Early Versus Delayed Laparoscopic Cholecystectomy, after Percutaneous Gall Bladder Drainage, for Grade II Acute Cholecystitis TG18 in Patients with Concomitant Cardiopulmonary Disease.

Background: The advancement in medical care has led to an increase in patients with acute cholecystitis (AC) and cardiopulmonary comorbidities referred for surgery. Grade II AC, according to Tokyo Guidelines in 2018 (TG18), is characterized by severe local inflammation with no systemic affection. The optimal treatment for patients with high-risk grade II AC has not yet been clearly established, which is still a dilemma. For these patients, laparoscopic cholecystectomy (LC), despite being the only definitive treatment, is still a challenge. The introduction of percutaneous cholecystostomy as a temporary minimally invasive alternative technique allows an immediate gallbladder decompression with a rapid clinical improvement. However, the next step after percutaneous transhepatic gall bladder drainage (PTGBD) in these high-risk patients is still a debate, with no definitive consensus about the ideal treatment of choice as well as its optimal timing. In our study, we followed a treatment algorithm for high-risk patients that involved early gallbladder decompression by PTGBD, followed by LC at different intervals once the patient is considered fit for surgery. Method: A retrospective study of 58 patients with high-risk grade II AC with cardiopulmonary comorbidity from our medical records was included. They were managed initially with PTGBD, an LC was then performed either within 7 days after drain insertion (early group, 26 patients), while an LC was performed later for the remaining patients within 6-8 weeks after PTGBD (late group, 32 patients). The results of the two groups were analyzed. Result: Procalcitonin and C-reactive protein were significantly higher in the late group. No significant difference was found between both groups with regard to operative time, PTGBD-related complications, and major perioperative complications. Timing after PTGBD did not affect the incidence of operative complications. Total hospital stay was significantly shorter in the early group. Conclusion: PTGBD is a safe initial intervention for high-risk patients with AC with a low morbidity and high success rate. Urgent LC after PTGBD can be performed safely for well-selected high-risk patients with the timing of surgery is personalized according to each patient's clinical situation. Early LC (after PTGBD) has the advantage of shorter hospital stay, low cost, as well as avoiding the risk of biliary complications and mortality if waiting a delayed surgery with no significant difference in morbidity compared with late LC.

Novel anchoring device for endoscopic ultrasound-guided gallbladder drainage: Secondary publication.

BACKGROUND: Recently, endoscopic ultrasound-guided gallbladder drainage has attracted much attention. However, the risk management of adverse events and techniques to avoid them are not yet mature. Difficulty dilating the fistula with a dilator or placing a stent for drainage often prolongs the procedure time, which increases the risk of peritonitis or the procedure failure rate. Therefore, the result of the procedure will be unstable, and one cause is the lack of adhesion between the gallbladder and the digestive tract walls. METHODS: We developed an anchor to fix the stomach and gallbladder walls prior to endoscopic ultrasound-guided gallbladder drainage in four live pigs using the anchor. RESULTS: The stomach and gallbladder walls were fixed in three pigs, and technical success was achieved in all three pigs. In two pigs that were dissected 17 and 34 days post-procedure, respectively, fixation occurred in one pig. In the other pig, anchoring of the gallbladder and stomach walls did not occur because the wings of the anchor in the gallbladder were damaged. CONCLUSIONS: Although issues remain regarding efficacy and safety, we plan to make improvements in this novel device and aim for clinical application.

EUS-guided gallbladder drainage in high-risk surgical patients with acute cholecystitis-procedure outcomes and evaluation of mortality predictors.

BACKGROUND: Recent evidences suggest that gallbladder drainage is the treatment of choice in elderly or high-risk surgical patients with acute cholecystitis (AC). Despite better outcomes compared to other approaches, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is burdened by high mortality. The aim of the study was to evaluate predictive factors for mortality in high-risk surgical patients who underwent EUS-GBD for AC. METHODS: A retrospective analysis of a prospectively maintained database was performed. Electrocautery-enhanced lumen-apposing metal stents were used; all recorded variables were evaluated as potential predictive factors for mortality. RESULTS: Thirty-four patients underwent EUS for suspected AC and 25 (44% male, age 78) were finally included. Technical, clinical success rate and adverse events rate were 92%, 88%, and 16%, respectively. 30-day and 1-year mortality were 12% and 32%. On univariate analysis, age-adjusted Charlson Comorbidity Index (CCI) (OR 20.8[4-68.2]), acute kidney injury (AKI) (OR 21.4[2.6-52.1]) and clinical success (OR 8.9[1.2-11.6]) were related to 30-day mortality. On multivariate analysis, CCI and AKI were independently related to long-term mortality. Kaplan-Meier curves showed an increased long-term mortality in patients with CCI > 6 (hazard ratio 7.6[1.7-34.6]) and AKI (hazard ratio 11.3[1.4-91.5]). CONCLUSIONS: Severe comorbidities and AKI were independent predictive factors confirming of long-term mortality after EUS-GBD. Outcomes of EUS-GBD appear more influenced by patients' conditions rather than by procedure success.

The choice of operation timing of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD) for acute cholecystitis: a retrospective clinical analysis.

BACKGROUND: This study aimed to evaluate the timing of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD). METHODS: Patients with acute moderate to severe cholecystitis treated by LC after PTGBD in the Department of Hepatobiliary and Pancreatic Surgery, Nankai Hospital (N-362) between January 2017 and August 2019were retrospectively enrolled into this study. According to the interval times from PTGBD to LC, the patients were divided into six groups, including group A (105 cases, within 1 week), group B (62 cases, 1-2 weeks), group C (34 cases, 3-4 weeks), group D (54 cases, 5-8 weeks), group E (24 cases, 9-12 weeks), and group F (83 cases, over 12 weeks). The gender, age, hospital stay, duration of operation, rate of conversion to laparotomy, incidence of complications, and hospitalization expenses of the six groups were evaluated and compared. RESULTS: Of the 362 cases of LC, 346 patients were operated successfully (95.6%), 10 were converted to laparotomy (2.8%), 16 had various complications (4.4%), and 2 died (0.6%). There were no significant differences between groups in the gender ratio, complication rate, and rate of conversion to laparotomy. The hospital stay and hospitalization expenses in group A were the least and significantly lower than those in other groups (P<0.01), and the duration of operation in group D was the longest and significantly higher than that in groups A, B, E, and F (P<0.05). CONCLUSIONS: For non-elderly patients diagnosed with acute moderate to severe cholecystitis with an anesthesia risk score [American Society of Anesthesiologists (ASA)] ≤2, LC is recommended to be performed within 1 week after PTGBD surgery. If delayed LC is performed within 2 to 8 weeks after PTGBD, the operation time will be longer due to inflammatory edema and fibrous adhesion of the gallbladder triangle. If PTGBD is performed for more than 2 months and the clinical circumstances are good, delayed LC can be considered to reduce the inconvenience of patients with a long-term catheter as much as possible.

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

BACKGROUND: Percutaneous transhepatic gallbladder drainage (PTGBD) is recommended for acute cholecystitis patients at high risk for surgical treatment. However, there is no evidence about the best timing of surgery after PTGBD. Here, we retrospectively investigated the influence of the interval between PTGBD and surgery on perioperative outcomes and examined the optimal timing of surgery after PTGBD. METHODS: We performed a retrospective analysis of 22 patients who underwent cholecystectomy after PTGBD from January 2008 to August 2019. We examined perioperative factors between patients with an interval of ≤ 7 days between PTGBD and cholecystectomy (≤ 7-day group; n = 12) and those with an interval of ≥ 8 days (≥ 8-day group; n = 10). Moreover, we also examined perioperative factors between patients with an interval of ≤ 14 days from PTGBD to cholecystectomy (≤ 14-day group; n = 10) and those with an interval of ≥ 15 days (≥ 15-day group; n = 12). RESULTS: Of the 22 patients, 9 had Grade I cholecystitis, 12 had Grade II cholecystitis, and 2 had Grade III cholecystitis. Nine patients had high-grade cholecystitis before PTGBD and 13 had a poor general condition. We examined perioperative factors between patients with an interval of ≤ 7 days between PTGBD and cholecystectomy (≤ 7-day group; n = 12) and those with an interval of ≥ 8 days (≥ 8-day group; n = 10). The C-reactive protein (CRP) level before surgery was significantly higher (12.70 ± 1.95 mg/dL vs. 1.13 ± 2.13 mg/dL, p = 0.0007) and the total hospitalization was shorter (17.6 ± 8.0 days vs. 54.1 ± 8.8 days, p = 0.0060) in the ≤ 7-day group than in the ≥ 8-day group. We also examined perioperative factors between patients with an interval of ≤ 14 days from PTGBD to cholecystectomy (≤ 14-day group; n = 14) and those with an interval of ≥ 15 days (≥ 15-day group; n = 8). The CRP level before surgery was significantly higher (11.13 ± 2.00 mg/dL vs. 0.99 ± 2.64 mg/dL, p = 0.0062) and the total hospitalization was shorter (19.5 ± 7.2 days vs. 59.9 ± 9.5 days, p = 0.0029) in the ≤ 14-day group than in the ≥ 15-day group. However, there were no significant differences between the ≤ 14-day group and the ≥ 15-day group in the levels of hepatic enzymes before surgery, adhesion grade, amount of bleeding during surgery, operative duration, frequency of surgical complications, or length of hospitalization after surgery. CONCLUSIONS: The interval between PTGBD and surgery has little influence on perioperative outcomes.

Efficacy of releasing impacted gallstones after percutaneous transhepatic gallbladder drainage for acute cholecystitis and consideration of the surgical difficulty during laparoscopic cholecystectomy.

INTRODUCTION: Laparoscopic cholecystectomy (LC) is considered difficult in patients with an impacted gallstone (IG). We examined the efficacy of releasing an IG after percutaneous transhepatic gallbladder drainage (PTGBD) for acute cholecystitis (AC) and the usefulness of the Difficulty Score (DS) proposed in the Tokyo Guidelines 2018. METHODS: Data were collected from 28 patients who underwent LC after PTGBD for AC caused by an IG in our department. The IG was released by flushing the gallbladder with saline or performing cholecystography. Release of the IG was evaluated based on cholecystography or drainage findings. Surgical outcomes were evaluated by comparing whether the IG could be released. RESULTS: Nine patients had an IG (IG group) and 19 had a released IG at the time of surgery. Operation time was significantly longer (P = .008), Critical View of Safety score was significantly lower (P = .019), and DS was significantly higher (P < .001) in the IG group. In multivariate analysis, DS was the only independent factor for operation time (odds ratio = 8.943, 95% confidence interval 1.179-167.032; P = .033). CONCLUSION: Releasing an IG may reduce surgical difficulty and maintain surgical safety. DS can be useful in predicting surgical outcomes.

Comparison of emergency cholecystectomy and delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in patients with acute cholecystitis: a systematic review and meta-analysis.

Laparoscopic cholecystectomy and percutaneous transhepatic gallbladder drainage (PTGBD) are common treatments for patients with acute cholecystitis. However, the safety and efficacy of emergency laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC) after PTGBD in patients with acute cholecystitis remain unclear. The PubMed, EMBASE, and Cochrane Library databases were searched through October 2019. The quality of the included nonrandomized studies was assessed using the Methodological Index for Nonrandomized Studies (MINORS). The meta-analysis was performed using STATA version 14.2. A random-effects model was used to calculate the outcomes. A total of fifteen studies involving 1780 patients with acute cholecystitis were included in the meta-analysis. DLC after PTGBD was associated with a shorter operative time (SMD - 0.51; 95% CI - 0.89 to - 0.13; P = 0.008), a lower conversion rate (RR 0.43; 95% CI 0.26 to 0.69; P = 0.001), less intraoperative blood loss (SMD - 0.59; 95% CI - 0.96 to - 0.22; P = 0.002) and longer time of total hospital stay compared to ELC (SMD 0.91; 95% CI 0.57-1.24; P < 0.001). There was no difference in the postoperative complications (RR 0.68; 95% CI 0.48-0.97; P = 0.035), biliary leakage (RR 0.65; 95% CI 0.34-1.22; P = 0.175) or mortality (RR 1.04; 95% CI 0.39-2.80; P = 0.933). Compared to ELC, DLC after PTGBD had the advantages of a shorter operative time, a lower conversion rate and less intraoperative blood loss.

Surgical outcomes of percutaneous transhepatic gallbladder drainage in acute cholecystitis grade II patients according to time of surgery.

BACKGROUND: The objective of this study was to determine the appropriate timing for surgical intervention for Grade II acute cholecystitis patients. The study compares the clinical outcomes of patients in Group A, who were treated with early laparoscopic cholecystectomy (ELC) within the first two weeks of hospitalization, and Group B, treated with delayed laparoscopic cholecystectomy (DLC) after recovering from symptoms and that received conservative treatment and were discharged for more than two weeks. METHODS: From November 2011 to June 2019, from a total of 196 acute cholecystitis patients that received percutaneous transhepatic gallbladder drainage (PTGBD) insertion, we conducted a retrospective review of the group that received early laparoscopic cholecystectomy within 2 weeks and the group that received delayed laparoscopic cholecystectomy. The clinical characteristics and post-treatment outcomes were evaluated. RESULTS: In all patients treated with PTGBD insertion, Group A, the patients who were treated with ELC, showed a significantly longer mean operative time than Group B, the patients who were treated with DLC (72.46 ± 46.396 vs. 54.08 ± 27.12, P = 0.001). Similarly, Group A showed a significantly longer postoperative hospital stay compared to Group B (5.71 ± 5.062 vs. 4.27 ± 2.931, P = 0.014). CONCLUSION: In patients with Grade II acute cholecystitis with PTGBD insertion, DLC produces better outcomes with shorter hospital stay and operative time than ELC. These results suggest that DLC may lead to a better outcome than ELC, specifically when deciding the timing for laparoscopic cholecystectomy in patients diagnosed with acute Grade II cholecystitis.

Safety of EUS-guided gallbladder drainage using a lumen-apposing metal stent in patients requiring anticoagulation.

BACKGROUND AND AIMS: EUS-guided gallbladder drainage (EUS-GBD) can be used to treat acute cholecystitis in patients with medical comorbidities that prevent definitive operative management. Historically, nonsurgical management of cholecystitis was achieved by way of percutaneous gallbladder drainage. METHODS: We examined the periprocedural bleeding rate of EUS-GBD for acute cholecystitis using lumen-apposing metal stents in 5 high-surgical-risk patients requiring anticoagulation. Data on 5 nonoperative candidates with acute cholecystitis who underwent EUS-GBD were studied retrospectively. RESULTS: There were no immediate or delayed postprocedure adverse events, including bleeding. CONCLUSIONS: Although further study is needed, EUS-GBD appears safe in patients who require periprocedural anticoagulation.

Three-way comparative study of endoscopic ultrasound-guided transmural gallbladder drainage using lumen-apposing metal stents versus endoscopic transpapillary drainage versus percutaneous cholecystostomy for gallbladder drainage in high-risk surgical patients with acute cholecystitis: clinical outcomes and success in an International, Multicenter Study.

BACKGROUND: Percutaneous cholecystostomy tube (PTGBD), endoscopic retrograde cholangiopancreatography with transpapillary gallbladder drainage (TP), and endoscopic ultrasound-guided transmural gallbladder drainage (EGBD) using lumen-apposing metal stents (LAMS) have been offered for gallbladder decompression for acute cholecystitis in high-risk surgical patients. Yet, there are limited data comparing these therapies. Our aim was to compare the safety and efficacy of EGBD to TP and PTGBD for gallbladder drainage. METHODS: We retrospectively collected high-risk surgical patients from six centers with acute cholecystitis who underwent gallbladder drainage by EGBD, TP, or PTGBD. Data included technical success (gallbladder drainage), clinical success (acute cholecystitis resolution), adverse events (AE), and follow-up. RESULTS: From 2010 to 2016, 372 patients underwent gallbladder drainage, with 146 by PTGBD, 124 by TP, and 102 drained by EGBD. Technical (98% vs. 88% vs. 94%; p = 0.004) and Clinical (97% vs. 90% vs. 80%; p < 0.001) success rates were significantly higher with PTGBD and EGBD compared to TP. PTGBD group had statistically significantly higher number of complications as compared to EGBD and TP groups (2 0% vs. 2% vs. 5%; p = 0.01). Mean hospital stay in the EGBD group was significantly less than TP and PTGBD (16 vs. 18 vs. 19 days; p = 0.01), while additional surgical intervention was significantly higher in the PTGBD group compared to the EGBD and TP groups (49% vs. 4% vs. 11%; p < 0.0001). CONCLUSIONS: EGBD with LAMS is an effective and safer alternative to TP and PTGBD for treatment of patients with acute cholecystitis who cannot undergo surgery. EGBD with LAMS has significantly lower overall AEs, hospital stay, and unplanned admissions compared to PTGBD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01522573.

A case of choledocholithiasis treated by parallel cannulation along with PTGBD rendezvous.

We herewith describe a case of choledocholithiasis, with large duodenal diverticula, endoscopically treated by the parallel cannulation method alongside the extended percutaneous transhepatic gallbladder drainage (PTGBD) tube. An 81-year-old man was admitted to hospital with complaint of abdominal pain and high-grade fever. The patient was treated by PTGBD and was referred to our institution. Endoscopic retrograde cholangiography (ERC) showed a wildly winding lower bile duct, so that we could not approach the bile duct stone at that time. Next, we extended a PTGBD tube into the duodenal lumen and stretched the lower bile duct straight. Then, the bile stone was successfully moved out through ampulla without any complication.