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Endoscopic transpapillary gallbladder stenting (ETGS) has been proposed as one of the adjunctive treatments, apart from antibiotics, before surgery in patients with acute cholecystitis whose cholecystectomy could not be performed or was deferred. Currently, there are no comparative data on the outcomes of ETGS in those who receive and do not receive ETGS. We aimed to compare the rates of recurrent cholecystitis at 3 and 6 months in these 2 groups. Between 2020 and 2023, eligible acute calculous cholecystitis patients with a high probability of common bile duct stone, who were surgical candidates but could not have an early cholecystectomy during COVID-19 surgical lockdown, were randomized into groups A (received ETGS) and B (did not receive ETGS). A definitive cholecystectomy was performed at 3 months or later in both groups. A total of 120 eligible patients were randomized into group A (n = 60) and group B (n = 60). In group A, technical and clinical success rates were 90% (54 of 60) and 100% (54 of 54), respectively. Based on intention-to-treat analysis, group A had a significantly lower rate of recurrence than group B at 3 months (0% [0 of 60] vs 18.3% [11 of 60]; P =.001). At 3–6 months, group A showed a nonsignificantly lower rate of recurrent cholecystitis compared to group B (0% [0 of 32] vs 10% [3 of 30]; P =.11). ETGS could prevent recurrent cholecystitis in acute cholecystitis patients with common bile duct stone whose cholecystectomy was deferred for 3 months. In those who did not receive ETGS, the majority of recurrences occurred within 3 months. (Thaiclinicaltrials.org , Number TCTR20200913001) [Display omitted] Endoscopic transpapillary gallbladder stenting is a useful temporary treatment before definitive cholecystectomy in patients with mild to moderate acute cholecystitis with deferred surgery for 3 months. [ABSTRACT FROM AUTHOR]

Background: Magnetic resonance cholangiopancreatography (MRCP) provides a noninvasive and fast modality for imaging the biliary tree when choledocholithiasis is suspected. Guidelines suggest that MRCP is recommended when strong or moderate signs of common bile duct (CBD) stones are present. Well-performed prospective studies are scarce regarding the sensitivity and specificity of preoperative MRCP in patients with acute cholecystitis in comparison with intraoperative cholangiography, ERCP, or choledochoscopy. Methods: We performed a prospective, observational population-based feasibility study in Central Finland Hospital Nova between January 2019 and December 2019. We examined the diagnostic performance of preoperative MRCP on consecutive patients with acute cholecystitis scheduled for index admission cholecystectomy. The accuracy of MRCP was verified with IOC, choledochoscopy, or ERCP. The interobserver reliability of the image quality of MRCP and the sensitivity and specificity of choledocholithiasis were observed independently by three experienced radiologists. Results: A total of 180 consecutive patients diagnosed with acute cholecystitis followed by index admission cholecystectomy were identified. MRCP was performed in 113/180 (62.8%) patients, and complementary perioperative imaging of the bile ducts was performed in 72/113 (63.7%) patients. The incidence of choledocholithiasis was high (29.2%). In acute cholecystitis, the sensitivity (76.2–85.7%) and specificity (84.3–92.2%) of MRCP were equally compared to the literature with unselected patient groups. The best visibility was observed in the common hepatic duct, the inferior CBD, and the central hepatic duct. The interobserver reliability was excellent for determining the size and quantity of CBD stones. Conclusion: In acute cholecystitis, MRCP yields high negative predictive value regarding detection of choledocholithiasis. If CBD stones were discovered, the interobserver reliability was excellent when measuring the size and number of CBD stones. The best-visualized area was the distal part of the biliary tract, which provides good preoperative workup if choledocholithiasis is present. [ABSTRACT FROM AUTHOR]

Acute cholecystitis is a painful inflammatory disease of the gallbladder. The Low Cervical-2 Plane Block is a retrolaminar block that targets the C3, C4, and C5 spinal nerves, which provide sensory innervation to the gallbladder, in order to potentially provide analgesia to patients with pain associated with acute cholecystitis. In this brief report, a softly embalmed cadaver was injected with a dye mixture bilaterally. Subsequent cadaveric dissection revealed spread of the injectate deep to the prevertebral fascia to the C4 lamina on the right side and the C5 lamina on the left side. Also, diffusion of the anesthetic over the ligamenta flava could spread inferiorly and laterally to the spinal nerve roots of C3-C5 and thus potentially target the direct sensory innervation of the gallbladder. The Low Cervical-2 Plane Block is a potentially effective modality for treating intractable pain from acute cholecystitis. However, further cadaveric injections are needed to confirm the exact extent of spread of anesthetic. Clinical application of the Low Cervical-2 Plane Block in patients with acute cholecystitis is needed to establish the efficacy of this theoretical technique. [ABSTRACT FROM AUTHOR]

Acute cholecystitis (AC) is a very common disease in clinical practice. Laparoscopic cholecystectomy remains the gold standard treatment for AC, however due to aging population, the increased prevalence of multiple comorbidities and the extensive use of anticoagulants, surgical procedures may be too risky when dealing with patients in emergency settings. In these subsets of patients, a mini-invasive management may be an effective option, both as a definitive treatment or as bridge-to-surgery. In this paper, several non-operative treatments are described and their benefits and drawbacks are highlighted. Percutaneous gallbladder drainage (PT-GBD) is one of the most common and widespread techniques. It is easy to perform and has a good cost/benefit ratio. Endoscopic transpapillary gallbladder drainage (ETGBD) is a challenging procedure that is usually performed in high volume centers by expert endoscopists, and it has a specific indication for selected cases. EUS-guided drainage (EUS-GBD) is still not widely available, but it is an effective procedure that could have several advantages, especially in rate of reinterventions. All these treatment options should be considered together in a stepwise approach and addressed to patients after an accurate case-by-case evaluation in a multidisciplinary discussion. In this review, we provide a possible flowchart in order to optimize treatments, resource and provide to patients a tailored approach. [ABSTRACT FROM AUTHOR]

Acute cholecystitis is one of the most common causes of acute abdomen. Early laparoscopic cholecystectomy is the gold standard treatment, still burdened by a risk of intraoperative biliary duct injury. An alternative strategy to manage patients with severe acute cholecystitis is the percutaneous gallbladder drainage (PGBD). The Italian Society of Emergency Surgery and Trauma performed a systematic review and meta-analysis with the aim to clarify controversies about the preoperative use of PGBD. We extracted 32 studies: 9 Randomized Control Trial Studies (RCTs) and 23 no RCTs. The incidence of post-operative complications was lower in the PGBD associated at LC than in the LC alone (RCTs: RR 0.28, 95% CI 0.14 to 0.56, I2 = 63%). The incidence of the post-operative biliary leakage was higher in late PGBD' group (RCTs: RR 0.18, 95% CI 0.04 to 0.80). The incidence of intraabdominal abscess, blood loss, conversion to open, subtotal cholecystectomy, operative time and wound infection was lower in PGBD' group. The total hospital stay was the same. A strong recommendation is performed to the use of the PGBD + LC than upfront LC to reduce biliary leakage (recommendation "strong positive") in high risk acute cholecystitis especially in patients with higher perioperative risks or longstanding acute cholecystitis. For post-operative complications a recommendation "positive weak" suggests that PGBD + LC could be used than upfront LC to reduce the rate of post-operative complications. • Laparoscopic cholecystectomy is still burdened by a certain risk of biliary injury. • An alternative strategy to manage acute cholecystitis is the cholecystostomy. • Lower complications in the drainage before laparoscopic cholecystectomy group. • Secondary outcomes are in favour of the drainage before the cholecystectomy. • Cholecystostomy before cholecystectomy is recommended in severe cholecystitis. [ABSTRACT FROM AUTHOR]

Acute right upper quadrant pain is one of the most common presenting symptoms in hospital emergency departments, as well as outpatient settings. Although gallstone-related acute cholecystitis is a leading consideration in diagnosis, a myriad of extrabiliary sources including hepatic, pancreatic, gastroduodenal, and musculoskeletal should also be considered. This document focuses on the diagnostic accuracy of imaging studies performed specifically to evaluate acute right upper quadrant pain, with biliary etiologies including acute cholecystitis and its complications being the most common. An additional consideration of extrabiliary sources such as acute pancreatitis, peptic ulcer disease, ascending cholangitis, liver abscess, hepatitis, and painful liver neoplasms remain a diagnostic consideration in the right clinical setting. The use of radiographs, ultrasound, nuclear medicine, CT, and MRI for these indications are discussed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. [ABSTRACT FROM AUTHOR]

Endoscopic gallbladder drainage is a feasible and efficacious alternative to percutaneous drainage in the management of acute cholecystitis for high-risk surgical candidates. Endoscopic ultrasound–guided gallbladder drainage and per-oral cholecystoscopy is facilitated by the use of lumen-apposing metal stents. Endoscopic ultrasound–guided gallbladder drainage should be performed by those expert in advanced therapeutic endoscopic ultrasound. Multidisciplinary collaboration between interventional radiology and surgery is paramount in the care of these patients. Choosing the optimal drainage method is dependent on individual patient characteristics. This commentary was drawn from a review of the literature to provide practical advice. Because this was not a systematic review, we did not perform any formal rating of the quality of evidence or strength of the presented considerations. This expert commentary was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer-review by the Clinical Practice Updates Committee and external peer-review through standard procedures of Clinical Gastroenterology and Hepatology. [ABSTRACT FROM AUTHOR]

Background: The organization of healthcare could have an impact on the outcome of patients treated for acute cholecystitis (AC). The aim of this study was to analyze the way in which patients with AC are managed relative to the level of care by the treating hospital.Methods: Data were collected from the Swedish Register for Gallstone Surgery and ERCP (GallRiks). Cholecystectomies between 2010 and 2019 were included. The inclusion criterion was acute cholecystectomy in patients with AC operated at either tertiary referral centers (TRCs) or regional hospitals.Results: A total of 24,194 cholecystectomies with AC met the inclusion criterion. The time between admission and acute surgery was significantly elongated at TRCs compared with regional hospitals (2.2 ± 1.7 days vs. 1.6 ± 1.4 days, mean ± SD; p < 0.0001). Patients with a history of AC were more frequent at TRC (10.1% vs. 8.9%, p < 0.0056) and had a higher adverse event rate compared with those at regional hospitals (OR 1.61; CI 1.40-1.84, p < 0.0001). Surprisingly, an increased number of hospital beds correlated slightly with an increased number of days between admission and surgery (R2 = 0.132; p = 0.0075).Conclusion: Compared with regional hospitals, patients with AC had to wait longer at TRCs before surgery. A history of AC significantly increased the risk of adverse events. These findings indicate that logistic and organizational aspects of hospital care may affect the management of patients with AC. However, whether these findings can be generalized to healthcare organizations outside Sweden requires further investigation. [ABSTRACT FROM AUTHOR]

Biliary hamartomas are rare congenital development anomaly of bile ducts, which are detected incidentally. They often present as multiple lesions on liver surface which resembles metastatic lesions. We report a case of acute calculous cholecystitis ultimately diagnosed to have asymptomatic multiple biliary hamartomas. A 42-year-old male with no co-morbidities presented with pain in upper abdomen associated with fever and vomiting. Contrast enhanced computed tomography (CECT) of abdomen showed acute calculous cholecystitis, hepatomegaly with fatty changes in liver. On laparoscopy the liver was found to have grey-white nodular lesions of about 0.5 cm in diameter scattered on the surface of both the lobes. One of the lesion was biopsied along with cholecystectomy. Biliary hamartoma commonly referred to as "von Meyenburg complexes" are uncommon lesions found in the liver which are usually asymptomatic. In this case the patient presented with symptoms of acute cholecystitis but the biopsy report from liver lesions proved to be benign biliary hamartoma which on initial impression looked like multiple liver secondaries. We have described a case of an adult with multiple biliary hamartoma which was an incidental finding. Biliary hamartoma is a rare entity which can sometime mimic metastasis in the liver. Thus, histopathological confirmation is essential before planning any further treatment. • Biliary hamartomas are rare phenomena which are detected incidentally. • They occur due to developmental anomaly of bile ducts, which appear as greyish white lesions on the surface of liver. • They appear as multiple lesions on the surface of liver which sometimes resembles secondaries. • Confirmation by tissue biopsy is recommended before ruling out malignancy. [ABSTRACT FROM AUTHOR]

• Timing of cholecystectomy is still a controversial area in acute cholecystitis management. • Evidence supports early over delayed laparoscopic cholecystectomy due to more favourable outcomes. • Severity of acute cholecystitis must be considered as it influences timing. • The Tokyo Guidelines (2018) are the most widely accepted diagnostic and severity scoring system for acute cholecystitis. [ABSTRACT FROM AUTHOR]

Purpose: To determine effects on admission, treatment, and outcome for acute cholecystitis during the course of the COVID-19 pandemic in 2020 and 2021.Methods: Retrospective analysis of claims data from 74 German hospitals. Study periods were defined from March 5, 2020 (start of first wave) to June 20, 2021 (end of third wave) and compared to corresponding control periods (March 2018 to February 2020). All in-patients with acute cholecystitis were included. Distribution of cases, type of surgery, comorbidities, surgical outcome, and length of stay of all cases with acute cholecystitis and cholecystectomy were compared. In addition, we analyzed the type of treatment (non-surgical, cholecystostomy, or cholecystectomy) for all cases with main diagnosis of acute cholecystitis.Results: We could not demonstrate differences in daily admissions over the course of the pandemic (11.2-12.7 patients vs. 11.9-12.6 patients for control periods). Proportion of patients with non-surgical treatment was low and not increased (11.7-17.3% vs. 14.5-18.4%). Cholecystostomy was rare throughout all periods (0-0.5% of all patients). We did not observe an increase in open surgery (proportion of open cholecystectomies 3.4-5.5%). Mortality was generally low (1.5-1.9%) with no differences between periods. Median length of stay was 4 days throughout all periods.Conclusion: The numerous restrictions during the COVID-19 pandemic did not result in an increase of admissions or surgery for acute cholecystitis. Laparoscopic cholecystectomy has been safely applied during the pandemic. Our results may assure the ability to maintain high quality of surgical care even in times of disruptions to the health care system. [ABSTRACT FROM AUTHOR]

Background: It is unclear whether cholecystectomy is beneficial after percutaneous transhepatic gallbladder drainage (PTGBD) in elderly patients with acute cholecystitis (AC). Methods: This single-center, retrospective study included 202 patients aged >80 years with AC without common bile duct (CBD) stones who underwent PTGBD between January 2010 and December 2019. Results: One hundred and forty-two patients underwent elective laparoscopic cholecystectomy (ELC), and 60 underwent conservative treatment, specifically PTGBD removal (PTGBD-R) in 36 patients and PTGBD maintained (PTGBD-M) in 24 patients. The postoperative major complication (POMC) rate in the ELC group was 8.5%. The cumulative incidence for recurrence of biliary events (BE) in the PTGBD-R group was 22.2%. The cumulative incidence for PTGBD-related complication in the PTGBD-M group was 70.8%. Mortality after initial treatment was not significantly different between the three groups (2.8% vs. 2.8% vs. 8.3%, p=0.381). In multivariate analysis, a Charlson age comorbidity index ≥6 and body mass index ≤19 were significant risk factors for POMC after ELC, and a closed cystic duct was a significant risk factor for recurrent BE after PTGBD-R. Conclusion: ELC is recommended in AC after PTGBD for selected patients aged >80 years without CBD stones due to the high recurrence rate of BE after PTGBD-R and the difficulty associated with PTGBD-M. [ABSTRACT FROM AUTHOR]

Acute cholecystitis (AC) is a life-threatening emergency in elderly patients. To compare the commonly used management strategies for elderly patients with AC as well as resulting morbidity, mortality and length of hospital stay (LOS). All patients ≥ 65 years admitted to our emergency department for AC between January 1st, 2014 and December 31st, 2018 were included in the study. We compared patients that received medical treatment to patients who received operative procedures. In order to correct for baseline covariates and factors associated to clinical management, we used a 1:1 propensity score matching (PSM) analysis. The primary outcome was the overall in-hospital mortality. Secondary outcomes included occurrence of major complications and LOS. A total of 1075 patients were enrolled: 483 patients received a medical treatment and 592 patients underwent interventional procedures. After PSM, 770 patients (385 for each treatment group) were included in the analysis. The analysis revealed that both mortality and cumulative major complications were similar in medical and interventional group. We found that among comorbidities, Charlson comorbidity index and congestive heart failure were significantly higher in the medical treatment group (5 [4-6] vs. 4 [3-6] and 11.7% vs. 4.7%, respectively; p <0.001). LOS was slightly lower in the medical treatment group (7.0 days [4.9–11.1] vs. 7.9 [4.9–13.5]; p = 0.046). Medical management outcomes for AC in elderly patients were similar to operative treatments in terms of mortality and cumulative major complications. A conservative approach should always be considered. [ABSTRACT FROM AUTHOR]

Introduction: Severity of cholecystitis can be defined by the presence of histopathological changes such as gangrene, perforation, and empyema. Severe cholecystitis correlates with higher morbidity and longer hospital stay. The present review aimed to identify the predictors of severe cholecystitis.Methods: Electronic databases including PubMed, Scopus, and Cochrane library were searched in the period of January 1980 to March 2019. The main outcome of this review was to assess the predictability of pre-operative parameters such as Leukocytosis, fever, tachycardia, gallbladder wall edema, gallbladder distension, serum platelet count, and gallbladder mural striation. The role of patients' characteristics including age, gender, and diabetes mellitus in predicting severe cholecystitis was also assessed.Results: A total of 8823 patients were analysed. The mean age of patients was 67.14 ± 4.17. The parameters that had the highest Odds ratio in predicting severe cholecystitis were all findings on CT scanning and included attenuation of arterial phase, mural striation of the gallbladder, and decreased gallbladder wall enhancement.Conclusion: We conclude that CT findings were the most significant predictors of severe cholecystitis. Patients with clinical and laboratory predictors of severe cholecystitis should be urgently evaluated with contrast CT scan to rule out any severe complications. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy (LC) is considered to be the gold standard in the early management of acute cholecystitis however, recommendations for routine drain insertion in the acute setting are unavailable.Study Design: A systematic review of literature review and metanalysis was conducted. All studies comparing drain versus no drain after LC for acute cholecystitis were included.Results: Seven studies, with 1274 patients, were included. Postoperative wound infection rates (relative risk (RR) 0.30, 95% confidence interval (CI) 0.10 to 0.88; I2 = 0%) and postoperative abdominal collection requiring drainage (RR 1.20, 95% CI 0.35 to 4.12; I 2 = 0%) were lower in the no-drain group, but this was only significant for wounded infections on subgroup analysis of RCTs. Length of stay hospital (mean difference (MD) -0.49, 95% CI -0.89 to -0.09; I 2 = 69%) and operative time (MD -8.13, 95% CI -13.87 to -2.38; I 2 = 92%) were significantly shorter in the no drain group however this was in the context of significant heterogeneity.Conclusion: The available data suggests that acute cholecystitis is not an indication for routine drain placement after LC. However, these results must be interpreted with caution due to the limitations of the included studies. In effect, the main issue of this meta-analysis lies on the limitations of the included studies themselves, because of a considerable heterogeneity among the included works, particularly for the inclusion criteria of patients and reported severity of acute cholecystitis. Further work is required to produce evidence which will definitively alter clinical practice.Level Of Evidence: Level 2a (systematic review of cohort studies). Oxford CEBM levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Gangrenous cholecystitis (GC) is a particularly severe form of acute cholecystitis (AC) and is associated with an increased risk of postoperative morbidity and mortality. Recent reports show that surgeons are remarkably unsuccessful in diagnosing GC.Methods: We conducted a retrospective study involving 587 patients with AC. Logistic regression analysis was used to identify independent predictive factors of GC. We assigned points for the score according to the regression coefficient. The area under the curve (AUC) was determined using receiver operating characteristic (ROC) curves. The scoring system was then prospectively validated on a second population. We validated 2 previously published scoring models.Results: Six independent predictive factors of GC were identified: [3-]4 ASA score, temperature, duration of symptoms, WBC, male gender, and pericholecystic fluid. A predictive score of GC was established based on these independent predictive factors. Sensitivity was 81.4%; specificity was 70%. The AUC of this clinicoradiological score was 0.83. The AUC of our score was higher than that of the first published score (the AUC was 0.75 in the original report and 0.78 in the validation model using our dataset) and that of the second published score (the AUC was 0.77 in the original report and 0.72 in the validation model using our dataset).Conclusions: The AUC of our score exceeded 0.80, indicating that this score can help in diagnosing patients with GC, and thus in prioritizing these patients for surgery or choosing the adapted technique of drainage in critically ill patients. [ABSTRACT FROM AUTHOR]

To evaluate the association between the CT rim sign and gangrenous cholecystitis (GC) and increased surgical difficulty. Patients who had a contrast enhanced CT of the abdomen and pelvis, followed by non-elective cholecystectomy were analyzed. The scans were reviewed for the CT rim sign by radiologists blinded to the pathologic and clinical outcomes. Demographic and clinical characteristics were compared between patients with and without GC using t -tests or Wilcoxon ranked sum test for continuous variables, and Fishers' exact test for categorical variables, when appropriate. A logistic regression model was fitted with multiple risk factors. Odds ratios as well as 95% confidence intervals were then calculated for the risk factors. A secondary analysis predicting increased surgical difficulty, defined as an operative time of greater than 2 h or increased conversion rate to open surgery, was also examined. A total of 100 patients were included; 20 of which had GC. On imaging, patients with GC were more likely to have a CT rim sign (65% vs 32.5%, OR = 3.80, 95% CI: 1.24–12.7, p = 0.011). The presence of the CT rim sign did not reach a statistically significant association with an operative time >2 h or conversion to open case (56.52% vs 33.77%, OR = 2.55, p = 0.056). The CT rim sign can be utilized to raise the possibility of GC, however the presence of the CT rim sign does not demonstrate an association with increased surgical difficulty. • Acute cholecystitis is one of the most common etiologies of acute abdominal pain in the emergency department. • CT rim sign is a likely more common imaging finding, which can suggest the possibility of gangrenous cholecystitis. • However, our study did not demonstrate an association between the CT rim sign and operative difficulty. [ABSTRACT FROM AUTHOR]

Background: While percutaneous cholecystostomy (PC) is a recommended treatment strategy in lieu of cholecystectomy (CCY) for acute cholecystitis among patients who may not be considered good surgical candidates, reports on disparities in treatment utilization remain limited. The aim of this study was to investigate the role of demographic, clinical, and socioeconomic factors in treatment of acute cholecystitis.Methods: Patients with a diagnosis of acute cholecystitis who underwent CCY versus PC were reviewed from the U.S. Nationwide Inpatient Sample (NIS) database between 2008-2014. Measured variables including age, race/ethnicity, Charlson comorbidity index (CCI), hospital type/region, insurance payer, household income, length of stay (LOS), hospital cost, and mortality were compared using chi-square and ANOVA. Multivariable logistic regression was performed to identify specific predictors of cholecystitis treatment.Results: A total of 1,492,877 patients (CCY:n=1,435,255 versus PC:n=57,622) were analyzed. The majority of patients that received PC were at urban teaching hospitals (65.2%). LOS was significantly longer with higher associated costs for PC [(11.1±11.0 versus 4.5±5.3 days; P<0.001) and ($99577±138850 versus $48399±58330; P<0.001)]. Mortality was also increased for patients that received PC compared to CCY (8.8% versus 0.6%; P<0.001). Multivariable regression demonstrated multiple socioeconomic and healthcare-related factors influencing the utilization of PC including male gender, Black or Asian race/ethnicity, Medicare payer status, urban hospital location, and household income (all P<0.001).Conclusion: Although patients receiving PC had higher CCI scores, multiple socioeconomic and healthcare related factors appeared to also influence this treatment decision. Additional studies to investigate these disparities are indicated to improve outcomes for all individuals with this condition. [ABSTRACT FROM AUTHOR]

Background: Current guidelines recommend laparoscopic cholecystectomy be offered for patients with acute cholecystitis except those deemed as high risk. Few studies have examined the impact of frailty on outcomes for patients undergoing laparoscopic cholecystectomy. Therefore, the aim of this study was to determine the association of frailty with postoperative morbidity and mortality in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. Methods: Patients undergoing laparoscopic cholecystectomy for acute cholecystectomy were identified from 2005 to 2010 in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP). The Modified Frailty Index (mFI) was used a surrogate for frailty, and patients were stratified as non-frail (mFI 0), low frailty (mFI 1–2), intermediate frailty (mFI 3–4) and high frailty (mFI ≥ 5). Univariable and multivariable analyses were performed. Receiver operator curves (ROC) and an area under the curve (AUC) were generated to determine accuracy of mFI in predicting postoperative morbidity and mortality. Results: Of the 6898 patients undergoing laparoscopic cholecystectomy, 3245 (47%) patients were non-frail. There were 2913 (42%) patients with low-frailty, 649 (9%) patients with intermediate frailty, and 91 (2%) with high frailty. Clavien IV complications were higher for intermediate frail patients (OR 1.81, 95% CI 1.00–3.28, p = 0.050) and high-frail patients (OR 4.59, 95% CI 1.98–10.7, p < 0.001). Additionally, mortality was higher for patients with intermediate frailty (OR 4.69, 95% CI 1.37–16.0, p = 0.014) and high frailty (OR 12.2, 95% CI 2.67–55.5, p = 0.001). The mFI had excellent accuracy for mortality (AUC = 0.83) and Clavien IV complications (AUC = 0.73). Conclusion: Frailty is associated with postoperative morbidity and mortality in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. [ABSTRACT FROM AUTHOR]

• Acute cholecystitis with empyema and Mirizzi Syndrome mimics both XGC and malignancy. • Subtotal fenestrating cholecystectomy is both safe and effective in these cases. • PTC can be considered over ERCP for first-line pre-operative biliary drainage. Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome (MS) is a complex surgical problem both diagnostically and in terms of management as it mimics both xanthogranulomatous cholecystitis (XGC) and gallbladder carcinoma. A 48-year-old gentleman was referred to us with biliary colic and weight loss with ultrasound findings of gallstones. At subsequent follow-up he became deeply jaundiced with deranged liver function and a CT showing a gallbladder mass and dilated biliary tree. Follow-up MRCP suggested XGC and concomitant MS, but a malignant process could not be excluded. Pre-operative fine needle aspiration cytology (FNAC) at the time of percutaneous biliary drainage for his jaundice demonstrated XGC with no evidence of malignancy. Given the dense inflammation and a tense empyema at laparoscopy, he underwent a subtotal fenestrating cholecystectomy. The final histopathological diagnosis was acute cholecystitis. Our patient likely had unrecognised acute cholecystitis which progressed to a complex mass with empyema and type I Mirizzi Syndrome, ultimately resulting in severe obstructive jaundice mimicking gallbladder carcinoma. Given that a laparoscopic total cholecystectomy is dangerous in these cases of severe inflammation, a laparoscopic subtotal cholecystectomy has been shown to be a safe alternative to more invasive strategies and was successfully utilised in our patient. Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome is a rare manifestation that requires adequate pre-operative work-up to exclude malignancy. Subtotal fenestrating cholecystectomy is a safe and effective alternative to open surgery in these cases of complex inflammation. [ABSTRACT FROM AUTHOR]

Background: White blood cell levels (WBC) is the only biologic determinant criterion of the severity assessment of acute cholecystitis (AC) in the revised Tokyo Guidelines 2018 (TG18). The aims of this study were to evaluate the discriminative powers of common inflammatory markers (neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP)) compared with WBC for the severity of AC, and the risk for conversion to open surgery and to determine their diagnostic cutoff levels.Methods: This was a prospective cohort study. Over 3 years, 556 patients underwent laparoscopic cholecystectomy for AC. Patients were classified into two groups: 139 cases of advanced acute cholecystitis (AAC) (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis), and 417 cases of non-advanced acute cholecystitis (NAAC). Multiple logistic regression and receiver-operating characteristic curve analysis were employed to explore which variables (WBC, CRP, and neutrophil-to-lymphocyte ratio (NLR)) were statistically significant in predicting AAC and conversion to open surgery.Results: On multivariable logistic regression analysis, male gender (OR = 0.4; p = 0.05), diabetes mellitus (OR = 7.8; p = 0.005), 3-4 ASA score (OR = 5.34; p = 0.037), body temperature (OR = 2.65; p = 0.014), and CRP (OR = 1.01; p = 0.0001) were associated independently with AAC. The value of the area under the curve (AUC) of the CRP (0.75) was higher than that of WBC (0.67) and NLR (0.62) for diagnosing AAC. CRP was the only predictive factor of conversion in multivariate analysis (OR = 1.008 [1.003-1.013]. Comparing areas under the receiver operating characteristic curves, it was the CRP that had the highest discriminative power in terms of conversion.Conclusion: CRP is the best inflammatory marker predictive of AAC and of conversion to open surgery. We think that our results would support a multicenter-international study to confirm the findings, and if supported, CRP should be considered as a severity criterion of acute cholecystitis in the next revised version of the Guidelines of Tokyo. [ABSTRACT FROM AUTHOR]

The purpose of this study is to assess the utility of an abdominal and/or pelvic ultrasound (US) performed within 24 h after a negative CT of the abdomen and pelvis (CTAP) in the emergency department (ED). The secondary endpoint is to assess whether there is a significant increase in length of stay (LOS) in the ED due to immediate US reimaging. We reviewed the imaging reports of 335 patients over the course of 3 years in our ED who had an US within 24 h after a negative CTAP. We then assessed type of US and whether the US showed any acute findings. We also evaluated LOS in the ED. Out of 335 patients, there were only three US cases suspicious for acute surgical pathology (3/335 or 0.9%). On 30-day clinical follow-up, only one of the three cases was confirmed as cholecystitis on pathology. The most common non-surgical findings on US not initially reported on CTAP were ovarian cysts (29/83) and gallstones (9/83). Additionally, the LOS for patients who received both a CTAP and US was 119 min longer than patients who only received a CTAP. US abdomen and/or pelvis reimaging within 24 h following a negative CTAP is unlikely to change surgical management in the acute setting. US reimaging can still be useful in diagnosing non-surgical pathology, which could serve to explain the patient's pain. US reimaging after negative CTAP is associated with an average increase in the ED LOS. • Ordering an abdomen and/or pelvic US after a negative CTAP is unlikely to change surgical management in the acute setting. • Length of stay in the ER may be unnecessarily increased in patients who undergo an US after negative CTAP. • Follow up US after negative CTAP may explain a patient's pain (non-surgical) i.e. gallstones or ovarian cysts. [ABSTRACT FROM AUTHOR]

• "Giant" gallbladder development in the context of acute on chronic cholecystitis is extremely rare and may present with atypical symptoms secondary to mass effect. • Current grading systems for acute cholecystitis severity do not include assessment based on size making them insufficient in predicting "giant" gallbladder surgical prognosis. • Laparoscopic cholecystectomy was performed successfully despite the large gallbladder size without intraoperative/postoperative complications. Gallbladder disease is a common surgical pathology. Gallstones can remain asymptomatic or develop into an acute cholecystitis and need for surgical intervention. Significant enlargement of the gallbladder well beyond the normal volume is rare. Such "giant" gallbladders can affect feasibility of subsequent management options. An 80-year-old female presented to the emergency department with a two-day history of acute on chronic gastric reflux with nausea and vomiting. On examination, she had right upper quadrant abdominal pain. CT imaging identified an enormous gallbladder creating mass effect and compression on the distal stomach. She underwent successful laparoscopic cholecystectomy and was discharged from the hospital the next day, doing well. On two-week follow up, her reflux symptoms had completely resolved and she had no complaints. Giant gallbladders are a rare entity. Our patient's case is unique in both its occurrence as well as presentation with predominant reflux symptoms secondary to mass effect by the enlarged gallbladder. Current cholecystitis grading systems do not utilize size as a means of predicting severity and risk of operative complications or difficulty of procedure. Laparoscopic cholecystectomy was a successful approach in managing this extreme pathology. Updated classifications systems that include size and mass effect as a predictive measure are needed to better assess surgical outcomes, especially in "giant" gallbladder disease. Despite the large size and potential mass effect on surrounding structures, laparoscopic cholecystectomy can still be attempted if no other contraindications exist. [ABSTRACT FROM AUTHOR]

• A combination of abdominal signs and symptoms with early warning scores could be used to screen patients needing immediate acute care surgery. • A tailored diagnostic step-up approach based on the hospital's resources is recommended. • Ultrasound and plain X-ray may be important diagnostic tools in remote areas. • The source of infection should be totally controlled as soon as possible. • Laparoscopy can be performed safely in remote areas to manage intra-abdominal infections. Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines. The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020. The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible. The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections. [ABSTRACT FROM AUTHOR]

Background: The optimal timing for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is still controversial. The aim of this study was to assess the outcomes of ELC in patients with delayed presentation.Methods: Retrospective analysis of 381 patients who underwent ELC for ACC between January 2010 and September 2018. Included patients were classified into two groups according to the timing of surgery from the onset of symptoms: group 1 (G1) within the first 7 days and group 2 (G2) beyond 7 days.Results: There were no significant differences regarding conversion rate (G1 8.6% vs. G2 11.8%; p = 0.527), operative time (G1 100 min [75-120] vs. G2 120 min [71-150]; p = 0.060), bile duct injuries (G1 0.3% vs. G2 0%; p = 1), major postoperative complications (G1 11% vs. G2 5.9%; p = 0.557), reoperation rates (G1 1.4% vs. G2 0%; p = 1), length of stay (G1 4 days [3-7] vs. G2 5 days [3-7]; p = 0.539), readmissions (G1 3.7% vs. G2 5.9%; p = 0.633) and costs (G1 6035 € [3693-8330] vs. G2 7243 € [4921-11,336]; p = 0.395).Conclusion: ELC may be considered for patients with ACC who can tolerate surgery with more than 1 week of symptom duration. [ABSTRACT FROM AUTHOR]

Background: Percutaneous transhepatic gallbladder drainage (PTGBD) is an alternative treatment for acute cholecystitis (AC). We aimed to understand the natural course of AC in patients treated with PTGBD but without later definitive treatments, such as laparoscopic cholecystectomy.Methods: This was a retrospective study of the period from June 2010 to December 2016, during which time 2371 patients were diagnosed with AC and 625 received PTGBD treatment. Among the 625 patients, 237 received no definitive treatment. A biliary event after the initial AC episode was the outcome of interest. In addition, the competing risk of death unrelated to biliary causes was present in the cohort. Therefore, a competing risk model was applied for analysis.Results: The cumulative incidence of biliary events was 29.8% with a median of 4.27 months, while the competing event, i.e., death unrelated to a biliary event, was noted in 14.9% of patients with a median 23.54 months. The risk factors of biliary events were prolonged PTGBD indwelling and an abnormal PTGBD cholangiogram. The risk factors of death unrelated to a biliary event included a high Charlson comorbidity index and the initial AC severity.Conclusions: Definitive cholecystectomy is still recommended for patients undergoing PTGBD treatment due to the high incidence of later biliary events. A thorough preoperative evaluation is necessary for those patients before elective cholecystectomy because of the inferior life expectancy and physical status. [ABSTRACT FROM AUTHOR]

Background: Percutaneous cholecystostomy (PCT) is a safe method of gallbladder drainage in the setting of severe or complicated acute cholecystitis (AC), particularly in patients who are high-risk surgical candidates. Small case series suggest that PCT aids resolution of acute cholecystitis in up to 90% of patients. However, reluctance is observed in utilising PCT more frequently, due to concerns that we are committing comorbid patients to an interval surgical procedure for which they may not be suitable.Aim: The aim of this study was to assess the clinical and survival outcomes of PCT use, with particular emphasis on a subgroup of patients who did not proceed to cholecystectomy.Methods: A retrospective analysis was performed of all patients with severe acute cholecystitis who required PCT insertion in a tertiary referral hospital from 2010 to 2015. Patient demographics and clinical data including systemic inflammatory response (SIRS) scores at presentation, readmissions and clinical and survival outcomes were analysed. Statistical analysis was performed using SPSS v.22 and GraphPad Prism v.7.Results: In total, 157 patients (59% males) with AC underwent PCT insertion during the study period. Median age at presentation was 71 years (range 29-94). A median SIRS score of 3 was noted at presentation. Patients required a median of two cholecystostomy tube changes/replacements (range 1-10) during treatment. Transhepatic tube placement was the preferred approach (69%) with 31% of tubes being placed via transabdominal approach. Only 55% proceeded to interval cholecystectomy. Of the 70 patients treated with PCT alone, their median age was 75 years. In this subgroup, only 12.9% (n = 9) developed recurrent biliary sepsis necessitating readmission following initial resolution of symptoms and tube removal. All episodes of recurrent biliary sepsis presented within 6 months of index presentation, and definitive PCT removal in this group was performed at a median of 3 months. No difference in survival was observed between both groups.Conclusion: Almost 90% of patients with AC who are managed definitively with a PCT will recover uneventfully without recurrent sepsis following PCT removal. This is a viable option for older, comorbid patients who are unfit for surgical intervention and is not associated with significantly increased mortality. [ABSTRACT FROM AUTHOR]

• Laparoscopic cholecystostomy is a safe alternative in high-risk acute cholecystitis. • A low-carbohydrate diet with exercise is effective in nonalcoholic steatohepatitis. • Liver fibrosis due to NASH cirrhosis improves with limited sugar intake. Laparoscopic cholecystectomy for patients with acute cholecystitis and liver cirrhosis is associated with increased risk. We present an obese patient with acute cholecystitis and liver cirrhosis caused by nonalcoholic steatohepatitis (NASH), who was successfully managed with laparoscopic cholecystostomy and a low-carbohydrate diet with exercise. A 61-year-old woman presented with right upper quadrant abdominal pain. Ultrasonography and computed tomography were consistent with acute cholecystitis with multiple stones and cirrhosis. The patient had no history of alcohol intake, and serologic tests were negative. The patient's body mass index was 39 kg/m2 (154 cm, 93 kg) and NASH was suspected. Percutaneous transhepatic drainage was impossible because of the anatomic position of the gallbladder. Emergency laparoscopic cholecystostomy was performed initially for drainage. A low-carbohydrate diet and exercise were started for weight loss and her weight reduced by 19 kg over three months. Open cholecystectomy was performed uneventfully, and liver biopsy suggested NASH. Laparoscopic cholecystostomy is a reasonable temporary alternative to cholecystectomy in patients with acute cholecystitis and increased surgical risk. Weight loss with diet and exercise can be effective in patients with NASH. A low-carbohydrate diet is a reasonable treatment for NASH, because glucose is converted to triglycerides and stored as lipid in the liver. Laparoscopic cholecystostomy was effective in this obese patient with acute cholecystitis and NASH cirrhosis. Using a low-carbohydrate diet with exercise, her weight decreased, and subsequent open cholecystectomy was uneventful. [ABSTRACT FROM AUTHOR]

Objectives: Guidelines for antibiotic treatment of acute cholecystitis are based on studies using culture techniques for microbial identification. Microbial culture has well described limitations and more comprehensive data on the microbial spectrum may support adjustments of these recommendations. We used next generation sequencing to conduct a thorough microbiological characterization of bile-samples from patients with moderate and severe acute cholecystitis.Methods: We prospectively included patients with moderate and severe acute cholecystitis, undergoing percutaneous or perioperative drainage of the gall bladder. Bile samples were analyzed using both culture and deep sequencing of bacterial 16S rRNA and rpoB genes and the fungal ITS2-segment. Clinical details were evaluated by medical record review.Results: Thirty-six patients with moderate and severe acute cholecystitis were included. Bile from 31 (86%) of these contained bacteria (29) and/or fungi (5) as determined by sequencing. Culture identified only 40 (38%) of the 106 microbes identified by sequencing. In none of the 15 polymicrobial samples did culture detect all present microbes. Frequently identified bacteria often missed by culture included oral streptococci, anaerobic bacteria, enterococci and Enterobacteriaceae other than Klebsiella spp. and Escherichia coli.Conclusions: Culture techniques display decreased sensitivity for the microbial diagnostics of acute cholecystitis leaving possible pathogens undetected. [ABSTRACT FROM AUTHOR]

Predicting severe acute cholecystitis (SAC) is important because the mortality rate is higher for patients with SAC than for non-SAC (NSAC) patients. We evaluated the predictive value of the delta neutrophil index (DNI), which is greater in patients with infectious and inflammatory conditions, for SAC among patients in the emergency department (ED). This retrospective observational study included 379 consecutive adult patients with AC admitted to the ED from January 2015 to December 2016. The included patients were classified into 2 groups (NSAC and SAC) according to the Tokyo Guidelines 2018. White blood cell (WBC) count, C-reactive protein (CRP) levels, and DNI values were assessed at ED admission. The SAC group contained 28 patients (7.4%). DNI was among the early predictors of SAC and was an inflammatory marker with a significantly higher predictive value than WBC count or CRP level for detecting SAC. The predictive power of DNI was significantly higher than that of CRP when used in conjunction with WBC count, abdominal computed tomography, and clinical variables. DNI measured at ED admission may serve as an early predictor of SAC. [ABSTRACT FROM AUTHOR]

Membranous fat necrosis is a rare histological finding. Despite its low incidence and lack of clinical significance, it can involve various organs. Majority of membranous fat necrosis cases are diagnosed in breast lumps and skin in comparison to intra-abdominal lesions. There has been only one reported case of membranous fat necrosis of gall bladder in literature. A 56-year-old female patient with previous history of diabetes mellitus and hypertension was administered due to abdominal pain and fever. Based on her physical exam, lab data, and ultrasonography, she was diagnosed by cholangitis. After primary care, she went under cholecystectomy. The histological finding of gall bladder revealed crenulated fatty membranes phagocytized by macrophages in Hematoxylin and Eosin (H&E) staining. Moreover, necrosis and giant cells were seen on Sudan black staining. Hence, the diagnosis of membranous fat necrosis in gall bladder was made. Membranous fat necrosis occurs when peripheral blood circulation is compromised. Ischemia of fat tissue cause fatty membranous material accumulation acting as foreign bodies. Hence, it can attract inflammatory response. Regarding pathology, phagocyted membranous by macrophages and giant cells is diagnostic. Sudan black, Luxol fast blue (LFB), long Ziehl-Neelsen, and D-PAS are positive in membranous fat necrosis. Membranous fat necrosis of gall bladder is a rare entity. This is the second reported case of such diagnosis. Nonetheless, further pathological investigations are necessary. • Membranous fat necrosis, gall bladder, acute cholangitis [ABSTRACT FROM AUTHOR]

Objectives: The perforation of the gallbladder (GP) is one of the most significant complications of acute cholecystitis. A biochemical marker indicating the GP has not been determined fully to date. Pentraxin 3 and pro-adrenomedullin (Pro-ADM) proteins are novel acute phase reactants. We aimed to investigate the relationship between serum Pentraxin 3 and Pro-ADM and the GP in patients with acute cholecystitis.Methods: This prospective cross-sectional study was conducted on patients with acute cholecystitis in a tertiary care emergency department during the six-month period. The acute cholecystitis patients were divided into two groups as with GP, and without GP. Additionally, patients with GP were evaluated according to pericholecystic fluid and gallbladder wall thickness. Serum levels of pro-ADM and pentraxin 3, WBC, CRP and sedimentation rate were measured in all patients.Results: A total of 60 patients with acute cholecystitis were included in the study. Pro-ADM and pentraxin 3 levels were significantly higher in patients with GP and the with pericholecystic free fluid (p < 0.0001). There was no significant relationship between serum pentraxin 3 and pro-ADM with gallbladder wall thickness (p > 0.05) According to the ROC analysis, serum Pentraxin 3 levels of ≥4.9 ng/mL could predict GP with a sensitivity of 75% and a specificity of 85% and serum pro-ADM levels of ≥97 nmol/L with sensitivity and specificity of 100% and 95%.Conclusion: Our study results reveal that serum Pentraxin 3 and pro-ADM may be novel biochemical parameters in the detection of GP in acute cholecystitis cases. [ABSTRACT FROM AUTHOR]

• Gallbladder volvulus (GV) is a rare disease with less than 400 cases reported in the English literature. • Preoperative diagnosis is a major challenge with only 4 cases being diagnosed on radiology. • Critical constellation of presenting symptoms and signs along with radiology can help in timely diagnosis of GV. Introduction: Gallbladder volvulus (GV) is a rare disease with less than 400 cases reported in the English literature. The pre-operative diagnosis of GV is difficult as none of the imaging modalities are accurate. Once diagnosed, the mainstay of treatment is emergency surgical derotation and cholecystectomy. Presentation of case: A 83-old lady presented with right upper quadrant pain and fever for 3 days. Abdominal imaging revealed the presence of a distended, floating gallbladder located outside its normal fossa with thickened non-enhancing wall and a twisted pedicle suggestive GV. The patient underwent emergency laparotomy because the laparoscopic approach was refused by the anesthetist due to the history of pulmonary emphysema. Intraoperatively, the gallbladder was found be gangrenous and rotated in anti-clockwise direction around the cystic pedicle. The gallbladder was de-rotated followed by cholecystectomy. Discussion: GV is an uncommon cause for abdominal pain and occurs due to rotation of gall bladder on its mesentery along the axis of the cystic duct and the cystic artery. Pre-operative diagnosis continues to be a major challenge with only 4 cases reported in the literature diagnosed with pre-operative imaging. This case is one of the rare cases diagnosed with pre-operative imaging. It is often misdiagnosed as acute cholecystitis before surgery. However, critical constellation of presenting signs and symptoms along with radiological findings may guide the surgeon to accurate and timely diagnosis of GV before surgical intervention. Conclusion: Although rare, it is important to consider GV as a differential diagnosis in an elderly patient with acute cholecystitis. [ABSTRACT FROM AUTHOR]

Beneficial effects of cholecystectomy in acute cholecystitis (AC) might be weakened by complications. The age-adjusted Charlson Comorbidity Index (CCI) assesses disease relevance in the prediction of one-year mortality. To evaluate whether age-adjusted CCI predicted complications (including surgical complications, intensive care unit [ICU] admission, and in-hospital death) among patients undergoing cholecystectomy for AC. Associations between age-adjusted CCI and the length of hospital stay have been also evaluated. 271 patients were enrolled at Ospedale Policlinico San Martino (Genoa, Italy) between 2005 and 2013. Clinical data and blood samples were collected. Patients' median age was 67 years. They underwent more frequently video-laparoscopic cholecystectomy with a limited rate of conversion to open cholecystectomy. Surgical complications occurred in 23 patients (8.5%). 6 patients (2.2%) needed ICU admission, while death occurred in 4 patients (1.5%). According to the cut-off point identified by ROC curve, an age-adjusted CCI cut-off value of 5 was found predictive for in-hospital complications also when confounders were considered (OR 1.35, 95% CI 1.02–1.79, p = 0.035). No association between adjusted CCI and the length of hospital stay was found. In patients surgically treated for AC, age-adjusted CCI could represent an additional tool, along with available risk scores, to help surgeons in choosing the best therapeutic option. [ABSTRACT FROM AUTHOR]

Abstract Background Severe acute cholecystitis (AC) is defined by the association of organ dysfunction, including hematological dysfunction, with AC. Severe AC is often complicated by disseminated intravascular coagulation (DIC), the diagnostic criteria of which overlap with AC-associated hematological dysfunction. Since the diagnosis of DIC often delays definitive surgical management of severe AC, treatment of DIC in this setting is clinically important. Recombinant human soluble thrombomodulin (rTM) is a new agent that has proven clinically useful for treating DIC. However, the relevance of rTM to sepsis-induced DIC caused by AC has not been clinically evaluated. This retrospective multicenter study aimed to determine the clinical impact of rTM on sepsis-induced DIC caused by AC. Methods This retrospective multicenter study initially included 68 consecutive patients and proceeded between July 2014 and December 2017. The inclusion criterion was sepsis-induced DIC caused by severe AC due to benign disease. Sixteen of the 68 patients were excluded in this study due to having advanced malignant tumors. Finally, 42 patients were enrolled in this study. We treated DIC with AC using Recomodulin® Injection (rTM) at doses of 130 or 380 U/kg/day. Results 17 and 25 patients were treated with and without rTM, respectively. Values on days 3 and 7 did not significantly differ between the groups for PT-INR (P = 0.38 and P = 0.16, respectively) and FDP (P = 0.06 and P = 0.08, respectively), and PLT was significantly increased in the rTM group at day 7 (P = 0.03). Resolution rates of DIC on day 7 were significantly higher in the group treated with, than without rTM (94.1% [16/17] vs. 68.0% [17/25], P = 0.04). Two patients in each group died of sepsis-induced DIC associated with severe AC, and thus mortality rates did not significantly differ. Conclusions rTM can may be improve the resolution rate of sepsis-induced DIC due to severe AC. Future studies should include more patients to validate our findings. Highlights • Recombinant human soluble thrombomodulin (rTM) has been developed as a key drug for disseminated intravascular coagulation (DIC). • This retrospective multicenter study aimed to determine the clinical impact of rTM on sepsis-induced DIC caused by severe acute cholecystitis. • Resolution rates of DIC on day 7 were significantly higher in the group treated with, than without rTM (94.1% [16/17] vs. 68.0% [17/25], P=0.04). • rTM appears to have clinical benefit for sepsis-induced DIC patients with severe acute cholecystitis. [ABSTRACT FROM AUTHOR]

Background: Data comparing outcomes following cholecystectomy and cholecystostomy tube placement (CTP) in elderly patients are lacking. We aimed to compare the post-procedural outcomes between cholecystectomy and CTP in elderly patients with acute cholecystitis.Methods: We performed a retrospective, population-based analysis using the National Inpatient Sample for the period 2000-2014. Patients ≥ 65 years old admitted with a primary diagnosis of acute cholecystitis and who underwent either cholecystectomy or CTP during their hospitalization were included. Multivariable linear and logistic regression models were used to analyze post-procedural complications, mortality, length of stay, and total charges. The effect of procedure type on patient outcomes, stratified by acalculous and calculous cholecystitis, was also performed.Results: A total of 200,915 patients were included, of which 7516 underwent CTP and 193,399 underwent cholecystectomy. The median age of patients undergoing CTP and cholecystectomy was 80 (IQR 73-87) and 75 (IQR 70-81), respectively. Patients undergoing CTP were more likely to have post-procedural infection (OR 2.25; 95% CI 2.07, 2.45), bleeding (OR 1.28; 95% CI 1.19, 1.37), and inpatient mortality (OR 9.27; 95% CI 7.95, 10.81). On average, CTP patients stayed 1.25 days longer (95% CI 1.14, 1.37) in hospital after the procedure. The benefits of cholecystectomy were consistent in patients with acalculous and calculous cholecystitis.Conclusions: Elderly patients with both acalculous and calculous acute cholecystitis managed with CTP have higher incidences of post-procedural morbidity and mortality, and longer post-procedure length of hospital stay, as compared to cholecystectomy. Unless prohibitive surgical risks exist, elderly patients with acute cholecystitis should undergo cholecystectomy. [ABSTRACT FROM AUTHOR]

Highlights • A rapid imaging protocol with defined clinical criteria for acute cholecystitis (AC) resulted in significant improvements in perioperative and quality measures. • Acute on chronic cholecystitis (ACC) may present with typical and/or atypical clinical features of AC, and was the most common pathology found in our specimens for the RIP. • HIDA and CT scan had similar performance for de novo AC. However, diagnostic performance for both studies was reduced in the setting of ACC. • Delayed filling of the gallbladder on HIDA in a patient with high risk features is ACC until proven otherwise, and urgent cholecystectomy should be considered. Abstract Introduction In this study we assess the impact of a "rapid imaging protocol" (RIP) on outcomes in patients with suspected acute cholecystitis (AC). Methods From January 2017 to January 2018, a prospective cohort study was implemented using a RIP with hepatoscintigraphy (HIDA) or CT scan (first available, goal within 4 h) in patients (n = 52) presenting with highly suspected AC and a clinical feature score of ≥1. For the latter, the following presenting features were scored as follows: 1 point for WBC count ≥10,000 (109/L), 1.5 points for glucose ≥140 (mg/dl), and/or 1 point for age ≥50 yrs. The historical control was all patients admitted with suspected AC in a 1.5-year period (n = 117) under our previous "delayed imaging protocol" (DIP), which used US ± HIDA (post-admission) in select patients. Primary end points included: compare outcome and quality measures between the groups, evaluate diagnostic imaging performance for AC, and evaluate our proposed clinical feature score in the setting of AC. Results Histopathologic features consistent with AC was more frequent in patients in the RIP (64% vs 39%, p = 0.008). The pooled positive predictive value of HIDA and CT scan for AC were 85% vs 94%, respectively. The RIP was associated with a significant reduction in time to surgery, length of stay, and conversions to open (p < 0.001, respectively). A clinical feature score of 3.5 predicted the likelihood of AC in 95% of the cases (x2 for linear trend = 42, p < 0.001). Conclusion A protocol centered around rapid identification, defined clinical criteria (i.e. clinical feature score), and confirmation with non-user dependent imaging modalities has resulted in favorable outcomes. CT may be the study of choice when the likelihood of AC is high because it is superior at identifying severity. [ABSTRACT FROM AUTHOR]

• Left-sided gallbladder. • Acute Choleystitis. • Laparoscopic Cholecystectomy. A true left sided gallbladder (T-LSG) is a rare finding mostly discovered incidentally during laparoscopy and often associated with several anatomic anomalies; surgical approach may be challenging with an increased risk of intra-operative injuries and conversion to open. A 76 years old woman presented with acute cholecystitis. The left sided gallbladder was unexpectedly discovered as an intra-operative finding. Laparoscopic cholecystectomy was carried out using our usual trocar set-up without the need of intra-operative cholangiography or conversion to open. LSG is reported to be associated with a higher risk of intraoperative bile duct injuries (up to 7.3%) due to anomalies of the bile duct, portal vein, and other structures. Achieving the Critical View of Safety by opening Calot's triangle is essential to avoid bile duct injuries. Experienced surgeons could safely approach LSG laparoscopically, also in emergency setting, without major changing in their surgical technique with limitation of diathermy use and prudent dissection of anatomical structures to avoid biliary injuries. Intra-operative cholangiography is not mandatory. [ABSTRACT FROM AUTHOR]

We evaluated the diagnostic performance of ultrasonography (US) plus superb microvascular imaging (SMI) compared with conventional US alone for diagnosing acute cholecystitis. We included 54 patients with suspected biliary disease. The SMI pixel count showing flow signal was measured in the region of interest of the gallbladder bed of the liver. Two radiologists independently evaluated imaging features and rated five-point diagnostic likelihood level before versus after the additional SMI using the cutoff SMI pixel count. The SMI pixel count was significantly higher in acute than in non-acute cholecystitis (169.84 vs. 27.48, p < 0.001). The optimal SMI cutoff pixel count for predicting acute cholecystitis obtained by receiver operating characteristic curve was 56.67(82.8% sensitivity, 92.0% specificity). The area under the curve value was significantly higher after the additional SMI than before (0.798-0.863 vs. 0.701-0.736, p < 0.05). US plus SMI could objectively improve diagnostic performance compared with conventional US for acute cholecystitis. [ABSTRACT FROM AUTHOR]

Background: Some authors have proposed different predictive factors of severe acute cholecystitis, but generally, the results of risk analyses are expressed as odds ratios, which makes it difficult to apply in the clinical practice of the acute care surgeon. The severe form of acute cholecystitis should include both gangrenous and phlegmonous cholecystitis, due to their severe clinical course, and cholecystectomy should not be delayed. The aim of this study was to create a nomogram to obtain a graphical tool to compute the probability of having a severe acute cholecystitis.Methods: This is a retrospective study on 393 patients who underwent emergency cholecystectomy between January 2010 and December 2015 at the Acute Care Surgery Service of the S. Anna University Hospital of Ferrara, Italy. Patients were classified as having a non-severe acute cholecystitis or a severe acute cholecystitis (i.e., gangrenous and phlegmonous) based on the final pathology report. The baseline characteristics, pre-operative signs, and abdominal ultrasound (US) findings were assessed with a stepwise multivariate logistic regression analysis to predict the risk of severe acute cholecystitis, and a nomogram was created.Results: Age as a continuous variable, WBC count ≥ 12.4 × 103/μl, CRP ≥9.9 mg/dl, and presence of US thickening of the gallbladder wall were significantly associated with severe acute cholecystitis at final pathology report. A significant interaction between the effect of age and CRP was found. Four risk classes were identified based on the nomogram total points.Conclusions: Patients with a nomogram total point ≥ 74 should be considered at high risk of severe acute cholecystitis (at 74 total point, sensitivity = 78.5%; specificity = 78.2%; accuracy = 78.3%) and this finding could be useful for surgical planning once confirmed in a prospective study comparing the risk score stratification and clinical outcomes. [ABSTRACT FROM AUTHOR]

Summary Background Recent advances in laparoscopic techniques and perioperative care have changed the indications for surgery in elderly patients. Consequently, the willingness to offer early surgery for acute cholecystitis continues to increase. This study aims to assess the perioperative outcome of early cholecystectomy for acute calculous cholecystitis in elderly patients. Patients and methods All consecutive patients treated by early cholecystectomy for acute calculous cholecystitis in a major teaching hospital, between January 2002 and November 2016, were retrospectively analyzed. The outcome of elderly patients (≥ 75 years) was compared to that of all others. Conversion rate, 30 days morbidity, 30 days mortality and length of hospital stay were assessed. Results Early cholecystectomy for acute calculous cholecystitis was performed in 703 patients: 121 (17%) aged ≥ 75 years and 582 (83%) aged < 75 years. Significantly more elderly patients had an ASA score ≥ 3 (37% vs. 8%, P < 0.001). Morbidity was higher in the elderly group (17% vs. 8%, P < 0.004), mainly attributable to the high incidence of cystic stump leakage in this group; a complication that no longer occurred after changing the technique of ligation of the cystic stump. The cardiopulmonary complication rate (4% vs. 3%, P = 0.35) as well as mortality did not significantly differ (3% vs. 1%, P = 0.07). The conversion rate was higher in the elderly group (18% vs. 5%, P < 0.001) and the median postoperative length of hospital stay was longer (5.0 vs. 3.0 days, P < 0.001). Conclusion Early laparoscopic cholecystectomy is a treatment well suited to elderly patients with mild and moderate acute cholecystitis. [ABSTRACT FROM AUTHOR]

Acute cholecystitis is a common cause of hospital admissions and can result in critically ill patients. For those patients not amenable to cholecystectomy, endoscopic drainage via transpapillary cystic duct stenting or transmural drainage offers a temporizing method for urgent gallbladder decompression. Endoscopic ultrasonography (EUS) and the development of novel lumen apposing metal stents can allow for more permanent drainage with comparable outcomes to percutaneous transhepatic catheters. The merits of this approach including the technical and clinical advantages of EUS-guided drainage are discussed further in this review article. [ABSTRACT FROM AUTHOR]

Summary Background The relationship between the severity assessment of acute cholecystitis based on the Tokyo Guidelines and the risk for conversion from laparoscopic surgery to open surgery has been assessed in few previous reports, with conflicting results. Methods A retrospective review of patients with acute cholecystitis within a single system from 2010 to 2013 was performed. The diagnosis and severity of acute cholecystitis were assigned by the Tokyo Guidelines 2013 (TG13). The primary outcome measure was conversion to open cholecystectomy. Results During the period of study, 493 patients were operated by laparoscopy for acute cholecystitis. Laparoscopic cholecystectomy was intraoperatively converted to open surgery in 56 cases (11.4%). The multivariate analysis showed that the risk factors for conversion to open surgery included male gender (OR: 2.15; IC 95% [1.18–3.9]), diabetes (OR: 2.22; IC 95% [1.13–4.33]), total bilirubin levels (OR: 1.02; IC 95% [1–1.05]), and the TG13 severity classification (OR: 4.44; IC 95% [2.25–8.75]). Conclusions The independent risk factors for conversion to open surgery included male sex, diabetes mellitus, total bilirubin level, and TG13 grade. TG13 grade was found to be the most powerful predictive factor for conversion as it had the highest OR. [ABSTRACT FROM AUTHOR]

Introduction: Studies have shown that same-admission laparoscopic cholecystectomy (SALC) is superior to delayed laparoscopic cholecystectomy (DLC) for acute cholecystitis (AC). However, no studies have compared both modalities in patients with delayed presentation. The aim of the study was to compare outcomes between SALC and DLC in AC patients with more than 7-day symptom duration.Methods: A retrospective analysis of 83 AC patients who underwent LC after presenting with >7 days of symptoms from June 2010 to June 2015 was performed. Patients were divided into L-SALC and L-DLC, defined as LC performed within the same admission and between 4 and 24 weeks after discharge, respectively. Peri-operative outcomes were evaluated.Results: In L-SALC patients, the intra-operative severity was higher (p < 0.001) and median operative time was longer (L-SALC, 107 min (46-220) vs L-DLC, 95 mins (25-186)) (p = 0.048). Conversion rates were also higher in L-SALC than that in L-DLC (L-SALC, 21.4% vs L-DLC, 4.9%) (p = 0.048). While post-operative morbidity was similar, L-SALC was associated with a longer post-operative length of stay as compared to L-DLC (L-SALC, 2 (1-17) vs L-DLC, 1 (1-6)) (p < 0.001).Conclusion: DLC provides lower conversion rates and shorter length of stay in AC patients presenting beyond 7 days of symptoms. This group of patients should be offered DLC. [ABSTRACT FROM AUTHOR]

Up-front cholecystectomy is the recommended therapy for acute cholecystitis (AC). However, the scientific basis for the definition of the optimal timing for surgery is scarce. The aim of this study was to analyze how the timing of surgery, after the admission to hospital for AC, affects the intra- and postoperative outcomes. Within the national Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks), all patients undergoing cholecystectomy for acute cholecystitis between January 2006 and December 2014 were identified. Data regarding patient characteristics, intra- and postoperative adverse events (AEs), bile duct injuries, and 30- and 90-day mortality risk were captured, and the correlation between the surgical timing and these parameters was analyzed. In total, data on 87,108 cholecystectomies were analyzed of which 15,760 (18.1 %) were performed due to AC. Bile duct injury, 30- and 90-day mortality risk, and intra- and postoperative AEs were significantly higher if the time from admission to surgery exceeded 4 days. The time course between surgery and complication risks seemed to be optimal if surgery was done within 2 days after hospital admission. Although AC patients operated on the day of hospital admission had a slightly increased AE rate as well as 30- and 90-day mortality rates than those operated during the interval of 1-2 days after admission, the bile duct injury and conversion rates were, in fact, significantly lower. The optimal timing of cholecystectomy for patients with AC seems to be within 2 days after admission. However, the somewhat higher frequency of AE on admission day may emphasize the importance of optimizing the patient before surgery as well as ensuring that adequate surgical resources are available. [ABSTRACT FROM AUTHOR]

• For patients aged ≥ 80 years with moderate to severe acute cholecystitis, the morbidity and mortality rates of cholecystectomy are not high. • Early cholecystectomy (< 6 weeks) and delayed cholecystectomy (≥ 6 weeks) have similar rates in conversion surgery, perioperative complications, and operative mortality. • Early cholecystectomy has lower risks of recurrent acute cholecystitis and further biliary events compared with delayed cholecystectomy. Acute cholecystitis (AC) is a life-threatening infectious/inflammatory disease in older patients. This study aimed to investigate the safety and optimal timing of surgery in patients aged ≥ 80 years with moderate to severe AC who received percutaneous transhepatic gallbladder drainage (PTGBD). From January 2008 to February 2021, 152 patients were retrospectively enrolled. Clinical outcomes were compared among patients who received laparoscopic cholecystectomy (LC), open cholecystectomy (OC), and conversion surgery, and between those who received early (< 6 weeks after PTGBD) and delayed cholecystectomy (≥ 6 weeks after PTGBD). Logistic regression analysis was used to identify risk factors for recurrent AC, further biliary events, conversion, and perioperative complications. Sixty-seven patients underwent LC, 62 underwent OC, and 23 underwent conversion surgery. Operation-related complications and mortality rates did not differ among the types of surgery; however, LC group had shorter operative time than the other groups. Eighty-two patients underwent early cholecystectomy, while 70 underwent delayed cholecystectomy. There were no differences in operative time, operation-related complications, and mortality rates between the groups. However, higher rates of recurrent AC and biliary events were observed in the delayed cholecystectomy group (52.9% vs. 4.9% and 57.1% vs. 8.5%, p < 0.001). On multivariate analysis, delayed cholecystectomy was a significant risk factor for recurrent AC (odds ratio [OR] = 19.42, p < 0.001) and further biliary events (OR = 15.95, p < 0.001). Early cholecystectomy is recommended for patients aged ≥ 80 years with moderate to severe AC following PTGBD. [Display omitted] [ABSTRACT FROM AUTHOR]

Introduction Kyphoscoliosis, which is a deformity of the spine caused by aging and osteoporosis, results in various surgical difficulties for laparoscopic cholecystectomy (LC) due to low-lying costal arches, such as a small abdominal working space, disturbance of the surgical view and decreased controllability of the surgical instrument. Presentation of case We herein report the case of a 92-year old woman with severe kyphoscoliosis who was diagnosed with Grade II acute cholecystitis. Taking her general status into consideration, emergency percutaneous transhepatic gallbladder drainage (PTGBD) was initially performed. After PTGBD, the patient’s physical status and systemic inflammation markedly improved. She then underwent interval LC. The surgical view of the upper abdomen including the gallbladder was entirely interrupted by bilateral low-lying costal arches with adhesion to the greater omentum. To access the gallbladder without interruption by the low-lying costal arch, the first umbilical port was changed to a multi-port with surgical glove and an additional port was added in the left abdomen. Consequently, LC was safely accomplished with the creation of the critical view. Discussion A low-lying costal arch due to kyphoscoliosis can prevent surgeons from accessing the gallbladder. LC with the standard 4-port method could not be accomplished because of insufficient lifting of the low-lying costal arch. Devised placement of the ports is needed to access the gallbladder between bilateral low-lying costal arches. Conclusion A transumbilical multi-port and left abdominal port may be effective for successful LC of acute cholecystitis with kyphoscoliosis. [ABSTRACT FROM AUTHOR]

Gastrointestinal complications secondary to fish bone ingestion are rare, however important to recognize in timely manner to prevent morbidity and mortality. Diagnosis is often challenging in setting of non-specific and variable symptoms and lack of history of fish bone ingestion. Diagnostic imaging particularly computed tomography is crucial for diagnosis. However, emphasis should be given on identifying underlying cause of abdominal complications because fish bone is often missed unless specifically looked for. Identification of fish bone is essential for extraction of the inciting nidus. Emergency physician should be aware of this entity to identify it and triage the patients in timely manner. We describe here cases of sub-capsular liver abscess and acute cholecystitis caused by fish bone ingestion. The fish bone as a cause of these complication was initially missed in emergency. [ABSTRACT FROM AUTHOR]

Background: Hemorrhagic cholecystitis is a rare complication of acute cholecystitis and is a potentially fatal diagnosis. It may be difficult to detect because the symptoms are similar to more common diagnoses. Point-of-care ultrasound is a useful imaging technique in the emergency setting and is readily available to allow for immediate interpretation and application of the results to guide medical decision making.Case Report: We report a 76-year-old man with a history of hypertension, hyperlipidemia, diabetes, atrial fibrillation on warfarin, and coronary artery disease presenting with epigastric pain radiating to the back, nausea, and vomiting who was found to have hemorrhagic cholecystitis with gallbladder perforation. Ultrasound of the abdominal right upper quadrant showed a large, hyperechoic, nonshadowing, globular structure visualized within the lumen of the gallbladder extending from the neck through the body. The gallbladder wall was noted to be 0.72 cm with wall edema, focal pericholecystic fluid, and a positive sonographic Murphy sign suggestive of acute cholecystitis. The abnormal appearance of the gallbladder contents was suspected to be blood. Computed tomography angiography was performed and confirmed the diagnosis of acute hemorrhagic cholecystitis with perforation. Blood was noted to track from the cystic duct to the gallbladder lumen. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is a unique case of hemorrhagic cholecystitis visualized on bedside ultrasound. This case shows that the use of point-of-care ultrasound by emergency medicine providers can facilitate the rapid recognition and treatment of specific, life-threatening hepatobiliary pathology while excluding alternate diagnoses. [ABSTRACT FROM AUTHOR]