Safety and Efficacy of Percutaneous Cholecystostomy for Emphysematous Cholecystitis

Abstract

Objective: The objective of the study was to evaluate the safety and efficacy of percutaneous cholecystostomy (PC) in treating critically ill patients with emphysematous cholecystitis who were deemed poor surgical candidates.

Materials and methods: The Institutional Review Board exemption was obtained for this retrospective study. Patients with emphysematous cholecystitis who were deemed to be poor operative candidates by the treating surgeon and underwent PC placement between May 2008 and April 2017 at a single institution were identified through a medical records search. Demographics, laboratory values, imaging data, procedural technique, complications, hospitalization course, clinical outcome, and survival data were obtained.

Results: Ten consecutive patients were included, with a mean age of 75.0 ± 12.2 years, including six men and four women. The most common comorbidity was diabetes (60%, 6/10) followed by hypertension (40%, 4/10). Intraluminal or intramural gas as well as gallbladder wall thickening were noted in all patients. Procedure technical success rate was 100%. There was a complete resolution of symptoms in 90% (9/10) of patients at a mean of 2.9 ± 1.4 days post-procedure. Thirty-day survival rate was 90% (9/10); one patient died on the 6^th post- procedure day from sepsis. Two more deaths occurred within a year after PC from unrelated causes. About 50% (5/10) of patients underwent elective cholecystectomy at a median interval of 69 days post-procedure. In 40% (4/10) of patients, cholecystostomy was the definitive treatment, with tube removal at a median of 140 days post- procedure.

Conclusion: PC appears to be a safe and generally effective alternative management option in patients with emphysematous cholecystitis that is considered very high risk for surgery.

Keywords: Acute cholecystitis; Emphysematous cholecystitis; Percutaneous cholecystostomy.

Figure 1:

An 82-year-old woman with serous adenocarcinoma of the ovary and peritoneal metastases, who presented with acute abdominal pain. (a) CT scan of the abdomen shows gallbladder wall thickening with intraluminal and intramural gas (arrows). (b) Fluoroscopy image during cholecystostomy also shows the intramural gas (arrows). (c) Cholecystostomy tube check done 4 months after the procedure shows a widely patent cystic duct with free passage of contrast into the duodenum. The tube was subsequently removed, and the patient did not require a cholecystectomy.

Figure 2:

A 62-year-old man with diabetes who presented with abdominal pain and nausea of 5-day duration. Sagittal (a) and transverse (b) gray scale ultrasound showed a distended gallbladder with gas (black arrows) within the anterior wall, which is causing “dirty” acoustic shadowing. Also note the focal fluid collections anterior to the gallbladder (white arrows, a, b), which is concerning for gallbladder perforation. (c) Axial T2-weighted MRI scan confirmed the findings of gas within the gallbladder wall (black arrow) and fluid collections (white arrows).

Figure 3:

Distribution of comorbidities in the study population.