Percutaneous cholecystostomy in acute cholecystitis; a retrospective analysis of a large series of 104 patients

Acute cholecystitis is a commonly encountered disease in surgical departments and the number of treated patients is increasing as the population ages. Standard treatment for acute cholecystitis has for many years been laparoscopic cholecystectomy (LC) in the acute phase. Many of these patients are, however, multi-morbid and not fit for surgery, whereas laparoscopic cholecystectomy is the treatment of choice in young, fit patients. LC might be a relatively simple procedure when undertaken during the early phase of the disease, whereas LC during the period one to six weeks after onset of illness by most authors is considered more challenging and in some cases even hazardous [1-4]. Lee et al. has, however, documented that there is no difference whether the operation was performed as an emergency, in the intermediate interval or after five weeks [5]. The scientific evidence for advocating any specific therapy for acute calculous cholecystitis is sparse. Even the Tokyo guidelines for acute cholecystitis are mainly based on opinions among well-known surgeons and not on high-quality scientific evidence [6]. Some researchers have also questioned the necessity at all for surgery in acute cholecystitis, even in the long term [7,8]. Conservative treatment with antibiotics and percutaneous drainage are reported as an adequate alternative to surgery, although most authors recommend delayed cholecystectomy in these cases [9,10].

The purpose of this study was to evaluate the efficacy of percutaneous drainage of the gall bladder in patients with severe acute cholecystitis or cholecystitis not responding to antibiotic therapy. Main outcome was resolution of cholecystitis, postoperative complications and later need for cholecystectomy.

During the period 2007 – October 2013 a total of 104 patients had a percutaneous cholecystostomy (PC) due to suspected acute cholecystitis. There were 57 men and 47 women with a median age of 73,5 years (range 22 – 96).

Insertion of the drain was successful in all but one patient, in which the gall bladder was completely impacted with stones. Three patients had repositioning or reinsertion of their drains. Seven drains were found to be dislocated with part of it being located intraabdominally at control fluoroscopy. One drain was occluded and two patients had a bile leak from the site of insertion in the gall bladder and into the abdomen. These two patients were successfully treated with percutaneous drainage. Two drains were changed due to technical problems (occluded drain and extraabdominal leak). One patient had a PTD in addition to the gall bladder drain due to continuous septicemia (Table 2). After insertion of the drain some patients complained of abdominal pain. This was thought to be related to minor bile leakage and pain was easily relieved by analgesics. Apart from this there were no serious complications reported. Drains were removed median 6,5 days after insertion (range 1 – 75 days).

In addition to the clinical evaluation, effect of drainage was also evaluated by CRP and white blood cell count (WBC). CRP at the day of drainage was median 263 (range 32 – 485), at day two 124 (range 12 – 476) and at day four 48 (range 4 – 351) (Figure 1). CRP and WBC were not normally distributed and Wilcoxon’s nonparametric test revealed a significant reduction from day 0 to day 2 and day 4 for both variables. Resolution of symptoms occurred in 101 patients (97%), whereas in two patients there was no obvious effect following drainage (not stated in one patient).

Postoperative mortality within 30 days was 4 of 105 patients (3,8%). Two of these were related to their biliary disease and none to the drain. One 81 year old patient with a cardiovascular history (ASA 2) was found dead in his bed three days after drainage, whereas the other patient was a 91 year old woman that died the day after drainage with a cardiovascular history (ASA 4) and bile sepsis. Median length of stay post-drainage was seven days (range 1 – 53). Total hospital stay was median 10 days (range 1–53).

Follow-up after drainage was median 12 months (range 0 – 78). During that time 25 patients had died. No patients having undergone laparoscopic cholecystectomy had died, whereas two patients had died following open cholecystectomy, both from cancer and more than one year postoperatively.

The main findings in this study were that gall bladder drainage in most patients had an immediate and beneficial effect on acute cholecystitis. Furthermore, the procedure could be performed without almost any major complications.

According to the Tokyo guidelines mild (Grade I) acute cholecystitis in an early stage should be treated with cholecystectomy, preferably laparoscopic, whereas moderate and severe (Grade II and III) cholecystitis lasting longer than 5 – 7 days should be treated conservatively with antibiotics and eventually also percutaneous cholecystostomy, followed by a delayed cholecystectomy [11]. These recommendations are, however, not supported by high-quality scientific evidence, but developed based on best clinical evidence and discussions at the international Consensus Meeting held in Tokyo on April 1–2, 2006. Some studies have questioned this statement and even shown that the results are equivalent or even better if cholecystectomy is performed early [1,2,12], or even in the intermediate period one to five weeks after onset. A few small studies have compared cholecystectomy with antibiotic therapy and the conclusion of these are that about one third of the conservatively treated patients will need a cholecystectomy later due to new symptoms [7,8]. This is in keeping with what we found where 30% had a later cholecystectomy. It should, however, be noted that a high proportion of these patients needed a conversion from laparoscopic to open surgery due to severe intraoperative adhesions. Furthermore, it is recommended that patients with a severe cholecystitis and patients with extensive comorbidity might benefit from percutaneous drainage of the gall bladder and with cholecystectomy later on [6]. Our main treatment policy for acute cholecystitis has been antibiotic therapy in the early phase. When the response to this is not satisfactory the patients are offered percutaneous drainage of the gall bladder. During the later years the indications for such drainage have been more liberal due to good results and minor complications following the procedure. For this reason we have also drained some rather young patients with minor comorbidities when the response to antibiotic therapy was not satisfactory. It should, however, be noted that about 50% of our patients had cardiovascular diseases or cancer, and that about the same proportion were classified as ASA III and IV. When this treatment strategy is successful the patients are evaluated as out-patients for a later cholecystectomy if they still have attacks of biliary colic. In our setting cholecystectomy is not a mandatory procedure after cholecystitis. The rationale for this policy is supported by several studies which have documented that about one third of the patients will need a later cholecystectomy [7,8].

We found that PC could be performed with a low complication rate. The outcome was also satisfactory with a symptomatic relief in 96% of the patients and a low rate of complications. This is in accordance with the findings of Byrne et al. [13] that documented a complication rate of 4,5% and a 100% success rate. Although the cystic duct most often was blocked at the time of drain insertion, this blockage was in most cases resolved during the control study some days later. It should also be noted that the drain could be removed safely without any severe leakage. There is an ongoing debate in the literature if this might be related to the technique of drain insertion whereby the drain is introduced through a small brim of the liver [10,13]. The main reason for the long median time of draining was related to some patients being discharged with their drains in place and removed at a later stage at a visit to the out-patient clinic.

30-day post-procedure mortality was in this series 3,6%. This is of the same order as what was reported in the review paper of Winbladh et al. [14] for acute cholecystectomy (4%) and far lower than they reported for PC (15,4%).

So far, there are only two published randomized studies related to percutaneous drainage of the gallbladder in calculous cholecystitis. Hatzidakis et al. found no difference in complications following PC and antibiotics versus conservative treatment only [15], whereas Akyurek et al. concluded that PC and early laparoscopic cholecystectomy (LC) was favorable compared to PC and LC later on [16]. In a review including those randomized trials Gurusamy et al. concluded that so far there is no hard evidence concerning the benefit of PC in acute cholecystitis [17]. This was also the conclusion in the systematic review paper of PC [13]. The results following the Dutch “Chocolate study” randomizing between PC and LC in severely morbid patients will hopefully solve some of these issues [18]. It might be questioned if a pragmatic use of PC in severe acute cholecystitis represents a cost-effective strategy. Obviously, most studies document that the hospital stay is shorter when laparoscopic cholecystectomy is performed early versus later on [19,20]. IT should, however, be noted that about 70% of the PC patients in our study did not undergo a future cholecystectomy. The major limitation of our patient series is that it represents a retrospective study. In addition, the indications for PC are not strict defined and recommendations for future use should therefore be drawn with caution.

In conclusion, percutaneous cholecystostomy is a valid alternative for patients with acute cholecystitis Grade II - III. The relief of symptoms is almost instant, the complication rate is minimal and the post-procedure mortality of the same order as that following cholecystectomy in the acute phase.