Open surgical cholecystostomy under local anaesthesia as salvage therapy of acute cholecystitis during the 4th COVID-19 wave in Northern Italy: experience from a rural hospital.

The COVID-19 pandemic outbreak delayed interventions of elective surgery worldwide. In Italy, the first western country to be affected, 410000 operations formerly planned were cancelled with the beginning of the first wave. Symptomatic cholelithiasis represents one of the most common, benign medical conditions in the world leading the affected patients to general surgeons'attention; in 0.5% of cases gallstones (symptomatic or not) can complicate with acute lithiasic cholecystitis (ALC) whose universally acknowledged treatment of choice is laparoscopic cholecystectomy. Delaying in surgery of ALC can increase the rate of complications like severe ALC, acute cholangitis and sepsis. The 4th wave of COVID 19 in Northern Italy induced further stress on the healthcare system. In fact, the occurrence of difficult communication and delays in ALC patients transfer between first and second level hospitals lead to the re-emergence of obsolete surgical procedures. In our rural hospital, in fact, a 92 years old patient affected with ALC and several comorbidities was treated with a successful emergency surgical procedure of transperitoneal cholecistostomy in lieu of a radiological transperitoneal approach. Such a choice was dictated by the absence of an interventional radiology unit in our hospital as well as the unavailability of patient transfer to our central referral hub (the hospital of Parma) due to hospital overcrowding secondary to the 4th wave of COVID 19 pandemic.

Factors Affecting Early Cholecystectomy for Acute Cholecystitis in Older People-A Population-Based Study.

OBJECTIVES: Acute cholecystitis is one of the most common surgical presentations in Australia and increases with age. Guidelines recommend early laparoscopic cholecystectomy (within 7 days), as it results in shorter length of stay, reduced costs and readmission rates. Despite this, there is a perception that early cholecystectomy may result in higher morbidity and conversion to open surgery in older patients. Our objective is to report the proportion of early versus delayed cholecystectomy in older patients in New South Wales (NSW), Australia, and to compare health outcomes and factors influencing variation. DESIGN: This is a retrospective population-based cohort study of all cholecystectomies for primary acute cholecystitis in NSW residents aged >50, between 2009 and 2019. The primary outcome was the proportion of early versus delayed cholecystectomy. We used multilevel multivariable logistic regression analyses adjusted for age, sex, comorbidities, insurance status, socio-economic status and hospital characteristics. RESULTS: A high rate (85%) of the 47,478 cholecystectomies in older patients were performed within 7 days of admission. Delayed surgery was associated with increasing age and comorbidity, male sex, Medicare-only insurance and surgery in low- or medium-volume centres. Early surgery was associated with shorter overall length of stay, fewer readmissions, less conversion to open surgery and lower bile duct injury rates. CONCLUSION: A high proportion of adults with cholecystitis are undergoing early cholecystectomy in NSW. Our results support the efficacy of early cholecystectomy in older patients and identify potentially modifiable factors relevant to health care professionals and policymakers.

A feasibility study of percutaneous transhepatic gallbladder filling (PTGBF) in a swine model.

Background: Treatments for acute cholecystitis include cholecystectomy and percutaneous drainage. However, some patients are at high risk for surgery, and prolonged drainage can decrease their quality of life. Purpose: To determine the feasibility of percutaneous transhepatic gallbladder filling (PTGBF) with n-butyl-cyanoacrylate (NBCA) in a swine model. Material and methods: After the induction of general anesthesia, percutaneous transhepatic gallbladder puncture to a pig weighing 49 kg using a 20-G-percutaneous transhepatic cholangio drain (PTCD) needle was performed under ultrasound guidance. A 2.1 F-microcatheter was inserted through the outer PTCD needle, then the cystic duct was coil-embolized. The microcatheter was removed, the gallbladder was filled with 25% NBCA-Lipiodol, then the PTCD needle was withdrawn without complications. Blood was sampled and CT images were acquired from the pig immediately after the procedure and on postoperative day 7. The pig was euthanized on postoperative day 7 and the gallbladder was evaluated by microscopy. Results: Vital signs were stable, and the CT images showed that the gallbladder contained NBCA-Lipiodol without complications such as leakage. Hepatobiliary enzymes were not elevated. Histological findings demonstrated loss of most mucosa with partial regeneration, and lymphocytic infiltration. The muscle layer was intact. Conclusion: This technique might offer a feasible alternative to surgery for high-risk patients with acute cholecystitis, but further studies are needed to determine the safety and long-term effects of this procedure.

THE USE OF MICROBIOLOGICAL AND LABORATORY DATA IN THE CHOICE OF EMPIRICAL ANTIBIOTIC THERAPY IN PATIENTS UNDERGOING LAPAROSCOPIC CHOLECYSTECTOMY - THE ROLE OF LOCAL ANTIBIOGRAMS.

Antibiotic therapy is indicated during acute cholecystitis. However, in the treatment of uncomplicated cholelithiasis, prophylactic use of antibiotics is controversial. Microbiological and laboratory data are the basis for the choice of antibiotic treatment. However, monitoring and updating local antibiograms is important because they ensure effective therapy in the given clinical environment. The study included 110 consecutive patients who underwent laparoscopic cholecystectomy, divided into the group of uncomplicated cholelithiasis (n=60) and the group of acute cholecystitis (n=50). Preoperative data included age, sex, body mass index, leukocytes, C-reactive protein, and ultrasound examination. Bile samples for bacteriological testing were obtained under aseptic conditions during the surgery. Cultures were evaluated for aerobic, anaerobic and fungal organisms using routine tests. After the surgery, gallbladder specimens were sent for histopathological examination. In the group of uncomplicated cholelithiasis, 6/60 positive samples were found, and in the group of acute cholecystitis, there were 25/50 positive microbiological findings. Citrobacter sp. and Enterococcus faecalis predominated in the group of uncomplicated cholelithiasis, and Escherichia coli, Enterococcus faecalis, Proteus mirabilis and Citrobacter sp. in the group of acute cholecystitis. Antibiotics were administered to 49/50 patients with acute cholecystitis and to 32/60 patients with uncomplicated cholelithiasis. Cefazolin was the most frequently used antibiotic and also the most resistant antibiotic. To conclude, the administration of antibiotics in elective patients is not justified. The results of this study indicate that third-generation cephalosporin or ciprofloxacin + metronidazole should be administered in mild and moderate acute cholecystitis, and fourth-generation cephalosporin + metronidazole in severe acute cholecystitis in this local setting. The appropriate use of antibiotic agents is crucial and should be integrated into good clinical practice and standards of care.

Open Cholecystostomy Under Local Anesthesia for Acute Cholecystitis in the Elderly and High-Risk Surgical Patients.

BACKGROUND: The morbidity and mortality rates associated with cholecystectomy for acute cholecystitis are higher in the critically ill elderly population. As an alternative to cholecystectomy, we report the results of treatment of acute cholecystitis in the elderly after open cholecystolithotomy with cholecystostomy tube placement under local anesthesia. METHODS: A case series was performed on 5 patients from August 2007 to April 2010 who presented with acute cholecystitis and underwent an open cholecystolithotomy and tube placement. Thirty-day mortality, intra- and immediate-postoperative complications, clinical improvement after drainage, additional biliary procedures needed, and outcome after cholecystostomy tube removal were recorded. RESULTS: Open cholecystolithotomy and tube placement were performed successfully in all patients and permitted resolution of the acute attack in all after a mean period of 3.75 days. Thirty-day mortality was 0%. Patients did not experience any intraoperative complications. We observed 100% rate of successful short-term outcomes in our patients including resolution pain, and objectively, normalization of leukocytosis, and defervescence. None of the patients required emergency cholecystectomy. All patients had their cholecystostomy tubes removed at a mean postoperative day 27. There were no cases of biliary leakage or tube dislodgement. There were no recurrences of acute cholecystitis within the mean follow-up of 20.75 months. DISCUSSION: Emergency open cholecystolithotomy and cholecystostomy tube placement represent an effective, safe, and definitive alternative treatment strategy for acute gallstone cholecystitis in selected elderly patients with a mortality rate of 0% in the authors' experience.

A safe sequential treatment approach for patients who have acute cholecystitis with severe inflammation: Transmural gallbladder drainage followed by laparoscopic cholecystectomy under the guidance of fluorescence imaging.

INTRODUCTION: For patients who have acute severe cholecystitis, urgent/early biliary drainage followed by delayed/elective laparoscopic cholecystectomy is recommended according to the Tokyo Guidelines 2018. Percutaneous transhepatic gallbladder drainage is an established technique. Recently, transmural gallbladder drainage under the guidance of endoscopic ultrasonography (EUS-GBD) was reported as a safe alternative. During surgery, fluorescence imaging using indocyanine green (ICG) has been increasingly used for visualizing the bile ducts. Herein, we report a sequential treatment approach which ensures safety without impairing normal activities before cholecystectomy: EUS-GBD followed by laparoscopic cholecystectomy using ICG fluorescence imaging. MATERIALS AND SURGICAL TECHNIQUE: A 66-year-old man with acute cholecystitis underwent urgent EUS-GBD and had the drainage tube placement through the duodenum into the gallbladder. During 2.5 months of the waiting period, he had no clinical troubles. After insertion of a laparoscope, we found a structure between the gallbladder and the duodenum. We injected 0.025 mg/mL of ICG into the nasobiliary drainage tube (placed in the gallbladder through the duodenum) and confirmed that the structure was a fistula. After removing the tube, the fistula was divided using a surgical stapler under the guidance of fluorescence imaging. The cystic and common bile ducts were also clearly visualized as fluorescence. DISCUSSION: We reported a safe sequential treatment approach for the patient who required biliary drainage: EUS-GBD followed by laparoscopic cholecystectomy under the guidance of ICG fluorescence imaging. This sequential approach may improve patients' satisfaction with respect to quality of life during the waiting period and may ensure the safety of laparoscopic cholecystectomy.

Histological examination of the gallbladder following routine cholecystectomy? A selective analysis is justified.

BACKGROUND: It was hitherto common practice to analyse each removed gallbladder for the presence of gall bladder cancer (GBC) although this approach may be questioned. The aim of this study was to determine whether a policy of selective histopathological analysis (Sel-HPA) is oncologically safe and cost effective. METHODS: This retrospective study was conducted in a single Dutch teaching hospital. Immediately following cholecystectomy, the surgeon decided on the basis of inspection and palpation whether histological examination was indicated. The Dutch Comprehensive Cancer Organisation (IKNL) registry was used to identify the number of GBC during this time period. RESULTS: Of 2271 patients who underwent a cholecystectomy in our institution between January 2012 and December 2017, 1083 (47.7%) were deemed indicated for histopathological analysis. Sixteen pathological gallbladders (1.5%) were identified in that period (intestinal metaplasia, n = 3; low grade dysplasia n = 7; carcinoma n = 6). During follow-up, no patient was found to have GBC recurrence in the population whose gallbladder was not sent for pathology (52.3%, n = 1188, median 49 months of follow up). The percentage of gallbladders that were analysed decreased over the six years of observation from 83% to 38%. Our policy of Sel-HP saved over €65 000. CONCLUSIONS: A policy of selective histopathology after cholecystectomy is oncologically safe and reduces costs.

Non-alcoholic Wernicke encephalopathy: great masquerader.

Thiamine is an important coenzyme, which is essential for metabolism and maintaining cellular osmotic gradient. Thiamine deficiency can cause focal lactic acidosis, alteration of the blood-brain barrier and the production of free radicals through cell death by necrosis and apoptosis. Wernicke encephalopathy (WE) is a clinical diagnosis. Cytotoxic and vasogenic oedema are the most typical neuroimaging findings of WE, presenting as bilateral symmetrical hyperintense signals on T2-weighted MR images. MRI is not necessary for the diagnosis of WE, but it can be helpful in ruling out alternative diagnosis. We present the case of an 61-year-old man with the history of class II obesity presenting with diplopia, dysarthria and vertigo, confirmed to be non-alcoholic WE. We aim to highlight the occurrence of WE in patients with large bowel resection though. Delay in diagnosis, particularly in obese individuals due to lack of suspicion, can lead to grim prognosis.

Microbiologic Data in Acute Cholecystitis: Ten Years' Experience from Bile Cultures Obtained during Percutaneous Cholecystostomy.

BACKGROUND: The aim of the study was to describe the microbiology and susceptibility patterns in acute cholecystitis by examining bile culture results from patients who underwent percutaneous cholecystostomy and examine concordance with empiric treatment. PATIENTS AND METHODS: A total of 124 patients with acute cholecystitis underwent percutaneous cholecystostomy between 2003 and 2012 at Emek Medical Center, Israel. Data on bile and blood culture results, isolate susceptibility, and clinical outcomes were retrieved from patient files. RESULTS: Bile cultures obtained from 116 patients were positive in 70 (60.3%) patients. Blood cultures obtained from 77 patients were positive in 23 (31.1%). Escherichia coli was the most common isolate in 28.6% of bile cultures and 43.5% of blood cultures. The concordance between empiric treatment coverage and culture isolate susceptibility was 67.6%. In most discordant cases, the isolates were Enterobacter spp. (40.9%) and Enterococcus spp. (31.8%). Overall, the in-hospital mortality rate was 7%: 2% in patients with concordant treatment compared with 14% in patients with discordant treatment (p = 0.09). Empiric antibiotic regimens were adequate in only two-thirds of patients. CONCLUSIONS: There might be a trend for poorer outcome in patients treated with inadequate antibiotic agents, emphasizing the importance of tailoring antibiotic treatment.

[PREVENTION OF INFLAMMATORY COMPLICATIONS AFTER CHOLECYSTECTOMY IF BROWN STONES IN THE GALL BLADDER AND ITS DESTRUCTIVE CHANGES].

The experience of treatment in the clinic of 47 patients with acute calculous cholecystitis was analysed. The removal of the gallbladder found brown pigment stones. The clinical course of the disease in such patients, ultrasound data and instrumental methods were described. The triple antibiotic therapy application helped to reduce the risk of infection of bile, the elimination of the inflammatory process.

Early Cholecystectomy for Acute Cholecystitis Offers the Best Outcomes at the Least Cost: A Model-Based Cost-Utility Analysis.

BACKGROUND: The application of early cholecystectomy for acute cholecystitis remains inconsistent across hospitals worldwide. Given the constrained nature of health care spending, careful consideration of costs relative to the clinical consequences of alternative treatments should support decision making. We present a cost-utility analysis comparing alternative time frames of cholecystectomy for acute cholecystitis. STUDY DESIGN: A Markov model with a 5-year time horizon was developed to compare costs and quality-adjusted life-years (QALY) gained from 3 alternative management strategies for the treatment of acute cholecystitis: early cholecystectomy (within 7 days of presentation), delayed elective cholecystectomy (8 to 12 weeks from presentation), and watchful waiting, where cholecystectomy is performed urgently only if recurrent symptoms arise. Model inputs were selected to reflect patients with uncomplicated acute cholecystitis-without concurrent common bile duct obstruction, pancreatitis, or severe sepsis. Real-world outcome probability and cost estimates included in the model were derived from analysis of population-based administrative databases for the province of Ontario, Canada. The QALY values were derived from utilities identified in published literature. Parameter uncertainty was evaluated through probabilistic sensitivity analyses. RESULTS: Early cholecystectomy was less costly (C$6,905 per person) and more effective (4.20 QALYs per person) than delayed cholecystectomy (C$8,511; 4.18 QALYs per person) or watchful waiting (C$7,274; 3.99 QALYs per person). Probabilistic sensitivity analysis showed early cholecystectomy was the preferred management in 72% of model iterations, given a cost-effectiveness threshold of C$50,000 per QALY. CONCLUSIONS: This cost-utility analysis suggests early cholecystectomy is the optimal management of uncomplicated acute cholecystitis. Furthermore, deferring surgery until recurrent symptoms arise is associated with the worst clinical outcomes.

Single center retrospective analysis of early vs. delayed treatment in acute calculous cholecystitis: application of a clinical pathway and an economic analysis.

BACKGROUND: Treatment option and timing for surgery in case of acute calculous cholecystitis (ACC) is still a matter of discussion. Tokyo Guidelines (TG13) offers some rules but they don't reflect entirely the information of Evidence Based Medicine (EBM). This study aimed to draw some consideration from our practice in the application of the guidelines and put forward the clinical, economic and organizational effect of it. METHODS: The study is a single center retrospective study based on administrative database formed by gathering information from clinical registry. Data were collected between January 1st, 2008 and April 30th, 2013. A cutoff point was established on May 15th, 2010 when we moved from a single surgeon method to a shared EBM method to treat ACC. The economic aspect was developed considering health service reimburse and hospital costs. RESULTS: Five hundred and two patients were selected, 203 patients before the organizational change (Group 0) and 299 after (Group 1). In Group 0, 24.63% of the patients were treated with early laparoscopic cholecystectomy (ELC) and 39.4% received surgery delayed in second admission (DLC). After the change, 57.5% of the patients were treated with ELC while 13% were treated with DLC. Median length of stay (LOS) was significantly lower after the change (9.5 vs. 7.3, p<0.0001), and no difference in terms of complication was noticed. CONCLUSION: Application of evidence based medicine in clinical practice resulted in better results. Economically, the clinical change resulted in a proper use of resources with a positive gap between the costs and refund to the hospital.

Success of elective cholecystectomy treatment plans after emergency department visit.

BACKGROUND: Differentiation between patients with acute cholecystitis and patients with severe biliary colic can be challenging. Patients with undiagnosed acute cholecystitis can incur repeat emergency department (ED) visits, which is resource intensive. METHODS: Billing records from 2000-2013 of all adults who visited the ED in the 30 d preceding their cholecystectomy were analyzed. Patients who were discharged from the ED and underwent elective cholecystectomy were compared with those who were discharged and returned to the ED within 30 d. T-tests, chi-square tests, and multivariable analysis were used as appropriate. RESULTS: From 2000-2013, 3138 patients (34%) presented to the ED within 30 d before surgery, 63% were women, mean age 51 y, and of those 1625 were directly admitted from the ED for cholecystectomy, whereas 1513 patients left the ED to return for an elective cholecystectomy. Patients who were discharged were younger (mean age 49 versus 54 y, P < 0.001) and had shorter ED stays (5.9 versus 7.2 h, P < 0.001) than the patients admitted immediately. Of the discharged patients, 303 (20%) returned to the ED within 30 d to undergo urgent cholecystectomy. Compared with patients with successful elective cholecystectomy after the ED visit, those who failed the pathway were more likely to have an American Society of Anesthesiologists score ≥3 and were <40 or ≥60 compared with the successful group. CONCLUSIONS: One in five patients failed the elective cholecystectomy pathway after ED discharge, leading to additional patient distress and use of resources. Further risk factor assessment may help design efficient care pathways.

[Mini-invasive technologies in treatment of acute cholecystitis in patients with high operational and anesthetic risk].

The treatment results of 769 patients with acute calculous cholecystitis and high operational and anesthetic risk at admission are presented in the retrospective study. High risk was determined by expressed comorbidities, diseases' terms, the complications of acute cholecystitis, age, which was more than 60 years in most cases. The patients were divided into 2 groups depending on the severity of comorbidity and the possible effects of its correction. The first group included 617 perspective patients for cholecystectomy. And the second group included 152 patients unpromising for this. Concept of stage treatment was used in the first group including primary decompression of the gallbladder by using of percutaneous transhepatic micro-cholecystostomy under ultrasound guidance. Cholecystectomy was performed after correction of comorbidities, complications of acute cholecystitis, and readjustment of extrahepatic bile ducts by endoscopy if necessary. Laparoscopic cholecystectomy was successfully performed in 587 patients. There was open cholecystectomy in 11 cases. Cholecystectomy was done in 19 patients as a result of conversion. Cholecystostomy from minimal access with extraction of stones under local anesthesia was performed in the second group for decompression and as definitive treatment. There was not observed deaths in patients with high operational and anesthetic risk as a result of such tactics. Postoperatively 1.7% of patients had complications that were successfully resolved.

Gallbladder complications associated with molecular targeted therapies: clinical and imaging features.

OBJECTIVES: To evaluate the clinical and imaging features of molecular target therapies (MTT)-associated gallbladder complications. METHODS: The clinical presentation, imaging features, management, and outcome in six consecutive patients, who developed gallbladder complications while on monotherapy with MTT, were studied. RESULTS: Imaging features included gallbladder distension, edema, hyperemia, pericholecystic fluid, and stranding. Two of the six patients were asymptomatic and continued the drug due to good response. Four of the six patients developed acute cholecystitis and required drug discontinuation temporarily or permanently with 2/4 patients requiring surgery. CONCLUSION: MTT can be associated with gallbladder complications that may need temporary or permanent discontinuation of the associated drug.

[Optimization of an acute destructive cholecystitis treatment using application of mini-laparotomy access, laser irradiation and regional lymphotropic therapy].

Comparative analysis of the treatment results in 120 patients, suffering destructive form of biliary calculous disease (DFBCD) was performed. Depending on operative access and postoperative conservative therapy applied the patients were divided into two groups. In the main group in 58 patients, suffering DFBCD, a minilaparotomy access was applied, using "mini-assistant" apparatus named after M. I. Prudkov and postoperatively--low-intensive laser irradiation and regional lymphotropic therapy. In a comparison group in 62 patients various laparotomic accesses were used, and a standard postoperative therapy was performed. Normalization of clinical, laboratory and immune indices in the main group were observed in twice earlier than in a control one, and economical together with moral-psychological effect was measured in reduction of the medicines quantity used as well as the patients stationary stay.