ObjectiveA prospective randomized study was undertaken to compare early with delayed laparoscopic cholecystectomy for acute cholecystitis. Summary Background DataLaparoscopic cholecystectomy for acute cholecystitis is associated with high complication and conversion rates. It is not known whether there is a role for initial conservative treatment followed by interval elective operation. MethodDuring a 26-month period, 99 patients with a clinical diagnosis of acute cholecystitis were randomly assigned to early laparoscopic cholecystectomy within 72 hours of admission (early group, n = 49) or delayed interval surgery after initial medical treatment (delayed group, n = 50). Thirteen patients (four in the early group and nine in the delayed group) were excluded because of refusal of operation (n = 6), misdiagnosis (n = 5), contraindication for surgery (n = 1), or loss to follow-up (n = 1). ResultsEight of 41 patients in the delayed group underwent urgent operation at a median of 63 hours (range, 32 to 140 hours) after admission because of spreading peritonitis (n = 3) and persistent fever (n = 5). Afthough the delayed group required less frequent modifications in operative technique and a shorter operative time, there was a tendency toward a higher conversion rate (23% vs. 11 %; p = 0.174) and complication rate (29% vs. 13%; p = 0.07). For 38 patients with symptoms exceeding 72 hours before admission, the conversion rate remained high after delayed surgery (30% vs. 17%; p = 0.454). In addition, delayed laparoscopic cholecystectomy prolonged the total hospital stay (11 days vs. 6 days; p < 0.001) and recuperation period (19 days vs. 12 days; p < 0.001). ConclusionsInitial conservative treatment followed by delayed interval surgery cannot reduce the morbidity and conversion rate of laparoscopic cholecystectomy for acute cholecystitis. Early operation within 72 hours of admission has both medical and socioeconomic benefits and is the preferred approach for patients managed by surgeons with adequate experience in laparoscopic cholecystectomy.Although recent studies1-6 have reported that laparoscopic cholecystectomy is a safe and effective treatment for acute cholecystitis, the optimal timing for the procedure remains unknown. In the prelaparoscopic era, prospective randomized studies7 8 demonstrated that early open cholecystectomy within 7 days of the onset of symptoms was superior to delayed interval surgery because of a shorter total hospital stay and recuperation period. The same economic advantage should also apply if early surgery can be accomplished with the laparoscopic technique. However, the potential hazard of severe complications and the high conversion rate of laparoscopic cholecystectomy in the phase of acute inflammation is a major concern.9"10 Theoretically, conservative treatment with antibiotics followed by interval elective operation several weeks after the acute inflammation subsides may result in a safer operation with a lower conversion rate. Koo and Thirlby11 suggested that there was a role for del...

A prospective study was performed on 358 patients to examine the diagnosis, management, and natural history of fish bone ingestion. All patients admitted with the complaint had a thorough oral examination. Flexible endoscopy under local pharyngeal anesthesia would be performed on patients with negative findings. Of 117 fish bones encountered, 103 were removed (direct removal, 21; endoscopic removal, 82) and 12 were inadvertently dislodged. One was missed and the other one necessitated removal with rigid laryngoesophagoscopy under general anesthesia. Morbidity (1%) occurred in patients with triangular bones in the hypopharynx, resulting in one mucosal tear and two lengthy procedures. Mean hospital stay was 7 hours. Prediction of the presence of fish bones by symptoms and radiograph was poor. The location of symptoms, however, was useful in guiding the endoscopist to the site of lodgment. Of patients who refused endoscopy, only one (2.8%) developed retropharyngeal abscess. As compared to those who received endoscopy, 31.8% had fish bones detected. As the yield of fish bone detected was also inversely related to the duration of symptoms, we strongly suspect that most of the unremoved fish bones would be dislodged and passed. However, because of the serious potential complication from fish bone ingestion, we believe that a combination of oral examination followed by flexible endoscopy is indicated in all patients. When triangular bones in the hypopharynx are encountered, rigid laryngoesophagoscopy should be considered. This protocol had safely and effectively dealt with the present series of patients.

Endoscopic biliary drainage is a safe and effective measure for the initial control of severe acute cholangitis due to choledocholithiasis and to reduce the mortality associated with the condition.