Yonsei Med J.  2010 Jul;51(4):540-545. 10.3349/ymj.2010.51.4.540.

Better Treatment Strategies for Patients with Acute Cholecystitis and American Society of Anesthesiologists Classification 3 or Greater

• Yun SS
• Hwang DW
• Kim SW
• Park SH
• Park SJ
• Lee DS
• Kim HJ

• KMID: 1805191
• DOI: http://doi.org/10.3349/ymj.2010.51.4.540

Abstract

PURPOSE
Laparoscopic cholecystectomy is the best treatment choice for acute cholecystitis. However, it still carries high conversion and mortality rates. The purpose of this study was to find out better treatment strategies for high surgical risk patients with acute cholecystitis.
MATERIALS AND METHODS
Between January 2002 and June 2008, we performed percutaneous cholecystostomy instead of emergency cholecystectomy in 44 patients with acute cholecystitis and American Society of Anesthesiologists (ASA) classification 3 or greater. This was performed in 31 patients as a bridge procedure before elective cholecystectomy (bridge group) and as a palliative procedure in 11 patients (palliation group).
RESULTS
The mean age of patients was 71.6 years (range 52-86 years). The mean ASA classifications before and after percutaneous cholecystostomy were 3.3 +/- 0.5 and 2.5 +/- 0.6, respectively, in the bridge group, and 3.6 +/- 0.7 and 3.1 +/- 1.0, in the palliation group, respectively. Percutaneous cholecystostomy was technically successful in all patients. There were two deaths after percutaneous cholecystostomy in the palliation group due to underlying ischemic heart disease and multiple organ failure. Resumption of oral intake was possible 2.9 +/- 1.8 days in the bridge group and 3.9 +/- 3.5 days in the palliation group after percutaneous cholecystostomy. We attempted 17 laparoscopic cholecystectomies and experienced one failure due to bile duct injury (success rate: 94.1%). The postoperative course of all cholecystectomy patients was uneventful.
CONCLUSION
Percutaneous cholecystostomy is an effective bridge procedure before cholecystectomy in patients with acute cholecystitis and ASA classification 3 or greater.

Keyword

Percutaneous cholecystectomy; acute cholecystitis; American Society of Anesthesiologists classification

Figure

• 

  Fig. 1 Flow chart of outcomes in 44 patients with acute cholecystitis undergoing percutaneous cholecystostomy. PC, percutaneous cholecystostomy; LC, laparoscopic cholecystectomy; OC, open cholecystectomy.

Reference

1. Ji W, Li LT, Li JS. Role of laparoscopic subtotal cholecystectomy in the treatment of complicated cholecystitis. Hepatobiliary Pancreat Dis Int. 2006. 5:584–589.

2. Csikesz NG, Tseng JF, Shah SA. Trends in surgical management for acute cholecystitis. Surgery. 2008. 144:283–289.

3. Spira RM, Nissan A, Zamir O, Cohen T, Fields SI, Freund HR. Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis. Am J Surg. 2002. 183:62–66.

4. Yi NJ, Han HS, Min SK. The safety of a laparoscopic cholecystectomy in acute cholecystitis in high-risk patients older than sixty with stratification based on ASA score. Minim Invasive Ther Allied Technol. 2006. 15:159–164.

5. Lee HK, Han HS, Min SK, Lee JH. Sex-based analysis of the outcome of laparoscopic cholecystectomy for acute cholecystitis. Br J Surg. 2005. 92:463–466.

6. Patterson EJ, McLoughlin RF, Mathieson JR, Cooperberg PL, MacFarlane JK. An alternative approach to acute cholecystitis. Percutaneous cholecystostomy and interval laparoscopic cholecystectomy. Surg Endosc. 1996. 10:1185–1188.

7. Wong SK, Yu SC, Lam YH, Chung SS. Percutaneous cholecystostomy and endoscopic cholecystolithotripsy in the management of acute cholecystitis. Surg Endosc. 1999. 13:48–52.

8. Li JC, Lee DW, Lai CW, Li AC, Chu DW, Chan AC. Percutaneous cholecystostomy for the treatment of acute cholecystitis in the critically ill and elderly. Hong Kong Med J. 2004. 10:389–393.

9. Bakkaloglu K, Yanar H, Guloglu R, Taviloglu K, Tunca F, Aksoy M, et al. Ultrasound guided percutaneous cholecystostomy in high-risk patients for surgical intervention. World J Gastroenterol. 2006. 12:7179–7182.

10. List WF, Kröll W, Filzwieser G. [Perioperative risk in critically ill surgical patients]. Anaesthesist. 1985. 34:612–618.

11. Ghahreman A, McCall JL, Windsor JA. Cholecystostomy: a review of recent experience. Aust N Z J Surg. 1999. 69:837–840.

12. Watanabe Y, Sato M, Abe Y, Iseki S, Sato N, Kimura S. Preceding PTGBD decreases complications of laparoscopic cholecystectomy for patients with acute suppurative cholecystitis. J Laparoendosc Surg. 1996. 6:161–165.

13. Tseng LJ, Tsai CC, Mo LR, Lin RC, Kuo JY, Chang KK, et al. Palliative percutaneous transhepatic gallbladder drainage of gallbladder empyema before laparoscopic cholecystectomy. Hepatogastroenterology. 2000. 47:932–936.

14. Eldar S, Eitan A, Bickel A, Sabo E, Cohen A, Abrahamson J, et al. The impact of patient delay and physician delay on the outcome of laparoscopic cholecystectomy for acute cholecystitis. Am J Surg. 1999. 178:303–307.

15. Pessaux P, Tuech JJ, Rouge C, Duplessis R, Cervi C, Arnaud JP. Laparoscopic cholecystectomy in acute cholecystitis. A prospective comparative study in patients with acute vs. chronic cholecystitis. Surg Endosc. 2000. 14:358–361.

16. Amendolara M, Perri S, Pasquale E, Biasiato R. [Surgical treatment in acute cholecystitis emergencies]. Chir Ital. 2001. 53:375–381.

17. Roslyn JJ, Binns GS, Hughes EF, Saunders-Kirkwood K, Zinner MJ, Cates JA. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg. 1993. 218:129–137.

18. Kocher T, Herzog U, Schuppisser JP, Tondelli P. [Laparoscopic and open cholecystectomy in 954 patients. A prospective evaluation]. Helv Chir Acta. 1994. 60:761–765.

19. Hatzidakis AA, Prassopoulos P, Petinarakis I, Sanidas E, Chrysos E, Chalkiadakis G, et al. Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment. Eur Radiol. 2002. 12:1778–1784.

20. Johnson AB, Fink AS. Alternative methods for management of the complicated gallbladder. Semin Laparosc Surg. 1998. 5:115–120.

21. Pessaux P, Lebigot J, Tuech JJ, Regenet N, Aube C, Ridereau C, et al. [Percutaneous cholecystostomy for acute cholecystitis in high-risk patients]. Ann Chir. 2000. 125:738–743.

22. Teoh WM, Cade RJ, Banting SW, Mackay S, Hassen AS. Percutaneous cholecystostomy in the management of acute cholecystitis. ANZ J Surg. 2005. 75:396–398.

23. Leveau P, Andersson E, Carlgren I, Willner J, Andersson R. Percutaneous cholecystostomy: a bridge to surgery or definite management of acute cholecystitis in high-risk patients? Scand J Gastroenterol. 2008. 43:593–596.

24. Welschbillig-Meunier K, Pessaux P, Lebigot J, Lermite E, Aube Ch, Brehant O, et al. Percutaneous cholecystostomy for high-risk patients with acute cholecystitis. Surg Endosc. 2005. 19:1256–1259.

25. Casillas RA, Yegiyants S, Collins JC. Early laparoscopic cholecystectomy is the preferred management of acute cholecystitis. Arch Surg. 2008. 143:533–537.

26. Kiviluoto T, Sirén J, Luukkonen P, Kivilaakso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet. 1998. 351:321–325.

27. Lo CM, Liu CL, Fan ST, Lai EC, Wong J. Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Ann Surg. 1998. 227:461–467.

28. Koo KP, Thirlby RC. Laparoscopic cholecystectomy in acute cholecystitis. What is the optimal timing for operation? Arch Surg. 1996. 131:540–544.

29. Lujan JA, Parrilla P, Robles R, Marin P, Torralba JA, Garcia-Ayllon J. Laparoscopic cholecystectomy vs open cholecystectomy in the treatment of acute cholecystitis: a prospective study. Arch Surg. 1998. 133:173–175.

30. Tsumura H, Ichikawa T, Hiyama E, Kagawa T, Nishihara M, Murakami Y, et al. An evaluation of laparoscopic cholecystectomy after selective percutaneous transhepatic gallbladder drainage for acute cholecystitis. Gastrointest Endosc. 2004. 59:839–844.

31. Shirai Y, Tsukada K, Kawaguchi H, Ohtani T, Muto T, Hatakeyama K. Percutaneous transhepatic cholecystostomy for acute acalculous cholecystitis. Br J Surg. 1993. 80:1440–1442.

32. Famulari C, Macri A, Galipo S, Terranova M, Freni O, Cuzzocrea D. The role of ultrasonographic percutaneous cholecystostomy in treatment of acute cholecystitis. Hepatogastroenterology. 1996. 43:538–541.

33. Sugiyama M, Tokuhara M, Atomi Y. Is percutaneous cholecystostomy the optimal treatment for acute cholecystitis in the very elderly? World J Surg. 1998. 22:459–463.

34. Van Steenbergen W, Ponette E, Marchal G, Pelemans W, Aerts R, Fevery J, et al. Percutaneous transhepatic cholecystostomy for acute complicated cholecystitis in elderly patients. Am J Gastroenterol. 1990. 85:1363–1369.