今日の臨床サポート

急性胆嚢炎

著者: 浅井浩司 東邦大学医療センター大橋病院 外科

監修: 真弓俊彦 産業医科大学 救急医学

著者校正済:2021/11/02
現在監修レビュー中
参考ガイドライン:
  1. 急性胆管炎・胆嚢炎診療ガイドライン改訂出版委員会:急性胆管炎・胆嚢炎診療ガイドライン2018 第3版
患者向け説明資料

概要・推奨   

  1. 急性胆嚢炎の典型的な症状は、上腹部痛(右季肋部痛、心窩部痛)、悪心・嘔吐、発熱で、特に右季肋部圧痛、Murphy徴候が特徴的である。
  1. 急性胆嚢炎発症との関連が示唆される薬剤はフィブラート、スタチン、エストロゲンによるホルモン置換療法である(推奨度2)。
  1. 急性胆嚢炎の診断には、特異的な血液検査所見はなく、全身の炎症所見(白血球数、CRP)をチェックする必要がある(推奨度1)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に はご契約が必要となります。閲覧にはご契約が必要となります。閲覧に はご契約が必要となります。閲覧にはご契約が必要とな ります。閲覧にはご契約が必要となります。閲覧には
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご 契約が必 要となります。閲覧にはご契約が必要となります。閲覧にはご契
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧 にはご契約が必要となり ます。閲覧にはご契約が必要となります。 閲覧にはご契約 が必 要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
浅井浩司 : 特に申告事項無し[2021年]
監修:真弓俊彦 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 急性胆嚢炎の原因の90~95%は胆嚢結石であり、結石の嵌頓による胆嚢管閉塞と胆嚢内胆汁うっ滞に引き続き、胆嚢粘膜障害が起こり、炎症性メディエーターの活性化が引き起こされる。一方、急性無石胆嚢炎は急性胆嚢炎の3.7~14%を占め、その危険因子は、手術、外傷、長期のICU滞在、感染症、熱傷や経静脈栄養などである。
  1. 日本人の胆石保有率は約10%といわれている。無症候性胆石保有者の有症状化率は、年率1~3%、生涯で約20%、特に急性胆嚢炎の発症が3.8~12%、胆管炎が0.3~1.6%との報告がある。
  1. 急性胆嚢炎の合併病態としては、壊疽性胆嚢炎・穿孔、化膿性胆嚢炎、気腫性胆嚢炎が挙げられ、これらの頻度は2~26%である。このような症例に対しては緊急手術を適応することとなる。
  1. 急性胆嚢炎の死亡率に関して、2000年以降の報告では、おおむね1%未満である。時代や地域による差を顕著に認めず、米国の最近のレビューでも0.6%と記されている。
  1. 急性胆嚢炎の死因として、以前は胆嚢摘出術後の感染性合併症(上行性胆管炎、肝膿瘍、敗血症など)が多かったが、最近では、術後早期の感染症による死亡は激減し、心筋梗塞、心不全、肺塞栓などの心血管障害や肝腎不全による死亡が相対的に増加している。
問診・診察のポイント  
  1. 急性胆嚢炎の最も典型的な症状は右季肋部痛であり(38~93%)、右季肋部痛と心窩部痛を合わせると72~93%である。次いで悪心・嘔吐が多く(約70%)、発熱は62%にみられる。38℃を超える高熱は3割程度であり、高熱の頻度は高くはない。
  1. 急性胆嚢炎では、筋性防御が約半数にみられる。右季肋部に腫瘤を触知することは多くなく、反跳痛や硬直が認められることも少ない。一方、Murphy徴候は、急性胆嚢炎の診断に対する感度は50~60%程度であり、特異度に関しては96%[1]、79%[2]と高い。なお、高齢者では感度が低い。
  1. Murphy徴候とは、「検者の手で右季肋下を圧迫した状態で患者に深吸気を促した際、疼痛により吸気が止まる所見を認めた場合陽性と判断すること」をいう。Murphyが1903年に胆石症の徴候として記載し、のちに急性胆嚢炎の徴候として用いられている。右季肋部に直接的な圧痛を認める場合はMurphy徴候の判定は困難である。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

まずは15日間無料トライアル
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

著者: Robert L Trowbridge, Nicole K Rutkowski, Kaveh G Shojania
雑誌名: JAMA. 2003 Jan 1;289(1):80-6.
Abstract/Text CONTEXT: Although few patients with acute abdominal pain will prove to have cholecystitis, ruling in or ruling out acute cholecystitis consumes substantial diagnostic resources.
OBJECTIVE: To determine if aspects of the history and physical examination or basic laboratory testing clearly identify patients who require diagnostic imaging tests to rule in or rule out the diagnosis of acute cholecystitis.
DATA SOURCES: Electronic search of the Science Citation Index, Cochrane Library, and English-language articles from January 1966 through November 2000 indexed in MEDLINE. We also hand-searched Index Medicus for 1950-1965, and scanned references in identified articles and bibliographies of prominent textbooks of physical examination, surgery, and gastroenterology. To identify relevant articles appearing since the comprehensive search, we repeated the MEDLINE search in July 2002.
STUDY SELECTION: Included studies evaluated the role of the history, physical examination, and/or laboratory tests in adults with abdominal pain or suspected acute cholecystitis. Studies had to report data from a control group found not to have acute cholecystitis. Acceptable definitions of cholecystitis included surgery, pathologic examination, hepatic iminodiacetic acid scan or right upper quadrant ultrasound, or clinical course consistent with acute cholecystitis and no evidence for an alternate diagnosis. Studies of acalculous cholecystitis were included. Seventeen of 195 identified studies met the inclusion criteria.
DATA EXTRACTION: Two authors independently abstracted data from the 17 included studies. Disagreements were resolved by discussion and consensus with a third author.
DATA SYNTHESIS: No clinical or laboratory finding had a sufficiently high positive likelihood ratio (LR) or low negative LR to rule in or rule out the diagnosis of acute cholecystitis. Possible exceptions were the Murphy sign (positive LR, 2.8; 95% CI, 0.8-8.6) and right upper quadrant tenderness (negative LR, 0.4; 95% CI, 0.2-1.1), though the 95% CIs for both included 1.0. Available data on diagnostic confirmation rates at laparotomy and test characteristics of relevant radiological investigations suggest that the diagnostic impression of acute cholecystitis has a positive LR of 25 to 30. Unfortunately, the available literature does not identify the specific combinations of clinical and laboratory findings that presumably account for this diagnostic success.
CONCLUSIONS: No single clinical finding or laboratory test carries sufficient weight to establish or exclude cholecystitis without further testing (eg, right upper quadrant ultrasound). Combinations of certain symptoms, signs, and laboratory results likely have more useful LRs, and presumably inform the diagnostic impressions of experienced clinicians. Pending further research characterizing the pretest probabilities associated with different clinical presentations, the evaluation of patients with abdominal pain suggestive of cholecystitis will continue to rely heavily on the clinical gestalt and diagnostic imaging.

PMID 12503981  JAMA. 2003 Jan 1;289(1):80-6.
著者: Masamichi Yokoe, Jiro Hata, Tadahiro Takada, Steven M Strasberg, Horacio J Asbun, Go Wakabayashi, Kazuto Kozaka, Itaru Endo, Daniel J Deziel, Fumihiko Miura, Kohji Okamoto, Tsann-Long Hwang, Wayne Shih-Wei Huang, Chen-Guo Ker, Miin-Fu Chen, Ho-Seong Han, Yoo-Seok Yoon, In-Seok Choi, Dong-Sup Yoon, Yoshinori Noguchi, Satoru Shikata, Tomohiko Ukai, Ryota Higuchi, Toshifumi Gabata, Yasuhisa Mori, Yukio Iwashita, Taizo Hibi, Palepu Jagannath, Eduard Jonas, Kui-Hin Liau, Christos Dervenis, Dirk J Gouma, Daniel Cherqui, Giulio Belli, O James Garden, Mariano Eduardo Giménez, Eduardo de Santibañes, Kenji Suzuki, Akiko Umezawa, Avinash Nivritti Supe, Henry A Pitt, Harjit Singh, Angus C W Chan, Wan Yee Lau, Anthony Yuen Bun Teoh, Goro Honda, Atsushi Sugioka, Koji Asai, Harumi Gomi, Takao Itoi, Seiki Kiriyama, Masahiro Yoshida, Toshihiko Mayumi, Naoki Matsumura, Hiromi Tokumura, Seigo Kitano, Koichi Hirata, Kazuo Inui, Yoshinobu Sumiyama, Masakazu Yamamoto
雑誌名: J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):41-54. doi: 10.1002/jhbp.515. Epub 2018 Jan 9.
Abstract/Text The Tokyo Guidelines 2013 (TG13) for acute cholangitis and cholecystitis were globally disseminated and various clinical studies about the management of acute cholecystitis were reported by many researchers and clinicians from all over the world. The 1st edition of the Tokyo Guidelines 2007 (TG07) was revised in 2013. According to that revision, the TG13 diagnostic criteria of acute cholecystitis provided better specificity and higher diagnostic accuracy. Thorough our literature search about diagnostic criteria for acute cholecystitis, new and strong evidence that had been released from 2013 to 2017 was not found with serious and important issues about using TG13 diagnostic criteria of acute cholecystitis. On the other hand, the TG13 severity grading for acute cholecystitis has been validated in numerous studies. As a result of these reviews, the TG13 severity grading for acute cholecystitis was significantly associated with parameters including 30-day overall mortality, length of hospital stay, conversion rates to open surgery, and medical costs. In terms of severity assessment, breakthrough and intensive literature for revising severity grading was not reported. Consequently, TG13 diagnostic criteria and severity grading were judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18/TG13 diagnostic criteria and severity grading of acute cholecystitis without any modification. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

© 2018 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
PMID 29032636  J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):41-54. doi・・・
著者: P P Michielsen, H Fierens, Y M Van Maercke
雑誌名: Drug Saf. 1992 Jan-Feb;7(1):32-45.
Abstract/Text A great variety of drugs is reported to induce gallbladder disease by various pathogenetic mechanisms. Early epidemiological studies indicated a doubled risk of gallbladder disease in women taking oral contraceptives. More recent studies, however, have failed to confirm those findings; these conflicting results might be explained by the different methods used to define gallbladder disease. It was shown that the lithogenic index of the bile is increased during intake of oral contraceptives. Estrogens cause hypersecretion of cholesterol in bile, due to increase in lipoprotein uptake by the hepatocyte. Progesterone inhibits acyl coenzyme A-cholesterol acyl transferase (ACAT) activity, causing delayed conversion of cholesterol to cholesterol esters. Of the lipid lowering drugs, only clofibrate has been shown to increase the risk for gallstone formation. The other fibric acid derivatives have similar properties, but clinical experience is not as extensive. They seem to be inhibitors of the ACAT enzyme system, thereby rendering bile more lithogenic. Conflicting epidemiological data exist regarding the induction of acute cholecystitis by thiazide diuretics. Ceftriaxone, a third-generation cephalosporin, is reported to induce biliary sludge in 25 to 45% of patients, an effect which is reversible after discontinuing the drug. The sludge is occasionally a clinical problem. It was clearly demonstrated that this sludge is caused by precipitation of the calcium salt of ceftriaxone excreted in the bile. Long term use of octreotide is complicated by gallstone formation in approximately 50% of patients after 1 year of therapy, due to gallbladder stasis. Hepatic artery infusion chemotherapy by implanted pump is shown to be associated with a very high risk of chemically induced cholecystitis. Prophylactic cholecystectomy at the time of pump implantation is therefore advocated. Some drugs, such as erythromcyin or ampicillin, are reported to cause hypersensitivity-induced cholecystitis. Furthermore, there are reports on the influence of cyclosporin, dapsone, anticoagulant treatment, and narcotic and anticholinergic medication in causing gallbladder disease.

PMID 1536697  Drug Saf. 1992 Jan-Feb;7(1):32-45.
著者:
雑誌名: Lancet. 1982 Oct 30;2(8305):957-9.
Abstract/Text
PMID 6127462  Lancet. 1982 Oct 30;2(8305):957-9.
著者: J Cooper, H Geizerova, M F Oliver
雑誌名: Lancet. 1975 May 10;1(7915):1083.
Abstract/Text
PMID 48743  Lancet. 1975 May 10;1(7915):1083.
著者: F X Caroli-Bosc, P Le Gall, P Pugliese, B Delabre, C Caroli-Bosc, J F Demarquay, J P Delmont, P Rampal, J C Montet, General Practitioners' Group of Vidauban
雑誌名: Dig Dis Sci. 2001 Mar;46(3):540-4.
Abstract/Text Fibrate derivatives and HMG-CoA reductase inhibitors modify homeostasis of cholesterol. The aim of this study was to assess in an unselected population whether these hypolipidemic drugs are risk factors for cholelithiasis or, conversely, are protective agents. Both sexes, all socioeconomic categories, pregnant women, and cholecystectomized subjects were included. Clinical data collection and gallbladder ultrasonography were both carried out in a double-blind fashion. Fibrate derivatives were predominantly fenofibrate, HMG-CoA reductase inhibitors were simvastatin and pravastatin. On univariate analysis, age (>50 years), sex, and use of fibrates were found to be significantly related to the presence of cholelithiasis. Age, sex, and fibrate treatment remained independently correlated with the presence of gallstones on multivariate analysis. With fibrates, the relative risk for lithiasis was 1.7 (P = 0.04). The HMG-CoA reductase inhibitors were not associated with a protective effect on univariate analysis. Of the lipid-lowering drugs, only fibrate derivatives were found to increase the risk of gallstone formation.

PMID 11318529  Dig Dis Sci. 2001 Mar;46(3):540-4.
著者: Chung-Jyi Tsai, Michael F Leitzmann, Walter C Willett, Edward L Giovannucci
雑誌名: Gastroenterology. 2009 May;136(5):1593-600. doi: 10.1053/j.gastro.2009.01.042. Epub 2009 Jan 24.
Abstract/Text BACKGROUND & AIMS: Statins can reduce biliary cholesterol secretion independently of their ability to inhibit cholesterol synthesis. Statins also prevent the formation of gallstones in animal studies, although the effect of statins on human gallstone disease has been controversial.
METHODS: We examined the relationship between the use of statins and the risk of cholecystectomy in a cohort of US women. As part of the prospective Nurses' Health Study, participants biennially reported their history of gallstone disease and whether they had undergone cholecystectomy. Women also reported lifetime use of statins retrospectively in 2000. We conducted a retrospective analysis of statin using data collected in 2000, to define use from 1994 forward, and a prospective analysis for general lipid-lowering drugs from 1994 to 2004.
RESULTS: In the statin analysis we ascertained 2479 cases of cholecystectomy during 305,197 person-years of follow-up evaluation. The multivariate relative risk for current statin users, compared with nonusers, was 0.82 (95% confidence interval, 0.70-0.96). In the analysis of general cholesterol-lowering drugs, we ascertained 3420 cases of cholecystectomy during 511,411 person-years of follow-up evaluation. Compared with nonusers, the multivariate relative risk for current users of general cholesterol-lowering drugs, mostly statins in this cohort, was 0.88 (95% confidence interval, 0.79-0.98).
CONCLUSIONS: Statin use appears to reduce the risk of cholecystectomy in women.

PMID 19208351  Gastroenterology. 2009 May;136(5):1593-600. doi: 10.105・・・
著者: Michael Bodmer, Yolanda B Brauchli, Stephan Krähenbühl, Susan S Jick, Christoph R Meier
雑誌名: JAMA. 2009 Nov 11;302(18):2001-7. doi: 10.1001/jama.2009.1601.
Abstract/Text CONTEXT: Gallstone disease is a leading cause of morbidity in western countries and carries a high economic burden. Statins decrease hepatic cholesterol biosynthesis and may therefore lower the risk of cholesterol gallstones by reducing the cholesterol concentration in the bile. Data on this association in humans are scarce.
OBJECTIVE: To study the association between the use of statins, fibrates, or other lipid-lowering agents and the risk of incident gallstone disease followed by cholecystectomy.
DESIGN, SETTING, AND PARTICIPANTS: Case-control analysis using the UK-based General Practice Research Database. Incident patients between 1994 and 2008 and 4 controls per each patient were identified and matched on age, sex, general practice, calendar time, and years of history in the database. The study population was 76% women and the mean (SD) age was 53.4 (15.0) years at the index date. Conditional logistic regression was used to estimate the odds ratio (OR) of developing gallstones followed by cholecystectomy in relation to exposure to lipid-lowering agents, stratified by exposure timing and duration. The ORs and 95% confidence intervals (CIs) were adjusted for smoking, body mass index, ischemic heart disease, stroke, and estrogen use.
MAIN OUTCOME MEASURE: The adjusted OR (AOR) for developing gallstone disease followed by cholecystectomy in relation to exposure to lipid-lowering agents.
RESULTS: A total of 27,035 patients with cholecystectomy and 106,531 matched controls were identified, including 2396 patients and 8868 controls who had statin use. Compared with nonuse, current statin use (last prescription recorded within 90 days before the first-time diagnosis of the disease) was 1.0% for patients and 0.8% for controls (AOR, 1.10; 95% CI, 0.95-1.27) for 1 to 4 prescriptions; 2.6% vs 2.4% (AOR, 0.85; 95% CI, 0.77-0.93) for 5 to 19 prescriptions, and 3.2% vs 3.7% (AOR, 0.64; 95% CI, 0.59-0.70) for 20 or more prescriptions. The AORs for current use of statins defined as 20 or more prescriptions were similar (around 0.6) across age, sex, and body mass index categories, and across the statin class.
CONCLUSION: Long-term use of statins was associated with a decreased risk of gallstones followed by cholecystectomy.

PMID 19903921  JAMA. 2009 Nov 11;302(18):2001-7. doi: 10.1001/jama.200・・・
著者: Eugene Merzon, Noel S Weiss, Alex James Lustman, Asher Elhayani, Julian Dresner, Shlomo Vinker
雑誌名: Expert Opin Drug Saf. 2010 Jul;9(4):539-43. doi: 10.1517/14740338.2010.485190.
Abstract/Text BACKGROUND: Gallstone disease is common in Western countries. Statins reduce biliary cholesterol secretion and have anti-inflammatory effects, suggesting that they may play a role in reducing the incidence of surgically treated gallstone disease.
AIM: To examine a potential association between statin administration and risk of cholecystectomy.
METHODS: We conducted a population-based case-control study of surgically treated gallstone disease using the database of Clalit Health Services (CHS). The study population consisted of all individuals age 40 - 85 enrolled with the central region of CHS during the period 1 January 2000 to 31 December 2006. We identified patients who underwent cholecystectomy between 1 January 2003 and 31 December 2006 (n = 1465). Controls (n = 5860) were individually matched on year of birth and sex in a 4:1 ratio. Multivariable conditional logistic regression models to compute the odds ratio of cholecystectomy associated with statin therapy were constructed to control for patients' clinical and socio-demographic characteristics.
RESULTS: Statin use with at least 80% adherence to treatment was associated with about 30% reduction in the risk of cholecystectomy (adjusted odds ratio 0.69; 95% CI 0.57 - 0.84).
CONCLUSION: The results of our large population-based study suggest that the use of statins reduces the risk of surgery for gallstone disease.

PMID 20482330  Expert Opin Drug Saf. 2010 Jul;9(4):539-43. doi: 10.151・・・
著者: Rune Erichsen, Trine Frøslev, Timothy L Lash, Lars Pedersen, Henrik Toft Sørensen
雑誌名: Am J Epidemiol. 2011 Jan 15;173(2):162-70. doi: 10.1093/aje/kwq361. Epub 2010 Nov 17.
Abstract/Text Most gallstones originate from cholesterol-supersaturated bile. Statins inhibit hepatic cholesterol biosynthesis and therefore may reduce the risk of gallstone disease. Population-based evidence, however, is sparse. Thus, the authors conducted a population-based case-control study using medical databases from northern Denmark (1.7 million inhabitants) to identify 32,494 cases of gallstones occurring between 1996 and 2008 and to identify age-, sex-, and county-matched population controls for each case. Cases and their matched controls who were exposed to lipid-lowering drugs were categorized as current users if their last prescription was redeemed ≤90 days before the case's diagnosis date; otherwise, they were categorized as former users. Conditional logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals for gallstone disease in patients treated with lipid-lowering drugs. In current users, the adjusted odds ratios associating statin use with the occurrence of gallstone disease were 1.17 (95% confidence interval (CI): 1.06, 1.30) for those who had 1-4 prescriptions, 0.89 (95% CI: 0.80, 0.97) for those who had 5-19 prescriptions, and 0.76 (95% CI: 0.69, 0.84) for those who had ≥20 total prescriptions. In former users, the corresponding adjusted odds ratios were 1.24 (95% CI: 1.11, 1.39), 0.97 (95% CI: 0.86, 1.10), and 0.79 (95% CI: 0.64, 0.97), respectively. The use of other lipid-lowering drugs showed no similar association.

PMID 21084557  Am J Epidemiol. 2011 Jan 15;173(2):162-70. doi: 10.1093・・・
著者: Ute Wagnetz, Jeff Jaskolka, Peter Yang, Kartik S Jhaveri
雑誌名: J Comput Assist Tomogr. 2010 May-Jun;34(3):348-53. doi: 10.1097/RCT.0b013e3181caaea3.
Abstract/Text PURPOSE: To determine the incidence and clinical outcome of acute ischemic cholecystitis after transarterial chemoembolization (TACE) of hepatocellular carcinoma.
MATERIALS AND METHODS: In this ethics board-approved study, a retrospective review of 355 TACE procedures performed in 246 patients during a 5-year period was performed. The review of postintervention computed tomography (CT) reports for findings indicative of acute cholecystitis identified 12 patients (4.9%). In these patients, all CT scans, laboratory results (white blood cell count, alkaline phosphatase level, total bilirubin level), and clinical reports were analyzed to assess imaging findings and outcomes at the following time points: before TACE, within the first week after the procedure, as well as 1 and 6 months post-TACE.
RESULTS: In 11 of 12 cases, the dominant finding on CT was new gallbladder wall thickening of up to 12 mm, which developed within 24 hours in 10 patients and within the first month after TACE in 1 patient. Gallbladder wall thickening persisted in 1 patient for at least 6 months. Eleven of 12 patients showed deposition of Lipiodol in the gallbladder wall. In 1 patient, the dominant finding on CT was pericholecystic stranding that resolved on follow-up CT after 1 month. None of the patients demonstrated gas in the gallbladder wall, significant pericholecystic fluid, abdominal or liver abscesses. Blood work results revealed transient increase in white blood cell count, alkaline phosphatase level, and total bilirubin level, not different from that seen after TACE in patients without CT evidence of cholecystitis. Clinical reports documented transient right upper quadrant pain for a few days and up to 1 month in 1 case with eventual symptom relief. None of the cases required surgical or radiological intervention. All but 1 case demonstrated normal gallbladder wall thickness after 6 months.
CONCLUSIONS: Acute ischemic cholecystitis is not an uncommon complication after TACE. However, it is self-limiting and does not seem to require any intervention or surgery.

PMID 20498534  J Comput Assist Tomogr. 2010 May-Jun;34(3):348-53. doi:・・・
著者: Heidi D Nelson, Linda L Humphrey, Peggy Nygren, Steven M Teutsch, Janet D Allan
雑誌名: JAMA. 2002 Aug 21;288(7):872-81.
Abstract/Text CONTEXT: Although postmenopausal hormone replacement therapy (HRT) is widely used in the United States, new evidence about its benefits and harms requires reconsideration of its use for the primary prevention of chronic conditions.
OBJECTIVE: To assess the benefits and harms of HRT for the primary prevention of cardiovascular disease, thromboembolism, osteoporosis, cancer, dementia, and cholecystitis by reviewing the literature, conducting meta-analyses, and calculating outcome rates.
DATA SOURCES: All relevant English-language studies were identified in MEDLINE (1966-2001), HealthSTAR (1975-2001), Cochrane Library databases, and reference lists of key articles. Recent results of the Women's Health Initiative (WHI) and the Heart and Estrogen/progestin Replacement Study (HERS) are included for reported outcomes.
STUDY SELECTION AND DATA EXTRACTION: We used all published studies of HRT if they contained a comparison group of HRT nonusers and reported data relating to HRT use and clinical outcomes of interest. Studies were excluded if the population was selected according to prior events or presence of conditions associated with higher risks for targeted outcomes.
DATA SYNTHESIS: Meta-analyses of observational studies indicated summary relative risks (RRs) for coronary heart disease (CHD) incidence and mortality that were significantly reduced among current HRT users only, although risk for incidence was not reduced when only studies that controlled for socioeconomic status were included. The WHI reported increased CHD events (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.02-1.63). Stroke incidence but not mortality was significantly increased among HRT users in the meta-analysis and the WHI. The meta-analysis indicated that risk was significantly elevated for thromboembolic stroke (RR, 1.20; 95% CI, 1.01-1.40) but not subarachnoid or intracerebral stroke. Risk of venous thromboembolism among current HRT users was increased overall (RR, 2.14; 95% CI, 1.64-2.81) and was highest during the first year of use (RR, 3.49; 95% CI, 2.33-5.59) according to a meta-analysis of 12 studies. Protection against osteoporotic fractures is supported by a meta-analysis of 22 estrogen trials, cohort studies, results of the WHI, and trials with bone density outcomes. Current estrogen users have an increased risk of breast cancer that increases with duration of use. Endometrial cancer incidence, but not mortality, is increased with unopposed estrogen use but not with estrogen with progestin. A meta-analysis of 18 observational studies showed a 20% reduction in colon cancer incidence among women who had ever used HRT (RR, 0.80; 95% CI, 0.74-0.86), a finding supported by the WHI. Women symptomatic from menopause had improvement in certain aspects of cognition. Current studies of estrogen and dementia are not definitive. In a cohort study, current HRT users had an age-adjusted RR for cholecystitis of 1.8 (95% CI, 1.6-2.0), increasing to 2.5 (95% CI, 2.0-2.9) after 5 years of use.
CONCLUSIONS: Benefits of HRT include prevention of osteoporotic fractures and colorectal cancer, while prevention of dementia is uncertain. Harms include CHD, stroke, thromboembolic events, breast cancer with 5 or more years of use, and cholecystitis.

PMID 12186605  JAMA. 2002 Aug 21;288(7):872-81.
著者: Dominic J Cirillo, Robert B Wallace, Rebecca J Rodabough, Philip Greenland, Andrea Z LaCroix, Marian C Limacher, Joseph C Larson
雑誌名: JAMA. 2005 Jan 19;293(3):330-9. doi: 10.1001/jama.293.3.330.
Abstract/Text CONTEXT: Estrogen therapy is thought to promote gallstone formation and cholecystitis but most data derive from observational studies rather than randomized trials.
OBJECTIVE: To determine the effect of estrogen therapy in healthy postmenopausal women on gallbladder disease outcomes.
DESIGN, SETTING, AND PARTICIPANTS: Two randomized, double-blind, placebo-controlled trials conducted at 40 US clinical centers. The volunteer sample was 22,579 community-dwelling women aged 50 to 79 years without prior cholecystectomy.
INTERVENTION: Women with hysterectomy were randomized to 0.625 mg/d of conjugated equine estrogens (CEE) or placebo (n = 8376). Women without hysterectomy were randomized to estrogen plus progestin (E + P), given as CEE plus 2.5 mg/d of medroxyprogesterone acetate (n = 14,203).
MAIN OUTCOME MEASURES: Participants reported hospitalizations for gallbladder diseases and gallbladder-related procedures, with events ascertained through medical record review. Cox proportional hazards regression was used to assess hazard ratios (HRs) and 95% confidence intervals (CIs) using intention-to-treat and time-to-event methods.
RESULTS: The CEE and the E + P groups were similar to their respective placebo groups at baseline. The mean follow-up times were 7.1 years and 5.6 years for the CEE and the E + P trials, respectively. The annual incidence rate for any gallbladder event was 78 events per 10,000 person-years for the CEE group (vs 47/10,000 person-years for placebo) and 55 per 10,000 person-years for E + P (vs 35/10,000 person-years for placebo). Both trials showed greater risk of any gallbladder disease or surgery with estrogen (CEE: HR, 1.67; 95% CI, 1.35-2.06; E + P: HR, 1.59; 95% CI, 1.28-1.97). Both trials indicated a higher risk for cholecystitis (CEE: HR, 1.80; 95% CI, 1.42-2.28; E + P: HR, 1.54; 95% CI 1.22-1.94); and for cholelithiasis (CEE: HR, 1.86; 95% CI, 1.48-2.35; E + P: HR, 1.68; 95% CI, 1.34-2.11) for estrogen users. Also, women undergoing estrogen therapy were more likely to receive cholecystectomy (CEE: HR, 1.93; 95% CI, 1.52-2.44; E + P: HR, 1.67; 95% CI, 1.32-2.11), but not other biliary tract surgery (CEE: HR, 1.18; 95% CI, 0.68-2.04; E + P: HR, 1.49; 95% CI, 0.78-2.84).
CONCLUSIONS: These data suggest an increase in risk of biliary tract disease among postmenopausal women using estrogen therapy. The morbidity and cost associated with these outcomes may need to be considered in decisions regarding the use of estrogen therapy.

PMID 15657326  JAMA. 2005 Jan 19;293(3):330-9. doi: 10.1001/jama.293.3・・・
著者: T Juvonen, H Kiviniemi, O Niemelä, M I Kairaluoma
雑誌名: Eur J Surg. 1992 Jun-Jul;158(6-7):365-9.
Abstract/Text OBJECTIVE: To assess the value of ultrasonography together with C reactive protein concentration in predicting which patients with acute cholecystitis require immediate operation.
DESIGN: Prospective study.
SETTING: Oulu University Hospital, Finland.
SUBJECTS: 129 consecutive patients admitted with suspected acute cholecystitis 1988-89.
MAIN OUTCOME MEASURES: Correlation of ultrasonographic findings and C reactive protein concentrations with histological findings.
RESULTS: Ultrasonography correctly classified 86 of 108 patients with acute cholecystitis (79%). When the findings were combined with those of increased concentrations of C reactive protein the accuracy rose to 105 of 108 (97%). Large increases in C reactive protein concentrations were associated with both infected bile and gangrene of the gall bladder.
CONCLUSIONS: The combination of ultrasonography and measurement of C reactive protein concentration is recommended in the routine investigation of all patients with suspected acute cholecystitis. Serum C reactive protein concentrations should be monitored regularly to select those patients who require emergency operation.

PMID 1356470  Eur J Surg. 1992 Jun-Jul;158(6-7):365-9.
著者: P A Abboud, P F Malet, J A Berlin, R Staroscik, M D Cabana, J R Clarke, J A Shea, J S Schwartz, S V Williams
雑誌名: Gastrointest Endosc. 1996 Oct;44(4):450-5.
Abstract/Text BACKGROUND: The decision of whether or not to investigate for common bile duct stones before cholecystectomy utilizes clinical, laboratory, and radiologic information (indicators). There is tremendous individual variation among clinicians in the criteria used for making this decision. Our aim was to perform a meta-analysis of published data to estimate the performance characteristics of the most commonly used preoperative indicators of common bile duct stones.
METHODS: Using predetermined exclusion criteria, we selected articles from a MEDLINE search and bibliographic review. Weighted averages were used to determine summary sensitivity, specificity, and positive and negative likelihood ratios for each indicator for stones.
RESULTS: From 2221 citations identified, 22 studies met inclusion criteria. The 10 indicators examined were reported in a common fashion in three or more articles, and could be assessed preoperatively. Seven exhibited a specificity greater than 90%. Indicators with positive likelihood ratios of 10 or above were cholangitis, preoperative jaundice, and ultrasound evidence of common bile duct stones. Positive likelihood ratios for dilated common bile duct on ultrasound, hyperbilirubinemia, and jaundice ranged from almost 4 to almost 7. Elevated levels of alkaline phosphatase, pancreatitis, cholecystitis, and hyperamylasemia exhibited positive likelihood ratios of less than 3.
CONCLUSIONS: This meta-analysis has identified indicators for duct stones and ranked them according to likelihood ratios. These findings can be applied as guidelines for whether to investigate for duct stones before cholecystectomy.

PMID 8905367  Gastrointest Endosc. 1996 Oct;44(4):450-5.
著者: J A Shea, J A Berlin, J J Escarce, J R Clarke, B P Kinosian, M D Cabana, W W Tsai, N Horangic, P F Malet, J S Schwartz
雑誌名: Arch Intern Med. 1994 Nov 28;154(22):2573-81.
Abstract/Text BACKGROUND: The purpose of this study was to estimate the sensitivity and specificity of diagnostic tests for gallstones and acute cholecystitis.
METHODS: All English-language articles published from 1966 through 1992 about tests used in the diagnosis of biliary tract disease were identified through MEDLINE. From 1614 titles, 666 abstracts were examined and 322 articles were read to identify 61 articles with information about sensitivity and specificity. Application of exclusion criteria based on clinical and methodologic criteria left 30 articles for analysis. Cluster-sampling methods were adapted to obtain combined estimates of sensitivities and specificities. Adjustments were made to estimates that were biased because the gold standard was applied preferentially to patients with positive test results.
RESULTS: Ultrasound has the best unadjusted sensitivity (0.97; 95% confidence interval, 0.95 to 0.99) and specificity (0.95; 95% confidence interval, 0.88 to 1.00) for evaluating patients with suspected gallstones. Adjusted values are 0.84 (0.76 to 0.92) and 0.99 (0.97 to 1.00), respectively. Adjusted and unadjusted results for oral cholecystogram were lower. Radionuclide scanning has the best sensitivity (0.97; 95% confidence interval, 0.96 to 0.98) and specificity (0.90; 95% confidence interval, 0.86 to 0.95) for evaluating patients with suspected acute cholecystitis; test performance is unaffected by delayed imaging. Unadjusted sensitivity and specificity of ultrasound in evaluating patients with suspected acute cholecystitis are 0.94 (0.92 to 0.96) and 0.78 (0.61 to 0.96); adjusted values are 0.88 (0.74 to 1.00) and 0.80 (0.62 to 0.98).
CONCLUSIONS: Ultrasound is superior to oral cholecystogram for diagnosing cholelithiasis, and radionuclide scanning is the test of choice for acute cholecystitis. However, sensitivities and specificities are somewhat lower than commonly reported. We recommend estimates that are midway between the adjusted and unadjusted values.

PMID 7979854  Arch Intern Med. 1994 Nov 28;154(22):2573-81.
著者: C L Rosen, D F Brown, Y Chang, C Moore, N J Averill, L J Arkoff, C J McCabe, R E Wolfe
雑誌名: Am J Emerg Med. 2001 Jan;19(1):32-6. doi: 10.1053/ajem.2001.20028.
Abstract/Text This article investigates the use of bedside abdominal ultrasonography (BAU) performed by emergency physicians (EPs) to screen patients for cholelithiasis and cholecystitis. In this prospective study EPs performed BAU on 116 patients. Agreement between BAU and formal abdominal ultrasound (FUS) performed in the radiology department for detecting cholelithiasis and cholecystitis was determined using Kappa statistics. Test characteristics of BAU for detecting cholelithiasis and acute cholecystitis were calculated. Agreement between BAU and FUS was 0.71 for cholelithiasis and 0.46 for acute cholecystitis. Test characteristics of BAU for cholelithiasis were sensitivity 92%, specificity 78%, positive predictive value (PPV) 86%, negative predictive value (NPV) 88%. Test characteristics of BAU for acute cholecystitis compared with clinical follow-up were sensitivity 91%, specificity 66%, PPV 70%, NPV 90%. BAU may be used to exclude cholelithiasis and is sensitive for cholecystitis. However, when EPs with limited experience identify cholecystitis a confirmatory test is warranted before cholecystectomy.

PMID 11146014  Am J Emerg Med. 2001 Jan;19(1):32-6. doi: 10.1053/ajem.・・・
著者: J L Kendall, R J Shimp
雑誌名: J Emerg Med. 2001 Jul;21(1):7-13.
Abstract/Text The objectives of this study were to determine the accuracy of Emergency Physicians (EP) performing focused right upper quadrant (RUQ) ultrasound, to quantify how sonographic experience affects accuracy for gallbladder pathology, and to establish the time needed to complete a focused RUQ ultrasound. A convenience sample of patients with suspected gallbladder disease received a focused RUQ ultrasound by an EP. Sonographic findings, number of previous RUQ ultrasounds performed, and time for examination completion were recorded. Each patient then had a formal RUQ ultrasound by a sonographer blinded to the focused RUQ ultrasound results. Focused RUQ and formal ultrasound findings were compared, with the exception of the sonographic Murphy sign, which was compared to pathology reports. One hundred nine patients were enrolled. Fifty-one had gallstones. Forty-nine were detected by EPs, yielding a sensitivity of 96% [95% confidence interval (CI).87-.99]. Of the 58 patients without gallstones, 51 were correctly diagnosed by EPs (specificity = 88%, 95% CI.77-.95). The sonographic Murphy sign was present during 54 emergency examinations, but in only 24 formal studies. When compared to pathology reports, the emergency sonographic Murphy sign had a sensitivity of 75% compared to the formal ultrasound sensitivity of 45% for acute cholecystitis. EPs were less accurate for other sonographic findings, and level of experience had little effect on sensitivity or specificity for detecting gallstones. Eighty-three percent of emergency studies were completed in less than 10 min. Gallstones are accurately detected by EPs in a timely fashion. Additionally, compared to the radiologist's interpretation, the EP-detected sonographic Murphy sign was more sensitive for diagnosing acute cholecystitis.

PMID 11399381  J Emerg Med. 2001 Jul;21(1):7-13.
著者: P Soyer, J P Brouland, M Boudiaf, M Kardache, J P Pelage, Y Panis, P Valleur, R Rymer
雑誌名: AJR Am J Roentgenol. 1998 Jul;171(1):183-8. doi: 10.2214/ajr.171.1.9648785.
Abstract/Text OBJECTIVE: Color velocity imaging is a color sonographic technique that uses data contained in gray-scale B-mode image scan lines to determine blood flow velocity. We prospectively determined if color velocity imaging and power Doppler sonography can be used to differentiate acute from chronic cholecystitis. We analyzed the potential role of using these two color imaging techniques as an adjunct to conventional gray-scale sonography to differentiate acute from chronic cholecystitis.
SUBJECTS AND METHODS: One hundred twenty-nine patients with acute right upper quadrant pain or clinically suspected cholecystitis underwent color velocity imaging and power Doppler sonography of the gallbladder as an adjunct to gray-scale sonography. Morphologic criteria were analyzed on gray-scale sonography, and the presence of flow within the gallbladder wall was assessed with color velocity imaging and power Doppler sonography. Imaging findings were compared with pathologic findings in the 50 patients who underwent cholecystectomy and with clinical and biologic findings in the 79 patients who did not undergo cholecystectomy.
RESULTS: Twenty-two patients had surgically proven acute cholecystitis, 28 patients had surgically proven chronic cholecystitis, and 79 patients had no gallbladder disease. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of gray-scale sonography for revealing acute cholecystitis were 86%, 99%, 92%, 87%, and 97%, respectively. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of color velocity imaging and power Doppler sonography for revealing acute cholecystitis were 95%, 100%, 99%, 100%, and 99%, respectively.
CONCLUSION: The accuracy of color velocity imaging and power Doppler sonography in revealing acute cholecystitis is significantly greater than the accuracy of gray-scale sonography.

PMID 9648785  AJR Am J Roentgenol. 1998 Jul;171(1):183-8. doi: 10.221・・・
著者: R T Harvey, W T Miller
雑誌名: Radiology. 1999 Dec;213(3):831-6. doi: 10.1148/radiology.213.3.r99dc17831.
Abstract/Text PURPOSE: To evaluate the utility of ultrasonography (US) versus that of computed tomography (CT) for assessment of acute biliary disease.
MATERIALS AND METHODS: Radiologic reports and clinical charts were reviewed in all patients who underwent US and CT within 48 hours of each other for evaluation of acute right upper quadrant pain. Radiologic findings and clinical outcome were correlated.
RESULTS: CT was the initial imaging study in 57 patients, and CT findings resulted in underdiagnosis or misdiagnosis of acute biliary disease in eight of 11 patients. Follow-up US results were suggestive of the correct diagnosis and provided additional clinical information in seven of these eight patients. US findings resulted in altered clinical treatment in six of 11 patients with acute biliary disease. US was the initial study in 66 patients, and US findings were suggestive of biliary disease or the correct diagnosis in seven of seven patients with acute biliary disease. Follow-up CT did not result in changes in clinical treatment in any patient with acute biliary disease.
CONCLUSION: Initial US is better than initial CT in patients suspected of having acute biliary disease. Follow-up CT provides no additional information regarding the biliary system, and its use should be limited to those patients with a wider differential diagnosis or with confusing clinical symptoms and signs.

PMID 10580962  Radiology. 1999 Dec;213(3):831-6. doi: 10.1148/radiolog・・・
著者: Young Kon Kim, Hyo Sung Kwak, Chong Soo Kim, Young Min Han, Tae Oh Jeong, In Hee Kim, Hee Chul Yu
雑誌名: Clin Imaging. 2009 Jul-Aug;33(4):274-80. doi: 10.1016/j.clinimag.2008.11.004.
Abstract/Text OBJECTIVE: The objective of this study was to determine the most predictive CT feature of the mild forms or early manifestations of acute cholecystitis.
MATERIALS AND METHODS: Two radiologists analyzed CT of 34 patients with mild or early acute cholecystitis and 34 control patients for pericholecystic increased attenuation on the arterial phase, indistinctness of the interface between the gallbladder (GB) and the liver, enhancement of the GB wall, and increased attenuation of the GB bile.
RESULTS: There were significant differences in the mean values for each CT feature but increased attenuation of the GB bile between patients and control group (P<.05). The most significant predictor of mild or early acute cholecystitis on CT was the presence of pericholecystic increased attenuation on the arterial phase (sensitivity, 82.4%), followed by indistinctness of the interface between the GB and liver (sensitivity, 38.0%), which were identified by both observers with good agreement (kappa=0.735 and kappa=0.687).
CONCLUSIONS: The pericholecystic increased attenuation on arterial phase CT was the most significant predictor of mild forms or early manifestations of acute cholecystitis.

PMID 19559349  Clin Imaging. 2009 Jul-Aug;33(4):274-80. doi: 10.1016/j・・・
著者: Shou-Wu Lee, Sheng-Shun Yang, Chi-Sen Chang, Hong-Jeh Yeh
雑誌名: J Gastroenterol Hepatol. 2009 Dec;24(12):1857-61. doi: 10.1111/j.1440-1746.2009.05923.x.
Abstract/Text BACKGROUND AND AIM: Prompt treatments for acute calculous cholecystitis can reduce both mortality and morbidity. The aim of this retrospective study was to assess the impact of the Tokyo guidelines on management of patients with acute cholecystitis.
METHODS: The records of patients admitted due to acute calculous cholecystitis were collected between January 2007 and June 2008. Exclusion criteria included acalculous, hepatobiliary malignancy, younger than 18 years old and mortality unrelated to cholecystitis. These 235 patients were classified into three groups; grade I, grade II and grade III, according to the severity grading in the Tokyo guidelines for acute cholecystitis. They were further classified into two subgroups; those compatible with and incompatible with managements suggested in the Tokyo guidelines, for comparison.
RESULTS: Lower levels of platelets, lower blood pressure, higher levels of C-reactive protein, blood urine nitrogen, prothrombin time, bilirubin, alkaline phosphatase, and more incidences of positive microorganisms cultured in bile or blood, were found in patients as the severity of disease progressed. Shorter mean length of hospital stay was compatible with the Tokyo guidelines, but no significant differences in outcomes, including incidences of survival, post-surgery complications and mortality, were found between the two subgroups.
CONCLUSION: No significant benefit of the application of the Tokyo guidelines in the management of patients was found between the two subgroups except for reduced mean length of hospital stay. The application of the Tokyo guidelines for improving the outcomes of patients with acute cholecystitis needs further investigation and evaluation.

PMID 19686411  J Gastroenterol Hepatol. 2009 Dec;24(12):1857-61. doi: ・・・
著者: Masamichi Yokoe, Tadahiro Takada, Tsann-Long Hwang, Itaru Endo, Kohei Akazawa, Fumihiko Miura, Toshihiko Mayumi, Rintaro Mori, Miin-Fu Chen, Yi-Yin Jan, Chen-Guo Ker, Hsiu-Po Wang, Takao Itoi, Harumi Gomi, Seiki Kiriyama, Keita Wada, Hiroki Yamaue, Masaru Miyazaki, Masakazu Yamamoto
雑誌名: J Hepatobiliary Pancreat Sci. 2017 Jun;24(6):319-328. doi: 10.1002/jhbp.450. Epub 2017 May 14.
Abstract/Text BACKGROUND: Since the publication of the Tokyo Guidelines (TG13) for the management of acute cholecystitis (AC), multidirectional studies have been published. However, epidemiological research about AC with big data was not projected. The aim of this study was to reveal the actual clinical conditions of AC.
METHOD: The study was designed as an international multicenter retrospective study of AC in Japan and Taiwan from 2011 to 2013. The factors investigated comprised data related to demographic, history, physical examinations, laboratory and imaging findings. Based on these data, we investigated the various values of AC, and real situation with respect to severity and treatment.
RESULTS: A total of 5,459 patients with AC were reviewed. Thirty-day mortality rate was 1.1%. Based on the diagnostic criteria, 4,088 patients had a definite diagnosis and 291 had a suspected diagnosis. According to the severity grading, 939 patients were classified as Grade III, 2,308 as Grade II, and 2,130 as Grade I. Cholecystectomy was performed in total of 4,266 patients and 2,765 patients had laparoscopic cholecystectomy. The main etiologies were gallbladder stones in 4,623 cases.
CONCLUSION: This epidemiological study with large population will undoubtedly contribute to establish the best practice for managing AC worldwide.

© 2017 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
PMID 28316140  J Hepatobiliary Pancreat Sci. 2017 Jun;24(6):319-328. d・・・
著者: A K Singh, P Sagar
雑誌名: Abdom Imaging. 2005 Mar-Apr;30(2):218-21. doi: 10.1007/s00261-004-0217-0. Epub 2005 Jan 20.
Abstract/Text The aim of this study is to determine the usefulness of different patterns of gallbladder mucosal enhancement on contrast-enhanced computed tomography (CT) for differentiating between gangrenous and uncomplicated acute cholecystitis. This retrospective evaluation involved 56 patients with histopathologically proved acute cholecystitis (32 with gangrenous and 24 with uncomplicated acute cholecystitis) who had preoperative contrast-enhanced CT imaging. CT in 38 patients showed a gallbladder mucosal enhancement pattern that could be categorized into continuous, discontinuous, and/or irregular categories. In the other 18 patients, the mucosal enhancement pattern could not be classified due to lack of mucosal enhancement or inadequate mucosal enhancement. On contrast-enhanced CT evaluation, continuous and discontinuous and/or irregular mucosal enhancement patterns were seen in 20 and 18 patients, respectively. Among the 20 patients with continuous mucosal enhancement, 17 had uncomplicated acute cholecystitis. Seventeen of the 18 patients with discontinuous and/or irregular mucosal enhancement had gangrenous cholecystitis. The sensitivity and positive predictive value (PPV) of discontinuous and/or irregular mucosal enhancement in the diagnosis of gangrenous cholecystitis were 30.3% and 94.4% (17 of 18), respectively. The sensitivity and PPV of continuous mucosal enhancement in the diagnosis of uncomplicated acute cholecystitis were 30.3% and 85.5% (17 of 20), respectively. There was a statistically significant difference (p=0.0005) between the PPV of discontinuous and/or irregular (94.4%) and that of continuous (15%) mucosal enhancement for predicting gangrenous cholecystitis. The pattern of gallbladder mucosal enhancement on CT can be used as a reliable criterion for distinguishing acute, uncomplicated cholecystitis from gangrenous cholecystitis.

PMID 15812680  Abdom Imaging. 2005 Mar-Apr;30(2):218-21. doi: 10.1007/・・・
著者: Cheng-Hsien Wu, Chien-Cheng Chen, Chao-Jan Wang, Yon-Cheong Wong, Li-Jen Wang, Chen-Chih Huang, Wan-Chak Lo, Huan-Wu Chen
雑誌名: Abdom Imaging. 2011 Apr;36(2):174-8. doi: 10.1007/s00261-010-9612-x.
Abstract/Text In acute cholecystitis, the presence of gangrene is associated with higher morbidity and mortality and necessitates open surgical intervention rather than laparoscopic cholecystectomy. As Murphy's sign may be absent, gangrene may not be detected ultrasonographically. This retrospective study evaluated indications of acute gangrenous cholecystitis on computed tomography (CT) in 25 patients, who were proven as having acute cholecysitis surgically and pathologically within 3 days of pre-operative CT. The CT images were reviewed by two board-certified radiologists blind to the initial CT report. Acute gangrenous cholecystitis was significantly correlated with the CT signs of perfusion defect (PD) of the gallbladder wall (P = 0.02), pericholecystic stranding (PS) (P = 0.028), and no-gallstone condition (No-ST) (P = 0.026). The presence of PD was associated with acute gangrenous cholecystitis with a relatively high accuracy (80%), a sensitivity of 70.6%, a specificity of 100%, a positive predictive value (PPV) of 100%, and a negative predictive value (NPV) of 61.5%. The combination CT signs of PD or No-ST improved the accuracy for acute gangrenous cholecystitis to 92%, with a sensitivity, specificity, PPV, and NPV of 88.2%, 100%, 100%, and 80%, respectively. Other CT signs were highly specific for acute gangrenous cholecystitis but of low sensitivity, including mucosal hemorrhage, mucosal sloughing, wall irregularity, pericholecystic abscess, gas formation, and portal venous thrombosis. CT was found to accurately diagnose acute cholecystitis, with the presence of PD, PS, or No-ST significantly correlated with that of gangrenous change. Thus, CT is useful in the preoperative detection of acute gangrenous cholecystitis.

PMID 20425109  Abdom Imaging. 2011 Apr;36(2):174-8. doi: 10.1007/s0026・・・
著者: Kohji Okamoto, Kenji Suzuki, Tadahiro Takada, Steven M Strasberg, Horacio J Asbun, Itaru Endo, Yukio Iwashita, Taizo Hibi, Henry A Pitt, Akiko Umezawa, Koji Asai, Ho-Seong Han, Tsann-Long Hwang, Yasuhisa Mori, Yoo-Seok Yoon, Wayne Shih-Wei Huang, Giulio Belli, Christos Dervenis, Masamichi Yokoe, Seiki Kiriyama, Takao Itoi, Palepu Jagannath, O James Garden, Fumihiko Miura, Masafumi Nakamura, Akihiko Horiguchi, Go Wakabayashi, Daniel Cherqui, Eduardo de Santibañes, Satoru Shikata, Yoshinori Noguchi, Tomohiko Ukai, Ryota Higuchi, Keita Wada, Goro Honda, Avinash Nivritti Supe, Masahiro Yoshida, Toshihiko Mayumi, Dirk J Gouma, Daniel J Deziel, Kui-Hin Liau, Miin-Fu Chen, Kazunori Shibao, Keng-Hao Liu, Cheng-Hsi Su, Angus C W Chan, Dong-Sup Yoon, In-Seok Choi, Eduard Jonas, Xiao-Ping Chen, Sheung Tat Fan, Chen-Guo Ker, Mariano Eduardo Giménez, Seigo Kitano, Masafumi Inomata, Koichi Hirata, Kazuo Inui, Yoshinobu Sumiyama, Masakazu Yamamoto
雑誌名: J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):55-72. doi: 10.1002/jhbp.516. Epub 2017 Dec 20.
Abstract/Text We propose a new flowchart for the treatment of acute cholecystitis (AC) in the Tokyo Guidelines 2018 (TG18). Grade III AC was not indicated for straightforward laparoscopic cholecystectomy (Lap-C). Following analysis of subsequent clinical investigations and drawing on Big Data in particular, TG18 proposes that some Grade III AC can be treated by Lap-C when performed at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. For Grade I, TG18 recommends early Lap-C if the patients meet the criteria of Charlson comorbidity index (CCI) ≤5 and American Society of Anesthesiologists physical status classification (ASA-PS) ≤2. For Grade II AC, if patients meet the criteria of CCI ≤5 and ASA-PS ≤2, TG18 recommends early Lap-C performed by experienced surgeons; and if not, after medical treatment and/or gallbladder drainage, Lap-C would be indicated. TG18 proposes that Lap-C is indicated in Grade III patients with strict criteria. These are that the patients have favorable organ system failure, and negative predictive factors, who meet the criteria of CCI ≤3 and ASA-PS ≤2 and who are being treated at an advanced center (where experienced surgeons practice). If the patient is not considered suitable for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed Lap-C once the patient's overall condition has improved. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

© 2017 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
PMID 29045062  J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):55-72. doi・・・
著者: Itaru Endo, Tadahiro Takada, Tsann-Long Hwang, Kohei Akazawa, Rintaro Mori, Fumihiko Miura, Masamichi Yokoe, Takao Itoi, Harumi Gomi, Miin-Fu Chen, Yi-Yin Jan, Chen-Guo Ker, Hsiu-Po Wang, Seiki Kiriyama, Keita Wada, Hiroki Yamaue, Masaru Miyazaki, Masakazu Yamamoto
雑誌名: J Hepatobiliary Pancreat Sci. 2017 Jun;24(6):346-361. doi: 10.1002/jhbp.456. Epub 2017 May 31.
Abstract/Text BACKGROUND: Although early laparoscopic cholecystectomy is widely performed for acute cholecystitis, the optimal timing of a cholecystectomy in clinically ill patients remains controversial. This study aims to determine the best practice for the patients presenting with acute cholecystitis focused on disease severity and comorbidities.
METHODS: An international multicentric retrospective observational study was conducted over a 2-year period. Patients were divided into four groups: Group A: primary cholecystectomy; Group B: cholecystectomy after gallbladder drainage; Group C: gallbladder drainage alone; and Group D: medical treatment alone.
RESULTS: The subjects of analyses were 5,329 patients. There were statistically significant differences in mortality rates between patients with Charlson comorbidity index (CCI) scores below and above 6 (P < 0.001). The shortest operative time was observed in Group A patients who underwent surgery 0-3 days after admission (P < 0.01). Multiple regression analysis revealed CCI and low body mass index <20 as predictive factors of 30-day mortality in Grade I+II patients. Also, jaundice, neurological dysfunction, and respiratory dysfunction were predictive factors of 30-day mortality in Grade III patients. In Grade III patients without predictive factors, there were no difference in mortality between Group A and Group B (0% vs. 0%), whereas Group A patients had higher mortality rates than that of Group B patients (9.3% vs. 0.0%) in cases with at least one predictive factor.
CONCLUSION: Even patients with Grade III severity, primary cholecystectomy can be performed safely if they have no predictive factors of mortality. Gallbladder drainage may have a therapeutic role in subgroups with higher CCI or higher disease severity.

© 2017 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
PMID 28419741  J Hepatobiliary Pancreat Sci. 2017 Jun;24(6):346-361. d・・・
著者: Harumi Gomi, Joseph S Solomkin, David Schlossberg, Kohji Okamoto, Tadahiro Takada, Steven M Strasberg, Tomohiko Ukai, Itaru Endo, Yukio Iwashita, Taizo Hibi, Henry A Pitt, Naohisa Matsunaga, Yoriyuki Takamori, Akiko Umezawa, Koji Asai, Kenji Suzuki, Ho-Seong Han, Tsann-Long Hwang, Yasuhisa Mori, Yoo-Seok Yoon, Wayne Shih-Wei Huang, Giulio Belli, Christos Dervenis, Masamichi Yokoe, Seiki Kiriyama, Takao Itoi, Palepu Jagannath, O James Garden, Fumihiko Miura, Eduardo de Santibañes, Satoru Shikata, Yoshinori Noguchi, Keita Wada, Goro Honda, Avinash Nivritti Supe, Masahiro Yoshida, Toshihiko Mayumi, Dirk J Gouma, Daniel J Deziel, Kui-Hin Liau, Miin-Fu Chen, Keng-Hao Liu, Cheng-Hsi Su, Angus C W Chan, Dong-Sup Yoon, In-Seok Choi, Eduard Jonas, Xiao-Ping Chen, Sheung Tat Fan, Chen-Guo Ker, Mariano Eduardo Giménez, Seigo Kitano, Masafumi Inomata, Shuntaro Mukai, Ryota Higuchi, Koichi Hirata, Kazuo Inui, Yoshinobu Sumiyama, Masakazu Yamamoto
雑誌名: J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):3-16. doi: 10.1002/jhbp.518. Epub 2018 Jan 9.
Abstract/Text Antimicrobial therapy is a mainstay of the management for patients with acute cholangitis and/or cholecystitis. The Tokyo Guidelines 2018 (TG18) provides recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections. The listed agents are for empirical therapy provided before the infecting isolates are identified. Antimicrobial agents are listed by class-definitions and TG18 severity grade I, II, and III subcategorized by clinical settings. In the era of emerging and increasing antimicrobial resistance, monitoring and updating local antibiograms is underscored. Prudent antimicrobial usage and early de-escalation or termination of antimicrobial therapy are now important parts of decision-making. What is new in TG18 is that the duration of antimicrobial therapy for both acute cholangitis and cholecystitis is systematically reviewed. Prophylactic antimicrobial usage for elective endoscopic retrograde cholangiopancreatography is no longer recommended and the section was deleted in TG18. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

© 2018 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
PMID 29090866  J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):3-16. doi:・・・
著者: E A Akriviadis, M Hatzigavriel, D Kapnias, J Kirimlidis, A Markantas, A Garyfallos
雑誌名: Gastroenterology. 1997 Jul;113(1):225-31.
Abstract/Text BACKGROUND & AIMS: Nonsteroidal anti-inflammatory drugs (NSAIDs) have been used to relieve biliary colic. Follow-up was limited in previous studies, and the role of NSAIDs in the natural history of biliary colic has not been clarified. The purpose of this study was to evaluate the efficacy of diclofenac, a potent NSAID, in the the immediate symptomatic relief of biliary colic and the prevention of cholelithiasis-related complications.
METHODS: Fifty-three patients with cholelithiasis and biliary colic were enrolled in this randomized, double-blind, placebo-controlled study. They received a single 75-mg (3 mL) intramuscular injection of diclofenac (n = 27) or similarly administered 3 mL of saline (n = 26). All patients were followed up for at least 3 days. The effect of either treatment was assessed by changes in the severity of pain and the development of cholelithiasis-related complications.
RESULTS: Complete relief of pain was obtained in 21 diclofenac and in 7 placebo patients; progression to acute cholecystitis was observed in 4 and 11 patients, respectively. Fewer overall complications were observed in the diclofenac group.
CONCLUSIONS: In patients with cholelithiasis who present with biliary colic, a single 75-mg intramuscular dose of diclofenac can provide satisfactory pain relief and decrease substantially the rate of progression to acute cholecystitis.

PMID 9207282  Gastroenterology. 1997 Jul;113(1):225-31.
著者: Anup Kumar, Jagpreet S Deed, Bharat Bhasin, Ashok Kumar, Shaji Thomas
雑誌名: ANZ J Surg. 2004 Jul;74(7):573-6. doi: 10.1111/j.1445-2197.2004.03058.x.
Abstract/Text BACKGROUND: Although non-steroidal anti-inflammatory drugs (NSAID) and spasmolytics have been used to relieve biliary colic, the role of these drugs in the natural history of biliary colic has not been clarified. The objective of the present study is to compare the efficacy of intramuscular diclofenac with intramuscular hyoscine in the treatment of pain of acute biliary colic, and to study their role in the natural history of biliary colic and in the prevention of cholelithiasis-related complications.
METHODS: Seventy-two consecutive patients with biliary colic were enrolled in this prospective, randomized, double-blind study. They received either a single 75 mg intramuscular dose of diclofenac (n = 36) or similarly administered 20 mg of hyoscine (n = 36). Pain severity was recorded on a visual analogue scale 30 min, 1 h, 2 h and 4 h after injection of the drug. Patients were then followed closely for the next 72 h for persistence or relapse of pain, or development of acute cholecystitis, or drug related complications.
RESULTS: Diclofenac provided much more rapid relief of pain than hyoscine, as shown by significantly lesser pain scores after injection of the drug. 91.7% of patients on diclofenac were completely relieved of pain at 4 h as compared to 69.4% with hyoscine (P = 0.037). Progression to acute cholecystitis was seen in only 16.66% of patients on diclofenac as compared to 52.77% on hyoscine (P = 0.003).
CONCLUSIONS: In patients with biliary colic, diclofenac gives much faster and more effective pain relief in a significantly larger number of patients as compared with hyoscine. Most remarkably, diclofenac can prevent progression of biliary colic to acute cholecystitis in a significant number of patients.

PMID 15230794  ANZ J Surg. 2004 Jul;74(7):573-6. doi: 10.1111/j.1445-2・・・
著者: Satoru Shikata, Yoshinori Noguchi, Tsuguya Fukui
雑誌名: Surg Today. 2005;35(7):553-60. doi: 10.1007/s00595-005-2998-3.
Abstract/Text PURPOSE: We performed a meta-analysis of randomized controlled trials to determine the optimal timing of laparoscopic cholecystectomy and open cholecystectomy for acute cholecystitis.
METHODS: We retrieved randomized controlled trials (RCTs) that compared early with delayed cholecystectomy for acute cholecystitis by systematically searching Medline and the Cochrane Library for studies published between 1966 and 2003. The outcomes of primary interest were mortality and morbidity.
RESULTS: The ten trials we analyzed comprised 1 014 subjects; 534 were assigned to the early group and 480 assigned to the delayed group. The combined risk difference of mortality appeared to favor open cholecystectomy in the early period (risk difference, -0.02; 95% confidence interval, -0.44 to -0.00), but no differences were found among laparoscopic procedures or among all procedures. The combined risk difference of morbidity showed no differences between the open and laparoscopic procedures. The combined risk difference of the rate of conversion to open surgery showed no differences in the included laparoscopic studies; however, the combined total hospital stay was significantly shorter in the early group than in the delayed group.
CONCLUSIONS: There is no advantage to delaying cholecystectomy for acute cholecystitis on the basis of outcomes in mortality, morbidity, rate of conversion to open surgery, and mean hospital stay. Thus, early cholecystectomy should be performed for patients with acute cholecystitis.

PMID 15976952  Surg Today. 2005;35(7):553-60. doi: 10.1007/s00595-005-・・・
著者: H Lau, C Y Lo, N G Patil, W K Yuen
雑誌名: Surg Endosc. 2006 Jan;20(1):82-7. doi: 10.1007/s00464-005-0100-2. Epub 2005 Oct 24.
Abstract/Text BACKGROUND: Early laparoscopic cholecystectomy has been advocated for the management of acute cholecystitis, but little evidence exists to support the superiority of this approach over delayed-interval operation. The current systematic review was undertaken to compare the outcomes and efficacy between early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis in an evidence-based approach using metaanalytical techniques.
METHODS: A search of electronic databases, including MEDLINE and EMBASE, was conducted to identify relevant articles published between January 1988 and June 2004. Only randomized or quasi-randomized prospective clinical trials in the English language comparing the outcomes of early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis were recruited. Both qualitative and quantitative statistical analyses were performed. The effect size of outcome parameters was estimated by odds ratio or weighted mean difference where feasible and appropriate.
RESULTS: A total of four clinical trials comprising 504 patients met the inclusion criteria. Failure of conservative treatment requiring emergency cholecystectomy occurred for 43 patients (23%) in the delayed group. Metaanalyses demonstrated a significantly shortened total length of hospital stay in the early group (weighted mean difference, -1.12; 95% confidence interval [CI], -1.42 to -0.99; p < 0.001). Pooled estimates did not show any significant differences between the two approaches in terms of operation time, conversion rate, overall complication rate, incidence of bile leakage, and intraabdominal collection.
CONCLUSIONS: The safety and efficacy of early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis were comparable. Because evidence suggested that early laparoscopic cholecystectomy reduced the total length of hospital stay and the risk of readmissions attributable to recurrent acute cholecystitis, it is therefore a more cost-effective approach for the management of acute cholecystitis.

PMID 16247580  Surg Endosc. 2006 Jan;20(1):82-7. doi: 10.1007/s00464-0・・・
著者: Tamim Siddiqui, Alisdair MacDonald, Peter S Chong, John T Jenkins
雑誌名: Am J Surg. 2008 Jan;195(1):40-7. doi: 10.1016/j.amjsurg.2007.03.004.
Abstract/Text BACKGROUND: The appropriate timing for laparoscopic cholecystectomy in the treatment of acute cholecystitis remains controversial. More recent evaluation indicates early laparoscopic surgery may be a safe option in acute cholecystitis, although conversion rates may be higher. No conclusive evidence establishing best practice in terms of clinical benefit exists.
METHODS: All randomized clinical studies published between 1987 and 2006 comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis were analyzed, irrespective of language, blinding, or publication status. Exclusions were quasi-randomized trials, inadequate follow-up description, or allocation concealment. Endpoints included conversion rates, postoperative complications, total hospital stay, and operation time. Random and fixed-effect models were used to aggregate the study endpoints and assess heterogeneity.
RESULTS: Four studies containing 375 patients were included. No significant study heterogeneity or publication bias was found. There was no significant difference in conversion rates (odds ratio = .915 [95% confidence interval (CI), .567-1.477], P = .718) and postoperative complications (odds ratio = 1.073 [95% CI, .599-1.477], P = .813) between both groups. Operation time was significantly reduced (weighted mean difference [WMD] = .412 [95% CI, .149-.675], P = .002) with delayed cholecystectomy. The total hospital stay was significantly reduced (WMD = .905 [95% CI, .630-1.179], P = .0005) with early cholecystectomy. The postoperative stay was significantly reduced in the delayed group (WMD = .393 [95% CI, .128-.659], P = .004).
CONCLUSIONS: These meta-analysis data suggest that early laparoscopic cholecystectomy allows significantly shorter total hospital stay at the cost of a significantly longer operation time with no significant differences in conversion rates or complications.

PMID 18070735  Am J Surg. 2008 Jan;195(1):40-7. doi: 10.1016/j.amjsurg・・・
著者: K Gurusamy, K Samraj, C Gluud, E Wilson, B R Davidson
雑誌名: Br J Surg. 2010 Feb;97(2):141-50. doi: 10.1002/bjs.6870.
Abstract/Text BACKGROUND: : In many countries laparoscopic cholecystectomy for acute cholecystitis is mainly performed after the acute episode has settled because of the anticipated increased risk of morbidity and higher conversion rate from laparoscopic to open cholecystectomy.
METHODS: : A systematic review was performed with meta-analysis of randomized clinical trials of early laparoscopic cholecystectomy (ELC; performed within 1 week of onset of symptoms) versus delayed laparoscopic cholecystectomy (performed at least 6 weeks after symptoms settled) for acute cholecystitis. Trials were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded and reference lists. Risk ratio (RR) or mean difference was calculated with 95 per cent confidence intervals (c.i.) based on intention-to-treat analysis.
RESULTS: : Five trials with 451 patients were included. There was no significant difference between the two groups in terms of bile duct injury (RR 0.64 (95 per cent c.i. 0.15 to 2.65)) or conversion to open cholecystectomy (RR 0.88 (95 per cent c.i. 0.62 to 1.25)). The total hospital stay was shorter by 4 days for ELC (mean difference -4.12 (95 per cent c.i. -5.22 to -3.03) days).
CONCLUSION: : ELC during acute cholecystitis appears safe and shortens the total hospital stay.

Copyright (c) 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
PMID 20035546  Br J Surg. 2010 Feb;97(2):141-50. doi: 10.1002/bjs.6870・・・
著者: Steven L Zacks, Robert S Sandler, Robert Rutledge, Robert S Brown
雑誌名: Am J Gastroenterol. 2002 Feb;97(2):334-40. doi: 10.1111/j.1572-0241.2002.05466.x.
Abstract/Text OBJECTIVES: Laparoscopic cholecystectomy (LC) has become a popular alternative to open cholecystectomy (OC). Previous studies comparing outcomes in LC and OC used small selected cohorts of patients and did not control for comorbid conditions that might affect outcome. The aims of this study were to characterize the morbidity, mortality, and costs of LC and OC in a large unselected cohort of patients.
METHODS: We used the population-based North Carolina Discharge Abstract Database (NCHDAD) for January 1, 1991, to September 30, 1994 (n = 850,000) to identify patients undergoing OC and LC. We identified the indications for surgery, complications, and type of perioperative biliary imaging used. We compared length of stay, hospital charges, complications, morbidity, and mortality between OC and LC patients. To account for variations in outcomes from differences in age and comorbidity between the OC and LC groups, we used the age-adjusted Charlson Comorbidity Index in regression analyses quantifying the association between type of surgery and outcome.
RESULTS: Our cohort consisted of 43,433 patients (19,662 LC and 23,771 OC). The mean age-adjusted Charlson Comorbidity Index score was slightly higher for the OC compared to the LC group (4.3 vs 4.1, p < 0.05). The OC patients had longer hospitalizations, generated more charges ($12,125 vs $9,139, p < 0.05), and required home care more often. The crude risk ratio comparing risk of death in OC to LC was 5.0 (95% CI = 3.9-6.5). After controlling for age, comorbidity, and sex, the odds of dying in the OC group was still 3.3 times (95% CI = 1.4-7.3) greater than in the LC group. In the LC group, the number of patients with acute cholecystitis rose over the study period, whereas the number of patients with chronic cholecystitis declined. In the OC group, the number of patients with acute and chronic cholecystitis declined. The use of intraoperative cholangiography was greater in the OC group but declined in both groups over the study period. The use of ERCP was greater in the LC group and increased in both groups over time.
CONCLUSIONS: The introduction of LC has resulted in a change in the management of cholecystitis. Despite a higher proportion of patients with acute cholecystitis, the risk of dying was significantly less in LC than in OC patients, even after controlling for age and comorbidity. Based on lower costs and better outcomes, LC seems to be the treatment of choice for acute and chronic cholecystitis.

PMID 11866270  Am J Gastroenterol. 2002 Feb;97(2):334-40. doi: 10.1111・・・
著者: J L Flowers, R W Bailey, W A Scovill, K A Zucker
雑誌名: Am J Surg. 1991 Mar;161(3):388-92.
Abstract/Text Laparoscopic cholecystectomy has rapidly emerged as a popular alternative to traditional laparotomy and cholecystectomy. Acute cholecystitis has been considered to be a relative or absolute contraindication to laparoscopic surgery. After gaining extensive experience in laparoscopic biliary tract surgery, this procedure was attempted in 15 patients with acute cholecystitis. All patients were operated on within 72 hours of admission. In five patients, the laparoscopic procedure was converted to an open laparotomy; in one patient, a localized abscess was found, and in the other four patients, extensive inflammation and edema precluded a safe dissection of the vascular and ductal structures. Laparoscopic cholangiography was performed in 14 patients and proved valuable in demonstrating the ductal anatomy. Patients were discharged an average of 2.7 days after the laparoscopic procedure. Laparoscopic cholecystectomy may be safely performed by experienced surgeons in patients with acute cholecystitis. To ensure a low complication rate, a low threshold for converting the procedure to an open laparotomy must be maintained if the ductal and vascular anatomy cannot be safely demonstrated.

PMID 1825764  Am J Surg. 1991 Mar;161(3):388-92.
著者: M Johansson, A Thune, L Nelvin, M Stiernstam, B Westman, L Lundell
雑誌名: Br J Surg. 2005 Jan;92(1):44-9. doi: 10.1002/bjs.4836.
Abstract/Text BACKGROUND: The aim of this prospective trial was to determine whether surgical approach (open versus laparoscopic) had an impact on morbidity and postoperative recovery after cholecystectomy for acute cholecystitis.
METHODS: Seventy patients who met the criteria for acute cholecystitis were randomized to open or laparoscopic cholecystectomy. The type of operation was unknown to the patient and all hospital staff involved in the postoperative care.
RESULTS: The two groups were similar with respect to demographic and clinical characteristics. There were no significant differences in rate of postoperative complications, pain score at discharge and sick leave. In eight patients a laparoscopic procedure was converted to open cholecystectomy. Median operating time was 90 (range 30-155) and 80 (range 50-170) min in the laparoscopic and open groups respectively (P = 0.040). The direct medical costs were equivalent in the two groups. Although median postoperative hospital stay was 2 days in each group, it was significantly shorter in the laparoscopic group (P = 0.011).
CONCLUSION: Cholecystectomy for acute cholecystitis can be performed by either laparoscopic or open techniques without any major clinically relevant differences in postoperative outcome. Both techniques offer low morbidity and rapid postoperative recovery.

PMID 15584058  Br J Surg. 2005 Jan;92(1):44-9. doi: 10.1002/bjs.4836.
著者: Go Wakabayashi, Yukio Iwashita, Taizo Hibi, Tadahiro Takada, Steven M Strasberg, Horacio J Asbun, Itaru Endo, Akiko Umezawa, Koji Asai, Kenji Suzuki, Yasuhisa Mori, Kohji Okamoto, Henry A Pitt, Ho-Seong Han, Tsann-Long Hwang, Yoo-Seok Yoon, Dong-Sup Yoon, In-Seok Choi, Wayne Shih-Wei Huang, Mariano Eduardo Giménez, O James Garden, Dirk J Gouma, Giulio Belli, Christos Dervenis, Palepu Jagannath, Angus C W Chan, Wan Yee Lau, Keng-Hao Liu, Cheng-Hsi Su, Takeyuki Misawa, Masafumi Nakamura, Akihiko Horiguchi, Nobumi Tagaya, Shuichi Fujioka, Ryota Higuchi, Satoru Shikata, Yoshinori Noguchi, Tomohiko Ukai, Masamichi Yokoe, Daniel Cherqui, Goro Honda, Atsushi Sugioka, Eduardo de Santibañes, Avinash Nivritti Supe, Hiromi Tokumura, Taizo Kimura, Masahiro Yoshida, Toshihiko Mayumi, Seigo Kitano, Masafumi Inomata, Koichi Hirata, Yoshinobu Sumiyama, Kazuo Inui, Masakazu Yamamoto
雑誌名: J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):73-86. doi: 10.1002/jhbp.517. Epub 2018 Jan 10.
Abstract/Text In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

© 2018 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
PMID 29095575  J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):73-86. doi・・・
著者: Yukio Iwashita, Taizo Hibi, Tetsuji Ohyama, Akiko Umezawa, Tadahiro Takada, Steven M Strasberg, Horacio J Asbun, Henry A Pitt, Ho-Seong Han, Tsann-Long Hwang, Kenji Suzuki, Yoo-Seok Yoon, In-Seok Choi, Dong-Sup Yoon, Wayne Shih-Wei Huang, Masahiro Yoshida, Go Wakabayashi, Fumihiko Miura, Kohji Okamoto, Itaru Endo, Eduardo de Santibañes, Mariano Eduardo Giménez, John A Windsor, O James Garden, Dirk J Gouma, Daniel Cherqui, Giulio Belli, Christos Dervenis, Daniel J Deziel, Eduard Jonas, Palepu Jagannath, Avinash Nivritti Supe, Harjit Singh, Kui-Hin Liau, Xiao-Ping Chen, Angus C W Chan, Wan Yee Lau, Sheung Tat Fan, Miin-Fu Chen, Myung-Hwan Kim, Goro Honda, Atsushi Sugioka, Koji Asai, Keita Wada, Yasuhisa Mori, Ryota Higuchi, Takeyuki Misawa, Manabu Watanabe, Naoki Matsumura, Toshiki Rikiyama, Naohiro Sata, Nobuyasu Kano, Hiromi Tokumura, Taizo Kimura, Seigo Kitano, Masafumi Inomata, Koichi Hirata, Yoshinobu Sumiyama, Kazuo Inui, Masakazu Yamamoto
雑誌名: J Hepatobiliary Pancreat Sci. 2017 Nov;24(11):591-602. doi: 10.1002/jhbp.503. Epub 2017 Oct 23.
Abstract/Text Bile duct injury (BDI) during laparoscopic cholecystectomy remains a serious iatrogenic surgical complication. BDI most often occurs as a result of misidentification of the anatomy; however, clinical evidence on its precise mechanism and surgeons' perceptions is scarce. Surgeons from Japan, Korea, Taiwan, and the USA, etc. (n = 614) participated in a questionnaire regarding their BDI experience and near-misses; and perceptions on landmarks, intraoperative findings, and surgical techniques. Respondents voted for a Delphi process and graded each item on a five-point scale. The consensus was built when ≥80% of overall responses were 4 or 5. Response rates for the first- and second-round Delphi were 60.6% and 74.9%, respectively. Misidentification of local anatomy accounted for 76.2% of BDI. Final consensus was reached on: (1) Effective retraction of the gallbladder, (2) Always obtaining critical view of safety, and (3) Avoiding excessive use of electrocautery/clipping as vital procedures; and (4) Calot's triangle area and (5) Critical view of safety as important landmarks. For (6) Impacted gallstone and (7) Severe fibrosis/scarring in Calot's triangle, bail-out procedures may be indicated. A consensus was reached among expert surgeons on relevant landmarks and intraoperative findings and appropriate surgical techniques to avoid BDI.

© 2017 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
PMID 28884962  J Hepatobiliary Pancreat Sci. 2017 Nov;24(11):591-602. ・・・
著者: Yasuhisa Mori, Takao Itoi, Todd H Baron, Tadahiro Takada, Steven M Strasberg, Henry A Pitt, Tomohiko Ukai, Satoru Shikata, Yoshinori Noguchi, Anthony Yuen Bun Teoh, Myung-Hwan Kim, Horacio J Asbun, Itaru Endo, Masamichi Yokoe, Fumihiko Miura, Kohji Okamoto, Kenji Suzuki, Akiko Umezawa, Yukio Iwashita, Taizo Hibi, Go Wakabayashi, Ho-Seong Han, Yoo-Seok Yoon, In-Seok Choi, Tsann-Long Hwang, Miin-Fu Chen, O James Garden, Harjit Singh, Kui-Hin Liau, Wayne Shih-Wei Huang, Dirk J Gouma, Giulio Belli, Christos Dervenis, Eduardo de Santibañes, Mariano Eduardo Giménez, John A Windsor, Wan Yee Lau, Daniel Cherqui, Palepu Jagannath, Avinash Nivritti Supe, Keng-Hao Liu, Cheng-Hsi Su, Daniel J Deziel, Xiao-Ping Chen, Sheung Tat Fan, Chen-Guo Ker, Eduard Jonas, Robert Padbury, Shuntaro Mukai, Goro Honda, Atsushi Sugioka, Koji Asai, Ryota Higuchi, Keita Wada, Masahiro Yoshida, Toshihiko Mayumi, Koichi Hirata, Yoshinobu Sumiyama, Kazuo Inui, Masakazu Yamamoto
雑誌名: J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):87-95. doi: 10.1002/jhbp.504. Epub 2017 Nov 21.
Abstract/Text Since the publication of the Tokyo Guidelines in 2007 and their revision in 2013, appropriate management for acute cholecystitis has been more clearly established. Since the last revision, several manuscripts, especially for alternative endoscopic techniques, have been reported; therefore, additional evaluation and refinement of the 2013 Guidelines is required. We describe a standard drainage method for surgically high-risk patients with acute cholecystitis and the latest developed endoscopic gallbladder drainage techniques described in the updated Tokyo Guidelines 2018 (TG18). Our study confirmed that percutaneous transhepatic gallbladder drainage should be considered the first alternative to surgical intervention in surgically high-risk patients with acute cholecystitis. Also, endoscopic transpapillary gallbladder drainage or endoscopic ultrasound-guided gallbladder drainage can be considered in high-volume institutes by skilled endoscopists. In the endoscopic transpapillary approach, either endoscopic naso-gallbladder drainage or gallbladder stenting can be considered for gallbladder drainage. We also introduce special techniques and the latest outcomes of endoscopic ultrasound-guided gallbladder drainage studies. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

© 2017 Japanese Society of Hepato-Biliary-Pancreatic Surgery.
PMID 28888080  J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):87-95. doi・・・
著者: Anders Winbladh, Per Gullstrand, Joar Svanvik, Per Sandström
雑誌名: HPB (Oxford). 2009 May;11(3):183-93. doi: 10.1111/j.1477-2574.2009.00052.x.
Abstract/Text OBJECTIVES: Percutaneous cholecystostomy (PC) is an established low-mortality treatment option for elderly and critically ill patients with acute cholecystitis. The primary aim of this review is to find out if there is any evidence in the literature to recommend PC rather than cholecystectomy for acute cholecystitis in the elderly population.
METHODS: In April 2007, a systematic electronic database search was performed on the subject of PC and cholecystectomy in the elderly population. After exclusions, 53 studies remained, comprising 1918 patients. Three papers described randomized controlled trials (RCTs), but none compared the outcomes of PC and cholecystectomy. A total of 19 papers on mortality after cholecystectomy in patients aged >65 years were identified.
RESULTS: Successful intervention was seen in 85.6% of patients with acute cholecystitis. A total of 40% of patients treated with PC were later cholecystectomized, with a mortality rate of 1.96%. Procedure mortality was 0.36%, but 30-day mortality rates were 15.4 % in patients treated with PC and 4.5% in those treated with acute cholecystectomy (P < 0.001).
CONCLUSIONS: There are no controlled studies evaluating the outcome of PC vs. cholecystectomy and the papers reviewed are of evidence grade C. It is not possible to make definitive recommendations regarding treatment by PC or cholecystectomy in elderly or critically ill patients with acute cholecystitis. Low mortality rates after cholecystectomy in elderly patients with acute cholecystitis have been reported in recent years and therefore we believe it is time to launch an RCT to address this issue.

PMID 19590646  HPB (Oxford). 2009 May;11(3):183-93. doi: 10.1111/j.147・・・
著者: E Melloul, A Denys, N Demartines, J-M Calmes, M Schäfer
雑誌名: World J Surg. 2011 Apr;35(4):826-33. doi: 10.1007/s00268-011-0985-y.
Abstract/Text BACKGROUND: The aim if this study was to compare percutaneous drainage (PD) of the gallbladder to emergency cholecystectomy (EC) in a well-defined patient group with sepsis related to acute calculous/acalculous cholecystitis (ACC/AAC).
METHODS: Between 2001 and 2007, all consecutive patients of our ICU treated by either PD or EC were retrospectively analyzed. Cases were collected from a prospective database. Percutaneous drainage was performed by a transhepatic route and EC by open or laparoscopic approach. Patients' general condition and organ dysfunction were assessed by two validated scoring systems (SAPS II and SOFA, respectively). Morbidity, mortality, and long-term outcome were systematically reviewed and analyzed in both groups.
RESULTS: Forty-two patients [median age = 65.5 years (range = 32-94)] were included; 45% underwent EC (ten laparoscopic, nine open) and 55% PD (n = 23). Both patient groups had similar preoperative characteristics. Percutaneous drainage and EC were successful in 91 and 100% of patients, respectively. Organ dysfunctions were similarly improved by the third postoperative/postdrainage days. Despite undergoing PD, two patients required EC due to gangrenous cholecystitis. The conversion rate after laparoscopy was 20%. Overall morbidity was 8.7% after PD and 47% after EC (P = 0.011). Major morbidity was 0% after PD and 21% after EC (P = 0.034). The mortality rate was not different (13% after PD and 16% after EC, P = 1.0) and the deaths were all related to the patients' preexisting disease. Hospital and ICU stays were not different. Recurrent symptoms (17%) occurred only after ACC in the PD group.
CONCLUSIONS: In high-risk patients, PD and EC are both efficient in the resolution of acute cholecystitis sepsis. However, EC is associated with a higher procedure-related morbidity and the laparoscopic approach is not always possible. Percutaneous drainage represents a valuable intervention, but secondary cholecystectomy is mandatory in cases of acute calculous cholecystitis.

PMID 21318431  World J Surg. 2011 Apr;35(4):826-33. doi: 10.1007/s0026・・・

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから