Optimal treatment of acute cholecystitis

218 Pages·2012·0English

Optimal treatment of
acute cholecystitis

Charlotte Susan Loozen
OPTIMAL TREATMENT OF ACUTE CHOLECYSTITIS
Thesis, Utrecht University, The Netherlands

Copyright © by C. S. Loozen, 2017
Printed by Ipskamp printing
ISBN 978-94-028-0704-2

The studies described in Chapter 2, Chapter 3 and Chapter 9 were financially
supported by the St. Antonius Research Foundation (St. Antonius Onderzoeksfonds)
Publication of this thesis was financially supported by maatschap heelkunde van het St.
Antonius Ziekenhuis, raad van bestuur van het St. Antonius Ziekenhuis, Nederlandse
Vereniging voor Endoscopische Chirurgie and Chipsoft B.V.
Optimal treatment of
acute cholecystitis

Optimale behandeling van cholecystitis acuta
(met een samenvatting in het Nederlands)

PROEFSCHIFT
Ter verkrijging van de graad van doctor
aan de Universiteit Utrecht
op gezag van de rector magnificus, prof. Dr. M.R. Vriens,
ingevolge het besluit van het college voor promoties
in het openbaar te verdedigen
op dinsdag 5 september 2017
des middags te 4.15
door
Charlotte Susan Loozen
Geboren op 3 februari 1988
te Haarlem
PROMOTOR:
Prof. dr. M.R. Vriens

CO-PROMOTOREN:
Dr. D. Boerma
Dr. H. C. van Santvoort
Aan mijn lieve moedertje
(en ‘n beetje aan papa)
CONTENTS
CHAPTER 1 General introduction and thesis outline 9

PART I TREATMENT STRATEGIES FOR ACUTE CHOLECYSTITIS

CHAPTER 2 Randomized clinical trial of extended versus single-dose 19
perioperative antibiotic prophylaxis for acute calculous
cholecystitis
British Journal of Surgery, 2017

CHAPTER 3 The use of perioperative antibiotic prophylaxis in the 35
treatment of acute cholecystitis (PEANUTS II trial): study
protocol for a randomized controlled trial
Accepted for publication in Trials (minor revisions)

CHAPTER 4 Conservative treatment of acute cholecystitis: a systematic 53
review and pooled analysis
Surgical endoscopy, 2017

CHAPTER 5 The optimal treatment of patients with mild and moderate 73
acute cholecystitis: time for a revision of the Tokyo
Guidelines
Surgical Endoscopy, 2017

CHAPTER 6 Stand van Zaken: behandeling van cholecystitis acuta 87
Accepted for publication in Nederlands Tijdschrift Voor
Geneeskunde (minor revisions)

PART II MANAGEMENT OF HIGH-RISK PATIENTS WITH ACUTE
CHOLECYSTITIS

CHAPTER 7 Acute cholecystitis in elderly patients: a case for early 103
cholecystectomy
Journal of visceral surgery, 2017

6
OPTIMAL TREATMENT OF ACUTE CHOLECYSTITIS
CHAPTER 8 Early cholecystectomy for acute cholecystitis in the elderly
population: a systematic review and meta-analysis 115
Digestive surgery, 2017

CHAPTER 9 Laparoscopic cholecystectomy versus percutaneous catheter 133
drainage for acute calculous cholecystitis in high-risk patients
Submitted

PART III SURGICAL TREATMENT OF COMMON BILE DUCT
STONES

CHAPTER 10 Surgical treatment of common bile duct stones 163
Gallstones: recent advance in epidemiology, pathogenesis,
diagnosis and management (book), 2016

CHAPTER 11 Summary and general discussion 191

APPENDICES
Dutch Summary (Nederlandse samenvatting) 202
Review Committee 209
Authors and affiliations 210
Acknowledgements (dankwoord) 213
Curriculum Vitae 215

7
OPTIMAL TREATMENT OF ACUTE CHOLECYSTITIS

CHAPTER 1

General introduction
and thesis outline
CHAPTER 1
INTRODUCTION
Acute cholecystitis is a common indication for hospital admission and an increasing
burden on the Western health care system. More than 90% of cases of acute cholecystitis
are associated with cholelithiasis; a condition that afflicts at least 10% of the people in
Western countries.1 The prevalence of gallstones increases with age; in patients aged ≥ 60
the prevalence rate ranges from 20% to 30%2,3 and increases to 80% in institutionalized
individuals aged ≥ 90.4
The key element in the pathogenesis of acute calculous cholecystitis seems to be an
obstruction of the cystic duct in the presence of bile supersaturated with cholesterol.4
Brief impaction may cause pain only, whereas prolonged impaction can result in
inflammation. With inflammation, the gallbladder becomes enlarged and tense, and wall
thickening and an exudate of pericholecystic fluid may develop.5 While in most cases the
inflammation initially is sterile, secondary infection occurs in approximately 30-50% of
the patients,6 most commonly caused by E. coli and K. pneumoniae. Bacterial
superinfection with gas-forming organisms may lead to gas in the wall or lumen of the
gallbladder (emphysematous cholecystitis). The wall of the gallbladder may undergo
necrosis and gangrene (gangrenous cholecystitis). Without appropriate treatment, the
gallbladder may perforate, leading to the development of an abscess or generalized
peritonitis.5
Acute cholecystitis usually starts with an attack of biliary colic, often in a patient who had
previous attacks. The pain persists and localizes in the right upper quadrant. Besides a
positive Murphy’s sign and tenderness in the right upper quadrant, also fever and
elevation in the white blood cell count are classically described.7 According to the
international guidelines for the management of acute cholecystitis, the "Tokyo
guidelines", acute cholecystitis is clinically suspected if at least one local sign of
inflammation (Murphy’s sign or pain, tenderness or mass in the right upper quadrant) and
one sign of systematic inflammation (fever, leucocytosis, elevated C-reactive protein
level) is present.8 Only if confirmed by imaging, the diagnosis is definitive. Several
imaging modalities can be used. Ultrasonography is usually favoured as the first test
because it is relatively inexpensive and widely available, it involves no radiation exposure
and has high sensitivity and specificity (81% and 83%, respectively).9 Typical diagnostic
findings include thickening of the gallbladder wall, presence of pericholecystic fluids and
a sonographic Murphy’s sign. Scintigraphy and CT-tomography are usually reserved for
10
OPTIMAL TREATMENT OF ACUTE CHOLECYSTITIS