What is the role of percutaneous cholecystectomy (PC) tubes in managing acute cholecystitis?

Role of Percutaneous Cholecystostomy Tubes in Managing Acute Cholecystitis

Percutaneous cholecystostomy (PC) should be reserved for high-risk patients with acute cholecystitis who are deemed unfit for surgery, particularly those over 65 years with ASA III/IV status or septic shock, serving as either definitive management or a bridge to interval cholecystectomy. 1

Patient Selection for Percutaneous Cholecystostomy

Indications for PC

• Primary candidates:
  • Elderly patients (>65 years)
  • High ASA score (III or IV)
  • Poor performance status (3-4)
  • Septic shock
  • Failed medical therapy (antibiotics for 24-48 hours without improvement)
  • Multiple comorbidities making immediate surgery high-risk 1, 2

Risk Factors Associated with PC Utilization

• Advanced age over 65 years
• History of abdominal surgery
• Higher ASA score
• Elevated white blood cell count
• Elevated C-reactive protein levels 1

Clinical Effectiveness

PC is highly effective in the emergency management of acute cholecystitis in high-risk patients:

• Clinical resolution of toxemia within 24-48 hours in 82-92% of patients 1, 3
• Significant reduction in inflammatory markers (leukocytosis, C-reactive protein) and fever 1
• Success rate of 91-100% in reducing inflammatory status and controlling infection 1, 4

Technical Considerations

Approach

• Transhepatic approach is preferred over transperitoneal approach because it:
  • Reduces risk of biliary leak
  • Allows longer drain placement
  • Leads to quicker maturation of drainage tract
  • Decreases risk of portal vessel injury and hollow viscus injuries 1, 5

Procedure

• Can be performed under local anesthesia
• Typically uses 8F-10F pigtail catheters
• Placement guided by ultrasound or CT, with or without fluoroscopic adjunct 3
• Antibiotics should be administered prior to procedure 3

Complications

• Overall complication rate: 3.4-25.9% 1
• Common complications:
  • Bile duct leak and biliary peritonitis
  • Portal or parenchymal vessel injury and bleeding
  • Catheter dislodgement
  • Colon injury
  • Vagal reaction 1
• Transhepatic approach carries risk of pneumothorax and bleeding from liver parenchyma 1

Management After PC Placement

PC as Definitive Treatment

• 35-72% of patients may not require further treatment after PC 1, 3
• In patients with severe comorbidities, tubes can be safely left in place with low complication rates 3
• Among patients treated with PC alone, only 12.9% develop recurrent biliary sepsis after tube removal 5
• Recurrent episodes typically occur within 6 months of initial presentation 5

PC as Bridge to Surgery

• PC should be considered as a bridge to cholecystectomy in high-risk patients to convert them to moderate-risk patients more suitable for surgery 1
• After clinical improvement, interval cholecystectomy can be performed under better conditions 1
• Laparoscopic cholecystectomy is possible in 81.2% of cases following PC 1
• Important consideration: Subsequent surgery may be more technically challenging due to:
  • Adhesions
  • Gallbladder wall thickness
  • Tendency for bleeding
  • Difficulty identifying anatomical structures 1

Tube Management

• Median duration of tube placement: approximately 3 months 5
• Patients may require multiple tube changes/replacements during treatment (median of 2) 5
• Tubes can be safely removed once gallstones are cleared 3
• Stone size ≥1cm is associated with higher recurrence of acute cholecystitis if cholecystectomy is not performed 4

Outcomes and Survival

• In-hospital mortality: 12.3-36%, reflecting severity of underlying conditions rather than procedure-related complications 3, 4
• Shock on admission is an independent risk factor for in-hospital death 4
• No significant difference in 1-year and 3-year overall survival between patients who undergo subsequent cholecystectomy versus those who don't (82% vs 81% and 59% vs 63%, respectively) 4

Important Caveats

• PC should not be the first-line treatment for most patients with acute cholecystitis
• A randomized trial showed higher rates of postprocedural complications with PC (65%) compared to laparoscopic cholecystectomy (12%) 6
• The role of PC in acute cholecystitis is still not entirely clear, with ongoing trials (like the CHOCOLATE trial) potentially providing more definitive information 1
• PC should be used selectively in patients truly unfit for surgery rather than as a routine alternative to cholecystectomy 2

In summary, PC is a valuable option for managing acute cholecystitis in high-risk patients, either as a bridge to surgery or as definitive management in those who remain poor surgical candidates. The decision should be based on patient risk factors, with the transhepatic approach preferred for better outcomes.