Websurg, e-Surgery 關於腹腔鏡手術

ACUTE CHOLECYSTITIS: POSTOPERATIVE MANAGEMENT

B Navez, MD , Hôpital Saint Joseph, Gilly, Belgium
D Mutter, MD, PhD , Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Operative time

2. Conversions

3. Postoperative analgesia

4. Antibiotic therapy

5. Complications

6. Hospital stay

7. References

1. Operative time for acute cholecystitis

On the average, cholecystectomies for acute cholecystitis take longer to perform than elective cholecystectomies with a mean operative time of 115 minutes ( Navez et al., 2001 ) to 141 minutes ( Pessaux et al., 2000 ).

1. Operative time

2. Conversions

3. Postoperative analgesia

4. Antibiotic therapy

5. Complications

6. Hospital stay

7. References

2. Conversions

Conversion is a safety measure and should never be regarded as a failure of the laparoscopic approach. The threshold for conversion should be kept low in cases of acute cholecystitis where operative difficulty is significant. Such a conversion could prevent intraoperative complications.

2.1. Conversion rate

The conversion rate for acute cholecystitis is higher than for elective cholecystectomy due to the inflammatory state of the gallbladder increasing the operative difficulty (1.5% to 35% vs. 5%, Hashizume et al., 1998 ). This conversion rate is estimated at 20% ( Navez et al., 2001; Hunter, 1996; Lai et al., 1998 ) to 30% ( Pessaux et al., 2000 ).

2.2. Decision to convert

The decision to convert is taken, on the average, within 32 to 69 minutes from the outset of the procedure based on the experience of the operator ( Navez et al., 2001; Pessaux et al., 2000 ). The main factors leading to a conversion are (in decreasing order of frequency):

intraoperative hemorrhage;
difficulty in anatomical identification of the structures of the triangle of Calot;
suspicion of a CBD injury;
suspicion of a carcinoma of the gallbladder.

2.3. Risk factors for conversion

Risk factors for conversion are well-established ( Eldar et al., 1999; Greenwald et al., 2000; Navez et al., 2001 ):

sex (more frequent in men);
age greater than 65 years;
the severity of acute cholecystitis (gangrene or thickening of the gallbladder wall to greater than 5 mm);
operative delay;
experience of the operative team;
previous history of upper abdominal surgery representing a risk factor for conversion unrelated to the local inflammatory stage of the gallbladder or adjoining tissues (25% conversion rate vs. 4% in the absence of such a history).

1. Operative time

2. Conversions

3. Postoperative analgesia

4. Antibiotic therapy

5. Complications

6. Hospital stay

7. References

3. Postoperative analgesia

Goals:

treat the pain before its onset;
avoid nausea and vomiting (additional source of pain and potentially detrimental to the surgical repair)

-> use of Droperidol (Inapsine®) at anti-emetic dosage

Note: Doses are standardized for a healthy 70 kg patient (when not specified as dose/kg).

An analgesic ketamine dose (0.5 mg/kg, KETALAR®) is injected during the anesthesiologic induction in order to antagonize the NMDA receptors. (NOTE: there is no effect on the patient’s level of consciousness at these doses).
Excellent curarization and analgesia during the operative procedure. Injection of 1 mg of Droperidol (DROLEPTAN®).
Non-opioid analgesics used about 30 min. before the end of the anesthesia:
- NSAID (e.g. Ketoprofen, 50 to 100 mg) (there are no side effects at these doses, notably on hemostasis);
- 1 g of paracetamol per rectum or 2 g of paracetamol PO.
Tramadol hydrochloride administered (postoperative pain, 100 mg initially then 50 mg every 10-20 min. if necessary during first hour to total maximum 250 mg (including initial dose) in first hour, then 50-100 mg every 4-6 hours; maximum 600 mg daily) with 0.5 mg of Droperidol for every 100 mg of Tramadol hydrochloride to prevent nausea
For breakthrough pain, morphine titration (2 to 3 mg IV morphine every 5 to 10 min. until the visual analogue scale for the assessment of pain <= 3 is reached) in the recovery room:
- to anticipate nausea/vomiting, Droperidol is given with morphine (0.5 mg of Droperidol for 10 mg of morphine),
- the Patient Controlled Analgesia (PCA) is rarely used: if it is, Droperidol is associated with morphine in the PCA reservoir at the dosage indicated above.
As soon as liquid intake is resumed and if no nausea or vomiting occur, soluble paracetamol is administered: 1 g every 4-6 hours.
Continue regular NSAIDs (eg, Ketoprofen 50 mg every 8 hours orally).

This analgesic protocol has proven to be effective in our services.
Effective relief of postoperative shoulder pain has not yet been found (currently under study).

1. Operative time

2. Conversions

3. Postoperative analgesia

4. Antibiotic therapy

5. Complications

6. Hospital stay

7. References

4. Postoperative antibiotic therapy

Excluding the specific indication of biliary peritonitis, medical therapy following cholecystectomy for acute cholecystitis includes in addition to analgesic therapy:

a brief period of fluid electrolyte ressuscitation followed by resumption of oral intake in the immediate postoperative period ( Lo et al., 1996 );
antibiotic therapy.

The duration of postoperative antibiotic therapy has rarely been evaluated. Despite scarce clinical evidence, postoperative antibiotic therapy is usually recommended for 5 days intravenously ( Muller et al., 1997 ) or 7 to 10 days ( Wetsphal and Brogard, 1999 ).
On the other hand, some authors tailor the antibiotic therapy based on the clinical progress of the patient. Antibiotic therapy is terminated when:

the patient is afebrile for 24 to 48 hours ( Eldar et al., 1998 );
the patient is afebrile for 48 hours, has normal abdominal motility and has no leukocytosis ( Yellin et al., 1993 ).

1. Operative time

2. Conversions

3. Postoperative analgesia

4. Antibiotic therapy

5. Complications

6. Hospital stay

7. References

5. Postoperative complications

The rate of postoperative complications after cholecystectomy for acute cholecystitis is of the order of 20%.
Infectious complications related to the septic state are more frequent.

Infectious complications (%) ( Lo et al., 1996; Eldar et al., 1998; Navez et al., 2001 ).

Abdominal wall infection	5-11%
Peritonitis	4.5%
Pulmonary infection	3-4.5%
Urinary infection	0.5-5%
Fever of unknown origin	0.5%
Subphrenic abscess	0.25%

Other complications include:

Biliary leak	3.7-4.5%
CBD injury	0-2%
Bleeding	2%
Pancreatitis	2%
Postoperative ileus	2%

5.1. Bile leak

There are 2 types of postoperative bile leaks:
Cystic duct leaks. This is due to multiple causes:

poor identification of the cystic duct stump during the operative intervention;
or lack of identification of the cystic duct during the dissection;
leakage from the cystic duct stump despite the application of a clip or an Endoloop;
tearing of the cystic duct stump leading to a lateral hole in the CBD.

CBD injury:
The laparoscopic approach to acute cholecystitis carries a significant risk of CBD injury. However, this data is extracted from historical series with no recent controlled studies comparing laparoscopic to the open approach in the setting of acute cholecystitis.
In the hands of experienced laparoscopic teams, there does not appear to be an increase in the rate of CBD injury using the laparoscopic approach to cholecystectomy for acute cholecystitis as opposed to the open one. This is probably due to the technical expertise of the operators as well as the greater care exerted during these cases and the higher conversion rate within this context.
The reported injuries of the CBD in the various series are listed below:

Series	Rate of CBD injury (% - n =)	Number of patients
Kum et al., 1994	1.5 (1)	66
Koo and Thirlby, 1996	0	60
Bickel et al., 1996	1 (1)	94
Lo et al., 1996	0	52
Garber et al., 1997	0	194
Lai et al., 1998	0	104
Lo et al., 1998	0	99
Lujan et al., 1998	0	114
Eldar et al., 1999	1.4 (5)	348
Kiviluoto et al., 1998	0	32
Arvieux-Barthelemy et al., 1999	1 (1)	95
Navez et al., 2001	0.5 (3)	605

5.2. Late complications

The most common complication (8%) is an abdominal wall abscess ( Lo et al., 1993 ) often located at the extraction site of the gallbladder. Prophylactic antibiotic administration allows a significant reduction of abdominal wall infectious complications: from 15% to 6% ( Meijer et al., 1990 ).
Intraperitoneal subphrenic abscesses are direct consequence of rupture of the gallbladder during the procedure (17%) leading to spillage of stones and secondary infection around these stones within the peritoneal cavity ( Hashizume et al., 1998 ).

5.3. Mortality

The mortality rate for cholecystectomy for acute cholecystitis is low and comparable to that of elective cholecystectomy (1% for Garber et al., 1997 ; 0 to 3% for Hashizume et al., 1998 ). This mortality rate is elevated in high risk patients, especially in patients over the age of 65: 9.8% to 16% ( Hashizume et al., 1998 ).

1. Operative time

2. Conversions

3. Postoperative analgesia

4. Antibiotic therapy

5. Complications

6. Hospital stay

7. References

6. Hospital stay

Hospital stay following cholecystectomy for acute cholecystitis is longer than in the elective setting. It averages 3 to 7 days (6.9 days for Pessaux et al., 2000 ; 6.7 days for Lo et al., 1998 ).

It is shorter compared to patients who are converted (6.7 vs. 15 days; Lo et al., 1998 ).
It is shorter compared to patients who are operated on by laparotomy (3.3 vs. 6.8 days).

1. Operative time

2. Conversions

3. Postoperative analgesia

4. Antibiotic therapy

5. Complications

6. Hospital stay

7. References

7. References

Arvieux-Barthelemy C, Mestrallet JP, Bouchard F, Delannoy P, Radmanesh O, Zattara A et al. Traitement chirurgical de la cholécystite aiguë. Etude rétrospective portant sur une série de 192 patients opérés en 3 ans. Ann Chir 1999;53:472-81.
Bickel A, Rappaport A, Kanievski V, Vaksman I, Haj M, Geron N et al . Laparoscopic management of acute cholecystitis. Prognostic factors for success. Surg Endosc 1996;10:1045-9.
Eldar S, Eitan A, Bickel A, Sabo E, Cohen A, Abrahamson J et al . The impact of patient delay and physician delay on the outcome of laparoscopic cholecystectomy for acute cholecystitis. Am J Surg 1999;178:303-7.
Eldar S, Sabo E, Nash E, Abrahamson J, Matter I. Laparoscopic cholecystecomy for the various types of gallbladder inflammation: a prospective trial. Surg Laparosc Endosc 1998;8:200
Garber SM, Korman J, Cosgrove JM, Cohen JR. Early laparoscopic cholecystectomy for acute cholecystitis. Surg Endosc 1997;11:347-50.
Greenwald JA, McMullen HF, Coppa GF, Newman RM. Standardization of surgeon-controlled variables: impact on outcome in patients with acute cholecystitis. Ann Surg 2000;231:339-44.
Hashizume M, Sugimachi K, MacFadyen BV. The clinical management and results of surgery for acute cholecystitis. Semin Laparosc Surg 1998;5:69-80. Review.
Hunter JG. Acute cholecystitis revisited: get it while it’s hot. Ann Surg 1998;227:468-9.
Kiviluoto T, Siren J, Luukkonen P, Kivilaasko E. Randomized trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet 1998;351:321-5.
Koo KP, Thirlby RC. Laparoscopic cholecystectomy in acute cholecystitis. What is the optimal timing for operation? Arch Surg 1996;131:540-5; discussion 544-5.
Kum CK, Goh PM, Isaac JR, Tekant Y, Ngoi SS. Laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 1994;81:1651-4.
Lai PB, Kwong KH, Leung KL, Kwok SP, Chan AC, Chung SC et al . Randomized trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 1998;85:764-7.
Lo CM, Liu CL, Lai EC, Fan ST, Wong J. Early versus delayed laparoscopic cholecystectomy for treatment of acute cholecystitis. Ann Surg 1996;223:37-42.
Lo CM, Liu CL, Fan ST, Lai EC, Wong J. Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Ann Surg 1998;227:461-7.
Lujan JA, Parilla P, Robles R, Marin P, Torralba JA, Garcia-Ayllon J. Laparoscopic cholecystectomy vs open cholecystectomy in the treatment of acute cholecystitis: a prospective study. Arch Surg 1998;133:173-5.
Meijer WS, Schmitz PI, Jeekel J. Meta-analysis of randomized controlled clinical trials of antibiotic prophylaxis in biliary tract surgery. Br J Surg 1990;77:283-90.
Muller EL, Pitt HA, Thompson JE, Jr., Doty JE, Mann LL, Manchester B. Antibiotics in infections of the biliary tract. Surg Gynecol Obstet 1987;165:285-92.
Pessaux P, Tuech JJ, Regenet N, Fauvet R, Boyer J, Arnaud JP. Cholecystéctomie laparoscopique dans le traitement des cholécystites aiguës. Etude prospective non randomisée. Gastroenterol Clin Biol 2000;24:400-3.
Wetsphal JF, Brogard JM. Biliary tract infections: a guide to drug treatment. Drugs 1999;57:81-91. Review.
Yellin AE, Berne TV, Appleman MD, Heseltine PN, Gill MA, Okamoto MP et al . A randomized study of cefepime versus the combination of gentamicin and mezlocillin as an adjunct to surgical treatment in patients with acute cholecystitis. Surg Gynecol Obstet 1993;177 Suppl:23-9; discussion 35-40

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