Percutaneous Cholecystostomy in Acute Cholecystitis-Predictors of Recurrence and Interval Cholecystectomy

Ultrasound-Guided Interventions in the Biliary System

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

Laparoscopic cholecystectomy versus antibiotic therapy for acute cholecystitis in patients over 75 years: Randomized clinical trial and retrospective cohort study

BACKGROUND AND OBJECTIVE

The prevalence of acute cholecystitis among elderly patients is increasing. The aim of this study was to compare laparoscopic cholecystectomy (LC) to antibiotics in elderly patients with acute cholecystitis.

METHODS

A randomized multicenter clinical trial including patients over 75 years with acute calculous cholecystitis was conducted in four hospitals in Finland between January 2017 and December 2019. Patients were randomized to undergo LC or antibiotic therapy. Due to patient enrollment challenges, the trial was prematurely terminated in December 2019. To assess all eligible patients, we performed a retrospective cohort study including all patients over 75 years with acute cholecystitis during the study period. The primary outcome was morbidity. Predefined secondary outcomes included mortality, readmission rate, and length of hospital stay.

RESULTS

Among 42 randomized patients (LC n = 24, antibiotics n = 18, mean age 82 years, 43% women), the complication rate was 17% (n = 4/24) after cholecystectomy and 33% (n = 6/18, 5/6 patients underwent cholecystectomy due to antibiotic treatment failure) after antibiotics (p = 0.209). In the retrospective cohort (n = 630, mean age 83 years, 49% women), 37% (236/630) of the patients were treated with cholecystectomy and 63% (394/630) with antibiotics. Readmissions were less common after surgical treatment compared with antibiotics in both randomized and retrospective cohort patients (8% vs 44%, p < 0.001% and 11 vs 32%, p < 0.001, respectively). There was no 30-day mortality within the randomized trial. In the retrospective patient cohort, overall mortality was 6% (35/630).

CONCLUSIONS

LC may be superior to antibiotic therapy for acute cholecystitis in the selected group of elderly patients with acute cholecystitis.

The impact of interval cholecystectomy timing after percutaneous transhepatic cholecystostomy on post-operative adverse outcomes

OBJECTIVE

This study aims to explore how timing of interval of cholecystectomy (IC) after percutaneous transhepatic cholecystostomy tube (PTC) placement impacts post-operative outcomes.

METHODS

A retrospective database analysis of New York State SPARCs database of IC between 2005 and 2015. The timing for IC ranged between > 1 week and < 2 years. Patients undergoing this procedure were further divided into quartiles using 4-time intervals; 1-5 weeks (Q1), 5-8 weeks (Q2), 8-12 weeks(Q3), and > 12 weeks(Q4). The study's primary outcome was hospital length of stay (LOS). Secondary outcomes included discharge status, 30-day readmission, 30-day ED visit, and 90-day reoperation, surgery type, complication, and bile duct injury. Multivariable regression models were used to compare patients across the four-time intervals after adjusting for confounding factors.

RESULTS

A total of 1038 patients with a history of PTC followed by IC between > 1 week and < 2 years were included in the final analysis. The median time to IC was 7.7 weeks. Q2 and Q3 both had a significantly higher median LOS of 3 days versus Q1 and Q4 at median of 5 days (p < 0.0001). Patients from racial and ethnic minorities (e.g., African Americans and Hispanics) were more likely to get their IC after 12 weeks (p < 0.05). Further, Black patients had a significantly higher median LOS than White, non-Hispanic patients (8 days vs 4 days, p < 0.0001) and were more likely to have open procedure. Multivariable regression analysis identified shorter LOS during Q2 (Ratio, 0.76, 95%, 0.67-0.87, p < 0.0001), and Q3 (Ratio 0.75, 95% CI, 065-0.86, p < 0.0001) compared to those who got their IC in Q4. Similar findings exist when comparing Q2 and Q3 to those receiving treatment during Q1.

CONCLUSION

A time interval of 5-12 weeks between PTC and IC was associated with a decreased LOS. This study also suggests the persistence of racial disparities among these patients.

Percutaneous Cholecystostomy in Severe Acute Cholecystitis: An Observational Study From a Single Institute

Background Although percutaneous cholecystostomy (PC) is generally accepted as a bridge to definitive therapy for acute cholecystitis (AC), which remains cholecystectomy, some patients did not undergo cholecystectomy, mainly due to contraindications to surgery. Here, we aimed to investigate the predictors of recurrence and the outcome after PC. Methods This is a retrospective study from a single general hospital at Tunbridge Wells, United Kingdom. One hundred twenty-six patients who presented with AC grade 3 and were initially managed with PC were included. In addition, the proportion of patients who did not undergo subsequent laparoscopic cholecystectomy (LC) and their characteristics were analyzed. Results The mean age of the study cohort was 72 (36-98) years, and the median length of drain insertion was 39.5 days. The majority (52%) presented with severe AC grade 3 with failed medical treatment to control the disease, while 7% had an emphysematous gallbladder. Eighty percent of patients did not develop any further attacks of AC after PC removal. The most common comorbidity was hypertension (35%). The mean age-adjusted Charlson comorbidity score was 3.72. Thirty-six percent (45/126) of the study cohort underwent LC, while the remaining patients did not receive any surgical intervention. Nine percent were deemed unfit for surgery. Forty-one patients (33%) were managed conservatively as they did not have a further attack of cholecystitis after PC removal or had a mild attack managed with antibiotics. In addition, 22% experienced procedural complications, including a blocked stent, pain, and cellulitis around the tube. The 30-day mortality rate of patients who did not undergo LC was 5%. Predictors of interval cholecystectomy were younger age, calculus cholecystitis, low Charslson index score, and uncomplicated and shorter length of hospital stay with PC. Conclusion Most severe AC patients treated initially with PC did not undergo subsequent LC. Therefore, PC in high-surgical-risk patients with AC could be a definitive treatment.

What makes acute cholecystitis recur after removing the percutaneous cholecystostomy tube?

Percutaneous transhepatic gallbladder drainage (PTGBD) is an alternative treatment option for acute cholecystitis. However, the disease may recur after PTGBD catheter removal. This study aimed to evaluate the role of endoscopic sphincterotomy and other risk factors in reducing the recurrence of cholecystitis.We retrospectively analyzed data from 1088 patients who underwent PTGBD for cholecystitis at Kyungpook National University Hospital, Republic of Korea, between January 2011 and April 2018.A total of 115 patients were enrolled in the study. The recurrence rate of cholecystitis was 17.4% (n = 20) during a median follow-up period of 1159 (range, 369-2774) days. Endoscopic biliary sphincterotomy did not significantly affect the recurrence rate of cholecystitis (P = .561). In multivariable analysis, cystic duct stones (P = .013) and PTGBD catheter migration before the prescheduled removal time (P = .002) were identified as independent risk factors for cholecystitis recurrence after PTGBD.To reduce post-PTGBD recurrence in cholecystitis, caution must be exercised to avoid inadvertent dislodging of the PTGBD catheter. In cases of cholecystitis with cystic duct stones, cholecystectomy should be considered only after careful assessment of postoperative risks. Instead, transluminal endoscopic gallbladder drainage could represent a promising option for the prevention of recurrent cholecystitis.

Percutaneous cholecystostomy as a definitive treatment for moderate and severe acute acalculous cholecystitis: a retrospective observational study

BACKGROUND

In this study, we aimed to investigate risk factors for the relapse of moderate and severe acute acalculous cholecystitis (AAC) patients after initial percutaneous cholecystostomy (PC) and to identify the predictors of patient outcomes when choosing PC as a definitive treatment for AAC.

MATERIALS AND METHODS

The study population comprised 44 patients (median age 76 years; range 31-94 years) with moderate or severe AAC who underwent PC without subsequent cholecystectomy. According to the results of follow-up (followed for a median period of 17 months), the data of patients with recurrence versus no recurrence were compared. Patients were divided into the death and non-death groups based on patient status within 60 days after PC.

RESULTS

Twenty-one (47.7%) had no recurrence of cholecystitis during the follow-up period after catheter removal (61-1348 days), six (13.6%) experienced recurrence of cholecystitis after PC, and 17 (38.6%) patients died during the indwelling tube period (5-60 days). The multivariate analysis showed that coronary heart disease (CHD) or congestive heart failure (odds ratio [OR] 26.50; 95% confidence interval [CI] 1.21-582.06; P = 0.038) was positively correlated with recurrence. The age-adjusted Charlson comorbidity index (OR 1.53; 95% CI 1.08-2.17; P = 0.018) was independently associated with 60-day mortality after PC.

CONCLUSIONS

Our results suggest that CHD or congestive heart failure was an independent risk factor for relapse in moderate and severe AAC patients after initial PC. AAC patients with more comorbidities had worse outcomes.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of outcomes of the patients with acute cholecystitis treated in the COVID-19 pandemic and pre-pandemic period

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has affected the health care system in an unpredictable way. In this study, we aimed to analyze the effects of the pandemic process on the disease severity on admission, management strategies, and outcomes of patients.

METHODS

The medical records of the patients who applied to the emergency department and consulted to the general surgery clinic from March 2020 until January 2021 were retrospectively reviewed as the pandemic period. For the control group, patients' medical records in the same time interval of 2019 were evaluated as the pre-pandemic period.

RESULTS

A total of 88 patients in the pre-pandemic period and 89 patients in the pandemic period were treated for acute cholecystitis. There was no statistically significant difference between the two groups in terms of the treatment strategies and length of hospital stay between the two periods (p=0.087 and p=0.587, respectively).

CONCLUSIONS

In the pandemic period, it is thought that postponing and bridging treatments may replace surgery for reducing the risk of contamination of both patients and health care workers.

[Acute Cholecystitis in high-risk surgical patients: sonographic and endoscopic treatment options]

Cholecystectomy is the gold standard in the treatment of acute cholecystitis, but has a significantly increased risk in multimorbid patients or in the severe course of acute cholecystitis. In such cases, drainage of the damaged gallbladder in combination with antibiotic therapy may be superior to primary surgery. The drainage can either be performed as sonographically guided percutaneous transhepatic gallbladder drainage or as EUS-guided transmural stent placement or endoscopic-transpapillary gallbladder drainage. These minimally invasive alternatives to cholecystectomy can be used both as long-term therapy for permanently inoperable patients and temporarily for patients in whom the cholecystectomy is intended after improvement of the general condition. In this overview, the various drainage methods are discussed with regard to technical requirements, immediate and long-term clinical results and complications. With advances in stent design, EUS-guided transmural stent placement from the stomach or duodenum into the gallbladder is becoming the preferred method of gallbladder drainage in centers with the appropriate expertise.

Image-guided percutaneous cholecystostomy: a comprehensive review

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

Long-term outcomes of acute acalculous cholecystitis treated by non-surgical management

Although cholecystectomy is generally recommended for acute acalculous cholecystitis (AAC) treatment, non-surgical management can be considered in patients at a high risk for surgery. This study compared outcomes of surgical and non-surgical management and analyzed the long-term outcomes of AAC patients managed non-surgically.We retrospectively analyzed 89 patients diagnosed with AAC between January 1, 2007 and April 30, 2014. These patients were divided into 2 groups: non-surgical (n = 41) and surgical (n = 48). Non-surgical management methods were percutaneous cholecystostomy (PC, n = 14) and antibiotics only (n = 27). The non-surgical group was followed up for >3 years after treatment.The mean age was slightly higher in the non-surgical group than in the surgical group without significant difference. The prevalence of cerebrovascular accident in the non-surgical group was significantly higher than that in the surgical group (26.8% vs 8.3%, P = .020). Mean hospital stay was not statistically different between two groups. The surgical group had a significantly higher incidence of posttreatment complications than the non-surgical group (18.8% vs 2.4%, P = .015). During the mean follow-up of 5.7 years, AAC recurred in 4 (9.8%) patients in the non-surgical group. Three patients underwent cholecystectomy, 1 was treated with antibiotics, and no recurrence-related death occurred. The recurrence rate of AAC was not different between PC and antibiotics only groups (14.3% vs 7.4%, P = .596).Recurrence was observed in 9.8% of AAC patients treated non-surgically and the outcome in the non-surgical group was not inferior to that in the surgical group.