Removing Symptomatic Gallstones at their First Emergency Presentation

INTRODUCTION Early operations for symptomatic gallstones are gaining favour as the complication rate is thought to be lower and it reduces the overall morbidity. This study was performed to clarify how frequently early operations were being performed and what benefits resulted. PATIENTS AND METHODS Case notes of 171 patients who underwent laparoscopic cholecystectomy at Princess Alexandra Hospital Harlow were retrospectively reviewed. They were grouped according to their initial diagnosis (cholelithiasis, acute cholecystitis) and the delay to surgery (early, interval). Forty-one cases were excluded as they either had incomplete notes or the initial diagnosis was a different manifestation of gallstones such as pancreatitis. Those receiving interval operations were then grouped according to the mode of their initial presentation. A total of 130 case notes were analysed. RESULTS The delay for an interval operation was 3–6 months compared with less than 2 weeks for early operations. Of patients with acute cholecystitis, 43% had early operations but only 12% of patients with cholelithiasis. Waiting for interval operations was associated with multiple re-admissions equivalent to an average of one extra presentation to accident and emergency per patient. This was particularly marked if the initial presentation was to accident and emergency rather than out-patients (P = 0.003). Complication rates were also higher in the interval group. CONCLUSIONS Early cholecystectomy on the next available list is likely to reduce morbidity and the long-term in-patient burden so should be recommended for all patients presenting as an emergency with symptomatic gallstones.

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The Application of Tokyo Guideline 2018 (TG18) and Outcome Analysis in Patients with Initial Diagnosis of Both Acute Cholecystitis and Acute Cholangitis

HPB ◽

10.1016/j.hpb.2020.11.911 ◽

2021 ◽

Vol 23 ◽

pp. S357

Author(s):

Y.-R. Chang ◽

C.-N. Yeh ◽

S.-Y. Wang ◽

Y.-Y. Jan

Keyword(s):

Acute Cholecystitis ◽

Acute Cholangitis ◽

Initial Diagnosis ◽

Outcome Analysis

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Review of Operative Treatment of Delayed Presentation of Acute Cholecystitis

The American Surgeon ◽

10.1177/000313481908500140 ◽

2019 ◽

Vol 85 (1) ◽

pp. 98-102

Author(s):

Ryan D. Eubanks ◽

Kenneth R. Hassler ◽

Grant Huish ◽

Tammy Kopelman ◽

Ross F. Goldberg

Keyword(s):

Acute Cholecystitis ◽

Symptom Onset ◽

Postoperative Bleeding ◽

Index Admission ◽

Complication Rates ◽

Delayed Presentation ◽

Estimated Blood Loss ◽

Before And After ◽

Group A ◽

Group B

Treatment of patients with delayed acute cholecystitis (AC) includes antibiotics and interval cholecystectomy based on proposed change at 72 hours from symptom onset to a chronic fibrotic phase with concern for increased complication rates. The purpose of our study was to compare the outcomes of patients undergoing laparoscopic cholecystectomy (LC) for AC before and after this golden 72-hour window. After institutional review board approval, a retrospective study was performed of patients presenting over two years with AC, who underwent LC during the index admission. A chart review was performed, and patients were divided into symptoms <72 hours (group A) and symptoms >72 hours (group B). Complications were defined as postoperative bleeding, return to operating room, and bile leaks. One hundred and eighty-four patients met the study criteria. Group A included 96 patients managed 5 to 71 hours after symptom onset, whereas Group B encompassed 88 patients with symptoms 72 to 336 hours. Both groups had similar baseline demographics and disease severity. No statistically significant differences were noted between the groups regarding overall complications or 30-day morbidity; however, Group B had an increased hospital stay length (P < 0.0001) and estimated blood loss (P = 0.028). LC seems safe despite duration of symptomatology and should be considered during the index admission in all AC patients.

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Similar Phenotypes Demonstrated upon Initial Diagnosis and at Time of Recurrence in Relapsed DLBCL

Blood ◽

10.1182/blood.v128.22.5299.5299 ◽

2016 ◽

Vol 128 (22) ◽

pp. 5299-5299 ◽

Cited By ~ 1

Author(s):

Jie Qu ◽

Matthew J Maurer ◽

James R Cerhan ◽

Anne J. Novak ◽

Thomas M. Habermann ◽

...

Keyword(s):

B Cell ◽

Initial Treatment ◽

Immunohistochemical Staining ◽

B Cell Lymphoma ◽

Initial Diagnosis ◽

Initial Presentation ◽

Response To Treatment ◽

Cell Of Origin ◽

University Of Iowa ◽

Diagnostic Time

Abstract BACKGROUND: Diffuse large B-cell lymphoma, not otherwise specified (DLBCL), though defined as one disease entity, consists of two main cell-of-origin (COO) subtypes, germinal center B-cell like (GCB) and activated B-cell like (ABC), with the latter predicting a significantly worse prognosis using conventional chemotherapy. Up to 40% of all patients diagnosed with DLBCL will experience relapse, and outcomes are generally poor in this setting. In this study, we examine the proportion of GCB vs. non-GCB subtypes at initial diagnosis and at time of relapse, and assess the incidence of reclassification from one subtype to another. METHODS: Patients were prospectively enrolled in the University of Iowa/Mayo Clinic SPORE Molecular Epidemiology Resource (MER) within 9 months of diagnosis and followed for relapse, retreatment, and death. All relapse events were validated by review of the medical record. This analysis includes patients diagnosed with DLBCL who underwent initial treatment and subsequently experienced relapse as confirmed by biopsy. Immunohistochemical staining data including CD10, Bcl-6, and Mum-1, were collected from available pathology reports and classified to either GCB or non-GCB subtypes as predicted by the Hans algorithm. We compared subtype classification and individual immunohistochemical data both at the time of diagnosis and relapse. The overall subtype agreement between the two diagnostic time points was assessed. RESULTS: 1023 patients with newly diagnosed DLBCL were enrolled in the MER from 2002 - 2012. Of those, 249 had documented disease relapse. Of those analyzed, a total of 43 patients had COO classification based on the Hans algorithm from tissue biopsy at both diagnosis and relapse. Thirty patients were characterized as GCB DLBCL on initial presentation, and upon relapse 28 were noted to be GCB, while 2 were noted to be the non-GCB subtype. Of the 13 that were characterized as non-GCB on initial presentation, 10 remained non-GCB while 3 were reclassified as GCB. The overall agreement of DLBCL COO phenotypes between initial diagnosis and relapse was 88%. Seven percent of those initially diagnosed as GCB were reclassified as non-GCB subtype; in contrast, 23% of those initially diagnosed as non-GCB had changed to GCB upon relapse. Similar analysis was performed on individual immunohistochemical staining factors including CD10, Bcl-6, and Mum-1, and we observed overall agreement of 88%, 87%, and 91%, respectively. CONCLUSIONS: A majority of patients with relapsed DLBCL exhibit similar COO phenotypes at initial presentation and at relapse, and the incidence of reclassification from one subtype to another is uncommon. This suggests that the initial treatment regimen for DLBCL rarely alters the basic cancer phenotype when immunohistochemistry laboratory technical factors and pathologist interpretive discrepancies are excluded as causes for this change. However, reclassification from GCB to non-GCB subtypes is observed in a minority of cases, which may affect the overall outcome and response to treatment. Further studies are needed using gene expression to categorize COO and to examine the factors surrounding the time of relapse for possible harbingers of relapse as well as the behavior and outcome of reclassified DLBCL. Table Table. Disclosures Ansell: BMS, Seattle Genetics, Merck, Celldex and Affimed: Research Funding.

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Brain metastases in patients with urothelial carcinoma.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.6_suppl.282 ◽

2013 ◽

Vol 31 (6_suppl) ◽

pp. 282-282

Author(s):

Helen Jane Boyle ◽

Emilie Lavergne ◽

Jean Pierre Droz ◽

Nathalie Bonnin ◽

Aude Flechon

Keyword(s):

Brain Metastases ◽

Urothelial Carcinoma ◽

Metastatic Disease ◽

Cox Model ◽

Brain Mri ◽

Brain Lesion ◽

Local Treatment ◽

Local Therapy ◽

Initial Diagnosis ◽

Initial Presentation

282 Background: Muscle invasive urothelial cancers are infrequent. Patients (pts) with metastatic disease have poor prognosis. Brain metastases (BM) are rare. The aim of this retrospective study is to analyse the characteristics, the treatment and the evolution of patients with BM treated in a single centre. Methods: Thirty pts with BM were identified among the 1591 pts with urothelial carcinoma seen at the Centre Léon Bérard, between 1994 and 2011. The study population was described, overall survival (OS) from diagnosis of BM was estimated by Kaplan-Meier method and prognostic factors were explored using a Cox model. Results: Twenty seven pts in our series were male. Median age at initial diagnosis was 60 years (range: 33.9-78.9 years). Twenty two pts had primary bladder tumours and 8 upper urinary tract tumours. Twenty four pts underwent surgery for their primary lesion, 2 received chemoradiotherapy and 4 did not receive any radical local treatment. Six pts had metastatic disease at initial presentation: 3 were operated on. Median delay between initial diagnosis and BM was 16.6 months (range: 0-56.4 months), 3 patients had BM at initial presentation. Median time between first metastases and BM was 10 months (range=0-52 months). Eleven patients developed BM as one of the first sites of metastases. BM were symptomatic in 28 pts: specific neurological symptoms (n=25), headaches (n=6), epilepsy (n=2). For the 2 other pts, they were discovered on a systematic brain MRI. Eighteen pts had cerebral metastases only, 5 pts had cerebellar metastases only, 6 had both; the last patient had cerebral, cerebellar and meningeal involvement. Half of the pts had only 1 brain lesion. Five pts were operated on: 4 received postoperative radiotherapy; 19 patients were given radiotherapy alone and 6 did not get any local therapy. In this series, median OS from diagnosis of BM was 3.4 months (IC95% [2.2-10.3]). Only the administration of chemotherapy after the diagnosis of BM was significantly associated with OS; probably because only fit enough patients were offered treatment. Conclusions: Prognosis of patients with urothelial carcinoma and BM is poor; however some patients have long survivals. Treatment is not codified as there is little data in the literature.

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Acute Cholecystitis at Initial Presentation of Microscopic Polyangiitis

The American Journal of Medicine ◽

10.1016/j.amjmed.2015.04.023 ◽

2015 ◽

Vol 128 (9) ◽

pp. e5-e7 ◽

Cited By ~ 1

Author(s):

César Pérez-Vega ◽

Eduardo Rodríguez de Castro-Hurtado ◽

María del Mar Barrio-Molina ◽

Javier Narváez

Keyword(s):

Acute Cholecystitis ◽

Microscopic Polyangiitis ◽

Initial Presentation

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Acute Laparoscopic Cholecystectomy: Delays in Acute Surgery and Cost Analysis of Aproposed New Service

Bulletin of The Royal College of Surgeons of England ◽

10.1308/147363511x579468 ◽

2011 ◽

Vol 93 (7) ◽

pp. 261-265

Author(s):

AJ Cockbain ◽

AL Young ◽

E McGinnes ◽

GJ Toogood

Keyword(s):

Laparoscopic Cholecystectomy ◽

Acute Cholecystitis ◽

Meta Analysis ◽

Gallstone Disease ◽

Cochrane Review ◽

Length Of Hospital Stay ◽

Biliary Colic ◽

Complication Rates ◽

Acute Surgery ◽

Symptomatic Gallstone Disease

Acute laparoscopic cholecystectomy (ALC) is widely considered the most appropriate management for patients presenting with acute cholecystitis as supported by a recent meta-analysis and Cochrane review. Although the benefit of ALC is less clear in patients with biliary colic, few would disagree that earlier cholecystectomy is preferable for most patients with symptomatic gallstone disease. ALC has similar complication rates to elective laparoscopic cholecystectomy (ELC) and a reduced total length of hospital stay. Recurrent symptoms from untreated gallstone disease are common, with the risk of developing more severe complications such as acute cholecystitis, acute pancreatitis or cholangitis while waiting for an operation. It has been reported that patients awaiting ELC after an acute admission have significantly more general practitioner (GP) attendances than those who receive ALC, that they have an average of one emergency department attendance for symptom recurrence and that one in six requires hospital admission due to the severity of recurrent symptoms.

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Laparoscopic Cholecystectomy for Acute Gallbladder Disease During Index Admission- 11 the Optimum Timing for Surgery

Journal of Surgical Sciences ◽

10.3329/jss.v16i1.14442 ◽

2013 ◽

Vol 16 (1) ◽

pp. 11-17

Author(s):

Md Ibrahim Siddique ◽

Md Atiar Rahman ◽

Md Shahadot Hossain Sheikh ◽

Khander Manzoor Murshed ◽

Samia Mubin ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

Hospital Stay ◽

Acute Cholecystitis ◽

Open Cholecystectomy ◽

Gallbladder Disease ◽

Index Admission ◽

Laparoscopic Procedure ◽

Complication Rates ◽

Financial Benefit ◽

Conversion To Open Cholecystectomy

Background: Laparoscopic cholecystectomy, initially considered a contraindication for the treatment of acute gallbladder disease, is now being practiced for treating acute cholecystitis worldwide. The purpose of the study is to evaluate the outcome of laparoscopic procedure in the management of acute gallbladder disease during the index admission in terms of safety and feasibility, hospital stay and the rates of complications and conversion to open cholecystectomy. Methods: Between January 2009 to December 2011, 174 patients (103 female, 71 male) with median age 43.5 years (range 27-73 years) with the diagnosis of acute gallbladder disease underwent laparoscopic cholecystectomy. Diagnosis of acute cholecystitis was made from history, physical findings and ultrasound evidence of acute inflammatory changes. Results: Median time from onset of symptoms to surgery was 70 hours. Median operative time was 76.5 minutes. Conversion rate was 1.7%. Minor post-operative complications occurred in 13.5% cases of laparoscopic procedure, which did not require further intervention. Median post-operative hospital stay was 2.5 days and total length of hospital stay was median 4.4 days. There was no mortality. Conclusion: In expert hands laparoscopic cholecystectomy for acute gallbladder disease during the index admission is safe with better clinical results, shorter hospital stay and an acceptable conversion and complication rates with additional financial benefit to the patients. DOI: http://dx.doi.org/10.3329/jss.v16i1.14442 Journal of Surgical Sciences (2012) Vol. 16 (1) : 11-17

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921 Management of Acute Cholecystitis - the MACHO Study

British Journal of Surgery ◽

10.1093/bjs/znab258.067 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

R Clarke ◽

Keyword(s):

Logistic Regression ◽

Acute Cholecystitis ◽

Clinical Outcomes ◽

Standard Treatment ◽

Complication Rates ◽

Timely Manner ◽

Clinical Coding ◽

Grade Ii ◽

Surgical Condition ◽

Grade Iii

Abstract Background Acute cholecystitis is a common surgical condition. Gold standard treatment is index cholecystectomy, although there are reasons this might not be offered. The aim of this study was to explore treatments and outcomes in patients with acute cholecystitis. Method A multicentre retrospective study was carried out to identify a historic three-month cohort. Patients were identified through clinical coding. Demographics, clinical outcomes, comorbidities, Tokyo grade, and intervention descriptors were collected. Logistic regression was performed to identify characteristics of patients receiving a drain, and to propensity match for clinical outcomes. Results Seven centres reported on 1130 patients. Median age was 62 years, and 145 (12.8%) had grade III cholecystitis. Grade III cholecystitis was present in 19 (25.6%) of those who underwent cholecystostomy, 34 (9.3%) of those who underwent index cholecystectomy, and 92 (13.3%) of those who were conservatively managed. Overall complication rates were higher for those managed with cholecystostomy (36.5%) or conservatively (22.6%) vs index cholecystectomy (7.5%) (p < 0.001). Logistic regression found CCI and grade III cholecystitis were associated with increased rates of any complication. Increased CCI and grade II/III cholecystitis were associated with increased rates of major complications. Conclusions 'Hot' laparoscopic cholecystectomy seems to be offered to mild cases in fit patients. Patients with grade III disease and moderate comorbidities may not have cholecystectomy in a timely manner, leaving them at risk of repeated severe episodes.

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