Effective use of percutaneous cholecystostomy in high-risk surgical patients - Techniques, tube management, and results

Hypothesis: Percutaneous cholecystostomy (PC) is an effective, safe treatme nt in patients with suspected acute cholecystitis and severe concomitant co morbidity. Design: Retrospective medical record review from March 1989 to March 1998. Setting: Referral community teaching hospital (450 beds) in rural Wisconsin . Patients: Twenty-two consecutive patients underwent PC tube placement over a 10-year period. Twenty procedures were for acute cholecystitis (14 calcul ous, 6 acalculous) and 2 were for diagnostic dilemmas. Nineteen (86%) of 22 patients were American Society of Anesthesiologists class 4; 3 (14%) were class 3. Interventions: Pigtail catheters (8F-10F) placed by means of ultrasound or computed tomographic localization, with or without fluoroscopic adjunct. Main Outcome Measures: Thirty-day mortality, complications, clinical improv ement as determined by fever and pain resolution, normalization of leukocyt osis, further biliary procedures required, and outcome after drain removal. Results: Twenty-two patients underwent PC for presumed acute cholecystitis based on ultrasound and clinical findings. All patients received antibiotic s prior to PC for 24 or more hours. Thirty-day mortality was 36% (8 patient s), reflecting severity of concomitant disease. Minor complications occurre d in 3 of 22 patients. Clinical improvement occurred in 18 (82%) of 22 pati ents-15 (68%) within 48 hours. Follow-up of fourteen 30-day survivors is as follows: 7 (50%) had drains removed because the gallbladder was stone free , 4 (29%) had drains remaining due to persistent stones, 2 (14%) underwent cholecystectomy, and 1 (7%) awaits scheduled surgery. Only 1 (121.5%) of 8 patients developed biliary complications after drain removal, requiring end oscopic retrograde cholangiopancreatography 9 months after drain removal. O ne patient required urgent cholecystectomy after failure to respond to PC. This patient died of a perioperative myocardial infarction. Conclusions: Percutaneous cholecystostomy is an effective, safe treatment i n patients with suspected acute cholecystitis and severe concomitant comorb idity. Laparoscopic cholecystectomy is recommended as definitive treatment for patients whose risk for general anesthesia improves in follow-up. Drain s can be safely removed once all gallstones are cleared. In patients with s evere concomitant disease, drains can be left with a low-incidence of compl ications if stones remain.