Ultrasound-guided percutaneous cholecystostomy in acute cholecystitis: case vignette and review of the technique.
ABSTRACT: Acute cholecystitis is a frequent condition. Although cholecystectomy is the indicated treatment of this entity, it cannot be performed in some high-risk surgery patients, such as critically ill or those with multiple comorbidities. In these non-uncommon scenarios, percutaneous cholecystostomy is the recommended alternative treatment, which allows immediate decompression and drainage of the acutely inflamed gallbladder and thus reducing the patient's symptoms and the systemic inflammatory response. Ultrasound is the imaging method of choice to guide the percutaneous cholecystostomy procedure due to its real-time guidance, lack of ionizing radiation and portability, avoiding the need to transfer unhealthy patients to the radiology department. We will review the ultrasound-guided percutaneous cholecystostomy procedure, of special interest for radiologists, surgeons, and also intensive care and emergency physicians.
Project description:Acute cholecystitis is a common diagnosis. However, the heterogeneity of presentation makes it difficult to standardize management. Although surgery is the mainstay of treatment, critically ill patients have been managed via percutaneous cholecystostomy. However, the role of percutaneous cholecystostomy in the management of such patients has not been clearly established. This systematic review will compare the outcomes of critically ill patients with acute cholecystitis managed with percutaneous cholecystostomy to those of similar patients managed with cholecystectomy.Systematic searches will be conducted across relevant health databases including the Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, Embase, and Scopus using the following keywords: (acute cholecystitis OR severe cholecystitis OR cholecystitis) AND (cholecystectomy OR laparoscopic cholecystectomy OR open cholecystectomy) AND (Cholecystostomy OR percutaneous cholecystectomy OR gallbladder drain OR gallbladder tube OR transhepatic gallbladder drain OR transhepatic gallbladder tube OR cholecystostomy tube). The reference lists of eligible articles will be hand searched. Articles from 2000-2014 will be identified using the key terms "acute cholecystitis, cholecystectomy, and percutaneous cholecystostomy". Studies including both interventions will be included. Relevant data will be extracted from eligible studies using a specially designed data extraction sheet. The Newcastle-Ottawa scale will be used to assess the quality of non-randomized studies. Central tendencies will be reported in terms of means and standard deviations where necessary, and risk ratios will be calculated where possible. All calculations will be performed with a 95 % confidence interval. Furthermore, the Fisher's exact test will be used for the calculation of significance, which will be set at p?<?0.05. Pooled estimates will be presented after consideration of both clinical and methodological heterogeneity of included studies. Both interventions would be compared with regard to in-hospital mortality, 30-day mortality, procedure-dependent complications, re-intervention, length of intensive care unit (ICU) stay, length of hospital stay, re-admission, and cost of treatment. The review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.This systematic review aims at identifying and evaluating the clinical value of percutaneous cholecystostomy in the management of critically ill patients with acute cholecystitis.PROSPERO CRD42015016205.
Project description: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.
Project description:The purpose of this study was to evaluate the clinical course and possible benefit of a percutaneous cholecystostomy in patients with acute cholecystitis.Retrospective study of 104 patients with severe cholecystitis or cholecystitis not responding to antibiotic therapy treated with percutaneous drainage of the gall bladder (PC) during the period 2007 - 2013. Primary outcome was relief of cholecystitis, complications following the procedure and need for later cholecystectomy.There were 57 men and 47 women with a median age of 73,5 years (range 22 - 96). 43% of the patients were ASA III or IV and 91% had cholecystitis Grade 2 or 3. About 60% of the patients had severe comorbidity (cardiovascular disease or active cancer). Drain insertion was successful in all but one patient and complications were mild, apart from two patients that needed percutaneous drainage of intraabdominal fluid collection due to bile leakage. The drain was left in place for 1 - 75 days (median 6,5). When evaluated clinically and by blood tests (CRP and white blood cell counts) we found resolution of symptoms in 101 patients (97,2%), whereas 2 patients had no obvious effect of drainage. Four patients died within 30 days, no deaths were related to the drainage procedure. Follow-up after drainage was median 12 months (range 0 - 78). During that time cholecystectomy was performed in 30 patients and 24 patients had died. Following cholecystectomy, two had died, both from cancer and more than one year after the operation.Patients with acute cholecystitis were promptly relieved from their symptoms following PC. There were only minor complications following the procedure and only about 30% of the patients had a later cholecystectomy.
Project description:The optimal timing of percutaneous cholecystostomy for severe acute cholecystitis is unclear. The aim of this study was to investigate the timing of percutaneous cholecystostomy and its relationship to clinical outcomes in patients with inoperable acute severe cholecystitis.From 2008 to 2010, 209 consecutive patients who were admitted to our hospital due to acute cholecystitis and were treated by percutaneous cholecystostomy were retrospectively reviewed. The time periods from symptom onset to when percutaneous cholecystostomy was performed and when patients were discharged were recorded.In the 209 patients, the median time period between symptom onset and percutaneous cholecystostomy was 23?hours (range, 3-95?hours). The early intervention group (?24?hours, n?=?109) had a significantly lower procedure-related bleeding rate (0.0% vs 5.0%, P?=?0.018) and shorter hospital stay (15.8?±?12.9 vs 21.0?±?17.5 days) as compared with the late intervention group (>24?hours, n?=?100). Delayed percutaneous cholecystostomy was a significant independent factor for a longer hospital stay (odds ratio 3.03, P?=?0.001).In inoperable patients with acute severe cholecystitis, early percutaneous cholecystostomy reduced hospital stay and procedure-related bleeding without increasing the mortality rate.
Project description:Objective:The objective of the study was to evaluate the safety and efficacy of percutaneous cholecystostomy (PC) in treating critically ill patients with emphysematous cholecystitis who were deemed poor surgical candidates. Materials and Methods:The Institutional Review Board exemption was obtained for this retrospective study. Patients with emphysematous cholecystitis who were deemed to be poor operative candidates by the treating surgeon and underwent PC placement between May 2008 and April 2017 at a single institution were identified through a medical records search. Demographics, laboratory values, imaging data, procedural technique, complications, hospitalization course, clinical outcome, and survival data were obtained. Results:Ten consecutive patients were included, with a mean age of 75.0 ± 12.2 years, including six men and four women. The most common comorbidity was diabetes (60%, 6/10) followed by hypertension (40%, 4/10). Intraluminal or intramural gas as well as gallbladder wall thickening were noted in all patients. Procedure technical success rate was 100%. There was a complete resolution of symptoms in 90% (9/10) of patients at a mean of 2.9 ± 1.4 days post-procedure. Thirty-day survival rate was 90% (9/10); one patient died on the 6th post- procedure day from sepsis. Two more deaths occurred within a year after PC from unrelated causes. About 50% (5/10) of patients underwent elective cholecystectomy at a median interval of 69 days post-procedure. In 40% (4/10) of patients, cholecystostomy was the definitive treatment, with tube removal at a median of 140 days post- procedure. Conclusion:PC appears to be a safe and generally effective alternative management option in patients with emphysematous cholecystitis that is considered very high risk for surgery.
Project description:BACKGROUND:The Tokyo Guidelines recommend initial cholecystostomy tube drainage, antibiotics, and delayed cholecystectomy in patients with grade III cholecystitis. STUDY DESIGN:We used Medicare data (1996 to 2010) to identify patients 66 years and older who were admitted with grade III acute cholecystitis. We evaluated adherence to the Tokyo Guidelines and compared mortality, readmission, and complication rates with and without cholecystostomy tube placement in a propensity-matched (1:3) cohort of patients with grade III cholecystitis. RESULTS:There were 8,818 patients admitted with grade III cholecystitis; 565 patients (6.4%) had a cholecystostomy tube placed. Cholecystostomy tube placement increased from 3.9% to 9.7% during the study period. Compared with 1,689 propensity-matched controls, patients with cholecystostomy tube placement had higher 30-day (hazard ratio [HR] = 1.26; 95% CI 1.05 to 1.50), 90-day (HR = 1.26; 95% CI 1.08 to 1.46), and 2-year mortality (HR = 1.19; 95% CI 1.04 to 1.36) and were less likely to undergo cholecystectomy in the 2 years after initial hospitalization (33.4% vs 64.4%; HR = 0.26; 95% CI 0.21 to 0.31). Readmissions were also higher at 30 days (HR = 2.93; 95% CI 2.12 to 4.05), 90 days (HR = 3.48; 95% CI 2.60 to 4.64), and 2 years (HR = 3.08; 95% CI 2.87 to 4.90). CONCLUSIONS:Since the introduction of the Tokyo Guidelines (2007), use of cholecystostomy tubes in patients with grade III cholecystitis has increased, but the majority of patients do not get cholecystostomy tube drainage as first-line therapy. Cholecystostomy tube placement was associated with lower rates of definitive treatment with cholecystectomy, higher mortality, and higher readmission rates. These data suggest a need for additional evaluation and refinement of the Tokyo Guidelines.
Project description:Laparoscopic cholecystectomy can be a challenging procedure in gallbladders with chronic disease. We describe a patient with chronic cholecystitis and difficult visualisation of the gallbladder at surgery who underwent laparoscopic hepatotomy along the drainage tube of the cholecystostomy. In this way, the gallbladder was identified to avoid non-visualisation of ductal anatomy. This exceptional solution should be added to the surgical options if anatomical recognition is difficult and complete removal of the gallbladder is too risky.
Project description:Acute cholecystitis is a life-threatening emergency in elderly patients. This population-based cohort study aimed to evaluate the commonly used management strategies for elderly patients with acute cholecystitis as well as resulting mortality and re-admission rates.Data from all consecutive elderly patients (≥ 80 years) admitted with acute cholecystitis in England from 1997 to 2012 were captured from the Hospital Episode Statistics database. Influence of management strategies upon mortality was analyzed with adjustment for patient demographics and treatment year.47,500 elderly patients were admitted as an emergency with acute cholecystitis. On the index emergency admission the majority of patients (n = 42,620, 89.7%) received conservative treatment, 3539 (7.5%) had cholecystectomy, and 1341 (2.8%) underwent cholecystostomy. In the short term, 30-day mortality was increased in the emergency cholecystectomy group (11.6%) compared to those managed conservatively (9.9%) (p < 0.001). This was offset by the long-term benefits of cholecystectomy with a reduced 1-year mortality [20.8 vs. 27.1% for those managed conservatively (p < 0.001)]. Management with percutaneous cholecystostomy had increased 30-day and 1-year mortality (13.4 and 35.0%, respectively). The annual proportion of cholecystectomies performed laparoscopically increased from 27% in 2006 to 59% in 2012. Within the cholecystectomy group, laparoscopic approach was an independent predictor of reduced 30-day mortality (OR 0.16, 95% CI 0.10-0.25). Following conservative management, there were 16,088 admissions with further cholecystitis. Only 11% of patients initially managed conservatively or with cholecystostomy received subsequent cholecystectomy.Acute cholecystitis is associated with significant mortality in elderly patients. Potential benefits of emergency cholecystectomy in selected elderly patients include reduced rate of readmissions and 1-year mortality. Laparoscopic approach for emergency cholecystectomy was associated with an 84% relative risk reduction in 30-day mortality compared to open surgery.
Project description:Acute calculous cholecystitis (ACC) is the most frequent complication of cholelithiasis and represents one-third of all surgical emergency hospital admissions, many aspects of the disease are still a matter of debate. Knowledge of the current evidence may allow the surgical team to develop practical bedside decision-making strategies, aiming at a less demanding procedure and lower frequency of complications. In this regard, recommendations on the diagnosis supported by specific criteria and severity scores are being implemented, to prioritize patients eligible for urgency surgery. Laparoscopic cholecystectomy is the best treatment for ACC and the procedure should ideally be performed within 72 h. Early surgery is associated with better results in comparison to delayed surgery. In addition, when to suspect associated common bile duct stones and how to treat them when found are still debated. The antimicrobial agents are indicated for high-risk patients and especially in the presence of gallbladder necrosis. The use of broad-spectrum antibiotics and in some cases with antifungal agents is related to better prognosis. Moreover, an emerging strategy of not converting to open, a difficult laparoscopic cholecystectomy and performing a subtotal cholecystectomy is recommended by adept surgical teams. Some authors support the use of percutaneous cholecystostomy as an alternative emergency treatment for acute Cholecystitis for patients with severe comorbidities.
Project description:Besides cholecystectomy (CC), percutaneous cholecystostomy (PC) has been recommended for the management of critically ill patients with acute cholecystitis. However, solid evidence on the benefit of PC in this subgroup of patients is lacking.In accordance with the PRISMA guidelines for systematic reviews, we systematically searched the Cochrane Library, CINAHL, MEDLINE, Embase, and Scopus for relevant studies published between 2000 and 2014. Two investigators independently screened the studies included.Six studies with a total of 337 500 patients (PC 10 045, CC 327 455) were included for meta-analysis. Significant differences in favor of CC were recorded with regard to the rate of mortality (OR 4.28, [1.72 to 10.62], p = 0.0017), length of hospital stay (OR 1.41, [1.02 to 1.95], p = 0.04), and the rate of readmission for biliary complaints (OR 2.16, [1.72 to 2.73], p<0.0001). There was no statistically significant difference between both intervention arms with regard to complications (OR 0.74, [0.36 to 1.53], p = 0.42) and re-interventions (OR 7.69, [0.68 to 87.33], p = 0.10).The benefit of percutaneous cholecystostomy (PC) over cholecystectomy (CC) in the management of critically ill patients with acute cholecystitis could not be proven in this systematic review.