Endoscopic Ultrasound-Guided Naso-gallbladder Drainage Using a Dedicated Catheter for Acute Cholecystitis After Transpapillary Metal Stent Placement for Malignant Biliary Obstruction.

BACKGROUND: Acute cholecystitis is a significant adverse event after self-expandable metal stent (SEMS) placement for malignant biliary obstruction (MBO); however, no appropriate treatment strategy has been established for its management. AIMS: This study aimed to examine the feasibility and utility of endoscopic ultrasound-guided naso-gallbladder drainage (EUS-NGBD) for the management of acute cholecystitis occurring after SEMS placement. METHODS: This retrospective study investigated consecutive patients with acute cholecystitis after SEMS placement for unresectable MBO, in whom EUS-NGBD was attempted. The study outcomes included technical success, clinical success, procedure time, adverse event, and cholecystitis recurrence, associated with the procedure. RESULTS: During the study period, EUS-NGBD was performed for SEMS-related acute cholecystitis in 30 patients with MBO. The technical and clinical success rates were 96.7% (29/30) and 96.6% (28/29), respectively. The median procedure time was 15 min, and rate of procedure-related adverse event was 3.3% (1/30). The median duration from the procedure to tube removal was 9 days. No adverse events were observed after removal. The median hospitalization duration after the procedure was 14 days, and the median duration to the (re-)start of chemotherapy from cholecystitis onset was 13 days. The median overall survival after EUS-NGBD was 123 days, and the rate of cholecystitis recurrence until death was 4.2% (1/28). CONCLUSIONS: This study demonstrated that EUS-NGBD possesses good technical and clinical feasibility with an acceptable adverse event rates and short hospitalization and chemotherapy withdrawal period. Therefore, EUS-NGBD may be a good option for the treatment of SEMS-related cholecystitis in patients with MBO.

Diseases of the Gallbladder and Biliary Tree.

Diseases of the gallbladder include a spectrum of gallstone diseases (cholelithiasis, cholecystitis, choledocholithiasis, and cholangitis), cysts, polyps, and malignancy. In this review, we present the incidence, risk factors, clinical presentation, diagnosis, and treatment of these various conditions. Importantly, we report when more urgent referral is indicated, as well as red flags that warrant further intervention and/or management.

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.

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.

Cholecystocolonic fistula following endoscopic ultrasound-guided gallbladder drainage for stump cholecystitis.

Cholecystocolonic fistulas are a rare sequela of gallstone disease. Presenting symptoms are variable but a triad of chronic diarrhea, vitamin K malabsorption, and pneumobilia has been proposed. If untreated, recurrent biliary sepsis can occur with substantial morbidity and mortality. Definitive management is surgical although endoscopic treatment has been described in nonsurgical patients. We present a case of a cholecystocolonic fistula following transgastric endoscopic ultrasound-guided gallbladder drainage with a lumen-apposing metal stent for stump cholecystitis. The patient's presenting symptom was diarrhea. Upper endoscopy and cholecystoscopy 4 weeks following gallbladder drainage revealed a cholecystocolonic fistula. The cholecystogastric tract was closed through the scope clips. The patient had no episodes of cholangitis and had a patent biliary tree with a prior biliary sphincterotomy so clinical observation was chosen. Colonoscopy 1 month later confirmed the closure of the fistula and the patient had a resolution of diarrhea. Our case highlights a novel adverse event of endoscopic ultrasound-guided gallbladder drainage caused by direct pressure of the lumen apposing metal and double pigtail stents on an already inflamed gallbladder wall. Endoscopic therapies that aid in transcapillary biliary drainage are viable alternatives to surgery and can result in fistula closure.

PARAMETERS OF CENTRAL AND INTRACARDIAC HAEMODYNAMICS IN WOMEN WITH THYROID HYPERPLASIA AND ACALCULOUS CHOLECYSTITIS.

OBJECTIVE: Aim: The study aimed to investigate some parameters of functional status of central and intracardiac haemodynamics in women with thyroid hyperplasia and acalculous cholecystitis. PATIENTS AND METHODS: Materials and Methods: Functional changes of haemodynamic status in women with thyroid hyperplasia and acalculous cholecystitis were investigated. All data are obtained through general and special clinical methods, standard and special laboratory methods of examination, physiological, biochemical and statistical methods. Parameters of central and intracardiac haemodynamics have been recorded by the method of two-dimensional M-mode echocardiography in the echo chamber "Toshiba-140" (Japan) at the resting state. RESULTS: Results: An increase in heart rate (by 45.6%) was observed in patients, which led to decreased duration of cardiac cycle and ejection time. Statistically significant (p<0.05, 11.7% on average) increase in total peripheral vascular resistance was indicated. Dynamics of changes of parameters of central and intracardiac haemodynamics indicates different parallel existing pathways of secondary disturbances in the part of cardiovascular system. A significant increase in peripheral vascular resistance associated with decreased elasticity (increased vascular rigidity) of the arteries is the element of concentric type of left ventricular hypertrophy. The increase in volume in the absence of vasospastic reactions and increasing venous tone is an element of eccentric hypertrophy. CONCLUSION: Conclusions: It is possible to talk about the presence of systolic dysfunction in patients, which, however, is predominantly of functional character. The revealed specific changes in homeostatic haemodynamic characteristics in the women's body with thyroid hyperplasia and acalculous cholecystitis require the development of new, more effective and preferably drug-free (due to liver pathology and detoxification dysfunction) approaches to medical treatment of such patients.

Incremental net benefit of cholecystectomy compared with alternative treatments in people with gallstones or cholecystitis: a systematic review and meta-analysis of cost-utility studies.

INTRODUCTION: Cholecystectomy is a standard treatment in the management of symptomatic gallstone disease. Current literature has contradicting views on the cost-effectiveness of different cholecystectomy treatments. We have conducted a systematic reappraisal of literature concerning the cost-effectiveness of cholecystectomy in management of gallstone disease. METHODS: We systematically searched for economic evaluation studies from PubMed, Embase and Scopus for eligible studies from inception up to July 2020. We pooled the incremental net benefit (INB) with a 95% CI using a random-effects model. We assessed the heterogeneity using the Cochrane-Q test, I2 statistic. We have used the modified economic evaluation bias (ECOBIAS) checklist for quality assessment of the selected studies. We assessed the possibility of publication bias using a funnel plot and Egger's test. RESULTS: We have selected 28 studies for systematic review from a search that retrieved 8710 studies. Among them, seven studies were eligible for meta-analysis, all from high-income countries (HIC). Studies mainly reported comparisons between surgical treatments, but non-surgical gallstone disease management studies were limited. The early laparoscopic cholecystectomy (ELC) was significantly more cost-effective compared with the delayed laparoscopic cholecystectomy (DLC) with an INB of US$1221 (US$187 to US$2255) but with high heterogeneity (I2=73.32%). The subgroup and sensitivity analysis also supported that ELC is the most cost-effective option for managing gallstone disease or cholecystitis. CONCLUSION: ELC is more cost-effective than DLC in the treatment of gallstone disease or cholecystitis in HICs. There was insufficient literature on comparison with other treatment options, such as conservative management and limited evidence from other economies. PROSPERO REGISTRATION NUMBER: CRD42020194052.

A population-based analysis of the impact of the COVID-19 pandemic on common abdominal and gynecological emergency department visits.

BACKGROUND: Reduced use of the emergency department during the COVID-19 pandemic may result in increased disease acuity when patients do seek health care services. We sought to evaluate emergency department visits for common abdominal and gynecologic conditions before and at the beginning of the pandemic to determine whether changes in emergency department attendance had serious consequences for patients. METHODS: We conducted a population-based analysis using administrative data to evaluate the weekly rate of emergency department visits pre-COVID-19 (Jan. 1-Mar. 10, 2020) and during the beginning of the COVID-19 pandemic (Mar. 11-June 30, 2020), compared with a historical control period (Jan. 1-July 1, 2019). All residents of Ontario, Canada, presenting to the emergency department with appendicitis, cholecystitis, ectopic pregnancy or miscarriage were included. We evaluated weekly incidence rate ratios (IRRs) of emergency department visits, management strategies and clinical outcomes. RESULTS: Across all study periods, 39 691 emergency department visits met inclusion criteria (40.2 % appendicitis, 32.1% miscarriage, 21.3% cholecystitis, 6.4% ectopic pregnancy). Baseline characteristics of patients presenting to the emergency department did not vary across study periods. After an initial reduction in emergency department visits, presentations for cholecystitis and ectopic pregnancy quickly returned to expected levels. However, presentations for appendicitis and miscarriage showed sustained reductions (IRR 0.61-0.80), with 1087 and 984 fewer visits, respectively, after the start of the pandemic, relative to 2019. Management strategies, complications and mortality rates were similar across study periods for all conditions. INTERPRETATION: Although our study showed evidence of emergency department avoidance in Ontario during the first wave of the COVID-19 pandemic, no adverse consequences were evident. Emergency care and outcomes for patients were similar before and during the pandemic.

Antibiotic stewardship in UK surgical departments: challenges and possible solutions.

Antibiotics are one of the most widely used classes of drugs within hospitals in the UK. They have a wide range of uses within all surgical specialties, both as preoperative prophylaxis and for treatment of acute surgical conditions. Antimicrobial resistance has increasingly been seen as a major issue, as the production of new antibiotics has decreased and overall use worldwide has increased. With the COVID-19 pandemic increasing concerns about antimicrobial resistance, there is an ever-increasing need for action. This article examines the particular challenges of antibiotic stewardship in surgical departments within the UK, and outlines possible solutions for improving adherence and reducing the risk of antimicrobial resistance in the future.

COVID-19 Pandemic and the Cholecystitis Experience at a Major Urban Safety-Net Hospital.

BACKGROUND: Acute cholecystitis is a common reason for emergency general surgery admission. The declaration of the COVID-19 pandemic may have resulted in treatment delays and corresponding increases in severity of disease. This study compared cholecystitis admissions and disease severity pre- and postdeclaration of pandemic. MATERIALS AND METHODS: Retrospective review of adult acute cholecystitis admissions (January 1,2020-May 31, 2020). Corresponding time periods in 2018 and 2019 comprised the historical control. Difference-in-differences analysis compared biweekly cholecystitis admissions pre- and postdeclaration in 2020 to the historical control. Odds of increased severity of disease presentation were assessed using multivariable logistic regression. RESULTS: Cholecystitis admissions decreased 48.7% from 5.2 to 2.67 cases (RR 0.51 [0.28,0.96], P = 0.04) following pandemic declaration when comparing 2020 to historical control (P = 0.02). After stratifying by severity, only Tokyo I admissions declined significantly postdeclaration (RR 0.42 [0.18,0.97]), when compared to historical control (P = 0.02). There was no change in odds of presenting with severe disease after the pandemic declaration (aOR 1.00 [95% CI 0.30, 3.38] P < 0.99) despite significantly longer lengths of symptoms reported in mild cases. CONCLUSIONS: Postpandemic declaration we experienced a significant decrease in cholecystitis admissions without corresponding increases in disease severity. The pandemic impacted healthcare-seeking behaviors, with fewer mild presentations. Given that the pandemic did not increase odds of presenting with increased severity of disease, our data suggests that not all mild cases of cholecystitis progress to worsening disease and some may resolve without medical or surgical intervention.

Cholelithiasis and cholecystitis in children and adolescents: Does this increasing diagnosis require a common guideline for pediatricians and pediatric surgeons?

BACKGROUND: In contrast to adults, for whom guidelines on the cholelithiasis treatment exist, there is no consistent treatment of pediatric patients with cholelithiasis throughout national and international departments, most probably due to the lack of evidence-based studies. METHODS: We evaluated the German management of pediatric cholelithiasis in a dual approach. Firstly, a retrospective, inter-divisional study was established, comparing diagnostics and therapy of patients of the pediatric surgery department with the management of patients aged < 25 years of the visceral surgery department in our institution over the past ten years. Secondarily, a nation-wide online survey was implemented through the German Society of Pediatric Surgery. RESULTS: Management of pediatric patients with cholelithiasis was primarily performed by pediatricians in the retrospective analysis (p < 0.001). Pediatric complicated cholelithiasis was not managed acutely in the majority of cases with a median time between diagnosis and surgery of 22 days (range 4 days-8 months vs. 3 days in visceral surgery subgroup (range 0 days-10 months), p = 0.003). However, the outcome remained comparable. The hospital's own results triggered a nation-wide survey with a response rate of 38%. Primary pediatric medical management of patients was confirmed by 36 respondents (71%). In case of acute cholecystitis, 22% of participants perform a cholecystectomy within 24 h after diagnosis. Open questions revealed that complicated cholelithiasis is managed individually. CONCLUSIONS: The management of pediatric cholelithiasis differs between various hospitals and between pediatricians and pediatric surgeons. Evidence-based large-scale population studies as well as a common guideline may represent very important tools for treating this increasing diagnosis.

Clinical acupuncture therapy for chronic cholecystitis: A protocol for systematic review and meta-analysis.

ABSTRACT: Chronic cholecystitis is a common chronic disease in clinical practice. The incidence of chronic cholecystitis is gradually increasing due to changes in eating habits and even if acute infections aren't treated in time, it can cause serious complications, continue to plague people's daily life and become an economic burden to society. Currently, the curative effect of chronic cholecystitis under the control of western medicine is still lacking and there are adverse reactions. However, based on current clinical controlled trials acupuncture therapy for chronic cholecystitis has gradually become a complementary treatment. Therefore, this systematic review aims to explore the safety and feasibility of acupuncture therapy in the treatment of chronic cholecystitis. METHODS: We will search the following databases: Medline, PubMed, Cochrane Database of Systematic Reviews, Embase, Chinese Biomedical Literatures Database, China National Knowledge Infrastructure, Wang Fang Database, Chinese Scientific Journal Database from inception to February 2021 without any language restriction. At the same time, relevant literature will be searched manually. The main search terms include: "Acupuncture," "Cholecystitis." Data entry will be completed by 2 researchers separately. After entry, cross-checking will be performed to ensure the authenticity of the information. The main outcome criteria include: including the total effective rate of the patient; the traditional Chinese medicine symptom score of the patient includes: abdominal pain, tenderness in the right upper abdomen, and so on; secondary outcome criteria include: gallbladder contraction function and gallbladder thickness, VAS scores, recurrence rate, adverse reactions; use Cochrane risk bias assessment to evaluate and score the included randomized controlled trial; meta-analysis will be performed using RevMan 5.4.0 software. The heterogeneity test is based on the thresholds of P and I2, In order to use solid or random effects models. RESULTS: This systematic review only evaluates the safety and limitations of acupuncture therapy in the treatment of chronic cholecystitis. We will report the full text in the near future. CONCLUSION: This study will explore the safety and limitations of acupuncture therapy in the treatment of chronic cholecystitis, so that acupuncture therapy will be more widely used clinically. TRIAL REGISTRATION NUMBER: INPLASY202120020.

Gallbladder Disorders: A Comprehensive Review.

Gallbladder disorders encompass a wide breadth of diseases that vary in severity. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of cholelithiasis-related disease, acute acalculous cholecystitis, functional gallbladder disorder, gallbladder polyps, gallbladder hydrops, porcelain gallbladder, and gallbladder cancer.

Management of non traumatic surgical emergencies during the COVID-19 pandemia.

In December 2019, in Wuhan, China, the first cases of what would be known as COVID-19, a disease caused by an RNA virus called SARS-CoV-2, were described. Its spread was rapid and wide, leading the World Health Organization to declare a pandemic in March 2020. The disease has distinct clinical presentations, from asymptomatic to critical cases, with high lethality. Parallel to this, patients with non-traumatic surgical emergencies, such as acute appendicitis and cholecystitis, continue to be treated at the emergency services. In this regard, there were several doubts on how to approach these cases, among them: how to quickly identify the patient with COVID-19, what is the impact of the abdominal surgical disease and its treatment on the evolution of patients with COVID-19, in addition to the discussion about the role of the non-operative treatment for abdominal disease under these circumstances. In this review, we discuss these problems based on the available evidence.

Microbiology and risk factors for gram-positive Cocci bacteremia in biliary infections.

BACKGROUND: The rapid antibiotics treatment targeted to a specific pathogen can improve clinical outcomes of septicemia. We aimed to evaluate the clinical characteristics and outcomes of biliary septicemia caused by cholangitis or cholecystitis according to causative organisms. METHODS: We performed a retrospective cohort study in 151 patients diagnosed with cholangitis or cholecystitis with bacterial septicemia from January 2013 to December 2015. All patients showed clinical evidence of biliary tract infection and had blood isolates that demonstrated septicemia. RESULTS: Gram-negative, gram-positive, and both types of bacteria caused 84.1% (127/151), 13.2% (20/151), and 2.6% (4/151) episodes of septicemia, respectively. The most common infecting organisms were Escherichia coli among gram-negative bacteria and Enterococcus species (Enterococcus casseliflavus and Enterococcus faecalis) among gram-positive bacteria. There were no differences in mortality, re-admission rate, and need for emergency decompression procedures between the gram-positive and gram-negative septicemia groups. In univariate analysis, previous gastrectomy history was associated with gram-positive bacteremia. Multivariate analysis also showed that previous gastrectomy history was strongly associated with gram-positive septicemia (Odds ratio = 5.47, 95% CI: 1.19-25.23; P = 0.029). CONCLUSIONS: Previous gastrectomy history was related to biliary septicemia induced by gram-positive organisms. This information would aid the choice of empirical antibiotics.

Disseminated Coccidioidomycosis to the Gallbladder.

Coccidioidomycosis is an infection caused by inhalation of arthroconidia produced by dimorphic fungi in the genus Coccidioides. Forty percent of patients will develop an influenza-like illness with symptoms suggestive of a mild and self-limited respiratory infection; however, 5% of these individuals will develop extrapulmonary disseminated disease. An immunocompromised patient presented with right upper quadrant pain, ultrasound with pericholecystic fluid, in which a percutaneous cholecystostomy contained biliary fluid that grew the fungus Coccidioides immitis. Patient was initiated on intravenous amphotericin therapy and was followed closely with postoperative bile drainage with eventual laparoscopic cholecystectomy. We present a very rare case of disseminated coccidioidomycosis to the gallbladder.