Does Age Influence in Endoscopic Therapeutic Success on the Biliary Tract?

Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as empyema, gangrene, perforation of the gallbladder, and sepsis. The gold standard treatment for AC is laparoscopic cholecystectomy. However, for a small group of AC patients, the risk of laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these critically ill patients, percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to cholecystectomy. The objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons, endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological, and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise; c) Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous or endoscopic gallbladder drainage is not available; d) Percutaneous cholecystostomy and endoscopic gallbladder drainage should be performed only in well-equipped hospitals with experienced interventional radiologist and/or endoscopist; e) Cholecystostomy catheter should be removed after resolution of AC. However, in patients who have no clinical condition to undergo cholecystectomy, the catheter may be maintained for a prolonged period or even definitively; f) If the cholecystostomy catheter is maintained for a long period of time several complications may occur, such as bleeding, bile leakage, obstruction, pain at the insertion site, accidental removal of the catheter, and recurrent AC; g) The ideal waiting time between cholecystostomy and cholecystectomy has not yet been established and ranges from immediately after clinical improvement to months. h) Long waiting periods between cholecystostomy and cholecystectomy may be associated with new episodes of acute cholecystitis, multiple hospital readmissions, and increased costs. Finally, when selecting the best treatment option other aspects should also be considered, such as costs, procedures available at the medical center, and the patient’s desire. The patient and his family should be fully informed about all treatment options, so they can help making the final decision.

Section: Introductionmentioning

confidence: 99%

Acute Cholecystitis in High-Risk Patients. Surgical, Radiological, or Endoscopic Treatment? Brazilian College of Digestive Surgery Position Paper

COELHO,

COSTA,

ENNE

et al. 2023

“…The migration of parasitic elements into the bile ducts throughout the cystic communication may generate a biliary obstructive syndrome with secondary acute cholangitis 7 . Although there are different biliary drainage techniques, endoscopic retrograde cholangiopancreatography (ERCP) is actually considered the first-line drainage procedure in biliary obstruction syndrome, mainly due to its high effectiveness and lower risk of adverse events 4 , 6 , 9 . In this article, we aim to highlight the role of ERCP in patients with acute cholangitis secondary to cholangiohydatidosis.…”

Section: Introductionmentioning

confidence: 99%

Therapeutic Approach of Complicated Hydatid Disease: Role of Endoscopic Retrograde Cholangiopancreatography in Cholangiohydatidosis

González-Arboleda

Pizarro²,

Lindner³

et al. 2022

BACKGROUND: Hydatid disease, a parasitic infestation caused by Echinococcus granulosus larvae, is an infectious disease endemic in different areas, such as India, Australia, and South America. The liver is well known as the organ most commonly affected by hydatid disease and may present a wide variety of complications such as hepatothoracic hydatid transit, cyst superinfection, intra-abdominal dissemination, and communication of the biliary cyst with extravasation of parasitic material into the bile duct, also called cholangiohydatidosis. Humans are considered an intermediate host, exposed to these larvae by hand-to-mouth contamination of the feces of infected dogs. AIM: This study aimed to highlight the role of endoscopic retrograde cholangiopancreatography in patients with acute cholangitis secondary to cholangiohydatidosis. METHODS: Considering the imaging findings in a 36-year-old female patient with computed tomography and magnetic resonance imaging showing a complex cystic lesion in liver segment VI, with multiple internal vesicles and a wall defect cyst that communicates with the intrahepatic biliary tree, endoscopic biliary drainage was performed by endoscopic retrograde cholangiopancreatography with papillotomy, leading to the discharge of multiple obstructive cysts and hydatid sand from the main bile duct. RESULTS: Clinical and laboratory findings improved after drainage, with hospital discharge under oral antiparasitic treatment before complete surgical resection of the hepatic hydatid cyst. CONCLUSIONS: Endoscopic retrograde cholangiopancreatography is a safe and useful method for the treatment of biliary complications of hepatic hydatid disease and should be considered the first-line procedure for biliary drainage in cases of cholangiohydatid disease involving secondary acute cholangitis.

Cholecystectomy With Intraoperative Endoscopic Retrograde Cholangiopancreatography: Does the Order Matter?

Castelan Filho,

Zapelini,

Cacciatori

et al. 2024

BACKGROUND: The recommended treatment for cholecystocholedocholithiasis is cholecystectomy (CCT) associated with endoscopic retrograde cholangiopancreatography (ERCP). CCT with intraoperative ERCP is associated with higher success rates and lower hospital stays and hospital costs. However, some case series do not describe the exact methodology used: whether ERCP or CCT was performed first. AIMS: Verify if there is a difference, in terms of outcomes and complications, when intraoperative ERCP is performed immediately before or after CCT. METHODS: This is a retrospective case-control study analyzing all patients who underwent CCT with intraoperative ERCP between January 2021 and June 2022, in a tertiary hospital in southern Brazil, for the treatment of cholecystocholedocholithiasis. RESULTS: Out of 37 patients analyzed, 16 (43.2%) underwent ERCP first, immediately followed by CCT. The overall success rate for the cannulation of the bile duct was 91.9%, and bile duct clearance was achieved in 75.7% of cases. The post-ERCP pancreatitis rate was 10.8%. When comparing the "ERCP First" and "CCT First" groups, there was no difference in technical difficulty for performing CCT. The "CCT First" group had a higher rate of success in bile duct cannulation (p=0.020, p<0.05). Younger ages, presence of stones in the distal common bile duct and shorter duration of the procedure were factors statistically associated with the success of the bile duct clearance. Lymphopenia and cholecystitis as an initial presentation, in turn, were associated with failure to clear the bile duct. CONCLUSIONS: There was no significant difference in terms of complications and success in clearing the bile ducts among patients undergoing CCT and ERCP in the same surgical/anesthetic procedure, regardless of which procedure was performed first. Lymphopenia and cholecystitis have been associated with failure to clear the bile duct.