Acute Cholecystitis 2
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To operate or not to operate?On acute cholecystitis in elderly and critically ill patientsDr. Prashanth SreeramojuAssistant Professor of SurgeryMontefiore-Einstein Medical Center
Goal :To provide evidence supporting the non-operative management of acute cholecystitis(AC) in elderly and critically ill patients as a safe and effective bridge treatment strategy
Introduction Definitions of termsElderly > 65 yearsSevere acute cholecystitis - based on Tokyo Guidelines (TG07) acute cholecystitis with systemic or organ dysfunction/sCritically ill pts ASA class IV or above APACHE II score > 12; SAPS >15 (Simplified Acute Physiology Score); SOFA (Sequential Organ Failure Assessment)
Tokyo Guidelines for acute cholecystitis (TG 07)Mild - RUQ pain w/murphys signs and USG findings (40-70%)Moderate - acute cholecystitis w/ WBC >18K; >72hrs of symptoms; palpable tender mass (25%-60%)Severe - acute cholecystitis with organ dysfunction/s
- Severe acute cholecystitisIncidence - 1.2-6% are severe acute cholecystitis Severe acute cholecystitis acute cholecystitis along with one of the below:Cardiac dysfunction (pressor requirement)Neurologic dysfunction (altered mental status)Hepatic dysfunction (INR >1.5)Renal dysfunction (Cr > 2.0mg/dl)Respiratory dysfunction (PaO2/FiO2 ratio
Cholecystitis in critically ill ptsCalculus cholecystitis (ACC) vs Acalculus cholcystitis(AAC)AAC seen in 10-20%High mortality rates of up to 50%
Non-operative management of cholecystitis Antibiotics covering gram bacilli and anaerobic organismsGall bladder drainage proceduresPercutaneous vs Endoscopic transpapillary approach
Revisiting Percutaneous Cholecystostmy for Acute Cholecystitis Based on a 10-Year Experience (Arch Surg. 2012;147(5):416-422)Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study (Am J Surg 2013 206(6), 935-941)Non-operative management of acute cholecystitis in the elderly (Br J Surg 2012; 99: 12541261)Percutaneous Drainage versus Emergency Cholecystectomy for the Treatment of Acute Cholecystitis in Critically Ill Patients: Does it Matter? (World J Surg (2011) 35:826833 )Studies comparing percutaneous cholecystostomy(PC) vs cholecystectomy(CCY)A nationwide examination of outcomes of percutaneous cholecystostomy compared with cholecystectomy for acute cholecystitis (Surg Endosc (2013) 27:34063411)
Study groupTime frameType of studyMorbidity PC CCY MortalityPC CCYLength of stayConver-sion rateTalamini et al, 20131998-2010Retrospective 4.1%8.5%p
Limitations in the literatureRecommendation grading (Guyatt and colleagues) -2CNo randomized/prospective trials
Cholecystitis in cirrhosis and pregnancyAC in CirrhosisMorbidity rates child A 18%; Childs B 37% ; Child C 75%MELD score >13 - complication ratesAC in pregnancy Conservative management in 1st and 3rd trimester
Gall bladder mass indications for non-surgical management Unresectable tumors Stage III/IV 5-year survival rate 5% and 1 % respectively Median OS 5.8monthsManagementBiliary drainage procedures - ERCP/PTCClinical TrialsGemcitabine or 5-FU based CTxBest supportive care
Objectives of non-operative management
Avoids general anesthesia riskOptimizes pt for definitive treatmentAvoids Higher risk of conversion Decreases morbidity rate
To operate? or Not to operate !
References:-A nationwide examination of outcomes of percutaneous cholecystostomy compared with cholecystectomy for acute cholecystitis, 1998-2010.Surg Endosc (2013) 27:34063411Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study. Am J Surg 2013 206(6), 935-9412013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg. 2013; 8: 3.TG13 surgical management of acute cholecyst. J Hepatobiliary Pancreat Sci. 2013 Jan;20(1):89-96Non-operative management of acute cholecystitis in the elderly. British J Surg 2012; 99: 12541261
Revisiting Percutaneous Cholecystostomy for Acute Cholecystitis Based on a 10-Year Experience. Arch Surg. 2012;147(5):416-422Percutaneous Drainage versus Emergency Cholecystectomy for the Treatment of Acute Cholecystitis in Critically Ill Patients: Does it Matter? World J Surg (2011) 35:826833 NCCN guidelines consortium Laparoscopic management of appendicitis and symptomatic cholelithiasis during pregnancy. Langenbecks Arch Surg. 2006 Sep;391(5):467-71Cirrhosis is not a contraindication to laparoscopic cholecystectomy: results and practical recommendations. HPB (Oxford). 2011 Mar;13(3):192-7.
My goal for today is to convince the audience and Definition of terms Literature considers anyone aged above 65 years as elderly Definition of severe acute cholecystitis is based on TG07 which is acute cholecystitis with an organ dysfunction or multipleMost of the studies in the literature considered a pt as critically ill, if they belong to ASA class IV or above or if they have APACHE two score of more than 12 or SAPS of more than 15All those measurements consider acute physiological changes and chronic comorbidities.
Tokyo Guidelines for acute cholecystitis were published in 2007 to provide diagnostic criteria and severity assessment criteria for acute cholecystitis. They have proposed these guidelines for appropriate treatment strategies and better outcomes. For the purpose of todays talk we will concentrate on severe acute cholecystitis. Its incidence is about 1-6% among the pts present with acute cholecystitis. Severe cholecystitis is associated with an organ or multiple organ dysfunction as listed below.Gallstones is still a common cause of cholecystitis in critically ill patients. However, Acalculous cholecystitis is seen in about 10-20% of criitically pts. Cholecystitis in critically ill patients is associated with high mortality rates of up to 50% compared to mere 1% in non-critically ill patients.Surgical management in these patients carry mortality rate of 4-6%
Non operative management for cholecystitis involves broad spectrum antibiotics covering gram bacilli and anaerobic organisms and gall bladder drainage procedures It can be done either percutaneously or endoscopically under monitored anesthesia care. Of course better pain control; a happy patient, a happy doctor!!I did extensive literature search to find best evidence for non-operative management of cholecystitis in critically ill patients and to prove my talk for today. Unfortunately, I found mostly retrospective studies and only few of them made head to head comparison between nonoperative and surgical management. Surgical management involves laparoscopic cholecystectomy or open. I have selected five of those studies and assimilated in to this table highlighting their key findings. Rather findings which we are interested in !!Frist study is a nationwide examination.. recently published in Surgical Endoscopy journal. A retrospective study involving patients in the time frame 1998-2010. There is a homogenous distribution of Patients characteristics in each group. It showed that group managed non-operatively has significantly lower morbidity rate compared to surgical group. Their high mortality rate in conservative mgmt groups is explained due to their critically ill condition not due to cholecystitis or procedure. Second study- is another recently published paper in the Am J of surgery titled Emergent cholecyst.. another retrospective study showing significantly low morbidty rate in nonopeartive mgmt compared to CCY group.Third study - retrospectively evalauted non-op mgmt of acute cholecystis in elderly. Published in British J of surgery in 2012- demonstrated low complication rate in non-op mgmt Fourth study published in World J of surgery, year 2011 comparing percutaneous drainage vs. emergency cholecystectomy for the treatment of acute cholecystitis in critically ill pts. It showed similar results of significantly low morbidity rate in percutaneous groupLast study I would like to discuss showed contradictory results compared to previously described studies. It is paper from Archives of surgery published in 2012 ,assessing the data from VA hospital in Boston.. Reviewing a decade experience of percutaneous cholecystomy for acute cholecystitis. It was a poorly analyzed study. Comparing apples with oranges.. Pts in the PC are significantly sicker pts with ASA class IV compared to pts in surgery group who belong to ASA class I or II.
Limitations in the literature, as per Recommendation grading system, current literature provides a weak evidence for non-operative management. There are no randomized or prospective trials so far.. Surgical intervention for Cholecystitis in Childs C cirrhosis patients carry significantly higher morbidity rates compared to Child A and Child B cirrhosis. Pts with high MELD score more than 13 are prone for increased complicationsManagement of cholecystitis in pregnancy has been always a challenge, as we need to worry about two life's. Old data suggests non-operative management in the 1st and 3rd trimester with Safe window of opportunity for surgical intervention in the second trimester. However, new literature shows a cholecystectomy can be safely performed in any trimester. It might be due to advancements of surgical technology and surgeons becoming more skillful laparoscopically.Pregnant pts who are conservatively managed before have 40-50% recurrence of symptoms.Unresectable gall bladder tumors is an another indication for conservative management. Most of these pts belong to stage III and IV as per TNM staging system. They have poor 5- year