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Introduction: Rates of subtotal cholecystectomy (STC) are increasing in response to challenging cases of laparoscopic cholecystectomy (LC) to avoid bile duct injury, yet are associated with significant morbidity. The present study identifies risk factors for STC and both derives and validates a risk model for STC. Methods: LC performed for all biliary pathology across three general surgical units were included (2015–2020). Clinicopathological, intraoperative and post-operative details were reported. Backward stepwise multivariable regression was performed to derive the most parsimonious predictive model for STC. Bootstrapping was performed for internal validation and patients were categorised into risk groups. Results: Overall, 2768 patients underwent LC (median age, 53 years; median ASA, 2; median BMI, 29.7 kg/m2), including 99 cases (3.6%) of STC. Post-operatively following STC, there were bile leaks in 29.3%, collections in 19.2% and retained stones in 10.1% of patients. Post-operative intervention was performed in 29.3%, including ERCP (22.2%), laparoscopy (5.0%) and laparotomy (3.0%). The following variables were positive predictors of STC and were included in the final model: age > 60 years, male sex, diabetes mellitus, acute cholecystitis (AC), increased severity of AC (CRP > 90 mg/L), ≥ 3 biliary admissions, pre-operative ERCP with/without stent, pre-operative cholecystostomy and emergency LC (AUC = 0.84). Low, medium and high-risk groups had a STC rate of 0.8%, 3.9% and 24.5%, respectively. Discussion: The present study determines the morbidity of STC and identifies high-risk features associated with STC. A risk model for STC is derived and internally validated to help surgeons identify high-risk patients and both improve pre-operative decision-making and patient counselling. [ABSTRACT FROM AUTHOR]

Objectives: Some patients undergo both computed tomography (CT) and ultrasound (US) sequentially as part of the same evaluation for acute cholecystitis (AC). Our goal was to perform a systematic review and meta-analysis comparing the diagnostic performance of US and CT in the diagnosis of AC. Materials and methods: Databases were searched for relevant published studies through November 2023. The primary objective was to compare the head-to-head performance of US and CT using surgical intervention or clinical follow-up as the reference standard. For the secondary analysis, all individual US and CT studies were analyzed. The pooled sensitivities, specificities, and areas under the curve (AUCs) were determined along with 95% confidence intervals (CIs). The prevalence of imaging findings was also evaluated. Results: Sixty-four studies met the inclusion criteria. In the primary analysis of head-to-head studies (n = 5), CT had a pooled sensitivity of 83.9% (95% CI, 78.4–88.2%) versus 79.0% (95% CI, 68.8–86.6%) of US (p = 0.44). The pooled specificity of CT was 94% (95% CI, 82.0–98.0%) versus 93.6% (95% CI, 79.4–98.2%) of US (p = 0.85). The concordance of positive or negative test between both modalities was 82.3% (95% CI, 72.1–89.4%). US and CT led to a positive change in management in only 4 to 8% of cases, respectively, when ordered sequentially after the other test. Conclusion: The diagnostic performance of CT is comparable to US for the diagnosis of acute cholecystitis, with a high rate of concordance between the two modalities. Clinical relevance statement: A subsequent US after a positive or negative CT for suspected acute cholecystitis may be unnecessary in most cases. Key Points: When there is clinical suspicion of acute cholecystitis, patients will often undergo both CT and US. CT has similar sensitivity and specificity compared to US for the diagnosis of acute cholecystitis. The concordance rate between CT and US for the diagnosis of acute cholecystitis is 82.3%. [ABSTRACT FROM AUTHOR]

Purpose: After the Tokyo 2018 guidelines (TG2018) were published, evidence from the 2018 CHOCOLATE RCT supported early cholecystectomy for acute cholecystitis (AC), even in high-risk patients. This study aims to investigate AC management at our tertiary care center in the years following these publications. Methods: A retrospective cohort study was performed on patients admitted from 2018 to 2023. AC severity was graded using TG2018 definitions. Comorbidities were summarized using Charlson Comorbidity Index (CCI) and frailty using the 5-item modified Frailty Index (5mFI). Compliance with TG2018 recommendations for management strategy was investigated. Outcomes were compared between patients who underwent surgery versus non-operative management (NOM). Subset analysis based on patients' age, frailty, and comorbidities was performed. Results: Among 642 AC patients, 57% underwent cholecystectomy and 43% NOM (22% percutaneous cholecystostomy, 21% antibiotics only). NOM patients had greater length of stay (LOS), complications, deaths, readmissions, and discharge to nursing/rehab versus surgery patients. In 70% of patients managed non-operatively, TG2018 were not followed. Patients managed non-operatively despite TG2018 were more likely to undergo delayed cholecystectomy compared to those in whom guidelines were followed (17% vs. 4%). In subset analysis, healthy octogenarians were significantly less likely to be managed according to TG2018 (9.4%); patients undergoing surgery had a trend towards shorter LOS (3.1 vs. 4.8 days) than those managed non-operatively but no difference in other outcomes. Conclusion: Most patients undergoing NOM could potentially undergo cholecystectomy if guidelines are considered. A more objective approach to risk assessment may optimize patient selection and outcomes. [ABSTRACT FROM AUTHOR]

Background: Patients with acute cholecystitis (AC) presenting with unfavorable systemic or local conditions are often managed with percutaneous cholecystostomy (PC) as a temporary measure. The clinical outcomes of interval cholecystectomy following PC remain unclear. The aim of the study was to identify the association between the timing of cholecystectomy following PC for AC and perioperative complication rates at interval cholecystectomy. We hypothesized that there would be a specific time interval to cholecystectomy associated with lower risk for adverse events. Methods: This was a retrospective (2018–2020) multicenter study at 8 participating hospital systems of adult patients with AC, managed with PC and interval cholecystectomy. Demographics, comorbidities, treatment details, and outcomes were examined. Patients were grouped based on quartiles for timing of surgery after PC (< 7, 7–9, 10–13, > 13 weeks). The primary outcome was a composite endpoint of bile duct injury, reoperation, readmission, image-guided intervention, endoscopic intervention, conversion to open surgery, or death. Results: There were 188 patients with a median age of 66 years with AC classified as mild (41%), moderate (47%), and severe (12%). Median days from PC to surgery were 65 (Q1 = 48, Q3 = 91). Laparoscopic cholecystectomy (89.9%) was the most commonly planned approach (robotic 6.4%, 3.7% open) and 28 (14.9%) were converted to open. The composite endpoint was reported in 51 patients (27.1%). A biliary injury occurred in 7 (3.7%) patients. Time to surgery and intraoperative drain placement were independently associated with the composite outcome. Cholecystectomy within 7 weeks of PC was associated with decreased risk (OR = 0.36, 95% CI 0.13–0.97) of the composite endpoint, compared to patients undergoing surgery > 13 weeks after PC. Conclusion: Timing of surgery following PC was associated with procedural outcomes. Patients undergoing surgery before 7 weeks experienced significantly less morbidity than patients having delayed cholecystectomy. These results should be considered in patient selection and management after PC. [ABSTRACT FROM AUTHOR]

Background: Gallbladder cysts are rare diseases with very few reported cases, and no clinical or histological definition has been established. Furthermore, cases of giant cysts outside the gallbladder wall are extremely rare. We report a rare case of giant gallbladder cyst with acute cholecystitis. Case presentation: An 85-year-old woman with appetite loss and right lower abdominal pain lasting 2 days presented to our hospital. At first, the patient's abdominal pain was mild to moderate with no fever. Blood tests revealed a white blood cell count of 10,950/mm3, and the C-reactive protein (CRP) level was 14.35 mg/dl. A contrast-enhanced computed tomography (CT) scan of the abdomen revealed a grossly distended gallbladder (14.5 × 14.5 × 8.7 cm) with an incarcerated stone in the cystic duct. The patient was treated by percutaneous transhepatic gallbladder drainage (PTGBD) with 735 ml of drainage fluid. Oral contrast magnetic resonance cholangiopancreatography (MRCP) revealed that gallbladder swelling remained (14.0 × 6.5 cm) 3 days after PTGBD. We performed laparoscopic cholecystectomy 6 days after PTGBD. Because of the severe adhesion around the junction of the cystic and common bile ducts, we performed open cholecystectomy. The resected specimen was 14 × 11 cm in size and consisted of a gallbladder (6 × 7 cm) with a stone (2.4 × 1.8 cm) in the gallbladder and a large cystic lesion (18 × 18 cm) outside the gallbladder wall. The cystic lesion had a wall thickness of 6 to 12 mm and internal septal structures and contained hemorrhagic and necrotic tissue. Histological examination revealed that the specimens showed a mildly swollen gallbladder and a cystic lesion on the outside of the gallbladder wall, adjacent to the gallbladder wall, with wall thickening and inflammation. The cystic lesion suggested gallbladder duplication, gallbladder diverticulum or extension of the Rokitansky-Aschoff sinus (RAS). There was no malignancy. The patient's postoperative course was uneventful, and she was discharged 5 days after the operation. Conclusion: We present a very rare case of giant gallbladder cyst with acute cholecystitis revealed by cholecystectomy. [ABSTRACT FROM AUTHOR]

Postoperative delirium (POD) is one of the most common complications of surgery. This study aimed to identify the risk factors for POD in patients undergoing cholecystectomy for acute cholecystitis. This retrospective study included 77 patients who underwent cholecystectomy for acute cholecystitis between January 2015, and December 2020. Multiple logistic regression analysis was used to identify the factors associated with the development of delirium as the primary endpoint. Patients were divided into POD (n = 18) and non-POD (n = 59) groups and their demographic features and clinical results were compared. A significant model associated with delirium onset was predicted (Nagelkerke’s R2 = 0.382), and the significantly correlated factors were C-reactive protein/albumin ratio (CAR), Subjective Global Assessment (SGA) score, and history of psychiatric disease. The predictive value of CAR for POD was evaluated using ROC analysis; the area under the curve of CAR was 0.731, with a cutoff value of 3.69. CAR, SGA score, and a history of psychiatric disease were identified as factors associated with the development of POD in patients with acute cholecystitis. In particular, the new preoperative evaluation of CAR may be beneficial as an assessment measure of the risk factor for the development of POD. [ABSTRACT FROM AUTHOR]

Background: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) offers a safe and minimally invasive alternative for percutaneous cholecystostomy (PCC) in acute cholecystitis patients with high-surgical risk. Additionally, EUS-GBD serves as a rescue biliary drainage in malignant distal biliary obstruction. Despite its widespread application, data within the Indian context remains sparse. This study aims to report the outcomes of EUS-GBD through the first multi-center study from India. Methods: We retrospectively analyzed patients undergoing EUS-GBD at six tertiary care centers of India from March 2022 to November 2023. EUS-GBD was performed by free hand or over-the-guidewire technique with lumen-apposing metal stent (LAMS) or large caliber metal stent (LCMS). The primary outcome was technical success (defined as successful deployment of stent between gallbladder and stomach/duodenal lumen). The secondary outcomes were clinical success (defined as resolution of symptoms of acute cholecystitis and more than > 50% reduction in bilirubin level within two weeks in distal biliary obstruction), adverse event rate, 30-day mortality rate and 90-day reintervention rate. Results: Total 29 patients (mean age 65.86 ± 12.91, 11 female) underwent EUS-GBD. The indication for EUS-GBD were acute cholecystitis (79.31%) and rescue biliary drainage for malignant distal biliary obstruction (20.69%). LAMS was deployed in 92.86%, predominantly by free-hand technique (78.57%). Technical and clinical success rates were 96.55% and 82.75%, respectively. Adverse events occurred in 27.59% patients, with severe adverse events (bile leak and bleeding) being uncommon (10%). Both 30-day mortality rate and 90-day reintervention rate were 13.79% in patients. Cholecysto-duodenal fistula facilitated cholecystoscopic intervention and stone removal in one patient and transgastric EUS-GBD did not hamper bilio-enteric anastomosis during Whipple surgery in two patients. Conclusion: EUS-GBD is a safe and effective technique for managing acute cholecystitis in high-risk patients and for biliary drainage in cases with malignant distal biliary obstruction. [ABSTRACT FROM AUTHOR]

Background: A critical view of safety (CVS) is important to ensure safe laparoscopic cholecystectomy. When the CVS is not possible, subtotal cholecystectomy is performed. While considering subtotal cholecystectomy, surgeons are often concerned about preventing bile leakage from the cystic ducts. The two main types of subtotal cholecystectomy for acute cholecystitis are fenestrating and reconstituting. Previously, there were no selection criteria for these two; therefore, open conversion was performed. This study aimed to evaluate our goal-oriented approach to choose fenestrating or reconstituting subtotal cholecystectomy for acute cholecystitis. Methods: We introduced our goal-oriented approach in April 2019. Before introducing this approach, laparoscopic cholecystectomy for acute cholecystitis was performed without criteria for subtotal cholecystectomy. After our approach was introduced, laparoscopic cholecystectomy for acute cholecystitis was performed according to the subtotal cholecystectomy criteria. We retrospectively reviewed the medical records of patients who underwent laparoscopic cholecystectomy for acute cholecystitis between 2015 and 2021. Laparoscopic cholecystectomy for acute cholecystitis was performed by surgeons regardless of whether they were novices or veterans. Results: The period from April 2015 to March 2019 was before the introduction (BI) of our approach, the period from April 2019 to December 2021 was after the introduction (AI) of our approach. There were 177 and 186 patients with acute cholecystitis during the BI and AI periods, respectively. There were no significant differences between groups in terms of preoperative characteristics, operative time, and blood loss. No difference in the laparoscopic subtotal cholecystectomy rate between groups (10.2% [BI] vs. 13.9% [AI]; p = 0.266) was obserbed. The open conversion rate during the BI period was significantly higher than that during the AI period (7.4% vs. 1.6%; p = 0.015). Conclusions: Our goal-oriented approach is feasible, safe, and easy for many surgeons to understand. [ABSTRACT FROM AUTHOR]

Purpose: To formulate and evaluate the diagnostic performance and utility of a new CT difficulty score in predicting difficult laparoscopic surgery in cases of gallbladder (GB) perforation. Methods: This prospective single centre study included a total of 48 diagnosed cases of GB perforation on CT between December 2021 and June 2023, out of which 24 patients were operated. A new 6-point CT difficulty scoring system was devised to predict difficult laparoscopic approach, based on patterns of inflammation around the perforated GB that were found to be surgically relevant. The pre-operative imaging findings on CT were studied in detail and correlation coefficients of various imaging findings were calculated to predict difficult surgery. Results: On CECT, the type of perforation, according to the revised Niemeier's classification could be exactly delineated in all 48 patients. A CT difficulty score of ≥ 3 was found to a good predictor difficult laparoscopic approach, with statistical significance (p = 0.001), sensitivity of 94.44%, specificity of 83.33%, PPV of 94.44% and NPV of 83.33%. Inflammatory changes around duodenum showed maximum correlation coefficient of 0.744 (p = 0.0001), around colon showed a correlation coefficient of 0.657 (p = 0.0005), and in the omentum had a correlation coefficient of 0.5 (p = 0.013)). Inter-observer agreement was also calculated for various findings and it was found to have moderate to strong agreement (κ value 0.5–1.0). Conclusion: The CT difficulty scoring system can be an effective tool in predicting difficult laparoscopic surgery in cases of GB perforation in an emergency setting which can help in decision making and improved patient outcome. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to investigate the efficacy of percutaneous cholecystostomy (PC) in the geriatric patients with acute cholecystitis. Materials and methods: The records of geriatric patients with high surgical risk who underwent percutaneous cholecystostomy for acute cholecystitis were reviewed retrospectively. Results: The median age of 134 patients who underwent percutaneous cholecystostomy was 77 (65–98) years and 63.4% were women. The mean length of hospital stay was 5 (4–18) days, and the follow-up period until the procedure was 2 (1–6) days. Murphy's sign was positive in 79.1% of patients on physical examination, and the remaining patients (20.9%) had only tenderness on examination. As USG findings, 59.0% of the patients had a gall bladder wall thickness (> 4 mm) with pericholecystic fluid. Additional imaging method, abdominal CT, was performed in 29 patients (21.6%), MRCP was performed in three patients (2.2%), and ERCP was performed in one patient (0.7%). Bacterial growth was detected in 27.6% of the bile cultures performed. During the follow-up period, laparoscopic cholecystectomy was performed in 60.4% of the patients and open cholecystectomy was performed in 5.2% of the patients electively. 34.3% of the patients did not undergo any surgery. Bile leakage was detected in two patients (1.5%) as a procedure-related complication, and no mortality was observed. Conclusion: Abdominal ultrasonography-guided PC is a safe and effective method in the management of acute cholecystitis in high-risk patients in the geriatric age group. [ABSTRACT FROM AUTHOR]

Purpose: This study investigates the efficacy of erector spinae plane block (ESPB) for managing perioperative and postoperative pain in patients undergoing percutaneous cholecystostomy (PC) for acute cholecystitis, particularly in high-risk elderly patients with extensive comorbidities and limited functional status. Methods: In a retrospective single-center study, 58 high-risk patients scheduled for PC were assessed. ESPB was administered to 23 patients, while 22 received conscious sedation. Pain intensity was measured using the numeric rating scale before any analgesic or ESPB administration, during the procedure and at 1 and 12 h post-procedure and secondary outcomes included adverse effects and additional analgesic requirements. Results: The ESPB group experienced significant pain reduction during and post-procedure compared to the conscious sedation group (p = 0.002). Procedure times were shorter (p = 0.015), and postoperative tramadol was less frequently needed in the ESPB group (p = 0.007). The incidence of nausea was also lower in the ESPB group (p = 0.001). No ESPB-related complications were reported. Conclusion: ESPB significantly alleviates perioperative and postoperative pain in PC patients, reducing additional analgesic use and side effects. It holds promise as a key component of pain management for high-risk surgical patients. Level of Evidence: Level 3, Non-randomized controlled cohort/follow-up study. [ABSTRACT FROM AUTHOR]

Purpose: To analyze if, after implementation of an evidence-based local multidisciplinary protocol for acute cholecystitis (AC), an intermediate surgical audit could improve early cholecystectomy (EC) rate and other therapeutic indicators. Methods: Longitudinal cohort study at a tertiary center. The local protocol, promoted, created, and periodically revised by the Acute Care Surgery Unit (ACSu) was updated and approved on March 2019. A specific registry was prospectively fulfilled with demographics, comorbidity, type of presentation, diagnostic items, therapeutic decision, and clinical course, considering both non-operative management (NOM) or cholecystectomy, early and delayed (EC and DC). Phase 1: April 2019–April 2021. A critical analysis and a surgical audit with the participation of all the involved Departments were then performed, especially focusing on improving global EC rate, considered primary outcome. Phase 2: May 2021–May 2023. Software SPSS 23.0 was used to compare data between phases. Results: Initial EC rate was significantly higher on Phase 2 (39.3%vs52.5%, p < 0.004), as a significantly inferior rate of patients were initially bailed out from EC to NOM because of comorbidity (14.4%vs8%, p < 0.02) and grade II with severe inflammatory signs (7%vs3%, p < 0.04). A higher percentage of patients was recovered for EC after an initial decision of NOM on Phase 2, but without reaching statistical significance (21.8%vs29.2%, n.s.). Global EC rate significantly increased between phases (52.5%vs66.3%, p < 0.002) without increasing morbidity and mortality. A significant minor percentage of elective cholecystectomies after AC episodes had to be performed on Phase 2 (14%vs6.7%, p < 0.009). Complex EC and those indicated after readmission or NOM failure were usually performed by the ACSu staff. Conclusion: To adequately follow up the implementation of a local protocol for AC healthcare, registering and periodically analyzing data allow to perform intermediate surgical audits, useful to improve therapeutic indicators, especially EC rate. AC constitutes an ideal model to work with an ACSu. [ABSTRACT FROM AUTHOR]

Background: Preoperative diagnosis of gallbladder amyloidosis is usually difficult. In our case, the patient exhibited gallbladder dyskinesia, which led us to suspect cholecystic amyloidosis. We were able to safely perform surgery before cholecystitis onset. Case presentation: A 59-year-old male patient with a history of multiple myeloma and cardiac amyloidosis presented to our hospital with a chief complaint of epicardial pain. Abdominal ultrasonography and computed tomography revealed an enlarged gallbladder and biliary sludge without any specific imaging findings of cholecystitis. After percutaneous transhepatic gallbladder aspiration (PTGBA), the patient experienced recurrent bile retention and right upper quadrant pain. Flopropione was effective in relieving these symptoms. Based on his symptoms and laboratory findings, we diagnosed the patient with dyskinesia of the gallbladder. Considering his medical history, we suspected that it was caused by amyloidosis of the gallbladder. A laparoscopic cholecystectomy was performed. The histopathological examination showed amyloid deposits in the gallbladder mucosa, from the intrinsic layer to the submucosa, and in the peripheral nerves of the gallbladder neck. The patient was discharged on postoperative day 5 and has had no recurrence of abdominal pain since then. Conclusion: In our case, gallbladder dyskinesia symptoms led us to suspect gallbladder amyloidosis. We safely surgically treated the patient before cholecystitis onset. [ABSTRACT FROM AUTHOR]

Dealing with acute cholecystitis in high-risk, critically ill, and unfit-for-surgery patients is frequent during daily practice and requires complex management. Several procedures exist to postpone and/or prevent surgical intervention in those patients who temporarily or definitively cannot undergo surgery. After a systematic review of the literature, an expert panel from the Italian Society of Emergency Surgery and Trauma (SICUT) discussed the different issues and statements in subsequent rounds. The final version of the statements was discussed during the annual meeting in Rome (September 2022). The present paper presents the definitive conclusions of the discussion. Fifteen statements based on the literature evidence were provided. The statements gave precise indications regarding the decisional process and the management of patients who cannot temporarily or definitively undergo cholecystectomy for acute cholecystitis. Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients should be multidisciplinary. The different gallbladder drainage methods must be tailored according to each patient and based on the expertise of the hospital. Percutaneous gallbladder drainage is recommended as the first choice as a bridge to surgery or in severely physiologically deranged patients. Endoscopic gallbladder drainage (cholecystoduodenostomy and cholecystogastrostomy) is suggested as a second-line alternative especially as a definitive procedure for those patients not amenable to surgical management. Trans-papillary gallbladder drainage is the last option to be reserved only to those unfit for other techniques. Delayed laparoscopic cholecystectomy in patients with percutaneous gallbladder drainage is suggested in all those patients recovering from the conditions that previously discouraged surgical intervention after at least 6 weeks from the gallbladder drainage. [ABSTRACT FROM AUTHOR]

Percutaneous cholecystostomy (PC) is often preferred over early cholecystectomy (EC) for elderly patients presenting with acute cholecystitis (AC). However, there is a lack of solid data on this issue. Following the PRISMA guidelines, we searched the Medline and Web of Science databases for reports published before December 2022. Studies that assessed elderly patients (aged 65 years and older) with AC treated using PC, in comparison with those treated with EC, were included. Outcomes analyzed were perioperative outcomes and readmissions. The literature search yielded 3279 records, from which 7 papers (1208 patients) met the inclusion criteria. No clinical trials were identified. Patients undergoing PC comprised a higher percentage of cases with ASA III or IV status (OR 3.49, 95%CI 1.59–7.69, p = 0.009) and individuals with moderate to severe AC (OR 1.78, 95%CI 1.00–3.16, p = 0.05). No significant differences were observed in terms of mortality and morbidity. However, patients in the PC groups exhibited a higher rate of readmissions (OR 3.77, 95%CI 2.35–6.05, p < 0.001) and a greater incidence of persistent or recurrent gallstone disease (OR 12.60, 95%CI 3.09–51.38, p < 0.001). Elderly patients selected for PC, displayed greater frailty and more severe AC, but did not exhibit increased post-interventional morbidity and mortality compared to those undergoing EC. Despite their inferior life expectancy, they still presented a greater likelihood of persistent or recurrent disease compared to the control group. [ABSTRACT FROM AUTHOR]

Gallstone-related disease comprises a spectrum of conditions resulting from biliary stone formation, leading to obstruction and inflammatory complications. These can significantly impact patient quality of life and carry high morbidity if not accurately detected. Appropriate imaging is essential for evaluating the extent of gallstone disease and assuring appropriate clinical management. Magnetic Resonance Imaging (MRI) techniques (including Magnetic Resonance Cholangiopancreatography (MRCP) are increasingly used for diagnosis of gallstone disease and its complications and provide high contrast resolution and facilitate tissue-level assessment of gallstone disease processes. In this review we seek to delve deep into the spectrum of MR imaging in diagnose of gallstone-related disease within the gallbladder and complications related to migration of the gallstones to the gall bladder neck or cystic duct, common hepatic duct or bile duct (choledocholithiasis) and beyond, including gallstone pancreatitis, gallstone ileus, Bouveret syndrome, and dropped gallstones, by offering key examples from our practice. Furthermore, we will specifically highlight the crucial role of MRI and MRCP for enhancing diagnostic accuracy and improving patient outcomes in gallstone-related disease and showcase relevant surgical pathology specimens of various gallstone related complications. [ABSTRACT FROM AUTHOR]

The main purpose of this study is to explore the outcomes of patients found to have gallbladder cancer during investigation and diagnosis of acute cholecystitis. The incidence of primary gallbladder cancer co-existing in acute cholecystitis is not well defined in the literature, with anecdotal reports suggesting that they experience worse outcomes than patients with gallbladder cancer found incidentally. Methods: A retrospective review of all patients with gallbladder cancer managed at the Canberra Health Service between 1998 and May 2022 were identified and reviewed. Results: A total of 65 patients were diagnosed with primary gallbladder cancer during the study period with a mean age of 70.4 years (SD 11.4, range 59–81.8 years) and a female preponderance (74% versus 26%) with a ratio of 2.8. Twenty (31%) patients presented with acute calculus cholecystitis and were found to have a primary gallbladder cancer. This group of patients were older and predominantly female, but the difference was not statistically significant. The overall 5-year survival in the cohort was 20% (stage 1 63%, stage 2 23%, stage 3 16%, and stage 4 0%). There was no statistically significant difference in survival between those who presented with acute cholecystitis vs other presentations. Conclusions: A third of the patients with gallbladder cancer presented with acute cholecystitis. There was no statistically significant difference in survival in those with bile spillage during cholecystectomy as well those presenting with acute cholecystitis. [ABSTRACT FROM AUTHOR]

Background: Acute cholecystitis is a significant adverse event after self-expandable metal stent (SEMS) placement for malignant biliary obstruction (MBO); however, no appropriate treatment strategy has been established for its management. Aims: This study aimed to examine the feasibility and utility of endoscopic ultrasound-guided naso-gallbladder drainage (EUS-NGBD) for the management of acute cholecystitis occurring after SEMS placement. Methods: This retrospective study investigated consecutive patients with acute cholecystitis after SEMS placement for unresectable MBO, in whom EUS-NGBD was attempted. The study outcomes included technical success, clinical success, procedure time, adverse event, and cholecystitis recurrence, associated with the procedure. Results: During the study period, EUS-NGBD was performed for SEMS-related acute cholecystitis in 30 patients with MBO. The technical and clinical success rates were 96.7% (29/30) and 96.6% (28/29), respectively. The median procedure time was 15 min, and rate of procedure-related adverse event was 3.3% (1/30). The median duration from the procedure to tube removal was 9 days. No adverse events were observed after removal. The median hospitalization duration after the procedure was 14 days, and the median duration to the (re-)start of chemotherapy from cholecystitis onset was 13 days. The median overall survival after EUS-NGBD was 123 days, and the rate of cholecystitis recurrence until death was 4.2% (1/28). Conclusions: This study demonstrated that EUS-NGBD possesses good technical and clinical feasibility with an acceptable adverse event rates and short hospitalization and chemotherapy withdrawal period. Therefore, EUS-NGBD may be a good option for the treatment of SEMS-related cholecystitis in patients with MBO. [ABSTRACT FROM AUTHOR]

Background: Existing guidelines for predicting common bile duct stones (CBDS) are not specific for acute calculous cholecystitis (ACC). This paper is a posthoc analysis of the S.P.Ri.M.A.C.C study aiming to prospectively validate on a large independent cohort of patients the Israeli Score (IS) in predicting CBDS in patients with ACC. Methods: The S.P.Ri.M.A.C.C. study is an observational multicenter prospective study endorsed by the World Society of Emergency Surgery (WSES). Between September 1st, 2021, and September 1st, 2022, 1201 participants were included. The Chi-Square test was used to compare categorical data. A Cochran-Armitage test was run to determine whether a linear trend existed between the IS and the presence of CBDS. To assess the accuracy of the prediction model, the receiver operating characteristic (ROC) curve was generated, and the area under the ROC curve (AUC) was calculated. Logistic regression was run to obtain Odds Ratio (OR). A two-tailed p < 0.05 was considered statistically significant. Results: The rate of CBDS was 1.8% in patients with an IS of 0, 4.2% in patients with an IS of 1, 24.5% in patients with 2 and 56.3% in patients with 3 (p < 0.001). The Cochran-Armitage test of trend showed a statistically significant linear trend, p < 0.001. Patients with an IS of 3 had 64.4 times (95% CI 24.8–166.9) higher odds of having associated CBDS than patients with an IS of 0. The AUC of the ROC curve of IS for the prediction of CBDS was 0.809 (95% CI 0.752–0.865, p < 0.001). By applying the highest cut-off point (3), the specificity reached 99%, while using the lowest cut-off value (0), the sensitivity reached 100%. Conclusion: The IS is a reliable tool to predict CBDS associated with ACC. The algorithm derived from the IS could optimize the management of patients with ACC. [ABSTRACT FROM AUTHOR]

Background: Acute cholecystitis (AC) is one of the most prevalent diseases in clinical practice. Poor surgical candidates may benefit from early percutaneous cholecystostomy (PC) drainage followed by interval cholecystectomy (IC), which is the definitive treatment. The optimal timing between the PC drainage and the IC has not been identified. This study aimed to investigate how the duration between PC and IC affects perioperative outcomes and identify the optimal IC timing to minimize complications. Methods: This retrospective cohort study included all adult patients diagnosed with AC who underwent PC followed by IC at a single institution center between 2014 and 2022. Patients with a history of hepatobiliary surgery, stones in the common bile duct, cirrhosis, active malignancy, or prolonged immunosuppression were excluded. The analysis did not include cases with major concurrent procedures during cholecystectomy, previously aborted cholecystectomies, or failure of the PC drain to control the inflammation. Linear and logistic regression models were used to analyze the impact of the interval between PC and IC on intra- and perioperative outcomes. Results: One hundred thirty-two patients (62.1% male) with a mean age of 64.4 ± 15 (mean ± SD) years were diagnosed with AC (25% mild, 47.7% moderate, 27.3% severe). All patients underwent PC followed by IC after a median of 64 [48–91] days. Longer ICU stay was associated with longer time intervals between PC and IC (Coef 105.98, p < 0.001). No significant variations were detected in the intraoperative and perioperative outcomes between patients undergoing IC within versus after 8 weeks from PC placement. However, a higher percentage of patients with delayed IC (after 8 weeks) were discharged home (96.4% vs. 83.7%; p = 0.019). Conclusions: Patients may benefit from undergoing IC after the 8-week cutoff after PC. However, very long periods between PC and IC procedures may increase the risk of longer ICU stay. [ABSTRACT FROM AUTHOR]

Background: Edwardsiella tarda (E. tarda) is a Gram-negative facultative anaerobe belonging to Enterobacteriales and is commonly isolated from fishes and reptiles. Infection due to E. tarda is uncommon among humans, with a reported human retention rate of 0.001%. It can cause sepsis in the elderly or those with pre-existing conditions such as liver failure, autoimmune disease, or malignancy. E. tarda is susceptible to many antibiotics; however, a high mortality rate (approximately 40%) has been reported with sepsis. Case presentation: A 65-year-old woman presented to our hospital with a chief complaint of fever and abdominal pain for 2 days. Her blood tests showed elevated inflammatory markers, and contrast-enhanced computed tomography showed distention and wall thickening of the gallbladder and inflammation of peri-gallbladder fat. Subsequently, a diagnosis of cholecystitis with systemic inflammatory response syndrome was made. Laparoscopic cholecystectomy was performed after starting antimicrobial therapy. Blood culture of samples obtained on admission were positive for E. tarda, which was also detected in bile juice culture. Therefore, she was diagnosed with bacteremia caused by E. tarda, and postoperative antimicrobial therapy was continued. The patient improved, and there were no complications. Conclusions: We experienced an extremely rare case of acute cholecystitis caused by E. tarda. Only a few cases of acute cholecystitis due to E. tarda have been reported. Furthermore, similar to this case, no previous study has reported the detection of E. tarda in both blood and bile cultures in acute cholecystitis cases. In addition to appropriate surgical intervention, continuous administration of antibiotics based on culture results resulted in a favorable outcome. [ABSTRACT FROM AUTHOR]

Purpose: To compare the complication rate and clinical outcomes for percutaneous cholecystostomy (PC) in patients with or without coagulopathy. Materials and methods: We retrospectively reviewed electronic medical chart of patients who underwent ultrasound-guided PC with a 8.5-F drainage tube for acute cholecystitis between November 2003 and March 2017. We divided the patients into two groups: patients with coagulopathy (international normalized ratio > 1.5 or platelet count < 50 × 109/L or with a history of anticoagulant medication in preceding 5 days) and patients without coagulopathy. Duration of drainage, duration of hospital stay, 30-day mortality and complication rates were compared between these two groups. Student's t test, Chi-square test or Fisher's exact test was used for bivariate analyses. Age, age-adjusted Charlson Comorbidity Index (ACCI) and sepsis-adjusted complication rates were also compared. Results: In total, 141 patients had PC (mean age was 73.3 years [SD 13.3]; range 33–96 years; 94 men and 47 women). Fifty-two patients (36.9%) had coagulopathy and 89 patients (63.1%) were without any history of coagulopathy. Hemorrhagic complication rate was 3.5% (5 out of 141 patients, including 4 with coagulopathy and 1 without). One patient with coagulopathy died due to the hemorrhage. Duration of drainage was longer in patients with coagulopathy than patients without coagulopathy (20.0 days vs. 14.8 days; P = 0.033). No significant difference was observed with regard to duration of hospital stay (32.3 days vs. 25.6 days; P = 0.103) and 30-day mortality (7.7% vs. 1.1%; P = 0.062). The overall complication rate did not significantly differ (9.6% and 11.2%; P = 0.763), nor did age, ACCI or sepsis-adjusted complications. Conclusion: Clinical outcomes and complications rates after PC did not statistically differ between patients with and without coagulopathy, but there was a tendency of higher risk of hemorrhage in coagulopathy patients. Therefore, the indication of this procedure should be carefully determined. [ABSTRACT FROM AUTHOR]

Background: Early laparoscopic cholecystectomy (ELC) for acute cholecystitis (AC) poses multiple challenges. The Tokyo Guidelines 2018 (TG18) eliminated the time limit (< 72 h) and expanded the surgical indication to severe AC. This study aimed to evaluate the clinical outcomes of ELC for AC following the TG18 in a single high-volume center. Methods: From 2019 to 2021, we managed all AC patients with a TG18 flowchart and prospectively enrolled those who underwent ELC within 7 days of symptom onset. The primary outcome was overall morbidity, with a comparison between mild (Grade I) and moderate/severe (Grade II/III) AC. Results: During the study period, 201 patients underwent ELC was for Grade I (56.2%), II (40.3%), and III (3.5%) ACs. Mean age was 69 ± 15.2 years and time to surgery from symptom onset was 0 (12.9%), 1–3 (66.7%), and 4–7 days (20.4%). Mean operative time and blood loss were 118.9 ± 42.7 min and 57.8 ± 99.4 mL, respectively. The critical view of safety (CVS) was achieved in 76.1% of patients, and bailout procedures were performed in 21.4%. There were no open conversions or bile duct injuries. Major morbidities (Clavien–Dindo classification ≥ IIIa) were observed in 5.5% of cases and mortality in 0.5%. Comparing Grades II/III to Grade I, operative time was longer (112.3 vs. 127.3 min, p = 0.014), blood loss was higher (40.3 vs. 80.1 mL, p = 0.005), the CVS rate was lower (83.2 vs. 67.0%, p = 0.012), and the major morbidity rate was higher (1.8 vs. 10.2%, p = 0.012). In the subgroup analysis of Grade II/III, there were no significant differences in major morbidities (p = 0.288) between the two groups (0–3 vs. 4–7 days). Conclusion: ELC for AC following TG18 is feasible with low morbidity rates. However, ELC for Grade II/III ACs remains challenging, and surgeons must carefully assess intraoperative difficulties and surgical risks before proceeding. [ABSTRACT FROM AUTHOR]

Background : Surgeons can minimize the risk of bile duct injury (BDI) during challenging mini-invasive cholecystectomy through technical standardization by means of a precise anatomical landmark identification (Critical View of Safety) and advanced technology for biliary visualization. Among these systems, the adoption of magnified stereoscopic 3-dimensional view provided by robotic platforms and near infrared fluorescent cholangiography (NIRF-C) is the most promising. Methods: In this prospective cohort study, we evaluated all consecutive minimally invasive cholecystectomies (laparoscopic and robotic) performed with NIRF-C between May 2022 and January 2023 at General Surgery Unit, Department of Health Sciences, University of Milan, San Paolo Hospital (Milan, Italy). Inclusions criteria were as follows: (1) acute cholecystitis (emergency group), (2) history of chronic cholecystitis or complicated cholelithiasis (deferred urgent group), (3) difficult cases (patients affected by cirrhosis, with scleroatrophic gallbladder or BMI > 35 kg/m2). For each group, the detection rate and visualization order of the main biliary structures were reported (cystic duct, CD; common hepatic duct, CHD; common bile duct, CBD; and CD-CHD junction). Results: A total of 101 consecutive patients were enrolled, including 83 laparoscopic and 18 robotic cholecystectomies. All patients were stratified into three subgroups: (a) emergency group (n = 33, 32.7%), (b) deferred urgent group (n = 46, 45.5%), (c) difficult group (n = 22, 21.8%). Visualization of at least one biliary structure was possible in 94.1% of cases (95/101). Interestingly, all four main structures were detected in 43.6% of cases (44/101). The CD was the structure identified most frequently, being recognized in 91/101 patients (90.1%), followed by CBD (83.2%), CHD (62.4%), and CD-CHD junction (52.5%). In the subset of patients that underwent emergency surgery for AC, the CD-CHD confluence was identified in only 45.5% of cases. However, early and precise identification of CBD (75.8%) and CD (87.9%) allowed safe isolation, clipping, and transection of the cystic duct. In the deferred urgent group, the CBD and the CD were easily identified as first structure in a high percentage of cases (65.2% and 41.3% respectively), whereas the CD-CHD junction was the third structure to be identified in 67.4% of cases, the highest value among the three subgroups. In the difficult group, NIRF-C did not prove to be a useful tool for biliary visualization. The rates of failure of visualization were elevated: CBD (27.3%), CD (18.2%), CHD (54.5%), and CD-CHD (68.2%). Conclusions: NIRF-C is a powerful real-time diagnostic tool to detect CBD and CD during minimally invasive cholecystectomy, especially when inflammation due to acute or chronic cholecystitis subverted the anatomy of the hepatoduodenal ligament. [ABSTRACT FROM AUTHOR]

Introduction: Although cases of acute cholecystitis, acute pancreatitis, and acute appendicitis following dengue virus infections have been documented, very few large-scale studies have investigated the postdengue risk of these acute abdominal conditions. Methods: This retrospective population-based cohort study included all patients with laboratory-confirmed dengue from 2002 to 2015 in Taiwan and 1:4 nondengue individuals matched by age, sex, area of residence, and symptom onset time. Multivariate Cox proportional hazards regression models were used to investigate the short-term (≤ 30 days), medium-term (31–365 days), and long-term (> 1 year) risks of acute cholecystitis, pancreatitis, and appendicitis after dengue infection, adjusted for age, sex, area of residence, urbanization level, monthly income level, and comorbidities. Bonferroni correction was used for multiple testing; E-values were used to assess the robustness of the results to unmeasured confounding. Results: This study included 65,694 individuals with dengue and 262,776 individuals without dengue. Patients with dengue had a significantly increased risk of acute cholecystitis (adjusted hazard ratio (aHR) 60.21; 95% CI 29.11–124.54; P < 0.0001, E-value = 119.92) and acute pancreatitis (aHR 17.13; 95% CI 7.66–38.29; P < 0.0001, E-value = 33.75) within the first 30 days postinfection compared to those without dengue, but this increased risk was not present after that. The incidence rates of acute cholecystitis and pancreatitis in the first 30 days were 18.79 and 5.27 per 10,000, respectively. No increased risk of acute appendicitis was observed among patients with acute dengue infection. Conclusion: This study was the first large epidemiological study to show a significantly increased risk of acute cholecystitis and pancreatitis among patients with dengue during the acute phase of dengue infection, while no such association was observed for acute appendicitis. Early identification of acute cholecystitis and pancreatitis in patients with dengue is crucial for preventing fatal complications. [ABSTRACT FROM AUTHOR]

Laparoscopic cholecystectomy is the gold standard for the treatment of acute cholecystitis (AC). Percutaneous cholecystostomy (PC) for management of AC is increasing; safe and less invasive than laparoscopic cholecystectomy and is very useful in selected patients with severe comorbidities, not suitable for surgery/general anesthesia. We conducted a retrospective observational study between 2016 and 2021 of patients treated with PC for AC, based on the application of the Tokyo guidelines 13/18. The aim was to analyse the clinical results and management of PC in patients undergoing elective or emergency cholecystectomy. Subsequently, a retrospective analytical study was designed to compare various cohorts: elective or emergency surgery and management with PC alone; patients with/without a high surgical risk; and elective vs emergency surgery. Hundred and ninety five patients with AC were treated with PC. Mean age was 74 years, 59.5% were ASA class III/IV, and the mean Charlson comorbidity index was 5.5. Adherence to Tokyo guidelines regarding indication of PC was 50.8%. The rate of complications associated to PC was 12.3% and the 90-day mortality rate was 14.4%. Mean length of time using PC was 10.7 days. Emergency surgery was performed in 4.6%. The overall success rate using PC was 66.7%, and the 1-year readmission rate due to biliary complications after PC was 28.2%. The rate of scheduled cholecystectomy after PC was 22.6%. Conversion to laparotomy and open approach was more frequent in patients who underwent emergency surgery (p = 0.009). No differences were found in 90-day mortality or in the complication rate. PC achieves improvements in the inflammation and infection associated with AC. In our series, it proved to be an effective and safe treatment during the acute episode of AC. Mortality in patients treated with PC is high due to their older age, greater morbidity, and higher Charlson comorbidity index scores. After PC, emergency surgery is uncommon but readmission due to biliary events is high. Cholecystectomy after PC is the definitive treatment and the laparoscopic approach is feasible. Clinical trial registery: The study was registered in the public accessible database clinicaltrials.gov with the ClinicalTrials.gov ID: NCT05153031. Public release date: 12/09/2021. [ABSTRACT FROM AUTHOR]

Background: CA19-9 is strongly expressed in malignant tumors of the digestive system and is widely used as a marker for gastrointestinal cancer. In this report, we describe a case of acute cholecystitis in which CA19-9 was markedly elevated. Case presentation: A 53-year-old man was admitted to our hospital with a diagnosis of acute cholecystitis after being referred to our hospital with a chief complaint of fever and right hypochondrial pain. CA19-9 was abnormally high at 17,539.1 U/ml. Although the possibility of malignancy was considered, there was no obvious malignant lesion on imaging; the patient was diagnosed with cholecystitis, and laparoscopic cholecystectomy was performed the day after admission. The surgical specimen showed no malignant findings either grossly or in the final pathological examination. There were no complications in the patient's postoperative course, and he was discharged from the hospital on the third postoperative day. CA19-9 level quickly returned to within normal range after surgery. Conclusions: In acute cholecystitis, CA19-9 levels exceeding 10,000 U/ml are very rare. We report a case of acute cholecystitis without malignant findings despite a high CA19-9 level. [ABSTRACT FROM AUTHOR]

Background: Bailout surgery (BOS; partial cholecystectomy, open conversion, and fundus-first approach) has been recommended for difficult cases to ensure safe performance of cholecystectomy. However, the efficacy of BOS for preventing intraoperative massive bleeding and bile duct injury (BDI) remains unclear, especially in the context of acute cholecystitis (AC). This study aimed to retrospectively validate the feasibility of BOS for AC. Methods: We enrolled 479 patients who underwent emergency cholecystectomies for AC between 2011 and 2021. Univariate and multivariate analyses were performed to detect the risk factors for BOS in patients with AC. Perioperative variables were compared between patients who underwent total cholecystectomy (TC) and those who underwent BOS. Propensity score matching analysis was performed to compare the two groups. Results: Significant differences in American Society of Anesthesiologists physical status and Charlson Comorbidity Index scores, TG18 severity grading, white blood cell count, and albumin and C-reactive protein (CRP) levels were found between the TC and BOS groups. Preoperative CT imaging demonstrated severe inflammation evidenced by gallbladder wall thickness, enhancement of the liver bed, and duodenal edema in the BOS group compared to the TC group. Postoperative complications were significantly higher in the BOS group than in the TC group. Further, BDI was completely prevented by BOS. Multivariate analysis identified TG18 grade ≥ II, CRP ≥ 7.7, and duodenal edema as independent risk factors for BOS. After PSM analysis, postoperative complications were not worse in patients who underwent BOS rather than TC. Among BOS procedures, laparoscopic BOS (lap-BOS) was the most efficacious in preventing intraoperative blood loss and postoperative bile leakage. Conclusion: Severity grading > II, elevated CRP levels, or duodenum edema revealed by CT were determined to be risk factors impeding total cholecystectomy. BOS is a safe, feasible, and efficacious procedure for preventing BDI. Among BOS procedures, lap-BOS showed better postoperative outcomes. [ABSTRACT FROM AUTHOR]

Choledocholithiasis is more common in acute cholecystitis than in elective situations. Preoperative diagnosis of choledocholithiasis is essential to facilitate adequate planning of CBD (common bile duct) stone removal, preferably performed as a single-stage procedure. The purpose of this study was to test the feasibility of routine preoperative magnetic resonance cholangiopancreatography (MRCP) in acute cholecystitis followed by consequent cholecystectomy. A total of 180 consecutive patients operated for acute cholecystitis between January 2019 and December 2019 were prospectively enrolled. Preoperative routine MRCP was performed for bile duct evaluation when feasible. The control cohort consisted of 180 consecutive patients undergoing emergency laparoscopic cholecystectomy before the study period. Intraoperative cholangiography was used routinely in both groups when technically achievable. We examined the proportion of patients recruited in preoperative MRCP, possible time delay to MRCP and surgery, and the incidence of CBD stones compared to the control cohort. Routine MRCP in acute cholecystitis was achieved in 114/180 (63%) patients compared to 42/180 (23.3%) patients of the control group. The triage time from emergency to MRCP and the operating theatre was similar in both cohorts. The percentage of patients diagnosed with choledocholithiasis in the study group was notably higher (almost 18% vs 11%), p < 0.05. After a median follow-up time of 2.5 years in the study group and almost 4 years in the control group, recurrent choledocholithiasis was not detected in either group. Routine MRCP in patients with acute cholecystitis can be implemented with a fair execution rate in a population-based setting with minor effects on hospital stay and delays but higher detection of choledocholithiasis. We observed no additional benefit compared to the selective use of MRCP. However, routine preoperative MRCP allows an advantage when considering the appropriate exploration method if choledocholithiasis is detected. [ABSTRACT FROM AUTHOR]

Background: The deadline for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is the subject of much debate. The aim of this study was to assess outcomes of ELC in patients with more than 7 days of symptoms. Methods: It is a retrospective analysis of 564 patients having undergone ELC for ACC between January 2003 and June 2021. Patients were divided into two groups according to the timing between the onset of symptoms and surgery: group 1 (G1), within the first 7 days of symptoms, and group 2 (G2) after day 7 of symptoms. Results: Apart from a longer operative time (G1 80 min vs. G2 90 min; p = 0.016), there were no significant differences regarding conversion rate (G1 14.5% vs. G2 13.2%; p = 0.748), both intra- and postoperative complications, mainly bile duct injuries (G1 0.2% vs. G2 0%; p = 1) and bile leakage (G1 1.2% vs. G2 0%; p = 1) and postoperative length of stay (G1 2 days [1–3] vs. G2 2 days [1–4]; p = 0.125). Conclusion: Early laparoscopic cholecystectomy could be proposed for patients with acute calculous cholecystitis even beyond 7 days of symptoms. [ABSTRACT FROM AUTHOR]

This review focuses mainly on the imaging diagnosis, treatment, and complications of acute cholecystitis which is the most common benign disease of the gallbladder. The American College of Radiology appropriateness criteria for the imaging evaluation of patients with right upper quadrant pain and the Tokyo Guidelines for evaluating patients with acute cholecystitis and acute cholangitis are presented. The recent articles for using US, CT, MR, and HIDA in the evaluation of patients with suspected acute cholecystitis are reviewed in detail. The clinical management and postoperative complications are described. Because gallbladder polyps and adenomyomatosis can mimic gallbladder malignancies and acute cholecystitis, their imaging findings and management are presented. Finally, due the recent literature reporting better results with CT than US in the diagnosis of acute cholecystitis, a suggested approach for imaging patients with right upper quadrant pain and possible acute cholecystitis is presented in an addendum. [ABSTRACT FROM AUTHOR]

Background: The timing of cholecystectomy in relation to outcomes has been debated. To our knowledge, there are no large population-based studies looking at outcomes and complications of delayed cholecystectomy [DC] (> 72 h after presentation). This study utilizes a statewide database to determine whether there are differences in patient outcomes for DC performed at 3–4 days, 5–6 days, and ≥ 7 days after presentation. Methods: The New York SPARCS database was used to identify adult patients presenting with a diagnosis of acute cholecystitis from 2005 to 2017. Patients aged < 18, those with missing identifier or procedure-date information, those who underwent early cholecystectomy < 72 h or upon readmission, were excluded. Patients undergoing DC at 3–4 days, 5–6 days, and ≥ 7 days were compared in terms of overall complications, hospital length of stay (LOS), 30-day readmissions/emergency department (ED) visits, and 30-day mortality. Results: 30,259 patients were identified. DCs were performed within 3–4 days (n = 19,845, 65.6%), 5–6 days (n = 6432, 21.3%), and ≥ 7 days (n = 3982, 13.2%). There was a stepwise deterioration in outcomes with increased delay to surgery (Fig. 1). When comparing 3–4 and ≥ 7 days, overall complications (OR = 0.418, 95% CI: 0.387–0.452), 30-day readmissions (OR = 0.609, 95% CI: 0.549–0.674), 30-day ED visits (OR = 0.697, 95% CI: 0.637–0.763), 30-day mortality (OR = 0.601, 95% CI: 0.400–0.904), and LOS (OR = 0.729, 95% CI: 0.710–0.748) were lower in the 3–4 day cohort. Conclusions: DC within 3–4 days is associated with fewer complications, readmissions and ED visits, and reduced LOS compared to DC at 5–6 or ≥ 7 days after presentation. In addition, 30-day mortality was also significantly different comparing 3–4 with ≥ 7-day cohorts. These data are important for guiding patients in the consent process and may point to choosing an earlier interval cholecystectomy for high-risk patients. [ABSTRACT FROM AUTHOR]

Objective: Our study aims to identify the optimal timing between a percutaneous cholecystostomy (PC) and cholecystectomy to reduce the number of poor surgical outcomes.Background: Biliary disease is a common surgical disease and laparoscopic cholecystectomy is the preferred strategy for the management of acute cholecystitis. However, in high-risk surgical patients, a PC tube may be placed instead. In the 2018 Tokyo Guidelines, the optimal timing of cholecystectomy following a PC has been identified as an important future research question.Methods: This is a retrospective study that focuses on identifying the ideal timing of cholecystectomy after PC tube placement to minimize complications. Poor surgical outcomes were measured as 90-day reoperations, 30-day readmissions, 30-day emergency department (ED) visits, length of stay (LOS), and discharge destination. Patients were selected from the New York SPARCS database from 2005 to September 30, 2015.Results: 1213 records that consisted of both PC and cholecystectomy were collected. No significant differences in 30-day readmissions, 90-day reoperations, and 30-day ED visits in relation to timing between PC and cholecystectomy were found. Additionally, the decision to replace or not replace dislodged PC tubes was not associated with 90-day reoperation, 30-day readmission, 30-day ED visit, LOS, or discharge destination. However, discharge destination and LOS were significantly different between early intervention of 3 days or less between PC and cholecystectomy and late intervention of more than 14 days with late intervention being associated with shorter LOS and more home discharges.Conclusion: Performing a cholecystectomy more than 14 days after a PC is associated with better surgical outcomes. [ABSTRACT FROM AUTHOR]

Objective: The Endoscopic Surgical Skill Qualification System (ESSQS) was developed by the Japan Society for Endoscopic Surgery as a means of subjectively assessing the proficiency of laparoscopic surgeons. We conducted a study to evaluate how involvement of an ESSQS skill-qualified (SQ) surgeon influences short-term outcomes of laparoscopic cholecystectomy performed for acute cholecystitis. Summary of background data: Previous reports suggest that assessment of the video-rating system is a potential tool to discriminate laparoscopic surgeons' proficiency and top-rated surgeons face less surgical mortality and morbidity in bariatric surgery. Methods: Data from the National Clinical Database regarding laparoscopic cholecystectomy performed for acute cholecystitis between January 2016 and December 2018 were analyzed. Outcomes were compared between patients grouped according to involvement vs. non-involvement of an SQ surgeon. Outcomes were also compared between patients grouped according to whether their operation was performed by biliary tract-, stomach-, or colon-qualified surgeon. Results: Of the 309,998 laparoscopic cholecystectomies during the study period, 65,295 were suitable for inclusion in the study and 13,670 (20.9%) were performed by an SQ surgeon. Patients' clinical characteristics did not differ between groups. Thirty-day mortality was significantly lower in the SQ group (0.1%) 16/13,670 than in the non-SQ group (0.2%) 140/51,625 (P = 0.001). Thirty-day mortality was [0.1% (9/7173)] in the biliary tract-qualified group, [0.2% (5/3527)] in the stomach-qualified group, and [0.1% (2/3240)] in the colon-qualified group. Conclusion: Surgeons with ESSQS certification outperform the non-skilled surgeons in terms of surgical mortality in 30 and 90 days. Further verification of the value of the ESSQS is warranted and similar systems may be needed in countries across the world to ensure patient safety and control the quality of surgical treatments. [ABSTRACT FROM AUTHOR]

Objectives: Acute cholecystitis is a complication in critically ill patients. However, a few studies have described its incidence, risk factors, and mortality in patients who underwent cardiovascular surgery. We investigated the incidence, perioperative predictors, and clinical features of acute cholecystitis after cardiovascular surgery. Methods: This retrospective cohort study examined 7013 patients who underwent cardiovascular surgery between October 2000 and March 2019 at a tertiary care hospital. We collected preoperative, intraoperative, and postoperative data from our database and electronic medical records. The primary outcome was the incidence of postoperative cholecystitis until hospital discharge. A multivariable logistic regression analysis to estimate perioperative predictors of acute cholecystitis was conducted. We described the clinical characteristics of patients complicated with acute cholecystitis. Results: Among the 7013 patients, 51 (0.7%) developed acute cholecystitis. Logistic regression analysis found that circulatory arrest (odds ratio [OR] 1.97; 95% confidence interval [CI] 1.04–3.74; P = 0.037) and intraoperative massive transfusion (OR 2.03; 95% CI 1.03–4.01; P = 0.041) were associated with the incidences of cholecystitis. In-hospital mortality was significantly higher in the cholecystitis group than in the non-cholecystitis group (13.7% vs 3.9%, P = 0.004). Aortic disease was more frequent in the cholecystitis group (54.9% vs 38.6%, P = 0.021). The median time of acute cholecystitis onset from surgery was 12.5 days (interquartile range 7.0–27.75). Twenty-six patients (51.0%) developed asymptomatic cholecystitis. Conclusions: Approximately 1% of patients who underwent cardiovascular surgery developed postoperative cholecystitis; half of them were asymptomatic. Since cholecystitis is associated with high mortality, it is a complication after cardiovascular surgery that needs to be considered. [ABSTRACT FROM AUTHOR]

Background: Although gallstone disease increases with aging, elderly patients are less likely to undergo cholecystectomy. This is because age itself is a negative predictor after cholecystectomy. The ACS-NSQIP risk calculator can therefore help surgeons decide whether to operate or not. However, little is known about the accuracy of this model outside the ACS National Surgical Quality Improvement Program. The aim of the present study is to evaluate the ability of the ACS-NSQIP model to predict the clinical outcomes of patients aged 80 years or older undergoing elective or emergency cholecystectomy. Study design: The study focused on 263 patients over 80 years of age operated on between 2010 and 2019: 174 were treated as emergencies because of acute cholecystitis (66.2%). Outcomes evaluated are those predicted by the ACS-NSQIP calculator within 30 days of surgery. The ACS-NSQIP model was tested for both discrimination and calibration. Differences among observed and expected outcomes were evaluated. Results: When considering all patients, the discrimination of mortality was very high, as it was that of severe complications. Considering only the elective cholecystectomies, the discrimination capacity of ACS-NSQIP risk calculator has consistently worsened in each outcome while it remains high considering the emergency cholecystectomies. In the evaluation of the emergency cholecystectomy, the model showed a very high discriminatory ability and, more importantly, it showed an excellent calibration. Comparisons between main outcomes showed small or even negligible differences between observed and expected values. Conclusion: The results of the present study suggest that clinical decisions on cholecystectomy in a patient aged 80 years or older should be assisted through the ACS-NSQIP model. [ABSTRACT FROM AUTHOR]

Background: Percutaneous transhepatic gallbladder drainage (PTGBD) plays an important role in the treatment of elderly patients and/or patients in poor health with acute cholecystitis (AC). The primary aim of this study is to determine how these factors influence the clinical outcome of PTGBD. Moreover, we assessed the timing and results of subsequent cholecystectomies. Patients and Methods: We retrospectively examined the results of 162 patients undergoing PTGBD between 2010 and 2020 (male–female ratio: 51.23% vs. 48.77%; mean age: 71.43 ± 13.22 years). Patient's performance status and intervention outcomes were assessed with clinical success rates (CSR) and in-hospital mortality. The conversion rate (CR) of possible urgent or delayed, elective laparoscopic cholecystectomies (LC) after PTGBD were analysed. Results: PTGBD was the definitive treatment in 42.18% of patients, while it was a bridging therapy prior to cholecystectomy (CCY) for the other patients. CSR was 87.97%, it was only 64.29% in grade III AC. In 9.87% of the cases, urgent LC was necessary after PTGBD, and its conversion rate was approximately equal to that of elective LC (18.18 vs. 17.46%, respectively, p = 0.2217). Overall, the post-PTGBD in-hospital mortality was 11.72%, while the same figure was 0% for grade I AC, 7.41% for grade II and 40.91% for grade III. Based on logistic regression analyses, in-hospital mortality (OR 6.07; CI 1.79–20.56), clinical progression (OR 7.62; CI 2.64–22.05) and the need for emergency CCY (OR 14.75; CI 3.07–70.81) were mostly determined by AC severity grade. Conclusion: PTGBD is an easy-to-perform intervention with promising clinical success rates in the treatment of acute cholecystitis. After PTGBD, the level of gallbladder inflammation played a decisive role in the course of AC. In a severe, grade III inflammation, we have to consider low CSR and high mortality. [ABSTRACT FROM AUTHOR]

Background: The use of cholecystostomy (c-tube) in acute cholecystitis (AC) has increased yet there is limited evidence to guide surgical decision-making after placement. As a result, there is variability in the use and timing of cholecystectomy after c-tube. We aimed to describe patient characteristics, outcomes, and biliary-related utilization in those who did and did not have cholecystectomy after c-tube. Methods: This is a retrospective cohort study (2007–2017) using the MarketScan® claims database of patients (18–63 years) with at least 3 months of follow-up (or death). ICD-9/10 and CPT codes were used to identify AC, c-tube placement, cholecystectomy and determine Elixhauser comorbidity index. Results: A total of 2386 patients (47.5% female, mean age 52.5 [SD 9.9] years) with AC underwent c-tube with an 11.2% 90-day mortality. Among survivors, by three months 57% underwent cholecystectomy (mean 34.8 days [95% CI: 33.3–36.3]). Cholecystectomy after c-tube was more common in those with fewer comorbid conditions (mean 2.41 [95% CI: 2.26–2.56] vs 4.56 [95%CI: 4.36–4.76]). Biliary episodes prior to cholecystectomy occurred in 12.5% and were associated with eventual cholecystectomy (HR 1.49 [1.32–1.68]). Biliary-specific hospital and ICU days were similar between groups. Biliary-specific ED visits were more common among patients with cholecystectomy (mean 1.39 [95% CI: 1.29–1.48] vs 0.94 [95% CI: 0.85–1.03]). Conclusion: More than half of patients treated with c-tube underwent cholecystectomy by three months—most within five weeks of AC diagnosis. The high frequency of use and short time to cholecystectomy after c-tube raises questions about potential overuse of c-tube in the initial period. Future work should aim to understand how patient experience and indication for c-tube influence the likelihood and timing of subsequent cholecystectomy. [ABSTRACT FROM AUTHOR]

Background: Dropped gallstones during laparoscopic cholecystectomy (LC) sometimes induce postoperative infectious complications. However, pleural empyema rarely occurs as a complication of LC. Case presentation: We present the case of a 66-year-old woman with right pleural empyema. She previously underwent LC for acute gangrenous cholecystitis 11 months ago. The operative report revealed iatrogenic gallbladder perforation and stone spillage. The bacterial culture of the gallbladder bile was positive for Escherichia coli. Chest and abdominal computed tomography revealed right pleural effusion, perihepatic fluid collection, and multiple small radiopaque density masses. Although ultrasound-guided transthoracic drainage was performed, the drainage was incomplete, and systemic inflammatory reaction persisted. Consequently, thoracotomy and laparotomy with gallstone retrieval were performed, and the patient recovered completely. The patient has remained well without complications after 14 months of follow-up. Conclusions: We report a rare case of pleural empyema caused by dropped gallstones after LC. This case emphasized the importance of completely retrieving the dropped gallstones to prevent late infectious complications after LC. [ABSTRACT FROM AUTHOR]

Objective: Early detection of complicated cholecystitis, particularly gallbladder empyema, is important. Yet only a handful of patients are correctly diagnosed prior to intervention. The purpose of this study was to evaluate the sonographic and computed tomography features associated with gallbladder empyema compared with the intraoperative findings and histopathological examination.Materials and Methods: We retrospectively reviewed ultrasound and CT images for 146 patients with clinical suspicion of cholecystitis from January 2013 until December 2018. Ultrasound criteria reviewed included calculus, wall thickening, pericholecystic fluid, gallbladder distension and presence of echogenic material within the gallbladder. For CT, criteria reviewed were wall thickening, gallbladder distension, mucosal enhancement, pericholecystic fluid and hyperdense bile with an attenuation value of more than 20 HU. Association of these findings was made with intraoperative and pathological findings of 85 patients with proven gallbladder empyema.Results: Sonographic signs that were statistically significantly associated with gallbladder empyema (p < 0.05) were thickened gallbladder wall (mean 5.4 versus 3.0 mm), distended gallbladder (mean 8.5 versus 6.4cm), pericholecystic fluid and echogenic material within the gallbladder. No significant association between gallstones and gallbladder empyema. Scores of two and more out of four significant sonographic findings were found to have an association with higher chances of developing gallbladder empyema (p < 0.05, odds ratio: 10). None of the CT features was found to be significant with gallbladder empyema (p > 0.05).Conclusion: A combination of few ultrasound features has a high significant association with gallbladder empyema. Thus, in the proper clinical setting, these findings should alarm the sonographic operator on the possibility of gallbladder empyema. [ABSTRACT FROM AUTHOR]

Bernard–Soulier syndrome is an inherited coagulopathy, with an incidence of one per million. Hemorrhagic cholecystitis is a rare and life-threatening complication of acute cholecystitis. Less than 50 patients have been reported in the previous literature. Bleeding diathesis and anticoagulant treatment are well-known predisposing factors for hemorrhagic cholecystitis. We present a 57-year-old male patient who was referred to our department with a complaint of right upper quadrant abdominal pain. Contrast-enhanced computed tomography revealed a high-density mass associated with the gallbladder lumen, and blood clot in the gallbladder lumen and hemoperitoneum which were compatible for hemorrhagic cholecystitis and gallbladder perforation. The patient underwent urgent cholecystectomy. Hemorrhagic cholecystitis often manifests as typical acute cholecystitis presentation; but several clinical findings such as fever, lower gastrointestinal bleeding or severe intraabdominal bleeding-related hypovolemic shock may also occur. Most of the described cases in prior literature have been reported to use anticoagulant medications. This report describes the second hemorrhagic cholecystitis patient with inherited bleeding diathesis and the first case with Bernard–Soulier syndrome. [ABSTRACT FROM AUTHOR]

Acute cholecystitis (AC) is a common emergency condition with severity ranging from mild to severe. Gallstones and critical illnesses are the common predisposing factors. Mild AC is primarily managed with medical therapy and early cholecystectomy. Moderate and severe AC require individualized treatment with a preference for early cholecystectomy. However, cholecystectomy may not always be feasible due to co-morbidities. Hence, this group of patients needs minimally invasive methods to drain the gallbladder (GB). Percutaneous cholecystostomy (PC) is the image-guided drainage of GB in the setting of moderate to severe AC. There are different approaches to PC. The technical aspects, success, and complications of PC as well as management of cholecystostomy catheter after the patient recovers from the acute episode should be thoroughly understood by the interventional radiologist. We present an extensive up-to-date review of the essential aspects of PC including indications, contraindications, techniques, and outcomes, including complications and success rates. [ABSTRACT FROM AUTHOR]

Purpose: To identify early sonographic features of gangrenous cholecystitis. Materials and methods: 101 patients with acute cholecystitis and a pre-operative sonogram were retrospectively reviewed by three radiologists in this IRB-approved and HIPAA-compliant study. Imaging data were correlated with histologic findings and compared using the Fisher's exact test or Student t test with p < 0.05 to determine statistical significance. Results: Forty-eight patients had gangrenous cholecystitis and 53 had non-gangrenous acute cholecystitis. Patients with gangrenous cholecystitis tended to be older (67 ± 17 vs 48 ± 18 years; p = 0.0001), male (ratio of male:female 2:1 vs 0.6:1; p = 0.005), tachycardic (60% vs 28%; p = 0.001), and diabetic (25% vs 8%; p = 0.001). Median time between pre-operative sonogram and surgery was 1 day. On imaging, patients with gangrenous cholecystitis were more likely to have echogenic pericholecystic fat (p = 0.001), mucosal discontinuity (p = 0.010), and frank perforation (p = 0.004), while no statistically significant differences were seen in the presence of sloughed mucosa (p = 0.104), pericholecystic fluid (p = 0.523) or wall striations (p = 0.839). In patients with gangrenous cholecystitis and echogenic pericholecystic fat, a smaller subset had concurrent mucosal discontinuity (57%), and a smaller subset of those had concurrent frank perforation (58%). The positive likelihood ratios for gangrenous cholecystitis with echogenic fat and mucosal discontinuity were 4.6 (95% confidence interval 1.9–11.3) and 14.4 (2.0–106), respectively. Conclusion: Echogenic pericholecystic fat and mucosal discontinuity are early sonographic findings that may help identify gangrenous cholecystitis prior to late findings of frank perforation. [ABSTRACT FROM AUTHOR]

Background: Percutaneous transhepatic gallbladder drainage (PTGBD) is an important procedure for initial treatment of severe acute cholecystitis (AC) that is contraindicated for early laparoscopic cholecystectomy (LC). We presented our primary experience on a new approach of cholangiography via PTGBD (PTGBD-C) for preoperative delineation of biliary anatomy. Methods: A retrospective analysis was conducted on 93 patients who received PTGBD followed by LC for AC, with allocation into 2 groups that were PTGBD with (PTGBD-C group, 32 patients) or without (PTGBD-N group, 61 patients) cholangiography. All the clinical data, including demographics, cholangiography findings, operations, and complications, were collected and analyzed. Results: Cholangiography was attempted in 32 patients with a success of 31 cases, and the most common complication was transient fever in 3 patients. PTGBD-C group of patients showed significantly less operation time (83.2 ± 22.32 vs. 106.5 ± 40.25 min, P = 0.041) and conversion rate (0 vs. 2). There was no statistical difference in terms of postoperative hospitalization and complications. Conclusions: PTGBD-C is a feasible and safe procedure for severe AC patients with delayed LC. It has advantages of direct cholangiography, being easy to perform and cost-effective, thus should be considered for clinical usage. [ABSTRACT FROM AUTHOR]

Background: Both one-stage [laparoscopic cholecystectomy (LC) plus laparoscopic common bile duct exploration (LCBDE)] and two-stage [endoscopic retrograde cholangiopancreatography (ERCP) followed by sequential LC] approaches are effective treatment for concomitant common bile duct (CBD) stones and gallstone. Although many studies compared one-stage with two-stage surgical approach for cholecysto-choledocholithiasis, there are very few studies compared the two management strategies for acute cholecystitis (AC) associated with CBD stones. Methods: Between January 2014 and December 2019, patients with concomitant AC and CBD stones proposed to early surgery were retrospectively studied. The patients were scheduled to undergo either the one-stage [LCBDE and LC (LCBDE+LC) were undertaken at the same operation] or two-stage [preoperative ERCP for CBD stone clearance was followed by LC 1–3 days later (pre-ERCP+LC)] procedure. The success rate of complete stone clearance, procedure-related complication, hospital stay, hospitalization charges and later biliary complications were compared between the two groups. Results: Sixty patients were included in the study, 28 in the one-stage group and 32 in the two-stage group. There was no significant difference in the success rate of complete stone clearance (96.4% vs. 93.8%, P = 1.000), complication rate (10.7% vs. 9.4%, P = 1.000), incidence of pancreatitis (0 vs. 6.3%, P = 0.494) or length of hospital stay (12 ± 5 vs. 11 ± 4 days, P = 0.393) between the two groups. Conclusion: For patients with concomitant AC and choledocholithiasis proposed to early surgery, both the one-stage (LCBDE+LC) and two-stage (pre-ERCP+LC) approaches were acceptable and broadly comparable in achieving clearance of CBD stones. [ABSTRACT FROM AUTHOR]

Purpose: Identify an algorithm using clinical and ultrasound (US) parameters with high diagnostic performance for acute cholecystitis. Methods: Consecutive emergency department (ED) patients from 4/1/2019 to 12/31/2019 were retrospectively reviewed to record non-US parameters and make US observations. Outcomes were categorized as either: (1) acute cholecystitis; or (2) negative acute cholecystitis. Pivot tables identified parameter combinations either not found with acute cholecystitis or with predictive value for acute cholecystitis to establish the algorithm. US Division radiologists finalized an US report prior to ED disposition without use of the algorithm. Radiologist impression and algorithm prediction for acute cholecystitis were categorized as either (1) acute cholecystitis; (2) negative acute cholecystitis; or (3) inconclusive. Results: Three hundred and sixty-six studies on 357 patients (mean age, 51 yrs ± 20 yrs; 215 women) met the inclusion criteria. 10.9% (40/366) of US studies had acute cholecystitis, 12.6% (46/366) had pathologically identified chronic cholecystitis without acute cholecystitis, and 76.5% (280/366) were negative acute cholecystitis. Algorithm compared to radiologist diagnostic performance was as follows: (1) sensitivity: 90.0% vs. 55.0%, p < 0.001; (2) augmented sensitivity (defined as when inconclusive categorization is considered consistent with acute cholecystitis): 100% vs. 85.0%, p < 0.001; (3) specificity: 93.6% vs. 94.8%, p = 0.50; (4) diagnostic rate (opposite of inconclusive rate): 96.4% vs. 93.2%, p = 0.04; (5) adverse outcome rate: 0.0% vs. 1.6%, p undefined. Conclusion: For acute cholecystitis, an algorithm using non-binary ultrasound and clinical assessments had higher sensitivity, higher diagnostic rate, and fewer adverse outcomes, than subspecialty radiologist impressions. [ABSTRACT FROM AUTHOR]

Purposes: Acute cholangitis and cholecystitis can become severe conditions as a result of inappropriate therapeutic administration and thereafter become increasingly resistant to antimicrobial treatment. The simultaneous detection of the bacterial nucleic acid and antimicrobial resistance gene is covered by the national health insurance program in Japan for sepsis. In this study, we evaluate the use of a multichannel gene autoanalyzer (Verigene system) for the quick detection of causative bacteria in cases of acute cholangitis and cholecystitis. Methods: This study included 108 patients diagnosed with acute cholangitis or cholecystitis between June 2015 and November 2018. A bacterial culture test and Verigene assay were used to evaluate the bile samples. Results: The most commonly isolated bacteria were Escherichia coli, which includes six extended-spectrum beta-lactamase (ESBL)-producing E. coli. Among the patients with positive bile cultures, bacteria were detected in 35.7% of cases via the Verigene system. The detection rates of the Verigene system significantly increased when the number of bacterial colonies was ≥ 106 colony-forming unit (CFU)/mL (58.1%). Cases with a maximum colony quantity of ≥ 106 CFU/mL exhibited higher inflammation, suggesting the presence of a bacterial infection. Conclusions: The Verigene system might be a new method for the quick detection of causative bacteria in patients with infectious acute cholangitis and cholecystitis. [ABSTRACT FROM AUTHOR]

Background: Subtotal cholecystectomy (SC) is a useful procedure for avoiding bile duct injury in patients with difficult gallbladder. However, risk factors for conversion to SC, especially preoperative magnetic resonance cholangiopancreatography (MRCP) findings that predict conversion to SC, have not been investigated in detail. Methods: A total of 290 patients with acute cholecystitis who underwent laparoscopic cholecystectomy at our hospital between November 2011 and March 2020 were included. Patient characteristics and perioperative outcomes were reviewed, and preoperative clinical factors predicting conversion to SC were investigated. Results: Forty-three patients underwent SC, whereas the remaining 247 patients underwent total cholecystectomy. An American Society of Anesthesiologists (ASA) score of 3 or greater (p = 0.011), surgery on or after 9 days from symptom onset (p < 0.001), obscuration of the gallbladder wall around the neck on MRCP images (p = 0.010) and disruption of the common hepatic duct on MRCP images (p < 0.001) were significantly associated with conversion to SC. Logistic regression analyses revealed that an ASA score of 3 or greater (odds ratio = 2.667, p = 0.020), surgery on or after 9 days from symptom onset (odds ratio = 4.229, p < 0.001) and disruption of the common hepatic duct on MRCP images (odds ratio = 4.478, p = 0.002) were independent predictors for conversion to SC. Conclusions: Early surgery yielded a lower risk for conversion to SC. Disruption of the common hepatic duct on preoperative MRCP images is associated with a risk for conversion to SC. [ABSTRACT FROM AUTHOR]

Background: Acute cholecystitis (AC) is a common surgical emergency. The Tokyo Guidelines 2018 (TG18) provides a reliable algorithm for the treatment of AC patients to achieve optimal outcomes. However, the economic benefits have not been validated. We hypothesize that good outcomes and cost savings can both be achieved if patients are treated according to the TG18. Method: This retrospective study included 275 patients who underwent cholecystectomy in a 15-month span. Patients were divided into three groups (group 1: mild AC; group 2: moderate AC with American Society of Anesthesiologists (ASA) physical status class ≤ 2 and Charlson Comorbidity Index (CCI) score ≤ 5; and group 3: moderate AC with ASA class ≥ 3, CCI score ≥ 6, or severe AC). Each group was further divided into two subgroups according to management (followed or deviated from the TG18). Patient demographics, clinical outcomes, and hospital costs were compared. Results: For group 1 patients, 77 (81%) were treated according to the TG18 and had a significantly higher successful laparoscopic cholecystectomy (LC) rate (100%), lower hospital cost ($1896 vs $2388), and shorter hospital stay (2.9 vs 8 days) than those whose treatment deviated from the TG18. For group 2 patients, 50 (67%) were treated according to the TG18 and had a significantly lower hospital cost ($1926 vs $2856), shorter hospital stay (3.9 vs 9.9 days), and lower complication rate (0% vs 12.5%). For group 3 patients, 62 (58%) were treated according to the TG18 and had a significantly lower intensive care unit (ICU) admission rate (9.7% vs 25%), but a longer hospital stay (12.6 vs 7.8 days). However, their hospital costs were similar. Early LC in group 3 patients did not have economic benefits over gallbladder drainage and delayed LC. Conclusion: The TG18 are the state-of-the-art guidelines for the treatment of AC, achieving both satisfactory outcomes and cost-effectiveness. [ABSTRACT FROM AUTHOR]