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Teoh AYB, Kitano M, Itoi T, Pérez-Miranda M, Ogura T, Chan SM, Serna-Higuera C, Omoto S, Torres-Yuste R, Tsuichiya T, Wong KT, Leung CH, Chiu PWY, Ng EKW, Lau JYW. Endosonography-guided gallbladder drainage versus percutaneous cholecystostomy in very high-risk surgical patients with acute cholecystitis: an international randomised multicentre controlled superiority trial (DRAC 1). Gut 2020; 69:1085-1091. [PMID: 32165407 DOI: 10.1136/gutjnl-2019-319996] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The optimal management of acute cholecystitis in patients at very high risk for cholecystectomy is uncertain. The aim of the current study was to compare endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD) to percutaneous cholecystostomy (PT-GBD) as a definitive treatment in these patients under a randomised controlled trial. DESIGN Consecutive patients suffering from acute calculous cholecystitis but were at very high-risk for cholecystectomy were recruited. The primary outcome was the 1-year adverse events rate. Secondary outcomes include technical and clinical success, 30-day adverse events, pain scores, unplanned readmissions, re-interventions and mortalities. RESULTS Between August 2014 to February 2018, 80 patients were recruited. EUS-GBD significantly reduced 1 year adverse events (10 (25.6%) vs 31 (77.5%), p<0.001), 30-day adverse events (5 (12.8%) vs 19 (47.5%), p=0.010), re-interventions after 30 days (1/39 (2.6%) vs 12/40 (30%), p=0.001), number of unplanned readmissions (6/39 (15.4%) vs 20/40 (50%), p=0.002) and recurrent cholecystitis (1/39 (2.6%) vs 8/40 (20%), p=0.029). Postprocedural pain scores and analgesic requirements were also less (p=0.034). The technical success (97.4% vs 100%, p=0.494), clinical success (92.3% vs 92.5%, p=1) and 30-day mortality (7.7% vs 10%, p=1) were statistically similar. The predictor to recurrent acute cholecystitis was the performance of PT-GBD (OR (95% CI)=5.63 (1.20-53.90), p=0.027). CONCLUSION EUS-GBD improved outcomes as compared to PT-GBD in those patients that not candidates for cholecystectomy. EUS-GBD should be the procedure of choice provided that the expertise is available after a multi-disciplinary meeting. Further studies are required to determine the long-term efficacy. TRIAL REGISTRATION NUMBER NCT02212717.
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Affiliation(s)
- Anthony Y B Teoh
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Manuel Pérez-Miranda
- Gastroenterology and Hepatology, University Hospital Rio Hortega, Valladolid, Spain
| | - Takeshi Ogura
- 2nd Department of Internal Medicine, Osaka Medical College, Takatuki, Japan
| | | | - Carlos Serna-Higuera
- Gastroenterology and Hepatology, University Hospital Rio Hortega, Valladolid, Spain
| | - Shunsuke Omoto
- Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-sayama, Japan
| | - Raul Torres-Yuste
- Gastroenterology and Hepatology, University Hospital Rio Hortega, Valladolid, Spain
| | - Takayoshi Tsuichiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Ka Tak Wong
- Department of Diagnostic Radiology and Organ Imaging, The Chinese University of Hong Kong, Hong Kong, China
| | - Chi-Ho Leung
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Philip Wai Yan Chiu
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Enders Kwok Wai Ng
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - James Yun Wong Lau
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
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Teoh A, Perez-Miranda M, Kunda R, Lee SS, Irani S, Yeaton P, Sun S, Baron TH, Moon JH, Holt B, Khor CJ, Rerknimitr R, Bapaye A, Chan SM, Choi HJ, James TW, Kongkam P, Lee YN, Parekh P, Ridtitid W, Serna-Higuera C, Tan DM, Torres-Yuste R. Outcomes of an international multicenter registry on EUS-guided gallbladder drainage in patients at high risk for cholecystectomy. Endosc Int Open 2019; 7:E964-E973. [PMID: 31367676 PMCID: PMC6656552 DOI: 10.1055/a-0915-2098] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 04/10/2019] [Indexed: 12/15/2022] Open
Abstract
Background and study aims The aim of the current study was to review the outcomes of a large-scale international registry on endoscopic ultrasound-guided gallbladder drainage (EGBD) that encompasses different stent systems in patients who are at high-risk for cholecystectomy. Patients and methods This was a retrospective international multicenter registry on EGBD created by 13 institutions around the world. Consecutive patients who received EGBD for several indications were included. Outcomes include technical and clinical success, unplanned procedural events (UPE), adverse events (AEs), mortality, recurrent cholecystitis and learning curve of the procedure. Results Between June 2011 and November 2017, 379 patients were recruited to the study. Technical and clinical success were achieved in 95.3 % and 90.8 % of the patients, respectively. The 30-day AE rate was 15.3 % and 30-day mortality was 9.2 %. UPEs were significantly more common in patients with EGBD performed for conversion of cholecystostomy and symptomatic gallstones ( P < 0.001); and by endoscopists with experience of fewer than 25 procedures ( P = 0.033). Both presence of clinical failure ( P = 0.014; RR 8.69 95 %CI [1.56 - 48.47]) and endoscopist experience with fewer than 25 procedures ( P = 0.002; RR 4.68 95 %CI [1.79 - 12.26]) were significant predictors of 30-day AEs. Presence of 30-day AEs was a significant predictor of mortality ( P < 0.001; RR 103 95 %CI [11.24 - 944.04]). Conclusion EGBD was associated with high success rates in this large-scale study. EGBD performed for indications other than acute cholecystitis was associated with higher UPEs. The number of cases required to gain competency with the technique by experienced interventional endosonographers was 25 procedures.
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Affiliation(s)
- A.Y. Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | | | - Rastislav Kunda
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Sang Soo Lee
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Paul Yeaton
- Department of Gastroenterology, Carilion Clinic, Roanoke, Virginia, United States
| | - Siyu Sun
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Todd Huntley Baron
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Jong Ho Moon
- Department of Internal Medicine, SoonChunHyang University College of Medicine, Bucheon Hospital, Bucheon/Seoul, Republic of Korea
| | - Bronte Holt
- Division of Gastroenterology, St Vincentʼs Hospital, Melbourne, Australia
| | - Christopher J.L. Khor
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok
| | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, India
| | - Shannon Melissa Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hyun Jong Choi
- Department of Internal Medicine, SoonChunHyang University College of Medicine, Bucheon Hospital, Bucheon/Seoul, Republic of Korea
| | - Theodore William James
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Pradermchai Kongkam
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok
| | - Yun Nah Lee
- Department of Internal Medicine, SoonChunHyang University College of Medicine, Bucheon Hospital, Bucheon/Seoul, Republic of Korea
| | - Parth Parekh
- Eastern Virginia Medical School, Norfolk, Virginia, United States
| | - Wiriyaporn Ridtitid
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok
| | | | - Damien M.Y. Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Raul Torres-Yuste
- Department of Medicine, University Hospital Rio Hortega, Valladolid, Spain
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Abstract
We report a case of acute cholestatic hepatitis in an immunocompetent young male with cytomegalovirus (CMV) primoinfection episode. The severity of the clinical symptoms led to a high-dose treatment with parenteral ganciclovir, with an immediate response and total resolution of symptoms. Therapeutic options are discussed, particularly the use of ganciclovir, even in immunocompetent patients when the severity of the symptoms could demand it.
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Affiliation(s)
- C Serna-Higuera
- Department of Gastroenterology, Ramón y Cajal Hospital, Faculty of Medicine, Alcalá de Henares University, Madrid, Spain
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