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

Therapeutic Endoscopic Ultrasound and Endoscopic Ultrasound-Endoscopic Retrograde Cholangiopancreatography Interventions

Therapeutic endoscopic ultrasound (EUS) encompasses an array of procedures to manage pancreaticobiliary and luminal gastrointestinal disorders. Therapeutic EUS procedures include EUS-guided rendezvous of the pancreatic and biliary ducts, as well as direct drainage of the bile duct, pancreatic duct, and gallbladder, drainage of pancreatic fluid collections, and luminal anastomosis creation. These procedures have a range of required equipment, approaches, clinical outcomes, and adverse events dependent on both procedure-related and patient-related factors. In expert hands, these procedures provide patients with less invasive options and can achieve excellent clinical outcomes.

Management of Gallstone Disease

Gallstone disease has plagued humanity since antiquity. Its recognition and treatment has been refined through decades as surgical technique and imaging capabilities have advanced. With the rise of the obesity epidemic and metabolic syndrome, its prevalence is also increasing. This review provides an overview of the various manifestations of gallstone disease and treatment modalities appropriate for its resolution.

Predictive factors associated with Bile culture positivity And phenotypiCal antIbiogram resistance patterns in patients taken to LaparOscopic cholecystectomy (BACILO): protocol for a prospective observational cohort study and development of a prognostic prediction model

INTRODUCTION

Bile fluid is aseptic under normal conditions; however, in the presence of cholecystitis, its susceptibility to bacterial colonisation varies, with reported rates of 20%-70% of cases. This process is referred to as bactibilia and/or bacteriobilia and can be considered a secondary complication of biliary stasis and cholecystitis in general. In the management of acute cholecystitis, the antibiotic regimen should be prescribed based on the presumed pathogens involved, taking into consideration the risk factors for resistance patterns according to demographics and local exposure. The aim of this study is to determine the predictive factors for bile culture positivity and antibiotic resistance in patients who underwent laparoscopic cholecystectomy in the Méderi Hospital Network. We hope to develop a predictive model that allows us to better guide antibiotic therapy.

METHODS AND ANALYSIS

This is a prospective observational cohort study with prognostic prediction model. Patients who will undergo laparoscopic cholecystectomy and have bile cultures taken in the Méderi Hospital Network during the study period will be included. The dependent variables will be positive bile culture and antibiotic resistance, and the predictive variables will be age, presence of diabetes, diagnosis of choledocholithiasis, diagnosis of cholecystitis and severity of cholecystitis according to the Tokyo criteria. The minimum sample size has been calculated at 703 patients. Follow-up will continue until a control appointment 15 days after the procedure. The primary outcomes are bile culture positivity and phenotypical antibiogram resistance. For each outcome, a multivariate logistic regression will be performed using frequentist and Bayesian prediction techniques.

ETHICS AND DISSEMINATION

This study was approved by the Méderi network research department committee (CIMED) and by Universidad del Rosario's Research Ethics Committee (CEI-UR; DVO005 2555-CV1837). Written informed consent is required for participation. The results will be disseminated through the submission of an academic article to a high-impact scientific journal, presentations at academic conferences, and sharing with our institution's faculty to inform antimicrobial therapy management based on local epidemiological data.

TRIAL REGISTRATION NUMBER

NCT06314399.

Interval cholecystectomy following drainage procedures for acute cholecystitis: percutaneous transhepatic vs endoscopic transpapillary gallbladder drainage

BACKGROUND

Gallbladder drainage procedures are often considered for acute cholecystitis (AC) patients with significant peri-operative risks. While percutaneous transhepatic gallbladder drainage (PTGBD) has been evaluated in previous studies, there is scarce data on the feasibility and efficacy of endoscopic transpapillary gallbladder stenting (ETGBS) in patients with AC. This study aimed to compare the characteristics of interval cholecystectomy following ETGBS and PTGBD.

METHODS

This retrospective descriptive study included patients who underwent ETGBS and/or PTGBD for AC and subsequently underwent interval cholecystectomy between 2018 and 2023. Demographics, operative technique, and postoperative complications of patients with ETGBS and PTGBD were compared.

RESULTS

A total of 59 patients were included (14 ETGBS and 45 PTGBD). The median days between ETGBS and cholecystectomy were significantly longer than the PTGBD group (64 [45-150] days vs. 16 [10-42] days, p=0.045). The median operation time was significantly longer in the ETGBS group.　Among 33 patients who underwent subtotal cholecystectomy, the ERGBS group more frequently required closure of the gallbladder stump due to the difficulty in ligating the cystic duct compared to the PTGBD group (75.0% vs. 28.0%, p=0.035). Similarly, the fundus-first approach was more commonly selected in the ERGBS group (62.5% vs. 28.0%, p=0.01). No significant differences in the incidence of postoperative complications were observed between the two groups.

CONCLUSIONS

Interval cholecystectomy following ETGBS is more technically demanding compared to PTGBD. Laparoscopic subtotal cholecystectomy following ETGBS could be a potential treatment option for patients who are unfit for early surgery, with the recognition of the difficulty in ligating the cystic duct.

Clinical update on acute cholecystitis and biliary pancreatitis: between certainties and grey areas

Acute calculous cholecystitis (ACC) and acute biliary pancreatitis (ABP) are significant complications of gallstone disease. This review aims to provide a comprehensive analysis of current management practices for ACC and ABP. The Tokyo Guidelines (TG) and World Society of Emergency Surgery (WSES) guidelines recommend early laparoscopic cholecystectomy (ELC) as the treatment of choice for ACC. High-risk patients may benefit from alternative treatments like biliary drainage, with emerging techniques such as endoscopic drainage showing promise. ABP requires prompt diagnosis and intervention. The Revised Atlanta Classification (RAC) criteria are used for diagnosis, with endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy as primary treatments. Minimally invasive approaches are preferred for managing complications like infected pancreatic necrosis, with the endoscopic step-up method showing superior outcomes. The management of ACC and ABP continues to evolve. Future research is needed to refine guidelines further and address existing controversies, ultimately improving patient outcomes in these acute biliary conditions.

Associations between temporal eating patterns and energy distribution patterns with gallstones: a cross-sectional study based on NHANES 2017-2018

BACKGROUND

Gallstones are strongly associated with eating occasion (EO) and energy distribution, but few studies have addressed this aspect. Therefore, we utilize the data from 2017 to 2018 National Health and Nutrition Examination Survey (NHANES) to explore the association between temporal eating patterns and energy distribution patterns with the incidence of gallstones.

METHODS

Our study comprised participants who completed the NHANES dietary intake interview and self-reported health questionnaire at age 20 or older. The self-report method for gallstones (have you ever been told by a doctor) was used. We use the latent class analysis (LCA) identified temporal eating patterns, and identified energy distribution patterns through latent profile analysis (LPA). The association between temporal eating patterns, energy distribution patterns, and gallstones was examined using logistic regression modeling.

RESULTS

The study included a total of 4,692 participants. LCA identified four temporal eating patterns labeled as "Conventional," "Early breakfast," "Later breakfast," and "Grazing." Compared to the "Conventional" pattern, the "Early breakfast" pattern (OR 0.809, 95%CI 0.808-0.811) was associated with a reduced risk of gallstones, while the "Later breakfast" (OR 1.435, 95%CI 1.432-1.438) and "Grazing" (OR 1.147, 95%CI 1.145-1.148) patterns were associated with an increased risk of gallstones. LPA identified four energy distribution patterns labeled as "Guideline," "High carbohydrates," "Carbs-fat balance," and "High fat." The "High carbohydrates" pattern (OR 1.329, 95%CI 1.326-1.331) was associated with an increased risk of gallstones compared to the "Guideline" pattern. The "Carbs-fat balance" pattern (OR 0.877, 95%CI 0.876-0.879) and the "High fat" pattern (OR 0.848, 95%CI 0.846-0.850) were significantly and negatively associated with the risk of gallstones.

CONCLUSIONS

To summarize, inappropriate timing of eating and energy sources are associated with gallstones. As a dietary prevention measure for gallstones, we suggest adhering to a regular eating routine and avoiding overly casual and frequent food consumption. If the main EO routine occurs in the morning, this time should not exceed 9:00 a.m. Additionally, reducing carbohydrate intake and maintaining a moderate level of fat intake is believed to contribute to a lower risk of gallstones.

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.

Acute cholecystitis management at a tertiary care center: are we following current guidelines?

PURPOSE

After the Tokyo 2018 guidelines (TG2018) were published, evidence from the 2018 CHOCOLATE RCT supported early cholecystectomy for acute cholecystitis (AC), even in high-risk patients. This study aims to investigate AC management at our tertiary care center in the years following these publications.

METHODS

A retrospective cohort study was performed on patients admitted from 2018 to 2023. AC severity was graded using TG2018 definitions. Comorbidities were summarized using Charlson Comorbidity Index (CCI) and frailty using the 5-item modified Frailty Index (5mFI). Compliance with TG2018 recommendations for management strategy was investigated. Outcomes were compared between patients who underwent surgery versus non-operative management (NOM). Subset analysis based on patients' age, frailty, and comorbidities was performed.

RESULTS

Among 642 AC patients, 57% underwent cholecystectomy and 43% NOM (22% percutaneous cholecystostomy, 21% antibiotics only). NOM patients had greater length of stay (LOS), complications, deaths, readmissions, and discharge to nursing/rehab versus surgery patients. In 70% of patients managed non-operatively, TG2018 were not followed. Patients managed non-operatively despite TG2018 were more likely to undergo delayed cholecystectomy compared to those in whom guidelines were followed (17% vs. 4%). In subset analysis, healthy octogenarians were significantly less likely to be managed according to TG2018 (9.4%); patients undergoing surgery had a trend towards shorter LOS (3.1 vs. 4.8 days) than those managed non-operatively but no difference in other outcomes.

CONCLUSION

Most patients undergoing NOM could potentially undergo cholecystectomy if guidelines are considered. A more objective approach to risk assessment may optimize patient selection and outcomes.

International Delphi consensus on the management of percutaneous choleystostomy in acute cholecystitis (E-AHPBA, ANS, WSES societies)

BACKGROUND

There has been a progressive increase in the use of percutaneous cholecystostomy (PC) in acute cholecystitis (AC) over the last decades due to population aging, and the support of guidelines (Tokyo Guidelines (TG), World Society of Emergency Surgery (WSES) Guidelines) as a valid therapeutical option. However, there are many unanswered questions about the management of PCs. An international consensus on indications and PC management using Delphi methodology with contributions from experts from three surgical societies (EAHPBA, ANS, WSES) have been performed.

METHODS

A two-round Delphi consensus, which included 27 questions, was sent to key opinion leaders in AC. Participants were asked to indicate their 'agreement/disagreement' using a 5-point Likert scale. Survey items with less than 70% consensus were excluded from the second round. For inclusion in the final recommendations, each survey item had to have reached a group consensus (≥ 70% agreement) by the end of the two survey rounds.

RESULTS

54 completed both rounds (82% of invitees). Six questions got > 70% and are included in consensus recommendations: In patients with acute cholecystitis, when there is a clear indication of PC, it is not necessary to wait 48 h to be carried out; Surgery is the first therapeutic option for the TG grade II acute cholecystitis in a patient suitable for surgery; Before PC removal a cholangiography should be done; There is no indication for PC in Tokyo Guidelines (TG) grade I patients; Transhepatic approach is the route of choice for PC; and after PC, laparoscopic cholecystectomy is the preferred approach (93.1%).

CONCLUSIONS

Only six statements about PC management after AC got an international consensus. An international guideline about the management of PCs are necessary.

Fenestrating Versus Reconstituting Subtotal Cholecystectomy: Systematic Review and Meta-Analysis on Bile Leak, Bile Duct Injury, and Outcomes

Symptoms of gallstone disease are the most common reason for cholecystectomy. Fenestration reduces the likelihood of severe inflammation or scarring after normal treatments are used, and it also enhances control over bile outflow. The goal of reconstituted cholecystectomy is to lessen symptoms like pain and jaundice without undergoing the high-risk procedures associated with more invasive procedures. The reconstituted and fenestrated procedures were assessed by a meta-analysis and systematic review. Of the five studies, 189 (34.2%) had a reconstituted subtotal cholecystectomy, and 363 (65.8%) had a fenestrated subtotal cholecystectomy, which had populations from the United States of America, the United Kingdom, Japan, and Turkey. Two individuals from three trials had bile duct injury, according to three studies. Whereas the fenestrated group reported no bile injury from 236 individuals (0%), the reconstituted group reported two bile duct injuries from 100 patients (2%). The incidence was found to be lower in the fenestrated group (OR 10.81; CI 95% 1.03-113.65; p = 0.39; I2 = 0%) than in the reconstituted group. Four studies revealed 92 cases of bile leaks: 19 out of 155 cases (12.3%) were reconstituted, and 73 out of 351 cases (20.8%) were fenestrated. Between the two groups, there was a significant difference in bile leakage (OR 0.72; CI 95% 0.23-2.32; p = 0.03; I2 = 66%). Two studies reported the establishment of fistulas following surgery in 58 patients in the reconstituted group (5.2%) and 120 patients in the fenestrated group (2.5%) (p = 0.56, I2 = 0%, and OR 0.65; CI 95% 0.12-3.38); however, there was no statistically significant difference between the groups. Following a fenestrated partial cholecystectomy, postoperative bile leakage, fistula development, wound infection, and retained stones are more prevalent. Additionally, we saw that the fenestrated method was being used more frequently for post-operative endoscopic retrograde cholangiopancreatography (ERCP). The subtotal cholecystectomy technique used should be chosen according to the surgeon's comfort level and experience with the various techniques and intraoperative findings, even if the reconstituted procedure could be preferred when feasible. To completely understand the role of each method in the general surgeon's toolkit for treating complex gallbladder (GB) patients, longer-term follow-up studies are still necessary.

Evaluation of the surgical management strategy for acute cholecystitis in patients over 75years old

INTRODUCTION

Acute cholecystitis occurs frequently in the elderly. According to the current recommendations specific to the characteristics of each case, these patients are most often treated by delayed cholecystectomy after medical treatment. Our study aimed to compare the success rate of this strategy in patients over and under 75years of age.

PATIENTS AND METHODS

This was a retrospective single-center analytic observational study that included patients who were hospitalized for acute cholecystitis in a geriatric postoperative unit (unité postopératoire gériatrique [UPOG]) and gastrointestinal surgery unit between 2021 and 2022. The main endpoint was the failure rate of deferred cholecystectomy. Secondary endpoints included: respect for the recommended operative delay, loss of the patient's functional independence during hospitalization, and the reason for surgical abstention.

RESULTS

In total, 290 patients were included. The strategy of delayed elective cholecystectomy was not achieved in 31 (44%) patients 75years old or older vs. eight (18%) patients younger than 75years old (P=0.005). The main reason was the decision not to operate after medical treatment. In both groups, the recommended operative interval was equitably respected and the loss of autonomy during hospitalization was minor. More than one-third of the elderly patients scheduled for elective surgery finally refused to undergo surgery.

CONCLUSION

The strategy of routine elective cholecystectomy should not be strict in the elderly with acute cholecystitis; the indication for this procedure should take into account the wishes as well as the physiological status of the patient.

Minimally invasive subtotal cholecystectomy. What surgeons need to know

Minimally invasive laparoscopic cholecystectomy is among the most frequently performed abdominal surgeries. Bile duct injury is a significative complication that occurs in about 0.2-0.3% of open procedures and 0.5% of laparoscopic surgeries, with concomitant vasculobiliary injuries in 12-61% of cases. Most of these lesions occurs during challenging severe cholecystitis where the intense inflammation obscures the hepatocystic anatomy. In this case a bailout strategy such as a subtotal cholecystectomy should be considered. Subtotal cholecystectomy is a surgical technique performed to remove a portion of the gallbladder while leaving part of it behind. In such complex cholecystectomies, surgeons should be aware of this technique, and subtotal cholecystectomy should be part of their surgical armamentarium. We aim to familiarize surgeons with bailout techniques like subtotal cholecystectomy and gallbladder emptying for challenging acute cholecystectomy cases to reduce the risk of vasculobiliary injury. This multimedia article provides, a comprehensive step-by-step overview of the different possible minimally invasive subtotal cholecystectomy procedures, we outline five distinct techniques for conducting subtotal cholecystectomy, including some tips and tricks and demonstrates the usefulness of a minimally invasive approach. Finally, we emphasize the importance of carefully choosing between laparoscopic and robotic approaches and suggests using adjunctive tools, such as preoperative indocyanine green, to better identify common bile duct anatomy.

Fenestrating vs reconstituting laparoscopic subtotal cholecystectomy: a systematic review and meta-analysis

INTRODUCTION

Laparoscopic cholecystectomy is one of the most frequently performed procedures by general surgeons. Strategies for minimizing bile duct injuries including use of the critical view of safety method, as outlined by the SAGES Safe Cholecystectomy Program, are not always possible. Subtotal cholecystectomy has emerged as a safe "bail-out" maneuver to avoid iatrogenic bile duct injury in these difficult cases. Strasberg and colleagues defined two main types of subtotal cholecystectomies: reconstituting and fenestrating. As there is a paucity of studies comparing the two subtypes of laparoscopic subtotal cholecystectomy (LSC), we performed a systematic review and meta-analysis comparing the reconstituting and fenestrating techniques for managing the difficult gallbladder.

METHODS

A search of PubMed, Embase, and Cochrane databases was conducted to identify prospective and retrospective studies comparing fenestrating and reconstituting LSC. The outcomes of interest were bile leak, reoperation, readmissions, completion cholecystectomy, postoperative ERCP, and retained CBD stones.

RESULTS

We screened 2855 studies and included 13 studies with a total population of 985 patients. Among them, 330 patients (33.5%) underwent reconstituting LSC and 655 patients (55.5%) underwent fenestrating LSC. Twelve studies were retrospective, and one was prospective. Notably, reconstituting STC was associated with decreased incidence of bile leak (OR 0.29; CI 95% 0.16-0.55; p = 0.0002; I2 = 36%). We also noted increased rates of postoperative ERCP with fenestrating STC in sensitivity analysis (OR 0.32; CI 95% 0.16-0.64; p = 0.001; I2 = 31%). In addition, there was no difference between the two techniques regarding the rates of completion of cholecystectomy, reoperation, readmission, and retained CBD stones.

CONCLUSIONS

Fenestrating LSC leads to a higher incidence of postoperative bile leakage. In addition, our sensitivity analysis revealed that the fenestrating technique is associated with a higher incidence of postoperative ERCP. Further randomized trials and studies with longer-term follow-up are still necessary to better understand these techniques in the difficult gallbladder cases.

Clinical application of prone position to suppress respiratory movement artifacts in supine position during magnetic resonance cholangiopancreatography/MRI

PURPOSE

To compare the image quality of magnetic resonance cholangiopancreatography (MRCP) in the supine position and prone position under the conditions of the same equipment, the same sequence (3D Navigator Triggered Sampling Perfection with Application-Optimized Contrast Using Different Flip-angle Evolutions, 3D-NT-SPACE) and the same patient, and to explore the clinical application value of prone position in MRCP examination to suppress respiratory motion artifacts.

METHODS

53 participants who underwent MRCP in our hospital from April 2020 to August 2022 were prospectively collected. The 3D-NT-SPACE sequence was used in these patients. The visibility of the common bile duct, common hepatic duct, main pancreatic duct, and first- and second- and third-level branches of the intrahepatic bile duct and the comfort of the participants in two positions were subjective-evaluated. The Signal-to-noise ratio (SNR) and contrast-to-noise ratio were objective-evaluated. Statistical analysis was performed using Shapiro-Wilk, Levene's, Mann Whitney U test, Pearson chi-square test, and one-sample chi-square test.

RESULTS

53 patients (51.92 years ± 2.02, 20 men) were evaluated. There were significant differences in the second- and third-level branches visibility score, the main pancreatic duct visibility score, the image quality score of the pancreaticobiliary tree, the blur and motion artifact score, the total image quality score, and SNR between the two positions (p < 0.05).

CONCLUSIONS

The overall image quality of the prone position was better than that of the supine position. The prone position is a useful complement to the supine position.

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.

Early Versus Delayed Laparoscopic Cholecystectomy, after Percutaneous Gall Bladder Drainage, for Grade II Acute Cholecystitis TG18 in Patients with Concomitant Cardiopulmonary Disease

Background: The advancement in medical care has led to an increase in patients with acute cholecystitis (AC) and cardiopulmonary comorbidities referred for surgery. Grade II AC, according to Tokyo Guidelines in 2018 (TG18), is characterized by severe local inflammation with no systemic affection. The optimal treatment for patients with high-risk grade II AC has not yet been clearly established, which is still a dilemma. For these patients, laparoscopic cholecystectomy (LC), despite being the only definitive treatment, is still a challenge. The introduction of percutaneous cholecystostomy as a temporary minimally invasive alternative technique allows an immediate gallbladder decompression with a rapid clinical improvement. However, the next step after percutaneous transhepatic gall bladder drainage (PTGBD) in these high-risk patients is still a debate, with no definitive consensus about the ideal treatment of choice as well as its optimal timing. In our study, we followed a treatment algorithm for high-risk patients that involved early gallbladder decompression by PTGBD, followed by LC at different intervals once the patient is considered fit for surgery. Method: A retrospective study of 58 patients with high-risk grade II AC with cardiopulmonary comorbidity from our medical records was included. They were managed initially with PTGBD, an LC was then performed either within 7 days after drain insertion (early group, 26 patients), while an LC was performed later for the remaining patients within 6-8 weeks after PTGBD (late group, 32 patients). The results of the two groups were analyzed. Result: Procalcitonin and C-reactive protein were significantly higher in the late group. No significant difference was found between both groups with regard to operative time, PTGBD-related complications, and major perioperative complications. Timing after PTGBD did not affect the incidence of operative complications. Total hospital stay was significantly shorter in the early group. Conclusion: PTGBD is a safe initial intervention for high-risk patients with AC with a low morbidity and high success rate. Urgent LC after PTGBD can be performed safely for well-selected high-risk patients with the timing of surgery is personalized according to each patient's clinical situation. Early LC (after PTGBD) has the advantage of shorter hospital stay, low cost, as well as avoiding the risk of biliary complications and mortality if waiting a delayed surgery with no significant difference in morbidity compared with late LC.

Evaluation and mitigation of the limitations of large language models in clinical decision-making

Clinical decision-making is one of the most impactful parts of a physician's responsibilities and stands to benefit greatly from artificial intelligence solutions and large language models (LLMs) in particular. However, while LLMs have achieved excellent performance on medical licensing exams, these tests fail to assess many skills necessary for deployment in a realistic clinical decision-making environment, including gathering information, adhering to guidelines, and integrating into clinical workflows. Here we have created a curated dataset based on the Medical Information Mart for Intensive Care database spanning 2,400 real patient cases and four common abdominal pathologies as well as a framework to simulate a realistic clinical setting. We show that current state-of-the-art LLMs do not accurately diagnose patients across all pathologies (performing significantly worse than physicians), follow neither diagnostic nor treatment guidelines, and cannot interpret laboratory results, thus posing a serious risk to the health of patients. Furthermore, we move beyond diagnostic accuracy and demonstrate that they cannot be easily integrated into existing workflows because they often fail to follow instructions and are sensitive to both the quantity and order of information. Overall, our analysis reveals that LLMs are currently not ready for autonomous clinical decision-making while providing a dataset and framework to guide future studies.

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.

Ultrasound of the gallbladder: not the same bag of tricks

Imaging evaluation of the gallbladder is a fundamental skill in the majority of radiology practice. Due to ease of accessibility, low cost, lack of ionizing radiation, and excellent spatial resolution, ultrasound is often the first imaging modality used to evaluate the gallbladder. In this invited article we review and update how ultrasound can evaluate common pathologies including gallbladder polyps, tumefactive sludge, adenomyomatosis, and acute cholecystitis. We also discuss the role of Doppler, microvascular flow imaging, and contrast enhanced ultrasound in the sonographic assessment of the gallbladder.

Cholecystopleural fistula: A case report and literature review

INTRODUCTION

Gallstone with acute cholecystitis is one of the most common diseases in the clinic. If the disease is serious, gallbladder gangrene, perforation, and sepsis may be caused. Gallbladder diseases rarely cause thoracic-related complications, especially pleural fistula, which is very rare in clinical practice.

PATIENT CONCERNS

A 52-year-old male patient was admitted to the emergency department for 1 month with recurrent right middle and upper abdominal pain.

DIAGNOSIS

Computed tomography diagnosis: cholecystitis and peri-inflammation, small abscess around the base of the gallbladder, local peritonitis, and bilateral pleural effusion.

INTERVENTIONS

After admission, conservative treatment was given. On the 4th day of admission, the symptoms worsened, and an emergency catheter drainage was performed on the right thoracic cavity to extract 900 mL of dark yellow effusion. After the operation, a large amount of bili-like fluid was continuously drained from the thoracic drainage tube. After the iatrogenic biliary fistula caused by thoracic puncture was excluded, cholecystopleural fistula was considered to be cholecystopleural fistula. On the 6th day of admission, endoscopic retrograde cholangiopancreatography (ERCP) + cholecystography + Oddi sphincterotomy + laminating biliary stent was performed in the emergency department, and cholecystopleural fistula was confirmed during the operation.

OUTCOMES

The patient recovered well after surgery, computed tomography examination on the 20th day after surgery indicated that pleural effusion was significantly reduced, and the patient was cured and discharged. The patient returned to the hospital 8 months after the ERCP operation to pull out the bile duct-covered stent. The patient did not complain of any discomfort after the postoperative follow-up for 3 years, and no recurrence of stones, empyema, and other conditions was found.

CONCLUSION

Cholecystopleural fistula is one of the serious complications of acute cholecystitis, which is easy to misdiagnose clinically. If the gallbladder inflammation is severe, accompanied by pleural effusion, the pleural effusion is bili-like liquid, or the content of bilirubin is abnormally elevated, the existence of the disease should be considered. Once the diagnosis is clear, active surgical intervention is needed to reduce the occurrence of complications. Endoscopic therapy (ERCP) can be used as both a diagnostic method and an important minimally invasive treatment.

Management and patient outcomes following admission with acute cholecystitis in Ireland: A national registry-based study

INTRODUCTION

Acute cholecystitis is a common general surgical emergency, accounting for 3-10 % of all patients attending with acute abdominal pain. International guidelines suggest that emergency cholecystectomy is the treatment of choice for uncomplicated acute cholecystitis where feasible. There is a paucity of published data on the uptake of emergency cholecystectomy in Ireland.

AIM

The aim of this study was to evaluate the management of acute cholecystitis in Ireland and to establish the rate of emergency cholecystectomy performed.

METHODS

All patients with acute cholecystitis presenting to public hospitals in Ireland between January 2017 and July 2023 were identified using the National Quality Assurance and Improvement System (NQAIS). Data were collected on patient demographics, co-morbidities, length of stay, operative intervention, endoscopic intervention, critical care admissions, in-patient mortality, and readmissions. Propensity score matched analysis and logistic regression were performed to account for selection bias in comparing patients managed with cholecystectomy and those managed conservatively.

RESULTS

20,886 admission episodes were identified involving 17,958 patients. 3585 (20 %) patients underwent emergency cholecystectomy in total. 3436 (96 %) of these were performed laparoscopically, with 140 (4 %) requiring conversion to an open procedure, and common bile duct injuries occurring in 4 (0.1 %) of patients. In comparison to patients treated conservatively, patients who underwent cholecystectomy were younger (median 50 v 60 years, p < 0.001) and more likely to be female (64 % v 55 % p < 0.001). Following propensity score matched analysis, those who had an emergency cholecystectomy had reduced length of stay (LOS) (median 5 days (IQR 3-8) v 6 days (interquartile range (IQR) 3-10), p < 0.001) and fewer readmissions to hospital (282 (8 %) v 492 (14 %), p < 0.001). On logistic regression, age >65 (OR 1.526), CCI >3 (OR 2.281) and non-operative management (OR 1.136) were significant risk factors for adverse outcome.

CONCLUSION

Uptake of emergency cholecystectomy in Ireland remains low, and is carried out on a younger, fitter cohort of patients. In those patients, however, it is associated with improved outcomes for cholecystitis compared to conservative management, including shorter LOS and reduced readmission rates for matched cohorts.

Association between triglyceride-glucose index and gallstones: a cross-sectional study

This study used data from the National Health and Nutrition Examination Survey (NHANES) to investigate the relationship between the triglyceride-glucose (TyG) index and gallstones. We evaluated the data collected between 2017 to 2020. To evaluate the relationship between TyG index and gallstones, logistic regression analysis, basic characteristics of participants, subgroup analysis, and smooth curve fitting were utilized. The study included 3870 participants over the age of 20 years, 403 of whom reported gallstones, with a prevalence rate of 10.4%. After adjusting for all confounding factors, the risk of gallstones increased by 41% for each unit increase in the TyG index (OR 1.41, 95% CI 1.07, 1.86). The smooth curve fitting also showed a positive correlation between the TyG index and gallstones. Subgroup analysis revealed a significant positive relationship between the TyG index and the risk of gallstones in those aged < 50 years, women, individuals with total cholesterol levels > 200 mg/dL, individuals with body mass index (BMI) > 25, and individuals without diabetes. The risk of gallstones is positively correlated with a higher TyG index. Thus, the TyG index can be used as a predictor of the risk of gallstones.

Clinical and Epidemiological Profile of Patients Presenting With Acute Abdomen to the Emergency Department of a Tertiary Care Hospital

BACKGROUND

 Acute abdomen is a common and urgent clinical condition requiring prompt diagnosis and treatment. This study determines the clinical and epidemiological profile of patients presenting with acute abdomen at a tertiary care hospital.

OBJECTIVE

To describe the demographic characteristics, provisional diagnoses, treatment modalities, and pain management effectiveness in patients with acute abdomen.

METHODS

 This prospective observational study was conducted in the Emergency Medicine department at Dr. D. Y. Patil Medical College, Hospital & Research Center, Pimpri, Pune, over a specified period. The study included patients presenting with acute abdomen, aged above 14 years, excluding those with traumatic acute abdomen and pregnant patients. A sample size of 146 was calculated based on the proportion of ureteric colic cases, with a 95% confidence interval and a 6% margin of error; however, a total of 176 patients were included in the study. Data collection involved recording demographic details, clinical features, provisional diagnoses, and pain scores, as well as performing required blood investigations and ultrasonography. Pain scores were assessed before and after treatment. Patients will be given non-steroidal anti-inflammatory drugs (NSAIDs) or opioid analgesia, depending on the clinical severity. Emergency medicine residents, in consultation with the on-call consultant, determined the disposition of patients, deciding if they required surgical or conservative management.

RESULTS

The study found that the majority of patients, n = 130 (73.86%), were aged 26-50 years, with cases n = 103 (58.52%) being males and cases n = 73 (41.48%) females. Acute appendicitis was the most common diagnosis, n = 41 (24.43%), followed by urolithiasis n = 33 (18.75%). Surgical interventions were required for n = 78 (45.08%) of patients, highlighting the urgent nature of these conditions. Pain management was effective, with significant reductions in pain scores post-treatment (mean visual analog score (VAS) decreased from 6.22 to 2.33, and mean numerical rating score (NRS) from 6.05 to 2.10; p < 0.001).

CONCLUSION

 The study underscores the high prevalence of gastrointestinal and renal conditions in patients with acute abdomen, particularly in middle-aged adults. The high rate of surgical interventions reflects the urgent nature of these conditions. Significant reductions in pain scores demonstrated effective pain management. Comprehensive care strategies are essential for optimizing patient outcomes. Future research with larger sample sizes and multi-center participation is recommended to validate these findings and enhance management protocols for acute abdomen.

Comparison of biliary protein spectrum in gallstone patients with obesity and those with normal body weight

BACKGROUND

Obesity is a common public health issue and is currently deemed a disease. Research has shown that the risk of gallstones in individuals with obesity is elevated. This study aimed to explore the bile proteomics differences between cholelithiasis patients with obesity and normal body weight.

METHODS

Bile samples from 20 patients (10 with obesity and 10 with normal body weight) who underwent laparoscopic cholecystectomy at our center were subjected to tandem mass tag labeling (TMT) and liquid chromatography-tandem mass spectrometry (LC-MS/MS), followed by further bioinformatic analysis.

RESULTS

Among the differentially expressed proteins, 23 were upregulated and 67 were downregulated. Bioinformatic analysis indicated that these differentially expressed proteins were mainly involved in cell development, inflammatory responses, glycerolipid metabolic processes, and protein activation cascades. In addition, the activity of the peroxisome proliferator-activated receptor (PPAR, a subfamily of nuclear receptors) signaling pathway was decreased in the Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis. Two downregulated proteins in the PPAR signaling pathway, APO A-I and APO A-II, were confirmed using enzyme-linked immunosorbent assay.

CONCLUSIONS

The PPAR signaling pathway may play a crucial role in the development of cholelithiasis among patients with obesity. Furthermore, biliary proteomics profiling of gallstones patients with obesity is revealed, providing a reference for future research.

Incidence of Endoscopic Retrograde Cholangiography after Subtotal Fenestrating and Reconstituting Cholecystectomy

BACKGROUND

Laparoscopic subtotal cholecystectomy (SC) is used for the difficult cholecystectomy, but published experience with resource use for SC is limited. We hypothesized that the need for advanced resources are common after SC.

STUDY DESIGN

This was a retrospective review of laparoscopic cholecystectomies between 2017 and 2021 at a large center. SC cases were identified using a medical record tool. Baseline characteristics were assessed with Student's t -test and chi-square test. Primary outcome was endoscopic retrograde cholangiography (ERC) within 60 days. Secondary outcomes were reconstituted SC on postoperative ERC and length of stay (LOS). Uni- and multivariable logistic regression were used for binary outcomes. Multiple linear regression was used for LOS. Covariates included were age, sex, BMI, and American Society of Anesthesiology class.

RESULTS

A total of 1,222 laparoscopic cholecystectomies were performed between 2017 and 2021. Of these, 87 (7%) were SC. Male (p < 0.001) and older (p < 0.001) patients were more likely to undergo SC. Odds of postoperative ERC were higher in the SC group (odds ratio 9.79, 95% CI 5.90 to16.23, p < 0.001). There was no difference in preoperative ERC (17% vs 21%, p = 0.38). Reconstituting SC had lower odds of postoperative ERC (odds ratio 0.12, 95% CI 0.023 to 0.58, p = 0.009). LOS was 1.81 times higher in the SC group (p ≤ 0.001). Postoperative ERC was not associated with LOS (p = 0.24).

CONCLUSIONS

We present one of the largest single-center series of SC. Patients who underwent SC are more likely to be male, older, have higher American Society of Anesthesiology class, and have increased LOS. SC should be performed when access to ERC and interventional radiology is available. In the absence of these adjuncts, reconstituting SC decreases the need for early ERC, but long-term outcomes are unknown.

Laparoscopic vs open approach for acute cholecystitis in octogenarians. A prospective multicenter observational nationwide study

BACKGROUND

The world population is aging, with octogenarians expected to reach over 400 million by 2050. Acute cholecystitis is a serious complication in the elderly. Age is not a contraindication for emergency cholecystectomy, an option that can both save lives and preserve quality of life.

METHODS

The present study aimed to compare open and laparoscopic surgical approaches. Over six months, 38 emergency surgery units enrolled all consecutive octogenarians with acute cholecystitis undergoing cholecystectomy. Postoperative outcomes were compared after propensity score matching analysis.

RESULTS

The study included 212 patients (84 years [81-86], 47.2% women). The open approach was used in 32.1% of patients, and the laparoscopic approach in 67.9%. After propensity score matching, a decrease in hospital stays (open, 8 days [6-13]; laparoscopic, 5 days [4-8]; P < .001), 30-day morbidity (open, 48.5%; laparoscopic, 26.5%; P = .01), and 30-day mortality (open, 13.2%, laparoscopic, 1.5%; P = .02) was found. Among the specific postoperative complications, a decrease in septicemia (open, 14.7%; laparoscopic, 0%; P = .001) was observed.

CONCLUSIONS

Laparoscopic approach was used in two out of three octogenarians. After propensity score matching, octogenarians undergoing laparoscopic approach had shorter length of hospital stay, fewer 30-day postoperative complications, fewer episodes of septicemia, and less 30-day mortality than octogenarians undergoing open approach. These findings suggest that the laparoscopic approach may be the preferred choice for octogenarians with acute cholecystitis undergoing cholecystectomy.

Robotic versus laparoscopic general surgery in the emergency setting: a systematic review

Robot-assisted general surgery, an advanced technology in minimally invasive procedures, is increasingly employed in elective general surgery, showing benefits over laparoscopy in specific cases. Although laparoscopy remains a standard approach for common acute abdominal conditions, the role of robotic surgery in emergency general surgery remains uncertain. This systematic review aims to compare outcomes in acute general surgery settings for robotic versus laparoscopic surgeries. A PRISMA-compliant systematic search across MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane Library was conducted. The literature review focused on articles comparing perioperative outcomes of emergency general surgery managed laparoscopically versus robot-assisted. A descriptive analysis was performed, and outcome measures were recorded. Six articles, involving 1,063 patients, compared outcomes of robotic and laparoscopic procedures. Two articles covered cholecystectomies, while the others addressed ileocaecal resection, subtotal colectomy, hiatal hernia and repair of perforated gastrojejunal ulcers. The level of evidence was low. Laparoscopic bowel resection in patients with inflammatory bowel disease (IBD) had higher complications; no significant differences were found in complications for other operations. Operative time showed no differences for cholecystectomies, but robotic approaches took longer for other procedures. Robotic cases had shorter hospital length of stay, although the associated costs were significantly higher. Perioperative outcomes for emergency robotic surgery in selected general surgery conditions are comparable to laparoscopic surgery. However, recommending robotic surgery in the acute setting necessitates a well-powered large population study for stronger evidence.

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.

Associations of cholecystectomy with the risk of gastroesophageal reflux disease: a mendelian randomization study

BACKGROUND

Cholecystectomy is the standard surgery for patients with gallbladder disease, but the impact of cholecystectomy on gastroesophageal reflux disease (GERD) is not clear.

METHODS

We obtained genetic variants associated with cholecystectomy at a genome-wide significant level (P value<5 × 10-8) as instrumental variables (IVs) and performed Mendelian randomization (MR) to explore the relationship with GERD.

RESULTS

The Inverse Variance Weighted analysis (IVW) showed that the risk of GERD in patients after cholecystectomy increased (OR=2.19; 95% CI: 1.18 - 4.09). At the same time, the analysis results of weighted median (OR=2.30; 95% CI: 1.51 - 3.48) and weighted mode (OR=2.21; 95% CI: 1.42 - 3.45) were also consistent with the direction of the IVW analysis and were statistically significant (P<0.05).

CONCLUSIONS

This study shows that patients who have undergone cholecystectomy are a susceptible population of GERD.

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

BACKGROUND

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluating effectiveness and safety of combined percutaneous transhepatic gallbladder drainage and laparoscopic cholecystectomy in acute cholecystitis patients: Meta-analysis

BACKGROUND

Acute cholecystitis (AC) is a common disease in general surgery. Laparoscopic cholecystectomy (LC) is widely recognized as the "gold standard" surgical procedure for treating AC. For low-risk patients without complications, LC is the recommended treatment plan, but there is still controversy regarding the treatment strategy for moderate AC patients, which relies more on the surgeon's experience and the medical platform of the visiting unit. Percutaneous transhepatic gallbladder puncture drainage (PTGBD) can effectively alleviate gallbladder inflammation, reduce gallbladder wall edema and adhesion around the gallbladder, and create a "time window" for elective surgery.

AIM

To compare the clinical efficacy and safety of LC or PTGBD combined with LC for treating AC patients, providing a theoretical basis for choosing reasonable surgical methods for AC patients.

METHODS

In this study, we conducted a clinical investigation regarding the combined use of PTGBD tubes for the treatment of gastric cancer patients with AC. We performed searches in the following databases: PubMed, Web of Science, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang Database. The search encompassed literature published from the inception of these databases to the present. Subsequently, relevant data were extracted, and a meta-analysis was conducted using RevMan 5.3 software.

RESULTS

A comprehensive analysis was conducted, encompassing 24 studies involving a total of 2564 patients. These patients were categorized into two groups: 1371 in the LC group and 1193 in the PTGBD + LC group. The outcomes of the meta-analysis revealed noteworthy disparities between the PTGBD + LC group and the LC group in multiple dimensions: (1) Operative time: Mean difference (MD) = 17.51, 95%CI: 9.53-25.49, P < 0.01; (2) Conversion to open surgery rate: Odds ratio (OR) = 2.95, 95%CI: 1.90-4.58, P < 0.01; (3) Intraoperative bleeding loss: MD = 32.27, 95%CI: 23.03-41.50, P < 0.01; (4) Postoperative hospital stay: MD = 1.44, 95%CI: 0.14-2.73, P = 0.03; (5) Overall postoperative complication rate: OR = 1.88, 95%CI: 1.45-2.43, P < 0.01; (6) Bile duct injury: OR = 2.17, 95%CI: 1.30-3.64, P = 0.003; (7) Intra-abdominal hemorrhage: OR = 2.45, 95%CI: 1.06-5.64, P = 0.004; and (8) Wound infection: OR = 0. These findings consistently favored the PTGBD + LC group over the LC group. There were no significant differences in the total duration of hospitalization [MD = -1.85, 95%CI: -4.86-1.16, P = 0.23] or bile leakage [OR = 1.33, 95%CI: 0.81-2.18, P = 0.26] between the two groups.

CONCLUSION

The combination of PTGBD tubes with LC for AC treatment demonstrated superior clinical efficacy and enhanced safety, suggesting its broader application value in clinical practice.

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

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

Management of complex acute biliary disease for the general surgeon: A narrative review

Acute gallbladder diseases are a common surgical emergency faced by General Surgeons that can sometimes be quite challenging. These complex biliary diseases require multifaceted and expeditious care, optimized based on hospital facility and operating room (OR) resources and the expertise of the surgical team. Effective management of biliary emergencies requires two foundational principles: achieving source control while mitigating the risk of injury to the biliary tree and its blood supply. This review article highlights salient literature on seven complex biliary diseases: acute cholecystitis, cholangitis, Mirizzi syndrome, gallstone ileus with cholecystoenteric fistula, gallstone pancreatitis, gall bladder cancer, and post-cholecystectomy bile leak.

Laparoscopic cholecystectomy in calculous cholecystitis: are antibiotics necessary?

Laparoscopic cholecystectomy in patients with cholecystitis is considered the best, appropriate and safe method of treatment for gallstone disease. However, the role of antibiotic administration before or after cholecystectomy to reduce infectious complications, particularly surgical site infections, or mortality is less clear. Many patients receive empiric antibiotics, but the feasibility of their use has not been proven. Some guidelines suggest the use of antibiotic prophylaxis for all cholecystectomies, although current evidence does not indicate any benefit to this practice in the absence of risk factors. This review examines the results of antibiotic use in laparoscopic cholecystectomy for chronic and acute calculous cholecystitis. Most studies argue against the need to use prophylactic antibiotics during elective surgery in low-risk patients. In cases of mild and moderate acute cholecystitis, the use of antibiotics to prevent postoperative infectious complications has no evidence of effectiveness, although these recommendations are also ambiguous. It is not recommended to use postoperative antibiotics after elective laparoscopic cholecystectomy, as well as for mild or moderate acute cholecystitis. However, additional studies with well-defined patient populations and comparable outcomes are needed to better assess the most appropriate timing and duration of antibiotic use in patients undergoing laparoscopic cholecystectomy. We used MedLine database on the PubMed platform and the Cochrane library to search for literature sources.

Improving early cholecystectomy rate in acute cholecystitis with an evidence-based local multidisciplinary protocol and a surgical audit: single-center experience through an Acute Care Surgery Division

PURPOSE

To analyze if, after implementation of an evidence-based local multidisciplinary protocol for acute cholecystitis (AC), an intermediate surgical audit could improve early cholecystectomy (EC) rate and other therapeutic indicators.

METHODS

Longitudinal cohort study at a tertiary center. The local protocol, promoted, created, and periodically revised by the Acute Care Surgery Unit (ACSu) was updated and approved on March 2019. A specific registry was prospectively fulfilled with demographics, comorbidity, type of presentation, diagnostic items, therapeutic decision, and clinical course, considering both non-operative management (NOM) or cholecystectomy, early and delayed (EC and DC). Phase 1: April 2019-April 2021. A critical analysis and a surgical audit with the participation of all the involved Departments were then performed, especially focusing on improving global EC rate, considered primary outcome. Phase 2: May 2021-May 2023. Software SPSS 23.0 was used to compare data between phases.

RESULTS

Initial EC rate was significantly higher on Phase 2 (39.3%vs52.5%, p < 0.004), as a significantly inferior rate of patients were initially bailed out from EC to NOM because of comorbidity (14.4%vs8%, p < 0.02) and grade II with severe inflammatory signs (7%vs3%, p < 0.04). A higher percentage of patients was recovered for EC after an initial decision of NOM on Phase 2, but without reaching statistical significance (21.8%vs29.2%, n.s.). Global EC rate significantly increased between phases (52.5%vs66.3%, p < 0.002) without increasing morbidity and mortality. A significant minor percentage of elective cholecystectomies after AC episodes had to be performed on Phase 2 (14%vs6.7%, p < 0.009). Complex EC and those indicated after readmission or NOM failure were usually performed by the ACSu staff.

CONCLUSION

To adequately follow up the implementation of a local protocol for AC healthcare, registering and periodically analyzing data allow to perform intermediate surgical audits, useful to improve therapeutic indicators, especially EC rate. AC constitutes an ideal model to work with an ACSu.

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

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

Impact of the COVID-19 pandemic on outcomes of cholecystectomy for acute cholecystitis: a national cohort study

BACKGROUND

The COVID-19 pandemic was associated with significant disruptions to healthcare provision globally and in Aotearoa New Zealand. It remains unclear how this disruption affected the surgical management of acute cholecystitis and whether there are ongoing impacts.

METHODS

We conducted a secondary analysis of two multicentre cohort studies (CHOLECOVID and CHOLENZ) on patients who underwent cholecystectomy for acute cholecystitis. Participants were categorized into pre-pandemic (September-November 2019), pandemic (March-May 2020), and late-pandemic (August-October 2021) phases. Baseline demographics, clinical management, and 30-day postoperative complications were assessed between phases. Multivariable logistic regression was used to explore the impact of timing of operation on rates of hospital readmission and postoperative complications.

RESULTS

517 participants were included, of whom 85 (16%) were in the pre-pandemic-phase, 52 (10%) were in the pandemic phase, and 380 (73%) were in the late-pandemic phase. Pandemic and late-pandemic phase participants were more comorbid and had higher rates of obesity and deranged blood results than pre-pandemic. After multivariable adjustment, there were no differences in rates of hospital readmission or postoperative complications at 30-day follow-up across phases.

CONCLUSION

The COVID-19 pandemic had minimal impacts on the provision of cholecystectomy for acute cholecystitis in Aotearoa New Zealand. However, patients managed during the COVID-19 pandemic were more comorbid and had higher rates of obesity and elevated inflammatory markers.

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

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

Percutaneous cholecystostomy in elderly patients with acute cholecystitis: a systematic review and meta-analysis

Percutaneous cholecystostomy (PC) is often preferred over early cholecystectomy (EC) for elderly patients presenting with acute cholecystitis (AC). However, there is a lack of solid data on this issue. Following the PRISMA guidelines, we searched the Medline and Web of Science databases for reports published before December 2022. Studies that assessed elderly patients (aged 65 years and older) with AC treated using PC, in comparison with those treated with EC, were included. Outcomes analyzed were perioperative outcomes and readmissions. The literature search yielded 3279 records, from which 7 papers (1208 patients) met the inclusion criteria. No clinical trials were identified. Patients undergoing PC comprised a higher percentage of cases with ASA III or IV status (OR 3.49, 95%CI 1.59-7.69, p = 0.009) and individuals with moderate to severe AC (OR 1.78, 95%CI 1.00-3.16, p = 0.05). No significant differences were observed in terms of mortality and morbidity. However, patients in the PC groups exhibited a higher rate of readmissions (OR 3.77, 95%CI 2.35-6.05, p < 0.001) and a greater incidence of persistent or recurrent gallstone disease (OR 12.60, 95%CI 3.09-51.38, p < 0.001). Elderly patients selected for PC, displayed greater frailty and more severe AC, but did not exhibit increased post-interventional morbidity and mortality compared to those undergoing EC. Despite their inferior life expectancy, they still presented a greater likelihood of persistent or recurrent disease compared to the control group.

Textbook outcome in urgent early cholecystectomy for acute calculous cholecystitis: results post hoc of the S.P.Ri.M.A.C.C study

INTRODUCTION

A textbook outcome patient is one in which the operative course passes uneventful, without complications, readmission or mortality. There is a lack of publications in terms of TO on acute cholecystitis.

OBJETIVE

The objective of this study is to analyze the achievement of TO in patients with urgent early cholecystectomy (UEC) for Acute Cholecystitis. and to identify which factors are related to achieving TO.

MATERIALS AND METHODS

This is a post hoc study of the SPRiMACC study. It´s a prospective multicenter observational study run by WSES. The criteria to define TO in urgent early cholecystectomy (TOUEC) were no 30-day mortality, no 30-day postoperative complications, no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile), and full laparoscopic surgery. Patients who met all these conditions were taken as presenting a TOUEC.

OUTCOMES

1246 urgent early cholecystectomies for ACC were included. In all, 789 patients (63.3%) achieved all TOUEC parameters, while 457 (36.6%) failed to achieve one or more parameters and were considered non-TOUEC. The patients who achieved TOUEC were younger had significantly lower scores on all the risk scales analyzed. In the serological tests, TOUEC patients had lower values for in a lot of variables than non-TOUEC patients. The TOUEC group had lower rates of complicated cholecystitis. Considering operative time, a shorter duration was also associated with a higher probability of reaching TOUEC.

CONCLUSION

Knowledge of the factors that influence the TOUEC can allow us to improve our results in terms of textbook outcome.

Association between dietary magnesium intake and gallstones: the mediating role of atherogenic index of plasma

BACKGROUND

Dyslipidemia and abnormalities in cholesterol metabolism are commonly observed in individuals with gallstone disease. Previous research has demonstrated that dietary magnesium can influence lipid metabolism. The atherogenic index of plasma (AIP) has emerged as a novel lipid marker. This study aimed to examine the possible correlation between dietary magnesium intake and gallstones and the potential mediating role of AIP in US adults.

METHODS

A total of 4,841 adults were included in this study from the National Health and Nutrition Examination Survey (NHANES) conducted from 2017 to 2020. A variety of statistical techniques such as logistic regression, subgroup analysis, smoothed curve fitting, and causal mediation analysis were utilized to analyze the information collected from the participants.

RESULTS

In the fully adjusted model, a statistically noteworthy inverse relationship was observed between dietary magnesium intake and the presence of gallstones, as indicated by an odds ratio (OR) of 0.58 and a 95% confidence interval (CI) of (0.42, 0.81). Causal intermediary analysis revealed that the association between magnesium intake and gallstones was partially mediated by AIP, with a mediation ratio of 3.2%.

CONCLUSION

According to this study, dietary magnesium intake had a significant linear negative association with the prevalence of gallstones, in which AIP played a mediating role. This discovery offers novel perspectives on the prevention and management of gallstones.

Outcomes after laparoscopic cholecystectomy in patients older than 80 years: two-years follow-up

BACKGROUND

The laparoscopic cholecystectomy is the treatment of choice for patients with benign biliary disease. It is necessary to evaluate survival after laparoscopic cholecystectomy in patients over 80 years old to determine whether the long-term mortality rate is higher than the reported recurrence rate. If so, this age group could benefit from a more conservative approach, such as antibiotic treatment or cholecystostomy. Therefore, the aim of this study was to evaluate the factors associated with 2 years survival after laparoscopic cholecystectomy in patients over 80 years old.

METHODS

We conducted a retrospective observational cohort study. We included all patients over 80 years old who underwent laparoscopic cholecystectomy. Survival analysis was conducted using the Kaplan‒Meier method. Cox regression analysis was implemented to determine potential factors associated with mortality at 24 months.

RESULTS

A total of 144 patients were included in the study, of whom 37 (25.69%) died at the two-year follow-up. Survival curves were compared for different ASA groups, showing a higher proportion of survivors at two years among patients classified as ASA 1-2 at 87.50% compared to ASA 3-4 at 63.75% (p = 0.001). An ASA score of 3-4 was identified as a statistically significant factor associated with mortality, indicating a higher risk (HR: 2.71, CI95%:1.20-6.14).

CONCLUSIONS

ASA 3-4 patients may benefit from conservative management due to their higher risk of mortality at 2 years and a lower probability of disease recurrence.

Intraoperative transcystic laparoscopic common bile duct stone clearance with SpyGlass™ discover during emergency and elective cholecystectomy: a single-center case series

BACKGROUND AND STUDY AIM

The development of a new cholangioscope, the SpyGlass™ Discover (Boston Scientific), has allowed the laparoscopic transcystic common bile duct exploration and stone clearance. The possibility of simultaneous treatment of choledocholithiasis during early laparoscopic cholecystectomy offers the opportunity to enormously reduce the time between acute cholecystitis diagnosis and the execution of cholecystectomy with better outcomes for patients. Furthermore, an altered anatomy of the gastrointestinal tract is not an obstacle to this technique. The aim of the study was to determine whether this new procedure is feasible, safe, and effective.

PATIENTS AND METHODS

The investigation employs a retrospective case series study including all consecutive patients with a diagnosis of common bile duct stones undergoing cholecystectomy and intraoperative laparoscopic common bile duct clearance using SpyGlass™ Discover at IRCCS Policlinico San Matteo in Pavia (Italy). Eighteen patients were included from May 2022 to May 2023.

RESULTS

A complete clearance of the common bile duct was obtained in 88.9% of patients. The mean postoperative length of stay was 3 days. No major complications occurred. After a median follow-up of 8 months, no recurrence of biliary events or readmissions occurred.

CONCLUSION

This procedure has proven to be feasible, safe, and effective.

Image-guided percutaneous cholecystostomy: challenging the norms

Image-guided percutaneous cholecystostomy (IGPC) is a widely recognized and regularly employed procedure in numerous institutions, serving as an indispensable cornerstone in the management of patients with acute cholecystitis. The most up-to-date literature has found that the transperitoneal route is at least as safe as the transhepatic route and that both the trocar and Seldinger techniques are equally safe and effective. The above novel insights may offer reassurance and alleviate concerns among operators performing IGPC by dispelling the fixation on previously established beliefs and thus providing flexibility, which lightens the load on the operator. Future studies could further investigate these findings and shed light on potential disparities in the safety and efficacy profiles associated with the subcostal and intercostal approaches, different drainage catheter sizes, and/or the impact of operator experience on complication rates.

Test Characteristics of Emergency Medicine-Performed Point-of-Care Ultrasound for the Diagnosis of Acute Cholecystitis: A Systematic Review and Meta-analysis

Acute cholecystitis accounts for up to 9% of hospital admissions for acute abdominal pain, and best practice entails early surgical management. Ultrasound is the standard modality used to confirm diagnosis. Our objective was to perform a systematic review and meta-analysis to determine the diagnostic accuracy of emergency physician-performed point-of-care ultrasound for the diagnosis of acute cholecystitis when compared with a reference standard of final diagnosis (informed by available surgical pathology, discharge diagnosis, and radiology-performed ultrasound). We completed a systematic review and meta-analysis, registered in PROSPERO, in adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched 7 databases as well as gray literature in the form of select conference abstracts from inception to February 8, 2023. Two independent reviewers completed study selection, data extraction, and risk of bias (QUADAS-2) assessment. Disagreements were resolved by consensus with a third reviewer. Data were extracted from eligible studies to create 2 × 2 tables for diagnostic accuracy meta-analysis. Hierarchical Summary Receiver Operating Characteristic models were constructed. Of 1855 titles/abstracts, 40 were selected for full-text review. Ten studies (n=2356) were included. Emergency physician-performed point-of-care ultrasound with final diagnosis as the reference standard (7 studies, n=1,772) had a pooled sensitivity of 70.9% (95% confidence interval [CI] 62.3 to 78.2), specificity of 94.4% (95% CI 88.2 to 97.5), positive likelihood ratio of 12.7 (5.8 to 27.5), and negative likelihood ratio of 0.31 (0.23 to 0.41) for the diagnosis of acute cholecystitis. Emergency physician-performed point-of-care ultrasound has high specificity and moderate sensitivity for the diagnosis of acute cholecystitis in patients with clinical suspicion. This review supports the use of emergency physician-performed point-of-care ultrasound to rule in a diagnosis of acute cholecystitis in the emergency department, which may help expedite definitive management.