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Rubio-García JJ, Velilla Vico D, Villodre Tudela C, Irurzun López J, Contreras Padilla D, Alcázar López C, Carbonell Morote S, Ramia-Ángel JM. Impact of percutaneous cholecystostomy in the management of acute cholecystitis: a retrospective cohort study at a tertiary center. Updates Surg 2023:10.1007/s13304-023-01499-3. [PMID: 36991301 PMCID: PMC10054213 DOI: 10.1007/s13304-023-01499-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 03/22/2023] [Indexed: 03/31/2023]
Abstract
Laparoscopic cholecystectomy is the gold standard for the treatment of acute cholecystitis (AC). Percutaneous cholecystostomy (PC) for management of AC is increasing; safe and less invasive than laparoscopic cholecystectomy and is very useful in selected patients with severe comorbidities, not suitable for surgery/general anesthesia. We conducted a retrospective observational study between 2016 and 2021 of patients treated with PC for AC, based on the application of the Tokyo guidelines 13/18. The aim was to analyse the clinical results and management of PC in patients undergoing elective or emergency cholecystectomy. Subsequently, a retrospective analytical study was designed to compare various cohorts: elective or emergency surgery and management with PC alone; patients with/without a high surgical risk; and elective vs emergency surgery. Hundred and ninety five patients with AC were treated with PC. Mean age was 74 years, 59.5% were ASA class III/IV, and the mean Charlson comorbidity index was 5.5. Adherence to Tokyo guidelines regarding indication of PC was 50.8%. The rate of complications associated to PC was 12.3% and the 90-day mortality rate was 14.4%. Mean length of time using PC was 10.7 days. Emergency surgery was performed in 4.6%. The overall success rate using PC was 66.7%, and the 1-year readmission rate due to biliary complications after PC was 28.2%. The rate of scheduled cholecystectomy after PC was 22.6%. Conversion to laparotomy and open approach was more frequent in patients who underwent emergency surgery (p = 0.009). No differences were found in 90-day mortality or in the complication rate. PC achieves improvements in the inflammation and infection associated with AC. In our series, it proved to be an effective and safe treatment during the acute episode of AC. Mortality in patients treated with PC is high due to their older age, greater morbidity, and higher Charlson comorbidity index scores. After PC, emergency surgery is uncommon but readmission due to biliary events is high. Cholecystectomy after PC is the definitive treatment and the laparoscopic approach is feasible. Clinical trial registery: The study was registered in the public accessible database clinicaltrials.gov with the ClinicalTrials.gov ID: NCT05153031. Public release date: 12/09/2021.
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Affiliation(s)
- J J Rubio-García
- Hospital General Universitario de Alicante, Servicio de Cirugía General y Aparato Digestivo, Alicante, Spain.
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain.
- , Alicante, Spain.
| | - D Velilla Vico
- Hospital General Universitario de Alicante, Servicio de Cirugía General y Aparato Digestivo, Alicante, Spain
| | - C Villodre Tudela
- Hospital General Universitario de Alicante, Servicio de Cirugía General y Aparato Digestivo, Alicante, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - J Irurzun López
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
- Hospital General Universitario de Alicante, Servicio de Radiodiagnóstico, Alicante, Spain
| | - D Contreras Padilla
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
- Hospital General Universitario de Alicante, Servicio de Radiodiagnóstico, Alicante, Spain
| | - C Alcázar López
- Hospital General Universitario de Alicante, Servicio de Cirugía General y Aparato Digestivo, Alicante, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - S Carbonell Morote
- Hospital General Universitario de Alicante, Servicio de Cirugía General y Aparato Digestivo, Alicante, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - J M Ramia-Ángel
- Hospital General Universitario de Alicante, Servicio de Cirugía General y Aparato Digestivo, Alicante, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
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Wang X, Niu X, Tao P, Zhang Y, Su H, Wang X. Comparison of the safety and effectiveness of different surgical timing for acute cholecystitis after percutaneous transhepatic gallbladder drainage: a systematic review and meta-analysis. Langenbecks Arch Surg 2023; 408:125. [PMID: 36943587 DOI: 10.1007/s00423-023-02861-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 03/07/2023] [Indexed: 03/23/2023]
Abstract
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.
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Affiliation(s)
- Xuyun Wang
- General Surgery Cadre Ward, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
- Gansu Provincial Hospital, 204 West Donggang R.D., Lanzhou, Gansu, 730000, China
| | - Xiangdong Niu
- General Surgery Cadre Ward, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
- Gansu Provincial Hospital, 204 West Donggang R.D., Lanzhou, Gansu, 730000, China
| | - Pengxian Tao
- General Surgery Cadre Ward, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
- Gansu Provincial Hospital, 204 West Donggang R.D., Lanzhou, Gansu, 730000, China
| | - Yan Zhang
- General Surgery Cadre Ward, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China
- Gansu Provincial Hospital, 204 West Donggang R.D., Lanzhou, Gansu, 730000, China
| | - He Su
- General Surgery Cadre Ward, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China.
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China.
- Gansu Provincial Hospital, 204 West Donggang R.D., Lanzhou, Gansu, 730000, China.
| | - Xiaopeng Wang
- General Surgery Cadre Ward, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China.
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou, Gansu, 730000, China.
- Gansu Provincial Hospital, 204 West Donggang R.D., Lanzhou, Gansu, 730000, China.
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Chang YR, Wu CH, Chen HW, Hung YL, Hu CH, Huang RY, Wu MJ, Kou HW, Chen MY, Tsai CY, Wang SY, Liu KH, Hsu JT, Yeh CN, Liu NJ, Jan YY. Optimal Timing of Cholecystectomy for Patients with Concurrent Acute Cholecystitis and Acute Cholangitis after Successful Biliary Drainage by Interventional Endoscopic Retrograde Cholangiopancreatography. J Clin Med 2022; 11:jcm11216603. [PMID: 36362831 PMCID: PMC9654930 DOI: 10.3390/jcm11216603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/28/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Concurrent acute cholecystitis and acute cholangitis is a unique clinical situation. We tried to investigate the optimal timing of cholecystectomy after adequate biliary drainage under this condition. Methods: From January 2012 to November 2017, we retrospectively screened all in-hospitalized patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and then identified patients with concurrent acute cholecystitis and acute cholangitis from the cohort. The selected patients were stratified into two groups: one-stage intervention (OSI) group (intended laparoscopic cholecystectomy at the same hospitalization) vs. two-stage intervention (TSI) group (interval intended laparoscopic cholecystectomy). Interrogated outcomes included recurrent biliary events, length of hospitalization, and surgical outcomes. Results: There were 147 patients ultimately enrolled for analysis (OSI vs. TSI, 96 vs. 51). Regarding surgical outcomes, there was no significant difference between the OSI group and TSI group, including intraoperative blood transfusion (1.0% vs. 2.0%, p = 1.000), conversion to open procedure (3.1% vs. 7.8%, p = 0.236), postoperative complication (6.3% vs. 11.8%, p = 0.342), operation time (118.0 min vs. 125.8 min, p = 0.869), and postoperative days until discharge (3.37 days vs. 4.02 days, p = 0.643). In the RBE analysis, the OSI group presented a significantly lower incidence of overall RBE (5.2% vs. 41.2%, p < 0.001) than the TSI group. Conclusions: Patients with an initial diagnosis of concurrent acute cholecystitis and cholangitis undergoing cholecystectomy after ERCP drainage during the same hospitalization period may receive some benefit in terms of clinical outcomes.
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Affiliation(s)
- Yau-Ren Chang
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chi-Huan Wu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Huan-Wu Chen
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Yu-Liang Hung
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chia-Hsiang Hu
- Department of General Surgery, Jen Ai Chang Gung Health, Dali Branch, Taichung 412224, Taiwan
| | - Ruo-Yi Huang
- Department of General Surgery, Jen Ai Chang Gung Health, Dali Branch, Taichung 412224, Taiwan
| | - Min-Jung Wu
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Hao-Wei Kou
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Ming-Yang Chen
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chun-Yi Tsai
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Shang-Yu Wang
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Correspondence: or ; Fax: +886-3-3285818
| | - Keng-Hao Liu
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Jun-Te Hsu
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chun-Nan Yeh
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Nai-Jen Liu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Yi-Yin Jan
- Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
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Park SM, Kim HJ, Kang TU, Swan H, Ahn HS. Cholecystectomy reduces the risk of myocardial and cerebral infarction in patients with gallstone-related infection. Sci Rep 2022; 12:16749. [PMID: 36202881 DOI: 10.1038/s41598-022-20700-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 09/16/2022] [Indexed: 11/13/2022] Open
Abstract
We compared the risk of myocardial infarction (MI) or cerebral infarction (CI) in patients with or without-gallstone-related infection (GSI) and change in the risk following cholecystectomy. GSI (n = 84,467) and non-GSI (n = 406,800) patients with age- and sex-matched controls (n = 4,912,670) were identified from Korean population based data. The adjusted hazard ratios (aHRs) of MI or CI were analyzed in both groups treated with or without cholecystectomy. Subgroup analysis was performed for both sexes and different ages. The risk of MI or CI was higher in the GSI group than in the non-GSI group (aHR for MI; 1.32 vs. 1.07, aHR for CI; 1.24 vs. 1.06, respectively). The risk reduction rate of MI following cholecystectomy was 11.4% in the GSI group, whereas it was 0% in the non-GSI group. The risk of CI after cholecystectomy was more reduced in the GSI group than in the non-GSI group (16.1% and 4.7%, respectively). The original risk of MI or CI in patients with gallstones and risk reduction rates following cholecystectomy were higher in females and younger patients than in males and older patients. Increased risk of MI or CI and greater risk reduction following cholecystectomy were seen in patients with GSI.
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Kang C, Zhang J, Hou S, Wang J, Li X, Li X, Chi X, Shan H, Zhang Q, Liu T. The Efficacy of Percutaneous Transhepatic Gallbladder Drainage Combined with Gallbladder-Preserving Cholecystolithotomy in High-Risk Patients with Acute Calculous Cholecystitis. J Inflamm Res 2022; 15:2901-2910. [PMID: 35602663 PMCID: PMC9114648 DOI: 10.2147/jir.s363610] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/13/2022] [Indexed: 12/07/2022] Open
Abstract
Objective This study aimed to investigate the value of combining percutaneous transhepatic gallbladder drainage (PTGD) with gallbladder-preserving cholecystolithotomy (GPC) in high-risk patients with acute calculous cholecystitis. Methods Clinical data from 74 high-risk patients with acute calculous cholecystitis, admitted to our hospital between October 2018 and September 2021, were analyzed retrospectively. All the patients underwent PTGD, and 59 of them underwent delayed cholecystectomy, while 14 patients were subjected to GPC 8-12 weeks after the PTGD; one patient, whose life expectancy was fewer than 6 months, was not treated for gallstones after PTGD. Results In all 74 patients, symptom remission was achieved after the PTGD therapy, and the incidence of catheter-related complications was 10.8%. Among the 59 patients who underwent delayed cholecystectomy (DC) after PTGD, there was a complication incidence of 6.8%. Of the 14 patients who underwent GPC after the PTGD, 13 patients were subjected to the removal of drainage tubes, 1 patient received cholecystostomy catheter draining externally, and two patients (14.3%) had complications. There were no perioperative deaths. Conclusion Percutaneous transhepatic gallbladder drainage, combined with GPC, is a safe and effective treatment that is suitable for high-risk patients with acute calculous cholecystitis who cannot receive DC. This combined method allows for early acute cholecystitis to settle, helps to remove gallstones at a later stage, and solves the problem of long-term tube drainage after PTGD.
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Affiliation(s)
- Chunbo Kang
- General Surgery Department, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, People’s Republic of China
| | - Jie Zhang
- General Surgery Department, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, People’s Republic of China
| | - Shiyang Hou
- General Surgery Department, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, People’s Republic of China
| | - Jinlei Wang
- General Surgery Department, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, People’s Republic of China
| | - Xubin Li
- General Surgery Department, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, People’s Republic of China
| | - Xiaowei Li
- General Surgery Department, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, People’s Republic of China
| | - Xiaoqian Chi
- General Surgery Department, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, People’s Republic of China
| | - Haifeng Shan
- General Surgery Department, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, People’s Republic of China
| | - Qijun Zhang
- General Surgery Department, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, People’s Republic of China
| | - Tiejun Liu
- General Surgery Department, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, 100144, People’s Republic of China
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Lee SJ, Choi IS, Moon JI, Yoon DS, Lee SE, Sung NS, Kwon SU, Bae IE, Roh SJ, Choi WJ. Elective Laparoscopic Cholecystectomy Is Better than Conservative Treatment in Elderly Patients with Acute Cholecystitis After Percutaneous Transhepatic Gallbladder Drainage. J Gastrointest Surg 2021; 25:3170-7. [PMID: 34173163 DOI: 10.1007/s11605-021-05067-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/07/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND It is unclear whether cholecystectomy is beneficial after percutaneous transhepatic gallbladder drainage (PTGBD) in elderly patients with acute cholecystitis (AC). METHODS This single-center, retrospective study included 202 patients aged >80 years with AC without common bile duct (CBD) stones who underwent PTGBD between January 2010 and December 2019. RESULTS One hundred and forty-two patients underwent elective laparoscopic cholecystectomy (ELC), and 60 underwent conservative treatment, specifically PTGBD removal (PTGBD-R) in 36 patients and PTGBD maintained (PTGBD-M) in 24 patients. The postoperative major complication (POMC) rate in the ELC group was 8.5%. The cumulative incidence for recurrence of biliary events (BE) in the PTGBD-R group was 22.2%. The cumulative incidence for PTGBD-related complication in the PTGBD-M group was 70.8%. Mortality after initial treatment was not significantly different between the three groups (2.8% vs. 2.8% vs. 8.3%, p=0.381). In multivariate analysis, a Charlson age comorbidity index ≥6 and body mass index ≤19 were significant risk factors for POMC after ELC, and a closed cystic duct was a significant risk factor for recurrent BE after PTGBD-R. CONCLUSION ELC is recommended in AC after PTGBD for selected patients aged >80 years without CBD stones due to the high recurrence rate of BE after PTGBD-R and the difficulty associated with PTGBD-M.
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Han J, Xue D, Tuo H, Liang Z, Wang C, Peng Y. Percutaneous Transhepatic Gallbladder Drainage Combined with Laparoscopic Cholecystectomy Versus Emergency Laparoscopic Cholecystectomy for the Treatment of Moderate Acute Cholecystitis: A Meta-Analysis. J Laparoendosc Adv Surg Tech A 2021; 32:733-739. [PMID: 34748409 DOI: 10.1089/lap.2021.0579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: We compared the clinical outcomes of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD) with those of emergency LC (ELC) in patients with moderate acute cholecystitis (AC) as per the Tokyo Guidelines. Methods: A meta-analysis of clinical comparative studies investigating the efficacy of PTGBD combined with LC (PTGBD + LC) versus ELC for moderate AC patients was performed. Results: The PTGBD + LC group had a shorter operative time (mean difference [MD] = -25.02 minutes; 95% confidence interval [95% CI] -35.50 to -14.54; P < .00001), less intraoperative bleeding (MD = -33.38 mL; 95% CI -45.43 to -21.33; P < .00001), shorter postoperative hospital stay (MD = -2.37 days; 95% CI -3.30 to -1.44; P < .00001), lower conversion rate (odds ratio [OR] 0.23; 95% CI 0.11-0.48; P < .0001), and lower total postoperative morbidity (OR 0.26; 95% CI, 0.10-0.67; P = .005) compared with the ELC group. There was no significant difference in total hospital stay (MD = 1.71 days; 95% CI -0.17 to 3.60; P = .08) and the incidence of bile leak (OR 0.30; 95% CI 0.07-1.29; P = .11). Conclusions: Compared with ELC, LC after PTGBD can effectively reduce the difficulty of operation, total postoperative morbidity, and conversion rate, and shorten the postoperative hospital stay and operative duration in patients with moderate AC as per the Tokyo Guidelines. In clinical practice, it is necessary to formulate individualized treatment plans based on the condition and willingness of the patients.
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Affiliation(s)
- Jingzhao Han
- Department of Graduate School, Hebei Medical University, Shijiazhuang, China.,Department of Hepatobiliary Surgery, Hebei General Hospital, Shijiazhuang, China
| | - Dongdong Xue
- Department of Hepatobiliary Surgery, Hebei General Hospital, Shijiazhuang, China
| | - Hongfang Tuo
- Department of Hepatobiliary Surgery, Hebei General Hospital, Shijiazhuang, China
| | - Ze Liang
- Department of Hepatobiliary Surgery, Hebei General Hospital, Shijiazhuang, China
| | - Chuncheng Wang
- Department of Hepatobiliary Surgery, Hebei General Hospital, Shijiazhuang, China
| | - Yanhui Peng
- Department of Hepatobiliary Surgery, Hebei General Hospital, Shijiazhuang, China
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Yao P, Chang Z, Liu Z. Factors influencing failure to undergo interval cholecystectomy after percutaneous cholecystostomy among patients with acute cholecystitis: a retrospective study. BMC Gastroenterol 2021; 21:410. [PMID: 34711183 PMCID: PMC8555182 DOI: 10.1186/s12876-021-01989-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 10/20/2021] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Peng Yao
- Department of Radiology, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Heping District, Shenyang, 110004, China
| | - Zhihui Chang
- Department of Radiology, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Heping District, Shenyang, 110004, China.
| | - Zhaoyu Liu
- Department of Radiology, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Heping District, Shenyang, 110004, China
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Wang SY, Yeh CN, Jan YY, Chen MF. Management of Gallstones and Acute Cholecystitis in Patients with Liver Cirrhosis: What Should We Consider When Performing Surgery? Gut Liver 2021; 15:517-527. [PMID: 32921635 PMCID: PMC8283297 DOI: 10.5009/gnl20052] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/19/2020] [Accepted: 07/27/2020] [Indexed: 02/06/2023] Open
Abstract
Acute cholecystitis and several gallbladder stone-related conditions, such as impacted common bile duct stones, cholangitis, and biliary pancreatitis, are common medical conditions in daily practice. An early cholecystectomy or drainage procedure with delayed cholecystectomy is the current standard of treatment based on published clinical guidelines. Cirrhosis is not only a condition of chronically impaired hepatic function but also has systemic effects in patients. In cirrhotic individuals, several predisposing factors, including changes in the bile acid composition, increased nucleation of bile, and decreased motility of the gallbladder, contribute to the formation of biliary stones and the possibility of symptomatic cholelithiasis, which is an indication for surgical treatment. In addition to these predisposing factors for cholelithiasis, systemic effects and local anatomic consequences related to cirrhosis lead to anesthesiologic risks and perioperative complications in cirrhotic patients. Therefore, the treatment of the aforementioned biliary conditions in cirrhotic patients has become a challenging issue. In this review, we focus on cholecystectomy for cirrhotic patients and summarize the surgical indications, risk stratification, surgical procedures, and surgical outcomes specific to cirrhotic patients with symptomatic cholelithiasis.
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Affiliation(s)
- Shang Yu Wang
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chun Nan Yeh
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yi Yin Jan
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Miin Fu Chen
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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Hung YL, Chen HW, Tsai CY, Chen TC, Wang SY, Sung CM, Hsu JT, Yeh TS, Yeh CN, Jan YY. The optimal timing of interval laparoscopic cholecystectomy following percutaneous cholecystostomy based on pathological findings and the incidence of biliary events. J Hepatobiliary Pancreat Sci 2021; 28:751-759. [PMID: 34129718 DOI: 10.1002/jhbp.1012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/24/2021] [Accepted: 06/02/2021] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Yu-Liang Hung
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Huan-Wu Chen
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Chun-Yi Tsai
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Tse-Ching Chen
- Department of Anatomic Pathology, College of Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Shang-Yu Wang
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan City, Taiwan
| | - Chang-Mu Sung
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Jun-Te Hsu
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Ta-Sen Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Chun-Nan Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yi-Yin Jan
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
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11
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Chung HY, Hsu CC, Hung YL, Chen HW, Wong MS, Fu CY, Tsai CY, Chen MY, Wang SY, Hsu JT, Yeh TS, Yeh CN, Jan YY. Alternative application of percutaneous cholecystostomy in patients with biliary obstruction. Abdom Radiol (NY) 2021; 46:2891-2899. [PMID: 33388808 DOI: 10.1007/s00261-020-02898-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/28/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Percutaneous cholecystostomy (PC) is an important modality for acute cholecystitis and has been applied for other clinical scenarios as well. In the present study, we aimed to investigate an alternative use of PC for obstructive jaundice. METHODS From January 2012 to December 2018, eligible subjects were selected from patients undergoing PC in our institute. The characteristics, spectrum of underlying disease, indication for PC performance, details of the procedure, and treatment effect were all investigated. RESULTS During the study period, 1364 patients underwent PC. Seventy patients fulfilled the defined inclusion criteria. While 47 patients were diagnosed with malignant biliary obstruction with or without cholangitis, 23 patients were diagnosed with nonmalignant biliary obstruction and acute cholangitis. There were 63 patients (90%) diagnosed with acute cholangitis. Pancreatic cancer (n = 24, 51%) and advanced malignancy (n = 28, 59%) were noted mostly in the group with malignant biliary obstruction. Treatment effects were proven by laboratory data, including the white blood cell count, C-reactive protein level, and hepatic function. CONCLUSION PC can temporize definitive therapies and serve as an alternative treatment for patients with nonmalignant conditions. For patients with advanced malignancy, PC can serve as a palliative procedure that has a high success rate and low complication rate and effectively relieves biliary obstruction.
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Affiliation(s)
- Hung-Yu Chung
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chih-Chieh Hsu
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Yu-Liang Hung
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Huan-Wu Chen
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Man Si Wong
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chih-Yuan Fu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chun-Yi Tsai
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Ming-Yang Chen
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Shang-Yu Wang
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan.
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan.
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan.
| | - Jun-Te Hsu
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan
| | - Ta-Sen Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chun-Nan Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
- School of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 333, Taiwan
| | - Yi-Yin Jan
- Division of General Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
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12
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Hung YL, Sung CM, Fu CY, Liao CH, Wang SY, Hsu JT, Yeh TS, Yeh CN, Jan YY. Management of Patients With Acute Cholecystitis After Percutaneous Cholecystostomy: From the Acute Stage to Definitive Surgical Treatment. Front Surg 2021; 8:616320. [PMID: 33937313 PMCID: PMC8083985 DOI: 10.3389/fsurg.2021.616320] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/22/2021] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Yu-Liang Hung
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chang-Mu Sung
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chih-Yuan Fu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chien-Hung Liao
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shang-Yu Wang
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jun-Te Hsu
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ta-Sen Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Nan Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Yin Jan
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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13
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Wang CC, Tseng MH, Wu SW, Yang TW, Sung WW, Wang YT, Lee HL, Shiu BH, Lin CC, Tsai MC. The Role of Series Cholecystectomy in High Risk Acute Cholecystitis Patients Who Underwent Gallbladder Drainage. Front Surg 2021; 8:630916. [PMID: 33659271 PMCID: PMC7917216 DOI: 10.3389/fsurg.2021.630916] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/08/2021] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Chi-Chih Wang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Division of Gastroenterology and Hepatology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ming-Hseng Tseng
- Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan
| | - Sheng-Wen Wu
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Division of Nephrology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Tzu-Wei Yang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Division of Gastroenterology and Hepatology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Wen-Wei Sung
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Urology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yao-Tung Wang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Division of Pulmonary Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Hsiang-Lin Lee
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Bei-Hao Shiu
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chun-Che Lin
- Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan
| | - Ming-Chang Tsai
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Division of Gastroenterology and Hepatology, Chung Shan Medical University Hospital, Taichung, Taiwan
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14
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Hung YL, Chen HW, Fu CY, Tsai CY, Chong SW, Wang SY, Hsu JT, Yeh TS, Yeh CN, Jan YY. Surgical outcomes of patients with maintained or removed percutaneous cholecystostomy before intended laparoscopic cholecystectomy. J Hepatobiliary Pancreat Sci 2020; 27:461-469. [PMID: 32281739 DOI: 10.1002/jhbp.740] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/11/2020] [Accepted: 03/02/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Percutaneous cholecystostomy (PC) followed by definitive cholecystectomy is an alternative treatment for acute cholecystitis (AC). We retrospectively investigated the impact of PC tube removal before definitive cholecystectomy on surgical outcomes. METHODS From 2012 to 2017, 942 AC patients underwent PC at a single institute. Eligible patients were selected according to inclusion criteria. Demographic data, clinical and laboratory parameters, and treatment outcomes were extracted from medical records. Categorization of patients and subsequent subgroup analysis were based on cholangiography. RESULTS The rate of emergent cholecystectomy in the PC tube removal group was higher than that in the PC tube preserved group (OR = 2.969, 95% CI 1.334-6.612, P = 0.008). In subgroup analysis of patients with patent bile flow under cholangiography, the rate of emergent cholecystectomy was higher in the PC tube removal group (OR = 3.173, 95% CI 1.182-8.523, P = 0.022), though the incidence of complications was higher in the PC tube preserved group (P = 0.012). In addition, routine preoperative cholangiography had no clinical impact on surgical outcome. CONCLUSION Percutaneous cholecystostomy tube can be removed before subsequent LC to avoid postoperative complications, though removal of the PC tube is associated with an increased likelihood of emergent cholecystectomy.
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Affiliation(s)
- Yu-Liang Hung
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Huan-Wu Chen
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chih-Yuan Fu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chun-Yi Tsai
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Sio-Wai Chong
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shang-Yu Wang
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jun-Te Hsu
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ta-Sen Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chun-Nan Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yi-Yin Jan
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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