Acute acalculous cholecystitis immediately after gastric operation: Case report and literatures review

Table 1 Clinical data of the three cases

	Case 1	Case 2	Case 3
First admission
Gender	Male	Male	Male
Age (yr)	54	79	72
BP (mmHg)	130/70	120/80	120/80
Diagnosis	Gastric cancer	Gastric cancer	Gastric cancer
Gallbladder disease	No	No	No
Surgery	Total gastrectomy	Total gastrectomy	Distal gastrectomy
Anastomosis	Roux-en Y	Roux-en Y	Billroth I
Complications	No	No	Infection of abdominal cavity and the incision
Time of feeding	Day 7	Day 7	Day 22
Time of discharge	Day 8	Day 9	Day 28
Pathology	Poorly differentiated adenocarcinoma	Poorly differentiated adenocarcinoma	Mucinous adenocarcinoma
TNM stage	T2bn0m0	T4aN3M0	T4an3m0
Onset of acute acalculous cholecystitis after gastric surgery
Symptoms	Fever, upper abdominal discomfort, vomiting	Fever, upper abdominal pain	Fever, upper abdominal pain, vomiting
Onset time	Day 13	Day 9	Day 38
Incentive	Postprandial	Postprandial	Postprandial
Temperature (°C)	39.5	38.5	38
BP (mmHg)	100/60	90/60	160/100
Physical examination	Percussion pain of hepatic region	Percussion pain of hepatic region	Tenderness of right upper quadrant abdomen
Septic shock	Day 1 after onset	Day 0 after onset	No septic shock
WBC (109/L)	24.35	17.8	11.9
PLT (109/L)	121	106	403
Amyl (U/L)	46	73	74
TB/CB (μmol/L)	6.7/5	85/74	11.4/6
ALT/AST (U/L)	47/51	225/671	27/22
r-GT (U/L)	118	338	61
PCT (ng/mL)	21.23	> 100	NA
CRP (mg/L)	136.3	138.1	NA
Cr (μmol/L)	156	151	52
APTT/PT (s)	36.8/16.5	42.8/18.7	40.8/13.3
INR	1.33	1.62	1.16
CT performance	Pericholecystic fluid collection, gallbladder enlargement	Pericholecystic, abdominal and pelvic fluid collection, gallbladder enlargement	NA
Ultrasonography	Thickened wall of enlarged gallbladder	NA	Thickened wall of enlarged gallbladder
Severity grading (Tokyo guideline)	Severe	Severe	Mild
Treatment for acute acalculous cholecystitis
Time of treatment	36 h after onset	17 h after onset	10 h after onset
Type of treatment	Cholecystostomy	Cholecystectomy	Interventional percutaneous gallbladder drainage
Ascites	No	400 mL	No
Gallbladder size (cm)	8 × 4	10 × 6	10 × 4.5
Gangrene formation	Yes	Yes	NA
Complications	No	Hepatic failure and respiratory dysfunction	No
Pathology	Necrosis of gallbladder wall	Necrosis of gallbladder wall	NA
Survival	Yes	No	Yes
Time of recovery or death	Day 14 after the treatment	Day 42 after the treatment	Day 5 after the treatment

NA: Not available; BP: Blood pressure; WBC: White blood cell; PLT: Platelet; Amyl: Amylase; TB/CB: Total bilirubin/Conjugated bilirubin; ALT/AST: Alanine aminotransferase/Aspartate aminotransferase; r-GT: r-Glutamyl transferase; PCT: Procalcitonin; CRP: C reactive protein; Cr: Creatinine; APTT/PT: Activated partial thromboplastin time/Prothrombin time; INR: International normalized ratio.

Table 2 Acalculous cholecystitis after gastric operation

Ref.	Year	Gender	Age (yr)	Prior surgery	Days after surgery	Treatment	Gangrene formation	Survival
Schwegman et al[27]	1953	Male	43	TG	11	CO/PTGD	No	Yes
Glenn et al[28]	1979	Male	65	PG	45	CE	NA	No
Howard[5]	1981	Male	42	DG	NA	CE	No	NA
Lens et al[29]	1981	Male	75	TG	NA	CO/PTGD	NA	Yes
	1981	Male	77	TG	NA	CE	NA	Yes
Glenn et al[30]	1982	Male	55	DG	42	CO/PTGD	NA	Yes
Becker et al[31]	1986	Male	37	TG	7	CE	No	NA
Fabian et al[32]	1986	Male	68	PG	NA	CE	NA	No
Jensen et al[33]	1987	Male	NA	TG	NA	NA	NA	NA
	1987	Male	NA	TG	NA	NA	NA	NA
	1987	Male	NA	PG	NA	NA	NA	NA
Berger et al[34]	1989	NA	NA	TG	NA	CO/PTGD	NA	NA
	1989	NA	NA	TG	NA	CO/PTGD	NA	NA
Wu et al[35]	1995	Male	56	TG	18	CE	Yes	No
	1995	Male	62	TG	21	CO/PTGD	NA	Yes
	1995	Male	66	TG	19	CE	Yes	No
	1995	Male	64	TG	8	CE	Yes	Yes
	1995	Male	65	TG	11	CE	Yes	Yes
	1995	Male	57	TG	14	CE	No	Yes
	1995	Male	75	TG	18	CE	Yes	Yes
	1995	Male	72	TG	16	CE	Yes	Yes
	1995	Male	74	TG	18	CE	No	Yes
Paull[36]	2001	Female	71	PG	11	CE	Yes	Yes
Oh et al[37]	2009	NA	NA	TG	NA	CE	NA	Yes
	2009	NA	NA	TG	NA	CE	NA	Yes
	2009	NA	NA	TG	NA	CE	NA	Yes
	2009	NA	NA	TG	NA	CE	NA	Yes
	2009	NA	NA	TG	NA	CO/PTGD	NA	Yes
Liu et al[38]	2010	Female	64	DG	9	AA	NA	Yes
	2010	Male	76	DG	14	CO/PTGD	NA	Yes
	2010	Male	64	TG	14	CO/PTGD	NA	Yes
Liu (our report)	2013	Male	60	TG	10	CO/PTGD	Yes	Yes
	2013	Male	79	TG	9	CE	Yes	No
	2013	Male	72	DG	37	CO/PTGD	NA	Yes

TG: Total gastrectomy; DG: Distal gastrectomy; PG: Proximal gastrectomy; NA: Not available; PTGD: Percutaneous transhepatic gallbladder drainage; CE: Cholecystectomy; CO: Cholecystostomy; AA: Antibiotics alone.

Table 3 Statistical analysis for all 34 cases of acute acalculous cholecystitis after gastric operation n (%)

	Gender			Age			Surgery				Treatment				Gangrene formation
	Male	Female	P value	< 65 yr	≥65 yr	P value	TG	DG	PG	P value	CE	CO/ PTGD	AA	P value	Yes	No	P value
Age (yr)			1.000
< 65	10 (45.5)	1 (50.0)
≥ 65	12 (54.5)	1 (50.0)
Surgery			0.111			0.217
TG	18 (72.0)	0 (0.0)		8 (72.7)	8 (61.5)
DG	4 (16.0)	1 (50.0)		3 (27.3)	2 (15.4)
PG	3 (12.0)	1 (50.0)		0 (0.0)	3 (23.1)
Treatment			0.003			0.221				0.054
CE	14 (63.6)	1 (50.0)		5 (45.5)	10 (76.9)		15 (65.2)	1 (20.0)	3(100.0)
CO/PTGD	8 (36.4)	0 (0.0)		5 (45.5)	3 (23.1)		8 (34.8)	3 (60.0)	0 (0.0)
AA	0 (0.0)	1 (50.0)		1 (9.1)	0 (0.0)		0 (0.0)	1 (20.0)	0 (0.0)
Gangrene formation			1.000			0.266				0.303				1.000
Yes	8 (61.5)	1 (100.0)		3 (42.9)	6 (85.7)		8 (66.7)	0 (0.0)	1 (100.0)		8 (66.7)	1 (50.0)	0 (0.0)
No	5 (38.5)	0 (0.0)		4 (57.1)	1 (14.3)		4 (33.3)	1 (100.0)	0 (0.0)		4 (33.3)	1 (50.0)	0 (0.0)
Survival			1.000			0.360				0.058				0.165			0.509
Yes	15 (75.0)	2 (100.0)		8 (88.9)	9 (69.2)		17 (85.0)	4 (100.0)	1 (33.3)		12 (70.6)	7 (100.0)	1 (100.0)		6 (66.7)	3 (100.0)
No	5 (27.8)	0 (0.0)		1 (11.1)	4 (30.8)		3 (15.0)	0 (0.0)	2 (66.7)		5 (29.4)	0 (0.0)	0 (0.0)		3 (33.3)	0 (0.0)

TG: Total gastrectomy; DG: Distal gastrectomy; PG: Proximal gastrectomy; PTGD: Percutaneous transhepatic gallbladder drainage; CE: Cholecystectomy; CO: Cholecystostomy; AA: Antibiotics alone.