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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.

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.

Pancreaticoduodenal Artery Aneurysms A Report of Two Cases and Review of the Literature

Pancreaticoduodenal artery aneurysms are rare but challenging surgical problems. While physical examination, ultrasound, and computed tomography scans may suggest the diagnosis, more definitive information may be achieved noninvasively by scintiangiog raphy. Angiography is the diagnostic gold standard and remains crucial for rational planning of operative strategy. Surgical repair is usually achieved by exclusion or endoa neurysmorrhaphy. Through use of modern diagnostic and surgical approaches, mortality rates have been reduced from as high as 22% to 6%. The authors herein describe 2 patients with pancreaticoduodenal artery aneurysms and review the management strate gies of this challenging problem.