Percutaneous cholecystostomy for acute cholecystitis in high-risk patients

Seventeen high-risk critically ill patients with suspected cholecystitis underwent percutaneous transhepatic cholecystostomy between 1981 and 1986 using Hawkins' needle guide system for gallbladder intubation. Acute cholecystitis was documented in 15 patients, including 1 with common bile duct obstruction. Two other patients had common bile duct obstruction secondary to metastatic cancer (one patient) and chronic pancreatic fibrosis (one patient). There was rapid resolution of the signs and symptoms of cholecystitis, sepsis, or both in 16 of the 17 patients. One critically ill patient with positive findings on blood culture and an organism resistant to triple antibiotic therapy died soon after percutaneous cholecystostomy. In the entire group of 17 patients, there was no evidence of bile leaks or other catheter complications. Six patients subsequently underwent successful cholecystectomy and two underwent common bile duct exploration without complications. One patient underwent cholecystojejunostomy, and in three patients, the catheter was removed with no sequelae of cholecystitis. Two remaining patients had the catheter in place and were awaiting operation at last follow-up. Three of four patients who died within 30 days of percutaneous transhepatic cholangiographic cholecystostomy died either from the terminal malignant condition (two patients) or from arrhythmia (one patient with cirrhosis). This review suggests that percutaneous cholecystostomy is a safe and effective procedure for resolving acute cholecystitis in high-risk patients. In addition, the technique of percutaneous transhepatic cholangiographic cholecystostomy appears well suited for percutaneous dissolution of stones, sclerosis of the gallbladder, or both in selected high-risk critically ill patients.     

Percutaneous cholecystostomy in acute cholecystitis in high-risk patients: an analysis of 69 patients

BACKGROUND: Optimal treatment of acute cholecystitis in high-risk patients with acute cholecystitis continues to be a difficult therapeutic problem. With the development of more advanced radiological imaging techniques, percutaneous cholecystostomy (PCS) has been presented as an effective treatment alternative in critically ill patients. This paper reports our experiences of percutaneous cholecystostomy in the treatment of acute cholecystitis in a well defined high-risk patient group. METHODS: The data concerning 69 high-risk patients with acute cholecystitis treated by percutaneous cholecystostomy in Oulu University Hospital and Kokkola Central Hospital were analyzed. RESULTS: Ultrasound showed gallbladder stones in 71% (49/69) of the patients and 29% of them presented with acalculous cholecystitis. After PCS, pain diminished in 94% (61/65), fever in 90% (35/39), CRP values in 87% (53/61) and leucocyte count in 84% (46/55) of the patients. Before PCS, the CRP value was 132+/-106 mg/l and after PCS 79+/-73 mg/l (P = 0.001) and corresponding leucocyte counts were 14.7+/-5.0 and 9.3+/-3.2 (P = 0.001), respectively. The antegrade cholecystocholangiography was performed in 29 patients after PCS, and common bile duct stones were detected in 8 patients; these stones were treated by endoscopic papillotomy. Complications after PCS occurred in 17 patients (26%), but only two patients required emergency laparotomy. Mortality was 19% (13/69). Acute cholecystitis alone was the cause of death in only three patients. Mostly, fatal outcome was caused by the serious underlying diseases. CONCLUSION: According to our results, PCS should be the method of choice in high-risk patients with acute cholecystitis.     

Ultrasound-guided percutaneous transhepatic cholecystostomy for acute acalculous cholecystitis

Ultrasound-guided percutaneous transhepatic cholecystostomy was performed in six critically ill patients who had acute acalculous cholecystitis. The clinical conditions of all six patients improved dramatically following transhepatic cholecystostomy. No complications of this bedside procedure occurred. Cholangiography via the inserted pigtail catheter was normal in four patients. Their catheters were removed after ten to 21 days. At follow-up examinations at four to 30 months they were free of signs of gallbladder disease. In one patient, ultrasonography showed desquamation of the mucosa in the gallbladder, which led to the decision to perform cholecystectomy two days after cholecystostomy. One patient, suffering from cholangiocarcinoma, died 120 days after cholecystostomy with the catheter in situ. In our experience, ultrasound-guided percutaneous transhepatic cholecystostomy is the treatment of choice to overcome a critical period in patients with acute acalculous cholecystitis. When post-drainage cholangiography is normal, cholecystectomy at a later stage is not indicated in the majority of these patients.     

Ultrasound-guided percutaneous cholecystostomy in high-risk surgical patients

BACKGROUND AND AIMS: In critically ill patients, cholecystectomy is associated with a high mortality rate. The aim of this study was to evaluate the safety, efficacy and long-term outcome of ultrasound-guided percutaneous cholecystostomy (USGPC) in critically ill patients with acute cholecystitis. MATERIALS AND METHODS: Clinical records of 51 patients, all considered high-risk surgical patients, with acute cholecystitis treated with USGPC between 1987 and 1999, were retrospectively reviewed. Response was defined as improvement in clinical symptoms and signs, and/or reduction in c-reactive protein and white blood count levels within 72 h. Long-term results were evaluated by means of clinical records and written correspondence. RESULTS: Gallbladder stones were seen in 28 patients whereas 23 had acalculous cholecystitis. Ninety percent showed clinical improvement after USGPC. Cholecystectomy was performed in 16%, of which 6% after recurrent cholecystitis. Recurrence of cholecystitis occurred in 22%. Hospital mortality was 16%. None of the deaths was procedure related or related to acute cholecystitis alone. Major complications relating to the USGPC were rare (4%), while minor catheter-related complications were quite common. CONCLUSIONS: USGPC is a procedure with few complications and a high success rate. In patients with acalculous cholecystitis as well as in many patients with calculous cholecystitis, no further treatment was needed.     

Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis

BACKGROUND: The ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography (CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced open cholecystostomy for the treatment of acute cholecystitis in critically ill patients. METHODS: The aim of the present study was to evaluate the results of a 5-year protocol using PTHC followed by delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis in critically ill patients. We reviewed the charts of 55 patients who underwent PTHC at the Hadassah University Hospital Mount Scopus during the years 1994 to 1999. RESULTS: The main indications for PTHC among this group of severely sick and high-risk patients was biliary sepsis and septic shock in 23 patients (42%); and severe comorbidities in 32 patients (58%). The median age was 74 (32 to 98) years, 33 were female and 22 male. Successful biliary drainage by PTHC was achieved in 54 of 55 (98%) of the patients. The majority of the patients (31 of 55) were drained transhepaticlly under CT guidance. The rest, (24 of 55) were drained using ultrasound guidance followed by cholecystography for verification. Complications included hepatic bleeding that required surgical intervention in 1 patient and dislodgment of the catheter in 9 patients that was reinserted in 2 patients. Three patients died of multisystem organ failure 12 to 50 days following the procedure. The remaining 52 patients recovered well with a mean hospital stay of 15.5 plus minus 11.4 days. Thirty-one patients were able to undergo delayed surgery: 28 underwent laparoscopic cholecystectomy of whom 4 (14%) were converted to open cholecystectomy. This was compared with a 1.9% conversion rate in 1,498 elective laparoscopic cholecystectomies performed at the same time period (P = 0.012). Another 3 patients underwent planned open cholecystectomy, 1 urgent and 2 combined with other abdominal procedures. There was no surgery associated mortality, severe morbidity, or bile duct injury. CONCLUSIONS: The use of PTHC in critically ill patients with acute cholecystitis is both safe and effective.     

Die Intensivgallenblase als Schockorgan

Acute acalculous cholecystitis (AAC) represents a severe disease in critically ill patients. The pathogenesis of acute necroinflammatory gallbladder disease is multifactorial and intensive care unit (ICU) patients show multiple risk factors. In addition AAC is difficult to diagnose because of the vague physical and non-specific technical findings. Only the combination of clinical and technical findings including the challenging physical examination of critically ill patients, laboratory results and ultrasound or computed tomography (CT) scan, will lead to the diagnosis. The condition of AAC has a rapid progress to gallbladder necrosis, gangrene and perforation and these complications are reflected in the high morbidity and mortality rates, therefore, therapy should be promptly initiated. If there are no clinical contraindications for an operative approach cholecystectomy is the definitive treatment and both open and laparoscopic procedures have been used. In unstable, critically ill patients percutaneous cholecystostomy should be immediately performed. In addition, transpapillary endoscopic drainage is also possible if there are contraindications for percutaneous cholecystostomy. Patients who fail to improve or deteriorate following interventional drainage should be reconsidered for cholecystectomy. Due to the fact that more than 90? % of patients treated with percutaneous cholecystostomy showed no recurrence of symptoms during a period of more than 1 year, it is still unclear if percutaneous cholecystostomy is the definitive treatment of AAC for unstable patients or if delayed cholecystectomy is still necessary.     

Cholescintigraphy in the critically ill

Critical review of cholescintigraphy in critically ill patients suggests the examination will not conclusively prove or disprove the diagnosis of acute cholecystitis. Of 17 scans performed in critically ill patients with clinical evidence of acute cholecystitis, 7 were true-negative, 1 was false-negative, 6 were false-positive, and 3 were nondiagnostic. Cholestasis and hepatocyte dysfunction, common in the critically ill, result in abnormal clearance of hepatobiliary radionuclide imaging agents, decreasing the usefulness of cholescintigraphy in this patient population. Diagnosing acute cholecystitis in a critically ill patient remains difficult.     

Laparoscopic cholecystostomy is a safe and effective alternative in critically ill patients with acute cholecystitis: two cases

Emergency cholecystectomy for acute cholecystitis in critically ill patients with organ failure and sepsis carries a high risk of morbidity and mortality. Temporizing interventions such as laparoscopic cholecystostomy can help the patient to recover from the critical illness by deferring the definitive procedure to a later, safer period. We describe our experience of laparoscopic cholecystostomy performed in two critically ill patients. In the first case, a 56-year-old man with hypertension, diabetes, and ischemic heart disease, was admitted for evaluation of malena. During the course of his stay, he developed acute calculous cholecystitis, acute renal failure, and right pleural effusion. In the second case, a 68-year-old man presented with diabetes, hypertension, diabetic nephropathy, acute chronic renal failure, and acute calculous cholecystitis. Both patients failed to improve with conservative measures and underwent laparoscopic cholecystostomy under local anesthesia and sedation in view of severe comorbidities and sepsis. Both patients recovered from sepsis. Laparoscopic cholecystectomy was performed uneventfully after six and eight weeks, respectively, and both patients were doing well at one-year follow-up.     

Percutaneous cholecystostomy for high-risk patients with acute cholecystitis

Background Cholecystectomy remains the best treatment for acute cholecystitis but may cause high morbidity and mortality in critically ill or elderly patients. Methods From October 1995 to March 2004, percutaneous cholecystostomy was performed in 65 patients with acute cholecystitis. The mean age was 78 years (range, 45–95). All patients were American Society of Anesthesiologists (ASA) class III (n = 51) or ASA IV (n = 14). Results Percutaneous cholecystostomy was technically successful in 63 patients (97%) with no attributable mortality or major complications. In two patients, bile drainage was inefficient, requiring emergency laparoscopic cholecystectomy. One patient developed necrotic cholecystitis and died. The 30-day mortality rate was 13.8% (n = 9); eight patients died of respiratory or cardiac complications related to comorbidities. Mean drainage time was 18 days (range, 9–60). Postoperative length of hospital stay was 15 days (range, 7–30). Early and delayed cholecystitis occurred in six and five patients, respectively. During follow-up (mean, 20.4 months), five patients died of their underlying medical condition at 5, 6, 8, 12, and 14 months, respectively. In this study, delayed elective cholecystectomy was performed in 10 patients (15.3%). Conclusions Percutaneous cholecystostomy is a valuable and effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.     

Cholecystostomy. Expected outcome in primary and secondary biliary disorders

Cholecystostomy is used for biliary-tree drainage when simplicity and speed are of prime importance. Its frequency of use and the subsequent mortality rates, vary among surgeons and institutions. This review analyzes 50 cholecystostomies performed over 6 years at one institution, and defines outcome as related to presenting symptoms. Twenty five patients (Group 1) presented with symptoms of acute cholecystitis, and underwent cholecystostomy. Twenty (80%) had gallstones and five (20%) were acalculous. Two patients died, a mortality rate of 8 per cent. Twenty five other patients (Group 2) developed signs suggesting cholecystitis during hospitalization for an unrelated illness. Only 50 per cent (13/25) of Group 2 patients were found to have cholecystitis at operation (eight calculous, five acalculous). Mortality was 62 per cent (8/13) in the Group 2 patients with inflammatory cholecystitis, and 50 per cent (6/12) for the patients with normal gallbladders. A positive outcome may be anticipated if cholecystostomy is used in patients admitted with acute cholecystitis who present too great a surgical risk for formal cholecystectomy. In contrast, the diagnosis of cholecystitis in the critically ill patient can be difficult and the prognosis for survival is not good, even after cholecystostomy.     

Emphysematous cholecystitis

Emphysematous cholecystitis is an uncommon variant of acute cholecystitis, and a communication between biliary ducts and gastrointestinal tract should be evaluated. Making the diagnosis often is straightforward on plain abdominal radiography. Prompt diagnosis of emphysematous cholecystitis is critical, and the standard treatment is emergent cholecystectomy. In severely ill patients, percutaneous cholecystostomy with broad-spectrum antibiotics may be an alternative choice for treatment.     

Short- and long-term outcomes following percutaneous cholecystostomy for acute cholecystitis in high-risk patients

Background  

Percutaneous cholecystostomy is a less invasive method to treat acute cholecystitis in patients who are critically ill or have serious medical comorbidities precluding the use of general anesthesia. It remains controversial whether interval cholecystectomy is warranted. The objectives of the study were to determine the success rate and complications of percutaneous cholecystostomy and the proportion of patients without recurrent attacks in whom interval cholecystectomy was not needed.     

Emergency cholecystostomy and subsequent cholecystectomy for acute gallstone cholecystitis in the elderly

BACKGROUND: The morbidity and mortality rates associated with acute cholecystitis are higher in the elderly. This study reports the results of treatment of acute cholecystitis in the elderly with emergency ultrasonographically guided percutaneous cholecystostomy followed by elective cholecystectomy after endoscopic treatment of any common bile duct stones diagnosed by percutaneous cholangiography. METHODS: From January 1989 to December 1998, 92 patients aged over 70 years were treated for acute gallstone cholecystitis. A group of 84 patients with ultrasonographic signs of severe cholecystitis or an American Society of Anesthesiologists score of II to IV were submitted to ultrasonographically guided percutaneous cholecystostomy. Transcatheter cholangiography was performed in all patients and endoscopic sphincterotomy was performed before operation in patients with common bile duct stones. After resolution of the acute phase and treatment of any associated diseases, patients were submitted to cholecystectomy. RESULTS: Cholecystostomy was performed successfully in 83 patients and permitted resolution of the acute attack in all after a mean period of 1.8 days. Cholangiography yielded a diagnosis of non-gallstone obstruction in one patient and common bile duct stones in 19 patients; preoperative endoscopic sphincterotomy and stone extraction was performed in 18 patients. Elective cholecystectomy was then performed in 70 patients with no deaths and a morbidity rate of 24 per cent. CONCLUSION: Combining emergency ultrasonographically guided percutaneous cholecystostomy, preoperative endoscopic treatment of common bile duct stones and subsequent elective cholecystectomy constitutes an optimal treatment regimen for acute gallstone cholecystitis in selected elderly patients with a mortality rate of zero in the authors' experience.     

Laparoscopy in the critically ill

Background: Laparoscopy was evaluated in critically ill patients with suspected acute cholecystitis, mesenteric ischemia, or gastrointestinal perforation. We studied laparoscopy to assess its utility, accuracy, and effect on cardiopulmonary stability. Methods: Twenty-six surgical ICU patients with possible abdominal sepsis underwent laparoscopy. Nineteen were post cardiac surgery; the remainder had other diagnoses. Video laparoscopy was performed with hemodynamic monitoring and inotropic support as needed. Eight patients had bedside laparoscopy. Results: Fifteen patients had suspected acute cholecystitis. Laparoscopy was positive in 10; four had open cholecystectomy, four laparoscopic cholecystectomy, and two tube cholecystostomy. Nine patients had suspected mesenteric ischemia; laparoscopy was positive in five, revealing cirrhosis in two and ischemic bowel in three. Two patients had suspected perforated viscus with colonic perforation in one and one false negative. There were no adverse hemodynamic events. Conclusions: Laparoscopy can be performed safely in critically ill patients. It is useful in patients with acute cholecystitis and in patients who are post cardiac surgery with refractory lactic acidosis in whom a diagnosis of mesenteric ischemia is considered.     

Selective use of tube cholecystostomy with interval laparoscopic cholecystectomy in acute cholecystitis

HYPOTHESIS: Tube cholecystostomy followed by interval laparoscopic cholecystectomy is a sale and efficacious treatment option in critically ill patients with acute cholecystitis. DESIGN: Retrospective cohort study within a 4 1/2%-year period. SETTING: University hospital. PATIENTS: Of 324 patients who underwent laparoscopic cholecystectomy, 65 (20%) had acute cholecystitis; 15 of these 65 patients (mean age, 75 years) underwent tube cholecystostomy. INTERVENTION: Thirteen patients at high risk for general anesthesia because of underlying medical conditions underwent percutaneous tube cholecystostomy with local anesthesia. Laparoscopic tube cholecystostomy was performed on 2 patients during attempted laparoscopic cholecystectomy because of severe inflammation. Interval laparoscopic cholecystectomy was attempted after an average of 12 weeks. MAIN OUTCOME MEASURES: Technical details and clinical outcome. RESULTS: Prompt clinical response was observed in 13 (87%) of the patients after tube cholecystostomy. Twelve patients (80%) underwent interval cholecystectomy. Laparoscopic cholecystectomy was attempted in 11 patients and was successful in 10 (91%), with 1 conversion to open cholecystectomy. One patient had interval open cholecystectomy during definitive operation for esophageal cancer and another had emergency open cholecystectomy due to tube dislodgment. Two patients (13%) had complications related to tube cholecystostomy and 2 patients died from sepsis before interval operation. One patient died from sepsis after combined esophagectomy and cholecystectomy. Postoperative minor complications developed in 2 patients. At a mean follow-up of 16.7 months (range, 0.5-53 months), all patients were free of biliary symptoms. CONCLUSIONS: Tube cholecystostomy allowed for resolution of sepsis and delay of definitive surgery in selected patients. Interval laparoscopic cholecystectomy was safely performed once sepsis and acute infection had resolved in this patient group at high risk for general anesthesia and conversion to open cholecystectomy. Just as catheter drainage of acute infection with interval appendectomy is accepted in patients with periappendiceal abscess, tube cholecystostomy with interval laparoscopic cholecystectomy should have a role in the management of selected patients with acute cholecystitis.     

Percutaneous cholecystostomy for acute cholecystitis in high-risk patients

AIM OF THE STUDY: The aim of this retrospective study was to report the results of percutaneous cholecystostomy in a selected group of high-risk patients with contraindications of general anesthesia. PATIENTS AND METHODS: From October 1995 to December 1999, a percutaneous cholecystostomy was performed in 29 patients with acute cholecystitis. There were 20 women and nine men with a mean age of 80.6 years (range: 59 to 95 years). All the patients were ASA III (N = 23) or ASA IV (N = 6). Ultrasound-guided percutaneous cholecystostomy was performed in 24 cases and computed tomography-guided cholecystostomy in five cases. RESULTS: Percutaneous cholecystostomy was easily performed in 28 cases; there was one failed procedure. The drainage was not efficient in three patients who were operated on with one postoperative death of a patient who had a necrotic cholecystitis. There was no mortality in relation with cholecystostomy. One patient died at day 15 from myocardia infarction. The morbidity rate was 3.4% (one case). Postoperative length of hospital stay was 13 days (range: 7-30 days). The duration of the entire procedure ranged from 9 to 60 days (mean: 20 days). The mean follow-up of patients was 17 months (range: 4-40 months). One patient had recurrent acute cholecystitis and another one had angiocholitis; two patients underwent delayed elective laparoscopic cholecystectomy; 20 patients remained asymptomatic and 16 were still alive at the time of this study (13 with biliary stones and three without). CONCLUSION: Percutaneous cholecystostomy is a valuable alternative procedure for high-risk patients with acute cholecystitis. It's a safe and usually effective procedure without mortality and with a low morbidity. Whenever possible, percutaneous cholecystostomy should be followed by laparoscopic cholecystectomy.     

Acalculous cholecystitis: its role as a complication of major burn injury

The authors present four cases of acute acalculous cholecystitis complicating major burn injury and review the recent literature on acalculous cholecystitis. All patients were men and ranged in age from 22 to 40 years. The mean extent of the burn was 50% of the total body surface area, with an average 29% third-degree component. All four patients survived. Because of their severity, major burn injuries expose patients to many risks, including acute acalculous cholecystitis. Recent experimental evidence supports a vascular insult through the activation of Factor XII pathways as the initial event. A diagnosis is made on clinical grounds, supported by laboratory and ultrasonographic findings, in a patient with a burn covering more than 30% of the total body surface area and who has signs of acute cholecystitis. Cholecystectomy is the treatment of choice; tube cholecystostomy is reserved for critically ill patients.     

¿Es segura y eficaz la colecistostomía percutánea en la colecistitis aguda? Análisis de los efectos adversos asociados a la técnica

IntroductionThe main objective of our study is to assess the safety and efficacy of percutaneous cholecystostomy for the treatment of acute cholecystitis, determining the incidence of adverse effects in patients undergoing this procedure.Material and methodObservational study with consecutive inclusion of all patients diagnosed with acute cholecystitis for 10 years. The main variable studied was morbidity (adverse effects) collected prospectively. Minimum one-year follow-up of patients undergoing percutaneous cholecystostomy.ResultsOf 1223 patients admitted for acute cholecystitis, 66 patients required percutaneous cholecystostomy. 21% of these have presented some adverse effect, with a total of 22 adverse effects. Only 5 of these effects, presented by 5 patients (7.6%), could have been attributed to the gallbladder drainage itself. The mortality associated with the technique is 1.5%. After cholecystostomy, one third of the patients (22 patients) have undergone cholecystectomy. Urgent surgery was performed due to failure of percutaneous treatment in 2 patients, and delayed in another 2 patients due to recurrence of the inflammatory process. The rest of the cholecystectomized patients underwent scheduled surgery, and the procedure could be performed laparoscopically in 16 patients (72.7%).ConclusionWe consider percutaneous cholecystostomy as a safe and effective technique because it is associated with a low incidence of morbidity and mortality, and it should be considered as a bridge or definitive alternative in those patients who do not receive urgent cholecystectomy after failure of conservative antibiotic treatment.     

Percutaneous cholecystostomy is an effective treatment for high-risk patients with acute cholecystitis

We sought to determine the safety, efficacy, and outcome of percutaneous cholecystostomy (PC) in all patients undergoing the procedure at our institutions. We reviewed 53 consecutive cases of acute cholecystitis seen at our hospitals over 5.5 years in which PC was performed at the initial treatment. Follow-up was obtained by chart review and telephone questionnaire. Acute cholecystitis was the primary admitting diagnosis in 18 cases. In the remaining 35, cholecystitis developed during hospitalization. All patients were considered high surgical risks on the basis of the presence of comorbid conditions. The gallbladder was successfully catheterized under radiologic guidance in all patients and with no immediate procedure-related morbidity. Acute cholecystitis resolved in 44 of 53 patients (83%), whereas nine patients (17%) did not improve clinically after PC and died during the same hospitalization. A total of 33 (62%) eventually survived hospitalization. Elective cholecystectomy was done in 25 patients with no mortality. After cholecystectomy, three of these patients subsequently died of other causes, whereas 22 are alive. Eight patients did not undergo cholecystectomy because of underlying medical conditions or because they had acalculous cholecystitis. These patients remained free of biliary problems after removal of their cholecystostomy tube, but two have subsequently died of nonbiliary conditions. Percutaneous cholecystostomy is a safe, effective treatment for high-risk patients with acute cholecystitis. Cholecystostomy can be followed by elective cholecystectomy at a later time if the patient's condition permits or by expectant conservative management in patients who have had acalculous cholecystitis or have a very high mortality risk with surgery.     

Acute gallstone cholecystitis in the elderly

BACKGROUND: The treatment of acute cholecystitis in the elderly is still a subject of debate, particularly with reference to the timing of surgery and the role of laparoscopy. PATIENTS: From January 1994 to June 2002 we observed 27 patients aged over 70 years with acute calcolous cholecystitis. The patients were submitted to ultrasonographic percutaneous cholecystostomy within 12 h of the acute attack. For two patients (7.4%) at high operative risk, we chose a conservative treatment. Twenty-five patients (92.6%) were submitted, in 15 cases (60%) within 5 days and in 10 patients (40%) within 8 days, to a laparoscopic cholecystectomy. Statistical significance was accepted when the value of p was less than 0.05. RESULTS: Ultrasonographic percutaneous cholecystostomy was performed successfully in all patients, without major morbidity or mortality, and complete resolution of clinical symptoms was obtained within 48 h. The conversion rate of laparoscopy was 20% (13.3% in patients submitted to surgery within 5 days and 30% in the group submitted within 8 days--p > 0.05). The postoperative morbidity rate was 24%; it was higher (40% versus 15%) in patients converted to laparotomy (p > 0.05); mortality was 4%. The period of hospitalization was 11 days in patients operated laparoscopically and 21 days in those converted to open cholecystectomy (p < 0.001). CONCLUSIONS: The more rational treatment of acute calcolous cholecystitis in elderly patients is represented by ultrasonographic percutaneous cholecystostomy followed, within 5 days, by laparoscopic cholecystectomy using an abdominal insufflation maximum to 12 mmHg and a limited 10-15 degrees head-up tilt.