Ultrasound guided percutaneous cholecystostomy in high-risk patients for surgical intervention

Percutaneous cholecystostomy tube placement as a bridge to cholecystectomy for grade III acute cholecystitis: A national analysis

Introduction

Percutaneous cholecystostomy (PCT) is an alternative to cholecystectomy (CCY) in high-risk surgical candidates with severe acute cholecystitis. A subset of these patients ultimately undergo delayed CCY. We therefore compared outcomes of delayed CCY in patients with grade III acute cholecystitis who received a PCT on index admission, to those who did not.

Methods

Non-elective adult hospitalizations for grade III acute cholecystitis that underwent delayed CCY were identified in the 2016-2020 Nationwide Readmission Database. Patients who received a PCT during their index admission comprised the PCT group (others: Non-PCT). Outcomes were assessed for the CCY hospitalization. Entropy balancing was used to generate sample weights to adjust for differences in baseline characteristics. Regression models were created to evaluate the association between PCT and the outcomes of interest.

Results

Of an estimated 13,782 patients, 13.3 % comprised PCT. Compared to Non-PCT, PCT were older (71.1 ± 13.1 vs 67.4 ± 15.3 years) and more commonly in the highest income quartile (22.5 vs 16.1 %, both p < 0.001). After risk adjustment, PCT was associated with reduced odds of respiratory (AOR 0.67, CI 0.54-0.83) and infectious (AOR 0.77, CI 0.62-0.96) complications after eventual CCY. Finally, PCT had comparable pLOS (β +0.31, CI [-0.14, 0.77]) and operative hospitalization costs (β $800, CI [-2300, +600]).

Conclusion

In the present study, PCT was associated with decreased odds of perioperative complications and comparable resource utilization upon readmission CCY. Our findings suggest that PCT may be helpful in bridging patients with grade III acute cholecystitis to eventual CCY.

Outcomes of endoscopic retrograde cholangiopancreatography-guided gallbladder drainage compared to percutaneous cholecystostomy in acute cholecystitis

Backgrounds/Aims

Endoscopic retrograde cholangiopancreatography-guided gallbladder drainage (ERGD) is an alternative to percutaneous cholecystostomy (PTC) for hospitalized acute cholecystitis (AC) patients.

Methods

We retrospectively analyzed propensity score matched (PSM) AC hospitalizations using the National Inpatient Sample database between 2016 and 2019 to compare the outcomes of ERGD and PTC.

Results

After PSM, there were 3,360 AC hospitalizations, with 48.8% undergoing PTC and 51.2% undergoing ERGD. There was no difference in median length of stay between the PTC and ERGD cohorts (p = 0.110). There was a higher median hospitalization cost in the ERGD cohort, $62,562 (interquartile range [IQR] $40,707-97,978) compared to PTC, $40,413 (IQR $25,244-65,608; p < 0.001). The 30-day inpatient mortality was significantly lower in hospitalizations with ERGD compared to PTC (adjusted hazard ratio 0.16, 95% confidence interval [CI]: 0.1-0.41; p < 0.001). There was no difference in association with blood transfusions, acute renal failure, ileus, small bowel obstruction, and open cholecystectomy conversion (p > 0.05) between hospitalizations with ERGD and PTC. There was lower association of acute hypoxic respiratory failure (adjusted ratio [AOR] 0.46, 95% CI: 0.29-0.72; p = 0.001), hypovolemia (AOR 0.66, 95% CI: 0.49-0.82; p = 0.009) and higher association of lower gastrointestinal bleed (AOR 1.94, 95% CI: 1.48-2.54; p < 0.001) with ERGD compared to PTC.

Conclusions

ERGD is a safer alternative to PTC in patients with AC. The risk complications are lower in ERGD compared to PTC but no difference exists based on mortality or conversion to open cholecystectomy.

Efficacy of endoscopic gallbladder drainage in patients with acute cholecystitis

Background

Early cholecystectomy is recommended for patients with acute cholecystitis. However, emergency surgery may not be indicated due to complications and disease severity. Patients requiring drainage are usually treated with percutaneous transhepatic gallbladder drainage (PTGBD), whereas patients with biliary duct stones undergo endoscopic stones removal followed by endoscopic gallbladder drainage (EGBD). Herein, we investigated the efficacy of EGBD in patients with acute cholecystitis.

Methods

Overall, 101 patients receiving laparoscopic cholecystectomy between September 2019 and September 2020 in our department were retrospectively analyzed.

Results

The patients (n = 101) were divided into three groups: control group that did not undergo drainage (n = 68), a group that underwent EGBD (n = 7), and a group that underwent PTGBD (n = 26). Median surgery time was 107, 166, and 143 min, respectively. Control group had a significantly shorter surgery time, whereas it did not significantly differ between EGBD and PTGBD groups. The median amount of bleeding was 5 g, 7 g, and 7.5 g, respectively, and control group had significantly less bleeding than the drainage group. We further divided patients into the following subgroups: patients requiring a 5 mm clip to ligate the cystic duct, patients requiring a 10 mm clip due to the thickness of the cystic duct, patients requiring an automatic suturing device, and patients undergoing subtotal cholecystectomy due to impossible cystic duct ligation. There was no significant difference between EGBD and PTGBD regarding the clip used or the need for an automatic suturing device and subtotal cholecystectomy.

Conclusions

There was no significant difference between EGBD and PTGBD groups regarding surgery time or bleeding amount when surgery was performed after gallbladder drainage for acute cholecystitis. Therefore, EGBD was considered a useful preoperative drainage method requiring no drainage bag.

Lumen Apposition: A Changing Landscape in Therapeutic Endoscopy

The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.

Lumen Apposition: A Changing Landscape in Therapeutic Endoscopy

The concept of endoscopic lumen apposition has seen a dramatic shift in the last several decades. Early natural orifice trans-luminal endoscopic surgery (NOTES) concepts have transformed into specialized lumen-apposing metal stents (LAMSs) and delivery devices, which provide endoscopists a minimally invasive alternative to surgical intervention. These LAMSs have become the bedrock of therapeutic endoscopy and provide treatment for a wide spectrum of gastrointestinal disorders. In this review, we summarize the changing landscape of therapeutic endoscopy by highlighting the use of LAMS and future directions as well as alternative devices to achieve lumen apposition.

Minimally Invasive Management of Acute Cholecystitis and Frailty Assessment in Geriatric Patients

The aim was to compare laparoscopic cholecystectomy (LC) with the percutaneous cholecystostomy (PC) for the management of acute lithiasic cholecystitis in geriatric patients and investigate the decision-making using frailty assessment. A retrospective analysis was performed in all patients aged over 65 years who were treated for acute cholecystitis at our hospital in a period of 5 years. Patients were divided in LC and PC groups. In total, 111 (54.1%) patients were subjected to LC and 94 (45.9%) to PC. The American Society of Anesthesiologists (ASA) and the Clinical Frailty Score were lower for the LC group. However, for patients over 85 years of age, frailty scores between groups were not statistically different. Morbidity and mortality between groups were not statistically different. Both LC and PC are safe and efficient in geriatric patients. Frailty score may better drive the selection of patients to be managed laparoscopically.

Endoscopic gallbladder drainage for symptomatic gallbladder disease: a cumulative systematic review meta-analysis

BACKGROUND

Endoscopic ultrasound (EUS)-guided transmural or endoscopic retrograde cholangiography (ERC)-based transpapillary drainage may provide alternative treatment strategies for high-risk surgical candidates with symptomatic gallbladder (GB) disease. The primary aim of this study was to perform a systematic review and meta-analysis to investigate the efficacy and safety of endoscopic GB drainage for patients with symptomatic GB disease.

METHODS

Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed in accordance with PRISMA and MOOSE guidelines. Pooled proportions were calculated for measured outcomes including technical success, clinical success, adverse event rate, recurrence rate, and rate of reintervention. Subgroup analyses were performed for transmural versus transpapillary, transmural lumen apposing stent (LAMS), and comparison to percutaneous transhepatic drainage. Heterogeneity was assessed with I² statistics. Publication bias was ascertained by funnel plot and Egger regression testing.

RESULTS

Thirty-six studies (n = 1538) were included. Overall, endoscopic GB drainage achieved a technical and clinical success of 87.33% [(95% CI 84.42-89.77); I² = 39.55] and 84.16% [(95% CI 80.30-87.38); I² = 52.61], with an adverse event rate of 11.00% [(95% CI 9.25-13.03); I² = 7.08]. On subgroup analyses, EUS-guided transmural compared to ERC-assisted transpapillary drainage resulted in higher technical and clinical success rates [OR 3.91 (95% CI 1.52-10.09); P = 0.005 and OR 4.59 (95% CI 1.84-11.46); P = 0.001] and lower recurrence rate [OR 0.17 (95% CI 0.06-0.52); P = 0.002]. Among EUS-guided LAMS studies, technical success was 94.65% [(95% CI 91.54-96.67); I² = 0.00], clinical success was 92.06% [(95% CI 88.65-94.51); I² = 0.00], and adverse event rate was 11.71% [(95% CI 8.92-15.23); I² = 0.00]. Compared to percutaneous drainage, EUS-guided drainage possessed a similar efficacy and safety with significantly lower rate of reintervention [OR 0.05 (95% CI 0.02-0.13); P < 0.001].

DISCUSSION

Endoscopic GB drainage is a safe and effective treatment for high-risk surgical candidates with symptomatic GB disease. EUS-guided transmural drainage is superior to transpapillary drainage and associated with a lower rate of reintervention compared to percutaneous transhepatic drainage.

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.

Outcomes of Patients Treated With Upfront Cholecystostomy for Severe Acute Cholecystitis

INTRODUCTION

Percutaneous cholecystostomy tube (PCT) placement is a treatment method for acute cholecystitis, both in adult patients unsuitable for surgery and those failing to improve with conservative management. The purpose of this study was to assess the outcomes of patients undergoing cholecystostomy.

MATERIALS AND METHODS

A review of consecutive patients who underwent PCT insertion over a 10-year period was performed. Outcomes assessed included cholecystostomy dwell time, tubogram requirement, cholecystostomy reinsertion, cholecystectomy, bile leaks, and mortality.

RESULTS

One hundred eight patients (77 male individuals, 31 female individuals) were included. The mean age was 70 years (range: 29 to 93 y). A total of 89 transhepatic and 19 transperitoneal PCTs were inserted. Fifty-nine patients (55%) had a subsequent tubogram to assess cystic duct patency or catheter position. Mean catheter dwell time was 17 days (range: 1 to 154 d). Eleven (10%) required PCT reinsertion. Time to reinsertion ranged from 2 to 163 days (mean=38 d). Fifty-three patients (50%) had no further biliary intervention after removal of the cholecystostomy catheter. One patient required subsequent drainage of a hepatic abscess, and another developed a biloma. Thirty-two patients (30%) underwent cholecystectomy (66% laparoscopic, 34% open). Thirty-day mortality after PCT insertion was 8.3%. Twenty patients (19%) died of non-cholecystostomy-related illness during the 10-year follow-up period.

CONCLUSIONS

Cholecystostomy is an important treatment method of acute cholecystitis as a bridge to cholecystectomy or as an alternative definitive treatment option in those unsuitable for surgery. A tubogram is not always necessary before tube removal. Cholecystostomy tubes can be removed safely with little risk of bile leak if patients are clinically well, and clean-appearing bile is draining.

Acute cholecystitis in elderly and high-risk surgical patients: is percutaneous cholecystostomy preferable to emergency cholecystectomy?

OBJECTIVE

To investigate whether percutaneous cholecystostomy (PC) for the treatment of acute calculous cholecystitis (ACC) has better results than emergency cholecystectomy (EC) in elderly and high-risk surgical patients.

METHODS

Patients ≥ 70 years and/or ≥ ASA-PS 3 with ACC treated with PC or EC between 2005 and 2016 were retrospectively reviewed. Both techniques were compared regarding morbi-mortality, hospital stay, complications and readmissions. A subgroup analysis in higher risk patients (≥ 70 years plus ≥ ASA-PS 3) was also performed. A binary logistic regression analysis for outcome variables to calculate the OR was carried out.

RESULTS

A total of 461 patients were included in the study. The results of PC were worse compared to EC: 30-day mortality (8.6 vs. 1.7%, OR 18.4), 90-day mortality (10.4 vs. 2.1%, OR 10.3), length of stay (days) (13.21 ± 8.2 vs. 7.48 ± 7.67, OR 8.7) and readmission rate (35.1 vs. 12.6%, OR 4.7). Complications were lower for PC (14 vs. 22.6%, OR 0.41), but there were no significant differences in the number of severe complications (Clavien-Dindo ≥ III). Higher-risk subgroup analysis (n = 193; PC = 128, EC = 65) showed similar results to the whole series. Patients with ACC for more than 3 days had more risk of severe complications in both groups (OR 2.26; OR 2.76).

CONCLUSION

PC was associated with an increased risk of mortality at 30 and 90 days, more readmissions and longer hospital stay. Although PC presents a lower risk of complications, the percentage of severe complications (Clavien-Dindo ≥ III) does not show significant differences.

Managing Gallstone Disease in the Elderly

Geriatric patients tend to have subtle presentations of biliary disorders and, if untreated, can decompensate acutely. Each biliary disorder warrants formulation of an individualized treatment plan with a multidisciplinary approach. Acute cholecystitis, a common complication of gallstones, is initially managed by conservative measures and subsequently, among patients with optimal surgical risk, through laparoscopic or open cholecystectomy. High-risk patients undergo temporization, percutaneous or endoscopic, followed by definitive intervention. Acute cholecystitis with complications (ie, perforation, gangrene, or small bowel obstruction) warrants emergent cholecystectomy. Gallstone migration into the biliary system can cause choledocholithiasis, often complicated by biliary pancreatitis or cholangitis if not intervened. Therapy for choledocholithiasis is based on biliary clearance through endoscopic and, infrequently, surgical approaches.

Alternative uses of lumen apposing metal stents

The advent of lumen apposing metal stents (LAMS) has revolutionized the management of many complex gastroenterological conditions that previously required surgical or radiological interventions. These procedures have garnered popularity due to their minimally invasive nature, higher technical and clinical success rate and lower rate of adverse events. By virtue of their unique design, LAMS provide more efficient drainage, serve as conduit for endoscopic access, are associated with lower rates of leakage and are easy to be removed. Initially used for drainage of pancreatic fluid collections, the use of LAMS has been extended to gallbladder and biliary drainage, treatment of luminal strictures, creation of gastrointestinal fistulae, pancreaticobiliary drainage, improved access for surgically altered anatomy, and drainage of intra-abdominal and pelvic abscesses as well as post-surgical fluid collections. As new indications of endosonographic techniques and LAMS continue to evolve, this review summarizes the current role of LAMS in the management of these various complex conditions and also highlights clinical pearls to guide successful placement of LAMS.

Body-Mounted MRI-Conditional Parallel Robot for Percutaneous Interventions Structural Improvement, Calibration, and Accuracy Analysis

To assist in percutaneous interventions in the lower back under magnetic resonance imaging guidance, a 4 degree-of-freedom body-mounted parallel robot is developed. The robot structure is improved comparatively to a previously developed robot, to increase the stability, enhance accuracy, and streamline the assembly and calibration process. The optimized assembly and calibration workflows are carried out, and the system accuracy is evaluated. The results demonstrate that the system positioning and angular accuracy are 2.28±1.1 mm and 1.94±1.01 degrees respectively. The results show that the new system has a promising and consistent behavior.

EUS-guided gallbladder drainage with a lumen-apposing metal stent versus endoscopic transpapillary gallbladder drainage for the treatment of acute cholecystitis (with videos)

BACKGROUND AND AIMS

There is an evolving role for EUS-guided transmural gallbladder (GB) drainage. Endoscopic transpapillary GB drainage is a well-established, nonoperative treatment for acute cholecystitis. We compared the outcomes of 78 cases of EUS-guided versus transpapillary GB drainage at a single, U.S.-based, high-volume endoscopy center.

METHODS

This was a retrospective analysis performed from May 2013 to January 2018, identified from a database of nonoperative patients with acute cholecystitis. Both electrocautery-enhanced and nonelectrocautery-enhanced lumen-apposing metal stents were used. For transpapillary drainage, guidewire access was obtained and then a transpapillary 7F × 15-cm double-pigtail plastic stent was placed.

RESULTS

In patients who had successful transpapillary or transmural drainage, demographics data were similar. Technical success was observed in 39 of 40 patients (97.5%) who underwent first attempt at EUS-guided drainage versus 32 of 38 patients (84.2%) for first-attempt transpapillary drainage (adjusted odds ratio, 9.83; 95% confidence interval, .93-103.86). Clinical success was significantly higher with EUS drainage in 38 of 40 patients (95.0%) versus transpapillary drainage in 29 of 38 patients (76.3%) (adjusted odds ratio, 7.14; 95% confidence interval, 1.32-38.52). Recurrent cholecystitis was lower in the EUS-guided drainage group (2.6% vs 18.8%, respectively; P = .023) on univariate analysis but only trended to significance in a multiple regression model. Duration of follow-up, reintervention rates, hospital length of stay, and overall adverse event rates were similar between groups.

CONCLUSIONS

EUS-guided GB drainage results in a higher clinical success rate compared with transpapillary drainage and may be associated with a lower recurrence rate of cholecystitis. However, transpapillary drainage should be considered as the first-line treatment for patients who are surgical candidates but require temporizing measures or require an ERCP for alternative reasons.

2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population

Background

Gallstone disease is very common afflicting 20 million people in the USA. In Europe, the overall incidence of gallstone disease is 18.8% in women and 9.5% in men. The frequency of gallstones related disease increases by age. The elderly population is increasing worldwide.

Aim

The present guidelines aims to report the results of the World Society of Emergency Surgery (WSES) and Italian Surgical Society for Elderly (SICG) consensus conference on acute calcolous cholecystitis (ACC) focused on elderly population.

Material and methods

The 2016 WSES guidelines on ACC were used as baseline; six questions have been used to investigate the particularities in elderly population; the answers have been developed in terms of differences compared to the general population and to statements of the 2016 WSES Guidelines. The Consensus Conference discusses, voted, and modified the statements. International experts contributed in the elaboration of final statements and evaluation of the level of scientific evidences.

Results

The quality of the studies available decreases when we approach ACC in elderly. Same admission laparoscopic cholecystectomy should be suggested for elderly people with ACC; frailty scores as well as clinical and surgical risk scores could be adopted but no general consensus exist. The role of cholecystostomy is uncertain.

Discussion and conclusions

The evaluation of pro and cons for surgery or for alternative treatments in elderly suffering of ACC is more complex than in young people; also, the oldest old age is not a contraindication for surgery; however, a larger use of frailty and surgical risk scores could contribute to reach the best clinical judgment by the surgeon. The present guidelines offer the opportunity to share with the scientific community a baseline for future researches and discussion.

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

INTRODUCTION

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

METHODS

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

FINDINGS

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

Endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis with a lumen-apposing metal stent: a systematic review of case series

Management of patients with acute cholecystitis unfit for surgery is challenging. Recently, endoscopic ultrasound (EUS)-guided gallbladder drainage with a lumen-apposing metal stent (LAMS) has been introduced for these patients. We performed a systematic review and pooled-data analysis in this field. A comprehensive review of case series on gallbladder drainage with EUS-guided LAMS placement was performed. Only case series with at least five patients were considered. The rates of technical success, clinical success, and adverse events were computed. Overall, nine case series with a total of 226 patients were identified. The stent was positioned successfully in 215 cases [95.1%, 95% confidence interval (CI)=92.3-98]. Clinical success was achieved in 207 patients, corresponding to a 91.6% (95% CI=88-95.2) rate at intention-to-treat analysis and 96.3% (95% CI=93.7-99) at per-protocol analysis. A total of 24 (10.6%) adverse events occurred, including 11 (4.9%) cases during the procedure, and 13 (5.7%) observed at follow-up (median=6 months; range: 2-12 months). A surgical approach was required in only 25% of patients with a major adverse event. No case of procedure-related death was reported. EUS-guided LAMS placement for gallbladder drainage in patients with acute cholecystitis not suitable for surgery is highly successful and acceptably safe.

Hemorrhagic Cholecystitis after Warfarin Use for Deep Vein Thrombosis

Hemorrhagic cholecystitis is an uncommon form of acute cholecystitis which can be rapidly fatal. It may be hard to detect as it frequently presents with symptoms found in other, more common diagnoses. We report the case of a 63 year old man recently started on anticoagulation for deep vein thrombosis who was found to have hemorrhagic cholecystitis.

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

BACKGROUND AND STUDY AIM

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Cholecystostomy Treatment in an ICU Population: Complications and Risks

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

Endoscopic Gallbladder Drainage for Acute Cholecystitis

Background/Aims

Surgery is the mainstay of treatment for cholecystitis. However, gallbladder stenting (GBS) has shown promise in debilitated or high-risk patients. Endoscopic transpapillary GBS and endoscopic ultrasound-guided GBS (EUS-GBS) have been proposed as safe and effective modalities for gallbladder drainage.

Methods

Data from patients with cholecystitis were prospectively collected from August 2004 to May 2013 from two United States academic university hospitals and analyzed retrospectively. The following treatment algorithm was adopted. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and cystic duct stenting was initially attempted. If deemed feasible by the endoscopist, EUS-GBS was then pursued.

Results

During the study period, 139 patients underwent endoscopic gallbladder drainage. Among these, drainage was performed in 94 and 45 cases for benign and malignant indications, respectively. Successful endoscopic gallbladder drainage was defined as decompression of the gallbladder without incidence of cholecystitis, and was achieved with ERCP and cystic duct stenting in 117 of 128 cases (91%). Successful endoscopic gallbladder drainage was also achieved with EUS-guided gallbladder drainage using transmural stent placement in 11 of 11 cases (100%). Complications occurred in 11 cases (8%).

Conclusions

Endoscopic gallbladder drainage techniques are safe and efficacious methods for gallbladder decompression in non-surgical patients with comorbidities.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Percutaneous cholecystostomy is an effective definitive treatment option for acute acalculous cholecystitis

AIMS

Acute acalculous cholecystitis can be treated with percutaneous cholecystostomy in critically ill patients unfit for surgery. However, the evidence on the outcome is sparse. We conducted a retrospective analysis of acute acalculous cholecystitis patients treated with percutaneous cholecystostomy during a 10-year study period.

METHODS

An observational study of 56 consecutive patients treated with percutaneous cholecystostomy for acute acalculous cholecystitis was conducted in the period from 1 June 2002 to 31 May 2012. All data were obtained by review of medical records.

RESULTS

A total of 56 consecutive patients were treated with percutaneous cholecystostomy for acute acalculous cholecystitis. Six patients (10.7%) died within 30 days after the procedure. Percutaneous cholecystostomy could serve as a definitive treatment option in 45 patients (80.4%), whereas 1 patient (1.8%) required cholecystectomy due to recurrence of cholecystitis. Four patients (7.1%) were treated with percutaneous cholecystostomy as a bridging procedure to subsequent elective laparoscopic cholecystectomy within a median of 8.8 months (range: 7.7-33.4 months). There was no significant difference in the risk of cholecystitis recurrence between patients with (6/37) and without (2/3) contrast passage to the duodenum on cholangiography (p = 0.096).

CONCLUSION

Percutaneous cholecystostomy is successful as a definitive treatment option in the majority of patients with acute acalculous cholecystitis. It is associated with a low rate of mortality and subsequent cholecystectomy.

Endoscopic ultrasound-guided endoluminal drainage of the gallbladder

For patients with acute cholecystitis who are not suitable for surgery, endoscopic ultrasound-guided endoluminal drainage of the gallbladder (EUS-GBD) has been developed to overcome the limitations of percutaneous transhepatic gallbladder drainage when endoscopic transpapillary gallbladder drainage is not feasible. In the present review we have summarized the studies describing EUS-GBD. Indications, techniques, accessories, endoprostheses, limitations and complications reported in the different studies are discussed. There were 90 documented cases in the literature. The overall reported technical success rate was 87/90 (96.7%). All patients with technical success were clinically successful. A total of 11/90 (12.2%) patients had complications including pneumoperitoneum, bile peritonitis and stent migration. The advantage of EUS-GBD is its ability to provide gallbladder drainage especially in situations where percutaneous or transpapillary drainage is not feasible or is technically challenging. It also provides the option of internal drainage and the ability to carry out therapeutic maneuvers via cholecystoscopy.

Endoscopic ultrasonography-guided cholecystogastrostomy in patients with unresectable pancreatic cancer using anti-migratory metal stents: a new approach

Cholecystectomy is contraindicated in patients with comorbidities or unresectable cancer. Percutaneous transhepatic gallbladder drainage (PTGBD) is typically offered with response rates ranging from 56% to 100%, but has several risks such as bleeding, pneumothorax, pneumoperitoneum, bile leak, and/or catheter migration. Endoscopic transpapillary gallbladder drainage (ETGD) and endoscopic ultrasound-guided transmural gallbladder drainage (EUS-GBD) are alternative endoscopic modalities that have a technical feasibility, efficacy and safety profile comparable with PTGBD. In this report, we present the first case series of transgastric EUS-GBD with placement of a fully covered self-expandable metal stent with anti-migratory fins. In three pancreatic cancer cases with acute cholecystitis when ETGD was unsuccessful, there were no bile leaks or procedurally related complications. There were no acute cholecystitis recurrences. In conclusion, EUS-GBD is a promising, minimally invasive treatment for acute cholecystitis. Additional comparative studies are needed to validate the benefit of this technique.

Percutaneous cholecystostomy is appropriate as definitive treatment for acute cholecystitis in critically ill patients: a single center, cross-sectional study

BACKGROUND/AIMS

Percutaneous cholecystostomy (PC) is an effective treatment for cholecystitis in high-risk surgical patients. However, there is no definitive agreement on the need for additional cholecystectomy in these patients.

METHODS

All patients who were admitted to Cheju Halla General Hospital (Jeju, Korea) for acute cholecystitis and who underwent ultrasonography-guided PC between 2007 and 2012 were consecutively enrolled in this study. Among 82 total patients enrolled, 35 underwent laparoscopic cholecystectomy after recovery and 47 received the best supportive care (BSC) without additional surgery.

RESULTS

The technical and clinical success rates for PC were 100% and 97.5%, respectively. The overall mean survival was 12.8 months. In the BSC group, mean survival was 5.4 months, and in the cholecystectomy group, mean survival was 22.4 months (p<0.01). However, there was no significant difference between these groups in multivariate analysis (relative risk [RR]=1.92; 95% CI, 0.77-4.77; p=0.16). However, advanced age (RR=1.05; 95% CI, 1.02-1.08; p=0.001) and higher class in the American Society of Anesthesiologists' physical status (RR=3.06; 95% CI, 1.37-6.83, p=0.006) were significantly associated with survival in the multivariate analysis. Among the 47 patients in the BSC group, the cholecystostomy tube was removed in 31 patients per protocol. Recurrent cholecystitis was not observed in either group of patients during the follow-up period.

CONCLUSIONS

In high-risk surgical patients, PC without additional cholecystectomy might be the best definitive management. Furthermore, the cholecystostomy drainage catheter can be safely removed in certain patients.

Percutaneous cholecystostomy is a definitive treatment for acute cholecystitis in elderly high-risk patients

Percutaneous cholecystostomy (PC) is an alternative treatment for acute cholecystitis (AC) in elderly patients with high surgical risk and has lower morbidity and mortality than emergency cholecystectomy. There is controversy about whether cholecystectomy should be performed after PC in elderly high-risk patients. Medical records of patients with AC admitted to the Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, China, between January 2004 and July 2009 were reviewed retrospectively. The elderly high-risk patients with AC who underwent PC were selected for further study. The safety, efficacy, and long-term outcome of PC without cholecystectomy were evaluated in these patients. The symptoms of AC resolved in 98.6 per cent of patients; drainage-related morbidity and mortality rates were 4.1 and 1.4 per cent, respectively. No patient underwent cholecystectomy after PC. The recurrence rate of cholecystitis was 4.1 per cent. The one-year survival rate was 82.2 per cent, and the three-year survival rate was 39.7 per cent. No death was related to cholecystitis, but one patient died of septic shock on the second day after PC. Considering limited survival and a low recurrence rate of cholecystitis in elderly high-risk patients with AC, we propose that PC is a definitive treatment and cholecystectomy is not necessary after resolution of AC symptoms.

Endoscopic management of acute cholecystitis

Acute cholecystitis is a commonly encountered medical emergency that is managed surgically with excellent results. Recent experiences with endoscopic cystic duct stent placement and cholecystectomy using the NOTES (Natural Orifice Transluminal Endoscopic Surgery) approach have inspired endoscopists to identify other less invasive means for treating cholecystitis. The ability to access and drain obstructive bile ducts in real time using endoscopic ultrasound guidance has led to recent reports of successful gallbladder drainage using similar techniques. This article discusses the current state of the endoscopic management of acute and acalculous cholecystitis, and outlines a consensus approach to the management of these patients.

Complication rate of ultrasound-guided percutaneous cholecystostomy in patients with coagulopathy

OBJECTIVE

The purpose of this article is to compare the complication rate for ultrasound-guided percutaneous cholecystostomy in patients with coagulopathy to the rate in patients with normal coagulation.

MATERIALS AND METHODS

We performed a database search for patients who underwent ultrasound-guided percutaneous cholecystostomy from January 2000 through December 2010. Patients were divided into those with normal coagulation and those with coagulopathy, as documented by abnormal laboratory values (international normalized ratio ≥ 1.5 and platelet count ≤ 50 × 10(9)/L) or history of anticoagulant medication in the preceding 5 days. Medical records were reviewed, and complication rates and subsequent treatment was recorded. Statistical analysis was performed using the Fisher exact and chi-square tests.

RESULTS

Two hundred forty-two patients underwent ultrasound-guided percutaneous cholecystostomy (132 men and 110 women; mean [± SD] age, 73.9 ± 15.9 years; range, 22-104 years). One hundred thirty-two patients were coagulopathic and 110 had normal coagulation. Major complications related to ultrasound-guided percutaneous cholecystostomy were rare (4/242 cases [1.7%]) and included hemorrhage requiring transfusion (n = 1), death directly related to the procedure (n = 1), sepsis related to the procedure (n = 1), and abscess or biloma formation (n = 1). All of these occurred in the group with normal coagulation. Fourteen additional deaths (5.8%) that occurred within 30 days of the procedure were related to comorbidities. Minor catheter-related complications (15/242 [6.2%]) were due to catheter dislodgement (n = 11 [4.5%]), failure of placement (n = 1 [0.4%]), and hemorrhage not requiring transfusion (n = 3 [1.2%]). Two of the minor hemorrhagic complications were seen in the coagulopathic group and one in the normal coagulation group (p = 0.599).

CONCLUSION

There is no difference in the complication rate for ultrasound-guided percutaneous cholecystostomy in patients who are coagulopathic compared with those who have normal coagulation.

Short- and long-term outcomes following percutaneous cholecystostomy for acute cholecystitis in high-risk patients

BACKGROUND

Percutaneous cholecystostomy is a less invasive method to treat acute cholecystitis in patients who are critically ill or have serious medical comorbidities precluding the use of general anesthesia. It remains controversial whether interval cholecystectomy is warranted. The objectives of the study were to determine the success rate and complications of percutaneous cholecystostomy and the proportion of patients without recurrent attacks in whom interval cholecystectomy was not needed.

METHODS

This was a retrospective review to determine the outcomes after percutaneous cholecystostomy for acute calculous cholecystitis between 1995 and 2007. Administrative data were used to better capture recurrent symptoms requiring treatment.

RESULTS

Sixty-eight patients with a mean age of 74 years were identified. Sixty-seven (98.5%) underwent successful insertion of the cholecystostomy tubes. Eleven patients suffered tube-related complications, including tube dislodgment (9), tube blockage (1), and bleeding that was controlled with conservative management (1). The initial episode of cholecystitis was treated successfully in 58 patients (85%). The overall in-hospital and 30-day mortality were both 15% (10 patients). A total of 7 patients (10%) underwent cholecystectomy while still in hospital. There were 39 patients at risk for recurrent disease who survived the initial episode and did not receive an interval cholecystectomy. Of these 39 patients, 16 (41%) suffered recurrent gallbladder-related disease.

CONCLUSIONS

Percutaneous cholecystostomy is an alternative to cholecystectomy in patients with acute calculous cholecystitis who are at high risk for surgical mortality and morbidity. It appears to have a low complication rate and good clinical success. Because a significant number of patients suffer recurrent attacks, elective cholecystectomy should be considered routinely. Unfortunately, firm criteria for selecting percutaneous cholecystostomy over cholecystectomy are lacking, and the surgeon's clinical judgment is critically important.

Early Laparoscopic Cholecystectomy Is the Appropriate Management for Acute Gangrenous Cholecystitis

Treatment of severe acute cholecystitis by laparoscopic cholecystectomy remains controversial because of technical difficulties and high rates of complications. We determined whether early laparoscopic cholecystectomy is appropriate for acute gangrenous cholecystitis. The medical records of 116 patients with acute gangrenous cholecystitis admitted to the Korea University Guro Hospital between January 2005 and December 2009 were reviewed. The early operation group, those patients who had cholecystectomies within 4 days of the diagnosis, was compared with the delayed operation group, who had cholecystectomies 4 days after the diagnosis. Of the 116 patients, 57 were in the early operation group and 59 were in the delayed operation group. There were no statistical differences between the groups with respect to gender, age, body mass index, operative methods, major complications, duration of symptoms, mean operative time (98 vs 107 minutes), or postoperative hospital stay. However, the total hospital stay was significantly longer in the delayed operation group. More patients underwent preoperative percutaneous cholecystostomy in the delayed operation group (3.5 vs 15.3%). Early laparoscopic cholecystectomy for acute gangrenous cholecystitis is safe and feasible. There is no advantage to postponing an urgent operation in patients with acute gangrenous cholecystitis.

Results of percutaneous transhepatic cholecystostomy for high surgical risk patients with acute cholecystitis

AIM

To assess the efficacy and safety of percutaneous transhepatic cholecystostomy (PTC) in treatment for acute cholecystitis in high surgical risk patients.

PATIENTS AND METHODS

A retrospective review was carried out from January 1999 to June 2007 on 23 patients, 11 males and 12 females, who underwent PTC for the management of acute cholecystitis at the Department of Surgery, Queen Mary Hospital, Hong Kong, China. The mean age of the patients was 83. They all had either clinical or radiological evidence of acute cholecystitis and had significant pre-morbid diseases. The median follow-up period on them was 35 months.

RESULTS

All the PTCs performed were technically successful. One patient died from procedure-related haemoperitoneum, while 87% (n = 20) of all the patients had clinical resolution of sepsis by 20 h after PTC. Eight patients underwent elective cholecystectomy afterwards (62.5% with the laparoscopic approach). Eight patients had dislodgement of the PTC catheter and one of them developed recurrent acute cholecystitis 3 months after PTC. That patient was treated conservatively. Four patients died from their pre-morbid conditions during the follow-up period.

CONCLUSION

PTC was a safe and effective alternative for treating acute cholecystitis in this group of patients. Thirteen of them without elective cholecystectomy performed did not have recurrent acute cholecystitis after a single session of PTC. It may be considered as a definitive treatment for this group of patients.

Better treatment strategies for patients with acute cholecystitis and American Society of Anesthesiologists classification 3 or greater

PURPOSE

Laparoscopic cholecystectomy is the best treatment choice for acute cholecystitis. However, it still carries high conversion and mortality rates. The purpose of this study was to find out better treatment strategies for high surgical risk patients with acute cholecystitis.

MATERIALS AND METHODS

Between January 2002 and June 2008, we performed percutaneous cholecystostomy instead of emergency cholecystectomy in 44 patients with acute cholecystitis and American Society of Anesthesiologists (ASA) classification 3 or greater. This was performed in 31 patients as a bridge procedure before elective cholecystectomy (bridge group) and as a palliative procedure in 11 patients (palliation group).

RESULTS

The mean age of patients was 71.6 years (range 52-86 years). The mean ASA classifications before and after percutaneous cholecystostomy were 3.3 +/- 0.5 and 2.5 +/- 0.6, respectively, in the bridge group, and 3.6 +/- 0.7 and 3.1 +/- 1.0, in the palliation group, respectively. Percutaneous cholecystostomy was technically successful in all patients. There were two deaths after percutaneous cholecystostomy in the palliation group due to underlying ischemic heart disease and multiple organ failure. Resumption of oral intake was possible 2.9 +/- 1.8 days in the bridge group and 3.9 +/- 3.5 days in the palliation group after percutaneous cholecystostomy. We attempted 17 laparoscopic cholecystectomies and experienced one failure due to bile duct injury (success rate: 94.1%). The postoperative course of all cholecystectomy patients was uneventful.

CONCLUSION

Percutaneous cholecystostomy is an effective bridge procedure before cholecystectomy in patients with acute cholecystitis and ASA classification 3 or greater.

Gallbladder drainage guided by endoscopic ultrasound

The gold-standard management of acute cholecystitis is cholecystectomy. Surgical intervention may be contraindicated due to permanent causes. To date, the classical approach is percutaneous cholecystostomy in patients unresponsive to medical therapy. However, with this treatment some patients may experience discomfort, complications and a decrease in their quality of life. In these cases, endoscopic ultrasound (EUS)-guided gallbladder drainage may represent an effective minimally invasive alternative. Our objective is to describe in detail this new and not well-known technique: EUS-guided cholecystenterostomy. We will describe how the patient should be prepared, what accessories are needed and how the technique is performed. We will also discuss the possible indications for this technique and will provide a brief review based on published reports and our own experience.