Percutaneous Cholecystostomy Research Articles

Acute cholecystitis management at a tertiary care center: are we following current guidelines?

After the Tokyo 2018 guidelines (TG2018) were published, evidence from the 2018 CHOCOLATE RCT supported early cholecystectomy for acute cholecystitis (AC), even in high-risk patients. This study aims to investigate AC management at our tertiary care center in the years following these publications. A retrospective cohort study was performed on patients admitted from 2018 to 2023. AC severity was graded using TG2018 definitions. Comorbidities were summarized using Charlson Comorbidity Index (CCI) and frailty using the 5-item modified Frailty Index (5mFI). Compliance with TG2018 recommendations for management strategy was investigated. Outcomes were compared between patients who underwent surgery versus non-operative management (NOM). Subset analysis based on patients' age, frailty, and comorbidities was performed. Among 642 AC patients, 57% underwent cholecystectomy and 43% NOM (22% percutaneous cholecystostomy, 21% antibiotics only). NOM patients had greater length of stay (LOS), complications, deaths, readmissions, and discharge to nursing/rehab versus surgery patients. In 70% of patients managed non-operatively, TG2018 were not followed. Patients managed non-operatively despite TG2018 were more likely to undergo delayed cholecystectomy compared to those in whom guidelines were followed (17% vs. 4%). In subset analysis, healthy octogenarians were significantly less likely to be managed according to TG2018 (9.4%); patients undergoing surgery had a trend towards shorter LOS (3.1 vs. 4.8 days) than those managed non-operatively but no difference in other outcomes. Most patients undergoing NOM could potentially undergo cholecystectomy if guidelines are considered. A more objective approach to risk assessment may optimize patient selection and outcomes.

Transhepatic Cholangiography and Biliary Drainage: Basic Concepts and Technique

AbstractPercutaneous transhepatic biliary procedures are essential for managing a variety of hepatobiliary conditions, particularly when endoscopic retrograde cholangiopancreatography is not feasible or has failed, or when patients are unstable. This review article provides a comprehensive overview of the indications, contraindications, and procedural steps for biliary puncture, focusing on techniques such as percutaneous transhepatic biliary drainage (PTBD) and percutaneous cholecystostomy. We also address strategies for accessing minimally dilated biliary systems and performing bedside PTBD. The article highlights the increasing demand for these interventions due to rising incidences of biliary diseases such as gallbladder cancer and cholangiocarcinoma, as well as complications arising from previous surgeries. Furthermore, we discuss common and life-threatening complications associated with these procedures, including biliary leaks, hemorrhage, and sepsis, and provide guidance on effective management strategies. Understanding these procedures and their potential complications is crucial for optimizing patient care and outcomes in complex biliary conditions.

International Delphi consensus on the management of percutaneous choleystostomy in acute cholecystitis (E-AHPBA, ANS, WSES societies)

BackgroundThere has been a progressive increase in the use of percutaneous cholecystostomy (PC) in acute cholecystitis (AC) over the last decades due to population aging, and the support of guidelines (Tokyo Guidelines (TG), World Society of Emergency Surgery (WSES) Guidelines) as a valid therapeutical option. However, there are many unanswered questions about the management of PCs. An international consensus on indications and PC management using Delphi methodology with contributions from experts from three surgical societies (EAHPBA, ANS, WSES) have been performed.MethodsA two-round Delphi consensus, which included 27 questions, was sent to key opinion leaders in AC. Participants were asked to indicate their ‘agreement/disagreement’ using a 5-point Likert scale. Survey items with less than 70% consensus were excluded from the second round. For inclusion in the final recommendations, each survey item had to have reached a group consensus (≥ 70% agreement) by the end of the two survey rounds.Results54 completed both rounds (82% of invitees). Six questions got > 70% and are included in consensus recommendations: In patients with acute cholecystitis, when there is a clear indication of PC, it is not necessary to wait 48 h to be carried out; Surgery is the first therapeutic option for the TG grade II acute cholecystitis in a patient suitable for surgery; Before PC removal a cholangiography should be done; There is no indication for PC in Tokyo Guidelines (TG) grade I patients; Transhepatic approach is the route of choice for PC; and after PC, laparoscopic cholecystectomy is the preferred approach (93.1%).ConclusionsOnly six statements about PC management after AC got an international consensus. An international guideline about the management of PCs are necessary.

The impact of routine cholangiography for asymptomatic patients after cholecystostomy insertion for acute cholecystitis

BackgroundWe aim to investigate the impact of routine cholangiography on asymptomatic patients with percutaneous cholecystostomy (PCC) for acute cholecystitis (AC). MethodsThe study included all patients treated with PCC for AC from 2017 to 2020 ​at a single academic center. Patients who underwent routine cholangiography within 30 days post-discharge while asymptomatic were compared to patients who were only followed clinically. ResultsThe groups (cholangiography group, n ​= ​44, and control group, n ​= ​145) were similar in terms of age, comorbidities, and clinical presentation. The readmission rate for biliary disease in the cholangiography group was nearly half that of the control group (22.7 ​% vs. 40.7 ​%, p ​= ​0.05) over an average follow-up of 10.4 months. The time to drain removal, cholecystectomy rate, and time to operation were comparable between the groups (42 vs. 40 days, p ​= ​0.47, 52.3 ​% vs 53.1 ​%, p ​= ​NS and 69 vs. 82 days, p ​= ​0.17, respectively). ConclusionsRoutine cholangiography can help reduce biliary disease readmissions among asymptomatic patients with PCC for AC without delaying further treatment.

Percutaneous Cholecystostomy for Acute Cholecystitis During Spaceflight

INTRODUCTION: Acute calculous cholecystitis is a common surgical emergency and cholecystectomy is the gold-standard treatment. However, alternative drainage modalities such as percutaneous cholecystostomy tube (PCT) placement have been proposed for poor surgical candidates or in remote environments, such as space. We reviewed the literature to assess the theoretical utility of PCT to treat acute cholecystitis during long-duration spaceflight or on the Moon or Mars. METHODS: A systematic review of 16 peer-reviewed articles published since 2018 was completed to describe the terrestrial efficacy of PCT placement for acute calculous cholecystitis. RESULTS: The mean initial clinical success rate after PCT was 89.9% (range 82.2–100.0%). Duration of indwelling PCT ranged from median 6 to 58 d. Mean rate of recurrent cholecystitis was 15.8% (range 5.0–36.4%). A mean 35.6% of patients (range 18.0–61.0%) required interval cholecystectomy. Mean 30-d mortality was 9.6% (range 5.8–14.0%). A mean 18.6% of patients (range 7.2–30.0%) required repeat percutaneous intervention due to PCT placement complications. DISCUSSION: While PCT achieves high rates of early resolution of cholecystitis, the long-term outcomes after PCT are relatively poor, with risk of recurrent cholecystitis, need for cholecystectomy, and frequent postprocedural complications requiring repeat procedural interventions. In cislunar space, the return to Earth for cholecystectomy following PCT may be achieved, eliminating some of these concerns. However, with long-duration space travel such as a mission to Mars, PCT is likely inadequate for the long-term treatment of cholecystitis. Prophylactic cholecystectomy, developing surgical capabilities in space, or preflight screening ultrasound for cholelithiasis should be seriously considered for long-duration spaceflight. Lazow SP, Siu M, Brown L, Kamine TH. Percutaneous cholecystostomy for acute cholecystitis during spaceflight. Aerosp Med Hum Perform. 2024; 95(10):771–776.

Endoscopic Transpapillary Gallbladder Drainage with Two Stents Versus One Stent Reduces Re-Interventions: A Multicenter Study

Background and AimsEndoscopic transpapillary gallbladder drainage (ETGBD) is a therapeutic option for gallstone-related gallbladder disease in non-surgical candidates. However, the optimal stenting strategy and follow-up has not been established. We aimed to determine whether there was a decreased need for unplanned reintervention in patients undergoing placement of two transpapillary gallbladder stents as compared to one. MethodsWe performed a multicenter retrospective analysis of patients undergoing ETGBD between June 2013 and October 2022. The primary outcome was clinical success as defined by resolution of symptoms without the need for another drainage strategy. Secondary outcomes included the adverse events of post-ERCP pancreatitis, cholangitis, bleeding, perforation, or death. Factors associated with placement of two stents, unplanned reintervention, and adverse events were assessed. ResultsWe included 75 patients undergoing ETGBD, with a median follow-up of 407 days (IQR: 71-1504). Technical and clinical success were 88.2% and 81.3%, respectively. Unplanned reintervention was significantly lower in the double stenting group (0% vs. 25.4%, P=0.02). Use of a 7 French stent (OR: 15.5; 95% CI: 1.9-125; p=0.01) and presence of a percutaneous cholecystostomy tube (OR: 10.8; 95% CI: 2.8-41.3; p=0.001) were associated with placement of two stents. There was no significant difference in adverse events between groups (OR: 0.9; 95% CI: 0.09-8.8; P=0.94). ConclusionsETGBD is safe and effective in non-operative candidates. Single transpapillary gallbladder stenting is associated with more unplanned reinterventions, and 7 French stent diameter and prior percutaneous cholecystostomy tube may be associated with ability to place a second stent. Endoscopists should consider planned exchange of solitary transpapillary gallbladder stents or interval placement of a second stent if placement of two stents was unsuccessful at the index procedure.

Multicenter analysis of the efficacy of early cholecystectomy and preoperative cholecystostomy for severe acute cholecystitis: a retrospective study of data from the multi-institutional database of the Hiroshima Surgical Study Group of Clinical Oncology

BackgroundSevere acute cholecystitis (AC) is a challenging disease because it comprises coexisting systemic infections that lead to vital organ dysfunction. This study evaluated the optimal surgical timing and efficacy of preoperative percutaneous cholecystostomy (PC) for patients with severe AC.MethodsData of 142 patients who underwent cholecystectomy for severe AC between 2011 and 2021 were retrospectively collected from the multi-institutional database of the Hiroshima Surgical Study Group of Clinical Oncology. Patients were divided into the early cholecystectomy (EC) group (within 72 h of symptom onset) and delayed cholecystectomy (DC) group. They were also subdivided into the upfront cholecystectomy group and preoperative PC before cholecystectomy group. The diagnosis and severity of AC were graded according to the Tokyo Guidelines 2018. Clinicopathological variables and outcomes were compared.ResultsNo significant differences in age, body mass index, American Society of Anesthesiologists (ASA) classification, and Charlson comorbidity index between the EC and DC groups were observed. Preoperative drainage was more commonly performed for the DC group than for the EC group. Local severe AC features were more commonly detected in the DC group than in the EC group. The postoperative outcomes of the EC and DC groups were comparable. Compared to the PC before cholecystectomy group, the upfront cholecystectomy group included more patients with ASA physical status ≥ 3 and more patients who used oral warfarin. Warfarin usage and cardiovascular dysfunction rates of the PC after cholecystectomy group were higher than those of the upfront cholecystectomy group. PC was associated with significantly less intraoperative bleeding and shorter hospital stays.ConclusionsPatients who can tolerate general anesthesia are good candidates for EC. Patients who use warfarin and those with cardiovascular dysfunction are considered to be at high risk for postoperative complications; therefore, to prevent AC recurrence during the waiting period, PC before cholecystectomy during the same admission is more appropriate than upfront cholecystectomy for these patients.

WP4.7 - Use of cholecystostomy to manage acute cholecystitis in high risk patients in a rural hospital

Abstract Aim To evaluate outcomes after percutaneous cholecystostomy (PC) in patients with acute cholecystitis in a rural DGH. Methods Retrospective data collection on patients who underwent PC between October 2019 and January 2024. Variables collected included; Demographics, ASA grade, Charlson Comorbidity Index (CCI), inflammatory markers, length of hospital stay (LOS), complications, duration of PC, mortality and subsequent management. Results Complete data was available on 58 patients. 53.5% were male and mean age was 74±10.5years. 42(73%) patients were ASA III or above, 17(29%) had moderate CCI (3-4) and 35(60%) had severe CCI score of 5 or above. No difference noted in inflammatory markers from Day 1 to day of cholecystostomy (p=0.43) reflecting failure to antibiotic treatment. 15.5% of patients needed critical care. Average duration of PC in situ was 48 days; 11(19%) had PC in for >80 days. 27(46.5%) patients underwent cholecystograms prior to removal and 19% were abnormal. Median LOS was 12(2-159) days. 4(6.9%) patients had complications from PC insertion. 30-day and 1-year mortality was 3.5% and 5% respectively. Care episodes needed following discharge with PC in situ was 2(Mean). 17(29.3%) patients had cholecystectomy following PC removal with 12% having open conversion. Conclusions Percutaneous cholecystostomy offers a safe alternative to laparoscopic cholecystectomy in managing acute cholecystitis in high risk patients. Subsequent cholecystectomy has a higher rate of conversion to open.

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.

Multisociety research collaboration: timing of cholecystectomy following cholecystostomy drainage for acute cholecystitis.

Patients with acute cholecystitis (AC) presenting with unfavorable systemic or local conditions are often managed with percutaneous cholecystostomy (PC) as a temporary measure. The clinical outcomes of interval cholecystectomy following PC remain unclear. The aim of the study was to identify the association between the timing of cholecystectomy following PC for AC and perioperative complication rates at interval cholecystectomy. We hypothesized that there would be a specific time interval to cholecystectomy associated with lower risk for adverse events. This was a retrospective (2018-2020) multicenter study at 8 participating hospital systems of adult patients with AC, managed with PC and interval cholecystectomy. Demographics, comorbidities, treatment details, and outcomes were examined. Patients were grouped based on quartiles for timing of surgery after PC (< 7, 7-9, 10-13, > 13weeks). The primary outcome was a composite endpoint of bile duct injury, reoperation, readmission, image-guided intervention, endoscopic intervention, conversion to open surgery, or death. There were 188 patients with a median age of 66years with AC classified as mild (41%), moderate (47%), and severe (12%). Median days from PC to surgery were 65 (Q1 = 48, Q3 = 91). Laparoscopic cholecystectomy (89.9%) was the most commonly planned approach (robotic 6.4%, 3.7% open) and 28 (14.9%) were converted to open. The composite endpoint was reported in 51 patients (27.1%). A biliary injury occurred in 7 (3.7%) patients. Time to surgery and intraoperative drain placement were independently associated with the composite outcome. Cholecystectomy within 7weeks of PC was associated with decreased risk (OR = 0.36, 95% CI 0.13-0.97) of the composite endpoint, compared to patients undergoing surgery > 13weeks after PC. Timing of surgery following PC was associated with procedural outcomes. Patients undergoing surgery before 7weeks experienced significantly less morbidity than patients having delayed cholecystectomy. These results should be considered in patient selection and management after PC.

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.

Acute Calculus Cholecystitis: An Update: Review Article

The management of acute calculus cholecystitis has evolved from conservative treatment with intra-venous antibiotics and analgesics to early cholecystectomy. Cholecystectomy is considered the definitive management of acute calculus cholecystitis and laparoscopic cholecystectomy is the gold standard in the management of acute calculus cholecystitis. The management of acute calculus cholecystitis can be divided into early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy. The current trend in the management of acute calculus cholecystitis is early laparoscopic cholecystectomy. The grey areas in the management of acute calculus cholecystitis include the timing of early laparoscopic cholecystectomy and the role of percutaneous cholecystostomy in high-risk patients. We have conducted this review article to look at the role of conservative treatment, the time for performing an early laparoscopic cholecystectomy and the role of percutaneous cholecystostomy.

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

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

Updates on Antibiotic Regimens in Acute Cholecystitis.

Acute cholecystitis is one of the most common surgical diseases, which may progress from mild to severe cases. When combined with bacteremia, the mortality rate of acute cholecystitis reaches up to 10-20%. The standard of care in patients with acute cholecystitis is early laparoscopic cholecystectomy. Percutaneous cholecystostomy or endoscopic procedures are alternative treatments in selective cases. Nevertheless, antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis. Patients with acute cholecystitis have a bile bacterial colonization rate of 35-60%. The most frequently isolated microorganisms are Escherichia coli, Klebsiella spp., Streptococcus spp., Enterococcus spp., and Clostridium spp. Early empirical antimicrobial therapy along with source control of infection is the cornerstone for a successful treatment. In these cases, the choice of antibiotic must be made considering some factors (e.g., the severity of the clinical manifestations, the onset of the infection if acquired in hospital or in the community, the penetration of the drug into the bile, and any drug resistance). Furthermore, therapy must be modified based on bile cultures in cases of severe cholecystitis. Antibiotic stewardship is the key to the correct management of bile-related infections. It is necessary to be aware of the appropriate therapeutic scheme and its precise duration. The appropriate use of antibiotic agents is crucial and should be integrated into good clinical practice and standards of care.

Outcomes of endoscopic ultrasound-guided gallbladder drainage: A multicenter study from India (with video).

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) offers a safe and minimally invasive alternative for percutaneous cholecystostomy (PCC) in acute cholecystitis patients with high-surgical risk. Additionally, EUS-GBD serves as a rescue biliary drainage in malignant distal biliary obstruction. Despite its widespread application, data within the Indian context remains sparse. This study aims to report the outcomes of EUS-GBD through the first multi-center study from India. We retrospectively analyzed patients undergoing EUS-GBD at six tertiary care centers of India from March 2022 to November 2023. EUS-GBD was performed by free hand or over-the-guidewire technique with lumen-apposing metal stent (LAMS) or large caliber metal stent (LCMS). The primary outcome was technical success (defined as successful deployment of stent between gallbladder and stomach/duodenal lumen). The secondary outcomes were clinical success (defined as resolution of symptoms of acute cholecystitis and more than > 50% reduction in bilirubin level within two weeks in distal biliary obstruction), adverse event rate, 30-day mortality rate and 90-day reintervention rate. Total29 patients (mean age 65.86 ± 12.91, 11 female) underwent EUS-GBD. The indication for EUS-GBD were acute cholecystitis (79.31%) and rescue biliary drainage for malignant distal biliary obstruction (20.69%). LAMS was deployed in 92.86%, predominantly by free-hand technique (78.57%). Technical and clinical success rates were 96.55% and 82.75%, respectively. Adverse events occurred in 27.59% patients, with severe adverse events (bile leak and bleeding) being uncommon (10%). Both 30-day mortality rate and 90-day reintervention rate were 13.79% in patients. Cholecysto-duodenal fistula facilitated cholecystoscopic intervention and stone removal in one patient and transgastric EUS-GBD did not hamper bilio-enteric anastomosis during Whipple surgery in two patients. EUS-GBD is a safe and effective technique for managing acute cholecystitis in high-risk patients and for biliary drainage in cases with malignant distal biliary obstruction.

Gallbladder Volvulus: A Rare Case of Pre-operative Diagnostic Quandary

&amp;lt;i&amp;gt;Introduction: &amp;lt;/i&amp;gt;Gallbladder volvulus (GBV) is a rare but critical condition characterized by torsion of the gallbladder on its mesentery. Prompt surgical intervention is crucial in preventing complications and improving patient outcomes. Despite advancements in imaging techniques, diagnosing GBV remains challenging due to its nonspecific clinical presentation and low preoperative detection rates.&amp;lt;i&amp;gt; Case Details: &amp;lt;/i&amp;gt;This paper presents the case of a 79-year-old female presenting with symptoms suggestive of acute appendicitis and urinary tract infection. Imaging, including Computed Tomography (CT), ultrasound, (US) and magnetic resonance cholangiopancreatography (MRCP), were indicative of acute acalculous cholecystitis. Intraoperatively, a necrotic gangrenous gallbladder was encountered, resulting from GBV. &amp;lt;i&amp;gt;Discussion: &amp;lt;/i&amp;gt;GBV poses diagnostic difficulties due to its variable presentation and low preoperative detection rates. Misdiagnoses poses significant risk of mismanagement, especially in the elderly and high risk populations, where non-operative management is attempted (antibiotics, percutaneous cholecystostomy, etc.) leading to increased morbidity and mortality. Therefore, high index of suspicion and correlation with imaging findings are crucial for accurate diagnosis. While various imaging modalities can assist in diagnosis, interpretation may be challenging, as demonstrated in this case. Surgical intervention, preferably through laparoscopy, is the cornerstone of treatment and offers favorable outcomes when performed promptly.&amp;lt;i&amp;gt; Conclusion: &amp;lt;/i&amp;gt;In conclusion, GBV is a rare but potentially life-threatening condition that necessitates early recognition and surgical intervention. Despite challenges in diagnosis, a comprehensive clinical and radiological approach is crucial for timely management and optimal patient outcomes. Further research and awareness are warranted to enhance early diagnosis of this uncommon entity.

The Multifaceted Impact of Gallstones: Understanding Complications and Management Strategies.

Gallstones, or cholelithiasis, represent a prevalent gastrointestinal disorder characterized by the formation of calculi within the gallbladder. This review aims to provide a comprehensive analysis of the complications associated with gallstones, with a focus on their pathophysiology, clinical manifestations, diagnostic methodologies, and management strategies. Gallstone-related complications encompass a broad spectrum, including biliary colic, acute cholecystitis, choledocholithiasis, acute pancreatitis, and cholangitis. The pathogenesis of these complications primarily involves biliary obstruction and subsequent infection, leading to significant morbidity and potential mortality. Diagnostic evaluation of gallstone complications employs various imaging techniques, such as ultrasonography, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP), each with distinct advantages and limitations. Therapeutic approaches are discussed, ranging from conservative management with pharmacotherapy and bile acid dissolution agents to interventional procedures like extracorporeal shock wave lithotripsy (ESWL) and percutaneous cholecystostomy. Surgical management, particularly laparoscopic cholecystectomy, remains the gold standard for definitive treatment. Additionally, advancements in endoscopic techniques, including endoscopic sphincterotomy(EST) and cholangioscopy, are highlighted. This review synthesizes current research findings and clinical guidelines, aiming to enhance the understanding and management of gallstone-related complications among healthcare professionals, thereby improving patient outcomes and reducing the burden of this common ailment.

Percutaneous cholecystostomy in acute cholecystitis – Narrative review article

Percutaneous cholecystostomy is often performed to treat high-risk patients with acute cholecystitis who are not suitable for cholecystectomy. It is performed by the interventional radiologist and can be performed through the transhepatic or transperitoneal route (direct gallbladder puncture, without passing through the liver). Percutaneous cholecystostomy is used as a bridging procedure to stabilize high-risk patients with acute cholecystitis. We prepared this narrative review article to describe the indications for performing this procedure and the consequences of its performance and to compare it with emergency cholecystectomy.

Association of biliary distention with a diagnosis of acute cholecystitis

BackgroundGallbladder distention has been described in radiology literature but its value on point-of-care ultrasound (PoCUS) performed by emergency physicians is unclear. We sought to determine the test characteristics of gallbladder distention on PoCUS for cholecystitis (acute or chronic), and secondarily whether distention was associated with an obstructing stone-in-neck (SIN), acute cholecystitis on subsequent pathology report, and longer cholecystectomy operative times. MethodsThis was a dual-site retrospective cohort study of all Emergency Department (ED) patients that underwent diagnostic biliary PoCUS and were subsequently admitted from 11/1/2020 to 10/31/2022. Patients with pregnancy, liver failure, ascites, hepatobiliary cancer, prior cholecystectomy, or known cholecystitis were excluded. Gallbladder distention was defined as a width ≥4 cm or a length ≥10 cm. Saved ultrasound images were reviewed by three independent reviewers who obtained measurements during the review. Test characteristics, Cohen's kappa (κ), and strength of association between distention and our variables (acute cholecystitis on pathology report and SIN on PoCUS) were calculated using a Chi Square analysis, where intervention (cholecystectomy, percutaneous cholecystostomy, or intravenous antibiotics) was used as the reference standard for AC. A one-tail two sample t-test was calculated for mean operative times. ResultsOf 280 admitted patients who underwent ED biliary PoCUS, 53 were excluded, and 227 were analyzed. Of the 227 patients, 113 (49.8%) had cholecystitis according to our reference standard, and 68 (30.0%) had distention on PoCUS: 32 distended by both width and length, 16 distended by width alone, and 20 distended by length alone. Agreement between investigators was substantial for width (κ 0.630) and length (κ 0.676). Distention was 85.09% (95% CI 77.20–91.07%) specific and 45.1% (95% CI 35.8–54.8%) sensitive for cholecystitis. There was an association between distention and SIN; odds ratio (OR) 2.76 (95% CI 1.54–4.97). Distention of both length and width was associated with acute over chronic cholecystitis; OR 4.32 (95% CI 1.42–13.14). Among patients with acute cholecystitis, mean operative times were 114 min in patients with distention and 89 min in patients without distention (p = 0.03). ConclusionGallbladder distention on PoCUS was specific for cholecystitis (acute or chronic), and associated with SIN, acute cholecystitis on subsequent pathology report, and longer cholecystectomy operative times. Measurement of gallbladder dimensions as part of the assessment of cholecystitis may be advantageous.