Long‐term outcome and recurrence factors after percutaneous cholecystostomy as a definitive treatment for acute cholecystitis

Abstract

Background and Aim Percutaneous cholecystostomy (PC) has been frequently used as an alternative treatment for acute cholecystitis in seriously ill patients unfit for surgery. The aim of this study was to investigate the recurrence rate and risk factors of recurrence. Methods Medical records of 102 patients who were followed up for more than 1 year after PC tube removal among 716 patients who underwent PC for acute cholecystitis treatment were retrospectively analyzed. Results The recurrence rate of acute cholecystitis after PC tube removal was 20.6% (21/102), and the mean time to recur was 660 days. Underlying cancer (odds ratio [OR]: 3.369; 95% confidence interval [CI]: 1.006–11.282; P = 0.0489), PC duration shorter than 44 days (OR: 5.596; 95% CI: 1.35–23.201; P = 0.0176), and the presence of common bile duct stone in initial imaging studies (OR: 24.393; 95% CI: 2.696–220.746; P = 0.0045) were positively correlated with recurrence. Tubogram before PC tube removal did not significantly lower the recurrence. However, PC tube clamping for several days significantly lowered the recurrence (OR: 0.108; 95% CI: 0.015–0.794; P = 0.0288). Fifty‐nine (57.8%) had acalculous cholecystitis. Calculous cholecystitis was negatively correlated with recurrence (OR: 0.267; 95% CI: 0.074–0.967; P = 0.0444). Receiver operating characteristic curve of the prediction model for recurrence verified its accuracy (area under the curve: 0.8475). Conclusion We should try to keep PC more than 6 weeks and clamp for 1–2 weeks before removal. For those with the presence of common bile duct stones, calculous cholecystitis, and underlying malignancy, we should keep PC for longer duration and carefully observe symptoms and signs of recurrence.

Management of Patients With Acute Cholecystitis After Percutaneous Cholecystostomy: From the Acute Stage to Definitive Surgical Treatment

“…In addition, an animal experiment revealed that biofilms on PC tubes could also contribute to another episode of cholecystitis (42,43). The clinical factors that could impact the recurrence of biliary disease have also been investigated, such as complicated cholecystitis, elevated CRP, and duration of PC catheter maintenance (28,37,44,45). All of this evidence supports interval cholecystectomy as the first choice after PC placement if the patients can tolerate surgery.…”

“…Prior to removing the PC tube, we suggest performing a clamping test. While there is no standardized clamping test, patients should be able to tolerate continuous clamping for at least 24-48 h (24,45,61). During the clamping period, there should be no symptoms and signs of recurrence; otherwise, the drainage tube cannot be removed.…”

“…Some physicians considered patency to be defined as no obstruction of cystic duct and common bile duct with illustration of duodenum, others considered patency to be defined as non-obstructed cystic ducts, which mainly focus on the outlet of gallbladder (15,24,32,44,61,74). A patent bile duct is important because residual choledocholithiasis in the biliary tree is a potential risk factor for recurrent cholecystitis (12,45). For AC patients with PC placement, cholangiography was commonly utilized during the follow-up period or when concerning the removal of PC tubes.…”

“…Loftus et al conducted a retrospective study focusing on patients who underwent routine surveillance cholangiography and patients who underwent on-demand cholangiography and revealed that patients who underwent on-demand cholangiography were associated with early PC tube removal and early cholecystectomy, but both groups had similar recurrence rates (76). Furthermore, Park et al indicated that cholangiography was not associated with a lower recurrence rate, while the use of a clamping test was a protective factor associated with a lower incidence of recurrent AC (45). In our opinion, since the clamping test may lower the recurrence rate of AC after tube removal, applying the clamping test as a screening tool prior to cholangiography may be a novel approach in patients suitable for PC tube removal (Figure 2).…”

The Need for Accurate Risk Assessment in a High-Risk Patient Population: A NSQIP Study Evaluating Outcomes of Cholecystectomy in the Patient With Cancer

“…In a study of 102 patients with acute cholecystitis managed with percutaneous biliary drainage, Park and colleagues found an overall recurrence rate of 20.6% with median recurrence time of 660 d. In patients with cancer, the recurrence rate was 42.9%, with multivariate analysis revealing an odds ratio of 3.4 (95% CI, 1.0-11.28, P ¼ 0.05). 37 Cancer conferred a higher risk of recurrence with percutaneous drainage, but with a median recurrence time of more than a year, this may present a viable option for patients undergoing treatment for their malignancy or in the late stages of their disease. Endoscopic gallbladder drainage, whether it be retrograde cholangiography with transpapillary drainage (ETC) or ultrasound-guided cholecystostomy (EUSC), represents another therapeutic option for immediate source control in cholecystitis.…”