Multi-institutional Retrospective Study of Percutaneous Cholangioscopy-Assisted Lithotripsy for Inoperable Calculous Cholecystitis.

PURPOSE: This study aimed to assess the safety and efficacy of percutaneous lithotripsy for gallstone eradication in patients with calculous cholecystitis with stones >1 cm. MATERIALS AND METHODS: Multi-institutional institutional review board approved retrospective review of patients who presented with calculous cholecystitis and were not determined to be surgical candidates. All patients underwent percutaneous cholecystostomy tube placement for acute infection, which was later exchanged for a large sheath for ShockPulse (Olympus, Tokyo, Japan) lithotripsy and stone destruction. Review parameters included procedural technical and clinical data, including clinical presentation, mean length of hospital stay, and postintervention symptom reduction. RESULTS: Twelve patients (mean age, 74.6 years; range, 52-94 years; 6 men and 6 women) underwent large-bore sheath (24-30 F) cholangioscopy-assisted gallstone destruction via rigid lithotripsy. The size of the gallstones ranged from 1.2 to 4.0 cm. All patients had prior cholecystostomy access for a mean of 25 weeks before gallstone extraction to ensure tract maturation via transhepatic or transperitoneal access. The technical success rate in single-session stone removal was 100%, with no major procedure-related adverse events. All patients were symptom- and pain-free after the procedure. The mean procedure time was 111.5 minutes, and the mean fluoroscopy time was 19.2 minutes. The median length of hospital stay was 1 day after the procedure. The mean time from percutaneous lithotripsy to biliary tube removal was 35 days (range, 17-45 days). CONCLUSIONS: Fluoroscopy-guided percutaneous rigid lithotripsy is a safe and effective procedure for gallstone destruction and extraction in patients who are poor surgical candidates with large lumen-occupying cholelithiasis.

Transarterial embolisation of cystic artery pseudo aneurysm: a rare complication of acute cholecystitis.

Pseudo aneurysm of cystic artery is an extremely rare complication which may occur in association with cholecystitis, liver biopsy, biliary interventions, pancreatitis and laparoscopic cholecystectomy. We report the case of a 55 years old male patient who presented with complaint of right upper quadrant pain, haematemesis and melena, he underwent CT scan abdomen that revealed perforated gall bladder with cystic artery pseudo aneurysm secondary to acute cholecystitis. An angiogram was performed that confirmed small cystic artery pseudo aneurysm. Selective embolisation of cystic artery was done, resulting in complete exclusion of pseudo aneurysm. The patient recovered completely.

[Management of acute cholecystitis]. / Prise en charge de la cholécystite aiguë.

Acute cholecystitis is an inflammation of the gallbladder most often related to gallstones. The diagnostic and severity criteria are well described by the Tokyo criteria. Early laparoscopic cholecystectomy remains the treatment of choice. It can also be performed in elderly patients and in pregnant women during any trimester. For patients not eligible for surgery, percutaneous or echo-endoscopic gallbladder drainage (EUS-GBD) are effective treatment alternatives. The management of acute cholecystitis must therefore be adapted to each patient by carefully evaluating the risks and benefits associated with surgery.

La cholécystite aiguë est une inflammation de la vésicule biliaire le plus souvent liée à des calculs biliaires. Les critères diagnostiques et de sévérité sont bien décrits par les critères de Tokyo. La cholécystectomie laparoscopique précoce reste le traitement de choix. Elle peut être également réalisée chez les patients âgés et chez les femmes enceintes pendant n'importe quel trimestre. Pour les patients non éligibles à la chirurgie, les drainages de la vésicule biliaire par voie percutanée ou échoendoscopique (EUS-GBD) sont des alternatives thérapeutiques efficaces. La prise en charge de la cholécystite aiguë doit donc être adaptée à chaque patient en évaluant de façon attentive les risques et bénéfices associés à la chirurgie.

Determinants of outcomes of transmural EUS-guided gallbladder drainage: systematic review with proportion meta-analysis and meta-regression.

BACKGROUND AND AIMS: Transmural EUS-guided gallbladder drainage (EUS-GBD) has been increasingly used in the treatment of gallbladder diseases. Aims of the study were to provide a comprehensive meta-analysis and meta-regression of features and outcomes of this procedure. METHODS: MEDLINE, Scopus, Web of science, and Cochrane databases were searched for literature pertinent to transmural EUS-GBD up to May 2021. Random-effect meta-analysis of proportions and meta-regression of potential modifiers of outcome measures considered were applied. Outcome measures were technical success rate, overall clinical success, and procedure-related adverse events (AEs). RESULTS: Twenty-seven articles were identified including 1004 patients enrolled between February 2009 and February 2020. Acute cholecystitis was present in 98.7% of cases. Pooled technical success was 98.0% (95% CI 96.3, 99.3; heterogeneity: 23.6%), the overall clinical success was 95.4% (95% CI 92.8, 97.5; heterogeneity: 35.3%), and procedure-related AEs occurred in 14.8% (95% CI 8.8, 21.8; heterogeneity: 82.4%), being stent malfunction/dislodgement the most frequent (3.5%). Procedural-related mortality was 1‰. Meta-regression showed that center experience proxied to > 10 cases/year increased the technical success rate (odds ratio [OR]: 2.84; 95% CI 1.06, 7.59) and the overall clinical success (OR: 3.52; 95% CI 1.33, 9.33). The use of anti-migrating devices also increased the overall clinical success (OR: 2.16; 95% CI 1.07, 4.36) while reducing procedure-related AEs (OR: 0.36; 95% CI 0.14, 0.98). CONCLUSION: Physicians' experience and anti-migrating devices are the main determinants of main clinical outcomes after EUS-GBD, suggesting that treatment in expert centers would optimize results.

Clinical Presentation of Acute Cholecystitis during the COVID-19 Outbreak.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on healthcare systems worldwide. The fear of seeking medical attention to avoid the possibility of being infected may have altered the course of some diseases. OBJECTIVES: To describe our experience with the management of patients with acute cholecystitis during the pandemic at our medical center. METHODS: We compared patients treated for acute cholecystitis between 1 March and 31 August 2020 (Group I) to patients admitted with the same diagnosis during the same months in 2019 (Group II). We evaluated demographics, presenting symptoms, laboratory and imaging findings at presentation, the disease's clinical course, management, and outcome. RESULTS: Group I consisted of 101 patients and group II included 94 patients. No differences were noted for age (66 years, IQR 48-78 vs. 66 years, IQR 47-76; P = 0.50) and sex (57.4% vs. 51.1% females; P = 0.39) between the two groups. The delay between symptom onset and hospital admission was longer for Group I patients (3 days, IQR 2-7 vs. 2 days, IQR 1-3; P = 0.002). Moderate to severe disease was more commonly encountered in Group I (59.4% vs. 37.2%, P = 0.003). Group I patients more often failed conservative management (36% vs. 6%, P = 0.001) and had a higher conversion rate to open surgery (15.4% vs. 0%, P = 0.025). CONCLUSIONS: Patients presenting with acute cholecystitis during the COVID-19 pandemic more often presented late to the emergency department and more showed adverse outcomes.

Pyogenic Liver Abscess Complicating Acute Cholecystitis: Different Management Options.

Acute cholecystitis, which is usually associated with gallstones is one of the most common surgical causes of emergency hospital admission and may be further complicated by mural necrosis, perforation and abscess formation. Perforation of the gallbladder is a relatively uncommon complication of acute cholecystitis (0.8-3.2% in recent reviews). The intrahepatic perforation causing a liver abscess is an extremely rare condition, anecdotally reported in the scientific literature, even in the rare types of subacute or acute perforation. Liver abscess caused by gallbladder perforation can be a life-threatening complication with a reported mortality of 5.6%. The treatment of synchronous pyogenic liver abscess and acute cholecystitis may be challenging. We reported three cases of liver abscess due to acute cholecystitis in which different therapeutical approaches were employed. The first case was treated with antibiotics and interval laparoscopic cholecystectomy; the second case was treated with emergency cholecystectomy; and the third case with percutaneous aspiration of the abscess only. The appropriate therapeutical method in these cases depends on the patient's clinical condition, the on-site expertise that is available in the hospital, and the experience of the surgeon.

Outcomes Following an Index Emergency Admission With Cholecystitis: A National Cohort Study.

OBJECTIVE: The objective of this study was to evaluate the differences between patients who undergo cholecystectomy following index admission for cholecystitis, and those who are managed nonoperatively. SUMMARY BACKGROUND DATA: Index emergency cholecystectomy following acute cholecystitis is widely recommended by national guidelines, but its effect on clinical outcomes remains uncertain. METHODS: Data collected routinely from the Hospital Episode Statistics database (all admissions to National Health Service organizations in England and Wales) were extracted between April 1, 2002 and March 31, 2015. Analyses were limited to patients aged over 18 years with a primary diagnosis of cholecystitis. Exclusions included records with missing or invalid datasets, patients who had previously undergone a cholecystectomy, patients who had died without a cholecystectomy, and those undergoing cholecystectomy for malignancy, pancreatitis, or choledocholithiasis. Patients were grouped as either "no cholecystectomy" where they had never undergone a cholecystectomy following discharge, or "cholecystectomy." The latter group was then subdivided as "emergency cholecystectomy" when cholecystectomy was performed during their index emergency admission, or "interval cholecystectomy" when a cholecystectomy was performed within 12 months following a subsequent (emergency or elective) admission. Propensity Score Matching was used to match emergency and interval cholecystectomy groups. Main outcome measures included 1) One-year total length of hospital stay due to biliary causes following an index emergency admission with cholecystitis. 2) One-year mortality; defined as death occurring within 1 year following the index emergency admission with acute cholecystitis. RESULTS: Of the 99,139 patients admitted as an emergency with acute cholecystitis, 51.1% (47,626) did not undergo a cholecystectomy within 1 year of index admission. These patients were older, with more comorbidities (Charlson Comorbidity Score ≥ 5 in 23.5% vs. 8.1%, P < 0.001) when compared to patients who did have a cholecystectomy. While all-cause 1-year mortality was higher in the nonoperated versus the operated group (12.2% vs. 2.0%, P < 0.001), gallbladder-related deaths were significantly lower than all other causes of death in the non-operated group (3.3% vs. 8.9%, P < 0.001). Following matching, 1-year total hospital admission time was significantly higher following emergency compared with interval cholecystectomy (17.7 d vs. 13 d, P < 0.001). CONCLUSIONS: Over 50% of patients in England did not undergo cholecystectomy following index admission for acute cholecystitis. Mortality was higher in the nonoperated group, which was mostly due to non-gallbladder pathologies but total hospital admission time for biliary causes was lower over 12 months. Increasing the numbers of emergency cholecystectomy may risk over-treating patients with acute cholecystitis and increasing their time spent admitted to hospital.

Endoscopic Transpapillary Gallbladder Drainage for Acute Cholecystitis.

The mainstay of management of acute cholecystitis has been surgical, with percutaneous gallbladder drainage in patients deemed high risk for surgical intervention. Endoscopic management of acute cholecytitis with transpapillary and transmural drainage of the gall bladder is emerging as a viable alternative in high-risk surgical patients. In this article, we discuss the background, current status, technical challenges and strategies to overcome them, adverse events, and outcomes of endoscopic transpapillary gallbladder drainage for management of acute cholecystitis.

Is It Safe to Manage Acute Cholecystitis Nonoperatively During Pregnancy?: A Nationwide Analysis of Morbidity According to Management Strategy.

OBJECTIVES: To compare cholecystectomy (CCY) and nonoperative treatment (no-CCY) for acute cholecystitis in pregnancy. SUMMARY OF BACKGROUND DATA: Current Society of Gastrointestinal and Endoscopic Surgery guidelines recommend CCY over nonoperative management of acute cholecystitis during pregnancy, and the American College of Obstetricians and Gynecologists recommend medically necessary surgery regardless of trimester. This approach has been recently questioned. METHODS: Pregnant women admitted with acute cholecystitis were identified using the Nationwide Readmission Database 2010-2015. Propensity-score adjusted logistic regression models were used to compare CCY and no-CCY. The primary outcome was a composite measure of adverse maternal-fetal outcomes (intrauterine death/stillbirth, poor fetal growth, abortion, preterm delivery, C-section, obstetric bleeding, infection of the amniotic fluid, venous thromboembolism). RESULTS: There were 6390 pregnant women with acute cholecystitis: 38.2% underwent CCY, of which 5.1% were open. Patients were more likely to be managed operatively in their second trimester (First 43.9%, Second 59.1%, Third 34.2%; P < 0.01). Patients managed with CCY did not differ in age, insurance, income, Charlson Comorbidity Index, diabetes or obesity when compared to no-CCY (all P > 0.05), but were less likely to have a previous C-section, gestational diabetes, preeclampsia/eclampsia or be in the third trimester (P ≤ 0.01). Risk-adjusted analyses showed that no-CCY was associated with significantly increased maternal-fetal complications during the index admission [odds ratio 3.0 (95% confidence interval 2.08-4.34), P < 0.01] and 30-day readmissions [odds ratio 1.61 (confidence interval % CI 1.12-2.32), P < 0.01]. CONCLUSIONS: Contrary to current guidelines, most pregnant women admitted in the US with acute cholecystitis are managed nonoperatively. This is associated with over twice the odds of maternal-fetal complications in addition to increased readmissions.

Cystic Duct Embolization with Chemical Gallbladder Ablation for the Treatment of Acute Calculous Cholecystitis in High-Risk Patients: A Prospective Single-Center Study.

PURPOSE: To demonstrate the feasibility of cystic duct embolization and chemical gallbladder ablation as an alternative to cholecystectomy in high-risk patients with calculous cholecystitis who were not candidates for surgery. MATERIALS AND METHODS: This prospective study included 10 patients with acute cholecystitis (7 males and 3 females) aged 70-91 years (average age, 81.6 years) between 2013 and 2019. A cholecystostomy catheter was inserted during the acute phase, followed by cystic duct coil embolization performed via the existing drainage tube tract. Once asymptomatic, 3% aethoxysklerol was injected into the gallbladder, and the drain was removed upon sonographic confirmation that the gallbladder remained contracted. Each phase of the procedure was performed with an interval of 2-3 weeks. Clinical, cholangiographic, and sonographic data were collected before and after drain removal at 1-month follow-up. RESULTS: Cystic duct embolization was technically successful in all patients, with no immediate post-procedure complications. Gallbladder ablation performed in 10 patients was technically successful in all of them (median follow-up, 11 months). One patient required repeat ablation at 14 months, and the prolonged biliary excretions of 1 other patient ceased only at 8 months. CONCLUSIONS: Cystic duct embolization with gallbladder ablation is a feasible procedure for patients in whom cholecystectomy is contraindicated.

Management of Acute Cholecystitis during Neoadjuvant Therapy in Patients with Pancreatic Adenocarcinoma.

BACKGROUND: Patients with localized pancreatic cancer (PC) can develop acute cholecystitis during neoadjuvant therapy; optimal management remains undefined. METHODS: Consecutive patients with localized PC who had indwelling biliary stents and received neoadjuvant therapy were reviewed. Time from stent placement to the development of acute cholecystitis was calculated. Patients were categorized as having surgical versus nonoperative management of cholecystitis. Time to PC resection was defined as the time from the start of treatment to pancreatic resection. RESULTS: Of the 283 patients with indwelling biliary stents, acute cholecystitis occurred in 17 (6%) patients. The median time from the date of stent placement to the development of cholecystitis was 2.3 months [interquartile range (IQR) 4.6 months]. Acute cholecystitis was managed with cholecystostomy tube placement in 15 (88%) patients and cholecystectomy in 2 (12%). In total, 189 (67%) of the 283 patients completed all intended neoadjuvant therapy and surgery; 10 (59%) of the 17 patients with cholecystitis (10 of 15 managed with a cholecystostomy tube and 0 of 2 managed with cholecystectomy) and 179 (67%) of the 266 patients without cholecystitis (p = 0.47). The median time to PC resection was 3.2 months for the 179 patients without cholecystitis and 3.6 months for the 10 patients with cholecystitis (p = 1.00). CONCLUSIONS: Acute cholecystitis occurred in 6% of patients with indwelling biliary stents during neoadjuvant therapy. Management with a cholecystostomy tube did not delay the completion of neoadjuvant therapy and surgery and should be considered the optimal management of this complication.

Endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for high risk surgical patients with acute cholecystitis: a systematic review and meta-analysis.

BACKGROUND: Recent evidence suggests that endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an effective and safe alternative to percutaneous drainage (PT-GBD). We conducted a systematic review and meta-analysis to compare these two procedures in high risk surgical patients with acute cholecystitis. METHODS: A comprehensive electronic literature search was conducted for all articles published up to October 2017 to identify comparative studies between EUS-GBD and PT-GBD. A meta-analysis was performed on outcomes including technical success, clinical success, post-procedure adverse events, length of hospital stay, unplanned hospital readmission, need for reintervention, recurrent cholecystitis, and disease- or treatment-related mortality for these two procedures. RESULTS: Five comparative studies (206 patients in the EUS-GBD group vs. 289 patients in the PT-GBD group), were included in the final analysis. There were no statistically significant differences in technical success (odds ratio [OR] 0.43, 95 % confidence interval [CI] 0.12 to 1.58; P  = 0.21; I 2 = 0 %) and clinical success (OR 1.07, 95 %CI 0.36 to 3.16; P  = 0.90; I 2 = 44 %) between the two procedures. EUS-GBD had fewer adverse events than PT-GBD (OR 0.43, 95 %CI 0.18 to 1.00; P  = 0.05; I 2 = 66 %). Moreover, patients undergoing EUS-GBD had shorter hospital stays, with pooled standard mean difference of - 2.53 (95 %CI - 4.28 to - 0.78; P = 0.005; I 2 = 98 %), and required significantly fewer reinterventions (OR 0.16, 95 %CI 0.04 to 0.042; P <  0.001; I 2 = 32 %) resulting in significantly fewer unplanned readmissions (OR 0.16, 95 %CI 0.05 to 0.53; P  = 0.003; I 2 = 79 %). CONCLUSIONS: EUS-GBD was associated with lower rates of post-procedure adverse events, shorter hospital stays, and fewer reinterventions and readmissions compared with PT-GBD in patients with acute cholecystitis who were unfit for surgery.

Validation of Tokyo Guideline 2013 as Treatment of Acute Cholecystitis by Real World Data.

BACKGROUND: The Tokyo Guidelines (TG; 2013) indicated that emergency cholecystectomy is an important early treatment option for acute cholecystitis; however, surgical intervention is not necessarily indicated in patients with advanced age. We evaluated percutaneous transhepatic gallbladder aspiration (PTGBA), percutaneous transhepatic gallbladder drainage (PTGBD), and the administration of antibiotics alone as treatment options for acute -cholecystitis. METHODS: From January 2010 to December 2017, 159 patients with acute cholecystitis were treated at our institution. The data from these patients were retrospectively analyzed. RESULTS: Of these 159 cases, 109 underwent PTGBA, 28 underwent PTGBD, and 22 were administered antibiotics alone. None of the 159 patients needed urgent (early) cholecystectomy, and all patients were discharged without mortality. PTGBA was unsuccessful in only 6 of 109 patients; PTGBD was performed in these 6 cases. Long-term follow-up was conducted in all cases. Of the 159 patients, 146 had gallbladder stones initially, while 13 had none at the time of presentation. Of these 146 patients with gallbladder stones, 84 underwent elective cholecystectomy, while 62 did not. Of the 84 patients who underwent elective cholecystectomy, 2 developed choledocholithiasis; of the 62 patients who did not undergo elective cholecystectomy, 5 developed choledocholithiasis and 2 developed acute cholecystitis. The incidences of choledocholithiasis and acute cholecystitis did not significantly differ between the 2 groups (p = 0.06). CONCLUSIONS: Despite the recommendations in the TG (2013), emergency cholecystectomy was not needed in any of the present patients with acute cholecystitis. Acute cholecystitis can be successfully treated with -PTGBA or PTGBD, which are simple procedures with good short- and long-term safety. These procedures are highly recommended for patients with acute cholecystitis, especially in the elderly population.

Early percutaneous cholecystostomy versus antibiotic treatment for mild and moderate acute cholecystitis: A retrospective cohort study.

BACKGROUND: Percutaneous cholecystostomy (PC) is an effective treatment for severe acute cholecystitis (AC). Guidelines recommend PC as rescue therapy for patients with mild or moderate AC who do not receive emergent cholecystectomy. This study aims to investigate whether PC could be a first-line treatment for these patients. METHODS: Adult patients admitted through the emergency department between October 2004 and December 2013 were retrospectively reviewed. Patients with mild or moderate AC who did not undergo emergent cholecystectomy were included. Early PC was defined as a PC tube inserted within 24 h of diagnosis. The outcomes were compared between patients who received antibiotics plus early PC (early PC group) and those who received antibiotic treatment alone (antibiotic group). RESULTS: A total of 698 patients were included. The mean age was 63.4 years. There were 171 patients in the early PC group and 527 patients in the antibiotic group. Multivariable logistic regression analyses indicated that early PC was significantly associated with a decreased rate of prolonged fever (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.16-0.57; p < 0.001). Early PC also correlated with both increased short-term (OR, 15.95; 95% CI, 5.73-44.38; p < 0.001) and long-term treatment success (OR, 4.27; 95% CI, 2.55-7.15; p < 0.001). CONCLUSION: For patients with mild/moderate AC without emergent cholecystectomy, early PC might expedite sepsis resolution and improve the treatment success rate compared with antibiotic treatment alone. This result should be deemed as hypothesis-generating and should be examined in a randomized controlled trial.

The impact of delayed source control and antimicrobial therapy in 196 patients with cholecystitis-associated septic shock: a cohort analysis

Background: Cholecystitis-associated septic shock carries a significant mortality. Our aim was to determine whether timing of source control affects survival in cholecystitis patients with septic shock. Methods: We conducted a nested cohort study of all patients with cholecystitis-associated septic shock from an international, multicentre database (1996­2015). Multivariable logistic regression was performed to determine associations between clinical factors and in-hospital mortality. The results were used to inform a classification and regression tree (CART) analysis that modelled the association between disease severity (APACHE II), time to source control and survival. Results: Among 196 patients with cholecystitis-associated septic shock, overall mortality was 37%. Compared with nonsurvivors (n = 72), survivors (n = 124) had lower mean admission APACHE II scores (21 v. 27, p < 0.001) and lower median admission serum lactate (2.4 v. 6.8 µmol/L, p < 0.001). Survivors were more likely to receive appropriate antimicrobial therapy earlier (median 2.8 v. 6.1 h from shock, p = 0.012). Survivors were also more likely to undergo successful source control earlier (median 9.8 v. 24.7 h from shock, p < 0.001). Adjusting for covariates, APACHE II (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.06­1.21 per increment) and delayed source control > 16 h (OR 4.45, 95% CI 1.88­10.70) were independently associated with increased mortality (all p < 0.001). The CART analysis showed that patients with APACHE II scores of 15­26 benefitted most from source control within 16 h (p < 0.0001). Conclusion: In patients with cholecystitis-associated septic shock, admission APACHE II score and delay in source control (cholecystectomy or percutaneous cholecystostomy drainage) significantly affected hospital outcomes.

Contexte: Le choc septique associé à une cholécystite s'accompagne d'une mortalité significative. Notre but était de déterminer si le moment du contrôle de la source affecte la survie chez les patients atteints de cholécystite qui se trouvent en choc septique. Méthodes: Nous avons procédé à une étude de cohorte nichée regroupant tous les patients ayant présenté un choc septique associé à une cholécystite à partir d'une base de données multicentrique internationale (1996­2015). La régression logistique multivariée a été utilisée pour déterminer les liens entre les facteurs cliniques et la mortalité perhospitalière. Les résultats ont été utilisés pour éclairer une analyse par arbre de classification (CART) qui modélisait le lien entre la gravité de la maladie (APACHE II), le temps nécessaire au contrôle de la source et la survie. Résultats: Parmi 196 patients souffrant d'un choc septique associé à une cholécystite, la mortalité globale a été de 37 %. Comparativement aux patients décédés (n = 72), les survivants (n = 124) présentaient à l'admission des scores APACHE II moyens plus bas (21 c. 27, p < 0,001) et un taux de lactate sérique médian plus bas (2,4 c. 6,8 µmol/L, p < 0,001). Les survivants étaient plus susceptibles de recevoir une antibiothérapie adéquate plus hâtive (médiane 2,8 c. 6,1 h suivant le choc, p = 0,012). Les survivants étaient aussi plus susceptibles de bénéficier plus hâtivement d'un contrôle réussi de la source (médiane 9,8 c. 24,7 h suivant le choc, p < 0,001). L'ajustement pour tenir compte des covariables du score APACHE II (rapport des cotes [RC] 1,13, intervalle de confiance [IC] de 95 % 1,06­1,21 par palier) et le retard du contrôle de la source > 16 h (RC 4,45, IC de 95 % 1,88­10,70) ont été associés indépendamment à une mortalité plus élevée (tous deux p < 0,001). L'analyse CART a révélé que les patients ayant des scores APACHE II de 15­26 ont le plus bénéficié d'un contrôle de la source dans les 16 h (p < 0,0001). Conclusion: Chez les patients présentant un choc septique associé à une cholécystite, le score APACHE II à l'admission et le retard de contrôle de la source (cholécystectomie ou drainage par cholécystotomie percutanée) ont significativement influé sur les résultats hospitaliers.

Acute calculous cholecystitis: a real-life management study in a tertiary teaching hospital.

AIM: to describe the management of acute calculous cholecystitis in a tertiary teaching hospital and the outcomes obtained. MATERIAL AND METHODS: a retrospective single tertiary center cohort study. RESULTS: medical records of 487 patients were analyzed. The mean follow-up was 44.5 ± 17.0 months. Treatment alternatives were cholecystectomy (64.3%), conservative treatment (23.0%), endoscopic retrograde cholangiopancreatography (17.4%), percutaneous cholecystostomy (10.7%) and endoscopic ultrasound-guided gallbladder drainage (0.8%). Most cholecystectomies were delayed (88.8%). Recurrences occurred in 38.2% of patients. Although cholecystectomy was the therapeutic approach with the lowest recurrence rate once performed, 44.6% of patients that underwent delayed surgery had pre-surgical recurrences. CONCLUSIONS: delayed cholecystectomy is still commonly performed, even though it is related with a high frequency of preoperative recurrences.

[A retrospective analysis of clinical characteristics and mortality risks in elderly patients with acute cholecystitis and cholangitis].

Objective: To analyze the clinical characteristics and explore the risk predictors on mortality in elderly patients with acute cholecystitis and cholangitis. Methods: We conducted a retrospective analysis of elderly patients hospitalized in the Second Medical Center of General Liberation Army Hospital for acute cholecystitis and cholangitis during 2000 to 2018. Clinical data and risk predictors on mortality were assessed. The patients were stratified into three groups based on age:Ⅰ (65-74 years old),Ⅱ (75-84 years old), and Ⅲ (≥85 years old). Logistic regression analysis was used to identify the predictors of mortality. Results: A total of 574 patients were finally enrolled with the mean age 87.6 years including 191 in group Ⅰ, 167 in group Ⅱ, and 216 in group Ⅲ. The main cause of acute cholecystitis and cholangitis was gallstone (76.3%),and the main symptom was abdominal pain (62.9%),followed by chills(62.5%),fever(59.8%),jaundice (47.2%) and septic shock(26.3%). Cholecystitis was the most common diagnosis in groups Ⅰ and Ⅱ,whereas it was cholangitis in group Ⅲ. Percutaneous transhepatic biliary/gallbladder drainage (PTBD/PTGD) and endoscopic retrograde cholangiopancreatography (ERCP) were administrated more frequently in groups Ⅲ. A total of 35 patients (6.1%) died during follow-up. Senior in age (OR=11.1),the Charlson comorbidity index (OR=19.5),cancers (OR=9.6),blood stream infections (OR=7.4),severity of cholecystitis and cholangitis (OR=4.2) were risk factors associated with mortality. Conclusions: Even in the elderly patients with acute cholecystitis and cholangitis,comorbidity is one of the main factors affecting clinical outcomes. Due to the poor performance, this group of population presents more severe disease and undergoes conservative treatment strategies.

[A Case of Gallbladder Metastasis from Breast Cancer with Acute Calculous Cholecystitis].

In June 2018, a 75-year-old woman was admitted for right upper quadrant pain. She had a history of radical mastectomy for left breast cancer in April 2009. The axillary lymph node, bone, gastric, and pleural metastases had been treated with hormonal therapy for 2 years from April 2016. Based on the examination findings, we diagnosed her with acute calculous cholecystitis and performed emergency percutaneous transhepatic gallbladder drainage(PTGBD). Eleven days after PTGBD, we performed laparoscopic cholecystectomy. Pathological examination revealed a metastatic tumor from breast cancer in her gallbladder. Although her postoperative course was uneventful, the patient died of progression of the other organ metastasis 7 months after cholecystectomy. Gallbladder metastasis should be considered in patients with advanced breast cancer who present symptoms of cholecystitis.

[Percutaneous cholecystostomy as treatment for acute cholecystitis at Landspitali University Hospital 2010 - 2016].

INTRODUCTION: Acute cholecystitis is one of the most common reasons for acute admission in abdominal surgery. The recom-mended therapy is cholecystectomy but occasionally that is not possible and a conservative treatment with intravenous antibiotics is used. Should the patient not respond to conservative treatment a percutaneous catheter can be placed in the gallbladder (cholecystostomy). The aim of the study was to look at the frequency of which cholecystostomies were used and the complication rates at Landspitali, The National University Hospital of Iceland. MATERIALS AND METHODS: A retrospective study where patient charts of those with ICD - diagnosis numbers K80 - 85 at Landspitali University Hospital looked at and patients who received cholecystostomies were identified in the period from 2010 - 2016. Clinical information was registered in Excel. Descriptive statistics were used. RESULTS: A total of 4423 patients were diagnosed with biliary disease during the study period. 1255 (28%) of them had acute cholecystitis with mean age of 58 years (range: 18 - 99). A cholecystostomy was put in 88 patients (14%), mean age 71 years (range: 28 - 92). A transhepatic route was used for 62 (70%) and the drain was in place for an average of 12 days (range: 0 - 87). A secondary cholangiography was performed in 71 cases. Seventeen patients were discharged home with the cholecystostomy in place. Half of the patients underwent a laparoscopic cholecystectomy 101 days from drain insertion (range: 30 - 258). A total of 28 complications were noted in 27 patients (31%) and the most common complication was dislodgement of the catheter (n=20). Five patients (6%) died within thirty days of the intervention, three from septic shock and two from reasons unrelated to the treatment. CONCLUSIONS: Cholecystostomy is not a common choice of treatment for acute cholecystitis at Landspitali, The National University Hospital of Iceland. Few serious complications arise from the treatment and no patients died in relation to the intervention.

Evolution in the management of acute cholecystitis in the elderly: population-based cohort study.

BACKGROUND: Acute cholecystitis is a life-threatening emergency in elderly patients. This population-based cohort study aimed to evaluate the commonly used management strategies for elderly patients with acute cholecystitis as well as resulting mortality and re-admission rates. METHODS: Data from all consecutive elderly patients (≥ 80 years) admitted with acute cholecystitis in England from 1997 to 2012 were captured from the Hospital Episode Statistics database. Influence of management strategies upon mortality was analyzed with adjustment for patient demographics and treatment year. RESULTS: 47,500 elderly patients were admitted as an emergency with acute cholecystitis. On the index emergency admission the majority of patients (n = 42,620, 89.7%) received conservative treatment, 3539 (7.5%) had cholecystectomy, and 1341 (2.8%) underwent cholecystostomy. In the short term, 30-day mortality was increased in the emergency cholecystectomy group (11.6%) compared to those managed conservatively (9.9%) (p < 0.001). This was offset by the long-term benefits of cholecystectomy with a reduced 1-year mortality [20.8 vs. 27.1% for those managed conservatively (p < 0.001)]. Management with percutaneous cholecystostomy had increased 30-day and 1-year mortality (13.4 and 35.0%, respectively). The annual proportion of cholecystectomies performed laparoscopically increased from 27% in 2006 to 59% in 2012. Within the cholecystectomy group, laparoscopic approach was an independent predictor of reduced 30-day mortality (OR 0.16, 95% CI 0.10-0.25). Following conservative management, there were 16,088 admissions with further cholecystitis. Only 11% of patients initially managed conservatively or with cholecystostomy received subsequent cholecystectomy. CONCLUSION: Acute cholecystitis is associated with significant mortality in elderly patients. Potential benefits of emergency cholecystectomy in selected elderly patients include reduced rate of readmissions and 1-year mortality. Laparoscopic approach for emergency cholecystectomy was associated with an 84% relative risk reduction in 30-day mortality compared to open surgery.