AN ALTERNATIVE APPROACH TO ACUTE CHOLECYSTITIS - PERCUTANEOUS CHOLECYSTOSTOMY AND INTERVAL LAPAROSCOPIC CHOLECYSTECTOMY

Background: The mainstay of therapy for acute cholecystitis is cholecy stectomy, which has a mortality of 5-30% in high-risk patients such as the elderly or critically ill. An alternative treatment option in pat ients suffering from acute cholecystitis with contraindications to eme rgency surgery is percutaneous cholecystostomy (PC) followed by interv al laparoscopic cholecystectomy. Percutaneous cholecystostomy yields 1 0-12% mortality in high-risk patients and is therefore a safe temporiz ing measure, allowing delayed, elective cholecystectomy when the patie nt is in better condition for surgery. Methods: Hospital charts and ra diology films were reviewed for all 50 patients who underwent PC for a cute cholecystitis between January 1990 and September 1993. Most patie nts were high risk for emergency cholecystectomy by virtue of their cr itical illness or underlying medical condition. Twenty-five patients w ent on to have interval cholecystectomies. We recorded whether they un derwent laparoscopic or open cholecystectomy, as elective or emergency procedures, and we recorded direct complications, mortality, and post operative length of hospital stay. Results: Relief of symptoms occurre d within 48 h of PC in 90% of patients, and two patients had complicat ions of PC. Laparoscopic cholecystectomy was attempted in 13 patients and competed in nine. Four patients (31%) required conversion from lap aroscopic to open cholecystectomies due to extensive adhesions (3) or bleeding (1). Three patients had direct complications of laparoscopic cholecystectomy. There was no mortality or major bile duct injury. Con clusion: Percutaneous cholecystostomy followed by interval laparoscopi c cholecystectomy is a safe, minimally invasive approach which can be employed safely in the critically ill patient when contraindications t o emergency surgery exist.