|Year : 2019 | Volume
| Issue : 3 | Page : 157-161
Is cholecystostomy tube insertion a real bridge for cholecystectomy in acute cholecystitis? A retrospective cohort study
Abdullah M Alotaibi1, Osama Nafea2, Ahmad M Deeb3, Zeyad Yousef4
1 Department of Medicine, Ministry of the National Guard – Health Affairs; King Saud Bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
2 King Saud Bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center; Department of Surgery, Ministry of the National Guard – Health Affairs, Riyadh, Saudi Arabia
3 King Saud Bin Abdulaziz University for Health Sciences; Research Office, King Abdullah International Medical Research Center; Department of Surgery, Ministry of the National Guard – Health Affairs, Riyadh, Saudi Arabia
4 King Abdullah International Medical Research Center; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences; Department of Surgery, Ministry of the National Guard – Health Affairs, Riyadh, Saudi Arabia
|Date of Web Publication||9-Dec-2019|
Dr. Zeyad Yousef
College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh; Department of Surgery, Ministry of the National Guard – Health Affairs, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh
Source of Support: None, Conflict of Interest: None
Background: Percutaneous cholecystostomy (PC) is an alternative treatment in high-risk acute cholecystitis (AC) patients. However, it is debatable whether PC should be considered as a definitive procedure or to be used as a temporizing measure before the definitive cholecystectomy. The aim of this study is to determine if PC is always a bridge for interval cholecystectomy in patients treated at tertiary care center in Saudi Arabia.Materials and Methods: This retrospective cohort study was conducted at a tertiary care center in Saudi Arabia for patients who underwent PC for AC during the period from January 2010 to January 2015. We evaluated the PC tube indications, complications, and outcomes (successful response).Results: A total of 63 patients were included in this study. Around half of the patients were male (54%) with a median age of 69 years. The median hospital length of stay was 17 days, in which 30% of the patients were admitted to the intensive care unit, with a hospital mortality of 25%. The successful response to PC was 79%, with 21% of patients undergoing cholecystectomy.Conclusion: PC is not always a bridge for interval cholecystectomy. However, more studies for patients in whom PC is selected as definite treatment are required.
Keywords: Cholecystectomy, cholecystitis, cholecystostomy
|How to cite this article:|
Alotaibi AM, Nafea O, Deeb AM, Yousef Z. Is cholecystostomy tube insertion a real bridge for cholecystectomy in acute cholecystitis? A retrospective cohort study. Saudi J Health Sci 2019;8:157-61
|How to cite this URL:|
Alotaibi AM, Nafea O, Deeb AM, Yousef Z. Is cholecystostomy tube insertion a real bridge for cholecystectomy in acute cholecystitis? A retrospective cohort study. Saudi J Health Sci [serial online] 2019 [cited 2020 Jan 25];8:157-61. Available from: http://www.saudijhealthsci.org/text.asp?2019/8/3/157/272444
| Introduction|| |
Acute cholecystitis (AC) remains one of the most common surgical conditions; it often affects the elderly and patients with serious medical comorbidities. The standard treatment of AC is laparoscopic cholecystectomy (LC).,, However, gallbladder drainage such as percutaneous cholecystostomy (PC) is an alternative treatment in high-risk patients who cannot safely undergo urgent or early cholecystectomy.,,
It is debatable whether PC should be considered as a definitive procedure or to be used as a temporizing measure before the definitive cholecystectomy as an elective procedure in high-risk patients with AC.,, The recurrence of cholecystitis and biliary symptoms, comorbidities, or/and complications after PC play vital role in surgical decisions.
Several studies suggested that PC as an alternative to surgery is a safe and effective treatment of AC in high-risk patients with low morbidity, mortality, and cholecystitis recurrence rate.,,, Other studies supported the using of PC as temporizing measure before the definitive surgery in high-risk patients.,,,
On the other hand, PC was found to be associated with high mortality or worsening outcomes., Whereas, other studies reported the lacking of firm criteria of PC treatment over cholecystectomy or even failure to determine the role of PC in the treatment of high-risk surgical patients.,, A recent randomized controlled trial (RCT) which was concluded early after major complications occurred after percutaneous drainage, reported that LC compared with percutaneous catheter drainage reduced the rate of major complications in high-risk patients with AC.
This study reported the PC profile for AC at a tertiary care center in Saudi Arabia. The primary purpose of this study was to determine if PC is always a bridge for interval cholecystectomy in patients treated at tertiary care center in Saudi Arabia.
| Materials and Methods|| |
This was a retrospective cohort study, in which PC tube indications and complications were evaluated by reviewing patients' files. Patients were followed up after discharge to identify if interval cholecystectomy was performed or not.
The study was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia, a tertiary health-care center with a bed capacity of around 1200 beds. The study was approved by the Institutional Review Board in King Abdullah International Medical Research Center.
A total of 63 patients who underwent PC for AC during the period from January 2010 to January 2015 were identified. The inclusion criteria were all patients, regardless of their age or gender, admitted under general surgery as AC or consulted later for AC after being admitted under other specialties with different primary diagnoses. Exclusion criteria were patients who had AC without PC insertion or when PC was inserted for other indications, i.e., malignant obstruction or gallbladder perforation.
The patient medical records were reviewed from the electronic medical record system and the patients' files; however, a radiological system was the access for radiological images and reports. The following variables were recorded: patient related, i.e., demographic data, comorbidities, vital signs and laboratory results (complete blood count and liver function test [LFT]) on admission and after tube insertion, and radiological study results; PC related, i.e., indications, early or delayed complications, and follow-up radiological studies (ultrasound [US], computed tomography, magnetic resonance cholangiopancreatography, or cholangiogram) either before or after discharge; interval cholecystectomy related, i.e. date of surgery, complications, and operative and pathological reports; and nonoperated group related, i.e., booking for surgery, readmission with another attack, and death while waiting. The patients were followed up until cholecystectomy, death, or up to February 2015.
AC was defined in this study according to Tokyo Guidelines 2013. The successful response to PC was defined as an improvement in the patient's symptoms and signs such as right upper quadrant pain and fever, trends of LFT, and white blood count test (WBC) toward normal levels. The LFT laboratory value results after tube insertion were classified into initially normal, improved, and no change in which it was high before and after PC insertion and worsened. Death during the same admission was defined as in-hospital mortality because no patients died within 30 days after discharge.
All variables were summarized and reported across the study cohorts using descriptive statistics. Categorical variables were reported as numbers and percentages. Continuous variables were reported as mean and standard deviation or median and quartiles (Q1, Q3). JMP®, Version 13. SAS Institute Inc., Cary, NC, 1989-2019 was used to analyze the data.
| Results|| |
Sixty-three patients with PC placement met the inclusion criteria; among them, 34 (54%) were males. The median patients' age was 69 years (quartile range, 62, 76). The only admitting diagnosis of AC was found in 37 (58%) patients. Thirty-nine patients (62%) were admitted primarily under general surgery. In the remaining 24 patients (38.0%), internal medicine, cardiology, hematology, and orthopedics were the primary admitting specialties accounting for 13, 5, 4, and 2 patients, respectively. In these cases, the admitting diagnoses were not related to the gallbladder disease; rather, it was related to patients' comorbidities. However, the general surgery team was consulted later for clinical or radiological evidence of AC. Patients' demographics and comorbidities are shown in [Table 1]. Vital signs, diagnostic imaging results before tube insertion, and laboratory values in the 1st admission day are shown in [Table 2].
|Table 1: Characteristics and comorbidities of percutaneous cholecystostomy patients|
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|Table 2: Vital signs, diagnostic imaging results, and laboratory values of percutaneous cholecystostomy patients|
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The median duration of hospital length of stay was 17 (Q1–Q3: 10, 41) days. The total number of patients needed intensive care unit (ICU) admission was 19 (30%), with a median ICU length of stay of 21 days (12, 35). The in-hospital mortality rate was 16 (25%), and causes of death included septic shock, cardiac arrest, and multiple organ failure. Of them, nine patients were admitted to the ICU with the indications of sepsis, septic shock, and multiple organ failure.
The indications for PC insertion were acute calculous cholecystitis in 49 (80%) patients and acute acalculous cholecystitis in 12 (20%) patients. Among the first group, 12 patients had associated perforation of the gallbladder, three patients had obstructive jaundice, and 1 had empyema. Sixty-two patients underwent the procedure at the interventional radiology suite, all with US assistance; the route was transperitoneal in three patients secondary to liver cirrhosis or patient instability whereas transhepatic in 59 patients (94%). However, intraoperative transperitoneal cholecystostomy tube was inserted in one patient due to liver cirrhosis and failure to progress. There were no tube-related complications reported, and the median of tube stay was 12 (0, 28); however, the length of tube stay in 18 patients could not be identified either due to poor chart documentation or loss of follow-up.
A successful response to PC insertion was encountered in 49 (79%) patients who showed clinical improvement and trend down of leukocytosis. However, LFT trended down after initial elevation only in 17 (27%) patients, as it was normal in the other 32 (52%) on presentation. In four (6%) patients, there was no change in LFT that was high before and after tube insertion, whereas in nine (15%) patients, it worsened after tube insertion (seven of them died during the same admission).
Out of the 63 patients included in this study, only 13 patients (21%) underwent interval cholecystectomy, whereas 50 patients (79%) did not have cholecystectomy, of which 16 (25%) died during the same admission.
For patients who went for surgery, 11 had a LC and 2 were converted to open cholecystectomy due to anatomical difficulty. The gallbladder pathological reports showed acute on top of chronic calculus cholecystitis in eight patients, chronic cholecystitis in three patients, and severe acute necrotizing cholecystitis in two patients. PC was repeated on three occasions; in two patients during the same admission due to incidental removal and blockage, whereas in one patient, it was 3 months later due to another attack of AC.
For the remaining 34 patients, 5 died, 6 booked for surgery but not done, and 23 lost to follow-up. The PC insertion outcome for the 63 patients is summarized in [Table 3] and [Figure 1].
| Discussion|| |
This study reported the PC profile for AC at a tertiary care center in Saudi Arabia. It aimed to determine if PC is always a bridge for interval cholecystectomy in patients treated at tertiary care centers in Saudi Arabia. In this study, the majority of our patients had the PC inserted with the transhepatic approach and under US guidance.
In our study population, the clinical response to PC tube insertion was 79%, in which there was an improvement in the clinical symptoms, signs, and laboratory results (WBC and LFT) within 3–5 days. Only one patient in our study had recurrence of AC for which he had another PC tube insertion. These results were consistent with those of other published studies,, and this shows how effective is PC as a treating modality when surgery carries a high risk.
In our study, fifty patients (79%) did not have cholecystectomy, 3 of them had a recent PC insertion. However, the number of patients who underwent cholecystectomy after tube insertion varies widely between studies. For example, in one study, only three out of sixty patients (5%) had cholecystectomy after tube insertion due to the low relapse rate, but in another study, 12 out of 15 (80%) had cholecystectomy after PC insertion. In one (86 patients) out of two RCTs (156 patients) published in a systematic review conducted on high-risk subjects with AC, only 9 out of 44 patients had PC followed by LC, which was close to our result in which only 13 out of 63 patients had LC (16 in-hospital death), which highlights the fact that not all patients after PC underwent LC. Although the Cochrane review did not define the role of PC in high-risk patients, PC followed by early LC (within 4 days) decreases the cost and the hospital stay compared to delay LC (after 8 weeks).
In another systematic review, around 42% of patients underwent cholecystectomy after PC, in comparison to our study where 21% (n = 13) of patients had surgery. The in-hospital mortality in our study was higher than the review, 25% versus 15.4%. Furthermore, the review reported that elderly or critically ill patients have a higher mortality rate after PC (15.4%) which might be due to their high-risk nature, in comparison to immediate cholecystectomy (4.5%).
When it comes to long-term survival, a large retrospective study (43,341 patients) which included only patients with acalculous cholecystitis reported that cholecystectomy may improve the long-term survival, unlike PC which does not improve survival. A recent RCT concluded that although mortality was not different between LC and PC, LC compared to PC reduced the rate of major complications in high-risk patients with AC. In high-risk patients with AC, whether conservative treatment alone or with PC, PC followed by early cholecystectomy or followed by delay cholecystectomy remains a controversial issue.
The limitations of our study are the retrospective nature and the small sample size. The question of whether PC is a definite treatment still remains unanswered. A prospective study with a large sample size, long-term follow-up, specific inclusion criteria, and a comparison between patients who had PC with cholecystectomy and without cholecystectomy might be helpful to reach a better conclusion.
| Conclusion|| |
Although the status of some patients was unknown due to loss of follow-up, we found that PC is not always a bridge for interval cholecystectomy because not all the patients had an elective booking for surgery. We believe as other authors,,, that surgery after PC might not be needed especially at high risk when mortality is a concern. However, we think that more evidence is required and specific guidelines for patients in whom PC is selected as a definite treatment are needed.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]