Percutaneous Cholecystostomy in High Risk Patients with Acute Cholecystitis

Aims and Objectives: To assess efficacy and safety of percutaneous cholecystostomy (PC) in high risk patients with acute cholecystitis. Materials and Methods: The study was carried out in high risk patients with acute calculous or acalculous cholecystitis. Patients qualifying for the study were subjected to PC under ultrasound (USG) guidance. A cholecystogram was done postoperatively, to help establish satisfactory catheter position. Results: 24 (70.59%) patients had empyema-gallbladder, 8 (23.53%) had acute calcular cholecystitis and 2 (5.9%) patients were diagnosed as acalcular cholecystitis. None of the patients was fit for general anesthesia at the time of admission. Median hospital-stay after performing procedure was 4 days. Clinical success rate was reported 100% in our study. Bile cultures yielded growth of E Coli in 10 (29.41%), klebsela in 8 (23.53%), pseudomonas aeruginosa in 6 (17.65%) and Proteus mirabilis in 4 (11.8%) of patients. 6 (17.65%) patients did not grow any organism in their bile. Growth noted was sensitive to imipenem 29.41% (10), ciprofloxacin 17.65% (6), levofloxacin 17.65% % (6) and cefuroxime 11.76% (4). No major complication was recorded in our study. No procedure related death was observed. Tube displacement occurred in one patient and minor bleeding was reported in 2 patients. Catheter was removed after a mean of 25.25 days. All patients underwent definitive surgical intervention during the follow up period of 3 months. Conclusion: USG guided PC is a safe and effective procedure for treating high-risk patients who present with acute cholecystitis. Once the acute symptoms diminish or resolve, it should be followed by elective surgery.

Efficacy and safety of conversion of percutaneous cholecystostomy to endoscopic transpapillary gallbladder stenting in high-risk surgical patients

Background:Endoscopic transpapillary gallbladder stenting(ETGBS)has been used as an alternative to percutaneous cholecystostomy in patients with acute cholecystitis who are considered unfit for surgery.However,there are few data on the efficacy and safety of ETGBS replacement of percutaneous cholecystostomy in high-risk surgical patients.This study aimed to evaluate the feasibility,efficacy,and safety of ETGBS to replace percutaneous cholecystostomy in high-risk surgical patients.Methods:This single center retrospective study reviewed the data of patients who attempted ETGBS to replace percutaneous cholecystostomy between January 2017 and September 2019.The technical success,clinical success,adverse events,and stent patency were evaluated.Results:ETGBS was performed in 43 patients(24 male,mean age 80.7±7.4 years)to replace percutaneous cholecystostomy due to high surgical risk.The technical success rate and clinical success rate were 97.7%(42/43)and 90.5%(38/42),respectively.Procedure-related adverse events and stent-related late adverse events occurred in 7.0%(3/43)and 11.6%(5/43),respectively.Of the patients who successfully underwent ETGBS(n=42),only one had recurrent acute cholecystitis during follow-up.The median stent patency was 415 days(interquartile range 240–528 days).Conclusions:ETGBS,as a secondary intervention for the purpose of internalizing gallbladder drainage in patients following placement of a percutaneous cholecystostomy,is safe,effective,and technically feasible.Thus,conversion of percutaneous cholecystostomy to ETGBS may be considered as a viable option in high-risk surgical patients.

Pancreatic tuberculosis mimicking pancreatic carcinoma during anti-tuberculosis therapy:A case report

Pancreatic tuberculosis(TB) is a rare condition,even in immunocompetent hosts.A case is presented of pancreatic TB that mimicked pancreatic head carcinoma in a 40-year-old immunocompetent male patient.The patient was admitted to our hospital after suffering for nine days from epigastralgia and obstructive jaundice.Computed tomography revealed a pancreatic mass that mimicked a pancreatic head carcinoma.The patient had undergone an operation four months prior for thoracic TB and was undergoing anti-TB therapy.A previous abdominal ultrasound was unremarkable with the exception of gallbladder steroid deposits.The patient underwent surgery due to the progressive discomfort of the upper abdomen and a mass that resembled a pancreatic malignancy.A biopsy of the pancreas and lymph nodes was performed,revealing TB infection.The patient received a cholecystostomy tube and recovered after being administered standard anti-TB therapy for 15 mo.This case is reported to emphasize the rarecontribution of pancreatic TB to pancreatic masses and obstructive jaundice.

Endoscopic ultrasound guided interventional procedures

Endoscopic ultrasound(EUS) has emerged as an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy. EUS provides access to many organs and lesions which are in proximity to the gastrointestinal tract and thus giving an opportunity to target them for therapeutic and diagnostic purposes. This modality also provides a real time opportunityto target the required area while avoiding adjacent vascular and other structures. Therapeutic EUS has found role in management of pancreatic fluid collections, biliary and pancreatic duct drainage in cases of failed endoscopic retrograde cholangiopancreatography, drainage of gallbladder, celiac plexus neurolysis/blockage, drainage of mediastinal and intra-abdominal abscesses and collections and in targeted cancer chemotherapy and radiotherapy. Infact, therapeutic EUS has emerged as the therapy of choice for management of pancreatic pseudocysts and recent innovations like fully covered removable metallic stents have improved results in patients with organised necrosis. Similarly, EUS guided drainage of biliary tract and pancreatic duct helps drainage of these systems in patients with failed cannulation, inaccessible papilla as with duodenal/gastric obstruction or surgically altered anatomy. EUS guided gall bladder drainage is a useful emergent procedure in patients with acute cholecystitis who are not fit for surgery. EUS guided celiac plexus neurolysis and blockage is more effective and less morbid vis-à-vis the percutaneous technique. The field of interventional EUS is rapidly advancing and many more interventions are being continuously added. This review focuses on the current status of evidence vis-à-vis the established indications of therapeutic EUS.

Gallbladder drainage guided by endoscopic ultrasound

The gold-standard management of acute cholecystitis is cholecystectomy.Surgical intervention may be contraindicated due to permanent causes.To date,the classical approach is percutaneous cholecystostomy in patients unresponsive to medical therapy.However, with this treatment some patients may experience discomfort,complications and a decrease in their quality of life.In these cases,endoscopic ultrasound (EUS)-guided gallbladder drainage may represent an effective minimally invasive alternative.Our objective is to describe in detail this new and not well-known technique:EUS-guided cholecystenterostomy.We will describe how the patient should be prepared,what accessories are needed and how the technique is performed.We will also discuss the possible indications for this technique and will provide a brief review based on published reports and our own experience.

Radiological interventions in malignant biliary obstruction

Malignant biliary obstruction is commonly caused by gall bladder carcinoma, cholangiocarcinoma and metastatic nodes. Percutaneous interventions play an important role in managing these patients. Biliary drainage, which forms the major bulk of radiological interventions, can be pal iative in inoperable patients or pre-operative to improve liver function prior to surgery. Other interventions include cholecystostomy and radiofrequency ablation. We present here the indications, contraindications, technique and complications of the radiological interventions performed in patients with malignant biliary obstruction.

Chemical cholecystectomy

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Call for action:Increased healthcare utilization with growing use of percutaneous cholecystectomy tube over initial cholecystectomy in cirrhotics

Background:Acute calculous cholecystitis(ACC)is frequently seen in cirrhotics,with some being poor candidates for initial cholecystectomy.Instead,these patients may undergo percutaneous cholecystostomy tube(PCT)placement.We studied the healthcare utilization and predictors of cholecystectomy and PCT in patients with ACC.Methods:The National Database was queried to study all cirrhotics and non-cirrhotics with ACC between 2010-2014 who underwent initial PCT(with or without follow-up cholecystectomy)or cholecystectomy.Cirrhotic patients were divided into compensated and decompensated cirrhosis.Independent predictors and outcomes of initial PCT and failure to undergo subsequent cholecystectomy were studied.Results:Out of 919189 patients with ACC,13283(1.4%)had cirrhosis.Among cirrhotics,cholecystec-tomy was performed in 12790(96.3%)and PCT in the remaining 493(3.7%).PCT was more frequent in cirrhotics(3.7%)than in non-cirrhotics(1.4%).Multivariate analyses showed increased early readmis-sions[odds ratio(OR)=2.12,95%confidence interval(CI):1.43-3.13,P<0.001],length of stay(effect ratio=1.39,95%CI:1.20-1.61,P<0.001),calendar-year hospital cost(effect ratio=1.34,95%CI:1.28-1.39,P<0.001)and calendar-year mortality(hazard ratio=1.89,95%CI:1.07-3.29,P=0.030)in cir-rhotics undergoing initial PCT compared to cholecystectomy.Decompensated cirrhosis(OR=2.25,95%CI:1.67-3.03,P<0.001)had the highest odds of getting initial PCT.Cirrhosis,regardless of compensated(OR=0.56,95%CI:0.34-0.90,P=0.020)or decompensated(OR=0.28,95%CI:0.14-0.59,P<0.001),reduced the chances of getting a subsequent cholecystectomy.Conclusions:Cirrhotic patients undergo fewer cholecystectomy incurring initial PCT instead.Moreover,the rates of follow-up cholecystectomy are lower in cirrhotics.Increased healthcare utilization is seen with initial PCT amongst cirrhotic patients.This situation reflects suboptimal management of ACC in cirrhotics and a call for action.

Conservative management of type 2 gallbladder perforation in a child

Gallbladder perforation(GBP) is a rare but serious complication of cholecystitis and needs to be managed promptly. Acalculus cholecystitis leading to GBP is frequently associated with enteric fever and found in critically ill patients, and a surgical approach is not always feasible in such patients. Use of percutaneous tube cholecystostomy(PTC) in such patients is a known entity but it is usually followed by interval cholecystectomy. Here we report a case of perforated gallbladder in a child managed conservatively and successfully with PTC as the definitive treatment wherein cholecystectomy was avoided. The functionality of the gallbladder was confirmed by a Tc99m-HIDA scan.

Percutaneous imaging-guided interventions for acute biliary disorders in high surgical risk patients

AIM:To evaluate the efficacy of percutaneous imagingguided biliary interventions in the management of acute biliary disorders in high surgical risk patients.METHODS:One hundred and twenty two patients underwent 139 percutaneous imaging-guided biliary interventions during the period between January 2007 to December 2009.The patients included 73 women and 49 men with a mean age of 61 years(range 35-90 years).Fifty nine patients had acute biliary obstruction,26 patients had acute biliary infection and 37 patients had abnormal collections.The procedures were performed under computed tomography(CT)-(73 patients),sonographic-(41 patients),and fluoroscopic-guidance(25 patients).Success rates and complications were determined.The χ2 test with Yates' correction for continuity was applied to compare between these procedures.A P value < 0.05 was considered significant.RESULTS:The success rates for draining acute biliary obstruction under CT-,fluoroscopy-or ultrasoundguidance were 93.3,62.5 and 46.1,respectively with significant P values(P = 0.026 and 0.002,respectively).In acute biliary infection,successful drainage was achieved in 22 patients(84.6).The success rates in patients drained under ultrasound-and CT-guidance were 46.1 and 88.8,respectively and drainage under CT-guidance was significantly higher(P = 0.0293).In 13 patients with bilomas,percutaneous drainage was successful in 11 patients(84.6).Ten out of 12 cases with hepatic abscesses were drained with a success rate of 83.3.In addition,the success rate of drainage in 12 cases with pancreatic pseudocysts was 83.3.The reported complications were two deaths,four major and seven minor complications.CONCLUSION:Percutaneous imaging-guided biliary interventions help to promptly diagnose and effectively treat acute biliary disorders.They either cure the disorders or relieve sepsis and jaundice before operations.

Clinical course of percutaneous cholecystostomies:A crosssectional study

BACKGROUND Although cholecystectomy is the standard treatment modality,it has been shown that perioperative mortality is approaching 19%in critical and elderly patients.Percutaneous cholecystostomy(PC)can be considered as a safer option with a significantly lower complication rate in these patients.AIM To assess the clinical course of acute cholecystitis(AC)in patients we treated with PC.METHODS The study included 82 patients with GradeⅠ,ⅡorⅢAC according to the Tokyo Guidelines 2018(TG18)and treated with PC.The patients’demographic and clinical features,laboratory parameters,and radiological findings were retrospectively obtained from their medical records.RESULTS Eighty-two patients,45(54.9%)were male,and the median age was 76(35-98)years.According to TG18,25 patients(30.5%)had GradeⅠ,34(41.5%)GradeⅡ,and 23(28%)GradeⅢAC.The American Society of Anesthesiologists(ASA)physical status score wasⅢor more in 78 patients(95.1%).The patients,who had been treated with PC,were divided into two groups:discharged patients and those who died in hospital.The groups statistically significantly differed only concerning the ASA score(P=0.0001)and WBCC(P=0.025).Two months after discharge,two patients(3%)were readmitted with AC,and the intervention was repeated.Nine of the discharged patients(13.6%)underwent interval open cholecystectomy or laparoscopic cholecystectomy(8/1)within six to eight weeks after PC.The median follow-up time of these patients was 128(12-365)wk,and their median lifetime was 36(1-332)wk.CONCLUSION For high clinical success in AC treatment,PC is recommended for high-risk patients with moderate-severe AC according to TG18,elderly patients,and especially those with ASA scores of≥Ⅲ.According to our results,PC,a safe,effective and minimally invasive treatment,should be preferred in cases suffering from AC with high risk of mortality associated with cholecystectomy.

Percutaneous Cholecystomy Guided by Ultrasound for Acute Cholecystitis in High-risk Aged Patients

Objective The aim of the present study was to assess experience with percutaneous cholecystostomy (PC) in high risk aged patients with presumed acute cholecystitis. Methods\ PC was performed by transhepatic route under local anaesthesia guided by ultrasonography cholecystostomy catheters. The catheters used include the Cope loop(produced by Japan hakko). Results\ PC was performed successfully in all 18 patients, without immediate procedural or technical complications. Symptoms and clinical signs of cholecystitis resolved within 24 48 h after the procedures in all but one patient. Conclusion\ PC is a cost effective ,mini invasive, and reliable alternative to surgical placement of cholecystostomy tubes in critically ill patient. This study also can be used in hepatic abscess, obstructive jaundice and necrostic pancreatitis caused by stone or tumor.\;