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

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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 cho- lecystectomy. 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 condi- tion 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 cho- lecystostomy 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 ARCH SURG/ VOL 135, MAR 2000 WWW.ARCHSURG.COM 341 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 PATIENTS, MATERIALS, fluoroscopy guidance in 12 patients. Adequate visualiza- tion of the gallbladder using ultrasonography was not pos- AND METHODS sible in 1 patient and this patient underwent percutane- ous 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 .38°C) in 12 was sent for culture (Figure 1 and Figure 2). (80%), nausea or vomiting in 10 (67%), and diffuse abdomi- nal 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
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