Laparoscopic tube cholecystostomy: still useful in the management of complicated acute cholecystitis

The preferred treatment for acute cholecystitis is laparoscopic cholecystectomy. Conversion to open operation may be necessary in cases where the anatomy is unclear or complications are encountered. Laparoscopic tube cholecystostomy remains an alternative to open surgery in cases where the gallbladder is judged too inflamed to allow for laparoscopic removal and in cases where the patient is too sick to tolerate a more extensive procedure. It also provides access for diagnostic cholangiography. We report three patients with acute cholecystitis who underwent laparoscopic cholecystostomy and interval laparoscopic cholecystectomy without complications. Laparoscopic tube cholecystostomy is safe and remains a useful option in select patients with complicated acute cholecystitis.

[Endoscopic, percutaneous and laparoscopic treatment for acute biliary pancreatitis]

AIM OF THE STUDY

The aim of this study is to evaluate the results of acute gallstone pancreatitis treatment and to discuss indications in relation with the different forms of the disease.

MATERIAL AND METHOD

From january 1992 to june 2001, 137 patients have been treated for an acute gallstone pancreatitis. Diagnostic criteria were given by the history, clinical examination, biochemical and radiological findings. After exclusion of patients with a systemic disease, a group of 129 patients have been enrolled in a treatment regimen with an endoscopic retrograde cholangiopancreatography (ERCP) and eventual sphincterotomy, a percutaneous US-guided cholecystostomy (PC) when necessary and an elective laparoscopic cholecystectomy.

RESULTS

ERCP has been successfully performed in 121/129 patients. A PC has been performed in 5/8 patients of the failed endoscopic procedure and in 14 with acute cholecystitis. Retrograde and percutaneous cholangiographies showed main bile duct stones in 89 patients, a dilatation of the main bile duct without stones in 26 patients and a negative finding in 6 patients. An endoscopic sphincterotomy has been performed in 117 patients. A laparoscopic cholecystectomy has been performed in 118 patients. Mortality and morbidity rates were 1.6 and 10.3%, respectively.

CONCLUSION

ERCP and sphincterotomy seem to be indicated in all patients observed during the first 72 hours. Endoscopic treatment and percutaneous procedure make it possible to reduce at a very low rate the cases with an unfavourable course of the disease. A definitive treatment may then be performed by the way of a laparoscopic cholecystectomy.

Measurement of needle-tip bioimpedance to facilitate percutaneous access of the urinary and biliary systems: first assessment of an experimental system

RATIONALE AND OBJECTIVES

Percutaneous access to the renal collecting system or biliary system is most frequently performed under image guidance. However, current techniques lack a feedback mechanism to help confirm successful access. A percutaneous needle system has been developed consisting of a modified 18-gauge percutaneous access needle that measures tissue impedance at its needle tip. Initial results in utilizing this novel system to determine successful access into dilated kidney and gall bladder specimens are reported.

METHODS

Impedance measurements were recorded as the needle was precisely advanced through ex vivo kidney and liver/gall bladder specimens. In an anesthetized porcine model, impedance values were recorded with laparoscopic visualization as the needle was advanced percutaneously through abdominal wall, liver, and into gall bladder.

RESULTS

A characteristic, reproducible drop in impedance was noted with successful entry into ex vivo distended kidney and gall bladder specimens. This feature was also noted during in vivo percutaneous cholecystostomy.

CONCLUSIONS

A measurable, characteristic drop in tissue impedance signifies successful entry into the urinary and biliary systems. This impedance needle system may facilitate current percutaneous access techniques.

[Ultrasound-guided trans-parietohepatic cholecystostomy in the critical patient: current indications]

The appearance of acute cholecystitis can make to complicate a natural history of cholelitiasis or post-operating time of patients that have concomitant predisposition factors. The best therapy is the cholecystectomy but somewhere for the critical general conditions is too much dangerous to make a surgical procedure. However we need to stabilize patients conditions, also for a short time. Our experience suggest us that percutaneous transhepatic cholecystostomy is a simple method without any complications, efficacious to resolve the acute sepsis in patients with cholecystitis that not be able to tolerate a surgical procedure.

A new biliodigestive anastomosis technique to prevent reflux and stasis

BACKGROUND

The Roux-en-Y procedure for biliodigestive drainage is most widely accepted, but 10% to 15% of patients postoperatively suffer from a blind-loop syndrome or cholangitis due to motility disorders. A new biliodigestive technique is evaluated in a rat model to prevent these complications.

METHODS

This experimental study in Wistar rats compares the Roux-en-Y technique with a new biliodigestive anastomosis creating a jejunal loop with luminal occlusion. Clinical parameters, small bowel motility, bacteriologic growth, and liver histopathology were evaluated in native and postoperative animals within a study period of 180 days.

RESULTS

Both operative procedures were well tolerated. After 6 months intense fibrosis of the liver and high-grade purulent cholangitis were observed in animals in the Roux-en-Y group. In these animals enterobacter and enterococci overgrowth was found. Myoelectric small bowel recordings revealed significant impairment of slow-wave frequency, aboral velocity, and action potentials (percentage of phase III) in Roux-en-Y animals.

CONCLUSIONS

Motility disorders after conventional Roux-en-Y biliodigestive anastomosis are pivotal for histomorphological damage and infectious findings and can be prevented by using the new technique to create a jejunal loop with luminal occlusion.

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.

[Minimally invasive surgery in cholelithiasis]

The results of minimally invasive surgical interventions (percutaneous transhepatic cholecystostomy, retrograde cholangiopancreatography with endoscopic papillosphincterotomy, percutaneous transhepatic cholangiostomy with endobiliary intervention, extracorporeal shock wave lithotripsy, laparoscopic cholecystectomy) in 1590 patients were analyzed, 2 methods and more were used in 74 of them. In 155 patients minimally invasive interventions were combined with open surgery. Rational combination of minimally invasive methods in cholelithiasis permits to cure majority of the patients, to avoid open operation and associated complications.

[Percutaneous cholecystostomy for acute cholecystitis in high-risk patients]

AIM OF THE STUDY

The aim of this retrospective study was to report the results of percutaneous cholecystostomy in a selected group of high-risk patients with contraindications of general anesthesia.

PATIENTS AND METHODS

From October 1995 to December 1999, a percutaneous cholecystostomy was performed in 29 patients with acute cholecystitis. There were 20 women and nine men with a mean age of 80.6 years (range: 59 to 95 years). All the patients were ASA III (N = 23) or ASA IV (N = 6). Ultrasound-guided percutaneous cholecystostomy was performed in 24 cases and computed tomography-guided cholecystostomy in five cases.

RESULTS

Percutaneous cholecystostomy was easily performed in 28 cases; there was one failed procedure. The drainage was not efficient in three patients who were operated on with one postoperative death of a patient who had a necrotic cholecystitis. There was no mortality in relation with cholecystostomy. One patient died at day 15 from myocardia infarction. The morbidity rate was 3.4% (one case). Postoperative length of hospital stay was 13 days (range: 7-30 days). The duration of the entire procedure ranged from 9 to 60 days (mean: 20 days). The mean follow-up of patients was 17 months (range: 4-40 months). One patient had recurrent acute cholecystitis and another one had angiocholitis; two patients underwent delayed elective laparoscopic cholecystectomy; 20 patients remained asymptomatic and 16 were still alive at the time of this study (13 with biliary stones and three without).

CONCLUSION

Percutaneous cholecystostomy is a valuable alternative procedure for high-risk patients with acute cholecystitis. It's a safe and usually effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.

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.

Ultrasound-guided percutaneous cholecystostomy as an initial treatment for acute cholecystitis in elderly patients

BACKGROUND/AIMS

Acute cholecystitis may atypically present itself in the elderly, thus causing diagnostic and therapeutic problems, and it is well recognized as a high-risk condition for morbidity. The outcome has been attributed to the presence of severe co-morbid disease. In an attempt to minimize the postoperative morbidity and mortality, we performed ultrasound-guided percutaneous transhepatic cholecystostomy (PC) on elderly patients with acute cholecystitis for both initial treatment and subsequent diagnosis of their biliary tract disorders.

METHODS

Those being more than 70 years old, had acute episode of cholecystitis for more than 48 h and still had positive Murphy's signs and distended gallbladders were candidates for ultrasound-guided PC.

RESULTS

Forty-two elderly patients underwent ultrasound-guided PC. Once the condition of each patient showed signs of improvement and stability, cholangiography was performed via PC tube. The results of the cholangiography showed 20 patients with gallbladder stones, 16 with common bile duct stones and 6 with acalculous cholecystitis. Once stable enough, 32 patients underwent definite surgery, 18 having cholecystectomies, 14 having cholecystectomies and choledocholithotomies. The 6 patients with acalculous cholecystitis had the PC tube removed 3 weeks later, without further surgery. Two patients had gallbladder stones removed by choledochofiberscope. Two patients had common bile duct stone removed by endoscopic sphincteroplasty. Although postoperative complications occurred in 5 patients (11.9%), no instance of operative mortality was found.

CONCLUSION

Our findings lead us to conclude that the use of PC in the early treatment of acute cholecystitis in elderly patients can decrease postoperative morbidity and mortality.

Percutaneous cholecystostomy is an effective treatment for high-risk patients with acute cholecystitis

We sought to determine the safety, efficacy, and outcome of percutaneous cholecystostomy (PC) in all patients undergoing the procedure at our institutions. We reviewed 53 consecutive cases of acute cholecystitis seen at our hospitals over 5.5 years in which PC was performed at the initial treatment. Follow-up was obtained by chart review and telephone questionnaire. Acute cholecystitis was the primary admitting diagnosis in 18 cases. In the remaining 35, cholecystitis developed during hospitalization. All patients were considered high surgical risks on the basis of the presence of comorbid conditions. The gallbladder was successfully catheterized under radiologic guidance in all patients and with no immediate procedure-related morbidity. Acute cholecystitis resolved in 44 of 53 patients (83%), whereas nine patients (17%) did not improve clinically after PC and died during the same hospitalization. A total of 33 (62%) eventually survived hospitalization. Elective cholecystectomy was done in 25 patients with no mortality. After cholecystectomy, three of these patients subsequently died of other causes, whereas 22 are alive. Eight patients did not undergo cholecystectomy because of underlying medical conditions or because they had acalculous cholecystitis. These patients remained free of biliary problems after removal of their cholecystostomy tube, but two have subsequently died of nonbiliary conditions. Percutaneous cholecystostomy is a safe, effective treatment for high-risk patients with acute cholecystitis. Cholecystostomy can be followed by elective cholecystectomy at a later time if the patient's condition permits or by expectant conservative management in patients who have had acalculous cholecystitis or have a very high mortality risk with surgery.

Cholecystostomy: an unusual approach to stenting of a distal common bile duct stricture

Strictures, both benign and malignant, of the distal common bile duct (CBD) are reasonably common, and if stented are usually approached endoscopically via the duodenum, or transhepatically via an intrahepatic and then common hepatic duct. We describe a case of endoscopic stenting of a distal CBD stricture over a wire passed percutaneously through the gallbladder, cystic duct and into the duodenum. To our knowledge, this has not been previously described.

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.

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.

[Echo-guided percutaneous cholecystostomy in the treatment of acute cholecystitis]

Ultrasound-guided cholecystostomy (UGC) is indicated for high-risk patients with acute cholecystitis (AC). The advantage of this approach is greatest for critically ill patients who develop AC while in the intensive care unit (ICU). Moreover, in ICU patients with unexplained sepsis UGC serves as a diagnostic maneuver since it may allow the identification of a biliary infection. UGC has a high therapeutic efficacy approaching 100% in patients with a well-established diagnosis of AC. Morbidity is low and almost entirely related to catheter dislodgment. Trans-catheter cholecystocholangiograms (TCC), indispensable for planning any further treatment, must be delayed until the resolution of the sepsis. The risk of recurrence depends on AC etiology. Acalculous AC entails a low recurrence risk and may often be managed non-operatively. After the resolution of the sepsis, all calculous AC should be considered for cholecystectomy. However, if the operative risk remains high the possibility of avoiding the operation depends on the TCC demonstration of the patency of the cystic duct. The catheter should remain in place until operation. In case of non-operative management withdrawal should be delayed until the resolution of the sepsis. Laparoscopy is suitable in case of recent inflammation.

Percutaneous cholecystostomy for acute cholecystitis in critically ill patients

BACKGROUND/AIMS

The aim of this study was to ascertain the therapeutic efficacy of percutaneous cholecystostomy in a selected group of high-risk patients who were physiologically unable to tolerate an open procedure.

METHODOLOGY

We reviewed the hospital records of 11 critically ill patients who underwent percutaneous cholecystostomy for acute cholecystitis during the intensive care unit course of major underlying diseases.

RESULTS

Percutaneous cholecystostomy was easily performed in all cases (feasibility rate: 100%). No procedure-related death was recorded and minor complications occurred in 2 patients (18%). Percutaneous cholecystostomy led to resolution of the sepsis in all but 1 patient with gangrenous calcolous cholecystitis who required emergent cholecystectomy (success rate: 91%). Percutaneous cholecystostomy was the permanent treatment in all patients with acalcolous cholecystitis. Among patients with calcolous cholecystitis, 4 underwent delayed elective cholecystectomy, 1 required no further treatment, and 2 eventually died from the evolution of their underlying diseases. After a mean follow-up of 25 months (range: 12-32 months), none of the patients managed non-operatively required surgery or re-hospitalization.

CONCLUSIONS

Ease of performance, low complication rate, and high success rate make percutaneous cholecystostomy the procedure of choice for critically ill patients with acute cholecystitis. Whenever possible, percutaneous cholecystostomy should be followed by elective cholecystectomy. However, especially in acalcolous cholecystitis, it may constitute the definitive treatment.

Percutaneous cholecystostomy and endoscopic cholecystolithotripsy in the management of acute cholecystitis

BACKGROUND

Percutaneous cholecystostomy is a valuable alternative temporary measure for acute cholecystitis in elderly patients with severe underlying cardiopulmonary disease, but the subsequent management of gallbladder calculi is still controversial.

METHODS

Eleven patients treated with percutaneous endoscopic cholecystolithotripsy after percutaneous cholecystostomy were evaluated retrospectively.

RESULTS

All patients showed clinical improvement after percutaneous cholecystostomy. Tract dilation succeeded in 9 patients. Complete stone clearance was achieved in seven patients over one to four sessions (average, two sessions). Stone extraction could not be completed in two patients because gallbladder access was lost in one patient, and the other refused further procedure. There were three complications, with two biliary fistulas and one major bile leakage leading to emergency cholecystectomy. The duration of the entire procedure ranged from 30 to 126 days (mean, 58 days). During the follow-up (mean 17.2 months), one patient had recurrent cholangitis and the others remained asymptomatic.

CONCLUSIONS

Percutaneous cholecystolithotripsy after percutaneous cholecystostomy is a safe alternative in the management of high-risk elderly patients with acute cholecystitis.

[Method of punction transcutaneous cholecystostomy and device for accomplishment]

The author has developed a mode of punctional transcutaneous cholecystostomy--under ultrasound scanning control and the device for its accomplishment. The mode and the device provide increase of safety of the operation and the possibility of usage of ultrasound scanning without special punctional transducer. The results of clinical application of the developed method and the device in patients with acute cholecystitis are effective.

Percutaneous cholecystostomy in acute cholecystitis in high-risk patients: an analysis of 69 patients

BACKGROUND

Optimal treatment of acute cholecystitis in high-risk patients with acute cholecystitis continues to be a difficult therapeutic problem. With the development of more advanced radiological imaging techniques, percutaneous cholecystostomy (PCS) has been presented as an effective treatment alternative in critically ill patients. This paper reports our experiences of percutaneous cholecystostomy in the treatment of acute cholecystitis in a well defined high-risk patient group.

METHODS

The data concerning 69 high-risk patients with acute cholecystitis treated by percutaneous cholecystostomy in Oulu University Hospital and Kokkola Central Hospital were analyzed.

RESULTS

Ultrasound showed gallbladder stones in 71% (49/69) of the patients and 29% of them presented with acalculous cholecystitis. After PCS, pain diminished in 94% (61/65), fever in 90% (35/39), CRP values in 87% (53/61) and leucocyte count in 84% (46/55) of the patients. Before PCS, the CRP value was 132+/-106 mg/l and after PCS 79+/-73 mg/l (P = 0.001) and corresponding leucocyte counts were 14.7+/-5.0 and 9.3+/-3.2 (P = 0.001), respectively. The antegrade cholecystocholangiography was performed in 29 patients after PCS, and common bile duct stones were detected in 8 patients; these stones were treated by endoscopic papillotomy. Complications after PCS occurred in 17 patients (26%), but only two patients required emergency laparotomy. Mortality was 19% (13/69). Acute cholecystitis alone was the cause of death in only three patients. Mostly, fatal outcome was caused by the serious underlying diseases.

CONCLUSION

According to our results, PCS should be the method of choice in high-risk patients with acute cholecystitis.

[Comments on emergency treatment of biliary lithiasis in patients over 75 years of age. Apropos of 157 cases]

Surgery remains the ideal emergency treatment for biliary lithiasis in elderly subjects despite perioperative morbidity and mortality. Minimally invasive techniques appear promising but require assessment. The aim of this work was to determine the usefulness of these techniques and evaluate outcome in a series of 157 patients over 75 years of age who were hospitalized in an emergency setting of complicated biliary lithiasis from January 1990 to December 1996. There were 103 women and 54 men, mean age 82 years. The patients' general status was evaluated according to the ASA classification; 66% of the patients were ASA III, IV or V. Diagnoses at admission were acute cholecystitis (n = 71, 45%), angiocholitis (n = 50, 31%) subintrant hepatic colic (n = 17, 10.8%), pancreatitis (n = 10, 6%), isolated jaundice (n = 2), peritonitis (n = 2) and occlusion (n = 5). Within 24 hours of admission, 7 patients underwent emergency surgery, and the 150 others were given medical treatment. Among these 150 patients, cure was considered to have been achieved with medical treatment alone in 41 (subsequent surgery being required in only one 6 months later), semi-emergency was performed in 17, and a minimally invasive procedure was performed in the 92 others (echo-guided percutaneous cholecystostomy in 42, endoscopic sphincterotomy in 50) followed by a subsequent operation in 29. In the 103 patients (65.5%) in this series who did not undergo surgery, mortality was 3.8% and in the 54 patients (34.5%) who did, mortality was 15%, but this rate was only 6.9% when the open procedure followed a minimally invasive technique. Surgical treatment of complicated biliary disease remains the ideal therapy but indications should be carefully weighed in these elderly fragilized subjects. Under surgical observation, abstention from surgery or use of minimally invasive techniques can play an important role in the therapeutic strategy aimed at lowering perioperative mortality.

[The use of preoperative percutaneous transhepatic cholecystostomy in obstructive jaundice]

In 133 patients with obturating jaundice the conventional treatment was applied (group I), in 36 patients as a first phase of surgical treatment the transcutaneous transhepatic cholecystectomy was conducted (group II). The postoperative complications frequency have constituted 37.3 and 30.5%, mortality--27.8 and 13.9% accordingly.