Optimal timing of percutaneous transhepatic gallbladder drainage and subsequent laparoscopic cholecystectomy according to the severity of acute cholecystitis.

Optimal timing of percutaneous transhepatic gallbladder drainage (PTGBD) and subsequent laparoscopic cholecystectomy (LC) according to the severity of acute cholecystitis (AC) is not established. Total 739 patients with AC without common bile duct stone who underwent PTGBD and subsequent LC from January 2010 to December 2019 were retrospectively reviewed. We defined difficult surgery (DS; open conversion, subtotal cholecystectomy, adjacent organ injury, transfusion, operative time ≥ 90 minutes, or estimated blood loss ≥ 100 milliliters) and poor postoperative outcomes (PPO; postoperative hospital stays ≥ 7 days, or postoperative complication ≥ grade II). The receiver operating characteristic analyses were performed for evaluating appropriate duration from onset of symptom to PTGBD (duration A) and from PTGBD to LC (duration B). Of the 739 patients, 458 were for grade I AC, and 281 were for grade II/III AC. In grade I AC, the cut-off value for the relationship between duration A and PIO was 4.5 days. The cut-off value for the relationship between duration B and PPO was 7.5 days. In multivariate analysis, duration A ≥ 5 days and duration B ≥ 8 days were statistically significant predictors for DS and PPO, respectively. In grade II/III AC, the cut-off value for the relationship between duration A and PPO was 2.5 days. In multivariate analysis, duration A ≤ 2 days was statistically significant predictor for PPO. Optimal timing of PTGBD and LC is for duration from onset of symptom to PTGBD ≤ 4 days with duration from PTGBD to LC ≤ 7 days in grade I AC, and for duration from onset of symptom to PTGBD > 2 days.

A retrospective review of percutaneous transhepatic gallbladder drainage for non-responsive or otherwise non-operable acute cholecystitis in a tertiary hospital

Introduction: Percutaneous transhepatic gallbladder drainage (PTGBD) is a safe, effective initial treatment for acute cholecystitis in high-risk patients. Laparoscopic cholecystectomy (LC) is the definitive treatment. This study evaluates the feasibility and optimal timing of LC post-PTGBD at Le Van Thinh Hospital, as outcomes may be similar regardless of surgical timing. Patients and Methods: A prospective descriptive case series was conducted from January 2022 to June 2024 at the General Surgery Department of Le Van Thinh Hospital. Patients diagnosed with grade II, III acute calculous cholecystitis who underwent PTGBD followed by LC were included. Patients were categorized into two groups based on the timing of surgery: within (group A) or beyond four weeks (Group B) post-PTGBD. Results: Seventeen patients underwent LC after PTGBD (mean age 68.76 ± 17.70 years; 41.2% male). Mean operative time was 114 ± 28.51 minutes with no conversions to open surgery. Intraoperative and postoperative complications occurred in 11.8% and 23.5% of patients, respectively. The mean hospital stay was 7 ± 1.83 days. Patients in Group A were generally younger and had fewer comorbidities and lower ASA scores compared to those in Group B. Although overall surgical outcomes were comparable, intraoperative complications were more frequent in Group B. Conclusions: LC following PTGBD for acute calculous cholecystitis is a safe and effective procedure, with low complication rates in appropriately selected patients with well-managed infections and comorbid conditions. Keywords: Acute calculous cholecystitis, percutaneous transhepatic gallbladder drainage, laparoscopic cholecystectomy. References Yamashita Y, Takada T, Kawarada Y, Nimura Y, Hirota M, Miura F, et al. Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg. 2007 Jan;14(1):91–7. Okamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepato Biliary Pancreat. 2018 Jan;25(1):55–72. El-Gendi A, El-Shafei M, Emara D. Emergency Versus Delayed Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage in Grade II Acute Cholecystitis Patients. Journal of Gastrointestinal Surgery. 2017 Feb;21(2):284–93. Jeon HW, Jung KU, Lee MY, Hong HP, Shin JH, Lee SR. Surgical outcomes of percutaneous transhepatic gallbladder drainage in acute cholecystitis grade II patients according to time of surgery. Asian Journal of Surgery. 2021 Jan;44(1):334–8. Lee R, Ha H, Han YS, Kwon HJ, Ryeom H, Chun JM. Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis. Medicine. 2017 Nov;96(44):e8533. Nguyen Thanh Sang, Vo Duc Tam, Bui Hong Minh Hau. Role of percutaneous transhepatic gallbladder drainage in the management of acute calculous cholecystitis. Ho Chi Minh City Journal of Medicine. 2015;19(5):84-90. Nguyen Anh Dung, Nguyen Cao Cuong, Tran Hoang Nhut. Comparison of outcomes between emergency laparoscopic cholecystectomy and laparoscopic cholecystectomy after gallbladder drainage in grade II acute calculous cholecystitis at Binh Dan Hospital. Pham Ngoc Thach Journal of Medicine and Pharmacy. 2022;1(2):106-115. Ke CW, Wu SD. Comparison of Emergency Cholecystectomy with Delayed Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage in Patients with Moderate Acute Cholecystitis. J Laparoendosc Adv Surg Tech A. 2018 Jun;28(6):705–12. Kimura K, Adachi E, Omori S, Toyohara A, Higashi T, Kippei Ohgaki, et al. The influence of the interval between percutaneous transhepatic gallbladder drainage and cholecystectomy on perioperative outcomes: a retrospective study. BMC gastroenterology. 2021 May 19;21(1). Lyu Y, Li T, Wang B, Cheng Y. Early laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for acute cholecystitis. Scientific Reports. 2021 Jan 28;11(1). Download file PDF

Interval cholecystectomy following drainage procedures for acute cholecystitis: percutaneous transhepatic vs endoscopic transpapillary gallbladder drainage

BackgroundSevere adhesions and fibrosis between the posterior wall of the gallbladder and liver bed often render total cholecystectomy after percutaneous transhepatic gallbladder drainage (PTGBD) difficult, leading to high open conversion rates. Since the publication of Tokyo Guidelines 2018 (TG18), our policy has shifted from open conversion to subtotal cholecystectomy (SC) when total laparoscopic cholecystectomy for difficult cases of cholecystitis is not feasible. Recently, SC has been frequently applied as bailout surgery for complicated cholecystitis. Nonetheless, the efficacy and validity of laparoscopic SC after PTGBD remain unclear. This study aimed to evaluate the safety and feasibility of laparoscopic SC after PTGBD for grade II or III acute cholecystitis (AC) by comparing two periods of altered surgical strategies.MethodsThis retrospective cohort study was conducted between January 2013 and December 2020. A total of 44 eligible patients with grade II or III AC were divided according to the time of cholecystitis onset into the pre-TG18 group (2013–2017, n = 17) and post-TG18 group (2018–2020, n = 27). Patients’ background demographics, surgical method, surgical results, and postoperative complications were compared.ResultsThe interval between PTGBD and surgery was significantly longer in the post-TG18 group than in the pre-TG18 group (15 [interquartile range: 9–42] days vs. 8 [4–11] days; P = 0.010). The frequency of laparoscopic cholecystectomy significantly increased from 52.9% in the pre-TG18 group to 88.9% in the post-TG18 group (P = 0.007), whereas the frequency of SC was 23.5% and 40.7%, respectively, which showed no statistically significant difference (P = 0.241). However, the rate of laparoscopic SC significantly increased from 0 to 90.9% among 15 SC cases, whereas the rate of open SC significantly plummeted from 100 to 9.1% (P = 0.001). Significant differences in the operative time, amount of intraoperative bleeding, and incidence of postoperative complications (wound infection and subhepatic abscess) were not observed. Mortality, bile leakage, and bile duct injury did not occur in either group.ConclusionsFor grade II or III AC after PTGBD, aggressive adoption of SC increased the completion rate of laparoscopic surgery. Laparoscopic SC is a safe and feasible treatment option.

Objective To investigate the application value of early and delayed laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGD) in 65 years of age or older patients with severe acute cholecystitis. Methods The prospective study was conducted. The clinical data of 80 patients with severe acute cholecystitis who were admitted to Shanxi Dayi Hospital of Shanxi Academy of Medical Sciences from May 2016 to January 2018 were collected. All patients were divided into two groups by random number table, including patients undergoing LC 72 h later after extubation of PTGD in the PTGD + early LC group, and patients undergoing LC 5-14 days later after extubation of PTGD in the PTGD + delayed LC group. Observation indicators: (1) surgical situations; (2) analysis of liver function before and after LC in the two groups; (3) analysis of serum-related inflammatory factors before and after LC in the two groups; (4) follow-up situations. Patients were followed up by outpatient examination or telephone interview to detect the postoperative complications in the postoperative three months up to April 2018. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was done using the paired t test. Count data were represented as absolute number, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Results Eighty patients were screened for eligibility, including 41 males and 39 females, aged from 65 to 70 years, with an average age of 67 years. There were 40 patients in the PTGD + early LC group and 40 in the PTGD + delayed LC group, respectively. (1) Surgical situations: the operation time, volume of intra-operative blood loss, and duration of postoperative hospital stay were (52±15)minutes, (29±11)mL, (18.9±1.6)days in the PTGD + early LC group, and (88±13)minutes, (69±11)mL, (27.7±4.8)days in the PTGD + delayed LC group, respectively, showing significant differences in the above indicators between the two groups (t=11.668, 16.219, 11.000, P 0.05), meanwhile, there were significant differences in the levels of AST, ALT, ALP, GGT, TBil after LC between the two groups (t=2.683, 10.067, 19.931, 6.508, 2.380, P 0.05), meanwhile, there were significant differences in the levels of IL-1, IL-6, high-sensitivity CRP, and TNF-α after LC between the two groups (t=24.844, 13.092, 4.833, 15.185, P<0.05). (4) Follow-up situations: 80 patients were followed up for 3 months. Two patients in the PTGD + early LC group had postoperative complications, including 1 of bile duct injury and 1 of incisional infection; 9 patients of PTGD + delayed LC group had postoperative complications, including 3 of bile duct injury, 3 of multiple organ failure, 2 of incisional infection, 1 of death. There was a significant difference in the postoperative complication between the two groups (χ2=5.165, P<0.05). Conclusion Early LC after PTGD can effectively shorten operation time, reduce volume of intraoperative blood loss, shorten duration of postoperative hospital stay, protect liver function, reduce the expression of serum inflammatory factors at 24 hours after surgery, and reduce postoperative complications. Key words: Severe acute cholecystitis; Percutaneous transhepatic gallbladder drainage; Cholecystectomy; Early surgery; Delayed surgery; Laparoscopy

BACKGROUNDB-mode-ultrasound-guided percutaneous cholecystostomy (PC) may be performed by a transhepatic or transperitoneal approach, called percutaneous transhepatic gallbladder drainage (PHGD) and percutaneous transperitoneal gallbladder drainage (PPGD), respectively. We compared the impact of PC related to the route of catheter placement on subsequent laparoscopic cholecystectomy (LC).AIMTo compare the impact of PC related to the route of catheter placement on subsequent LC.METHODSWe retrospectively studied 103 patients with acute calculous cholecystitis who underwent scheduled LC after PC between January 2010 and January 2019. Group I included 58 patients who underwent scheduled LC after PHGD. Group II included 45 patients who underwent scheduled LC after PPGD. Clinical outcomes were analyzed according to each group.RESULTSBaseline demographic characteristics did not differ significantly between both groups (P > 0.05). Both PHGD and PPGD were able to quickly resolve cholecystitis sepsis. Group I showed significantly higher efficacy than group II in terms of lower pain score during puncture (3.1 vs 4.5; P = 0.001) and at 12 h follow-up (1.5 vs 2.2; P = 0.001), lower rate of fever within 24 h after PC (13.8% vs 42.2%; P = 0.001), shorted operation duration (118.3 vs 139.6 min; P = 0.001), lower amount of intraoperative bleeding (72.1 vs 109.4 mL; P = 0.001) and shorter length of hospital stay (14.3 d vs 18.0 d; P = 0.001). However, group II had significantly lower rate of local bleeding at the PC site (2.2% vs 20.7%; P = 0.005) and lower rate of severe adhesion (33.5% vs 55.2%; P = 0.048). No significant differences were noted between both groups regarding the conversion rate to laparotomy, rate of subtotal cholecystectomy, complications and pathology.CONCLUSIONB-mode-ultrasound-guided PHGD is superior to PPGD followed by LC for treatment of acute calculous cholecystitis, with shorter operating time, minimal amount of intraoperative bleeding and short length of hospital stay.

Objective To evaluate the application of percutaneous transhepatic gallbladder drainage (PTGD) in the treatment of acute calculous cholecystitis in 3 kinds of special population including the elderly, cirrhosis or mid and late-stage pregnant women. Methods Clinical data of 292 patients with acute calculous cholecystitis among 3 kinds of special population who underwent PTGD in Baoji Central Hospital of Shaanxi between January 2009 and December 2015 were analyzed retrospectively. The informed consents of all patients were obtained and the local ethical committee approval was received. There were 105 males and 187 females, aged from 22-91 and with a median age of 47 years old. 176 cases were elderly patients, 77 were with cirrhosis and 39 were mid and late-stage pregnant women. Ultrasound-guided PTGD was performed in the patients to relieve gallbladder tension rapidly, and laparoscopic cholecystectomy (LC) was performed according to the patient's condition. Efficacy of cholecystitis control in elderly patients before and after PTGD as well as the efficacy of surgical treatment in patients with liver cirrhosis or mid and late-stage pregnant women were observed. Cholecystitis indexes before and after PTGD were compared using t test. Results Symptoms of elderly patients significantly improved 3 d after PTGD. The average WBC, C-reactive protein and procalcitonin were (9.8±0.5)×109/L, (22.0±1.3) μg/L and (0.15±0.02) μg/L, which were significantly lower than preoperative (12.5±0.4)×109/L, (35.0±2.8) μg/L and (0.25±0.03) μg/L, respectively (t=-18.725, -29.062, -21.287; P<0.05). Cholecystitis in 77 patients with liver cirrhosis were effectively controlled within 1 week after PTGD, including 66 received sequential LC and 1 converted to open cholecystectomy, witha length of operation (31±9) min, intraoperative blood loss (21±5) ml and postoperative length of hospital stay (4.3±0.6) d. Cholecystitis in 39 mid and late-stage pregnant women were effectively controlled 1 week after PTGD. These patients received elective LC during the period after PTGD to 1 month after delivery, including 1 converted to open cholecystectomy. Conclusions For patients with acute calculous cholecystitis in3 kinds of special population including the elderly, those with cirrhosis or mid and late-stage pregnant women, PTGD can effectively control the cholecystitis with the advantages of simple operation, minimally invasive, safety and effectiveness, and sequential elective LC can reduce the risk of emergent surgery. Key words: Drainage; Aged; Liver cirrhosis; Pregnancy; Cholecystectomy, laparoscopic

Patients with moderate (grade II) acute cholecystitis patients, as defined by the 2013 Tokyo Guidelines, were retrospectively compared with respect to emergency cholecystectomy (EC) and delayed cholecystectomy (DC) after percutaneous transhepatic gallbladder drainage (PTGBD) to determine the better treatment strategy. Forty-nine of 103 patients with PTGBD and 47 of 54 patients with EC were assessed for eligibility from January 2013 to January 2017. Patients with the following conditions were included: (i) moderate (grade II) acute cholecystitis diagnosed by the 2013 Tokyo Guidelines; (ii) no common bile duct stones; (iii) no atrophic cholecystitis; (iv) no decompensated liver cirrhosis and massive ascites; (v) no diffuse peritonitis; (vi) surgeons are professors or associate professors; and (vii) PTGBD is not the only procedure for the patient defined by clinicians. The preoperative characteristics and postoperative outcomes were analyzed. PTGBD was performed by experienced interventional radiologists and cholecystectomy was performed by professors or associate professors. Patients in the EC and PTGBD + DC groups had similar demographic, clinical, preoperative laboratory, and imaging characteristics. Both PTGBD and EC resolved the cholecystitis quickly. Compared to the PTGBD + DC group, EC patients had more intraoperative bleeding (101 ± 125 mL versus 33 ± 37 mL, P = .003), longer duration of postoperative abdominal drainage (9.0 ± 12.9 days versus 3.4 ± 2.1 days, P = .041), more patients converted to open cholecystectomy (OC; 19.1% versus 4.1%, P = .021), more OC patients (14.9% versus 0%, P = .005), more patients with gangrenous cholecystitis (40.4% versus 8.2%, P < .001), more cholecystitis patients with perforation (12.8% versus 0%, P = .012), a higher incidence of respiratory failure (14.8% versus 2.0%, P = .029), more admissions to the intensive care unit (ICU) (21.3% versus 2.0%, P = .003), and longer postoperative hospital stays (8.2 ± 3.2 days versus 11.6 ± 4.6 days, P < .001) in the PTGBD + DC group. In addition, there were statistically more OC patients (63.2% versus 14.3%, P = .001) in the nonbiliary surgeon group than the biliary surgeon group. In patients with moderate (grade II) acute cholecystitis, PTGBD and EC were highly efficient in resolving cholecystitis. DC patients after PTGBD had better outcomes with a lower rate of OC, less intraoperative bleeding, shorter duration of postoperative abdominal drainage, shorter hospital stays after cholecystectomy, a lower incidence of respiratory failure, fewer admissions to the ICU than EC, and reversed the pathologic process affecting the gallbladder. The total postoperative hospital stay was longer in the PTGBD + DC group.

According to the Tokyo Guidelines 2018 (TG18), the standard treatment strategy for acute cholecystitis is laparoscopic cholecystectomy.1 However, gallbladder drainage is indicated when the risk of emergency surgery is deemed high based on the Charlson Comorbidity Index and the American Society of Anesthesiologists Physical Status scores. The standard recommended drainage technique is percutaneous transhepatic gallbladder drainage (PTGBD) owing to its high technical success rate and high clinical success rate; however, long-term outcomes have not been considered in this recommendation. In some cases, elective cholecystectomy can also be high risk, due to the patient's general condition or their wish to avoid surgical treatment after gallbladder drainage has resolved acute cholecystitis. In such cases, the strategy for gallbladder drainage must consider long-term management, including prevention of recurrence. In terms of long-term management, endoscopic drainage techniques are promising, such as endoscopic transpapillary gallbladder drainage (ETGBD) or endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), which allows for internal drainage.2 Although ETGBD is a safe and useful treatment for acute cholecystitis, obstruction of the cystic duct due to tortuosity and inflammation makes the procedure technically challenging, and a systematic review reported a pooled technical success rate of 80–83%, which is lower than that for PTGBD or EUS-GBD.3 In terms of long-term outcomes, some studies have reported that endoscopic placement of a long-term stent in the gallbladder of high-risk surgical patients after ETGBD was associated with lower recurrence of cholecystitis compared with PTGBD. However, a recent long-term comparative study highlighted that longer indwelling periods after ETGBD were associated with a higher occurrence of other late adverse events such as common bile duct stone, cholangitis, or gallbladder perforation.4 Many recent studies have reported the efficacy of EUS-GBD, including long-term outcomes, yet serious adverse events such as biliary peritonitis caused by technical failure are a concern. The development of devices such as the one-step deployment system for lumen-apposing metal stents (LAMS) and the accumulation of technical experience have led to EUS-GBD becoming more widely used in high-volume centers. In a recent meta-analysis comparing EUS-GBD with PTGBD for the management of acute cholecystitis, in a total of 495 patients, EUS-GBD was associated with a significantly lower adverse events rate, shorter hospital stays, and a lower re-intervention rate, with no significant difference in relation to technical and clinical success rates.5 Based on these clinical data, recent European Society of Gastrointestinal Endoscopy guidelines recommend that EUS-GBD should be favored over PTGBD for patients with high surgical risk when both techniques are available, owing to the lower rates of adverse events and need for re-intervention associated with EUS-GBD.6 The efficacy and safety of conversion from PTGBD to EUS-GBD in patients with high surgical risk has also been reported.7 Certainly, long-term management of the percutaneous drainage tube after PTGBD has disadvantages such as discomfort, pain, and skin problems. However, in clinical practice, the drainage tube can be removed early in some cases if a tube cholecystogram shows a patent cystic duct following the resolution of gallstone impaction. This is an important point because it affects long-term clinical outcomes, but it has not been taken into consideration in previous studies. In this issue of Digestive Endoscopy, Cho et al.8 retrospectively compared the short- and long-term clinical outcomes of EUS-GBD when using a fully covered metal stent with antimigration function and PTGBD categorized into an ex situ group (tube removal group) and in situ group (tube remaining group). They report similar technical and clinical success rates between the EUS-GBD and PTGBD groups, although early adverse events were less common in the EUS-GBD group. Furthermore, the recurrence rate of cholecystitis in the EUS-GBD group (6.0%) was similar to that in the PTGBD ex situ group (9.6%) but significantly lower than that in the PTGBD in situ group (23.5%). These results support the following treatment strategies for acute cholecystitis in patients with high surgical risk at institutions where EUS-GBD cannot be performed. First, PTGBD is performed, and after the cholecystitis improves, tube cholecystography is performed. If the cystic duct is patent, the percutaneous drainage tube is removed. If the cholecystic duct is obstructed, the patient is transferred to institutions where EUS-GBD can be performed. For long-term management, conversion to EUS-GBD targets the prevention of recurrence. Many studies have reported on optimal strategies for gallbladder drainage in patients with high surgical risk, but several issues remain to be resolved. The risk factors for emergency cholecystectomy have been well investigated, and TG18 provides clear criteria for this procedure depending on the severity of cholecystitis and the patient's general condition. However, there are no clear criteria for elective cholecystectomy after gallbladder drainage. For patients at high risk for emergency cholecystectomy, a comparative study of elective cholecystectomy after drainage vs. drainage treatment strategies is warranted to examine long-term outcomes, including prevention of recurrence. Furthermore, despite increasing reports of the usefulness of EUS-GBD, including its long-term outcomes, a standard technique has not been established and varies among studies. In particular, the type of drainage stents placed often differ. EUS-GBD most commonly uses fully covered biliary metal stents, but some have additional antimigration features or other novel design advantages (e.g., the novel tornado metal stent9), and it should be noted that there is currently insufficient evidence about long-term outcomes.2 LAMS show promise for EUS-GBD for acute cholecystitis, with a delivery system that allows for one-step deployment, a high drainage capacity, and a strong lumen-apposing function, which makes them highly effective in preventing stent migration. However, there are concerns about the safety of their long-term placement (i.e., buried stent syndrome), especially in the case of the transgastric approach. When LAMS are placed for EUS-GBD, it is possible to treat gallstones (the cause of cholecystitis) through the lumen of the LAMS after drainage. One recent randomized controlled trial reported better long-term outcomes, including recurrence of cholecystitis, with a treatment strategy of EUS-GBD with LAMS followed by additional treatment of gallstones and finally LAMS removal than with PTGBD.10 It is necessary to establish a standard treatment strategy for acute cholecystitis with EUS-GBD that considers long-term outcomes, and then compare the strategy with that of elective cholecystectomy after emergency drainage or other drainage treatment strategies in patients with high surgical risk. Author T.I. is a consultant for Boston Scientific Japan. The other author declares no conflict of interest for this article. None.

Objective To investigate the effect of different surgical procedures in treating patients with acute calculous cholecystitis. Methods A retrospective analysis were performed in 221 patients with acute calculous cholecystitis from January 2013 to June 2016 in our hospital, who were divided into laparoscopic cholecystectomy (LC) group (emergency LC, n=152), percutaneous transhepatic gallbladder drainage (PTGD) + LC group (n=46) and open cholecystectomy (OC) group (n=23). Baseline and clinical data were compared between three groups. Statistical analysis were performed by using SPSS19.0 statistical software. Measurement data such as perioperative indicators were expressed as mean±standard deviation and examined by using t-test and analysis of variance. The incidence of postoperative complications and baseline data were compared by using chi square test. A P value of <0.05 was considered as statistically significant difference. Results ⑴Age and severity of cholecystitis in PTGD+ LC group were significantly higher than those in other two groups respectively (P 0.05). ⑵Operation time in PTGD+ LC group was significantly higher than that in LC group, and total hospitalization time and hospitalization expenses in PTGD+ LC group were significantly higher than those in other two groups respectively (P 0.05). There was no significant difference of the incidence of postoperative complications between three groups (P>0.05). Conclusions For patients with acute calculous cholecystitis without obvious surgical contraindications, emergency LC is the preferred treatment method. For those who could not undergo emergency surgery, PTGD cuold be performed first, then considering the next step. Key words: Cholecystitis, Acute; Cholecystectomy, Laparoscopic; Gallstones; Cholecystectomy; Laparotomy

BackgroundStandards in treatment of acute cholecystitis (AC) in the elderly and high-risk patients has not been established. Our study evaluated the efficacy and safety of B-mode ultrasound-guided percutaneous transhepatic gallbladder drainage (PTGD) in combination with laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) in elderly and high-risk patients.MethodsOur study enrolled 35 elderly and high-risk AC patients, hospitalized between January 2010 and April 2014 at the Wenzhou People's Hospital. The patients underwent B-mode ultrasound-guided PTGD and LC (PTGD + LC group). As controls, a separate group of 35 elderly and high-risk AC patients who underwent LC alone (LC group) during the same period at the same hospital were randomly selected from a pool of 186 such cases. The volume of bleeding, surgery time, postoperative length of stay, conversion rate to laparotomy and complication rates (bile leakage, bleeding, incisional hernia, incision infection, pulmonary infarction and respiratory failure) were recorded for each patient in the two groups.ResultsAll patients in the PTGD + LC group successfully underwent PTGD. In the PTGD + LC group, abdominal pain in patients was relieved and leukocyte count, alkaline phosphatase level, total bilirubin and carbohydrate antigen 19-9 (CA19-9) decreased to normal range, and alanine aminotransferase and aspartate aminotransferase levels improved significantly within 72 h after treatment. All patients in the PTGD + LC group underwent LC within 6–10 weeks after PTGD. Our study revealed that PTGD + LC showed a significantly higher efficacy and safety compared to LC alone in AC treatment, as measured by the following parameters: duration of operation, postoperative length of hospital stay, volume of bleeding, conversion rate to laparotomy and complication rate (operation time of LC: 55.6 ± 23.3 min vs. 91.35 ± 25.1 min; hospitalized period after LC: 3.0 ± 1.3 d vs. 7.0 ± 1.7 d; intraoperative bleeding: 28.7 ± 15.2 ml vs. 60.38 ± 16.4 ml; conversion to laparotomy: 3 cases vs. 10 cases; complication: 3 cases vs. 8 cases; all P < 0.05 ).ConclusionOur results suggest that B-mode ultrasound-guided PTGD in combination with LC is superior to LC alone for treatment of AC in elderly and high-risk patients, showing multiple advantages of minimal wounding, accelerated recovery, higher safety and efficacy, and fewer complications.

Objective To compare the effects between percutaneous transhepatic gallbladder drainage (PTGD) plus delayed laparoscopic cholecystectomy (LC) in comparison with emergency LC for elderly patients with acute cholecystitis. Methods From June 2011 to December 2014, the clinical data of elderly patients with acute cholecystitis receiving PTGD plus LC and emergency LC were retrospectively studied. Results In this study 38 patients received PTGD plus LC, 59 patients received emergency LC. Patients in PTGD+ LC group had longer operative time (67±14) min and higher conversion rate (5 cases) than those in LC group (51±13) min, 1 case (t=5.741, χ2=5.057, P<0.05), but had quicker bowel function recovery time (24.5±6.4) h, shorter hospital stay (4.2±1.8 ) d, less complications (3 cases) than those in LC group (27±5.2) h, (6.2±1.9) d, 17 cases (t=2.11, t=5.165, χ2=6.18, P<0.05). Conclusions Percutaneous transhepatic gallbladder drainage plus delayed cholecystectomy is safe for elderly patients with acute cholecystitis. Key words: Cholecystolithiasis; Cholecystectomy, laparoscopic; Drainage

Acute cholecystitis (AC) is a common emergency requiring timely surgical intervention. While laparoscopic cholecystectomy (LC) is the standard treatment, the optimal timing for LC following percutaneous transhepatic gallbladder drainage (PTGBD) remains debated. This study evaluates and compares the safety and efficacy of early LC after PTGBD, immediate LC without PTGBD, and delayed LC following PTGBD. A retrospective cohort study was conducted at a Level I referral center, analyzing 1436 patients diagnosed with AC and managed surgically between 2010 and 2018. Patients were categorized into three groups: early LC after PTGBD (Early group, n = 18), immediate LC without PTGBD (Immediate group, n = 1243), and delayed LC following PTGBD (Delayed group, n = 175). Patient demographics, clinical characteristics, and surgical outcomes were analyzed using inverse probability of treatment weighting (IPTW) to adjust for baseline differences. Compared to the Immediate group, the Early group had a higher proportion of older patients and multiple comorbidities. After adjustment, adverse event rates were similar between both groups, but major complications were lower in the Early group. Compared to the Delayed group, the Early group demonstrated significantly shorter hospital stays and lower major complication rates. Early LC after PTGBD during the same admission is a viable alternative to delayed LC, reducing hospital stay and complications. Immediate LC remains the preferred approach for eligible patients without prior PTGBD. Further prospective studies are needed to refine the optimal timing of LC following PTGBD.

Objective To investigate the clinical effect of percutaneous transhepatic gallbladder drainage (PTGD) combined with laparoscopic cholecystectomy (LC) in the treatment of elderly patients with high-risk acute suppurative cholecystitis. Methods The clinical data of 158 elderly patients with acute suppurative cholecystitis treated in the First People’s Hospital of Yangquan from March 2015 to May 2018 were retrospectively analyzed. According to the interval between PTGD and LC, the patients were divided into two groups: control group (LC 30-59 days after PTGD, 79 cases) and observation group (LC 60-89 days after PTGD, 79 cases). The biochemical indexes, including white blood cell (WBC), alkaline phosphatase (ALP), total bilirubin (TBIL), clinical indexes and conversion rate of laparotomy were compared between the two groups. Results In the 158 patients, WBC, ALP and TBIL levels after PTGD were lower than those before PTGD, and the difference was statistically significant (P<0.05). In the observation group, the amount of blood loss during LC was less than that in the control group, and the duration of LC surgery and postoperative hospital stay were both shorter than those in the control group, with statistically significant differences (P<0.05). There was no case of conversion to laparotomy in the observation group; however, rate of coversion to laparotomy was 6.33% in the control group; there was significant difference between the two groups (P<0.05). Conclusions LC operation for elderly patients with high-risk acute suppurative cholecystitis 60-89 days after PTGD can effectively reduce the amount of bleeding during LC operation, shorten the operation time of LC, reduce the conversion rate of laparotomy, and facilitate early recovery of patients. Key words: Acute suppurative cholecystitis; Aged; Percutaneous hepatic and gallbladder drainage; Laparoscopic cholecystectomy; Ultrasound