World J. Surg., 3, 107-110, 1979
The Value of Early Surgery and Routine Operative Cholangiography in the Management of Acute Cholecystitis Raphael Reiss, M.D., Serge Pikelnie, M.D., and Moshe Engelberg, M.D. Departments of Surgeryand Radiology,MeirGeneral Hospital, Kefar-Saba,and Universityof Tel-Aviv,SacklerMedicalSchool,TelAviv, Israel dures. Despite this, many aspects of management remain controversial. The results in some recently published series have been less than perfect, with mortality rates of up to 8% and frequent failures, such as residual stones or injuries to the common bile duct [1-3]. The principal areas of controversy have been the following: 1. Timing of surgery. In many centers, the advantages of early surgery [4, 5] have been emphasized, while in others, the conservative approach [6, 7] with elective surgery at a later date has been preferred. Comparative studies attempting a statistically valid comparison between the 2 concepts have given equivocal results [8, 9]. 2. Routine use of operative cholangiography. Operative cholangiography in elective cases has been performed in many surgical centers and has decreased mortality and morbidity. However, in acute cases, its use is infrequent, probably for technical reasons. Few, if any, authors recommend its routine use. 3. Extent of surgery. While cholecystostomy historically can claim priority over cholecystectomy, its use in elective operations has practically ceased. In acute cases, however, many surgeons still recommend this limited procedure in a wide spectrum of clinical circumstances. This prospective study of 182 consecutive operations for acute cholecystitis was conceived to assess the value of a therapeutic policy consisting of the following principles: 1. Early surgery, performed within 48 hours after
Acute cholecystitis remains one of the most frequent abdominal emergencies, and yet many aspects of its management remain controversial. This prospective study of 182 consecutive operations for acute cholecystitis was conceived to assess the value of early surgery and routine operative cholangiography in the improvement of both immediate and long-term results. The patients ranged from 26 to 82 years of age, with about 1/3 of them above 60 years. Gangrenous changes were encountered in 21% of patients, and perforated cholecystitis occurred in 2%. No biliary calculi were found in 6%. Cholecystectomy was performed in all patients. A technically successful operative cholangiography via the cystic duct was performed in 94% of patients. No complications due to cholangiography were encountered, and the procedure was 93% accurate (11 false positives, 0 false negatives). The common bile duct was explored in 48 patients (26%) and found to be diseased in 75% of them. There was one postoperative death (0.5%), caused by sepsis and gastrointestinal bleeding. Clinical and x-ray follow-up, ranging from 2-6 years, disclosed 4 residual stones (2%). We conclude that a therapeutic policy combining early surgery with routine operative cholangiography improves results and decreases the incidence of residual ductal abnormalities.
Surgery for acute cholecystitis is one of the most frequently performed urgent intra-abdominal proce-
Presented at the XXVIIth Congress of the SociEt6 Internationale de Chirurgie, Kyoto, Japan, September 3-8, 1977. Reprint requests: Raphael Reiss, M.D., Head of Surgical Department B., Meir General Hospital, Kefar-Saba, Israel.
0364-2313/79/0003-0107 $01.00 9 1979 Soci6t6 Internationale de Chirurgie 107
World J. Surg. Vol. 3, No. 1, 1979
108
Table 1. Initial findings prior to surgery and operative
Table 2. Results of bile cultures and antibiotic sensitivity
cholangiography in 182 patients.
studies in 182 patients.
Acute cholecystitis Gangrenous cholecystitis Perforated cholecystitis Biliary calculi None 1-9
10 or more
Number of patients
Percentage
140 38 4
77 21 2
10 74 98
6 41 53
full diagnostic investigation and adequate preparation. 2. Routine operative cholangiography to avoid both unnecessary explorations and residual pathological conditions in the common bile duct. 3. One-stage definitive procedure, including cholecystectomy and elimination of stones or fibrosis in the common bile duct. Temporary measures, such as cholecystostomy, were not used in this series.
Material and Methods
This group of 182 patients comprises all patients with acute cholecystitis operated on during an 8year period at our hospital. Only histologically confirmed cases were included; patients showing malignant changes were excluded. Intravenous cholangiography was performed within 6 hours of admission, except when diagnosis was previously established. During the later years of the study, endoscopic retrograde cholangiopancreatography was performed in cases of jaundice or inconclusive cholangiography. Operative cholangiography was performed in 95% of the patients, using accepted techniques and an operating table adapted for cholangiography (Veller). The average duration of the operative cholangiography was 7 minutes, and the development of films in the operating room took an average of 5 minutes. Bile cultures and sensitivity studies were performed in all patients. All available patients were submitted for clinical and x-ray follow-up 1 year after surgery.
Results
The patients ranged in age from 26-82 years; 74 of them were above 60 years of age. There were 109 women and 73 men. The gallbladder showed gangrenous changes in 21% of the patients and was perforated in 2%. Ninety-four percent of the patients had 1 or more gallstones (Table 1).
Number of patients Percentage Positive bile culture
99
Escherichia coli
Salmonella Other gram-negative bacteria Miscellaneous Negative bile cultures Antibiotic sensitivity Gentamycin Chloramphenicol Cephaloridine Ampicillin
83
55 52 3 31 14 45 86 71 65 45
Bile cultures were positive in 99 patients (55%) (Table 2). The incidence of positive cultures increased sharply in diabetic and in jaundiced patients. Gram-negative bacteria were found in 36% of the patients. Studies of bacterial sensitivity to commonly used antibiotics showed gentamycin to be the most effective. A technically successful operative cholangiography via the cystic duct was performed in 169 patients (94%) (Fig. 1). Cholangiograms of 47 patients were interpreted as positive, but 11 were false positive. There were no false negatives. Thus, there was an overall accuracy rate of 93%. No complications due to operative cholangiography were encountered in this series. Forty-eight patients (26%) had common bile duct exploration, and 75% were found to have either stones or fibrosis (Table 3). There was a 25% incidence of jaundice. A strong correlation between bilirubin levels and the presence of common bile duct abnormalities was established. Of the 36 patients with either ductal fibrosis or stones, 75% had a bilirubin level of 3 mg% or more. Eight percent of the patients gave a history of pancreatitis; 58% of them had common bile duct abnormalities. Diabetes mellitus was present in 16% of patients; this is 4 times the rate encountered in elective biliary surgery in our hospital. The diabetic patients displayed high rates of positive bile cultures (80%) and of septic complications (35%). Contrary to other published studies, there was no correlation between the number of stones in the gallbladder and involvement of the common bile duct. Thirty-seven percent of patients without stones in the gallbladder had choledochal fibrosis or stones. One death occurred due to sepsis complicated by acute gastrointestinal bleeding. The most frequently encountered complication was wound infection, which occurred in 32 patients (17%). This rate is more than 3 times as high as in elective cases. On
R. Reiss et al.: Management of Acute Cholecystitis
INTERPRETED 9
47
ABNORMAL CBD FINDINGS 37 CASES
POS,TIVEI
CASES
I
NO ABNORMAL FINDINGS II CASES
INTERPRETED
L
NEGATIVEI
22 CASES
/
%
CBD EXPLORATION NO ABNORMAL FINDINGS I CASE
FALSE- POSITIVE
NO CBD EXPLORATION NO ABNORMAL F UP FINDINGS 121 CASES
FALSE - NEGATIVE O CASES
II CASES 7 %
TOTAL
109
ACCURACY
--
Fig. 1. Results of operative cholangiography in 169 patients.
93 %
the average, wound infection increased hospitalization by 4 days (12 days versus 8 for uncomplicated cases). Occurrence of wound infections correlated positively with diabetes and positive bile cultures. We found no correlation between septic complications and the presence of jaundice or the age of the patient. Most patients (87%) in this series received antibiotics postoperatively. The antibiotics used most frequently were ampicillin, cephaloridine, and gentamycin. There were 4 instances of respiratory complications and 4 other patients had miscellaneous complications. The patients were followed up for 1-6 years. Four cases of residual stones and 1 case of residual sphincter fibrosis were diagnosed. Three of the patients with residual stones underwent further surgery; one patient refused an additional operation. There were no strictures or traumatic injuries to the common bile duct or the hepatic artery.
Discussion
The controversy over the proper timing of intervention in acute cholecystitis has centered around emergency versus elective surgery. In this study, we have chosen an intermediate solution, namely, early surgery within 48 hours of admission to the surgical ward. The 48-hour period was used for preparation and adequate diagnostic investigation. The use of intravenous cholangiography and endoscopic retrograde cholangiopancreatography, when needed, considerably reduced the number of diagnostic errors. Definitive surgery was performed in all cases, and temporary cholecystostomy was avoided. Operative cholangiography has proven particularly valuable in the management of acute cholecystitis. The edema around the vital structures
Table 3. Results of exploration of the common bile duct in
48 patients.
Choledochal calculi Choledochal fibrosis No abnormal findings Internal drainage performed Choledochoduodenostomy Sphincteroplasty
Number of patients
Percentage
28 8 12 13 11 2
58 17 25 27
renders the palpation of stones difficult and makes the common bile duct and hepatic artery prone to injury. The routine use of operative cholangiography under emergency conditions minimizes the risks of the operation and remains the only practical and reliable guide for formal choledochal exploration. With proper equipment and the skill gained by routine use, operative cholangiography in acute cases is not difficult to perform or time-consuming, and is of great clinical value. In our view, the results of this study, in particular the low mortality rate, low incidence of residual stones, and absence of traumatic injuries to the common bile duct, support the therapeutic policy we have recommended. The management of acute cholecystitis by early surgery and routine operative cholangiography leads to decreased operative mortality and morbidity, decreased hospitalization, and better long-term results. References
1. Gagic, N., Frey, C.F., Gaines, R.: Acute cholecystitis. Surg. Gynecol. Obstet. 140:868, 1975 2. Du Plessis, D.J., Jersky, J.: The management of acute cholecystitis. Surg. Clin. North Am. 53:1071, 1973
110
3. Glenn, F.: Acute cholecystitis. Surg. Gynecol. Obstet. 143:56, 1976 4. Schein, C.J.: Acute Cholecystitis. New York, Harper and Row, 1971, p. 309 5. Klingensmith, W., Watkins, W.: Cholecystectomy in acute cho!ecystitis. Arch. Surg. 92:689, 1966 6. Ellis, H.: Surgical progress 1975. Postgrad. Med. J. 52:121, 1976 7. Halasz, N.A.: Counterfeit cholecystitis. Am. J. Surg. 130:189, 1975 8. McArthur, P., Cuschieri, A., Sells, R.A., Shields, R.:
World J. Surg. Vol. 3, No. 1, 1979
Controlled clinical trial of early versus interval cholecystectomy. Br. J. Surg. 62:850, 1975 9. van der Linden, W., Sunzel, H.: Early versus delayed operation for acute cholecystitis. Am. J. Surg. 120:7, 1970
French S u m m a r y and Invited C o m m e n t a r i e s by C. F. Frey; R. Shields; W . van der Linden on pp. 1 3 6 - 1 4 0 .
The Value of Early Surgery and Routine Operative Cholangiography in the Management of Acute Cholecystitis Raphael Reiss, M.D., Serge Pikelnie, M.D., and Moshe Engelberg, M.D. Departments of Surgeryand Radiology,MeirGeneral Hospital, Kefar-Saba,and Universityof Tel-Aviv,SacklerMedicalSchool,TelAviv, Israel dures. Despite this, many aspects of management remain controversial. The results in some recently published series have been less than perfect, with mortality rates of up to 8% and frequent failures, such as residual stones or injuries to the common bile duct [1-3]. The principal areas of controversy have been the following: 1. Timing of surgery. In many centers, the advantages of early surgery [4, 5] have been emphasized, while in others, the conservative approach [6, 7] with elective surgery at a later date has been preferred. Comparative studies attempting a statistically valid comparison between the 2 concepts have given equivocal results [8, 9]. 2. Routine use of operative cholangiography. Operative cholangiography in elective cases has been performed in many surgical centers and has decreased mortality and morbidity. However, in acute cases, its use is infrequent, probably for technical reasons. Few, if any, authors recommend its routine use. 3. Extent of surgery. While cholecystostomy historically can claim priority over cholecystectomy, its use in elective operations has practically ceased. In acute cases, however, many surgeons still recommend this limited procedure in a wide spectrum of clinical circumstances. This prospective study of 182 consecutive operations for acute cholecystitis was conceived to assess the value of a therapeutic policy consisting of the following principles: 1. Early surgery, performed within 48 hours after
Acute cholecystitis remains one of the most frequent abdominal emergencies, and yet many aspects of its management remain controversial. This prospective study of 182 consecutive operations for acute cholecystitis was conceived to assess the value of early surgery and routine operative cholangiography in the improvement of both immediate and long-term results. The patients ranged from 26 to 82 years of age, with about 1/3 of them above 60 years. Gangrenous changes were encountered in 21% of patients, and perforated cholecystitis occurred in 2%. No biliary calculi were found in 6%. Cholecystectomy was performed in all patients. A technically successful operative cholangiography via the cystic duct was performed in 94% of patients. No complications due to cholangiography were encountered, and the procedure was 93% accurate (11 false positives, 0 false negatives). The common bile duct was explored in 48 patients (26%) and found to be diseased in 75% of them. There was one postoperative death (0.5%), caused by sepsis and gastrointestinal bleeding. Clinical and x-ray follow-up, ranging from 2-6 years, disclosed 4 residual stones (2%). We conclude that a therapeutic policy combining early surgery with routine operative cholangiography improves results and decreases the incidence of residual ductal abnormalities.
Surgery for acute cholecystitis is one of the most frequently performed urgent intra-abdominal proce-
Presented at the XXVIIth Congress of the SociEt6 Internationale de Chirurgie, Kyoto, Japan, September 3-8, 1977. Reprint requests: Raphael Reiss, M.D., Head of Surgical Department B., Meir General Hospital, Kefar-Saba, Israel.
0364-2313/79/0003-0107 $01.00 9 1979 Soci6t6 Internationale de Chirurgie 107
World J. Surg. Vol. 3, No. 1, 1979
108
Table 1. Initial findings prior to surgery and operative
Table 2. Results of bile cultures and antibiotic sensitivity
cholangiography in 182 patients.
studies in 182 patients.
Acute cholecystitis Gangrenous cholecystitis Perforated cholecystitis Biliary calculi None 1-9
10 or more
Number of patients
Percentage
140 38 4
77 21 2
10 74 98
6 41 53
full diagnostic investigation and adequate preparation. 2. Routine operative cholangiography to avoid both unnecessary explorations and residual pathological conditions in the common bile duct. 3. One-stage definitive procedure, including cholecystectomy and elimination of stones or fibrosis in the common bile duct. Temporary measures, such as cholecystostomy, were not used in this series.
Material and Methods
This group of 182 patients comprises all patients with acute cholecystitis operated on during an 8year period at our hospital. Only histologically confirmed cases were included; patients showing malignant changes were excluded. Intravenous cholangiography was performed within 6 hours of admission, except when diagnosis was previously established. During the later years of the study, endoscopic retrograde cholangiopancreatography was performed in cases of jaundice or inconclusive cholangiography. Operative cholangiography was performed in 95% of the patients, using accepted techniques and an operating table adapted for cholangiography (Veller). The average duration of the operative cholangiography was 7 minutes, and the development of films in the operating room took an average of 5 minutes. Bile cultures and sensitivity studies were performed in all patients. All available patients were submitted for clinical and x-ray follow-up 1 year after surgery.
Results
The patients ranged in age from 26-82 years; 74 of them were above 60 years of age. There were 109 women and 73 men. The gallbladder showed gangrenous changes in 21% of the patients and was perforated in 2%. Ninety-four percent of the patients had 1 or more gallstones (Table 1).
Number of patients Percentage Positive bile culture
99
Escherichia coli
Salmonella Other gram-negative bacteria Miscellaneous Negative bile cultures Antibiotic sensitivity Gentamycin Chloramphenicol Cephaloridine Ampicillin
83
55 52 3 31 14 45 86 71 65 45
Bile cultures were positive in 99 patients (55%) (Table 2). The incidence of positive cultures increased sharply in diabetic and in jaundiced patients. Gram-negative bacteria were found in 36% of the patients. Studies of bacterial sensitivity to commonly used antibiotics showed gentamycin to be the most effective. A technically successful operative cholangiography via the cystic duct was performed in 169 patients (94%) (Fig. 1). Cholangiograms of 47 patients were interpreted as positive, but 11 were false positive. There were no false negatives. Thus, there was an overall accuracy rate of 93%. No complications due to operative cholangiography were encountered in this series. Forty-eight patients (26%) had common bile duct exploration, and 75% were found to have either stones or fibrosis (Table 3). There was a 25% incidence of jaundice. A strong correlation between bilirubin levels and the presence of common bile duct abnormalities was established. Of the 36 patients with either ductal fibrosis or stones, 75% had a bilirubin level of 3 mg% or more. Eight percent of the patients gave a history of pancreatitis; 58% of them had common bile duct abnormalities. Diabetes mellitus was present in 16% of patients; this is 4 times the rate encountered in elective biliary surgery in our hospital. The diabetic patients displayed high rates of positive bile cultures (80%) and of septic complications (35%). Contrary to other published studies, there was no correlation between the number of stones in the gallbladder and involvement of the common bile duct. Thirty-seven percent of patients without stones in the gallbladder had choledochal fibrosis or stones. One death occurred due to sepsis complicated by acute gastrointestinal bleeding. The most frequently encountered complication was wound infection, which occurred in 32 patients (17%). This rate is more than 3 times as high as in elective cases. On
R. Reiss et al.: Management of Acute Cholecystitis
INTERPRETED 9
47
ABNORMAL CBD FINDINGS 37 CASES
POS,TIVEI
CASES
I
NO ABNORMAL FINDINGS II CASES
INTERPRETED
L
NEGATIVEI
22 CASES
/
%
CBD EXPLORATION NO ABNORMAL FINDINGS I CASE
FALSE- POSITIVE
NO CBD EXPLORATION NO ABNORMAL F UP FINDINGS 121 CASES
FALSE - NEGATIVE O CASES
II CASES 7 %
TOTAL
109
ACCURACY
--
Fig. 1. Results of operative cholangiography in 169 patients.
93 %
the average, wound infection increased hospitalization by 4 days (12 days versus 8 for uncomplicated cases). Occurrence of wound infections correlated positively with diabetes and positive bile cultures. We found no correlation between septic complications and the presence of jaundice or the age of the patient. Most patients (87%) in this series received antibiotics postoperatively. The antibiotics used most frequently were ampicillin, cephaloridine, and gentamycin. There were 4 instances of respiratory complications and 4 other patients had miscellaneous complications. The patients were followed up for 1-6 years. Four cases of residual stones and 1 case of residual sphincter fibrosis were diagnosed. Three of the patients with residual stones underwent further surgery; one patient refused an additional operation. There were no strictures or traumatic injuries to the common bile duct or the hepatic artery.
Discussion
The controversy over the proper timing of intervention in acute cholecystitis has centered around emergency versus elective surgery. In this study, we have chosen an intermediate solution, namely, early surgery within 48 hours of admission to the surgical ward. The 48-hour period was used for preparation and adequate diagnostic investigation. The use of intravenous cholangiography and endoscopic retrograde cholangiopancreatography, when needed, considerably reduced the number of diagnostic errors. Definitive surgery was performed in all cases, and temporary cholecystostomy was avoided. Operative cholangiography has proven particularly valuable in the management of acute cholecystitis. The edema around the vital structures
Table 3. Results of exploration of the common bile duct in
48 patients.
Choledochal calculi Choledochal fibrosis No abnormal findings Internal drainage performed Choledochoduodenostomy Sphincteroplasty
Number of patients
Percentage
28 8 12 13 11 2
58 17 25 27
renders the palpation of stones difficult and makes the common bile duct and hepatic artery prone to injury. The routine use of operative cholangiography under emergency conditions minimizes the risks of the operation and remains the only practical and reliable guide for formal choledochal exploration. With proper equipment and the skill gained by routine use, operative cholangiography in acute cases is not difficult to perform or time-consuming, and is of great clinical value. In our view, the results of this study, in particular the low mortality rate, low incidence of residual stones, and absence of traumatic injuries to the common bile duct, support the therapeutic policy we have recommended. The management of acute cholecystitis by early surgery and routine operative cholangiography leads to decreased operative mortality and morbidity, decreased hospitalization, and better long-term results. References
1. Gagic, N., Frey, C.F., Gaines, R.: Acute cholecystitis. Surg. Gynecol. Obstet. 140:868, 1975 2. Du Plessis, D.J., Jersky, J.: The management of acute cholecystitis. Surg. Clin. North Am. 53:1071, 1973
110
3. Glenn, F.: Acute cholecystitis. Surg. Gynecol. Obstet. 143:56, 1976 4. Schein, C.J.: Acute Cholecystitis. New York, Harper and Row, 1971, p. 309 5. Klingensmith, W., Watkins, W.: Cholecystectomy in acute cho!ecystitis. Arch. Surg. 92:689, 1966 6. Ellis, H.: Surgical progress 1975. Postgrad. Med. J. 52:121, 1976 7. Halasz, N.A.: Counterfeit cholecystitis. Am. J. Surg. 130:189, 1975 8. McArthur, P., Cuschieri, A., Sells, R.A., Shields, R.:
World J. Surg. Vol. 3, No. 1, 1979
Controlled clinical trial of early versus interval cholecystectomy. Br. J. Surg. 62:850, 1975 9. van der Linden, W., Sunzel, H.: Early versus delayed operation for acute cholecystitis. Am. J. Surg. 120:7, 1970
French S u m m a r y and Invited C o m m e n t a r i e s by C. F. Frey; R. Shields; W . van der Linden on pp. 1 3 6 - 1 4 0 .
