Percutaneous cholecystostomy for treatment of acute cholecystitis in the era of early laparoscopic cholecystectomy

摘要

BACKGROUND:: Acute cholecystitis is a common surgical problem that is optimally managed by early laparoscopic cholecystectomy when possible. Percutaneous cholecystostomy (PC) has been used in certain high-risk cases as a bridge to surgery or for definitive therapy. The aim of this study was to determine the short-term and long-term outcomes of patients with acute cholecystitis treated by PC. STUDY DESIGN:: Patients with acute cholecystitis treated by PC between 2005 and 2011 in a tertiary hospital were identified from a prospectively maintained database. Outcome differences between patients with acalculous acute cholecystitis (AAC) and those with acute cholecystitis relating to gallstones were determined. RESULTS:: There were 32 cases from a total of 443 patients with acute cholecystitis treated by PC during the study period. The overall 30-day mortality rate after PC was 9%. There were 8 patients with AAC in this series. Ischemic heart disease and chronic renal failure were noted in 47% and 41% of patients, respectively. In all cases, patients were considered unfit for surgery. AAC was more common in male patients. In all other aspects patients with AAC had similar characteristics to those with gallstones. Patients underwent percutaneous drainage a median of 3 days after admission with a direct transperitoneal route used in 16 (75%) cases. Positive bile cultures from the gallbladder were noted in 60% of cases tested. Complications were noted in 53% of patients and were related to the cholecystostomy tube in 19% of cases. Subsequent cholecystectomy was performed in 9 (28%) patients, at a median of 73 days after initial tube insertion. No differences in morbidity and mortality were noted between patients with AAC and those with gallstones. The overall mean and 12 months survival was 43 months and 72%, respectively. Hypotension at presentation (odds ratio 9.2; 95% confidence interval, 1.4-59.8; P=0.019) and absence of bile duct filling on cholecystography (odds ratio 4.6; 95% confidence interval, 1.2-16.3; P=0.017) were independently associated with decreased survival. CONCLUSIONS:: PC can be performed safely in patients considered unfit for surgery at presentation. Outcomes are similar in patients with or without gallstones. Hypotension and absence of common bile duct filling on initial cholangiography are markers of decreased long-term survival. A significant number of patients require subsequent definitive cholecystectomy.