[Percutaneous cholecystostomy in acute cholecystitis--a solution for risk patient groups?]

In treating acute cholecystitis in patients with a high operative risk, the general rule is to treat conservatively, with surgery indicated in those patients where this therapy is insufficient. Cholecystotomy is one alternative method of treatment. Due to its disadvantages, it belongs to one of the most seldomly used surgical procedures. These drawbacks, however, may be curtailed by using a percutaneous cholecystotomy (PC) done under CT or US navigation. The authors here recount their experiences of treating acute cholecystitis with PC in two case studies, relating difficulties in indication, technical performance, and complications of the procedure. In accordance with scientific literature, we consider PC an effective treatment method with minimal complications.

Gallstone disease: Surgical aspects of symptomatic cholecystolithiasis and acute cholecystitis

Indications for cholecystectomy are limited to clearly symptomatic gallstones. Relatively high failure rates of pain relief are probably caused by incorrect selection of patients for the operation. Contraindications for (laparoscopic) cholecystectomy are related to anaesthesiological considerations. Laparoscopic cholecystectomy was accepted by consensus as the gold standard within 5 years of its introduction. Nevertheless, both the classical open and small-incision cholecystectomies are safe alternatives, and superiority of any one of the three techniques over the others has not been proven. Primary outcome measures (mortality, complications, and symptom relief) seem to be equal for the three techniques. Acute cholecystitis is a complication of gallstones. Generally it is recommended that early cholecystectomy be performed, as delayed cholecystectomy is associated with longer total hospital stay and convalescence due to recurrent cholecystitis episodes. Cholecystostomy is an alternative technique for patients unfit for general anaesthesia. Reported complication and conversion rates in cholecystectomy for acute cholecystitis vary, but are higher than for symptomatic cholecystolithiasis. New developments--such as robot-assisted surgery--are expected to have a significant impact in the near future.

Percutaneous cholecystostomy using a central venous catheter is effective for treating high-risk patients with acute cholecystitis

Percutaneous cholecystostomy (PC) using a pigtail catheter is performed on high-risk patients with acute cholecystitis as their general condition does not usually allow them to undergo a "definite" cholecystectomy. However, this method of PC is time-consuming and expensive and requires an interventional radiologist and specially designed radiologic equipment. To determine whether another PC approach was viable, we retrospectively compared patients who underwent PC using a central venous catheter (group A, n = 15) with those who underwent standard pigtail catheter PC (group B, n = 29). The waiting time prior to undergoing the PC was 1.8 days in group A and 3.5 days in group B (P < 0.05). The cost per patient was 293,364 won (254.44 dollars) for group A, and 438,719 won (380.50 dollars) for group B (P < 0.05). There were 4 complications in group A and 5 in group B. Following PC, 7 patients in group A and 15 patients in group B underwent delayed definite cholecystectomy, and there were no differences between these groups in terms of complications, mortality, and the delayed definite cholecystectomy surgical method. We conclude that in combination with careful patient selection, PC using a central venous catheter in high-risk patients with acute cholecystitis is a viable alternative to pigtail catheter PC.

Ultrasound-guided percutaneous cholecystostomy for acute cholecystitis in critically ill patients: one center's experience

BACKGROUND/AIMS

The standard treatment for acute cholecystitis is cholecystectomy; however, cholecystectomy is not an option in some patients who are too high-risk for emergency surgery. Ultrasound-guided percutaneous cholecystostomy is an alternative for such patients. This study presents one center's five-year clinical experience with ultrasound-guided percutaneous cholecystostomy for treatment of acute cholecystitis.

METHODS

In this study the records of all patients (18 total; mean age, 68.2+/-15.4 years; range, 42-91 years) who underwent ultrasound-guided percutaneous cholecystostomy for acute cholecystitis between June 1998 and October 2003 were reviewed. Duration of hospitalization, duration of tube placement, mortality and morbidity after tube placement, complication rates, culture results for aspirated bile, and clinical outcomes were analyzed.

RESULTS

Fourteen patients were diagnosed with acute calculous cholecystitis and four were diagnosed with acalculous cholecystitis. The average hospital stay was 19+/-12.6 days (range, 5-52 days), and the average duration of catheter drainage was 20.5+/-19.1 days (range, 1-75 days). Six patients underwent open cholecystectomy between days 16 and 26 of catheter drainage, and none had postoperative complications.

CONCLUSIONS

Ultrasound-guided percutaneous cholecystostomy is a relatively safe and easy method for treating acute cholecystitis in critically ill patients. The risk of complications is low and the likelihood of success is high.

Segment VI cholangiocholecystostomy for unresectable malignant obstruction at the hepatic hilum

Anastomosis between the segment VI intrahepatic bile duct and the stump of the cystic duct was done to relieve obstructive jaundice caused by high biliary malignant obstruction. This procedure is considered to be a safe and easy method to provide good palliation in patients with unresectable hepatic hilar carcinoma.

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.

Chemical ablation of the gallbladder: clinical application and long-term observations

BACKGROUND

We investigated whether minicholecystostomy followed by chemical ablation of the gallbladder could be used as a alternative to cholecystectomy in patients at high risk for complications of surgery.

METHODS

From January 1990 through January 2003, 34 patients at high risk underwent minicholecystostomy. Six weeks after the operation, microwave irradiation was provided to burn the mucosa of the cystic duct at locations at 3, 6, 9, and 12 o'clock around the orifice. Each location was treated eight times at 50 mA for 10 sec. Then chemical ablation of the gallbladder was performed by infusing 95% ethanol into the gallbladder cavity for 30 min. For each sclerosis course, the procedure was repeated every 4 h for a total of eight times. Approximately 2 weeks later, the drainage tube was removed from the gallbladder after cholecystography showed that no cavity other than the lumen of the tube remained in the gallbladder.

RESULTS

Patients tolerated the procedure well and were followed with ultrasonography for 2-14 years (mean, 9). Twenty-nine patients had no complications or side effects, and five patients developed a 1.5- to 3- cm mucocele in the gallbladder. The long-term success rate of sclerotherapy was 85.3% (29/34). No recurrent cholecystitis, new stone or formation, canceration were encountered at the site of the gallbladder.

CONCLUSIONS

Minicholecystostomy followed by chemical ablation of the gallbladder was a safe, effective, and simple procedure for treating high-risk patients with acute cholecystitis and/or cholelithiasis.

Predicting Infected Bile Among Patients Undergoing Percutaneous Cholecystostomy

PURPOSE

Patients may not achieve a clinical benefit after percutaneous cholecystostomy due to the inherent difficulty in identifying patients who truly have infected gallbladders. We attempted to identify imaging and biochemical parameters which would help to predict which patients have infected gallbladders.

METHODS

A retrospective review was performed of 52 patients undergoing percutaneous cholecystostomy for clinical suspicion of acute cholecystitis in whom bile culture results were available. Multiple imaging and biochemical variables were examined alone and in combination as predictors of infected bile, using logistic regression.

RESULTS

Of the 52 patients, 25 (48%) had infected bile. Organisms cultured included Enterococcus, Enterobacter, Klebsiella, Pseudomonas, E. coli, Citrobacter and Candida. No biochemical parameters were significantly predictive of infected bile; white blood cell count >15,000 was weakly associated with greater odds of infected bile (odds ratio 2.0, p = NS). The presence of gallstones, sludge, gallbladder wall thickening and pericholecystic fluid by ultrasound or CT were not predictive of infected bile, alone or in combination, although a trend was observed among patients with CT findings of acute cholecystitis toward a higher 30-day mortality. Radionuclide scans were performed in 31% of patients; all were positive and 66% of these patients had infected bile. Since no patient who underwent a radionuclide scan had a negative study, this variable could not be entered into the regression model due to collinearity.

CONCLUSION

No single CT or ultrasound imaging variable was predictive of infected bile, and only a weak association of white blood cell count with infected bile was seen. No other biochemical parameters had any association with infected bile. The ability of radionuclide scanning to predict infected bile was higher than that of ultrasound or CT. This study illustrates the continued challenge to identify bacterial cholecystitis among patients referred for percutaneous cholecystostomy.

Gallbladder aspiration for acute cholecystitis in average-surgical-risk patients

We conducted a retrospective case note review to assess whether or not gallbladder aspiration can be applied as a temporary measure for the treatment of acute cholecystitis in average-surgical-risk patients. Gallbladder aspiration was performed in 79 consecutive average-surgical-risk patients with acute cholecystitis, who had no indications of emergent surgery and who complained of severe colicky pain. Elective surgery became possible in 92% of patients by gallbladder aspiration. The percentage reached 97 when percutaneous cholecystostomy was added (four patients). Emergent surgery was needed in one patient suffering bile leakage following gallbladder aspiration. Colicky pain was controlled soon after the procedure in most cases. Neither major complications nor mortalities were observed in the following surgical therapies. It is suggested that gallbladder aspiration might be applied as a temporary measure for acute cholecystitis in average-surgical-risk patients, although early surgery should remain the primary choice of therapy in such patients.

Percutaneous cholecystostomy for the treatment of acute cholecystitis in the critically ill and elderly

OBJECTIVE

To evaluate the clinical efficacy and outcomes of percutaneous cholecystostomy as an alternative treatment option for elderly and critically ill patients who have acute cholecystitis.

PATIENTS AND METHODS

The medical records of patients who underwent emergency percutaneous cholecystostomy at the North District Hospital, Hong Kong from September 1999 to July 2002 were reviewed. Indications for the procedure, patient demographics, and other clinical details were recorded.

RESULTS

A total of 25 patients (10 male, 15 female) with a median age of 81 years (range, 39-97 years) presented with acute cholecystitis and underwent percutaneous cholecystostomy with ultrasound guidance. Two patients required emergency cholecystectomy on day 1 after the procedures because of deteriorating conditions. The rest of the patients clinically improved after drainage. There was no major periprocedural complication, and four patients had their catheter accidentally dislodged but did not require re-insertion. There were five in-patient mortalities, although the majority of these deaths were from unrelated illness. Subsequently, only six patients underwent elective cholecystectomy, one open and five laparoscopic. Two patients were offered percutaneous endoscopic cholecystolithotripsy, one defaulted and the other could not tolerate the procedure. Eleven patients declined further intervention due to the high surgical risks, three of these patients developed biliary symptoms, one had acute cholecystitis, and the other two had cholangitis. The rest of patients had no symptoms related to the gallstones. The median follow-up period was 81 weeks (range, 27-162 weeks).

CONCLUSION

Percutaneous cholecystostomy is a viable treatment option for elderly and critically ill patients presenting with acute cholecystitis. It has a high success rate with minimal procedure-related complications. Elective cholecystostomy is the treatment of choice for low-risk patients after the initial acute cholecystitis.

[Outcomes of percutaneous cholecystostomy in patients with high surgical risk]

PURPOSE

To evaluate the effectiveness of the percutaneous cholecystostomy with the follow up results of our patients.

MATERIALS AND METHODS

We retrospectively evaluated the medical records of 37 patients who underwent percutaneous cholecystostomy. Eighteen female and 19 male patients were included into this study between the ages of 7 and 88 years. All of our patients had acute cholecystitis or eventually developed acute cholecystitis except one. Seven year old male patient with Non-Hodgkin lymphoma underwent percutaneous cholecystostomy due to elevation of liver function tests and direct bilirubin. Since he had dilated intrahepatic biliary ducts due to a lymphadenopathy compression at portal hilus, percutaneous cholecystostomy was performed to decompress the biliary system to decrease the bilirubin and liver function tests to normal levels for initiating appropriate chemotherapy protocol. All the procedures were carried under fluoroscopic and sonographic guidance through transhepatic or transperitoneal approach with 6 to 10 F drainage catheters.

RESULTS

Recovery from the acute cholecystitis symptoms was achieved in 31 patients (86%) in follow-up. No procedure-related mortality was observed. The only major complication was intraperitoneal bleeding due to underlying coagulopathy which was treated with blood transfusion. Eight patients (21.6%) died in 30 days after the percutaneous intervention procedure. In the patient with Non-Hodgkin lymphoma at the age of 7, however, the procedure to decrease the bilirubin levels was successful and chemotherapy was given subsequently; he had died after 31 days due to his aggressive primary disease. Catheterization times were between 2 days and 60 days due to accompanied diseases. Six patients (16.7%) were finally undergone to cholecystectomy after the risks for surgery had been reduced. ERCP was performed in 2 patients (5.6%) for stone extraction from common bile duct. Eighteen patients (50%) were recovered from the acute illness and following the control cholangiograms, catheters were taken out consequently.

CONCLUSION

Percutaneous cholecystostomy under ultrasonographic and fluoroscopic 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.

Surgeon-performed ultrasound in the ICU setting

Evaluation of critically ill patients is often challenging due to altered sensorium, underlying disease, and the presence of multiple drains or monitoring devices. In such circumstances, the ability of physicians to perform ultrasound examinations in the intensive care unit provides a useful diagnostic and therapeutic adjunct. In this article,we review the application of surgeon-performed ultrasonography in the evaluation and management of critically ill patients.

Ultrasound-guided percutaneous cholecystostomy: update on technique and clinical applications

Acute cholecystitis is one of the most frequent causes for emergency admissions to General Surgery Departments. Due to the increased morbidity and high-risk of mortality, patients with severe underlying disease or a debilitated general condition are initially treated conservatively by administration of antibiotics, decompression, and drainage of the gallbladder. Percutaneous cholecystostomy (PC) is a minimally invasive method of percutaneous placement of a catheter, under ultrasound guidance, in the gallbladder lumen. PC can be performed at the bed-side and help the patient as well as physicians searching for a site and cause of sepsis. Dynamic ultrasound visualization of the puncture needle and gallbladder is crucial to avoid complications. PC cholecystectomy is an efficacious procedure with reported clinical response rates of 56%-100%. Clinical response is considered when a decrease in white blood cell count, defervescence, and decrease in the need for vasopressors are present. Patients with gallstones and symptoms and signs localized to the right upper quadrant are more likely to respond. Mortality is associated mainly with the underlying medical conditions. Ultrasound-guided PC can be followed by elective cholecystectomy at a later stage if the patient's condition permits, or by expectant or conservative management in those with acalculous cholecystitis.

US-guided Percutaneous Cholecystostomy: Features Predicting Culture-Positive Bile and Clinical Outcome

PURPOSE

To assess sonographic and clinical features that might be used to predict infected bile and/or patient outcome from ultrasonography (US)-guided percutaneous cholecystostomy.

MATERIALS AND METHODS

Between February 1997 and August 2002 at one institution, 112 patients underwent US-guided percutaneous cholecystostomy (59 men, 53 women; average age, 69.3 years). All US images were scored on a defined semiquantitative scale according to preset parameters: (a) gallbladder distention, (b) sludge and/or stones, (c) wall appearance, (d) pericholecystic fluid, and (e) common bile duct size and/or choledocholithiasis. Separate and total scores were generated. Retrospective evaluation of (a) the bacteriologic growth of aspirated bile and its color and (b) clinical indices (fever, white blood cell count, bilirubin level, liver function test results) was conducted by reviewing medical records. For each patient, the clinical manifestation was classified into four groups: (a) localized right upper quadrant symptoms, (b) generalized abdominal symptoms, (c) unexplained sepsis, or (d) sepsis with other known infection. Logistic regression models, exact Wilcoxon-Mann-Whitney test, and the Kruskal-Wallis test were used.

RESULTS

Forty-seven (44%) of 107 patients had infected bile. A logistic regression model showed that wall appearance, distention, bile color, and pericholecystic fluid were not individually significant predictors for culture-positive bile, leaving sludge and/or stones (P =.003, odds ratio = 1.647), common bile duct status (P =.02, odds ratio = 2.214), and total score (P =.007, odds ratio = 1.267). No US covariates or clinical indices predicted clinical outcome. Clinical manifestation was predictive of clinical outcome (P =.001) and aspirating culture-positive bile (P =.008); specifically, 30 (86%) of 35 patients with right upper quadrant symptoms had their condition improve, compared with one (7%) of 15 asymptomatic patients with other known causes of infection.

CONCLUSION

US variables can be used to predict culture-positive bile but not patient outcome. Clinical manifestation is important because patients with right upper quadrant symptoms have the best clinical outcome.

[The sphincter-related biliodigestive anastomoses in anomalies of bile ducts]

The authors made an analysis of anomalies of the bile ducts with special reference to anatomical peculiarities and iatrogenic lesions of the bile ducts. The anomalies of bile ducts were found in 2.07% of 676 patients operated on for complicated cholelithiasis. Primary operative interventions and reoperations in the patients were completed with the formation of the constriction-biliodigestive anastomoses of different levels having antireflux functions. The authors describe the operation technique and results of the treatment of bile duct obstruction.

Percutaneous cholecystostomy: a nonsurgical therapeutic option for acute cholecystitis in high-risk and critically ill patients

Percutaneous cholecystostomy offers a potentially important type of therapy for critically ill patients with acute cholecystitis who present high risk when undergoing laparotomy or laparoscopy under general anesthesia. It offers a distinct advantage for these kinds of patients by avoiding the risks of the surgical intervention. Percutaneous cholecystostomy is a safe and effective minimally invasive procedure with a high success rate and low procedure-related complications. It should be considered not only in temporary management of calculous cholecystitis, but also in definitive treatment in cases of acalculous cholecystitis.

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 in the management of acute cholecystitis

BACKGROUND

The mainstay of therapy for acute cholecystitis is cholecystectomy, which has a mortality of 14-30% in high risk patients. An alternative approach in patients suffering from acute cholecystitis with contraindications to emergency surgery is percutaneous cholecystostomy.

OBJECTIVE

To evaluate the efficacy and safety of percutaneous cholecystostomy as the initial treatment of acute cholecystitis in high risk patients.

METHODS

Eighty consecutive patients (42 men, 38 women) underwent ultrasound-guided percutaneous cholecystostomy over a 5 year period. Sixty-five patients suffered from acute calculous cholecystitis, 4 patients had acalculous cholecystitis, and 11 patients had sepsis of unknown origin.

RESULTS

Sixty-eight patients improved after the percutaneous gallbladder drainage, 10 patients died from co-morbid disease and 2 patients died from biliary peritonitis. During a 1 year follow-up, 32 of the patients underwent interval cholecystectomy, 4 additional patients died from a co-morbid disease, 18 patients did not suffer from any gallbladder symptoms, and 14 were lost to follow-up.

CONCLUSIONS

Percutaneous cholecystostomy is an effective contribution to the treatment of acute cholecystitis in high risk patients.

Percutaneous cholecystocholedochostomy for cholecystitis and cystic duct obstruction in gallbladder carcinoma

Percutaneous cholecystocholedochostomy was performed in a patient with acute cholecystitis caused by cystic duct obstruction by gallbladder carcinoma, but removal of the percutaneous cholecystostomy catheter was unsuccessful because of continuing discharge. After creation of a cholecystocholedochostomy through the cholecystostomy tract with use of a transjugular liver access set and a 21-gauge needle, self-expandable metallic stents were placed in the narrowed common bile duct and the newly created tract between the gallbladder and the common hepatic duct. The external cholecystostomy catheter was successfully removed after the procedure. Jaundice occurred 70 days later as a result of tumor invasion above the segment with the stent, and an additional stent was placed. The patient died of diffuse metastasis 143 days after creation of the cholecystocholedochostomy without recurrence of cholecystitis.

Cholecysto-choledochostomy plus construction of subcutaneous cholecystic tunnel in treatment of choledocholith

OBJECTIVE

To avoid the pitfalls of choledochotomy with T-tube drainage in the treatment of choledocholith.

METHODS

A novel operation was designed as cholecysto-choledochostomy plus construction of subcutaneous cholecystic tunnel. After the common bile duct was cut open and stones were removed, the gallbladder was appropriately dissociated and the cholecystic ampulla was incised. Then, the incision of the cholecystic ampulla was anastomosed to the opened common bile duct, and the cholecystic fundus was fixed out of the abdominal muscular stratum.

RESULTS

Twenty-one patients with choledocholith underwent this operation successfully and recovered well without postoperative complications. One of them was diagnosed as having recurrent stones in 2 years and 3 months after operation. Consequently, the subcutaneous cholecystic tunnel was opened under local anesthesia to remove successfully the stones with choledochoscope.

CONCLUSION

This operation provides a convenient way to remove postoperative recurrent stones with choledochoscope and avoid receliotomy.

[The treatment of gallstone disease in the elderly]

Gallstone diseases (asymptomatic, symptomatic and complicated) are frequently seen in the elderly; the prevalence increases proportionally with age. At higher ages (> 60 years) the presentation of symptomatic or complicated gallstone disease is frequently atypical. Complicated gallstone disease (especially cholecystitis and cholangitis) in the elderly is associated with high morbidity and mortality rates. The introduction of laparoscopic cholecystectomy has decreased the morbidity and mortality rates of symptomatic and complicated gallstone disease in the elderly; for elective procedures in particular, the risks hardly differ from those for younger patients. Percutaneous cholecystostomy is an effective and safe alternative for (laparoscopic) cholecystectomy in high-risk patients with an acute cholecystitis. Endoscopic retrograde cholangiopancreaticography (ERCP) with sphincterotomy is also the treatment of choice for common bile duct stones in the elderly. After removal of common bile duct stones (whether or not accompanied by cholangitis or pancreatitis) a laparoscopic cholecystectomy should be performed, unless contraindications are present.

Percutaneous cholecystostomy with locking trocar: how I do it?

Cholecystectomy and open cholecystostomy are associated with a high mortality rate in critically ill patients. Ultrasound-guided percutaneous cholecystostomy has a high success rate with few complications. The following method of percutaneous cholecystostomy with locking trocar (LT) under direct laparoscopic vision is seen to be an effective, safe, and practical procedure. After the abdomen is prepared from xiphisternum to symphysis pubis, the umbilicus and surrounding skin are infiltrated with 1% combined lignocaine and adrenaline. A 10-mm laparoscopy trocar is inserted via a 10-mm subumbilical incision. After a camera is inserted via the trocar, the abdomen and gallbladder are exposed. The skin of the geometric projection of fundus is infiltrated with the same solution, and a 5-mm LT is introduced via a 5-mm skin incision directed to the fundus of the gallbladder guided by the direct view of a laparoscope. When the LT has penetrated to the gallbladder, the bile and contents of the gallbladder are aspirated immediately to reduce the pressure, and the trocar is locked. The locked trocar is fixed to the abdominal wall under traction until the completion of peritonization to prevent bile leakage. The gallstones can be extracted through the trocar by a laparoscopy forceps. This technique was used for a 75-year-old woman with calculous cholecystitis and cardiopulmonary insufficiency, and her progress at this writing is good.

Treatment of transient posttraumatic bile-duct stenosis by laparoscopic-assisted cholecystotomy

A 10-year-old boy developed severe obstructive jaundice following blunt abdominal trauma. Endoscopic retrograde cholangiography and magnetic resonance cholangiography revealed a stricture of the common bile duct. A cholecystostomy tube was inserted under laparoscopic guidance. After temporary bile drainage and a cholecystoenteric bypass the patient recovered.

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 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.