PAPER Effective Use of Percutaneous Cholecystostomy in High-Risk Surgical Patients Techniques, Tube Management, and Results Clark A. Davis, MD; Jeffrey Landercasper, MD; Lincoln H. Gundersen, MD; Pamela J. Lambert, RN Hypothesis: Percutaneous cholecystostomy (PC) is an cal findings. All patients received antibiotics prior to PC effective, safe treatment in patients with suspected acute for 24 or more hours. Thirty-day mortality was 36% (8 cholecystitis and severe concomitant comorbidity. patients), reflecting severity of concomitant disease. Mi- nor complications occurred in 3 of 22 patients. Clinical Design: Retrospective medical record review from March improvement occurred in 18 (82%) of 22 patients—15 1989 to March 1998. (68%) within 48 hours. Follow-up of fourteen 30-day sur- vivors is as follows: 7 (50%) had drains removed be- Setting: Referral community teaching hospital (450 beds) cause the gallbladder was stone free, 4 (29%) had drains in rural Wisconsin. remaining due to persistent stones, 2 (14%) underwent cholecystectomy, and 1 (7%) awaits scheduled surgery. Patients: Twenty-two consecutive patients underwent Only 1 (12.5%) of 8 patients developed biliary compli- PC tube placement over a 10-year period. Twenty pro- cations after drain removal, requiring endoscopic retro- cedures were for acute cholecystitis (14 calculous, 6 acal- grade cholangiopancreatography 9 months after drain re- culous) and 2 were for diagnostic dilemmas. Nineteen moval. One patient required urgent cholecystectomy after (86%) of 22 patients were American Society of Anesthe- failure to respond to PC. This patient died of a periop- siologists class 4; 3 (14%) were class 3. erative myocardial infarction. Interventions: Pigtail catheters (8F-10F) placed by Conclusions: Percutaneous cholecystostomy is an ef- means of ultrasound or computed tomographic localiza- fective, safe treatment in patients with suspected acute tion, with or without fluoroscopic adjunct. cholecystitis and severe concomitant comorbidity. Lapa- roscopic cholecystectomy is recommended as definitive Main Outcome Measures: Thirty-day mortality, com- treatment for patients whose risk for general anesthesia plications, clinical improvement as determined by fever and improves in follow-up. Drains can be safely removed once pain resolution, normalization of leukocytosis, further bili- all gallstones are cleared. In patients with severe con- ary procedures required, and outcome after drain removal. comitant disease, drains can be left with a low incidence of complications if stones remain. Results: Twenty-two patients underwent PC for pre- sumed acute cholecystitis based on ultrasound and clini- Arch Surg. 1999;134:727-732 MERGENT SURGERY for acute Shirai et al7 advocated percutaneous cho- cholecystitis in the elderly lecystostomy (PC) as the preferred treat- has been reported to have a ment for acute acalculous cholecystitis. No mortality rate as high as 14% deaths were reported in 15 patients. to 19%.1,2 In contrast, elec- tive surgery in this same age group has See Invited Critique E 1,2 mortality as low as 0.7% to 2%. Gen- at end of article eral anesthetic risk for patients with sig- nificant comorbidities has been deter- Percutaneous cholecystostomy has mined by the American Society of beenshowntobeeffectivetreatmentforacute Anesthesiologists (ASA) classification. cholecystitis in the elderly and critically ill Mortality per 1000 patients has been cal- by several authors.7-13 However, there have culated to range from 18.2 to 77.6 for ASA From the Departments of class 3 and 4, respectively.3 Acute acalcu- Surgery (Drs Davis and lous cholecystitis is commonly associ- Landercasper and Ms Lambert) ated with critical illness, and mortality rates This article is also available on our and Radiology (Dr Gundersen), Web site: www.ama-assn.org/surgery. Gundersen Lutheran Medical up to 67% have been documented after 4-6 Center, La Crosse, Wis. cholecystectomy. To lower mortality, ARCH SURG/ VOL 134, JULY 1999 727 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 PATIENTS AND METHODS failed to clinically respond to a trial of intravenous antibi- otics prior to PC tube placement. The diagnosis of acute cholecystitis was established A retrospective chart review of 22 consecutive patients by the findings of right upper quadrant pain, fever, and by undergoing PC from March 1989 to March 1998 in a ter- the ultrasonographic findings of gallbladder wall thicken- tiary, 450-bed, rural hospital in La Crosse, Wis, was con- ing (.3 mm), pericholecystic fluid, gallbladder disten- ducted. Patients were reviewed for demographic features, co- tion, and sonographic Murphy sign. Twenty patients had morbidity, and ASA class. Risk factors for acute cholecystitis acute cholecystitis; 16 patients had calculous disease and were determined. Approximately 3000 cholecystectomies 4 had acalculous disease. Two patients underwent PC for were performed during this time, resulting in an approxi- the diagnostic dilemma of sepsis of unknown origin. Clini- mate 0.7% ratio of PC tube placement compared with cho- cal improvement was determined by normalization of leu- lecystectomy. There were 14 men and 8 women with mean kocytosis (,10.5 3 109/L) and/or resolution of pain or fe- age of 77 years (range, 58-97 years). All patients had sig- ver (temperature ,38°C). nificant comorbidity, as shown in the tabulation below. Placement of PC tubes was accomplished with local anesthesia. Pigtail catheters (8F-10F) were placed with the No. (%) Seldinger technique. Ultrasound was used for guidance in Comorbidity of Patients 21 (95%) of 22, and computed tomographic scan in 1 (4%). Cardiac disease (coronary artery disease, 17 (77) Technical success was achieved in all patients. The tech- congestive heart failure, recent myocardial infarction) nique used computed tomography or ultrasound position- Respiratory disease 11 (50) ing of the needle. Fluoroscopy was used to verify place- (chronic obstructive pulmonary ment of the guidewire. Tubes were placed for gravity, and disease, respiratory failure) routine irrigation was not performed. A subcostal ap- Renal failure/insufficiency 10 (45) proach was preferred over a transhepatic approach. Tubes Sepsis/multisystem organ failure 6 (27) were left in place for a minimum of 6 days. Cholangio- Diabetes 3 (14) grams were performed before tube removal to determine Abdominal aortic aneurysm rupture 1 (4) if stones were present and to confirm cystic duct patency. Stones were removed percutaneously by a variety of tech- Nineteen (86%) of 22 patients were ASA class 4, and niques including irrigation, baskets, and mechanical frag- 3 (14%) were ASA class 3. Eight (36%) patients had un- mentation. Exclusion criteria for PC tube placement in- dergone other surgery within 30 days of PC tube place- cluded international normalized ratio greater than 2.5, partial ment, and 10 (45%) of 22 had been receiving total paren- thromboplastin time greater than 45 seconds, and platelet teral nutrition. The patients included in this study had all count less than 75 3 109/L. been few descriptions detailing the management, follow- 22 Patients up,andlong-termoutcomeofpatientsdischargedwithdrains in place. Nonsurvivors of 30 d Survivors Our techniques, results, complications, and recom- n = 8 n = 14 mendations for the long-term treatment of high-risk sur- gical patients with acute cholecystitis are discussed. Clinical Response Clinical Response RESULTS Yes No Yes No n = 4 n = 4 n = 14 n = 0 Percutaneous cholecystostomy tube placement for pre- Figure 1. Clinical response to percutaneous cholecystostomy in 22 patients. sumed acute cholecystitis based on ultrasound and clini- cal findings was performed in 20 patients. Two addi- tional patients underwent PC for sepsis of unknown kocytosis within 48 hours. Complications of PC tube source thought likely to be biliary related. All patients placement occurred in 3 (14%) of 22 patients, including received intravenous antibiotics prior to PC for 24 or more bile leakage around the skin in 2 patients and tube dis- hours with failure to improve clinically. Of the patients lodgment that required replacement in 1 patient. Nine with acute cholecystitis, 14 had calculous disease and 6 (43%) of 21 bile cultures were positive. Two patients had had acalculous disease. Ultrasound findings in these pa- 2 organisms present. Organisms are listed in the tabula- tients included 15 with wall thickening (.3 mm), 9 with tion below. pericholecystic fluid, 6 with gallbladder distention, and Organism No. of Cultures 7 with a positive sonographic Murphy sign. Escherichia coli 2 Figure 1 and Figure 2 illustrate the clinical course Enterobacter 2 of all 22 patients. Clinical improvement occurred in 18 Enterococcus 2 (82%) of 22 patients—15 (68%) within 48 hours. All non- Klebsiella 1 Salmonella 1 responders died within 30 days of PC. Deaths were not Bacteroides 1 believed to be related to PC or biliary sepsis and are fur- Clostridium perfringens 1 ther characterized below. Of the responders to PC, 12 Pseudomonas aeruginosa 1 patients had fever resolution and 6 had resolution of leu- No organism cultured 12 ARCH SURG/ VOL 134, JULY 1999 728 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 22 Patients Nonsurvivors of 30 d Survivors n = 8 n = 14 Cause of Death Multiple Organ Failure 4 Drains Remain Drains Removed Myocardial Infarction 2 n = 4 n = 10 Sepsis (Not Biliary Related) 1