Prospective evaluation of patients with acute cholecystitis treated with percutaneous cholecystostomy and interval laparoscopic cholecystectomy

Does percutaneous cholecystostomy timing in high anaesthetic-risk patients impact on outcome?

The optimal timing for percutaneous cholecystostomy (PCT) in patients with acute biliary sepsis, who are high-risk for cholecystectomy, requires further investigation. We aimed to study local factors influencing the timing to PCT placement, and investigate patient outcomes in early (≤ 48 h) vs. delayed PCT over a six-year period. A retrospective observational study investigating patients who required a PCT at a single hospital in the UK between January 2014 and December 2019. Placement of a PCT was at the discretion of the on-call surgical consultant according to their own personal experience and not based on a standard local protocol. Clinical outcomes, hospital statistics and details of any subsequent bridging surgery were analysed using multivariate logistic regression models adjusting for age, sex, Charlson Comorbidity Index (CCI) and American Society of Anaesthesiologists (ASA) grade. There were 72 patients with 35/72 (48.6%) classed as TG18 AC grade 3; 26/72 (36.1%) had an early PCT placed and 46/72 (63.9%) delayed. Median age was 76 (65-83) years, 52.8% were female, and 51.4% were classed ASA ≥ 3 with 94.0% scoring CCI > 2. Trial on antibiotic therapy was the primary reason for delayed PCT. In adjusted models, early PCT was associated with a shorter length in hospital stay (OR 3.02, p = 0.044), successful definitive treatment (OR 6.26, p = 0.009); and reduced likelihood for catheter dislodgment (OR 0.12, p = 0.004) with fewer patients bridging to later emergency open surgery (OR 0.19, p = 0.024). Clinical outcomes may be superior in urgent or early PCT for high anaesthetic-risk patients following acute biliary sepsis.

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.

Systematic review and meta-analysis of early vs late interval laparoscopic cholecystectomy following percutaneous cholecystostomy

BACKGROUND

High risk surgical patients with acute cholecystitis are commonly treated with percutaneous cholecystostomy (PTC) drainage. The optimal timing of subsequent interval laparoscopic cholecystectomy (LC) remains unclear.

METHODS

Medline, EMBASE, and Scopus were searched to identify studies published between 01/01/2000 and 31/12/2020, reporting on interval LC outcomes in patients initially treated by PTC. Early and late interval LC were defined as <30 and ≥ 30 days respectively. The Methodological Index for Nonrandomized Studies was used for quality assessment. Meta-analysis of proportions was conducted using a random-effects model.

RESULTS

A total of 512 studies were screened, 41 met the inclusion criteria. There were 22 studies in both early and late interval LC groups, with 3 included studies reporting both early and late groups. Following quality assessment, 29 studies were included in the meta-analysis. There were no significant differences between early and late interval LC in terms of conversion rates (7.2% vs 8.3%, p = 0.854), 90-day morbidity (12.8% vs 15.9%, p = 0.496), and 90-day mortality (0.25% vs 0.32%, p = 0.704). Heterogeneity was significant (I²>50%) in all groups.

CONCLUSION

Current evidence of interval LC within or beyond 30 days demonstrates no significant impact on outcomes. Patient factors, clinical experience, and hospital facilities may prove more important predictors.

Early Rupture of Iatrogenic Cystic Artery Pseudoaneurysm After Unsuccessful Laparoscopic Cholecystectomy: A Case Report

Laparoscopic cholecystectomy has been established as the gold-standard method to deal with symptomatic cholelithiasis and cholecystitis. Although, like any other surgical procedure, it may have complications that affect the mortality and morbidity of patients. More specifically, the cystic artery pseudoaneurysm is considered a rare complication of laparoscopic cholecystectomy, which despite its rarity, may be fatal for the patient. Herein, we present the case of a 67-year-old man with a ruptured iatrogenic cystic artery pseudoaneurysm in the early postoperative period after laparoscopic cholecystectomy that converted to open wherein a cholecystostomy catheter was placed. The patient was hospitalized in our surgical unit, and he was treated with cystic artery embolization initially and secondary with elective open cholecystectomy.

Management of Patients With Acute Cholecystitis After Percutaneous Cholecystostomy: From the Acute Stage to Definitive Surgical Treatment

Percutaneous cholecystostomy (PC) has become an important procedure for the treatment of acute cholecystitis (AC). PC is currently applied for patients who cannot undergo immediate laparoscopic cholecystectomy. However, the management following PC has not been well-reviewed. The efficacy of PC tubes has already been indicated, and compared to complications of other invasive biliary procedures, complications related to PC are rare. Following the resolution of AC, patients who can tolerate anesthesia and the surgical risk should undergo interval cholecystectomy to reduce the recurrence of biliary events. For patients unfit for surgery, whether owing to comorbidities, anesthesia risks, or surgical risks, expectant management may be applied; however, a high incidence of recurrence has been noted. In addition, several interesting issues, such as the indications for cholangiography via the PC tube, removal or maintenance of the PC catheter before definitive treatment, and timing of elective surgery, are all discussed in this review, and a relevant decision-making flowchart is proposed. PC is an effective and safe intervention, whether as expectant treatment or bridge therapy to definitive surgery. High-level evidence of post-PC care is still necessary to modify current practices.

Clinical course of percutaneous cholecystostomies: A cross-sectional study

BACKGROUND

Although cholecystectomy is the standard treatment modality, it has been shown that perioperative mortality is approaching 19% in critical and elderly patients. Percutaneous cholecystostomy (PC) can be considered as a safer option with a significantly lower complication rate in these patients.

AIM

To assess the clinical course of acute cholecystitis (AC) in patients we treated with PC.

METHODS

The study included 82 patients with Grade I, II or III AC according to the Tokyo Guidelines 2018 (TG18) and treated with PC. The patients’ demographic and clinical features, laboratory parameters, and radiological findings were retrospectively obtained from their medical records.

RESULTS

Eighty-two patients, 45 (54.9%) were male, and the median age was 76 (35-98) years. According to TG18, 25 patients (30.5%) had Grade I, 34 (41.5%) Grade II, and 23 (28%) Grade III AC. The American Society of Anesthesiologists (ASA) physical status score was III or more in 78 patients (95.1%). The patients, who had been treated with PC, were divided into two groups: discharged patients and those who died in hospital. The groups statistically significantly differed only concerning the ASA score (P = 0.0001) and WBCC (P = 0.025). Two months after discharge, two patients (3%) were readmitted with AC, and the intervention was repeated. Nine of the discharged patients (13.6%) underwent interval open cholecystectomy or laparoscopic cholecystectomy (8/1) within six to eight weeks after PC. The median follow-up time of these patients was 128 (12-365) wk, and their median lifetime was 36 (1-332) wk.

CONCLUSION

For high clinical success in AC treatment, PC is recommended for high-risk patients with moderate-severe AC according to TG18, elderly patients, and especially those with ASA scores of ≥ III. According to our results, PC, a safe, effective and minimally invasive treatment, should be preferred in cases suffering from AC with high risk of mortality associated with cholecystectomy.

Usability of Intraoperative Fluorescence Imaging with Indocyanine Green During Laparoscopic Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage

BACKGROUND

Patients with persistent symptoms of acute cholecystitis for >72 h who cannot undergo urgent laparoscopic cholecystectomy (LC) often undergo percutaneous transhepatic gallbladder drainage (PTGBD) and delayed LC. However, intraoperative near-infrared fluorescence with indocyanine green (ICG) has recently become available in various surgical settings. Therefore, we evaluated the usability of intraoperative fluorescence imaging with ICG for LC after PTGBD in patients with acute cholecystitis.

METHODS

The preoperative and postoperative clinical characteristics of patients who underwent LC after PTGBD were retrospectively analyzed.

RESULTS

In total, 130 patients were reviewed. Intraoperative ICG fluorescence imaging was used in 39 (30.0%) patients, and none developed adverse reactions. Patients with ICG fluorescence imaging had a significantly shorter operative time (129 ± 46 vs. 150 ± 56 min, p = 0.0455), markedly lower conversion rate (2.6% vs. 22.0%, p = 0.0017), and lower proportion of subtotal cholecystectomy (0.0% vs. 6.6%, p = 0.0359) than patients without ICG fluorescence imaging. Independent risk factors for conversion to laparotomy during LC after PTGBD were the performance of PTGBD after 48 h from onset (OR 3.52; 95% CI 1.11-12.21; p = 0.0322), an unremoved PTGBD tube on LC (4.48, 1.46-15.00, p = 0.0084), and surgery without ICG (8.00, 1.28-159.47, p = 0.0231).

CONCLUSION

Intraoperative ICG fluorescence imaging produced better surgical outcomes without any adverse reactions. Early performance of PTGBD and intraoperative ICG fluorescence imaging can reduce the surgical difficulties in LC after PTGBD for acute cholecystitis.

Cholecystectomy following percutaneous cholecystostomy tube placement leads to higher rate of CBD injuries

INTRODUCTION

Percutaneous cholecystostomy tube (PCT) placement is often the management of severe acute cholecystitis in the unstable patient. PCT can be later reversed and cholecystectomy performed. The purpose of this study is to investigate the incidence of subsequent cholecystectomy and clinical factors associated with subsequent procedure.

METHODS

The SPARCS, an administrative database, was used to search all patients undergoing PCT placement between 2000 and 2012 in the state of New York. Using a unique identifier, all patients were followed for subsequent cholecystectomy procedures for at least 2 years. Patients were also followed up to 2014 for potential CBD injury during subsequent laparoscopic (LC) or open cholecystectomy (OC). Univariate and multivariable regression analysis were performed when appropriate.

RESULTS

There were 9738 patients identified who underwent PCT placements. The incidence of patients who had a PCT in 2000-2012, which subsequently underwent cholecystectomy increased from 25.0% in 2000 to 31.7% in 2012. In addition, patients undergoing subsequent LC increased from 11.8% in 2000 to 22.2% in 2012, while the incidence of OC decreased from 13.2% in 2000 to 9.5% in 2012. After accounting for other confounding factors, younger male patients, race as white compared to black, who didn't have any complications during PCT placement were more likely to undergo subsequent cholecystectomy (p < 0.05). Average time to LC was 122.0 days versus 159.6 days for OC (p < 0.0001). From the patients who underwent cholecystectomy following PCT, 47 patients experienced CBD injury (1.6%).

CONCLUSIONS

Incidence of cholecystectomy following PCT increased during the study period. Surgeons seem to be more comfortable performing LC as rate of LC increased from 11.8 to 22.2%. However, rate of CBD injury is higher during subsequent cholecystectomy compared to that of the general population. Caution should be used when performing subsequent cholecystectomy following PCT, as these procedures may be more technically challenging.

Percutaneous cholecystostomy… why, when, what next? A systematic review of past decade

INTRODUCTION

Percutaneous cholecystostomy tube drainage has played a vital role in management of cholecystitis in patients where surgery is not appropriate. However, management differs from unit to unit and even between different consultants in the same unit. We conducted this systematic review to understand which of these resulted in the best patient outcomes.

METHODS

We conducted a systematic review using the PubMed database for publication between January 2006 to December 2016. Keyword variants of 'cholecystostomy' and 'cholecystitis' were combined to identify potential relevant papers for inclusion.

FINDINGS

We identified 46 studies comprising a total of 312,085 patients from 20 different countries. These papers were reviewed, critically appraised and summarised in table format. Percutaneous cholecystostomy tube drainage is an important treatment modality with an excellent safety profile. It has been used successfully both as a definitive procedure and as a bridge to surgery. There continues to be great variation, however, when it comes to the indications, timing and management of these drains. As far as we are aware, this is the only systematic review to cover the past 10 years. It provides a much-needed update, considering all the technological development and new treatment options in laparoscopic surgery and interventional radiology.

Efficacy of preoperative percutaneous cholecystostomy in the management of acute cholecystitis according to severity grades

BACKGROUND/AIMS

The aim of this retrospective study was to assess the efficacy of percutaneous cholecystostomy (PC) for patients with acute cholecystitis (AC) according to severity.

METHODS

A total of 325 patients who underwent cholecystectomy between January 2008 and October 2010 were enrolled. Patients were classified into three groups based on severity grade according to the Tokyo guidelines for AC: grade I (mild), grade II (moderate), and grade III (severe). These groups were further classified into two subgroups based on whether or not they underwent preoperative PC.

RESULTS

A total of 184 patients were classified into the grade I group (57%), 135 patients were classified into the grade II group (42%), and five patients were classified into the grade III group (1%). In the grade I and II groups, the mean length of hospital stay was significantly shorter in the patients who did not undergo PC than in those who received PC (10.7 ± 4.4 vs. 13.7 ± 5.8, p < 0.001; 11.8 ± 6.5 vs. 16.9 ± 12.5, p = 0.003, respectively). The mean length of preoperative hospital stay was significantly shorter in the patients without PC than in those with PC in the grade I and II groups (5.8 ± 3.3 vs. 8.2 ± 4.6, p = 0.001; 6.0 ± 4.4 vs. 8.8 ± 5.2, p = 0.002). In addition, the operative time was shorter in patients without PC, especially in the grade I group (94.6 ± 36.4 vs. 107.3 ± 33.5, p = 0.034).

CONCLUSIONS

Preoperative PC should be reserved for only selected patients with mild or moderate AC. No significant benefit of preoperative PC was identified with respect to clinical outcome or complications.

Is Interval Cholecystectomy Necessary After Percutaneous Cholecystostomy in High-Risk Acute Cholecystitis Patients?

Objectives:

Percutaneous cholecystostomy (PC) for acute cholecystitis (AC) is frequently performed in high-risk surgical patients as an alternative treatment modality. However, debate remains over whether or not an interval cholecystectomy for these patients should be performed. The aim of this study was to investigate the outcomes of PC in high-risk surgical patients with AC.

Methods:

Between September 2013 and June 2016, 27 of 952 patients with AC were treated with PC. The data collection included demographic variables, including comorbidities, the timing of the PC, the length of the hospital stay, the follow-up period, the complications related to PC, and readmission to hospital.

Results:

There were 16 female and 11 male patients, with a mean age of 73±12.4 years (range: 49-97 years). Comorbid diseases included ischemic heart disease (n=6), diabetes mellitus (n=5), chronic obstructive pulmonary disease (n=6), and others (n=10). The mean timing of PC was 2.2±1.4 days (range: 1-3 days). The mean length of hospital stay was 9.6±2.1 days (range: 7-14 days), and the catheter was removed after the first month. The mean follow-up period after the PC catheter removal was 19.6±8.6 months (range: 10-38 months). Only 6 patients (22.2 %) were readmitted to the hospital. Cholecystectomy was performed in 4 cases, and 2 responded to medical treatment.

Conclusion:

Despite ongoing controversy about the management of AC in high-risk surgical patients, PC is an adequate and safely applicable procedure in this group of patients. However, an interval cholecystectomy should be considered in persistent cases, which account for a small percentage. Longer-term follow-up studies with a larger sample size are needed to support our results.

Outcomes of percutaneous cholecystostomy and predictors of subsequent cholecystectomy

BACKGROUND

The use of a percutaneous cholecystostomy (PC) in the management of severe acute cholecystitis is a well recognized alternative to acute cholecystectomy. The need for definitive surgical management remains controversial.

METHODS

A retrospective analysis of hospital records at Nambour General Hospital between 2012 and 2016 was conducted and data relating to indications, demographics, comorbidities and outcomes were collected.

RESULTS

Thirty PC patients (20 male and 10 female) were identified, with a mean age of 77 years (range 46-93). Thirteen proceeded to cholecystectomy, nine elective and four emergent. Mean time to operation was 97 days (range 1-480). Ten were performed laparoscopically with a complication rate of 23% (3/13). One patient in the operative group died. Seventeen patients did not proceed to cholecystectomy. Fifteen resolved and were discharged, and two died. Three of those discharged were readmitted with gallstone disease requiring treatment, one of which died. A total of 71% (12/17) of the non-operative group died and three of those had a cause of death related to gallstone disease. The operative group was younger (P = 0.01) and had a lower estimated mortality risk (P < 0.05). In this cohort, this translated to an overall survival benefit (P < 0.01).

CONCLUSION

Predictors of eventual cholecystectomy include younger age and lower estimated mortality risk. Patients who require a PC for the treatment of acute cholecystitis and subsequently go on to cholecystectomy can expect to have a favourable outcome.

Outcomes of Consistent Conservative Management for Acute Cholecystitis Followed by Delayed Cholecystectomy

OBJECTIVE

This study's objective was to assess outcomes of a totally conservative strategy for acute cholecystitis (AC) followed by delayed elective cholecystectomy.

PATIENTS AND METHODS

Consecutive patients who underwent cholecystectomy for AC were divided into the Emergent and Elective cholecystectomy groups. Patients in the elective cholecystectomy group were divided into early, medium, and late groups according to time from symptoms onset.

RESULTS

The success rate for conservative management reached 97.2%. Increased blood loss and a higher conversion rate were significantly associated with the emergent group. Patients in the late group had significantly lower operative time and tended to have lower blood loss and less frequent conversion to open surgery than those in the early and medium groups.

CONCLUSIONS

Most AC cases could be managed conservatively, and elective cholecystectomy was performed safely regardless of the time. Elective cholecystectomy carried out in late phase was likely to be associated with decreased surgical difficulty.

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.

Outcomes in Older Patients with Grade III Cholecystitis and Cholecystostomy Tube Placement: A Propensity Score Analysis

BACKGROUND

The Tokyo Guidelines recommend initial cholecystostomy tube drainage, antibiotics, and delayed cholecystectomy in patients with grade III cholecystitis.

STUDY DESIGN

We used Medicare data (1996 to 2010) to identify patients 66 years and older who were admitted with grade III acute cholecystitis. We evaluated adherence to the Tokyo Guidelines and compared mortality, readmission, and complication rates with and without cholecystostomy tube placement in a propensity-matched (1:3) cohort of patients with grade III cholecystitis.

RESULTS

There were 8,818 patients admitted with grade III cholecystitis; 565 patients (6.4%) had a cholecystostomy tube placed. Cholecystostomy tube placement increased from 3.9% to 9.7% during the study period. Compared with 1,689 propensity-matched controls, patients with cholecystostomy tube placement had higher 30-day (hazard ratio [HR] = 1.26; 95% CI 1.05 to 1.50), 90-day (HR = 1.26; 95% CI 1.08 to 1.46), and 2-year mortality (HR = 1.19; 95% CI 1.04 to 1.36) and were less likely to undergo cholecystectomy in the 2 years after initial hospitalization (33.4% vs 64.4%; HR = 0.26; 95% CI 0.21 to 0.31). Readmissions were also higher at 30 days (HR = 2.93; 95% CI 2.12 to 4.05), 90 days (HR = 3.48; 95% CI 2.60 to 4.64), and 2 years (HR = 3.08; 95% CI 2.87 to 4.90).

CONCLUSIONS

Since the introduction of the Tokyo Guidelines (2007), use of cholecystostomy tubes in patients with grade III cholecystitis has increased, but the majority of patients do not get cholecystostomy tube drainage as first-line therapy. Cholecystostomy tube placement was associated with lower rates of definitive treatment with cholecystectomy, higher mortality, and higher readmission rates. These data suggest a need for additional evaluation and refinement of the Tokyo Guidelines.

Current role of percutaneous transhepatic gallbladder aspiration: from palliative to curative management for acute cholecystitis

BACKGROUND

The present study assessed conservative management of acute cholecystitis (AC) with a focus on percutaneous transhepatic gallbladder aspiration (PTGBA).

METHODS

Consecutive 275 patients with AC who underwent PTGBA were reviewed. Patients aged ≥80 years and/or with American Society of Anesthesiologists score III to IV and/or performance status 3 to 4 were defined as high risk. Patients were classified according to duration from symptom onset to first PTGBA: within 3 days (early PTGBA) or over 3 days (late PTGBA). They were also classified according to duration from first PTGBA to surgery: within 30 days (early surgery) or over 30 days (late surgery).

RESULTS

A total of 263 patients (95.6%) showed recovery after PTGBA. There were no significant differences in operating time, blood loss, operating procedure, conversion rate to open surgery, postoperative complications, or postoperative hospital stay between the early and late PTGBA groups or between the early and late surgery groups. No significant complications associated with PTGBA or surgery were observed, including in those at high risk.

CONCLUSIONS

Percutaneous transhepatic gallbladder aspiration can be a useful alternative for most patients with AC, including those at high risk. Elective cholecystectomy can be performed safely regardless of the timing of PTGBA or surgery.

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.

Systematic review of antibiotic treatment for acute calculous cholecystitis

BACKGROUND

Intravenous antibiotics are frequently used in the initial management of acute calculous cholecystitis (ACC), although supportive care alone preceding delayed elective cholecystectomy may be sufficient. This systematic review assessed the success rate of antibiotics in the treatment of ACC.

METHODS

A systematic search of MEDLINE, Embase and Cochrane Library databases was performed. Primary outcomes were the need for emergency intervention and recurrence of ACC after initial non-operative management of ACC. Risk of bias was assessed. Pooled event rates were calculated using a random-effects model.

RESULTS

Twelve randomized trials, four prospective and ten retrospective studies were included. Only one trial including 84 patients compared treatment with antibiotics to that with no antibiotics; there was no significant difference between the two groups in terms of length of hospital stay and morbidity. Some 5830 patients with ACC were included, of whom 2997 had early cholecystectomy, 2791 received initial antibiotic treatment, and 42 were treated conservatively. Risk of bias was high in most studies, and all but three studies had a low level of evidence. For randomized studies, pooled event rates were 15 (95 per cent c.i. 10 to 22) per cent for the need for emergency intervention and 10 (5 to 20) per cent for recurrence of ACC. The pooled event rate for both outcomes combined was 20 (13 to 30) per cent.

CONCLUSION

Antibiotics are not indicated for the conservative management of ACC or in patients scheduled for cholecystectomy.

High rate of common bile duct stones and postoperative abscess following percutaneous cholecystostomy

INTRODUCTION

The short and long-term outcomes in patients managed with percutaneous cholecystostomy (PCY) at a single institution are described.

METHODS

A retrospective study was conducted for patients treated between February 2000 and November 2012. Patient charts, imaging and biochemical data were reviewed. Patient demographics, presenting clinical features and treatment variables were noted. Outcome variables were length of admission, 30-day mortality, 30-day unplanned readmission, tube dislodgement, abscess formation, subsequent endoscopic retrograde cholangiography and surgery, complications after surgery and median overall survival.

RESULTS

PCY was performed for 55 patients for acute cholecystitis where surgical risk was very high. The 30-day readmission rate was 20% (n=11), the 30-day mortality rate was 9% (n=5) and median survival was 59 months (95% confidence interval: 30-88 months). The median follow-up duration was 68 months. Tubes were dislodged in 15 patients (27%) and an abscess occurred after PCY in 5 patients (9%). Subsequent endoscopic common bile duct stone extraction was required in 20 patients (36%). Cholecystectomy was planned in 22 patients and an abscess occurred following the cholecystectomy in 5 (23%).

CONCLUSIONS

Although a PCY is lifesaving, significant morbidity can arise during recovery. This study demonstrates a high rate of choledocholithiasis (44%), tube dislodgement (27%) and postoperative abscess (23%) compared with previous reports.

Timing of percutaneous cholecystostomy affects conversion rate of delayed laparoscopic cholecystectomy for severe acute cholecystitis

BACKGROUND

Percutaneous cholecystostomy is reserved for very high-operative-risk patients suffering from severe acute cholecystitis, who do not respond to conservative treatment. It is associated with high conversion rate to open surgery, when cholecystectomy is held later on. Our objective was to assess whether early timing of percutaneous cholecystostomy decreases conversion rate of delayed laparoscopic cholecystectomy to open surgery.

METHODS

The study population included 59 patients who underwent percutaneous cholecystostomy for severe cholecystitis and then proceeded to delayed interval laparoscopic cholecystectomy. The study consisted of a retrospective survey of medical files, based on a prospective enrollment of the data. We assessed conversion rate between two groups based on the time period from onset of symptoms and from admission to hospital until performance of cholecystostomy.

RESULTS

Regarding the time from onset of pain to drainage, early cholecystostomy (within 2 days, group I) was associated with 8.3% conversion rate, in contrast to 33.3% in group II (3-6 days from onset of symptoms). Regarding the day of admission to hospital, early drainage revealed 16% conversion rate in contrast to 40.7% in later drainage (p = 0.047, Chi-square test). We found correlation between time interval of symptoms and admission to conversion rate, according to Spearman's correlation coefficient.

CONCLUSIONS

Early percutaneous cholecystostomy does decrease conversion rate of delayed laparoscopic cholecystectomy, possibly by halting the propagation of the inflammatory process and its consequences. When decision regarding the necessity to perform drainage of the severely inflamed gallbladder is established, it is suggested to be done as soon as possible.

Percutaneous cholecystostomy is an effective treatment option for acute calculous cholecystitis: a 10-year experience

BACKGROUND

Percutaneous cholecystostomy (PC) can be used to treat patients with acute calculous cholecystitis (ACC) who are considered to be unfit for surgery. However, this procedure has been insufficiently investigated. This paper presents the results of a 10-year experience with this treatment modality.

METHODS

A retrospective observational study of all consecutive patients treated with PC for ACC in the period from 1 May 2002 to 30 April 2012 was conducted. All data were collected from patients' medical records.

RESULTS

A total of 278 patients were treated with PC for ACC. Of these, 13 (4.7%) died within 30 days, 28 (10.1%) underwent early laparoscopic cholecystectomy and three (1.1%) patients were lost from follow-up. Of the remaining 234 patients, 55 (23.5%) were readmitted for the recurrence of cholecystitis. In 128 (54.7%) patients, PC was the definitive treatment (median follow-up time: 5 years), whereas 51 (21.8%) patients were treated with elective laparoscopic cholecystectomy. The frequency of recurrence of cholecystitis in patients with contrast passage to the duodenum on cholangiography was lower than that in patients without contrast passage (21.1% versus 36.7%; P = 0.037).

CONCLUSIONS

The present study, which is the largest ever conducted in this treatment area, supports the hypothesis that PC is an effective treatment modality for critically ill patients with ACC unfit for surgery and results in a low rate of 30-day mortality.

Tube cholecystostomy before cholecystectomy for the treatment of acute cholecystitis

BACKGROUND AND OBJECTIVES

Percutaneous cholecystostomy is currently indicated for patients with cholecystitis who might be poor candidates for operative cholecystectomy. We performed a study to evaluate the long-term outcome of patients undergoing emergent tube cholecystostomy.

METHODS

This study was a retrospective chart review of patients who underwent tube cholecystostomy from July 1, 2005, to July 1, 2012.

RESULTS

During the study period, 82 patients underwent 125 cholecystostomy tube placements. Four patients (5%) died during the year after tube placement. The mean hospital length of stay for survivors was 8.8 days (range, 1-59 days). Twenty-eight patients (34%) required at least 1 additional percutaneous procedure (range, 1-6) for gallbladder drainage. Twenty-nine patients (34%) ultimately underwent cholecystectomy. Surgery was performed a mean of 7 weeks after cholecystostomy tube placement. Laparoscopic cholecystectomy was attempted in 25 operative patients but required conversion to an open approach in 8 cases (32%). In another 4 cases, planned open cholecystectomy was performed. Major postoperative complications were limited to 2 patients with postoperative common bile duct obstruction requiring endoscopic retrograde cholangiopancreatography, 1 patient requiring a return to the operating room for hemoperitoneum, and 2 patients with bile leak from the cystic duct stump.

CONCLUSIONS

In high-risk patients receiving cholecystostomy tubes for acute cholecystitis, only about one third will undergo surgical cholecystectomy. Laparoscopic cholecystectomy performed in this circumstance has a higher rate of conversion to open surgery and higher hepatobiliary morbidity rate.

Meta-analysis of laparoscopic vs open cholecystectomy in elderly patients

AIM: To investigate the comparative effect of laparoscopic and open cholecystectomy in elderly patients.

METHODS: Laparoscopic cholecystectomy has induced a revolution in the treatment of gallbladder disease. Nevertheless, surgeons have been reluctant to implement the concepts of minimally invasive surgery in older patients. A systematic review of Medline was embarked on, up to June 2013. Studies which provided outcome data on patients aged 65 years or older, subjected to laparoscopic or open cholecystectomy were considered. Mortality, morbidity, cardiac and pulmonary complications were the outcome measures of treatment effect. The methodological quality of selected studies was appraised using valid assessment tools. Τhe random-effects model was applied to synthesize outcome data.

RESULTS: Out of a total of 337 records, thirteen articles (2 randomized and 11 observational studies) reporting on the outcome of 101559 patients (48195 in the laparoscopic and 53364 in the open treatment group, respectively) were identified. Odds ratios (OR) were constantly in favor of laparoscopic surgery, in terms of mortality (1.0% vs 4.4%, OR = 0.24, 95%CI: 0.17-0.35, P < 0.00001), morbidity (11.5% vs 21.3%, OR = 0.44, 95%CI: 0.33-0.59, P < 0.00001), cardiac (0.6% vs 1.2%, OR = 0.55, 95%CI: 0.38-0.80, P = 0.002) and respiratory complications (2.8% vs 5.0%, OR = 0.55, 95%CI: 0.51-0.60, P < 0.00001). Critical analysis of solid study data, demonstrated a trend towards improved outcomes for the laparoscopic concept, when adjusted for age and co-morbid diseases.

CONCLUSION: Further high-quality evidence is necessary to draw definite conclusions, although best-available evidence supports the selective use of laparoscopy in this patient population.

Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis

BACKGROUND

In low-risk patients with acute cholecystitis who did not respond to nonoperative treatment, we prospectively compared treatment with emergency laparoscopic cholecystectomy or percutaneous transhepatic cholecystostomy followed by delayed cholecystectomy.

METHODS

In 91 patients (American Society of Anesthesiologists class I or II) who had symptoms of acute cholecystitis ≥72 hours at hospital admission and who did not respond to nonoperative treatment (48 hours), 48 patients were treated with emergency laparoscopic cholecystectomy and 43 patients were treated with delayed cholecystectomy at ≥4 weeks after insertion of a percutaneous transhepatic cholecystostomy catheter. After initial treatment, the patients were followed up for 23 months on average (range 7-29).

RESULT

Compared with the patients who had emergency laparoscopic cholecystectomy, the patients who were treated with percutaneous transhepatic cholecystostomy and delayed cholecystectomy had a lower frequency of conversion to open surgery [19 (40%) vs 8 (19%); P=0.029], a frequency of intraoperative bleeding ≥100 mL [16 (33%) vs 4 (9%); P=0.006], a mean postoperative hospital stay (5.3+/-3.3 vs 3.0+/-2.4 days; P=0.001), and a frequency of complications [17 (35%) vs 4 (9%); P=0.003].

CONCLUSION

In patients with acute cholecystitis who presented to the hospital ≥72 hours after symptom onset and did not respond to nonoperative treatment for 48 hours, percutaneous transhepatic cholecystostomy with delayed laparoscopic cholecystectomy produced better outcomes and fewer complications than emergency laparoscopic cholecystectomy.

Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy in patients with moderate acute cholecystitis under antithrombotic therapy

BACKGROUND

Standard treatment for acute cholecystitis (AC) in patients receiving antithrombotic drugs has not been established. We evaluated the safety of percutaneous transhepatic gallbladder drainage (PTGBD) followed by elective laparoscopic cholecystectomy (LC) in patients with moderate AC who were receiving antithrombotics.

METHODS

Seventy-five patients received PTGBD from January 2006 to March 2013 followed by elective LC for moderate AC. Patients were divided into Group A, which consisted of patients receiving antithrombotic therapy (n = 23), and Group B, which included the remaining patients (n = 52). We analyzed clinical outcomes and perioperative complications between groups.

RESULTS

No hemorrhagic events occurred during PTGBD insertion regardless of antithrombotic treatment. The open conversion rate was not significantly different between the two groups. Postoperative complications were found in 10 patients (13.3%). The rate of postoperative complications in Group A was slightly higher than that in Group B, but the difference was not significant (21.7% vs. 9.6%; P = 0.15). Complications associated with PTGBD occurred in six patients (8%). There were no significant differences in the incidence of these complications, operation time, intraoperative blood loss, or length of postoperative hospital stay.

CONCLUSIONS

Percutaneous transhepatic gallbladder drainage followed by elective LC may be an effective therapeutic strategy for moderate AC in patients receiving antithrombotic therapy.

Clinical outcomes of a percutaneous cholecystostomy for acute cholecystitis: a multicentre analysis

BACKGROUND

The aim of this study was to review a series of consecutive percutaneous cholecystostomies (PC) to analyse the clinical outcomes.

METHODS

All patients who underwent a PC between 2000 and 2010 were reviewed retrospectively for indications, complications, and short- and long-term outcomes.

RESULTS

Fifty-three patients underwent a PC with a median age was 74 years (range 14-93). 92.4% (n = 49) of patients were American Society of Anesthesiologists (ASA) III and IV. 82% (43/53) had ultrasound-guided drainage whereas 18% (10/53) had computed tomography (CT)-guided drainage. 71.6% (n = 38) of PC's employed a transhepatic route and 28.4% (n = 15) transabdominal route. 13% (7/53) of patients developed complications including bile leaks (n = 5), haemorrhage (n = 1) and a duodenal fistula (n = 1). All bile leaks were noted with transabdominal access (5 versus 0, P = 0.001). 18/53 of patients underwent a cholecystectomy of 4/18 was done on the index admission. 6/18 cholecystectomies (33%) underwent a laparoscopic cholecystectomy and the remaining required conversion to an open cholecystectomy (67%). 13/53 (22%) patients were readmitted with recurrent cholecystitis during follow-up of which 7 (54%) had a repeated PC. 12/53 patients died on the index admission. The overall 1-year mortality was 37.7% (20/53).

CONCLUSIONS

Only a small fraction of patients undergoing a PC proceed to a cholecystectomy with a high risk of conversion to an open procedure. A quarter of patients presented with recurrent cholecystitis during follow-up. The mortality rate is high during the index admission from sepsis and within the 1 year of follow-up from other causes.

Early versus delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage

BACKGROUND

Percutaneous transhepatic gallbladder drainage (PTGBD) is a procedure to resolve acute cholecystitis (AC). It may decrease the technical difficulty of laparoscopic cholecystectomy (LC) and thus may facilitate successful surgery when a patients' condition improves. However, the timing of LC after PTGBD remains controversial.

METHODS

From 2004 to 2010, cholecystectomy after PTGBD was performed in 67 patients with AC. Group I members underwent LC within 72 h of PTGBD (n = 21), whereas group II members underwent LC at more than 72 h after PTGBD (n = 46).

RESULTS

The open conversion rate was similar in the two groups. The perioperative complication rate was higher in group I than in group II, but with marginal significance (19.0 vs. 4.3%; p = 0.07). Mean operative time was longer in group I than in group II (79.3 ± 25.3 vs. 53.7 ± 45.3 min; p = 0.02). However, overall hospital stay was shorter in group I than in group II, but with marginal significance (10.8 ± 4.5 vs. 14.7 ± 9.3 days; p = 0.08).

CONCLUSIONS

Pros and cons were well balanced between the two groups. Decisions on the timing of cholecystectomy after PTGBD should be made based on considerations of patient condition, hospital facilities, and surgical experience.

Can percutaneous cholecystostomy be a definitive management for acute acalculous cholecystitis?

GOALS

To evaluate the safety, efficacy, and long-term outcome of percutaneous cholecystostomy without additional cholecystectomy as a definitive treatment for acute acalculous cholecystitis (AAC).

BACKGROUND

AAC mainly occurs in seriously ill patients, and for those considered to be at high-risk for cholecystectomy, immediate percutaneous cholecystostomy can be a simple alternative interim treatment. However, no consensus has been reached on the issue of additional cholecystectomy.

STUDY

The medical records of 57 patients that underwent percutaneous cholecystostomy for AAC at a single institution between 1995 and 2010 were retrospectively analyzed.

RESULTS

Percutaneous cholecystostomy was technically successful in all patients, and no major complications relating to the procedure were encountered. Symptoms resolved within 4 days in 53 of the 57 (93%) patients. The in-hospital mortality rate was 21% (11/57) and elective cholecystectomy was performed in 18/57 (31%). Twenty-eight patients were managed non-operatively and cholecystostomy tubes were subsequently removed. These 28 patients were follow-up over a median 32 months and recurrent cholecystitis occurred in 2 (7%).

CONCLUSION

Percutaneous cholecystostomy is an effective procedure and a good alternative for patients unfit to undergo immediate surgery because of severe sepsis or an underlying comorbidity. After patients with AAC have recovered from percutaneous cholecystostomy, further treatment such as cholecystectomy might not be needed.

Clinical review of laparoscopic cholecystectomy in acute cholecystitis

BACKGROUNDS/AIMS

Laparoscopic cholecystectomy is the best treatment choice for acute cholecystitis. However, its higher conversion rate and postoperative morbidities remain controversial. The purpose of this retrospective study is to evaluate the clinical significance of laparoscopic cholecystectomy that is performed at our institution in patients with acute cholecystitis.

METHODS

Between January 2003 and December 2009, a retrospective study was carried out for 190 cases of acute cholecystitis undergoing laparoscopic cholecystectomy at our institution. They were divided into 2 groups, based on the time of operation from the onset of the symptom and other previous abdominal operation history. These groups were compared in the conversion rate and perioperative clinical outcomes, such as sex, age, accompanied disease, operation time, complications, postoperative hospital stay, total hospital stay and total costs.

RESULTS

We compared the two groups based on the timing of laparoscopic cholecystectomy and history of previous abdominal operation. There were no significant differences in the open conversion rate, postoperative complications and postoperative hospital stay, total hospital stay and total costs. The sex ratio, female in the previous abdominal operation group, was larger than the non-previous abdominal operation group (70.2% vs. 43.2%, p=0.003, OR=0.32 [95% CI, 0.15-0.70]). Early operation group was larger than delayed operation group, at previous abdominal operation history (26.1% vs. 13.3%, p=0.026, OR=0.43 [95% CI, 0.20-0.91]) and closed suction drain use (79.3% vs. 66.3%, p=0.044, OR=0.51 [95% CI, 0.27-0.99]).

CONCLUSIONS

Although this study was limited, early laparoscopic cholecystectomy for acute cholecystitis with previous abdominal operation history seems to be safe and feasible for patients, having a benefit of decrease in total hospital stay.

Impact of delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis

Laparoscopic cholecystectomy (LC) for complicated acute cholecystitis is associated with high rates of complications and conversion to open cholecystectomy. Percutaneous transhepatic gallbladder drainage (PTGBD) is a safe and effective treatment for acute inflammation of the gallbladder. This study was a retrospective analysis of patients who underwent an LC with or without PTGBD for complicated acute cholecystitis at our hospital between January 2002 and January 2007. Patients were classified into 3 groups: group 1, patients who underwent an LC without preoperative PTGBD (n=60); group 2, patients who underwent an early scheduled LC within 7 days of PTGBD (n=35); and group 3, patients in whom the LC was delayed for a mean of 19.9 days (range, 14 to 39 d) after PTGBD (n=38). The conversion rate to open cholecystectomy and the postoperative complication rate were lower in group 3 than in group 1 (P<0.05). Elective delayed LC after PTGBD may lower the conversion and complication rates of patients with complicated acute cholecystitis.