Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment

Abstract

Our objective was to compare the effectiveness of percutaneous cholecystostomy (PC) vs conservative treatment (CO) in high-risk patients with acute cholecystitis. The study was randomized and comprised 123 high-risk patients with acute cholecystitis. All patients fulfilled the ultrasonographic criteria of acute inflammation and had an APACHE II score > or =12. Percutaneous cholecystostomy guided by US or CT was successful in 60 of 63 patients (95.2%) who comprised the PC group. Sixty patients were conservatively treated (CO group). One patient died after unsuccessful PC (1.6%). Resolution of symptoms occurred in 54 of 63 patients (86%). Eleven patients (17.5%) died either of ongoing sepsis (n=6) or severe underlying disease (n=5) within 30 days. Seven patients (11%) were operated on because of persisting symptoms (n=3), catheter dislodgment (n=3), or unsuccessful PC (n=1). Cholecystolithotripsy was performed in 5 patients (8%). Elective surgery was performed in 9 cases (14%). No further treatment was needed in 32 patients (51%). In the CO group, 52 patients (87%) fully recovered and 8 patients (13%) died of ongoing sepsis within 30 days. All successfully treated patients showed clinical improvement during the first 3 days of treatment. Percutaneous cholecystostomy in high-risk patients with acute cholecystitis did not decrease mortality in relation to conservative treatment. Percutaneous cholecystostomy might be suggested to patients not presenting clinical improvement following 3 days of conservative treatment, to critically ill intensive care unit patients, or to candidates for percutaneous cholecystolithotripsy.

Improving the outcome of acute cholecystitis: the non-standardized treatment must no longer be employed

“…In the therapeutic algorithms of these same guidelines, biliary drainage is recommended for patients with grade II and III acute cholecystitis and high surgical risk [35][36]. Some authors recommend grading acute cholecystitis and employing the ASA, POSSUM, P-POSSUM, APACHE II classification system or other anesthetic risk scales in patients with moderate-severe acute cholecystitis who are at high risk (ASA> 3, APACHE> 12), as their morbidity is higher, and their mortality surpasses 15% [37][38][39]. In critically ill patients, although percutaneous gallbladder drainage is recommended due to its clinical efficacy and simplicity, the morbidity associated with this procedure is high.…”

Akutno vnetje žolčnika – zgodnja operacija ali poskus konzervativnega zdravljenja?

“…6. trombocitopenija (< 100.000/mm3). strokoVni čLanek akutnim holecistitisom povišane vnetne kazalce (levkocitoza, povišan C-reaktivni protein, CRP), medtem ko so pri bolnikih z napadom biliarnih kolik vnetni kazalci praviloma v mejah normalnih vrednosti (3,4,16). Od slikovnih preiskav pride v prvi vrsti v poštev ultrazvočni pregled (UZ) trebuha.…”

“…obolevnosti in umrljivosti pri starejši populaciji, pri sladkornih bolnikih in nosečnicah (3). Dejavniki, ki so povezani z nastankom žolčnih kamnov, so debelost, starost in določena zdravila, predvsem peroralna kontracepcijska sredstva (4).…”

“…Pri teh bolnikih je še toliko bolj pomembno zgodnje diagnosticiranje in čimprejšnje kirurško zdravljenje, kolikor splošno stanje bolnika to dopušča (5). Zgodnja holecistektomija pri teh bolnikih zmanjša zaplete ob in po operaciji ter možnost ponovitve v primeru konzervativnega zdravljenja (3). Zgodnja laparoskopska holecistektomija se priporoča tudi pri starejših bolnikih, ker je sorazmerno varna s sprejemljivim tveganjem za zaplete po posegu.…”

Bile Aspiration for Diagnosis of Candida glabrata Cholecystitis

“…In our case percutaneous cholecystostomy not only demonstrated the double yeast infection but also in addition at least partially cured the local infection. Recently, a study compared percutaneous cholecystostomy with surgery in high-risk patients with acute cholecystitis, demonstrating a low rate of complications [14].…”