Management strategies for acute cholecystitis in late pregnancy: a multicenter retrospective study

OBJECTIVE

This study aims to investigate the management strategies for acute cholecystitis in the third trimester of pregnancy by comparing the effectiveness of three different treatments.

METHODS

Clinical data of 102 patients with acute cholecystitis in third trimester of pregnancy admitted to three Tertiary Hospitals from January 2010 to June 2020 were collected and divided into 3 groups according to the primary treatment during their first hospitalization: Group A (surgical group; n = 11), Group B (percutaneous transhepatic gallbladder drainage (PTGD) group, n = 29) and Group C (conservative treatment group, n = 62). The length of stay, readmission rate, and preterm delivery rate of each group were analyzed retrospectively.

RESULTS

The average age of patients included in this study was 29 ± 2.16 years with an average gestational cycle of 35.26 ± 1.02 weeks. The readmission rates of patients in groups A, B, and C were 9.09%, 24.14%, and 58.06%; the preterm delivery rates were 9.09%, 3.45%, and 12.90%; and the length of stay was 4.02 ± 1.02 days, 12.53 ± 2.21 days, and 11.22 ± 2.09 days, respectively. The readmission rate was lower in group A than in groups B and C, the preterm delivery rate was lower in group B than in groups A and C, and the length of stay was shorter in group A than in groups B and C (all with statistically significant differences, P < 0.05).

CONCLUSION

Patients with acute cholecystitis in late pregnancy need to be appropriately graded for severity and offered a sound treatment strategy after a thorough assessment of the condition while taking into account the willingness of the patients. For patients with mild severity, conservative treatment can be adopted; for patients with moderate or severe inflammation, PTGD can be performed first for symptom control, and wait till after delivery for surgery to be considered; and in some cases of critical condition and poor symptom control, surgical intervention should be promptly performed.

Increased difficulty and complications of delayed laparoscopic cholecystectomy following percutaneous transhepatic gallbladder drainage in acute cholecystitis: a retrospective study

BACKGROUND

Percutaneous transhepatic gallbladder drainage (PTGBD) is a relatively less invasive alternative treatment to cholecystostomy. However, the influence of the difficulty of delayed laparoscopic cholecystectomy (DLC) after PTGBD on clinical outcomes remains unknown. This study aimed to evaluate the clinical effects of DLC following PTGBD.

METHODS

The clinical data of 113 patients diagnosed with moderate (grade II) acute cholecystitis according to the 2018 Tokyo Guidelines in the acute phase and who underwent DLC in our hospital from January 2018 to February 2022 were retrospectively collected and separated into two groups according to whether they received PTGBD treatment in the acute stage. The PTGBD group comprised 27 cases, and the no-PTGBD group included 86 cases. The TG18 difficulty score was used to evaluate every surgical procedure in the cases by reviewing the surgical videos. The clinical baseline characteristics and post-treatment outcomes were also evaluated.

RESULTS

Both groups showed significant differences in length of postoperative stay, blood loss, operation time, and difficulty score. The PTGBD group showed a significantly longer postoperative stay and operation time, more blood loss, and a much higher difficulty score than the no-PTGBD group. Conversion rates did not differ. The morbidity rate in the PTGBD group was statistically higher.

CONCLUSIONS

PTGBD is an efficient way to relieve the symptoms of acute cholecystitis. However, it may increase the difficulty and complications of DLC.

Comparison of the safety and effectiveness of different surgical timing for acute cholecystitis after percutaneous transhepatic gallbladder drainage: a systematic review and meta-analysis

BACKGROUND

To compare the efficacy and safety of laparoscopic cholecystectomy (LC) in the treatment of acute cholecystitis (AC) at different time points after percutaneous transhepatic gallbladder drainage (PTGBD).

METHODS

PubMed, EMBASE, Cochrane Library, and Web of Science were searched from database inception to 1 May 2022. The last date of search was the May 30, 2022. The Newcastle-Ottawa scale (NOS) was used to conduct quality assessments, and RevMan (Version 5.4) was used to perform the meta-analysis.

RESULTS

A total of 12 studies and 4379 patients were analyzed. Compared with the < 2-week group, the ≥ 2-week group had shorter operation time, less intraoperative blood loss, shorter postoperative hospital stay, lower rate of conversion to laparotomy, and fewer complications. There was no statistical difference between the two groups regarding bile duct injury, bile leakage, and total cost.

CONCLUSIONS

The evidence indicates that the ≥ 2-week group has the advantage in less intraoperative blood loss, minor tissue damage, quick recovery, and sound healing in treating AC. It can be seen that LC after 2 weeks is safe and effective for AC patients who have already undergone PTGBD and is recommended, but further confirmation is needed in a larger sample of randomized controlled studies.

Early cholecystectomy following percutaneous transhepatic gallbladder drainage is effective for moderate to severe acute cholecystitis in the octogenarians

BACKGROUND

Acute cholecystitis (AC) is a life-threatening infectious/inflammatory disease in older patients. This study aimed to investigate the safety and optimal timing of surgery in patients aged ≥ 80 years with moderate to severe AC who received percutaneous transhepatic gallbladder drainage (PTGBD).

METHODS

From January 2008 to February 2021, 152 patients were retrospectively enrolled. Clinical outcomes were compared among patients who received laparoscopic cholecystectomy (LC), open cholecystectomy (OC), and conversion surgery, and between those who received early (< 6 weeks after PTGBD) and delayed cholecystectomy (≥ 6 weeks after PTGBD). Logistic regression analysis was used to identify risk factors for recurrent AC, further biliary events, conversion, and perioperative complications.

RESULTS

Sixty-seven patients underwent LC, 62 underwent OC, and 23 underwent conversion surgery. Operation-related complications and mortality rates did not differ among the types of surgery; however, LC group had shorter operative time than the other groups. Eighty-two patients underwent early cholecystectomy, while 70 underwent delayed cholecystectomy. There were no differences in operative time, operation-related complications, and mortality rates between the groups. However, higher rates of recurrent AC and biliary events were observed in the delayed cholecystectomy group (52.9% vs. 4.9% and 57.1% vs. 8.5%, p < 0.001). On multivariate analysis, delayed cholecystectomy was a significant risk factor for recurrent AC (odds ratio [OR] = 19.42, p < 0.001) and further biliary events (OR = 15.95, p < 0.001).

CONCLUSIONS

Early cholecystectomy is recommended for patients aged ≥ 80 years with moderate to severe AC following PTGBD.

Navigation by modified and dynamic intraoperative cholangiography during laparoscopic subtotal cholecystectomy for difficult gallbladder

We used modified and dynamic intraoperative cholangiography (IOC) navigation during laparoscopic subtotal cholecystectomy for difficult gallbladders. We have defined an IOC that does not open the cystic duct as a modified IOC. Modified IOC methods include the percutaneous transhepatic gallbladder drainage (PTGBD) tube method, the infundibulum puncture method, and the infundibulum cannulation method. Case 1 was chronic cholecystitis after PTGBD for acute cholecystitis with pericholecystic abscess. In this case, modified IOC was performed via PTGBD, and biliary anatomy and incarcerated stone were confirmed. Case 2 was chronic cholecystitis after endoscopic sphincterotomy for cholecystocholedocholithiasis. In this case, modified IOC was performed via gallbladder puncture needle, and biliary anatomy and incision line were confirmed. The target point on the laparoscopic image was determined by moving the tip of the grasping forceps under modified IOC, which we call modified and dynamic IOC. We conclude that the navigation by the modified and dynamic IOC via PTGBD tube or puncture needle is useful to identify biliary anatomy, incarcerated gallbladder stone, and safe incision line during laparoscopic subtotal cholecystectomy .

Urgent versus elective laparoscopic cholecystectomy following percutaneous transhepatic gallbladder drainage for high-risk grade II acute cholecystitis

BACKGROUND

The aim of this study was to evaluate the safety of urgent laparoscopic cholecystectomy (Lap-C) for grade II acute cholecystitis (AC) in high-risk patients who were defined by Tokyo Guideline 18 as having age-adjusted Charlson comorbidity index ≥6 or American Society of Anesthesiologists physical status classification (ASA-PS) ≥ 3, compared with elective Lap-C following percutaneous transhepatic gallbladder drainage (PTGBD).

METHODS

In 73 grade II AC patients who underwent Lap-C from January 2012 to March 2021, 35 were identified as high-risk; 22 underwent urgent Lap-C (urgent group) and 13 PTGBD followed by elective Lap-C (elective group). Surgical and perioperative outcomes were analyzed.

RESULTS

There was no significant difference in operation time (median: 101 min vs 125 min; P = 0.371), blood loss (25 ml vs 7 ml; P = 0.853), morbidity rate (31.8% vs 38.5%; P = 0.726), or the incidence of total perioperative major complications (13.6% vs 15.4%; P = 1.000) between the two groups. The total duration of treatment was significantly shorter in the urgent group than the elective group (11 days vs 71 days; P < 0.001). Multivariate analysis revealed that blood loss ≥45 ml [odds ratio (OS): 12.14, 95% confidence interval (CI): 2.03-72.42, P = 0.006], and age ≥75 years with ASA-PS ≥ 3 (OS: 9.85, 95%CI: 1.26-77.26, P = 0.03) were the independent risk factors for total perioperative major complications.

CONCLUSION

In well-selected high-risk patients with grade II AC, urgent Lap-C can be performed with comparable safety to elective Lap-C following PTGBD.

Endoscopic Management of Acute Cholecystitis

Endoscopic drainage of the gallbladder for acute cholecystitis can be performed with the transpapillary method or endoscopic ultrasound (EUS)-guided method. EUS-guided gallbladder drainage (EUS-GBD) is gaining popularity as the treatment of choice for acute cholecystitis in patients who are deemed high-risk for cholecystectomy (CCY). It provides an alternative to percutaneous drainage and laparoscopic CCY in these patients. With the development of lumen-apposing metal stents (LAMS), the procedure is associated with high rates of technical and clinical success with low rates of adverse events (AEs). The aim of this article is to provide an overview of the current status of EUS-GBD including the indications, techniques, stent systems in-use, and how the procedure compares to conventional techniques are outlined. Furthermore, the feasibility of cholecystoscopy and advanced gallbladder interventions is explored. Finally, a comparison in outcomes of EUS-GBD versus laparoscopic CCY is provided giving some initial data in support of the procedure as an alternative to surgery in a selected group of patients.

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.

Elective Laparoscopic Cholecystectomy Is Better than Conservative Treatment in Elderly Patients with Acute Cholecystitis After Percutaneous Transhepatic Gallbladder Drainage

BACKGROUND

It is unclear whether cholecystectomy is beneficial after percutaneous transhepatic gallbladder drainage (PTGBD) in elderly patients with acute cholecystitis (AC).

METHODS

This single-center, retrospective study included 202 patients aged >80 years with AC without common bile duct (CBD) stones who underwent PTGBD between January 2010 and December 2019.

RESULTS

One hundred and forty-two patients underwent elective laparoscopic cholecystectomy (ELC), and 60 underwent conservative treatment, specifically PTGBD removal (PTGBD-R) in 36 patients and PTGBD maintained (PTGBD-M) in 24 patients. The postoperative major complication (POMC) rate in the ELC group was 8.5%. The cumulative incidence for recurrence of biliary events (BE) in the PTGBD-R group was 22.2%. The cumulative incidence for PTGBD-related complication in the PTGBD-M group was 70.8%. Mortality after initial treatment was not significantly different between the three groups (2.8% vs. 2.8% vs. 8.3%, p=0.381). In multivariate analysis, a Charlson age comorbidity index ≥6 and body mass index ≤19 were significant risk factors for POMC after ELC, and a closed cystic duct was a significant risk factor for recurrent BE after PTGBD-R.

CONCLUSION

ELC is recommended in AC after PTGBD for selected patients aged >80 years without CBD stones due to the high recurrence rate of BE after PTGBD-R and the difficulty associated with PTGBD-M.

Laparoscopic subtotal cholecystectomy after percutaneous transhepatic gallbladder drainage for grade II or III acute cholecystitis

Background

Severe adhesions and fibrosis between the posterior wall of the gallbladder and liver bed often render total cholecystectomy after percutaneous transhepatic gallbladder drainage (PTGBD) difficult, leading to high open conversion rates. Since the publication of Tokyo Guidelines 2018 (TG18), our policy has shifted from open conversion to subtotal cholecystectomy (SC) when total laparoscopic cholecystectomy for difficult cases of cholecystitis is not feasible. Recently, SC has been frequently applied as bailout surgery for complicated cholecystitis. Nonetheless, the efficacy and validity of laparoscopic SC after PTGBD remain unclear. This study aimed to evaluate the safety and feasibility of laparoscopic SC after PTGBD for grade II or III acute cholecystitis (AC) by comparing two periods of altered surgical strategies.

Methods

This retrospective cohort study was conducted between January 2013 and December 2020. A total of 44 eligible patients with grade II or III AC were divided according to the time of cholecystitis onset into the pre-TG18 group (2013–2017, n = 17) and post-TG18 group (2018–2020, n = 27). Patients’ background demographics, surgical method, surgical results, and postoperative complications were compared.

Results

The interval between PTGBD and surgery was significantly longer in the post-TG18 group than in the pre-TG18 group (15 [interquartile range: 9–42] days vs. 8 [4–11] days; P = 0.010). The frequency of laparoscopic cholecystectomy significantly increased from 52.9% in the pre-TG18 group to 88.9% in the post-TG18 group (P = 0.007), whereas the frequency of SC was 23.5% and 40.7%, respectively, which showed no statistically significant difference (P = 0.241). However, the rate of laparoscopic SC significantly increased from 0 to 90.9% among 15 SC cases, whereas the rate of open SC significantly plummeted from 100 to 9.1% (P = 0.001). Significant differences in the operative time, amount of intraoperative bleeding, and incidence of postoperative complications (wound infection and subhepatic abscess) were not observed. Mortality, bile leakage, and bile duct injury did not occur in either group.

Conclusions

For grade II or III AC after PTGBD, aggressive adoption of SC increased the completion rate of laparoscopic surgery. Laparoscopic SC is a safe and feasible treatment option.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01387-w.

The efficacy and safety of preoperative cholangiography via percutaneous transhepatic gallbladder drainage (PTGBD) for difficult laparoscopic cholecystectomy (LC)

BACKGROUND

Percutaneous transhepatic gallbladder drainage (PTGBD) is an important procedure for initial treatment of severe acute cholecystitis (AC) that is contraindicated for early laparoscopic cholecystectomy (LC). We presented our primary experience on a new approach of cholangiography via PTGBD (PTGBD-C) for preoperative delineation of biliary anatomy.

METHODS

A retrospective analysis was conducted on 93 patients who received PTGBD followed by LC for AC, with allocation into 2 groups that were PTGBD with (PTGBD-C group, 32 patients) or without (PTGBD-N group, 61 patients) cholangiography. All the clinical data, including demographics, cholangiography findings, operations, and complications, were collected and analyzed.

RESULTS

Cholangiography was attempted in 32 patients with a success of 31 cases, and the most common complication was transient fever in 3 patients. PTGBD-C group of patients showed significantly less operation time (83.2 ± 22.32 vs. 106.5 ± 40.25 min, P = 0.041) and conversion rate (0 vs. 2). There was no statistical difference in terms of postoperative hospitalization and complications.

CONCLUSIONS

PTGBD-C is a feasible and safe procedure for severe AC patients with delayed LC. It has advantages of direct cholangiography, being easy to perform and cost-effective, thus should be considered for clinical usage.

Laparoscopic cholecystectomy after endoscopic trans-papillary gallbladder stenting for acute cholecystitis: a pilot study of surgical feasibility

BACKGROUND

Percutaneous transhepatic gallbladder drainage (PTGBD) is indicated for patients with acute cholecystitis (AC) who are not indicated for urgent surgery, but external tubes reduce quality of life (QOL) while waiting for elective surgery. The objective of the present study was to investigate the feasibility of laparoscopic cholecystectomy after endoscopic trans-papillary gallbladder stenting (ETGBS) comparing with after PTGBD.

METHODS

Intraoperative and postoperative outcomes of patients with ETGBS and PTGBD were retrospectively compared.

RESULTS

Eighteen ETGBS and ten PTGBD patients were compared. Differences in the duration of ETGBS and PTGBD [median 209 min (range 107-357) and median 161 min (range 130-273), respectively, P = 0.10], median blood loss [ETGBS 2 (range 2-180 ml) and PTGBD 24 (range 2-100 ml), P = 0.89], switch to laparotomy (ETGBS 11% and PTGBD 20%, P = 0.52), and median postoperative hospital stay [ETGBS 8 (range 4-24 days) and ETGBS 8 (range 4-16 days), P = 0.99]. Thickening of the cystic duct that occurred in 60% of the ETGBS patients and none of the PTGBD patients (P = 0.005) interfered with closure of the duct by clipping. No obstruction occurred in ETGBS patients.

CONCLUSION

ETGBS did not make laparoscopic cholecystectomy less feasible than after PTGBD. This is a pilot study, and further investigations are needed to validate the results of the present study.

Impact of B-mode-ultrasound-guided transhepatic and transperitoneal cholecystostomy tube placement on laparoscopic cholecystectomy

BACKGROUND

B-mode-ultrasound-guided percutaneous cholecystostomy (PC) may be performed by a transhepatic or transperitoneal approach, called percutaneous transhepatic gallbladder drainage (PHGD) and percutaneous transperitoneal gallbladder drainage (PPGD), respectively. We compared the impact of PC related to the route of catheter placement on subsequent laparoscopic cholecystectomy (LC).

AIM

To compare the impact of PC related to the route of catheter placement on subsequent LC.

METHODS

We retrospectively studied 103 patients with acute calculous cholecystitis who underwent scheduled LC after PC between January 2010 and January 2019. Group I included 58 patients who underwent scheduled LC after PHGD. Group II included 45 patients who underwent scheduled LC after PPGD. Clinical outcomes were analyzed according to each group.

RESULTS

Baseline demographic characteristics did not differ significantly between both groups (P > 0.05). Both PHGD and PPGD were able to quickly resolve cholecystitis sepsis. Group I showed significantly higher efficacy than group II in terms of lower pain score during puncture (3.1 vs 4.5; P = 0.001) and at 12 h follow-up (1.5 vs 2.2; P = 0.001), lower rate of fever within 24 h after PC (13.8% vs 42.2%; P = 0.001), shorted operation duration (118.3 vs 139.6 min; P = 0.001), lower amount of intraoperative bleeding (72.1 vs 109.4 mL; P = 0.001) and shorter length of hospital stay (14.3 d vs 18.0 d; P = 0.001). However, group II had significantly lower rate of local bleeding at the PC site (2.2% vs 20.7%; P = 0.005) and lower rate of severe adhesion (33.5% vs 55.2%; P = 0.048). No significant differences were noted between both groups regarding the conversion rate to laparotomy, rate of subtotal cholecystectomy, complications and pathology.

CONCLUSION

B-mode-ultrasound-guided PHGD is superior to PPGD followed by LC for treatment of acute calculous cholecystitis, with shorter operating time, minimal amount of intraoperative bleeding and short length of hospital stay.

Hemoperitoneum and sepsis from transhepatic gallbladder perforation of acute cholecystitis: A case report

We report a case of hemoperitoneum and sepsis from transhepatic gallbladder perforation in an 87-year-old male with acute cholecystitis who had past history of endoscopic sphincterotomy for common bile duct stone. Contrast-enhanced computed tomography (CT) showed intrahepatic and subcapsular low density areas. A wall defect of gallbladder was seen in coronal and sagittal - sections at the liver bed. Fluids obtained through the paracentesis were hemorrhagic. Percutaneous transhepatic gallbladder drainage (PTGBD) was attempted. First cholangiography revealed an orifice of fistula. Further injection of contrast medium drained into the intrahepatic secondary abscess and intraperitoneal cavity confirming the diagnosis of transhepatic gallbladder perforation. We conclude that contrast-enhanced CT with coronal and sagittal - sections and cholangiography via PTGBD tube are useful to confirm diagnosis of transhepatic gallbladder perforation.

Natural Course of Acute Cholecystitis in Patients Treated With Percutaneous Transhepatic Gallbladder Drainage Without Elective Cholecystectomy

BACKGROUND

Percutaneous transhepatic gallbladder drainage (PTGBD) is an alternative treatment for acute cholecystitis (AC). We aimed to understand the natural course of AC in patients treated with PTGBD but without later definitive treatments, such as laparoscopic cholecystectomy.

METHODS

This was a retrospective study of the period from June 2010 to December 2016, during which time 2371 patients were diagnosed with AC and 625 received PTGBD treatment. Among the 625 patients, 237 received no definitive treatment. A biliary event after the initial AC episode was the outcome of interest. In addition, the competing risk of death unrelated to biliary causes was present in the cohort. Therefore, a competing risk model was applied for analysis.

RESULTS

The cumulative incidence of biliary events was 29.8% with a median of 4.27 months, while the competing event, i.e., death unrelated to a biliary event, was noted in 14.9% of patients with a median 23.54 months. The risk factors of biliary events were prolonged PTGBD indwelling and an abnormal PTGBD cholangiogram. The risk factors of death unrelated to a biliary event included a high Charlson comorbidity index and the initial AC severity.

CONCLUSIONS

Definitive cholecystectomy is still recommended for patients undergoing PTGBD treatment due to the high incidence of later biliary events. A thorough preoperative evaluation is necessary for those patients before elective cholecystectomy because of the inferior life expectancy and physical status.

Current Status in the Treatment of Acute Cholecystitis Patients Receiving Antithrombotic Therapy: Is Endoscopic Drainage Feasible?- A Systematic Review

The bleeding complication risk of surgery or percutaneous transhepatic gallbladder drainage (PTGBD) may increase in patients with acute cholecystitis receiving antithrombotic therapy (ATT). Endoscopic gallbladder drainage (EGBD) may be recommended for such patients. English articles published between 1991 and 2018 in peer-reviewed journals that discuss cholecystectomy, PTGBD, and EGBD in patients with ATT or coagulopathy were reviewed to assess the safety of the procedures, especially in terms of the bleeding complication. There were 8 studies on cholecystectomy, 3 on PTGBD, and 1 on endoscopic transpapillary gallbladder drainage (ETGBD) in patients receiving ATT. With respect to EGBD, 28 studies on ETGBD (including 1 study already mentioned above) and 26 studies on endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) were also analyzed. The overall bleeding complication rate in patients with ATT who underwent cholecystectomy was significantly higher than that in patients without ATT (6.5% [23/354] vs. 1.2% [26/2,224], p<0.001). However, the bleeding risk of cholecystectomy and PTGBD in patients receiving ATT was controversial. The overall technical success, clinical success, and bleeding complication rates of ETGBD vs. EUS-GBD were 84% vs. 96% (p<0.001), 92% vs. 97% (p<0.001), and 0.65% vs. 2.1% (p=0.005), respectively. One patient treated with ETGBD experienced bleeding complication among 191 patients with bleeding tendency. ETGBD may be an ideal drainage procedure for patients receiving ATT from the viewpoint of bleeding, although EUS-GBD is also efficacious.

Endoscopic Ultrasonography-Guided Gallbladder Drainage as a Treatment Option for Acute Cholecystitis after Metal Stent Placement in Malignant Biliary Strictures

Background/Aims

It is often difficult to manage acute cholecystitis after metal stent (MS) placement in unresectable malignant biliary strictures. The aim of this study was to evaluate the feasibility of endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) for acute cholecystitis.

Methods

The clinical outcomes of 10 patients who underwent EUS-GBD for acute cholecystitis after MS placement between January 2011 and August 2018 were retrospectively evaluated. The procedural outcomes of percutaneous transhepatic gallbladder drainage (PTGBD) with tube placement (n=11 cases) and aspiration (PTGBA) (n=27 cases) during the study period were evaluated as a reference.

Results

The technical success and clinical effectiveness rates of EUS-GBD were 90% (9/10) and 89% (8/9), respectively. Severe bile leakage that required surgical treatment occurred in one case. Acute cholecystitis recurred after stent dislocation in 38% (3/8) of the cases. Both PTGBD and PTGBA were technically successful in all cases without severe adverse events and clinically effective in 91% and 63% of the cases, respectively.

Conclusions

EUS-GBD after MS placement was a feasible option for treating acute cholecystitis. However, it was a rescue technique following the established percutaneous intervention in the current setting because of the immature technical methodology, including dedicated devices, which need further development.

Validation of Tokyo Guideline 2013 as Treatment of Acute Cholecystitis by Real World Data

BACKGROUND

The Tokyo Guidelines (TG; 2013) indicated that emergency cholecystectomy is an important early treatment option for acute cholecystitis; however, surgical intervention is not necessarily indicated in patients with advanced age. We evaluated percutaneous transhepatic gallbladder aspiration (PTGBA), percutaneous transhepatic gallbladder drainage (PTGBD), and the administration of antibiotics alone as treatment options for acute -cholecystitis.

METHODS

From January 2010 to December 2017, 159 patients with acute cholecystitis were treated at our institution. The data from these patients were retrospectively analyzed.

RESULTS

Of these 159 cases, 109 underwent PTGBA, 28 underwent PTGBD, and 22 were administered antibiotics alone. None of the 159 patients needed urgent (early) cholecystectomy, and all patients were discharged without mortality. PTGBA was unsuccessful in only 6 of 109 patients; PTGBD was performed in these 6 cases. Long-term follow-up was conducted in all cases. Of the 159 patients, 146 had gallbladder stones initially, while 13 had none at the time of presentation. Of these 146 patients with gallbladder stones, 84 underwent elective cholecystectomy, while 62 did not. Of the 84 patients who underwent elective cholecystectomy, 2 developed choledocholithiasis; of the 62 patients who did not undergo elective cholecystectomy, 5 developed choledocholithiasis and 2 developed acute cholecystitis. The incidences of choledocholithiasis and acute cholecystitis did not significantly differ between the 2 groups (p = 0.06).

CONCLUSIONS

Despite the recommendations in the TG (2013), emergency cholecystectomy was not needed in any of the present patients with acute cholecystitis. Acute cholecystitis can be successfully treated with -PTGBA or PTGBD, which are simple procedures with good short- and long-term safety. These procedures are highly recommended for patients with acute cholecystitis, especially in the elderly population.

[Clinical evaluation of gallbladder and common bile duct stones treated though cholecystostomy tube]

Objective: To investigate the efficacy, feasibility and safety of treatment of gallbladder and common bile duct stones treated through cholecystostomy tube. Methods: The clinical data of 17 patients with gallbladder and common bile duct stones treated through cholecystostomy tube from January 2012 to December 2016 was analyzed retrospectively. Results: Seventeen patients were successfully treated with percutaneous transhepatic gallbladder (PTGD), and 88.2% (15/17) patients had clinical symptom relief. There was no complication happened after PTGD and fistula expansion. All the stones were removed and there was 11.7% (2/17) of gallbladder bleeding, 5.9% (1/17) of pancreatitis, and 5.9% (1/17) of hyperamylasemia after stones extraction. The patients had gone through an average treatment period of 87.8±16.0 days, hospitalization of 5.5±0.6 times and 43.3±4.5 days, cost of 60.0±8.0 thousand, 6.9±0.9 operations, 1.4±0.6 stone extraction operations with the average time of 58.4±21.2 min. The duodenal papillary balloon dilatation rate was 82.4% (14/17). Conclusion: The treatment through cholecystostomy tube is an effective, safe and feasible technique for gallbladder and common bile duct stones. However, there are many shortcomings such as long treatment cycle, large number of hospitalization and operations, difficult operation and high cost.

[Emergency cholecystectomy versus percutaneous transhepatic gallbladder drainage followed by delayed cholecystectomy in patients with moderate acute cholecystitis]

Objective: To analysis the curative effect of emergency cholecystectomy (EC) and percutaneous transhepatic gallbladder drainage (PTGBD) followed by delayed cholecystectomy (DC) on the patients with moderate acute cholecystitis. Methods: The perioperative dataof patients in EC group (n=47) and in PTGBD-DC group (n=49) were compared retrospectively. Results: Compared to PTGBD+ DC group, EC patients had a significantly more postoperative abdominal drainage time [(9.0±12.9) vs (3.4±2.1) days, P=0.041], more postoperative hospital stay after cholecystectomy [(8.2±3.2) vs (5.1±1.8) days, P=0.004], more intraoperative bleeding [(101±125) vs (33±37) ml, P=0.003], more patients of LC conversion to open cholecystectomy (OC) (19.1% vs 4.1%, P=0.021) and more patients of OC(14.9% vs 0, P=0.005). Also, there were higher incidence of respiratory failure(14.8% vs 2.0%, P=0.029), and admission for ICU(21.3% vs 2.0 %, P=0.003). Also, patients of total OC in non-biliary surgeons group were more than that of biliary surgeons group statistically(63.2% vs 14.3 %, P=0.001). Conclusion: PTGBD followed by DC in the treatment of moderate acute cholecystitis was better than EC, especially in patients with complicated comorbidities and in non-biliary surgeons.

Clinical Evaluation of Continuous Renal Replacement Therapy in Combination with Ultrasound-Guided Percutaneous Transhepatic Gallbladder Drainage for Acute Severe Biliary Pancreatitis: a Retrospective Study

BACKGROUND/AIMS

This study aimed to report the clinical efficacy of continuous renal replacement therapy (CRRT) in combination with ultrasound-guided percutaneous transhepatic gallbladder drainage (PTGD) (CRRT+PTGD) in the treatment of acute severe biliary pancreatitis (ASBP).

METHODS

Between January 2010 and January 2016, 40 cases of patients with ASBP who received routine CRRT (CRRT group) and 40 of those who received CRRT+PTGD (CRRT+PTGD group) at the Affiliated Hospital of Qingdao University (Qingdao, China) were retrospectively reviewed. Clinical (including abdominal pain remission time, gastrointestinal decompression time, Intensive Care Unit (ICU) hospital stay, respirator treatment time, and mortality rate), laboratory (white blood cells [WBC], platelet [PLT], procalcitonin [PCT], C-reactive protein [CRP], total bilirubin [TBIL], alanine aminotransferase [ALT], albumin [ALB], and blood lactic acid [Lac]) parameters, various critical disease scores, and incidence of complications after the treatment were compared between the two groups.

RESULTS

Compared with those in the routine CRRT group, patients in the CRRT+PTGD group exhibited significant remission of clinical symptoms (i.e. shorter abdominal pain remission time, gastrointestinal decompression time, respirator treatment time and ICU hospital stay) (all P<0.05), change of laboratory parameters (WBC, PLT, PCT, CRP, TBIL, ALT) (P<0.05), and improvement of various critical disease scores (P<0.05). Moreover, the variation of most of the above parameters after versus before the treatment was greater in the CRRT+PTGD group than in the CRRT group (all P<0.05).

CONCLUSION

CRRT in combination with PTGD is more effective in the treatment of ASBP than CRRT alone.

Optimal timing of cholecystectomy after percutaneous gallbladder drainage for severe cholecystitis

Background

The Tokyo guideline for acute cholecystitis recommended percutaneous transhepatic gallbladder drainage followed by cholecystectomy for severe acute cholecystitis, but the optimal timing for the subsequent cholecystectomy remains controversial.

Methods

Sixty-seven patients who underwent either laparoscopic or open cholecystectomy after percutaneous transhepatic gallbladder drainage for severe acute cholecystitis were enrolled and divided into difficult cholecystectomy (group A) and non-difficult cholecystectomy (group B). Patients who had one of these conditions were placed in group A: 1) conversion from laparoscopic to open cholecystectomy; 2) subtotal cholecystectomy and/or mucoclasis; 3) necrotizing cholecystitis or pericholecystic abscess formation; 4) tight adhesions around the gallbladder neck; and 5) unsuccessfully treated using PTGBD. Preoperative characteristics and postoperative outcomes were analyzed.

Results

The interval between percutaneous transhepatic gallbladder drainage and cholecystectomy in Group B was longer than that in Group A (631 h vs. 325 h; p = 0.031). Postoperative complications occurred more frequently when the interval was less than 216 h compared to when it was more than 216 h (35.7 vs. 7.6%; p = 0.006).

Conclusions

Cholecystectomy for severe acute cholecystitis was technically difficult when performed within 216 h after percutaneous transhepatic gallbladder drainage.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-017-0631-8) contains supplementary material, which is available to authorized users.

Percutaneous and endoscopic gallbladder drainage for acute cholecystitis: international multicenter comparative study using propensity score-matched analysis

BACKGROUND

Tokyo Guideline 2013 (TG13) proposed three drainage techniques for the treatment of acute cholecystitis. We evaluated the clinical efficacy and adverse events between percutaneous transhepatic intervention (PTGBI) including percutaneous transhepatic gallbladder drainage (PTGBD) and percutaneous transhepatic gallbladder aspiration (PTGBA) and endoscopic transpapillary gallbladder drainage (EGBD).

METHODS

A cohort study was performed using propensity score matching to reduce treatment selection bias. This involved the analysis of collected data for 1,764 patients who underwent PTGBI and EGBD.

RESULTS

Propensity score matching extracted 330 pairs of patients. The difference in the clinical success rate within 3 days between PTGBI and EGBD were 62.5% and 69.8%, respectively (P = 0.085). The differences in the suboptimal clinical success rates within 7 days between PTGBI and EGBD were 87.6% and 89.2% (P = 0.579). The differences in the complication rate between PTGBI and EGBD were 4.8% and 8.2% (P = 0.083). The differences in the complication rate among PTGBD, PTGBA and EGBD were 5.6%, 1.6% and 8.2% (P = 0.11). Median required days of PTGBD (3.0 days) was significantly longer than those of PTGBA and EGBD (1.5 and 2.0 days, respectively) (P = 0.001).

CONCLUSION

The current study showed the PTGBI showed similar clinical efficacy compared with EGBD without significant discrepancy of complication rate for the treatment of acute cholecystitis.

Signal Intensity of Superb Microvascular Imaging Correlates with the Severity of Acute Cholecystitis

Evaluation of the severity of acute cholecystitis is critical for the management of this condition. Superb microvascular imaging (SMI) enables the assessment of slow blood flow of small vessels without any contrast medium. An 84-year-old man visited our hospital with right upper abdominal pain. Computed tomography and abdominal ultrasonography showed a slight thickening of the gallbladder. White blood cell count and C-reactive protein levels were elevated. He was diagnosed with acute cholecystitis and treated conservatively with antibiotics. Two days later, his condition worsened and percutaneous transhepatic gallbladder drainage (PTGBD) was performed. The patient recovered and was discharged, and his drainage was withdrawn 7 days later. On admission, color-coded SMI (cSMI) showed pulsatory signals on the slightly thickened gallbladder wall. On the day of PTGBD, the intensity of the signal on cSMI had increased. Once the patient was cured, no further signal was observed on the gallbladder wall with either cSMI or mSMI. In conclusion, the strong pulsatory signal correlated with the severity of acute cholecystitis observed with cSMI and mSMI. Illustrating the signal intensity is useful for the evaluation of the severity of acute cholecystitis.

Optimal timing for performing percutaneous transhepatic gallbladder drainage and subsequent cholecystectomy for better management of acute cholecystitis

BACKGROUND

We aimed to clarify the appropriate timing for performing percutaneous transhepatic gallbladder drainage (PTGBD) and cholecystectomy, and the effect of PTGBD on surgical difficulty in acute cholecystitis patients.

METHODS

We retrospectively examined 46 patients who underwent laparoscopic cholecystectomy (LC) after PTGBD for acute cholecystitis. We evaluated the duration from acute cholecystitis onset to PTGBD and the appropriate interval from PTGBD to elective LC. Intraoperative blood loss, operating time, rate of conversion to open surgery, and rate of severe adhesion were the objective and subjective measures.

RESULTS

Based on the cut-off value calculated using the Youden index, the group with a duration from acute cholecystitis onset to PTGBD of ≤73.5 h had a significantly shorter operating time (127.5 min vs. 180.0 min, P = 0.007), lower rate of severe adhesion (3/20 vs. 14/26, P = 0.007), and lower rate of conversion to open surgery (2/20 vs. 13/26, P = 0.004); moreover, the interval from PTGBD to elective LC did not significantly differ between these groups.

CONCLUSION

The most important predictor of successful LC following PTGBD for acute cholecystitis was a duration from acute cholecystitis onset to PTGBD of ≤73.5 h. Hence, PTGBD should be performed immediately in cases where early cholecystectomy is not indicated.

The safety and efficacy of percutaneous transhepatic gallbladder drainage in elderly patients with acute cholecystitis before laparoscopic cholecystectomy

PURPOSE

Laparoscopic cholecystectomy (LC) is the standard management for acute cholecystitis. Percutaneous transhepatic gallbladder drainage (PTGBD) may be an alternative interim strategy before surgery in elderly patients with comorbidities. This study was designed to evaluate the safety and efficacy of PTGBD for elderly patients (>60 years) with acute cholecystitis.

METHODS

We reviewed consecutive patients diagnosed with acute cholecystitis between January 2009 and December 2013. Group I included patients who underwent PTGBD, and patients of group II did not undergo PTGBD before LC.

RESULTS

All 116 patients (72.7 ± 7.1 years) were analyzed. The preoperative details of group I (n = 39) and group II (n = 77) were not significantly different. There was no significant difference in operative time (P = 0.057) and intraoperative estimated blood loss (P = 0.291). The rate of conversion to open operation of group I was significantly lower than that of group II (12.8% vs. 32.5%, P < 0.050). No significant difference of postoperative morbidity was found between the two groups (25.6% vs. 26.0%, P = 0.969). In addition, perioperative mortality was not significantly different. Preoperative hospital stay of group I was significantly longer than that of group II (10.3 ± 5.7 days vs. 4.4 ± 2.8 days, P < 0.050). However, two groups were not significantly different in total hospital stay (16.3 ± 9.0 days vs. 13.4 ± 6.5 days, P = 0.074).

CONCLUSION

PTGBD is a proper preoperative management before LC for elderly patients with acute cholecystitis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis

Backgrounds/Aims

In the treatment of complicated cholecystitis, laparoscopic cholecystectomy (LC) has limited efficacy due to its substantial post-operative complications. In addition, the clinical characteristics of complicated cholecystitis (CC) patients were suspected as advanced age with highly risky comorbidity. Percutaneous transhepatic gall bladder (PTGBD) drainage could be an alternative option for successful LC. Hence, this study evaluated the outcome of PTGBD for CC within and after 5 days.

Methods

The medical records of 109 consecutive CC patients who had undergone an LC between January 2007 and December 2011 were retrospectively reviewed and compared with the medical records of CC patients who had undergone an LC within 72 hours of (group I, n=63) or 5 days after PTGBD (group II, n=40). In addition, group I was divided into group Ia (n=46) and group Ib (n=17), according to the patients' development of open-conversion or post-operative complications. The clinical outcomes of the four groups were analyzed.

Results

There was a significantly higher reference to age, the ASA score grading, and predominant comorbidities in group II than in group I. The peri-operative results of group II showed lower blood loss and relatively shorter operating times than those of group I. In the cases of early LC within 72 hours (group Ia vs. group Ib), the difference was statistically insignificant.

Conclusions

The delayed LC after PTGBD for complicated cholecystitis with high clinical risk had better results in this study, although it prolonged the patient's hospital stay.

Peritoneal bleeding due to percutaneous transhepatic gallbladder drainage: An autopsy report

A 77-year-old man underwent percutaneous transhepatic gallbladder drainage (PTGBD) for acute cholecystitis as a preoperative procedure; however, he suddenly suffered cardiopulmonary arrest 4 h after the PTGBD and died. There were three centesis scars for the PTGBD, and only one pathway from the most dorsal centesis scar reached the gallbladder. Microscopically, the PTGBD pathway crossed and injured the intrahepatic arterial wall, and hepatic parenchymal bleeding extended along the PTGBD pathway to the inferior surface of the liver. Blood flowed to the peritoneal cavity through a small gap between the liver and gallbladder. Consequently, the PTGBD caused lethal bleeding. When the percutaneous transhepatic cholangio drainage/PTGBD pathway runs close to vessels near the liver surface, it might be necessary to deal with the possibility of rapid and lethal peritoneal bleeding.

Biliopleural fistula: A rare complication of percutaneous transhepatic gallbladder drainage

A 79-year-old previously healthy man presented with acute acalculous cholecystitis with obstruction of the biliary tract. He was successfully treated with antibiotics and percutaneous transhepatic gallbladder drainage, but returned to the hospital two days after discharge with a rare complication of this technique, biliopleural fistula. A thoracostomy tube was inserted to drain the pleural effusion, and the patient’s previous antibiotics reinstated. After two weeks of drainage and antibiotics, the fistula healed spontaneously without the need for further intervention.