Mena Boules, MD, Ivy Haskins, MD, Mario Farias-Kovac, MD, Daniel Guerron, MD, David Schechtman, MD, Michael Samotowka, MD, Gordon McLennan, MD, R. Matthew Walsh, MD, Gareth Morris-Stiff, MD. Cleveland Clinic
Introduction: Cholecystectomy is the preferred management option for acute cholecystitis, with percutaneous cholecystostomy (PC) considered a viable option in high-risk patients. The aim of this study was to evaluate the efficacy and outcomes of PC in a tertiary referral center.
Methods: We retrospectively reviewed all patients that had undergone PC from 2000 to 2012. Data collected included baseline demographics, co-morbidities, details of PC placement and management, and post-procedure outcomes. Additionally, we calculated the age adjusted Charlson comorbidity index (CCI) for all patients.
Results: A total of 183 patients received a PC consisting of 88 (48%) females, and 95 (52%) males. The mean age and CCI were 68.0 ± 14.3 years, and 5.4 ± 2.2 respectively. A total of 68 (37%) patients underwent cholecystectomy after a mean duration of 118 ± 110 days following PC. Mean age, and CCI of cholecystectomy patients were 63.0 ± 14.5 years, and 4.4 ±2.6 respectively, both of which were significantly less (p< 0.0001) than the remainder of the patients. 19 (28%) patients underwent early (<30 days) cholecystectomies, and 49 (72%) patients that underwent late (>30 days) cholecystectomy. Surgical indications for all patients include calculous cholecystitis (n= 37, 54%), acalculous cholecystitis (n=26, 38%), gangrenous (n=3, 4%), and gallbladder obstruction (n=2, 2.8%). 38 (56%) patients underwent a laparoscopic approach, and the remaining 30 (44%) patients underwent primary open procedures.
In addition to those having PC removed at time of cholecystectomy 55 patients had elective removal of their PC. The mean age and CCI was 70 ± 14.0 years, and 5.8 ± 2.8 respectively. Only 9 (16%) patients had recurrence of symptoms post-PC removal. Mean age, and CCI of patients with recurrence was 68 ± 17.5 years, and 5.2 ± 3.0 respectively. 5/9 (55.5%) patients underwent cholecystectomy (n=3 laparoscopic; n=2 open primary), 2 (22%) received a second PC, and the remaining 2 (22%) patients underwent ERCP with sphincterotomy for relief of extra-biliary complications (pancreatitis, jaundice).
For 60 patients, PC was definitive therapy for their cholecystitis. This group was significantly older (Mean age: 72.3 ± 13 years) and had higher CCIs (Mean CCI: 6.4 ± 2.25), which were significantly less (p< 0.05) than the operated or tube removal groups.
Conclusion: After stabilization of acute medical conditions 37% of patients underwent cholecystectomy, and 30% had planned removal of the PC with only 16% requiring further intervention. For frail patients not suitable for cholecystectomy, PC is an effective therapy.