Percutaneous Cholecystostomy Is Appropriate as Definitive Treatment for Acute Cholecystitis in Critically Ill Patients: A Single Center, Cross-sectional Study

Byung Hyo Cha; Ha Hun Song; Young Nam Kim; Won Jung Jeon; Sang Jin Lee; Jin Dong Kim; Hak Hyun Lee; Ban Seok Lee; Sang Hyub Lee

doi:10.4166/kjg.2014.63.1.32

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Cha, Song, Kim, Jeon, Lee, Kim, Lee, Lee, and Lee: Percutaneous Cholecystostomy Is Appropriate as Definitive Treatment for Acute Cholecystitis in Critically Ill Patients: A Single Center, Cross-sectional Study

Original Article

Korean J Gastroenterol 2014;63(1):32-38.

Published online: 4 October 2014

DOI: https://doi.org/10.4166/kjg.2014.63.1.32

Percutaneous Cholecystostomy Is Appropriate as Definitive Treatment for Acute Cholecystitis in Critically Ill Patients: A Single Center, Cross-sectional Study

Byung Hyo Cha^*, Ha Hun Song¹, Young Nam Kim, Won Jung Jeon, Sang Jin Lee, Jin Dong Kim, Hak Hyun Lee, Ban Seok Lee, Sang Hyub Lee^1,^*

Digestive Disease Center, Department of Internal Medicine, Cheju Halla General Hospital, Jeju, Korea

¹Department of Radiology, Cheju Halla General Hospital, Jeju, Korea

²Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea

Correspondence to: Byung Hyo Cha, Digestive Disease Center, Department of Internal Medicine, Cheju Halla General Hospital, Doreongno 65, Jeju 690-766, Korea. Tel: +82-64-740-8050, Fax: +82-64-743-3110, E-mail: drhyo@hotmail.com

^* Byung Hyo Cha and Sang Hyub Lee equally contributed as co-first authors.

Received 8 November 2013 Revised 10 December 2013 Accepted 10 December 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

Percutaneous cholecystostomy (PC) is an effective treatment for cholecystitis in high-risk surgical patients. However, there is no definitive agreement on the need for additional cholecystectomy in these patients.

Methods

All patients who were admitted to Cheju Halla General Hospital (Jeju, Korea) for acute cholecystitis and who underwent ultrasonography-guided PC between 2007 and 2012 were consecutively enrolled in this study. Among 82 total patients enrolled, 35 underwent laparoscopic cholecystectomy after recovery and 47 received the best supportive care (BSC) without additional surgery.

Results

The technical and clinical success rates for PC were 100% and 97.5%, respectively. The overall mean survival was 12.8 months. In the BSC group, mean survival was 5.4 months, and in the cholecystectomy group, mean survival was 22.4 months (p＜0.01). However, there was no significant difference between these groups in multivariate analysis (relative risk [RR]=1.92; 95% CI, 0.77–4.77; p=0.16). However, advanced age (RR=1.05; 95% CI, 1.02–1.08; p=0.001) and higher class in the American Society of Anesthesiologists' physical status (RR=3.06; 95% CI, 1.37–6.83, p=0.006) were significantly associated with survival in the multivariate analysis. Among the 47 patients in the BSC group, the cholecystostomy tube was removed in 31 patients per protocol. Recurrent cholecystitis was not observed in either group of patients during the follow-up period.

Conclusions

In high-risk surgical patients, PC without additional cholecystectomy might be the best definitive management. Furthermore, the cholecystostomy drainage catheter can be safely removed in certain patients.

Keywords: Acute cholecystitis, Cholecystectomy, Comorbidity, Cholecystostomy, Elderly

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Fig. 1.

Clinical outcomes of 82 patients that underwent percutaneous cholecystostomy in Cheju Halla General Hospital (Jeju, Korea) between 2007 to 2012. BSC, best supportive care.

Fig. 2.

Flow chart of the post-cho-lecystostomy management protocol devised by Digestive Disease Center in Cheju Halla General Hospital (Jeju, Korea).^a Impacted stone, obstructive mass, or sustained radiocontrast media (remaining ＞3 hours).

Fig. 3.

Cumulative survival rates of 2 treatment groups (cholecystectomy vs. the best supportive care [BSC]) after percutaneous cholecystostomy.

Fig. 4.

Cumulative survival rates of remained vs. removed groups after percutaneous cholecystostomy.

Table 1.

Comorbidities of the Subjects^a

Disease category	Value
Advanced malignant disease	23 (16.5)
Renal failure	20 (14.4))
Severe cardiovascular disease	19 (13.7)
Septic shock	18 (12.9)
Severe cerebrovascular disease	15 (10.8)
Severe neuropsychiatric disease	13 (9.4)
Severe bone and spinal disease	9 (6.5)
COPD	7 (5.0)
Miscellaneous	6 (4.3)
Heart failure	4 (2.9)
Chronic repiratory disease	3 (2.2)
Decompesated liver cirrhosis	2 (1.4)
Total response	139 (100.0)

Values are presented as n (%).

^a Eighty-seven patients who underwent percutaneous cholecystostomy in Cheju Halla General Hospital, Jeju, Korea, between 2007 and 2012. COPD, chronic obstructive pulmonary disease.

Table 2.

Baseline Characteristics of the Subjects^a

	Cholecystectomy group (n=35)	Best supportive care group (n=47)	Total (n=82)	p-value
Age (yr)	71.0±12.2	73.0±14.7	72.1±13.7	0.519
Sex				0.460
Male	20 (57.1)	23 (48.9)	43 (52.4)
Female	15 (42.9)	24 (51.1)	39 (47.6)
ASA class				＜0.001
≤3	31 (88.6)	18 (38.3)	49 (59.8)
≥4	4 (11.4)	29 (61.7)	33 (40.2)
ECOG class				＜0.001
≤2	26 (74.3)	6 (12.8)	32 (39.0)
≥3	9 (25.7)	41 (87.2)	50 (61.0)
Gallstone				0.130
Acalculous	12 (34.3)	24 (51.1)	36 (44.0)
Calculous	23 (65.7)	23 (48.9)	46 (56.0)
Hypotension				0.210
Yes	5 (14.3)	12 (25.5)	17 (20.7)
No	30 (85.7)	35 (74.5)	65 (79.3)
Renal failure				0.340
Yes	6 (17.1)	12 (26.1)	18 (22.2)
No	29 (82.9)	34 (73.9)	63 (77.8)
ICU admission				＜0.01
Yes	1 (2.9)	20 (43.5)	21 (25.9)
No	34 (97.1)	26 (56.5)	60 (74.1)
Follow-up	9.5	4.0	5.2	0.623
duration (mo)	(0.8–87.7)	(4.0–51.5)	(5.4–87.7)
Survival time	15.3	2.4	4.4	0.001
(mo)	(0.8–92.0)	(0.1–24.8)	(0.1–92.0)

Values are presented as mean±SD, n (%), or median (range).

^a Eighty-two enrolled acute cholecystitis patients who underwent ultrasound-guided percutaneous cholecystostomy. ASA class, American Society of Anesthesiologists' physical status classification; ECOG, Eastern Cooperative Oncology Group; ICU, intensive care unit.

Table 3.

Multivariate Analysis of Overall Survival Rates of Total Cholecystitis Subjects with Percutaneous Cholecystostomy^a

Variable	p-value	Exp (B)	95% CI
Variable	p-value	Exp (B)	Lower	Upper
Age	0.001	1.05	1.02	1.08
Sex (male vs. female)	0.300	1.42	0.73	2.75
Cholecystectomy vs. BSC grou	p 0.160	1.92	0.77	4.77
ASA class (≤3 vs. ≥4)	0.006	3.06	1.37	6.83
Comorbidity (≤2 vs. ≥3)	0.092	0.54	0.26	1.11
ICU admission (yes vs. no)	0.420	1.37	0.64	2.93

^a By the Cox proportional hazard model using the log-rank test. BSC, best supportive care; ASA class, American Society of Anesthesiologists' physical status classification; ICU, intensive care unit.

Table 4.

Baseline Characteristics and Clinical Outcomes of 2 Subgroups among 47 Best Supportive Care (BSC) Patients

Content	Remained group (n=16)	Removed group (n=31)	Total BSC group (n=47)	p-value
Age (yr)	77.2±12.2	70.8±15.6	73.0±14.7	0.121
Sex				0.365
Male	6 (37.5)	17 (54.8)	23 (48.9)
Female	10 (62.5)	14 (45.2)	24 (51.1)
Duration of PC (day)	43.8±50.7	29.6±41.2	34.6±44.6	0.363
Comorbidity (n)	1.8±1.1	2.3±1.3	2.1±1.2	0.171
ASA class				0.161
≤3	8 (50.0)	10 (32.3)	18 (38.3)
≥4	8 (50.0)	21 (67.7)	29 (61.7)
ECOG class				0.031
≤2	4 (25.0)	2 (6.5)	6 (12.8)
≥3	12 (75.0)	29 (93.5)	41 (87.2)
Gallbladder polyp				0.763
Acalculous	8 (50.0)	16 (51.6)	24 (51.1)
Calculous	8 (50.0)	15 (48.4)	23 (48.9)
Hypotension				0.223
Yes	6 (37.5)	6 (19.4)	12 (25.5)
No	10 (62.5)	25 (80.6)	35 (74.5)
Renal failure				0.040
Yes	7 (43.8)	5 (16.1)	12 (25.5)
No	9 (56.3)	26 (83.9)	35 (74.5)
ICU admission				0.172
Yes	9 (60.0)	11 (35.5)	20 (43.5)
No	6 (40.0)	20 (64.5)	26 (56.5)
Follow up	2.6	7.1	4.1	0.049
(mo)	(0.1–24.8)	(0.4–51.5)	(0.1–51.5)
Survival time	3.2	7.9	6.9	0.012
(mo)	(0.1–20.7)	(0.5–71.3)	(0.1–71.3)

Values are presented as mean±SD, n (%), or median (range). PC, percutaneous cholecystostomy; ASA class, American Society of Anesthesiologists' physical status classification; ECOG, Eastern Cooperative Oncology Group; ICU, intensive care unit.

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