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    • br Conclusion br Acknowledgments This work was supported

    2018-11-14


    Conclusion
    Acknowledgments This work was supported by grants from Taipei Veterans General Hospital (V100E1-011); National Science Council (100-2321-B-010-022), and National Yang-Ming University, Ministry of Education.
    Introduction Laparoscopic cholecystectomy (LC) has been the treatment of choice for gallbladder lesions over recent decades. Although LC was initially considered to be a contraindication for acute cholecystitis, many patients with acute DIG-11-dUTP cholecystitis have undergone emergency LC, and this procedure has been accepted as a safe procedure, with an operating time and complications similar to those of “regular” cholecystectomy, and a shorter hospital stay compared to late LC. Issues such as the conversion rate and safety in the critically ill, elderly patients, and high surgical risk patients are still, however, controversial. Patients with end-stage renal disease (ESRD) undergoing maintenance hemodialysis are considered to have a high surgical risk because they have higher co-morbidities and higher American Society of Anesthesiologists (ASA) scores, making them unsuitable for surgery. The number of ESRD patients with acute calculous cholecystitis who need surgical intervention has increased because of better medical care and improvements in surgical techniques. Most of these patients in Taiwan receive conservative treatment because their families and clinical physicians are concerned about the high surgical risks.
    Purpose
    Patients and methods
    Results All the patients presented with mild-to-moderate acute cholecystitis, as determined on the basis of Tokyo guideline, with leukocytosis and right upper quadrant abdominal tenderness. Preoperative laboratory data revealed normal or mildly elevated levels of liver DIG-11-dUTP in most patients.
    Discussion Coagulopathy with easily bleeding, immunocompromise, and delayed wound healing have been causes of mortality after surgery in ESRD patients, as reported by Yeh et al. Toh and colleagues reported high complication rates of 15% and 50% and mortality rates of 10% and 70% in the elective and emergency groups, respectively. A history of hemodialysis of more than 24 months was another factor related to mortality, but this was not observed in our study. Bender et al reported similar high morbidity and mortality rates of 25% and 50% in 12 chronic hemodialysis patients. Most of their patients underwent emergency surgery because of nonocclusive mesenteric ischemia. These findings showed a high surgical risk in chronic hemodialysis patients, especially in those undergoing emergent surgery. The prevalence of biliary lithiasis is greater than 10% in the general adult population and 33.3% in chronic renal failure patients undergoing maintenance hemodialysis. LC is widely accepted as the standard treatment method for gallbladder stones with acute cholecystitis. Short hospital stay (3 days), conversion rates of about 6%, and a relatively low complication rate of 16% were reported by Lo et al. No perioperative mortality occurred in their study. Although many studies report similar results, few studies have focused on ESRD patients with acute calculous cholecystitis undergoing chronic hemodialysis. Because of the high surgical risk and high ASA scores, percutaneous cholecystostomy was recommended as a first-line therapy for chronic hemodialysis patients with acute cholecystitis by Gumus. In 14 patients, the mean catheter-maintaining time was 31.7 days, and the hospital stay was 12 days. One patient had developed new-onset cholecystitis in the acalculous group at the 6-month follow-up. Three patients died from septicemia and multiple organ failure following the failure of percutaneous cholecystostomy. The author suggested the use of percutaneous cholecystostomy as the definitive treatment in acalculous patients on chronic hemodialysis and as palliative management for calculous patients. Morse et al reported cholecystostomy and subsequent cholecystectomy for the management of acute cholecystitis in critically ill patients. The long hospital stay (28 days) and long duration of cholecystostomy tube insertion with a high recurrent cholecystitis rate (8/13) presented a challenge for the treatment of acute cholecystitis in critically ill patients. Removal of the cholecystostomy tube without subsequent cholecystectomy resulted in recurrent cholecystitis and a high mortality rate of about 37% (3/8).