Early Percutaneous Cholecystostomy in Severe Acute Cholecystitis Reduces the Complication Rate and Duration of Hospital Stay

Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients: the Italian Society of Emergency Surgery and Trauma (SICUT) guidelines

Dealing with acute cholecystitis in high-risk, critically ill, and unfit-for-surgery patients is frequent during daily practice and requires complex management. Several procedures exist to postpone and/or prevent surgical intervention in those patients who temporarily or definitively cannot undergo surgery. After a systematic review of the literature, an expert panel from the Italian Society of Emergency Surgery and Trauma (SICUT) discussed the different issues and statements in subsequent rounds. The final version of the statements was discussed during the annual meeting in Rome (September 2022). The present paper presents the definitive conclusions of the discussion. Fifteen statements based on the literature evidence were provided. The statements gave precise indications regarding the decisional process and the management of patients who cannot temporarily or definitively undergo cholecystectomy for acute cholecystitis. Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients should be multidisciplinary. The different gallbladder drainage methods must be tailored according to each patient and based on the expertise of the hospital. Percutaneous gallbladder drainage is recommended as the first choice as a bridge to surgery or in severely physiologically deranged patients. Endoscopic gallbladder drainage (cholecystoduodenostomy and cholecystogastrostomy) is suggested as a second-line alternative especially as a definitive procedure for those patients not amenable to surgical management. Trans-papillary gallbladder drainage is the last option to be reserved only to those unfit for other techniques. Delayed laparoscopic cholecystectomy in patients with percutaneous gallbladder drainage is suggested in all those patients recovering from the conditions that previously discouraged surgical intervention after at least 6 weeks from the gallbladder drainage.

A Pilot Study of Percutaneous Cholecystoenteric Anastomosis: A New Option for High-Risk Patients with Symptomatic Gallstones

PURPOSE

To evaluate the safety and effectiveness of percutaneous cholecystoenteric anastomosis (PCEA) creation in patients with indwelling cholecystostomy tubes who are high-risk surgical candidates.

MATERIALS AND METHODS

Fourteen (male, 10; female, 4) patients with a mean age of 79 years (range, 53-92 years) with previously inserted cholecystostomy tubes underwent PCEA with the adjacent duodenum using a lumen-apposing metal stent (LAMS) between January 2015 and October 2022. Intraprocedural adverse events and postprocedural safety and effectiveness outcomes were evaluated. Nine procedures were performed under sedation and 5 under general anesthesia.

RESULTS

Technical success was achieved in 100% of the patients. In 12 patients (86%), the existing cholecystostomy tube was removed after the insertion of the LAMS. Three patients (21%) had a pre-existing cholecystoduodenal fistula, in which the stent was placed, and 11 (79%) underwent creation of a de novo anastomosis. The mean procedure time was 1.5 hours (range, 1-2 hours). The mean length of stay after the procedure was 2.4 days (range, 1-10 days). There were no intraprocedural adverse events. One patient with severe pre-existing cardiac comorbidities died during his postprocedural stay despite a technically successful procedure. One patient had delayed closure of the long-standing cholecystocutaneous tract.

CONCLUSIONS

Early clinical experience with PCEA using an LAMS suggests that it is a safe and effective option for the creation of internal gallbladder drainage in patients who are not candidates for surgical cholecystectomy.

Current Operative Approaches to the Diseased Gallbladder. Diagnosis and Management Updates for General Surgeons

Cholecystitis is a common diagnosis which requires management by general surgeons. Morbidity from cholecystitis is often life-threatening, especially in patients with underlying liver cirrhosis or other medical comorbidities. Diagnosis and management of this disease can vary among providers and hospitals. The decision to utilize a radiological or endoscopic temporizing maneuver in severe acute cholecystitis and the timing of later definitive cholecystectomy are relevant points of discussion within general surgery societies. In the last 5 years, the use of intraoperative ductal imaging by conventional vs fluorescence cholangiography had gained significant interest due to the widespread availability of indocyanine green. Finally, the operative strategies and how to manage intra-/postoperative complications are very important to optimizing patient outcomes. In this review paper, we discuss all treatment aspects of cholecystitis and provide updates in its management.

Assessment of Gallbladder Drainage Methods in the Treatment of Acute Cholecystitis: A Literature Review

Gallbladder drainage is a treatment option in high-risk surgical patients with moderate or severe acute cholecystitis. It may be applied as a bridge to cholecystectomy or a definitive treatment option. Apart from the simple and widely accessible percutaneous cholecystostomy, new attractive techniques have emerged in the previous decade, including endoscopic transpapillary gallbladder drainage and endoscopic ultrasound-guided gallbladder drainage. The aim of this paper is to present currently available drainage techniques in the treatment of AC; evaluate their technical and clinical effectiveness, advantages, possible adverse events, and patient outcomes; and illuminate the decision-making path when choosing among various treatment modalities for each patient, depending on their clinical characteristics and the accessibility of methods.

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.

Acute cholecystitis: Which flow-chart for the most appropriate management?

Acute cholecystitis (AC) is a very common disease in clinical practice. Laparoscopic cholecystectomy remains the gold standard treatment for AC, however due to aging population, the increased prevalence of multiple comorbidities and the extensive use of anticoagulants, surgical procedures may be too risky when dealing with patients in emergency settings. In these subsets of patients, a mini-invasive management may be an effective option, both as a definitive treatment or as bridge-to-surgery. In this paper, several non-operative treatments are described and their benefits and drawbacks are highlighted. Percutaneous gallbladder drainage (PT-GBD) is one of the most common and widespread techniques. It is easy to perform and has a good cost/benefit ratio. Endoscopic transpapillary gallbladder drainage (ETGBD) is a challenging procedure that is usually performed in high volume centers by expert endoscopists, and it has a specific indication for selected cases. EUS-guided drainage (EUS-GBD) is still not widely available, but it is an effective procedure that could have several advantages, especially in rate of reinterventions. All these treatment options should be considered together in a stepwise approach and addressed to patients after an accurate case-by-case evaluation in a multidisciplinary discussion. In this review, we provide a possible flowchart in order to optimize treatments, resource and provide to patients a tailored approach.

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.

A novel approach to distinguish complicated and non-complicated acute cholecystitis: Decision tree method

It is difficult to differentiate between non-complicated acute cholecystitis (NCAC) and complicated acute cholecystitis (CAC) preoperatively, which are two separate pathologies with different management. The aim of this study was to create an algorithm that distinguishes between CAC and NCAC using the decision tree method, which includes simple examinations. In this retrospective study, the patients were divided into 2 groups: CAC (149 patients) and NCAC (885 patients). Parameters such as patient demographic data, American Society of Anesthesiologists (ASA) score, Tokyo grade, comorbidity findings, white blood cell (WBC) count, neutrophil/lymphocyte ratio, C-reactive protein (CRP) level, albumin level, CRP/albumin ratio (CAR), and gallbladder wall thickness (GBWT) were evaluated. In this algorithm, the CRP value became a very important parameter in the distinction between NCAC and CAC. Age was an important predictive factor in patients with CRP levels >57 mg/L, and the critical value for age was 42. After the age factor, the important parameters in the decision tree were WBC and GBWT. In patients with a CRP value of ≤57 mg/L, GBWT is decisive and the critical value is 4.85 mm. Age, neutrophil/lymphocyte ratio, and WBC count were among the other important factors after GBWT. Sex, ASA score, Tokyo grade, comorbidity, CAR, and albumin value did not have an effect on the distinction between NCAC and CAC. In statistical analysis, significant differences were found groups in terms of gender (34.8% vs 51.7% male), ASA score (P < .001), Tokyo grade (P < .001), comorbidity (P < .001), albumin (4 vs 3.4 g/dL), and CAR (2.4 vs 38.4). By means of this algorithm, which includes low-cost examinations, NCAC and CAC distinction can be made easily and quickly within limited possibilities. Preoperative prediction of pathologies that are difficult to manage, such as CAC, can minimize patient morbidity and mortality.

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.

Early cholecystectomy following percutaneous transhepatic gallbladder drainage is effective for moderate to severe acute cholecystitis in the octogenarians

BACKGROUND

Acute cholecystitis (AC) is a life-threatening infectious/inflammatory disease in older patients. This study aimed to investigate the safety and optimal timing of surgery in patients aged ≥ 80 years with moderate to severe AC who received percutaneous transhepatic gallbladder drainage (PTGBD).

METHODS

From January 2008 to February 2021, 152 patients were retrospectively enrolled. Clinical outcomes were compared among patients who received laparoscopic cholecystectomy (LC), open cholecystectomy (OC), and conversion surgery, and between those who received early (< 6 weeks after PTGBD) and delayed cholecystectomy (≥ 6 weeks after PTGBD). Logistic regression analysis was used to identify risk factors for recurrent AC, further biliary events, conversion, and perioperative complications.

RESULTS

Sixty-seven patients underwent LC, 62 underwent OC, and 23 underwent conversion surgery. Operation-related complications and mortality rates did not differ among the types of surgery; however, LC group had shorter operative time than the other groups. Eighty-two patients underwent early cholecystectomy, while 70 underwent delayed cholecystectomy. There were no differences in operative time, operation-related complications, and mortality rates between the groups. However, higher rates of recurrent AC and biliary events were observed in the delayed cholecystectomy group (52.9% vs. 4.9% and 57.1% vs. 8.5%, p < 0.001). On multivariate analysis, delayed cholecystectomy was a significant risk factor for recurrent AC (odds ratio [OR] = 19.42, p < 0.001) and further biliary events (OR = 15.95, p < 0.001).

CONCLUSIONS

Early cholecystectomy is recommended for patients aged ≥ 80 years with moderate to severe AC following PTGBD.

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.

Prognostic clinical indexes for prediction of acute gangrenous cholecystitis and acute purulent cholecystitis

Background

Preoperative prediction of severe cholecystitis (SC), including acute gangrenous cholecystitis (AGC) and acute purulent cholecystitis (APC), as opposed to acute exacerbation of chronic cholecystitis (ACC), is of great significance, as SC is associated with high mortality rate.

Methods

In this study, we retrospectively investigated medical records of 114 cholecystitis patients, treated in Shanghai No. 6 People’s Hospital from February 2009 to July 2020. Gallbladder wall thickness (GBWT), indexes of blood routine examination, including white blood cell (WBC), alkaline phosphatase (ALP), the percentage of neutrophil, alanine transaminase (ALT), aspartate aminotransferase (AST), fibrinogen (FIB), gamma-glutamyl transferase, prothrombin time and total bilirubin were evaluated. One-way analysis of variance (ANOVA) was used to evaluate significant differences between a certain kind of SC and ACC to select a prediction index for each kind of SC. Receiver operating characteristic (ROC) curve analysis was conducted to identify the prediction effectiveness of these indexes and their optimal cut-off values.

Results

Higher WBC and lower ALP were associated with AGC diagnosis (P < 0.05). Higher percentage of neutrophils was indicative of APC and AGC, while higher GBWT was significantly associated with APC diagnosis (P < 0.05) The optimal cut-off values for these indexes were established at 11.1*109/L (OR: 5.333, 95% CI 2.576–10.68, P < 0.0001, sensitivity: 72.73%, specificity: 66.67%), 79.75% (OR: 5.735, 95% CI 2.749–12.05, P < 0.0001, sensitivity: 77.92%, specificity: 61.9%) and 5.5 mm (OR: 22, 95% CI 4.757–83.42, P < 0.0001, sensitivity: 78.57%, specificity: 85.71%), respectively.

Conclusion

We established a predictive model for the differentiations of APC and AGC from ACC using clinical indexes, such as GBWT, the percentage of neutrophil and WBC, and determined cut-off values for these indexes based on ROC curves. Index values exceeding these cut-off values will allow to diagnose patients as APC and AGC, as opposed to a diagnosis of ACC.

Safe and effective short-time percutaneous cholecystostomy: A retrospective observational study

The introduction of percutaneous cholecystostomy (PCT) has shifted the paradigm in treatment of acute calculous and acalculous cholecystitis. PCT has high success and low complication rates, but there are still unresolved issues regarding the duration of the procedure. The aim of our study is to determine the characteristics and outcome of patients treated with short-term PCT drainage. Patients who were admitted to the Department of gastroenterology and the Department of Abdominal Surgery at the University Hospital Center Split under the diagnosis of acute cholecystitis and who were treated with the PCT, in a period between January 2015 and January 2020, were retrospectively included in the study. During that timeframe we identified 92 patients and have analyzed their characteristics and clinical outcomes. The statistical analysis included the Kaplan-Meier method for calculating survival curves for grades 2 and 3, the log-rank test for testing the difference between survival rates of grade 2 and 3 patients, and logistic regression to determine variables that affected the outcome of our patients. According to the Tokyo guidelines, most of the patients (74, 80.43%) met the criteria for grade 2 cholecystitis, and the minority had grade 1 (9, 9.78%) and grade 3 (9, 9.78%) cholecystitis. The average drainage duration was 10.1 ± 4.8 (3-28) days. We identified mild complications in 6 cases. Nine patients (10%) had lethal outcome. The mortality in the largest group of patients with grade 2 cholecystitis was 5.48% and as high as 71.43% in patients with grade 3 cholecystitis. The complication rate was 6.5%. One quarter of gallbladder aspirates showed a ciprofloxacin resistance. Short-time PCT lasting approximately 10 days can be used safely and effectively for the treatment of patients with acute cholecystitis.

Computed tomography-guided percutaneous cholecystostomy: a single institution's 6-year experience

BACKGROUND

Acute cholecystitis (AC) is an emergency commonly managed by a surgical department. The interventional part of the standard treatment algorithm includes laparoscopic or open cholecystectomy. Percutaneous cholecystostomy (PC) under imaging guidance is recommended as the first-line approach in the subset of high-risk patients for perioperative complications, as a bridging therapy to elective surgery or as a definitive solution. The aim of the present study was to evaluate the mortality and morbidity of PC performed under computed tomographic (CT) guidance in patients at high surgical risk.

METHODS

Medical and imaging records from all consecutive patients who underwent a CTPC between 2015 and 2020 were reviewed. Adult patients with a definite indication for CTPC were recruited and mortality 7 and 30 days post-procedure was recorded. Variables potentially affecting those outcomes were retrieved and included in our analysis.

RESULTS

Eighty-six consecutive patients at high risk for surgical management were identified and included in the present study. Most patients (58.1%) were diagnosed with AC, while 14 (16.3%) had concurrent AC and cholangitis, 13 (15.2%) gallbladder empyema, and 9 (10.4%) hydrops. The 7- and 30-day mortality rates were 16.3% (14/86) and 22.1% (19/86), respectively, and were significantly associated with patients' hospitalization in the intensive care unit (P<0.05). Other parameters investigated, such as age, sex, diagnosis, catheter diameter, and duration of hospital stay were not significantly associated with our primary outcome.

CONCLUSION

PC is a safe alternative to surgery in patients with high perioperative risk, thus providing acceptable mortality rates.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Percutaneous Image-Guided Biliary Procedures

Percutaneous biliary interventions are among the commonly performed nonvascular radiological interventions. Most common of these interventions is the percutaneous transhepatic biliary drainage for malignant biliary obstruction. Other biliary procedures performed include percutaneous cholecystostomy, biliary stenting, drainage for bile leaks, and various procedures like balloon dilatation, stenting, and large-bore catheter drainage for bilioenteric or post-transplant anastomotic strictures. Although these procedures are being performed for ages, no standard guidelines have been formulated. This article attempts at preparing guidelines for performing various percutaneous image-guided biliary procedures along with discussion on the published evidence in this field.

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.

Impact of B-mode-ultrasound-guided transhepatic and transperitoneal cholecystostomy tube placement on laparoscopic cholecystectomy

BACKGROUND

B-mode-ultrasound-guided percutaneous cholecystostomy (PC) may be performed by a transhepatic or transperitoneal approach, called percutaneous transhepatic gallbladder drainage (PHGD) and percutaneous transperitoneal gallbladder drainage (PPGD), respectively. We compared the impact of PC related to the route of catheter placement on subsequent laparoscopic cholecystectomy (LC).

AIM

To compare the impact of PC related to the route of catheter placement on subsequent LC.

METHODS

We retrospectively studied 103 patients with acute calculous cholecystitis who underwent scheduled LC after PC between January 2010 and January 2019. Group I included 58 patients who underwent scheduled LC after PHGD. Group II included 45 patients who underwent scheduled LC after PPGD. Clinical outcomes were analyzed according to each group.

RESULTS

Baseline demographic characteristics did not differ significantly between both groups (P > 0.05). Both PHGD and PPGD were able to quickly resolve cholecystitis sepsis. Group I showed significantly higher efficacy than group II in terms of lower pain score during puncture (3.1 vs 4.5; P = 0.001) and at 12 h follow-up (1.5 vs 2.2; P = 0.001), lower rate of fever within 24 h after PC (13.8% vs 42.2%; P = 0.001), shorted operation duration (118.3 vs 139.6 min; P = 0.001), lower amount of intraoperative bleeding (72.1 vs 109.4 mL; P = 0.001) and shorter length of hospital stay (14.3 d vs 18.0 d; P = 0.001). However, group II had significantly lower rate of local bleeding at the PC site (2.2% vs 20.7%; P = 0.005) and lower rate of severe adhesion (33.5% vs 55.2%; P = 0.048). No significant differences were noted between both groups regarding the conversion rate to laparotomy, rate of subtotal cholecystectomy, complications and pathology.

CONCLUSION

B-mode-ultrasound-guided PHGD is superior to PPGD followed by LC for treatment of acute calculous cholecystitis, with shorter operating time, minimal amount of intraoperative bleeding and short length of hospital stay.

Percutaneous Cholecystostomy Placement in Cases of Non-operative Cholecystitis: A Retrospective Cohort Analysis

BACKGROUND

Acute (calculous) cholecystitis (AC) is an extremely common surgical presentation, managed by cholecystectomy. Percutaneous cholecystostomy (PC) is an alternative; however, its safety and efficacy, along with subsequent cholecystectomy, are underreported in South Africa, where patients often present late and access to emergency operating theatre is constrained. The aim of the study was to demonstrate the outcomes of PC in patients with AC not responding to antimicrobials.

MATERIALS AND METHODS

A retrospective cohort review of patient records, who underwent PC in Groote Schuur Hospital, Cape Town, between May 2013 and July 2016, was performed. Patients with PC for malignancy or acalculous cholecystitis were excluded. Technical success, clinical response, procedure-related morbidity and mortality were recorded. Interval LC parameters were investigated.

RESULTS

Technical success and clinical improvement was seen in 29 of 37 patients (78.38%) who had PC. Malposition (8.11%) was the most common complication. Two patients required emergency surgery (5.4%), while one tube was dislodged. Median tube placement duration was 25 days (range 1-211). Post-procedure, 16 patients (43.24%) went on to have LC, of which 50% (eight patients) required conversion to open surgery and 25% (four) had subtotal cholecystectomy. Median surgical time was 130 min. There were no procedure-related mortalities but eight patients (21.62%) died in the 90-day period following tube insertion.

CONCLUSION

In patients with AC, PC is safe, with high technical success and low complication rate. Subsequent cholecystectomy should be performed, but is usually challenging. The requirement for PC may predict a more complex disease process.

Acute cholecystitis during COVID-19 pandemic: a multisocietary position statement

Following the spread of the infection from the new SARS-CoV2 coronavirus in March 2020, several surgical societies have released their recommendations to manage the implications of the COVID-19 pandemic for the daily clinical practice. The recommendations on emergency surgery have fueled a debate among surgeons on an international level.We maintain that laparoscopic cholecystectomy remains the treatment of choice for acute cholecystitis, even in the COVID-19 era. Moreover, since laparoscopic cholecystectomy is not more likely to spread the COVID-19 infection than open cholecystectomy, it must be organized in such a way as to be carried out safely even in the present situation, to guarantee the patient with the best outcomes that minimally invasive surgery has shown to have.

It Is Always Early with Point-of-Care Ultrasound

A 56-year-old male was admitted to the emergency department for acute pulmonary edema and septic shock, yet no clear source of infection was noted upon physical examination. Due to his unstable condition, bedside ultrasound was performed. A heterogeneous mass in the liver was noted; hence, a tentative diagnosis of liver abscess was made. The abscess was confirmed by abdominal magnetic resonance imaging. Drainage of the abscess was attempted and guided by early ultrasound. This case highlights that point-of-care ultrasound, when performed by an ultrasound-capable critical care physician, can significantly decrease the time to diagnosis for septic patients.

Emergent Treatment of Acute Cholangitis and Acute Cholecystitis

Acute pathology of the biliary tract including cholangitis and cholecystitis can lead to biliary sepsis if early decompression is not performed. This article provides an overview of the presenting signs and symptoms and role of interventional radiology in the management of patients with acute cholangitis or acute cholecystitis. It is especially important to understand the role of IR in the context of other treatment options including medical management, endoscopy, and surgery.

Clinical and Survival Outcomes Using Percutaneous Cholecystostomy Tube Alone or Subsequent Interval Cholecystectomy to Treat Acute Cholecystitis

BACKGROUND

Percutaneous cholecystostomy (PCT) is a safe method of gallbladder drainage in the setting of severe or complicated acute cholecystitis (AC), particularly in patients who are high-risk surgical candidates. Small case series suggest that PCT aids resolution of acute cholecystitis in up to 90% of patients. However, reluctance is observed in utilising PCT more frequently, due to concerns that we are committing comorbid patients to an interval surgical procedure for which they may not be suitable.

AIM

The aim of this study was to assess the clinical and survival outcomes of PCT use, with particular emphasis on a subgroup of patients who did not proceed to cholecystectomy.

METHODS

A retrospective analysis was performed of all patients with severe acute cholecystitis who required PCT insertion in a tertiary referral hospital from 2010 to 2015. Patient demographics and clinical data including systemic inflammatory response (SIRS) scores at presentation, readmissions and clinical and survival outcomes were analysed. Statistical analysis was performed using SPSS v.22 and GraphPad Prism v.7.

RESULTS

In total, 157 patients (59% males) with AC underwent PCT insertion during the study period. Median age at presentation was 71 years (range 29-94). A median SIRS score of 3 was noted at presentation. Patients required a median of two cholecystostomy tube changes/replacements (range 1-10) during treatment. Transhepatic tube placement was the preferred approach (69%) with 31% of tubes being placed via transabdominal approach. Only 55% proceeded to interval cholecystectomy. Of the 70 patients treated with PCT alone, their median age was 75 years. In this subgroup, only 12.9% (n = 9) developed recurrent biliary sepsis necessitating readmission following initial resolution of symptoms and tube removal. All episodes of recurrent biliary sepsis presented within 6 months of index presentation, and definitive PCT removal in this group was performed at a median of 3 months. No difference in survival was observed between both groups.

CONCLUSION

Almost 90% of patients with AC who are managed definitively with a PCT will recover uneventfully without recurrent sepsis following PCT removal. This is a viable option for older, comorbid patients who are unfit for surgical intervention and is not associated with significantly increased mortality.

The impact of delayed source control and antimicrobial therapy in 196 patients with cholecystitis-associated septic shock: a cohort analysis

Background

Cholecystitis-associated septic shock carries a significant mortality. Our aim was to determine whether timing of source control affects survival in cholecystitis patients with septic shock.

Methods

We conducted a nested cohort study of all patients with cholecystitis-associated septic shock from an international, multicentre database (1996–2015). Multivariable logistic regression was performed to determine associations between clinical factors and in-hospital mortality. The results were used to inform a classification and regression tree (CART) analysis that modelled the association between disease severity (APACHE II), time to source control and survival.

Results

Among 196 patients with cholecystitis-associated septic shock, overall mortality was 37%. Compared with nonsurvivors (n = 72), survivors (n = 124) had lower mean admission APACHE II scores (21 v. 27, p < 0.001) and lower median admission serum lactate (2.4 v. 6.8 μmol/L, p < 0.001). Survivors were more likely to receive appropriate antimicrobial therapy earlier (median 2.8 v. 6.1 h from shock, p = 0.012). Survivors were also more likely to undergo successful source control earlier (median 9.8 v. 24.7 h from shock, p < 0.001). Adjusting for covariates, APACHE II (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.06–1.21 per increment) and delayed source control > 16 h (OR 4.45, 95% CI 1.88–10.70) were independently associated with increased mortality (all p < 0.001). The CART analysis showed that patients with APACHE II scores of 15–26 benefitted most from source control within 16 h (p < 0.0001).

Conclusion

In patients with cholecystitis-associated septic shock, admission APACHE II score and delay in source control (cholecystectomy or percutaneous cholecystostomy drainage) significantly affected hospital outcomes.

Antibiotic use in patients with acute cholecystitis after percutaneous cholecystostomy

BACKGROUND

Currently, evidence regarding the strategies of antibiotic use in patients with acute cholecystitis after receiving percutaneous cholecystostomy is limited. Hence, we aimed to investigate the outcomes in patients with inoperable acute cholecystitis receiving narrow or broad-spectrum antibiotics after percutaneous cholecystostomy.

METHODS

A total of 117 patients receiving percutaneous cholecystostomy were categorized into moderate and severe acute cholecystitis defined by the Tokyo guideline and then divided into group A (narrow-spectrum antibiotic use) and group B (broad-spectrum antibiotic use). The clinical outcomes and complications were analyzed.

RESULTS

In moderate acute cholecystitis (n = 80), group A patients (n = 62) had similar early recurrent rate (11.3% vs 16.7%; p = 0.544) and a shorter length of hospital stay (13.4 ± 8.6 vs 18.6 ± 9.4 days; p = 0.009) as compared with group B patients (n = 18). No in-hospital mortality occurred in moderate acute cholecystitis. In severe acute cholecystitis (n = 37), both groups had similar length of hospital stay (16.3 ± 12.2 vs 20.9 ± 9.5 days; p = 0.051), early recurrent rate (0% vs 16.7%; p = 0.105), and in-hospital mortality rate (5.3% vs 16.7%; p = 0.340). Although group B patients with severe cholecystitis had higher serum levels of alkaline phosphatase (Alk-P) and higher proportion of underlying malignancy, American Society of Anesthesiologists (ASA) class IV and septic shock, the clinical outcomes were not inferior to patients in group A.

CONCLUSION

In moderate acute cholecystitis after percutaneous cholecystostomy, patients receiving narrow-spectrum antibiotics have comparable clinical outcomes as those treated with broad-spectrum antibiotics. However, in severe acute cholecystitis, broad-spectrum antibiotics might still be necessary to rescue these patients.

Percutaneous cholecystostomy as treatment for acute cholecystitis: What has happened over the last five years? A literature review

Acute cholecystitis is one of the most frequent diseases faced by the general surgeon. In recent decades, different prognostic factors have been observed, and effective treatments described, to improve the results in patients with said pathology (lower morbidity and mortality, shorter hospital stay, and minimum conversion of laparoscopic to open procedures). In general, laparoscopic cholecystectomy is the standard treatment for acute cholecystitis, but it is not exempt from complications, especially in patients with numerous comorbidities or those that are critically ill. Percutaneous cholecystostomy emerged as a less invasive alternative for the treatment of acute cholecystitis in patients with organ failure or a prohibitive surgical risk. Even though it is an effective procedure, its usefulness and precise indications are subjects of debate. In addition, there is little evidence on cholecystostomy catheter management. We carried out a review of the literature covering the main aspects physicians involved in the management of acute cholecystitis should be familiar with.

Advances in the management of acute cholecystitis

The diagnosis and management of acute cholecystitis (AC) continues to evolve. Among the most common surgically treated conditions in the USA, appropriate diagnosis and management of AC require astute clinical judgment and operative skill. Useful diagnostic and grading systems have been developed, most notably the Tokyo guidelines, but some recent clinical validation studies have questioned their generalizability to the US population. The timing of surgical intervention is another area that requires further investigation. US surgeons traditionally pursue laparoscopic cholecystectomy (LC) for AC patients with symptoms onset <72 hours, but for patients with symptoms over 72 hours, surgeons often elect to treat the patients with antibiotics and delay LC for 4-6 weeks to permit the inflammation to subside. This practice has recently been called into question, as there are data suggesting that LC even for AC patients with over 72 hours of symptoms confers decreased morbidity, shorter length of stay, and reduced overall healthcare costs. Finally, the role of percutaneous cholecystostomy (PC) needs to be better defined. Traditional role of PC is a temporizing measure for patients who are poor surgical candidates. However, there are data suggesting that in AC patients with organ failure, PC patients suffered higher mortality and readmission rates when compared with a propensity-matched LC cohort. Beyond diagnosis, the surgical management of AC can be remarkably challenging. All surgeons need to be familiar with best-practice surgical techniques, adjunct intra-operative imaging, and bail-out options when performing LC.

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.

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.

Early percutaneous cholecystostomy versus antibiotic treatment for mild and moderate acute cholecystitis: A retrospective cohort study

BACKGROUND

Percutaneous cholecystostomy (PC) is an effective treatment for severe acute cholecystitis (AC). Guidelines recommend PC as rescue therapy for patients with mild or moderate AC who do not receive emergent cholecystectomy. This study aims to investigate whether PC could be a first-line treatment for these patients.

METHODS

Adult patients admitted through the emergency department between October 2004 and December 2013 were retrospectively reviewed. Patients with mild or moderate AC who did not undergo emergent cholecystectomy were included. Early PC was defined as a PC tube inserted within 24 h of diagnosis. The outcomes were compared between patients who received antibiotics plus early PC (early PC group) and those who received antibiotic treatment alone (antibiotic group).

RESULTS

A total of 698 patients were included. The mean age was 63.4 years. There were 171 patients in the early PC group and 527 patients in the antibiotic group. Multivariable logistic regression analyses indicated that early PC was significantly associated with a decreased rate of prolonged fever (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.16-0.57; p < 0.001). Early PC also correlated with both increased short-term (OR, 15.95; 95% CI, 5.73-44.38; p < 0.001) and long-term treatment success (OR, 4.27; 95% CI, 2.55-7.15; p < 0.001).

CONCLUSION

For patients with mild/moderate AC without emergent cholecystectomy, early PC might expedite sepsis resolution and improve the treatment success rate compared with antibiotic treatment alone. This result should be deemed as hypothesis-generating and should be examined in a randomized controlled trial.

Efficacy and Safety of Lumen Apposing Self-Expandable Metal Stents for EUS Guided Cholecystostomy: A Meta-Analysis and Systematic Review

BACKGROUND

Patients with acute cholecystitis are treated with early cholecystectomy. A subset of patients are unfit for surgery due to comorbidities and late presentation. Prompt gall bladder drainage (GBD) with percutaneous or endoscopic approach remains a viable therapeutic option for nonoperative candidates. Endoscopic ultrasound (EUS) guided transluminal gall bladder drainage (EUS-GBD) continues to evolve as an alternative approach to percutaneous drainage. With continued refinement in stent technology, lumen apposing self-expandable metal stent (LAMS) offers several advantages. We performed a pooled analysis on the efficacy and safety of EUS-GBD with LAMS in nonoperative candidates with acute cholecystitis.

METHODS

Extensive English language literature search was performed in Medline, Embase, Cochrane Central, and Google Scholar using keywords "endoscopic ultrasound", "stent", "gallbladder", "acute cholecystitis", and "cholecystostomy" from Jan 2000 to Dec 2016. Fixed and random effects models were used to calculate the pooled proportions.

RESULTS

Data was extracted from 13 studies that met the inclusion criteria (n = 233). Pooled proportion of technical success was 93.86% (95% CI = 90.56 to 96.49) and clinical success was 92.48% (95% CI = 88.9 to 95.42). Overall complication rate was 18.31% (95% CI = 13.49 to 23.68) and stent related complication rate was 8.16% (95% CI = 4.03 to 14.96) in the pooled percentage of patients. Pooled proportion for perforation was 6.71% (95% CI 3.65 to 10.6) and recurrent cholangitis/cholecystitis was noted in 4.05% (95% CI = 1.64 to 7.48). Publication bias calculated using Harbord-Egger bias indicator gave a value of -0.61 (95%  CI = -1.39 to 0.16, p = 0.11). The Begg-Mazumdar indicator for bias gave Kendall's tau b value of -0.42 (p ≥ 0.05).

CONCLUSIONS

EUS-GBD with LAMS is a safe and alternative treatment modality for patients needing gallbladder drainage, with acceptable intraprocedural and postprocedural complications. However, due to the limited data and lack of direct comparison with other methods, further controlled trials are necessary to estimate the overall efficacy and safety and the role of EUS-GBD with LAMS in management of nonoperative patients with acute cholecystitis.

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.

Management of acute cholecystitis

PURPOSE OF REVIEW

Various aspects of the management of acute calculous cholecystitis, including type and timing of surgery, role of antibiotics, and nonoperative management, remain controversial. This review focuses on recently published studies addressing the timing of cholecystectomy, use of cholecystostomy tubes, and role of antibiotics in this condition.

RECENT FINDINGS

In most cases, the diagnosis of acute cholecystitis can be initially confirmed with an abdominal ultrasound. Early laparoscopic cholecystectomy (within 24-72 h of symptom onset) is better than delayed surgery (>7 days) for most patients with grade I and II diseases. Percutaneous cholecystostomy and novel endoscopic gallbladder drainage interventions may be used as a temporizing measure or as definitive therapy in those who are too sick to undergo surgery. Studies are conflicting as to whether antibiotics are required for the treatment of uncomplicated cases.

SUMMARY

Cholecystectomy remains the only definitive therapy for acute cholecystitis. Current guidelines recommend treatment on the basis of disease severity at presentation. Antibiotics and a variety of minimally invasive nonsurgical interventions, although not definitive, play an adjunctive role in the management of the disease.

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.

Percutaneous Cholecystostomy: Evidence-Based Current Clinical Practice

The role of percutaneous cholecystostomy (PC) in the management of acute cholecystitis and cholangitis is outlined in the revised 2013 Tokyo Guidelines. These two emergencies constitute the vast majority of PC performed today for therapeutic purposes, and research has repeatedly shown the utility of PC in these conditions. PC is typically employed in the management of critically ill patients who are not surgical candidates. Indications and contraindications to PC are reviewed. Additional innovative applications of PC have been developed since it was first described in 1980. These include biliary drainage, dilation of biliary strictures, and stenting of the biliary tree including the common bile duct. Special consideration must be given to the patient selection criteria when deciding who can benefit from PC. Patient comorbidities can also influence the PC technique employed. Both transhepatic and transperitoneal approaches have distinct advantages and disadvantages. The technical success rate for PC is 95 to 100% and the complication rate is extremely low. Most complications are minor.