- Email: [email protected]
The surgical treatment of acute cholecystitis
THE SURGICAL TREATMENT H. K. BONN, Assistant
M.D.,
OF ACUTE CHOLECYSTITIS*
AND
P.A.C.S.
C.
A.
Instructor
Professor of Surgery, College of Medical EvangeIists LOS ANGELES,
C
has aptly stated that sound judgment is required to choose the opportune moment for surgica1 intervention in acute choIecystitis and that any attempt to standardize the time of operation is hazardous. An earIy operation, as defined by Cave, impIies an interva1 of from twenty-four hours to seven days, whiIe a deIayed procedure is one done after the acute process has subsided, a matter of weeks or even months. Likewise surgeons may be cIassified into three groups: “ (I) those who operate immediateIy upon admission of the patient to the hospita1 (apparentIy regardIess of the time eIapsed “immediate” group; (2) since onset)-the those who operate between the first and fifth days (where apparentIy eIapsed time since onset is given consideration)-the “earIy” group; and (3) those who deIay intervention for weeks or even months.” It is Cave’s conviction that the mortaIity rate in the hands of the majority of surgeons is better in the so-caIIed “earIy” group than in the “immediate” group. As a starting point in the consideration of the surgica1 treatment of acute choIecystitis Graham’s statement is singuIarIy apropos, viz., that “the danger of operation in acute choIecystitis cannot be demonstrated in a hospita1 that usuaIIy practices deIay, for onIy the bad cases wiI1 receive earIy operation. ConverseIy, a hospita1 that beIieves in earIy operation cannot speak with authority about the dangers of deIay.” From a bacterioIogic and surgica1 viewpoint, the findings of Edmund Andrews are of importance in this connection: (I) in many cases it is not possibIe to obtain posiAVE
BACHHUBER,
M.D.,
of Surgery, CoIIege of h,ledicaI Evangelists
CALIFORNIA
tive cultures in what appears to be a very acute inffammation of the gaII-bIadder; (2) many cases which seem to show empyema have steriIe cuItures; (3) in many cases there is a stone in the cystic duct or in the ampuIIa, apparentIy sIowing the bIood flow from the gaII-bIadder. An acute bacteria1 choIecystitis may not be the cause, but rather edema and obstruction of the bIood suppIy. If these are aIIowed to quiet down, acute bacteria1 infection wiII deveIop. This is the expIanation of perichoIecystitis and abscess deveIoping in the gaII-bIadder, producing technica difficuIties in its Iater remova1. Burggeman drew a clear anaIogy when he decIared that acute choIecystitis may be compared to acute saIpingitis in that it rareIy kiIIs if treated conservatively. The comparison between acute choIecystitis and acute appendicitis is not in consonance with the cIinica1 facts. H. F. Graham, in a series of 197 consecutive cases, operated upon twenty within forty-eight hours of the onset of the acute symptoms, with one death (pancreatitis), a mortaIity of 3 per cent. This is, of course, a smaI1 series. In the remaining 150 cases operated upon after the forty-eight hour interva1, the mortality was 6.2 per cent. Pratt, quoted by Graham and Waters, records twenty-three choIecystectomies done within twenty-four hours of hospital entrance, without a death. The time of acute iIIness prior to hospita1 entrance and operation is not stated. In a series of fortyfive cases there were no deaths when operation was done within forty-eight hours after onset of the disease.
* From the Surgical Division of the LOSAngeIes County HospitaI and the Surgical Department Medical Evangetists, Los AngeIes. 447
F.A.C.S.
of the CoIlege of
448
American
Journal
Smith reports
of Surgery
Bonn,
Bachhuber-ChoIecystitis
in a series of 1,053 cases:
MortaIity Acute, 107 cases, IO deaths, (operg, 3 ated upon at once). . Subsided, (three or four days without fever before operation), 94 cases, 5 deaths, (operation from forty-eight hours to seven days 5.3 after onset). . 3.3 Chronic, 754 cases, 24 deaths. Duct stones, g8 cases, 32 deaths. 33. o Total number of cases 1053, 71 deaths........................ 6.7
Five of the cases of the acute series (5 per cent) were perforated, a11 in the first three days after onset of the iIIness; eight were gangrenous; eIeven empyemas were found; and eIeven had abscesses Iocated outside the gaII-bIadder. In severa patients more than one of these compIications was present. In the preceding thirty-three patients (one-third of the acute group) there occurred five deaths, one-haIf of the total. Thus since a11fuIminating cases (the thirtythree compIicated cases) were incIuded in the mortaIity statistics of the acute group these figures are not entireIy accurate. If one deducts the thirty-three compIicated cases from the 107 cases Iisted, there remain seventy-four strictIy acute choIecystitis cases in which there were five deaths, 6.5 per cent mortaIity. Smith, despite the trend toward earIy surgery, and certain contrary opinions, believes that ectomy in acute choIecystitis is a definiteIy more diffIcuIt technica procedure and states that in such cases it may be necessary to rempve the gaII-bIadder at the ampulla rather than at the duct, as a matter of safety. Two of the cases in his series were reoperated for stones present in the remnant of the gaII-bIadder. Smith in a recent reversa1 of opinion, now believes that surgery in acute ChoIecystitis is unwise unIess the evidence points to free perforation, in which instance immediate operation shouId be done. Graham compiIed a Iist of 153 cases of acute choIecystitis from the wards of the Toronto Genera1 HospitaI for the period from JuIy, I, 1926 to January I, 1934. Of these 153 cases, twenty-four refused sur-
SEPTEMBER, ,940
gery and in sixty-one surgery was not advised for various reasons. Thus of sixtyeight operated cases six were operated upon at once with one death, 16 per cent mortaIity. In sixty-two cases deIayed surgery was done, with three deaths, 4.8 per cent mortaIity. Four deaths occurred in the sixtyeight cases, a mortality of 5.8 per cent. The average time from onset to hospita1 entrance was six days. In a series of fifty-two private patients, Graham operated immediateIy in seven cases and deIayed surgery in forty-five. There were four fata cases in the series, a mortaIity of 7.7 per cent. In the deIayed surgery group of forty-five, there were a11 of these patients eIeven perforations; survived. These cases were seen earIier after onset than those of the series of Toronto Genera1 HospitaI. Pennoyer studied 300 consecutive cases of cIinicaIIy acute choIecystitis, at the RooseveIt HospitaI, New York City, the cases dating back to 1918. The routine treatment had been to delay surgery in such cases unti1 the acute symptoms subsided, operation being done onIy if urgent compIications indicated such intervention. During more recent years, earIy surgery has been advocated, the reason for the change being that the danger of compIication was considered greater than the danger of operative interference. Operation is now done within five days of onset unIess there is definite improvement. ChoIecystostomy rather than choIecystectomy is done, on the basis of safety. In this series, the charts of I ,474 patients with gaII-bIadder disease were studied. The 300 cases of acute choIecystitis presented here represent a carefu1 seIection incIuding those in which the advocates of earIy operation have presented evidence of justified intervention. There were thirty deaths in the entire series, a mortaIity of IO per cent. In these fata cases, the average time of acute iIIness prior to hospita1 entrance was four days; they were observed for two and one-third days prior to operation. Thus a tota of
NF\\
SIKIES VOL.
XLIX,
No.
3
Bonn,
Bachhuber-Cholecystitis
six and one-third days represents the average time from onset to operation. Of these thirty deaths, twenty-one actuaIIy died as a result of operative procedure, a 7 per cent mortahty. Fifteen deaths occurred in a series of fifty-nine cases (20 per cent of the entire series of 300), in which emergency operation was done within tweIve hours of hospital entrance. In this series of fiftynine, there were thirty-two cases, 54 per cent, incorrectIy diagnosed. Thus, the fifteen deaths, operated at once as emergencies, represent a mortaIity of 23 per cent. The remaining 241 patients had been acutely iI for four days prior to hospita1 entrance. Of these, thirty-three, after an average deIay of five days, were found not subsiding or actually becoming worse. They were therefore operated upon in the presence of acute symptoms, seven deaths ensuing, a mortality of 20 per cent. In the remaining 208 cases the symptoms subsided after an average of eight days. Thus the total time from onset to operation in these 208 cases was at least tweIve days. There were five deaths in this group, a mortaIity.rate of 2.3 per cent. In the entire group of 241 cases there were twelve deaths, a mortahty of 5 per cent. Of the 300 cases, 20 per cent showed some gangrene of the gall-bladder walI and thirty cases showed delinite rupture with resuhant local peritonitis. Cutler, in the discussion of Pennoyer’s paper, insisted that only cases seen within a few hours of the onset of the attack, not two to live days after onset, shouId be operated upon at once. WhippIe is of the same opinion. Leidberg beheves that moderateIy severe cases of acute ChoIecystitis should be operated upon in two or three days, unless specific contraindications are present. Branch and ZoIlinger (235 cases) performed immediate surgery in thirty-four cases, the mortality being 20.3 per cent. In 195 cases they waited an average of 4.7 days before surgery; operative mortality was reduced to 8.7 per cent.
American
Journal
of Surgwy
449
Heuer, in a summary of 1,066 cases of acute ChoIecystitis subject to surgery, found a genera1 mortality of 8 per cent and an individua1 mortahty varying between 4.7 per cent to 22.5 per cent. The report of Judd and PhiIlips, concerning 508 cases of acute cholecystitis, showed a mortahty percentage of 4.7. There were sixty-eight cases of perforation or gangrene, 13 per cent. Cave comments that only fourteen of these 508 patients had emergency operations. Also to be noted is the fact that of the sixty-eight cases having gangrene or perforation, sixty-one had the lesion walled off into a Iocalized abscess. Cave has the delinite conviction that the acuteIy inflamed gaII-bIadder rareIy perforates into the free abdomina1 cavity, causing a diffuse peritonitis, but that the percentage of Iocalized abscess following perforation is quite large. Eliason and McLaughIin report nine perforations in a series of 500 consecutive hospita1 admissions for biIiarv disease, a percentage of I 3. AI1 had Iocalized abscess, six being admitted as emergency cases. IncIusive of their own 500 cases, they record a summary of 7,316 cases; ninety-six instances of perforation occurred, 0.77 per cent. Perforation in the cases of the different surgeons of this series ranged from 0.9 to 2.5 per cent, mortahty from 1 I per cent (Eliason and McLaughIin) to 44 per cent. Touroff found that 20 per cent of seventyfive cases of acute choIecystitis, in the presence of minimal or absent chnical manifestations, had progressive gall-bladder lesions. The remaining 80 per cent (sixty cases) had Iesions that were subsiding or capable of subsidence. Touroff beIieves that if subsidence does not occur promptly and proceed reguIarly, earIy operation is indicated. In cases w-ith subsided clinica maniearIy operation, rather than festations, Iater in the “interva1” is indicated. Shoemaker reviewed 274 operations upon the bihary tract, done by staff surgeons of the Los AngeIes County HospitaI from I 929 to I 93 I. These patients were selected from I, I 86 admitted to the hospital with a diagnosis of acute or chronic cholecystitis. Of
450
American Journal of Surgery
Bonn,
Bachhuber-ChoIecystitis
the number of patients admitted, approximateIy 25 per cent were operated upon. Of these, thirty-seven died, a mortaIity of 13.5 per cent. Discarding the six malignancies in the series, the mortahty becomes I 1.3 per cent. There were two cases of acute uIcerative choIecystitis, one abscess of the liver, two gangrenous gaII-bIadders and four empyemas in this series. In this survery covering a11 biIiary cases admitted to the Los AngeIes County HospitaI for the five-year period, 1933-1938, we have been particuIarIy interested in attempting to determine how much inff uence, if any, the eIapsed time from the onset of an acute ChoIecystitis to operation is reIated to complications and mortaIity, the criterion to be the pathoIogic diagnosis rather than the surgeon’s operative report, in a11 cases where choIecystectomy was done. In those instances where choIecystostomy was done, the surgeon’s operative report was used, unIess a portion of the gaII-bIadder had been exised and used for pathoIogic examination. QuestionabIe cases in the origina Iist have been discarded whenever there was insuffIcient data. A tota of I 3 I cases were thus excIuded. These wouId probabIy have beIonged in Group I or 2. Likewise a11 cases of primary pancreatic disease and a11maIignancies of the biIiary tract (sixty-six) have been excIuded. It has been impossibIe to tabuIate the cystic duct stone cases separateIy because of Iack of data. They are therefore incIuded in the genera1 tabIes. We are of the opinion that the importance of the cystic duct stone cases, as reIated to vicious compIications and resuhant increased mortabty, has not been suffIcientIy stressed. The universa1 poIicy of this hospita1 has been to defer surgery unti1 the acute attack has subsided, subject to the indications for emergency operations at the discretion and judgment of the attending surgeons. It is uncommon for the acute case to enter the hospita1 within forty-eight hours of the onset. The patient has been III usuaIIy from two to seven days before hospita1 entrance.
SEPTEMBER, 19*0
The suggestion of some observers that operation be done in the first forty-eight hours is Iimited in its appIicabiIity in this hospita1. There were 955 patients admitted with a diagnosis of biIiary disease in the period 1933-1938. This incIudes a11 questionabIe biIiary and maIignant cases, which were excIuded from our fina tabIes. In the entire group, there were 704 surgica1 interventions. Acute ChoIecystitis was diagnosed in 25 I patients. Six cases are excIuded because of insuffIcient data, Ieaving 245. None of this group was operated upon; either the patient refused surgica1 intervention or the surgeon objected, usuaIIy on the basis of other additiona and advanced pathoIogy, especiaIIy cardiorena1 disease. There were fifteen deaths in this nonoperative group, a mortahty of 6 per cent. Nine autopsies were done, and in a11 but two instances, the cause of death was other than acute choIecystitis or its comphcations. However, a11 autopsies showed the presence of ChoIecystitis. Since 230 of these 245 unoparated patients apparentIy recovered and were dismissed from the hospita1 in from five to fourteen days, there is presumptive evidence that the incidence of perforation, gangrene and abscess may not be so high as some observers report. The operative cases have been tabuIated in three groups : Group I represents a11cases operated upon within forty-eight hours of the onset of the iIIness. Group 2 incIudes those cases operated upon from the third to the sixth day incIusive after onset, and Group 3 those cases operated upon after the sixth day. AI1 questionabIe cases (197) have been excIuded. Group I. Operation done within fortyeight hours of onset. There were sixteen cases in this group, eight choIecystectomies and eight choIecystostomies, with three deaths, a mortahty of 19 per cent. There were five choIecystectomies in femaIes, no deaths; three in maIes with one death: the mortaIity thus being 12.5 per
NIT\\
SMUES
VOL.
X1.1X, No. 3
Bonn,
Bachhuber-ChoIecystitis
cent. PathoIogic diagnoses were: two subone marked subacute, one emacute, and three chronic pyema, one gangrene cholecystitis. TABLE I GROUP I (Operated upon within 48 hours of onset)
I 0
0 I
Ameriran
.lournul
of Surgerv
35
1
deaths), twelve in males (two deaths). The pathoIogic diagnosis were: seven acute, nine subacute, five uIcerative, two gangrenous, one hydrops and twenty-four chronic. The five ulcerative cases were further cIassified as: one recent acute, one subacute, one acute and two chronic. Sixteen cholecystostomies were done with one death, a mortaIity of 6.2 per cent. In eIeven females there were no deaths. The pathoIogy was given as one subacute, one gangrene and one empyema. In the five males there was one death. upon afier the sixth Group 3. Operated day since onset. The greater portion of this
I
i
-
I-ABLE
Tot& 16 cases, 3 deaths, mortality, Ig per cent 8 ectomies, I death, mortality, 12.5 per cent 8 ostomies, 2 deaths, mortality, 25 per cent
IL1
3 (Operated upon after the 6th day al’tt.r. onset GROUP
i
The eight choIecystostomies were evenIy divided as to sex. There were two deaths, a maIe and a femaIe, giving a mortahty of 23 per cent. One hydrops and one empyema were incIuded. Group 2. Operated upon from forty-eight bows to the seventh day after onset. There
were sixty-four
cases in this
group,
with
(Purulent. I recentacute,z subacute, I chronic) (Ulcerative, 4 acute, I recentacute.8 subacute, 15 Totat, 4~~7cases, 23 deaths, mortality, 3.4 per
chronic) cent
390 ectomies, 20 deaths, mortality, 5.1 per cent 37 ostomies, 3 deaths, mortality. 8 I per cent
TABLE II GROUP 2 (Operated upon from 48 hours to the 7th day after onset)
-
F
~ ect.
361
2
-I-
0
group was operated on from the fourteenth to the twenty-first day after onset, the majority on the fourteenth day. Cases of perforation, gangrene, empyema, acute uIcerative and puruIent were operated upon between the seventh and fourteenth days after onset. (TabIe III.)
I
TABLE
-
LOS -
I acute, I recent acute, I subacute, 2 chronic) TotaI, 64 cases, 5 deaths, mortality, 7.8 per cent 48 ectomies, 4 deaths, mortality, 8.3 per cent 16 ostomies, I death, mortaIity, 6.25 per cent
ANGELES
IV
GENERAL
HOSPITAL
1933-1938
(Ulcerative,
five deaths, a mortaIity of 8 per cent. Forty-eight choIecystectomies were done, with four deaths, a mortaIity of 8.3 per cent. There were thirty-six in femaIes (2
7o* Surgical interventions. 638 BiIiary surgery soIely 307 Corrected list, biIiary surgeq Group 1.. Groupz.................. Group3 .._..........__..
Per Cent 12,lortality 13.3 j
8.~7 1Q.l) 7.8 54
This group comprises 427 cases, with twenty-three deaths, a mortality of 5.4 per
452
American
Journal
of Surgery
Bonn,
SEPTEMBER, ,940
Bachhuber-ChoIecystitis
cent. There were 390 choIecystectomies with twenty deaths, a mortaIity of 5.1 per cent. In this group 31 I were femaIes, incIuding thirteen deaths. The pathoIogic diagnoses in these 3 I I cases incIuded : eight acute, fifty-eight subacute, 208 chronic, one cholesterosis, one gangrene, one hyand twenty-one four puruIent, drops, uIcerative. The uIcerative cases were further cIassified as: acute uIcerative three, subacute seven and chronic eleven. The purulent were also further cIassified as acute one, subacute two and chronic one. No report was given in ten instances. There were seventy-nine choIecystectomies in maIes, with seven deaths. Three were acute, eighteen subacute, forty-five chronic, one empyema, one gangrene and seven uIcerative; the Iatter cIassified as: acute one, subacute one, recent acute one, and four chronic. No report was given in four cases. Thirty-seven cho1ecystostomie.s were done, twenty-seven in femaIes and ten in maIes, with three deaths, a mortaIity of 8.1 per cent. There was one death in a femaIe. Three empyemas were incIuded. In the ten maIes two deaths occurred. One two perforations, three emgangrene, pyemas and three chronic choIecystitis were present. SUMMARY
We are in accord with Smith in the belief that operation within forty-eight hours of onset carries too high a mortaIity to warrant much consideration, especiaIIy in the wards of a pubIic charitabIe hospital whose patients are not infrequentIy poor surgica1 risks. Furthermore, these patients often do not come to the hospita1 within forty-eight hours of the acute onset. Our opportunities have been Iimited as regards statistics for this group. Our entire Group I series has IittIe positive vaIue since it is too smaI1 in numbers. We are inclined to the view of CutIer and WhippIe that any earIy operation,
preferabIy choIecystectomy, shouId be done within six to tweIve hours of onset. So far as we have been abIe to determine, apparentIy the peak of the disease is reached in from one to four days. In Group 2, after forty-eight hours, seven acute, ten subacute, five ujcerative, four gangrenous, two empyemas and one hydrops were present; in other words, considerabIe acute pathoIogy remained. The chronic cases, aImost a third, showed subsidence of the pathoIogy. NevertheIess the mortality for this group had dropped by 60 per cent, from the 19 per cent of Group I to 7.8 in Group 2. In Group 3, in which operation occurred after six days (most of them about the fourteenth day), we stiI1 find evidence of acute gaII-bIadder pathoIogy. There was evidence of an active pathoIogy in 130 cases out of 427 supposedIy subsided cases. In a11 of these we waited, and in the majority of instances they showed minima1 clinica manifestations when operated upon. Yet acute Iesions were present in 31 per cent of cases. The mortaIity, however, dropped from 19 per cent in Group I and 7.8 per cent in Group 2 to 5.4 per cent in Group 3. There were nine deaths in Group 3 due to accidenta injuries of ducts and bIood vesseIs. These deaths represented aImost 40 per cent of the tota mortaIity of this group; if these nine deaths were eIiminated the mortaIity wouId be 3.5 per cent. COMMENT
The very frequent occurrence of acute pathoIogy in Groups 2 and 3 does much to influence our belief that no absolute time can be set as to the opportune moment to operate. We are, however, firmly convinced of the verity of Touroff’s observations, that advanced pathoIogy may be present with minima1 cIinica1 manifestations and that each case shouId be conducted on a knowIedge of Touroff’s pertinent facts and be sharpIy individuaIized.
NE% SERIES VOL. XLIX,
No. 3
Bonn,
American Journal of Surp~y
Bachhuber-Cholecystitis
We are of the opinion that, except for those cases of perforation and gangrene which may apparentIy occur at any and a11 times, the mortality percentage wilI probably be lowest when operation is done about fourteen days after onset. REFERENCES BRU;GEMAN, H. 0. Tr. West. S. A., pp. 331-338, 1927. CAVE, H. W. Surg., Gpec. eY Obst., 66: 308, 1938.
ELIASON, E. L.,
and
~ICLAUGHLIN, C. W.
453
Ann. Surg.,
99: 914, 1934. GRAHAM, I-1. F., and WATERS, II. S. Ann.
Surg., 99:
893, 1934. GRAHAM. R. R. Canad. M. A. J.. 12: 281. 10x5. _-’ HEWER, 6. J. Ann. Surg., 99: 88;,“1934.-. LEIDBERC, N. Acta cbir. Scandinav., 1937, Supp. 47. NIEMEIER, 0. W. Ann. Surg., 99: 922, 1034. PENNOYER, G. P. Ann. Swg., 107: 543, 1938. SHOEMAKER, H. Caiijorornia ~ZTWest. Med., 38: 22, 1933. SMITH, M. K. Ann. Surg., 98: 766, 1933. TOUROFF, A. 5 W. Ann. Surg., 99: goo, 1934.
NON-LITHOGENOUS cholecystitis occurs in IO per cent of cases. As has been previousIy indicated, the infection is of a haematogenous origin, and is caused by a particuIar strain of streptococcus which exhibits a predilection for the waI1 of the gaII-bIadder. From-“Surgery of the AIimentary Tract” by Devine (WiIIiams & Wilkins Company).
M.D.,
OF ACUTE CHOLECYSTITIS*
AND
P.A.C.S.
C.
A.
Instructor
Professor of Surgery, College of Medical EvangeIists LOS ANGELES,
C
has aptly stated that sound judgment is required to choose the opportune moment for surgica1 intervention in acute choIecystitis and that any attempt to standardize the time of operation is hazardous. An earIy operation, as defined by Cave, impIies an interva1 of from twenty-four hours to seven days, whiIe a deIayed procedure is one done after the acute process has subsided, a matter of weeks or even months. Likewise surgeons may be cIassified into three groups: “ (I) those who operate immediateIy upon admission of the patient to the hospita1 (apparentIy regardIess of the time eIapsed “immediate” group; (2) since onset)-the those who operate between the first and fifth days (where apparentIy eIapsed time since onset is given consideration)-the “earIy” group; and (3) those who deIay intervention for weeks or even months.” It is Cave’s conviction that the mortaIity rate in the hands of the majority of surgeons is better in the so-caIIed “earIy” group than in the “immediate” group. As a starting point in the consideration of the surgica1 treatment of acute choIecystitis Graham’s statement is singuIarIy apropos, viz., that “the danger of operation in acute choIecystitis cannot be demonstrated in a hospita1 that usuaIIy practices deIay, for onIy the bad cases wiI1 receive earIy operation. ConverseIy, a hospita1 that beIieves in earIy operation cannot speak with authority about the dangers of deIay.” From a bacterioIogic and surgica1 viewpoint, the findings of Edmund Andrews are of importance in this connection: (I) in many cases it is not possibIe to obtain posiAVE
BACHHUBER,
M.D.,
of Surgery, CoIIege of h,ledicaI Evangelists
CALIFORNIA
tive cultures in what appears to be a very acute inffammation of the gaII-bIadder; (2) many cases which seem to show empyema have steriIe cuItures; (3) in many cases there is a stone in the cystic duct or in the ampuIIa, apparentIy sIowing the bIood flow from the gaII-bIadder. An acute bacteria1 choIecystitis may not be the cause, but rather edema and obstruction of the bIood suppIy. If these are aIIowed to quiet down, acute bacteria1 infection wiII deveIop. This is the expIanation of perichoIecystitis and abscess deveIoping in the gaII-bIadder, producing technica difficuIties in its Iater remova1. Burggeman drew a clear anaIogy when he decIared that acute choIecystitis may be compared to acute saIpingitis in that it rareIy kiIIs if treated conservatively. The comparison between acute choIecystitis and acute appendicitis is not in consonance with the cIinica1 facts. H. F. Graham, in a series of 197 consecutive cases, operated upon twenty within forty-eight hours of the onset of the acute symptoms, with one death (pancreatitis), a mortaIity of 3 per cent. This is, of course, a smaI1 series. In the remaining 150 cases operated upon after the forty-eight hour interva1, the mortality was 6.2 per cent. Pratt, quoted by Graham and Waters, records twenty-three choIecystectomies done within twenty-four hours of hospital entrance, without a death. The time of acute iIIness prior to hospita1 entrance and operation is not stated. In a series of fortyfive cases there were no deaths when operation was done within forty-eight hours after onset of the disease.
* From the Surgical Division of the LOSAngeIes County HospitaI and the Surgical Department Medical Evangetists, Los AngeIes. 447
F.A.C.S.
of the CoIlege of
448
American
Journal
Smith reports
of Surgery
Bonn,
Bachhuber-ChoIecystitis
in a series of 1,053 cases:
MortaIity Acute, 107 cases, IO deaths, (operg, 3 ated upon at once). . Subsided, (three or four days without fever before operation), 94 cases, 5 deaths, (operation from forty-eight hours to seven days 5.3 after onset). . 3.3 Chronic, 754 cases, 24 deaths. Duct stones, g8 cases, 32 deaths. 33. o Total number of cases 1053, 71 deaths........................ 6.7
Five of the cases of the acute series (5 per cent) were perforated, a11 in the first three days after onset of the iIIness; eight were gangrenous; eIeven empyemas were found; and eIeven had abscesses Iocated outside the gaII-bIadder. In severa patients more than one of these compIications was present. In the preceding thirty-three patients (one-third of the acute group) there occurred five deaths, one-haIf of the total. Thus since a11fuIminating cases (the thirtythree compIicated cases) were incIuded in the mortaIity statistics of the acute group these figures are not entireIy accurate. If one deducts the thirty-three compIicated cases from the 107 cases Iisted, there remain seventy-four strictIy acute choIecystitis cases in which there were five deaths, 6.5 per cent mortaIity. Smith, despite the trend toward earIy surgery, and certain contrary opinions, believes that ectomy in acute choIecystitis is a definiteIy more diffIcuIt technica procedure and states that in such cases it may be necessary to rempve the gaII-bIadder at the ampulla rather than at the duct, as a matter of safety. Two of the cases in his series were reoperated for stones present in the remnant of the gaII-bIadder. Smith in a recent reversa1 of opinion, now believes that surgery in acute ChoIecystitis is unwise unIess the evidence points to free perforation, in which instance immediate operation shouId be done. Graham compiIed a Iist of 153 cases of acute choIecystitis from the wards of the Toronto Genera1 HospitaI for the period from JuIy, I, 1926 to January I, 1934. Of these 153 cases, twenty-four refused sur-
SEPTEMBER, ,940
gery and in sixty-one surgery was not advised for various reasons. Thus of sixtyeight operated cases six were operated upon at once with one death, 16 per cent mortaIity. In sixty-two cases deIayed surgery was done, with three deaths, 4.8 per cent mortaIity. Four deaths occurred in the sixtyeight cases, a mortality of 5.8 per cent. The average time from onset to hospita1 entrance was six days. In a series of fifty-two private patients, Graham operated immediateIy in seven cases and deIayed surgery in forty-five. There were four fata cases in the series, a mortaIity of 7.7 per cent. In the deIayed surgery group of forty-five, there were a11 of these patients eIeven perforations; survived. These cases were seen earIier after onset than those of the series of Toronto Genera1 HospitaI. Pennoyer studied 300 consecutive cases of cIinicaIIy acute choIecystitis, at the RooseveIt HospitaI, New York City, the cases dating back to 1918. The routine treatment had been to delay surgery in such cases unti1 the acute symptoms subsided, operation being done onIy if urgent compIications indicated such intervention. During more recent years, earIy surgery has been advocated, the reason for the change being that the danger of compIication was considered greater than the danger of operative interference. Operation is now done within five days of onset unIess there is definite improvement. ChoIecystostomy rather than choIecystectomy is done, on the basis of safety. In this series, the charts of I ,474 patients with gaII-bIadder disease were studied. The 300 cases of acute choIecystitis presented here represent a carefu1 seIection incIuding those in which the advocates of earIy operation have presented evidence of justified intervention. There were thirty deaths in the entire series, a mortaIity of IO per cent. In these fata cases, the average time of acute iIIness prior to hospita1 entrance was four days; they were observed for two and one-third days prior to operation. Thus a tota of
NF\\
SIKIES VOL.
XLIX,
No.
3
Bonn,
Bachhuber-Cholecystitis
six and one-third days represents the average time from onset to operation. Of these thirty deaths, twenty-one actuaIIy died as a result of operative procedure, a 7 per cent mortahty. Fifteen deaths occurred in a series of fifty-nine cases (20 per cent of the entire series of 300), in which emergency operation was done within tweIve hours of hospital entrance. In this series of fiftynine, there were thirty-two cases, 54 per cent, incorrectIy diagnosed. Thus, the fifteen deaths, operated at once as emergencies, represent a mortaIity of 23 per cent. The remaining 241 patients had been acutely iI for four days prior to hospita1 entrance. Of these, thirty-three, after an average deIay of five days, were found not subsiding or actually becoming worse. They were therefore operated upon in the presence of acute symptoms, seven deaths ensuing, a mortality of 20 per cent. In the remaining 208 cases the symptoms subsided after an average of eight days. Thus the total time from onset to operation in these 208 cases was at least tweIve days. There were five deaths in this group, a mortaIity.rate of 2.3 per cent. In the entire group of 241 cases there were twelve deaths, a mortahty of 5 per cent. Of the 300 cases, 20 per cent showed some gangrene of the gall-bladder walI and thirty cases showed delinite rupture with resuhant local peritonitis. Cutler, in the discussion of Pennoyer’s paper, insisted that only cases seen within a few hours of the onset of the attack, not two to live days after onset, shouId be operated upon at once. WhippIe is of the same opinion. Leidberg beheves that moderateIy severe cases of acute ChoIecystitis should be operated upon in two or three days, unless specific contraindications are present. Branch and ZoIlinger (235 cases) performed immediate surgery in thirty-four cases, the mortality being 20.3 per cent. In 195 cases they waited an average of 4.7 days before surgery; operative mortality was reduced to 8.7 per cent.
American
Journal
of Surgwy
449
Heuer, in a summary of 1,066 cases of acute ChoIecystitis subject to surgery, found a genera1 mortality of 8 per cent and an individua1 mortahty varying between 4.7 per cent to 22.5 per cent. The report of Judd and PhiIlips, concerning 508 cases of acute cholecystitis, showed a mortahty percentage of 4.7. There were sixty-eight cases of perforation or gangrene, 13 per cent. Cave comments that only fourteen of these 508 patients had emergency operations. Also to be noted is the fact that of the sixty-eight cases having gangrene or perforation, sixty-one had the lesion walled off into a Iocalized abscess. Cave has the delinite conviction that the acuteIy inflamed gaII-bIadder rareIy perforates into the free abdomina1 cavity, causing a diffuse peritonitis, but that the percentage of Iocalized abscess following perforation is quite large. Eliason and McLaughIin report nine perforations in a series of 500 consecutive hospita1 admissions for biIiarv disease, a percentage of I 3. AI1 had Iocalized abscess, six being admitted as emergency cases. IncIusive of their own 500 cases, they record a summary of 7,316 cases; ninety-six instances of perforation occurred, 0.77 per cent. Perforation in the cases of the different surgeons of this series ranged from 0.9 to 2.5 per cent, mortahty from 1 I per cent (Eliason and McLaughIin) to 44 per cent. Touroff found that 20 per cent of seventyfive cases of acute choIecystitis, in the presence of minimal or absent chnical manifestations, had progressive gall-bladder lesions. The remaining 80 per cent (sixty cases) had Iesions that were subsiding or capable of subsidence. Touroff beIieves that if subsidence does not occur promptly and proceed reguIarly, earIy operation is indicated. In cases w-ith subsided clinica maniearIy operation, rather than festations, Iater in the “interva1” is indicated. Shoemaker reviewed 274 operations upon the bihary tract, done by staff surgeons of the Los AngeIes County HospitaI from I 929 to I 93 I. These patients were selected from I, I 86 admitted to the hospital with a diagnosis of acute or chronic cholecystitis. Of
450
American Journal of Surgery
Bonn,
Bachhuber-ChoIecystitis
the number of patients admitted, approximateIy 25 per cent were operated upon. Of these, thirty-seven died, a mortaIity of 13.5 per cent. Discarding the six malignancies in the series, the mortahty becomes I 1.3 per cent. There were two cases of acute uIcerative choIecystitis, one abscess of the liver, two gangrenous gaII-bIadders and four empyemas in this series. In this survery covering a11 biIiary cases admitted to the Los AngeIes County HospitaI for the five-year period, 1933-1938, we have been particuIarIy interested in attempting to determine how much inff uence, if any, the eIapsed time from the onset of an acute ChoIecystitis to operation is reIated to complications and mortaIity, the criterion to be the pathoIogic diagnosis rather than the surgeon’s operative report, in a11 cases where choIecystectomy was done. In those instances where choIecystostomy was done, the surgeon’s operative report was used, unIess a portion of the gaII-bIadder had been exised and used for pathoIogic examination. QuestionabIe cases in the origina Iist have been discarded whenever there was insuffIcient data. A tota of I 3 I cases were thus excIuded. These wouId probabIy have beIonged in Group I or 2. Likewise a11 cases of primary pancreatic disease and a11maIignancies of the biIiary tract (sixty-six) have been excIuded. It has been impossibIe to tabuIate the cystic duct stone cases separateIy because of Iack of data. They are therefore incIuded in the genera1 tabIes. We are of the opinion that the importance of the cystic duct stone cases, as reIated to vicious compIications and resuhant increased mortabty, has not been suffIcientIy stressed. The universa1 poIicy of this hospita1 has been to defer surgery unti1 the acute attack has subsided, subject to the indications for emergency operations at the discretion and judgment of the attending surgeons. It is uncommon for the acute case to enter the hospita1 within forty-eight hours of the onset. The patient has been III usuaIIy from two to seven days before hospita1 entrance.
SEPTEMBER, 19*0
The suggestion of some observers that operation be done in the first forty-eight hours is Iimited in its appIicabiIity in this hospita1. There were 955 patients admitted with a diagnosis of biIiary disease in the period 1933-1938. This incIudes a11 questionabIe biIiary and maIignant cases, which were excIuded from our fina tabIes. In the entire group, there were 704 surgica1 interventions. Acute ChoIecystitis was diagnosed in 25 I patients. Six cases are excIuded because of insuffIcient data, Ieaving 245. None of this group was operated upon; either the patient refused surgica1 intervention or the surgeon objected, usuaIIy on the basis of other additiona and advanced pathoIogy, especiaIIy cardiorena1 disease. There were fifteen deaths in this nonoperative group, a mortahty of 6 per cent. Nine autopsies were done, and in a11 but two instances, the cause of death was other than acute choIecystitis or its comphcations. However, a11 autopsies showed the presence of ChoIecystitis. Since 230 of these 245 unoparated patients apparentIy recovered and were dismissed from the hospita1 in from five to fourteen days, there is presumptive evidence that the incidence of perforation, gangrene and abscess may not be so high as some observers report. The operative cases have been tabuIated in three groups : Group I represents a11cases operated upon within forty-eight hours of the onset of the iIIness. Group 2 incIudes those cases operated upon from the third to the sixth day incIusive after onset, and Group 3 those cases operated upon after the sixth day. AI1 questionabIe cases (197) have been excIuded. Group I. Operation done within fortyeight hours of onset. There were sixteen cases in this group, eight choIecystectomies and eight choIecystostomies, with three deaths, a mortahty of 19 per cent. There were five choIecystectomies in femaIes, no deaths; three in maIes with one death: the mortaIity thus being 12.5 per
NIT\\
SMUES
VOL.
X1.1X, No. 3
Bonn,
Bachhuber-ChoIecystitis
cent. PathoIogic diagnoses were: two subone marked subacute, one emacute, and three chronic pyema, one gangrene cholecystitis. TABLE I GROUP I (Operated upon within 48 hours of onset)
I 0
0 I
Ameriran
.lournul
of Surgerv
35
1
deaths), twelve in males (two deaths). The pathoIogic diagnosis were: seven acute, nine subacute, five uIcerative, two gangrenous, one hydrops and twenty-four chronic. The five ulcerative cases were further cIassified as: one recent acute, one subacute, one acute and two chronic. Sixteen cholecystostomies were done with one death, a mortaIity of 6.2 per cent. In eIeven females there were no deaths. The pathoIogy was given as one subacute, one gangrene and one empyema. In the five males there was one death. upon afier the sixth Group 3. Operated day since onset. The greater portion of this
I
i
-
I-ABLE
Tot& 16 cases, 3 deaths, mortality, Ig per cent 8 ectomies, I death, mortality, 12.5 per cent 8 ostomies, 2 deaths, mortality, 25 per cent
IL1
3 (Operated upon after the 6th day al’tt.r. onset GROUP
i
The eight choIecystostomies were evenIy divided as to sex. There were two deaths, a maIe and a femaIe, giving a mortahty of 23 per cent. One hydrops and one empyema were incIuded. Group 2. Operated upon from forty-eight bows to the seventh day after onset. There
were sixty-four
cases in this
group,
with
(Purulent. I recentacute,z subacute, I chronic) (Ulcerative, 4 acute, I recentacute.8 subacute, 15 Totat, 4~~7cases, 23 deaths, mortality, 3.4 per
chronic) cent
390 ectomies, 20 deaths, mortality, 5.1 per cent 37 ostomies, 3 deaths, mortality. 8 I per cent
TABLE II GROUP 2 (Operated upon from 48 hours to the 7th day after onset)
-
F
~ ect.
361
2
-I-
0
group was operated on from the fourteenth to the twenty-first day after onset, the majority on the fourteenth day. Cases of perforation, gangrene, empyema, acute uIcerative and puruIent were operated upon between the seventh and fourteenth days after onset. (TabIe III.)
I
TABLE
-
LOS -
I acute, I recent acute, I subacute, 2 chronic) TotaI, 64 cases, 5 deaths, mortality, 7.8 per cent 48 ectomies, 4 deaths, mortality, 8.3 per cent 16 ostomies, I death, mortaIity, 6.25 per cent
ANGELES
IV
GENERAL
HOSPITAL
1933-1938
(Ulcerative,
five deaths, a mortaIity of 8 per cent. Forty-eight choIecystectomies were done, with four deaths, a mortaIity of 8.3 per cent. There were thirty-six in femaIes (2
7o* Surgical interventions. 638 BiIiary surgery soIely 307 Corrected list, biIiary surgeq Group 1.. Groupz.................. Group3 .._..........__..
Per Cent 12,lortality 13.3 j
8.~7 1Q.l) 7.8 54
This group comprises 427 cases, with twenty-three deaths, a mortality of 5.4 per
452
American
Journal
of Surgery
Bonn,
SEPTEMBER, ,940
Bachhuber-ChoIecystitis
cent. There were 390 choIecystectomies with twenty deaths, a mortaIity of 5.1 per cent. In this group 31 I were femaIes, incIuding thirteen deaths. The pathoIogic diagnoses in these 3 I I cases incIuded : eight acute, fifty-eight subacute, 208 chronic, one cholesterosis, one gangrene, one hyand twenty-one four puruIent, drops, uIcerative. The uIcerative cases were further cIassified as: acute uIcerative three, subacute seven and chronic eleven. The purulent were also further cIassified as acute one, subacute two and chronic one. No report was given in ten instances. There were seventy-nine choIecystectomies in maIes, with seven deaths. Three were acute, eighteen subacute, forty-five chronic, one empyema, one gangrene and seven uIcerative; the Iatter cIassified as: acute one, subacute one, recent acute one, and four chronic. No report was given in four cases. Thirty-seven cho1ecystostomie.s were done, twenty-seven in femaIes and ten in maIes, with three deaths, a mortaIity of 8.1 per cent. There was one death in a femaIe. Three empyemas were incIuded. In the ten maIes two deaths occurred. One two perforations, three emgangrene, pyemas and three chronic choIecystitis were present. SUMMARY
We are in accord with Smith in the belief that operation within forty-eight hours of onset carries too high a mortaIity to warrant much consideration, especiaIIy in the wards of a pubIic charitabIe hospital whose patients are not infrequentIy poor surgica1 risks. Furthermore, these patients often do not come to the hospita1 within forty-eight hours of the acute onset. Our opportunities have been Iimited as regards statistics for this group. Our entire Group I series has IittIe positive vaIue since it is too smaI1 in numbers. We are inclined to the view of CutIer and WhippIe that any earIy operation,
preferabIy choIecystectomy, shouId be done within six to tweIve hours of onset. So far as we have been abIe to determine, apparentIy the peak of the disease is reached in from one to four days. In Group 2, after forty-eight hours, seven acute, ten subacute, five ujcerative, four gangrenous, two empyemas and one hydrops were present; in other words, considerabIe acute pathoIogy remained. The chronic cases, aImost a third, showed subsidence of the pathoIogy. NevertheIess the mortality for this group had dropped by 60 per cent, from the 19 per cent of Group I to 7.8 in Group 2. In Group 3, in which operation occurred after six days (most of them about the fourteenth day), we stiI1 find evidence of acute gaII-bIadder pathoIogy. There was evidence of an active pathoIogy in 130 cases out of 427 supposedIy subsided cases. In a11 of these we waited, and in the majority of instances they showed minima1 clinica manifestations when operated upon. Yet acute Iesions were present in 31 per cent of cases. The mortaIity, however, dropped from 19 per cent in Group I and 7.8 per cent in Group 2 to 5.4 per cent in Group 3. There were nine deaths in Group 3 due to accidenta injuries of ducts and bIood vesseIs. These deaths represented aImost 40 per cent of the tota mortaIity of this group; if these nine deaths were eIiminated the mortaIity wouId be 3.5 per cent. COMMENT
The very frequent occurrence of acute pathoIogy in Groups 2 and 3 does much to influence our belief that no absolute time can be set as to the opportune moment to operate. We are, however, firmly convinced of the verity of Touroff’s observations, that advanced pathoIogy may be present with minima1 cIinica1 manifestations and that each case shouId be conducted on a knowIedge of Touroff’s pertinent facts and be sharpIy individuaIized.
NE% SERIES VOL. XLIX,
No. 3
Bonn,
American Journal of Surp~y
Bachhuber-Cholecystitis
We are of the opinion that, except for those cases of perforation and gangrene which may apparentIy occur at any and a11 times, the mortality percentage wilI probably be lowest when operation is done about fourteen days after onset. REFERENCES BRU;GEMAN, H. 0. Tr. West. S. A., pp. 331-338, 1927. CAVE, H. W. Surg., Gpec. eY Obst., 66: 308, 1938.
ELIASON, E. L.,
and
~ICLAUGHLIN, C. W.
453
Ann. Surg.,
99: 914, 1934. GRAHAM, I-1. F., and WATERS, II. S. Ann.
Surg., 99:
893, 1934. GRAHAM. R. R. Canad. M. A. J.. 12: 281. 10x5. _-’ HEWER, 6. J. Ann. Surg., 99: 88;,“1934.-. LEIDBERC, N. Acta cbir. Scandinav., 1937, Supp. 47. NIEMEIER, 0. W. Ann. Surg., 99: 922, 1034. PENNOYER, G. P. Ann. Swg., 107: 543, 1938. SHOEMAKER, H. Caiijorornia ~ZTWest. Med., 38: 22, 1933. SMITH, M. K. Ann. Surg., 98: 766, 1933. TOUROFF, A. 5 W. Ann. Surg., 99: goo, 1934.
NON-LITHOGENOUS cholecystitis occurs in IO per cent of cases. As has been previousIy indicated, the infection is of a haematogenous origin, and is caused by a particuIar strain of streptococcus which exhibits a predilection for the waI1 of the gaII-bIadder. From-“Surgery of the AIimentary Tract” by Devine (WiIIiams & Wilkins Company).