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GASTROINTESTINAL & ABDOMINAL Table of Contents   
Year : 2003  |  Volume : 13  |  Issue : 3  |  Page : 307-310
Percutaneous cholecystostomy - an alternative to surgery in a high-risk patient with acalculus cholecystitis


Departments of Interventional Radiology & Gastro Intestinal Surgery # Malabar Institute of Medical Sciences Calicut- 673 016, Kerala, India

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Keywords: Percutaneous Cholecystostomy, Acalculus cholecystitis.

How to cite this article:
Ramakrishnan K G, Menon S, Mathew A, Mohan M. Percutaneous cholecystostomy - an alternative to surgery in a high-risk patient with acalculus cholecystitis. Indian J Radiol Imaging 2003;13:307-10

How to cite this URL:
Ramakrishnan K G, Menon S, Mathew A, Mohan M. Percutaneous cholecystostomy - an alternative to surgery in a high-risk patient with acalculus cholecystitis. Indian J Radiol Imaging [serial online] 2003 [cited 2014 Oct 24];13:307-10. Available from: http://www.ijri.org/text.asp?2003/13/3/307/28705

   Introduction Top


Emergency Cholecystectomy in critically ill patients with co-morbid factors is associated with increased mortality and poor treatment outcome. Percutaneous Cholecystostomy (PC) is a relatively safe and effective temporizing procedure in patients with cholecystitis who are at high risk for surgery and anesthesia.


   Case report Top


A 63-year-old diabetic patient with coronary artery disease (ASA IV) was admitted with complaints of right hypochondrial pain, nausea and vomiting of five days duration. He was febrile (Temp 38oC) and abdominal examination revealed a markedly tender mass with guarding and rebound tenderness. Examination of chest revealed features of bilateral basal pneumonitis.

Laboratory investigations showed leucocytosis, raised ESR and elevated blood sugar. Liver function tests and coagulation profile were normal.

US examination showed markedly distended Gallbladder (GB) with oedematous wall. There were no GB calculi. US also revealed fluid in the GB fossa and around the GB, which was consistent with a diagnosis of Acalculus cholecystitis [Figure - 1].

Taking into account the patient's age, underlying coronary artery disease, ongoing sepsis, presence of pneumonitis and delayed presentation, it was felt that an emergency Cholecystectomy under general anesthesia posed a high-risk. Hence it was decided to perform PC as an initial temporizing procedure and consider an interval Cholecystectomy at a later date.

Under US guidance a 22G Chiba needle was introduced into GB through percutaneous transhepatic route [Figure - 2]. Rest of the procedure was carried out under fluoroscopic guidance in the Cath lab.

The initial biliary sample was sent for culture and sensitivity. An Accustick Introducer System (Boston Scientific) was introduced into the GB over a 0.018" guide wire [Figure - 3]. On confirming optimal position within the GB and having ruled out a biliary leak a 0.035" Stiff angled guide wire was introduced into the GB and the track dilated using fascial dilators. This was followed by introduction of 7F pigtail catheter for drainage. Cholecystogram revealed obstruction at cystic duct [Figure - 4],[Figure - 5],[Figure - 6],[Figure - 7].

Patient had remarkable symptomatic improvement within 36 hrs and was afebrile and pain free.

Follow up US a week later revealed complete decompression of the GB with no evidence of calculus [Figure - 8]. A Cholecystogram at this time revealed persistent obstruction at the cystic duct and the findings were confirmed on CT scan [Figure - 9],[Figure - 10]. The pigtail drainage was retained for one more week. Two weeks later the Cholecystogram was repeated, which revealed prompt filling of the biliary ducts and contrast drainage into the duodenum. There was no evidence of calculus either in the GB or in the Common Bile Duct [Figure - 11]. The catheter was removed after confirming the presence of the mature tract. Patient is on follow up and has remained asymptomatic for the last two months.


   Discussion Top


Percutaneous Cholecystostomy (PC) is an image guided Interventional procedure, which involves introduction of a drainage catheter into the GB. In certain clinical situations PC has important clinical applications.

Based on the pathophysiological basis, acute cholecystitis is classified into Acute Calculus Cholecystitis and Acute Acalculus Cholecystitis. Acute cholecystitis is a common condition and the management depends upon the type, imaging findings, clinical condition and institutional experience.

Cholecystectomy is the standard treatment for calculus cholecystitis [1]. However in an acute situation where the patient presents late and has other co-morbid factors this procedure is associated with higher morbidity and mortality. These co-morbid factors include advanced age, respiratory, cardiac, renal or hepatic dysfunction and sepsis with multi organ dysfunction. Emergency Cholecystectomy in these critically ill patients is associated with a reported mortality rate of 4.4%-7.5% [2],[4]. The morbidity of surgical procedures is also quite high with a reported incidence of 13% in the age group of 65-75 years and 18% in patients aged over 75 years [3]. Surgical Cholecystostomy is an option but this still has a mortality rate of 4.2% when performed in an emergency situation with afore mentioned co-morbid factors [5]. PC serves as an effective minimally invasive procedure and provides immediate solution, which helps to stabilize these patients. An elective surgical procedure can be planned at a later date if required. Such a management strategy reduces the risk and complications associated with an emergency Cholecystectomy on these high-risk patients. Acalculus cholecystitis occurs typically in patients who are admitted in intensive care units following conditions such as shock, major surgery, severe burns and patients who are on total parentral nutrition.

PC has a high technical success in the hands of experienced Radiologists. Reported technical success of PC is in the range of 95%-100% [6],[7],[8]. Either US or CT can be utilized as the imaging modality for initial introduction of needle into GB. PC may be performed by either transhepatic or transperitoneal approach. Transperitoneal approach is favoured when GB is adequately distended and in presence of hepatic dysfunction. While transhepatic approach is considered appropriate in presence of ascites in order to minimize biliary leak [10].

PC is a relatively safe procedure with a reported minor complication rate of 4.0%-18.0% [6],[9],[11] such as vagal reaction and catheter dislodgement. Major complications include biliary peritonitis, haemorrhage and intestinal perforation. Van Sonnenberg et al reported major complication rate of 3.9% in a large series of 127 patients [6].

Clinical improvement following PC usually takes 36 to 48 hours. Hatzidakis et al reported a response rate of 87% by the third day following procedure [10].

PC was initially developed as a minimally invasive method of providing GB decompression in elderly and very ill patients with Acute Calculus Choelcystitis, who were unfit for surgery. Over the years, the indications for PC have expanded. Currently PC has application in management of Acalculus Cholecystitis, complication of cholecystitis such as perforation, Empyema, Peri cholecystitic Abscess and also in providing access to GB prior to procedures such as gallstone dissolution and percutaneous cholecystolithotomy. It may also be useful in patients with lower CBD obstruction and non-dilated Intra Hepatic Biliary Radicles who are too ill to be considered for any other procedure.

In select patient population, PC is a safe procedure with a lower complication rate and higher response rate. In high-risk patients who present with acute cholecystitis, unresponsive to medical treatment, PC is a safe and effective temporizing measure, which ensures adequate drainage of the infective material. When this is coupled with appropriate antibiotics it can help to tide over a life-threatening situation. In Acalculus cholecystitis PC is often the definitive treatment.

 
   References Top

1.Nahrwold DL. Acute cholecystitis. In: Sabiston D Jr, ed. Textbook of surgery, 15th ed. Philadelphia: Saunders, 1997:1126-1131   Back to cited text no. 1    
2.Maxwell JG, Tyler BA, Rutledge R, Brinker CC, Maxwell BG, Covington DL (1998) Cholecystectomy in patients aged 80 and older. Am J Surg 176:627-631   Back to cited text no. 2    
3.Firilas A, Duke BE, Max MH (1996) Laparoscopic cholecystectomy in the elderly. Surg Endosc 10:33-35   Back to cited text no. 3    
4.Escarse JJ, Shea JA, Chen W, Qian Z, Schwartz JS (1995) Outcomes of open cholecystectomy in the elderly. A longitudinal analysis of 21,000 cases in the pre-laparoscopic era. Surgery 117:156-164   Back to cited text no. 4    
5.Privalov VA, Shramchenko VA, Gubnitskii AE, Privalov AV (1998) Surgical management of acute cholecystitis in elderly and old age patients. Khirurgiia 7:28-30   Back to cited text no. 5    
6.Van Sonnenberg E, D'Agostino HB, Goodacre BW, Sanchez RB, Casola G (1992) Percutaneous gallbladder puncture and cholecystostomy: results, complications, and caveats for safety. Radiology 183:167-170   Back to cited text no. 6    
7.England RE, McDermott VG, Smith TP, Suhocki PV, Payne CS, Newman GE (1997) Percutaneous Cholecystostomy: who responds? Am J Roentgenol 168:1247-1251   Back to cited text no. 7    
8.Sugiyama M, Tokuhara M, Atomi Y (1998) Is Percutaneous Cholecystostomy the optimal treatment for acute cholecystitis in the very elderly? World J Surg 22:459-463   Back to cited text no. 8    
9.Boggi U, Candio G, Campatelli A, Oleggini M, Pietrabissa A, Filipponi F, Bellini R, Mazzotta D, Mosca F (1999) Percutaneous Cholecystostomy for acute cholecystitis in critically ill patients. Hepatogastroenterology 46:121-125   Back to cited text no. 9    
10.Hatzidakis et al, (2002) Acute cholecystitis in high-risk patients: Percutaneous Cholecystostomy vs conservative treatment Eur Radio 12:1778-1784.   Back to cited text no. 10    
11.Van Overhagen H, Meyers H, Tilanus HW, Jeekel J, Lameris JS (1996) Percutaneous Cholecystostomy for patients with acute cholecystitis and an increased surgical risk. Cardiovasc Intervent Radiol 19:72-76  Back to cited text no. 11    

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Correspondence Address:
K G Ramakrishnan
Department of Interventional Radiology, Malabar Institute of Medical Sciences Calicut- 673 016, Kerala
India
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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11]



 

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