Cholecystectomy In High-risk Patients Research Articles

Laparoscopic Cholecystectomy in Cardiogenic Shock And Heart Failure.

Background: Patients with cardiogenic shock (CS) or heart failure can develop ischemic cholecystitis from a systemic low-flow state. Cholecystectomy in high-risk patients is controversial. Percutaneous cholecystostomy tube (PCT) is often the chosen intervention; however, data on PCT as definitive treatment are conflicting. Data on cholecystectomy in these patients are limited. This study discusses outcomes following laparoscopic cholecystectomy (LC) in this patient population. Methods: This is a retrospective review of patients who underwent LC from 2015 to 2019 while hospitalized for CS or heart failure. Surgical services are provided by fellowship-trained minimally invasive surgeons at a single, academic, tertiary-care center. Patient characteristics are reported as frequencies' percentages for categorical variables. Odds ratio is used to determine the association between comorbidities and complications. Results: Twenty-four patients underwent LC. Around 83% were white and 79% were male. Many were anticoagulated (88%), with Class IV heart failure (63%), and required vasopressors (46%) at the time of surgery. Fourteen of 24 (58%) had at least one circulatory device at the time of surgery: extracorporeal membrane oxygenation, left ventricular assist device, Impella, tandem heart, and total artificial heart. Four patients (17%) had PCT preoperatively. Fifteen days were the average interval between diagnosis and surgery. Pneumoperitoneum was tolerated by all, and 0% converted to open. Most common complication was bleeding (52%). Nine patients (37.5%) underwent 21 reoperations, one of which (4%) was related to cholecystectomy. Mortality occurred in 5 patients (20.8%); interval between cholecystectomy and mortality ranged 6-30 days. Conclusion: Although high risk, LC is a treatment option in patients with ischemic cholecystitis at risk for death from sepsis.

Endoscopic transpapillary gallbladder stenting for acute cholecystitis

Background Cholecystectomy is the treatment of choice for acute cholecystitis. However, the mortality rate of emergency cholecystectomy in high-risk patients with severe comorbidities remains unsatisfactory. Endoscopic transpapillary gallbladder stenting (ETGBS) has emerged as a useful interventional endoscopic technique for the management of acute cholecystitis. Aim The purpose of this research was to assess the safety and effectiveness of ETGBS in the treatment of acute cholecystitis in elderly individuals who were not good candidates for surgery. Patients and methods We studied 35 elderly patients, 60 years of age or older, receiving treatment at Aswan University Hospital’s surgery department for acute cholecystitis. Every patient had ETGBS, involving the insertion of a 7-Fr stent into the gallbladder. If ETGBS was unsuccessful, percutaneous transhepatic gallbladder draining was carried out. The effectiveness of ETGBS was the primary outcome measure in this investigation. Results ETGBS was successful in 30 (85%) individuals with acute cholecystitis. 8.57% (3/35) of the cases had early adverse events (AEs). Three patients had endoscopic sphincterotomy hemorrhage, one had minor pancreatitis, and one patient experienced obstructive jaundice as early AEs. There were 8.57% (3/35) late AEs. Late AEs included cholangitis in one patient and cholecystitis recurrence in two others. Percutaneous transhepatic gallbladder drainage was used for the five individuals in whom ETGBS failed. Conclusion ETGBS appears to be a successful treatment for elderly patients with acute cholecystitis who are unsuitable for surgery.

Comparison of trans-gastric vs trans-enteric (trans-duodenal or trans-jejunal) endoscopic ultrasound guided gallbladder drainage using lumen apposing metal stents.

Endoscopic ultrasound guided gallbladder drainage (EUS-GBD) is being increasingly used in practice (either as a bridge to cholecystectomy in high-risk patients or as destination therapy in non-surgical patients). Stents are used to create a conduit between the lumen of the gallbladder (GB) and the intestinal lumen through the gastric or enteric routes. Among the various types of stents used, cautery-enhanced lumen apposing metallic stents (LAMS) may be associated with fewer adverse events (AEs). To compare the clinical success, technical success, and rate of AEs between transgastric (TG) and trans-enteric [transduodenal (TD)/transjejunal (TJ)] approach to GB drainage. Further, we analyzed whether using cautery enhanced stents during EUS-GBD impacts the above parameters. Study was registered in PROSPERO (CRD42022319019) and comprehensive literature review was conducted. Manuscripts were reviewed for the data collection: Rate of AEs, clinical success, and technical success. Random effects model was utilized for the analysis. No statistically significant difference in clinical and technical success between the TD/TJ and TG approaches (P > 0.05) were noted. There was no statistically significant difference in the rate of AEs when comparing two-arm studies only. However, when all studies were included in the analysis difference was almost significant favoring the TD/TJ approach. When comparing cautery-enhanced LAMS with non-cautery enhanced LAMS, a statistically significant difference in the rate of AEs was observed when all the studies were included, with the rate being higher in non-cautery enhanced stents (14.0% vs 37.8%; P < 0.01). As per our study results, TD/TJ approach appears to be associated with lower rate of adverse events and comparable efficacy when compared to the TG approach for the EUS-GBD. Additionally, use of cautery-enhanced LAMS for EUS-GBD is associated with a more favorable adverse event profile compared to cold LAMS. Though the approach chosen depends on several patient and physician factors, the above findings could help in deciding the ideal drainage route when both TG and TD/TJ approaches are feasible.

Cystic Duct Embolization with Chemical Gallbladder Ablation for the Treatment of Acute Calculous Cholecystitis in High-Risk Patients: A Prospective Single-Center Study

PurposeTo demonstrate the feasibility of cystic duct embolization and chemical gallbladder ablation as an alternative to cholecystectomy in high-risk patients with calculous cholecystitis who were not candidates for surgery. Materials and MethodsThis prospective study included 10 patients with acute cholecystitis (7 males and 3 females) aged 70–91 years (average age, 81.6 years) between 2013 and 2019. A cholecystostomy catheter was inserted during the acute phase, followed by cystic duct coil embolization performed via the existing drainage tube tract. Once asymptomatic, 3% aethoxysklerol was injected into the gallbladder, and the drain was removed upon sonographic confirmation that the gallbladder remained contracted. Each phase of the procedure was performed with an interval of 2–3 weeks. Clinical, cholangiographic, and sonographic data were collected before and after drain removal at 1-month follow-up. ResultsCystic duct embolization was technically successful in all patients, with no immediate post-procedure complications. Gallbladder ablation performed in 10 patients was technically successful in all of them (median follow-up, 11 months). One patient required repeat ablation at 14 months, and the prolonged biliary excretions of 1 other patient ceased only at 8 months. ConclusionsCystic duct embolization with gallbladder ablation is a feasible procedure for patients in whom cholecystectomy is contraindicated.

Percutaneous Cholecystostomy as an Alternative to Cholecystectomy in High-Risk Patients with Acute Cholecystitis

Background: Cholecystectomy is the standard treatment for patients with acute cholecystitis. On the other hand, percutaneous cholecystostomy (PC) is an alternative for patients at high-risk for surgery. The aim of this study was to evaluate the clinical outcomes of PC.&#x0D; Methods: Surgically high-risk patients with acute cholecystits having undergone PC at our institution between January 2014 – January 2017 were evaluated. Data including the indications for PC, route of insertion, technical success, clinical improvement, length of hospital stay, mortality rates, procedure related complications, subsequent admissions and performance of interval cholecystectomy were recorded and analyzed.&#x0D; Results: The study group consisted of 30 patients with a mean age of 75.3 ( range: 49–99) years. The indications for PC were acute calculous cholecystitis in 28 (93.3%) and acalculous cholecystitis in 2 (6.7%) patients. All procedures were performed via the transhepatic route. Twenty-five PCs (84.4%) resulted in clinical improvement within five days. A repeated PC was performed in two (6.7%) patients. Seven (23.3%) patients underwent a subsequent cholecystectomy after 6 weeks. An emergent cholecystectomy was performed in one (3.3%) patient. Five (16.7%) patients died from underlying comorbid diseases, unrelated to the biliary system, during the follow-up.&#x0D; Conclusions: Patients with acute cholecystitis were promptly relieved from their symptoms following PC. There were only minor complications following the procedure and an interval cholecystectomy was necessary in only 23.3% of the patients. PC is a safe alternative to choecystectomy in high-risk patients with acute cholecystitis with satisfactory results.

Abstract No. 514 - Gallbladder cryoablation: survival studies in a swine model for a potential alternative to surgical cholecystectomy in high-risk patients

Abstract No. 514 - Gallbladder cryoablation: survival studies in a swine model for a potential alternative to surgical cholecystectomy in high-risk patients

Video Laparoscopic Cholecystectomy: The Last Diagnostic Step or the First Surgical Procedure to Prevent Cancer? A Review of Incidental Gallbladder Cancer

Aim: Incidental gallbladder cancer (GBC) is a more and more frequent medical entity discovered on the specimen after a cholecystectomy. The aim of our study is to value the importance of cholecystectomy as last diagnostic step or surgical procedure to prevent invasive gallbladder cancer. Histologicalroutinary examination of surgical specimen could discover a lot of hidden gallbladder cancer. Material and methods: We collected data on patients treated with video laparoscopic cholecystectomy (VLC) for lithiasis, from January 2000 to December 2015. We selected 477 patients, who underwent VLC after a preoperative gallstones positive US, and who had histologic analysis of gallbladder specimens. Our outcomes were retrospectively analyzed and compared to international results for a global review. Results: VLC has been realized in all patients with a rate of conversion of 5%. In 4 of these patients (0.9%) was incidentally discovered a GBC during pathological exam of specimens. All the samples showed adenocarcinoma-type lesions. Discussion: The incidental finding of gallbladder cancer during VLC is a quite rare event; incidence goes from 0.2 to 2.9% (0.9% in our personal experience). Good results in term of overall survival were obtained for pTis and pT1a, while higher stages are related to a poor prognosis, especially in elderly population (due to comorbidities and less therapeutic choices). Most severe stages are related to an extremely high mortality rate. Conclusions: VLC has an important role in diagnosing and treating gallbladder cancer. Lesions Tis and T1a can be efficiently treated with the only VLC approach, while more severe stages require further procedures. For this reason, we suggest the importance of a preventive cholecystectomy in high risk patients, followed by histological examination in selected cases. Keywords: Gallbladder carcinoma; Lithiasis; Histological examination; Elective approach; Prevention; Videolaparoscopic cholecystectomy.

Endoscopic Transpapillary Gallbladder Stent Placement Is Safe and Effective in High-Risk Patients Without Cirrhosis.

Endoscopic transpapillary gallbladder stent (ETGS) placement is a proposed minimally invasive alternative to cholecystectomy in high-risk patients with symptomatic gallbladder disease. To describe the safety and efficacy of ETGS placement in 29 consecutive patients without cirrhosis. A retrospective analysis of consecutive ETGS cases from 2005 to 2013 at a referral center was undertaken. The mean age was 70years (range 40-91), and 62% were hospitalized. The most common indication for ETGS was acute calculus cholecystitis (52%). Comorbidities precluding cholecystectomy included advanced cancer (45%), severe cardiopulmonary disease (21%), and advanced age/frailty (17%). Eighty-six percent of the patients had an ASA class of III or IV, and the Charlson comorbidity index was >3 in 55%. An ETGS was successfully placed in 22 patients (76%) with 18 being successful on the first attempt. A percutaneous rendezvous approach was required to obtain cystic duct access in six patients (21%). During a mean follow-up of 376days, a sustained clinical response was noted in 90% of the patients with a stent placed. No peri-procedural complications were noted. However, two patients developed delayed complications of abdominal pain and cholangitis. Six patients were alive with their original stent still in place at a mean follow-up of 2.5years. ETGS is an effective and safe alternative to cholecystectomy in high-risk patients. Technical success can be facilitated by a percutaneous rendezvous technique. Our data and those of others suggest that scheduled stent exchanges may not be required unless a clinical change occurs.

Prophylactic Mesh vs Suture in the Closure of the Umbilical Trocar Site after Laparoscopic Cholecystectomy in High-Risk Patients for Incisional Hernia. A Randomized Clinical Trial

Prosthetic repair has become the standard method for hernia repair. Mesh placement for the prevention of trocar site incisional hernia (TSIH) is still a controversial issue. We tested the hypothesis that closure with an intraperitoneal prophylactic mesh of the umbilical trocar after a laparoscopic cholecystectomy can reduce the incidence of a TSIH in high-risk patients. A randomized clinical trial was conducted among patients undergoing elective laparoscopic cholecystectomy who presented the following high-risk factors for incisional hernia, according to the literature: age 65 years and older, diabetes mellitus, chronic pulmonary disease, and obesity (ie, body mass index ≥30 kg/m(2)). Patients were assigned to have closure of the umbilical trocar site with either nonabsorbable sutures (group A) or intraperitoneal polypropylene omega-3 mesh (group B). Trocar site incisional hernia, pain, and surgical complications were evaluated at the early postoperative course and at 1, 6, and 12 months after surgery. A total of 106 patients were randomized into the study and 92 patients were finally analyzed, including 47 in group A and 45 in group B. The TSIH rate was higher in group A (31.9%) than in group B (4.4%) (odds ratio = 10.1; 95% CI, 2.15-47.6; p < 0.001)). The wound infection rate was 4.3%; 8.5% in group A and 0% in group B (odds ratio = 2.04; 95% CI, 1.7-2.5; p = 0.045). Median postoperative pain evaluated by a visual analogue scale was 3 in group A and 2 in group B (p = 0.05). No differences were observed in complication rate, operative time, or hospital stay between the groups. Prosthetic closure of the umbilical trocar site after laparoscopic surgery could become the standard method for preventing TSIH in high-risk patients.

Percutaneous cholecystostomy as an alternative to cholecystectomy in high risk patients with biliary sepsis: a district general hospital experience

Cholecystectomy is the standard treatment for patients with acute cholecystitis. However, percutaneous cholecystostomy (PC) is an alternative for patients at high risk for surgery. We present our five-year clinical experience with the aim of evaluating the efficacy of PC in high risk patients. A retrospective review was performed on 30 consecutive patients who underwent PC at our institution. The indications for cholecystostomy, route of insertion, technical success, clinical improvement, length of hospitalisation, in-hospital or 30-day mortality, complications, subsequent admissions and performance of interval cholecystectomy were recorded. The median follow-up period was 25 months (range: 1-52 months). Thirty-two PCs were performed in thirty patients (mean age: 76.1 years; range: 52-90 years). The indications for PC were acute calculous cholecystitis (29/32), acalculous cholecystitis (1/32) and emphysematous cholecystitis (2/32). The route of insertion was transperitoneal for 22/32 PCs (68.8%) and transhepatic for 10/32 (31.2%). The procedure was technically successful in all patients although 2/22 transperitoneal drains (9.1%) were dislodged subsequently. Twenty-seven PCs (84.4%) resulted in clinical improvement within five days. The in-hospital or 30-day mortality rate was 16.7% (5/30). Eleven patients (36.7%) had a subsequent cholecystectomy: 6 were laparoscopic and 5 converted to open procedures at a median interval of 58 days (range: 1-124 days). PCs are straightforward with few complications. Most patients improve clinically and the procedure can therefore be used as a definitive treatment in unfit patients or as a bridge to surgery in those who might subsequently prove fit for a definitive operation.

Percutaneous Cholecystostomy: A Safe Alternative to Cholecystectomy in High Risk Patients

Percutaneous Cholecystostomy: A Safe Alternative to Cholecystectomy in High Risk Patients

Percutaneous Cholecystolithotomy: A Case for Fulguration of the Gallbladder Wall

Percutaneous cholecystolithotomy (PC) has been described previously as an alternative to laparoscopic cholecystectomy in high-risk patients and in those with adherent gallbladders that are not amenable for laparoscopic cholecystectomy. However, it is associated with a high (41%) recurrence of cholelithiasis due to intact gallbladder mucosa. In this paper, we describe a case of PC with fulguration of the gallbladder mucosa to scar and defunctionalize the mucosa and thus prevent recurrence of stones. After 12 months of follow-up, the patient remains asymptomatic.

Thoracic paravertebral nerve block as the sole anaesthesia for open cholecystectomy in high risk patients

Thoracic paravertebral nerve block as the sole anaesthesia for open cholecystectomy in high risk patients

55: Thoracic paravertebral nerve block as the sole anaesthesia for open cholecystectomy in high risk patients

55: Thoracic paravertebral nerve block as the sole anaesthesia for open cholecystectomy in high risk patients

Cholecystectomy in high-risk patients: A comparison between open cholecystectomy and laparoscopic cholecystectomy

SummaryLaparoscopic cholecystectomy offers many advantages, yet patients with a history of cardiopulmonary problems are at an increased risk because of the hemodynamic and respiratory effects of pneumoperitoneum. Between June 1990 and November 1997, a laparoscopic cholecystectomy was performed on 31 high risk patients [American Society of Anesthesiology (ASA) IV] and 40 conventional cholecystectomies were performed on patients with the same operative risk (ASA IV). In total, 15.5% (n = 11) of these patients experienced intraoperative cardiopulmonary complications, occurring with approximately the same frequency in both groups. General post-operative complications were seen in 28.2% (n=20) of all cases, the conventionally operated patients were more often affected [37.5% (n=15) versus 16.1 % (n=5) (p<0.05)]. The hospital stay was longer for patients with an open cholecystectomy, at 13.9±8.7 days, in comparison to those with a laparoscopic cholecystectomy, at 7.8±5 days (p<0.001). In high risk patients there is an increased rate of perioperative complications; this study shows the intraoperative risk is the same, but the post-operative complication rate is lower for laparoscopic cholecystectomy.

Endoscopic sphincterotomy for biliary pancreatitis: An alternative to cholecystectomy in high-risk patients

Recurrent biliary pancreatitis frequently is associated with an intact gallbladder containing stones. This condition has been effectively treated by removing the gallbladder, but there is evidence that endoscopic sphincterotomy might obviate the need for cholecystectomy in some patients. We performed prophylactic sphincterotomy in 49 patients who presented with biliary pancreatitis more than once and who were considered at risk for surgery. The majority (39 patients) were treated electively after resolution of pancreatitis, while the remainder (10 patients) were treated urgently during their index admission because of continuing symptoms. No patient experienced recurrent pancreatitis over a mean follow-up period of 48 months. No mortality occurred in this endoscopic series, and no significant morbidity was experienced. Based on our results, we advocate performing sphincterotomy in the aged patient or younger patients considered at high risk for surgery who present with a history of recurrent pancreatitis and cholelithiasis. (Gastrointest Endosc 1994;40:573-5.)

Postoperative infectious complications of laparoscopic cholecystectomy in high-risk patients

Introduct ion Although an increasing number of laparoscopic cholecystectomy (LC) procedures have been performed each year since its introduction, little has been documented in regard to the infectious complications associated with this technique. In the most extensive evaluation to date, Myers et al. reported 18 infections (14 wound, 2 abscesses, 1 empyema, 1 pneumonia) following 1,518 LC operations (1.2%). Other reviews have placed the rate of postsurgical infection at 03.3%. Early in the genesis of this procedure, high-risk patients were excluded. As physicians became more adept at this operation, fewer restrictions were encountered, and these patients soon were added into the patient base. The purpose of this article is to review the postsurgical infections associated with patients undergoing LC.