Jack Abrahamson

Laparoscopic Cholecystectomy for Acute Cholecystitis: Prospective Trial

Abstract. This prospective study determines the indications for and the optimal timing of laparoscopic cholecystectomy (LC) following the onset of acute cholecystitis. It also evaluates preoperative and operative factors associated with conversion from laparoscopic cholecystectomy to open cholecystectomy in the presence of acute cholecystitis. Having been established as the procedure of choice for elective cholelithiasis, LC is now also used for management of acute cholecystitis. Under these circumstances the procedure may be difficult and challenging. Certain favorable and unfavorable conditions may be present that influence the conversion and complication rates. Information about these conditions may be helpful for elucidating the optimal circumstances for LC or when the procedure is best avoided. We performed LC on an emergency basis as soon as the diagnosis was made on all patients presenting with acute cholecystitis from January 1994 to December 1995. All preoperative, operative, and postoperative data were collected on standardized forms. Of the 137 patients registered, 130 were eligible for the audit. Seven patients found by laparoscopic intraoperative cholangiography to have choledocholithiasis were converted for common bile duct exploration and were excluded from the study. Altogether 93 patients (72%) underwent successful LC and 37 (28%) needed conversion to open cholecystectomy. The conversion rate of acute gangrenous cholecystitis (49%) was significantly higher than that for uncomplicated acute cholecystitis (4.5%) (p< 0.00001) and for hydrops (28.5%) and empyema of the gallbladder (28.5%) (p= 0.004). The difference in conversion between the group with acute necrotizing (gangrenous) cholecystitis and the two groups with hydrops and empyema of the gallbladder was not statistically significant (p= 0.07). The complication rates of acute cholecystitis, hydrops, empyema of the gallbladder, and gangrenous cholecystitis were 9.0%, 9.5%, 14.0%, and 20.0%, respectively (p= NS). Patients with an operative delay of 96 hours or less from the onset of acute cholecystitis had a conversion rate of 23%, whereas a delay of more than 96 hours was associated with a conversion rate of 47% (p= 0.022). The complication rate was 8.5% in the laparoscopic group and 27% in the converted group (p= 0.013). Patients over 65 years of age, with a history of biliary disease, a nonpalpable gallbladder, WBC count over 13,000/cc, and acute gangrenous cholecystitis were independently associated with a high LC conversion rate; male patients, finding large bile stones, serum bilirubin over 0.8 mg/dl, and WBC count over 13,000/cc were independently associated with a high complication rate following laparoscopic surgery with or without conversion. Generally, LC can be performed safely for acute cholecystitis, with acceptably low conversion and complication rates. Different forms of cholecystitis carry various conversion and complication rates in selected cases. LC for acute cholecystitis should be performed within 96 hours of the onset of disease. Predictors of conversion and complications may be helpful when planning the laparoscopic approach to acute cholecystitis.

Delay of surgery in acute appendicitis

BACKGROUND AND OBJECTIVES It is generally assumed that delayed diagnosis of acute appendicitis results in higher morbidity but this assumption is not strongly supported in the literature. We attempt to define the effect of patient and physician delay on the outcome of patients with acute appendicitis. PATIENTS AND METHODS We studied 486 patients admitted between 1980 and 1992. Patient delay in presenting to a physician and surgeon delay from hospital admission to operation were studied in relation to stage of disease at operation as well as to postoperative complications. RESULTS Postoperative complications occurred in 10% of cases with simple acute appendicitis versus about 20% of cases with gangrenous or perforated appendicitis (P <0.001). The mean patient delay from onset of symptoms to presentation to a physician was 1.7 days in simple acute appendicitis versus 2.3 days in gangrenous or perforated appendicitis (P <0.001). Mean surgeon delay was 13.6 hours in simple acute appendicitis versus 14.5 hours in advanced appendicitis (P = NS). CONCLUSION Delay in patient presentation adversely affects the stage of disease in acute appendicitis and leads to increased incidence of infectious complications and to prolonged hospital stay. Conversely, physician delay does not affect the stage of disease. A surgeons decision to observe patients in hospital in order to clarify the diagnosis is justified, as it does not adversely affect outcome.

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

AbstractBackground: 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/cc3, and advanced cholecystitis, predicted conversion with a sensitivity of 74%, a specificity of 86%, a positive predictive value of ∼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°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.

The impact of patient delay and physician delay on the outcome of laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND Laparoscopic cholecystectomy is now used in the management of acute cholecystitis. Under these circumstances unfavorable conditions may result in conversion and complications. Information about these conditions may help in planning the laparoscopic approach or in proceeding directly to open cholecystectomy. This study was initiated to evaluate perioperative factors associated with conversion and complications of laparoscopic cholecystectomy in acute cholecystitis. Special attention was paid to the duration of complaints until surgery, to the delay on the part of the patient, and to the delay on the part of the physician. METHODS Between January 1994 and December 1997, we attempted to perform laparoscopic cholecystectomy on 348 patients with acute cholecystitis. All perioperative data were collected on standardized forms. RESULTS There were 182 cases (52%) of acute uncomplicated cholecystitis, 90 (26%) of gangrenous cholecystitis, 33 of hydrops (9.5%), and 43 of empyema of the gallbladder (12.5%). Seventy six patients (22%) needed conversion to open cholecystectomy and complications occurred in 57 cases. Advanced cholecystitis was associated with significant patient delay (P = 0.01), and it had a significantly higher conversion rate (39%) compared with early cholecystitis (14.5%); (P <0.00001). Conversion rates were also associated with male gender (P = 0.0017), a history of biliary disease (P = 0.0085), and a patient delay of >48 hours (P = 0.028). The total and infectious complication rates were associated with an age older than 60 years (P = 0.023 and 0.007, respectively) and male gender (P = 0.026 and 0.014, respectively). CONCLUSIONS In acute cholecystitis, patient delay is associated with a high conversion rate. Early timing of laparoscopic cholecystectomy tends to reduce the conversion rate, as well as the total and the infectious complication rates. Male gender, a history of biliary disease, and advanced cholecystitis are associated with conversion. Male and older patients are associated with a high total and infectious complication rates.

Arterial occlusive disease in occult cancer

Thromboembolism frequently complicates advanced cancer. The incidence of TE as one of the initial manifestations of occult cancer and the diagnostic value of TE as a signal of a possible unrecognized tumor were the subjects of recent studies. TE may precede the diagnosis of cancer by several months or years. The polymorphism of manifestations of paraneoplastic TE has been described previously. An accelerated course of intermittent claudication and of ischemic heart disease has been described in patients with cancer and probably represents additional variants of Trousseaus syndrome. Recently, clues for the presence of occult neoplasms in patients with TE have been proposed. Their value in the stratification of patients needs to be established in prospective studies. That cancer may be responsible for a precipitated course of coronary or peripheral arterial disease raises the question of whether work-up is recommended to uncover a silent malignancy in a patient who has been referred for treatment of these severe ischemic syndromes.

Laparoscopic cholecystectomy for acute cholecystitis: how do fever and leucocytosis relate to conversion and complications?

OBJECTIVE To find out whether fever and raised white cell count (WCC) are associated with conversion and complications of laparoscopic cholecystectomy in acute cholecystitis, and whether their presence could help in deciding the place of laparoscopic procedures. DESIGN Prospective study. SETTING Teaching hospital, Israel. SUBJECTS 256 patients who were treated for clinical acute cholecystitis between January 1994 and November 1997. INTERVENTIONS Emergency laparoscopic cholecystectomy. MAIN OUTCOME MEASURES Raised temperature and WCC; incidence of conversion and complications. RESULTS Raised temperature (>38 degrees C) was independently associated with advanced cholecystitis (p = 0.002, odds ratio [OR] 2.7) and a palpable gallbladder preoperatively (p = 0.02, OR 2.1). Total complications correlated with a temperature of >38 degrees C. Raised WCC (>15 x 10(9)/L) was independently associated with age >45 years (p = 0.02, OR 2.4), a palpable gallbladder preoperatively (p = 0.001, OR 2.9), and a raised temperature (>38 degrees C) (p < 0.0001, OR 6.2). Conversion was associated with a WCC >18 x 10(9)/L (p = 0.0, OR 3.2). CONCLUSION A WCC of >18 x 10(9)/L may assist in predicting conversion, and fever of >38 degrees C may assist in predicting the development of complications.

Histoplasmosis of kidneys presenting as chronic recurrent renal disease.

Histoplasmosis is a well-known infectious disease that can sometimes run a mysterious and unexpected course. A case is reported that presented as a chronic renal process, with right pyelocutaneous fistula and prolonged purulent discharge as well as focal calcifications of the left kidney with recurrent stone formation. Histopathologic examination of the right kidney, removed in 1975, showed noncaseating granulomas, but the precise diagnosis was not made until 1983, when histopathologic re-examination followed partial resection of the left kidney, for recurrent stone formation. This article emphasizes the difficulty in diagnosing a noncaseating granulomatous disease in general and histoplasmosis in particular, especially when the urogenital tract is involved, with isolated local manifestations. It underlines the progressive and damaging character of this chronic disease, the variety of its manifestations, and attempts to increase awareness of this potentially treatable disease.

Neuropraxis Secondary to Hemorrhage in a Traumatic Dislocation of the Shoulder

A case of traumatic shoulder dislocation associated with a tear of the subscapular artery is presented. The main clinical feature was a dramatic neurologic loss of the brachial plexus, reversed by exploration, evacuation of hematoma, and ligation of the bleeding vessel. Early surgical decompression to achieve neurologic recovery is emphasized.

Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy in Acute Cholecystitis: Artificial Neural Networks Improve the Prediction of Conversion

Laparoscopic cholecystectomy is now also performed for acute cholecystitis. In the presence of inflammatory conditions, technical difficulties leading to conversion to open cholecystectomy may occur and overshadow the advantages of the laparoscopic approach. Factors associated with these undue events combined with techniques capable of learning from them may help in determining when to completely avoid the laparoscopic procedure. In this study we determined predictors of conversion in acute cholecystitis and tested their predictive ability by means of statistical multivariate analysis and artificial neural networks. Between January 1994 and February 1997, 225 patients underwent laparoscopic cholecystectomy for acute cholecystitis. Preoperative and operative data were prospectively collected on standardized forms. The first 180 laparoscopically approached cases entered the training set, which was learned by both the statistical and the artificial neural networks methods. Conversion was first studied in relation to a set of preoperative data. Prediction models were then fitted by both of these methods. The last 45 operated cases, which remained unknown to the learning systems, served for testing the fitted models. The forward stepwise logistic regression technique, the forward stepwise linear discriminant analysis, and the artificial neural networks method enabled positive prediction of conversion in 0%, 27%, and 100% of the cases, and a negative prediction in 80%, 85.5%, and 97% respectively, in the training set. A positive prediction of conversion in 0%, 25%, and 67% of the cases, and a negative prediction in 82%, 88%, and 94%, respectively, in the untrained, validation set of patients. An artificial neural networks based model provides a practical tool for the prediction of successful laparoscopic cholecystectomies and their conversion. The high degree of certainty of prediction in untrained cases reveals its potential, and justifies, under appropriate conditions, the complete avoidance of laparoscopy and turning directly to open cholecystectomy. Laparoscopic cholecystectomy (LC) is established as the treatment of choice for cholecystolithiasis, and it is now being proposed for the treatment of acute cholecystitis (AC) as well [1, 2]. However, technical difficulties may occur in the presence of inflammatory conditions, and in 20% to 30% of cases conversion to open cholecystectomy may be inevitable [3, 4]. Under these circumstances, the conversion and its consequences may overshadow all advantages of the laparoscopic procedure, making this approach unsafe, uneconomic, inefficient, and possibly inferior to the traditional open cholecystectomy. In about three-quarters of the cases of acute cholecystitis laparoscopic cholecystectomy can be performed safely, while in the remaining quarter open cholecystectomy may be preferable, illustrating how important it is, preoperatively, to be able to discriminate between these two groups. By identifying the subset of patients with a high potential for conversion, the laparoscopic attempt can be avoided by proceeding directly to an open operation. Appropriate study of the acute cholecystitis cases approached laparoscopically, including analysis of the factors associated with undue events, may serve to define predictors of conversion, may assist in planning a more effective and more efficient approach toward laparoscopic cholecystectomy, and may help in determining when to completely avoid the procedure. The multivariate statistical discriminant analysis (MVA) [5] and the multilayered artificial neural networks (ANNs) [6] are two techniques capable of deriving information from labeled data and then generalizing this knowledge so that the outcome of further unseen but similar cases can be predicted. The MVA has the power of observation, analysis, and prediction of events, as well as defining factors associated with them. The ANNs perform, in addition, multiple nonlinear transformations, using their many parallel components; they constitute a model of computation that is stronger than the conventional statistical computation models [7, 8]. Because of their proven accuracy in pattern recognition [9, 10], the ANNs have gradually been introduced over the last 5 years into various laboratory and clinical settings in medicine. Applications include diagnostic [11–13], imaging [14–17], and outcome prediction [18–25]. Although the potential of this new tool has not yet been fully perceived, some of the reported results are impressive and promising. This study was initiated to find factors associated with conversion to open cholecystectomy (by univariate analysis), then to identify predictors of conversion (by the MVA method), and finally to compare the effectiveness of the MVA and the ANN methods in predicting conversion. In our comparative study, data for both methods were derived from examples of a learning set of patients (training set), but the interpolative capabilities were verCorrespondence to: S. Eldar, M.D., e-mail: mdeldar@tx.technion.ac.il ified with data from a new and untrained group of patients

Clinical Significance of Paraneoplastic Syndrome

The prevalence, clinical presentations, and diagnostic significance of the paraneoplastic syndrome (PNS) in the setting of a department of internal medicine in a community hospital was studied. During a 7-year period (1979-1985) a total of 167 patients among 11,000 hospitalized patients were diagnosed as having a malignant neoplasia previously unknown. From this group we selected all cases who presented with one or more of the known clinical PNSs. Forty-two cases, i.e., 25% fulfilled the selection criteria. Their prevalence in our population was higher than usually found in the literature. Sixteen different categories of PNS were observed. They occurred 55 times, since more than one PNS was present in 9 cases. No significant correlation was observed between any type of PNS and any particular class of malignant neoplasia. At the time of initial evaluation, PNSs were associated with stage I malignancy in 15 cases, with stages II and III in 8 and 3 cases, respectively, and with stage IV in 22 cases. PNSs were the leading symptom or sign in 56% of the patients. In these patients the PNS determined the direction of work-up in the search for a malignant tumor. However, PNSs were essential for suspecting cancer in stage I of the disease in 6 cases only, i.e., 14%. We stress that awareness of the clinical implications of these syndromes may permit an earlier diagnosis of malignancy.