Percutaneous cholecystotomy in acute cholecystitis

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Percutaneous cholecystotomy in acute cholecystitis. 27-7-2013 JHGR. Treatment of acute cholecystitis. Emergency cholecystectomy Convervative treatment with interval cholecystectomy Percutaneous cholecystotomy - PowerPoint PPT Presentation

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  • Percutaneous cholecystotomy in acute cholecystitis27-7-2013JHGR

  • Treatment of acute cholecystitisEmergency cholecystectomyConvervative treatment with interval cholecystectomyPercutaneous cholecystotomy

    In elderly patients with AC and a low operative risk, CCY carries a 10% operative mortality rate, which increases by 3-fold in patients with a high operative risk.Rates of conversion from laparoscopic to open CCY for AC (11%-28%) compared with those for elective CCY (5%).

    1. Keus F, Gooszen HG, van Laarhoven CJ: Open, small-incision, or aparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis. An overview of Cochrane Hepato-Biliary Group reviews. Cochrane Database Syst Rev 2010, 20(1):CD008318.2. Pessaux P, Regenet N, Tuech JJ, Rouge C, Bergamaschi R, Arnaud JP: Laparoscopic versus open cholecystectomy: a prospective comparative study in the elderly with acute cholecystitis. Surg Laparosc Endosc Percutan Tech 2001, 11:252-255.3. Bingener J, Richards ML, Schwesinger WH, Strodel WE, Sirinek KR: Laparoscopic cholecystectomy for elderly patients: gold standard for golden years? Arch Surg 2003, 138:531-535.4. Decker G, Goergen M, Philippart P, Mendes da CP: Laparoscopic cholecystectomy for acute cholecystitis in geriatric patients. Acta Chir Belg 2001, 101:294-299.5. Kirshtein B, Bayme M, Bolotin A, Mizrahi S, Lantsberg L: Laparoscopic cholecystectomy for acute cholecystitis in the elderly: is it safe? Surg Laparosc Endosc Percutan Tech 2008, 18:334-339.6. Winbladh A, Gullstrand P, Svanvik J, Sandstrom P: Systematic review of cholecystostomy as a treatment option in acute cholecystitis. HPB (Oxford) 2009, 11:183-193.7. Brunt LM, Quasebarth MA, Dunnegan DL, Soper NJ: Outcomes analysis of laparoscopic cholecystectomy in the extremely elderly. Surg Endosc 2001, 15:700-705.8. Kauvar DS, Brown BD, Braswell AW, Harnisch M: Laparoscopic cholecystectomy in the elderly: increased operative complications and conversions to laparotomy. J Laparoendosc Adv Surg Tech 2005, A 15:379-382.

  • Percutaneous cholecystotomyfirst described by Radder in 1980immediate decompression of the acutely inflamed gallbladder diagnostic tool in patients with unexplained sepsis. Cholecystostomy drainage can even be performed at the bedside in the intensive care unit (ICU) in critically ill patients.

  • Absolute contraindications to PCInterposed bowel preventing access to the gallbladdersevere bleeding diathesis

  • Relative contraindications for PCdecompressed gallbladder due to perforationgallbladder completely packed with calculiGallbladder cancer

  • Currrent evidence

    How to perform When to perform Who to perform

  • How to performSector probe, 5-8MHz probeSubcostal/ intercostalTranshepatic/ transabdominalSedation and analgesiaPuncture technique: seldinger versus trocarimage confirmation of the placement of the catheter within The gallbladderlocking pigtail drain fixed to the skin with suture or adhesive dressing

  • Transhepatic VS transperitoneal

  • Post procedural careAntibioticsDaily flush with 10ml NSCholecystogram: patency, position, gall stoneTract maturation: ~2/52Removal: 1mth after trial of spigot/ clamp drainRecurrence rates of calculus cholecystitis are as high as 46% at 3-years

  • OutcomeSuccessful rate >90%Successful clinical response: 85.6% (1498/1751)Median time to clinical improvement:3 daysAcute complications: haemorrhage, sepsis (either exacerbation or de-novo), vasovagal reactions, bile leak, bowel perforation, and pneumothorax. (3%)Catheter migration is the most common complication, in 8.6% (98/1144) of patientsMortality resulting from biliary infection is 3.6% (64/1768), and directly resulting from PC as 0.4% (7/1861 patients).30days mortality rates from PC :1-25%, compares to a mortality rate of 0.96% (5/523) for patients undergoing elective surgical cholecystectomy, and 13% (7/54) patients post-emergency surgery.Lack of prospective, randomized, controlled trials limits the ability to define its specific role

    Winbladh A, Gullstrand P, Svanvik J, et al. Systematic review of cholecystostomy as a treatment option in acute cholecystitis. HPB (Oxford) 2009;11:183e93Chang L, Moonka R, Stelzner M. Percutaneous cholecystostomy for acute cholecystitis in veteran patients. Am J Surg 2000;180:198e202. 56. Avrahami R, Badani E, Watemberg S, et al. The role of percutaneous transhepatic cholecystostomy in the management of acute cholecystitis in high-risk patients. Int Surg 1995;80:111e4

  • When to perform2009 Cochrane review :no level A or level B evidence to support the use of PC over CCY in AC.53 studies, 1918 patients significantly higher 30-day mortality rate after PC (15.4%) compared with CCY (4.5%) (P
  • PC VS SurgeryRevisiting Percutaneous Cholecystostomy for Acute Cholecystitis Based on a 10-Year Experience Youmna Abi-Haidar, MD; Vivian Sanchez, MD; Sandra A. Williams, MS; Kamal M. F. Itani, MD Arch Surg. 2012;147(5):416-422Design: Retrospective cohort study.

    Patients: All consecutive patients with AC per the Tokyo criteria who underwent PC or CCY from January 1, 2001, through December 31, 2010.

    Main Outcome Measures: Differences in baseline characteristics and outcomes between PC and CCY patients, odds of PC vs CCY use, and odds of death after PC or CCY.

  • ConclusionPC should be reserved for patients with prohibitive risks for surgery, irrespective of the severity of AC or the risk of conversion from laparoscopic to open CCY. Targeted investigations into operative risk stratification models for AC patients are warranted.

  • PC VS conservative treatmentHatzidakis AA, Prassopoulos P, Petinarakis I, Sanidas E, Chrysos E, Chalkiadakis G, et al. Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment. Eur Radiol 2002;12(7):1778e84.60 patients (42 with calculous and 18 with acalculous cholecystitis): conservative treatment,63 patients (44 with calculous and 19 with acalculous cholecystitis) :PC.APACHE II score of >=12Tubes were successfully placed in 60 of the 63 patients (95%) in the PC group, 54 patients (86%) had clinical resolution of cholecystitis7 had surgery due to tube dislodgement (3 patients), persisting symptoms (3 patients), or after unsuccessful PC (1 patient). 30-day mortality in the PC group: 18%.

  • PC VS conservative treatmentHatzidakis AA, Prassopoulos P, Petinarakis I, Sanidas E, Chrysos E, Chalkiadakis G, et al. Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment. Eur Radiol 2002;12(7):1778e84.conservative group: successful resolution of symptoms in 52 of 60 patients (87%) 30-day mortality rate: 13% (8 patients).no significant difference in mortality between the two groupsConclusion: PC did not reduce mortality compared to conservative treatment of cholecystitis. PC should be reserved for those who fail to improve with conservative treatment initially ~3 days

  • Haemodialysis patientsan independent risk factor for developing acute cholecystitisincidence of acute cholecystitis being 5.8 per 1000 patient-years in the ESRD patients, compared with 0.92 per 1000 patient-years in the control groupMortality rates of up to 70% following emergency abdominal surgery in haemodialysis patientsretrospective study showed 100% technical success, and 79% clinical success in 11 out of 14 chronic HD patients with ASA grade IV, treated with PC for acute cholecystitis, with a mean follow-up time of 13.3 (4-21) months

    Chen Y-T, Ou S-M, Chao P-W, et al. Acute cholecystitis in end-stage renal disease patients: a nation-wide longitudinal study. Dig Liver Dis 2012. 8. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373e83.

  • ICU patients, acalculous cholecystitisacalculous cholecystitis, which accounts for 2-14% of all cases of acute series of 57 patients with acute acalculous cholecystitis, PC was technically successful in all patients, with symptomatic resolution within 4 days in 93%. Of the 28 patients managed with PC as the definitive treatment, cholecystostomy tubes were removed within a median period of 51 days. Recurrent acute cholecystitis occurred in 7% (2/28) over a median follow-up of 32 months

    Hamp T, Fridrich P, Mauritz W, et al. Cholecystitis after trauma. J Trauma 2009;66:400e6. Pelinka LE, Schmidhammer R, Hamid L, et al. Acute acalculous cholecystitis after trauma: a prospective study. J Trauma 2003;55:323e9.Theodorou P, Maurer CA, Spanholtz TA, et al. Acalculous cholecystitis in severely burned patients: incidence and predisposing factors. Burns 2009;35:405e11.

  • Pregnancygallstones: 1-3% of patientsAcute cholecystitis in pregnancy traditionally managed conservatively, leading to prolonged treatment, anxiety, and multiple hospital admissionsas a temporizing measure until elective cholecystectomy post-partumfirst or final trimester treated with less invasive procedures, i.e percutaneous techniques, enabling elective cholecystectomy in the safe second trimester, or post-partum, cholecystectomy

    Dietrich 3rd CS, Hill CC, Hueman M. Surgical diseases presenting in pregnancy. Surg Clin North Am 2008;88:403e19. viieviii.

  • Who to performvascular surgeons with endovascular skills clinical records of all high-risk patients who underwent PC placement by surgeons (group A; n 22) for acute cholecystitis were reviewed. Treatment outcomes were compared with patients who underwent PC by interventional radiologists (group B; n 26).

    Percutaneous cholecystostomy for acute cholecystitis in high-risk patients: experience of a surgeon-initiated interventional programEric J. Silberfein, M.D., Wei Zhou, M.D., Panagioti