Abstracts
1999 Digestive Disease Week

# 2069 PERCUTANEOUS CHOLECYSTOSTOMY IN CRITICALLY ILL PATIENTS
Gerald M. Fried, Craig Baldry, McGill Univ Health Ctr, Montreal, PQ Canada

Percutaneous cholecystostomy (PC) is an alternative to surgery for acute cholecystitis in critically-ill or high-risk patients. Our goals were to evaluate mortality and morbidity, identify factors predictive of response to PC, and make recommendations for long-term management. 54 pts (36 males, mean age 66) underwent PC from 6/91 to 12/97. Data on co-morbid conditions, TPN, vital signs, lab data, ultrasound and cholecystogram reports were recorded. A favorable response was defined as return to normal of either temperature or WBC within 3 d or of liver function tests within 7 d. Chi-square analysis was used to test for significance of factors associated with outcome. P<0.05 was considered significant. Of the 54 patients, 19 had gallstones (GS), 35 did not (25 sludge, 10 neither sludge nor stones). PC drains were left in-situ for a median of 14 d (range: 1-375). 45 pts (83%) improved, but 7 had recurrent symptoms after tube removal (mean follow-up 256 d); 6/7 had GS. 8 pts were unchanged and 1 deteriorated. A favorable response was more likely in females, the absence of sepsis, and the presence of GS or sludge. Age, TPN, trauma, ACBP, immunosuppression, + bile cultures, jaundice, or U/S findings of GB distension, wall thickening, pericholecystic fluid, or pus on insertion were not predictive of a favorable response. Factors predictive of recurrence were age > 70 (p<0.001), peri-cholecystic fluid (p<0.05), GS (p<0.01), and pus in gallbladder (p<0.05). Pts with GS vs those without were more likely to show improvement (100% vs 74%, p< 0.05), more likely to have recurrence after tube removal (32% pts vs 3%, p <0.01) and less likely to die in hospital (11% vs 54%, p< 0.01). 3 complications related to placement of the percutaneous cholecystostomy (subcapsular hepatic hematoma, cholangitis, intra-abdominal bile leak). Hospital mortality rate was 39%; significant predictors of mortality were sepsis, immunosuppression and acalculous disease. Percutaneous cholecystostomy is a safe and effective procedure as an alternative to emergency cholecystectomy in critically ill patients. Patients with calculous disease derive more benefit than those with acalculous disease, but also have a higher incidence of recurrence.

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