Conservative treatment versus endoscopic sphincterotomy in the initial management of acute cholecystitis in elderly patients at high surgical risk. Conservative treatment for acute cholecystitis: clinical and radiographic predictors of failure. Prospective evaluation of patients with acute cholecystitis treated with percutaneous cholecystostomy and interval laparoscopic cholecystectomy. Acute cholecystitis: delayed surgery or observation. A randomized clinical trial. Laparoscopic Cholecystectomy for Acute Cholecystitis: Is It Really Safe? Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. [Acute cholecystitis--early or delayed cholecystectomy]. Randomization to surgery or observation in patients with symptomatic gallbladder stone disease. The problem of evidence-based medicine in clinical practice. Prospective Evaluation of Emergency Versus Delayed Laparoscopic Cholecystectomy for Early Cholecystitis Laparoscopic Cholecystectomy for Acute Cholecystitis: Prospective Trial Long-term follow-up of a randomized controlled trial of observation versus surgery for acute cholecystitis: Non-operative management is an option in some patients A prospective randomized trial comparing pneumoperitoneum and U-shaped retractor elevation for laparoscopic cholecystectomy Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a prospective randomized trial Impact of Choice of Therapeutic Strategy for Acute Cholecystitis on Patient’s Health-Related Quality of Life Percutaneous Drainage versus Emergency Cholecystectomy for the Treatment of Acute Cholecystitis in Critically Ill Patients: Does it Matter? Incidence, Risk Factors, and Prevention of Biliary Tract Injuries during Laparoscopic Cholecystectomy in Switzerland Long-term ursodeoxycholic acid therapy is associated with reduced risk of biliary pain and acute cholecystitis in patients with gallbladder stones: a cohort analysis. [Acute cholecystitis: timing of surgery]. Management of acute cholecystitis in the laparoscopic era: Results of a prospective, randomized clinical trial Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): Study protocol for a randomized controlled trial Evaluation of Early versus Delayed Laparoscopic Cholecystectomy in Acute Cholecystitis Effect of Estrogen plus Progestin on Risk for Biliary Tract Surgery in Postmenopausal Women with Coronary Artery Disease: The Heart and Estrogen/progestin Replacement Study Surgical infections after laparoscopic cholecystectomy: ceftriaxone vs ceftazidime antibiotic prophylaxis. A prospective study.
BACKGROUND AND STUDY AIMS Surgery in elderly patients with acute cholecystitis is quite a high-risk procedure . The recent finding that activated pancreatic enzyme is present in sterile bile from the acutely inflamed gallbladder suggests that obstruction at the level of the common channel is a possible precipitating factor . It was therefore hypothesized that an initial endoscopic sphincterotomy in patients with acute cholecystitis might improve the clinical course . PATIENTS AND METHODS A prospect i ve unselected series of 105 patients over 65 years of age ( 52 men , 53 women ; mean age 78 ) suffering from acute cholecystitis were initially treated on a r and om basis with either conservative methods or endoscopic sphincterotomy . Within the first 72 h after the onset of symptoms , all 52 patients in the endoscopic sphincterotomy group were managed by endoscopic retro grade cholangiopancreatography ( ERCP ) , combined with endoscopic sphincterotomy in 50 cases . The main study parameter was the need for emergency cholecystectomy  within the first week after admission . RESULTS Biliary sepsis requiring emergency surgery occurred in 15 patients in the conservatively treated group , in contrast with none of the 52 patients in the endoscopic sphincterotomy group ( P < 0.001 ) . Iatrogenic complications after endoscopic sphincterotomy  occurred in three patients , one of whom required surgery , while two were managed by conservative means . The clinical course improved , avoiding the need for emergency cholecystectomy and other interventions , in 48 patients in the endoscopic sphincterotomy group and in 36 patients in the conservatively treated group ( P < 0.01 ) . CONCLUSIONS The clinical course after endoscopic sphincterotomy  improved in the majority of elderly patients suffering from acute cholecystitis , suggesting that early relief of obstruction at the level of the common channel reduces the risk of developing biliary sepsis . The majority of these patients can undergo surgery electively or can receive further conservative treatment BACKGROUND Current treatment options for acute calculous cholecystitis include either early cholecystectomy , or conservative treatment consisting of intravenous antibiotics and an interval cholecystectomy several weeks later . Percutaneous drainage is reserved for patients in whom conservative therapy failed or as a salvage procedure for high risk patients . OBJECTIVE To identify clinical and radiographic factors leading to failure of conservative treatment . METHODS We prospect ively collected data on consecutive patients admitted with the diagnosis of acute cholecystitis . Parameters were compared between patients who were successfully treated conservatively and those who required percutaneous cholecystostomy . Logistic regression analysis was performed to identify predictors for failure of conservative treatment . RESULTS The study population comprised 103 patients with a median age of 60 who were treated for acute cholecystitis . Twenty-seven patients ( 26.2 % ) required PC . On univariate analysis , age above 70 years , diabetes , elevated white blood cell count , tachycardia ( > 100 beats/min ) at admission , and a distended gallbladder ( > 5 cm transverse diameter ) were found to be significantly more common in the PC group ( P < 0.001 ) . WBC was higher in the PC group throughout the initial 48 hours . On multivariate analysis , age above 70 ( odds ratio 3.6 ) , diabetes ( OR 9.4 ) , tachycardia at admission ( OR 5.6 ) , and a distended gallbladder ( OR 8.5 ) were predictors for cholecystostomy ( P < 0.001 ) . Age above 70 ( OR 5.2 ) and WBC $ 15,000 ( OR 13.7 ) were predictors for failure of conservative treatment after 24 and 48 hours ( P < 0.001 ) . CONCLUSIONS Age above 70 , diabetes , and a distended gallbladder are predictors for failure of conservative treatment and such patients should be considered for early cholecystostomy . Persistently elevated WBC ( > 15,000 ) suggests refractory disease and should play a central role in the clinical follow-up and decision-making process for elderly patients with acute cholecystitis BACKGROUND Emergency laparoscopic cholecystectomy has been advocated for the treatment of acute cholecystitis ; however it can be a difficult task , especially in public hospitals , with relatively high conversion and complication rates . Percutaneous cholecystostomy is a simple and effective procedure allowing patients to recover from the acute event and undergo elective laparoscopic surgery at a later stage . METHODS We prospect ively assessed a protocol of initial conservative treatment in patients admitted with acute cholecystitis . Patients who did not respond to medical treatment were treated by percutaneous cholecystostomy .  Following discharge the patients were seen in the outpatient clinic and elective laparoscopic cholecystectomy was considered and scheduled as necessary . The details of the operation were collected with emphasis on complications and conversion rate . RESULTS During a 3-year period , 224 patients who were admitted with acute calculous cholecystitis entered the protocol . Fifty-four patients did not improve under medical treatment and percutaneous cholecystostomy was performed . In spite of adequate drainage , 5 patients still did not improve : 3 patients were successfully operated upon urgently and recovered , while 2 patients who had severe concomitant diseases and multi-organ failure , died . Forty-nine patients were discharged with the catheter and later re-evaluated for elective operation . In 7 patients common bile duct stones were found and were removed by ERCP prior to the elective operation . Twenty-five patients underwent delayed laparoscopic cholecystectomy with a low conversion rate ( 8 % ) , and only minor complications ( 16 % ) . CONCLUSIONS Conservative treatment and delayed operation is still an acceptable choice in the treatment of acute cholecystitis . Percutaneous cholecystostomy is an effective tool , with high success rate and low morbidity , and allows for better pre-operative evaluation of the biliary system and safe interval laparoscopic surgery . Laparoscopic cholecystectomy after drainage of the gall bladder is a low morbidity procedure with relatively low conversion rate BACKGROUND The aim of the present study was to compare the risk of observation versus that of cholecystectomy in acute cholecystitis in patients r and omly allocated to delayed operation or conservative treatment . METHODS One-hundred- and -eighty patients were considered for participation in the study ; 71 were excluded according to predefined criteria and 45 did not join for other reasons . The remaining 64 patients were r and omized to cholecystectomy ( n = 31 ) or observation ( n = 33 ) . R and omized patients were contacted regularly and followed up for a median of 67 months . All gallstone-related hospital contacts were registered in both r and omized and excluded patients . RESULTS Gallstone-related complications or emergency admissions for pain occurred in six patients in the operation group ( 19 % ; 95 % CI 5%-33 % ) and in 12 patients ( 36 % ; 9 % CI 20%-53 % ) in the observation group . Twenty-seven of 31 patients r and omized to cholecystectomy had a  cholecystectomy  at a median of 3.6 months after r and omization , and , of these , 3 ( 11 % ; 95 % CI 0%-23 % ) suffered a major and 7 ( 26 % ; 95 % CI 9%-42 % ) a minor complication . Ten patients r and omized to observation later had their gallbladders removed , 1 ( 10 % ; 95 % CI 0%-29 % ) patient had a major and 1 ( 10 % ; 95 % CI 0%-29 % ) a minor complication . We found no mortality after cholecystectomy . CONCLUSIONS We found a certain risk of subsequent gallstone-related events following conservative treatment of acute cholecystitis , but the data also show that cholecystectomy should not necessarily be compulsory after acute cholecystitis Abstract . The prospect ively collected data from 530 cholecystectomies performed in a university clinic from October 1989 to March 1991 were analyzed after 1 to 3 years of follow-up . The aim of this study was to compare the results of laparoscopic cholecystectomy ( LC ) for acute cholecystitis with that for routine symptomatic gallbladders . The preoperative , intraoperative , and postoperative parameters of 424 routine ( noninflamed ) LCs and 54 LCs for acutely inflamed gallbladders were compared under the “ intention to treat ” principle . Operating time was longer in the inflamed group ( median 97 minutes versus 75 minutes;p < 0.0001 ) . Significantly more adhesions ( 20 % versus 8 % ) , more blood loss ( 48 % versus 19 % ) , a higher incidence of bile spillage ( 28 % versus 12 % ) , and lost stones ( 19 % versus 8 % ) were encountered in patients with acute cholecystitis . Common bile duct ( CBD ) injuries were also more frequent in that group ( 5.5 % versus 0.2%;p = 0.005 ) . The rate of conversion to open surgery was higher than with routine LCs ( 13 % versus 4 % ) . There were two deaths in the routine LC group and none in the acutely inflamed group . There was no difference in postoperative pain intensity or postoperative fatigue according to visual analog scale measurements . Patients with acute cholecystitis stayed only 1 day longer ( median 4 days versus 3 days ) in hospital . The quality of life scores indicate return to almost normal values by the 14th postoperative day . Long-term follow-up ( 1–3 years ) did not reveal any delayed clinical adverse effects . In summary , LC for inflamed gallbladders has a higher conversion rate than LC for routine symptomatic gallbladders . If successfully performed , it has definite benefit for the patient in terms of better postoperative recovery . The trade-off is that the risk of CBD injury is significantly higher OBJECTIVE A prospect i ve r and omized study was undertaken to compare early with delayed laparoscopic cholecystectomy for acute cholecystitis . SUMMARY BACKGROUND DATA Laparoscopic cholecystectomy for acute cholecystitis is associated with high complication and conversion rates . It is not known whether there is a role for initial conservative treatment followed by interval elective operation . METHOD During a 26-month period , 99 patients with a clinical diagnosis of acute cholecystitis were r and omly assigned to  early laparoscopic cholecystectomy within 72 hours of admission  ( early group , n = 49 ) or delayed interval surgery after initial medical treatment ( delayed group , n = 50 ) . Thirteen patients ( four in the early group and nine in the delayed group ) were excluded because of refusal of operation ( n = 6 ) , misdiagnosis ( n = 5 ) , contraindication for surgery ( n = 1 ) , or loss to follow-up ( n = 1 ) . RESULTS Eight of 41 patients in the delayed group underwent urgent operation at a median of 63 hours ( range , 32 to 140 hours ) after admission because of spreading peritonitis ( n = 3 ) and persistent fever ( n = 5 ) . Although the delayed group required less frequent modifications in operative technique and a shorter operative time , there was a tendency toward a higher conversion rate ( 23 % vs. 11 % ; p = 0.174 ) and complication rate ( 29 % vs. 13 % ; p = 0.07 ) . For 38 patients with symptoms exceeding 72 hours before admission , the conversion rate remained high after delayed surgery ( 30 % vs. 17 % ; p = 0.454 ) . In addition , delayed laparoscopic cholecystectomy prolonged the total hospital stay ( 11 days vs. 6 days ; p < 0.001 ) and recuperation period ( 19 days vs. 12 days ; p < 0.001 ) . CONCLUSIONS Initial conservative treatment followed by delayed interval surgery can not reduce the morbidity and conversion rate of laparoscopic cholecystectomy for acute cholecystitis . Early operation within 72 hours of admission has both medical and socioeconomic benefits and is the preferred approach for patients managed by surgeons with adequate experience in laparoscopic cholecystectomy INTRODUCTION In our population biliary tract diseases are the most frequent surgical entity . If the diagnosis of acute cholecystitis is relatively clear and the time from onset of the disease does not exceed 72 hours , early cholecystectomy is recommended . The aim of this prospect i ve study was to use certain analytical procedures in order to compare early and late results of early and delayed cholecystectomy . MATERIAL AND METHODS 240 patients were divided into two groups : Group I : patients treated by early cholecystectomy and Group II : patients treated by delayed cholecystectomy .  We compared the following : intraoperative findings , postoperative morbidity and mortality , complications , average number of patient-days and histopathological changes . RESULTS During the investigated period ( 1998 - 1999 ) , 599 ( 35.95 % ) patients with acute and 1.067 ( 64.05 % ) patients with chronic cholecystitis were treated at the Clinic of Abdominal and Endocrine Surgery of the Clinical Center Novi Sad . Out of 599 patients with acute cholecystitis , 489 ( 81.63 % ) patients underwent surgery , whereas 110 ( 18.37 % ) were treated conservatively . In regard to chronic cholecystitis , 963 ( 90.25 % ) patients were surgically treated , and 104 ( 9.75 % ) patients were conservatively treated . All patients from Group I were operated within 24 - 48 hours from onset of the disease or during 24 hours of hospitalization . They were hospitalized due to signs of cholecystitis for the first time , whereas this was the second hospitalization for all patients from Group II , 42 + /- 2.3 days after first hospitalization on average . Regarding sick leave in Group I patients it was calculated as follows : hospital days + home treatment and it made 32 + /- 3.7 days . In Group II it was calculated as follows : first hospitalization + home treatment + second hospitalization + home treatment making 53 + /- 6.7 days . CONCLUSIONS The number and type of early and late complications in Group II patients justifies early cholecystectomy ; in acute cholecystitis , cholecystectomy should be performed within 24 - 48 hours from the onset of the disease ; in regard to late , early cholecystectomies are characterized by significantly shorter period of recovery and sick leave BACKGROUND The description and underst and ing of gallbladder stone disease in the medical literature are difficult because an assessment of the natural course of this symptomatic disease , with separation of patients in strictly defined groups , is generally lacking . METHOD A multicenter study was carried out with patients r and omized to either surgery or conservative , expectant treatment to examine optimal treatment and natural history in well-defined groups of symptomatic gallbladder stone disease with pain , episodes only ( study group 1 ) or acute cholecystitis ( study group 2 ) . The patients were between 18 and 80 years of age and had right upper quadrant or midline epigastric pain and ultrasonographic evidence of gallbladder stone , with or without acute cholecystitis . Medical treatment was ordinated on the basis of signs and symptom severity . Patients r and omized to surgery  were placed on the hospital 's waiting list and electively operated on with cholecystectomy as soon as conveniently possible . Preliminary results of follow-up are based on question naires mailed at regular intervals and consultations if required by the patients ' symptoms . Quality of life and freedom from pain are study end points for evaluation . RESULTS Five hundred and one patients were considered for the study , 318 patients ( 63.5 % ) belonging to group 1 and 183 ( 36.5 % ) to group 2 . One hundred and eighty-four patients ( 36.7 % ) were r and omized , 120 ( 24 % ) in group 1 and 64 ( 12.7 % ) in group 2 . Three hundred and seventeen patients ( 63.3 % ) , with an equal proportion from each study group , were excluded , the largest number of patients because of incapacitating pain or serious presenting symptoms ( 26 % ) . More women ( 81 % ) than men ( 19 % ) had pain alone ( group 1 ) , but the sex ratio was reduced , 56 % women and 44 % men , in patients with acute cholecystitis ( group 2 ) , with a highly significant difference ( P = < 0.001 ) between the two groups . A significant difference in patient withdrawal from r and omized treatment was registered , with 24 % from observation and 12 % from surgery ( P = 0.032 ) , but with an equal distribution in the two study groups . CONCLUSIONS A r and omized trial of this nature is feasible but extremely difficult to perform because of the heterogeneous nature of gallbladder stone disease , leading to exclusion of many patients and difficulties in measuring and evaluating outcome variables Treatment of acute cholecystitis is still under debate . The aim of this study was to evaluate the efficacy of early laparoscopic cholecystectomy ( ELC ) in comparison with conservative treatment followed by delayed laparoscopic cholecystectomy ( DLC ) in the management of acute cholecystitis . This prospect i ve comparative study involved two groups of patients presenting with acute cholecystitis within 72 hours of the onset of symptoms . ELC was performed in 82 consecutive patients , whereas DLC was performed in 87 patients who previously underwent medical treatment .  Surgical variables , hospital stay , and postoperative morbidity were evaluated in both groups . Time of surgery and conversion rate were lower in the ELC group . Postoperative morbidity was similar in both groups . Overall hospital stay was shorter in the ELC group . ELC within 72 hours of the onset of acute cholecystitis is a safe procedure with better results than DLC in terms of surgical timing , conversion rate , and hospital stay Abstract . This prospect i ve 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 st and ardized 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 Abstract Background . Cholecystectomy is routinely recommended to prevent recurrent disease after an initial episode of acute cholecystitis . Therefore , r and omized controlled trials have mainly focused on the timing of surgery , but many patients scheduled for cholecystectomy have deferred surgery with long periods of symptom-free intervals . Our present aim is to examine the long-term feasibility and safety of observation compared with surgery . Methods . Trial of 64 patients with acute cholecystitis previously r and omized to observation or cholecystectomy  , which examined outcome in terms of completed r and omized treatment and appearance of further symptoms and the need for surgical treatment .  Thirty-three patients were r and omized to observation and 31 patients to cholecystectomy .  Median follow-up was 14 years . Results . Of the 33 patients r and omized to observation , 11 ( 33 % ) experienced a new event of gallstone-related disease ( eight ( 24.2 % ) had acute cholecystitis ) and 11 ( 33 % ) were operated . No significant difference ( p = 0.565 ) was found between the two r and omized groups with regard to recurrent disease or complications . Virtually no surgery took place after 5 years of follow-up . The difference in completed r and omized treatment between the groups was not significant ( p = 0.077 ) . Long-term mortality was equal in those operated and in those observed . Conclusions . Twenty-four percent of the patients experienced recurrent cholecystitis , but escalation of disease severity or increased mortality was not observed . Long-term observation after acute cholecystitis was feasible in two-thirds of the patients as the risk for recurrent disease was negligible after 5 years Summary Between April and August 1991 , 83 Japanese patients with symptomatic gallstones underwent laparoscopic cholecystectomy in our clinics . A prospect i ve r and omized trial was carried out to examine the safety , efficacy , and complications of the two techniques , pneumoperitoneum vs an elevating method using a U-shaped retractor .  Forty-two patients were r and omly allocated to the pneumoperitoneum ( P ) group and 41 to the U-shaped retractor ( U ) group . These two groups were well matched with respect to age , sex , etiology , and the severity of the chronic cholecystitis .  Laparoscopic resection was successful for 88.1 % ( 37/42 ) in the P group and 100 % ( 41/41 ) in the U group . In patients with a severe fibrotic gallbladder , the rate of success was significantly higher ( P<0.05 ) in the U group ( 100 % , 6/6 ) than in the P group ( 11.8 % , 1/6 ) . In the moderately inflamed group , the operation time ( mean±SD ) was significantly ( P<0.01 ) less in the U group ( 58.7±22.7 ) than in theP group ( 87.3±18.3 ) . With the U-shaped retractor the usual surgical instruments can be used , and a rapid and safer laparoscopic cholecystectomy can be carried out . We prefer this approach to a pneumoperitoneum for patients with an inflamed gallbladder as hospital stay and pain are minimal Background : The role of laparoscopic cholecystectomy for acute cholecystitis is not yet clearly established . The aim of this prospect i ve r and omized study was to evaluate the safety and feasibility of laparoscopic cholecystectomy for acute cholecystitis and to compare the results with delayed cholecystectomy . Methods : Between January 2001 and November 2002 , 40 patients with a diagnosis of acute cholecystitis were assigned r and omly to early laparoscopic cholecystectomy within 24 h of admission ( early group , n = 20 ) or to initial conservative treatment followed by delayed laparoscopic cholecystectomy , 6 to 12 weeks later ( delayed group , n = 20 ) . Results : There was no significant difference in the conversion rates ( early , 25 % vs delayed , 25 % ) , operating times ( early , 104 min vs delayed , 93 min ) , postoperative analgesia requirements ( early , 5.3 days vs delayed , 4.8 days ) , or postoperative complications ( early , 15 % vs delayed , 20 % ) . However , the early group had significantly more blood loss ( 228 vs 114 ml ) and shorter hospital stay ( 4.1 vs 10.1 days ) . Conclusions : Early laparoscopic cholecystectomy for acute cholecystitis is safe and feasible , offering the additional benefit of a shorter hospital stay . It should be offered to patients with acute cholecystitis , provided the surgery is performed within 72 to 96 h of the onset of symptoms Background : The aim of this prospect i ve , r and omized study was to determine if health related quality of life is affected by the choice of surgical strategy in the management of acute cholecystitis . Material and Methods : After diagnostic workup , patients were r and omized to one of two groups : ( 1 ) early laparoscopic cholecystectomy  ( i.e. within 7 days after onset of symptoms ) or ( 2 ) initial conservative treatment followed by delayed laparoscopic cholecystectomy .  Seventy-four patients entered the early operation group and 71 patients were assigned to the delayed  operation  strategy . Assessment s of quality of life were made at 1 , 3 and 6 months after surgery , and in the delayed operation group also one month after the initial conservative treatment . Results : The gastrointestinal symptom scores were significantly better in three dimensions ( diarrhea , indigestion , abdominal pain ) one month after surgery for the acute operation group ( p < 0.01 ) . Three and 6 months after the operation we were unable to detect any significant differences between the groups . The patients in the delayed operation group did not appear to suffer from more symptoms in the period of time waiting for their elective operation . Psychological general well-being showed no major differences between the groups . Conclusion : Cholecystectomy in the acute phase of acute cholecystitis offers a significant reduction of gastrointestinal symptoms during the first postoperative month and to that associated improved quality of life in this group of patients Background The aim if this study was to compare percutaneous drainage ( PD ) of the gallbladder to emergency cholecystectomy ( EC ) in a well-defined patient group with sepsis related to acute calculous/acalculous cholecystitis ( ACC/AAC ) . Methods Between 2001 and 2007 , all consecutive patients of our ICU treated by either PD or EC were retrospectively analyzed . Cases were collected from a prospect i ve data base . Percutaneous drainage was performed by a transhepatic route and EC by open or laparoscopic approach . Patients ’ general condition and organ dysfunction were assessed by two vali date d scoring systems ( SAPS II and SOFA , respectively ) . Morbidity , mortality , and long-term outcome were systematic ally review ed and analyzed in both groups . Results Forty-two patients [ median age = 65.5 years ( range = 32–94 ) ] were included ; 45 % underwent EC  ( ten laparoscopic , nine open ) and 55 % PD ( n = 23 ) . Both patient groups had similar preoperative characteristics .  Percutaneous drainage and EC  were successful in 91 and 100 % of patients , respectively . Organ dysfunctions were similarly improved by the third postoperative/postdrainage days . Despite undergoing PD , two patients required EC due to gangrenous cholecystitis . The conversion rate after laparoscopy was 20 % . Overall morbidity was 8.7 % after PD and 47 % after EC ( P = 0.011 ) . Major morbidity was 0 % after PD and 21 % after EC ( P = 0.034 ) . The mortality rate was not different ( 13 % after PD and 16 % after EC , P = 1.0 ) and the deaths were all related to the patients ’ preexisting disease . Hospital and ICU stays were not different . Recurrent symptoms ( 17 % ) occurred only after ACC in the PD group . Conclusions In high-risk patients , PD and EC are both efficient in the resolution of acute cholecystitis sepsis . However , EC is associated with a higher procedure-related morbidity and the laparoscopic approach is not always possible . Percutaneous drainage represents a valuable intervention , but secondary cholecystectomy is m and atory in cases of acute calculous cholecystitis Abstract . Bile duct injury ( BDI ) during  laparoscopic cholecystectomy ( LC )  which may result in patient disability or death are reported to occur more frequently when compared to open surgery . The aim of this nationwide prospect i ve study beyond the laparoscopic learning curve was to analyze the incidence , risk factors , and management of major BDI . During a 3-year period ( 1995–1997 ) 130 items of all LC data were collected on a central computer system from 84 surgical institutions in Switzerl and by the Swiss Association of Laparoscopic and Thoracoscopic Surgery and evaluated for major BDIs . Simple biliary leakage was excluded from analysis . There were 12,111 patients with a mean age of 55 years ( 3–98 years ) enrolled in the study .  The overall BDI incidence was 0.3 % , 0.18 % for symptomatic gallstones , and 0.36 % for acute cholecystitis . In cases of severe chronic cholecystitis with shrunken gallbladder , the incidence was as high as 3 % . Morbidity and mortality rates were significantly increased in BDIs . BDI was recognized intraoperatively in 80.6 % , in 64 % of cases by help of intraoperative cholangiography . Immediate surgical repair was performed laparoscopically ( suture or T-drainage ) in 21 % ; in 79 % , open repair ( 34 % simple suture , 66 % Roux-en-Y reconstruction ) was needed . The BDI incidence did not decrease during the last 7 years . In 47 % , BDIs were caused by experienced laparoscopic surgeons , perhaps because they tend to operate on more difficult patients . In conclusion , the incidence of major BDIs remains constant in Switzerl and at a level of 0.3 % , which is still higher when compared to open surgery . However , most cases are now detected intraoperatively and immediately repaired which ensures a good long-term outcome . For preventing such injuries , exact anatomical knowledge with its variants and a meticulous surgical dissecting technique especially in case of acute inflammation or shrunken gallbladder are m and atory Whether ursodeoxycholic acid ( UDCA ) therapy alters the long-term clinical course of gallstones ( GS ) without stone dissolution remains unknown . We aim ed to clarify the relationship between long-term UDCA therapy and risks of biliary pain or acute cholecystitis in GS patients . We also aim ed to identify factors affecting the natural course , and to explore a simple patient selection criteria for UDCA therapy . A cohort of 527 uncomplicated GS patients with or without UDCA ( 600 mg/d ) followed for up to 18 years was analyzed . Patients who had frequent attacks or were complicated with cholecystitis were converted to cholecystectomy . History and UDCA therapy were identified on Cox analysis as 2 factors affecting the long-term clinical course . In patients without therapy , history was the only predictor of biliary pain among various patient or stone characteristics ; biliary pain was rare in asymptomatic patients , while frequent in symptomatic patients ( P < .001 ) . UDCA therapy was associated with reduced risk for biliary pain in both symptomatic ( 62 % vs. 92 % in untreated patients at 10 years ; P < .001 ; relative risk , 0.19 ; 95 % CI , 0.10 - 0.34 ) and asymptomatic patients ( 6 % vs. 12 % in untreated patients at 10 years ; P = .037 ; relative risk , 0.19 ; 95 % CI , 0.04 - 0.91 ) . Risk for the conversion was also reduced in UDCA-treated symptomatic patients ( 26 % vs. 88 % in untreated patients at 10 years , P < .001 ; relative risk , 0.08 ; 95 % CI , 0.03 - 0.22 ) . These effects were independent of stone dissolution . Three factors were identified on Cox analysis as affecting GS dissolution : radiolucency , small size ( < 10 mm ) of stones , and visualized gallbladder ( GB ) on cholecystogram . A selection criteria based on these appears to exhibit high sensitivity ( 74 % ) and specificity ( 95 % ) for dissolution . UDCA therapy might be considered in symptomatic patients fulfilling these criteria , and also in patients who have significant surgical risk , because the longterm therapy is clearly associated with reduced risk of biliary pain and acute cholecystitis The authors report their own experience about 156 cases of acute cholecystitis observed between January 1991 and October 1992 . The most part of the patients were between 30 and 65 years old ( 84 cases observed ) . In 27 cases , for the positive evolution of the pathology , it was put on practice a non operative treatment . The other 129 cases were treated surgically . The patients with lithiasic cholecystitis were 148 ; those affected by non lithiasic cholecystitis were 5 ; and 3 of them presented an acute cholecystitis as a manifestation of a carcinoma . Between the various diagnostic methods , the echography , executed in emergency , is considered as an indispensable one , for having changed completely the diagnostic approach . It is discussed , particularly , the timing of surgery , an aspect able to influence considerably the therapeutic iter and its results . There are analysed the criteria for whom some authors are favourable to a medical treatment of the acute cholecystitis , postponing the operation , while other of them are favourable to an early surgical treatment . The authors ' casuistry put in evidence 110 operations effectuated in emergency ( < 12 hours ) , 19 operations after an 12 - 72 hours interval , no operations at a long distance ( 1 - 10 months ) . The results are to be considered satisfactory : 1 deceased ( on 129 operated cases , 0.78 % ) ; 10 immediate complications ( 7.75 % ) : 8 suppurations of the wound , 1 biliar fistula and 1 internal hemorrhage after video-laparoscopic operation ; 2 late complications ( 1.55 % ) : they were relapsing gallstones . The aim of this work is to offer a contribution to codification of the treatment of the acute cholecystitis , on the ground of the acquired experience The aim of this prospect i ve , r and omized study was to determine whether laparoscopic cholecystectomy should be performed as an early or a delayed operation in patients with acute cholecystitis . After diagnostic workup , patients were r and omized to one of two groups : ( 1 ) early laparoscopic cholecystectomy  ( i.e. , within 7 days after onset of symptoms ) or ( 2 ) initial conservative treatment followed by delayed laparoscopic cholecystectomy 6 to 8 weeks later .  Seventy-four patients were placed in the early-operation group , and 71 patients were assigned to the delayed-operation strategy . There was no significant difference in conversion rates ( early 31 % vs. delayed 29 % ) , operating times ( early 98 [ range 30 to 355 ] minutes vs. delayed 100 [ 45 to 280 ] minutes ) , or complications . Failure with the conservative treatment strategy was noted in 26 % of these patients . The total hospital stay was significantly shorter in the early group ( 5 [ range 3 to 63 ] days ) vs. the delayed group ( 8 [ range 4 to 50 ] days ; P < 0.05 ) . Despite a high conversion rate , early laparoscopic cholecystectomy offered significant advantages in the management of acute cholecystitis compared to a conservative strategy . The greatest advantage was a reduced total hospital stay Background Laparoscopic cholecystectomy in acute calculous cholecystitis in high risk patients can lead to significant morbidity and mortality .  Percutaneous cholecystostomy may be an alternative treatment option but the current literature does not provide the surgical community with evidence based advice . Methods / Design The CHOCOLATE trial is a r and omised controlled , parallel-group , superiority multicenter trial . High risk patients , defined as APACHE-II score 7 - 14 , with acute calculous cholecystitis will be r and omised to  laparoscopic cholecystectomy or percutaneous cholecystostomy . During a two year period 284 patients will be enrolled from 30 high volume teaching hospitals . The primary endpoint is a composite endpoint of major complications within three months following r and omization and need for re-intervention and mortality during the follow-up period of one year . Secondary endpoints include all other complications , duration of hospital admission , difficulty of procedures and total costs . Discussion The CHOCOLATE trial is design ed to provide the surgical community with an evidence based guideline in the treatment of acute calculous cholecystitis in high risk patients .Trial Registration Netherl and s Trial Register ( NTR ) : Background . The role of early laparoscopic cholecystectomy for acute cholecystitis with cholelithiasis is not yet established . The aim of our prospect i ve r and omized study was to evaluate the safety and feasibility of early LC for acute cholecystitis and to compare the results with delayed LC . Methods . Between March 2007 to December 2008 , 50 patients with diagnosis of acute cholecystitis were assigned r and omly to early group , n = 25 ( LC within 24 hrs of admission ) , and delayed group , n = 25 ( initial conservative treatment followed by delayed LC , 6–8 weeks later ) . Results . We found in our study that the conversion rate in early LC and delayed LC was 16 % and 8 % , respectively , Operation time for early LC was 69.4 min versus 66.4 min for delayed LC  , postoperative complications for early LC were 24 % versus 8 % for delayed LC  , and blood loss was 159.6 mL early group versus 146.8 mL for delayed group . However early LC had significantly shorter hospital stay ( 4.1 days versus 8.6 days ) . Conclusions . Early LC for acute cholecystitis with cholelithiasis is safe and feasible , offering the additional benefit of shorter hospital stay . It should be offered to the patients with acute cholecystitis , provided that the surgery is performed within 96 hrs of acute symptoms by an experienced surgeon Data from the Third National Health and Nutrition Examination Survey ( 1 ) indicate that 11 % of U.S. women have a history of clinical gallbladder diseasethat is , either previous cholecystectomy or self-reported history of gallstones . Factors associated with gallbladder disease , at least in some studies , include older age , female sex , white ethnicity/race , obesity , rapid weight loss , and , among women , greater parity , use of oral estrogencontaining contraceptives , and postmenopausal estrogen therapy ( 2 ) . These associations , in general , have been based on observational data and may partly reflect the effects of ascertainment and recall bias , as well as confounding . While some observational studies suggest that estrogens increase the risk for gallbladder disease by as much as twofold to fourfold ( 3 ) , such an association has not been reported consistently ( 2 , 3 ) . The effect of combined estrogen plus progestin therapy has been less well studied , and no recent clinical trial data exist on the relation of such therapy to the risk for biliary tract surgery among postmenopausal women . To determine whether estrogen plus progestin therapy is associated with the risk for biliary tract surgery among postmenopausal women , we analyzed data from the Heart and Estrogen/progestin Replacement Study ( HERS ) , the first large r and omized , double-blind trial of estrogen plus progestin therapy for the secondary prevention of coronary heart disease ( 4 ) . Gallbladder disease events , including biliary tract surgery , were among several prespecified secondary outcomes of interest . Methods Participants Between 1 February 1993 and 1 October 1994 , 2763 postmenopausal women with coronary artery disease were recruited from 20 clinical centers across the United States for participation in HERS , a r and omized , double-blind study of the effect of combined , continuous estrogenprogestin therapy ( conjugated equine estrogens , 0.625 mg/d , and medroxyprogesterone acetate , 2.5 mg/d ) on recurrent coronary heart disease events . Baseline data , which were collected at the visits for initial screening and r and om allocation , included demographic characteristics , medical history , risk factors for coronary heart disease , physical examination , and laboratory data . Women were not eligible to enroll in HERS if they had used any estrogen or female hormones within the previous 3 months , including pills , suppositories , injections , vaginal creams , or transdermal patches . We excluded 510 women from these analyses who reported at enrollment a history of surgical gallbladder removal . We did include , however , 123 women with a self-reported history of gallstones who had not undergone cholecystectomy . After these exclusions , data from 2253 participants were available for analysis . Measurements Baseline data included participant age , years of education , number of pregnancies , ethnicity/race ( white , African American , or other ) , past use of postmenopausal estrogen therapy , history of cigarette smoking , history of alcohol consumption , and diabetes mellitus . Data were also obtained on use of lipid-lowering medications and antihypertensive medications , including thiazide diuretics .  Participants who stated that they had smoked at least 100 cigarettes in their life were considered to have a history of smoking . Participants were asked , Has a doctor told you that you had diabetes , sugar diabetes , or high blood sugar ? Those who answered yes were classified as having a history of diabetes . Women with a history of gestational diabetes only were classified as not having diabetes mellitus . Participants were weighed without shoes or outdoor clothing on a st and ard balance-beam scale to the nearest 0.1 kg . Height was measured to the nearest 0.1 cm by using the height rod of a st and ard beam scale or , where available , a wall-mounted stadiometer . We calculated the body mass index as weight (kg)/height ( m2 ) . At baseline , year 1 , and the end of the study , serum lipid and lipoprotein levels were obtained from all participants and were measured at the Johns Hopkins Lipoprotein Analytical Laboratory , Baltimore , Maryl and , which is certified by the U.S. Centers for Disease Control and Prevention for the measurement of serum lipids and lipoproteins . Ascertainment of End Points Participants were determined to have incident gallbladder disease by physician adjudicators who were blinded to the r and omization status [ active hormone treatment or placebo ] . Symptomatic nonsurgical biliary tract disease was defined as a hospital admission for acute cholecystitis , choledocholithiasis , or gallstone pancreatitis and was established on the basis of 1 ) reported symptoms in combination with elevated levels on liver function testing and gallstones with dilated biliary ducts on abdominal ultrasonography or 2 ) nuclear medicine scan diagnostic of acute gallbladder disease . Incident biliary tract surgery , which included  cholecystectomy , sphincterotomy , or bile duct exploration  , was established by review of operative reports and discharge summaries . All biliary tract surgeries were cholecystectomies with the exception of 12 sphincterotomies and 2 stent insertions . Nonsurgical and surgical gallbladder disease events were considered separate end points and are mutually exclusive . The main HERS results , reported in 1998 ( 4 ) , were based on the near-final data available at that time . We present the up date d and final results for incident biliary tract events ( 5 ) . Statistical Analysis We used unpaired two-tailed t-tests to compare the age , level of education , number of pregnancies , body mass index , alcohol consumption , serum lipid level , and lipoprotein levels of the women r and omly assigned to receive postmenopausal hormone therapy or placebo .  Using chi-square tests , we compared the hormone therapy and placebo groups according to ethnicity/race , history of lipid-lowering medication use , pre study postmenopausal estrogen use , thiazide diuretic use , cigarette smoking , ascorbic acid supplement use , history of gallbladder disease , and diabetes mellitus . The treatment groups were divided fairly equally with respect to baseline variables , except for statin use . To analyze the association between postmenopausal hormone therapy and incident gallbladder disease events , we used unadjusted and statin useadjusted proportional hazards models . All risk estimates were derived solely from proportional hazards models . We also estimated KaplanMeier curves for time to occurrence of biliary tract surgery , according to treatment assignment . The number of participants needed to be treated for a new case of biliary tract surgery to occur was calculated by using the incidence rates per person-year of observation . For predictor variables other than treatment assignment , we calculated the hazard ratio and 95 % CI by using proportional hazards regression models to estimate the risk for incident biliary tract surgery . We used simple regression models that controlled only for treatment assignment ; we also used multivariable regression models that included variables with a previously reported association with gallbladder disease . Our model-fitting methods relied primarily on biological criteria ; we began by including factors previously reported to be associated with gallbladder disease . Although the risk for type I errors is always present when c and i date predictors are many relative to the number of outcomes , our model-building process accounted for this possibility when we considered the statistical significance of the result ing multivariable model . Results were confirmed by using stepwise and backwards selection methods . We identified one statistically significant interaction between postmenopausal hormone treatment and smoking . Adjustment for this interaction did not substantially affect the hazard ratios for other variables entered in the multivariable models . We performed these analyses by using SAS software ( 6 ) . A correlation between outcomes at each clinical center could potentially affect the SEs for the relative hazard estimates . Therefore , to control for such potential clustering by center , we used STATA software ( 7 ) to generate robust SEs for the proportional hazards models ( 8) . Because site-specific practice patterns could confound the relation of statin use to biliary tract surgery , we also examined statistical models that included clinical center as a fixed effect . We calculated the number of participants needed to be treated to result in one additional biliary tract surgery  by using the reciprocal of the absolute risk increase . However , because the 95 % CI for the absolute risk increase included zero , the CI for the number needed to treat for harm ( NNTH ) included . We use a method described by Altman ( 9 ) to present the CI in these circumstances . The CI around the NNTH will therefore range from an NNTH to to a number needed to treat for benefit ( NNTB ) . Role of the Funding Source Wyeth-Ayerst Research funded HERS . The study was design ed and carried out by the HERS investigators , including scientists from Wyeth-Ayerst Research . Investigators at the HERS Coordinating Center at the University of California , San Francisco , collected the outcome data , supervised the adjudication of outcome events , and analyzed the data . Results Gallbladder disease was particularly prevalent among this cohort of postmenopausal women with coronary artery disease . Twenty-three percent of women reported a history of cholelithiasis or cholecystectomy at baseline ( 10 ) . With the exception of statin use , which was more prevalent among women assigned to receive placebo ( P = 0.01 ) , the distribution of baseline variables was similar in both treatment groups ( Table 1 ) . Approximately 23 % of the HERS participants had a history of pre-enrollment hormone use ; the type and duration did not differ between the treatment groups . Table 1 . Selected Baseline Characteristics of Postmenopausal Women Receiving Hormone Therapy or Placebo  in the Heart and Estrogen/progestin Replacement Study ( HERS ) A The incidence of surgical infections  after laparoscopic cholecystectomy is reported to be < 2 % , because of the minimal trauma due to this approach . We report the results of a prospect i ve study of antibiotic prophylaxis in laparoscopic cholecystectomy , comparing ceftriaxone vs ceftazidime .  From Jan 1 to Dec 31 2002 a consecutive series of 242 cholecystectomies were performed , consisting in 18 open cholecystectomies and 224 laparoscopic cholecystectomies , 7 of which ( 3.1 % ) were converted to open cholecystectomies for technical and /or anatomical reasons . One hundred and eleven patients received 1 g i.v . ceftazidime 1 h before surgery , and 105 patients 1 g i.v . ceftriaxone on an alternate basis . Thirty-nine patients ( 17.4 % ) with acute cholecystitis received at least one booster dose at the end of the operation ; 30 out of 39 were given further therapy for 2 - 3 days , i.e. 1 g i.v . bid . Twenty-two patients treated elsewhere with ceftriaxone or ceftazidime before surgery were transferred to another prophylactic regimen . The final diagnosis in the laparoscopic cholecystectomy group was 219 bile stones , 3 adenomas , and 2 occult carcinomas .  We had 4 complications ( 1.8 % of 217 laparoscopic cholecystectomies ) , 2 of which were minor ( infection of the umbilical access by S. aureus ) and 2 major ( 1 biliary fistula [ accessory duct ] and 1 acute pancreatitis ) , both treated conservatively . Positive bile cultures ( 27 cases ) were unrelated to the clinical course . The incidence of infections after laparoscopic cholecystectomy in our prospect i ve series was < 2 % . Ceftriaxone is confirmed as the gold st and ard in biliary tract surgery , but ceftazidime was equivalent ( no statistical difference between the two antibiotics , P=0.59 NS ) . Ultra-short prophylaxis is enough in most cases , except in cholecystitis . We found no correlation between positive bile cultures and surgical infections after laparoscopic cholecystectomy . The umbilicus was the preferred site of infection in obese patients after the laparoscopic procedure . Major complications are usually related to technical pitfalls
Discussion Conservative treatment of acute calculous cholecystitis during index admission seems feasible and safe , especially in patients with mild disease .
Background In medical practice , the tendency to remove an inflamed gallbladder is deeply rooted .
Cholecystectomy , however , is associated with relatively high complication rates , and therefore the decision whether or not to perform surgery should be well considered .
For some patients , the surgical risk – benefit profile may favour conservative treatment .
The objective of this study was to examine the short- and long-term outcome of conservative treatment of patients with acute calculous cholecystitis .