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The Efficacy of Preoperative Percutaneous Cholecystostomy for Acute Cholecystitis with Gallbladder Perforation 담낭천공을 동반한 급성담낭염 환자에서 수술 전 경피적담낭배액술의 효용성에 관한 연구

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The Efficacy of Preoperative Percutaneous Cholecystostomy for Acute Cholecystitis with Gallbladder Perforation 담낭천공을 동반한 급성담낭염 환자에서 수술 전 경피적담낭배액술의 효용성에 관한 연구 Original Article pISSN 1738-2637 / eISSN 2288-2928 J Korean Soc Radiol 2017;77(6):372-381 https://doi.org/10.3348/jksr.2017.77.6.372 The Efficacy of Preoperative Percutaneous Cholecystostomy for Acute Cholecystitis with Gallbladder Perforation 담낭천공을 동반한 급성담낭염 환자에서 수술 전 경피적담낭배액술의 효용성에 관한 연구 Bo Ra Kim, MD, Jeong-Hyun Jo, MD, Byeong-Ho Park, MD* Department of Radiology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea Purpose: Treatment of acute cholecystitis with gallbladder perforation remains Index terms controversial. We aimed to determine the feasibility of percutaneous cholecystosto- Cholecystostomy my (PC) in these patients. Cholecystitis, Acute Materials and Methods: We retrospectively reviewed patients who had acute Cholecystectomy cholecystitis with gallbladder perforation at a single institution. Group 1 (n = 27; M:F = 18:9; mean age, 69.9 years) consisted of patients who received PC followed Received May 12, 2017 by cholecystectomy, and group 2 (n = 16; M:F = 8:8; mean age 57.1 years) consisted Revised June 3, 2017 of patients who were treated with cholecystectomy only. Preoperative details, in- Accepted June 26, 2017 cluding sex, age, underlying medical history, signs of systemic inflammatory re- *Corresponding author: Byeong-Ho Park, MD Department of Radiology, Dong-A University Hospital, sponse syndrome (SIRS), laboratory findings, body mass index, presence of gallstone, Dong-A University College of Medicine, 26 Daesingong- and type of perforation; treatment-related variables, including laparoscopic or open won-ro, Seo-gu, Busan 49201, Korea. cholecystectomy, conversion to laparotomy, blood loss, surgical time and anesthesia Tel. 82-51-240-5371 Fax. 82-51-253-4931 E-mail: [email protected] time; and outcome, including postoperative complications and hospital stay were analyzed. This is an Open Access article distributed under the terms Results: There was no significant difference in preoperative details, treatment-re- of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) lated variables, postoperative complications, and postoperative hospital stay. Howev- which permits unrestricted non-commercial use, distri- er, preoperative hospital stay (median, 14 days vs. 8 days; p < 0.05) and total hospital bution, and reproduction in any medium, provided the stay (median, 22 days vs. 14.5 days; p < 0.05) were significantly longer in group 1 than original work is properly cited. in group 2. Conclusion: The preferred treatment of acute cholecystitis with gallbladder perfo- ration might be cholecystectomy without preoperative PC; however, preoperative PC can be a safe, optional treatment in elderly patients with signs of SIRS. INTRODUCTION abdominal viscera. Since this original classification was published, other classifi- Gallbladder perforation is a complication of acute cholecysti- cation systems with more complicated subtypes have been sug- tis, occurring in 2–42% of patients with acute cholecystitis (1, gested, and diagnostic tools and therapeutic options have 2). Since Niemeier (3) classified gallbladder perforation into emerged (2). There are several treatment options for acute cho- three types, modified Niemeier classification of gallbladder per- lecystitis with gallbladder perforation, such as simple drainage, foration (4) has been used: type I, acute perforation into the endoscopic treatment, and surgical cholecystectomy. However, free peritoneal cavity; type II, subacute perforation of the gall- no consensus has been reached regarding the standard treat- bladder surrounded by an abscess; and type III, chronic perfo- ment for acute cholecystitis with gallbladder perforation (2, 5). ration with fistula formation between the gallbladder and other Laparoscopic cholecystectomy is regarded as one of the stan- 372 Copyrights © 2017 The Korean Society of Radiology Bo Ra Kim, et al dard treatments in patients with acute cholecystitis, and early 57.1 years (range, 20–81 years). laparoscopic cholecystectomy within 48 to 96 hours after symp- Acute cholecystitis with gallbladder perforation was diag- tom onset is recommended (6-10), although percutaneous cho- nosed based on the patients’ symptoms, physical examination, lecystostomy (PC) is chosen for initial treatment in high-risk laboratory findings, and imaging studies, including computed patients and when emergent surgery is not possible due to tomography and/or ultrasonography (US). Imaging findings manpower constraints (7, 9, 11). However, the efficacy of PC for making the diagnosis were defects in the wall of the gallblad- before cholecystectomy in acute cholecystitis remains contro- der and/or pericholecystic abscess formation, in addition to the versial; some surgeons advocate preoperative PC in critically ill findings of acute cholecystitis-distension of the gallbladder, or elderly patients, while others suggest that it has poor out- thickening of the gallbladder wall, and pericholecystic hyperemia. comes, with a longer hospital stay and a higher rate of conver- The presence of cholelithiasis and modified Niemeier’s type of sion to open surgery (7-10). gallbladder perforation were evaluated on imaging studies. Furthermore, treatment options for acute cholecystitis com- bined with gallbladder perforation in various situations remain Treatment controversial and have not yet been standardized. When the patient was older than 50 years of age and systemic Therefore, the purpose of this study was to evaluate outcomes inflammatory response syndrome (SIRS) was suspected (n = in patients with acute cholecystitis combined with gallbladder 15) or emergent surgery was not possible due to manpower perforation who were treated only with cholecystectomy and constraints such as shortage of surgeons, anesthetists or equip- those who were treated with preoperative PC followed by cho- ment (n = 12), PC was conducted before surgical treatment. If lecystectomy. the patient was younger than 50 years of age (n = 7) or the pa- tient was older than 50 years of age but did not have SIRS and MATERIALS AND METHODS emergent operation was possible (n = 9), cholecystectomy was conducted without preoperative PC (Table 1, Fig. 1). Patients and Study Groups SIRS was defined when more than two of the following were For this study, approval from the Institutional Review Board noted: body temperature > 38°C or < 36°C, heart rate > 90 beats/ of our institution was obtained (DAUHIRB-16-177). Medical min, respiratory rate > 20/min or PaCO2 < 32 mm Hg, and white records were retrospectively reviewed, so the requirement for blood cell (WBC) count > 12000/mm3 or < 4000/mm3 or > 10% obtaining informed consent was waived. immature bands (12). Among the 2202 patients who underwent cholecystectomy For PC, a transhepatic or transperitoneal approach was cho- from 2010 to 2014 at our institution, 600 patients had been op- sen, and an 8-French catheter was inserted into the gallbladder erated for acute cholecystitis. In the other 1602 patients, chole- under US and fluoroscopy guidance. The patients were conser- cystectomy was conducted for various reasons such as gallblad- vatively treated in the hospital, and surgical treatment was per- der cancer, chronic cholecystitis, and gallbladder polyp(s), or formed when clinical improvement, including the disappear- additional cholecystectomy was performed in cases of gastric ance of signs of SIRS, was achieved. cancer surgery and hepatic malignancy surgery. Among the Open or laparoscopic cholecystectomy was conducted based former 600 patients, 43 patients underwent operation due to on the patient’s status, such as adhesion due to previous abdomi- acute cholecystitis combined with gallbladder perforation. nal surgery. For laparoscopic cholecystectomy, three or four Among them, group 1 (n = 27) included patients who had been ports were inserted in the umbilical, epigastric, and subcostal treated with preoperative PC followed by surgical treatment. areas. When severe adhesion or severe inflammation was ob- Group 2 (n = 16) included patients who had been treated with served intraoperatively in patients in whom laparoscopic surgery cholecystectomy only. There were 18 male and 9 female patients was planned, the surgical procedure was converted from laparo- in group 1, with a mean age of 69.9 years (range, 51–83 years), scopic surgery to laparotomy. and 8 male and 8 female patients in group 2, with a mean age of jksronline.org J Korean Soc Radiol 2017;77(6):372-381 373 Percutaneous Cholecystostomy for Perforated Cholecystitis Postoperative Complications and Hospital Stay (BMI), presence of gallstone, and type of perforation; treatment- For evaluation of treatment-related complications, complica- related variables, such as laparoscopic or open cholecystectomy, tions were categorized as surgical site infection, biliary compli- conversion to laparotomy, blood loss, surgical time and anesthe- cations, pulmonary complications, postoperative bleeding, ileus, wound dehiscence, complications requiring re-operation, PC-re- ≥ 50 years of age No lated complications, etc. Cholecystectomy only Hospital stay was subcategorized as preoperative hospital stay, Yes (group 2; n = 16) postoperative hospital stay, and total hospital stay. To assess the effect of signs of SIRS on these treatment outcome Systemic inflammatory Yes response syndrome variables, the presence of SIRS in the two groups, as well as com- No Is emergent operation plications and hospital stay were analyzed. Yes possible? (surgeons, etc.) No Statistical
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