Percutaneous Cholecystostomy Tube Research Articles

WP5.18 - Quality Improvement Project – Assessing current practice of percutaneous cholecystostomy tube (PCT) management in a DGH and proposal of local guidelines

Abstract Rationale The absence of evidence-based guidelines for Percutaneous Cholecystostomy Tube (PCT) management has led to a lack of standardization in its care across NHS Trusts. Existing literature provides varied recommendations. Davis et al.(1999) suggested allowing 7-10 days for tract maturation, although they did not describe how this was evaluated. Other authors recommended proposals based on their local practice. Aim To establish standardized care following PCT insertion at our DGH, focusing on improving efficiency and ensuring uniformity in performance. Methods A retrospective cohort study was conducted, reviewing the period between January 2021 to December 2022. 68 patients were identified to have PCT insertions. Results Findings revealed 24% (16/68) had no documented discharge plan. 57% (39/68) of patients had a planned Surgical Assessment Unit review within a wide timeframe (4-49 days). A tubogram was arranged for 47 of 68 patients (69%) meaning the rest had no fluoroscopic examination before PCT removal. This was performed on average at 4.8 weeks and (range 1-10 weeks). 31% (21/68) had no UGI clinic review. The mean PCT removal time was 9.4 weeks with some outliers ranging between 0.5 to upto 40.5 weeks. Conclusion While some patients had PCT in-situ for longer than necessary, in two cases PCTs were removed prematurely, though no complications were recorded. The observed practice variability prompted the introduction of a local pathway, with recommendations from UGI consultants. This initiative should help prevent delays in patient care, particularly considering that the rotating junior doctors usually will lack familiarity with the management of such cases.

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.

Approaches to Cholecystitis: Surgical, Endoscopic, and Percutaneous Management.

Acute cholecystitis (AC) is associated with significant morbidity and mortality. Minimally invasive laparoscopic cholecystectomy remains the gold standard of treatment. Therapeutic endoscopy for management of AC continues to emerge as a favorable alternative to percutaneous gallbladder drainage in patients with prohibitive operative risk. Endoscopic management of AC includes transpapillary and transmural stenting. When patient-specific factors prevent both surgical and endoscopic treatment, percutaneous cholecystostomy tube (PCT) placement is an option. Early studies show PCT to have worse outcomes when compared against all other described treatment options for the management of AC.

Gallbladder perforation during endoscopic internalization of percutaneous cholecystostomy tube: lessons learned

Gallbladder perforation during endoscopic internalization of percutaneous cholecystostomy tube: lessons learned

A Review on Endoscopic Management of Acute Cholecystitis: Endoscopic Ultrasound-Guided Gallbladder Drainage and Endoscopic Transpapillary Gallbladder Drainage.

A percutaneous cholecystostomy tube (PCT) is the conventionally favored nonoperative intervention for treating acute cholecystitis. However, PCT is beset by high adverse event rates, need for scheduled reintervention, and inadvertent dislodgement, as well as patient dissatisfaction with a percutaneous drain. Recent advances in endoscopic therapy involve the implementation of endoscopic transpapillary drainage (ETP-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), which are increasingly preferred over PCT due to their favorable technical and clinical success combined with lower complication rates. In this article, we provide a comprehensive review of the literature on EUS-GBD and ETP-GBD, delineating instances when clinicians should opt for endoscopic management and highlighting potential risks associated with each approach.

Percutaneous cholecystostomy tube placement as a bridge to cholecystectomy for grade III acute cholecystitis: A national analysis

IntroductionPercutaneous cholecystostomy (PCT) is an alternative to cholecystectomy (CCY) in high-risk surgical candidates with severe acute cholecystitis. A subset of these patients ultimately undergo delayed CCY. We therefore compared outcomes of delayed CCY in patients with grade III acute cholecystitis who received a PCT on index admission, to those who did not. MethodsNon-elective adult hospitalizations for grade III acute cholecystitis that underwent delayed CCY were identified in the 2016–2020 Nationwide Readmission Database. Patients who received a PCT during their index admission comprised the PCT group (others: Non-PCT). Outcomes were assessed for the CCY hospitalization. Entropy balancing was used to generate sample weights to adjust for differences in baseline characteristics. Regression models were created to evaluate the association between PCT and the outcomes of interest. ResultsOf an estimated 13,782 patients, 13.3 % comprised PCT. Compared to Non-PCT, PCT were older (71.1 ± 13.1 vs 67.4 ± 15.3 years) and more commonly in the highest income quartile (22.5 vs 16.1 %, both p < 0.001). After risk adjustment, PCT was associated with reduced odds of respiratory (AOR 0.67, CI 0.54–0.83) and infectious (AOR 0.77, CI 0.62–0.96) complications after eventual CCY. Finally, PCT had comparable pLOS (β +0.31, CI [−0.14, 0.77]) and operative hospitalization costs (β $800, CI [−2300, +600]). ConclusionIn the present study, PCT was associated with decreased odds of perioperative complications and comparable resource utilization upon readmission CCY. Our findings suggest that PCT may be helpful in bridging patients with grade III acute cholecystitis to eventual CCY.

The Utility of Routinely Performing a Short-Interval Cholecystogram following Cholecystostomy Tube Placement

Abstract Purpose The purpose of this study is to evaluate the utility of routinely performing short-interval cholecystogram (SIC) following percutaneous cholecystostomy tube (PCT) placement and to identify predictive factors for early PCT dislodgment. Materials and Methods We conducted retrospective review of 224 adult patients who underwent PCT placement for acute cholecystitis at a single tertiary care medical center. SIC was defined as occurring at least 1 day after PCT placement and prior to the patient being discharged from the hospital. Early PCT dislodgment was defined as occurring within 2 months of placement. Results Among 224 patients, 181 (80%) patients underwent SIC on average 3 days after PCT. Of these, 175 (97%) had PCT appropriately positioned, while 6 (3%) showed tube malposition outside the gallbladder. Patients who underwent a SIC demonstrated a similar rate of early tube dislodgment compared to those discharged without this procedure (12.6 vs. 14.3%, p = 0.81). Notably, patients with a body mass index exceeding 40 kg/m2 had a higher likelihood of early cholecystostomy tube dislodgment (29 vs. 14%, p = 0.038). Conclusion Routinely performing a SIC following PCT may offer limited benefit. We recommend selectively performing this study on patients with clinically suspected tube dislodgement.

Bedside Ultrasound-Guided Percutaneous Cholecystostomy in Critically Ill Patients—Outcomes in 51 Patients

Abstract Purpose The aim of this study was to report technical and clinical success of bedside ultrasound-guided percutaneous cholecystostomy (PC) tube placement in intensive care unit (ICU). Materials and Methods This is a retrospective study of 51 patients (36 males:15 females, mean age: 67 years) who underwent ultrasound-guided PC from May 2015 to January 2020. The indication for cholecystostomy tube placement, comorbidities, imaging finding, technical success, clinical success, timing of surgery post-cholecystostomy tube placement, indwelling catheter time, complications, and follow-up were recorded. Results Indications for cholecystostomy tube placement were acute calculous cholecystitis (n = 43; 84.3%), perforated cholecystitis (n = 5; 9.8%), and emphysematous cholecystitis (n = 3; 5.9%). Most of the patients had multiple comorbidities; these were diabetes mellitus, hypertension, cardiovascular disease, chronic renal disease, underlying malignancy, and multisystem disease with sepsis. All patients had undergone PC through transhepatic approach under ultrasound guidance in ICU. Technical success rate of the procedure was 100%. Clinical success rate was 92.1% (47/51) and among these 44/51 (86.2%) patients underwent definitive elective cholecystectomy, 3/51 (5.9%) patients had elective tube removal. Three of fifty-one (5.9%) patients did not improve; among these two underwent emergency surgery, while there was 1/51 (1.9%) mortality due to ongoing sepsis and multiorgan dysfunction. There were no procedure-related mortalities or procedure-related major complications. One patient had bile leak due to multiple attempts for cholecystostomy placement. Mean tube indwelling time was 13 days (range: 3–45 days). Conclusion Ultrasound-guided PC can be safely performed in ICU in critically ill patients unfit for surgery with high technical and clinical success rates. Early laparoscopic cholecystectomy should be preferred after stabilization of clinical condition following cholecystostomy.

Safety and adverse events of EUS-guided gallbladder drainage using lumen-apposing metal stents and percutaneous cholecystostomy tubes: a systematic review and meta-analysis

Background and AimsEndoscopic ultrasound-guided gallbladder drainage using lumen-apposing metal stent (EUS-GBD-LAMS) and percutaneous cholecystostomy for gallbladder drainage (PTGBD) are the alternative treatment modalities in high-risk surgical patients with acute cholecystitis (AC). Our study aims to compare these procedures’ safety for AC in surgically suboptimal candidates. MethodsSix studies compared the two groups' early, delayed, and overall adverse events, length of hospital stay, re-interventions, and re-admissions rate. A random effect model calculated odds ratios with a 95% confidence interval (CI). ResultsThe two groups had similar early adverse events; however, EUS-GBD-LAMS was associated with a lower rate of delayed (OR: 0.21) [95% CI: 0.07-0.61], p = < 0.01) and overall adverse events (OR: 0.43) [95% CI: 0.30-0.61], p = < 0.01). Patients with EUS-GBD-LAMS had a lower hospital stay than PTGBD. ConclusionsEUS-GBD-LAMS is a safer option than PTGBD and is associated with a shorter hospital stay in non-surgical candidates with AC.

The impact of interval cholecystectomy timing after percutaneous transhepatic cholecystostomy on post-operative adverse outcomes.

This study aims to explore how timing of interval of cholecystectomy (IC) after percutaneous transhepatic cholecystostomy tube (PTC) placement impacts post-operative outcomes. A retrospective database analysis of New York State SPARCs database of IC between 2005 and 2015. The timing forIC ranged between > 1week and < 2years. Patients undergoing this procedurewere further divided into quartiles using 4-time intervals; 1-5weeks (Q1), 5-8weeks (Q2), 8-12weeks(Q3), and > 12weeks(Q4). The study's primary outcome was hospital length of stay (LOS). Secondary outcomes included discharge status, 30-day readmission, 30-day ED visit, and 90-day reoperation, surgery type, complication, and bile duct injury. Multivariable regression models were used to compare patients across the four-time intervals after adjusting for confounding factors. A total of 1038 patients with a history of PTC followed by IC between > 1week and < 2years were included in the final analysis. The median time to IC was 7.7weeks. Q2 and Q3 both had a significantly higher median LOS of 3days versus Q1 and Q4 at median of 5days (p < 0.0001). Patients from racial and ethnic minorities (e.g., African Americans and Hispanics) were more likely to get their IC after 12weeks (p < 0.05). Further, Black patients had a significantly higher median LOS than White, non-Hispanic patients (8days vs 4days, p < 0.0001) and were more likely to have open procedure. Multivariable regression analysis identified shorter LOS during Q2 (Ratio, 0.76, 95%, 0.67-0.87, p < 0.0001), and Q3 (Ratio 0.75, 95% CI, 065-0.86, p < 0.0001) compared to those who got their IC in Q4. Similar findings exist when comparing Q2 and Q3 to those receiving treatment during Q1. A time interval of 5-12weeks between PTC and IC was associated with a decreased LOS. This study also suggests the persistence of racial disparities among these patients.

Endoscopic Gallbladder Drainage Conversion versus Conservative Treatment Following Percutaneous Gallbladder Drainage in High-Risk Surgical Patients.

There are no consensus guidelines for patients with acute cholecystitis undergoing percutaneous cholecystostomy who are unfit for interval cholecystectomy. The current study aimed to compare the clinical outcomes of endoscopic gallbladder drainage, i.e. conversion from percutaneous cholecystostomy (including endoscopic transpapillary gallbladder stenting and endoscopic ultrasound-guided gallbladder drainage), and conservative treatment after percutaneous cholecystostomy tube removal. This retrospective review included patients who underwent percutaneous cholecystostomy for acute cholecystitis between January 2017 and December 2020. Consecutive patients who underwent endoscopic gallbladder drainage or percutaneous cholecystostomy tube removal without interval cholecystectomy were included. Outcome measures included recurrent acute cholecystitis and unplanned readmission due to gallstone-related diseases. During the study period, 238 patients were selected (63 underwent endoscopic gallbladder drainage conversion and 175 underwent conservative treatment). Patients who underwent endoscopic gallbladder drainage conversion had lower rates of recurrent acute cholecystitis (3 [4.76%] vs 31 [17.71%], p=0.012) and unplanned readmission due to gallstone-related diseases (6 [9.52%] vs 40 [22.86%], p=0.022) than those who underwent conservative treatment following percutaneous cholecystostomy tube removal. In the univariate and multivariate analyses, calculus cholecystitis (odds ratio, 13.75; 95% confidence interval, 1.83 to 102.83; p=0.011) and conversion of endoscopic gallbladder drainage (odds ratio, 0.23; 95% confidence interval, 0.06 to 0.78; p=0.019) were significant predictive factors for recurrent acute cholecystitis. Endoscopic gallbladder drainage conversion led to more favorable outcomes than conservative treatment after percutaneous cholecystostomy tube removal. Therefore, endoscopic gallbladder drainage conversion may be considered a promising treatment option for patients undergoing percutaneous cholecystostomy who are at a high surgical risk.

Association of nonalcoholic fatty liver disease with acute cholangitis: a nationwide propensity-matched analysis from the United States

Background Nonalcoholic fatty liver disease (NAFLD) has previously been linked to several disease states with an impact on patient outcomes. However, clinical evidence on the association between NAFLD and acute cholangitis (AC) remains scarce. We aimed to evaluate the potential association between NAFLD and AC. Methods We conducted a retrospective cohort study using the US National Inpatient Sample database from 2016 to 2019 to analyze primary AC hospitalizations with NAFLD compared to non-NAFLD in a 1:1 propensity-matched population. Results A total of 1550 AC patients with NAFLD were matched to 1550 AC patients without NAFLD. NAFLD had a higher association with AC when compared to patients without NAFLD, with an odds ratio of 2.33 (95% CI [1.81–3.0], P < 0.001). The length of stay was higher in NAFLD than in non-NAFLD (4 vs 3 days, P < 0.001). The median inpatient charges in NAFLD were also higher than in the non-NAFLD cohort ($36,182 vs $35,244, P < 0.001). Inpatient mortality was higher in NAFLD compared to non-NAFLD (1.6% vs 0%, P < 0.001). There was an increased prevalence of portal vein thrombosis (3.2% vs 0%), acute kidney injury (24.2% vs 17.7%), sepsis (3.2% vs 1.6%), mechanical ventilation (3.2% vs 0%), and percutaneous cholecystostomy tube insertion (3.2% vs 1.6%) in NAFLD compared to non-NAFLD (P < 0.05). NAFLD also had a higher association with acute cholecystitis, with an odds ratio of 3.70 (95% CI [3.19–4.29], P < 0.001). Conclusions This study showed an association between NALFD and AC, resulting in increased length of stay, hospital charges, and inpatient mortality. Underlying NAFLD also increases acute complications of AC.

Cholecystectomy After Percutaneous Cholecystostomy for Acute Cholecystitis: Experience and Outcomes in an Academic Practice.

Percutaneous cholecystostomy (PC) tube insertion has been shown to be an effective treatment of acute cholecystitis (AC) as a temporary step to subsequent laparoscopic cholecystectomy (LC). However, the optimal time gap between PC implantation and LC has not been identified. Adult patients who underwent PC followed by LC for the treatment of AC between 2016 and 2020 were retrospectively reviewed and analyzed. One hundred twelve patients, consisting of 59.8% males, were included and received LC after a median of 65 [48 - 96.5] days following the PC placement. No deaths or reoperations occurred within 30days, but 16 (14.3%) patients were readmitted, and 16 (14.3%) required subsequent reintervention. Although a longer interval between PC and LC had no effect on perioperative outcomes, it was associated with considerably longer intensive care unit (ICU) stay. According to these findings, patients may benefit from early LC following PC for the treatment of AC.

Impact of COVID-19 Pandemic on Management and Outcomes of Acute Cholecystitis at US Academic Centers.

The COVID-19 pandemic has had wide-ranging effects on management of medical conditions. Many hospitals encountered staffing shortages, limited operating room availability, and shortage of hospital beds. There was increased psychological stress and fear of contracting COVID-19 infection, leading to delay in medical care for various disease processes. The objective of this study was to examine changes in management and outcomes attributed to the COVID-19 pandemic in patients presenting with acute calculus cholecystitis at US academic centers. Using the Vizient database, patients with the diagnosis of acute calculus cholecystitis who underwent intervention during the 15 months before the pandemic (prepandemic, October 2018 to December 2019) were compared with 15 months during the pandemic (pandemic, March 2020 to May 2021). Outcomes measures included demographics, characteristics, type of intervention, length of stay, in-hospital mortality, and direct cost. There were 146,459 patients with acute calculus cholecystitis identified (prepandemic: 74,605 vs pandemic: 71,854). Patients in the pandemic group were more likely to undergo medical management (29.4% vs 31.8%; p < 0.001) or percutaneous cholecystostomy tube placement (21.5% vs 18%; p < 0.001) and less likely to undergo laparoscopic cholecystectomy (69.8% vs 73.0%; p < 0.001). Patients in the pandemic group who underwent procedural intervention had longer length of stay (6.5 days vs 5.9 days; p < 0.001), higher in-hospital death (3.1% vs 2.3%; p < 0.001), and higher cost ($14,609 vs $12,570; p < 0.001). In this analysis of patients with acute calculus cholecystitis, there were distinct changes in the management and outcomes of patients due to the COVID-19 pandemic. Changes in the type of intervention and outcomes are likely related to delayed presentation with increases in the severity and complexity of the disease.

Practice Patterns of Endoscopists Performing Endoscopic Gallbladder Drainage

Background and AimsThe standard of care for treatment of patients with acute cholecystitis is cholecystectomy. However, many patients are unfit for surgery due to substantial medical comorbidities, or surgery is technically challenging due to anatomic considerations. Options for patients who are not surgical candidates include percutaneous cholecystostomy tube placement by interventional radiology, endoscopic gallbladder drainage (EGBD), or conservative management. Over the last decade, techniques of EGBD have been employed for temporary or definitive gallbladder drainage in patients with acute cholecystitis who are not surgical candidates. Despite growing interest and clinical use of EGBD, little is known about practice patterns of EGBD. Our aim was to survey endoscopists to evaluate the practice patterns and technical considerations regarding EGBD. MethodsAn 18-item survey was distributed to all members of the American Society of Gastrointestinal Endoscopy. Each response was included in the final analysis. Descriptive statistics were calculated using frequencies and percentages. ResultsResponses were received from 217 endoscopists. Of these, 178 perform endoscopic ultrasound-guided gallbladder draining and 178 perform endoscopic transpapillary gallbladder drainage. The preferred approach for EGBD was endoscopic ultrasound-guided gallbladder drainage in 58.8%, endoscopic retrograde cholangiopancreatography (ERCP)-guided transpapillary gallbladder stent placement in 30.2%, and no preference in 11%. ConclusionDespite growing interest in EGBD, significant heterogeneity in practice patterns exists. Further study is needed to better understand these differences and provide data for future guidelines.

238. Acalculous Cholecystitis: A Novel and Lethal Unrecognized Complication in Severe CoVID 19

Abstract Background SARS-COV-2 infection is known to cause tissue damage in several organs outside of the respiratory tract. The pathogenesis of tissue damage is hypothesized to be caused by direct viral damage, endothelial injury, and ischemic or thrombotic events. Gastrointestinal symptoms were first characterized mainly as diarrhea and diffuse abdominal pain and discomfort, which can be hard to interpret in the setting of a generalized inflammatory response; gallbladder injury and inflammation causing acute acalculous cholecystitis has been scarcely reported Methods Here we discuss five cases of patients presenting with symptoms of cholecystitis. All five patients underwent multiple imaging studies, and all of them were compatible with acute cholecystitis; some of them had an imaging report of lithiasic cholecystitis, while the rest were reported with microlithiasis or biliary sludge. Four out of the five patients underwent laparoscopic cholecystectomy; biopsies were taken, consistently those reported with acalculous cholecystitis. The remaining patient died of CoVID 19 complications prior to surgery, but after a percutaneous cholecystostomy tube was placed. Results All these patients have in common the prolonged fasting, because they all required invasive mechanical ventilation, consequently, they all developed multiple focal pneumonia and respiratory distress syndrome. This fast is related to the development of gangrenous ischemia in the gallbladder, which manifests as a late complication due to SARS-CoV-2 infection, in addition to being related to angiotensin-2 converting receptors and virus replication proteins, as well as the pro-inflammatory and hypoxia state that in itself causes the infection (9). All showed a cholestatic pattern, highlighting that this complication developed in an average time of 3 weeks after the onset of SARS-CoV2 symptoms, in addition to the fact that in most cases a negative test was already shown at the time of the complication. Conclusion Acalculous cholecystitis is one of the extrapulmonary complications that has been seen in patients with this infection, not being the most common, but one of those that has generated a higher mortality rate in patients due to its late diagnosis and non-specific clinical picture in certain occasions (9). Disclosures All Authors: No reported disclosures.

Multi-institutional Retrospective Study of Percutaneous Cholangioscopy-Assisted Lithotripsy for Inoperable Calculous Cholecystitis

PurposeThis study aimed to assess the safety and efficacy of percutaneous lithotripsy for gallstone eradication in patients with calculous cholecystitis with stones >1 cm. Materials and MethodsMulti-institutional institutional review board approved retrospective review of patients who presented with calculous cholecystitis and were not determined to be surgical candidates. All patients underwent percutaneous cholecystostomy tube placement for acute infection, which was later exchanged for a large sheath for ShockPulse (Olympus, Tokyo, Japan) lithotripsy and stone destruction. Review parameters included procedural technical and clinical data, including clinical presentation, mean length of hospital stay, and postintervention symptom reduction. ResultsTwelve patients (mean age, 74.6 years; range, 52–94 years; 6 men and 6 women) underwent large-bore sheath (24–30 F) cholangioscopy-assisted gallstone destruction via rigid lithotripsy. The size of the gallstones ranged from 1.2 to 4.0 cm. All patients had prior cholecystostomy access for a mean of 25 weeks before gallstone extraction to ensure tract maturation via transhepatic or transperitoneal access. The technical success rate in single-session stone removal was 100%, with no major procedure-related adverse events. All patients were symptom- and pain-free after the procedure. The mean procedure time was 111.5 minutes, and the mean fluoroscopy time was 19.2 minutes. The median length of hospital stay was 1 day after the procedure. The mean time from percutaneous lithotripsy to biliary tube removal was 35 days (range, 17–45 days). ConclusionsFluoroscopy-guided percutaneous rigid lithotripsy is a safe and effective procedure for gallstone destruction and extraction in patients who are poor surgical candidates with large lumen-occupying cholelithiasis.

S2830 EUS-Guided Cholecystoduodenostomy Gallbladder Mass Biopsy via AXIOS™ Stent

Introduction: Gallbladder carcinoma (GBC) is a rare malignancy with an incidence rate of 2-4 people per 100,000 with a 5% five-year survival rate.1 Imaging modalities typically used to diagnose GBC are Magnetic Resonance Imaging (MRI), Computed Tomography (CT), and Magnetic resonance cholangiopancreatography (MRCP). However, an emerging diagnostic technique is Endoscopic Ultrasound (EUS) which has a more favorable sensitivity at 92-97%.2 Following imaging diagnostics, either surgery or tissue biopsy is sought. Ultrasound-guided fine-needle aspiration (FNA) and Endoscopic retrograde cholangiopancreatography (ERCP) have been used as modalities for achieving a biopsy.3 EUS-guided cholecystoduodenostomy (EUS-CDS) has emerged as a new alternative in high-risk patients. This procedure involves using endoscopic ultrasound to identify an area where the AXIOS delivery catheter can be inserted to deploy a stent. We present the case of an 89-year-old male who underwent a trans-AXIOS stent gallbladder mass biopsy during EUS-CDS. Case Description/Methods: An 89-year-old male with a past medical history of coronary artery disease, heart failure with reduced ejection fraction, and atrial fibrillation was admitted for cholecystitis. Interventional radiology (IR) was consulted to place a percutaneous cholecystostomy tube. Outside hospital records had reported concern for gallbladder malignancy. Gastroenterology (GI) was then consulted and recommended further workup with MRCP. This showed multiple lesions within the gallbladder. Contrast-enhanced ultrasound was then done, which showed the enhancement of 3 polypoid lesions within the gallbladder lumen shown in Figure a. EUS-CDS was then done via the AXIOS stent, which demonstrated multiple masses within the lumen. Finally, multiple biopsies of the masses shown in Figure b were taken. Subsequent pathology (Figures 1c and 1d) is shown.The patient was later seen by surgery; however, he was not a surgical candidate. Instead, he was seen by oncology and was placed on Gemcitabine-Cisplatin therapy. Discussion: GBC is primarily found in the later stages of its course, and when found preoperatively, only 15-47% are suitable for resection.4 This case presents a unique way in which a high-risk individual was able to undergo a biopsy. It will be essential to consider EUS-CDS as means to not only perform gallbladder drainage but also for tissue diagnosis. As this is an emerging technique, it is vital to contribute cases and experiences to the literature for further investigations.Figure 1.: a) shows one of the three intraluminal gallbladder polyps (white arrow). Largest Measuring 2.7cm. b) is the endoscopic picture of the friable necrotic appearing mass proceeding multiple biopsies (white arrow). c) shows WT 10X dysplasia = 100X magnification of background dysplasia – left side of the tissue demonstrate inflamed no neoplastic epithelium with basally oriented nuclei, compared to high-grade dysplasia with loss of nuclear polarity, nuclear atypia, and enlarged hyperchromatic nuclei. d) shows WT 20X adenocarcinoma = 200X magnification- cohesive aggregate of neoplastic glandular cells with surface ulceration and luminal necrotic debris.

What happens after percutaneous cholecystostomy tube for acute calculous cholecystitis?

• PCT can be a temporary treatment for acute calculous cholecystitis. • High incidence of biliary complications after PCT placement calls for timely cholecystectomy. • Interval cholecystectomy is recommended after PCT for calculous cholecystitis. Acute cholecystitis is commonly treated with laparoscopic cholecystectomy, if feasible. However, critically ill patients can be managed with a percutaneous cholecystostomy tube (PCT) for biliary drainage. This is a temporizing measure and does not represent a final treatment. We aimed to compare the outcomes of performing an interval cholecystectomy vs. conservative management after PCT placement. We conducted a retrospective study of all patients with a PCT placed for acute calculous cholecystitis (ACC) at a single center from October 2010 to March 2015. Ninety-five patients (median age 79 years) underwent PCT placement for ACC. Only 26.3% of patients underwent interval cholecystectomy. The mortality rate within 6 weeks of ACC diagnosis was higher in the non-surgical group but this was not statistically significant. The number of re-admissions and complications of biliary disease was higher in the surgical group before undergoing interval cholecystectomy, specifically, choledocholithiasis (44% vs. 21.4%; p = 0.03). Patients who had an ICU admission [OR 0.21; 95% CI 0.07-0.66] or increased age [OR 0.94; 95% CI 0.89-0.98] were less likely to undergo interval cholecystectomy. Nine cholecystectomies were performed laparoscopic, 6 were converted to open and 10 were done in an open fashion. The complication rate in the first 30 days after cholecystectomy was 56%. Most complications occurred when surgery was performed in an open or converted to open technique (11/14=78.6%) vs. laparoscopic (3/14=21.4%). The relatively high incidence of biliary complications in the period between PCT placement and cholecystectomy calls for timely cholecystectomy in patients treated with PCT. When feasible, patients with a history of ACC should undergo interval cholecystectomy.

EP-434 Is Cholecystostomy the correct temporising strategy for complicated cholecystitis and how should it be utilised to meet the NICE criteria for ‘early cholecystectomy’

Abstract Aims The incidence of undiagnosed gallstones is reported in up to 22% of females, with acute cholecystitis (AC) being a common emergency presentation. NICE guidance recommends index cholecystectomy for patients with proven gallstones. Emergency Laparoscopic Cholecystectomy (LC) in co-morbid patients carries a risk, with percutaneous cholecystostomy tube (PTC) insertion utilised as a temporising measure to relieve sepsis. Whilst effective at decompression, the long-term outcomes are unclear. Methods We retrospectively reviewed all patients undergoing emergency PTC between 2019 and 2021 in our hospital. Data collection included: demographics, ASA classification, Clavien-Dindo grades, cholecystostomy complications. Results A total 24 patients (12:12 male:female) underwent emergency PTC. Median age was 73 years (range 31–89) and median ASA grade of 3 (ASA 1 n=3, ASA 2 n=8, ASA 3 n=7, ASA 4 n=6). Median time from PTC insertion to LC was 20 weeks (range 6–73 weeks). Morbidity post PTC according to Clavien-Dindo grades were: 4 with grade 3 (16.7%), 5 with grade 4 (8.3%) and 5 with grade 5 (20.8%). 8 patients (33.3%) re-presented with further cholecystitis. 4 (16.7%) patients had completion LC, without complication. Conclusions Our findings highlight significant morbidity and mortality in this high-risk cohort secondary to complicated AC. 20 patients (83.3%) did not undergo a completion cholecystectomy, despite 18 being ASA 1–3. We suggest a judicious use of PTC and a greater focus on index multi-disciplinary surgical fitness assessment in order to optimise a patient for acute LC. This strategy is key to enable full adoption of AUGIS guidance for performing LC within 72 hours.