Percutaneous drainage for acute calculous cholecystitis.

BACKGROUND: Acute calculous cholecystitis is a frequently encountered problem in surgical practice; laparoscopic cholecystectomy (LC) is the standard treatment. LC for acute cholecystitis can be a more difficult procedure than elective LC for cholelithiasis and is associated with increased operating time, higher conversion rate, and more postoperative complications. In the elderly patient with comorbidity, surgery can result in serious complications and even mortality. Percutaneous drainage (percutaneous cholecystostomy; PC) may be an alternative treatment. There is no hard evidence in current literature regarding the safety, success rate, and specific technique of this procedure, nor is there consensus on the indications.

AIM: To evaluate the safety and efficacy of PC in treatment of acute calculous cholecystitis in high-risk surgical patients.

METHODS: From January 2009 until May 2010, 101 patients with acute calculous cholecystitis were treated, of whom 27 with PC. Of these 27 patients, comorbidity and American Society of Anesthesiologists (ASA) classification were determined, indication for drainage instead of cholecystectomy was recorded, and procedure-related data were collected. Primary outcomes were overall morbidity, mortality, and recurrent biliary events. Secondary outcomes were time to recovery and need for and difficulty of interval laparoscopic cholecystectomy.

RESULTS: The cohort included 15 male and 12 female patients with median age of 83 years (range 69-90 years). Most patients were ASA 3 (n = 18) or ASA 2 (n = 8); one patient was ASA 4. Indication for drainage was age and/or comorbidity in 24 cases and duration of symptoms in 3 cases. Antibiotic treatment was given in all but seven patients. The drain was in situ for a median period of 19 days (range 5-57 days). Relief of symptoms occurred in 26 patients; drain luxation occurred in nine patients, only in two patients with clinical consequences. Overall mortality rate was 14.8% (n = 4) with a procedure-related mortality rate of 3.7%. Median time to full recovery was 8 days. With median follow-up of 8 weeks, four patients underwent interval cholecystectomy.

CONCLUSIONS: Percutaneous drainage in acute calculous cholecystitis in high-risk patients seems to be a safe and successful treatment option in patients less eligible for surgery. There are many controversies in the current literature, and evidence-based guidelines for the indication of PC in treatment of acute calculous cholecystitis are needed.