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.     

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.     

Acute acalculous cholecystitis after cardiovascular surgery

The development of acute acalculous cholecystitis (AAC) after cardiovascular surgery is an infrequent but devastating complication, the etiology and management of which remains controversial. To evaluate the etiology, treatment, and outcome of patients with AAC, the cases of six patients encountered within an 8-year period who developed AAC after cardiovascular surgery requiring cardiopulmonary bypass (CPB) were reviewed. Atherosclerotic risk factors including diabetes, hyperlipidemia, and smoking were evident in five patients, three of whom had a history of stroke or arteriosclerosis obliterans, while low cardiac output was recognized in three. Percutaneous transhepatic cholecystostomy was performed in five patients, and another required cholecystectomy for peritonitis due to gangrene of the gallbladder. Two patients died of respiratory failure and sepsis after 15 and 82 days of percutaneous drainage, respectively; however, the four survivors had an excellent outcome without any biliary tract disease during a mean follow-up period of 5.3 years. In conclusion, AAC after cardiovascular surgery may result from hypoperfusion of the gallbladder due to various factors including CPB, visceral atherosclerosis, and low cardiac output. We advocate early percutaneous cholecystostomy for patients without peritonitis, while early cholecystectomy is indicated for those with peritonitis.     

Percutaneous cholecystostomy and endoscopic cholecystolithotripsy in the management of acute cholecystitis

Background: Percutaneous cholecystostomy is a valuable alternative temporary measure for acute cholecystitis in elderly patients with severe underlying cardiopulmonary disease, but the subsequent management of gallbladder calculi is still controversial. Methods: Eleven patients treated with percutaneous endoscopic cholecystolithotripsy after percutaneous cholecystostomy were evaluated retrospectively. Results: All patients showed clinical improvement after percutaneous cholecystostomy. Tract dilation succeeded in 9 patients. Complete stone clearance was achieved in seven patients over one to four sessions (average, two sessions). Stone extraction could not be completed in two patients because gallbladder access was lost in one patient, and the other refused further procedure. There were three complications, with two biliary fistulas and one major bile leakage leading to emergency cholecystectomy. The duration of the entire procedure ranged from 30 to 126 days (mean, 58 days). During the follow-up (mean 17.2 months), one patient had recurrent cholangitis and the others remained asymptomatic. Conclusions: Percutaneous cholecystolithotripsy after percutaneous cholecystostomy is a safe alternative in the management of high-risk elderly patients with acute cholecystitis. Received: 26 February 1998/Accepted: 17 July 1998     

Laparoscopic reintervention for residual gallstone disease

Laparoscopic reintervention is being increasingly performed in patients who have previously undergone surgery for gallstone disease. A few patients with gallbladder remnants or a cystic duct stump with residual stones have recurrent symptoms of biliary disease. Patients with bile duct injuries were excluded from the study. We reviewed our experience in treating such patients over a 4-year period, January 1998 through December 2001. Five patients underwent laparoscopic reintervention after previous surgery for gallstone disease performed elsewhere during the period mentioned above. Of these 5 patients, 3 had impacted stones in gallbladder remnants (laparoscopic cholecystectomy, 2; open cholecystectomy, 1) and 2 had recurrent symptoms after cholecystolithotomy and tube cholecystostomy (conventional surgery) performed elsewhere. Laparoscopic excision of the gall bladder remnants was done in 3 patients and a formal laparoscopic cholecystectomy was done in 2 patients who had previously undergone cholecystolithotomy and tube cholecystostomy. The mean operating time was 42 minutes. No drainage was required postoperatively. All patients were symptom-free during a mean follow-up of 2.3 years (range, 7 months to 4 years). Reintervention may be required for patients with residual gallstones whose symptoms recur after gallbladder surgery such as cholecystectomy, subtotal cholecystectomy, and tube cholecystostomy. It is safe and feasible to remove the gallbladder or gallbladder remnants in such patients laparoscopically.     

Endoscopic and sparing surgical interventions in the treatment of patients with acute cholecystitis and high surgical risk]

Laparoscopic gallbladder drainage was performed as an alternative intervention to an emergency operation in 97 patients with acute cholecystitis whose ages ranged from 60 to 89 years. One patient died from thromboembolism of the pulmonary artery. After acute inflammation was arrested, 37 patients underwent cholecystectomy. The risk of a radical operation was ascertained to be very high in 58 cases. In 19 of these cases endoscopic cleansing of the cystic cavity was performed through cholecystostomy formed during laparoscopic drainage of the gallbladder. In 39 cases the therapeutic process was completed by a sparing operation--sanative cholecystostomy which was carried out under local anesthesia. There were no fatal outcomes in these groups. Endoscopic papillosphincterotomy was conducted in 17 patients, with stones in the gallbladder and choledocholithiasis, after which the stones were removed. The performance of endoscopic and surgical interventions which cause minimal injury provides for adequate sanative treatment of the gallbladder in cases in which cholecystectomy is an extremely high risk.     

Laparoscopic tube cholecystostomy: still useful in the management of complicated acute cholecystitis

The preferred treatment for acute cholecystitis is laparoscopic cholecystectomy. Conversion to open operation may be necessary in cases where the anatomy is unclear or complications are encountered. Laparoscopic tube cholecystostomy remains an alternative to open surgery in cases where the gallbladder is judged too inflamed to allow for laparoscopic removal and in cases where the patient is too sick to tolerate a more extensive procedure. It also provides access for diagnostic cholangiography. We report three patients with acute cholecystitis who underwent laparoscopic cholecystostomy and interval laparoscopic cholecystectomy without complications. Laparoscopic tube cholecystostomy is safe and remains a useful option in select patients with complicated acute cholecystitis.     

Use of endoscopic and surgical methods in the treatment of patients with acute cholecystitis

Laparoscopic gallbladder drainage (LGBD) was undertaken to arrest acute inflammation in 121 patients suffering from acute cholecystitis and serious concomitant diseases. Their ages ranged from 30 to 89 years. Cholecystectomy was carried out in 78 patients after complete abatement of the inflammatory process. When the risk of a radical operation was very high treatment was restricted to cleansing of the gallbladder cavity (CGBC). In 9 patients stones were removed from the gallbladder through a cholecystostoma, formed during LGBD, using a choledochoscope. Cleansing cholecystostomy under local anesthesia was conducted in 19 cases. Fifteen patients who were treated by CGBC had choledocholithiasis; they were subjected to endoscopic papillosphincterotomy. The death rate was 1.6%.     

Reassessment of simple cholecystostomy.

Cholecystostomy was performed on 22 patients with acute cholecystitis after partial (13) or complete (9) removal of gallbladder stones. One patient had complementary common-duct drainage. Early mortality occurred in two patients. Three patients with associated cholangitis but intraoperative reflux of cysticduct bile were all treated by cholecystostomy alone and survived. For the poor-risk patient with cholecystitis, cholecystostomy is effective. When there is associated cholangitis and documented cystic-duct patency, cholecystostomy is also sufficient. When accompanying cholangitis is associated with cystic-duct occlusion, choledochotomy and T tube drainage should be added.     

Gallbladder sepsis after stent insertion for bile duct obstruction: management by percutaneous cholecystostomy.

Of 364 patients undergoing insertion of a biliary endoprosthesis in 1989, six (1.6 per cent) developed gallbladder sepsis. Three patients had cholangiocarcinoma, two had carcinoma of the pancreas and one had a benign biliary stricture. Two of the five patients with malignancy had gallbladder stones, and the patient with a benign stricture developed stones after 3 years of stenting. Three patients developed gallbladder sepsis early after endoprosthesis insertion (less than 6 days), while in the other three it occurred late (greater than 6 months). All six patients failed to respond to antibiotics and were successfully managed by percutaneous cholecystostomy; the patient with a benign biliary stricture also had cholecystolithotomy. The gallbladder drainage tubes were removed or became dislodged at intervals varying from 2 weeks to 6 months without complications. Percutaneous cholecystostomy is the treatment of choice for gallbladder sepsis unresponsive to antibiotics in patients with a biliary endoprosthesis in situ.     

胆囊穿刺造瘘后双通道胆道镜保胆取石与腹腔镜胆囊切除术治疗老年患者结石性胆囊炎疗效的比较

目的比较超声引导双通道胆囊穿刺造瘘联合胆道镜保胆取石与胆囊穿刺造瘘后行腹腔镜胆囊切除术（1aparoscopiccholecystectomy,LC）治疗老年患者急性结石性胆囊炎的临床疗效。方法回顾性分析2012年1～9月接受双通道胆囊穿刺造瘘联合胆道镜保胆取石治疗的30例老年结石性胆囊炎（保胆取石组）和胆囊穿刺造瘘后行Lc治疗的30例老年结石性胆囊炎（Lc组）的临床资料,比较2组手术操作时间、术中出血量、住院时间、消化不良症状发生率等。结果60例均穿刺置管成功,带管时间14d-2个月,平均30d。4～8周后,保胆取石组30例成功行胆道镜取石,结石取净率100％,取石过程中无出血、漏胆、继发胆总管结石、切口感染等手术并发症。LC组28例三孔法完成LC,2例因粘连组织难以分离中转开腹手术,术中、术后均无严重并发症。保胆取石组术中出血量（8．8±1．7）ml,显著少于LC组（18．9±1．2）ml（t=-25．968,P=0．000）;保胆取石组住院时间（4．4±0．6）d,显著短于LC组（5．6±0．5）d（t=-8．243,P=0．000）。保胆取石组术后随访3、6、12个月,B超检查1例复发,5例有上腹部不适、腹泻、食欲不佳等消化不良症状,发生率16．7％（5／30）,LC组术后21例有消化不良症状,发生率70．o％（21／30）,2组比较有显著性差异（x2=17．376,P=0．000）。结论超声引导双通道胆囊穿刺造瘘联合胆道镜保胆取石操作简便,在术中出血量、住院时间、远期生活质量等方面均优于胆囊造瘘后行LC。     

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.     

经皮胆囊微造瘘联合肾镜治疗老年急性结石性胆囊炎研究(附62报告)

目的探讨经皮胆囊微造瘘联合肾镜治疗高危老年急性结石性胆囊炎的临床体会。方法回顾分析62例高危老年急性结石性胆囊炎患者临床资料,评估经皮胆囊微造瘘联合肾镜治疗结石性胆囊炎的技术价值。结果 62例高危老年急性胆囊炎患者行"经皮胆囊造瘘联合经皮肾镜治疗",72 h内症状有明显缓解。并发症:3例切口感染,2例因胆囊活检显示癌变再次入院治疗,余60例全部带管出院,或转内科治疗原发内科疾患。术后3、6、12个月随访未发生胆囊炎再发。结论经皮胆囊微造瘘联合肾镜治疗高危老年急性结石性胆囊炎是一种安全、有效的方法,具有重要临床应用价值。     

Acute acalculous cholecystitis in the critically ill patient

Nine cases of acute acalculous cholecystitis were diagnosed in the surgical intensive care unit at Hartford Hospital during a 2 year period after abdominal, cardiovascular, and traumatic surgery. A tender mass in the right upper quadrant was suggestive but not diagnostic of the condition. Hyperamylasemia was seen in all patients. Ultrasonography is the most useful diagnostic tool; serial studies reveal progressive gallbladder dilatation and edema. Tube cholecystostomy was used in five patients and cholecystectomy in four. Cholecystostomy led to resolution of the inflammatory process in all five patients. Cholecystectomy should be reserved for those patients with extensive gallbladder necrosis. Six of the nine patients in the series died, all from multiple systems failure with concomitant sepsis. Hypotension is probably central to the development of acute acalculous cholecystitis. In the face of elevated intraluminal gallbladder pressure caused by ampullary edema and increased bile viscosity, hypotension may result in mucosal ischemia and necrosis with subsequent bacterial colonization. Acute acalculous cholecystitis represents another organ failure in critically ill patients who are experiencing progressive failure of multiple organ systems. An aggressive approach to the manifestations of organ failure, including acalculous cholecystitis, must be employed.     

¿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.     

Tube Cholecystostomy Before Cholecystectomy for the Treatment of Acute Cholecystitis

Methods:This study was a retrospective chart review of patients who underwent tube cholecystostomy from July 1, 2005, to July 1, 2012.Results:During the study period, 82 patients underwent 125 cholecystostomy tube placements. Four patients (5%) died during the year after tube placement. The mean hospital length of stay for survivors was 8.8 days (range, 1–59 days). Twenty-eight patients (34%) required at least 1 additional percutaneous procedure (range, 1–6) for gallbladder drainage. Twenty-nine patients (34%) ultimately underwent cholecystectomy. Surgery was performed a mean of 7 weeks after cholecystostomy tube placement. Laparoscopic cholecystectomy was attempted in 25 operative patients but required conversion to an open approach in 8 cases (32%). In another 4 cases, planned open cholecystectomy was performed. Major postoperative complications were limited to 2 patients with postoperative common bile duct obstruction requiring endoscopic retrograde cholangiopancreatography, 1 patient requiring a return to the operating room for hemoperitoneum, and 2 patients with bile leak from the cystic duct stump.Conclusions:In high-risk patients receiving cholecystostomy tubes for acute cholecystitis, only about one third will undergo surgical cholecystectomy. Laparoscopic cholecystectomy performed in this circumstance has a higher rate of conversion to open surgery and higher hepatobiliary morbidity rate.     

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.     

Long Term Survival in a Patient Following Resection for Carcinoma of the Gallbladder and Rectum

We describe a 66-year-old man who presented initially with acute cholecystitis. He was treated by cholecystostomy and biopsy of the gallbladder mucosa which revealed carcinoma of the gallbladder. Four weeks later a cholecystectomy was performed followed by resection of the common bile duct, common hepatic duct and segments IV and V of the liver and a hepaticojejunostomy. Sixteen months later an abdomino-perineal resection was performed for a moderately differentiated Dukes′ stage C carcinoma of the rectum. He is alive and without evidence of recurrence seven years later. Few patients survive for this length of time following resection of either carcinoma of the gallbladder or rectum. This case report demonstrates the value of aggressive surgical treatment in patients with early carcinoma of the gallbladder.     

Cholecystectomy: clinical experience with a large series

This large series of 1,035 consecutive operations with a primary diagnosis of inflammatory or calculus disease of the gallbladder included a large number of elderly patients with the greatest incidence in the seventh and eighth decades of life. Operation was performed after initial stabilization when acute illness presented and without prolonged delay of medical treatment. Cholecystectomy was almost always able to be performed successfully at the initial operation. This approach produced low rates of morbidity and mortality when compared with reports from large university centers and with reports advocating delayed operation for acute cholecystitis or planned cholecystostomy in elderly and high risk patients. Operative cholangiograms were rarely performed and rates of residual or retained common duct stones were low. Length of hospital stay was related to age and performance of a common duct exploration. Draining the subhepatic space routinely by way of a separate peritoneal stab incision and removing the drain within 48 hours produced a low rate of wound complications.     

Acute acalculous cholecystitis

Sixty-three patients, 49 men and 14 women, developed acute cholecystitis without gallbladder stones. Only eight patients had a history suggestive of gallbladder disease. In 17 patients cholecystitis developed in the postoperative period, and cholecystitis occurred in 7 patients who had extensive trauma. The signs and symptoms did not differ markedly from those found when acute cholecystitis is associated with cholelithiasis. Pain and tenderness in the right upper abdominal quadrant, vomiting, abdominal distention, decreased bowel sounds, jaundice and fever were common. Thirty (47.6 percent) gallbladder specimens had gangrene, and perforation occurred in five instances. Bacteria were cultured from 28 of 43 bile specimens. E. coli was the most common organism.A high incidence of acalculous gallbladders is found when acute cholecystitis occurs in the postoperative period or after trauma and in children. Decreased blood flow to the gallbladder, cystic duct obstruction and concentrated bile are necessary to produce experimental cholecystitis. These factors are probably necessary in humans also. Decreased gallbladder perfusion caused by shock, congestive heart failure and arteriosclerosis probably contributed to the development of acute acalculous cholecystitis in these patients.