Percutaneous cholecystostomy: prognostic factors and comparison to cholecystectomy

A new method for predicting SIRS after percutaneous transhepatic gallbladder drainage

The occurrence of systemic inflammatory response after percutaneous transhepatic gallbladder drainage brings great risks to patients and is one of the challenges faced by clinicians. Therefore, it is of great significance to find a suitable prediction method for clinicians to intervene early and reduce the transformation of serious complications. Easy-to-obtain and objectively measured clinical features were screened, and logistic regression was used to construct a prediction model. The predictive ability of the model was evaluated by using the receiver operating characteristic curve and the decision curve in the validation set and the training set, respectively. Nine clinical features (CRP, Fever, DBIL, Obstruction, Bile properties, PCT, Length, Width, and Volume factor) were used to construct the prediction model, and the validation results showed that the prediction model had good performance in the training set (AUC = 0.83) and the validation set (AUC = 0.81). The decision curve also showed that the predictive ability of the model incorporating nine clinical features is better than that of a single clinical feature. The model we constructed can accurately predict the occurrence of SIRS, which can guide clinicians to take treatment measures and avoid the deterioration of complications.

Does percutaneous cholecystostomy affect prognosis of patients with acute cholecystitis that are unresponsive to conservative treatment?

Background

Percutaneous cholecystostomy (PC) can be used as bridging or definitive therapy in some cases of acute cholecystitis. We aimed to compare hospital stay and survival of patients that underwent PC insertion because of acute calculus cholecystitis (ACC) compared to those who did not.

Methods

This is a retrospective study in which patients with gangrenous cholecystitis and perforation were excluded. Regression models were used to evaluate the influence of PC on mortality and hospital stay.

Results

Six hundred and eighty-three patients were admitted because of ACC, and 50 patients were referred to PC. Indication for PC insertion were high disease severity index (DSI, 8 pts) and failure of conservative treatment with total disease duration >7 days (42 pts). Those who underwent PC were older (76.0 ± 12.4 vs. 60.8 ± 19.2, P < 0.001); PC was associated with longer hospital stay (12.8 vs. 6.5 days) and higher one-year mortality (20% vs. 4.9%, P < 0.001). Among patients with non-severe disease severity index (DSI), PC was associated with longer length of hospital stay and higher one-year mortality compared to patients treated conservatively (9.9 ± 0.6 vs. 6.0 ± 0.2 days, and 16.7% vs. 4.0%, respectively, P < 0.001 for both). For patients with severe DSI, PC was associated with similar length of hospital stay and one-year mortality compared to similar patients treated conservatively (16.1 ± 8.1 vs. 18.4 ± 4.0 days, and 37.5% vs. 22.6%, respectively, P = 0.802 and P = 0.389, respectively).

Conclusions

In patients with mild-moderate DSI unresponsive to conservative treatment, PC may be associated with deteriorated prognosis compared to conservative treatment. The decision to insert PC in patients unresponsive to conservative therapy even with disease duration >7 days must be re-evaluated.

What is the effect of percutaneous cholesistostomy in patients with acute cholecystitis? when is the right time for the procedure?

BACKGROUND

Acute cholecystitis (AC) is one of the most common emergency diseases in surgical practice. Although the gold standard treatment is laparoscopic cholecystectomy, percutaneous cholecystostomy (PC) is performed in some patients due to age, comorbidity, and delays in admission. We aimed to investigate the effect of timing on the clinical process of patients undergoing PC.

METHODS

Patients who underwent PC between February 2017 and December 2021 were included in the study. Those who un-derwent PC in the first 72 h were determined as the early PC group, and those who underwent PC after 72 h were determined as the late PC group. Demographic information of the patients, clinical information before drainage, biochemical values of the first 3 days, length of hospital stay, morbidity and mortality in the early and late period after drainage, and elective cholecystectomy information were recorded. These data were compared between the two groups.

RESULTS

One hundred and twenty-two patients were included in the study. Early PC was performed in 98 patients (80.3%) and late PC was performed in 24 patients (19.7%). The median follow-up period was 26.6 months (min: 0.25-max: 67) in the early PC group and 26.4 months (min: 0.6-max: 66) in the late PC group (P=0.408). There was no statistically significant difference in mean age, distribu-tion of males and women, concomitant disease, Charlson Comorbidity Index, hepatopancreatobiliary pathology (HPBP), endoscopic retrograde cholangiopancreatography in history and grade (TG18) compared to Tokyo classification (P>0.05). There was no difference between the biochemical parameters (P>0.05). In our study, the median length of hospital stay was 6 (min: 2-max: 36) days in the early PC group, and the median was 9 days (min: 5-max: 20) in the late PC group (P<0.001). A total of 25 patients developed HPBP after PC, 16 of which were AC. There was no statistically significant difference between the early and late PC groups in terms of HPBP develop-ment after PC (P=0.576). There was no statistically significant difference between the early and late PC group in terms of the rate of surgery and type of operation (emergency/elective, open/laparoscopic/conversion, total/subtotal, duration) (P>0.05).

CONCLUSION

Discussions about the right timing are ongoing. In our study, we found that patients who underwent early PC had shorter hospital stays. There was no difference between the early and late groups in terms of patient characteristics and severity of AC. PC procedure in AC should be based on algorithms determined by objective data instead of patient-based indications with ran-domized controlled trials.

Management of Acute Cholecystitis in High-Risk Patients: Percutaneous Gallbladder Drainage as a Definitive Treatment vs. Emergency Cholecystectomy-Systematic Review and Meta-Analysis

BACKGROUND

This systematic review aims to investigate whether percutaneous transhepatic gallbladder biliary drainage (PTGBD) is superior to emergency cholecystectomy (EC) as a definitive treatment in high-risk patients with acute cholecystitis (AC).

MATERIAL AND METHODS

A systematic literature search was performed until December 2022 using the Scopus, Medline/PubMed and Web of Science databases.

RESULTS

Seventeen studies have been included with a total of 783,672 patients (32,634 treated with PTGBD vs. 4663 who underwent laparoscopic cholecystectomy, 343 who had open cholecystectomy and 746,032 who had some form of cholecystectomy, but without laparoscopic or open approach being specified). An analysis of the results shows that PTGBD, despite being less invasive, is not associated with lower morbidity with respect to EC (RR 0.77 95% CI [0.44 to 1.34]; I2 = 99%; p = 0.36). A lower postoperative mortality was reported in patients who underwent EC (2.37%) with respect to the PTGBD group (13.78%) (RR 4.21; 95% CI [2.69 to 6.58]; p < 0.00001); furthermore, the risk of hospital readmission for biliary complications (RR 2.19 95% CI [1.72 to 2.79]; I2 = 48%; p < 0.00001) and hospital stay (MD 4.29 95% CI [2.40 to 6.19]; p < 0.00001) were lower in the EC group.

CONCLUSIONS

In our systematic review, the majority of studies have very low-quality evidence and more RCTs are needed; furthermore, PTGBD is inferior in the treatment of AC in high-risk patients. The definition of high-risk patients is important in interpreting the results, but the methods of assessment and definitions differ between studies. The results of our systematic review and meta-analysis failed to demonstrate any advantage of using PTGBD over ER as a definitive treatment of AC in critically ill patients, which suggests that EC should be considered as the treatment of choice even in very high-risk patients. Most likely, the inferiority of PTGBD versus early LC for high-risk patients is related to an association of various patient-side factor conditions and the severity of acute cholecystitis.

Impact of percutaneous cholecystostomy in the management of acute cholecystitis: a retrospective cohort study at a tertiary center

Laparoscopic cholecystectomy is the gold standard for the treatment of acute cholecystitis (AC). Percutaneous cholecystostomy (PC) for management of AC is increasing; safe and less invasive than laparoscopic cholecystectomy and is very useful in selected patients with severe comorbidities, not suitable for surgery/general anesthesia. We conducted a retrospective observational study between 2016 and 2021 of patients treated with PC for AC, based on the application of the Tokyo guidelines 13/18. The aim was to analyse the clinical results and management of PC in patients undergoing elective or emergency cholecystectomy. Subsequently, a retrospective analytical study was designed to compare various cohorts: elective or emergency surgery and management with PC alone; patients with/without a high surgical risk; and elective vs emergency surgery. Hundred and ninety five patients with AC were treated with PC. Mean age was 74 years, 59.5% were ASA class III/IV, and the mean Charlson comorbidity index was 5.5. Adherence to Tokyo guidelines regarding indication of PC was 50.8%. The rate of complications associated to PC was 12.3% and the 90-day mortality rate was 14.4%. Mean length of time using PC was 10.7 days. Emergency surgery was performed in 4.6%. The overall success rate using PC was 66.7%, and the 1-year readmission rate due to biliary complications after PC was 28.2%. The rate of scheduled cholecystectomy after PC was 22.6%. Conversion to laparotomy and open approach was more frequent in patients who underwent emergency surgery (p = 0.009). No differences were found in 90-day mortality or in the complication rate. PC achieves improvements in the inflammation and infection associated with AC. In our series, it proved to be an effective and safe treatment during the acute episode of AC. Mortality in patients treated with PC is high due to their older age, greater morbidity, and higher Charlson comorbidity index scores. After PC, emergency surgery is uncommon but readmission due to biliary events is high. Cholecystectomy after PC is the definitive treatment and the laparoscopic approach is feasible. Clinical trial registery: The study was registered in the public accessible database clinicaltrials.gov with the ClinicalTrials.gov ID: NCT05153031. Public release date: 12/09/2021.

Persistent acute cholecystitis after cholecystostomy - increased mortality due to treatment approach?

BACKGROUND

Percutaneous cholecystostomy (PC) is a treatment option for acute cholecystitis (AC) in cases where cholecystectomy (CCY) is not feasible due to limited health conditions. The use of PC remains questionable. The aim was to retrospectively analyse the outcome of patients after PC.

METHODS

All patients who underwent PC for AC at a tertiary referral hospital over 10 years were included. Descriptive statistics, analysed mortality with and without CCY after PC, and a multivariable logistic regression for potential confounder and a landmark sensitivity analysis for immortal time bias were used.

RESULTS

Of 158 patients, 79 were treated with PC alone and 79 had PC with subsequent CCY. Without CCY, 48% (38 patients) died compared to 9% with CCY. In the multivariable analysis CCY was associated with 85% lower risk of mortality. The landmark analysis was compatible with the main analyses. Direct PC-complications occurred in 17% patients. Histologically, 22/75 (29%) specimens showed chronic cholecystitis, and 76% AC.

CONCLUSION

Due to the high mortality rate of PC alone, performing up-front CCY is proposed. PC represents no definitive treatment for AC and should remain a short-term solution because of the persistent inflammatory focus. According to these findings, almost all specimens showed persistent inflammation.

Factors influencing failure to undergo interval cholecystectomy after percutaneous cholecystostomy among patients with acute cholecystitis: a retrospective study

Background

Percutaneous cholecystostomy (PC) with interval cholecystectomy is an effective treatment modality in high-risk patients with acute cholecystitis. However, some patients still fail to undergo interval cholecystectomy after PC, with the reasons rarely reported. Hence, this study aimed to explore the factors that prevent a patient from undergoing interval cholecystectomy.

Methods

Data from patients with acute cholecystitis who had undergone PC from January 1, 2017 to December 31, 2019 in our hospital were retrospectively collected. The follow-up endpoint was the patient undergoing cholecystectomy. Patients who failed to undergo cholecystectomy were followed up every three months until death. Univariate and multivariate analyses were performed to analyze the factors influencing failure to undergo interval cholecystectomy. A nomogram was used to predict the numerical probability of non-interval cholecystectomy.

Results

Overall, 205 participants were identified, and 67 (32.7%) did not undergo cholecystectomy during the follow-up period. Multivariate analysis revealed that having a Tokyo Guidelines 2018 (TG18) grade III status (odds ratio [OR]: 3.83; 95% confidence interval [CI]: 1.27–11.49; p = 0.017), acalculous cholecystitis (OR: 4.55; 95% CI: 1.59–12.50; p = 0.005), an albumin level < 28 g/L (OR: 4.15; 95% CI: 1.09–15.81; p = 0.037), and a history of malignancy (OR: 4.65; 95% CI: 1.62–13.37; p = 0.004) were independent risk factors for a patient’s failure to undergo interval cholecystectomy. Among them, the presence of a history of malignancy exhibited the highest influence in the nomogram for predicting non-interval cholecystectomy.

Conclusions

Having a TG18 grade III status, acalculous cholecystitis, severe hypoproteinemia, and a history of malignancy influence the failure to undergo cholecystectomy after PC in patients with acute cholecystitis.

Percutaneous cholecystostomy versus emergency cholecystectomy for the treatment of acute calculous cholecystitis in high-risk surgical patients: a meta-analysis and systematic review

The present meta-analysis was performed to compare the efficacy and safety of percutaneous cholecystostomy (PC) versus emergency cholecystectomy (EC) for the treatment of acute calculous cholecystitis (ACC) in high-risk surgical patients. Literature searches for eligible studies were performed using MEDLINE, EMBASE and the Cochrane Library. Quality assessment was conducted in each study. Meta-analyses were performed to demonstrate the pooled effects of relative risk (RR) with 95% confidence intervals (CI). A total of 8960 patients from 6 studies were finally included. PC resulted in increased risks of mortality (RR = 2.87; CI = 1.33-6.18; p = 0.007) and readmission rate (RR = 4.70; CI = 3.30-6.70; p < 0.00001) as compared with EC. No significant difference was detected between PC and EC in terms of morbidity, severe complication rate or hospitalization length. Moreover, PC was associated with significantly higher risks of mortality (RR = 7.47; CI = 1.88-29.72; p = 0.004), morbidity (RR = 3.71; 95% CI = 1.78-7.75; p = 0.0005), readmission rate (RR = 7.91; CI = 3.80-16.49; p < 0.00001), and hospitalization length (WMD = 6.92; CI = 5.89-7.95; p < 0.00001) when directly compared with laparoscopic cholecystectomy (LC). Therefore, EC is superior to PC for the treatment of ACC in high-risk surgical patients, and LC is the preferred surgical strategy.

Management of Patients With Acute Cholecystitis After Percutaneous Cholecystostomy: From the Acute Stage to Definitive Surgical Treatment

Percutaneous cholecystostomy (PC) has become an important procedure for the treatment of acute cholecystitis (AC). PC is currently applied for patients who cannot undergo immediate laparoscopic cholecystectomy. However, the management following PC has not been well-reviewed. The efficacy of PC tubes has already been indicated, and compared to complications of other invasive biliary procedures, complications related to PC are rare. Following the resolution of AC, patients who can tolerate anesthesia and the surgical risk should undergo interval cholecystectomy to reduce the recurrence of biliary events. For patients unfit for surgery, whether owing to comorbidities, anesthesia risks, or surgical risks, expectant management may be applied; however, a high incidence of recurrence has been noted. In addition, several interesting issues, such as the indications for cholangiography via the PC tube, removal or maintenance of the PC catheter before definitive treatment, and timing of elective surgery, are all discussed in this review, and a relevant decision-making flowchart is proposed. PC is an effective and safe intervention, whether as expectant treatment or bridge therapy to definitive surgery. High-level evidence of post-PC care is still necessary to modify current practices.

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.

Short- and long-term outcomes of percutaneous cholecystostomy in an Australian population

BACKGROUND

Percutaneous cholecystostomy (PC) is a well-recognized management option for the treatment of acute cholecystitis (AC) in high-risk patients. Patient characteristics, efficacy and particularly the longer-term outcomes for patients having PC across the Hunter New England Local Health District were analysed.

METHODS

A retrospective audit from January 2013 to September 2017 was undertaken. Patients were followed up until September 2019. All were retrospectively risk assessed using the P-POSSUM risk assessment tool, complications and mortality were recorded. In addition to short-term data, longer-term outcomes including patient's living situation at 6 and 12 months were analysed.

RESULTS

A total of 82 patients were assessed at ≥12 months post procedure or until death. Successful initial gallbladder drainage was achieved in 99% of cases. The mean P-POSSUM score for mortality was 11%, confirming that this is a high-risk group; 17% had inpatient complications recorded; 10% of these were major (Clavien-Dindo ≥III). Outpatient complications were seen in 45%, 59% underwent further biliary tree intervention and 24% had recurrent AC. Thirty-day mortality was 12% and 1-year mortality was 22%. Functional capacity changed significantly for 41% of patients at 1 year, with 12% requiring a new admission to high-level nursing home care.

CONCLUSION

Our series represents the largest reported Australasian series of PC for AC published to date. It confirms that PC is well-established and safe in high-risk patients. However, further intervention rates and recurrence rates of AC are high and escalation of dependency of care affects almost half of patients.

Cholecystectomy Vs. Cholecystostomy for the Management of Acute Cholecystitis in Elderly Patients

BACKGROUND

Data comparing outcomes following cholecystectomy and cholecystostomy tube placement (CTP) in elderly patients are lacking. We aimed to compare the post-procedural outcomes between cholecystectomy and CTP in elderly patients with acute cholecystitis.

METHODS

We performed a retrospective, population-based analysis using the National Inpatient Sample for the period 2000-2014. Patients ≥ 65 years old admitted with a primary diagnosis of acute cholecystitis and who underwent either cholecystectomy or CTP during their hospitalization were included. Multivariable linear and logistic regression models were used to analyze post-procedural complications, mortality, length of stay, and total charges. The effect of procedure type on patient outcomes, stratified by acalculous and calculous cholecystitis, was also performed.

RESULTS

A total of 200,915 patients were included, of which 7516 underwent CTP and 193,399 underwent cholecystectomy. The median age of patients undergoing CTP and cholecystectomy was 80 (IQR 73-87) and 75 (IQR 70-81), respectively. Patients undergoing CTP were more likely to have post-procedural infection (OR 2.25; 95% CI 2.07, 2.45), bleeding (OR 1.28; 95% CI 1.19, 1.37), and inpatient mortality (OR 9.27; 95% CI 7.95, 10.81). On average, CTP patients stayed 1.25 days longer (95% CI 1.14, 1.37) in hospital after the procedure. The benefits of cholecystectomy were consistent in patients with acalculous and calculous cholecystitis.

CONCLUSIONS

Elderly patients with both acalculous and calculous acute cholecystitis managed with CTP have higher incidences of post-procedural morbidity and mortality, and longer post-procedure length of hospital stay, as compared to cholecystectomy. Unless prohibitive surgical risks exist, elderly patients with acute cholecystitis should undergo cholecystectomy.