Percutaneous cholecystostomy: An update for the 2020s

Outcome Predictors of Percutaneous Cholecystostomy As Definitive Versus Bridging Treatment for Acute Cholecystitis

Introduction Percutaneous cholecystostomy (PC) is a treatment option for patients with acute cholecystitis (AC) who are too unwell, or too morbid for laparoscopic cholecystectomy (LC). Some patients have PC as a definitive treatment, whereas others have PC as a bridging treatment prior to LC. The aim of this study is to investigate patient characteristics and mortality among those who received PC as definitive treatment versus bridging treatment. Methods Our study retrospectively reviewed all patients treated with PC for AC from February 2019 to November 2022 at the Torbay and South Devon NHS Foundation Trust, Torquay, England. Fifty patients underwent PC for AC, with 48 patients having follow-up data available for analysis. Of these, 26 patients (54%) only received PC (definitive PC), and 22 patients (46%) later underwent LC (bridging LC). Results In this study, 68.8% of the patients were male, with a mean age of 76 ± 9 years. The overall mean Charlson Comorbidity Index (CCI) score was 4.96 ± 1.12, and the mean American Society of Anesthesiologists (ASA) score was 2.83 ± 0.36. The median PC drain duration was 42 days. Six patients (12.5%) had a recurrence of AC with a mean of 57 days onset after PC insertion. Twelve patients (25%) experienced PC complications: 11 (23%) were minor, involving pain or a dislodged tube, and one (2%) was major, resulting in a subhepatic abscess. The median duration from PC insertion to LC surgery was 50.5 days. The bridging LC cohort had a 30-day and one-year mortality of 0%, while the definitive PC cohort had a 30-day mortality of 30.8% (eight patients) and a one-year mortality of 46.1% (12 patients). The bridging LC cohort compared to the definitive PC cohort had a significantly lower CCI (4.39 vs 5.57, p<0.05), and a significantly lower ASA (2.61 vs 3.04, p<0.05). The one-year survival cohort compared to the 30-day mortality cohort had significantly lower ASA (2.71 vs 3.25 p<0.05), and a non-significantly lower CCI (4.66 vs 5.86 p=0.094). The presence of negative predictive factors of respiratory dysfunction and hyperbilirubinemia had higher 30-day and 90-day mortality rates of 31.3% and 37.5%, compared to their absence of 9.4% and 21.4% respectively. Conclusion Our results demonstrate that PC is a safe procedure with a high success rate and low complications. We showed that PC is an effective treatment option for bridging a select cohort of patients to receive a delayed LC. Furthermore, the data suggests ASA and CCI scoring can be used as clinical adjuncts to assess whether bridging patients from PC to LC is appropriate. Finally, ASA, respiratory dysfunction, and hyperbilirubinemia can be used as significant negative predictors of post-PC mortality.

Hotspots and difficulties of biliary surgery in older patients

With the accelerated aging society in China, the incidence of biliary surgical diseases in the elderly has increased significantly. The clinical characteristics of these patients indicate that improving treatment outcomes and realizing healthy aging are worthy of attention. How to effectively improve the treatment effect of geriatric biliary surgical diseases has attracted widespread attention. This paper reviews and comments on the hotspots and difficulties of biliary surgery in older patients from six aspects: (1) higher morbidity associated with an aging society, (2) prevention and control of pre-operative risks, (3) extending the indications of laparoscopic surgery, (4) urgent standardization of minimally invasive surgery, (5) precise technological progress in hepatobiliary surgery, and (6) guarantee of peri-operative safety. It is of great significance to fully understand the focus of controversy, actively make use of its favorable factors, and effectively avoid its unfavorable factors, for further improving the therapeutic effects of geriatric biliary surgical diseases, and thus benefits the vast older patients with biliary surgical diseases. Accordingly, a historical record with the highest age of 93 years for laparoscopic transcystic common bile duct exploration has been created by us recently.

Ultrasound-guided percutaneous cholecystostomy as bridging or definitive treatment in patients with acute cholecystitis grade II or III

Background

We aimed to investigate the extent to which ultrasound (US)-guided percutaneous cholecystostomy (PC) is used as a bridging or definitive therapy for grade II and III acute cholecystitis and whether this treatment causes significant changes in C-reactive protein (CRP) and direct bilirubin (DB) levels in the first 72 h and the first three weeks.

Methods

We included 145 consecutive patients who underwent PC over 17 years. No patient had cirrhosis. PC was performed in the interventional radiology department under US guidance.

Results

US-guided PC was the definitive treatment for more than half of the patients (51.7%) and decreased DB levels significantly more than CRP levels.

Conclusion

No statistically significant correlation between those whose CRP and DB levels normalized within three weeks and those who did not and required a second invasive procedure. Nevertheless, the bridging treatment group was significantly older than the definitive treatment group.

[Percutaneous cholecystostomy in multi-field hospital]

OBJECTIVE

To analyze the indications, technical features and results of percutaneous cholecystostomy.

MATERIAL AND METHODS

A retrospective single-center study of the results of percutaneous cholecystostomy over 13-year period was carried out. The indications for surgery, technical features and outcomes were studied.

RESULTS

The indications for percutaneous cholecystostomy were acute cholecystitis in 40 (63.5%) cases and obstructive jaundice in 23 (36.5%) cases. In acute cholecystitis, cholecystectomy was denied due to severe acute and decompensated chronic diseases. In case of obstructive jaundice, cholecystostomy was preferred if other methods of biliary decompression were impossible. Drainage with locking thread was used in 44 (69.8%) patients. A total of 13 (21.3%) cases of drainage migration were noted. Incidence of migration of catheters with locking threads was 13.6%, without locking threads - 41.2% (p=0.033). Subsequent cholecystectomy was performed in 10 (15.9%) patients. In case of obstructive jaundice, cholecystostomy did not lead to destructive cholecystitis in any case. Six patients with acute cholecystitis had progressive gallbladder destruction. Overall postoperative in-hospital mortality was 36.5% (n=23). Mortality in the group of acute cholecystitis was 32.5% (n=13), in the group of obstructive jaundice - 43.5% (n=10). Mortality was higher in acute cholecystitis Grade III (75.0%) compared to Grade II (21.9%; p=0.008).

CONCLUSION

Cholecystostomy is a rare (reserve) intervention. Locking thread significantly reduces the incidence of migration of cholecystostomy catheter. Progressive gallbladder destruction required cholecystectomy in 15% of cases. Treatment of patients with acute cholecystitis depends on physical status and comorbidities.

Does percutaneous cholecystostomy timing in high anaesthetic-risk patients impact on outcome?

The optimal timing for percutaneous cholecystostomy (PCT) in patients with acute biliary sepsis, who are high-risk for cholecystectomy, requires further investigation. We aimed to study local factors influencing the timing to PCT placement, and investigate patient outcomes in early (≤ 48 h) vs. delayed PCT over a six-year period. A retrospective observational study investigating patients who required a PCT at a single hospital in the UK between January 2014 and December 2019. Placement of a PCT was at the discretion of the on-call surgical consultant according to their own personal experience and not based on a standard local protocol. Clinical outcomes, hospital statistics and details of any subsequent bridging surgery were analysed using multivariate logistic regression models adjusting for age, sex, Charlson Comorbidity Index (CCI) and American Society of Anaesthesiologists (ASA) grade. There were 72 patients with 35/72 (48.6%) classed as TG18 AC grade 3; 26/72 (36.1%) had an early PCT placed and 46/72 (63.9%) delayed. Median age was 76 (65-83) years, 52.8% were female, and 51.4% were classed ASA ≥ 3 with 94.0% scoring CCI > 2. Trial on antibiotic therapy was the primary reason for delayed PCT. In adjusted models, early PCT was associated with a shorter length in hospital stay (OR 3.02, p = 0.044), successful definitive treatment (OR 6.26, p = 0.009); and reduced likelihood for catheter dislodgment (OR 0.12, p = 0.004) with fewer patients bridging to later emergency open surgery (OR 0.19, p = 0.024). Clinical outcomes may be superior in urgent or early PCT for high anaesthetic-risk patients following acute biliary sepsis.