Risk factors for gallbladder contractility after cholecystolithotomy in elderly high-risk surgical patients

Abstract

Objective: Cholecystolithiasis is a common disease in the elderly patient. The routine therapy is open or laparoscopic cholecystectomy. In the previous study, we designed a minimally invasive cholecystolithotomy based on percutaneous cholecystostomy combined with a choledochoscope (PCCLC) under local anesthesia.

Methods: To investigate the effect of PCCLC on the gallbladder contractility function, PCCLC and laparoscope combined with a choledochoscope were compared in this study.

Results: The preoperational age and American Society of Anesthesiologists (ASA) scores, as well as postoperational lithotrity rate and common biliary duct stone rate in the PCCLC group, were significantly higher than the choledochoscope group. However, the pre- and postoperational gallbladder ejection fraction was not significantly different. Univariable and multivariable logistic regression analyses indicated that the preoperational thickness of gallbladder wall (odds ratio [OR]: 0.540; 95% confidence interval [CI]: 0.317-0.920; P=0.023) and lithotrity (OR: 0.150; 95% CI: 0.023-0.965; P=0.046) were risk factors for postoperational gallbladder ejection fraction. The area under receiver operating characteristics curve was 0.714 (P=0.016; 95% CI: 0.553-0.854).

Conclusion: PCCLC strategy should be carried out cautiously. First, restricted by the diameter of the drainage tube, the PCCLC should be used only for small gallstones in high-risk surgical patients. Second, the usage of lithotrity should be strictly limited to avoid undermining the gallbladder contractility and increasing the risk of secondary common bile duct stones.

Keywords: GBEF; cholecystolithotomy; gallbladder motility; lithotrity; thickness of gallbladder wall.

Figure 1

The schematic representation of percutaneous cholecystostomy combined with choledochoscope procedures. Notes: (A) Ultrasound-guided percutaneous cholecystostomy. The white arrow indicates the percutaneous transhepatic puncture route. The yellow arrow shows the sheath combined with a puncture needle. The red arrow indicates puncture needles getting into the colecyst. (B) Manipulation of cholecystolithotrity using a choledochoscope. The black arrow indicates the cholecystolithotrity procedures using a choledochoscope of retrieval basket.

Figure 2

A significant alleviation of GBEF before and after surgery. Notes: (A, B) Preoperational ultrasound results. Preoperational ultrasound found a single stone with a diameter of 15.6 mm. The white arrow shows the single stone. Preoperational GBEF was 39%. (C, D) Postoperational ultrasound results. Postoperational ultrasound found no stone residual. Postoperational GBEF was 63%. Abbreviation: GBEF, gallbladder ejection fraction.

Figure 3

A significant deterioration of GBEF before and after surgery. Notes: (A, B) Preoperational ultrasound results. Preoperational ultrasound found multiple stones with the largest diameter of 26 mm. The white arrow shows the single stone. Preoperational GBEF was 68%. This patient adopted lithotrity because of the large diameter of stones. (C, D) Postoperational ultrasound results. Postoperational ultrasound found no stone residual. Postoperational GBEF was 46%. Abbreviation: GBEF, gallbladder ejection fraction.

Figure 4

ROC analysis of the gallbladder wall in predicting the postoperational gallbladder contractility. Notes: The preoperational thickness of the gallbladder wall presented discrimination with an area under the ROC curve of 0.714 (P=0.016, 95% confidence interval: 0.553–0.854). The green line represents the reference line. Every blue dot represents a predictive result. Abbreviation: ROC, receiver operating characteristic curve.

Figure 5

Postoperational cholecystography results. Notes: (A, B) Postoperational cholecystography results. Postoperational cholecystography found no stone residual in the gallbladder. The white arrow shows the tube with a water balloon. The black arrow shows the suspicious stone. (C, D) Other postoperational cholecystography results. Preoperational endoscopic retrograde cholangiopancreatography did not obtain any positive findings. However, postoperational cholecystography found a suspicious stone in common bile duct but no residual stone in the gallbladder. Postoperational endoscopic sphincterotomy solved that complication.