Cholecystitis In High-risk Patients Research Articles

PWE-093 Is cholecystostomy a good alternative treatment for acute cholecystitis in high risk patients?

<h3>Introduction</h3> Cholecystectomy is the treatment of choice for acute cholecystitis whose management in high risk surgical patients could be a difficult dilemma. With the development of interventional radiological skills, percutaneous cholecystostomy (PCS) could represent a less invasive option. <h3>Method</h3> This is a retrospective single Centre study; data were collected from our hospital electronic record system. From February 2009 to March 2014 there were 353 patients admitted with acute cholecystitis. Of these 39 were considered high risk for surgery and underwent PCS during their hospital stay. The radiological approach was trans-peritoneal in 29 patients and trans-hepatic in 10 patients. Median follow-up was 19 months. Aim of the study was to assess the outcomes of percutaneous cholecystostomy in high risk patients. <h3>Results</h3> There were 27 male (69.2%) and 12 female (30.8%) with mean age of 72 years (range 41–90 yrs). Twenty seven patients had PCS as definitive treatment (group A) and 12 patients as a bridge to cholecystectomy (group B). There were no post-procedures complications. Three patients in group B required conversion to open surgery (25%). Mean length of hospital stay was 15.7 days (group A and B). ITU admission was required for 8 patients (20.5%). Five patients in group A were readmitted once with another episode of cholecystitis after PCS (18.5%), with a median time to readmission of 85 days (3 patients readmitted within 90 days). One patient in group B was readmitted with cholecystitis after 2 years before proceeding to cholecystectomy, and 2 patients were readmitted after cholecystectomy (16.6%) for intra-abdominal collections treated with percutaneous ragiological drainage. Seven patients died (17.9%) as a result of severe biliary sepsis during their index hospital admission. <h3>Conclusion</h3> PCS is a safe approach in high risk patients with acute cholecystitis and can provide satisfactory long-term results when cholecystectomy is not a viable option. <h3>Disclosure of interest</h3> None Declared.

Percutaneous cholecystostomy treatment for acute cholecystitis in high risk patients

AimTo assess the efficacy and safety of percutaneous cholecystostomy in treatment of acute cholecystitis in high risk patients. Patients and methodsThis retrospective study included 21 patients with clinical and sonographic signs of acute cholecystitis and comorbid disease who underwent percutaneous cholecystostomy for management of acute cholecystitis from June 2009 to January 2014. ResultsPercutaneous cholecystostomy was technically successful in 19 patients and showed positive clinical response at 72h in 17 patients. Bile leakage due to catheter dislodgement in one patient was managed by change of catheter and re-insertion. The second patient had partial rupture of gall bladder, five patients underwent cholecystectomy. After cholecystostomy there were reductions of leukocytosis and C – reactive protein. ConclusionAs an alternative to surgery, percutaneous cholecystostomy is a safe and effective method of treatment in critically ill patients with acute cholecystitis.

Long-term outcomes after endoscopic ultrasonography-guided gallbladder drainage for acute cholecystitis

Endoscopic ultrasonography-guided transmural gallbladder drainage (EUS-GBD) has been proposed for the management of acute cholecystitis in high risk patients; however, little is known about the long-term outcomes of this treatment. The aim of this study was to evaluate the procedural and long-term outcomes of EUS-GBD with self-expandable metallic stent (SEMS). Data for this retrospective study were obtained from a prospectively collected EUS database. Patients with acute cholecystitis who were deemed unsuitable for cholecystectomy were included. Study outcomes were technical and clinical success, adverse events, and stent patency. EUS-GBD was technically and clinically successful in 62/63 patients (98.4 %; 95 % confidence interval [CI] 94.9 % - 100 %). Procedural adverse events included duodenal perforation (n = 1, 1.6 %) and self-limiting pneumoperitoneum (n = 2, 3.2 %), all of which resolved with conservative treatment. Long-term outcomes of EUS-GBD were evaluated in 56 patients who were followed for a median of 275 days (range 40 - 1185 days). Late adverse events developed in four patients (7.1 %; 95 %CI 5.7 % - 8.4 %), including asymptomatic distal stent migration (n = 2), and acute cholecystitis due to stent occlusion (n = 2). Two patients with occluded stent were successfully treated endoscopically (reintervention rate of 3.6 %). A total of 54 patients (96.4 %) had no recurrence of acute cholecystitis during follow-up. Median stent patency time was 190 days overall (range 15 - 1185 days) and 458 days (range 151 - 1185 days) for the 28 patients who were alive at the study end. The cumulative stent patency rate was 86 % at 3 years. EUS-GBD with an SEMS for acute cholecystitis showed excellent long-term outcomes and may be a definitive treatment in patients who are unsuitable for cholecystectomy because of advanced malignancy or high surgical risk.

831 Outcomes of EUS-Guided Transmural Gallbladder Drainage With a Metal Stent in Patients With Acute Cholecystitis Unsuitable for Cholecystectomy

Recently, EUS-guided transmural gallbladder drainage (EUS-GBD) has been reported as an alternative method for managing acute cholecystitis in high risk patients, but little is known about the long-term outcomes in terms of stent patency, and clinical progress.

Can Percutaneous Cholecystostomy be a Definitive Management for Acute Cholecystitis in High-risk Patients?

To evaluate the efficacy, long-term outcome, and safety of percutaneous cholecystostomy (PC) in high-risk surgical patients. This was a retrospective descriptive review of the medical records of 36 patients who underwent PC for acute cholecystitis (AC) at a single institution between 2000 and 2011. Primary outcomes were overall morbidity, mortality, and need for interval cholecystectomy. PC was initially successful, and symptoms disappeared within 3 days in all patients. Seven patients (2 during hospitalization and 5 during follow-up) died, 6 for a reason unrelated to AC, and 1 succumbed to a sepsis-related condition caused by uncontrolled cholecystitis progression. Elective cholecystectomy was performed in 6 patients. PC was a definitive treatment in 63.9% of patients. PC is a safe and efficient treatment option for patients with AC who are less eligible for surgery. After patients recover from PC, further treatment such as cholecystectomy may not be needed.

Changing Trends and Outcomes in the Use of Percutaneous Cholecystostomy Tubes for Acute Cholecystitis

Percutaneous cholecystostomy tube (PCT) placement serves as a treatment option for acute cholecystitis in elderly and critically ill patients. The objective of this study was to compare PCT and cholecystectomy outcomes over time. PCTs placed from April 1, 1998, to December 31, 2009 (time period 2) were retrospectively reviewed. Patients who underwent cholecystectomies served as matched controls. Institutional data from March 1, 1989, to March 31, 1998 (time period 1) were reviewed to compare trends. A total of 143 patients successfully underwent PCT placement in time period 2. When compared with patients undergoing cholecystectomy, PCT patients had a higher rate of cardiovascular disease (66% vs 26%, P = 0.001), diabetes (27% vs 13%, P = 0.001), and a higher mean Charlson comorbidity index (3.27 vs 1.07, P = 0.001). Compared with the first time period, patients undergoing PCT in the second time period had lower American Society of Anesthesiologist's classifications (American Society of Anesthesiologist's class I, II: 0% vs 18%, P = 0.001). Thirty-day mortality decreased from 36% to 12% in patients undergoing PCT (P = 0.001). Among patients with acute cholecystitis, percutaneous cholecystostomy tubes were placed in older patients with increased comorbidities compared to cholecystectomy. Mortality rates after PCT decreased over time.

Two staged minimally invasive treatment for acute cholecystitis in high risk patients.

The most optimal treatment for acute cholecystitis in high risk patients and severe acute cholecystitis remains still controversial. We review the outcomes of a two step treatment with percutaneous cholecystostomy and delayed laparoscopic cholecystectomy (DLC). We collected data prospectively from January 2004 to April 2010 from 26 patients that underwent percutaneous transhepatic CT-guided cholecystostomy and DLC. Percutaneous transhepatic CT-guided cholecystostomy was achieved in all cases with no complications. There was just one catheter dislodgement. Most of patients, 92%, improved after drainage. There was one case of mortality. Laparoscopic cholecystectomy was achieved in 88% of patients with no mortality, and a low rate of morbidity (7.6%) and of conversion to open surgery. Pre-operative percutaneous cholangiogram showed additional and useful information in 55.5% of patients. Two-step minimally invasive treatment combining percutaneous transhepatic CT-guided cholecystostomy and DLC is safe and feasible and report low morbi-mortality rates.

Percutaneous cholecystostomy (PC) in the management of acute cholecystitis in high risk patients.

To determine the role of ultrasound-guided percutaneous cholecystostomy (PC) regarding complications and outcome in the management of acute cholecystitis in patients high risk for surgery and anaesthesia and not responding to conservative management. Observational case series. The study was carried out at The Aga Khan University Hospital, Karachi, from January 2003 to December 2007. The study included patients admitted with acute cholecystitis considered unfit for immediate surgery but not responding to conservative management. Percutaneous cholecystostomy was conducted under ultrasound guidance. The studied variables included patients' demographics, co-morbid, ultrasound findings of biliary tree, indication for percutaneous cholecystostomy, its route, complication during or after procedure, patient's clinical outcome (upto 48 hours) and 30 days follow-up. Those with incomplete medical record and follow-up were excluded. Data were analyzed and results compiled using SPSS 16.0 version. Mean and standard deviation for quantitative variable like age was derived. Proportions were computed for complications and patient's clinical outcome. Forty one patients with complete medical record were studied including 15 (37%) males and 26 (63%) females. Mean age was 65 +/-13.5 years. Indications for PC included calculus cholecystitis in 25, acalculous cholecystitis in 10, empyema in 04 and gallbladder perforation in 02 patients. No complication was seen during or after procedure in 31 (75%) patients. Complications occurred in 10 (25%) patients including vagal reaction, pain during procedure, tube blockage, catheter dislodgement and bile leakage. Favourable clinical response (improvement in clinical symptoms) was noted in 34 (83%) patients. Seven (17%) patients did not show any improvement in clinical condition after the procedure. On 30 days follow-up, 9 patients had undergone cholecystectomy, 5 (12%) patients expired due to underlying clinical conditions and the rest were settled without requiring an immediate cholecystectomy. There was no direct procedure-related mortality. Imaging guided PC is a safe and effective procedure for immediate management of non-resolving acute cholecystitis in patients high risk for surgery and anaesthesia and not responding to conservative management.

Short- and long-term outcomes following percutaneous cholecystostomy for acute cholecystitis in high-risk patients

Percutaneous cholecystostomy is a less invasive method to treat acute cholecystitis in patients who are critically ill or have serious medical comorbidities precluding the use of general anesthesia. It remains controversial whether interval cholecystectomy is warranted. The objectives of the study were to determine the success rate and complications of percutaneous cholecystostomy and the proportion of patients without recurrent attacks in whom interval cholecystectomy was not needed. This was a retrospective review to determine the outcomes after percutaneous cholecystostomy for acute calculous cholecystitis between 1995 and 2007. Administrative data were used to better capture recurrent symptoms requiring treatment. Sixty-eight patients with a mean age of 74 years were identified. Sixty-seven (98.5%) underwent successful insertion of the cholecystostomy tubes. Eleven patients suffered tube-related complications, including tube dislodgment (9), tube blockage (1), and bleeding that was controlled with conservative management (1). The initial episode of cholecystitis was treated successfully in 58 patients (85%). The overall in-hospital and 30-day mortality were both 15% (10 patients). A total of 7 patients (10%) underwent cholecystectomy while still in hospital. There were 39 patients at risk for recurrent disease who survived the initial episode and did not receive an interval cholecystectomy. Of these 39 patients, 16 (41%) suffered recurrent gallbladder-related disease. Percutaneous cholecystostomy is an alternative to cholecystectomy in patients with acute calculous cholecystitis who are at high risk for surgical mortality and morbidity. It appears to have a low complication rate and good clinical success. Because a significant number of patients suffer recurrent attacks, elective cholecystectomy should be considered routinely. Unfortunately, firm criteria for selecting percutaneous cholecystostomy over cholecystectomy are lacking, and the surgeon's clinical judgment is critically important.

Percutaneous drainage for acute calculous cholecystitis

Acute calculous cholecystitis is a frequently encountered problem in surgical practice; laparoscopic cholecystectomy (LC) is the standard treatment. LC for acute cholecystitis can be a more difficult procedure than elective LC for cholelithiasis and is associated with increased operating time, higher conversion rate, and more postoperative complications. In the elderly patient with comorbidity, surgery can result in serious complications and even mortality. Percutaneous drainage (percutaneous cholecystostomy; PC) may be an alternative treatment. There is no hard evidence in current literature regarding the safety, success rate, and specific technique of this procedure, nor is there consensus on the indications. To evaluate the safety and efficacy of PC in treatment of acute calculous cholecystitis in high-risk surgical patients. From January 2009 until May 2010, 101 patients with acute calculous cholecystitis were treated, of whom 27 with PC. Of these 27 patients, comorbidity and American Society of Anesthesiologists (ASA) classification were determined, indication for drainage instead of cholecystectomy was recorded, and procedure-related data were collected. Primary outcomes were overall morbidity, mortality, and recurrent biliary events. Secondary outcomes were time to recovery and need for and difficulty of interval laparoscopic cholecystectomy. The cohort included 15 male and 12 female patients with median age of 83years (range 69-90years). Most patients were ASA 3 (n=18) or ASA 2 (n=8); one patient was ASA 4. Indication for drainage was age and/or comorbidity in 24 cases and duration of symptoms in 3 cases. Antibiotic treatment was given in all but seven patients. The drain was in situ for a median period of 19days (range 5-57days). Relief of symptoms occurred in 26 patients; drain luxation occurred in nine patients, only in two patients with clinical consequences. Overall mortality rate was 14.8% (n=4) with a procedure-related mortality rate of 3.7%. Median time to full recovery was 8days. With median follow-up of 8weeks, four patients underwent interval cholecystectomy. Percutaneous drainage in acute calculous cholecystitis in high-risk patients seems to be a safe and successful treatment option in patients less eligible for surgery. There are many controversies in the current literature, and evidence-based guidelines for the indication of PC in treatment of acute calculous cholecystitis are needed.

Efficiency of Percutanous Choecystostomy in Management of Acute Cholecystitis in High-Risk Patients.

To evaluate the effectiveness of percutaneous cholecystostomy in management of acute cholecystitis in critically ill high-risk patients who cannot undergo cholecystectomy. METHODS: We retrospectively reviewed the medical records of patients who underwent percutaneous cholecystostomy at KFMC, Riyadh, KSA, in the period from January 2008 to January 2010. A total of 22 patients were included, twelve were males (55%) and ten were females (45%). Age ranged between 28 and 85 years; with a mean age of 63 years. All patients had clinical and radiological evidence of acute cholecystitis (14 calculous and 8 acalculous). The indications for percutanous cholecystostony in the patients with calculous cholecystitis were classified into four categories {1} High risk for surgery due to associated severe co-morbidity, {2} Cholecystitis during late pregnancy, {3} Severe cholecystitis (not responding to conservative management) and {4} Suspected empyema of the gallbladder. Fourteen patients (64%) had transperitoneal percutaneous cholecystostomy and 8 patients (36%) had the transhepatic proceducre, under both ultrasonic and fluoroscopic guidance. Patients’ responses were monitored clinically by monitoring the vital and the abdominal signs and laboratory by series of WBCC estimations. Drainage catheters were left in situ for periods ranging between 2 and 8 weeks with a mean period of 4 weeks. Laparoscopic cholecystectomy was subsequently done in 8 patients with calculous cholecystitis (61.5%) after an interval of 4 to 6 weeks. RESULTS: Percutaneous cholecystostomy was achieved successfully in all patients. No procedure-related mortality was observed apart from minor bile leakage in one patient of the transperitoneal approach group which resolved spontaneously. One patient with empyema of the gallbladder did not show adequate clinical response after 72 hours of percutaneous drainage and was taken for urgent cholecystectomy. Laparoscopic cholecystectomy was done in 8 patients 0ut of the remaining 13 patients with calculous cholecystitis after an interval of 4 to 6 weeks without operative difficulties or conversion to open surgery. CONCLUSION: Percutaneous cholecystostomy under ultrasonographic and fluoroscopic guidance is a safe, easy-to-perform and effective procedure with high success rates and low morbidity rates for management of critically ill and high-risk patients with acute cholecystitis.

Percutaneous cholecystostomy: A bridge to surgery or definite management of acute cholecystitis in high-risk patients?

Objective. Cholecystectomy is the standard treatment for acute cholecystitis, but in high-risk patients with serious comorbidity and in patients of advanced age there is substantial morbidity and mortality associated with the intervention. In these selected patients, percutaneous cholecystostomy (PCS) is an alternative mode of management. The aim of the present study was to evaluate the outcome of PCS in selected patients with acute cholecystitis. Material and methods. Thirty-five patients, representing 0.6% of all acute cholecystitis patients managed during the period 1994–2003, were subjected to PCS. Patients’ charts were reviewed retrospectively for age, gender, comorbidity, hospital stay, procedure, complications and final outcome, including requirement of additional interventions. Results. PCS was considered successful in 34/35 patients, 26 of whom responded within 3 days. Two patients required additional cholecystectomy 3 days and 20 months, respectively, after the PCS procedure. Two patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and one patient underwent rotation lithotripsy. Four patients suffered recurrent biliary complaints after the acute episode of cholecystitis, while the only serious procedure-related complication was bile leakage from the gallbladder in one patient, which necessitated cholecystectomy. Conclusions. PCS is a comparatively safe and efficient procedure in the treatment of acute cholecystitis in high-risk patients with serious comorbidity and in elderly patients, contraindicating the general anaesthesia required for laparoscopic or open cholecystectomy.

Percutaneous cholecystostomy for acute cholecystitis in high-risk patients: experience of a surgeon-initiated interventional program

Background The treatment of choice for acute cholecystitis is cholecystectomy. However, percutaneous cholecystostomy (PC) is an alternative treatment in patients who are at high risk for urgent surgery. This study reviews our experience of PC for treatment of acute cholecystitis in a surgeon-initiated interventional program. Methods Clinical records of all high-risk patients who underwent PC placement by surgeons (group A; n = 22) for acute cholecystitis were reviewed. Treatment outcomes were compared with patients who underwent PC by interventional radiologists (group B; n = 26). Results Similar technical success, procedural complication, or treatment outcome were noted between the two groups. Seven patients (32%) in group A and 9 patients (35%) in group B underwent delayed elective cholecystectomy surgery. The time elapsed between the diagnosis to PC placement in groups A and B was 6.6 ± 3.5 hours and 18.5 ± 4.3 hours, respectively ( P < .02). Conclusions Ultrasound-guided PC is a safe and effective treatment for acute cholecystitis in high-risk surgical patients. Surgeons with endovascular skills can obtain clinical competence in this catheter-based procedure, which provides an added armamentarium in surgical biliary disease management.

Management of Acute Calculous Cholecystitis in High-Risk Patients

Emergency cholecystectomy for acute cholecystitis is associated with high morbidity and mortality rates in patients with significant comorbidities and high-risk surgery. The aim of this study was to evaluate the effectiveness, possible advantages, and complications of percutaneous cholecystostomy (PC) followed by an early laparoscopic cholecystectomy (LC) in relation to conservative treatment followed by a delayed LC in high-surgical risk patients. Between 2002 and 2004, patients were randomly classified into 2 groups: the first group consisted of patients who had PC followed by an early LC (PCLC group, n = 31) and the second group consisted of patients who had conservative treatment followed by a delayed LC (DLC group, n = 30). The groups were statistically compared regarding their demographic, comorbidity, hospital stay, conversion, and complication rates. PC was technically successful in 31 patients with no attributable mortality or major complications. No difference had been found in regarding demographic, comorbidity, and complication rates. In PCLC group, all the patients experienced symptom relief within 24 hours, and early LC was attempted in 31 patients once their clinical condition was sufficiently stable, this was successfully accomplished in 29 (93.5%). In the DLC group, delayed LC was attempted in 30 patients, and this was successfully accomplished in 26 (86.6%). The hospital stay was shorter and cost was in the PCLC group was lower than in the DLC group. PC allows resolution of sepsis in patients at high surgical risk. Early LC could be safely performed once sepsis and acute infection resolved in these patients.

Percutaneous transhepatic gallbladder stenting for recurrent acute acalculous cholecystitis after failed endoscopic attempt

Endoscopic gallbladder stenting is useful palliative therapy for acute cholecystitis in high-risk patients. Although the success rate of endoscopic gallbladder stenting is 79%-100%, an alternative method has not been reported. We succeeded in employing a method for percutaneous gallbladder stenting (PTGS) and herein describe this new method. A patient with acute acalculous cholecystitis related to ischemic atherosclerotic vascular disease, cholangitis due to Lemmel syndrome, and severe congestive heart failure underwent PTGS through the cystic duct from the gallbladder to the duodenal papilla, because an endoscopic method failed in the treatment of Lemmel syndrome. Because we were unable to place endoscopic transpapillary gallbladder drainage, percutaneous transhepatic gallbladder drainage (PTGBD) was performed and both the cholecystitis and cholangitis ceased. PTGS was performed as an alternative to endoscopic gallbladder stenting. Access to the cystic duct and gallbladder was obtained by the PTGBD route, using a guidewire (0.035-inch diameter) and seeking catheter (6.5 Fr) under fluoroscopic control. A 7-Fr 12-cm double-pigtail biliary polyethylene stent was placed. The patient remained asymptomatic for 3 months after the PTGS until he died, of an acute recurrent myocardial infarction. This new PTGS placement is an alternative treatment for symptomatic gallbladder disease in patients with increased operative risk when the endoscopic method is unsuccessful.

Colecistectomia laparoscópica em pacientes de alto risco

OBJETIVO: Relatar a experiência com a colecistectomia laparoscópica na colecistite aguda, em pacientes de alto risco (ASA 4). MÉTODO: De 1982 a 2001 foram realizadas, na Clínica Especializada em Doenças do Aparelho Digestivo (DIGEST), 1507 colecistectomias laparoscópicas, sendo 150 (10%) em colecistite aguda, dentre as quais 10 (0,7%) em pacientes ASA 4. RESULTADOS: Entre estes 10 pacientes observou-se uma faixa etária elevada com média de 70,9 anos (variando entre 50 e 89 anos), maior freqüência do sexo masculino (60%), período de internação pré-operatório bastante variável (de três a 22 dias), prevalência elevada de colecistite aguda alitiásica (30%) e grande freqüência de insuficiência renal (40%) dentre as doenças associadas. Como complicações de pós-operatório houve uma coleção sub-hepática tratada por drenagem guiada por ultrassonografia; duas infecções de sítio operatório, tratadas pela abertura da pele do portal infectado, e um óbito decorrente da perpetuação do quadro séptico em paciente previamente submetido a colecistostomia percutânea. Não houve necessidade de conversão em nenhum dos pacientes operados. CONCLUSÃO: Os autores concluem pela viabilidade do método laparoscópico no tratamento da colecistite aguda em pacientes de alto risco, observando-se algumas estratégias específicas.

Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis

Background: The ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography (CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced open cholecystostomy for the treatment of acute cholecystitis in critically ill patients. Methods: The aim of the present study was to evaluate the results of a 5-year protocol using PTHC followed by delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis in critically ill patients. We reviewed the charts of 55 patients who underwent PTHC at the Hadassah University Hospital Mount Scopus during the years 1994 to 1999. Results: The main indications for PTHC among this group of severely sick and high-risk patients was biliary sepsis and septic shock in 23 patients (42%); and severe comorbidities in 32 patients (58%). The median age was 74 (32 to 98) years, 33 were female and 22 male. Successful biliary drainage by PTHC was achieved in 54 of 55 (98%) of the patients. The majority of the patients (31 of 55) were drained transhepaticlly under CT guidance. The rest, (24 of 55) were drained using ultrasound guidance followed by cholecystography for verification. Complications included hepatic bleeding that required surgical intervention in 1 patient and dislodgment of the catheter in 9 patients that was reinserted in 2 patients. Three patients died of multisystem organ failure 12 to 50 days following the procedure. The remaining 52 patients recovered well with a mean hospital stay of 15.5 ± 11.4 days. Thirty-one patients were able to undergo delayed surgery: 28 underwent laparoscopic cholecystectomy of whom 4 (14%) were converted to open cholecystectomy. This was compared with a 1.9% conversion rate in 1,498 elective laparoscopic cholecystectomies performed at the same time period ( P = 0.012). Another 3 patients underwent planned open cholecystectomy, 1 urgent and 2 combined with other abdominal procedures. There was no surgery associated mortality, severe morbidity, or bile duct injury. Conclusions: The use of PTHC in critically ill patients with acute cholecystitis is both safe and effective.

Nonsurgical Treatment of Cholecystitis in High-Risk Patients

When patients who are at high operative risk develop acute cholecystitis, 2 options are less invasive than cholecystectomy: In percutaneous cholecystostomy, a catheter is placed in the gallbladder under ultrasound guidance and fluid is allowed to drain for weeks or even months; in contrast, gallbladder aspiration is …

Perkutane Cholezystostomie in der Behandlung der akuten Cholezystitis des Risikopatienten

Percutaneous cholecystostomy was performed in 17 poor surgical risk patients. 16 patients developed acute acalculous cholecystitis postoperatively in the intensive care unit, 1 patient had an acute cholecystitis with calculi. Diagnostic imaging using CT and US was specific for acute cholecystitis in 58% only. Percutaneous cholecystostomy was the definitive treatment in 69% of the patients. Additional cholecystectomy was required in 3 patients with complicated cholecystitis, in 1 patient with bile leakage after catheter dislocation and in 1 patient with gallbladder calculi. 3 patients died, 2 of them from reasons unrelated to the gallbladder disease. Radiology-guided percutaneous cholecystostomy performed by a transhepatic approach is a safe and effective procedure for acute cholecystitis in high-risk patients.

Percutaneous cholecystostomy for acute cholecystitis in high-risk patients

Abstract Seventeen high-risk critically ill patients with suspected cholecystitis underwent percutaneous transhepatic cholecystostomy between 1981 and 1986 using Hawkins' needle guide system for gallbladder intubation. Acute cholecystitis was documented in 15 patients, including 1 with common bile duct obstruction. Two other patients had common bile duct obstruction secondary to metastatic cancer (one patient) and chronic pancreatic fibrosis (one patient). There was rapid resolution of the signs and symptoms of cholecystitis, sepsis, or both in 16 of the 17 patients. One critically ill patient with positive findings on blood culture and an organism resistant to triple antibiotic therapy died soon after percutaneous cholecystostomy. In the entire group of 17 patients, there was no evidence of bile leaks or other catheter complications. Six patients subsequently underwent successful cholecystectomy and two underwent common bile duct exploration without complications. One patient underwent cholecystojejunostomy, and in three patients, the catheter was removed with no sequelae of cholecystitis. Two remaining patients had the catheter in place and were awaiting operation at last follow-up. Three of four patients who died within 30 days of percutaneous transhepatic cholangiographic cholecystostomy died either from the terminal malignant condition (two patients) or from arrhythmia (one patient with cirrhosis). This review suggests that percutaneous cholecystostomy is a safe and effective procedure for resolving acute cholecystitis in high-risk patients. In addition, the technique of percutaneous transhepatic cholangiographic cholecystostomy appears well suited for percutaneous dissolution of stones, sclerosis of the gallbladder, or both in selected high-risk critically ill patients.