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Comprehensive Review of the Management of Patients With Acute Cholecystitis Who Are Ineligible for Surgery
Todd H Baron1, Irving Jorge2, Ali Husnain3
1Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC.
Insights
Treatments for acute cholecystitis in non-surgical patients include percutaneous cholecystostomy (PC) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD). Further research is needed to optimize these minimally invasive approaches.
Area of Science:
- Gastroenterology
- Interventional Radiology
- Surgical Oncology
Background:
- Cholecystectomy is the standard treatment for acute cholecystitis (AC).
- Non-surgical candidates often require percutaneous or endoscopic interventions.
- Emerging data supports endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) and percutaneous techniques.
Purpose of the Study:
- To review current literature on AC treatments for non-surgical candidates.
- To provide management guidelines for this patient population.
Main Methods:
- Expert panel review of current literature.
- Recommendations based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.
Main Results:
- Percutaneous cholecystostomy (PC) is recommended for patients ineligible for lumen-apposing metal stent (LAMS) or with reversible conditions.
- EUS-GBD with LAMS is a recommended therapy for eligible, never-surgical candidates with calculous AC.
- Definitive treatments like percutaneous cholecysto-lithotripsy/lithectomy and cholecystoduodenal stenting should be considered when surgery is not feasible.
Conclusions:
- Management of AC in non-surgical patients is challenging and varies by institution.
- A protocol integrating percutaneous and endoscopic approaches with multidisciplinary collaboration is proposed.
- Further research is essential to evaluate these evolving techniques due to limited current literature.
Objective:
Review the current literature for available treatments for acute cholecystitis (AC) in nonsurgical candidates and provide guidelines for the management of these patients.
Background:
Cholecystectomy is the gold-standard treatment modality for AC. A considerable number of patients who are not eligible for surgery are managed by percutaneous and endoscopic techniques. There is recent data regarding endoscopic ultrasound-guided gallbladder drainage and emerging percutaneous approaches to address cholelithiasis and remove drains.
Methods:
An expert panel of surgeons, gastroenterologists, and interventional radiologists reviewed the current literature and provided recommendations for AC management in nonsurgical candidates. Recommendations were based on relevant evidence, with quality and strength assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.
Results:
Percutaneous cholecystostomy is advised for patients ineligible for lumen-apposing metal stent (LAMS) or with reversible conditions, aiming to bridge to cholecystectomy. The optimal timing of cholecystectomy after percutaneous cholecystostomy remains unclear. In cases where surgery is not feasible, potential definitive treatments such as percutaneous cholecystolithotripsy/lithectomy and cholecystoduodenal stenting should be considered. For calculous AC, endoscopic ultrasound-guided gallbladder drainage with LAMS is recommended as a therapy for never-surgical candidates if they are eligible for monitored anesthesia care or general anesthesia and there is institutional expertise and minimal intervening ascites.
Conclusions:
The management of AC in nonsurgical candidates remains a challenge, with institutional protocols varying based on physician preferences and expertise. The proposed protocol integrates percutaneous and endoscopic approaches and emphasizes the need for multidisciplinary collaboration. Further research is required to evaluate these evolving management techniques, as the current literature is limited.
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