Tokyo Guidelines 2018: management strategies for gallbladder drainage in patients with acute cholecystitis (with videos)

Benefits of endoscopic gallbladder stenting following percutaneous transhepatic gallbladder drainage

BACKGROUND

Endoscopic transpapillary gallbladder drainage is challenging because of the complexity of the procedure and high incidence of adverse events (AEs). To overcome these problems, endoscopic gallbladder stenting (EGBS) after percutaneous transhepatic gallbladder drainage (PTGBD) can be effective, as it mitigates inflammation and adhesion.

AIM

To examine the benefits of EGBS after PTGBD to assess its efficacy and impact on AEs.

METHODS

We retrospectively analyzed data from 35 patients who underwent EGBS after PTGBD at a single center between January 2016 and December 2023. The primary outcomes were technical success and AEs, and the rate of recurrent cholecystitis was evaluated. In addition, the reasons for the failure of the procedure were identified.

RESULTS

Among the 35 patients, the technical success rate was 77.1% and the final contrast of the cystic duct was successful in 97.1% of patients. The incidence of early AEs was relatively low (11.4%), with no instances of cystic duct perforation. The rate of recurrent cholecystitis was 3.7%, and no other biliary events were observed.

CONCLUSION

EGBS after PTGBD may be significantly beneficial, with a substantial success rate and minimal AEs in both short- and long-term follow-ups.

Preoperative systemic and local inflammation are independent risk factors for difficult laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage

Background

Laparoscopic cholecystectomy (LC) is required for acute cholecystitis patient with percutaneous transhepatic gallbladder drainage (PTGBD). However, it's unknown how to distinguishing the surgical difficulty for these patients.

Methods

Data of patients who underwent LC after PTGBD between 2016 and 2022 were collected. Patients were categorized into difficult and non-difficult operations based on operative time, blood loss, and surgical conversion. Performance of prediction model was evaluated by ROC, calibration, and decision curves.

Results

A total of 127 patients were analyzed, including 91 in non-difficult operation group and 36 in difficult operation group. Elevated CRP (P = 0.011), pericholecystic effusion (P < 0.001), and contact with stomach or duodenal (P = 0.015) were independent risk factors for difficult LC after PTGBD. A nomogram was developed according to these risk factors, and was well-calibrated and good at distinguishing difficult LC after PTGBD.

Conclusion

Preoperative elevated systemic and local inflammation indictors are predictors for difficult LC after PTGBD.

The Success Rate Is Lower but Completion Rate of Laparoscopic Cholecystectomy Is higher in Endoscopic Transpapillary Gallbladder Drainage than Percutaneous Gallbladder Drainage for Acute Cholecystitis

BACKGROUND

We investigated the success and complication rates of endoscopic transpapillary gallbladder drainage (ETGBD) and percutaneous transhepatic gallbladder drainage (PTGBD) and the outcomes of subsequent cholecystectomy for acute cholecystitis.

METHODS

Patients (N=178) who underwent cholecystectomy after ETGBD or PTGBD were retrospectively assessed.

RESULTS

ETGBD was successful in 47 (85.5%) of 55 procedures, whereas PTGBD was successful in 123 (100%) of 123 sessions ( P <0.001). Complications related to ETGBD and PTGBD occurred in 6 (12.8%) of 47 and 16 (13.0%) of 123 patients, respectively ( P =0.97). After propensity matching, 43 patients from each group were selected. Median time from drainage to cholecystectomy was 48 (14 to 560) days with ETGBD and 35 (1 to 90) days with PTGBD ( P =0.004). Laparoscopy was selected more often in the ETGBD group (97.7%) than in the PTGBD group (79.1%) ( P =0.007), and conversion from laparoscopy to open cholecystectomy was more common with PTGBD (41.2%) than with ETGBD (7.1%) ( P <0.001). Mean operation time was significantly shorter with ETGBD (135.8±66.7 min) than with PTGBD (195.8±62.2 min) ( P <0.001). The incidence of Clavien-Dindo grade ≥III postoperative complications was 9.3% with ETGBD and 11.6% with PTGBD ( P =0.99).

CONCLUSIONS

The success rate is lower but completion of laparoscopic cholecystectomy is more in endoscopic gallbladder drainage than percutaneous gallbladder drainage for acute cholecystitis.

Endoscopic Ultrasonography-Guided Gallbladder Drainage

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has emerged as a popular alternative to percutaneous cholecystostomy and endoscopic transpapillary gallbladder drainage for patients suffering from acute calculous cholecystitis who are at high risk for surgery. Multiple cohorts, meta-analyses, and a randomized controlled trial have shown that EUS-GBD has lower rates of recurrent cholecystitis and unplanned reinterventions, while achieving similar technical and clinical success rates than transpapillary cystic duct stenting. The essential steps, precautions in performing EUS-GBD and long-term management will be discussed in this article.

Endoscopic Gallbladder Stenting to Prevent Recurrent Cholecystitis in Deferred Cholecystectomy: A Randomized Trial

BACKGROUND & AIMS

Endoscopic transpapillary gallbladder stenting (ETGS) has been proposed as one of the adjunctive treatments, apart from antibiotics, before surgery in patients with acute cholecystitis whose cholecystectomy could not be performed or was deferred. Currently, there are no comparative data on the outcomes of ETGS in those who receive and do not receive ETGS. We aimed to compare the rates of recurrent cholecystitis at 3 and 6 months in these 2 groups.

METHODS

Between 2020 and 2023, eligible acute calculous cholecystitis patients with a high probability of common bile duct stone, who were surgical candidates but could not have an early cholecystectomy during COVID-19 surgical lockdown, were randomized into groups A (received ETGS) and B (did not receive ETGS). A definitive cholecystectomy was performed at 3 months or later in both groups.

RESULTS

A total of 120 eligible patients were randomized into group A (n = 60) and group B (n = 60). In group A, technical and clinical success rates were 90% (54 of 60) and 100% (54 of 54), respectively. Based on intention-to-treat analysis, group A had a significantly lower rate of recurrence than group B at 3 months (0% [0 of 60] vs 18.3% [11 of 60]; P = .001). At 3-6 months, group A showed a nonsignificantly lower rate of recurrent cholecystitis compared to group B (0% [0 of 32] vs 10% [3 of 30]; P = .11).

CONCLUSIONS

ETGS could prevent recurrent cholecystitis in acute cholecystitis patients with common bile duct stone whose cholecystectomy was deferred for 3 months. In those who did not receive ETGS, the majority of recurrences occurred within 3 months. (Thaiclinicaltrials.org, Number TCTR20200913001).

Percutaneous cholecystostomy in acute complicated versus uncomplicated cholecystitis; is there a difference in outcomes? A single-center experience

BACKGROUND

Percutaneous cholecystostomy (PC) is a therapeutic intervention for acute cholecystitis. The benefits of cholecystostomy have been demonstrated in the medical literature, with up to 90% of acute cholecystitis cases shown to resolve postoperatively, and only 40% of patients subsequently undergoing an interval cholecystectomy.

PURPOSE

To compare the survival outcomes between acute complicated and uncomplicated cholecystitis in patients undergoing PC as an initial intervention, as there is a paucity of evidence in the literature on this perspective.

MATERIAL AND METHODS

A retrospective search was conducted of all patients who underwent PC for acute cholecystitis between August 2016 and December 2020 at a tertiary institution. A total of 100 patients were included in this study.

RESULTS

The outcome, in the form of 30-day mortality, 90-day mortality, being alive after six months, and reintervention, was compared between complicated and uncomplicated cases using the chi-square test or Fisher's exact test. There was no statistically significant difference in any of the compared outcomes. The only variable that showed a statistically significant association with the risk of mortality was acute kidney injury (AKI) at admission. Patients who had stage 1, 2, or 3 AKI had a higher hazard for mortality as compared to patients with no kidney disease.

CONCLUSION

Our results demonstrate that PC is a safe and effective procedure. Mortality is not affected by the presence of complications. The results have, however, highlighted the importance of recognizing and treating AKI, an independent risk factor affecting mortality.

Efficacy of early laparoscopic cholecystectomy compared with percutaneous transhepatic gallbladder drainage in treating acute calculous cholecystitis in elderly patients

BACKGROUND

Acute calculous cholecystitis is a common acute disease in elderly patients. This study aimed to evaluate the efficacy of early laparoscopic cholecystectomy (ELC) compared to percutaneous transhepatic gallbladder drainage (PTGD) for treating acute calculous cholecystitis in elderly patients.

METHODS

This retrospective study compared the clinical outcomes of two groups of elderly patients treated with ELC (group A) and PTGD (group B) from January 2018 to December 2021. Preoperative clinical characteristics and postoperative treatment outcomes were analyzed for both groups.

RESULTS

There were no statistically significant differences in preoperative clinical characteristics between the ELC and PTGD groups. ELC took longer to perform (69.8 ± 15.9 min vs. 29.6 ± 5.3 min, p < 0.001) but resulted in a significantly shorter duration of pain (1.9 ± 0.9 days vs. 3.9 ± 1.0 days, p < 0.001) and hospital stay (6.3 ± 2.5 days vs. 9.9 ± 3.6 days, p < 0.001), and a lower rate of sepsis (3.4% vs. 16.9%, p < 0.019). Time to soft diet was faster in the ELC group (1.5 ± 0.9 days vs. 3.0 ± 1.6 days, p < 0.001). Fewer patients in the ELC group experienced surgical reintervention than in the PTGD group (0% vs. 5.6%, p = 0.043). The incidence of postoperative complications and readmission rates in the ELC group were significantly lower than those in the PTGD group (ELC, 3.6%; PTGD, 25.4%, p = 0.001).

CONCLUSIONS

ELC is an effective treatment option for acute calculous cholecystitis in elderly patients, and has the added benefits of low postoperative complication rates, rapid recovery, shorter duration of pain, and excellent curative effects as compared to PTGD.

Surgical outcomes of patients with acute cholecystitis treated with gallbladder drainage followed by early cholecystectomy

AIM

This study aimed to investigate the impact of preoperative gallbladder drainage and the specific drainage method used on surgical outcomes in patients undergoing surgery for acute cholecystitis.

METHODS

This single-center retrospective cohort study included 221 patients who underwent early cholecystectomy between January 2016 and December 2020. Clinical data and outcomes of 140 patients who did not undergo drainage, 22 patients who underwent preoperative percutaneous transhepatic gallbladder drainage (PTGBD), and 59 patients who underwent preoperative endoscopic naso-gallbladder drainage (ENGBD) were compared.

RESULTS

There was no difference in the operation time, blood loss, postoperative complications, or length of postoperative hospital stay between patients who did and did not undergo drainage. Among patients who underwent drainage, there was no difference between the ENGBD and PTGBD groups in operation time, blood loss, or postoperative complications; however, more patients in the PTGBD group underwent laparotomy and had a significantly longer postoperative hospital stay. The presence and type of drainage were not risk factors for postoperative complications.

CONCLUSION

The presence or absence of preoperative gallbladder drainage for acute cholecystitis and the type of drainage may not significantly affect surgical outcomes.

The Diagnosis and Treatment of Acute Cholecystitis: A Comprehensive Narrative Review for a Practical Approach

Acute cholecystitis (AC), generally associated with the presence of gallstones, is a relatively frequent disease that can lead to serious complications. For these reasons, AC warrants prompt clinical diagnosis and management. There is general agreement in terms of considering early laparoscopic cholecystectomy (ELC) to be the best treatment for AC. The optimal timeframe to perform ELC is within 72 h from diagnosis, with a possible extension of up to 7-10 days from symptom onset. In the first hours or days after hospital admission, before an ELC procedure, the patient's medical management comprises fasting, intravenous fluid infusion, antimicrobial therapy, and possible administration of analgesics. Additionally, concomitant conditions such as choledocholithiasis, cholangitis, biliary pancreatitis, or systemic complications must be recognized and adequately treated. The importance of ELC is related to the frequent recurrence of symptoms and complications of gallstone disease in the interval period between the onset of AC and surgical intervention. In patients who are not eligible for ELC, it is suggested to delay surgery at least 6 weeks after the clinical presentation. Critically ill patients, who are unfit for surgery, may require rescue treatments, such as percutaneous or endoscopic gallbladder drainage (GBD). A particular treatment approach should be applied to special populations such as pregnant women, cirrhotic, and elderly patients. In this review, we provide a practical diagnostic and therapeutic approach to AC, even in specific clinical situations, based on evidence from the literature.

Role of advanced endoscopy in the management of inflammatory digestive diseases (pancreas and biliary tract)

The progress of endoscopic diagnosis and treatment for inflammatory diseases of the biliary tract and pancreas have been remarkable. Endoscopic ultrasonography (EUS) and EUS-elastography are used for the diagnosis of early chronic pancreatitis and evaluation of endocrine and exocrine function in chronic pancreatitis. Notably, extracorporeal shock wave lithotripsy and electrohydraulic shock wave lithotripsy have improved the endoscopic stone removal rate in patients for whom pancreatic stone removal is difficult. Studies have reported the use of self-expanding metal stents for stent placement for pancreatic duct stenosis and EUS-guided pancreatic drainage for refractory pancreatic duct strictures. Furthermore, EUS-guided drainage using a double-pigtailed plastic stent has been performed for the management of symptomatic pancreatic fluid collection after acute pancreatitis. Recently, lumen-apposing metal stents have led to advances in the treatment of walled-off necrosis after acute pancreatitis. EUS-guided biliary drainage is an alternative to refractory endoscopic biliary drainage and percutaneous transhepatic biliary drainage for the treatment of acute cholangitis. The placement of an inside stent followed by switching to uncovered self-expanding metal stents in difficult-to-treat cases has been proposed for acute cholangitis by malignant biliary obstruction. Endoscopic transpapillary gallbladder drainage is an alternative to percutaneous transhepatic gallbladder drainage for severe and some cases of moderate acute cholecystitis. EUS-guided gallbladder drainage has been reported as an alternative to percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. However, it is important to understand the advantages and disadvantages of each drainage method and select the optimal drainage method for each case.

Endoscopic Gallbladder Drainage: A Comprehensive Review on Indications, Techniques, and Future Perspectives

In recent years, therapeutic endoscopy has become a fundamental tool in the management of gallbladder diseases in light of its minimal invasiveness, high clinical efficacy, and good safety profile. Both endoscopic transpapillary gallbladder drainage (TGBD) and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD) provide effective internal drainage in patients with acute cholecystitis unfit for cholecystectomy, avoiding the drawbacks of external percutaneous gallbladder drainage (PGBD). The availability of dedicated lumen-apposing metal stents (LAMS) for EUS-guided transluminal interventions contributed to the expansion of endoscopic therapies for acute cholecystitis, making endoscopic gallbladder drainage easier, faster, and hence more widely available. Moreover, EUS-GBD with LAMS opened the possibility of several cholecystoscopy-guided interventions, such as gallstone lithotripsy and clearance. Finally, EUS-GBD has also been proposed as a rescue drainage modality in malignant biliary obstruction after failure of standard techniques, with encouraging results. In this review, we will describe the TBGD and EUS-GBD techniques, and we will discuss the available data on clinical efficacy in different settings in comparison with PGBD. Finally, we will comment on the future perspectives of EUS-GBD, discussing the areas of uncertainty in which new data are more strongly awaited.

Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients: the Italian Society of Emergency Surgery and Trauma (SICUT) guidelines

Dealing with acute cholecystitis in high-risk, critically ill, and unfit-for-surgery patients is frequent during daily practice and requires complex management. Several procedures exist to postpone and/or prevent surgical intervention in those patients who temporarily or definitively cannot undergo surgery. After a systematic review of the literature, an expert panel from the Italian Society of Emergency Surgery and Trauma (SICUT) discussed the different issues and statements in subsequent rounds. The final version of the statements was discussed during the annual meeting in Rome (September 2022). The present paper presents the definitive conclusions of the discussion. Fifteen statements based on the literature evidence were provided. The statements gave precise indications regarding the decisional process and the management of patients who cannot temporarily or definitively undergo cholecystectomy for acute cholecystitis. Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients should be multidisciplinary. The different gallbladder drainage methods must be tailored according to each patient and based on the expertise of the hospital. Percutaneous gallbladder drainage is recommended as the first choice as a bridge to surgery or in severely physiologically deranged patients. Endoscopic gallbladder drainage (cholecystoduodenostomy and cholecystogastrostomy) is suggested as a second-line alternative especially as a definitive procedure for those patients not amenable to surgical management. Trans-papillary gallbladder drainage is the last option to be reserved only to those unfit for other techniques. Delayed laparoscopic cholecystectomy in patients with percutaneous gallbladder drainage is suggested in all those patients recovering from the conditions that previously discouraged surgical intervention after at least 6 weeks from the gallbladder drainage.

Elective Cholecystectomy After Endoscopic Gallbladder Stenting for Acute Cholecystitis: A Propensity Score Matching Analysis

OBJECTIVE

To investigate the influence of endoscopic gallbladder stenting (EGBS) on subsequent cholecystectomy. We retrospectively compared the surgical outcomes of EGBS, followed by elective cholecystectomy with those of immediate cholecystectomy (IC).

PATIENTS AND METHODS

A total of 503 patients were included in this study. Patients who underwent EGBS as initial treatment for acute cholecystitis, followed by elective cholecystectomy, were included in the EGBS group and patients who underwent IC during hospitalization were included in the IC group. Propensity score matching analysis was used to compare the surgical outcomes. In addition, the factors that increased the amount of bleeding were examined by multivariate analysis after matching.

RESULTS

Fifty-seven matched pairs were obtained after propensity matching the EGBS group and the IC group. The rate of laparoscopic cholecystectomy in the EGBS versus IC groups was 91.2% versus 49.1% ( P < 0.001). The amount of bleeding was 5 mL in the EGBS versus 188 mL in the IC group ( P < 0.001). In the EGBS and IC groups, multivariate analysis of factors associated with more blood loss revealed IC (odds ratio: 4.76, 95% CI: 1.25-20.76, P = 0.022) as an independent risk factor.

CONCLUSION

EGBS as the initial treatment for acute cholecystitis and subsequent elective cholecystectomy after the inflammation has disappeared can be performed in minimally invasive procedures and safely.

Factors predicting technical failure of endoscopic transpapillary gallbladder drainage for acute cholecystitis

Objectives

Endoscopic transpapillary gallbladder drainage (ETGBD) is a highly technical procedure, but few studies have evaluated factors that predict its technical success. Therefore, in this study, we sought to identify predictors of technically successful ETGBD.

Methods

One hundred and eighty-two patients who underwent ETGBD for acute cholecystitis at our hospital were retrospectively investigated. Factors associated with technical failure were identified by focusing on clinical characteristics, anatomical features (direction of the cystic duct branch and course of the cystic duct), and procedural factors (cystic duct and gallbladder with or without contrast and cystic duct injury).

Results

The technical success rate was 84.6% (154/182) and the clinical success rate was 96.1% (148/154). The adverse event rate was 11.0% (20/182; cystic duct injury in 13 patients, pancreatitis in six, and liver abscess in one. Univariate and multivariate analyses identified the right cranial direction and spiral-type course of the cystic duct to be significant anatomical features and cystic duct injury to be a significant procedural feature contributing to the technical failure of ETGBD.

Conclusions

ETGBD is a highly practical procedure for patients with acute cholecystitis. However, difficulty is encountered in some cases because of anatomical and procedural factors. Our results suggest that ETGBD may be difficult and thus should not be performed in cases with the right cranial direction or spiral-type course of the cystic duct or those with cystic duct injury.

Acalculous Cholecystitis in COVID-19 Patients: A Narrative Review

Acute acalculous cholecystitis (AAC) represents cholecystitis without gallstones, occurring in approximately 5-10% of all cases of acute cholecystitis in adults. Several risk factors have been recognized, while infectious diseases can be a cause of cholecystitis in otherwise healthy people. Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has spread worldwide, leading to an unprecedented pandemic. The virus enters cells through the binding of the spike protein to angiotensin-converting enzyme 2 (ACE2) receptors expressed in many human tissues, including the epithelial cells of the gastrointestinal (GI) tract, and this explains the symptoms emanating from the digestive system. Acute cholecystitis has been reported in patients with COVID-19. The purpose of this review is to provide a detailed analysis of the current literature on the pathogenesis, diagnosis, management, and outcomes of AAC in patients with COVID-19.

Ultrasound-Guided Interventions in the Biliary System

Ultrasound guidance in biliary interventions has become the standard tool to facilitate percutaneous biliary drainage as well as percutaneous gall bladder drainage. Monitoring of the needle tip whilst penetrating the tissue in real time using ultrasound allows precise manoeuvres and exact targeting without radiation exposure. Without the need for fluoroscopy, ultrasound-guided drainage procedures can be performed bedside as a sometimes life-saving procedure in patients with severe cholangitis/cholecystitis when they are critically ill in intensive care units and cannot be transported to a fluoroscopy suite. This article describes the current data background and guidelines and focuses on specific sonographic aspects of both the procedures of percutaneous biliary drainage and gallbladder drainage.

Influence of Percutaneous Transhepatic Gallbladder Aspiration and Drainage for Severe Acute Cholecystitis on the Surgical Outcomes of Subsequent Laparoscopic Cholecystectomy: Post Hoc Analysis of the CSGO-HBP-017 (CSGO-HBP-017C)

OBJECTIVE

Percutaneous transhepatic gallbladder aspiration (PTGBA) and/or drainage (PTGBD) are useful approaches in the management of acute cholecystitis in patients who cannot tolerate surgery because of poor general condition or severe inflammation. However, reports regarding its effect on the surgical outcomes of subsequent laparoscopic cholecystectomy (LC) are sparse. The aim of this retrospective study was to investigate the influence of PTGBA on surgical outcomes of subsequent LC by comparing the only-PTGBA group, including patients who did not need the additional-PTGBD, versus the additional-PTGBD group, including those who needed the additional-PTGBD after PTGBA.

PATIENTS AND METHODS

We conducted a post hoc analysis of our multi-institutional data. This study included 63 patients who underwent LC after PTGBA, and we compared the surgical outcomes between the only-PTGBA group (n = 56) and the additional-PTGBD group (n = 7).

RESULTS

No postoperative complications occurred among the 63 patients, and the postoperative hospital stay was 11 ± 12 days. Fourteen patients (22.2%) had a recurrence of cholecystitis, of whom 7 patients (11.1%) needed the additional-PTGBD after PTGBA. Significantly longer operative time (245 ± 74 vs 159 ± 65 min, P = 0.0017) and postoperative hospital stay (22 ± 27 vs 10 ± 9 d, P = 0.0118) and greater intraoperative blood loss (279 ± 385 vs 70 ± 208 mL, P = 0.0283) were observed among patients in the additional-PTGBD group compared with the only-PTGBA group, whereas the rates of postoperative complications (Clavien-Dindo grade ≥3: 0% each) and conversion to open surgery (28.6% vs 8.9%, P = 0.1705) were comparable.

CONCLUSION

PTGBA for acute cholecystitis could result in good surgical outcomes of subsequent LC, especially regarding postoperative complications. However, we should keep in mind that the additional-PTGBD after PTGBA failure, which sometimes happened, would be associated with increased operative difficulty and longer recovery.

Endoscopic ultrasound-guided gallbladder drainage with long-term lumen-apposing metal stent indwell: 1-year results from a prospective nationwide observational study

BACKGROUND AND AIM

This study aimed to determine safety and risk factors for adverse events (AEs) of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with long-term indwell of lumen-apposing metal stents (LAMS).

METHODS

This study is a multicenter prospective observational study on consecutive high surgical-risk patients requiring gallbladder drainage who underwent EUS-GBD with LAMS over 12 months. Centralized telephone follow-up interviews were conducted every 3 months for 1 year. Patients were censored at LAMS removal, cholecystectomy, or death. AE-free survival was determined using log-rank tests. Cumulative risks were estimated using life-table analysis.

RESULTS

Eighty-two patients were included (53.7% male, median [interquartile range] age of 84.6 [76.5-89.8] years, and 85.4% with acute cholecystitis). Technical success was achieved in 79 (96.3%), and clinical success in 73 (89%). No patient was lost to follow-up; 45 patients (54.9%) completed 1-year follow-up with in situ LAMS. Median (interquartile range) LAMS indwell time was 364 (47-367) days. Overall, 12 (14.6%) patients presented 14 AEs, including 5 (6.1%) recurrent biliary events (3 acute cholangitis, 1 mild acute pancreatitis, and 1 acute cholecystitis). Patients with pancreatobiliary malignancy had an increased risk of recurrent biliary events (33% vs 1.5%, P = 0.001). The overall 1-year cumulative risk of recurrent biliary events was 9.7% (4.1-21.8%). The 1-year risk of AEs and of severe AEs was 18.8% (11-31.2%) and 7.9% (3.3-18.2%), respectively. Pancreatobiliary malignancy was the single risk factor for recurrent biliary events; LAMS misdeployment was the strongest risk factor for AEs.

CONCLUSIONS

Long-term LAMS indwell does not increase the risk of delayed AEs following EUS-GBD.

A Pilot Study of Percutaneous Cholecystoenteric Anastomosis: A New Option for High-Risk Patients with Symptomatic Gallstones

PURPOSE

To evaluate the safety and effectiveness of percutaneous cholecystoenteric anastomosis (PCEA) creation in patients with indwelling cholecystostomy tubes who are high-risk surgical candidates.

MATERIALS AND METHODS

Fourteen (male, 10; female, 4) patients with a mean age of 79 years (range, 53-92 years) with previously inserted cholecystostomy tubes underwent PCEA with the adjacent duodenum using a lumen-apposing metal stent (LAMS) between January 2015 and October 2022. Intraprocedural adverse events and postprocedural safety and effectiveness outcomes were evaluated. Nine procedures were performed under sedation and 5 under general anesthesia.

RESULTS

Technical success was achieved in 100% of the patients. In 12 patients (86%), the existing cholecystostomy tube was removed after the insertion of the LAMS. Three patients (21%) had a pre-existing cholecystoduodenal fistula, in which the stent was placed, and 11 (79%) underwent creation of a de novo anastomosis. The mean procedure time was 1.5 hours (range, 1-2 hours). The mean length of stay after the procedure was 2.4 days (range, 1-10 days). There were no intraprocedural adverse events. One patient with severe pre-existing cardiac comorbidities died during his postprocedural stay despite a technically successful procedure. One patient had delayed closure of the long-standing cholecystocutaneous tract.

CONCLUSIONS

Early clinical experience with PCEA using an LAMS suggests that it is a safe and effective option for the creation of internal gallbladder drainage in patients who are not candidates for surgical cholecystectomy.

Percutaneous transhepatic gallbladder drainage versus endoscopic gallbladder stenting for managing acute cholecystitis until laparoscopic cholecystectomy

INTRODUCTION

Gallbladder drainage by methods such as percutaneous transhepatic gallbladder drainage (PTGBD) or endoscopic gallbladder stenting (EGBS) is important in the early management of moderate to severe acute cholecystitis.

METHODS

In patients undergoing laparoscopic cholecystectomy (LC) for acute cholecystitis after a month or more of gallbladder drainage, the clinical course was compared between patients initially treated with PTGBD or EGBS.

RESULTS

Among 331 patients undergoing LC for cholecystitis between 2018 and 2022, 43 first underwent 1 or more months of gallbladder drainage. The median interval between drainage initiation and LC was 89 days (range, 28-261) among 34 patients with PTGBD and 70 days (range, 62-188) among nine with EGBS (p = 0.644). During this waiting period, PTGBD was clamped in six patients and removed in five. Cholecystitis relapsed in three PTGBD patients (9%) and four EGBS patients (44%; p = 0.026). Relapses were managed with medications. Cholecystectomy duration (p = 0.022), intraoperative blood loss (p = 0.026), frequency of abdominal drain insertion (p = 0.023), and resort to bailout surgery such as fundus-first approaches (p = 0.030) were significantly greater in patients with EGBS. Postoperative complications were somewhat likelier (p = 0.095) and postoperative hospital stays were longer (p = 0.007) in the EGBS group.

CONCLUSION

Among patients whose LC was performed 1 or more months after initiation of drainage, daily living during the waiting period associated with drainage was well supported by EGBS, but LC and the postoperative course were more complicated than in PTGBD patients.

Comparison of the effects of ampulla-guided realignment and conventional gallbladder triangle anatomy in difficult laparoscopic cholecystectomy

OBJECTIVE

To compare the effects of ampulla-guided realignment and conventional gallbladder triangle anatomy in difficult laparoscopic cholecystectomy (DLC).

METHODS

From June 2021 to August 2022, data from 100 patients undergoing DLC at Nanjing Hospital of Traditional Chinese Medicine were analyzed retrospectively. Patients were divided into two groups: the experimental group (LC with the ampulla-guided realignment) and the control group (conventional LC with triangular gallbladder anatomy), with 50 patients per group. The intraoperative blood loss, operation time, postoperative drainage tube indwelling time, hospitalization time, bile duct injury rate, operation conversion rate, and incidence of postoperative complications were recorded and compared between the two groups. The pain response and daily activities of the patients in the two groups were evaluated 48 h after the operation.

RESULTS

The amount of intraoperative blood loss, postoperative drainage tube indwelling time, hospital stay, operation conversion rate, pain degree at 24 and 48 h after operation, bile duct injury incidence, and total postoperative complication rate were shorter or lower in the experimental group than those in the control group (p < 0.05). The Barthel index scores of both groups were higher 48 h after the operation than before the operation, and the experimental group was higher than the control group (p < 0.05).

CONCLUSION

The ampulla-guided alignment in DLC surgery was more beneficial in promoting postoperative recovery, reducing postoperative pain response, reducing the incidence of postoperative complications, and reducing bile duct injury.

Assessment of Gallbladder Drainage Methods in the Treatment of Acute Cholecystitis: A Literature Review

Gallbladder drainage is a treatment option in high-risk surgical patients with moderate or severe acute cholecystitis. It may be applied as a bridge to cholecystectomy or a definitive treatment option. Apart from the simple and widely accessible percutaneous cholecystostomy, new attractive techniques have emerged in the previous decade, including endoscopic transpapillary gallbladder drainage and endoscopic ultrasound-guided gallbladder drainage. The aim of this paper is to present currently available drainage techniques in the treatment of AC; evaluate their technical and clinical effectiveness, advantages, possible adverse events, and patient outcomes; and illuminate the decision-making path when choosing among various treatment modalities for each patient, depending on their clinical characteristics and the accessibility of methods.

Laparoscopic cholecystectomy assisted by combined intravenous and intracholecystic fluorescent cholangiography: a case report

This case report describes a laparoscopic approach using fluorescence imaging guidance to treat gangrenous cholecystitis with perforation (GCP). A male patient in his early 60s presented with 3 days of right upper abdominal pain. Computed tomography and ultrasonography findings were consistent with a stone incarcerated in the gallbladder neck, GCP, and localized peritonitis. Percutaneous gallbladder drainage was initially performed, followed by laparoscopic cholecystectomy 7 days later, using combined intravenous and intracholecystic fluorescent cholangiography. This technique allowed visualization of the cystic and common bile ducts during surgery and enabled safe removal of the diseased gallbladder. The patient recovered well without complications, and reported no pain or discomfort at a 2-month follow-up.

Endoscopic Ultrasound-Guided Naso-gallbladder Drainage Using a Dedicated Catheter for Acute Cholecystitis After Transpapillary Metal Stent Placement for Malignant Biliary Obstruction

BACKGROUND

Acute cholecystitis is a significant adverse event after self-expandable metal stent (SEMS) placement for malignant biliary obstruction (MBO); however, no appropriate treatment strategy has been established for its management.

AIMS

This study aimed to examine the feasibility and utility of endoscopic ultrasound-guided naso-gallbladder drainage (EUS-NGBD) for the management of acute cholecystitis occurring after SEMS placement.

METHODS

This retrospective study investigated consecutive patients with acute cholecystitis after SEMS placement for unresectable MBO, in whom EUS-NGBD was attempted. The study outcomes included technical success, clinical success, procedure time, adverse event, and cholecystitis recurrence, associated with the procedure.

RESULTS

During the study period, EUS-NGBD was performed for SEMS-related acute cholecystitis in 30 patients with MBO. The technical and clinical success rates were 96.7% (29/30) and 96.6% (28/29), respectively. The median procedure time was 15 min, and rate of procedure-related adverse event was 3.3% (1/30). The median duration from the procedure to tube removal was 9 days. No adverse events were observed after removal. The median hospitalization duration after the procedure was 14 days, and the median duration to the (re-)start of chemotherapy from cholecystitis onset was 13 days. The median overall survival after EUS-NGBD was 123 days, and the rate of cholecystitis recurrence until death was 4.2% (1/28).

CONCLUSIONS

This study demonstrated that EUS-NGBD possesses good technical and clinical feasibility with an acceptable adverse event rates and short hospitalization and chemotherapy withdrawal period. Therefore, EUS-NGBD may be a good option for the treatment of SEMS-related cholecystitis in patients with MBO.

Endoscopic gallbladder inside-stenting combined with aspirated lavage for calculous cholecystitis in poor surgical candidates: a prospective pilot study

Although long-term stent placement via endoscopic gallbladder stenting (EGBS) reportedly reduces cholecystitis recurrence in patients unfit to undergo cholecystectomy, it can increase the frequency of other late adverse events (AEs) such as cholangitis. This study aimed to examine the feasibility of endoscopic gallbladder inside-stenting (EGB-IS) with lavage and aspiration. This prospective, single-center, pilot study enrolled 83 patients with acute calculous cholecystitis who were poor candidates for surgery. A dedicated catheter with eight side holes was used for lavage and aspiration, and a dedicated single-pigtail stent equipped with a thread was used for EGB-IS. Outcomes such as technical success, clinical success, early AEs, recurrence of cholecystitis, and other symptomatic late AEs associated with EGB-IS with lavage and aspiration were evaluated. The technical and clinical success rates were 80.7% (67/83) and 98.5% (66/67), respectively. The rate of early AEs was 3.6% (3/83). The rate of recurrent cholecystitis was 4.5% (3/66) and that of symptomatic late AEs (besides cholecystitis) was 6.1% (4/66). Consequently, the rate of overall late AEs (cholecystitis plus other events) was 10.6% (7/66). The 1-, 2-, and 3-year cumulative incidence rates of all late AEs were 3.2%, 11.2%, and 18.9%, respectively. EGB-IS with lavage and aspiration for calculous cholecystitis showed promising results in poor surgical candidates. EGB-IS may be useful when EGBS with long-term stent placement is planned, since prevention of cholecystitis recurrence, without a rise in the incidence of other AEs, is anticipated.

Management strategies for acute cholecystitis in late pregnancy: a multicenter retrospective study

OBJECTIVE

This study aims to investigate the management strategies for acute cholecystitis in the third trimester of pregnancy by comparing the effectiveness of three different treatments.

METHODS

Clinical data of 102 patients with acute cholecystitis in third trimester of pregnancy admitted to three Tertiary Hospitals from January 2010 to June 2020 were collected and divided into 3 groups according to the primary treatment during their first hospitalization: Group A (surgical group; n = 11), Group B (percutaneous transhepatic gallbladder drainage (PTGD) group, n = 29) and Group C (conservative treatment group, n = 62). The length of stay, readmission rate, and preterm delivery rate of each group were analyzed retrospectively.

RESULTS

The average age of patients included in this study was 29 ± 2.16 years with an average gestational cycle of 35.26 ± 1.02 weeks. The readmission rates of patients in groups A, B, and C were 9.09%, 24.14%, and 58.06%; the preterm delivery rates were 9.09%, 3.45%, and 12.90%; and the length of stay was 4.02 ± 1.02 days, 12.53 ± 2.21 days, and 11.22 ± 2.09 days, respectively. The readmission rate was lower in group A than in groups B and C, the preterm delivery rate was lower in group B than in groups A and C, and the length of stay was shorter in group A than in groups B and C (all with statistically significant differences, P < 0.05).

CONCLUSION

Patients with acute cholecystitis in late pregnancy need to be appropriately graded for severity and offered a sound treatment strategy after a thorough assessment of the condition while taking into account the willingness of the patients. For patients with mild severity, conservative treatment can be adopted; for patients with moderate or severe inflammation, PTGD can be performed first for symptom control, and wait till after delivery for surgery to be considered; and in some cases of critical condition and poor symptom control, surgical intervention should be promptly performed.

Strategy Comparison of Endoscopic Ultrasound-Guided Gallbladder Drainage to Percutaneous Transhepatic Gallbladder Drainage, Following Failed Emergent Endoscopic Transpapillary Gallbladder Drainage

Endoscopic transpapillary gallbladder drainage (ETGBD) is recommended for patients with acute cholecystitis at high risk for surgery/percutaneous transhepatic gallbladder drainage (PTGBD). Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has higher success and mortality rates than ETGBD. Optimal endoscopic drainage remains controversial. Patients with moderate/severe acute cholecystitis and high risk for surgery/PTGBD who underwent ETGBD were enrolled. In the new-ETGBD (N-ETGBD)/traditional-ETGBD (T-ETGBD) strategy, patients in whom the initial ETGBD failed underwent rescue-EUS-GBD in the same endoscopic session/rescue-PTGBD, respectively. Therapeutic outcomes were compared. Patients who could not undergo rescue-EUS-GBD/PTGBD owing to poor general conditions received conservative treatment. Technical success was defined as successful ETGBD or successful rescue-EUS-GBD/PTGBD. Forty-one/forty patients were enrolled in the N-ETGBD/T-ETGBD groups, respectively. The N-ETGBD group had a higher, though non-significant, technical success rate compared to the T-ETGBD group (97.6 vs. 90.0%, p = 0.157). The endoscopic technical success rate was significantly higher in the N-ETGBD than in the T-ETGBD group (97.6 vs. 82.5%, p = 0.023). The clinical success/adverse event rates were similar between both groups. The hospitalization duration was significantly shorter in the N-ETGBD than in the T-ETGBD group (6.6 ± 3.9 vs. 10.1 ± 6.4 days, p < 0.001). ETGBD with EUS-GBD as a rescue backup may be an ideal hybrid drainage for emergency endoscopic gallbladder drainage in high-risk surgical patients.

Comparison between percutaneous transhepatic gallbladder drainage and upfront laparoscopic cholecystectomy in patients with moderate-to-severe acute cholecystitis: a propensity score-matched analysis

Purpose

In the Tokyo Guidelines 2018 (TG18), emergency laparoscopic cholecystectomy is recognized as a crucial early treatment option for acute cholecystitis. However, early laparoscopic intervention in patients with moderate-to-severe acute cholecystitis or those with severe comorbidities may increase the risk of complications. Therefore, in the present study, we investigated the association between early laparoscopic cholecystectomy and percutaneous transhepatic gallbladder drainage (PTGBD) in moderate-to-severe acute cholecystitis patients.

Methods

We retrospectively analyzed 835 TG18 grade II or III acute cholecystitis patients who underwent laparoscopic cholecystectomy at 4 tertiary medical centers in the Republic of Korea. Patients were classified into 2 groups according to whether PTGBD was performed before surgery, and their short-term postoperative outcomes were analyzed retrospectively.

Results

The patients were divided into 2 groups, and 1:1 propensity score matching was conducted to establish the PTGBD group (n = 201) and the early laparoscopic cholecystectomy group (n = 201). The PTGBD group experienced significantly higher rates of preoperative systemic inflammatory response syndrome (24.9% vs. 6.5%, P < 0.001), pneumonia (7.5% vs. 3.0%, P = 0.045), and cardiac disease (67.2% vs. 57.7%, P = 0.041) than the early operation group. However, there was no difference in biliary complication (hazard ratio, 1.103; 95% confidence interval, 0.519-2.343; P = 0.799) between the PTGBD group and early laparoscopic cholecystectomy group.

Conclusion

In most cases of moderate-to-severe cholecystitis, early laparoscopic cholecystectomy was relatively feasible. However, PTGBD should be considered if patients have the risk factor of underlying disease when experiencing general anesthesia.

Endoscopic ultrasound in the management of acute cholecystitis: Practical review

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has emerged over the last years as an alternative procedure to percutaneous drainage (PT)-GBD in patients with acute cholecystitis (AC) at high surgical risk. This process has been driven by the advent of lumen-apposing metal stents (LAMS) with electrocautery-enhanced capability, which has rendered the drainage procedure easier to accomplish and safer. Studies and meta-analyses have proven the superiority of EUS-GBD over PT-GBD in high-surgical-risk patients with AC. Little evidence exists in the same setting that EUS-GBD compares equally with laparoscopic cholecystectomy (LC). Moreover, EUS-GBD might theoretically have a possible role in patients at high surgical risk with an indication to undergo cholecystectomy or with a high probability of conversion from LC to open cholecystectomy. Properly designed studies are needed to better clarify the role of EUS-GBD in these patient populations.

Comparison of trans-gastric vs trans-enteric (trans-duodenal or trans-jejunal) endoscopic ultrasound guided gallbladder drainage using lumen apposing metal stents

BACKGROUND

Endoscopic ultrasound guided gallbladder drainage (EUS-GBD) is being increasingly used in practice (either as a bridge to cholecystectomy in high-risk patients or as destination therapy in non-surgical patients). Stents are used to create a conduit between the lumen of the gallbladder (GB) and the intestinal lumen through the gastric or enteric routes. Among the various types of stents used, cautery-enhanced lumen apposing metallic stents (LAMS) may be associated with fewer adverse events (AEs).

AIM

To compare the clinical success, technical success, and rate of AEs between transgastric (TG) and trans-enteric [transduodenal (TD)/transjejunal (TJ)] approach to GB drainage. Further, we analyzed whether using cautery enhanced stents during EUS-GBD impacts the above parameters.

METHODS

Study was registered in PROSPERO (CRD42022319019) and comprehensive literature review was conducted. Manuscripts were reviewed for the data collection: Rate of AEs, clinical success, and technical success. Random effects model was utilized for the analysis.

RESULTS

No statistically significant difference in clinical and technical success between the TD/TJ and TG approaches (P > 0.05) were noted. There was no statistically significant difference in the rate of AEs when comparing two-arm studies only. However, when all studies were included in the analysis difference was almost significant favoring the TD/TJ approach. When comparing cautery-enhanced LAMS with non-cautery enhanced LAMS, a statistically significant difference in the rate of AEs was observed when all the studies were included, with the rate being higher in non-cautery enhanced stents (14.0% vs 37.8%; P < 0.01).

CONCLUSION

As per our study results, TD/TJ approach appears to be associated with lower rate of adverse events and comparable efficacy when compared to the TG approach for the EUS-GBD. Additionally, use of cautery-enhanced LAMS for EUS-GBD is associated with a more favorable adverse event profile compared to cold LAMS. Though the approach chosen depends on several patient and physician factors, the above findings could help in deciding the ideal drainage route when both TG and TD/TJ approaches are feasible.

Increased difficulty and complications of delayed laparoscopic cholecystectomy following percutaneous transhepatic gallbladder drainage in acute cholecystitis: a retrospective study

BACKGROUND

Percutaneous transhepatic gallbladder drainage (PTGBD) is a relatively less invasive alternative treatment to cholecystostomy. However, the influence of the difficulty of delayed laparoscopic cholecystectomy (DLC) after PTGBD on clinical outcomes remains unknown. This study aimed to evaluate the clinical effects of DLC following PTGBD.

METHODS

The clinical data of 113 patients diagnosed with moderate (grade II) acute cholecystitis according to the 2018 Tokyo Guidelines in the acute phase and who underwent DLC in our hospital from January 2018 to February 2022 were retrospectively collected and separated into two groups according to whether they received PTGBD treatment in the acute stage. The PTGBD group comprised 27 cases, and the no-PTGBD group included 86 cases. The TG18 difficulty score was used to evaluate every surgical procedure in the cases by reviewing the surgical videos. The clinical baseline characteristics and post-treatment outcomes were also evaluated.

RESULTS

Both groups showed significant differences in length of postoperative stay, blood loss, operation time, and difficulty score. The PTGBD group showed a significantly longer postoperative stay and operation time, more blood loss, and a much higher difficulty score than the no-PTGBD group. Conversion rates did not differ. The morbidity rate in the PTGBD group was statistically higher.

CONCLUSIONS

PTGBD is an efficient way to relieve the symptoms of acute cholecystitis. However, it may increase the difficulty and complications of DLC.

Therapeutic Endoscopic Ultrasound: Current Indications and Future Perspectives

The transcendence of endoscopic ultrasound (EUS) from diagnostic to therapeutic tool has revolutionized management options in the field of gastroenterology. Through EUS-guided methods, pancreaticobiliary obstruction can now be utilized as an alternative to surgical and percutaneous approaches. This modality also allows for gallbladder drainage in patients who are not ideal operative candidates. By utilizing its unique imaging capabilities, EUS also allows for drainage access points in cases of gastric outlet obstruction as well as windows to ablate pancreatic cystic lesions. As technical progress continues to evolve, interventional gastroenterology continues to push the envelope of minimally invasive therapeutic procedures in a multidisciplinary setting. In this comprehensive review, we set out to describe current indications and innovations through EUS.

Cystic duct straightening using a fine-gauge balloon dilator for successful endoscopic transpapillary gallbladder stenting

Endoscopic transpapillary gallbladder stenting is sometimes inhibited by a cystic duct loop, necessitating cystic duct straightening. Mandai and colleagues report a novel technique for straightening the looped cystic duct using a fine-gauge balloon dilator, which is useful during endoscopic gallbladder stenting when the double-guidewire technique fails.

Endoscopic internalization by cutting versus removal of the endoscopic transpapillary naso-gallbladder drainage tube in preoperative management of acute cholecystitis: A retrospective multicenter cohort study

BACKGROUND

Endoscopic transpapillary naso-gallbladder drainage (ENGBD) has been reported to be an effective treatment option for acute cholecystitis. At our institution, ENGBD was first placed for external fistula management, and endoscopic internalization by cutting was performed, shifting to endoscopic transpapillary gallbladder stenting (EGBS) after improvement of cholecystitis. However, there has been no comparative study to define which preoperative management is better: converting ENGBD to EGBS or removing ENGBD. The study aimed to compare the incidence rate of the late adverse events (AEs) related to biliary system between shifting from ENGBD to EGBS and removal of ENGBD.

METHODS

We retrospectively studied 122 patients who underwent ENGBD for acute cholecystitis between January 2010 and October 2022. The patients were divided into two groups: the cutting group (converting ENGBD to EGBS) and the removal group (removal of ENGBD). The short and late clinical outcomes were compared between groups.

RESULTS

Endoscopic transpapillary naso-gallbladder drainage was successfully placed in 78.6% (96/122), and elective cholecystectomy was performed in 31 and 36 patients in the cutting and removal groups, respectively. The cumulative late-AE rates were 6.4% and 33.3% (p = .007), with a median waiting period for elective cholecystectomy of 58 and 33 days (p = .390) in the cutting and removal groups, respectively. In the multivariate analysis, only endoscopic internalization by cutting was an independent factor affecting late AEs.

CONCLUSION

Endoscopic internalization by cutting ENGBD after the resolution of acute cholecystitis was considered effective in reducing the risk of late AEs during the waiting period for an elective cholecystectomy.

Acute cholecystitis: Which flow-chart for the most appropriate management?

Acute cholecystitis (AC) is a very common disease in clinical practice. Laparoscopic cholecystectomy remains the gold standard treatment for AC, however due to aging population, the increased prevalence of multiple comorbidities and the extensive use of anticoagulants, surgical procedures may be too risky when dealing with patients in emergency settings. In these subsets of patients, a mini-invasive management may be an effective option, both as a definitive treatment or as bridge-to-surgery. In this paper, several non-operative treatments are described and their benefits and drawbacks are highlighted. Percutaneous gallbladder drainage (PT-GBD) is one of the most common and widespread techniques. It is easy to perform and has a good cost/benefit ratio. Endoscopic transpapillary gallbladder drainage (ETGBD) is a challenging procedure that is usually performed in high volume centers by expert endoscopists, and it has a specific indication for selected cases. EUS-guided drainage (EUS-GBD) is still not widely available, but it is an effective procedure that could have several advantages, especially in rate of reinterventions. All these treatment options should be considered together in a stepwise approach and addressed to patients after an accurate case-by-case evaluation in a multidisciplinary discussion. In this review, we provide a possible flowchart in order to optimize treatments, resource and provide to patients a tailored approach.

Comparison of the long-term outcomes of EUS-guided gallbladder drainage and endoscopic transpapillary gallbladder drainage for calculous cholecystitis in poor surgical candidates: a multicenter propensity score-matched analysis

BACKGROUND AND AIMS

Although long-term stent placement using endoscopic transpapillary gallbladder drainage (ETGBD) and EUS-guided gallbladder drainage (EUS-GBD) reportedly reduces cholecystitis recurrence, comparative evidence of their safety and efficacy is scarce. This study aimed to examine and compare the long-term utility of EUS-GBD versus that of ETGBD in poor surgical candidates.

METHODS

A total of 379 high-risk surgical patients with acute calculous cholecystitis met the eligibility criteria for enrollment in this study. The technical success and adverse events (AEs) were compared between the EUS-GBD and ETGBD groups, and propensity score matching was performed to adjust for differences between the groups. Both groups underwent plastic stent placement, and scheduled stent exchange and removal were not performed in either group.

RESULTS

The technical success rate of EUS-GBD was significantly higher than that of ETGBD (96.7% vs 78.9%, P < .001), whereas the early AE rate did not differ significantly between the 2 methods (7.8% vs 8.9%, P = 1.000). The rate of recurrent cholecystitis did not differ significantly (3.8% vs 3.0%, P = 1.000), but the rate of symptomatic late AEs, in addition to cholecystitis, was significantly lower with EUS-GBD than with ETGBD (1.3% vs 13.4%, P = .006). Consequently, the overall late AE rate was significantly lower with EUS-GBD (5.0% vs 16.4%, P = .029). Multivariate analysis revealed that EUS-GBD was associated with a significantly longer time to late AE (hazard ratio, .26; 95% confidence interval, .10-.67; P = .005).

CONCLUSIONS

Long-term stent placement via EUS-GBD is a promising potential option for limiting late AEs, including recurrence, in poor surgical candidates with calculous cholecystitis.

Postoperative bleeding after percutaneous transhepatic gallbladder drainage and aspiration in patients receiving antithrombotic therapy

This study aimed to investigate the bleeding risk associated with percutaneous transhepatic gallbladder interventions in patients with acute cholecystitis receiving antithrombotic therapy. In this retrospective study, 194 consecutive patients who underwent percutaneous transhepatic gallbladder interventions for acute cholecystitis between April 2011 and April 2021 were enrolled. Patients were sorted into four groups: no prior antithrombotic therapy, discontinued antithrombotic drugs, single antithrombotic drug continued perioperatively, and multiple antithrombotic drugs continued perioperatively. The risk of postoperative bleeding after percutaneous transhepatic gallbladder interventions was evaluated via multivariate logistic regression analysis. Of the 116 (59.8%) patients receiving antithrombotic therapy, 32 (16.5%) discontinued antithrombotic drugs before their respective procedure, 50 (25.8%) continued a single antithrombotic drug, and 34 (17.5%) continued multiple antithrombotic drugs during the perioperative period. The rates of significant and severe bleeding were 10.3% (20/194) and 3.1% (6/194), respectively. The rate of significant bleeding was significantly higher in patients who continued multiple antithrombotic drugs than in patients who received no prior antithrombotic therapy (P = 0.006). In the multivariate logistic regression analysis, the continuation of multiple antithrombotic drugs during the perioperative period was a risk factor for significant bleeding after percutaneous transhepatic gallbladder interventions. In conclusion, the perioperative continuation of multiple antithrombotic drugs is a risk factor for postoperative bleeding after percutaneous transhepatic gallbladder interventions.

Early Management of Severe Biliary Infection in the Era of the Tokyo Guidelines

Sepsis of biliary origin is increasing worldwide and has become one of the leading causes of emergency department admissions. The presence of multi-resistant bacteria (MRB) is increasing, and mortality rates may reach 20%. This review focuses on the changes induced by the Tokyo guidelines and new concepts related to the early treatment of severe biliary disease. If cholecystitis or cholangitis is suspected, ultrasound is the imaging test of choice. Appropriate empirical antibiotic treatment should be initiated promptly, and selection should be performed while bearing in mind the severity and risk factors for MRB. In acute cholecystitis, laparoscopic cholecystectomy is the main therapeutic intervention. In patients not suitable for surgery, percutaneous cholecystostomy is a valid alternative for controlling the infection. Treatment of severe acute cholangitis is based on endoscopic or transhepatic bile duct drainage and antibiotic therapy. Endoscopic ultrasound and other new endoscopic techniques have been added to the arsenal as novel alternatives in high-risk patients. However, biliary infections remain serious conditions that can lead to sepsis and death. The introduction of internationally accepted guidelines, based on clinical presentation, laboratory tests, and imaging, provides a framework for their rapid diagnosis and treatment. Prompt assessment of patient severity, timely initiation of antimicrobials, and early control of the source of infection are essential to reduce morbidity and mortality rates.

Endoscopic Ultrasound-Guided Gallbladder Drainage: Beyond Cholecystitis

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an alternative to surgery for acute cholecystitis (AC) in poor operative candidates. However, the role of EUS-GBD in non-cholecystitis (NC) indications has not been well studied. We compared the clinical outcomes of EUS-GBD for AC and NC indications. Consecutive patients undergoing EUS-GBD for all indications at a single center were retrospectively analyzed. Fifty-one patients underwent EUS-GBD during the study period. Thirty-nine (76%) patients had AC while 12 (24%) had NC indications. NC indications included malignant biliary obstruction (n = 8), symptomatic cholelithiasis (n = 1), gallstone pancreatitis (n = 1), choledocholithiasis (n = 1), and Mirizzi's syndrome (n = 1). Technical success was noted in 92% (36/39) for AC and 92% (11/12) for NC (p > 0.99). The clinical success rate was 94% and 100%, respectively (p > 0.99). There were four adverse events in the AC group and 3 in the NC group (p = 0.33). Procedure duration (median 43 vs. 45 min, p = 0.37), post-procedure length of stay (median 3 vs. 3 days, p = 0.97), and total gallbladder-related procedures (median 2 vs. 2, p = 0.59) were similar. EUS-GBD for NC indications is similarly safe and effective as EUS-GBD in AC.

Hotspots and difficulties of biliary surgery in older patients

ABSTRACT

With the accelerated aging society in China, the incidence of biliary surgical diseases in the elderly has increased significantly. The clinical characteristics of these patients indicate that improving treatment outcomes and realizing healthy aging are worthy of attention. How to effectively improve the treatment effect of geriatric biliary surgical diseases has attracted widespread attention. This paper reviews and comments on the hotspots and difficulties of biliary surgery in older patients from six aspects: (1) higher morbidity associated with an aging society, (2) prevention and control of pre-operative risks, (3) extending the indications of laparoscopic surgery, (4) urgent standardization of minimally invasive surgery, (5) precise technological progress in hepatobiliary surgery, and (6) guarantee of peri-operative safety. It is of great significance to fully understand the focus of controversy, actively make use of its favorable factors, and effectively avoid its unfavorable factors, for further improving the therapeutic effects of geriatric biliary surgical diseases, and thus benefits the vast older patients with biliary surgical diseases. Accordingly, a historical record with the highest age of 93 years for laparoscopic transcystic common bile duct exploration has been created by us recently.

AGA Clinical Practice Update on Role of EUS-Guided Gallbladder Drainage in Acute Cholecystitis: Commentary

DESCRIPTION

Endoscopic gallbladder drainage is a feasible and efficacious alternative to percutaneous drainage in the management of acute cholecystitis for high-risk surgical candidates. Endoscopic ultrasound-guided gallbladder drainage and per-oral cholecystoscopy is facilitated by the use of lumen-apposing metal stents. Endoscopic ultrasound-guided gallbladder drainage should be performed by those expert in advanced therapeutic endoscopic ultrasound. Multidisciplinary collaboration between interventional radiology and surgery is paramount in the care of these patients. Choosing the optimal drainage method is dependent on individual patient characteristics.

METHODS

This commentary was drawn from a review of the literature to provide practical advice. Because this was not a systematic review, we did not perform any formal rating of the quality of evidence or strength of the presented considerations. This expert commentary was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer-review by the Clinical Practice Updates Committee and external peer-review through standard procedures of Clinical Gastroenterology and Hepatology.

Ultrasound-guided percutaneous cholecystostomy as bridging or definitive treatment in patients with acute cholecystitis grade II or III

Background

We aimed to investigate the extent to which ultrasound (US)-guided percutaneous cholecystostomy (PC) is used as a bridging or definitive therapy for grade II and III acute cholecystitis and whether this treatment causes significant changes in C-reactive protein (CRP) and direct bilirubin (DB) levels in the first 72 h and the first three weeks.

Methods

We included 145 consecutive patients who underwent PC over 17 years. No patient had cirrhosis. PC was performed in the interventional radiology department under US guidance.

Results

US-guided PC was the definitive treatment for more than half of the patients (51.7%) and decreased DB levels significantly more than CRP levels.

Conclusion

No statistically significant correlation between those whose CRP and DB levels normalized within three weeks and those who did not and required a second invasive procedure. Nevertheless, the bridging treatment group was significantly older than the definitive treatment group.

Comparison of the safety and effectiveness of different surgical timing for acute cholecystitis after percutaneous transhepatic gallbladder drainage: a systematic review and meta-analysis

BACKGROUND

To compare the efficacy and safety of laparoscopic cholecystectomy (LC) in the treatment of acute cholecystitis (AC) at different time points after percutaneous transhepatic gallbladder drainage (PTGBD).

METHODS

PubMed, EMBASE, Cochrane Library, and Web of Science were searched from database inception to 1 May 2022. The last date of search was the May 30, 2022. The Newcastle-Ottawa scale (NOS) was used to conduct quality assessments, and RevMan (Version 5.4) was used to perform the meta-analysis.

RESULTS

A total of 12 studies and 4379 patients were analyzed. Compared with the < 2-week group, the ≥ 2-week group had shorter operation time, less intraoperative blood loss, shorter postoperative hospital stay, lower rate of conversion to laparotomy, and fewer complications. There was no statistical difference between the two groups regarding bile duct injury, bile leakage, and total cost.

CONCLUSIONS

The evidence indicates that the ≥ 2-week group has the advantage in less intraoperative blood loss, minor tissue damage, quick recovery, and sound healing in treating AC. It can be seen that LC after 2 weeks is safe and effective for AC patients who have already undergone PTGBD and is recommended, but further confirmation is needed in a larger sample of randomized controlled studies.

Clinical outcomes and predictors of technical failure of endoscopic transpapillary gallbladder drainage in acute cholecystitis

BACKGROUND AND AIMS

Endoscopic transpapillary gallbladder drainage (ETGBD) has been performed as an alternative therapy against cholecystectomy in patients with acute cholecystitis. To date, few studies have reported the safety, efficacy, and factors affecting ETGBD. We evaluated the clinical outcomes and predictors of technical failure of ETGBD.

METHODS

Patients with acute cholecystitis who underwent ETGBD were retrospectively reviewed, and consecutive patients were included in the study. The technical success rate, clinical success rate, adverse events, and the predictors associated with the technical failure of ETGBD were investigated.

RESULTS

A total of 242 patients were enrolled in the study. The technical success rate of ETGBD and clinical success rate of technically successful ETGBD cases were 87% and 93%, respectively. We experienced cystic duct injury in 24 patients as an ETGBD-related adverse event, and pancreatitis in 12 patients as an endoscopic retrograde cholangiopancreatography-related adverse event. Multivariate analysis indicated that cystic duct injury was the independent predictor associated with the technical failure of ETGBD (odds ratio, 11; 95% confidence interval, 3.9-29; p < 0.001).

CONCLUSIONS

ETGBD was a safe and effective treatment method for acute cholecystitis with acceptable adverse events. There was no predictor based on the information from patient characteristics; however, cystic duct injury was associated with the technical failure of ETGBD.