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Evolving Treatment Paradigms for Acute Cholecystitis: Comment on “Surgical Management of Acute Cholecystitis at a Tertiary Care Center in the Modern Era”

Evolving Treatment Paradigms for Acute Cholecystitis: Comment on “Surgical Management of Acute... Over the past 2 decades, laparoscopy has revolutionized the surgical management of AC. Within the limits of a retrospective study, this review of 809 patients documents the progressive use of LC and the gradual abandonment of OC at a tertiary medical center. In most cases of AC, the critical operative anatomy can be demonstrated, despite inflammatory changes. The authors confirm that LC can be completed by most (as opposed to selected) general surgeons with minimal risk of bile duct injury. Operative cholangiography is usually unnecessary when the anatomy is clear. Cholangiography was used liberally in this study; the actual indications such as elevated liver function test results are not discussed. We usually perform endoscopic retrograde cholangiopancreatography before surgery if choledocholithiasis is suspected. If anatomic landmarks are unclear laparoscopically, there are several options. We frequently convert to OC in this setting (eg, when a large gallstone is impacted in the neck of a thickened immobile gallbladder). Wiseman et al mention the uncommon performance of laparoscopic partial cholecystectomy in 9 patients; outcomes of these patients would be of interest. Older patients with multiple comorbidities are a growing challenge and a subject for further studies. Percutaneous cholecystostomy quiets down the acute illness and allows later medical management, LC, or OC. Following surgical evaluation, we customarily perform percutaneous cholecystostomy in the interventional radiology suite. In this study, many procedures were performed in the operating room. Did this subject patients to unnecessary anesthesia, risk, and cost? Was a planned LC aborted in some of these cases? The selection process for later cholecystectomy is not described. Presumably, the procedure was chosen for symptomatic patients with manageable comorbidities. Did eligible patients undergo tube cholangiography? Such studies could identify patients at higher risk for further attacks, with findings such as immobile gallstones in the gallbladder neck, cystic duct obstruction, or choledocholithiasis. Back to top Article Information Correspondence: Dr Welch, 85 Seymour St, Hartford, CT 06117 (jwelch@ctsurgical.com). Financial Disclosure: None reported. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Evolving Treatment Paradigms for Acute Cholecystitis: Comment on “Surgical Management of Acute Cholecystitis at a Tertiary Care Center in the Modern Era”

Archives of Surgery , Volume 145 (5) – May 1, 2010

Evolving Treatment Paradigms for Acute Cholecystitis: Comment on “Surgical Management of Acute Cholecystitis at a Tertiary Care Center in the Modern Era”

Abstract

Over the past 2 decades, laparoscopy has revolutionized the surgical management of AC. Within the limits of a retrospective study, this review of 809 patients documents the progressive use of LC and the gradual abandonment of OC at a tertiary medical center. In most cases of AC, the critical operative anatomy can be demonstrated, despite inflammatory changes. The authors confirm that LC can be completed by most (as opposed to selected) general surgeons with minimal risk of bile duct injury....
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Publisher
American Medical Association
Copyright
Copyright © 2010 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.2010.53
Publisher site
See Article on Publisher Site

Abstract

Over the past 2 decades, laparoscopy has revolutionized the surgical management of AC. Within the limits of a retrospective study, this review of 809 patients documents the progressive use of LC and the gradual abandonment of OC at a tertiary medical center. In most cases of AC, the critical operative anatomy can be demonstrated, despite inflammatory changes. The authors confirm that LC can be completed by most (as opposed to selected) general surgeons with minimal risk of bile duct injury. Operative cholangiography is usually unnecessary when the anatomy is clear. Cholangiography was used liberally in this study; the actual indications such as elevated liver function test results are not discussed. We usually perform endoscopic retrograde cholangiopancreatography before surgery if choledocholithiasis is suspected. If anatomic landmarks are unclear laparoscopically, there are several options. We frequently convert to OC in this setting (eg, when a large gallstone is impacted in the neck of a thickened immobile gallbladder). Wiseman et al mention the uncommon performance of laparoscopic partial cholecystectomy in 9 patients; outcomes of these patients would be of interest. Older patients with multiple comorbidities are a growing challenge and a subject for further studies. Percutaneous cholecystostomy quiets down the acute illness and allows later medical management, LC, or OC. Following surgical evaluation, we customarily perform percutaneous cholecystostomy in the interventional radiology suite. In this study, many procedures were performed in the operating room. Did this subject patients to unnecessary anesthesia, risk, and cost? Was a planned LC aborted in some of these cases? The selection process for later cholecystectomy is not described. Presumably, the procedure was chosen for symptomatic patients with manageable comorbidities. Did eligible patients undergo tube cholangiography? Such studies could identify patients at higher risk for further attacks, with findings such as immobile gallstones in the gallbladder neck, cystic duct obstruction, or choledocholithiasis. Back to top Article Information Correspondence: Dr Welch, 85 Seymour St, Hartford, CT 06117 (jwelch@ctsurgical.com). Financial Disclosure: None reported.

Journal

Archives of SurgeryAmerican Medical Association

Published: May 1, 2010

Keywords: cholecystitis, acute,surgical procedures, operative,tertiary care hospitals

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