas de la patología del área vesicular para que los resultados sean comparables (AU)

Tratamiento quirúrgico de la colecistitis aguda / Surgical treatment of the acute cholecystitis

Se analizan los resultados del tratamiento quirúrgico de la colecistitis aguda en 291 pacientes operados por laparotomía y 43 por vía laparoscópica. La relación hombre/mujer hallada fue de 2/3 y la edad promedio de 53,7 años. El 12% se operó con alguna complicación (la más común fue el coleperitoneo en el 7,2% de los casos). Cuando se empleó la laparotomía o colecistectomía incompleta en el 6,2% de los casos; con la vía laparoscópica debió convertirse a cielo abierto en el 6,5%. Con laparostomía se constataron 9 accidentes intraoperatorios (3,1%); se complicaron 39 pacientes (13,3%) y fallecieron 8(2,6%). En la vía laparoscópica no hubo accidentes ni mortalidad y se complicó un caso (2,4%). La mortalidad en relación a la forma anatomopatológica fue significativamente mayor para la grangrenosa (p<0,05); en cambio no lo fue en relación a enfermedades asociadas, la edad y el tiempo de evolución. Se controlaron 177 casos, comprobándose 7,2% de complicaciones alejadas (litiasis residual, eventraciones)

Propuesta de clasificación laparoscopica de la patologia vesicular y su correlación con los resultados quirúrgicos / Laparoscopic classification of biliary vesicular pathology and your correlation with surgical results

Se realizaron 205 colecistectomias laparoscópicas y proponen una clasificación laparoscópica de la patología vesicular basados en los hallazgos anatomoquirúrgicos de la región operatoria. En cada grupo fueron estudiadas las complicaciones intraoperatorias, las postoperatorias, las conversiones a colecistectomia convencional y las reoperaciones. Demuestran que en los tipos A y B los inconvenientes intraoperatorios son escasos y no hay complicaciones postoperatorias. En los tipos C tuvieron el 44,7% de dificultades intraoperatorias y en el 18,4% conversión a colecistectomía por laparotomia. En este grupo el 10% se complicó en el postoperatorio y debieron ser reoperados, con un fallecido por hemorragia digestiva alta. Todos los tipos D fueron convertidos a colecistectomia convencional. Se propone el uso de la clasificación laparoscópica con el objeto de homogeneizar los grupos de pacientes sometidos a colecistectomia y poder comparar los resultados

Tratamiento quirúrgico de la colecistitis aguda / Surgical treatment of the acute cholecystitis

Se analizan los resultados del tratamiento quirúrgico de la colecistitis aguda en 291 pacientes operados por laparotomía y 43 por vía laparoscópica. La relación hombre/mujer hallada fue de 2/3 y la edad promedio de 53,7 años. El 12% se operó con alguna complicación (la más común fue el coleperitoneo en el 7,2% de los casos). Cuando se empleó la laparotomía o colecistectomía incompleta en el 6,2% de los casos; con la vía laparoscópica debió convertirse a cielo abierto en el 6,5%. Con laparostomía se constataron 9 accidentes intraoperatorios (3,1%); se complicaron 39 pacientes (13,3%) y fallecieron 8(2,6%). En la vía laparoscópica no hubo accidentes ni mortalidad y se complicó un caso (2,4%). La mortalidad en relación a la forma anatomopatológica fue significativamente mayor para la grangrenosa (p<0,05); en cambio no lo fue en relación a enfermedades asociadas, la edad y el tiempo de evolución. Se controlaron 177 casos, comprobándose 7,2% de complicaciones alejadas (litiasis residual, eventraciones)