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Background: We compared the clinical outcomes of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD) with those of emergency LC (ELC) in patients with mod...

Introduction Laparoscopic cholecystectomy is the most frequent procedure for the general surgeon. Biliary injury is a concern that must be addressed with the purpose of lowering the rate. The critical view of safety (CVS) is a target of dissection that impulses safety during the procedure. Objective Determine by an ambispective analysis the safety during dissection of laparoscopic cholecystectomy in Hospital Civil de Culiacan (Mexico). Methods Descriptive, ambispective, observational, cross-sectional. Patients admitted to the operating room for a laparoscopic cholecystectomy were scored with Doublet photography rating criteria from January 1st 2015 to January 31, 2017. Results 321 patients were evaluated, 77.9% were female and 22.1% male. The mean age was 45.57 ± 16.17 years. 65.4% had admission diagnosis of cholelithiasis, 24.3% acute cholecystitis, 5.9% chronic cholecystitis, 3.7% hydrocolecist and 0.6% pyocolecist. Surgeries were scored with Doublet photography. The CVS was obtained in 41.4% of the procedures with a statistical significance between a HPB surgeon and a general surgery resident (p ≤ 0.05). Conclusion Recording Doublet photography provides a reliable CVS dissection criterion. It can be easily reproduced during laparoscopic cholecystectomy. The identification of cystic structures adds to the culture of safety during laparoscopic cholecystectomy.

Resumen Introduccion El objetivo principal de nuestro estudio es valorar la seguridad y la eficacia de la colecistostomia percutanea para el tratamiento de la colecistitis aguda determinando la incidencia de efectos adversos que presentan los pacientes sometidos a este procedimiento. Material y metodo Estudio observacional con inclusion consecutiva de todos los pacientes con diagnostico de colecistitis aguda durante 10 anos. La variable principal estudiada ha sido la morbilidad (efectos adversos) recogida de forma prospectiva. Seguimiento minimo de un ano de los pacientes sometidos a colecistostomia percutanea. Resultados De 1.223 pacientes ingresados por colecistitis aguda, 66 pacientes han precisado colecistostomia percutanea. El 21% de estos han presentado algun efecto adverso, con un total de 22 efectos adversos. Tan solo 5 de estos efectos, presentados por 5 pacientes (7,6%), han podido ser atribuidos al propio drenaje vesicular. La mortalidad asociada a la tecnica es del 1,5%. Tras la colecistostomia un tercio de los pacientes (22 pacientes) han sido sometidos a colecistectomia. Se ha realizado intervencion quirurgica urgente por fracaso del tratamiento percutaneo en 2 pacientes, y diferida en otros 2 pacientes por recidiva del proceso inflamatorio. El resto de los pacientes colecistectomizados han sido intervenidos de forma programada pudiendose llevar a cabo el procedimiento de forma laparoscopica en 16 pacientes (72,7%). Conclusion Consideramos la colecistostomia percutanea como tecnica segura y eficaz por relacionarse con una baja incidencia de morbimortalidad, debiendose considerar como alternativa puente o definitiva en aquellos pacientes no tributarios de colecistectomia urgente tras fracaso del tratamiento conservador con antibiotico.

Background Strasberg proposed classifying subtotal cholecystectomy techniques into fenestrating (fSC) and reconstituting (rSC) subtypes. The aim of this study is to compare our outcomes of laparoscopic subtotal cholecystectomies of both subtypes against laparoscopic total cholecystectomy (TC) in difficult emergency laparoscopic cholecystectomies. Methods Patients undergoing emergency laparoscopic cholecystectomy were identified over 2 years and all Nassar scale 3 and 4 cholecystectomies were included for analysis. Results 108 fSC and 24 rSC were compared against 317 TC. Patients undergoing fSC and rSC were older and more likely to be male. fSC (128 min) and rSC (141 min) recorded longer median operative times than TC (109). Post-operative ERCP was more common after rSC (16.7%). Patients undergoing fSC (2 days) and rSC (3.5 days) had longer post-operative stays. Bile leaks were more likely in fSC (9.3%) and rSC (8.3%) compared to TC (1.9%), Long term morbidity was higher in the rSC group (12.5% vs 10%). And these were solely due to gallbladder remnant complications. Conclusion Laparoscopic fSC and rSC techniques are associated with a higher rate of bile leaks and rSC has more long term morbidty as compared to TC.

The incidence of acute cholecystitis has a seasonal peak in summer. However, the reason for such seasonality remains unclear. This retrospective cohort study was performed to examine the association between ambient temperature and acute cholecystitis.We identified admissions for acute cholecystitis from January 2011 to December 2017 from a nationwide inpatient database in Japan. We performed a Poisson regression analysis to investigate the association between ambient temperature and admission for acute cholecystitis with adjustment for relative humidity, national holidays, day of the week, and year. We accounted for clustering of the outcome within prefectures using a generalized estimating equation.We analyzed 601 665 admissions for acute cholecystitis. With an ambient temperature of 5.0 °C-9.9 °C as a reference, Poisson regression showed that the number of admissions increased significantly with increasing temperature (highest above 30 °C; relative risk, 1.35; 95% confidence interval, 1.34-1.37). An ambient temperature of5.0 °C was also associated with higher admission for acute cholecystitis than an ambient temperature of 5.0 °C-9.9 °C (relative risk, 1.23; 95% confidence interval, 1.21-1.25).The present nationwide Japanese inpatient database study showed that high temperature (≥10.0 °C) and low temperature (5.0 °C) were associated with increased admission for acute cholecystitis.

Жовчнокам’яна хвороба та запальні захворювання жовчних шляхів становлять серйозну проблему в галузі охорони здоров’я в розвинених країнах. Гострий холецистит є третьою з основних причин екстреної госпіталізації в хірургічне відділення, і з віком його частота збільшується. Гострий холецистит визначається як гостре запалення жовчного міхура, що часто спостерігається за наявністю жовчних каменів. Методи лікування гострого холециститу варіюють в різних медичних центрах по всьому світу. У деяких лікарнях, в основному в США, найбільш поширеним методом лікування є рання лапароскопічна холецистектомія протягом 72 годин від появи симптомів або госпіталізації. Проте у Великобританії та багатьох інших центрах Європи лікування гострого холециститу є консервативним (голод, внутрішньовенне введення рідини та антибіотики), у цьому випадку лапароскопічна холецистектомія відкладається. Причини затримки операції різняться між установами і базуються на припущені про зниження ускладнень під час хірургічного втручання, даних про наявність місць та графіка виконання операцій, витратах і політиці лікарні. Протягом багатьох років цей підхід показав відносно низьку частоту ускладнень, в основному тих, що стосуються травми жовчних протоків, — < 1 %. Але сучасні підходи, що засновані на принципах доказової медицини, довели безпеку й ефективність ранньої лапароскопічної холецистектомії, що аналогічна відстроченій. Протягом останніх п’яти років було розроблено кілька настанов щодо регулювання інфекції жовчних шляхів. Вони включають у себе кампанію за виживання хворих на сепсис (Surviving Sepsis Campaign, 2008) і рекомендації з лікування складних внутрішньочеревних інфекцій, розроблені Хірургічною асоціацією Північної Америки з інфекцій (Surgical Infection Society — SIS-НС) і Асоціацією інфекційних хвороб Америки (Infectious Diseases Society of America — IDSA) 2010 року. Крім того, були затверджені нові препарати та режими дозування, у тому числі схеми з більш високими дозами для піперациліну/тазобактаму, меропенему, левофлоксацину та дорибаксу. Були з’ясовані проблеми фармакокінетики і фармакодинаміки антибактеріальних препаратів. З моменту виходу Токійських рекомендацій 2007 р. детальніше повідомлялося про появу резистентності до антибактеріальних препаратів серед клінічних штамів ентеробактерій у пацієнтів із позалікарняною внутрішньочеревною інфекцією, що зумовило появу розширеного спектра бета-лактамази (extended-spectrum β-lactamase) і карбапенемів. Нарешті, в оновлених Токійських рекомендаціях 2013 р. були переглянуті діагностичні критерії та ступінь тяжкості гострого холециститу та холангіту відповідно до нової структури антибактеріальної терапії. Антибактеріальні препарати повинні використовуватися розумно при антимікробній терапії в кожній установі, в області та країні. Недавнє глобальне поширення антибактеріальної резистентності дає підставу для запобігання їй у сучасній практиці. Токійські рекомендації 2013 р. забезпечують практичне керівництво для лікарів і хірургів, які беруть участь в лікуванні позалікарняної та нозокоміальної гострої жовчної інфекції. У цьому питанні залишається багато невизначеного. Безперервний моніторинг місцевої стійкості до антибактеріальних препаратів і подальші дослідження при гострому холециститі та холангіті мають бути виправданими.

Background: Laparoscopic cholecystectomy (LCC) carries a 0.3-1.8% risk of bile duct injury (BDI). This study investigated if intraoperative photo documentation of the critical view of safety (CVS) is related to lower rates of BDIs and postoperative complications in LCC. Methods: Surgeons were instructed to take photos of the view before clipping the cystic duct and artery. Two independent raters scored the photos 0-6 using predefined criteria for CVS. Mean scores of >= 4.5 were satisfactory. Results: The study consisted of 1532 patients undergoing LCC between April 2018 and October 2019. CVS was satisfactory in 354 (23.1%), unsatisfactory in 823 (53.7%), and photos were missing in 355 (23.2%) patients. Patients with satisfactory CVS had the lowest BDI rate compared with unsatisfactory CVS or missing photos (0.3% vs. 1.0% vs. 2.3%, p = 0.012). Four major BDIs (Strasberg D-E) occurred, but none in patients with satisfactory CVS. Patients with satisfactory CVS had the lowest postoperative complication rate compared with patients with unsatisfactory CVS or without photos (4.8% vs. 7.9 vs. 9.9%, p = 0.011). Of patients with acute cholecystitis, 15.7% had satisfactory CVS, whereas 26.8% without cholecystitis had satisfactory CVS (p < 0.001). Conclusion: Intraoperative photo documentation of satisfactory CVS is associated with lower rates of BDIs and complications.

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; p0.001). 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.

Objective To provide optimal health care for patients with acute cholecystitis in need of acute cholecystectomy, resource allocation has to be optimized. The aim of this study was to assess possible regional inequity regarding the treatment of acute cholecystitis and explore regional differences in the management of acute cholecystitis. Methods Data were retrieved from the Swedish National Register for Gallstone Surgery and Endoscopic Retrograde CholangioPancreatography. Between January 2010 and December 2019, 22,985 patients who underwent cholecystectomy for acute cholecystitis and without prior history of acute cholecystitis were included in the study. The ratio of cholecystectomies with acute cholecystitis performed within two days of admission to hospital compared to population density was studied. Furthermore, the proportion of acute performed cholecystectomies within two days of admission in regions, with or without tertiary care centers, was also examined. Results No correlation between population density and proportion of acute performed cholecystectomies was found. Regions without tertiary care centers had a higher proportion of acute cholecystectomies performed within two days (5-10%). The difference in the ratio of acute cholecystectomies within two days of admission was significant for all years investigated except 2010. Conclusions The presence of a tertiary referral center within the region had a greater influence than the population density on the chance of undergoing acute cholecystectomy for patients with acute cholecystitis. There are several potential explanations for this, one being an interference of the needs of patients requiring tertiary referral center care with the needs of patients in need of acute care surgery.

Zusammenfassung Hintergrund Die Standardtherapie der akuten Cholezystitis ist die laparoskopische Cholezystektomie. Bei Patienten mit hohem Operationsrisiko kommen alternative Verfahren zur Anwendung. Die perkutane Drainage ist allgemein verfügbar. Die alternative transpapilläre Drainage der Gallenblase über den Ductus cysticus hat nur begrenzte Erfolgsaussichten. Mit der weiten Verbreitung der interventionellen Endosonografie und der Entwicklung neuer Stentsysteme hat sich die endosonografische Gallenblasendrainage als sicheres und zuverlässiges Verfahren erwiesen. Material und Methode Wir berichten retrospektiv über unsere Erfahrungen mit der endosonografischen Gallenblasendrainage an 11 konsekutiven Patienten bei akuter Cholezystitis zwischen Dezember 2018 und Januar 2021. Ergebnisse Es wird über 11 Patienten mit akuter Cholezystitis mit einem mittleren Lebensalter von 84,5 Jahren (70–95 Jahre) berichtet. Bei allen Patienten lagen schwere allgemeine Begleitkrankheiten oder fortgeschrittene abdominelle Tumoren beziehungsweise die Kombination beider Konditionen vor. Nach interdisziplinärer Beratung wurde die Indikation zur interventionellen Therapie gestellt. Diese wurde in 9 Fällen mittels alleiniger endosonografischer Drainage und in 2 Fällen mittels perkutaner und zweizeitiger endosonografischer Drainage durchgeführt. Technischer Erfolg wurde bei 10 Fällen (91%), klinischer Erfolg bei 9 Fällen (82%) erzielt. Es gab in 2 Fällen prozedurenbezogene Komplikationen, die zur Operation führten. Schlussfolgerung Im Falle hoher Operationsrisiken stellt die endosonografische Drainage der Gallenblase eine sichere und definitive Therapie dar. Diese kann allein oder in Kombination mit einer perkutanen Drainage erfolgen. Die endosonografische Drainage ist der alleinigen perkutanen Drainage durch geringere Komplikationsraten und niedrigere Raten notwendiger Folgeeingriffe überlegen. Daher sollte in Fällen eines inadäquat hohen Operationsrisikos die endosonografische Drainage der Gallenblase der perkutanen vorgezogen worden, vor allem, wenn eine definitive Therapie erforderlich ist.

Background Cholecystitis is one of the most common infections treated surgically in the United States. Surgical risk is prohibitive in some patients, leading to alternative therapeutic strategies, including medical management (antibiotics) with or without percutaneous cholecystostomy tube (PCT) drainage. Materials and methods Using the Healthcare Cost and Utilization Project (HCUP) National Readmission Database (NRD), we performed a retrospective review to compare medically managed patients with or without PCT placement by evaluating 60-day readmissions rates, health care costs, and hospital length of stay (LOS). Both study groups were matched using the Elixhauser comorbidity index, age, and sex. Univariate and multivariate statistical analyses were performed using STATA. Results 776,766 patients were included in the analysis. The population receiving PCT placement was on average 16 years older (69.9 vs 53.6 years; P < .01), less likely to be female (40.7% vs 59.3%; P < .01), and had almost twice as many comorbidities (3.36 vs 1.81; P < .01) compared to the population receiving medical management. After matching our data to account for these incongruities, PCT patients were still 10.4 times more likely to be readmitted, had a 11.6% increase in the cost of care, and a 37.6% increase in LOS compared to those managed medically. Discussion Percutaneous cholecystostomy tube placement for cholecystitis is associated with a higher readmission rate, increased charges, and increased LOS compared to antibiotic therapy alone, even after correcting for age, sex, and comorbidities.

Background The morbidity and mortality rates associated with cholecystectomy for acute cholecystitis are higher in the critically ill elderly population. As an alternative to cholecystectomy, we report the results of treatment of acute cholecystitis in the elderly after open cholecystolithotomy with cholecystostomy tube placement under local anesthesia. Methods A case series was performed on 5 patients from August 2007 to April 2010 who presented with acute cholecystitis and underwent an open cholecystolithotomy and tube placement. Thirty-day mortality, intra- and immediate-postoperative complications, clinical improvement after drainage, additional biliary procedures needed, and outcome after cholecystostomy tube removal were recorded. Results Open cholecystolithotomy and tube placement were performed successfully in all patients and permitted resolution of the acute attack in all after a mean period of 3.75 days. Thirty-day mortality was 0%. Patients did not experience any intraoperative complications. We observed 100% rate of successful short-term outcomes in our patients including resolution pain, and objectively, normalization of leukocytosis, and defervescence. None of the patients required emergency cholecystectomy. All patients had their cholecystostomy tubes removed at a mean postoperative day 27. There were no cases of biliary leakage or tube dislodgement. There were no recurrences of acute cholecystitis within the mean follow-up of 20.75 months. Discussion Emergency open cholecystolithotomy and cholecystostomy tube placement represent an effective, safe, and definitive alternative treatment strategy for acute gallstone cholecystitis in selected elderly patients with a mortality rate of 0% in the authors’ experience.

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. 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. 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. 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.

Background The outcome of percutaneous cholecystostomy (PC) in malignant patients with acute cholecystitis (AC) after biliary stent insertion has not been investigated in a large group. Purpose To evaluate the clinical outcomes of PC for AC after stent insertion in patients with malignant biliary obstruction. Material and Methods From April 2007 to February 2019, 107 patients (57 men, 52 women; mean age = 67.5 years; age range = 27–93 years) who had undergone PC for AC after biliary stent insertion were retrospectively evaluated. Of the 107 patients, 86 underwent biliary stent insertion by the endoscopic approach and the remaining 21 patients by the percutaneous approach. All patients were classified into three groups: those with stent-induced AC; those with cancer-induced AC; and those with AC without mechanical cause (biliary stent, GB stone, or cancer invasion). The mean survival time, recurrence rate, symptom improvement, and cystic duct patency in each patient group were analyzed. Results Stent-induced AC (n = 40, 37.4%) developed with a mean onset time of six days (range = 0–14 days), AC without mechanical cause (n = 27, 25.2%), 87 days (range = 15–273 days), and cancer-induced AC (n = 40, 37.4%), 137 days (range = 15–447 days) after stent insertion. Symptom resolution and significant improvement in laboratory test values were achieved in 95 patients (88.8%) within four days after PC. Conclusion PC is a technically safe and effective method for the treatment of AC after biliary stent insertion in patients with malignant biliary obstruction.

Актуальность. После лапароскопических холецистэктомий (ЛХЭ) при остром холецистите (ОХ) часто возникают послеоперационная тошнота и рвота (ПОТР), седация, дегидратация, послеоперационная боль. Цель: определить оптимальный метод анестезиологического обеспечения при ЛХЭ по поводу ОХ. Материалы и методы. К исследованию привлечены 339 больных, прооперированных по поводу ЛХЭ в КУ КОС «Киевская областная клиническая больница» за пе­риод 2013–2017 годы. Больные были распределены на 3 группы в соответствии со схемой анестезиологического обеспечения. В 1-й группе (n = 112) проводилась анестезия без использования опиоидов (дексмедетомидин, лидокаин, пропофол) и искусственной вентиляции легких (ИВЛ). Вторая группа (n = 117): прoпoфoл с фентанилом и ИВЛ. В 3-й группе (n = 110) проводился наркоз ceвoфлурaнoм в комбинации с фентанилом и ИВЛ. В послеоперационном периоде все больные получали перорально парацетамол 500 мг (до 4 раз в сутки), декскетопрофена трометамол 25 мг (до 3 раз в сутки), а при неэффективности обезболивания (оценка по ВАШ свыше 4 баллов): в 1-й группе — трамадол 100 мг, во 2-й и 3-й группах — морфин 5–10 мг внутримышечно. Результаты. В 1-й группе в начале операции показатели частоты сердечных сокращений и средние значения артериального давления после индукции, при интубации на 3, 5 и 7-й минутах пневмоперитонеума были значительно выше, чем в других группах (p < 0,05). Только один пациент 1-й группы требовал ондансетрона для лечения ПОТР против 8 и 6 больных 2-й и 3-й групп соответственно (р < 0,05). Оценки послеоперационной боли у пациентов разных групп были идентичными и не имели статистической разницы (p > 0,05). Выводы. Для анестезиологического обеспечения ЛХЭ по поводу ОХ может быть использована любая из предложенных методик. При использовании безопиоидной анестезии в интраоперационном периоде чаще регистрировались гипертензивные реакции и тахикардия, однако в послеоперационном периоде были ниже показатели использования анальгетиков спасения и частота развития ПОТР. Таким образом, безопиоидная анестезия при ЛХЭ наиболее показана пациентам с рисками развития ПОТР и опийной наркоманией в анамнезе.

BACKGROUND There are several case reports of acute cholecystitis as the initial presentation of lymphoma of the gallbladder; all reports describe non-Hodgkin lymphoma or its subtypes on histopathology of the gallbladder tissue itself. Interestingly, there is no description in the literature of Hodgkin lymphoma causing hilar lymphadenopathy, inevitably presenting as ruptured cholecystitis with imaging mimicking gallbladder adenocarcinoma. CASE SUMMARY A 48-year-old man with a past medical history of diabetes mellitus presented with progressive abdominal pain, jaundice, night sweats, weakness, and unintended weight loss for one month. Work-up revealed a mass in the region of the porta hepatis causing obstructions of the cystic and common hepatic ducts, gallbladder rupture, as well as retroperitoneal lymphadenopathy. The clinical picture and imaging findings were suspicious for locally advanced gallbladder adenocarcinoma causing ruptured cholecystitis and cholangitis, with metastases to retroperitoneal lymph nodes. Minimally invasive techniques, including endoscopic duct brushings and percutaneous lymph node biopsy, were inadequate for tissue diagnosis. Therefore, this case required exploratory laparotomy, open cholecystectomy, and periaortic lymph node dissection for histopathological assessment and definitive diagnosis. Hodgkin lymphoma was present in the lymph nodes while the gallbladder specimen had no evidence of malignancy. CONCLUSION This clinical scenario highlights the importance of histopathological assessment in diagnosing gallbladder malignancy in a patient with gallbladder perforation and a grossly positive positron emission tomography/computed tomography scan. For both gallbladder adenocarcinoma and Hodgkin lymphoma, medical and surgical therapies must be tailored to the specific disease entity in order to achieve optimal long-term survival rates.

Introduction The covid‐19 pandemic has had a drastic impact on all medical services. Acute cholecystitis is a serious condition that accounts for a considerable percentage of general surgical acute admissions. Therefore, the Royal College of Surgeons' Commissioning guidance' recommended urgent admission to secondary care and early cholecystectomy. During the first wave of hospital admissions associated with COVID‐19, most guidelines recommended conservative treatment in order to limit the admission rates and free up spaces for COVID‐19‐infected patients. However, reviews of this approach have not been widely done to assess the results and, in turn, planning our future management approach when future pressures on in‐patient admissions are inevitable. Methods Our study included all acute cholecystitis patients who needed surgical intervention in one Centre in the UK over three distinct periods (pre‐COVID‐19, during the first lockdown, and lockdown ease). Comparison between these groups were done regarding intraoperative and postoperative results. Results The conservative management led to a high rate of readmission. Moreover, delayed cholecystectomy was associated with increased operative difficulties such as extensive adhesions, intraoperative blood loss, and/or complicated gall bladder pathologies such as perforated or gangrenous gall bladder (29.9%, 16.7%, and 24.8%, respectively). The resulting postoperative complications of surgical and nonsurgical resulted in a longer hospital stay (13.5 d). Conclusion The crisis approach for acute cholecystitis management failed to deliver the hoped outcome. Instead, it backfired and did the exact opposite, leading to longer hospital stays and extra burden to the patient and the healthcare system.

ZusammenfassungDie Cholezystektomie ist der Goldstandard in der Behandlung der akuten Cholezystitis, hat aber bei multimorbiden Patienten oder bei schwerem Verlauf der akuten Cholezystitis ein deutlich erhöhtes OP-Risiko. In solchen Fällen kann eine Drainage der entzündeten Gallenblase in Kombination mit antibiotischer Therapie der primären Operation überlegen sein. Die Drainage kann entweder als sonografisch geführte perkutan transhepatische Gallenblasendrainage, als EUS-geführte transmurale Stentplatzierung oder endoskopisch-transpapilläre Gallenblasendrainage erfolgen. Diese minimalinvasiven Alternativen zur Cholezystektomie können sowohl als Langzeittherapie bei dauerhaft inoperablen Patienten als auch vorübergehend bei Patienten eingesetzt werden, bei denen die Cholezystektomie nach Verbesserung des Allgemeinzustands angestrebt wird.In dieser Übersicht werden die verschiedenen Drainagemethoden im Hinblick auf technische Anforderungen sowie klinische Sofort- und Langzeitergebnisse und Komplikationen diskutiert. Mit Fortschritten im Stentdesign entwickelt sich die EUS-geführte transmurale Stentplatzierung von Magen oder Duodenum in die Gallenblase zur bevorzugten Methode der Gallenblasendrainage in Zentren mit entsprechender Expertise.

Background/Aim: Percutaneous cholecystostomy (PC) is an alternative procedure to surgery in selected patients with acute cholecystitis (AC). This study aimed to review the clinical and surgical results of patients who underwent percutaneous cholecystostomy. Methods: The records of patients who underwent PC for AC were evaluated for age, gender, comorbidities, survey, catheterization timing, complications, control, removal timing, operation type, interval time, pathology, C-reactive protein (CRP) level and white blood cell count (WBC), ultrasonography (USG) and computed tomography (CT) results. Results: One hundred and thirty-six AC patients who underwent PC were included in the study. The median age was 73 (32-96) years and 57.3% of the patients were male. Out of the 136, 106 (78%) had an American Society of Anesthesiologists (ASA) classification score of 3 or 4. The median Charlson’s comorbidity index (CCI) score was 5 (0-13). The median timing of catheterization was 23 (20-144) hours and length of hospital stay (LOS) was 3 (1-25) days. Dislocation was the most common complication of PC, and 7.4% (n=10) had recurrent AC. The median time until tube removal was 26.5 (1-238) days. Among all, 41.2% (n=56) of the patients underwent interval cholecystectomy, which equates to 76.8% of the those performed laparoscopically. The median time until the operation was 100 (1-264) days. Chronic cholecystitis was the most common pathology of cholecystectomy after PC. Bacterial bile cultures were analyzed in 36 of the patients and showed positive results in 66.7%, with no overall effect on the outcome. Nine patients (6.6%) died.Conclusion: The importance of PC in AC increased with the Covid19 pandemic. PC was performed especially for old patients with ASA ≥3, and CCI ≥5 due to lower complication and recurrence rates. PC could be the final treatment for selected AC patients. Interval cholecystectomies performed after 8 weeks had a shorter LOS and a lower rate of complication.

Gallbladder diseases are an important health concern affecting approximately 20% of the population in developed countries. Acute cholecystitis is the most common complication of gallstones. The aim of our study is to determine the use of Nesfatin-1, which is an easily applicable and fast resulting and is thought to have an association with inflammatory events, in the diagnosis and grading of acute cholecystitis.Patients who admitted and were hospitalized and treated with the acute cholecystitis diagnosis in İstanbul Training and Research Hospital between July 1, 2020, and December 1, 2020, were included in the study. The patients were divided in threemain groups as mild, moderate, and severe according to Tokyo Guidelines 2018 based on their routine blood tests and imaging results. All patients who are included in the study were tested for their blood leukocyte, neutrophil, lymphocyte, Nesfatin-1 levels, and neutrophil/lymphocyte ratios within the first 24 h of their hospitalization.With at least 15 patients in each group, 61 volunteers in total were included in the study as healthy volunteers, mild, moderate, and severe cholecystitis. The average age of the participants were 58.11±19.76 years. About 47.54% of the participants were female and 52.46% weremale. In the study, Nesfatin-1 levels in the patient groups were found to be lower than the control group. In the subgroup analyzes, Nesfatin-1 values in the middle patient group were found to be significantly lower than the control group; however, there was no statistically significant relationship between the severity of the disease and Nesfatin-1.Nesfatin-1 may guide the clinician for the diagnosis of the disease; however, no significant relationship was found between Nesfatin-1 and the severity or stage of the disease.

BACKGROUND Percutaneous transhepatic gallbladder drainage has been the most frequently performed treatment for acute cholecystitis for patients who are not candidates for surgery. Endoscopic transpapillary gallbladder drainage (ETGBD) has evolved into an alternative treatment. There have been numerous retrospective and prospective studies evaluating ETGBD for acute cholecystitis, though results have been variable. AIM To evaluate the efficacy and safety of ETGBD in the treatment of inoperable patients with acute cholecystitis. METHODS We performed a systematic review of major literature databases including PubMed, OVID, Science Direct, Google Scholar (from inception to March 2021) to identify studies reporting technical and clinical success, and post procedure adverse events in ETGBD. Weighted pooled rates were then calculated using fixed effects models for technical and clinical success, and post procedure adverse events, including recurrent cholecystitis. RESULTS We found 21 relevant articles that were then included in the study. In all 1307 patients were identified. The pooled technical success rate was 82.62% [95% confidence interval (CI): 80.63-84.52]. The pooled clinical success rate was found to be 94.87% (95%CI: 93.54-96.05). The pooled overall complication rate was 8.83% (95%CI: 7.42-10.34). Pooled rates of post procedure adverse events were bleeding 1.03% (95%CI: 0.58-1.62), perforation 0.78% (95%CI: 0.39-1.29), peritonitis/bile leak 0.45% (95%CI: 0.17-0.87), and pancreatitis 1.98% (95%CI: 1.33-2.76). The pooled rates of stent occlusion and migration were 0.39% (95%CI: 0.13-0.78) and 1.3% (95%CI: 0.75-1.99) respectively. The pooled rate of cholecystitis recurrence following ETGBD was 1.48% (95%CI: 0.92-2.16). CONCLUSION Our meta-analysis suggests that ETGBD is a feasible and efficacious treatment for inoperable patients with acute cholecystitis.

Introduction The Coronavirus-19 (COVID-19) pandemic has led to a 50–70% reduction in acute non-COVID-19 presentations to emergency departments globally. Aim To determine the impact of COVID-19 on incidence, severity, and outcomes of acute surgical admissions in an Irish University teaching hospital. Methods Descriptive data concerning patients presenting with acute appendicitis, diverticulitis, and cholecystitis were analysed and compared from March–May 2020 to March–May 2019. Results Acute surgical admissions decreased in March from 191 (2020) to 55 (2019) (55%), before increasing by 28% in April (2019: 119, 2020: 153). Admissions due to acute cholecystitis reduced by 33% (2019: 33, 2020: 22), with increased severity at presentation (P = 0.079) and higher 30-day readmission rates (P = 0.056) reported. Acute appendicitis presentations decreased by 44% (2019: 78, 2020: 43, P = 0.019), with an increase in severity (P P P = 0.029) in 2020 compared to the same period in 2019. Conclusion COVID-19 has potentiated a significant reduction in acute surgical presentations to our hospital. Patients presenting with acute appendicitis during the pandemic had more severe disease, were more likely to have complications, and were significantly more likely to be managed conservatively when compared to historical data.

Artificial intelligence and computer vision have revolutionized laparoscopic surgical video analysis. However, there is no multi-center study focused on deep learning-based laparoscopic cholecystectomy phases recognizing. This work aims to apply artificial intelligence in recognizing and analyzing phases in laparoscopic cholecystectomy videos from multiple centers. This observational cohort-study included 163 laparoscopic cholecystectomy videos collected from four medical centers. Videos were labeled by surgeons and a deep-learning model was developed based on 90 videos. Thereafter, the performance of the model was tested in additional ten videos by comparing it with the annotated ground truth of the surgeon. Deep-learning models were trained to identify laparoscopic cholecystectomy phases. The performance of models was measured using precision, recall, F1 score, and overall accuracy. With a high overall accuracy of the model, additional 63 videos as an analysis set were analyzed by the model to identify different phases. Mean concordance correlation coefficient for annotations of the surgeons across all operative phases was 92.38%. Also, the overall phase recognition accuracy of laparoscopic cholecystectomy by the model was 91.05%. In the analysis set, there was an average surgery time of 2195 ± 896 s, with a huge individual variance of different surgical phases. Notably, laparoscopic cholecystectomy in acute cholecystitis cases had prolonged overall durations, and the surgeon would spend more time in mobilizing the hepatocystic triangle phase. A deep-learning model based on multiple centers data can identify phases of laparoscopic cholecystectomy with a high degree of accuracy. With continued refinements, artificial intelligence could be utilized in huge data surgery analysis to achieve clinically relevant future applications.

To compare conventional and dual-energy CT (DECT) for the diagnosis of acute cholecystitis and gangrene. Fifty-seven consecutive adult patients with abdominal pain who underwent IV contrast-enhanced abdominal DECT on a dual-layer (dlDECT) or rapid-switching (rsDECT) scanner from September, 2018 to April, 2021 with cholecystectomy and pathology-confirmed cholecystitis were retrospectively reviewed, and compared with 57 consecutive adult patients without cholecystitis from the same interval scanned with DECT. Images were reviewed independently by two abdominal radiologists with 12 and 16 years of experience in two sessions 4 weeks apart, blinded to clinical data. Initially, only blended reconstructions (simulating conventional single-energy CT images) were reviewed (CT). Subsequently, CT and DECT reconstructions including low-keV virtual monoenergetic images and iodine maps were reviewed. Gallbladder fossa hyperemia, pericholecystic fluid, subjective presence of gangrene, heterogeneous wall enhancement, sloughed membranes, intramural air, abscess, overall impression of the presence of acute cholecystitis, and intramural iodine density were assessed. Gallbladder fossa hyperemia was detected with increased sensitivity on DECT (R1, 61.4%; R2, 75.4%) vs. CT (R1, 22.8%; R2, 15.8%). DECT showed increased sensitivity for gangrene (R1, 24.6%; R2, 38.6%) vs. CT (R1, 5.3%; R2, 14%), heterogeneous wall enhancement (DECT: R1, 33.3%; R2, 63.2% vs. CT: R1, 7%; R2, 31.6%), and cholecystitis (DECT: R1, 86%; R2, 89.5% vs. CT: R1, 77.2%; R2, 70.2%). In addition, DECT was more sensitive for the detection of acute cholecystitis (R1, 86%; R2, 89.5%) vs. CT (R1, 77.2%; R2, 70.2%). Iodine density threshold of 1.2 mg/ml, 0.8 mg/mL, and 0.5 mg/mL showed specificity for gangrenous cholecystitis of 78.26%, 86.96%, and 95.65%, respectively, using the rsDECT platform. DECT showed improved sensitivity compared to conventional CT for detection of acute cholecystitis. Iodine density measurements may be helpful to diagnose gangrene.

Acute calculous cholecystitis (AC) is a syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation. In the preoperative planning, the severity of AC should be considered as well as time of onset of symptoms and patient comorbidities. The aim of the present study was to investigate the role of an early PCT assessment in the emergency department in predicting the outcomes of laparoscopic surgery for AC. Retrospective, mono-centric study conducted in a teaching urban hospital. We evaluated all patients admitted to our ED from January 1st, 2015, to December 31st, 2019, underwent laparoscopic cholecystectomy for AC having a preoperative PCT determination in ED. A total of 2285 patients in our ED were admitted for AC. Among them 822 patients were treated surgically, 174 had a PCT determination in ED. Median age was 63 [50–74]. Overall, 33 patients (19.0%) had major complications (MC): 32 needed an open surgery conversion, and 3 among them deceased. Multivariate analysis demonstrated that PCT, WBC, BUN, and CCI were significantly associated to MC in our cohort. When we calculated the area under the ROC curve with regard to MC, a procalcitonin value > 0.09 at admission had sensitivity = 84.8% [68.1–94.9] and specificity = 51.8% [43.2–60.3] for the occurrence of MC. Our results, suggest that a PCT > 0.09 ng/mL at ED admission, could be associated to a poor surgical outcome in patients treated by laparoscopic surgery for AC.

Background: A laparoscopic cholecystectomy is a fundamental approach to treating acute cholecystitis, and the timing of performing this given treatment is associated with clinical outcomes. It is unknown whether surgical indication, risk, and consequences of laparoscopic cholecystectomy for acute cholecystitis differ from those for the chronic form, making it questionable whether urgent laparoscopic cholecystectomy is the best approach even in severe acute cases. Objective: This study aimed to evaluate surgical indication, risk, and outcomes of laparoscopic cholecystectomy for acute cholecystitis. Methods: This prospective observational study was carried out at Bangladesh Medical College Hospital (Uttara Campus) from July 2006 to November 2008. A total of 103 acute cholecystitis patients were observed to evaluate the safety, risk, and outcomes (includes hospital stay, joining to routine daily works) of laparoscopic cholecystectomy. Result: Male and female ratio is 1:4, and the mean age in our series is 47 years. Acute calculas cholecystitis ultra-sonogram feature shows the highest percentage (85.4%) compare to the other four parts. The study also confirmations around 69% did not get any complications, and bleeding was the most frequently observed (16%) complication. The overall outcomes in this research were observed around 75% of total operated patients did not experience any difficulty and said they fit entirely. The other 19% who had some complications include Pain, RTI, Seroma, Jaundice, Cholangitis, Wound infection). Conclusion: Regarding bile duct injury and prolonged complications, laparoscopic surgery is not a very good treatment option for acute cholecystitis.

Summary. Objective. To improve the results of treatment of patients with jaundice syndrome by improving the diagnosis quality of obstructive jaundice and improving methods of surgical treatment. Materials and methods. The results of diagnosis and treatment of 272 patients with benign jaundice syndrome admitted to the clinic on an urgent basis from 2010 to 2020 were analyzed. Differential diagnosis of the nature of jaundice and its cause was carried out according to ultrasound and ERCP. Results. Based on the revealed differences in the data of histostructures of the gallbladder wall in patients with acute cholecystitis, hepatitis, and liver cirrhosis, we determined ultrasound criteria for the differential diagnosis of mechanical and parenchymal jaundice. Ultrasound made it possible in a short time to determine the obstructive or parenchymal nature of jaundice by the nature of changes in the liver and the wall of the gallbladder. (Patent № 134089 dated April 25, 2019).In cases of mechanical origin of jaundice, ultrasound data helped to establish its cause and determine the tactics of treatment. Conclusion. 1. Morphological changes in the wall of the gallbladder in patients with acute cholecystitis, hepatitis and liver cirrhosis are qualitatively different from each other. 2. The combination of changes in the liver and the wall of the gallbladder revealed by ultrasound examination makes it possible to differentiate parenchymal and obstructive jaundice with a high degree of reliability.

Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting to the emergency department. Ultrasound, computed tomography, HIDA scans, and magnetic resonance imaging are increasingly utilized to evaluate suspected cases. The prognosis of acute cholecystitis is usually excellent with timely diagnosis and management. However, complications associated with cholecystitis pose a considerable challenge to the clinician and radiologist. Complications of acute cholecystitis may result from secondary bacterial infection or mural ischemia secondary to increased intramural pressure. The recognized subtypes of complicated cholecystitis are hemorrhagic, gangrenous, and emphysematous cholecystitis, as well as gallbladder perforation. Acute acalculous cholecystitis is a form of cholecystitis that occurs as a complication of severe illness in the absence of gallstones or without gallstone-related inflammation. Complicated cholecystitis may cause significant morbidity and mortality, and early diagnosis and recognition play a pivotal role in the management and early surgical planning. As appropriate utilization of imaging resources plays an essential role in diagnosis and management, the emergency radiologist should be aware of the spectrum of complications related to cholecystitis and the characteristic imaging features. This article aims to offer a comprehensive contemporary review of clinical and cross-sectional imaging findings of complications associated with cholecystitis. In conclusion, cross-sectional imaging is pivotal in identifying the complications related to cholecystitis. Preoperative detection of this complicated cholecystitis can help the care providers and operating surgeon to be prepared for a potentially more complicated procedure and course of recovery.

OBJECTIVE. The purpose of this study was to report national utilization trends and outcomes after percutaneous cholecystostomy, cholecystectomy, or no intervention among patients admitted to hospitals with acute cholecystitis. MATERIALS AND METHODS. The Nationwide Inpatient Sample was queried from 2005 to 2014. Admissions were identified and stratified into treatment groups of percutaneous cholecystostomy, cholecystectomy, and no intervention on the basis of International Classification of Diseases, 9th revision, codes. Outcomes, including length of stay, inpatient mortality, and complications including hemorrhage and bile peritonitis, were identified. Multivariate analysis was performed to identify mortality risk by treatment type after adjustment for baseline comorbidities and risk of mortality. RESULTS. Among 2,550,013 patients (58.6% women, 41.4% men; mean age, 55.9 years) admitted for acute cholecystitis over the study duration, 73,841 (2.9%) patients underwent percutaneous cholecystostomy, 2,005,728 (78.7%) underwent cholecystectomy, and 459,585 (18.0%) did not undergo either procedure. Use of percutaneous cholecystostomy increased from 2985 procedures in 2005 to 12,650 in 2014. The percutaneous cholecystostomy cohort had a higher mean age (70.6 years) than the other two groups (cholecystectomy, 53.8 years; no intervention, 62.5 years), a higher mean comorbidity index (cholecystostomy, 3.74; cholecystectomy, 1.77; no intervention, 2.65), and a higher mean risk of mortality index (cholecystostomy, 2.88; cholecystectomy, 1.45; no intervention, 2.07) (p < .05). Unadjusted inpatient all-cause mortality was 10.1% in the percutaneous cholecystostomy, 0.8% in the cholecystectomy, and 5.2% in the no intervention cohorts. After adjustment for baseline mortality risk, percutaneous cholecystostomy (odds ratio, 0.78; 95% CI, 0.76-0.81) and cholecystectomy (odds ratio, 0.42; 95% CI, 0.41-0.43) were associated with reduced mortality compared with no intervention. CONCLUSION. Use of percutaneous cholecystostomy is increasing among patients admitted with acute cholecystitis. After adjustment for baseline comorbidities, percutaneous cholecystostomy is associated with improved odds of survival compared with no intervention.

Gallbladder gangrene and perforation are an important complication of acute calculous cholecystitis and are dif-ficult to detect preoperatively. Therefore, in this study, we aimed to evaluate whether serum inflammatory parameters are predictive factors for complicated cholecystitis (CC).In the present study, histopathological findings of 250 patients who were operated on with the diagnosis of acute chole-cystitis (AC) in the emergency department between 2014 and 2019 were evaluated and the cases were divided into two groups as AC and CC. Parameters, including age, gender, body mass index, white blood cell (WBC) count, C-reactive protein (CRP), neutrophil-to-lym-phocyte ratio (NLR), mean platelet volume (MPV), and platelet distribution width (PDW), were examined for their ability to predict CC.The findings obtained in this study showed that WBC, CRP, and NLR were significantly higher in the CC group (p0.05). WBC9.000 cells/ml, CRP29.0, and NLR4.3 were the factors that could predict CC. There was no significant difference between the two groups concerning MPV and PDW (p0.05). CC was observed more frequently in patients over 65 years of age, but there was not a statistically significant difference (p=0468).WBC, CRP, and NLR are valuable biochemical markers in predicting complicated AC. Advanced age may be a help-ful predictive factor for CC. These factors may be helpful in making an early cholecystectomy decision.

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. 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. 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. 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.

Background/Aims: Although endoscopic transpapillary gallbladder drainage (ETGBD) has been reported as an alternative procedure for acute cholecystitis, it requires advanced endoscopic techniques. In terms of the certainty of achieving drainage, it remains a challenging procedure. The aim of the current study was to elucidate the practical efficacy of cholangioscopic assistance and to develop a new classification that could be used to evaluate the technical difficulty of ETGBD and provide a theoretical strategy to apply cholangioscopy appropriately for difficult ETGBD. Methods: A total of 101 patients undergoing ETGBD were retrospectively studied. The characteristics and technical outcomes of ETGBD with conventional ETGBD (C-ETGBD) and Spy- Glass DS-assisted ETGBD (SG-ETGBD) were evaluated. The characteristics and technique-dependent factors of unsuccessful C-ETGBD/SG-ETGBD were evaluated using the classification based on the steps of the procedure. The predictive factors of successful C-ETGBD/SG-ETGBD were examined. Results: C-ETGBD was successful in 73 patients (72.3%). SG-ETGBD was successful in 11 of 13 patients (84.6%) who had C-ETGBD failure. Optional SG-ETGBD significantly increased the final success rate (94.1%) compared to C-ETGBD alone (p=0.003). ETGBD procedures could be classified into four steps. SG-assistance worked as an excellent troubleshooter in step 1 (failure to identify the cystic duct orifice) and step 2 (failure of guidewire advancement across the downturned angle of cystic duct takeoff). Magnetic resonance cholangiopancreatography could provide predictive information based on the classification. Conclusions: Optional SG-ETGBD achieved a significantly higher success rate than C-ETGBD alone. Step classification is helpful for determining the technical difficulty of ETGBD and developing a theoretical strategy to apply cholangioscopy in a coordinated manner. (Gut Liver 2021;15:476-485)

Graphical Abstract fx1, Resumen español Introducción: La pandemia COVID-19 ha tenido una repercusión extraordinaria sobre los hospitales españoles, que han reorganizado sus recursos para tratar a estos pacientes, limitando su capacidad de atender otras patologías frecuentes. El presente estudio analiza la repercusión sobre el tratamiento de la colelitiasis y la colecistitis aguda. Métodos: Se ha realizado un estudio nacional descriptivo mediante una encuesta online voluntaria, realizada en Google Drive™, distribuida por correo electrónico desde la Asociación Española de Cirujanos (AEC) a todos los cirujanos miembros. Resultados: Se han recibido 153 encuestas (una por centro). El 96.7% de ellos han suspendido las colecistectomías electivas. El tratamiento conservador de la colecistitis aguda no complicada se ha realizado en un 90% de los casos (siendo previamente del 18%) y, en las colecistitis intervenidas, el 95% ha optado por abordaje laparoscópico. Un 49% realiza algún test preoperatorio para SARS-CoV-2, y el 57% comunican haber tenido casos de confirmación postoperatoria tras alguna intervención, con peor evolución postoperatoria en el 54%. Conclusiones: Esta encuesta revela que las mayorías de los centros están siguiendo las recomendaciones de las sociedades quirúrgicas durante la pandemia por COVID-19. Sin embargo, se observan algunos datos que precisan ser tenido en cuenta en la fase sucesivas de la pandemia.

Background Acute calculous cholecystitis (ACC) is the second most frequent surgical condition in emergency departments. The recommended treatment is the early laparoscopic cholecystectomy; however, the Tokyo Guidelines (TG) advocate for different initial treatments in some subgroups of patients without a strong evidence that all patients will benefit from them. There is no clear consensus in the literature about who is the unfit patient for surgical treatment. The primary aim of the study is to identify the risk factors for mortality in ACC and compare them with Tokyo Guidelines (TG) classification. Methods Retrospective unicentric cohort study of patients emergently admitted with and ACC during 1 January 2011 to 31 December 2016. The study comprised 963 patients. Primary outcome was the mortality after the diagnosis. A propensity score method was used to avoid confounding factors comparing surgical treatment and non-surgical treatment. Results The overall mortality was 3.6%. Mortality was associated with older age (68 + IQR 27 vs. 83 + IQR 5.5; P = 0.001) and higher Charlson Comorbidity Index (3.5 + 5.3 vs. 0+2; P = 0.001). A logistic regression model isolated four mortality risk factors (ACME): chronic obstructive pulmonary disease (OR 4.66 95% CI 1.7–12.8 P = 0.001), dementia (OR 4.12; 95% CI 1.34–12.7, P = 0.001), age > 80 years (OR 1.12: 95% CI 1.02–1.21, P = 0.001) and the need of preoperative vasoactive amines (OR 9.9: 95% CI 3.5–28.3, P = 0.001) which predicted the mortality in a 92% of the patients. The receiver operating characteristic curve yielded an area of 88% significantly higher that 68% (P = 0.003) from the TG classification. When comparing subgroups selected using propensity score matching with the same morbidity and severity of ACC, mortality was higher in the non-surgical treatment group. (26.2% vs. 10.5%). Conclusions Mortality was higher in ACC patients treated with non-surgical treatment. ACME identifies high-risk patients. The validation to ACME with a prospective multicenter study population could allow us to create a new alternative guideline to TG for treating ACC. Trial registration Retrospectively registered and recorded in Clinical Trials. NCT04744441

Objective: We aimed to find the frequency of gallbladder carcinoma and the relationship between dysplasia and metaplasia, which are among predisposing factors for carcinoma.Material and Methods: In this study, the histopathological results of 815 patients who underwent cholecystectomy between 2016-2019 in Ahi Evran Training and Research Hospital, Department of General Surgery were retrospectively analyzed.Results: Of the patients who underwent cholecystectomy, 591 (72.5%) were female and 224 (27.5%) were male. The average age was 50.5 years for women and 54.1 years for men. The general average age was 51.5 years. Cholecystectomy was performed laparoscopically in 698 (85.6%) patients while in 117 (14.4%) patients the operation was either started as open cholecystectomy or the decision to convert to open cholecystectomy was made later during the operation for different reasons. Gallbladder carcinoma was detected in two (0.24%) patients, one 62-year-old male and one 67-year-old female. The rate of gallbladder carcinoma was 0.4%for male patients and 0.1%for female patients. Metaplasia in the gallbladder was detected in 16 (1.96%) patients, 15 of which were female and one was male. The average age of these patients was 43.6 years. Dysplasia was detected in only a 48-year-old male patient (0.12%).Conclusion: Chronic irritation caused by the presence of gallstones leads to metaplasia which is a precancerous lesion. Therefore, we think that patients with gallstones should be evaluated for surgery or close follow-up, even if they do not have symptoms., Amaç: Çalışmamızda kliniğimizde yapılan kolesistektomileri retrospektif olarak tarayarak safra kesesi karsinomu sıklığını ve karsinom predispozan faktörleri arasında yer alan displazi ve metaplazi arasındaki ilişkiyi bulmayı amaçladık.Gereç ve Yöntemler: Bu çalışmada Ahi Evran Eğitim ve Araştırma Hastanesi Genel Cerrahi Anabilim Dalında 2016-2019 yılları arasında kolesistektomi ameliyatı yapılan 815 hastanın histopatolojik sonuçları retrospektif olarak incelenmiştir.Bulgular: Kolesistektomi yapılan hastaların 591’i (%72.5) kadın 224’ü (%27.5) erkekti. Yaş ortalaması kadınlarda 50.5 yıl, erkeklerde 54.1 yıl olarak bulundu. Genel yaş ortalaması 51.5 yıl idi. Kolesistektomi ameliyatı 698 (%85.6) hastaya laparoskopik olarak yapılmış, 117 (%14.4) hastada ise ya açık olarak başlanmış ya da sonradan farklı sebeplerle açık kolesistektomiye geçilmişti. Biri 62 yaşında erkek, diğeri 67 yaşında kadın olmak üzere iki (%0.24) hastada safra kesesi karsinomu saptandı. Erkek ve kadın cinsiyete göre safra kesesi karsinomu oranı sırasıyla %0.4 ve %.0.1 idi. Safra kesesinde metaplazi 16 (%1.96) hastada saptandı. Hastaların 15 tanesi kadın, bir tanesi erkekti. Bu hastaların yaş ortalaması 43.6 yıl idi. Sadece 48 yaşında bir erkek hastada displazi saptandı (%0.12).Sonuç: Safra taşı varlığının neden olduğu kronik irritasyon, prekanseröz bir lezyon olan metaplaziye yol açmaktadır. Bu nedenle safra taşı olan hastaların semptomları olmasa dahi ameliyat için değerlendirilmesinin ya da yakın takibinin uygun olacağını düşünmekteyiz.

Background: Laparoscopic cholecystectomy (LC) has become the standard treatment for symptomatic cholelithiasis. Bile duct injury and accidental gallbladder perforation with spillage of bile and stone are common complications of LC. This study was carried out to assess the early complications of gallbladder perforation during LC, and identify the risk factor of that perforation. Objectives: to evaluate the early complications which may occur after the perforation of the gallbladder during laparoscopic cholecystectomy and to determine the risk factors which are associated with the perforation of the gall bladder. Subjects and methods: A prospective comparative study on 192 patients who underwent LC between August 2012 to January 2014 in Baghdad teaching hospital. Data were collected, Patients with and without gallbladder perforation were compared in terms of gender, age, anatomic difficulty, the experience of the surgeon, omental and other organ adhesions to the gall bladder. Results: fifty-five patients had a perforation of GB during LC, 46 patients had GB perforated during dissection of gallbladder bed from hepatic fossa. The mean operative time and duration of postoperative hospitalization were longer in the perforated group, perforation occurs more frequently in acute cholecystitis compared to chronic cholecystitis. There were significant risk factors related to gallbladder perforation which include male gender, AC, adhesion around the gallbladder, and experience of the surgeon. Conclusion: accidental gallbladder perforation leading to longer operative and hospital time which loss the advantage of LC. The male gender, AC, and experience of the surgeon had the main risk factors of the perforated gallbladder.

Background. Gallstone ileus is a rare complication of cholelithiasis accounting for 0.3–2.1% total acute intestinal obstructions. The recent years are witnessing a sharply elevated incidence of cholelithiasis and its entailed complications. The major diagnostic biases are the atypical clinical presentation, instrumental and laboratory evidence, and a relative paucity of surgical cases.Aim. Highlighting to surgeons the feasibility of this rare reluctantly diagnosed form of acute small bowel obstruction.Materials and methods. The article presents the clinical observations of gallstone-induced small intestinal obstruction collected at a surgery unit of the Bashkir State Medical University Clinic. Patients had surgeries for cholecystoduodenal fistula embolisation, gastro/enterotomy and lithoextraction followed by gastro/enterotomy wound suturing.Results and discussion. Patients had a benign postoperative period are were discharged in a satisfactory condition on day 7–10 after surgery for outpatient surveillance.Conclusion. Surgeons need to contemplate this pathology to ensure timely diagnosis and treatment, as well as avoid possible complications. Mostly important still is a timely gallbladder resection upon diagnosing cholelithiasis via laparoscopic cholecystectomy as a “gold standard” in treatment for this disease.

Acute cholecystitis can be difficult to diagnose in the emergency department (ED); no single finding can rule in or rule out the disease. A prediction score for the diagnosis of acute cholecystitis for use at the bedside would be of great value to expedite the management of patients presenting with possible acute cholecystitis. The 2013 Tokyo Guidelines is a validated method for the diagnosis of acute cholecystitis but its prognostic capability is limited. The purpose of this study was to prospectively validate the Bedside Sonographic Acute Cholecystitis (SAC) Score utilizing a combination of only historical symptoms, physical exam signs, and point-of-care ultrasound (POCUS) findings for the prediction of the diagnosis of acute cholecystitis in ED patients.This was a prospective observational validation study of the Bedside SAC Score. The study was conducted at two tertiary referral academic centers in Boston, Massachusetts. From April 2016 to March 2019, adult patients (≥18 years old) with suspected acute cholecystitis were enrolled via convenience sampling and underwent a physical exam and a focused biliary POCUS in the ED. Three symptoms and signs (post-prandial symptoms, RUQ tenderness, and Murphy's sign) and two sonographic findings (gallbladder wall thickening and the presence of gallstones) were combined to calculate the Bedside Sonographic Acute Cholecystitis (SAC) Score. The final diagnosis of acute cholecystitis was determined from chart review or patient follow-up up to 30 days after the initial assessment. In patients who underwent operative intervention, surgical pathology was used to confirm the diagnosis of acute cholecystitis. Sensitivity, specificity, PPV and NPV of the Bedside SAC Score were calculated for various cut off points.153 patients were included in the analysis. Using a previously defined cutoff of ≥ 4, the Bedside SAC Score had a sensitivity of 88.9% (95% CI 73.9%-96.9%), and a specificity of 67.5% (95% CI 58.2%-75.9%). A Bedside SAC Score of2 had a sensitivity of 100% (95% CI 90.3%-100%) and specificity of 35% (95% CI 26.5%-44.4%). A Bedside SAC Score of ≥ 7 had a sensitivity of 44.4% (95% CI 27.9%-61.9%) and specificity of 95.7% (95% CI 90.3%-98.6%).A bedside prediction score for the diagnosis of acute cholecystitis would have great utility in the ED. The Bedside SAC Score would be most helpful as a rule out for patients with a low Bedside SAC Score2 (sensitivity of 100%) or as a rule in for patients with a high Bedside SAC Score ≥ 7 (specificity of 95.7%). Prospective validation with a larger study is required.

Background Choledochoduodenostomy (CD) is believed to cause certain long-term complications, such as sump syndrome and reflux gastritis. Therefore, CD is considered inferior to a Roux-and-Y hepaticojejunostomy (HJ). The aim of this study was to compare short- and long-term outcomes following CD and HJ for benign biliary diseases. Methods This was a retrospective, matched case-control study of patients undergoing biliary-digestive anastomosis for benign diseases between 2000 and 2016 in a tertiary centre. Patients undergoing CD and HJ were matched 1:1 based on age, sex, ASA-classification, indication, history of abdominal surgery or acute cholecystitis/pancreatitis. Short- and long-term outcomes were compared. Results Of 336 patients undergoing biliary-digestive anastomoses, 27 patients underwent CD. Matching resulted in two comparable groups of 26 patients each. Overall morbidity after HJ and CD was comparable: 30.8% versus 26.9% (p>0.999). Long-term complications occurred in 23.1% after HJ, and in 50% after CD (p=0.118). After CD, 2 patients (7.7%) developed sump syndrome. Both patients with an anastomotic stricture after HJ could be managed by endoscopic/radiological re-intervention, whilst all six patients with a stricture after CD required surgical re-intervention (p=0.016). Conclusion Although short-term complications were comparable, the number of anastomotic strictures was higher in patients undergoing CD. We therefore conclude that HJ is the biliary bypass of choice while CD should be performed in selected patients only.

Background: Laparoscopic Cholecystectomy is now accepted as being safe for acute cholecystitis. However, it has not become routine, because the exact timing and approach to the surgical management remains ill define. Careful selection of patients, the knowledge of typical procedure-related complications, and their best treatment are the key points for a safe Laparoscopic Cholecystectomy. Objective: To compare the early and delayed Laparoscopic Cholecystectomy in the acute phase in terms of frequency of conversion to open cholecystectomy. Study Design: Randomized clinical trial. Settings: Department of Surgery, Divisional Headquarter Hospital, Faisalabad. Punjab Medical College, Faisalabad Pakistan. Duration: Study was carried out over a period of six months from June 2018 to May 2019. Methodology: A total of 152 cases (76 cases in each group) were included in this study. All patients were randomly allocated to either group i.e., group -A early Laparoscopic Cholecystectomy and group-B delayed Laparoscopic Cholecystectomy. Results: Mean age was 39.09 + 8.8 and 37.05+ 8.5 years in group- A and B, respectively. In group-A, male patients were 48 (63.2%) and female patients were 28 (36.8%). Similarly, in group-B, male patients were 41 (53.9%) and female patients were 35 (46.1%). Conversion to open cholecystectomy was required in 6 patients (7.9%) of group-A and 16 patients (21.0%) of group – B. Significant difference between two groups was observed (P= 0.021). Conclusion: Early laparoscopic cholecystectomy for acute cholecystitis is safe and feasible in terms of less frequency of conversion to open cholecystectomy.

Introduction: COVID-19 infection has spread throughout the world and is considered a pandemic. Since its appearance, the number of non-COVID-19 patients admitted to hospitals has decreased and patients differ care for emergency diseases. We analyze the impact of the SARS-CoV-2 coronavirus pandemic on the management of acute cholecystitis. Material and methods: Retrospective observational study that includes all patients diagnosed with acute cholecystitis during the SARS-CoV-2 coronavirus pandemic (period between March 11th and June 21st, 2020) and patients diagnosed with acute cholecystitis in the same period, the previous year in our center. Patient’s features, management, postoperative complications and mean hospital stay were compared. Results: In 2020, 19 patients with acute cholecystitis were diagnosed compared to 21 who were registered in the same period in 2019. The mean number of days from symptoms onset in 2020 was 2.42±1.8 days, while in 2019 it was 3.5±3.1 days (p=0.32). The percentage of cholecystectomies, percutaneous cholecystostomies and conservative management was similar in both periods. Among patients who underwent cholecystectomy in 2020, 37.5% had no complications, 62.5% had accidental opening of the gallbladder, and none had bleeding. Among patients who underwent cholecystectomy in 2019, 81.8% had no complications, 9.09% had accidental opening of the gallbladder, and 9.09% presented bleeding. The mean stay in 2020 was 4.21±3.2 days, compared to 8.57±7.4 days in 2019 (p=0.005). Two patients of 19 diagnosed with acute cholecystitis in 2020 had COVID-19 disease. Conclusion: The mean stay of the patients was shorter in 2020 period. These results can be explained by an early surgical management. So, early laparoscopic cholecystectomy should be considered as a treatment for acute cholecystitis in COVID-19 times if the clinical and hospital situation allows it. We found no differences in the number of patients diagnosed with acute cholecystitis between the two periods, nor in the mean number of days from the onset of symptoms.

Purpose:This study examined whether abdominal plain computed tomography (CT) can predict surgical difficulty in acute cholecystitis., Methods:We retrospectively analyzed 84 consecutive patients who underwent laparoscopic cholecystectomy for acute cholecystitis between January 2015 and December 2018. We distinguished three degrees of surgical difficulty based on the operative time and blood loss: difficult, both ≥120 minutes and ≥ 100 mL, respectively (n = 27); moderate, either ≥120 minutes or ≥ 100 mL, respectively (n = 30); and easy, both, Results:Mean age, albumin levels, C-reactive protein levels, and the CT attenuation around the gallbladder (P < .001) were significantly different between groups. The surgical difficulty was unrelated to the timing of surgery. The postoperative complications were more frequent in operations more than 72 hours after disease onset (P = .04) and with CT attenuation around the gallbladder of ≥1.4 (P = .036)., Conclusion:High attenuation around the gallbladder on plain CT predicted a high surgical difficulty of laparoscopic cholecystectomy. We recommend measuring the CT attenuation around the gallbladder in patients with acute cholecystitis.

Background and Aims EUS-guided gallbladder drainage (EUS-GBD) is a safe alternative to percutaneous cholecystostomy (PT-GBD) for acute cholecystitis. How the procedure compares with laparoscopic cholecystectomy (LC) is uncertain. The aim of the current study is to compare the outcomes of EUS-GBD with LC for acute cholecystitis. Methods This was propensity score analysis of all patients admitted for acute cholecystitis between 2012 and 2018. Consecutive patients who received EUS-GBD or LC were included. Patients were matched for age, sex, and age-adjusted Charlson score. Outcome measurements included 30-day adverse events, mortality, recurrent cholecystitis, recurrent biliary events, reinterventions, and readmissions. Results During the study period, 60 patients were selected (30 EUS-GBD vs 30 LC) after propensity score matching. Technical success rates (100% vs 100%), clinical success rates (93.3% vs 100%, P = 1), lengths of hospital stay (6.8 [8.1] vs 5.5 [2.7], P = 1), 30-day adverse events (4 [13.3%] vs 4 [13.3%], P = 1), and mortality rates (2 [6.7%] vs 0 [0%], P = .492) were similar. The rates of recurrent biliary events (3 [10%] vs 3 [10%], P = .784), reinterventions (4 [13.3%] vs 3 [10%], P = 1), and unplanned readmissions (3 [10%] vs 3 [10%], P = .784) in 1 year were also similar. Conclusions The outcomes of EUS-GBD for acute cholecystitis were comparable with LC with acceptable rates of recurrent acute cholecystitis. These results support the role of EUS-GBD as an alternative to LC in patients who may or may not be surgically fit to undergo definitive cholecystectomy.

Background: Acute acalculous cholecystitis (AAC) is an inflammation of the gallbladder without gallstones in the setting of critical illness. It represents 2%–15% of acute cholecystitis (AC) cases....

Introduction: There is an ongoing debate over the timings of laparoscopic cholecystectomy in acute cholecystitis. Most authors recommend surgery within the first 72 hours. We offer laparoscopic cholecystectomies in every patient with acute cholecystitis regardless of the timing of presentation. Material and methods: We prospectively analyzed outcomes of our protocol of any time acute cholecystitis. We perform laparoscopic cholecystectomies within the first 24 hours of presentation to us without considering time since attack if the patient is not in septic shock where we follow survival sepsis guidelines. Results: We performed 110 laparoscopic cholecystectomies between April, 2019-March, 2020. We prefer single-dose preoperative antibiotics (third-generation cephalosporin) in all laparoscopic cholecystectomies. A total of 79 patients were having acute cholecystitis. 67 patients were having grade 2 and 12 patients were having grade 3 cholecystitis according to Tokyo guidelines. 50 patients were presented more than 72 hours after the attack. 21 patients presented more than 48 hours but less than 72 hours. 8 patients presented within 24 hours. The mean duration of the presentation was 120 hours. 5 patients presented after more than 7 days. One patient was having grade 3 cholecystitis and was having septic shock so he was managed with percutaneous cholecystostomy and according to survival sepsis, protocol and lap choly were done after 72 hours. Out of 79 patients included in the study, 2 patients were converted to open; in 3 patients we performed lap subtotal cholecystectomy due to difficult calot triangle. Out of these only 2 patients developed port site infection and 3 patients developed bilioma which was managed by percutaneous drainage. All patients were discharged the same day or the next day. Only two patients with bilioma were readmitted. Rest all of the patients had an uneventful recovery. Conclusion: There is no need to strictly follow the 72-hour time limit for laparoscopic cholecystectomy in acute cholecystitis. Any time laparoscopic cholecystectomy should be the rule inexperienced centre.