Cholecystitis In High-risk Surgical Patients Research Articles

Percutaneous cholecystostomy versus emergency cholecystectomy for the treatment of acute calculous cholecystitis in high-risk surgical patients: a meta-analysis and systematic review.

The present meta-analysis was performed to compare the efficacy and safety of percutaneous cholecystostomy (PC) versus emergency cholecystectomy (EC) for the treatment of acute calculous cholecystitis (ACC) in high-risk surgical patients. Literature searches for eligible studies were performed using MEDLINE, EMBASE and the Cochrane Library. Quality assessment was conducted in each study. Meta-analyses were performed to demonstrate the pooled effects of relative risk (RR) with 95% confidence intervals (CI). A total of 8960 patients from 6 studies were finally included. PC resulted in increased risks of mortality (RR = 2.87; CI = 1.33-6.18; p = 0.007) and readmission rate (RR = 4.70; CI = 3.30-6.70; p < 0.00001) as compared with EC. No significant difference was detected between PC and EC in terms of morbidity, severe complication rate or hospitalization length. Moreover, PC was associated with significantly higher risks of mortality (RR = 7.47; CI = 1.88-29.72; p = 0.004), morbidity (RR = 3.71; 95% CI = 1.78-7.75; p = 0.0005), readmission rate (RR = 7.91; CI = 3.80-16.49; p < 0.00001), and hospitalization length (WMD = 6.92; CI = 5.89-7.95; p < 0.00001) when directly compared with laparoscopic cholecystectomy (LC). Therefore, EC is superior to PC for the treatment of ACC in high-risk surgical patients, and LC is the preferred surgical strategy.

Permanent endoscopic gallbladder stenting versus removal of gallbladder drainage, long-term outcomes after management of acute cholecystitis in high-risk surgical patients for cholecystectomy: Multi-center retrospective cohort study.

Endoscopic transpapillary gallbladder drainage (EGBD) has been reported as an effective gallbladder drainage treatment option for acute cholecystitis in high-risk surgical patients. However, the long-term outcomes such as cholecystitis' recurrence rate after placement of EGB stenting (EGBS) have not been well studied yet. The aim of the present study was to compare the long-term outcome of EGBS and removal of gallbladder drainage after percutaneous transhepatic gallbladder drainage (PTGBD) or endoscopic nasogallbladder drainage (ENGBD) for acute cholecystitis in high-risk surgical patients and clarify the usefulness of long-term placement of EGBS. We retrospectively studied 180 high-risk surgical patients with acute cholecystitis between January 2010 and December 2018. The patients were divided into two groups: EGBS group (long-term placement of EGBS) or Removal group (removal of drainage tube after PTGBD or ENGBD). Clinical outcomes, including long-term results, were compared between the groups. The cumulative late adverse event (AE) rates were 5.0% and 22.1% in the EGBS and Removal group (P=.002), with a median follow-up period of 375 and 307days in the two groups, respectively. The cumulative cholecystitis recurrence rate was 5.0% (2/40) in the EGBS group and 16% (21/131) in the Removal group (P=.024), respectively. In the multivariate analysis for late AE, only EGBS was an independent risk factor with a decreasing value. The permanent EGBS in high-risk surgical patients with acute cholecystitis was considered effective in reducing the risk of late AE.

Treatment of acute cholecystitis in high-risk surgical patients.

Acute cholecystitis (AC) is the most common biliary stone disease complication. While there is consensus regarding cholecystectomy for AC, gallbladder drainage is indicated in elderly or high-risk surgical patients. We systematically reviewed available evidence in the field of EUS-guided gallbladder drainage (EUS-GBD) for AC in high-risk surgical patients. The studies were classified according to their level of evidence (LE) according to the Oxford Centre for Evidence Based Medicine classification. Literature search retrieved 175 manuscripts; most of them were expert opinions (LE V, N.=53) or case-series (LE IV, N.=29). There was no meta-analysis of RCT (LE Ia), while two randomized controlled trials (LE Ib) demonstrated that EUS-GBD was superior to percutaneous transhepatic-GBD (PT-GBD) regarding long-term outcomes (adverse events, recurrent cholecystitis, and reintervention). Several meta-analyses of cohort studies (LE IIa, N.=11) were designed to compare the three available drainage strategies (endoscopic, echoendoscopic and percutaneous) and to assess the pooled risk of adverse events. Comparison between surgery and EUS-GBD was done in a single retrospective study with a propensity score analysis (LE III). The outcomes of conversion from PT-GBD to EUS-GBD were covered by few retrospective studies (LE III). Several manuscripts (N.=69) were published on EUS-GBD as a rescue strategy in case of malignant biliary obstruction. The levels of evidence of EUS-GBD in the literature have evolved from initial descriptive studies to recent randomized controlled trials and meta-analysis of cohort studies. While several articles addressed the comparison among different techniques for GBD, in our opinion some topics and questions have not been adequately investigated. are still debated.

Therapeutic endoscopic ultrasound: current indications and future perspectives.

Endoscopic ultrasound (EUS) is rapidly evolving from a diagnostic into a mainly therapeutic procedure, similarly to what previously occurred to endoscopic retrograde cholangio-pancreatography (ERCP). The capability to easily access adjacent organs and structures with a minimally invasive approach as well as the availability of dedicated devices are driving this process. Several therapeutic procedures can be performed under EUS-guidance, such as drainage of pancreatic fluid collections, of the biliary system after ERCP failure, of the gallbladder for acute cholecystitis in high-risk surgical patients, as well as endoscopic gastroenteral-anastomosis creation. The introduction of dedicated lumen-apposing metal stents in the latest years has made these procedures technically easier. However, further improvements of stent design will be required in the next future. Moreover, data on long-term efficacy and safety coming from well-designed randomized multicenter controlled trials are still needed to bring EUS-guided procedures to the next level.

Efficacy and safety of endoscopic laser lithotripsy and lithotomythrough the lumen-apposing metal stent for giantgallbladder stones.

Background and AimsEUS-guided gallbladder drainage has been increasingly applied for acute cholecystitis in high-risk surgical patients. In cases of EUS-guided gallbladder drainage with lumen-apposing metal stents (LAMSs), endoscopic retrieval of gallstones becomes feasible. However, retrieval of giant gallstones is still difficult because of the limited space in the saddle section of the LAMS. In this study, we aimed to evaluate the efficacy and safety of endoscopic laser lithotripsy and lithotomy through LAMSs for the removal of giant gallstones.MethodsFive consecutive patients with recurrent cholecystitis due to giant gallstones were enrolled. We proceeded with EUS-guided LAMS implantation. Endoscopic laser lithotripsy and lithotomy then was performed through the LAMSs, and the stents were removed after all stones were extracted. The patients were followed up at scheduled times.ResultsEUS-guided LAMS implantation was successfully performed, and target gallstones were completely removed in all 5 patients. There was no severe bleeding, perforation, or stent migration during the operation. No recurrence of gallstones was found at late follow-up.ConclusionsEndoscopic laser lithotripsy and lithotomy through LAMSs could be a safe and effective approach for removal of giant gallstones.

Gallbladder Cryoablation for Chronic Cholecystitis in High-Risk Surgical Patients: 1-Year Clinical Experience with Imaging Follow-up

PurposeTo assess the short-term safety and efficacy of gallbladder cryoablation in high-risk patients. Materials and MethodsA single-center, retrospective review of clinical and imaging follow-up from patients who were referred for gallbladder cryoablation between August 2018 and July 2019 was performed. All patients had serious pre-procedural comorbidities and were unacceptable surgical candidates (mean age, 52.5 years; mean American Society of Anesthesiologists score, 3.67). Primary efficacy measures included technical success, absence of symptoms after cholecystostomy tube removal, and imaging evidence of cystic duct obstruction and gallbladder involution. The primary safety measure was the absence of Society of Interventional Radiology moderate or greater adverse events. ResultsTechnical success was 86%, with 1 of 7 patients unable to undergo cryoablation because of adhesions preventing hydrodissection of the colon away from the gallbladder. Mean duration of clinical follow-up after discharge was 278 days (range, 59–498 days). Abdominal pain was absent in all patients after ablation. Cholecystostomy tubes were removed immediately after ablation (n = 5) or on post-procedure day 11 (n = 1). Computed tomography or magnetic resonance imaging was obtained at 1–3 months (n = 6), 4–6 months (n = 4), and 6–12 months (n = 5) after the procedure and demonstrated gallbladder involution in 5 of 6 patients. One patient had asymptomatic distention of the gallbladder on follow-up imaging. Hepatobiliary iminodiacetic acid scans were completed in 5 of 6 patients 1 month after ablation and demonstrated cystic duct occlusion in all 5 patients. One moderate adverse event (infection) and 1 life-threatening adverse event (hemorrhage) occurred. ConclusionsGallbladder cryoablation might be a viable treatment option for high-risk patients with gallbladder disease and warrants further investigation.

3:00 PM Abstract No. 99 ■ DISTINGUISHED ABSTRACT Gallbladder cryoablation for chronic cholecystitis in high-risk surgical patients: early clinical experience and imaging follow-up

To assess the short-term safety and efficacy of gallbladder cryoablation in high-risk patients. Patients with cholecystitis previously treated with a cholecystostomy tube (n = 6) or biliary colic (n = 1), who were referred for gallbladder cryoablation between August 2018 and July 2019 were followed clinically and with imaging for 3-12 months. All patients had significant preprocedural comorbidities and were deemed unacceptable surgical candidates by an attending surgeon. Primary efficacy measures were technical success of the procedure, absence of symptoms at 1 month, and imaging evidence of cystic duct obstruction and gallbladder devitalization. The primary safety measure was the presence/absence of the Society of Interventional Radiology’s moderate or greater adverse events. There was no peri-procedure, early (<30 day), or in-hospital mortality. Technical success was 86% with 1 of 7 patients unable to undergo cryoablation because of adhesions preventing hydrodissection of the colon away from the gallbladder. Abdominal pain was absent in all patients 1 month after ablation. At least 1 CT or MR was completed 1-6 months after ablation and demonstrated evidence of gallbladder involution in 4/6 patients. Hepatobiliary iminodiacetic acid scans were completed in 5/6 patients 1 month after ablation and demonstrated cystic duct occlusion in all 5 patients. One moderate and 1 life-threatening adverse event occurred. These early outcomes suggest that gallbladder cryoablation may be a viable treatment option for high-risk patients with gallbladder disease and warrant further investigation.

EUS-guided versus endoscopic transpapillary gallbladder drainage in high-risk surgical patients with acute cholecystitis: a systematic review and meta-analysis

In patients with acute cholecystitis who are deemed high risk for cholecystectomy, percutaneous cholecystostomy (PC) was historically performed for gallbladder drainage (GBD). There are several limitations associated with PC. Endoscopic GBD [Endoscopic transpapillary GBD (ET-GBD) and EUS-guided GBD (EUS-GBD)] is an alternative to PC. We performed a systematic review and meta-analysis to compare the effectiveness and safety of EUS-GBD versus ET-GBD. We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GBD versus ET-GBD in the management of acute cholecystitis in high-risk surgical patients. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GBD and ET-GBD groups were calculated. Five studies with a total of 857 patients (EUS-GBD vs ET-GBD: 259 vs 598 patients) were included in the analysis. EUS-GBD was associated with higher technical [pooled OR 5.22 (95% CI 2.03-13.44; p = 0.0006; I2 = 20%)] and clinical success [pooled OR 4.16 (95% CI 2.00-8.66; p = 0.0001; I2 = 19%)] compared to ET-GBD. There was no statistically significant difference in the rate of overall adverse events [pooled OR 1.30 (95% CI 0.77-2.22; p = 0.33, I2 = 0%)]. EUS-GBD was associated with lower rate of recurrent cholecystitis [pooled OR 0.33 (95% CI 0.14-0.79; p = 0.01; I2 = 0%)]. There was low heterogeneity in the analyses. EUS-GBD has higher rate of technical and clinical success compared to ET-GBD. While the rates of overall adverse events are statistically similar, EUS-GBD has lower rate of recurrent cholecystitis. Hence, EUS-GBD is preferable to ET-GBD for endoscopic management of acute cholecystitis in select high-risk surgical patients.

1335 Unchewed Food: The Enemy of Lumen-Apposing Metal Stent Placement in EUS-Gallbladder Drainage

INTRODUCTION: Lumen-apposing metal stents (LAMS) represent a novel therapeutic endoscopic tool for the treatment of acute cholecystitis in high-risk surgical patients via transluminal EUS guided gallbladder (GB) drainage with reported 92-98% success rates. We describe a patient's successful EUS guided drainage and subsequent clinical deterioration after food related LAMS occlusion. CASE DESCRIPTION/METHODS: A 63-year-old man with extensive cardiopulmonary disease, GB hydrops, chronic cholecystitis and prior course of decompression with percutaneous cholecystostomy tube (PTC), was re-evaluated for worsening post-prandial abdominal pain. A CT showed a hydropic GB with layering stones and sludge, concerning for cholecystitis. Semi-urgent decompression with IR cholecystostomy tube vs. EUS-GB drainage was suggested because of his poor surgical candidacy. The patient declined PTC due to reduced quality of life and lack of symptomatic relief in the past. A linear EUS evaluation showed a distended, thick walled GB (12 cm in size) with sludge and debris. A cholecystoenterostomy via doppler EUS was created, followed by deployment of a 15 mm LAMS stent with immediate drainage of copious purulent bile. A 7 Fr × 7 cm double pigtail stent was placed across the LAMS. Despite a technically successful procedure, the patient did not experience clinical improvement. A follow up CT demonstrated decreased GB distention, appropriate LAMS position and related intraluminal GB gas; yet increased GB wall thickening, pericholecystic fluid, and fat stranding in the perihepatic region were consistent with worsening acute cholecystitis. A repeat EGD was performed to ensure proper LAMS location and patency. Large unchewed food pieces in the duodenal bulb and an at least partially occluded LAMS, due to food-debris, were discovered. The LAMS and GB lumen were cleared of food debris using a combination of forceps and water irrigation. The patient was placed on a full liquid diet and subsequently demonstrated clinical improvement. DISCUSSION: EUS-guided GB drainage with LAMS placement is a viable alternative to cholecystectomy for high risk surgical candidates when performed in clinical centers of expertise. Procedural success is high, yet lack of clinical improvement may require further evaluation for possible LAMS occlusion. We describe a case of lack of improvement due to documented occlusion of the LAMS related to poorly chewed food. Dietary counseling for patients post LAMS placement may be beneficial.

EUS-guided cholecystostomy versus endoscopic transpapillary cholecystostomy for acute cholecystitis in high-risk surgical patients

Endoscopic gallbladder drainage (GBD) has been performed as an alternative to percutaneous drainage for acute cholecystitis. To date, there has been no comparative study between EUS-guided cholecystostomy (EUSC) and endoscopic transpapillary cholecystostomy (ETC). The aim of this study was to compare the outcomes of EUSC and ETC. A retrospective review of an endoscopic GBD database prospectively collected at the Asan Medical Center (between July 2010 and December 2014) was performed to identify consecutive patients with acute cholecystitis who underwent attempted endoscopic GBD. Procedural and long-term outcomes were evaluated using inverse probability of treatment weighting (IPTW). A total of 172 patients (76 in the EUSC group and 96 in the ETC group) were included in this study. Seven patients who failed to undergo ETC crossed over to the EUSC group. After adjustment with the IPTW method, technical success (99.3% vs 86.6%, P< .01) and clinical success (99.3% vs 86%, P< .01) rates were significantly higher in the EUSC group than in the ETC group. The procedure-related adverse event rate was significantly higher in the ETC group (7.1% vs 19.3%, P= .02). The cholecystitis or cholangitis recurrence rate (12.4% vs 3.2%) was also higher in the ETC group than in the EUSC group, as identified using Cox analysis (hazard ratio, 3.01; 95% confidence interval, .73-12.9; P= .04). In patients with acute cholecystitis who are unfit for surgery, EUSC may be a more suitable treatment method than ETC.

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 &amp;lt; 0.001, P &amp;lt; 0.001, and P &amp;lt; 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 &amp;lt; 0.001). Length of hospital stay was significantly shorter in the LC group compared with the PC group (P &amp;lt; 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.

Endoscopic Ultrasound-Guided Transmural by Gastroenterologist vs Percutaneous Transhepatic by Interventional Radiologist for Gallbladder Drainage in Acute Cholecystitis in High-Risk Surgical Patients

Endoscopic Ultrasound-Guided Transmural by Gastroenterologist vs Percutaneous Transhepatic by Interventional Radiologist for Gallbladder Drainage in Acute Cholecystitis in High-Risk Surgical Patients

Endoscopic ultrasound-guided transmural stenting for gallbladder drainage in high-risk patients with acute cholecystitis: a systematic review and pooled analysis.

Endoscopic ultrasound-guided transmural stenting for gallbladder drainage is an emerging alternative for the treatment of acute cholecystitis in high-risk surgical patients. A variety of stents have been described, including plastic stents, self-expandable metal stents (SEMSs), and lumen-apposing metal stents (LAMSs). LAMSs represent the only specifically designed stent for transmural gallbladder drainage. A systematic review was performed to evaluate the feasibility and efficacy of EUS-guided drainage (EUS-GBD) in acute cholecystitis using different types of stents. A computer-assisted literature search up to September 2015 was performed using two electronic databases, MEDLINE and EMBASE. Search terms included MeSH and non-MeSH terms relating to acute cholecystitis, gallbladder drainage, endoscopic gallbladder drainage, endoscopic ultrasound gallbladder drainage, alone or in combination. Additional articles were retrieved by hand-searching from references of relevant studies. Pooled technical success, clinical success, and adverse event rates were calculated. Twenty-one studies met the inclusion criteria, and the eligible cases were 166. The overall technical success rate, clinical success rate, and frequency of adverse events were 95.8, 93.4, and 12.0%, respectively. The technical success rate was 100% using plastic stents, 98.6% using SEMSs, and 91.5% using LAMSs. The clinical success rate was 100, 94.4, and 90.1% after the deployment of plastic stents, SEMSs, and LAMSs, respectively. The frequency of adverse events was 18.2% using plastic stents, 12.3% using SEMSs, and 9.9% using LAMSs. Among the different drainage approaches in the non-surgical management of acute cholecystitis, EUS-guided transmural stenting for gallbladder drainage appears to be feasible, safe, and effective. LAMSs seem to have high potentials in terms of efficacy and safety, although further prospective studies are needed.

Long-term outcomes of endoscopic gallbladder stenting in high-risk surgical patients with calculous cholecystitis (with videos)

Recently, endoscopic gallbladder stenting (EGBS) has been performed to prevent recurrences in high-risk surgical patients with cholecystitis. However, evidence regarding the long-term outcomes of EGBS is sparse. We investigated the cholecystitis recurrence rate in high-risk surgical patients with acute calculous cholecystitis and compared the cholecystitis recurrence rates in patients in whom EGBS was performed with those in patients who were observed after percutaneous drainage. We studied 64 consecutive high-risk surgical patients with acute calculous cholecystitis who required gallbladder decompression between 2007 and 2014. We divided the patient cohort into patients who underwent observation after percutaneous drainage between 2007 and 2011 (OAPD group) and those who underwent EGBS between 2012 and 2014 (EGBS group), and we compared the groups. The technical success rate of EGBS was 82.9% based on the intention-to-treat analysis. The cholecystitis recurrence rates were 17.2% in the OAPD group and 0% in the EGBS group, a difference that was significant (P = .043). There was also a significant difference between the groups with respect to the time to recurrent cholecystitis, which was determined by using Kaplan-Meier analysis (P = .015). The overall biliary event rates were 24.1% in the OAPD group and 9.1% in the EGBS group, and no significant difference was noted (P = .207). EGBS reduced the recurrence of cholecystitis in high-risk surgical patients with calculous cholecystitis. However, stent-related adverse events may occur, and modifications are necessary to reduce these.

EUS-guided gall bladder drainage with a lumen-apposing metal stent: a prospective long-term evaluation

Endoscopic ultrasound-guided gall bladder drainage (EUS-GBD) has been shown to be comparable with percutaneous gall bladder drainage (PTGBD) in terms of technical feasibility and clinical efficacy for the treatment of...

738 EUS-Guided Drainage With a Large Diameter Metal Stent Is a Safe Treatment for Acute Cholecystitis in High-Risk Surgical Patients

Percutaneous gallbladder drainage is the treatment of choice in high-risk surgical patients with acute cholecystitis. However, continuous drainage is associated with patient discomfort and risk of inadvertent drain removal which may lead to bile leakage and recurrent cholecystitis. Recently, EUS-guided transmural drainage has been reported as an alternative treatment option.

Percutaneous Cholecystostomy Is Appropriate as Definitive Treatment for Acute Cholecystitis in Critically Ill Patients: A Single Center, Cross-sectional Study

Percutaneous cholecystostomy (PC) is an effective treatment for cholecystitis in high-risk surgical patients. However, there is no definitive agreement on the need for additional cholecystectomy in these patients. All patients who were admitted to Cheju Halla General Hospital (Jeju, Korea) for acute cholecystitis and who underwent ultrasonography-guided PC between 2007 and 2012 were consecutively enrolled in this study. Among 82 total patients enrolled, 35 underwent laparoscopic cholecystectomy after recovery and 47 received the best supportive care (BSC) without additional surgery. The technical and clinical success rates for PC were 100% and 97.5%, respectively. The overall mean survival was 12.8 months. In the BSC group, mean survival was 5.4 months, and in the cholecystectomy group, mean survival was 22.4 months (p<0.01). However, there was no significant difference between these groups in multivariate analysis (relative risk [RR]=1.92; 95% CI, 0.77-4.77; p=0.16). However, advanced age (RR=1.05; 95% CI, 1.02-1.08; p=0.001) and higher class in the American Society of Anesthesiologists' physical status (RR=3.06; 95% CI, 1.37-6.83, p=0.006) were significantly associated with survival in the multivariate analysis. Among the 47 patients in the BSC group, the cholecystostomy tube was removed in 31 patients per protocol. Recurrent cholecystitis was not observed in either group of patients during the follow-up period. In high-risk surgical patients, PC without additional cholecystectomy might be the best definitive management. Furthermore, the cholecystostomy drainage catheter can be safely removed in certain patients.

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.

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.