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With technological advances in endoscopic ultrasonography, endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) was introduced as a treatment option for acute cholecystitis. Recently, new studies have emerged, suggesting that EUS‐GBD has a lower adverse event rate and reintervention rate, when compared to percutaneous drainage and endoscopic transpapillary gallbladder drainage. There is growing interest in the different technical aspects of EUS‐GBD, such as the puncture approach, choice of stents, and long‐term management. There are also cohorts on performing EUS‐GBD in potential surgical candidates. This review article gathers the latest evidence on EUS‐GBD, including its indications, procedural techniques, choice of equipment, outcomes, postprocedural care, and the controversial extended indications. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy with ultrasonic dissection presents a compelling alternative to conventional electrocautery. The evidence for elective cholecystectomy supports the adoption of ultrasonic dissection, citing advantages such as reduced operating time, diminished bleeding, shorter hospital stays and decreased postoperative pain and nausea. However, the efficacy of this procedure in emergency surgery and patients diagnosed with acute cholecystitis remains uncertain. The aim of this study was to compare outcomes of electrocautery and ultrasonic dissection in patients with acute cholecystitis. Methods: A randomized, parallel, double-blinded, multicentre controlled trial was conducted across eight Swedish hospitals. Eligible participants were individuals aged ≥ 18 years with acute cholecystitis lasting ≤ 7 days. Laparoscopic cholecystectomy was performed in the emergency setting as soon as local circumstances permitted. Random allocation to electrocautery or ultrasonic dissection was performed in a 1:1 ratio. The primary endpoint was the total complication rate, analysed using an intention-to-treat approach. The primary outcome was analysed using logistic generalized estimated equations. Patients, postoperative caregivers, and follow-up personnel were blinded to group assignment. Results: From September 2019 to March 2023, 300 patients were enrolled and randomly assigned to electrocautery dissection (n = 148) and ultrasonic dissection (n = 152). No significant difference in complication rate was observed between the groups (risk difference [RD] 1.6%, 95% confidence interval [CI], − 7.2% to 10.4%, P = 0.720). No significant disparities in operating time, conversion rate, hospital stay or readmission rates between the groups were noted. Haemostatic agents were more frequently used in electrocautery dissection (RD 10.6%, 95% CI, 1.3% to 19.8%, P = 0.025). Conclusions: Ultrasonic dissection and electrocautery dissection demonstrate comparable risks for complications in emergency surgery for patients with acute cholecystitis. Ultrasonic dissection is a viable alternative to electrocautery dissection or can be used as a complementary method in laparoscopic cholecystectomy for acute cholecystitis. Trial registration: The trial was registered prior to conducting the research on http://clinical.trials.gov, NCT03014817. [ABSTRACT FROM AUTHOR]

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]

This study aimed to investigate the impact of preoperative gallbladder drainage and the specific drainage method used on surgical outcomes in patients undergoing surgery for acute cholecystitis. This single-center retrospective cohort study included 221 patients who underwent early cholecystectomy between January 2016 and December 2020. Clinical data and outcomes of 140 patients who did not undergo drainage, 22 patients who underwent preoperative percutaneous transhepatic gallbladder drainage (PTGBD), and 59 patients who underwent preoperative endoscopic naso-gallbladder drainage (ENGBD) were compared. There was no difference in the operation time, blood loss, postoperative complications, or length of postoperative hospital stay between patients who did and did not undergo drainage. Among patients who underwent drainage, there was no difference between the ENGBD and PTGBD groups in operation time, blood loss, or postoperative complications; however, more patients in the PTGBD group underwent laparotomy and had a significantly longer postoperative hospital stay. The presence and type of drainage were not risk factors for postoperative complications. The presence or absence of preoperative gallbladder drainage for acute cholecystitis and the type of drainage may not significantly affect surgical outcomes. [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: Heart failure is a clinical syndrome characterized by decreased cardiac output, leading to systemic organ hypoxia and resulting in dyspnea, pulmonary edema, organ congestion, and pleural effusion. Owing to the diverse clinical manifestations of heart failure, early diagnosis can be challenging, and misdiagnosis may occur occasionally. The use of echocardiography and blood brain natriuretic peptide can aid in obtaining a more accurate diagnosis. Case presentation: This article presents two case reports of patients who were misdiagnosed with acute cholecystitis. Both patients were young Mongolia males (age 26 and 39 years) who presented to the emergency department with acute upper abdominal pain, abdominal ultrasound revealed gallbladder enlargement, and blood tests suggested mild elevation of bilirubin levels. However, despite the absence of procalcitonin and C-reactive protein elevation, the patients were admitted to the general surgical department with a diagnosis of "acute cholecystitis." Both patients were given treatment for cholecystitis, but their vital signs did not improve, while later examinations confirmed heart failure. After treatment with diuretics and cardiac glycosides, both patients' symptoms were relieved. Conclusion: We aim to highlight the clinical manifestations of heart failure and differentiate it from rare conditions such as acute cholecystitis. Physicians should make accurate diagnoses on the basis of physical examinations, laboratory testing and imaging, and surveys while avoiding diagnostic heuristics or mindsets. By sharing these two case reports, we hope to increase awareness to prevent potential complications and improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: There has been a progressive increase in the use of percutaneous cholecystostomy (PC) in acute cholecystitis (AC) over the last decades due to population aging, and the support of guidelines (Tokyo Guidelines (TG), World Society of Emergency Surgery (WSES) Guidelines) as a valid therapeutical option. However, there are many unanswered questions about the management of PCs. An international consensus on indications and PC management using Delphi methodology with contributions from experts from three surgical societies (EAHPBA, ANS, WSES) have been performed. Methods: A two-round Delphi consensus, which included 27 questions, was sent to key opinion leaders in AC. Participants were asked to indicate their 'agreement/disagreement' using a 5-point Likert scale. Survey items with less than 70% consensus were excluded from the second round. For inclusion in the final recommendations, each survey item had to have reached a group consensus (≥ 70% agreement) by the end of the two survey rounds. Results: 54 completed both rounds (82% of invitees). Six questions got > 70% and are included in consensus recommendations: In patients with acute cholecystitis, when there is a clear indication of PC, it is not necessary to wait 48 h to be carried out; Surgery is the first therapeutic option for the TG grade II acute cholecystitis in a patient suitable for surgery; Before PC removal a cholangiography should be done; There is no indication for PC in Tokyo Guidelines (TG) grade I patients; Transhepatic approach is the route of choice for PC; and after PC, laparoscopic cholecystectomy is the preferred approach (93.1%). Conclusions: Only six statements about PC management after AC got an international consensus. An international guideline about the management of PCs are necessary. [ABSTRACT FROM AUTHOR]

Background: The 2018 Tokyo Guidelines (TG18) are used to classify the severity of acute cholecystitis (AC) but insufficient to predict the length of hospital stay (LOS). Methods: For patients with AC, clinical factors and computed tomography features, including our proposed grading system of pericholecystic fat stranding were used for predicting an LOS of ≥7 days in the logistic regression models. Results: Our multivariable model showed age ≥ 65 years (OR: 2.56, p < 0.001), C-reactive protein (CRP) ≥ 2 mg/dL (OR: 1.97, p = 0.013), gamma-glutamyltransferase levels (OR: 2.460, p = 0.001), TG18 grade (OR: 2.89 per grade, p < 0.001), and moderate to severe pericholecystic fat stranding (OR: 2.14, p = 0.012) exhibited prolonged LOS ≥ 7 days. Conclusions: We developed a scoring model, including TG18 grades (score of 1–3 per grade), our grading system of fat stranding (score of 1), CRP (score of 1), and gamma-glutamyltransferase (score of 1), and a cutoff of >3 had highest diagnostic performance. [ABSTRACT FROM AUTHOR]

This article provides an overview of laparoscopic cholecystectomy (LC), a minimally invasive procedure for gallbladder removal. LC has become a widely accepted and safe alternative to open cholecystectomy (OC), although complications such as bile duct injury can still occur. The article also explores the use of LC for acute cholecystitis and laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis, as well as alternative procedures for challenging cases. The need for further research on preoperative assessment methods and the use of new technologies in LC is highlighted. Additionally, the article discusses studies comparing different surgical techniques for common bile duct stone removal, finding no significant difference in success rates but variations in adverse events and hospital stay duration. The authors recommend laparoscopic surgery for pediatric patients but note insufficient evidence to support its use in adults. The text concludes by emphasizing the importance of training in laparoscopic common bile duct exploration and its potential benefits. [Extracted from the article]

This article is part of a clinical practice guideline update on the risk assessment, diagnostic imaging, and microbiological evaluation of complicated intraabdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America. In this article, the panel provides recommendations for diagnostic imaging of suspected acute cholecystitis and acute cholangitis. The panel's recommendations are based on evidence derived from systematic literature reviews and adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. [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: Bile duct injury (BDI) is one of the most severe complications during cholecystectomy. Early identification of risk factors for BDI may permit risk reduction strategies and inform patient consent. Objective: This study aimed to define patient, provider, and systemic factors associated with BDI; BDI incidence; and short-term outcomes of BDI after urgent cholecystectomy. Methods: Patients who underwent urgent cholecystectomy for acute cholecystitis were retrospectively screened (2020-2022). All patients who sustained BDI were included without exclusions. Demographics, clinical data, and outcomes were collected and compared with descriptive statistics. Results: During the study period, BDI occurred in 4 (0.5%) of 728 patients who underwent urgent cholecystectomy for acute cholecystitis. Most BDI cases (75%) took place overnight or during the weekend. The attending surgeon was almost exclusively (75%) in their first year of practice. BDI was recognized during index operation in 2 cases (50%). Hepatobiliary surgery performed the bile duct repair in all 4 cases. Two complications occurred (50%). All patients were followed by hepatobiliary surgery in the outpatient setting and returned to their baseline level of function within 2 months of hospital discharge. Conclusion: Most BDI occurred in procedures attended by first-year faculty during after hours cholecystectomies, suggesting a role for increased proctorship in early career attendings in addition to in-hours cholecystectomy for acute cholecystitis. The timely return to baseline function experienced by these patients emphasizes the favorable outcomes associated with early recognition of BDI and involvement of hepatobiliary surgery. Further examination with multicenter evaluation would be beneficial to validate these study findings. [ABSTRACT FROM AUTHOR]

• The 2018 Tokyo guidelines (TG18) made recommendations for the management of acute cholecystitis without any reference to age. • Nothing was mentioned specifically about the fragile, elderly patient. • Deferred management in patients with contra-indications to immediate management occurs often in the elderly. • A two-stage strategy is achieved in only about half of elderly patients. Acute cholecystitis occurs frequently in the elderly. According to the current recommendations specific to the characteristics of each case, these patients are most often treated by delayed cholecystectomy after medical treatment. Our study aimed to compare the success rate of this strategy in patients over and under 75 years of age. This was a retrospective single-center analytic observational study that included patients who were hospitalized for acute cholecystitis in a geriatric postoperative unit (unité postopératoire gériatrique [UPOG]) and gastrointestinal surgery unit between 2021 and 2022. The main endpoint was the failure rate of deferred cholecystectomy. Secondary endpoints included: respect for the recommended operative delay, loss of the patient's functional independence during hospitalization, and the reason for surgical abstention. In total, 290 patients were included. The strategy of delayed elective cholecystectomy was not achieved in 31 (44%) patients 75 years old or older vs. eight (18%) patients younger than 75 years old (P = 0.005). The main reason was the decision not to operate after medical treatment. In both groups, the recommended operative interval was equitably respected and the loss of autonomy during hospitalization was minor. More than one-third of the elderly patients scheduled for elective surgery finally refused to undergo surgery. The strategy of routine elective cholecystectomy should not be strict in the elderly with acute cholecystitis; the indication for this procedure should take into account the wishes as well as the physiological status of the patient. [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: Gallbladder perforation (GBP) is a rare but life-threatening complication of acute cholecystitis. Despite advancements in imaging technology and biochemical analysis, perforations are still diagnosed intraoperatively in some cases. This situation has revealed the need for new markers in the diagnosis of perforation. In this study, we aimed to analyze the role of biomarkers in the diagnosis of perforated cholecystitis cases. METHODS: In this retrospective study, blood samples (white blood cells (WBC), hemoglobin, platelet count, C-reactive protein (CRP), albumin, CRP/albumin ratio (CAR), neutrophil-lymphocyte ratio (NLR), urea, creatinine, glucose, amylase, lipase, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), total bilirubin, direct bilirubin) were analyzed in patients who were diagnosed with acute cholecystitis in the emergency department. RESULTS: One hundred seventy patients were divided into two groups according to the presence or absence of gallbladder perforation. Sixty-three (37.1%) patients had perforation. Transition from laparoscopy to open operation, intensive care unit admission, length of hospital stay, and mortality were higher in the perforated group compared to the non-perforated group. When we analyzed the patients according to laboratory findings, there was a difference in WBC, NLR, CRP, albumin, and CAR parameters in the perforation group. In regression analysis, CRP and CAR performed better. CONCLUSION: Our study showed that CRP and CAR may be diagnostic biomarkers with low specificity and sensitivity in predicting GBP in patients with acute cholecystitis. This marker is a low-cost and easily accessible parameter that may help clinicians make an early diagnosis and plan appropriate treatment for this condition with high morbidity and mortality. [ABSTRACT FROM AUTHOR]

This study aimed to investigate the role of inflammatory markers and progranulin levels in diagnosing cholecystitis, assessing their potential as diagnostic biomarkers. The research involved 54 patients diagnosed with acute cholecystitis in the emergency department. Routine complete blood count and biochemistry analyses were conducted. Blood samples were obtained, centrifuged, and stored at -80°C. Progranulin levels in sera were assessed using a spectrophotometric method. Statistical analysis was carried out using SPSS v.22.0, revealing significant variances between patients and healthy controls. Acute cholecystitis patients exhibited elevated levels of inflammatory markers (white blood cells, C-reactive protein, procalcitonin) and decreased progranulin levels compared to controls. Progranulin showed a high sensitivity (86.5%) and specificity (87.5%) in diagnosing acute cholecystitis. Other markers had varying sensitivity and specificity values. Inflammatory markers, particularly progranulin, show promise in diagnosing cholecystitis. Evaluating these markers together can enhance diagnostic accuracy. Further studies are needed to validate these findings and explore progranulin's specificity to cholecystitis. [ABSTRACT FROM AUTHOR]

Abstract Background Laparoscopic cholecystectomy with ultrasonic dissection presents a compelling alternative to conventional electrocautery. The evidence for elective cholecystectomy supports the adoption of ultrasonic dissection, citing advantages such as reduced operating time, diminished bleeding, shorter hospital stays and decreased postoperative pain and nausea. However, the efficacy of this procedure in emergency surgery and patients diagnosed with acute cholecystitis remains uncertain. The aim of this study was to compare outcomes of electrocautery and ultrasonic dissection in patients with acute cholecystitis. Methods A randomized, parallel, double-blinded, multicentre controlled trial was conducted across eight Swedish hospitals. Eligible participants were individuals aged ≥ 18 years with acute cholecystitis lasting ≤ 7 days. Laparoscopic cholecystectomy was performed in the emergency setting as soon as local circumstances permitted. Random allocation to electrocautery or ultrasonic dissection was performed in a 1:1 ratio. The primary endpoint was the total complication rate, analysed using an intention-to-treat approach. The primary outcome was analysed using logistic generalized estimated equations. Patients, postoperative caregivers, and follow-up personnel were blinded to group assignment. Results From September 2019 to March 2023, 300 patients were enrolled and randomly assigned to electrocautery dissection (n = 148) and ultrasonic dissection (n = 152). No significant difference in complication rate was observed between the groups (risk difference [RD] 1.6%, 95% confidence interval [CI], − 7.2% to 10.4%, P = 0.720). No significant disparities in operating time, conversion rate, hospital stay or readmission rates between the groups were noted. Haemostatic agents were more frequently used in electrocautery dissection (RD 10.6%, 95% CI, 1.3% to 19.8%, P = 0.025). Conclusions Ultrasonic dissection and electrocautery dissection demonstrate comparable risks for complications in emergency surgery for patients with acute cholecystitis. Ultrasonic dissection is a viable alternative to electrocautery dissection or can be used as a complementary method in laparoscopic cholecystectomy for acute cholecystitis. Trial registration The trial was registered prior to conducting the research on http://clinical.trials.gov , NCT03014817.

Abstract Background Heart failure is a clinical syndrome characterized by decreased cardiac output, leading to systemic organ hypoxia and resulting in dyspnea, pulmonary edema, organ congestion, and pleural effusion. Owing to the diverse clinical manifestations of heart failure, early diagnosis can be challenging, and misdiagnosis may occur occasionally. The use of echocardiography and blood brain natriuretic peptide can aid in obtaining a more accurate diagnosis. Case presentation This article presents two case reports of patients who were misdiagnosed with acute cholecystitis. Both patients were young Mongolia males (age 26 and 39 years) who presented to the emergency department with acute upper abdominal pain, abdominal ultrasound revealed gallbladder enlargement, and blood tests suggested mild elevation of bilirubin levels. However, despite the absence of procalcitonin and C-reactive protein elevation, the patients were admitted to the general surgical department with a diagnosis of “acute cholecystitis.” Both patients were given treatment for cholecystitis, but their vital signs did not improve, while later examinations confirmed heart failure. After treatment with diuretics and cardiac glycosides, both patients’ symptoms were relieved. Conclusion We aim to highlight the clinical manifestations of heart failure and differentiate it from rare conditions such as acute cholecystitis. Physicians should make accurate diagnoses on the basis of physical examinations, laboratory testing and imaging, and surveys while avoiding diagnostic heuristics or mindsets. By sharing these two case reports, we hope to increase awareness to prevent potential complications and improve patient outcomes.

Abstract Background There has been a progressive increase in the use of percutaneous cholecystostomy (PC) in acute cholecystitis (AC) over the last decades due to population aging, and the support of guidelines (Tokyo Guidelines (TG), World Society of Emergency Surgery (WSES) Guidelines) as a valid therapeutical option. However, there are many unanswered questions about the management of PCs. An international consensus on indications and PC management using Delphi methodology with contributions from experts from three surgical societies (EAHPBA, ANS, WSES) have been performed. Methods A two-round Delphi consensus, which included 27 questions, was sent to key opinion leaders in AC. Participants were asked to indicate their ‘agreement/disagreement’ using a 5-point Likert scale. Survey items with less than 70% consensus were excluded from the second round. For inclusion in the final recommendations, each survey item had to have reached a group consensus (≥ 70% agreement) by the end of the two survey rounds. Results 54 completed both rounds (82% of invitees). Six questions got > 70% and are included in consensus recommendations: In patients with acute cholecystitis, when there is a clear indication of PC, it is not necessary to wait 48 h to be carried out; Surgery is the first therapeutic option for the TG grade II acute cholecystitis in a patient suitable for surgery; Before PC removal a cholangiography should be done; There is no indication for PC in Tokyo Guidelines (TG) grade I patients; Transhepatic approach is the route of choice for PC; and after PC, laparoscopic cholecystectomy is the preferred approach (93.1%). Conclusions Only six statements about PC management after AC got an international consensus. An international guideline about the management of PCs are necessary.

Abdominal pain in patients with significant alcohol use and smoking history presents diagnostic challenges due to overlapping clinical features of complications like acute cholecystitis and peptic ulcers. The unreliable physical examinations of intoxicated patients often complicate accurate diagnosis. We present a case of a 56-year-old male with a history of alcoholism and smoking, who presented to the emergency department with nonspecific abdominal pain. Initial imaging suggested cholecystitis, but due to the patient's intoxication, his physical examination was unreliable. During a laparoscopic cholecystectomy, a perforated prepyloric ulcer was unexpectedly discovered, sealed by the gallbladder. This case highlights the limitations of relying solely on imaging for diagnosing abdominal conditions in intoxicated patients. The intraoperative discovery of the perforated ulcer necessitated a shift in the surgical approach, emphasizing the need for flexibility in surgical planning and a high index of suspicion for other abdominal pathologies in patients with significant lifestyle risks. The successful management of this patient through adaptive surgical techniques and comprehensive postoperative care, including Helicobacter pylori eradication therapy, underscores the importance of maintaining a broad differential diagnosis and readiness to adapt surgical plans. This approach is essential for managing complex cases effectively, ensuring that both the immediate surgical issues and underlying causes are addressed to optimize recovery and prevent recurrence.

Abstract 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.

Objective: To investigate the effectiveness of the systemic immune- inflammatory (SII) index and other inflammatory parameters in predicting mortality among patients with acute cholecystitis (AC). Methods: 279 Patients presented to the emergency department with abdominal pain and diagnosis of AC between September 2021 and September 2023 were included in the study. Demographic data, laboratory parameters, clinical follow-ups, and outcomes of the patients were recorded. Results: The mean age of the patients was (55.0±16.3) years and 36.6% were male. 63.8% Had gallbladder/choledochal stones and 49.5% underwent surgery. The mortality rate was 6.1%. Advanced age (P=0.170) and prolonged hospitalization (P=0.011) were statistically significant risk factors for mortality. Decreased lymphocyte count (P=0.020) and increased C-reactive protein (CRP) levels (P=0.033) were found to be risk factors for mortality. According to the mortality predictor ROC analysis results, the cut-off for SII index was 3 138 (AUC=0.817, sensitivity=70.5%, specificity=84.7%), the cut-off for neutrophil count was 15.28×103/ mm3 (AUC=0.761, sensitivity=52.9%, specificity=95.0%), the cut-off for leukocyte count was 19.0×103/mm3 (AUC= 0.714, sensitivity=52.9%, specificity=98.0%), cut-off for CRP was 74.55 (AUC=0.758, sensitivity=70.5%, specificity=79.0%), cut-off for aspartate transaminase (AST) was 33.0 IU/L (AUC=0.658, sensitivity=82.3%, specificity=50.3%). Conclusions: The SII index may be a good predictor of mortality with high sensitivity and specificity. Elevated levels of neutrophils, leukocytes, CRP, and AST are other inflammatory parameters that can be used to predict mortality associated with AC.

Background: Acute cholecystitis is the most frequent illnesses that necessitate surgical procedures in an emergency. Research indicates that performing cholecystectomy at an early stage leads to improved results, reduced hospital stays, and lower healthcare expenses. Early diagnosis is crucial during the presentation of a patient in the emergency ward and can be achieved by a precise clinical examination and the use of suitable diagnostic procedures. Ultrasound is regarded as the ideal initial imaging approach for individuals suspected of acute cholecystitis clinically. Objective: To examine the diagnostic precision of emergency sonographic signs in patients with suspected acute cholecystitis, while considering histopathology as the gold standard. Methods: A cross-sectional study at the selected hospital of Karachi conducted over one year, on 103 patients who met the diagnostic criteria. Mean and standard deviation for continuous data and frequencies with percentages were calculated for categorical data. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were measured. A p-value of ≤0.05 is significant. Results: 47 (45.6%) were male and 56 (54.4%) were female. The mean age was 47.47 (8.57) years and the duration of symptoms was 7.19 (2.14) hours. Out of 103 patients, sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of emergency sonographic signs for the diagnosis of acute cholecystitis by keeping histopathology as the gold standard was 81.1%, 88.2%, 93.3%, 69.7%, and 83.4% respectively. Conclusion: Emergency sonographic findings are effective in the identification and diagnosis of acute cholecystitis. The histopathological diagnosis correlated well with the ultrasound diagnosis of acute cholecystitis. This methodology will enhance the quality of medical care and increase patient safety

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]

Abstract Background Emergency cholecystectomy is the mainstay in treating acute cholecystitis (AC). In actual practice, perioperative prophylactic antibiotics are used to prevent postoperative infectious complications (PIC), but their effectiveness lacks evidence. We aim to investigate the efficacy of prophylactic antibiotics in emergency cholecystectomy. Methods We searched PubMed, Embase, Cochrane CENTRAL, Web of Science (WOS), and Scopus up to June 14, 2023. We included randomized controlled trials (RCTs) that involved patients diagnosed with mild to moderate AC according to Tokyo guidelines who were undergoing emergency cholecystectomy and were administered preoperative and/or postoperative antibiotics as an intervention group and compared to a placebo group. For dichotomous data, we applied the risk ratio (RR) and the 95% confidence interval (CI), while for continuous data, we used the mean difference (MD) and 95% CI. Results We included seven RCTs encompassing a collective sample size of 1747 patients. Our analysis showed no significant differences regarding total PIC (RR = 0.84 with 95% CI (0.63, 1.12), P = 0.23), surgical site infection (RR = 0.79 with 95% CI (0.56, 1.12), P = 0.19), distant infections (RR = 1.01 with 95% CI (0.55, 1.88), P = 0.97), non-infectious complications (RR = 0.84 with 95% CI (0.64, 1.11), P = 0.22), mortality (RR = 0.34 with 95% CI (0.04, 3.23), P = 0.35), and readmission (RR = 0.69 with 95% CI (0.43, 1.11), P = 0.13). Conclusion Perioperative antibiotics in patients with mild to moderate acute cholecystitis did not show a significant reduction of postoperative infectious complications after emergency cholecystectomy. (PROSPERO registration number: CRD42023438755).

Leptospirosis is a bacterium with a worldwide distribution and belongs to the group of zoonoses that can affect both humans and animals. Most cases of leptospirosis present as a mild, anicteric infection. However, a small percentage of cases develop Weil’s disease, characterized by bleeding and elevated levels of bilirubin and liver enzymes. It can also cause inflammation of the gallbladder. Acute acalculous cholecystitis has been described as a manifestation of leptospirosis in a small percentage of cases; however, no association between leptospirosis and acute acalculous cholecystitis has been found in the literature.

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]

Background: Emergency cholecystectomy is the mainstay in treating acute cholecystitis (AC). In actual practice, perioperative prophylactic antibiotics are used to prevent postoperative infectious complications (PIC), but their effectiveness lacks evidence. We aim to investigate the efficacy of prophylactic antibiotics in emergency cholecystectomy. Methods: We searched PubMed, Embase, Cochrane CENTRAL, Web of Science (WOS), and Scopus up to June 14, 2023. We included randomized controlled trials (RCTs) that involved patients diagnosed with mild to moderate AC according to Tokyo guidelines who were undergoing emergency cholecystectomy and were administered preoperative and/or postoperative antibiotics as an intervention group and compared to a placebo group. For dichotomous data, we applied the risk ratio (RR) and the 95% confidence interval (CI), while for continuous data, we used the mean difference (MD) and 95% CI. Results: We included seven RCTs encompassing a collective sample size of 1747 patients. Our analysis showed no significant differences regarding total PIC (RR = 0.84 with 95% CI (0.63, 1.12), P = 0.23), surgical site infection (RR = 0.79 with 95% CI (0.56, 1.12), P = 0.19), distant infections (RR = 1.01 with 95% CI (0.55, 1.88), P = 0.97), non-infectious complications (RR = 0.84 with 95% CI (0.64, 1.11), P = 0.22), mortality (RR = 0.34 with 95% CI (0.04, 3.23), P = 0.35), and readmission (RR = 0.69 with 95% CI (0.43, 1.11), P = 0.13). Conclusion: Perioperative antibiotics in patients with mild to moderate acute cholecystitis did not show a significant reduction of postoperative infectious complications after emergency cholecystectomy. (PROSPERO registration number: CRD42023438755). [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]

Background: Situs inversus totalis (SIT) is a rare congenital condition characterized by the mirror-image reversal of the thoracic and abdominal organs. SIT presents significant challenges during surgical procedures that require anatomical familiarity and dexterity, such as laparoscopic cholecystectomy. Case Presentation: A 73-year-old woman with SIT presented with a 2-day history of left-sided hypochondrial colicky abdominal pain aggravated by food intake and associated with nausea. Physical examination revealed a positive Murphy's sign in the left hypochondrium. Laboratory tests showed leukocytosis and elevated liver enzymes. Imaging (See Figures 1-4) confirmed acute cholecystitis with the gallbladder in the left upper quadrant. The patient was scheduled for laparoscopic cholecystectomy. Preoperative planning involved detailed imaging and coordination with the anesthesiology team. The surgical technique was adapted for SIT, including specific patient positioning and a mirror-image approach. The gallbladder was successfully removed, with careful dissection of the cystic duct and artery. Postoperative management included non-steroidal anti-inflammatory drugs, opioids, and monitoring. The patient's recovery was uneventful, and she was discharged on the third postoperative day with follow-up instructions. The care plan included pain management, regular monitoring, early mobilization, diet progression, and scheduled outpatient visits. Conclusion: Laparoscopic cholecystectomy in patients with SIT requires careful preoperative planning, skilled surgical techniques, and effective team communication. Despite these challenges, successful outcomes are possible with meticulous attention to detail and adaptation to the reversed anatomy. [ABSTRACT FROM AUTHOR]

Gallbaldder disorders represent a prevalent pathology encounterd in daily practice, both in emergency and ambulatory settings. Transabdominal ultrasound has a high accuracy for the diagnosis of gallstones and acute cholecystitis. Contrast enhanced ultrasound (CEUS) can depict and characterized the vascular pattern in cases of inflammatory or malignant processes. In an emergency situation such as acute cholecystitis in patients with comorbidities, CEUS can acurate identify a gangrenous cholecystitis; subsequently the medical management can rely on this technique. The differential diagnosis of benign vs malignant pathology, in cases of segmental or diffuse wall thickening, can also benefit from CEUS. In this paper we aimed to discuss and to illustrate the role of CEUS in gallbladder pathology. [ABSTRACT FROM AUTHOR]

Objective: Our aim is to demonstrate the effectiveness of percutaneous cholecystostomy (PC) in the treatment of patients with acute cholecystitis (AC) before and during the COVID-19 pandemic and to show that it is a safe procedure for healthcare professionals and patients. Materials and Methods: Demographic, clinical and laboratory data, technical success of PC, clinical response to treatment, duration of hospital stay, of patients with AK who applied to our hospital and underwent PC procedure in a total of 24 months before and during the pandemic, one-month post-procedure observation, and complications were compared. Results: PC was applied to a total of 124 patients in the pre-pandemic period (52) and pandemic period (72) examined in the study. The median age was 73.5 (25-93) in the pre-pandemic period, and 64 (23-90) in the pandemic period, and the difference between these was found to be significant (p=0.004). Clinical improvement due to PC was detected in 43 (86%) patients in the pre-pandemic period, and in 61 (84.7%) patients in the pandemic period, no significant differences were detected between the two groups (p=1.000). The day of hospitalization median value was 3 (1-18) days in pandemic period, and 3 (1-30) days in the pandemic period, and no significant differences were detected between the groups (p=0.794). Conclusion: PC treatment in patients with AC during the pandemic and pre-pandemic periods is effective and safe for both the patient and the healthcare professionals who perform the procedure. [ABSTRACT FROM AUTHOR]

Acute cholecystitis is one of the most common surgical diseases, which may progress from mild to severe cases. When combined with bacteremia, the mortality rate of acute cholecystitis reaches up to 10–20%. The standard of care in patients with acute cholecystitis is early laparoscopic cholecystectomy. Percutaneous cholecystostomy or endoscopic procedures are alternative treatments in selective cases. Nevertheless, antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis. Patients with acute cholecystitis have a bile bacterial colonization rate of 35–60%. The most frequently isolated microorganisms are Escherichia coli, Klebsiella spp., Streptococcus spp., Enterococcus spp., and Clostridium spp. Early empirical antimicrobial therapy along with source control of infection is the cornerstone for a successful treatment. In these cases, the choice of antibiotic must be made considering some factors (e.g., the severity of the clinical manifestations, the onset of the infection if acquired in hospital or in the community, the penetration of the drug into the bile, and any drug resistance). Furthermore, therapy must be modified based on bile cultures in cases of severe cholecystitis. Antibiotic stewardship is the key to the correct management of bile-related infections. It is necessary to be aware of the appropriate therapeutic scheme and its precise duration. The appropriate use of antibiotic agents is crucial and should be integrated into good clinical practice and standards of care. [ABSTRACT FROM AUTHOR]

Background: Percutaneous cholecystostomy (PC) is a therapeutic intervention for acute cholecystitis. The benefits of cholecystostomy have been demonstrated in the medical literature, with up to 90% of acute cholecystitis cases shown to resolve postoperatively, and only 40% of patients subsequently undergoing an interval cholecystectomy. Purpose: To compare the survival outcomes between acute complicated and uncomplicated cholecystitis in patients undergoing PC as an initial intervention, as there is a paucity of evidence in the literature on this perspective. Material and Methods: A retrospective search was conducted of all patients who underwent PC for acute cholecystitis between August 2016 and December 2020 at a tertiary institution. A total of 100 patients were included in this study. Results: The outcome, in the form of 30-day mortality, 90-day mortality, being alive after six months, and reintervention, was compared between complicated and uncomplicated cases using the chi-square test or Fisher's exact test. There was no statistically significant difference in any of the compared outcomes. The only variable that showed a statistically significant association with the risk of mortality was acute kidney injury (AKI) at admission. Patients who had stage 1, 2, or 3 AKI had a higher hazard for mortality as compared to patients with no kidney disease. Conclusion: Our results demonstrate that PC is a safe and effective procedure. Mortality is not affected by the presence of complications. The results have, however, highlighted the importance of recognizing and treating AKI, an independent risk factor affecting mortality. [ABSTRACT FROM AUTHOR]

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

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]

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]

BackgroundLaparoscopic cholecystectomy (LC) is the preferred treatment for acute cholecystitis (AC). However, the optimal timing for LC in AC management remains uncertain, with early cholecystectomy (EC) and interval cholecystectomy (IC) being two common approaches influenced by various factors.MethodsThis retrospective study, conducted at a tertiary care teaching hospital in Karachi, Pakistan, aimed to compare the outcomes of EC vs. IC for AC management. Patient data from January 2019 to September 2019 were analyzed with a focus on operative complications, duration of surgery, and postoperative hospital stay. The inclusion criteria were based on the Tokyo Guidelines, and patients underwent LC within 3 days of symptom onset in the EC group and after 6 weeks in the IC group.ResultsAmong 147 eligible patients, 100 underwent LC (50 in each group). No significant differences were observed in the sex distribution or mean age between the two groups. The EC group experienced fewer operative complications (12%) than the IC group (34%), with statistically significant differences observed. Nevertheless, no substantial variations in operative time or postoperative hospital stay were observed between the groups.ConclusionReduced complications in the EC group underscore its safety and efficacy. Nonetheless, further validation through multicenter studies is essential to substantiate these findings.

Amaç: Laparoskopik kolesistektomi (LC) akut kolesistit için standart tedavi olmasına rağmen, optimal zamanlaması halen tartışmalıdır. Bu çalışmada amacımız acil kolesistektominin ameliyat sonuçları ile tekrarlayan akut kolesistit ile başvuran hastalara uygulanan elektif kolesistektomi vakalarını karşılaştırarak uygun kolesistektomi zamanını belirlemektir. Yöntem: 1 Ocak 2021 – 1 Aralık 2022 tarihleri arasında kolesistektomi planlanan 200 hastanın verileri kullanılrak yapıldı. Bekleme sürecinde tekrarlayan kolesistit atakları ile hastanemize başvuran tüm olgular retrospektif olarak değerlendirildi. Hastaların demografik verileri, hastalığın evresi, ameliyat öncesi ve sonrası hastanede kalış süresi, ameliyat süresi, açık ameliyat oranı, dren kullanımı, içi boş organ yaralanması, safra yolu yaralanması, kanama, yara enfeksiyonu, ameliyat sonrası kolleksiyon toplanma ve ölüm oranları analiz edildi.Bulgular: Tekrarlayan kolesistit ile başvuran 200 hastanın 80’ nine (%40) acil LC (grup 1), 120 hastaya (%60) elektif LC (grup 2) uygulandı. Ameliyat öncesi hastanede kalış süresi grup 2'de anlamlı olarak daha uzun bulundu ve ortalama cerrahi süresi grup 1'de anlamlı olarak daha uzundu (sırasıyla p=0,001 ve p=0,035). Mide veya bağırsak yaralanması, safra yolu yaralanması, yara enfeksiyonu ve mortalite oranında gruplar arasında anlamlı bir fark yoktu. Açık cerrahi ve postoperatif kolleksiyon toplanma oranları her iki grup arasında karşılaştırıldı ve iki grup arasında fark saptanamadı (p>0,05). Kronik kolesistitte postoperatif intravenöz (i.v) tramadol kullanımı daha fazla bulunmuşdur (p

This study aimed to investigate the role of inflammatory markers and progranulin levels in diagnosing cholecystitis, assessing their potential as diagnostic biomarkers. The research involved 54 patients diagnosed with acute cholecystitis in the emergency department. Routine complete blood count and biochemistry analyses were conducted. Blood samples were obtained, centrifuged, and stored at -80°C. Progranulin levels in sera were assessed using a spectrophotometric method. Statistical analysis was carried out using SPSS v.22.0, revealing significant variances between patients and healthy controls. Acute cholecystitis patients exhibited elevated levels of inflammatory markers (white blood cells, C-reactive protein, procalcitonin) and decreased progranulin levels compared to controls. Progranulin showed a high sensitivity (86.5%) and specificity (87.5%) in diagnosing acute cholecystitis. Other markers had varying sensitivity and specificity values. Inflammatory markers, particularly progranulin, show promise in diagnosing cholecystitis. Evaluating these markers together can enhance diagnostic accuracy. Further studies are needed to validate these findings and explore progranulin's specificity to cholecystitis. [Med-Science 2024; 13(3.000): 649-53]

Purpose The aim of this study was to report technical and clinical success of bedside ultrasound-guided percutaneous cholecystostomy (PC) tube placement in intensive care unit (ICU).

Background/Aims: There are no consensus guidelines for patients with acute cholecystitis undergoing percutaneous cholecystostomy who are unfit for interval cholecystectomy. The current study aimed to compare the clinical outcomes of endoscopic gallbladder drainage, i.e. conversion from percutaneous cholecystostomy (including endoscopic transpapillary gallbladder stenting and endoscopic ultrasound-guided gallbladder drainage), and conservative treatment after percutaneous cholecystostomy tube removal. Methods : This retrospective review included patients who underwent percutaneous cholecystostomy for acute cholecystitis between January 2017 and December 2020. Consecutive patients who underwent endoscopic gallbladder drainage or percutaneous cholecystostomy tube removal without interval cholecystectomy were included. Outcome measures included recurrent acute cholecystitis and unplanned readmission due to gallstone-related diseases. Results : During the study period, 238 patients were selected (63 underwent endoscopic gallbladder drainage conversion and 175 underwent conservative treatment). Patients who underwent endoscopic gallbladder drainage conversion had lower rates of recurrent acute cholecystitis (3 [4.76%] vs 31 [17.71%], p=0.012) and unplanned readmission due to gallstone-related diseases (6 [9.52%] vs 40 [22.86%], p=0.022) than those who underwent conservative treatment following percutaneous cholecystostomy tube removal. In the univariate and multivariate analyses, calculus cholecystitis (odds ratio, 13.75; 95% confidence interval, 1.83 to 102.83; p=0.011) and conversion of endoscopic gallbladder drainage (odds ratio, 0.23; 95% confidence interval, 0.06 to 0.78; p=0.019) were significant predictive factors for recurrent acute cholecystitis. Conclusion : s: Endoscopic gallbladder drainage conversion led to more favorable outcomes than conservative treatment after percutaneous cholecystostomy tube removal. Therefore, endoscopic gallbladder drainage conversion may be considered a promising treatment option for patients undergoing percutaneous cholecystostomy who are at a high surgical risk.

Abstract Introduction A textbook outcome patient is one in which the operative course passes uneventful, without complications, readmission or mortality. There is a lack of publications in terms of TO on acute cholecystitis. Objetive The objective of this study is to analyze the achievement of TO in patients with urgent early cholecystectomy (UEC) for Acute Cholecystitis. and to identify which factors are related to achieving TO. Materials and methods This is a post hoc study of the SPRiMACC study. It´s a prospective multicenter observational study run by WSES. The criteria to define TO in urgent early cholecystectomy (TOUEC) were no 30-day mortality, no 30-day postoperative complications, no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile), and full laparoscopic surgery. Patients who met all these conditions were taken as presenting a TOUEC. Outcomes 1246 urgent early cholecystectomies for ACC were included. In all, 789 patients (63.3%) achieved all TOUEC parameters, while 457 (36.6%) failed to achieve one or more parameters and were considered non-TOUEC. The patients who achieved TOUEC were younger had significantly lower scores on all the risk scales analyzed. In the serological tests, TOUEC patients had lower values for in a lot of variables than non-TOUEC patients. The TOUEC group had lower rates of complicated cholecystitis. Considering operative time, a shorter duration was also associated with a higher probability of reaching TOUEC. Conclusion Knowledge of the factors that influence the TOUEC can allow us to improve our results in terms of textbook outcome.

Acute cholecystitis (AC), generally associated with the presence of gallstones, is a relatively frequent disease that can lead to serious complications. For these reasons, AC warrants prompt clinical diagnosis and management. There is general agreement in terms of considering early laparoscopic cholecystectomy (ELC) to be the best treatment for AC. The optimal timeframe to perform ELC is within 72 h from diagnosis, with a possible extension of up to 7–10 days from symptom onset. In the first hours or days after hospital admission, before an ELC procedure, the patient's medical management comprises fasting, intravenous fluid infusion, antimicrobial therapy, and possible administration of analgesics. Additionally, concomitant conditions such as choledocholithiasis, cholangitis, biliary pancreatitis, or systemic complications must be recognized and adequately treated. The importance of ELC is related to the frequent recurrence of symptoms and complications of gallstone disease in the interval period between the onset of AC and surgical intervention. In patients who are not eligible for ELC, it is suggested to delay surgery at least 6 weeks after the clinical presentation. Critically ill patients, who are unfit for surgery, may require rescue treatments, such as percutaneous or endoscopic gallbladder drainage (GBD). A particular treatment approach should be applied to special populations such as pregnant women, cirrhotic, and elderly patients. In this review, we provide a practical diagnostic and therapeutic approach to AC, even in specific clinical situations, based on evidence from the literature. [ABSTRACT FROM AUTHOR]

Simple Summary: In this review, first, the history of EUS-guided biliary drainage (EUS-BD) is summarized. In the following chapters controversies arising from various approaches and challenges in EUS-BD, EUS-guided gallbladder drainage (EUS-GBD) and alternatively performed procedures are discussed from different points of view on the background of the available evidence. In addition, for all topics arguments in favor and against the techniques are described and reflected. The topics include "Why do we need procedures other than ERCP?"; "Should EUS-BD and ERCP be performed by the same operator?"; rendezvous techniques, including "Should rendezvous be used first?" and "Which rendezvous route should be used?"; percutaneous transhepatic cholangiography and biliary drainage (PTBD); "Should PTBD and EUS-BD be performed by the same physician?"; "Do we need cystotomes?"; "Do we need bougies?"; "Are all EUS needles the same for EUS-BD?"; "Plastic or metal stents?"; and adverse events. In this 14th document in a series of papers entitled "Controversies in Endoscopic Ultrasound" we discuss various aspects of EUS-guided biliary drainage that are debated in the literature and in practice. Endoscopic retrograde cholangiography is still the reference technique for therapeutic biliary access, but EUS-guided techniques for biliary access and drainage have developed into safe and highly effective alternative options. However, EUS-guided biliary drainage techniques are technically demanding procedures for which few training models are currently available. Different access routes require modifications to the basic technique and specific instruments. In experienced hands, percutaneous transhepatic cholangiodrainage is also a good alternative. Therefore, in this paper, we compare arguments for different options of biliary drainage and different technical modifications. [ABSTRACT FROM AUTHOR]

Background: Acute abdomen is a frequent occurrence in emergency department settings and often necessitates prompt diagnosis and urgent surgical intervention. Owing to the overlapping symptoms of many serious and benign intra-abdominal conditions, identifying life-threatening situations early in their progression can be challenging. The current study aimed to assess the diagnostic effectiveness of abdominal ultrasound in identifying common conditions presenting as an acute abdomen. Methods: This prospective comparative study included patients presenting with an acute abdomen at the Emergency Department of CDSIMER. Clinical diagnoses were established, followed by abdominal ultrasound. Ultrasound findings were compared with intraoperative observations and histopathological results, or in cases in which surgery was not performed, based on CT scan findings. Various diagnostic performance parameters, including sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), and accuracy, were used for the statistical analysis. Results: A total of 77 patients with acute abdominal pain were included in the study. Appendicitis was the most common diagnosis (33.77%), followed by cholecystitis (20.77%), pancreatitis (16.88%), intestinal obstruction (12.98%), and enteric perforation (15.58%). USG may have moderate accuracy for some conditions, such as appendicitis, acute intestinal obstruction, and acute cholecystitis, where it has shown acceptable sensitivity. CT scans are likely to have higher overall accuracy; across different conditions, CT scans are generally expected to be more accurate than USG for diagnosing acute abdominal conditions because of their ability to provide more detailed anatomical images. Conclusion: Ultrasound is a highly effective imaging modality for accurate diagnosis of acute appendicitis, acute intestinal obstruction, and acute cholecystitis. Even in hospitals lacking highly advanced imaging facilities, clinical assessment combined with ultrasound results can provide reliable diagnostic accuracy. [ABSTRACT FROM AUTHOR]