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Clinical Outcomes of Percutaneous Cholecystostomy Tube Placement in Critically Ill Patients With Acute Cholecystitis
Kenneth Sirinek*, Ronald M. Stewart, Kent Van Sickle, Wayne Schwesinger
Surgery, UTHSCSA, San Antonio, TX
BACKGROUND: The surgical treatment of acute cholecystitis in critically ill patients is associated with significant morbidity and mortality. Percutaneous placement of a cholecystostomy tube (PCT) is a widely available, less risky approach but is generally thought to mandate an interval cholecystectomy at some later date. In this study, we evaluated all acute cholecystitis patients treated initially with PCT to assess their subsequent courses and the overall outcomes.
METHODS: Data from all patients undergoing PCT placement in the decade 2004-2013 were prospectively collected and retrospectively reviewed. Statistical analysis was performed using the Chi-Square test.
RESULTS: One hundred fifty three critically ill patients (M/F = 99/54) with a mean age of 58 years (range = 22-95) underwent PCT at our tertiary care hospital over the ten year period of the study. Fever and symptoms (primarily pain and nausea) resolved within 48 hours in 143 patients (93.5%) while another 10 patients required urgent cholecystectomy within 1-4 days for unremitting signs and symptoms (6.5%). One hundred and one patients treated by PCT did not proceed to operation but had their tubes removed or replaced with no recurrent episodes of acute cholecystitis (66%). However, twelve of the patients in this group eventually died from their associated comorbidities (12%). Interval cholecystectomy was performed in another group of fifty-two patients at a mean of 68 days following PCT (range = 1-186 days) with no postoperative mortality. Five patients in this group also underwent intraoperative cholangiography with all studies negative for choledocholithiasis. Compared to all 7734 patients undergoing cholecystectomy at this hospital during the same decade, the 52 PCT patients undergoing cholecystectomy were 14 times more likely to have an initial open cholecystectomy (OC) (1.8% vs 25%) and they experienced an eight-fold higher conversion rate to open procedure when laparoscopic cholecystectomy (LC) was attempted (2.2% vs 18%). (Table)
CONCLUSIONS: 1.PCT is both a safe and an effective initial treatment for acute cholecystitis in critically ill patients who are not candidates for urgent biliary surgery. 2. The majority of patients treated with PCT do not require interval cholecystectomy and often remain asymptomatic even after removal of the cholecystostomy tube. 3. When cholecystectomy is performed after PCT it is associated with an increased conversion rate but a satisfactory eventual outcome.
Table
| 2004-2013 | # of
Cholecystectomies | # Attempted
LC (%) | # LC→OC (%) | # OC (%) | Tot # OC (%) | | All Patients | 7734 | 7594 (98.2%) | 167 (2.2%) | 140 (1.8%) | 307 (4%) | | PCT Patients | 52 | 39 (75%)* | 7 (18%)* | 13 (25%)* | 20 (38.5%)* |
*P<.001 by Chi-Square analysis
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