Gallstones: laparoscopic treatment--cholecystectomy, cholecystostomy, and lithotripsy. Our own technique

The authors describe their own technique for the treatment of gallbladder stones using a laparoscopic approach. They first evacuate the stones with the aid of an intracorporal ultrasonic lithotriptor (Olympus, LTUS). Next they perform a cholecystostomy (17 cases) or a cholecystectomy (25 cases). The first 42 cases are reported, and the results have been good.

Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment

Our objective was to compare the effectiveness of percutaneous cholecystostomy (PC) vs conservative treatment (CO) in high-risk patients with acute cholecystitis. The study was randomized and comprised 123 high-risk patients with acute cholecystitis. All patients fulfilled the ultrasonographic criteria of acute inflammation and had an APACHE II score > or =12. Percutaneous cholecystostomy guided by US or CT was successful in 60 of 63 patients (95.2%) who comprised the PC group. Sixty patients were conservatively treated (CO group). One patient died after unsuccessful PC (1.6%). Resolution of symptoms occurred in 54 of 63 patients (86%). Eleven patients (17.5%) died either of ongoing sepsis (n=6) or severe underlying disease (n=5) within 30 days. Seven patients (11%) were operated on because of persisting symptoms (n=3), catheter dislodgment (n=3), or unsuccessful PC (n=1). Cholecystolithotripsy was performed in 5 patients (8%). Elective surgery was performed in 9 cases (14%). No further treatment was needed in 32 patients (51%). In the CO group, 52 patients (87%) fully recovered and 8 patients (13%) died of ongoing sepsis within 30 days. All successfully treated patients showed clinical improvement during the first 3 days of treatment. Percutaneous cholecystostomy in high-risk patients with acute cholecystitis did not decrease mortality in relation to conservative treatment. Percutaneous cholecystostomy might be suggested to patients not presenting clinical improvement following 3 days of conservative treatment, to critically ill intensive care unit patients, or to candidates for percutaneous cholecystolithotripsy.

Percutaneous gallbladder puncture and cholecystostomy: results, complications, and caveats for safety

The authors describe the technical results in 127 patients who underwent diagnostic gallbladder puncture and percutaneous cholecystostomy. The procedures were performed for a variety of indications including treatment of acute calculous or acalculous cholecystitis, drainage of obstructive jaundice or gallbladder perforation, percutaneous removal or dissolution of gallstones, diagnostic cholecystocholangiography, and gallbladder biopsy. Successful completion of the intended procedure was achieved in 125 of 127 patients (98.4%). Major complications occurred in 11 patients (8.7%); these included bile peritonitis, bleeding, vagal reactions, hypotension, catheter dislodgement, and acute respiratory distress. Minor complications were noted in five patients (3.9%). The 30-day mortality rate was 3.1% (four patients); the deaths were due to the underlying diseases. The data help support percutaneous cholecystostomy as a primary interventional radiologic procedure that has an extremely high likelihood of technical success. Recommendations to minimize or avoid complications are presented.

Is percutaneous cholecystostomy the optimal treatment for acute cholecystitis in the very elderly?

In elderly patients emergent cholecystectomy for acute cholecystitis is a high risk procedure. We prospectively assessed the value of percutaneous cholecystostomy for acute cholecystitis in 38 consecutive elderly (> or = 80 years) patients. All 38 underwent percutaneous transhepatic cholecystostomy under ultrasonographic and fluoroscopic guidance for acute cholecystitis (25 calculous, 13 acalculous). Eight (21%) patients had acute severe medical problems, such as shock and respiratory distress. Thirty-one (82%) patients had chronic severe underlying diseases, including cardiovascular and neurologic diseases. Cholecystostomy was successful in all 38 patients. Prompt clinical improvement was obtained in 36 (95%) patients. Morbidity and mortality rates were 3% and 3%, respectively. After cholecystostomy, 10 patients with cholelithiasis underwent elective cholecystectomy without serious complications. Two patients underwent percutaneous cholecystolithotomy, which produced complete resolution of symptoms. Four of 12 patients with and none of 12 without cholelithiasis had recurrent cholecystitis after catheter removal during a mean follow-up of 1.8 years. A second cholecystostomy was successful in these four patients. Elderly patients are often poor surgical candidates because of severe cholecystitis or concomitant medical problems. Percutaneous cholecystostomy is a safe, effective treatment for acute cholecystitis even in elderly patients. For calculous cholecystitis, cholecystostomy can be followed by elective surgery, if possible, or by nonsurgical treatment or expectant conservative management in high-risk patients. Cholecystostomy may be a definitive treatment for acalculous cholecystitis.

Percutaneous cholecystostomy in critically ill patients: early response and final outcome in 82 patients

OBJECTIVE

Patients in the intensive care unit are at increased risk of developing acute calculous and acalculous cholecystitis. Diagnosis based on clinical and sonographic findings is difficult in the presence of severe intercurrent disease. We did a study to evaluate the efficacy of percutaneous cholecystostomy as a diagnostic and therapeutic maneuver in 82 patients in the intensive care unit who had persistent unexplained sepsis.

SUBJECTS AND METHODS

Eighty-two patients with unexplained sepsis underwent percutaneous cholecystostomy after a complete clinical, laboratory, and radiologic search showed no source of sepsis outside the gallbladder. All patients were febrile, 65 had an increased WBC count, and 37 were receiving vasopressors. Sonographic abnormalities included a distended gallbladder (71 patients), sludge (63 patients), gallstones (26 patients), wall thickening (34 patients), pericholecystic fluid (25 patients), and Murphy's sign (19 patients).

RESULTS

Sonographic findings were not helpful in predicting response to percutaneous cholecystostomy. A dramatic improvement in clinical condition was observed in 48 patients (59%) within 48 hr. Signs of improvement included defervescence (41 patients), discontinuance of vasopressors (26 patients), and reduction in WBC count (33 patients). No clinical response was observed in 34 patients (41%). No complications related to catheter insertion occurred.

CONCLUSION

Because acute cholecystitis is difficult to diagnose in patients in the intensive care unit, percutaneous cholecystostomy serves as a diagnostic and therapeutic maneuver in patients with unexplained sepsis when the gallbladder is the suspected source of sepsis. A response rate to percutaneous cholecystostomy of 59% was seen in this study. The gallbladder was cleared as a potential source of sepsis in the remaining patients.

Percutaneous cholecystostomy: an alternative to surgical cholecystostomy for acute cholecystitis?

Emergency percutaneous cholecystostomy was successfully performed in 39 of 40 attempted procedures in 37 hospitalized patients with possible acute cholecystitis. All cholecystostomies were performed with ultrasound guidance and preferentially with the transhepatic route, and all but four were performed at the patient's bedside. The patients had been hospitalized an average of 27 days before the procedure. Twenty-two of the 37 patients (59%) eventually died during hospitalization because of other medical or surgical problems. Only minor complications related to percutaneous cholecystostomy placement occurred in this series: catheter dislodgment without sequelae (n = 2) and significant abdominal pain (n = 2). Technical problems included guide-wire buckling during catheter insertion (n = 1) and failed attempted cholecystostomy (n = 1). Percutaneous cholecystostomy is a safe alternative to surgical cholecystostomy in the treatment of patients suspected of having acute cholecystitis.

EUS-guided transmural cholecystostomy as rescue management for acute cholecystitis in elderly or high-risk patients: a prospective feasibility study

BACKGROUND

Although EUS-guided drainage procedures have been used to collect peripancreatic fluids, little is known regarding EUS-guided transmural gallbladder drainage for high-risk patients with acute cholecystitis.

OBJECTIVE

Our purpose was to evaluate the technical feasibility and outcomes of EUS-guided transmural cholecystostomy as rescue management in elderly and high-risk patients with acute cholecystitis.

DESIGN

Single-center prospective study.

SETTING

Tertiary referral center.

PATIENTS

Nine elderly or high-risk patients diagnosed with acute cholecystitis.

INTERVENTIONS

All inflamed gallbladders were drained by EUS-guided transmural cholecystostomy.

MAIN OUTCOME MEASUREMENT

Clinical resolution of acute cholecystitis.

RESULTS

After the drainage procedures, there were no immediate complications such as bleeding, bile leak, or peritonitis, except for 1 patient who had pneumoperitoneum. After EUS-guided transmural cholecystostomy, all patients showed rapid clinical improvement within 72 hours.

LIMITATIONS

Small number of patients.

CONCLUSION

EUS-guided transmural cholecystostomy may be feasible and safe as initial, interim, or even definitive treatment of patients with severe acute cholecystitis who are at high operative risk for immediate cholecystectomy.

Percutaneous cholecystostomy in patients with acute cholecystitis: experience of 45 patients at a US referral center

BACKGROUND

Standard treatment for acute cholecystitis is cholecystectomy, but some patients are at high risk for immediate surgery. Percutaneous cholecystostomy might be the procedure of choice in this group. We reviewed the experience of percutaneous cholecystostomy in a large tertiary center population.

STUDY DESIGN

We performed a retrospective analysis of patients who underwent percutaneous cholecystostomy, and recorded indications for cholecystostomy, duration of tube placement, clinical outcome, death within 30 days of procedure, complications, bacteriology of aspirated bile, gallbladder contents, and performance of interval cholecystectomy.

RESULTS

Forty-five patients (mean age 63 years) had cholecystostomy tubes placed from July 1999 to March 2002. All had confirmed or presumed acute cholecystitis. Mean duration of tube insertion was 54.3 days. Thirty-six patients improved clinically within 5 days. Nine patients died within 30 days; only one death was directly related to gallbladder sepsis. Nine patients subsequently had laparoscopic cholecystectomy, eight had open cholecystectomy, and two had cholecystoenterostomy. Cholecystectomy was planned in another five patients. Cholecystostomy tubes leaked in two patients, blocked in four, and dislodged in one. One patient developed a hemoperitoneum. Bile aspirated at cholecystostomy was culture positive in 12 patients, negative in 16, and not sent or recorded in 17. Twenty-two patients had gallstones, 10 had sludge, 9 had both, and 4 had neither.

CONCLUSIONS

In experienced hands, percutaneous cholecystostomy is easy to perform, with low complication and high success rates. It is the procedure of choice in patients with acute cholecystitis unfit for emergency surgery. Patients often improve clinically, so that cholecystectomy can be done electively.

Percutaneous cholecystostomy for high-risk patients with acute cholecystitis

BACKGROUND

Cholecystectomy remains the best treatment for acute cholecystitis but may cause high morbidity and mortality in critically ill or elderly patients.

METHODS

From October 1995 to March 2004, percutaneous cholecystostomy was performed in 65 patients with acute cholecystitis. The mean age was 78 years (range, 45-95). All patients were American Society of Anesthesiologists (ASA) class III (n = 51) or ASA IV (n = 14).

RESULTS

Percutaneous cholecystostomy was technically successful in 63 patients (97%) with no attributable mortality or major complications. In two patients, bile drainage was inefficient, requiring emergency laparoscopic cholecystectomy. One patient developed necrotic cholecystitis and died. The 30-day mortality rate was 13.8% (n = 9); eight patients died of respiratory or cardiac complications related to comorbidities. Mean drainage time was 18 days (range, 9-60). Postoperative length of hospital stay was 15 days (range, 7-30). Early and delayed cholecystitis occurred in six and five patients, respectively. During follow-up (mean, 20.4 months), five patients died of their underlying medical condition at 5, 6, 8, 12, and 14 months, respectively. In this study, delayed elective cholecystectomy was performed in 10 patients (15.3%).

CONCLUSIONS

Percutaneous cholecystostomy is a valuable and effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.

Percutaneous cholecystostomy

Percutaneous cholecystostomy (PC), a technique that consists of percutaneous catheter placement in the gallbladder lumen under imaging guidance, has become an alternative to surgical cholecystostomy in recent years. Indications of PC include calculous or acalculous cholecystitis, cholangitis, biliary obstruction and opacification of biliary ducts. It also provides a potential route for stone dissolution therapy and stone extraction. Under aseptic conditions and ultrasound guidance, using local anesthesia, the procedure is carried out by using either modified Seldinger technique or trocar technique. Transhepatic or transperitoneal puncture can be performed as an access route. Several days after the procedure transcatheter cholangiography is performed to assess the patency of cystic duct, presence of gallstones and catheter position. The tract is considered mature in the absence of leakage to the peritoneal cavity, subhepatic, subcapsular, or subdiaphragmatic spaces. Response rates to PC in the literature are between the range of 56-100% as the variation of different patient population. Complications associated with PC usually occur immediately or within days and include haemorrhage, vagal reactions, sepsis, bile peritonitis, pneumothorax, perforation of the intestinal loop, secondary infection or colonisation of the gallbladder and catheter dislodgment. Late complications have been reported as catheter dislodgment and recurrent cholecystitis. PC under ultrasonographic guidance is a cost-effective, easy to perform and reliable procedure with low complication and high success rates for critically ill patients with acute cholecystitis. It is generally followed by elective cholecystectomy, if possible. However, it may be definitive treatment, especially in acalculous cholecystitis.

Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): study protocol for a randomized controlled trial

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.

Effective use of percutaneous cholecystostomy in high-risk surgical patients: techniques, tube management, and results

HYPOTHESIS

Percutaneous cholecystostomy (PC) is an effective, safe treatment in patients with suspected acute cholecystitis and severe concomitant comorbidity.

DESIGN

Retrospective medical record review from March 1989 to March 1998.

SETTING

Referral community teaching hospital (450 beds) in rural Wisconsin.

PATIENTS

Twenty-two consecutive patients underwent PC tube placement over a 10-year period. Twenty procedures were for acute cholecystitis (14 calculous, 6 acalculous) and 2 were for diagnostic dilemmas. Nineteen (86%) of 22 patients were American Society of Anesthesiologists class 4; 3 (14%) were class 3.

INTERVENTIONS

Pigtail catheters (8F-10F) placed by means of ultrasound or computed tomographic localization, with or without fluoroscopic adjunct.

MAIN OUTCOME MEASURES

Thirty-day mortality, complications, clinical improvement as determined by fever and pain resolution, normalization of leukocytosis, further biliary procedures required, and outcome after drain removal.

RESULTS

Twenty-two patients underwent PC for presumed acute cholecystitis based on ultrasound and clinical findings. All patients received antibiotics prior to PC for 24 or more hours. Thirty-day mortality was 36% (8 patients), reflecting severity of concomitant disease. Minor complications occurred in 3 of 22 patients. Clinical improvement occurred in 18 (82%) of 22 patients-15 (68%) within 48 hours. Follow-up of fourteen 30-day survivors is as follows: 7 (50%) had drains removed because the gallbladder was stone free, 4 (29%) had drains remaining due to persistent stones, 2 (14%) underwent cholecystectomy, and 1 (7%) awaits scheduled surgery. Only 1 (12.5%) of 8 patients developed biliary complications after drain removal, requiring endoscopic retrograde cholangiopancreatography 9 months after drain removal. One patient required urgent cholecystectomy after failure to respond to PC. This patient died of a perioperative myocardial infarction.

CONCLUSIONS

Percutaneous cholecystostomy is an effective, safe treatment in patients with suspected acute cholecystitis and severe concomitant comorbidity. Laparoscopic cholecystectomy is recommended as definitive treatment for patients whose risk for general anesthesia improves in follow-up. Drains can be safely removed once all gallstones are cleared. In patients with severe concomitant disease, drains can be left with a low incidence of complications if stones remain.

Emergency cholecystostomy and subsequent cholecystectomy for acute gallstone cholecystitis in the elderly

BACKGROUND

The morbidity and mortality rates associated with acute cholecystitis are higher in the elderly. This study reports the results of treatment of acute cholecystitis in the elderly with emergency ultrasonographically guided percutaneous cholecystostomy followed by elective cholecystectomy after endoscopic treatment of any common bile duct stones diagnosed by percutaneous cholangiography.

METHODS

From January 1989 to December 1998, 92 patients aged over 70 years were treated for acute gallstone cholecystitis. A group of 84 patients with ultrasonographic signs of severe cholecystitis or an American Society of Anesthesiologists score of II to IV were submitted to ultrasonographically guided percutaneous cholecystostomy. Transcatheter cholangiography was performed in all patients and endoscopic sphincterotomy was performed before operation in patients with common bile duct stones. After resolution of the acute phase and treatment of any associated diseases, patients were submitted to cholecystectomy.

RESULTS

Cholecystostomy was performed successfully in 83 patients and permitted resolution of the acute attack in all after a mean period of 1.8 days. Cholangiography yielded a diagnosis of non-gallstone obstruction in one patient and common bile duct stones in 19 patients; preoperative endoscopic sphincterotomy and stone extraction was performed in 18 patients. Elective cholecystectomy was then performed in 70 patients with no deaths and a morbidity rate of 24 per cent.

CONCLUSION

Combining emergency ultrasonographically guided percutaneous cholecystostomy, preoperative endoscopic treatment of common bile duct stones and subsequent elective cholecystectomy constitutes an optimal treatment regimen for acute gallstone cholecystitis in selected elderly patients with a mortality rate of zero in the authors' experience.

Percutaneous cholecystostomy: diagnostic and therapeutic efficacy

Percutaneous cholecystostomy was performed in 32 patients for treatment of suspected cholecystitis (16 patients), decompression of biliary obstruction (six patients), or performance of diagnostic cholangiography (ten patients). The gallbladder was successfully catheterized in 32 of 32 patients (100%), and therapeutic or diagnostic benefit was achieved in 29 of 32 patients (91%). There were no major complications and no procedure-related deaths. There were four minor complications. In the 14 patients with severe cholecystitis there was substantial clinical improvement in 13. Five patients underwent catheter withdrawal after stabilization or long-term drainage. In biliary obstruction, hyperbilirubinemia was successfully treated with percutaneous cholecystostomy in five of six patients, and associated cholangitis was successfully treated in four of four. Ten patients underwent transcholecystic cholangiography; diagnostic visualization was achieved in all, including seven who underwent percutaneous cholecystostomy-assisted transhepatic biliary drainage. Percutaneous cholecystostomy is a safe and effective procedure in diagnosis and treatment of biliary tract problems.

Treatment of critically ill patients with sepsis of unknown cause: value of percutaneous cholecystostomy

Because of the difficulty in diagnosing acute cholecystitis in critically ill patients with severe intercurrent illness by clinical and imaging methods or percutaneous aspiration of the gallbladder, a trial of percutaneous cholecystostomy was performed in 24 patients in the intensive-care unit with persistent, unexplained sepsis after a complete clinical, laboratory, and radiologic search showed no alternative source of infection. Persistent high fevers, despite antibiotic therapy, were present in all patients, with elevated WBC count in 18 patients, vague abdominal tenderness in 11, and septic shock requiring vasopressors in 15. Sonographically, all patients had distended, spherical gallbladders, six had gallstones, eight had wall thickening, three had pericholecystic fluid, and four had Murphy's sign. All patients were seen by a senior abdominal surgeon, who agreed to a trial of percutaneous cholecystostomy. Fourteen patients (58%) responded to percutaneous cholecystostomy, as evidenced by a decrease in WBC count, defervescence, and the ability to be weaned off vasopressors. Bile cultures were positive in four patients. Ten patients (42%) did not respond to percutaneous cholecystostomy; five eventually died of unrelated causes. A respiratory source of infection was eventually found in three of these 10 patients, with no proved source of infection in the remainder. No complications related to catheter insertion occurred in this group of patients. Bile leaks occurred in two patients when the percutaneous cholecystostomy catheter was removed, but without serious consequence. Our experience suggests that a lower threshold for performing percutaneous cholecystostomy in this difficult clinical subset of patients is worthwhile.

Percutaneous cholecystostomy in the diagnosis and treatment of acute cholecystitis in the high-risk patient

We performed percutaneous cholecystostomy in 22 critically ill patients with suspected acute cholecystitis. This procedure accurately diagnosed acute cholecystitis in 17 of these 22 patients and excluded the diagnosis in the other 5 patients. Moreover, percutaneous cholecystostomy stabilized the conditions of 16 of the 17 patients with acute cholecystitis, allowing elective surgery in 8 patients and effectively treating 8 patients who never became surgical candidates. Percutaneous cholecystostomy and bile cultures are useful in the diagnosis and treatment of acute cholecystitis and should be performed in critically ill patients with clinical, laboratory, and radiologic evidence of acute cholecystitis and an excessive risk for cholecystectomy.

Ultrasound guided percutaneous cholecystostomy in high-risk patients for surgical intervention

AIM

To assess the efficacy and safety of ultrasound guided percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis in a well-defined high risk patients under general anesthesia.

METHODS

The data of 27 consecutive patients who underwent percutaneous transhepatic cholecystostomy for the management of acute cholecystitis from January 1999 to June 2003 was retrospectively evaluated. All of the patients had both clinical and sonographic signs of acute cholecystitis and had comorbid diseases.

RESULTS

Ultrasound revealed gallbladder stones in 25 patients and acalculous cholecystitis in two patients. Cholecystostomy catheters were removed 14-32 d (mean 23 d) after the procedure in cases where complete regression of all symptoms was achieved. There were statistically significant reductions in leukocytosis, (13.7 x 10(3)+/-1.3 x 10(3) microg/L vs 13 x 10(3)+/-1 x 10(3) microg/L, P < 0.05 for 24 h after PC; 13.7 x 10(3)+/-1.3 x 10(3) microg/L vs 8.3 x 10(3)+/-1.2 x 10(3) microg/L, P < 0.0001 for 72 h after PC), C -reactive protein (51.2+/-18.5 mg/L vs 27.3+/-10.4 mg/L, P < 0.05 for 24 h after PC; 51.2+/-18.5 mg/L vs 5.4+/-1.5 mg/L, P < 0.0001 for 72 h after PC), and fever (38+/-0.35 centigrade vs 37.3+/-0.32 centigrade, P < 0.05 for 24 h after PC; 38+/-0.35 centigrade vs 36.9+/-0.15 centigrade, P < 0.0001 for 72 h after PC). Sphincterotomy and stone extraction was performed successfully with endoscopic retrograde cholangio-pancreatography (ERCP) in three patients. After cholecystostomy, 5 (18%) patients underwent delayed cholecystectomy without any complications. Three out of 22 patients were admitted with recurrent acute cholecystitis during the follow-up and recovered with medical treatment. Catheter dislodgement occurred in three patients spontaneously, and two of them were managed by reinsertion of the catheter.

CONCLUSION

As an alternative to surgery, percutaneous cholecystostomy seems to be a safe method in critically ill patients with acute cholecystitis and can be performed with low mortality and morbidity. Delayed cholecystectomy and ERCP, if needed, can be performed after the acute period has been resolved by percutaneous cholecystostomy.

Ultrasound-guided percutaneous cholecystostomy in high-risk surgical patients

BACKGROUND AND AIMS

In critically ill patients, cholecystectomy is associated with a high mortality rate. The aim of this study was to evaluate the safety, efficacy and long-term outcome of ultrasound-guided percutaneous cholecystostomy (USGPC) in critically ill patients with acute cholecystitis.

MATERIALS AND METHODS

Clinical records of 51 patients, all considered high-risk surgical patients, with acute cholecystitis treated with USGPC between 1987 and 1999, were retrospectively reviewed. Response was defined as improvement in clinical symptoms and signs, and/or reduction in c-reactive protein and white blood count levels within 72 h. Long-term results were evaluated by means of clinical records and written correspondence.

RESULTS

Gallbladder stones were seen in 28 patients whereas 23 had acalculous cholecystitis. Ninety percent showed clinical improvement after USGPC. Cholecystectomy was performed in 16%, of which 6% after recurrent cholecystitis. Recurrence of cholecystitis occurred in 22%. Hospital mortality was 16%. None of the deaths was procedure related or related to acute cholecystitis alone. Major complications relating to the USGPC were rare (4%), while minor catheter-related complications were quite common.

CONCLUSIONS

USGPC is a procedure with few complications and a high success rate. In patients with acalculous cholecystitis as well as in many patients with calculous cholecystitis, no further treatment was needed.

Percutaneous cholecystostomy for high-risk surgical patients with acute calculous cholecystitis

BACKGROUND

The management of people at high risk of perioperative death due to their general condition (high-risk surgical patients) with acute calculous cholecystitis is controversial, with no clear guidelines. In particular, the role of percutaneous cholecystostomy in these patients has not been defined.

OBJECTIVES

To compare the benefits (temporary or permanent relief of symptoms) and harms (recurrence of symptoms, procedure-related morbidity) of percutaneous cholecystostomy in the management of high-risk individuals with symptomatic gallstones.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded to December 2012 to identify the randomised clinical trials. We also handsearched the references lists of identified trials.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or publication status) addressing this issue.

DATA COLLECTION AND ANALYSIS

Two review authors collected data independently. For each outcome, we calculated the P values using Fisher's exact test or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included two trials with 156 participants for this review. The comparisons included in these two trials were percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy (1 trial; 70 participants) and percutaneous cholecystostomy versus conservative treatment (1 trial; 86 participants). Both trials had high risk of bias. Percutaneous cholecystostomy with early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy: There was no significant difference in mortality between the two intervention groups (0/37 versus 1/33; Fisher's exact test: P value = 0.47). There was no significant difference in overall morbidity between the two intervention groups (1/31 versus 2/30; Fisher's exact test: P value = 0.61). This trial did not report on quality of life. There was no significant difference in the proportion of participants requiring conversion to open cholecystectomy between the two intervention groups (2/31 percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus 4/30 delayed laparoscopic cholecystectomy; Fisher's exact test: P value = 0.43). The mean total hospital stay was significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group (1 trial; 61 participants; MD -9.90 days; 95% CI -12.31 to -7.49). The mean total costs were significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group (1 trial; 61 participants; MD -1123.00 USD; 95% CI -1336.60 to -909.40). Percutaneous cholecystostomy versus conservative treatment: Nine of the 44 participants underwent delayed cholecystectomy in the percutaneous cholecystostomy group. Seven of the 42 participants underwent delayed cholecystectomy in the conservative treatment group. There was no significant difference in mortality between the two intervention groups (6/44 versus 7/42; Fisher's exact test: P value = 0.77). There was no significant difference in overall morbidity between the two intervention groups (6/44 versus 3/42; Fisher's exact test: P value = 0.49). The number of participants who underwent laparoscopic cholecystectomy was not reported in this trial. Therefore, we were unable to calculate the proportion of participants who underwent conversion to open cholecystectomy. The other outcomes, total hospital stay, quality of life, and total costs, were not reported in this trial.

AUTHORS' CONCLUSIONS

Based on the current available evidence from randomised clinical trials, we are unable to determine the role of percutaneous cholecystostomy in the clinical management of high-risk surgical patients with acute cholecystitis. There is a need for adequately powered randomised clinical trials of low risk of bias on this issue.

Laparoscopic cholecystjejunostomy as palliation for obstructive jaundice in inoperable carcinoma of pancreas

Malignant obstructive jaundice can be palliated by either surgical bypass, which has the advantage of long-term patency, or by stent placement, which has the advantage of initial lower morbidity and mortality. We describe a technique, laparoscopic cholecystjejunostomy, which has the advantage of both. We predict that laparoscopic surgery, which has already had a major impact on biliary stone surgery, will also have a major impact on interventional endoscopic retrograde cholangiopancreatography.

Percutaneous cholecystostomy for acute cholecystitis in critically ill patients

BACKGROUND

Cholecystectomy remains the best treatment for acute cholecystitis but may cause high morbidity or mortality in critically ill or elderly patients.

METHODS

We report a retrospective study of ultrasonography-guided percutaneous cholecystostomy (USGPC) performed between 1988 and 1994 in 41 patients (mean age, 77.8 years; range, 42-95 years) as an alternative to surgery.

RESULTS

Five patients (12.2%) died in the hospital, four (9.8%) subsequently underwent operation without complications, six (15%) had a recurrence of cholecystitis between 3 and 24 months after withdrawal of drainage, and 26 patients are cured without recurrence after a mean follow-up of 33 months (range, 3-67 months).

CONCLUSIONS

USGPC appears to be the treatment of choice for high-risk patients, especially those with postoperative cholecystitis, severe acute calculous pancreatitis, or total parenteral nutrition.

Percutaneous cholecystostomy: who responds?

OBJECTIVE

Our purpose was to identify clinical or radiologic features predictive of response to percutaneous cholecystostomy performed for the treatment of acute cholecystitis.

MATERIALS AND METHODS

The clinical records and radiologic images of patients who underwent percutaneous cholecystostomy for suspected acute cholecystitis between January 1987 and July 1994 were retrospectively reviewed. A response to percutaneous cholecystostomy was defined as an improvement in clinical symptoms and signs or reduction in fever and WBC to normal within 72 hr of percutaneous cholecystostomy. The number and type of radiologic investigations were reviewed by two radiologists. The presence of gallstones, gallbladder wall thickening, distention, and pericholecystic fluid was recorded. The clinical and radiologic findings were analyzed for their relationship to response to percutaneous cholecystostomy.

RESULTS

Sixty-one percutaneous cholecystostomies were performed in 37 male and 24 female patients and were technically successful in 59. Thirty-one patients had gallstones, 28 did not. Thirty-one patients were in the intensive care unit, and 15 were ventilated. Complications occurred in six (10%): misplacement of the percutaneous cholecystostomy catheter in the colon (one), exacerbation of sepsis (three), and bile leakage (two). The mortality rate was 2%--one of the patients with septic shock succumbed to a cardiac arrest 3 days after the procedure. Forty-three patients (73%) responded to percutaneous cholecystostomy. Patients with gallstones and symptoms and signs localized to the right upper quadrant of the abdomen were more likely to respond (p = .006). The only individual radiologic feature predictive of a positive response was the presence of pericholecystic fluid in patients with gallstones (p = .03). The presence of all four radiologic findings was also associated with a positive response (p = .039). The results of bile cultures were not predictive of response. Of the 16 nonresponders, six had documented biliary sepsis and cholecystitis.

CONCLUSION

Clinical symptoms and signs referable to the gallbladder, the presence of pericholecystic fluid in patients with gallstones, and the presence of an increasing number of radiologic findings in any one patient are predictive of a positive response to percutaneous cholecystostomy.

Percutaneous cholecystostomy: the radiologist's role in treating acute cholecystitis

Acute cholecystitis is a common condition, with laparoscopic cholecystectomy considered the gold-standard for surgical management. However, surgical options are often unfavourable in patients who are very unwell, or have numerous medical co-morbidities, in which the mortality rates are significant. Percutaneous cholecystostomy (PC) is an image-guided intervention, used to decompress the gallbladder, reducing patient's symptoms and the systemic inflammatory response. PC has been shown to be beneficial in high-risk patient groups, predominantly as a bridging therapy; allowing safer elective cholecystectomy once the patient has recovered from the acute illness; or, in the minority, as a definitive treatment in patients deemed unfit for surgery. This review aims to develop a broader understanding of PC, discussing its specific indications, patient management, technical factors, imaging guidance, and outcomes following the procedure.

Early Percutaneous Cholecystostomy in Severe Acute Cholecystitis Reduces the Complication Rate and Duration of Hospital Stay

The optimal timing of percutaneous cholecystostomy for severe acute cholecystitis is unclear. The aim of this study was to investigate the timing of percutaneous cholecystostomy and its relationship to clinical outcomes in patients with inoperable acute severe cholecystitis.From 2008 to 2010, 209 consecutive patients who were admitted to our hospital due to acute cholecystitis and were treated by percutaneous cholecystostomy were retrospectively reviewed. The time periods from symptom onset to when percutaneous cholecystostomy was performed and when patients were discharged were recorded.In the 209 patients, the median time period between symptom onset and percutaneous cholecystostomy was 23 hours (range, 3-95 hours). The early intervention group (≤24 hours, n = 109) had a significantly lower procedure-related bleeding rate (0.0% vs 5.0%, P = 0.018) and shorter hospital stay (15.8 ± 12.9 vs 21.0 ± 17.5 days) as compared with the late intervention group (>24 hours, n = 100). Delayed percutaneous cholecystostomy was a significant independent factor for a longer hospital stay (odds ratio 3.03, P = 0.001).In inoperable patients with acute severe cholecystitis, early percutaneous cholecystostomy reduced hospital stay and procedure-related bleeding without increasing the mortality rate.

Percutaneous cholecystostomy for acute cholecystitis in veteran patients

BACKGROUND

Surgical cholecystostomy has been shown to carry a significantly higher mortality rate at Veterans Administration (VA) hospitals than at non-federal hospitals in the past.

METHODS

A retrospective outcomes study was undertaken at a large VA medical center with a policy favoring radiologic over surgical cholecystostomy over the past 9 years. Records of 24 consecutive patients with acute cholecystitis were reviewed to evaluate the effectiveness of the procedure.

RESULTS

Cholecystostomy was performed radiologically in 22 patients and surgically in 2 patients. Most (78%) of patients improved within 48 hours. The periprocedural mortality was 25%. The majority of these patients died from unrelated illnesses. Four patients developed complications, none of which required operative intervention.

CONCLUSIONS

Comorbidities are the most important mortality factor for cholecystostomies in VA patients. Radiologic tube placement is effective and uncomplicated in most cases.