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Clinical Audit Clinical Audit

onon

EmergencyEmergency Percutaneous CholecystostomyPercutaneous Cholecystostomy

Interventional Radiology DivisionDepartment of Diagnostic RadiologyPamela Youde Nethersole Eastern Hospital

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OverviewOverview

BackgroundPercutaneous Cholecystostomy (PCC)Objectives of AuditResultsDiscussion

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BackgroundBackground

Acute cholecystitisManagement

Conservative vs. OperativeCholecystectomy vs. Percutaneous Cholecystostomy

Overseas experience Technical success rate (97-100%)Effectiveness (90-94%)Complication rate (3.3-16%)

Local experienceLi JC, Lee DW, Lai CW, Li AC, Chu DW, Chan AC. Percutaneous cholecystostomy for the treatment of acute cholecystitis in the critically ill and elderly. Hong Kong Med J. 2004 Dec;10(6):389-93.

RRAADDIIOOLLOOGGYY Schematic Diagram of PCC

Liver

GB

Chest Wall

Percutaneous CholecystostomyPercutaneous Cholecystostomy(PCC)(PCC)

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Percutaneous CholecystostomyPercutaneous Cholecystostomy

Indications:Critically ill or elderly patients with calculouscholecystitisAcute acalculous cholecystitis

Local AnesthesiaTechniques

Transhepatic approachTransperitoneal approach

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Ultrasound Guided Ultrasound Guided TranshepaticTranshepatic Puncture of Puncture of the the InflammedInflammed GallbladderGallbladder

GB

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CholecystogramCholecystogram

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Percutaneous CholecystostomyPercutaneous Cholecystostomy

Complication:Bile leakage resulting in peritonitisVagal effect of catheter placement (bradycardiaand hypotension)Hemobilia (usually transient and self-limiting)Mortality 3-36%

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Objectives of AuditObjectives of Audit

To assess the clinical parameters of the patients undergoing percutaneous cholecystostomy. To evaluate the technical aspects of percutaneous cholecystostomy. To follow up the patients after percutaneous cholecystostomy.

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Material & MethodsMaterial & Methods

Retrospective ReviewSelection criteria

All patients who underwent PCC from 01.06.2003 to 31.05.2005

Data retrieved from CMS and RIS

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Data CollectionData CollectionDemographics

AgeGenderDate & time of procedure

Clinical parametersAbdominal painBody temperatureHemodynamic StabilityBilirubin levelWCCPlatelet countINRRadiological diagnosis by modalityTime between radiological exam and PCC

Technical parametersImaging guidanceApproachCalibre of puncture needleUse of Exchange catheterSize of Fascial dilatrosDrainage catheter usedAnchorage of the catheterFentanyl usageTime of procedure

ResultTechnical resultBile cultureDeathTime between mortality and PCCComplicationBlood tests after PCCDuration of hospital stayOperation (Cholecystectomy)Time between operation and PCC

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DemographicsDemographics

Total 46 patients (M:F = 22:24) Mean age = 79.6 years (median = 80.0 years).

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Clinical PresentationClinical Presentation

58.7

78.2

33.3

79.3

100.0

0 25 50 75 100

Elevated Bilirubin

Elevated WCC

Septic Shock

Fever

Pain

Percentage

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Radiological Diagnosis by ModalityRadiological Diagnosis by Modality

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Technical Aspects of Technical Aspects of Percutaneous Percutaneous CholecystostomyCholecystostomy

All procedures performed under ultrasound and fluoroscopic guidance Transhepatic approach - 34 patients (73.9%) Transperitoneal approach - 6 patients (13.0%)Time of procedure (mean = 27minutes)

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ResultsResults

Technically successful PCC in 100%Positive bile culture in 32/45 (71.1%)Rapid clinical improvement in 41/46 patients (89.1%)Duration of hospital stay - 15 days (median) Elective cholecystectomy performed in 11 patients (23.9%).

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Result Result -- ComplicationComplication

Catheter displacement: 3 patients (6.5%).

1 Reinsertion 2 Treated conservatively

Time of occurenceBetween 3 days – 1 week in 1patient> 1 week in 2 patients

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Result Result -- MortalityMortality

Deaths in 6 patients (10.5%) and all are not related to the procedureUncontrolled sepsis in 2 patients

Patient 1 (M/65)Refused cholecystectomyKlebsiella (Resistant to Ampicillin, Cefazolin, Cefoxitin Cefuroxime)Given Tazocin, Metronidazole

Patient 2 (M/79)Disseminated intravascular coagulopathy at presentation

Other medical conditions in 4 patients

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Discussion: ComparisonDiscussion: Comparison

28%Median 22d

20%16%(minor)

92%100%25Li

90%

94%

90%

89.1%

Clinical Response

30

16

65

46

No. of Patients

90%--3.3%(minor)

100%Ito

44%-18%18%(1 major)

94%Teoh

15.3%Mean 15d13.8%No major ones

97%Welschbillig

23.9%Median 15d

10.5%6.5%(minor)

100%PYNEH

Elective cholecystec-

tomy

Duration of stayDeathsComplicationTechnical

ResultAuthors

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ConclusionConclusion

Our results are comparable with overseas and local data.Percutaneous Cholecystostomy is a safe and effective treatment of acute cholecystitis with high success and low complication rates. It can also minimize the morbidity and mortality relating to the complications from emergency operation on those critically ill patients, as cholecystectomy can be arranged on an elective basis after the patient's condition improves.

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ReferencesReferences

Li JC, Lee DW, Lai CW, Li AC, Chu DW, Chan AC. Percutaneous cholecystostomy for the treatment of acute cholecystitis in the critically ill and elderly. Hong Kong Med J. 2004 Dec;10(6):389-93.Welschbillig-Meunier K, Pessaux P, Lebigot J, Lermite E, Aube Ch,Brehant O, Hamy A, Arnaud JP. Percutaneous cholecystostomy for high-risk patients with acute cholecystitis. Surg Endosc. 2005 Sep;19(9):1256-9. Epub 2005 Jul 14.Teoh WM, Cade RJ, Banting SW, Mackay S, Hassen AS. Percutaneous cholecystostomy in the management of acute cholecystitis. ANZ J Surg. 2005 Jun;75(6):396-8. Ito K, Fujita N, Noda Y, Kobayashi G, Kimura K, Sugawara T, Horaguchi J. Percutaneous cholecystostomy versus gallbladder aspiration for acute cholecystitis: a prospective randomized controlled trial. AJR Am J Roentgenol. 2004 Jul;183(1):193-6.