Percutaneous Cholecystostomy to Manage a Hot Gallbladder: A Single Center Experience

Effectiveness and Safety of Cholecystectomy Versus Percutaneous Cholecystostomy for Acute Cholecystitis in Older and High-Risk Surgical Patients: A Systematic Review

Acute cholecystitis (AC) is a prevalent surgical emergency, particularly among elderly individuals who present with high perioperative risks. While early cholecystectomy (CCY) is the standard treatment, percutaneous cholecystostomy (PC) is proposed as an alternative for high-risk patients. This systematic review aims to evaluate the comparative safety and efficacy of CCY versus PC in managing AC among elderly and high-risk surgical patients. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was conducted across multiple electronic databases, including PubMed/Medline, Cochrane Central Register of Controlled Trials (CENTRAL), ScienceDirect, Europe PMC, ClinicalTrials.gov, and EBSCO Open Dissertations, from July 1 to 15, 2024. Studies published from January 2019 to July 15, 2024, were included if they focused on patients aged 65 and older or those classified as high-risk surgical candidates. The review encompassed 72,366 participants across 22 studies, predominantly observational. Key outcomes assessed included postoperative complications, readmission rates, recurrence of cholecystitis, and mortality rates. This study highlights the need for individualized treatment strategies for managing AC in elderly populations. While CCY remains the preferred approach when feasible, PC offers a critical alternative for high-risk patients. Future research is necessary to optimize outcomes for this vulnerable population.

Outcomes of Percutaneous Image-Guided and Laparoscopic Cholecystostomies in High-Risk Patients With Acute Calculus Cholecystitis: A Five-Year District General Hospital Experience

Introduction Acute cholecystitis (AC), inflammation of the gall bladder, is one of the most common emergency surgical presentations. In the UK, approximately 15% of the population is estimated to have gallstones, and approximately 20% of them can develop AC. Laparoscopic cholecystectomy (LC) is considered the definitive management of AC. However, cholecystectomy carries a very high risk of morbidity and mortality in high-risk frail patients with multiple comorbidities who are deemed unfit for surgery. Percutaneous cholecystostomy (PC), both image-guided and laparoscopic, is generally acknowledged as an interim treatment measure before definitive management, which is the LC. Materials and methods This is a retrospective study from the Royal Albert Edward Infirmary, a district general hospital (DGH) based in Wigan, UK. The medical records of all the patients who were admitted to the surgical department and underwent PC between January 2017 and December 2022 were analyzed. Patients with previous hepato-pancreato-biliary (HPB) malignancy, who underwent open cholecystostomy, or those with abdominal ascites were excluded from the study. Information was collected regarding the age, gender, American Society of Anaesthesiologists (ASA) grades, success rates of both procedures as temporary or definitive management, duration of hospital stay, 30-day and 1-year mortality after the procedure, timing of the procedure, and long-term complications after the procedure, particularly those related to cholecystostomy tube dislodgment or blockage. Results Twenty-seven patients who underwent PC were divided into two groups: group A, consisting of 10 patients who underwent laparoscopic cholecystostomies, and group B, consisting of 17 patients who had ultrasound (US)-guided cholecystostomies. The mean age of the patients in group A was 66.7 as compared to 75.1 in group B. Most of the patients were in ASA groups III (14) and IV (10). About 74% of patients had procedures done during the day and 26% had PC at night time. The mean hospital stay was 13.5 days. About 55% of patients had planned elective LC as a definitive management. Following the treatment, two patients died within 30 days, and eight patients passed away within a year. About 40% of the patients had complications related to the tube dislodgment and blockage. Conclusion This study concludes that PC, using both laparoscopic and US-guided techniques, can serve as an interim as well as a definitive measure, particularly in patients who are at high risk for anesthesia and the procedure itself and have multiple comorbidities.

Outcome Predictors of Percutaneous Cholecystostomy As Definitive Versus Bridging Treatment for Acute Cholecystitis

Introduction Percutaneous cholecystostomy (PC) is a treatment option for patients with acute cholecystitis (AC) who are too unwell, or too morbid for laparoscopic cholecystectomy (LC). Some patients have PC as a definitive treatment, whereas others have PC as a bridging treatment prior to LC. The aim of this study is to investigate patient characteristics and mortality among those who received PC as definitive treatment versus bridging treatment. Methods Our study retrospectively reviewed all patients treated with PC for AC from February 2019 to November 2022 at the Torbay and South Devon NHS Foundation Trust, Torquay, England. Fifty patients underwent PC for AC, with 48 patients having follow-up data available for analysis. Of these, 26 patients (54%) only received PC (definitive PC), and 22 patients (46%) later underwent LC (bridging LC). Results In this study, 68.8% of the patients were male, with a mean age of 76 ± 9 years. The overall mean Charlson Comorbidity Index (CCI) score was 4.96 ± 1.12, and the mean American Society of Anesthesiologists (ASA) score was 2.83 ± 0.36. The median PC drain duration was 42 days. Six patients (12.5%) had a recurrence of AC with a mean of 57 days onset after PC insertion. Twelve patients (25%) experienced PC complications: 11 (23%) were minor, involving pain or a dislodged tube, and one (2%) was major, resulting in a subhepatic abscess. The median duration from PC insertion to LC surgery was 50.5 days. The bridging LC cohort had a 30-day and one-year mortality of 0%, while the definitive PC cohort had a 30-day mortality of 30.8% (eight patients) and a one-year mortality of 46.1% (12 patients). The bridging LC cohort compared to the definitive PC cohort had a significantly lower CCI (4.39 vs 5.57, p<0.05), and a significantly lower ASA (2.61 vs 3.04, p<0.05). The one-year survival cohort compared to the 30-day mortality cohort had significantly lower ASA (2.71 vs 3.25 p<0.05), and a non-significantly lower CCI (4.66 vs 5.86 p=0.094). The presence of negative predictive factors of respiratory dysfunction and hyperbilirubinemia had higher 30-day and 90-day mortality rates of 31.3% and 37.5%, compared to their absence of 9.4% and 21.4% respectively. Conclusion Our results demonstrate that PC is a safe procedure with a high success rate and low complications. We showed that PC is an effective treatment option for bridging a select cohort of patients to receive a delayed LC. Furthermore, the data suggests ASA and CCI scoring can be used as clinical adjuncts to assess whether bridging patients from PC to LC is appropriate. Finally, ASA, respiratory dysfunction, and hyperbilirubinemia can be used as significant negative predictors of post-PC mortality.