Percutaneous Cholecystostomy Tube Placement Research Articles

Finding the Most Favorable Timing for Cholecystectomy after Percutaneous Cholecystostomy Tube Placement: An Analysis of Institutional and National Data

Early cholecystectomy (E-CCY; 8 weeks or less) after percutaneous cholecystostomy tube (PCT) placement has been associated with increased postoperative complications, but this finding has not been validated at a national level and PCT-related complications and interventions (PCT-RCIs) were not evaluated. Adults with PCT for acute cholecystitis subsequently undergoing CCY were identified within the Nationwide Readmission Database (2010-2015) and our institution (2017-2019). Adjusted relative risks (aRRs) of postoperative complications were estimated using Poisson regression comparing E-CCY with delayed cholecystectomy (D-CCY; more than 8 weeks) within the nationwide cohort. Institutional PCT-RCIs, operative data, and postoperative outcomes were compared between E-CCY and D-CCY using chi-square and Kruskal-Wallis tests. Of 6,145 patients from the Nationwide Readmission Database, 32.9% were D-CCY. Risk-adjusted analysis identified no differences between E-CCY and D-CCY in complications (aRR 0.98; 95% CI, 0.89 to 1.07), mortality (aRR 0.88; 95% CI, 0.43 to 1.81), or 30-day readmissions (aRR 1.04; 95% CI, 0.85 to 1.27). Risk-adjusted analyses assessing the association of time to interval cholecystectomy (IC) with morbidity indicated an increased risk of surgical complications in the first month after PCT placement (aRR 1.17; 95% CI, 1.08 to 1.33). In the institutional cohort (E-CCY, n= 23; D-CCY, n= 45), there were no statistically significant differences found in estimated blood loss, length of stay, and postoperative complications. There were increased PCT-RCIs in the D-CCY group (26.9% E-CCY vs 69% D-CCY; p < 0.01) based on our unadjusted analysis. Increased operative complications when IC is performed within 1 month of PCT placement and increased PCT-RCIs when IC is performed 8 weeks after PCT placement suggest that the most favorable timing for IC is between 4 and 8 weeks after PCT placement.

S1919 Acute Esophageal Obstruction: A Unique Case of a Thrombus Impaction

INTRODUCTION: Esophageal obstruction is a common gastrointestinal emergency generally caused by foreign objects in children and by food in adults. There are no prior reports in the medical literature of an esophageal obstruction caused by a large thrombus. We present a case that demonstrates a unique cause of esophageal obstruction in order to help clinicians broaden their differential in such a case. CASE DESCRIPTION/METHODS: A 71-year-old male with coronary artery disease, atrial fibrillation on apixaban, and insulin-dependent diabetes presented to the emergency department with right upper quadrant pain. He was found to have acute cholecystitis and given his comorbidities he was successfully treated with percutaneous cholecystostomy tube placement. On the day of planned discharge the patient began to experience sudden onset dysphagia with coffee-ground emesis. His dysphagia progressed in a matter of hours to the point that he was spitting up his secretions, raising suspicion for an esophageal obstruction. A few hours later he developed frank hematemesis associated with tachycardia which prompted an emergent upper endoscopy. Exam showed a large distal esophageal thrombus obliterating the lumen. No active bleeding was noted. The gastroscope was used to apply forward gentle pressure to the right aspect of the thrombus. This intervention was unsuccessful. Next, using a 3 × 5.5-cm RescueNet™ retrieval net the large thrombus was grasped and successfully extracted. The thrombus measured 9 x 2-cm. Inspection of the underlying esophageal mucosa revealed Grade D erosive esophagitis. His severe esophagitis was treated with omeprazole 40 mg twice daily for 8 weeks. The patient was able to tolerate oral intake following this endoscopic intervention and he was discharged home the following day, after admitting to his providers a long history of intermittent dysphagia to solids. Repeat upper endoscopy to check for esophageal healing and outpatient high resolution esophageal manometry are planned for further work up of an underlying motility disorder pending lifting of pandemic-related scheduling restrictions. DISCUSSION: We believe this is first case of acute esophageal obstruction by large impacted thrombus. In addition, this case potentially demonstrates two pathologies, esophagitis and suspected dysmotility, resulting in a unique presentation. Clinicians must keep a broad differential for patients who develop esophageal obstruction without discrete food bolus ingestion.Figure 1.: Tubular shaped, distal esophageal thrombus impacting the distal esophagus.Figure 2.: Portion of the thrombus removed.Figure 3.: Distal esophagus with Grade D erosive esophagitis.

Cholecystostomy as an Exclusive Access to Remove Cystic, Common Hepatic, and Common Bile Duct Stones.

OBJECTIVE. The purpose of this article was to evaluate the feasibility and efficacy of percutaneous fluoroscopic-guided stone retrieval from the cystic duct and antegrade common bile duct (CBD) stone advancement into the duodenum exclusively through a cholecystostomy tube. MATERIALS AND METHODS. Twenty-one patients with acute cholecystitis and choledocholithiasis or an impacted cystic duct stone who underwent percutaneous cholecystostomy tube placement were retrospectively enrolled in this study. The patients had a contra-indication for cholecystectomy (17 patients because of comorbidities and one who declined surgery) or had failed endoscopic retrograde stone removal attempts (three patients). RESULTS. The 21 patients underwent subsequent percutaneous CBD (17 patients) and cystic duct (nine patients) stone removal on follow-up sessions through the percutaneous cholecystostomy track using moderate sedation. A total of 32 stone removal procedures were performed. Seventeen patients underwent balloon dilatation sphincterotomy, after which the CBD stones were pushed forward into the duodenum using a compliant balloon. Seven patients also had stone removal from the cystic duct by a stone retrieval basket. The primary technical success rate for removal of all CBD and cystic duct stones was 76%. The secondary technical success rate was 100%. The clinical success rate was 74%. All patients tolerated the procedures well without major complication. The clinical follow-up interval ranged from 2 to 2310 days (median, 30 days), with no incidence of postprocedural complications. CONCLUSION. Percutaneous transcholecystic common bile and cystic duct stone removal through an existing cholecystostomy access is a safe and effective procedure that is well tolerated.

Su1320 SAFETY OF EUS GUIDED GALL BLADDER DRAINAGE IN GRADE 4 CHOLECYSTITIS

Acute cholecystitis with a perforated gall bladder (GB) is described as grade 4 cholecystitis. Studies have shown higher intraoperative bile duct injuries and complications in patients with perforated GB with increased costs, increased length of stay, and increased conversion to open cholecystectomy. For, patients who are poor operative candidates, decompression can be achieved with percutaneous GB drainage. Alternatively, EUS guided GB drainage (EUS-GBD) has been shown to be safe and effective in acute cholecystitis, however, there is no existing data on EUS-GBD in patients with perforated GB. We describe a multicenter case series of EUS-GBD in the setting of grade 4 cholecystitis. We performed a multicenter retrospective review of patients with acute cholecystitis and GB perforation who underwent EUS-GBD using Lumen Apposing Metal Stents (LAMS). Technical success (TS) was defined as successful placement of EUS guided LAMS with a transduodenal or transgastric approach. Clinical success was defined as resolution of acute cholecystitis, fever, pain, and leukocytosis. A total of 5 patient underwent EUS-GBD in this multicenter cohort. Four males and 1 female with a median age of 69 (age range 58-88 years). Indications for procedure was acute cholecystitis with perforated gall bladder. Etiologies included calculus cholecystitis (N=3) and malignant biliary stricture (N=2) resulting in cystic duct obstruction. All patients were deemed non-surgical candidates due to medical comorbidities (N=5). Imaging was consistent with perforated GB (Image 1). All procedures were performed under GA with noted ASA classes 3 (N=3) and class 4 (N=2). GB perforation was observed on EUS and confirmed on cholecystoscopy (Image 2). TS and CS was observed in 100% of the cases with no procedure related complications. Antibiotics were used for an average of 8 days. Average length of procedure was 70 minutes. One patient developed stent occlusion at 1 month and again 1 year. This was treated endoscopically with removal of food debris. Average follow up was otherwise unremarkable for all patients for average of 13 months. Our case series shows it is technically feasible and safe to achieve adequate drainage using a LAMS for patients with grade 4 cholecystitis which can avoid surgery or indefinite percutaneous cholecystostomy tube placement and complications related to that. Additionally, there were no procedure related complications and all patients had resolution of inflammatory and infectious symptoms with the transmural approach. Larger prospective studies may further define the efficacy of endoscopic management in grade 4 cholecystitis using LAMS EUS-GBD approach.Image 2.GB perforation on EUS and cholecystoscopyView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Outcomes of Patients Treated With Upfront Cholecystostomy for Severe Acute Cholecystitis.

Percutaneous cholecystostomy tube (PCT) placement is a treatment method for acute cholecystitis, both in adult patients unsuitable for surgery and those failing to improve with conservative management. The purpose of this study was to assess the outcomes of patients undergoing cholecystostomy. A review of consecutive patients who underwent PCT insertion over a 10-year period was performed. Outcomes assessed included cholecystostomy dwell time, tubogram requirement, cholecystostomy reinsertion, cholecystectomy, bile leaks, and mortality. One hundred eight patients (77 male individuals, 31 female individuals) were included. The mean age was 70 years (range: 29 to 93 y). A total of 89 transhepatic and 19 transperitoneal PCTs were inserted. Fifty-nine patients (55%) had a subsequent tubogram to assess cystic duct patency or catheter position. Mean catheter dwell time was 17 days (range: 1 to 154 d). Eleven (10%) required PCT reinsertion. Time to reinsertion ranged from 2 to 163 days (mean=38 d). Fifty-three patients (50%) had no further biliary intervention after removal of the cholecystostomy catheter. One patient required subsequent drainage of a hepatic abscess, and another developed a biloma. Thirty-two patients (30%) underwent cholecystectomy (66% laparoscopic, 34% open). Thirty-day mortality after PCT insertion was 8.3%. Twenty patients (19%) died of non-cholecystostomy-related illness during the 10-year follow-up period. Cholecystostomy is an important treatment method of acute cholecystitis as a bridge to cholecystectomy or as an alternative definitive treatment option in those unsuitable for surgery. A tubogram is not always necessary before tube removal. Cholecystostomy tubes can be removed safely with little risk of bile leak if patients are clinically well, and clean-appearing bile is draining.

1100 Outcomes of Cholecystostomy With and Without Follow-Up Cholecystectomy in Patients With Cirrhosis

INTRODUCTION: Cirrhotic patients are twice as likely as the general population to form gallstones and are therefore at increased risk for acute cholecystitis. Cholecystectomy (CCY) is currently the definitive therapy for cholecystitis, but cirrhotic patients have been shown to have dramatically higher mortality rates during CCY in previous studies. Percutaneous cholecystostomy tube (PCT) placement is therefore an alternative to CCY in cirrhosis. Subsequently these patients require CCY. However, data on PCT and subsequent CCY cirrhotics are not reported. We studied the trends and outcomes of PCT with and without follow-up CCY in cirrhotic patients. METHODS: The National Readmissions Database (NRD), using pre-validated ICD-9 codes was queried to study the patients with acute calculous cholecystitis between the years of 2010-2014 who underwent either CCY or PCT with or without follow-up CCY. Study groups included non-cirrhotics (NC), compensated cirrhotics (CC) and decompensated cirrhotics (DC). DC patients were classified using Baveno IV criteria. Variables included were patient and hospital characteristics, Elixhauser co-morbidities, rates of CCY, rates of PCT with or without follow-up CCY, and approach to CCY- open vs closed. Primary outcomes included 30-day readmission rates, plus index and calendar year mortality. Secondary outcomes were rates of PCT placement, rates of CCY after PCT, length of stay and cost. RESULTS: PCT are more commonly placed in cirrhotics (3.7%) compared to non-cirrhotics with acute cholecystitis (1.4%). Within cirrhotics, DC (7.7%) received far more PCT than CC (2.9%). Inversely, NC underwent more CCY vs CC and DC (98.9%, 97.4% and 92.9%, respectively). Predictors of PCT were DC (P &lt; 0.001), but not CC (P = 0.23) compared to NC. PCT was followed by CCY less in cirrhotics than NC with DC having the lowest rates (NC: 39.9%, CC: 28.6%, and DC: 16.1%). Presence of CC and DC were predictors of not receiving CCY after PCT ((OR: 0.57; CI: 0.35-0.92) and (OR:0.29; CI:0.14-0.60), respectively). Finally, outcomes of CCY after PCT were shown to be similar between NC vs all cirrhotics with all comparisons not being statistically significant. CONCLUSION: Cirrhosis was seen as a risk factor for PCT without subsequent CCY with DC having the lowest rates. However, while CC and DC had lower rates of CCY after PCT, their outcomes were similar to NC. Allowing time for medical optimization with PCT tubes, especially in CC, may result in similar surgical outcomes to NC undergoing follow-up CCY.

2181 Gallbladder Irrigation via Cholecystostomy Tube as a Novel Technique for Improving EUS-Guidance During Placement of Lumen-Apposing Metal Stent (LAMS) for Cholecystoduodenostomy

INTRODUCTION: Cholecystectomy is the preferred treatment of acute cholecystitis, but it may be relatively contraindicated in patients with medical comorbidities or advanced age. Non-surgical approaches include percutaneous transhepatic cholecystostomy tube and endosonographic stent placement. Adequate endosonographic imaging of the gallbladder is essential for correct stent deployment. CASE DESCRIPTION/METHODS: A 55-year-old male was admitted for endoscopic cholecystoduodenostomy for palliation of chronic cholecystitis. He had prior admissions for cholecystitis and choledocholithiasis with cholangitis with prior ERCPs requiring sphincterotomy, sphincteroplasty, stone removal and common bile duct stent placement. He was a poor candidate for cholecystectomy due to multiple medical comorbidities and chronic anticoagulation and was referred for endoscopic therapy. The patient was brought to the endoscopy suite and placed under general anesthesia. The Olympus linear echoendoscope was passed to the second portion of the duodenum. The gallbladder was collapsed due to prior patent sphincterotomy and sphincteroplasty. With IR assistance, the gallbladder was irrigated with normal saline boluses of to a volume of 600 mL. Due to the patent sphincterotomy, the gallbladder would collapse requiring additional irrigation. Maximal size of the gallbladder 30 mm in the long axis and 20 mm in the short axis. The duodenal wall and the gallbladder were punctured under endosonographic guidance using the hot AXIOS electrocautery-enhanced delivery system. A stoma was created and a 15 × 10 mm AXIOS stent was placed with flanges in close approximation to the gallbladder and duodenal wall through the cholecystoduodenostomy. The echoendoscope was then withdrawn. Next, a solution of normal saline and methylene blue was injected through the percutaneous cholecystostomy tube and this solution was seen to flow from the duodenal portion of the AXIOS stent on endoscopic views, confirming adequate location of the AXIOS stent in the gallbladder and duodenum. DISCUSSION: The patient did well in the immediate post-procedural period. Six days post-procedure, he was noted to have melena in the setting of supratherapeutic INR and aPTT. Repeat upper endoscopy showed no evidence of bleeding. The AXIOS stent appeared normal on endoscopic views. Due to the difficulty of stent placement and palliative intent, we left the AXIOS stent in situ. The patient is currently asymptomatic and was referred to IR for removal of percutaneous cholecystostomy tube.

Early cholecystectomy (≤ 8weeks) following percutaneous cholecystostomy tube placement is associated with higher morbidity.

Percutaneous cholecystostomy tube (PCT) placement is often the initial management approach to severe acute cholecystitis in the unstable patient. However, the timing of cholecystectomy after PCT has not been carefully examined. The purpose of this study was to compare outcomes of early versus late cholecystectomy following PCT placement. The New York SPARCS administrative database was searched for all patients undergoing PCT placement between 2000 and 2012. Patients were followed for subsequent cholecystectomy (CCX) procedures up to 2014. Subsequent cholecystectomies were divided into early (≤ 8weeks) versus late (> 8weeks) groups. Outcomes included overall complications, 30-day readmissions, 30-day Emergency Department (ED) visits, and length of stay (LOS). Multivariable regression models were used to examine the differences in clinical outcomes between these two groups, after adjusting for possible confounding factors. There were 9728 patients who underwent PCT placement identified during the time period, as early subsequent cholecystectomy was performed in 1211 patients (40.4%), while 1787 (59.6%) patients had a late cholecystectomy. Average time to cholecystectomy was 38days in the early group, versus 203days in the late group. After adjusting for other confounding factors, patients with early CCX had a significantly higher risk of overall complications and longer LOS compared to the late CCX group (P = 0.01 and P = 0.0004, respectively). There were no significant differences in 30-day readmissions and 30-day ED visits. Furthermore, there was no significant difference in the risk of CBD injury between the two groups (n = 21, 1.7% in the early cholecystectomy group and n = 26, 1.5% in the late cholecystectomy group). Early cholecystectomy (≤ 8weeks) is associated with a higher risk of complications and longer hospital LOS compared to cholecystectomy performed at > 8weeks. Surgeons should be aware and should delay cholecystectomy beyond 8weeks to improve outcomes.

CHANGING TRENDS IN SURGICAL MANAGEMENT FOR ACUTE CHOLECYSTITIS, IN LIGHT OF TOKYO GUIDELINES - 14 YEAR EXPERIENCE

To look for trends in surgical management of acute cholecystitis and compare the outcomes of patients with severe condition. The retrospective study was conducted at Aga Khan University Hospital, Karachi, from January to December 2016, and comprised data of adult patients who underwent cholecystectomy for acute cholecystitis from January 1, 2001, to December 31, 2014. Record of patients from 2001 to 2007 was designated in Group-1 while Group-II covered period between 2008 and 2014. Severe cases of acute cholecystitis were divided into similar period-based Group-A and Group-B. Data was analysed using SPSS 20. Of the 1153 patients, 521(45.2%) were males. The overall mean age was 49.3+14 years. There were 309(36.2%) patents in Group-I and 844(73.2%) in Group-II. Early laparoscopic-cholecystectomy was performed in 907(78%) patients. Postoperative morbidity was observed in 73(6.3%) patients. In Group-II, there was significant increase in early cholecystectomy, decrease in conversion rates and use of percutaneous cholecystostomy tube placement (p<0.05 each). In patients with severe acute cholecystitis, higher rate of early cholecystectomy was found in Group-A but it was not significant, and the same was the case in terms of conversion rate, postoperative morbidity and hospital stay (p>0.05 each). Over the years, the institutional experience of managing acute cholecystitis has changed dramatically which has helped improve the level of care for the patients.

Cholecystectomy following percutaneous cholecystostomy tube placement leads to higher rate of CBD injuries.

Percutaneous cholecystostomy tube (PCT) placement is often the management of severe acute cholecystitis in the unstable patient. PCT can be later reversed and cholecystectomy performed. The purpose of this study is to investigate the incidence of subsequent cholecystectomy and clinical factors associated with subsequent procedure. The SPARCS, an administrative database, was used to search all patients undergoing PCT placement between 2000 and 2012 in the state of New York. Using a unique identifier, all patients were followed for subsequent cholecystectomy procedures for at least 2years. Patients were also followed up to 2014 for potential CBD injury during subsequent laparoscopic (LC) or open cholecystectomy (OC). Univariate and multivariable regression analysis were performed when appropriate. There were 9738 patients identified who underwent PCT placements. The incidence of patients who had a PCT in 2000-2012, which subsequently underwent cholecystectomy increased from 25.0% in 2000 to 31.7% in 2012. In addition, patients undergoing subsequent LC increased from 11.8% in 2000 to 22.2% in 2012, while the incidence of OC decreased from 13.2% in 2000 to 9.5% in 2012. After accounting for other confounding factors, younger male patients, race as white compared to black, who didn't have any complications during PCT placement were more likely to undergo subsequent cholecystectomy (p < 0.05). Average time to LC was 122.0 days versus 159.6 days for OC (p < 0.0001). From the patients who underwent cholecystectomy following PCT, 47 patients experienced CBD injury (1.6%). Incidence of cholecystectomy following PCT increased during the study period. Surgeons seem to be more comfortable performing LC as rate of LC increased from 11.8 to 22.2%. However, rate of CBD injury is higher during subsequent cholecystectomy compared to that of the general population. Caution should be used when performing subsequent cholecystectomy following PCT, as these procedures may be more technically challenging.

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

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

What Are the Long-Term Complications of Percutaneous Cholecystostomy Tube (PCT) Placement After Discharge From the Hospital?

What Are the Long-Term Complications of Percutaneous Cholecystostomy Tube (PCT) Placement After Discharge From the Hospital?

What Are the Outcomes of Percutaneous Cholecystostomy Tube (PCT) in Pancreatobiliary Cancer (PBCA) Patients With Acute Cholecystitis (AC)?

Introduction: Background & Aim: AC affects over 20 million Americans and leads to an annual cost exceeding US$ 6 billion. Optimal treatment is early cholecystectomy. Patients with PBCA and AC may be very challenging to manage and often require multiple procedure interventions. We aim to study our long-term institutional experience of patients with PBCA undergoing PCT. Methods: Methods: Retrospective cohort study of high-risk surgical patients with AC hospitalized at the Cleveland Clinic between 2002 and 2017. AC, PBCA and PCT were identified by ICD9 codes. The primary outcome was inpatient mortality, PCT complications and re-interventions. We adjusted for age, gender and BMI. We constructed multivariable logistic regression models using SAS software. Results: Results: PCT was placed in 377 patients, 25 (6.7%) of these patients had a PBCA causing AC. Most common malignancy was pancreatic cancer, 13 (52%), followed by liver metastases, 7 (28%), ampullary masses, 3 (12%), and cholangiocarcinoma, 2 (8%). Patients with PBCA were more likely to have interventions done than patients without malignancy, as 12% vs 2% had PTHC placement (p=0.003) and 16% vs 5% had ERCP post PCT placement (p=0.039). Interestingly, patients with malignancy required less ICU admissions than patients without, 24% vs 59% (p<0.001), with less subsequent inhospital deaths, 12% vs 21%, although not statistically different (p=0.30). Conclusion: Limitations: Retrospective study, potential misclassification (some PTC patients will not have ICD9 code). Strength: Robust patient cohort. Long-term follow up. Adjusted for age, gender and race. Limited data on PBCA and PCT outcomes. Conclusion: PCT is a viable option for PBCA patients with AC not suitable for emergent cholecystectomy, However it is associated with high rate of other interventions (PTHC, ERCP). PBCA had lower mortality and ICU requirement, which is surprising. Further and larger studies are needed to further study this topic.35_A Figure 1. Outcomes of interest and cancer

Role of Percutaneous Cholecystostomy Tube Placement in the Management of Acute Calculus Cholecystitis in High Risk Patients

Introduction: For acute cholecystitis standard of care is an urgent laparoscopic cholecystectomy. In patients with uncontrolled medical illnesses, a percutaneous cholecystostomy tube along with antibiotic therapy can be an alternate. We evaluate the use of percutaneous cholecystostomy tube in patients with acute calculus cholecystitis but considered unfit for immediate surgery. Materials and methods: This was a retrospective review of adult patients who underwent percutaneous cholecystostomy tube placement from 2010 to 2016. Results: Sixty-Five patients met the inclusion criteria. Mean age was 58.5 years .Forty-Four patients (67.7%) were males. More than 60% of the patients had ASA III/IV. 43 patients underwent interval cholecystectomy and 22 did not. Out of 43 who underwent interval laparoscopic cholecystectomy, mean operative time was 134.9 minutes (S.D+/−57.8). Five (11.6%) patients were converted to open cholecystectomy, 2 (4.6%) developed CBD injury and 7 (16.2%) developed SSI. Out of 22 patients who were followed after tube removal, 3 (13.6%) developed recurrence of symptoms and 19 (86.4%) remained symptom free. Catheter related problems occurred in 4 (18%) patients and our mean follow up was 19 months (S.D +/− 8). Conclusion: Percutaneous cholecystostomy is a good alternative for patients unfit to undergo immediate surgery. Laparoscopic cholecystectomy after tube placement becomes technically challenging as is seen by the increased rate of conversion, bile duct injury and wound infection. Recurrence of symptoms after tube removal are in a low range, therefore percutaneous tube placement can be considered a definitive management who are high risk for surgery.

Clinical and operative outcomes of patients with acute cholecystitis who are treated initially with image-guided cholecystostomy.

Percutaneous cholecystostomy (PC) tube placement followed by delayed cholecystectomy has been shown to be an effective treatment option in high-risk populations such as older and critically ill patients. The goal of this study was to review the short- and long-term clinical and operative outcomes of patients with acute cholecystitis initially treated with PC tube placement. We conducted a retrospective review of patients who underwent image-guided PC tube insertion between 2001 and 2011 at the Royal University Hospital or St. Paul's Hospital, Saskatoon. Clinical outcomes, complications and elective cholecystectomy follow-up were noted. A total of 140 patients underwent PC tube insertion, 76 men and 64 women with a mean age of 68.4 (standard deviation 17.7) years. Of the 140, 94 (67.1%) had an American Society of Anesthesiologists classification score of III or IV. Percutaneous cholecystostomy tubes remained in place for a median of 21.0 days, and the median hospital stay was 7.0 days. Readmission owing to complications from PC tubes occurred in 21 patients (15.0%), and 10 (7.1%) were readmitted with recurrent cholecystitis after tube removal. Forty-four patients (31.4%) returned for subsequent elective cholecystectomy, of whom 32 (73%) underwent laparoscopic cholecystectomy, 4 (9%) underwent open cholecystectomy, and 8 (18%) underwent laparoscopic converted to open cholecystectomy. Percutaneous cholecystostomy is a safe procedure that can be performed in patients who are older or have numerous comorbidities. However, less than one-third of such patients in our cohort subsequently had the definitive intervention of elective cholecystectomy, with a high rate of conversion from laparoscopic to open cholecystectomy.

Role of Percutaneous Cholecystostomy Tube Placement in the Management of Acute Calculus Cholecystitis in High Risk Patients.

To evaluate the utility of percutaneous cholecystostomy tube in patients with acute calculus cholecystitis, who are considered unfit for immediate surgery. Observational study. The Aga Khan University Hospital, Karachi, Pakistan, from January 2010 to December 2014. All adult patients who underwent percutaneous cholecystostomy tube placement for acute calculous cholecystitis were included. These patients were divided into two groups for further analysis. Group-I consisted those who had interval cholecystectomy after tube placement and Group-II were those who had no further treatment. Recurrence of symptoms, infections and operation related complications were noted. Sixty-five patients met the inclusion criteria. Mean age was 58.5 years. Forty-four patients (67.7%) were males. Forty-three patients underwent interval cholecystectomy (Group-I) and 22 did not (Group-II). Mean operative time was 134.9 +57.8 minutes. Five (11.6%) patients were converted to open cholecystectomy, two (4.6%) developed CBD injury, and seven (16.2%) developed surgical site infection. In Group-II, three patients (13.6%) developed recurrence of symptoms and 19 (86.4%) remained symptom-free. Catheter related problems occurred in four (18%) patients. Mean follow-up was 19 +8 months. Percutaneous cholecystostomy is a good alternative for patients unfit to undergo immediate surgery. Recurrence of symptoms after tube removal are in a low range; therefore, it can be considered a definitive management for high risk patients. Laparoscopic cholecystectomy after tube placement becomes technically challenging.

Sa1422 - Long-Term Outcomes of Percutaneous Cholecystostomy Tube (Pct) Placement in High-Risk Surgical Patients with Acute Cholecystitis (Ac)

Sa1422 - Long-Term Outcomes of Percutaneous Cholecystostomy Tube (Pct) Placement in High-Risk Surgical Patients with Acute Cholecystitis (Ac)

4:03 PM Abstract No. 168 Results of percutaneous cholecystostomy tube placement in 324 patients

Determine the technical success and clinical outcome of cholecystostomy tube placement along with removal rate after placement. A database search was performed from January 2010 to September 2017 for the term “cholecystostomy tube” yielding 1,160 patients. Patients with no indication for cholecystostomy (n = 625; 53.9%) or an outside hospital placed cholecystostomy (n = 211; 18%) were excluded. 324 (27.9%) patients with cholecystostomy tubes were included in the analysis. 312 (96.2%) tubes were placed by interventional radiology and 12 (3.8%) intraoperatively by surgery. Indication for cholecystostomy tube placement, ultrasound findings, initial lab studies, candidacy for surgery, comorbidities, access route, tube size, dwell time, bile culture results, reason for tube removal, follow-up, and complications were recorded. The indications for cholecystostomy tube placement included: acute cholecystitis (n = 270; 83.3%), perforated cholecystitis (n = 22; 6.8%), and emphysematous cholecystitis (n = 18; 5.6%). Ultrasound findings included: wall thickening (n = 208; 64.2%), calculi (n = 187; 57.7%), and pericholecystic fluid (n = 143; 44.1%). 297 (91.7%) patients were not surgical candidates. The most frequent reason for removal was cholecystectomy (n = 96; 29.6%). 36 (11.1%) had a patent cystic duct on follow-up, 19 (5.9%) had cholecystoscopy and stone removal, 15 (4.6%) underwent double J stent placement, and 3 (0.01%) had liver transplants. 94 patients died (29%), 33 (10.2%) had tubes migrate or fall out. 256 (79%) had transhepatic and 56 (17.2%) had transperitoneal tubes. Mean tube size was 7-French. Mean dwell time was 89 days (range, 0-586 days). 45 (13.9%) patients had tubes at the end of study period, and 19 (4.2%) were lost to follow-up, 13 (28.9%) had ongoing tube changes, 8 (17.8%) scheduled cholecystectomy, and 4 (8.9%) getting downsized with plans for removal. 321 (99%) of patients had no major adverse events, 2 (0.006%) had bile leak, and 1 (0.001%) developed septic shock. Cholecystostomy tube placement was possible in all patients and clinical symptoms resolved after placement in all cases. A majority of patients were able to have their tubes removed.

Emergent cholecystectomy is superior to percutaneous cholecystostomy tube placement in critically ill patients with emergent calculous cholecystitis

BackgroundThe role of percutaneous cholecystostomy (PC) is undefined in patients with multiple comorbidities presenting with emergent calculous cholecystitis (CC). This study compared outcomes between PC, laparoscopic (LC), and open cholecystectomy (OC). MethodsThe Vizient UHC database was queried for high-risk patients with CC who underwent PC, LC, OC, or laparoscopic converted to open cholecystectomy (CONV). Demographics, outcomes, mortality, length of stay (LOS), and direct cost were compared between the groups. ResultsLC was the most common approach with the lowest risk of death, complications, LOS, and cost. Complication risk was highest in OC. Nearly 20% of patients underwent PC. Complication rate, LOS, infection, aspiration pneumonia, and mortality were higher in PC. Direct cost was lowest in LC, followed by CONV, PC, and OC. ConclusionsEmergent cholecystectomy for CC in high-risk patients is safer and more cost effective than PC and this study supports the use of cholecystectomy as the primary treatment approach in these patients.

A Prototype Educational Model for Hepatobiliary Interventions: Unveiling the Role of Graphic Designers in Medical 3D Printing.

In the context of medical three-dimensional (3D) printing, in addition to 3D reconstruction from cross-sectional imaging, graphic design plays a role in developing and/or enhancing 3D-printed models. A custom prototype modular 3D model of the liver was graphically designed depicting segmental anatomy of the parenchyma containing color-coded hepatic vasculature and biliary tree. Subsequently, 3D printing was performed using transparent resin for the surface of the liver and polyamide material to develop hollow internal structures that allow for passage of catheters and wires. A number of concepts were incorporated into the model. A representative mass with surrounding feeding arterial supply was embedded to demonstrate tumor embolization. A straight narrow hollow tract connecting the mass to the surface of the liver, displaying the path of a biopsy device's needle, and the concept of needle "throw" length was designed. A connection between the middle hepatic and right portal veins was created to demonstrate transjugular intrahepatic portosystemic shunt (TIPS) placement. A hollow amorphous structure representing an abscess was created to allow the demonstration of drainage catheter placement with the formation of pigtail tip. Percutaneous biliary drain and cholecystostomy tube placement were also represented. The skills of graphic designers may be utilized in creating highly customized 3D-printed models. A model was developed for the demonstration and simulation of multiple hepatobiliary interventions, for training purposes, patient counseling and consenting, and as a prototype for future development of a functioning interventional phantom.