World J. Surg. 14, 567-571, 1990
World Journal of Surgery 9 1990 by the Soci~t~ Internationale de Chirurgie
Changing Trends in Surgery for Acute Cholecystitis Raphael Reiss, M.D., Israel Nudelrnan, M.D., Chaim Gutman, M.D., and Alexander A. Deutsch, M.B., Ch.B. Department of Surgery "B," Beilinson Medical Center, Petah Tiqva, and Tel Aviv University Sackler School of Medicine, Petah Tiqva, Israel Surgery for acute cholecystitis has become the most frequent abdominal surgery in most hospitals, yet aspects of its management remain controversial. The aim of this study was to focus on the recent trends by demonstrating the principal differences between 2 series of patients operated on during 10-year intervals. Two hundred fifty-six consecutive operations for acute cholecystitis were performed from 1970 to 1977 (group O) and were compared to 260 cases operated from 1980 to 1987 (group N). Thirty-six variables were recorded in each case. All data obtained were computer recorded and analyzed. Several trends were observed in group N" 1. The population was significantly older with a higher proportion of males and diabetics. 2. There was a marked increase in common bile duct stones, acalculous cholecystitis, and gangrenous changes in the gallbladder. 3. There was a significant increase in patients operated on within 48 hours of admission. 4. There was a significant increase in the number of patients without previous history of biliary symptoms. 5. There was a significant decrease in the rate of wound infections and no statistically significant differences in mortality (N: 3.0%, O:
2. Wide introduction of real-time sonography as the optimal preoperative and operative diagnosis modality. 3. Availability and rising quality of postoperative intensive care. 4. Development of new nonoperative methods that may be used in selected instances, particularly endoscopic papillotomy and percutaneous transhepatic cholecystostomy. The principal aim of this study was to focus on trends in the management of acute cholecystitis by comparing 2 groups operated on for acute cholecystitis 10 years apart (group O: 1970-1977, group N: 1980-1987). All cases were treated by the same surgical team, headed by the senior author. The surgical philosophy during both periods was guided by a preference for early and definitive surgery. Because of this fact, the differences that have occurred, indeed, represent changes and trends rather than local factors related to the therapeutic regimen.
2.7%). 6. A decrease of the average postoperative hospital stay of 3.2 days was observed. In spite of the older and sicker population in group N, no significant increase in mortality occurred and the postoperative hospital stay was reduced.
Surgery for acute cholecystitis has become the most frequent abdominal operation in most hospitals while, at the same time, the number of elective cholecystectomies has shown a tendency to decrease. The need for operative cholecystectomy for acute chotecystitis has not been questioned; however, many points, such as timing and extent of surgery, have been a matter of some controversy [1-8]. Over the last 2 decades, radical changes have occurred in the diagnosis and management of acute cholecystitis, the following being the most significant [%13]: 1. Increasing number of elderly and compromised patients who have gallstones. Presented at the Soci6t6 Internationale de Chirurgie in Toronto, Ontario, Canada, September, 1989. Reprint requests: Professor Raphael Reiss, Head, Department of Surgery B, Beilinson Medical Center, Petah Tiqva 49 100, Israel.
Material a n d M e t h o d s
All data were drawn from a computer-held database, established by the authors in early 1970, that carries full and detailed information on more than 3,000 consecutive cholecystectomies. In addition to routine information concerning preoperative, operative, and postoperative data, information of special interest to the authors such as number of stones in the gallbladder and the bile ducts, bile bacteriology, and microscopic changes in the gallbladder wall have been included. The data were analyzed using a dBase III software package (Ashton-Tate Co.) and a standard statistical package. Values o f p of less than 0.05 were considered as statistically significant. The search disclosed 256 cholecystectomies performed for acute cholecystitis during period O and 260 during period N. Comparison of these 2 groups was the main focus of the study. The policy in our department throughout both periods was early and definitive surgery. All patients were drained using a soft latex drain which was usually removed after 48 hours. Perioperative antibiotics were administered and usually continued until the third postoperative day. Cefazolin was used for most cases during period O and a combination of gentamicin plus ampicillin for most cases in period N. The presence of acute cholecystitis was determined by the clinical picture and con-
568
World J. Surg. Vol. 14, No. 5, Sept./Oct. 1990
Table 1. Trends in surgery for acute cholecystitis: General data and sex distribution.
Sex (%) Male Female Total no. of cholecystectomies Acute cholecystitis (n) % Acute: All cases
Group O (1970-1977)
Group N (1980-1987)
35.4 64.6 1,558 256 16.4
41.2 58.8 1,002 260 25.9
Table 4. Trends in surgery for acute cholecystitis: Clinical manifestations, operative findings, and operative procedures.
Jaundice (bilirubin 2.9 mg%) Diabetes meUitus Pancreatitis
Group O
Group N
No. of cases %
No. of cases %
44
17.2
52
48 18
18.8 7.0
67 17
20.0 Not significant 25.8 p < 0.01 6.5 Not significant
p < 0.001
Table 2. Trends in surgery for acute cholecystitis: Age distribution. Group O
Group N
z L~b~
^~* (yr)
No. of cases
%
No. of cases
%
1-69 70-79 80 and older
216 32 8
84.4 12.5 3.1
143 74 43
55.0 28.5 16.5
Acalculous cholecystitis Choledochal stones Positive bile cultures p < 0.001
Gangrenous changes Perforation
Table 3. Trends in surgery for acute cholecystitis: Previous history of biliary symptoms, and surgery performed within 48 hours of admission.
Previous history of biliary symptoms (%) Surgery performed within 48 hr of admission: n (%)
Group O
Group N
53.8
38.4
p < 0.001
187 (73.0)
248 (95.4)
p < 0.001
Cholecystectomy
Group O
Group N
No. of cases %
No. of cases %
16 56 148
6.3 21.9 57.8
34 77 153
57 8
22.3 3.1
77 6
13.3 p < 0.01 29.6 p < 0.05 58.9 Not significant 29.6 p < 0.01 2.3 Not significant
Group O
Group N
No. of cases %
No. of cases %
256
260
Choledochal exploration Choledochoduodenostomy
78 19
100 30.5 7.4
100
Not significant 36.5 p < 0.05 4.2 Not significant
95 11
Table 5. Trends in surgery for acute cholecystitis: Surgical results. firmed by the pathologist. Patients in whom the diagnosis was not pathologically confirmed were excluded.
Group O No. of cases
Results
During the period under consideration, the proportion of acute cases increased from 16.4% to 25.9% (Table 1). The proportion of males increased significantly from 35.4% to 41.2%. A dramatic increase was noted in the age of the patients operated on for acute cholecystitis (Table 2). In the age group of 70-79, the rate of increase was more than 100%, and an increase of almost 500% was noted in patients in the 80 and older group (Table 2). Almost 50% in group O had no previous history of symptoms related to the biliary tract. The rate of such patients in whom acute cholecystitis was the first clinical manifestation increased to 61.6% (Table 3) in group N. Other manifestations more frequent in group N were hyperbilirubinemia and diabetes mellitus. The incidence of pancreatitis was about equal in both groups (Table 4). Another significant change was in timing; while most patients in both groups were operated within 48 hours, the precise rate varied significantly: 73% for group O, 95.4% for group N (Table 3). Marked changes were noted in operative findings (Table 4). A very significant increase was noted in the rate of acalculous cholecystitis and in the rate of bile duct stones. A considerable increase was noted in the incidence of gangrenous changes in the gallbladder wall (22.2% versus 29.6%). There was no significant change in the incidence of positive bile
Mortality Wound infection and septic complications Average postoperative hospital stay (days)
Group N %
No. of cases
%
7
2.7
8
3.1
39
15.2
15
5.8
12.1
8.9
Not significant p < 0.001 p < 0.05
cultures and no change in the type of bacteria cultured, mostly
E. coli and Klebsiella, as previously reported [12]. Following a long established policy, cholecystectomy was performed in all cases. There was a slight increase in the rate of choledochal exploration and a slight decrease in the rate of choledochoduodenostomies performed (Table 4). Operative papillotomy was not performed in any of the cases. The mortality was less than 3% with no significant difference between the 2 groups (Table 5). All deaths in group N occurred in patients older than 70 years of age and all but one of the deaths in group O were in the same age group. The most common causes of death in this group were: 1. Septic complications and multiple organ failure. 2. Cardiac complications and sudden unexplained death.
R. Reiss et ai.: Acute Cholecystitis
Morbidity consisted mostly of wound infections and septic complications in which a significant decrease occurred in group N; cardiorespiratory complications were about equal in both groups. A highly significant decrease of 3.2 days was noted in postoperative hospital stay between the 2 groups. The incidence of diagnosed residual stones was less than 1% in both groups. Discussion
The most remarkable finding in this study is the changing profile of the prospective candidates of surgery for acute cholecystitis. As our indications for elective surgery are changing, excluding patients with silent stones as well as mild atypical symptoms, the rate of patients operated on in the acute stage of their disease tends to increase. We surgeons are faced with a much older group of patients, of which one-third of patients are older than 70 years of age and more than 16% are older than 80 years of age. The aging of the population is, of course, responsible for a larger number of patients presenting with cardiovascular disease and diabetes mellitus. The higher number of gangrenous changes in the gallbladder and choledochal stones is probably at least partly related to the increase in age [14-16]. The policy of operating on patients with acute cholecystitis within 48 hours was in existence throughout both periods; however, it was c a r d e d out more consistently in period N. The principal reason, in our view, was the availability of a reliable, rapid, and noninvasive diagnostic technique: real-time ultrasonography [17, 18]. In our experience, the specificity of this technique in diagnosing acute cholecystitis was higher than 95% and facilitated the decision-making process In many difficult cases (2 falsepositive and 82 true-negative cases were observed during period N). It should be emphasized that the majority of patients had no previous history o f biliary tract disease. This rather undermines the validity of the argument that wide indications of elective cholecysectomy would decrease the need for surgery under acute circumstances. The mortality in this series was less than 3% and did not vary significantly between groups N and O. In spite of the fact that group N was much sicker and older, it appears that the age factor was somehow compensated by early surgery and wider use of intensive postoperative care. The significant decrease in wound infections and septic complications is probably also due to early surgery and possibly to more appropriate use of antibiotic prophylaxis [19, 20]. The reduction of the postoperative stay resulted mostly from a decreased number of septic complications but also from policy changes. This reduction of hospita! stay obviously decreased the overall cost of the operative care and renders this alternative as more attractive compared to other options [21]. in light of the data described, what may be the use of nonsurgical alternatives such as endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholecystostomy? It appears that the present experience and the knowledge of high rates of gangrenous changes in the gallbladder wall will preclude the systematic use of such techniques in the management of acute cholecystitis. At the present time, substi-
569
tutes for surgery may be used only in suitable, very high-risk patients as well as in patients refusing surgery. R~sum~
Alors que la chirurgie de la cholrcystite aigu~ est devenue l'une des plu s frrquentes de la chirurgie abdominale hospitali~re, certains aspects de son traitement restent controversrs. Le but de cette 6tude 6tait de drterminer les tendances actuelles en comparant 2 srries de patients o p r r r s ~t 10 ans d'intervalle. On a compar6 256 cas de cholrcystite aiguE o p r r r s entre 1970 et 1977 (groupe O) avec 260 cas op6r6s entre 1980 et 1987 (groupe N). Trente-six variables ont 6t6 enregistrres dans chaque cas, entrrs dans un ordinateur et analysrs. Les rrsultats montrent que dans le groupe N (par rapport au group O): I. l'~ge 6tait significativement plus 61evr; la proportion d'hommes et de diabrtiques 6tait plus importante; 2. il y avait plus de lithiases de la voie biliaire principale, de chol6cystite alithiasique et de gangrene de la vrsicule; 3. il y avait significativement plus de patients o p r r r s dans les premieres 48 heures apr~s l'admission; 4. i! y avait significativement plus de patients sans a n t r c r d e n t s biliaires: 5. il y avait significativement moins d'abc~s de parois, mais pas de diffrrence de mortalit6 (N: 3.0%: O: 2.7%); 6. la durre moyenne d'hospitalisation post-op6ratoire 6tait plus courte de 3.2 jours. Malgr6 une population plus hgre et plus malade dans le groupe N, il n'y avait pas de diffrrence significative de mortalit6 et la durre moyenne du srjour hospitalier 6tait moindre. Resumen
La cirugia por colecistitis aguda ha venido a ser la operact6n abdominal m~s frecuente en la mayoria de los hospitales; sin embargo varios aspectos relativos a su manejo contintian siendo motivo de controversia. El prop6sito del presente estudio fue identificar las tendencias recientes mediante la demonstraci6n de las diferencias entre 2 series de pacientes operados en periodos de 10 afios. Dos cientos cincuenta y seis operaciones consecutivas por colecistitis aguda fueron realizadas entre 1970 y 1977 (grupo O); se hizo la comparaci6n con 260 casos operados entre 1980 y 1987 (grupo N). Se registraron 36 variables en cada caso. La totalidad de los datos fue registrada y analizada por computador. 1. L a poblaci6n en el grupo N apareci6 considerablemente m~is anciana y con una mayor proporci6n de hombres y de diabrticos. 2. Se observ6 un incremento en el ntimero de pacientes con c~ilculos en el colrdoco, con colecistitis acalculosa, y con alteraciones gangrenosas en la vesfcula biliar. 3. Hubo un aumento significativo en el ntimero de pacientes operados en las primeras 48 horas de su admisi6n. 4. Se present6 un aumento significativo en el ndmero de pacientes sin historia previa de sintomas biliares. 5. Hubo un descenso significativo en la tasa de infecci6n de
570
herida sin diferencias estadfsticamente significativas en la mortalidad (N: 3.0%, O: 2.7%). 6. Se observ6 una hospitalizaci6n m~is corta, de 3.2 dfas menos, A pesar d e que la poblaci6n del grupo N fue m~is anciana y m~is enferma, no se present6 un aumento significativo en la mortalidad y se redujo el peri0do postoperatorio de hospita!izaci6n. References
1. Reiss, R., Deutsch, A.A., Nudelman, I., Hadda, M.: A new look at acute cholecystitis. Mt. Sinai J. Med. 53:103, 1986 2. Gagic, N., Frey, C.F., Gaines, R.: Acute cholecystitis. Surg. Gynecol. Obstet. 140~868, 1975 3. Du Plessis, D.J:, Jersky, J.: Th e management of acute cholecystitis. Surg. Clin. North Am. 53:1071, 1973 4. Glenn, F.: Acute cholecystitis. Surg. Gynecol. Obstet. 143:56, 1976 5. Schein, C.J.: Acute Cholecystitis, New York, Harper and Row, 1971, pp. 309-319 6. Klingensmith, W., Watkins, W.: Cholecystectomy in acute cholecystitis. Arch. Surg. 92:689, 1966 7. Ellis, H.: Surgical progress 1975. Postgrad. Med. J. 52:121, 1976 8. Halasz, N.A.: Counterfeit cholecystitis. Am. J. Surg. 130:189, 1975 9. McArthur, P., Cuschieri, A., Sells, R.A., Shields, R.: Controlled clinical trial of early versus interval cholecystectomy. Br. J. Surg. 62:850, 1975
Invited Commentary Leslie Wise, M.D. Department of Surgery, Long Island Jewish Medical Center, New Hyde Park, New York, U.S.A.
This study is timely and brings out a number of interesting points. 1. There seems to be a decrease in the number of elective cholecystectomies performed which may be due to a change in attitude. More a n d more surgeons tend not to advise elective cholecystectomy for the asymptomatic patient [1]. In addition, although this did not affect the current series, probably a number of patients will be advised to undergo lithotripsy, if anything, for the asymptomatic stone. 2. There is a significant increase in the number of elderly patients (70+ years) being operated on for acute cholecystitis. This is probably due to a change in our attitude and significantly improved postoperative care i n surgical intensive care units in the 1980's a s compared to the 1970's. Indeed, in this particular group of patients, they had zero mortality in the acutely operated cases. The question which has not been discussed in this article is the management of patients who are in their 80's or 90's. Should some of these patients be treated conservatively altogether? Of course, there is no way we can argue with the authors, results since they had zero mortality in 43 of these cases. It is well known that about 85% of cases of acute cholecystitis can be successfully managed by conservative
World J. Surg. Vol. 14, No. 5, Sept./Oct. 1990
10. Van der Linden, W., Sunzel, H.: Early versus delayed operation for acute cholecystitis. Am. J. Surg. 120:7, 1970 11. Reiss, R., Pikeline, S , Engelberg, M.: The value of early surgery and routine operative cholangiography in th e management of acute ch01ecystitis. World J. Surg. 3:107, 1979 12. Reiss, R., E!iashiv, A., Deutsch, A.A.: Septic complications and bile cultures in 800 cholecystectomies. World J. Surg. 6:195, 1982 13. Gutman, H., Kott, I., Haddad, M., Reiss, R.: Changing trends in surgery for benign gallbladder disease. Am. J. Gastroenterol. 83:545, 1988 14. Hickman, M.S., Schwesinger, W.H.: Acute cholecystitis in the diabetic. A case-control study of outcome. Arch. Surg. 123:409, 1988 15. Ranshoff, D.F., Miller, G.L., Forsythe, S.B., Herman, R.E.: Outcome of acute cholecystitis in patients with diabetes mellitus. Ann. Intern. Med. 106:829, 1987 16. Pickleman, J.: Controversies in biliary tract surgery. Can. J. Surg. 29:429, 1986 17. Miyazaki, K., Uchiyama, A., Nakayama, F.: Use of ultrasonographic risk score in the timing of operative intervention for acute cholecystitis. Arch. Surg. 123:487, 1988 18. Addison, N.V., Finan, P.J.: Urgent and early cholecystectomy for acute gallbladder disease. Br. J. Surg. 75:141, 1988 19. Auguste, L.J., Angus, L., Wise, L.: Timing of surgical intervention for acute cholecystitis. Dig. Surg. 4:199, !987 20. Mitchell, A., Morris, P.J.: Trends in management of acute cholecystitis. Br. Med. J. 284:27, 1982 21. Fowkes, F.G.R., Gunn, A.A.: The management of acute cholecystitis and hospital cost. Br. J. Surg. 67:3, 1980
therapy without surgery [2]. Although there are no really good data on the long-term results of acute cholecystitis treated nonsurgically, it seems that only 20% will develop recurrent acute cholecystitis over a period of 5 years. Since the life expectancy at age 80 is probably not much more than 5 years, the chances of t h e s e patients getting into serious problems requiring surgery is probably not very high. Not that we recommend nonoperative management of these cases in general, but I believe that in some cases, nonoperative management should be considered. 3. In approximately 50% of these patients, the first manifestation of biliary tract disease was acute cholecystitis. This is an interesting observation; the fact that this incidence has increased from 38% to 53% may possibiy reflect the fact that currently we tend n o t to operate on patients with asymptomatic gallstones. 4. In the authors' experience in Israel, the average postoperative hospital stay decreased from 12.1 days to 8.9 days. This decreased hospital stay is really reflective of the increased emphasis on health care costs. In our medical center in New York, emergency cholecystectomies had a mean total length Of stay of 17.8 days and a charge of $11,436 as opposed to a mean length of stay of 8.0 days and a charge of $4,763 for elective cholecystectomie ~ [3]. The authors in this particular study only discuss postoperativ e hospital stay; it would probably have been more meaningful to discuss total hospital Stay (i.e., preand postoperative stay). 5. In this series, all patients were drained with a soft latex drain. I think most surgeons would now advocate a closed-
World Journal of Surgery 9 1990 by the Soci~t~ Internationale de Chirurgie
Changing Trends in Surgery for Acute Cholecystitis Raphael Reiss, M.D., Israel Nudelrnan, M.D., Chaim Gutman, M.D., and Alexander A. Deutsch, M.B., Ch.B. Department of Surgery "B," Beilinson Medical Center, Petah Tiqva, and Tel Aviv University Sackler School of Medicine, Petah Tiqva, Israel Surgery for acute cholecystitis has become the most frequent abdominal surgery in most hospitals, yet aspects of its management remain controversial. The aim of this study was to focus on the recent trends by demonstrating the principal differences between 2 series of patients operated on during 10-year intervals. Two hundred fifty-six consecutive operations for acute cholecystitis were performed from 1970 to 1977 (group O) and were compared to 260 cases operated from 1980 to 1987 (group N). Thirty-six variables were recorded in each case. All data obtained were computer recorded and analyzed. Several trends were observed in group N" 1. The population was significantly older with a higher proportion of males and diabetics. 2. There was a marked increase in common bile duct stones, acalculous cholecystitis, and gangrenous changes in the gallbladder. 3. There was a significant increase in patients operated on within 48 hours of admission. 4. There was a significant increase in the number of patients without previous history of biliary symptoms. 5. There was a significant decrease in the rate of wound infections and no statistically significant differences in mortality (N: 3.0%, O:
2. Wide introduction of real-time sonography as the optimal preoperative and operative diagnosis modality. 3. Availability and rising quality of postoperative intensive care. 4. Development of new nonoperative methods that may be used in selected instances, particularly endoscopic papillotomy and percutaneous transhepatic cholecystostomy. The principal aim of this study was to focus on trends in the management of acute cholecystitis by comparing 2 groups operated on for acute cholecystitis 10 years apart (group O: 1970-1977, group N: 1980-1987). All cases were treated by the same surgical team, headed by the senior author. The surgical philosophy during both periods was guided by a preference for early and definitive surgery. Because of this fact, the differences that have occurred, indeed, represent changes and trends rather than local factors related to the therapeutic regimen.
2.7%). 6. A decrease of the average postoperative hospital stay of 3.2 days was observed. In spite of the older and sicker population in group N, no significant increase in mortality occurred and the postoperative hospital stay was reduced.
Surgery for acute cholecystitis has become the most frequent abdominal operation in most hospitals while, at the same time, the number of elective cholecystectomies has shown a tendency to decrease. The need for operative cholecystectomy for acute chotecystitis has not been questioned; however, many points, such as timing and extent of surgery, have been a matter of some controversy [1-8]. Over the last 2 decades, radical changes have occurred in the diagnosis and management of acute cholecystitis, the following being the most significant [%13]: 1. Increasing number of elderly and compromised patients who have gallstones. Presented at the Soci6t6 Internationale de Chirurgie in Toronto, Ontario, Canada, September, 1989. Reprint requests: Professor Raphael Reiss, Head, Department of Surgery B, Beilinson Medical Center, Petah Tiqva 49 100, Israel.
Material a n d M e t h o d s
All data were drawn from a computer-held database, established by the authors in early 1970, that carries full and detailed information on more than 3,000 consecutive cholecystectomies. In addition to routine information concerning preoperative, operative, and postoperative data, information of special interest to the authors such as number of stones in the gallbladder and the bile ducts, bile bacteriology, and microscopic changes in the gallbladder wall have been included. The data were analyzed using a dBase III software package (Ashton-Tate Co.) and a standard statistical package. Values o f p of less than 0.05 were considered as statistically significant. The search disclosed 256 cholecystectomies performed for acute cholecystitis during period O and 260 during period N. Comparison of these 2 groups was the main focus of the study. The policy in our department throughout both periods was early and definitive surgery. All patients were drained using a soft latex drain which was usually removed after 48 hours. Perioperative antibiotics were administered and usually continued until the third postoperative day. Cefazolin was used for most cases during period O and a combination of gentamicin plus ampicillin for most cases in period N. The presence of acute cholecystitis was determined by the clinical picture and con-
568
World J. Surg. Vol. 14, No. 5, Sept./Oct. 1990
Table 1. Trends in surgery for acute cholecystitis: General data and sex distribution.
Sex (%) Male Female Total no. of cholecystectomies Acute cholecystitis (n) % Acute: All cases
Group O (1970-1977)
Group N (1980-1987)
35.4 64.6 1,558 256 16.4
41.2 58.8 1,002 260 25.9
Table 4. Trends in surgery for acute cholecystitis: Clinical manifestations, operative findings, and operative procedures.
Jaundice (bilirubin 2.9 mg%) Diabetes meUitus Pancreatitis
Group O
Group N
No. of cases %
No. of cases %
44
17.2
52
48 18
18.8 7.0
67 17
20.0 Not significant 25.8 p < 0.01 6.5 Not significant
p < 0.001
Table 2. Trends in surgery for acute cholecystitis: Age distribution. Group O
Group N
z L~b~
^~* (yr)
No. of cases
%
No. of cases
%
1-69 70-79 80 and older
216 32 8
84.4 12.5 3.1
143 74 43
55.0 28.5 16.5
Acalculous cholecystitis Choledochal stones Positive bile cultures p < 0.001
Gangrenous changes Perforation
Table 3. Trends in surgery for acute cholecystitis: Previous history of biliary symptoms, and surgery performed within 48 hours of admission.
Previous history of biliary symptoms (%) Surgery performed within 48 hr of admission: n (%)
Group O
Group N
53.8
38.4
p < 0.001
187 (73.0)
248 (95.4)
p < 0.001
Cholecystectomy
Group O
Group N
No. of cases %
No. of cases %
16 56 148
6.3 21.9 57.8
34 77 153
57 8
22.3 3.1
77 6
13.3 p < 0.01 29.6 p < 0.05 58.9 Not significant 29.6 p < 0.01 2.3 Not significant
Group O
Group N
No. of cases %
No. of cases %
256
260
Choledochal exploration Choledochoduodenostomy
78 19
100 30.5 7.4
100
Not significant 36.5 p < 0.05 4.2 Not significant
95 11
Table 5. Trends in surgery for acute cholecystitis: Surgical results. firmed by the pathologist. Patients in whom the diagnosis was not pathologically confirmed were excluded.
Group O No. of cases
Results
During the period under consideration, the proportion of acute cases increased from 16.4% to 25.9% (Table 1). The proportion of males increased significantly from 35.4% to 41.2%. A dramatic increase was noted in the age of the patients operated on for acute cholecystitis (Table 2). In the age group of 70-79, the rate of increase was more than 100%, and an increase of almost 500% was noted in patients in the 80 and older group (Table 2). Almost 50% in group O had no previous history of symptoms related to the biliary tract. The rate of such patients in whom acute cholecystitis was the first clinical manifestation increased to 61.6% (Table 3) in group N. Other manifestations more frequent in group N were hyperbilirubinemia and diabetes mellitus. The incidence of pancreatitis was about equal in both groups (Table 4). Another significant change was in timing; while most patients in both groups were operated within 48 hours, the precise rate varied significantly: 73% for group O, 95.4% for group N (Table 3). Marked changes were noted in operative findings (Table 4). A very significant increase was noted in the rate of acalculous cholecystitis and in the rate of bile duct stones. A considerable increase was noted in the incidence of gangrenous changes in the gallbladder wall (22.2% versus 29.6%). There was no significant change in the incidence of positive bile
Mortality Wound infection and septic complications Average postoperative hospital stay (days)
Group N %
No. of cases
%
7
2.7
8
3.1
39
15.2
15
5.8
12.1
8.9
Not significant p < 0.001 p < 0.05
cultures and no change in the type of bacteria cultured, mostly
E. coli and Klebsiella, as previously reported [12]. Following a long established policy, cholecystectomy was performed in all cases. There was a slight increase in the rate of choledochal exploration and a slight decrease in the rate of choledochoduodenostomies performed (Table 4). Operative papillotomy was not performed in any of the cases. The mortality was less than 3% with no significant difference between the 2 groups (Table 5). All deaths in group N occurred in patients older than 70 years of age and all but one of the deaths in group O were in the same age group. The most common causes of death in this group were: 1. Septic complications and multiple organ failure. 2. Cardiac complications and sudden unexplained death.
R. Reiss et ai.: Acute Cholecystitis
Morbidity consisted mostly of wound infections and septic complications in which a significant decrease occurred in group N; cardiorespiratory complications were about equal in both groups. A highly significant decrease of 3.2 days was noted in postoperative hospital stay between the 2 groups. The incidence of diagnosed residual stones was less than 1% in both groups. Discussion
The most remarkable finding in this study is the changing profile of the prospective candidates of surgery for acute cholecystitis. As our indications for elective surgery are changing, excluding patients with silent stones as well as mild atypical symptoms, the rate of patients operated on in the acute stage of their disease tends to increase. We surgeons are faced with a much older group of patients, of which one-third of patients are older than 70 years of age and more than 16% are older than 80 years of age. The aging of the population is, of course, responsible for a larger number of patients presenting with cardiovascular disease and diabetes mellitus. The higher number of gangrenous changes in the gallbladder and choledochal stones is probably at least partly related to the increase in age [14-16]. The policy of operating on patients with acute cholecystitis within 48 hours was in existence throughout both periods; however, it was c a r d e d out more consistently in period N. The principal reason, in our view, was the availability of a reliable, rapid, and noninvasive diagnostic technique: real-time ultrasonography [17, 18]. In our experience, the specificity of this technique in diagnosing acute cholecystitis was higher than 95% and facilitated the decision-making process In many difficult cases (2 falsepositive and 82 true-negative cases were observed during period N). It should be emphasized that the majority of patients had no previous history o f biliary tract disease. This rather undermines the validity of the argument that wide indications of elective cholecysectomy would decrease the need for surgery under acute circumstances. The mortality in this series was less than 3% and did not vary significantly between groups N and O. In spite of the fact that group N was much sicker and older, it appears that the age factor was somehow compensated by early surgery and wider use of intensive postoperative care. The significant decrease in wound infections and septic complications is probably also due to early surgery and possibly to more appropriate use of antibiotic prophylaxis [19, 20]. The reduction of the postoperative stay resulted mostly from a decreased number of septic complications but also from policy changes. This reduction of hospita! stay obviously decreased the overall cost of the operative care and renders this alternative as more attractive compared to other options [21]. in light of the data described, what may be the use of nonsurgical alternatives such as endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholecystostomy? It appears that the present experience and the knowledge of high rates of gangrenous changes in the gallbladder wall will preclude the systematic use of such techniques in the management of acute cholecystitis. At the present time, substi-
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tutes for surgery may be used only in suitable, very high-risk patients as well as in patients refusing surgery. R~sum~
Alors que la chirurgie de la cholrcystite aigu~ est devenue l'une des plu s frrquentes de la chirurgie abdominale hospitali~re, certains aspects de son traitement restent controversrs. Le but de cette 6tude 6tait de drterminer les tendances actuelles en comparant 2 srries de patients o p r r r s ~t 10 ans d'intervalle. On a compar6 256 cas de cholrcystite aiguE o p r r r s entre 1970 et 1977 (groupe O) avec 260 cas op6r6s entre 1980 et 1987 (groupe N). Trente-six variables ont 6t6 enregistrres dans chaque cas, entrrs dans un ordinateur et analysrs. Les rrsultats montrent que dans le groupe N (par rapport au group O): I. l'~ge 6tait significativement plus 61evr; la proportion d'hommes et de diabrtiques 6tait plus importante; 2. il y avait plus de lithiases de la voie biliaire principale, de chol6cystite alithiasique et de gangrene de la vrsicule; 3. il y avait significativement plus de patients o p r r r s dans les premieres 48 heures apr~s l'admission; 4. i! y avait significativement plus de patients sans a n t r c r d e n t s biliaires: 5. il y avait significativement moins d'abc~s de parois, mais pas de diffrrence de mortalit6 (N: 3.0%: O: 2.7%); 6. la durre moyenne d'hospitalisation post-op6ratoire 6tait plus courte de 3.2 jours. Malgr6 une population plus hgre et plus malade dans le groupe N, il n'y avait pas de diffrrence significative de mortalit6 et la durre moyenne du srjour hospitalier 6tait moindre. Resumen
La cirugia por colecistitis aguda ha venido a ser la operact6n abdominal m~s frecuente en la mayoria de los hospitales; sin embargo varios aspectos relativos a su manejo contintian siendo motivo de controversia. El prop6sito del presente estudio fue identificar las tendencias recientes mediante la demonstraci6n de las diferencias entre 2 series de pacientes operados en periodos de 10 afios. Dos cientos cincuenta y seis operaciones consecutivas por colecistitis aguda fueron realizadas entre 1970 y 1977 (grupo O); se hizo la comparaci6n con 260 casos operados entre 1980 y 1987 (grupo N). Se registraron 36 variables en cada caso. La totalidad de los datos fue registrada y analizada por computador. 1. L a poblaci6n en el grupo N apareci6 considerablemente m~is anciana y con una mayor proporci6n de hombres y de diabrticos. 2. Se observ6 un incremento en el ntimero de pacientes con c~ilculos en el colrdoco, con colecistitis acalculosa, y con alteraciones gangrenosas en la vesfcula biliar. 3. Hubo un aumento significativo en el ntimero de pacientes operados en las primeras 48 horas de su admisi6n. 4. Se present6 un aumento significativo en el ndmero de pacientes sin historia previa de sintomas biliares. 5. Hubo un descenso significativo en la tasa de infecci6n de
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herida sin diferencias estadfsticamente significativas en la mortalidad (N: 3.0%, O: 2.7%). 6. Se observ6 una hospitalizaci6n m~is corta, de 3.2 dfas menos, A pesar d e que la poblaci6n del grupo N fue m~is anciana y m~is enferma, no se present6 un aumento significativo en la mortalidad y se redujo el peri0do postoperatorio de hospita!izaci6n. References
1. Reiss, R., Deutsch, A.A., Nudelman, I., Hadda, M.: A new look at acute cholecystitis. Mt. Sinai J. Med. 53:103, 1986 2. Gagic, N., Frey, C.F., Gaines, R.: Acute cholecystitis. Surg. Gynecol. Obstet. 140~868, 1975 3. Du Plessis, D.J:, Jersky, J.: Th e management of acute cholecystitis. Surg. Clin. North Am. 53:1071, 1973 4. Glenn, F.: Acute cholecystitis. Surg. Gynecol. Obstet. 143:56, 1976 5. Schein, C.J.: Acute Cholecystitis, New York, Harper and Row, 1971, pp. 309-319 6. Klingensmith, W., Watkins, W.: Cholecystectomy in acute cholecystitis. Arch. Surg. 92:689, 1966 7. Ellis, H.: Surgical progress 1975. Postgrad. Med. J. 52:121, 1976 8. Halasz, N.A.: Counterfeit cholecystitis. Am. J. Surg. 130:189, 1975 9. McArthur, P., Cuschieri, A., Sells, R.A., Shields, R.: Controlled clinical trial of early versus interval cholecystectomy. Br. J. Surg. 62:850, 1975
Invited Commentary Leslie Wise, M.D. Department of Surgery, Long Island Jewish Medical Center, New Hyde Park, New York, U.S.A.
This study is timely and brings out a number of interesting points. 1. There seems to be a decrease in the number of elective cholecystectomies performed which may be due to a change in attitude. More a n d more surgeons tend not to advise elective cholecystectomy for the asymptomatic patient [1]. In addition, although this did not affect the current series, probably a number of patients will be advised to undergo lithotripsy, if anything, for the asymptomatic stone. 2. There is a significant increase in the number of elderly patients (70+ years) being operated on for acute cholecystitis. This is probably due to a change in our attitude and significantly improved postoperative care i n surgical intensive care units in the 1980's a s compared to the 1970's. Indeed, in this particular group of patients, they had zero mortality in the acutely operated cases. The question which has not been discussed in this article is the management of patients who are in their 80's or 90's. Should some of these patients be treated conservatively altogether? Of course, there is no way we can argue with the authors, results since they had zero mortality in 43 of these cases. It is well known that about 85% of cases of acute cholecystitis can be successfully managed by conservative
World J. Surg. Vol. 14, No. 5, Sept./Oct. 1990
10. Van der Linden, W., Sunzel, H.: Early versus delayed operation for acute cholecystitis. Am. J. Surg. 120:7, 1970 11. Reiss, R., Pikeline, S , Engelberg, M.: The value of early surgery and routine operative cholangiography in th e management of acute ch01ecystitis. World J. Surg. 3:107, 1979 12. Reiss, R., E!iashiv, A., Deutsch, A.A.: Septic complications and bile cultures in 800 cholecystectomies. World J. Surg. 6:195, 1982 13. Gutman, H., Kott, I., Haddad, M., Reiss, R.: Changing trends in surgery for benign gallbladder disease. Am. J. Gastroenterol. 83:545, 1988 14. Hickman, M.S., Schwesinger, W.H.: Acute cholecystitis in the diabetic. A case-control study of outcome. Arch. Surg. 123:409, 1988 15. Ranshoff, D.F., Miller, G.L., Forsythe, S.B., Herman, R.E.: Outcome of acute cholecystitis in patients with diabetes mellitus. Ann. Intern. Med. 106:829, 1987 16. Pickleman, J.: Controversies in biliary tract surgery. Can. J. Surg. 29:429, 1986 17. Miyazaki, K., Uchiyama, A., Nakayama, F.: Use of ultrasonographic risk score in the timing of operative intervention for acute cholecystitis. Arch. Surg. 123:487, 1988 18. Addison, N.V., Finan, P.J.: Urgent and early cholecystectomy for acute gallbladder disease. Br. J. Surg. 75:141, 1988 19. Auguste, L.J., Angus, L., Wise, L.: Timing of surgical intervention for acute cholecystitis. Dig. Surg. 4:199, !987 20. Mitchell, A., Morris, P.J.: Trends in management of acute cholecystitis. Br. Med. J. 284:27, 1982 21. Fowkes, F.G.R., Gunn, A.A.: The management of acute cholecystitis and hospital cost. Br. J. Surg. 67:3, 1980
therapy without surgery [2]. Although there are no really good data on the long-term results of acute cholecystitis treated nonsurgically, it seems that only 20% will develop recurrent acute cholecystitis over a period of 5 years. Since the life expectancy at age 80 is probably not much more than 5 years, the chances of t h e s e patients getting into serious problems requiring surgery is probably not very high. Not that we recommend nonoperative management of these cases in general, but I believe that in some cases, nonoperative management should be considered. 3. In approximately 50% of these patients, the first manifestation of biliary tract disease was acute cholecystitis. This is an interesting observation; the fact that this incidence has increased from 38% to 53% may possibiy reflect the fact that currently we tend n o t to operate on patients with asymptomatic gallstones. 4. In the authors' experience in Israel, the average postoperative hospital stay decreased from 12.1 days to 8.9 days. This decreased hospital stay is really reflective of the increased emphasis on health care costs. In our medical center in New York, emergency cholecystectomies had a mean total length Of stay of 17.8 days and a charge of $11,436 as opposed to a mean length of stay of 8.0 days and a charge of $4,763 for elective cholecystectomie ~ [3]. The authors in this particular study only discuss postoperativ e hospital stay; it would probably have been more meaningful to discuss total hospital Stay (i.e., preand postoperative stay). 5. In this series, all patients were drained with a soft latex drain. I think most surgeons would now advocate a closed-
