Page 27 - World Journal of Laparoscopic Surgery

Laparoscopic Cholecystectomy in Gangrenous Cholecystitis
examination [leukocytosis, total serum bilirubin (TSB), aspartate Gangrenous cholecystitis is a rare but serious complication of
transaminase (AST), alanine transaminase (APT) and serum AC. The pathophysiology is GB distension resulting in increased
creatinine]. Preoperative radiological findings on contrast- tension and pressure on the GB wall. The distension leads to
enhanced computerized tomography (CECT) of the abdomen ischemic changes and necrosis of the GB wall. Inflammation and
and magnetic resonance imaging (MRI) of the abdomen were also ischemia of the GB wall show progressive worsening with age due
analyzed. Intraoperative findings, histopathology examination to deteriorating venous insufficiency with age, resulting in more
features, postoperative morbidity, and length of hospital and ICU necrosis and perforation. 13,14 Various studies have shown that the
stay were compared for the three groups. risk of developing GC is higher in males as compared to females. 2,15
Our study showed a male:female ratio of 1.4:1, which is similar to a
16
results study by Saber et al. With increasing age the incidence of GC rises,
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In the study period, 55 cases of GC were identified. About 26 Yacoub et al. reported age >45 years as a risk factor for GC. Fang
and Yerkovich reported in their studies the median age of patients
(47.27%) patients underwent LC, OC was performed in 23 (41.82%) of GC was 65 years, this is also similar to the study of Hunt and
and LC was converted to OC (LC-OC) in 6 (10.91%) patients. In the Chu. 2,18 Fang et al. also demonstrated an independent association
LC group 13 patients were male and 13 were female (50% each), of age with GC, and each 5-year increase in age was associated with
in the OC group 14 (60.87%) were males and 9 (39.13%) were an 18% increase in the likelihood of GC. Our study also showed
2
females, while in the OC-LC group 5 (83.33%) were males and similar findings with a median age of patients in LC, OC, and LC-OC
1 (16.66%) was female. The median age of the patients in the LC, groups as 58.12 ± 16.66, 65.65 ± 11.13, and 58.16 ± 12.79 years
OC, and LC-OC groups was 58.12 ± 16.66 years, 65.65 ± 11.13 years, respectively.
and 58.16 ± 12.79 years respectively. Patients with hypertension The majority of the patients had one or more comorbidities
accounted for 45.45% (25 patients), while 41.81% (23 patients) in this study. In the patient cohort, there was a prevalence of
were diagnosed with diabetes. Moreover, 16.36% (9 patients) hypertension in 45.45% of cases, diabetes in 41.81% of cases, and
had CAD, and 14.54% (8 patients) were on antiplatelet therapy. a prior history of CAD in 16.36% of cases. Various other studies
Preoperatively leukocytosis was seen in 22 (40%) patients, raised have also documented similar findings. 2,3,18 The theory purported
bilirubin in 13 (23.63%) patients, impaired AST/ALT in 7 (12.72%) in literature is that atherosclerosis of cystic artery may contribute
and raised alkaline phosphatase in 6 (10.90%) patients. Creatinine to vascular insufficiency which leads to the development of
was raised in 8 (14.54%) patients. CECT abdomen was done GC. Fang and Yerkovich reported a novel association between
19
preoperatively in 15 patients. GB distension (60%), gall stones antiplatelet medication and GC. Our study also showed that
2
(53.3%), wall thickening (53.3%), irregular or absent wall (40%), and a 14.54% of patients were on antiplatelet medications with the
pericholecystic fluid (40%) were the common findings. Few patients number being more in OC (26.08%) and LC-OC group (16.6%). This
had pericholecystic abscess (20%), adjacent liver changes (13.34%), finding is also consistent with the pathophysiological theory that
and mural striations (6.67%) on the CECT abdomen. Magnetic proposes vascular insufficiency due to atherosclerosis leads to the
resonance imaging abdomen was done in 23 patients. Distended development of GC.
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GB with the edematous wall was the commonest finding (78.26%) Leukocytosis was present in 22 (40%) patients. Leukocytosis as
on MRI, followed by irregular mucosal surface (47.82%) and absence an independent predictor of GC has been shown in many studies. 2,17
of enhancement of wall (43.78%). Time taken from admission to Findings in preoperative CECT abdomen were GB distension (60%),
surgery was 0.84 ± 1.54, 3 ± 4.75, 0.66 ± 0.55 days in LC, OC, LC-OC GB wall thickening (53.3%), gallstones (53.3%), irregular or absent
groups respectively with p-value = 0.0008. wall (40%), and pericholecystic fluid (40%). Other findings were
During cholecystectomy adhesions were the commonest pericholecystic abscess (20%), liver changes (13.34%), and mural
finding (80%), distended GB was seen in 50.9% and thick GB wall striations (6.67%). Various studies have reported similar findings in
was present in 30.9%. Gall bladder was perforated in 29.09%, and CT in patients of GC. 20,21 Magnetic resonance imaging abdomen
bile or pus in the abdomen was seen in 9.09%. Histopathological showed distended GB with the edematous wall (78.26%), irregular
examination findings of resected specimens were mucosal mucosal surface (47.82%), and absence of wall enhancement
ulceration (98.18%), diffuse edema (74.55%), prominent thickening (34.78%). Similar findings have been reported in other studies as
of the wall (60%), and necrosis (52.72%). Postoperative morbidity well. 20,21
was seen in 10 (18.18%) patients. four patients had wound We also studied the time taken from admission to surgery for
infection, delirium, and atrial fibrillation was seen in two patients the patient. This was found to be significantly less (p-0.00080) in LC
each, and one patient each developed myocardial infarction and patients (0.84 ± 1.54 days) as compared to the OC group (3 ± 4.75
bronchospasm. Average hospital and ICU stay in the LC group were days). Thus, validating the theory that early surgery leads to better
the shortest (3.76 ± 1.94 days, and 0.53 ± 1.38 days respectively). results and increased chances of laparoscopic surgery. Delayed
Hospital and ICU stay in the OC group was 10.8 ± 5.76 and 2.43 ± surgery due to delay in diagnosis can lead to more chances of
5.35 days respectively. The average stay of the LC-OC group in the open surgery and prolonged stay in the hospital. The conversion
hospital and ICU was 9 ± 6.75 and 3.5 ± 6.8 days. The p-value for rate of LC to OC was 18.75% in our study. Various studies have
hospital and ICU stay was 0.0001 and 0.0179 respectively.
reported conversion rates varying from 14 to 35% for GC. 4,11,12 Dense
adhesions, insufficient anatomic exploration, bleeding, and injury
dIscussIon to the bile duct are the main causes of conversion to open. In our
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We performed a retrospective study to analyze the demographics, study also adhesions, GB perforation, and thick GB walls were found
radiological findings, time from diagnosis to surgery, safety of in patients who underwent LC-OC.
laparoscopic surgery, postoperative complications, and a hospital Postoperative hospital stay of patients was significantly shorter
stay of patients with GC. in patients undergoing LC as compared to patients with open

26 World Journal of Laparoscopic Surgery, Volume 16 Issue 1 (January–April 2023)