GALLSTONES IN CRITICALLY ILL PATIENTS WITH ACUTE CALCULOUS CHOLECYSTITIS TREATED BY PERCUTANEOUS CHOLECYSTOSTOMY - NONSURGICAL THERAPEUTIC OPTIONS

OBJECTIVE. Patients with acute calculous cholecystitis require removal of gallstones (generally cholecystectomy), as acute cholecystitis is likely to recur if gallstones are left in situ. The purpose of this st udy was to assess the role of nonsurgical techniques for treating gall stones in critically ill patients with acute calculous cholecystitis m anaged by percutaneous cholecystostomy. MATERIALS AND METHODS. Twenty- six critically ill patients with complex medical and surgical problems who were in intensive care units underwent emergent percutaneous chol ecystostomy for acute calculous cholecystitis. Seven of the 26 patient s subsequently died of multiple organ failure. Curative gallstone ther apies were tried in the surviving 19 patients, seven of whom underwent elective surgical cholecystectomy. Nonsurgical management was attempt ed in 12 of 19 patients, including six with terminal disease who were treated with long-term gallbladder drainage, three who were treated wi th methyl tert-butyl ether for stone dissolution, two who had percutan eous cholecystolithotomy, and one who had a gallbladder stone that had passed into the common bile duct and was retrieved endoscopically. RE SULTS. Long-term gallbladder drainage was successful in all six patien ts with terminal disease in whom it was attempted; they experienced no further episodes of cholecystitis. In four of the other six patients treated with nonsurgical therapies (percutaneous cholecystolithotomy, stone dissolution with methyl tert-butyl ether, and endoscopic removal ), gallstones were successfully removed and no further therapy was req uired. Percutaneous therapies failed in two patients, who then had cho lecystectomy. CONCLUSION. Nonsurgical gallstone therapies should be at tempted in high-risk patients with acute calculous cholecystitis. Some patients may benefit form longterm catheter drainage of the gallbladd er.