الفهرس 
Acute CholecystitisOnly 14 pages are availabe for public view
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Abstract
Acute cholecystitis is defined as acute inflammation involving the gallbladder wall. Gallstones accounts for 95% of all causes of acute cholecystitis. It is the second most common cause of inflammatory acute abdomen.
Since early 1990s, laparoscopic cholecystectomy had become the standard treatment for patients with symptomatic cholecystolithiasis.
We aimed in this study to evaluate the safety, the feasibility and the best timing of laparoscopic cholecystectomy in cases with acute calculus cholecystitis.
This study was analytical prospective study, which includes 50 patients who present with acute calculus cholecystitis admitted in the general surgery department at Damanhur Medical National Institute in the period from April 2016 to December 2018.
The diagnosis of acute calculus cholecystitis was made clinically followed by ultrasonography in all patients according to revised Tokyo guidelines diagnostic and severity assessment criteria 2013.
The included patients in this study were those who meet the diagnostic criteria of acute cholecystitis, as a definite diagnosis, according to revised Tokyo guidelines (TG13/TG18), with grade I (mild) or grade II (moderate) acute cholecystitis according to TG13/TG18 severity assessment criteria and who were ASA-PS < III, CCI< 6.
The excluded Patients are those with severe (grade III) acute cholecystitis according to severity assessment criteria of TG13/TG18, pancreatitis or cholangitis, diagnostic uncertainty, concomitant malignant disease, patients with concomitant common bile duct stone or those with ASA-PS ≥ III and CCI ≥ 6.
All the patients included in this study was treated by early laparoscopic cholecystectomy.
According to the severity, the patients were divided in into mild (n=26)) and moderate groups (n=24)), while according to timing of surgery, the patients were divided into group 1: ≤ 3 days from the onset of symptoms (n=26), group 2: > 3 days to ≤ 7 days (n=16) and group 3: > 7 days (n=8). Thirty four (68%) patients of the studied cases were females (and 32% (n=16) of them were males.
The results of the comparison between mild and moderate group, regarding the preoperative data shows a significant difference between both groups in preoperative TLC, CRP, Temperature and timing of surgery, as the moderate group being associated with higher levels of these parameters and being associated with a significant delayed timing of surgery.
Moderate group has been associated with statistically significant higher intraoperative difficulty and being associated with a significant prolonged mean operative time (72.54±21.93) versus (47.12±8.85) minutes in the mild group. However, the mean of intraoperative blood loss was significantly larger in the moderate group, there was no blood loss that require blood transfusion or conversion to open surgery.
Three cases (12.5%) of the moderate group and none of the mild group was converted to open surgery. The difference between both groups is statistically insignificant.
As regards postoperative complications, there was no reported mortality in the current study. There was also no bile duct injury or postoperative bleeding.
Moderate group was associated with higher incidence of postoperative complications including port site infection, seroma and postoperative ileus with insignificant difference between both groups.
Furthermore, moderate group was associated with a significant higher incidence of postoperative fever and pain severity and consequently higher analgesic dose. The mean total hospital stay was significantly longer in the moderate group (33 ±17.06 hours) than mild group (24 hours).
In comparison among the timing group, the distribution of preoperative TLC, CRP and temperature showed significant difference among the three timing groupsA delay in the timing of surgery was associated with higher incidence of intraoperative difficulties, there was a significant higher incidence of dense adhesions, more complex gallbladder phlegmons and the presence of peicholecystic pus with the advance of time (group 3> group2 > group 1). There was also a significant higher incidence of spillage of contents and difficult retrieval of gall bladder with delay of surgery.
Delayed surgery was also associated with a significant longer operative time and being associated with larger amounts of intraoperative blood loss.
Furthermore, delayed surgery was associated with higher incidence of postoperative complications regarding port site infection, seroma and ileus. It also was associated with significant higher incidence of postoperative fever, more severe pain and consequently higher doses of analgesia.
The conversion rate in our study was 6%. group 3 (> 7 days) was associated with statistically significant higher incidence of conversion than group 2 (4-7 days) while, for all cases of group 1, LC was completed successfully.
The mean hospital stay was significantly longer in group 3 than group 2 (45±23.9) versus (27±8.2) hours respectively, while, all patients of group one were discharged home within 24 hours.
It may thus be concluded that laparoscopic cholecystectomy for both grade I and grade II AC according Tokyo guidelines 2013 severity assessment is safe and feasible procedure and should be performed as early as possible, as early LC is associated with the least complications and least intraoperative difficulty particularly when performed within seven days from the onset of symptoms.