Acute cholecystitis in high surgical risk patients: percutaneous cholecystostomy or emergency cholecystectomy?

Management of Acute Cholecystitis in High-Risk Patients: Percutaneous Gallbladder Drainage as a Definitive Treatment vs. Emergency Cholecystectomy-Systematic Review and Meta-Analysis

BACKGROUND

This systematic review aims to investigate whether percutaneous transhepatic gallbladder biliary drainage (PTGBD) is superior to emergency cholecystectomy (EC) as a definitive treatment in high-risk patients with acute cholecystitis (AC).

MATERIAL AND METHODS

A systematic literature search was performed until December 2022 using the Scopus, Medline/PubMed and Web of Science databases.

RESULTS

Seventeen studies have been included with a total of 783,672 patients (32,634 treated with PTGBD vs. 4663 who underwent laparoscopic cholecystectomy, 343 who had open cholecystectomy and 746,032 who had some form of cholecystectomy, but without laparoscopic or open approach being specified). An analysis of the results shows that PTGBD, despite being less invasive, is not associated with lower morbidity with respect to EC (RR 0.77 95% CI [0.44 to 1.34]; I2 = 99%; p = 0.36). A lower postoperative mortality was reported in patients who underwent EC (2.37%) with respect to the PTGBD group (13.78%) (RR 4.21; 95% CI [2.69 to 6.58]; p < 0.00001); furthermore, the risk of hospital readmission for biliary complications (RR 2.19 95% CI [1.72 to 2.79]; I2 = 48%; p < 0.00001) and hospital stay (MD 4.29 95% CI [2.40 to 6.19]; p < 0.00001) were lower in the EC group.

CONCLUSIONS

In our systematic review, the majority of studies have very low-quality evidence and more RCTs are needed; furthermore, PTGBD is inferior in the treatment of AC in high-risk patients. The definition of high-risk patients is important in interpreting the results, but the methods of assessment and definitions differ between studies. The results of our systematic review and meta-analysis failed to demonstrate any advantage of using PTGBD over ER as a definitive treatment of AC in critically ill patients, which suggests that EC should be considered as the treatment of choice even in very high-risk patients. Most likely, the inferiority of PTGBD versus early LC for high-risk patients is related to an association of various patient-side factor conditions and the severity of acute cholecystitis.

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.

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

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

Ultrasound-Guided Percutaneous Transhepatic Gallbladder Drainage Improves the Prognosis of Patients with Severe Acute Cholecystitis

The aim of this study was to investigate the clinical efficacy of ultrasound-guided percutaneous transhepatic gallbladder drainage (PTGD) for the treatment of severe acute cholecystitis (AC). The data of 40 patients diagnosed with severe AC at our hospital between August 2020 and June 2021 were retrieved and classified into a PTGD group, open cholecystostomy (OC) group, laparoscopic cholecystectomy (LC) group, and conventional conservative treatment (CT) group. Before treatment and on days 1, 3, 5, and 7 after treatment, their serum levels of alanine aminotransferase (ALT), alkaline phosphatase (ALP), aspartate aminotransferase (AST), total bilirubin (TBIL), triglyceride (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), white blood cell count (WBC), IL-2, IL-4, IL-6, IL-8, and cancer antigen 19–9 (CA19-9) were measured. Additionally, clinical manifestations such as body temperature and pain score were monitored before treatment and at 24, 48, and 72 hours after treatment. The recovery time and complications/adverse reactions were statistically analyzed, and the Kaplan–Meier survival curve was plotted. After treatment, compared with the other three groups, the PTGD group had a significant reduction in serum indicators, including WBC and inflammatory factors, recovery time, pain score, and complications, and benefitted from better treatment efficacy and higher survival rate. Thus, ultrasound-guided PTGD was found to be more effective in treating severe AC patients and was associated with improved patient prognoses.

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.

Outcomes of percutaneous cholecystostomy in elderly patients: a systematic review and meta-analysis

INTRODUCTION

Percutaneous cholecystostomy (PC) represents a management option to control sepsis in patients with acute cholecystitis, who are unable to tolerate surgery.

AIM

This review aimed to evaluate the outcomes of elderly patients treated with PC and compare it with emergent cholecystectomy.

MATERIAL AND METHODS

An electronic search of the Embase, Medline Web of Science, and Cochrane databases was performed. Percutaneous cholecystostomy was used as the reference group, and weighted mean differences (WMD) were calculated for the effect of PC on continuous variables, and pooled odds ratios (POR) were calculated for discrete variables.

RESULTS

There were 20 trials included in this review. Utilisation of PC was associated with significantly increased mortality (POR = 4.85; 95% CI: 1.02-7.30; p = 0.0001) and increased re-admission rates (POR = 2.95; 95% CI: 2.21-3.87; p < 0.0001).

CONCLUSIONS

This pooled analysis established that patients treated with PC appear to have increased mortality and readmission rates relative to those managed with cholecystectomy.

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.

Percutaneous Cholecystostomy Placement in Cases of Non-operative Cholecystitis: A Retrospective Cohort Analysis

BACKGROUND

Acute (calculous) cholecystitis (AC) is an extremely common surgical presentation, managed by cholecystectomy. Percutaneous cholecystostomy (PC) is an alternative; however, its safety and efficacy, along with subsequent cholecystectomy, are underreported in South Africa, where patients often present late and access to emergency operating theatre is constrained. The aim of the study was to demonstrate the outcomes of PC in patients with AC not responding to antimicrobials.

MATERIALS AND METHODS

A retrospective cohort review of patient records, who underwent PC in Groote Schuur Hospital, Cape Town, between May 2013 and July 2016, was performed. Patients with PC for malignancy or acalculous cholecystitis were excluded. Technical success, clinical response, procedure-related morbidity and mortality were recorded. Interval LC parameters were investigated.

RESULTS

Technical success and clinical improvement was seen in 29 of 37 patients (78.38%) who had PC. Malposition (8.11%) was the most common complication. Two patients required emergency surgery (5.4%), while one tube was dislodged. Median tube placement duration was 25 days (range 1-211). Post-procedure, 16 patients (43.24%) went on to have LC, of which 50% (eight patients) required conversion to open surgery and 25% (four) had subtotal cholecystectomy. Median surgical time was 130 min. There were no procedure-related mortalities but eight patients (21.62%) died in the 90-day period following tube insertion.

CONCLUSION

In patients with AC, PC is safe, with high technical success and low complication rate. Subsequent cholecystectomy should be performed, but is usually challenging. The requirement for PC may predict a more complex disease process.

Safety of Percutaneous Cholecystostomy Early Removal: A Retrospective Cohort Study

INTRODUCTION

There are no strong recommendations regarding the management of percutaneous cholecystostomy (PC). The aim of this study was to assess the safety of early PC removal in terms of complications and recurrent disease.

MATERIALS AND METHODS

Retrospective observational study of consecutive patients who underwent PC for acute cholecystitis from January 2012 to December 2017. We first evaluated PC-related complications and recurrent disease in patients whose drainage was removed as inpatients (IPR) or as outpatients (OPR). Patients were then divided into 2 groups according to the timing of PC removal: G1 with the PC removed within the first 7 days after its collocation and G2 with the PC removed after 7 days.

RESULTS

We included 151 patients. Patients in the OPR group had their catheters removed after 52 days (26 to 67 d) while the IPR group after 8 days (6 to 11 d); P<0.001. No difference was seen regarding complications, recurrent disease rate, or readmissions.G1 was comprised of 56 patients (37.1%), whereas G2 had 95 (62.9%). When G1 was compared with G2, no differences were seen in terms of complications. However, G1 presented a shorter duration of antibiotic treatment with 11 days (8 to 14 d) versus 15 days (12 to 23 d) in G2; P<0.001, but had a higher rate of recurrent disease 32.1% versus 14.7% in G2; P=0.014 and a higher rate of readmission 30.3% versus 13.6% in G2; P=0.019.

CONCLUSIONS

Removal of the PC during the index admission was not associated with a higher risk of complications. However, the PC removal before 7 days could be related to an increase in recurrent disease and readmissions.

Conservative Management of Gallstone Disease in the Elderly Population: Outcomes and Recurrence

BACKGROUND & AIMS

The prevalence of gallstone disease increases with age, being early cholecystectomy the most accepted treatment in the vast majority of patients in order to prevent complications and recurrence. The aim of this study is to determine the recurrence rate and its possible predictors after initial non-operative management.

MATERIALS AND METHODS

We reviewed a consecutive series of patients, older than 65 years, admitted for a gallstone-related disease and treated with a non-operative management between January 2010 and December 2013. We analyzed comorbidities, clinical data, diagnosis, management, recurrence, and its treatment. Median follow-up after the discharge was 2 years. Recurrence was analyzed by a Kaplan-Meier survival curve. Possible recurrence's predictors were analyzed.

RESULTS

The study included 226 patients. Mean age was 80.4 ± 7.2 years, 127 (56%) were female. The main causes of index hospitalization were acute cholecystitis (58%) and biliary pancreatitis (18.1%). After 2 years of follow-up, the recurrence rate was 39.8%; mean time to recurrence was 255.2 ± 42.1 days, 81% of patients recurred within 1 year. Bile duct disease implied a higher recurrence rate than the gallbladder disease group (52% vs 33%, p < 0.001). Subjects with two or more diagnoses during index admission presented higher recurrence rate (32% vs 49%, p < 0.001).

CONCLUSION

More than a third of elderly patients could present a recurrence within 2 years after initial non-operative management. Early cholecystectomy should be considered at index admission in order to prevent recurrence.

Clinical and operative outcomes of patients with acute cholecystitis who are treated initially with image-guided cholecystostomy

BACKGROUND

Percutaneous cholecystostomy (PC) tube placement followed by delayed cholecystectomy has been shown to be an effective treatment option in high-risk populations such as older and critically ill patients. The goal of this study was to review the short- and long-term clinical and operative outcomes of patients with acute cholecystitis initially treated with PC tube placement.

METHODS

We conducted a retrospective review of patients who underwent image-guided PC tube insertion between 2001 and 2011 at the Royal University Hospital or St. Paul's Hospital, Saskatoon. Clinical outcomes, complications and elective cholecystectomy follow-up were noted.

RESULTS

A total of 140 patients underwent PC tube insertion, 76 men and 64 women with a mean age of 68.4 (standard deviation 17.7) years. Of the 140, 94 (67.1%) had an American Society of Anesthesiologists classification score of III or IV. Percutaneous cholecystostomy tubes remained in place for a median of 21.0 days, and the median hospital stay was 7.0 days. Readmission owing to complications from PC tubes occurred in 21 patients (15.0%), and 10 (7.1%) were readmitted with recurrent cholecystitis after tube removal. Forty-four patients (31.4%) returned for subsequent elective cholecystectomy, of whom 32 (73%) underwent laparoscopic cholecystectomy, 4 (9%) underwent open cholecystectomy, and 8 (18%) underwent laparoscopic converted to open cholecystectomy.

CONCLUSION

Percutaneous cholecystostomy is a safe procedure that can be performed in patients who are older or have numerous comorbidities. However, less than one-third of such patients in our cohort subsequently had the definitive intervention of elective cholecystectomy, with a high rate of conversion from laparoscopic to open cholecystectomy.

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.

The Treatment of Critically Ill Patients With Acute Cholecystitis

BACKGROUND

Besides cholecystectomy (CC), percutaneous cholecystostomy (PC) has been recommended for the management of critically ill patients with acute cholecystitis. However, solid evidence on the benefit of PC in this subgroup of patients is lacking.

METHODS

In accordance with the PRISMA guidelines for systematic reviews, we systematically searched the Cochrane Library, CINAHL, MEDLINE, Embase, and Scopus for relevant studies published between 2000 and 2014. Two investigators independently screened the studies included.

RESULTS

Six studies with a total of 337 500 patients (PC 10 045, CC 327 455) were included for meta-analysis. Significant differences in favor of CC were recorded with regard to the rate of mortality (OR 4.28, [1.72 to 10.62], p = 0.0017), length of hospital stay (OR 1.41, [1.02 to 1.95], p = 0.04), and the rate of readmission for biliary complaints (OR 2.16, [1.72 to 2.73], p<0.0001). There was no statistically significant difference between both intervention arms with regard to complications (OR 0.74, [0.36 to 1.53], p = 0.42) and re-interventions (OR 7.69, [0.68 to 87.33], p = 0.10).

CONCLUSION

The benefit of percutaneous cholecystostomy (PC) over cholecystectomy (CC) in the management of critically ill patients with acute cholecystitis could not be proven in this systematic review.

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.

Impact of comorbidities on the postoperative outcomes of acute cholecystitis following early cholecystectomy

PURPOSES

The purpose of this study was to evaluate the influence of comorbidities on the surgical outcomes of early cholecystectomy for acute cholecystitis.

METHODS

Data were retrospectively collected for patients with acute cholecystitis who underwent early cholecystectomy. Patients were separated into three groups based on the cholecystitis severity grade, and the surgical outcomes of early cholecystectomy were analyzed. Patients with mild and moderate cholecystitis were subdivided into a comorbidity group (n = 10) and a non-comorbidity group (n = 83).

RESULTS

There were 57 (55.3%) patients with mild cholecystitis, 36 (35.0%) with moderate cholecystitis, and 10 (9.7%) with severe cholecystitis. The surgical outcomes were significantly worse for patients with severe cholecystitis than for patients with mild or moderate cholecystitis. There were no postoperative deaths after cholecystectomy. There were no significant differences in the complication rate (P = 0.629), conversion rate (P = 0.114), or intraoperative blood loss (P = 0.147) between the comorbidity and non-comorbidity groups.

CONCLUSION

Our findings suggest that early cholecystectomy can be performed safely for patients with mild and moderate cholecystitis even if comorbidities are present. Early cholecystectomy may be an alternative treatment strategy for patients with severe cholecystitis who are candidates for anesthesia and surgery.

Conservative treatment of acute cholecystitis: a systematic review and pooled analysis

BACKGROUND

In medical practice, the tendency to remove an inflamed gallbladder is deeply rooted. Cholecystectomy, however, is associated with relatively high complication rates, and therefore the decision whether or not to perform surgery should be well considered. For some patients, the surgical risk-benefit profile may favour conservative treatment. The objective of this study was to examine the short- and long-term outcome of conservative treatment of patients with acute calculous cholecystitis.

METHODS

A systematic search of MEDLINE, Embase and Cochrane Library databases was performed. Prospective studies reporting on the success rate of conservative treatment (i.e. non-invasive treatment) of acute cholecystitis during index admission were included, as well as prospective and retrospective studies reporting on the recurrence rate of gallstone-related disease during long-term follow-up (i.e. ≥12 months) after initial non-surgical management. Study selection was undertaken independently by two reviewers using predefined criteria. The risk of bias was assessed. The pooled success and mortality rate during index admission and the pooled recurrence rate of gallstone-related disease during long-term follow-up were calculated using a random-effects model.

RESULTS

A total of 1841 patients were included in 10 randomized controlled trials and 14 non-randomized studies. Conservative treatment during index admission was successful in 87 % of patients with acute calculous cholecystitis and in 96 % of patients with mild disease. In the long term, 22 % of the patients developed recurrent gallstone-related disease. Pooled analysis showed a success rate of 86 % (95 % CI 0.8-0.9), a mortality rate of 0.5 % (95 % CI 0.001-0.009) and a recurrence rate of 20 % (95 % CI 0.1-0.3).

DISCUSSION

Conservative treatment of acute calculous cholecystitis during index admission seems feasible and safe, especially in patients with mild disease. During long-term follow-up, less than a quarter of the patients appear to develop recurrent gallstone-related disease, although this outcome is based on limited data.

Evaluation of Early Cholecystectomy versus Delayed Cholecystectomy in the Treatment of Acute Cholecystitis

Objective. To evaluate if early cholecystectomy (EC) is the most appropriate treatment for acute cholecystitis compared to delayed cholecystectomy (DC). Patients and Methods. A retrospective cohort study of 1043 patients was carried out, with a group of 531 EC cases and a group of 512 DC patients. The following parameters were recorded: (1) postoperative hospital morbidity, (2) hospital mortality, (3) days of hospital stay, (4) readmissions, (5) admission to the Intensive Care Unit (ICU), (6) type of surgery, (7) operating time, and (8) reoperations. In addition, we estimated the direct cost savings of implementing an EC program. Results. The overall morbidity of the EC group (29.9%) was significantly lower than the DC group (38.7%). EC demonstrated significantly better results than DC in days of hospital stay (8.9 versus 15.8 days), readmission percentage (6.8% versus 21.9%), and percentage of ICU admission (2.3% versus 7.8%), which can result in reducing the direct costs. The patients who benefited most from an EC were those with a Charlson index > 3. Conclusions. EC is safe in patients with acute cholecystitis and could lead to a reduction in the direct costs of treatment.

2016 WSES guidelines on acute calculous cholecystitis

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Outcomes of percutaneous cholecystostomy and predictors of eventual cholecystectomy

BACKGROUND

Percutaneous cholecystostomy (PC) is an established treatment for high surgical risk patients with acute cholecystitis. This paper studies factors predictive of mortality and eventual cholecystectomy.

METHODS

A retrospective review of all patients who underwent PC from March 2005 to March 2015 was performed. Patient demographics, clinical features, comorbidity profile, grade of cholecystitis, interval between cholecystitis diagnosis and PC, and method of PC were studied. Length of stay, complications, readmission rate, mortality and eventual cholecystectomy were studied. For patients with eventual cholecystectomy, operative data and perioperative outcomes were studied.

RESULTS

One hundred and three patients with median age of 80 years (range 43-105) underwent PC. Median interval to PC was 2 days (range 0-15). 9.7% of patients had complications. Median length of stay was 19 days (range 3-206). 41% underwent eventual cholecystectomy. 30-day mortality rate was 10.7%. Higher APACHE II scores (P = 0.004), higher Charlson comorbidity index (CCI) (P = 0.009), and longer interval from diagnosis to PC (P = 0.037) were associated with in-hospital mortality. Younger age (P = 0.015), lower APACHE II scores (P = 0.043) and lower CCI (P = 0.002) were associated with eventual cholecystectomy.

CONCLUSION

Percutaneous cholecystostomy is safe and effective in treatment of acute cholecystitis. Prompt PC improves survival in high risk surgical patients. Comorbidity severity is associated with mortality. Patients with lesser comorbidity are likely to receive eventual cholecystectomy.

Efficacy and safety of B-mode ultrasound-guided percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy for acute cholecystitis in elderly and high-risk patients

Background

Standards in treatment of acute cholecystitis (AC) in the elderly and high-risk patients has not been established. Our study evaluated the efficacy and safety of B-mode ultrasound-guided percutaneous transhepatic gallbladder drainage (PTGD) in combination with laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) in elderly and high-risk patients.

Methods

Our study enrolled 35 elderly and high-risk AC patients, hospitalized between January 2010 and April 2014 at the Wenzhou People's Hospital. The patients underwent B-mode ultrasound-guided PTGD and LC (PTGD + LC group). As controls, a separate group of 35 elderly and high-risk AC patients who underwent LC alone (LC group) during the same period at the same hospital were randomly selected from a pool of 186 such cases. The volume of bleeding, surgery time, postoperative length of stay, conversion rate to laparotomy and complication rates (bile leakage, bleeding, incisional hernia, incision infection, pulmonary infarction and respiratory failure) were recorded for each patient in the two groups.

Results

All patients in the PTGD + LC group successfully underwent PTGD. In the PTGD + LC group, abdominal pain in patients was relieved and leukocyte count, alkaline phosphatase level, total bilirubin and carbohydrate antigen 19-9 (CA19-9) decreased to normal range, and alanine aminotransferase and aspartate aminotransferase levels improved significantly within 72 h after treatment. All patients in the PTGD + LC group underwent LC within 6–10 weeks after PTGD. Our study revealed that PTGD + LC showed a significantly higher efficacy and safety compared to LC alone in AC treatment, as measured by the following parameters: duration of operation, postoperative length of hospital stay, volume of bleeding, conversion rate to laparotomy and complication rate (operation time of LC: 55.6 ± 23.3 min vs. 91.35 ± 25.1 min; hospitalized period after LC: 3.0 ± 1.3 d vs. 7.0 ± 1.7 d; intraoperative bleeding: 28.7 ± 15.2 ml vs. 60.38 ± 16.4 ml; conversion to laparotomy: 3 cases vs. 10 cases; complication: 3 cases vs. 8 cases; all P < 0.05 ).

Conclusion

Our results suggest that B-mode ultrasound-guided PTGD in combination with LC is superior to LC alone for treatment of AC in elderly and high-risk patients, showing multiple advantages of minimal wounding, accelerated recovery, higher safety and efficacy, and fewer complications.

Early Percutaneous Cholecystostomy in Severe Acute Cholecystitis Reduces the Complication Rate and Duration of Hospital Stay

The optimal timing of percutaneous cholecystostomy for severe acute cholecystitis is unclear. The aim of this study was to investigate the timing of percutaneous cholecystostomy and its relationship to clinical outcomes in patients with inoperable acute severe cholecystitis.From 2008 to 2010, 209 consecutive patients who were admitted to our hospital due to acute cholecystitis and were treated by percutaneous cholecystostomy were retrospectively reviewed. The time periods from symptom onset to when percutaneous cholecystostomy was performed and when patients were discharged were recorded.In the 209 patients, the median time period between symptom onset and percutaneous cholecystostomy was 23 hours (range, 3-95 hours). The early intervention group (≤24 hours, n = 109) had a significantly lower procedure-related bleeding rate (0.0% vs 5.0%, P = 0.018) and shorter hospital stay (15.8 ± 12.9 vs 21.0 ± 17.5 days) as compared with the late intervention group (>24 hours, n = 100). Delayed percutaneous cholecystostomy was a significant independent factor for a longer hospital stay (odds ratio 3.03, P = 0.001).In inoperable patients with acute severe cholecystitis, early percutaneous cholecystostomy reduced hospital stay and procedure-related bleeding without increasing the mortality rate.

Perioperative outcomes of delayed laparoscopic cholecystectomy for acute calculous cholecystitis with and without percutaneous cholecystostomy

INTRODUCTION

The role of percutaneous cholecystostomy (PC) in the management of patients with acute calculous cholecystitis (ACC) remains controversial. The aim of this study is to report operative outcomes in a large cohort of patients undergoing PC before their delayed laparoscopic cholecystectomy (DLC).

METHODS

All patients who underwent DLC because of ACC between 2003 and 2012 were included. Outcomes of patients with and without previous PC were compared.

RESULTS

Of 639 patients who underwent DLC because of ACC at our institution during a 10-year time interval beginning 2003, 163 (25.5%) patients had PC before their DLC. Patients who underwent PC were older (64 ± 1 years vs 48 ± 0.8 years, P < .001) and had more comorbid conditions (P < .001). Accumulated duration of stay was longer in the PC group (16.2 ± 0.4 days vs 9.7 ± 0.1 days, P < .001). Rate of conversion to open procedure was greater in the PC group (11% vs 4%, P = .001) and operative time was longer (142 ± 4 minutes vs 107 ± 4 minutes, P < .001). Patients in the PC group had a greater rate of biliary-related complications (10% vs 4%, P = .003) and surgical-site infections; both superficial (5% vs 1%, P = .004) and deep (7% vs 3%, P = .04). On multivariable analysis PC was an independent risk factor for conversion to open cholecystectomy (odds ratio 2.67 95% CI 1.18-6.72) as well as to biliary-related complications (odds ratio 4.85 95% CI 1.57-14.92).

CONCLUSION

DLC for ACC in patients with previous PC is associated with longer duration of stay, more readmissions, and, most importantly, greater conversion rate, biliary related complications, and surgical-site infections.

Surgical management of acute cholecystitis

BACKGROUND

Acute cholecystitis occurs in approximately 1% of patients with known gallstones. It presents as a surgical emergency and usually requires hospitalisation for treatment. It is associated with significant morbidity and mortality, particularly in the elderly. Cholecystectomy is advocated for acute cholecystitis; however, the timing of cholecystectomy and the value of the additional treatments have been a matter of debate. This review examines the available evidence regarding the optimal surgical management of patients with acute cholecystitis.

METHODS

A literature search was performed on the MEDLINE, EMBASE and WHO International Clinical Trials Registry Platform, databases for English language publications. The MeSH headings 'cholecystitis', 'acute', 'gallbladder', 'inflammation', 'surgery', 'cholecystectomy', 'laparoscopic', 'robotic', 'telerobotic' and 'computer-assisted' were used.

RESULTS

Data from eight randomised controlled trails and three population-based analyses show that early cholecystectomy for acute cholecystitis performed on the index admission is safe and not associated with increased conversion rates or morbidity in comparison to conservative treatment followed by elective cholecystectomy. Delaying cholecystectomy increases readmissions for gallstone-related events, complications, hospital stay and mortality in the elderly. Early cholecystectomy is also more cost-effective. Randomised trials addressing antibiotic use in acute cholecystitis suggest that antibiotics should be stopped on the day of cholecystectomy. Insufficient trials have been performed to address the optimal analgesia regime post cholecystectomy. Similarly, a lack of trials on intraoperative cholangiography and management of common bile duct stones in patients with acute cholecystitis means that treatment of concomitant bile duct stones should be based on institutional expertise and resource availability. As regards acute cholecystitis in elderly and high-risk patients, case series and retrospective studies would suggest that cholecystectomy is more effective and of lower mortality than percutaneous cholecystostomy. There is not enough evidence to support the routine use of robotic surgery, single-incision laparoscopic cholecystectomy or natural orifice transluminal endoscopic surgery (NOTES) in the treatment of acute cholecystitis.

CONCLUSIONS

Trial evidence would favour a policy of early laparoscopic cholecystectomy following admission with acute cholecystitis. The optimal approach to support early cholecystectomy is suggested but requires evidence from further randomised trials.

TG13 indications and techniques for gallbladder drainage in acute cholecystitis (with videos)

Percutaneous transhepatic gallbladder drainage (PTGBD) is considered a safe alternative to early cholecystectomy, especially in surgically high-risk patients with acute cholecystitis. Although randomized prospective controlled trials are lacking, data from most retrospective studies demonstrate that PTGBD is the most common gallbladder drainage method. There are several alternatives to PTGBD. Percutaneous transhepatic gallbladder aspiration is a simple alternative drainage method with fewer complications; however, its clinical usefulness has been shown only by case-series studies. Endoscopic naso-gallbladder drainage and gallbladder stenting via a transpapillary endoscopic approach are also alternative methods in acute cholecystitis, but both of them have technical difficulties resulting in lower success rates than that of PTGBD. Recently, endoscopic ultrasonography-guided transmural gallbladder drainage has been reported as a special technique for gallbladder drainage. However, it is not yet an established technique. Therefore, it should be performed in high-volume institutes by skilled endoscopists. Further prospective evaluations of the feasibility, safety, and efficacy of these various approaches are needed. This article describes indications and techniques of drainage for acute cholecystitis.Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

Surgery for acute gallbladder disease in Sweden 1989-2006--a register study

OBJECTIVE

Since early 1970s, prospective randomized controlled trials have emphasized the advantages of early cholecystectomy in patients with acute cholecystitis, compared to elective delayed cholecystectomy. The aim of this investigation was to study surgery for acute gallbladder disease in Sweden during a 15-year period when open cholecystectomy was replaced by a laparoscopic procedure.

MATERIAL AND METHODS

Data from the Swedish National Patient Register and the Cause of Death Register 1988-2006 comprising hospital stays with a primary diagnosis of gallbladder/gallstone disease in Sweden were retrieved. Patients were analyzed with reference to timing of cholecystectomy, length of hospital stay, and mortality.

RESULTS

Emergency cholecystectomy at index (first) admission or at readmission within 2 years of index admission was performed in 32.2% and 6.1% of patients, respectively. Elective cholecystectomy within 2 years of index admission was performed in 20.3% patients, whereas 41.3% of all patients did not undergo cholecystectomy within 2 years. Standardized mortality ratio did not significantly change during the audit period. Total hospital stay (days at index stay and subsequent stay(s) for biliary diagnoses within 2 years) was shorter for patients who had emergency cholecystectomy at first admission compared to patients with later or no cholecystectomy within 2 years.

CONCLUSIONS

Around 30% of patients with acute gallbladder disease were operated with cholecystectomy during the first admission with no time trend from 1990 through 2004. A total of 40% of patients with acute gallbladder disease were not cholecystectomized within 2 years. Analysis of outcome of long-term conservative treatment is warranted.

2013 WSES guidelines for management of intra-abdominal infections

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.

ABC's of writing medical papers in English

Publishing medical papers in English is important as English remains the predominant language for most medical papers (both electronic and traditional journal publications). In addition, journals with the highest impact factors are published in English and a publication in English thus enhances the visibility of authors and their institutions, and is important for promotion in some academic centers. This article reviews the basic principles that will help you successfully publish a manuscript in English. Although other books and articles are available on this subject, there are relatively few references. The present article is based on this author's experience of publishing nearly 400 articles in English. It will emphasize writing original articles, but the principles can be applied to virtually any type of manuscript.