Presence of cystic duct stone is a risk for postoperative retained stones in patients with acute cholecystitis.

PURPOSE: Retained stones (RS) in the common bile duct (CBD) are one of the major problems after laparoscopic cholecystectomy and usually require endoscopic treatment. However, few reports have investigated risk factors for the development of RS in the CBD. METHODS: A total of 325 patients with acute cholecystitis underwent laparoscopic cholecystectomy at our hospital between January 2013 and Jury 2021. Patient characteristics, including radiographic factors and perioperative outcomes, were reviewed, and perioperative factors predicting RS in the CBD were investigated. RESULTS: RS in the CBD were developed in 34 patients. All 34 patients were treated endoscopically. ASA-PS class 3 or more (p = 0.029, odds ratio = 2.601), subtotal cholecystectomy performance (p = 0.004, odds ratio = 3.783) and the presence of cystic duct stones (p < 0.001, odds ratio = 11.759) were found by logistic regression analysis to be independent risk factors for developing RS in the CBD. Cystic duct stones were preoperatively detected in 60 patients. Of these, 21 cases were not detected on magnetic resonance cholangiopancreatography (MRCP) but on CT, while 15 cases were not detected on CT but on MRCP. CONCLUSIONS: The presence of cystic duct stones on preoperative CT or MRCP is a crucial risk factor for developing RS in the CBD. Both CT and MRCP are useful to avoid overlooking cystic duct stones.

Prediction of extensive necrotic change in acute gangrenous cholecystitis.

PURPOSE: Gangrenous cholecystitis (GC) is a severe type of acute cholecystitis that implies higher mortality and morbidity rates than uncomplicated cholecystitis. The characteristics of GC are various for each case. However, preoperative predictors of GC with extensive necrotic change have not been investigated well. METHODS: A total of 239 patients who were pathologically diagnosed with GC underwent laparoscopic cholecystectomy at our hospital between January 2013 and December 2021. Of these, 135 patients were included in this study and were subdivided into the extensive necrosis group (patients with necrotic change extending to the neck of the gallbladder, n = 18) and the control group (patients with necrotic change limited to the fundus or body, not extending to the neck, n = 117) according to each operation video. Patient characteristics and perioperative factors predicting extensive necrotic change were investigated. RESULTS: Pericholecystic fat stranding (83.3 vs. 53.8%, p = 0.018) and absence of wall enhancement on preoperative CT images (50.0 vs. 24.7%, p = 0.026) were significantly associated with extensive necrosis. Seven of 18 patients in the extensive necrosis group showed necrotic changes beyond the infundibulum. The absence of wall enhancement on preoperative CT images (71.4 vs. 28.8%, p = 0.018) was significantly associated with necrotic changes beyond the infundibulum. CONCLUSIONS: Pericholecystic fat stranding and absence of wall enhancement on preoperative enhanced CT are predictors of extensive necrotic change in patients with GC. In addition, the absence of wall enhancement also predicts the presence of necrotic changes beyond the infundibulum.

Does the presence of an appendicolith or abscess predict failure of nonoperative management of patients with acute appendicitis?

PURPOSE: Nonoperative management (NOM) has been widely accepted as one of the standard treatments for patients with acute appendicitis. However, predictive factors for the failure of NOM have not been thoroughly investigated. METHODS: A total of 196 patients with acute appendicitis underwent NOM between April 2014 and December 2020. Of these 196 patients, 24 patients failed NOM and required emergency surgery (failure group: n = 24), while the other 172 patients were successfully treated with NOM (success group: n = 172). These two groups were compared, and the predictive factors for the failure of NOM were investigated. RESULTS: The number of patients who had a previous history of stroke was significantly increased in the failure group (12.5% vs. 2.9%, p = 0.026). Incarceration of an appendicolith on CT images was significantly associated with the failure group (20.8% vs. 1.7%, p < 0.001), while neither the presence of an appendicolith nor abscess was associated. The presence of periappendiceal fluid was significantly associated with the failure group (50.0% vs. 26.7%, p = 0.019). The incarceration of an appendicolith (p < 0.001, odds ratio = 19.85) and periappendiceal fluid (p = 0.009, odds ratio = 3.62) were found to be independent risk factors for failure of NOM. Neither the presence of an appendicolith nor abscess was associated with the recurrence of appendicitis. CONCLUSIONS: The presence of an appendicolith or abscess was not a crucial factor for surgery. Incarceration of an appendicolith and periappendiceal fluid on CT images was predictive factors for the failure of NOM.

Are Preoperative CT Findings Useful for Predicting Postoperative Intraabdominal Abscess in the Patients with Acute Appendicitis?

Background and objective: In patients with acute appendicitis (AA), preoperative computed tomography (CT) findings suggesting development of intraabdominal abscess (IAA) had not been widely used. The aim of this study was to investigate the preoperative clinical and radiological factors that predict the development of a postoperative IAA in patients with AA who were treated by laparoscopic appendectomy (LA). Methods: Two hundred and sixteen patients with pathologically proven AA underwent LA between January 2013 and March 2018 in our department. Medical records and preoperative CT images of these 216 patients were retrospectively reviewed and the predictive factors of postoperative IAA were investigated. In addition, patients were divided into complicated appendicitis (CA) and simple appendicitis (SA) and perioperative factors of two groups were compared. Results: One hundred and forty-seven patients were diagnosed with CA, while the other 69 patients were diagnosed with SA. Sixteen patients developed postoperative IAA in the CA group, while no patients in the SA group did. The univariate analysis revealed that time from onset to surgery more than 3 days (p = 0.011), the preoperative CT finding of periappendiceal fluid (p = 0.003), abscess (p < 0.001), and free air (p < 0.001), operation time more than 120 min (p = 0.023) and placement of a drainage tube (p < 0.001) were significantly associated with the development of IAA. Multivariate analysis revealed that the preoperative CT finding of free air was independently associated with the development of IAA (p = 0.007, odds ratio = 5.427, 95% CI: 1.586⁻18.57). Conclusions: IAA developed predominantly in patients with CA. Preoperative CT findings of free air was found to be an independent predictor for the development of IAA. Surgeons should be meticulous in managing the postoperative course of patients with this finding.

Is postponed laparoscopic appendectomy justified for patients with acute appendicitis?

INTRODUCTION: Recent meta-analyses revealed that laparoscopic appendectomy (LA) is a feasible procedure even for patients with complicated appendicitis. More than a few patients with acute appendicitis arrive at the hospital during night shifts and have their operation postponed for various reasons. However, the feasibility and disadvantages of this so-called "postponed laparoscopic appendectomy" (PLA) remain controversial. METHODS: We included 149 patients who underwent LA for acute appendicitis within 48 h of diagnosis between January 2013 and May 2018. Patients were divided into an immediate LA group (patients who underwent LA within 4 h of diagnosis, n = 84) and a PLA group (patients who underwent LA 4-48 h after diagnosis, n = 65). Comparisons were made between these groups. RESULTS: The preoperative characteristics of the patients in the immediate LA and PLA groups were not significantly different. Operative time was significantly longer in the PLA group than in the LA group (92.5 ± 40.8 vs 78.1 ± 29.7 min, P = 0.012). The incidence of postoperative complications (grade II or higher) was significantly greater in the PLA group than in the LA group (32.3% vs 17.8%, P = 0.041). Multivariate analysis revealed that a preoperative CT finding of periappendiceal fluid (P = 0.005, odds ratio = 4.71) and surgery 4-48 h after diagnosis (P = 0.005, odds ratio = 4.425) were independent risk factors of postoperative complications (grade II or higher). CONCLUSIONS: For patients with acute appendicitis, surgeons should perform immediate LA, if that is the patient's preferred surgical treatment, as long as there is no special reason to postpone surgery.

CT value of the intestine is useful predictor for differentiate irreversible ischaemic changes in strangulated ileus.

PURPOSE: To determine the differential points of strangulated ileus with and without irreversible ischaemic changes, especially on preoperative computed tomography (CT) images. METHODS: Seventy patients with strangulated ileus underwent emergency operations between January 2009 and July 2016 in our department. Of these patients, 57 met the study requirements, including 30 patients who had irreversible ischaemic changes (ischaemic group; n = 30) and 27 patients who had reversible ischaemic changes during laparotomy (non-ischaemic group; n = 27). We compared the preoperative clinical and radiographic factors between the ischaemic and non-ischaemic groups. RESULTS: Univariate analysis revealed that a mean CT value of the intestine in an unenhanced image ≥16.5 HU (p < 0.001), a mean CT value ratio of the intestine (enhanced/unenhanced image) <1.5 (p < 0.001), presence of mesenteric fluid (p = 0.002) and presence of free peritoneal fluid (p = 0.009) were associated with the ischaemic group. CONCLUSIONS: Calculation of the mean CT value of a strangulated intestine may be a useful method for predicting irreversible ischaemic changes in addition to the presence of mesenteric fluid or free peritoneal fluid.