Laparoscopic management and clinical outcome of emphysematous cholecystitis

Background: As opposed to acute, chronic, and acalculus cholecystitis, emph ysematous cholecystitis (EC) is associated with significant morbidity and m ortality. Only a few studies have specifically reviewed the operative manag ement and clinical outcome of EC. This study documents the operative manage ment and clinical outcome of EC at the Cleveland Clinic Foundation. Methods: Between January 1996 and June 1999, 18 consecutive patients underw ent cholecystectomy for emphysematous cholecystitis at our institution. All charts were reviewed retrospectively, and patients undergoing concurrent p rocedures were excluded. Mean values +/- standard deviation (SD) of the mea n were calculated for patient demographics, preoperative. white blood cell count (WBC), bilirubin, alkaline phosphatase, and length of hospital stay. Operative procedure (laparoscopic, converted, or open), preoperative imagin g studies, operative time, ICU stay, morbidity, and mortality were reviewed . Results: Patients presented with a mean age of 53.4 years (range, 18-80) an d a male/female ratio of 3.5 (14/4). There were no differences between grou ps in terms of patient demographics. Mean WBC on admission was 14.2 K/muL ( range, 5.4-19.7). Mean alkaline phosphatase and total bilirubin were 115 U/ L (range, 45-428) and 1.4 mg/dl (range, 0.5-3.4), respectively. Thirteen pa tients (72%) were completed laparoscopically, two patients (11%) were conve rted to an open procedure, and three patients (17%) had open surgery. Overa ll mean length of hospital stay was 5 days (range, 1-18). Two patients from the open group ultimately died 1 year later due to progression of preexist ing illness. One of these patients had congestive heart failure and chronic renal failure; the other had metastatic malignant melanoma. None of the pa tients died in the immediate perioperative period. There were five complica tions (27.8%). Two patients presented with bleeding secondary to heparin an d coumadin therapy. One developed sepsis, and another developed leakage fro m the cystic duct stump, necessitating an endoscopic retrograde cholangiopa ncreatogram (ERCP) with stent decompression. The fifth complication, ileus, required readmission 3 days postoperatively, but the patient responded to conservative management. Complications were evenly distributed between the th-ree groups. There were two complications in the laparoscopic group, two in the open group, and one in the conversion group. All other patients were alive at the time of this publication. Conclusions: Using current techniques, patients with EC can be managed succ essfully utilizing laparoscopy. Morbidity and mortality appear to be slight ly higher than published reports for acute, chronic, and acalculus cholecys titis. Conversion rates are comparable to patients with acute and chronic c holecystitis who undergo laparoscopic cholecystectomy. Based on these data, laparoscopic cholecystectomy should be considered the first-line treatment for patients with known or suspected EC.