Surg Endosc (2011) 25:3642–3646 DOI 10.1007/s00464-011-1771-5
Percutaneous drainage for acute calculous cholecystitis K. Kortram • T. S. de Vries Reilingh • M. J. Wiezer • B. van Ramshorst • D. Boerma
Received: 18 August 2010 / Accepted: 12 May 2011 / Published online: 3 June 2011 Ó Springer Science+Business Media, LLC 2011
Abstract Background Acute calculous cholecystitis is a frequently encountered problem in surgical practice; laparoscopic cholecystectomy (LC) is the standard treatment. LC for acute cholecystitis can be a more difficult procedure than elective LC for cholelithiasis and is associated with increased operating time, higher conversion rate, and more postoperative complications. In the elderly patient with comorbidity, surgery can result in serious complications and even mortality. Percutaneous drainage (percutaneous cholecystostomy; PC) may be an alternative treatment. There is no hard evidence in current literature regarding the safety, success rate, and specific technique of this procedure, nor is there consensus on the indications. Aim To evaluate the safety and efficacy of PC in treatment of acute calculous cholecystitis in high-risk surgical patients. Methods From January 2009 until May 2010, 101 patients with acute calculous cholecystitis were treated, of whom 27 with PC. Of these 27 patients, comorbidity and American Society of Anesthesiologists (ASA) classification were determined, indication for drainage instead of cholecystectomy was recorded, and procedure-related data were collected. Primary outcomes were overall morbidity, mortality, and recurrent biliary events. Secondary
K. Kortram T. S. de Vries Reilingh M. J. Wiezer B. van Ramshorst D. Boerma (&) Department of Surgery, St. Antonius Hospital, Koekoekslaan 1, Postbus 2500, 3430, EM, Nieuwegein, The Netherlands e-mail:
[email protected] Present Address: T. S. de Vries Reilingh Elkerliek Hospital, PO Box 98, 5700 AB, Helmond, The Netherlands
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outcomes were time to recovery and need for and difficulty of interval laparoscopic cholecystectomy. Results The cohort included 15 male and 12 female patients with median age of 83 years (range 69–90 years). Most patients were ASA 3 (n = 18) or ASA 2 (n = 8); one patient was ASA 4. Indication for drainage was age and/or comorbidity in 24 cases and duration of symptoms in 3 cases. Antibiotic treatment was given in all but seven patients. The drain was in situ for a median period of 19 days (range 5–57 days). Relief of symptoms occurred in 26 patients; drain luxation occurred in nine patients, only in two patients with clinical consequences. Overall mortality rate was 14.8% (n = 4) with a procedure-related mortality rate of 3.7%. Median time to full recovery was 8 days. With median follow-up of 8 weeks, four patients underwent interval cholecystectomy. Conclusions Percutaneous drainage in acute calculous cholecystitis in high-risk patients seems to be a safe and successful treatment option in patients less eligible for surgery. There are many controversies in the current literature, and evidence-based guidelines for the indication of PC in treatment of acute calculous cholecystitis are needed. Keywords Cholecystitis Calculous Cholecystostomy Percutaneous Drainage
Acute calculous cholecystitis (ACC) is a frequently encountered disease in general surgical practice. Laparoscopic cholecystectomy (LC) is currently the treatment of choice [1]. In elderly patients and patients with significant comorbidity, acute cholecystectomy can result in serious morbidity up to 41% [2–6] and mortality up to 4.5% [2–8]. In these patients, nonsurgical treatment with administration of intravenous antibiotics or percutaneous drainage of
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the gallbladder is an alternative therapeutic modality. According to the Dutch guidelines for gallstone disease [9], percutaneous cholecystostomy (PC) can be a useful option in patients unfit for surgery, but routine use has no additional value over antibiotic treatment in the therapy of ACC in the general population [10]. Despite this statement, in clinical practice both PC and antibiotic treatment are often used, and clear selection criteria for either treatment are lacking. In our hospital, we regard PC as a useful treatment option for ACC in patients who have higher risk for surgical intervention at time of presentation, but this definition is vague and open to multiple interpretations. Aside from these patients, there is a trend for use of PC to treat patients with ACC who have been symptomatic for more than 1 week and still have signs of a hydropic, inflamed gallbladder on ultrasound. To assess the exact use of PC in our hospital, we evaluated the clinical course of all consecutive patients undergoing PC for ACC between January 2009 and May 2010.
Patients and methods A retrospective analysis was performed on all patients treated for acute cholecystitis between January 2009 and May 2010. During the study period, 101 patients presented at our hospital with acute calculous cholecystitis (ACC). ACC was diagnosed according to the Tokyo guidelines [11]: patients should have either pain in the right upper quadrant or a positive Murphy sign, a sign of systemic inflammation being either fever ([38°C) or history of having had fever in the past days, or elevated infection parameters (C-reactive protein and or white blood count). The clinical diagnosis was confirmed by either ultrasound or computed tomography (CT) scan of the abdomen showing a thickened gallbladder wall and presence of concrements or sludge in the gallbladder. Of these 101 patients, 27 underwent PC and are the subject of this study. Of the remaining 74 patients, 1 was treated with intravenous antibiotics and 73 underwent emergency LC. Patient characteristics including gender, age, comorbidity, and American Society of Anesthesiologists (ASA) classification were documented. Duration of symptoms, laboratory data, and Acute Physiology and Chronic Health Evaluation (APACHE) II score at presentation were documented, as was the indication for PC. PC was performed under radiological guidance, preferably via transperitoneal route. Routinely, an 8.5-French MacLock catheter was used, with the intent to leave the catheter in place for at least 3 weeks. Primary outcomes were success rate, defined as resolution of symptoms without need for additional therapy, procedurerelated complications, overall mortality, and recurrent
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biliary events. Secondary outcomes were time to complete recovery and need for and difficulty of interval cholecystectomy. Median follow-up was 8 weeks (2–72 weeks). Statistical analysis was performed using SPSS version 16.0.
Results Of 27 patients, 15 were male and 12 were female, with median age of 83 years (range 69–90 years). Most patients (n = 25) presented to the emergency department; two patients were admitted to the intensive care unit (ICU) of our hospital for respiratory insufficiency due to pneumonia in combination with chronic obstructive pulmonary disease (COPD). Both developed acute cholecystitis during their stay in the ICU. Median ASA classification was III (range II–IV). Nine patients had been previously diagnosed with gallbladder stones. Patient characteristics are specified in Tables 1 and 2. Median duration of symptoms on presentation was 4 days (range 1–8 days). Indication for PC instead of LC was age and/or comorbidity in 24 patients and duration of symptoms (more than 1 week) in 3 patients. Eighteen patients received antibiotics in addition to PC. Administration of antibiotics was solely dependent on the preference of the surgeon on call. Successful PC was accomplished in 92.6% of patients (n = 25), and median duration of drainage was 19 days (range 5–57 days). Drain luxation was seen in nine patients (33.3%), but only in two patients did this luxation have clinical consequences: one patient needed drain replacement and in one deceased patient autopsy demonstrated luxated drain and remaining fulminant cholecystitis. The overall complication rate was 25.9% (n = 7). Four patients developed non-drain-related complications; three complications were drain related. Most complications were
Table 1 Patient characteristics of 27 patients with acute calculous cholecystitis treated with percutaneous drainage Gender Male Female Median (range) age, years
15 12 83 (69–90)
ASA classification II
8
III
18
IV
1
Indication Comorbidity/age
24
Duration of symptoms
3
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3644 Table 2 Specified characteristics for 27 individual patients with acute calculous cholecystitis treated with percutaneous drainage
AF atrial fibrillation, CAG coronary artery angiography, CABG coronary artery bypass graft, COPD chronic obstructive pulmonary disease, CVA cerebral vascular accident, DM diabetes mellitus, IBD inflammatory bowel disease, TIA transient ischemic attack
Surg Endosc (2011) 25:3642–3646
Patient
Age (years)
ASA
1
69
2
5
Lung carcinoma with liver metastases
2
69
3
10
Mitral valve replacement, pacemaker
3
87
3
11
Asthma bronchiale, myocardial infarction, TIA
4
86
2
12
5
87
3
8
6
88
3
19
COPD, decompensatio cordis, pulmonary fibrosis
7
80
2
10
CVA, hypertension
8
81
3
16
CABG, COPD, decompensatio cordis, renal insufficiency
9
90
3
15
CAG, aorta valve replacement, renal insufficiency
10
84
3
11
AF, CAG, DM, IBD
11
81
3
9
12
85
2
18
13
71
2
6
Hypertension
14
78
3
9
AF, CABG, COPD, CVA, hypertension
15 16
86 81
3 2
6 6
CABG, DM Hypertension
17
83
3
20
CABG, hypertension, renal insufficiency
18
70
3
8
CABG, CVA, DM, myocardial infarction
19
71
3
9
AF, CVA, DM, hypertension, renal insufficiency
20
83
3
9
AF, IBD, M. Parkinson
21
86
4
19
COPD, hypertension, pneumonia/pneumosepsis
22
78
2
11
AF, hypertension
23
69
2
14
24
84
3
8
25
83
3
12
AF, CABG, hypertension
26
87
3
16
AF, COPD, decompensatio cordis
27
84
3
8
minor (n = 4, 14.8%) and did not require intervention: transient ileus (n = 1), drain-site infection (n = 1), and atrial fibrillation, treated with medication (n = 2). Two major complications were drain related: one patient, transhepatically treated, required surgical exploration of a bilioma in the abdominal wall, and one patient developed respiratory insufficiency due to aspiration; during CT scan to exclude intra-abdominal complication the patient aspirated massively, resulting in cardiac arrest. Autopsy showed luxated drain and fulminant cholecystitis. The third major complication was pneumonia with acute respiratory distress syndrome (ARDS) resulting in death. The overall mortality rate was 14.8% (n = 4); the procedure-related mortality was 3.7% (n = 1). One patient who was already in ICU because of respiratory failure previous to diagnosis of ACC died as a result of his pulmonary condition. One patient died at home after discharge, due to cerebral hemorrhage. With median follow-up of 8 weeks (range 2–72 weeks), six patients developed recurrent biliary symptoms (19.7%). In two patients ACC recurred (8.6%), 1 and 4 months,
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APACHE
Comorbidity
AF AF, CVA, DM, hypertension, hypothyroidism
Hypertension, myocardial infarction, pacemaker AF, hypertension, hypothyroidism
DM AF, CABG, DM
COPD, CVA
respectively, post drain removal; one could be treated with antibiotics, and the other needed renewed PC and, electively, LC. In a total of four patients elective LC was performed, with a median interval of 6 months post drainage (range 1–17 months), because of recurrent biliary symptoms. In one of these patients the procedure was converted to open cholecystectomy. All four patients had uneventful postoperative course (Table 3).
Discussion Our results show that, in a group of high-risk patients with acute calculous cholecystitis considered unfit for surgery, 92.6% could initially successfully be treated with percutaneous drainage. The overall complication rate was 25.9%, but most complications were minor, and only half of the complications were drain related. With major procedurerelated complication rate of 7.4% and procedure-related mortality of 3.7%, percutaneous drainage seems to be a safe and effective treatment option in patients with acute
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calculous cholecystitis and increased surgical risk. Our data are comparable to results reported by others [6, 12]. In a recent systematic review conducted by Winbladh et al. [6] the overall morbidity rate of PC was 32%. As complications were reported in only half of the studies, this may represent a serious underestimation of the actual complication rate. The overall mortality rate of PC was 12.7%, and the procedure-related mortality was 3.6%. These results are concurrent with our findings of 14.8% overall mortality and 3.7% procedure-related mortality. In the current literature, complication rates for elective LC in elderly or otherwise high-risk surgical patients vary from 5 to 17% [2, 3, 7, 8] and mortality rates vary from 0 to 1.7% [7, 13]. When LC is performed for acute cholecystitis in this population, rates are higher, with complication rates up to 41% [2–5, 7, 8, 14] and mortality rates up to 4.5% [4–6]. Although mortality after LC is reported to be lower than after PC, it is likely that this may be attributed to selection bias. Many controversies in the treatment of acute calculous cholecystitis in patients with increased surgical risk remain. In the present series, three patients underwent PC because of symptom duration of more than 1 week rather than
Table 3 Treatment and results of 27 patients with acute calculous cholecystitis, treated with percutaneous drainage Presentation ED ICU Treatment
25 2
Ultrasound guided
25
CT guided
2
Transperitoneal
25
Transhepatic
2
Antibiotics
18
Median duration of drainage (days)
19 (5–57)
because of sepsis or critical illness. These patients could probably have been treated well conservatively. Whether even clinical observation and/or administration of antibiotics is indicated is unclear. Eighteen patients who underwent PC additionally received intravenous antibiotics. Retrospectively, we were not able to clarify why these patients required antibiotic support. Another remaining question is whether transperitoneal versus transhepatic drainage should be chosen. Although the transhepatic route shows quicker maturation of the drain tract, luxation and complication rates do not differ between the two techniques [15, 16]. In our study, numbers of transhepatic drainage were too small (n = 2) to suggest any preferential route. In this study we performed PC for those patients deemed unfit for, or with increased risks during, surgical intervention, attributed to older age, comorbidity or more severe course of acute cholecystitis. Therefore, it can be assumed that the patients treated with PC are generally more severely ill than those undergoing emergency surgery. Morbidity and mortality rates in high-risk patients with ACC remain high. PC could be an alternative treatment strategy in a selected group of patients, but our results as well as current literature leave many questions unanswered. In addition, it has to be taken into account that the followup duration in our group is relatively short, which may contribute to underestimation of the rate of recurrent cholecystitis. To optimize the treatment and outcome of this vulnerable patient category we are in need of a clear and evidence-based guideline. A randomized controlled trial was recently started, comparing PC with LC in high-risk patients with ACC. Disclosures Authors Kortram, de Vries Reilingh, Wiezer, van Ramshorst, and Boerma have no conflicts of interest or financial ties to disclosure.
Results Median time to recovery (days)
8 (3–20)
Adequate drainage
25 (92.6%)
Drain luxation
9 (33%)
Replacement
1
Complications
7 (25.9%)
Minor
4 (14.8%)
Major
3 (11.1%)
Mortality Procedure related
4 (14.8%) 1 (3.7%)
30-day
3
Recurrence
2 (8.6%)
Interval cholecystectomy ED emergency department, ICU intensive care unit
4
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