Recurrent Cholecystitis Research Articles

Clinical and operative outcomes of patients with acute cholecystitis who are treated initially with image-guided cholecystostomy.

Percutaneous cholecystostomy (PC) tube placement followed by delayed cholecystectomy has been shown to be an effective treatment option in high-risk populations such as older and critically ill patients. The goal of this study was to review the short- and long-term clinical and operative outcomes of patients with acute cholecystitis initially treated with PC tube placement. We conducted a retrospective review of patients who underwent image-guided PC tube insertion between 2001 and 2011 at the Royal University Hospital or St. Paul's Hospital, Saskatoon. Clinical outcomes, complications and elective cholecystectomy follow-up were noted. A total of 140 patients underwent PC tube insertion, 76 men and 64 women with a mean age of 68.4 (standard deviation 17.7) years. Of the 140, 94 (67.1%) had an American Society of Anesthesiologists classification score of III or IV. Percutaneous cholecystostomy tubes remained in place for a median of 21.0 days, and the median hospital stay was 7.0 days. Readmission owing to complications from PC tubes occurred in 21 patients (15.0%), and 10 (7.1%) were readmitted with recurrent cholecystitis after tube removal. Forty-four patients (31.4%) returned for subsequent elective cholecystectomy, of whom 32 (73%) underwent laparoscopic cholecystectomy, 4 (9%) underwent open cholecystectomy, and 8 (18%) underwent laparoscopic converted to open cholecystectomy. Percutaneous cholecystostomy is a safe procedure that can be performed in patients who are older or have numerous comorbidities. However, less than one-third of such patients in our cohort subsequently had the definitive intervention of elective cholecystectomy, with a high rate of conversion from laparoscopic to open cholecystectomy.

Endoscopic Ultrasound-Guided Gallbladder Drainage Using a Lumen-Apposing Metal Stent for Acute Cholecystitis: A Systematic Review.

Surgery remains the standard treatment for acute cholecystitis except in high-risk candidates where percutaneous transhepatic gallbladder drainage (PT-GBD), endoscopic transpapillary cystic duct stenting (ET-CDS), and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) are potential choices. PT-GBD is contraindicated in patients with coagulopathy or ascites and is not preferred by patients owing to aesthetic reasons. ET-CDS is successful only if the cystic duct can be visualized and cannulated. For 189 patients who underwent EUS-GBD via insertion of a lumen-apposing metal stent (LAMS), the composite technical success rate was 95.2%, which increased to 96.8% when LAMS was combined with co-axial self-expandable metal stent (SEMS). The composite clinical success rate was 96.7%. We observed a small risk of recurrent cholecystitis (5.1%), gastrointestinal bleeding (2.6%) and stent migration (1.1%). Cautery enhanced LAMS significantly decreases the stent deployment time compared to non-cautery enhanced LAMS. Prophylactic placement of a pigtail stent or SEMS through the LAMS avoids re-interventions, particularly in patients, where it is intended to remain in situ indefinitely. Limited evidence suggests that the efficacy of EUS-GBD via LAMS is comparable to that of PT-GBD with the former showing better results in postoperative pain, length of hospitalization, and need for antibiotics. EUS-GBD via LAMS is a safe and efficacious option when performed by experts.

A primary study on curative effects of endoscopic ultrasound-guided gallbladder drainage for patients with acute cholecystitis and high surgical risk

Objective To investigate the efficacy and safety of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) for patients with acute cholecystitis, who are unfit for cholecystectomy. Methods Patients who underwent EUS-GBD at Hangzhou First People′s Hospital from April 2015 to December 2016 were enrolled in this study. Clinical data were collected, and effectiveness and complications were analyzed. Results EUS-GBD was achieved in all 5 patients, and the mean procedure time of EUS-GBD was 26.0±3.1 min. Double pigtail plastic stents were successfully placed in 4 patients. A nasobiliary drainage tube was placed in 1 patient and the tube was endoscopically cut 5 days after procedure acting as internal drainage. All patients recovered without complications and no procedure-related death occurred. During the follow-up period (46-692 d), no patient experienced recurrent cholecystitis and stent migration. Conclusion At an experienced endoscopic center, EUS-GBD is a safe, effective and minimally invasive method for patients with acute cholecystitis and high surgical risk. Key words: Cholecystitis, acute; Endosonography; Stents; Endoscopic gallbladder drainage

Interventional Radiology-Operated Cholecystoscopy for the Management of Symptomatic Cholelithiasis: Approach, Technical Success, Safety, and Clinical Outcomes.

The objective of our study was to report the technique, complications, and clinical outcomes of interventional radiology-operated cholecystoscopy with stone removal for the management of symptomatic cholelithiasis. Ten (77%) men and three (23%) women (mean age, 65 years) with symptomatic cholelithiasis underwent cholecystostomy followed by interventional radiology-operated cholecystoscopy with stone removal. Major comorbidities precluding cholecystectomy included prior cardiac, pulmonary, or abdominal surgery; cirrhosis; sepsis with hyponatremia; seizure disorder; developmental delay; and cholecystoduodenal fistula. Cholecystostomy access, time between cholecystostomy and cholecystoscopy, endoscopic and fragmentation devices used, technical success, procedure time, fluoroscopy time, complications, length of hospital stay, time between cholecystoscopy and cholecystostomy removal, follow-up, and acute cholecystitis recurrence were recorded. Eleven (85%) patients underwent transhepatic cholecystostomy, and two (15%) patients underwent transperitoneal cholecystostomy. The mean time from cholecystostomy to cholecystoscopy was 151 days. Flexible endoscopy was used in eight (62%) patients, rigid endoscopy in three (23%), and both flexible and rigid in two (15%). Electrohydraulic lithotripsy was used in eight procedures, nitinol baskets in seven, ultrasonic lithotripsy in two, and percutaneous thrombectomy devices in one. Primary technical success was achieved in 11 (85%) patients, and secondary technical success was achieved in 13 (100%) patients. The mean procedure time was 164 minutes, and the mean number of procedures required to clear all gallstones was 1. One (8%) patient developed acute pancreatitis, and one (8%) patient died of gastrointestinal hemorrhage. The median hospital length of stay after cholecystoscopy was 1 day for postoperative monitoring. The mean time between cholecystoscopy and cholecystostomy removal was 39 days. One (8%) patient developed recurrent acute cholecystitis 1095 days after cholecystoscopy. Interventional radiology-operated cholecystoscopy may serve as an effective method for percutaneous gallstone removal in patients with multiple comorbidities precluding cholecystectomy.

Long-Term Management of Recurrent Cholecystitis after Initial Conservative Treatment: Endoscopic Transpapillary Gallbladder Stenting.

Background Endoscopic transpapillary gallbladder stenting (ETGBS) is an effective procedure for treating high-risk patients with acute cholecystitis and severe comorbidities. However, the efficacy of ETGBS for recurrent cholecystitis (RC) remains unclear. This study aimed to explore its efficacy in patients with RC for whom cholecystectomy is contraindicated because of its high surgical risk. Methods Data on 19 high-risk patients who had undergone ETGBS for RC after initial conservative therapy in our institution between June 2006 and May 2012 were retrospectively examined. The primary outcome was the clinical success rate, which was defined as no recurrences of acute cholecystitis after ETGBS until death or the end of the follow-up period. Secondary outcomes were technical success rate and adverse events (AEs). Results The clinical success rate of ETGBS was 100%, the technical success rate 94.7%, and AE rate 5%: one patient developed procedure-related mild acute pancreatitis. The clinical courses of all patients were as follows: four died of nonbiliary disease, and the remaining 15 were subsequently treated conservatively. The median duration of follow-up was 14.95 months (range 3–42 months). Conclusions ETGBS is an effective alternative for managing RC in high-risk patients with severe comorbidities.

The impact of a percutaneous cholecystostomy catheter in situ until the time of cholecystectomy on the development of recurrent acute cholecystitis: a historical cohort study.

the optimal duration of percutaneous cholecystostomy in patients with acute cholecystitis is unknown. this study was a retrospective analysis of patients (age ≥ 18 years) who underwent percutaneous cholecystostomy due to acute calculous cholecystitis. Patients were grouped according to treatment modality: percutaneous cholecystostomy as a definitive treatment (group 1), subsequent surgical treatment after the removal of the catheter (group 2) and those remaining in situ (group 3). The development of gallstone-related complications was the main outcome. there were 24 females (43.6%) and 31 males (56.4%) included in the study with a mean age of 64.8 ± 15.9 years. There were 16 (29.1%), 19 (34.5%) and 20 (36.4%) patients in groups 1, 2, and 3, respectively. The catheter withdrawal time for group 1 and group 2 was 18.2 ± 6.9 and 20.7 ± 13.4 days, respectively. Surgical treatment was performed after a mean of 85.4 ± 93.5 days following catheter removal in group 2 and a mean of 64 ± 32.5 days while the PC tube was in place in group 3. There were one (6.3%) and two cases of a recurrence (10.5%) in groups 1 and 2, respectively. Two patients developed choledocholithiasis (10%) in group 3. maintaining percutaneous cholecystostomy tubes in place until the time of surgery in surgically fit patients may help to prevent a recurrence after acute calculous cholecystitis.

Endoscopic ultrasound-guided gallbladder drainage: Results of long-term follow-up.

Background/Aim:Recently, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has emerged using a self-expandable metallic stent (SEMS). The aim of the study was to evaluate the long-term outcomes of this procedure. In addition, the efficacy and safety of EUS-GBD with SEMS were assessed.Patients and Methods:Thirteen consecutive patients who underwent EUS-GBD for acute cholecystitis between February 2014 and September 2016 were included in this retrospective study. EUS-GBD was performed under the guidance of EUS and fluoroscopy, through puncturing the gallbladder with a needle, inserting a guidewire, dilating the puncture hole, and placing a SEMS.Results:The rates of technical success, functional success, and adverse events were 100%, 92.3% and 7.7%, respectively. The median procedure time was 26.9 min (range 19–42 min). The median follow-up time was 240 days (range 14–945 days) and during this follow-up period recurrence of cholecystitis was observed in one patient (7.7%).Conclusion:EUS-GBD with a SEMS is a possible alternative treatment for acute cholecystitis in high surgical risk patients. Long-term outcomes after EUS-GBD were promising.

Case-control study on necessity of cholecystectomy for patients with bile duct stones combined with gallbladder stones after clearance of stones

Objective To discuss necessity of cholecystectomy for patients with stones in their bile ducts and gallbladders in the absence of absolute operation indications of cholecystectomy after clearance of bile duct stones with ERCP. Methods Data of less than 70-year-old patients with stones in their bile ducts and gallbladders but without absolute operation indications of cholecystectomy admitted to the First People′s Hospital of Hangzhou from January 2012 to December 2014 were retrospectively analyzed. Patients were divided into cholecystectomy group and gallbladders in situ group after bile duct stones removal with ERCP. The hospitalization time, recurrent biliary events, complications of operation were compared between two groups. Results A total of 128 patients were included and followed up for (24.031±9.170) months with 64 cases in conservative group and 64 cases in cholecystectomy group. Incidence of recurrent biliary events in the cholecystectomy group and conservative group were 7.8% (5/64) and 10.9%(7/64) (P=0.544). Among cases of recurrent biliary events, incidences of cholangitis in the two groups were 7.8%(5/64) and 4.7%(3/64) respectively (P=0.465), incidences of pancreatitis were 0(0/64) and 1.6%(1/64) respectively (P=0.315), incidences of common bile duct stones were 7.8%(5/64) and 7.8%(5/64) respectively (P=1). No recurrent cholecystitis occurred. There were no differences in ERCP-related complications between the cholecystectomy group[23.4%(15/64)] and the conservative group[12.5%(8/64)](P=0.107). But 4 patients (6.3%) in cholecystectomy group had LC-related complications during the follow-up period, 3 cases of infection and 1 ileus. The hospital stay in conservative group was shorter than that in cholecystectomy group (5.906±4.614 days VS 14.313±6.312 days, P<0.001). The hospitalization expenses in two groups were (45 196±12 518) yuan and (22 160±11 755) yuan(P<0.001). Conclusion Conservative methods yield to shorter hospitalization and lower expenses without cholecystectomy-related complications. Conservative management for gallbladder stones after ERCP for biliary duct stones is recommended for patients who had no absolute operation indications of cholecystectomy. Key words: Common bile duct stones; Gallbladder stones; Retrospective study

Outcome comparison between percutaneous cholecystostomy and cholecystectomy: a 10-year population-based analysis

BackgroundControversy surrounding the role of percutaneous cholecystostomy (PC) is fed by the absence of large amounts of data concerning its outcomes, and many authors have maintained that there is no evidence to support a recommendation for PC rather than cholecystectomy (CCS) in elderly or critically ill patients with acute cholecystitis (AC).MethodsWe conducted this study by tracking trends in the utilization and outcomes of PC and CCS using longitudinal health research data in Taiwan.ResultsAnalyses were conducted on 236,742 patients, 11,184 of whom had undergone PC and 225,558 of whom had undergone CCS. Average annual percentage changes (AAPCs) from 2003 to 2012 increased significantly by 18.34% each year for PC and by 2.82% each year for CCS. The subset analyzes showed that the mortality rates were far higher in patients underwent PC than in patients underwent CCS in all subgroups, which increased from a minimum of 1.45-fold to a maximum of 34.22-fold. The gap of the mortality rates between PC group and CCS group narrowed as the patients aged and with the seriousness of the diseases increased. Most patients with PC or CCS who died in-hospital or within 30 days after discharge were 70 years of age or older, and a large number of them received a CCI score of at least 1. The AAPCs of the overall mortality rates from 2003 to 2012 decreased by 6.78% each year for PC and by 7.33% each year for CCS. PC was related to a higher rate of cholecystitis recurrence and readmission for complications, but a lower rate of in-hospital complications and routine discharge than CCS, and 36.41% of all patients treated with PC underwent subsequent CCS. Additionally, the patients with PC experienced longer hospital stays and generated higher costs than the patients with CCS.ConclusionPatients who underwent PC demonstrated poorer prognoses than did patients who underwent CCS. The role of PC in the Tokyo guidelines may be overstated; it is not as safe as the Tokyo guidelines have suggested in moderate-grade cholecystitis cases, and it should be limited to only the elderly and sicker patients.

Role of percutaneous cholecystostomy for acute acalculous cholecystitis: clinical outcomes of 271 patients.

To examine the outcomes of percutaneous cholecystostomy (PC) in patients with acute acalculous cholecystitis (AAC). The study population comprised 271 patients (mean age, 72 years; range, 22-97 years, male, n=169) with AAC treated with PC with or without subsequent cholecystectomy. Clinical data from total 271 patients were analysed, and outcomes were assessed according to whether the catheter was removed or remained indwelling. Patient survival and recurrence rates were calculated. Symptom resolution and significant improvement of laboratory test values were achieved in 235 patients (86.7%) within 4 days after PC. Complications occurred in six patients (2.2%). Interval elective cholecystectomy was performed in 127 (46.8%) patients. Among the remaining 121 patients, successful removal of the PC catheter was achieved in 88 patients (72.7%) at a mean of 30 days (range, 4-365 days). Of the catheter removal group, 86/88 (97.7%) were successfully treated with the initial PC, whereas two (2.3%) experienced recurrence of cholecystitis. Cumulative recurrence rates were 1.1%, 2.7%, and 2.7% at 1, 2, and 8 years, respectively. The good therapeutic outcomes of PC and low recurrence rate suggest that PC can be a definitive treatment option in the majority of AAC patients. • Many patients with AAC are too ill to undergo cholecystectomy. • PC in AAC patients shows low complication and recurrence rate. • PC solely can be a definitive treatment option in the majority of AAC patients.

Endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis with a silicone-covered nitinol short bilaterally flared stent: a case series.

Background and study aim Gallbladder drainage in patients with cholecystitis who are unsuitable for surgery may be performed by endoscopic ultrasound (EUS)-guided placement of specifically designed fully covered metal stents. We describe the first case series of patients treated with a silicone-covered nitinol stent with bilateral anchor flanges. Patients and methods Data from consecutive patients with acute cholecystitis who were deemed unsuitable candidates for surgery were collected. The stent placement procedure was performed in two tertiary endoscopy centers by four experienced endoscopists. Technical and clinical success rates, as well as adverse events and clinical outcome at follow-up, were assessed. Results EUS-guided drainage for cholecystitis was performed in 16 patients (mean age 84 years; nine males). Technical and clinical success rates were 100 % (16/16) and 94 % (15/16), respectively; an early failure due to stone impaction occurred in the remaining case and required placement of a new stent. Symptom relief occurred in 11/15 cases (73 %) within 1 day, and within 2 days in the remaining 4 patients. Bleeding occurred in two patients (13 %): in one patient intraprocedural bleeding was successfully stopped during endoscopy; and delayed bleeding occurred in one patient requiring arterial embolization for catastrophic bleeding (patient died 10 days later). No cases of cholecystitis recurrence or biliary obstruction were observed during a median follow-up of 112 days (range 49 – 180 days). Conclusions Our data showed that EUS-guided gallbladder drainage with a specially designed stent is feasible and successful in patients with acute cholecystitis who are unfit for surgery.

Endoscopic Transpapillary Gallstone Removal with Recurrent Acute Cholecystitis

급성 결석성 담낭염의 ê·¼ë³¸ì ì¸ 치료는 복강경하 ë‹´ë‚­ì ˆì œìˆ ì´ë‚˜ ìˆ˜ìˆ ì´ 위험하거나 ê·¸ 외 여러 가지 ì´ìœ ë¡œ 담낭 ì ˆì œìˆ ì„ í• ìˆ˜ 없는 경우 경피 ê²½ê°„ì  담낭 ë°°ì•¡ìˆ ì„ ì‹œí–‰í• ìˆ˜ 있다. PTGBD는 급성 증상의 완화를 위한 ìœ ìš©í•œ 방법이나 오랫동안 PTGBD를 ìœ ì¹˜í• ê²½ìš° 여러 ë¬¸ì œë“¤ì´ ë°œìƒí• ìˆ˜ 있다. 본 증례는 급성 결석성 담낭염으로 진단된 환자가 PTGBD를 시행한 후 ìž ì› 당시 대장암을 동시에 ì§„ë‹¨ë°›ê³ ë‚˜ì„œ ìˆ˜ìˆ ì  치료를 거부하여 PTGBD를 ì œê±°í•˜ì˜€ìœ¼ë‚˜ 급성 담낭염의 재발로 PTGBD를 3ë „ê°„ 7차례 교체하면서 ìœ ì§€í•˜ê²Œ ë˜ì—ˆê³ , 이후 내시경 역행성 담췌관 ì¡°ì˜ìˆ ì„ 시행하여 십이지장 ìœ ë‘ë¶€ë¥¼ 통해 담낭 내 담석을 ì„±ê³µì ìœ¼ë¡œ ì œê±°í•˜ê³ , 27개월간 ì¶”ì  관찰하였으나 급성 담낭염의 재발 없이 ì„±ê³µì ìœ¼ë¡œ 치료된 증례를 ë³´ê³ í•˜ê³ ìž 한다. Keywords: 결석성 담낭염, ë‹´ë‚­ë°°ì•¡ìˆ , 내시경 역행성 담췌 관 조영ìˆ

Expanding role of percutaneous cholecystostomy and interventional radiology for the management of acute cholecystitis: An analysis of 144 patients.

To investigate the rates of interval cholecystectomy and recurrent cholecystitis after initial percutaneous cholecystostomy (PC) and identify predictors of patient outcome after PC. A total of 144 patients with acute cholecystitis who were treated with PC were included. There were 96 men and 48 women, with a mean age of 71±13 (SD) years (range: 25-100 years). Patient characteristics, diagnostic imaging studies and results of laboratory tests at initial presentation, clinical outcomes after the initial PC treatment were reviewed. Among the 144 patients, 56 patients were referred for acute acalculous and 88 patients for calculus cholecystitis. Five procedure-related major complications (3.6%) were observed including bile peritonitis (n=3), hematoma (n=1) and abscess formation (n=1). Recurrent acute cholecystitis after initial clinical resolution and PC tube removal was observed in 8 patients (6.0%). The rate of interval cholecystectomy was 33.6% (47/140) with an average interval period of 100±482 (SD) days (range: 3-1017 days). PC was a definitive treatment in 85 patients (60.7%) whereas 39 patients (27.9%) had elective interval cholecystectomy without having recurrent cholecystitis. The clinical outcomes after PC did not significantly differ between patients with calculous cholecystitis and those with acalculous cholecystitis. Multiple prior abdominal operations were associated with higher rates of recurrent cholecystitis. For both acute acalculous and calculous cholecystitis, PC is an effective and definitive treatment modality for more than two thirds of our study patients over 3.5-year study period with low rates of recurrent disease and interval cholecystectomy.

EUS-guided gallbladder drainage in patients with acute cholecystitis and high surgical risk using an electrocautery-enhanced lumen-apposing metal stent device

In high-risk surgical patients, the treatment of choice of acute cholecystitis is percutaneous transhepatic gallbladder drainage (PTGBD). Recently, a novel endoscopic device containing a lumen-apposing metal stent with an electrocautery (ECE-LAMS) on the tip has been developed. High-risk surgical patients with acute cholecystitis who underwent EUS-guided gallbladder drainage (EUS-GBD) with the novel device were retrospectively retrieved from 7 tertiary care referral centers. Main endpoints were technical and clinical success rates, rate of procedural adverse events, and short- and long-term adverse events. Seventy-five patients (mean age, 75 ± 11 years; 36 men) underwent EUS-GBD. The procedure was technically and clinically successful in 98.7% and 95.9% of cases, respectively. Three patients without resolution of cholecystitis died, and 2 patients had procedure-related adverse events: 1 perforation requiring surgery and 1 major bleeding resolved conservatively. The mean follow-up for the entire cohort was 201 ± 226 days. Seven patients (9.6%) died within the first 30 days; 50 patients (71.4%) were alive at the last date of follow-up. Short- and long-term adverse events occurred in 6 patients: 3 had recurrent cholecystitis, 2 had migration of the stent, and 1 developed Bouveret syndrome, all managed nonsurgically. Overall, 8 adverse events (10.7%) occurred in the entire cohort of patients. The novel ECE-LAMS for high-risk surgical patients with acute cholecystitis is safe, with a high technical and clinical success rate. Future multicenter studies comparing EUS-GBD versus PTGBD are warranted to determine which procedure is safer and clinically more effective for patients with high surgical risk acute cholecystitis.

Antibiotics May be Safely Discontinued Within One Week of Percutaneous Cholecystostomy.

For patients with acute cholecystitis managed with percutaneous cholecystostomy (PC), the optimal duration of post-procedural antibiotic therapy is unknown. Our objective was to compare short versus long courses of antibiotics with the hypothesis that patients with persistent signs of systemic inflammation 72h following PC would receive prolonged antibiotic therapy and that antibiotic duration would not affect outcomes. We performed a retrospective cohort analysis of 81 patients who underwent PC for acute cholecystitis at two hospitals during a 41-month period ending November 2014. Patients who received short (≤7day) courses of post-procedural antibiotics were compared to patients who received long (>7day) courses. Treatment response to PC was evaluated by systemic inflammatory response syndrome (SIRS) criteria. Logistic and linear regressions were used to evaluate associations between antibiotic duration and outcomes. Patients who received short (n=30) and long courses (n=51) of antibiotics had similar age, comorbidities, severity of cholecystitis, pre-procedural vital signs, treatment response, and culture results. There were no differences in recurrent cholecystitis (13 vs. 12%), requirement for open/converted to open cholecystectomy (23 vs. 22%), or 1-year mortality (20 vs. 18%). On logistic and linear regressions, antibiotic duration as a continuous variable was not predictive of any salient outcomes. Patients who received short and long courses of post-PC antibiotics had similar baseline characteristics and outcomes. Antibiotic duration did not predict recurrent cholecystitis, interval open cholecystectomy, or mortality. These findings suggest that antibiotics may be safely discontinued within one week of uncomplicated PC.

Feasibility of conversion of percutaneous cholecystostomy to internal transmural endoscopic ultrasound-guided gallbladder drainage.

Background/Aim:Percutaneous cholecystostomy [percutaneous transhepatic gallbladder drainage (PTGBD)] is the treatment of choice in surgically unfit patients with acute cholecystitis. However, PTGBD tube removal after symptoms resolution results in 41–46% recurrence. This study aims to demonstrate the feasibility of the conversion of PTGBD to transmural endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using plastic stents in patients unfit for cholecystectomy.Patients and Methods:Patients who underwent internal transmural EUS-GBD as a conversion from PTGBD were reviewed. EUS-GBD was performed after the improvement of cholecystitis due to recurrent cholecystitis and PTGBD intolerance. One or two 7-Fr double pigtail plastic stent insertion with or without temporary endoscopic naso-gallbladder drainage (ENGBD) insertion was performed.Results:Six patients (age 61–88), with three cases of acute cholecystitis after metallic biliary stenting and three cases of calculus cholecystitis, who underwent PTGBD were included. EUS-GBD was performed 10–63 days after PTGBD, using one plastic stent in five cases, two stents in one case, with temporary ENGBD in two cases. The technical success and clinical success were achieved and the PTGBD tubes were subsequently removed in all patients. All ENGBD tubes were removed within 5 days after insertion. Bile leak with peritonitis was demonstrated in one case, which was treated conservatively. No recurrent cholecystitis was seen during 3–26 months of follow-up.Conclusion:The conversion of percutaneous cholecystostomy to internal transmural EUS-GBD with plastic stents is feasible for patients unfit for cholecystectomy. However, more studies are still needed to confirm the results.

Pancreatic ascariasis as an unusual cause of recurrent pancreatitis: An endoscopic ultrasound diagnosis

Background:Ascaris lumbricoides infestation is endemic in tropical countries. Most infections are asymptomatic, but it can produce a wide spectrum of manifestations including hepatobiliary and pancreatic complications. Biliopancreatic ascariasis is rare outside the endemic regions.Case Report:We report a case of recurrent pancreatitis, symptomatic for the last 2 years, multiple hospitalizations, various imagings with ultrasonography, computed tomography, and magnetic resonance cholangiopancreatography failed to establish the etiology, and endoscopic ultrasound revealed an adult A. lumbricoides worm inside the main pancreatic duct. The patient underwent endoscopic retrograde cholangiopancreatography with extraction of the dead worm; deworming was done with albendazole 400 mg, single dose. Patient is symptom-free for the last 1 year.Discussion and Conclusion:Biliary ascariasis is a common occurrence in endemic regions and is causally associated with biliary colic, acute cholangitis, acute pancreatitis and its complications, recurrent pyogenic cholangitis, acute cholecystitis, and liver abscess. Secondary to smaller duct diameter, migration of A. lumbricoides into the pancreatic duct is uncommon. Even in highly endemic areas such as Kashmir, India, pancreatic ascariasis was rare and represented only 1.4% of all hepatobiliopancreatic ascariasis. Endoscopy ultrasound is a useful modality in diagnosis and management of patients with pancreatic ascariasis.

Endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis: Long-term outcomes after removal of a self-expandable metal stent

AIMTo assess the long-term outcomes of this procedure after removal of self-expandable metal stent (SEMS). The efficacy and safety of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with SEMS were also assessed.METHODSBetween January 2010 and April 2015, 12 patients with acute calculous cholecystitis, who were deemed unsuitable for cholecystectomy, underwent EUS-GBD with a SEMS. EUS-GBD was performed under the guidance of EUS and fluoroscopy, by puncturing the gallbladder with a needle, inserting a guidewire, dilating the puncture hole, and placing a SEMS. The SEMS was removed and/or replaced with a 7-Fr plastic pigtail stent after cholecystitis improved. The technical and clinical success rates, adverse event rate, and recurrence rate were all measured.RESULTSThe rates of technical success, clinical success, and adverse events were 100%, 100%, and 0%, respectively. After cholecystitis improved, the SEMS was removed without replacement in eight patients, whereas it was replaced with a 7-Fr pigtail stent in four patients. Recurrence was seen in one patient (8.3%) who did not receive a replacement pigtail stent. The median follow-up period after EUS-GBD was 304 d (78-1492).CONCLUSIONEUS-GBD with a SEMS is a possible alternative treatment for acute cholecystitis. Long-term outcomes after removal of the SEMS were excellent. Removal of the SEMS at 4-wk after SEMS placement and improvement of symptoms might avoid migration of the stent and recurrence of cholecystitis due to food impaction.

Percutaneous cholecystostomy for acute cholecystitis in high-risk elderly patients

Emergency cholecystectomy for acute cholecystitis (AC) is associated with high morbidity and mortality rates in elderly patients with significant comorbidities. The aim of this study was to evaluate percutaneous cholecystostomy for AC in elderly patients with various coexisting diseases. We retrospectively reviewed the records of 4311 patients with AC treated in Mackay Memorial Hospital between the years 2000 and 2015. The clinical course of AC was compared between nonelderly (age ≤70 years) and elderly patients (age>70 years). In total, 67 elderly patients and 32 nonelderly patients received percutaneous cholecystostomy. The rate of percutaneous cholecystostomy increased between the years 2011 and 2015 (from 2.5% to 12.2%) and this procedure was more common in the elderly group (p=0.009). In addition, the comorbidities of ischemic heart disease and chronic kidney disease were higher in elderly than in nonelderly patients (p=0.014 and p=0.015, respectively). The American Society of Anesthesiologists' classification was higher in the elderly patients (p=0.001). The overall survival-free rate of recurrent cholecystitis in patients who did not receive cholecystectomy was not significantly different in the two groups. When compared with emergent cholecystectomy in high-risk elderly patients, percutaneous cholecystostomy resulted in reduced hospital stay and morbidity (p=0.002 and p=0.013, respectively). Our results demonstrate that percutaneous cholecystostomy has become a common and early treatment for AC in high-risk elderly patients with ischemic heart disease or chronic kidney disease. Identifying such patients will possibly improve clinical outcomes, reduce hospital stay and morbidity, and facilitate delayed laparoscopic cholecystectomy.

Gallbladder small cell carcinoma: a case report and literature review.

Gallbladder small cell carcinoma (SCC) comprises only 0.5 % of all gallbladder cancer and consists of aggressive tumors with poor survival outcomes against current treatments. These tumors are most common in elderly females, particularly those with cholecystolithiasis. We report the case of a 79-year-old woman with gallbladder small cell carcinoma. The patient had intermittent right upper quadrant abdominal pain and was admitted to our hospital due to suspected acute cholecystitis. She regularly received medical treatment for diabetes, hypertension, and dyslipidemia. On initial laboratory evaluation, the levels of aspartate aminotransferase (AST), total bilirubin, and C-reactive protein (CRP) were markedly elevated. She underwent computed tomography (CT) for screening. CT images showed a thick-walled gallbladder containing multiple stones and multiple 3-cm-sized round nodular lesions, which were suggestive of metastatic lymph nodes. After percutaneous transhepatic gallbladder drainage was performed, endoscopic ultrasound-guided fine needle aspiration of enlarged lymph nodes resulted in a diagnosis of small cell carcinoma or adenocarcinoma. However, we could not identify the primary lesion before the surgery because of no decisive factors. We performed cholecystectomy because there was a possibility of cholecystitis recurrence risk and also partial liver resection because we suspected tumor invasion. The final pathological diagnosis was neuroendocrine carcinoma of the gallbladder, small cell type. The tumor stage was IVb, T3aN1M1. The patient died 13 weeks after the surgery. In the present paper, we review the current available English-language literature of gallbladder SCC.