Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment

The difficult laparoscopic cholecystectomy: a narrative review

BACKGROUND/PURPOSE

Laparoscopic cholecystectomy is one of the most commonly performed general surgical procedures. Difficult laparoscopic cholecystectomy is associated with increased operative time, hospital stay, complication rates, open conversion, treatment costs, and mortality. This study aimed to provide a comprehensive literature review on difficult laparoscopic cholecystectomy.

METHODS

A literature search was conducted for articles published in English up to June 2024 using common databases including PubMed/MIDLINE, Web of Science, Google Scholar, and ScienceDirect. Keywords included "safe laparoscopic cholecystectomy", "difficult laparoscopic cholecystectomy", "acute cholecystitis", "prevention of bile duct injuries", "intraoperative cholangiography," "bailout procedure," and "subtotal cholecystectomy". Only clinical trials, systematic reviews/meta-analyses, and review articles were included. Studies involving children, robotic cholecystectomy, single incision laparoscopic cholecystectomy, open cholecystectomy, and cholecystectomy for indications other than gallstone disease were excluded.

RESULTS/DISCUSSION

Emergency laparoscopic cholecystectomy for acute cholecystitis is ideally performed within 72 h of symptom onset, with a maximum window of 7-10 days. Intraoperative cholangiography can help clarify unclear biliary anatomy and detect bile duct injuries. In the "impossible gallbladder", laparoscopic cholecystostomy or gallbladder aspiration may be considered. When dissection of Calot's triangle is deemed hazardous or impossible, the fundus-first approach allows for completion of the procedure with either total cholecystectomy or subtotal cholecystectomy. Subtotal cholecystectomy is effective in preventing bile duct injuries, can be performed laparoscopically, and is currently the best available bailout approach for difficult laparoscopic cholecystectomy.

CONCLUSION

Difficult laparoscopic cholecystectomy is a common clinical scenario that requires a judicious approach by experienced surgeons in appropriate settings. When difficult laparoscopic cholecystectomy is encountered, various bailout strategies are available. Currently, subtotal cholecystectomy is likely the most effective bailout approach.

Early Laparoscopic Cholecystectomy Versus Percutaneous Cholecystostomy Followed by Delayed Laparoscopic Cholecystectomy in Patients with Grade II Acute Cholecystitis According to Tokyo Guidelines TG18

Introduction: In the past, most patients with acute cholecystitis (AC) were treated conservatively. However, strong evidence from various studies has shown that laparoscopic cholecystectomy (LC) is safe and should be the primary treatment for AC. However, this may not be the case for all AC grades. This study aimed to compare two recommended approaches for grade II AC as outlined in the Tokyo guidelines TG18, focusing on early operative outcomes. Methods: We conducted a retrospective review of medical records for all patients diagnosed with grade II AC. The study compared patients who underwent early LC (group A, n = 130) with those who initially received percutaneous cholecystostomy (PC) followed by LC (group B, n = 90). Results: Both groups had similar Tokyo classification parameters. However, there were significant differences in baseline data, operative challenges, and postoperative complications. Cholecystostomy-related complications were observed in seven patients. The conversion rate for was 25% for group A and 5% for group B. The incidence of intraoperative biliary injury was 10% for group A and 2.2% for group B. In group A, 92% of patients with biliary injury and 80% of those who required conversion to open surgery had evidence of localized inflammation around the gallbladder. Conclusion: For selected patients with grade II AC and higher risks, PC placement can be beneficial in preventing life-threatening consequences. The study suggests a 2-month interval between PC and subsequent LC. Overall, performing LC after PC was found to be easier than early LC. Local inflammatory changes, including empyema, were associated with higher complication rates in the early LC group.

Indications and clinical outcomes of percutaneous cholecystostomies in acute cholecystitis: a study from Qatar

INTRODUCTION

Acute cholecystitis (AC) is a prevalent condition in emergency departments (EDs). Standard care involves early laparoscopic cholecystectomy; however, in cases of delayed presentation, high surgical risk, or during situations like the COVID-19 pandemic, percutaneous cholecystostomy (PC) serves as an alternative management strategy. This study reports our center's experience with PC in managing AC, providing insights from a unique geographical context.

METHODS

We conducted a retrospective review of 97 patients undergoing PC operation from June 1, 2016, to January 1, 2021. The data collected included demographic details, indications for PC, clinical outcomes, ICU admissions, overall mortality, and long-term follow-up.

RESULTS

The cohort comprised 61.9% male patients with a mean age of 67.2 ± 15.5 years. The primary comorbidity was hypertension (83.5%), and 88.6% had an ASA (American Society of Anesthesiologists) score of ≥ III. The main cause of AC was calculous type, and 15.2% of cases were acalculous cholecystitis. Main Tokyo Guidelines 18 (TG 18) grade was grade II and was found in 56.4% of patients. The readmission rate was 33.1% and overall mortality rate was 34% during follow-up. The native population in Qatar were older and burdened with more co-morbidities. High risk of surgery was the main indication for PC, followed by delayed presentation of AC. Patients with delayed presentations were younger (p = 0.051), had higher albumin levels (p = 0.005), and had lower ICU admission rates (p = 0.002) and mortality (p = 0.014) than those with multiple comorbidities. The overall Mortality rates post-PC were 34%, predominantly attributed to underlying conditions rather than the PC procedure itself. Patients who proceeded to post-PC cholecystectomy were younger, had higher albumin levels, and experienced fewer readmissions (p < 0.05).

CONCLUSION

In high-risk patients or when surgical risk is prohibitive, PC is a viable and effective alternative for AC management. Post-PC cholecystectomy was associated with favorable outcomes, suggesting PC as a bridge to surgery in selected patients. This study highlights the role of PC in a high-risk population within our regional setting.

Postinsertion Management of Cholecystostomy Tubes for Acute Cholecystitis: A Systematic Review

BACKGROUND

Percutaneous gallbladder drainage (PGD) is indicated to treat high-risk patients with acute cholecystitis. Trends suggest increasing use of PGD over time as the population ages and lives longer with multiple comorbidities. There is no consensus on the management of cholecystostomies tube once inserted. This review aims to synthesize and describe the most common protocols in terms of the need and timing of follow-up imaging, management of a destination tube, timing of tube removal, and optimal interval time from tube positioning to delayed cholecystectomy.

METHODS

The study protocol has been registered on the International Prospective Register of Systematic Reviews-PROSPERO. Studies on adult patients diagnosed with acute cholecystitis who underwent a PGD from 2000 to November 2023 were included. The databases searched were MEDLINE, Embase, and Cochrane. The quality assessment tools provided by the NHLBI (National Heart, Lung, and Blood Institute) were applied and descriptive statistics were performed.

RESULTS

We included 22,349 patients from 94 studies with overall fair quality (6 prospective and 88 retrospective). In 92.7% of papers, the authors checked by imaging all patients with a PGD (41 studies included). Depending on protocol time, 30% of studies performed imaging within the first 2 weeks and 35% before tube removal (40 studies included). In the case of a destination tube, 56% of studies reported removing the tube (25 studies included). In the case of tube removal, the mean time after insertion was more than 4 weeks in 24 of the 33 included studies (73%). Interval cholecystectomies are more frequently performed after 5 weeks from PGD (32/38 included studies, 84%). Limitations included high clinical heterogeneity and prevalent retrospective studies.

CONCLUSIONS

A standard management for percutaneous cholecystostomy after insertion is difficult to define based on existing evidence, and currently we can only rely on the most common existing protocols.

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.

EUS-Guided Gallbladder Drainage Using a Lumen-Apposing Metal Stent for Acute Cholecystitis: Results of a Nationwide Study with Long-Term Follow-Up

BACKGROUND

Although endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using lumen-apposing metal stents (LAMS) has become one of the treatments of choice for acute cholecystitis (AC) in fragile patients, scant data are available on real-life settings and long-term outcomes.

METHODS

We performed a multicenter retrospective study including EUS-guided GBD using LAMS for AC in 19 Italian centers from June 2014 to July 2020. The primary outcomes were technical and clinical success, and the secondary outcomes were the rate of adverse events (AE) and long-term follow-up.

RESULTS

In total, 116 patients (48.3% female) were included, with a mean age of 82.7 ± 11 years. LAMS were placed, transgastric in 44.8% of cases, transduodenal in 53.3% and transjejunal in 1.7%, in patients with altered anatomy. Technical success was achieved in 94% and clinical success in 87.1% of cases. The mean follow-up was 309 days. AEs occurred in 12/116 pts (10.3%); 8/12 were intraprocedural, while 1 was classified as early (<15 days) and 3 as delayed (>15 days). According to the ASGE lexicon, two (16.7%) were mild, three (25%) were moderate, and seven (58.3%) were severe. No fatal AEs occurred. In subgroup analysis of 40 patients with a follow-up longer than one year, no recurrence of AC was observed.

CONCLUSIONS

EUS-GBD had high technical and clinical success rates, despite the non-negligible rate of AEs, thus representing an effective treatment option for fragile patients.

Current Operative Approaches to the Diseased Gallbladder. Diagnosis and Management Updates for General Surgeons

Cholecystitis is a common diagnosis which requires management by general surgeons. Morbidity from cholecystitis is often life-threatening, especially in patients with underlying liver cirrhosis or other medical comorbidities. Diagnosis and management of this disease can vary among providers and hospitals. The decision to utilize a radiological or endoscopic temporizing maneuver in severe acute cholecystitis and the timing of later definitive cholecystectomy are relevant points of discussion within general surgery societies. In the last 5 years, the use of intraoperative ductal imaging by conventional vs fluorescence cholangiography had gained significant interest due to the widespread availability of indocyanine green. Finally, the operative strategies and how to manage intra-/postoperative complications are very important to optimizing patient outcomes. In this review paper, we discuss all treatment aspects of cholecystitis and provide updates in its management.

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.

The Efficacy and Safety of EUS-Guided Gallbladder Drainage as a Bridge to Surgery for Patients with Acute Cholecystitis

BACKGROUND AND AIM

This study aimed to compare the efficacy and safety of endoscopic ultrasound-guided gallbladder drainage and percutaneous transhepatic gallbladder drainage as a bridge to surgery in patients with acute cholecystitis unfit for urgent cholecystectomy.

METHODS

This retrospective study included 46 patients who underwent cholecystectomy following endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) or percutaneous transhepatic gallbladder drainage (PTGBD) for acute cholecystitis in NTT Tokyo Medical Center. We surveyed 35 patients as the EUS-GBD group and 11 patients as the PTGBD group, and compared the rate of technical success of the cholecystectomy and periprocedural adverse events. A 7-F, 10-cm double pigtail plastic stent was used for ultrasound-guided gallbladder drainage.

RESULTS

The rate of technical success of cholecystectomy was 100% in both groups. Regarding postsurgical adverse events, no significant difference was noted between the two groups (EUS-GBD group, 11.4%, vs. PTGBD group, 9.0%; p = 0.472).

CONCLUSIONS

EUS-GBD as a BTS seems to be an alternative for patients with AC because it can ensure lower adverse events. On the other hand, there are two major limitations in this study--the sample size is small and there is a risk of selection bias.

Long-term outcomes of endoscopic ultrasound-guided gallbladder drainage versus in situ or ex situ percutaneous gallbladder drainage in real-world practice

OBJECTIVES

Many studies showed better outcomes of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) when compared with percutaneous transhepatic gallbladder drainage (P-GBD) in which most tubes were left in situ. However, no studies have directly compared EUS-GBD with P-GBD after tube removal (ex situ). We compared the long-term outcomes of EUS-GBD and ex situ or in situ P-GBD in high surgical risk patients with acute cholecystitis.

METHODS

We reviewed the records of 182 patients (EUS-GBD, n = 75; P-GBD, n = 107) who underwent gallbladder drainage. The procedural outcomes, long-term outcomes, and adverse events were compared.

RESULTS

The EUS-GBD group and the P-GBD group had similar rates of technical and clinical success. Early adverse events were less common in the EUS-GBD group (5.5% vs. 18.9%, P = 0.010). The long-term outcomes were evaluated in 168 patients (EUS-GBD, n = 67; P-GBD ex situ, n = 84; P-GBD in situ, n = 17). The rate of cholecystitis recurrence in the EUS-GBD group (6.0%) was similar to that in the P-GBD ex situ group (9.6%, P = 0.422), but significantly lower than that in the P-GBD in situ group (23.5%, P = 0.049). P-GBD in situ was a significant predictor of recurrent cholecystitis (hazard ratio 14.6; 95% confidence interval 2.9-72.8).

CONCLUSION

The long-term recurrence rate of acute cholecystitis in patients who underwent EUS-GBD was comparable to that in patients whose P-GBD could be removed. However, patients in whom P-GBD could not be removed showed higher rates of recurrent cholecystitis than patients with EUS-GBD.

High rates of recurrence of gallstone associated episodes following acute cholecystitis during long term follow-up: a retrospective comparative study of patients who did not receive surgery

INTRODUCTION

Patients who are admitted with acute cholecystitis (AC) and do not undergo urgent cholecystectomy, are usually referred for interval cholecystectomy. Many do not have surgery for various reasons, and some of those do not suffer from any recurrent symptoms. The primary objective of this study was to assess the rate and nature of recurrent gallstone-related events in this population over a long period, and its association with demographic and clinical parameters. A secondary objective was to assess the reasons for not undergoing surgery.

METHODS

This is a retrospective cohort study, where the study group were adult patients admitted with AC. Patients that have suffered recurrent episodes were compared with those who did not. A control group of patients that had undergone cholecystectomy following an admission with AC was used for comparison. Demographic and clinical parameters were recorded for all patients, and the association with a recurrent episode was analyzed using univariate analysis.

RESULTS

The study population was 197 patients. The group of patients who did not undergo surgery were significantly older (68.7 vs 54.2) and sicker (ASA > 3 50% vs 19%). The rate of recurrent episodes in the study group was 38.5%, and it was not found to be associated with the studied parameters. There was a trend towards higher gallstone disease specific mortality in the study group (5.5% vs 1.45% p = 0.062).

CONCLUSIONS

This is a study of long-term follow-up of patients following an episode of AC we showed that the rate of recurrent episodes is quite high and involves severe inflammatory diseases, such as obstructive jaundice and pancreatitis.

Pyogenic Liver Abscess Complicating Acute Cholecystitis: Different Management Options

Acute cholecystitis, which is usually associated with gallstones is one of the most common surgical causes of emergency hospital admission and may be further complicated by mural necrosis, perforation and abscess formation. Perforation of the gallbladder is a relatively uncommon complication of acute cholecystitis (0.8–3.2% in recent reviews). The intrahepatic perforation causing a liver abscess is an extremely rare condition, anecdotally reported in the scientific literature, even in the rare types of subacute or acute perforation. Liver abscess caused by gallbladder perforation can be a life-threatening complication with a reported mortality of 5.6%. The treatment of synchronous pyogenic liver abscess and acute cholecystitis may be challenging. We reported three cases of liver abscess due to acute cholecystitis in which different therapeutical approaches were employed. The first case was treated with antibiotics and interval laparoscopic cholecystectomy; the second case was treated with emergency cholecystectomy; and the third case with percutaneous aspiration of the abscess only. The appropriate therapeutical method in these cases depends on the patient’s clinical condition, the on-site expertise that is available in the hospital, and the experience of the surgeon.

Laparoscopic Cholecystectomy Versus Percutaneous Cholecystostomy: Suitability of APACHE-II Score, ASA Grade, and Tokyo Guidelines 18 Grade as Predictors of Outcome in Patients With Acute Cholecystitis

INTRODUCTION

Intervention options in acute cholecystitis (AC) include drainage (percutaneous/endoscopic) or surgery. Several scoring systems have been used to risk stratify acute surgical patients, but few have been validated. This study investigated the suitability of Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, American Society of Anesthesiologist (ASA) grade, and Tokyo Guidelines 2018 (TG18) grade as predictors of outcome and assess laparoscopic cholecystectomy versus percutaneous cholecystostomy (PC) as treatment options in patients with AC.

MATERIALS AND METHODS

Retrospective data was collected from patients that underwent acute inpatient cholecystectomy (index admission), urgent interval cholecystectomy (2 to 4 wk) and PC between 2016 and 2018. Data included baseline demographics, co-morbidities, ASA grade, APACHE-II score, TG18 grade, morbidity, and mortality. A P-value of <0.05 was statistically significant. Area under the receiver operating characteristic curve was calculated to compare accuracy of APACHE-II, ASA and TG18 in predicting morbidity.

RESULTS

A total of 344 consecutive patients (266 cholecystectomies and 84 PC) were included in the study. Significant difference in co-morbidities [median Charlson Co-Morbidity Index (CCI) 1 surgery and 4 cholecystostomy (PC) (P<0.05)], median APACHE-II score (3 surgery and 9 PC), median TG18 grade (1 surgery and 2 PC) and mortality rate [0% surgery and 7% cholecystostomy (PC)]. TG18 grade alone predicted postoperative/postprocedure morbidity (receiver operating characteristic; AUC=0.884; 95% confidence interval: 0.845-0.923; odds ratio: 4.38, 96% confidence interval, P<0.05).

DISCUSSION

Utilization of the TG18 grade have shown to be more accurate in risk stratifying and predicting outcomes in patients with AC and therefore may appropriately guide biliary intervention.PC can be utilized in a select group of septic and co-morbid patients (myocardial infarction <6 weeks, chest infection and acute cerebrovascular accident) unable to withstand surgical intervention or in those with complex biliary disease (Mirizzi Syndrome). In a proportion, PC drains sepsis to improve critical state of the patient enough to consider an interval cholecystectomy with satisfactory outcomes.

Percutaneous Cholecystostomy: A Bridge to Less Morbidity

Percutaneous cholecystostomy (PC) is a minimally invasive procedure for decompressing gall bladder (GB) or biliary system in emergency settings, performed in patients with GB or biliary diseases who are at high risk for surgical exploration. Indications range from acute cholecystitis in seriously ill patients to overdistended GB with impending perforation to overt GB perforation. This procedure, by allowing biliary drainage, helps in controlling the infection and optimizing the patient's condition for definitive treatment in the form of elective surgery if possible, thus acting as a bridge to a definitive treatment option. In some cases, such as acute acalculous cholecystitis, it may obviate the need for surgery, and in malignant biliary obstruction, it may be used as a palliative measure to keep GB decompressed. This review article focuses on and revisits many aspects of PC including technical aspects, clinical indications, outcomes, and safety of the procedure, in addition to its role as bridge therapy versus definitive therapy versus palliative option. It includes observations based on the author's own work experience and review of the literature.

Endoscopic Ultrasound-Guided Biliary Interventions in Liver Disease

If endoscopic retrograde cholangiopancreatography (ERCP) fails in cases of biliary obstruction and jaundice, percutaneous drains have been traditionally the current second-line option. Endoscopic ultrasonography-guided biliary drainage (EUS-BD) with choledocoduodenostomy or hepaticogastrostomy is alternative modality that have shown equivalent or better technical and clinical success compared with percutaneous drainage. Similarly, EUS-guided gallbladder drainage has emerged as a therapeutic option in acute cholecystitis as well. Furthermore, EUS-BD avoids some of the pitfalls of percutaneous drainage. Current research in EUS-BD involves optimizing devices to improve technical and clinical success. In centers with advanced endoscopists trained in these procedures, EUS-BD is an excellent second-line modality.

When to remove the drainage catheter in patients with percutaneous cholecystostomy?

OBJECTIVE

The treatment for patients with acute calculous cholecystitis who have high surgical risk with percutaneous cholecystostomy instead of surgery is an appropriate alternative choice. The aim of this study was to examine the promising percutaneous cholecystostomy intervention to share our experiences about the duration of catheter that has yet to be determined.

METHODS

A total of 163 patients diagnosed with acute calculous cholecystitis and treated with percutaneous cholecystostomy between January 2011 and July 2020 were reviewed retrospectively. The Tokyo Guidelines 2018 were used to diagnose and grade patients with acute cholecystitis.

RESULTS

The mean age was 71.81±12.81 years. According to the Tokyo grading, 143 patients had grade 2 and 20 patients had grade 3 disease. The mean duration of catheter was 39.12±37 (1-270) days. Minimal bile leakage into the peritoneum was noted in 3 (1.8%) patients during the procedure. The rate of complications during follow-up of the patients who underwent percutaneous cholecystostomy was 6.9% (n=11), and the most common complication was catheter dislocation. Cholecystectomy was performed in 33.1% (n=54) of the patients at follow-up. Post-cholecystectomy complication rate was 12.9%. At the follow-up, the rate of recurrent acute cholecystitis episodes was 5.5%, while the mortality rate was 1.8%. The length of follow-up was five years.

CONCLUSIONS

The rate of recurrence was significantly higher among the patients with catheter for <21 days. We recommend that the duration of catheter should be minimum 21 days in patients undergoing percutaneous cholecystostomy.

APACHE IV system helps to determine role of cholecystostomy in elderly patients with acute cholecystitis

Objective

Cholecystostomy is a palliative treatment for patients unfit to undergo immediate cholecystectomy. Nevertheless, the role of cholecystostomy in the clinical management of such patients remains unclear. The Acute Physiology and Chronic Health Evaluation IV (APACHE IV) scoring system is useful for estimating the hospital mortality of high-risk patients. We evaluated the therapeutic effect of cholecystostomy by the APACHE IV scoring system in patients aged >65 years with acute cholecystitis.

Methods

In total, 597 patients aged >65 years with acute cholecystitis were retrospectively analyzed using APACHE IV scores.

Results

The fitness of the APACHE IV score prediction was good, with an area under the receiver operating characteristic curve of 0.894. The chi square independence test indicated that compared with conservative treatment, cholecystostomy may have different effects on mortality for patients whose estimated mortality rate was >10%. Comparison of the estimated mortality of patients before and after cholecystostomy indicated that the estimated mortality was significantly lower after than before puncture, both in the whole patient group and in the group with an estimated mortality of >10%.

Conclusion

The APACHE IV scoring system showed that cholecystostomy is a safe and effective treatment for elderly high-risk patients with acute cholecystitis.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Percutaneous Image-Guided Biliary Procedures

Percutaneous biliary interventions are among the commonly performed nonvascular radiological interventions. Most common of these interventions is the percutaneous transhepatic biliary drainage for malignant biliary obstruction. Other biliary procedures performed include percutaneous cholecystostomy, biliary stenting, drainage for bile leaks, and various procedures like balloon dilatation, stenting, and large-bore catheter drainage for bilioenteric or post-transplant anastomotic strictures. Although these procedures are being performed for ages, no standard guidelines have been formulated. This article attempts at preparing guidelines for performing various percutaneous image-guided biliary procedures along with discussion on the published evidence in this field.

Advancements in Endoscopic Biliary Interventions by Gastroenterology

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic technique in which a specialized side-viewing endoscope is guided into the duodenum, allowing for instruments to access the biliary and pancreatic ducts. ERCP was initially developed as a diagnostic tool as computed tomography was in its infancy during that time. ERCP has evolved since its inception in the 1960s to becoming not only a valuable diagnostic resource but now an effective therapeutic intervention in the treatment of various biliary disorders. The most common biliary interventions performed by ERCP include the management of biliary obstructions for benign and malignant indications. Additionally, endoscopic ultrasound (EUS) has been increasingly utilized in diagnosing and intervening on pancreaticobiliary lesion. This article will discuss the various methods currently available for various endoscopic biliary interventions and future interventional techniques. For the management of biliary strictures, EUS can be utilized with fine need aspiration, while ERCP can be used for the placement of various stents and diagnostic modalities. Another example is radiofrequency ablation, which can be used for the treatment of hilar strictures. Achieving bile duct access can be challenging in patients with complicated clinical scenarios; other techniques that can be used for bile duct access include EUS-guided rendezvous approach, transluminal approach, Choleodochoduodenostomy, and hepatogastrostomy, along with gaining access in complicated anatomy such as in patients with Rou-en-Y anatomy. Another useful endoscopic tool is nonsurgical drainage of the gallbladder, which can be a suitable option when patients are not optimal surgical candidates. There has also been an increase in outpatient utilization of ERCP, which was previously seen as a predominantly inpatient procedure in the past. Possible future evolutions of biliary interventions include robotic manipulation of a duodenoscope and direct infusion of chemotherapeutic or immunomodulatory agents into the pancreaticobiliary tree. These advancements will depend on parallel advancements in other imaging and laboratory as well as breakthrough technology or techniques by other disciplines including interventional radiology and minimally invasive surgery.

Image-guided percutaneous cholecystostomy: a comprehensive review

Acute cholecystitis (AC) is a common emergency condition with severity ranging from mild to severe. Gallstones and critical illnesses are the common predisposing factors. Mild AC is primarily managed with medical therapy and early cholecystectomy. Moderate and severe AC require individualized treatment with a preference for early cholecystectomy. However, cholecystectomy may not always be feasible due to co-morbidities. Hence, this group of patients needs minimally invasive methods to drain the gallbladder (GB). Percutaneous cholecystostomy (PC) is the image-guided drainage of GB in the setting of moderate to severe AC. There are different approaches to PC. The technical aspects, success, and complications of PC as well as management of cholecystostomy catheter after the patient recovers from the acute episode should be thoroughly understood by the interventional radiologist. We present an extensive up-to-date review of the essential aspects of PC including indications, contraindications, techniques, and outcomes, including complications and success rates.

Healthcare Disparities in the Management of Acute Cholecystitis: Impact of Race, Gender, and Socioeconomic Factors on Cholecystectomy vs Percutaneous Cholecystostomy

BACKGROUND

While percutaneous cholecystostomy (PC) is a recommended treatment strategy in lieu of cholecystectomy (CCY) for acute cholecystitis among patients who may not be considered good surgical candidates, reports on disparities in treatment utilization remain limited. The aim of this study was to investigate the role of demographic, clinical, and socioeconomic factors in treatment of acute cholecystitis.

METHODS

Patients with a diagnosis of acute cholecystitis who underwent CCY versus PC were reviewed from the U.S. Nationwide Inpatient Sample (NIS) database between 2008-2014. Measured variables including age, race/ethnicity, Charlson comorbidity index (CCI), hospital type/region, insurance payer, household income, length of stay (LOS), hospital cost, and mortality were compared using chi-square and ANOVA. Multivariable logistic regression was performed to identify specific predictors of cholecystitis treatment.

RESULTS

A total of 1,492,877 patients (CCY:n=1,435,255 versus PC:n=57,622) were analyzed. The majority of patients that received PC were at urban teaching hospitals (65.2%). LOS was significantly longer with higher associated costs for PC [(11.1±11.0 versus 4.5±5.3 days; P<0.001) and ($99577±138850 versus $48399±58330; P<0.001)]. Mortality was also increased for patients that received PC compared to CCY (8.8% versus 0.6%; P<0.001). Multivariable regression demonstrated multiple socioeconomic and healthcare-related factors influencing the utilization of PC including male gender, Black or Asian race/ethnicity, Medicare payer status, urban hospital location, and household income (all P<0.001).

CONCLUSION

Although patients receiving PC had higher CCI scores, multiple socioeconomic and healthcare related factors appeared to also influence this treatment decision. Additional studies to investigate these disparities are indicated to improve outcomes for all individuals with this condition.

The Role of Series Cholecystectomy in High Risk Acute Cholecystitis Patients Who Underwent Gallbladder Drainage

Background: Cholecystectomy (CCY) is the only definitive therapy for acute cholecystitis. We conducted this study to evaluate which patients may not benefit from further CCY after percutaneous transhepatic gallbladder drainage (PTGBD) has been performed in acute cholecystitis patients.

Methods: Acute cholecystitis patients with PTGBD treatment were selected from one million random samples from the National Health Insurance Research Database obtained between January 2004 and December 2010. Recurrent biliary events (RBEs), RBE-related medical costs, RBE-related mortality rate and an RBE-free survival curve were compared in patients who accepted CCY within 2 months and patients without CCY within 2 months after the index admission.

Results: Three hundred and sixty-five acute cholecystitis patients underwent PTGBD at the index admission. A total of 190 patients underwent further CCY within 2 months after the index admission. The other 175 patients did not accept further CCY within 2 months after the index admission. RBE-free survival was significantly better in the CCY within 2 months group (60 vs. 42%, p < 0.001). The RBE-free survival of the CCY within 2 months group was similar to that of the no CCY within 2 months group in patients ≥ 80 years old and patients with a Charlson Comorbidity Index (CCI) score ≥ 9.

Conclusions: We confirmed CCY after PTGBD reduced RBEs, RBE-related medical expenses, and the RBE-related mortality rate in patients with acute cholecystitis. In patients who accepted PTGBD, the RBE and survival benefits of subsequent CCY within 2 months became insignificant in patients ≥ 80 years old or with a CCI score ≥ 9.

Endoscopic transpapillary gallbladder drainage for acute cholecystitis is feasible for patients receiving antithrombotic therapy

OBJECTIVES

Patients with acute cholecystitis receiving antithrombotic therapy (ATT) have an increased risk of bleeding complications during surgery and percutaneous drainage. Endoscopic transpapillary gallbladder drainage (ETGBD) is recommended for such cases; however, evidence is limited. To investigate this issue further, we performed a retrospective multicenter study.

METHODS

One hundred thirty patients with acute cholecystitis who underwent ETGBD were enrolled. They were divided into an ATT group (continuation of ATT on the day of the procedure and/or heparin substitution) and a Non-ATT group (discontinuation or no use of ATT). The primary outcome was bleeding complication rate, and the secondary outcomes were technical success rate, clinical success rate and total complication rate.

RESULTS

Eighty-three patients were enrolled in the ATT group, and 47 were enrolled in the Non-ATT group. In the ATT group, 42.2% continued multi-agent ATT. No bleeding complications occurred in either group. There were no significant differences between the ATT and Non-ATT groups in the technical success rate (84.3% vs 89.4%, P = 0.426 respectively) or the clinical success rate (97.1% vs 100%, P = 0.259, respectively). The overall early complication rate was 3.1% (4/130): mild pancreatitis (n = 3) and cholangitis (n = 1). Stent dysfunction was found in 10.9% of patients (at 196 days on average), and the 12-month stent patency rate was 69.0%.

CONCLUSIONS

No significant difference was found in the bleeding complication rate between ETGBD with and without ATT. ETGBD may be an ideal drainage method for patients with acute cholecystitis receiving ATT.

Laparoscopic Surgery and the debate on its safety during COVID-19 pandemic: A systematic review of recommendations

INTRODUCTION

The transmission of COVID-19 virus since the outbreak of viral pneumonia due to SARS-CoV-2 gave rise to protective operative measures. Aerosol generating procedures such as laparoscopic surgery are known to be associated with increased risks of viral transmission to the healthcare workers. The safety of laparoscopy during the pandemic was then debated. We aimed to systematically review the literature regarding the safe use of laparoscopy during COVID-19.

METHODS

We performed a systematic search using PubMed and ScienceDirect databases from inception to 1st May, 2020. The following search terms were used: ''laparoscopic surgery and COVID-19''; ''minimally invasive surgery and COVID-19''. Search items were considered from the nature of the articles, date of publication, aims and findings in relation to use of laparoscopic surgery during COVID-19. The study protocol was registered with PROSPERO register for systematic reviews (CRD42020183432).

RESULTS

Altogether, 174 relevant citations were identified and reviewed for this study, of which 22 articles were included. The analysis of the findings in relation to laparoscopic surgery during the pandemic were presented in tabular form. We completed the common recommendations for performing laparoscopy during the COVID-19 pandemic in forms of pre-, intra- and postoperative phases.

CONCLUSION

There is no scientific evidence to date for the transmission of COVID-19 by laparoscopic surgery. Laparoscopy can be used with precautions because of its benefits compared to open surgery. If safe, conservative management is the primary alternative during the pandemic. We concluded that recommended precautions should be respected while performing laparoscopy during the pandemic.

Characteristics and outcome of elderly patients admitted for acute Cholecystitis to medical or surgical wards

BACKGROUND

Elderly patients admitted because of acute cholecystitis are usually not operated during their initial admission and receive conservative treatment. To help formulate a new admission policy regarding elderly patients with acute cholecystitis we compared the demographic and clinical characteristics and outcome of patients > 65 with acute cholecystitis admitted to medical or surgical wards.

METHODS

This retrospective study included all patients > 65 years admitted for acute cholecystitis between January, 2009 and September, 2016. Data were retrieved from the electronic health records.

RESULTS

A total of 187 patients were detected, 54 (29%) in medical departments and 133 (71%) in surgical wards. The mean age (±SD) was 80 ± 7.5 and was higher among those in medical than surgical wards (84 ± 7 versus 79 ± 7, p <  0.05). Patients hospitalized in medical departments had more comorbidity, disability and mental impairment. However, there was no difference in mortality between the two groups, 1 (2%) and 6 (4%) respectively. Independent predictors for hospitalization in medical departments were chronic obstructive pulmonary disease (OR = 9.8, 95% C. I 1.6-59) and the Norton Scale score (NSS)(OR = 0.7, 95% C. I 0.7-0.8). Impaired mental condition was the only predictor for hospitalization > 1 week. The strongest predictor for having cholecystostomy was admission to the surgical department (OR = 14.7, 95% C. I 3.9-56.7). Linear regression showed a negative correlation between NSS and length of hospitalization (LOH; Beta = - 0.5).

CONCLUSION

Elderly patients with acute cholecystitis who require conservative management, especially those with severe functional and mental impairment can be safely hospitalized in medical departments. Outcome was not inferior in terms of mortality and LOH. These results have practical policy implications for the placement of elderly patients with acute cholecystitis in medical rather than surgical departments.

[Cholecystostomy in acute cholecystitis in modern surgical practice]

OBJECTIVE

To improve the results of treatment of acute cholecystitis.

MATERIAL AND METHODS

A historical cohort study (1965-2016) included 1248 patients with acute obstructive cholecystitis and 154 patients with acute obstructive cholecystitis combined with ductal complications and obstructive jaundice. Cholecystostomy was used in all patients. A systematic review of the evidence base on the use of cholecystostomy in high-risk patients was carried out.

RESULTS

Cholecystostomy through laparotomy was performed in 240 patients for the period 1965-1981. Overall mortality was 3.6%. Staged treatment strategy has been applied since 1982. Laparoscopic cholecystostomy followed by cholecystectomy through laparotomy was performed in 225 patients for the period from 1982 to 1992. Overall mortality rate was 3.2%. Laparoscopic cholecystostomy (n=617) followed by staged laparoscopic cholecystectomy has been applied for the period from 1993 to 2007. Overall mortality decreased up to 1.1%. Indications for laparoscopic cholecystostomy and staged treatment have been limited since 2008 (n=166). Overall mortality rate was 0.6%. The maximum postoperative mortality after cholecystostomy in some years reached 14.8%.

Simultaneous surgeries through laparotomy in patients with acute obstructive cholecystitis and ductal complications were followed by mortality rate 8%, staged laparoscopic cholecystostomy and other minimally invasive technologies (endoscopic papillosphincterotomy with lithoextraction and laparoscopic cholecystectomy) - 4.7%.

CONCLUSION

External drainage of the gallbladder is more effective as additional method within staged minimally invasive treatment of complicated cholecystitis rather separate operation. Further analysis of treatment of high-risk patients with acute cholecystitis (as most often selected for cholecystostomy) is required considering the absence of evidence base on this issue.

Percutaneous cholecystostomy - An option in selected patients with acute cholecystitis

While urgent percutaneous cholecystostomy (PC) was introduced as an alternative to acute surgical treatment for acute cholecystitis (AC), the current place of PC in the treatment algorithm for AC is challenged. We evaluate demographics and outcomes of PC in routine clinical practice in a population-based cohort.Retrospective evaluation of consecutive patients treated with PC for AC between 2000 and 2015. The severity of cholecystitis was graded according to the 2013 Tokyo Guidelines.One hundred forty-nine patients were included (82; 55% males) (median age of 72.5 years; range, 21-92). The Tokyo Guidelines criteria of 2013 (TG13) severity grade distribution was 4%, 61.7%, and 34.2% for grades I, II, and III, respectively. No difference was observed between males and females with regard to age, American Society of Anesthesiologists (ASA) score, comorbidities, or previous history of cholecystitis. PC was successfully performed in all but 1 patient, and complications were few and minor. Less than half (48.3%) of all patients subsequently received definitive surgical treatment, mostly (83.3%) laparoscopy. No or minor complications were encountered in 58 (80.6%) patients. Operated patients were significantly younger (P = <.001) and had lower ASA scores (P = .005), less comorbidities (P < .001), and had more seldomly a severe grade 3 cholecystitis (P < .001) than non-operated patients.PC is useful in selected patients with AC. However, since only a half of the patients eventually received definitive surgical treatment, a better routine decision-making based on proper criteria may enable an improved allocation of the individual patient for tailored treatment according to the disease severity, the patient's comorbidity burden, and also to the treatment options available at the institution to prevent overutilization of a non-definitive treatment approach. Comprehension of this responsibility should be acknowledged by hospitals with an emergency surgical service, although the clinical decision-making remains a challenge of the responsible surgeon on call.

Natural Course of Acute Cholecystitis in Patients Treated With Percutaneous Transhepatic Gallbladder Drainage Without Elective Cholecystectomy

BACKGROUND

Percutaneous transhepatic gallbladder drainage (PTGBD) is an alternative treatment for acute cholecystitis (AC). We aimed to understand the natural course of AC in patients treated with PTGBD but without later definitive treatments, such as laparoscopic cholecystectomy.

METHODS

This was a retrospective study of the period from June 2010 to December 2016, during which time 2371 patients were diagnosed with AC and 625 received PTGBD treatment. Among the 625 patients, 237 received no definitive treatment. A biliary event after the initial AC episode was the outcome of interest. In addition, the competing risk of death unrelated to biliary causes was present in the cohort. Therefore, a competing risk model was applied for analysis.

RESULTS

The cumulative incidence of biliary events was 29.8% with a median of 4.27 months, while the competing event, i.e., death unrelated to a biliary event, was noted in 14.9% of patients with a median 23.54 months. The risk factors of biliary events were prolonged PTGBD indwelling and an abnormal PTGBD cholangiogram. The risk factors of death unrelated to a biliary event included a high Charlson comorbidity index and the initial AC severity.

CONCLUSIONS

Definitive cholecystectomy is still recommended for patients undergoing PTGBD treatment due to the high incidence of later biliary events. A thorough preoperative evaluation is necessary for those patients before elective cholecystectomy because of the inferior life expectancy and physical status.

Clinical and Survival Outcomes Using Percutaneous Cholecystostomy Tube Alone or Subsequent Interval Cholecystectomy to Treat Acute Cholecystitis

BACKGROUND

Percutaneous cholecystostomy (PCT) is a safe method of gallbladder drainage in the setting of severe or complicated acute cholecystitis (AC), particularly in patients who are high-risk surgical candidates. Small case series suggest that PCT aids resolution of acute cholecystitis in up to 90% of patients. However, reluctance is observed in utilising PCT more frequently, due to concerns that we are committing comorbid patients to an interval surgical procedure for which they may not be suitable.

AIM

The aim of this study was to assess the clinical and survival outcomes of PCT use, with particular emphasis on a subgroup of patients who did not proceed to cholecystectomy.

METHODS

A retrospective analysis was performed of all patients with severe acute cholecystitis who required PCT insertion in a tertiary referral hospital from 2010 to 2015. Patient demographics and clinical data including systemic inflammatory response (SIRS) scores at presentation, readmissions and clinical and survival outcomes were analysed. Statistical analysis was performed using SPSS v.22 and GraphPad Prism v.7.

RESULTS

In total, 157 patients (59% males) with AC underwent PCT insertion during the study period. Median age at presentation was 71 years (range 29-94). A median SIRS score of 3 was noted at presentation. Patients required a median of two cholecystostomy tube changes/replacements (range 1-10) during treatment. Transhepatic tube placement was the preferred approach (69%) with 31% of tubes being placed via transabdominal approach. Only 55% proceeded to interval cholecystectomy. Of the 70 patients treated with PCT alone, their median age was 75 years. In this subgroup, only 12.9% (n = 9) developed recurrent biliary sepsis necessitating readmission following initial resolution of symptoms and tube removal. All episodes of recurrent biliary sepsis presented within 6 months of index presentation, and definitive PCT removal in this group was performed at a median of 3 months. No difference in survival was observed between both groups.

CONCLUSION

Almost 90% of patients with AC who are managed definitively with a PCT will recover uneventfully without recurrent sepsis following PCT removal. This is a viable option for older, comorbid patients who are unfit for surgical intervention and is not associated with significantly increased mortality.

EUS-guided gallbladder drainage: a learning curve modified by technical progress

Introduction  Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an efficacious and safe option for patients who cannot undergo cholecystectomy. It is a technically challenging procedure, requiring skills in EUS, and ERCP. The aim of this study was to define the learning curve for EUS-GBD. Patients and methods  Consecutive patients undergoing EUS-GBD by a single operator were included from a prospective registry over 5 years. Demographics, procedure information, post-procedure follow-up data, and information on adverse events were collected. Non-linear regression and CUSUM analyses were conducted for the learning curve. Clinical success was defined as resolution of cholecystitis post-procedure. Results  Forty-eight patients were included (58 % male, mean age 76 years). Twenty patients (42 %) had malignant cholecystitis. Most patients had lumen-apposing metal stents (LAMS) (15 mm, n = 29, 60 %; 10 mm, n = 8, 7 %). The remaining patients had FCSEMS (n = 9, 19 %) or plastic stents alone (n = 2, 4 %). Clinical success was achieved in 36 (86 %) of patients. Of the remaining 12, 7 were lost to follow-up and 5 had persistent cholecystitis. 9 patients (19 %) had adverse events including bleeding (n = 4), liver abscesses (n = 2), and hypotension. Two patients passed away post-procedure. Median procedure time was 41 minutes (range 16 - 121 min), with the 41-minute time occurring during the 19th procedure. Procedure durations further reduced, with the last 10 procedures being 20 minutes or under (nonlinear regression p value P  < 0.0001). Conclusion  Endoscopists experienced in EUS-GBD are expected to achieve a reduction in procedure time over successive cases, with efficiency reached at 41 minutes and a learning rate of 19 cases. Continued improvement is demonstrated with additional experience.

Transcholecystic approach for distal common bile duct stricture in a non-dilated biliary system: an alternative route

A 63-year-old patient was admitted to intensive treatment unit with biliary sepsis due to a small distal common bile duct stone. Endoscopic retrograde cholangiopancreatography was initially attempted for insertion of a biliary stent but failed due to the presence of a periampullary diverticulum. Referral to interventional radiology for percutaneous drainage was considered the next alternative even though there was no dilatation of intrahepatic ducts. Due to complete absence of intrahepatic duct dilatation, the traditional percutaneous transhepatic route was considered rather challenging. An alternative percutaneous approach via the gallbladder and subsequent catheterisation of the duodenum via the distal common bile duct was successfully performed instead without complication. We would like to describe this technique as an alternative option for drainage of the non-dilated biliary system in patients with sepsis.

A New Technique of Endoscopic Transpapillary Gallbladder Drainage Combined with Intraductal Ultrasonography for the Treatment of Acute Cholecystitis

Background/Aims:

Endoscopic transpapillary gallbladder drainage (ETGBD) is useful for the treatment of acute cholecystitis; however, the technique is difficult to perform. When intraductal ultrasonography (IDUS) is combined with ETGBD, the orifice of the cystic duct in the common bile duct may be more easily detected in the cannulation procedure. The aim of this study was to evaluate the efficacy of ETGBD with IDUS compared with that of ETGBD alone.

Methods:

A total of 100 consecutive patients with acute cholecystitis requiring ETGBD were retrospectively recruited. The first 50 consecutive patients were treated using ETGBD without IDUS, and the next 50 patients were treated using ETGBD with IDUS. Through propensity score matching analysis, we compared the clinical outcomes between the groups. The primary outcome was the technical success rate.

Results:

The technical success rate of ETGBD with IDUS was significantly higher than that of ETGBD without IDUS (92.0% vs. 76.0%, p=0.044). There was no significant difference in procedure length between the two groups (74.0 min vs. 66.7 min, p=0.310). The complication rate of ETGBD with IDUS was significantly higher than that of ETGBD without IDUS (6.0% vs. 0%, p<0.001); however, only one case showed an IDUS technique-related complication (pancreatitis).

Conclusions:

The assistance of IDUS may be useful in ETGBD.

Initial experience with endoscopic ultrasound-guided gallbladder drainage

Introduction

Patients with acute cholecystitis who are unsuitable for cholecystectomy undergo conservative treatment or percutaneous transhepatic gallbladder drainage. As these two methods are not always successful, further treatment options are needed. One increasingly popular method is endoscopic ultrasound-guided gallbladder drainage (EUSGBD), whereby stents are placed so as to create a permanent fistula connecting the gallbladder to the stomach or the duodenal bulb, thus enabling drainage of its contents to the gastrointestinal tract.

Aim

To present our early experience with EUSGBD for the treatment of cholecystitis in patients who are not suitable for cholecystectomy.

Material and methods

The procedure was performed in 5 patients with acute cholecystitis. Two patients also had symptoms of biliary obstruction due to pancreatic head cancer. An ultrasound endoscope was used to create a fistula between the gallbladder and the stomach or between the gallbladder and the duodenal bulb, in which a self-expandable metallic stent (SEMS) was placed.

Results

All procedures were performed with no perioperative complications. In all patients, the clinical symptoms of cholecystitis subsided within 3-15 days. In those patients who also showed symptoms of biliary obstruction, these symptoms subsided within 3-6 days following the procedure.

Conclusions

The EUSGBD seems to be an effective and safe treatment for acute cholecystitis in patients unsuitable for cholecystectomy. It can also be used to treat jaundice caused by obstruction of the common bile duct, when no other methods can be used. The method is particularly promising in cases of concurrent acute cholecystitis and common bile duct obstruction.

Percutaneous Cholecystostomy Versus Conservative Treatment for Acute Cholecystitis: a Cohort Study

BACKGROUND

Percutaneous cholecystostomy is frequently used as a treatment option for acute calculous cholecystitis in patients unfit for surgery. There is sparse evidence on the long-term impact of cholecystostomy on gallstone-related morbidity and mortality in patients with acute calculous cholecystitis. This study describes the long-term outcome of acute calculous cholecystitis following percutaneous cholecystostomy compared to conservative treatment.

METHODS

This was a cohort study of patients admitted at our institution from 2006 to 2015 with acute calculous cholecystitis without early or delayed cholecystectomy. Endpoints were gallstone-related readmissions, recurrent cholecystitis, and overall mortality.

RESULTS

The investigation included 201 patients of whom 97 (48.2%) underwent percutaneous cholecystostomy. Patients in the cholecystostomy group had significantly higher age, comorbidity level, and inflammatory response at admission. The median duration of catheter placement in the cholecystostomy group was 6 days. The complication rate of cholecystostomy was 3.1% and the mortality during the index admission was 3.5%. The median follow-up was 1.6 years. The rate of gallstone-related readmissions was 38.6%, and 25.3% had recurrence of cholecystitis. Cox regression analyses revealed no significant differences in gallstone-related readmissions, recurrence of acute calculous cholecystitis, and overall mortality in the two groups.

CONCLUSIONS

Percutaneous cholecystostomy in the treatment of acute calculous cholecystitis was neither associated with long-term benefits nor complications. Based on the high gallstone-related readmission rates of this study population and todays perioperative improvements, we suggest rethinking the indications for non-operative management including percutaneous cholecystostomy in acute calculous cholecystitis.

Preliminary Report of Percutaneous Cholecystostomy as Diagnosis and Treatment of Biliary Tract Trauma

BACKGROUND

Biliary leak following severe blunt liver injuries is a complex problem becoming more frequent with improvements in non-operative management. Standard treatment requires main bile duct drainage usually performed by endoscopic sphincterotomy and stent placement. We report our experience with cholecystostomy as a first minimally invasive diagnostic and therapeutic approach.

METHODS

We performed a retrospective analysis of consecutive patients with post-traumatic biliary leak between 2006 and 2015. In the first period (2006-2010), biliary fistula was managed using perihepatic drainage and endoscopic, percutaneous or surgical main bile duct drainage. After 2010, cholecystostomy as an initial minimally invasive approach was performed.

RESULTS

Of 341 patients with blunt liver injury, 18 had a post-traumatic biliary leak. Ten patients received standard treatment and eight patients underwent cholecystostomy. The cholecystostomy (62.5%) and the standard treatment (80%) groups presented similar success rates as the first biliary drainage procedure (p = 0.41). Cholecystostomy presented no severe complications and resulted, when successful, in a bile flow rate inversion between the perihepatic drains and the gallbladder drain within a median [IQR] 4 days [1-7]. The median time for bile leak resolution was 26 days in the cholecystostomy group and 39 days in the standard treatment group (p = 0.09). No significant difference was found considering median duration of hospital stay (54 and 74 days, respectively, p = 0.37) or resuscitation stay (17.5 and 19.5 days, p = 0.59).

CONCLUSION

Cholecystostomy in non-operative management of biliary fistula after blunt liver injury could be an effective, simple and safe first-line procedure in the diagnostic and therapeutic approach of post-traumatic biliary tract injuries.

Hybrid procedure combining endoscopic gallbladder lavage and internal drainage with elective cholecystectomy for acute cholecystitis: A prospective pilot study (The BLADE study)

BACKGROUND AND AIM

Percutaneous transhepatic drainage is the most common method for non-operative gallbladder drainage, but the technique does have several disadvantages because of its invasive nature and requirement for continuous drainage. To overcome these disadvantages, we developed a novel procedure, endoscopic gallbladder lavage followed by stent placement, carried out in a single endoscopic session. Our aim was to prospectively evaluate the efficacy and safety of this procedure in patients with acute cholecystitis.

METHODS

Patients diagnosed with moderate cholecystitis at four tertiary care centers were enrolled in this study. We initially placed a 5-Fr tube to carry out gallbladder lavage. The tube was then cut to the optimal length and placed as a stent. Main outcomes were procedural and clinical success rates.

RESULTS

The procedure was attempted in 40 patients and was successful in 30 (75.0%). Minor adverse events occurred in two (5.0%) patients: perforation of the cystic duct by the guidewire in one patient and pancreatitis in the other. Among the 30 patients in whom the procedure was successfully done, clinical resolution was obtained in 29 (96.6%). Elective cholecystectomy was carried out in 37 patients (92.5%), with a median delay after drainage of 42 days (range, 12-138 days). There were no adverse events during the waiting period.

CONCLUSIONS

Gallbladder rinsing followed by internal drainage using a 5-Fr nasobiliary tube is considered an effective and safe alternative to other techniques, providing an acceptable success rate in patients with acute cholecystitis prior to elective surgery.

CLINICAL TRIAL INFORMATION

http://www.umin.ac.jp/ctr/index.htm (ID: UMIN-000009680).

Percutaneous cholecystostomy for delayed laparoscopic cholecystectomy in patients with acute cholecystitis: analysis of a single-centre experience and literature review

INTRODUCTION

Percutaneous cholecystostomy (PC) has been used as a relatively safe and efficient temporising measure in the treatment of acute cholecystitis (AC) in high-risk patients with serious co-morbidity and in elderly patients.

AIM

To assess the effectiveness, possible advantages, and complication of delayed laparoscopic cholecystectomy (LC) following PC in patients with AC.

MATERIAL AND METHODS

A total of 52 LC for AC were divided into two groups: the first group consisted of patients who had PC followed by LC (PCLC group, n = 12), and the second group consisted of patients who had conservative treatment followed by LC (non-PCLC group, n = 40). Eight of these patients were males and four were female. The groups were statistically compared regarding their demographic, comorbidity, hospital stay, conservation, and complication rates. PC was performed via the transhepatic route under ultrasound guidance using local anaesthesia.

RESULTS

Percutaneous cholecystostomy was technically successful in 12 patients with no attributable mortality or major complications. Upon the regression of cholecystitis and the decrease in APACHE-II scores, the PC catheter was unplugged and elective LC was scheduled for after 8 weeks. Ninety-two percent had complete resolution of symptoms within 48 h of intervention while 8% had partial resolution. All of the patients in PCLC and non-PCLC groups recovered well from cholecystectomy.

CONCLUSIONS

This study suggests that PCLC would not significantly improve the outcome of LC as assessed by conversion and morbidity rate and hospital stay compared with non-PCLC. Percutaneous cholecystostomy is a valid alternative for patients with acute cholecystitis. And our study shows that the laparoscopic cholecystectomy is a good option in high-risk patients who have been treated by percutaneous cholecystostomy for acute cholecystitis.

Endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis with a silicone-covered nitinol short bilaterally flared stent: a case series

BACKGROUND AND STUDY AIM

Gallbladder drainage in patients with cholecystitis who are unsuitable for surgery may be performed by endoscopic ultrasound (EUS)-guided placement of specifically designed fully covered metal stents. We describe the first case series of patients treated with a silicone-covered nitinol stent with bilateral anchor flanges.

PATIENTS AND METHODS

Data from consecutive patients with acute cholecystitis who were deemed unsuitable candidates for surgery were collected. The stent placement procedure was performed in two tertiary endoscopy centers by four experienced endoscopists. Technical and clinical success rates, as well as adverse events and clinical outcome at follow-up, were assessed.

RESULTS

EUS-guided drainage for cholecystitis was performed in 16 patients (mean age 84 years; nine males). Technical and clinical success rates were 100 % (16/16) and 94 % (15/16), respectively; an early failure due to stone impaction occurred in the remaining case and required placement of a new stent. Symptom relief occurred in 11/15 cases (73 %) within 1 day, and within 2 days in the remaining 4 patients. Bleeding occurred in two patients (13 %): in one patient intraprocedural bleeding was successfully stopped during endoscopy; and delayed bleeding occurred in one patient requiring arterial embolization for catastrophic bleeding (patient died 10 days later). No cases of cholecystitis recurrence or biliary obstruction were observed during a median follow-up of 112 days (range 49 - 180 days).

CONCLUSIONS

Our data showed that EUS-guided gallbladder drainage with a specially designed stent is feasible and successful in patients with acute cholecystitis who are unfit for surgery.

Acute cholecystitis in elderly patients: A case for early cholecystectomy

BACKGROUND

Recent advances in laparoscopic techniques and perioperative care have changed the indications for surgery in elderly patients. Consequently, the willingness to offer early surgery for acute cholecystitis continues to increase. This study aims to assess the perioperative outcome of early cholecystectomy for acute calculous cholecystitis in elderly patients.

PATIENTS AND METHODS

All consecutive patients treated by early cholecystectomy for acute calculous cholecystitis in a major teaching hospital, between January 2002 and November 2016, were retrospectively analyzed. The outcome of elderly patients (≥75 years) was compared to that of all others. Conversion rate, 30 days morbidity, 30 days mortality and length of hospital stay were assessed.

RESULTS

Early cholecystectomy for acute calculous cholecystitis was performed in 703 patients: 121 (17%) aged ≥75 years and 582 (83%) aged <75 years. Significantly more elderly patients had an ASA score ≥3 (37% vs. 8%, P<0.001). Morbidity was higher in the elderly group (17% vs. 8%, P<0.004), mainly attributable to the high incidence of cystic stump leakage in this group; a complication that no longer occurred after changing the technique of ligation of the cystic stump. The cardiopulmonary complication rate (4% vs. 3%, P=0.35) as well as mortality did not significantly differ (3% vs. 1%, P=0.07). The conversion rate was higher in the elderly group (18% vs. 5%, P<0.001) and the median postoperative length of hospital stay was longer (5.0 vs. 3.0 days, P<0.001).

CONCLUSION

Early laparoscopic cholecystectomy is a treatment well suited to elderly patients with mild and moderate acute cholecystitis.

Percutaneous transhepatic papilla balloon dilatation combined with a percutaneous transcystic approach for removing concurrent gallbladder stone and common bile duct stone in a patient with billroth II gastrectomy and acute cholecystitis: A case report

BACKGROUND

A 61-year-old man presented with upper abdominal pain and jaundice. Abdominal computed tomography imaging revealed stones in the gallbladder and the common bile duct, with a thickening of the gallbladder wall and an obvious increase in the volume of the gallbladder. Initial treatment using endoscopic retrograde cholangiopancreatography failed due to the presence of surgically altered gastrointestinal anatomy. Stones in the gallbladder and common bile duct were subsequently removed concurrently via percutaneous transhepatic papilla balloon dilatation combined with a percutaneous transcystic approach. Liver function recovered rapidly, with total bilirubin and direct bilirubin levels decreasing to normal, with a concomitant improvement in hemoglobin and thrombocyte levels and resolution of the upper abdominal pain and jaundice.

CONCLUSION

Percutaneous transhepatic papilla balloon dilatation, combined with a percutaneous transcystic approach, provided an effective alternative treatment for removing concurrent stones in the common bile duct and gallbladder in a patient with a previous Billroth II gastrectomy and presenting with an acute cholecystitis.

Percutaneous cholecystostomy: prognostic factors and comparison to cholecystectomy

BACKGROUND

Data regarding long-term outcomes following percutaneous cholecystostomy (PC) are limited, and comparisons to cholecystectomy (CCY) are lacking. We hypothesized that chronic disease burden would predict 1-year mortality following PC, and that outcomes following PC and CCY would be similar when controlling for preprocedural risk factors.

METHODS

We performed a 10-year retrospective cohort analysis of patients with acute cholecystitis managed by PC (n = 114) or CCY (n = 234). Treatment response was assessed by systemic inflammatory response syndrome (SIRS) criteria at PC/CCY and 72 h later. Logistic regression identified predictors of 30-day and 1-year mortality following PC. PC and CCY patients were matched by age, Tokyo Guidelines (TG13) cholecystitis severity grade, and VASQIP calculator predicted mortality (n = 42/group).

RESULTS

The presence of SIRS at 72 h following PC was associated with 30-day mortality [OR 8.9 (95% CI 2.6-30)]. SIRS at 72 h was present in and 21.4% of all PC patients, significantly higher than unmatched CCY patients (4.7%, p = 0.048). Independent predictors of 1-year mortality following PC were DNR status [19.7 (2.1-186)], disseminated cancer [7.5 (2.1-26)], and congestive heart failure [3.9 (1.4-11)]. PC patients with none of these risk factors had 17.9% 90-day mortality and no deaths after 90 days; late deaths continued to occur among patients with DNR, CHF, or disseminated cancer. At baseline, PC patients had greater acute and chronic disease burden than CCY patients. After matching, PC and CCY patients had similar age (69 vs. 70 years), TG13 grade (2.4 vs. 2.4), and predicted 30-day mortality (5.5 vs. 6.8%). Matched PC patients had higher 30-day mortality (14.3 vs. 2.4%, p = 0.109) and 180-day mortality (28.6 vs. 7.1%, p = 0.048).

CONCLUSIONS

Treatment response to PC predicted 30-day mortality; DNR status, and chronic diseases predicted 1-year mortality. Although the matching procedure did not eliminate selection bias, PC was associated with persistent systemic inflammation and higher long-term mortality than CCY.

Cholecystostomy Treatment in an ICU Population: Complications and Risks

BACKGROUND

Percutaneous cholecystostomy tube placement has widely been used as an alternative treatment to cholecystectomy, especially in advanced disease or critically ill patients. Reported postprocedural complication rates have varied significantly over the last decade. The goal of this study is to evaluate the safety of percutaneous cholecystostomy tube treatment in critically ill patients.

STUDY DESIGN

We performed a retrospective chart analysis of 96 critically ill patients who underwent cholecystostomy tube placement during an intensive care unit (ICU) stay between 2005 and 2010 in a tertiary care center in central Massachusetts. Complications within 72 hours of cholecystostomy tube placement and any morbidity or mortality relating to presence of cholecystostomy tube were considered.

RESULTS

A total of 65 male and 31 female patients with a mean age of 67.4 years underwent percutaneous cholecystostomy tube placement during an ICU stay. Sixty-six patients experienced a total of 121 complications, resulting in an overall complication rate of 69%. Fifty-four of these complications resulted from the actual procedure or the presence of the cholecystostomy tube; the other 67 complications occurred within 72 hours of the cholecystostomy procedure. Ten patients died. Tube dislodgment was the most common complication with a total of 34 episodes.

CONCLUSIONS

Cholecystostomy tube placement is associated with frequent complications, the most common of which is tube dislodgment. Severe complications may contribute to serious morbidity and death in an ICU population. Complication rates may be underreported in the medical literature. The potential impact of cholecystostomy tube placement in critically ill patients should not be underestimated.

Percutaneous cholecystostomy in the management of high-risk patients presenting with acute cholecystitis: Timing and outcome at a single institution

BACKGROUND

Cholecystectomy is the standard of care in acute cholecystitis (AC). Percutaneous cholecystostomy (PC) is an effective alternative for high-risk surgical cases.

METHODS

A retrospective analysis is presented of AC patients treated with PC drainage at a single tertiary institution over a 21 month period, assessing outcome and complications.

RESULTS

Of 119 patients, 103 had clinical improvement after PC insertion. There were 7 peri-procedural deaths (5.9%), all in elderly high-risk cases. Overall, 56/103 cases (54%) were definitively managed with PC drainage with 41 patients (40%) undergoing an elective cholecystectomy (75% performed laparoscopically). The timing of PC insertion did not affect AC resolution or drain-related complications, although more patients underwent an elective cholecystectomy if PC placement was delayed (>24 h after admission).

CONCLUSIONS

In AC, drainage by a PC catheter is a safe and effective procedure. It may be used either as a bridge to elective cholecystectomy or in selected cases as definitive therapy.

Conservative treatment of acute cholecystitis: a systematic review and pooled analysis

BACKGROUND

In medical practice, the tendency to remove an inflamed gallbladder is deeply rooted. Cholecystectomy, however, is associated with relatively high complication rates, and therefore the decision whether or not to perform surgery should be well considered. For some patients, the surgical risk-benefit profile may favour conservative treatment. The objective of this study was to examine the short- and long-term outcome of conservative treatment of patients with acute calculous cholecystitis.

METHODS

A systematic search of MEDLINE, Embase and Cochrane Library databases was performed. Prospective studies reporting on the success rate of conservative treatment (i.e. non-invasive treatment) of acute cholecystitis during index admission were included, as well as prospective and retrospective studies reporting on the recurrence rate of gallstone-related disease during long-term follow-up (i.e. ≥12 months) after initial non-surgical management. Study selection was undertaken independently by two reviewers using predefined criteria. The risk of bias was assessed. The pooled success and mortality rate during index admission and the pooled recurrence rate of gallstone-related disease during long-term follow-up were calculated using a random-effects model.

RESULTS

A total of 1841 patients were included in 10 randomized controlled trials and 14 non-randomized studies. Conservative treatment during index admission was successful in 87 % of patients with acute calculous cholecystitis and in 96 % of patients with mild disease. In the long term, 22 % of the patients developed recurrent gallstone-related disease. Pooled analysis showed a success rate of 86 % (95 % CI 0.8-0.9), a mortality rate of 0.5 % (95 % CI 0.001-0.009) and a recurrence rate of 20 % (95 % CI 0.1-0.3).

DISCUSSION

Conservative treatment of acute calculous cholecystitis during index admission seems feasible and safe, especially in patients with mild disease. During long-term follow-up, less than a quarter of the patients appear to develop recurrent gallstone-related disease, although this outcome is based on limited data.

Emergency Versus Delayed Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage in Grade II Acute Cholecystitis Patients

INTRODUCTION

In grade II acute cholecystitis patients presenting more than 72 h after onset of symptoms, we prospectively compared treatment with emergency (ELC) to delayed laparoscopic cholecystectomy performed 6 weeks after percutaneous transhepatic gallbladder drainage (PTGBD).

METHODS

Four hundred ninety-five patients with acute cholecystitis were assessed for eligibility; 345 were excluded or declined to participate. One hundred fifty patients were treated after consent with either ELC or PTGBD.

RESULTS

Both PTGBD and ELC were able to resolve quickly cholecystitis sepsis. ELC patients had a significantly higher conversion rate (24 vs. 2.7 %, P < 0.001), longer mean operative time (87.8 ± 33.06 vs. 38.09 ± 8.23 min, P < 0.001), higher intraoperative blood loss (41.73 ± 51.09 vs. 26.33 ± 23.86, P = 0.008), and longer duration of postoperative hospital stay (51.71 ± 49.39 vs. 10.76 ± 5.75 h, P < 0.001) than those in the PTGBD group. Postoperative complications were significantly more frequent in the ELC group (26.7 vs. 2.7 %, P < 0.001) with a significant increase in incidence (10.7 %) of bile leak (P = 0.006) compared to those in the PTGBD group.

CONCLUSION(S)

PTGBD and ELC are highly efficient in resolving cholecystitis sepsis. Delayed cholecystectomy after PTGBD produces better outcomes with a lower conversion rate, fewer procedure-related complications, and a shorter hospital stay than emergency cholecystectomy.