Pgy 4 Medical Center of Central Georgia- Navicent Health Macon, Georgia, United States
Objectives: Management of acute cholecystitis in critically ill patients has been an evolving field over many decades. Percutaneous cholecystostomy tubes (PCT) tubes have been historically used as a temporizing treatment for infectious conditions involving the gallbladder in patients who are poor operative candidates due to the severity of the patient's condition and/or associated medical comorbidities. Traditionally an cholecystectomy would be performed in the interim after improvement in the patient’s medical condition. We believe that the interval cholecystectomy is not necessary in a majority of patients and can be managed simply with tube removal and observation. We performed a retrospective analysis for our patient population to assess our current practice and patient outcomes.
Methods: A 4-year retrospective analysis of all patients who received a PCT for acute cholecystitis at our facility was performed. We identified patients who received a PCT during this time and reviewed post placement management until either tube removal or cholecystectomy. We then looked at outcomes that included tube failure, recurrent cholecystitis, surgical technique and any surgical complications. We compared the two groups to look at overall outcomes.
Results: We identified 63 patients who received a cholecystostomy tube. Twenty-six (26) of these ended up undergoing cholecystectomy, 38 did not. Of the 38 that did not receive cholecystectomy, 14 followed up and had confirmed tube removal. We had no instances of recurrent cholecystitis in these patients and no obvious complications secondary to removal. In our surgical population we identified a statistically significant number of perioperative complications, 9/26, including extensive LOA, open cholecystectomy, bowel injuries and diaphragm injuries. We also identified 1 death in the cholecystectomy group during the operative admission and no mortality found in those who underwent tube removal. Of those who underwent tube removal, only 6/14 underwent cholangiogram prior to removal with the rest being removed based on symptomatology.
Conclusion: We reviewed the management in our facility and found that patients managed with cholecystectomy versus tube removal and observation had similar patient characteristics. We found patients overall did well with PCT removal and observation without increased incidence of recurrent cholecystitis. We also found a statistically significant number of surgical complications in those that underwent interval cholecystectomy. Overall, we conclude that PTC removal and observation is a safe management strategy and may reduce complications associated with cholecystectomy in this patient population. Further investigation should be performed to identify factors that would predict successful tube removal.
