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Cirocchi R, Amato L, Ungania S, Buononato M, Tebala GD, Cirillo B, Avenia S, Cozza V, Costa G, Davies RJ, Sapienza P, Coccolini F, Mingoli A, Chiarugi M, Brachini G. Management of Acute Cholecystitis in High-Risk Patients: Percutaneous Gallbladder Drainage as a Definitive Treatment vs. Emergency Cholecystectomy-Systematic Review and Meta-Analysis. J Clin Med 2023; 12:4903. [PMID: 37568306 PMCID: PMC10419867 DOI: 10.3390/jcm12154903] [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: 04/21/2023] [Revised: 07/23/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND This systematic review aims to investigate whether percutaneous transhepatic gallbladder biliary drainage (PTGBD) is superior to emergency cholecystectomy (EC) as a definitive treatment in high-risk patients with acute cholecystitis (AC). MATERIAL AND METHODS A systematic literature search was performed until December 2022 using the Scopus, Medline/PubMed and Web of Science databases. RESULTS Seventeen studies have been included with a total of 783,672 patients (32,634 treated with PTGBD vs. 4663 who underwent laparoscopic cholecystectomy, 343 who had open cholecystectomy and 746,032 who had some form of cholecystectomy, but without laparoscopic or open approach being specified). An analysis of the results shows that PTGBD, despite being less invasive, is not associated with lower morbidity with respect to EC (RR 0.77 95% CI [0.44 to 1.34]; I2 = 99%; p = 0.36). A lower postoperative mortality was reported in patients who underwent EC (2.37%) with respect to the PTGBD group (13.78%) (RR 4.21; 95% CI [2.69 to 6.58]; p < 0.00001); furthermore, the risk of hospital readmission for biliary complications (RR 2.19 95% CI [1.72 to 2.79]; I2 = 48%; p < 0.00001) and hospital stay (MD 4.29 95% CI [2.40 to 6.19]; p < 0.00001) were lower in the EC group. CONCLUSIONS In our systematic review, the majority of studies have very low-quality evidence and more RCTs are needed; furthermore, PTGBD is inferior in the treatment of AC in high-risk patients. The definition of high-risk patients is important in interpreting the results, but the methods of assessment and definitions differ between studies. The results of our systematic review and meta-analysis failed to demonstrate any advantage of using PTGBD over ER as a definitive treatment of AC in critically ill patients, which suggests that EC should be considered as the treatment of choice even in very high-risk patients. Most likely, the inferiority of PTGBD versus early LC for high-risk patients is related to an association of various patient-side factor conditions and the severity of acute cholecystitis.
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Affiliation(s)
- Roberto Cirocchi
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (S.A.)
| | - Lavinia Amato
- Department of General and Emergency Surgery, S. Maria della Stella Hospital, 05018 Orvieto, Italy
| | - Serena Ungania
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (S.A.)
| | - Massimo Buononato
- Department of General and Emergency Surgery, S. Maria della Stella Hospital, 05018 Orvieto, Italy
| | | | - Bruno Cirillo
- Emergency Department, Policlinico Umberto I, Sapienza University, 00161 Rome, Italy
| | - Stefano Avenia
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (S.A.)
| | - Valerio Cozza
- Department of Emergency Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Gianluca Costa
- Surgery Center, University Campus Bio-Medico of Rome, 00128 Rome, Italy
| | - Richard Justin Davies
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Paolo Sapienza
- Emergency Department, Policlinico Umberto I, Sapienza University, 00161 Rome, Italy
| | - Federico Coccolini
- Department of Emergency Surgery, Azienda Ospedaliero, Universitaria of Pisa, 56125 Pisa, Italy
| | - Andrea Mingoli
- Emergency Department, Policlinico Umberto I, Sapienza University, 00161 Rome, Italy
| | - Massimo Chiarugi
- Department of Emergency Surgery, Azienda Ospedaliero, Universitaria of Pisa, 56125 Pisa, Italy
| | - Gioia Brachini
- Emergency Department, Policlinico Umberto I, Sapienza University, 00161 Rome, Italy
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Slama EM, Hosseini M, Staszak RM, Setya VR. Open Cholecystostomy Under Local Anesthesia for Acute Cholecystitis in the Elderly and High-Risk Surgical Patients. Am Surg 2021; 88:434-438. [PMID: 34734555 DOI: 10.1177/00031348211050593] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The morbidity and mortality rates associated with cholecystectomy for acute cholecystitis are higher in the critically ill elderly population. As an alternative to cholecystectomy, we report the results of treatment of acute cholecystitis in the elderly after open cholecystolithotomy with cholecystostomy tube placement under local anesthesia. METHODS A case series was performed on 5 patients from August 2007 to April 2010 who presented with acute cholecystitis and underwent an open cholecystolithotomy and tube placement. Thirty-day mortality, intra- and immediate-postoperative complications, clinical improvement after drainage, additional biliary procedures needed, and outcome after cholecystostomy tube removal were recorded. RESULTS Open cholecystolithotomy and tube placement were performed successfully in all patients and permitted resolution of the acute attack in all after a mean period of 3.75 days. Thirty-day mortality was 0%. Patients did not experience any intraoperative complications. We observed 100% rate of successful short-term outcomes in our patients including resolution pain, and objectively, normalization of leukocytosis, and defervescence. None of the patients required emergency cholecystectomy. All patients had their cholecystostomy tubes removed at a mean postoperative day 27. There were no cases of biliary leakage or tube dislodgement. There were no recurrences of acute cholecystitis within the mean follow-up of 20.75 months. DISCUSSION Emergency open cholecystolithotomy and cholecystostomy tube placement represent an effective, safe, and definitive alternative treatment strategy for acute gallstone cholecystitis in selected elderly patients with a mortality rate of 0% in the authors' experience.
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Affiliation(s)
- Eliza M Slama
- Department of Surgery, 21963Ascension Saint Agnes Hospital, Baltimore, MD, USA
| | - Motahar Hosseini
- Department of Cardiothoracic Surgery, 4352Mayo Clinic, Rochester, MN, USA
| | - Ryan M Staszak
- Department of Trauma, Acute Care, and Critical Care Surgery, 328945Pennsylvania State University Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Viney R Setya
- Department of Surgery, 21963Ascension Saint Agnes Hospital, Baltimore, MD, USA
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