M. N. Bhatt1, M. Ghio1, L. Sadri1, S. Sarkar1, G. Kasotakis1, C. Nasrsule1, B. Sarkar1 1Boston Medical Center,Department Of Trauma And Acute Care Surgery,Boston, MA, USA
Introduction: Acute cholecystitis (AC) is a common acute illness, with the preferred treatment being cholecystectomy. However, in high-risk patients, a less invasive option of percutaneous cholecystostomy tube placement (PC) is preferable. Patients can subsequently either undergo interval cholecystectomy (IC) or PC can be utilized as definitive treatment. Currently, there is little evidence to guide patient care after PC. We sought to demonstrate the clinical outcomes of PC and identify the predictors of recurrent disease as well as successful IC.
Methods: A retrospective chart review of patients undergoing PC for AC between 2008 and 2016 at a single tertiary care center was performed. Basic patient demographics, laboratory & imaging findings, and patient outcomes including mortality, readmissions, hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, recurrence, and IC were collected. Univariate and multivariate analyses were performed using logistic regression, Wilcoxon Rank, and multi-variable logistic regression models.
Results: Of 145 patients, 96 (67%) had calculous and 47 (33%) had acalculous cholecystitis. PCs were performed in these patients due to their high preoperative risks; 72 (49%) had chronic prohibitive risks and 73 (51%) had acute prohibitive risks. There were 55 (38%) peri-procedural complications, 44 of which were PC dislodgment. Mean duration of PC was 93 days. Recurrence rate for AC was 18%; median duration to recurrence was 65 days. Patients with calculous cholecystitis were more likely to have AC recurrence (OR = 3.24, p = 0.018), whereas length of antibiotics course or duration of PC had no significant correlation with AC recurrence. 41 (28%) patients underwent IC. Patients with acute prohibitive risks and shorter antibiotics course (≤ 7 days) were more likely to undergo IC (OR = 6.66 & 2.10, p = <0.001 & 0.048), and most were completed laparoscopically (OR = 6.84, p = <0.0001). There were only two peri-operative complications and no peri-operative mortality. Mean hospital and ICU LOS were longer for patients with acalculous cholecystitis compared to calculous (22 vs. 11 days, p = <0.0001). 30-day readmission rate was 29%. Patients with acalculous cholecystitis had higher 30-day readmission rate (OR = 2.42, p = 0.020). 30-day mortality after PC was 9%. The follow up was for 26(3-53) months and survival analysis revealed that patients receiving IC had greater survival compared to PC as a definitive option.
Conclusion: PCs are a viable option for high-risk patients with AC. Calculous cholecystitis is a strong predictor of AC recurrence after PC. A longer (>7 days) antibiotics course is not associated with lower recurrence and should be avoided. Patients undergoing IC have better overall survival. PCs, although safe, should not be considered as a definitive treatment, especially in patients with acute critical illness where a successful IC can be performed laparoscopically with minimal complications.