title: Percutaneous Drainage versus Emergency Cholecystectomy for the Treatment of Acute Cholecystitis in Critically Ill Patients: Does it Matter? Laparoscopic Versus Open Cholecystectomy: A Prospective Comparative Study in the Elderly With Acute Cholecystitis Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a prospective randomized trial Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): Study protocol for a randomized controlled trial Systematic review of cholecystostomy as a treatment option in acute cholecystitis. Acute Cholecystitis: Early Versus Delayed Cholecystectomy, A Multicenter Randomized Trial (ACDC Study, NCT00447304) Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment A retrospective comparison of older and younger adults undergoing early laparoscopic cholecystectomy for mild to moderate calculous cholecystitis. Conservative treatment versus endoscopic sphincterotomy in the initial management of acute cholecystitis in elderly patients at high surgical risk.
abstract: 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 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 : The role of laparoscopic cholecystectomy for acute cholecystitis is not yet clearly established . The aim of this prospect i ve r and omized study was to evaluate the safety and feasibility of laparoscopic cholecystectomy for acute cholecystitis and to compare the results with delayed cholecystectomy . Methods : Between January 2001 and November 2002 , 40 patients with a diagnosis of acute cholecystitis were assigned r and omly to early laparoscopic cholecystectomy within 24 h of admission ( early group , n = 20 ) or to initial conservative treatment followed by delayed laparoscopic cholecystectomy , 6 to 12 weeks later ( delayed group , n = 20 ) . Results : There was no significant difference in the conversion rates ( early , 25 % vs delayed , 25 % ) , operating times ( early , 104 min vs delayed , 93 min ) , postoperative analgesia requirements ( early , 5.3 days vs delayed , 4.8 days ) , or postoperative complications ( early , 15 % vs delayed , 20 % ) . However , the early group had significantly more blood loss ( 228 vs 114 ml ) and shorter hospital stay ( 4.1 vs 10.1 days ) . Conclusions : Early laparoscopic cholecystectomy for acute cholecystitis is safe and feasible , offering the additional benefit of a shorter hospital stay . It should be offered to patients with acute cholecystitis , provided the surgery is performed within 72 to 96 h of the onset of symptoms Background Laparoscopic cholecystectomy in acute calculous cholecystitis in high risk patients can lead to significant morbidity and mortality .  Percutaneous cholecystostomy may be an alternative treatment option but the current literature does not provide the surgical community with evidence based advice . Methods / Design The CHOCOLATE trial is a r and omised controlled , parallel-group , superiority multicenter trial . High risk patients , defined as APACHE-II score 7 - 14 , with acute calculous cholecystitis will be r and omised to  laparoscopic cholecystectomy or percutaneous cholecystostomy . During a two year period 284 patients will be enrolled from 30 high volume teaching hospitals . The primary endpoint is a composite endpoint of major complications within three months following r and omization and need for re-intervention and mortality during the follow-up period of one year . Secondary endpoints include all other complications , duration of hospital admission , difficulty of procedures and total costs . Discussion The CHOCOLATE trial is design ed to provide the surgical community with an evidence based guideline in the treatment of acute calculous cholecystitis in high risk patients .Trial Registration Netherl and s Trial Register ( NTR ) : 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 Objective : Acute cholecystitis is a common disease , and laparoscopic surgery is the st and ard of care . Background : Optimal timing of surgery for acute cholecystitis remains controversial : either early surgery shortly after hospital admission or delayed elective surgery after a conservative treatment with antibiotics . Methods : The ACDC ( “ Acute Cholecystitis — early laparoscopic surgery versus antibiotic therapy and Delayed elective Cholecystectomy ” ) study is a r and omized , prospect i ve , open-label , parallel group trial . Patients were r and omly assigned to receive immediate surgery within 24 hours of hospital admission ( group ILC ) or initial antibiotic treatment , followed by delayed laparoscopic cholecystectomy at days 7 to 45 ( group DLC ) . For infection , all patients were treated with moxifloxacin for at least 48 hours . Primary endpoint was occurrence of predefined relevant morbidity within 75 days . Secondary endpoints were as follows : ( 1 ) 75-day morbidity using a scoring system ; ( 2 ) conversion rate ; ( 3 ) change of antibiotic therapy ; ( 4 ) mortality ; ( 5 ) costs ; and ( 6 ) length of hospital stay . Results : Morbidity rate was significantly lower in group ILC ( 304 patients ) than in group DLC ( 314 patients ): 11.8 % versus 34.4 % . Conversion rate to open surgery and mortality did not differ significantly between groups . Mean length of hospital stay ( 5.4 days vs 10.0 days ; P < 0.001 ) and total hospital costs ( & OV0556;2919 vs & OV0556;4262 ; P < 0.001 ) were significantly lower in group ILC . Conclusions : In this large , r and omized trial , laparoscopic cholecystectomy within 24 hours of hospital admission was shown to be superior to the conservative approach concerning morbidity and costs . Therefore , we believe that immediate laparoscopic cholecystectomy should become therapy of choice for acute cholecystitis in operable patients . ( NCT00447304 Abstract . Our objective was to compare the effectiveness of percutaneous cholecystostomy ( PC ) vs conservative treatment ( CO ) in high-risk patients with acute cholecystitis . The study was r and omized and comprised 123 high-risk patients with acute cholecystitis . All patients fulfilled the ultrasonographic criteria of acute inflammation and had an APACHE II score ≥12 .  Percutaneous cholecystostomy guided by US or CT was successful in 60 of 63 patients ( 95.2 % ) who comprised the PC group . Sixty patients were conservatively treated ( CO group ) . One patient died after unsuccessful PC ( 1.6 % ) . Resolution of symptoms occurred in 54 of 63 patients ( 86 % ) . Eleven patients ( 17.5 % ) died either of ongoing sepsis ( n=6 ) or severe underlying disease ( n=5 ) within 30 days . Seven patients ( 11 % ) were operated on because of persisting symptoms ( n=3 ) , catheter dislodgment ( n=3 ) , or unsuccessful PC ( n=1 ) . Cholecystolithotripsy was performed in 5 patients ( 8 % ) . Elective surgery was performed in 9 cases ( 14 % ) . No further treatment was needed in 32 patients ( 51 % ) . In the CO group , 52 patients ( 87 % ) fully recovered and 8 patients ( 13 % ) died of ongoing sepsis within 30 days . All successfully treated patients showed clinical improvement during the first 3 days of treatment . Percutaneous cholecystostomy in high-risk patients with acute cholecystitis did not decrease mortality in relation to conservative treatment . Percutaneous cholecystostomy might be suggested to patients not presenting clinical improvement following 3 days of conservative treatment , to critically ill intensive care unit patients , or to c and i date s for percutaneous cholecystolithotripsy 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 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
target: Conclusion : Early cholecystectomy seems to be a feasible treatment in elderly patients with acute cholecystitis .
background: 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 .