Optimal timing of cholecystectomy after percutaneous gallbladder drainage for severe cholecystitis

Early Laparoscopic Cholecystectomy Versus Percutaneous Cholecystostomy Followed by Delayed Laparoscopic Cholecystectomy in Patients with Grade II Acute Cholecystitis According to Tokyo Guidelines TG18

Introduction: In the past, most patients with acute cholecystitis (AC) were treated conservatively. However, strong evidence from various studies has shown that laparoscopic cholecystectomy (LC) is safe and should be the primary treatment for AC. However, this may not be the case for all AC grades. This study aimed to compare two recommended approaches for grade II AC as outlined in the Tokyo guidelines TG18, focusing on early operative outcomes. Methods: We conducted a retrospective review of medical records for all patients diagnosed with grade II AC. The study compared patients who underwent early LC (group A, n = 130) with those who initially received percutaneous cholecystostomy (PC) followed by LC (group B, n = 90). Results: Both groups had similar Tokyo classification parameters. However, there were significant differences in baseline data, operative challenges, and postoperative complications. Cholecystostomy-related complications were observed in seven patients. The conversion rate for was 25% for group A and 5% for group B. The incidence of intraoperative biliary injury was 10% for group A and 2.2% for group B. In group A, 92% of patients with biliary injury and 80% of those who required conversion to open surgery had evidence of localized inflammation around the gallbladder. Conclusion: For selected patients with grade II AC and higher risks, PC placement can be beneficial in preventing life-threatening consequences. The study suggests a 2-month interval between PC and subsequent LC. Overall, performing LC after PC was found to be easier than early LC. Local inflammatory changes, including empyema, were associated with higher complication rates in the early LC group.

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.

Time from drainage to surgery is an independent predictor of morbidity for moderate-to-severe acute cholecystitis: a multivarirble analysis of 259 patients

BACKGROUND

Acute cholecystitis (AC) is an acute inflammatory disease of the gallbladder and one of the most frequent causes of acute abdominal pain. Early cholecystectomy is recommended for mild cholecystitis. However, the optimal surgical timing for moderate-to-severe cholecystitis requiring percutaneous transhepatic gallbladder drainage (PTGBD) remains unclear. We hypothesized that early elective surgery after PTGBD would reduce surgical morbidity.

METHODS

A retrospective analysis was performed on adult patients who underwent elective surgery for AC after PTGBD at our hospital between January 2011 and December 2020. Patient demographics, perioperative findings, and postoperative morbidity and mortality rates were also investigated. The patients were divided into two groups based on postoperative morbidity, and univariable analysis was performed for preoperative factors. Multivariable logistic regression analysis was performed for the potential independent variables.

RESULTS

A total of 891 patients were screened for eligibility, and 259 were included in the analysis. Among these patients, 32 developed postoperative morbidity; however, there was no postoperative mortality. Multivariable analysis revealed that the time from PTGBD to surgery was an independent predictor of surgical morbidity (odds ratio, 1.05; 95% confidence interval: 1.01-1.10).

CONCLUSION

In early elective surgery for moderate-to-severe AC requiring PTGBD, a shorter interval from biliary drainage to surgery may decrease surgical morbidity.

Effect of surgical timing on postoperative outcomes in patients with acute cholecystitis after delayed percutaneous transhepatic gallbladder drainage

BACKGROUND

To date, the optimal timing for percutaneous transhepatic gallbladder drainage (PTGBD), particularly for patients who have missed the optimal window for emergency laparoscopic cholecystectomy (LC) (within 72 hours of symptom onset) has not been determined.

AIM

To study the effects of LC timing on outcomes of grade II/III acute cholecystitis (AC) in patients with delayed PTGBD.

METHODS

Data of patients diagnosed with Tokyo Guidelines 2018 grade II or III AC who underwent delayed PTGBD followed by LC at a single hospital between 2018 and 2022 were retrospectively studied. According to the interval between gallbladder drainage and cholecystectomy, the patients were divided into early and delayed LC groups. Outcomes including surgery time, postoperative complications and hospital stay, and patient satisfaction were analyzed and compared between the two groups using t- and χ 2 tests.

RESULTS

There were no significant differences between the two groups in intraoperative blood loss, postoperative abdominal drainage tube placement time, pain index, or total disease duration (all P > 0.05). Compared with those of the early LC group, the delayed group showed significant decreases in the length of procedure (surgery time), conversion rate to open surgery, degree of adhesions, surgical complications, postoperative hospital stay, and total treatment costs, and increased patient satisfaction despite a longer interval before PTGBD (all P < 0.05).

CONCLUSION

For patients with grade II/III AC with delayed PTGBD, LC should be performed 2 weeks after PTGBD to decrease postoperative complications and hospital stays and improve patient satisfaction.

Predictors of the Difficulty of Laparoscopic Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage for Grade II Acute Cholecystitis

BACKGROUND

The predictors of difficulty performing laparoscopic cholecystectomy (LC) following percutaneous transhepatic gallbladder drainage (PTGBD) for grade II acute cholecystitis have not been clearly understood.

METHODS

This retrospective study was performed between January 2019 and February 2023 and involved 102 eligible patients with grade II acute cholecystitis. Patients were categorized into 2 groups: difficult LC group (n=14) and nondifficult LC group (n=88). Preoperative characteristics and postoperative outcomes were analyzed, and a logistic regression model was used for multivariate analyses of the significant factors identified in the univariate analyses.

RESULTS

Logistic multivariable regression analysis revealed that C-reactive protein (CRP) levels (odds ratio [OR]: 1.028, 95% confidence interval [CI]: 1.013-1.044; P <0.05), and time intervals between PTGBD and LC (OR: 1.047, 95% CI: 1.003-1.092; P =0.034) were independent predictors of difficult LC. When preoperative CRP was >154 mg/L, LC difficulty, blood loss, and operative time increased ( P <0.05, P =0.01, P =0.01, respectively) compared with CRP <154 mg/L. Difficult LC, increased blood loss, and longer operative time occurred more frequently when the interval between PTGBD and LC was >35 days compared with <35 days ( P <0.05, P =0.003, P =0.002, respectively).

CONCLUSIONS

CRP levels >154 mg/L and intervals between PTGBD and LC exceeding 35 days are associated with greater LC difficulty.

Multisociety research collaboration: timing of cholecystectomy following cholecystostomy drainage for acute cholecystitis

BACKGROUND

Patients with acute cholecystitis (AC) presenting with unfavorable systemic or local conditions are often managed with percutaneous cholecystostomy (PC) as a temporary measure. The clinical outcomes of interval cholecystectomy following PC remain unclear. The aim of the study was to identify the association between the timing of cholecystectomy following PC for AC and perioperative complication rates at interval cholecystectomy. We hypothesized that there would be a specific time interval to cholecystectomy associated with lower risk for adverse events.

METHODS

This was a retrospective (2018-2020) multicenter study at 8 participating hospital systems of adult patients with AC, managed with PC and interval cholecystectomy. Demographics, comorbidities, treatment details, and outcomes were examined. Patients were grouped based on quartiles for timing of surgery after PC (< 7, 7-9, 10-13, > 13 weeks). The primary outcome was a composite endpoint of bile duct injury, reoperation, readmission, image-guided intervention, endoscopic intervention, conversion to open surgery, or death.

RESULTS

There were 188 patients with a median age of 66 years with AC classified as mild (41%), moderate (47%), and severe (12%). Median days from PC to surgery were 65 (Q1 = 48, Q3 = 91). Laparoscopic cholecystectomy (89.9%) was the most commonly planned approach (robotic 6.4%, 3.7% open) and 28 (14.9%) were converted to open. The composite endpoint was reported in 51 patients (27.1%). A biliary injury occurred in 7 (3.7%) patients. Time to surgery and intraoperative drain placement were independently associated with the composite outcome. Cholecystectomy within 7 weeks of PC was associated with decreased risk (OR = 0.36, 95% CI 0.13-0.97) of the composite endpoint, compared to patients undergoing surgery > 13 weeks after PC.

CONCLUSION

Timing of surgery following PC was associated with procedural outcomes. Patients undergoing surgery before 7 weeks experienced significantly less morbidity than patients having delayed cholecystectomy. These results should be considered in patient selection and management after PC.

An Acute Gangrenous Cholecystitis Caused by Candida auris: A Case From a Greek Hospital

Candida-related infections have increased dramatically in recent years, particularly in severely sick or immunocompromised individuals. Furthermore, the discovery of Candida auris in 2009 as a fungus resistant to numerous antifungal treatments has increased its significance. This microorganism is linked to high transmission rates among hospitalized patients, resulting in life-threatening infections and complications. This is a complete case study that explains the reasons and suitable therapy for this medical condition. Despite receiving adequate therapy, individuals with acute gangrenous cholecystitis typically have a poor prognosis. As a result, physicians must be aware of this illness and provide the best therapy as soon as possible. Here, we present a case of gangrenous cholecystitis caused by Candida auris in a 58-year-old woman.

The Success Rate Is Lower but Completion Rate of Laparoscopic Cholecystectomy Is higher in Endoscopic Transpapillary Gallbladder Drainage than Percutaneous Gallbladder Drainage for Acute Cholecystitis

BACKGROUND

We investigated the success and complication rates of endoscopic transpapillary gallbladder drainage (ETGBD) and percutaneous transhepatic gallbladder drainage (PTGBD) and the outcomes of subsequent cholecystectomy for acute cholecystitis.

METHODS

Patients (N=178) who underwent cholecystectomy after ETGBD or PTGBD were retrospectively assessed.

RESULTS

ETGBD was successful in 47 (85.5%) of 55 procedures, whereas PTGBD was successful in 123 (100%) of 123 sessions ( P <0.001). Complications related to ETGBD and PTGBD occurred in 6 (12.8%) of 47 and 16 (13.0%) of 123 patients, respectively ( P =0.97). After propensity matching, 43 patients from each group were selected. Median time from drainage to cholecystectomy was 48 (14 to 560) days with ETGBD and 35 (1 to 90) days with PTGBD ( P =0.004). Laparoscopy was selected more often in the ETGBD group (97.7%) than in the PTGBD group (79.1%) ( P =0.007), and conversion from laparoscopy to open cholecystectomy was more common with PTGBD (41.2%) than with ETGBD (7.1%) ( P <0.001). Mean operation time was significantly shorter with ETGBD (135.8±66.7 min) than with PTGBD (195.8±62.2 min) ( P <0.001). The incidence of Clavien-Dindo grade ≥III postoperative complications was 9.3% with ETGBD and 11.6% with PTGBD ( P =0.99).

CONCLUSIONS

The success rate is lower but completion of laparoscopic cholecystectomy is more in endoscopic gallbladder drainage than percutaneous gallbladder drainage for acute cholecystitis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Percutaneous transhepatic gallbladder drainage versus endoscopic gallbladder stenting for managing acute cholecystitis until laparoscopic cholecystectomy

INTRODUCTION

Gallbladder drainage by methods such as percutaneous transhepatic gallbladder drainage (PTGBD) or endoscopic gallbladder stenting (EGBS) is important in the early management of moderate to severe acute cholecystitis.

METHODS

In patients undergoing laparoscopic cholecystectomy (LC) for acute cholecystitis after a month or more of gallbladder drainage, the clinical course was compared between patients initially treated with PTGBD or EGBS.

RESULTS

Among 331 patients undergoing LC for cholecystitis between 2018 and 2022, 43 first underwent 1 or more months of gallbladder drainage. The median interval between drainage initiation and LC was 89 days (range, 28-261) among 34 patients with PTGBD and 70 days (range, 62-188) among nine with EGBS (p = 0.644). During this waiting period, PTGBD was clamped in six patients and removed in five. Cholecystitis relapsed in three PTGBD patients (9%) and four EGBS patients (44%; p = 0.026). Relapses were managed with medications. Cholecystectomy duration (p = 0.022), intraoperative blood loss (p = 0.026), frequency of abdominal drain insertion (p = 0.023), and resort to bailout surgery such as fundus-first approaches (p = 0.030) were significantly greater in patients with EGBS. Postoperative complications were somewhat likelier (p = 0.095) and postoperative hospital stays were longer (p = 0.007) in the EGBS group.

CONCLUSION

Among patients whose LC was performed 1 or more months after initiation of drainage, daily living during the waiting period associated with drainage was well supported by EGBS, but LC and the postoperative course were more complicated than in PTGBD patients.

Comparison between percutaneous transhepatic gallbladder drainage and upfront laparoscopic cholecystectomy in patients with moderate-to-severe acute cholecystitis: a propensity score-matched analysis

Purpose

In the Tokyo Guidelines 2018 (TG18), emergency laparoscopic cholecystectomy is recognized as a crucial early treatment option for acute cholecystitis. However, early laparoscopic intervention in patients with moderate-to-severe acute cholecystitis or those with severe comorbidities may increase the risk of complications. Therefore, in the present study, we investigated the association between early laparoscopic cholecystectomy and percutaneous transhepatic gallbladder drainage (PTGBD) in moderate-to-severe acute cholecystitis patients.

Methods

We retrospectively analyzed 835 TG18 grade II or III acute cholecystitis patients who underwent laparoscopic cholecystectomy at 4 tertiary medical centers in the Republic of Korea. Patients were classified into 2 groups according to whether PTGBD was performed before surgery, and their short-term postoperative outcomes were analyzed retrospectively.

Results

The patients were divided into 2 groups, and 1:1 propensity score matching was conducted to establish the PTGBD group (n = 201) and the early laparoscopic cholecystectomy group (n = 201). The PTGBD group experienced significantly higher rates of preoperative systemic inflammatory response syndrome (24.9% vs. 6.5%, P < 0.001), pneumonia (7.5% vs. 3.0%, P = 0.045), and cardiac disease (67.2% vs. 57.7%, P = 0.041) than the early operation group. However, there was no difference in biliary complication (hazard ratio, 1.103; 95% confidence interval, 0.519-2.343; P = 0.799) between the PTGBD group and early laparoscopic cholecystectomy group.

Conclusion

In most cases of moderate-to-severe cholecystitis, early laparoscopic cholecystectomy was relatively feasible. However, PTGBD should be considered if patients have the risk factor of underlying disease when experiencing general anesthesia.

Optimal Timing of Laparoscopic Cholecystectomy After Conservative Therapy for Acute Cholecystitis

BACKGROUND/AIM

According to the Tokyo Guidelines 2018, the operation for acute cholecystitis is recommended to be performed as early as possible. However, there are cases in which early surgeries cannot be performed due to complications of patients or facility conditions, resulting in elective surgery. Hence, we retrospectively analyzed elective surgery cases in this study.

PATIENTS AND METHODS

There were 345 patients who were underwent laparoscopic cholecystectomy (LC) at our hospital from January 2019 to December 2020 in this retrospective study. A total of 83 patients underwent LC more than 3 days after conservative treatment. The elective LC patients were divided into the Early group (4-90 days after onset, n=36) and the Delayed group [91 days or more (13 weeks or more) after onset, n=31], excluding 16 patients who underwent percutaneous transhepatic gallbladder drainage.

RESULTS

As for operative time, there was a significant difference between the Delayed and Early groups (91.2 vs. 117 minutes, p=0.0108). And also, there was a significant difference in the postoperative hospital stay, which was significantly shorter in the Delayed group than in the Early group (3.4 vs. 5.9 days, p=0.0436). Although there were no significant differences in either conversion rates or complication rates, both of these were decreasing in the Delayed group. In particular, there were no complications in the Delayed group.

CONCLUSION

When the conservative treatment for acute cholecystitis precedes and precludes urgent/early LC within 3 days, delaying LC for at least 91 days (13 weeks or more) after onset could reduce operative time and postoperative hospital stay. Moreover, there would be no complications after LC, and the rates of conversion during LC may be kept low.

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.

Systematic review and meta-analysis of early vs late interval laparoscopic cholecystectomy following percutaneous cholecystostomy

BACKGROUND

High risk surgical patients with acute cholecystitis are commonly treated with percutaneous cholecystostomy (PTC) drainage. The optimal timing of subsequent interval laparoscopic cholecystectomy (LC) remains unclear.

METHODS

Medline, EMBASE, and Scopus were searched to identify studies published between 01/01/2000 and 31/12/2020, reporting on interval LC outcomes in patients initially treated by PTC. Early and late interval LC were defined as <30 and ≥ 30 days respectively. The Methodological Index for Nonrandomized Studies was used for quality assessment. Meta-analysis of proportions was conducted using a random-effects model.

RESULTS

A total of 512 studies were screened, 41 met the inclusion criteria. There were 22 studies in both early and late interval LC groups, with 3 included studies reporting both early and late groups. Following quality assessment, 29 studies were included in the meta-analysis. There were no significant differences between early and late interval LC in terms of conversion rates (7.2% vs 8.3%, p = 0.854), 90-day morbidity (12.8% vs 15.9%, p = 0.496), and 90-day mortality (0.25% vs 0.32%, p = 0.704). Heterogeneity was significant (I²>50%) in all groups.

CONCLUSION

Current evidence of interval LC within or beyond 30 days demonstrates no significant impact on outcomes. Patient factors, clinical experience, and hospital facilities may prove more important predictors.

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.

Optimal timing of percutaneous transhepatic gallbladder drainage and subsequent laparoscopic cholecystectomy according to the severity of acute cholecystitis

Backgrounds/Aims

The optimal timing of percutaneous transhepatic gallbladder drainage (PTGBD) and subsequent laparoscopic cholecystectomy (LC) according to the severity of acute cholecystitis (AC) has not been established yet.

Methods

This single-center, retrospective study included 695 patients with grade I or II AC without common bile duct stones who underwent PTGBD and subsequent LC between January 2010 and December 2019. Difficult surgery (DS) (open conversion, subtotal cholecystectomy, adjacent organ injury, transfusion, operation time ≥ 90 minutes, or estimated blood loss ≥ 100 mL) and poor postoperative outcome (PPO) (postoperative hospital stay ≥ 7 days or Clavien-Dindo grade ≥ II postoperative complication) were defined to comprehensively evaluate intraoperative and postoperative outcomes, respectively.

Results

Of 695 patients, 403 had grade I AC and 292 had grade II AC. According to the receiver operating characteristic curve and multivariate logistic regression analyses, an interval from symptom onset to PTGBD of > 3.5 days and an interval from PTGBD to LC of > 7.5 days were significant predictors of DS and PPO, respectively, in grade I AC. In grade II AC, the timing of PTGBD and subsequent LC were not statistically related to DS or PPO.

Conclusions

In grade I AC, performing PTGBD within 3.5 days after symptom onset can reduce surgical difficulties and subsequently performing LC within 7.5 days after PTGBD can improve postoperative outcomes. In grade II AC, early PTGBD cannot improve the surgical difficulty. In addition, the timing of subsequent LC is not correlated with surgical difficulties or postoperative outcomes.

Necrotizing Cholecystitis in the Gallbladder: A Case Report

Infections caused by Candida species have shown a considerable increase in frequency in the recent past, and hence they are a cause of significant concern among medical practitioners. There are many factors that contribute to the occurrence of Candida-related infections in particular groups of patients. In this report, we present a case that highlights the causes and appropriate treatment methods of the condition. Patients with acute necrotizing cholecystitis often show poor outcomes after treatment, and hence physicians need to be alert when dealing with patients with this condition and should provide the best treatment method. We report a case of necrotizing cholecystitis in a 55-year-old female with a medical history of cholelithiasis, obesity, seizures, cocaine abuse, and anemia. She also reported lower abdominal pain, felt bloated, and complained of headache, dizziness, lack of appetite, shortness of breath, and vomiting. The patient underwent several lab tests as well as a CT scan of the abdomen, hepatobiliary iminodiacetic acid (HIDA) scan, endoscopy, and cholecystectomy.

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 optimal timing of interval laparoscopic cholecystectomy following percutaneous cholecystostomy based on pathological findings and the incidence of biliary events

BACKGROUND

The incidence of biliary events (BE) following percutaneous cholecystostomy (PC) in acute cholecystitis (AC) patients is high. Therefore, definitive laparoscopic cholecystectomy (LC) is recommended. We aimed to investigate the optimal timing of LC following PC with regard to the clinical course and pathological findings.

METHODS

All 744 AC patients with PC were included. The incidence and median number of BE were investigated with the concept of competing risks. The 344 patients with interval LC were divided into two groups based on the pathological findings of resected gallbladders: the acute/acute-and-chronic group (AANC group) (n = 221) and the chronic group (n = 123). A comparative analysis of the demographic data and perioperative outcomes was performed.

RESULTS

Among the 744 AC patients with PC, 142 patients experienced recurrent BE. The cumulative incidence of BE was 26.6%, and the median time to recurrence was 67.5 days. The PC-to-LC days of the chronic group were longer than those of the AANC group (73.51 vs 63.00, P < .001). The multivariate analysis indicated that the operation time was longer in the AANC group than in the chronic group (P = .040).

CONCLUSION

In terms of the clinical course and sequential pathological changes in the gallbladder, a 9- to 10-week interval after PC is the optimal timing for LC.

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.

The influence of the interval between percutaneous transhepatic gallbladder drainage and cholecystectomy on perioperative outcomes: a retrospective study

BACKGROUND

Percutaneous transhepatic gallbladder drainage (PTGBD) is recommended for acute cholecystitis patients at high risk for surgical treatment. However, there is no evidence about the best timing of surgery after PTGBD. Here, we retrospectively investigated the influence of the interval between PTGBD and surgery on perioperative outcomes and examined the optimal timing of surgery after PTGBD.

METHODS

We performed a retrospective analysis of 22 patients who underwent cholecystectomy after PTGBD from January 2008 to August 2019. We examined perioperative factors between patients with an interval of ≤ 7 days between PTGBD and cholecystectomy (≤ 7-day group; n = 12) and those with an interval of ≥ 8 days (≥ 8-day group; n = 10). Moreover, we also examined perioperative factors between patients with an interval of ≤ 14 days from PTGBD to cholecystectomy (≤ 14-day group; n = 10) and those with an interval of ≥ 15 days (≥ 15-day group; n = 12).

RESULTS

Of the 22 patients, 9 had Grade I cholecystitis, 12 had Grade II cholecystitis, and 2 had Grade III cholecystitis. Nine patients had high-grade cholecystitis before PTGBD and 13 had a poor general condition. We examined perioperative factors between patients with an interval of ≤ 7 days between PTGBD and cholecystectomy (≤ 7-day group; n = 12) and those with an interval of ≥ 8 days (≥ 8-day group; n = 10). The C-reactive protein (CRP) level before surgery was significantly higher (12.70 ± 1.95 mg/dL vs. 1.13 ± 2.13 mg/dL, p = 0.0007) and the total hospitalization was shorter (17.6 ± 8.0 days vs. 54.1 ± 8.8 days, p = 0.0060) in the ≤ 7-day group than in the ≥ 8-day group. We also examined perioperative factors between patients with an interval of ≤ 14 days from PTGBD to cholecystectomy (≤ 14-day group; n = 14) and those with an interval of ≥ 15 days (≥ 15-day group; n = 8). The CRP level before surgery was significantly higher (11.13 ± 2.00 mg/dL vs. 0.99 ± 2.64 mg/dL, p = 0.0062) and the total hospitalization was shorter (19.5 ± 7.2 days vs. 59.9 ± 9.5 days, p = 0.0029) in the ≤ 14-day group than in the ≥ 15-day group. However, there were no significant differences between the ≤ 14-day group and the ≥ 15-day group in the levels of hepatic enzymes before surgery, adhesion grade, amount of bleeding during surgery, operative duration, frequency of surgical complications, or length of hospitalization after surgery.

CONCLUSIONS

The interval between PTGBD and surgery has little influence on perioperative outcomes.

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.

Early laparoscopic cholecystectomy following percutaneous transhepatic gallbladder drainage is feasible in low-risk patients with acute cholecystitis

BACKGROUND

Laparoscopic cholecystectomy (Lap-C) is generally performed following percutaneous transhepatic gallbladder drainage (PTGBD) in patients with acute cholecystitis (AC). However, the timing of Lap-C and risk factors for postoperative complications following PTGBD are still unclear.

METHODS

We analyzed 331 patients with AC who underwent Lap-C following PTGBD. Univariate and multivariate logistic regression analyses were used for identifying risk factors associated with poor surgical outcomes, including postoperative complications in the total group and the early Lap-C subgroup (n = 152). Based on the Tokyo guideline 2013 (TG 13), all patients were divided into two groups according to the period (2009-2013, pre-TG 13 group; 2014-2020, post-TG 13 group), and each analysis was performed in those subgroups.

RESULTS

We found that early Lap-C (≤ 42 days after PTGBD) was associated with postoperative complications (OR 2.04, P = .022). Importantly, subgroup analyses revealed that Charlson comorbidity index (CCI) (OR 6.15, P < .001) and cholecystitis severity grade (OR 2.93, P = .014) were independent risk factors of postoperative complications in the early Lap-C group. Among the early Lap-C group, high CCI was also an independent risk factor for surgical complications in both pre-TG 13 (OR 14.87, P = .003) and post-TG 13 (OR 3.23, P = .046) groups. Interestingly, we found that the incidence of postoperative complications in the low-risk early Lap-C group was not different from the delayed group, even in the cases of very early surgery (≤ 1 week following PTGBD).

CONCLUSIONS

These findings suggest that early Lap-C is feasible following PTGBD, especially in low-risk patients, although future prospective large-scale studies are needed.

The Role of Series Cholecystectomy in High Risk Acute Cholecystitis Patients Who Underwent Gallbladder Drainage

Background: Cholecystectomy (CCY) is the only definitive therapy for acute cholecystitis. We conducted this study to evaluate which patients may not benefit from further CCY after percutaneous transhepatic gallbladder drainage (PTGBD) has been performed in acute cholecystitis patients.

Methods: Acute cholecystitis patients with PTGBD treatment were selected from one million random samples from the National Health Insurance Research Database obtained between January 2004 and December 2010. Recurrent biliary events (RBEs), RBE-related medical costs, RBE-related mortality rate and an RBE-free survival curve were compared in patients who accepted CCY within 2 months and patients without CCY within 2 months after the index admission.

Results: Three hundred and sixty-five acute cholecystitis patients underwent PTGBD at the index admission. A total of 190 patients underwent further CCY within 2 months after the index admission. The other 175 patients did not accept further CCY within 2 months after the index admission. RBE-free survival was significantly better in the CCY within 2 months group (60 vs. 42%, p < 0.001). The RBE-free survival of the CCY within 2 months group was similar to that of the no CCY within 2 months group in patients ≥ 80 years old and patients with a Charlson Comorbidity Index (CCI) score ≥ 9.

Conclusions: We confirmed CCY after PTGBD reduced RBEs, RBE-related medical expenses, and the RBE-related mortality rate in patients with acute cholecystitis. In patients who accepted PTGBD, the RBE and survival benefits of subsequent CCY within 2 months became insignificant in patients ≥ 80 years old or with a CCI score ≥ 9.

Early laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for acute cholecystitis

There is no consensus on the optimal timing of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD) for patients with acute cholecystitis (AC). We retrospectively evaluated patients who underwent LC after PTGBD between 1 February 2016 and 1 February 2020. We divided patients into three groups according to the interval time between PTGBD and LC as follows: Group I (within 1 week), (Group II, 1 week to 1 month), and Group III (> 1 month) and analyzed patients' perioperative outcomes. We enrolled 100 patients in this study (Group I, n = 22; Group II, n = 30; Group III, n = 48). We found no significant difference between the groups regarding patients' baseline characteristics and no significant difference regarding operation time and estimated blood loss (p = 0.69, p = 0.26, respectively). The incidence of conversion to open cholecystectomy was similar in the three groups (p = 0.37), and we found no significant difference regarding postoperative complications (p = 0.987). Group I had shorter total hospital stays and medical costs (p = 0.005, p < 0.001, respectively) vs Group II and Group III. Early LC within 1 week after PTGBD is safe and effective, with comparable intraoperative outcomes, postoperative complications, and conversion rates to open cholecystectomy. Furthermore, early LC could decrease postoperative length of hospital stay and medical costs.

The evaluation of ENGBD versus PTGBD in high-risk acute cholecystitis: A single-center prospective randomized controlled trial

BACKGROUND

Gallbladder drainage plays a key role in the management of acute cholecystitis (AC) patients. Percutaneous transhepatic gallbladder drainage (PTGBD) is commonly used while endoscopic naso-gallbladder drainage (ENGBD) serves as an alternative.

METHODS

A single center, prospective randomized controlled trial was performed. Eligible AC patients were randomly assigned to ENGBD or PTGBD group. Randomization was a computer-generated list with 1:1 allocation. All patients received cholecystectomy 2-3 months after drainage. The primary endpoint was abdominal pain score, and the intention-to-treat population was analyzed. (ClinicalTrials.gov: NCT03701464).

FINDINGS

Between Oct 1, 2018 and Feb 29, 2020, 22 out of 61 consecutive AC patients were enrolled in the final analysis. The mean abdominal pain scores before drainage, and at 24, 48, and 72 h after drainage in ENGBD were 6.9 ± 1.1, 4.3 ± 1.2, 2.2 ± 0.8 and 1.5 ± 0.5, respectively, while those of PTGBD were 7.4 ± 1.2, 6.2 ± 1.2, 5.3 ± 1.0 and 3.7 ± 0.9; and the mean gallbladder area tenderness scores were 8.4 ± 1.2, 5.7 ± 0.9, 3.5 ± 0.7, 2.5 ± 0.5 for ENGBD and 8.6 ± 0.9, 7.3 ± 1.0, 7.4 ± 0.5, 4.8 ± 0.9 for PTGBD. The mean abdominal pain and gallbladder area tenderness scores of the ENGBD significantly decreased than the PTGBD (group × time interaction P<0.001, respectively). ENGBD group presented lower post-operative hemorrhage and abdominal drainage tube placement rates (median (IQR) 15[5-20] vs 40[20-70]ml, 3vs9, P = 0.03), and pathological grade and lymphocyte count were observed (P = 0.004) between groups. No adverse events were observed in 3 months follow-up.

INTERPRETATION

Compared to PTGBD, ENGBD group presented less pain, better gallbladder pathological grades and less surgical difficulties during cholecystectomy procedures.

FUNDING

National Natural Science Foundation of China (82060551).

Evaluating the advantages of treating acute cholecystitis by following the Tokyo Guidelines 2018 (TG18): a study emphasizing clinical outcomes and medical expenditures

BACKGROUND

Acute cholecystitis (AC) is a common surgical emergency. The Tokyo Guidelines 2018 (TG18) provides a reliable algorithm for the treatment of AC patients to achieve optimal outcomes. However, the economic benefits have not been validated. We hypothesize that good outcomes and cost savings can both be achieved if patients are treated according to the TG18.

METHOD

This retrospective study included 275 patients who underwent cholecystectomy in a 15-month span. Patients were divided into three groups (group 1: mild AC; group 2: moderate AC with American Society of Anesthesiologists (ASA) physical status class ≤ 2 and Charlson Comorbidity Index (CCI) score ≤ 5; and group 3: moderate AC with ASA class ≥ 3, CCI score ≥ 6, or severe AC). Each group was further divided into two subgroups according to management (followed or deviated from the TG18). Patient demographics, clinical outcomes, and hospital costs were compared.

RESULTS

For group 1 patients, 77 (81%) were treated according to the TG18 and had a significantly higher successful laparoscopic cholecystectomy (LC) rate (100%), lower hospital cost ($1896 vs $2388), and shorter hospital stay (2.9 vs 8 days) than those whose treatment deviated from the TG18. For group 2 patients, 50 (67%) were treated according to the TG18 and had a significantly lower hospital cost ($1926 vs $2856), shorter hospital stay (3.9 vs 9.9 days), and lower complication rate (0% vs 12.5%). For group 3 patients, 62 (58%) were treated according to the TG18 and had a significantly lower intensive care unit (ICU) admission rate (9.7% vs 25%), but a longer hospital stay (12.6 vs 7.8 days). However, their hospital costs were similar. Early LC in group 3 patients did not have economic benefits over gallbladder drainage and delayed LC.

CONCLUSION

The TG18 are the state-of-the-art guidelines for the treatment of AC, achieving both satisfactory outcomes and cost-effectiveness.

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.

Comparison of laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy in aged acute calculous cholecystitis: a cohort study

BACKGROUND

In elderly patients with calculous acute cholecystitis, the risk of emergency surgery is high, and percutaneous cholecystostomy tube drainage (PC) combined with delayed laparoscopic cholecystectomy (DLC) may be a good choice. We retrospectively compared laparoscopic cholecystectomy (LC) to DLC after PC to determine which is the better treatment strategy.

METHOD

We performed a retrospective cohort analysis of 752 patients with acute calculous cholecystitis. Patients with the following conditions were included: (1) age > 65 years old; (2) patients with a grade 2 or 3 severity of cholecystitis according to the 2013 Tokyo Guidelines (TG13); (3) the surgeons who performed the LC were professors or associate professors and (4) the DLC was performed in our hospital after PC. Patients who missed their 30-day follow-up; were diagnosed with bile duct stones, cholangitis or gallstone pancreatitis or were pregnant were excluded from the study. A total of 51 of 314 patients who underwent LC and 73 of 438 patients who underwent PC + DLC were assessed. PC + DLC and LC patients were matched by cholecystitis severity grade according to the TG13, and the National Surgical Quality Improvement Program (NSQIP) calculator was used to predict mortality (n = 21/group). Preoperative characteristics and postoperative outcomes were analysed.

RESULTS

Compared to the matched LC group, the DLC group had less intraoperative bleeding (42.2 vs 75.3 mL, p = 0.014), shorter hospital stays (4.9 vs 7.4 days, p = 0.010) and lower rates of type A bile duct injury (4.8% vs 14.3%, p = 0.035) and type D (0 vs 9.5%, p = 0.002) according to Strasberg classification, residual stones (4.8 vs 14.3%, p = 0.035) and gastrointestinal organ injury (0 vs 3.6%, p < 0.001). Patients in the DLC group had lower incidences of ICU admission and death and a significantly lower incidence of repeat surgery.

CONCLUSION

In elderly patients treated for acute calculous cholecystitis, the 30-day mortality and complication rates were lower for PC + DLC than for LC. However, the total hospitalisation time was significantly prolonged and the costs were significantly higher for PC + DLC.

Timing of cholecystectomy after percutaneous transhepatic gallbladder drainage for acute cholecystitis: a nationwide inpatient database study

BACKGROUND

Optimal interval from percutaneous transhepatic gallbladder drainage (PTGBD) to cholecystectomy for acute cholecystitis remains unclear.

METHODS

We analyzed patients undergoing cholecystectomy following PTGBD for acute cholecystitis, using a national database. We performed restricted cubic spline (RCS) analyses to investigate the association of interval from PTGBD to cholecystectomy with outcomes (mortality/morbidity, blood transfusion, duration of anesthesia, and postoperative hospital stay).

RESULTS

Among 9,256 patients, RCS analyses showed reverse J-shaped associations of the interval with mortality/morbidity and blood transfusion, and J-shaped associations of the interval with both duration of anesthesia and postoperative hospital stay. Each interval was compared with the bottom of the spline curve. Patients with intervals ≤6 days or ≥27 days had higher mortality/morbidity than those with a 10-day interval. Patients with intervals ≤8 days had higher proportions of blood transfusion than those with a 10-day interval. Patients with intervals ≥17 days had longer duration of anesthesia than those with a 5-day interval. Postoperative hospital stay was longer among those with intervals ≤10 days or ≥19 days than those with a 15-day interval.

CONCLUSIONS

Based on the mortality/morbidity data, the optimum time to perform cholecystectomy is between 7 and 26 days after PTGBD.

Comparison of endoscopic naso-gallbladder drainage and percutaneous transhepatic gallbladder drainage in acute suppurative cholecystitis: Study Protocol Clinical Trial (SPIRIT Compliant)

INTRODUCTION

Transitional drainage, which is followed by cholecystectomy plays a key role in the management of acute cholecystitis, especially in high-risk surgical patients. Endoscopic naso-gallbladder drainage (ENGBD) is an alternative to percutaneous transhepatic gallbladder drainage (PTGBD) for patients who need temporary drainage. There is a lack of prospective comparison on the relevant outcomes of the two drainage methods during the period of drainage, especially the subsequent cholecystectomy.

METHODS

This is a randomized controlled two-arm non-blind single center trial. Patients with acute cholecystitis undergo emergent or early cholecystectomy and need drainage will be randomly assigned to group PTGBD or ENGBD. Pain score is defined as the primary endpoint, whereas several secondary endpoints, such as the rates of technical success, clinical remission, open conversion of cholecystectomy will be determined to elucidate more detailed differences between two groups. The general feasibility, safety, and quality checks required for high-quality evidence will be adhered to.

DISCUSSION

This study would provide the first type A evidence concerning the comparison of ENGBD versus PTGBD in surgically high-risk patients with acute cholecystitis, it will be the first trial designed to determine the impact of two drainage methods on not only peri-drainage but also peri-LC.

TRIAL REGISTRATION

NCT03701464. Registered on October 10, 2018.

Cholecystectomy following percutaneous cholecystostomy tube placement leads to higher rate of CBD injuries

INTRODUCTION

Percutaneous cholecystostomy tube (PCT) placement is often the management of severe acute cholecystitis in the unstable patient. PCT can be later reversed and cholecystectomy performed. The purpose of this study is to investigate the incidence of subsequent cholecystectomy and clinical factors associated with subsequent procedure.

METHODS

The SPARCS, an administrative database, was used to search all patients undergoing PCT placement between 2000 and 2012 in the state of New York. Using a unique identifier, all patients were followed for subsequent cholecystectomy procedures for at least 2 years. Patients were also followed up to 2014 for potential CBD injury during subsequent laparoscopic (LC) or open cholecystectomy (OC). Univariate and multivariable regression analysis were performed when appropriate.

RESULTS

There were 9738 patients identified who underwent PCT placements. The incidence of patients who had a PCT in 2000-2012, which subsequently underwent cholecystectomy increased from 25.0% in 2000 to 31.7% in 2012. In addition, patients undergoing subsequent LC increased from 11.8% in 2000 to 22.2% in 2012, while the incidence of OC decreased from 13.2% in 2000 to 9.5% in 2012. After accounting for other confounding factors, younger male patients, race as white compared to black, who didn't have any complications during PCT placement were more likely to undergo subsequent cholecystectomy (p < 0.05). Average time to LC was 122.0 days versus 159.6 days for OC (p < 0.0001). From the patients who underwent cholecystectomy following PCT, 47 patients experienced CBD injury (1.6%).

CONCLUSIONS

Incidence of cholecystectomy following PCT increased during the study period. Surgeons seem to be more comfortable performing LC as rate of LC increased from 11.8 to 22.2%. However, rate of CBD injury is higher during subsequent cholecystectomy compared to that of the general population. Caution should be used when performing subsequent cholecystectomy following PCT, as these procedures may be more technically challenging.

The association between bowel obstruction and the management of cholelithiasis and cholecystitis in elderly patients: A population-based cohort study

AIMS

This study aimed to evaluate the risk of bowel events among elderly patients treated using only PTGBD (Percutaneous Gallbladder Drainage), or a cholecystectomy on its own, or PTGBD combined with a subsequent cholecystectomy.

METHODS

A retrospective population-based cohort study was conducted with newly diagnosed cholelithiasis and cholecystitis patients who had no bowel obstruction history and were aged over 65 years during the period of January 1, 2000 to December 31, 2010. These patients were placed into 3 separate study cohorts; PTGBD alone, cholecystectomy alone and PTGBD with subsequent laparoscopic cholecystectomy, with the cohort frequencies matched by age and gender. We defined the index date as the time of the initial cholelithiasis and cholecystitis diagnosis date and began observation and suspended follow-up when the patient had either withdrawn from their health insurance, developed bowel obstruction or reached the date of December 31, 2011.

RESULTS

The incidences of bowel obstruction were 24.6, 19.2 and 13.6 per 1000 person-years for PTGBD cohort, cholecystectomy cohort and PTGBD respectively, with a subsequent laparoscopic cholecystectomy cohort. Compared with the PTGBD cohort, (which was adjusted for age, gender, CCI score and laparotomy history), the hazard ratio of bowel obstruction was 0.77 (95% Confidence Interval (CI) = 0.59-1.00) and 0.57 (95% CI = 0.43-0.76) for the cholecystectomy cohort and PTGBD with a subsequent laparoscopic cholecystectomy cohort respectively.

CONCLUSION

For treatment of cholelithiasis and cholecystitis in elderly patients, PTGBD with a subsequent cholecystectomy could benefit patients by providing a lower risk of ileus or intestinal obstruction.

Comparison of Emergency Cholecystectomy with Delayed Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage in Patients with Moderate Acute Cholecystitis

INTRODUCTION

Patients with moderate (grade II) acute cholecystitis patients, as defined by the 2013 Tokyo Guidelines, were retrospectively compared with respect to emergency cholecystectomy (EC) and delayed cholecystectomy (DC) after percutaneous transhepatic gallbladder drainage (PTGBD) to determine the better treatment strategy.

METHODS

Forty-nine of 103 patients with PTGBD and 47 of 54 patients with EC were assessed for eligibility from January 2013 to January 2017. Patients with the following conditions were included: (i) moderate (grade II) acute cholecystitis diagnosed by the 2013 Tokyo Guidelines; (ii) no common bile duct stones; (iii) no atrophic cholecystitis; (iv) no decompensated liver cirrhosis and massive ascites; (v) no diffuse peritonitis; (vi) surgeons are professors or associate professors; and (vii) PTGBD is not the only procedure for the patient defined by clinicians. The preoperative characteristics and postoperative outcomes were analyzed. PTGBD was performed by experienced interventional radiologists and cholecystectomy was performed by professors or associate professors.

RESULTS

Patients in the EC and PTGBD + DC groups had similar demographic, clinical, preoperative laboratory, and imaging characteristics. Both PTGBD and EC resolved the cholecystitis quickly. Compared to the PTGBD + DC group, EC patients had more intraoperative bleeding (101 ± 125 mL versus 33 ± 37 mL, P = .003), longer duration of postoperative abdominal drainage (9.0 ± 12.9 days versus 3.4 ± 2.1 days, P = .041), more patients converted to open cholecystectomy (OC; 19.1% versus 4.1%, P = .021), more OC patients (14.9% versus 0%, P = .005), more patients with gangrenous cholecystitis (40.4% versus 8.2%, P < .001), more cholecystitis patients with perforation (12.8% versus 0%, P = .012), a higher incidence of respiratory failure (14.8% versus 2.0%, P = .029), more admissions to the intensive care unit (ICU) (21.3% versus 2.0%, P = .003), and longer postoperative hospital stays (8.2 ± 3.2 days versus 11.6 ± 4.6 days, P < .001) in the PTGBD + DC group. In addition, there were statistically more OC patients (63.2% versus 14.3%, P = .001) in the nonbiliary surgeon group than the biliary surgeon group.

CONCLUSION(S)

In patients with moderate (grade II) acute cholecystitis, PTGBD and EC were highly efficient in resolving cholecystitis. DC patients after PTGBD had better outcomes with a lower rate of OC, less intraoperative bleeding, shorter duration of postoperative abdominal drainage, shorter hospital stays after cholecystectomy, a lower incidence of respiratory failure, fewer admissions to the ICU than EC, and reversed the pathologic process affecting the gallbladder. The total postoperative hospital stay was longer in the PTGBD + DC group.

Is Interval Cholecystectomy Necessary After Percutaneous Cholecystostomy in High-Risk Acute Cholecystitis Patients?

Objectives:

Percutaneous cholecystostomy (PC) for acute cholecystitis (AC) is frequently performed in high-risk surgical patients as an alternative treatment modality. However, debate remains over whether or not an interval cholecystectomy for these patients should be performed. The aim of this study was to investigate the outcomes of PC in high-risk surgical patients with AC.

Methods:

Between September 2013 and June 2016, 27 of 952 patients with AC were treated with PC. The data collection included demographic variables, including comorbidities, the timing of the PC, the length of the hospital stay, the follow-up period, the complications related to PC, and readmission to hospital.

Results:

There were 16 female and 11 male patients, with a mean age of 73±12.4 years (range: 49-97 years). Comorbid diseases included ischemic heart disease (n=6), diabetes mellitus (n=5), chronic obstructive pulmonary disease (n=6), and others (n=10). The mean timing of PC was 2.2±1.4 days (range: 1-3 days). The mean length of hospital stay was 9.6±2.1 days (range: 7-14 days), and the catheter was removed after the first month. The mean follow-up period after the PC catheter removal was 19.6±8.6 months (range: 10-38 months). Only 6 patients (22.2 %) were readmitted to the hospital. Cholecystectomy was performed in 4 cases, and 2 responded to medical treatment.

Conclusion:

Despite ongoing controversy about the management of AC in high-risk surgical patients, PC is an adequate and safely applicable procedure in this group of patients. However, an interval cholecystectomy should be considered in persistent cases, which account for a small percentage. Longer-term follow-up studies with a larger sample size are needed to support our results.

Percutaneous Transhepatic Gallbladder Drainage Combined with Laparoscopic Cholecystectomy: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To investigate the clinical effect of the laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGD) in elder acute cholecystitis.

METHODS

The Cochrane Library, PubMed, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang Databases were searched for randomized controlled trials (RCTs) on LC after PTGD in elder acute cholecystitis published from 1970 to July 2017. Two researchers selected RCTs, extracted data, and evaluated methodological quality independently, and RevMan 5.3 software was used for the meta-analysis. The chi-square test was used for heterogeneity analysis of RCTs included, and the funnel plots were used to evaluate publication bias.

RESULTS

A total of 9 RCTs with 1000 patients were included in this analysis. Compared with the direct LC Group, the PTGD Group has significant better effect in operative duration (minutes) [standard mean difference (SMD) = -1.37, 95% confidence interval (95% CI): -2.52 to -0.22, P = .02], the amount of intraoperative bleeding (mL) (SMD = -1.38, 95% CI: -2.11 to -0.65, P = .0002), conversion rate to laparotomy (%) [odds ratio (OR) = 0.16, 95% CI: 0.08 to 0.31, P < .00001], postoperative complication morbidity (%) (OR = 0.29, 95% CI: 0.17 to 0.51, P < .0001), and postoperative hospital stay (days) (SMD = -1.26, 95% CI: -1.94 to -0.59, P = .0003). The funnel plots were slightly asymmetric, which suggested the presence of publication bias.

CONCLUSION

The PTGD before scheduled LC can effectively not only shorten operative duration, intraoperative bleeding less, and postoperative hospital stay but also decrease the rate to laparotomy and postoperative complication morbidity in elder acute cholecystitis, and it is recommended to be regarded as the preferred therapy of the elder patients.