Between April 2014 and March 2018, 223 patients underwent cholecystectomy at the Department of Surgery, Japanese Red Cross Kanazawa Hospital, Kanazawa, Japan. Of these 248 patients, we excluded 80 patients because they underwent emergency surgery for acute cholecystitis within 72 hours (n = 44), were diagnosed with gallbladder polyp (n = 18) or gallbladder cancer (n = 6), or they underwent choledocholithotomy or simultaneous resection of other organs (n = 12). Therefore, the final study group constituted 168 patients treated by cholecystectomy for acute cholangitis and cholecystitis caused by gallstones after conservative therapy of > 72 hours. Preoperative clinical diagnoses were made on the basis of each patient’s history of right upper abdominal pain and tenderness, fever, blood examinations such as blood cell counts, and increased C-reactive protein (CRP), aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, γ- glutamyltranspeptidase, and total bilirubin levels. Additionally, positive signs on ultrasonography or computed tomography (CT) of a thickened gallbladder wall and pericholecystic fluid collection were confirmed by expert ultrasonographers and two radiologists. The severity classification of patients’ cholangitis and cholecystitis was graded according to the 2018 Tokyo Guidelines . All resected specimens were evaluated histopathologically by the same pathologist. This study was approved by the Institutional Review Board of the Japanese Red Cross Kanazawa Hospital.
Because of the lack of full-time anesthesiologists, we performed initial conservative therapy for acute cholecystitis after obtaining patients’ consent and after excluding patients who could not be treated conservatively and who required emergency surgery. Conservative treatment was defined as antibacterial therapy, fasting, infusion management, and analgesia. Antibiotics were tazobactam and piperacillin hydrate, and pain management involved nonsteroidal anti-inflammatory drugs or acetaminophen. A single gastroenterologist performed endoscopic retrograde biliary drainage for acute cholangitis. Oral intake resumed when improved abdominal tenderness was observed, and we discharged patients after confirming improvement in their inflammatory response according to blood examination findings. When we discharged patients from the hospital, we discussed the necessity of surgery and scheduled elective LC at least 4 weeks after conservative therapy. We defined preoperative waiting days in this study as from the day the appointment for surgery was scheduled to the day of the elective surgical procedure.
LC was performed using a standard four-trocar technique. Briefly, the anesthetized patient was placed in the standard supine, crucifix, reverse-Trendelenburg position, with the surgeon on the patient’s left side. Pneumoperitoneum was achieved by visually-guided, cannular carbon dioxide insufflation. Dissection began at Calot’s triangle to confirm a safe surgical field of view, then the cystic duct, common bile duct, and cystic artery were exposed and divided between the clips. Intraoperative cholangiography was not routinely performed. When the anatomy of Calot’s triangle was unclear or inflammation in the gallbladder neck was advanced, the bile duct stump was treated at the neck, and cholecystectomy was limited to a partial resection. The gallbladder was carefully mobilized from the liver bed using electrocautery, and an endo-bag was always used to remove the gallbladder to prevent wound infection. The abdominal cavity was irrigated before the trocars were removed, and the fascial defects were closed.
The data were retrospectively collected from medical records and operative reports. We divided patients into a recurrent group (group A) and a nonrecurrent group (group B) of acute cholangitis and cholecystitis while waiting for cholecystectomy, and we evaluated the outcomes for each group. We evaluated patients’ clinical characteristics on admission, namely, patient’s American Society of Anesthesiologists physical status (ASA-PS) score and age-adjusted Charlson comorbidity index (CCI), medical history associated with gallstones, laboratory data before cholecystectomy, abdominal CT, and surgical outcomes. For the analyses, we used the highest values for the laboratory data and CT measurements from the first episode of acute cholangitis and cholecystitis. Evaluated surgical outcomes were the conversion rate, operation time, blood loss (minimal bleeding was defined as 0 mL), operative complications, presence or absence of a drain, and length of hospital stay.
Values were expressed as means ± standard deviations, and we used the two-sided Student’s t test and the Mann–Whitney U test for continuous data. The cutoff values for the continuous variables were calculated using a receiver operating characteristic curve analysis, and comparisons were made using the Chi-squared test with Yates’ correction. Variables considered to have an apparent confounding effect were excluded from the multivariate analysis, even if found to be significant in the univariate analysis. All statistical analyses were performed using the SPSS software package, version 10.0 (IBM Corp., Armonk, NY, USA). Significance was defined as P < 0.05.