Percutaneous cholecystostomy for the diagnosis and treatment of acute calculous and acalculous cholecystitis

ACR Appropriateness Criteria® Right Upper Quadrant Pain: 2022 Update

Acute right upper quadrant pain is one of the most common presenting symptoms in hospital emergency departments, as well as outpatient settings. Although gallstone-related acute cholecystitis is a leading consideration in diagnosis, a myriad of extrabiliary sources including hepatic, pancreatic, gastroduodenal, and musculoskeletal should also be considered. This document focuses on the diagnostic accuracy of imaging studies performed specifically to evaluate acute right upper quadrant pain, with biliary etiologies including acute cholecystitis and its complications being the most common. An additional consideration of extrabiliary sources such as acute pancreatitis, peptic ulcer disease, ascending cholangitis, liver abscess, hepatitis, and painful liver neoplasms remain a diagnostic consideration in the right clinical setting. The use of radiographs, ultrasound, nuclear medicine, CT, and MRI for these indications are discussed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Novel anchoring device for endoscopic ultrasound-guided gallbladder drainage: secondary publication

BACKGROUND

Recently, endoscopic ultrasound-guided gallbladder drainage has attracted much attention. However, the risk management of adverse events and techniques to avoid them are not yet mature. Difficulty dilating the fistula with a dilator or placing a stent for drainage often prolongs the procedure time, which increases the risk of peritonitis or the procedure failure rate. Therefore, the result of the procedure will be unstable, and one cause is the lack of adhesion between the gallbladder and the digestive tract walls.

METHODS

We developed an anchor to fix the stomach and gallbladder walls prior to endoscopic ultrasound-guided gallbladder drainage in four live pigs using the anchor.

RESULTS

The stomach and gallbladder walls were fixed in three pigs, and technical success was achieved in all three pigs. In two pigs that were dissected 17 and 34 days post-procedure, respectively, fixation occurred in one pig. In the other pig, anchoring of the gallbladder and stomach walls did not occur because the wings of the anchor in the gallbladder were damaged.

CONCLUSIONS

Although issues remain regarding efficacy and safety, we plan to make improvements in this novel device and aim for clinical application.

Gallbladder: Role of Interventional Radiology

Percutaneous cholecystostomy is an established procedure for the management of patients with acute cholecystitis and with significant medical comorbidities that would make laparoscopic cholecystectomy excessively risky. In this review, we will explore the role of percutaneous cholecystostomy in the management of acute cholecystitis as well as other applications in the management of biliary pathology. The indications, grading, technical considerations, and postprocedure management in the setting of acute cholecystitis are discussed. In addition, we will discuss the potential role of percutaneous cholecystostomy in the management of gallstones and biliary strictures, in establishing internal biliary drainage, and in a joint setting with other clinicians such as gastroenterologists in the management of complex biliary pathology.

Comparing outcomes of percutaneous cholecystostomy drain placement between patients within and outside of Tokyo guidelines diagnostic criteria for acute cholecystitis

OBJECTIVE

To compare outcomes following percutaneous cholecystostomy drain placement based on presence or absence of Tokyo Guidelines diagnostic criteria for acute cholecystitis.

METHODS

Chart review was performed to identify the presence or absence of Tokyo Guidelines diagnostic criteria for acute cholecystitis in 146 patients who underwent percutaneous cholecystostomy between 2012 and 2015. Those who met criteria were compared to those who did not in terms of demographics, laboratory values, drain indwelling time, treatment response, eventual surgical management, and 30-day mortality.

RESULTS

94 patients (64%) met Tokyo Guidelines diagnostic criteria, while 52 did not (36%). Patients within criteria had a shorter mean length of stay (13.5 days vs 18.9 days), were more likely to have a positive gallbladder fluid culture (64.5% vs 28.6%), demonstrated greater response to treatment (87.2% vs 32.7%), and had lower 30-day mortality (6.4% vs 37.8%). There was no significant difference in terms of ICU requirement (38.3% vs 38.9%), mean drain indwelling time (58.8 days vs 65.3 days), eventual laparoscopic cholecystectomy (40.4% vs 25.0%), or open cholecystectomy performed (9.5% vs 9.6%).

CONCLUSION

Patients outside of Tokyo Guidelines diagnostic criteria for acute cholecystitis were less likely to respond to treatment with percutaneous cholecystostomy and had worse outcomes. Further research may be indicated to better define the indications for percutaneous cholecystostomy placement in this group.

Similar Efficacies of Endoscopic Ultrasound Gallbladder Drainage With a Lumen-Apposing Metal Stent Versus Percutaneous Transhepatic Gallbladder Drainage for Acute Cholecystitis

BACKGROUND & AIMS

Acute cholecystitis in patients who are not candidates for surgery is often managed with percutaneous transhepatic gallbladder drainage (PT-GBD). Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with a lumen-apposing metal stent (LAMS) is an effective alternative to PT-GBD. We compared the technical success of EUS-GBD versus PT-GBD, and patient outcomes, numbers of adverse events (AEs), length of hospital stay, pain scores, and repeat interventions.

METHODS

We performed a retrospective study to compare EUS-GBD versus PT-GBD at 7 centers (5 in the United States, 1 in Europe, and 1 in Asia), from 2013 through 2015, in management of acute cholecystitis in patients who are not candidates for surgery. A total of 90 patients (56 men) with acute cholecystitis (61 calculous, 29 acalculous) underwent EUS-GBD (n = 45) or PT-GBD (n = 45). Data were collected on technical success, clinical success (resolution of symptoms or laboratory and/or radiologic abnormalities within 3 days of intervention), and need for repeat intervention. Characteristics were compared using Student t tests for continuous variables and the chi-square test, or the Fisher exact test, when appropriate, for categorical variables. Adverse events were graded according to American Society for Gastrointestinal Endoscopy definitions and compared using the Fisher exact test. Postprocedure pain scores were compared using the Mann-Whitney U test.

RESULTS

Baseline characteristics, type, and clinical severity of cholecystitis were comparable between groups. In the EUS-GBD group, noncautery LAMS were used in 30 patients and cautery-enhanced LAMS were used in 15. Technical success was achieved for 98% of patients in the EUS-GBD and 100% of the patients in the PT-GBD group (P = .88). Clinical success was achieved by 96% of patients in the EUS-GBD group and 91% in the PT-GBD group (P = .20). There was a nonsignificant trend toward fewer AEs in the EUS-GBD group (5 patients; 11%) than in the PT-GBD group (14 patients; 32%) (P = .065). There were no significant differences in the severity of the AEs: mild, 2 in the EUS-GBD group versus 5 in the PT-GBD group (P = .27); moderate, 4 versus 3 (P = .98); severe, 1 versus 3 (P = .62); or deaths, 1 versus 3 (P = .61). The mean postprocedure pain score was lower in the EUS-GBD group than in the PT-GBD group (2.5 vs 6.5; P < .05). The EUS-GBD group had a shorter average length of stay in the hospital (3 days) than the PT-GBD group (9 days) (P < .05) and fewer repeat interventions (11 vs 112) (P < .05). The average number of repeat interventions per patients was 0.2 ± 0.4 EUS-GBD group versus 2.5 ± 2.8 in the PT-GBD group (P < .05). Median follow-up after drainage was comparable in EUS-GBD group (215 days; range, 1-621 days) versus the PT-GBD group (265 days; range, 1-1638 days).

CONCLUSIONS

EUS-GBD has similar technical and clinical success compared with PT-GBD and should be considered an alternative for patients who are not candidates for surgery. Patients who undergo EUS-GBD seem to have shorter hospital stays, lower pain scores, and fewer repeated interventions, with a trend toward fewer AEs. A prospective, comparative study is needed to confirm these results.

International collaborative study on EUS-guided gallbladder drainage: Are we ready for prime time?

BACKGROUND

Cholecystectomy remains the gold standard treatment of cholecystitis. Endoscopic treatment of cholecystitis includes transpapillary gallbladder drainage. Recently, endoscopic ultrasound-guided transmural drainage of the gallbladder (EUS-GBD) has been reported. This study reports the cumulative experience of an international group performing EUS-GBD.

METHODS

Cases of EUS-GBD from January 2012 to November 2013 from 3 tertiary-care institutions were captured in a registry. Patient demographics, disease characteristics, procedural and clinical outcomes were recorded.

RESULTS

35 patients (15 malignant, 20 benign) were included. Median age was 81 years (SD=13.76 years), sixteen (46%) were males. Median follow-up was 91.5 days (SD=157 days). Transmural access was obtained from the stomach (n=17) or duodenum (n=18). Stents placed included plastic (n=6), metal (n=20), or combination (n=7). Technical success was achieved in 91.4% (n=32). Immediate adverse events (14%) included: bleeding, stent migration, cholecystitis and hemoperitoneum. Delayed adverse events (11%) included abscess formation and recurrence of cholecystitis. Long-term clinical success rate was 89%. Stent type and puncture site were not associated with immediate (p=0.88, p=0.62), or long-term (p=0.47, p=0.27) success.

CONCLUSIONS

EUS-GBD appears to be feasible, safe, and effective. Prospective studies are needed to confirm these findings and identify the best technique to use.

CLINICAL TRIAL REGISTRATION

NCT01522573.

EUS-guided gallbladder drainage with a lumen-apposing metal stent (with video)

BACKGROUND AND AIMS

Nonsurgical techniques for gallbladder drainage are percutaneous, and endoscopic. EUS-guided transmural gallbladder drainage (EUS-GBD) is a relatively new approach, although data are limited. Our aim was to describe the outcome after EUS-GBD with a lumen-apposing metal stent (LAMS).

PATIENTS AND METHODS

This was a retrospective review of prospectively collected data on 15 nonsurgical patients who underwent EUS-GBD for various indications. Procedures were performed at 3 tertiary care centers with expertise in the management of complex biliary problems. The main outcome measures were technical and clinical success and adverse events.

RESULTS

Fifteen patients (8 male, 7 female) with a median age of 74 years (range 42-89) underwent EUS-GBD by using a LAMS to decompress the gallbladder (7 patients calculous cholecystitis, 4 acalculous cholecystitis, 2 patients biliary obstruction, 1 patient gallbladder hydrops, 1 patient symptomatic cholelithiasis). Patients were nonsurgical candidates according to the American Society of Anesthesiologists Physical Status Classification System; findings were class IV or higher in 9 patients and advanced malignancies in 6. Percutaneous transhepatic gallbladder drainage (PT-GBD) was refused by all patients and was further precluded by perihepatic ascites in 3 patients, coagulopathy or need for anticoagulation in 4 patients, and need for internal biliary drainage in 2 patients. Transduodenal access and stenting was achieved in 14 of 15 patients and transgastric stenting was achieved in 1. Technical success was achieved in 14 of 15 patients (93%), whereas clinical success was achieved in all 15 patients with a median follow-up of 160 days. One mild adverse event (postprocedure fever for 3 days) was noted. The limitations of this study are the small select group of patients and retrospective study design.

CONCLUSIONS

EUS-GBD with a LAMS is technically safe and effective for decompressing the gallbladder for cholecystitis and biliary or cystic duct obstruction in patients who are poor surgical candidates.

Acute acalculous cholecystitis in the critically ill: risk factors and surgical strategies

PURPOSE

Acute acalculous cholecystitis (AAC) is characterized by severe gallbladder inflammation without cystic duct obstruction. Critical illness and neurological deficits are often associated with AAC, and early radiologic imaging is necessary for the detection and timely treatment of AAC. In critically ill patients, effective surgical management is difficult. This review examines the three common surgical treatments for AAC (open cholecystectomy (OC), laparoscopic cholecystectomy (LC), or percutaneous cholecystostomy (PC)), their prevalence in current literature, and the perioperative outcomes of these different approaches using a large retrospective database.

MATERIALS AND METHODS

This review examined literature gathered from PubMed and Google Scholar to select more than 50 sources with data pertinent to AAC; of which 20 are described in a summary table. Outcomes from our previous research and several updated results were obtained from the University HealthSystem Consortium (UHC) database.

RESULTS

LC has proven effective in treating AAC when the risks of general anesthesia and the chance for conversion to OC are low. In critically ill patients with multiple comorbidities, PC or OC may be the only available options. Data in the literature and an examination of outcomes within a national database indicate that for severely ill patients, PC may be safer and met with better outcomes than OC for the healthier set of AAC patients.

CONCLUSIONS

We suggest a three-pronged approach to surgical resolution of AAC. Patients that are healthy enough to tolerate LC should undergo LC early in the course of the disease. In critically ill patients, patients with multiple comorbidities, a high conversion risk, or who are poor surgical candidates, PC may be the safest and most successful intervention.

Endoscopic ultrasound-guided gallbladder drainage for the management of acute cholecystitis (with video)

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has been introduced as an alternative to percutaneous transhepatic gallbladder drainage for the treatment of acute cholecystitis in non-surgical candidates. A systematic review of the English language literature through PubMed search until June 2014 was conducted. One hundred and fifty-five patients with acute cholecystitis treated with EUS-GBD in eight studies and 12 case reports, and two patients with EUS-GBD for other causes were identified. Overall, technical success was obtained in 153 patients (97.45%) and clinical success in 150 (99.34%) patients with acute cholecystitis. Adverse events developed in less than 8% of patients, all of them managed conservatively. EUS-GBD has been performed with plastic stents, nasobiliary drainage tubes, standard or modified tubular self-expandable metal stents (SEMS) and lumen-apposing metal stents (LAMS) by different authors with apparently similar outcomes. No comparison studies between stent types for EUS-GBD have been reported. EUS-GBD is a promising novel alternative intervention for the treatment of acute cholecystitis in high surgical risk patients. Feasibility, safety and efficacy in published studies from expert centers are very high compared to currently available alternatives. Further studies are needed to establish the safety and long-term outcomes of this procedure in other practice settings before EUS-GBD can be widely disseminated.

Severe bleeding after percutaneous transhepatic drainage of the biliary system: effect of antithrombotic agents--analysis of 34 606 cases from a Japanese nationwide administrative database

PURPOSE

To investigate the relationship between antithrombotic agents (antiplatelet agents and anticoagulants) and severe bleeding after percutaneous transhepatic biliary drainage (PTBD) for biliary obstruction, or cholecystostomy for acute cholecystitis.

MATERIALS AND METHODS

This retrospective study was institutional review board-approved, and patient consent was waived. Between July 2007 and March 2012, 34 606 patients who underwent PTBD (23 375 patients) or cholecystostomy (11 231 patients) were identified in the Diagnosis Procedure Combination database covering 1119 Japanese hospitals. The association between oral administration of antithrombotic agents prior to the procedure and severe bleeding was evaluated, with adjustment for other potential risk factors, such as age, chronic renal failure, liver cirrhosis, and procedure type. Users of antithrombotic agents were categorized as the continuation group, when they took these agents on the procedure day, or as the discontinuation group, when none were taken. Severe bleeding was defined as bleeding which required red blood cell transfusion or transcatheter arterial embolization within 3 days of the procedure. Univariate and multivariate logistic regression models fitted with generalized estimating equations were performed to evaluate the effect of antithrombotic agents on the bleeding complication.

RESULTS

Overall, 780 of 34 606 patients (2.3%) experienced severe bleeding. In the multivariate model, continuation of antiplatelet agents was significantly associated with severe bleeding versus nonuse (odds ratio [OR], 1.87; 95% confidence interval [CI]: 1.14, 3.05; P = .013), whereas discontinuation of antiplatelet agents showed no association (OR, 0.92; 95% CI: 0.70, 1.20; P = .517). The effect of neither continuation nor discontinuation of anticoagulants on severe bleeding was significant. Other significant risk factors for bleeding included older age, chronic renal failure, liver cirrhosis, academic hospital, and PTBD.

CONCLUSION

The continuation of antiplatelet agents can increase severe bleeding after percutaneous transhepatic drainage, whereas the effect of continuation of anticoagulants was inconclusive.

Clinical outcomes of a percutaneous cholecystostomy for acute cholecystitis: a multicentre analysis

BACKGROUND

The aim of this study was to review a series of consecutive percutaneous cholecystostomies (PC) to analyse the clinical outcomes.

METHODS

All patients who underwent a PC between 2000 and 2010 were reviewed retrospectively for indications, complications, and short- and long-term outcomes.

RESULTS

Fifty-three patients underwent a PC with a median age was 74 years (range 14-93). 92.4% (n = 49) of patients were American Society of Anesthesiologists (ASA) III and IV. 82% (43/53) had ultrasound-guided drainage whereas 18% (10/53) had computed tomography (CT)-guided drainage. 71.6% (n = 38) of PC's employed a transhepatic route and 28.4% (n = 15) transabdominal route. 13% (7/53) of patients developed complications including bile leaks (n = 5), haemorrhage (n = 1) and a duodenal fistula (n = 1). All bile leaks were noted with transabdominal access (5 versus 0, P = 0.001). 18/53 of patients underwent a cholecystectomy of 4/18 was done on the index admission. 6/18 cholecystectomies (33%) underwent a laparoscopic cholecystectomy and the remaining required conversion to an open cholecystectomy (67%). 13/53 (22%) patients were readmitted with recurrent cholecystitis during follow-up of which 7 (54%) had a repeated PC. 12/53 patients died on the index admission. The overall 1-year mortality was 37.7% (20/53).

CONCLUSIONS

Only a small fraction of patients undergoing a PC proceed to a cholecystectomy with a high risk of conversion to an open procedure. A quarter of patients presented with recurrent cholecystitis during follow-up. The mortality rate is high during the index admission from sepsis and within the 1 year of follow-up from other causes.

Endoscopic ultrasound-guided transmural and percutaneous transhepatic gallbladder drainage are comparable for acute cholecystitis

BACKGROUND & AIMS

Endoscopic ultrasound-guided transmural gallbladder drainage (EUS-GBD) is an alternative to percutaneous transhepatic gallbladder drainage (PTGBD) for patients with acute, high-risk, or advanced-stage cholecystitis who do not respond to initial medical treatment and cannot undergo emergency cholecystectomy. However, the technical feasibility, efficacy, and safety of EUS-GBD and PTGBD have not been compared.

METHODS

Fifty-nine patients with acute cholecystitis, who did not respond to initial medical treatment and were unsuitable for an emergency cholecystectomy, were chosen randomly to undergo EUS-GBD (n = 30) or PTGBD (n = 29). The technical feasibility, efficacy, and safety of EUS-GBD and PTGBD were compared.

RESULTS

EUS-GBD and PTGBD showed similar technical (97% [29 of 30] vs 97% [28 of 29]; 95% 1-sided confidence interval lower limit, -7%; P = .001 for noninferiority margin of 15%) and clinical (100% [29 of 29] vs 96% [27 of 28]; 95% 1-sided confidence interval lower limit, -2%; P = .0001 for noninferiority margin of 15%) success rates, and similar rates of complications (7% [2 of 30] vs 3% [1 of 29]; P = .492 in the Fisher exact test) and conversions to open cholecystectomy (9% [2 of 23] vs 12% [3 of 26]; P = .999 in the Fisher exact test). The median post-procedure pain score was significantly lower after EUS-GBD than after PTGBD (1 vs 5; P < .001 in the Mann-Whitney U test).

CONCLUSIONS

EUS-GBD is comparable with PTGBD in terms of the technical feasibility and efficacy; there were no statistical differences in the safety. EUS-GBD is a good alternative for high-risk patients with acute cholecystitis who cannot undergo an emergency cholecystectomy.

Complicated cholecystitis: the complementary roles of sonography and computed tomography

Acute cholecystitis is a common cause of abdominal pain in the Western world. Unless treated promptly, patients with acute cholecystitis may develop complications such as gangrenous, perforated, or emphysematous cholecystitis. Because of the increased morbidity and mortality of complicated cholecystitis, early diagnosis and treatment are essential for optimal patient care. Nevertheless, complicated cholecystitis may pose significant challenges with cross-sectional imaging, including sonography and computed tomography (CT). Interpreting radiologists should be familiar with the spectrum of sonographic findings seen with complicated cholecystitis and as well as understand the complementary role of CT. Worrisome imaging findings for complicated cholecystitis include intraluminal findings (sloughed mucosa, hemorrhage, abnormal gas), gallbladder wall abnormalities (striations, asymmetric wall thickening, abnormal gas, loss of sonoreflectivity and contrast enhancement), and pericholecystic changes (echogenic fat, pericholecystic fluid, abscess formation). Finally, diagnosis of complicated cholecystitis by sonography and CT can guide alternative treatments including minimally invasive percutaneous and endoscopic options.

Percutaneous cholecystostomy for acute cholecystitis: ten-year experience

PURPOSE

To review the clinical course of patients with acute cholecystitis treated by percutaneous cholecystostomy, and to identify risk factors retrospectively that predict outcome.

MATERIALS AND METHODS

A total of 106 patients diagnosed with acute cholecystitis were treated by percutaneous cholecystostomy during a 10-year period. Seventy-one (67%) presented to the emergency department (ED) specifically for acute cholecystitis, and 35 (23%) were inpatients previously admitted for other conditions. Outcomes of the two groups were compared with respect to severity of illness, leukocytosis, bile culture, liver function tests, imaging features, time intervals from onset of symptoms to medical and percutaneous intervention, and whether surgical cholecystectomy was later performed.

RESULTS

Overall, 72 patients (68%) showed an improvement clinically, whereas 34 (32%) showed no improvement or a clinically worsened condition after cholecystostomy. Patients who presented to the ED primarily with acute cholecystitis fared better (84% of patients showed improvement) than inpatients (34% showed improvement; P < .0001). Gallstones were identified in 54% of patients who presented to the ED, whereas acalculous cholecystitis was more commonly diagnosed in inpatients (54%). Patients with sepsis had worse outcomes overall (P < .0001). Bacterial bile cultures were analyzed in 95% of patients and showed positive results in 52%, with no overall effect on outcome. There was no correlation between the time of onset of symptoms until antibiotic therapy or cholecystostomy in either group. Long-term outcomes for both groups were better for those who later underwent cholecystectomy (P < .0001).

CONCLUSIONS

Outcomes after percutaneous cholecystostomy for acute cholecystitis are better when the disease is primary and not precipitated by concurrent illness.

Acute acalculous cholecystitis

Acute acalculous cholecystitis (ACC) can develop with or without gallstones after surgery and in critically ill or injured patients. Diabetes mellitus, malignant disease, abdominal vasculitis, congestive heart failure, cholesterol embolization, shock, and cardiac arrest also have been associated with AAC. The pathogenesis of AAC is complex and multifactorial. Ultrasound of the gallbladder is most accurate for the diagnosis of AAC in the critically ill patient. CT is probably of comparable accuracy, but carries both advantages and disadvantages. Rapid improvement may be expected when AAC is diagnosed correctly and cholecystostomy is performed timely.

Systematic review of cholecystostomy as a treatment option in acute cholecystitis

OBJECTIVES

Percutaneous cholecystostomy (PC) is an established low-mortality treatment option for elderly and critically ill patients with acute cholecystitis. The primary aim of this review is to find out if there is any evidence in the literature to recommend PC rather than cholecystectomy for acute cholecystitis in the elderly population.

METHODS

In April 2007, a systematic electronic database search was performed on the subject of PC and cholecystectomy in the elderly population. After exclusions, 53 studies remained, comprising 1918 patients. Three papers described randomized controlled trials (RCTs), but none compared the outcomes of PC and cholecystectomy. A total of 19 papers on mortality after cholecystectomy in patients aged >65 years were identified.

RESULTS

Successful intervention was seen in 85.6% of patients with acute cholecystitis. A total of 40% of patients treated with PC were later cholecystectomized, with a mortality rate of 1.96%. Procedure mortality was 0.36%, but 30-day mortality rates were 15.4 % in patients treated with PC and 4.5% in those treated with acute cholecystectomy (P < 0.001).

CONCLUSIONS

There are no controlled studies evaluating the outcome of PC vs. cholecystectomy and the papers reviewed are of evidence grade C. It is not possible to make definitive recommendations regarding treatment by PC or cholecystectomy in elderly or critically ill patients with acute cholecystitis. Low mortality rates after cholecystectomy in elderly patients with acute cholecystitis have been reported in recent years and therefore we believe it is time to launch an RCT to address this issue.

Contemporary minimally invasive approaches to the management of acute cholecystitis: a review and appraisal

Acute cholecystitis is one of the most common emergency admissions in surgical practice. This review appraises the available evidence from the English-language literature regarding the minimally invasive approaches to the management of this condition. The following aspects of care are reviewed and appraised: (1) the diagnostic criteria for acute cholecystitis, (2) the optimal timing for cholecystectomy (early, delayed, or interval surgery), (3) the optimal approach to cholecystectomy (laparoscopic versus open), (4) the role of intraoperative cholangiography, and (5) the management of patients unfit for surgery.

Role of laparoscopic cholecystectomy in the early management of acute gallbladder disease

Background

This study evaluated the role of laparoscopic surgery in the early management of acute gallbladder disease in a single large UK teaching hospital.

Methods

Details of all emergency admissions for acute gallbladder disease from January 2000 to December 2001 were identified and additional information from the hospital records was reviewed retrospectively.

Results

Three hundred and eighty-five patients with gallstone disease (243 acute biliary pain, 142 acute cholecystitis) and 15 with acalculous disease were identified. The conversion rate was higher during early laparoscopic surgery for acute calculous cholecystitis than in operations for acute biliary pain (19 versus 4 per cent; P = 0·002). In patients with acute calculous cholecystitis the conversion rate was significantly lower in operations within 48 h of admission (one of 26) than when surgery was delayed beyond 48 h (14 of 52) or subsequently carried out electively (seven of 21) (P = 0·014). Elective surgery for previous acute cholecystitis was associated with a higher conversion rate (seven of 21 patients) than elective surgery for biliary pain (three of 65) (P = 0·002).

Conclusion

Laparoscopic cholecystectomy for acute calculous cholecystitis should be performed, where possible, within the first 48 h of admission.

Acute renal failure associated with Legionella pneumonia and acute cholecystitis

BACKGROUND AND AIMS

Acute cholecystitis in critically ill patients has a high morbidity and mortality. We observed a number of patients presenting with Legionella pneumonia and acute renal failure who subsequently developed acute cholecystitis. There has previously been no reported association between Legionella pneumonia, renal failure and cholecystitis, prompting this examination of the cases and review of the available literature.

METHODS

The Western Hospital patient record discharge codes (DRG) from 1993 to 2001 were searched retrospectively for all cases of Legionella pneumonia or acute renal failure requiring dialysis (ARF) at presentation or during their period of hospitalization. Acute cholecystitis was then included as a cross-search and results analysed.

RESULTS

Twenty-six cases of isolated Legionella pneumonia and 112 of ARF were identified with a further 10 having both conditions simultaneously. Of these 10 cases, three were identified as also having acute cholecystitis. The combination of Legionella pneumonia and ARF was associated with an increased risk of acute cholecystitis (P = 0.002) whereas neither condition in isolation demonstrated this association.

CONCLUSIONS

Patients with Legionella pneumonia can become critically ill with multiple complications including acute renal failure requiring dialysis. In this setting, they may have an increased risk of developing acute cholecystitis, which clinically can be difficult to ascertain. Diagnosis requires a high index of suspicion and vigilance.

US-guided Percutaneous Cholecystostomy: Features Predicting Culture-Positive Bile and Clinical Outcome

PURPOSE

To assess sonographic and clinical features that might be used to predict infected bile and/or patient outcome from ultrasonography (US)-guided percutaneous cholecystostomy.

MATERIALS AND METHODS

Between February 1997 and August 2002 at one institution, 112 patients underwent US-guided percutaneous cholecystostomy (59 men, 53 women; average age, 69.3 years). All US images were scored on a defined semiquantitative scale according to preset parameters: (a) gallbladder distention, (b) sludge and/or stones, (c) wall appearance, (d) pericholecystic fluid, and (e) common bile duct size and/or choledocholithiasis. Separate and total scores were generated. Retrospective evaluation of (a) the bacteriologic growth of aspirated bile and its color and (b) clinical indices (fever, white blood cell count, bilirubin level, liver function test results) was conducted by reviewing medical records. For each patient, the clinical manifestation was classified into four groups: (a) localized right upper quadrant symptoms, (b) generalized abdominal symptoms, (c) unexplained sepsis, or (d) sepsis with other known infection. Logistic regression models, exact Wilcoxon-Mann-Whitney test, and the Kruskal-Wallis test were used.

RESULTS

Forty-seven (44%) of 107 patients had infected bile. A logistic regression model showed that wall appearance, distention, bile color, and pericholecystic fluid were not individually significant predictors for culture-positive bile, leaving sludge and/or stones (P =.003, odds ratio = 1.647), common bile duct status (P =.02, odds ratio = 2.214), and total score (P =.007, odds ratio = 1.267). No US covariates or clinical indices predicted clinical outcome. Clinical manifestation was predictive of clinical outcome (P =.001) and aspirating culture-positive bile (P =.008); specifically, 30 (86%) of 35 patients with right upper quadrant symptoms had their condition improve, compared with one (7%) of 15 asymptomatic patients with other known causes of infection.

CONCLUSION

US variables can be used to predict culture-positive bile but not patient outcome. Clinical manifestation is important because patients with right upper quadrant symptoms have the best clinical outcome.

Acute acalculous cholecystitis

Acute cholecystitis can develop without gallstones in critically ill or injured patients. However, the development of acute acalculous cholecystitis is not limited to surgical or injured patients, or even to the intensive care unit. Diabetes, malignant disease, abdominal vasculitis, congestive heart failure, cholesterol embolization, and shock or cardiac arrest have been associated with acute acalculous cholecystitis. Children may also be affected, especially after a viral illness. The pathogenesis of acute acalculous cholecystitis is a paradigm of complexity. Ischemia and reperfusion injury, or the effects of eicosanoid proinflammatory mediators, appear to be the central mechanisms, but bile stasis, opioid therapy, positive-pressure ventilation, and total parenteral nutrition have all been implicated. Ultrasound of the gallbladder is the most accurate diagnostic modality in the critically ill patient, with gallbladder wall thickness of 3.5 mm or greater and pericholecystic fluid being the two most reliable criteria. The historical treatment of choice for acute acalculous cholecystitis has been cholecystectomy, but percutaneous cholecystostomy is now the mainstay of therapy, controlling the disease in about 85% of patients. Rapid improvement can be expected when the procedure is performed properly. The mortality rates (historically about 30%) for percutaneous and open cholecystostomy appear to be similar, reflecting the severity of illness, but improved resuscitation and critical care may portend a decreased risk of death. Interval cholecystectomy is usually not indicated after acute acalculous cholecystitis in survivors; if the absence of gallstones is confirmed and the precipitating disorder has been controlled, the cholecystostomy tube can be pulled out after the patient has recovered.

Gastrointestinal disorders of the critically ill. Biliary sludge and cholecystitis

Biliary sludge develops commonly in critically ill patients and may be associated with biliary colic, acute pancreatitis or acute cholecystitis. Sludge often resolves upon resolution of the underlying pathogenetic factor. It is generally diagnosed on sonography. Treatment of sludge itself is unnecessary unless further complications develop. Acute acalculous cholecystitis also develops frequently in critically ill patients. It may be difficult to diagnose in these patients, manifesting only as unexplained fever, leukocytosis or sepsis. Sonography and hepatobiliary scintigraphy are the most useful diagnostic tests. Management decisions should take into account the underlying co-morbid conditions. For many patients, percutaneous cholecystostomy may be the best management option. Cholecystostomy may also provide definitive drainage as patients recover and underlying critical illness resolves.

Percutaneous cholecystostomy

Percutaneous cholecystostomy (PC), a technique that consists of percutaneous catheter placement in the gallbladder lumen under imaging guidance, has become an alternative to surgical cholecystostomy in recent years. Indications of PC include calculous or acalculous cholecystitis, cholangitis, biliary obstruction and opacification of biliary ducts. It also provides a potential route for stone dissolution therapy and stone extraction. Under aseptic conditions and ultrasound guidance, using local anesthesia, the procedure is carried out by using either modified Seldinger technique or trocar technique. Transhepatic or transperitoneal puncture can be performed as an access route. Several days after the procedure transcatheter cholangiography is performed to assess the patency of cystic duct, presence of gallstones and catheter position. The tract is considered mature in the absence of leakage to the peritoneal cavity, subhepatic, subcapsular, or subdiaphragmatic spaces. Response rates to PC in the literature are between the range of 56-100% as the variation of different patient population. Complications associated with PC usually occur immediately or within days and include haemorrhage, vagal reactions, sepsis, bile peritonitis, pneumothorax, perforation of the intestinal loop, secondary infection or colonisation of the gallbladder and catheter dislodgment. Late complications have been reported as catheter dislodgment and recurrent cholecystitis. PC under ultrasonographic guidance is a cost-effective, easy to perform and reliable procedure with low complication and high success rates for critically ill patients with acute cholecystitis. It is generally followed by elective cholecystectomy, if possible. However, it may be definitive treatment, especially in acalculous cholecystitis.

Treatment of acute cholecystitis in non-critically ill patients at high surgical risk: comparison of clinical outcomes after gallbladder aspiration and after percutaneous cholecystostomy

OBJECTIVE

This study was performed to compare the clinical outcome after gallbladder aspiration with that after percutaneous cholecystostomy in non-critically ill patients with acute cholecystitis who were at high risk from surgery.

MATERIALS AND METHODS

Medical records of 53 consecutive non-critically ill, high-surgical-risk patients admitted with acute cholecystitis between July 1995 and July 1999 were reviewed. Thirty-one had gallbladder aspiration and 22 had percutaneous cholecystostomy. The primary outcome measure of clinical response within 72 hr and the secondary outcome measures of overall positive response rate, complication rate, time to resolution, and rate of recurrence of acute cholecystitis were compared between the two groups.

RESULTS

Gallbladder aspiration and percutaneous cholecystostomy were technically successful in 30 (97%) and 21 (97%) patients, respectively; of these, 23 (77%) and 19 (90%) patients responded clinically within 72 hr (p > 0.2). Complications occurred in three patients (12%) after percutaneous cholecystostomy and in none after gallbladder aspiration (p < 0.05). No significant difference was noted in the other secondary outcome measures of the two groups.

CONCLUSION

We found no significant difference in the clinical outcomes of gallbladder aspiration and percutaneous cholecystostomy in the treatment of acute cholecystitis in high-surgical-risk patients who are not critically ill. However, we found gallbladder aspiration to be significantly safer. Therefore, gallbladder aspiration should be the procedure of choice in high-risk patients with acute cholecystitis who are not critically ill, and percutaneous cholecystectomy should be reserved as a salvage procedure if gallbladder aspiration is technically or clinically unsuccessful.

Percutaneous cholecystostomy for acute cholecystitis in veteran patients

BACKGROUND

Surgical cholecystostomy has been shown to carry a significantly higher mortality rate at Veterans Administration (VA) hospitals than at non-federal hospitals in the past.

METHODS

A retrospective outcomes study was undertaken at a large VA medical center with a policy favoring radiologic over surgical cholecystostomy over the past 9 years. Records of 24 consecutive patients with acute cholecystitis were reviewed to evaluate the effectiveness of the procedure.

RESULTS

Cholecystostomy was performed radiologically in 22 patients and surgically in 2 patients. Most (78%) of patients improved within 48 hours. The periprocedural mortality was 25%. The majority of these patients died from unrelated illnesses. Four patients developed complications, none of which required operative intervention.

CONCLUSIONS

Comorbidities are the most important mortality factor for cholecystostomies in VA patients. Radiologic tube placement is effective and uncomplicated in most cases.

Prevalence and significance of gallbladder abnormalities seen on sonography in intensive care unit patients

OBJECTIVE

We evaluated sonographic abnormalities of the gallbladder other than acalculous cholecystitis across a broad range of intensive care unit (ICU) patients.

SUBJECTS AND METHODS

Fifty-five consecutive patients (age range, 18-94 years old; mean age, 56 years; 33 men, 22 women), who were admitted to the ICU with a variety of diagnoses, underwent sonography of the gallbladder twice a week. Patients with gallbladder calculi were excluded from the study. The gallbladder was examined for the recognized sonographic features of acalculous cholecystitis: gallbladder wall thickening, gallbladder distention, intramural gallbladder lucencies (striated gallbladder wall), pericholecystic fluid, gallbladder sludge, and Murphy's sign. These findings were correlated with clinical and laboratory parameters that are associated with acalculous cholecystitis: fever, WBC, liver function tests, levels of serum bilirubin, mechanical ventilation status, and administration of parenteral nutrition, narcotic analgesics, antibiotics, and pressor agents.

RESULTS

Eleven of the 55 patients were found to have gallbladder calculi and were excluded from the study. Thirty-seven (84%) of the remaining 44 patients had at least one sonographic abnormality while in the ICU. Twenty-five (57%) of the 44 patients had as many as three abnormalities found on sonography, and six (14%) of 44 patients had four or five sonographic findings of gallbladder abnormalities while in the ICU. No statistically significant correlation was found among any of these sonographic abnormalities and the clinical and laboratory parameters.

CONCLUSION

Gallbladder abnormalities are frequently seen on sonography in ICU patients, even if these patients are not suspected of having acalculous cholecystitis; therefore, sonography appears to be of limited value in diagnosing acalculous cholecystitis in ICU patients.

Percutaneous Cholecystectomy in the Intensive Care Patient

The diagnosis of acute cholecystitis in the intensive care patient is often problematic. While most patients with acute cholecystitis present with fever, increased white count, or symptomatology pertaining to the gallbladder, occasionally these patients may be comatose and often present a diagnostic dilemma. Surgical cholecystectomy is the treatment of choice for acute cholecystitis, but this therapy carries with it a high mortality rate in the desperately ill patient. Thus surgical cholecystostomy has been advocated as a temporizing procedure to be performed until these patients stabilize. More recently percutaneous cholecystostomy, performed at the patient's bedside under ultrasound guidance, has been successfully performed using small-size catheters. This is a low-risk temporizing procedure when performed by well-trained personnel. In fact, percutaneous cholecystostomy has been shown to be a definitive treatment in patients with acute acalculous cholecystitis. Patients with calculous cholecystitis may require more definitive therapy, such as cholecystectomy. Presented is a review of the development and the current applications of percutaneous cholecystostomy in intensive care patients with suspected acute cholecystitis.

Cholelithiasis and acute cholecystitis

Although much is still to be learned about the pathogenesis of cholelithiasis, recent investigations have greatly advanced our knowledge regarding the mechanisms of cholesterol supersaturation and nucleation. Laparoscopic cholecystectomy has lessened the usual peri-operative morbidity of cholecystectomy, but is associated with a higher bile duct injury rate. Acute cholecystitis, the commonest complication of cholelithiasis, is a chemical inflammation usually requiring cystic duct obstruction and supersaturated bile. The treatment of this condition in the laparoscopic era is controversial. Early operation may lessen hospital stay but an increased risk of biliary injury has been reported.