Introduction

Acute gangrenous cholecystitis, a severe complication of cholecystitis, carries a high risks of morbidity and mortality. Despite its severity, preoperative diagnosis is challenging, often only confirmed during surgery, highlighting the need for effective pre-operative predictors to facilitate timely surgical intervention. Therefore, we analyzed various factors that could predict acute gangrenous cholecystitis in patients undergoing laparoscopic cholecystectomy.

Aims & Methods

We conducted a retrospective review of patients who underwent laparoscopic cholecystectomy at Bundang Jasaeng General Hospital between January 2018 and December 2021. From this group, we included only those patients who proceeded directly to surgery without any radiologic interventional treatments. Prior to surgery, all patients underwent an ultrasonographic examination of the gallbladder.

Results

Our study investigated 314 patients diagnosed with acute cholecystitis, of which 37 (11.8%) were identified with acute gangrenous cholecystitis. Analysis revealed that patients with gangrenous cholecystitis were significantly older, more likely to be male, and had a higher prevalence of chronic kidney disease compared to those with uncomplicated cholecystitis. Laboratory results indicated higher WBC, C-reactive protein, and delta neutrophil index (DNI) levels in gangrenous cases, with a DNI level of 0.5% or higher marking a notable increase in risk. Ultrasound findings showed a higher incidence of sonographic Murphy’s signs (9% vs. 21.6%, p=0.039), thickened gallbladder wall (3.1 ± 0.9 mm vs 5.2 ± 0.9 mm, p < 0.001) and defects (0.4% vs. 5.6%, p=0.035) in gangrenous cholecystitis. Univariate and multivariate analyses highlighted that a thickened gallbladder wall remained a significant predictor of gangrenous cholecystitis (p<0.001).

Conclusion

Patients diagnosed with gangrenous cholecystitis were typically older, more frequently male, and had a higher prevalence of chronic kidney disease. The results of this study suggest that thickened GB wall (≥ 4 mm) is an effective predicator of gangrenous cholecystitis; therefore, urgent management is recommended for these patients due to the high morbidity and mortality associated with the condition.

Introduction

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has emerged as a minimally invasive alternative to percutaneous drainage for high-risk surgical patients with acute cholecystitis. Although EUS-GBD is gaining traction in clinical practice, real-world data in complex and high-risk patients remain scarce, particularly regarding outcomes in perforated or malignant cases. While its efficacy is increasingly recognized, data on predictors of success and complications remain limited.

Aims & Methods

This retrospective study explored potential clinical and procedural factors associated with outcomes following EUS-GBD. Patients undergoing EUS-GBD for acute cholecystitis between October 2021 and January 2024 at a tertiary center were included. All procedures were performed by endoscopists with advanced training in interventional EUS. Data on demographics, comorbidities, procedural details, and outcomes were collected. Clinical success was defined as resolution of sepsis or cholecystitis symptoms within 48 hours. Complications included bile leak, infection, and the need for reintervention. Due to the limited sample size, statistical analysis was descriptive and exploratory.

Results

Thirteen patients (6 females, median age 69.1 years [IQR 45–90]) underwent EUS-GBD during the study period. Indications included gallstones (53.8%), malignant cystic duct obstruction (38.4%), and ischemia (7.7%). Reasons for non-surgical management included terminal malignancy (n=6, 46.2%), coronary artery disease (n=5, 38.5%), cirrhosis with hepatocellular carcinoma (n=1, 7.7%), and the patient’s choice (n=1, 7.7%). Lumen-apposing metal stents (LAMS) were placed transgastrically in 10 patients (n=10, 77%) and transduodenally in 3 (n=3, 23%).
Two patients (15.4%) presented with gallbladder perforation and pericholecystic abscess at the time of EUS-GBD. Both cases achieved full resolution following the drainage procedure, indicating that EUS-GBD may serve as a valuable rescue therapy in complicated acute cholecystitis.
Clinical success was achieved in 12 out of 13 patients (92.3%). One patient (7.7%) developed a bile leak, associated with the presence of ascites and hepatocellular carcinoma. Median post-procedural hospital stay was 6.8 days (IQR 3–20). Exploratory analysis suggested a trend toward higher complication rates in patients with ascites and those undergoing transgastric drainage, though no definitive conclusions could be drawn. At 30-day follow-up, no late adverse events or stent-related complications were reported.

Conclusion

EUS-GBD is a highly effective and safe treatment option for acute cholecystitis in patients unfit for surgery, with rapid symptom resolution and acceptable hospital stay duration. Notably, the resolution of pericholecystic abscesses in two cases of gallbladder perforation suggests that EUS-GBD may be beneficial even in more complex clinical scenarios. Preliminary data from this small cohort suggest that the presence of ascites and transgastric access may increase the risk of adverse events. These findings support the role of EUS-GBD not only as a safe alternative in high-risk patients but also as a potentially definitive solution in anatomically and clinically challenging cases. Further prospective studies with more significant patient populations are warranted to validate these early observations and optimize outcomes in this vulnerable population.

Introduction

Acute cholangitis (AC) is an important clinical problem which is associated with mortality upto 10%. The association between timing of ERCP and clinical outcomes of AC are not well studied. The current study is aimed to evaluate whether ERCP within 48 hours is associated with improved clinical outcomes.

Aims & Methods

This is single center retrospective analysis of prospectively maintained database. All patients who admitted with AC at AIG Hospitals, Hyderabad between January 2022 to December 2022 were included in study if they underwent ERCP. Patients satisfying diagnostic criteria of AC according to Tokyo Guidelines and stratified according to severity of AC. We evaluated association between ERCP within 48 hours and length of hospital stay, need for reintervention and re-admissions, mortality in-hospital and at 3 months follow.

Results

A total of consecutive 301 patients underwent ERCP during study period; of which 217 patients (31.3% females; mean age 54.02 ± 14.9 years) underwent ERCP within 48 hours of admission. Remaining 84 (32.1% females; mean age 56.56 ± 13.9 years) underwent ERCP after 48 hours. 58 (26.7%) and 22 (26.2%) patients with severe cholangitis (grade 3 as per Tokyo Guidelines) underwent ERCP within 48hours and beyond 48 hours respectively. The proportion of patients with malignant biliary obstruction was 34.1% (74/217) and 46.6% (39/84) in ERCP within 48 hours and beyond respectively. There was no statistically significant difference for overall mortality (6.45%vs7.14%, p 0.83); need for reinterventions (46.1% versus 54.8%, p 0.53) and readmissions (62.2% versus 58.33%; p 0.18). The length of hospital stay during 1^st admission was significantly higher in ERCP beyond 48hours group (9.48 ± 6.50 versus 12.86 ± 7.25 days; p 0.0001).

Conclusion

The current study indicates that ERCP within 48 hours for AC is associated with decreased length of hospital stay while overall mortality, need for reinterventions, readmissions are comparable. There is unmet need to confirm these findings by randomized controlled study.

Introduction

Early drainage of the biliary tract is significant in managing patients with acute cholangitis. In cases where endoscopic retrograde cholangiopancreatography (ERCP) is not feasible, percutaneous transhepatic gallbladder drainage (PTGBD) is considered as an alternative treatment. Several studies indicate that PTGBD is a well-established treatment as well as ERCP, however there is limited literature of evaluation and comparison of these procedures in elderly people.

Aims & Methods

This study aimed to compare the clinical outcomes of ERCP and PTGBD in elderly patients with acute cholangitis. We retrospectively compared patients aged 70 years or older who underwent ERCP or PTGBD between 2019 and 2022.

Results

Among 129 cases of acute cholangitis, 101 patients underwent ERCP, while 28 patients underwent PTGBD. Benign and malignant biliary obstruction were present in 76% (98/129) and 24% (31/129), respectively. The mean age was 84.2 years in ERCP and 84.5 years in PTGBD. Main reasons for performing PTGBD were postoperative stomach in 21% (6/28), unstable vital signs in 46% (13/28), full-stomach in 25% (7/28), and failure to perform ERCP in 14% (4/28). The overall technical success rate was 91% (92/101) in ERCP and 100% (28/28) in PTGBD. Senior residents performed the entire PTGBD procedure, while only 63% (64/101) of ERCP cases were performed by senior residents. Both ERCP and PTGBD showed improvement in jaundice (T-Bil -0.72 vs. -0.45, P>0.05), liver dysfunction (AST -178.7 vs. -206.6, P>0.05; ALT -57.4 vs. -77.4, P>0.05), and inflammatory response (white blood cell count -5.4x103 vs. -7.4x103, P>0.05) in blood tests after the procedure. However, acute pancreatitis occurred in 5% (5/101) after ERCP, leading to mortality in 2% (2/101). Other complications were observed in 19% (19/101), including bleeding after endoscopic sphincterotomy (EST) in 4% (4/101). In contrast, PTGBD caused no major complications or drainage failure, although tube dislocation occurred in 18% (5/28). The median length of stay was longer in PTGBD (25 days) compared to ERCP (15.2 days).

Conclusion

Both ERCP and PTGBD are effective treatments for acute cholangitis in elderly patients. Besides, PTGBD has an advantage of a higher technical success rate and fewer procedure-related complications compared to ERCP.

References

1. Li YL, Wong KH, Chiu KW, Cheng AK, Cheung RK, Yam MK, Chan AL, Chan VS, Law MW, Lee PS. Percutaneous cholecystostomy for high-risk patients with acute cholangitis. Medicine (Baltimore). 2018 May;97(19):e0735. doi: 10.1097/MD.0000000000010735. PMID: 29742738; PMCID: PMC5959387.
2. Kiriyama S, Kozaka K, Takada T, et al.Tokyo guidelines 2018: Diagnostic criteria and severity grading of acute cholangitis (with videos).J Hepatobiliary Pancreat Sci2018;25:17–30.

Introduction

In laparoscopic cholecystectomy (LC), intraoperative cholangiography (IOC) is recommended to clarify biliary anatomy, detect choledocholithiasis and identify complications. IOC interpretation may be performed by either surgeons or radiologists, but it remains unclear which approach is preferable. This study investigates how the type of medical specialist interpreting the IOC affects surgical outcomes and operating time.

Aims & Methods

All LCs registered in the Swedish Registry of Gallstone surgery and Endoscopic retrograde Cholangiopancreatography (GallRik) between January 1, 2009, and December 31, 2020, were included. A complementary survey was distributed to all participating surgical clinics to determine local IOC interpretation practices. Registry and survey data were linked and outcomes were analysed using mixed model analysis and logistic regression.

Results

A total of 118.556 procedures from 61 surgical units were included. Operating time was longer when radiologists assessed the IOC (mean differences 11.3 minutes; 95% CI 1.60-20.89). Intraoperative complications were more common with radiologist interpretation (2.6% vs 1.5%; OR 0.58, 95% CI 0.52-0.63), while postoperative complications were slightly higher with surgeon-led interpretation (8.2% vs 7.3%; OR 1.14, 95% CI 1.08-1.20). Bile duct injury rates (0.3%; OR 1.0, 95% CI 0.79-1.27) and detection of choledocholithiasis (12.4% vs 12.6%; OR 1.02, 95% CI 0.90-0.99) were similar between groups.

Conclusion

Surgeon-led IOC interpretation is associated with shorter operating times and fewer intraoperative complications, without increasing the risk of bile duct injury or missed choledocholithiasis. Routine radiologist involvement may be unnecessary and an inefficient use of resources.

Introduction

According to guidelines for acute cholangitis management (Tokyo 2018), urgent drainage of the biliary tract is indicated in moderate and severe cases. However, it does not consider factors such as bacteraemia or comorbidities. In addition, the availability of immediate biliary drainage may be limited in some centres.

Aims & Methods

Aims: To evaluate the clinical characteristics of acute cholangitis in our environment and to identify predictive factors of severity.
Methods: A retrospective study of clinical and analytical variables at admission of 331 patients diagnosed with acute cholangitis at Hospital del Mar (2018-2021). Analysis of predictive factors for mortality during admission and at 30 days from discharge. Severty was assessed as association of mortality with clinical, haemodynamic and analytical variables analyzed via logistic regression. Analysis of differences in mortality between early drainage (before 48 hours) and late drainage through Pearson Chi squared test.

Results

The average age was 78 years, 53% were men, 35% had a smoking habit and 17.5% had a Charlson index of high morbidity (>5p). As relevant antecedents they had: diabetes (32.1%), COPD (11.48%), heart failure (16.92%) and ischaemic heart disease (10.3%). The causes of cholangitis were: choledocholithiasis (48.33%) and both benign and malignant strictures (24.92%), 26.75% of cholangitis did not have a clear cause. Choledocholithiasis was diagnosed by endoscopic ultrasound (41.67%), CT scan (23.72%), magnetic ressonance (19.87%) or abdominal ultrasound (14.74%). 197 patients required biliary drainage, median time to drainage of 5 days. The median hospital stay was 9 days and 6.65% of patients needed intensive care unit (ICU) admission.
Mortality was 4.23% during admission and 3.34% at 30 days from discharge. Intra-hospital mortality was related to high morbidity (p<0,002), a malignant aetiology of the cholangitis (p<0,026), alkaline phosphatase (AP) >300UI/L (p<0,005), CRP (C reactive protein) >8mg/dl (p<0,006), low albumin <3,3g/dl (p<0,007) and high leukocytes >12x10^3/uL (p<0,022). Mortality at 30 days was associated with low levels of albumin, high levels of AP and CRP, high morbidity and a malignant origin of the cholangitis. In the multivariate analysis for intrahospital mortality, having high morbidity, AP>300 U/L and CRP>8mg/dl, were predictors of intra-hospital mortality (OR 2,34, IC 95% 1,19-4,16; OR 6,37 IC 95% 1,20-31,01; OR 5,10 IC95% 1,05-24,68; respectively). A malignant origin of a biliary stenosis was significantly associated with higher risk of mortality at 30 days after discharge (OR 12,57 IC 95% 1,58-100,17). There were no differences in mortality of moderate and severe cholangitis between those drained before 48h of admission and those drained after 48h (p=0,571). In those patients who had the risk factors for mortality we identified, no differences in mortality were found between drainage before and after 48h of admission.

Conclusion

Patients with a high Charlson score, initial PA >300 U/L or initial CRP >8 mg/dL have a higher risk of mortality and therefore, should be considered as useful factors to prioritize those patients who need urgent drainage.

Introduction

Laparoscopic cholecystectomy (LC) for symptomatic cholecystolithiasis is one of the most performed abdominal surgeries worldwide, with 700,000 procedures performed in the United States of America annually. (1) However, postoperative outcomes are often mediocre, with 20-40% of patients experiencing persistent pain. (2-3) This is primarily due to the absence of selection criteria for surgery. Internationally, the ROME III criteria are used; however, they are developed as a diagnostic measure for symptomatic cholecystolithiasis rather than a tool to predict surgical outcomes. (4) A randomized trial comparing usual care with a restrictive, criteria-based strategy, utilizing the ROME III criteria, showed that abdominal pain persists in 40% of patients regardless of the study arm. (5) That the ROME criteria are insufficient to predict a pain-free state is at least partly attributable to the sole focus on pain characteristics with inattention to accompanying functional gastrointestinal disease (FGID). Coexistence of FGID is important to consider, as a recent trial showed that 30% of patients with symptomatic cholecystolithiasis meet the criteria for FGID, which is associated with a 2.5-fold increased risk of persistent pain post-cholecystectomy. (6) The poor outcome of LC, accompanying FGID, and the limited predictive value of the ROME criteria to reach a pain-free state, underline the need to develop a tool that aids the surgeon and gastroenterologist in deciding if a patient will benefit from surgery. (7) Therefore, this study presents the development and validation of a clinical decision tool to predict short- and long-term surgical outcomes and to select patients for cholecystectomy.

Aims & Methods

This study evaluates five-year follow-up data of 2 multicentre prospective trials. These studies included a total of 1561 patients diagnosed with symptomatic cholecystolithiasis in 25 hospitals. The primary aim was to develop a predictive model to predict clinically relevant pain reduction five years after cholecystectomy. The model development process included multivariable regression analysis, internal and external validation. Model performance on external validation was assessed through flexible calibration plots, C statistic and decision curve analysis. The TRIPOD guideline were followed.

Results

A total of 1240 of 1561 patients (79.4%) had undergone cholecystectomy at five-year follow-up. After surgery, 746 of 1240 patients (70.2%) reported a clinically relevant pain reduction. A multivariable model showed that male sex, increased VAS pain score at baseline, pain radiating to the back, nausea, and absence of obstipation, diarrhoea and postprandial bloating were independent predictors of clinical pain reduction after cholecystectomy. External validation indicated a good discrimination and calibration between patients with and without clinically relevant pain reduction (C statistic of 0.75; 95% CI, 0.70-0.79).

Conclusion

We developed and validated a model to predict the long-term clinical pain reduction following LC in patients with abdominal pain and gallstones. By adapting the SUCCESS criteria to predict the outcome of surgery, we can enhance the shared decision-making process, allow more tailored care to patients with FGID, reduce ineffective operations, and improve surgical outcomes. Based on our results we advocate for utilizing the ROME III criteria for diagnosing symptomatic cholecystolithiasis, while adopting the SUCCESS criteria for selecting patients for treatment.

References

1. Lammert F, et al. Gallstones. Nat Rev Dis Primers 2016; 2:16024.
2. Wennmacker S, et al. Consistency of patient-reported outcomes after cholecystectomy and their implications on current surgical practice: a prospective multicenter cohort study. Surg Endosc 2017; 31: 215–24.
3. Thistle JL, et al. Factors that predict relief from upper abdominal pain after cholecystectomy. Clin Gastroenterol Hepatol 2011; 9: 891–96.
4. Thunnissen FM, et al. Patients with Clinically Suspected Gallstone Disease: A More Selective Ultrasound May Improve Treatment Related Outcomes. J Clin Med. 2023 Jun 20;12(12):4162.
5. van Dijk AH, et al. Restrictive strategy versus usual care for cholecystectomy in patients with gallstones and abdominal pain (SECURE): a multicentre, randomised, parallel-arm, non-inferiority trial. Lancet 2019; 393(10188):2322-2330.
6. de Jong JJ, et al. Functional Dyspepsia and Irritable Bowel Syndrome are Highly Prevalent in Patients With Gallstones and Are Negatively Associated With Outcomes After Cholecystectomy: A Prospective, Multicenter, Observational Study (PERFECT - Trial). Ann Surg. 2022 Jun 1;275(6):e766-e772.
7. Latenstein CSS, et al. SECURE trial collaborators. A Clinical Decision Tool for Selection of Patients With Symptomatic Cholelithiasis for Cholecystectomy Based on Reduction of Pain and a Pain-Free State Following Surgery. JAMA Surg. 2021 Oct 1;156(10):e213706.

Disclosure

There is no conflict of interes