Managing patients with cholecystitis and cholangitis—inflammation of the gallbladder and of the bile ducts, respectively—now includes a diverse spectrum of diagnostic and therapeutic options for these intra-abdominal infections.
Studies suggest that acute cholecystitis affects approximately 200,000 people in the US annually. Cholangitis, a relatively uncommon condition, affects thousands of individuals each year, with some studies showing as many as 9% of hospitalized patients with gallstone disease are diagnosed with acute cholangitis.
In Monday’s Panel Session, “Cholecystitis, Cholangitis, and Contemporary Management of the Common Bile Duct,” Nirav C. Thosani, MD, MHA, described why endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is a safe and effective alternative for high-risk surgical patients with acute cholecystitis. He outlined study data that support EUS-GBD as a superior intervention with higher technical success and lower recurrence rates compared to percutaneous gallbladder drainage and endoscopic transpapillary gallbladder drainage.
“Procedural complications can be minimized with specialized training, use of phantom models in a simulated environment, and prior experience with other lumen-apposing metal stent indications,” said Dr. Thosani, noting that EUS-GBD does not preclude eventual cholecystectomy.
Richard Miskimins, MD, FACS, presented an overview of the basic techniques involved in minimally invasive common bile duct exploration (CBDE), and outlined seven “simple” steps for the procedure, including obtaining wire access, cystic duct dilation (if required), choledochoscope insertion and maneuvering, stone capture, stone extraction, completion of the cholangiogram, and cystic duct ligation.
“If you can’t pass a wire into the duodenum in 10 minutes, you should stop,” Dr. Miskimins said. He also described essential “pitfalls” that surgeons should be aware of when performing a CBDE, including poor room preparation, a small, narrow, or friable cystic duct, abnormal angle or insertion of cystic duct, and inadequate irrigation pressure.
In addition, the session featured pro/con presentations weighing the benefits and drawbacks of traditional strategies versus robotic-assisted procedures for managing cholecystitis and cholangitis.
“Newer is not always better,” said Caroline Reinke, MD, FACS, referring to the evidence-based advantages of laparoscopic cholecystectomy (lap chole). “This is an amazing procedure that gets patients home quickly with a same-day discharge or 1–2-day hospital stay.”
She also highlighted the cost-effectiveness of the procedure, citing a 2019 study that analyzed 7,601 laparoscopic cholecystectomies performed at 20 hospitals by 227 surgeons. The average cost per case ranged from $296 at the lowest cost center to $658 at the highest cost center.
Dr. Reinke called for a “reclaiming of the management of common duct stones in acute care surgery,” asserting that “acute care surgeons who are on the front line of the biliary consults in the emergency department are perfectly positioned to surgically manage common bile duct stones.”
In her closing remarks, she championed the use of the “old tried and true” approach, which can be done safely, with low morbidity, reduced time in the OR, and greater access to equitable care.
Presenting the other side of the debate, Christopher C. McCoy, MD, FACS, supported the use of newer approaches, specifically robotics, for managing cholecystitis and cholangitis. “My opponents would have you think that new technology and techniques prolong already challenging OR cases, are too costly, and offer no significant patient benefit,” he said.
Comparing both approaches, Dr. McCoy noted that robotic-assisted lap choles have “lower risk of serious complications, decreased conversion to open procedures, and lower odds of hospitalization—under 24 hours.”
Regarding longer operative times, some studies suggest that experienced surgeons can perform this procedure in under 30 minutes with the use of a robotic platform.
Dr. McCoy also underscored the improved ergonomic benefit of using robotic technology in the OR, which enables surgeons to sit at a customizable console and operated with enhanced dexterity.
When the moderator asked session attendees which modality they preferred by a show of hands, there was enthusiastic support for both, especially the robotic approach.
