What Are the Outcomes of Percutaneous Cholecystostomy Tube (PCT) in Cirrhosis Patients Deemed High-Risk Surgical Candidates With Acute Cholecystitis (AC)?

Abstract

Introduction: AC affects over 20 million Americans and leads to an annual cost exceeding US$ 6 billion. Optimal treatment is early cholecystectomy (CCY). Liver cirrhosis is the 8th leading cause of death in the US. We aim to study our long-term institutional experience of cirrhosis patients undergoing PCT. Methods: Retrospective cohort study of high-risk surgical patients with AC hospitalized at the Cleveland Clinic between 2002 and 2017. AC, cirrhosis and PCT were identified by ICD9 codes. The primary outcome was inpatient mortality and number of PCT re-interventions. We adjusted for age, gender and BMI. We constructed multivariable logistic regression models using SAS software. Results: PCT was placed in 377 patients, 24 (6.4%) were patients with cirrhosis. Mean Child Pugh score was 9.2, whereas the mean MELD score was 20. 6 (25%) were Child Pugh class A, 7 (29%) were Child Pugh class B, and the majority, 11 (46%), were Child Pugh class C. After PCT placement, there was no significant difference between non-cirrhotic and cirrhotic patients in the occurrence of biliary colic (0.5% vs 0%, p=0.99), cholangitis (0.8% vs 4%, p=0.23), choledocholithiasis (2% vs 0%, p=0.49), or biliary pancreatitis (0.2% vs 0%, p=0.99). However, cirrhotic patients were more likely to have recurrence of acute cholecystitis than non-cirrhotic patients (12% vs 3%, p=0.019), and they were more likely to die in the hospital (50% vs 18%, p 2 months post-PCT, cirrhotic patients had almost 5 times higher risk of requiring a cholecystectomy than non-cirrhotic patients (HR 4.8, p<0.001). Conclusion: Limitations: Retrospective study, potential misclassification (some PTC patients will not have ICD9 code). Strength: Robust patient cohort. Long-term follow up in special population. Very limited data on PCT outcomes in cirrhosis. Adjusted for age, gender and race. Conclusion: Cirrhosis patients that undergo PCT during AC have higher inpatient mortality when compared to non-cirrhosis. Cirrhosis patients undergo CCY at a higher rate after >2 months of PCT placement. There was no difference on PCT complications, post-PCT biliary complications, ER visits and re-hospitalizations between cirrhotic and non-cirrhotic patients.865_A Figure 1. Outcomes of interest and cirrhosis865_B Figure 2. Post-PCT Cholecystectomy by Presence of Cirrhosis