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

Part 1: Current Concepts in Radiologic Imaging and Intervention in Acute Cholecystitis

Acute calculous cholecystitis and acute acalculous cholecystitis are encountered commonly among critically ill, often elderly, patients. Multidisciplinary management of these conditions is essential, with intensivists, surgeons, diagnostic radiologists, interventional radiologists, infectious disease physicians, gastroenterologists, and endoscopists able to contribute to patient care. In this article intended predominantly for intensivists, we will review the imaging findings and radiologic treatment of critically ill patients with acute calculous cholecystitis and acute acalculous cholecystitis.

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.

The impact of interval cholecystectomy timing after percutaneous transhepatic cholecystostomy on post-operative adverse outcomes

OBJECTIVE

This study aims to explore how timing of interval of cholecystectomy (IC) after percutaneous transhepatic cholecystostomy tube (PTC) placement impacts post-operative outcomes.

METHODS

A retrospective database analysis of New York State SPARCs database of IC between 2005 and 2015. The timing for IC ranged between > 1 week and < 2 years. Patients undergoing this procedure were further divided into quartiles using 4-time intervals; 1-5 weeks (Q1), 5-8 weeks (Q2), 8-12 weeks(Q3), and > 12 weeks(Q4). The study's primary outcome was hospital length of stay (LOS). Secondary outcomes included discharge status, 30-day readmission, 30-day ED visit, and 90-day reoperation, surgery type, complication, and bile duct injury. Multivariable regression models were used to compare patients across the four-time intervals after adjusting for confounding factors.

RESULTS

A total of 1038 patients with a history of PTC followed by IC between > 1 week and < 2 years were included in the final analysis. The median time to IC was 7.7 weeks. Q2 and Q3 both had a significantly higher median LOS of 3 days versus Q1 and Q4 at median of 5 days (p < 0.0001). Patients from racial and ethnic minorities (e.g., African Americans and Hispanics) were more likely to get their IC after 12 weeks (p < 0.05). Further, Black patients had a significantly higher median LOS than White, non-Hispanic patients (8 days vs 4 days, p < 0.0001) and were more likely to have open procedure. Multivariable regression analysis identified shorter LOS during Q2 (Ratio, 0.76, 95%, 0.67-0.87, p < 0.0001), and Q3 (Ratio 0.75, 95% CI, 065-0.86, p < 0.0001) compared to those who got their IC in Q4. Similar findings exist when comparing Q2 and Q3 to those receiving treatment during Q1.

CONCLUSION

A time interval of 5-12 weeks between PTC and IC was associated with a decreased LOS. This study also suggests the persistence of racial disparities among these patients.

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.

Percutaneous cholecystostomy: techniques and applications

Acute cholecystitis (AC) is a critical condition requiring immediate medical attention and treatment and is one of the most frequently encountered acute abdomen emergencies in surgical practice, requiring hospitalization. Laparoscopic cholecystectomy is considered the favored treatment for patients with AC who are fit for surgery. However, in high-risk patients considered poor surgical candidates, percutaneous cholecystostomy (PC) has been suggested and employed as a safe and reliable alternative option. PC is a minimally invasive, nonsurgical, image-guided intervention that drains and decompresses the gallbladder, thereby preventing its perforation and sepsis. It can act as a bridge to surgery, but it may also serve as a definitive treatment for some patients. The goal of this review is to familiarize physicians with PC and, more importantly, its applications and techniques, pre- and post-procedural considerations, and adverse events.

ACUTE CHOLECYSTITIS IN HIGH-RISK PATIENTS. SURGICAL, RADIOLOGICAL, OR ENDOSCOPIC TREATMENT? BRAZILIAN COLLEGE OF DIGESTIVE SURGERY POSITION PAPER

Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as empyema, gangrene, perforation of the gallbladder, and sepsis. The gold standard treatment for AC is laparoscopic cholecystectomy. However, for a small group of AC patients, the risk of laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these critically ill patients, percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to cholecystectomy. The objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons, endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological, and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise; c) Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous or endoscopic gallbladder drainage is not available; d) Percutaneous cholecystostomy and endoscopic gallbladder drainage should be performed only in well-equipped hospitals with experienced interventional radiologist and/or endoscopist; e) Cholecystostomy catheter should be removed after resolution of AC. However, in patients who have no clinical condition to undergo cholecystectomy, the catheter may be maintained for a prolonged period or even definitively; f) If the cholecystostomy catheter is maintained for a long period of time several complications may occur, such as bleeding, bile leakage, obstruction, pain at the insertion site, accidental removal of the catheter, and recurrent AC; g) The ideal waiting time between cholecystostomy and cholecystectomy has not yet been established and ranges from immediately after clinical improvement to months. h) Long waiting periods between cholecystostomy and cholecystectomy may be associated with new episodes of acute cholecystitis, multiple hospital readmissions, and increased costs. Finally, when selecting the best treatment option other aspects should also be considered, such as costs, procedures available at the medical center, and the patient's desire. The patient and his family should be fully informed about all treatment options, so they can help making the final decision.

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.

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.

Percutaneous Cholecystostomy Tubes versus Medical Management for Acute Cholecystitis

BACKGROUND

Cholecystitis is one of the most common infections treated surgically in the United States. Surgical risk is prohibitive in some patients, leading to alternative therapeutic strategies, including medical management (antibiotics) with or without percutaneous cholecystostomy tube (PCT) drainage.

MATERIALS AND METHODS

Using the Healthcare Cost and Utilization Project (HCUP) National Readmission Database (NRD), we performed a retrospective review to compare medically managed patients with or without PCT placement by evaluating 60-day readmissions rates, health care costs, and hospital length of stay (LOS). Both study groups were matched using the Elixhauser comorbidity index, age, and sex. Univariate and multivariate statistical analyses were performed using STATA.

RESULTS

776,766 patients were included in the analysis. The population receiving PCT placement was on average 16 years older (69.9 vs 53.6 years; P < .01), less likely to be female (40.7% vs 59.3%; P < .01), and had almost twice as many comorbidities (3.36 vs 1.81; P < .01) compared to the population receiving medical management. After matching our data to account for these incongruities, PCT patients were still 10.4 times more likely to be readmitted, had a 11.6% increase in the cost of care, and a 37.6% increase in LOS compared to those managed medically.

DISCUSSION

Percutaneous cholecystostomy tube placement for cholecystitis is associated with a higher readmission rate, increased charges, and increased LOS compared to antibiotic therapy alone, even after correcting for age, sex, and comorbidities.

Percutaneous Cholecystostomy Tube for Acute Cholecystitis: Quantifying Outcomes and Prognosis

BACKGROUND

Percutaneous cholecystostomy tubes (PCT) are utilized in the management of acute cholecystitis in patients deemed unsuitable for surgery. However, the drive for these decisions and the outcomes remain understudied. We sought to characterize the practices and utilization of PCT and evaluate associated outcomes at an urban medical center.

METHODS

Patients undergoing PCT placement over a 12-y study period ending May 2019 were reviewed. Demographics, clinical presentation, labs, imaging studies, and outcomes were abstracted. The primary and secondary outcomes were 30-d mortality and interval cholecystectomy, respectively.

RESULTS

Two hundred and four patients met inclusion criteria: 59.3% were male with a median age of 67.5 y and a National Surgical Quality Improvement Program (NSQIP) risk of serious complication of 8.0%. Overall, 57.8% of patients were located in an intensive care unit setting. The majority (80.9%) had an ultrasound and 48.5% had a hepatobiliary iminodiacetic acid scan. The overall 30-d mortality was 31.9%: 41.5% for intensive care unit and 18.6% for ward patients (P < 0.01). Of patients surviving beyond 30 d (n = 139), the PCT was removed from 106 (76.3%), and a cholecystectomy was performed in 55 (39.6%) at a median interval of 58.0 d. A forward logistic regression identified total bilirubin (Adjusted Odds Ratio: 1.12, adjusted P < 0.01) and NSQIP risk of serious complication (Adjusted Odds Ratio: 1.16, adjusted P < 0.01) as the only predictors for 30-d mortality.

CONCLUSIONS

Patients selected for PCT placement have a high mortality risk. Despite subsequent removal of the PCT, the majority of surviving patients did not undergo an interval cholecystectomy. Total bilirubin and NSQIP risk of serious complication are useful adjuncts in predicting 30-d mortality in these patients.

Patterns of care after cholecystostomy tube placement

BACKGROUND

The use of cholecystostomy (c-tube) in acute cholecystitis (AC) has increased yet there is limited evidence to guide surgical decision-making after placement. As a result, there is variability in the use and timing of cholecystectomy after c-tube. We aimed to describe patient characteristics, outcomes, and biliary-related utilization in those who did and did not have cholecystectomy after c-tube.

METHODS

This is a retrospective cohort study (2007-2017) using the MarketScan® claims database of patients (18-63 years) with at least 3 months of follow-up (or death). ICD-9/10 and CPT codes were used to identify AC, c-tube placement, cholecystectomy and determine Elixhauser comorbidity index.

RESULTS

A total of 2386 patients (47.5% female, mean age 52.5 [SD 9.9] years) with AC underwent c-tube with an 11.2% 90-day mortality. Among survivors, by three months 57% underwent cholecystectomy (mean 34.8 days [95% CI: 33.3-36.3]). Cholecystectomy after c-tube was more common in those with fewer comorbid conditions (mean 2.41 [95% CI: 2.26-2.56] vs 4.56 [95%CI: 4.36-4.76]). Biliary episodes prior to cholecystectomy occurred in 12.5% and were associated with eventual cholecystectomy (HR 1.49 [1.32-1.68]). Biliary-specific hospital and ICU days were similar between groups. Biliary-specific ED visits were more common among patients with cholecystectomy (mean 1.39 [95% CI: 1.29-1.48] vs 0.94 [95% CI: 0.85-1.03]).

CONCLUSION

More than half of patients treated with c-tube underwent cholecystectomy by three months-most within five weeks of AC diagnosis. The high frequency of use and short time to cholecystectomy after c-tube raises questions about potential overuse of c-tube in the initial period. Future work should aim to understand how patient experience and indication for c-tube influence the likelihood and timing of subsequent cholecystectomy.

Image-guided percutaneous cholecystostomy: a comprehensive review

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

Healthcare Disparities in the Management of Acute Cholecystitis: Impact of Race, Gender, and Socioeconomic Factors on Cholecystectomy vs Percutaneous Cholecystostomy

BACKGROUND

While percutaneous cholecystostomy (PC) is a recommended treatment strategy in lieu of cholecystectomy (CCY) for acute cholecystitis among patients who may not be considered good surgical candidates, reports on disparities in treatment utilization remain limited. The aim of this study was to investigate the role of demographic, clinical, and socioeconomic factors in treatment of acute cholecystitis.

METHODS

Patients with a diagnosis of acute cholecystitis who underwent CCY versus PC were reviewed from the U.S. Nationwide Inpatient Sample (NIS) database between 2008-2014. Measured variables including age, race/ethnicity, Charlson comorbidity index (CCI), hospital type/region, insurance payer, household income, length of stay (LOS), hospital cost, and mortality were compared using chi-square and ANOVA. Multivariable logistic regression was performed to identify specific predictors of cholecystitis treatment.

RESULTS

A total of 1,492,877 patients (CCY:n=1,435,255 versus PC:n=57,622) were analyzed. The majority of patients that received PC were at urban teaching hospitals (65.2%). LOS was significantly longer with higher associated costs for PC [(11.1±11.0 versus 4.5±5.3 days; P<0.001) and ($99577±138850 versus $48399±58330; P<0.001)]. Mortality was also increased for patients that received PC compared to CCY (8.8% versus 0.6%; P<0.001). Multivariable regression demonstrated multiple socioeconomic and healthcare-related factors influencing the utilization of PC including male gender, Black or Asian race/ethnicity, Medicare payer status, urban hospital location, and household income (all P<0.001).

CONCLUSION

Although patients receiving PC had higher CCI scores, multiple socioeconomic and healthcare related factors appeared to also influence this treatment decision. Additional studies to investigate these disparities are indicated to improve outcomes for all individuals with this condition.

[Emergency Surgery and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeons]

La infección por el nuevo coronavirus SARS-CoV-2 (enfermedad por coronavirus 2019 [COVID-19]) ha determinado la necesidad de la reorganización de muchos centros hospitalarios en el mundo. España, como uno de los epicentros de la enfermedad, ha debido asumir cambios en la práctica totalidad de su territorio. Sin embargo, y desde el inicio de la pandemia, en todos los centros que atienden urgencias quirúrgicas ha sido necesario el mantenimiento de su cobertura, aunque igualmente ha sido inevitable introducir directrices especiales de ajuste al nuevo escenario que permitan el mantenimiento de la excelencia en la calidad asistencial. Este documento desarrolla una serie de indicaciones generales para la cirugía de urgencias y la atención al politraumatizado desarrolladas desde la literatura disponible y consensuadas por un subgrupo de profesionales desde el grupo general Cirugía-AEC-COVID-19. Estas medidas van encaminadas a contemplar un riguroso control de la exposición en pacientes y profesionales, a tener en cuenta las implicaciones de la pandemia sobre diferentes escenarios perioperatorios relacionados con la urgencia y a una adaptación ajustada a la situación del centro en relación con la atención a pacientes infectados.