H. Mazeh1, I. Mizrahi1, J. Yuval1, G. Almogy1, M. Bala1, N. Abu Ata1, E. Kuchuk1, J. Rachmuth1, A. Nissan1, A. Eid1 1Hadassah-Hebrew University Medical Center,Surgery,Jerusalem, , Israel
Introduction:
The role of percutaneous cholecystostomy (PC) in the management of patients with acute calculous cholecystitis (ACC) remains controversial, and data is limited to small-scale studies. The aim of the present study is to report peri-operative outcomes of a large cohort of patients, managed with PC prior to their cholecystectomy.
Methods:
The hospital Electronic Medical Record (EMR) was searched for all patients underwent delayed cholecystectomy due to ACC, between 2003- 2012. All patients managed by PC prior to surgery were identified. Patient EMR were reviewed to record demographics, clinical presentation at index admission, and during interval period, and operative and post-operative data. Patients who underwent delayed cholecystectomy following ACC without PC during the study period, served as control group.
Results:
During the study period 640 patients underwent delayed laparoscopic cholecystectomy (LC) following ACC at our institution. Of the entire cohort, 163 (25%) patients underwent delayed LC with prior PC insertion and 477 (75%) patients underwent interval LC with no prior PC intervention. Patients in the PC group were older (64±1 vs. 48±0.8, p<0.001), had a higher ASA score (2.02 vs. 1.78, p=0.01), and had significantly more co-morbid conditions (p<0.001). Combined ACC with cholangitis at the index admission was more commonly observed in the PC group (7% vs. 1%, p<0.001). The accumulated length of stay (LOS) for all admissions was significantly longer in the PC group (16.2±0.4 days, vs. 9.7±0.1 days, p<0.001). During the time interval between ACC and LC there were 12% of accidental tube ejection, 4% of peri-tubal leakage, and 8.5% of patients requiring tube re-insertion. Emergency room referrals (30% vs. 8%, p<0.001), as well as re-admission rates (33% vs.12%, p<0.001), within 90 days post-surgery, were higher in the PC group. Laparoscopic to open conversion rate was higher in the PC group (11% vs. 3.7%, p=0.001) and operative time was significantly longer (142±4 minutes vs. 107±4 minutes, p<0.001). Patients in the PC group presented with a higher rate of biliary tract injury (9.2% vs. 2%, p<0.001) and surgical site infections (SSI), both superficial (4.9% vs. 1%, p=0.004), and deep (7.3% vs. 2.9%, p=0.04). Comorbidity related complications were similar between the groups.
Conclusion:
Managing patients with ACC using PC is associated with longer LOS, higher rate of readmissions, and most importantly, higher conversion rate, biliary tract injuries, and SSI.