Percutaneous cholecystostomy in the management of high-risk patients presenting with acute cholecystitis: Timing and outcome at a single institution

Atlas for Cholangioscopy and Cholecystoscopy: A Primer for Diagnostic and Therapeutic Endoscopy in the Biliary Tree and Gallbladder

Percutaneous endoscopy of the biliary system (cholangioscopy) and gallbladder (cholecystoscopy) has significantly impacted diagnostic and therapeutic approaches to many diseases in interventional radiology, overcoming previous challenges related to scope size and rigidity. The current endoscopes offer enhanced maneuverability within narrow tubular structures such as bile ducts. Before endoscopy, reliance on 2D imaging modalities limited real-time visualization during percutaneous procedures. Percutaneous endoscopy provides 3D perspectives, enabling a better appreciation of normal structures, targeted biopsy of lesions, and accurate deployment of therapeutic interventions. This review aims to explore percutaneous endoscopic findings across various biliary and gallbladder pathologies.

Ultrasound-Guided Interventions in the Biliary System

Ultrasound guidance in biliary interventions has become the standard tool to facilitate percutaneous biliary drainage as well as percutaneous gall bladder drainage. Monitoring of the needle tip whilst penetrating the tissue in real time using ultrasound allows precise manoeuvres and exact targeting without radiation exposure. Without the need for fluoroscopy, ultrasound-guided drainage procedures can be performed bedside as a sometimes life-saving procedure in patients with severe cholangitis/cholecystitis when they are critically ill in intensive care units and cannot be transported to a fluoroscopy suite. This article describes the current data background and guidelines and focuses on specific sonographic aspects of both the procedures of percutaneous biliary drainage and gallbladder drainage.

Percutaneous Transhepatic Cholangioscopy Interventions-Updates

Percutaneous transhepatic cholangioscopy (PTCS) was initially described around the same time that peroral cholangioscopy (POSC) was developed. The cited utility attributed to PTCS is the ability to be utilized in the subset of patients with surgical proximal bowel anatomy, often precluding the use of traditional POSC. However, since first described, PTCS use has been limited due to a lack of physician awareness and a lack of procedure-specific equipment and supplies. With recent developments of PTSC-specific equipment, there has been an expansion in the possible interventions able to be performed during PTCS, resulting in a rapid increase in clinical use. This short review will serve as a comprehensive update of the previous and more recent novel interventions now able to be performed during PTCS.

Retrospective comparison of clinical outcomes of ultrasound-guided percutaneous cholecystostomy in patients with and without coagulopathy: a single center's experience

PURPOSE

To compare the complication rate and clinical outcomes for percutaneous cholecystostomy (PC) in patients with or without coagulopathy.

MATERIALS AND METHODS

We retrospectively reviewed electronic medical chart of patients who underwent ultrasound-guided PC with a 8.5-F drainage tube for acute cholecystitis between November 2003 and March 2017. We divided the patients into two groups: patients with coagulopathy (international normalized ratio > 1.5 or platelet count < 50 × 109/L or with a history of anticoagulant medication in preceding 5 days) and patients without coagulopathy. Duration of drainage, duration of hospital stay, 30-day mortality and complication rates were compared between these two groups. Student's t test, Chi-square test or Fisher's exact test was used for bivariate analyses. Age, age-adjusted Charlson Comorbidity Index (ACCI) and sepsis-adjusted complication rates were also compared.

RESULTS

In total, 141 patients had PC (mean age was 73.3 years [SD 13.3]; range 33-96 years; 94 men and 47 women). Fifty-two patients (36.9%) had coagulopathy and 89 patients (63.1%) were without any history of coagulopathy. Hemorrhagic complication rate was 3.5% (5 out of 141 patients, including 4 with coagulopathy and 1 without). One patient with coagulopathy died due to the hemorrhage. Duration of drainage was longer in patients with coagulopathy than patients without coagulopathy (20.0 days vs. 14.8 days; P = 0.033). No significant difference was observed with regard to duration of hospital stay (32.3 days vs. 25.6 days; P = 0.103) and 30-day mortality (7.7% vs. 1.1%; P = 0.062). The overall complication rate did not significantly differ (9.6% and 11.2%; P = 0.763), nor did age, ACCI or sepsis-adjusted complications.

CONCLUSION

Clinical outcomes and complications rates after PC did not statistically differ between patients with and without coagulopathy, but there was a tendency of higher risk of hemorrhage in coagulopathy patients. Therefore, the indication of this procedure should be carefully determined.

Factors affecting the recurrence of acute cholecystitis after treatment with percutaneous cholecystostomy

BACKGROUND

The aim of this study was to determine the recurrence rate of patients who did not have interval cholecystectomy after treatment with percutaneous cholecystostomy and to investigate the factors that may affect the recurrence.

METHODS

Patients who did not undergo interval cholecystectomy after percutaneous cholecystostomy treatment between 2015 and 2021 were retrospectively screened for recurrence.

RESULTS

36.3% of the patients had recurrence. Recurrence was found more frequently in patients with fever symptoms at the time of admission to the emergency department (p = 0.003). Recurrence was found to be more frequent in those who had a previous cholecystitis attack (p = 0.016). It was determined that patients with high lipase and procalcitonin levels had statistically more frequent attacks (p = 0.043, p = 0.003). It was observed that the duration of catheter insertion was longer in patients who had relapses (p = 0.019). The cut-off value for lipase was calculated as 15.5, and the cut-off value for procalcitonin as 0.955, in order to identify patients at high risk for recurrence. In the multivariate analysis for the development of recurrence, presence of fever, a history of previous cholecystitis attack, lipase value higher than 15.5 and procalcitonin value higher than 0.955 were found to be risk factors.

CONCLUSIONS

Percutaneous cholecystostomy is an effective treatment method in acute cholecystitis. Insertion of the catheter within the first 24 h may reduce the recurrence rate. Recurrence is more common in the first 3 months following removal of the cholecystostomy catheter. Having a previous history of cholecystitis attack, fever symptom at the time of admission, elevated lipase and procalcitonin are risk factors for recurrence.

The Rise and Fall of Percutaneous Cholecystostomy in a Community Hospital: Is It Possible to Turn the Tide of History?

BACKGROUND

Laparoscopic cholecystectomy is the gold standard for treatment of acute cholecystitis. Percutaneous cholecystostomy (PC) drains are alternatives to cholecystectomy in critically ill patients in whom surgery carries an unacceptably high risk. Recently, several studies demonstrated a significant increase in complications in patients undergoing PC in comparison to laparoscopic cholecystectomy.

METHODS

We conducted a retrospective analysis of patients who underwent PC drainage or cholecystectomy from 2014 through 2019 at our institution. We determined the rate of PC use and performed a linear regression analysis to evaluate PC utilization over time. After creating institutional guidelines and reeducating physicians on appropriate use of PC drainage in 2019, we compared PC utilization to prior years.

RESULTS

A total of 146 PCs and 3163 cholecystectomies were performed over the study period. Of the cholecystectomies, 754 (23.8%) were performed in hospitalized patients under urgent or emergent conditions. Of the patients with acute cholecystitis, 16.2% were treated with PC. Linear regression analysis demonstrated a significant association between year and rate of PC procedures (p<0.001). The rate of PC rose from 13.8 to 22.5% between 2014 and 2018 and dropped to 10.9% (p=0.006) in 2019 after the reeducation program.

CONCLUSIONS

With a rising rate of PC utilization and in light of recent studies suggesting increased complications and healthcare costs for patients undergoing this procedure, care needs to be taken to ensure that only appropriate patients are referred for PC. Publication of institutional guidelines, resident and attending surgeon reeducation, and case review can reduce placement of unnecessary PCs.

Call for action: Increased healthcare utilization with growing use of percutaneous cholecystectomy tube over initial cholecystectomy in cirrhotics

BACKGROUND

Acute calculous cholecystitis (ACC) is frequently seen in cirrhotics, with some being poor candidates for initial cholecystectomy. Instead, these patients may undergo percutaneous cholecystostomy tube (PCT) placement. We studied the healthcare utilization and predictors of cholecystectomy and PCT in patients with ACC.

METHODS

The National Database was queried to study all cirrhotics and non-cirrhotics with ACC between 2010-2014 who underwent initial PCT (with or without follow-up cholecystectomy) or cholecystectomy. Cirrhotic patients were divided into compensated and decompensated cirrhosis. Independent predictors and outcomes of initial PCT and failure to undergo subsequent cholecystectomy were studied.

RESULTS

Out of 919 189 patients with ACC, 13 283 (1.4%) had cirrhosis. Among cirrhotics, cholecystectomy was performed in 12 790 (96.3%) and PCT in the remaining 493 (3.7%). PCT was more frequent in cirrhotics (3.7%) than in non-cirrhotics (1.4%). Multivariate analyses showed increased early readmissions [odds ratio (OR) = 2.12, 95% confidence interval (CI): 1.43-3.13, P < 0.001], length of stay (effect ratio = 1.39, 95% CI: 1.20-1.61, P < 0.001), calendar-year hospital cost (effect ratio = 1.34, 95% CI: 1.28-1.39, P < 0.001) and calendar-year mortality (hazard ratio = 1.89, 95% CI: 1.07-3.29, P = 0.030) in cirrhotics undergoing initial PCT compared to cholecystectomy. Decompensated cirrhosis (OR = 2.25, 95% CI: 1.67-3.03, P < 0.001) had the highest odds of getting initial PCT. Cirrhosis, regardless of compensated (OR = 0.56, 95% CI: 0.34-0.90, P = 0.020) or decompensated (OR = 0.28, 95% CI: 0.14-0.59, P < 0.001), reduced the chances of getting a subsequent cholecystectomy.

CONCLUSIONS

Cirrhotic patients undergo fewer cholecystectomy incurring initial PCT instead. Moreover, the rates of follow-up cholecystectomy are lower in cirrhotics. Increased healthcare utilization is seen with initial PCT amongst cirrhotic patients. This situation reflects suboptimal management of ACC in cirrhotics and a call for action.

Structures, processes and models of care for emergency general surgery in Ontario: a cross-sectional survey

BACKGROUND

Emergency general surgery (EGS) patients require urgent surgical evaluation and intervention for various conditions, such as infectious or obstructive diseases of the gastrointestinal tract. We aimed to characterize the structures and processes that are relevant to the delivery of EGS care across Ontario hospitals and to evaluate the availability of critical resources at hospitals with formal EGS models.

METHODS

Between August 2019 and July 2020, we conducted a cross-sectional survey of Ontario hospitals that offered urgent general surgery (defined as the ability to provide nonelective surgical intervention within 24 to 48 hours of presentation) to adults. People with intimate knowledge of their hospital's EGS program completed a Web-based or telephone survey characterizing the program's organizational structure and staffing, operating room availability, interventional radiology and interventional endoscopy availability, intensive care unit availability and staffing, and regional participation. Their responses were compiled and comparisons were made between hospitals with and without formal EGS models of care, as well as between hospitals based on size and academic status.

RESULTS

Of the 114 Ontario hospitals identified, 109 responded (95.6% response rate). A third (34.6%; n = 37/107) of hospitals had EGS models of care. Thirty-four of these (91.9%) were large (> 100-bed) institutions that would be likely to have increased resources. However, even for hospitals of similar size, those with EGS models had increased staffing levels compared to those without (clinical associates 17.6% [n = 3/17] v. 10.0% [n = 2/20]; nurse practitioners or physician assistants 27.8% [n = 5/18] v. 14.3% [n = 3/21]). They also had better access to diagnostic and interventional equipment (24/7 access to computed tomography 94.1% [n = 16/17] v. 69.2% [n = 18/26]), interventional radiology (88.9% [n = 16/18] v. 42.3% [n = 11/26]), endoscopy (100% [n = 18/18] v. 69.2% [n = 18/26]) and endoscopic retrograde cholangiopancreatography (77.8% [n = 14/18] v. 42.3% [n = 11/26]), as well as dedicated operating room time (72.2% [n = 13/18] v. 0% [n = 0/25]).

INTERPRETATION

The structures and processes available to care for patients requiring EGS in Ontario were highly variable between hospitals. Hospitals with formal EGS models were more likely to have access to key resources.

[Acute Cholecystitis in high-risk surgical patients: sonographic and endoscopic treatment options]

Cholecystectomy is the gold standard in the treatment of acute cholecystitis, but has a significantly increased risk in multimorbid patients or in the severe course of acute cholecystitis. In such cases, drainage of the damaged gallbladder in combination with antibiotic therapy may be superior to primary surgery. The drainage can either be performed as sonographically guided percutaneous transhepatic gallbladder drainage or as EUS-guided transmural stent placement or endoscopic-transpapillary gallbladder drainage. These minimally invasive alternatives to cholecystectomy can be used both as long-term therapy for permanently inoperable patients and temporarily for patients in whom the cholecystectomy is intended after improvement of the general condition. In this overview, the various drainage methods are discussed with regard to technical requirements, immediate and long-term clinical results and complications. With advances in stent design, EUS-guided transmural stent placement from the stomach or duodenum into the gallbladder is becoming the preferred method of gallbladder drainage in centers with the appropriate expertise.

COVID-19 outbreak and acute cholecystitis in a Hub Hospital in Milan: wider indications for percutaneous cholecystostomy

Background

COVID-19 pandemic has impacted the Italian National Health Care system at many different levels, causing a complete reorganization of surgical wards. In this context, our study retrospectively analysed the management strategy for patients with acute cholecystitis.

Methods

We analysed all patients admitted to our Emergency Department for acute cholecystitis between February and April 2020 and we graded each case according to 2018 Tokyo Guidelines. All patients were tested for positivity to SARS-CoV-2 and received an initial conservative treatment. We focused on patients submitted to cholecystostomy during the acute phase of pandemic and their subsequent disease evolution.

Results

Thirty-seven patients were admitted for acute cholecystitis (13 grade I, 16 grade II, 8 grade III). According to Tokyo Guidelines (2018), patients were successfully treated with antibiotic only, bedside percutaneous transhepatic gallbladder drainage (PC) and laparoscopic cholecystectomy (LC) in 29.7%, 21.6% and 48.7% of cases respectively. Therapeutic strategy of three out of 8 cases, otherwise fit for surgery, submitted to bedside percutaneous transhepatic gallbladder drainage (37.5%), were directly modified by COVID-19 pandemic: one due to the SARS-CoV-2 positivity, while two others due to unavailability of operating room and intensive care unit for post-operative monitoring respectively. Overall success rate of percutaneous cholecystostomy was of 87.5%. The mean post-procedural hospitalization length was 9 days, and no related adverse events were observed apart from transient parietal bleeding, conservatively treated. Once discharged, two patients required readmission because of acute biliary symptoms. Median time of drainage removal was 43 days and only 50% patients thereafter underwent cholecystectomy.

Conclusions

Percutaneous cholecystostomy has shown to be an effective and safe treatment thus acquiring an increased relevance in the first phase of the pandemic. Nowadays, considering we are forced to live with the SARS-CoV-2 virus, PC should be considered as a virtuous, alternative tool for potentially all COVID-19 positive patients and selectively for negative cases unresponsive to conservative therapy and unfit for surgery.

Characteristics and outcome of elderly patients admitted for acute Cholecystitis to medical or surgical wards

BACKGROUND

Elderly patients admitted because of acute cholecystitis are usually not operated during their initial admission and receive conservative treatment. To help formulate a new admission policy regarding elderly patients with acute cholecystitis we compared the demographic and clinical characteristics and outcome of patients > 65 with acute cholecystitis admitted to medical or surgical wards.

METHODS

This retrospective study included all patients > 65 years admitted for acute cholecystitis between January, 2009 and September, 2016. Data were retrieved from the electronic health records.

RESULTS

A total of 187 patients were detected, 54 (29%) in medical departments and 133 (71%) in surgical wards. The mean age (±SD) was 80 ± 7.5 and was higher among those in medical than surgical wards (84 ± 7 versus 79 ± 7, p <  0.05). Patients hospitalized in medical departments had more comorbidity, disability and mental impairment. However, there was no difference in mortality between the two groups, 1 (2%) and 6 (4%) respectively. Independent predictors for hospitalization in medical departments were chronic obstructive pulmonary disease (OR = 9.8, 95% C. I 1.6-59) and the Norton Scale score (NSS)(OR = 0.7, 95% C. I 0.7-0.8). Impaired mental condition was the only predictor for hospitalization > 1 week. The strongest predictor for having cholecystostomy was admission to the surgical department (OR = 14.7, 95% C. I 3.9-56.7). Linear regression showed a negative correlation between NSS and length of hospitalization (LOH; Beta = - 0.5).

CONCLUSION

Elderly patients with acute cholecystitis who require conservative management, especially those with severe functional and mental impairment can be safely hospitalized in medical departments. Outcome was not inferior in terms of mortality and LOH. These results have practical policy implications for the placement of elderly patients with acute cholecystitis in medical rather than surgical departments.

Image-Guided Palliative Interventions

This article reviews a few surgical palliative care procedures that can be performed by surgeons and interventional radiologists using image-guided techniques. Treatment of recurrent pleural effusions, gastrostomy feeding tube maintenance, percutaneous cholecystostomy, and transjugular intrahepatic portosystemic shunts (TIPS) with embolotherapy of bleeding stomal varices is discussed.

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.

Outcome after cholecystectomy in the elderly

BACKGROUND

Cholecystectomy is considered the standard treatment for acute cholecystitis and symptomatic gallstones. An increasing number of frail elderly patients are being referred for this surgical treatment. A better understanding of surgical outcome in the elderly is needed to improve quality of care.

METHODS

A retrospective analysis of 565 patients who underwent cholecystectomy was performed. Focus of the analyses was on postoperative complications and its predictors.

RESULTS

The study population was divided in two cohorts; aged <70. More complications were found in patients aged ≥70 years. More elderly patients were admitted to the intensive care, respectively 4.0% and 14.1% (P = 0.045). Hospital mortality was 6% in patients aged ≥70 years vs 0.6% in patients <70.

CONCLUSION

In elderly patients, the complication and mortality rate following cholecystectomy is higher than previously reported. For high-risk patients aged ≥70 with cholecystitis, alternative therapies should be considered as a bridge to surgery or definite treatment.

Endoscopic ultrasound guided gallbladder drainage - is it ready for prime time?

Management of acute cholecystitis includes initial stabilization and antibiotics. However, the most definitive treatment is cholecystectomy. A small percentage of patients who are not suitable for surgery due to the severity of cholecystitis or comorbidities will require a temporary measure as a bridge to surgery or permanent nonoperative management to decrease the mortality and morbidity. Most of these patients who require conservative management were managed with percutaneous transhepatic cholecystostomy or trans-papillary drainage of gallbladder drainage with cystic duct stenting through endoscopic retrograde cholangiopancreaticography (ERCP). Although, these conservative measures are effective, they can cause significant discomfort to the patients especially if used as a long-term measure. In view of this, there is a need for further minimally invasive procedures, which is safe, effective and comfortable to patients. Endoscopic ultrasound (EUS) guided gallbladder drainage is a novel method of gallbladder drainage first described in 2007^[1]. Over the last decade, EUS guided gallbladder drainage has evolved as an effective alternative to percutaneous cholecystostomy and trans-papillary gallbladder drainage. Our goal is to review available literature regarding the scope of EUS guided gallbladder drainage as a viable alternative to percutaneous cholecystostomy or cystic duct stenting through ERCP among patients who are not suitable for cholecystectomy.

Interventional Radiology-Operated Cholecystoscopy for the Management of Symptomatic Cholelithiasis: Approach, Technical Success, Safety, and Clinical Outcomes

OBJECTIVE

The objective of our study was to report the technique, complications, and clinical outcomes of interventional radiology-operated cholecystoscopy with stone removal for the management of symptomatic cholelithiasis.

MATERIALS AND METHODS

Ten (77%) men and three (23%) women (mean age, 65 years) with symptomatic cholelithiasis underwent cholecystostomy followed by interventional radiology-operated cholecystoscopy with stone removal. Major comorbidities precluding cholecystectomy included prior cardiac, pulmonary, or abdominal surgery; cirrhosis; sepsis with hyponatremia; seizure disorder; developmental delay; and cholecystoduodenal fistula. Cholecystostomy access, time between cholecystostomy and cholecystoscopy, endoscopic and fragmentation devices used, technical success, procedure time, fluoroscopy time, complications, length of hospital stay, time between cholecystoscopy and cholecystostomy removal, follow-up, and acute cholecystitis recurrence were recorded.

RESULTS

Eleven (85%) patients underwent transhepatic cholecystostomy, and two (15%) patients underwent transperitoneal cholecystostomy. The mean time from cholecystostomy to cholecystoscopy was 151 days. Flexible endoscopy was used in eight (62%) patients, rigid endoscopy in three (23%), and both flexible and rigid in two (15%). Electrohydraulic lithotripsy was used in eight procedures, nitinol baskets in seven, ultrasonic lithotripsy in two, and percutaneous thrombectomy devices in one. Primary technical success was achieved in 11 (85%) patients, and secondary technical success was achieved in 13 (100%) patients. The mean procedure time was 164 minutes, and the mean number of procedures required to clear all gallstones was 1. One (8%) patient developed acute pancreatitis, and one (8%) patient died of gastrointestinal hemorrhage. The median hospital length of stay after cholecystoscopy was 1 day for postoperative monitoring. The mean time between cholecystoscopy and cholecystostomy removal was 39 days. One (8%) patient developed recurrent acute cholecystitis 1095 days after cholecystoscopy.

CONCLUSION

Interventional radiology-operated cholecystoscopy may serve as an effective method for percutaneous gallstone removal in patients with multiple comorbidities precluding cholecystectomy.

Percutaneous Cholecystostomy: Long-Term Outcomes in 324 Patients

PURPOSE

To report technical success and clinical outcome of cholecystostomy tube placement along with timing-and method-of tube removal.

MATERIALS AND METHODS

A retrospective review of cholecystostomy tubes placed from January 2010 to September 2017 was performed at a single academic center. This search yielded 1160 patients. Of these patients, 324 (27.9%) met inclusion criteria for cholecystostomy placement, 199 (61.4%) males and 125 (38.6%) females, with mean age of 67 years (range 6-101 years). The indication for cholecystostomy tube placement, technical success, surgical candidacy, medical comorbidities, clinical outcome, tube indwelling time, complications, and follow-up were recorded.

RESULTS

Indications for cholecystostomy tube placement included: acute cholecystitis (n = 270; 83.3%), perforated cholecystitis (n = 22; 6.8%), emphysematous cholecystitis (n = 18; 5.6%), and other (n = 14; 4.3%). Technical success was 100%. Many patients had multiple medical comorbidities including (most commonly): debilitation (n = 211; 65.1%), cardiovascular disease (n = 194; 59.9%), multisystem disease (n = 181; 55.9%), and malignancy (n = 131; 40.4%). After tube placement, 96 (29.6%) patients underwent definitive cholecystectomy, 94 expired (29.0%), 36 (11.1%) had a patent cystic duct on follow-up cholangiogram and subsequent cholecystostomy removal, 14 (4.3%) underwent cholecystoscopy with stone removal, and 3 (0.9%) had liver transplantation. Forty-five (13.9%) patients had indwelling tubes at the end of the study period. Mean tube indwelling time was 89 days (range 0-586 days).

CONCLUSION

Technical success for cholecystostomy tube placement was 100% with all patients having clinical resolution of acute cholecystitis. Many patients were able to have tubes subsequently removed.

Percutaneous cholecystostomy for severe (Tokyo 2013 stage III) acute cholecystitis

PURPOSES

To evaluate the impact of percutaneous cholecystostomy (PC) on severe acute cholecystitis (AC).

METHODS

According to the ICD-9 classification, we retrospectively retrieved medical records of patients discharged with a diagnosis of AC from January 2007 to December 2016 at our hospital. Patients were then stratified according to the Tokyo 2013 (TG 13) AC severity criteria. Grade III AC was diagnosed according to the TG 13 criteria. Indications for PC were failure of optimal medical treatment within 48 h, worsening of clinical condition within early medical treatment, patients unfit for upfront surgery and patient's preference. Ascites was considered a contraindication to PC while coagulopathy was considered a minor contraindication. Primary end points were: clinical improvement, morbidity and related mortality. Secondary endpoints were AC recurrences and elective laparoscopic cholecystectomies (LS). Response was evaluated by clinical and blood test improvement. Morbidity was evaluated according to the Dindo-Clavien scale.

RESULTS

A total of 117 eligible patients were diagnosed as grade III AC. Of these, 29 (24.7%) underwent PC. The procedure was completed in all cases. Overall morbidity rate was 20.6%. Main complication was the drainage dislodgement due to involuntary patient's movement. Overall mortality was 17.2% but no causes of death were dependent upon the procedure. Clinical improvement was reported in 95.5% of surviving patients.

CONCLUSION

This study confirms that PC is a valuable tool in the treatment of severe AC. Randomized trials are needed to clarify the criteria for patient selection and to optimize the timing for both cholecystostomy and cholecystectomy.

Outcomes of percutaneous cholecystostomy and predictors of subsequent cholecystectomy

BACKGROUND

The use of a percutaneous cholecystostomy (PC) in the management of severe acute cholecystitis is a well recognized alternative to acute cholecystectomy. The need for definitive surgical management remains controversial.

METHODS

A retrospective analysis of hospital records at Nambour General Hospital between 2012 and 2016 was conducted and data relating to indications, demographics, comorbidities and outcomes were collected.

RESULTS

Thirty PC patients (20 male and 10 female) were identified, with a mean age of 77 years (range 46-93). Thirteen proceeded to cholecystectomy, nine elective and four emergent. Mean time to operation was 97 days (range 1-480). Ten were performed laparoscopically with a complication rate of 23% (3/13). One patient in the operative group died. Seventeen patients did not proceed to cholecystectomy. Fifteen resolved and were discharged, and two died. Three of those discharged were readmitted with gallstone disease requiring treatment, one of which died. A total of 71% (12/17) of the non-operative group died and three of those had a cause of death related to gallstone disease. The operative group was younger (P = 0.01) and had a lower estimated mortality risk (P < 0.05). In this cohort, this translated to an overall survival benefit (P < 0.01).

CONCLUSION

Predictors of eventual cholecystectomy include younger age and lower estimated mortality risk. Patients who require a PC for the treatment of acute cholecystitis and subsequently go on to cholecystectomy can expect to have a favourable outcome.