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AbstractObjectiveTo assess whether laparoscopic cholecystectomy is superior to percutaneous catheter drainage in high risk patients with acute calculous cholecystitis.DesignMulticentre, randomised controlled, superiority trial.Setting11 hospitals in the Netherlands, February 2011 to January 2016.Participants142 high risk patients with acute calculous cholecystitis were randomly allocated to laparoscopic cholecystectomy (n=66) or to percutaneous catheter drainage (n=68). High risk was defined as an acute physiological assessment and chronic health evaluation II (APACHE II) score of 7 or more.Main outcome measuresThe primary endpoints were death within one year and the occurrence of major complications, defined as infectious and cardiopulmonary complications within one month, need for reintervention (surgical, radiological, or endoscopic that had to be related to acute cholecystitis) within one year, or recurrent biliary disease within one year.ResultsThe trial was concluded early after a planned interim analysis. The rate of death did not differ between the laparoscopic cholecystectomy and percutaneous catheter drainage group (3% v 9%, P=0.27), but major complications occurred in eight of 66 patients (12%) assigned to cholecystectomy and in 44 of 68 patients (65%) assigned to percutaneous drainage (risk ratio 0.19, 95% confidence interval 0.10 to 0.37; P<0.001). In the drainage group 45 patients (66%) required a reintervention compared with eight patients (12%) in the cholecystectomy group (P<0.001). Recurrent biliary disease occurred more often in the percutaneous drainage group (53% v 5%, P<0.001), and the median length of hospital stay was longer (9 days v 5 days, P<0.001).ConclusionLaparoscopic cholecystectomy compared with percutaneous catheter drainage reduced the rate of major complications in high risk patients with acute cholecystitis.Trial registrationDutch Trial Register NTR2666.

BackgroundIn elderly patients with calculous acute cholecystitis, the risk of emergency surgery is high, and percutaneous cholecystostomy tube drainage (PC) combined with delayed laparoscopic cholecystectomy (DLC) may be a good choice. We retrospectively compared laparoscopic cholecystectomy (LC) to DLC after PC to determine which is the better treatment strategy.MethodWe performed a retrospective cohort analysis of 752 patients with acute calculous cholecystitis. Patients with the following conditions were included: (1) age > 65 years old; (2) patients with a grade 2 or 3 severity of cholecystitis according to the 2013 Tokyo Guidelines (TG13); (3) the surgeons who performed the LC were professors or associate professors and (4) the DLC was performed in our hospital after PC. Patients who missed their 30-day follow-up; were diagnosed with bile duct stones, cholangitis or gallstone pancreatitis or were pregnant were excluded from the study. A total of 51 of 314 patients who underwent LC and 73 of 438 patients who underwent PC + DLC were assessed. PC + DLC and LC patients were matched by cholecystitis severity grade according to the TG13, and the National Surgical Quality Improvement Program (NSQIP) calculator was used to predict mortality (n = 21/group). Preoperative characteristics and postoperative outcomes were analysed.ResultsCompared to the matched LC group, the DLC group had less intraoperative bleeding (42.2 vs 75.3 mL, p = 0.014), shorter hospital stays (4.9 vs 7.4 days, p = 0.010) and lower rates of type A bile duct injury (4.8% vs 14.3%, p = 0.035) and type D (0 vs 9.5%, p = 0.002) according to Strasberg classification, residual stones (4.8 vs 14.3%, p = 0.035) and gastrointestinal organ injury (0 vs 3.6%, p < 0.001). Patients in the DLC group had lower incidences of ICU admission and death and a significantly lower incidence of repeat surgery.ConclusionIn elderly patients treated for acute calculous cholecystitis, the 30-day mortality and complication rates were lower for PC + DLC than for LC. However, the total hospitalisation time was significantly prolonged and the costs were significantly higher for PC + DLC.

Background Laparoscopic cholecystectomy in acute calculous cholecystitis in high risk patients can lead to significant morbidity and mortality. Percutaneous cholecystostomy may be an alternative treatment option but the current literature does not provide the surgical community with evidence based advice. Methods/Design The CHOCOLATE trial is a randomised controlled, parallel-group, superiority multicenter trial. High risk patients, defined as APACHE-II score 7-14, with acute calculous cholecystitis will be randomised to laparoscopic cholecystectomy or percutaneous cholecystostomy. During a two year period 284 patients will be enrolled from 30 high volume teaching hospitals. The primary endpoint is a composite endpoint of major complications within three months following randomization and need for re-intervention and mortality during the follow-up period of one year. Secondary endpoints include all other complications, duration of hospital admission, difficulty of procedures and total costs. Discussion The CHOCOLATE trial is designed to provide the surgical community with an evidence based guideline in the treatment of acute calculous cholecystitis in high risk patients. Trial Registration Netherlands Trial Register (NTR): NTR2666

Laparoscopic cholecystectomy (LC) has become the treatment of choice for elective cholecystectomy, but controversy persists over use of this approach in the treatment of acute cholecystitis. We undertook a randomised comparison of the safety and outcome of LC and open cholecystectomy (OC) in patients with acute cholecystitis. 63 of 68 consecutive patients who met criteria for acute cholecystitis were randomly assigned OC (31 patients) or LC (32 patients). The primary endpoints were hospital mortality and morbidity, length of hospital stay, and length of sick leave from work. Analysis was by intention to treat. Suspected bile-duct stones were investigated by preoperative endoscopic retrograde cholangiography (LC group) or intraoperative cholangiography (OC group). The two randomised groups were similar in demographic, physical, and clinical characteristics. 48% of the patients in the OC group and 59% in the LC group were older than 60 years. 13 patients in each group had gangrene or empyema, and one in each group had perforation of the gallbladder causing diffuse peritonitis. Five (16%) patients in the LC group required conversion to OC, in most because severe inflammation distorted the anatomy of Calot's triangle. There were no deaths or bile-duct lesions in either group, but the postoperative complication rate was significantly (p=0·0048) higher in the OC than in the LC group: seven (23%) patients had major and six (19%) minor complications after OC, whereas only one (3%) minor complication occurred after LC. The postoperative hospital stay was significantly shorter in the LC than the OC group (median 4 [IQR 2–5] vs 6 [5–8] days; p=0·0063). Mean length of sick leave was shorter in the LC group (13·9 vs 30·1 days; 95% CI for difference 10·9–21·7). Even though LC for acute and gangrenous cholecystitis is technically demanding, in experienced hands it is safe and effective. It does not increase the mortality rate, and the morbidity rate seems to be even lower than that in OC. However, a moderately high conversion rate must be accepted.

Background In medical practice, the tendency to remove an inflamed gallbladder is deeply rooted. Cholecystectomy, however, is associated with relatively high complication rates, and therefore the decision whether or not to perform surgery should be well considered. For some patients, the surgical risk–benefit profile may favour conservative treatment. The objective of this study was to examine the short- and long-term outcome of conservative treatment of patients with acute calculous cholecystitis. Methods A systematic search of MEDLINE, Embase and Cochrane Library databases was performed. Prospective studies reporting on the success rate of conservative treatment (i.e. non-invasive treatment) of acute cholecystitis during index admission were included, as well as prospective and retrospective studies reporting on the recurrence rate of gallstone-related disease during long-term follow - up (i.e. ≥12 months) after initial non-surgical management. Study selection was undertaken independently by two reviewers using predefined criteria. The risk of bias was assessed. The pooled success and mortality rate during index admission and the pooled recurrence rate of gallstone-related disease during long-term follow-up were calculated using a random-effects model. Results A total of 1841 patients were included in 10 randomized controlled trials and 14 non-randomized studies. Conservative treatment during index admission was successful in 87 % of patients with acute calculous cholecystitis and in 96 % of patients with mild disease. In the long term, 22 % of the patients developed recurrent gallstone-related disease. Pooled analysis showed a success rate of 86 % (95 % CI 0.8–0.9), a mortality rate of 0.5 % (95 % CI 0.001–0.009) and a recurrence rate of 20 % (95 % CI 0.1–0.3). Discussion Conservative treatment of acute calculous cholecystitis during index admission seems feasible and safe, especially in patients with mild disease. During long-term follow-up, less than a quarter of the patients appear to develop recurrent gallstone-related disease, although this outcome is based on limited data.

The diagnosis of acute cholecystitis in critically ill patients carries a high mortality rate. Although decompression and drainage of the gallbladder through a cholecystostomy tube may be used as a temporary treatment of acute cholecystitis in this population, there is still some debate about the management of the tube and the subsequent need for a cholecystectomy. This series evaluates the clinical course and outcomes of critically ill patients who underwent the insertion of cholecystostomy tubes for the initial treatment of acute cholecystitis. This is a retrospective review of critically ill patients admitted to the hospital intensive care unit who were diagnosed with acute cholecystitis and underwent a cholecystostomy tube as a temporary treatment for the disease. Patients were identified through the Greenville Hospital System electronic medical records coding database. Medical records were reviewed for demographic data, diagnoses, imaging, complications, and outcomes. From January 2002 through June 2008, 50 patients were identified for the study. The mean age was 72 ± 11 years, and the majority (66%) were men. The following comorbidities were found: severe cardiovascular disease (40 patients), respiratory failure (30 patients), and multisystem organ dysfunction (30 patients). The mean intensive care unit length of stay (LOS) was 16 ± 9 days, and the mean hospital LOS was 28 ± 27 days. At 30 days, the morbidity associated with the cholecystostomy tube itself was 4 per cent, but overall in-hospital morbidity and mortality rates were 62 and 50 per cent, respectively. Of the 25 patients who survived longer than 30 days, 12 retained their cholecystostomy tubes until they underwent cholecystectomy (four open, seven laparoscopic). All of the remaining 13 patients had their cholecystostomy tubes removed, and eight developed recurrent cholecystitis. Of these patients with recurrent of cholecystitis, five had cholecystectomy or repeat cholecystostomy, but the remaining three patients died. Although this is a small patient population, these data suggest that, in critically ill patients, cholecystostomy tubes should remain in place until the patient is deemed medically suitable to undergo cholecystectomy. Removal of the cholecystostomy tube without subsequent cholecystectomy is associated with a high incidence of recurrent cholecystitis and devastating consequences.

Background During the coronavirus disease (COVID-19) pandemic, there has been a surge in cases of acute cholecystitis. The ChoCO-W global prospective study reported a higher incidence of gangrenous cholecystitis and adverse outcomes in COVID-19 patients. Through this secondary analysis of the ChoCO-W study data, we aim to identify significant risk factors for mortality in patients with acute cholecystitis during the COVID-19 pandemic, emphasizing the role of COVID-19 infection in patient outcomes and treatment efficacy.” Methods The ChoCO-W global prospective study reported data from 2546 patients collected at 218 centers from 42 countries admitted with acute cholecystitis during the COVID-19 pandemic, from October 1, 2020, to October 31, 2021. Sixty-four of them died. Nonparametric statistical univariate analysis was performed to compare patients who died and patients who survived. Significant factors were then entered into a logistic regression model to define factors predicting mortality. Results The significant independent factors that predicted death in the logistic regression model with were COVID-19 infection ( p  < 0.001), postoperative complications ( p  < 0.001), and type (open/laparoscopic) of surgical intervention ( p  = 0.003). The odds of death increased 5 times with the COVID-19 infection, 6 times in the presence of complications, and it was reduced by 86% with adequate source control. Survivors predominantly underwent urgent laparoscopic cholecystectomy (52.3% vs. 23.4%). Conclusions COVID-19 was an independent risk factor for death in patients with acute cholecystitis. Early laparoscopic cholecystectomy has emerged as the cornerstone of treatment for hemodynamically stable patients. Highlights Study Objective: Investigated the factors predicting mortality in patients with acute cholecystitis during the COVID-19 pandemic. Cohort Size: Analyzed 2,546 patients from 218 centers in 42 countries between October 2020 and October 2021. Key Findings: COVID-19 infection increased mortality risk by five times in patients with acute cholecystitis. Postoperative complications elevated the odds of death sixfold. Early laparoscopic cholecystectomy significantly reduced mortality by 86%. Surgical Impact: Survivors were more likely to have undergone urgent laparoscopic surgery, suggesting it as a safer intervention during the pandemic. Clinical Relevance: COVID-19 was confirmed as an independent predictor of death, highlighting the need for urgent intervention in stable patients with acute cholecystitis.

During the reproductive years, women have a 4-fold higher prevalence of gallstones than men, making gallbladder disease a critically important topic in women's health. Among age-matched women and men hospitalized for cholecystitis, gender based differences in demographics, management, and economic and clinical outcomes were identified. A cross-sectional study was conducted using the Nationwide Inpatient Sample. Outcomes were mortality, complications, length of stay, and cost. Women accounted for 65% of admissions for cholecystitis, with women more likely to have shorter time to surgery (1.6 vs 1.9 days) and laparoscopy (86 vs 76%) (P < .05). After cholecystectomy, women had lower mortality (.6% vs 1.1%), fewer complications (16.9 vs 24.1), shorter lengths of stay (4.2 vs 5.4 days), and lower costs ($10,556 vs $13,201) (P < .05). On multivariate analysis of age-matched patients, women had lower odds of mortality (odds ratio [OR], .75), complications (OR, .86), length of stay (OR, .95), and cost (OR, .93). Longer time to surgery and open cholecystectomy were independent predictors of worse outcomes. In cholecystitis and cholecystectomy, women have better clinical and economic outcomes then age-matched men.

Background Percutaneous cholecystostomy is frequently used as a treatment option for acute calculous cholecystitis in patients unfit for surgery. There is sparse evidence on the long-term impact of cholecystostomy on gallstone-related morbidity and mortality in patients with acute calculous cholecystitis. This study describes the long-term outcome of acute calculous cholecystitis following percutaneous cholecystostomy compared to conservative treatment. Methods This was a cohort study of patients admitted at our institution from 2006 to 2015 with acute calculous cholecystitis without early or delayed cholecystectomy. Endpoints were gallstone-related readmissions, recurrent cholecystitis, and overall mortality. Results The investigation included 201 patients of whom 97 (48.2%) underwent percutaneous cholecystostomy. Patients in the cholecystostomy group had significantly higher age, comorbidity level, and inflammatory response at admission. The median duration of catheter placement in the cholecystostomy group was 6 days. The complication rate of cholecystostomy was 3.1% and the mortality during the index admission was 3.5%. The median follow-up was 1.6 years. The rate of gallstone-related readmissions was 38.6%, and 25.3% had recurrence of cholecystitis. Cox regression analyses revealed no significant differences in gallstone-related readmissions, recurrence of acute calculous cholecystitis, and overall mortality in the two groups. Conclusions Percutaneous cholecystostomy in the treatment of acute calculous cholecystitis was neither associated with long-term benefits nor complications. Based on the high gallstone-related readmission rates of this study population and todays perioperative improvements, we suggest rethinking the indications for non-operative management including percutaneous cholecystostomy in acute calculous cholecystitis.

INTRODUCTION:Few studies have examined outcomes of laparoscopic cholecystectomy for acute cholecystitis in patients with heart failure (HF). This study was to assess the impact of HF on cholecystectomy outcomes.METHODS:Data from the United States Nationwide Inpatient Sample (NIS) from 2016 to 2020 were examined. Adults 20 years and older diagnosed with acute cholecystitis who underwent laparoscopic cholecystectomy were included. Patients were categorized into groups with and without pre-existing HF.RESULTS:Outcomes assessed included inhospital mortality, nonroutine discharge, length of hospital stay, total hospital cost, and complications. Propensity score matching at a 1:1 ratio was conducted to balance between-group characteristics. Associations between HF and the outcomes were determined using univariate and multivariable regression analyses. After propensity score matching, 11,646 patients were included in the analysis: 5,823 with HF and 5,823 without. Patients with HF had significantly elevated risks of inhospital mortality (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [CI]: 1.44-3.17), nonroutine discharge (aOR = 1.80, 95% CI: 1.61-2.01), and complications (aOR = 1.51, 95% CI: 1.40-1.63). Patients with HF also had longer length of hospital stay (1.52 days, 95% CI: 1.45-1.60) and higher total hospital costs (16.64 thousand USD, 95% CI: 15.58-17.70). The outcomes of patients with HF were seen in those with HF reduced ejection fraction and HF with preserved ejection fraction.DISCUSSION:Patients with HF, either HF reduced ejection fraction or HF with preserved ejection fraction, have increased risk of adverse inpatient outcomes after laparoscopic cholecystectomy for acute cholecystitis. This emphasizes the importance of tailored perioperative care to optimize patient outcomes.