Y. Kasahara et al.: Postoperative Acute Cholecystitis
2. J6nsson, P.-E., Andersson, A.: Postoperative acute acalculous cholecystitis. Arch. Surg. 111:1097, 1976 3. Itoh, T.: [A case of gallbladder necrosis after gastrectomy]. Arch. Jap. Chir. 32:320, 1963 4. Schein, C.J.: Acute Cholecystitis, 1st edition. New York, Harper & Row, 1972, pp. 213-215 5. Knuddsen, R.J., Zuber, W.F.: Acute cholecystitis in the postoperative period. N. Engl. J. Med. 269:289, 1963 6. Ottinger, L.W.: Acute cholecystitis as a postoperative complication. Ann. Surg. 184:162, 1976 7. Munster, A.M., Brown, J.R.: Acalculous cholecystitis. Am. J. Surg. 113:730, 1967 8. Glenn, F., Wantz, E.: Acute cholecystitis following the surgical treatment of unrelated disease. Surg. Gynecol. Obstet. 102:145, 1956 9. Levin, M.N.: Acute cholecystitis following surgery unrelated to the biliary tract. J.A.M.A. 177:644, 1961 10. Thompson, J.W., Ferris, D.O.: Acute cholecystitis
665
11. 12. 13. 14.
15. 16.
complicating operation for other diseases. Ann. Surg. 155:489, 1962 Womack, N.A., Haffner, H.: Cholesterolosis: its significance in the badly damaged gallbladder. Ann. Surg. 119:391, 1944 Lindberg, E.F., Grinnan, G.L.B., Smith, L.: Acalculus cholecystitis in Vietnam casualties. Ann. Surg. 171:152, 1970 Sparkman, R.S.: Abdominal emergencies following unrelated surgical procedures. Ann. Surg. 135:863, 1952 Shirakawa, Y., Matsumine, K., Takahashi, M.: [A case of acute acalculus cholecystitis due to insufficiency of the biliary sphincter]. Jap. J. Gastroenterol. 72:1064, 1975 Howard, R.J., Delaney, J.P.: Postoperative cholecystitis. Am. J. Dig. Dis. 17:213, 1972 Golden, G.T., Sears, H.F., Wangensteen, S.L.: Posttraumatic cholecystitis. Am. Surg. 37:371, 1971
Invited Commentary Per-Ebbe J6nsson, M.D. University of Lund, Lund, Sweden This paper reminds us again o f a rare postoperative complication, postoperative acute cholecystitis, which was first reported in 1844 by Duncan who wrote of a patient with gangrenous cholecystitis after surgery for femoral hernia [1]. The well-known mortality o f this complication is confirmed by the present authors, in whose selected series the mortality rate was 32%. Acute cholecystitis after trauma, posttraumatic acute cholecystitis, has a similar etiological origin and pathological findings as postoperative cholecystitis and, therefore, should be discussed under the same heading. Posttraumatic acute cholecystitis has been mainly reported after multiple trauma and war injuries [2]. This condition has not been discussed in the present paper. There are 2 characteristics that distinguish postoperative (posttraumatic) acute cholecystitis from ordinary acute cholecystitis, namely, the frequency of the acalculous form and the sex ratio. In ordinary acute cholecystitis, the frequency of the acalculous form is about 5-10% [3]. Of published cases, 46% of postoperative acute cholecystitis and 92% o f the posttraumatic cases have been of the acalculous form [4]. The male-to-female ratio, judged from a review of all published cases of postoperative cholecystitis, has been 7 to 1 for the acalculous
form and 1 to 1 for the calculous form [4]. Ordinary acute cholecystitis is much more c o m m o n among women, but the sex difference decreases with increasing age and is nearly 1 to 1 in older patients. Therefore, it can be anticipated that surgery or trauma and accompanying calculous cholecystitis is just a coincidence. This has not been subjected to analysis by the authors. The diagnosis of postoperative acute acalculous cholecystitis can only be confirmed by surgery. In case 3 in the present paper, the diagnosis o f this form of cholecystitis was established by oral cholecystography. This cannot be considered sufficient. After trauma and surgery, patients surprisingly often show symptoms and signs simulating cholecystitis, which subside after about a week. In the Japanese material, there are 7 patients who are included without operatively confirmed diagnosis. Postoperative acalculous cholecystitis is mostly seen after abdominal surgery, particularly colon surgery [4]. In the present review, about 75% of the cases occurred after esophageal and stomach surgery. This can depend on a difference in the proportion of surgical diseases compared with other countries. After extra-abdominal surgery, acalculous cholecystitis has mostly been observed in connection with orthopedic surgery, such as osteo-
666
synthesis of hip fractures or total hip replacement. The high mortality rate may be caused by the more fulminant course of acute postoperative acalculous cholecystitis than that seen in ordinary acute cholecystitis, with early appearance of gangrene and perforation. Further, there is often a delay in diagnosis. The diagnosis is more difficult after intraabdominal surgery than after extra-abdominal procedures, since the usual postoperative abdominal symptoms can mask the symptoms of cholecystitis, and the surgeon's attention is directed towards complications related to the performed operation. In the present series, the diagnosis was correct in about 30% of cases, a figure similar to that of other series. Initially, half of the patients in this Japanese material were treated by cholecystostomy, which the authors recommend as suitable treatment of very sick patients. The paper does not inform us about the course of all the patients treated in this way, so the mortality rate may have been considerably higher after cholecystostomy. In most cases, there is extensive gangrene of the gallbladder wall and thick viscous bile in the gallbladder lumen and biliary tree, so that simple drainage is insufficient. The toxic effect on the peritoneum and the liver still remains and the patient has less chance of survival. The cause of postoperative cholecystitis is probably multifactorial. Most of these factors are mentioned in this paper. The onset of a chemical cholecystitis is probably precipitated by a combination of functional biliary stasis caused by the viscous concentrated bile and ischemia of the gallbladder wall. All surgeons must reckon with postoperative acute (acalculous) cholecystitis as a possible, but rare, complication after any form of operation, but mostly after abdominal surgery. Cholecystectomy must be regarded as the most suitable treatment of this severe form of cholecystitis.
References
1. Duncan, J.: Femoral hernia; gangraene of gallbladder; extravasation of bile; peritonitis; death. North. J. Med. 2:151, 1844 2. Lindberg, E.F., Grinnan, G.L.B., Smith, L.: Acalculous cholecystitis in Viet Nam casualties. Ann. Surg. 171:152, 1970 3. Munster, A.M., Brown, J.R.: Acalculous cholecystitis. Am. J. Surg. 113:730, 1967 4. J6nsson, P.-E., Andersson, A_.: Postoperative acute acalculous cholecystitis. Arch. Surg. 111:1097, 1976
World J. Surg. Vol. 2, No. 5, September, 1978
Invited Commentary Leslie W. Ottinger, M.D. Massachusetts General Hospital, Boston, Massachusetts, U.S.A.
The authors clearly describe the characteristics of postoperative cholecystitis that make it not only a curious, but also a lethal, condition compared to ordinary cholecystitis. Included are the predominence of men over women, the low incidence of calculi, the high frequency of gangrene, perforation and empyema, and the high mortality rate, 32% in their series. Although in most of their cases the complication followed surgery of the alimentary tract, the important point is made that it may occur after various operations, even those not involving the abdomen and its contents. Symptoms included abdominal pain and fever in most patients, and many had nausea and vomiting. Two-thirds had leukocytosis, and in one-third, an abdominal mass was present. Despite this, the correct diagnosis was overlooked in 32 of 49 patients. This, along with the complications of gangrene, necrosis and empyema, perhaps explains the surprisingly high mortality rate of the complication. Of course, the preceding illness and advanced age of the patient also contributed to the high mortality rate. A single unified explanation for these attacks cannot be offered. Almost all authors agree that stasis and inspissation of gallbladder bile is important, a condition that is fostered by fasting, dehydration, and narcotics. Other factors with either clinical observations or experimental evidence in their support are an increased pigment load due to multiple transfusions, bacterial seeding of the gallbladder from the blood stream, and ischemic injury of the gallbladder, possible multiple causes being suggested. In some cases, stimulation resulting from the resumption of oral alimentation and the presence of gallstones clearly have a role. As prevention is not possible, successful management of postoperative cholecystitis has 2 components. The first is an awareness of the complication, leading to the earliest possible detection. The second is prompt surgical intervention, either cholecystectomy or cholecystostomy. Although this will not prevent perforation and empyema, it can minimize their complications and thus help to reduce morbidity and mortality.
2. J6nsson, P.-E., Andersson, A.: Postoperative acute acalculous cholecystitis. Arch. Surg. 111:1097, 1976 3. Itoh, T.: [A case of gallbladder necrosis after gastrectomy]. Arch. Jap. Chir. 32:320, 1963 4. Schein, C.J.: Acute Cholecystitis, 1st edition. New York, Harper & Row, 1972, pp. 213-215 5. Knuddsen, R.J., Zuber, W.F.: Acute cholecystitis in the postoperative period. N. Engl. J. Med. 269:289, 1963 6. Ottinger, L.W.: Acute cholecystitis as a postoperative complication. Ann. Surg. 184:162, 1976 7. Munster, A.M., Brown, J.R.: Acalculous cholecystitis. Am. J. Surg. 113:730, 1967 8. Glenn, F., Wantz, E.: Acute cholecystitis following the surgical treatment of unrelated disease. Surg. Gynecol. Obstet. 102:145, 1956 9. Levin, M.N.: Acute cholecystitis following surgery unrelated to the biliary tract. J.A.M.A. 177:644, 1961 10. Thompson, J.W., Ferris, D.O.: Acute cholecystitis
665
11. 12. 13. 14.
15. 16.
complicating operation for other diseases. Ann. Surg. 155:489, 1962 Womack, N.A., Haffner, H.: Cholesterolosis: its significance in the badly damaged gallbladder. Ann. Surg. 119:391, 1944 Lindberg, E.F., Grinnan, G.L.B., Smith, L.: Acalculus cholecystitis in Vietnam casualties. Ann. Surg. 171:152, 1970 Sparkman, R.S.: Abdominal emergencies following unrelated surgical procedures. Ann. Surg. 135:863, 1952 Shirakawa, Y., Matsumine, K., Takahashi, M.: [A case of acute acalculus cholecystitis due to insufficiency of the biliary sphincter]. Jap. J. Gastroenterol. 72:1064, 1975 Howard, R.J., Delaney, J.P.: Postoperative cholecystitis. Am. J. Dig. Dis. 17:213, 1972 Golden, G.T., Sears, H.F., Wangensteen, S.L.: Posttraumatic cholecystitis. Am. Surg. 37:371, 1971
Invited Commentary Per-Ebbe J6nsson, M.D. University of Lund, Lund, Sweden This paper reminds us again o f a rare postoperative complication, postoperative acute cholecystitis, which was first reported in 1844 by Duncan who wrote of a patient with gangrenous cholecystitis after surgery for femoral hernia [1]. The well-known mortality o f this complication is confirmed by the present authors, in whose selected series the mortality rate was 32%. Acute cholecystitis after trauma, posttraumatic acute cholecystitis, has a similar etiological origin and pathological findings as postoperative cholecystitis and, therefore, should be discussed under the same heading. Posttraumatic acute cholecystitis has been mainly reported after multiple trauma and war injuries [2]. This condition has not been discussed in the present paper. There are 2 characteristics that distinguish postoperative (posttraumatic) acute cholecystitis from ordinary acute cholecystitis, namely, the frequency of the acalculous form and the sex ratio. In ordinary acute cholecystitis, the frequency of the acalculous form is about 5-10% [3]. Of published cases, 46% of postoperative acute cholecystitis and 92% o f the posttraumatic cases have been of the acalculous form [4]. The male-to-female ratio, judged from a review of all published cases of postoperative cholecystitis, has been 7 to 1 for the acalculous
form and 1 to 1 for the calculous form [4]. Ordinary acute cholecystitis is much more c o m m o n among women, but the sex difference decreases with increasing age and is nearly 1 to 1 in older patients. Therefore, it can be anticipated that surgery or trauma and accompanying calculous cholecystitis is just a coincidence. This has not been subjected to analysis by the authors. The diagnosis of postoperative acute acalculous cholecystitis can only be confirmed by surgery. In case 3 in the present paper, the diagnosis o f this form of cholecystitis was established by oral cholecystography. This cannot be considered sufficient. After trauma and surgery, patients surprisingly often show symptoms and signs simulating cholecystitis, which subside after about a week. In the Japanese material, there are 7 patients who are included without operatively confirmed diagnosis. Postoperative acalculous cholecystitis is mostly seen after abdominal surgery, particularly colon surgery [4]. In the present review, about 75% of the cases occurred after esophageal and stomach surgery. This can depend on a difference in the proportion of surgical diseases compared with other countries. After extra-abdominal surgery, acalculous cholecystitis has mostly been observed in connection with orthopedic surgery, such as osteo-
666
synthesis of hip fractures or total hip replacement. The high mortality rate may be caused by the more fulminant course of acute postoperative acalculous cholecystitis than that seen in ordinary acute cholecystitis, with early appearance of gangrene and perforation. Further, there is often a delay in diagnosis. The diagnosis is more difficult after intraabdominal surgery than after extra-abdominal procedures, since the usual postoperative abdominal symptoms can mask the symptoms of cholecystitis, and the surgeon's attention is directed towards complications related to the performed operation. In the present series, the diagnosis was correct in about 30% of cases, a figure similar to that of other series. Initially, half of the patients in this Japanese material were treated by cholecystostomy, which the authors recommend as suitable treatment of very sick patients. The paper does not inform us about the course of all the patients treated in this way, so the mortality rate may have been considerably higher after cholecystostomy. In most cases, there is extensive gangrene of the gallbladder wall and thick viscous bile in the gallbladder lumen and biliary tree, so that simple drainage is insufficient. The toxic effect on the peritoneum and the liver still remains and the patient has less chance of survival. The cause of postoperative cholecystitis is probably multifactorial. Most of these factors are mentioned in this paper. The onset of a chemical cholecystitis is probably precipitated by a combination of functional biliary stasis caused by the viscous concentrated bile and ischemia of the gallbladder wall. All surgeons must reckon with postoperative acute (acalculous) cholecystitis as a possible, but rare, complication after any form of operation, but mostly after abdominal surgery. Cholecystectomy must be regarded as the most suitable treatment of this severe form of cholecystitis.
References
1. Duncan, J.: Femoral hernia; gangraene of gallbladder; extravasation of bile; peritonitis; death. North. J. Med. 2:151, 1844 2. Lindberg, E.F., Grinnan, G.L.B., Smith, L.: Acalculous cholecystitis in Viet Nam casualties. Ann. Surg. 171:152, 1970 3. Munster, A.M., Brown, J.R.: Acalculous cholecystitis. Am. J. Surg. 113:730, 1967 4. J6nsson, P.-E., Andersson, A_.: Postoperative acute acalculous cholecystitis. Arch. Surg. 111:1097, 1976
World J. Surg. Vol. 2, No. 5, September, 1978
Invited Commentary Leslie W. Ottinger, M.D. Massachusetts General Hospital, Boston, Massachusetts, U.S.A.
The authors clearly describe the characteristics of postoperative cholecystitis that make it not only a curious, but also a lethal, condition compared to ordinary cholecystitis. Included are the predominence of men over women, the low incidence of calculi, the high frequency of gangrene, perforation and empyema, and the high mortality rate, 32% in their series. Although in most of their cases the complication followed surgery of the alimentary tract, the important point is made that it may occur after various operations, even those not involving the abdomen and its contents. Symptoms included abdominal pain and fever in most patients, and many had nausea and vomiting. Two-thirds had leukocytosis, and in one-third, an abdominal mass was present. Despite this, the correct diagnosis was overlooked in 32 of 49 patients. This, along with the complications of gangrene, necrosis and empyema, perhaps explains the surprisingly high mortality rate of the complication. Of course, the preceding illness and advanced age of the patient also contributed to the high mortality rate. A single unified explanation for these attacks cannot be offered. Almost all authors agree that stasis and inspissation of gallbladder bile is important, a condition that is fostered by fasting, dehydration, and narcotics. Other factors with either clinical observations or experimental evidence in their support are an increased pigment load due to multiple transfusions, bacterial seeding of the gallbladder from the blood stream, and ischemic injury of the gallbladder, possible multiple causes being suggested. In some cases, stimulation resulting from the resumption of oral alimentation and the presence of gallstones clearly have a role. As prevention is not possible, successful management of postoperative cholecystitis has 2 components. The first is an awareness of the complication, leading to the earliest possible detection. The second is prompt surgical intervention, either cholecystectomy or cholecystostomy. Although this will not prevent perforation and empyema, it can minimize their complications and thus help to reduce morbidity and mortality.
