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Long-Term Outcomes Following Percutaneous Cholecystostomy Tube Placement for Treatment of Acute Calculous Cholecystitis
Donna Marie L. Alvino*1, Zhi Ven Fong1, Colin J. McCarthy2, Keith D. Lillemoe1, Peter R. Mueller2, Peter J. Fagenholz1
1Surgery, Massachusetts General Hospital, Boston, MA; 2Radiology, Massachusetts General Hospital, Boston, MA
Introduction: Percutaneous cholecystostomy tube (PCT) placement is considered to be a safe and effective treatment for elderly and critically ill patients suffering from acute cholecystitis, but data regarding long-term outcomes following PCT are limited. We sought to describe the rates of procedural complications, recurrent biliary complications, and successful laparoscopic cholecystectomy following PCT in the largest cohort to date of patients with acute calculous cholecystitis.
Methods: Retrospective data were gathered from hospital records of 423 patients undergoing PCT placement between 1997 and 2015. Exclusion criteria included tube placement for acalculous cholecystitis (n=124), obstructing malignancy (n=9), or tube placement following aborted cholecystectomy (n=2). Recurrent biliary events were defined as cholecystitis, cholangitis or gallstone pancreatitis.
Results: A total of 288 patients underwent PCT for acute calculous cholecystitis. The mean age was 72 ± 15 years and the mean age-adjusted Charlson comorbidity index was 5 ± 2. Tube dysfunction (malposition or obstruction) occurred in 132 patients (46%), with 80 patients (28%) requiring re-intervention (tube exchange or repositioning), while 19 patients (7%) developed procedure-related complications such as bile leak or hemorrhage. Elective interval cholecystectomy was performed for 102 patients (35%). Patients who underwent an interval cholecystectomy had lower rates of recurrent biliary events when compared to patients who did not undergo an interval operation (8% vs 27%; p<0.001). Six of the eight cases of recurrent biliary complications in the interval cholecystectomy group occurred prior to interval cholecystectomy, whereas only two occurred post-operatively due to retained gallstones. Successful laparoscopic cholecystectomy was completed in 46% of cases in the interval cholecystectomy group, as compared to 22% of those undergoing non-elective cholecystectomy as a result of recurrent biliary event (p=0.01). The operative complication rate was 17% among all cholecystectomy recipients, with wound infection being the most common complication (12%).
Conclusions: PCT placement for acute calculous cholecystitis is associated with a low complication rate, but a high rate of tube dysfunction and frequently requires re-intervention. Interval cholecystectomy decreases the likelihood of recurrent biliary events, but can only be achieved laparoscopically in about half of cases. These are the most complete data to date describing outcomes after PCT and should inform clinical decision making and patient counseling.
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