Percutaneous Transhepatic Cholecystostomy Research Articles

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.

EFFICACY OF PERCUTANEOUS TRANSHEPATIC CHOLECYSTOSTOMY IN ACUTEOBSTRUCTIVE CHOLECYSTITIS

Acute obstructive cholecystitis is a common disease with a significant risk of mortality and complications. Active surgical tactics, such as open and laparoscopic access, pose a significant risk for elderly patients with concomitant diseases on the background of acute cholecystitis. The aim of our study is to analyze the effectiveness of percutaneous transhepatic cholecystostomy (PTCS) in acute obstructive cholecystitis (AOC) and subsequent laparoscopic cholecystectomy (LCE). Materials and methods. Retrospectively, we analyzed 64 patients treated with AOC in the period from 2017 to 2021 at the NSCS named after A.N. Syzganov. We divided them into 2 groups depending on surgical treatment. The first group: patients who were performedPTCS (n=29) at the first stage. The second stage, LCE was performed during the waiting period from 3 days to 72 days. The second group: patients who underwent LCE without drainage of the gallbladder (n=35). Also, the patients of the first group were divided into 3 subgroups depending on the waiting time: group A - LCE was performed within 10 days after PTCS, subgroup B - LCE was performed after from 2 to 4 weeks (n=12), patients of the subgroup C, LCE were performed after 4 weeks after PTCS. Preoperative, intraoperative data and postoperative complications were analyzed. Results. According to preoperative data, there was no significant difference in body temperature, laboratory data and concomitant diseases. The statistical difference was revealed only in the age of patients (65.3±9.0 vs 53.4±15.4). The duration of the operation in the second group of LCE was longer compared to the first group, but no significant difference was detected (108.1 ± 30.5 vs 117.9 ± 39.9). In the postoperative period after LCE, complications were observed in 5 (14.2%) cases: bleeding in 4 (11.4%) cases and suppuration of the postoperative wound in 1 (2.8%) case. Conversion was performed in 10 (15.6%) cases, and in one (1.5%) case, the choledochal wall was injured intraoperatively. There was no significant difference between groups A, B and C. Conclusion.The use of two-stage treatment significantly reduces the conversion to open surgery, significantly reduces postoperative complications and hospital stay in the postoperative period. According to the results of our research, the most optimal interval between PTCS and LCE is a period of more than 4 weeks.

Management of Cholelithiasis in Cirrhotic Patients.

Gallstone disease (GD) is a common disease worldwide and has a higher incidence in cirrhotic patients than in the general population. The main indications for cholecystectomy surgery in cirrhotic patients remain symptomatic cholelithiasis and its complications. Over the past two decades, numerous published reports have attested to the feasibility and safety of laparoscopic cholecystectomy in cirrhotic patients. Surgery in patients with liver cirrhosis represents an additional source of stress for an already impaired liver function and perioperative complications are remarkably high compared to non-cirrhotic patients, despite significant advances in surgical management. Therefore, preoperative risk stratification and adequate patient selection are mandatory to minimize postoperative complications. We have conducted a systematic review of the literature over the last 22 years for specific information on indications for surgery in cirrhotic patients and individual percentages of Child-Pugh grades undergoing treatment. There are very few reported cases of cholecystectomy and minimally invasive treatment, such as percutaneous transhepatic cholecystostomy (PTC), in patients with Child-Pugh grade C cirrhosis. With this work, we would like to pay attention to the treatment of cholelithiasis in cirrhotic patients who are still able to undergo cholecystectomy, thus also encouraging this type of intervention in cases of asymptomatic cholelithiasis in patients with Child-Pugh grades A and B.

THE USE OF ANTEGRADE ENDOBILIARY INTERVENTIONS IN BENIGN DISEASES OF THE BILIARY TRACT COMPLICATED BY MECHANICAL JAUNDICE

Introduction. One of the most common manifestations of diseases of the biliary tract are strictures or stenoses. They can have malignant, inflammatory and traumatic etiology, as well as be accompanied by mechanical jaundice syndrome.&#x0D; Aim. To study the results of the use of antegrade endobiliary interventions in benign diseases of the biliary tract complicated by mechanical jaundice.&#x0D; Materials and methods. An analysis of surgical treatment of 34 patients with benign diseases of the biliary tract complicated by mechanical jaundice (MJ) in the SI “V.T. Zatsev IGUS NAMSU». Choledocholithiasis was the cause of MF in 21 (61.8 %) cases, stricture of the LV in 6 (17.6 %) and stricture of the biliodigestive anastomosis (BDA) in 7 (20.6 %) patients. BDA strictures developed after the following operations: biliobiliostomy — 1 (14.3 %), hepaticojejunostomy — 3 (42.9 %), choledochoduodenoanastomosis — 2 (28.5 %) and hepaticoduodenostomy — 1 (14.3 %) %).&#x0D; Research results. External percutaneous transhepatic cholangiodrainage was performed in 7 (46.7 %) patients, external-internal percutaneous transhepatic cholangiodrainage was performed in 6 (40 %), percutaneous transhepatic cholecystostomy was performed in 2 (13.4 %) patients. With slightly dilated intrahepatic ducts (&lt;5 mm) cholangiodrainage was established in 3 (20 %) patients. Of these, in 3 (20.0 %) cases, a separate percutaneous transhepatic cholangiodrainage of the right and left lobular ducts of the liver was performed. Performing percutaneous transhepatic cholangiography and percutaneous transhepatic cholangiodrainage allows to determine the level and nature of biliary block in a minimally invasive way, to perform biliary decompression and prevention of complications after an unsuccessful attempt at endoscopic treatment.&#x0D; Conclusions. By using antegrade endobiliary interventions, we were able to reduce the risk of biliary decompression complications compared with patients who had unsuccessful attempts at endoscopic treatment from 15 (78.9 %) to 1 (6.67 %), and to reduce the number of complications after reconstructive rehabilitation. operations from 10 (52.6 %) to 1 (6.67 %) and the mortality rate from 2 (10.5 %) to 1 (6.67 %).

Abstract No. 573 The role of image-guided percutaneous cholecystostomy as a primary treatment in children

To evaluate the indications, technical success, and complications of percutaneous trans-hepatic cholecystostomy in children. A single-center, IRB reviewed and exempted 20 years retrospective study of children who had IR-guided percutaneous trans-hepatic cholecystostomy. Data collected included; patient demographics, tube indication, tube size and type, duration of drainage, complications, and comorbid conditions. Exclusion criteria; drainage catheter exchange for pre-existing surgical tubes. A total of 14 primary trans-hepatic PCT procedures were performed in 14 patients using trans-hepatic access. The median age at intervention was 3.56 years with IQR (0.27–10.6 years), mean weight was 25 kg (range, 3.7–65.5 kg), 6 of whom were infants, and < 10 kg. Indications included; inspissated bile syndrome (50%, n = 7), acalculous cholecystitis (21%, n = 3), tumor-related obstructive jaundice (14%, n = 2), biliary calculi (7%, n = 1), suspected biliary atresia (7%, n = 1). Technical success was 85.7% (N = 12/14), two failed procedures, 2/14 bladder wall perforation followed by surgical drain placement. Catheter size ranged from 5- to 8.5-Fr, with the most common type of catheter being a Dawson-Muller Catheter (58.3%, n = 8/12). Comorbidities including, hematologic malignancies (n = 2), cystic fibrosis (n = 2), congenital heart disease (n = 2), renal transplant, viral congestive heart failure on ECMO, sickle cell disease, primary sclerosing cholangitis, and tracheoesophageal fistula were present in 12/14 patients. The median catheter tube dwell time was 13 days, IQR (6–31 days). Of the successful placements, there were no major complications. Three minor complications, self- limited GB wall perforation in 1 and premature tube dislodgement in 2 infants of the 12 successfully placed drainage tubes. In children, PCT can be used as a primary treatment modality for hepatobiliary disorders with good technical success but this procedure can be challenging, and in this study, failures were reflective of the initial experience.

2181 Gallbladder Irrigation via Cholecystostomy Tube as a Novel Technique for Improving EUS-Guidance During Placement of Lumen-Apposing Metal Stent (LAMS) for Cholecystoduodenostomy

INTRODUCTION: Cholecystectomy is the preferred treatment of acute cholecystitis, but it may be relatively contraindicated in patients with medical comorbidities or advanced age. Non-surgical approaches include percutaneous transhepatic cholecystostomy tube and endosonographic stent placement. Adequate endosonographic imaging of the gallbladder is essential for correct stent deployment. CASE DESCRIPTION/METHODS: A 55-year-old male was admitted for endoscopic cholecystoduodenostomy for palliation of chronic cholecystitis. He had prior admissions for cholecystitis and choledocholithiasis with cholangitis with prior ERCPs requiring sphincterotomy, sphincteroplasty, stone removal and common bile duct stent placement. He was a poor candidate for cholecystectomy due to multiple medical comorbidities and chronic anticoagulation and was referred for endoscopic therapy. The patient was brought to the endoscopy suite and placed under general anesthesia. The Olympus linear echoendoscope was passed to the second portion of the duodenum. The gallbladder was collapsed due to prior patent sphincterotomy and sphincteroplasty. With IR assistance, the gallbladder was irrigated with normal saline boluses of to a volume of 600 mL. Due to the patent sphincterotomy, the gallbladder would collapse requiring additional irrigation. Maximal size of the gallbladder 30 mm in the long axis and 20 mm in the short axis. The duodenal wall and the gallbladder were punctured under endosonographic guidance using the hot AXIOS electrocautery-enhanced delivery system. A stoma was created and a 15 × 10 mm AXIOS stent was placed with flanges in close approximation to the gallbladder and duodenal wall through the cholecystoduodenostomy. The echoendoscope was then withdrawn. Next, a solution of normal saline and methylene blue was injected through the percutaneous cholecystostomy tube and this solution was seen to flow from the duodenal portion of the AXIOS stent on endoscopic views, confirming adequate location of the AXIOS stent in the gallbladder and duodenum. DISCUSSION: The patient did well in the immediate post-procedural period. Six days post-procedure, he was noted to have melena in the setting of supratherapeutic INR and aPTT. Repeat upper endoscopy showed no evidence of bleeding. The AXIOS stent appeared normal on endoscopic views. Due to the difficulty of stent placement and palliative intent, we left the AXIOS stent in situ. The patient is currently asymptomatic and was referred to IR for removal of percutaneous cholecystostomy tube.

Gall Bladder Drainage for Acute Cholecystitis in Surgically Unfit Patients: Endoscopic Ultrasound Guided Transmural Drainage or Endoscopic Transpapillary Drainage!

AbstractAcute cholecystitis (AC) is a potentially serious condition that is associated with significant morbidity and mortality. Laparoscopic cholecystectomy is the treatment of choice of AC in surgically fit candidates. However, high-risk surgical patients with AC are a therapeutic dilemma. Various alternative treatment options available include percutaneous transhepatic cholecystostomy (PTC), endoscopic ultrasound (EUS)-guided gall bladder (GB) drainage or endoscopic transpapillary drainage of GB. Due to higher complication, unplanned hospital readmission rate, risk of tube dislodgement, and high risk of recurrent acute cholecystitis associated with PTC, endoscopic drainage GB is the preferred, minimally invasive treatment option. Both endoscopic transpapillary GB drainage as well as EUS-guided transmural drainage of GB are effective GB drainage options, but both of them have not been compared in terms of their efficacy and safety. In this news and views, we have discussed two interesting articles which have compared EUS-guided GB drainage and endoscopic transpapillary drainage.

Surgical decision making in patients with cirrhosis: a systematic review of the literature

Background: The incidence of cirrhosis is increasing and many patients affected by this disease process will require some form of operation (elective vs emergent). In these individuals, the decision making process can be quite demanding. These individuals require adequate assessment for the degree of hepatic dysfunction, extent of both portal hypertension and their comorbidities for perioperative optimization. Some of the common operations performed in patients with cirrhosis involve biliary, colorectal disease and ventral hernias. The primary aim of this study is a systematic review of the literature to determine the decision making process involved with three common emergent surgical cases. Methods: A systematic review of the literature using Pubmed, Medline and Embase was performed. Non case reports and retrospective reviews of patients with cirrhosis undergoing emergency surgery were identified. In addition to the systematic review, 3 specific cases were utilized to highlight the issues involving patients with cirrhosis and common gastrointestinal emergencies. These cases involved patients with cirrhosis who developed: ischemic bowel, acute cholecystitis and an incarcerated umbilical hernia. The decision making aspect in each case involved deciding whether to perform a primary anastomosis post bowel resection versus creation of a stoma, laparoscopic cholecystectomy versus percutaneous drainage and finally the ideal management of an incarcerated umbilical hernia with ascites. Results: High grade evidence for decision making is lacking. In patients with cirrhosis complicated by ischemic bowel, individuals with Child Pugh A or a MELD score <10 display the best outcomes. Whether to create a stoma versus resection and primary anastomosis in end stage liver disease, there is no level 1 evidence to support either. There were no studies identified for this patient population and most studies involved individuals with colorectal disease. However, in the French Association of Surgery series, patients with cirrhosis that had a protective stoma are at risk for stoma complications such as ascites leakage, ascites infection, peristomal varices. There was a 7% fistula rate in individuals with resection and primary anastomosis. Acute cholecystitis in patients with Child Pugh A/B can be treated with laparoscopic cholecystectomy and or subtotal cholecystectomy. For Child Pugh C medical management should be attempted followed by percutaneous transhepatic cholecystostomy tube as necessary. Finally, individuals with an incarcerated umbilical hernia should have emergent surgery and repair of their hernia. Intraoperatively placed closed suction drains can be used to control post-operative ascites and allow for adequate wound healing. Ascites should also be managed aggressively with medical therapy and possible emergent Transjugular Intrahepatic Portosystemic Shunt (TIPS) as necessary. Conclusion: Advanced liver disease complicates many common gastrointestinal surgeries. The decision making process surrounding these operations is far from standardized as high grade evidence recommending optimal management is lacking. Management of cirrhosis in these not un- common emergency settings rely mostly on retrospective data and small cohort studies thus the treatment can vary from surgeon to surgeon.

Endoscopic ultrasound guided gallbladder drainage - is it ready for prime time?

Management of acute cholecystitis includes initial stabilization and antibiotics. However, the most definitive treatment is cholecystectomy. A small percentage of patients who are not suitable for surgery due to the severity of cholecystitis or comorbidities will require a temporary measure as a bridge to surgery or permanent nonoperative management to decrease the mortality and morbidity. Most of these patients who require conservative management were managed with percutaneous transhepatic cholecystostomy or trans-papillary drainage of gallbladder drainage with cystic duct stenting through endoscopic retrograde cholangiopancreaticography (ERCP). Although, these conservative measures are effective, they can cause significant discomfort to the patients especially if used as a long-term measure. In view of this, there is a need for further minimally invasive procedures, which is safe, effective and comfortable to patients. Endoscopic ultrasound (EUS) guided gallbladder drainage is a novel method of gallbladder drainage first described in 2007[1]. Over the last decade, EUS guided gallbladder drainage has evolved as an effective alternative to percutaneous cholecystostomy and trans-papillary gallbladder drainage. Our goal is to review available literature regarding the scope of EUS guided gallbladder drainage as a viable alternative to percutaneous cholecystostomy or cystic duct stenting through ERCP among patients who are not suitable for cholecystectomy.

Role and Place of Minimally Invasive Interventions in Treatment of Hepatopancreatoduodenal Diseases in Elderly Patients

Aim. To estimate and improve outcomes in elderly patients with hepatopancreatoduodenal diseases. Material and Methods. 221 minimally invasive drainage interventions were performed as the first stage of treatment in 193 patients with obstructive jaundice. At the second stage pancreatoduodenectomy was performed in 4 patients, biliodigestive anastomosis – in 27, percutaneous transhepatic endoprosthesis – in 28, antegrade stenting with nitinol stents – in 12, endoscopic stenting – in 6 cases. After endoscopic lithoextraction cholecystectomy, holedocholitotomy via minimal access was performed in 7 patients, through laparotomy – in 3 cases. Results. There were 72 complications at the first stage of treatment, 44 in percutaneous group and 28 in endoscopic interventions. In group of cancer patients cholangitis was the most common, in case of benign diseases – bleeding from the papilla after papillotomy. 10 (4.8%) deaths were observed after minimally invasive interventions. Total number of deaths – 42 patients (20.3%). Overall incidence of postoperative complications at both stages of treatment in cancer patients was 34.3% (32 patients). Conclusion. Percutaneous and endoscopic methods of biliary tract decompression is effective treatment of obstructive jaundice in elderly patients. Percutaneous transhepatic cholecystostomy is preffered in absence of intrahepatic hypertension. In high risk patients stenting or extrahepatic biliary endoprosthesis are recommended as a final treatment. Percutaneous transhepatic cholangiostomy with stricture recanalization and placement of distal drainage proximal to papilla is indicated to prevent postoperative pancreatitis in case of extrahepatic bile ducts cancer and intact area of papilla. The use of nitinol stents is indicated in patients with neoplastic lesion of middle and proximal third of common bile duct.

Abstract No. 560 Comparing clinical outcomes of percutaneous transperitoneal versus transhepatic cholecystostomy for acute cholecystitis

Abstract No. 560 Comparing clinical outcomes of percutaneous transperitoneal versus transhepatic cholecystostomy for acute cholecystitis

Current Status of Endoscopic Gallbladder Drainage.

The gold standard for treatment of acute cholecystitis is laparoscopic cholecystectomy. However, cholecystectomy is often not suitable for surgically unfit patients who are too frail due to various co-morbidities. As such, several less invasive endoscopic treatment modalities have been developed to control sepsis, either as a definitive treatment or as a temporizing modality until the patient is stable enough to undergo cholecystectomy at a later stage. Recent developments in endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with endoscopic ultrasound EUS-specific stents having lumen-apposing properties have demonstrated potential as a definitive treatment modality. Furthermore, advanced gallbladder procedures can be performed using the stents as a portal. With similar effectiveness as percutaneous transhepatic cholecystostomy and lower rates of adverse events reported in some studies, EUS-GBD has opened exciting possibilities in becoming the next best alternative in treating acute cholecystitis in surgically unfit patients. The aim of this review article is to provide a summary of the various methods of gallbladder drainage GBD with particular focus on EUS-GBD and the many new prospects it allows.

Percutaneous biliary intervention: tips and tricks

Percutaneous biliary intervention encompasses diagnostic cholangiography, which is rarely used in isolation now, and therapeutic biliary drainage including percutaneous transhepatic biliary drainage and transhepatic cholecystostomy. With the advantage of being minimally invasive and hence, relatively atraumatic, this technique has made significant foray into management of biliary obstruction (both benign and malignant) and post-surgical biliary complications. This review focuses on the key technical aspects of the procedure along with the commonly anticipated complications that have a significant bearing on the outcome. The authors, thereby, attempt to add their own experience to the existing literature about the various tricky situations that may be encountered during the course of the procedure and tips to circumvent them.Â

хирургическая тактика при остром холецистите, осложнённом холедохолитиазом и механической желтухой

Objective: To improve the results of surgical treatment of acute cholecystitis complicated by both choledocholithiasis and obstructive jaundice. Methods: The study is based on the results of complex diagnosis and treatment of 140 patients with acute cholecystitis (AC), with complicated choledocholithiasis and mechanical jaundice. Seventy-six of patients (54.3%) had medium and severe obstructive jaundice, and 64 (45.7%) had slight mechanical jaundice. In 28 (43.75%) observations cholecystocholedocholithiasis, complicated by mechanical jaundice, was not accompanied by systemic inflammatory complications, in the remaining 36 (56.25%) observations there was cholangitis (n = 16) and biliary sepsis (n = 20). Results: Surgical approach consisted of the step-by-step approach in all 140 patients. Thus, in 64 (45.7%) observations in the presence of choledocholithiasis and mechanical jaundice, endoscopic retrograde cholangiopancreatography was performed in the first stage with an attempt of endoscopic papillosphincterotomy (EPST) and lithoextraction. In 18 cases, with phlegmonous-calculous cholecystitis and choledocholithiasis with mechanical jaundice, combined interventions were performed – percutaneous transhepatic cholecystostomy with EPST and lithoextraction. Of the 38 patients with slight mechanical jaundice, in 20 cases, the first stage was performed by percutaneoustranshepatic cholecystostomy, in 18 – by percutaneous cholecystomy through infiltration (n = 10) and drainage techniques for perivesical abscess (n = 8). In 38 cases, with gangrenous cholecystitis (n = 28), gallbladder empyema (n = 6) and local biliary peritonitis (n = 4), cholecystectomy was performed from mini-laparotomy access followed by choledocholithotomy. Conclusion: Surgical approach with AC, in complicated choledocholithiasis and in obstructive jaundice, should be differentiated and justify the implementation of phased minimally invasive surgical procedures. Keywords: Acute cholecystitis, choledocholithiasis, obstructive jaundice.

Clinical efficacy of percutaneous transhepatic cholecystostomy combined with laparoscopic cholecystectomy for elderly patients with severe calculous cholecystitis

Clinical efficacy of percutaneous transhepatic cholecystostomy combined with laparoscopic cholecystectomy for elderly patients with severe calculous cholecystitis

A Unique Case of Radiation-Induced Cardiac, Biliary, and Duodenal Strictures in a Patient With Prior Hodgkin’s Lymphoma

Introduction: A 48-year-old man with a history significant for mantle radiation and chemotherapy completed in 1989 for Hodgkin’s lymphoma and a more recent history of cardiac stenting secondary to radiationinduced cardiac stenosis presented to Albany Medical Center with a 1.5-week history of jaundice. MRI showed a diffusely dilated bile duct to the level of the ampulla with intrahepatic biliary dilation. He underwent EUS/ERCP, which showed the upper third of the main bile duct to contain a single high-grade localized stenosis 30 mm in length with markedly dilated left and right hepatic ducts and dilation of all intrahepatic branches. An area of duodenal stenosis was also noted at the time of the endoscopy, requiring balloon dilation prior to completion of the ERCP. Cytologic brushings of the stricture were negative. In subsequent months, the patient had multiple repeat ERCPs with metal stent placement and exchanges. The patient also continued to have a persistent duodenal stenosis requiring balloon dilation prior to each ERCP. Eventually placement of bilateral plastic biliary stents was performed due to recurrent episodes of cholangitis and failure after repeated metal stenting. Repeat duct brushings continued to return negative. General surgery was consulted for surgical evaluation of a hepaticojejunostomy for treatment of his recurrent high-grade biliary stricture. In the operating room the patient was found to have a significant amount of inflammation and scarring secondary to radiation, involving the right upper quadrant with the duodenum stuck against the porta hepatis along with omentum and colon overlying this. This created a mass-like effect in the porta hepatis and made the possibility of a safe and complete dissection too high risk. A percutaneous transhepatic cholecystostomy tube was placed for long-term management of his biliary stricture. Mantle radiation has long been known to cause delayed complications in the form of cardiac disease and secondary cancers. Our case demonstrates a unique presentation of cardiac, biliary, and GI tract stricturing. This patient presented not only with the common presence of cardiac stenosis and requisite coronary stenting, but was quite distinctive in terms of the resultant involvement of both the biliary system and GI tract, with recurrent biliary stricturing requiring repeated metal stenting and the development of duodenal stenosis requiring repeated balloon dilation. Although radiation-induced biliary and duodenal stenosis has been reported, such a latent presentation from prior mantle radiation is rare in the literature.

Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis

In low-risk patients with acute cholecystitis who did not respond to nonoperative treatment, we prospectively compared treatment with emergency laparoscopic cholecystectomy or percutaneous transhepatic cholecystostomy followed by delayed cholecystectomy. In 91 patients (American Society of Anesthesiologists class I or II) who had symptoms of acute cholecystitis ≥72 hours at hospital admission and who did not respond to nonoperative treatment (48 hours), 48 patients were treated with emergency laparoscopic cholecystectomy and 43 patients were treated with delayed cholecystectomy at ≥4 weeks after insertion of a percutaneous transhepatic cholecystostomy catheter. After initial treatment, the patients were followed up for 23 months on average (range 7-29). Compared with the patients who had emergency laparoscopic cholecystectomy, the patients who were treated with percutaneous transhepatic cholecystostomy and delayed cholecystectomy had a lower frequency of conversion to open surgery [19 (40%) vs 8 (19%); P=0.029], a frequency of intraoperative bleeding ≥100 mL [16 (33%) vs 4 (9%); P=0.006], a mean postoperative hospital stay (5.3+/-3.3 vs 3.0+/-2.4 days; P=0.001), and a frequency of complications [17 (35%) vs 4 (9%); P=0.003]. In patients with acute cholecystitis who presented to the hospital ≥72 hours after symptom onset and did not respond to nonoperative treatment for 48 hours, percutaneous transhepatic cholecystostomy with delayed laparoscopic cholecystectomy produced better outcomes and fewer complications than emergency laparoscopic cholecystectomy.

Delayed Laparoscopic Cholecystectomy Is Safe and Effective for Acute Severe Calculous Cholecystitis in Patients with Advanced Cirrhosis: A Single Center Experience

Acute calculous cholecystitis is a common disease in cirrhotic patients. Laparoscopic cholecystectomy can resolve this problem but is performed based on the premise that the local inflammation must been controlled. An Initial ultrasound guided percutaneous transhepatic cholecystostomy may reduce the local inflammation and provide advantages in subsequent surgery. In this paper, we detailed our experience of treating acute severe calculous cholecystitis in patients with advanced cirrhosis by delayed laparoscopic cholecystectomy plus initiated ultrasound guided percutaneous transhepatic cholecystostomy and provided the analysis of the treatment effect. We hope this paper can provided a kind of standard procedure for this special disease; however, further prospective comparative randomized trials are needed to assess this treatment in cirrhotic patients with acute cholecystitis.

Percutaneous transhepatic cholecystostomy followed by mini-laparotomy cholecystectomy for acute obstructive cholecystitis in the high-risk elderly

Objective To study the use of ultrasound-guided percutaneous transhepatic cholecystostomy (PTGD) followed by selective minilaparotomy cholecystectomy (MC) for acute obstructive cholecystitis in the high-risk elderly.Method A retrospective study was conducted on 120 patients who received ultrasound-guided PTGD followed by selective MC from January 2008 to December 2010.Results PTGD+ MC were performed successfully on 120 patients with acute severe obstructive chole cystitis.In all the patients,the abdominal pain was relieved within 2-3 h of operation,and the temperature decreased to normal from 24- 48 h after operation.The average time of drainage was 10 days.In 97 patients MC was performed 1 week after PTGD,and in 23 patients 2 weeks after PTGD.Bleeding from gallbladder bed occurred in 1 patient.No patient suffered from bile leak.There was no major complication or death after PTGD+ MC.Conclusion PTGD followed by selective MC is a simple,efficacious and minimally invasive treatment for high-risk elderly patients with acute obstructive cholecystitis. Key words: Cholecystitis; Elderly; Minimally invasive

Percutaneous Transhepatic Cholecystostomy for Choledocholithiasis with Acute Cholangitis in High-Risk Patients

To evaluate the safety and feasibility of percutaneous transhepatic cholecystostomy for choledocholithiasis with acute cholangitis in high-risk patients. Six high-risk patients of choledocholithiasis complicated with moderate to severe acute cholangitis underwent percutaneous transhepatic cholecystostomy and subsequent interval open surgery from January, 2008 to October 2010. These patients, who were not suitable for both endoscopic and transhepatic biliary drainage, were reviewed retrospectively. Percutaneous transhepatic cholecystostomy was performed uneventfully. One patient developed hemoperitoneum which was successfully controlled by conservative treatment. Biliary peritonitits occurred in two patients, one ceased to leak spontaneously, the other developed a biloma which was cured by repuncture. No procedure-related death occurred. Sepsis was relieved completely 3 to 4 days after procedure. Two patients underwent interval open exploration of the common bile duct. One patient who recovered from sepsis succumbed on day 12 post-cholecystostomy because of an acute cardiac infarct. The other 3 patients were cured of sepsis and discharged without further treatment. The results showed that ultrasound-guided percutaneous transhepatic cholecystostomy is a safe and effective procedure for choledocholithiasis with moderate to severe acute cholangitis in highly selected high-risk surgical patients. It may deserve to become a definitive therapy for subsequent surgical management. Larger controlled studies are needed to further confirm our findings.