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Rapid Responses: Rapid Responses published:
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Evidence needed to justify automatic referral
- Jeremy D Budd (21 September 2002)
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choice of antimicrobial agent for acute cholecystitis
- Martin G Cormican (28 September 2002)
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Acute Cholecystitis in the elderly
- Sudhir Kumar, Andrew L Tambyraja, Lecturer, Stephen J Nixon, Consultant Surgeon (14 October 2002)
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A Cautionary Note
- Nicholas J Kenefick, Paul W. Houghton (5 November 2002)
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Is Biliary Pain a colic?
- Daniel R McGrath, Allan D. Spigelman (24 February 2003)
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Jeremy D Budd, GP Principal Bridgwater TA6 5YB
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In this otherwise evidence-based review of cholecystitis, the authors make the assertion no less than three times that "All patients suspected of having acute cholecystitis should be referred to hospital." I would like them to provide more evidence or justification for this conclusion. I believe that it is quite common for general practitioners in the UK to respond to complaints of right upper abdominal pain, with local tenderness and fever, with a prescription for a broad-spectrum antibiotic and a presumptive diagnosis of cholecystitis, and arrangements for clinical review but not necessarily immediate hospital admission. This clinical situation is not particularly common, so I am not concerned that an automatic referral to hospital would generate great numbers, but the outcomes associated with suspected cholecystitis in primary care may not be so serious as in the populations considered by the authors. |
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Martin G Cormican, Consultant Microbiologis/Professor of Bacteriology Department of Bacteriology, NUI, Galway, Galway Ireland (no postcode)
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In this informative article relating to management of acute cholecystitis most of the recommendations are supported by citation however the following recommendation appears to be unsupported. "A second generation or newer cephalosporin should be used (for example, cefuroxime 1.5 g every 6-8 hours) with metronidazole (500 mg every 8 hours)." While the recommendation is a reasonable therapeutic opiton there are a number of alternatives to use of cephalosporins. I am concerned that this "should be used" recommendation is more definitive than is justified. I belive there is little evidence that the regime specified is superior to others and no evidence of its superiority is cited. |
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Sudhir Kumar, Associate Specialist in Surgery Department of Surgery, Royal Infirmary, Edinburgh EH3 9YW UK, Andrew L Tambyraja, Lecturer, Stephen J Nixon, Consultant Surgeon
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Editor- Indar and Beckingham's review of acute cholecystitis (AC)(ref 1)makes no reference to AC in the elderly. Patients aged 60 years and over account for around 50% of cases of AC (ref 2). The elderly patients often present with significant co-morbidity and reported to have a mortality of 1 - 3% after laparoscopic cholecystectomy (LC) for AC (REF 3,4), compared to near 0% mortality in the younger patients. Most of this mortality is related to co-existing medical illnesses. In our recent 10 year review of LC in patients over 80 years and over, 24%(28/117) had presented with AC (ref 5). Conversion to open cholecystectomy was required in 10.7% (3/28)of the patients. There was no bile duct injury or hospital mortality. Conversion to open cholecystecomy has the same morbidity and mortality as open cholecystectomy. It is better to have an experienced laparoscopic surgeon to deal with a difficult cholecystectomy rather than the author's suggestion of a low threshold for conversion to open procedure. We agree with the authors that early LC is safe for most patients admitted with AC. The elderly patients , however, may benefit from optimising their coexisting medical condition prior to LC for acute cholecystitis. References: 1. Indar AA and Beckingham IJ. Acute Cholecystitis. BMJ 2002;325:639-643 2. Kiviluoto, Siren J, Luukkonen P, Kivilaalso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet 1998;351:321-325. 3. Pessaux P, Tuech JJ, Derouet N, Rouge C, Regenet C, Arnaud JP. Laparoscopic cholecystectomy in the elderly: a prospective study. Surg Endosc 2000;14:1067-9. 4. Decker B, Georgen M, Phillipart P, Mendes da costa P. Laparoscopic cholecystectomy for acute cholecystitis in geriatric patients. Acta Chir Belg 2001;101:294-9. 5. Tambyraja AL, Kumar S, Nixon SJ. Morbidity and Mortality of laparoscopic cholecystectomy in patients over 80 years old - 10 year review. (abstract) Br J Surg 2002;89 (suppl. 1 ):3 |
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Nicholas J Kenefick, Specialist Registrar Torbay Hospital, Torquay, TQ7 3AA, Paul W. Houghton
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Dear Sir, we enjoyed reading your clinical review article “Acute Cholecystitis”. You conclude that resuscitation followed by early laparoscopic cholecystectomy is the optimal treatment for acute cholecystitis. There are however several other factors that we feel are relevant to this decision and in particular to the safety of this approach. In a recent survey ninety per cent of UK surgeons practice initial conservative management followed by delayed interval laparoscopic cholecystectomy (1). While we correctly strive towards evidence-based clinical medicine the experience of senior surgeons, the majority of whom share a common practice based on successful treatment and the occurrence of complications, should not however be ignored lightly. While there are many papers reporting that early laparoscopic cholecystectomy can be performed safely these series tend to illustrate that experienced and interested laparoscopic surgeons, with the appropriate infrastructure available, are able to produce excellent results. Similar results may not be easily reproducible in general surgical practice. Importantly there are data, not included in your review, which would challenge this finding. Pessaux et al (2) performed a prospective study on early (<3 days) versus late laparoscopic cholecystectomy for histologically confirmed cholecystitis in 132 patients. This showed a conversion rate of (early v. late) 38.6% v. 9.6%, p<0.001 and a postoperative morbidity of 15% v. 6.6%, p<0.001. Kum et al (3) prospectively collected data on 530 cholecystectomies for acute cholecystitis with a conversion rate of (early v. late) 13% v. 4%, a bile spillage rate of 28% v. 12% and a common bile duct injury rate of 5.5% v. 0.2%, p=0.005. Early surgery for acute cholecystitis will necessarily remove the current problem of patients developing recurrent symptoms while awaiting delayed surgery. However primum non nocere is one of the primary aims of a surgeon. Based on the presented data, in particular the increased conversion rate, increased complications and increased incidence of common bile duct injuries, we feel that this potential benefit is outweighed by the increased risk. Therefore while there may be a role for early surgery in selected cases this may not be the current optimal treatment. REFERENCES 1 Cameron IC, Chadwick C, Philips J, Johnson AG. Acute cholecystitis -room for improvement. Ann R Coll Surg Engl 2002 Jan;84(1):10-3. 2 Pessaux P, Tuech JJ, Rouge C, Duplessis R, Cervi C, Arnaud JP. Laparoscopic cholecystectomy in acute cholecystitis. A prospective comparative study in patients with acute vs. chronic cholecystitis. Surg Endosc 2000 Apr;14(4):358-61. 3 Kum CK, Eypasch E, Lefering R, Paul A, Neugebauer E, Troidl H. Laparoscopic cholecystectomy for acute cholecystitis: is it really safe? World J Surg 1996 Jan;20(1):43-8;discussion:48-9. Competing interests: None declared |
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Daniel R McGrath, Lecturer, Surgical Science University of Newcastle, NSW 2308, Australia, Allan D. Spigelman
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Dear Sir:
On reading this educational review paper, I noticed the propagation of a longstanding misnomer, namely biliary colic. Are the authors implying that biliary colic is a true colic which comes in waves? Biliary pain is now accepted as a severe pain rising to a plateau and remaining constant for at least 1 hour 1. Peritoneal irritation, as demonstrated by Murphy’s sign, differentiates biliary pain from acute cholecystitis.
References
1. Ransohoff DF, Gracie WA. Treatment of gallstones. Annals of Internal Medicine 1993; 119(7 Pt 1):606-19. Competing interests: None declared |
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