Palliative percutaneous transhepatic gallbladder drainage of gallbladder empyema before laparoscopic cholecystectomy

Background/Aims: This study is conducted to evaluate the feasibility of per cutaneous transhepatic gallbladder drainage prior to laparoscopic cholecyst ectomy for the treatment of gallbladder empyema. We also determine the sono graphic findings, causative organism, clinical signs and symptoms, laborato ry data, associated underlying medical disorders and the complications rela ted to both cholecystostomy and laparoscopic cholecystectomy. Methodology: One hundred and forty-five cases of gallbladder empyema were i ncluded in this study which was composed of 80 males and 65 females, aged 2 2-94 years with a mean age of 71-years. All patients underwent percutaneous transhepatic gallbladder drainage under ultrasound and fluoroscopic guidan ce, and laparoscopic cholecystectomy was carried out thereafter. We analyze d the clinical presentations (signs, symptoms, laboratory and ultrasonograp hic findings, concomitant medical disorders), causative organisms and the c omplications related to percutaneous cholecystostomy and laparoscopic chole cystectomy. Results: Percutaneous transhepatic gallbladder drainage was performed succe ssfully in all patients within 48 hours after clinical diagnosis of acute c holecystitis. Complications related to percutaneous transhepatic gallbladde r drainage were bile leakage after tract dilatation noted in 2 patients (1. 4%), and 20 (14%) patients had pain at the puncture site which radiated to the right shoulder during the procedure, but resolved spontaneously within an hour later. On admission, 102 (70%) patients presented as right upper qu adrant pain, 39 (27%) as epigastric pain, 90 (62%) as fever, 108 (74%) pati ents had leukocytosis, and 33 (22.7%) patients were septic. AST and ALT wer e elevated in 57% and 51% of patients, respectively. Alkaline phosphatase w as elevated in 56% of patients, and 34% of those patients had combined comm on bile duct stones. Gallbladder stones were documented in 135 (93%) patien ts, while the remaining 10 (7%) cases were acalculous. Five (3.4%) patients had combined gallbladder adenocarcinoma, 7 (4.8%) had liver abscess, while 13 (9%) had biliary pancreatitis. The ultrasonographic Endings included ga llbladder distension (93%), wall thickening (90%), pericholecystic fluid ac cumulation (15%), intraluminal sludge or stone (93%) and intraluminal air ( 13.9%). Bile culture were positive in 83% of the cases and showed gram-nega tive bacteria in 75%,grampositive in 30%, anaerobes in 7%, while no growth in the remaining 17% of the cases. The common pathogens were Escherichia co li (57%), Enterococcus (27%), Klebsiella pneumonia (18%), Morganella morgan ii (7.6%), Pseudomonas aeruginosa (4.1%) and Salmonella (0.7%). The total p ostoperative complication rate was 17%, which included wound infection, ble eding, subhepatic abscess, cystic duct stump leak, common bile duct injury and pneumonia. Postoperative mortality was 2.6%. Conversion rate to open ch olecystectomy was 27%. Clinical conditions improved within 48 hours after c holecystostomy in 93% of patients. Time interval between cholecystostomy an d elective cholecystectomy was 2-21 days with a mean of 4 days. Total hospi tal stay was 5-38 days (mean: 11 days). Conclusions: Percutaneous transhepatic gallbladder drainage is a safe and e ffective procedure for the initial management of gallbladder empyema. We hi ghly recommend this preoperative drainage procedure in patient with sepsis, and for those highrisk patients such as old age and with underlying medica l illnesses. This procedure can stabilized the patient so that an appropria te therapeutic planning can be achieved.