CYSTIC DUCT STENTING VERSUS OTHER TREATMENT MODALITIES FOR MANAGEMENT OF ACUTE CHOLECYSTITIS IN PATIENTS WITH DECOMPENSATED CIRRHOSIS

Introduction: Acute cholecystitis in the setting of decompensated cirrhosis is a feared complication with high morbidity and mortality. We compared outcomes of cystic duct stenting via ERCP to other modalities including percutaneous cholecystostomy, cholecystectomy, and medical management in this setting. Methods: We performed a retrospective cohort study. After obtaining IRB approval, we used International Classification of Diseases- 10th Edition codes to identify patients who presented with acute cholecystitis and had an underlying diagnosis of cirrhosis with MELD-Na of at least 15 or higher from Jan 2015 to Dec 2022 at our center. Primary outcome was 30-day mortality. Our secondary outcomes were 1-year mortality, 30-day readmission and worsening of liver disease as characterized by increasing MELD-Na or new onset ascites or encephalopathy following acute cholecystitis. Results: 368 charts were reviewed to identify 67 patients who met inclusion criteria (clinical evidence and documentation that supported acute cholecystitis in the setting of a MELD-Na ≥15). 19 (28.3%) patients underwent ERCP with cystic duct stenting and were compared to 48 (71.6%) patients who were managed by other modalities: cholecystectomy (n=12), percutaneous cholecystostomy (n=17), supportive care (n=19). The median follow up was 21 months for both groups. There was no major difference in demographics, etiology of cirrhosis, hepatocellular cancer (P=0.37) presence of ascites (P=0.67) and encephalopathy (P=0.54) between the 2 groups. Mean MELD-Na is similar at 22.0 and 22.4 between the 2 groups (P=0.84). Two (10.5%) patients died in the cystic duct stent group due to complications of cirrhosis within 30 days compared to 9 (18.8%) in the control group with a RR 0.91 (confidence interval [CI]: 0.8-1.1, P= 0.71). We found a significant difference in the protective effect of cystic duct stenting compared to other modalities on 1 month readmission rate and decline in liver function with RR of 0.56 (0.4-0.9, P= 0.038) and RR 0.49 (CI 0.3-0.8, P= 0.01) respectively. The only complication in the cystic duct stent group was pancreatitis (n=1, 5.2%) that was managed supportively. Percutaneous cholecystostomy had the highest rates of 30-day readmission (73.3%) and worsening liver function (85.7%) (Table 1). Conclusion: In our cohort, cystic duct stenting via ERCP appears safe and prevents readmissions and further decompensation of liver disease in patients with decompensated cirrhosis who present with acute cholecystitis. Table 1. - Comparison of cystic duct stenting with other modalities for management of acute cholecystitis in patients with decompensated cirrhosis Cystic Duct Stent (N=19) Other Treatment Options (48) P-Value Age (yrs), Mean ± SD 54.26 ± 14.4 58.25 ± 14.7 0.31 Gender (female), n (%) 7 (36.8) 22 (45.8) 0.5 Etiology of Cirrhosis Alcohol, n (%) 10 (52.6) 24 (51.1) 0.41 NASH, n (%) 1 (5.3) 8 (17.0) Hepatitis C, n (%) 4 (21.1) 8 (17.0) Others, n (%) 3 (15.6) 8 (17.0) HCC, n (%) 3 (15.8) 4 (8.3) 0.37 Ascites, n (%) 13 (68.4) 29 (61.7) 0.61 Encephalopathy, n (%) 7 (36.8) 14 (29.2) 0.54 MELD-Na, Mean ± SD 22.00 ± 4.8 22.38 ± 7.5 0.84 Sepsis On Presentation, n (%) 10 (52.6) 28 (58.3) 0.67 HIDA Positive, n (%) 11 (57.9) 27 (56.3) 0.9 30-Day Mortality, n (%) 2 (10.5) 9 (18.8) 0.41 1-Year Mortality, n (%) 3 (15.8) 14 (29.2) 0.26 30-Day Re-admission, n (%) 5 (27.8) 25 (56.8) 0.04 Worsening Liver Function, n (%) 6 (31.6) 28 (66.7) 0.01