Subsequent Cholecystectomy Research Articles

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.

Open versus laparoscopic completion cholecystectomy in patients with previous open partial cholecystectomy; a retrospective comparative study

Background: Some patients report recurrence or persistence of their manifestations after cholecystectomy, and retained gallstones may be a relevant etiology for their complaint. Completion cholecystectomy is advised for these cases to alleviate their manifestations. No previous studies have compared the outcomes of open versus laparoscopic outcomes in these patients, especially in patients who had initial open partial procedures. That is why we performed this study to report the perioperative outcomes of the two approaches in such patients. Methodology: This is a retrospective analysis of 80 patients who had a completion cholecystectomy in our center (40 open and 40 laparoscopic cases) after initial open partial cholecystectomy. Results: The duration elapsed since the primary procedure had an average of 18 months in the open group and 21 months in the laparoscopic group. Abdominal pain and dyspepsia were the most common presentations. Some patients had stump cholecystitis or jaundice. The intraoperative assessment revealed either the residual gallbladder or a long cystic duct stump. Laparoscopy yielded shorter operative time, earlier oral intake, and shorter hospitalization periods compared to the open approach (P<0.05). The latter was associated with a 20% wound infection rate that was never encountered after laparoscopy (P =0.003). Conclusion: Previous open partial cholecystectomy does not hinder subsequent laparoscopic completion cholecystectomy. Additionally, laparoscopy is associated with better perioperative outcomes than the open approach.

The Success Rate Is Lower but Completion Rate of Laparoscopic Cholecystectomy Is higher in Endoscopic Transpapillary Gallbladder Drainage than Percutaneous Gallbladder Drainage for Acute Cholecystitis.

We investigated the success and complication rates of endoscopic transpapillary gallbladder drainage (ETGBD) and percutaneous transhepatic gallbladder drainage (PTGBD) and the outcomes of subsequent cholecystectomy for acute cholecystitis. Patients (N=178) who underwent cholecystectomy after ETGBD or PTGBD were retrospectively assessed. ETGBD was successful in 47 (85.5%) of 55 procedures, whereas PTGBD was successful in 123 (100%) of 123 sessions ( P <0.001). Complications related to ETGBD and PTGBD occurred in 6 (12.8%) of 47 and 16 (13.0%) of 123 patients, respectively ( P =0.97). After propensity matching, 43 patients from each group were selected. Median time from drainage to cholecystectomy was 48 (14 to 560) days with ETGBD and 35 (1 to 90) days with PTGBD ( P =0.004). Laparoscopy was selected more often in the ETGBD group (97.7%) than in the PTGBD group (79.1%) ( P =0.007), and conversion from laparoscopy to open cholecystectomy was more common with PTGBD (41.2%) than with ETGBD (7.1%) ( P <0.001). Mean operation time was significantly shorter with ETGBD (135.8±66.7min) than with PTGBD (195.8±62.2min) ( P <0.001). The incidence of Clavien-Dindo grade ≥III postoperative complications was 9.3% with ETGBD and 11.6% with PTGBD ( P =0.99). The success rate is lower but completion of laparoscopic cholecystectomy is more in endoscopic gallbladder drainage than percutaneous gallbladder drainage for acute cholecystitis.

Elective Cholecystectomy After Endoscopic Gallbladder Stenting for Acute Cholecystitis: A Propensity Score Matching Analysis.

To investigate the influence of endoscopic gallbladder stenting (EGBS) on subsequent cholecystectomy. We retrospectively compared the surgical outcomes of EGBS, followed by elective cholecystectomy with those of immediate cholecystectomy (IC). A total of 503 patients were included in this study. Patients who underwent EGBS as initial treatment for acute cholecystitis, followed by elective cholecystectomy, were included in the EGBS group and patients who underwent IC during hospitalization were included in the IC group. Propensity score matching analysis was used to compare the surgical outcomes. In addition, the factors that increased the amount of bleeding were examined by multivariate analysis after matching. Fifty-seven matched pairs were obtained after propensity matching the EGBS group and the IC group. The rate of laparoscopic cholecystectomy in the EGBS versus IC groups was 91.2% versus 49.1% ( P < 0.001). The amount of bleeding was 5mL in the EGBS versus 188mL in the IC group ( P < 0.001). In the EGBS and IC groups, multivariate analysis of factors associated with more blood loss revealed IC (odds ratio: 4.76, 95% CI: 1.25-20.76, P = 0.022) as an independent risk factor. EGBS as the initial treatment for acute cholecystitis and subsequent elective cholecystectomy after the inflammation has disappeared can be performed in minimally invasive procedures and safely.

Gallstone formation and subsequent cholecystectomy after oncological gastric and esophageal resection.

Gallstone formation is increased after gastric (GR) or esophageal resection (ER); however, the exact pathophysiology is not fully understood yet. Symptomatic cholecystolithiasis and the need for subsequent cholecystectomy after upper gastrointestinal resection can alter the outcome in oncological patients. There is an ongoing discussion if these patients benefit from a simultaneous prophylactic cholecystectomy.This study aims to analyze the risk of gallstone formation after GR or ER and the perioperative course of a subsequent cholecystectomy. In this study, all patients were included, who underwent an oncological gastric or esophageal resection at the Medical University of Innsbruck, Department of Visceral, Transplant and Thoracic Surgery in the years 2003-2021. A simultaneous cholecystectomy was performed in 29.8% with GR and in 2.1% with ER (p < 0.001). There was no significant difference in complications or length-of-stay between patients with simultaneous vs. no simultaneous cholecystectomy. Newly developed gallstones tended to be more common after GR (16% vs. 10% ER), after reconstruction without preservation of the duodenal passage (17% vs. 11% with) and after GR with lymph node dissection (19% vs. 5% without). After ER, subsequent cholecystectomy was significant less frequently (11.4% vs. 2.9% OR) (p = 0.005). The subsequent cholecystectomy was performed openly in 57.1% with major complications classified as Clavien-Dindo ≥ 3a in 14.3%. Based on the findings of our study, we do not recommend simultaneous cholecystectomy routinely in oncological gastric or esophageal resections. An individualized approach depending on risk factors like extensive lymphadenectomy or duodenal passage can be discussed.

The effect of previous endoscopic retrograde cholangiopancreatography on subsequent laparoscopic cholecystectomy: The retrospective analysis of 1500 patients.

Laparoscopic cholecystectomy (LC) is the gold standard for patients with acute cholecystitis at early period. However, 15%-20% of patients with acute cholecystitis develop obstructive jaundice, cholangitis and bile duct stones ultimately requiring endoscopic retrograde cholangiopancreatography (ERCP). In such cases, a two-session approach is usually recommended, first ERCP followed by LC thereafter. However, the effect of prior ERCP on the difficulty of subsequent LC is unknown. Hence, the aim of the present study is to determine the effects of previous ERCP on the results of LC. In this study, the files of 1500 patients who underwent LC were reviewed retrospectively. The patients were divided into three groups (500 patients for each group). The patients undergoing LC for asymptomatic cholelithiasis were assigned to the L-e group. The patients who underwent LC for acute cholecystitis were assigned to the L-c group. The patients with acute cholecystitis who underwent ERCP first and then LC were assigned to the L-ercp group. The rates of conversion to open cholecystectomy, operation times, complication rates and hospital stays of the three groups were compared. The results of LC performed after ERCP are similar to the results of LC for cholecystitis without ERCP in terms of operation time, hospital stay, conversion and complications. Previous ERCP does not affect the safety and effectiveness of early LC in patients with acute cholecystitis.

The outcomes of ERCP performed for bile duct stones in patients who had subsequent laparoscopic cholecystectomy: results from a large retrospective single-centre study

The outcomes of ERCP performed for bile duct stones in patients who had subsequent laparoscopic cholecystectomy: results from a large retrospective single-centre study

Influence of Percutaneous Transhepatic Gallbladder Aspiration and Drainage for Severe Acute Cholecystitis on the Surgical Outcomes of Subsequent Laparoscopic Cholecystectomy: Post Hoc Analysis of the CSGO-HBP-017 (CSGO-HBP-017C).

Percutaneous transhepatic gallbladder aspiration (PTGBA) and/or drainage (PTGBD) are useful approaches in the management of acute cholecystitis in patients who cannot tolerate surgery because of poor general condition or severe inflammation. However, reports regarding its effect on the surgical outcomes of subsequent laparoscopic cholecystectomy (LC) are sparse. The aim of this retrospective study was to investigate the influence of PTGBA on surgical outcomes of subsequent LC by comparing the only-PTGBA group, including patients who did not need the additional-PTGBD, versus the additional-PTGBD group, including those who needed the additional-PTGBD after PTGBA. We conducted a post hoc analysis of our multi-institutional data. This study included 63 patients who underwent LC after PTGBA, and we compared the surgical outcomes between the only-PTGBA group (n = 56) and the additional-PTGBD group (n = 7). No postoperative complications occurred among the 63 patients, and the postoperative hospital stay was 11 ± 12 days. Fourteen patients (22.2%) had a recurrence of cholecystitis, of whom 7 patients (11.1%) needed the additional-PTGBD after PTGBA. Significantly longer operative time (245 ± 74 vs 159 ± 65 min, P = 0.0017) and postoperative hospital stay (22 ± 27 vs 10 ± 9 d, P = 0.0118) and greater intraoperative blood loss (279 ± 385 vs 70 ± 208 mL, P = 0.0283) were observed among patients in the additional-PTGBD group compared with the only-PTGBA group, whereas the rates of postoperative complications (Clavien-Dindo grade ≥3: 0% each) and conversion to open surgery (28.6% vs 8.9%, P = 0.1705) were comparable. PTGBA for acute cholecystitis could result in good surgical outcomes of subsequent LC, especially regarding postoperative complications. However, we should keep in mind that the additional-PTGBD after PTGBA failure, which sometimes happened, would be associated with increased operative difficulty and longer recovery.

Impact of percutaneous cholecystostomy on National Health Service (NHS) service provision and subsequent clinical as well as surgical outcomes.

Abstract Aims To evaluate the impact of percutaneous cholecystostomy on the NHS and clinical/surgical outcomes. Methods Retrospective analysis of patients who underwent percutaneous cholecystostomy between 01/01/2020 to 31/12/2022. Data collected included patient demographics, procedure (indications, mean time for insertion/removal), microbiology (bile aspirate, blood culture), imaging (endoscopic retrograde cholangio-pancreatography (ERCP) / tubogram) performed, clinical outcome, number of planned/unplanned follow-ups and difficulty of cholecystectomy. Results The cohort included 33 patients (20 male, 13 female) with mean age of 74 years. Top indications were (1) gallbladder empyema identified on computed tomographic imaging (76%) and (2) being unfit for surgery i.e., significant comorbidities (55%) / septic (30%). Mean time of insertion and removal was 5 and 59 days, respectively. Escherichia coli (67%) was the most common microorganism from bile aspirate. Most (52%) blood cultures showed no growth. Within the initial admission, majority (82%) did not have ERCP and one-third (36%) had a tubogram. In terms of outcome, 14 (42%) subsequently had cholecystectomy, 12 (36%) were discharged, 6 (18%) died and 1 (3%) is awaiting cholecystectomy. There was a mean of 2 follow-ups before patients were discharged from service. Of those who underwent cholecystectomy, 12/14 were done electively, 12/14 were total cholecystectomy and 13/14 were laparoscopic. Mean surgical time was 116 minutes. Conclusions Percutaneous cholecystostomy is an effective treatment/bridging therapy for patients unsuitable for emergency cholecystectomy. It does not reduce time/difficulty of subsequent cholecystectomy. However, it does put a strain on the NHS with regards to length of stay and planned/unplanned follow-ups.

Gangrenous Gallbladder Perforation: Varied Presentation, Management, and Treatment Outcome

Abstract Introduction: Gangrenous cholecystitis (GC) is a serious complication associated with cholecystitis and usually presents with greater mortality than uncomplicated cholecystitis. It may be associated with cholelithiasis or can be due to acalculous cholecystitis. Acalculous cholecystitis is usually associated with elderly age and or associated with comorbidities such as diabetes mellitus (DM), coronary artery disease, and chronic debilitated bedridden patients. Since these patients are elderly, have other symptomatology of chronic illnesses, and usually suffer from peripheral neuropathy, the diagnosis can be missed in initial stages. We present here a case series of five patients with GC who presented in whom the diagnosis was missed initially and subsequent surgical intervention resulted in rapid recovery. Material and Methods: The aim of this study was to emphasize on the importance of keeping index of suspicion and early surgical intervention in such cases to prevent morbidity and mortality. Patients studied in this case series were initially admitted to the medical ward and surgical consult was sought later. Delay in seeking surgical consult ranged from 1 to 4 days. All of them underwent cross-sectional imaging in form of contrast-enhanced computed tomography abdomen and subsequent open cholecystectomy based on imaging findings of perforated gallbladder, intraoperatively these patients were found to have perforated gallbladder secondary to GC. Results: Out of the five patients studied, 3 (60%) were female and 2 (40%) were male, with a mean age of 64.5 (55–73) years. DM constitute most frequently accompanying medical issues (80%). Surgical site infection was seen as the most common postoperative complication. Longer delay time before diagnosis was determined as independent risk factor affecting morbidity and mortality.

Subsequent cholecystectomy improve recurrent biliary event‐free survival in high‐risk acute cholecystitis patients after gallbladder drainage

AbstractCholelithiasis is a disease with increasing prevalence over the decades. Gallbladder drainage (GBD) is an alternative choice in critically ill patients who cannot tolerate early surgery for acute cholecystitis. In previous data, early or delayed cholecystectomy (CCY) leads to less recurrent biliary events (RBEs) comparing to using a wait‐and‐see strategy. We wondered if a subsequent CCY strategy after GBD can benefit patients with high surgical risk. This study aimed to explore the clinical outcome after percutaneous transhepatic GBD and risk factors for RBEs. We studied 180 adult acute cholecystitis patients who received percutaneous transhepatic GBD during index admission between July 2017 and December 2018 in Chung Shan Medical University Hospital and Changhua Christian Hospital after exclusion of patients died during the index admission or lost follow‐up within 30 days. We further divided these patients into those who received subsequent CCY within 2 months and those who received no CCY within 2 months. RBEs, mortality, and biliary event‐related mortality were compared. Multivariate analysis was applied to find the most important factors of RBE‐free survival. There were 8 cases (13.6%) in the subsequent CCY group that experienced recurrent biliary events, whereas 39 cases (32.2%) experienced recurrent biliary events in the no CCY within 2 months group. The proportion and average recurrent biliary events per person were all significantly lower in the subsequent CCY group. Although the overall mortality rate was higher in the group that had no CCY within 2 months (16.5% vs 5.1%), the RBE‐related mortality difference was insignificant. The most decisive factor to determine RBE‐free survival is whether there was a subsequent CCY or not (HR: 0.485, 95% CI: 0.250‐0.941, P = .032). We found that subsequent CCY can decrease further RBEs and improve RBE‐free survival in high‐risk patients with acute cholecystitis that accepted percutaneous transhepatic GBD initially.

THE IMPACT OF BODY MASS INDEX ON SEVERITY OF ACUTE CALCULOUS CHOLECYSTITIS

INTRODUCTION: Acute Calculous cholecystitis(ACC) represents &gt;90% of all cases of acute cholecystitis and accounts for 3–11% of hospital admissions. Obesity is dened as global epidemic by WHO. Obesity is an established risk factor for the cholesterol gallstone and subsequent cholecystectomy. Despite many reports on association of body-weight to gallstone disease, the effect of body-weight in severity of the cholecystitis has been rarely reported. Hence, this study was undertaken to assess the severity of association between the body mass index and severity of acute Calculous cholecystitis. OBJECTIVES: 1. To compare the association of obesity with severity of acute cholecystitis. 2. To study the associated pathological changes in the gall-bladder. METHODOLOGY: A cross-sectional study was carried out over a period of 18months from October2019-July2021 in the department of generalsurgery, Bapuji Hospital, Chigateri General Hospital, Davangere among 50 obese-patients with acute cholecystitis along with obesity(BMI &gt;25kg/sq.mt) undergoing cholecystectomy. The data analysis was done using IBM statistical-package for social sciences(IBM SPSS). RESULTS: The mean age of the study population was 45.22±9.25yrs. The mean BMI of the patients was 29.85±2.76 Kg/sq.mt. 56% were overweight, 38% were obese classI and 6% were obese classII. Based on Tokyo guidelines2013 on acute cholecystitis in the present study 32% had GradeI (mild), 54% had GradeII (moderate) and 14% cases had GradeIII (severe) cholecystitis. There was a statistical signicant association between BMI and severity of cholecystitis with more severe cases with increased BMI. Among 50cases posted for laparoscopic-cholecystectomy 18%cases were converted to open-cholecystectomy. Obesity is a documented risk factor for the forma CONCLUSION: tion of gall-stone and BMI is used as a tool to measure obesity. In our study we found a positive association of body mass index and severity of acute CALCULOUS cholecystitis

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

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

Is concomitant cholecystectomy at the time of bariatric surgery justified? a retrospective study

Nowadays, sleeve Gastrectomy (SG) has become a cornerstone in treating morbid obesity, a condition that has turned into one of the most important health concerns worldwide. Nonetheless, gallbladder (GB) disease remains a frequently seen problem after weight loss. The performance of concomitant cholecystectomy with SG (SCC) is yet still controversial. The study's aim is to assess the safety of performing SCC, the operative time, length of hospital stay (LOS) and the postoperative complications. This is a retrospective case-control study, conducted in Lebanon, comparing patients treated with SG, as control group A, to patients who underwent SCC (group B). Out of 120 patients included in the study, 100 underwent SG and 20 underwent SCC. Those who underwent SCC had an abnormal abdominal ultrasound (US) preoperatively. Out of the patients who had a SG, 40 patients (13.7%) underwent a subsequent cholecystectomy due to GB disease. Eight out of 40 patients (20%) suffered from complications, mainly related to common bile duct stone migration, requiring endoscopic retrograde cholangiopancreatography (ERCP). The mean time until presentation for cholelithiasis post bariatric surgery was 13.03 (±10.01) months and the mean weight loss achieved was 29.9 (±8.8) Kilograms. The mean operative time was increased by 29.9 min (min) for SCC (146.7 min) compared to SG alone (116.8 min). Our study results showed that the incidence of symptomatic GB disease post bariatric surgery (BS) was relatively high and cholecystectomy at that time was not straightforward. Also, SCC performance was highly dependent on the result of the preoperative US.

Acute hemorrhagic cholecystitis as a rare cause of hemobilia.

Hemobilia is an unusual type of gastrointestinal bleeding most frequently due to iatrogenic injury, trauma, or neoplasia. Acute cholecystitis as a cause of hemobilia is rare. We present the case study of a patient with bleeding from eroded gallbladder mucosa in the setting of severe calculous cholecystitis. The hemorrhagic episode was preceded by acute ERCP due to obstructive icterus with extraction of the calculi, followed by the development of severe acute pancreatitis. These factors initially misled the diagnosis. The bleeding was not hemodynamically important and routine diagnostic methods did not reveal its exact source. Direct choledochoscopy (SpyGlassTM) proved to be helpful in determining the right diagnosis, as it ruled out any injury or tumor in the main bile ducts and considerably supported the assumption of intrabladder bleeding. Surgical revision confirmed the cause, and subsequent cholecystectomy solved the whole problem.

One-step laparoscopic cholecystectomy with common bile duct exploration and stone extraction versus two-step endoscopic retrograde cholangiography with stone extraction plus laparoscopic cholecystectomy for patients with common bile duct stones: a randomised feasibility and pilot clinical trial—the preGallStep trial

BackgroundEndoscopic retrograde cholangiography (ERC) with stone extraction and papillotomy with subsequent laparoscopic cholecystectomy—the two-step approach—is the standard treatment of common bile duct stones in many countries. However, ERC is associated with a high risk of complications and more than half of patients require multiple ERCs. Meta-analyses of randomised clinical trials find no major differences of the two-step approach in comparison with laparoscopic cholecystectomy with intraoperative laparoscopic stone clearance—the one-step approach. Currently, there are insufficient data to ascertain superiority.MethodsThe preGallstep trial is an investigator-initiated, multicentre randomised feasibility and pilot clinical trial with blinded outcome assessment. Eligible patients are patients with common bile duct stones (identified by magnetic resonance cholagiopancreatography), age 18 years or above with the possibility to perform both interventions within a reasonable time. We intent to randomise 150 participants allocated 1:1. The experimental intervention is the one-step approach. This consists of laparoscopic common bile duct exploration plus laparoscopic cholecystectomy. The control intervention is the two-step approach which consists of ERC plus sphincterotomy (first step) and subsequent laparoscopic cholecystectomy (second step). Feasibility outcomes include the proportion of eligible patients not wanting to participate, reasons for rejection to participate, difficulties during the informed consent procedure, difficulties with randomisation, difficulties with data management, difficulties with blinding patient charts and forms and difficulties with maintaining blinding for the outcome assessors. The primary pilot outcome is the proportion of participants with at least one postoperative complication according to the Clavien-Dindo score grade II and above until 90 days after randomisation. This outcome will be used for a future sample size calculation of a larger pragmatic trial. Further, a range of clinical explorative outcomes will be assessed.DiscussionAs no sample size is estimated in this trial, there is a risk of wrongly assessing the effect on the patient-related outcome. The surgical procedures cannot be blinded. However, blinding will be employed in all other aspects of the trial, including the establishment of a blinded outcome adjudication committee with three independent assessors. Heterogeneity in screening, randomisation, diagnostics, treatment procedures, interventions and follow-up across trial sites may cause challenges in conducting a larger pragmatic trial. To monitor inter-site differences, we have implemented a central data monitoring scheme.Trial registrationClinicalTrials.gov identification: NCT04801238, Registered on 16 March 2021

Percutaneous Cholecystostomy in Severe Acute Cholecystitis: An Observational Study From a Single Institute.

Background Although percutaneous cholecystostomy (PC) is generally accepted as a bridge to definitive therapy for acute cholecystitis (AC), which remains cholecystectomy, some patients did not undergo cholecystectomy, mainly due to contraindications to surgery. Here, we aimed to investigate the predictors of recurrence and the outcome after PC. Methods This is a retrospective study from a single general hospital at Tunbridge Wells, United Kingdom. One hundred twenty-six patients who presented with AC grade 3 and were initially managed with PC were included. In addition, the proportion of patients who did not undergo subsequent laparoscopic cholecystectomy (LC) and their characteristics were analyzed. Results The mean age of the study cohort was 72 (36-98) years, and the median length of drain insertion was 39.5 days. The majority (52%) presented with severe AC grade 3 with failed medical treatment to control the disease, while 7% had an emphysematous gallbladder. Eighty percent of patients did not develop any further attacks of AC after PC removal. The most common comorbidity was hypertension (35%). The mean age-adjusted Charlson comorbidity score was 3.72. Thirty-six percent (45/126) of the study cohort underwent LC, while the remaining patients did not receive any surgical intervention. Nine percent were deemed unfit for surgery. Forty-one patients (33%) were managed conservatively as they did not have a further attack of cholecystitis after PC removal or had a mild attack managed with antibiotics. In addition, 22% experienced procedural complications, including a blocked stent, pain, and cellulitis around the tube. The 30-day mortality rate of patients who did not undergo LC was 5%. Predictors of interval cholecystectomy were younger age, calculus cholecystitis, low Charslson index score, and uncomplicated and shorter length of hospital stay with PC. Conclusion Most severe AC patients treated initially with PC did not undergo subsequent LC. Therefore, PC in high-surgical-risk patients with AC could be a definitive treatment.

Percutaneous cholecystostomy in multi-field hospital

To analyze the indications, technical features and results of percutaneous cholecystostomy. A retrospective single-center study of the results of percutaneous cholecystostomy over 13-year period was carried out. The indications for surgery, technical features and outcomes were studied. The indications for percutaneous cholecystostomy were acute cholecystitis in 40 (63.5%) cases and obstructive jaundice in 23 (36.5%) cases. In acute cholecystitis, cholecystectomy was denied due to severe acute and decompensated chronic diseases. In case of obstructive jaundice, cholecystostomy was preferred if other methods of biliary decompression were impossible. Drainage with locking thread was used in 44 (69.8%) patients. A total of 13 (21.3%) cases of drainage migration were noted. Incidence of migration of catheters with locking threads was 13.6%, without locking threads - 41.2% (p=0.033). Subsequent cholecystectomy was performed in 10 (15.9%) patients. In case of obstructive jaundice, cholecystostomy did not lead to destructive cholecystitis in any case. Six patients with acute cholecystitis had progressive gallbladder destruction. Overall postoperative in-hospital mortality was 36.5% (n=23). Mortality in the group of acute cholecystitis was 32.5% (n=13), in the group of obstructive jaundice - 43.5% (n=10). Mortality was higher in acute cholecystitis Grade III (75.0%) compared to Grade II (21.9%; p=0.008). Cholecystostomy is a rare (reserve) intervention. Locking thread significantly reduces the incidence of migration of cholecystostomy catheter. Progressive gallbladder destruction required cholecystectomy in 15% of cases. Treatment of patients with acute cholecystitis depends on physical status and comorbidities.

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.

Wait-and-see strategy is justified after ERCP and endoscopic sphincterotomy in elderly patients with common biliary duct stones.

Older patients with simultaneous main bile duct and gallbladder stones, especially those with high-surgical risks, create a common clinical dilemma. After successful endoscopic removal of main bile duct stones, should these patients undergo laparoscopic cholecystectomy to reduce risk of recurrent biliary events? In this population-based cohort study, we report long-term outcomes of a wait-and-see strategy after successful endoscopic extraction of main bile duct stones. Consecutive patients 75 years or older undergoing endoscopic stone extraction without subsequent cholecystectomy in two tertiary academic centers between January 2010 and December 2018 were included. Primary outcome measure was recurrence of biliary events. Secondary outcome measures were operation-related morbidity and mortality. A total of 450 patients (median age, 85 years; 61% female) were included, with a median follow-up time of 36 months (0-120 months). Recurrent biliary events occurred in 51 patients (11%), with a median time from index hospital admission to recurrence of 307 days (12-1993 days). The most common biliary event was acute cholecystitis (7.1%). Twelve patients had cholangitis (2.7%) and two biliary pancreatitis (0.4%). Only one patient (0.4%) underwent surgery due to later gallstone-related symptoms. Eighteen patients (4.0%) required endoscopic intervention and 16 (3.5%) underwent surgery. There were no operation-associated deaths or morbidity among those undergoing later surgical or endoscopic interventions. In elderly patients, it is relatively safe to leave gallbladder in situ after successful sphincterotomy and endoscopic common bile duct stone removal. In elderly and frail patients, a wait-and-see strategy without routine cholecystectomy rarely leads to clinically significant consequences. Therapeutic/Care Management; Level III.