Systematic review of cholecystostomy as a treatment option in acute cholecystitis. Conservative treatment versus endoscopic sphincterotomy in the initial management of acute cholecystitis in elderly patients at high surgical risk. Management of acute cholecystitis in the laparoscopic era: Results of a prospective, randomized clinical trial Early minilaparoscopic cholecystectomy in patients with acute cholecystitis. Acute cholecystitis in high surgical risk patients: percutaneous cholecystostomy or emergency cholecystectomy? A retrospective comparison of older and younger adults undergoing early laparoscopic cholecystectomy for mild to moderate calculous cholecystitis. Prospective Evaluation of Emergency Versus Delayed Laparoscopic Cholecystectomy for Early Cholecystitis Routine early laparoscopic cholecystectomy for acute cholecystitis after conclusion of a randomized controlled trial Percutaneous Drainage versus Emergency Cholecystectomy for the Treatment of Acute Cholecystitis in Critically Ill Patients: Does it Matter? [Acute cholecystitis--early or delayed cholecystectomy]. Impact of Choice of Therapeutic Strategy for Acute Cholecystitis on Patient’s Health-Related Quality of Life Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a prospective randomized trial Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Laparoscopic Versus Open Cholecystectomy: A Prospective Comparative Study in the Elderly With Acute Cholecystitis Evidence‐based management of pain after laparoscopic cholecystectomy: a PROSPECT review update Prospective evaluation of patients with acute cholecystitis treated with percutaneous cholecystostomy and interval laparoscopic cholecystectomy. 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 Evaluation of Early versus Delayed Laparoscopic Cholecystectomy in Acute Cholecystitis Fast‐track surgery: the next revolution in surgical care following laparoscopy The HAC trial (harmonic for acute cholecystitis): a randomized, double-blind, controlled trial comparing the use of harmonic scalpel to monopolar diathermy for laparoscopic cholecystectomy in cases of acute cholecystitis Acute cholecystitis: delayed surgery or observation. A randomized clinical trial. Laparoscopic single site (LESS) and classic video-laparoscopic cholecystectomy in the elderly: A single centre experience. The Effectiveness of Psychosocial Interventions as Adjuncts to Orthopaedic Surgery: A Systematic Review Protocol
OBJECTIVES Percutaneous cholecystostomy ( PC ) is an established low-mortality treatment option for elderly and critically ill patients with acute cholecystitis . The primary aim of this review is to find out if there is any evidence in the literature to recommend PC rather than cholecystectomy for acute cholecystitis in the elderly population . METHODS In April 2007 , a systematic electronic data base search was performed on the subject of PC and cholecystectomy in the elderly population . After exclusions , 53 studies remained , comprising 1918 patients . Three papers described r and omized controlled trials ( RCTs ) , but none compared the outcomes of PC and cholecystectomy . A total of 19 papers on  mortality after cholecystectomy  in patients aged > 65 years were identified . RESULTS Successful intervention was seen in 85.6 % of patients with acute cholecystitis . A total of 40 % of patients treated with PC were later cholecystectomized , with a mortality rate of 1.96 % . Procedure mortality was 0.36 % , but 30-day mortality rates were 15.4 % in patients treated with PC and 4.5 % in those treated with acute cholecystectomy ( P < 0.001 ) . CONCLUSIONS There are no controlled studies evaluating the outcome of PC vs. cholecystectomy and the papers review ed are of evidence grade C. It is not possible to make definitive recommendations regarding treatment by PC or cholecystectomy in elderly or critically ill patients with acute cholecystitis . Low mortality rates after cholecystectomy in elderly patients with acute cholecystitis have been reported in recent years and therefore we believe it is time to launch an RCT to address this issue 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 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 Recently , techniques using fine-caliber instruments ( 2 or 3 mm in diameter ) for laparoscopic cholecystectomy , called minilaparoscopic cholecystectomy ( MLC ) , were reported to be superior to conventional LC ( CLC , using 5 mm instruments ) in postoperative course and cosmetic outcome . However , the use of MLC to date has been largely restricted to uncomplicated situations . Since CLC has been proved to be a safe and efficient technique for acute cholecystitis especially if conducted early , this study tests the feasibility and safety of MLC for acute cholecystitis . METHODS Sixty-nine consecutive patients with acute cholecystitis were prospect ively r and omized to  minilaparoscopic  ( n = 38 ) or conventional laparoscopic  ( n = 31 )  cholecystectomy  , and the operations were conducted within 2 days of admission whenever possible . Despite different operative techniques , both groups of patients received identical preoperative preparation , evaluation and postoperative care . The two groups were compared for patient characteristics , results of laboratory tests , predictive score for LC difficulties , operative time , operative complications , hospitalization days and need for meperidine injection for wound pain . RESULTS The conversion rate was 7.9 % ( 3 of 38 ) for the MLC group and 6.5 % ( 2 of 31 ) for the CLC group . Nine patients in the  MLC group and 7 in the CLC group had concomitant choledocholithiasis and underwent endoscopic stone retrieval  before operation . The age , sex , predictive score for LC difficulties , preoperative leukocyte count , length of hospital stay and requirement of intramuscular meperidine injections were similar for both groups of patients , while , the operative times were marginally longer in the MLC group ( 113.8 + /- 30.8 versus 98.2 + /- 33.2 minutes , P = 0.056 ) . No major complications occurred in either group . CONCLUSIONS The results of cholecystectomy for acute cholecystitis by MLC are as good as those of CLC if the operation is performed early , with obvious smaller incisions and minimal complications . MLC is a safe and effective procedure for patients with acute cholecystitis , and has an acceptable low conversion rate BACKGROUND Percutaneous cholecystostomy ( PC ) is an alternative treatment in  acute cholecystitis ( AC ) in high-risk or elderly patients although its advantage over emergency cholecystectomy has not yet been established . STUDY DESIGN AC prospect i ve data base analysis in high-risk patients treated by PC ( group 1 , 29 patients ) or emergency cholecystectomy ( group 2 , 32 patients ) . Surgical risk was estimated by physiological POSSUM , Charlson , Apache II , and American Society of Anesthesiologists ( ASA ) scores . RESULTS The groups showed homogeneity concerning age and surgical risk . PC allowed AC resolution in 19 patients ( 70.4 % ) , but 8 ( 29.6 % ) needed emergency cholecystectomy .  Morbidity and mortality rates were 31 % and 17.2 % , respectively . Mortality was significantly associated with ASA IV ( P = .01 ) . In group 2 , the morbidity rate was 28.1 % without mortality . There was no statistical difference in morbidity ( P = .6 ) although mortality was significantly higher in group 1 ( P = .02 ) . CONCLUSIONS PC seems of little benefit and ought to be left for those very old patients with surgical contraindication OBJECTIVES To compare the demographic characteristics and intra- and postoperative outcomes in elderly adults ( ≥75 ) with those of younger adults undergoing early ( < 5 days after onset of complaints ) cholecystectomy .  DESIGN Retrospective analysis from May 2010 to August 2012 . SETTING R and omized , multicenter , clinical trial ( ABCAL Study , NCT01015417 ) . PARTICIPANTS Individuals with mild or moderate acute calculous cholecystitis ( ACC ) according to the Tokyo Guidelines ( N=414 ; n=78 aged 75 - 94 , median 82 ; n=336 aged 18 - 74 , median 49 ) . MEASUREMENTS Demographic characteristics and pre- , intra- , and postoperative data . RESULTS The elderly group was more likely to have an American Society of Anesthesiologists score of 3 or greater ( 62 % vs 23 % , P<.001 ) , higher serum creatinine ( 103 vs 74 μmol/L , P<.001 ) , and more-severe ACC ( moderate ACC ( 62 % vs 50 % , P=.05 ) , gangrenous cholecystitis ( 38 % vs 15 % , P=.001 ) ) on preoperative imaging and confirmed intraoperatively . Ulcerated mucosa ( 76 % vs 61 % , P=.001 ) was significantly more frequent in the elderly group . Operative time , postoperative mortality , and postoperative infectious ( 18 % vs 14 % , P=.35 ) and noninfectious ( 9 % vs 3 % , P=.80 ) complications were similar between the two groups . Median length of stay ( 7.0 vs 5.0 days , P=.54 ) and readmission rate ( 15 % vs 4 % , P=.07 ) were not significantly higher in the elderly group . No significant difference was observed for the subgroup of participants aged 80 and older . CONCLUSION In this r and omized trial that included a selected sample of older adults , there was no difference in major outcomes between elderly adults and their younger counterparts after early cholecystectomy . The findings are limited because important geriatric outcomes such as delirium and functional decline were not examined 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 The aim of this retrospective review was to assess the clinical outcomes of  laparoscopic cholecystectomy  for acute cholecystitis since the conclusion of a r and omized controlled trial in 1997 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 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 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 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 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 The aim of this prospect i ve comparative study was to determine the feasibility and the efficacy of laparoscopic cholecystectomy for acute cholecystitis in patients older than 75 years of age and to compare the results with those of open cholecystectomy . From January 1992 to December 1999 , 139 patients older than 75 years of age underwent cholecystectomy for acute cholecystitis . The two groups of patients with cholecystolithiasis included 50 patients who underwent laparoscopic cholecystectomy ( group 1 ) and 89 patients who underwent open cholecystectomy ( group 2 ) . Group 1 consisted of 30 women and 20 men , with a mean age of 81.9 years ( range , 75–98 ) . Group 2 consisted of 51 women and 38 men , with a mean age of 81.9 years ( range , 75–93 ) . There was no difference in the American Society of Anesthesiologists classification in both groups . The length of the surgery ( 103.3 vs. 149.7 minutes ) , postoperative length of stay ( 7.7 vs. 12.7 days ) , and inpatient rehabilitation ( 15 vs. 42 patients ) were significantly shorter in group 1 than in group 2 . The postoperative morbidity rate was not different between the groups . There was no mortality in group 1 , but four patients died in group 2 ( P = 0.29 ) . The conversion rate was 32 % ( n = 16 ) in group 1 . In summary , laparoscopic cholecystectomy  in elderly patients with acute cholecystitis  is safe and effective .  Laparoscopic cholecystectomy in elderly patients restores them to the best possible quality of life with the lowest cost to them physiologically Background : Significant pain can be experienced after laparoscopic cholecystectomy . This systematic review aims to formulate PROSPECT ( PROcedure SPECific Postoperative Pain ManagemenT ) recommendations to reduce postoperative pain after laparoscopic cholecystectomy . Methods : R and omised controlled trials published in the English language from January 2006 ( date of last PROSPECT review ) to December 2017 , assessing analgesic , anaesthetic , or operative interventions for laparoscopic cholecystectomy in adults , and reporting pain scores , were retrieved from MEDLINE and Cochrane data bases using PRISMA ( Preferred Reporting Items for Systematic Review s and Meta‐Analyses ) search protocol s. PROSPECT methodology was used , and recommendations were formulated after review and discussion by the PROSPECT group ( an international group of leading pain specialists and surgeons ) . Results : Of 1988 r and omised controlled trials identified , 258 met the inclusion criteria and were included in this review . The studies were of mixed method ological quality , and quantitative analysis was not performed because of heterogeneous study design and how outcomes were reported . Conclusions : We recommend basic analgesic techniques : paracetamol + NSAID or cyclooxygenase‐2 specific inhibitor + surgical site local anaesthetic infiltration . Paracetamol and NSAID should be started before or during operation with dexamethasone ( GRADE A ) . Opioid should be reserved for rescue analgesia only ( GRADE B ) . Gabapentanoids , intraperitoneal local anaesthetic  , and  transversus abdominis plane blocks  are not recommended ( GRADE D ) unless basic analgesia is not possible . Surgically , we recommend low‐pressure pneumoperitoneum , postprocedure saline lavage , and aspiration of pneumoperitoneum ( GRADE A ) . Single‐port incision techniques are not recommended to reduce pain ( GRADE A ) 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 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 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 Fast-track surgery , also named enhanced recovery after surgery ( ERAS ) , is in my opinion the most important innovation after the advent of laparoscopy ( in the 1990s ) in the field of  colorectal surgery  ( as in other fields of surgery ) . It is defined as a multimodal pathway aim ing to reduce surgical stress by using pain-free procedures with less organ dysfunction , less morbidity and better recovery . ERAS has been popularized by Henrik Kehlet and his team since the early 2000s [ 1 ] and has rapidly gained popularity around the world because of its remarkable benefits and safety . The concept of ERAS is to make use of the improvement of anaesthetic and analgesic techniques , the development of minimally invasive surgery and evidence -based perioperative care . It involves a number of items , beginning from the first medical visit before surgery to discharge . The items are all evidence based being derived from r and omized controlled trials or meta-analyses . The reader can find the references related to the ERAS items in the valuable consensus review published by the European ERAS group [ 2 ] and the paper of Kehlet and Wilmore [ 3 ] . Through this pathway , the patient can benefit from the best available evidence in anaesthesia , analgesia , perioperative fluid management , surgical procedures , nutrition and ambulation . I will focus in this editorial on the role of ERAS in colorectal surgery , but readers should be aware that ERAS has been applied and vali date d in other abdominal procedures , and in urology , gynaecology , vascular sugery , endocrine surgery , orthopaedic surgery , etc . [ 3 ] . The numerous items or components ( Figure 1 ) involve the preoperative , intra-operative and postoperative periods , necessitating close collaboration between surgeons ( no bowel preparation , no routine nasogastric tube , minimally invasive surgery , no routine abdominal drainage and early postoperative diet ) , anaesthesiologists ( fasting duration of two hours for liquids and six hours for solids , carbohydrate loading , no routine preoperative sedation , avoiding long-acting opioids , epidural analgesia , preventing postoperative nausea and vomiting , preventing intra-operative hypothermia , perioperative fluid restriction and postoperative analgesia ) and nurses and physiotherapists ( early nutrition and mobilisation ) . Several r and omized trials and four meta-analyses [ 4–7 ] have demonstrated the safety and efficacy of ERAS , not only in reducing total length of hospital stay and morbidity , but also in improving patient satisfaction when compared with conventional care . The metaanalyses included both r and omized and non-r and omized studies , the most recent and the largest [ 6 ] showing a reduction of 2.5 days in total hospital stay and significantly less morbidity ( OR 0.54 [ 0.45–0.69 ] ) in favour of the ERAS group , with no difference in readmission rate . A recent meta- analysis focusing on major colorectal surgery demonstrated that the ERAS programme can reduce morbidity by up to 50 % [ 7 ] . ERAS raises three questions . ( i ) What is the respective role of each ERAS item ? ( ii ) Does the ERAS protocol increase the workload of ward nursing staff ? ( iii ) How should this new paradigm be implemented ? Several anaesthesiologists are reluctant to use epidural analgesia in daily practice , mainly when patients are undergoing laparoscopic surgery . Epidural analgesia ( well known to be associated with less pain ) during laparoscopic surgery has been assessed in meta-analyses and r and omized trials but the conclusions are not concordant [ 8,9 ] . In my own daily practice , epidural analgesia is safe and efficacious in relieving pain and allowing early oral intake and mobilization , but it is obvious that its proper role in the ERAS protocol compared with other analgesic regimens such as non-opioid multimodal analgesia , local anaesthesia and continuous wound perfusion , in the era of laparoscopic surgery needs further evaluation . The roleof laparoscopyhas also been debated [ 10 ] . Two small r and omized trials have shown conflicting results [ 11,12 ] , but a recent large r and omized trial [ 13 ] involving four arms ( laparoscopy with ERAS vs laparoscopy with conventional care , vs open surgery with ERAS vs open surgery with conventional care ) has demonstrated a shorter hospital stay after laparoscopic colonic surgery with ERAS , the other outcomes being similar . The conclusion of the authors was that ‘ the most optimal perioperative treatment for patients requiring segmental colectomy for coloncancer is laparoscopic resection embedded in an ERAS program ’ , suggesting that laparoscopic surgery is an important component of ERAS . The same team has performed a futher multivariate linear regression analysis on the same data and showed that the components significantly associated with a successful ERAS programme were laparoscopic surgery , normal diet at postoperative days one , two and three and enforced mobilization at postoperative days one , two and three ( Vlug M , personal communication ) . There is a feeling that the ERAS programme could increase the workload of nursing staff . The nursing Background The HARMONIC SCALPEL ( H ) is an advanced ultrasonic cutting and coagulating surgical device with important clinical advantages , such as : reduced ligature dem and ; greater precision due to minimal lateral thermal tissue damage ; minimal smoke production ; absence of electric corrents running through the patient . However , there are no prospect i ve RCTs demonstrating the advantages of H compared to the conventional monopolar diathermy ( MD ) during laparoscopic cholecystectomy ( LC ) in cases of acute cholecystitis ( AC ) . Methods This study was a prospect i ve , single-center , r and omized trial ( Trial Registration Number : NCT00746850 ) design ed to investigate whether the use of H can reduce the incidence of intra-operative conversion during LC in cases of AC , compared to the use of MD . Patients were divided into two groups : both groups underwent early LC , within 72 hours of diagnosis , using H and MD respectively ( H = experimental/ study group , MD = control group ) . The study was design ed and conducted in accordance with the regulations of Good Clinical Practice . Results 42 patients were r and omly assigned the use of H ( 21 patients ) or MD ( 21 patients ) during LC . The two groups were comparable in terms of basic patient characteristics . Mean operating time in the H group was 101.3 minutes compared to 106.4 minutes in the control group ( p = ns ) ; overall blood loss was significantly lower in the H group . Conversion rate was 4.7 % for the H group , which was significantly lower than the 33 % conversion rate for the control group ( p<0.05 ) . Post-operative morbidity rates differed slightly : 19 % and 23 % in the H and control groups , respectively ( p = ns ) . Average post-operative hospitalization lasted 5.2 days in the H group compared to 5.4 days in the control group ( p = ns ) . Conclusions The use of H appears to correlate with reduced rates of laparoscopic-open conversion . Given this evidence , H may be more suitable than MD for technically dem and ing cases of AC 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 Laparoscopic cholecystectomy ( LC ) is the gold-st and ard surgical method used to treat gallbladder diseases . Recently Laparoendoscopic single site surgery ( LESS ) has gained greater interest and diffusion for the surgical treatment of several pathologies . In elderly patients , just few r and omized controlled trials are present in the literature that confirm the clinical advantages of LESS compared with the classic laparoscopic procedures . We present in this paper the preliminary results of this r and omized prospect i ve study regarding the feasibility and safety of LESS cholecystectomy versus classic laparoscopic technique . We demonstrated that LESS technique compared with traditional technique show some advantages like : acceptable operative times , lower post-operative discomfort and sometimes reduction added complications . In addition we also demonstrate that fewer incisions and less scarring which mean less pain , and fewer parietal complications are related to this surgical procedure . In conclusion in the elderly  LESS cholecystectomy technique is to be considered a suitable alternative to traditional three-port cholecystectomy AIMS Pain and anxiety are commonly reported among those undergoing orthopaedic surgery . Improvement in anxiety and pain control might be achieved by supplementing st and ard care with psychological interventions . However , the effectiveness of adjunctive psychosocial interventions in anxiety and pain control have not been addressed sufficiently by previous systematic review s in orthopaedic surgeries . The present study aim ed to assess the effectiveness of adjunctive psychosocial techniques to improve perioperative clinical care in orthopaedic surgery , to identify the most effective intervention types and to evaluate potential moderators . METHODS We will perform a systematic review and meta- analysis to address the study aims . PubMed , PsycINFO , CINAHL and ProQuest Dissertations & Theses will be search ed between 1980 and 2015 . Prospect i ve controlled clinical trials completed in adults , contrasting st and ard care and st and ard care supplemented with psychosocial methods  , will be eligible for inclusion . Effectiveness will be assessed through the outcomes of postoperative pain intensity , analgesic requirement , perioperative anxiety , quality of life and postoperative recovery . The results of a r and om-effect meta- analysis will be reported . To aid implementation of best practice , moderating effects of the type and timing of psychosocial intervention , type of surgical intervention and type of anaesthesia will be evaluated through meta-regression . Sensitivity analyses and subgroup contrasts will follow as necessary . DISCUSSION Recommendations will be made to improve medical care in orthopaedic procedures . The quality of evidence will be rated using GRADE criteria . Copyright © 2016 John Wiley & Sons ,
Conclusion : Early cholecystectomy seems to be a feasible treatment in elderly patients with acute cholecystitis .
Background : In the era of advanced surgical techniques and improved perioperative care , the willingness to perform emergency operations in elderly patients continues to increase .
This systematic review aim ed at assessing the clinical outcomes of early cholecystectomy in elderly patients with acute cholecystitis .