laparoscopic cholecystectomy in acute cholecystitis, and whether their presence could help in ... bladder on HIDA scan. .... Table III. Factors associated with white cell count in 256 patients having laparoscopic cholecystectomy for acute.
ORIGINAL ARTICLE
Laparoscopic Cholecystectomy for Acute Cholecystitis: How Do Fever and Leucocytosis Relate to Conversion and Complications? Sarel Halachmi,1 Noa DiCastro,1 Ibrahim Matter,1 Ayala Cohen,2 Edmond Sabo,1 Jorge G. Mogilner,1 Jack Abrahamson1 and Samuel Eldar1 From the 1Department of Surgery, Bnai Zion Medical Center and the Faculty of Medicine and 2Faculty of Industrial Engineering and Management, Technion, Israel Institute of Technology, Haifa, Israel
Eur J Surg 2000; 166: 136–140 ABSTRACT Objective: To find out whether fever and raised white cell count (WCC) are associated with conversion and complications of laparoscopic cholecystectomy in acute cholecystitis, and whether their presence could help in deciding the place of laparoscopic procedures. Design: Prospective study. Setting: Teaching hospital, Israel. Subjects: 256 patients who were treated for clinical acute cholecystitis between January 1994 and November 1997. Interventions: Emergency laparoscopic cholecystectomy. Main outcome measures: Raised temperature and WCC; incidence of conversion and complications. Results: Raised temperature (>38°C) was independently associated with advanced cholecystitis (p = 0.002, odds ratio [OR] 2.7) and a palpable gallbladder preoperatively (p = 0.02, OR 2.1). Total complications correlated with a temperature of >38°C. Raised WCC (>15 109/L) was independently associated with age >45 years (p = 0.02, OR 2.4), a palpable gallbladder preoperatively (p = 0.001, OR 2.9), and a raised temperature (>38°C) (p < 0.0001, OR 6.2). Conversion was associated with a WCC >18 109/L (p = 0.01, OR 3.2). Conclusion: A WCC of >18 109/L may assist in predicting conversion, and fever of >38°C may assist in predicting the development of complications. Key words: laparoscopic cholecystectomy, acute cholecystitis, leucocytosis, fever, conversion of laparoscopic cholecystectomy, complications of laparoscopic cholecystectomy.
INTRODUCTION Laparoscopic cholecystectomy (LC) has been established as the gold standard for the elective treatment of cholecystolithiasis, and is now being increasingly used for the treatment of acute cholecystitis as well (8, 9). It is, however, uncertain whether all patients with acute cholecystitis should be treated laparoscopically. When a LC is done for an inflammatory condition, there may be technical difficulties that lead to conversion, and complications may develop; these problems may outweigh the advantages of the laparoscopic procedure, in which case open cholecystectomy would be safer. If LC is to be used selectively in acute cholecystitis, the criteria for selection must be defined. Factors associated with conversion and complications may help to predict them, and defining these predictors may assist in planning LC. Fever and raised white cell count (WCC) are nonspecific responses to infection and usually rise and fall 2000 Scandinavian University Press. ISSN 1102–4151
in parallel with the severity of the process. They are routinely recorded, and insofar as they are associated with conversion and complications, may serve to plan the operative approach. This prospective study was initiated in an attempt to define predictors of conversion and complications, in particular fever and a raised WCC. PATIENTS AND METHODS Study group Between January 1994 and November 1997, 269 patients aged 18 to 92 years (mean [SD] 55 [16]) were treated for acute cholecystitis in the department of surgery at Bnai Zion Medical Center. The clinical diagnosis was made if the patient had right upper quadrant pain and tenderness, fever, and a raised WCC. The diagnosis was confirmed by ultrasound in 92% of the cases, by HIDA in 15%, and by computed Eur J Surg 166
Laparoscopic cholecystectomy for acute cholecystitis Table I. Complications of laparoscopic surgery in acute cholecystitis Laparoscopic Converted group group (n = 205) (n = 51) Complications: Wound infection Atelectasis Pneumonia Acute pancreatitis Intraperitoneal bile leak Subphrenic abscess Prolonged fever Pseudomembranous enterocolitis Urinary tract infection
2 4 7 3 9 0 3
8 1 1 0 1 1 0
1 1
0 0
Forty four complications developed in 42 patients: One developed atelectasis and an intraperitoneal bile leak, and one atelectasis and pseudomembranous enterocolitis.
tomography (CT) in 2% of the cases. The preoperative diagnosis of acute cholecystitis was based on ultrasound findings of a thickened and oedematous gallbladder, pericholecystic fluid, or a non-filling gallbladder on HIDA scan. As soon as the diagnosis was made, cephazolin was given intravenously and all patients were listed for emergency laparoscopic cholecystectomy. One of four senior surgeons, each of whom had done at least 200 laparoscopic cholecystectomies, was involved in every procedure. Hydrops and empyema were diagnosed intraoperatively, while acute and gangrenous cholecystitis were confirmed histopathologically. To enable the oedematous and friable gallbladder to be handled, the standard four-trocar operative technique was slightly modified as described previously (3, 9). In a selected group of 57 patients (21%) with serum
137
bilirubin concentration of 26 mmol/L or more, or alkaline phosphatase activity of over 15 U/L intraoperative cholangiography was used. Choledocholithiasis was diagnosed in 13 of them. These patients had their operations converted to open choledochotomy and were excluded from the study. The remaining 44 patients (16%) whose operative cholangiograms showed clear bile ducts, were included in the study group. Data collection Data sheets were generated for the collection of personal, preoperative, operative, and postoperative details. The preoperative notes included history of gallbladder disease (in the form of biliary colic, obstructive jaundice, or previous acute cholecystitis), the duration of current complaints (as an indication of the onset of the disease), the presence of a palpable gallbladder, temperature, and laboratory data including WCC, serum bilirubin concentration, and diastase and alkaline phosphatase activities. Operative findings included hydrops or empyema of the gallbladder, acute or gangrenous cholecystitis, the size of the gallstones, accidental laceration of the gallbladder, reasons for conversion, and duration of operation. Postoperative data included the use of drains, the duration of antibiotics, the amount of analgesics used, complications, and length of hospital stay. Acute cholecystitis and hydrops were grouped together as early cholecystitis, while gangrenous cholecystitis and empyema of the gallbladder were classified as advanced cholecystitis. Laparoscopic operations that lasted longer than 90 minutes were defined as technically difficult procedures. Complications were classified as surgical infections (wound infection, intra-abdominal abscess, and prolonged fever postoperatively), non-infective surgical (such as bile duct injury, and haemorrhage), remote
Table II. Factors associated with temperature in 256 patients having laparoscopic cholecystectomy for acute cholecystitis. Data are expressed as number of patients unless otherwise stated Temperature (°C):
Mean (SD) age (years): Range Advanced cholecystitis Palpable gallbladder History of gallbladder disease Median WCC 109/L Range Median duration of operation (min) Range Developed complication Converted to open operation
