Endoscopic transpapillary stenting for the management of acute cholecystitis.

INTRODUCTION: Cholecystectomy is the gold standard treatment of acute cholecystitis. Patients who are considered not to be candidates for cholecystectomy are commonly recommended to undergo percutaneous transhepatic gallbladder drainage (PTGBD) tube placement; however, external drainage is undesirable for many patients. Endoscopic transpapillary stent placement (ETSP) has been described as an alternative method for decompression of the gallbladder. Data in support of this technique is limited to a handful of observational studies with variable indications. Our study sought to expand on the available data for the use of ETSP exclusively in the context of acute cholecystitis. METHODS: We performed a retrospective chart review of patients with cholecystitis who underwent ETSP at our institution between January 2012 and July 2018. We collected data on indication, comorbidities, length of stay, laboratory values, outcomes, additional procedures, and whether cholecystectomy was eventually performed. RESULTS: During the study period, 12 patients underwent ETSP. The mean age was 68.2 years (± SD 12.4) with an average Anesthesia Society Assessment (ASA) class of 3.2. The Charlson Comorbidity Index was greater than seven in 75% of patients, indicating a 0% estimated 10-year survival. The National Surgical Quality Improvement Program (NSQIP) surgical risk calculator was used to estimate an average mortality risk for laparoscopic cholecystectomy of 4.8% (± 3.3, 95% CI) in our study population; the estimated risk in the general population is 0.1%. Immediate resolution of symptoms with endoscopic drainage was achieved in 11 of 12 patients (91.7%); one patient experienced no symptom resolution with endoscopic drainage nor subsequent PTGBD tube placement. Six of 12 (50%) patients experienced recurrence of symptoms requiring hospitalization, and two of 12 patients (16.7%) died secondary to biliary sepsis. CONCLUSION: Endoscopic transpapillary stent placement is an alternative method for the management of acute cholecystitis patients who are not candidates for surgery. ETSP has a high technical success rate; however, it may result in a high rate of symptom recurrence and should only be utilized in select patients. Randomized studies would be beneficial to further investigate the utility and safety of ETSP in the management of acute cholecystitis.

Outcomes following early versus delayed cholecystectomy performed for acute cholangitis.

BACKGROUND: Early cholecystectomy following an episode of gallstone pancreatitis is data supported, however, there is minimal literature regarding the optimal timing for cholecystectomy following an episode of acute cholangitis. Our study aims to determine the ideal timing for laparoscopic cholecystectomy following an episode of acute cholangitis. METHODS: A retrospective chart review was done on cholecystectomies performed for cholangitis at our institution from 2008 to 2015. Patients were compared based on timing of cholecystectomy (i.e., index admission versus delayed) and Tokyo severity grade (I-III). RESULTS: We identified 151 patients who underwent cholecystectomy for cholangitis at our institution from 2008 to 2015. Cholecystectomy was performed during the index admission for 61.6% of patients and Tokyo grade (TG) did not affect the rate of cholecystectomy during index admission (TG1 65.2%, TG2 64.1%, TG3 52.8%; p = 0.46). There was no difference in average operative time (89.0 min vs. 96.6 min; p = 0.36) or conversion to open cholecystectomy (5.4% vs. 10.3%; p = 0.34) between early and late cholecystectomy groups. There was also no statistically significant difference in intra-operative complications (9.7% vs. 15.5%; p = 0.28) or overall complication rates (16.1% vs. 29.3%; p = 0.05) based on timing of cholecystectomy; however, post-operative complications were significantly higher for the delayed cholecystectomy group (20.7% vs. 6.5%; p = 0.01). CONCLUSIONS: Early cholecystectomy after cholangitis is safe to perform and is not associated with higher operative times or rate of conversion to open, regardless of Tokyo grade. Due to the risk of developing recurrent cholangitis and a higher rate of post-operative complications seen with delayed cholecystectomy, our recommendation is to perform cholecystectomy during the index admission.