In the name of God

Percutaneous cholecystostomy in the management of high-risk patients presenting with acute cholecystitis: Timing and outcome at a single institution

Introduction This study retrospectively assesses those patients presenting with AC who underwent PC placement at a single tertiary instutition , examining their clinical outcome , PC – related complication , recurrent admissions and their requirement for delayed cholecystectomy.

Patients and methods The study , conducted at the Kaplan medical center , include patients admitted with a diagnosis of AC between 1/11/2011 and 1/7/2014. All patients with AC were managed with intravenous antibiotics , most commonly using combination of cefuroxime and metronidazole with standard analgesics.

All PC placements were performed by a consultant interventional radiologist under ultrasonographic or CT guidance. In general,a transhepatic approach to the gall bladder was preferred where a trans-abdominal approach was used if the gallbladder was distended and adherent to the abdominal wall or when unfavourable anatomy precluded a transhepatic approach.

Placement of a PC was accomplished under local anesthesia using a Seldinger guidewire technique dilating the tract and deploying either a 6Fr or an 8 Fr pigtail catheter depending upon the viscosity of the gallbladder contents. “early insertion” of a PC was recorded when the drain was placed within 24 h of the admission and confirmation of the diagnosis, with “late insertion” recorded if PC placement was made 24 h after admission.

The principal indication for early PC insertion was for patients deemed high surgical risk with late PC insertions performed in those clinically unresponsive patients or in those cases deteriorating under non-operative management. All patients are discharged with the PC to open drainage. A cholangiogram is then performed via the PC at 2e3 weeks following discharge. Clinical improvement was charted if the patient was discharged from hospital without the need for emergency surgery during the first admission.

Demographic patient data were collected along with laboratory analyses, details of coincident comorbidities, biliary cultures, imaging findings (the presence of gallbladder wall thickening, gallstones,gallbladder distension and a pericholecystic fluid collection)along with the timing of PC placement and removal. Data concerning procedural complications, in-hospital mortality,outcome and elective surgical disposition were all collated.

Results Over the period of the study, the overall number of AC admissions to the hospital was 678 with 119 (17.6%) undergoing PC placement. These latter analysed cases included 52 females (43.7%,mean age 77.9 years) and 67 males (56.3%, mean age 74.2 years)with a total mean age of 75.8 years (±13.6 years).

All cases of AC were due to calculous cholecystitis with a median symptom duration of 2 days (range 1e14 days). The median time between the commencement of symptoms and PC insertion was 4 days (range 1-17 days).

Table 1 Clinical characteristics of enrolled patients. Characteristics Total (n ¼ 119) Age, years (SD) 75.8 (13.6) Male, n (%) 67 (56.3) Comorbidity, n (%) Diabetes mellitus 45 (37.8) Hypertension 80 (67.2) Ischemic heart disease 33 (27.7) Congestive heart failure 9 (7.6) Hyperlipidemia 48 (40.3) Dementia 16 (13.4) Atrial fibrillation 15 (12.6) Chronic renal failure 13 (10.9) Chronic obstructive airways disease 3 (2.5) Cerebrovascular accident 13 (10.9) Hyperthyroidism 8 (6.7)

119 patients 16 urgent surgery/death 103 patient discharged 7 deaths 9 operation 41 elective cholecystectomy 62 follow-up only 6 without surgery 1 patient operated 6 urgent operation 56 no operation

Table 2 Early mortalities after PC placement during the first admission. Pt No. Age (yrs) PC placement Outcome 1. 89 Failed CT Died at 2 days eseptic shock 2. 80 Septic despite PC Died at 3 days. Combined AC þ ischemic colitis 3. 95 Septic despite PC Died at 3 days e septic shock 4. 86 Septic despite PC Died at 2 days -necrotic gallbladder 5. 88 Failed CT Died at 6 days - pneumonia 6. 93 Failed CT Died at 14 days erespiratory failure 7. 90 Septic despite PC Died at 40 days e multiorgan failure

Table 3 Clinical demographic features and outcomes for the early and late PC drainage groups.a Early PC N ¼ 56 (47.1%) Late PC n ¼ 63 (52.9%) P-value Males number (%) 33 (58.9) 34 (54) 0.586 Females number (%) 23 (41.1) 29 (46) Total mean age, years (SD) 80.39 71.68 0.069 Diabetes mellitus 20 (35.7) 25 (39.7) 0.956 Mean timing 2.67 3.16 0.443 Clinical improvement (%) 49 (87.5) 54 (85.7) 0.776 Emergency surgery (%) 5 (8.9) 5 (7.9) 0.846 Type Open 1 1 Laparoscopic 1 Conversion 3 4 In-hospital (%) 3 (12) 4 (30.8) 0.157 30-day (%) 4 (16) 3 (23.1) 0.593 Elective surgery (%) 13 (23.2) 28 (44.4) 0.015 Open 1 Laparoscopic 8 23 Recurrent admission (%) 21 (37.5) 26 (41.3) 0.675

Table 4 Drain-related complications according to timing of percutaneous cholecystostomy. Early PC Late PC P-value Number (%) 23 (41.1) 25 (39.7) 0.878 Leak 1 (4.3) 4 (16) 0.187 Unintentional removal 15 (62.5) 16 (64) 0.93 Drain occlusion 2 (8.7) 2 (8) 0.93 Drain hemorrhage 1 (4.3) 1 (4) 0.952

Discussion This retrospective study shows that percutaneous cholecystostomy (PC) is an effective treatment for acute cholecystitis (AC) with only small numbers requiring emergency cholecystectomy during the first (index) admission.One-third of patients needed a repeat admission for AC during follow-up with frequently a successful repeat PC drainage for management. Deployment of a PC catheter is a safe procedure with an acceptable initial mortality and in just over half of the cases, PC drainage functions as the definitive treatment without the need for surgery.

The idea that PC drainage can function as definitive treatment proved justified with 54% being successfully managed by PC drainage alone. Of the remainder of the patients, one-third needed a repeat admission with successful repeat PC placement when indicated. The rates of clinical resolution in males and females was high in our study (88.1% and 84.6%, respectively) and were comparable with other reports.