Gallstones

Takeaway points cholecystitis RUQ pain minimal elevations in labs LFTs, Bilirubin

Cholangitis LFTs > 1000s, Bilirubin up, WBC up

Diagnose - U/S -> HIDA -> CT -> ERCP -> 

Txt - Zosyn, ctx, flagyl, ciprofloxacin, flagyl, imipenem, meropenem

cholecystectomy in 48-72 hours laparoscopic

Targets: Strep, Klebsiella, e. coli

Cholecystitis: 

Complications: cholecystenteric fistula (gallstone ileus)

mirizzi syndrome: gallstone in cystic duct, jaundice, dilated common hepatic duct caused by extrinsic compression

 

Ciprofloxacin, flagyl

Levofloxacin started by the emergency department. Levofloxacin has more broad coverage and less resistant profile compared to ciprofloxacin

Cholecystectomy

Cholecystitis

HIDA scan

CT abdomen / pelvis

Cholecystitis at last admission

Became chronic 

 

Correlate to exclude cholecystitis

HIDA would be useful

Maybe cholecystitis / maybe not cholecystitis

HIDA scan at last admission would know cholecystitis or not

If gallbladder is contracting not cholecystitis

If gallbladder is not contracting cholecystitis

RUQ ultrasound then HIDA scan

Cholecystitis became chronic

Tired, poor oral intake, fever

 

 

Biliary colic 30 to 6 hours

20 minutes to 6 hours

Nausea and vomiting

Fever, leukocytosis, elevated liver enzymes indicate acute cholecystitis / obstruction

 

Cholecystitis epigastric or RUQ pain, fever, bilirubin < 4mg / dl

Minimally elevated AST / ALT leukocytosis

Calculous or acalculous

Bilirubin > 4mg / dl

AST + ALT > 1000 U/L

Cholangitis right upper quadrant pain, fever, jaundice plus shock and mental status changes

Bilirubin > 4

AST + ALT high

More extreme, more jaundice, more obstructive pattern

Gallstone ileus

Biliary colic

Small bowel obstructive

 

Obstruction

U/S / CT scan there is air in the biliary tree. Where does air come from? Fistula between the bowels and bladder. Cholecystenteric fistula

Mirizzi syndrome

- Gallstone in the cystic duct, jaundice, and dilated common hepatic duct

Gallbladder will enlarge, will press the ducts. Press the common hepatic duct.

Because it compresses, will cause jaundice. Will give jaundice. Cholecystitisusually cholic in gallbladder will not give jaundice.

Obstruction in cystic duct, gallbladder get bigger, compress common hepatic duct

Obstruct pathway for the drainage. Make patient have jaundice.

Acute cholecystitis beta lactam / beta lactamase inhibitor cephalosporin + metronidazole

No pcn levoquine

Acute cholangitis

Surgery before hospital discharge

ERCP removal of CBD.

Surgery before discharge

Acute cholangitis same antibiotics+ ERCP removal of common bile duct stone

When there is obstruction have to relieve

Have to get rid of infection

Is this cholecystitis or cholangitis? 

Liver enzymes doesn’t have to be high to diagnose cholecystitis. Not necessarily cholecystitis. Cholecystitis doesn’t affect the drainage of the liver secretions. Cholecystectomy when?

 

 

Abx of 

 

Urgent ERCP

 

E incidental findings, clinical observation

Piperacillin Tazobactam

Cholecystitis, acute: IV: 3.375 g or 4.5 g every 6 hours; continue for 1 day after gallbladder removal or until clinical resolution in patients managed nonoperatively

Ampicillin Sulbactam

3 g every 6 hours; following clinical improvement, transition to oral step-down therapy and continue antibiotics until resolution, typically for a total of 7 to 14 days.

from the JAMA Network this is JAMA  clinical reviews interviews and ideas  

about Innovations in Medicine  Science and clinical practice

I'm Dr KristIn Walter associate editor at JAMA  and a pulmonary critical care physician I'm  

joined today by Dr Anthony Charles who is chief  of the division of trauma critical care and acute  

care surgery director of the ECMO program and  director of global surgery at the University  

of North Carolina in Chapel Hill North Carolina  Dr Charles is also an associate editor at JAMA  

we will be discussing the article of the Dr  Charles co-wrote with Dr Jared R Gallagher  

entitled acute cholecystitis a review which  was published in the March 8 2022 issue of Jama  

thank you for joining us Dr Charles thank you  very much and I'm happy to be here to start off  

approximately how many people in the U.S are  diagnosed with acute cholecystitis each year  

approximately 200 000 people are diagnosed  with acute cystitis in the United States  

and the most important risk factor for  acute cholecystitis is the presence of  

gallstones can you discuss how many people in  the U.S are estimated to have gallstones and  

what percentage will go on to develop acute  cholecystitis over their lifetime close to 25  

million people currently have gallstones in  the United States but only approximately 20  

percent of those patients will actually become  symptomatic of any sort of gallbladder issues  

within those approximately five percent  will end up having acute cholecystitis  

so it sounds like there are a lot of people  walking around with gallstones uh what are some  

important risk factors for gallstones first of  all patients with hemolytic anemias particularly  

sickle cell disease and thalassemia have an  increased risk of having gallstones obesity  

is a known risk factor but interestingly also a  rapid weight loss if you lose approximately 25  

percent of your week within a year you'll  have a higher chance of having gallstones  

there are some medications that have been known to  be associated with the formation of gallstones and  

those are things like Oxford tide or hypoglycemic  medications particularly the newer Newark glucagon  

are like peptide analogues are like exanatide  and lower anglutite so this will be the main  

risk factors for causal information and what  about difference in Sex and also pregnancy  

so gallstones are more likely in women than in  men but as you age by the time you're over 65  

this differences go away and of course pregnancy  is a known risk factor for gallstones the exact  

ideology of why pregnancy causes gallstones is  not very clear but in the prenatal period and  

also in the postpartum period there's a high  chance of having all students or or biliary  

sludge which is this combination of mucos and  cholesterol crystals within the gallbladder  

and in terms of pathophysiology your article  discusses how after a gallstone obstructs the  

cystic duct acute cholecystitis progresses  in three distinct phases can you describe  

those phases for us certainly there's the acute  phase in which you have 

Initial

- gallbladder wall congestion + edema 2-4 days

- Hemorrhagic phase blood w/in wall leading to necrosis, can perforate necrosis and ischemia

- Omentum can get stuck to gallbladder

Acute complicated cholecystitis

- gangrene as gallbladder wall is dead and gallbladder wall perforation resulting in biliary peritonitis

- cholecystoduodenal fistula

- gallstone ileus

Acalculous cholecystitis

initials of gallbladder  

wall congestion and edema and this typically lasts  two to four days from the onset of symptoms this  

stem can then progress into what is a what I'll  call a hemorrhagic phase in which you have blood  

within the wall of the gallbladder and that can  potentially lead to necrosis of the wall of the  

gallbladder in some patients this may perforate  uh let's get the area of necrosis and ischemia  

and then the third phase of course is after you  are roughly around about three to five days after  

the onset of symptoms you may end up going through  what I call a chronic or a purulent face and this  

is characterized by leukocyte infiltration passed  within the gallbladder and gross infection within  

the gallbladder wall typically these patients  will have the the omentum stuck to the gallbladder  

and they are less sick at this point in time and  this the third faces occurs on day six and later  

and how would you define acute complicated  cholecystitis acute complicated cholecystitis is  

essentially a patient that has acute cholecystitis  that has resulted in either gangrene as the  

gallbladder wall is dead has a gallbladder wall  perforation a resulting in biliary peritonitis  

or has essentially a cholecysto duodenal fistula  that is the gallbladder has now attached itself  

to the duodenum and stones have gone across  and then they have what we call a gallstone  

Alias that is the stone is now of causing  a small ball of structure this will be the  

as of the complicated cholecystitis in which  the managements are slightly more challenging  

and now I'd like to shift to a calculus acute  cholecystitis how common is this condition and  

what are some risk factors for  a calculus corollary cystitis  

so a calculator Society is typically a cause  between five and ten percent of the population  

the risk factors are essentially patients in the  critical care setting critically ill patients  

they're in the ICU for other non-biliary related  reasons either following major trauma major Burns  

being on a total parenteral Nutrition is a risk  factor for a calculus cholecystitis this will be  

the main risk factors but other things such as  you know I haven't had cardiopulmonary bypass  

will be a reason to have a calculus cholecystitis  and just to clarify that represents about five  

percent of all acute cholecystatus cases correct  and what is thought to be the pathogenesis of  

acute cholecystitis without a gallstone because  certainly with gallstone it makes sense there's a  

blockage of the duct but what is the pathogenesis  of this disease certainly what typically happens  

is that you have bile stasis so imagine if you  will a patients in the ICU has not been fed orally  

the bile on the gallbladder essentially just sits  there you don't get the normal squeeze to eject  

bile from the gallbladder the gallbladder  distends and with this distension you're  

essentially compress the blood vessels to the  wall of the gallbladder and some people actually  

believe that you actually have some Associated  endothelial injury secondary to the inflammation  

caused by the bile stasis that you started  off with and that's what we think causes it  

it is very hard to say but that's a presumptive uh  hypothesis regarding how a calculus cholecystitis  

occur more importantly these patients have other  reasons to have endothelial injury they're usually  

in the ICU for sepsis or for trauma or for burn  and this can result in a hypoperfusion State and  

that clearly would reduce the blood supply  to the one of the gallbladder and hence you  

may end up having a calculus quality status of  the inflammation of the wall of the gallbladder  

interesting in terms of the diagnosis of acute  cholecystitis ultrasonography is considered the  

initial Imaging modality of choice can  you describe the diagnostic accuracy of  

the ultrasound for acute echolicystitis and  what's the typical findings are on ultrasound  

so certainly so the ultrasound is actually  preferred as the first modality because it is  

non-invasive and it is relatively low cost  and easily accessible and most nearly all  

hospitals will have it and there's no ionizing  radiation associated with this this sensitivity  

for diagnosis or calculus Society is about  each one percent and the specific disease is  

about 80 in acute cholecystitis the signs of acute  cholecystitis on ultrasound include pericolicistic  

fluid which is essentially freed around the  gallbladder the gallbladder will be distended  

you'll see edema of the gallbladder wall and  gallstones or sludge may be seen and that those  

are the typical signs of acute cholecystitis on  ultrasonography and what are some other Imaging  

modalities that may be used for diagnosis of  acute cholecystitis and when should they be  

used certainly if a patient has signs or symptoms  of vacuole societies and ultrasounds does not give  

you the typical findings the alternative uh  include a CT scan of the abdomen and pelvis  

looking at the right of accordance a CT scan  may be used uh the gallstone detection of the  

CT scan is dependent on the type of gallstones  that are present if they're cholesterol Stones  

they may not essentially light up and also on CT  scan depending on the thickness of the slices on  

the CT scan you may actually miss stones on  the gallbladder however CT scan may also show  

your thickened gallbladder wall pericolocystic  fluid fat stranding around the gallbladder the  

hepatobiliary cintigraphy is actually regarded  as the gold standard also known as a Hider scan  

and essentially this is a test in which our radio  Tracer technician label radio Tracer is injected  

into the patient and the patients should have been  fastened for four to six hours and effectively  

if the patient has got a patent cystic duct the  gallbladder will light up on the scan which means  

the patient does not have acute cholecystitis  if the patient has acute cholecystitis the  

gallbladder will not be visualized and this  is a very very sensitive and specific test for  

acute cholecystitis the sensitivity is about  96 and the specificity is about 90 percent  

all the tests that potentially can help you is  a MRI and magnetic resonance imaging or an MRCP  

MRI of gallbladder will show gallstones make  sure gallbladder won't thickening gallbladder  

oil distension fluid around the liver and  pericolas cystic fluid and any single one of the  

signs a suggestion of acute cystitis the MRI has a  sensitivity of 88 and a specificity or 89 percent  

the importance of the MRCP lies in the fact  that if there are other concomitant issues in  

the biliary system such as cholidocolithiasis  that is Stones within the common bile duct you  

may see this and this may help assist in planning  the therapeutic approach but all in all ultrasound  

is the first test that you should get and I  particular scentography is the gold standard  

in terms of treatment cholecystectomy is  a recommended treatment for calculus acute  

cholecystitis and the laparoscopic approach is  the standard of care in the U.S can you discuss  

the benefits of doing an early cholecystectomy  within one to three days of onset of symptoms  

versus later certainly in the past there was  a belief that if a patient shows up with a  

cused choli societies perhaps one should wait to  let the inflammation cool down but there's been  

several studies and randomized clinical trials  that have shown that undergoing laparoscopic  

cholecystectomy within 24 hours of admission  is beneficial one the patient spends less time  

in the hospital your complication rates are  lower recoveries quicker than the Infectious  

process is limited this was come when we compare  early versus delayed and delayed is typically  

defined as having your cholecystectomy  approximately three days after admission  

there's a significant advantage to  having your gallbladder removed early  

and what percentage of cholecystectomies  that start with a laparoscopic approach  

end up being converted to an open cholecystectomy  approximately two to fifteen percent of patients  

undergoing laparoscopic cholecystectomy  will be converted to an open cholecystectomy  

and are there certain risk factors that make it  more likely that a cholecystectomy will need to be  

converted from a laparoscopic to an open approach  those in the delayed cholecystectomy group are  

more likely to be converted to open being male  being of older age having a high body mass index  

all higher risk factors for undergoing uh  conversion from laparoscopic to open but for  

us in surgery one of the greatest risk factors  is having a prior abdominal operation so if you  

have an upper midline abdominal incision given the  adhesions that may occur in the midline and also  

in the right upper quadrants this increases  your chances of undergoing a conversion from  

laparoscopic to open cholecystectomy and then  lastly having a complicated acute cholecystitis  

increases your chances of conversion to open and  then shifting to pregnant individuals is there  

anything different about their management for  acute cholecystitis that you'd like to discuss  

non-gynecological surgery occurs in approximately  one to two percent of pregnant patients and a lot  

of the abdominal surgeries are going to get  things like acute appendicitis cystectomy in  

the first trimester of pregnancy you're  going to treat the patients the same  

some people have always felt that you should  try and avoid an abdominal operation if you  

can in pregnancy but when it comes to acute  cholecystitis the current guidelines from the  

American College of obstetrics and gynecologists  and the Society of the American gastrointestinal  

and endoscopic surgeons recommends  laparoscopic cholecystectomy be performed  

after acute cholecystitis in any trimester of  pregnancy in the presence of Accu cholecystitis  

and what about elderly patients with acute  cholecystitis should they receive any different  

treatment than standard treatment elderly  patients should undergo standard treatments  

I think the decision in the elderly is really  cloudied by any Associated comorbidities that  

they may have most people who actually would  suggest that you should go ahead and remove  

an elderly and women say Elder years old age  over 65 some people may not think that is old  

and so we'll just call them older patients age  over 65. there's a survival benefits to going  

ahead and removing their gallbladder as opposed  to any other alternative therapeutic strategies  

and another important point that was brought up  in your review was the use of antibiotics in acute  

cholecystitis can you discuss the recommended use  of pre-operative and post-operative antibiotics  

uh certainly once the diagnosis of acute  our polycystitis has made a prior to your  

laparoscopic cholecystectomy patients should  be placed on on IV antibiotics and typically  

the commonest organisms are gram negatives uh E  coli capsular and those patients were placed on  

combination antibiotics such as amoxicillin  tasobactin and in the pre-surgery period or  

the purpose of period antibiotics should be given  the operating room you can also give antibiotics  

before you start the case post-operatively there's  no evidence that a prolonged antibiotics or any  

antibiotics after the gallbladder has been removed  is beneficial and certain patients for the curly  

cystitis have a high perioperative risk either due  to critical illness or because they have multiple  

medical comorbidities can you discuss the option  of percutaneous cholecystostomy tube placement  

in patients with the calculus sclerosis or  patients that are critically ill with Calculus  

cholecystitis given their critical illness and  their significant operative risks percutiness  

tube has always been an option essentially that  is putting the tube through the liver into the  

gallbladder to decompress the gallbladder and  trying to drain any sort of pure lenses on the  

gallbladder has been thought to provide a survival  advantage in reality patience being managed in the  

presence of calculus cholecystitis being managed  with purple discolor testosterone tube do worse  

they have a higher mortality High infection  have a higher reoperative rates eventually  

that patients who you just take to the operating  room and do a laparoscopy called statutory or an  

open cholesterectomy so by and large with  Calculus or in calculus status laparoscopy  

color cystectomy possible open cholesterectomy is  the way to go there's a small subset of patients

in which surgery is significantly prohibitive  those patients May benefit from a percutaneous  

cholesterol switch tube placement but this  should be the exception rather than the rule  

is there anything we haven't discussed about  acute cholecystitis or its management that  

you'd like to mention to our Jama audience  certainly there appears to be a significant  

disparities in patients presenting with  acute cholecystitis in the United States  

underrepresented minority patients since present  later and this could be uh due to access of  

the healthcare system and hence there are more  likely to present with complicated cholecystitis  

but by and large I think early laparoscopic  cholesterectomy should be the standard of care  

that was Dr Anthony Charles who is chief  of the division of trauma critical care  

and acute care surgery director of the ECMO  program and director of global surgery at  

the University of North Carolina in Chapel  Hill North Carolina thank you for sharing  

your thoughts with us about this important  topic thank you very much it was my pleasure  

I'm Walter thank you for listening this episode  was produced by Daniel morrow at the Jana Network  

the audio team here also includes Jesse mccorders  Shelly steffens Lisa Hardy Audrey foreman and  

Mary Lynn perkola Dr Robert golub is the JAMA  executive Deputy Editor to follow this and other  

Gemma Network podcasts please visit us online  at jananetworkaudio.com thanks for listening

good morning thank you to sages for the

opportunity to present such an important

topic that's near and dear to most

general surgeons heart the call for

acute cholecystitis from the ER on a

weekend has become one of the more

dreaded phone calls at least I get on a

call weekend and I would like to present

in this talk an opportunity to provide

another approach sort of a pre-op

bailout procedure and to provide

guidelines based on dr. Santos's

excellent talk to rescue us and maybe

rescue the patient from these difficult

surgeries on a weekend or evening or any

time and their associated complications

so I have no financial disclosures but

as I was preparing this talk and going

through the week listening to some of

the very negative connotations that are

statistically associated with Coley

cystoscopy tubes I realized I had one

very important disclosure for this talk

I am an academic but community surgeon

my main practice is at a 150 bed

Hospital where we do about 8,000 cases a

year in inner-city Allentown so the

perspective that I have is that I do not

have surgical residents on a routine

basis to go see the patient or evaluate

them and if it's Saturday at 2:00

o'clock my our staff maybe the

orthopaedic scrub tech who may know the

difference between a Maryland and a

grasper but not much more than that and

so I really have to take in account what

my resources are as I move forward with

proceeding to surgery on an acute

cholecystitis

so my disclosure is that my bias is that

I live on the frontlines of community

hospital work and I think that does

influence some of our decision tree and

it should so many of us look at this cat

Cat scan

scan on the right hand side here with a

little bit of dread you know if I don't

know about your er but in my ER if you

have belly pain or a few breathe you get

a cat scan so even before the ultrasound

so a living breathing patient will get a

cat scan and usually an ER resident

calls you and says I have somebody with

right upper quadrant pain and their cat

scan shows acute cholecystitis you got

to come operate and you know most of us

are trying to figure out based on that

presentation do we really need to come

in is this really an urgent case to call

the staff in for the weekend.a time the

expense

the burnout level of calling the staff

in and so we need some guidelines to

figure out what to do the slide on the

right hand side is actually more of my

worst nightmare because somebody called

in the ultrasound tech and they showed

no wall thickening and no fluid and it

should be an easy gallbladder just whip

it out at four o'clock on the Saturday

and I put my laparoscope in and

ultrasound maybe wasn't quite what they

advertised it to be as anyone had that

happen here I'm sure somebody has right

so ultrasounds are by far the most

specific and sensitive test however I at

least in my practice I've seen some of

them low me into a complacency that

doesn't necessarily come true

Culture of safety

so I feel very strongly that the culture

of safety and cholecystectomy is more

than just the critical view and this is

something that's very passionate about I

believe the culture of safety is not

just what you do in the operating room

but what you do in your surgical

judgment are there cases when you need

to learn to back away from the table or

not even go there in the first place and

avoid surgical intervention the culture

of safety is more than just knowing how

to operate but it's knowing how to be a

good surgeon and a good physician for

Consider avoidance

your patient so consider avoidance as a

appropriate technique for avoiding the

difficult cholecystectomy this is a bail

out procedure that's actually pretty

reasonable we all know these risk

factors elderly you know the ER calls

you I've got a 300-pound gentleman who's

cholecystitis for about three years he's

known he's had gall stones but he never

came in and now it's 4:30 on Saturday

afternoon and he doesn't feel like I

can't get him home because I can't

control his pain so could you just come

operate on him and take care of this for

me you know and you know maybe he's a

drink or two and has a little bit of

cirrhosis and ironically for the point

of this talk if he's had a percutaneous

Coley cystoscopy tube in the past that

even adds to his risk factors so

consider avoidance as an appropriate

bailout procedure before you even get

started so if you do get one of these

Why drain

patients and we'll talk about the

guidelines on how to get there why would

you do a brain a drainage procedure well

for me there's two ways to look at it

first of all a drainage procedure is a

bridging procedure and

is one of the well-known bridges in

Seattle and this bridging procedure is

in low-risk patients who you know

eventually I'm gonna take their

gallbladder out there if I can just get

them over the hump of this weekend maybe

I'll take it out in a week maybe I'll

take it out in six weeks and we'll we'll

talk about the literature in that and in

some patients minority perhaps but in

some patients this is a definitive

procedure if you have a 93 year-old

demented lady from the nursing home this

might be her one and only treatment for

her gall bladder disease it might not be

appropriate to proceed with further

surgery down the line so as dr. Santos

The Tokyo Guidelines

has eloquently described there are the

Tokyo guidelines I had pulled it up on

my phone since I didn't take a picture

of it and I would encourage every one of

you here to download the app I don't

mind while I'm talking go ahead and look

at your phones and download the app and

the reason being especially for those of

us who are in solo practice which I was

for many years or in an outlying

Community Hospital it gives us some very

objective criteria to help us with our

decision-making and I think especially

for the academic surgeons in the room

who have presidents and fellows that's a

really important point that I a

perspective that I would like to bring

to the table when you're alone in a

Community Hospital up in the Pocono

Mountains for example and you don't have

any help or anyone to run the cat scan

by say hey what would you do about this

or your partner maybe is in Miami for

the weekend and he's not around you it

helps to have some objective criteria to

sort of soothe your ego for lack of a

better word to say I can handle this I'm

at acute care surgeon I can rip anything

out and instead having some guidelines

will really help you determine hey maybe

a cooler wiser head would back away from

the table on this and I'm not saying you

would back away from every acute

cholecystitis but having some objective

guidelines really gives you a sense of I

don't know accomplishment or something

that you can actually have some basis

for your decision so to go in a little

more detail for the next two or three

slides for the Tokyo guidelines there

are three major factors that make up

those recommendations

the Charleston comorbidity index the

anesthesia criteria and then the Tokyo

guidelines the the grading criteria

themselves which dr. Santos went through

Charleston comorbidity index

so

those of you not familiar the Charleston

comorbidity insects index uses icd-9

codes and assigns a weight for each of

these conditions and as the number rises

the predicted mortality rate rises and

the treatment requires more healthcare

resources so you can see if they've had

an MI they get a point if they're

diabetic they may get one or two points

and if they have a malignancy or liver

disease they might get up to six points

and the the sort of cutoff that I read

in the literature somewhere about four

or five if you accumulate four or five

points you're really going to start

increasing your burn bida T and

mortality from this disease then we're

Anesthesia performance status scores

all familiar with the anesthesia

performance status scores obviously the

higher the grade the more likely they're

gonna be perioperative anesthesia or

surgical complications I think we all

know those and the Tokyo grading

severity which we just went over very

nicely combines your clinical status

your physical examination your

laboratory values and your radiographic

findings and I think that's a nice way

to to correlate your grading severity

and as dr. Santos showed in his table

there is a significant and reproducible

relationship between the 30-day

mortality and grades

excuse me and grade three severity

there's a significant almost five and a

half percent mortality and that's all

comers that's fairly significant five

and a half or six out of 100 of your

patients will die so with most of you do

at least a hundred gallbladders a year

maybe more can you imagine five of them

dying that's a pretty big number so the

correlation is is very significant and

we need to keep that in mind so let's go

Flow charts

over the flow charts a little bit in

more depth of how you might make your

decision to back away from that table

I think grade one's pretty easy we all

know this patient they're less than 72

hours they have a fairly low grade mild

acute cholecystitis if it's 2:00 in the

morning antibiotics and supportive care

certainly appropriate there's no need to

burn out your staff and bring them in

for every gallbladder anymore I know

when I trained that's what we did but

maybe that's not necessary but if it's a

Saturday morning you might not want to

wait till Monday morning to take care of

that

some people might opt for observation

but early cholecystectomy is certainly

appropriate

Evaluation

great two gets a little more sticky of

course again we can start with

antibiotics and supportive care and

remember out in the community many of us

do not have residents and in fact I

don't even have a PA many days in the

hospital so I have to haul myself in to

really make this evaluation so if I have

if I'm feeling strong that day or if I

think my partner's not out of town and I

think that they have a reasonable good

favorable factors these symbols here

refer back to the chart with the type of

factors of a comorbidity index and the a

sa class so if they have some favorable

factors maybe I might proceed with a

cholecystectomy knowing that it might be

hard knowing that I might want to have

my better team and a PA to help me that

I know that knows what's doing I'd call

my PA in and not not try to do this with

the scrub tech and myself but if they

have sort of negative risk factors if

they have acute renal injury and several

of those comorbidity indexes I may want

to consider early drainage and again if

you download this app it'll walk you

through this very nicely and tell you

you know within your clinical judgment

what you might want to consider to again

back away from the table and we'll talk

about what to do next after we finish

the talk on drainage so again for people

who have a Charleston insects index of

greater than four and an a si of greater

than three these are people who might

not even withstand surgery and there's a

fair amount of evidence in the Tokyo

guidelines to support this now grade

Grade 3 Severe

three none of us here experienced

academic institution or not really want

to operate on a grade 3 severe

cholecystitis these are people that even

with antibiotics and general organ

support they are very sick they're

septic from their cholecystitis and

there is some of us here who would say

well the best thing to do is get that

gallbladder out and that is true but it

may not be the appropriate step at this

point you have to really look at these

guidelines and consider your judgment so

if they have good factors if you're at

my Bethlehem campus maybe and you have

an advanced laparoscopic surgeon I think

that's very may be doable but I want to

pause for a second here and say consider

your own skills very carefully none of

us like to think that we don't

advanced skills none of us would like to

say oh you know maybe I'm not quite good

enough to take this gallbladder out it's

really not a matter of good enough it's

a matter of having multiple experienced

surgeons in the room together with

different eyes and different skill sets

so put your ego aside at the door you

don't have to say you're not a good

laparoscopic surgeon to decline a grade

partner available or backup available

again I was in solo practice for many

years and these these gall bladders

struck fear in my heart for sure and I

dreaded doing them so if they have a

poor performance score or they have

negative predictive factors I think the

majority of this graph goes too early

and urgent gallbladder drainage and I've

even done this in the operating room

when I've been lulled into a going to

the O R and I get that first picture of

an acute cholecystitis I've drained them

in the operating room I've called IR in

and sometimes my colleagues will come in

and I'd in some cases when I was in some

remote hospitals I put a Foley in the

top of the gallbladder and left a JP

drain next to it because I knew this was

not the appropriate thing

so there are bailout methods that will

get you out of trouble if you don't

perforate the gallbladder to start and

you could handle it very gingerly and

you kind of lift it up and say wow this

one is ugly there are ways to bailout

without ever having to cut into the

gallbladder most of us are familiar with

Drainage

transit paddock drainages this can this

used to be done by the surgeons and can

be done at bedside especially if that

cat scan shows a very distended gall

bladder near the anterior abdominal wall

and I think it's fairly straightforward

Other options

however there are other procedures that

one can do if you have cooperative GI

guys who are willing to come in at night

or in the weekend or maybe it can wait

till Monday morning on some cases there

are reasons for maybe not taking a

percutaneous approach you can do the SU

endoscopic or endo ultrasound drainage

and the patients that would be good

candidates maybe the patients on an

antiplatelet therapy one of those ones

new ones I don't know they come up with

new ones every week and I have to re

remind myself of them but there are some

that are not reversible and they just

took it that morning before they came in

because their doctor told them to take

it every day and maybe a surgery or

percutaneous approach isn't the greatest

option people who have their transverse

colon sitting on top of their liver or

they have significant ascites and

putting a percutaneous drain is not the

best option so there are ways to do this

ER CP scope

without ever making an incision so this

is the ER CP scope running a catheter

wire into the gall bladder through the

common bile duct ran systole and then a

nasal biliary tube is placed over that

wire and out through the nose and

draining them this is a very old-school

type of to of this nasal biliary - but

it actually works very well through ERCP

or even endo ultrasound guidance I

believe endo ultrasound may have to do a

sort of a trans gastric approach so if

they're a bleeder that might not be

great but if they're in a Sai T's

patient that would be a great option for

Coley cystoscopy tube

them

does the Coley cystoscopy tube always

help well this study was put out and

showed from the southern surgical

Association and it shows in grade three

patients a percutaneous drain was

actually associated with a higher

mortality readmissions and a prolonged

hospital stay so it's not a free lunch

it's not a gift that gets you off the

hook but I also question why that why

that is these are all grade three

patients their mortality is five and a

half percent all comers no matter what

you do so as we'll see a little bit

later in the talk are we self selecting

a bias against these tubes because we're

really picking the worst of the worst

patients it's like when we first started

liver transplants we only got patients

that were dying and then the the

outcomes weren't so great because they

were already so far over the curve that

we sort of selected ourselves out so now

you put a tube in what the what do you

do now you put them on some antibiotics

emia send them home in a couple days

with a tube

maybe you'll squirt the tube to see if

the cystic duct is open or maybe you

just kind of sent him home and say a

Hail Mary or two well these four studies

looked at patients who underwent early

cholecystectomy defined as less than ten

days often less than a week and in three

of the four studies you can see that

there there was a higher incidence of

post-operative complication higher

bleeding volumes in the early group so

although one study didn't really find

anything they found equivalent rates for

post-operative complications in

operative times I think the consensus at

this point is yet to be reached on

whether early cholecystectomy is

appropriate from the cost perspective

sure that's great for the administrator

but it's not net necessarily proven to

be safe or effective

and there's a reason you didn't want to

go in there - in the first place so a

week is maybe not enough time to

consider I think most of us out in the

community

wait the standard four to six to even

eight weeks I try to wait as long as I

can get them to hold the tube and

although some of our talks this week

have talked about difficulties with the

tube I think for the most part they're

very manageable if you let the patient

know that they're not the most

comfortable thing in the world but they

are manageable and has potentially saved

their life or a significant complication

Cholecystectomy

so there was a very nice study presented

by Stony Brook earlier in this

conference and with their permission I

borrowed one of their slides

dr. el tre showed us that the rate of

cholecystectomy following a percutaneous

drainage is actually increased I guess

in the older days people didn't

necessarily go on to a cholecystectomy

but now surgeons seem to be more

comfortable with it however the rate of

common bile duct injury was

significantly higher after a

percutaneous drainage to that of the

general population but again we're

looking at people who are probably grade

injury rate would be alone if they did

not have that tube so there are

recommendations where that caution

should be used when performing that

cholecystectomy was these procedures may

be more typically challenging but I

would also port forward to you that you

can prepare you can have your best team

available you can have your alternative

energy devices ready to go and you can

Percutaneous cholecystectomy

have appropriate assistance so

percutaneous collies estas to me do as I

say not as I do

it's true cholecystectomy is the only

definitive treatment for calculous

cholecystitis but in the United States

our Tokyo guidelines are not really

adhered to and this was made mention in

their studies and are we unnecessarily

putting patients at risk by forging

ahead by saying that we're a trauma

surgeon or were alone in the EO r with

the ortho team on-call trying to take

these gall bladders out on Saturday at

found in some places where I work the

nearest next surgeon is 40 minutes away

if I get into a significant vascular

injury it's me

and the scrub tech and that's not

necessarily a place we all want to be

sure we could transfer them to the big

house but that's not encouraged these

days the flipside is are we only

choosing the worst pay

to drain buying the results of the

subsequent surgeries and so our studies

look like these patients who have tube

draining are really had a higher risk

for bile duct injury that's true but

they were at a higher risk before we

started so the answer to the question to

drain are not to drain yes source

control most patients will improve with

source control we know that some will

not but almost all patients will I

encourage you to download those Tokio

guidelines especially if you're in a

private solo or community practice and

you don't have somebody clearly nearby

as a back-up plan and download them and

use them as a guide for you it gives you

some substantive information that's

based on good data reliable data that

will allow you to sort of get off the

hook if you need to and back away from

the table and not let your own personal

interest take over your judgment the

subsequent case may not be easy but you

can come in prepared you can maybe have

your partner or an advanced a minimally

invasive surgery on standby you can

transfer them to another center if it's

something you don't want to deal with in

your Community Hospital and maybe just

maybe you'll turn this diagnostic

laparoscopy into that all right thank

you very much for your attention and it

will entertain questions at the end of

the cases