Long-term outcome and recurrence factors after percutaneous cholecystostomy as a definitive treatment for acute cholecystitis

Management of high-surgical-risk patients with acute cholecystitis following percutaneous cholecystostomy: results of an international Delphi consensus study

BACKGROUND

The management of high-surgical-risk patients with moderate to severe acute cholecystitis is challenging in clinical practice. Early laparoscopic cholecystectomy is considered the gold standard for patients who do not respond to conservative treatment. However, for those unfit for surgery due to high risk, alternative treatment options, such as percutaneous cholecystostomy (PC), are available. There are no clear guidelines regarding the management of patients following PC. The primary aim of this study was to propose indications for PC in high-surgical-risk patients with acute cholecystitis and to establish management strategies for gallbladder drainage, either as a bridge to surgery or as a definitive treatment, according to available literature.

MATERIALS AND METHODS

After a targeted literature review, International and Italian experts in the field from the Italian Society of Research in Surgery (SIRC) and the Italian Society of Emergency Surgery and Trauma (SICUT) were consulted to provide their evidence-based opinions on the topic. Statements were proposed during subsequent rounds using the Delphi methodology. Ten statements were provided, and the final agreement is presented in this study.

RESULTS

Patients with moderate acute cholecystitis, a Charlson Comorbidity Index (CCI) ≥ 6, and American Society of Anesthesiologists-Performance Status (ASA-PS) ≥ 3 who fail conservative treatment should undergo laparoscopic cholecystectomy as the first-line approach. For those with severe acute cholecystitis at high-surgical risk, percutaneous cholecystostomy is recommended to relieve symptoms within 24-48 hours. Once the infection is controlled, we should assess which patients may be candidates for interval laparoscopic cholecystectomy. For patients selected for surgery, laparoscopic cholecystectomy is recommended at least six weeks after PC placement. In patients not suitable for surgery, such as those with CCI ≥ 6 and ASA-PS ≥ 4, percutaneous cholecystostomy should remain in place for at least three weeks, after which, following radiographic confirmation of biliary tree patency, the tube may be removed.

CONCLUSIONS

This consensus, developed through a multidisciplinary collaboration of interventional radiologists, gastroenterologists, and surgeons, provides a clear and practical guide for managing high-risk surgical patients with acute cholecystitis.

Optimal Timing of Percutaneous Cholecystostomy across Different Grades of Acute Cholecystitis: A Retrospective Cohort Study

PURPOSE

To investigate the effect of percutaneous cholecystostomy (PC) tube placement timing on clinical outcomes in patients with Grade I-III acute cholecystitis (AC) who did not undergo surgery.

MATERIALS AND METHODS

This retrospective single-center cohort study included patients with AC who initially underwent PC between October 2018 and December 2022. The following outcomes were analyzed: (a) rate of all-cause in-hospital mortality (IHM), (b) length of hospital stay (LOS), (c) duration of intensive care unit stay, and (d) rate of recurrence, which were correlated with clinical and procedural characteristics, disease severity, and PC timing. Subgroup analysis was then performed to investigate the effects of drainage timing across different severity grades.

RESULTS

This study included 183 patients. Severity grade, drainage timing, age, and Charlson Comorbidity Index score significantly influenced LOS (P < .001, P = .002, P = .001, and P = .010, respectively). In the subgroup analysis, PC performed within 24 hours in patients with Grade II AC significantly shortened LOS (median, 7.0 vs 10.0 days; P = .028). In patients with Grade III AC, PC performed after 6 hours significantly extended LOS (median, 19.0 vs 9.0 days; P = .010). Multivariate analysis indicated that IHM was associated with severity grade and age (P = .009 and P = .008, respectively) but not drainage timing.

CONCLUSIONS

Urgent drainage may be unnecessary for patients with Grade I or II AC. However, a reduction in LOS was observed for patients with Grade III AC who underwent PC within 6 hours and those with Grade II AC who underwent PC within 24 hours after admission.

Relapse in gallstone disease after non-operative management of acute cholecystitis: a population-based study

OBJECTIVE

Non-operative management (NOM) of acute cholecystitis (ACC) may be preferable in patients with advanced inflammation, long duration of symptoms or severe comorbidities. This study aims to investigate time to recurrence and patient factors predicting relapse in gallstone complications after NOM.

METHODS

Records of 1634 patients treated for ACC at three Swedish centres between 2017 and 2020 were analysed, with 909 managed non-operatively. Data were linked to the National Gallstone Surgery registry for those who later underwent surgery. The time to relapse of gallstone complications was calculated and Cox proportional hazards regression was used to analyse new gallstone complications and adjust for multiple variables.

RESULTS

Of the 909 non-operatively managed patients, 348 patients suffered a new gallstone complication. The median time to recurrence was 82 days. Of those who recurred, 27% did so within 30 days, 17% between 31 and 60 days, 27% between 61 days and 6 months, 16% between 6 months and 1 year and 13% later than 1 year. Younger patients with their first gallstone complication had a lower risk of new complications compared with those with previous gallstone complications. In older individuals, there was no difference in the risk of relapse regardless of previous gallstone complications, but they were more likely to be readmitted than younger patients.

CONCLUSION

Delayed cholecystectomy should be prioritised for younger patients with a history of gallstone disease if early cholecystectomy is not feasible. Delayed cholecystectomy should be scheduled without a prior outpatient clinic visit to minimise delays.

Postinsertion Management of Cholecystostomy Tubes for Acute Cholecystitis: A Systematic Review

BACKGROUND

Percutaneous gallbladder drainage (PGD) is indicated to treat high-risk patients with acute cholecystitis. Trends suggest increasing use of PGD over time as the population ages and lives longer with multiple comorbidities. There is no consensus on the management of cholecystostomies tube once inserted. This review aims to synthesize and describe the most common protocols in terms of the need and timing of follow-up imaging, management of a destination tube, timing of tube removal, and optimal interval time from tube positioning to delayed cholecystectomy.

METHODS

The study protocol has been registered on the International Prospective Register of Systematic Reviews-PROSPERO. Studies on adult patients diagnosed with acute cholecystitis who underwent a PGD from 2000 to November 2023 were included. The databases searched were MEDLINE, Embase, and Cochrane. The quality assessment tools provided by the NHLBI (National Heart, Lung, and Blood Institute) were applied and descriptive statistics were performed.

RESULTS

We included 22,349 patients from 94 studies with overall fair quality (6 prospective and 88 retrospective). In 92.7% of papers, the authors checked by imaging all patients with a PGD (41 studies included). Depending on protocol time, 30% of studies performed imaging within the first 2 weeks and 35% before tube removal (40 studies included). In the case of a destination tube, 56% of studies reported removing the tube (25 studies included). In the case of tube removal, the mean time after insertion was more than 4 weeks in 24 of the 33 included studies (73%). Interval cholecystectomies are more frequently performed after 5 weeks from PGD (32/38 included studies, 84%). Limitations included high clinical heterogeneity and prevalent retrospective studies.

CONCLUSIONS

A standard management for percutaneous cholecystostomy after insertion is difficult to define based on existing evidence, and currently we can only rely on the most common existing protocols.

The impact of routine cholangiography for asymptomatic patients after cholecystostomy insertion for acute cholecystitis

BACKGROUND

We aim to investigate the impact of routine cholangiography on asymptomatic patients with percutaneous cholecystostomy (PCC) for acute cholecystitis (AC).

METHODS

The study included all patients treated with PCC for AC from 2017 to 2020 ​at a single academic center. Patients who underwent routine cholangiography within 30 days post-discharge while asymptomatic were compared to patients who were only followed clinically.

RESULTS

The groups (cholangiography group, n ​= ​44, and control group, n ​= ​145) were similar in terms of age, comorbidities, and clinical presentation. The readmission rate for biliary disease in the cholangiography group was nearly half that of the control group (22.7 ​% vs. 40.7 ​%, p ​= ​0.05) over an average follow-up of 10.4 months. The time to drain removal, cholecystectomy rate, and time to operation were comparable between the groups (42 vs. 40 days, p ​= ​0.47, 52.3 ​% vs 53.1 ​%, p ​= ​NS and 69 vs. 82 days, p ​= ​0.17, respectively).

CONCLUSIONS

Routine cholangiography can help reduce biliary disease readmissions among asymptomatic patients with PCC for AC without delaying further treatment.

Low skeletal muscle mass and high visceral adiposity are associated with recurrence of acute cholecystitis after conservative management: A propensity score-matched cohort study

BACKGROUND

Recurrent acute cholecystitis (RAC) can occur after non-surgical treatment for acute cholecystitis (AC), and can be more severe in comparison to the first episode of AC. Low skeletal muscle mass or adiposity have various effects in several diseases. We aimed to clarify the relationship between RAC and body parameters.

METHODS

Patients with AC who were treated at our hospital between January 2011 and March 2022 were enrolled. The psoas muscle mass and adipose tissue area at the third lumbar level were measured using computed tomography at the first episode of AC. The areas were divided by height to obtain the psoas muscle mass index (PMI) and subcutaneous/visceral adipose tissue index (SATI/VATI). According to median VATI, SATI and PMI values by sex, patients were divided into the high and low PMI groups. We performed propensity score matching to eliminate the baseline differences between the high PMI and low PMI groups and analyzed the cumulative incidence and predictors of RAC.

RESULTS

The entire cohort was divided into the high PMI (n = 81) and low PMI (n = 80) groups. In the propensity score-matched cohort there were 57 patients in each group. In Kaplan-Meier analysis, the low PMI group and the high VATI group had a significantly higher cumulative incidence of RAC than their counterparts (log-rank P = 0.001 and 0.015, respectively). In a multivariate Cox regression analysis, the hazard ratios of low PMI and low VATI for RAC were 5.250 (95% confidence interval 1.083-25.450, P = 0.039) and 0.158 (95% confidence interval: 0.026-0.937, P = 0.042), respectively.

CONCLUSIONS

Low skeletal muscle mass and high visceral adiposity were independent risk factors for RAC.

What is the ideal timing of cholecystectomy after percutaneous cholecystostomy for acute cholecystitis?

BACKGROUND

Acute cholecystitis (AC) is one of the most prevalent diseases in clinical practice. Poor surgical candidates may benefit from early percutaneous cholecystostomy (PC) drainage followed by interval cholecystectomy (IC), which is the definitive treatment. The optimal timing between the PC drainage and the IC has not been identified. This study aimed to investigate how the duration between PC and IC affects perioperative outcomes and identify the optimal IC timing to minimize complications.

METHODS

This retrospective cohort study included all adult patients diagnosed with AC who underwent PC followed by IC at a single institution center between 2014 and 2022. Patients with a history of hepatobiliary surgery, stones in the common bile duct, cirrhosis, active malignancy, or prolonged immunosuppression were excluded. The analysis did not include cases with major concurrent procedures during cholecystectomy, previously aborted cholecystectomies, or failure of the PC drain to control the inflammation. Linear and logistic regression models were used to analyze the impact of the interval between PC and IC on intra- and perioperative outcomes.

RESULTS

One hundred thirty-two patients (62.1% male) with a mean age of 64.4 ± 15 (mean ± SD) years were diagnosed with AC (25% mild, 47.7% moderate, 27.3% severe). All patients underwent PC followed by IC after a median of 64 [48-91] days. Longer ICU stay was associated with longer time intervals between PC and IC (Coef 105.98, p < 0.001). No significant variations were detected in the intraoperative and perioperative outcomes between patients undergoing IC within versus after 8 weeks from PC placement. However, a higher percentage of patients with delayed IC (after 8 weeks) were discharged home (96.4% vs. 83.7%; p = 0.019).

CONCLUSIONS

Patients may benefit from undergoing IC after the 8-week cutoff after PC. However, very long periods between PC and IC procedures may increase the risk of longer ICU stay.

Percutaneous cholecystostomy as a definitive treatment for acute acalculous cholecystitis: clinical outcomes and risk factors for recurrent cholecystitis

OBJECTIVE

To investigate the outcomes of percutaneous cholecystostomy (PC) as a definitive treatment for acute acalculous cholecystitis (AAC) and to identify the risk factors for cholecystitis recurrence after catheter removal.

METHODS

Between January 2008 and December 2017, 124 patients who had undergone PC as definitive treatment for moderate or severe AAC. The initial clinical success, complications, and recurrent cholecystitis after PC removal were retrospectively assessed. Twenty-one relevant variables were analyzed to identify risk factors for recurrent cholecystitis.

RESULTS

Clinical effectiveness was achieved in 107 patients (86.3%) at 3 days and in all patients (100%) at 5 days after PC placement. Six Grade 2 adverse events occurred, including catheter dislodgement (n = 3) and clogging (n = 3), which required catheter exchange. The PC catheter was removed in 123 patients (99.2%), with a median indwelling duration of 18 days (range 5-116 days). During the follow-up period (median, 1624 days; range, 40-4945 days), five patients experienced recurrent cholecystitis (4.1%). The cumulative recurrence rates were 3.3%, 4.1%, and 4.1% at 6 months, 1 year, and 5 years, respectively. Multivariate analysis revealed that an age-adjusted Charlson comorbidity index (aCCI)≥7 positively correlated with recurrence (OR, 1.97; 95% confidence interval, 1.07-3.64; p = 0.029).

CONCLUSIONS

Definitive PC is a safe and effective treatment option for patients with AAC. The PC catheters can be safely removed in most patients. An aCCI≥7 was a risk factor for cholecystitis recurrence after catheter removal.

ADVANCES IN KNOWLEDGE

1. Percutaneous cholecystostomy (PC) is a safe and effective as a definitive treatment in patients with acute acalculous cholecystitis (AAC).2. PC can be safely removed after recover from AAC in the majority of patients (99.2%) with low rate of recurrence of cholecystitis (4.1%).3. Age-adjusted Charlson comorbidity index ≥7 was a risk factor for recurrence of cholecystitis after PC removal.

Factors affecting the recurrence of acute cholecystitis after treatment with percutaneous cholecystostomy

BACKGROUND

The aim of this study was to determine the recurrence rate of patients who did not have interval cholecystectomy after treatment with percutaneous cholecystostomy and to investigate the factors that may affect the recurrence.

METHODS

Patients who did not undergo interval cholecystectomy after percutaneous cholecystostomy treatment between 2015 and 2021 were retrospectively screened for recurrence.

RESULTS

36.3% of the patients had recurrence. Recurrence was found more frequently in patients with fever symptoms at the time of admission to the emergency department (p = 0.003). Recurrence was found to be more frequent in those who had a previous cholecystitis attack (p = 0.016). It was determined that patients with high lipase and procalcitonin levels had statistically more frequent attacks (p = 0.043, p = 0.003). It was observed that the duration of catheter insertion was longer in patients who had relapses (p = 0.019). The cut-off value for lipase was calculated as 15.5, and the cut-off value for procalcitonin as 0.955, in order to identify patients at high risk for recurrence. In the multivariate analysis for the development of recurrence, presence of fever, a history of previous cholecystitis attack, lipase value higher than 15.5 and procalcitonin value higher than 0.955 were found to be risk factors.

CONCLUSIONS

Percutaneous cholecystostomy is an effective treatment method in acute cholecystitis. Insertion of the catheter within the first 24 h may reduce the recurrence rate. Recurrence is more common in the first 3 months following removal of the cholecystostomy catheter. Having a previous history of cholecystitis attack, fever symptom at the time of admission, elevated lipase and procalcitonin are risk factors for recurrence.

Nationwide Outcomes following Percutaneous Cholecystostomy for Acute Calculous Cholecystitis and the Impact of Coronavirus Disease 2019: Results of the Multicentre Audit of Cholecystostomy and Further Interventions (MACAFI study)

PURPOSE

To assess the mortality, readmission rates, and practice variation of percutaneous cholecystostomy (PC) in patients with acute calculous cholecystitis in the United Kingdom (UK).

MATERIALS AND METHODS

A total of 1,186 consecutive patients (636 men [53.6%]; median age, 75 years; range, 24-102 years) who underwent PC for acute calculous cholecystitis between January 1, 2019, and December 31, 2020, were included from 36 UK hospitals. The exclusion criteria were diagnostic aspirations, absence of acute calculous cholecystitis, and age less than 16 years. The coronavirus disease 2019 (COVID-19) lockdown was declared on March 26, 2020, in the UK, which served to distinguish among groups.

RESULTS

Most patients (66.3%) underwent PC as definitive treatment, whereas 31.3% underwent PC as a bridge to surgery. The overall 30-day readmission rate was 42.2% (500/1,186), and the 30-day mortality was 9.1% (108/1,186). Centers performing fewer than 30 PCs per year had higher 90-day mortality than those performing more than 60 (19.3% vs 11.0%, respectively; P = .006). A greater proportion of patients presented with complicated acute calculous cholecystitis during the COVID-19 pandemic compared to prior (49.9% vs 40.9%, respectively; P = .007), resulting in more PCs (61.3 vs 37.9 per month, respectively; P < .001). More PCs were performed in tertiary hospitals than in district general hospitals (9 vs 3 per 100 beds, respectively; P < .001), with a greater proportion performed as a bridge to surgery (50.5% vs 22.8%, respectively; P < .001).

CONCLUSIONS

The practice of PC is highly variable throughout the UK. The readmission rates are high, and there is significant correlation between mortality and PC case volume.

Percutaneous Cystic Duct Interventions and Drain Internalization for Calculous Cholecystitis in Patients Ineligible for Surgery

PURPOSE

To evaluate the feasibility, effectiveness, and outcomes of percutaneous cholecystostomy drain internalization in patients with calculous cholecystitis who were not surgical candidates.

MATERIALS AND METHODS

Percutaneous cystic duct interventions were attempted in 17 patients (with the intent to place dual cholecystoduodenal stents) who were deemed unfit for surgery and had previously undergone percutaneous cholecystostomies for acute calculous cholecystitis. Baseline demographics, technical success, time from percutaneous cholecystostomy to internalization (dual cholecystoduodenal stent placement), stent patency duration, and adverse event rates were evaluated.

RESULTS

Fifteen (88%) of 17 procedures to cross the cystic duct were technically successful. Of these 17 patients, 13 (76%) underwent successful placement of dual cholecystoduodenal stents. Two of these 13 patients (who had successful dual cholecystoduodenal stent placement) needed repeat percutaneous cholecystostomy drains (1 patient had stent migration leading to recurrent cholecystitis, and the other had a perihepatic biloma). The 1-year patency rate was 77% (95% CI, 47%-100%).

CONCLUSIONS

Dual cholecystoduodenal stent placement in nonsurgical patients is a technically feasible treatment option with the goal to remove percutaneous cholecystostomy drains.

Management of Symptomatic Gallstone Disease during COVID-19 Lockdown in a High-Resource Setting: Is There a Need for Treatment Alterations?

Introduction

Cholecystectomy (CCE) is the treatment of choice of symptomatic gallstones. Due to the SARS-CoV-2 pandemic, operating room (OR) capacities have been reduced. The goal of this study was to evaluate the duration of symptoms of patients presenting with gallstone disease during a lockdown, the surgical management, and the severity grade of their disease.

Materials and Methods

A cohort study of 353 CCEs performed at a university hospital over two 10-week periods during 2 pandemic lockdowns in Germany compared to corresponding periods in 2018 and 2019.

Results

During the lockdowns, 101 CCEs were performed compared to 252 in the prior years. The number of elective CCEs was reduced to save OR capacities (p < 0.001), and the most common indication for CCE was acute cholecystitis. The median time to CCE after symptom onset was 3 days in both groups for acute cholecystitis. The severity of cholecystitis was comparable (p = 0.760). The time to CCE after choledocholithiasis was shorter during the lockdowns (median of 4 days vs. 9 days; p = 0.006).

Conclusions

The incidence and severity of acute cholecystitis during the lockdowns were comparable to the prior years. Acute care surgery was provided at the expense of elective procedures, and there was no need for treatment alterations.

Correlation of Inpatients Suffering from Acute Acalculous Cholecystitis during ICU Treatment with Acute Physiology and Chronic Health Evaluation II Score, Duration of Ventilator Use, and Time on Total Parenteral Nutrition

Objective

To explore the correlation of inpatients suffering from acute acalculous cholecystitis (AAC) during ICU treatment with Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, duration of ventilator use, and time on total parenteral nutrition (TPN).

Methods

From March 2016 to March 2022, the clinical data of 47 patients with AAC who received ICU treatment in our hospital were retrospectively reviewed, and these patients were included in the AAC group. Another 36 patients treated in the ICU in the same period with age and gender matching with those in the AAC group were selected as the non-AAC group. Patients' various clinical data were recorded to analyze the correlation of AAC with APACHE-II score, duration of ventilator use, and time on TPN.

Results

The shock time, duration of ventilator usage, and duration of sedative medicine use were all substantially longer in the AAC group than in the non-AAC group, according to the univariate analysis (P < 0.05); the amount of norepinephrine used, white blood cell count, C-reactive protein (CRP) amount, and APACHE-II score were significantly higher in the AAC group than in the non-AAC group (P < 0.05); between the two groups, the time on TPN and fasting time were different, but with no statistical significance (P > 0.05); after performing Spearman's correlation with the significantly between-group different indicators, the result showed that the amount of norepinephrine used, duration of ventilator use, white blood cell count, and CRP amount were significantly correlated with the occurrence of AAC, and the correlation was positive (P all <0.001).

Conclusion

The APACHE-II score and time on TPN are not significantly correlated with the occurrence of AAC; and the amount of norepinephrine used, duration of ventilator use, white blood cell count, and serum CRP are positively correlated with the occurrence of AAC. Measuring the variations in the levels of various markers can signal the onset of AAC or reflect the state and prognosis, suggesting a possible application in clinic-based targeted prevention and treatment of AAC.

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

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

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors influencing failure to undergo interval cholecystectomy after percutaneous cholecystostomy among patients with acute cholecystitis: a retrospective study

Background

Percutaneous cholecystostomy (PC) with interval cholecystectomy is an effective treatment modality in high-risk patients with acute cholecystitis. However, some patients still fail to undergo interval cholecystectomy after PC, with the reasons rarely reported. Hence, this study aimed to explore the factors that prevent a patient from undergoing interval cholecystectomy.

Methods

Data from patients with acute cholecystitis who had undergone PC from January 1, 2017 to December 31, 2019 in our hospital were retrospectively collected. The follow-up endpoint was the patient undergoing cholecystectomy. Patients who failed to undergo cholecystectomy were followed up every three months until death. Univariate and multivariate analyses were performed to analyze the factors influencing failure to undergo interval cholecystectomy. A nomogram was used to predict the numerical probability of non-interval cholecystectomy.

Results

Overall, 205 participants were identified, and 67 (32.7%) did not undergo cholecystectomy during the follow-up period. Multivariate analysis revealed that having a Tokyo Guidelines 2018 (TG18) grade III status (odds ratio [OR]: 3.83; 95% confidence interval [CI]: 1.27–11.49; p = 0.017), acalculous cholecystitis (OR: 4.55; 95% CI: 1.59–12.50; p = 0.005), an albumin level < 28 g/L (OR: 4.15; 95% CI: 1.09–15.81; p = 0.037), and a history of malignancy (OR: 4.65; 95% CI: 1.62–13.37; p = 0.004) were independent risk factors for a patient’s failure to undergo interval cholecystectomy. Among them, the presence of a history of malignancy exhibited the highest influence in the nomogram for predicting non-interval cholecystectomy.

Conclusions

Having a TG18 grade III status, acalculous cholecystitis, severe hypoproteinemia, and a history of malignancy influence the failure to undergo cholecystectomy after PC in patients with acute cholecystitis.

Image-guided percutaneous cholecystostomy: a comprehensive review

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

Percutaneous cholecystostomy versus emergency cholecystectomy for the treatment of acute calculous cholecystitis in high-risk surgical patients: a meta-analysis and systematic review

The present meta-analysis was performed to compare the efficacy and safety of percutaneous cholecystostomy (PC) versus emergency cholecystectomy (EC) for the treatment of acute calculous cholecystitis (ACC) in high-risk surgical patients. Literature searches for eligible studies were performed using MEDLINE, EMBASE and the Cochrane Library. Quality assessment was conducted in each study. Meta-analyses were performed to demonstrate the pooled effects of relative risk (RR) with 95% confidence intervals (CI). A total of 8960 patients from 6 studies were finally included. PC resulted in increased risks of mortality (RR = 2.87; CI = 1.33-6.18; p = 0.007) and readmission rate (RR = 4.70; CI = 3.30-6.70; p < 0.00001) as compared with EC. No significant difference was detected between PC and EC in terms of morbidity, severe complication rate or hospitalization length. Moreover, PC was associated with significantly higher risks of mortality (RR = 7.47; CI = 1.88-29.72; p = 0.004), morbidity (RR = 3.71; 95% CI = 1.78-7.75; p = 0.0005), readmission rate (RR = 7.91; CI = 3.80-16.49; p < 0.00001), and hospitalization length (WMD = 6.92; CI = 5.89-7.95; p < 0.00001) when directly compared with laparoscopic cholecystectomy (LC). Therefore, EC is superior to PC for the treatment of ACC in high-risk surgical patients, and LC is the preferred surgical strategy.

Management of Patients With Acute Cholecystitis After Percutaneous Cholecystostomy: From the Acute Stage to Definitive Surgical Treatment

Percutaneous cholecystostomy (PC) has become an important procedure for the treatment of acute cholecystitis (AC). PC is currently applied for patients who cannot undergo immediate laparoscopic cholecystectomy. However, the management following PC has not been well-reviewed. The efficacy of PC tubes has already been indicated, and compared to complications of other invasive biliary procedures, complications related to PC are rare. Following the resolution of AC, patients who can tolerate anesthesia and the surgical risk should undergo interval cholecystectomy to reduce the recurrence of biliary events. For patients unfit for surgery, whether owing to comorbidities, anesthesia risks, or surgical risks, expectant management may be applied; however, a high incidence of recurrence has been noted. In addition, several interesting issues, such as the indications for cholangiography via the PC tube, removal or maintenance of the PC catheter before definitive treatment, and timing of elective surgery, are all discussed in this review, and a relevant decision-making flowchart is proposed. PC is an effective and safe intervention, whether as expectant treatment or bridge therapy to definitive surgery. High-level evidence of post-PC care is still necessary to modify current practices.

The Need for Accurate Risk Assessment in a High-Risk Patient Population: A NSQIP Study Evaluating Outcomes of Cholecystectomy in the Patient With Cancer

BACKGROUND

Cholecystectomy is considered a low-risk procedure with proven safety in many high-risk patient populations. However, the risk of cholecystectomy in patients with active cancer has not been established.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried to identify all patients with disseminated cancer who underwent cholecystectomy from 2005 to 2016. Postcholecystectomy outcomes were defined for patients with cancer and those without by comparing several outcomes measures. A multivariate model was used to estimate the odds of 30-d mortality.

RESULTS

We compared outcomes in 3097 patients with disseminated cancer to a matched cohort of patients without cancer. Patients with cancer had more comorbidities at baseline: dyspnea (10.5% versus 7.0%, P < 0.0001), steroid use (10.1% versus 3.0%, P < 0.0001), and loss of >10% body weight in 6-mo prior (9.3% versus 1.6%, P < 0.0001). Patients with cancer sustained higher rates of wound (2.3% versus 5.6%, P < 0.0001), respiratory (1.4% versus 3.9%, P < 0.0001), and cardiovascular (2.0% versus 6.8%, P < 0.0001) complications. In addition, patients with disseminated cancer experienced a longer length of stay and higher 30-d mortality. Multivariate modeling showed that the odds of 30-d mortality was 3.3 times greater in patients with cancer.

CONCLUSIONS

Compared to patients without cancer, those with disseminated cancer are at higher risk of complication and mortality following cholecystectomy. Traditional treatment algorithms should be used with caution and care decisions individualized based on the patient's disease status and treatment goals.