Prospective study comparing early versus delayed laparoscopic/ open cholecystectomy for cholecystitis

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DISSERTATION ON

PROSPECTIVE STUDY COMPARING EARLY

VERSUS DELAYED LAPAROSCOPIC/OPEN

CHOLECYSTECTOMY FOR CHOLECYSTITIS

M.S.DEGREE EXAMINATION

BRANCH – I

GENERAL SURGERY

STANLEY MEDICAL COLLEGE AND HOSPITAL

THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY

CHENNAI

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CERTIFICATE

This is to certify that dissertation entitled,”

Prospective study

comparing early versus delayed laparoscopic/open

cholecystectomy for Cholecystitis”

is a bonafide record of work done by Dr.E.Shenbaga Seetha Priya, in the Department of General Surgery, Stanley Medical College, Chennai, during his Post Graduate Course from 2015-2018 under the guidance and supervision of

Prof.Dr.T.SIVAKUMAR, M.S., This is submitted in partial fulfilment for the award of M.S. DEGREE EXAMINATION- BRANCH I (GENERAL SURGERY) to be held in May 2018 under the Tamilnadu, DR.M.G.R. Medical University, Chennai.

Prof. Dr.PONNAMBALAM NAMASIVAYAM, M.D.,

The Dean

Stanley Medical College Chennai

Prof. Dr.T.Sivakumar M.S.,

Professor

Department of General Surgery Stanley Medical College, Chennai

PROF.DR.A.K.RAJENDRAN

M.S.,

Professor and Head

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DECLARATION

I declare that this dissertation entitled”

P

rospective study comparing

early versus delayed laparoscopic/open cholecystectomy for

Cholecystitis

” is a record of work done by me in the Department of General Surgery, Stanley Medical College, Chennai, during my Post Graduate Course from 2015-2018 under the guidance and supervision of my unit chief PROF.DR.T.SIVAKUMAR M.S. It is submitted in partial fulfillment for the award of M.S. DEGREE EXAMINATION – BRANCH I (GENERAL SURGERY) to be held in May 2018 under the Tamilnadu Dr.M.G.R. Medical University, Chennai. This record of work has not been submitted previously by me for the award of any degree or diploma from any other university.

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ACKNOWLEDGEMENT

I express my extreme gratitude to Prof.T.Sivakumar M.S., my unit chief, for his constant guidance and suggestion throughout my study period.

I express my profound gratitude to Prof. Dr. G. Manoharan M.S.,

professor of Surgery for his support and help during my study.

I owe a great depth of gratitude to Prof.Dr.S.Ponnambalam Namasivayam, Dean, Government Stanley Medical College and Hospital, Chennai for his kind permission and making this study possible.

I am grateful to Dr.G.Chandrasekar M.S. and Dr.Jim Jebakumar M.S., assistant professors of General Surgery for their kind assistance and timely guidance throughout my course.

I thank the DEAN, Stanley Medical College for permitting me to use the hospital facilities for my study

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PLAGIARISM CERTIFICATE

This is to certify that this dissertation work titled “PROSPECTIVE STUDY

COMPARING EARLY VERSUS DELAYED LAPAROSCOPIC/OPEN

CHOLECYSTECTOMY FOR CHOLECYSTITIS” of the candidate

Dr.E.SHENBAGA SEETHAPRIYA with Registration Number 221511060 for the

award of M.S GENERAL SURGERY. I personally verified the urkund.com website

for plagiarism check. I found that the uploaded file containing from introduction to

conclusion pages shows a result of 13% plagiarism in this dissertation.

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CONTENTS

Chapter Title Page

No.

1 INTRODUCTION 1

2 AIM AND OBJECTIVE OF THE STUDY 5

3 REVIEW OF LITERATURE 5

4 MATERIALS AND METHODS 48

5 RESULTS 57

6 DISCUSSION 73

7 CONCLUSION 84

8 BIBLIOGRAPHY 85

9 PROFORMA 94

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INTRODUCTION:

Biliarytract diseases are the commonest abdominal conditions, probably next to appendicitis ,that the surgeons ,gastroenterologist and radiologist encounter in day to day life and gall bladder diseases are the most frequently encountered biliary tract disease .

Acute cholecystitis is a pathology of inflammatory origin , usually associated with cholelithiasis, with a higher incidence in our environment. Other risk factors for acute cholecystitis include immunocompromised states, sepsis, diabetes and prolonged total parenteral nutrition. Complications of acute inflammation of gallbladder includes chronic inflammation, empyema, mucocele and perforation of gallbladder. The anatomy atcalot’s triangle in acute cholecystitis is distorted due to adhesions which makes delayed cholecystectomy somewhat difficult. The treatment of cholecystitis involves an important socioeconomic impact.

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phenomenon,during a second hospitalization.The second is a delayed cholecystectomy ,scheduled during the same hospitalization. The third is an early cholecystectomy ,as soon as possible after admission .[8,9]More studies were focused on the timing of cholecystectomy during the same hospitalization , should it be performed in acute phase or scheduled after a few days of medical treatment.

Laparoscopic cholecystectomy is widely established as the standard operation in acute cholecystitis .The traditional teaching has been a two stage treatment for acute cholecystitis with an initial conservative management followed by an interval laparoscopic cholecystectomy.Laparoscopic cholecystectomy is avoided for acute cholecystitis due to concerns about the potential hazards of complications,especially common bile duct injury and a high conversion rate to open cholecystectomy.The conversion rates for elective laparoscopic cholecystectomy range from 3-7 %.However in presence of acute inflammation ,higher conversion rates of up to 30 % have been reported.Several studies have reported favourable outcomes with a low conversion rate if patients are operated within 96 hours of admission.[4,6]

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cholecystectomy [DC] during a later admission after conservative treatment. Early cholecystectomy performed within 2 to 3 days of presentation is preferred over interval or delayed cholecystectomy that is performed 6 to 10 weeks after initial admission or before the end of the planned cooling off period.Surgeons have opted for interval cholecystectomy after a period of 6 -8 weeks .Large surgical centres have published their successful management of acute cholecystitis with urgent laparoscopic cholecystectomy.[11,12]

The first studies assessed EC as a treatment for acute cholecystitis date back to the 1950 s. In 1970, the first controlled study was published by Vander linden and Sunzel demonstrating better morbidity and shorter average hospital stay after EC. [4].The exponential development of laparoscopic surgery occurred during 1990’s.Since last 20 years ,increasing number of surgeons has favoured a policy of early surgery .Several randomized studies in the early 1980 has shown that performing early cholecystectomy for acute cholecystitis was better than delayed cholecystectomy in terms of operative feasibility ,post operative complications and shorter hospital stay .[1-3]

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Although literature favours laparosopic EC, most evidence comes from prospective studies specifically designed to prove this particular aspect. Initially laparoscopic cholecystectomy was contraindicated in acute cholecystitis because of the fear of increased morbidity and high rates [60%] of conversion to open cholecystectomy. Bile duct injury during laparoscopic cholecystectomy was a major concern.[6-11]

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2. AIM AND OBJECTIVE OF THE STUDY

To compare the safety, intra-operative difficulty, postoperative morbidity, duration of stay in hospital and effectiveness of early lap/open versus delayed lap/open cholecystectomy in cholecystitis.

3. REVIEW OF LITERATURE:

An English surgeon Walton [1923] first advocated early operation for acute cholecystitis. Charles.S.Jones [1960] suggested that early surgery as a general policy\ for management of acute cholecystitis might reduce mortality .[22,23]Roggs and Dunphy [1950] interviewing 150 surgeons found general agreement that the period between fourth and twelfth days from the acute attack were particularly dangerous but concluded that immediate operation was the treatment of choice no matter how long the duration of the disease.

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Abdullah .M. Tahaet al have concluded that early cholecystectomy is feasible and safe for acute cholecystitis. Early laparoscopic surgery offers definitive treatment at the initial admission and avoids the problems of failed conservative management and recurrent symptoms ,which requires emergency surgery .[44]

X.DWU ,M-Liu et al conducted a meta analysis of randomized controlled trials comparing early laproscopic cholecystectomy with late laproscopic cholecystectomy to compare the cost effectiveness, quality of life ,safety and effectiveness of ELC with DLC.[58,60] Results showed that ELC is associated with lower hospital cost, fewer work days lost and great patient satisfication.

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ANATOMY OF GALLBLADDER :

The gallbladder is a pear shaped gastrointestinal organ within the abdominal cavity .It is used as a temporary storage for bile, a fluid produced in the liver.It is concentrated and released from the gallbladder in response to eating.

It is a peritoneal structure, and in the right hypochondriac region. Anatomically it is a small reminiscent of a pear in shape, lying in a fossa between the right and quadrate lobes on the inferior aspect of liver.

ANATOMICAL RELATIONS OF GALLBLADDER :

Anteriorly and superiorly: Inferior border of the liver and the anterior abdominal wall

Posteriorly: Transverse colon and proximal duodenum

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ANATOMICAL STRUCTURE OF GALL BLADDER:

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[A] Common hepatic duct

[B]Gall bladder

[C]Cystic duct

[D]Common bile duct

DEVELOPMENT :

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GALLBLADDER :

The human gall bladder is a slate blue pyriform sac partly sunk in a fossa in the inferior surface of the liver . It extends forwards from a point near the right end of portahepatis to the inferior hepatic border .Its upper surface is attached to the liver by connective tissue ; elsewhere it is completely covered peritoneum continued from the hepatic surface . Occasionally it is invested by peritoneum and even to the liver by a short mesentery . In the adult , it is about 7.5 to 12.5 cm long ,3 cm broad at its widest and 30 – 50 ml in capacity , but capable of considerable distension in certain pathological condition . It is described as having fundus , body ,infundibulum and neck.

FUNDUS:

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BODY :

The largest part of the gall bladder ,it is occasionally in contact with the transverse colon and proximal duodenum.The body is directed up ,back and to the left ,near the right end of the porta it is continuos with the infundibulum of the gall bladder .It is related above to the liver , below to the transverse colon and further back to the first and upper end of the second segments of the duodenum.

INFUNDIBULUM :

The infundibulum is the part between the body and neck of the gallbladder .Hartmann’s pouch is a bulging of the inferior surface of the infundibulum ,which is the first part usually to form adhesions to this part of the gut .Broca first described Hartmann’s pouch and it was regarded as a constant feature of gallbladder . But Davies and Harding [1942] have shown its association with pathological conditions ,especially dilatations .

NECK:

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THE BILIARY TREE:

Bile is secreted from the gall bladder in to the gastrointestinal tract via a serious of ducts,known as the biliary tree.These ducts extend from the liver ,communicating with the gallbladder and pancreasand end at an opening in to the second part of duodenum .

The biliary tree begins with the left and right hepatic ducts ,which drains bile from the liver where it has been synthesized .These two ducts amalgamate to form the common hepatic duct ,which runs alongside of hepatic vein . As the common hepatic duct descends it is joined by the cystic duct which is a continuation of the neck of the gallbladder. The common hepatic duct and cystic duct combine to form the common bile duct.

As the common bile duct continues to descend , it passes posteriorly to the proximal duodenum and joins the pancreatic duct of the pancreas forming the hepatopancreatic ampulla of vater. This then empties in to the duodenum.

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ARTERIAL SUPPLY :

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LYMPHATIC DRAINAGE :

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posterior pancreaticoduodenal nodes .Hepatic nodes also collect from vessels accompanying the hepatic ducts and upper part of the bile duct .Subserosal lymphaticsconnect with hepatic sub serosal lymphatics.

NERVESUPPLY :

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from the anterior portion of the hepatic plexus. The nerve supply of the common bile duct derives from the posterior part of the hepatic plexus. The main nerve of the common bile duct lies dorsally and corresponds to the right portion of the posterior hepatic plexus . The later provides smaller branches that travel inferiorly along the common duct until the major papilla in the duodenum. The fact that the hepatic plexus comprises both efferent and afferent fibres explains the projection of biliary pain in to the right upper abdomen and epigastrium and in to the right shoulder .The hepatic plexus of the vagus nerve supplies cholinergic fibres to the gall bladder ,bile duct and the liver .The vagal branches also contain peptide containing nerves containing agents such as substance P, somatostatin ,enkephalins and the vasoactive intestinal peptide .

MICROSTRUCTURE OF THE GALL BLADDER :

The wall of the gall bladder consists of a mucosa ,fibromuscular layer, a perimuscular connective tissue layer and a serosa on all of its surface except the hepatic ,where an adventitia attaches it to the liver .

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indentations in the mucosa .In cross section ,these diverticula in the lamina propria resemble tubular glands ; however ,there are no glands in the the gall bladder [except in the neck region ].

The lining epithelium is a simple tall columnar epithelium with lightly stained cytoplasm and basal nuclei . The lamina propria contains loose connective tissue and some diffuse lymphatic tissue .

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ANATOMY RELEVANT TO CHOLECYSTECTOMY:

Knowledge of relevant anatomy is important for safe execution of any operative procedure .Specifically in the context of a cholecystectomy. It has been recognized since long that misinterpretation of normal anatomy as well as the presence anatomical variations contribute to the occurrence of major postoperative complications especially biliary injuries.

CYSTIC DUCT :

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The cystic duct joins the gallbladder at the neck and this angle may be fairly acute. Also the mode of joining may be smooth tapering or abrupt. Double cystic ducts are described but are extremely rare and therefore two ductal structures entering the gallbladder should always be viewed with suspicion.

CALOT ‘S TRIANGLE:

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CYSTIC ARTERY AND RIGHT HEPATIC ARTERY :

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It usually gives off an anterior or superficial branch and a posterior deep branch.This branching usually takes place near the gallbladder . The right hepatic artery normally courses behind the bile duct and joins the right pedicle high up in the calotstriangle.It may come very close to the gallbladder and the cystic duct in the form of a caterpillar or Moynihan’s hump.If such a lump is present the cystic artery is very short.In this situation the RHA is either liable to be mistakenly identified as the cystic artery or torn in attempts to ligate the cystic artery.

ANOMALIES OF THE CYSTIC AND HEPATIC ARTERY :

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ANOMALIES OF GALL BLADDER :

Anomalies in number:

1. Agenesis of the gall bladder.

2. Duplication of the gall bladder.

3. Triple gall bladder.

Anomalies in shape :

1. Bilobed gall bladder.

2. Rudimentary gall bladder.

3. Diverticulum of the gall bladder.

4. Hour glass stricture or dumb bell gall bladder.

5. Phrygian cap gall bladder.

6. Multiseptate gall bladder.

7. Kinking of the gall bladder.

Anomalies in position;

1. Left sided gall bladder.

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3. Intra hepatic gall bladder.

4. Retrodisplaced gall bladder.

5. Supra hepatic gall bladder.

ANOMALIES OF THE CYSTIC DUCT;

1. Very short or long cystic duct.

2. Absence of cystic duct.

3. Cystic duct opening in to the right or left hepatic duct.

4. Cystic duct opening directly in to the duodenum.

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PHYSIOLOGY OF BILE FORMATION:

Bile contains substances that are actively secreted into it across the canalicular membrane, such as bile acids, phosphatidylcholine, conjugated bilirubin, cholesterol, and xenobiotics. Each of these enters the bile by means of a specific canalicular transporter. It is the active secretion of bile acids, however, that is believed to be the primary driving force for the initial formation of canalicular bile. Because they are osmotically active, the canalicular bile is transiently hypertonic. However, the tight junctions that join adjacent hepatocytes are relatively permeable and thus a number of additional substances passively enter the bile from the plasma by diff usion. These substances include water, glucose, calcium, glutathione, amino

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those of the hepatocytes, although they remain freely permeable to water and thus bile remains isotonic. The ductules scavenge plasma constituents, such as glucose and amino acids, and return them to the circulation by active transport. Glutathione is also hydrolyzed to its constituent amino acids by an enzyme, gamma glutamyltranspeptidase (GGT), expressed on the apical membrane of the cholangiocytes. Removal of glucose and amino acids is likely important to prevent bacterial overgrowth of the bile, particularly during gallbladder storage . The ductules also secrete bicarbonate in response to secretin in the postprandial period, as well as IgA and mucus for protection.

FUNCTIONS OF THE GALLBLADDER:

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overall concentration of sodium ions rises with a concomitant loss of chloride and bicarbonate as the bile is concentrated). When the bile duct and cystic duct are clamped, the intrabiliary pressure rises to about 320 mm of bile in 30 min, and bile secretion stops. However, when the bile duct is clamped and the cystic duct is left open, water is reabsorbed in the gallbladder, and the intrabiliary pressure rises only to about 100 mm of bile in several hours.

REGULATION OF BILIARY SECRETION

When food enters the mouth, the resistance of the sphincter of Oddi decreases under both neural and hormonal influences. Fatty acids and amino acids in the duodenum release CCK, which causes gallbladder contraction. The production of bile is increased by stimulation of the vagus nerves and by the hormone secretin, which increases the water and HCO 3 – content of bile. Substances that increase the secretion of bile are known as choleretics. Bile acids themselves are among the most important physiologic choleretics.

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contraction (via acetylcholine (ACh)) and relaxation of the sphincter of Oddi to permit bile outfl ow (via NO and vasoactive intestinal polypeptide (VIP)).

EFFECTS OF CHOLECYSTECTOMY :

The periodic discharge of bile from the gallbladder aids digestion but is not essential for it. Cholecystectomized patients maintain good health and nutrition with a constant slow discharge of bile into the duodenum, although eventually the bile duct becomes somewhat dilated, and more bile tends to enter the duodenum after meals than at other times. Cholecystectomized patients can even tolerate fried foods, although they generally must avoid foods that are particularly high in fat content.

VISUALIZING THE GALLBLADDER:

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ducts. The response of the gallbladder to CCK can then be observed following intravenous administration of the hormone. The biliary tree can also be visualized by injecting contrast media from an endoscope channel maneuvered into the sphincter of Oddi, in a procedure known as endoscopic retrograde cholangiopancreatography.

CHOLECYSTITIS:

Cholecystitis is inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct by gallstones arising from the gall bladder. Uncomplicated cholecystitis has an excellent prognosis ; the development of complications such as perforation or gangrene renders the prognosis less favourable.

EPIDEMIOLOGY:

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ETIOLOGY:

Risk factors for calculouscholecystitis include the following :

• Female sex, Obesity, Rapid weight loss, Oc pills, Pregnancy, Increasing age.

Acalculouscholecystitis related to conditions associated with biliary stasis and include the following :

• Critical illness,major surgery or severe trauma,burns,longterm parenteral nutrition,prolonged fasting.

Other causes:

• Myocardial infarction,sickle cell disease ,salmonella infections,diabetes,patient with AIDS .

PATHOPHYSIOLOGY :

Ninety percent of cases of cholecystitis involve stones in the gallbladder,with the other 10% cases representing acalculouscholecystitis.

ACUTE CALCULOUS CHOLECYSTITIS:

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sterile but often becomes infected by bacteria predominantly E.coli,Klebsiella,Streptococcus and clostridium species.Inflammation can spread to the outer covering of the gallbladder and surrounding structures such as the diaphragm,causing referred right shoulder pain.

ACALCULOUS CHOLECYSTITIS :

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CHRONIC CHOLECYSTITIS:

Chronic cholecystitis occurs after repeated episodes of acute cholecystitis and is almost always due to gallstones.Chroniccholecystitis may be asymptomatic ,may present as a more severe case of acute cholecystitis,or may lead to a number of complications such as gangrene,perforationor fistula formation.

MECHANISM:

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swelling of gallbladder. Inflammation and swelling of the gallbladder can reduce normal blood flow to areas of the

gallbladder, which can lead to cell death due to inadequate oxygen.

SIGNS AND SYMPTOMS:

The most common presenting symptom of acute cholecystitis is upper abdominal pain, which may initially be colicky but almost always become constant. Nausea and vomiting are generally present, and fever may be noted.

The physical examination may reveal the following :

 Fever

 Tachycardia

 Tenderness in the right upper quadrant or epigastricregion,often guarding or rebound.

 Palpable gallbladder or fullness of the right upper quadrant.

 Jaundice.

DIAGNOSIS:

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Blood Examination:

In someone suspected of having cholecystitis blood tests are done as markers of inflammation.[complete blood count,c-reactive protein ]as well as bilirubin levels in order to assess for bile duct blockage.Complete blood count shows increased blood cell count [12,000 -15,000].Bilirubin levels are mildly elevated[1-4 mg/dl].The degree of elevation of these laboratory values may depend on the degree of inflammation of the gallbladder.

Imaging:

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TREATMENT :

Medical management:

Supportive measures may be instituted prior to surgery.The measures include fluid resuscitation.Intravenous opioids can be used for pain control.Antibiotics are often not needed.If used they should target enteritis organisms such as E.coli and Bacteriods .This may consist of a broad spectrum antibiotic such as piperacillin-tazobactam,ampicillin-sulbactam,ticarcillin-clavulanate,a third generation cephalosporin or a quinolone antibiotic and anaerobic bacteria coverage such as metronidazole.

Surgery:

For most people with acute cholecystitis ,the treatment of choice is surgical removal of the gallbladder ,laparoscopic cholecystectomy. Laparoscopic cholecystectomy is performed using several small incisions located at various points across the abdomen.Several studies have demonstrated the superiority of laparoscopic cholecystectomy when compared to open cholecystectomy .Additionally, laparoscopic surgery is associated with a lower rate of surgical site infection.

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compared to delayed treatment may result in shorter hospital stays and a decreased risk of enquiring an emergency procedure.There is no difference in terms of negative outcomes including bile duct injury or conversion to open cholecystectomy.For early cholecystectomy,the most common reason is inflammation that hides calot’s triangle .For delayed surgery ,the most common reason was fibrotic adhesions.

COMPLICATIONS:

A number of complications may occur from cholecystitis if not detected early or properly treated .Signs of complication include high fever, shock and jaundice. Complication.

GANGRENE:

Cholecystitis causes the gallbladder to become distended and firm. Distension can lead to decreased blood flow to the gallbladder, causing tissue death and eventually gangrene. Once tissue has died the gallbladder is at greatly increased risk of rupture. Rupture is a rare but serious complication that leads to abscess formation or peritonitis. Massive rupture of the gallbladder has a mortality rate of 30 %

EMPYEMA:

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similar to uncomplicated cholecystitis but greater severity ; high fever ,severe abdominal pain,more severely elevated white cell count.

FISTULA FORMATION AND GALLSTONE ILEUS:

The inflammation of cholecystitis can lead to adhesions between the gallbladder and other parts of the gastrointestinal tract,most commonly the duodenum.These adhesions can lead to formation of direct connections between the gallbladder and gastrointestinal tract called fistulas.With these direct connections ,gallstone can pass from the gallbladder to the intestines .Gallstones can get trapped in the gastrointestinal tract,most commonly at the connection between the small and` large intestines.When a gallstone gets trapped ,it can lead to an intestinal obstruction `,called gallstone ileus,leading to abdominal pain ,vomiting ,constipation and abdominal distension.

CHOLECYSTECTOMY:

Cholecystectomy is the surgical removal of the gallbladder. It is a common treatment of symptomatic gallstones and other gallbladder conditions .Surgical options include the standard procedure, called laparoscopic cholecystectomy and an older more invasive procedure ,called open cholecystectomy.

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Indications for cholecystectomy include inflammation of the gallbladder,biliarycolic,risk factors for gallbladder cancer and pancreatitis caused by gall stones.

Cholecystitis may be acute or chronic, and may or may not involve the presence of gallstones. Cholecystectomy can prevent the relapse of pancreatitis that is caused by gallstones that block the common bile duct.

LAPAROSCOPIC CHOLECYSTECTOMY:

Laparoscopic cholecystectomy has now replaced open cholecystectomy as the first choice of treatment for gallstones and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach. This is because open surgery leaves the patient more prone to infection .Sometimes, a laparoscopic cholecystectomy will be converted to an open cholecystectomy for technical reasons for safety.

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performs the operation by manipulating the surgical instruments through the operating ports.

To begin the operation, the patient is placed in the supine position on the operating table and anaesthetized. A scalpel is used to make small incision at the umbilicus .Using either a veres needle or Hasson technique, the abdominal cavity is entered. The surgeon inflates the abdominal cavity with carbon dioxide to create a working space. The camera is placed through the umbilical port and the abdominal cavity is inspected. Additional ports are opened inferior to the ribs at the epigastric, midclavicular and anterior axillary positions. The gallbladder fundus is identified grasped and retracted superiorly.With a second grasper ,the gallbladder infundibulum is retracted laterally to expose and calot’striangle. The triangle is gently dissected to clear the peritoneal covering and obtain a view of the underlying structures .The cystic duct and the cystic artery are identified,clipped with tiny titanium clips and cut .The gallbladder is dissected away from the liver bed and removed through one of the ports. This type of surgery requires meticulous surgical skill, but in straight forward cases, it can be done about an hour.

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surgery or ‘LESS’ or single incision laparoscopic surgery or ‘SILS’. In this procedure ,instead of making 3-4 small different cuts ,a single cut is made through the navel [umbilicus].Through this cut ,specialized rotaculating instruments are inserted to do the surgery. The advantage of LESS/SILS operation is that the number of cuts is further reduced to one and this cut is also not visible after the operation is done as it is hidden inside the navel.

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OPEN CHOLECYSTECTOMY:

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Open cholecystectomy is associated with greater post operative pain and wound complications such as wound infection and incisional hernia compared to laparoscopic, so it is reserved for selected cases.

COMPLICATIONS :

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• Emphysematous cholecystitis • Bile leak

• Bile duct in jury • Abscess

• Wound infection • Bleeding

• Organ injury

• Fatty acids and fat soluble vitamins malabsorption

Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting in less,quickerhealing,improved cosmetic results and fewer complications such as infection and adhesions. Most patients can be discharged on the same or following day as the surgery, and can return to any type of occupation in about a week.

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4.MATERIALS AND METHODS:

SOURCE OF DATA:

This will be a prospective study conducted in Department of General surgery, Government Stanley Medical College from October 2016 to August 2017.

METHOD OF DATA COLLECTION;

• A sample size of 25 is taken

• From cases attending our institute for treatment of acute cholecystitis

• Patients are made to understand and sign the informed consent form

• Patients with acute cholecystitis are subjected to early lap/open cholecystectomy within 7 days of onset of symptoms.

• Another sample size is subjected to late cholecystectomy atleast 6 weeks after symptoms have subsided.

• The results will be tabulated and scrutinized statistically based on safety, effectiveness, outcome, complications, quality of life, and early resumption of activities.

SAMPLE SIZE:

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STUDY DESIGN;

Prospective study

INCLUSION CRITERIA :

• Adult patients aged 25 to 60 years admitted with acute cholecystitis.

EXCLUSION CRITERIA:

• Age below 18 years or more than 65 years. • Any obvious septicaemia.

• Patients treated with steroids, immunosuppressive drugs or chemotherapy.

• Any other serious pre existingcardiovascular, pulmonary, immunological diseases.

• Choledocholithiasis.

METHODOLOGY:

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tenderness ,temperature exceeding 37.5 and total count more than 12000 ] and ultrasonographic criteria [thickened edematous distended gall bladder ,positive sonographic murphy’s sign .presence of gallstones and fluid collection.

STUDY OF CASES:

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CLINICAL DATA AND LABORATORY RESULTS

EARLY GROUP [n=25]

LATE GROUP[n=25]

AGE [YEARS] 40.5 +/- 11.4 38.6 +/- 11.4

SEX [M :F] 1:1 1:1

PREVIOUS BILIARY SYMPTOMS

3 4

DURATION OF ACUTE SYMPTOMS [HOURS]

35 +/- 18.2 37.1 +/-24.7

DURATION OF SYMPTOMS[DAYS]

2 5

MAXIMUM TEMPERATURE

99.7 +/- 0.2 99.2+/- 0.1

TOTAL LEUKOCYTE COUNT[>11,000/ML]

13,000 11,000

TOTAL

BILIRUBIN[mg%]

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EARLY GROUP [n=25]

LATE GROUP[n=25]

ASPARTATE

TRANSAMINASE[U/L]

40.7+/- 20 30.8+/- 14

ALANINE

TRANSAMINASE[U/L]

35.3 +/- 18 26.4+/- 14

ALKALINE

PHOSPHATASE[IU/L]

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ULTRASOUND FINDINGS OF PATIENTS

ULTRASOUND

FINDINGS

EARLY GROUP

[n=25]

LATE GROUP

[n=25]

Thickened edematous gall bladder

13 [52%] 12 [48%]

Distended gall bladder 16 [64%] 15 [60%]

Presence of gall stones 21 [84%] 21 [84%]

U/S Murphy’s sign positive

10 [40%] 13 [52%]

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MANAGEMENT OF CASES:

Patient with symptoms more than seven days, previous upper abdominal surgery, coexisting common bile duct stones or significant medical disease rendering them unfit for laparoscopic surgery were excluded from the study.

The patients who presented with acute symptoms were treated as follows;

1.] Nasogastric tube aspiration.

2.] Intravenous fluid.

3.] Broad spectrum antibiotics.

4.] Analgesics.

5.] Vitamin B complex, Vitamin C, Vitamin K.

6.] Antispasmodics

7.] H 2 –receptor blocking drugs.

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ampicillin,gentamycin and metronidazole was given. The patients who responded to conservative treatment underwent an elective laparoscopic cholecystectomy 6 weeks after acute episode has subsided.

SURGICAL PROCEDURE:

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necessary.Haemostasis was achieved in gallbladder bed ,and after a thorough saline lavage ,a suction drain was placed if clinically indicated and the incision closed .When required open procedure was performed through a right subcostal incision.

INTRAOPERATIVE ASSESSMENT:

Intraoperatively patients were assessed for intraoperative complications like difficulty in identifying calot’striangle, bile duct injury and bile leaks and results were tabulated for both early and late groups for statistical analysis.

POST OPERATIVE ASSESSMENT:

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.Sutures were removed after 8 to 10 days .Some stable patients were discharged early without removing sutures after good recovery.

FOLLOW UP:

At the time of discharge from hospital all the patients were advised revisit for check up. First check up done after 2 weeks, and then monthly for three months and then six monthly and when required basis.

When the patients visited for check up , they were enquired regarding persistence of previous symptoms ,general improvement of health condition and for appearance of newer symptoms and then a thorough examination of the patient made and investigations done whenever necessary.

STUDY PARAMETERS:

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5.OBSERVATION AND RESULTS:

STATISTICAL ANALYSIS:

The collected data were analysed with IBS.SPSS statistics software 23.0 version .To describe about the data descriptive statistics frequency analysis , percentage analysis were used for categorical variables and the mean and S.D. were used for continuos variables .To find the significant difference between the bivariate samples in independent groups the unpaired sample t-test was used .To find the significance in categorical data Chi –square and Fischer’s Exact was used .In all the above statistical tools the probability value .05 is considered as significant level.

P-value Highly significant at p < .01 P-value No significant at p > .05

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TABLE :1 AGE DISTRIBUTION

In our study the average age of patients was in a range of 43 +/_ 12 Year, in the early group and was around 42 +/- 12 Years in the late group .

43

42

35 36 37 38 39 40 41 42 43 44

Early Late

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TABLE :2 SEX VARIATION:

Groups

Total Early Late

SEX F Count % withinGroup s 12 48.0% 13 52.0% 25 50.0% M Count

% withinGroup s 13 52.0% 12 48.0% 25 50.0% Total Count

% withinGroup s 25 100.0% 25 100.0% 50 100.0%

In this study among early group there were 48% female population in early group and 52% female population in late group .among male population 52% belonged to early group and 48% belonged to late group.

48.0% 52.0%

52.0% 48.0%

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TABLE:3 Treatment Groups Groups

Total Early Late

LAPAROSCOPIC Count % withinGroups 17 68.0% 19 76.0% 36 72.0% OPEN Count % within Groups

8 32.0% 6 24.0% 14 28.0% Total Count % withinGroups 25

100.0%

25 100.0%

50 100.0%

Among the early group 17 [68%] underwent laproscopic cholecystectomy and 8 [32%] underwent open cholecystectomy . In the late group 19 [76%]underwentlaproscopic cholecystectomy and 6 [24%] underwent open cholecystectomy.

68.0% 76.0%

32.0% 24.0%

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TABLE :4

INTRAOP DIFFICULTY

Groups

Total Early Late

INTRAOP DIFFICULTY

No Count % within Groups

15 60.0% 15 60.0% 30 60.0% Yes Count

% within Groups

10 40.0% 10 40.0% 20 40.0% Total Count % within Groups 25

100.0%

25 100.0%

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In the early there was 40% difficulty in identifying Calot’s triangle and in the late group 40 % had difficulty in identifying Calot,s triangle. In both groups 60% cases didn,t have difficulty in the intra-operative period.

60.0% 60.0%

40.0% 40.0%

0% 20% 40% 60% 80% 100%

Early Late

Intra Op difficulty

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TABLE :5 INTRA OPERATIVE DIFFICULTY.

Chi-Square Tests

Value Df

Asymp. Sig. (2-sided) Exact Sig. (2- sided) Exact Sig. (1- sided) Pearson Chi-Square Continuity Correctionb Likelihood Ratio

Fisher's Exact Test Linear-by-Linear Association N of Valid Cases

.000a .000 .000 .000 50 1 1 1 1 1.000 1.000 1.000 1.000

1.000 .613

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TABLE :6 BILE LEAK

88.0% 76.0% 12.0% 24.0% 0% 20% 40% 60% 80% 100% Early Late

Bile leak

No Yes Groups Total Early Late

BILE LEAK No Count % withinGroups 22 88.0% 19 76.0% 41 82.0%

Yes Count % withinGroups 3 12.0% 6 24.0% 9 18.0%

Total Count

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TABLE: 7

Chi-Square Tests

Value Df

Asymp. Sig. (2-sided) Exact Sig. (2- sided) Exact Sig. (1- sided) Pearson Chi-Square Continuity Correctionb Likelihood Ratio

Fisher's Exact Test

Linear-by-Linear Association

N of Valid Cases

1.220a .542 1.239 1.195 50 1 1 1 1 .269 .462 .266 .274

.463 .232

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TABLE :8 POSTOP WOUND INFECTION

Groups

Total Early Late

POSTOP WOUND INFECTION

No Count % withinGroups 21 84.0% 19 76.0% 40 80.0%

Yes Count % withinGroups 4 16.0% 6 24.0% 10 20.0%

Total Count

% withinGroups 25 100.0% 25 100.0% 50 100.0%

84.0% 76.0%

16.0% 24.0%

0% 20% 40% 60% 80% 100% Early Late

Post Op wound infection

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TABLE:9

Chi-Square Tests

Value DF

Asymp. Sig. (2-sided) Exact Sig. (2- sided) Exact Sig. (1- sided) Pearson Chi-Square Continuity Correctionb Likelihood Ratio Fisher's Exact Test

Linear-by-Linear Association N of Valid Cases

.500a .125 .503 .490 50 1 1 1 1 .480 .724 .478

.484 .725 .363

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TABLE:10 ATELECTASIS

Groups

Total Early Late

ATELECTASIS No Count % withinGroups 19 76.0% 15 60.0% 34 68.0%

Yes Count % withinGroups 6 24.0% 10 40.0% 16 32.0%

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TABLE :11

Chi-Square Tests

Value df

Asymp. Sig. (2-sided) Exact Sig. (2- sided) Exact Sig. (1- sided) Pearson Chi-Square Continuity Correctionb Likelihood Ratio Fisher's Exact Test

Linear-by-Linear Association

N of Valid Cases

1.471a .827 1.482 1.441 50 1 1 1 1 .225 .363 .223

.230 .364 .182

In the early group 6 patients [24%] and 10 patients [ 40%] had lung infections .76 % in the early group and 60 % in the late group had lung infections . p value obtained by Pearsons Chi-square test

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TABLE :12 T-Test

Groups

N Mean Std. Deviation

Std. Error Mean

AGE Early Late 25 25 42.96 41.84 13.440 8.740 2.688 1.748

DURATIONOF Early SYMPTOMS Late

25 25 4.28 33.24 1.568 6.753 .314 1.351

DURATIONOF STAY IN Early HOSPITAL Late

25 25 9.52 14.84 6.423 6.466 1.285 1.293 10 15 0 2 4 6 8 10 12 14 16 Early Late

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6. DISCUSSION:

In the early years of laparoscopic surgery ,acute cholecystitis was considered a relative contraindication to laparoscopic cholecystectomy. Recently it has been shown that laparoscopic cholecystectomy is feasible and safe for acute cholecystitis. Various studies have reported higher conversion rates ,ranging from 6% to 35 % .for early cholecystectomy used to manage acute cholecystitis. The higher conversion rates obviates the advantages of early laparoscopic cholecystectomy.[53,56,62,66]It is therefore argued that if delayed laparoscopic cholecytectomy leads to a technically easier surgery with a lower conversion rate , it may be a better treatment option for acute cholecystitis. Adam et al [1947] was of the opinion that surgical treatment should be carried within 26 -72 hours of onset of symptoms.[39]. Zinninzer [1934],Mentzer [1936],Wright et al [1960],Ahmed [1992] all favoured early cholecystectomy.[41,47].

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However, the increasing experience of the surgeons with laparoscopic procedures and advances in the imaging techniques and operating instruments ,laparoscopic cholecystectomy is increasing applicable in the setting of acute cholecystitis .

The general belief that initial conservative treatment increases the chance of successful laparoscopic cholecystectomy at a later date probably is not true, as borne out by this study. In our study both early and delayed groups had similar difficulty in identifying calot’s triangle .In the early group ,the friable and edematous gallbladder tore when grasped .Moreover ,there was excessive oozing attributable to acute inflammation .

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The most common serious complications of LC are bile duct injury ,which is fatal and necessary for reoperation.[13] .Misidentification of common bile duct as the cystic duct is the most common cause of bile duct injury.Bile duct injury is probably the most important issue in a comparison of both early and delayed groups .[5].Around three patients in the early group [12%] had bile duct injury and six patients in the late group had bile duct injury [24%].However in the early group one case was converted to open due to short cystic duct and three patients in the late group were converted to open due to major bile leak in two cases and injury to common bile duct in one case.

One patient in the delayed group had a rent in the cystic duct – common bile duct junction while traction was applied to the Hartmann’s pouch. This was detected during the laparoscopic procedure, so considering the friable nature of the tissues the procedure was converted to open surgery and the rent was closed with a single interrupted suture of 4-0 vicryl. This patient had features of cholangitis in the immediate post operative period but settled with higher antibiotics.

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retrograde cholangiopancreatography and stenting .An abdominal ultrasound done 6 months later were normal. Other 2 patients in the early group and 5 patients in the delayed group with cystic duct injury were observed in the post operative period and were managed conservatively and had no significant complications .An abdominal ultrasound done 6 weeks later were normal.

Thus, overall, there was one major complication in the early and delayed groups .This was probably attributable to cholangitis .Thus, although the magnitude of the complication was same in both groups, we strongly believe that with increasing experience, these problems can be overcome.

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In our study, subhepatic drain was required for 40% of the early group patients and 60% of the delayed group patients. On the other hand, in the delayed cases, the increase in dense adhesions around the gallbladder after initial conservative treatment made laparoscopic dissection more difficult and constituted the main reason for intra-operative difficulty in identifying the calot’s triangle and bile duct injury.

Our study supports the belief that inflammation associated with acute cholecystitis creates an edematous plane around the gallbladder ,thus facilitating its dissection from the surrounding structures .Waiting for the inflammation to settle down allows maturation of the surrounding inflammation and results in organization of the adhesions , leading to scarring and contraction ,which makes the dissection more difficult .The inflammation in early stages may not necessarily involve the calot’s triangle , chronic inflammation often scars and distorts calot’s triangle ,making dissection in this area more difficult.

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results in both groups .With adequate analgesia, antibiotic cover and physiotherapy lung atelectasis could be possibly prevented in both early and delayed groups . One advantage in late group is that, when surgery is postponed for a period of six weeks they get adequate time to treat any pre –existing lung infections and time to improve the pulmonary function with pre-operative physiotherapy.

However, lung atelectasis in both Early and delayed group also involves any pre-existing infection, poor lung compliance, old age group and history of chronic smoking. Hence belonging to either the early or delayed group does not fully correlate with the prevalence of lung infection post operatively in both groups. So with adequate analgesia and physiotherapy with good antibiotic cover can prevent post operative lung atelectasis to a great extent. The significance of belonging to either early or delayed group does not play a major role in lung infections.

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patients [24%] had infection in the wound site .Post operative infection in the wound site had other causes too apart from timing of surgery which includes poor general hygiene, diabetic ,contamination with gallbladder in attempt to deliver it through port site .

Patients in both early and delayed groups presented with serous discharge from the wound site on day 5 or day 6 followed by purulent discharge in some case. Pus sent for culture sensitivity and antibiotics were started appropriately. Most of the culture were positive for gram negative organisms and sensitive to Penicilllin ,Aminoglycosides and Cephalosporins .Patients were treated with appropriate antibiotics with regular dressing. Most of the patients responded well to this management.

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R.A. Pyne [1969] in his study found that the average duration of hospital stay to be around to be 16 days for delayed cholecystectomy.[45] .Duration of stay was around 10 days for the early group and around 15 days for the delayed group from the time of admission for symptoms followed by surgery up to suture removal in some cases and good general condition in some cases.The prolonged stay in the early groups were due to bile duct injury ,post operative wound infection or lung infections .I.Ahmed [1992] in his study found that the average duration of hospital stay in early cholecystectomy group to be ten days .[44] .The total hospital stay was shorter by 5 days in the early group when compared to the delayed group . This may result from the more treatment and therapies following intraoperative and post operative complications.

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cholecystectomy for cholecystitis had a shorter duration of stay when compared to the delayed group.

Early cholecystectomy is safe and shortens hospital stay and reduces the risk of repeated cholecystitis. Early cholecystectomy was found to decrease the morbidity during the waiting period for elective laparoscopic cholecystectectomy , operating time and hospital stay .In a recent survey evaluating surgical approaches for acute gallbladder disease between 1989 and 2006 in Sweden , total hospital stay was found to be shorter for patients who had emergency cholecystectomy at first admission compared with patients with elective cholecystectomy.

Similar to the above clinical studies , we found that hospitalization duration was significantly shorter and work lost days were lower with early laparoscopic cholecystectomy compared with delayed laparoscopic cholecystectomy for cholecystitis .Therefore we conclude that early cholecystectomy for acute cholecystitis is advantageous in terms of the length of hospital stay without increase in morbidity and mortality .

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cholecystectomy. Early cholecystectomy is therefore advantageous when compared to delayed cholecystectomy.

The present study had some limitations . The sample size was considerably small and a significant difference in p value could not be obtained .Though difficulty in identifying the Calot’s triangle was similar in both groups with a p value of 1.0 which was not much significant, the duration of surgery was quite prolonged in the delayed groups due to dense adhesions .Two patients in early group and two patients in delayed group underwent conversion to open surgery due to difficult anatomy and bloody field which causes difficult visualization . This difference is insignificant we believe that conversion to open procedure is inevitable in laparoscopic management of acute cholecystitis and is not considered a complication.

Another dreaded complication is bile duct injury an bile leak ,which was lesser among the early group when compared to the delayed cholecystectomy group, with a p value of 0.483 .Post operative wound infection was also less in the early group with a p value of 0.725 .Lung atelectasis was less common in the early group with a p value of 0.225 .

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CONCLUSION:

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BIBLIOGRAPHY:

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2. E. H. Ellison, J. H. Miholland, and S. R. Friesen, Early Operation for Acute Cholecystitis. Current Surgical Management, Saunders, Philadelphia, Pa, USA, 1957.

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5. T. Kiviluoto, J. Sirén, P. Luukkonen, and E. Kivilaakso, “Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis,” The Lancet, vol. 351, no. 9099, pp. 321– 325, 1998.

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cholecystectomy for acute cholecystitis,” Annals of Surgery, vol. 227, no. 4, pp. 461–467, 1998

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8. C. F. Chandler, J. S. Lane, P. Ferguson, J. E. Thompson, and S. W. Ashley, “Prospective evaluation of early versus delayed laparoscopic cholecystectomy for treatment of acute cholecystitis,” The American Surgeon, vol. 66, no. 9, pp. 896–900, 2000.

9. A. S. Serralta, J. L. Bueno, M. R. Planells, and D. R. Rodero, “Prospective evaluation of emergency versus delayed laparoscopic cholecystectomy for early cholecystitis,” Surgical , Endoscopy and Percutaneous Techniques, vol. 13, no. 2, pp. 71–75, 2003.

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11. S. B. Kolla, S. Aggarwal, A. Kumar et al., “Early vs delayed laparoscopic cholecystectomy for acute cholecystitis: a prospective randomized trial,” Surgical Endoscopy and Other Interventional Techniques, vol. 18, no. 9, pp. 1323–1327, 2004.

12. K. S. Gurusamy and K. Samraj, “Early versus delayed laparoscopic cholecystectomy for acute cholecystitis (review),” Cochrane Database of Systematic Reviews, no. 4, Article ID CD005440, 2006.

13. T. Siddiqui, A. MacDonald, P. S. Chong, and J. T. Jenkins, “Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a meta-analysis of randomized clinical trials,” The American Journal of Surgery, vol. 195, no. 1, pp. 40–47, 2008

14. K. S. Gurusamy, K. Samraj, C. Gluud, E. Wilson, and B. R. Davidson, “Meta-analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis,” British Journal of Surgery, vol. 97, no. 2, pp. 141–150, 2010.

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16. K. S. Gurusamy, C. Davidson, C. Gluud, and B. R. Davidson, “Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis,” The Cochrane Database of Systematic Reviews, no. 6, Article ID CD005440, 2013.

17. C. N. Gutt, J. Encke, J. Köninger et al., “Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDc Study, nct00447304),” Annals of Surgery, vol. 258, no. 3, pp. 385–393, 2013.

18. M. Vetrhus, O. Søreide, I. Nesvik, and K. Søndenaa, “Acute cholecystitis: delayed surgery or observation. A randomized clinical trial,” Scandinavian Journal of Gastroenterology, vol. 38, no. 9, pp. 985– 990, 2003.

19. C. Papi, M. Catarci, L. D'Ambrosio et al., “Timing of cholecystectomy for acute calculouscholecystitis: a meta-analysis,” The American Journal of Gastroenterology, vol. 99, no. 1, pp. 147–155, 2004.

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21. E. H. Livingston and R. V. Rege, “A nationwide study of conversion from laparoscopic to open cholecystectomy,” The American Journal of Surgery, vol. 188, no. 3, pp. 205–211, 2004.

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35. Bhansali, 1980. J.O.PG Med. 26: 74-85.

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52. Al-Haizar N, Duca S, Molnar G, Vasilescu A, Nicolescu N (2002) Incidents and postoperative complications of laparoscopic cholecystectomy for acute cholecystitis. Rom J Gastroenterol 11:115– 119

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10 PROFORMA HOSPITAL NO:

MRD No: NAME: AGE: SEX:

ADDRESS: OCCUPATION:

SOCIOECONOMIC STATUS: DATE OF ADMISSION:

DATE OF OPERATION: DATE OF DISCHARGE: HOSPITAL STAY:

CHIEF COMPLAINTS:

1] Pain abdomen.

2] Nausea and Vomiting. 3] Fever.

4]Jaundice.

5]Any other specific complaints. History of present illness:

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11 • Site

• Severity –mild/moderate/severe. • Duration.

• Time and mode of onset. • Nature and relation to food. • Referred to .

• Radiated to.

• Aggravating and Relieving factors. 2]Vomiting :

• Started before or after the onset of pain. • Projectile / Non projectile.

• Frequency . • Amount.

• Nature – Color,contents.Taste,Smell. 3] Fever :

• Type – Continuos / intermittent/remittent. • Grade – Low/moderate/high.

• Associated with chill or rigor or not. 4] Jaundice :

• Duration

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• Whether associated with itching or not. • Colour of urine and stool.

5] Associated symptoms : • Loss of appetite . • Weight loss.

• Flatulent dyspepsia. • Bowel habit.

• Micturition.

TREATMENT /DRUG HISTORY :

Whether he /she is taking any medications for the present disease or other reasons .

PAST HISTORY :

Past h/o Diabetes /Hypertension /Tuberculosis/Malaria/Typhoid fever .

Past h/o any surgery. PERSONAL HISTORY :

• Dietary habit : Vegetarian / Non vegetarian . • Alcoholic / Non alcoholic.

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Whether any of the family members is suffering or did suffer from similar complaints were specifically asked.

A] GENERAL EXAMINATION:

The following points were taken in to account 1.] Appearance .

2.] Decubitus . 3.] Built, 4.] Nutrition. 5.] Pallor. 6.] Icterus. 7.] Cyanosis. 8.] Edema. 9.] Dehydration. 10.] Clubbing. 11.] Pulse rate. 12.] B.P.

13.] Respiratory rate.

EXAMINATION OF ABDOMEN: A.] INSPECTION:

• Size and Shape.

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14 • Distension: General / Local. • Respiratory movement. • Visible lump.

• Visible peristalsis.

• Inspection of hernia orifices and genito-urinary area . B.] PALPATION :

Guarding / Rigidity.

Tenderness / Murphy’s sign.. C.] PERCUSSION:

Note : Dull /Tympanic. Liver dullness .

Shifting dullness. Fluid thrill.

D.] AUSCULTATION: Peristaltic sound.

Any bruit over any part of abdomen. PER RECTAL EXAMINATION : Faecal staining or clay coloured stools. OTHER SYSTEM EXAMINATIONS: 1. Central nervous system.

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15 3. Respiratory system.

PROVISIONAL DIAGNOSIS : INVESTIGATIONS :

Blood :Hb% , TLC ,DLC ,BT,CT. ESR, ABO and Rh grouping. Fasting blood sugar.

Blood urea ,Serumcreatinine.

Urine : Albumin, Sugar ,microscopic examination and urobilinogen in urine.

LIVER FUNCTION TESTS :

• Serum bilirubin [conjugated / unconjugated]. • Serum protein

• SGOT. • SGPT.

• Serum alkaline phosphatase. • Gamma GlutamylTranspeptidase. • Prothrombin time.

RADIOLOGICAL EXAMINATION : • Chest x ray [ P A view ]

• Ultrasonography of abdomen especially hepato biliary system. SPECIAL INVESTIGATIONS :

• ECG.

Figure

TABLE  :1 AGE DISTRIBUTION

TABLE :1

AGE DISTRIBUTION p.67
TABLE :2 SEX VARIATION:

TABLE :2

SEX VARIATION: p.68
TABLE:3 Treatment Groups
TABLE:3 Treatment Groups p.69
TABLE :4 INTRAOP DIFFICULTY

TABLE :4

INTRAOP DIFFICULTY p.70
TABLE :5 INTRA OPERATIVE DIFFICULTY.

TABLE :5

INTRA OPERATIVE DIFFICULTY. p.72
TABLE :6 BILE LEAK

TABLE :6

BILE LEAK p.73
TABLE: 7 Chi-Square Tests
TABLE: 7 Chi-Square Tests p.74
TABLE :8 POSTOP WOUND INFECTION

TABLE :8

POSTOP WOUND INFECTION p.75
TABLE:9 Chi-Square Tests
TABLE:9 Chi-Square Tests p.76
TABLE:10 ATELECTASIS
TABLE:10 ATELECTASIS p.77
TABLE :11 Chi-Square Tests

TABLE :11

Chi-Square Tests p.78
TABLE :12 T-Test

TABLE :12

T-Test p.79

References

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