Pre-surgery age-adjusted Charlson Comorbidity Index is associated with worse outcomes in acute cholecystitis

Background: Beneficial effects of cholecystectomy in acute cholecystitis (AC) might be weakened by complications. The age-adjusted Charlson Comorbidity Index (CCI) assesses disease relevance in the prediction of one-year mortality. Aims: To evaluate whether age-adjusted CCI predicted complications (including surgical complications, intensive care unit [ICU] admission, and in-hospital death) among patients undergoing cholecystectomy for AC. Associations between age-adjusted CCI and the length of hospital stay have been also evaluated. Methods: 271 patients were enrolled at Ospedale Policlinico San Martino (Genoa, Italy) between 2005 and 2013. Clinical data and blood samples were collected. Results: Patients\u2019 median age was 67 years. They underwent more frequently video-laparoscopic cholecystectomy with a limited rate of conversion to open cholecystectomy. Surgical complications occurred in 23 patients (8.5%). 6 patients (2.2%) needed ICU admission, while death occurred in 4 patients (1.5%). According to the cut-off point identified by ROC curve, an age-adjusted CCI cut-off value of 5 was found predictive for in-hospital complications also when confounders were considered (OR 1.35, 95% CI 1.02\u20131.79, p = 0.035). No association between adjusted CCI and the length of hospital stay was found. Conclusions: In patients surgically treated for AC, age-adjusted CCI could represent an additional tool, along with available risk scores, to help surgeons in choosing the best therapeutic option

Surgery to Treat Symptomatic Mobile Cecum Syndrome Is Safe and Associated with Good Recovery Outcomes

The mobile cecum syndrome includes a spectrum of conditions. The cecal volvulus represents the acute form, with typical feature of a bowel obstruction that needs immediate operative treatment. On the other hand, a chronic form of mobile cecum syndrome which is the most common form reported a history of intermittent crampy abdominal pain, distension, and constipation. In this study, five patients came to our attention during the last ten years, presenting different symptoms due to a mobile cecum. All patients were investigated by several diagnostic techniques according to the specific clinical setting. All patients were found to have the cecum and ascending colon unattached to the posterior peritoneum. Surgery was the treatment of choice. In our experience, the best diagnostic technique was computed tomography scan, especially if performed in the Trendelenburg position. We also propose virtual colonoscopy as a good option for diagnosis (in patients with chronic syndrome) and follow-up after surgery. In conclusion, laparoscopic approach guaranteed a good result, with no symptoms of recurrence, in both acute and elective treatments. The diagnosis of mobile cecum needs a high index of suspicion and a targeted radiological investigation. Surgery, especially laparoscopic cecopexy and appendectomy, is the recommended treatment

Pitfalls and fatal complications after iterative endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography management of biliary tract cysts. When to do open surgery (cyst resection; hepaticojejunostomy) or liver transplant?

Biliary tract cysts are a group of rare congenital diseases that have been classified by Todani in 8 types. Hepaticojejunostomy has been the preferred intervention for Type I and IV biliary cysts. It has been postulated that, due to the low incidence of cancerization of Types II and III biliary cysts, a less invasive approach could be suggested, namely cyst resection in Type II, and endoscopic sphincterotomy with opening of choledochocele in small (<3 cm) Type III cysts from old patients. Moreover, Caroli disease has been proposed to be treated by percutaneous biliary drainages. The aim of the present study is to propose the therapeutics strategies to follow for the management of biliary tract cysts, in case of failure of percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP). From 2008 to May 2014, three patients with congenital biliary tract cysts were followed. Two patients were found to be affected by bilateral liver Caroli disease and another young patient was found to be affected by a Type III biliary cyst (choledochocele). Patients affected by Caroli disease presented cholangitis, jaundice and fever and have been submitted to PTC. PTC, after an initial brief relief of the symptoms, failed in both cases. One of these patients with recurrent post PTC cholangitis was then successfully treated by orthotopic liver transplant. The other patient affected by Caroli disease died after multiple PTC. The young patient affected by choledochocele suffered from pancreatitis and jaundice and was submitted to ERCP. Endoscopic resection of choledochocele was followed by hemorrhagia and a fatal fungal sepsis. Minimally invasive approaches have been widely used in the management of biliary tract cysts. Diffuse bilateral Caroli disease of the liver can be initially managed by percutaneous drainage but if cholangitis recurs, in our opinion, it is useful to consider an open surgery procedure such as orthotopic liver transplant. Type III biliary cyst (choledococele) can be managed by ERCP if patient is old and the cyst is small (<3 cm) but when the cyst is larger than 3 cm, symptomatic, and the patient is young, one approach to take into consideration is open duodenostomy with choledochocele resection and reimplantation of the common bile and of Wirsung ducts into the duodenal mucosa