TG13 current terminology, etiology, and epidemiology of acute cholangitis and cholecystitis

Preoperative predictors of difficult early laparoscopic cholecystectomy among patients with acute calculous cholecystitis in Egypt

BACKGROUND

Early laparoscopic cholecystectomy (ELC) in the setting of acute calculous cholecystitis (ACC) requires to be performed by highly-skilled surgeons to avoid complications. The purpose of this study is to identify preoperative factors that would predict difficult ELC among patients with ACC prior to proceeding with surgery.

METHODS

We retrospectively reviewed all patients who received ELC within 10 days from the onset of symptoms of ACC between August 1, 2018, and December 31, 2022. They were divided into 2 groups according to the difficulty of surgery.

RESULTS

149 patients with ACC received ELC during the study period. ELC was considered difficult in 52 patients (35%). Five preoperative factors were identified as significant predictors of difficult ELC (DELC) on multivariate analysis: duration of acute attack ≥ 4 days from the onset of symptoms till surgery (OR 34.4, P < 0.001), ultrasound showing largest gallstone size > 20 mm (OR 20.2, P = 0.029), ultrasound showing gallstone impaction in Hartmann's pouch (OR 7.2, P = 0.017), history of prior episode(s) of acute attack (OR 6.8, P = 0.048), and diabetes mellitus (OR 5.8, P = 0.046).

CONCLUSION

Careful preoperative assessment of patients with ACC is crucial among junior surgeons with limited surgical expertise prior to proceeding with ELC to identify those at risk of DELC to potentially reduce postoperative morbidity and mortality. If encountered, a management plan should be made, and surgery should proceed only upon confirming the availability of experienced surgeons in the field of biliary and laparoscopic surgery to supervise or assist in the procedure. Alternatively, such group of patients should rather be transferred to more advanced surgical centers which offer higher level of care to maintain patient safety and optimal surgical outcomes. More importantly, bail-out procedures should always be resorted to whenever DELC is encountered intraoperatively to prevent further surgical damage.

Bailout for the Difficult Gallbladder: Subtotal vs. Open Cholecystectomy-A Retrospective Tertiary Care Center Experience

Background and Objectives: A difficult gallbladder anatomy augments the risk of bile duct injuries (BDIs) and other complications during a laparoscopic cholecystectomy. This study compares the outcomes of a laparoscopic subtotal cholecystectomy (LSTC) and open total cholecystectomy (OTC) for difficult cholecystectomies. Materials and Methods: This retrospective analysis of gallbladder procedures (LSTC or OTC) from 2016 to 2023 examined patient demographics, surgical details, and postoperative results. The primary outcome was the incidence of a BDI. Secondary outcomes included operative duration, blood loss, and postoperative complications. Results: Seventy-one patients were included in the study. Of them, 59.2% (n = 42) underwent an LSTC and 44.6% (n = 29) underwent an OTC. The LSTC cohort was more likely to have a day-surgery case with a same-day discharge (33.3% vs. 0%, p = 0.009), less blood loss (71.4 ± 82.26 vs. 184.8 ± 234.86, p = 0.009), and a shorter operative duration (187.86 ± 68.74 vs. 258.62 ± 134.52 min, p = 0.008). Furthermore, BDI was significantly lower in the LSTC group (2.4% vs. 17.2%, p = 0.045). However, there were no significant differences between the two groups concerning intraoperative drain placement, peri-cholecystic fluid collection, bile leak, and other complications (p > 0.05). Conclusions: LSTC is a safe and effective alternative to OTC for challenging gallbladder cases. Further studies with larger sample sizes and longer follow-up periods as well as different study designs are warranted.

Genetic evidence causally linking gastroesophageal reflux disease to cholecystitis: a two-sample mendelian randomization study

BACKGROUND

Gastroesophageal reflux disease (GERD) and cholecystitis share overlapping symptoms, including belching, acid reflux, and heartburn. Despite this, the causal relationship between these two conditions remains unclear. This study aimed to investigate the causal link between GERD and cholecystitis using a Mendelian randomization (MR) approach.

METHODS

A two-sample MR analysis was conducted using the inverse variance weighted (IVW), weighted median, weighted mode, and MR-Egger method to assess the causal effects of GERD on the cholecystitis risk. Genome-wide association studies (GWASs) on GERD (N cases = 129080; N controls = 473524) and cholecystitis (N cases = 1930; N controls =359264) were obtained from the IEU Open GWAS project. Various techniques were employed to assess pleiotropy and heterogeneity.

RESULTS

Seventy-seven single nucleotide polymorphisms from GERD GWASs were selected as instrumental variables (IVs). The primary IVW method revealed a significant association between GERD and an increased risk of cholecystitis (odds ratio = 1.004; 95% confidence interval = 1.003-1.005, p = 2.68 × 10- 9). The absence of heterogeneity and pleiotropy in the data supports the reliability of the results.

CONCLUSIONS

GERD was positively associated with the risk of cholecystitis. This study provides insights into potential avenues for the development of prevention strategies and treatment options for cholecystitis in patients with GERD. These findings contribute to our understanding of the complex interplay between GERD and cholecystitis.

Surgical Management of the Horrible Gallbladder

Laparoscopic cholecystectomy is one of the most frequently performed operations by general surgeons, with up to 1 million cholecystectomies performed annually in the United States alone. Despite familiarity, common bile duct injury occurs in no less than 0.2% of cholecystectomies, with significant associated morbidity. Understanding biliary anatomy, surgical techniques, pitfalls, and bailout maneuvers is critical to optimizing outcomes when encountering the horrible gallbladder. This article describes normal and aberrant biliary anatomy, complicated cholelithiasis, ways to recognize cholecystitis, and considerations of surgical approach.

Cholecystoappendiceal fistula associated with xanthogranulomatous cholecystitis

Xanthogranulomatous cholecystitis is a rare chronic inflammatory disease of the gallbladder associated with complications such as perforation, dense adhesions and fistulation. We present a case of a female patient in her 20s who presented with three episodes of recurrent cholecystitis over 3 months. Her medical history included an endoscopic retrograde cholangiopancreatography for obstructive jaundice due to choledocholithiasis. As there was no possibility of performing an urgent cholecystectomy during her initial admission, she was listed for an elective operation. Laparoscopic inspection revealed a pericholecystic mass involving the omentum, transverse colon, duodenum and liver and findings suspicious of a cholecystoappendiceal fistula. Laparoscopic cholecystectomy and appendicectomy were performed. Early index admission laparoscopic cholecystectomy should be performed in patients with acute cholecystitis to prevent higher grades of operative difficulty and associated complications. This case presentation-cholecystoappendiceal fistula associated with xanthogranulomatous cholecystitis-emphasises the necessity of complying with national guidelines in managing acute calculous cholecystitis.

Acute cholangitis: a state-of-the-art review

Acute cholangitis is a potentially life-threatening bacterial infection of the intra and/or extrahepatic bile ducts. It remains the second and third cause of community-acquired and hospital-acquired bacteremia, respectively, and is associated with mortality rates of up to 15%, despite advances in broad-spectrum antimicrobial therapy and improved access to emergency biliary tract decompression procedures. Even though not much has changed in recent years in terms of diagnosis or treatment, new data have emerged regarding multidrug-resistant bacteria that serve as etiologic agents of cholangitis. Moreover, different approaches in antibiotic regimes depending on severity grading and bile sample cultures as well as novel minimally invasive endoscopic procedures that can help when consecrated treatments such as endoscopic retrograde cholangiopancreatography (ERCP) fail, cannot be performed, or are unavailable have been proposed. This state-of-the-art review aims to offer a complete and updated assessment of the epidemiology, novel diagnostic and therapeutic methods, complications, and prognostic variables of acute cholangitis. The authors will review the prognostic implications of unusual complications, the relevance of regular bile samples and antibiograms, and their new role in guiding antibiotic therapy and limiting antibiotic resistance to present an organized and comprehensive approach to the care of acute cholangitis.

Updates on Antibiotic Regimens in Acute Cholecystitis

Acute cholecystitis is one of the most common surgical diseases, which may progress from mild to severe cases. When combined with bacteremia, the mortality rate of acute cholecystitis reaches up to 10-20%. The standard of care in patients with acute cholecystitis is early laparoscopic cholecystectomy. Percutaneous cholecystostomy or endoscopic procedures are alternative treatments in selective cases. Nevertheless, antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis. Patients with acute cholecystitis have a bile bacterial colonization rate of 35-60%. The most frequently isolated microorganisms are Escherichia coli, Klebsiella spp., Streptococcus spp., Enterococcus spp., and Clostridium spp. Early empirical antimicrobial therapy along with source control of infection is the cornerstone for a successful treatment. In these cases, the choice of antibiotic must be made considering some factors (e.g., the severity of the clinical manifestations, the onset of the infection if acquired in hospital or in the community, the penetration of the drug into the bile, and any drug resistance). Furthermore, therapy must be modified based on bile cultures in cases of severe cholecystitis. Antibiotic stewardship is the key to the correct management of bile-related infections. It is necessary to be aware of the appropriate therapeutic scheme and its precise duration. The appropriate use of antibiotic agents is crucial and should be integrated into good clinical practice and standards of care.

Application of 3-Step Laparoscopic Cholecystectomy in Acute Difficult Cholecystitis

BACKGROUND

With the aging of the global population, the incidence rate of acute cholecystitis is increasing. Laparoscopic cholecystectomy is considered as the first choice to treat acute cholecystitis. How to effectively avoid serious intraoperative complications such as bile duct and blood vessel injury is still a difficult problem that puzzles surgeons. This paper introduces the application of laparoscopic cholecystectomy, a new surgical concept, in acute difficult cholecystitis.

METHODS

This retrospective analysis was carried out from January 2019 to January 2021. A total of 36 patients with acute difficult cholecystitis underwent 3-step laparoscopic cholecystectomy. The general information, clinical features, surgical methods, surgical results, and postoperative complications of the patients were analyzed.

RESULTS

All patients successfully completed the surgery, one of them was converted to laparotomy, and the other 35 cases were treated with 3-step laparoscopic cholecystectomy. Postoperative bile leakage occurred in 2 cases (5.56%), secondary choledocholithiasis in 1 case (2.78%), and hepatic effusion in 1 case (2.78%). No postoperative bleeding, septal infection, and other complications occurred, and no postoperative colon injury, gastroduodenal injury, liver injury, bile duct injury, vascular injury, and other surgery-related complications occurred. All 36 patients were discharged from hospital after successful recovery. No one died 30 days after surgery, and there was no abnormality in outpatient follow-up for 3 months after surgery.

CONCLUSIONS

Three-step laparoscopic cholecystectomy seems to be safer and more feasible for acute difficult cholecystitis patients. Compared with traditional laparoscopic cholecystectomy or partial cholecystectomy, 3-step laparoscopic cholecystectomy has the advantages of safe surgery and less complications, which is worth trying by clinicians.

Subtotal vs total cholecystectomy for difficult gallbladders: A systematic review and meta-analysis

INTRODUCTION

With severely inflamed gallbladders, laparoscopic cholecystectomy can be difficult and may require procedures like subtotal cholecystectomy (SC). Few studies exist comparing SC and total cholecystectomy (TC) in the setting of severe biliary inflammation. This meta-analysis aims to compare SC and TC for difficult gallbladders.

METHODS

Medline-OVID, Embase-OVID, and Cinahl were searched including only studies comparing SC to TC for difficult gallbladders. Primary outcome was CBD injury. Secondary outcomes included bile leak, duodenal injury, retained stone, bleeding, intraabdominal collection, wound infection, reoperation, and mortality.

RESULTS

Ten studies were included. Compared to TC, SC significantly lowered the risk for CBD injury (0 ​% vs. 1.6 ​%, RR 0.30, 95%CI 0.10-0.87) but increased risk of bile leaks (RR 3.5, 95%CI 1.79-6.84), postoperative ERCP (RR 2.86, 95%CI 1.53-5.35), intraabdominal collections (RR 2.55, 95%CI 1.32-4.93), and reoperation (RR 2.92, 95%CI 1.14-7.47).

CONCLUSION

SC is a reasonable alternative to difficult gallbladders that may decrease the risk of CBD injuries. Knowing both approaches is crucial to manage the difficult gallbladder while minimizing harm. Further studies are needed to understand the value of SC for difficult cholecystectomy.

Right Hepatic Artery Pseudoaneurysm Post-laparoscopic Cholecystectomy: A Case Report of Endovascular Stent-Graft Management

Gallstone-related diseases like cholelithiasis contribute significantly to global morbidity and mortality. Laparoscopic cholecystectomy (LC) is the gold standard for gallbladder removal but is associated with rare but severe complications, including hepatic artery pseudoaneurysms (PAs). A 72-year-old female presented with acute abdominal pain and upper gastrointestinal bleeding following a recent LC. Laboratory studies confirmed anemia with a hemoglobin level of 10 g/dL. Liver function tests were deranged, showing elevated alanine aminotransferase (ALT) at 209 U/L, aspartate aminotransferase (AST) at 472 U/L, total bilirubin levels at 3.29 mg/dL, and direct bilirubin levels at 2.7 mg/dL. A contrast-enhanced computed tomography scan revealed a PA adjacent to the right hepatic artery. Given the strong suspicion of a hepatic PA as the source of her symptoms, an endovascular stent was placed by an interventional radiologist. Post-procedure, the patient showed a favorable clinical course with cessation of symptoms and was discharged after eight days. This case emphasizes the importance of early identification of hepatic artery PAs following LC, a potentially life-threatening complication. It also suggests that endovascular stent placement can be an effective alternative to traditional transarterial embolization for managing these PAs. Additional research is needed to evaluate the long-term effectiveness and safety of these two methods in comparison.

Association between reduced muscle mass and poor prognosis of biliary sepsis

Sepsis is a life-threatening disease, contributing to significant morbidity and mortality. This study aimed to investigate the association between low muscle mass and the prognosis of patients with biliary sepsis, focusing on outcomes such as length of hospital stay (LOS), intensive care unit (ICU) admission, and in-hospital mortality. This retrospective, single-center, observational study included adult patients with biliary sepsis who visited the emergency department between January 2016 and December 2021. Low muscle mass was assessed using the psoas muscle index (PMI). Using computed tomography imaging, the area of both sides of the psoas muscle at the L3 level was measured, and the PMI, corrected by the patient's height was calculated. The primary outcome was in-hospital mortality, and the secondary outcomes were intensive care unit (ICU) admission, LOS, and 14-day mortality. A total of 745 patients were included in this study. Low muscle mass was defined as a PMI < 421 mm2/m2 for males and < 268 mm2/m2 for females with the lower quartile of PMI according to sex. The cohort was classified into sarcopenic (n = 189) and non-sarcopenic (n = 556) groups. There was a significant association between low muscle mass and in-hospital mortality (odds ratio, 3.81; 95% confidence interval, 1.08-13.47; p < 0.001), while there was no significant association between low muscle mass and ICU admission. In addition, the median LOS in the sarcopenic group (10 [7-14] days) was significantly longer than the median (8 [6-11] days) in the non-sarcopenic group. Low muscle mass was significantly associated with clinical outcomes, particularly in-hospital mortality and LOS, in patients with biliary sepsis.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Elevated plasma and bile levels of corisin, a microbiota-derived proapoptotic peptide, in patients with severe acute cholangitis

BACKGROUND

Acute cholangitis is a severe, life-threatening infection of the biliary system that requires early diagnosis and treatment. The Tokyo Guidelines recommend a combination of clinical, laboratory, and imaging findings for diagnosis and severity assessment, but there are still challenges in identifying severe cases that need immediate intervention. The microbiota and its derived products have been implicated in the pathogenesis of acute cholangitis. Corisin is a microbiome-derived peptide that induces cell apoptosis, acute tissue injury, and inflammation. This study aimed to evaluate the potential of plasma and bile corisin as a biomarker of acute cholangitis.

METHODS

Forty patients with acute cholangitis associated with choledocholithiasis or malignant disease were enrolled. Nine patients without acute cholangitis were used as controls. Corisin was measured by enzyme immunoassays in plasma and bile samples. Patients were classified into severe and non-severe groups. The associations of plasma and bile corisin with the clinical grade of acute cholangitis and other parameters were analyzed by univariate and multivariate regression analysis.

RESULTS

Plasma and bile corisin levels were significantly higher in patients with acute cholangitis than in controls. Patients with severe acute cholangitis had significantly higher plasma and bile corisin levels than those with non-severe form of the disease. Bile corisin level was significantly correlated with markers of inflammation, coagulation, fibrinolysis, and renal function. Univariate analysis revealed a significant association of bile corisin but a weak association of plasma corisin with the clinical grade of acute cholangitis. In contrast, multivariate analysis showed a significant relationship between plasma corisin level and the disease clinical grade. The receiver operating characteristic curve analysis showed low sensitivity but high specificity for plasma and bile corisin to detect the severity of acute cholangitis. The plasma and bile corisin sensitivity was increased when serum C-reactive protein level was included in the receiver operating characteristic curve analysis.

CONCLUSIONS

Overall, these findings suggest that plasma and bile corisin levels may be useful biomarkers for diagnosing and monitoring acute cholangitis and that corisin may play a role in the pathophysiology of the disease by modulating inflammatory, coagulation and renal pathways.

Can sarcopenia predict poor prognosis of sepsis due to acute cholecystitis?

AIM OF THE STUDY

As sepsis is a life-threatening disease, it is important to predict the prognosis in the early stages to establish treatment plans. This study aimed to investigate the association between sarcopenia, determined by the psoas muscle area, and the prognosis of sepsis due to acute cholecystitis.

METHODS

This retrospective single-center observational study included adult patients with sepsis due to acute cholecystitis who visited the emergency department between January 2016 and December 2021. The area of both sides of the psoas muscle at the L3 level was measured, and the psoas muscle index (PMI) corrected by the patient's height was calculated. Sarcopenia was determined based on PMI. The primary outcome was in-hospital mortality, and secondary outcomes were intensive care unit (ICU) admission, length of hospital stay (LOS), and 14-day mortality.

RESULTS

A total of 374 patients were included in this study. In this cohort, the lower quartile of PMI according to gender was set as the cut-off value to define sarcopenia. Sarcopenia was defined as PMI < 423 mm2/m2 for males and < 269 mm2/m2 for females. There were 94 patients in the sarcopenic group and 280 in the non-sarcopenic group. There was a significant association between sarcopenia and ICU admission (odds ratio [OR], 1.98; 95% confidence interval [CI], 1.05-3.76), and there was also a significant association between sarcopenia and in-hospital mortality (OR, 6.40; 95%CI, 1.13-36.09). Additionally, the median LOS in the sarcopenic group (11.5 (Cruz-Jentoft et al., 2010; Kawaguchi et al., 2019; Kim et al., 2017; Ritz et al., 2021; Cox et al., 2021; Lee et al., 2018; Okada et al., 2021; Prashanthi et al., n.d.; Amini et al., 2015; Fearon et al., 2011) days) was significantly longer than the median (8 (Rosenberg, 1989, 1997; Cruz-Jentoft et al., 2010; Kawaguchi et al., 2019; Kim et al., 2017; Ritz et al., 2021) days) in the non-sarcopenic group.

CONCLUSIONS

In patients with sepsis due to acute cholecystitis, sarcopenia was significantly associated with ICU admission, LOS, and in-hospital mortality.

Cholecystitis in older patients following hip fracture: a case series and literature review

OBJECTIVE

This study's aim is to describe the characteristics of perioperative acute cholecystitis in older patients with hip fracture.

METHODS

From January 1, 2018, to April 30, 2023, 7,746 medical records were retrospectively collected for patients aged ≥ 65 years who were hospitalised for hip fracture in Beijing Jishuitan Hospital, Capital Medical University. We reviewed 10 cases with confirmed diagnoses of acute cholecystitis.

RESULTS

Of these 10 cases, five femoral neck fractures and five intertrochanteric fractures received orthopaedic surgery. The ratio of males to females was 2:8, the median age was 83.1 years (71-91 years), and there was a median BMI of 25.35 (15.56-35.16). 50% of cases had a poor functional capacity before fracture of below four metabolic equivalents. The median onset time of acute cholecystitis was five days (2-14 days) after fracture, including five cases before orthopaedic surgery and five cases after orthopaedic surgery. All patients had anorexia and fever during the course of the disease. In seven cases of calculous cholecystitis, two underwent percutaneous transhepatic biliary drainage, and one underwent percutaneous cholecystostomy. Two cases of calculous cholecystitis had poor prognosis; one died 49 days after fracture operation, and the reason for death was multiple organ failure caused by severe infection. The other one developed acute cerebellar infarction after gallbladder surgery through treatment in an intensive care unit and neurology department. The case was discharged with dysphasia, and the duration from fracture to discharge was 92 days.

CONCLUSION

This is the first study on the characteristics of acute cholecystitis in older patients with hip fracture in China. The incidence of acute cholecystitis in our study was 0.13%, with a high risk of in-hospital mortality and elevated hospitalisation costs. Our 10 cases with hip fractures accompanied by acute cholecystitis have common characteristics of poor-to-moderate functional capacity before fracture, increased blood glucose levels and enhanced protein metabolism after fracture. The death and the severe case have similar characteristics of low BMI, multiple underlying diseases, high plasma osmotic pressure and calculous cholecystitis, which occurred after orthopaedic surgery. These issues require attention and prompt, active intervention. Related issues require further research.

Diagnostic value of the serum lactate level as a predictor of bacteremia in patients with acute cholangitis

BACKGROUND

Patients with acute cholangitis (AC) have increased mortality when associated with bacteremia. This study aimed to evaluate the predictive ability of serum lactate (Lac) for positive bacteremia in patients with acute cholangitis.

METHODS

In this single-center, retrospective study, 138 consecutive patients with AC were analyzed. Their blood samples were collected and Lac was measured.

RESULTS

A total of 50 patients showed grade I, 50 showed grade II, and 38 showed grade III severity according to the Tokyo Guidelines 2018. Positive bacteremia was observed in 71 patients, of which 15 showed grade I, 25 showed grade II, and 31 showed grade III severity. Logistic regression analysis showed that Lac was a significant predictor of bacteremia. The area under the curve of Lac and procalcitonin (PCT) for bacteremia were 0.737 and 0.780, respectively. The optimal cutoff values for bacteremia were 17 mg/dL and 2.8 ng/mL, with sensitivity of 69.0% and 68.3%, respectively. Sensitivity of Lac and PCT for bacteremia in grade I was 58.3% and 25.0%, respectively. Three patients died from AC, all of whom were positive for bacteremia and hyperlactatemia.

CONCLUSION

Lac is useful for predicting bacteremia in patients with AC.

Predicting early biliary infection after stenting of malignant biliary obstruction: model development and internal validation

PURPOSE

To analyze the risk factors and develop a clinical prediction model for early biliary infection (EBI) after percutaneous transhepatic biliary stenting (PTBS) in patients with malignant biliary obstruction (MBO).

METHODS

The clinical data of 236 patients with MBO treated with PTBS from June 2012 to June 2021 were retrospectively analyzed. Independent risk factors were analyzed by univariate and multivariate logistic regression, and a nomogram model was constructed based on the results. Discrimination, calibration, and clinical usefulness of this model were further assessed.

RESULTS

The technical success rate of PTBS was 100%, and EBI after PTBS was 20.3%. Multivariate logistic regression analysis showed that hilar MBO (P = 0.020), diabetes (P = 0.001), previous surgical or endoscopic intervention (P = 0.007), procedure time > 60 min (P = 0.007), and intraprocedural biliary hemorrhage (P = 0.003) were independent risk factors for EBI after PTBS. A nomogram model was developed to predict the probability of EBI. ROC curves showed good discrimination of the model (area under curve = 0.831). The calibration plot indicated that the predicted probability of EBI by this model was in good agreement with the actual probability of EBI. The DCA curves showed that the net benefit of nomogram-assisted decisions was higher than or equal to the net benefit of treatment for all or none at a wide threshold probability (0-0.8).

CONCLUSION

The nomogram model based on the above independent risk factors can predict the probability of EBI and model-assisted treatment decisions contribute to improved clinical outcome. Therefore, MBO patients with probability of EBI > 0.20 based on the model should be recommended for perioperative broad-spectrum antibiotics and close monitoring.

Sonographic Assessment of Acute Versus Chronic Cholecystitis: An Ultrasound Probability Stratification Model

OBJECTIVES

What sonographic variables are most predictive for acute cholecystitis? What variables differentiate acute and chronic cholecystitis?

METHODS

The surgical pathology database was reviewed to identify adult patients who underwent cholecystectomy for cholecystitis and had a preceding ultrasound of the right upper quadrant within 7 days. A total of 236 patients were included in the study. A comprehensive imaging review was performed to assess for gallstones, gallbladder wall thickening, gallbladder distension, pericholecystic fluid, gallstone mobility, the sonographic Murphy's sign, mural hyperemia, and the common hepatic artery peak systolic velocity.

RESULTS

Of 236 patients with a cholecystectomy, 119 had acute cholecystitis and 117 had chronic cholecystitis on surgical pathology. Statistical models were created for prediction. The simple model consists of three sonographic variables and has a sensitivity of 60% and specificity of 83% in predicting acute versus chronic cholecystitis. The most predictive variables for acute cholecystitis were elevated common hepatic artery peak systolic velocity, gallbladder distension, and gallbladder mural abnormalities. If a patient had all three of these findings on their preoperative ultrasound, the patient had a 96% chance of having acute cholecystitis. Two of these variables gave a 73-93% chance of having acute cholecystitis. One of the three variables gave a 40-76% chance of having acute cholecystitis. If the patient had 0 of 3 of the predictor variables, there was a 29% chance of having acute cholecystitis.

CONCLUSIONS

Gallbladder distension, gallbladder mural abnormalities, and elevated common hepatic artery peak systolic velocity are the most important sonographic variables in predicting acute versus chronic cholecystitis.

Advanced or metastatic biliary tract cancer in Japan: a study using the Japan Medical Data Center payer claims database

Aim: Biliary tract cancers are aggressive, with poor prognosis. This study describes clinical characteristics, treatment patterns and healthcare resource utilization in patients with metastatic biliary tract cancer in Japan. Materials & methods: This cohort-based study collected data from the Japan Medical Data Center claims database (2014-2018). Results: A total of 325 patients were included; 65.2% were male and the mean age was 59.2 years. A 47.6% had an Elixhauser Comorbidity Index score ≥5. Most frequent regimens were gemcitabine + cisplatin (52.9%) for first-line therapy and tegafur + gimeracil + oteracil for second-line therapy (48.6%) and third-line therapy (27.2%). Approximately 77% of patients had ≥1 hospital admission, with a median length of 57 days. Conclusion: This study provides insights on the characteristics and burden of metastatic biliary tract cancer in Japan, highlighting high disease burden in a younger population.

Short vs long-course antibiotic therapy in adults with acute cholangitis: A systematic review, meta-analysis, and evidence quality assessment

BACKGROUND

Acute cholangitis (AC) constitutes an infection with increased mortality rates in the past. Due to new diagnostic tools and therapeutic methods, the mortality of AC has been significantly reduced nowadays. The initial antibiotic treatment of AC has been oriented to the most common pathogens connected to this infection. However, the optimal duration of the antibiotic treatment of AC is still debatable.

AIM

To investigate if shorter-course antibiotic treatments could be similarly effective to long-course treatments in adults with AC.

METHODS

This study constitutes a systematic review and meta-analysis of the existing literature concerning the duration of antibiotic therapy of AC and an assessment of the quality of the evidence. The study was conducted in accordance with the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analyses. Fifteen studies were included in the systematic review, and eight were eligible for meta-analysis. Due to heterogeneous duration cutoffs, three study-analysis groups were formed, with a cutoff of 2-3, 6-7, and 14 d.

RESULTS

A total of 2763 patients were included in the systematic review, and 1313 were accounted for the meta-analysis. The mean age was 73.66 ± 14.67 years, and the male and female ratio was 1:08. No significant differences were observed in the mortality rates of antibiotic treatment of 2-3 d, compared to longer treatments (odds ratio = 0.78, 95% confidence interval: 0.23-2.67, I² = 9%) and the recurrence rates and hospitalization length were also not different in all study groups.

CONCLUSION

Short- and long-course antibiotic treatments may be similarly effective concerning the mortality and recurrence rates of AC. Safe conclusions cannot be extracted concerning the hospitalization duration.

Comprehensive review on small common bile duct stones

Common bile duct stones are among the most common conditions encountered by endoscopists. Therefore, it is well researched; however, some items, such as indications for endoscopic papillary balloon dilatation (EPBD), safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant, selection strategy for retrieval balloons and baskets, lack adequate evidence. Therefore, the guidelines have been updated with new research, while others remain unchanged due to weak evidence. In this review, we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation, stone retrieval devices, difficult-to-treat cases, troubleshooting during the procedure, and complicated cases of cholangitis, cholecystolithiasis, or distal biliary stricture.

Characteristics and clinical outcomes of acute cholangitis in older patients

PURPOSE

Few studies are available on older patients with acute cholangitis. In this study, we aimed to examine the clinical characteristics of older patients with acute cholangitis.

METHODS

Patients aged 65 years and over who were diagnosed with acute cholangitis between February 2019 and August 2022 were analyzed retrospectively. Patients eligible for the study were divided into two groups as those aged ≥ 80 years (octogenarian) and those aged 65-79 years (non-octogenarian). These two groups were then compared for many clinical characteristics. In addition, factors associated with in-hospital mortality were identified. Finally, a subgroup analysis was performed in patients with non-malignant etiology.

RESULTS

Of a total of 309 enrolled patients, 120 (38.8%) were in the octogenarian group and 189 (61.2%) were in the non-octogenarian group. The mean age was 77.2 ± 8.0 years and 51.8% were women. Severe disease and intensive care unit admission rates were higher in the octogenarian group (p = 0.035 and p = 0.002, respectively), but there was no significant difference in the rate of in-hospital mortality (p = 0.146). Malignant etiology (OR 2.990, 95% CI 1.131-7.904) and hypoalbuminemia (OR 0.824, 95% CI 0.751-0.903) were independent risk factors for in-hospital mortality. In the subgroup analysis of non-malignant etiology, the octogenarian group had a significantly higher in-hospital mortality rate than the non-octogenarian group (8.8% vs. 3.2%, p = 0.048).

CONCLUSIONS

Among older patients with acute cholangitis, clinicians should closely monitor those aged 80 years and over, as well as those with malignant etiology and hypoalbuminemia, due to their high risk of serious clinical events.

Can endoscopic retrograde cholangiopancreatography-related procedures for resolving acute cholangitis be effectively and safely performed in patients with surgically altered anatomy? Comparison study to evaluate the timing of short-type single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography

OBJECTIVES

Balloon enteroscopy (BE)-assisted endoscopic retrograde cholangiopancreatography (ERCP)-related procedures to resolve acute cholangitis (AC) in patients with surgically altered anatomy (SAA) are limited. There is a lack of evidence on whether the timing of BE-assisted ERCP affects clinical outcomes in patients with AC. This study aimed to evaluate the clinical outcomes of short-type single-balloon enteroscopy (short SBE)-assisted ERCP in patients with SAA and AC.

METHODS

Patients with AC who underwent short SBE-assisted ERCP procedures between September 2011 and April 2022 were retrospectively reviewed. The outcomes of procedures undergone at ≤24 h and >24 h were compared. The primary outcome was the length of stay (LOS).

RESULTS

Overall, 56 patients underwent procedures at ≤24 h, and 58 patients at >24 h. The procedural success and adverse event rates of short SBE-assisted ERCP were 87.7% (95% confidence interval [CI] 80.3-93.1%) and 4.4% (95% CI 1.4-9.9%), respectively. Patients with severe (Grade III) AC and systemic inflammatory response syndrome were more in early (at ≤24 h) ERCP groups. LOS and median time from ERCP procedures to discharge were shorter in the early group. Procedural success and adverse event rates between both groups had no significant differences. Multivariable linear regression analysis showed that ERCP performed at ≤24 h was associated with shorter LOS, while severe cholangitis and malignant biliary obstruction were associated with longer LOS.

CONCLUSIONS

Short SBE-assisted ERCP is effective and safe in patients with SAA and AC. Early procedures seemed to attribute early improvement of general condition, thus shortening the LOS.

Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone-induced acute cholangitis and pancreatitis

Urgent or emergency endoscopic retrograde cholangiopancreatography (ERCP) is indicated for gallstone-induced acute cholangitis and pancreatitis. The technique and optimal timing of ERCP depend on the disease state, its severity, anatomy, patient background, and the institutional situation. Endoscopic transpapillary biliary drainage within 24 h is recommended for moderate to severe acute cholangitis. The clinical outcomes of biliary drainage with nasobiliary drainage tube placement and plastic stent placement are comparable, and the choice is made on a case-by-case basis considering the advantages and disadvantages of each. The addition of endoscopic sphincterotomy (EST) is basically not necessary when performing drainage alone, but single-session stone removal following EST is acceptable in mild to moderate cholangitis cases without antithrombotic therapy or coagulopathy. For gallstone pancreatitis, early ERCP/EST are recommended in cases with impacted gallstones in the papilla. In some cases of gallstone pancreatitis, a gallstone impacted in the papilla has already spontaneously passed into the duodenum, and early ERCP/EST lacks efficacy in such cases, with unfavorable findings of cholangitis or cholestasis. If it is difficult to diagnose the presence of gallstones impacted in the papilla on imaging, endoscopic ultrasonography can be useful in determining the indication for ERCP.

EUS-guided biliary drainage in patients with moderate-severe cholangitis is safe and effective: a multi-center experience

BACKGROUND

Patients with moderate-severe cholangitis require urgent/early biliary drainage and failed endoscopic retrograde cholangiopancreatography (ERCP) warrants use of percutaneous drainage. While endoscopic ultrasound-guided biliary drainage (EUS-BD) has evolved as an effective salvage modality but its safety and efficacy data in moderate-severe cholangitis are limited.

PATIENTS AND METHODS

All consecutive moderate-severe cholangitis patients, with failed/technically non-feasible ERCP requiring EUS-BD in two tertiary care centers were included. Baseline laboratory and demographic parameters were documented. Technical and clinical success were primary outcome measures. Additionally, effective biliary drainage, adverse events due to procedure, hospital stay, ICU stay, and mortality were noted.

RESULTS

Of the 49 patients (23 male; 46.9%) presenting with moderate/severe cholangitis, 23 (46.9%) had severe cholangitis. The median Charleston comorbidity index was 7.0 (IQR 2.0). Majority had malignant disease (87.8%) and 25 (51.0%) had inaccessible papilla. Technical success was achieved in 48 cases (98.0%), while clinical success with improvement of cholangitis was noted in 44 of 48 cases (91.7%). Effective biliary drainage was noted in 85.4% (41/48) cases. Adverse events in the form of mostly bleeding and bile leak were noted in 5 cases (10.2%) but managed conservatively. Distal obstruction exhibited significantly better clinical success (100% vs. 78.9%; p = 0.02) than hilar obstruction. Severe cholangitis had significantly lower clinical success (81.8% vs. 100%; p = 0.04) than moderate cholangitis.

CONCLUSION

EUS-BD can be a safe and effective alternative option for patients with moderate to severe cholangitis, even with significant pre-morbid conditions, with acceptable adverse events rate.

The increasing incidence and high body mass index-related burden of gallbladder and biliary diseases-A results from global burden of disease study 2019

BACKGROUND

Gallbladder and biliary diseases are common gastrointestinal conditions associated with huge socioeconomic costs and are considered risk factors for cardiovascular diseases and digestive system cancers. The prevalence and incidence of gallbladder and biliary diseases have not received enough attention from 1990 to 2019. Several non-communicable diseases were associated with the incidence of gallbladder and biliary diseases. It is necessary to clarify the change in the incidence and disability burden of gallbladder and biliary diseases worldwide.

METHODS

Data on high body mass index (BMI)-related disease burden and incidence, years of life lost prematurely, and years lived with disability (YLDs) due to gallbladder and biliary diseases were obtained from the Global Burden of Disease 2019. The estimated annual percentage change was calculated to qualify the gallbladder and biliary disease burden change.

RESULTS

The global age-standardized incidence rate has increased from 585.35 per 100,000 (95% UI: 506.05-679.86) in 1990 to 634.32 per 100,000 (95% UI: 540.21-742.93) in 2019. And the increase in incidence was positively correlated with rising high BMI-related summary exposure value. The high BMI-related YLDs of gallbladder and biliary diseases have increased worldwide over time. Globally, the 25-49 age group suffered a rapid rise in incidence and high BMI attributable to the YLDs rate of gallbladder and biliary diseases.

CONCLUSION

The global incidence and high BMI-related YLDs of gallbladder and biliary diseases remain prominent to increase over the past 30 years. Notably, the incidence and high BMI-related YLDs among people aged 25-49 years have rapidly increased over time. Therefore, high BMI should be emphasized in strategic priorities for controlling gallbladder and biliary diseases.

Early and Direct Endoscopic Stone Removal in the Moderate Grade of Acute Cholangitis with Choledocholithiasis Was Safe and Effective: A Prospective Study

BACKGROUND

Evidence supporting the feasibility of single-stage stone removal in patients with a moderate grade of acute cholangitis remains insufficient. The maximal size of a common bile-duct stone suitable for removal during a single-stage ERCP in a moderate grade of acute cholangitis is unknown.

METHODS

We prospectively enrolled 196 endoscopic retrograde cholangiopancreatography (ERCP)-naïve patients diagnosed with acute cholangitis and choledocholithiasis. For eligible patients, single-stage treatment involved stone removal at initial ERCP.

RESULTS

A total of 123 patients were included in the final analysis. The success rate of complete stone extraction was similar between patients with mild and moderate grades of acute cholangitis (89.2% vs. 95.9%; p = 0. 181). Complication rates were comparable between the two groups. In the moderate grade of the cholangitis group, among patients who underwent early single-stage ERCP, the length of hospitalization declined as short as the patients in the mild grade of cholangitis (10.6 ± 6.2 vs. 10.1 ± 5.1 days; p = 0.408). In the multivariate analysis, early ERCP indicated shorter hospitalization times (≤10 days) (odds ratio (OR), 3.981; p = 0.001). A stone size less than 1.5 cm presented a high success rate (98.0%) for complete stone removal.

CONCLUSIONS

Single-stage retrograde endoscopic stone removal in mild and moderate grades of acute cholangitis may be safe and effective, which can obviate the requirement for a second session, thus reducing medical expenses.

CLINICALTRIALS

gov: NCT03754491.

Comparative Study on Nosocomial Biliary Tract Infection Rate Between Biliary Stent Loaded with Radioactive 125 I Seeds and Conventional Biliary Stent in the Treatment of Distal Malignant Biliary Obstruction

BACKGROUND

The purpose of this prospective randomized study was to compare the nosocomial biliary tract infection rate of biliary stent implantation with a biliary stent loaded with radioactive 125 I seeds (radioactive biliary stent, RBS) and conventional biliary stent (CBS); additionally, to preliminary discuss the causes of postoperative cholangitis. Moreover, the results will provide clinical evidence for the prevention of postoperative biliary tract infection.

MATERIALS AND METHODS

We prospectively analyzed the nosocomial infection rate of the distal malignant biliary obstruction (MBO) treatment by stent implantation with RBS and CBS. All MBO patients who initially visited our tertiary hospital between July 2015 and December 2019 (n= 196) were evaluated, enrolled, and randomly divided into 2 groups, RBS (n=97) and CBS (n=99) group. χ 2 test was used to evaluate the categorical data, and t test was used to evaluate the numerical data.

RESULTS

Our analysis of the study showed the incidence of postoperative infections of a biliary tract of the RBS group (23.7%) was significantly higher than the CBS group (11.1%). The difference was statistically significant (χ 2 =5.425, P =0.020). Our study also showed the most common pathogenic bacteria after surgery was Escherichia coli (26.5%).

CONCLUSION

Treatment for distal MBO with biliary stent loaded with radioactive 125 I seeds had a higher nosocomial infection rate, and the most common pathogenic bacteria was E coli. , Supplemental Digital Content 1, http://links.lww.com/sle/A350.

Analysis of the Effect of Laparoscopic Cholecystectomy for Acute Cholecystitis after Percutaneous Transhepatic Gallbladder Puncture and Drainage

Objective

To assess the effect of laparoscopic cholecystectomy for acute cholecystitis after percutaneous transhepatic gallbladder drainage (PTGBD).

Methods

A total of 70 patients with acute cholecystitis diagnosed and treated in our hospital between April 2020 and November 2021 were recruited and assigned to receive either conventional treatment (conventional group) or PTGBD plus laparoscopic cholecystectomy (experimental group) according to the order of admission (with January 2021 as the cut-off time point), with 35 cases in each group. Outcome measures included treatment outcomes, surgical indices, and postoperative recovery.

Results

Patients in the experimental group showed significantly less intraoperative hemorrhage volume and shorter operative time, time-lapse before passing gas, and hospital stay (83.15 ± 31.17, 32.54 ± 12.61, 23.02 ± 4.61, 7.98 ± 3.24) versus those in the conventional group (120.56 ± 30.55, 61.01 ± 15.54, 28.15 ± 5.91, 11.95 ± 4.15) (P < 0.05). The incidence of conversion to open surgery and postoperative drainage in the experimental group was significantly lower (2.86%, 5.71%) than that of the conventional group (25.71%, 45.71%) (P < 0.05). The differences in the postoperative body temperature of the two groups did not come up to statistical standard (P > 0.05). The experimental group had faster body temperature recovery and leukocyte recovery and better leukocyte levels (1.25 ± 0.56, 2.36 ± 0.48, 7.92 ± 1.36) than the conventional group (3.11 ± 1.05, 5.41 ± 0.63, 10.52 ± 2.78) (P < 0.05). There was 1 (2.86%) case of pneumothorax and 1 (2.86%) case of intestinal bleeding in the experimental group, and there were 2 (5.71%) cases of biliary leakage, 3 (8.57%) cases of pneumothorax, 4 (11.43%) cases of intestinal bleeding, 5.71% cases of incisional infection, 1 (2.86%) case of respiratory failure, and 1 (2.86%) case of liver damage in the conventional group. The experimental group showed a significantly lower incidence of complications (5.71%) versus the conventional group (37.14%) (P < 0.05).

Conclusion

PTGBD plus laparoscopic cholecystectomy for acute cholecystitis effectively improves surgical safety, promotes patients' postoperative recovery, and reduces the incidence of conversion to open surgery and postoperative complications with a high safety profile. Further trials are, however, required prior to clinical promotion.

Incidence and Risk Factors for Hospital-acquired Cholecystitis

BACKGROUND

Acute cholecystitis can occur both inside and outside hospital settings. However, little is known about the clinical characteristics of hospital-acquired cholecystitis (HAC).

AIM

The objective of our study is to investigate the clinical characteristics of HAC in a tertiary academic hospital.

METHODS

This retrospective cohort study included hospitalized patients who were found to have gallstones without cholecystitis or cholangitis on admission between January 2018 and December 2021. We used multivariate logistic regression analysis to make comparisons between patients with and without HAC.

FINDINGS

A total of 890 patients met the inclusion criteria and were evaluated in this study. Forty-one patients (4.6%) developed HAC during the study period. Multivariate logistic regression analysis showed that a history of cholecystitis or cholangitis, fasting at least one day, and gallstones in the gallbladder neck were independently associated with increased risk of HAC. HAC occurred most frequently after about several weeks of admission, and only four patients (9.8%) had bacteremia.

CONCLUSIONS

HAC was relatively common among hospitalized patients. Physicians should be aware of the possibility of HAC in symptomatic hospitalized patients with certain risk factors.

The Effect of MDT Collaborative Nursing Combined with Hierarchical Nursing Management Model on the Quality of Life and Comfort of Patients with Gallbladder Stones Combined with Acute Cholecystitis after Surgery

Objective

To explore the effect of MDT (multidisciplinary team) collaborative nursing combined with hierarchical nursing management mode on the quality of life and comfort of patients with gallbladder stones combined with acute cholecystitis after surgery.

Methods

A total of 120 patients with gallbladder stones and acute cholecystitis who were treated in our hospital from March 2019 to March 2021 were selected as prospective research objects. According to the order of care, they were divided into control group and observation group with 60 cases each. Among them, the control group implements a hierarchical nursing management model, and the observation group implements MDT collaborative nursing based on this and compares the impact of the two groups on patient's quality of life scores, daily self-care ability, nursing satisfaction, and comfort after nursing.

Results

Before nursing, the comparison of the quality of life score, nursing comfort, and nursing ability of the two groups of patients was not statistically significant (P > 0.05). After nursing, the mental vitality score, social interaction score, emotional restriction score, and mental status of the observation group were significantly higher than those of the control group. Statistics showed that the difference was statistically significant (P < 0.05). After nursing, the scores of social comfort, physical comfort, and psychological comfort of the observation group were significantly higher than those of the control group, and statistics showed that the difference was statistically significant (P < 0.05). The health knowledge level, self-care skills, self-care responsibility, and self-concept of the observation group after nursing were higher than those of the control group, while the score of depression and mood disorder was significantly lower than that of the control group. Statistics showed that this difference was statistically significant (P < 0.05). After nursing, patients in the observation group had higher operating technique scores, service attitude scores, health education scores, psychological intervention scores, and nursing quality scores than those of the control group. Statistics showed that the difference was statistically significant (P < 0.05).

Conclusion

MDT collaborative nursing combined with hierarchical nursing management mode can effectively improve the self-care ability of patients with gallbladder stones complicated with acute cholecystitis, effectively improve the quality of life of patients, and improve the satisfaction and comfort of patients with nursing care. The postnursing care of patients after inflammation has a certain reference value.

Incidence, risk factors, and prognosis of acute kidney injury in hospitalized patients with acute cholangitis

BACKGROUND

The association between acute cholangitis (AC) and acute kidney injury (AKI) remains unclear. We investigated the incidence, and clinical course of AKI in patients with AC, and the long-term prognosis.

METHODS

We performed a single-center retrospective study of patients hospitalized with AC in a tertiary care center from January 2011 to December 2017. The risk factors for AKI were evaluated, and AKI severity was analyzed using the Systemic Inflammatory Response System (SIRS), quick sequential organ failure assessment (qSOFA) score, and 2018 Tokyo Guidelines (TG) grade. To calculate the relative risk of death based on AKI, hazard ratios (HRs) and 95% confidence intervals (CIs) were obtained using Cox's proportional hazard models.

RESULTS

A total of 1,438 patients with AC were included, of whom 18.2% (n = 261) developed AKI. AKI patients were older, and had a lower systolic blood pressure and more comorbidities including hypertension (HT), chronic kidney disease, and cardiovascular accidents. Disease severity (as assessed by SIRS, qSOFA, and the Tokyo Guidelines grade) was higher in the AKI group, as was the in-hospital mortality rate. Multivariate analysis revealed that age, HT, SIRS and qSOFA scores ≥ 2, and TG grade of III were significant risk factors for AKI. Kaplan-Meier analysis revealed significantly higher mortality in the AKI than non-AKI group. AKI (HR = 1.853; 95% CI: 1.115-3.079) and TG grade III (HR = 2.139; 95% CI: 1.190-3,846) were independent predictors of all-cause AC mortality, even after adjusting for all covariates. The annual rate of decline in the estimated glomerular filtration rate was faster in the AKI than non-AKI group (2.9 ± 6.7 vs. 0.5 ± 5.3 mL/min/1.73 m2/year, p < 0.001).

CONCLUSIONS

AKI development increased AC severity and mortality. Our results suggest that clinicians should monitor AKI status and perform appropriate management as soon as possible.

Recurrent cholangitis after choledochoduodenostomy: A case report

Introduction

Recurrent cholangitis is a long-term consequence of choledochoduodenostomy (CDD) that requires urgent treatment. The frequency of recurrent cholangitis ranges between 2.5 and 15.7%. This case demonstrated the importance of rapid and precise diagnosis through screening and therapeutic modalities in recurrent cholangitis.

Presentation of case

A male patient presented with a history of recurring right upper abdominal discomfort during the previous 3 years. The pain had been intermittent but had become more intense during the prior month. The patient was diagnosed with recurrent cholangitis following CDD. The therapeutic plan was closure of the CDD, which was identified as the cause of the recurrent cholangitis, and biliary drainage by modified Roux-en-Y choledochojejunostomy.

Discussion

Recurrent cholangitis was diagnosed based on clinical manifestations, including recurring right upper abdomen discomfort, jaundice, and fever accompanied with consistent laboratory and imaging findings. Drainage of bile into the distal common bile duct (CBD) is reduced in the side-to-side CDD arrangement. Consequently, the distal CBD becomes a reservoir with inadequate drainage, predisposing this so-called ‘sump’ to debris accumulation and cholangitis. The surgery was considered successful in preventing the recurrent cholangitis.

Conclusion

The recurrent cholangitis was occurred due to inadequate biliary drainage. The choledochojejunostomy procedure with modified Roux-en-Y might prevent the recurrent cholangitis by improving biliary drainage to the enteric.

•

Recurrent cholangitis in side-to-side CDD may be induced by infection.

•

Recurrent cholangitis manifests with symptoms such as abdominal pain, jaundice, and fever.

•

The principal treatment is to enhance the biliary drainage of the CBD to the anastomosis

Effect of the COVID-19 Pandemic on the Management of Acute Cholecystitis and Assessment of the Crisis Approach: A Multicenter Experience in Egypt

INTRODUCTION

The covid-19 pandemic has had a drastic impact on all medical services. Acute cholecystitis is a serious condition that accounts for a considerable percentage of general surgical acute admissions. Therefore, the Royal College of Surgeons' Commissioning guidance' recommended urgent admission to secondary care and early cholecystectomy. During the first wave of hospital admissions associated with COVID-19, most guidelines recommended conservative treatment in order to limit the admission rates and free up spaces for COVID-19-infected patients. However, reviews of this approach have not been widely done to assess the results and, in turn, planning our future management approach when future pressures on in-patient admissions are inevitable.

METHODS

Our study included all acute cholecystitis patients who needed surgical intervention in one Centre in the UK over three distinct periods (pre-COVID-19, during the first lockdown, and lockdown ease). Comparison between these groups were done regarding intraoperative and postoperative results.

RESULTS

The conservative management led to a high rate of readmission. Moreover, delayed cholecystectomy was associated with increased operative difficulties such as extensive adhesions, intraoperative blood loss, and/or complicated gall bladder pathologies such as perforated or gangrenous gall bladder (29.9%, 16.7%, and 24.8%, respectively). The resulting postoperative complications of surgical and nonsurgical resulted in a longer hospital stay (13.5 d).

CONCLUSION

The crisis approach for acute cholecystitis management failed to deliver the hoped outcome. Instead, it backfired and did the exact opposite, leading to longer hospital stays and extra burden to the patient and the healthcare system.

IS THE ANATOMICAL SEQUENCE OF GASTRIC AND BILIARY ANASTOMOSIS IN THE PANCREATODUODENECTOMY RECONSTRUCTION THE CAUSE OF AN INCREASE IN THE INCIDENCE OF CHOLANGITIS? A TECHNICAL VARIANT PRESENTATION AND INITIAL RESULTS

Several methods have been proposed for the reconstruction of digestive transit after pancreatoduodenectomy. Biliary anastomosis positioned before gastric anastomosis helps reduce postoperative reflux and cholangitis.

The Possible Association of Non-Alcoholic Fatty Liver Disease with Acute Cholangitis: A Retrospective Multicenter Cohort Study

Non-alcoholic fatty liver disease (NAFLD) is increasingly encountered. It is associated with several comorbid diseases. However, its association with infectious biliary diseases is still unknown. Aims: We aimed to assess whether NAFLD is a risk factor for the development of acute cholangitis among patients with common bile duct (CBD) stones. Methods: We performed a retrospective study, including all patients with a documented diagnosis of CBD stone that had available data on the presence or absence of NAFLD. Descriptive analysis using univariate and multivariate models was used to assess whether an association existed between NAFLD and acute cholangitis. Results: We included 811 patients. Of them, 161 patients presented with acute cholangitis, vs. 650 patients who presented with symptomatic CBD stone without cholangitis. NAFLD was significantly more common in the cholangitis group compared to the non-cholangitis group (15.5% vs. 8.3%, p = 0.01). In univariate analysis, age (Odds ratio (OR) 1.04, p < 0.0001), male gender (OR 1.47, p = 0.03), hypertension (OR 1.81, p = 0.0008), hyperlipidemia (OR 1.59, p = 0.01), and NAFLD (OR 2.04, p = 0.006) were significantly associated with acute cholangitis. In multivariate analysis, NAFLD kept its association with acute cholangitis irrespective of age (OR 2.15, p = 0.005). Conclusions: NALFD showed a significant association with acute cholangitis among patients with a CBD stone. Clinicians should encourage treatment of NAFLD in general, and especially in the setting of gallstone disease.

Canine extrahepatic biliary disease: what have we learned?

Extrahepatic biliary disease in dogs is commonly encountered in clinical practice worldwide. Diseases in this segment of the biliary tract are diverse and can manifest with mild clinical signs or can be life-threatening. In the last decade there have been advances in diagnostic tests, imaging modalities and therapeutic interventions as well as the identification of novel prognostic variables that could improve outcomes in dogs with extrahepatic biliary disease. Therefore, the objective of this review was to summarise clinically relevant updates of extrahepatic biliary disease in dogs.

Seasonal Variation and Severity of Acute Abdomen in Japan: A Nine-Year Retrospective Analysis

The seasonal incidence of acute abdomens, such as appendicitis, is reportedly more common in summer but is reported less frequently in Asia. Additionally, seasonal variations in the severity of acute abdomens have been evaluated insufficiently. This study evaluated the seasonal variations in the incidence and severity of acute abdomens in Japan. This retrospective observational study used a multicenter database containing data from 42 acute hospitals in Japan. We included all patients diagnosed with acute appendicitis, diverticulitis, cholecystitis, and cholangitis between January 2011 and December 2019. Baseline patient data included admission date, sequential organ failure assessment score, presence of sepsis, and disseminated intravascular coagulation. We enrolled 24,708 patients with acute abdomen. Seasonal admissions for all four acute abdominal diseases were the highest in summer [acute appendicitis, (OR = 1.35; 95% CI = 1.28-1.43); diverticulitis, (OR = 1.23; 95% CI = 1.16-1.31; cholecystitis (OR = 1.23; 95% CI = 1.11-1.36); and cholangitis (OR = 1.23; 95% CI = 1.12-1.36)]. The proportion of patients with sepsis and disseminated intravascular coagulation as well as the total SOFA score for each disease, did not differ significantly across seasons. Seasonal variations in disease severity were not observed.

Subtotal cholecystectomy for difficult acute cholecystitis: how to finalize safely by laparoscopy-a systematic review

Background

Aim of this study was to clarify the best laparoscopic subtotal cholecystectomy (LSTC) technique for finalizing a difficult cholecystectomy.

Patients and methods

A review was performed (1987–2021) searching "difficulty cholecystectomy" AND/OR "subtotal cholecystectomy". The LSTC techniques considered were as follows: type A, leaving posterior wall attached to the liver and the remainder of the gallbladder stump open; type B, like type A but with the stump closed; type C, resection of both the anterior and posterior gallbladder walls and the stump closed; type D, like type C but with the stump open. Morbidity (including mortality) was analysed with Dindo–Clavien classification.

Results

Nineteen articles were included. Of the 13,340 patients screened, 678 (8.2%) had cholecystectomy finalized by LSTC: 346 patients (51.0%) had type A LSTC, 134 patients (19.8%) had type B LSTC, 198 patients (29.2%) had type C LSTC, and 198 patients (0%) had type D LSTC. Bile leakage was found in 83 patients (12.2%), and recorded in 58 patients (69.9%) treated by type A. Twenty-three patients (3.4%) developed a subhepatic collection, 19 of whom (82.6%) were treated by type A. Other complications were reported in 72 patients (10.6%). The Dindo–Clavien classification was four for grade I, 27 for grade II, 126 for grade IIIa, 18 for grade IIIb, zero for grade IV and three for grade V.

Conclusion

In the case of LSTC, closure of the gallbladder stump represents the best method to avoid complications. Careful exploration of the gallbladder stump is mandatory, washing the abdominal cavity and leaving drainage.

New anti-reflux plastic stent to reduce the risk of stent-related cholangitis in the treatment of biliary strictures

BACKGROUND

There is little data available on the role of new anti-reflux plastic stents (ARPSs).

AIM

To compare the use of ARPSs with that of traditional plastic stents (TPSs) for patients with biliary strictures.

METHODS

Consecutive patients with biliary strictures who underwent first endoscopic biliary stenting between February 2016 and May 2019 were included. The onset of stent-related cholangitis, stent patency, clinical success, and other adverse events were evaluated.

RESULTS

Sixty-seven patients in the ARPS group and 66 patients in the TPS group were included in the final analyses. Fewer patients experienced stent-related cholangitis in the ARPS group than that in the TPS group (8 patients vs 18 patients; P = 0.030). The median time till the onset of first stent-related cholangitis was later in the ARPS group than that in the TPS group (128.5 d vs 76 d; P = 0.039). The cumulative median stent patency in the ARPS group was 185 d, which was significantly longer than that in the TPS group (133 d; P = 0.001). The clinical success rates and other adverse events did not significantly differ between both groups.

CONCLUSION

Placement of new ARPS might be a safe and effective optional therapeutic strategy to reduce the risk of stent-related cholangitis and prolong stent patency.

A case of obstructive jaundice without biliary stones in a low resource setting

Although not common, Mirizzi's syndrome (type 1) is a differential diagnosis in a patient with cholecystitis and obstructive jaundice, after a thorough clinical assessment. The jaundice would be resolved by cholecystectomy.

The Efficacy of Intraoperative Fluorescent Imaging Using Indocyanine Green for Cholangiography During Cholecystectomy and Hepatectomy

Purpose

Bile duct injury is one of the most serious complications of laparoscopic cholecystectomy. Intraoperative indocyanine green (ICG) cholangiography is a safe and useful navigation modality for confirming the biliary anatomy. ICG cholangiography is expected to be a routine method for helping avoid bile duct injuries.

Patients and Methods

We examined 25 patients who underwent intraoperative cholangiography using ICG fluorescence. Two methods of ICG injection are used: intrabiliary injection (percutaneous transhepatic gallbladder drainage [PTGBD], gallbladder [GB] puncture and endoscopic nasobiliary drainage [ENBD]) at a dosage of 0.025 mg during the operation or intravenous injection with 2.5 mg ICG preoperatively.

Results

There were 24 patients who underwent laparoscopic cholecystectomy and 1 patient who underwent hepatectomy. For laparoscopic cholecystectomy, the average operation time was 127 (50–197) minutes, and estimated blood loss was 43.2 (0–400) g. The ICG administration route was intravenous injections in 12 cases and intrabiliary injection in 12 cases (GB injection: 3 cases, PTGBD: 8 cases, ENBD:1 case). The course of the biliary tree was able to be confirmed in all cases that received direct injection into the biliary tract, whereas bile structures were recognizable in only 10 cases (83.3%) with intravenous injection. The postoperative hospital stay was 4.6 (3–9) days, and no postoperative complications (Clavien–Dindo ≧IIIa) were observed. For hepatectomy, a tumor located near the left Glissonian pedicle was resected using a fluorescence image guide. Biliary structures were fluorescent without injury after resecting the tumor. No adverse events due to ICG administration were observed, and the procedure was able to be performed safely.

Conclusion

ICG fluorescence imaging allows surgeons to visualize the course of the biliary tree in real time during cholecystectomy and hepatectomy. This is considered essential for hepatobiliary surgery to prevent biliary tree injury and ensure safe surgery.

Factors Associated with Mortality in Severe Acute Cholangitis in a Moroccan Intensive Care Unit: A Retrospective Analysis of 140 Cases

BACKGROUND

Severe acute cholangitis is a life-threatening biliary infection, leading to organ dysfunction, septic shock, and naturally death. Mortality has dropped significantly in the past years through improving resuscitation and biliary drainage techniques. The aim of our study is to analyze our daily practice and the factors associated with mortality.

METHODS

A retrospective study including severe acute cholangitis patients admitted to our unit from January 2009 to December 2018. Variables analyzed (univariate then multivariate analysis) were age, sex, history, origin, evolution time, bilirubin, etiology, organ dysfunction, qSOFA, SOFA, TOKYO, biliary drainage timing and technique, shock, antibiotherapy, and resuscitation.

RESULTS

140 patients were included in this study. Average age was 61. Sex ratio M/F was 0.59. Lithiasis etiology was dominant (69%). SOFA average score upon admission was 8. Ceftriaxone + metronidazole was the empirical antibiotic used in 87%. Average time to biliary drainage was 1.58 ± 0.89 days. Endoscopic unblocking was the technique used in 76%. Mean duration of ICU stay was 6 days. Mortality rate was 28%. Statistically significant factors for mortality (p < 0.05) were history of taking anticoagulant treatment, use of catecholamines and mechanical ventilation during ICU stay, and delay in consultation and administration of antibiotic therapy.

CONCLUSIONS

Early recognition, antibiotics, resuscitation, and minimally invasive biliary drainage have improved patient outcomes although there is still progress to be made. Moreover, as multiple organ failure is often associated with mortality in severe acute cholangitis, predictive risk factors of organ failure should be more investigated.

Urgent and early EUS-guided biliary drainage in patients with acute cholangitis

Background and Objectives:

EUS-guided biliary drainage (EUS-BD) has been reported as an effective alternative drainage technique. However, clinical data on EUS-BD for patients with acute cholangitis (AC) are limited. The aim of this study was to analyze the clinical outcomes of EUS-BD in patients with AC.

Patients and Methods:

Nineteen patients with AC who underwent urgent or early drainage (within 96 h) by EUS-guided hepaticoenterostomy (EUS-HES) between January 2014 and November 2019 were retrospectively reviewed. Furthermore, the clinical outcomes of EUS-HES using a plastic stent in the AC group (n = 15) were compared to those in the non-AC group (n = 88).

Results:

In the 19 AC cases, the technical and clinical success rate was 100% with 5.3% of moderate adverse events (biliary peritonitis [n = 1]). Regarding the comparison between the AC group and the non-AC group, the clinical success rate was 100% in both groups and the adverse event rate was not statistically significantly different (P = 0.88). Although the recurrent biliary obstruction (RBO) rate was not statistically significantly different (P = 0.43), the early RBO rate was statistically significantly higher in the AC group (26.7% vs. 3.4%, P < 0.001). Kaplan–Meier curves showed that AC was associated with a shorter time to RBO (P = 0.046). The presence of AC was found to be an independent risk factor of early RBO (odds ratio = 10.3; P = 0.005).

Conclusions:

Urgent or early biliary drainage (within 96 h) by EUS-BD can be a feasible and safe alternative procedure for patients with AC, although there is a tendency of early RBO.

Acute Cholecystitis Following Allogeneic Hematopoietic Stem Cell Transplantation: Clinical Features, Outcomes, Risk Factors, and Prediction Model

Acute cholecystitis (AC) is a potentially fatal complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT); however, only limited information is available on its clinical features, outcomes, and risk management strategies. This retrospective, nested, case-control study included 6701 patients undergoing allo-HSCT at our center from January 2004 to June 2019. In total, 72 patients (1.1%) were diagnosed with AC; among these, acute acalculous cholecystitis had a slightly higher prevalence (42 patients, 58.3%). Patients with moderate and severe AC exhibited remarkably worse overall survival (P = .001) and non-relapse mortality (P = .011) than others. Survival of haploidentical HSCT recipients with AC was comparable to that for patients with human leukocyte antigen (HLA)-identical donors. Age ≥ 18 years, antecedent stage II to IV acute graft-versus-host disease, and total parenteral nutrition were identified as potential risk factors for AC following allo-HSCT, while haploidentical transplantations were not more susceptible to AC than HLA-identical HSCT. Based on these criteria, a risk score model was developed and validated to estimate the probability of AC following allo-HSCT. The model separates all patients into low-, intermediate-, and high-risk groups and thereby provides a basis for early detection of this complication in the management of allo-HSCT.

2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis

BACKGROUND

Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC.

MATERIALS AND METHODS

The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached.

RESULTS

The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal.

CONCLUSIONS, KNOWLEDGE GAPS AND RESEARCH RECOMMENDATIONS

ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.

Impact of Preoperative Cholangitis on Short-term Outcomes Among Patients Undergoing Liver Resection

BACKGROUND

The impact of preoperative cholangitis (PC) on perioperative outcomes among patients undergoing liver resection remains poorly defined. We sought to characterize the prevalence of PC among patients undergoing hepatectomy and define the impact of PC on postoperative outcomes.

METHODS

Patients who underwent liver resection between 2013 and 2015 were identified using the Center for Medicare Services (CMS) 100% Limited Data Set (LDS) Standard Analytic Files (SAFs). Short-term outcomes after liver resection, stratified by the presence of PC, were examined. Subgroup analyses were performed to evaluate the relationship between the timing of liver resection relative to PC.

RESULTS

Among 7392 patients undergoing liver resection, 251 patients (3.4%) experienced PC. Patients with PC were more likely to be male (59.0% vs. 50.6%) and to have a benign diagnosis (34.3% vs. 19.8%) compared with patients without PC (both p<0.05). On multivariable analysis, PC was associated with increased odds of experiencing a complication (OR 1.54, 95%CI 1.17-2.03), extended LOS (OR 2.60, 95%CI 1.99-3.39), 90-day mortality (OR 2.31, 95%CI 1.64-3.26), and higher Medicare expenditures (OR 3.32, 95%CI 2.55-4.32). Among patients with PC, requirement of both endoscopic and percutaneous biliary drainage (OR 5.16, 95%CI 1.36-9.61), as well as liver resection < 2 weeks after PC (OR 2.92, 95%CI 1.13-7.57) were associated with higher odds of 90-day mortality.

CONCLUSION

Approximately 1 in 30 Medicare beneficiaries undergoing liver resection had a history of PC. PC was associated with an increased risk of adverse short-term outcomes and higher healthcare expenditures among patients undergoing hepatectomy.

Microbiology and risk factors for gram-positive Cocci bacteremia in biliary infections

BACKGROUND

The rapid antibiotics treatment targeted to a specific pathogen can improve clinical outcomes of septicemia. We aimed to evaluate the clinical characteristics and outcomes of biliary septicemia caused by cholangitis or cholecystitis according to causative organisms.

METHODS

We performed a retrospective cohort study in 151 patients diagnosed with cholangitis or cholecystitis with bacterial septicemia from January 2013 to December 2015. All patients showed clinical evidence of biliary tract infection and had blood isolates that demonstrated septicemia.

RESULTS

Gram-negative, gram-positive, and both types of bacteria caused 84.1% (127/151), 13.2% (20/151), and 2.6% (4/151) episodes of septicemia, respectively. The most common infecting organisms were Escherichia coli among gram-negative bacteria and Enterococcus species (Enterococcus casseliflavus and Enterococcus faecalis) among gram-positive bacteria. There were no differences in mortality, re-admission rate, and need for emergency decompression procedures between the gram-positive and gram-negative septicemia groups. In univariate analysis, previous gastrectomy history was associated with gram-positive bacteremia. Multivariate analysis also showed that previous gastrectomy history was strongly associated with gram-positive septicemia (Odds ratio = 5.47, 95% CI: 1.19-25.23; P = 0.029).

CONCLUSIONS

Previous gastrectomy history was related to biliary septicemia induced by gram-positive organisms. This information would aid the choice of empirical antibiotics.

Percutaneous transhepatic biliary drainage in patients at higher risk for adverse events: experience from a tertiary care referral center

BACKGROUND

Despite advances in endoscopic drainage procedures, percutaneous transhepatic biliary drainage (PTBD) remains an essential interventional radiology (IR) procedure. Several factors may adversely affect the success of PTBD. We report the experience of our IR unit with PTBD in patients considered at higher risk for adverse events.

MATERIAL

Consecutive PTBDs performed between November 2017 and April 2019 were retrospectively reviewed. The patients at increased risk for adverse events from PTBD, defined by one or more of the following factors: non-dilated system, moderate amount of perihepatic fluid, coagulopathy, altered sensorium, and PTBD performed at bedside, were identified. Technical success, complications, and outcome at 3 months were recorded.

RESULTS

During the study period, PTBDs were performed in 90 patients. PTBDs in 57 (63.3%) patients (mean age 47.6 years, 35 females) were identified as predisposing to higher risk for adverse events. Left and right PTBD were performed in 37 (64.9%) and 15 (26.3%) patients, respectively. Bilateral PTBDs were performed in three (5.2%) patients. In two (3.5%) cases, biliary access was obtained via percutaneous cholecystostomy. Overall technical success of 91.2% (n = 52) was achieved. Carcinoma gallbladder was the most common underlying cause. Non-dilated ductal system was the most common condition deemed to predispose to higher risk for adverse events (n = 32, 56.1%), followed by perihepatic fluid (n = 9, 15.8%), and deranged coagulation parameters (n = 9, 15.8%). PTBD was performed at bedside in intensive care unit in 5 (8.8%) patients. Two (3.5%) patients had altered sensorium. Major complications in the form of biliary peritonitis were observed in three (5.2%) patients. No procedure-related mortality was observed.

CONCLUSION

PTBD can be effectively and safely performed even in situations deemed to predispose patients to increased risk for adverse events. Thus, the mere presence of these conditions should not cause a denial of PTBD.

[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.