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...

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Published in:	The American journal of surgery Vol. 183; no. 1; pp. 62 - 66
Main Authors:	Spira, Ram M, Nissan, Aviran, Zamir, Oded, Cohen, Tzeela, Fields, Scott I, Freund, Herbert R
Format:	Journal Article
Language:	English
Published:	New York, NY Elsevier Inc 2002 Elsevier Elsevier Limited
Subjects:	Acute cholecystitis Acute Disease Adult Age Factors Aged Aged, 80 and over Anesthesia Antibiotics Bile ducts Biological and medical sciences Catheters Cholecystectomy Cholecystectomy - methods Cholecystitis Cholecystitis - surgery Comorbidity Complications Computed tomography Critical Illness Critically ill Female Gallbladder Gallbladder diseases Hospitals Humans Intensive care Laparoscopic cholecystectomy Laparoscopy Laparoscopy - methods Laparotomy Leukocytes Liver - surgery Liver, biliary tract, pancreas, portal circulation, spleen Male Medical instruments Medical sciences Middle Aged Morbidity Mortality Patients Percutaneous cholecystostomy Peritonitis Postoperative Complications - prevention & control Retrospective Studies Risk Factors Risk groups Sepsis Sepsis - etiology Septic shock Shock, Septic - etiology Surgery Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases Surgery of the digestive system Surgical anastomosis Time Factors Tomography, X-Ray Computed Tropical medicine Ultrasound Asia Israel United States > US Percutaneous cholecystostomy Laparoscopic cholecystectomy Critically ill Acute cholecystitis Cholecystectomy Human Endoscopic surgery Critical state Acute Surgical drainage Laparoscopy Biliary tract disease Association Treatment Surgery Lithiasis Digestive diseases Complication Gallbladder Cholecystitis Delayed time
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Summary:	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.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23
ISSN:	0002-9610 1879-1883
DOI:	10.1016/S0002-9610(01)00849-2