Akut kolesistit þiddeti (Tokyo 2018 kýlavuzu) erken veya geç kolesistektomi kararýný etkilemeli mi?

AMAÇ: Akut kolesistit nedeniyle baþvuran hastalarda yatýþ anýnda yapýlan (erken kolesisitektomi) ile gecikmiþ kolesistektomi arasýndaki komplikasyon oranlarýný karþýlaþtýrmak, ayný zamanda kolesistit þiddetinin kolesistektomi zamanlamasýna etkisi olup olmadýðýný incelemeyi amaçladýk. GEREÇ VE YÖNTEM: Çalýþma geriye dönük olarak planlandý ve hastanemiz etik kurul onayý alýndý. Üçüncü basamak hastanemize akut kolesistit ile baþvuran hastalarýn bilgileri hastane veri tabanýndan tarandý. Hastalar akut kolesistit nedeniyle acile baþvuran, erken ve geç dönem kolesistektomi yapýlan gruplar olarak ikiye ayrýldý. Akut kolesistit þiddetini belirlemek için Tokyo 2018 akut kolesistit rehberi kullanýldý. Hastalarýn ameliyat öncesi-sonrasý verileri incelendi ve komplikasyonlarý deðerlendirildi.
BULGULAR: Çalýþmaya dahil edilme kriterlerini karþýlayan 158 hastanýn verileri geriye dönük olarak incelendi. Geç dönem kolesistektomi ile karþýlaþtýrdýðýmýzda, erken dönem kolesistektomi yaptýðýmýz hastalarda komplikasyon oranlarý artmýþtýr (sýrasýyla %8.1, %32.2 p<0.001). Tokyo 2018 rehberine göre akut kolesistit þiddeti Tokyo 1, 2 ve 3 olarak gruplandýrýldýðýnda Tokyo 1 olan hastalarda erken dönemde, geç dönem kolesistektomi yapýlanlara göre daha fazla komplikasyon gözledi (sýrasýyla, %22.6, %4.2, p=0.004). Komplikasyonlar incelendiðinde özellikle pulmoner emboli, pnömoni, intra abdominal apse geliþimi, sepsis ve yara yeri enfeksiyonunun erken dönem ameliyat edilenlerde anlamlý olarak daha yüksek olduðu görülmüþtür. Komplikasyonlar üzerine etkili olan etkenler incelendiðinde Tokyo skorunun 2 ve üzeri olmasý (OR: 4.161), kreatin yüksekliði (OR: 5.496) ve ek hastalýk varlýðý (OR: 4.238) komplikasyon geliþim riskini arttýrmaktadýr.
TARTIÞMA: Tokyo 2 ve üzeri hastalar, Tokyo 1 olan hastalarla karþýlatýrýldýðýnda kolesistektomi sonrasý daha fazla komplikasyon geliþmektedir. Erken dönem ameliyat edilen hastalarda ise Tokyo 1 kolesistitli hastalarda daha fazla komplikasyon geliþtiði görülmüþtür. Kolesitektomi zamanlamasýný belirlemede akut kolesistit þiddetinin etkisini belirlemek için ileri çalýþmalara ihtiyaç vardir.

Should the severity of acute cholecystitis (Tokyo 2018 guideline) affect the decision of early or delayed cholecystectomy?

BACKGROUND: In our study, we aimed to compare the complication rates of patients presenting with acute cholecystitis and undergoing surgery at the time of hospitalization (early cholecystectomy) and delayed cholecystectomy and also to examine whether the severity of cholecystitis has an effect on the timing of cholecystectomy.
METHODS: The study was planned retrospectively and the approval of the ethics committee of our hospital was obtained. The patient files of the patients who were admitted to our tertiary hospital with acute cholecystitis were accessed through the hospital archive system. The patients were divided into two groups, those who were admitted to the emergency department for acute chole-cystitis and who underwent early cholecystectomy and delayed cholecystectomy. The Tokyo 2018 acute cholecystitis guideline was used to determine the severity of acute cholecystitis. Pre-operative and post-operative data of the patients were examined and their complications were evaluated.
RESULTS: The data of 158 patients who met the inclusion criteria were retrospectively analyzed. Compared with delayed chole-cystectomy, complication rates increased in patients who underwent early cholecystectomy (8.1% and 32.2%, respectively, p<0.001). According to the Tokyo 2018 guideline, patients with acute cholecystitis were grouped as Tokyo 1, 2, and 3; and of Tokyo 1 patients, more complications were observed in those who underwent early cholecystectomy (22.6% and 4.2%, respectively, p=0.004). When the complications were examined, it was observed that pulmonary embolism, pneumonia, intra-abdominal abscess development, sepsis, and wound infection were significantly higher in those who were operated early. When the factors affecting complications are examined, having a Tokyo score of 2 and above (OR: 4.161), high creatinine levels (OR: 5.496), and presence of additional disease (OR: 4.238) increase the risk of developing complications.
CONCLUSION: More complications occur after cholecystectomy in patients with Tokyo 2 and above, when compared with patients with Tokyo 1. It was observed that more complications developed in patients with Tokyo 1 cholecystitis who were operated in the early period. Further studies are needed to determine the effect of acute cholecystitis severity in determining the timing of cholecystectomy.