Acute gallstone cholecystitis in the elderly: treatment with emergency ultrasonographic percutaneous cholecystostomy and interval laparoscopic cholecystectomy

Percutaneous cholecystostomy as a bridge therapy in the geriatric age group with acute cholecystitis

OBJECTIVE

The aim of this study was to investigate the efficacy of percutaneous cholecystostomy (PC) in the geriatric patients with acute cholecystitis.

MATERIALS AND METHODS

The records of geriatric patients with high surgical risk who underwent percutaneous cholecystostomy for acute cholecystitis were reviewed retrospectively.

RESULTS

The median age of 134 patients who underwent percutaneous cholecystostomy was 77 (65-98) years and 63.4% were women. The mean length of hospital stay was 5 (4-18) days, and the follow-up period until the procedure was 2 (1-6) days. Murphy's sign was positive in 79.1% of patients on physical examination, and the remaining patients (20.9%) had only tenderness on examination. As USG findings, 59.0% of the patients had a gall bladder wall thickness (> 4 mm) with pericholecystic fluid. Additional imaging method, abdominal CT, was performed in 29 patients (21.6%), MRCP was performed in three patients (2.2%), and ERCP was performed in one patient (0.7%). Bacterial growth was detected in 27.6% of the bile cultures performed. During the follow-up period, laparoscopic cholecystectomy was performed in 60.4% of the patients and open cholecystectomy was performed in 5.2% of the patients electively. 34.3% of the patients did not undergo any surgery. Bile leakage was detected in two patients (1.5%) as a procedure-related complication, and no mortality was observed.

CONCLUSION

Abdominal ultrasonography-guided PC is a safe and effective method in the management of acute cholecystitis in high-risk patients in the geriatric age group.

Does percutaneous cholecystostomy timing in high anaesthetic-risk patients impact on outcome?

The optimal timing for percutaneous cholecystostomy (PCT) in patients with acute biliary sepsis, who are high-risk for cholecystectomy, requires further investigation. We aimed to study local factors influencing the timing to PCT placement, and investigate patient outcomes in early (≤ 48 h) vs. delayed PCT over a six-year period. A retrospective observational study investigating patients who required a PCT at a single hospital in the UK between January 2014 and December 2019. Placement of a PCT was at the discretion of the on-call surgical consultant according to their own personal experience and not based on a standard local protocol. Clinical outcomes, hospital statistics and details of any subsequent bridging surgery were analysed using multivariate logistic regression models adjusting for age, sex, Charlson Comorbidity Index (CCI) and American Society of Anaesthesiologists (ASA) grade. There were 72 patients with 35/72 (48.6%) classed as TG18 AC grade 3; 26/72 (36.1%) had an early PCT placed and 46/72 (63.9%) delayed. Median age was 76 (65-83) years, 52.8% were female, and 51.4% were classed ASA ≥ 3 with 94.0% scoring CCI > 2. Trial on antibiotic therapy was the primary reason for delayed PCT. In adjusted models, early PCT was associated with a shorter length in hospital stay (OR 3.02, p = 0.044), successful definitive treatment (OR 6.26, p = 0.009); and reduced likelihood for catheter dislodgment (OR 0.12, p = 0.004) with fewer patients bridging to later emergency open surgery (OR 0.19, p = 0.024). Clinical outcomes may be superior in urgent or early PCT for high anaesthetic-risk patients following acute biliary sepsis.

Systematic review and meta-analysis of early vs late interval laparoscopic cholecystectomy following percutaneous cholecystostomy

BACKGROUND

High risk surgical patients with acute cholecystitis are commonly treated with percutaneous cholecystostomy (PTC) drainage. The optimal timing of subsequent interval laparoscopic cholecystectomy (LC) remains unclear.

METHODS

Medline, EMBASE, and Scopus were searched to identify studies published between 01/01/2000 and 31/12/2020, reporting on interval LC outcomes in patients initially treated by PTC. Early and late interval LC were defined as <30 and ≥ 30 days respectively. The Methodological Index for Nonrandomized Studies was used for quality assessment. Meta-analysis of proportions was conducted using a random-effects model.

RESULTS

A total of 512 studies were screened, 41 met the inclusion criteria. There were 22 studies in both early and late interval LC groups, with 3 included studies reporting both early and late groups. Following quality assessment, 29 studies were included in the meta-analysis. There were no significant differences between early and late interval LC in terms of conversion rates (7.2% vs 8.3%, p = 0.854), 90-day morbidity (12.8% vs 15.9%, p = 0.496), and 90-day mortality (0.25% vs 0.32%, p = 0.704). Heterogeneity was significant (I²>50%) in all groups.

CONCLUSION

Current evidence of interval LC within or beyond 30 days demonstrates no significant impact on outcomes. Patient factors, clinical experience, and hospital facilities may prove more important predictors.

Minimally Invasive Management of Acute Cholecystitis and Frailty Assessment in Geriatric Patients

The aim was to compare laparoscopic cholecystectomy (LC) with the percutaneous cholecystostomy (PC) for the management of acute lithiasic cholecystitis in geriatric patients and investigate the decision-making using frailty assessment. A retrospective analysis was performed in all patients aged over 65 years who were treated for acute cholecystitis at our hospital in a period of 5 years. Patients were divided in LC and PC groups. In total, 111 (54.1%) patients were subjected to LC and 94 (45.9%) to PC. The American Society of Anesthesiologists (ASA) and the Clinical Frailty Score were lower for the LC group. However, for patients over 85 years of age, frailty scores between groups were not statistically different. Morbidity and mortality between groups were not statistically different. Both LC and PC are safe and efficient in geriatric patients. Frailty score may better drive the selection of patients to be managed laparoscopically.

Image-guided percutaneous cholecystostomy: a comprehensive review

Acute cholecystitis (AC) is a common emergency condition with severity ranging from mild to severe. Gallstones and critical illnesses are the common predisposing factors. Mild AC is primarily managed with medical therapy and early cholecystectomy. Moderate and severe AC require individualized treatment with a preference for early cholecystectomy. However, cholecystectomy may not always be feasible due to co-morbidities. Hence, this group of patients needs minimally invasive methods to drain the gallbladder (GB). Percutaneous cholecystostomy (PC) is the image-guided drainage of GB in the setting of moderate to severe AC. There are different approaches to PC. The technical aspects, success, and complications of PC as well as management of cholecystostomy catheter after the patient recovers from the acute episode should be thoroughly understood by the interventional radiologist. We present an extensive up-to-date review of the essential aspects of PC including indications, contraindications, techniques, and outcomes, including complications and success rates.

Outcomes of percutaneous cholecystostomy in elderly patients: a systematic review and meta-analysis

INTRODUCTION

Percutaneous cholecystostomy (PC) represents a management option to control sepsis in patients with acute cholecystitis, who are unable to tolerate surgery.

AIM

This review aimed to evaluate the outcomes of elderly patients treated with PC and compare it with emergent cholecystectomy.

MATERIAL AND METHODS

An electronic search of the Embase, Medline Web of Science, and Cochrane databases was performed. Percutaneous cholecystostomy was used as the reference group, and weighted mean differences (WMD) were calculated for the effect of PC on continuous variables, and pooled odds ratios (POR) were calculated for discrete variables.

RESULTS

There were 20 trials included in this review. Utilisation of PC was associated with significantly increased mortality (POR = 4.85; 95% CI: 1.02-7.30; p = 0.0001) and increased re-admission rates (POR = 2.95; 95% CI: 2.21-3.87; p < 0.0001).

CONCLUSIONS

This pooled analysis established that patients treated with PC appear to have increased mortality and readmission rates relative to those managed with cholecystectomy.

Clinical course of percutaneous cholecystostomies: A cross-sectional study

BACKGROUND

Although cholecystectomy is the standard treatment modality, it has been shown that perioperative mortality is approaching 19% in critical and elderly patients. Percutaneous cholecystostomy (PC) can be considered as a safer option with a significantly lower complication rate in these patients.

AIM

To assess the clinical course of acute cholecystitis (AC) in patients we treated with PC.

METHODS

The study included 82 patients with Grade I, II or III AC according to the Tokyo Guidelines 2018 (TG18) and treated with PC. The patients’ demographic and clinical features, laboratory parameters, and radiological findings were retrospectively obtained from their medical records.

RESULTS

Eighty-two patients, 45 (54.9%) were male, and the median age was 76 (35-98) years. According to TG18, 25 patients (30.5%) had Grade I, 34 (41.5%) Grade II, and 23 (28%) Grade III AC. The American Society of Anesthesiologists (ASA) physical status score was III or more in 78 patients (95.1%). The patients, who had been treated with PC, were divided into two groups: discharged patients and those who died in hospital. The groups statistically significantly differed only concerning the ASA score (P = 0.0001) and WBCC (P = 0.025). Two months after discharge, two patients (3%) were readmitted with AC, and the intervention was repeated. Nine of the discharged patients (13.6%) underwent interval open cholecystectomy or laparoscopic cholecystectomy (8/1) within six to eight weeks after PC. The median follow-up time of these patients was 128 (12-365) wk, and their median lifetime was 36 (1-332) wk.

CONCLUSION

For high clinical success in AC treatment, PC is recommended for high-risk patients with moderate-severe AC according to TG18, elderly patients, and especially those with ASA scores of ≥ III. According to our results, PC, a safe, effective and minimally invasive treatment, should be preferred in cases suffering from AC with high risk of mortality associated with cholecystectomy.

Two-Center Prospective Comparison of the Trocar and Seldinger Techniques for Percutaneous Cholecystostomy

OBJECTIVE. The purpose of this study is to compare the safety and efficacy of the bedside ultrasound (US)-guided trocar technique versus the US- and fluoroscopy-guided Seldinger technique for percutaneous cholecystostomy (PC). SUBJECTS AND METHODS. This prospective noninferiority study compared the bedside US-guided trocar technique for PC (the trocar group; 53 patients [28 men and 25 women]; mean [± SD] age, 74.31 ± 16.19 years) with the US- and fluoroscopy-guided Seldinger technique for PC (the Seldinger group; 52 patients [26 men and 26 women], mean age, 79.92 ± 13.38 years) in consecutive patients undergoing PC at two large tertiary university hospitals. The primary endpoints were technical success and procedure-related complication rates. Secondary endpoints included procedural duration, pain assessment, and clinical success after up to 3 months of follow-up. RESULTS. PC was successfully performed for all 105 patients. The clinical success rate was similar between the two study groups (86.8% in the trocar group vs 76.9% in the Seldinger group; p = 0.09). Mean procedural time was significantly lower in the trocar group than in the Seldinger group (1.77 ± 1.62 vs 4.88 ± 2.68 min; p < 0.0001). Significantly more procedure-related complications were noted in the Seldinger group than in the trocar group (11.5% vs 1.9%; p = 0.02). Among patients in the Seldinger group, bile leak occurred in 7.7%, abscess formation in 1.9%, and gallbladder rupture in 1.9%. No procedure-related death was noted. Minor bleeding occurred in one patient (1.9%) in the trocar group, but the bleeding resolved on its own. The mean pain score during the procedure was significantly lower in the Seldinger group than in the trocar group (3.2 ± 1.77 vs 4.76 ± 2.17; p = 0.01). At 12 hours after the procedure, the mean pain score was significantly lower for patients in the trocar group (0.78 ± 1.0 vs 3.12 ± 1.36; p = 0.0001). CONCLUSION. Use of the bedside US-guided trocar technique for PC was equally effective as the Seldinger technique but was associated with fewer procedure-related complications, required less procedural time, and resulted in decreased postprocedural pain, compared with fluoroscopically guided PC using the Seldinger technique.

Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound-Guided Gallbladder Drainage

"Gallbladder disease is one of the most common gastrointestinal diseases encountered in clinical practice. Surgical removal and percutaneous drainage are both widely available and effective in the management of acute cholecystitis. Several endoscopic approaches exist as an alternative to these interventions. These include transpapillary approaches via endoscopic retrograde cholangiopancreatography (ERCP), transmural drainage and access approaches via endoscopic ultrasound (EUS), and endoscopic surgical approaches using natural orifice transluminal endoscopic surgery (NOTES) techniques. This article reviews the epidemiology and pathophysiology of gallbladder diseases and discusses the various percutaneous, surgical, and endoscopic approaches to managing gallbladder disease."

Percutaneous cholecystostomy… why, when, what next? A systematic review of past decade

INTRODUCTION

Percutaneous cholecystostomy tube drainage has played a vital role in management of cholecystitis in patients where surgery is not appropriate. However, management differs from unit to unit and even between different consultants in the same unit. We conducted this systematic review to understand which of these resulted in the best patient outcomes.

METHODS

We conducted a systematic review using the PubMed database for publication between January 2006 to December 2016. Keyword variants of 'cholecystostomy' and 'cholecystitis' were combined to identify potential relevant papers for inclusion.

FINDINGS

We identified 46 studies comprising a total of 312,085 patients from 20 different countries. These papers were reviewed, critically appraised and summarised in table format. Percutaneous cholecystostomy tube drainage is an important treatment modality with an excellent safety profile. It has been used successfully both as a definitive procedure and as a bridge to surgery. There continues to be great variation, however, when it comes to the indications, timing and management of these drains. As far as we are aware, this is the only systematic review to cover the past 10 years. It provides a much-needed update, considering all the technological development and new treatment options in laparoscopic surgery and interventional radiology.

Evolution in the management of acute cholecystitis in the elderly: population-based cohort study

BACKGROUND

Acute cholecystitis is a life-threatening emergency in elderly patients. This population-based cohort study aimed to evaluate the commonly used management strategies for elderly patients with acute cholecystitis as well as resulting mortality and re-admission rates.

METHODS

Data from all consecutive elderly patients (≥ 80 years) admitted with acute cholecystitis in England from 1997 to 2012 were captured from the Hospital Episode Statistics database. Influence of management strategies upon mortality was analyzed with adjustment for patient demographics and treatment year.

RESULTS

47,500 elderly patients were admitted as an emergency with acute cholecystitis. On the index emergency admission the majority of patients (n = 42,620, 89.7%) received conservative treatment, 3539 (7.5%) had cholecystectomy, and 1341 (2.8%) underwent cholecystostomy. In the short term, 30-day mortality was increased in the emergency cholecystectomy group (11.6%) compared to those managed conservatively (9.9%) (p < 0.001). This was offset by the long-term benefits of cholecystectomy with a reduced 1-year mortality [20.8 vs. 27.1% for those managed conservatively (p < 0.001)]. Management with percutaneous cholecystostomy had increased 30-day and 1-year mortality (13.4 and 35.0%, respectively). The annual proportion of cholecystectomies performed laparoscopically increased from 27% in 2006 to 59% in 2012. Within the cholecystectomy group, laparoscopic approach was an independent predictor of reduced 30-day mortality (OR 0.16, 95% CI 0.10-0.25). Following conservative management, there were 16,088 admissions with further cholecystitis. Only 11% of patients initially managed conservatively or with cholecystostomy received subsequent cholecystectomy.

CONCLUSION

Acute cholecystitis is associated with significant mortality in elderly patients. Potential benefits of emergency cholecystectomy in selected elderly patients include reduced rate of readmissions and 1-year mortality. Laparoscopic approach for emergency cholecystectomy was associated with an 84% relative risk reduction in 30-day mortality compared to open surgery.

Is Interval Cholecystectomy Necessary After Percutaneous Cholecystostomy in High-Risk Acute Cholecystitis Patients?

Objectives:

Percutaneous cholecystostomy (PC) for acute cholecystitis (AC) is frequently performed in high-risk surgical patients as an alternative treatment modality. However, debate remains over whether or not an interval cholecystectomy for these patients should be performed. The aim of this study was to investigate the outcomes of PC in high-risk surgical patients with AC.

Methods:

Between September 2013 and June 2016, 27 of 952 patients with AC were treated with PC. The data collection included demographic variables, including comorbidities, the timing of the PC, the length of the hospital stay, the follow-up period, the complications related to PC, and readmission to hospital.

Results:

There were 16 female and 11 male patients, with a mean age of 73±12.4 years (range: 49-97 years). Comorbid diseases included ischemic heart disease (n=6), diabetes mellitus (n=5), chronic obstructive pulmonary disease (n=6), and others (n=10). The mean timing of PC was 2.2±1.4 days (range: 1-3 days). The mean length of hospital stay was 9.6±2.1 days (range: 7-14 days), and the catheter was removed after the first month. The mean follow-up period after the PC catheter removal was 19.6±8.6 months (range: 10-38 months). Only 6 patients (22.2 %) were readmitted to the hospital. Cholecystectomy was performed in 4 cases, and 2 responded to medical treatment.

Conclusion:

Despite ongoing controversy about the management of AC in high-risk surgical patients, PC is an adequate and safely applicable procedure in this group of patients. However, an interval cholecystectomy should be considered in persistent cases, which account for a small percentage. Longer-term follow-up studies with a larger sample size are needed to support our results.

Long-Term Outcomes Following Percutaneous Cholecystostomy Tube Placement for Treatment of Acute Calculous Cholecystitis

INTRODUCTION

Percutaneous cholecystostomy tube (PCT) placement is considered a safe alternative to cholecystectomy for the treatment of acute calculous cholecystitis (ACC), but data regarding long-term outcomes following PCT are limited.

METHODS

We retrospectively reviewed our institutional experience of patients undergoing PCT for ACC between 1997 and 2015. Recurrent biliary events were defined as cholecystitis, cholangitis, or gallstone pancreatitis.

RESULTS

PCT was placed for 288 patients with ACC. Mean age and age-adjusted Charlson comorbidity index were 72 ± 15 years and 5.3 ± 2.4, respectively. Following PCT placement, 91% of patients successfully resolved their episode of ACC. PCT dysfunction occurred in 132 patients (46%), with 80 patients (28%) requiring re-intervention, while 7% developed procedure-related complications. Interval cholecystectomy reduced the risk of recurrent biliary events to 7% from 21% (p = 0.002). Cholecystectomy was completed laparoscopically in 45% of patients receiving an interval operation vs. 22% of those undergoing urgent surgery for PCT failure or recurrent biliary event (p = 0.03).

CONCLUSIONS

PCT placement is a highly successful treatment for acute calculous cholecystitis and is associated with low complication rate, but high rate of tube dysfunction requiring frequent re-intervention. Interval cholecystectomy is associated with a decreased likelihood of recurrent biliary events and increased likelihood of successful laparoscopic completion.

Cholecystostomy Treatment in an ICU Population: Complications and Risks

BACKGROUND

Percutaneous cholecystostomy tube placement has widely been used as an alternative treatment to cholecystectomy, especially in advanced disease or critically ill patients. Reported postprocedural complication rates have varied significantly over the last decade. The goal of this study is to evaluate the safety of percutaneous cholecystostomy tube treatment in critically ill patients.

STUDY DESIGN

We performed a retrospective chart analysis of 96 critically ill patients who underwent cholecystostomy tube placement during an intensive care unit (ICU) stay between 2005 and 2010 in a tertiary care center in central Massachusetts. Complications within 72 hours of cholecystostomy tube placement and any morbidity or mortality relating to presence of cholecystostomy tube were considered.

RESULTS

A total of 65 male and 31 female patients with a mean age of 67.4 years underwent percutaneous cholecystostomy tube placement during an ICU stay. Sixty-six patients experienced a total of 121 complications, resulting in an overall complication rate of 69%. Fifty-four of these complications resulted from the actual procedure or the presence of the cholecystostomy tube; the other 67 complications occurred within 72 hours of the cholecystostomy procedure. Ten patients died. Tube dislodgment was the most common complication with a total of 34 episodes.

CONCLUSIONS

Cholecystostomy tube placement is associated with frequent complications, the most common of which is tube dislodgment. Severe complications may contribute to serious morbidity and death in an ICU population. Complication rates may be underreported in the medical literature. The potential impact of cholecystostomy tube placement in critically ill patients should not be underestimated.

The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

High rate of common bile duct stones and postoperative abscess following percutaneous cholecystostomy

INTRODUCTION

The short and long-term outcomes in patients managed with percutaneous cholecystostomy (PCY) at a single institution are described.

METHODS

A retrospective study was conducted for patients treated between February 2000 and November 2012. Patient charts, imaging and biochemical data were reviewed. Patient demographics, presenting clinical features and treatment variables were noted. Outcome variables were length of admission, 30-day mortality, 30-day unplanned readmission, tube dislodgement, abscess formation, subsequent endoscopic retrograde cholangiography and surgery, complications after surgery and median overall survival.

RESULTS

PCY was performed for 55 patients for acute cholecystitis where surgical risk was very high. The 30-day readmission rate was 20% (n=11), the 30-day mortality rate was 9% (n=5) and median survival was 59 months (95% confidence interval: 30-88 months). The median follow-up duration was 68 months. Tubes were dislodged in 15 patients (27%) and an abscess occurred after PCY in 5 patients (9%). Subsequent endoscopic common bile duct stone extraction was required in 20 patients (36%). Cholecystectomy was planned in 22 patients and an abscess occurred following the cholecystectomy in 5 (23%).

CONCLUSIONS

Although a PCY is lifesaving, significant morbidity can arise during recovery. This study demonstrates a high rate of choledocholithiasis (44%), tube dislodgement (27%) and postoperative abscess (23%) compared with previous reports.

Timing of percutaneous cholecystostomy affects conversion rate of delayed laparoscopic cholecystectomy for severe acute cholecystitis

BACKGROUND

Percutaneous cholecystostomy is reserved for very high-operative-risk patients suffering from severe acute cholecystitis, who do not respond to conservative treatment. It is associated with high conversion rate to open surgery, when cholecystectomy is held later on. Our objective was to assess whether early timing of percutaneous cholecystostomy decreases conversion rate of delayed laparoscopic cholecystectomy to open surgery.

METHODS

The study population included 59 patients who underwent percutaneous cholecystostomy for severe cholecystitis and then proceeded to delayed interval laparoscopic cholecystectomy. The study consisted of a retrospective survey of medical files, based on a prospective enrollment of the data. We assessed conversion rate between two groups based on the time period from onset of symptoms and from admission to hospital until performance of cholecystostomy.

RESULTS

Regarding the time from onset of pain to drainage, early cholecystostomy (within 2 days, group I) was associated with 8.3% conversion rate, in contrast to 33.3% in group II (3-6 days from onset of symptoms). Regarding the day of admission to hospital, early drainage revealed 16% conversion rate in contrast to 40.7% in later drainage (p = 0.047, Chi-square test). We found correlation between time interval of symptoms and admission to conversion rate, according to Spearman's correlation coefficient.

CONCLUSIONS

Early percutaneous cholecystostomy does decrease conversion rate of delayed laparoscopic cholecystectomy, possibly by halting the propagation of the inflammatory process and its consequences. When decision regarding the necessity to perform drainage of the severely inflamed gallbladder is established, it is suggested to be done as soon as possible.

Patient outcomes after treatment with percutaneous cholecystostomy for biliary sepsis

INTRODUCTION

Acute cholecystitis is among the most common general surgical presentations. There is a cohort of patients who develop systemic sepsis and complications of acute cholecystitis. These patients are often elderly and co-morbid. Conservative management with percutaneous cholecystostomy has been shown to be a safe and effective management option in the acute setting. However, there is currently no consensus for the further management of these patients. In particular, there is a paucity of data on readmission rates and subsequent operative or non-operative management.

METHODS

A retrospective study was carried out of patients treated with a percutaneous cholecystostomy for biliary sepsis over a three-year period in a UK teaching hospital. Outcome measures were subsequent operative or conservative management, conversion rates, operative complications and readmission rates.

RESULTS

Twenty-five patients had a percutaneous cholecystostomy for the treatment of acute biliary sepsis. The median follow-up duration was 35 months. Thirteen patients (52%) had operative treatment. In the operative group, 6/13 had a laparoscopic cholecystectomy, 2/13 had a planned open cholecystectomy, 2/13 had abandoned procedures and 3/13 had a converted procedure. Complications in the operative group included: postoperative mortality (1/13), common bile duct injury requiring drainage and endoscopic stenting (1/13) and one patient required readmission with recurrent pain. In the non-operative group, 5/12 patients were readmitted with biliary sepsis, 5/12 had no readmissions, 1/12 died in the community and 1/12 was readmitted with biliary colic.

CONCLUSIONS

Percutaneous cholecystostomy is a recognised treatment modality for elderly, co-morbid patients with biliary sepsis. Nevertheless, the readmission rate in this group is relatively high at 5/12 (42%). Patients who undergo subsequent operative management have a conversion rate of 3/13 (23%) and a significant complication rate of 2/13 (15%). The further management of patients having undergone percutaneous cholecystostomy requires careful consideration on an individual case basis. The P-POSSUM (Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) may aid decision making.

Percutaneous cholecystostomy for acute cholecystitis in patients with high comorbidity and re-evaluation of treatment efficacy

BACKGROUND

In high-risk and unfit-for-surgery patients with acute cholecystitis (AC), treatment options are controversial. Few studies have reported the results of long-term follow-up. This study aimed to evaluate the clinical course of patients after removal of the percutaneous cholecystostomy (PC) catheter in high-risk patients with AC, time interval to relapse, and factors influencing relapse.

METHODS

From 2000 to 2011, 183 patients with AC underwent PC and catheter removal in Seoul National University Hospital and Boramae Hospital, Korea. Sixty cases were reviewed retrospectively after excluding cases with intended interval cholecystectomy, malignant biliary obstruction, loss to follow-up, and insufficient follow-up information.

RESULTS

The mean age was 68.6 ± 13.8 years, and the mean Karnofsky performance score was 24.8 ± 9.7. After insertion of a PC catheter, symptom resolution and improvement on imaging were achieved in 95% and 97.9% of patients, respectively. Laboratory values were also improved (P < .01). There was no mortality during admission; 2 patients (3.3%) experienced complications during removal of the PC catheter. Relapse was observed in 7 patients (11.7%) during a median follow-up of 38.1 ± 24.8 months. There were no differences in clinical, laboratory, or imaging findings between relapsing and nonrelapsing patients. Therefore, prediction of relapse was not possible.

CONCLUSION

Among high-risk patients with AC, 88.3% were managed with PC without relapse within a median follow-up period of 38.1 months, despite radiologically severe AC in some patients. We conclude that a temporary PC can be a first-line treatment for AC without interval cholecystectomy.

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.

Percutaneous cholecystostomy is a definitive treatment for acute cholecystitis in elderly high-risk patients

Percutaneous cholecystostomy (PC) is an alternative treatment for acute cholecystitis (AC) in elderly patients with high surgical risk and has lower morbidity and mortality than emergency cholecystectomy. There is controversy about whether cholecystectomy should be performed after PC in elderly high-risk patients. Medical records of patients with AC admitted to the Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, China, between January 2004 and July 2009 were reviewed retrospectively. The elderly high-risk patients with AC who underwent PC were selected for further study. The safety, efficacy, and long-term outcome of PC without cholecystectomy were evaluated in these patients. The symptoms of AC resolved in 98.6 per cent of patients; drainage-related morbidity and mortality rates were 4.1 and 1.4 per cent, respectively. No patient underwent cholecystectomy after PC. The recurrence rate of cholecystitis was 4.1 per cent. The one-year survival rate was 82.2 per cent, and the three-year survival rate was 39.7 per cent. No death was related to cholecystitis, but one patient died of septic shock on the second day after PC. Considering limited survival and a low recurrence rate of cholecystitis in elderly high-risk patients with AC, we propose that PC is a definitive treatment and cholecystectomy is not necessary after resolution of AC symptoms.

Cholecystostomy: a bridge to hospital discharge but not delayed cholecystectomy

BACKGROUND

Current data on the clinical course of patients with acute cholecystitis managed with percutaneous cholecystostomy (PC) are limited by small sample size and imperfect follow-up. We present the characteristics and clinical course of a population-based cohort with acute cholecystitis managed with PC.

METHODS

We designed a retrospective cohort study using administrative databases capturing all emergency department (ED) visits and hospital admissions within a geographic region with a population of more than 13 million. From all adults with a first emergency admission for acute cholecystitis from 2004 to 2011, those managed with PC were included in the cohort. The cumulative incidences of subsequent cholecystectomy and death were calculated, considering death a competing risk to cholecystectomy. Polytomous logistic regression was then used to examine differences in patient characteristics across outcome status at 1 year: cholecystectomy, dead without cholecystectomy, or alive without cholecystectomy. Moreover, the risk of a gallstone-related ED visit or hospital admission after discharge was estimated using the Kaplan-Meier method.

RESULTS

Of 27,718 patients with acute cholecystitis, 890 (3.3%) underwent PC. The cohort was elderly with a mean (SD) age of 75 (14) years, and 14% were in the intensive care unit on the day of PC. In-hospital mortality was 5%. By 1 year after PC, only 40% had undergone cholecystectomy, while an additional 18% had died without cholecystectomy. The risk of a gallstone-related ED visit or hospital admission was 49% by 1 year after discharge.

CONCLUSION

While PC is often performed with the intent of delayed cholecystectomy, less than half of patients actually go on to surgery. High mortality and likely ongoing contraindications to surgery preclude intervention in most patients, although the risk of gallstone-related ED visit or hospital admission remains high. Further prospective investigation is warranted to clarify the potential mortality and quality-of-life gains from elective cholecystectomy following PC.

LEVEL OF EVIDENCE

Prognostic study, level III.

Surgical management of gallbladder disease in the very elderly: are we operating them at the right time?

BACKGROUND

As life expectancy rises worldwide and the prevalence of gallstones increases with age, the number of very elderly patients requiring treatment for gallstone diseases is increasing. The aim of this study was to compare the results of cholecystectomy in patients 80 years or older according to different clinical presentations.

METHODS

This is a retrospective study of 81 patients 80 years or older. Indications for surgery were stratified into three groups: outpatients (symptomatic chronic cholecystitis), inpatients (complicated gallstone diseases), and urgent patients (acute cholecystitis). Data analysis included age, sex, the American Society of Anesthesiologists score, indication for surgery, length of hospital stay, morbidity, and mortality.

RESULTS

The mean age of the patients was 83.9 (range 80-94 years); there were 34 (42%) men. Thirty patients were operated on for acute cholecystitis. Patients in the urgency group significantly required the ICU more often, required a longer hospital stay, and had more complications, with 32% mortality. No differences were found between inpatients and outpatients, with both groups presenting low morbidity, no mortality, and the same postoperative length of stay.

CONCLUSION

More than 80% of the patients were operated on because of complicated gallstone disease. Although the outcomes of patients undergoing semielective cholecystectomy were similar to those of patients treated as outpatients, patients operated with acute cholecystitis presented extremely high morbidity and mortality rates. Thus, we can only recommend that early elective cholecystectomy be performed in elderly patients as soon as they are found to have symptomatic gallstones. Also, further trials are required to elucidate the optimal management of acute cholecystitis in elderly patients.

The management of acute cholecystitis in chronic hemodialysis patients: percutaneous cholecystostomy versus cholecystectomy

INTRODUCTION

Treatment of acute cholecystitis in chronic hemodialysis (HD) patients still remains controversial. Because of underlying disease that can influence surgical results, less invasive alternative managements have been tried over the last decades. The goal of this study was to analyze the results of cholecystectomy versus percutaneous cholecystostomy for acute cholecystitis (AC) in chronic HD patients.

METHODS

All patients with end-stage renal disease who were treated for AC were identified retrospectively from our medical records. Between July 2007 and September 2011, 47 patients were treated for AC while they were on chronic HD. The records of these patients were reviewed for documented AC and its treatment.

RESULTS

Of the 47 HD patients, 26 (55.3 %) underwent cholecystectomy (CC), while 21 (44. 7 %) had a percutaneous cholecystostomy (PC) for AC as an initial treatment. The mean length of follow-up was 20.4 ± 16 months in PC and 18 ± 15 months in CC patients. The success rate was higher in CC patients compared to PC patients (92. 3 versus 66.7 %, p = 0.0698). Eleven (52. 4 %) patients who had PC subsequently underwent CC; six open CC and five delayed laparoscopic CC were performed. Of the 26 patients who underwent CC, 18 were performed emergently due to the persistence of AC-related symptoms and gangrenous and perforated gallbladders. Eight were initially treated conservatively and then underwent elective cholecystectomy at an interval of 32 ± 24 (range = 14-59) days following initial treatment. In emergent CC, 10 (55.6 %) were completed laparoscopically, three were open, and five (33.3 %) had conversions. In elective CC patients, two were conversions, but the remainder (75 %) had laparoscopic CC. Readmission rates were higher in the PC group (33.3 versus 12.5 %, p = 0.1732). Although AC-related mortality was higher in PC patients, there was no statistically significant difference in the patient survival rate between the two groups (Kaplan-Meier analysis, Fig. 1, 19 versus 7.7 %; p = 0.4035), and the overall mortality rate was higher in the PC group (33.7 versus 15.7 %, p = 0.2737).

CONCLUSION

This study confirms that the safety and effectiveness of CC has a higher success rate and lower morbidity and mortality rate compared with percutaneous cholecystostomy for acute cholecystitis in chronic HD patients.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Percutaneous cholecystostomy in high-risk elderly patients with acute cholecystitis: a lifesaving option

PURPOSE

To analyze the results of percutaneous cholecystostomy in in high-risk elderly patients with acute cholecystitis.

MATERIALS AND METHODS

Between June 2010 and May 2011, 11 patients aged over 60 who had at least 1 systemic disease and underwent percutaneous cholecystostomy were reviewed retrospectively.

RESULTS

The procedure was technically successful in 10 (90.9%) patients. Clinical improvement was achieved in 81.8% of patients within 72 hours. Two patients received emergency surgery while elective cholecystostomy was performed in 5 patients. Percutaneous cholecystostomy was performed singly in 4 (36.4%) patients. Early complication rate was 18.2%. Two (18.2%) patients died.

CONCLUSION

Percutaneous cholecystostomy can be performed with low mortality and morbidity. Cholecystectomy should be performed in all patients with suitable general conditions due to the high recurrence rates of percutaneous cholecystostomy.

Can percutaneous cholecystostomy be a definitive management for acute acalculous cholecystitis?

GOALS

To evaluate the safety, efficacy, and long-term outcome of percutaneous cholecystostomy without additional cholecystectomy as a definitive treatment for acute acalculous cholecystitis (AAC).

BACKGROUND

AAC mainly occurs in seriously ill patients, and for those considered to be at high-risk for cholecystectomy, immediate percutaneous cholecystostomy can be a simple alternative interim treatment. However, no consensus has been reached on the issue of additional cholecystectomy.

STUDY

The medical records of 57 patients that underwent percutaneous cholecystostomy for AAC at a single institution between 1995 and 2010 were retrospectively analyzed.

RESULTS

Percutaneous cholecystostomy was technically successful in all patients, and no major complications relating to the procedure were encountered. Symptoms resolved within 4 days in 53 of the 57 (93%) patients. The in-hospital mortality rate was 21% (11/57) and elective cholecystectomy was performed in 18/57 (31%). Twenty-eight patients were managed non-operatively and cholecystostomy tubes were subsequently removed. These 28 patients were follow-up over a median 32 months and recurrent cholecystitis occurred in 2 (7%).

CONCLUSION

Percutaneous cholecystostomy is an effective procedure and a good alternative for patients unfit to undergo immediate surgery because of severe sepsis or an underlying comorbidity. After patients with AAC have recovered from percutaneous cholecystostomy, further treatment such as cholecystectomy might not be needed.

Systematic review of cholecystostomy as a treatment option in acute cholecystitis

OBJECTIVES

Percutaneous cholecystostomy (PC) is an established low-mortality treatment option for elderly and critically ill patients with acute cholecystitis. The primary aim of this review is to find out if there is any evidence in the literature to recommend PC rather than cholecystectomy for acute cholecystitis in the elderly population.

METHODS

In April 2007, a systematic electronic database search was performed on the subject of PC and cholecystectomy in the elderly population. After exclusions, 53 studies remained, comprising 1918 patients. Three papers described randomized controlled trials (RCTs), but none compared the outcomes of PC and cholecystectomy. A total of 19 papers on mortality after cholecystectomy in patients aged >65 years were identified.

RESULTS

Successful intervention was seen in 85.6% of patients with acute cholecystitis. A total of 40% of patients treated with PC were later cholecystectomized, with a mortality rate of 1.96%. Procedure mortality was 0.36%, but 30-day mortality rates were 15.4 % in patients treated with PC and 4.5% in those treated with acute cholecystectomy (P < 0.001).

CONCLUSIONS

There are no controlled studies evaluating the outcome of PC vs. cholecystectomy and the papers reviewed are of evidence grade C. It is not possible to make definitive recommendations regarding treatment by PC or cholecystectomy in elderly or critically ill patients with acute cholecystitis. Low mortality rates after cholecystectomy in elderly patients with acute cholecystitis have been reported in recent years and therefore we believe it is time to launch an RCT to address this issue.

Laparoscopic cholecystectomy for acute cholecystitis in the elderly: is it safe?

BACKGROUND

The purpose of this study was to evaluate the outcome of laparoscopic cholecystectomy (LC) in patients with acute cholecystitis aged 75 years and older.

MATERIALS AND METHODS

A retrospective chart review was performed on the 1216 cholecystectomies performed in our department from 2000 to 2005. A total of 225 patients underwent attempted LC for acute cholecystitis, of whom 42 were more than 75 years old and 183 younger.

RESULTS

There was no difference in mean duration of symptoms before admission and length of hospital stay before surgery (3.8 d in elderly vs. 3.1 in younger patients, and 2.8 vs. 2.3 d, respectively). In all, 21% of the elderly patients had American Society of Anesthesiologists score III and IV. Mean operative time and conversion rate to open surgery were similar in both groups. Postoperative stay was longer in elderly (3.9 vs. 2.8). The postoperative complications rate and mortality were significantly higher in the elderly group (31% vs. 15%, and 4.8% vs. 0.5%, respectively).

CONCLUSIONS

LC in elderly patients suffering from acute cholecystitis is feasible and effective. It is associated with a higher rate of morbidity unrelated to the surgical site and mortality in elderly compared with younger patients. Stronger selection of elderly patients for surgery is needed.

Percutaneous cholecystostomy without interval cholecystectomy as definitive treatment of acute cholecystitis in elderly and critically ill patients

OBJECTIVE

The aim of this study was to evaluate the safety and effectiveness of percutaneous cholecystostomy without interval cholecystectomy as definitive treatment for acute cholecystitis in elderly or critically ill patients with various coexisting diseases who were unfit for surgery under general anesthesia.

DESIGN

Between July 2004 and June 2006, 24 consecutive elderly and critically ill patients unfit for surgery, suffering from acute cholecystitis, and in whom significant comorbid factors were present, underwent percutaneous cholecystostomy as an emergency procedure at Laiko General Hospital. The diagnosis and the severity of acute cholecystitis were based on the Tokyo Guidelines, whereas the American Society of Anesthesiologists' (ASA) physical status classification was used for the perioperative risk stratification for cholecystectomy.

RESULTS

There were 14 male and 10 female patients with a median age of 79 years. Acute cholecystitis was classified as grade 2 in 20 patients and as grade 3 in 4 patients; 17 patients were classified as ASA score III and 7 as ASA score IV, whereas a total of 52 comorbid factors were present. Gallstones were disclosed as the underlying etiology in 23 patients, whereas one patient was diagnosed as suffering from acalculous cholecystitis. Percutaneous cholecystostomy was technically feasible in all patients (100%). Clinical improvement was noticed in 14 patients within 24 hours and in all patients within 72 hours. Statistically significant reduction in the values of white blood cells, C-reactive protein, and axillary body temperature were observed within 72 hours. The procedure-related mortality was 4%, whereas within a median follow-up of 17.5 months, definitive and effective control of symptoms was achieved in 90.5% of the patients.

CONCLUSIONS

For the subgroup of extremely high-risk and unfit for surgery patients, percutaneous cholecystostomy might be considered as the definitive treatment since it controls the local symptoms and the systemic inflammatory response.

Percutaneous cholecystostomy: a bridge to surgery or definite management of acute cholecystitis in high-risk patients?

OBJECTIVE

Cholecystectomy is the standard treatment for acute cholecystitis, but in high-risk patients with serious comorbidity and in patients of advanced age there is substantial morbidity and mortality associated with the intervention. In these selected patients, percutaneous cholecystostomy (PCS) is an alternative mode of management. The aim of the present study was to evaluate the outcome of PCS in selected patients with acute cholecystitis.

MATERIAL AND METHODS

Thirty-five patients, representing 0.6% of all acute cholecystitis patients managed during the period 1994-2003, were subjected to PCS. Patients' charts were reviewed retrospectively for age, gender, comorbidity, hospital stay, procedure, complications and final outcome, including requirement of additional interventions.

RESULTS

PCS was considered successful in 34/35 patients, 26 of whom responded within 3 days. Two patients required additional cholecystectomy 3 days and 20 months, respectively, after the PCS procedure. Two patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and one patient underwent rotation lithotripsy. Four patients suffered recurrent biliary complaints after the acute episode of cholecystitis, while the only serious procedure-related complication was bile leakage from the gallbladder in one patient, which necessitated cholecystectomy.

CONCLUSIONS

PCS is a comparatively safe and efficient procedure in the treatment of acute cholecystitis in high-risk patients with serious comorbidity and in elderly patients, contraindicating the general anaesthesia required for laparoscopic or open cholecystectomy.

Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department

OBJECTIVES

To investigate clinical features and outcomes in patients with acute cholecystitis with gall bladder perforation receiving open cholecystectomy or percutaneous transhepatic gall bladder drainage in the emergency department.

METHODS

From 1996 through 2005, 33 patients with non-traumatic gall bladder perforation, among 585 patients with acute cholecystitis, were enrolled. Patients were divided into two groups: open cholecystectomy in 16 patients and percutaneous transhepatic gall bladder drainage in 17 patients. Medical records, including demographic data, past history of systemic diseases or gallbladder stones, initial clinical presentations, laboratory data, physical status, therapeutic interventions, and outcomes, were analysed.

RESULTS

Mean patient age was 72.6 years (range 54-92 years). 28 patients (84.8%) were male. Median time of symptom onset before emergency department diagnosis was 5 days (range 0.5-30 days). Estimated incidence of gall bladder perforation was 5.6% (33/585). 27 patients (81.8%) had gallstones operatively or in image studies. All patients had either right upper quadrant pain/tenderness or epigastric pain/tenderness. Only 9 (27.3%) patients had positive Murphy's sign. Six patients in the percutaneous transhepatic gall bladder drainage group received further open cholecystectomy. Overall mortality was 24.2% (8/33). The direct cause of death was disease related sepsis in all patients. Patients receiving percutaneous transhepatic gall bladder drainage had a higher survival rate than those receiving open cholecystectomy (100% vs 50%, p<0.001). No differences in complications and length of hospital stay of survivors were observed between groups.

CONCLUSIONS

In this study, we delineated clinical features of patients with gall bladder perforation. Better clinical outcome is observed for percutaneous transhepatic gall bladder drainage, and this is suggested as an initial therapeutic choice, especially in high risk patients who are likely to need surgery.

Laparoscopic cholecystectomy after open cholecystostomy for gallbladder empyema: a case report

The case of a patient with gallbladder empyema initially drained through a minilaparotomy procedure under local anesthesia with a tube cholecystostomy is reported in this paper. Eight weeks later, the patient underwent an elective interval laparoscopic cholecystectomy. At laparoscopy, the gallbladder and the cholecystostomy tube were dissected free from the abdominal wall and the greater omentum, which was attached to the gallbladder. The tube was removed from the gallbladder fundus, and the operation was completed laparoscopically without any major problems.