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When Should We Perform Cholecystectomy for Severe Acute Cholecystitis Following Percutaneous Transhepatic Gallbladder Drainage?
Koetsu Inoue*, Tatsuya Ueno, Michinaga Takahashi, Shinji Goto, Ryouichi Anzai, Kentarou Shima, Orie Suzuki, Masanobu Hayashi, Hiroo Naitoh
surgery, South miyagi medical center, Oogawara-mach, Shibata-gun, Japan
Background: According to the Tokyo guideline for management of acute cholecystitis, percutaneous transhepatic gallbladder drainage (PTGBD) followed by cholecystectomy is recommended for severe acute cholecystitis. Optimal timing for subsequent cholecystectomy, however, is still controversial. Aim of this study is to assess whether or not duration between PTGBD and cholecystectomy affects technical difficulty of cholecystectomy, and thereby to determine the optimal timing for cholecystectomy.
Method: Medical records were retrospectively reviewed for 77 patients who underwent either laparoscopic or open cholecystectomy after PTGBD between 2002 and 2015. Seventeen cases were excluded for some reasons (ex. adhesion of previous operation, bleeding caused by liver cirrhosis, emergency operation for biliary peritonitis after PTGBD, relapsed cholecystitis following PTGBD, cholecystectomy with other operation). Sixty patients were divided into two groups; patients whose operation was difficult (Group A) and not so difficult (Group B). A patient who had either of these conditions below was defined to belong to Group A; 1. conversion from laparoscopic to open cholecystectomy, 2. atypical cholecystectomy of subtotal cholecystectomy and/or mucoclasis, 3. severe necrotizing cholecystitis or pericholecystic abscess formation, 4. tight adhesion at the GB neck. Statistical analysis was performed by two-tailed Student’s t-test and/or Pearson’s chi-square test.
Results: Completion rate of laparoscopic cholecystectomy did not differ between Group A and B (63.3% vs. 80%, p=0.152). Duration between PTGBD and cholecystectomy in Group B was longer than that in Group A (642 vs. 108 hrs, p=0.047). Because cut off value of the duration between PTGBD and cholecystectomy was 216 hrs according to Receiver Operating Characteristic curve, we divided patients into short duration (SD) and long duration (LD) groups based on this value. Blood loss and operating time in SD group were greater than LD group (206 vs. 73 ml, p=0.048, and 144 vs. 116 min, p=0.022). Postoperative complications except for surgical site infection, occurred more frequently in SD group than LD group (33.3% vs. 8.3%, p=0.022). Postoperative hospital stay, however, did not differ between two groups. (10 vs. 8.2 days, p=0.238).
Conclusion: These results indicate that cholecystectomy is technically difficult at short duration after PTGBD, and cholecystectomy should be performed later than 216 hrs after PTGBD in patients with acute cholecystis.
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