Current Literature

Criteria Are Identified that Could Be Used to Recommend Early Cholesystectomy

Kartik A, Jorge IA, Webb C, et al. Defining Biliary Hyperkinesia and The Role of Cholecystectomy. J Am Coll Surg. 2023, in press.

A strong clinical definition of biliary hyperkinesia that could be used to recommend early cholecystectomy has not been confirmed based on available evidence; the condition is generally diagnosed based on the Rome IV criteria that include symptoms such as right upper quadrant pain, nausea, and vomiting in a patient without gallstones. Recently, radioisotope cholescintigraphy (gallbladder ejection fraction of 80% or more) has been added to the diagnostic criteria.

This article reported a retrospective study of patients from a single healthcare system (n = 2,929) who underwent cholescintigraphy as part of an effort to precisely define the clinical characteristics of biliary hyperkinesia. Cholecystectomy was performed in 141 patients, and a gallbladder ejection fraction >80% was associated with symptom relief in 81% of these patients.

The authors concluded that the combination of typical symptoms, absence of gallstones, and a gallbladder ejection fraction of more than 80% are useful clinical criteria for diagnosing biliary hyperkinesia. Use of this set of criteria has the potential to quickly identify patients who will benefit from cholecystectomy and could reduce emergency department visits and healthcare costs.

Cholecystectomy during Index Admission Is the Most Effective Approach for Frail Patients with Acute Biliary Pancreatitis

Nelson AC, Bhogadi SK, Hosseinpour H, et al. There Is No Such Thing as Too Soon: Long-Term Outcomes of Early Cholecystectomy for Frail Geriatric Patients with Acute Biliary Pancreatitis. J Am Coll Surg. 2023, in press.

Optimum timing of cholecystectomy in frail, older patients with acute biliary pancreatitis (ABP) is a notable clinical challenge in surgical practice. This study used data from a national database to compare outcomes of patients (n = 7,941) diagnosed with ABP who were managed with cholecystectomy (CCY) during the index admission (n = 5,294) or managed nonoperatively with endoscopic retrograde cholangiopancreatography.

The main outcomes of interest were readmission within 6 months, mortality, and length of stay. A secondary outcome of interest was the rate of unplanned pancreatic procedures or cholecystectomy. Patients who underwent early CCY had significantly lower rates of readmission and significantly reduced length of stay and mortality. Nonoperative management failed in 7% of patients, and more than half of this group required unplanned CCY.

The authors concluded that careful preoperative preparation and CCY during the index admission was the safest and most effective approach for elderly, frail patients with ABP.

Article Examines Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma

Hutchinson PJ, Adams H, Mohan M, et al. Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma. N Engl J Med 2023;388(24):2219-29. doi: 10.1056/NEJMoa2214172 [published Online First: 20230423]

Acute subdural hematoma is a condition treated with surgical evacuation of the hematoma using craniotomy (bone flap retained) or craniectomy (bone flap removed for prevention in intracranial hypertension). The study reported in this article sought to determine whether craniectomy was associated with improved outcomes.

The authors conducted a randomized prospective trial comparing bone flap removal (n = 222) with craniotomy alone (n = 228). The main outcome of interest was the 8-point Glasgow Outcome Score (range: death to “good recovery”) determined at 6 and 12 months after the index procedure. The primary outcome scores were similar in the two patient groups. Repeat cranial surgery was necessary in 14.6% of the craniotomy group and 7% of the craniectomy group. Wound complication rates were higher in the craniectomy group (12.2% vs 3.9%).

The authors concluded that craniotomy was associated with a significant risk for delayed procedures for management of intracranial hypertension but had lower rates of wound complications. They noted that craniectomy may be the preferred approach in resource-limited settings where close observation for detection of intracranial hypertension by expert critical care personnel is not available.

Editorial

Gopinath S. Traumatic Acute Subdural Hematoma - Should the Bone Flap Be Removed or Replaced? N Engl J Med 2023;388(24):2288-89. doi: 10.1056/NEJMe2302936 [published Online First: 20230423]

In the editorial by Shankar Gopinath, MD, that accompanied the article, important points were emphasized: wound complication rates were higher in the craniectomy group, but rates of wound infection were low in both groups and the other wound complications encountered were easily treatable. For these reasons, the editorialist concluded that choosing craniectomy to reduce the risk of intracranial hypertension was appropriate.