Does persistent cholecystitis after cholecystostomy increase mortality?

Abstract

Abstract Objective Numerous publications describe percutaneous cholecystostomy (PC) as a possible treatment option for acute cholecystitis (AC) in selected cases where laparoscopic or open cholecystectomy (CHE) is not feasible due to limited health conditions. Whereas certain experts propose PC as a definitive therapy option for AC, a number of studies question the use of PC, due to high complication rates, no additional benefit of PC compared to CHE, and an increased mortality. The aim of our study was to retrospectively analyze the outcome of patients treated with PC over an extended period of time. Methods We conducted a retrospective study of patients who underwent PC for AC at a tertiary referral hospital during the last 10 years. The collected data included basic demographics, details about PC procedure, outcome, surgical-rate and final histologic diagnosis. Results Out of 158 patients (median age 75 years) treated with PC for AC, 47 (30%) died without undergoing subsequent CHE. Half of the PC patients (79) underwent subsequent CHE (8% in the hot phase), with 97% of these patients undergoing subsequent CHE within one year after PC. Seven (5%) of them died within the first year. The overall Charlson Comorbidity Index (CCI) was 6.4 (CHE vs. no CHE 5.3 vs. 7.4). Histologically, 22 (29%) of the 75 analyzed specimens showed chronic cholecystitis (CC), and 57 patients (68%) had signs of an AC. In 48 patients (30%), a complication after PC occurred. Conclusion In our collective, the 1-year survival after PC was 72%. The majority of these patients were in limited health conditions with a mean pre-PC CCI > 5, which implies a potential one-year mortality rate of over 85%. Histologic examination of almost all cholecystectomy specimens showed persistent inflammation. To our knowledge, this is the first extensive report of histologic findings in gallbladder specimens after PC. Based on our findings, especially in view of the high mortality rate of PC patients, we propose CHE as the treatment of choice in AC, even in chronically ill and elderly patients after stabilization, e.g. with a PC. PC represents no definitive treatment for AC and should remain a short-term solution because of the persistent inflammatory focus. Because CHE in a critically ill patient can be challenging, it should be performed by the most experienced surgeons.