Percutaneous Cholecystostomy Tube in Acute Cholecystitis: Our Experience in a Tertiary Center in Saudi Arabia

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1 9 KUWAIT MEDICAL JOURNAL June 0 Original Article Percutaneous Cholecystostomy Tube in Acute Cholecystitis: Our Experience in a Tertiary Center in Saudi Arabia Faisal A Al-Saif, Hamad S AlSubaie, Rafif E Mattar, Shabaz Ahmed Qazi, Turki R AlFuhaid, Ahmad Zubaidi Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia Department of Radiology, King Abdulaziz Medical City, Riyadh, Saudi Arabia Department of Radiology, King Fahad Medical City, Riyadh, Saudi Arabia Kuwait Medical Journal 0; 50 (): 9-9 ABSTRACT Objectives: A higher conversion rate from laparoscopic to open cholecystectomy in the setting of acute cholecystitis was reported, with an increased risk for morbidity and longer hospital stay. In critically ill patients with gallbladder stones and cholecystitis, percutaneous gallbladder drainage serves as a temporizing procedure, palliating the gallbladder-related sepsis. Compared with surgery in critically ill patients, percutaneous drainage has a relatively low complication rate and is rapidly effective. We report our institution s experience in using percutaneous cholecystostomy tube (PCT) insertion as a temporizing measure prior to laparoscopic cholecystectomy. Design: A retrospective study on prospectively collected data Settings: Tertiary care center in Riyadh, Saudi Arabia Subjects: Patients who underwent PCT insertion for acute cholecystitis Intervention: PCT insertion Main outcome measure(s): Clinical picture of the patient, hospital stay and sepsis indicators Results: A total of 5 patients underwent a PCT insertion for acute cholecystitis. Clinical improvement of the patients symptoms (right upper quadrant pain and fever) and normalization of white blood cells following the insertion of the PCT was achieved in 66 hours.75 days (range : - 7 days). The mean hospitalization time was 5. days and the median was 5 ( ) days. All patients subsequently underwent laparoscopic cholecystectomy without conversion nor common bile duct injury in our series. Conclusion: PCT insertion followed by laparoscopic cholecystectomy is an effective and safe treatment in patients with acute cholecystitis and concomitant comorbidities. KEYWORDS: acute care, emergency surgery, empyema, gallbladder, gallstone disease INTRODUCTION Eleven to 0% of patients with symptomatic gall stones present with acute cholecystitis [,]. Although the laparoscopic approach was initially contraindicated, owing to experience, the application of laparoscopic surgery has extended to the treatment of patients with acute cholecystitis. Notably, laparoscopic cholecystectomy has similar operation times, shorter hospital stay and smaller complication rates compared to that of the open technique [,]. The conversion rate of laparoscopic cholecystectomy for acute cholecystitis has been reported to range from % to % [,5], which is significantly higher than the rate reported for elective laparoscopic cholecystectomy (less than 5%) [5]. With conversion, not only is the advantage of this minimally invasive procedure lost, but the cost and complication rates are also increased []. In critically ill patients with gallbladder stones and cholecystitis, percutaneous gallbladder drainage serves as a temporizing procedure, palliating the gallbladderrelated sepsis while the underlying critical conditions are treated. Subsequently, surgery can be performed semi- electively. Compared with surgery in critically ill patients, percutaneous drainage has a relatively low complication rate and is rapidly effective [6]. Address correspondence to: Dr. Faisal A Al-Saif, MBBS FRCSC ABS FACS, Executive Director of Health Affairs, Associate Professor & Consultant, Hepato-Pancreatico Biliary & Transplant Surgeon, Department of Surgery, College of Medicine, King Saud University, P.O Box 705, Riyadh, Saudi Arabia. Tel: , Fax: , falsaif@ksu.edu.sa, rmattar@live.com

2 June 0 KUWAIT MEDICAL JOURNAL 95 SUBJECTS AND METHODS The study was approved by the institution s ethical committee. From the interventional radiology database at our institution, we identified 5 patients who underwent percutaneous decompression of the gallbladder for treatment of acute cholecystitis between February 97 and May 00. Table : Demographics of the patients (n = 5) Patient Demographics and Characteristics Sex Male Female Age 60 > 60 Mean of age Standard deviation Associated factors Advanced cardiovascular diseases Advanced respiratory diseases Empyema of gall bladder Unresponsive to broad spectrum antibiotics Unclear anatomy intra-operatively Hemodynamic instability Uncontrolled diabetes mellitus Advanced malignancy Surgeons preference Number of Patients Percentage Patients demographics were reviewed, as well as their symptoms, signs and co-morbid conditions (Tables, ). Blood works, mainly complete blood counts and liver function tests (LFTs) (Table ) were collected, in addition to all diagnostic radiological studies. 0 0 Table : Symptoms, signs and ultrasound findings of the studied patients Symptoms, Signs, and Ultrasound Findings Symptoms Right upper quadrant abdominal pain Fever Nausea Vomiting Anorexia Jaundice Pruritus Dark urine Pale stool Signs Fever > ºC Palpable masses Tender right upper quadrant area Leukocytosis Ultrasound findings Gall stones Sludge Wall thickening Pericholecystic fluid Murphy's sign Gas (gangrenous gall bladder) Distended gall bladder Number of Patients Percentage 00 6 The main outcome was time to improvement after tube insertion, i.e. normal white blood cell (WBC) count, absence of fever, and absence of pain (Table ). We also looked at the length of hospital stay, percutaneous cholecystostomy tube (PCT) placement, early and late complications, removal indications (Fig. ), and any further biliary procedures (Fig. ) PCT removed when the output is nil (%) PCT removed when the output is nil and the cholangiogram showed normal flow (%) PCT removed with a normal result of the cholangiogram, regardless of output (%) PCT continued to drain until urgent cholecystectomy done Lost Fig : Times of removal of PCT Elective laparoscopic cholecystectomy Urgent laparoscopic cholecystectomy Continue to drain due to cystic duct stone till laparoscopic cholecystectomy Operation not done due to the morbidity, drain removed after 5 days Died due to cardiac arrest Signed DAMA and lost Fig : Final outcomes in patients with and without response to PCT

3 96 Percutaneous Cholecystostomy Tube in Acute Cholecystitis: Our Experience in a Tertiary Center... June 0 Percutaneous Cholecystostomy Tube (PCT) placement PCT insertion was performed in critically ill patients with strong clinical and imaging evidence of acute cholecystitis who were deemed unfit to undergo immediate surgery (Table ). Acute cholecystitis was diagnosed based on both the clinical and radiological picture. All of our patients were kept in fasting and broad-spectrum IV antibiotics were administered as part of their initial managment. Percutaneous cholecystostomy technique PCT insertion was performed under sterile conditions using intravenous sedation and local anesthesia with % lidocaine hydrochloride. The procedure was performed using ultrasound (US) guidance in 0 patients. Adequate visualization of the gallbladder using US was not possible in patients, who then underwent PCT insertion under computerized tomography (CT) scan guidance. Additionally, patients underwent cholecystostomy tube placement intra-operatively. An -F pigtail catheter was placed into the gallbladder using a single step technique via a transhepatic or transperitoneal approach. PCT was considered technically successful when the pigtail catheter was visualized sonographically in the gallbladder lumen and the gallbladder contents could be aspirated freely through the PCT. All patients had their vital signs monitored and were observed for symptoms of local pain or shoulder discomfort upto four hours after the procedure. RESULTS Demographics and pre-operative status There were 7 males and females. Mean patient age was 5.56 years (range 0-0 years) (Table ). The diagnosis of acute cholecystitis was made in all patients on the basis of clinical and radiological findings (Table ). The most common symptoms were right upper quadrant pain in 5 patients (00%), vomiting in patients (6%), nausea in patients (%), and fever in patients (%) (Table ). While the most common sign was right upper quadrant tenderness in patients (9%), patients (%) also presented with fever (temperature > C), and a palpable mass in patients (%). Eighteen patients (7%) had leukocytosis (Table ). None of the patients developed gallstone pancreatitis. Associated factors were advanced cardiovascular diseases (5, 0%), advanced respiratory diseases (, %), empyema of the gall bladder (5, 0%), unresponsiveness to broad spectrum antibiotics (, %), unclear anatomy intraoperatively (, %), hemodynamic instability (, %), uncontrolled diabetes mellitus (, %), advanced malignancy (, %), and surgeons preference (, %) (Table ). Our radiological studies consisted of abdominal US as the initial confirmatory test for acute cholecystitis, which almost all our patients underwent ( of the 5). The US diagnostic criteria used were the signs of acute inflammation of the gall bladder; this included presence of gall stones, sludge, wall thickening, pericholecystic fluid, sonographic Murphy s sign, and gas in the gallbladder wall (Table ). US was diagnostic of acute cholecystitis in patients (96%), and one patient (%) had his diagnostic US at another institution. Abdominal CT scan was performed in seven patients (%). Hepatobiliary (HIDA) scan was not done for any of our patients. Post-operative outcomes The procedure was successful at the time of insertion of the catheter in all patients. Clinical improvement of the patients symptoms (right upper quadrant pain and fever) and normalization of WBC following the insertion of the PCT was achieved in 66 hours (.75 days on average). All patients showed clinical improvement within a week of tube placement, although notably, the majority (%) improved within days (Table ). Table : Time taken for improvement after PCT insertion (i.e. normal WBC, no fever, no pain) Time till improvement (days) - 7 Number of patients (%) (%) The mean hospitalization time was 5. days, ranging from - days. The majority of patients (%) spent weeks or less in the hospital. While the mean draining duration was 9.67 days, around two thirds of the PCTs drained for a month or less ( patients, 6%). Five PCTs continued to drain for 56 days (0%), whereas a minority continued to drain until an urgent laparoscopic cholecystectomy was performed ( patients, %). Patients were observed daily for early or late complications, including bile peritonitis, bleeding, vagal hypotension and bradycardia, vagal bradycardia alone, respiratory distress and catheter dislodgment. There were no immediate complications. Two patients did have a minor leak, however they did not need any further biliary intervention. Twenty patients (0%) later underwent elective laparoscopic cholecystectomy with no conversion and no common bile duct (CBD) injury, two patients

4 June 0 KUWAIT MEDICAL JOURNAL 97 (%) had urgent cholecystectomies, one patient (%) had the PCT removed and is being followed up while receiving chemotherapy, one patient (%) died due to a cardiac arrest unrelated to PCT, and one patient (%) was lost to follow up (Fig. ). We didn t encounter any CBD injury nor did we need to convert to an open procedure in any of the operated cases. Cholecystocholangiography was performed prior to the removal of the catheter to visualize the bile tree and gallbladder in patients (%), 0 patients (0%) had a normal flow and two patients (%) had a stone at the cystic duct, while the other patients (5%) did not undergo choelcystocholangiography. PCT was removed in patients (%) after resolution of symptoms and signs, and a nil output from the PCT was observed. Seven patients (%) had PCT removed when the output was nil and the cholecystocholangiography was within normal flow. Three patients (%) had PCT removed with a normal result of cholecystocholangiography regardless of the output. Two patients (%) had the PCT removed intraoperatively. Finally, one patient (%) was lost to follow up with the tube. No complications were faced in the patients (96%) after removal of the PCT, however as aforementioned, one patient (%) was lost to follow up before removal of the PCT. All patients subsequently underwent laparascopic cholecystectomy without conversion or CBD injury in our series. DISCUSSION PCT is an effective, safe, temporizing treatment in patients with acute cholecystitis who have a concomitant co-morbidity that prevents them from undergoing immediate cholecystectomies [7-9]. There is a wide range of reasons for not performing cholecystectomy and thus inserting a PCT instead, but the most common are cardiopulmonary disorders [0]. In rare cases, potentially difficult emergency surgery can be avoided with PCT insertion []. Following PCT insertion, most patients will have resolution of their symptoms [9]. Therefore, cholecystectomy can be performed at a later stage as an elective procedure when the patient s condition has improved []. Drains can be safely removed when drainage has stopped without the need for cholangiography. If drainage continues, then cholangiography needs to be performed. A normal study means PCT can be safely removed []. Laparoscopic cholecystectomy remains the definitive treatment when the patient s condition permits []. CONCLUSION Percutaneous cholecystostomy tube insertion, followed by laparoscopic cholecystectomy, is an effective and safe treatment in patients with acute cholecystitis and concomitant comorbidities. The drains can be safely removed after a nil output reading, or with normal result of a cholangiogram, regardless of the output. This is to be followed by a laparoscopic cholecystectomy in a later elective setting. We have not experienced any conversion procedures nor biliary injuries. However, larger studies are needed to generalize this statement. AKNOWLEDGMENT We would like to thank Dr. Faisal Al-alem, MBBS, SBGS from the Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia for his assistance in the publication process of this article. Author contributions: Al-Saif FA generated the idea and provided the patient cohort; AlSubaie HS did the literature review and wrote the manuscript; Mattar RE reviewed and edited the manuscript; Qazi SA and AlFuhaid TR provided interventional radiology expertise; Zubaidi A supervised the process. REFERENCES. Lo CM, Fan ST, Liu CL, Lai EC, Wong J. Early decision for conversion of laparoscopic to open cholecystectomy for treatment of acute cholecystitis. Am J Surg 997; 7: Williams LF Jr, Chapman WC, Bonau RA, McGee EC Jr, Boyd RW, Jacobs JK. Comparison of laparoscopic cholecystectomy with open cholecystectomy in a single center. Am J Surg 99; 5: Bickel A, Rappaport A, Kanievski V, Vaksman I, Haj M, Geron N, et al. Laparoscopic management of acute cholecystitis. Prognostic factors for success. Surg Endosc 996; 0: Assalia A, Kopelman D, Hashmonai M. Emergency minilaparotomy cholecystectomy for acute cholecystitis: prospective randomized trial-- implications for the laparoscopic era. World J Surg 997; : Kum CK, Eypasch E, Lefering R, Paul A, Neugebauer E, Troidl H. Laparoscopic cholecystectomy for acute cholecystitis: is it really safe? World J Surg 996; 0: Wise JN, Gervais DA, Akman A, Harisinghani M, Hahn PF, Mueller PR. Percutaneous cholecystostomy catheter removal and incidence of clinically significant bile leaks: a clinical approach to catheter management. AJR Am J Roentgenol 005; :7-5.

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