Adverse events of self-expandable metal stent placement for malignant distal biliary obstruction: a large multicenter study.

BACKGROUND AND AIMS: Endoscopic placement of self-expandable metal stents (SEMSs) for malignant distal biliary obstruction (MDBO) may be accompanied by several types of adverse events. The present study analyzed the adverse events occurring after SEMS placement for MDBO. METHODS: The present study retrospectively investigated the incidence and types of adverse events in patients who underwent SEMS placement for MDBO between April 2018 and March 2021 at 26 hospitals. Risk factors for acute pancreatitis, cholecystitis, and recurrent biliary obstruction (RBO) were evaluated by univariate and multivariate analyses. RESULTS: Of the 1425 patients implanted with SEMSs for MDBO, 228 (16.0%) and 393 (27.6%) experienced early adverse events and RBO, respectively. Pancreatic duct without tumor involvement (P = .023), intact papilla (P = .025), and SEMS placement across the papilla (P = .037) were independent risk factors for acute pancreatitis. Tumor involvement in the orifice of the cystic duct was an independent risk factor for cholecystitis (P < .001). Use of fully and partially covered SEMSs was an independent risk factor for food impaction and/or sludge. Use of fully covered SEMSs was an independent risk factor for stent migration. Use of uncovered SEMSs and laser-cut SEMSs was an independent risk factor for tumor ingrowth. CONCLUSIONS: Pancreatic duct without tumor involvement, intact papilla, and SEMS placement across the papilla were independent risk factors for acute pancreatitis, and tumor involvement in the orifice of the cystic duct was an independent risk factor for cholecystitis. The risk factors for food impaction and/or sludge, stent migration, and tumor ingrowth differed among types of SEMSs.

Large Single-center Experience with Long-term Outcomes of EUS-guided Transmural Gallbladder Drainage.

GOALS: To describe the long-term outcomes of patients after EUS-guided gallbladder drainage (EUS-GBD), including those who underwent standardized stent exchanges for permanent plastic stents. BACKGROUND: EUS-GBD has become one of the first-line alternatives for gallbladder decompression, with outcomes and safety profiles comparable to that of percutaneous gallbladder drainage. However, the long-term outcomes of EUS-GBD are not well-described. We report our single-center experience of a large cohort who underwent EUS-GBD. STUDY: Patients who underwent EUS-GBD from August 2014 to December 2022 were included in the study. Patient demographics, comorbidities, and procedure details were recorded. Patients were followed until complete stent removal, end of study period, or death. Short and long-term outcomes include technical and clinical success, stent patency, recurrent cholecystitis, cholecystectomy, and death. RESULTS: During the study period, 128 patients were included. One hundred and one patients had benign indications for EUS-GBD, including cholecystitis and choledocholithiasis. Of those with malignant indications, 23 of 27 had distal malignant biliary obstruction. Technical and clinical successes were 95.3% and 95.1%, respectively. Stents were exchanged for 2 permanent double pigtail plastic stents in 43.0%. The mean stent patency was 421 days (488 d among those still alive) without any recurrent cholecystitis. CONCLUSION: EUS-GBD demonstrates prolonged stent patency and minimal long-term adverse events, particularly among patients who underwent stent exchanges for permanent plastic stents. EUS-GBD is also promising for patients presenting with choledocholithiasis and biliary colic who are not surgical candidates.

Symptomatic uncomplicated gallstone disease is associated with a high short-term risk of gallstone-related complications: a contemporary cohort study.

BACKGROUND: The natural history of symptomatic uncomplicated gallstone disease is largely unknown. We examined the risk of progressing from symptomatic uncomplicated to complicated gallstone disease in a large regional cohort of patients, where disruptions in elective surgical capacities have led to the indefinite postponement of surgery for benign conditions, including cholecystectomies. METHODS: Patients with radiologically diagnosed incident symptomatic and uncomplicated gallstone disease were identified from outpatient clinics and emergency departments on the Island of Funen, Denmark. The absolute risk of complications (cholecystitis, cholangitis, pancreatitis, acute cholecystectomy for unremitting pain) was calculated using death and elective cholecystectomies as competing risks using the Aalen-Johansen method. Cox proportional hazards regression analysis was used to estimate hazard ratios (HRs) of gallstone complications associated with patient and gallstone characteristics. RESULTS: Two hundred eighty-six patients diagnosed with incident symptomatic, uncomplicated gallstone disease from 1 January 2020 to 1 July 2023 were identified. During 79,170 person-years of observation, 176 (61.5%) patients developed a gallstone-related complication. The 6-, 12- and 24-month risk of developing gallstone-related complications were 36%, 55% and 81%. The risk of developing complications related to common bile duct stones was lowest with larger stones (aHR per millimeter increase = 0.89 (0.82-0.97), p < 0.01), while no covariates were statistically significantly associated with the risk of cholecystitis. Eighty-five (30%) patients underwent elective laparoscopic cholecystectomy, with one patient (1.2%) developing a gallstone-related complication afterward. CONCLUSIONS: The risk of developing complications to symptomatic gallstones in a general Scandinavian population is high, and prophylactic cholecystectomy should be considered.

Distinguishing characteristics of xanthogranulomatous cholecystitis and gallbladder adenocarcinoma: a persistent diagnostic dilemma.

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis which can resemble gallbladder adenocarcinoma (GAC) on preoperative imaging and present technical challenges in the performance of cholecystectomy. We examined our experience with each pathology to identify distinguishing characteristics that may guide patient counseling and surgical management. METHODS: A retrospective review of all pathologically confirmed cases of XGC and GAC following cholecystectomy between 2015 and 2021 at a single institution was performed. Clinical, biochemical, radiographic, and intraoperative features were compared. RESULTS: There were 37 cases of XGC and 20 cases of GAC. Patients with GAC were older (mean 70.3 years vs 58.0, p = 0.01) and exclusively female (100% vs 45.9%, p < 0.0001). There were no significant differences in accompanying symptoms between groups (nausea/vomiting, fevers, or jaundice). The mean maximum white blood cell count was elevated for XGC compared to GAC (16.4 vs 8.6 respectively, p = 0.044); however, there were no differences in the remainder of the biochemical profile, including bilirubin, liver transaminases, CEA, and CA 19-9. The presence of an intraluminal mass (61.1% vs 9.1%, p = 0.0001) and lymphadenopathy (18.8%. vs 0.0%, p = 0.045) were associated with malignancy, whereas gallbladder wall thickening as reported on imaging (87.9% vs 38.9%, p = 0.0008) and gallstones (76.5% vs. 50.0%, p = 0.053) were more often present with XGC. Cases of XGC more often had significant adhesions/inflammation (83.8% vs 55.0%, p = 0.03). CONCLUSION: Clinical features that may favor benign chronic cholecystitis over gallbladder adenocarcinoma include younger age, male gender, current or prior leukocytosis, and the absence of an intraluminal mass or lymphadenopathy. Laparoscopic cholecystectomy is a safe surgical option for equivocal presentations. Intraoperative frozen section or intentional staging of more extensive procedures based upon final histopathology are valuable surgical strategies.

Meta-analysis of fenestrating versus reconstituting subtotal cholecystectomy in the management of difficult gallbladder.

AIMS: To evaluate comparative outcomes of fenestrating and reconstituting subtotal cholecystectomy (STC) in patients with difficult gallbladder. METHODS: A systematic search of electronic data sources and bibliographic reference lists were conducted. All comparative studies reporting outcomes of laparoscopic fenestrating and reconstituting STC were included and their risk of bias were assessed using ROBINS-I tool. RESULTS: Seven comparative studies were included enrolling 590 patients undergoing laparoscopic STC using either fenestrating (n = 353) or reconstituting (n = 237) approaches. Although fenestrating STC was associated with a significantly higher rate of bile leak (OR: 2.47, p = 0.007) compared to reconstituting STC, both approaches were comparable in terms of resolution of bile leak without (RD: -0.02, p = 0.86) or with (OR: 1.84, p = 0.40) postoperative ERCP. Moreover, there was no significant difference in development of bile duct injury (RD: -0.02, p = 0.16), need for postoperative ERCP (OR: 1.36, p = 0.49), wound infection (RD: 0.03, p = 0.27), re-operation (OR: 0.95, p = 0.95), gallbladder remnant cholecystitis (OR: 0.21, p = 0.09) or need for completion cholecystectomy (RD: 0.01, p = 0.59) between two groups. CONCLUSIONS: Fenestrating STC is associated with a higher risk of bile leak than the reconstructing technique. This issue can be mitigated by routine use of drains, delayed drain removal, and in selected cases endoscopic therapy. We encourage the fenestrating approach considering trends in improved short- and long-term outcomes.

Gallbladder torsion.

ABSTRACT: Gallbladder torsion is a rare cause of acute surgical abdomen. Early recognition and surgical intervention are important for reducing complications and improving postoperative patient outcomes, but standard imaging and laboratory evaluation typically are indistinguishable from those of acute cholecystitis. This article describes a patient with gangrenous cholecystitis secondary to torsion and summarizes recommendations for evaluation and management.

HELICOBACTER PYLORI AND GALLBLADDER PATHOLOGIES: IS THERE A CAUSE-AND-EFFECT RELATIONSHIP?

The relationship between Helicobacter pylori infection and gallbladder diseases, particularly cholecystitis and gallbladder polyps, remains unclear. This study aimed to investigate the presence of H. pylori in gallbladder tissues and its potential role in gallbladder pathologies, as well as to examine the expression of chemokines CXCL2 and CXCL5 in these conditions. MATERIAL AND METHODS: A total of 137 laparoscopically excised gallbladders were analysed through histological examination, PCR for H. pylori-specific DNA, and quantitative real-time PCR for CXCL2 and CXCL5 gene expression. The study cohort included patients with acute calculous cholecystitis, chronic calculous cholecystitis, and gallbladder polyps. RESULTS: H. pylori was detected in 30.7% of cases by histological methods and 42.3% by PCR. Elevated expression of CXCL2 and CXCL5 was observed in 62% and 57.7% of cases, respectively, with a higher prevalence in acute cholecystitis compared to chronic conditions. However, no statistically significant association was found between H. pylori presence and the forms of cholecystitis, as well as between H. pylori presence and chemokine expression in gallbladder. CONCLUSIONS: The study did not establish a direct link between the presence of H. pylori infection and forms of gallbladder pathologies. The findings suggest that other factors other than H. pylori may contribute to the upregulation of CXCL2 and CXCL5 in gallbladder diseases. Further research is needed to elucidate the complex interactions between H. pylori, chemokines, and gallbladder pathologies.

Comparison of the long-term outcomes of EUS-guided gallbladder drainage and endoscopic transpapillary gallbladder drainage for calculous cholecystitis in poor surgical candidates: a multicenter propensity score-matched analysis.

BACKGROUND AND AIMS: Although long-term stent placement using endoscopic transpapillary gallbladder drainage (ETGBD) and EUS-guided gallbladder drainage (EUS-GBD) reportedly reduces cholecystitis recurrence, comparative evidence of their safety and efficacy is scarce. This study aimed to examine and compare the long-term utility of EUS-GBD versus that of ETGBD in poor surgical candidates. METHODS: A total of 379 high-risk surgical patients with acute calculous cholecystitis met the eligibility criteria for enrollment in this study. The technical success and adverse events (AEs) were compared between the EUS-GBD and ETGBD groups, and propensity score matching was performed to adjust for differences between the groups. Both groups underwent plastic stent placement, and scheduled stent exchange and removal were not performed in either group. RESULTS: The technical success rate of EUS-GBD was significantly higher than that of ETGBD (96.7% vs 78.9%, P < .001), whereas the early AE rate did not differ significantly between the 2 methods (7.8% vs 8.9%, P = 1.000). The rate of recurrent cholecystitis did not differ significantly (3.8% vs 3.0%, P = 1.000), but the rate of symptomatic late AEs, in addition to cholecystitis, was significantly lower with EUS-GBD than with ETGBD (1.3% vs 13.4%, P = .006). Consequently, the overall late AE rate was significantly lower with EUS-GBD (5.0% vs 16.4%, P = .029). Multivariate analysis revealed that EUS-GBD was associated with a significantly longer time to late AE (hazard ratio, .26; 95% confidence interval, .10-.67; P = .005). CONCLUSIONS: Long-term stent placement via EUS-GBD is a promising potential option for limiting late AEs, including recurrence, in poor surgical candidates with calculous cholecystitis.

Clinical Outcomes of Percutaneous Biliary Endoscopy: A 7-Year Single-Institution Experience.

PURPOSE: To evaluate safety and effectiveness of percutaneous biliary endoscopy (PBE) performed on patients ineligible for surgery or endoscopic retrograde cholangiopancreatography. MATERIALS AND METHODS: Retrospective review was conducted for all patients who underwent PBE at a single academic institution between June 2013 and February 2020; 39 patients underwent 58 choledochoscopy sessions, and 21 patients underwent 48 cholecystoscopy sessions. Choledochoscopy indications included stone removal (23 of 39 patients) or biliary stenosis evaluation (19 of 39 patients). Cholecystoscopy indications included calculous cholecystitis (18 of 21 patients) and symptomatic cholelithiasis (3 of 21 patients). Technical success, procedural and fluoroscopy times, and tube-free survival were assessed. RESULTS: For all PBEs performed for stone clearance, using disposable endoscopes led to shorter mean ± SD procedural (128.7 minutes ± 56.2 vs 240.2 minutes ± 184.6; P < .01) and fluoroscopy times (10.7 minutes ± 7.9 vs 16.5 minutes ± 12.0; P = .01) than using reusable endoscopes. Increasing institutional experience was associated with reduced procedural time (ß = -56.73; P < .001). Choledochoscopy technical success was 94.8% with 1 adverse event of bile duct perforation with bile leak requiring drainage. For patients with choledocholithiasis, biliary drains were removed in 14 (60.9%) patients, with a mean tube-free survival of 22.1 months ± 23.8. For cholecystoscopy, technical success was 93.8% with no adverse events. Cholecystostomy tubes were removed in 15 (71.4%) patients, with a mean tube-free survival of 7.5 months ± 8.8. CONCLUSIONS: This study supports PBE as a safe and feasible option for nonsurgical patients or those with altered anatomy precluding endoscopic retrograde cholangiopancreatography. Moreover, PBE may result in tube-free survival.

Percutaneous Cystic Duct Interventions and Drain Internalization for Calculous Cholecystitis in Patients Ineligible for Surgery.

PURPOSE: To evaluate the feasibility, effectiveness, and outcomes of percutaneous cholecystostomy drain internalization in patients with calculous cholecystitis who were not surgical candidates. MATERIALS AND METHODS: Percutaneous cystic duct interventions were attempted in 17 patients (with the intent to place dual cholecystoduodenal stents) who were deemed unfit for surgery and had previously undergone percutaneous cholecystostomies for acute calculous cholecystitis. Baseline demographics, technical success, time from percutaneous cholecystostomy to internalization (dual cholecystoduodenal stent placement), stent patency duration, and adverse event rates were evaluated. RESULTS: Fifteen (88%) of 17 procedures to cross the cystic duct were technically successful. Of these 17 patients, 13 (76%) underwent successful placement of dual cholecystoduodenal stents. Two of these 13 patients (who had successful dual cholecystoduodenal stent placement) needed repeat percutaneous cholecystostomy drains (1 patient had stent migration leading to recurrent cholecystitis, and the other had a perihepatic biloma). The 1-year patency rate was 77% (95% CI, 47%-100%). CONCLUSIONS: Dual cholecystoduodenal stent placement in nonsurgical patients is a technically feasible treatment option with the goal to remove percutaneous cholecystostomy drains.

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.

High level of tumor marker CA19-9 returned to normal after cholecystectomy in calculous cholecystitis patients.

BACKGROUND: High serum CA19-9 is usually caused by pancreaticobiliary malignancies, but it has also been found in a tiny minority of calculous cholecystitis patients. AIMS: To clarify the relationship between calculous cholecystitis and serum CA19-9. METHODS: Clinical data of calculous cholecystitis patients with high serum CA19-9 (high group, n = 20) and normal serum CA19-9 (normal group, n = 40) who underwent cholecystectomy were analyzed. Serum CA19-9 of high group were followed-up and gallbladder specimens were analyzed by immunohistochemistry. RESULTS: Serum CA19-9 in the high group ranged from 105 to 1635 U/ml, of which 30% exceeded 1000 U/ml. Follow-up results showed that 20 patient's serum CA19-9 returned to normal after cholecystectomy, including 4 closely followed-up patients whose serum CA19-9 recovered within one month. Immunohistochemical results revealed that CA19-9 was mildly positive only in mucosal epithelial cells in the normal group, but positive in mucosal epithelial cells, vascular endothelial cells, and intercellular substances in the high group, accounting for high serum CA19-9. CONCLUSION: Serum CA19-9 is proved to be associated with calculous cholecystitis for the first time, so that clinicians should consider calculous cholecystitis associated CA19-9 elevation in the clinic practice besides other CA19-9 related diseases.

Endoscopic Management of Gallbladder Disease.

PURPOSE OF REVIEW: Diseases of the gallbladder can be increasingly managed through endoscopic interventions, either serving as an alternative to or obviating the need for cholecystectomy. In this review, we aim to review the most recent data on endoscopic management of the most common gallbladder diseases. RECENT FINDINGS: The development of lumen-opposing metal stents (LAMS) marked a major shift in gallbladder management, with transmural techniques now well studied for management of cholecystitis. Endoscopic ultrasound (EUS) is also a well-developed technique for gallbladder imaging, comparable or superior to transabdominal ultrasound. Novel techniques with LAMS for gallbladder lesion/polyp resection and treatment of non-cholecystitis gallbladder diseases mark important milestones in gallbladder preservation and increasingly less invasive management of diseases of the gallbladder. There are multiple interventional endoscopic techniques that can be used to manage common gallbladder diseases including cholecystitis, cholelithiasis, gallbladder lesions/polyps, and gallbladder cancer. Ongoing development of novel therapeutic techniques holds promise for additional minimally invasive techniques in the future.

Learning curve for the surgical time of laparoscopic cholecystectomy performed by surgical trainees using the three-port method: how many cases are needed for stabilization?

BACKGROUND: The assessment of laparoscopic cholecystectomy (LC) skills using operating times has not been well reported. We examined the total and partial operating times for LC procedures performed by surgical trainees to determine the required number of surgeries until the surgical time stabilizes. METHODS: We reviewed the video records of 514 consecutive LCs using the three-port method, performed by 16 surgical trainees. The total and partial surgical times were calculated and correlated to the surgeons' experience. RESULTS: The median total surgical time for a trainee's first LC was 112 (range 71-226) minutes. It reduced rapidly after the first 20 LCs and plateaued to its minimum after approximately 60 cases. A statistically significant time decrease was observed between the first 10 (median, range 112, 46-252 min) and the next 50-59 cases (64, 34-198 min), but not between the 50-59 and the subsequent 100-109 cases (71, 33-127 min). The total times taken by trainees who had performed > 50 operations were not significantly different from those taken by instructors during the study period. Surgery for 125 patients with acute cholecystitis took a significantly longer time (median 99 vs. 74 min with non-acute cholecystitis); however, the abovementioned time reduction findings showed similar results regardless of the patient's acute inflammation status. The partial operating times around the cervical/cystic duct and gallbladder bed reduced uniformly between the first 10 and the following 50-59 cases. Although time variations in total and cervical/cystic duct operating times were not correlated to the surgical experience, time fluctuation of gallbladder bed procedures reduced after 60 cases. CONCLUSION: The time required to perform an LC was inversely correlated with the experience of surgical trainees and halved after the first 60 cases. The surgical experience required for LC time stabilization is approximately 60 cases.

Promoting a Culture of Safety in Cholecystectomy (COSIC) over a decade at a Philippine public regional hospital after the SAGES International Proctoring Course in Laparoscopic Cholecystectomy Course.

BACKGROUND: The SAGES International Proctoring Course for Laparoscopic Cholecystecomy accepts applications from low to middle-income countries for SAGES faculty to train local surgeons. A regional public hospital in the 10th most populous city in the Philippines was one of the chosen sites for the 1-week course in 2010. Two SAGES surgeons and one nurse trained two local surgeons and four nurses identified by the hospital director. METHODS: All patients seen in the out-patient clinic at the Zamboanga City Medical Center in the Philippines and scheduled for elective laparoscopic cholecystectomy from the first day of the course in August 2010 until December 2018 were entered into a prospectively collected database including demographics, pre-op diagnosis, operative findings, histopathologic diagnosis, conversion rates and 30-day complications including re-operations. RESULTS: 521 patients underwent laparoscopic cholecystectomy. Majority were female (63.7%) with a mean age of 45.9 years. Most procedures were completed laparoscopically with an open conversion rate of 3.3%. Three patients underwent laparoscopic subtotal cholecystectomy. Reported complications requiring reoperation included one stump necrosis, two incisional hernias and one retained stone. One serosal injury and one surgical site infection were also reported for an overall morbidity rate of 4.6%. Pathology showed chronic calculous cholecystitis in 92.8% of specimens. No 30-day mortality was recorded. CONCLUSION: The SAGES International Proctoring Course for Laparoscopic Cholecystectomy has been shown to be a successful method for global surgery training. A focused 1-week direct proctoring model in the Philippines showed a sustained culture of safety in cholecystectomy with low 30-day morbidity, complication and conversion rates over a decade following participation in this program.

Impact of fundus-first laparoscopic cholecystectomy for severe cholecystitis.

BACKGROUND: The Tokyo Guidelines 2018 proposed fundus-first laparoscopic cholecystectomy (FFLC) as a bailout surgery. This study investigated the clinical impact of FFLC for severe cholecystitis. METHODS: This study reviewed 772 patients who underwent laparoscopic cholecystectomy (LC) between 2015 and 2018. Of these patients, 171 patients were diagnosed with severe cholecystitis according to our difficulty scoring system. FFLC was not prevalent in our faculty for the first 2 years [early period group (EG)], whereas FFLC was predominantly used for the last 2 years [late period group (LG)]. There were 81 patients (47%) belonging to the EG and 90 patients (53%) in the LG. The clinical data and the surgical outcomes of these patients were retrospectively analyzed. RESULTS: The difficulty score did not differ between the two groups (11 vs. 11 points, p = 0.846). Patients underwent FFLC significantly more frequently in the LG (63% vs. 12%, p = 0.020). Laparoscopic subtotal cholecystectomy (LSC) was done in 10 patients (11%) of the LG, which was significantly low compared to that in the EG (n = 20, 25%) (p = 0.020). In all patients, LC was safely achieved without bile duct injury or conversion to laparotomy. The incidence of choledocholithiasis was significantly low in the LG (0 vs. 4, p = 0.048). The median postoperative hospital stay was significantly shorter in the LG (6 vs. 4 days, p < 0.001). CONCLUSION: After the introduction of FFLC, there were significant improvements in the surgical outcomes of LC for severe cholecystitis, including the rate of LSC, incidence of choledocholithiasis, and duration of postoperative hospital stay.

Retrospective validation of parkland grading scale in a Latin-American high-volume center.

BACKGROUND: Increased complication rates following laparoscopic cholecystectomies have been described, likely related to surgical difficulty, anatomical variations, and gallbladder inflammation severity. Parkland Grading Scale (PGS) stratifies the severity of intraoperative findings to predict operative difficulty and complications. This study aims to validate PGS as a postoperative-outcome predictive tool, comparing its performance with Tokyo Guidelines Grading System (TGGS). METHODS: This is a single-center retrospective cohort study where PGS and TGGS performances were evaluated regarding intraoperative and postoperative outcomes. Both univariate and bivariate analyses were performed on each severity grading scale using STATA-SE 16.0 software. Additionally, we proposed a Logistic Regression Model for each scale. Their association with outcomes was compared between both scales by their Receiver Operating Characteristic Curve. RESULTS: 400 Patients were included. Grade 1 predominance was observed for both PGS and TGGS (47.36% and 25.3%, respectively). A positive association was observed between higher PGS grades and inpatient postoperative care, length of stay, ICU care, and antibiotic requirement. Based on the area under the ROC curve, better performance was observed for PGS over TGGS in the evaluated outcomes. CONCLUSION: PGS performed better than TGGS as a predictive tool for inpatient postoperative care, length of stay, ICU, and antibiotic requirement, especially in severe cases.

Endoscopic ultrasound (EUS)-guided cholecystostomy versus percutaneous cholecystostomy (PTC) in the management of acute cholecystitis in patients unfit for surgery: a systematic review and meta-analysis.

BACKGROUND AND AIM: Surgical cholecystectomy is the gold standard strategy for the management of acute cholecystitis (AC). However, some patients are considered unfit for surgery due to certain comorbid conditions. As such, we aimed to compare less invasive treatment strategies such as endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) and percutaneous gallbladder drainage (PT-GBD) for the management of patients with AC who are suboptimal candidates for surgical cholecystectomy. METHODS: A comprehensive search of multiple electronic databases was performed to identify all the studies comparing EUS-GBD versus PT-GBD for patients with AC who were unfit for surgery. A subgroup analysis was also performed for comparison of the group undergoing drainage via cautery-enhanced lumen-apposing metal stents (LAMS) versus PT-GBD. The outcomes included technical and clinical success, adverse events (AEs), recurrent cholecystitis, reintervention, and hospital readmission. RESULTS: Eleven studies including 1155 patients were included in the statistical analysis. There was no difference between PT-GBD and EUS-GBD in all the evaluated outcomes. On the subgroup analysis, the endoscopic approach with cautery-enhanced LAMS was associated with lower rates of adverse events (RD = - 0.33 (95% CI - 0.52 to - 0.14; p = 0.0006), recurrent cholecystitis (- 0.05 RD (95% CI - 0.09 to - 0.02; p = 0.02), and hospital readmission (- 0.36 RD (95% CI-0.70 to - 0.03; p = 0.03) when compared to PT-GBD. All other outcomes were similar in the subgroup analyses. CONCLUSIONS: EUS-GBD using cautery-enhanced LAMS is superior to PT-GBD in terms of safety profile, recurrent cholecystitis, and hospital readmission rates in the management of patients with acute cholecystitis who are suboptimal candidates for cholecystectomy. However, when cautery-enhanced LAMS are not used, the outcomes of EUS-GBD and PT-GBD are similar. Thus, EUS-GBD with cautery-enhanced LAMS should be considered the preferable approach for gallbladder drainage for this challenging population.

Long-Term Impact of Endoscopic Gallbladder Stenting for Calculous Cholecystitis in Poor Surgical Candidates: A Multi-center Comparative Study.

BACKGROUND: Although long-term stent placement using endoscopic gallbladder stenting (EGBS) reportedly reduces cholecystitis recurrence in patients unfit to undergo cholecystectomy, its efficacy and safety remain uncertain. AIMS: This study aimed to examine the long-term effect of EGBS in poor surgical candidates of cholecystectomy. METHODS: A total of 528 high-risk surgical patients with acute calculous cholecystitis met this study's eligibility criteria. The technical success and adverse events (AE) were compared between patients who underwent EGBS and those who underwent percutaneous transhepatic gallbladder drainage (PTGBD). Elective stent exchange and removal were not performed after EGBS. The external tube was removed after improvement of cholecystitis following PTGBD. RESULTS: The technical success rate was significantly lower with EGBS compared to PTGBD (75.4% versus 98.7%, P < 0.001), while the early-AE rate did not differ significantly between the two methods (7.7% versus 4.3%, P = 0.146). The 1-, 3-, and 5-year cumulative incidence rates of cholecystitis were 3.8%, 7.2%, and 7.2% with EGBS, and 11.7%, 17.6%, and 30.2% with PTGBD, respectively (P = 0.001). Conversely, those of symptomatic late-AE (except cholecystitis) were 8.2%, 22.7%, and 31.4% with EGBS, and 7.5%, 10.9%, and 13.1% with PTGBD, respectively (P = 0.035). Thus, the 1-, 3-, and 5-year cumulative incidence of overall late-AE was 12.0%, 30.4%, and 40.4% with EGBS, and 19.2%, 28.3%, and 42.5% with PTGBD, respectively (P = 0.649). CONCLUSIONS: Long-term stent placement via EGBS is useful for preventing the recurrence of cholecystitis, but the success rate is low and the frequency of other late-AE increases with the prolongation of the indwelling period.

Effectiveness of preserved vagal nerve in totally laparoscopy radical distal gastrectomy: a matched-paired cohort analysis.

BACKGROUND: The aim of this retrospective matched-paired cohort study was to clarify the effectiveness of preserving the vagus nerve in totally laparoscopic radical distal gastrectomy (TLDG). METHODS: One hundred eighty-three patients with gastric cancer who underwent TLDG between February 2020 and March 2022 were included and followed up. Sixty-one patients with preservation of the vagal nerve (VPG) in the same period were matched (1:2) to conventional sacrificed (CG) cases for demographics, tumor characteristics, and tumor node metastasis stage. The evaluated variables included intraoperative and postoperative indices, symptoms, nutritional status, and gallstone formation at 1 year after gastrectomy between the two groups. RESULTS: Although the operation time was significantly increased in the VPG compared with the CG (198.0 ± 35.2 vs. 176.2 ± 35.2 min, P < 0.001), the mean time of gas passage in the VPG was significantly lower than that in the CG (68.1 ± 21.7 h vs. 75.4 ± 22.6 h, P = 0.038). The overall postoperative complication rate was similar between the two groups (P = 0.794). There was no statistically significant difference between the two groups hospital stay, total number of harvested lymph nodes, and mean number of examined lymph nodes at each station. During follow-up, the morbidity of gallstones or cholecystitis (8.2% vs. 20.5%, P = 0.036), chronic diarrhea (3.3% vs. 14.8%, P = 0.022), and constipation (4.9% vs. 16.4%, P = 0.032) were significantly lower in the VPG than in the CG in this study. Moreover, injury to the vagus nerve was found to be an independent risk factor for gallstone formation or cholecystitis and chronic diarrhea in univariate analysis and multivariate analysis. CONCLUSION: The vagus nerve plays an imperative role in gastrointestinal motility, and hepatic and celiac branch preservation mainly exerts efficacy and safety in patients who undergo TLDG.