Percutaneous cholecystostomy in critically ill patients: early response and final outcome in 82 patients

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.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

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.

Gallbladder: Role of Interventional Radiology

Percutaneous cholecystostomy is an established procedure for the management of patients with acute cholecystitis and with significant medical comorbidities that would make laparoscopic cholecystectomy excessively risky. In this review, we will explore the role of percutaneous cholecystostomy in the management of acute cholecystitis as well as other applications in the management of biliary pathology. The indications, grading, technical considerations, and postprocedure management in the setting of acute cholecystitis are discussed. In addition, we will discuss the potential role of percutaneous cholecystostomy in the management of gallstones and biliary strictures, in establishing internal biliary drainage, and in a joint setting with other clinicians such as gastroenterologists in the management of complex biliary pathology.

Comparing outcomes of percutaneous cholecystostomy drain placement between patients within and outside of Tokyo guidelines diagnostic criteria for acute cholecystitis

OBJECTIVE

To compare outcomes following percutaneous cholecystostomy drain placement based on presence or absence of Tokyo Guidelines diagnostic criteria for acute cholecystitis.

METHODS

Chart review was performed to identify the presence or absence of Tokyo Guidelines diagnostic criteria for acute cholecystitis in 146 patients who underwent percutaneous cholecystostomy between 2012 and 2015. Those who met criteria were compared to those who did not in terms of demographics, laboratory values, drain indwelling time, treatment response, eventual surgical management, and 30-day mortality.

RESULTS

94 patients (64%) met Tokyo Guidelines diagnostic criteria, while 52 did not (36%). Patients within criteria had a shorter mean length of stay (13.5 days vs 18.9 days), were more likely to have a positive gallbladder fluid culture (64.5% vs 28.6%), demonstrated greater response to treatment (87.2% vs 32.7%), and had lower 30-day mortality (6.4% vs 37.8%). There was no significant difference in terms of ICU requirement (38.3% vs 38.9%), mean drain indwelling time (58.8 days vs 65.3 days), eventual laparoscopic cholecystectomy (40.4% vs 25.0%), or open cholecystectomy performed (9.5% vs 9.6%).

CONCLUSION

Patients outside of Tokyo Guidelines diagnostic criteria for acute cholecystitis were less likely to respond to treatment with percutaneous cholecystostomy and had worse outcomes. Further research may be indicated to better define the indications for percutaneous cholecystostomy placement in this group.

All the World Is a Nail: Why Are Surgeons Resistant to Learn How to Place Cholecystostomy Drains in Seriously Ill Patients With Acute Acalculous Cholecystitis?

Surgeons routinely provide palliative care, but often the technical procedure needed for the palliative intervention is beyond our training and comfort zone. This case is an example of surgical palliative care that utilizes image-guided techniques to provide optimal care. A frail elderly patient with multiple comorbidities who had been hospitalized for other diseases was diagnosed with acute acalculous cholecystitis. General surgery and gastroenterology were initially consulted, and the patient was referred to interventional radiology for a percutaneous cholecystostomy. The procedure was technically successful, and the patient's clinical status improved. A few days later, a follow-up cholecystogram showed a decompressed gallbladder, patent cystic duct, a common bile duct free of stones, and dilute contrast in the duodenum. After 2 weeks, the fistula tract was interrogated and found to be intact. The cholecystostomy tube was removed without incident. This case is presented as a call to action for surgeons to learn the skills required to place percutaneous cholecystostomies themselves and to add it to their surgical armamentarium.

Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound-Guided Gallbladder Drainage

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

Long-term outcome and recurrence factors after percutaneous cholecystostomy as a definitive treatment for acute cholecystitis

BACKGROUND AND AIM

Percutaneous cholecystostomy (PC) has been frequently used as an alternative treatment for acute cholecystitis in seriously ill patients unfit for surgery. The aim of this study was to investigate the recurrence rate and risk factors of recurrence.

METHODS

Medical records of 102 patients who were followed up for more than 1 year after PC tube removal among 716 patients who underwent PC for acute cholecystitis treatment were retrospectively analyzed.

RESULTS

The recurrence rate of acute cholecystitis after PC tube removal was 20.6% (21/102), and the mean time to recur was 660 days. Underlying cancer (odds ratio [OR]: 3.369; 95% confidence interval [CI]: 1.006-11.282; P = 0.0489), PC duration shorter than 44 days (OR: 5.596; 95% CI: 1.35-23.201; P = 0.0176), and the presence of common bile duct stone in initial imaging studies (OR: 24.393; 95% CI: 2.696-220.746; P = 0.0045) were positively correlated with recurrence. Tubogram before PC tube removal did not significantly lower the recurrence. However, PC tube clamping for several days significantly lowered the recurrence (OR: 0.108; 95% CI: 0.015-0.794; P = 0.0288). Fifty-nine (57.8%) had acalculous cholecystitis. Calculous cholecystitis was negatively correlated with recurrence (OR: 0.267; 95% CI: 0.074-0.967; P = 0.0444). Receiver operating characteristic curve of the prediction model for recurrence verified its accuracy (area under the curve: 0.8475).

CONCLUSION

We should try to keep PC more than 6 weeks and clamp for 1-2 weeks before removal. For those with the presence of common bile duct stones, calculous cholecystitis, and underlying malignancy, we should keep PC for longer duration and carefully observe symptoms and signs of recurrence.

Percutaneous Cholecystostomy Versus Conservative Treatment for Acute Cholecystitis: a Cohort Study

BACKGROUND

Percutaneous cholecystostomy is frequently used as a treatment option for acute calculous cholecystitis in patients unfit for surgery. There is sparse evidence on the long-term impact of cholecystostomy on gallstone-related morbidity and mortality in patients with acute calculous cholecystitis. This study describes the long-term outcome of acute calculous cholecystitis following percutaneous cholecystostomy compared to conservative treatment.

METHODS

This was a cohort study of patients admitted at our institution from 2006 to 2015 with acute calculous cholecystitis without early or delayed cholecystectomy. Endpoints were gallstone-related readmissions, recurrent cholecystitis, and overall mortality.

RESULTS

The investigation included 201 patients of whom 97 (48.2%) underwent percutaneous cholecystostomy. Patients in the cholecystostomy group had significantly higher age, comorbidity level, and inflammatory response at admission. The median duration of catheter placement in the cholecystostomy group was 6 days. The complication rate of cholecystostomy was 3.1% and the mortality during the index admission was 3.5%. The median follow-up was 1.6 years. The rate of gallstone-related readmissions was 38.6%, and 25.3% had recurrence of cholecystitis. Cox regression analyses revealed no significant differences in gallstone-related readmissions, recurrence of acute calculous cholecystitis, and overall mortality in the two groups.

CONCLUSIONS

Percutaneous cholecystostomy in the treatment of acute calculous cholecystitis was neither associated with long-term benefits nor complications. Based on the high gallstone-related readmission rates of this study population and todays perioperative improvements, we suggest rethinking the indications for non-operative management including percutaneous cholecystostomy in acute calculous cholecystitis.

Emergency Cholecystectomy Versus Percutaneous Cholecystostomy for Treatment of Acute Cholecystitis in High-Risk Surgical Patients

Our aim is to present our experience with laparoscopic cholecystectomy (LC) and percutaneous cholecystostomy (PC) in high-risk patients with acute cholecystitis (AC). The guidelines for AC are still debatable for high-risk patients. We aimed to emphasize the role of LC as a primary treatment method in patients with severe AC instead of a treatment after PC according to the Tokyo Guidelines (TG). AC patients with high surgical risk [American Society of Anesthesiologists (ASA) III-IV] who were admitted to our department between March 2008 and November 2014 were retrospectively evaluated. Disease severity in all patients was assessed according to the 2007 TG for AC. Patients were either treated by emergency LC (group LC) or PC (group PC). Demographic data, ASA scores, treatment methods, rates of conversion to open surgery, duration of drainage, length of hospital stay, and morbidity and mortality rates were compared among groups. Age, ASA score, and TG07 severity scores in the PC group were significantly higher than that in the LC group (P < 0.001, P < 0.001, and P < 0.001, respectively). Sex distribution (P = 0.33), follow-up periods (P = 0.33), and morbidity (P = 0.86) were similar. In the patients with early surgical intervention, mortality was significantly lower (P < 0.001). Length of hospital stay was significantly shorter in the LC group compared with the PC group (P < 0.001). In high-risk surgical patients, PC can serve as an alternative treatment method because of its efficiency in the prevention of sepsis-related complications due to AC. However, LC still should be an option for severe AC with comparable short-term results.

Hemorrhagic Cholecystitis after Warfarin Use for Deep Vein Thrombosis

Hemorrhagic cholecystitis is an uncommon form of acute cholecystitis which can be rapidly fatal. It may be hard to detect as it frequently presents with symptoms found in other, more common diagnoses. We report the case of a 63 year old man recently started on anticoagulation for deep vein thrombosis who was found to have hemorrhagic cholecystitis.

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

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

Routine surveillance cholangiography after percutaneous cholecystostomy delays drain removal and cholecystectomy

INTRODUCTION

Percutaneous cholecystostomy (PC) is often performed for patients with acute cholecystitis who are at high risk for operative morbidity and mortality. However, the necessity for routine cholangiography after PC remains unclear. We hypothesized that routine surveillance cholangiography (RSC) after PC would provide no benefit compared to on-demand cholangiography (ODC) triggered by signs or symptoms of biliary pathology.

METHODS

We performed a 3-year retrospective cohort analysis of patients managed with PC for acute cholecystitis at two tertiary care hospitals. Patients who had routine surveillance cholangiography (RSC, n = 43) were compared to patients who had on-demand cholangiography (ODC, n = 41) triggered by recurrent biliary disease.

RESULTS

RSC and ODC groups were similar by severity of acute cholecystitis, presence of gallstones, systemic inflammatory response syndrome (SIRS) criteria at the time of PC, SIRS criteria 72 hours after PC, and hospital length of stay. Two patients in the ODC group developed clinical indications for cholangiography. All 44 RSC patients had cholangiography, and 67 total cholangiograms were performed in this group. Surveillance cholangiography identified six patients (14%) with cystic duct filling defect and seven patients (16%) with a common bile duct filling defect, all of whom were asymptomatic. Fifteen patients (35%) in the RSC group had 32 ERCP procedures; five patients (12%) in the ODC group had 7 ERCPs (p = 0.021). The ODC group had fewer days to drain removal (35 vs. 61, p < 0.001) and days to cholecystectomy (39 vs. 81, p = 0.005). Rates of recurrent cholecystitis, cholangitis, gallstone pancreatitis, drain removal, and cholecystectomy were similar between groups.

CONCLUSION

RSC after PC for acute cholecystitis identified biliary pathology in asymptomatic patients and propagated further testing, but did not provide clinical benefit. ODC was associated with earlier drain removal, earlier cholecystectomy, and decreased resource utilization.

LEVEL OF EVIDENCE

Prognostic study, level III; therapeutic study, level IV.

Acalculous Cholecystitis in Burn Patients: Is There a Role for Percutaneous Cholecystostomy?

Although acute acalculous cholecystitis is uncommon in burn patients, this condition can be rapidly fatal due to delays in diagnosis and treatment and should always be considered in the differential diagnosis when burn patients become septic, develop abdominal pain, or have hemodynamic instability. This article reviews the use of percutaneous cholecystostomy in burn patients as both a diagnostic and therapeutic intervention.

Percutaneous cholecystostomy versus laparoscopic cholecystectomy in patients with acute cholecystitis and failed conservative management: a matched-pair analysis

INTRODUCTION

The role of percutaneous cholecystostomy (PC) or laparoscopic cholecystectomy (LC) in the management of patients with acute cholecystitis presenting beyond 72 hours from the onset of symptoms is unclear and undefined. The aim of this study was to examine and compare the outcomes of PC or LC in the management of these patients, who failed 24 hours of initial nonoperative management.

PATIENTS AND METHODS

A retrospective chart review between January 1999 and October 2010 revealed 261 patients with acute calculus cholecystitis beyond 72 hours from onset of symptoms who failed initial nonoperative management. Twenty-three of 261 (8.8%) underwent PC and were compared with a similar 1:1 matched cohort of LC, matched using sex, age, race, BMI, diabetes, and sepsis to minimize the influence of treatment selection bias.

RESULTS

There was no significant difference between PC versus LC regarding morbidity [4/23 (17%) vs. 2/23 (9%), P=0.665] and mortality [3/23 (13%) vs. 0/23 (0%), P=0.233]. The length of hospital stay was significantly longer in the PC group (15.9±12.6 vs. 7.6±4.9 d, P=0.005).

CONCLUSION

In this matched cohort analysis, PC failed to show a significant reduction in morbidity compared with LC and was associated with a significantly longer hospital stay.

The safety and efficacy of percutaneous transhepatic gallbladder drainage in elderly patients with acute cholecystitis before laparoscopic cholecystectomy

PURPOSE

Laparoscopic cholecystectomy (LC) is the standard management for acute cholecystitis. Percutaneous transhepatic gallbladder drainage (PTGBD) may be an alternative interim strategy before surgery in elderly patients with comorbidities. This study was designed to evaluate the safety and efficacy of PTGBD for elderly patients (>60 years) with acute cholecystitis.

METHODS

We reviewed consecutive patients diagnosed with acute cholecystitis between January 2009 and December 2013. Group I included patients who underwent PTGBD, and patients of group II did not undergo PTGBD before LC.

RESULTS

All 116 patients (72.7 ± 7.1 years) were analyzed. The preoperative details of group I (n = 39) and group II (n = 77) were not significantly different. There was no significant difference in operative time (P = 0.057) and intraoperative estimated blood loss (P = 0.291). The rate of conversion to open operation of group I was significantly lower than that of group II (12.8% vs. 32.5%, P < 0.050). No significant difference of postoperative morbidity was found between the two groups (25.6% vs. 26.0%, P = 0.969). In addition, perioperative mortality was not significantly different. Preoperative hospital stay of group I was significantly longer than that of group II (10.3 ± 5.7 days vs. 4.4 ± 2.8 days, P < 0.050). However, two groups were not significantly different in total hospital stay (16.3 ± 9.0 days vs. 13.4 ± 6.5 days, P = 0.074).

CONCLUSION

PTGBD is a proper preoperative management before LC for elderly patients with acute cholecystitis.

Prevention and management of infectious complications of percutaneous interventions

Infectious complications following interventional radiology (IR) procedures can cause significant patient morbidity and, potentially, mortality. As the number and breadth of IR procedures grow, it becomes increasingly evident that interventional radiologists must possess a thorough understanding of these potential infectious complications. Furthermore, given the increasing incidence of antibiotic-resistant bacteria, emphasis on cost containment, and attention to quality of care, it is critical to have infection control strategies to maximize patient safety. This article reviews infectious complications associated with percutaneous ablation of liver tumors, transarterial embolization of liver tumors, uterine fibroid embolization, percutaneous nephrostomy, percutaneous biliary interventions, central venous catheters, and intravascular stents. Emphasis is placed on incidence, risk factors, prevention, and management. With the use of these strategies, IR procedures can be performed with reduced risk of infectious complications.

Acute acalculous cholecystitis in the critically ill: risk factors and surgical strategies

PURPOSE

Acute acalculous cholecystitis (AAC) is characterized by severe gallbladder inflammation without cystic duct obstruction. Critical illness and neurological deficits are often associated with AAC, and early radiologic imaging is necessary for the detection and timely treatment of AAC. In critically ill patients, effective surgical management is difficult. This review examines the three common surgical treatments for AAC (open cholecystectomy (OC), laparoscopic cholecystectomy (LC), or percutaneous cholecystostomy (PC)), their prevalence in current literature, and the perioperative outcomes of these different approaches using a large retrospective database.

MATERIALS AND METHODS

This review examined literature gathered from PubMed and Google Scholar to select more than 50 sources with data pertinent to AAC; of which 20 are described in a summary table. Outcomes from our previous research and several updated results were obtained from the University HealthSystem Consortium (UHC) database.

RESULTS

LC has proven effective in treating AAC when the risks of general anesthesia and the chance for conversion to OC are low. In critically ill patients with multiple comorbidities, PC or OC may be the only available options. Data in the literature and an examination of outcomes within a national database indicate that for severely ill patients, PC may be safer and met with better outcomes than OC for the healthier set of AAC patients.

CONCLUSIONS

We suggest a three-pronged approach to surgical resolution of AAC. Patients that are healthy enough to tolerate LC should undergo LC early in the course of the disease. In critically ill patients, patients with multiple comorbidities, a high conversion risk, or who are poor surgical candidates, PC may be the safest and most successful intervention.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Percutaneous cholecystostomy: the radiologist's role in treating acute cholecystitis

Acute cholecystitis is a common condition, with laparoscopic cholecystectomy considered the gold-standard for surgical management. However, surgical options are often unfavourable in patients who are very unwell, or have numerous medical co-morbidities, in which the mortality rates are significant. Percutaneous cholecystostomy (PC) is an image-guided intervention, used to decompress the gallbladder, reducing patient's symptoms and the systemic inflammatory response. PC has been shown to be beneficial in high-risk patient groups, predominantly as a bridging therapy; allowing safer elective cholecystectomy once the patient has recovered from the acute illness; or, in the minority, as a definitive treatment in patients deemed unfit for surgery. This review aims to develop a broader understanding of PC, discussing its specific indications, patient management, technical factors, imaging guidance, and outcomes following the procedure.

Complication rate of ultrasound-guided percutaneous cholecystostomy in patients with coagulopathy

OBJECTIVE

The purpose of this article is to compare the complication rate for ultrasound-guided percutaneous cholecystostomy in patients with coagulopathy to the rate in patients with normal coagulation.

MATERIALS AND METHODS

We performed a database search for patients who underwent ultrasound-guided percutaneous cholecystostomy from January 2000 through December 2010. Patients were divided into those with normal coagulation and those with coagulopathy, as documented by abnormal laboratory values (international normalized ratio ≥ 1.5 and platelet count ≤ 50 × 10(9)/L) or history of anticoagulant medication in the preceding 5 days. Medical records were reviewed, and complication rates and subsequent treatment was recorded. Statistical analysis was performed using the Fisher exact and chi-square tests.

RESULTS

Two hundred forty-two patients underwent ultrasound-guided percutaneous cholecystostomy (132 men and 110 women; mean [± SD] age, 73.9 ± 15.9 years; range, 22-104 years). One hundred thirty-two patients were coagulopathic and 110 had normal coagulation. Major complications related to ultrasound-guided percutaneous cholecystostomy were rare (4/242 cases [1.7%]) and included hemorrhage requiring transfusion (n = 1), death directly related to the procedure (n = 1), sepsis related to the procedure (n = 1), and abscess or biloma formation (n = 1). All of these occurred in the group with normal coagulation. Fourteen additional deaths (5.8%) that occurred within 30 days of the procedure were related to comorbidities. Minor catheter-related complications (15/242 [6.2%]) were due to catheter dislodgement (n = 11 [4.5%]), failure of placement (n = 1 [0.4%]), and hemorrhage not requiring transfusion (n = 3 [1.2%]). Two of the minor hemorrhagic complications were seen in the coagulopathic group and one in the normal coagulation group (p = 0.599).

CONCLUSION

There is no difference in the complication rate for ultrasound-guided percutaneous cholecystostomy in patients who are coagulopathic compared with those who have normal coagulation.

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

GOALS

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

BACKGROUND

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

STUDY

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

RESULTS

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

CONCLUSION

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

Percutaneous cholecystostomy as the sole treatment in critically ill and elderly patients

PURPOSE

This study was done to investigate the effectiveness and clinical outcome of percutaneous cholecystostomy (PC) of treating acute cholecystitis in critical ill and elderly patients.

MATERIALS AND METHODS

In the last 3 years, PC was performed on 30 elderly and critically ill patients (17 men, 13 women; mean age 78.6, range 57-97 years) with acute cholecystitis and comorbid diseases.

RESULTS

Technical success was 30/30 (100%). Clinical effectiveness was 30/30 (100%), with statistically significant reductions in while blood cell (WBC) count, C-reactive protein (CRP) and fever. Mean WBC upon admission (19.87×10(3)±1.61×10(3) /μl), axillary temperature (38.2±0.11 °C), and CRP (248.7±4.76 mg/l) values were significantly decreased in the 72 h following PC [12.9×10(3) ± 1.05×10(3)/μl (p≤0.0001), 37 ± 0.04 °C (p≤0.0001), 113.5 ± 3 mg/l (p≤0.0001), respectively]. Clinical and ultrasonographic (US) signs of acute cholecystitis decreased in all patients. There were no major complications or procedure-related deaths, and the morbidity rate was low (3/30; 10%).

CONCLUSIONS

PC appears to be a fast, easy and effective treatment for the acute phase of cholecystitis in elderly and critically ill patients. Procedure-related morbidity and mortality rates are very low compared with surgery. Conservative treatment for patients who are not eligible for surgery is acceptable.

Percutaneous cholecystostomy for acute cholecystitis: ten-year experience

PURPOSE

To review the clinical course of patients with acute cholecystitis treated by percutaneous cholecystostomy, and to identify risk factors retrospectively that predict outcome.

MATERIALS AND METHODS

A total of 106 patients diagnosed with acute cholecystitis were treated by percutaneous cholecystostomy during a 10-year period. Seventy-one (67%) presented to the emergency department (ED) specifically for acute cholecystitis, and 35 (23%) were inpatients previously admitted for other conditions. Outcomes of the two groups were compared with respect to severity of illness, leukocytosis, bile culture, liver function tests, imaging features, time intervals from onset of symptoms to medical and percutaneous intervention, and whether surgical cholecystectomy was later performed.

RESULTS

Overall, 72 patients (68%) showed an improvement clinically, whereas 34 (32%) showed no improvement or a clinically worsened condition after cholecystostomy. Patients who presented to the ED primarily with acute cholecystitis fared better (84% of patients showed improvement) than inpatients (34% showed improvement; P < .0001). Gallstones were identified in 54% of patients who presented to the ED, whereas acalculous cholecystitis was more commonly diagnosed in inpatients (54%). Patients with sepsis had worse outcomes overall (P < .0001). Bacterial bile cultures were analyzed in 95% of patients and showed positive results in 52%, with no overall effect on outcome. There was no correlation between the time of onset of symptoms until antibiotic therapy or cholecystostomy in either group. Long-term outcomes for both groups were better for those who later underwent cholecystectomy (P < .0001).

CONCLUSIONS

Outcomes after percutaneous cholecystostomy for acute cholecystitis are better when the disease is primary and not precipitated by concurrent illness.

Percutaneous management of biliary emergencies

Most biliary emergencies can be classified as either infectious or obstructive. Infectious complications include acute cholecystitis and cholangitis. Many of these can be treated either surgically or endoscopically, but in some instances, less-invasive percutaneous techniques can be utilized to successfully treat these conditions. Obstructive complications, especially in the setting of liver transplant, can be serious if not treated quickly. Percutaneous drainage is sometimes the only acceptable treatment alternative for these patients.

Lessons learned from quality assurance: errors in the diagnosis of acute cholecystitis on ultrasound and CT

OBJECTIVE

The purpose of this article is to study errors in the diagnosis of acute cholecystitis reported in the online departmental quality assurance (QA) database.

MATERIALS AND METHODS

The departmental QA database was searched from October 2005 to April 2010 for cases of acute cholecystitis. Errors were classified into overcalls and undercalls.

RESULTS

We identified 14 cases of misdiagnosis involving acute cholecystitis. Three cases were classified as overcalls (21%) and eleven as undercalls (79%). Eight cases of misdiagnosis involved ultrasound studies (57%) and six cases involved CT studies (43%). Cases of overcall on ultrasound showed gallbladder wall edema, but none portrayed distention of the gallbladder. The final diagnosis in these cases included hepatitis, sepsis, and a case of chronic cholecystitis. All misinterpretations of CT cases were classified as undercalls. Contributing factors to misdiagnosis were lack of recognition of wall edema (n = 6), gallbladder distention (n = 4), absence of gallbladder wall edema (n = 1), lack of conclusion in the report (n = 2), and hospitalization in the ICU (n = 2). A possible case clustering was observed just after July almost every year.

CONCLUSION

An important pitfall in the diagnosis of acute cholecystitis is lack of recognition of gallbladder wall edema on CT. A relaxed (nondistended) gallbladder provides important evidence against the diagnosis of acute cholecystitis. Intensive care patients with sepsis often have no specific signs for diagnosis of acute cholecystitis, making diagnosis especially challenging.

Biliary tract interventions

Biliary tract interventions remain a tremendous technical challenge to the interventionalist and require appropriate clinical postprocedural management. The increased use of endoscopy for biliary tract evaluation and intervention has served to largely replace percutaneous techniques, resulting in a decreased number of patients requiring primary percutaneous transhepatic biliary interventions. However, those patients who do present for percutaneous biliary procedures often represent a more technically difficult subset. Thorough familiarity with normal and variant biliary tract anatomy, and experience with a variety of techniques, will allow for successful biliary tract interventions in complex situations. This article reviews the current role of percutaneous transhepatic interventions in the emergency evaluation and management of biliary tract disease.

Acute acalculous cholecystitis: a review

Although recognized for more than 150 years, acute acalculous cholecystitis (AAC) remains an elusive diagnosis. This is likely because of the complex clinical setting in which this entity develops, the lack of large prospective controlled trials that evaluate various diagnostic modalities, and thus dependence on a small data base for clinical decision making. AAC most often occurs in critically ill patients, especially related to trauma, surgery, shock, burns, sepsis, total parenteral nutrition, and/or prolonged fasting. Clinically, AAC is difficult to diagnose because the findings of right upper-quadrant pain, fever, leukocytosis, and abnormal liver tests are not specific. AAC is associated with a high mortality, but early diagnosis and intervention can change this. Early diagnosis is the crux of debate surrounding AAC, and it usually rests with imaging modalities. There are no specific criteria to diagnose AAC. Therefore, this review discusses the imaging methods most likely to arrive at an early and accurate diagnosis despite the complexities of the radiologic modalities. A pragmatic approach is vital. A timely diagnosis will depend on a high index of suspicion in the appropriate patient, and the combined results of clinical findings (admittedly nonspecific), plus properly interpreted imaging. Sonogram (often sequential) and hepatic iminodiacetic acid scans are the most reliable modalities for diagnosis. It is generally agreed that cholecystectomy is the definitive therapy for AAC. However, at times a diagnostic/therapeutic drainage via interventional radiology/surgery may be necessary and life-saving, and may be the only treatment needed.

Percutaneous management of tumoral biliary obstruction in children

BACKGROUND

There is limited experience of percutaneous biliary interventions in children although they are safe and effective procedures.

OBJECTIVE

To evaluate the efficacy and safety of percutaneous management of tumoral biliary obstruction in children.

MATERIALS AND METHODS

Percutaneous biliary interventions were performed in eight children (six boys, two girls) with a mean age of 10.5 years (range 4-17 years). The interventions included percutaneous biliary drainage (five patients), percutaneous biliary drainage and placement of a self-expanding metallic stent (two patients), and percutaneous cholecystostomy (one patient). All patients had signs of obstructive jaundice and two had cholangitis.

RESULTS

All procedures were successful. No procedure-related mortality was observed. Bilirubin levels returned to normal in four of the eight patients. Findings of cholangitis resolved in the two affected patients after the procedure and antibiotic treatment. Two patients underwent surgery after percutaneous biliary drainage procedures. A self-expanding metallic stent was placed in two patients with malignancy and the stents remained patent until death.

CONCLUSION

Percutaneous biliary interventions can be performed safely for the management of tumoral biliary obstruction in children.

The role of sonography in imaging of the biliary tract

Sonography is the recommended initial imaging test in the evaluation of patients presenting with right upper quadrant pain or jaundice. Dependent upon clinical circumstances, the differential diagnosis includes choledocholithiasis, biliary stricture, or tumor. Sonography is very sensitive in detection of mechanical biliary obstruction and stone disease, although less sensitive for detection of obstructing tumors, including pancreatic carcinoma and cholangiocarcinoma. In patients with sonographically documented cholelithiasis and choledocholithiasis, laparoscopic cholecystectomy with operative clearance of the biliary stone disease is usually performed. In patients with clinically suspected biliary stone disease, without initial sonographic documentation of choledocholithiasis, endoscopic ultrasound or magnetic resonance cholangiopancreatography is the next logical imaging step. Endoscopic ultrasound documentation of choledocholithiasis in a postcholecystectomy patient should lead to retrograde cholangiography, sphincterotomy, and clearance of the ductal calculi by endoscopic catheter techniques. In patients with clinical and sonographic findings suggestive of malignant biliary obstruction, a multipass contrast-enhanced computed tomography (CT) examination to detect and stage possible pancreatic carcinoma, cholangiocarcinoma, or periductal neoplasm is usually recommended. Assessment of tumor resectability and staging can be performed by CT or a combination of CT and endoscopic ultrasound, the latter often combined with fine needle aspiration biopsy of suspected periductal tumor. In patients whose CT scan suggests hepatic hilar or central intrahepatic biliary tumor, percutaneous cholangiography and transhepatic biliary stent placement is usually followed by brushing or fluoroscopically directed fine needle aspiration biopsy for tissue diagnosis. Sonography is the imaging procedure of choice for biliary tract intervention, including cholecystostomy, guidance for percutaneous transhepatic cholangiography, and drainage of peribiliary abscesses.

Usefulness of single and repetitive percutaneous transhepatic gallbladder aspiration for the treatment of acute cholecystitis

BACKGROUND

The aim of this study was to evaluate the safety and usefulness of single and repetitive percutaneous transhepatic gallbladder aspiration (PTGBA) for the treatment of acute cholecystitis.

METHODS

PTGBA was performed in patients with acute cholecystitis who showed no improvement after treatment with broad-spectrum antibiotics. PTGBA was carried out at bedside. When the bile was too thick to be aspirated through a 21-gauge needle, an 18-gauge needle was used. Aspiration of the gallbladder contents and injection of antibiotics into the gallbladder were performed without the placement of a drainage catheter. When improvement was not observed after the first attempt, PTGBA was repeated.

RESULTS

Single PTGBA achieved improvement in 32 of 45 patients. In 11 of the remaining 13 patients, the second PTGBA was effective. In the remaining two patients, repetitive PTGBA was not carried out because of advanced cancer. In two of 45 patients, 18-gauge needles were necessary for PTGBA because of the high viscosity of the bile. PTGBA was carried out in three patients with blockage of the cystic duct by a stent, and it was effective in all three. Two patients whose conditions improved with a single PTGBA experienced a recurrence at 4 and 31 months, respectively, after PTGBA. No other severe complications related to PTGBA were observed in any patients.

CONCLUSIONS

For the treatment of acute cholecystitis that does not react to conservative therapies, PTGBA is a safe, simple, and effective treatment modality that can be performed at bedside without any severe complications.

Ultrasound guided percutaneous cholecystostomy in high-risk patients for surgical intervention

AIM

To assess the efficacy and safety of ultrasound guided percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis in a well-defined high risk patients under general anesthesia.

METHODS

The data of 27 consecutive patients who underwent percutaneous transhepatic cholecystostomy for the management of acute cholecystitis from January 1999 to June 2003 was retrospectively evaluated. All of the patients had both clinical and sonographic signs of acute cholecystitis and had comorbid diseases.

RESULTS

Ultrasound revealed gallbladder stones in 25 patients and acalculous cholecystitis in two patients. Cholecystostomy catheters were removed 14-32 d (mean 23 d) after the procedure in cases where complete regression of all symptoms was achieved. There were statistically significant reductions in leukocytosis, (13.7 x 10(3)+/-1.3 x 10(3) microg/L vs 13 x 10(3)+/-1 x 10(3) microg/L, P < 0.05 for 24 h after PC; 13.7 x 10(3)+/-1.3 x 10(3) microg/L vs 8.3 x 10(3)+/-1.2 x 10(3) microg/L, P < 0.0001 for 72 h after PC), C -reactive protein (51.2+/-18.5 mg/L vs 27.3+/-10.4 mg/L, P < 0.05 for 24 h after PC; 51.2+/-18.5 mg/L vs 5.4+/-1.5 mg/L, P < 0.0001 for 72 h after PC), and fever (38+/-0.35 centigrade vs 37.3+/-0.32 centigrade, P < 0.05 for 24 h after PC; 38+/-0.35 centigrade vs 36.9+/-0.15 centigrade, P < 0.0001 for 72 h after PC). Sphincterotomy and stone extraction was performed successfully with endoscopic retrograde cholangio-pancreatography (ERCP) in three patients. After cholecystostomy, 5 (18%) patients underwent delayed cholecystectomy without any complications. Three out of 22 patients were admitted with recurrent acute cholecystitis during the follow-up and recovered with medical treatment. Catheter dislodgement occurred in three patients spontaneously, and two of them were managed by reinsertion of the catheter.

CONCLUSION

As an alternative to surgery, percutaneous cholecystostomy seems to be a safe method in critically ill patients with acute cholecystitis and can be performed with low mortality and morbidity. Delayed cholecystectomy and ERCP, if needed, can be performed after the acute period has been resolved by percutaneous cholecystostomy.

Acute cholecystitis in burn patients

Acute cholecystitis is a complication in critical illnesses, including burns. The purpose of this report is to review one institution's experience with this complication during a 21-year time period. A computerized burn registry was used for data collection and analysis in this retrospective review. Twenty patients developed cholecystitis from a total burn admission population of 10,762 in this 21-year period (0.18%). Mean patient age was 43.5 years, and their mean burn size was 37.4% with a mean full-thickness burn size of 23% TBSA. Mean patient length of stay was 77.4 days. Sixteen of these patients were intubated and mechanically ventilated for a mean of 56 days. Total parental nutrition was required in 12 patients. The use of total parental nutrition steadily decreased over the length of the study, and early enteral tube feed use has become the norm. All but two patients were in the Burn Intensive Care Unit at the time of diagnosis. Men outnumbered women by three to one. Nine patients with positive sonograms were successfully managed without surgical intervention. Two of these patients also had positive hydroxy iminodiacetic acid scans. Surgically managed patients were treated with both open and laparoscopic cholecystectomy as well as cholecystostomy tube placement. Mortality was 25%. Acute cholecystitis remains a serious although relatively rare complication in burn patients. Patients often have an unreliable physical examination, several possible causes of fever, and abnormal laboratory results. A high index of suspicion and sound clinical judgment is required to manage this rare-but-challenging problem.

Organ system dysfunction following open cholecystectomy for acute acalculous cholecystitis in critically ill patients

BACKGROUND

Acute acalculous cholecystitis (AAC) refers to cholecystitis without gallstones and is a serious complication of critical illness. We describe the time course of organ system dysfunction associated with cholecystectomy in critically ill patients with AAC.

METHODS

The data of all intensive care unit (ICU) patients who had operatively confirmed AAC during their ICU stay between 2003 and 2004 were analyzed. Patients who also had other intra-abdominal pathologies were excluded. The Sequential Organ Failure Assessment (SOFA) scores were recorded 3 days before, on the day of operation and on the first, second, third and seventh post-operative day after cholecystectomy. The impact of open cholecystectomy on organ dysfunction was evaluated on the basis of the change in the total and individual organ SOFA scores.

RESULTS

Twenty-four patients underwent open cholecystectomy for AAC with no other intra-abdominal pathology. Sepsis was the most common admission diagnosis, followed by cardiovascular surgery. The mean (standard deviation, SD) Acute Physiology and Chronic Health Evaluation (APACHE II), Simplified Acute Physiology Score (SAPS) II and SOFA scores on admission were 24.7 (5.8), 44.3 (12.3) and 9.4 (3.2), respectively. The median (25th, 75th percentiles) total SOFA score 3 days before cholecystectomy was 7.5 (1.3, 8.0), which increased to 10.5 (8.3, 13.0) (P < 0.0001) by the day of cholecystectomy, indicating developing multiorgan dysfunction. After the operation, the score decreased to 5.5 (3.3, 10.8) (P = 0.004) by the seventh post-operative day. The change was most obvious in cardiovascular and respiratory SOFA scores.

CONCLUSIONS

AAC is associated with multiorgan dysfunction in critically ill patients. Open cholecystectomy seems to alter the course of multiorgan dysfunction in these patients.

Percutaneous cholecystostomy in the management of acute cholecystitis

BACKGROUND

Percutaneous cholecystostomy (PC) has been used in managing acute cholecystitis in the setting of a patient with severe comorbidities where emergency cholecystectomy would carry significant mortality. The present study aims to assess the role, efficacy and complications of PC in acute cholecystitis.

METHODS

Retrospective review of case notes of patients who underwent PC at Box Hill Hospital, Melbourne, Australia between July 1997 and December 2002.

RESULTS

Sixteen patients (mean age 75 years; range 50-96) underwent PC. Indications for PC were significant comorbidities (n = 6), failure of conservative treatment (n = 4), bile duct malignancy (n = 2), sepsis of unknown origin (n = 2), patient declined surgery (n = 1) and local perforation (n = 1). Technical success rate was 94%. Clinical response to PC was observed in 15 patients. Overall mortality was 18% (3/16) with one death caused by PC failure. Interval cholecystectomy was performed in seven patients (44%).

CONCLUSIONS

Percutaneous cholecystostomy is a useful alternative means of treating non-resolving acute cholecystitis in circumstances where emergency surgery is hazardous. It also offers effective palliation in patients not suitable for subsequent surgery.

Percutaneous cholecystostomy for high-risk patients with acute cholecystitis

BACKGROUND

Cholecystectomy remains the best treatment for acute cholecystitis but may cause high morbidity and mortality in critically ill or elderly patients.

METHODS

From October 1995 to March 2004, percutaneous cholecystostomy was performed in 65 patients with acute cholecystitis. The mean age was 78 years (range, 45-95). All patients were American Society of Anesthesiologists (ASA) class III (n = 51) or ASA IV (n = 14).

RESULTS

Percutaneous cholecystostomy was technically successful in 63 patients (97%) with no attributable mortality or major complications. In two patients, bile drainage was inefficient, requiring emergency laparoscopic cholecystectomy. One patient developed necrotic cholecystitis and died. The 30-day mortality rate was 13.8% (n = 9); eight patients died of respiratory or cardiac complications related to comorbidities. Mean drainage time was 18 days (range, 9-60). Postoperative length of hospital stay was 15 days (range, 7-30). Early and delayed cholecystitis occurred in six and five patients, respectively. During follow-up (mean, 20.4 months), five patients died of their underlying medical condition at 5, 6, 8, 12, and 14 months, respectively. In this study, delayed elective cholecystectomy was performed in 10 patients (15.3%).

CONCLUSIONS

Percutaneous cholecystostomy is a valuable and effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.

Percutaneous Cholecystostomy Catheter Removal and Incidence of Clinically Significant Bile Leaks: A Clinical Approach to Catheter Management

OBJECTIVE

We sought to determine the incidence of bile leaks upon removal of small-bore percutaneous cholecystostomy catheters and to evaluate clinical and imaging guidelines to ensure safe catheter removal.

MATERIALS AND METHODS

A retrospective evaluation of all gallbladder drainages performed over a 5-year period revealed 163 patients (range, 7-98 years) who underwent percutaneous cholecystostomy catheter placement. Medical records and imaging studies were reviewed to assess the events at catheter removal (e.g., inadvertent removal, controlled removal with cholangiography without tract imaging, or controlled removal with cholangiography with tract imaging) and the incidence of major and minor bile leaks.

RESULTS

The events at catheter removal were assessed in 66 patients. Group 1 was 45 patients whose catheters were removed after a minimum of approximately 3 weeks with a cholangiogram that established cystic and common duct patency and no imaging of the tract. Catheters were not removed until the patient recovered from acute illnesses that contributed to acalculous cholecystitis. Group 2 was 11 patients managed similarly to group 1 except that tract imaging was performed at catheter removal. Group 3 was 10 patients whose tubes came out inadvertently without cholangiogram or tract imaging. Two major (group 2 and group 3) and two minor (group 2) bile leaks occurred. No bile leaks occurred in group 1 (p = 0.006).

CONCLUSION

Major bile leaks occurred in 3% of patients, and minor leaks occurred with equal frequency. Tract imaging may not be necessary in patients with small-bore gallbladder catheters who have recovered from critical illness, show patent cystic and common ducts, and have had catheters for 3-6 weeks.

Predicting Infected Bile Among Patients Undergoing Percutaneous Cholecystostomy

PURPOSE

Patients may not achieve a clinical benefit after percutaneous cholecystostomy due to the inherent difficulty in identifying patients who truly have infected gallbladders. We attempted to identify imaging and biochemical parameters which would help to predict which patients have infected gallbladders.

METHODS

A retrospective review was performed of 52 patients undergoing percutaneous cholecystostomy for clinical suspicion of acute cholecystitis in whom bile culture results were available. Multiple imaging and biochemical variables were examined alone and in combination as predictors of infected bile, using logistic regression.

RESULTS

Of the 52 patients, 25 (48%) had infected bile. Organisms cultured included Enterococcus, Enterobacter, Klebsiella, Pseudomonas, E. coli, Citrobacter and Candida. No biochemical parameters were significantly predictive of infected bile; white blood cell count >15,000 was weakly associated with greater odds of infected bile (odds ratio 2.0, p = NS). The presence of gallstones, sludge, gallbladder wall thickening and pericholecystic fluid by ultrasound or CT were not predictive of infected bile, alone or in combination, although a trend was observed among patients with CT findings of acute cholecystitis toward a higher 30-day mortality. Radionuclide scans were performed in 31% of patients; all were positive and 66% of these patients had infected bile. Since no patient who underwent a radionuclide scan had a negative study, this variable could not be entered into the regression model due to collinearity.

CONCLUSION

No single CT or ultrasound imaging variable was predictive of infected bile, and only a weak association of white blood cell count with infected bile was seen. No other biochemical parameters had any association with infected bile. The ability of radionuclide scanning to predict infected bile was higher than that of ultrasound or CT. This study illustrates the continued challenge to identify bacterial cholecystitis among patients referred for percutaneous cholecystostomy.

Gallbladder aspiration for acute cholecystitis in average-surgical-risk patients

We conducted a retrospective case note review to assess whether or not gallbladder aspiration can be applied as a temporary measure for the treatment of acute cholecystitis in average-surgical-risk patients. Gallbladder aspiration was performed in 79 consecutive average-surgical-risk patients with acute cholecystitis, who had no indications of emergent surgery and who complained of severe colicky pain. Elective surgery became possible in 92% of patients by gallbladder aspiration. The percentage reached 97 when percutaneous cholecystostomy was added (four patients). Emergent surgery was needed in one patient suffering bile leakage following gallbladder aspiration. Colicky pain was controlled soon after the procedure in most cases. Neither major complications nor mortalities were observed in the following surgical therapies. It is suggested that gallbladder aspiration might be applied as a temporary measure for acute cholecystitis in average-surgical-risk patients, although early surgery should remain the primary choice of therapy in such patients.

Sepsis in the Interventional Radiology Patient

Interventional radiologists often treat patients who are at risk of becoming acutely septic while in the radiology department. Identifying those most at risk and initiating treatment plans before the acute situation are fundamental to this difficult group of patients. Treatment plans for life-threatening infection are based on controlling the source of infection and administering appropriate systemic antimicrobial therapy as well as volume and cardiopulmonary support. The purpose of this review is to provide a framework for the diagnosis and treatment of sepsis in the interventional radiology patient.

US-guided Percutaneous Cholecystostomy: Features Predicting Culture-Positive Bile and Clinical Outcome

PURPOSE

To assess sonographic and clinical features that might be used to predict infected bile and/or patient outcome from ultrasonography (US)-guided percutaneous cholecystostomy.

MATERIALS AND METHODS

Between February 1997 and August 2002 at one institution, 112 patients underwent US-guided percutaneous cholecystostomy (59 men, 53 women; average age, 69.3 years). All US images were scored on a defined semiquantitative scale according to preset parameters: (a) gallbladder distention, (b) sludge and/or stones, (c) wall appearance, (d) pericholecystic fluid, and (e) common bile duct size and/or choledocholithiasis. Separate and total scores were generated. Retrospective evaluation of (a) the bacteriologic growth of aspirated bile and its color and (b) clinical indices (fever, white blood cell count, bilirubin level, liver function test results) was conducted by reviewing medical records. For each patient, the clinical manifestation was classified into four groups: (a) localized right upper quadrant symptoms, (b) generalized abdominal symptoms, (c) unexplained sepsis, or (d) sepsis with other known infection. Logistic regression models, exact Wilcoxon-Mann-Whitney test, and the Kruskal-Wallis test were used.

RESULTS

Forty-seven (44%) of 107 patients had infected bile. A logistic regression model showed that wall appearance, distention, bile color, and pericholecystic fluid were not individually significant predictors for culture-positive bile, leaving sludge and/or stones (P =.003, odds ratio = 1.647), common bile duct status (P =.02, odds ratio = 2.214), and total score (P =.007, odds ratio = 1.267). No US covariates or clinical indices predicted clinical outcome. Clinical manifestation was predictive of clinical outcome (P =.001) and aspirating culture-positive bile (P =.008); specifically, 30 (86%) of 35 patients with right upper quadrant symptoms had their condition improve, compared with one (7%) of 15 asymptomatic patients with other known causes of infection.

CONCLUSION

US variables can be used to predict culture-positive bile but not patient outcome. Clinical manifestation is important because patients with right upper quadrant symptoms have the best clinical outcome.

Emergent ultrasound interventions

The interventionist can perform many emergent procedures with ultrasound guidance, because of its real-time, multiplanar imaging capability and portability. With the use of color Doppler, additional important information, such as aberrant vessels, can be ascertained to help plan needle trajectory. Ultrasound is also useful for nonemergent procedures, such as biopsies. All interventionists are encouraged to be facile with the use of ultrasound.