Changing trends and outcomes in the use of percutaneous cholecystostomy tubes for acute cholecystitis

Analysis of 73 Cases of Percutaneous Cholecystostomy for Acute Cholecystitis: Patient Selection is Key

Background: Percutaneous cholecystostomy (PC) rates have substantially increased in England over the past two decades. However, its utilization and clinical outcomes at a local level are not well documented or understood. This study aimed to characterize the cohort of patients who underwent PC and resulting clinical outcomes at a tertiary center for hepatobiliary and emergency general surgery. Methods: This is a retrospective cohort study of patients treated between 2012 and 2020 at a single center. A subgroup analysis was conducted to compare outcomes between Tokyo grade 2 and Tokyo grade 3 patients. Results: In the 73-patient cohort, a 57.1% increase in PC was observed between 2012 and 2020. Compared to the gold-standard Tokyo guidelines, 36 patients (49.3%) met the criteria for PC. Postprocedural complications occurred in 50 patients (68.5%), including PC tube dysfunction (27.4%), intra-abdominal abscess (20.5%), external bile leak (8.2%), and biloma (5.5%). Recurrent biliary infection developed in 30 patients (41.1%). Twenty-seven patients (37%) underwent emergency reinterventions due to acute cholecystitis recurrence. Twenty patients (27.4%) required radiological reintervention. Seven patients (9.6%) required emergency cholecystectomy, and ten patients (13.7%) underwent an elective cholecystectomy. Overall, 36 patients (49.3%) died during the follow-up period. Five patients (6.8%) died during index admission. Subgroup analysis demonstrated a higher rate of complications in the Tokyo grade 3 subgroup of 82.8% vs. 59.1% (P = .04). Patients from this subgroup were also more likely to require emergency additional abscess drainage (17.2% vs. 2.3%, P = .034). There was no significant difference in the number of emergency cholecystectomies performed between groups. Patients from the Tokyo grade 2 subgroup were more likely to have an elective cholecystectomy in the future (20.5% vs. 3.4%, P = .044). Conclusions: PC was overperformed in our patient cohort, and was associated with high postprocedure morbidity and mortality. Clinicians should be discerning in patient selection criteria for PC.

Management of Acute Cholecystitis in High-Risk Patients: Percutaneous Gallbladder Drainage as a Definitive Treatment vs. Emergency Cholecystectomy-Systematic Review and Meta-Analysis

BACKGROUND

This systematic review aims to investigate whether percutaneous transhepatic gallbladder biliary drainage (PTGBD) is superior to emergency cholecystectomy (EC) as a definitive treatment in high-risk patients with acute cholecystitis (AC).

MATERIAL AND METHODS

A systematic literature search was performed until December 2022 using the Scopus, Medline/PubMed and Web of Science databases.

RESULTS

Seventeen studies have been included with a total of 783,672 patients (32,634 treated with PTGBD vs. 4663 who underwent laparoscopic cholecystectomy, 343 who had open cholecystectomy and 746,032 who had some form of cholecystectomy, but without laparoscopic or open approach being specified). An analysis of the results shows that PTGBD, despite being less invasive, is not associated with lower morbidity with respect to EC (RR 0.77 95% CI [0.44 to 1.34]; I2 = 99%; p = 0.36). A lower postoperative mortality was reported in patients who underwent EC (2.37%) with respect to the PTGBD group (13.78%) (RR 4.21; 95% CI [2.69 to 6.58]; p < 0.00001); furthermore, the risk of hospital readmission for biliary complications (RR 2.19 95% CI [1.72 to 2.79]; I2 = 48%; p < 0.00001) and hospital stay (MD 4.29 95% CI [2.40 to 6.19]; p < 0.00001) were lower in the EC group.

CONCLUSIONS

In our systematic review, the majority of studies have very low-quality evidence and more RCTs are needed; furthermore, PTGBD is inferior in the treatment of AC in high-risk patients. The definition of high-risk patients is important in interpreting the results, but the methods of assessment and definitions differ between studies. The results of our systematic review and meta-analysis failed to demonstrate any advantage of using PTGBD over ER as a definitive treatment of AC in critically ill patients, which suggests that EC should be considered as the treatment of choice even in very high-risk patients. Most likely, the inferiority of PTGBD versus early LC for high-risk patients is related to an association of various patient-side factor conditions and the severity of acute cholecystitis.

Acute Cholecystitis: A Review

IMPORTANCE

Gallbladder disease affects approximately 20 million people in the US. Acute cholecystitis is diagnosed in approximately 200 000 people in the US each year.

OBSERVATIONS

Gallstone-associated cystic duct obstruction is responsible for 90% to 95% of the cases of acute cholecystitis. Approximately 5% to 10% of patients with acute cholecystitis have acalculous cholecystitis, defined as acute inflammation of the gallbladder without gallstones, typically in the setting of severe critical illness. The typical presentation of acute cholecystitis consists of acute right upper quadrant pain, fever, and nausea that may be associated with eating and physical examination findings of right upper quadrant tenderness. Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis. When an ultrasound result does not provide a definitive diagnosis, hepatobiliary scintigraphy (a nuclear medicine study that includes the intravenous injection of a radiotracer excreted in the bile) is the gold standard diagnostic test. Following diagnosis, early (performed within 1-3 days) vs late (performed after 3 days) laparoscopic cholecystectomy is associated with improved patient outcomes, including fewer composite postoperative complications (11.8% for early vs 34.4% for late), a shorter length of hospital stay (5.4 days vs 10.0 days), and lower hospital costs. During pregnancy, early laparoscopic cholecystectomy, compared with delayed operative management, is associated with a lower risk of maternal-fetal complications (1.6% for early vs 18.4% for delayed) and is recommended during all trimesters. In people older than 65 years of age, laparoscopic cholecystectomy is associated with lower mortality at 2-year follow-up (15.2%) compared with nonoperative management (29.3%). A percutaneous cholecystostomy tube, in which a drainage catheter is placed in the gallbladder lumen under image guidance, is an effective therapy for patients with an exceptionally high perioperative risk. However, percutaneous cholecystostomy tube placement in a randomized trial was associated with higher rates of postprocedural complications (65%) compared with laparoscopic cholecystectomy (12%). For patients with acalculous acute cholecystitis, percutaneous cholecystostomy tube should be reserved for patients who are severely ill at the time of diagnosis; all others should undergo a laparoscopic cholecystectomy.

CONCLUSIONS AND RELEVANCE

Acute cholecystitis, typically due to gallstone obstruction of the cystic duct, affects approximately 200 000 people in the US annually. In most patient populations, laparoscopic cholecystectomy, performed within 3 days of diagnosis, is the first-line therapy for acute cholecystitis.

The Rise and Fall of Percutaneous Cholecystostomy in a Community Hospital: Is It Possible to Turn the Tide of History?

BACKGROUND

Laparoscopic cholecystectomy is the gold standard for treatment of acute cholecystitis. Percutaneous cholecystostomy (PC) drains are alternatives to cholecystectomy in critically ill patients in whom surgery carries an unacceptably high risk. Recently, several studies demonstrated a significant increase in complications in patients undergoing PC in comparison to laparoscopic cholecystectomy.

METHODS

We conducted a retrospective analysis of patients who underwent PC drainage or cholecystectomy from 2014 through 2019 at our institution. We determined the rate of PC use and performed a linear regression analysis to evaluate PC utilization over time. After creating institutional guidelines and reeducating physicians on appropriate use of PC drainage in 2019, we compared PC utilization to prior years.

RESULTS

A total of 146 PCs and 3163 cholecystectomies were performed over the study period. Of the cholecystectomies, 754 (23.8%) were performed in hospitalized patients under urgent or emergent conditions. Of the patients with acute cholecystitis, 16.2% were treated with PC. Linear regression analysis demonstrated a significant association between year and rate of PC procedures (p<0.001). The rate of PC rose from 13.8 to 22.5% between 2014 and 2018 and dropped to 10.9% (p=0.006) in 2019 after the reeducation program.

CONCLUSIONS

With a rising rate of PC utilization and in light of recent studies suggesting increased complications and healthcare costs for patients undergoing this procedure, care needs to be taken to ensure that only appropriate patients are referred for PC. Publication of institutional guidelines, resident and attending surgeon reeducation, and case review can reduce placement of unnecessary PCs.

Minimally Invasive Management of Acute Cholecystitis and Frailty Assessment in Geriatric Patients

The aim was to compare laparoscopic cholecystectomy (LC) with the percutaneous cholecystostomy (PC) for the management of acute lithiasic cholecystitis in geriatric patients and investigate the decision-making using frailty assessment. A retrospective analysis was performed in all patients aged over 65 years who were treated for acute cholecystitis at our hospital in a period of 5 years. Patients were divided in LC and PC groups. In total, 111 (54.1%) patients were subjected to LC and 94 (45.9%) to PC. The American Society of Anesthesiologists (ASA) and the Clinical Frailty Score were lower for the LC group. However, for patients over 85 years of age, frailty scores between groups were not statistically different. Morbidity and mortality between groups were not statistically different. Both LC and PC are safe and efficient in geriatric patients. Frailty score may better drive the selection of patients to be managed laparoscopically.

APACHE IV system helps to determine role of cholecystostomy in elderly patients with acute cholecystitis

Objective

Cholecystostomy is a palliative treatment for patients unfit to undergo immediate cholecystectomy. Nevertheless, the role of cholecystostomy in the clinical management of such patients remains unclear. The Acute Physiology and Chronic Health Evaluation IV (APACHE IV) scoring system is useful for estimating the hospital mortality of high-risk patients. We evaluated the therapeutic effect of cholecystostomy by the APACHE IV scoring system in patients aged >65 years with acute cholecystitis.

Methods

In total, 597 patients aged >65 years with acute cholecystitis were retrospectively analyzed using APACHE IV scores.

Results

The fitness of the APACHE IV score prediction was good, with an area under the receiver operating characteristic curve of 0.894. The chi square independence test indicated that compared with conservative treatment, cholecystostomy may have different effects on mortality for patients whose estimated mortality rate was >10%. Comparison of the estimated mortality of patients before and after cholecystostomy indicated that the estimated mortality was significantly lower after than before puncture, both in the whole patient group and in the group with an estimated mortality of >10%.

Conclusion

The APACHE IV scoring system showed that cholecystostomy is a safe and effective treatment for elderly high-risk patients with acute cholecystitis.

A nationwide analysis of gallbladder surgery in England between 2000 and 2019

BACKGROUND

There are no reports on nationwide trends in subtotal cholecystectomy (STC) and cholecystostomy in England. We hypothesized that, as in the United States, a substantial increase in the utilization of these surgical procedures, over time, may be observed. We aimed to generate a reliable report on 4 of the most common gallbladder surgical procedures in England to allow cross-procedure comparisons and highlight significant changes in the management of benign gallbladder disease over time.

METHODS

We obtained data from NHS Digital and extracted population estimates from the Office of National Statistics. We examined the trends in the use of STC, cholecystostomy, cholecystolithotomy and total cholecystectomy (TC) between 2000 and 2019.

RESULTS

Of the 1,234,319 gallbladder surgeries performed, TC accounted for 96.8% (n = 1,194,786) and the other 3 surgeries for 3.2% (n = 39,533). The total number of gallbladder surgeries performed annually increased by 80.4% from 2000 to 2019. We detected increases in the counts of cholecystostomies by 723.1% (n = 290 in 2000 vs n = 2,387 in 2019) and STCs by 716.6% (n = 217 in 2000 vs n = 1,772 in 2019). Consequently, there was a decrease in the ratio of TC to STC (180:1 in 2000 vs 38:1 in 2019). A similar decrease was observed in the ratio of cholecystectomy to cholecystostomy (135:1 in 2000 vs 29:1 in 2019).

CONCLUSION

Increased utilization of STC and cholecystostomy was detected in England. These findings highlight the importance of regular monitoring of nationwide trends in gallbladder surgery and the associated clinical outcomes.

Frail geriatric patients with acute calculous cholecystitis: Operative versus nonoperative management?

INTRODUCTION

Nonoperative management of acute calculous cholecystitis (ACC) in the frail geriatric population is underexplored. The aim of our study was to examine long-term outcomes of frail geriatric patients with ACC treated with cholecystectomy compared with initial nonoperative management.

METHODS

We conducted a 2017 analysis of the Nationwide Readmissions Database and included frail geriatric (≥65 years) patients with ACC. Frailty was assessed using the five-factor modified frailty index. Patients were stratified into those undergoing cholecystectomy at index admission (operative management [OP]) versus those managed with nonoperative intervention (nonoperative management [NOP]). The NOP group was further subdivided into those who received antibiotics only and those who received percutaneous drainage. Primary outcomes were procedure-related complications in the OP group and 6-month failure of NOP (readmission with cholecystitis). Secondary outcomes were mortality and overall hospital length of stay.

RESULTS

A total of 53,412 geriatric patients with ACC were identified, 51.0% of whom were frail: 16,791 (61.6%) in OP group and 10,472 (38.4%) in NOP group (3,256 had percutaneous drainage, 7,216 received antibiotics only). Patients were comparable in age (76 ± 7 vs. 77 ± 8 years; p = 0.082) and modified frailty index (0.47 vs. 0.48; p = 0.132). Procedure-related complications in the OP group were 9.3%, and 6-month failure of NOP was 18.9%. Median time to failure of NOP management was 36 days (range, 12-78 days). Mortality was higher in the frail NOP group (5.2 vs. 3.2%; p < 0.001). The NOP group had more days of hospitalization (8 [4-15] vs. 5 [3-10]; p < 0.001). Both receiving antibiotics only (odds ratio, 1.6 [1.3-2.0]; p < 0.001) and receiving percutaneous drainage (odds ratio, 1.9 [1.7-2.2]; p < 0.001) were independently associated with increased mortality.

CONCLUSION

One in five patients failed NOP and subsequently had complicated hospital stays. Nonoperative management of frail elderly ACC patients may be associated with significant morbidity and mortality.

LEVEL OF EVIDENCE

Therapeutic, level IV.

The Bacteriology of Acute Cholecystitis: Comparison of Bile Cultures and Clinical Outcomes in Diabetic and Non-Diabetic Patients

BACKGROUND

Acute cholecystitis is one of the most common acute surgical diseases. Diabetic patients have been shown to have an increased risk for gallbladder disease, but the correlation between the severity of gallstone disease and diabetes is still debated. The aim of this study is to examine the possible difference in the disease process between patients with diabetes mellitus (DM) and those without.

PATIENTS AND METHODS

A retrospective study was conducted of all patients who underwent percutaneous cholecystostomy between 2005 and 2015 at Emek Medical Center, Afula, Israel. Demographic and medical history including data on bile and blood culture results, antimicrobial susceptibility, and clinical outcomes were retrieved from patient files.

RESULTS

The cohort included 272 patients. Mean age was 68 years old, 50.74% were male and 43.75% had diabetes mellitus. Bile cultures were obtained from 252 (92.64%) patients and were positive in 134 (53.2%) patients. In 11 patients (4%) two pathogens were isolated. Blood cultures obtained from 231 patients and were positive in 35 (15.2%). Escherichia coli was the most common isolate, and was seen in 22.3% of positive bile cultures and 40% of blood cultures. Although diabetic patients had significantly more positive bile cultures, the severity of the disease, according to the Tokyo guidelines, was not higher.

CONCLUSIONS

Acute cholecystitis was neither more severe nor had significant difference in bacteriological properties when comparing diabetic patients to non-diabetic ones.

Outcomes of percutaneous cholecystostomy in elderly patients: a systematic review and meta-analysis

INTRODUCTION

Percutaneous cholecystostomy (PC) represents a management option to control sepsis in patients with acute cholecystitis, who are unable to tolerate surgery.

AIM

This review aimed to evaluate the outcomes of elderly patients treated with PC and compare it with emergent cholecystectomy.

MATERIAL AND METHODS

An electronic search of the Embase, Medline Web of Science, and Cochrane databases was performed. Percutaneous cholecystostomy was used as the reference group, and weighted mean differences (WMD) were calculated for the effect of PC on continuous variables, and pooled odds ratios (POR) were calculated for discrete variables.

RESULTS

There were 20 trials included in this review. Utilisation of PC was associated with significantly increased mortality (POR = 4.85; 95% CI: 1.02-7.30; p = 0.0001) and increased re-admission rates (POR = 2.95; 95% CI: 2.21-3.87; p < 0.0001).

CONCLUSIONS

This pooled analysis established that patients treated with PC appear to have increased mortality and readmission rates relative to those managed with cholecystectomy.

Use of non-operative treatment and interval cholecystectomy for cholecystitis in patients with cancer

Background

Early cholecystectomy (EC) for acute cholecystitis (AC) is standard. Often patients with cancer are not EC candidates and require non-surgical treatments. We analyzed factors associated with non-surgical treatments and progression to interval cholecystectomy (IC).

Materials and methods

We performed a case-control study reviewing consults for AC from 2001 to 2017 in a tertiary cancer center. Study patients had cancer, abdominal pain, and positive imaging studies. Univariate analysis and regression modeling evaluated associations between non-surgical management, resolution of AC, and IC.

Results

206 patients met the criteria. 20 underwent EC, 132 took antibiotics (ABX), and were treated with 54 percutaneous cholecystostomy tubes (PCTs). AC resolution was higher with PCT versus ABX (94% vs. 80%, p=0.02). Univariate analysis revealed higher absolute neutrophil counts (ANCs) and longer length of stay in PCT, and logistic regression revealed independent associations of abdominal malignancy (OR=6.66, 95% CI 1.36 to 32.6, p=0.09), abdominal radiation (OR=0.09, 95% CI 0.02 to 0.53, p<0.01), and PCT with resolution of AC (OR=4.89, 95% CI 1.18 to 20.2, p=0.01). IC rate was 43%, and median time to IC after was 45 to 67 days. Multivariate analysis revealed nausea/vomiting and increasing platelets are independently associated with IC. Recent chemotherapy increases odds of IC in the presence of rising ANC (OR=1.14, 95% CI 1.00 to 1.30, p=0.05).

Conclusion

PCT has a higher success rate of resolving AC than ABX. Abdominal malignancy increases odds of resolution; abdominal radiation decreases odds. Nausea/vomiting and recent chemotherapy, coupled with rising ANC are associated with IC, but less than 50% of patients return for operation. PCT may not be a bridge to IC in our population.Level of evidence II.

Percutaneous cholecystostomy - An option in selected patients with acute cholecystitis

While urgent percutaneous cholecystostomy (PC) was introduced as an alternative to acute surgical treatment for acute cholecystitis (AC), the current place of PC in the treatment algorithm for AC is challenged. We evaluate demographics and outcomes of PC in routine clinical practice in a population-based cohort.Retrospective evaluation of consecutive patients treated with PC for AC between 2000 and 2015. The severity of cholecystitis was graded according to the 2013 Tokyo Guidelines.One hundred forty-nine patients were included (82; 55% males) (median age of 72.5 years; range, 21-92). The Tokyo Guidelines criteria of 2013 (TG13) severity grade distribution was 4%, 61.7%, and 34.2% for grades I, II, and III, respectively. No difference was observed between males and females with regard to age, American Society of Anesthesiologists (ASA) score, comorbidities, or previous history of cholecystitis. PC was successfully performed in all but 1 patient, and complications were few and minor. Less than half (48.3%) of all patients subsequently received definitive surgical treatment, mostly (83.3%) laparoscopy. No or minor complications were encountered in 58 (80.6%) patients. Operated patients were significantly younger (P = <.001) and had lower ASA scores (P = .005), less comorbidities (P < .001), and had more seldomly a severe grade 3 cholecystitis (P < .001) than non-operated patients.PC is useful in selected patients with AC. However, since only a half of the patients eventually received definitive surgical treatment, a better routine decision-making based on proper criteria may enable an improved allocation of the individual patient for tailored treatment according to the disease severity, the patient's comorbidity burden, and also to the treatment options available at the institution to prevent overutilization of a non-definitive treatment approach. Comprehension of this responsibility should be acknowledged by hospitals with an emergency surgical service, although the clinical decision-making remains a challenge of the responsible surgeon on call.

Cost effectiveness of endoscopic gallbladder drainage to treat acute cholecystitis in poor surgical candidates

BACKGROUND

Endoscopic gallbladder drainage (GBD) is an alternative to percutaneous GBD (PGBD) to treat acute cholecystitis, yielding similar success rates and fewer adverse events. To our knowledge, no cost-effectiveness analysis has compared these procedures. We performed an economic analysis to identify clinical and cost determinants of three treatment options for acute cholecystitis in poor surgical candidates.

METHODS

We compared three treatment strategies: PGBD, endoscopic retrograde cholangiographic transpapillary drainage (ERC-GBD), and endosonographic GBD (EUS-GBD). A decision tree was created over a 3-month period. Effectiveness was measured using hospital length of stay, including adverse events and readmissions. Costs of care were calculated from the National Inpatient Sample. Technical and clinical success estimates were obtained from the published literature. Cost effectiveness was measured as incremental cost effectiveness and compared to the national average cost of one hospital bed per diem.

RESULTS

Analysis of a hypothetical cohort of poor candidates for cholecystectomy showed that, compared to PGBD, ERC-GBD was a cost-saving strategy and EUS-GBD was cost effective, requiring $1312 per hospitalization day averted. Additional costs of endoscopic interventions were less than the average cost of one hospital bed per diem. Compared to ERC-GBD, EUS-GBD required expending an additional $8950 to prevent one additional day of hospitalization. Our model was considerably affected by lumen-apposing metal stent cost and hospital length of stay for patients managed conservatively and those requiring delayed surgery.

CONCLUSIONS

Endoscopic GBD is cost effective compared to PGBD, favoring ERC-GBD over EUS-GBD. Further efforts are needed to make endoscopic GBD available in more medical centers, reduce equipment costs, and shorten inpatient stay.

Percutaneous cholecystostomy in the management of acute cholecystitis - 10 years of experience

Introduction

The preferred treatment for acute cholecystitis is cholecystectomy, but for patients with precluded general anesthesia due to critical illness or multiple medical comorbidities it is not suitable. Cholecystostomy could be a minimally invasive therapeutic alternative.

Aim

To retrospectively evaluate the indications, technical features, efficacy, complications, patients’ development and relationships among monitored parameters of percutaneous computed tomography (CT)-guided cholecystostomies in cases of acute cholecystitis and find the role of this procedure in appropriate treatment selection.

Material and methods

Over the course of 10 years, 75 percutaneous cholecystostomy procedures in 69 patients were performed in cases with diagnosed acute cholecystitis, precluded general anesthesia and contraindicated cholecystectomy by an experienced surgeon and anesthesiologist. These interventions were done using only local anesthesia. The patients were men in 39 cases and women in 33 cases, aged 33 to 91 years.

Results

Technical success was achieved in all cases. The indications were sepsis in 34 (45.3%) cases, bridging acute gallbladder inflammatory status in 15 (20%) interventions, serious medical comorbidities in 8 (10.7%) cases, disseminated malignancy and cardiac failure in 6 cases each (both 8%) and neurological affections in 5 (6.5%) cases. Cholecystostomy was frequently the final solution in acalculous cholecystitis (79.3%). The 30-day mortality rate was determined at 10.7% and the overall complication rate was 21.3%, but all of these complications were managed conservatively or using minimally invasive treatment.

Conclusions

Percutaneous CT-guided cholecystostomy is reserved for patients with a serious medical status for various reasons that preclude surgical treatment and general anesthesia. Simultaneously, technical success and efficacy are high and the complication rate is acceptable.

Cholecystostomy: Are we using it correctly?

BACKGROUND

Percutaneous Cholecystostomy Tubes (PCT) have become an accepted and common modality of treating acute cholecystitis in patients that are not appropriate surgical candidates. As percutaneous gallbladder drainage has rapidly increased newer research suggests that the technique may be overused, and patients may be burdened with them for extended periods. We examined our experience with PCT placement to identify independent predictors of interval cholecystectomy versus destination PCT.

METHODS

All patients with cholecystitis initially treated with PCT from 2014 to 2017 were stratified by whether they underwent subsequent interval cholecystectomy. Demographic data, initial laboratory values, Tokyo Grade, Charlson Comorbidity Index, ASA Class, complications related to PCT, complications related to cholecystectomy, and mortality data were retrospectively collected. Descriptive statistics, univariable, and multivariable Poisson regression were performed.

RESULTS

165 patients received an initial cholecystostomy tube to treat cholecystitis. 61 (37%) patients went on to have an interval cholecystectomy. There were 4 complications reported after cholecystectomy. A total of 46 (27.9%) deaths were reported, only one of which was in the cholecystectomy group. Age, Tokyo Grade, liver function tests, ASA Class, and Charlson Comorbidity Index were significantly different between the interval cholecystectomy and no-cholecystectomy groups. Univariable regression was performed and variables with p < 0.2 were included in the multivariable model. Multivariable Poisson regression showed that increasing Tokyo Grade (IRR 0.454, p = 0.042, 95% CI 0.194-0.969); and increasing Charlson Comorbidity Score (IRR 0.890, p = 0.026, 95% CI 0.803-0.986) were associated with no-cholecystectomy. Higher Albumin (IRR 1.580, p = 0.011, 95% CI 1.111-2.244) was associated with having an interval cholecystectomy.

CONCLUSION

Patients in the no-cholecystectomy group were older, had more comorbidities, higher Tokyo Grade, ASA Class, and initial liver function test values than those that had interval cholecystectomy. Since interval cholecystectomy was performed with a low rate of complications, we may be too conservative in performing cholecystectomy after drainage and condemning many patients to destination tubes.

Cholecystectomy Vs. Cholecystostomy for the Management of Acute Cholecystitis in Elderly Patients

BACKGROUND

Data comparing outcomes following cholecystectomy and cholecystostomy tube placement (CTP) in elderly patients are lacking. We aimed to compare the post-procedural outcomes between cholecystectomy and CTP in elderly patients with acute cholecystitis.

METHODS

We performed a retrospective, population-based analysis using the National Inpatient Sample for the period 2000-2014. Patients ≥ 65 years old admitted with a primary diagnosis of acute cholecystitis and who underwent either cholecystectomy or CTP during their hospitalization were included. Multivariable linear and logistic regression models were used to analyze post-procedural complications, mortality, length of stay, and total charges. The effect of procedure type on patient outcomes, stratified by acalculous and calculous cholecystitis, was also performed.

RESULTS

A total of 200,915 patients were included, of which 7516 underwent CTP and 193,399 underwent cholecystectomy. The median age of patients undergoing CTP and cholecystectomy was 80 (IQR 73-87) and 75 (IQR 70-81), respectively. Patients undergoing CTP were more likely to have post-procedural infection (OR 2.25; 95% CI 2.07, 2.45), bleeding (OR 1.28; 95% CI 1.19, 1.37), and inpatient mortality (OR 9.27; 95% CI 7.95, 10.81). On average, CTP patients stayed 1.25 days longer (95% CI 1.14, 1.37) in hospital after the procedure. The benefits of cholecystectomy were consistent in patients with acalculous and calculous cholecystitis.

CONCLUSIONS

Elderly patients with both acalculous and calculous acute cholecystitis managed with CTP have higher incidences of post-procedural morbidity and mortality, and longer post-procedure length of hospital stay, as compared to cholecystectomy. Unless prohibitive surgical risks exist, elderly patients with acute cholecystitis should undergo cholecystectomy.

Percutaneous Cholecystostomy Versus Conservative Treatment for Acute Cholecystitis: a Cohort Study

BACKGROUND

Percutaneous cholecystostomy is frequently used as a treatment option for acute calculous cholecystitis in patients unfit for surgery. There is sparse evidence on the long-term impact of cholecystostomy on gallstone-related morbidity and mortality in patients with acute calculous cholecystitis. This study describes the long-term outcome of acute calculous cholecystitis following percutaneous cholecystostomy compared to conservative treatment.

METHODS

This was a cohort study of patients admitted at our institution from 2006 to 2015 with acute calculous cholecystitis without early or delayed cholecystectomy. Endpoints were gallstone-related readmissions, recurrent cholecystitis, and overall mortality.

RESULTS

The investigation included 201 patients of whom 97 (48.2%) underwent percutaneous cholecystostomy. Patients in the cholecystostomy group had significantly higher age, comorbidity level, and inflammatory response at admission. The median duration of catheter placement in the cholecystostomy group was 6 days. The complication rate of cholecystostomy was 3.1% and the mortality during the index admission was 3.5%. The median follow-up was 1.6 years. The rate of gallstone-related readmissions was 38.6%, and 25.3% had recurrence of cholecystitis. Cox regression analyses revealed no significant differences in gallstone-related readmissions, recurrence of acute calculous cholecystitis, and overall mortality in the two groups.

CONCLUSIONS

Percutaneous cholecystostomy in the treatment of acute calculous cholecystitis was neither associated with long-term benefits nor complications. Based on the high gallstone-related readmission rates of this study population and todays perioperative improvements, we suggest rethinking the indications for non-operative management including percutaneous cholecystostomy in acute calculous cholecystitis.

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

INTRODUCTION

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.

METHODS

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 2 years. 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.

RESULTS

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%).

CONCLUSIONS

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.

Percutaneous cholecystostomy… why, when, what next? A systematic review of past decade

INTRODUCTION

Percutaneous cholecystostomy tube drainage has played a vital role in management of cholecystitis in patients where surgery is not appropriate. However, management differs from unit to unit and even between different consultants in the same unit. We conducted this systematic review to understand which of these resulted in the best patient outcomes.

METHODS

We conducted a systematic review using the PubMed database for publication between January 2006 to December 2016. Keyword variants of 'cholecystostomy' and 'cholecystitis' were combined to identify potential relevant papers for inclusion.

FINDINGS

We identified 46 studies comprising a total of 312,085 patients from 20 different countries. These papers were reviewed, critically appraised and summarised in table format. Percutaneous cholecystostomy tube drainage is an important treatment modality with an excellent safety profile. It has been used successfully both as a definitive procedure and as a bridge to surgery. There continues to be great variation, however, when it comes to the indications, timing and management of these drains. As far as we are aware, this is the only systematic review to cover the past 10 years. It provides a much-needed update, considering all the technological development and new treatment options in laparoscopic surgery and interventional radiology.

Early percutaneous cholecystostomy versus antibiotic treatment for mild and moderate acute cholecystitis: A retrospective cohort study

BACKGROUND

Percutaneous cholecystostomy (PC) is an effective treatment for severe acute cholecystitis (AC). Guidelines recommend PC as rescue therapy for patients with mild or moderate AC who do not receive emergent cholecystectomy. This study aims to investigate whether PC could be a first-line treatment for these patients.

METHODS

Adult patients admitted through the emergency department between October 2004 and December 2013 were retrospectively reviewed. Patients with mild or moderate AC who did not undergo emergent cholecystectomy were included. Early PC was defined as a PC tube inserted within 24 h of diagnosis. The outcomes were compared between patients who received antibiotics plus early PC (early PC group) and those who received antibiotic treatment alone (antibiotic group).

RESULTS

A total of 698 patients were included. The mean age was 63.4 years. There were 171 patients in the early PC group and 527 patients in the antibiotic group. Multivariable logistic regression analyses indicated that early PC was significantly associated with a decreased rate of prolonged fever (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.16-0.57; p < 0.001). Early PC also correlated with both increased short-term (OR, 15.95; 95% CI, 5.73-44.38; p < 0.001) and long-term treatment success (OR, 4.27; 95% CI, 2.55-7.15; p < 0.001).

CONCLUSION

For patients with mild/moderate AC without emergent cholecystectomy, early PC might expedite sepsis resolution and improve the treatment success rate compared with antibiotic treatment alone. This result should be deemed as hypothesis-generating and should be examined in a randomized controlled trial.

Outcomes in the Utilization of Single Percutaneous Cholecystostomy in a Low-Income Population

Numerous studies have investigated the applicable populations for percutaneous cholecystostomy (PC) procedures, but the outcomes of PC in low-income populations (LIPs) have been insufficiently studied. Data for 11,184 patients who underwent PC were collected from the National Health Insurance Research Database of Taiwan during 2003 and 2012. The overall crude rate of single PC for the LIP was 64% higher than that for the general population (GP). After propensity score matching for the LIP and GP at a ratio of 1:5, the outcome analysis of patients who underwent PC showed that in-hospital mortality was significantly higher in the LIP group than in the GP group, but one-year recurrence was lower. The rates of 30-day mortality and in-hospital complications were higher for the LIP patients than for the GP patients, and the rate of routine discharge was lower, but the differences were not significant. In conclusion, LIP patients undergoing PC exhibit poor prognoses relative to GP patients, indicating that a low socioeconomic status has an adverse impact on the outcome of PC. We suggest that surgeons fully consider the patient’s financial situation during the operation and further consider the possible poor post-surgical outcomes for LIP patients.

Outcome comparison between percutaneous cholecystostomy and cholecystectomy: a 10-year population-based analysis

Background

Controversy surrounding the role of percutaneous cholecystostomy (PC) is fed by the absence of large amounts of data concerning its outcomes, and many authors have maintained that there is no evidence to support a recommendation for PC rather than cholecystectomy (CCS) in elderly or critically ill patients with acute cholecystitis (AC).

Methods

We conducted this study by tracking trends in the utilization and outcomes of PC and CCS using longitudinal health research data in Taiwan.

Results

Analyses were conducted on 236,742 patients, 11,184 of whom had undergone PC and 225,558 of whom had undergone CCS. Average annual percentage changes (AAPCs) from 2003 to 2012 increased significantly by 18.34% each year for PC and by 2.82% each year for CCS. The subset analyzes showed that the mortality rates were far higher in patients underwent PC than in patients underwent CCS in all subgroups, which increased from a minimum of 1.45-fold to a maximum of 34.22-fold. The gap of the mortality rates between PC group and CCS group narrowed as the patients aged and with the seriousness of the diseases increased. Most patients with PC or CCS who died in-hospital or within 30 days after discharge were 70 years of age or older, and a large number of them received a CCI score of at least 1. The AAPCs of the overall mortality rates from 2003 to 2012 decreased by 6.78% each year for PC and by 7.33% each year for CCS. PC was related to a higher rate of cholecystitis recurrence and readmission for complications, but a lower rate of in-hospital complications and routine discharge than CCS, and 36.41% of all patients treated with PC underwent subsequent CCS. Additionally, the patients with PC experienced longer hospital stays and generated higher costs than the patients with CCS.

Conclusion

Patients who underwent PC demonstrated poorer prognoses than did patients who underwent CCS. The role of PC in the Tokyo guidelines may be overstated; it is not as safe as the Tokyo guidelines have suggested in moderate-grade cholecystitis cases, and it should be limited to only the elderly and sicker patients.

Long-Term Outcomes Following Percutaneous Cholecystostomy Tube Placement for Treatment of Acute Calculous Cholecystitis

INTRODUCTION

Percutaneous cholecystostomy tube (PCT) placement is considered a safe alternative to cholecystectomy for the treatment of acute calculous cholecystitis (ACC), but data regarding long-term outcomes following PCT are limited.

METHODS

We retrospectively reviewed our institutional experience of patients undergoing PCT for ACC between 1997 and 2015. Recurrent biliary events were defined as cholecystitis, cholangitis, or gallstone pancreatitis.

RESULTS

PCT was placed for 288 patients with ACC. Mean age and age-adjusted Charlson comorbidity index were 72 ± 15 years and 5.3 ± 2.4, respectively. Following PCT placement, 91% of patients successfully resolved their episode of ACC. PCT dysfunction occurred in 132 patients (46%), with 80 patients (28%) requiring re-intervention, while 7% developed procedure-related complications. Interval cholecystectomy reduced the risk of recurrent biliary events to 7% from 21% (p = 0.002). Cholecystectomy was completed laparoscopically in 45% of patients receiving an interval operation vs. 22% of those undergoing urgent surgery for PCT failure or recurrent biliary event (p = 0.03).

CONCLUSIONS

PCT placement is a highly successful treatment for acute calculous cholecystitis and is associated with low complication rate, but high rate of tube dysfunction requiring frequent re-intervention. Interval cholecystectomy is associated with a decreased likelihood of recurrent biliary events and increased likelihood of successful laparoscopic completion.

Cholecystostomy Treatment in an ICU Population: Complications and Risks

BACKGROUND

Percutaneous cholecystostomy tube placement has widely been used as an alternative treatment to cholecystectomy, especially in advanced disease or critically ill patients. Reported postprocedural complication rates have varied significantly over the last decade. The goal of this study is to evaluate the safety of percutaneous cholecystostomy tube treatment in critically ill patients.

STUDY DESIGN

We performed a retrospective chart analysis of 96 critically ill patients who underwent cholecystostomy tube placement during an intensive care unit (ICU) stay between 2005 and 2010 in a tertiary care center in central Massachusetts. Complications within 72 hours of cholecystostomy tube placement and any morbidity or mortality relating to presence of cholecystostomy tube were considered.

RESULTS

A total of 65 male and 31 female patients with a mean age of 67.4 years underwent percutaneous cholecystostomy tube placement during an ICU stay. Sixty-six patients experienced a total of 121 complications, resulting in an overall complication rate of 69%. Fifty-four of these complications resulted from the actual procedure or the presence of the cholecystostomy tube; the other 67 complications occurred within 72 hours of the cholecystostomy procedure. Ten patients died. Tube dislodgment was the most common complication with a total of 34 episodes.

CONCLUSIONS

Cholecystostomy tube placement is associated with frequent complications, the most common of which is tube dislodgment. Severe complications may contribute to serious morbidity and death in an ICU population. Complication rates may be underreported in the medical literature. The potential impact of cholecystostomy tube placement in critically ill patients should not be underestimated.

What is the fate of the cholecystostomy tube following percutaneous cholecystostomy?

INTRODUCTION

Cholecystectomy is the preferred treatment for acute cholecystitis with percutaneous cholecystostomy (PC) considered an alternative therapy in severely debilitated patients. The aim of this study was to evaluate the efficacy and outcomes of PC at a tertiary referral center.

METHODS

We retrospectively reviewed all patients that had undergone PC from 2000 to 2014. Data collected included baseline demographics, comorbidities, details of PC placement and management, and post-procedure outcomes. The Charlson comorbidity index (CCI) was calculated for all patients at the time of PC.

RESULTS

Four hundred and twenty-four patients underwent PC placement from 2000 to 2014, and a total of 380 patients had long-term data available for review. Within this cohort, 223 (58.7 %) of the patients were male. The mean age at the time of PC placement was 65.3 ± 14.2 years of age, and the mean CCI was 3.2 ± 2.1 for all patients. One hundred and twenty-five (32.9 %) patients went on to have a cholecystectomy following PC placement. Comparison of patients who underwent PC followed by surgical intervention revealed that they were significantly younger (p = 0.0054) and had a lower CCI (p < 0.0001) compared to those who underwent PC alone.

CONCLUSIONS

PC placement appears to be a viable, long-term alternative to cholecystectomy for the management of biliary disease in high-risk patients. Old and frail patients benefit the most, and in this cohort PC may be the definitive treatment.

Surgical management of empyematous cholecystitis: a register study of over 12,000 cases from a regional quality control database in Germany

BACKGROUND

Acute cholecystitis is a common indication for surgery. Surgical outcomes depend among other factors on the extent of gallbladder inflammation. Data on the outcomes of patients undergoing cholecystectomy due to acute empyematous cholecystitis are rare.

METHODS

Data from a prospectively maintained quality control database in Germany were analyzed. Cases with empyematous cholecystitis were compared to cases without gallbladder empyema with regard to baseline features, clinical parameters and surgical outcomes.

RESULTS

A total of 12,069 patients with empyematous cholecystitis (EC) were compared to 33,296 patients without empyema. The male gender, advanced age, ASA score >2, elevated white blood count and fever were confirmed as risk factors for EC. The EC group differed significantly from the control group with regard to fever (28.0 vs. 9.5 %), elevated WBC (82.5 vs. 62.3 %) and positive findings from ultrasound sonography (87.4 vs. 76.9 %), p < 0001. Surgery lasted significantly longer in the EC group (86.1 ± 38.5 vs. 72.2 ± 33.6, p < 0.001). The rates of conversion (15.2 vs. 5.8 %), bile duct injury (0.8 vs. 0.4 %), re-intervention (5.5 vs. 2.6 %) and mortality (2.8 vs. 1.2 %) were significantly higher in the EC group, p < 0.001. Similarly, the length of stay (11.9 ± 10.5 vs. 8.8 ± 8.3, p < 0.001) was significantly longer in the EC group.

CONCLUSION

Empyematous cholecystitis is a severe form of acute cholecystitis with high rates of morbidity and mortality. Even the experienced laparoscopic surgeon should expect dissection difficulties, therefore the threshold for conversion in order to prevent bile duct injury should be low.

Long-Term Outcomes of Patients with Acute Cholecystitis after Successful Percutaneous Cholecystostomy Treatment and the Risk Factors for Recurrence: A Decade Experience at a Single Center

BACKGROUND

Percutaneous cholecystostomy tube (PCT) has been effectively used for the treatment of acute cholecystitis (AC) for patients unsuitable for early cholecystectomy. This retrospective study investigated the recurrence rate after successful PCT treatment and factors associated with recurrence.

METHODS

We reviewed patients treated with PCT for AC from October 2004 through December 2013. Patients with successful PCT treatment were those who were free from persistent PCT drainage. We used multivariable logistic regression analysis sequentially to identify factors associated with each outcome.

RESULTS

The study included 184 patients (mean age: 70.1 years). The average duration for parenteral antibiotics was 14.4 days and 20.0 days for PCT drainage. The one-year recurrence rate was 9.2% (17/184) with most recurrences occurring within two months (6.5%, 12/184) of the procedure. Complicated cholecystitis (odds ratio [OR]: 4.67; 95% confidence interval [CI]: 1.44-15.70; P = 0.01) and PCT drainage duration >32 days (OR: 4.92; 95% CI: 1.03-23.53; P = 0.05) positively correlated with one-year recurrence; parenteral antibiotics duration >10 days (OR: 0.21; 95% CI: 0.05-0.68; P = 0.01) was inversely associated with one-year recurrence.

CONCLUSIONS

The recurrence rate was low for patients after successful PCT treatment. Predictors for recurrence included the severity of initial AC and subsequently provided treatments.

Outcomes of percutaneous cholecystostomy and predictors of eventual cholecystectomy

BACKGROUND

Percutaneous cholecystostomy (PC) is an established treatment for high surgical risk patients with acute cholecystitis. This paper studies factors predictive of mortality and eventual cholecystectomy.

METHODS

A retrospective review of all patients who underwent PC from March 2005 to March 2015 was performed. Patient demographics, clinical features, comorbidity profile, grade of cholecystitis, interval between cholecystitis diagnosis and PC, and method of PC were studied. Length of stay, complications, readmission rate, mortality and eventual cholecystectomy were studied. For patients with eventual cholecystectomy, operative data and perioperative outcomes were studied.

RESULTS

One hundred and three patients with median age of 80 years (range 43-105) underwent PC. Median interval to PC was 2 days (range 0-15). 9.7% of patients had complications. Median length of stay was 19 days (range 3-206). 41% underwent eventual cholecystectomy. 30-day mortality rate was 10.7%. Higher APACHE II scores (P = 0.004), higher Charlson comorbidity index (CCI) (P = 0.009), and longer interval from diagnosis to PC (P = 0.037) were associated with in-hospital mortality. Younger age (P = 0.015), lower APACHE II scores (P = 0.043) and lower CCI (P = 0.002) were associated with eventual cholecystectomy.

CONCLUSION

Percutaneous cholecystostomy is safe and effective in treatment of acute cholecystitis. Prompt PC improves survival in high risk surgical patients. Comorbidity severity is associated with mortality. Patients with lesser comorbidity are likely to receive eventual cholecystectomy.

Primary cholecystectomy is feasible in elderly patients with acute cholecystitis

BACKGROUND

While early cholecystectomy is generally accepted as the standard procedure for young and fit patients with acute cholecystitis, controversy exits on the management of elderly and severely sick patients. We postulated that primary cholecystectomy is feasible in this subgroup. The aim of this study was to compare the outcomes of young and fit patients to those of elderly patients undergoing surgery for acute cholecystitis.

METHODS

The outcomes of elderly patients (≥70 years) undergoing surgery for acute cholecystitis in a primary care center in Germany were retrospectively compared to those of younger patients (<70 years).

RESULTS

152 patients, 74 aged ≥ 70 years (study group) and 78 < 70 years (control) were included for analysis. The study group was significantly older at the time of surgery (78 vs. 68 years, p = 0.02). Severe cholecystitis was seen in a significant number of cases in the study group, p = 0.01. Equally, the mean WBC (19.5 vs. 17, p = 0.02), CRP (26 vs. 22, p = 0.04) and APACHE II score (17 vs. 8, p = 0.01) were significantly higher in the study group. There was no significant difference in the duration of anesthesia (123 vs. 133 min, p = 0.70) and surgery (72 vs. 81 min, p = 0.90) amongst both groups. There was no significant difference in rate of complication amongst both groups (24 vs. 14%, p = 0.11). Two cases of mortality were recorded (1.3%) in the study group.

CONCLUSION

The age of the patient cannot be the sole factor in deciding whether or not a patient with acute cholecystitis is fit for surgery.

Assessing clinical outcomes of patients with acute calculous cholecystitis in addition to the Tokyo grading: a retrospective study

The management of acute cholecystitis is still based on clinical expertise. This study aims to investigate whether the outcome of acute cholecystitis can be related to the severity criteria of the Tokyo guidelines and additional clinical comorbidities. A total of 103 patients with acute cholecystitis were retrospectively enrolled and their medical records were reviewed. They were all classified according to therapeutic modality, including early cholecystectomy and antibiotic treatment with or without percutaneous cholecystostomy. The impact of the Tokyo guidelines and the presence of comorbidities on clinical outcome were assessed by univariate and multivariate regression analyses. According to Tokyo severity grading, 48 patients were Grade I, 31 patients were Grade II, and 24 patients were Grade III. The Grade III patients had a longer hospital stay than Grade II and Grade I patients (15.2 days, 9.2 days, and 7.3 days, respectively, p < 0.05). According to multivariate analysis, patients with Grade III Tokyo severity, higher Charlson's Comorbidity Score, and encountering complications had a longer hospital stay. Based on treatment modality, surgeons selected the patients with less severity and fewer comorbidities for cholecystectomy, and these patients had a shorter hospital stay. In addition to the grading of the Tokyo guidelines, comorbidities had an additional impact on clinical outcomes and should be an important consideration when making therapeutic decisions.

Management of acute cholecystitis: prevalence of percutaneous cholecystostomy and delayed cholecystectomy in the elderly

BACKGROUND

Published guidelines recommend early cholecystectomy for acute cholecystitis in the elderly. Alternatively, percutaneous cholecystostomy can be used in compromised patients.

METHODS

We reviewed 806 elderly patients diagnosed with biliary disease retrospectively identified through billing and diagnosis codes. Two hundred sixty-five patients with histologically documented acute cholecystitis were selected.

RESULTS

Initially, 75 patients had percutaneous cholecystostomy (Group 1), 64 (24 % underwent interval cholecystectomy, 74 (28 %) early (Group 2), and 127 (48 %) delayed cholecystectomy (Group 3). Group 1 was more likely to have American Society of Anesthesiologists (ASA) scores of 4 when compared to those in Groups 2 and 3 (p = 0.04). No difference existed among the groups when patients with an ASA of 4 were excluded: conversion rates (11 %), biliary leak, bowel injury, need for reoperation, or 30 days mortality. Patients in Group 1 and in Group 3 were five times (p = 0.04) and four times (p = 0.06) more likely, respectively, than those in Group 2 to have recurrent episodes of pancreatitis, cholecystitis, and cholangitis.

CONCLUSION

Patients were more likely to have delayed cholecystectomy after initial antibiotic therapy or cholecystostomy without the benefit of a lower conversion rate when compared to the early group, but they had higher recurrent episodes of cholecystitis/pancreatitis or cholangitis.