Selective Use of Tube Cholecystostomy with Interval Laparoscopic Cholecystectomy in Acute Cholecystitis

ORIGINAL ARTICLE Selective Use of Tube Cholecystostomy With Interval Laparoscopic Cholecystectomy in Acute Cholecystitis

Eren Berber, MD; Kristen L. Engle, MD; Andreas String, MD; Adella M. Garland, MD; George Chang, MD; James Macho, MD; Jeffrey M. Pearl, MD; Allan E. Siperstein, MD

Hypothesis: Tube cholecystostomy followed by inter- (87%) of the patients after tube cholecystostomy. Twelve val laparoscopic cholecystectomy is a safe and effica- patients (80%) underwent interval cholecystectomy. Lapa- cious treatment option in critically ill patients with acute roscopic cholecystectomy was attempted in 11 patients and cholecystitis. was successful in 10 (91%), with 1 conversion to open cholecystectomy. One patient had interval open cholecystec- Design: Retrospective cohort study within a 41⁄2-year tomy during definitive operation for esophageal cancer and period. another had emergency open cholecystectomy due to tube dislodgment. Two patients (13%) had complications Setting: University hospital. related to tube cholecystostomy and 2 patients died from sepsis before interval operation. One patient died from sep- Patients: Of 324 patients who underwent laparoscopic sis after combined esophagectomy and cholecystectomy. cholecystectomy, 65 (20%) had acute cholecystitis; 15 of Postoperative minor complications developed in 2 pa- these 65 patients (mean age, 75 years) underwent tube cho- tients. At a mean follow-up of 16.7 months (range, 0.5-53 lecystostomy. months), all patients were free of biliary symptoms.

Intervention: Thirteen patients at high risk for gen- Conclusions: Tube cholecystostomy allowed for resolu- eral anesthesia because of underlying medical condition of sepsis and delay of definitive surgery in selected tions underwent percutaneous tube cholecystostomy with patients. Interval laparoscopic cholecystectomy was safely local anesthesia. Laparoscopic tube cholecystostomy was performed once sepsis and acute infection had resolved performed on 2 patients during attempted laparoscopic in this patient group at high risk for general anesthesia and cholecystectomy because of severe inflammation. Inter- conversion to open cholecystectomy. Just as catheter drain- val laparoscopic cholecystectomy was attempted after an age of acute infection with interval appendectomy is ac- average of 12 weeks. cepted in patients with periappendiceal abscess, tube cholecystostomy with interval laparoscopic cholecystectomy Main Outcome Measures: Technical details and clini- should have a role in the management of selected pa- cal outcome. tients with acute cholecystitis.

Results: Prompt clinical response was observed in 13 Arch Surg. 2000;135:341-346

LEVEN PERCENT to 20% of pa- The conversion rate of laparoscopic tients requiring cholecystec- cholecystectomy for acute cholecystitis has tomy present with acute cho- been reported to range from 11% to lecystitis.1-6 Although the 28%,1,2,4,5,7-10 which is significantly higher laparoscopic approach was than the less than 5% rate reported for Einitially considered to be contraindicated for chronic cholecystitis.8,10 With conver- acute cholecystitis, with experience, the ap- sion, not only the advantage of this mini- From the Department of plication of laparoscopic surgery has ex- mally invasive procedure is lost, but also General Surgery, The tended to the treatment of patients with the cost and complication rate are in- Cleveland Clinic Foundation, acute cholecystitis with similar operation creased.1 Cleveland, Ohio (Drs Berber time, shorter hospital stay, and complica- The appropriate management of acute and Siperstein); and the tion rates compared with open cholecys- cholecystitis in critically ill or elderly pa- Department of Surgery, 2,7 University of California, San tectomy. Nevertheless, two issues of con- tients with underlying medical condi- Francisco, Mount Zion Medical cern are the higher rate of conversion to an tions is another controversial issue due to Center (Drs Engle, String, open procedure compared with elective high postoperative morbidity and mortal- Garland, Chang, Macho, cases and the management of elderly pa- ity rates after emergency cholecystec- and Pearl). tients with underlying medical conditions. tomy.3,11,12 Decompression of the acutely

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 PATIENTS, MATERIALS, fluoroscopy guidance in 12 patients. Adequate visualization of the gallbladder using ultrasonography was not pos- AND METHODS sible in 1 patient and this patient underwent percutaneous cholecystostomy with computed tomographic guidance. A 10F (12 patients) or 8.5F (1 patient) nephrostomy, Cope Between January 1, 1994, and May 13, 1998, 324 patients loop, or multipurpose catheter was placed into the gall- underwent laparoscopic cholecystectomy for symptom- bladder using the Seldinger exchange technique and se- atic gallstone disease at Mount Zion Medical Center of the cured in place. A transperitoneal route was used in 8 pa- University of California, San Francisco, and 65 (20%) of tients and a transhepatic route was used in 5 patients. A these patients had acute cholecystitis. Ten patients (3%), sample of bile was aspirated and sent for culture. 5 with acute and 5 with chronic cholecystitis, had conver- sions to open cholecystectomy. The conversion rates were LAPAROSCOPIC CHOLECYSTOSTOMY TECHNIQUE 7.7% for acute and 1.9% for chronic cases. In the same period, cholecystostomy was used for 15 Under general anesthesia, patients were prepared and draped patients with acute calculous cholecystitis. These patients as for laparoscopic cholecystectomy. The abdomen was en- are the subject of this study. There were 10 men and 5 women. tered with a trocar (Optiview; Ethicon-Endo Surgery, Cin- Mean patient age was 75 years (range, 43-92 years). Thir- cinnati, Ohio) at the umbilicus. The decision to proceed teen (87%) of the patients presented to the hospital within with cholecystostomy upon the finding of a gangrenous gall- 1 to 4 days after the onset of symptoms. The other 2 pa- bladder and severe inflammation was made after the sec- tients were undergoing evaluation for other conditions, spe- ond trocar was inserted in 1 patient and after the third was cifically dysphagia and upper gastrointestinal tract bleed- inserted in the other patient. Using laparoscopic ultra- ing. Three patients (20%) had a history of gallstones and 1 sound guidance, an 18-gauge needle was inserted in the sub- had undergone endoscopic retrograde cholangiopancrea- costal position at the midclavicular line into the gallblad- tography with sphincterotomy. The diagnosis of acute cho- der. After bile was aspirated, a guidewire was placed within lecystitis was made on the basis of clinical and radiologic find- the lumen of the gallbladder. This guidewire could be seen ings. The most common symptom was right upper quadrant on laparoscopic ultrasonography. Over this guidewire, a pain, which was experienced by 14 patients (93%). Other 14F Cope loop catheter was placed into the lumen of the signs and symptoms included right upper quadrant tender- gallbladder and was secured to the skin. A sample of bile ness in 13 patients (87%), fever (temperature Ͼ38°C) in 12 was sent for culture (Figure 1 and Figure 2). (80%), nausea or vomiting in 10 (67%), and diffuse abdominal pain in 1 (7%). Thirteen patients (87%) had leuko- LAPAROSCOPIC CHOLECYSTECTOMY cystosis, and results of liver function tests were abnormal TECHNIQUE in 7 patients (47%) (Table 1). One patient developed gallstone pancreatitis. Radiologic studies consisted of ab- In the absence of symptoms related to a complication, a con- dominal ultrasonography (n = 12), abdominal computed trol fistulogram was obtained within 30 to 45 days of tube tomography (n = 10), and cholescintigraphy (n = 2). placement to show the presence of gallstones and to check All of the patients received broad-spectrum antibiot- the tube. An average of 11.7 weeks (range, 7-22 weeks) was ics after the clinical diagnosis of acute cholecystitis was made. allowed to pass before interval cholecystectomy for the in- Patients were subjected to percutaneous cholecystostomy flammation to subside and the general condition of the pa- on the basis of their high risk for general anesthesia (13 tient to improve. After induction of endotracheal general an- patients) due to underlying medical conditions or critical esthesia, the abdomen was sterilely prepared and draped with illness. the cholecystostomy tube passed under the drapes so as to Laparoscopic cholecystectomy was attempted for 2 pa- be excluded from the field. The abdominal cavity was en- tients (13%) for whom general anesthesia was not contra- tered by direct visualization using an Optiview trocar with indicated. Laparoscopic cholecystostomy was performed on a 0° laparoscope. Thereafter, the laparoscope was changed these patients because of severe inflammation that pre- to a 45° scope (Figure 3). A 10-mm port was placed in the cluded safe dissection. subxiphoid position, followed by two 5-mm ports, one in Fourteen patients (93%) had other significant medi- the right lower abdomen used to grasp the fundus of the gall- cal problems. Thirteen patients (87%) were either Ameri- bladder and retract it into the right upper abdomen and one can Society of Anesthesiologists (ASA) status III or IV. Two in the right subcostal position used as the assistant port. Lapa- patients were evaluated as being ASA status II. roscopic ultrasonography was performed using a 7.5-MHz end-viewing laparoscopic ultrasound transducer (Endome- PERCUTANEOUS CHOLECYSTOSTOMY dix, Irvine, Calif). Fluorocholangiography was then per- TECHNIQUE formed by passing a Reddick cholangiocatheter into the cystic duct. The cholecystostomy tube was withdrawn at this Percutaneous cholecystostomy was performed under ster- time. After dissection of the Calot triangle, the gallbladder ile conditions using intravenous sedation and local anes- was separated from the liver bed using a curved spatula. The thesia with 1% subcutaneous lidocaine hydrochloride. gallbladder was then withdrawn through the subxiphoid port The procedure was performed by using ultrasound and after being placed into an endoscopic retrieval bag.

inflamed gallbladder by tube cholecystostomy with lo- Percutaneous cholecystostomy followed by inter- cal anesthesia allows these patients time to recover from val laparoscopic cholecystectomy has been proposed as critical illness while also allowing the inflammation to an alternative measure for patients at high risk for gen- subside. eral anesthesia. Similarly, there have been reports of lapa-

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Abnormal Result/No. Component Mean ± SD Value of Patients White blood cell count, ϫ109/L 15.2 ± 4.0 13/15 Aspartate aminotransferase, U/L 48 ± 66 2/15 Alanine aminotransferase, U/L 82 ± 129 2/8 Alkaline phosphatase, U/L 141 ± 127 6/15 Amylase, U/L 170 ± 432 1/14 Total bilirubin, µmol/L (mg/dL) 19 ± 15 (1.1 ± 0.9) 2/15

roscopic cholecystostomy performed to decrease the rate of conversion in cases with severe inflammation preclud- Figure 1. The multipurpose cholecystostomy set (Cook, Bloomington, Ind) ing safe dissection during attempted laparoscopic cho- used for laparoscopic cholecystostomy in this study. lecystectomy.13,14 The aim of this study was to review our experience to determine the safety and efficacy of the use of tube cholecystostomy with interval laparoscopic cholecystectomy in selected patients with acute cholecystitis.

RESULTS Resolution of clinical symptoms and signs of acute cholecystitis was observed in 13 (87%) of the patients after cholecystostomy (Figure 4). White blood cell counts of 4 patients failed to return to normal within 72 hours. Two of these patients continued to have an elevated white blood cell count and fever, despite the relief of abdominal pain. One of these patients was admitted to the intensive care unit with septicemia. The other patient was admitted to the hospital with a Figure 2. The placement of a pigtail catheter over guidewire catheter in a 4-day history of symptoms, established urinary tract gangrenous gallbladder during attempted laparoscopic cholecystectomy. infection, and renal failure. Both of these patients died 15 days and 8 days after percutaneous cholecystostomy, respectively, due to septic shock with multisystem organ failure. Nine patients (60%) had positive biliary cultures, 4 (44%) of whom had mixed organisms isolated. Entero- coccus species were the most frequently cultured patho- gens. Five patients (33%) also had positive cultures from other sites. Excluding the 2 patients who died, the average hospital stay for the cholecystostomy procedure was 9.8 days (range, 1-21 days). Three patients (20%) were admitted to the intensive care unit. The mean ± SD drainage from the cholecystostomy tube during the hospital stay of the patients was 131 ± 122 mL/d (Table 2). Twelve patients (80%) underwent interval cholecystectomy. Laparoscopic cholecystectomy was at- Figure 3. The appearance of the gallbladder during interval laparoscopic tempted in 11 patients, being successful in 10 (91%) with cholecystectomy. 1 of the patients having conversion to open cholecystectomy due to severe inflammation and gangrene of the gallbladder. One patient underwent interval open cholecys- biotic therapy after the tube was returned to gravita- tectomy during definitive operation for esophageal cancer tional drainage. Another patient with dementia re- and another had emergency open cholecystectomy as de- moved her cholecystostomy tube 2 days after the scribed below. procedure and required an emergency open cholecys- There were 2 complications (13%) related to the cho- tectomy. A large biliary collection in the subhepatic space lecystostomy tube that required intervention. One pa- and gangrene of the gallbladder were discovered at op- tient developed cholangitis due to clamping of the tube eration. Two patients had dislodgment of the cholecys- after discharge and responded to broad-spectrum anti- tostomy tube. One of these patients underwent tube

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 exchange over wire, but the other one remained asymp- Two patients experienced postoperative complica- tomatic despite mild elevation of the white blood cell tions. One patient developed angina pectoris after lapa- count, and underwent successful laparoscopic cholecys- roscopic cholecystectomy and the patient who under- tectomy at 8 weeks. Fistulograms obtained in 2 patients went conversion to an open procedure had a wound with abdominal pain demonstrated mild leakage around infection. Both of these patients recovered uneventfully. the tube in one patient and obstruction in the other (30 Pathologic evaluation revealed chronic cholecysti- days and 4 days, respectively, after tube placement). Both tis in 12 patients (92%) and acute cholecystitis in 1 pa- of these tubes were changed over wire under local anes- tient (who underwent emergency open cholecystectomy). thesia. The operation time for interval laparoscopic cho- Necrosis of the gallbladder was detected in 2 patients. lecystectomy averaged 118 minutes (range, 59-180 The patients were followed up for an average of 16.7 minutes). One of the patients underwent endoscopic months (range, 0.5-53 months). Except for 1 patient with retrograde cholangiopancreatography with sphincter- a mildly elevated serum bilirubin level due to starva- otomy 1 day after laparoscopic cholecystectomy for dis- tion, which resolved with nutritional support 8 months tal common bile duct stenosis. after interval laparoscopic cholecystectomy, none of the The patient who underwent combined esophagec- patients had any problems referable to the biliary tract. tomy and cholecystectomy developed sepsis and died on One patient died at 35 months due to cerebrovascular postoperative day 32. Excluding this patient, the aver- disease and urinary sepsis and 1 patient developed co- age length of hospital stay was 1.6 days (range, 1-4 days) lon cancer at 12 months. for the interval operation. One patient required intensive care for 3 days. COMMENT

17 Laparoscopic surgery is no longer considered a contra- 16 indication for acute cholecystitis and has become the pro- 15 cedure of choice due to decreased morbidity compared 2,7,15 14 with conventional open surgery. Nevertheless, two controversial issues are the high rate of conversion and /L 13 9

10 the management of critically ill patients who are not good

× 12 11 candidates for general anesthesia. Tube cholecystos- WBC, tomy with delayed laparoscopic cholecystectomy has been 10 proposed for the management of these patients as an al- 9 ternative treatment.13,14,16,17 8 Eighty-seven percent of the patients in our study were either ASA status III or IV and 93% were older than 65 Day Day 1 d 2 d 3 d of Admission of Procedure Postproc Postproc Postproc years. Within this high-risk group of patients, our ap- Time proach consisted of cholecystostomy tube placement, percutaneous or occasionally laparoscopic, followed by in- Figure 4. Line graph showing the significant decrease in mean ± SEM white blood cell count (WBC) of the patients after performance of tube terval laparoscopic cholecystectomy an average of 3 cholecystostomy. Postproc indicates postprocedure. months later (Figure 5).

Table 2. Characteristics of the Biliary Drainage Through the Cholecystostomy Tube

Patient No./ Macroscopic Drainage, Sex/Age, y Appearance Biliary Culture Results Other Culture Results* mL/d† 1/F/92 Pus Clostridium perfringens 88 2/M/83 Serosanguineous Enterococcus, Escherichia coli Coagulase-negative Staphylococcus (urine) 24 3/F/84 Pus Enterococcus, Citrobacter, Klebsiella 35 4/M/65 Turbid, dark green E coli 158 5/M/65 Dark brown Aspergillus Corynebacterium (blood), coagulase-negative 244 Staphylococcus (catheter) 6/M/79 Clear Proteus, Klebsiella Propionibacterium (blood) 172 7/F/79 Dark black Negative 251 8/M/75 Dark green Negative 48 9/M/67 Serosanguineous Negative 112 10/M/66 Serosanguineous Negative 65 11/F/86 Dark green Negative E coli (urine) 55 12/F/74 Dark brown Negative 335 13/M/43 Serosanguineous Enterococcus 200 14/M/79 Murky brown Cyanobacterium, Staphylococcus E coli (urine) 23 epidermidis 15/M/85 Murky brown E coli NR

*This column represents the positive results of clinically indicated additional cultures that were obtained. †Values refer to the drainage recorded during the hospital stay. NR indicates not recorded.

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 bladder, foreshortened cystic duct, and severe inflam- Acute Cholecystitis matory changes had conversion to the open procedure. Yes No High-Risk Patient We believe that an adequate time delay before interval cholecystectomy for the inflammation to subside is critical for successful laparoscopic intervention, which was Percutaneous Laparoscopic Cholecystostomy Tube Cholecystectomy an average of 12 weeks in our study. A conversion rate of 0% was reported for laparoscopic cholecystectomy af- No Safe Dissection ter an interval of 3 months,17 whereas a conversion rate Yes of 31% was observed in patients operated on 5 weeks af-

Laparoscopic Proceed With ter placement of percutaneous cholecystostomy tube for 14 Cholecystostomy Laparoscopic acute cholecystitis. Tube Cholecystectomy The postoperative complication rate for interval lapa-

Resolve in 48 h Resolve in 48 h roscopic cholecystectomy was 18% in our study, consist- ing of cardiac ischemia and wound infection. Patterson and No Yes Yes No colleagues14 reported a postoperative complication rate of Workup for Interval Emergency 23% in their 13 patients with attempted interval chole- Other Sources Laparoscopic Open of Sepsis Cholecystectomy Cholecystectomy cystectomy for acute cholecystitis. Our complication rate compares favorably with the 10% to 24% rate reported for Figure 5. Algorithm for the treatment of acute calculous cholecystitis. open cholecystectomy2,7,24 and 6.4% to 26.7% rate for laparoscopic cholecystectomy for acute cholecystitis.1,5,9 Con- Clinical resolution of toxemia was observed within verted cases have been reported to be associated with an 24 to 48 hours in 87% of our patients after cholecystos- increased morbidity.1,9 Similarly, 1 of the 2 complica- tomy. This is comparable to other studies reporting an tions we observed in our series was in the case converted 81% to 93% response rate.14,16,18 The mortality rate within to open cholecystectomy. The perioperative mortality in 30 days of the procedure was 13% in our study. Re- our interval laparoscopic cholecystectomy series was zero, ported mortality rates for percutaneous cholecystos- which compares favorably with the emergency open cho- tomy performed for acute cholecystitis in the literature lecystectomy mortality of 0% to 5%, which increases to range from 18% to 69%.14,16,19 The high mortality asso- between 6% to 30% in high-risk patients.25 ciated with this procedure is attributed to the presence In conclusion, tube cholecystostomy allowed for reso- of comorbid conditions in these selected patients. lution of sepsis and delay of definitive surgery in a selec- The relatively lower mortality rate in our series can tive group of patients. Interval laparoscopic cholecystec- be related to the prompt referral of the majority of the tomy could be safely performed once sepsis and acute patients by the primary care physicians to the hospital, infection had resolved in this patient group at high risk prompt diagnosis, and early administration of therapeu- for general anesthesia and conversion to open cholecys- tic measures including broad-spectrum antibiotics and tectomy. Just as catheter drainage of acute infection with decompressive tube cholecystostomy. Forty percent of interval appendectomy is accepted in patients with peri- the patients were admitted to the hospital less than 24 appendiceal abscess, tube cholecystostomy with interval hours after the onset of symptoms and 58% underwent laparoscopic cholecystectomy should have a role in the cholecystostomy in the first 48 hours after admission. management of selected patients with acute cholecystitis. The morbidity related to the cholecystostomy tube was 13% in our study and 20% of the patients required Presented as a poster at the 69th Annual Session of the Pa- catheter exchange. Bile leakage, hemorrhage, colonic in- cific Coast Surgical Association, February 14-17, 1998, San jury, and vasovagal reactions are among the percutane- Jose del Cabo, Baja California Sur, Mexico. ous procedure–related complications reported in the lit- Reprints: Allan E. Siperstein, MD, Department of Gen- erature.20,21 Catheter dislodgment has been reported in eral Surgery, Desk A80, The Cleveland Clinic Foundation, 5% to 10% of patients.21-23 Although inconvenient, the 9500 Euclid Ave, Cleveland, OH 44195 (e-mail: sipersa cholecystostomy tube should be left in place in these pa- @ccf.org). tients until the interval operation, as one of our patients developed cholangitis after clamping of the tube. 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